Florida Blue July 2016 Medication Guide

Transcription

July 2016
Medication Guide
Click to search for a drug name in this document
Contents
Introduction .................................................................... I
Responsible Steps Program ................................ VIII
Medication list .............................................................. II
Responsible Steps (Medical Pharmacy) Program .. VIII
Changes to the formulary ............................................. II
U/M Exception Requests ........................................ IX
Your Share of Expenses ............................................. III
Notice ..................................................................... IX
Pharmacy Benefits ...................................................... III
Using the Medication Guide ................................... IX
Medications that are not covered ............................... III
Condition Care Rx Program ........................................ IV
Abbreviation/acronym key ....................................... X
Preferred Medication List ........................................ 1
Generic drugs .............................................................. IV
Anti-Infective Drugs ................................................. 1
Mail Order Pharmacy .................................................. IV
Immunizing Agents ................................................ 15
Oral Chemotherapy Drugs .......................................... IV
Cancer Drugs ........................................................ 17
Over-the-counter (OTC) medications ........................... V
Hormones, Diabetes and Related Drugs .............. 22
Preventive medications ................................................ V
Heart and Circulatory Drugs .................................. 42
Immunizations .............................................................. V
Respiratory Drugs ................................................. 64
Women’s preventive Services ...................................... V
Gastrointestinal Drugs ........................................... 70
Specialty Pharmacy medications ................................. V
Genitourinary Drugs .............................................. 76
Participating Specialty Pharmacy Provider ................. VI
Central Nervous System Drugs ............................. 79
Three-month supply .................................................... VI
Pain Relief Drugs .................................................. 98
Pharmacy Options...................................................... VII
Neuromuscular Drugs ......................................... 109
Utilization Management Programs ............................. VII
Supplements ....................................................... 119
Obtaining Prior Coverage Authorization ................... VIII
Blood Modifying Drugs ........................................ 128
Responsible Quantity Program ................................. VIII
Topical Products.................................................. 137
Miscellaneous Categories ................................... 153
Index ...................................................................... 157
Please consider talking to your doctor about prescribing one of the formulary medications that are indicated as
covered under your plan; 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 www.floridablue.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.
Florida Blue July 2016 RX Medication Guide
Rev. 7/2016
Introduction
Florida Blue and Florida Blue HMO are pleased to present the Medication Guide. This is a general guide that includes an
abbreviated listing of Brand and Generic medications that are covered under your plan. Since coverage for medication varies
by the plan purchased by you or your employer, it’s important that you refer to your plan documents for complete coverage
details. When we refer to “plan documents” we are referring to one or more of the following: Benefit Booklet, Certificate of
Coverage, Contract, Member Handbook or prescription drug endorsement.
The Medication Guide provides helpful tips on how to make the most of your pharmacy benefits and details about the various
coverage programs that are designed to provide safe and appropriate medication when you need it. Changes in the
formulary can occur over time and the most up-to-date listing can always be found by viewing the Medication Guide online at
www.floridablue.com or by calling the customer service number listed on your member ID card. For the hearing impaired, call
Florida TTY Relay Service 711.
Si desea hablar sobre esta guía en español con uno de nuestros representantes, por favor llame al número de
atención al cliente indicado en su tarjeta de asegurado y pida ser transferido a un representante bilingüe.
NOTE: The decision concerning whether a prescription medication should be prescribed must be made by you and your
physician. Any and all decisions that require or pertain to independent professional medical judgments or training, or the need
for, and dosage of, a prescription medication, must be made solely by you and your treating physician in accordance with the
patient/physician relationship.
Key Tips and Coverage Guidelines
By following these simple guidelines, you will be assured that you are getting the maximum benefit from your plan.
• When you have your prescriptions filled, ask your pharmacist if a generic equivalent is available. Generic medications are
usually less expensive and most generics are covered unless specifically excluded under your plan documents.
• Select Brand Name medications are included in the formulary and are therefore available to you through your plan. The
List includes all covered brand name medications unless specifically excluded under your plan documents.
• Take this Guide with you when you visit your doctor or health care provider so that he or she is aware of the drugs listed
and cost impacts when you discuss medication options.
Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of Health
Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of
the Blue Cross and Blue Shield Association.
I
Medication List
The Medication Guide includes the Preferred Medication List and some commonly prescribed Non-Preferred prescription
medications. The Preferred Medication List reflects the current recommendations of Florida Blue and is developed in
conjunction with Prime Therapeutics’ National Pharmacy & Therapeutics Committee.
NOTE: This is not a complete listing of all covered prescriptions medications. Florida Blue reserves the right to modify (add,
remove or change) the tier or apply limits of coverage to any prescription medication in this Medication Guide at any time.
For your out-of-pocket expenses to be as low as possible, please consider asking your doctor to prescribe generic
medications, or if necessary, brand name medications that are included on the List. This will help ensure that your covered
medications are allowed and reimbursed under your plan. In addition, consider using a participating pharmacy to obtain your
covered medications because your out-of-pocket expenses should be lower than if you used a non-participating pharmacy.
To save the most money on medications, share this Medication Guide with your doctor or health care provider at each visit
so he or she is aware of the drugs listed and cost impacts when you discuss medication options.
Changes to the formulary
The Formulary List is subject to change at any time. It is reviewed quarterly to examine new medications and new
information about medications that are already on the market concerning safety, effectiveness and current use in therapy.
There are varying reasons changes are made to the medications listed in the Medication Guide:

The tier level of a medication included on the medication list may increase (change to a higher tier or non-covered) when
an FDA-approved bioequivalent generic medication becomes available.

Newly marketed prescription medications may not be covered until the Pharmacy & Therapeutics Committee has had an
opportunity to review the medication, to determine whether the medication will be covered and if so, which tier will apply
based on safety, efficacy and the availability of other products within that class of medications.
The most up to date information about modifications to the medications listed in this Medication Guide can be found by:
Going to www.floridablue.com.

Click on the Members tab.

Click on the Login Now button and either Login or Register.

Once Logged in, click on My Plan, then select Pharmacy from the drop down menu.

Under Medication Guide/Approved Drug Lists, click Medication Guide or Medication Guide Updates.
Medication Guides are posted every January and July, and Medication Guide Updates are posted January, April, July and
October.
II
Your Share of Expenses
Your cost share will depend on which cost share tier the medication is assigned. You can determine your out-of-pocket
amount for medication by reviewing your Schedule of Benefits.
If you or your provider requests a covered brand name medication when there is a generic medication available; you will be
responsible for:

the difference in cost between the generic medication and the brand name medication; and

the cost share applicable to brand name medication, as indicated on your Schedule of Benefits.
Pharmacy Benefits
The pharmacy benefit has three parts/components, called Tiers. This means that covered medications must be included in
one of the following Tiers, unless specifically excluded by your plan:
Tier 1: Covered Generic Prescription Medications
Tier 2: Covered Preferred Brand Prescription Medications
Tier 3: Covered Non-Preferred Brand Prescription Medications or Medications not listed on the Preferred Medication List
Specialty Medications: Covered Specialty Medications as indicated in the Medication List
Condition Care Rx* Value/HSA Preventive Prescription Medications
* Refer to the Condition Care Rx Program section of this Medication Guide for a description of the program
Medications that are not covered
Your pharmacy benefit may not cover select medications. Some of the reasons a medication may not be covered are:

The medication has been shown to have excessive adverse effects and/or safer alternatives.

The medication has a preferred formulary alternative or over-the-counter (OTC) alternative.

The medication is no longer marketed.

The medication has a widely available/distributed AB rated generic equivalent formulation.

The medication has not been approved by the FDA.

The medication has been repackaged — a pharmaceutical product that is removed from the original manufacturer
container (Brand Originator) and repackaged by another manufacturer with a different NDC.

The medication is not covered because of safety or effectiveness concerns.
A list of medications that are not covered may be found at Medications Not Covered List.
NOTE: To determine the medication exclusions that apply to your plan, check your plan documents. Coverage details are
also available to you by logging into the member section of www.floridablue.com.
III
Condition Care Rx Program
The Condition Care Rx Program is designed to help manage the cost of medications used to treat certain chronic conditions
and encourage medication adherence. If members have the Condition Care Rx Program as part of their benefits, they can
purchase medications from the Condition Care Rx Program Value/Health Savings Account Preventive List at a reduced cost.
A list of medications that are part of the Condition Care Rx Value Program may be found at: Condition Care Rx Program
Value List.
A list of medications that are part of the Condition Care Rx Program for Health Savings Account (HSA) compatible plans may
be found at: Condition Care Rx Program HSA Preventive List.
Note: Check your plan documents to determine if the Condition Care Rx Program applies to your plan and the applicable
cost share. Coverage details may also be available to you by logging into the member section of www.floridablue.com or by
calling the customer service number listed on your member ID card.
Generic drugs
Florida Blue encourages the use of generic medications as a way to provide high-quality medications at a reduced cost.
Generic medications are as safe and effective as their brand name counterparts, and are usually considerably less
expensive.
A Food and Drug Administration (FDA) approved generic medication may be substituted for its brand name counterpart
because it:

Contains the same active ingredient(s) as the brand name medication.

Is identical in strength, dosage form, and route of administration.

Is therapeutically equivalent and can be expected to have the same clinical effect and safety profile.
Check with your doctor or health care provider to determine if switching to a generic medication is appropriate for you.
Mail Order Pharmacy
Obtaining prescription medications through the mail order pharmacy may reduce the cost you pay for your prescription
medications.
Check you plan documents to determine if you plan provides a mail order pharmacy benefit.
Members who have pharmacy benefits through Florida Blue can access and print out the Mail Order Pharmacy Form on our
website, www.floridablue.com.
Note: If the original prescription was filled at a pharmacy other than the mail order pharmacy, you must submit a new original
three-month supply prescription with a quantity of up to a three-month supply and not less than a two-month supply along
with the Registration and Prescription Order Form. Prescriptions may not be transferred from a retail pharmacy to the Mail
Order Pharmacy.
Oral Chemotherapy Drugs
Oral chemotherapy drugs are drugs prescribed by a physician to kill or slow the growth of cancerous cells in a manner
consistent with the national accepted standards of practice. A list of these drugs can be found at: Oral Chemotherapy Drug
List.
IV
Over-the-Counter (OTC) medications
An over-the-counter medication can be an appropriate treatment for some conditions and may offer a lower cost alternative
to some commonly prescribed medications. Your pharmacy benefit may provide coverage for select OTC medications.
Some groups may customize their pharmacy plan to exclude coverage for OTC medications, so it is important to check your
plan documents to determine if OTC medications are covered under your plan. Only those OTC medications prescribed by
your physician and designated on the formulary with “OTC” in parenthesis following the medication name are eligible for
coverage.
NOTE: Check your plan documents to determine if this benefit applies to your plan. Coverage details are also available to
you logging into the member section of www.floridablue.com.
Patient Protection Affordable Care Act (PPACA) Preventive Services

Preventive medications - Certain preventive care services, medications, and immunizations are covered at no cost share
when purchased at a participating pharmacy.
A list of medications covered under this benefit may be found at: Preventive Medications List.

Immunizations - Certain vaccines which are covered under your preventive benefit can be administered by
pharmacists that are certified. Not all pharmacies provide services for vaccine administration. It is important to contact
the pharmacy prior to your visit to ensure availability and administration of the vaccine.
A list of vaccines that are covered under your pharmacy benefits may be found at: Pharmacy Benefit Vaccines List.

Women’s preventive services - Certain contraceptive medications or devices (e.g., oral contraceptives, emergency
contraceptive, and diaphragms) are covered at no cost share when purchased at a participating pharmacy.
A list of medications and devices covered under this benefit may be found at: Women’s Preventive Services List.
Specialty Pharmacy medications
Specialty Pharmacy medications are high-cost injectable, infused, oral or inhaled medications that generally require close
supervision and monitoring of the patient’s therapy.
NOTE: Check your plan documents for information on how Specialty Pharmacy medications are covered on your plan.
Coverage details are also available by calling the customer service number listed on your member ID card.
Specialty Medications are divided into two categories:

Self-Administered – Patients self-administer these Specialty Pharmacy medications themselves. Because these
medications are intended to be self-administered, these medications may not be covered if administered in a physician’s
office. If these medications are not obtained from a participating Specialty Pharmacy, out-of-network cost shares will
apply (where out-of-network coverage is available). A current listing of Self-Administered Specialty Medications can be
found here.

Self-administered injectable medications are designated in the Medication List with “inj” following the medication name
(e.g., enoxaparin inj). No other Self-administered injectables will be covered unless such injectable is identified as a
Specialty Drug in this Medication Guide. Self-administered injectables will be subject to the Brand or Generic cost share,
as described in your Schedule of Benefits. Florida Blue reserves the right to change the Self-administered injectables
covered through your plan at any time and for any reason.
V
Provider-Administered – These medications require the administration to be performed by a physician. The Specialty
Pharmacy medications are ordered by a provider and administered in an office or outpatient setting. Provideradministered Specialty Pharmacy medications are covered under your medical benefit. A current listing of ProviderAdministered Specialty Medications can be found here.
Note: Medications listed in the Self-Administered Specialty Drug List are not available through mail order.
Participating Specialty Pharmacy Provider
If you are currently taking a Specialty Pharmacy medication, then your network for Specialty Pharmacies is limited to the
following participating Specialty Pharmacy providers. Unless indicated below, any other pharmacy is considered a nonparticipating Specialty Pharmacy even if it participates in Florida Blue’s networks for non-Specialty Pharmacy medications.
Caremark Specialty Pharmacy Services
All Products
Phone: 1.866.278.5108
Fax: 1.800.323.2445
Caremark Specialty Pharmacy
Caremark Hemophilia Services
Hemophilia Products
Telephone: 1.866.792.2731
(Mon-Fri., 9:00 a.m. to 7:30 p.m. EST)
Fax: 1.866.811.7450
Prime Therapeutics Specialty Pharmacy
(Prime Specialty Pharmacy)
Telephone: 1.877.627.(MEDS) 6337
Fax: 1.877.828.3939
TTY 711
Prime Specialty Pharmacy
Prime Therapeutics Specialty Pharmacy
(Prime Specialty Pharmacy) is a wholly owned subsidiary
of Prime Therapeutics LLC.
Caremark Hemophilia
Note: Specialty Pharmacy medications are not covered when purchased through the Mail Order Pharmacy.
Self-administered specialty medications as classified by Florida Blue outside of the state of Florida may be obtained by a
member with a written prescription through the preferred specialty pharmacy providers Prime Specialty Pharmacy or
Caremark Specialty.
If a member resides or is traveling outsides the state of Florida and needs to receive a provider-administered specialty
medication, the prescribing physician should coordinate with the participating specialty pharmacy provider for their area or
contact the local BlueCross and BlueShield Plan. This coordination can help ensure members receive their medications at
the in-network cost share.
Members that receive a written prescription directly from their provider for a provider-administered specialty medication
should contact customer service for further assistance.
Three-month supply
Some plans allow you to purchase up to a three-month supply of medications. Check your Benefit Booklet, Certificate of
Coverage, Contract, Member Handbook or prescription drug endorsement to determine if your plan includes this benefit. In
addition to being able to obtain up to a three-month supply of medication through our mail order pharmacy, you may be able
to receive up to a three-month supply of your medication through a participating retail pharmacy. Please refer to your Benefit
Booklet, Certificate of Coverage, Contract, Member Handbook or prescription drug endorsement for complete coverage
details.
VI
Pharmacy Options
There are two different types of pharmacies for you to be aware of as you decide where to get your prescriptions filled – retail
pharmacies and specialty pharmacies. To save the most money, before you get a prescription filled, you should confirm
which pharmacy is considered ‘in-network’ for that particular medication.


Participating Pharmacy
o
Retail Pharmacy Network – Non-Specialty ‘Generic’ medications and ‘Brand Name’ medications listed in the
Medication Guide can be filled at these pharmacies at a lower cost to you than other pharmacies in your area. If you
go to a non-participating pharmacy, your prescription will cost you more.
o
Specialty Pharmacy Network – We have identified certain drugs as specialty drugs due to requirements such as
special handling, storage, training, distribution, and management of the therapy. These drugs are listed as a
‘Specialty Drug’ in this Medication Guide. To be covered under your pharmacy program at the in-network cost share,
they must be purchased at a preferred Specialty Pharmacy. These pharmacies are different than the retail
pharmacies and are identified in both the Provider Directory and this Medication Guide. Using an in-network
Specialty Pharmacy to provide these Specialty Drugs lowers the amount you pay for these medications.
Non-Participating Pharmacy
o
If your plan offers out-of-network pharmacy coverage, choosing a non-participating pharmacy will cost you more
money. You may have to pay the full cost of the medication and then file a claim to be reimbursed. Our payment will
be based on our Non-Participating Pharmacy Allowance minus your cost share. You will be responsible for your cost
share and the difference between our Allowance and the cost of the medication.
Utilization Management Programs
The Prior Authorization Program encourages the appropriate, safe and cost-effective use of medication. If you are currently
taking or are prescribed a medication that is included in the Prior Authorization Program, your physician will need to submit a
request form in order for your prescription to be considered for coverage. If you do not request and/or receive prior approval,
the medication will not be covered. A current listing of drugs requiring prior authorization are indicated in the prior
authorization column following the product name in the medication list.
Florida Blue reserves the right to change the medications that require Prior Authorization at any time and for any reason.
NOTE: Some groups may customize their pharmacy plan to exclude prior authorization requirements, so it is important to
check your plan documents to determine if prior authorization requirements apply to your plan. Coverage details are also
available to you by logging into the member section of www.floridablue.com.
Obtaining Prior Authorization
Information about Prior Authorization and forms for how to obtain a prior authorization approval can be found here:
Prior Authorization Program Information and Forms
NOTE: Your provider is required to complete and submit the Prior Authorization form in order for a coverage determination to
be made.
VII
Once a decision is made, you and/or your doctor will be informed of the decision. If the decision is made to authorize
coverage, the medication(s) and/or supplies may be obtained from a participating pharmacy or at the appropriate location if
the medication(s) will be administered by a health professional. Prior authorization approval does not waive your cost share.
If a decision is made to deny authorization, you are free to purchase the prescription medication, supplies or over-thecounter (OTC) medication, but you will have to pay the full cost of the medication and will not be entitled to reimbursement
under your plan.
NOTE: You have the right to request an appeal if coverage authorization is denied. Please refer to the “How to Appeal an
Adverse Benefit Determination” subsection of the Claims Processing or Appeal and Grievance Process section in your
current plan documents for information on how to file an appeal.
Responsible Quantity Program
The Responsible Quantity Program encourages the appropriate, safe and cost-effective use of medication by setting a
maximum quantity per month for a medication or supply. The quantity limitations are based on the Food and Drug
Administration guidelines and the manufacturer’s dosing recommendations. Medications that are subject to this program are
indicated in the quantity limits column following the product name in the medication list.
Florida Blue reserves the right to change the Drugs and the quantity limits subject to the Responsible Quantity Program at
any time and for any reason. In cases where a larger quantity of a Responsible Quantity Drug is medically required, your
doctor or health care provider can request an override.
Information about the Responsible Quantity Program and steps for how to obtain an exception can be found here:
Responsible Quantity Program Information
Responsible Steps Program
The Responsible Steps Program promotes the appropriate, safe, and effective use of medications and helps you save on
prescriptions. Responsible Steps is based on nationally recognized therapeutic guidelines, clinical evidence, and research.
For certain prescription medications, you are required to try designated or prerequisite medication(s) prior to trying a
medication subject to the Responsible Steps Program.
A list of current drugs included in the Responsible Steps Program may be found here:
Responsible Steps Program Information
Responsible Steps (Medical Pharmacy) Program
Certain physician-administered prescription drugs which are rendered in a physician’s office may be included in the
Responsible Steps for Medical Pharmacy Program. If you are taking a medication in the Responsible Steps Program, please
contact your physician/provider to discuss what medication options are best for you.
If, due to medical reasons, you cannot use the prerequisite drug and require the Responsible Steps Medication, your doctor
or health care provider may request prior authorization for an override. If the override request is approved, coverage will be
provided for the Responsible Steps Medication. Florida Blue reserves the right to change the drugs subject to the
Responsible Steps Program at any time and for any reason.
A list of current drugs included in the Responsible Steps Program may be found here:
Responsible Steps for Medical Pharmacy Program Information
VIII
U/M Exception Requests
If, for medical reasons, you require a quantity of medication outside the Responsible Quantity Program limits or you cannot
use one of the alternative medications and require the medication listed in the Responsible Steps or Responsible Steps for
Medical Pharmacy Programs, or you require a tier exception for an oral contraceptive drug, your physician may submit an
exception request by completing one of the forms below:
Formulary Exception Request
Prior Authorization Forms
Responsible Quantity Authorization Form
Responsible Steps Program Information and Authorization Forms
Responsible Steps for Medical Pharmacy Information and Authorization Forms
Oral Contraceptives Tier Exception Request Form
Notice
This Medication Guide shall not extend, vary, alter, replace, or waive any of the provisions, benefits, exclusions, limitations,
or conditions contained in your plan documents. In the event of any inconsistencies between the Medication Guide and the
provisions contained in your plan documents, the provisions contained in your plan documents shall control to the extent
necessary to effectuate the intent of Blue Cross and Blue Shield of Florida and Health Options, Inc.
Using the Medication Guide
The Medication List is organized into broad categories (e.g., Antibacterials). Below are descriptions of the columns
included the medication list.
Column 1.
Drug Name: lists the medication name. Generic medications are listed in lowercase boldface
(e.g., demeclocycline) Brand name medications are capitalized (e.g., ZITHROMAX packets).
Separate medication entries are shown for each dosage form and strength.
Note: Self-administered injectable medications are designated in the medication list with “inj” following the
medication name (e.g., enoxaparin inj).
Column 2.
Drug Tier: indicates the tier level and whether the medication is on the preventive list:
1 (Lowest Cost): Covered Generic Prescription Medications
2 (Higher Cost): Covered Preferred Brand Prescription Medications
3 (Highest Cost): Covered Non-Preferred Brand Prescription Medications or Medications not listed on the
Preferred Medication List
Column 3.
Specialty: indicates if the medication is a Self-Administered Specialty medication.
*If your Pharmacy plan has a separate cost share for Specialty medications, then all Specialty medications will
apply that cost share regardless of the Tier level displayed in the Medication List. Check your plan documents
to determine how coverage of Self-Administered Specialty medications applies to your plan.
Column 4.
Prior Authorization: indicates if the prior authorization requirement applies to the medication. If an
indicator is present in the column, then the prior authorization requirement applies.
Column 5.
Quantity Limit: indicates if quantity limits apply to the medication. If an indicator is present in the column,
then quantity limits apply.
IX
Column 6.
Responsible Steps: indicates if responsible steps apply to the medication. If an indicator is present in the
column then the Responsible Steps Program applies.
An asterisk (*) next to a drug name signifies that this drug may not be covered. Please refer to your plan documents.
Abbreviation/acronym key
Cap .........................................................capsules
chew tabs ................................. chewable tablets
OTC .................................................................. over-the-counter
PA .................................. Prior Coverage Authorization required
conc .................................................. concentrate
crm ............................................................. cream
QL ......... Responsible Quantity Program —quantity limit applies
RS .. Responsible Steps Program —Pre-requisite drug required
ext-release............................... extended-release
inhal ..................................................... inhalation
SI ....................................................Self-Administered Injectable
SL ............................................................................... sublingual
inj ............................................................injection
lotn .............................................................. lotion
SP ................................................................Specialty Pharmacy
soln ................................................................................ solution
NP .................................................. non-preferred
ODT ........................... orally disintegrating tablets
oint ......................................................... ointment
OSM ........................................... osmotic-release
supp ...................................................................... suppositories
susp ......................................................................... suspension
tabs .................................................................................. tablets
To determine if your drug is covered and/or find drug pricing, please login to Your Account on the Florida Blue
website at www.floridablue.com. In Your Account choose Tools, and then Compare Drug Prices.
X
ANTI-INFECTIVE DRUGS
PENICILLINS
amoxicillin & k clavulanate tab
250-125 mg
500-125 mg (Augmentin)
AMOXICILLIN – amoxicillin
(trihydrate) chew tab 250 mg
2
875-125 mg (Augmentin)
amoxicillin (trihydrate) cap
250 mg
1
AMOXICILLIN ER – amoxicillin
(trihydrate) tab sr 24hr 775 mg
3
1
AMOXICILLIN/CLAVULANATE P –
amoxicillin & k clavulanate chew
tab 200-28.5 mg
3
AMOXICILLIN/CLAVULANATE P –
amoxicillin & k clavulanate chew
tab 400-57 mg
3
1
AMPICILLIN – ampicillin for susp
125 mg/5ml
2
1
AMPICILLIN – ampicillin for susp
250 mg/5ml
2
ampicillin cap 250 mg
1
amoxicillin (trihydrate) for susp
200 mg/5ml
250 mg/5ml
400 mg/5ml
amoxicillin (trihydrate) tab
500 mg
1
1
1
ampicillin cap 500 mg
1
1
1
AUGMENTIN – amoxicillin & k
clavulanate tab 500-125 mg
3
1
clavulanate tab 875-125 mg
3
amoxicillin & k clavulanate
for susp 250-62.5 mg/5ml
(Augmentin)
1
clavulanate for susp 125-31.25
mg/5ml
2
amoxicillin & k clavulanate for
susp 400-57 mg/5ml
1
clavulanate for susp 250-62.5
mg/5ml
3
AUGMENTIN ES-600 – amoxicillin
& k clavulanate for susp 600-42.9
mg/5ml
3
AUGMENTIN XR – amoxicillin
& k clavulanate tab sr 12hr
1000-62.5 mg
3
dicloxacillin sodium cap 250 mg
1
amoxicillin (trihydrate) tab
875 mg
amoxicillin & k clavulanate for
susp 200-28.5 mg/5ml
amoxicillin & k clavulanate
for susp 600-42.9 mg/5ml
(Augmentin es-600)
1
amoxicillin & k clavulanate tab sr
12hr 1000-62.5 mg (Augmentin
xr)
1
KEY
Tier
1 = Covered Generic Drugs
2 = Preferred Brand Drugs
3 = Non-preferred Brand Drugs
•
= Responsible Rx Program
*
Responsible Steps
1
3
125 mg/5ml
Quantity Limits
1
AMOXICILLIN – amoxicillin
(trihydrate) chew tab 125 mg
amoxicillin (trihydrate) cap
500 mg
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
= May not be covered – see endorsement
X = Tier 4: Separate Specialty costshare
may apply – see endorsement
1
dicloxacillin sodium cap 500 mg
1
MOXATAG – amoxicillin (trihydrate) 3
tab sr 24hr 775 mg
1
penicillin v potassium for soln
125 mg/5ml
1
penicillin v potassium for soln
250 mg/5ml
1
penicillin v potassium tab
250 mg
1
penicillin v potassium tab
500 mg
CEPHALOSPORINS
CEFDITOREN PIVOXIL –
cefditoren pivoxil tab 400 mg
(base equivalent)
3
cefixime for susp 100 mg/5ml
(Suprax)
1
cefixime for susp 200 mg/5ml
(Suprax)
1
cefpodoxime proxetil for susp
50 mg/5ml
1
cefpodoxime proxetil for susp
100 mg/5ml
cefpodoxime proxetil tab 100 mg
CEDAX – ceftibuten cap 400 mg
3
cefpodoxime proxetil tab 200 mg
CEDAX – ceftibuten for susp 180
mg/5ml
3
cefprozil for susp 125 mg/5ml
CEFACLOR – cefaclor for susp
125 mg/5ml
3
250 mg/5ml
3
375 mg/5ml
3
cefaclor cap 250 mg
1
cefaclor cap 500 mg
cefprozil for susp 250 mg/5ml
cefprozil tab 250 mg
cefprozil tab 500 mg
1
1
1
1
1
1
CEFTIBUTEN – ceftibuten cap 400
mg
3
CEFTIBUTEN – ceftibuten for susp
180 mg/5ml
3
CEFTIN – cefuroxime axetil tab
500 mg
3
CEFTIN – cefuroxime axetil for
susp 125 mg/5ml
3
cefadroxil cap 500 mg
1
3
1
CEFTIN – cefuroxime axetil for
susp 250 mg/5ml
1
cefuroxime axetil tab 250 mg
1
1
cefuroxime axetil tab 500 mg
(Ceftin)
1
CEPHALEXIN – cephalexin tab
250 mg
3
CEPHALEXIN – cephalexin tab
500 mg
3
cephalexin cap 250 mg (Keflex)
1
cefadroxil tab 1 gm
cefdinir cap 300 mg
cefdinir for susp 125 mg/5ml
cefdinir for susp 250 mg/5ml
CEFDITOREN PIVOXIL –
cefditoren pivoxil tab 200 mg
(base equivalent)
KEY
1
1
1
3
Tier
•
*
Responsible Steps
1
3
cefadroxil for susp 500 mg/5ml
Quantity Limits
1
CEFACLOR ER – cefaclor
monohydrate tab sr 12hr 500 mg
cefadroxil for susp 250 mg/5ml
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
2
cephalexin for susp 125 mg/5ml
cephalexin for susp 250 mg/5ml
1
1
1
1
BIAXIN – clarithromycin for susp
250 mg/5ml
3
BIAXIN – clarithromycin tab 250
mg
3
BIAXIN – clarithromycin tab 500
mg
3
clarithromycin for susp
125 mg/5ml
1
KEFLEX – cephalexin cap 250 mg
3
3
3
SPECTRACEF – cefditoren pivoxil
tab 200 mg (base equivalent)
3
clarithromycin for susp
250 mg/5ml (Biaxin)
SPECTRACEF – cefditoren pivoxil
3
clarithromycin tab sr 24hr
500 mg
SUPRAX – cefixime cap 400 mg
2
1
SUPRAX – cefixime chew tab 100
mg
2
clarithromycin tab 250 mg
(Biaxin)
1
SUPRAX – cefixime chew tab 200
mg
2
clarithromycin tab 500 mg
(Biaxin)
DIFICID – fidaxomicin tab 200 mg
3
SUPRAX – cefixime for susp 100
mg/5ml
3
3
mg/5ml
3
E.E.S. GRANULES – erythromycin
ethylsuccinate for susp 200
mg/5ml
2
mg/5ml
2
E.E.S. 400 – erythromycin
ethylsuccinate tab 400 mg
ERY-TAB – erythromycin tab
delayed release 250 mg
2
MACROLIDES
2
azithromycin for susp
100 mg/5ml (Zithromax)
1
2
1
ERYPED 200 – erythromycin
mg/5ml
3
ERYPED 400 – erythromycin
mg/5ml
3
ERYTHROCIN STEARATE –
erythromycin stearate tab 250
mg
3
1
azithromycin tab 500 mg
(Zithromax)
1
(Zithromax)
1
KEY
Tier
•
*
Responsible Steps
1
3
(Zithromax)
Quantity Limits
1
AZITHROMYCIN – azithromycin
powd pack for susp 1 gm
azithromycin for susp
200 mg/5ml (Zithromax)
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
•
3
ERYTHROMYCIN BASE –
erythromycin tab 250 mg
3
doxycycline hyclate cap 100 mg
(Vibramycin)
1
ERYTHROMYCIN BASE –
erythromycin tab 500 mg
3
1
ERYTHROMYCIN
ETHYLSUCCINATE –
erythromycin ethylsuccinate tab
400 mg
2
doxycycline hyclate tab delayed
release 50 mg (Doryx)
erythromycin w/ delayed release
particles cap 250 mg
1
PCE – erythromycin w/ enteric
coated particles tab 333 mg
3
PCE – erythromycin w/ enteric
coated particles tab 500 mg
3
ZITHROMAX – azithromycin tab
250 mg
3
500 mg
3
600 mg
3
ZITHROMAX – azithromycin for
susp 100 mg/5ml
3
ZITHROMAX – azithromycin for
susp 200 mg/5ml
3
ZITHROMAX – azithromycin powd
pack for susp 1 gm
2
ZITHROMAX TRI-PAK –
3
ZITHROMAX Z-PAK –
3
ZMAX – azithromycin extended
release for oral susp 2 gm
3
TETRACYCLINES
demeclocycline hcl tab 150 mg
demeclocycline hcl tab 300 mg
doxycycline hyclate cap 50 mg
KEY
release 75 mg
release 100 mg
release 150 mg
release 200 mg (Doryx)
doxycycline hyclate tab 20 mg
doxycycline hyclate tab 100 mg
doxycycline monohydrate cap
50 mg
75 mg (Monodox)
100 mg (Monodox)
150 mg (Adoxa)
doxycycline monohydrate for
susp 25 mg/5ml (Vibramycin)
doxycycline monohydrate tab
50 mg (Adoxa)
75 mg (Adoxa)
100 mg (Adoxa pak 1/100)
150 mg (Adoxa pak 1/150)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
•
Responsible Steps
1
minocycline hcl cap 75 mg
(Minocin)
*
Quantity Limits
1
1
1
(Minocin)
Tier
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
4
(Minocin)
1
minocycline hcl tab sr 24hr
45 mg
1
90 mg
135 mg
minocycline hcl tab 50 mg
1
1
1
1
1
CIPRO XR – ciprofloxacinciprofloxacin hcl tab sr 24hr 500
mg (base eq)
3
CIPRO XR – ciprofloxacinciprofloxacin hcl tab sr 24hr 1000
mg(base eq)
3
ciprofloxacin for oral susp
250 mg/5ml (5%) (5 gm/100ml)
(Cipro)
1
ciprofloxacin for oral
susp 500 mg/5ml (10%)
(10 gm/100ml) (Cipro)
1
3
2
CIPROFLOXACIN HCL –
ciprofloxacin hcl tab 100 mg
(base equiv)
1
tetracycline hcl cap 250 mg
(Tetracycline hcl)
1
(base equiv) (Cipro)
(Tetracycline hcl)
1
(base equiv) (Cipro)
VIBRAMYCIN – doxycycline
calcium syrup 50 mg/5ml
3
(base equiv)
TETRACYCLINE HCL –
2
TETRACYCLINE HCL –
FLUOROQUINOLONES
AVELOX – moxifloxacin hcl tab 400 3
mg (base equiv)
3
AVELOX ABC PACK –
moxifloxacin hcl tab 400 mg
(base equiv)
CIPRO – ciprofloxacin for oral susp 3
250 mg/5ml (5%) (5 gm/100ml)
3
CIPRO – ciprofloxacin for oral
susp 500 mg/5ml (10%) (10
gm/100ml)
3
CIPRO – ciprofloxacin hcl tab 250
mg (base equiv)
3
CIPRO – ciprofloxacin hcl tab 500
mg (base equiv)
KEY
ciprofloxacin-ciprofloxacin hcl
tab sr 24hr 1000 mg(base eq)
(Cipro xr)
1
FACTIVE – gemifloxacin mesylate
tab 320 mg (base equiv)
3
LEVAQUIN – levofloxacin tab 250
mg
3
mg
3
mg
3
levofloxacin oral soln 25 mg/ml
1
•
*
Responsible Steps
Quantity Limits
1
1
1
ciprofloxacin-ciprofloxacin hcl
tab sr 24hr 500 mg (base eq)
(Cipro xr)
Tier
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
5
levofloxacin tab 250 mg
(Levaquin)
1
(Levaquin)
1
(Levaquin)
1
moxifloxacin hcl tab 400 mg
(base equiv) (Avelox)
1
OFLOXACIN – ofloxacin tab 400
mg
SULFONAMIDES
SULFADIAZINE – sulfadiazine tab
500 mg
AMINOGLYCOSIDES
isoniazid tab 100 mg
isoniazid tab 300 mg
3
3
3
MYAMBUTOL – ethambutol hcl tab
400 mg
3
MYCOBUTIN – rifabutin cap 150
mg
3
PASER – aminosalicylic acid cr
granules packet 4 gm
3
PRIFTIN – rifapentine tab 150 mg
2
pyrazinamide tab 500 mg
1
1
2
X
RIFADIN – rifampin cap 150 mg
3
RIFADIN – rifampin cap 300 mg
3
KITABIS PAK – tobramycin nebu
soln 300 mg/5ml
3
X
RIFAMATE – isoniazid & rifampin
cap 150-300 mg
2
neomycin sulfate tab 500 mg
1
rifampin cap 150 mg (Rifadin)
1
1
rifampin cap 300 mg (Rifadin)
3
TOBI – tobramycin nebu soln 300
mg/5ml
3
RIFATER – isoniazid-rifampin w/
pyrazinamide tab 50-120-300 mg
3
TOBI PODHALER – tobramycin
inhal cap 28 mg
2
SIRTURO – bedaquiline fumarate
3
tobramycin nebu soln
300 mg/5ml (Tobi)
1
TRECATOR – ethionamide tab 250
mg
TUBERCULOSIS
X
X
X
FUNGAL INFECTIONS
1
3
CYCLOSERINE – cycloserine cap
250 mg
3
ANCOBON – flucytosine cap 250
mg
3
ethambutol hcl tab 100 mg
(Myambutol)
1
ANCOBON – flucytosine cap 500
mg
3
ethambutol hcl tab 400 mg
(Myambutol)
1
BIO-STATIN – nystatin cap 500000
unit
3
ISONIAZID – isoniazid syrup 50
mg/5ml
2
BIO-STATIN – nystatin cap
1000000 unit
KEY
Tier
•
*
Responsible Steps
1
BETHKIS – tobramycin nebu soln
300 mg/4ml
paromomycin sulfate cap
250 mg
Quantity Limits
1
MYAMBUTOL – ethambutol hcl tab
100 mg
rifabutin cap 150 mg (Mycobutin)
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
6
CRESEMBA – isavuconazonium
sulfate cap 186 mg
3
DIFLUCAN – fluconazole tab 50
mg
3
mg
griseofulvin ultramicrosize tab
250 mg (Gris-peg)
•
1
3
ketoconazole tab 200 mg
1
3
LAMISIL – terbinafine hcl tab 250
mg
3
mg
•
3
NOXAFIL – posaconazole tab
3
mg
•
NOXAFIL – posaconazole susp 40
mg/ml
2
DIFLUCAN – fluconazole for susp
10 mg/ml
3
•
nystatin tab 500000 unit
1
DIFLUCAN – fluconazole for susp
40 mg/ml
3
fluconazole for susp 10 mg/ml
(Diflucan)
1
fluconazole for susp 40 mg/ml
(Diflucan)
1
fluconazole tab 50 mg (Diflucan)
1
SPORANOX – itraconazole oral
soln 10 mg/ml
2
•
SPORANOX – itraconazole cap
100 mg
3
•
SPORANOX PULSEPAK –
itraconazole cap 100 mg
3
•
terbinafine hcl tab 250 mg
(Lamisil)
1
•
3
•
1
VFEND – voriconazole for susp 40
mg/ml
flucytosine cap 250 mg
(Ancobon)
1
VFEND – voriconazole tab 50 mg
3
VFEND – voriconazole tab 200 mg
3
flucytosine cap 500 mg
(Ancobon)
1
voriconazole for susp 40 mg/ml
(Vfend)
1
•
•
•
GRIS-PEG – griseofulvin
ultramicrosize tab 125 mg
3
voriconazole tab 50 mg (Vfend)
1
GRIS-PEG – griseofulvin
ultramicrosize tab 250 mg
3
griseofulvin microsize susp
125 mg/5ml
1
griseofulvin microsize tab
500 mg
griseofulvin ultramicrosize tab
125 mg (Gris-peg)
KEY
1
voriconazole tab 200 mg (Vfend)
1
•
•
VIRAL INFECTIONS
Cytomegalovirus
1
1
VALCYTE – valganciclovir hcl for
soln 50 mg/ml (base equiv)
2
valganciclovir hcl tab 450 mg
(base equivalent) (Valcyte)
1
Hepatitis
Tier
•
Responsible Steps
1
itraconazole cap 100 mg
(Sporanox)
1
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
•
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
7
1
INTRON A – interferon alfa-2b for
inj 50000000 unit
2
X
BARACLUDE – entecavir oral soln
0.05 mg/ml
2
2
X
BARACLUDE – entecavir tab 0.5
mg
3
INTRON A W/DILUENT –
interferon alfa-2b for inj
10000000 unit
2
X
BARACLUDE – entecavir tab 1 mg
3
COPEGUS – ribavirin tab 200 mg
3
DAKLINZA – daclatasvir
dihydrochloride tab 30 mg (base
equivalent)
2
X •
X • •
18000000 unit
50000000 unit
2
X
equivalent)
2
X • •
lamivudine tab 100 mg (hbv)
(Epivir hbv)
1
3
X •
equivalent)
2
MODERIBA – ribavirin tab 200 mg
& ribavirin tab 400 mg dose pack
MODERIBA – ribavirin tab 400 mg
& ribavirin tab 600 mg dose pack
3
X •
entecavir tab 0.5 mg (Baraclude)
1
MODERIBA 1200 DOSE PACK –
ribavirin tab 600 mg
3
X •
entecavir tab 1 mg (Baraclude)
X • •
1
EPIVIR HBV – lamivudine tab 100
mg (hbv)
3
MODERIBA 800 DOSE PACK –
ribavirin tab 400 mg
3
X •
EPIVIR HBV – lamivudine oral soln
5 mg/ml (hbv)
2
OLYSIO – simeprevir sodium cap
150 mg (base equivalent)
3
X • •
HARVONI – ledipasvir-sofosbuvir
tab 90-400 mg
2
3
X •
HEPSERA – adefovir dipivoxil tab
10 mg
3
PEG-INTRON REDIPEN –
peginterferon alfa-2b for inj kit 50
mcg/0.5ml
3
X •
INTRON A – interferon alfa-2b inj
6000000 unit/ml
2
X
peginterferon alfa-2b for inj kit 80
mcg/0.5ml
X
X •
inj 10000000 unit
2
X
peginterferon alfa-2b for inj kit
120 mcg/0.5ml
3
10000000 unit/ml
2
3
X •
inj 18000000 unit
2
X
150 mcg/0.5ml
PEG-INTRON REDIPEN PAK 4 –
120 mcg/0.5ml
3
X •
KEY
X • •
Tier
•
*
Responsible Steps
adefovir dipivoxil tab 10 mg
(Hepsera)
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
8
X •
PEGASYS – peginterferon alfa-2a
inj 180 mcg/0.5ml
2
X •
PEGASYS PROCLICK –
peginterferon alfa-2a inj 135
mcg/0.5ml
2
X •
PEGASYS PROCLICK –
peginterferon alfa-2a inj 180
mcg/0.5ml
2
PEGINTRON – peginterferon
alfa-2b for inj kit 50 mcg/0.5ml
3
X •
3
X •
3
X •
3
X •
acyclovir tab 800 mg (Zovirax)
REBETOL – ribavirin cap 200 mg
3
3
famciclovir tab 250 mg (Famvir)
REBETOL – ribavirin soln 40 mg/
ml
X •
X •
RIBASPHERE – ribavirin tab 400
mg
3
X •
RIBASPHERE – ribavirin tab 600
mg
3
X •
RIBASPHERE RIBAPAK – ribavirin
tab 400 mg
3
X •
tab 600 mg
3
X •
tab 200 mg & ribavirin tab 400
mg dose pack
3
X •
tab 400 mg & ribavirin tab 600
mg dose pack
3
ribavirin cap 200 mg (Rebetol)
1
ribavirin tab 200 mg (Copegus)
KEY
X •
X •
2
TECHNIVIE – ombitasvirparitaprevir-ritonavir tab
12.5-75-50 mg
3
TYZEKA – telbivudine tab 600 mg
3
VIEKIRA PAK – ombitas-paritapreriton & dasab tab pak 12.5-75-50
& 250 mg
3
X • •
ZEPATIER – elbasvir-grazoprevir
tab 50-100 mg
3
X • •
Herpes
acyclovir cap 200 mg (Zovirax)
1
1
acyclovir tab 400 mg (Zovirax)
1
1
1
1
1
FAMVIR – famciclovir tab 125 mg
3
3
3
valacyclovir hcl tab 500 mg
(Valtrex)
1
valacyclovir hcl tab 1 gm
(Valtrex)
1
ZOVIRAX – acyclovir cap 200 mg
3
ZOVIRAX – acyclovir susp 200
mg/5ml
3
ZOVIRAX – acyclovir tab 400 mg
3
ZOVIRAX – acyclovir tab 800 mg
3
abacavir sulfate tab 300 mg
(base equiv) (Ziagen)
Tier
•
1
acyclovir susp 200 mg/5ml
(Zovirax)
HIV/AIDS
X •
X •
X • •
X • •
SOVALDI – sofosbuvir tab 400 mg
*
Responsible Steps
2
Quantity Limits
PEGASYS – peginterferon alfa-2a
inj 180 mcg/ml
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
1
•
9
1
APTIVUS – tipranavir cap 250 mg
2
APTIVUS – tipranavir oral soln 100
mg/ml
2
• •
• •
ATRIPLA – efavirenz-emtricitabinetenofovir df tab 600-200-300 mg
2
• •
COMBIVIR – lamivudinezidovudine tab 150-300 mg
3
• •
COMPLERA – emtricitabinerilpivirine-tenofovir df tab
200-25-300 mg
2
• •
CRIXIVAN – indinavir sulfate cap
200 mg
2
CRIXIVAN – indinavir sulfate cap
400 mg
didanosine delayed release
capsule 125 mg (Videx ec)
EPZICOM – abacavir sulfatelamivudine tab 600-300 mg
2
• •
EVOTAZ – atazanavir sulfatecobicistat tab 300-150 mg (base
equiv)
2
• •
FUZEON – enfuvirtide for inj 90 mg 2
3
GENVOYA – elvitegrav-cobicemtricitab-tenofov af tab
150-150-200-10 mg
INTELENCE – etravirine tab 25 mg 2
X • •
•
INTELENCE – etravirine tab 100
mg
2
• •
INTELENCE – etravirine tab 200
mg
2
• •
2
• •
INVIRASE – saquinavir mesylate
cap 200 mg
2
• •
1
•
INVIRASE – saquinavir mesylate
tab 500 mg
2
• •
1
•
2
• •
1
•
ISENTRESS – raltegravir
potassium tab 400 mg (base
equiv)
2
• •
1
•
potassium packet for susp 100
mg (base equiv)
potassium chew tab 25 mg (base
equiv)
2
• •
potassium chew tab 100 mg
(base equiv)
2
• •
KALETRA – lopinavir-ritonavir soln
400-100 mg/5ml (80-20 mg/ml)
2
• •
KALETRA – lopinavir-ritonavir tab
100-25 mg
2
• •
KALETRA – lopinavir-ritonavir tab
200-50 mg
2
• •
2
• •
EMTRIVA – emtricitabine caps 200
mg
2
• •
EMTRIVA – emtricitabine soln 10
mg/ml
2
• •
EPIVIR – lamivudine oral soln 10
mg/ml
3
• •
EPIVIR – lamivudine tab 150 mg
3
EPIVIR – lamivudine tab 300 mg
3
• •
• •
Tier
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
• •
• •
EDURANT – rilpivirine hcl tab 25
mg (base equivalent)
KEY
Drug Tier
•
abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg
(Trizivir)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
10
RESCRIPTOR – delavirdine
mesylate tab 100 mg
2
• •
1
•
•
•
RESCRIPTOR – delavirdine
mesylate tab 200 mg
2
• •
RETROVIR – zidovudine cap 100
mg
3
• •
LEXIVA – fosamprenavir calcium
2
• •
RETROVIR – zidovudine syrup 10
mg/ml
3
• •
LEXIVA – fosamprenavir calcium
susp 50 mg/ml (base equiv)
2
• •
2
• •
NEVIRAPINE – nevirapine susp 50
mg/5ml
2
• •
REYATAZ – atazanavir sulfate
oral powder packet 50 mg (base
equiv)
2
• •
nevirapine tab sr 24hr 100 mg
(Viramune xr)
1
•
REYATAZ – atazanavir sulfate cap
150 mg (base equiv)
2
• •
nevirapine tab sr 24hr 400 mg
(Viramune xr)
1
•
200 mg (base equiv)
2
• •
nevirapine tab 200 mg (Viramune) 1
2
NORVIR – ritonavir cap 100 mg
•
• •
• •
• •
300 mg (base equiv)
SELZENTRY – maraviroc tab 150
mg
2
• •
SELZENTRY – maraviroc tab 300
mg
2
• •
stavudine cap 15 mg (Zerit)
1
lamivudine tab 300 mg (Epivir)
lamivudine-zidovudine tab
150-300 mg (Combivir)
1
NORVIR – ritonavir tab 100 mg
2
NORVIR – ritonavir oral soln 80
mg/ml
2
ODEFSEY – emtricitabinerilpivirine-tenofovir af tab
200-25-25 mg
3
PREZCOBIX – darunavir-cobicistat
tab 800-150 mg
2
PREZISTA – darunavir ethanolate
susp 100 mg/ml (base equiv)
2
2
2
stavudine for oral soln 1 mg/ml
(Zerit)
1
•
•
•
•
•
• •
STRIBILD – elvitegrav-cobicemtricitab-tenofovdf tab
150-150-200-300 mg
2
• •
• •
SUSTIVA – efavirenz tab 600 mg
2
2
• •
SUSTIVA – efavirenz cap 50 mg
2
SUSTIVA – efavirenz cap 200 mg
2
• •
• •
• •
2
• •
TIVICAY – dolutegravir sodium tab
10 mg (base equiv)
2
KEY
• •
• •
• •
Tier
•
*
1
1
1
Responsible Steps
1
Quantity Limits
lamivudine tab 150 mg (Epivir)
Prior Authorization
•
Drug Name
Specialty/Tier 4
1
Drug Tier
lamivudine oral soln 10 mg/ml
(Epivir)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
11
25 mg (base equiv)
2
50 mg (base equiv)
2
• •
TRIUMEQ – abacavir-dolutegravirlamivudine tab 600-50-300 mg
2
• •
TRIZIVIR – abacavir sulfatelamivudine-zidovudine tab
300-150-300 mg
3
• •
TRUVADA – emtricitabine-tenofovir 2
disoproxil fumarate tab 100-150
mg
mg
mg
mg
2
TYBOST – cobicistat tab 150 mg
• •
•
•
•
•
•
•
•
•
VIRAMUNE – nevirapine tab 200
mg
3
• •
VIRAMUNE – nevirapine susp 50
mg/5ml
2
• •
VIRAMUNE XR – nevirapine tab sr
24hr 100 mg
2
• •
VIRAMUNE XR – nevirapine tab sr
24hr 400 mg
3
• •
VIREAD – tenofovir disoproxil
fumarate oral powder 40 mg/gm
2
• •
fumarate tab 150 mg
2
• •
fumarate tab 200 mg
2
• •
fumarate tab 250 mg
2
• •
fumarate tab 300 mg
2
• •
VITEKTA – elvitegravir tab 85 mg
2
VITEKTA – elvitegravir tab 150 mg
2
ZERIT – stavudine for oral soln 1
mg/ml
3
• •
• •
• •
ZERIT – stavudine cap 15 mg
3
3
3
3
VIDEX – didanosine for soln 2 gm
2
VIDEX – didanosine for soln 4 gm
2
VIDEX EC – didanosine delayed
release capsule 125 mg
3
3
• •
• •
ZIAGEN – abacavir sulfate tab 300
mg (base equiv)
3
3
•
•
•
•
•
• •
ZIAGEN – abacavir sulfate soln 20
mg/ml (base equiv)
2
3
• •
• •
zidovudine cap 100 mg (Retrovir)
1
VIRACEPT – nelfinavir mesylate
tab 250 mg
2
•
•
VIRACEPT – nelfinavir mesylate
tab 625 mg
2
• •
zidovudine syrup 10 mg/ml
(Retrovir)
1
zidovudine tab 300 mg
1
•
KEY
•
•
•
•
•
Influenza
Tier
•
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
12
FLUMADINE – rimantadine
hydrochloride tab 100 mg
3
RELENZA DISKHALER –
zanamivir aero powder breath
activated 5 mg/blister
3
rimantadine hydrochloride tab
100 mg (Flumadine)
1
mefloquine hcl tab 250 mg
•
1
PLAQUENIL – hydroxychloroquine
sulfate tab 200 mg
3
PRIMAQUINE PHOSPHATE –
primaquine phosphate tab 26.3
mg (15 mg base)
2
2
•
QUALAQUIN – quinine sulfate cap
324 mg
3
TAMIFLU – oseltamivir phosphate
for susp 6 mg/ml (base equiv)
•
•
quinine sulfate cap 324 mg
(Qualaquin)
1
cap 30 mg (base equiv)
2
•
2
•
2
•
MALARIA
ARALEN – chloroquine phosphate
tab 500 mg
3
atovaquone-proguanil hcl tab
62.5-25 mg (Malarone)
1
atovaquone-proguanil hcl tab
250-100 mg (Malarone)
chloroquine phosphate tab
250 mg
chloroquine phosphate tab
500 mg (Aralen)
2
hydroxychloroquine sulfate tab
200 mg (Plaquenil)
1
MALARONE – atovaquoneproguanil hcl tab 62.5-25 mg
3
MALARONE – atovaquoneproguanil hcl tab 250-100 mg
3
KEY
BILTRICIDE – praziquantel tab 600
mg
2
EMVERM – mebendazole chew
tab 100 mg
3
ivermectin tab 3 mg (Stromectol)
1
ALINIA – nitazoxanide tab 500 mg
1
DARAPRIM – pyrimethamine tab
25 mg
2
OTHER ANTI-INFECTIVES
1
2
ALBENZA – albendazole tab 200
mg
STROMECTOL – ivermectin tab 3
mg
1
COARTEM – artemetherlumefantrine tab 20-120 mg
WORM INFECTIONS
X • •
3
2
ALINIA – nitazoxanide for susp 100 2
mg/5ml
1
atovaquone susp 750 mg/5ml
(Mepron)
3
BACTRIM – sulfamethoxazoletrimethoprim tab 400-80 mg
BACTRIM DS – sulfamethoxazole- 3
trimethoprim tab 800-160 mg
2
CAYSTON – aztreonam lysine
for inhal soln 75 mg (base
equivalent)
CLEOCIN – clindamycin hcl cap 75 3
mg
Tier
•
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
13
CLEOCIN – clindamycin hcl cap
150 mg
3
metronidazole tab 250 mg
(Flagyl)
1
CLEOCIN – clindamycin hcl cap
300 mg
3
metronidazole tab 500 mg
(Flagyl)
1
CLEOCIN PEDIATRIC GRANULE
– clindamycin palmitate hcl for
soln 75 mg/5ml (base equiv)
3
NEBUPENT – pentamidine
isethionate for nebulization soln
300 mg
2
clindamycin hcl cap 75 mg
(Cleocin)
1
PRIMSOL – trimethoprim hcl oral
2
(Cleocin)
1
SIVEXTRO – tedizolid phosphate
tab 200 mg
2
(Cleocin)
1
1
clindamycin palmitate hcl for
(Cleocin pediatric gr)
1
sulfamethoxazole-trimethoprim
susp 200-40 mg/5ml
dapsone tab 25 mg
1
dapsone tab 100 mg
tab 400-80 mg (Bactrim)
tab 800-160 mg (Bactrim ds)
1
3
3
3
FLAGYL – metronidazole tab 250
mg
3
TINDAMAX – tinidazole tab 500
mg
1
FLAGYL – metronidazole tab 500
mg
3
tinidazole tab 250 mg (Tindamax)
FLAGYL ER – metronidazole tab sr 3
24hr 750 mg
IMPAVIDO – miltefosine cap 50 mg 3
1
3
VANCOCIN HCL – vancomycin hcl
cap 250 mg
3
vancomycin hcl cap 125 mg
(Vancocin hcl)
1
vancomycin hcl cap 250 mg
(Vancocin hcl)
1
MEPRON – atovaquone susp 750
mg/5ml
3
VIRAZOLE – ribavirin for inhal soln
6 gm
3
metronidazole cap 375 mg
(Flagyl)
1
XIFAXAN – rifaximin tab 200 mg
3
XIFAXAN – rifaximin tab 550 mg
2
3
KETEK – telithromycin tab 400 mg
3
linezolid for susp 100 mg/5ml
(Zyvox)
1
linezolid tab 600 mg (Zyvox)
1
KEY
•
•
Tier
•
*
Responsible Steps
1
VANCOCIN HCL – vancomycin hcl
cap 125 mg
KETEK – telithromycin tab 300 mg
Quantity Limits
1
FLAGYL – metronidazole cap 375
mg
trimethoprim tab 100 mg
• •
1
TINDAMAX – tinidazole tab 250
mg
tinidazole tab 500 mg (Tindamax)
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
• •
• •
14
ZYVOX – linezolid tab 600 mg
3
ZYVOX – linezolid for susp 100
mg/5ml
3
IMMUNIZING AGENTS
ACTHIB – haemophilus b
polysaccharide conjugate
vaccine for inj
3
ADACEL – tet tox-diph-acell
pertuss ad inj 5-2-15.5 lf-lfmcg/0.5ml
3
BEXSERO – meningococcal vac
b (recomb adsorbed) inj prefilled
syringe
3
BOOSTRIX – tet tox-diph-acell
pertuss ad inj 5-2.5-18.5 lf-lfmcg/0.5ml
3
CERVARIX – human
papillomavirus (hpv) bival (type
16, 18) recmb vac inj
3
DAPTACEL – diph, acellular pert &
tet tox inj 15 lf-10 mcg-5 lf/0.5ml
3
DIPHTHERIA/TETANUS TOXOID
– diphtheria-tetanus tox
adsorbed (dt) im inj 25-5
unit/0.5ml
3
ENGERIX-B – hepatitis b vaccine
(recombinant) susp 10 mcg/0.5ml
3
(recombinant) susp 20 mcg/ml
3
(recombinant) 10 mcg/0.5ml
3
(recombinant) 20 mcg/ml
3
FLU VACCINES
3
GAMMAGARD LIQUID –
immune globulin (human) iv or
subcutaneous soln 1 gm/10ml
2
KEY
X •
•
2
X •
2
X •
2
X •
2
X •
2
X •
GAMMAKED – immune globulin
(human) iv or subcutaneous soln
1 gm/10ml
2
X •
2.5 gm/25ml
2
X •
5 gm/50ml
2
X •
10 gm/100ml
2
X •
20 gm/200ml
2
X •
GAMUNEX-C – immune globulin
1 gm/10ml
2
X •
2.5 gm/25ml
2
X •
•
*
Responsible Steps
subcutaneous soln 2.5 gm/25ml
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Tier
Drug Tier
•
•
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
15
3
X •
X •
HYQVIA – immun glob inj 2.5
gm/25ml-hyaluron inj 200
unt/1.25 ml kit
3
X
20 gm/200ml
2
X •
HYQVIA – immun glob inj 5
gm/50ml-hyaluron inj 400 unt/2.5
ml kit
3
X
40 gm/400ml
2
X •
gm/100ml-hyaluron inj 800 unt/5
ml kit
3
X
GARDASIL – human
papillomavirus (hpv) quadrivalent
recombinant vac inj
3
unt/10 ml kit
3
X
GARDASIL 9 – human
papillomavirus (hpv) 9-valent
recomb vac susp pref syr
3
unt/15 ml kit
3
X
GARDASIL 9 – human
papillomavirus (hpv) 9-valent
recomb vac im susp
3
INFANRIX – diph, acellular pert &
tet tox inj 25 lf-58 mcg-10 lf/0.5ml
3
KINRIX – diph-tetanus tox ad-acell
pert & polio virus, ipv vac inj
3
HAVRIX – hepatitis a vaccine inj
susp 720 el unit/0.5ml
3
M-M-R II – measles, mumps &
rubella virus vaccines for inj
3
HAVRIX – hepatitis a vaccine inj
susp 1440 el unit/ml
3
MENACTRA – meningococcal
(a, c, y, and w-135) conjugate
vaccine inj
3
HIBERIX – haemophilus b
polysaccharide conjugate vac for
inj 10 mcg
3
3
X •
MENHIBRIX – meningococcal (c &
y)-haemophilus b tet tox conj vac
for inj
3
HIZENTRA – immune globulin
(human) subcutaneous inj 1
gm/5ml
X •
MENOMUNE-A/C/Y/W-135 –
meningococcal vaccine a, c, y,
and w-135 inj
3
gm/10ml
3
X •
MENVEO – meningococcal (a, c, y,
and w-135) oligo conj vac for inj
3
gm/20ml
3
PEDIARIX – diph-tetanus tox-acell
pert-hepatitis b-polio ipv vac inj
3
KEY
Tier
•
*
Responsible Steps
gm/50ml
Quantity Limits
2
Prior Authorization
10 gm/100ml
Drug Name
Specialty/Tier 4
X •
Drug Tier
2
Responsible Steps
5 gm/50ml
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
16
3
TWINRIX – hepatitis a (inact)-hep
b (recomb) vac inj 720-20 elumcg/ml
3
PENTACEL – diph-ac per-tet tox
ad-poliov-haemoph b poly vac for
im susp
3
VAQTA – hepatitis a vaccine inj
susp 25 unit/0.5ml
3
3
3
PNEUMOVAX 23 – pneumococcal
vaccine polyvalent inj 25
mcg/0.5ml
VAQTA – hepatitis a vaccine inj
susp 50 unit/ml
3
PNEUMOVAX 23/1 DOSE
– pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml
3
VARIVAX – varicella virus vac
live for subcutaneous inj 1350
pfu/0.5ml
3
PREVNAR 13 – pneumococcal 13valent conjugate vaccine inj
3
ZOSTAVAX – zoster vaccine live
for inj 19400 unit/0.65ml
PROQUAD – measles-mumpsrubella-varicella virus vaccines
for inj
3
QUADRACEL – diph-tetanus tox
ad-acell pert & polio virus, ipv
vac inj
3
RECOMBIVAX HB – hepatitis b
vaccine (recombinant) susp 5
mcg/0.5ml
3
mcg/ml
3
mcg/ml
3
TENIVAC – tetanus-diphtheria
toxoids (td) inj 5-2 lfu
CANCER DRUGS
•
•
•
•
•
•
•
•
•
•
ACTIMMUNE – interferon
gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)
2
X
AFINITOR – everolimus tab 2.5 mg
2
AFINITOR – everolimus tab 5 mg
2
AFINITOR – everolimus tab 7.5 mg
2
AFINITOR – everolimus tab 10 mg
2
AFINITOR DISPERZ – everolimus
tab for oral susp 2 mg
2
X
X
X
X
X
2
X • •
2
X • •
2
X • •
3
ALECENSA – alectinib hcl cap 150
ALKERAN – melphalan tab 2 mg
2
TETANUS/DIPHTHERIA TOXOID
– tetanus-diphtheria toxoids (td)
inj 2-2 lf/0.5ml
3
anastrozole tab 1 mg (Arimidex)
1
TRUMENBA – meningococcal
group b vaccine im susp prefilled
syringe
3
KEY
ARIMIDEX – anastrozole tab 1 mg
3
AROMASIN – exemestane tab 25
mg
3
bexarotene cap 75 mg (Targretin)
1
Tier
•
*
Responsible Steps
Quantity Limits
PEDVAX HIB – haemophilus b
polysaccharide conj vac im susp
7.5 mcg/0.5 ml
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
X •
17
bicalutamide tab 50 mg
(Casodex)
1
BOSULIF – bosutinib tab 100 mg
2
BOSULIF – bosutinib tab 500 mg
2
CAPRELSA – vandetanib tab 100
mg
2
X
X
X
X
X
CAPRELSA – vandetanib tab 300
mg
2
X • •
CASODEX – bicalutamide tab 50
mg
3
COMETRIQ – cabozantinib smalate cap 3 x 20 mg (60 mg
dose) kit
2
X • •
COMETRIQ – cabozantinib s-mal
cap 1 x 80 mg & 1 x 20 mg (100
dose) kit
2
X • •
COMETRIQ – cabozantinib s-mal
cap 1 x 80 mg & 3 x 20 mg (140
dose) kit
2
COTELLIC – cobimetinib fumarate
2
capecitabine tab 150 mg (Xeloda) 1
capecitabine tab 500 mg (Xeloda) 1
•
•
•
•
•
•
•
•
•
•
FARESTON – toremifene citrate
2
FARYDAK – panobinostat lactate
cap 10 mg (base equivalent)
2
X • •
2
X • •
2
X • •
flutamide cap 125 mg
1
GILOTRIF – afatinib dimaleate tab
2
X • •
2
X • •
2
X • •
GLEEVEC – imatinib mesylate tab
3
X • •
X • •
GLEEVEC – imatinib mesylate tab
3
X • •
GLEOSTINE – lomustine cap 5 mg
2
X • •
GLEOSTINE – lomustine cap 10
mg
2
X
X
mg
2
CYCLOPHOSPHAMIDE –
cyclophosphamide cap 25 mg
3
X
3
mg
2
CYCLOPHOSPHAMIDE –
cyclophosphamide cap 50 mg
X
EMCYT – estramustine phosphate
sodium cap 140 mg
2
ERIVEDGE – vismodegib cap 150
mg
2
ETOPOSIDE – etoposide cap 50
mg
2
exemestane tab 25 mg
(Aromasin)
1
KEY
X • •
HEXALEN – altretamine cap 50 mg 2
2
HYCAMTIN – topotecan hcl cap
0.25 mg (base equiv)
2
HYCAMTIN – topotecan hcl cap 1
mg (base equiv)
3
HYDREA – hydroxyurea cap 500
mg
1
hydroxyurea cap 500 mg
(Hydrea)
IBRANCE – palbociclib cap 75 mg 2
Tier
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
X
X •
X •
X • •
18
ICLUSIG – ponatinib hcl tab 15 mg
(base equiv)
2
X • •
X • •
X • •
ICLUSIG – ponatinib hcl tab 45 mg
(base equiv)
2
X • •
JAKAFI – ruxolitinib phosphate tab
2
X • •
imatinib mesylate tab 100 mg
(base equivalent) (Gleevec)
1
X • •
2
X • •
1
X • •
2
X • •
IMBRUVICA – ibrutinib cap 140 mg 2
2
INLYTA – axitinib tab 1 mg
LENVIMA 10 MG DAILY DOSE –
lenvatinib cap therapy pack 10
mg (10 mg daily dose)
lenvatinib cap therapy pack 10 &
4 mg (14 mg daily dose)
2
X • •
lenvatinib cap therapy pack 10 &
4 (2) mg (18 mg daily dose)
2
X • •
(2) mg (20 mg daily dose)
2
X • •
(2) & 4 mg (24 mg daily dose)
2
X • •
lenvatinib cap therapy pack 4 (2)
mg (8 mg daily dose)
2
X • •
letrozole tab 2.5 mg (Femara)
1
imatinib mesylate tab 400 mg
(base equivalent) (Gleevec)
INLYTA – axitinib tab 5 mg
2
6000000 unit/ml
2
X • •
X • •
X • •
X
10000000 unit/ml
2
X
inj 10000000 unit
2
X
inj 18000000 unit
2
X
inj 50000000 unit
2
X
10000000 unit
2
X
18000000 unit
2
50000000 unit
2
IRESSA – gefitinib tab 250 mg
2
2
KEY
X
X
X • •
X • •
2
X • •
2
X • •
LEUCOVORIN CALCIUM –
leucovorin calcium tab 10 mg
2
LEUCOVORIN CALCIUM –
2
1
2
leuprolide acetate inj kit 5 mg/ml
1
•
1
LEUKERAN – chlorambucil tab 2
mg
Tier
*
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
X •
19
X • •
LYNPARZA – olaparib cap 50 mg
2
X • •
X
X
LYSODREN – mitotane tab 500 mg 2
MATULANE – procarbazine hcl cap 2
50 mg
3
MEGACE ORAL – megestrol
acetate susp 40 mg/ml
megestrol acetate susp 40 mg/ml 1
(Megace oral)
1
megestrol acetate tab 20 mg
megestrol acetate tab 40 mg
1
MEKINIST – trametinib dimethyl
sulfoxide tab 0.5 mg (base
equivalent)
2
X • •
MEKINIST – trametinib dimethyl
sulfoxide tab 2 mg (base
equivalent)
2
X • •
mercaptopurine tab 50 mg
1
methotrexate sodium inj
50 mg/2ml (25 mg/ml)
methotrexate sodium tab 2.5 mg
(base equiv)
1
1
1
MYLERAN – busulfan tab 2 mg
2
NEXAVAR – sorafenib tosylate tab
2
NILANDRON – nilutamide tab 150
mg
2
NINLARO – ixazomib citrate cap
2.3 mg (base equivalent)
2
X • •
NINLARO – ixazomib citrate cap 3
2
X • •
NINLARO – ixazomib citrate cap 4
2
X • •
ODOMZO – sonidegib phosphate
2
X • •
POMALYST – pomalidomide cap 1
mg
2
X • •
mg
2
X • •
mg
2
X • •
X • •
MESNEX – mesna tab 400 mg
2
METHOTREXATE SODIUM –
methotrexate sodium inj 250
mg/10ml (25 mg/ml)
3
methotrexate sodium for inj
1 gm
1
mg
2
X • •
1
PURIXAN – mercaptopurine susp
2000 mg/100ml (20 mg/ml)
2
X
1
SOLTAMOX – tamoxifen citrate
oral soln 10 mg/5ml (base
equivalent)
3
SPRYCEL – dasatinib tab 20 mg
2
2
2
2
methotrexate sodium inj pf
50 mg/2ml (25 mg/ml)
100 mg/4ml (25 mg/ml)
200 mg/8ml (25 mg/ml)
250 mg/10ml (25 mg/ml)
KEY
1
1
Tier
•
*
Responsible Steps
2
Quantity Limits
LONSURF – trifluridine-tipiracil tab
20-8.19 mg
1000 mg/40ml (25 mg/ml)
Prior Authorization
X • •
Drug Name
Specialty/Tier 4
2
Drug Tier
LONSURF – trifluridine-tipiracil tab
15-6.14 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
X
X
X
X
•
•
•
•
•
•
•
•
20
TARCEVA – erlotinib hcl tab 100
2
X • •
2
TARCEVA – erlotinib hcl tab 150
2
X • •
SUTENT – sunitinib malate cap
2
X • •
TARGRETIN – bexarotene cap 75
mg
3
X •
SUTENT – sunitinib malate cap 25
2
X • •
TASIGNA – nilotinib hcl cap 150
2
X • •
SUTENT – sunitinib malate cap
2
X • •
TASIGNA – nilotinib hcl cap 200
2
X • •
SUTENT – sunitinib malate cap 50
2
X • •
TEMODAR – temozolomide cap 5
mg
3
X •
X
TEMODAR – temozolomide cap 20 3
mg
3
TEMODAR – temozolomide cap
100 mg
3
140 mg
3
180 mg
3
250 mg
1
temozolomide cap 5 mg
(Temodar)
1
(Temodar)
1
(Temodar)
1
(Temodar)
1
(Temodar)
1
(Temodar)
1
tretinoin cap 10 mg
X •
SYLATRON – peginterferon alfa-2b 2
for inj kit 200 mcg
for inj kit 300 mcg
for inj kit 600 mcg
3
SYNRIBO – omacetaxine
mepesuccinate for inj 3.5 mg
TABLOID – thioguanine tab 40 mg 2
X
X
X •
TAFINLAR – dabrafenib mesylate
2
X • •
TAFINLAR – dabrafenib mesylate
2
X • •
TAGRISSO – osimertinib mesylate
2
X • •
TAGRISSO – osimertinib mesylate
2
X • •
tamoxifen citrate tab 10 mg
(base equivalent)
1
tamoxifen citrate tab 20 mg
(base equivalent)
TARCEVA – erlotinib hcl tab 25 mg
(base equivalent)
KEY
1
2
X • •
Tier
•
*
Responsible Steps
STIVARGA – regorafenib tab 40
mg
Quantity Limits
2
Prior Authorization
X • •
X • •
X • •
Drug Name
Specialty/Tier 4
2
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
X •
X •
X •
X •
X •
X •
X •
X •
X •
X •
X •
21
TREXALL – methotrexate sodium
3
CORTEF – hydrocortisone tab 20
mg
3
tab 7.5 mg (base equiv)
3
CORTISONE ACETATE –
cortisone acetate tab 25 mg
3
3
DEXAMETHASONE –
dexamethasone soln 0.5 mg/5ml
2
3
2
TYKERB – lapatinib ditosylate tab
250 mg (base equiv)
2
X • •
DEXAMETHASONE –
dexamethasone tab 1 mg
2
VOTRIENT – pazopanib hcl tab
200 mg (base equiv)
2
X • •
DEXAMETHASONE –
dexamethasone elixir 0.5 mg/5ml
1
XALKORI – crizotinib cap 200 mg
2
XALKORI – crizotinib cap 250 mg
2
XELODA – capecitabine tab 150
mg
3
X • •
X • •
X • •
XELODA – capecitabine tab 500
mg
3
X • •
XTANDI – enzalutamide cap 40 mg
2
ZELBORAF – vemurafenib tab 240
mg
2
X • •
X • •
ZOLINZA – vorinostat cap 100 mg
2
ZYDELIG – idelalisib tab 100 mg
2
ZYDELIG – idelalisib tab 150 mg
2
ZYKADIA – ceritinib cap 150 mg
2
ZYTIGA – abiraterone acetate tab
250 mg
2
X
X
X
X
X
•
•
•
•
•
HORMONES, DIABETES AND RELATED DRUGS
CORTICOSTEROIDS
budesonide delayed release
particles cap 3 mg (Entocort ec)
1
mg
3
mg
3
KEY
•
•
•
•
•
DEXAMETHASONE INTENSOL –
dexamethasone conc 1 mg/ml
3
dexamethasone tab 0.5 mg
1
1
3
DEXPAK 6 DAY – dexamethasone
tab therapy pack 1.5 mg (21)
3
ENTOCORT EC – budesonide
delayed release particles cap 3
mg
3
fludrocortisone acetate tab
0.1 mg
1
1
hydrocortisone tab 10 mg
(Cortef)
1
hydrocortisone tab 20 mg
(Cortef)
1
•
*
Responsible Steps
1
DEXPAK 13 DAY –
dexamethasone tab therapy pack
1.5 mg (51)
Quantity Limits
1
3
Tier
1
DEXPAK 10 DAY –
dexamethasone tab therapy pack
1.5 mg (35)
hydrocortisone tab 5 mg (Cortef)
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
22
MEDROL – methylprednisolone tab 3
2 mg
4 mg
8 mg
16 mg
32 mg
3
MEDROL DOSEPAK –
methylprednisolone tab therapy
pack 4 mg (21)
1
methylprednisolone tab therapy
pack 4 mg (21) (Medrol
dosepak)
1
methylprednisolone tab 4 mg
(Medrol)
1
(Medrol)
1
(Medrol)
1
(Medrol)
3
MILLIPRED – prednisolone tab 5
mg
3
MILLIPRED – prednisolone sod
phosphate oral soln 10 mg/5ml
(base equiv)
MILLIPRED DP – prednisolone tab 3
therapy pack 5 mg (21)
MILLIPRED DP – prednisolone tab 3
3
ORAPRED ODT – prednisolone
sod phos orally disintegr tab 10
mg (base eq)
KEY
mg (base eq)
3
mg (base eq)
3
PEDIAPRED – prednisolone sod
phosph oral soln 6.7 mg/5ml (5
mg/5ml base)
3
prednisolone sod phos orally
disintegr tab 10 mg (base eq)
(Orapred odt)
1
(Orapred odt)
1
(Orapred odt)
1
prednisolone sod phosph oral
soln 6.7 mg/5ml (5 mg/5ml
base) (Pediapred)
1
prednisolone sod phosphate
oral soln 15 mg/5ml (base
equiv)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
1
PREDNISOLONE SODIUM
PHOSP – prednisolone sodium
(base eq)
3
prednisolone syrup 15 mg/5ml
(usp solution equivalent)
1
PREDNISONE – prednisone tab 50 2
mg
2
PREDNISONE – prednisone oral
soln 5 mg/5ml
3
PREDNISONE – prednisone tab
3
Tier
•
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
23
3
ANDROID – methyltestosterone
cap 10 mg
3
•
3
ANDROXY – fluoxymesterone tab
10 mg
3
•
PREDNISONE INTENSOL –
prednisone conc 5 mg/ml
3
danazol cap 50 mg
1
prednisone tab 1 mg
1
prednisone tab 2.5 mg
prednisone tab 5 mg
prednisone tab 10 mg
prednisone tab 20 mg
danazol cap 200 mg
1
1
1
1
UCERIS – budesonide tab sr 24hr
9 mg
3
VERIPRED 20 – prednisolone sod
(base equiv)
3
MALE HORMONES
danazol cap 100 mg
1
1
DEPO-TESTOSTERONE –
testosterone cypionate im inj in
oil 100 mg/ml
3
• •
DEPO-TESTOSTERONE –
testosterone cypionate im inj in
oil 200 mg/ml
3
• •
METHITEST – methyltestosterone
oral tab 10 mg
3
•
methyltestosterone cap 10 mg
(Testred)
1
•
OXANDRIN – oxandrolone tab 2.5
mg
3
ANADROL-50 – oxymetholone tab
50 mg
3
ANDRODERM – testosterone td
patch 24hr 2 mg/24hr
2
• •
OXANDRIN – oxandrolone tab 10
mg
3
ANDRODERM – testosterone td
patch 24hr 4 mg/24hr
2
• •
oxandrolone tab 2.5 mg
(Oxandrin)
1
ANDROGEL – testosterone td gel
25 mg/2.5gm (1%)
3
• •
oxandrolone tab 10 mg
(Oxandrin)
1
50 mg/5gm (1%)
3
• •
1
• •
20.25 mg/1.25gm (1.62%)
2
• •
testosterone cypionate im
inj in oil 100 mg/ml (Depotestosterone)
1
• •
40.5 mg/2.5gm (1.62%)
2
• •
testosterone cypionate im
inj in oil 200 mg/ml (Depotestosterone)
• •
testosterone enanthate im inj in
oil 200 mg/ml
1
ANDROGEL PUMP – testosterone
td gel 12.5 mg/act (1%)
3
• •
2
• •
1
ANDROGEL PUMP – testosterone
td gel 20.25 mg/act (1.62%)
testosterone td gel 25 mg/2.5gm
(1%) (Androgel)
• •
1
• •
KEY
testosterone td gel 50 mg/5gm
(1%) (Androgel)
Tier
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
24
testosterone td gel 12.5 mg/act
(1%) (Androgel pump)
ESTROGENS
1
COMBIPATCH – estradiolnorethindrone ace td pttw
0.05-0.14 mg/day
3
ACTIVELLA – estradiol &
norethindrone acetate tab 0.5-0.1
mg
3
COMBIPATCH – estradiolnorethindrone ace td pttw
0.05-0.25 mg/day
3
ACTIVELLA – estradiol &
norethindrone acetate tab 1-0.5
mg
3
DIVIGEL – estradiol td gel 0.25
mg/0.25gm (0.1%)
2
•
•
3
•
2
ALORA – estradiol td patch twice
weekly 0.025 mg/24hr
DIVIGEL – estradiol td gel 0.5
mg/0.5gm (0.1%)
3
•
•
weekly 0.05 mg/24hr
3
•
weekly 0.1 mg/24hr
3
•
ANGELIQ – drospirenone-estradiol
tab 0.25-0.5 mg
3
ANGELIQ – drospirenone-estradiol
tab 0.5-1 mg
3
CLIMARA – estradiol td patch
3
•
weekly 0.0375 mg/24hr (37.5
mcg/24hr)
3
•
DIVIGEL – estradiol td gel 1 mg/gm 2
(0.1%)
3
DUAVEE – conjugated estrogensbazedoxifene tab 0.45-20 mg
3
ELESTRIN – estradiol gel 0.06%
(0.52 mg/0.87 gm metered-dose
pump)
1
esterified estrogens &
methyltestosterone tab
0.625-1.25 mg
1
esterified estrogens &
methyltestosterone tab
1.25-2.5 mg
3
ESTRACE – estradiol tab 0.5 mg
weekly 0.05 mg/24hr
3
•
weekly 0.06 mg/24hr
3
•
3
weekly 0.1 mg/24hr
3
CLIMARA PRO – estradiollevonorgestrel td patch weekly
0.045-0.015 mg/day
2
KEY
ESTRACE – estradiol tab 1 mg
3
ESTRACE – estradiol tab 2 mg
3
estradiol & norethindrone
acetate tab 0.5-0.1 mg
(Activella)
1
•
estradiol & norethindrone
acetate tab 1-0.5 mg (Activella)
1
•
estradiol tab 1 mg (Estrace)
•
estradiol tab 0.5 mg (Estrace)
estradiol tab 2 mg (Estrace)
estradiol td patch twice weekly
0.025 mg/24hr (Vivelle-dot)
Tier
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
• •
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
•
1
1
1
1
•
25
•
1
•
1
•
estradiol td patch weekly
0.0375 mg/24hr (37.5 mcg/24hr)
(Climara)
1
•
0.05 mg/24hr (Climara)
1
•
1
•
1
•
1
•
ESTROGEL – estradiol gel 0.06%
(0.75 mg/1.25 gm metered-dose
pump)
2
•
ESTROPIPATE – estropipate tab
0.75 mg
3
ESTROPIPATE – estropipate tab
1.5 mg
3
ESTROPIPATE – estropipate tab 3
mg
3
EVAMIST – estradiol transdermal
spray 1.53 mg/spray
3
FEMHRT LOW DOSE –
norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg
3
•
MENEST – esterified estrogens tab 2
0.3 mg
KEY
Tier
•
*
Responsible Steps
1
Quantity Limits
•
0.625 mg
1.25 mg
2.5 mg
3
MENOSTAR – estradiol td patch
weekly 14 mcg/24hr
3
MINIVELLE – estradiol td patch
twice weekly 0.025 mg/24hr
3
3
3
3
1
estradiol tab 0.5 mg-2.5 mcg
(Femhrt low dose)
1
estradiol tab 1 mg-5 mcg
3
PREFEST – estradiol tab 1
mg(15)/estrad-norgestimate tab
1-0.09mg(15)
2
PREMARIN – estrogens,
conjugated tab 0.3 mg
2
2
2
2
Prior Authorization
1
Drug Name
Specialty/Tier 4
•
Drug Tier
1
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
•
•
•
•
•
•
26
PREMPHASE – conj est 0.625(14)/ 2
conj est-medroxypro ac tab
0.625-5mg(14)
PREMPRO – conjugated estrogen- 2
medroxyprogest acetate tab
0.3-1.5 mg
0.45-1.5 mg
0.625-2.5 mg
0.625-5 mg
VIVELLE-DOT – estradiol td patch 3
PROGESTINS
AYGESTIN – norethindrone
acetate tab 5 mg
3
medroxyprogesterone acetate
tab 2.5 mg (Provera)
1
tab 5 mg (Provera)
tab 10 mg (Provera)
MEGACE ES – megestrol acetate
susp 625 mg/5ml
KEY
Responsible Steps
Quantity Limits
Prior Authorization
1
norethindrone acetate tab 5 mg
(Aygestin)
1
progesterone micronized cap
100 mg (Prometrium)
1
progesterone micronized cap
200 mg (Prometrium)
Specialty/Tier 4
Drug Name
megestrol acetate susp
625 mg/5ml (Megace es)
1
PROVERA – medroxyprogesterone 3
acetate tab 2.5 mg
acetate tab 5 mg
acetate tab 10 mg
•
•
•
•
•
1
1
3
BIRTH CONTROL
BEYAZ – drospirenone-ethinyl
estrad-levomefolate tab
3-0.02-0.451 mg
3
BREVICON-28 – norethindrone &
ethinyl estradiol tab 0.5 mg-35
mcg
3
CAYA – diaphragm arc-spring
3
3
CYCLESSA – desogestethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mgmg
DESOGEN – desogestrel & ethinyl 3
estradiol tab 0.15 mg-30 mcg
ELLA – ulipristal acetate tab 30 mg 2
ENCARE – nonoxynol-9 vaginal
suppos 100 mg
3
ESTROSTEP FE – norethindrone
ac-ethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg
3
FC FEMALE CONDOM – condoms 3
- female
Tier
•
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
27
FC2 FEMALE CONDOM –
condoms - female
3
FEMCAP – cervical cap 22 mm
3
3
NECON 10/11-28 – norethindroneeth estradiol tab 0.5-35/1-35 mgmcg (10/11)
3
nonoxynol-9 gel 4%
1
3
3
FEMCON FE – norethindrone &
ethinyl estradiol-fe chew tab 0.4
mg-35 mcg
3
NOR-QD – norethindrone tab 0.35
mg
NORINYL 1+35 – norethindrone &
ethinyl estradiol tab 1 mg-35 mcg
3
GENERESS FE – norethindrone &
ethinyl estradiol-fe chew tab 0.8
mg-25 mcg
3
NUVARING – etonogestrel-ethinyl
estradiol va ring 0.120-0.015
mg/24hr
2
levonorgestrel tab 1.5 mg
1
OGESTREL – norgestrel & ethinyl
estradiol tab 0.5 mg-50 mcg
3
OMNIFLEX DIAPHRAGM –
diaphragms
3
OPTIONS CONCEPTROL VAGINA
– nonoxynol-9 gel 4%
3
OPTIONS GYNOL II VAGINAL –
nonoxynol-9 gel 3%
3
oral contraceptives –
all generics
1
LO LOESTRIN FE – norethin-eth
estradiol-fe tab 1 mg-10 mcg
(24)/10 mcg (2)
3
LOESTRIN FE 1.5/30 –
norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg
3
LOESTRIN FE 1/20 –
norethindrone ace & ethinyl
estradiol-fe tab 1 mg-20 mcg
3
LOSEASONIQUE – levonorg-eth
est tab 0.1-0.02mg(84) & eth est
tab 0.01mg(7)
3
MINASTRIN 24 FE – norethindrone 3
ace-eth estradiol-fe chew tab 1
mg-20 mcg (24)
3
MODICON – norethindrone &
ethinyl estradiol tab 0.5 mg-35
mcg
3
NATAZIA – estradiol valeratedienogest tab 3 mg /2-2 mg/2-3
mg/1 mg
NECON 1/50-28 – norethindrone & 3
mestranol tab 1 mg-50 mcg
KEY
ORTHO DIAPHRAGM COIL SPRI
– diaphragm coil spring kit 50
mm
3
mm
3
mm
3
ORTHO DIAPHRAGM FLAT SPRI
– diaphragm flat spring kit 55 mm
3
3
3
Tier
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
28
3
PRENTIF CAVITY-RIM CERVIC –
cervical cap 28 mm
3
3
cervical cap 31 mm
3
3
PRENTIF FITTING SET – cervical
caps
3
3
3
3
QUARTETTE – levonor-eth est tab
0.15-0.02/0.025/0.03 mg &eth est
0.01 mg
3
3
SAFYRAL – drospirenoneethinyl estrad-levomefolate tab
3-0.03-0.451 mg
ORTHO MICRONOR –
norethindrone tab 0.35 mg
3
3
ORTHO TRI-CYCLEN –
norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mgmcg
3
SEASONIQUE – levonorg-eth est
tab 0.15-0.03mg(84) & eth est
tab 0.01mg(7)
ORTHO TRI-CYCLEN LO –
norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mgmcg
3
ORTHO-CYCLEN – norgestimate
& ethinyl estradiol tab 0.25
mg-35 mcg
3
ORTHO-NOVUM 1/35 –
norethindrone & ethinyl estradiol
tab 1 mg-35 mcg
3
ORTHO-NOVUM 7/7/7 –
norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg
3
PLAN B ONE-STEP –
levonorgestrel tab 1.5 mg
3
cervical cap 22 mm
3
cervical cap 25 mm
3
KEY
Responsible Steps
Quantity Limits
SHUR-SEAL – nonoxynol-9 gel 2% 3
3
TODAY SPONGE – nonoxynol-9
vaginal sponge 1000 mg
3
TRI-NORINYL 28 –
norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg
3
VCF VAGINAL CONTRACEPTIVE
– nonoxynol-9 foam 12.5%
3
VCF VAGINAL CONTRACEPTIVE
– nonoxynol-9 film 28%
WIDE-SEAL SILICONE DIAPHR – 3
diaphragm wide seal 60 mm
Tier
•
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
29
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
WIDE-SEAL SILICONE DIAPHR –
3
ACTOS – pioglitazone hcl tab 45
mg (base equiv)
3
WIDE-SEAL SILICONE DIAPHR –
3
ALOGLIPTIN – alogliptin benzoate
3
• •
XULANE – norelgestrominethinyl estradiol td ptwk 150-35
mcg/24hr
3
3
• •
3
3
YASMIN 28 – drospirenone-ethinyl
estradiol tab 3-0.03 mg
• •
ALOGLIPTIN/METFORMIN HCL
– alogliptin-metformin hcl tab
12.5-500 mg
3
YAZ – drospirenone-ethinyl
estradiol tab 3-0.02 mg
3
• •
ZOVIA 1/50E – ethynodiol
diacetate & ethinyl estradiol tab 1
mg-50 mcg
3
ALOGLIPTIN/METFORMIN HCL
– alogliptin-metformin hcl tab
12.5-1000 mg
3
• •
ALOGLIPTIN/PIOGLITAZONE
– alogliptin-pioglitazone tab
12.5-15 mg
3
• •
12.5-30 mg
3
• •
12.5-45 mg
3
• •
ALOGLIPTIN/PIOGLITAZONE –
alogliptin-pioglitazone tab 25-15
mg
3
• •
INFERTILITY
BRAVELLE – urofollitropin purified
for inj 75 unit
DIABETES
acarbose tab 25 mg (Precose)
2
1
1
1
ACTOPLUS MET – pioglitazone
hcl-metformin hcl tab 15-500 mg
3
ACTOPLUS MET – pioglitazone
hcl-metformin hcl tab 15-850 mg
3
ACTOPLUS MET XR –
pioglitazone hcl-metformin hcl
tab sr 24hr 15-1000 mg
3
mg
3
• •
ACTOPLUS MET XR –
3
mg
3
• •
mg (base equiv)
3
AMARYL – glimepiride tab 1 mg
3
3
mg (base equiv)
3
3
AVANDIA – rosiglitazone maleate
3
KEY
Tier
•
*
30
AVANDIA – rosiglitazone maleate
3
BYDUREON – exenatide extended
release for susp pen-injector 2
mg
2
• •
BYDUREON – exenatide for inj
extended release susp 2 mg
2
• •
glipizide-metformin hcl tab
2.5-500 mg
BYETTA – exenatide soln peninjector 5 mcg/0.02ml
2
• •
5-500 mg
BYETTA – exenatide soln peninjector 10 mcg/0.04ml
2
• •
3
CHLORPROPAMIDE –
chlorpropamide tab 100 mg
3
GLUCAGEN HYPOKIT – glucagon
hcl (rdna) for inj 1 mg (base
equiv)
2
CHLORPROPAMIDE –
chlorpropamide tab 250 mg
3
GLUCAGON EMERGENCY KIT –
glucagon (rdna) for inj kit 1 mg
3
CYCLOSET – bromocriptine
mesylate tab 0.8 mg (base
equivalent)
3
GLUCOPHAGE – metformin hcl
tab 500 mg
tab 850 mg
3
DUETACT – pioglitazone hclglimepiride tab 30-2 mg
3
tab 1000 mg
3
DUETACT – pioglitazone hclglimepiride tab 30-4 mg
3
GLUCOPHAGE XR – metformin
hcl tab sr 24hr 500 mg
3
FARXIGA – dapagliflozin
propanediol tab 5 mg (base
equivalent)
3
GLUCOPHAGE XR – metformin
hcl tab sr 24hr 750 mg
3
GLUCOTROL – glipizide tab 5 mg
3
FARXIGA – dapagliflozin
propanediol tab 10 mg (base
equivalent)
3
glimepiride tab 1 mg (Amaryl)
1
• •
• •
1
1
glipizide tab sr 24hr 2.5 mg
(Glucotrol xl)
1
glipizide tab sr 24hr 5 mg
(Glucotrol xl)
1
glipizide tab sr 24hr 10 mg
(Glucotrol xl)
1
KEY
glipizide tab 5 mg (Glucotrol)
glipizide tab 10 mg (Glucotrol)
2.5-250 mg
Responsible Steps
Quantity Limits
1
1
1
1
1
GLUCOTROL – glipizide tab 10 mg 3
GLUCOTROL XL – glipizide tab sr 3
24hr 2.5 mg
24hr 5 mg
24hr 10 mg
3
GLUCOVANCE – glyburidemetformin tab 1.25-250 mg
3
GLUCOVANCE – glyburidemetformin tab 2.5-500 mg
Tier
•
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
31
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
GLUCOVANCE – glyburidemetformin tab 5-500 mg
3
INVOKAMET – canagliflozinmetformin hcl tab 150-500 mg
2
• •
glyburide micronized tab 1.5 mg
(Glynase)
1
2
• •
glyburide micronized tab 3 mg
(Glynase)
1
INVOKANA – canagliflozin tab 100
mg
2
• •
glyburide micronized tab 6 mg
(Glynase)
1
INVOKANA – canagliflozin tab 300
mg
2
• •
glyburide tab 1.25 mg
1
JANUMET – sitagliptin-metformin
hcl tab 50-500 mg
2
• •
JANUMET – sitagliptin-metformin
hcl tab 50-1000 mg
2
• •
JANUMET XR – sitagliptinmetformin hcl tab sr 24hr 50-500
mg
2
• •
JANUMET XR – sitagliptinmetformin hcl tab sr 24hr
50-1000 mg
2
• •
2
• •
glyburide tab 2.5 mg
glyburide tab 5 mg
glyburide-metformin tab
1.25-250 mg (Glucovance)
2.5-500 mg (Glucovance)
5-500 mg (Glucovance)
1
1
1
1
1
GLYNASE – glyburide micronized
tab 1.5 mg
3
tab 3 mg
3
JANUMET XR – sitagliptinmetformin hcl tab sr 24hr
100-1000 mg
JANUVIA – sitagliptin phosphate
2
tab 6 mg
3
• •
2
2
GLYSET – miglitol tab 25 mg
• •
2
2
• •
2
GLYXAMBI – empagliflozinlinagliptin tab 10-5 mg
3
• •
JENTADUETO – linagliptinmetformin hcl tab 2.5-500 mg
3
• •
GLYXAMBI – empagliflozinlinagliptin tab 25-5 mg
3
• •
3
• •
2
• •
3
• •
2
• •
KAZANO – alogliptin-metformin hcl
tab 12.5-500 mg
3
• •
KAZANO – alogliptin-metformin hcl
tab 12.5-1000 mg
3
• •
KEY
Tier
•
*
32
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
OSENI – alogliptin-pioglitazone tab
12.5-15 mg
3
• •
12.5-30 mg
3
• •
12.5-45 mg
3
• •
25-15 mg
3
• •
25-30 mg
3
• •
1
25-45 mg
3
• •
metformin hcl tab sr 24hr 750 mg
(Glucophage xr)
1
pioglitazone hcl tab 15 mg (base
equiv) (Actos)
1
metformin hcl tab 500 mg
(Glucophage)
1
equiv) (Actos)
(Glucophage)
1
equiv) (Actos)
(Glucophage)
1
pioglitazone hcl-glimepiride tab
30-2 mg (Duetact)
miglitol tab 25 mg (Glyset)
1
pioglitazone hcl-glimepiride tab
30-4 mg (Duetact)
KOMBIGLYZE XR – saxagliptinmetformin hcl tab sr 24hr
2.5-1000 mg
2
KOMBIGLYZE XR – saxagliptinmetformin hcl tab sr 24hr 5-500
mg
2
KOMBIGLYZE XR – saxagliptinmetformin hcl tab sr 24hr 5-1000
mg
2
KORLYM – mifepristone tab 300
mg
3
metformin hcl tab sr 24hr 500 mg
(Glucophage xr)
nateglinide tab 60 mg (Starlix)
nateglinide tab 120 mg (Starlix)
• •
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
• •
• •
X • •
1
tab 15-500 mg (Actoplus met)
1
1
tab 15-850 mg (Actoplus met)
1
1
1
1
1
PRANDIN – repaglinide tab 0.5 mg
3
• •
PRANDIN – repaglinide tab 1 mg
3
PRANDIN – repaglinide tab 2 mg
3
PRECOSE – acarbose tab 25 mg
3
3
3
PROGLYCEM – diazoxide susp 50
mg/ml
2
repaglinide tab 0.5 mg (Prandin)
1
3
NESINA – alogliptin benzoate tab
3
25 mg (base equiv)
3
• •
ONGLYZA – saxagliptin hcl tab 2.5
mg (base equiv)
2
• •
ONGLYZA – saxagliptin hcl tab 5
mg (base equiv)
2
• •
Tier
•
1
• •
KEY
1
*
33
repaglinide tab 1 mg (Prandin)
repaglinide tab 2 mg (Prandin)
1
1
REPAGLINIDE/METFORMIN HYD
– repaglinide-metformin hcl tab
1-500 mg
3
REPAGLINIDE/METFORMIN HYD
– repaglinide-metformin hcl tab
2-500 mg
3
RIOMET – metformin hcl oral soln
500 mg/5ml
3
STARLIX – nateglinide tab 60 mg
3
STARLIX – nateglinide tab 120 mg
3
SYMLINPEN 120 – pramlintide
acetate pen-inj 2700 mcg/2.7ml
(1000 mcg/ml)
2
SYMLINPEN 60 – pramlintide
acetate pen-inj 1500 mcg/1.5ml
(1000 mcg/ml)
2
TANZEUM – albiglutide for soln
pen-injector 30 mg
3
• •
TANZEUM – albiglutide for soln
pen-injector 50 mg
3
• •
TOLAZAMIDE – tolazamide tab
250 mg
3
TOLAZAMIDE – tolazamide tab
500 mg
3
TOLBUTAMIDE – tolbutamide tab
500 mg
3
TRADJENTA – linagliptin tab 5 mg
3
TRULICITY – dulaglutide soln peninjector 0.75 mg/0.5ml
3
• •
• •
TRULICITY – dulaglutide soln peninjector 1.5 mg/0.5ml
3
VICTOZA – liraglutide soln peninjector 18 mg/3ml (6 mg/ml)
2
KEY
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
XIGDUO XR – dapagliflozinmetformin hcl tab sr 24hr 5-500
mg
3
• •
mg
3
• •
mg
3
• •
XIGDUO XR – dapagliflozinmetformin hcl tab sr 24hr
10-1000 mg
3
• •
Insulins
Rapid-Acting Insulins
APIDRA – insulin glulisine inj 100
unit/ml
3
•
APIDRA SOLOSTAR – insulin
glulisine soln pen-injector inj 100
unit/ml
3
•
NOVOLOG – insulin aspart inj 100
unit/ml
2
NOVOLOG FLEXPEN – insulin
aspart soln pen-injector 100 unit/
ml
2
NOVOLOG PENFILL – insulin
aspart soln cartridge 100 unit/ml
2
Short-Acting Insulins
HUMULIN R U-500 (CONCENTR
– insulin regular (human) inj 500
unit/ml
3
3
• •
HUMULIN R U-500 KWIKPEN –
insulin regular (human) soln peninjector 500 unit/ml
• •
NOVOLIN R – insulin regular
(human) inj 100 unit/ml
2
Intermediate-Acting Insulins
Tier
•
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
34
NOVOLIN N – insulin nph (human)
(isophane) inj 100 unit/ml
2
ARMOUR THYROID – thyroid tab
60 mg (1 grain)
3
NOVOLIN 70/30 – insulin nph
isophane & regular human inj
100 unit/ml (70-30)
2
90 mg (1 1/2 grain)
3
120 mg (2 grain)
3
NOVOLOG MIX 70/30 – insulin
aspart prot & aspart (human) inj
100 unit/ml (70-30)
2
3
NOVOLOG MIX 70/30 PREFILL –
insulin aspart prot & aspart sus
pen-inj 100 unit/ml (70-30)
2
180 mg (3 grain)
240 mg (4 grain)
3
300 mg (5 grain)
3
CYTOMEL – liothyronine sodium
tab 5 mcg
3
tab 25 mcg
3
Basal Insulins
LANTUS – insulin glargine inj 100
unit/ml
2
LANTUS SOLOSTAR – insulin
glargine soln pen-injector 100
unit/ml
2
LEVEMIR – insulin detemir inj 100
unit/ml
2
tab 50 mcg
3
LEVEMIR FLEXTOUCH – insulin
detemir soln pen-injector 100
unit/ml
2
levothyroxine sodium tab
25 mcg (Synthroid)
1
TOUJEO SOLOSTAR – insulin
glargine soln pen-injector 300
unit/ml
2
TRESIBA FLEXTOUCH – insulin
degludec soln pen-injector 100
unit/ml
2
TRESIBA FLEXTOUCH – insulin
degludec soln pen-injector 200
unit/ml
2
THYROID REGULATION
50 mcg (Synthroid)
75 mcg (Synthroid)
88 mcg (Synthroid)
100 mcg (Synthroid)
112 mcg (Synthroid)
15 mg (1/4 grain)
3
125 mcg (Synthroid)
30 mg (1/2 grain)
3
137 mcg (Synthroid)
KEY
150 mcg (Synthroid)
Tier
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
1
1
1
1
1
1
1
1
35
175 mcg (Synthroid)
200 mcg (Synthroid)
1
NATURE-THROID – thyroid tab
325 mg (5 grain)
3
1
146.25 mg
3
1
liothyronine sodium tab 5 mcg
(Cytomel)
1
NATURE-THROID NT-2.5 – thyroid 3
tab 162.5 mg (2 1/2 grain)
1
propylthiouracil tab 50 mg
1
SYNTHROID – levothyroxine
sodium tab 25 mcg
3
(Cytomel)
sodium tab 50 mcg
3
(Cytomel)
1
sodium tab 75 mcg
3
methimazole tab 5 mg (Tapazole)
1
300 mcg (Synthroid)
methimazole tab 10 mg
(Tapazole)
1
sodium tab 88 mcg
3
16.25 mg
3
sodium tab 100 mcg
3
32.5 mg
3
sodium tab 112 mcg
3
48.75 mg (3/4 grain)
3
sodium tab 125 mcg
3
NATURE-THROID – thyroid tab 65
mg
3
sodium tab 137 mcg
3
81.25 mg
3
sodium tab 150 mcg
3
97.5 mg
3
sodium tab 175 mcg
3
113.75 mg
3
sodium tab 200 mcg
3
130 mg
3
sodium tab 300 mcg
3
195 mg
3
TAPAZOLE – methimazole tab 5
mg
3
260 mg
3
TAPAZOLE – methimazole tab 10
mg
3
KEY
Tier
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
36
thyroid tab 30 mg (1/2 grain)
(Armour thyroid)
1
WESTHROID – thyroid tab 32.5
mg
3
thyroid tab 60 mg (1 grain)
(Armour thyroid)
1
WESTHROID – thyroid tab 65 mg
3
WESTHROID – thyroid tab 97.5
mg
3
thyroid tab 90 mg (1 1/2 grain)
(Armour thyroid)
1
2
3
THYROLAR-1 – liotrix (t3-t4) tab
60 mg (12.5-50 mcg)
3
THYROLAR-1/2 – liotrix (t3-t4) tab
30 mg (6.25-25 mcg)
2
WP THYROID – thyroid tab 16.25
mg
3
THYROLAR-1/4 – liotrix (t3-t4) tab
15 mg (3.1-12.5 mcg)
2
mg
3
120 mg (25-100 mcg)
2
mg (3/4 grain)
3
180 mg (37.5-150 mcg)
2
WP THYROID – thyroid tab 65 mg
3
3
TIROSINT – levothyroxine sodium
cap 13 mcg
3
mg
3
cap 25 mcg
3
mg
3
cap 50 mcg
3
mg
3
cap 75 mcg
3
WP THYROID – thyroid tab 130
mg
cap 88 mcg
3
EGRIFTA – tesamorelin acetate for
inj 1 mg (base equiv)
3
X •
cap 100 mcg
3
EGRIFTA – tesamorelin acetate for
3
X •
cap 112 mcg
3
GENOTROPIN – somatropin for
subcutaneous inj 5 mg
3
X •
cap 125 mcg
3
GENOTROPIN – somatropin for inj
12 mg (13.8 mg overfill)
3
X •
cap 137 mcg
3
GENOTROPIN MINIQUICK –
somatropin for inj 0.2 mg
3
X •
cap 150 mcg
3
3
X •
KEY
GROWTH HORMONE
Tier
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
37
3
X •
X •
NUTROPIN AQ NUSPIN 20 –
somatropin inj 20 mg/2ml
3
X •
somatropin for inj 1 mg
3
X •
3
X •
3
X •
NUTROPIN AQ PEN – somatropin
inj 10 mg/2ml
3
X •
3
X •
OMNITROPE – somatropin inj 5
mg/1.5ml
3
X •
3
X •
OMNITROPE – somatropin inj 10
mg/1.5ml
3
X •
3
X •
OMNITROPE – somatropin for inj
5.8 mg
3
X •
3
X •
SAIZEN – somatropin (nonrefrigerated) for inj 5 mg
3
X •
HUMATROPE – somatropin for inj
5 mg
3
X •
SAIZEN – somatropin (nonrefrigerated) for inj 8.8 mg
3
X •
6 mg (18 unit)
3
X •
SAIZEN CLICK.EASY –
somatropin (non-refrigerated) for
inj 8.8 mg
3
X •
12 mg (36 unit)
3
X •
SEROSTIM – somatropin (nonrefrigerated) for subcutaneous inj
4 mg
3
X •
24 mg
3
X •
HUMATROPE COMBO PACK –
3
X •
5 mg
3
X •
INCRELEX – mecasermin inj 40
mg/4ml (10 mg/ml)
2
X •
3
X •
X •
6 mg
NORDITROPIN FLEXPRO –
somatropin inj 5 mg/1.5ml
2
2
X •
ZOMACTON – somatropin for
3
X •
2
X •
ZOMACTON – somatropin for inj
10 mg
3
X •
2
X •
ZORBTIVE – somatropin (nonrefrigerated) for subcutaneous inj
8.8 mg
3
X •
KEY
Tier
•
*
Responsible Steps
Quantity Limits
3
Prior Authorization
Drug Name
Specialty/Tier 4
X •
Drug Tier
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
38
OTHER HORMONES AND RELATED DRUGS
3
ACTONEL – risedronate sodium
tab 5 mg
3
tab 30 mg
3
tab 35 mg
3
tab 150 mg
3
ALENDRONATE SODIUM –
alendronate sodium oral soln 70
mg/75ml
3
ALENDRONATE SODIUM –
alendronate sodium tab 40 mg
1
• •
• •
• •
• •
• •
• •
(Fosamax)
1
•
•
•
•
ATELVIA – risedronate sodium tab
3
• •
BINOSTO – alendronate sodium
effervescent tab 70 mg
3
• •
BONIVA – ibandronate sodium tab
3
• •
BUPHENYL – sodium
phenylbutyrate tab 500 mg
3
X • •
BUPHENYL – sodium
phenylbutyrate oral powder 3 gm/
teaspoonful
3
X • •
cabergoline tab 0.5 mg
1
calcitonin (salmon) nasal soln
200 unit/act (Miacalcin)
calcitriol cap 0.25 mcg (Rocaltrol)
calcitriol cap 0.5 mcg (Rocaltrol)
KEY
1
1
1
1
1
calcitriol oral soln 1 mcg/ml
(Rocaltrol)
1
CARBAGLU – carglumic acid tab
200 mg
3
CARNITOR – levocarnitine tab 330
mg
3
CARNITOR – levocarnitine oral
soln 1 gm/10ml (10%)
3
CARNITOR SF – levocarnitine oral
soln 1 gm/10ml (10%)
3
CYSTADANE – betaine powder for
oral solution
3
DDAVP – desmopressin acetate
nasal soln 0.01% (refrigerated)
3
nasal spray soln 0.01%
3
tab 0.1 mg
3
tab 0.2 mg
3
DDAVP – desmopressin acetate inj
4 mcg/ml
3
desmopressin acetate inj 4 mcg/
ml (Ddavp)
1
desmopressin acetate nasal soln
0.01% (refrigerated) (Ddavp)
desmopressin acetate nasal
spray soln 0.01% (Ddavp)
desmopressin acetate nasal
spray soln 0.01% (refrigerated)
1
doxercalciferol cap 0.5 mcg
(Hectorol)
1
•
Responsible Steps
Quantity Limits
Prior Authorization
1
desmopressin acetate tab 0.2 mg
(Ddavp)
X •
1
1
*
X
1
desmopressin acetate tab 0.1 mg
(Ddavp)
Specialty/Tier 4
Drug Name
Tier
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
39
doxercalciferol cap 1 mcg
(Hectorol)
1
doxercalciferol cap 2.5 mcg
(Hectorol)
3
1
KUVAN – sapropterin
dihydrochloride powder packet
500 mg
1
ETIDRONATE DISODIUM –
etidronate disodium tab 200 mg
3
levocarnitine oral soln
1 gm/10ml (10%) (Carnitor)
1
ETIDRONATE DISODIUM –
etidronate disodium tab 400 mg
3
levocarnitine tab 330 mg
(Carnitor)
1
EVISTA – raloxifene hcl tab 60 mg
3
methylergonovine maleate tab
0.2 mg
FORTEO – teriparatide
(recombinant) inj 600 mcg/2.4ml
2
FORTICAL – calcitonin (salmon)
nasal soln 200 unit/act
3
FOSAMAX – alendronate sodium
tab 70 mg
3
FOSAMAX PLUS D – alendronate
sodium-cholecalciferol tab
70-2800 mg-unit
FOSAMAX PLUS D – alendronate
sodium-cholecalciferol tab
70-5600 mg-unit
3
MIACALCIN – calcitonin (salmon)
nasal soln 200 unit/act
3
• •
MYALEPT – metreleptin for
subcutaneous inj 11.3 mg
3
X • •
3
• •
NATPARA – parathyroid hormone
(recombinant) for inj cartridge 25
mcg
3
X •
3
• •
mcg
3
X •
mcg
3
X •
(recombinant) for inj cartridge
100 mcg
3
X •
octreotide acetate inj 50 mcg/ml
(0.05 mg/ml) (Sandostatin)
1
X
1
X
1
X
1
X
1
X
X •
X • •
•
X •
X •
octreotide acetate inj 1000 mcg/
ml (1 mg/ml) (Sandostatin)
Tier
•
*
Responsible Steps
Quantity Limits
X •
MIACALCIN – calcitonin (salmon)
inj 200 unit/ml
H.P. ACTHAR – corticotropin inj gel 3
80 unit/ml
3
HECTOROL – doxercalciferol cap
0.5 mcg
3
1 mcg
3
2.5 mcg
1
ibandronate sodium tab 150 mg
(base equivalent) (Boniva)
2
dihydrochloride soluble tab 100
mg
3
dihydrochloride powder packet
100 mg
KEY
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
40
ORFADIN – nitisinone susp 4 mg/
ml
2
ORFADIN – nitisinone cap 2 mg
2
2
2
OSPHENA – ospemifene tab 60
mg
3
paricalcitol cap 1 mcg (Zemplar)
1
paricalcitol cap 2 mcg (Zemplar)
paricalcitol cap 4 mcg
raloxifene hcl tab 60 mg (Evista)
X •
X •
X •
1
1
1
X
SANDOSTATIN – octreotide
acetate inj 200 mcg/ml (0.2 mg/
ml)
3
X
ml)
3
X
acetate inj 1000 mcg/ml (1 mg/
ml)
3
X
RAVICTI – glycerol phenylbutyrate
liquid 1.1 gm/ml
3
X • •
SENSIPAR – cinacalcet hcl tab 30
mg (base equiv)
2
•
risedronate sodium tab delayed
release 35 mg (Atelvia)
1
•
mg (base equiv)
2
•
risedronate sodium tab 5 mg
(Actonel)
1
•
mg (base equiv)
2
•
(Actonel)
1
•
3
X • •
(Actonel)
1
•
SIGNIFOR – pasireotide
diaspartate inj 0.3 mg/ml (base
equiv)
3
X • •
(Actonel)
1
•
equiv)
equiv)
3
X • •
sodium phenylbutyrate oral
powder 3 gm/teaspoonful
(Buphenyl)
1
X • •
SOMAVERT – pegvisomant for inj
10 mg (as protein)
2
X
15 mg (as protein)
2
X
20 mg (as protein)
2
X
25 mg (as protein)
2
X
ROCALTROL – calcitriol oral soln 1 3
mcg/ml
3
ROCALTROL – calcitriol cap 0.25
mcg
3
ROCALTROL – calcitriol cap 0.5
mcg
3
SAMSCA – tolvaptan tab 15 mg
SAMSCA – tolvaptan tab 30 mg
3
ml)
3
KEY
X
X
X
•
•
Tier
•
*
Responsible Steps
3
Quantity Limits
ml)
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
41
30 mg (as protein)
2
STIMATE – desmopressin acetate
nasal soln 1.5 mg/ml
2
STRENSIQ – asfotase alfa
subcutaneous inj 18 mg/0.45ml
2
X •
2
X •
subcutaneous inj 40 mg/ml
2
X •
2
X •
SYNAREL – nafarelin acetate
nasal soln 2 mg/ml (200 mcg/act)
(base eq)
2
XURIDEN – uridine triacetate oral
granules packet 2 gm
3
ZEMPLAR – paricalcitol cap 1 mcg
3
ZEMPLAR – paricalcitol cap 2 mcg
3
ACCURETIC – quinaprilhydrochlorothiazide tab 20-25 mg
3
ACEON – perindopril erbumine tab
4 mg
3
ACEON – perindopril erbumine tab
8 mg
3
ALTACE – ramipril cap 1.25 mg
3
ALTACE – ramipril cap 2.5 mg
3
ALTACE – ramipril cap 5 mg
3
ALTACE – ramipril cap 10 mg
3
1
X
benazepril &
hydrochlorothiazide tab
5-6.25 mg
X •
benazepril &
10-12.5 mg (Lotensin hct)
benazepril &
20-12.5 mg (Lotensin hct)
HEART AND CIRCULATORY DRUGS
ANGIOTENSIN CONVERTING ENZYME (ACE)
INHIBITORS AND COMBINATIONS
ACCUPRIL – quinapril hcl tab 5 mg 3
benazepril &
20-25 mg (Lotensin hct)
benazepril hcl tab 5 mg
1
1
(Lotensin)
1
ACCUPRIL – quinapril hcl tab 20
mg
3
(Lotensin)
1
mg
3
(Lotensin)
1
ACCURETIC – quinaprilhydrochlorothiazide tab 10-12.5
mg
3
captopril tab 12.5 mg
1
ACCURETIC – quinaprilhydrochlorothiazide tab 20-12.5
mg
3
KEY
captopril tab 100 mg
CAPTOPRIL/
HYDROCHLOROTHIA –
Tier
•
*
Responsible Steps
1
3
captopril tab 50 mg
Quantity Limits
1
mg
captopril tab 25 mg
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
X
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
1
1
1
2
42
3
CAPTOPRIL/
HYDROCHLOROTHIA –
captopril & hydrochlorothiazide
tab 50-15 mg
2
CAPTOPRIL/
HYDROCHLOROTHIA –
tab 50-25 mg
3
enalapril maleate &
5-12.5 mg
1
lisinopril & hydrochlorothiazide
tab 10-12.5 mg (Zestoretic)
tab 20-12.5 mg (Zestoretic)
tab 20-25 mg (Zestoretic)
lisinopril tab 2.5 mg (Zestril)
lisinopril tab 5 mg (Prinivil)
lisinopril tab 30 mg (Zestril)
lisinopril tab 40 mg (Zestril)
1
1
1
1
1
1
1
1
3
LOTENSIN – benazepril hcl tab 20
mg
3
mg
3
enalapril maleate tab 5 mg
(Vasotec)
1
3
(Vasotec)
1
LOTENSIN HCT – benazepril &
hydrochlorothiazide tab 10-12.5
mg
3
(Vasotec)
1
mg
3
hydrochlorothiazide tab 20-25 mg
3
EPANED – enalapril maleate for
oral soln 1 mg/ml
1
MAVIK – trandolapril tab 1 mg
3
fosinopril sodium &
10-12.5 mg
MAVIK – trandolapril tab 2 mg
3
moexipril hcl tab 7.5 mg
1
fosinopril sodium tab 10 mg
KEY
moexipril-hydrochlorothiazide
tab 7.5-12.5 mg
1
tab 15-12.5 mg
1
Tier
•
*
Responsible Steps
1
mg
moexipril hcl tab 15 mg
Quantity Limits
1
1
1
Prior Authorization
1
enalapril maleate tab 2.5 mg
(Vasotec)
fosinopril sodium &
20-12.5 mg
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
CAPTOPRIL/
HYDROCHLOROTHIA –
tab 25-25 mg
enalapril maleate &
10-25 mg (Vaseretic)
Specialty/Tier 4
Drug Name
tab 25-15 mg
Drug Tier
2016
1
1
1
43
tab 15-25 mg
perindopril erbumine tab 2 mg
ramipril cap 1.25 mg (Altace)
ramipril cap 2.5 mg (Altace)
ramipril cap 5 mg (Altace)
ramipril cap 10 mg (Altace)
trandolapril tab 1 mg (Mavik)
trandolapril tab 2 mg (Mavik)
trandolapril tab 4 mg
Responsible Steps
Quantity Limits
Prior Authorization
• •
ATACAND – candesartan cilexetil
tab 8 mg
3
• •
tab 16 mg
3
• •
1
tab 32 mg
3
• •
1
ATACAND HCT – candesartan
cilexetil-hydrochlorothiazide tab
16-12.5 mg
3
• •
32-12.5 mg
3
• •
32-25 mg
3
• •
AVALIDE – irbesartanhydrochlorothiazide tab 150-12.5
mg
3
• •
AVALIDE – irbesartanhydrochlorothiazide tab 300-12.5
mg
3
• •
AVAPRO – irbesartan tab 75 mg
3
3
3
•
•
•
•
amlodipine-valsartanhydrochlorothiazide tab
10-320-25 mg (Exforge hct)
1
1
1
1
1
1
1
1
1
1
1
ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS)
AND COMBINATIONS
1
•
5-160-12.5 mg (Exforge hct)
1
•
1
•
10-160-12.5 mg (Exforge hct)
KEY
Specialty/Tier 4
3
1
quinapril-hydrochlorothiazide
tab 20-25 mg (Accuretic)
Drug Tier
tab 4 mg
quinapril hcl tab 5 mg (Accupril)
tab 20-12.5 mg (Accuretic)
Responsible Steps
•
1
tab 10-12.5 mg (Accuretic)
Quantity Limits
1
1
(Aceon)
Prior Authorization
•
1
Drug Name
1
1
(Aceon)
Specialty/Tier 4
Drug Name
Drug Tier
2016
BENICAR – olmesartan medoxomil 3
tab 5 mg
tab 20 mg
Tier
•
*
•
•
•
•
• •
44
tab 40 mg
3
BENICAR HCT – olmesartan
medoxomil-hydrochlorothiazide
tab 20-12.5 mg
3
tab 40-12.5 mg
3
tab 40-25 mg
1
candesartan cilexetil tab 4 mg
(Atacand)
1
(Atacand)
1
(Atacand)
1
(Atacand)
1
candesartan cilexetilhydrochlorothiazide tab
16-12.5 mg (Atacand hct)
1
32-12.5 mg (Atacand hct)
1
32-25 mg (Atacand hct)
COZAAR – losartan potassium tab 3
25 mg
50 mg
100 mg
3
DIOVAN – valsartan tab 40 mg
3
3
KEY
Responsible Steps
Quantity Limits
3
• •
DIOVAN HCT – valsartanhydrochlorothiazide tab 80-12.5
mg
3
• •
• •
• •
mg
3
• •
• •
DIOVAN HCT – valsartanhydrochlorothiazide tab 160-25
mg
3
• •
•
mg
3
• •
DIOVAN HCT – valsartanhydrochlorothiazide tab 320-25
mg
3
• •
EDARBI – azilsartan medoxomil
tab 40 mg
3
• •
EDARBI – azilsartan medoxomil
tab 80 mg
3
• •
EDARBYCLOR – azilsartan
medoxomil-chlorthalidone tab
40-12.5 mg
3
• •
EDARBYCLOR – azilsartan
medoxomil-chlorthalidone tab
40-25 mg
3
• •
EPROSARTAN MESYLATE –
eprosartan mesylate tab 600 mg
3
• •
EXFORGE HCT – amlodipinevalsartan-hydrochlorothiazide tab
5-160-12.5 mg
3
• •
5-160-25 mg
3
• •
10-160-12.5 mg
3
• •
•
•
•
•
•
•
• •
• •
• •
• •
• •
• •
Tier
•
Prior Authorization
Drug Name
Specialty/Tier 4
• •
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
45
3
• •
HYZAAR – losartan potassium &
mg
3
• •
mg
3
• •
hydrochlorothiazide tab 100-25
mg
3
• •
irbesartan tab 75 mg (Avapro)
1
irbesartan-hydrochlorothiazide
tab 150-12.5 mg (Avalide)
irbesartan-hydrochlorothiazide
tab 300-12.5 mg (Avalide)
losartan potassium &
50-12.5 mg (Hyzaar)
100-12.5 mg (Hyzaar)
100-25 mg (Hyzaar)
1
1
1
1
1
•
1
•
•
TRIBENZOR – olmesartanamlodipine-hydrochlorothiazide
tab 20-5-12.5 mg
3
• •
•
tab 40-5-12.5 mg
3
• •
•
tab 40-5-25 mg
3
• •
tab 40-10-12.5 mg
3
• •
tab 40-10-25 mg
3
• •
valsartan tab 40 mg (Diovan)
1
•
1
•
losartan potassium tab 50 mg
(Cozaar)
1
•
(Cozaar)
1
•
telmisartan tab 40 mg (Micardis)
telmisartan-hydrochlorothiazide
tab 40-12.5 mg (Micardis hct)
tab 80-12.5 mg (Micardis hct)
tab 80-25 mg (Micardis hct)
Tier
•
• •
1
(Cozaar)
KEY
• •
1
•
1
•
•
•
•
•
•
•
•
•
•
•
•
1
MICARDIS – telmisartan tab 80 mg 3
3
MICARDIS HCT – telmisartanhydrochlorothiazide tab 40-12.5
mg
3
MICARDIS HCT – telmisartanhydrochlorothiazide tab 80-12.5
mg
3
MICARDIS HCT – telmisartanhydrochlorothiazide tab 80-25 mg
1
•
•
•
•
Responsible Steps
10-320-25 mg
Quantity Limits
• •
Prior Authorization
3
Drug Name
Specialty/Tier 4
10-160-25 mg
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
1
1
46
valsartan-hydrochlorothiazide
tab 80-12.5 mg (Diovan hct)
tab 160-25 mg (Diovan hct)
tab 320-25 mg (Diovan hct)
atenolol tab 100 mg (Tenormin)
betaxolol hcl tab 10 mg (Kerlone)
betaxolol hcl tab 20 mg (Kerlone)
bisoprolol & hydrochlorothiazide
tab 2.5-6.25 mg (Ziac)
tab 5-6.25 mg (Ziac)
tab 10-6.25 mg (Ziac)
bisoprolol fumarate tab 5 mg
(Zebeta)
KEY
•
1
•
BYSTOLIC – nebivolol hcl tab 2.5
3
BYSTOLIC – nebivolol hcl tab 5 mg 3
(base equivalent)
3
BYSTOLIC – nebivolol hcl tab 10
3
BYSTOLIC – nebivolol hcl tab 20
1
carvedilol tab 3.125 mg (Coreg)
carvedilol tab 25 mg (Coreg)
1
1
1
COREG – carvedilol tab 3.125 mg
3
3
3
COREG – carvedilol tab 25 mg
3
1
COREG CR – carvedilol phosphate 3
cap sr 24hr 10 mg
cap sr 24hr 20 mg
cap sr 24hr 40 mg
cap sr 24hr 80 mg
3
CORGARD – nadolol tab 20 mg
1
3
3
CORZIDE – nadolol &
bendroflumethiazide tab 40-5 mg
3
CORZIDE – nadolol &
bendroflumethiazide tab 80-5 mg
3
1
1
1
1
1
1
Tier
•
Responsible Steps
1
1
Quantity Limits
•
bisoprolol fumarate tab 10 mg
(Zebeta)
Prior Authorization
1
Drug Name
Specialty/Tier 4
•
1
Drug Tier
1
1
Responsible Steps
Quantity Limits
1
•
•
•
•
1
BETA BLOCKERS AND COMBINATIONS
1
acebutolol hcl cap 200 mg
(Sectral)
1
acebutolol hcl cap 400 mg
(Sectral)
1
atenolol & chlorthalidone tab
50-25 mg (Tenoretic 50)
1
atenolol & chlorthalidone tab
100-25 mg (Tenoretic 100)
1
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
47
DUTOPROL – metoprolol &
hydrochlorothiazide tab sr 24hr
25-12.5 mg
3
50-12.5 mg
3
100-12.5 mg
3
HEMANGEOL – propranolol hcl
oral soln 4.28 mg/ml
3
INDERAL LA – propranolol hcl cap
sr 24hr 60 mg
3
sr 24hr 80 mg
3
sr 24hr 120 mg
3
sr 24hr 160 mg
3
INDERAL XL – propranolol hcl
sustained-release beads cap sr
24hr 80 mg
3
INDERAL XL – propranolol hcl
24hr 120 mg
3
INNOPRAN XL – propranolol hcl
24hr 80 mg
2
INNOPRAN XL – propranolol hcl
24hr 120 mg
2
KERLONE – betaxolol hcl tab 10
mg
3
KERLONE – betaxolol hcl tab 20
mg
3
labetalol hcl tab 100 mg
1
KEY
3
LOPRESSOR – metoprolol tartrate
tab 50 mg
3
LOPRESSOR – metoprolol tartrate
tab 100 mg
3
LOPRESSOR HCT – metoprolol &
3
LOPRESSOR HCT – metoprolol &
mg
3
metoprolol &
50-25 mg (Lopressor hct)
1
metoprolol &
100-50 mg
Responsible Steps
Quantity Limits
Prior Authorization
1
LEVATOL – penbutolol sulfate tab
20 mg
metoprolol &
100-25 mg (Lopressor hct)
Specialty/Tier 4
Drug Name
1
1
metoprolol succinate tab sr 24hr 1
25 mg (tartrate equiv) (Toprol xl)
50 mg (tartrate equiv) (Toprol xl)
100 mg (tartrate equiv) (Toprol
xl)
200 mg (tartrate equiv) (Toprol
xl)
3
METOPROLOL TARTRATE –
metoprolol tartrate tab 37.5 mg
3
METOPROLOL TARTRATE –
metoprolol tartrate tab 75 mg
1
1
Tier
•
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
48
(Lopressor)
1
(Lopressor)
1
nadolol & bendroflumethiazide
tab 40-5 mg (Corzide)
1
nadolol & bendroflumethiazide
tab 80-5 mg (Corzide)
nadolol tab 20 mg (Corgard)
pindolol tab 5 mg
pindolol tab 10 mg
1
1
1
1
PROPRANOLOL HCL –
propranolol hcl oral soln 40
mg/5ml
2
propranolol hcl cap sr 24hr
60 mg (Inderal la)
1
120 mg (Inderal la)
160 mg (Inderal la)
propranolol hcl tab 10 mg
PROPRANOLOL/
HYDROCHLOROTH
KEY
1
1
1
1
1
1
1
1
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Tier
•
2
SECTRAL – acebutolol hcl cap 200 3
mg
SECTRAL – acebutolol hcl cap 400 3
mg
3
TENORETIC 100 – atenolol &
chlorthalidone tab 100-25 mg
3
TENORETIC 50 – atenolol &
chlorthalidone tab 50-25 mg
2
TIMOLOL MALEATE – timolol
maleate tab 5 mg
2
maleate tab 10 mg
2
maleate tab 20 mg
3
TOPROL XL – metoprolol
succinate tab sr 24hr 25 mg
(tartrate equiv)
3
(tartrate equiv)
3
(tartrate equiv)
3
(tartrate equiv)
3
ZEBETA – bisoprolol fumarate tab
5 mg
3
ZEBETA – bisoprolol fumarate tab
10 mg
1
2
Drug Name
– propranolol &
PROPRANOLOL/
HYDROCHLOROTH
– propranolol &
1
PROPRANOLOL HCL –
propranolol hcl oral soln 20
mg/5ml
80 mg (Inderal la)
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
49
ZIAC – bisoprolol &
hydrochlorothiazide tab 2.5-6.25
mg
3
mg
3
mg
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
1
•
1
•
1
•
AZOR – amlodipine besylateolmesartan medoxomil tab 5-20
mg
3
• •
mg
3
• •
mg
3
• •
mg
3
• •
CALAN – verapamil hcl tab 80 mg
3
amlodipine besylate-valsartan
tab 10-160 mg (Exforge)
CALAN – verapamil hcl tab 120 mg 3
3
CALAN SR – verapamil hcl tab cr
120 mg
3
180 mg
3
240 mg
3
CARDIZEM LA – diltiazem hcl
coated beads tab sr 24hr 120 mg
1
diltiazem hcl cap sr 12hr 60 mg
•
diltiazem hcl coated beads cap
sr 24hr 120 mg (Cardizem cd)
Tier
•
Drug Tier
Responsible Steps
Quantity Limits
Drug Name
CALCIUM CHANNEL BLOCKERS AND
COMBINATIONS
3
ADALAT CC – nifedipine tab sr
24hr 30 mg
3
24hr 60 mg
3
24hr 90 mg
1
amlodipine besylate tab 2.5 mg
(Norvasc)
1
amlodipine besylate tab 5 mg
(Norvasc)
1
amlodipine besylate tab 10 mg
(Norvasc)
1
amlodipine besylate-benazepril
hcl cap 2.5-10 mg
1
hcl cap 5-10 mg (Lotrel)
1
1
hcl cap 5-40 mg
1
1
1
KEY
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
1
1
1
1
1
1
50
diltiazem hcl coated beads tab sr
24hr 180 mg (Cardizem la)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
1
diltiazem hcl tab 30 mg
(Cardizem)
1
1
(Cardizem)
1
1
1
1
(Cardizem)
1
1
EXFORGE – amlodipine besylatevalsartan tab 5-160 mg
3
• •
1
3
• •
1
3
• •
1
3
• •
felodipine tab sr 24hr 2.5 mg
1
1
diltiazem hcl extended release
beads cap sr 24hr 120 mg
(Tiazac)
1
(Tiazac)
1
(Tiazac)
1
(Tiazac)
1
(Tiazac)
1
(Tiazac)
1
KEY
Specialty/Tier 4
Drug Name
Drug Tier
2016
felodipine tab sr 24hr 5 mg
felodipine tab sr 24hr 10 mg
isradipine cap 2.5 mg
isradipine cap 5 mg
1
1
1
LOTREL – amlodipine besylatebenazepril hcl cap 5-10 mg
3
3
3
3
nicardipine hcl cap 20 mg
1
nicardipine hcl cap 30 mg
nifedipine cap 10 mg (Procardia)
nifedipine cap 20 mg
nifedipine tab sr 24hr 30 mg
(Adalat cc)
Tier
•
1
*
1
1
1
1
51
(Adalat cc)
1
(Adalat cc)
1
nifedipine tab sr 24hr osmotic
release 30 mg (Procardia xl)
1
nimodipine cap 30 mg
1
1
2
NISOLDIPINE – nisoldipine tab sr
24hr 30 mg
2
24hr 40 mg
2
NISOLDIPINE ER – nisoldipine tab
sr 24hr 25.5 mg
2
nisoldipine tab sr 24hr 8.5 mg
(Sular)
1
nisoldipine tab sr 24hr 17 mg
(Sular)
1
nisoldipine tab sr 24hr 34 mg
(Sular)
1
NORVASC – amlodipine besylate
tab 2.5 mg
3
tab 5 mg
3
tab 10 mg
3
NYMALIZE – nimodipine oral soln
60 mg/20ml
3
PROCARDIA – nifedipine cap 10
mg
3
Tier
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
PROCARDIA XL – nifedipine tab sr 3
24hr osmotic release 30 mg
3
SULAR – nisoldipine tab sr 24hr
8.5 mg
SULAR – nisoldipine tab sr 24hr 17 3
mg
SULAR – nisoldipine tab sr 24hr 34 3
mg
TARKA – trandolapril-verapamil hcl 3
tab cr 1-240 mg
tab cr 2-180 mg
tab cr 2-240 mg
tab cr 4-240 mg
1
telmisartan-amlodipine tab
40-5 mg (Twynsta)
1
40-10 mg (Twynsta)
1
80-5 mg (Twynsta)
1
80-10 mg (Twynsta)
1
trandolapril-verapamil hcl tab cr
1-240 mg (Tarka)
1
2-180 mg (Tarka)
1
2-240 mg (Tarka)
1
4-240 mg (Tarka)
1
24hr 20 mg
KEY
Specialty/Tier 4
Drug Name
Drug Tier
2016
•
•
•
•
52
3
• •
TWYNSTA – telmisartanamlodipine tab 80-5 mg
3
• •
3
• •
verapamil hcl cap sr 24hr 100 mg
(Verelan pm)
3
VERELAN – verapamil hcl cap sr
24hr 360 mg
3
VERELAN PM – verapamil hcl cap
sr 24hr 100 mg
3
sr 24hr 200 mg
3
1
sr 24hr 300 mg
3
(Verelan)
1
CHEST PAIN
DILATRATE SR – isosorbide
dinitrate cap cr 40 mg
3
(Verelan)
1
ISOSORBIDE DINITRATE ER –
isosorbide dinitrate tab cr 40 mg
3
(Verelan pm)
1
1
isosorbide dinitrate tab 5 mg
(Isordil titradose)
1
(Verelan)
1
(Verelan pm)
1
(Verelan)
1
verapamil hcl tab cr 120 mg
(Calan sr)
1
(Calan sr)
1
(Calan sr)
1
verapamil hcl tab 40 mg
1
verapamil hcl tab 80 mg (Calan)
verapamil hcl tab 120 mg (Calan)
isosorbide mononitrate tab sr
24hr 30 mg
24hr 60 mg
24hr 120 mg
isosorbide mononitrate tab
10 mg
isosorbide mononitrate tab
20 mg
1
1
24hr 120 mg
3
24hr 180 mg
3
KEY
1
1
1
1
1
1
2
NITRO-DUR – nitroglycerin td
patch 24hr 0.1 mg/hr
3
3
•
1
NITRO-BID – nitroglycerin oint 2%
Tier
*
Responsible Steps
24hr 240 mg
Quantity Limits
• •
Prior Authorization
3
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
53
2
RANEXA – ranolazine tab sr 12hr
500 mg
3
3
RANEXA – ranolazine tab sr 12hr
1000 mg
3
3
CHOLESTEROL LOWERING
2
nitroglycerin cap cr 2.5 mg
1
nitroglycerin cap cr 6.5 mg
nitroglycerin cap cr 9 mg
1
1
NITROGLYCERIN LINGUAL –
nitroglycerin lingual aerosol 400
mcg/spray
3
nitroglycerin td patch 24hr
0.1 mg/hr (Nitro-dur)
1
1
1
1
nitroglycerin tl soln 0.4 mg/spray
(400 mcg/spray) (Nitrolingual
pumpspr)
1
NITROLINGUAL PUMPSPRAY –
nitroglycerin tl soln 0.4 mg/spray
(400 mcg/spray)
3
NITROMIST – nitroglycerin lingual
aerosol 400 mcg/spray
3
NITROSTAT – nitroglycerin sl tab
0.3 mg
2
0.4 mg
2
0.6 mg
2
KEY
ALTOPREV – lovastatin tab sr 24hr 3
20 mg
40 mg
60 mg
1
atorvastatin calcium tab 10 mg
(base equivalent) (Lipitor)
1
1
1
1
cholestyramine light powder
packets 4 gm
1
cholestyramine light powder
4 gm/dose (Questran light)
1
cholestyramine powder packets
4 gm (Questran)
1
cholestyramine powder 4 gm/
dose (Questran)
choline fenofibrate cap dr 45 mg 1
(fenofibric acid equiv) (Trilipix)
1
choline fenofibrate cap dr
135 mg (fenofibric acid equiv)
(Trilipix)
3
COLESTID – colestipol hcl tab 1
gm
3
COLESTID – colestipol hcl
granules 5 gm
Tier
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
• •
• •
• •
•
•
•
•
•
•
54
COLESTID – colestipol hcl granule
packets 5 gm
3
fenofibrate tab 54 mg (Lofibra)
fenofibrate tab 120 mg
(Fenoglide)
1
COLESTID FLAVORED –
colestipol hcl granules 5 gm
3
fenofibrate tab 145 mg (Tricor)
1
COLESTID FLAVORED –
colestipol hcl granule packets 5
gm
3
colestipol hcl granule packets
5 gm (Colestid flavored)
1
colestipol hcl granules 5 gm
(Colestid flavored)
1
colestipol hcl tab 1 gm (Colestid)
1
FENOFIBRIC ACID – fenofibric
acid tab 105 mg
3
• •
FIBRICOR – fenofibric acid tab 35
mg
3
• •
FIBRICOR – fenofibric acid tab 105 3
mg
1
fluvastatin sodium cap 20 mg
• •
•
CRESTOR – rosuvastatin calcium
tab 10 mg
2
•
tab 20 mg
2
•
fluvastatin sodium tab sr 24 hr
80 mg (Lescol xl)
tab 40 mg
2
•
gemfibrozil tab 600 mg (Lopid)
FENOFIBRATE – fenofibrate cap
50 mg
3
FENOFIBRATE – fenofibrate cap
150 mg
3
fenofibrate micronized cap
43 mg
1
134 mg (Lofibra)
200 mg (Lofibra)
fenofibrate tab 40 mg (Fenoglide)
fenofibrate tab 48 mg (Tricor)
KEY
JUXTAPID – lomitapide mesylate
3
X • •
3
X • •
3
X • •
3
X • •
3
X • •
•
KYNAMRO – mipomersen sodium
soln prefilled syringe 200 mg/ml
3
X • •
•
•
LESCOL XL – fluvastatin sodium
tab sr 24 hr 80 mg
3
• •
LIPOFEN – fenofibrate cap 50 mg
3
• •
•
•
•
1
1
Tier
•
1
3
•
1
1
•
•
•
• •
1
fluvastatin sodium cap 40 mg
1
•
X • •
• •
1
Responsible Steps
3
2
130 mg
Quantity Limits
FENOFIBRIC ACID – fenofibric
acid tab 35 mg
fenofibrate tab 160 mg (Lofibra)
1
•
•
•
•
• •
tab 5 mg
67 mg (Lofibra)
1
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
1
55
LIPOFEN – fenofibrate cap 150 mg 3
3
LIVALO – pitavastatin calcium tab
1 mg (base equiv)
3
2 mg (base equiv)
3
4 mg (base equiv)
3
LOFIBRA – fenofibrate tab 54 mg
• •
• •
LOFIBRA – fenofibrate tab 160 mg
3
LOFIBRA – fenofibrate micronized
cap 67 mg
3
• •
• •
• •
cap 134 mg
3
• •
cap 200 mg
3
• •
LOPID – gemfibrozil tab 600 mg
3
lovastatin tab 10 mg
1
NIASPAN – niacin tab cr 1000 mg
(antihyperlipidemic)
3
omega-3-acid ethyl esters cap
1 gm (Lovaza)
1
• •
PRALUENT – alirocumab
subcutaneous soln pen-injector
75 mg/ml
3
X • •
subcutaneous soln pen-injector
150 mg/ml
3
X • •
subcutaneous soln prefilled
syringe 75 mg/ml
3
X • •
syringe 150 mg/ml
3
X • •
PRAVACHOL – pravastatin sodium
tab 20 mg
3
• •
tab 40 mg
3
• •
tab 80 mg
3
• •
pravastatin sodium tab 10 mg
1
LOVAZA – omega-3-acid ethyl
esters cap 1 gm
3
• •
•
•
•
• •
MEVACOR – lovastatin tab 40 mg
3
• •
niacin tab cr 500 mg
(antihyperlipidemic) (Niaspan)
1
(Pravachol)
1
•
•
1
(Pravachol)
1
•
1
(Pravachol)
1
•
NIACOR – niacin
(antihyperlipidemic) tab 500 mg
3
QUESTRAN – cholestyramine
powder 4 gm/dose
3
3
QUESTRAN – cholestyramine
powder packets 4 gm
3
3
QUESTRAN LIGHT –
cholestyramine light powder 4
gm/dose
3
lovastatin tab 20 mg
lovastatin tab 40 mg (Mevacor)
KEY
1
1
Tier
•
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
• •
• •
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
56
REPATHA SURECLICK –
evolocumab subcutaneous soln
auto-injector 140 mg/ml
3
rosuvastatin calcium tab 5 mg
(Crestor)
1
(Crestor)
WELCHOL – colesevelam hcl
packet for susp 3.75 gm
2
ZETIA – ezetimibe tab 10 mg
2
ZOCOR – simvastatin tab 5 mg
3
3
• •
3
• •
3
1
3
(Crestor)
1
• •
(Crestor)
1
• •
simvastatin tab 5 mg (Zocor)
1
X • •
•
•
•
•
•
• •
• •
1
1
1
1
TRIGLIDE – fenofibrate tab 160 mg 3
TRILIPIX – choline fenofibrate cap 3
dr 45 mg (fenofibric acid equiv)
TRILIPIX – choline fenofibrate cap 3
dr 135 mg (fenofibric acid equiv)
3
VASCEPA – icosapent ethyl cap 1
gm
VYTORIN – ezetimibe-simvastatin 3
tab 10-10 mg
tab 10-20 mg
tab 10-40 mg
tab 10-80 mg
2
WELCHOL – colesevelam hcl tab
625 mg
KEY
• •
• •
• •
FLUID RETENTION
ACETAZOLAMIDE –
acetazolamide tab 125 mg
2
acetazolamide cap sr 12hr
500 mg (Diamox)
1
acetazolamide tab 250 mg
3
ALDACTAZIDE – spironolactone &
3
ALDACTONE – spironolactone tab
25 mg
3
50 mg
3
100 mg
3
amiloride & hydrochlorothiazide
tab 5-50 mg
1
• •
bumetanide tab 0.5 mg (Bumex)
• •
bumetanide tab 2 mg (Bumex)
• •
bumetanide tab 1 mg (Bumex)
1
3
BUMEX – bumetanide tab 2 mg
3
•
*
Prior Authorization
1
BUMEX – bumetanide tab 1 mg
1
3
•
•
•
•
•
•
1
BUMEX – bumetanide tab 0.5 mg
Tier
•
•
•
•
•
•
1
ALDACTAZIDE – spironolactone &
amiloride hcl tab 5 mg
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
X • •
Responsible Steps
3
Drug Name
Quantity Limits
REPATHA – evolocumab
syringe 140 mg/ml
Specialty/Tier 4
Drug Name
Drug Tier
2016
57
CHLOROTHIAZIDE –
chlorothiazide tab 250 mg
3
indapamide tab 2.5 mg
1
KEVEYIS – dichlorphenamide tab
50 mg
3
chlorothiazide tab 500 mg
1
CHLORTHALIDONE –
chlorthalidone tab 50 mg
2
LASIX – furosemide tab 20 mg
3
3
3
CHLORTHALIDONE –
3
1
MAXZIDE – triamterene &
3
3
DEMADEX – torsemide tab 10 mg
3
DEMADEX – torsemide tab 20 mg
3
DIAMOX – acetazolamide cap sr
12hr 500 mg
3
MAXZIDE-25 – triamterene &
hydrochlorothiazide tab 37.5-25
mg
1
DIURIL – chlorothiazide susp 250
mg/5ml
3
methazolamide tab 25 mg
(Neptazane)
1
DYAZIDE – triamterene &
hydrochlorothiazide cap 37.5-25
mg
3
methazolamide tab 50 mg
(Neptazane)
METHYCLOTHIAZIDE –
methyclothiazide tab 5 mg
3
DYRENIUM – triamterene cap 50
mg
3
metolazone tab 2.5 mg
1
DYRENIUM – triamterene cap 100
mg
3
EDECRIN – ethacrynic acid tab 25
mg
3
MICROZIDE – hydrochlorothiazide
cap 12.5 mg
3
FUROSEMIDE – furosemide oral
soln 8 mg/ml
3
NEPTAZANE – methazolamide tab
25 mg
3
furosemide oral soln 10 mg/ml
1
NEPTAZANE – methazolamide tab
50 mg
3
spironolactone &
25-25 mg (Aldactazide)
1
furosemide tab 20 mg (Lasix)
metolazone tab 5 mg
metolazone tab 10 mg
1
1
1
spironolactone tab 25 mg
(Aldactone)
1
hydrochlorothiazide tab 12.5 mg
1
(Aldactone)
1
(Aldactone)
1
hydrochlorothiazide tab 50 mg
indapamide tab 1.25 mg
KEY
1
1
Tier
•
*
Responsible Steps
Quantity Limits
1
1
1
X • •
1
hydrochlorothiazide cap 12.5 mg
(Microzide)
hydrochlorothiazide tab 25 mg
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
58
torsemide tab 5 mg (Demadex)
torsemide tab 100 mg
triamterene &
hydrochlorothiazide cap
37.5-25 mg (Dyazide)
triamterene &
37.5-25 mg (Maxzide-25)
triamterene &
75-50 mg (Maxzide)
TRIAMTERENE/
HYDROCHLOROTH
– triamterene &
hydrochlorothiazide cap 50-25
mg
HEART RHYTHM
amiodarone hcl tab 100 mg
1
disopyramide phosphate cap
100 mg (Norpace)
1
disopyramide phosphate cap
150 mg (Norpace)
1
1
dofetilide cap 125 mcg
(0.125 mg) (Tikosyn)
1
1
1
1
flecainide acetate tab 50 mg
1
mexiletine hcl cap 200 mg
1
1
1
1
MULTAQ – dronedarone hcl tab
2
3
(Cordarone)
1
3
1
NORPACE – disopyramide
phosphate cap 150 mg
NORPACE CR – disopyramide
phosphate cap sr 12hr 100 mg
3
NORPACE CR – disopyramide
phosphate cap sr 12hr 150 mg
3
propafenone hcl cap sr 12hr
225 mg (Rythmol sr)
1
3
BETAPACE – sotalol hcl tab 120
mg
3
BETAPACE – sotalol hcl tab 160
mg
3
BETAPACE AF – sotalol hcl (afib/
afl) tab 80 mg
3
afl) tab 120 mg
3
afl) tab 160 mg
3
CORDARONE – amiodarone hcl
tab 200 mg
3
KEY
325 mg (Rythmol sr)
425 mg (Rythmol sr)
propafenone hcl tab 150 mg
(Rythmol)
Tier
•
*
Responsible Steps
1
NORPACE – disopyramide
phosphate cap 100 mg
BETAPACE – sotalol hcl tab 80 mg
Quantity Limits
1
dofetilide cap 500 mcg (0.5 mg)
(Tikosyn)
1
1
1
3
1
dofetilide cap 250 mcg (0.25 mg)
(Tikosyn)
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
1
1
1
1
59
QUINIDINE SULFATE – quinidine
sulfate tab 200 mg
2
QUINIDINE SULFATE – quinidine
sulfate tab 300 mg
3
RYTHMOL – propafenone hcl tab
225 mg
3
RYTHMOL SR – propafenone hcl
cap sr 12hr 225 mg
3
cap sr 12hr 325 mg
3
cap sr 12hr 425 mg
3
sotalol hcl (afib/afl) tab 80 mg
(Betapace af)
1
(Betapace af)
1
(Betapace af)
1
sotalol hcl tab 80 mg (Betapace)
1
sotalol hcl tab 240 mg
1
3
TIKOSYN – dofetilide cap 125 mcg
(0.125 mg)
3
(0.25 mg)
3
(0.5 mg)
3
ADEMPAS – riociguat tab 0.5 mg
3
ADEMPAS – riociguat tab 1 mg
3
3
ADEMPAS – riociguat tab 2 mg
3
3
X
X
X
X
X
•
•
•
•
•
•
•
•
•
•
amlodipine besylate-atorvastatin
calcium tab 2.5-10 mg (Caduet)
1
calcium tab 5-10 mg (Caduet)
1
1
1
1
1
1
1
1
1
3
CADUET – amlodipine besylateatorvastatin calcium tab 2.5-10
mg
3
•
1
BIDIL – isosorbide dinitratehydralazine hcl tab 20-37.5 mg
Tier
*
Responsible Steps
X • •
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
2
OTHER HEART RELATED DRUGS
KEY
ADCIRCA – tadalafil tab 20 mg
(pah)
Drug Name
sotalol hcl tab 120 mg (Betapace) 1
sotalol hcl tab 160 mg (Betapace) 1
SOTYLIZE – sotalol hcl oral
solution 5 mg/ml
Quantity Limits
1
Prior Authorization
quinidine gluconate tab cr
324 mg
1
Specialty/Tier 4
Specialty/Tier 4
Drug Name
Drug Tier
2016
60
mg
3
mg
3
CADUET – amlodipine besylateatorvastatin calcium tab 5-10 mg
3
3
3
3
CADUET – amlodipine besylateatorvastatin calcium tab 10-10
mg
3
mg
3
mg
3
mg
3
CARDURA – doxazosin mesylate
tab 1 mg
CATAPRES – clonidine hcl tab 0.2
mg
3
mg
3
CATAPRES-TTS-1 – clonidine hcl
td patch weekly 0.1 mg/24hr
3
3
3
clonidine hcl tab 0.1 mg
(Catapres)
1
(Catapres)
1
(Catapres)
1
clonidine hcl td patch weekly
0.1 mg/24hr (Catapres-tts-1)
1
3
3
CLORPRES – clonidine &
chlorthalidone tab 0.2-15 mg
3
tab 2 mg
3
3
tab 4 mg
3
CORLANOR – ivabradine hcl tab 5
mg (base equiv)
3
tab 8 mg
3
CORLANOR – ivabradine hcl tab
7.5 mg (base equiv)
3
mg
3
DIBENZYLINE –
phenoxybenzamine hcl cap 10
mg
DIGOXIN – digoxin oral soln 0.05
mg/ml
2
•
*
Responsible Steps
1
3
Tier
Quantity Limits
1
KEY
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
61
digoxin tab 125 mcg (0.125 mg)
(Lanoxin)
1
LANOXIN – digoxin tab 187.5 mcg
(0.1875 mg)
3
digoxin tab 250 mcg (0.25 mg)
(Lanoxin)
1
LANOXIN – digoxin tab 250 mcg
(0.25 mg)
3
doxazosin mesylate tab 1 mg
(Cardura)
1
LETAIRIS – ambrisentan tab 5 mg
2
(Cardura)
1
LETAIRIS – ambrisentan tab 10 mg 2
1
methyldopa tab 250 mg
(Cardura)
1
(Cardura)
1
ENTRESTO – sacubitril-valsartan
tab 24-26 mg
3
tab 49-51 mg
3
• •
tab 97-103 mg
3
• •
eplerenone tab 25 mg (Inspra)
methyldopa tab 500 mg
X • •
X • •
1
METHYLDOPA/
HYDROCHLOROTHI
– methyldopa &
mg
3
METHYLDOPA/
HYDROCHLOROTHI
– methyldopa &
mg
3
1
midodrine hcl tab 2.5 mg
1
1
midodrine hcl tab 5 mg
1
midodrine hcl tab 10 mg
1
MINIPRESS – prazosin hcl cap 1
mg
3
mg
3
1
mg
3
INSPRA – eplerenone tab 25 mg
3
minoxidil tab 2.5 mg
1
INSPRA – eplerenone tab 50 mg
3
minoxidil tab 10 mg
ISOXSUPRINE HCL – isoxsuprine
hcl tab 20 mg
3
OPSUMIT – macitentan tab 10 mg
2
ORENITRAM – treprostinil
diolamine tab cr 0.125 mg (base
equiv)
3
isoxsuprine hcl tab 10 mg
1
X • •
X •
equiv)
3
X •
eplerenone tab 50 mg (Inspra)
guanfacine hcl tab 1 mg (Tenex)
guanfacine hcl tab 2 mg (Tenex)
hydralazine hcl tab 10 mg
1
1
1
LANOXIN – digoxin tab 62.5 mcg
(0.0625 mg)
3
LANOXIN – digoxin tab 125 mcg
(0.125 mg)
3
KEY
• •
Tier
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
1
1
1
62
phenoxybenzamine hcl cap
10 mg (Dibenzyline)
1
KEY
3
TENEX – guanfacine hcl tab 2 mg
3
terazosin hcl cap 1 mg
1
prazosin hcl cap 1 mg (Minipress) 1
REMODULIN – treprostinil sodium 3
inj 1 mg/ml (base equiv)
inj 2.5 mg/ml (base equiv)
3
REVATIO – sildenafil citrate for
suspension 10 mg/ml
1
sildenafil citrate tab 20 mg
(Revatio)
3
TEKTURNA – aliskiren fumarate
3
TEKTURNA – aliskiren fumarate
3
TEKTURNA HCT – aliskirenhydrochlorothiazide tab 150-12.5
mg
3
TEKTURNA HCT – aliskirenhydrochlorothiazide tab 150-25
mg
3
TEKTURNA HCT – aliskirenhydrochlorothiazide tab 300-12.5
mg
TENEX – guanfacine hcl tab 1 mg
1
1
1
2
X • •
TRACLEER – bosentan tab 125
mg
2
X • •
TYVASO – treprostinil inhalation
solution 0.6 mg/ml
3
X • •
TYVASO REFILL – treprostinil
inhalation solution 0.6 mg/ml
3
X • •
TYVASO STARTER – treprostinil
inhalation solution 0.6 mg/ml
3
X • •
UPTRAVI – selexipag tab therapy
pack 200 mcg (140) & 800 mcg
(60)
2
X • •
• •
UPTRAVI – selexipag tab 200 mcg
2
2
• •
2
2
UPTRAVI – selexipag tab 1000
mcg
2
X
X
X
X
X
mcg
2
X • •
mcg
2
X • •
mcg
2
X • •
X •
X •
X •
X • •
X • •
• •
• •
• •
Tier
•
• •
TRACLEER – bosentan tab 62.5
mg
X •
*
Responsible Steps
X •
3
Quantity Limits
3
TEKTURNA HCT – aliskirenhydrochlorothiazide tab 300-25
mg
Prior Authorization
equiv)
Drug Name
Specialty/Tier 4
X •
Drug Tier
3
Responsible Steps
diolamine tab cr 1 mg (base
equiv)
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
•
•
•
•
•
•
•
•
•
•
63
VECAMYL – mecamylamine hcl
tab 2.5 mg
3
VENTAVIS – iloprost inhalation
solution 10 mcg/ml
2
VENTAVIS – iloprost inhalation
solution 20 mcg/ml
2
X • •
CIALIS – tadalafil tab 2.5 mg
3
CIALIS – tadalafil tab 5 mg
3
• •
• •
LEVITRA* – vardenafil hcl tab 2.5
mg
2
ERECTILE DYSFUNCTION
EPINEPHRINE – epinephrine
solution auto-injector 0.15
mg/0.15ml (1:1000)
3
EPINEPHRINE – epinephrine
mg/0.3ml (1:1000)
3
EPIPEN 2-PAK – epinephrine
mg/0.3ml (1:1000)
2
EPIPEN-JR 2-PAK – epinephrine
mg/0.3ml (1:2000)
2
X • •
carbinoxamine maleate soln
4 mg/5ml
carbinoxamine maleate tab 4 mg
cetirizine hcl oral soln 1 mg/ml
(5 mg/5ml)
KEY
cyproheptadine hcl tab 4 mg
3
desloratadine tab 5 mg (Clarinex)
1
1
1
levocetirizine dihydrochloride
tab 5 mg (Xyzal)
1
loratadine tab 10 mg
promethazine hcl suppos
12.5 mg
promethazine hcl suppos 25 mg
promethazine hcl suppos 50 mg
promethazine hcl tab 12.5 mg
1
promethazine hcl tab 25 mg
1
NASAL PRODUCTS
1
ASTEPRO – azelastine hcl nasal
spray 0.15% (205.5 mcg/spray)
promethazine hcl tab 50 mg
Tier
•
*
Responsible Steps
1
levocetirizine dihydrochloride
soln 2.5 mg/5ml (0.5 mg/ml)
(Xyzal)
loratadine syrup 5 mg/5ml
Quantity Limits
1
DESLORATADINE ODT –
desloratadine tab orally
disintegrating 5 mg
loratadine rapidly-disintegrating
tab 10 mg (Claritin)
Prior Authorization
1
3
promethazine hcl syrup
6.25 mg/5ml
1
DESLORATADINE ODT –
desloratadine tab orally
disintegrating 2.5 mg
diphenhydramine hcl elixir
12.5 mg/5ml
Specialty/Tier 4
Drug Tier
cyproheptadine hcl syrup
2 mg/5ml
diphenhydramine hcl cap 50 mg
RESPIRATORY DRUGS
ANTIHISTAMINES
Drug Name
clemastine fumarate tab 2.68 mg
LEVITRA* – vardenafil hcl tab 5 mg 2
2
LEVITRA* – vardenafil hcl tab 10
mg
2
LEVITRA* – vardenafil hcl tab 20
mg
ALLERGIC REACTION KITS
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
1
1
1
1
1
1
1
1
1
1
3
•
64
azelastine hcl nasal spray 0.1%
(137 mcg/spray)
azelastine hcl nasal spray 0.15%
(205.5 mcg/spray) (Astepro)
BACTROBAN NASAL – mupirocin
calcium nasal oint 2%
3
flunisolide nasal soln 25 mcg/act
(0.025%)
1
•
1
•
1
ipratropium bromide nasal soln
0.03% (21 mcg/spray) (Atrovent)
1
ipratropium bromide nasal soln
0.06% (42 mcg/spray) (Atrovent)
1
olopatadine hcl nasal soln 0.6%
(Patanase)
PATANASE – olopatadine hcl nasal 3
soln 0.6%
1
triamcinolone acetonide nasal
aerosol suspension 55 mcg/act
3
TYZINE – tetrahydrozoline hcl
nasal soln 0.1%
3
TYZINE PEDIATRIC NASAL DR
– tetrahydrozoline hcl nasal soln
0.05%
•
fluticasone propionate nasal
susp 50 mcg/act
COUGH/COLD/ALLERGY
acetylcysteine inhal soln 10%
•
•
•
•
1
acetylcysteine inhal soln 20%
1
CODAR AR – chlorpheniramine w/
codeine liquid 2-8 mg/5ml
3
BENZONATATE – benzonatate cap 3
150 mg
1
benzonatate cap 100 mg
(Tessalon perles)
1
KEY
Responsible Steps
1
hydrocod polst-chlorphen polst
er susp 10-8 mg/5ml (Tussionex
pennkineti)
1
hydrocodone w/ homatropine
syrup 5-1.5 mg/5ml
1
hydrocodone w/ homatropine
tab 5-1.5 mg
3
HYPER-SAL – sodium chloride
soln nebu 7%
HYPERSAL – sodium chloride soln 3
nebu 3.5%
HYPERSAL – sodium chloride soln 3
nebu 7%
3
LEXUSS 210 – chlorpheniramine
w/ codeine liquid 2-10 mg/5ml
1
loratadine & pseudoephedrine
1
loratadine & pseudoephedrine
3
NEBUSAL – sodium chloride soln
nebu 6%
1
phenylephrine-promethazine
w/ codeine syrup
5-6.25-10 mg/5ml
1
promethazine & phenylephrine
syrup 6.25-5 mg/5ml
1
promethazine w/ codeine syrup
6.25-10 mg/5ml
1
promethazine-dm syrup
6.25-15 mg/5ml
1
pseudoeph-chlorphen
w/ hydrocodone soln
60-4-5 mg/5ml (Zutripro)
1
pseudoephed-bromphen-dm
syrup 30-2-10 mg/5ml
3
REZIRA – pseudoephedrine w/
hydrocodone soln 60-5 mg/5ml
Tier
•
Quantity Limits
•
Prior Authorization
1
Drug Name
Specialty/Tier 4
•
Drug Tier
1
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
65
sodium chloride soln nebu 0.9%
sodium chloride soln nebu 3%
1
1
(Hyper-sal)
1
1
•
AEROSPAN – flunisolide hfa inhal
aerosol 80 mcg/act
3
•
1
albuterol sulfate soln nebu
0.083% (2.5 mg/3ml)
TESSALON PERLES –
3
albuterol sulfate soln nebu 0.5%
(5 mg/ml)
TUSSIONEX PENNKINETIC EXT
– hydrocod polst-chlorphen polst
er susp 10-8 mg/5ml
3
0.63 mg/3ml (base equiv)
VITUZ – hydrocodonechlorpheniramine soln 5-4
mg/5ml
3
ZUTRIPRO – pseudoephchlorphen w/ hydrocodone soln
60-4-5 mg/5ml
3
albuterol sulfate syrup 2 mg/5ml
•
•
•
ADVAIR DISKUS – fluticasonesalmeterol aer powder ba 100-50
mcg/dose
2
mcg/dose
2
•
mcg/dose
2
•
ADVAIR HFA – fluticasonesalmeterol inhal aerosol 45-21
mcg/act
2
•
mcg/act
2
•
KEY
1
1
1
1
albuterol sulfate tab sr 12hr 8 mg
(Vospire er)
1
albuterol sulfate tab 2 mg
1
1
ALVESCO – ciclesonide inhal
aerosol 80 mcg/act
3
•
ALVESCO – ciclesonide inhal
aerosol 160 mcg/act
3
•
ANORO ELLIPTA – umeclidiniumvilanterol aero powd ba 62.5-25
mcg/inh
2
•
ARCAPTA NEOHALER –
indacaterol maleate inhal powder
cap 75 mcg (base equiv)
3
•
ARNUITY ELLIPTA – fluticasone
furoate aerosol powder breath
activ 100 mcg/act
2
•
ARNUITY ELLIPTA – fluticasone
furoate aerosol powder breath
activ 200 mcg/act
2
•
Tier
•
1
albuterol sulfate tab sr 12hr 4 mg
(Vospire er)
albuterol sulfate tab 4 mg
*
Responsible Steps
2
3
ACCOLATE – zafirlukast tab 10 mg 3
ACCOLATE – zafirlukast tab 20 mg 3
Quantity Limits
mcg/act
SSKI – potassium iodide soln 1
gm/ml
ASTHMA/COPD
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
66
2
ASMANEX HFA – mometasone
furoate inhal aerosol suspension
200 mcg/act
2
ASMANEX TWISTHALER 120
ME – mometasone furoate
inhal powd 220 mcg/inh (breath
activated)
2
MET – mometasone furoate
activated)
2
activated)
2
activated)
2
activated)
2
ATROVENT HFA – ipratropium
bromide hfa inhal aerosol 17
mcg/act
2
•
BREO ELLIPTA – fluticasone
furoate-vilanterol aero powd ba
100-25 mcg/inh
2
•
BREO ELLIPTA – fluticasone
furoate-vilanterol aero powd ba
200-25 mcg/inh
2
•
budesonide inhalation susp
0.25 mg/2ml (Pulmicort)
1
0.5 mg/2ml (Pulmicort)
KEY
1 mg/2ml (Pulmicort)
•
•
•
CROMOLYN SODIUM – cromolyn
sodium soln nebu 20 mg/2ml
3
DALIRESP – roflumilast tab 500
mcg
3
DULERA – mometasone furoateformoterol fumarate aerosol
100-5 mcg/act
2
•
DULERA – mometasone furoateformoterol fumarate aerosol
200-5 mcg/act
2
•
dyphylline-guaifenesin liqd
100-100 mg/5ml
1
•
•
•
ELIXOPHYLLIN – theophylline
elixir 80 mg/15ml
3
epinephrine hcl inj 1 mg/ml
1
epinephrine hcl soln prefilled
syringe 0.1 mg/ml
1
FLOVENT DISKUS – fluticasone
propionate aer pow ba 50 mcg/
blister
2
•
blister
2
•
blister
2
•
FLOVENT HFA – fluticasone
propionate hfa inhal aero 44
mcg/act (50/valve)
2
•
propionate hfa inhal aer 110 mcg/
act (125/valve)
2
•
•
*
Responsible Steps
Quantity Limits
Prior Authorization
1
3
Tier
Specialty/Tier 4
Drug Name
COMBIVENT RESPIMAT –
ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act
•
1
Drug Tier
•
ASMANEX HFA – mometasone
furoate inhal aerosol suspension
100 mcg/act
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
67
propionate hfa inhal aer 220
mcg/act (250/valve)
2
PERFOROMIST – formoterol
fumarate soln nebu 20 mcg/2ml
3
PROAIR HFA – albuterol sulfate
inhal aero 108 mcg/act (90mcg
base equiv)
2
•
PROAIR RESPICLICK – albuterol
sulfate aer pow ba 108 mcg/act
(90 mcg base equiv)
2
•
PROVENTIL HFA – albuterol
sulfate inhal aero 108 mcg/act
(90mcg base equiv)
3
•
PULMICORT – budesonide
inhalation susp 0.25 mg/2ml
3
inhalation susp 0.5 mg/2ml
3
inhalation susp 1 mg/2ml
3
PULMICORT FLEXHALER –
budesonide inhal aero powd 90
mcg/act (breath activated)
3
•
PULMICORT FLEXHALER –
budesonide inhal aero powd 180
mcg/act (breath activated)
3
•
QVAR – beclomethasone diprop
inhal aero soln 40 mcg/act (50/
valve)
2
•
QVAR – beclomethasone diprop
inhal aero soln 80 mcg/act (100/
valve)
2
•
SEREVENT DISKUS – salmeterol
xinafoate aer pow ba 50 mcg/
dose (base equiv)
3
•
•
SINGULAIR – montelukast sodium
oral granules packet 4 mg (base
equiv)
3
•
•
SPIRIVA HANDIHALER –
tiotropium bromide monohydrate
inhal cap 18 mcg (base equiv)
2
•
•
•
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Tier
Drug Tier
Responsible Steps
Quantity Limits
•
•
INCRUSE ELLIPTA – umeclidinium 2
br aero powd breath act 62.5
mcg/inh (base eq)
1
ipratropium bromide inhal soln
0.02%
1
ipratropium-albuterol nebu soln
0.5-2.5(3) mg/3ml
1
levalbuterol hcl soln nebu conc
1.25 mg/0.5ml (base equiv)
(Xopenex concentrate)
1
levalbuterol hcl soln nebu
(Xopenex)
1
(Xopenex)
1
(Xopenex)
3
METAPROTERENOL SULFATE –
metaproterenol sulfate syrup 10
mg/5ml
3
metaproterenol sulfate tab 10 mg
3
metaproterenol sulfate tab 20 mg
1
montelukast sodium chew tab
4 mg (base equiv) (Singulair)
1
montelukast sodium chew tab
5 mg (base equiv) (Singulair)
1
montelukast sodium
oral granules packet 4 mg
(base equiv) (Singulair)
1
montelukast sodium tab 10 mg
(base equiv) (Singulair)
KEY
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
68
•
STRIVERDI RESPIMAT –
olodaterol hcl inhal aerosol soln
2.5 mcg/act (base equiv)
2
SYMBICORT – budesonideformoterol fumarate dihyd
aerosol 80-4.5 mcg/act
2
•
SYMBICORT – budesonideformoterol fumarate dihyd
aerosol 160-4.5 mcg/act
2
•
terbutaline sulfate tab 2.5 mg
1
•
1
VOSPIRE ER – albuterol sulfate
tab sr 12hr 4 mg
3
VOSPIRE ER – albuterol sulfate
tab sr 12hr 8 mg
3
XOPENEX – levalbuterol hcl soln
nebu 0.31 mg/3ml (base equiv)
3
3
3
XOPENEX CONCENTRATE –
levalbuterol hcl soln nebu conc
1.25 mg/0.5ml (base equiv)
3
•
3
XOPENEX HFA – levalbuterol
tartrate inhal aerosol 45 mcg/act
(base equiv)
3
THEO-24 – theophylline cap sr
24hr 100 mg
•
24hr 200 mg
3
zafirlukast tab 10 mg (Accolate)
1
24hr 300 mg
3
3
•
•
•
24hr 400 mg
3
theophylline soln 80 mg/15ml
1
ESBRIET – pirfenidone cap 267
mg
3
X • •
KALYDECO – ivacaftor tab 150 mg
2
KALYDECO – ivacaftor packet 50
mg
2
X • •
X • •
KALYDECO – ivacaftor packet 75
mg
2
X • •
OFEV – nintedanib esylate cap 100 3
OFEV – nintedanib esylate cap 150 3
X • •
terbutaline sulfate tab 5 mg
theophylline tab sr 12hr 100 mg
zafirlukast tab 20 mg (Accolate)
ZYFLO CR – zileuton tab sr 12hr
600 mg
OTHER RESPIRATORY DRUGS
1
1
1
1
1
1
•
TUDORZA PRESSAIR – aclidinium 3
bromide aerosol powd breath
activated 400 mcg/act
KEY
Tier
•
*
1
Responsible Steps
2
2
Quantity Limits
SPIRIVA RESPIMAT – tiotropium
bromide monohydrate inhal
aerosol 2.5 mcg/act
VENTOLIN HFA – albuterol sulfate
inhal aero 108 mcg/act (90mcg
base equiv)
Prior Authorization
•
Drug Name
Specialty/Tier 4
2
Drug Tier
SPIRIVA RESPIMAT – tiotropium
bromide monohydrate inhal
aerosol 1.25 mcg/act
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
X • •
69
X
GASTROINTESTINAL DRUGS
LAXATIVES
bisacodyl tab & peg 3350-kclsod bicarb-nacl for soln kit
polyethylene glycol 3350 oral
packet
1
polyethylene glycol 3350 oral
powder
1
1
PREPOPIK – sod picosulfate-mg
oxide-citric acid pack 10 mg-3.5
gm-12 gm
3
SUPREP BOWEL PREP – sodium
sulfate-potassium sulfatemagnesium sulfate oral soln
3
COLYTE-FLAVOR PACKS – peg
3350-kcl-na bicarb-nacl-na
sulfate for soln 240 gm
3
GOLYTELY – peg 3350-kcl-na
bicarb-nacl-na sulfate packet
227.1 gm
3
GOLYTELY – peg 3350-kcl-na
bicarb-nacl-na sulfate for soln
236 gm
3
diphenoxylate w/ atropine tab
2.5-0.025 mg (Lomotil)
3
KRISTALOSE – lactulose oral
crystal packet 10 gm
3
DIPHENOXYLATE/ATROPINE
– diphenoxylate w/ atropine liq
2.5-0.025 mg/5ml
KRISTALOSE – lactulose oral
crystal packet 20 gm
3
FULYZAQ – crofelemer tab
3
lactulose solution 10 gm/15ml
1
LOMOTIL – diphenoxylate w/
atropine tab 2.5-0.025 mg
3
loperamide hcl cap 2 mg
1
ANTIDIARRHEALS
MOVIPREP – peg 3350-kcl-naclna sulfate-na ascorbate-c for soln
100 gm
3
NULYTELY/FLAVOR PACKS – peg
3350-kcl-sod bicarb-nacl for soln
420 gm
3
OSMOPREP – sod phos monosod phos di tabs 1.102-0.398
gm(1.5gm na phos)
3
peg 3350-kcl-sod bicarb-nacl
for soln 420 gm (Nulytely/flavor
pack)
1
peg 3350-kcl-na bicarb-naclna sulfate for soln 236 gm
(Golytely)
1
KEY
3
PAREGORIC – paregoric tincture 2
mg/5ml
3
RESTORA RX – lactobacillus
casei-folic acid cap 60-1.25 mg
3
amoxicillin cap-clarithro tablansopraz cap dr therapy pack
(Prevpac)
1
ANASPAZ – hyoscyamine sulfate
tab disp 0.125 mg
3
Tier
•
1
MOTOFEN – difenoxin w/ atropine
tab 1-0.025 mg
ULCER/GERD
*
Responsible Steps
2
1
Quantity Limits
PULMOZYME – dornase alfa inhal
soln 1 mg/ml
peg 3350-kcl-na bicarb-nacl-na
sulfate for soln 240 gm (Colyteflavor packs)
Prior Authorization
X • •
Drug Name
Specialty/Tier 4
3
Drug Tier
ORKAMBI – lumacaftor-ivacaftor
tab 200-125 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
70
BENTYL – dicyclomine hcl cap 10
mg
3
famotidine tab 40 mg (Pepcid)
GASTRINEX NF – hyoscyaminephenyltoloxamine cap 0.0625-15
mg
3
BENTYL – dicyclomine hcl tab 20
mg
3
CARAFATE – sucralfate tab 1 gm
3
1
CARAFATE – sucralfate susp 1
gm/10ml
2
glycopyrrolate tab 1 mg
chlordiazepoxide hcl-clidinium
bromide cap 5-2.5 mg (Librax)
1
hyoscyamine sulfate elixir
0.125 mg/5ml
1
hyoscyamine sulfate soln
0.125 mg/ml
cimetidine hcl soln 300 mg/5ml
cimetidine tab 200 mg
glycopyrrolate tab 2 mg
1
hyoscyamine sulfate tab disp
0.125 mg (Anaspaz)
1
hyoscyamine sulfate tab sl
0.125 mg (Levsin/sl)
1
1
1
1
1
1
1
hyoscyamine sulfate tab sr 12hr
0.375 mg (Levbid)
CYTOTEC – misoprostol tab 100
mcg
3
hyoscyamine sulfate tab
0.125 mg (Levsin)
CYTOTEC – misoprostol tab 200
mcg
3
lansoprazole cap delayed
release 15 mg (Prevacid)
dicyclomine hcl cap 10 mg
(Bentyl)
1
lansoprazole cap delayed
release 30 mg (Prevacid)
dicyclomine hcl oral soln
10 mg/5ml
1
LEVBID – hyoscyamine sulfate tab
sr 12hr 0.375 mg
3
dicyclomine hcl tab 20 mg
(Bentyl)
1
LEVSIN – hyoscyamine sulfate tab
0.125 mg
3
esomeprazole magnesium cap
delayed release 20 mg (base
eq) (Nexium)
1
LEVSIN/SL – hyoscyamine sulfate
tab sl 0.125 mg
3
methscopolamine bromide tab
2.5 mg (Pamine)
1
•
1
methscopolamine bromide tab
5 mg (Pamine forte)
1
1
•
1
•
1
famotidine for susp 40 mg/5ml
(Pepcid)
1
misoprostol tab 100 mcg
(Cytotec)
1
famotidine tab 20 mg (Pepcid)
1
misoprostol tab 200 mcg
(Cytotec)
1
KEY
Tier
•
*
Responsible Steps
1
3
esomeprazole magnesium cap
delayed release 40 mg (base
eq) (Nexium)
Quantity Limits
1
CUVPOSA – glycopyrrolate oral
soln 1 mg/5ml
•
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
71
NEXIUM – esomeprazole
magnesium for delayed release
susp pack 2.5 mg
2
susp packet 5 mg
2
susp packet 10 mg
pantoprazole sodium ec tab
40 mg (base equiv) (Protonix)
1
•
PREVPAC – amoxicillin capclarithro tab-lansopraz cap dr
therapy pack
3
2
•
PRILOSEC OTC – omeprazole
magnesium delayed release tab
20 mg (base equiv)
2
2
•
PROPANTHELINE BROMIDE –
propantheline bromide tab 15 mg
2
susp packet 20 mg
3
susp packet 40 mg
2
•
PYLERA – bismuth subcitmetronidazole-tetracycline cap
140-125-125 mg
1
nizatidine cap 150 mg
1
rabeprazole sodium ec tab
20 mg (Aciphex)
nizatidine cap 300 mg
1
OMECLAMOX-PAK – amoxicillin
cap-clarithro tab w/ omepraz cap
dr therapy pack
3
omeprazole cap delayed release
10 mg (Prilosec)
1
20 mg (Prilosec)
40 mg (Prilosec)
omeprazole-sodium bicarbonate
cap 20-1100 mg (Zegerid)
omeprazole-sodium bicarbonate
cap 40-1100 mg (Zegerid)
ranitidine hcl cap 150 mg
ranitidine hcl cap 300 mg
•
ranitidine hcl tab 150 mg (Zantac) 1
ranitidine hcl tab 300 mg (Zantac) 1
1
•
ROBINUL – glycopyrrolate tab 1
mg
3
1
•
ROBINUL FORTE – glycopyrrolate
tab 2 mg
3
1
•
sucralfate tab 1 gm (Carafate)
1
•
2
PAMINE – methscopolamine
bromide tab 2.5 mg
3
NAUSEA AND VOMITING
3
•
PAMINE FORTE –
methscopolamine bromide tab 5
mg
3
AKYNZEO – netupitantpalonosetron cap 300-0.5 mg
CESAMET – nabilone cap 1 mg
3
pantoprazole sodium ec tab
20 mg (base equiv) (Protonix)
1
•
• •
KEY
•
DICLEGIS – doxylamine-pyridoxine 3
tab delayed release 10-10 mg
1
dronabinol cap 2.5 mg (Marinol)
Tier
•
*
Responsible Steps
Quantity Limits
•
1
1
1
•
1
ranitidine hcl syrup 15 mg/ml
(75 mg/5ml)
SYMAX DUOTAB – hyoscyamine
sulfate tab cr 0.375 mg (0.125
mg ir/0.25 mg cr)
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
•
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
72
dronabinol cap 5 mg (Marinol)
dronabinol cap 10 mg (Marinol)
1
1
•
EMEND – aprepitant capsule
therapy pack 80 & 125 mg
2
EMEND – aprepitant capsule 40
mg
2
mg
2
•
mg
2
•
granisetron hcl tab 1 mg
1
•
MARINOL – dronabinol cap 2.5 mg
3
MARINOL – dronabinol cap 5 mg
3
MARINOL – dronabinol cap 10 mg
3
meclizine hcl tab 12.5 mg
1
meclizine hcl tab 25 mg
ondansetron hcl oral soln
4 mg/5ml (Zofran)
1
1
•
ondansetron hcl tab 8 mg
(Zofran)
1
•
1
ondansetron orally
disintegrating tab 4 mg (Zofran
odt)
1
•
•
ondansetron orally
disintegrating tab 8 mg (Zofran
odt)
1
•
SANCUSO – granisetron td patch
3.1 mg/24hr (contains 34.3 mg)
3
•
TIGAN – trimethobenzamide hcl
cap 300 mg
3
TRANSDERM-SCOP –
scopolamine td patch 72hr 1
mg/3days
3
trimethobenzamide hcl cap
300 mg (Tigan)
1
Responsible Steps
Prior Authorization
Specialty/Tier 4
Quantity Limits
•
VARUBI – rolapitant hcl tab 90 mg
(base equiv)
3
ZOFRAN – ondansetron hcl oral
soln 4 mg/5ml
3
ZOFRAN – ondansetron hcl tab 4
mg
3
•
ZOFRAN – ondansetron hcl tab 8
mg
3
•
ZOFRAN ODT – ondansetron
orally disintegrating tab 4 mg
3
•
ZOFRAN ODT – ondansetron
3
•
CREON – pancrelipase (lip-protamyl) dr cap 3000-9500-15000
unit
2
unit
2
unit
2
CREON – pancrelipase
(lip-prot-amyl) dr cap
24000-76000-120000 unit
2
CREON – pancrelipase
36000-114000-180000 unit
2
PANCREAZE – pancrelipase
4200-10000-17500 unit
3
Tier
•
Drug Tier
Drug Name
DIGESTIVE ENZYMES
– Pancreatic enzyme products:
1
(Zofran)
KEY
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
73
10500-25000-43750 unit
3
ZENPEP – pancrelipase
25000-85000-136000 unit
2
16800-40000-70000 unit
3
40000-136000-218000 unit
2
21000-37000-61000 unit
3
OTHER GASTROINTESTINAL DRUGS
3
ACTIGALL – ursodiol cap 300 mg
PERTZYE – pancrelipase (lip-protamyl) dr cap 8000-28750-30250
unit
3
PERTZYE – pancrelipase (lip-protamyl) dr cap 16000-57500-60500
unit
3
SUCRAID – sacrosidase soln 8500
unit/ml
3
VIOKACE – pancrelipase (lip-protamyl) tab 10440-39150-39150
unit
3
VIOKACE – pancrelipase (lip-protamyl) tab 20880-78300-78300
unit
3
alosetron hcl tab 0.5 mg (base
equiv) (Lotronex)
alosetron hcl tab 1 mg (base
equiv) (Lotronex)
AMITIZA – lubiprostone cap 24
mcg
3
APRISO – mesalamine cap sr 24hr
0.375 gm
3
ASACOL HD – mesalamine tab
2
AZULFIDINE – sulfasalazine tab
500 mg
3
AZULFIDINE EN-TABS –
sulfasalazine tab delayed release
500 mg
3
ZENPEP – pancrelipase (lip-protamyl) dr cap 3000-10000-16000
unit
2
2
balsalazide disodium cap
750 mg (Colazal)
1
unit
unit
2
calcium acetate (phosphate
binder) cap 667 mg (169 mg
ca) (Phoslo)
unit
2
20000-68000-109000 unit
2
KEY
CHENODAL – chenodiol tab 250
mg
2
CHOLBAM – cholic acid cap 50 mg 3
•
1
2
*
•
•
1
CANASA – mesalamine suppos
1000 mg
Tier
Responsible Steps
1
3
calcium acetate (phosphate
binder) tab 667 mg (Eliphos)
Quantity Limits
1
AMITIZA – lubiprostone cap 8 mcg
X
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
X •
74
CHOLBAM – cholic acid cap 250
mg
3
CIMZIA – certolizumab pegol for inj 3
kit 2 x 200 mg
CIMZIA – certolizumab pegol inj kit 3
2 x 200 mg/ml
3
CIMZIA STARTER KIT –
certolizumab pegol inj kit 6 x 200
mg/ml
3
COLAZAL – balsalazide disodium
cap 750 mg
1
cromolyn sodium oral conc
100 mg/5ml (Gastrocrom)
2
DELZICOL – mesalamine cap dr
400 mg
3
DIPENTUM – olsalazine sodium
cap 250 mg
3
ELIPHOS – calcium acetate
(phosphate binder) tab 667 mg
ENTEREG – alvimopan cap 12 mg 3
FOSRENOL – lanthanum
carbonate chew tab 500 mg
(elemental)
3
(elemental)
3
(elemental)
3
carbonate oral powder pack 750
mg (elemental)
3
carbonate oral powder pack 1000
mg (elemental)
3
GASTROCROM – cromolyn
sodium oral conc 100 mg/5ml
3
KEY
X • •
X • •
X • •
GATTEX – teduglutide (rdna) for inj
kit 5 mg
3
GIAZO – balsalazide disodium tab
1.1 gm
3
lactulose (encephalopathy)
solution 10 gm/15ml
1
LIALDA – mesalamine tab delayed
release 1.2 gm
metoclopramide hcl soln
5 mg/5ml (10 mg/10ml)
metoclopramide hcl tab 10 mg
(Reglan)
1
MOVANTIK – naloxegol oxalate tab 3
MOVANTIK – naloxegol oxalate tab 3
2
PENTASA – mesalamine cap cr
250 mg
2
PENTASA – mesalamine cap cr
500 mg
3
PHOSLO – calcium acetate
(phosphate binder) cap 667 mg
(169 mg ca)
3
PHOSLYRA – calcium acetate
(phosphate binder) oral soln 667
mg/5ml
REGLAN – metoclopramide hcl tab 3
5 mg
REGLAN – metoclopramide hcl tab 3
10 mg
•
Responsible Steps
Quantity Limits
Prior Authorization
1
1
*
•
•
1
metoclopramide hcl tab 5 mg
(Reglan)
X • •
2
LINZESS – linaclotide cap 145 mcg 3
LINZESS – linaclotide cap 290 mcg 3
mesalamine enema 4 gm
Specialty/Tier 4
Drug Name
Tier
Drug Tier
Responsible Steps
X •
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
•
•
75
RELISTOR – methylnaltrexone
bromide inj 8 mg/0.4ml (20 mg/
ml)
3
RELISTOR – methylnaltrexone
bromide inj 12 mg/0.6ml (20 mg/
ml)
3
•
RENAGEL – sevelamer hcl tab 400 3
mg
RENAGEL – sevelamer hcl tab 800 3
mg
RENVELA – sevelamer carbonate 2
tab 800 mg
packet 0.8 gm
packet 2.4 gm
SFROWASA – mesalamine sulfite- 3
free (sf) enema 4 gm/60ml
sulfasalazine tab delayed release 1
500 mg (Azulfidine en-tabs)
1
sulfasalazine tab 500 mg
(Azulfidine)
3
URSO FORTE – ursodiol tab 500
mg
3
URSO 250 – ursodiol tab 250 mg
ursodiol cap 300 mg (Actigall)
ursodiol tab 250 mg (Urso 250)
ursodiol tab 500 mg (Urso forte)
1
VIBERZI – eluxadoline tab 75 mg
3
VIBERZI – eluxadoline tab 100 mg
3
• •
• •
GENITOURINARY DRUGS
URINARY TRACT INFECTIONS
KEY
3
HIPREX – methenamine hippurate
tab 1 gm
3
MACROBID – nitrofurantoin
monohydrate macrocrystalline
cap 100 mg
3
MACRODANTIN – nitrofurantoin
macrocrystalline cap 25 mg
3
3
3
methenamine hippurate tab 1 gm
(Hiprex)
1
MONUROL – fosfomycin
tromethamine powd pack 3 gm
(base equivalent)
3
nitrofurantoin macrocrystalline
cap 25 mg (Macrodantin)
1
nitrofurantoin susp 25 mg/5ml
1
URINARY TRACT SPASMS
1
bethanechol chloride tab 10 mg
(Urecholine)
1
•
*
Responsible Steps
Quantity Limits
3
(Urecholine)
Prior Authorization
1
1
UROGESIC-BLUE –
methenamine-hyoscamine-meth
blue-sod phos tab 81.6 mg
Specialty/Tier 4
1
nitrofurantoin monohydrate
(Macrobid)
Tier
Drug Tier
FURADANTIN – nitrofurantoin
susp 25 mg/5ml
1
3
Drug Name
1
VELPHORO – sucroferric
oxyhydroxide chew tab 500 mg
Responsible Steps
•
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
76
(Urecholine)
1
tolterodine tartrate tab 1 mg
(Detrol)
1
•
(Urecholine)
1
1
•
darifenacin hydrobromide tab
sr 24hr 7.5 mg (base equiv)
(Enablex)
1
•
tolterodine tartrate tab 2 mg
(Detrol)
TOVIAZ – fesoterodine fumarate
tab sr 24hr 4 mg
3
•
1
•
TOVIAZ – fesoterodine fumarate
tab sr 24hr 8 mg
3
darifenacin hydrobromide tab
sr 24hr 15 mg (base equiv)
(Enablex)
•
1
•
ENABLEX – darifenacin
hydrobromide tab sr 24hr 7.5 mg
(base equiv)
3
trospium chloride cap sr 24hr
60 mg
1
•
ENABLEX – darifenacin
hydrobromide tab sr 24hr 15 mg
(base equiv)
3
flavoxate hcl tab 100 mg
1
•
•
trospium chloride tab 20 mg
URECHOLINE – bethanechol
chloride tab 5 mg
3
chloride tab 10 mg
3
chloride tab 25 mg
3
chloride tab 50 mg
3
VESICARE – solifenacin succinate
tab 5 mg
2
•
VESICARE – solifenacin succinate
tab 10 mg
2
•
GELNIQUE – oxybutynin chloride
td gel 10%
3
•
MYRBETRIQ – mirabegron tab sr
24 hr 25 mg
2
•
MYRBETRIQ – mirabegron tab sr
24 hr 50 mg
2
•
oxybutynin chloride syrup
5 mg/5ml
1
•
1
•
AVC – sulfanilamide vaginal cream
15%
1
•
1
•
1
1
•
•
1
•
CLEOCIN – clindamycin phosphate 3
vaginal cream 2%
CLEOCIN – clindamycin phosphate 2
vaginal suppos 100 mg
1
clindamycin phosphate vaginal
cream 2% (Cleocin)
3
CLINDESSE – clindamycin
phosphate (one dose) vaginal
cream 2%
oxybutynin chloride tab sr 24hr
5 mg (Ditropan xl)
10 mg (Ditropan xl)
15 mg (Ditropan xl)
oxybutynin chloride tab 5 mg
tolterodine tartrate cap sr 24hr
2 mg (Detrol la)
tolterodine tartrate cap sr 24hr
4 mg (Detrol la)
KEY
VAGINAL PRODUCTS
Tier
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
2
77
CRINONE – progesterone vaginal
gel 4%
3
VAGIFEM – estradiol vaginal tab
10 mcg
ESTRACE – estradiol vaginal
cream 0.1 mg/gm
3
OTHER GENITOURINARY DRUGS
ESTRING – estradiol vaginal ring 2
mg (7.5 mcg/24hrs)
3
FEM PH – acetic acid-oxyquinoline
vaginal gel 0.9-0.025%
3
FEMRING – estradiol acetate
vaginal ring 0.05 mg/24hr
3
•
FEMRING – estradiol acetate
vaginal ring 0.1 mg/24hr
3
•
•
acetic acid irrigation soln 0.25%
AVODART – dutasteride cap 0.5
mg
3
CARDURA XL – doxazosin
mesylate tab sr 24 hr 4 mg (base
equiv)
3
CARDURA XL – doxazosin
mesylate tab sr 24 hr 8 mg (base
equiv)
3
GYNAZOLE-1 – butoconazole
nitrate (one dose) vaginal cream
2%
3
3
2
METROGEL-VAGINAL –
metronidazole vaginal gel 0.75%
CYSTAGON – cysteamine
bitartrate cap 50 mg
1
CYSTAGON – cysteamine
bitartrate cap 150 mg
2
metronidazole vaginal gel 0.75%
(Metrogel-vaginal)
MICONAZOLE 3 – miconazole
nitrate vaginal suppos 200 mg
3
conjugated vaginal cream 0.625
mg/gm
2
CYTRA-3 – pot & sod citrates w/ cit 3
ac syrup 550-500-334 mg/5ml
dutasteride cap 0.5 mg (Avodart) 1
RELAGARD – acetic acidoxyquinoline vaginal gel
0.9-0.025%
3
TERAZOL 3 – terconazole vaginal
cream 0.8%
3
FLOMAX – tamsulosin hcl cap 0.4
mg
3
TERAZOL 7 – terconazole vaginal
cream 0.4%
3
JALYN – dutasteride-tamsulosin
hcl cap 0.5-0.4 mg
3
terconazole vaginal cream 0.4%
(Terazol 7)
1
2
terconazole vaginal cream 0.8%
(Terazol 3)
1
K-PHOS NO 2 – potassium &
sodium acid phosphates tab
305-700 mg
3
terconazole vaginal suppos
80 mg
1
LITHOSTAT – acetohydroxamic
acid tab 250 mg
2
finasteride tab 5 mg (Proscar)
1
•
1
ELMIRON – pentosan polysulfate
sodium caps 100 mg
Tier
*
Responsible Steps
1
1
KEY
Quantity Limits
2
alfuzosin hcl tab sr 24hr 10 mg
(Uroxatral)
dutasteride-tamsulosin hcl cap
0.5-0.4 mg (Jalyn)
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
•
78
ORACIT – sodium citrate & citric
acid soln 490-640 mg/5ml
3
tamsulosin hcl cap 0.4 mg
(Flomax)
1
phenazopyridine hcl tab 100 mg
(Pyridium)
1
THIOLA – tiopronin tab 100 mg
3
UROCIT-K 10 – potassium citrate
tab cr 10 meq (1080 mg)
3
phenazopyridine hcl tab 200 mg
(Pyridium)
1
1
3
pot & sod citrates w/ cit ac soln
550-500-334 mg/5ml
1
3
potassium citrate & citric acid
powder pack 3300-1002 mg
potassium citrate tab cr 5 meq
(540 mg) (Urocit-k 5)
(1080 mg) (Urocit-k 10)
(1620 mg) (Urocit-k 15)
ANXIETY
1
ALPRAZOLAM INTENSOL –
alprazolam conc 1 mg/ml
3
1
alprazolam orally disintegrating
tab 0.25 mg (Niravam)
1
3
PROCYSBI – cysteamine bitartrate
cap delayed release 75 mg (base
equiv)
3
PROSCAR – finasteride tab 5 mg
3
PYRIDIUM – phenazopyridine hcl
tab 100 mg
3
PYRIDIUM – phenazopyridine hcl
tab 200 mg
3
RAPAFLO – silodosin cap 4 mg
3
RAPAFLO – silodosin cap 8 mg
3
SHOHLS SOLUTION MODIFIED
– sodium citrate & citric acid soln
500-334 mg/5ml
3
sodium chloride irrigation soln
0.9%
1
X •
X •
tab 0.5 mg
tab 1 mg
tab 2 mg
Responsible Steps
Quantity Limits
1
1
1
alprazolam tab sr 24hr 1 mg
(Xanax xr)
1
(Xanax xr)
1
(Xanax xr)
1
alprazolam tab 0.25 mg (Xanax)
1
alprazolam tab 1 mg (Xanax)
alprazolam tab 2 mg (Xanax)
buspirone hcl tab 5 mg
buspirone hcl tab 7.5 mg
Tier
•
1
alprazolam tab sr 24hr 0.5 mg
(Xanax xr)
alprazolam tab 0.5 mg (Xanax)
1
sodium citrate & citric acid soln
500-334 mg/5ml (Shohls solution
modi)
KEY
X • •
CENTRAL NERVOUS SYSTEM DRUGS
1
PROCYSBI – cysteamine bitartrate
cap delayed release 25 mg (base
equiv)
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
1
1
1
1
1
79
chlordiazepoxide hcl cap 5 mg
clorazepate dipotassium tab
3.75 mg (Tranxene t)
7.5 mg (Tranxene t)
15 mg (Tranxene t)
1
hydroxyzine hcl tab 10 mg
1
DEPRESSION
amitriptyline hcl tab 10 mg
1
1
1
1
1
1
lorazepam conc 2 mg/ml
1
1
1
1
1
1
1
1
Responsible Steps
Quantity Limits
Prior Authorization
1
1
1
AMOXAPINE – amoxapine tab 25
mg
3
mg
3
mg
3
mg
3
ANAFRANIL – clomipramine hcl
cap 25 mg
3
cap 50 mg
3
cap 75 mg
3
bupropion hcl tab sr 12hr
100 mg (Wellbutrin sr)
1
•
1
•
1
1
(Elavil)
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
3
hydroxyzine pamoate cap 50 mg
(Vistaril)
KEY
1
VISTARIL – hydroxyzine pamoate
cap 50 mg
1
meprobamate tab 200 mg
1
1
1
hydroxyzine pamoate cap 25 mg
(Vistaril)
lorazepam tab 2 mg (Ativan)
1
3
3
lorazepam tab 1 mg (Ativan)
1
VISTARIL – hydroxyzine pamoate
cap 25 mg
HYDROXYZINE PAMOATE –
hydroxyzine pamoate cap 100
mg
lorazepam tab 0.5 mg (Ativan)
oxazepam cap 30 mg
1
1
hydroxyzine hcl syrup 10 mg/5ml
oxazepam cap 15 mg
1
diazepam conc 5 mg/ml
diazepam tab 10 mg (Valium)
oxazepam cap 10 mg
1
2
Drug Name
meprobamate tab 400 mg
1
DIAZEPAM – diazepam oral soln 1
mg/ml
Specialty/Tier 4
Drug Name
Drug Tier
2016
1
Tier
•
*
80
150 mg (Wellbutrin xl)
300 mg (Wellbutrin xl)
bupropion hcl tab 75 mg
bupropion hcl tab 100 mg
citalopram hydrobromide oral
soln 10 mg/5ml
citalopram hydrobromide tab
10 mg (base equiv) (Celexa)
DESVENLAFAXINE ER –
desvenlafaxine fumarate tab sr
24hr 100 mg (base equiv)
3
• •
DOXEPIN HCL – doxepin hcl cap
75 mg
2
1
doxepin hcl cap 10 mg
1
1
•
•
•
clomipramine hcl cap 75 mg
(Anafranil)
1
desipramine hcl tab 10 mg
(Norpramin)
1
(Norpramin)
1
1
doxepin hcl conc 10 mg/ml
duloxetine hcl enteric coated
pellets cap 20 mg (Cymbalta)
1
1
1
desvenlafaxine tab sr 24hr 50 mg
3
• •
desvenlafaxine tab sr 24hr 100
mg
3
• •
1
1
1
1
1
1
•
1
•
1
•
ELAVIL – amitriptyline hcl tab 25
mg
3
EMSAM – selegiline td patch 24hr
6 mg/24hr
3
9 mg/24hr
3
12 mg/24hr
3
escitalopram oxalate soln
5 mg/5ml (base equiv)
(Lexapro)
1
•
escitalopram oxalate tab 5 mg
(base equiv) (Lexapro)
1
•
1
•
Tier
•
Responsible Steps
• •
•
•
•
1
Quantity Limits
3
1
1
Prior Authorization
desvenlafaxine fumarate tab sr
24hr 50 mg (base equiv)
•
1
Specialty/Tier 4
Drug Name
1
1
KEY
Drug Tier
•
Responsible Steps
1
(Anafranil)
Quantity Limits
•
1
Prior Authorization
1
(Anafranil)
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
81
• •
FETZIMA – levomilnacipran
hcl cap sr 24hr 40 mg (base
equivalent)
3
equivalent)
3
equivalent)
3
FETZIMA TITRATION PACK –
levomilnacipran hcl cap sr 24hr
20 & 40 mg therapy pack
3
FLUOXETINE HCL – fluoxetine hcl
tab 60 mg
3
• •
fluoxetine hcl cap delayed
release 90 mg (Prozac weekly)
1
•
fluoxetine hcl cap 10 mg (Prozac) 1
•
•
•
•
• •
• •
fluvoxamine maleate cap sr 24hr
100 mg
fluvoxamine maleate cap sr 24hr
150 mg
fluvoxamine maleate tab 25 mg
KEY
1
imipramine hcl tab 25 mg
(Tofranil)
1
(Tofranil)
1
imipramine pamoate cap 75 mg
1
1
fluoxetine hcl solution
20 mg/5ml
1
fluoxetine hcl tab 10 mg
fluoxetine hcl tab 20 mg
(Tofranil)
• •
3
• •
KHEDEZLA – desvenlafaxine tab
sr 24hr 100 mg
3
• •
LEXAPRO – escitalopram oxalate
3
• •
MAPROTILINE HCL – maprotiline
hcl tab 25 mg
3
• •
hcl tab 50 mg
3
• •
hcl tab 75 mg
3
• •
MARPLAN – isocarboxazid tab 10
mg
3
mirtazapine orally disintegrating
tab 15 mg (Remeron soltab)
1
•
1
•
1
•
1
•
•
•
•
1
•
•
•
mirtazapine tab 7.5 mg
mirtazapine tab 15 mg (Remeron)
Tier
•
1
KHEDEZLA – desvenlafaxine tab
sr 24hr 50 mg
1
1
1
1
1
• •
• •
•
•
•
1
Responsible Steps
3
3
Quantity Limits
equivalent)
FORFIVO XL – bupropion hcl tab
sr 24hr 450 mg
Prior Authorization
•
Drug Name
Specialty/Tier 4
1
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
1
1
1
82
1
NARDIL – phenelzine sulfate tab
15 mg
3
NEFAZODONE HCL – nefazodone
hcl tab 100 mg
3
hcl tab 150 mg
3
hcl tab 200 mg
3
nefazodone hcl tab 50 mg
1
nefazodone hcl tab 250 mg
NORTRIPTYLINE HCL –
nortriptyline hcl soln 10 mg/5ml
nortriptyline hcl cap 10 mg
(Pamelor)
1
(Pamelor)
1
(Pamelor)
1
(Pamelor)
1
PAMELOR – nortriptyline hcl cap
10 mg
3
25 mg
3
50 mg
3
75 mg
3
PARNATE – tranylcypromine
sulfate tab 10 mg
3
paroxetine hcl tab sr 24hr
12.5 mg (Paxil cr)
1
KEY
paroxetine hcl tab sr 24hr
37.5 mg (Paxil cr)
paroxetine hcl tab 20 mg (Paxil)
PAXIL – paroxetine hcl oral susp
•
•
•
1
•
•
•
•
• •
1
1
1
3
1
• •
• •
• •
• •
• •
• •
• •
sertraline hcl oral conc 20 mg/ml
(Zoloft)
1
•
sertraline hcl tab 25 mg (Zoloft)
1
•
•
•
Tier
•
*
Responsible Steps
Quantity Limits
Prior Authorization
1
PEXEVA – paroxetine mesylate tab 3
10 mg (base equiv)
20 mg (base equiv)
30 mg (base equiv)
40 mg (base equiv)
1
phenelzine sulfate tab 15 mg
(Nardil)
2
PRISTIQ – desvenlafaxine
(base equiv)
2
(base equiv)
2
(base equiv)
1
protriptyline hcl tab 5 mg
protriptyline hcl tab 10 mg
Specialty/Tier 4
Drug Name
1
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
•
1
3
paroxetine hcl tab sr 24hr 25 mg
(Paxil cr)
Specialty/Tier 4
Drug Name
Drug Tier
2016
1
1
83
SURMONTIL – trimipramine
maleate cap 25 mg
3
maleate cap 50 mg
3
maleate cap 100 mg
3
tranylcypromine sulfate tab
10 mg (Parnate)
1
trazodone hcl tab 50 mg
1
1
1
1
trimipramine maleate cap 25 mg
(Surmontil)
1
trimipramine maleate cap 50 mg
(Surmontil)
1
trimipramine maleate cap
100 mg (Surmontil)
1
Responsible Steps
Quantity Limits
Prior Authorization
VENLAFAXINE HCL ER –
venlafaxine hcl tab sr 24hr 75 mg
(base equivalent)
3
• •
venlafaxine hcl tab sr 24hr 150
3
• •
venlafaxine hcl tab sr 24hr 225
2
• •
venlafaxine hcl tab sr 24hr
(Venlafaxine hcl er)
1
•
venlafaxine hcl tab sr 24hr 75 mg
(base equivalent) (Venlafaxine
hcl er)
1
•
venlafaxine hcl tab sr 24hr
(Venlafaxine hcl er)
1
•
venlafaxine hcl tab 25 mg
1
VIIBRYD – vilazodone hcl tab 10
mg
3
mg
3
• •
•
mg
3
• •
3
• •
•
VIIBRYD STARTER PACK –
vilazodone hcl tab starter kit 10
(7) & 20 (23) mg
ZOLOFT – sertraline hcl oral conc
20 mg/ml
3
• •
• •
venlafaxine hcl tab 37.5 mg
• •
3
TRINTELLIX – vortioxetine hbr tab
10 mg (base equiv)
3
20 mg (base equiv)
3
• •
venlafaxine hcl cap sr 24hr
(Effexor xr)
1
•
(Effexor xr)
1
(Effexor xr)
1
venlafaxine hcl tab sr 24hr 37.5
3
• •
1
1
1
1
PSYCHOTIC AND BIPOLAR DISORDERS
1
aripiprazole oral solution 1 mg/
ml
Tier
•
Specialty/Tier 4
Drug Name
•
•
•
•
•
• •
5 mg (base equiv)
KEY
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
•
84
aripiprazole tab 2 mg (Abilify)
chlorpromazine hcl tab 10 mg
1
1
1
1
1
1
1
1
1
1
CLOZAPINE ODT – clozapine
3
3
clozapine orally disintegrating
tab 25 mg (Fazaclo)
1
clozapine tab 50 mg
clozapine tab 100 mg (Clozaril)
clozapine tab 200 mg
1
1
1
1
3
CLOZARIL – clozapine tab 100 mg
3
EQUETRO – carbamazepine
(antipsychotic) cap sr 12hr 100
mg
3
3
mg
3
FANAPT – iloperidone tab 4 mg
3
3
3
3
FANAPT TITRATION PACK –
iloperidone tab 1 mg & 2 mg & 4
mg & 6 mg titration pak
3
FAZACLO – clozapine orally
disintegrating tab 12.5 mg
3
disintegrating tab 25 mg
3
3
3
3
FLUPHENAZINE HCL –
fluphenazine hcl elixir 2.5 mg/5ml
2
FLUPHENAZINE HCL –
fluphenazine hcl oral conc 5 mg/
ml
2
fluphenazine hcl tab 1 mg
1
haloperidol lactate oral conc
2 mg/ml
haloperidol tab 0.5 mg
Tier
•
*
Prior Authorization
Specialty/Tier 4
Drug Tier
mg
fluphenazine hcl tab 2.5 mg
1
CLOZARIL – clozapine tab 25 mg
KEY
•
•
•
•
•
•
1
Responsible Steps
•
3
clozapine tab 25 mg (Clozaril)
Quantity Limits
1
orally disintegrating tab 12.5 mg
clozapine orally disintegrating
tab 100 mg (Fazaclo)
Prior Authorization
•
Responsible Steps
aripiprazole orally disintegrating
tab 15 mg
1
Drug Name
Quantity Limits
aripiprazole orally disintegrating
tab 10 mg
Specialty/Tier 4
Drug Name
Drug Tier
2016
•
•
•
•
•
•
•
•
•
•
1
1
1
1
1
85
haloperidol tab 1 mg
1
1
1
lithium carbonate tab cr 300 mg
(Lithobid)
1
lithium carbonate tab cr 450 mg
1
1
lithium carbonate tab 300 mg
1
LITHOBID – lithium carbonate tab
cr 300 mg
3
loxapine succinate cap 5 mg
1
INVEGA – paliperidone tab sr 24hr
1.5 mg
3
• •
3 mg
3
• •
6 mg
3
• •
9 mg
3
LATUDA – lurasidone hcl tab 20
mg
1
1
1
1
• •
MOLINDONE HYDROCHLORIDE
– molindone hcl tab 5 mg
3
3
• •
3
3
• •
3
mg
• •
olanzapine orally disintegrating
tab 5 mg (Zyprexa zydis)
1
mg
3
•
• •
1
mg
3
•
• •
1
mg
3
•
LITHIUM – lithium oral solution 8
meq/5ml
2
1
•
3
1
LITHIUM CARBONATE – lithium
carbonate cap 150 mg
LITHIUM CARBONATE – lithium
carbonate cap 600 mg
3
olanzapine tab 7.5 mg (Zyprexa)
lithium carbonate cap 150 mg
(Lithium carbonate)
1
olanzapine tab 15 mg (Zyprexa)
1
(Lithium carbonate)
KEY
paliperidone tab sr 24hr 1.5 mg
(Invega)
1
•
•
•
•
•
•
•
paliperidone tab sr 24hr 3 mg
(Invega)
1
•
olanzapine tab 2.5 mg (Zyprexa)
1
Tier
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
1
1
1
1
1
86
•
perphenazine tab 2 mg
1
1
prochlorperazine suppos 25 mg
1
•
1
•
1
•
1
•
1
•
risperidone soln 1 mg/ml
(Risperdal)
1
•
risperidone tab 0.25 mg
(Risperdal)
1
•
risperidone tab 0.5 mg
(Risperdal)
1
•
risperidone tab 1 mg (Risperdal)
1
risperidone orally disintegrating
tab 2 mg (Risperdal m-tab)
1
prochlorperazine maleate tab
(Compazine)
1
1
1
•
tab 0.5 mg (Risperdal m-tab)
1
prochlorperazine maleate
(Compazine)
1
tab 0.25 mg
quetiapine fumarate tab 25 mg
(Seroquel)
1
•
(Seroquel)
1
•
(Seroquel)
1
•
(Seroquel)
1
•
(Seroquel)
1
(Seroquel)
Responsible Steps
1
Quantity Limits
(Invega)
Prior Authorization
•
Drug Name
Specialty/Tier 4
1
Drug Tier
(Invega)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
•
SAPHRIS – asenapine maleate sl
3
•
•
•
•
• •
1
•
3
• •
• •
3
REXULTI – brexpiprazole tab 0.25
mg
3
• •
• •
SEROQUEL XR – quetiapine
fumarate tab sr 24hr 50 mg
2
REXULTI – brexpiprazole tab 0.5
mg
3
• •
2
REXULTI – brexpiprazole tab 1 mg
3
• •
3
2
• •
3
3
2
• •
KEY
•
•
•
•
•
•
•
•
Tier
•
*
1
1
1
87
2
BUTISOL SODIUM – butabarbital
sodium tab 30 mg
3
thioridazine hcl tab 10 mg
1
1
estazolam tab 1 mg
1
thiothixene cap 1 mg
trifluoperazine hcl tab 1 mg
1
SLEEP AIDS
estazolam tab 2 mg
1
eszopiclone tab 1 mg (Lunesta)
1
1
1
1
1
1
1
1
1
1
1
1
FLURAZEPAM HCL – flurazepam
hcl cap 15 mg
3
FLURAZEPAM HCL – flurazepam
hcl cap 30 mg
3
HALCION – triazolam tab 0.25 mg
3
HETLIOZ – tasimelteon capsule 20
mg
3
PHENOBARBITAL – phenobarbital
tab 15 mg
2
tab 30 mg
2
VERSACLOZ – clozapine susp 50
mg/ml
3
• •
VRAYLAR – cariprazine hcl cap
therapy pack 1.5 mg (1) & 3 mg
(6)
3
• •
VRAYLAR – cariprazine hcl cap 1.5 3
3
VRAYLAR – cariprazine hcl cap 3
VRAYLAR – cariprazine hcl cap 4.5 3
3
VRAYLAR – cariprazine hcl cap 6
1
ziprasidone hcl cap 20 mg
(Geodon)
1
(Geodon)
1
(Geodon)
1
(Geodon)
• •
tab 60 mg
2
• •
tab 100 mg
2
• •
phenobarbital elixir 20 mg/5ml
1
• •
phenobarbital tab 32.4 mg
•
KEY
•
•
•
1
SECONAL SODIUM – secobarbital
sodium cap 100 mg
SONATA – zaleplon cap 5 mg
3
SONATA – zaleplon cap 10 mg
3
temazepam cap 7.5 mg (Restoril)
1
•
Responsible Steps
Quantity Limits
1
3
*
X • •
1
3
•
•
•
1
ROZEREM – ramelteon tab 8 mg
Tier
Prior Authorization
Drug Name
Specialty/Tier 4
• •
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
• •
• •
• •
88
temazepam cap 15 mg (Restoril)
1
temazepam cap 22.5 mg
(Restoril)
1
temazepam cap 30 mg (Restoril)
1
TRIAZOLAM – triazolam tab 0.125
mg
3
triazolam tab 0.25 mg (Halcion)
1
• •
ADDERALL XR – amphetaminedextroamphetamine cap sr 24hr
15 mg
3
• •
20 mg
3
• •
25 mg
3
• •
30 mg
3
• •
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
zolpidem tartrate tab cr 12.5 mg
(Ambien cr)
1
•
zolpidem tartrate tab 5 mg
(Ambien)
1
•
zolpidem tartrate tab 10 mg
(Ambien)
1
•
amphetaminedextroamphetamine cap sr
24hr 5 mg (Adderall xr)
• •
HYPERACTIVITY/NARCOLEPSY
1
ADDERALL – amphetaminedextroamphetamine tab 5 mg
3
ADDERALL – amphetaminedextroamphetamine tab 7.5 mg
3
• •
3
• •
ADDERALL – amphetaminedextroamphetamine tab 12.5 mg
3
• •
3
• •
3
• •
3
• •
5 mg
3
• •
KEY
amphetaminedextroamphetamine tab 5 mg
(Adderall)
Tier
•
*
Responsible Steps
3
zolpidem tartrate tab cr 6.25 mg
(Ambien cr)
zaleplon cap 10 mg (Sonata)
1
Quantity Limits
10 mg
•
•
•
zaleplon cap 5 mg (Sonata)
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
89
•
amphetaminedextroamphetamine tab
12.5 mg (Adderall)
1
•
1
clonidine hcl tab sr 12hr 0.1 mg
(Kapvay)
1
•
CONCERTA – methylphenidate hcl
tab sa osm 18 mg
2
• •
tab sa osm 27 mg
2
• •
tab sa osm 36 mg
2
• •
tab sa osm 54 mg
2
• •
DAYTRANA – methylphenidate td
patch 10 mg/9hr
3
• •
patch 15 mg/9hr
3
• •
(Adderall)
1
•
(Adderall)
1
•
(Adderall)
1
•
APTENSIO XR – methylphenidate
hcl cap er 24hr 10 mg (xr)
3
• •
patch 20 mg/9hr
3
• •
3
• •
patch 30 mg/9hr
3
• •
3
• •
DESOXYN – methamphetamine
hcl tab 5 mg
3
• •
3
• •
3
• •
3
• •
DEXEDRINE –
dextroamphetamine sulfate cap
sr 24hr 5 mg
3
• •
3
• •
DEXEDRINE –
sr 24hr 10 mg
3
• •
3
• •
ARMODAFINIL – armodafinil tab
200 mg
3
• •
DEXEDRINE –
sr 24hr 15 mg
1
•
armodafinil tab 50 mg (Nuvigil)
1
• •
• •
• •
dexmethylphenidate hcl cap sr
24 hr 5 mg (Focalin xr)
1
•
KEY
1
1
Tier
•
*
Responsible Steps
1
Quantity Limits
(Adderall)
caffeine citrate oral soln
60 mg/3ml (10 mg/ml base
equiv)
Prior Authorization
•
Drug Name
Specialty/Tier 4
1
Drug Tier
amphetaminedextroamphetamine tab 7.5 mg
(Adderall)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
90
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
DYANAVEL XR – amphetamine
extended release susp 2.5 mg/ml
3
• •
FOCALIN – dexmethylphenidate
hcl tab 2.5 mg
3
• •
hcl tab 5 mg
3
• •
hcl tab 10 mg
3
• •
FOCALIN XR –
24 hr 5 mg
3
• •
dexmethylphenidate hcl tab
2.5 mg (Focalin)
5 mg (Focalin)
10 mg (Focalin)
sr 24hr 5 mg (Dexedrine)
dextroamphetamine sulfate oral
solution 5 mg/5ml (Procentra)
dextroamphetamine sulfate tab
5 mg
dextroamphetamine sulfate tab
10 mg
KEY
3
• •
FOCALIN XR –
24 hr 15 mg
3
• •
FOCALIN XR –
24 hr 20 mg
3
• •
FOCALIN XR –
24 hr 25 mg
3
• •
FOCALIN XR –
24 hr 30 mg
3
• •
FOCALIN XR –
24 hr 35 mg
3
• •
FOCALIN XR –
24 hr 40 mg
3
• •
guanfacine hcl tab sr 24hr 1 mg
(base equiv) (Intuniv)
1
•
1
•
1
•
1
•
KAPVAY – clonidine hcl tab sr 12hr
0.1 mg
3
• •
METADATE CD – methylphenidate
hcl cap cr 10 mg (cd)
3
• •
3
• •
3
• •
•
*
Responsible Steps
FOCALIN XR –
24 hr 10 mg
Tier
Quantity Limits
•
Prior Authorization
1
Drug Name
Specialty/Tier 4
•
Drug Tier
1
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
91
• •
3
• •
methamphetamine hcl tab 5 mg
(Desoxyn)
1
•
METHYLIN – methylphenidate hcl
chew tab 2.5 mg
3
• •
chew tab 5 mg
3
• •
chew tab 10 mg
3
• •
soln 5 mg/5ml
3
• •
soln 10 mg/5ml
3
• •
methylphenidate hcl cap cr
10 mg (cd) (Metadate cd)
1
•
1
•
1
•
methylphenidate hcl cap sr 24hr
20 mg (la) (Ritalin la)
KEY
1
•
1
•
1
•
•
1
•
1
•
1
1
•
1
•
1
•
METHYLPHENIDATE HCL ER –
methylphenidate hcl tab sa osm
18 mg
3
• •
27 mg
3
• •
36 mg
3
• •
54 mg
3
• •
methylphenidate hcl tab sr 24hr
18 mg
3
• •
27 mg
3
• •
36 mg
3
• •
54 mg
3
• •
methylphenidate hcl soln
5 mg/5ml (Methylin)
1
•
1
•
1
•
1
•
methylphenidate hcl chew tab
2.5 mg (Methylin)
5 mg (Methylin)
10 mg (Methylin)
methylphenidate hcl soln
10 mg/5ml (Methylin)
methylphenidate hcl tab cr
10 mg
methylphenidate hcl tab cr
20 mg
Tier
•
*
Responsible Steps
3
Quantity Limits
Prior Authorization
• •
Drug Name
Specialty/Tier 4
3
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
92
•
methylphenidate hcl tab 20 mg
(Ritalin)
1
•
modafinil tab 100 mg (Provigil)
1
modafinil tab 200 mg (Provigil)
•
•
•
•
•
•
•
1
•
•
•
•
•
•
•
NUVIGIL – armodafinil tab 50 mg
3
3
3
3
PROCENTRA –
dextroamphetamine sulfate oral
solution 5 mg/5ml
3
QUILLICHEW ER –
extended release 20 mg
3
• •
QUILLICHEW ER –
3
• •
QUILLICHEW ER –
3
• •
QUILLIVANT XR –
methylphenidate hcl for er susp
25 mg/5ml (5 mg/ml)
3
• •
RITALIN – methylphenidate hcl tab
5 mg
3
10 mg
3
20 mg
3
RITALIN LA – methylphenidate hcl
cap sr 24hr 10 mg (la)
3
KEY
• •
• •
• •
• •
3
• •
3
• •
3
• •
3
• •
STRATTERA – atomoxetine hcl
3
• •
3
• •
3
• •
3
• •
3
• •
3
• •
3
• •
VYVANSE – lisdexamfetamine
dimesylate cap 10 mg
3
• •
3
• •
3
• •
3
• •
3
• •
3
• •
3
• •
Tier
•
*
Responsible Steps
1
Quantity Limits
(Ritalin)
Prior Authorization
•
Drug Name
Specialty/Tier 4
1
Drug Tier
(Ritalin)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
93
• •
ZENZEDI – dextroamphetamine
sulfate tab 15 mg
3
• •
sulfate tab 20 mg
3
• •
sulfate tab 30 mg
3
• •
AMPYRA – dalfampridine tab sr
12hr 10 mg
3
X • •
AUBAGIO – teriflunomide tab 7 mg
3
AUBAGIO – teriflunomide tab 14
mg
3
X • •
X • •
AVONEX – interferon beta-1a im
prefilled syringe kit 30 mcg/0.5ml
3
X • •
AVONEX – interferon beta-1a for
im inj kit 30mcg (33mcg(6.6 mu)/
vial)
3
X • •
AVONEX PEN – interferon beta-1a
im auto-injector kit 30 mcg/0.5ml
3
X • •
BETASERON – interferon beta-1b
for inj kit 0.3 mg
2
X • •
COPAXONE – glatiramer acetate
2
X • •
COPAXONE – glatiramer acetate
2
X • •
EXTAVIA – interferon beta-1b for
inj kit 0.3 mg
3
X • •
GILENYA – fingolimod hcl cap 0.5
mg (base equiv)
3
X • •
glatiramer acetate soln prefilled
syringe 20 mg/ml (Copaxone)
1
X • •
MULTIPLE SCLEROSIS
KEY
X • •
X • •
X • •
X • •
X • •
X • •
X • •
X • •
X • •
X • •
X • •
X • •
OTHER CENTRAL NERVOUS SYSTEM DRUGS
1
acamprosate calcium tab
Tier
•
X • •
Responsible Steps
3
Quantity Limits
sulfate tab 7.5 mg
PLEGRIDY – peginterferon beta-1a 2
soln pen-injector 125 mcg/0.5ml
2
PLEGRIDY – peginterferon
beta-1a soln prefilled syringe 125
mcg/0.5ml
2
PLEGRIDY STARTER PACK –
peginterferon beta-1a soln peninj 63 & 94 mcg/0.5ml pack
2
PLEGRIDY STARTER PACK –
peginterferon beta-1a soln pref
syr 63 & 94 mcg/0.5ml pack
2
REBIF – interferon beta-1a soln
pref syr 22 mcg/0.5ml (12mu/ml)
2
REBIF – interferon beta-1a soln
pref syr 44 mcg/0.5ml (24mu/ml)
2
REBIF REBIDOSE – interferon
beta-1a soln auto-inj 22
mcg/0.5ml (12mu/ml)
2
REBIF REBIDOSE – interferon
beta-1a soln auto-inj 44
mcg/0.5ml (24mu/ml)
2
REBIF REBIDOSE TITRATION –
interferon beta-1a auto-inj 6x8.8
mcg/0.2ml & 6x22 mcg/0.5ml
2
REBIF TITRATION PACK –
interferon beta-1a pref syr 6x8.8
mcg/0.2ml & 6x22 mcg/0.5ml
2
TECFIDERA – dimethyl fumarate
capsule delayed release 120 mg
2
TECFIDERA – dimethyl fumarate
capsule delayed release 240 mg
2
TECFIDERA STARTER PACK –
dimethyl fumarate capsule dr
starter pack 120 mg & 240 mg
Prior Authorization
• •
Drug Name
Specialty/Tier 4
3
Drug Tier
sulfate tab 2.5 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
94
ANTABUSE – disulfiram tab 250
mg
3
EXELON – rivastigmine td patch
24hr 13.3 mg/24hr
3
ANTABUSE – disulfiram tab 500
mg
3
EXELON – rivastigmine tartrate
cap 1.5 mg
3
ARICEPT – donepezil
3
cap 3 mg
3
3
cap 4.5 mg
3
3
cap 6 mg
3
BRISDELLE – paroxetine mesylate
cap 7.5 mg (base equiv)
3
FLUOXETINE – fluoxetine hcl
(pmdd) cap 10 mg
3
CHLORDIAZEPOXIDE/AMITRIPT
– chlordiazepoxide-amitriptyline
tab 5-12.5 mg
3
FLUOXETINE – fluoxetine hcl
(pmdd) cap 20 mg
3
3
3
CHLORDIAZEPOXIDE/AMITRIPT
– chlordiazepoxide-amitriptyline
tab 10-25 mg
GALANTAMINE HYDROBROMIDE
– galantamine hydrobromide oral
soln 4 mg/ml
1
galantamine hydrobromide cap
sr 24hr 8 mg (Razadyne er)
1
disulfiram tab 250 mg (Antabuse)
disulfiram tab 500 mg (Antabuse)
1
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
1
1
1
1
galantamine hydrobromide tab
4 mg (Razadyne)
1
8 mg (Razadyne)
1
12 mg (Razadyne)
3
•
ERGOLOID MESYLATES –
ergoloid mesylates tab 1 mg
3
GRALISE – gabapentin (oncedaily) tab 300 mg
3
•
24hr 4.6 mg/24hr
3
GRALISE – gabapentin (oncedaily) tab 600 mg
3
•
24hr 9.5 mg/24hr
3
GRALISE STARTER – gabapentin
(once-daily) tab pack 300 mg (9)
& 600 mg (69)
donepezil hydrochloride orally
donepezil hydrochloride orally
donepezil hydrochloride tab
5 mg (Aricept)
10 mg (Aricept)
23 mg (Aricept)
KEY
Tier
•
*
1
1
1
1
95
3
•
memantine hcl oral solution
2 mg/ml (Namenda)
1
memantine hcl tab 5 mg
(Namenda)
1
memantine hcl tab 10 mg
(Namenda)
1
memantine hcl tab 5 mg (28)
& 10 mg (21) titration pak
(Namenda titration pa)
1
naltrexone hcl tab 50 mg
1
NAMENDA – memantine hcl oral
solution 2 mg/ml
3
NAMENDA – memantine hcl tab 5
mg
3
3
NAMZARIC – memantine hcldonepezil hcl cap sr 24hr 28-10
mg
3
NUEDEXTA – dextromethorphan
hbr-quinidine sulfate cap 20-10
mg
3
olanzapine-fluoxetine hcl cap
3-25 mg (Symbyax)
1
•
1
•
1
•
1
•
1
•
6-25 mg (Symbyax)
6-50 mg (Symbyax)
12-25 mg (Symbyax)
12-50 mg (Symbyax)
NAMENDA – memantine hcl tab 10 3
mg
3
NAMENDA TITRATION PAK –
memantine hcl tab 5 mg (28) &
10 mg (21) titration pak
2
NAMENDA XR – memantine hcl
cap sr 24hr 7 mg
2
cap sr 24hr 14 mg
2
cap sr 24hr 21 mg
2
cap sr 24hr 28 mg
2
NAMENDA XR TITRATION PACK
– memantine hcl cap sr 24hr 7
mg & 14 mg & 21 mg & 28 mg
pack
KEY
NAMZARIC – memantine hcldonepezil hcl cap sr 24hr 14-10
mg
ORAP – pimozide tab 1 mg
3
ORAP – pimozide tab 2 mg
3
PERPHENAZINE/AMITRIPTYLIN
– perphenazine-amitriptyline tab
2-10 mg
3
2-25 mg
3
4-10 mg
3
4-25 mg
3
4-50 mg
3
pimozide tab 1 mg (Orap)
1
Tier
•
*
Responsible Steps
HORIZANT – gabapentin enacarbil
tab cr 600 mg
Quantity Limits
•
Prior Authorization
3
Drug Name
Specialty/Tier 4
HORIZANT – gabapentin enacarbil
tab cr 300 mg
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
96
pimozide tab 2 mg (Orap)
1
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
3
• •
RAZADYNE – galantamine
hydrobromide tab 4 mg
3
SAVELLA – milnacipran hcl tab 50
mg
3
• •
3
SAVELLA – milnacipran hcl tab
100 mg
3
• •
3
SAVELLA TITRATION PACK –
milnacipran hcl tab 12.5 mg (5) &
25 mg (8) & 50 mg (42) pak
RAZADYNE ER – galantamine
hydrobromide cap sr 24hr 8 mg
3
SYMBYAX – olanzapine-fluoxetine
hcl cap 3-25 mg
3
• •
3
hcl cap 6-25 mg
3
• •
3
hcl cap 6-50 mg
3
• •
rivastigmine tartrate cap 1.5 mg
(Exelon)
1
hcl cap 12-25 mg
3
• •
rivastigmine tartrate cap 3 mg
(Exelon)
1
hcl cap 12-50 mg
3
• •
rivastigmine tartrate cap 4.5 mg
(Exelon)
1
tetrabenazine tab 12.5 mg
(Xenazine)
1
X • •
rivastigmine tartrate cap 6 mg
(Exelon)
1
tetrabenazine tab 25 mg
(Xenazine)
1
X • •
rivastigmine td patch 24hr
4.6 mg/24hr (Exelon)
1
XENAZINE – tetrabenazine tab
12.5 mg
3
X • •
1
XENAZINE – tetrabenazine tab 25
mg
3
X • •
1
XYREM – sodium oxybate oral
solution 500 mg/ml
3
X • •
SARAFEM – fluoxetine hcl (pmdd)
tab 10 mg
3
TOBACCO CESSATION
1
SARAFEM – fluoxetine hcl (pmdd)
tab 20 mg
3
bupropion hcl (smoking
deterrent) tab sr 12hr 150 mg
(Zyban)
SAVELLA – milnacipran hcl tab
12.5 mg
3
• •
CHANTIX – varenicline tartrate tab
0.5 mg (base equiv)
2
SAVELLA – milnacipran hcl tab 25
mg
3
• •
CHANTIX – varenicline tartrate tab
1 mg (base equiv)
2
KEY
Tier
•
*
97
CHANTIX CONTINUING MONTH
– varenicline tartrate tab 1 mg
(base equiv)
2
CHANTIX STARTING MONTH PA
– varenicline tartrate tab 0.5 mg x
11 & tab 1 mg x 42 pack
2
nicotine polacrilex gum 2 mg
1
DISALCID – salsalate tab 500 mg
3
DISALCID – salsalate tab 750 mg
3
salsalate tab 500 mg (Disalcid)
1
salsalate tab 750 mg (Disalcid)
NARCOTIC DRUGS
1
1
•
1
•
1
•
1
•
1
•
ACTIQ – fentanyl citrate lozenge
on a handle 200 mcg
3
• •
on a handle 400 mcg
3
• •
1
on a handle 600 mcg
3
• •
1
•
on a handle 800 mcg
3
• •
1
•
on a handle 1200 mcg
3
butalbital-acetaminophencaffeine cap 50-300-40 mg
(Fioricet)
• •
3
• •
butalbital-acetaminophencaffeine cap 50-325-40 mg
1
•
on a handle 1600 mcg
3
butalbital-acetaminophencaffeine tab 50-325-40 mg
(Esgic)
1
•
ASPIRIN-CAFFEINE-DIHYDROC
– aspirin-caffeine-dihydrocodeine
cap 356.4-30-16 mg
1
• •
butalbital-aspirin-caffeine cap
50-325-40 mg (Fiorinal)
1
buprenorphine hcl sl tab 2 mg
(base equiv)
1
• •
nicotine polacrilex gum 4 mg
nicotine td patch 24hr 7 mg/24hr
nicotine td patch 24hr
14 mg/24hr
nicotine td patch 24hr
21 mg/24hr
acetaminophen w/ codeine soln
120-12 mg/5ml
1
acetaminophen w/ codeine tab
300-15 mg (Tylenol/codeine)
1
1
300-30 mg (Tylenol/codeine #3)
1
NICOTROL INHALER* – nicotine
inhaler system 10 mg (4 mg
delivered)
2
NICOTROL NS* – nicotine nasal
spray 10 mg/ml (0.5 mg/spray)
2
300-60 mg (Tylenol/codeine #4)
acetaminophen-caffeinedihydrocodeine cap
320.5-30-16 mg (Trezix)
PAIN RELIEF DRUGS
NON-NARCOTIC DRUGS
aspirin chew tab 81 mg
aspirin tab delayed release
81 mg
butalbital-acetaminophen tab
50-325 mg
diflunisal tab 500 mg
KEY
1
•
1
buprenorphine hcl sl tab 8 mg
(base equiv)
Tier
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
98
butorphanol tartrate nasal soln
10 mg/ml
1
DOLOPHINE – methadone hcl tab
10 mg
3
•
EMBEDA – morphine-naltrexone
cap cr 20-0.8 mg
3
• •
cap cr 30-1.2 mg
3
• •
3
• •
cap cr 50-2 mg
3
BUTRANS – buprenorphine td
patch weekly 5 mcg/hr
• •
• •
cap cr 60-2.4 mg
3
patch weekly 7.5 mcg/hr
3
• •
• •
cap cr 80-3.2 mg
3
3
• •
• •
cap cr 100-4 mg
3
3
• •
3
• •
3
EXALGO – hydromorphone hcl tab
er 24hr deter 8 mg
• •
3
•
er 24hr deter 12 mg
3
CAPITAL/CODEINE –
acetaminophen w/ codeine susp
120-12 mg/5ml
• •
3
• •
CODEINE SULFATE – codeine
sulfate tab 15 mg
3
•
er 24hr deter 16 mg
3
• •
sulfate tab 30 mg
3
•
er 24hr deter 32 mg
3
• •
sulfate tab 60 mg
3
•
FENTANYL – fentanyl td patch
72hr 37.5 mcg/hr
3
• •
codeine sulfate tab 15 mg
(Codeine sulfate)
1
•
72hr 62.5 mcg/hr
3
• •
(Codeine sulfate)
1
•
72hr 87.5 mcg/hr
1
• •
(Codeine sulfate)
1
•
fentanyl citrate lozenge on a
handle 200 mcg (Actiq)
1
• •
DILAUDID – hydromorphone hcl
liqd 1 mg/ml
3
•
1
• •
DOLOPHINE – methadone hcl tab
5 mg
3
•
1
• •
KEY
Tier
•
*
Responsible Steps
•
Quantity Limits
1
Prior Authorization
butalbital-aspirin-caff w/ codeine
cap 50-325-40-30 mg (Fiorinal/
codeine #3)
Drug Name
Specialty/Tier 4
•
Drug Tier
1
butalbital-acetaminophen-caff w/
cod cap 50-325-40-30 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
99
1
• •
fentanyl td patch 72hr 25 mcg/hr
(Duragesic)
1
• •
(Duragesic)
1
• •
(Duragesic)
1
fentanyl td patch 72hr 100 mcg/
hr (Duragesic)
1
• •
• •
•
FIORINAL/CODEINE #3 –
butalbital-aspirin-caff w/ codeine
cap 50-325-40-30 mg
3
hydrocodone-acetaminophen
soln 7.5-325 mg/15ml (Hycet)
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
soln 10-325 mg/15ml (Zamicet)
tab 2.5-325 mg
tab 10-325 mg (Norco)
tab 5-300 mg (Xodol)
tab 7.5-300 mg (Xodol)
tab 5-325 mg (Norco)
tab 7.5-325 mg (Norco)
tab 10-300 mg (Xodol)
hydrocodone-ibuprofen tab
5-200 mg (Reprexain)
KEY
•
1
•
HYDROMORPHONE HCL –
hydromorphone hcl suppos 3 mg
3
HYDROMORPHONE HCL ER –
hydromorphone hcl tab er 24hr
deter 32 mg
3
• •
hydromorphone hcl liqd 1 mg/ml
(Dilaudid)
1
•
deter 8 mg (Exalgo)
1
• •
1
• •
1
• •
hydromorphone hcl tab 2 mg
(Dilaudid)
1
•
(Dilaudid)
1
•
(Dilaudid)
1
•
KADIAN – morphine sulfate cap sr
24hr 10 mg
3
• •
24hr 20 mg
3
• •
24hr 30 mg
3
• •
24hr 40 mg
3
• •
24hr 50 mg
3
• •
24hr 60 mg
3
• •
24hr 80 mg
3
• •
deter 12 mg (Exalgo)
deter 16 mg (Exalgo)
Tier
•
1
*
Responsible Steps
(Duragesic)
10-200 mg (Ibudone)
Quantity Limits
• •
7.5-200 mg (Vicoprofen)
Prior Authorization
1
Drug Name
Specialty/Tier 4
• •
Drug Tier
1
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
100
• •
MEPERIDINE HCL – meperidine
hcl oral soln 50 mg/5ml
3
•
meperidine hcl tab 50 mg
1
•
•
meperidine hcl tab 100 mg
1
MEPERIDINE HCL/PROMETHAZI
– meperidine w/ promethazine
cap 50-25 mg
3
METHADONE HCL – methadone
hcl soln 5 mg/5ml
3
METHADONE HCL – methadone
hcl soln 10 mg/5ml
3
methadone hcl conc 10 mg/ml
(Methadose)
1
methadone hcl soln 5 mg/5ml
(Methadone hcl)
1
methadone hcl soln 10 mg/5ml
(Methadone hcl)
1
methadone hcl tab for oral susp
40 mg
1
•
•
•
•
•
•
methadone hcl tab 5 mg
(Dolophine)
1
•
methadone hcl tab 10 mg
(Dolophine)
1
•
METHADOSE – methadone hcl
conc 10 mg/ml
3
•
METHADOSE SUGAR-FREE –
methadone hcl conc 10 mg/ml
3
•
MORPHINE SULFATE – morphine
sulfate tab 15 mg
2
•
sulfate tab 30 mg
2
•
KEY
sulfate suppos 5 mg
3
sulfate suppos 10 mg
3
3
2
morphine sulfate cap sr 24hr
10 mg (Kadian)
1
• •
1
• •
1
• •
1
• •
1
• •
1
• •
1
• •
MORPHINE SULFATE ER –
morphine sulfate beads cap sr
24hr 30 mg
3
• •
24hr 45 mg
3
• •
24hr 60 mg
3
• •
24hr 75 mg
3
• •
24hr 90 mg
3
• •
20 mg (Kadian)
30 mg (Kadian)
50 mg (Kadian)
60 mg (Kadian)
80 mg (Kadian)
100 mg (Kadian)
Tier
•
*
Responsible Steps
3
Quantity Limits
24hr 200 mg
Prior Authorization
• •
Drug Name
Specialty/Tier 4
3
Drug Tier
24hr 100 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
101
3
morphine sulfate oral soln
10 mg/5ml
1
•
1
•
1
•
20 mg/5ml
100 mg/5ml (20 mg/ml)
morphine sulfate tab cr 15 mg
(Ms contin)
1
• •
(Ms contin)
1
• •
(Ms contin)
1
• •
(Ms contin)
1
• •
(Ms contin)
1
• •
NUCYNTA – tapentadol hcl tab 50
mg
3
•
NUCYNTA – tapentadol hcl tab 75
mg
3
•
•
NUCYNTA – tapentadol hcl tab 100 3
mg
NUCYNTA ER – tapentadol hcl tab 2
sr 12hr 50 mg
sr 12hr 100 mg
sr 12hr 150 mg
sr 12hr 200 mg
sr 12hr 250 mg
3
OPANA – oxymorphone hcl tab 5
mg
KEY
• •
• •
• •
• •
• •
•
OPANA – oxymorphone hcl tab 10
mg
3
•
OPANA ER (CRUSH RESISTANT
– oxymorphone hcl tab er 12hr
deter 5 mg
3
• •
deter 7.5 mg
3
• •
deter 10 mg
3
• •
deter 15 mg
3
• •
deter 20 mg
3
• •
deter 30 mg
3
• •
deter 40 mg
3
• •
oxycodone hcl cap 5 mg
1
1
•
•
OXYCODONE HCL ER –
oxycodone hcl tab er 12hr deter
10 mg
3
• •
15 mg
3
• •
20 mg
3
• •
30 mg
3
• •
oxycodone hcl conc 100 mg/5ml
(20 mg/ml)
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Tier
Drug Tier
• •
24hr 120 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
102
3
60 mg
3
80 mg
3
• •
oxycodone hcl soln 5 mg/5ml
1
•
•
oxycodone hcl tab 5 mg
(Roxicodone)
1
1
(Roxicodone)
1
1
• •
•
•
• •
OXYCONTIN – oxycodone hcl tab
er 12hr deter 20 mg
2
• •
er 12hr deter 30 mg
2
• •
er 12hr deter 40 mg
2
• •
er 12hr deter 60 mg
2
• •
er 12hr deter 80 mg
2
• •
oxymorphone hcl tab sr 12hr
5 mg
1
• •
1
• •
1
• •
1
• •
1
• •
1
• •
1
• •
oxymorphone hcl tab 5 mg
(Opana)
1
•
oxymorphone hcl tab 10 mg
(Opana)
1
•
1
7.5 mg
1
oxycodone w/ acetaminophen
tab 2.5-325 mg (Percocet)
1
•
1
•
1
•
1
•
1
•
OXYCODONE/ACETAMINOPHEN
– oxycodone w/ acetaminophen
soln 5-325 mg/5ml
3
•
OXYCODONE/IBUPROFEN –
oxycodone-ibuprofen tab 5-400
mg
3
pentazocine w/ naloxone tab
50-0.5 mg
3
er 12hr deter 10 mg
2
SYNALGOS-DC – aspirin-caffeinedihydrocodeine cap 356.4-30-16
mg
tramadol hcl tab sr 24hr 100 mg
1
tab 10-325 mg (Percocet)
oxycodone-aspirin tab
4.8355-325 mg (Percodan)
KEY
• •
10 mg
15 mg
20 mg
30 mg
40 mg
Tier
•
*
Responsible Steps
2
(Roxicodone)
tab 7.5-325 mg (Percocet)
Quantity Limits
er 12hr deter 15 mg
•
•
tab 5-325 mg (Percocet)
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
• •
40 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
• •
103
tramadol hcl tab sr 24hr biphasic
release 100 mg
1
• •
1
• •
1
• •
CELEBREX – celecoxib cap 100
mg
3
1
•
•
mg
3
mg
3
celecoxib cap 50 mg (Celebrex)
1
release 200 mg
release 300 mg
tramadol hcl tab 50 mg (Ultram)
tramadol-acetaminophen tab
37.5-325 mg (Ultracet)
1
•
TREZIX – acetaminophen-caffeine- 3
dihydrocodeine cap 320.5-30-16
mg
3
TYLENOL/CODEINE –
300-15 mg
3
TYLENOL/CODEINE #3 –
300-30 mg
3
TYLENOL/CODEINE #4 –
300-60 mg
3
ZAMICET – hydrocodoneacetaminophen soln 10-325
mg/15ml
•
3
ARCALYST – rilonacept for inj 220
mg
3
KEY
3
ARTHROTEC 75 – diclofenac w/
misoprostol tab delayed release
75-0.2 mg
3
CELEBREX – celecoxib cap 50 mg
3
•
•
•
RHEUMATOID AND OSTEOARTHRITIS
3
ACTEMRA – tocilizumab
syringe 162 mg/0.9ml
ANAPROX DS – naproxen sodium 3
tab 550 mg
3
ARAVA – leflunomide tab 10 mg
ARAVA – leflunomide tab 20 mg
ARTHROTEC 50 – diclofenac w/
misoprostol tab delayed release
50-0.2 mg
X • •
X • •
1
1
3
diclofenac potassium tab 50 mg
1
diclofenac sodium tab delayed
release 50 mg
release 75 mg
diclofenac sodium tab sr 24hr
100 mg
1
1
1
1
diclofenac w/ misoprostol tab
delayed release 50-0.2 mg
(Arthrotec 50)
1
diclofenac w/ misoprostol tab
delayed release 75-0.2 mg
(Arthrotec 75)
1
EC-NAPROSYN – naproxen tab ec 3
375 mg
Tier
•
1
DAYPRO – oxaprozin tab 600 mg
release 25 mg
Responsible Steps
1
1
Quantity Limits
(Ultram er)
• •
• •
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Drug Tier
Drug Name
Specialty/Tier 4
2016
*
104
EC-NAPROSYN – naproxen tab ec 3
500 mg
2
ENBREL – etanercept for
2
ENBREL – etanercept
syringe 25 mg/0.5ml
2
ENBREL – etanercept
syringe 50 mg/ml
2
ENBREL SURECLICK –
etanercept subcutaneous
solution auto-injector 50 mg/ml
1
etodolac cap 200 mg
etodolac cap 300 mg
etodolac tab sr 24hr 400 mg
etodolac tab 400 mg
etodolac tab 500 mg
FENOPROFEN CALCIUM –
fenoprofen calcium cap 200 mg
3
fenoprofen calcium cap 400 mg
3
FENORTHO – fenoprofen calcium
cap 200 mg
3
FENORTHO – fenoprofen calcium
cap 400 mg
3
flurbiprofen tab 50 mg
1
2
X • •
X • •
HUMIRA PEDIATRIC CROHNS D
– adalimumab prefilled syringe kit
40 mg/0.8ml
2
X • •
X • •
HUMIRA PEN – adalimumab peninjector kit 40 mg/0.8ml
2
X • •
HUMIRA PEN-CROHNS DISEASE
– adalimumab pen-injector kit 40
mg/0.8ml
2
X •
HUMIRA PEN-PSORIASIS STAR
– adalimumab pen-injector kit 40
mg/0.8ml
2
X •
ibuprofen susp 100 mg/5ml
1
ibuprofen tab 400 mg
1
1
1
INDOCIN – indomethacin susp 25
mg/5ml
3
INDOCIN – indomethacin suppos
50 mg
3
indomethacin cap cr 75 mg
1
indomethacin cap 25 mg
indomethacin cap 50 mg
ketoprofen cap 50 mg
ketoprofen cap 75 mg
1
1
1
1
KETOPROFEN ER – ketoprofen
cap sr 24hr 200 mg
3
ketorolac tromethamine tab
10 mg
1
Tier
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
HUMIRA – adalimumab prefilled
syringe kit 40 mg/0.8ml
X • •
1
Drug Tier
X • •
1
3
Responsible Steps
2
1
fenoprofen calcium tab 600 mg
Quantity Limits
X • •
1
3
Prior Authorization
X • •
1
FELDENE – piroxicam cap 20 mg
KEY
2
1
3
Drug Name
1
FELDENE – piroxicam cap 10 mg
flurbiprofen tab 100 mg
Specialty/Tier 4
Drug Name
Drug Tier
2016
•
105
KINERET – anakinra
syringe 100 mg/0.67ml
3
leflunomide tab 10 mg (Arava)
1
leflunomide tab 20 mg (Arava)
1
X • •
OTEZLA – apremilast tab starter
therapy pack 10 mg & 20 mg &
30 mg
3
X • •
OTEZLA – apremilast tab 30 mg
3
X • •
OTREXUP – methotrexate soln pf
auto-injector 7.5 mg/0.4ml
3
auto-injector 10 mg/0.4ml
3
MECLOFENAMATE SODIUM –
meclofenamate sodium cap 100
mg
3
mefenamic acid cap 250 mg
(Ponstel)
1
3
meloxicam tab 7.5 mg (Mobic)
1
3
3
nabumetone tab 500 mg
nabumetone tab 750 mg
1
1
NALFON – fenoprofen calcium cap
400 mg
3
3
NAPROSYN – naproxen tab 500
mg
3
3
NAPROSYN – naproxen susp 125
mg/5ml
3
oxaprozin tab 600 mg (Daypro)
1
naproxen sodium tab 275 mg
1
piroxicam cap 20 mg (Feldene)
naproxen sodium tab 550 mg
(Anaprox ds)
1
PONSTEL – mefenamic acid cap
250 mg
3
naproxen susp 125 mg/5ml
(Naprosyn)
1
RASUVO – methotrexate soln pf
3
naproxen tab ec 375 mg (Ecnaprosyn)
1
3
naproxen tab ec 500 mg (Ecnaprosyn)
1
3
naproxen tab 250 mg
1
3
3
naproxen tab 375 mg
naproxen tab 500 mg (Naprosyn)
KEY
piroxicam cap 10 mg (Feldene)
1
1
Tier
•
*
Responsible Steps
3
3
1
Quantity Limits
ORENCIA – abatacept
syringe 125 mg/ml
MECLOFENAMATE SODIUM –
meclofenamate sodium cap 50
mg
meloxicam tab 15 mg (Mobic)
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
X • •
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
1
1
106
3
almotriptan malate tab 6.25 mg
(Axert)
1
•
3
almotriptan malate tab 12.5 mg
(Axert)
1
•
3
ALSUMA – sumatriptan succinate
solution auto-injector 6 mg/0.5ml
3
•
3
AXERT – almotriptan malate tab
6.25 mg
3
•
3
AXERT – almotriptan malate tab
12.5 mg
3
•
RHEUMATREX – methotrexate
sodium tab 2.5 mg
(antirheumatic)
3
CAFERGOT – ergotamine w/
caffeine tab 1-100 mg
3
•
SIMPONI – golimumab
subcutaneous soln auto-injector
50 mg/0.5ml
2
X • •
D.H.E. 45 – dihydroergotamine
mesylate inj 1 mg/ml
3
RIDAURA – auranofin cap 3 mg
2
3
•
subcutaneous soln auto-injector
100 mg/ml
2
X • •
DIHYDROERGOTAMINE
MESYLAT – dihydroergotamine
mesylate nasal spray 4 mg/ml
dihydroergotamine mesylate inj
1 mg/ml (D.h.e. 45)
1
•
syringe 50 mg/0.5ml
2
X • •
syringe 100 mg/ml
2
X • •
sulindac tab 150 mg
1
sulindac tab 200 mg
1
TOLMETIN SODIUM – tolmetin
sodium tab 200 mg
3
TOLMETIN SODIUM – tolmetin
sodium tab 600 mg
3
tolmetin sodium cap 400 mg
1
XELJANZ – tofacitinib citrate tab 5
3
X • •
MIGRAINE HEADACHES
KEY
ERGOMAR – ergotamine tartrate sl 2
tab 2 mg
FROVA – frovatriptan succinate tab 3
frovatriptan succinate tab 2.5 mg 1
(base equivalent) (Frova)
2
IMITREX – sumatriptan nasal
spray 5 mg/act
2
IMITREX – sumatriptan nasal
spray 20 mg/act
1
isometheptene-caffeineacetaminophen tab
65-20-325 mg (Prodrin)
1
isometheptene-dichloralacetaminophen cap
65-100-325 mg
3
MIGERGOT – ergotamine w/
caffeine suppos 2-100 mg
Tier
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
•
•
•
•
107
•
naratriptan hcl tab 2.5 mg (base
equiv) (Amerge)
•
1
sumatriptan succinate solution
(Imitrex statdose sys)
1
•
cartridge 4 mg/0.5ml (Imitrex
statdose ref)
1
•
cartridge 6 mg/0.5ml (Imitrex
statdose ref)
1
•
PRODRIN – isometheptenecaffeine-acetaminophen tab
65-20-325 mg
3
RELPAX – eletriptan hydrobromide
3
•
sumatriptan succinate tab 25 mg
(Imitrex)
1
•
RELPAX – eletriptan hydrobromide
3
•
sumatriptan succinate tab 50 mg
(Imitrex)
1
•
rizatriptan benzoate oral
disintegrating tab 5 mg (base
eq) (Maxalt-mlt)
1
•
sumatriptan succinate tab
100 mg (Imitrex)
1
•
1
•
1
•
1
•
zolmitriptan orally disintegrating
tab 2.5 mg (Zomig zmt)
1
•
zolmitriptan tab 2.5 mg (Zomig)
1
•
1
•
1
•
SUMATRIPTAN SUCCINATE –
prefilled syringe 6 mg/0.5ml
3
•
sumatriptan succinate inj
6 mg/0.5ml (Imitrex)
1
•
COLCHICINE – colchicine cap 0.6
mg
3
1
•
COLCHICINE – colchicine tab 0.6
mg
3
colchicine w/ probenecid tab
0.5-500 mg
1
rizatriptan benzoate oral
disintegrating tab 10 mg (base
eq) (Maxalt-mlt)
rizatriptan benzoate tab 5 mg
(base equivalent) (Maxalt)
rizatriptan benzoate tab 10 mg
(base equivalent) (Maxalt)
sumatriptan nasal spray 5 mg/
act (Imitrex)
sumatriptan nasal spray 20 mg/
act (Imitrex)
(Imitrex statdose sys)
1
zolmitriptan orally disintegrating
tab 5 mg (Zomig zmt)
ZOMIG – zolmitriptan nasal spray
2.5 mg/spray unit
3
•
•
•
ZOMIG NASAL SPRAY –
zolmitriptan nasal spray 5 mg/
spray unit
3
•
zolmitriptan tab 5 mg (Zomig)
GOUT
allopurinol tab 100 mg (Zyloprim)
allopurinol tab 300 mg (Zyloprim)
COLCRYS – colchicine tab 0.6 mg
KEY
Tier
•
*
1
Responsible Steps
1
Quantity Limits
naratriptan hcl tab 1 mg (base
equiv) (Amerge)
Prior Authorization
•
Drug Name
Specialty/Tier 4
2
Drug Tier
MIGRANAL – dihydroergotamine
mesylate nasal spray 4 mg/ml
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
1
1
2
108
MITIGARE – colchicine cap 0.6 mg
3
probenecid tab 500 mg
1
carbamazepine tab sr 12hr
400 mg (Tegretol-xr)
1
3
CARBATROL – carbamazepine
cap sr 12hr 100 mg
3
3
cap sr 12hr 200 mg
3
cap sr 12hr 300 mg
3
CELONTIN – methsuximide cap
300 mg
2
APTIOM – eslicarbazepine acetate
tab 200 mg
3
clonazepam orally disintegrating
tab 0.125 mg
1
tab 400 mg
3
tab 600 mg
3
tab 0.25 mg
tab 800 mg
3
tab 0.5 mg
BANZEL – rufinamide susp 40 mg/
ml
3
tab 1 mg
BANZEL – rufinamide tab 200 mg
3
tab 2 mg
BANZEL – rufinamide tab 400 mg
3
carbamazepine cap sr 12hr
100 mg (Carbatrol)
1
3
ULORIC – febuxostat tab 80 mg
3
ZYLOPRIM – allopurinol tab 100
mg
ZYLOPRIM – allopurinol tab 300
mg
•
•
NEUROMUSCULAR DRUGS
SEIZURES
200 mg (Carbatrol)
300 mg (Carbatrol)
carbamazepine chew tab 100 mg
1
1
1
clonazepam tab 0.5 mg
(Klonopin)
1
clonazepam tab 1 mg (Klonopin)
1
1
1
clonazepam tab 2 mg (Klonopin)
1
DEPAKENE – valproate sodium
syrup 250 mg/5ml (base equiv)
3
1
DEPAKENE – valproic acid cap
250 mg
3
1
DEPAKOTE – divalproex sodium
tab delayed release 125 mg
3
1
3
1
3
KEY
Tier
•
*
Responsible Steps
1
carbamazepine susp 100 mg/5ml
(Tegretol)
Quantity Limits
1
carbamazepine tab 200 mg
(Tegretol)
ULORIC – febuxostat tab 40 mg
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
109
DEPAKOTE ER – divalproex
sodium tab sr 24 hr 250 mg
3
DEPAKOTE ER – divalproex
sodium tab sr 24 hr 500 mg
3
DEPAKOTE SPRINKLES –
divalproex sodium cap delayed
release sprinkle 125 mg
3
DIASTAT ACUDIAL – diazepam
rectal gel delivery system 10 mg
divalproex sodium tab sr 24 hr
250 mg (Depakote er)
divalproex sodium tab sr 24 hr
500 mg (Depakote er)
2
ethosuximide soln 250 mg/5ml
(Zarontin)
1
felbamate susp 600 mg/5ml
(Felbatol)
1
DIASTAT ACUDIAL – diazepam
rectal gel delivery system 20 mg
2
felbamate tab 400 mg (Felbatol)
1
DIASTAT PEDIATRIC – diazepam
rectal gel delivery system 2.5 mg
2
DIAZEPAM – diazepam rectal gel
delivery system 2.5 mg
3
FELBATOL – felbamate susp 600
mg/5ml
3
delivery system 10 mg
3
FELBATOL – felbamate tab 400
mg
3
delivery system 20 mg
3
FELBATOL – felbamate tab 600
mg
3
DILANTIN – phenytoin sodium
extended cap 30 mg
2
FYCOMPA – perampanel tab 2 mg
3
3
DILANTIN – phenytoin sodium
extended cap 100 mg
3
3
3
DILANTIN INFATABS – phenytoin
chew tab 50 mg
3
3
DILANTIN-125 – phenytoin susp
125 mg/5ml
3
FYCOMPA – perampanel tab 10
mg
3
divalproex sodium cap delayed
release sprinkle 125 mg
(Depakote sprinkles)
1
FYCOMPA – perampanel tab 12
mg
gabapentin cap 100 mg
(Neurontin)
1
(Neurontin)
1
divalproex sodium tab delayed
release 125 mg (Depakote)
1
1
(Neurontin)
1
1
gabapentin oral soln 250 mg/5ml
(Neurontin)
1
KEY
Tier
•
*
Responsible Steps
1
1
Quantity Limits
1
ethosuximide cap 250 mg
(Zarontin)
felbamate tab 600 mg (Felbatol)
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
1
110
gabapentin tab 600 mg
(Neurontin)
1
gabapentin tab 800 mg
(Neurontin)
1
GABITRIL – tiagabine hcl tab 2 mg
3
GABITRIL – tiagabine hcl tab 4 mg
3
GABITRIL – tiagabine hcl tab 12
mg
2
GABITRIL – tiagabine hcl tab 16
mg
2
KEPPRA – levetiracetam oral soln
100 mg/ml
LAMICTAL CHEWABLE DISPERS
– lamotrigine tab chewable
dispersible 25 mg
3
LAMICTAL ODT – lamotrigine tab
disp 25 mg (21) & 50 mg (7)
titration kit
3
disp 50 mg (42) & 100 mg (14)
titration kit
3
3
3
disp 25 (14) & 50 mg (14) & 100
mg (7) kit
LAMICTAL ODT – lamotrigine
3
KEPPRA – levetiracetam tab 250
mg
3
3
3
mg
3
3
mg
3
mg
3
LAMICTAL STARTER/NOT TAKI –
lamotrigine tab 25 mg (42) & 100
mg (7) starter kit
3
KEPPRA XR – levetiracetam tab sr
24hr 500 mg
3
KEPPRA XR – levetiracetam tab sr
24hr 750 mg
3
3
LAMICTAL – lamotrigine tab 25 mg
3
LAMICTAL STARTER/TAKING C –
lamotrigine tab 25 mg (84) & 100
mg (14) starter kit
LAMICTAL – lamotrigine tab 100
mg
3
3
mg
3
LAMICTAL STARTER/TAKING V –
lamotrigine tab 25 mg (35) starter
kit
3
mg
3
LAMICTAL XR – lamotrigine tab
sr 24hr 25 mg (21) & 50 mg (7)
titration kit
LAMICTAL CHEWABLE DISPERS
– lamotrigine tab chewable
dispersible 5 mg
3
LAMICTAL XR – lamotrigine tab sr
24hr 25 (14) & 50 mg (14) & 100
mg(7) kit
3
24hr 50 (14) & 100 mg(14) & 200
mg(7) kit
3
KEY
Tier
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
111
24hr 25 mg
3
lamotrigine tab sr 24hr 50 mg
(Lamictal xr)
1
24hr 50 mg
3
(Lamictal xr)
1
24hr 100 mg
3
(Lamictal xr)
1
24hr 200 mg
3
(Lamictal xr)
1
24hr 250 mg
3
(Lamictal xr)
1
24hr 300 mg
3
lamotrigine tab 25 mg (Lamictal)
1
lamotrigine orally disintegrating
tab 25 mg (Lamictal odt)
1
1
levetiracetam oral soln 100 mg/
ml (Keppra)
1
1
lamotrigine tab chewable
dispersible 5 mg (Lamictal
chewable di)
1
lamotrigine tab chewable
dispersible 25 mg (Lamictal
chewable di)
1
lamotrigine tab disp 25 mg (21) &
50 mg (7) titration kit (Lamictal
odt)
1
lamotrigine tab disp 50 mg (42)
& 100 mg (14) titration kit
(Lamictal odt)
1
lamotrigine tab disp 25 (14) &
50 mg (14) & 100 mg (7) kit
(Lamictal odt)
1
(Lamictal xr)
1
KEY
Responsible Steps
Quantity Limits
1
1
1
1
levetiracetam tab sr 24hr 500 mg
(Keppra xr)
1
levetiracetam tab sr 24hr 750 mg
(Keppra xr)
1
levetiracetam tab 250 mg
(Keppra)
1
(Keppra)
1
(Keppra)
1
(Keppra)
1
LYRICA – pregabalin soln 20 mg/
ml
3
• •
LYRICA – pregabalin cap 25 mg
3
3
3
3
3
•
•
•
•
•
Tier
•
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
•
•
•
•
•
112
3
3
3
NEURONTIN – gabapentin oral
soln 250 mg/5ml
3
NEURONTIN – gabapentin cap
100 mg
3
300 mg
3
400 mg
3
3
oxcarbazepine susp 300 mg/5ml
(60 mg/ml) (Trileptal)
1
PHENYTEK – phenytoin sodium
extended cap 200 mg
3
PHENYTEK – phenytoin sodium
extended cap 300 mg
3
phenytoin chew tab 50 mg
(Dilantin infatabs)
1
phenytoin sodium extended cap
100 mg (Dilantin)
1
300 mg (Phenytek)
1
POTIGA – ezogabine tab 50 mg
3
3
3
3
primidone tab 50 mg (Mysoline)
1
3
oxcarbazepine tab 150 mg
(Trileptal)
1
3
(Trileptal)
QUDEXY XR – topiramate cap er
24hr sprinkle 50 mg
1
24hr sprinkle 100 mg
3
(Trileptal)
3
OXTELLAR XR – oxcarbazepine
tab sr 24hr 150 mg
3
3
tab sr 24hr 300 mg
3
SABRIL – vigabatrin tab 500 mg
3
tab sr 24hr 600 mg
3
SABRIL – vigabatrin powd pack
500 mg
3
TEGRETOL – carbamazepine tab
200 mg
3
Tier
•
*
Responsible Steps
1
24hr sprinkle 25 mg
KEY
Quantity Limits
1
1
PEGANONE – ethotoin tab 250 mg 2
Prior Authorization
1
phenytoin susp 125 mg/5ml
(Dilantin-125)
primidone tab 250 mg (Mysoline)
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
• •
• •
• •
Drug Name
200 mg (Phenytek)
NEURONTIN – gabapentin tab 600 3
mg
NEURONTIN – gabapentin tab 800 3
mg
3
ONFI – clobazam suspension 2.5
mg/ml
3
ONFI – clobazam tab 10 mg
ONFI – clobazam tab 20 mg
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
113
TEGRETOL – carbamazepine susp 3
100 mg/5ml
3
TEGRETOL-XR – carbamazepine
tab sr 12hr 100 mg
3
tab sr 12hr 200 mg
3
tab sr 12hr 400 mg
1
tiagabine hcl tab 2 mg (Gabitril)
topiramate tab 50 mg (Topamax)
1
TRILEPTAL – oxcarbazepine susp
300 mg/5ml (60 mg/ml)
3
TRILEPTAL – oxcarbazepine tab
150 mg
3
3
tiagabine hcl tab 4 mg (Gabitril)
300 mg
600 mg
3
TOPAMAX – topiramate tab 25 mg
TOPAMAX – topiramate tab 50 mg
3
TOPAMAX – topiramate tab 100
mg
3
TOPAMAX – topiramate tab 200
mg
3
TOPAMAX SPRINKLE –
topiramate sprinkle cap 15 mg
3
TOPAMAX SPRINKLE –
3
TOPIRAMATE ER – topiramate
cap er 24hr sprinkle 25 mg
3
3
3
3
3
(Topamax sprinkle)
1
(Topamax sprinkle)
1
topiramate tab 25 mg (Topamax)
1
KEY
Responsible Steps
TROKENDI XR – topiramate cap sr 3
24hr 25 mg
24hr 50 mg
24hr 100 mg
24hr 200 mg
1
valproate sodium syrup
(Depakene)
1
valproic acid cap 250 mg
(Depakene)
VIMPAT – lacosamide oral solution 3
10 mg/ml
3
VIMPAT – lacosamide tab 50 mg
3
3
3
ZARONTIN – ethosuximide cap
250 mg
3
ZARONTIN – ethosuximide soln
250 mg/5ml
3
Tier
•
Quantity Limits
topiramate tab 100 mg (Topamax) 1
topiramate tab 200 mg (Topamax) 1
1
3
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
114
ZONEGRAN – zonisamide cap 25
mg
3
PARKINSON'S DISEASE
CARBIDOPA/LEVODOPA/
ENTACA – carbidopa-levodopaentacapone tabs 37.5-150-200
mg
3
3
1
CARBIDOPA/LEVODOPA/
ENTACA – carbidopa-levodopaentacapone tabs 50-200-200 mg
3
1
COMTAN – entacapone tab 200
mg
3
1
ELDEPRYL – selegiline hcl cap 5
mg
entacapone tab 200 mg (Comtan)
1
benztropine mesylate tab 0.5 mg
1
X
1
1
1
1
1
LODOSYN – carbidopa tab 25 mg
Tier
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Tier
3
2
KEY
Responsible Steps
CARBIDOPA/LEVODOPA/
mg
AZILECT – rasagiline mesylate tab
1 mg (base equiv)
carbidopa & levodopa tab cr
25-100 mg (Sinemet cr)
Quantity Limits
3
2
carbidopa & levodopa orally
disintegrating tab 25-250 mg
1
CARBIDOPA/LEVODOPA/
ENTACA – carbidopa-levodopaentacapone tabs 25-100-200 mg
1
AZILECT – rasagiline mesylate tab
0.5 mg (base equiv)
1
3
3
1
CARBIDOPA/LEVODOPA/
mg
APOKYN – apomorphine
hydrochloride inj 10 mg/ml
bromocriptine mesylate tab
2.5 mg
1
3
1
bromocriptine mesylate cap
5 mg (Parlodel)
carbidopa & levodopa tab
25-250 mg (Sinemet)
1
CARBIDOPA/LEVODOPA/
ENTACA – carbidopa-levodopaentacapone tabs 12.5-50-200 mg
amantadine hcl cap 100 mg
benztropine mesylate tab 2 mg
25-100 mg (Sinemet)
carbidopa tab 25 mg (Lodosyn)
2
benztropine mesylate tab 1 mg
10-100 mg (Sinemet)
1
AMANTADINE HCL – amantadine
hcl tab 100 mg
amantadine hcl syrup 50 mg/5ml
Drug Name
carbidopa & levodopa tab cr
50-200 mg (Sinemet cr)
ZONEGRAN – zonisamide cap 100 3
mg
1
zonisamide cap 25 mg
(Zonegran)
1
(Zonegran)
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
3
115
MIRAPEX – pramipexole
dihydrochloride tab 0.125 mg
3
3
3
3
dihydrochloride tab 1 mg
3
3
MIRAPEX ER – pramipexole
dihydrochloride tab sr 24hr 0.375
mg
3
mg
3
mg
3
mg
3
dihydrochloride tab sr 24hr 3 mg
3
mg
3
mg
3
Tier
•
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Drug Name
NEUPRO – rotigotine td patch 24hr 3
3 mg/24hr
4 mg/24hr
6 mg/24hr
8 mg/24hr
3
PARLODEL – bromocriptine
mesylate cap 5 mg
pramipexole dihydrochloride tab 1
sr 24hr 0.375 mg (Mirapex er)
sr 24hr 3 mg (Mirapex er)
0.125 mg (Mirapex)
0.25 mg (Mirapex)
0.5 mg (Mirapex)
0.75 mg (Mirapex)
1 mg (Mirapex)
1.5 mg (Mirapex)
REQUIP – ropinirole hydrochloride 3
tab 0.25 mg
1 mg/24hr
2 mg/24hr
KEY
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
116
REQUIP – ropinirole hydrochloride
tab 0.5 mg
3
tab 1 mg
3
tab 2 mg
ropinirole hydrochloride tab sr
24hr 8 mg (base equivalent)
(Requip xl)
1
1
3
(Requip xl)
tab 3 mg
3
ropinirole hydrochloride tab
0.25 mg (Requip)
1
tab 4 mg
3
0.5 mg (Requip)
tab 5 mg
3
1 mg (Requip)
REQUIP XL – ropinirole
hydrochloride tab sr 24hr 2 mg
(base equivalent)
3
2 mg (Requip)
(base equivalent)
3
(base equivalent)
3
(base equivalent)
3
(base equivalent)
3
(Requip xl)
1
(Requip xl)
1
(Requip xl)
1
KEY
3 mg (Requip)
4 mg (Requip)
5 mg (Requip)
selegiline hcl cap 5 mg (Eldepryl)
selegiline hcl tab 5 mg
1
1
1
1
1
3
SINEMET – carbidopa & levodopa
tab 25-250 mg
3
SINEMET CR – carbidopa &
levodopa tab cr 25-100 mg
3
SINEMET CR – carbidopa &
levodopa tab cr 50-200 mg
3
STALEVO 100 – carbidopalevodopa-entacapone tabs
25-100-200 mg
3
•
Responsible Steps
1
tab 25-100 mg
*
Quantity Limits
1
3
1
tab 10-100 mg
Tier
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
117
31.25-125-200 mg
3
37.5-150-200 mg
3
50-200-200 mg
3
12.5-50-200 mg
3
18.75-75-200 mg
3
TASMAR – tolcapone tab 100 mg
3
tolcapone tab 100 mg (Tasmar)
1
trihexyphenidyl hcl elixir 0.4 mg/
ml
trihexyphenidyl hcl tab 2 mg
trihexyphenidyl hcl tab 5 mg
MUSCLE RELAXANTS
baclofen tab 10 mg
baclofen tab 20 mg
carisoprodol tab 250 mg (Soma)
carisoprodol tab 350 mg (Soma)
carisoprodol w/ aspirin &
codeine tab 200-325-16 mg
carisoprodol w/ aspirin tab
200-325 mg
1
1
1
1
1
1
1
cyclobenzaprine hcl tab 5 mg
1
cyclobenzaprine hcl tab 10 mg
KEY
1
1
3
DANTRIUM – dantrolene sodium
cap 50 mg
3
dantrolene sodium cap 25 mg
(Dantrium)
1
(Dantrium)
1
1
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Responsible Steps
Quantity Limits
Prior Authorization
Tier
•
Drug Tier
DANTRIUM – dantrolene sodium
cap 25 mg
3
metaxalone tab 800 mg (Skelaxin) 1
1
methocarbamol tab 500 mg
(Robaxin)
1
methocarbamol tab 750 mg
(Robaxin-750)
1
orphenadrine citrate tab sr 12hr
100 mg
3
PARAFON FORTE DSC –
chlorzoxazone tab 500 mg
3
ROBAXIN – methocarbamol tab
500 mg
3
ROBAXIN-750 – methocarbamol
tab 750 mg
3
SKELAXIN – metaxalone tab 800
mg
1
tizanidine hcl cap 2 mg (base
equivalent) (Zanaflex)
1
1
1
tizanidine hcl tab 2 mg (base
equivalent)
1
tizanidine hcl tab 4 mg (base
1
1
Drug Name
METAXALONE – metaxalone tab
400 mg
1
chlorzoxazone tab 500 mg
(Parafon forte dsc)
cyclobenzaprine hcl tab 7.5 mg
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
118
ZANAFLEX – tizanidine hcl tab 4
3
ZANAFLEX – tizanidine hcl cap 2
3
3
3
3
cholecalciferol cap 1000 unit
1
cholecalciferol chew tab 400 unit
cholecalciferol chew tab 1000
unit
cholecalciferol drops 5000 unit/
ml (1000 unit/0.2ml)
KEY
cholecalciferol tab 1000 unit
ergocalciferol cap 50000 unit
MEPHYTON – phytonadione tab 5
mg
MULTIVITAMINS
1
1
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
1
1
1
1
1
1
2
ACTIVE OB – prenatal w/o a w/fe
cbn-fa-dha cap 20-1-320 mg
3
ATABEX EC – prenatal vit w/ dssiron carbonyl-fa tab dr 29-1 mg
3
BAL-CARE DHA – prenat w/fe
poly-na fered-fa tab 27-1 &
omega cap dr 430mg
3
BP FOLINATAL PLUS B – prenatal
w/ calcium carbonate-b6-b12-fa
tab 1 mg
3
BP MULTINATAL PLUS – prenatal
w/o a vit w/ fe fumarate-fa tab
30-1 mg
3
BP MULTINATAL PLUS – prenatal
w/o a vit w/ fe fum-fa tab chew
40-1 mg
3
C-NATE DHA – prenatal vit w/ fe
fum-fa-omega 3 cap 28-1-200
mg
3
CALCIUM PNV – prenatal w/o
vit a w/ fe fum-fa-omega 3 cap
28-1-250 mg
3
•
CITRANATAL ASSURE – prenat w/ 3
o a w/fecbn-fegl-dss-fa tab & dha
cap 300 mg pack
1
Tier
•
Drug Tier
Responsible Steps
1
AMINOBENZOATE POTASSIUM
– potassium aminobenzoate
packet 2 gm
Quantity Limits
cholecalciferol oral liquid 400
unit/ml
SUPPLEMENTS
VITAMINS
Drug Name
cholecalciferol drops 400
unit/0.03ml (per drop)
OTHER NEUROMUSCULAR DRUGS
3
GUANIDINE HCL – guanidine hcl
tab 125 mg
3
MESTINON – pyridostigmine
bromide tab 60 mg
2
MESTINON – pyridostigmine
bromide syrup 60 mg/5ml
3
MESTINON TIMESPAN –
pyridostigmine bromide tab cr
180 mg
1
pyridostigmine bromide tab cr
180 mg (Mestinon timespan)
1
pyridostigmine bromide tab
60 mg (Mestinon)
3
RILUTEK – riluzole tab 50 mg
riluzole tab 50 mg (Rilutek)
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
119
CITRANATAL B-CALM – prenat w/
o a w/fecbn-feglu-fa tab 20-1 mg
& vit b6 tab pak
3
ELITE-OB – prenatal vit w/ iron
carbonyl-fa tab 50-1.25 mg
3
ENBRACE HR – prenatal vit w/ fe
gly cys-fa-omega 3 fatty acids
cap
3
CITRANATAL DHA – prenat w/o
a w/fecbn-fegl-dss-fa tab & dha
cap 250 mg pack
3
3
3
CITRANATAL HARMONY – prenat
w/o a w/fe fum-fe cbn-dss-fa-dha
cap 27-1-260 mg
EXTRA-VIRT PLUS DHA –
prenatal w/o vit a w/ fe fum-docfa-dha cap 29-1.25-350 mg
3
FOCALGIN CA – prenat w/o a w/
fecbn-fegl-dss-fa tab & dha cap
300 mg pack
3
CITRANATAL RX – prenatal w/o a
w/ fe carbonyl-fe gluc-dss-fa tab
27-1mg
FOCALGIN 90 DHA – prenat w/o a
w/fecbn-fegl-dss-fa tab 90 &dha
cap 300mg pak
3
CITRANATAL 90 DHA – prenat w/
o a w/fecbn-fegl-dss-fa tab 90
&dha cap 300mg pak
3
FOLCAL DHA – prenatal w/o
vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg
3
CO-NATAL FA – prenatal vit w/ fe
fumarate-fa tab 29-1 mg
3
COMPLETE NATAL DHA – prenatfe bis-fe prot succ-fa-ca tab &
omega 3 cap 250 pk
3
FOLCAPS OMEGA 3 – prenatal vit
w/ fe cbn-fe asp glyc-fa-omega 3
cap 27-1mg
3
COMPLETENATE – prenatal vit w/
fe fumarate-fa chew tab 29-1 mg
3
3
CONCEPT DHA – prenatal w/fe
fum-fe poly -fa-omega 3 cap
53.5-38-1 mg
3
FOLET DHA – prenat w/fecbnbisg-methylf-dss tab dr & dha
cap pak
3
CONCEPT OB – prenatal w/o a w/
fe fum-fe poly-fa cap 130-92.4-1
mg
3
FOLET ONE – prenat w/o a w/
fecbn-bisg-methylf-dss-dha cap
38-1-225 mg
3
DOTHELLE DHA – prenatal w/
fe fum-fe poly -fa-omega 3 cap
53.5-38-1 mg
3
FOLIVANE-OB – prenatal w/o a w/
fe fum-fe poly-fa cap 130-92.4-1
mg
3
DUET DHA BALANCED – prenat
w/fe poly-na fered-fa tab 25-1 &
omega cap 267 mg
3
HEMENATAL OB – prenat vit-fe
poly cmplx-fe heme poly-fa tab
28-6-1 mg
3
DUET DHA 400 – prenat w/fe polyna fered-fa tab 25-1 & omega
cap 400 mg
3
HEMENATAL OB + DHA – prenatfe poly cmplx-fe heme poly-fa tab
& omega 3 cap pck
KEY
Responsible Steps
Quantity Limits
INATAL ADVANCE – prenatal vit w/ 3
dss-iron carbonyl-fa tab 90-1 mg
Tier
•
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
120
INATAL GT – prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
3
INATAL ULTRA – prenatal vit w/
3
INFANATE BALANCE – prenatal
w/o a w/fe cbn-dss-fa-dha cap
29-1-265 mg
3
LEVOMEFOLATE DHA – prenat w/
fe fum-l methylfolate-fa-dha cap
27-1.13-0.4 mg
3
NATELLE ONE – prenatal w/o
vit a w/ fe fum-fa-omega 3 cap
28-1-250 mg
3
NEEVO DHA – prenat w/o a w/
fefum-methylfol-omegas cap
27-1.13 mg
3
Tier
•
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Drug Name
NEPHROCAPS QT – b-complex w/ 3
c-biotin-d & folic acid tab disp 1
mg
3
NESTABS – prenatal vit w/o vit a
w/ fe bisglycinate-fa tab 32-1 mg
NESTABS ABC – prenatal w/o vit a 3
w/fe polysac-fa-ca tab & omega 3
cap
3
NESTABS DHA – prenat w/o a
w/ fe bisglyc-fa tab 32-1 mg &
omega cap pack
NEWGEN – prenatal vit w/o vit a w/ 3
fe bisglycinate-fa tab 32-1 mg
3
NEXA PLUS – prenatal w/o vit
a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg
3
NIVA-PLUS – prenatal vit w/ fe
3
O-CAL FA – prenatal vit w/ fe
3
O-CAL PRENATAL – prenatal vit
w/ fe fumarate-fa tab 15-1 mg
3
OB COMPLETE – prenatal vit w/
iron carbonyl-fa tab 50-1.25 mg
OB COMPLETE GOLD – prenat w/ 3
o a w/fecbn-methfol-fa-dha cap
27.5-1-200 mg
3
OB COMPLETE ONE – prenatal
w/o a w/fecbn-fe asp glyc-fa-fish
cap 50-1-476 mg
M-VIT – prenatal vit w/ fe fumarate- 3
fa tab 27-1 mg
3
MACNATAL CN DHA – prenatal
28-1-250 mg
3
MARNATAL-F – prenatal w/o vit a
w/ fe polysac cmplx-fa cap 60-1
mg
MYNATAL – prenatal multivitamins 3
& minerals w/ iron & fa cap 1 mg
MYNATAL ADVANCE – prenatal vit 3
w/ dss-iron carbonyl-fa tab 90-1
mg
3
MYNATAL PLUS – prenatal vit w/
fe fumarate-fa tab 65-1 mg
3
MYNATAL ULTRACAPLET –
prenatal vit w/ dss-iron carbonylfa tab 90-1 mg
3
MYNATAL-Z – prenatal vit w/ fe
MYNATE 90 PLUS – prenatal vit w/ 3
dss-fe fumarate-fa tab cr 90-1 mg
3
NATACHEW – prenatal vit w/ fe
fum-fe bisglycin-fa chew tab 28-1
mg
3
NATALVIT – prenatal vit w/ fe
KEY
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
121
OB COMPLETE PETITE – prenat
w/o a w/fecbn-feaspglyc-faomega cap 35-5-1-200 mg
3
PNV-SELECT – prenatal vit
w/ fe fum-methylfolate-fa tab
27-0.6-0.4 mg
3
OB COMPLETE PREMIER –
prenatal vit w/ fe cbn-fe asp glycfa tab 30-20-1 mg
3
PNV-TOTAL – prenat w/ fe cbn-fe
bisglyc-fa-fish oil cap 35-5-1.2
mg
3
OB COMPLETE/DHA – prenat w/
iron cbn-fe asp glyc-fa-omega
cap 30-10-1-200 mg
3
PNV-VP-U – prenatal w/o a vit w/
fe fumarate-fa cap 106.5-1 mg
3
3
PR NATAL 400 – prenat-fe bis-fe
prot succ-fa-ca tab & omega 3
cap 400 pk
3
OBSTETRIX DHA – prenat w/
fecbn-fa-dss tab 29-1 mg &
omega 3 cap 387 mg pak
PR NATAL 400 EC – prenat-fe bisfe prot succ-fa-ca tab & omega
cap dr 400 pk
3
OBSTETRIX EC – prenatal vit w/
3
PNV FERROUS FUMARATE/
DOCU – prenatal vit w/ dss-fe
3
PR NATAL 430 – prenat-fe bis-fe
prot succ-fa-ca tab & omega 3
cap 430 pk
3
PNV FOLIC ACID + IRON MUL –
prenatal vit w/ fe fumarate-fa tab
27-1 mg
3
PR NATAL 430 EC – prenat-fe bisfe prot succ-fa-ca tab & omega
cap dr 430 pk
3
PNV OB+DHA – prenat w/o a w/
fecbn-fegl-dss-fa tab & dha cap
250 mg pack
3
PREFERA OB – prenat vit-fe poly
cmplx-fe heme poly-fa tab 34-1
mg
3
PNV PRENATAL PLUS MULTIVI –
27-1 mg
3
PREFERAOB +DHA – prenat-fe
poly cmplx 28mg-fe heme poly-fa
tab&dha cap pack
3
PNV TABS 29-1 – prenatal vit w/
iron carbonyl-fa tab 29-1 mg
3
3
PNV-DHA – prenat w/o a w/
fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
3
PREFERAOB ONE – prenat-fe
poly cmplx-fe heme poly-fa-dha
cap 22-6-1-200 mg
3
PNV-DHA+DOCUSATE – prenatal
w/o vit a w/ fe fum-dss-fa-dha
cap 27-1.25-300 mg
3
PRENAISSANCE – prenatal w/o
29-1.25-325 mg
3
PNV-OMEGA – prenat w/o a w/ fe
fumerate-methylfolate-fa-omega
3 cap
3
PRENAISSANCE BALANCE –
prenatal w/o vit a w/ fe cbn-dssfa-dha cap 30-1-260 mg
PRENAISSANCE HARMONY DHA
– prenat w/fe poly-na fered-fa tab
27-1 & omega cap dr 380mg
3
KEY
Tier
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
122
PRENAISSANCE NEXT – prenatal
w/ calcium-vit b6-fa-ginger tab
1.2 mg
3
PRENATE DHA – prenat w/o a
w/fefum-methfol-fa-dha cap
28-0.6-0.4-300 mg
3
PRENAISSANCE NEXT-B –
prenatal w/ calcium-vit b6-faginger tab 1.22 mg
3
PRENATE DHA – prenat w/o a
w/feaspg-methfol-fa-dha cap
18-0.6-0.4-300 mg
3
PRENAISSANCE PLUS – prenatal
28-1-250 mg
3
PRENATE ELITE – prenatal w/
fe asp gly-l methylfol-fa tab
20-0.6-0.4 mg
3
PRENATA – prenatal w/o a vit w/ fe 3
fum-fa tab chew 29-1 mg
3
PRENATABS FA – prenatal vit w/
3
PRENATABS RX – prenatal vit w/
iron carbonyl-fa tab 29-1 mg
3
PRENATAL – prenatal vit w/ fe
PRENATAL PLUS – prenatal vit w/ 3
PRENATAL PLUS IRON – prenatal 3
vit w/ iron carbonyl-fa tab 29-1
mg
PRENATAL VITAMINS PLUS LO – 3
27-1 mg
3
PRENATAL 19 – prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
3
PRENATAL 19 – prenatal vit w/
dss-fe fumarate-fa tab 29-1 mg
3
PRENATAL-U – prenatal w/o a vit
w/ fe fumarate-fa cap 106.5-1 mg
PRENATE – prenat mv & min w/ l- 3
methylfolate-fa chew tab 0.6-0.4
mg
3
PRENATE AM – prenatal w/
calcium-vit b6-vit b12-fa-ginger
tab 1 mg
PRENATE ELITE – prenatal vit
w/ fe fum-methylfolate-fa tab
26-0.6-0.4 mg
3
PRENATE ENHANCE – prenat w/
o a w/fefum-methfol-fa-dha cap
28-0.6-0.4-400 mg
3
KEY
Responsible Steps
Quantity Limits
PRENATE ESSENTIAL – prenat w/ 3
o a w/feasp-methylf-fa-omeg cap
29-0.6-0.4-340 mg
PRENATE ESSENTIAL – prenat w/ 3
o a w/feaspg-methfol-fa-dha cap
18-0.6-0.4-300 mg
3
PRENATE MINI – prenat w/oa
w/fecb-feasp-meth-fa-dha cap
18-0.6-0.4-350 mg
3
PRENATE MINI – prenat w/o a
w/fecbn-methylf-fa-dha cap
29-0.6-0.4-350 mg
3
PRENATE PIXIE – prenat w/o a
w/feaspg-methfol-fa-dha cap
10-0.6-0.4-200 mg
3
PRENATE RESTORE – prenat w/
o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-400 mg
3
PRENATE STAR – prenatal vit w/
fe asparto glycinate-fa tab 20-1
mg
Tier
•
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
123
PRENA1 CHEW – prenat w/ b2b6-b12-d3-folic acid chew tab 1.4
mg
3
SELECT-OB – prenatal vit w/ fe
polysac cmplx-fa chew tab 29-1
mg
3
PRENA1 PEARL – prenat w/oa
w/fefum-na fered-fa-dha cap cr
30-1.4-200 mg
3
SELECT-OB – prenat w/
fepolycmplx-methylfol-fa chew
tab 29-0.6-0.4 mg
3
PREPLUS – prenatal vit w/ fe
3
3
PREQUE 10 – prenatal mv w/
fe carbonyl-dss-fa-dha tab
15-25-0.5-50 mg
3
SELECT-OB+DHA – prenatal mv
w/fe poly-fa chw 29-1 mg & dha
cap 250 mg pak
3
PRETAB – prenatal vit w/ fe
3
TARON-BC – prenat w/o a w/ fe
cbnyl-fa tab 20-1 mg & vit b6 tab
pak
3
PROVIDA DHA – prenat w/o a
w/fe fum-fe poly-fa-dha cap
16-16-1.25-110 mg
3
TARON-C DHA – prenatal w/fe
fum-fe poly -fa-omega 3 cap
53.5-38-1 mg
TARON-PREX – prenatal w/o
30-1.2-265 mg
3
THRIVITE RX – prenatal vit w/ iron
carbonyl-fa tab 29-1 mg
3
THRIVITE 19 – prenatal vit w/ dssfe fumarate-fa tab 29-1 mg
3
TL FOLATE – prenatal vit w/
fe fum-methylfolate-fa tab
27-0.5-0.5 mg
3
TL-CARE DHA – prenatal w/fe
fumarate-fa-dss-fish oil cap
27-1-500 mg
3
TL-SELECT – prenatal w/o vit
a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg
3
TRI-TABS DHA – prenat w/o a
w/ fe bisglyc-fa tab 32-1 mg &
omega cap pack
3
TRIADVANCE – prenatal vit w/
3
TRICARE – prenatal vit w/ fe
3
PROVIDA OB – prenatal w/o a w/fe 3
fum-fe poly-fa cap 20-20-1.25 mg
3
PUREFE OB PLUS – prenatal
w/o a w/fe fum-fe poly-fa cap
162.115.2-1 mg
R-NATAL OB – prenatal w/o a w/fe 3
cbn-fa-dha cap 20-1-320 mg
3
RELNATE DHA – prenatal vit w/
fe fum-fa-omega 3 cap 28-1-200
mg
3
RULAVITE DHA – prenat w/o a
27-0.6-0.4-300 mg
3
SE-NATAL 19 – prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
SE-NATAL 19 – prenatal vit w/ dss- 3
3
SE-TAN DHA – prenatal w/fe fumfe poly -fa-omega 3 cap 15-15-1
mg
KEY
Tier
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
124
TRICARE PRENATAL – prenat w/o
a w/fepyro-mfol chw 4.5-1 mg &
dha cap 150 thpk
3
VINACAL B – prenat w/o a w/
fecbn-feglu-fa tab 20-1 mg & vit
b6 tab pak
3
TRICARE PRENATAL COMPLEAT
– prenat w/o a fefum-fa tab 27-1
mg & fish oil chew cap pak
3
VINATE AZ EXTRA – prenatal vit
w/ fe bisglycinate chelate-fa tab
29-1 mg
3
TRICARE PRENATAL DHA ONE
– prenatal w/fe fumarate-fa-dssfish oil cap 27-1-500 mg
3
VINATE C – prenatal w/o a vit w/ fe
3
3
VINATE CALCIUM – prenatal vit w/
iron carbonyl-fe gluc-fa tab 27-1
mg
3
TRINATAL GT – prenatal vit w/
TRINATAL RX 1 – prenatal vit w/ fe
3
VINATE CARE – prenatal w/o a vit
w/ fe fum-fa tab chew 40-1 mg
3
TRINATE – prenatal vit w/ fe
3
3
TRISTART DHA – prenat w/o
a w/fecbn-methylf-fa-dha cap
31-0.6-0.4-200 mg
3
VINATE DHA RF – prenat w/o a
w/fefum-methylfol-omegas cap
27-1.13 mg
3
TRIVEEN-DUO DHA – prenatfe bis-fe prot succ-fa-ca tab &
omega 3 cap 400 pk
3
VINATE IC – prenatal w/o a w/fe
fum-fe poly-fa cap 162.115.2-1
mg
3
TRIVEEN-PRX RNF – prenatal w/
o vit a w/ fe fum-dss-fa-dha cap
26-1.2-300 mg
3
VINATE II – prenatal vit w/ fe
bisglycinate chelate-fa tab 29-1
mg
VINATE M – prenatal vit w/ sel-fe
3
ULTIMATECARE ONE – prenatal
vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg
3
VINATE ONE – prenatal vit w/ fe
3
3
VIRT NATE – prenatal vit w/ fe
3
ULTIMATECARE ONE NF –
prenatal w/fe cbnyl-fe asp glycfa-dss-omega cap 20-7-1 mg
3
VEMAVITE-PRX 2 – prenatal w/
o vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg
3
VIRT-ADVANCE – prenatal vit w/
VENA-BAL DHA – prenat w/fe
poly-na fered-fa tab 27-1 &
omega cap dr 430mg
3
KEY
Responsible Steps
Quantity Limits
VIRT-C DHA – prenatal w/fe fum-fe 3
poly -fa-omega 3 cap 53.5-38-1
mg
3
VIRT-CARE ONE – prenatal vit w/
fe cbn-fe asp glyc-fa-omega 3
cap 27-1mg
Tier
•
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
125
VIRT-NATE DHA – prenatal vit w/
fe fum-fa-omega 3 cap 28-1-200
mg
3
VITAFOL-ONE – prenatal mv w/
fe polysac cmplx-fa-dha cap
29-1-200 mg
3
VIRT-PN – prenatal vit w/ fe fummethylfolate-fa tab 27-0.6-0.4 mg
3
3
VIRT-PN DHA – prenat w/o a
27-0.6-0.4-300 mg
3
VITAMEDMD ONE RX/
QUATREFO – prenat w/o a
30-0.6-0.4-200 mg
3
VIRT-PN PLUS – prenat w/o a
w/ fe fumerate-methylfolate-faomega 3 cap
3
VITAMEDMD PLUS RX/QUATRE
– prenat w/o a w/ fe chelate-l
methylfol-fa tab & dha cap pk
3
VIRT-SELECT – prenatal w/o
29-1.25-325 mg
3
VITAMEDMD REDICHEW RX –
prenat w/ b2-b6-b12-d3-folic acid
chew tab 1.4 mg
3
VIRT-VITE GT – prenatal vit w/
3
VITAPEARL – prenat w/oa w/
fefum-na fered-fa-dha cap cr
30-1.4-200 mg
VIRTPREX – prenatal w/o vit a w/
fe fum-dss-fa-dha cap 26-1.2-300
mg
3
VITATRUE – prenat w/o a w/fe
chel-fa tab 30-1.4 mg & dha cap
300mg pk
3
VITA-PREN – prenatal vit w/
docusate-iron-fa tab 65-1 mg
3
VIVA DHA – prenatal vit w/ fe fumfa-omega 3 cap 28-1-200 mg
3
VITAFOL FE+ – prenat-fepolymethol-fa-dha cap 90-1-200 mg
& dss 50mg cap
3
VOL-NATE – prenatal vit w/ fe
3
3
VITAFOL GUMMIES – prenat vit
w/ fe phos-fa-omega chew tab
3.33-0.333-34.8 mg
3
VOL-PLUS – prenatal vit w/ fe
VOL-TAB RX – prenatal vit w/ iron
carbonyl-fa tab 29-1 mg
3
VITAFOL ULTRA – prenat w/
fe poly-methylfol-fa-dha cap
29-0.6-0.4-200 mg
3
VP-CH PLUS – prenatal w/o a w/fe
cbn-dss-fa-dha cap 29-1-265 mg
3
VP-CH-PNV – prenatal w/o vit a w/
fe cbn-dss-fa-dha cap 30-1-260
mg
3
VITAFOL-NANO – prenatal w/
o a w/ fefum-l methylfol-fa tab
18-0.6-0.4 mg
3
VITAFOL-OB – prenatal vit w/ fe
3
VITAFOL-OB+DHA – prenatal mv
w/fe fum-fa tab 65-1 mg & dha
cap 250 mg pack
3
KEY
Responsible Steps
Quantity Limits
VP-GGR-B6 PRENATAL – prenatal 3
w/ calcium-vit b6-fa-ginger tab
1.2 mg
3
VP-HEME OB – prenat vit-fe poly
cmplx-fe heme poly-fa tab 28-6-1
mg
Tier
•
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
126
VP-HEME OB + DHA – prenat-fe
poly cmplx-fe heme poly-fa tab &
omega 3 cap pck
3
FLURA-DROPS – sodium fluoride
soln 0.25 mg/drop f (from 0.55
mg/drop naf)
3
VP-HEME ONE – prenat-fe poly
cmplx-fe heme poly-fa-dha cap
22-6-1-200 mg
3
GALZIN – zinc acetate cap 25 mg
(elemental zinc)
3
3
3
VP-PNV-DHA – prenatal vit w/ fe
fum-fa-omega 3 cap 28-1-215.8
mg
GALZIN – zinc acetate cap 50 mg
(elemental zinc)
3
ZATEAN-CH – prenatal w/o a w/fe
cbn-dss-fa-dha cap 27-1-250 mg
3
K-PHOS – potassium phosphate
monobasic tab 500 mg
3
ZATEAN-PN DHA – prenat w/o
a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
3
K-PHOS NEUTRAL – pot phos
monobasic w/sod phos di &
monobas tab 155-852-130mg
3
ZATEAN-PN PLUS – prenat w/o a
w/ fe fumerate-methylfolate-faomega 3 cap
3
K-TAB – potassium chloride tab cr
8 meq (600 mg)
10 meq
3
20 meq (1500 mg)
3
KLOR-CON M15 – potassium
chloride microencapsulated crys
cr tab 15 meq
3
LOZI-FLUR – sodium fluoride
lozenge 1 mg f (from 2.2 mg naf)
3
LURIDE – sodium fluoride chew
tab 0.25 mg f (from 0.55 mg naf)
3
tab 0.5 mg f (from 1.1 mg naf)
3
tab 1 mg f (from 2.2 mg naf)
3
LURIDE – sodium fluoride soln 0.5
mg/ml f (from 1.1 mg/ml naf)
3
MINERALS AND ELECTROLYTES
EFFER-K – potassium
bicarbonate-citric acid effer tab
10 meq
3
EFFER-K – potassium
bicarbonate-citric acid effer tab
20 meq
3
FLORIVA – sodium fluoride-vitamin
d liqd drops 0.25 mg/ml-400 unit/
ml
3
FLUOR-A-DAY – sodium fluoridexylitol chew tab 0.55 (0.25 mg
f)-236.79 mg
3
FLUOR-A-DAY – sodium fluoridexylitol chew tab 2.2 (1 mg
f)-236.79 mg
3
FLUORABON – sodium fluoride
soln 0.25 mg/0.6ml (from 0.55
mg/0.6ml naf)
3
KEY
Responsible Steps
Quantity Limits
MICRO-K – potassium chloride cap 3
cr 8 meq
MICRO-K – potassium chloride cap 3
cr 10 meq
1
pot bicarbonate & chloride effer
tab 25 meq
Tier
•
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
127
pot phos monobasic w/sod
phos di & monobas tab
155-852-130mg (K-phos neutral)
potassium bicarbonate effer tab
25 meq
1
3
POTASSIUM CHLORIDE ER –
potassium chloride tab cr 20 meq
(1500 mg)
3
potassium chloride
microencapsulated crys cr tab
10 meq
1
potassium chloride tab cr 10
meq (K-tab)
sodium fluoride chew tab 1 mg f
(from 2.2 mg naf) (Luride)
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)
acetylcysteine cap 600 mg
3
NUTRESTORE – glutamine powd
pack 5 gm
3
3
1
3
1
AMICAR – aminocaproic acid oral
soln 0.25 gm/ml
3
1
AMICAR – aminocaproic acid tab
500 mg
3
1
AMICAR – aminocaproic acid tab
1000 mg
1
1
anagrelide hcl cap 0.5 mg
(Agrylin)
anagrelide hcl cap 1 mg
1
SODIUM FLUORIDE – sodium
fluoride tab 1 mg f (from 2.2 mg
naf)
2
ARANESP ALBUMIN FREE –
darbepoetin alfa soln prefilled
syringe 10 mcg/0.4ml
2
X •
2
X •
Tier
•
*
Responsible Steps
1
AGRYLIN – anagrelide hcl cap 0.5
mg
2
Quantity Limits
1
3
1
Prior Authorization
1
LECITHIN – lecithin granules
BLOOD MODIFYING DRUGS
Specialty/Tier 4
1
AGGRENOX – aspirindipyridamole cap sr 12hr 25-200
mg
SODIUM FLUORIDE – sodium
fluoride tab 0.5 mg f (from 1.1 mg
naf)
KEY
Drug Tier
sodium fluoride chew tab 0.5 mg
f (from 1.1 mg naf) (Luride)
POTASSIUM CHLORIDE ER –
(600 mg)
(600 mg)
Responsible Steps
1
1
potassium chloride powder
packet 20 meq
Quantity Limits
1
potassium chloride cap cr 10
meq (Micro-k)
potassium chloride oral soln
20% (40 meq/15ml)
Prior Authorization
sodium fluoride chew tab
0.25 mg f (from 0.55 mg naf)
(Luride)
1
potassium chloride oral soln
10% (20 meq/15ml)
Drug Name
1
potassium chloride cap cr 8 meq
(Micro-k)
potassium chloride
microencapsulated crys cr tab
20 meq
Specialty/Tier 4
Drug Name
Drug Tier
2016
128
2
2
X •
2
2
syringe 500 mcg/ml
2
darbepoetin alfa soln inj 25 mcg/
ml
2
ml
2
ml
2
X •
darbepoetin alfa soln inj 100
mcg/ml
2
X •
mcg/ml
2
KEY
mcg/ml
2
ARIXTRA – fondaparinux sodium
subcutaneous inj 2.5 mg/0.5ml
3
•
3
•
3
•
3
•
X •
ASPIRIN/DIPYRIDAMOLE –
aspirin-dipyridamole cap sr 12hr
25-200 mg
3
X •
BERINERT – c1 esterase inhibitor
(human) for iv inj kit 500 unit
3
BRILINTA – ticagrelor tab 60 mg
2
BRILINTA – ticagrelor tab 90 mg
2
carbonyl iron susp 15 mg/1.25ml
(elemental iron)
1
X •
X •
X •
X •
X •
CERDELGA – eliglustat tartrate
3
cilostazol tab 50 mg
1
cilostazol tab 100 mg
CINRYZE – c1 esterase inhibitor
(human) for iv inj 500 unit
2
clopidogrel bisulfate tab 75 mg
(base equiv) (Plavix)
1
clopidogrel bisulfate tab 300 mg
(base equiv) (Plavix)
3
COUMADIN – warfarin sodium tab
2 mg
3
2.5 mg
3
•
*
X •
X • •
X •
1
1 mg
Tier
1
Responsible Steps
X •
X •
Quantity Limits
2
Prior Authorization
Drug Name
Specialty/Tier 4
X •
Drug Tier
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
129
3 mg
3
4 mg
3
5 mg
3
6 mg
3
7.5 mg
3
10 mg
3
cyanocobalamin inj 1000 mcg/ml
1
enoxaparin sodium inj
60 mg/0.6ml (Lovenox)
enoxaparin sodium inj 100 mg/
ml (Lovenox)
enoxaparin sodium inj 150 mg/
ml (Lovenox)
300 mg/3ml (Lovenox)
•
1
•
1
•
1
•
1
•
1
•
3
X •
dipyridamole tab 25 mg
(Persantine)
1
3
X •
(Persantine)
1
EPOGEN – epoetin alfa inj 3000
unit/ml
3
X •
(Persantine)
1
unit/ml
3
X •
DROXIA – hydroxyurea cap 200
mg
2
unit/ml
3
X •
mg
2
unit/ml
3
mg
2
FERROUS SULFATE – ferrous
sulfate liquid 220 mg/5ml (44
mg/5ml elemental fe)
EFFIENT – prasugrel hcl tab 5 mg
(base equiv)
3
ferrous sulfate elixir 220 mg/5ml
(44 mg/5ml elemental fe)
1
ferrous sulfate soln 75 mg/ml
(15 mg/ml elemental fe)
ELIQUIS – apixaban tab 5 mg
2
1
•
•
•
1
•
KEY
2
folic acid tab 400 mcg
1
folic acid tab 1 mg
Tier
•
1
FIRAZYR – icatibant acetate inj 30
mg/3ml (base equivalent)
folic acid tab 800 mcg
*
Responsible Steps
1
unit/ml
EFFIENT – prasugrel hcl tab 10 mg 3
(base equiv)
2
ELIQUIS – apixaban tab 2.5 mg
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
X •
1
1
130
FOLIVANE-F – fe fum-fe poly-fa-cb3 cap 62.5-62.5-1-40-3mg(125
mg fe)
3
fondaparinux sodium
(Arixtra)
1
fondaparinux sodium
(Arixtra)
1
•
fondaparinux sodium
(Arixtra)
1
•
fondaparinux sodium
(Arixtra)
1
•
FRAGMIN – dalteparin sodium inj
10000 unit/ml
3
•
2500 unit/0.2ml
3
•
5000 unit/0.2ml
3
•
7500 unit/0.3ml
3
•
12500 unit/0.5ml
3
•
15000 unit/0.6ml
3
•
18000 unit/0.72ml
3
•
95000 unit/3.8ml
3
•
GRANIX – tbo-filgrastim soln
prefilled syringe 300 mcg/0.5ml
3
X •
GRANIX – tbo-filgrastim soln
3
X •
heparin sodium (porcine) inj
5000 unit/ml
1
KEY
•
INTEGRA F – fe fum-fe poly-fa-cb3 cap 62.5-62.5-1-40-3mg(125
mg fe)
3
LEUKINE – sargramostim
lyophilized for inj 250 mcg
2
LOVENOX – enoxaparin sodium inj 3
30 mg/0.3ml
40 mg/0.4ml
60 mg/0.6ml
80 mg/0.8ml
100 mg/ml
120 mg/0.8ml
150 mg/ml
300 mg/3ml
3
LYSTEDA – tranexamic acid tab
650 mg
3
MIRCERA – methoxy pegepoetin beta soln prefilled syr 50
mcg/0.3ml
3
MIRCERA – methoxy pegepoetin beta soln prefilled syr 75
mcg/0.3ml
3
MIRCERA – methoxy peg-epoetin
beta soln prefilled syr 100
mcg/0.3ml
3
MIRCERA – methoxy peg-epoetin
beta soln prefilled syr 200
mcg/0.3ml
3
NASCOBAL – cyanocobalamin
nasal spray 500 mcg/0.1ml
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Tier
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
X •
•
•
•
•
•
•
•
•
X
X
X
X
131
PROMACTA – eltrombopag
olamine tab 12.5 mg (base equiv)
3
X • •
X • •
olamine tab 25 mg (base equiv)
3
X • •
NEUPOGEN – filgrastim soln
2
X •
3
X • •
NEUPOGEN – filgrastim soln
(600 mcg/ml)
2
X •
3
X • •
NEUPOGEN – filgrastim inj 300
mcg/ml
2
X •
NEUPOGEN – filgrastim inj 480
mcg/1.6ml (300 mcg/ml)
2
X •
pentoxifylline tab cr 400 mg
1
PRADAXA – dabigatran etexilate
mesylate cap 75 mg (etexilate
base eq)
2
•
base eq)
2
•
base eq)
2
•
PROCRIT – epoetin alfa inj 2000
unit/ml
2
X •
unit/ml
2
X •
unit/ml
2
X •
unit/ml
2
X •
unit/ml
2
X •
unit/ml
2
X •
KEY
RUCONEST – c1 esterase inhibitor 3
(recombinant) for iv inj 2100 unit
SAVAYSA – edoxaban tosylate tab 3
1
tranexamic acid tab 650 mg
(Lysteda)
1
warfarin sodium tab 1 mg
(Coumadin)
1
(Coumadin)
1
warfarin sodium tab 2.5 mg
(Coumadin)
1
(Coumadin)
1
(Coumadin)
1
(Coumadin)
1
(Coumadin)
1
warfarin sodium tab 7.5 mg
(Coumadin)
1
(Coumadin)
Tier
•
*
Responsible Steps
2
Quantity Limits
NEULASTA ONPRO KIT –
pegfilgrastim soln prefilled
Prior Authorization
X • •
Drug Name
Specialty/Tier 4
2
Drug Tier
NEULASTA – pegfilgrastim soln
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
X •
•
•
•
132
XARELTO – rivaroxaban tab 10 mg 2
2
XARELTO STARTER PACK –
rivaroxaban tab starter therapy
pack 15 mg & 20 mg
2
ZARXIO – filgrastim-sndz soln
2
ZARXIO – filgrastim-sndz soln
ZAVESCA – miglustat cap 100 mg 3
X •
X • •
2
X •
ADYNOVATE – antihemophilic
factor recomb pegylated for inj
2000 unit
2
X •
ALPHANATE/VON WILLEBRAND
– antihemophilic factor/vwf
(human) for inj 250 unit
2
X •
2
X •
2
X •
2
X •
2
X •
ADVATE – antihemophilic factor
rahf-pfm for inj 250 unit
2
X •
2
X •
2
X •
2
X •
ALPHANINE SD – coagulation
factor ix for inj 500 unit
2
X •
2
X •
2
X •
2
X •
2
X •
2
X •
ALPROLIX – coagulation factor ix
(recomb) (rfixfc) for inj 250 unit
2
X •
250 unit
2
X •
2
X •
2
X •
500 unit
2
2
X •
2
X •
KEY
X •
Tier
•
*
Responsible Steps
1000 unit
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
•
•
•
•
X •
ZONTIVITY – vorapaxar sulfate tab 3
COAGULATION FACTORS
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
133
BEBULIN – factor ix complex for inj 2
200-1200 unit
2
BENEFIX – coagulation factor ix
(recombinant) for inj 250 unit
2
2
2
2
COAGADEX – coagulation factor x 2
COAGADEX – coagulation factor x 2
CORIFACT – factor xiii concentrate 2
(human) for inj kit 1000-1600 unit
ELOCTATE – antihemophilic factor 2
(recomb) rfviiifc for inj 250 unit
2
FEIBA – antiinhibitor coagulant
complex for inj
2
HELIXATE FS – antihemophilic
factor (recombinant) for inj kit
250 unit
KEY
2
X •
1000 unit
2
X •
2000 unit
2
X •
2
X •
X •
3000 unit
X •
HEMOFIL M – antihemophilic
factor (human) for inj 250 unit
2
X •
X •
2
X •
X •
2
X •
X •
2
X •
X •
HUMATE-P – antihemophilic factor/ 2
vwf (human) for inj 250-600 unit
vwf (human) for inj 500-1200 unit
vwf (human) for inj 1000-2400
unit
3
IDELVION – coagulation factor ix
(recomb) (rix-fp) for inj 250 unit
3
3
3
2
IXINITY – coagulation factor ix
X •
X •
X •
X •
X •
X •
X •
X •
X •
X •
X •
X •
•
*
Responsible Steps
500 unit
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Tier
Drug Tier
Responsible Steps
X •
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
X •
X •
X •
X •
X •
X •
X •
134
2
X •
X •
KOVALTRY – antihemophilic factor
3
KOATE-DVI – antihemophilic factor
2
X •
3
X •
2
3
X •
2
3
X •
KOGENATE FS – antihemophilic
250 unit
2
3
X •
500 unit
2
X •
MONOCLATE-P – antihemophilic
factor (human) for inj kit 250 unit
2
X •
1000 unit
2
X •
factor (human) for inj kit 1000
unit
2
X •
X •
factor (human) for inj kit 1500
unit
2
2000 unit
2
X •
X •
MONONINE – coagulation factor ix
for inj 500 unit
2
3000 unit
2
X •
2
X •
KOGENATE FS BIO-SET
– antihemophilic factor
(recombinant) for inj kit 250 unit
2
X •
MONONINE – coagulation factor ix
for inj 1000 unit
2
X •
KOGENATE FS BIO-SET
2
X •
NOVOEIGHT – antihemophilic
factor (recombinant) for inj 250
unit
2
X •
KOGENATE FS BIO-SET
2
X •
unit
2
X •
KOGENATE FS BIO-SET
2
X •
unit
unit
2
X •
KEY
X •
X •
X •
X •
Tier
•
*
Responsible Steps
KOGENATE FS BIO-SET
Quantity Limits
2
Prior Authorization
Drug Name
Specialty/Tier 4
X •
Drug Tier
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
135
2
X •
PROFILNINE – factor ix complex
for inj 1000 unit
2
X •
for inj 1500 unit
2
X •
PROFILNINE SD – factor ix
complex for inj 500 unit
2
X •
2
X •
2
X •
RECOMBINATE – antihemophilic
factor (recombinant) for inj
220-400 unit
2
X •
401-800 unit
2
X •
801-1240 unit
2
X •
1241-1800 unit
2
X •
2
X •
X •
1801-2400 unit
2
X •
RIXUBIS – coagulation factor ix
2
X •
X •
2
NUWIQ – antihemophilic factor
2
X •
X •
2
2
X •
X •
2
OBIZUR – antihemophilic factor
(recomb porc) rpfviii for inj 500
unit
2
X •
2
X •
2
unit
2
NOVOSEVEN RT – coagulation
factor viia (recomb) for inj 1 mg
(1000 mcg)
2
X •
(2000 mcg)
2
X •
(5000 mcg)
2
X •
(8000 mcg)
2
X •
2
X •
2
X •
2
X •
2
X •
2
KEY
X •
Tier
•
*
Responsible Steps
for inj 500 unit
unit
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
X •
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
136
KEY
Anti-infectives
3
X •
BACITRACIN – bacitracin ophth
oint 500 unit/gm
2
bacitracin-polymyxin b ophth
oint
1
X •
X •
X •
X •
X •
X •
BESIVANCE – besifloxacin hcl
ophth susp 0.6% (base equiv)
3
BETADINE OPHTHALMIC PREP –
povidone-iodine ophth soln 5%
3
BLEPH-10 – sulfacetamide sodium
ophth soln 10%
3
CILOXAN – ciprofloxacin hcl ophth
soln 0.3%
3
CILOXAN – ciprofloxacin hcl ophth
oint 0.3%
3
ciprofloxacin hcl ophth soln
0.3% (Ciloxan)
1
erythromycin ophth oint 5 mg/
gm
1
gatifloxacin ophth soln 0.5%
(Zymaxid)
1
gentamicin sulfate ophth oint
0.3%
1
gentamicin sulfate ophth soln
0.3%
levofloxacin ophth soln 0.5%
1
1
MITOSOL – mitomycin for ophth
soln kit 0.2 mg
3
MOXEZA – moxifloxacin hcl ophth
soln 0.5% (base eq) (2 times
daily)
3
Tier
•
Responsible Steps
EYE
AZASITE – azithromycin ophth
soln 1%
X •
Quantity Limits
TOPICAL PRODUCTS
X •
X •
Prior Authorization
X •
Drug Name
Specialty/Tier 4
WILATE – antihemophilic factor/vwf 2
(human) for inj 500-500 unit kit
WILATE – antihemophilic factor/vwf 2
(human) for inj 1000-1000 unit kit
2
XYNTHA – antihemophilic factor
recombinant paf for inj kit 250
unit
2
unit
2
unit
2
unit
2
XYNTHA SOLOFUSE –
antihemophilic factor
unit
2
XYNTHA SOLOFUSE –
unit
2
XYNTHA SOLOFUSE –
unit
2
XYNTHA SOLOFUSE –
unit
2
XYNTHA SOLOFUSE –
unit
Drug Tier
X •
Responsible Steps
2
TRETTEN – coagulation factor xiii
a-subunit for inj 2000-3125 unit
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
137
NATACYN – natamycin ophth susp
5%
2
VIROPTIC – trifluridine ophth soln
1%
3
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op
oin
1
ZIRGAN – ganciclovir ophth gel
0.15%
3
ZYMAXID – gatifloxacin ophth soln
0.5%
3
neomycin-polymy-gramicid op
sol 1.75-10000-0.025mg-untmg/ml (Neosporin)
1
NEOSPORIN – neomycinpolymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml
3
OCUFLOX – ofloxacin ophth soln
0.3%
3
ofloxacin ophth soln 0.3%
(Ocuflox)
1
polymyxin b-trimethoprim
ophth soln 10000 unit/ml-0.1%
(Polytrim)
1
POLYTRIM – polymyxin btrimethoprim ophth soln 10000
unit/ml-0.1%
3
SULFACETAMIDE SODIUM –
sulfacetamide sodium ophth oint
10%
3
sulfacetamide sodium ophth
soln 10% (Bleph-10)
1
tobramycin ophth soln 0.3%
(Tobrex)
1
TOBREX – tobramycin ophth soln
0.3%
3
TOBREX – tobramycin ophth oint
0.3%
3
trifluridine ophth soln 1%
(Viroptic)
1
Tier
•
Responsible Steps
Quantity Limits
Steroids and Combination Products
3
ALREX – loteprednol etabonate
ophth susp 0.2%
1
bacitracin-polymyxin-neomycinhc ophth oint 1%
2
BLEPHAMIDE – sulfacetamide
sodium-prednisolone ophth susp
10-0.2%
2
BLEPHAMIDE S.O.P. –
sulfacetamide sodiumprednisolone ophth oint 10-0.2%
3
DEXAMETHASONE SODIUM
PHOS – dexamethasone sodium
phosphate ophth soln 0.1%
3
DUREZOL – difluprednate ophth
emulsion 0.05%
FLAREX – fluorometholone acetate 3
ophth susp 0.1%
1
fluorometholone ophth susp
0.1% (Fml liquifilm)
3
FML – fluorometholone ophth oint
0.1%
3
FML FORTE – fluorometholone
ophth susp 0.25%
FML LIQUIFILM – fluorometholone 3
ophth susp 0.1%
LOTEMAX – loteprednol etabonate 2
ophth gel 0.5%
LOTEMAX – loteprednol etabonate 2
ophth oint 0.5%
VIGAMOX – moxifloxacin hcl ophth 2
soln 0.5% (base equiv)
KEY
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
138
LOTEMAX – loteprednol etabonate
ophth susp 0.5%
2
MAXIDEX – dexamethasone ophth
susp 0.1%
3
MAXITROL – neomycin-polymyxin- 3
dexamethasone ophth susp 0.1%
MAXITROL – neomycin-polymyxin- 3
dexamethasone ophth oint 0.1%
1
neomycin-polymyxindexamethasone ophth oint
0.1% (Maxitrol)
1
neomycin-polymyxindexamethasone ophth susp
0.1% (Maxitrol)
3
NEOMYCIN/POLYMYXIN/
HYDROC – neomycin-polymyxinhc ophth susp
3
OMNIPRED – prednisolone
acetate ophth susp 1%
3
PRED FORTE – prednisolone
acetate ophth susp 1%
3
PRED MILD – prednisolone
acetate ophth susp 0.12%
3
PRED-G – gentamicinprednisolone ace ophth susp
0.3-1%
3
PRED-G S.O.P. – gentamicinprednisolone ace ophth oint
0.3-0.6%
prednisolone acetate ophth susp 1
1% (Pred forte)
3
PREDNISOLONE SODIUM
PHOSP – prednisolone sodium
phosphate ophth soln 1%
1
sulfacetamide sodiumprednisolone ophth soln
10-0.23(0.25)%
KEY
TOBRADEX – tobramycindexamethasone ophth oint
0.3-0.1%
2
TOBRADEX – tobramycindexamethasone ophth susp
0.3-0.1%
3
TOBRADEX ST – tobramycindexamethasone ophth susp
0.3-0.05%
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
1
tobramycin-dexamethasone
ophth susp 0.3-0.1% (Tobradex)
3
VEXOL – rimexolone ophth susp
1%
3
ZYLET – loteprednol etabonatetobramycin ophth susp 0.5-0.3%
Glaucoma
ALPHAGAN P – brimonidine
tartrate ophth soln 0.1%
2
ALPHAGAN P – brimonidine
tartrate ophth soln 0.15%
3
apraclonidine hcl ophth soln
0.5% (base equivalent)
(Iopidine)
1
AZOPT – brinzolamide ophth susp
1%
3
BETAGAN – levobunolol hcl ophth
soln 0.5%
3
betaxolol hcl ophth soln 0.5%
1
BETIMOL – timolol ophth soln
0.25%
3
BETIMOL – timolol ophth soln
0.5%
3
BETOPTIC-S – betaxolol hcl ophth
susp 0.25%
3
BIMATOPROST – bimatoprost
ophth soln 0.03%
3
Tier
•
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
•
139
brimonidine tartrate ophth soln
0.15% (Alphagan p)
brimonidine tartrate ophth soln
0.2%
carteolol hcl ophth soln 1%
LUMIGAN – bimatoprost ophth
soln 0.01%
2
1
METIPRANOLOL – metipranolol
ophth soln 0.3%
3
1
PHOSPHOLINE IODIDE –
echothiophate iodide ophth for
soln 0.125%
3
pilocarpine hcl ophth soln 1%
(Isopto carpine)
1
(Isopto carpine)
1
(Isopto carpine)
1
3
COSOPT – dorzolamide hcl-timolol
maleate ophth soln 22.3-6.8 mg/
ml
3
COSOPT PF – dorzolamide
hcl-timolol maleate ophth sol
22.3-6.8 mg/ml pf
3
dorzolamide hcl ophth soln 2%
(Trusopt)
1
dorzolamide hcl-timolol maleate
ophth soln 22.3-6.8 mg/ml
(Cosopt)
1
IOPIDINE – apraclonidine
hcl ophth soln 0.5% (base
equivalent)
3
IOPIDINE – apraclonidine hcl
ophth soln 1% (base equivalent)
3
ISOPTO CARPINE – pilocarpine
hcl ophth soln 1%
3
hcl ophth soln 2%
3
hcl ophth soln 4%
3
ISTALOL – timolol maleate ophth
soln 0.5% (once-daily)
3
latanoprost ophth soln 0.005%
(Xalatan)
1
levobunolol hcl ophth soln 0.5%
(Betagan)
1
•
RESCULA – unoprostone isopropyl 3
ophth soln 0.15%
3
SIMBRINZA – brinzolamidebrimonidine tartrate ophth susp
1-0.2%
1
timolol maleate ophth gel
forming soln 0.25% (Timopticxe)
1
timolol maleate ophth gel
forming soln 0.5% (Timoptic-xe)
1
timolol maleate ophth soln
0.25% (Timoptic)
1
timolol maleate ophth soln 0.5%
(Timoptic)
TIMOPTIC – timolol maleate ophth 3
soln 0.25%
TIMOPTIC – timolol maleate ophth 3
soln 0.5%
3
TIMOPTIC OCUDOSE – timolol
maleate preservative free ophth
soln 0.25%
3
TIMOPTIC OCUDOSE – timolol
maleate preservative free ophth
soln 0.5%
Tier
•
*
•
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
1
COMBIGAN – brimonidine tartratetimolol maleate ophth soln
0.2-0.5%
KEY
Specialty/Tier 4
Drug Name
Drug Tier
2016
•
140
TIMOPTIC-XE – timolol maleate
ophth gel forming soln 0.25%
3
BEPREVE – bepotastine besilate
ophth soln 1.5%
3
TIMOPTIC-XE – timolol maleate
ophth gel forming soln 0.5%
3
3
TRAVATAN Z – travoprost ophth
soln 0.004% (benzalkonium free)
(bak free)
2
•
BROMFENAC – bromfenac
sodium ophth soln 0.09% (base
equivalent)
1
TRAVOPROST – travoprost ophth
soln 0.004%
3
•
bromfenac sodium ophth soln
0.09% (base equiv) (once-daily)
cromolyn sodium ophth soln 4%
TRUSOPT – dorzolamide hcl ophth 3
soln 2%
XALATAN – latanoprost ophth soln 3
0.005%
3
ZIOPTAN – tafluprost ophth soln
0.0015%
Other Eye Products
ACULAR – ketorolac tromethamine 3
ophth soln 0.5%
3
ACULAR LS – ketorolac
tromethamine ophth soln 0.4%
3
ACUVAIL – ketorolac
3
AKTEN – lidocaine hcl ophth gel
3.5%
ALCAINE – proparacaine hcl ophth 3
soln 0.5%
3
ALOCRIL – nedocromil sodium
ophth soln 2%
3
ALOMIDE – lodoxamide
2
ATROPINE SULFATE – atropine
sulfate ophth oint 1%
3
ATROPINE SULFATE – atropine
sulfate ophth soln 1%
1
azelastine hcl ophth soln 0.05%
KEY
3
•
CYCLOGYL – cyclopentolate hcl
ophth soln 1%
3
•
ophth soln 2%
3
CYCLOMYDRIL – cyclopentolate
w/ phenylephrine ophth soln
0.2-1%
3
cyclopentolate hcl ophth soln
0.5% (Cyclogyl)
1
2% (Cyclogyl)
diclofenac sodium ophth soln
0.1%
1
ELESTAT – epinastine hcl ophth
soln 0.05%
3
EMADINE – emedastine
difumarate ophth soln 0.05%
(base equiv)
3
epinastine hcl ophth soln 0.05%
(Elestat)
1
flurbiprofen sodium ophth soln
0.03% (Ocufen)
1
•
*
Responsible Steps
1
3
Quantity Limits
1
CYSTARAN – cysteamine
hcl ophth soln 0.44% (base
equivalent)
Tier
1
ophth soln 0.5%
1% (Cyclogyl)
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
X
•
141
homatropine hbr ophth soln 5%
(Isopto homatropine)
1
ILEVRO – nepafenac ophth susp
0.3%
3
ketorolac tromethamine ophth
soln 0.4% (Acular ls)
1
ketorolac tromethamine ophth
soln 0.5% (Acular)
tetracaine hcl ophth soln 0.5%
tropicamide ophth soln 0.5%
tropicamide ophth soln 1%
(Mydriacyl)
EAR
acetic acid otic soln 2%
1
1
1
2
1
3
LASTACAFT – alcaftadine ophth
soln 0.25%
3
antipyrine-benzocaine otic soln
54-14 mg/ml (5.4-1.4%)
MYDRIACYL – tropicamide ophth
soln 1%
3
CETRAXAL – ciprofloxacin hcl otic
soln 0.2% (base equivalent)
3
CIPRO HC – ciprofloxacinhydrocortisone otic susp 0.2-1%
3
CIPRODEX – ciprofloxacindexamethasone otic susp
0.3-0.1%
2
CIPROFLOXACIN – ciprofloxacin
hcl otic soln 0.2% (base
equivalent)
3
COLY-MYCIN S – neomycincolistin-hc-thonzonium otic susp
3.3-3-10-0.5 mg/ml
3
DERMOTIC – fluocinolone
acetonide (otic) oil 0.01%
3
fluocinolone acetonide (otic) oil
0.01% (Dermotic)
1
KEY
neomycin-polymyxin-hc otic
soln 1%
• •
neomycin-polymyxin-hc otic
susp 3.5 mg/ml-10000 unit/
ml-1%
ofloxacin otic soln 0.3%
Tier
•
*
Responsible Steps
1
ACETIC ACID/ALUMINUM ACET
– acetic acid 2% in aluminum
acetate otic soln
hydrocortisone w/ acetic acid
otic soln 1-2%
Quantity Limits
1
LACRISERT – artificial tear ophth
insert
NEVANAC – nepafenac ophth susp 3
0.1%
3
OCUFEN – flurbiprofen sodium
ophth soln 0.03%
1
olopatadine hcl ophth soln 0.1%
(base equivalent) (Patanol)
2
PATADAY – olopatadine hcl ophth
3
PATANOL – olopatadine hcl ophth
2
PAZEO – olopatadine hcl ophth
1
phenylephrine hcl ophth soln
2.5%
1
phenylephrine hcl ophth soln
10%
3
PROLENSA – bromfenac sodium
ophth soln 0.07% (base
equivalent)
1
proparacaine hcl ophth soln
0.5% (Alcaine)
3
RESTASIS – cyclosporine (ophth)
emulsion 0.05%
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
1
1
1
1
142
MOUTH AND THROAT (LOCAL)
benzocaine dental soln 20%
1
cevimeline hcl cap 30 mg
(Evoxac)
1
chlorhexidine gluconate soln
0.12% (Peridex)
1
clotrimazole troche 10 mg
1
EVOXAC – cevimeline hcl cap 30
mg
3
LIDOCAINE HCL – lidocaine hcl
laryngotracheal soln 4%
3
lidocaine hcl viscous soln 2%
1
nystatin susp 100000 unit/ml
1
ANALPRAM-HC – hydrocortisone
acetate w/ pramoxine rectal lotn
2.5-1%
3
ANALPRAM-HC – hydrocortisone
acetate w/ pramoxine rectal
cream 1-1%
3
ANALPRAM-HC SINGLES –
hydrocortisone acetate w/
pramoxine rectal cream 1-1%
3
ANALPRAM-HC SINGLES –
pramoxine rectal cream 2.5-1%
3
ANUSOL-HC – hydrocortisone
rectal cream 2.5%
3
ORAVIG – miconazole buccal tab
50 mg (mouth-throat)
3
CORTENEMA – hydrocortisone
enema 100 mg/60ml
3
PERIDEX – chlorhexidine
gluconate soln 0.12%
3
2
pilocarpine hcl tab 5 mg
(Salagen)
1
CORTIFOAM – hydrocortisone
acetate rectal foam 10% (90 mg/
dose)
1
pilocarpine hcl tab 7.5 mg
(Salagen)
1
hydrocortisone acetate suppos
25 mg
SALAGEN – pilocarpine hcl tab 5
mg
3
SALAGEN – pilocarpine hcl tab 7.5
mg
3
triamcinolone acetonide dental
paste 0.1%
1
ANORECTAL AGENTS
ANALPRAM HC – hydrocortisone
acetate w/ pramoxine rectal
cream 2.5-1%
3
ANALPRAM HC SINGLES –
3
KEY
pramoxine rectal cream 1-1%
(Analpram-hc singles)
1
(Analpram-hc singles)
1
hydrocortisone enema
100 mg/60ml (Cortenema)
1
hydrocortisone rectal cream 1%
(Proctocort)
1
hydrocortisone rectal cream
2.5% (Anusol-hc)
1
LIDOCAINE HCL-HYDROCORTIS
– lidocaine-hydrocortisone
acetate rectal gel 2.8-0.55%
3
PROCTOCORT – hydrocortisone
rectal cream 1%
3
Tier
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
143
PROCTOFOAM HC –
pramoxine rectal foam 1-1%
2
RECTIV – nitroglycerin oint 0.4%
3
UCERIS – budesonide rectal foam
2 mg/act
3
benzoyl peroxide gel 10%
1
1
1
1
CLEOCIN-T – clindamycin
phosphate soln 1%
3
phosphate lotion 1%
3
phosphate swab 1%
3
clindamycin phosph-benzoyl
peroxide (refrig) gel 1.2 (1)-5%
(Duac)
1
3
AVAR – sulfacetamide sodium w/
sulfur foam 9.5-5%
3
AVAR LS – sulfacetamide sodium
w/ sulfur foam 10-2%
3
clindamycin phosphate foam 1%
(Evoclin)
1
AZELEX – azelaic acid cream 20%
3
1
BENZAC AC WASH – benzoyl
peroxide liq 5%
3
clindamycin phosphate gel 1%
(Cleocin-t)
1
BENZACLIN – clindamycin
phosphate-benzoyl peroxide gel
1-5%
3
clindamycin phosphate lotion
1% (Cleocin-t)
BENZACLIN WITH PUMP –
clindamycin phosphate-benzoyl
peroxide gel 1-5%
3
BENZAMYCIN – benzoyl peroxideerythromycin gel 5-3%
3
BENZAMYCINPAK – benzoyl
peroxide-erythromycin gel pack
5-3%
3
BENZIQ – benzoyl peroxide gel
5.25 %
3
clindamycin phosphate soln 1%
(Cleocin-t)
1
clindamycin phosphate swab 1%
(Cleocin-t)
1
clindamycin phosphate-benzoyl
peroxide gel 1-5% (Benzaclin)
1
DIFFERIN* – adapalene cream
0.1%
3
DIFFERIN* – adapalene gel 0.1%
3
DIFFERIN* – adapalene gel 0.3%
3
DIFFERIN* – adapalene lotion
0.1%
3
•
*
Responsible Steps
1
1
Quantity Limits
1
benzoyl peroxideerythromycin gel 5-3%
(Benzamycin)
Tier
Prior Authorization
1
ADAPALENE* – adapalene lotion
0.1%
KEY
Specialty/Tier 4
Responsible Steps
Quantity Limits
Drug Tier
3
benzoyl peroxide lotion 6%
ACANYA – clindamycin phosphate- 3
benzoyl peroxide gel 1.2-2.5%
3
ACZONE – dapsone gel 5%
adapalene gel 0.3%* (Differin)
BENZIQ LS – benzoyl peroxide gel
2.75%
benzoyl peroxide liq 5.25%
Acne
adapalene gel 0.1%* (Differin)
Drug Name
benzoyl peroxide liq 10%
SKIN CONDITIONS/PRODUCTS
adapalene cream 0.1%* (Differin)
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
144
DUAC – clindamycin phosphbenzoyl peroxide (refrig) gel 1.2
(1)-5%
3
metronidazole lotion 0.75%
(Metrolotion)
1
NUOX – benzoyl peroxide-sulfur
gel 6-3%
3
EPIDUO – adapalene-benzoyl
peroxide gel 0.1-2.5%
3
RETIN-A* – tretinoin cream
0.025%
3
EPIDUO FORTE – adapalenebenzoyl peroxide gel 0.3-2.5%
3
3
RETIN-A* – tretinoin cream 0.05%
3
ERYGEL – erythromycin gel 2%
1
RETIN-A* – tretinoin cream 0.1%
3
erythromycin gel 2% (Erygel)
RETIN-A* – tretinoin gel 0.01%
3
RETIN-A* – tretinoin gel 0.025%
3
SODIUM SULFACETAMIDE/SULF
– sulfacetamide sodium-sulfur in
urea gel 10-5%
3
SOOLANTRA – ivermectin cream
1%
3
1
erythromycin pads 2%
erythromycin soln 2%
1
1
EVOCLIN – clindamycin phosphate 3
foam 1%
FINACEA – azelaic acid foam 15% 2
FINACEA – azelaic acid gel 15%
2
isotretinoin cap 10 mg – claravis,
myorisan, zenatane
1
sulfacetamide sodium lotion
10% (acne) (Klaron)
1
SULFOAM – sulfur shampoo 2%
3
2
•
1
TAZORAC* – tazarotene cream
0.05%
2
•
1
TAZORAC* – tazarotene cream
0.1%
TAZORAC* – tazarotene gel 0.05% 2
2
TAZORAC* – tazarotene gel 0.1%
•
•
myorisan, zenatane
myorisan, zenatane
myorisan, zenatane
KLARON – sulfacetamide sodium
lotion 10% (acne)
3
METROCREAM – metronidazole
cream 0.75%
3
METROGEL – metronidazole gel
1%
3
tretinoin cream 0.1%* (Retin-a)
METROLOTION – metronidazole
lotion 0.75%
3
tretinoin gel 0.025%* (Retin-a)
metronidazole cream 0.75%
(Metrocream)
1
metronidazole gel 0.75%
1
metronidazole gel 1% (Metrogel)
KEY
tretinoin gel 0.01%* (Retin-a)
tretinoin gel 0.05%* (Atralin)
ZACLIR CLEANSING – benzoyl
peroxide lotion 8%
Anti-infectives
1
acyclovir oint 5% (Zovirax)
Tier
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
1
1
1
1
1
1
3
1
145
ALTABAX – retapamulin oint 1%
3
EXTINA – ketoconazole foam 2%
3
BACTROBAN – mupirocin calcium
cream 2%
3
GENTAMICIN SULFATE –
gentamicin sulfate cream 0.1%
3
CENTANY – mupirocin oint 2%
3
3
ciclopirox gel 0.77%
1
GENTAMICIN SULFATE –
gentamicin sulfate oint 0.1%
1
GORDOFILM – salicylic & lactic
acids soln 16.7-16.7%
3
1
HALOTIN – haloprogin cream 1%
3
iodoquinol-hc cream 1%
1
ciclopirox olamine cream 0.77%
(base equiv)
ciclopirox olamine susp 0.77%
(base equiv)
ciclopirox shampoo 1% (Loprox
shampoo)
1
ciclopirox solution 8% (Penlac
nail lacquer)
1
clotrimazole cream 1%
1
•
KERALYT – salicylic acid gel 6%
3
ketoconazole cream 2%
1
ketoconazole foam 2% (Extina)
1
1
LAMISIL SPRAY – terbinafine hcl
soln 1%
3
1
LOPROX SHAMPOO – ciclopirox
shampoo 1%
3
LOTRISONE – clotrimazole w/
betamethasone cream 1-0.05%
3
CORTISPORIN – neomycinpolymyxin-hc crm 3.5 mg/
gm-10000 unt/gm-0.5%
3
3
CORTISPORIN – bacitracinpolymyxin-neomycin hc oint 1%
3
MENTAX – butenafine hcl cream
1%
1
DENAVIR – penciclovir cream 1%
3
mupirocin calcium cream 2%
(Bactroban)
1
•
mupirocin oint 2%
1
diclofenac sodium gel 1%
(Voltaren)
diclofenac sodium soln 1.5%
1
• •
clotrimazole w/ betamethasone
cream 1-0.05% (Lotrisone)
clotrimazole w/ betamethasone
lotion 1-0.05%
econazole nitrate cream 1%
1
1
ERTACZO – sertaconazole nitrate
cream 2%
3
EXELDERM – sulconazole nitrate
solution 1%
3
EXELDERM – sulconazole nitrate
cream 1%
3
KEY
naftifine hcl cream 2% (Naftin)
1
nystatin oint 100000 unit/gm
1
Responsible Steps
NIZORAL – ketoconazole shampoo 3
2%
1
nystatin cream 100000 unit/gm
nystatin topical powder
1
oxiconazole nitrate cream 1%
(Oxistat)
1
PENLAC NAIL LACQUER –
ciclopirox solution 8%
3
Tier
•
Quantity Limits
1
ketoconazole shampoo 2%
(Nizoral)
clotrimazole soln 1%
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
•
146
PYROGALLIC ACID – pyrogallolchlorobutanol oint 25-2%
3
AMCINONIDE – amcinonide lotion
0.1%
3
SALEX – salicylic acid shampoo
6%
3
AMCINONIDE – amcinonide oint
0.1%
3
SALICYLIC ACID – salicylic acid
soln 26%
3
3
salicylic acid cream 6%
1
APEXICON E – diflorasone
diacetate emollient base cream
0.05%
betamethasone dipropionate
augmented cream 0.05%
(Diprolene af)
1
augmented gel 0.05%
1
salicylic acid gel 6% (Keralyt)
1
SALICYLIC ACID IN AMMONIU
– salicylic acid in ammonium
lactate vehicle foam 6%
3
salicylic acid lotion 6%
1
augmented lotion 0.05%
(Diprolene)
1
1
1
augmented oint 0.05%
(Diprolene)
cream 0.05%
1
SULFAMYLON – mafenide acetate
packet for topical soln 5% (50
gm)
3
SULFAMYLON – mafenide acetate
cream 85 mg/gm
3
VOLTAREN – diclofenac sodium
gel 1%
2
salicylic acid shampoo 6%
(Salex)
1
SILVADENE – silver sulfadiazine
cream 1%
3
silver sulfadiazine cream 1%
(Silvadene)
Corticosteroids
lotion 0.05%
•
oint 0.05%
betamethasone valerate aerosol
foam 0.12% (Luxiq)
1
1
betamethasone valerate cream
0.1%
ALA SCALP – hydrocortisone
lotion 2%
3
betamethasone valerate lotion
0.1%
alclometasone dipropionate
cream 0.05% (Aclovate)
1
betamethasone valerate oint
0.1%
1
calcipotriene-betamethasone
dipropionate oint 0.005-0.064%
(Taclonex)
1
CAPEX – fluocinolone acetonide
shampoo 0.01%
2
KEY
Tier
•
*
Responsible Steps
1
3
AMCINONIDE – amcinonide cream 3
0.1%
Quantity Limits
1
ACLOVATE – alclometasone
dipropionate cream 0.05%
alclometasone dipropionate oint
0.05%
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
1
1
•
147
clobetasol propionate cream
0.05% (Temovate)
CORTANE-B – hydrocortisonepramoxine-chloroxylenol lot
10-10-1mg/ml
3
CUTIVATE – fluticasone propionate 3
cream 0.05%
CUTIVATE – fluticasone propionate 3
lotion 0.05%
3
DERMA-SMOOTHE/FS BODY –
fluocinolone acetonide oil 0.01%
(body oil)
3
DERMA-SMOOTHE/FS SCALP –
(scalp oil)
3
DERMATOP – prednicarbate
cream 0.1%
3
DERMATOP – prednicarbate oint
0.1%
DESONATE – desonide gel 0.05% 3
desonide cream 0.05%
(Desowen)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
•
•
•
1
desonide lotion 0.05% (Desowen) 1
1
desonide oint 0.05%
DESOWEN – desonide cream
0.05%
3
•
DESOWEN – desonide lotion
0.05%
3
•
DESOXIMETASONE –
desoximetasone cream 0.05%
3
DESOXIMETASONE –
desoximetasone oint 0.05%
3
•
desoximetasone cream 0.25%
(Topicort)
1
•
desoximetasone gel 0.05%
(Topicort)
1
desoximetasone oint 0.25%
(Topicort)
1
•
•
Tier
•
Drug Tier
Responsible Steps
Quantity Limits
1
1
clobetasol propionate emollient
base cream 0.05% (Temovate e)
1
clobetasol propionate emulsion
foam 0.05% (Olux-e)
1
clobetasol propionate foam
0.05% (Olux)
1
clobetasol propionate gel 0.05%
(Temovate)
1
clobetasol propionate lotion
0.05% (Clobex)
clobetasol propionate oint 0.05% 1
(Temovate)
1
clobetasol propionate shampoo
0.05% (Clobex)
1
clobetasol propionate soln
0.05% (Temovate)
1
clobetasol propionate spray
0.05% (Clobex)
3
CLOBEX – clobetasol propionate
spray 0.05%
3
lotion 0.05%
3
shampoo 0.05%
3
CLOCORTOLONE PIVALATE –
clocortolone pivalate cream 0.1%
3
CLOCORTOLONE PIVALATE
PUM – clocortolone pivalate
cream 0.1%
CLODERM – clocortolone pivalate 3
cream 0.1%
3
CLODERM PUMP – clocortolone
pivalate cream 0.1%
CORDRAN TAPE – flurandrenolide 3
tape 4 mcg/sqcm
KEY
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
148
DIFLORASONE DIACETATE –
diflorasone diacetate oint 0.05%
3
fluocinonide cream 0.1% (Vanos)
DIFLORASONE DIACETATE –
diflorasone diacetate cream
0.05%
3
fluocinonide emulsified base
cream 0.05%
DIPROLENE – betamethasone
dipropionate augmented lotion
0.05%
3
fluocinonide oint 0.05%
1
DIPROLENE – betamethasone
dipropionate augmented oint
0.05%
3
flurandrenolide cream 0.05%
(Cordran)
1
DIPROLENE AF – betamethasone
dipropionate augmented cream
0.05%
3
fluticasone propionate cream
0.05% (Cutivate)
ELOCON – mometasone furoate
solution 0.1% (lotion)
3
fluticasone propionate oint
0.005%
cream 0.1%
3
halobetasol propionate cream
0.05% (Ultravate)
oint 0.1%
3
halobetasol propionate oint
0.05% (Ultravate)
EPIFOAM – pramoxine-hc aerosol
foam 1-1%
3
hydrocortisone butyrate cream
0.1% (Locoid)
fluocinolone acetonide cream
0.01%
1
hydrocortisone butyrate
hydrophilic lipo base cream
0.1% (Locoid lipocream)
fluocinolone acetonide cream
0.025% (Synalar)
fluocinonide gel 0.05%
1
(scalp oil) (Derma-smoothe/fs
sca)
1
fluocinolone acetonide oint
0.025% (Synalar)
fluocinonide cream 0.05%
KEY
fluticasone propionate lotion
0.05% (Cutivate)
1
(body oil) (Derma-smoothe/fs
bod)
fluocinolone acetonide soln
0.01% (Synalar)
fluocinonide soln 0.05%
hydrocortisone butyrate oint
0.1% (Locoid)
hydrocortisone butyrate soln
0.1% (Locoid)
hydrocortisone cream 1%
hydrocortisone cream 2.5%
1
1
1
1
1
1
1
1
1
1
1
1
1
1
hydrocortisone lotion 2.5%
1
1
hydrocortisone oint 1%
Tier
•
*
Responsible Steps
1
1
1
Quantity Limits
1
hydrocortisone lotion 2% (Ala
scalp)
hydrocortisone oint 2.5%
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
1
1
149
hydrocortisone valerate cream
0.2%
hydrocortisone valerate oint
0.2% (Westcort)
PRAMOSONE – pramoxine-hc
lotion 1-1%
3
1
lotion 1-2.5%
3
prednicarbate cream 0.1%
(Dermatop)
1
prednicarbate oint 0.1%
(Dermatop)
1
PSORCON – diflorasone diacetate
cream 0.05%
3
3
•
LOCOID – hydrocortisone butyrate
cream 0.1%
3
•
lotion 0.1%
3
•
oint 0.1%
3
•
LOCOID LIPOCREAM –
hydrocortisone butyrate
hydrophilic lipo base cream 0.1%
3
•
LUXIQ – betamethasone valerate
aerosol foam 0.12%
3
•
mometasone furoate cream 0.1%
(Elocon)
1
mometasone furoate oint 0.1%
(Elocon)
1
mometasone furoate solution
0.1% (lotion) (Elocon)
1
NUCORT – hydrocortisone acetate
lotion 2%
3
nystatin-triamcinolone cream
100000-0.1 unit/gm-%
1
1
OLUX – clobetasol propionate
foam 0.05%
3
•
OLUX-E – clobetasol propionate
emulsion foam 0.05%
3
•
cream 1-1%
3
PRAMOSONE – pramoxine-hc oint
1-2.5%
3
KEY
•
*
Responsible Steps
Quantity Limits
Prior Authorization
SYNALAR – fluocinolone acetonide 3
soln 0.01%
cream 0.025%
oint 0.025%
3
TEMOVATE – clobetasol
propionate soln 0.05%
3
propionate cream 0.05%
3
propionate gel 0.05%
3
propionate oint 0.05%
3
TEMOVATE E – clobetasol
propionate emollient base cream
0.05%
TEXACORT – hydrocortisone soln 3
2.5%
3
TOPICORT – desoximetasone
spray 0.25%
TOPICORT – desoximetasone gel 3
0.05%
3
cream 0.05%
3
cream 0.25%
Tier
Specialty/Tier 4
Drug Name
1
soln 0.1%
nystatin-triamcinolone oint
100000-0.1 unit/gm-%
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
•
150
TOPICORT – desoximetasone oint
0.05%
3
TOPICORT – desoximetasone oint
0.25%
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
3
3
ARZOL SILVER NITRATE APP –
silver nitrate-potassium nitrate
applicator 75-25%
1
•
TRIAMCINOLONE ACETONIDE
– triamcinolone acetonide oint
0.5%
3
calcipotriene cream 0.005%
(Dovonex)
calcipotriene oint 0.005%
1
1
calcipotriene soln 0.005%
(50 mcg/ml)
1
triamcinolone acetonide aerosol
soln 0.147 mg/gm (Kenalog)
•
•
1
CALCITRIOL – calcitriol oint 3
mcg/gm
3
•
CARAC – fluorouracil cream 0.5%
2
COLLIGINIX – dimethiconeallantoin bandage 5-2%
3
CONDYLOX – podofilox soln 0.5%
3
CONDYLOX – podofilox gel 0.5%
2
COSENTYX – secukinumab
syringe 150 mg/ml
3
X • •
COSENTYX SENSOREADY PEN
– secukinumab subcutaneous
soln auto-injector 150 mg/ml
3
X • •
diclofenac sodium (actinic
keratoses) gel 3% (Solaraze)
1
• •
DOVONEX – calcipotriene cream
0.005%
3
•
DOXEPIN HYDROCHLORIDE –
doxepin hcl cream 5%
3
EFUDEX – fluorouracil cream 5%
3
ELIDEL – pimecrolimus cream 1%
3
ELIMITE – permethrin cream 5%
3
ESSENTRA WIPES 9X9" CLEAN
– isopropyl alcohol wipes 70%
3
EURAX – crotamiton cream 10%
3
EURAX – crotamiton lotion 10%
3
triamcinolone acetonide cream
0.025%
0.1%
0.5%
triamcinolone acetonide lotion
0.025%
triamcinolone acetonide lotion
0.1%
triamcinolone acetonide oint
0.025%
triamcinolone acetonide oint
0.1%
1
1
1
1
1
1
ULTRAVATE – halobetasol
propionate cream 0.05%
3
ULTRAVATE – halobetasol
propionate oint 0.05%
3
•
VERDESO – desonide foam 0.05% 3
3
WESTCORT – hydrocortisone
valerate oint 0.2%
Other Skin Products
acitretin cap 10 mg (Soriatane)
acitretin cap 17.5 mg (Soriatane)
acitretin cap 25 mg (Soriatane)
KEY
1
1
1
Tier
•
*
•
151
FLUOROPLEX – fluorouracil
cream 1%
3
FLUOROURACIL – fluorouracil
cream 0.5%
3
fluorouracil cream 5% (Efudex)
1
fluorouracil soln 2%
fluorouracil soln 5%
imiquimod cream 5% (Aldara)
PANRETIN – alitretinoin gel 0.1%
3
permethrin cream 5% (Elimite)
1
2
•
1
PICATO – ingenol mebutate gel
0.05%
2
•
1
podofilox soln 0.5% (Condylox)
1
1
3
•
PROTOPIC – tacrolimus oint 0.1%
3
•
LAC-HYDRIN – lactic acid
(ammonium lactate) lotion 12%
3
PRUDOXIN – doxepin hcl cream
5%
3
lactic acid (ammonium lactate)
cream 12% (Lac-hydrin)
1
REGENECARE – lidocaine hclcollagen-aloe vera gel 2%
3
1
REGRANEX – becaplermin gel
0.01%
3
LEVULAN KERASTICK –
aminolevulinic acid hcl for soln
20% (stick applicator)
3
SANTYL – collagenase oint 250
unit/gm
2
selenium sulfide lotion 2.5%
1
lidocaine hcl gel 2%
1
1
• •
1
3
1
3
LIDODERM – lidocaine patch 5%
3
SILVER NITRATE – silver nitrate
soln 0.5%
lindane shampoo 1%
1
soln 10%
3
lidocaine-prilocaine cream
2.5-2.5%
malathion lotion 0.5% (Ovide)
1
selenium sulfide-pyrithione zinc
in urea shampoo 2.25%
oint 10%
lidocaine patch 5% (Lidoderm)
• •
1
methoxsalen rapid cap 10 mg
(Oxsoralen ultra)
1
soln 25%
3
NATROBA – spinosad susp 0.9%
3
3
OVIDE – malathion lotion 0.5%
3
soln 50%
silver nitrate-potassium nitrate
applicator 75-25% (Arzol silver
nitrate)
1
OXSORALEN – methoxsalen lotion 3
1%
3
OXSORALEN ULTRA –
methoxsalen rapid cap 10 mg
KEY
Tier
•
Responsible Steps
PROTOPIC – tacrolimus oint
0.03%
3
lidocaine hcl soln 4% (Xylocaine)
Quantity Limits
PICATO – ingenol mebutate gel
0.015%
LAC-HYDRIN – lactic acid
(ammonium lactate) cream 12%
lactic acid (ammonium lactate)
lotion 12% (Lac-hydrin)
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
152
3
SODIUM SULFACETAMIDE
WASH – sulfacetamide sodium in
bakuchiol vehicle wash 10%
3
SOLARAZE – diclofenac sodium
(actinic keratoses) gel 3%
SORIATANE – acitretin cap 10 mg 3
• •
ZONALON – doxepin hcl cream
5%
3
8-MOP – methoxsalen cap 10 mg
2
3
SORIATANE – acitretin cap 25 mg
3
SORILUX – calcipotriene foam
0.005%
3
SPINOSAD – spinosad susp 0.9%
3
STELARA – ustekinumab soln
2
X • •
STELARA – ustekinumab soln
prefilled syringe 90 mg/ml
2
X • •
tacrolimus oint 0.03% (Protopic)
1
•
•
•
1
MISCELLANEOUS CATEGORIES
BLOOD GLUCOSE METERS –
BAYER BREEZE 2
2
BAYER CONTOUR NEXT/EZ/
LINK/USB
2
BAYER CONTOUR
2
GLUCAGEN DIAGNOSTIC –
glucagon hcl (rdna) diagnostic for
3
INSULIN PEN NEEDLES –
NOVOFINE, NOVOTWIST,
OTHER VARIOUS
MANUFACTURERS
2
TARGRETIN – bexarotene gel 1%
3
LANCET DEVICES – VARIOUS
MANUFACTURERS
2
TBC – trypsin w/ castor oil &
peruvian balsam spray
3
LANCETS – VARIOUS
MANUFACTURERS
2
TOLAK – fluorouracil cream 4%
3
ULESFIA – benzyl alcohol lotion
5%
3
2
URAMAXIN – urea in ammonium
lactate vehicle foam 20%
3
SYRINGES/NEEDLES – VARIOUS
MANUFACTURERS – for selfinjectable drug administration
TEST DISCS – VARIOUS
MANUFACTURERS
3
• •
TEST DISCS – BAYER BREEZE 2
2
TEST STRIPS – VARIOUS
MANUFACTURERS – glucose
blood test strip
3
•
• •
TEST STRIPS – BAYER
CONTOUR/NEXT
2
•
VALCHLOR – mechlorethamine hcl 2
gel 0.016% (base equivalent)
3
VECTICAL – calcitriol oint 3 mcg/
gm
3
VEREGEN – sinecatechins oint
15%
3
XYLOCAINE – lidocaine hcl soln
4%
X
•
MISCELLANEOUS DRUGS
ASTAGRAF XL – tacrolimus cap sr
24hr 0.5 mg
KEY
Tier
•
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Tier
Drug Name
DIABETIC SUPPLIES
SORIATANE – acitretin cap 17.5
mg
tacrolimus oint 0.1% (Protopic)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
*
3
153
24hr 1 mg
3
24hr 5 mg
3
AZASAN – azathioprine tab 75 mg
3
AZASAN – azathioprine tab 100
mg
azathioprine tab 50 mg (Imuran)
cyclosporine modified cap
100 mg (Neoral)
cyclosporine modified oral soln
100 mg/ml (Neoral)
X •
3
3
1
ENVARSUS XR – tacrolimus tab sr
24hr 0.75 mg
24hr 1 mg
3
24hr 4 mg
3
EVZIO – naloxone hcl solution
3
EXJADE – deferasirox tab for oral
susp 125 mg
2
X
BUNAVAIL – buprenorphinenaloxone buccal film 2.1-0.3 mg
(base equiv)
3
BUNAVAIL – buprenorphinenaloxone buccal film 4.2-0.7 mg
(base equiv)
3
BUNAVAIL – buprenorphinenaloxone buccal film 6.3-1 mg
(base equiv)
3
• •
1
• •
susp 250 mg
2
buprenorphine hcl-naloxone hcl
sl tab 2-0.5 mg (base equiv)
X
1
• •
susp 500 mg
2
X
FERRIPROX – deferiprone tab 500 3
mg
3
FERRIPROX – deferiprone oral
soln 100 mg/ml
IMURAN – azathioprine tab 50 mg 3
X
buprenorphine hcl-naloxone hcl
sl tab 8-2 mg (base equiv)
CELLCEPT – mycophenolate
mofetil cap 250 mg
3
mofetil tab 500 mg
3
mofetil for oral susp 200 mg/ml
3
CHEMET – succimer cap 100 mg
2
cyclosporine cap 25 mg
(Sandimmune)
1
cyclosporine cap 100 mg
(Sandimmune)
irrigation solution, physiological
1
JADENU – deferasirox tab 90 mg
3
3
3
1
KAYEXALATE – sodium
polystyrene sulfonate powder
3
CYCLOSPORINE MODIFIED –
cyclosporine modified cap 50 mg
3
lactated ringer's for irrigation
1
cyclosporine modified cap
25 mg (Neoral)
1
mycophenolate mofetil cap
250 mg (Cellcept)
KEY
X •
Tier
•
*
Responsible Steps
1
2
• •
Quantity Limits
1
DEPEN TITRATABS –
penicillamine tab 250 mg
• •
Prior Authorization
Drug Name
Specialty/Tier 4
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
• •
X
X
X
X
1
154
mycophenolate mofetil for oral
susp 200 mg/ml (Cellcept)
mycophenolate mofetil tab
500 mg (Cellcept)
mycophenolate sodium tab dr
180 mg (mycophenolic acid
equiv) (Myfortic)
mycophenolate sodium tab dr
360 mg (mycophenolic acid
equiv) (Myfortic)
1
1
1
1
MYFORTIC – mycophenolate
sodium tab dr 180 mg
(mycophenolic acid equiv)
3
MYFORTIC – mycophenolate
sodium tab dr 360 mg
(mycophenolic acid equiv)
3
NALOXONE HCL – naloxone hcl
inj 1 mg/ml
3
•
naloxone hcl inj 0.4 mg/ml
1
•
•
NARCAN – naloxone hcl nasal
spray 4 mg/0.1ml
2
NEORAL – cyclosporine modified
oral soln 100 mg/ml
3
cap 25 mg
3
cap 100 mg
3
PROGRAF – tacrolimus cap 0.5
mg
3
PROGRAF – tacrolimus cap 1 mg
3
PROGRAF – tacrolimus cap 5 mg
3
RADIOGARDASE – prussian blue
insoluble cap 0.5 gm
3
RAPAMUNE – sirolimus oral soln 1
mg/ml
2
3
RAPAMUNE – sirolimus tab 2 mg
3
REVLIMID – lenalidomide caps 2.5
mg
2
X • •
REVLIMID – lenalidomide cap 5
mg
2
X • •
mg
2
X • •
mg
2
X • •
mg
2
X • •
mg
2
X • •
ringer's solution for irrigation
1
SANDIMMUNE – cyclosporine oral
soln 100 mg/ml
3
SANDIMMUNE – cyclosporine cap
25 mg
3
SANDIMMUNE – cyclosporine cap
100 mg
3
sirolimus tab 0.5 mg (Rapamune)
1
sirolimus tab 2 mg (Rapamune)
sodium polystyrene sulfonate
oral susp 15 gm/60ml
powder (Kayexalate)
rectal susp 30 gm/120ml
1
1
1
1
1
SUBOXONE – buprenorphine hclnaloxone hcl sl film 2-0.5 mg
(base equiv)
2
• •
SUBOXONE – buprenorphine hclnaloxone hcl sl film 4-1 mg (base
equiv)
2
• •
•
*
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
RAPAMUNE – sirolimus tab 1 mg
Tier
Drug Tier
Drug Name
sirolimus tab 1 mg (Rapamune)
RAPAMUNE – sirolimus tab 0.5 mg 3
KEY
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
155
• •
SYPRINE – trientine hcl cap 250
mg
2
tacrolimus cap 0.5 mg (Prograf)
1
tacrolimus cap 1 mg (Prograf)
tacrolimus cap 5 mg (Prograf)
X •
1
1
THALOMID – thalidomide cap 50
mg
2
X • •
mg
2
X • •
mg
2
X • •
mg
2
X • •
VELTASSA – patiromer sorbitex
calcium for susp packet 8.4 gm
(base eq)
3
•
(base eq)
3
•
(base eq)
3
•
water for irrigation, sterile
irrigation soln
1
ZORTRESS – everolimus tab 0.25
mg
2
mg
2
mg
2
KEY
ZUBSOLV – buprenorphine hclnaloxone hcl sl tab 1.4-0.36 mg
(base eq)
3
• •
(base eq)
3
• •
(base eq)
3
• •
(base eq)
3
• •
(base eq)
3
• •
Tier
•
*
Responsible Steps
2
Quantity Limits
SUBOXONE – buprenorphine hclnaloxone hcl sl film 12-3 mg
(base equiv)
Prior Authorization
• •
Drug Name
Specialty/Tier 4
2
Drug Tier
SUBOXONE – buprenorphine hclnaloxone hcl sl film 8-2 mg (base
equiv)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty/Tier 4
Drug Name
Drug Tier
2016
156
2016
INDEX
A
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg (Trizivir)................................................ 10
abacavir sulfate tab 300 mg (base equiv) (Ziagen)......... 9
acamprosate calcium tab delayed release 333 mg....... 94
ACANYA – clindamycin phosphate-benzoyl peroxide gel
1.2-2.5%........................................................................... 144
acarbose tab 25 mg (Precose)........................................ 30
acarbose tab 50 mg (Precose)........................................ 30
acarbose tab 100 mg (Precose)...................................... 30
ACCOLATE – zafirlukast tab 10 mg................................... 66
ACCOLATE – zafirlukast tab 20 mg................................... 66
ACCUPRIL – quinapril hcl tab 5 mg.................................. 42
ACCUPRIL – quinapril hcl tab 10 mg................................ 42
ACCURETIC – quinapril-hydrochlorothiazide tab 10-12.5
mg...................................................................................... 42
ACCURETIC – quinapril-hydrochlorothiazide tab 20-12.5
mg...................................................................................... 42
ACCURETIC – quinapril-hydrochlorothiazide tab 20-25
mg...................................................................................... 42
acebutolol hcl cap 200 mg (Sectral)............................... 47
acebutolol hcl cap 400 mg (Sectral)............................... 47
ACEON – perindopril erbumine tab 4 mg.......................... 42
ACEON – perindopril erbumine tab 8 mg.......................... 42
acetaminophen-caffeine-dihydrocodeine cap
320.5-30-16 mg (Trezix)...................................................98
acetaminophen w/ codeine soln 120-12 mg/5ml........... 98
acetaminophen w/ codeine tab 300-15 mg (Tylenol/
codeine)............................................................................ 98
codeine #3)....................................................................... 98
codeine #4)....................................................................... 98
ACETAZOLAMIDE – acetazolamide tab 125 mg............... 57
acetazolamide cap sr 12hr 500 mg (Diamox)................ 57
acetazolamide tab 250 mg............................................... 57
ACETIC ACID/ALUMINUM ACET – acetic acid 2% in
aluminum acetate otic soln............................................. 142
acetic acid irrigation soln 0.25%.....................................78
acetic acid otic soln 2%................................................. 142
acetylcysteine cap 600 mg............................................ 128
acetylcysteine inhal soln 10%......................................... 65
acetylcysteine inhal soln 20%......................................... 65
acitretin cap 10 mg (Soriatane)..................................... 151
acitretin cap 17.5 mg (Soriatane).................................. 151
acitretin cap 25 mg (Soriatane)..................................... 151
ACLOVATE – alclometasone dipropionate cream
0.05%............................................................................... 147
ACTEMRA – tocilizumab subcutaneous soln prefilled
syringe 162 mg/0.9ml......................................................104
ACTHIB – haemophilus b polysaccharide conjugate
vaccine for inj.................................................................... 15
ACTIGALL – ursodiol cap 300 mg..................................... 74
ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)......................................................... 17
ACTIQ – fentanyl citrate lozenge on a handle 200
mcg.....................................................................................98
mcg.....................................................................................98
mcg.....................................................................................98
mcg.....................................................................................98
mcg.....................................................................................98
mcg.....................................................................................98
ACTIVELLA – estradiol & norethindrone acetate tab
0.5-0.1 mg..........................................................................25
ACTIVELLA – estradiol & norethindrone acetate tab 1-0.5
mg...................................................................................... 25
ACTIVE OB – prenatal w/o a w/fe cbn-fa-dha cap
20-1-320 mg.................................................................... 119
ACTONEL – risedronate sodium tab 5 mg........................ 39
ACTONEL – risedronate sodium tab 30 mg...................... 39
ACTONEL – risedronate sodium tab 35 mg...................... 39
ACTONEL – risedronate sodium tab 150 mg.................... 39
ACTOPLUS MET – pioglitazone hcl-metformin hcl tab
15-500 mg......................................................................... 30
ACTOPLUS MET – pioglitazone hcl-metformin hcl tab
15-850 mg......................................................................... 30
ACTOPLUS MET XR – pioglitazone hcl-metformin hcl tab
sr 24hr 15-1000 mg.......................................................... 30
ACTOPLUS MET XR – pioglitazone hcl-metformin hcl tab
sr 24hr 30-1000 mg.......................................................... 30
ACTOS – pioglitazone hcl tab 15 mg (base equiv)............ 30
ACULAR – ketorolac tromethamine ophth soln 0.5%...... 141
ACULAR LS – ketorolac tromethamine ophth soln
0.4%................................................................................. 141
ACUVAIL – ketorolac tromethamine ophth soln
0.45%............................................................................... 141
acyclovir cap 200 mg (Zovirax)......................................... 9
acyclovir oint 5% (Zovirax)............................................ 145
acyclovir susp 200 mg/5ml (Zovirax)............................... 9
acyclovir tab 400 mg (Zovirax)..........................................9
acyclovir tab 800 mg (Zovirax)..........................................9
ACZONE – dapsone gel 5%............................................ 144
ADACEL – tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lfmcg/0.5ml...........................................................................15
ADALAT CC – nifedipine tab sr 24hr 30 mg...................... 50
ADAPALENE – adapalene lotion 0.1%............................ 144
adapalene cream 0.1% (Differin)................................... 144
157
2016
adapalene gel 0.1% (Differin)........................................ 144
adapalene gel 0.3% (Differin)........................................ 144
ADCIRCA – tadalafil tab 20 mg (pah)................................ 60
ADDERALL – amphetamine-dextroamphetamine tab 5
mg...................................................................................... 89
ADDERALL – amphetamine-dextroamphetamine tab 7.5
mg...................................................................................... 89
mg...................................................................................... 89
ADDERALL – amphetamine-dextroamphetamine tab 12.5
mg...................................................................................... 89
mg...................................................................................... 89
mg...................................................................................... 89
mg...................................................................................... 89
ADDERALL XR – amphetamine-dextroamphetamine cap
sr 24hr 5 mg...................................................................... 89
sr 24hr 10 mg.................................................................... 89
sr 24hr 15 mg.................................................................... 89
sr 24hr 20 mg.................................................................... 89
sr 24hr 25 mg.................................................................... 89
sr 24hr 30 mg.................................................................... 89
adefovir dipivoxil tab 10 mg (Hepsera)............................ 8
ADEMPAS – riociguat tab 0.5 mg...................................... 60
ADEMPAS – riociguat tab 1 mg......................................... 60
ADEMPAS – riociguat tab 2 mg......................................... 60
ADVAIR DISKUS – fluticasone-salmeterol aer powder ba
100-50 mcg/dose............................................................... 66
250-50 mcg/dose............................................................... 66
500-50 mcg/dose............................................................... 66
ADVAIR HFA – fluticasone-salmeterol inhal aerosol 45-21
mcg/act............................................................................... 66
ADVAIR HFA – fluticasone-salmeterol inhal aerosol 115-21
mcg/act............................................................................... 66
ADVAIR HFA – fluticasone-salmeterol inhal aerosol
230-21 mcg/act.................................................................. 66
ADVATE – antihemophilic factor rahf-pfm for inj 250
unit....................................................................................133
unit....................................................................................133
unit....................................................................................133
unit....................................................................................133
unit....................................................................................133
unit....................................................................................133
unit....................................................................................133
ADYNOVATE – antihemophilic factor recomb pegylated for
inj 250 unit....................................................................... 133
inj 500 unit....................................................................... 133
inj 1000 unit..................................................................... 133
inj 2000 unit..................................................................... 133
AEROSPAN – flunisolide hfa inhal aerosol 80 mcg/act..... 66
AFINITOR DISPERZ – everolimus tab for oral susp 2
mg...................................................................................... 17
mg...................................................................................... 17
mg...................................................................................... 17
AFINITOR – everolimus tab 2.5 mg................................... 17
AFINITOR – everolimus tab 5 mg...................................... 17
AFINITOR – everolimus tab 7.5 mg................................... 17
AFINITOR – everolimus tab 10 mg.................................... 17
AGGRENOX – aspirin-dipyridamole cap sr 12hr 25-200
mg.................................................................................... 128
AGRYLIN – anagrelide hcl cap 0.5 mg............................ 128
AKTEN – lidocaine hcl ophth gel 3.5%............................ 141
AKYNZEO – netupitant-palonosetron cap 300-0.5 mg...... 72
ALA SCALP – hydrocortisone lotion 2%.......................... 147
ALBENZA – albendazole tab 200 mg................................ 13
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml).......... 66
albuterol sulfate soln nebu 0.5% (5 mg/ml)................... 66
albuterol sulfate soln nebu 0.63 mg/3ml (base
equiv)................................................................................. 66
albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv)................................................................................. 66
albuterol sulfate syrup 2 mg/5ml.................................... 66
albuterol sulfate tab 2 mg................................................ 66
albuterol sulfate tab 4 mg................................................ 66
albuterol sulfate tab sr 12hr 4 mg (Vospire er)..............66
albuterol sulfate tab sr 12hr 8 mg (Vospire er)..............66
ALCAINE – proparacaine hcl ophth soln 0.5%................ 141
alclometasone dipropionate cream 0.05%
(Aclovate)........................................................................ 147
alclometasone dipropionate oint 0.05%....................... 147
ALDACTAZIDE – spironolactone & hydrochlorothiazide tab
25-25 mg............................................................................57
ALDACTAZIDE – spironolactone & hydrochlorothiazide tab
50-50 mg............................................................................57
ALDACTONE – spironolactone tab 25 mg......................... 57
ALDACTONE – spironolactone tab 50 mg......................... 57
ALDACTONE – spironolactone tab 100 mg....................... 57
ALECENSA – alectinib hcl cap 150 mg (base
equivalent)......................................................................... 17
158
2016
ALENDRONATE SODIUM – alendronate sodium oral soln
70 mg/75ml........................................................................ 39
ALENDRONATE SODIUM – alendronate sodium tab 40
mg...................................................................................... 39
alendronate sodium tab 5 mg......................................... 39
alendronate sodium tab 10 mg....................................... 39
alendronate sodium tab 35 mg....................................... 39
alendronate sodium tab 70 mg (Fosamax).................... 39
alfuzosin hcl tab sr 24hr 10 mg (Uroxatral)................... 78
ALINIA – nitazoxanide for susp 100 mg/5ml...................... 13
ALINIA – nitazoxanide tab 500 mg.................................... 13
ALKERAN – melphalan tab 2 mg.......................................17
allopurinol tab 100 mg (Zyloprim)................................ 108
allopurinol tab 300 mg (Zyloprim)................................ 108
almotriptan malate tab 6.25 mg (Axert)........................107
almotriptan malate tab 12.5 mg (Axert)........................107
ALOCRIL – nedocromil sodium ophth soln 2%................141
ALOGLIPTIN/METFORMIN HCL – alogliptin-metformin hcl
tab 12.5-500 mg................................................................ 30
ALOGLIPTIN/METFORMIN HCL – alogliptin-metformin hcl
tab 12.5-1000 mg.............................................................. 30
ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone tab
12.5-15 mg........................................................................ 30
12.5-30 mg........................................................................ 30
12.5-45 mg........................................................................ 30
25-15 mg............................................................................30
25-30 mg............................................................................30
25-45 mg............................................................................30
ALOGLIPTIN – alogliptin benzoate tab 6.25 mg (base
equiv)................................................................................. 30
ALOGLIPTIN – alogliptin benzoate tab 12.5 mg (base
equiv)................................................................................. 30
ALOGLIPTIN – alogliptin benzoate tab 25 mg (base
equiv)................................................................................. 30
ALOMIDE – lodoxamide tromethamine ophth soln
0.1%................................................................................. 141
ALORA – estradiol td patch twice weekly 0.025
mg/24hr.............................................................................. 25
mg/24hr.............................................................................. 25
mg/24hr.............................................................................. 25
ALORA – estradiol td patch twice weekly 0.1 mg/24hr...... 25
alosetron hcl tab 0.5 mg (base equiv) (Lotronex)......... 74
alosetron hcl tab 1 mg (base equiv) (Lotronex)............ 74
ALPHAGAN P – brimonidine tartrate ophth soln
0.1%................................................................................. 139
ALPHAGAN P – brimonidine tartrate ophth soln
0.15%............................................................................... 139
ALPHANATE/VON WILLEBRAND – antihemophilic factor/
vwf (human) for inj 250 unit............................................ 133
vwf (human) for inj 500 unit............................................ 133
vwf (human) for inj 1000 unit.......................................... 133
ALPHANINE SD – coagulation factor ix for inj 500
unit....................................................................................133
unit....................................................................................133
unit....................................................................................133
ALPRAZOLAM INTENSOL – alprazolam conc 1 mg/
ml........................................................................................ 79
alprazolam orally disintegrating tab 0.5 mg.................. 79
alprazolam orally disintegrating tab 1 mg..................... 79
alprazolam orally disintegrating tab 2 mg..................... 79
alprazolam orally disintegrating tab 0.25 mg
(Niravam)...........................................................................79
alprazolam tab 0.25 mg (Xanax)......................................79
alprazolam tab 0.5 mg (Xanax)........................................79
alprazolam tab 1 mg (Xanax)...........................................79
alprazolam tab 2 mg (Xanax)...........................................79
alprazolam tab sr 24hr 0.5 mg (Xanax xr)...................... 79
alprazolam tab sr 24hr 1 mg (Xanax xr)......................... 79
ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj
250 unit............................................................................ 133
500 unit............................................................................ 133
1000 unit.......................................................................... 133
2000 unit.......................................................................... 133
3000 unit.......................................................................... 133
ALREX – loteprednol etabonate ophth susp 0.2%...........138
ALSUMA – sumatriptan succinate solution auto-injector 6
mg/0.5ml.......................................................................... 107
ALTABAX – retapamulin oint 1%...................................... 146
ALTACE – ramipril cap 1.25 mg......................................... 42
ALTACE – ramipril cap 2.5 mg........................................... 42
ALTACE – ramipril cap 5 mg.............................................. 42
ALTACE – ramipril cap 10 mg............................................ 42
ALTOPREV – lovastatin tab sr 24hr 20 mg........................54
ALVESCO – ciclesonide inhal aerosol 80 mcg/act............ 66
ALVESCO – ciclesonide inhal aerosol 160 mcg/act.......... 66
AMANTADINE HCL – amantadine hcl tab 100 mg.......... 115
amantadine hcl cap 100 mg.......................................... 115
amantadine hcl syrup 50 mg/5ml..................................115
AMARYL – glimepiride tab 1 mg........................................ 30
159
2016
AMCINONIDE – amcinonide cream 0.1%....................... 147
AMCINONIDE – amcinonide lotion 0.1%......................... 147
AMCINONIDE – amcinonide oint 0.1%............................ 147
AMICAR – aminocaproic acid oral soln 0.25 gm/ml.........128
AMICAR – aminocaproic acid tab 500 mg....................... 128
AMICAR – aminocaproic acid tab 1000 mg..................... 128
amiloride & hydrochlorothiazide tab 5-50 mg............... 57
amiloride hcl tab 5 mg..................................................... 57
AMINOBENZOATE POTASSIUM – potassium
aminobenzoate packet 2 gm.......................................... 119
amiodarone hcl tab 100 mg............................................. 59
amiodarone hcl tab 400 mg............................................. 59
amiodarone hcl tab 200 mg (Cordarone)....................... 59
AMITIZA – lubiprostone cap 8 mcg....................................74
AMITIZA – lubiprostone cap 24 mcg..................................74
amitriptyline hcl tab 10 mg.............................................. 80
amitriptyline hcl tab 100 mg............................................ 80
amitriptyline hcl tab 150 mg............................................ 80
amitriptyline hcl tab 25 mg (Elavil)................................. 80
amlodipine besylate-atorvastatin calcium tab 2.5-10
mg (Caduet)...................................................................... 60
mg (Caduet)...................................................................... 60
mg (Caduet)...................................................................... 60
amlodipine besylate-atorvastatin calcium tab 5-10 mg
(Caduet).............................................................................60
(Caduet).............................................................................60
(Caduet).............................................................................60
(Caduet).............................................................................60
(Caduet).............................................................................60
(Caduet).............................................................................60
(Caduet).............................................................................60
(Caduet).............................................................................60
amlodipine besylate-benazepril hcl cap 2.5-10 mg....... 50
amlodipine besylate-benazepril hcl cap 5-40 mg.......... 50
amlodipine besylate-benazepril hcl cap 5-10 mg
(Lotrel)............................................................................... 50
(Lotrel)............................................................................... 50
(Lotrel)............................................................................... 50
(Lotrel)............................................................................... 50
amlodipine besylate tab 2.5 mg (Norvasc).................... 50
amlodipine besylate tab 5 mg (Norvasc)....................... 50
amlodipine besylate tab 10 mg (Norvasc)..................... 50
amlodipine besylate-valsartan tab 5-160 mg
(Exforge)........................................................................... 50
(Exforge)........................................................................... 50
(Exforge)........................................................................... 50
(Exforge)........................................................................... 50
amlodipine-valsartan-hydrochlorothiazide tab
5-160-12.5 mg (Exforge hct)........................................... 44
amlodipine-valsartan-hydrochlorothiazide tab 5-160-25
mg (Exforge hct)..............................................................44
10-160-12.5 mg (Exforge hct).........................................44
10-160-25 mg (Exforge hct)............................................ 44
10-320-25 mg (Exforge hct)............................................ 44
AMOXAPINE – amoxapine tab 25 mg............................... 80
AMOXAPINE – amoxapine tab 50 mg............................... 80
AMOXAPINE – amoxapine tab 100 mg............................. 80
AMOXAPINE – amoxapine tab 150 mg............................. 80
AMOXICILLIN/CLAVULANATE P – amoxicillin & k
clavulanate chew tab 200-28.5 mg.....................................1
AMOXICILLIN/CLAVULANATE P – 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 400-57 mg/5ml...... 1
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
(Augmentin)........................................................................ 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)................................................................. 70
AMOXICILLIN ER – amoxicillin (trihydrate) tab sr 24hr 775
mg........................................................................................ 1
amoxicillin (trihydrate) cap 250 mg.................................. 1
amoxicillin (trihydrate) cap 500 mg.................................. 1
amoxicillin (trihydrate) for susp 125 mg/5ml................... 1
160
2016
amoxicillin (trihydrate) tab 500 mg................................... 1
amoxicillin (trihydrate) tab 875 mg................................... 1
amphetamine-dextroamphetamine cap sr 24hr 5 mg
(Adderall xr)..................................................................... 89
(Adderall xr)..................................................................... 89
(Adderall xr)..................................................................... 89
(Adderall xr)..................................................................... 89
(Adderall xr)..................................................................... 89
(Adderall xr)..................................................................... 89
amphetamine-dextroamphetamine tab 5 mg
(Adderall).......................................................................... 89
amphetamine-dextroamphetamine tab 7.5 mg
(Adderall).......................................................................... 90
(Adderall).......................................................................... 90
amphetamine-dextroamphetamine tab 12.5 mg
(Adderall).......................................................................... 90
(Adderall).......................................................................... 90
(Adderall).......................................................................... 90
(Adderall).......................................................................... 90
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
AMPYRA – dalfampridine tab sr 12hr 10 mg..................... 94
ANADROL-50 – oxymetholone tab 50 mg......................... 24
ANAFRANIL – clomipramine hcl cap 25 mg...................... 80
anagrelide hcl cap 1 mg................................................ 128
anagrelide hcl cap 0.5 mg (Agrylin)............................. 128
ANALPRAM-HC – hydrocortisone acetate w/ pramoxine
rectal cream 1-1%........................................................... 143
ANALPRAM HC – hydrocortisone acetate w/ pramoxine
rectal cream 2.5-1%........................................................ 143
ANALPRAM-HC – hydrocortisone acetate w/ pramoxine
rectal lotn 2.5-1%............................................................ 143
ANALPRAM-HC SINGLES – hydrocortisone acetate w/
pramoxine rectal cream 1-1%.........................................143
ANALPRAM-HC SINGLES – hydrocortisone acetate w/
pramoxine rectal cream 2.5-1%......................................143
ANALPRAM HC SINGLES – hydrocortisone acetate w/
pramoxine rectal cream 2.5-1%......................................143
ANAPROX DS – naproxen sodium tab 550 mg............... 104
ANASPAZ – hyoscyamine sulfate tab disp 0.125 mg........ 70
anastrozole tab 1 mg (Arimidex).....................................17
ANCOBON – flucytosine cap 250 mg.................................. 6
ANCOBON – flucytosine cap 500 mg.................................. 6
ANDRODERM – testosterone td patch 24hr 2
mg/24hr.............................................................................. 24
ANDRODERM – testosterone td patch 24hr 4
mg/24hr.............................................................................. 24
ANDROGEL PUMP – testosterone td gel 12.5 mg/act
(1%).................................................................................... 24
ANDROGEL PUMP – testosterone td gel 20.25 mg/act
(1.62%)............................................................................... 24
ANDROGEL – testosterone td gel 25 mg/2.5gm (1%).......24
ANDROGEL – testosterone td gel 50 mg/5gm (1%)..........24
ANDROGEL – testosterone td gel 20.25 mg/1.25gm
(1.62%)............................................................................... 24
ANDROGEL – testosterone td gel 40.5 mg/2.5gm
(1.62%)............................................................................... 24
ANDROID – methyltestosterone cap 10 mg...................... 24
ANDROXY – fluoxymesterone tab 10 mg.......................... 24
ANGELIQ – drospirenone-estradiol tab 0.25-0.5 mg......... 25
ANGELIQ – drospirenone-estradiol tab 0.5-1 mg.............. 25
ANORO ELLIPTA – umeclidinium-vilanterol aero powd ba
62.5-25 mcg/inh................................................................. 66
ANTABUSE – disulfiram tab 250 mg................................. 95
ANTABUSE – disulfiram tab 500 mg................................. 95
antipyrine-benzocaine otic soln 54-14 mg/ml
(5.4-1.4%)........................................................................ 142
ANUSOL-HC – hydrocortisone rectal cream 2.5%.......... 143
APEXICON E – diflorasone diacetate emollient base
cream 0.05%................................................................... 147
APIDRA – insulin glulisine inj 100 unit/ml.......................... 34
APIDRA SOLOSTAR – insulin glulisine soln pen-injector
inj 100 unit/ml.................................................................... 34
APOKYN – apomorphine hydrochloride inj 10 mg/ml...... 115
apraclonidine hcl ophth soln 0.5% (base equivalent)
(Iopidine)......................................................................... 139
APRISO – mesalamine cap sr 24hr 0.375 gm................... 74
APTENSIO XR – methylphenidate hcl cap er 24hr 10 mg
(xr)...................................................................................... 90
(xr)...................................................................................... 90
(xr)...................................................................................... 90
(xr)...................................................................................... 90
(xr)...................................................................................... 90
(xr)...................................................................................... 90
(xr)...................................................................................... 90
APTIOM – eslicarbazepine acetate tab 200 mg.............. 109
APTIVUS – tipranavir cap 250 mg..................................... 10
APTIVUS – tipranavir oral soln 100 mg/ml........................ 10
ARALEN – chloroquine phosphate tab 500 mg................. 13
161
2016
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25
mcg/ml..............................................................................129
mcg/ml..............................................................................129
mcg/ml..............................................................................129
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj
100 mcg/ml...................................................................... 129
200 mcg/ml...................................................................... 129
300 mcg/ml...................................................................... 129
ARANESP ALBUMIN FREE – darbepoetin alfa soln
prefilled syringe 10 mcg/0.4ml........................................ 128
prefilled syringe 25 mcg/0.42ml...................................... 128
prefilled syringe 500 mcg/ml........................................... 129
ARAVA – leflunomide tab 10 mg...................................... 104
ARAVA – leflunomide tab 20 mg...................................... 104
ARCALYST – rilonacept for inj 220 mg............................ 104
ARCAPTA NEOHALER – indacaterol maleate inhal
powder cap 75 mcg (base equiv)..................................... 66
ARICEPT – donepezil hydrochloride tab 5 mg.................. 95
ARICEPT – donepezil hydrochloride tab 10 mg................ 95
ARICEPT – donepezil hydrochloride tab 23 mg................ 95
ARIMIDEX – anastrozole tab 1 mg.................................... 17
aripiprazole orally disintegrating tab 10 mg.................. 85
aripiprazole orally disintegrating tab 15 mg.................. 85
aripiprazole oral solution 1 mg/ml.................................. 84
aripiprazole tab 2 mg (Abilify)......................................... 85
aripiprazole tab 5 mg (Abilify)......................................... 85
aripiprazole tab 10 mg (Abilify)....................................... 85
ARIXTRA – fondaparinux sodium subcutaneous inj 2.5
mg/0.5ml.......................................................................... 129
ARIXTRA – fondaparinux sodium subcutaneous inj 5
mg/0.4ml.......................................................................... 129
ARIXTRA – fondaparinux sodium subcutaneous inj 7.5
mg/0.6ml.......................................................................... 129
ARIXTRA – fondaparinux sodium subcutaneous inj 10
mg/0.8ml.......................................................................... 129
ARMODAFINIL – armodafinil tab 200 mg.......................... 90
armodafinil tab 50 mg (Nuvigil).......................................90
armodafinil tab 150 mg (Nuvigil).....................................90
armodafinil tab 250 mg (Nuvigil).....................................90
ARMOUR THYROID – thyroid tab 15 mg (1/4 grain).........35
ARMOUR THYROID – thyroid tab 30 mg (1/2 grain).........35
ARMOUR THYROID – thyroid tab 90 mg (1 1/2 grain)......35
ARMOUR THYROID – thyroid tab 60 mg (1 grain)........... 35
ARMOUR THYROID – thyroid tab 120 mg (2 grain)..........35
ARNUITY ELLIPTA – fluticasone furoate aerosol powder
breath activ 100 mcg/act.................................................. 66
ARNUITY ELLIPTA – fluticasone furoate aerosol powder
breath activ 200 mcg/act.................................................. 66
AROMASIN – exemestane tab 25 mg............................... 17
ARTHROTEC 50 – diclofenac w/ misoprostol tab delayed
release 50-0.2 mg........................................................... 104
ARTHROTEC 75 – diclofenac w/ misoprostol tab delayed
release 75-0.2 mg........................................................... 104
ARZOL SILVER NITRATE APP – silver nitrate-potassium
nitrate applicator 75-25%................................................ 151
ASACOL HD – mesalamine tab delayed release 800
mg...................................................................................... 74
ASMANEX HFA – mometasone furoate inhal aerosol
suspension 100 mcg/act................................................... 67
ASMANEX HFA – mometasone furoate inhal aerosol
suspension 200 mcg/act................................................... 67
ASMANEX TWISTHALER 120 ME – mometasone furoate
inhal powd 220 mcg/inh (breath activated)...................... 67
ASMANEX TWISTHALER 14 MET – mometasone furoate
inhal powd 110 mcg/inh (breath activated)....................... 67
ASPIRIN/DIPYRIDAMOLE – aspirin-dipyridamole cap sr
12hr 25-200 mg............................................................... 129
ASPIRIN-CAFFEINE-DIHYDROC – aspirin-caffeinedihydrocodeine cap 356.4-30-16 mg................................ 98
aspirin chew tab 81 mg.................................................... 98
aspirin tab delayed release 81 mg..................................98
ASTAGRAF XL – tacrolimus cap sr 24hr 0.5 mg............. 153
ASTAGRAF XL – tacrolimus cap sr 24hr 1 mg................ 154
ASTAGRAF XL – tacrolimus cap sr 24hr 5 mg................ 154
ASTEPRO – azelastine hcl nasal spray 0.15% (205.5 mcg/
spray)................................................................................. 64
ATABEX EC – prenatal vit w/ dss-iron carbonyl-fa tab dr
29-1 mg............................................................................119
ATACAND – candesartan cilexetil tab 4 mg....................... 44
ATACAND – candesartan cilexetil tab 8 mg....................... 44
ATACAND – candesartan cilexetil tab 16 mg..................... 44
ATACAND – candesartan cilexetil tab 32 mg..................... 44
162
2016
ATACAND HCT – candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg................................. 44
ATACAND HCT – candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg................................. 44
ATACAND HCT – candesartan cilexetilhydrochlorothiazide tab 32-25 mg.................................... 44
ATELVIA – risedronate sodium tab delayed release 35
mg...................................................................................... 39
atenolol & chlorthalidone tab 50-25 mg (Tenoretic
50)...................................................................................... 47
atenolol & chlorthalidone tab 100-25 mg (Tenoretic
100).................................................................................... 47
atenolol tab 25 mg (Tenormin)........................................ 47
atenolol tab 50 mg (Tenormin)........................................ 47
atenolol tab 100 mg (Tenormin)...................................... 47
atorvastatin calcium tab 10 mg (base equivalent)
(Lipitor).............................................................................. 54
(Lipitor).............................................................................. 54
(Lipitor).............................................................................. 54
(Lipitor).............................................................................. 54
atovaquone-proguanil hcl tab 62.5-25 mg
(Malarone)......................................................................... 13
atovaquone-proguanil hcl tab 250-100 mg
(Malarone)......................................................................... 13
atovaquone susp 750 mg/5ml (Mepron).........................13
ATRIPLA – efavirenz-emtricitabine-tenofovir df tab
600-200-300 mg................................................................ 10
ATROPINE SULFATE – atropine sulfate ophth oint
1%.................................................................................... 141
ATROPINE SULFATE – atropine sulfate ophth soln
1%.................................................................................... 141
ATROVENT HFA – ipratropium bromide hfa inhal aerosol
17 mcg/act......................................................................... 67
AUBAGIO – teriflunomide tab 7 mg................................... 94
AUBAGIO – teriflunomide tab 14 mg................................. 94
AUGMENTIN – amoxicillin & k clavulanate for susp
125-31.25 mg/5ml............................................................... 1
AUGMENTIN – amoxicillin & k clavulanate for susp
250-62.5 mg/5ml..................................................................1
AUGMENTIN – amoxicillin & k clavulanate tab 500-125
mg........................................................................................ 1
AUGMENTIN – amoxicillin & k clavulanate tab 875-125
mg........................................................................................ 1
AUGMENTIN ES-600 – amoxicillin & k clavulanate for
susp 600-42.9 mg/5ml........................................................ 1
AUGMENTIN XR – amoxicillin & k clavulanate tab sr 12hr
1000-62.5 mg...................................................................... 1
AVALIDE – irbesartan-hydrochlorothiazide tab 150-12.5
mg...................................................................................... 44
AVALIDE – irbesartan-hydrochlorothiazide tab 300-12.5
mg...................................................................................... 44
AVANDIA – rosiglitazone maleate tab 2 mg (base
equiv)................................................................................. 30
AVANDIA – rosiglitazone maleate tab 4 mg (base
equiv)................................................................................. 31
AVAPRO – irbesartan tab 75 mg....................................... 44
AVAPRO – irbesartan tab 150 mg..................................... 44
AVAPRO – irbesartan tab 300 mg..................................... 44
AVAR LS – sulfacetamide sodium w/ sulfur foam
10-2%............................................................................... 144
AVAR – sulfacetamide sodium w/ sulfur foam 9.5-5%..... 144
AVC – sulfanilamide vaginal cream 15%........................... 77
AVELOX ABC PACK – moxifloxacin hcl tab 400 mg (base
equiv)....................................................................................5
AVELOX – moxifloxacin hcl tab 400 mg (base equiv)..........5
AVODART – dutasteride cap 0.5 mg................................. 78
AVONEX – interferon beta-1a for im inj kit 30mcg
(33mcg(6.6 mu)/vial)......................................................... 94
AVONEX – interferon beta-1a im prefilled syringe kit 30
mcg/0.5ml...........................................................................94
AVONEX PEN – interferon beta-1a im auto-injector kit 30
mcg/0.5ml...........................................................................94
AXERT – almotriptan malate tab 6.25 mg....................... 107
AXERT – almotriptan malate tab 12.5 mg....................... 107
AYGESTIN – norethindrone acetate tab 5 mg................... 27
AZASAN – azathioprine tab 75 mg.................................. 154
AZASAN – azathioprine tab 100 mg................................ 154
AZASITE – azithromycin ophth soln 1%.......................... 137
azathioprine tab 50 mg (Imuran)................................... 154
azelastine hcl nasal spray 0.1% (137 mcg/spray)......... 65
azelastine hcl nasal spray 0.15% (205.5 mcg/spray)
(Astepro)........................................................................... 65
azelastine hcl ophth soln 0.05%................................... 141
AZELEX – azelaic acid cream 20%................................. 144
AZILECT – rasagiline mesylate tab 0.5 mg (base
equiv)............................................................................... 115
AZILECT – rasagiline mesylate tab 1 mg (base
equiv)............................................................................... 115
AZITHROMYCIN – azithromycin powd pack for susp 1
gm........................................................................................ 3
azithromycin for susp 100 mg/5ml (Zithromax).............. 3
azithromycin for susp 200 mg/5ml (Zithromax).............. 3
azithromycin tab 250 mg (Zithromax).............................. 3
AZOPT – brinzolamide ophth susp 1%............................ 139
AZOR – amlodipine besylate-olmesartan medoxomil tab
5-20 mg..............................................................................50
5-40 mg..............................................................................50
10-20 mg............................................................................50
10-40 mg............................................................................50
AZULFIDINE EN-TABS – sulfasalazine tab delayed
release 500 mg................................................................. 74
AZULFIDINE – sulfasalazine tab 500 mg.......................... 74
163
2016
B
BACITRACIN – bacitracin ophth oint 500 unit/gm........... 137
bacitracin-polymyxin b ophth oint................................137
bacitracin-polymyxin-neomycin-hc ophth oint 1%..... 138
baclofen tab 10 mg......................................................... 118
baclofen tab 20 mg......................................................... 118
BACTRIM DS – sulfamethoxazole-trimethoprim tab
800-160 mg....................................................................... 13
BACTRIM – sulfamethoxazole-trimethoprim tab 400-80
mg...................................................................................... 13
BACTROBAN – mupirocin calcium cream 2%.................146
BACTROBAN NASAL – mupirocin calcium nasal oint
2%...................................................................................... 65
BAL-CARE DHA – prenat w/fe poly-na fered-fa tab 27-1 &
omega cap dr 430mg...................................................... 119
balsalazide disodium cap 750 mg (Colazal).................. 74
BANZEL – rufinamide susp 40 mg/ml.............................. 109
BANZEL – rufinamide tab 200 mg................................... 109
BANZEL – rufinamide tab 400 mg................................... 109
BARACLUDE – entecavir oral soln 0.05 mg/ml................... 8
BARACLUDE – entecavir tab 0.5 mg.................................. 8
BARACLUDE – entecavir tab 1 mg..................................... 8
BEBULIN – factor ix complex for inj 200-1200 unit.......... 134
benazepril & hydrochlorothiazide tab 5-6.25 mg.......... 42
benazepril & hydrochlorothiazide tab 10-12.5 mg
(Lotensin hct)................................................................... 42
benazepril & hydrochlorothiazide tab 20-12.5 mg
(Lotensin hct)................................................................... 42
benazepril & hydrochlorothiazide tab 20-25 mg
(Lotensin hct)................................................................... 42
benazepril hcl tab 5 mg................................................... 42
benazepril hcl tab 10 mg (Lotensin)............................... 42
BENEFIX – coagulation factor ix (recombinant) for inj 250
unit....................................................................................134
unit....................................................................................134
unit....................................................................................134
unit....................................................................................134
unit....................................................................................134
BENICAR HCT – olmesartan medoxomilhydrochlorothiazide tab 20-12.5 mg................................. 45
BENICAR HCT – olmesartan medoxomilhydrochlorothiazide tab 40-12.5 mg................................. 45
BENICAR HCT – olmesartan medoxomilhydrochlorothiazide tab 40-25 mg.................................... 45
BENICAR – olmesartan medoxomil tab 5 mg.................... 44
BENICAR – olmesartan medoxomil tab 20 mg.................. 44
BENICAR – olmesartan medoxomil tab 40 mg.................. 45
BENTYL – dicyclomine hcl cap 10 mg............................... 71
BENTYL – dicyclomine hcl tab 20 mg............................... 71
BENZAC AC WASH – benzoyl peroxide liq 5%............... 144
BENZACLIN – clindamycin phosphate-benzoyl peroxide
gel 1-5%...........................................................................144
BENZACLIN WITH PUMP – clindamycin phosphatebenzoyl peroxide gel 1-5%............................................. 144
BENZAMYCIN – benzoyl peroxide-erythromycin gel
5-3%................................................................................. 144
BENZAMYCINPAK – benzoyl peroxide-erythromycin gel
pack 5-3%........................................................................ 144
BENZIQ – benzoyl peroxide gel 5.25 %.......................... 144
BENZIQ LS – benzoyl peroxide gel 2.75%...................... 144
benzocaine dental soln 20%..........................................143
BENZONATATE – benzonatate cap 150 mg......................65
benzonatate cap 200 mg.................................................. 65
benzonatate cap 100 mg (Tessalon perles)................... 65
benzoyl peroxide-erythromycin gel 5-3%
(Benzamycin)................................................................. 144
benzoyl peroxide gel 10%.............................................. 144
benzoyl peroxide liq 5.25%............................................ 144
benzoyl peroxide liq 10%............................................... 144
benzoyl peroxide lotion 6%........................................... 144
benztropine mesylate tab 0.5 mg..................................115
benztropine mesylate tab 1 mg.....................................115
benztropine mesylate tab 2 mg.....................................115
BEPREVE – bepotastine besilate ophth soln 1.5%......... 141
BERINERT – c1 esterase inhibitor (human) for iv inj kit
500 unit............................................................................ 129
BESIVANCE – besifloxacin hcl ophth susp 0.6% (base
equiv)............................................................................... 137
BETADINE OPHTHALMIC PREP – povidone-iodine ophth
soln 5%............................................................................ 137
BETAGAN – levobunolol hcl ophth soln 0.5%................. 139
betamethasone dipropionate augmented cream 0.05%
(Diprolene af)................................................................. 147
betamethasone dipropionate augmented gel
0.05%............................................................................... 147
betamethasone dipropionate augmented lotion 0.05%
(Diprolene)...................................................................... 147
betamethasone dipropionate augmented oint 0.05%
(Diprolene)...................................................................... 147
betamethasone dipropionate cream 0.05%................. 147
betamethasone dipropionate lotion 0.05%.................. 147
betamethasone dipropionate oint 0.05%..................... 147
betamethasone valerate aerosol foam 0.12%
(Luxiq)............................................................................. 147
betamethasone valerate cream 0.1%........................... 147
betamethasone valerate lotion 0.1%............................ 147
betamethasone valerate oint 0.1%............................... 147
BETAPACE AF – sotalol hcl (afib/afl) tab 80 mg................59
BETAPACE AF – sotalol hcl (afib/afl) tab 120 mg..............59
BETAPACE AF – sotalol hcl (afib/afl) tab 160 mg..............59
BETAPACE – sotalol hcl tab 80 mg................................... 59
BETAPACE – sotalol hcl tab 120 mg................................. 59
BETAPACE – sotalol hcl tab 160 mg................................. 59
BETASERON – interferon beta-1b for inj kit 0.3 mg.......... 94
betaxolol hcl ophth soln 0.5%.......................................139
164
2016
betaxolol hcl tab 10 mg (Kerlone).................................. 47
betaxolol hcl tab 20 mg (Kerlone).................................. 47
bethanechol chloride tab 5 mg (Urecholine)................. 76
bethanechol chloride tab 10 mg (Urecholine)............... 76
BETHKIS – tobramycin nebu soln 300 mg/4ml....................6
BETIMOL – timolol ophth soln 0.25%.............................. 139
BETIMOL – timolol ophth soln 0.5%................................ 139
BETOPTIC-S – betaxolol hcl ophth susp 0.25%..............139
bexarotene cap 75 mg (Targretin)................................... 17
BEXSERO – meningococcal vac b (recomb adsorbed) inj
prefilled syringe................................................................. 15
BEYAZ – drospirenone-ethinyl estrad-levomefolate tab
3-0.02-0.451 mg................................................................ 27
BIAXIN – clarithromycin for susp 250 mg/5ml..................... 3
BIAXIN – clarithromycin tab 250 mg.................................... 3
BIAXIN – clarithromycin tab 500 mg.................................... 3
bicalutamide tab 50 mg (Casodex)................................. 18
BIDIL – isosorbide dinitrate-hydralazine hcl tab 20-37.5
mg...................................................................................... 60
BILTRICIDE – praziquantel tab 600 mg............................. 13
BIMATOPROST – bimatoprost ophth soln 0.03%............139
BINOSTO – alendronate sodium effervescent tab 70
mg...................................................................................... 39
BIO-STATIN – nystatin cap 500000 unit.............................. 6
BIO-STATIN – nystatin cap 1000000 unit............................ 6
bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln
kit....................................................................................... 70
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
(Ziac).................................................................................. 47
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
(Ziac).................................................................................. 47
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
(Ziac).................................................................................. 47
bisoprolol fumarate tab 5 mg (Zebeta)...........................47
bisoprolol fumarate tab 10 mg (Zebeta).........................47
BLEPHAMIDE S.O.P. – sulfacetamide sodiumprednisolone ophth oint 10-0.2%.................................... 138
BLEPHAMIDE – sulfacetamide sodium-prednisolone
ophth susp 10-0.2%........................................................ 138
BLEPH-10 – sulfacetamide sodium ophth soln 10%....... 137
BLOOD GLUCOSE METERS – BAYER BREEZE 2....... 153
BLOOD GLUCOSE METERS – BAYER CONTOUR....... 153
BLOOD GLUCOSE METERS – BAYER CONTOUR
NEXT/EZ/LINK/USB........................................................ 153
BONIVA – ibandronate sodium tab 150 mg (base
equivalent)......................................................................... 39
BOOSTRIX – tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lflf-mcg/0.5ml....................................................................... 15
BOSULIF – bosutinib tab 100 mg...................................... 18
BOSULIF – bosutinib tab 500 mg...................................... 18
BP FOLINATAL PLUS B – prenatal w/ calcium carbonateb6-b12-fa tab 1 mg......................................................... 119
BP MULTINATAL PLUS – prenatal w/o a vit w/ fe
fumarate-fa tab 30-1 mg................................................. 119
BP MULTINATAL PLUS – prenatal w/o a vit w/ fe fum-fa
tab chew 40-1 mg........................................................... 119
BRAVELLE – urofollitropin purified for inj 75 unit...............30
BREO ELLIPTA – fluticasone furoate-vilanterol aero powd
ba 100-25 mcg/inh............................................................ 67
BREO ELLIPTA – fluticasone furoate-vilanterol aero powd
ba 200-25 mcg/inh............................................................ 67
BREVICON-28 – norethindrone & ethinyl estradiol tab 0.5
mg-35 mcg......................................................................... 27
BRILINTA – ticagrelor tab 60 mg..................................... 129
BRILINTA – ticagrelor tab 90 mg..................................... 129
brimonidine tartrate ophth soln 0.2%...........................140
brimonidine tartrate ophth soln 0.15% (Alphagan
p)...................................................................................... 140
BRISDELLE – paroxetine mesylate cap 7.5 mg (base
equiv)................................................................................. 95
BROMFENAC – bromfenac sodium ophth soln 0.09%
(base equivalent)............................................................. 141
bromfenac sodium ophth soln 0.09% (base equiv)
(once-daily)..................................................................... 141
bromocriptine mesylate cap 5 mg (Parlodel).............. 115
bromocriptine mesylate tab 2.5 mg.............................. 115
budesonide delayed release particles cap 3 mg
(Entocort ec).................................................................... 22
budesonide inhalation susp 0.25 mg/2ml
(Pulmicort)........................................................................ 67
budesonide inhalation susp 0.5 mg/2ml
(Pulmicort)........................................................................ 67
budesonide inhalation susp 1 mg/2ml (Pulmicort)....... 67
bumetanide tab 0.5 mg (Bumex)..................................... 57
bumetanide tab 1 mg (Bumex)........................................ 57
bumetanide tab 2 mg (Bumex)........................................ 57
BUMEX – bumetanide tab 0.5 mg..................................... 57
BUMEX – bumetanide tab 1 mg........................................ 57
BUMEX – bumetanide tab 2 mg........................................ 57
BUNAVAIL – buprenorphine-naloxone buccal film 2.1-0.3
mg (base equiv).............................................................. 154
BUNAVAIL – buprenorphine-naloxone buccal film 4.2-0.7
mg (base equiv).............................................................. 154
BUNAVAIL – buprenorphine-naloxone buccal film 6.3-1 mg
(base equiv)..................................................................... 154
BUPHENYL – sodium phenylbutyrate oral powder 3 gm/
teaspoonful........................................................................ 39
BUPHENYL – sodium phenylbutyrate tab 500 mg............ 39
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base
equiv)............................................................................... 154
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
equiv)............................................................................... 154
buprenorphine hcl sl tab 2 mg (base equiv)................. 98
buprenorphine hcl sl tab 8 mg (base equiv)................. 98
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
(Zyban).............................................................................. 97
bupropion hcl tab 75 mg................................................. 81
bupropion hcl tab 100 mg............................................... 81
bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr)......... 80
165
2016
bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl)......... 81
bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl)......... 81
buspirone hcl tab 5 mg.................................................... 79
buspirone hcl tab 7.5 mg................................................. 79
buspirone hcl tab 10 mg.................................................. 80
butalbital-acetaminophen-caffeine cap 50-325-40
mg...................................................................................... 98
butalbital-acetaminophen-caffeine cap 50-300-40 mg
(Fioricet)............................................................................ 98
butalbital-acetaminophen-caffeine tab 50-325-40 mg
(Esgic)............................................................................... 98
butalbital-acetaminophen-caff w/ cod cap 50-325-40-30
mg...................................................................................... 99
butalbital-acetaminophen tab 50-325 mg.......................98
butalbital-aspirin-caffeine cap 50-325-40 mg
(Fiorinal)............................................................................ 98
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
(Fiorinal/codeine #3)....................................................... 99
BUTISOL SODIUM – butabarbital sodium tab 30 mg........ 88
butorphanol tartrate nasal soln 10 mg/ml..................... 99
BUTRANS – buprenorphine td patch weekly 5 mcg/hr...... 99
BUTRANS – buprenorphine td patch weekly 7.5 mcg/
hr........................................................................................ 99
BUTRANS – buprenorphine td patch weekly 10 mcg/
hr........................................................................................ 99
hr........................................................................................ 99
hr........................................................................................ 99
BYDUREON – exenatide extended release for susp peninjector 2 mg...................................................................... 31
BYDUREON – exenatide for inj extended release susp 2
mg...................................................................................... 31
BYETTA – exenatide soln pen-injector 5 mcg/0.02ml........ 31
BYETTA – exenatide soln pen-injector 10 mcg/0.04ml...... 31
BYSTOLIC – nebivolol hcl tab 2.5 mg (base
equivalent)......................................................................... 47
BYSTOLIC – nebivolol hcl tab 5 mg (base equivalent)...... 47
BYSTOLIC – nebivolol hcl tab 10 mg (base
equivalent)......................................................................... 47
BYSTOLIC – nebivolol hcl tab 20 mg (base
equivalent)......................................................................... 47
C
cabergoline tab 0.5 mg.................................................... 39
CADUET – amlodipine besylate-atorvastatin calcium tab
2.5-10 mg...........................................................................60
2.5-20 mg...........................................................................61
2.5-40 mg...........................................................................61
5-10 mg..............................................................................61
5-20 mg..............................................................................61
5-40 mg..............................................................................61
5-80 mg..............................................................................61
10-10 mg............................................................................61
10-20 mg............................................................................61
10-40 mg............................................................................61
10-80 mg............................................................................61
CAFERGOT – ergotamine w/ caffeine tab 1-100 mg....... 107
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base
equiv)................................................................................. 90
CALAN SR – verapamil hcl tab cr 120 mg........................ 50
CALAN – verapamil hcl tab 80 mg.....................................50
CALAN – verapamil hcl tab 120 mg...................................50
calcipotriene-betamethasone dipropionate oint
0.005-0.064% (Taclonex)............................................... 147
calcipotriene cream 0.005% (Dovonex)........................151
calcipotriene oint 0.005%............................................... 151
calcipotriene soln 0.005% (50 mcg/ml)........................ 151
calcitonin (salmon) nasal soln 200 unit/act
(Miacalcin)........................................................................ 39
CALCITRIOL – calcitriol oint 3 mcg/gm........................... 151
calcitriol cap 0.25 mcg (Rocaltrol).................................. 39
calcitriol cap 0.5 mcg (Rocaltrol).................................... 39
calcitriol oral soln 1 mcg/ml (Rocaltrol)......................... 39
calcium acetate (phosphate binder) cap 667 mg (169
mg ca) (Phoslo)............................................................... 74
calcium acetate (phosphate binder) tab 667 mg
(Eliphos)............................................................................ 74
CALCIUM PNV – prenatal w/o vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg............................................................. 119
CANASA – mesalamine suppos 1000 mg......................... 74
candesartan cilexetil-hydrochlorothiazide tab 16-12.5
mg (Atacand hct)............................................................. 45
candesartan cilexetil-hydrochlorothiazide tab 32-12.5
mg (Atacand hct)............................................................. 45
candesartan cilexetil-hydrochlorothiazide tab 32-25
mg (Atacand hct)............................................................. 45
candesartan cilexetil tab 4 mg (Atacand)...................... 45
candesartan cilexetil tab 8 mg (Atacand)...................... 45
candesartan cilexetil tab 16 mg (Atacand).................... 45
candesartan cilexetil tab 32 mg (Atacand).................... 45
capecitabine tab 150 mg (Xeloda).................................. 18
capecitabine tab 500 mg (Xeloda).................................. 18
CAPEX – fluocinolone acetonide shampoo 0.01%.......... 147
CAPITAL/CODEINE – acetaminophen w/ codeine susp
120-12 mg/5ml...................................................................99
CAPRELSA – vandetanib tab 100 mg............................... 18
166
2016
CAPRELSA – vandetanib tab 300 mg............................... 18
CAPTOPRIL/HYDROCHLOROTHIA – captopril &
hydrochlorothiazide tab 25-15 mg.................................... 42
captopril tab 12.5 mg........................................................42
captopril tab 25 mg...........................................................42
captopril tab 50 mg...........................................................42
captopril tab 100 mg.........................................................42
CARAC – fluorouracil cream 0.5%................................... 151
CARAFATE – sucralfate susp 1 gm/10ml.......................... 71
CARAFATE – sucralfate tab 1 gm...................................... 71
CARBAGLU – carglumic acid tab 200 mg......................... 39
carbamazepine cap sr 12hr 100 mg (Carbatrol).......... 109
carbamazepine chew tab 100 mg................................. 109
carbamazepine susp 100 mg/5ml (Tegretol)................ 109
carbamazepine tab 200 mg (Tegretol).......................... 109
carbamazepine tab sr 12hr 100 mg (Tegretol-xr)........ 109
CARBATROL – carbamazepine cap sr 12hr 100 mg....... 109
CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopaentacapone tabs 12.5-50-200 mg...................................115
CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopaentacapone tabs 18.75-75-200 mg................................ 115
CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopaentacapone tabs 25-100-200 mg....................................115
CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopaentacapone tabs 31.25-125-200 mg.............................. 115
CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopaentacapone tabs 37.5-150-200 mg................................ 115
CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopaentacapone tabs 50-200-200 mg....................................115
carbidopa & levodopa orally disintegrating tab 10-100
mg.................................................................................... 115
mg.................................................................................... 115
mg.................................................................................... 115
carbidopa & levodopa tab cr 25-100 mg (Sinemet
cr)..................................................................................... 115
carbidopa & levodopa tab cr 50-200 mg (Sinemet
cr)..................................................................................... 115
carbidopa & levodopa tab 10-100 mg (Sinemet)......... 115
carbidopa tab 25 mg (Lodosyn).................................... 115
carbinoxamine maleate soln 4 mg/5ml.......................... 64
carbinoxamine maleate tab 4 mg....................................64
carbonyl iron susp 15 mg/1.25ml (elemental iron)..... 129
CARDIZEM LA – diltiazem hcl coated beads tab sr 24hr
120 mg............................................................................... 50
CARDURA – doxazosin mesylate tab 1 mg...................... 61
CARDURA XL – doxazosin mesylate tab sr 24 hr 4 mg
(base equiv)....................................................................... 78
CARDURA XL – doxazosin mesylate tab sr 24 hr 8 mg
(base equiv)....................................................................... 78
carisoprodol tab 250 mg (Soma).................................. 118
carisoprodol tab 350 mg (Soma).................................. 118
carisoprodol w/ aspirin & codeine tab 200-325-16
mg.................................................................................... 118
carisoprodol w/ aspirin tab 200-325 mg.......................118
CARNITOR – levocarnitine oral soln 1 gm/10ml (10%)..... 39
CARNITOR – levocarnitine tab 330 mg............................. 39
CARNITOR SF – levocarnitine oral soln 1 gm/10ml
(10%).................................................................................. 39
carteolol hcl ophth soln 1%.......................................... 140
carvedilol tab 3.125 mg (Coreg)...................................... 47
carvedilol tab 6.25 mg (Coreg)........................................ 47
carvedilol tab 12.5 mg (Coreg)........................................ 47
carvedilol tab 25 mg (Coreg)........................................... 47
CASODEX – bicalutamide tab 50 mg................................ 18
CATAPRES – clonidine hcl tab 0.1 mg.............................. 61
CATAPRES-TTS-1 – clonidine hcl td patch weekly 0.1
mg/24hr.............................................................................. 61
mg/24hr.............................................................................. 61
mg/24hr.............................................................................. 61
CAYA – diaphragm arc-spring............................................ 27
CAYSTON – aztreonam lysine for inhal soln 75 mg (base
equivalent)......................................................................... 13
CEDAX – ceftibuten cap 400 mg......................................... 2
CEDAX – ceftibuten for susp 180 mg/5ml........................... 2
cefaclor cap 250 mg........................................................... 2
cefaclor cap 500 mg........................................................... 2
CEFACLOR – cefaclor for susp 125 mg/5ml....................... 2
CEFACLOR ER – cefaclor monohydrate tab sr 12hr 500
mg........................................................................................ 2
cefadroxil cap 500 mg........................................................ 2
cefadroxil for susp 250 mg/5ml........................................ 2
cefadroxil for susp 500 mg/5ml........................................ 2
cefadroxil tab 1 gm............................................................. 2
cefdinir cap 300 mg............................................................ 2
cefdinir for susp 125 mg/5ml............................................ 2
cefdinir for susp 250 mg/5ml............................................ 2
167
2016
CEFDITOREN PIVOXIL – cefditoren pivoxil tab 200 mg
(base equivalent)................................................................. 2
CEFDITOREN PIVOXIL – cefditoren pivoxil tab 400 mg
(base equivalent)................................................................. 2
cefixime for susp 100 mg/5ml (Suprax)........................... 2
cefixime for susp 200 mg/5ml (Suprax)........................... 2
cefpodoxime proxetil for susp 50 mg/5ml....................... 2
cefpodoxime proxetil for susp 100 mg/5ml..................... 2
cefpodoxime proxetil tab 100 mg..................................... 2
cefpodoxime proxetil tab 200 mg..................................... 2
cefprozil for susp 125 mg/5ml...........................................2
cefprozil for susp 250 mg/5ml...........................................2
cefprozil tab 250 mg........................................................... 2
cefprozil tab 500 mg........................................................... 2
CEFTIBUTEN – ceftibuten cap 400 mg............................... 2
CEFTIBUTEN – ceftibuten for susp 180 mg/5ml................. 2
CEFTIN – cefuroxime axetil for susp 125 mg/5ml............... 2
CEFTIN – cefuroxime axetil for susp 250 mg/5ml............... 2
CEFTIN – cefuroxime axetil tab 500 mg.............................. 2
cefuroxime axetil tab 250 mg............................................ 2
cefuroxime axetil tab 500 mg (Ceftin).............................. 2
CELEBREX – celecoxib cap 50 mg................................. 104
CELEBREX – celecoxib cap 100 mg............................... 104
celecoxib cap 50 mg (Celebrex)....................................104
celecoxib cap 100 mg (Celebrex)..................................104
CELLCEPT – mycophenolate mofetil cap 250 mg...........154
CELLCEPT – mycophenolate mofetil for oral susp 200 mg/
ml...................................................................................... 154
CELLCEPT – mycophenolate mofetil tab 500 mg........... 154
CELONTIN – methsuximide cap 300 mg......................... 109
CENTANY – mupirocin oint 2%........................................ 146
cephalexin cap 250 mg (Keflex)........................................ 2
CEPHALEXIN – cephalexin tab 250 mg.............................. 2
CEPHALEXIN – cephalexin tab 500 mg.............................. 2
cephalexin for susp 125 mg/5ml....................................... 3
cephalexin for susp 250 mg/5ml....................................... 3
CERDELGA – eliglustat tartrate cap 84 mg (base
equivalent)....................................................................... 129
CERVARIX – human papillomavirus (hpv) bival (type 16,
18) recmb vac inj.............................................................. 15
CESAMET – nabilone cap 1 mg........................................ 72
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)................... 64
CETRAXAL – ciprofloxacin hcl otic soln 0.2% (base
equivalent)....................................................................... 142
cevimeline hcl cap 30 mg (Evoxac).............................. 143
CHANTIX CONTINUING MONTH – varenicline tartrate tab
1 mg (base equiv)............................................................. 98
CHANTIX STARTING MONTH PA – varenicline tartrate
tab 0.5 mg x 11 & tab 1 mg x 42 pack............................. 98
CHANTIX – varenicline tartrate tab 0.5 mg (base
equiv)................................................................................. 97
CHANTIX – varenicline tartrate tab 1 mg (base equiv)...... 97
CHEMET – succimer cap 100 mg....................................154
CHENODAL – chenodiol tab 250 mg.................................74
CHLORDIAZEPOXIDE/AMITRIPT – chlordiazepoxideamitriptyline tab 5-12.5 mg............................................... 95
CHLORDIAZEPOXIDE/AMITRIPT – chlordiazepoxideamitriptyline tab 10-25 mg................................................ 95
chlordiazepoxide hcl cap 5 mg....................................... 80
chlordiazepoxide hcl cap 10 mg..................................... 80
chlordiazepoxide hcl cap 25 mg..................................... 80
chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg
(Librax).............................................................................. 71
chlorhexidine gluconate soln 0.12% (Peridex)............ 143
chloroquine phosphate tab 250 mg................................13
chloroquine phosphate tab 500 mg (Aralen)................. 13
CHLOROTHIAZIDE – chlorothiazide tab 250 mg.............. 58
chlorothiazide tab 500 mg............................................... 58
chlorpromazine hcl tab 10 mg........................................ 85
chlorpromazine hcl tab 100 mg...................................... 85
chlorpromazine hcl tab 200 mg...................................... 85
CHLORPROPAMIDE – chlorpropamide tab 100 mg......... 31
CHLORPROPAMIDE – chlorpropamide tab 250 mg......... 31
CHLORTHALIDONE – chlorthalidone tab 50 mg.............. 58
CHLORTHALIDONE – chlorthalidone tab 100 mg............ 58
chlorthalidone tab 25 mg................................................. 58
chlorzoxazone tab 500 mg (Parafon forte dsc)........... 118
CHOLBAM – cholic acid cap 50 mg.................................. 74
CHOLBAM – cholic acid cap 250 mg................................ 75
cholecalciferol cap 1000 unit........................................ 119
cholecalciferol chew tab 400 unit................................. 119
cholecalciferol chew tab 1000 unit............................... 119
cholecalciferol drops 400 unit/0.03ml (per drop)........ 119
cholecalciferol drops 5000 unit/ml (1000
unit/0.2ml)....................................................................... 119
cholecalciferol oral liquid 400 unit/ml.......................... 119
cholecalciferol tab 400 unit........................................... 119
cholecalciferol tab 1000 unit......................................... 119
cholecalciferol tab 50000 unit....................................... 119
cholestyramine light powder 4 gm/dose (Questran
light)...................................................................................54
cholestyramine light powder packets 4 gm.................. 54
cholestyramine powder 4 gm/dose (Questran)............. 54
cholestyramine powder packets 4 gm (Questran)........ 54
choline fenofibrate cap dr 45 mg (fenofibric acid
equiv) (Trilipix)................................................................. 54
choline fenofibrate cap dr 135 mg (fenofibric acid
equiv) (Trilipix)................................................................. 54
CIALIS – tadalafil tab 2.5 mg............................................. 64
CIALIS – tadalafil tab 5 mg................................................ 64
ciclopirox gel 0.77%....................................................... 146
ciclopirox olamine cream 0.77% (base equiv).............146
ciclopirox olamine susp 0.77% (base equiv)............... 146
168
2016
ciclopirox shampoo 1% (Loprox shampoo)................ 146
ciclopirox solution 8% (Penlac nail lacquer)............... 146
cilostazol tab 50 mg....................................................... 129
cilostazol tab 100 mg..................................................... 129
CILOXAN – ciprofloxacin hcl ophth oint 0.3%..................137
CILOXAN – ciprofloxacin hcl ophth soln 0.3%................. 137
cimetidine hcl soln 300 mg/5ml...................................... 71
cimetidine tab 200 mg...................................................... 71
CIMZIA – certolizumab pegol for inj kit 2 x 200 mg........... 75
CIMZIA – certolizumab pegol inj kit 2 x 200 mg/ml............ 75
CIMZIA STARTER KIT – certolizumab pegol inj kit 6 x 200
mg/ml..................................................................................75
CINRYZE – c1 esterase inhibitor (human) for iv inj 500
unit....................................................................................129
CIPRO – ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml)............................................................................ 5
CIPRO – ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml)............................................................................ 5
CIPRO – ciprofloxacin hcl tab 250 mg (base equiv)............ 5
CIPRO – ciprofloxacin hcl tab 500 mg (base equiv)............ 5
CIPRODEX – ciprofloxacin-dexamethasone otic susp
0.3-0.1%........................................................................... 142
CIPROFLOXACIN – ciprofloxacin hcl otic soln 0.2% (base
equivalent)....................................................................... 142
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000
mg(base eq) (Cipro xr)..................................................... 5
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg
(base eq) (Cipro xr)........................................................... 5
ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml) (Cipro).............................................................. 5
ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml) (Cipro).............................................................. 5
CIPROFLOXACIN HCL – ciprofloxacin hcl tab 100 mg
(base equiv)......................................................................... 5
ciprofloxacin hcl ophth soln 0.3% (Ciloxan)............... 137
ciprofloxacin hcl tab 750 mg (base equiv).......................5
ciprofloxacin hcl tab 250 mg (base equiv) (Cipro).......... 5
ciprofloxacin hcl tab 500 mg (base equiv) (Cipro).......... 5
CIPRO HC – ciprofloxacin-hydrocortisone otic susp
0.2-1%.............................................................................. 142
CIPRO XR – ciprofloxacin-ciprofloxacin hcl tab sr 24hr
1000 mg(base eq)............................................................... 5
CIPRO XR – ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500
mg (base eq)....................................................................... 5
citalopram hydrobromide oral soln 10 mg/5ml............. 81
citalopram hydrobromide tab 10 mg (base equiv)
(Celexa)............................................................................. 81
(Celexa)............................................................................. 81
(Celexa)............................................................................. 81
CITRANATAL ASSURE – prenat w/o a w/fecbn-fegl-dss-fa
tab & dha cap 300 mg pack........................................... 119
CITRANATAL B-CALM – prenat w/o a w/fecbn-feglu-fa tab
20-1 mg & vit b6 tab pak................................................ 120
CITRANATAL DHA – prenat w/o a w/fecbn-fegl-dss-fa tab
& dha cap 250 mg pack................................................. 120
CITRANATAL 90 DHA – prenat w/o a w/fecbn-fegl-dss-fa
tab 90 &dha cap 300mg pak.......................................... 120
CITRANATAL HARMONY – prenat w/o a w/fe fum-fe cbndss-fa-dha cap 27-1-260 mg.......................................... 120
CITRANATAL RX – prenatal w/o a w/ fe carbonyl-fe glucdss-fa tab 27-1mg........................................................... 120
clarithromycin for susp 125 mg/5ml.................................3
clarithromycin for susp 250 mg/5ml (Biaxin).................. 3
clarithromycin tab 250 mg (Biaxin).................................. 3
clarithromycin tab 500 mg (Biaxin).................................. 3
clarithromycin tab sr 24hr 500 mg................................... 3
clemastine fumarate tab 2.68 mg....................................64
CLEOCIN – clindamycin hcl cap 75 mg............................. 13
CLEOCIN – clindamycin hcl cap 150 mg........................... 14
CLEOCIN – clindamycin hcl cap 300 mg........................... 14
CLEOCIN – clindamycin phosphate vaginal cream 2%..... 77
CLEOCIN – clindamycin phosphate vaginal suppos 100
mg...................................................................................... 77
CLEOCIN PEDIATRIC GRANULE – clindamycin palmitate
hcl for soln 75 mg/5ml (base equiv)................................. 14
CLEOCIN-T – clindamycin phosphate lotion 1%............. 144
CLEOCIN-T – clindamycin phosphate soln 1%............... 144
CLEOCIN-T – clindamycin phosphate swab 1%............. 144
CLIMARA – estradiol td patch weekly 0.025 mg/24hr....... 25
CLIMARA – estradiol td patch weekly 0.05 mg/24hr......... 25
CLIMARA – estradiol td patch weekly 0.06 mg/24hr......... 25
CLIMARA – estradiol td patch weekly 0.075 mg/24hr....... 25
CLIMARA – estradiol td patch weekly 0.1 mg/24hr........... 25
CLIMARA – estradiol td patch weekly 0.0375 mg/24hr
(37.5 mcg/24hr)................................................................. 25
CLIMARA PRO – estradiol-levonorgestrel td patch weekly
0.045-0.015 mg/day.......................................................... 25
clindamycin hcl cap 75 mg (Cleocin)............................. 14
clindamycin hcl cap 150 mg (Cleocin)........................... 14
clindamycin hcl cap 300 mg (Cleocin)........................... 14
clindamycin palmitate hcl for soln 75 mg/5ml (base
equiv) (Cleocin pediatric gr).......................................... 14
clindamycin phosphate-benzoyl peroxide gel 1-5%
(Benzaclin)...................................................................... 144
clindamycin phosphate foam 1% (Evoclin)................. 144
clindamycin phosphate gel 1% (Cleocin-t).................. 144
clindamycin phosphate lotion 1% (Cleocin-t)............. 144
clindamycin phosphate soln 1% (Cleocin-t)................ 144
clindamycin phosphate swab 1% (Cleocin-t).............. 144
clindamycin phosphate vaginal cream 2%
(Cleocin)............................................................................ 77
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2
(1)-5% (Duac)..................................................................144
CLINDESSE – clindamycin phosphate (one dose) vaginal
cream 2%...........................................................................77
clobetasol propionate cream 0.05% (Temovate)......... 148
169
2016
clobetasol propionate emollient base cream 0.05%
(Temovate e)................................................................... 148
clobetasol propionate emulsion foam 0.05% (Oluxe)...................................................................................... 148
clobetasol propionate foam 0.05% (Olux)................... 148
clobetasol propionate gel 0.05% (Temovate).............. 148
clobetasol propionate lotion 0.05% (Clobex).............. 148
clobetasol propionate oint 0.05% (Temovate)............. 148
clobetasol propionate shampoo 0.05% (Clobex)........ 148
clobetasol propionate soln 0.05% (Temovate)............ 148
clobetasol propionate spray 0.05% (Clobex).............. 148
CLOBEX – clobetasol propionate lotion 0.05%............... 148
CLOBEX – clobetasol propionate shampoo 0.05%......... 148
CLOBEX – clobetasol propionate spray 0.05%............... 148
CLOCORTOLONE PIVALATE – clocortolone pivalate
cream 0.1%..................................................................... 148
CLOCORTOLONE PIVALATE PUM – clocortolone pivalate
cream 0.1%..................................................................... 148
CLODERM – clocortolone pivalate cream 0.1%.............. 148
CLODERM PUMP – clocortolone pivalate cream
0.1%................................................................................. 148
clomipramine hcl cap 25 mg (Anafranil)........................ 81
clonazepam orally disintegrating tab 0.125 mg.......... 109
clonazepam orally disintegrating tab 0.25 mg............ 109
clonazepam orally disintegrating tab 0.5 mg.............. 109
clonazepam orally disintegrating tab 1 mg................. 109
clonazepam orally disintegrating tab 2 mg................. 109
clonazepam tab 0.5 mg (Klonopin)............................... 109
clonazepam tab 1 mg (Klonopin).................................. 109
clonazepam tab 2 mg (Klonopin).................................. 109
clonidine hcl tab 0.1 mg (Catapres)............................... 61
clonidine hcl tab sr 12hr 0.1 mg (Kapvay)..................... 90
clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1)...................................................................................61
clopidogrel bisulfate tab 75 mg (base equiv)
(Plavix)............................................................................ 129
clopidogrel bisulfate tab 300 mg (base equiv)
(Plavix)............................................................................ 129
clorazepate dipotassium tab 3.75 mg (Tranxene t)....... 80
clorazepate dipotassium tab 7.5 mg (Tranxene t)......... 80
clorazepate dipotassium tab 15 mg (Tranxene t).......... 80
CLORPRES – clonidine & chlorthalidone tab 0.1-15
mg...................................................................................... 61
mg...................................................................................... 61
mg...................................................................................... 61
clotrimazole cream 1%................................................... 146
clotrimazole soln 1%...................................................... 146
clotrimazole troche 10 mg............................................. 143
clotrimazole w/ betamethasone cream 1-0.05%
(Lotrisone)...................................................................... 146
clotrimazole w/ betamethasone lotion 1-0.05%........... 146
CLOZAPINE ODT – clozapine orally disintegrating tab
12.5 mg.............................................................................. 85
CLOZAPINE ODT – clozapine orally disintegrating tab 150
mg...................................................................................... 85
CLOZAPINE ODT – clozapine orally disintegrating tab 200
mg...................................................................................... 85
clozapine orally disintegrating tab 25 mg (Fazaclo)..... 85
clozapine orally disintegrating tab 100 mg
(Fazaclo)............................................................................85
clozapine tab 50 mg......................................................... 85
clozapine tab 200 mg....................................................... 85
clozapine tab 25 mg (Clozaril).........................................85
clozapine tab 100 mg (Clozaril).......................................85
CLOZARIL – clozapine tab 25 mg..................................... 85
CLOZARIL – clozapine tab 100 mg................................... 85
C-NATE DHA – prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg.................................................................... 119
COAGADEX – coagulation factor x (human) for inj 250
unit....................................................................................134
COAGADEX – coagulation factor x (human) for inj 500
unit....................................................................................134
COARTEM – artemether-lumefantrine tab 20-120 mg...... 13
CODAR AR – chlorpheniramine w/ codeine liquid 2-8
mg/5ml............................................................................... 65
CODEINE SULFATE – codeine sulfate tab 15 mg.............99
codeine sulfate tab 15 mg (Codeine sulfate)................. 99
COLAZAL – balsalazide disodium cap 750 mg................. 75
COLCHICINE – colchicine cap 0.6 mg............................ 108
COLCHICINE – colchicine tab 0.6 mg............................. 108
colchicine w/ probenecid tab 0.5-500 mg.................... 108
COLCRYS – colchicine tab 0.6 mg.................................. 108
COLESTID – colestipol hcl granule packets 5 gm............. 55
COLESTID – colestipol hcl granules 5 gm........................ 54
COLESTID – colestipol hcl tab 1 gm................................. 54
COLESTID FLAVORED – colestipol hcl granule packets 5
gm...................................................................................... 55
COLESTID FLAVORED – colestipol hcl granules 5
gm...................................................................................... 55
colestipol hcl granule packets 5 gm (Colestid
flavored)............................................................................ 55
colestipol hcl granules 5 gm (Colestid flavored).......... 55
colestipol hcl tab 1 gm (Colestid)...................................55
COLLIGINIX – dimethicone-allantoin bandage 5-2%...... 151
COLY-MYCIN S – neomycin-colistin-hc-thonzonium otic
susp 3.3-3-10-0.5 mg/ml................................................. 142
COLYTE-FLAVOR PACKS – peg 3350-kcl-na bicarb-naclna sulfate for soln 240 gm................................................ 70
170
2016
COMBIGAN – brimonidine tartrate-timolol maleate ophth
soln 0.2-0.5%...................................................................140
COMBIPATCH – estradiol-norethindrone ace td pttw
0.05-0.14 mg/day.............................................................. 25
COMBIPATCH – estradiol-norethindrone ace td pttw
0.05-0.25 mg/day.............................................................. 25
COMBIVENT RESPIMAT – ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act............................................ 67
COMBIVIR – lamivudine-zidovudine tab 150-300 mg....... 10
COMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60
mg dose) kit....................................................................... 18
COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20
mg (100 dose) kit.............................................................. 18
COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20
mg (140 dose) kit.............................................................. 18
COMPLERA – emtricitabine-rilpivirine-tenofovir df tab
200-25-300 mg.................................................................. 10
COMPLETE NATAL DHA – prenat-fe bis-fe prot succ-fa-ca
tab & omega 3 cap 250 pk............................................. 120
COMPLETENATE – prenatal vit w/ fe fumarate-fa chew
tab 29-1 mg..................................................................... 120
COMTAN – entacapone tab 200 mg................................ 115
CO-NATAL FA – prenatal vit w/ fe fumarate-fa tab 29-1
mg.................................................................................... 120
CONCEPT DHA – prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg............................................................ 120
CONCEPT OB – prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg................................................................. 120
CONCERTA – methylphenidate hcl tab sa osm 18 mg......90
CONDYLOX – podofilox gel 0.5%....................................151
CONDYLOX – podofilox soln 0.5%.................................. 151
COPAXONE – glatiramer acetate soln prefilled syringe 20
mg/ml..................................................................................94
COPAXONE – glatiramer acetate soln prefilled syringe 40
mg/ml..................................................................................94
COPEGUS – ribavirin tab 200 mg....................................... 8
CORDARONE – amiodarone hcl tab 200 mg.................... 59
CORDRAN TAPE – flurandrenolide tape 4 mcg/
sqcm................................................................................. 148
COREG – carvedilol tab 3.125 mg.....................................47
COREG – carvedilol tab 6.25 mg.......................................47
COREG – carvedilol tab 12.5 mg.......................................47
COREG – carvedilol tab 25 mg..........................................47
COREG CR – carvedilol phosphate cap sr 24hr 10
mg...................................................................................... 47
mg...................................................................................... 47
mg...................................................................................... 47
mg...................................................................................... 47
CORGARD – nadolol tab 20 mg........................................ 47
CORIFACT – factor xiii concentrate (human) for inj kit
1000-1600 unit................................................................ 134
CORLANOR – ivabradine hcl tab 5 mg (base equiv).........61
CORLANOR – ivabradine hcl tab 7.5 mg (base equiv)......61
CORTANE-B – hydrocortisone-pramoxine-chloroxylenol lot
10-10-1mg/ml................................................................... 148
CORTEF – hydrocortisone tab 5 mg.................................. 22
CORTEF – hydrocortisone tab 10 mg................................ 22
CORTEF – hydrocortisone tab 20 mg................................ 22
CORTENEMA – hydrocortisone enema 100 mg/60ml..... 143
CORTIFOAM – hydrocortisone acetate rectal foam 10%
(90 mg/dose)................................................................... 143
CORTISONE ACETATE – cortisone acetate tab 25
mg...................................................................................... 22
CORTISPORIN – bacitracin-polymyxin-neomycin hc oint
1%.................................................................................... 146
CORTISPORIN – neomycin-polymyxin-hc crm 3.5 mg/
gm-10000 unt/gm-0.5%...................................................146
CORZIDE – nadolol & bendroflumethiazide tab 40-5
mg...................................................................................... 47
CORZIDE – nadolol & bendroflumethiazide tab 80-5
mg...................................................................................... 47
COSENTYX – secukinumab subcutaneous soln prefilled
syringe 150 mg/ml........................................................... 151
COSENTYX SENSOREADY PEN – secukinumab
subcutaneous soln auto-injector 150 mg/ml................... 151
COSOPT – dorzolamide hcl-timolol maleate ophth soln
22.3-6.8 mg/ml.................................................................140
COSOPT PF – dorzolamide hcl-timolol maleate ophth sol
22.3-6.8 mg/ml pf............................................................ 140
COTELLIC – cobimetinib fumarate tab 20 mg (base
equivalent)......................................................................... 18
COUMADIN – warfarin sodium tab 1 mg......................... 129
COUMADIN – warfarin sodium tab 2.5 mg...................... 129
COUMADIN – warfarin sodium tab 7.5 mg...................... 130
COUMADIN – warfarin sodium tab 10 mg....................... 130
COZAAR – losartan potassium tab 25 mg......................... 45
COZAAR – losartan potassium tab 50 mg......................... 45
COZAAR – losartan potassium tab 100 mg....................... 45
CREON – pancrelipase (lip-prot-amyl) dr cap
3000-9500-15000 unit....................................................... 73
6000-19000-30000 unit..................................................... 73
12000-38000-60000 unit................................................... 73
24000-76000-120000 unit................................................. 73
36000-114000-180000 unit............................................... 73
CRESEMBA – isavuconazonium sulfate cap 186 mg..........7
171
2016
CRESTOR – rosuvastatin calcium tab 5 mg...................... 55
CRESTOR – rosuvastatin calcium tab 10 mg.................... 55
CRINONE – progesterone vaginal gel 4%......................... 78
CRIXIVAN – indinavir sulfate cap 200 mg......................... 10
CRIXIVAN – indinavir sulfate cap 400 mg......................... 10
CROMOLYN SODIUM – cromolyn sodium soln nebu 20
mg/2ml............................................................................... 67
cromolyn sodium ophth soln 4%..................................141
cromolyn sodium oral conc 100 mg/5ml
(Gastrocrom).................................................................... 75
CUTIVATE – fluticasone propionate cream 0.05%.......... 148
CUTIVATE – fluticasone propionate lotion 0.05%............ 148
CUVPOSA – glycopyrrolate oral soln 1 mg/5ml.................71
cyanocobalamin inj 1000 mcg/ml................................. 130
CYCLESSA – desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg......................... 27
cyclobenzaprine hcl tab 5 mg....................................... 118
cyclobenzaprine hcl tab 7.5 mg.................................... 118
cyclobenzaprine hcl tab 10 mg..................................... 118
CYCLOGYL – cyclopentolate hcl ophth soln 0.5%.......... 141
CYCLOGYL – cyclopentolate hcl ophth soln 1%............. 141
CYCLOGYL – cyclopentolate hcl ophth soln 2%............. 141
CYCLOMYDRIL – cyclopentolate w/ phenylephrine ophth
soln 0.2-1%...................................................................... 141
cyclopentolate hcl ophth soln 0.5% (Cyclogyl)........... 141
cyclopentolate hcl ophth soln 1% (Cyclogyl).............. 141
cyclopentolate hcl ophth soln 2% (Cyclogyl).............. 141
CYCLOPHOSPHAMIDE – cyclophosphamide cap 25
mg...................................................................................... 18
CYCLOPHOSPHAMIDE – cyclophosphamide cap 50
mg...................................................................................... 18
CYCLOSERINE – cycloserine cap 250 mg......................... 6
CYCLOSET – bromocriptine mesylate tab 0.8 mg (base
equivalent)......................................................................... 31
cyclosporine cap 25 mg (Sandimmune)...................... 154
cyclosporine cap 100 mg (Sandimmune).................... 154
cyclosporine modified cap 25 mg (Neoral).................. 154
cyclosporine modified cap 100 mg (Neoral)................ 154
CYCLOSPORINE MODIFIED – cyclosporine modified cap
50 mg............................................................................... 154
cyclosporine modified oral soln 100 mg/ml
(Neoral)............................................................................154
cyproheptadine hcl syrup 2 mg/5ml............................... 64
cyproheptadine hcl tab 4 mg.......................................... 64
CYSTADANE – betaine powder for oral solution............... 39
CYSTAGON – cysteamine bitartrate cap 50 mg................ 78
CYSTAGON – cysteamine bitartrate cap 150 mg.............. 78
CYSTARAN – cysteamine hcl ophth soln 0.44% (base
equivalent)....................................................................... 141
CYTOMEL – liothyronine sodium tab 5 mcg...................... 35
CYTOMEL – liothyronine sodium tab 25 mcg.................... 35
CYTOMEL – liothyronine sodium tab 50 mcg.................... 35
CYTOTEC – misoprostol tab 100 mcg............................... 71
CYTOTEC – misoprostol tab 200 mcg............................... 71
CYTRA-3 – pot & sod citrates w/ cit ac syrup 550-500-334
mg/5ml............................................................................... 78
D
DAKLINZA – daclatasvir dihydrochloride tab 30 mg (base
equivalent)............................................................................8
equivalent)............................................................................8
equivalent)............................................................................8
DALIRESP – roflumilast tab 500 mcg................................ 67
danazol cap 50 mg............................................................24
danazol cap 100 mg..........................................................24
danazol cap 200 mg..........................................................24
DANTRIUM – dantrolene sodium cap 25 mg.................. 118
DANTRIUM – dantrolene sodium cap 50 mg.................. 118
dantrolene sodium cap 100 mg.................................... 118
dantrolene sodium cap 25 mg (Dantrium)................... 118
dantrolene sodium cap 50 mg (Dantrium)................... 118
dapsone tab 25 mg........................................................... 14
dapsone tab 100 mg......................................................... 14
DAPTACEL – diph, acellular pert & tet tox inj 15 lf-10
mcg-5 lf/0.5ml.................................................................... 15
DARAPRIM – pyrimethamine tab 25 mg........................... 13
darifenacin hydrobromide tab sr 24hr 7.5 mg (base
equiv) (Enablex)............................................................... 77
darifenacin hydrobromide tab sr 24hr 15 mg (base
equiv) (Enablex)............................................................... 77
DAYPRO – oxaprozin tab 600 mg................................... 104
DAYTRANA – methylphenidate td patch 10 mg/9hr.......... 90
DDAVP – desmopressin acetate inj 4 mcg/ml................... 39
DDAVP – desmopressin acetate nasal soln 0.01%
(refrigerated)...................................................................... 39
DDAVP – desmopressin acetate nasal spray soln
0.01%................................................................................. 39
DDAVP – desmopressin acetate tab 0.1 mg......................39
DDAVP – desmopressin acetate tab 0.2 mg......................39
DELZICOL – mesalamine cap dr 400 mg.......................... 75
DEMADEX – torsemide tab 10 mg.................................... 58
DEMADEX – torsemide tab 20 mg.................................... 58
demeclocycline hcl tab 150 mg........................................ 4
demeclocycline hcl tab 300 mg........................................ 4
DENAVIR – penciclovir cream 1%................................... 146
DEPAKENE – valproate sodium syrup 250 mg/5ml (base
equiv)............................................................................... 109
DEPAKENE – valproic acid cap 250 mg.......................... 109
DEPAKOTE – divalproex sodium tab delayed release 125
mg.................................................................................... 109
mg.................................................................................... 109
mg.................................................................................... 109
172
2016
DEPAKOTE ER – divalproex sodium tab sr 24 hr 250
mg.................................................................................... 110
DEPAKOTE ER – divalproex sodium tab sr 24 hr 500
mg.................................................................................... 110
DEPAKOTE SPRINKLES – divalproex sodium cap
delayed release sprinkle 125 mg....................................110
DEPEN TITRATABS – penicillamine tab 250 mg............ 154
DEPO-TESTOSTERONE – testosterone cypionate im inj
in oil 100 mg/ml................................................................. 24
DEPO-TESTOSTERONE – testosterone cypionate im inj
in oil 200 mg/ml................................................................. 24
DERMA-SMOOTHE/FS BODY – fluocinolone acetonide oil
0.01% (body oil).............................................................. 148
DERMA-SMOOTHE/FS SCALP – fluocinolone acetonide
oil 0.01% (scalp oil).........................................................148
DERMATOP – prednicarbate cream 0.1%....................... 148
DERMATOP – prednicarbate oint 0.1%........................... 148
DERMOTIC – fluocinolone acetonide (otic) oil 0.01%..... 142
desipramine hcl tab 50 mg.............................................. 81
desipramine hcl tab 75 mg.............................................. 81
desipramine hcl tab 100 mg............................................ 81
desipramine hcl tab 150 mg............................................ 81
desipramine hcl tab 10 mg (Norpramin)........................ 81
desipramine hcl tab 25 mg (Norpramin)........................ 81
DESLORATADINE ODT – desloratadine tab orally
disintegrating 2.5 mg......................................................... 64
DESLORATADINE ODT – desloratadine tab orally
disintegrating 5 mg............................................................ 64
desloratadine tab 5 mg (Clarinex).................................. 64
desmopressin acetate inj 4 mcg/ml (Ddavp)................. 39
desmopressin acetate nasal soln 0.01% (refrigerated)
(Ddavp).............................................................................. 39
desmopressin acetate nasal spray soln 0.01%
(Ddavp).............................................................................. 39
desmopressin acetate nasal spray soln 0.01%
(refrigerated).....................................................................39
desmopressin acetate tab 0.1 mg (Ddavp).................... 39
desmopressin acetate tab 0.2 mg (Ddavp).................... 39
DESOGEN – desogestrel & ethinyl estradiol tab 0.15
mg-30 mcg......................................................................... 27
DESONATE – desonide gel 0.05%.................................. 148
desonide cream 0.05% (Desowen)............................... 148
desonide lotion 0.05% (Desowen)................................ 148
desonide oint 0.05%....................................................... 148
DESOWEN – desonide cream 0.05%.............................. 148
DESOWEN – desonide lotion 0.05%............................... 148
desoximetasone cream 0.25% (Topicort)..................... 148
DESOXIMETASONE – desoximetasone cream
0.05%............................................................................... 148
DESOXIMETASONE – desoximetasone oint 0.05%....... 148
desoximetasone gel 0.05% (Topicort).......................... 148
desoximetasone oint 0.25% (Topicort)......................... 148
DESOXYN – methamphetamine hcl tab 5 mg................... 90
DESVENLAFAXINE ER – desvenlafaxine fumarate tab sr
24hr 50 mg (base equiv).................................................. 81
DESVENLAFAXINE ER – desvenlafaxine fumarate tab sr
24hr 100 mg (base equiv)................................................ 81
DESVENLAFAXINE ER – desvenlafaxine tab sr 24hr 50
mg...................................................................................... 81
DESVENLAFAXINE ER – desvenlafaxine tab sr 24hr 100
mg...................................................................................... 81
DEXAMETHASONE – dexamethasone soln 0.5
mg/5ml............................................................................... 22
DEXAMETHASONE – dexamethasone tab 1 mg.............. 22
DEXAMETHASONE – dexamethasone tab 2 mg.............. 22
dexamethasone elixir 0.5 mg/5ml................................... 22
DEXAMETHASONE INTENSOL – dexamethasone conc 1
mg/ml..................................................................................22
DEXAMETHASONE SODIUM PHOS – dexamethasone
sodium phosphate ophth soln 0.1%............................... 138
dexamethasone tab 0.5 mg............................................. 22
dexamethasone tab 0.75 mg........................................... 22
dexamethasone tab 1.5 mg............................................. 22
dexamethasone tab 4 mg................................................ 22
dexamethasone tab 6 mg................................................ 22
DEXEDRINE – dextroamphetamine sulfate cap sr 24hr 5
mg...................................................................................... 90
mg...................................................................................... 90
mg...................................................................................... 90
dexmethylphenidate hcl cap sr 24 hr 5 mg (Focalin
xr)....................................................................................... 90
xr)....................................................................................... 90
xr)....................................................................................... 91
xr)....................................................................................... 91
xr)....................................................................................... 91
xr)....................................................................................... 91
dexmethylphenidate hcl tab 2.5 mg (Focalin)............... 91
dexmethylphenidate hcl tab 5 mg (Focalin).................. 91
dexmethylphenidate hcl tab 10 mg (Focalin)................ 91
DEXPAK 10 DAY – dexamethasone tab therapy pack 1.5
mg (35).............................................................................. 22
mg (51).............................................................................. 22
mg (21).............................................................................. 22
dextroamphetamine sulfate cap sr 24hr 5 mg
(Dexedrine)....................................................................... 91
(Dexedrine)....................................................................... 91
(Dexedrine)....................................................................... 91
dextroamphetamine sulfate oral solution 5 mg/5ml
(Procentra)........................................................................ 91
dextroamphetamine sulfate tab 5 mg.............................91
173
2016
dextroamphetamine sulfate tab 10 mg...........................91
D.H.E. 45 – dihydroergotamine mesylate inj 1 mg/ml...... 107
DIAMOX – acetazolamide cap sr 12hr 500 mg................. 58
DIASTAT ACUDIAL – diazepam rectal gel delivery system
10 mg............................................................................... 110
DIASTAT ACUDIAL – diazepam rectal gel delivery system
20 mg............................................................................... 110
DIASTAT PEDIATRIC – diazepam rectal gel delivery
system 2.5 mg................................................................. 110
diazepam conc 5 mg/ml................................................... 80
DIAZEPAM – diazepam oral soln 1 mg/ml......................... 80
DIAZEPAM – diazepam rectal gel delivery system 2.5
mg.................................................................................... 110
DIAZEPAM – diazepam rectal gel delivery system 10
mg.................................................................................... 110
DIAZEPAM – diazepam rectal gel delivery system 20
mg.................................................................................... 110
diazepam tab 2 mg (Valium)............................................ 80
diazepam tab 5 mg (Valium)............................................ 80
diazepam tab 10 mg (Valium).......................................... 80
DIBENZYLINE – phenoxybenzamine hcl cap 10 mg......... 61
DICLEGIS – doxylamine-pyridoxine tab delayed release
10-10 mg............................................................................72
diclofenac potassium tab 50 mg...................................104
diclofenac sodium (actinic keratoses) gel 3%
(Solaraze)........................................................................ 151
diclofenac sodium gel 1% (Voltaren)............................146
diclofenac sodium ophth soln 0.1%............................. 141
diclofenac sodium soln 1.5%........................................ 146
diclofenac sodium tab delayed release 25 mg............ 104
diclofenac sodium tab sr 24hr 100 mg........................ 104
diclofenac w/ misoprostol tab delayed release 50-0.2
mg (Arthrotec 50).......................................................... 104
diclofenac w/ misoprostol tab delayed release 75-0.2
mg (Arthrotec 75).......................................................... 104
dicloxacillin sodium cap 250 mg...................................... 1
dicloxacillin sodium cap 500 mg...................................... 2
dicyclomine hcl cap 10 mg (Bentyl)............................... 71
dicyclomine hcl oral soln 10 mg/5ml............................. 71
dicyclomine hcl tab 20 mg (Bentyl)................................ 71
didanosine delayed release capsule 125 mg (Videx
ec)...................................................................................... 10
ec)...................................................................................... 10
ec)...................................................................................... 10
ec)...................................................................................... 10
DIFFERIN – adapalene cream 0.1%................................144
DIFFERIN – adapalene gel 0.1%..................................... 144
DIFFERIN – adapalene gel 0.3%..................................... 144
DIFFERIN – adapalene lotion 0.1%................................. 144
DIFICID – fidaxomicin tab 200 mg....................................... 3
DIFLORASONE DIACETATE – diflorasone diacetate
cream 0.05%................................................................... 149
DIFLORASONE DIACETATE – diflorasone diacetate oint
0.05%............................................................................... 149
DIFLUCAN – fluconazole for susp 10 mg/ml....................... 7
DIFLUCAN – fluconazole for susp 40 mg/ml....................... 7
DIFLUCAN – fluconazole tab 50 mg.................................... 7
DIFLUCAN – fluconazole tab 100 mg.................................. 7
diflunisal tab 500 mg........................................................ 98
DIGOXIN – digoxin oral soln 0.05 mg/ml........................... 61
digoxin tab 125 mcg (0.125 mg) (Lanoxin).................... 62
digoxin tab 250 mcg (0.25 mg) (Lanoxin)...................... 62
DIHYDROERGOTAMINE MESYLAT – dihydroergotamine
mesylate nasal spray 4 mg/ml........................................ 107
dihydroergotamine mesylate inj 1 mg/ml (D.h.e.
45).................................................................................... 107
DILANTIN INFATABS – phenytoin chew tab 50 mg......... 110
DILANTIN – phenytoin sodium extended cap 30 mg....... 110
DILANTIN – phenytoin sodium extended cap 100 mg..... 110
DILANTIN-125 – phenytoin susp 125 mg/5ml................. 110
DILATRATE SR – isosorbide dinitrate cap cr 40 mg.......... 53
DILAUDID – hydromorphone hcl liqd 1 mg/ml................... 99
diltiazem hcl cap sr 12hr 60 mg......................................50
diltiazem hcl cap sr 12hr 90 mg......................................50
diltiazem hcl cap sr 12hr 120 mg....................................50
diltiazem hcl coated beads cap sr 24hr 120 mg
(Cardizem cd)................................................................... 50
(Cardizem cd)................................................................... 51
(Cardizem cd)................................................................... 51
(Cardizem cd)................................................................... 51
(Cardizem cd)................................................................... 51
diltiazem hcl coated beads tab sr 24hr 180 mg
(Cardizem la).................................................................... 51
(Cardizem la).................................................................... 51
(Cardizem la).................................................................... 51
(Cardizem la).................................................................... 51
(Cardizem la).................................................................... 51
diltiazem hcl extended release beads cap sr 24hr 120
mg (Tiazac)....................................................................... 51
mg (Tiazac)....................................................................... 51
mg (Tiazac)....................................................................... 51
174
2016
mg (Tiazac)....................................................................... 51
mg (Tiazac)....................................................................... 51
mg (Tiazac)....................................................................... 51
diltiazem hcl tab 90 mg.................................................... 51
diltiazem hcl tab 30 mg (Cardizem)................................ 51
diltiazem hcl tab 60 mg (Cardizem)................................ 51
diltiazem hcl tab 120 mg (Cardizem).............................. 51
DIOVAN HCT – valsartan-hydrochlorothiazide tab 80-12.5
mg...................................................................................... 45
DIOVAN HCT – valsartan-hydrochlorothiazide tab
160-12.5 mg...................................................................... 45
DIOVAN HCT – valsartan-hydrochlorothiazide tab 160-25
mg...................................................................................... 45
DIOVAN HCT – valsartan-hydrochlorothiazide tab
320-12.5 mg...................................................................... 45
DIOVAN HCT – valsartan-hydrochlorothiazide tab 320-25
mg...................................................................................... 45
DIOVAN – valsartan tab 40 mg.......................................... 45
DIOVAN – valsartan tab 80 mg.......................................... 45
DIOVAN – valsartan tab 160 mg........................................ 45
DIOVAN – valsartan tab 320 mg........................................ 45
DIPENTUM – olsalazine sodium cap 250 mg.................... 75
diphenhydramine hcl cap 50 mg.................................... 64
diphenhydramine hcl elixir 12.5 mg/5ml........................ 64
DIPHENOXYLATE/ATROPINE – diphenoxylate w/
atropine liq 2.5-0.025 mg/5ml........................................... 70
diphenoxylate w/ atropine tab 2.5-0.025 mg
(Lomotil)............................................................................ 70
DIPHTHERIA/TETANUS TOXOID – diphtheria-tetanus tox
adsorbed (dt) im inj 25-5 unit/0.5ml..................................15
DIPROLENE AF – betamethasone dipropionate
augmented cream 0.05%................................................ 149
DIPROLENE – betamethasone dipropionate augmented
lotion 0.05%..................................................................... 149
DIPROLENE – betamethasone dipropionate augmented
oint 0.05%........................................................................ 149
dipyridamole tab 25 mg (Persantine)........................... 130
DISALCID – salsalate tab 500 mg..................................... 98
DISALCID – salsalate tab 750 mg..................................... 98
disopyramide phosphate cap 100 mg (Norpace).......... 59
disopyramide phosphate cap 150 mg (Norpace).......... 59
disulfiram tab 250 mg (Antabuse).................................. 95
disulfiram tab 500 mg (Antabuse).................................. 95
DIURIL – chlorothiazide susp 250 mg/5ml.........................58
divalproex sodium cap delayed release sprinkle 125
mg (Depakote sprinkles).............................................. 110
divalproex sodium tab delayed release 125 mg
(Depakote)...................................................................... 110
(Depakote)...................................................................... 110
(Depakote)...................................................................... 110
divalproex sodium tab sr 24 hr 250 mg (Depakote
er)..................................................................................... 110
divalproex sodium tab sr 24 hr 500 mg (Depakote
er)..................................................................................... 110
DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%)........... 25
DIVIGEL – estradiol td gel 0.5 mg/0.5gm (0.1%)............... 25
DIVIGEL – estradiol td gel 1 mg/gm (0.1%).......................25
dofetilide cap 125 mcg (0.125 mg) (Tikosyn).................59
dofetilide cap 250 mcg (0.25 mg) (Tikosyn)...................59
dofetilide cap 500 mcg (0.5 mg) (Tikosyn).....................59
DOLOPHINE – methadone hcl tab 5 mg........................... 99
DOLOPHINE – methadone hcl tab 10 mg......................... 99
donepezil hydrochloride orally disintegrating tab 5
mg...................................................................................... 95
donepezil hydrochloride orally disintegrating tab 10
mg...................................................................................... 95
donepezil hydrochloride tab 5 mg (Aricept).................. 95
donepezil hydrochloride tab 10 mg (Aricept)................ 95
donepezil hydrochloride tab 23 mg (Aricept)................ 95
dorzolamide hcl ophth soln 2% (Trusopt)................... 140
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8
mg/ml (Cosopt).............................................................. 140
DOTHELLE DHA – prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg............................................................ 120
DOVONEX – calcipotriene cream 0.005%....................... 151
doxazosin mesylate tab 1 mg (Cardura)........................ 62
doxepin hcl cap 10 mg..................................................... 81
doxepin hcl cap 100 mg................................................... 81
doxepin hcl cap 150 mg................................................... 81
doxepin hcl conc 10 mg/ml............................................. 81
DOXEPIN HCL – doxepin hcl cap 75 mg.......................... 81
DOXEPIN HYDROCHLORIDE – doxepin hcl cream
5%.................................................................................... 151
doxercalciferol cap 0.5 mcg (Hectorol).......................... 39
doxercalciferol cap 1 mcg (Hectorol)............................. 40
doxercalciferol cap 2.5 mcg (Hectorol).......................... 40
doxycycline hyclate cap 50 mg.........................................4
doxycycline hyclate cap 100 mg (Vibramycin)................ 4
doxycycline hyclate tab delayed release 75 mg............. 4
doxycycline hyclate tab delayed release 100 mg........... 4
doxycycline hyclate tab delayed release 150 mg........... 4
doxycycline hyclate tab delayed release 50 mg
(Doryx)................................................................................. 4
doxycycline hyclate tab delayed release 200 mg
(Doryx)................................................................................. 4
doxycycline hyclate tab 20 mg......................................... 4
doxycycline hyclate tab 100 mg....................................... 4
doxycycline monohydrate cap 50 mg.............................. 4
doxycycline monohydrate cap 150 mg (Adoxa).............. 4
175
2016
doxycycline monohydrate cap 75 mg (Monodox)........... 4
doxycycline monohydrate cap 100 mg (Monodox)......... 4
doxycycline monohydrate for susp 25 mg/5ml
(Vibramycin)....................................................................... 4
doxycycline monohydrate tab 50 mg (Adoxa)................ 4
doxycycline monohydrate tab 75 mg (Adoxa)................ 4
doxycycline monohydrate tab 100 mg (Adoxa pak
1/100)................................................................................... 4
doxycycline monohydrate tab 150 mg (Adoxa pak
1/150)................................................................................... 4
dronabinol cap 2.5 mg (Marinol)..................................... 72
dronabinol cap 5 mg (Marinol)........................................ 73
dronabinol cap 10 mg (Marinol)...................................... 73
DROXIA – hydroxyurea cap 200 mg................................130
DUAC – clindamycin phosph-benzoyl peroxide (refrig) gel
1.2 (1)-5%........................................................................ 145
DUAVEE – conjugated estrogens-bazedoxifene tab
0.45-20 mg........................................................................ 25
DUETACT – pioglitazone hcl-glimepiride tab 30-2 mg....... 31
DUETACT – pioglitazone hcl-glimepiride tab 30-4 mg....... 31
DUET DHA BALANCED – prenat w/fe poly-na fered-fa tab
25-1 & omega cap 267 mg............................................. 120
DUET DHA 400 – prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 400 mg......................................................... 120
DULERA – mometasone furoate-formoterol fumarate
aerosol 100-5 mcg/act...................................................... 67
DULERA – mometasone furoate-formoterol fumarate
aerosol 200-5 mcg/act...................................................... 67
duloxetine hcl enteric coated pellets cap 20 mg
(Cymbalta)........................................................................ 81
(Cymbalta)........................................................................ 81
(Cymbalta)........................................................................ 81
DUREZOL – difluprednate ophth emulsion 0.05%.......... 138
dutasteride cap 0.5 mg (Avodart)................................... 78
dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn)....... 78
DUTOPROL – metoprolol & hydrochlorothiazide tab sr
24hr 25-12.5 mg................................................................ 48
24hr 50-12.5 mg................................................................ 48
24hr 100-12.5 mg.............................................................. 48
DYANAVEL XR – amphetamine extended release susp
2.5 mg/ml........................................................................... 91
DYAZIDE – triamterene & hydrochlorothiazide cap 37.5-25
mg...................................................................................... 58
dyphylline-guaifenesin liqd 100-100 mg/5ml................. 67
DYRENIUM – triamterene cap 50 mg................................ 58
DYRENIUM – triamterene cap 100 mg.............................. 58
E
EC-NAPROSYN – naproxen tab ec 375 mg.................... 104
EC-NAPROSYN – naproxen tab ec 500 mg.................... 105
econazole nitrate cream 1%.......................................... 146
EDARBI – azilsartan medoxomil tab 40 mg....................... 45
EDARBI – azilsartan medoxomil tab 80 mg....................... 45
EDARBYCLOR – azilsartan medoxomil-chlorthalidone tab
40-12.5 mg........................................................................ 45
EDARBYCLOR – azilsartan medoxomil-chlorthalidone tab
40-25 mg............................................................................45
EDECRIN – ethacrynic acid tab 25 mg.............................. 58
EDURANT – rilpivirine hcl tab 25 mg (base
equivalent)......................................................................... 10
E.E.S. 400 – erythromycin ethylsuccinate tab 400 mg........ 3
E.E.S. GRANULES – erythromycin ethylsuccinate for susp
200 mg/5ml.......................................................................... 3
EFFER-K – potassium bicarbonate-citric acid effer tab 10
meq.................................................................................. 127
EFFER-K – potassium bicarbonate-citric acid effer tab 20
meq.................................................................................. 127
EFFIENT – prasugrel hcl tab 5 mg (base equiv)............. 130
EFFIENT – prasugrel hcl tab 10 mg (base equiv)........... 130
EFUDEX – fluorouracil cream 5%.................................... 151
EGRIFTA – tesamorelin acetate for inj 1 mg (base
equiv)................................................................................. 37
EGRIFTA – tesamorelin acetate for inj 2 mg (base
equiv)................................................................................. 37
ELAVIL – amitriptyline hcl tab 25 mg................................. 81
ELDEPRYL – selegiline hcl cap 5 mg.............................. 115
ELESTAT – epinastine hcl ophth soln 0.05%................... 141
ELESTRIN – estradiol gel 0.06% (0.52 mg/0.87 gm
metered-dose pump)......................................................... 25
ELIDEL – pimecrolimus cream 1%.................................. 151
ELIMITE – permethrin cream 5%..................................... 151
ELIPHOS – calcium acetate (phosphate binder) tab 667
mg...................................................................................... 75
ELIQUIS – apixaban tab 2.5 mg...................................... 130
ELIQUIS – apixaban tab 5 mg......................................... 130
ELITE-OB – prenatal vit w/ iron carbonyl-fa tab 50-1.25
mg.................................................................................... 120
ELIXOPHYLLIN – theophylline elixir 80 mg/15ml.............. 67
ELLA – ulipristal acetate tab 30 mg................................... 27
ELMIRON – pentosan polysulfate sodium caps 100
mg...................................................................................... 78
ELOCON – mometasone furoate cream 0.1%.................149
ELOCON – mometasone furoate oint 0.1%..................... 149
ELOCON – mometasone furoate solution 0.1%
(lotion).............................................................................. 149
ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj
250 unit............................................................................ 134
500 unit............................................................................ 134
750 unit............................................................................ 134
1000 unit.......................................................................... 134
1500 unit.......................................................................... 134
176
2016
2000 unit.......................................................................... 134
3000 unit.......................................................................... 134
EMADINE – emedastine difumarate ophth soln 0.05%
(base equiv)..................................................................... 141
EMBEDA – morphine-naltrexone cap cr 20-0.8 mg........... 99
EMBEDA – morphine-naltrexone cap cr 50-2 mg.............. 99
EMBEDA – morphine-naltrexone cap cr 100-4 mg............ 99
EMCYT – estramustine phosphate sodium cap 140
mg...................................................................................... 18
EMEND – aprepitant capsule 40 mg..................................73
EMEND – aprepitant capsule 80 mg..................................73
EMEND – aprepitant capsule 125 mg................................73
EMEND – aprepitant capsule therapy pack 80 & 125
mg...................................................................................... 73
EMSAM – selegiline td patch 24hr 6 mg/24hr................... 81
EMSAM – selegiline td patch 24hr 9 mg/24hr................... 81
EMSAM – selegiline td patch 24hr 12 mg/24hr................. 81
EMTRIVA – emtricitabine caps 200 mg............................. 10
EMTRIVA – emtricitabine soln 10 mg/ml........................... 10
EMVERM – mebendazole chew tab 100 mg..................... 13
ENABLEX – darifenacin hydrobromide tab sr 24hr 7.5 mg
(base equiv)....................................................................... 77
ENABLEX – darifenacin hydrobromide tab sr 24hr 15 mg
(base equiv)....................................................................... 77
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg...................................................................................... 43
enalapril maleate & hydrochlorothiazide tab 10-25 mg
(Vaseretic)......................................................................... 43
enalapril maleate tab 2.5 mg (Vasotec).......................... 43
enalapril maleate tab 5 mg (Vasotec)............................. 43
enalapril maleate tab 10 mg (Vasotec)........................... 43
enalapril maleate tab 20 mg (Vasotec)........................... 43
ENBRACE HR – prenatal vit w/ fe gly cys-fa-omega 3 fatty
acids cap......................................................................... 120
ENBREL – etanercept for subcutaneous inj 25 mg......... 105
ENBREL – etanercept subcutaneous soln prefilled syringe
25 mg/0.5ml..................................................................... 105
ENBREL – etanercept subcutaneous soln prefilled syringe
50 mg/ml.......................................................................... 105
ENBREL SURECLICK – etanercept subcutaneous
solution auto-injector 50 mg/ml.......................................105
ENCARE – nonoxynol-9 vaginal suppos 100 mg.............. 27
ENGERIX-B – hepatitis b vaccine (recombinant) 10
mcg/0.5ml...........................................................................15
ENGERIX-B – hepatitis b vaccine (recombinant) 20 mcg/
ml........................................................................................ 15
ENGERIX-B – hepatitis b vaccine (recombinant) susp 10
mcg/0.5ml...........................................................................15
ENGERIX-B – hepatitis b vaccine (recombinant) susp 20
mcg/ml................................................................................ 15
enoxaparin sodium inj 30 mg/0.3ml (Lovenox)........... 130
enoxaparin sodium inj 100 mg/ml (Lovenox).............. 130
enoxaparin sodium inj 120 mg/0.8ml (Lovenox)......... 130
enoxaparin sodium inj 150 mg/ml (Lovenox).............. 130
enoxaparin sodium inj 300 mg/3ml (Lovenox)............ 130
entacapone tab 200 mg (Comtan).................................115
entecavir tab 0.5 mg (Baraclude)...................................... 8
entecavir tab 1 mg (Baraclude)......................................... 8
ENTEREG – alvimopan cap 12 mg................................... 75
ENTOCORT EC – budesonide delayed release particles
cap 3 mg............................................................................22
ENTRESTO – sacubitril-valsartan tab 24-26 mg............... 62
ENTRESTO – sacubitril-valsartan tab 49-51 mg............... 62
ENTRESTO – sacubitril-valsartan tab 97-103 mg............. 62
ENVARSUS XR – tacrolimus tab sr 24hr 0.75 mg........... 154
ENVARSUS XR – tacrolimus tab sr 24hr 1 mg................ 154
ENVARSUS XR – tacrolimus tab sr 24hr 4 mg................ 154
EPANED – enalapril maleate for oral soln 1 mg/ml........... 43
EPIDUO – adapalene-benzoyl peroxide gel 0.1-2.5%..... 145
EPIDUO FORTE – adapalene-benzoyl peroxide gel
0.3-2.5%........................................................................... 145
EPIFOAM – pramoxine-hc aerosol foam 1-1%................ 149
epinastine hcl ophth soln 0.05% (Elestat)................... 141
EPINEPHRINE – epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)........................................................... 64
EPINEPHRINE – epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................. 64
epinephrine hcl inj 1 mg/ml............................................. 67
epinephrine hcl soln prefilled syringe 0.1 mg/ml.......... 67
EPIPEN-JR 2-PAK – epinephrine solution auto-injector
0.15 mg/0.3ml (1:2000)..................................................... 64
EPIPEN 2-PAK – epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................. 64
EPIVIR HBV – lamivudine oral soln 5 mg/ml (hbv).............. 8
EPIVIR HBV – lamivudine tab 100 mg (hbv)....................... 8
EPIVIR – lamivudine oral soln 10 mg/ml........................... 10
EPIVIR – lamivudine tab 150 mg....................................... 10
EPIVIR – lamivudine tab 300 mg....................................... 10
eplerenone tab 25 mg (Inspra)........................................ 62
eplerenone tab 50 mg (Inspra)........................................ 62
EPOGEN – epoetin alfa inj 2000 unit/ml.......................... 130
EPOGEN – epoetin alfa inj 10000 unit/ml........................ 130
EPOGEN – epoetin alfa inj 20000 unit/ml........................ 130
EPROSARTAN MESYLATE – eprosartan mesylate tab
600 mg............................................................................... 45
EPZICOM – abacavir sulfate-lamivudine tab 600-300
mg...................................................................................... 10
EQUETRO – carbamazepine (antipsychotic) cap sr 12hr
100 mg............................................................................... 85
200 mg............................................................................... 85
177
2016
300 mg............................................................................... 85
ergocalciferol cap 50000 unit........................................ 119
ERGOLOID MESYLATES – ergoloid mesylates tab 1
mg...................................................................................... 95
ERGOMAR – ergotamine tartrate sl tab 2 mg................. 107
ERIVEDGE – vismodegib cap 150 mg.............................. 18
ERTACZO – sertaconazole nitrate cream 2%..................146
ERYGEL – erythromycin gel 2%...................................... 145
ERYPED 200 – erythromycin ethylsuccinate for susp 200
mg/5ml..................................................................................3
ERYPED 400 – erythromycin ethylsuccinate for susp 400
mg/5ml..................................................................................3
ERY-TAB – erythromycin tab delayed release 250 mg........ 3
ERYTHROCIN STEARATE – erythromycin stearate tab
250 mg................................................................................. 3
ERYTHROMYCIN BASE – erythromycin tab 250 mg.......... 4
ERYTHROMYCIN BASE – erythromycin tab 500 mg.......... 4
ERYTHROMYCIN ETHYLSUCCINATE – erythromycin
ethylsuccinate tab 400 mg.................................................. 4
erythromycin gel 2% (Erygel)........................................ 145
erythromycin ophth oint 5 mg/gm................................ 137
erythromycin pads 2%................................................... 145
erythromycin soln 2%.................................................... 145
erythromycin w/ delayed release particles cap 250
mg........................................................................................ 4
ESBRIET – pirfenidone cap 267 mg.................................. 69
escitalopram oxalate soln 5 mg/5ml (base equiv)
(Lexapro)........................................................................... 81
escitalopram oxalate tab 5 mg (base equiv)
(Lexapro)........................................................................... 81
(Lexapro)........................................................................... 81
(Lexapro)........................................................................... 82
esomeprazole magnesium cap delayed release 20 mg
(base eq) (Nexium).......................................................... 71
esomeprazole magnesium cap delayed release 40 mg
(base eq) (Nexium).......................................................... 71
ESSENTRA WIPES 9X9" CLEAN – isopropyl alcohol
wipes 70%....................................................................... 151
estazolam tab 1 mg.......................................................... 88
estazolam tab 2 mg.......................................................... 88
esterified estrogens & methyltestosterone tab
0.625-1.25 mg................................................................... 25
esterified estrogens & methyltestosterone tab 1.25-2.5
mg...................................................................................... 25
ESTRACE – estradiol tab 0.5 mg...................................... 25
ESTRACE – estradiol tab 1 mg......................................... 25
ESTRACE – estradiol tab 2 mg......................................... 25
ESTRACE – estradiol vaginal cream 0.1 mg/gm............... 78
estradiol & norethindrone acetate tab 0.5-0.1 mg
(Activella).......................................................................... 25
estradiol & norethindrone acetate tab 1-0.5 mg
(Activella).......................................................................... 25
estradiol tab 0.5 mg (Estrace)......................................... 25
estradiol tab 1 mg (Estrace)............................................ 25
estradiol tab 2 mg (Estrace)............................................ 25
estradiol td patch twice weekly 0.025 mg/24hr (Vivelledot).....................................................................................25
estradiol td patch twice weekly 0.0375 mg/24hr
(Vivelle-dot)...................................................................... 26
estradiol td patch weekly 0.025 mg/24hr (Climara).......26
estradiol td patch weekly 0.05 mg/24hr (Climara).........26
estradiol td patch weekly 0.06 mg/24hr (Climara).........26
estradiol td patch weekly 0.075 mg/24hr (Climara).......26
estradiol td patch weekly 0.1 mg/24hr (Climara)...........26
estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr) (Climara).........................................................26
ESTRING – estradiol vaginal ring 2 mg (7.5
mcg/24hrs)......................................................................... 78
ESTROGEL – estradiol gel 0.06% (0.75 mg/1.25 gm
metered-dose pump)......................................................... 26
ESTROPIPATE – estropipate tab 0.75 mg.........................26
ESTROPIPATE – estropipate tab 1.5 mg...........................26
ESTROPIPATE – estropipate tab 3 mg..............................26
ESTROSTEP FE – norethindrone ac-ethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg..................................................... 27
eszopiclone tab 1 mg (Lunesta)......................................88
ethambutol hcl tab 100 mg (Myambutol)......................... 6
ethambutol hcl tab 400 mg (Myambutol)......................... 6
ethosuximide cap 250 mg (Zarontin)............................110
ethosuximide soln 250 mg/5ml (Zarontin)................... 110
ETIDRONATE DISODIUM – etidronate disodium tab 200
mg...................................................................................... 40
ETIDRONATE DISODIUM – etidronate disodium tab 400
mg...................................................................................... 40
etodolac cap 200 mg...................................................... 105
etodolac cap 300 mg...................................................... 105
etodolac tab 400 mg....................................................... 105
etodolac tab 500 mg....................................................... 105
etodolac tab sr 24hr 400 mg......................................... 105
ETOPOSIDE – etoposide cap 50 mg................................. 18
EURAX – crotamiton cream 10%..................................... 151
EURAX – crotamiton lotion 10%...................................... 151
EVAMIST – estradiol transdermal spray 1.53 mg/
spray...................................................................................26
EVISTA – raloxifene hcl tab 60 mg.................................... 40
EVOCLIN – clindamycin phosphate foam 1%................. 145
178
2016
EVOTAZ – atazanavir sulfate-cobicistat tab 300-150 mg
(base equiv)....................................................................... 10
EVOXAC – cevimeline hcl cap 30 mg............................. 143
EVZIO – naloxone hcl solution auto-injector 0.4
mg/0.4ml.......................................................................... 154
EXALGO – hydromorphone hcl tab er 24hr deter 8 mg..... 99
EXALGO – hydromorphone hcl tab er 24hr deter 12
mg...................................................................................... 99
mg...................................................................................... 99
mg...................................................................................... 99
EXELDERM – sulconazole nitrate cream 1%.................. 146
EXELDERM – sulconazole nitrate solution 1%................146
EXELON – rivastigmine tartrate cap 1.5 mg...................... 95
EXELON – rivastigmine tartrate cap 3 mg......................... 95
EXELON – rivastigmine tartrate cap 4.5 mg...................... 95
EXELON – rivastigmine tartrate cap 6 mg......................... 95
EXELON – rivastigmine td patch 24hr 4.6 mg/24hr........... 95
EXELON – rivastigmine td patch 24hr 9.5 mg/24hr........... 95
EXELON – rivastigmine td patch 24hr 13.3 mg/24hr......... 95
exemestane tab 25 mg (Aromasin)................................. 18
EXFORGE – amlodipine besylate-valsartan tab 5-160
mg...................................................................................... 51
mg...................................................................................... 51
mg...................................................................................... 51
mg...................................................................................... 51
EXFORGE HCT – amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5 mg............................ 45
EXFORGE HCT – amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg............................... 45
EXFORGE HCT – amlodipine-valsartanhydrochlorothiazide tab 10-160-12.5 mg.......................... 45
EXFORGE HCT – amlodipine-valsartanhydrochlorothiazide tab 10-160-25 mg............................. 46
EXFORGE HCT – amlodipine-valsartanhydrochlorothiazide tab 10-320-25 mg............................. 46
EXJADE – deferasirox tab for oral susp 125 mg............. 154
EXTAVIA – interferon beta-1b for inj kit 0.3 mg................. 94
EXTINA – ketoconazole foam 2%.................................... 146
EXTRA-VIRT PLUS DHA – prenatal w/o vit a w/ fe fumdoc-fa-dha cap 29-1.25-350 mg..................................... 120
F
FACTIVE – gemifloxacin mesylate tab 320 mg (base
equiv)....................................................................................5
famciclovir tab 125 mg (Famvir)....................................... 9
famotidine for susp 40 mg/5ml (Pepcid)........................ 71
famotidine tab 20 mg (Pepcid)........................................ 71
famotidine tab 40 mg (Pepcid)........................................ 71
FAMVIR – famciclovir tab 125 mg........................................9
FANAPT – iloperidone tab 4 mg........................................ 85
FANAPT – iloperidone tab 8 mg........................................ 85
FANAPT – iloperidone tab 10 mg...................................... 85
FANAPT – iloperidone tab 12 mg...................................... 85
FANAPT TITRATION PACK – iloperidone tab 1 mg & 2 mg
& 4 mg & 6 mg titration pak............................................. 85
FARESTON – toremifene citrate tab 60 mg (base
equivalent)......................................................................... 18
FARXIGA – dapagliflozin propanediol tab 5 mg (base
equivalent)......................................................................... 31
FARXIGA – dapagliflozin propanediol tab 10 mg (base
equivalent)......................................................................... 31
FARYDAK – panobinostat lactate cap 10 mg (base
equivalent)......................................................................... 18
equivalent)......................................................................... 18
equivalent)......................................................................... 18
FAZACLO – clozapine orally disintegrating tab 12.5
mg...................................................................................... 85
FAZACLO – clozapine orally disintegrating tab 25 mg...... 85
FAZACLO – clozapine orally disintegrating tab 100
mg...................................................................................... 85
mg...................................................................................... 85
mg...................................................................................... 85
FC FEMALE CONDOM – condoms - female..................... 27
FC2 FEMALE CONDOM – condoms - female................... 28
FEIBA – antiinhibitor coagulant complex for inj............... 134
felbamate susp 600 mg/5ml (Felbatol)......................... 110
felbamate tab 400 mg (Felbatol)................................... 110
felbamate tab 600 mg (Felbatol)................................... 110
FELBATOL – felbamate susp 600 mg/5ml....................... 110
FELBATOL – felbamate tab 400 mg................................ 110
FELBATOL – felbamate tab 600 mg................................ 110
FELDENE – piroxicam cap 10 mg................................... 105
FELDENE – piroxicam cap 20 mg................................... 105
felodipine tab sr 24hr 2.5 mg.......................................... 51
felodipine tab sr 24hr 5 mg............................................. 51
felodipine tab sr 24hr 10 mg........................................... 51
FEMCAP – cervical cap 22 mm......................................... 28
FEMCON FE – norethindrone & ethinyl estradiol-fe chew
tab 0.4 mg-35 mcg............................................................ 28
FEMHRT LOW DOSE – norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg............................................ 26
FEM PH – acetic acid-oxyquinoline vaginal gel
0.9-0.025%......................................................................... 78
FEMRING – estradiol acetate vaginal ring 0.05
mg/24hr.............................................................................. 78
179
2016
FEMRING – estradiol acetate vaginal ring 0.1
mg/24hr.............................................................................. 78
FENOFIBRATE – fenofibrate cap 50 mg........................... 55
FENOFIBRATE – fenofibrate cap 150 mg......................... 55
fenofibrate micronized cap 43 mg.................................. 55
fenofibrate micronized cap 130 mg................................ 55
fenofibrate micronized cap 67 mg (Lofibra).................. 55
fenofibrate micronized cap 134 mg (Lofibra)................ 55
fenofibrate micronized cap 200 mg (Lofibra)................ 55
fenofibrate tab 40 mg (Fenoglide).................................. 55
fenofibrate tab 120 mg (Fenoglide)................................ 55
fenofibrate tab 54 mg (Lofibra)....................................... 55
fenofibrate tab 160 mg (Lofibra)..................................... 55
fenofibrate tab 48 mg (Tricor)......................................... 55
fenofibrate tab 145 mg (Tricor)....................................... 55
FENOFIBRIC ACID – fenofibric acid tab 35 mg................ 55
FENOFIBRIC ACID – fenofibric acid tab 105 mg.............. 55
FENOPROFEN CALCIUM – fenoprofen calcium cap 200
mg.................................................................................... 105
FENOPROFEN CALCIUM – fenoprofen calcium cap 400
mg.................................................................................... 105
FENOPROFEN CALCIUM – fenoprofen calcium tab 600
mg.................................................................................... 105
FENORTHO – fenoprofen calcium cap 200 mg...............105
FENORTHO – fenoprofen calcium cap 400 mg...............105
fentanyl citrate lozenge on a handle 200 mcg
(Actiq)................................................................................ 99
(Actiq)................................................................................ 99
(Actiq)................................................................................ 99
(Actiq)................................................................................ 99
(Actiq).............................................................................. 100
(Actiq).............................................................................. 100
FENTANYL – fentanyl td patch 72hr 37.5 mcg/hr.............. 99
fentanyl td patch 72hr 12 mcg/hr (Duragesic)............. 100
fentanyl td patch 72hr 100 mcg/hr (Duragesic)........... 100
FERRIPROX – deferiprone oral soln 100 mg/ml............. 154
FERRIPROX – deferiprone tab 500 mg........................... 154
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental
fe)..................................................................................... 130
FERROUS SULFATE – ferrous sulfate liquid 220 mg/5ml
(44 mg/5ml elemental fe)................................................ 130
ferrous sulfate soln 75 mg/ml (15 mg/ml elemental
fe)..................................................................................... 130
FETZIMA – levomilnacipran hcl cap sr 24hr 20 mg (base
equivalent)......................................................................... 82
equivalent)......................................................................... 82
equivalent)......................................................................... 82
equivalent)......................................................................... 82
FETZIMA TITRATION PACK – levomilnacipran hcl cap sr
24hr 20 & 40 mg therapy pack......................................... 82
FIBRICOR – fenofibric acid tab 35 mg.............................. 55
FIBRICOR – fenofibric acid tab 105 mg............................ 55
FINACEA – azelaic acid foam 15%................................. 145
FINACEA – azelaic acid gel 15%.....................................145
finasteride tab 5 mg (Proscar)........................................ 78
FIORINAL/CODEINE #3 – butalbital-aspirin-caff w/
codeine cap 50-325-40-30 mg........................................100
FIRAZYR – icatibant acetate inj 30 mg/3ml (base
equivalent)....................................................................... 130
FLAGYL ER – metronidazole tab sr 24hr 750 mg............. 14
FLAGYL – metronidazole cap 375 mg............................... 14
FLAGYL – metronidazole tab 250 mg................................14
FLAGYL – metronidazole tab 500 mg................................14
FLAREX – fluorometholone acetate ophth susp
0.1%................................................................................. 138
flavoxate hcl tab 100 mg..................................................77
flecainide acetate tab 50 mg........................................... 59
flecainide acetate tab 100 mg......................................... 59
flecainide acetate tab 150 mg......................................... 59
FLOMAX – tamsulosin hcl cap 0.4 mg.............................. 78
FLORIVA – sodium fluoride-vitamin d liqd drops 0.25 mg/
ml-400 unit/ml.................................................................. 127
FLOVENT DISKUS – fluticasone propionate aer pow ba
50 mcg/blister.................................................................... 67
100 mcg/blister.................................................................. 67
250 mcg/blister.................................................................. 67
FLOVENT HFA – fluticasone propionate hfa inhal aer 110
mcg/act (125/valve)........................................................... 67
FLOVENT HFA – fluticasone propionate hfa inhal aer 220
mcg/act (250/valve)........................................................... 68
FLOVENT HFA – fluticasone propionate hfa inhal aero 44
mcg/act (50/valve)............................................................. 67
fluconazole for susp 10 mg/ml (Diflucan)........................ 7
fluconazole for susp 40 mg/ml (Diflucan)........................ 7
fluconazole tab 50 mg (Diflucan)...................................... 7
fluconazole tab 100 mg (Diflucan).................................... 7
flucytosine cap 250 mg (Ancobon)...................................7
flucytosine cap 500 mg (Ancobon)...................................7
fludrocortisone acetate tab 0.1 mg.................................22
FLUMADINE – rimantadine hydrochloride tab 100 mg...... 13
flunisolide nasal soln 25 mcg/act (0.025%)................... 65
fluocinolone acetonide cream 0.01%........................... 149
fluocinolone acetonide cream 0.025% (Synalar)......... 149
180
2016
fluocinolone acetonide oil 0.01% (body oil) (Dermasmoothe/fs bod)............................................................ 149
fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca)............................................................. 149
fluocinolone acetonide oint 0.025% (Synalar)............. 149
fluocinolone acetonide (otic) oil 0.01% (Dermotic)..... 142
fluocinolone acetonide soln 0.01% (Synalar).............. 149
fluocinonide cream 0.05%............................................. 149
fluocinonide cream 0.1% (Vanos)................................. 149
fluocinonide emulsified base cream 0.05%................. 149
fluocinonide gel 0.05%................................................... 149
fluocinonide oint 0.05%..................................................149
fluocinonide soln 0.05%................................................. 149
FLUORABON – sodium fluoride soln 0.25 mg/0.6ml (from
0.55 mg/0.6ml naf).......................................................... 127
FLUOR-A-DAY – sodium fluoride-xylitol chew tab 0.55
(0.25 mg f)-236.79 mg.................................................... 127
FLUOR-A-DAY – sodium fluoride-xylitol chew tab 2.2 (1
mg f)-236.79 mg.............................................................. 127
fluorometholone ophth susp 0.1% (Fml liquifilm)...... 138
FLUOROPLEX – fluorouracil cream 1%.......................... 152
fluorouracil cream 5% (Efudex).................................... 152
FLUOROURACIL – fluorouracil cream 0.5%................... 152
fluorouracil soln 2%....................................................... 152
fluorouracil soln 5%....................................................... 152
FLUOXETINE – fluoxetine hcl (pmdd) cap 10 mg............. 95
FLUOXETINE – fluoxetine hcl (pmdd) cap 20 mg............. 95
fluoxetine hcl cap delayed release 90 mg (Prozac
weekly).............................................................................. 82
fluoxetine hcl cap 10 mg (Prozac).................................. 82
FLUOXETINE HCL – fluoxetine hcl tab 60 mg.................. 82
fluoxetine hcl solution 20 mg/5ml.................................. 82
fluoxetine hcl tab 10 mg.................................................. 82
fluoxetine hcl tab 20 mg.................................................. 82
FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5
mg/5ml............................................................................... 85
FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/
ml........................................................................................ 85
fluphenazine hcl tab 1 mg............................................... 85
fluphenazine hcl tab 2.5 mg............................................ 85
fluphenazine hcl tab 5 mg............................................... 85
fluphenazine hcl tab 10 mg............................................. 85
FLURA-DROPS – sodium fluoride soln 0.25 mg/drop f
(from 0.55 mg/drop naf).................................................. 127
flurandrenolide cream 0.05% (Cordran)....................... 149
FLURAZEPAM HCL – flurazepam hcl cap 15 mg..............88
FLURAZEPAM HCL – flurazepam hcl cap 30 mg..............88
flurbiprofen sodium ophth soln 0.03% (Ocufen)......... 141
flurbiprofen tab 50 mg................................................... 105
flurbiprofen tab 100 mg................................................. 105
flutamide cap 125 mg....................................................... 18
fluticasone propionate cream 0.05% (Cutivate).......... 149
fluticasone propionate lotion 0.05% (Cutivate)........... 149
fluticasone propionate nasal susp 50 mcg/act............. 65
fluticasone propionate oint 0.005%.............................. 149
FLU VACCINES.................................................................. 15
fluvastatin sodium cap 20 mg......................................... 55
fluvastatin sodium cap 40 mg......................................... 55
fluvastatin sodium tab sr 24 hr 80 mg (Lescol xl).........55
fluvoxamine maleate cap sr 24hr 100 mg...................... 82
fluvoxamine maleate cap sr 24hr 150 mg...................... 82
fluvoxamine maleate tab 25 mg...................................... 82
fluvoxamine maleate tab 50 mg...................................... 82
fluvoxamine maleate tab 100 mg.................................... 82
FML – fluorometholone ophth oint 0.1%.......................... 138
FML FORTE – fluorometholone ophth susp 0.25%......... 138
FML LIQUIFILM – fluorometholone ophth susp 0.1%......138
FOCALGIN CA – prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 300 mg pack..................................................... 120
FOCALGIN 90 DHA – prenat w/o a w/fecbn-fegl-dss-fa tab
90 &dha cap 300mg pak................................................ 120
FOCALIN – dexmethylphenidate hcl tab 2.5 mg................91
FOCALIN – dexmethylphenidate hcl tab 5 mg.................. 91
FOCALIN – dexmethylphenidate hcl tab 10 mg.................91
FOCALIN XR – dexmethylphenidate hcl cap sr 24 hr 5
mg...................................................................................... 91
mg...................................................................................... 91
mg...................................................................................... 91
mg...................................................................................... 91
mg...................................................................................... 91
mg...................................................................................... 91
mg...................................................................................... 91
mg...................................................................................... 91
FOLCAL DHA – prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 27-1.25-300 mg........................................................ 120
FOLCAPS OMEGA 3 – prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg................................................. 120
FOLET DHA – prenat w/fecbn-bisg-methylf-dss tab dr &
dha cap pak..................................................................... 120
FOLET ONE – prenat w/o a w/fecbn-bisg-methylf-dss-dha
cap 38-1-225 mg............................................................. 120
folic acid tab 400 mcg.................................................... 130
folic acid tab 800 mcg.................................................... 130
folic acid tab 1 mg.......................................................... 130
FOLIVANE-F – fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe)......................................131
FOLIVANE-OB – prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg................................................................. 120
fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml
(Arixtra)........................................................................... 131
fondaparinux sodium subcutaneous inj 5 mg/0.4ml
(Arixtra)........................................................................... 131
181
2016
fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml
(Arixtra)........................................................................... 131
fondaparinux sodium subcutaneous inj 10 mg/0.8ml
(Arixtra)........................................................................... 131
FORFIVO XL – bupropion hcl tab sr 24hr 450 mg............. 82
FORTEO – teriparatide (recombinant) inj 600
mcg/2.4ml...........................................................................40
FORTICAL – calcitonin (salmon) nasal soln 200 unit/
act....................................................................................... 40
FOSAMAX – alendronate sodium tab 70 mg..................... 40
FOSAMAX PLUS D – alendronate sodium-cholecalciferol
tab 70-2800 mg-unit.......................................................... 40
FOSAMAX PLUS D – alendronate sodium-cholecalciferol
tab 70-5600 mg-unit.......................................................... 40
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg...................................................................................... 43
fosinopril sodium & hydrochlorothiazide tab 20-12.5
mg...................................................................................... 43
fosinopril sodium tab 10 mg........................................... 43
FOSRENOL – lanthanum carbonate chew tab 500 mg
(elemental)......................................................................... 75
(elemental)......................................................................... 75
(elemental)......................................................................... 75
FOSRENOL – lanthanum carbonate oral powder pack 750
mg (elemental)...................................................................75
FOSRENOL – lanthanum carbonate oral powder pack
1000 mg (elemental)......................................................... 75
FRAGMIN – dalteparin sodium inj 10000 unit/ml............. 131
FRAGMIN – dalteparin sodium inj 2500 unit/0.2ml.......... 131
FRAGMIN – dalteparin sodium inj 12500 unit/0.5ml........ 131
FRAGMIN – dalteparin sodium inj 18000 unit/0.72ml...... 131
FROVA – frovatriptan succinate tab 2.5 mg (base
equivalent)....................................................................... 107
frovatriptan succinate tab 2.5 mg (base equivalent)
(Frova)............................................................................. 107
FULYZAQ – crofelemer tab delayed release 125 mg........ 70
FURADANTIN – nitrofurantoin susp 25 mg/5ml................ 76
FUROSEMIDE – furosemide oral soln 8 mg/ml................. 58
furosemide oral soln 10 mg/ml....................................... 58
furosemide tab 20 mg (Lasix)......................................... 58
FUZEON – enfuvirtide for inj 90 mg...................................10
FYCOMPA – perampanel tab 2 mg................................. 110
FYCOMPA – perampanel tab 10 mg............................... 110
FYCOMPA – perampanel tab 12 mg............................... 110
G
gabapentin cap 100 mg (Neurontin)............................. 110
gabapentin oral soln 250 mg/5ml (Neurontin)............. 110
gabapentin tab 600 mg (Neurontin).............................. 111
gabapentin tab 800 mg (Neurontin).............................. 111
GABITRIL – tiagabine hcl tab 2 mg................................. 111
GABITRIL – tiagabine hcl tab 4 mg................................. 111
GABITRIL – tiagabine hcl tab 12 mg............................... 111
GABITRIL – tiagabine hcl tab 16 mg............................... 111
galantamine hydrobromide cap sr 24hr 8 mg
(Razadyne er)................................................................... 95
(Razadyne er)................................................................... 95
(Razadyne er)................................................................... 95
GALANTAMINE HYDROBROMIDE – galantamine
hydrobromide oral soln 4 mg/ml....................................... 95
galantamine hydrobromide tab 4 mg (Razadyne)......... 95
galantamine hydrobromide tab 8 mg (Razadyne)......... 95
galantamine hydrobromide tab 12 mg (Razadyne)....... 95
GALZIN – zinc acetate cap 25 mg (elemental zinc).........127
GALZIN – zinc acetate cap 50 mg (elemental zinc).........127
GAMMAGARD LIQUID – immune globulin (human) iv or
subcutaneous soln 1 gm/10ml.......................................... 15
subcutaneous soln 2.5 gm/25ml....................................... 15
subcutaneous soln 10 gm/100ml...................................... 15
GAMMAKED – immune globulin (human) iv or
GAMUNEX-C – immune globulin (human) iv or
182
2016
GARDASIL – human papillomavirus (hpv) quadrivalent
recombinant vac inj........................................................... 16
GARDASIL 9 – human papillomavirus (hpv) 9-valent
recomb vac im susp.......................................................... 16
GARDASIL 9 – human papillomavirus (hpv) 9-valent
recomb vac susp pref syr................................................. 16
GASTRINEX NF – hyoscyamine-phenyltoloxamine cap
0.0625-15 mg.................................................................... 71
GASTROCROM – cromolyn sodium oral conc 100
mg/5ml............................................................................... 75
gatifloxacin ophth soln 0.5% (Zymaxid).......................137
GATTEX – teduglutide (rdna) for inj kit 5 mg..................... 75
GELNIQUE – oxybutynin chloride td gel 10%................... 77
gemfibrozil tab 600 mg (Lopid)....................................... 55
GENERESS FE – norethindrone & ethinyl estradiol-fe
chew tab 0.8 mg-25 mcg.................................................. 28
GENOTROPIN MINIQUICK – somatropin for inj 0.2
mg...................................................................................... 37
mg...................................................................................... 37
mg...................................................................................... 38
mg...................................................................................... 38
GENOTROPIN MINIQUICK – somatropin for inj 1 mg...... 38
mg...................................................................................... 38
mg...................................................................................... 38
mg...................................................................................... 38
mg...................................................................................... 38
GENOTROPIN MINIQUICK – somatropin for inj 2 mg...... 38
GENOTROPIN – somatropin for inj 12 mg (13.8 mg
overfill)................................................................................ 37
GENOTROPIN – somatropin for subcutaneous inj 5
mg...................................................................................... 37
GENTAMICIN SULFATE – gentamicin sulfate cream
0.1%................................................................................. 146
GENTAMICIN SULFATE – gentamicin sulfate oint
0.1%................................................................................. 146
gentamicin sulfate ophth oint 0.3%.............................. 137
gentamicin sulfate ophth soln 0.3%............................. 137
GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab
150-150-200-10 mg........................................................... 10
GIAZO – balsalazide disodium tab 1.1 gm........................ 75
GILENYA – fingolimod hcl cap 0.5 mg (base equiv).......... 94
GILOTRIF – afatinib dimaleate tab 20 mg (base
equivalent)......................................................................... 18
equivalent)......................................................................... 18
equivalent)......................................................................... 18
glatiramer acetate soln prefilled syringe 20 mg/ml
(Copaxone)....................................................................... 94
GLEEVEC – imatinib mesylate tab 100 mg (base
equivalent)......................................................................... 18
GLEEVEC – imatinib mesylate tab 400 mg (base
equivalent)......................................................................... 18
GLEOSTINE – lomustine cap 5 mg................................... 18
GLEOSTINE – lomustine cap 10 mg................................. 18
GLEOSTINE – lomustine cap 40 mg................................. 18
GLEOSTINE – lomustine cap 100 mg............................... 18
glimepiride tab 1 mg (Amaryl).........................................31
glipizide-metformin hcl tab 2.5-250 mg.......................... 31
glipizide-metformin hcl tab 2.5-500 mg.......................... 31
glipizide-metformin hcl tab 5-500 mg............................. 31
glipizide tab 5 mg (Glucotrol)..........................................31
glipizide tab 10 mg (Glucotrol)........................................31
glipizide tab sr 24hr 2.5 mg (Glucotrol xl)..................... 31
glipizide tab sr 24hr 5 mg (Glucotrol xl)........................ 31
glipizide tab sr 24hr 10 mg (Glucotrol xl)...................... 31
GLUCAGEN DIAGNOSTIC – glucagon hcl (rdna)
diagnostic for inj 1 mg (base equiv)............................... 153
GLUCAGEN HYPOKIT – glucagon hcl (rdna) for inj 1 mg
(base equiv)....................................................................... 31
GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj
kit 1 mg.............................................................................. 31
GLUCOPHAGE – metformin hcl tab 500 mg..................... 31
GLUCOPHAGE – metformin hcl tab 850 mg..................... 31
GLUCOPHAGE – metformin hcl tab 1000 mg................... 31
GLUCOPHAGE XR – metformin hcl tab sr 24hr 500
mg...................................................................................... 31
GLUCOPHAGE XR – metformin hcl tab sr 24hr 750
mg...................................................................................... 31
GLUCOTROL – glipizide tab 5 mg.....................................31
GLUCOTROL – glipizide tab 10 mg...................................31
GLUCOTROL XL – glipizide tab sr 24hr 2.5 mg................ 31
GLUCOTROL XL – glipizide tab sr 24hr 5 mg................... 31
GLUCOTROL XL – glipizide tab sr 24hr 10 mg................. 31
GLUCOVANCE – glyburide-metformin tab 1.25-250
mg...................................................................................... 31
GLUCOVANCE – glyburide-metformin tab 2.5-500 mg..... 31
GLUCOVANCE – glyburide-metformin tab 5-500 mg........ 32
glyburide-metformin tab 1.25-250 mg
(Glucovance).................................................................... 32
glyburide-metformin tab 2.5-500 mg (Glucovance)...... 32
glyburide-metformin tab 5-500 mg (Glucovance)......... 32
glyburide micronized tab 1.5 mg (Glynase)................... 32
glyburide micronized tab 3 mg (Glynase)...................... 32
glyburide micronized tab 6 mg (Glynase)...................... 32
glyburide tab 1.25 mg.......................................................32
glyburide tab 2.5 mg.........................................................32
glyburide tab 5 mg............................................................32
glycopyrrolate tab 1 mg................................................... 71
183
2016
glycopyrrolate tab 2 mg................................................... 71
GLYNASE – glyburide micronized tab 1.5 mg................... 32
GLYNASE – glyburide micronized tab 3 mg...................... 32
GLYNASE – glyburide micronized tab 6 mg...................... 32
GLYSET – miglitol tab 25 mg............................................. 32
GLYSET – miglitol tab 50 mg............................................. 32
GLYSET – miglitol tab 100 mg........................................... 32
GLYXAMBI – empagliflozin-linagliptin tab 10-5 mg........... 32
GLYXAMBI – empagliflozin-linagliptin tab 25-5 mg........... 32
GOLYTELY – peg 3350-kcl-na bicarb-nacl-na sulfate for
soln 236 gm....................................................................... 70
GOLYTELY – peg 3350-kcl-na bicarb-nacl-na sulfate
packet 227.1 gm................................................................70
GORDOFILM – salicylic & lactic acids soln
16.7-16.7%.......................................................................146
GRALISE – gabapentin (once-daily) tab 300 mg............... 95
GRALISE – gabapentin (once-daily) tab 600 mg............... 95
GRALISE STARTER – gabapentin (once-daily) tab pack
300 mg (9) & 600 mg (69)................................................ 95
granisetron hcl tab 1 mg................................................. 73
GRANIX – tbo-filgrastim soln prefilled syringe 300
mcg/0.5ml........................................................................ 131
GRANIX – tbo-filgrastim soln prefilled syringe 480
mcg/0.8ml........................................................................ 131
griseofulvin microsize susp 125 mg/5ml......................... 7
griseofulvin microsize tab 500 mg................................... 7
griseofulvin ultramicrosize tab 125 mg (Gris-peg)......... 7
griseofulvin ultramicrosize tab 250 mg (Gris-peg)......... 7
GRIS-PEG – griseofulvin ultramicrosize tab 125 mg........... 7
GRIS-PEG – griseofulvin ultramicrosize tab 250 mg........... 7
guanfacine hcl tab 1 mg (Tenex).................................... 62
guanfacine hcl tab 2 mg (Tenex).................................... 62
guanfacine hcl tab sr 24hr 1 mg (base equiv)
(Intuniv)............................................................................. 91
(Intuniv)............................................................................. 91
(Intuniv)............................................................................. 91
(Intuniv)............................................................................. 91
GUANIDINE HCL – guanidine hcl tab 125 mg................ 119
GYNAZOLE-1 – butoconazole nitrate (one dose) vaginal
cream 2%...........................................................................78
H
HALCION – triazolam tab 0.25 mg.................................... 88
halobetasol propionate cream 0.05% (Ultravate)........ 149
halobetasol propionate oint 0.05% (Ultravate)............ 149
haloperidol lactate oral conc 2 mg/ml............................85
haloperidol tab 0.5 mg..................................................... 85
haloperidol tab 1 mg........................................................ 86
haloperidol tab 10 mg...................................................... 86
haloperidol tab 20 mg...................................................... 86
HALOTIN – haloprogin cream 1%....................................146
HARVONI – ledipasvir-sofosbuvir tab 90-400 mg................ 8
HAVRIX – hepatitis a vaccine inj susp 720 el
unit/0.5ml............................................................................16
HAVRIX – hepatitis a vaccine inj susp 1440 el unit/ml....... 16
HECTOROL – doxercalciferol cap 0.5 mcg....................... 40
HECTOROL – doxercalciferol cap 1 mcg.......................... 40
HECTOROL – doxercalciferol cap 2.5 mcg....................... 40
HELIXATE FS – antihemophilic factor (recombinant) for inj
kit 250 unit....................................................................... 134
kit 500 unit....................................................................... 134
kit 1000 unit..................................................................... 134
kit 2000 unit..................................................................... 134
kit 3000 unit..................................................................... 134
HEMANGEOL – propranolol hcl oral soln 4.28 mg/ml....... 48
HEMENATAL OB + DHA – prenat-fe poly cmplx-fe heme
poly-fa tab & omega 3 cap pck...................................... 120
HEMENATAL OB – prenat vit-fe poly cmplx-fe heme polyfa tab 28-6-1 mg............................................................. 120
HEMOFIL M – antihemophilic factor (human) for inj 250
unit....................................................................................134
unit....................................................................................134
unit....................................................................................134
unit....................................................................................134
heparin sodium (porcine) inj 5000 unit/ml................... 131
HEPSERA – adefovir dipivoxil tab 10 mg............................ 8
HETLIOZ – tasimelteon capsule 20 mg............................. 88
HEXALEN – altretamine cap 50 mg...................................18
HIBERIX – haemophilus b polysaccharide conjugate vac
for inj 10 mcg.................................................................... 16
HIPREX – methenamine hippurate tab 1 gm..................... 76
HIZENTRA – immune globulin (human) subcutaneous inj
1 gm/5ml............................................................................ 16
2 gm/10ml.......................................................................... 16
4 gm/20ml.......................................................................... 16
10 gm/50ml........................................................................ 16
homatropine hbr ophth soln 5% (Isopto
homatropine).................................................................. 142
HORIZANT – gabapentin enacarbil tab cr 300 mg............ 96
HORIZANT – gabapentin enacarbil tab cr 600 mg............ 96
H.P. ACTHAR – corticotropin inj gel 80 unit/ml.................. 40
HUMATE-P – antihemophilic factor/vwf (human) for inj
250-600 unit.....................................................................134
500-1200 unit...................................................................134
1000-2400 unit................................................................ 134
184
2016
HUMATROPE COMBO PACK – somatropin for inj 5
mg...................................................................................... 38
HUMATROPE – somatropin for inj 5 mg............................38
HUMATROPE – somatropin for inj 24 mg..........................38
HUMATROPE – somatropin for inj 6 mg (18 unit)............. 38
HUMATROPE – somatropin for inj 12 mg (36 unit)........... 38
HUMIRA – adalimumab prefilled syringe kit 10
mg/0.2ml.......................................................................... 105
mg/0.4ml.......................................................................... 105
mg/0.8ml.......................................................................... 105
HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled
syringe kit 40 mg/0.8ml................................................... 105
HUMIRA PEN – adalimumab pen-injector kit 40
mg/0.8ml.......................................................................... 105
HUMIRA PEN-CROHNS DISEASE – adalimumab peninjector kit 40 mg/0.8ml................................................... 105
HUMIRA PEN-PSORIASIS STAR – adalimumab peninjector kit 40 mg/0.8ml................................................... 105
HUMULIN R U-500 (CONCENTR – insulin regular
(human) inj 500 unit/ml..................................................... 34
HUMULIN R U-500 KWIKPEN – insulin regular (human)
soln pen-injector 500 unit/ml............................................. 34
HYCAMTIN – topotecan hcl cap 0.25 mg (base equiv)..... 18
HYCAMTIN – topotecan hcl cap 1 mg (base equiv).......... 18
hydralazine hcl tab 10 mg............................................... 62
hydralazine hcl tab 100 mg............................................. 62
HYDREA – hydroxyurea cap 500 mg................................ 18
hydrochlorothiazide cap 12.5 mg (Microzide)............... 58
hydrochlorothiazide tab 12.5 mg.................................... 58
hydrochlorothiazide tab 25 mg....................................... 58
hydrochlorothiazide tab 50 mg....................................... 58
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
(Hycet)............................................................................. 100
hydrocodone-acetaminophen soln 10-325 mg/15ml
(Zamicet)......................................................................... 100
hydrocodone-acetaminophen tab 2.5-325 mg............. 100
hydrocodone-acetaminophen tab 7.5-325 mg
(Norco)............................................................................ 100
hydrocodone-acetaminophen tab 5-325 mg
(Norco)............................................................................ 100
(Norco)............................................................................ 100
hydrocodone-acetaminophen tab 7.5-300 mg
(Xodol)............................................................................. 100
(Xodol)............................................................................. 100
(Xodol)............................................................................. 100
hydrocodone-ibuprofen tab 10-200 mg (Ibudone)...... 100
hydrocodone-ibuprofen tab 5-200 mg (Reprexain)..... 100
hydrocodone-ibuprofen tab 7.5-200 mg
(Vicoprofen).................................................................... 100
hydrocodone w/ homatropine syrup 5-1.5 mg/5ml....... 65
hydrocodone w/ homatropine tab 5-1.5 mg................... 65
hydrocod polst-chlorphen polst er susp 10-8 mg/5ml
(Tussionex pennkineti)................................................... 65
hydrocortisone acetate suppos 25 mg........................ 143
hydrocortisone acetate w/ pramoxine rectal cream
1-1% (Analpram-hc singles)......................................... 143
hydrocortisone acetate w/ pramoxine rectal cream
2.5-1% (Analpram-hc singles)......................................143
hydrocortisone butyrate cream 0.1% (Locoid)............ 149
hydrocortisone butyrate hydrophilic lipo base cream
0.1% (Locoid lipocream)...............................................149
hydrocortisone butyrate oint 0.1% (Locoid)................ 149
hydrocortisone butyrate soln 0.1% (Locoid)............... 149
hydrocortisone cream 1%.............................................. 149
hydrocortisone cream 2.5%...........................................149
hydrocortisone enema 100 mg/60ml (Cortenema)...... 143
hydrocortisone lotion 2.5%........................................... 149
hydrocortisone lotion 2% (Ala scalp)........................... 149
hydrocortisone oint 1%.................................................. 149
hydrocortisone oint 2.5%............................................... 149
hydrocortisone rectal cream 2.5% (Anusol-hc).......... 143
hydrocortisone rectal cream 1% (Proctocort)............. 143
hydrocortisone tab 5 mg (Cortef)................................... 22
hydrocortisone tab 10 mg (Cortef)................................. 22
hydrocortisone tab 20 mg (Cortef)................................. 22
hydrocortisone valerate cream 0.2%............................ 150
hydrocortisone valerate oint 0.2% (Westcort)............. 150
hydrocortisone w/ acetic acid otic soln 1-2%............. 142
HYDROMORPHONE HCL ER – hydromorphone hcl tab er
24hr deter 32 mg............................................................ 100
HYDROMORPHONE HCL – hydromorphone hcl suppos 3
mg.................................................................................... 100
hydromorphone hcl liqd 1 mg/ml (Dilaudid)................ 100
hydromorphone hcl tab er 24hr deter 8 mg
(Exalgo)........................................................................... 100
(Exalgo)........................................................................... 100
(Exalgo)........................................................................... 100
hydromorphone hcl tab 2 mg (Dilaudid)...................... 100
hydroxychloroquine sulfate tab 200 mg (Plaquenil)..... 13
hydroxyurea cap 500 mg (Hydrea)................................. 18
hydroxyzine hcl syrup 10 mg/5ml...................................80
hydroxyzine hcl tab 10 mg.............................................. 80
hydroxyzine pamoate cap 25 mg (Vistaril).................... 80
hydroxyzine pamoate cap 50 mg (Vistaril).................... 80
HYDROXYZINE PAMOATE – hydroxyzine pamoate cap
100 mg............................................................................... 80
hyoscyamine sulfate elixir 0.125 mg/5ml....................... 71
hyoscyamine sulfate soln 0.125 mg/ml.......................... 71
hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)...... 71
185
2016
hyoscyamine sulfate tab 0.125 mg (Levsin).................. 71
hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl).......... 71
hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid)..... 71
HYPER-SAL – sodium chloride soln nebu 7%.................. 65
HYPERSAL – sodium chloride soln nebu 3.5%................. 65
HYPERSAL – sodium chloride soln nebu 7%.................... 65
HYQVIA – immun glob inj 2.5 gm/25ml-hyaluron inj 200
unt/1.25 ml kit.................................................................... 16
HYQVIA – immun glob inj 5 gm/50ml-hyaluron inj 400
unt/2.5 ml kit...................................................................... 16
unt/5 ml kit......................................................................... 16
unt/10 ml kit....................................................................... 16
unt/15 ml kit....................................................................... 16
HYZAAR – losartan potassium & hydrochlorothiazide tab
50-12.5 mg........................................................................ 46
100-12.5 mg...................................................................... 46
100-25 mg......................................................................... 46
I
ibandronate sodium tab 150 mg (base equivalent)
(Boniva)............................................................................. 40
IBRANCE – palbociclib cap 75 mg.................................... 18
IBRANCE – palbociclib cap 100 mg.................................. 19
IBRANCE – palbociclib cap 125 mg.................................. 19
ibuprofen susp 100 mg/5ml........................................... 105
ibuprofen tab 400 mg..................................................... 105
ibuprofen tab 600 mg..................................................... 105
ibuprofen tab 800 mg..................................................... 105
ICLUSIG – ponatinib hcl tab 15 mg (base equiv).............. 19
ICLUSIG – ponatinib hcl tab 45 mg (base equiv).............. 19
IDELVION – coagulation factor ix (recomb) (rix-fp) for inj
250 unit............................................................................ 134
500 unit............................................................................ 134
1000 unit.......................................................................... 134
2000 unit.......................................................................... 134
ILEVRO – nepafenac ophth susp 0.3%........................... 142
imatinib mesylate tab 100 mg (base equivalent)
(Gleevec)........................................................................... 19
imatinib mesylate tab 400 mg (base equivalent)
(Gleevec)........................................................................... 19
IMBRUVICA – ibrutinib cap 140 mg...................................19
imipramine hcl tab 10 mg (Tofranil)............................... 82
imipramine pamoate cap 75 mg......................................82
imipramine pamoate cap 100 mg....................................82
imiquimod cream 5% (Aldara)....................................... 152
IMITREX – sumatriptan nasal spray 5 mg/act................. 107
IMITREX – sumatriptan nasal spray 20 mg/act............... 107
IMPAVIDO – miltefosine cap 50 mg................................... 14
IMURAN – azathioprine tab 50 mg.................................. 154
INATAL ADVANCE – prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg..................................................................... 120
INATAL GT – prenatal vit w/ dss-iron carbonyl-fa tab 90-1
mg.................................................................................... 121
INATAL ULTRA – prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg............................................................................121
INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml)......... 38
INCRUSE ELLIPTA – umeclidinium br aero powd breath
act 62.5 mcg/inh (base eq)............................................... 68
indapamide tab 1.25 mg................................................... 58
indapamide tab 2.5 mg..................................................... 58
INDERAL LA – propranolol hcl cap sr 24hr 60 mg............ 48
INDERAL LA – propranolol hcl cap sr 24hr 80 mg............ 48
INDERAL LA – propranolol hcl cap sr 24hr 120 mg.......... 48
INDERAL LA – propranolol hcl cap sr 24hr 160 mg.......... 48
INDERAL XL – propranolol hcl sustained-release beads
cap sr 24hr 80 mg............................................................ 48
INDERAL XL – propranolol hcl sustained-release beads
cap sr 24hr 120 mg.......................................................... 48
INDOCIN – indomethacin suppos 50 mg......................... 105
INDOCIN – indomethacin susp 25 mg/5ml...................... 105
indomethacin cap cr 75 mg........................................... 105
indomethacin cap 25 mg............................................... 105
indomethacin cap 50 mg............................................... 105
INFANATE BALANCE – prenatal w/o a w/fe cbn-dss-fadha cap 29-1-265 mg......................................................121
INFANRIX – diph, acellular pert & tet tox inj 25 lf-58
mcg-10 lf/0.5ml.................................................................. 16
INLYTA – axitinib tab 1 mg................................................. 19
INLYTA – axitinib tab 5 mg................................................. 19
INNOPRAN XL – propranolol hcl sustained-release beads
cap sr 24hr 80 mg............................................................ 48
INNOPRAN XL – propranolol hcl sustained-release beads
cap sr 24hr 120 mg.......................................................... 48
INSPRA – eplerenone tab 25 mg.......................................62
INSPRA – eplerenone tab 50 mg.......................................62
INSULIN PEN NEEDLES – NOVOFINE, NOVOTWIST,
OTHER VARIOUS MANUFACTURERS......................... 153
INTEGRA F – fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe)......................................131
INTELENCE – etravirine tab 25 mg................................... 10
INTELENCE – etravirine tab 100 mg................................. 10
INTELENCE – etravirine tab 200 mg................................. 10
INTRON A – interferon alfa-2b for inj 10000000 unit...... 8,19
INTRON A – interferon alfa-2b inj 6000000 unit/ml........ 8,19
INTRON A – interferon alfa-2b inj 10000000 unit/ml...... 8,19
INTRON A W/DILUENT – interferon alfa-2b for inj
10000000 unit................................................................. 8,19
186
2016
18000000 unit................................................................. 8,19
50000000 unit................................................................. 8,19
INVEGA – paliperidone tab sr 24hr 1.5 mg....................... 86
INVEGA – paliperidone tab sr 24hr 3 mg.......................... 86
INVIRASE – saquinavir mesylate cap 200 mg...................10
INVIRASE – saquinavir mesylate tab 500 mg................... 10
INVOKAMET – canagliflozin-metformin hcl tab 50-500
mg...................................................................................... 32
mg...................................................................................... 32
mg...................................................................................... 32
mg...................................................................................... 32
INVOKANA – canagliflozin tab 100 mg..............................32
INVOKANA – canagliflozin tab 300 mg..............................32
iodoquinol-hc cream 1%................................................ 146
IOPIDINE – apraclonidine hcl ophth soln 0.5% (base
equivalent)....................................................................... 140
IOPIDINE – apraclonidine hcl ophth soln 1% (base
equivalent)....................................................................... 140
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml...... 68
ipratropium bromide inhal soln 0.02%........................... 68
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
(Atrovent).......................................................................... 65
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
(Atrovent).......................................................................... 65
irbesartan-hydrochlorothiazide tab 150-12.5 mg
(Avalide)............................................................................ 46
irbesartan-hydrochlorothiazide tab 300-12.5 mg
(Avalide)............................................................................ 46
irbesartan tab 75 mg (Avapro)........................................ 46
irbesartan tab 150 mg (Avapro)...................................... 46
irbesartan tab 300 mg (Avapro)...................................... 46
IRESSA – gefitinib tab 250 mg.......................................... 19
irrigation solution, physiological.................................. 154
ISENTRESS – raltegravir potassium chew tab 25 mg
(base equiv)....................................................................... 10
ISENTRESS – raltegravir potassium chew tab 100 mg
(base equiv)....................................................................... 10
ISENTRESS – raltegravir potassium packet for susp 100
mg (base equiv)................................................................ 10
ISENTRESS – raltegravir potassium tab 400 mg (base
equiv)................................................................................. 10
isometheptene-caffeine-acetaminophen tab 65-20-325
mg (Prodrin)................................................................... 107
isometheptene-dichloral-acetaminophen cap
65-100-325 mg................................................................ 107
ISONIAZID – isoniazid syrup 50 mg/5ml............................. 6
isoniazid tab 100 mg.......................................................... 6
isoniazid tab 300 mg.......................................................... 6
ISOPTO CARPINE – pilocarpine hcl ophth soln 1%........ 140
ISOSORBIDE DINITRATE ER – isosorbide dinitrate tab cr
40 mg................................................................................. 53
isosorbide dinitrate tab 10 mg........................................ 53
isosorbide dinitrate tab 5 mg (Isordil titradose)........... 53
isosorbide mononitrate tab 10 mg................................. 53
isosorbide mononitrate tab 20 mg................................. 53
isosorbide mononitrate tab sr 24hr 30 mg.................... 53
isosorbide mononitrate tab sr 24hr 60 mg.................... 53
isosorbide mononitrate tab sr 24hr 120 mg.................. 53
isotretinoin cap 10 mg – claravis, myorisan,
zenatane.......................................................................... 145
zenatane.......................................................................... 145
zenatane.......................................................................... 145
zenatane.......................................................................... 145
ISOXSUPRINE HCL – isoxsuprine hcl tab 20 mg............. 62
isoxsuprine hcl tab 10 mg............................................... 62
isradipine cap 2.5 mg....................................................... 51
isradipine cap 5 mg.......................................................... 51
ISTALOL – timolol maleate ophth soln 0.5% (oncedaily)................................................................................. 140
itraconazole cap 100 mg (Sporanox)................................7
ivermectin tab 3 mg (Stromectol)................................... 13
IXINITY – coagulation factor ix (recombinant) for inj 500
unit....................................................................................134
unit....................................................................................135
unit....................................................................................135
J
JADENU – deferasirox tab 90 mg.................................... 154
JADENU – deferasirox tab 180 mg.................................. 154
JADENU – deferasirox tab 360 mg.................................. 154
JAKAFI – ruxolitinib phosphate tab 5 mg (base
equivalent)......................................................................... 19
equivalent)......................................................................... 19
equivalent)......................................................................... 19
equivalent)......................................................................... 19
equivalent)......................................................................... 19
JALYN – dutasteride-tamsulosin hcl cap 0.5-0.4 mg......... 78
JANUMET – sitagliptin-metformin hcl tab 50-500 mg........ 32
JANUMET – sitagliptin-metformin hcl tab 50-1000 mg...... 32
JANUMET XR – sitagliptin-metformin hcl tab sr 24hr
50-500 mg......................................................................... 32
187
2016
50-1000 mg....................................................................... 32
100-1000 mg..................................................................... 32
JANUVIA – sitagliptin phosphate tab 25 mg (base
equiv)................................................................................. 32
equiv)................................................................................. 32
equiv)................................................................................. 32
JENTADUETO – linagliptin-metformin hcl tab 2.5-500
mg...................................................................................... 32
mg...................................................................................... 32
mg...................................................................................... 32
JUXTAPID – lomitapide mesylate cap 5 mg (base
equiv)................................................................................. 55
equiv)................................................................................. 55
equiv)................................................................................. 55
equiv)................................................................................. 55
equiv)................................................................................. 55
equiv)................................................................................. 55
K
KADIAN – morphine sulfate cap sr 24hr 10 mg............... 100
KADIAN – morphine sulfate cap sr 24hr 100 mg............. 101
KADIAN – morphine sulfate cap sr 24hr 200 mg............. 101
KALETRA – lopinavir-ritonavir soln 400-100 mg/5ml
(80-20 mg/ml).................................................................... 10
KALETRA – lopinavir-ritonavir tab 100-25 mg................... 10
KALETRA – lopinavir-ritonavir tab 200-50 mg................... 10
KALYDECO – ivacaftor packet 50 mg............................... 69
KALYDECO – ivacaftor packet 75 mg............................... 69
KALYDECO – ivacaftor tab 150 mg................................... 69
KAPVAY – clonidine hcl tab sr 12hr 0.1 mg....................... 91
KAYEXALATE – sodium polystyrene sulfonate
powder............................................................................. 154
KAZANO – alogliptin-metformin hcl tab 12.5-500 mg........ 32
KAZANO – alogliptin-metformin hcl tab 12.5-1000 mg...... 32
KEFLEX – cephalexin cap 250 mg...................................... 3
KEPPRA – levetiracetam oral soln 100 mg/ml.................111
KEPPRA – levetiracetam tab 250 mg.............................. 111
KEPPRA – levetiracetam tab 1000 mg............................ 111
KEPPRA XR – levetiracetam tab sr 24hr 500 mg............ 111
KEPPRA XR – levetiracetam tab sr 24hr 750 mg............ 111
KERALYT – salicylic acid gel 6%..................................... 146
KERLONE – betaxolol hcl tab 10 mg.................................48
KERLONE – betaxolol hcl tab 20 mg.................................48
KETEK – telithromycin tab 300 mg.................................... 14
KETEK – telithromycin tab 400 mg.................................... 14
ketoconazole cream 2%................................................. 146
ketoconazole foam 2% (Extina).....................................146
ketoconazole shampoo 2% (Nizoral)............................ 146
ketoconazole tab 200 mg................................................... 7
ketoprofen cap 50 mg.................................................... 105
ketoprofen cap 75 mg.................................................... 105
KETOPROFEN ER – ketoprofen cap sr 24hr 200 mg..... 105
ketorolac tromethamine ophth soln 0.5% (Acular)..... 142
ketorolac tromethamine ophth soln 0.4% (Acular
ls)..................................................................................... 142
ketorolac tromethamine tab 10 mg...............................105
KEVEYIS – dichlorphenamide tab 50 mg.......................... 58
KHEDEZLA – desvenlafaxine tab sr 24hr 50 mg............... 82
KHEDEZLA – desvenlafaxine tab sr 24hr 100 mg............. 82
KINERET – anakinra subcutaneous soln prefilled syringe
100 mg/0.67ml................................................................. 106
KINRIX – diph-tetanus tox ad-acell pert & polio virus, ipv
vac inj................................................................................. 16
KITABIS PAK – tobramycin nebu soln 300 mg/5ml............. 6
KLARON – sulfacetamide sodium lotion 10% (acne)...... 145
KLOR-CON M15 – potassium chloride microencapsulated
crys cr tab 15 meq.......................................................... 127
KOATE-DVI – antihemophilic factor (human) for inj 250
unit....................................................................................135
unit....................................................................................135
unit....................................................................................135
KOGENATE FS – antihemophilic factor (recombinant) for
inj kit 250 unit.................................................................. 135
inj kit 500 unit.................................................................. 135
inj kit 1000 unit................................................................ 135
inj kit 2000 unit................................................................ 135
inj kit 3000 unit................................................................ 135
KOGENATE FS BIO-SET – antihemophilic factor
(recombinant) for inj kit 250 unit..................................... 135
(recombinant) for inj kit 500 unit..................................... 135
(recombinant) for inj kit 1000 unit................................... 135
188
2016
KOMBIGLYZE XR – saxagliptin-metformin hcl tab sr 24hr
2.5-1000 mg...................................................................... 33
5-500 mg............................................................................33
5-1000 mg......................................................................... 33
KORLYM – mifepristone tab 300 mg................................. 33
KOVALTRY – antihemophilic factor (recombinant) for inj
250 unit............................................................................ 135
500 unit............................................................................ 135
1000 unit.......................................................................... 135
2000 unit.......................................................................... 135
3000 unit.......................................................................... 135
K-PHOS NEUTRAL – pot phos monobasic w/sod phos di
& monobas tab 155-852-130mg..................................... 127
K-PHOS NO 2 – potassium & sodium acid phosphates tab
305-700 mg....................................................................... 78
K-PHOS – potassium phosphate monobasic tab 500
mg.................................................................................... 127
KRISTALOSE – lactulose oral crystal packet 10 gm......... 70
KRISTALOSE – lactulose oral crystal packet 20 gm......... 70
K-TAB – potassium chloride tab cr 10 meq..................... 127
K-TAB – potassium chloride tab cr 8 meq (600 mg)........ 127
K-TAB – potassium chloride tab cr 20 meq (1500
mg)................................................................................... 127
KUVAN – sapropterin dihydrochloride powder packet 100
mg...................................................................................... 40
KUVAN – sapropterin dihydrochloride powder packet 500
mg...................................................................................... 40
KUVAN – sapropterin dihydrochloride soluble tab 100
mg...................................................................................... 40
KYNAMRO – mipomersen sodium soln prefilled syringe
200 mg/ml.......................................................................... 55
L
labetalol hcl tab 100 mg................................................... 48
LAC-HYDRIN – lactic acid (ammonium lactate) cream
12%.................................................................................. 152
LAC-HYDRIN – lactic acid (ammonium lactate) lotion
12%.................................................................................. 152
LACRISERT – artificial tear ophth insert.......................... 142
lactated ringer's for irrigation....................................... 154
lactic acid (ammonium lactate) cream 12% (Lachydrin)............................................................................. 152
lactic acid (ammonium lactate) lotion 12% (Lachydrin)............................................................................. 152
lactulose (encephalopathy) solution 10 gm/15ml......... 75
lactulose solution 10 gm/15ml........................................ 70
LAMICTAL CHEWABLE DISPERS – lamotrigine tab
chewable dispersible 5 mg............................................. 111
LAMICTAL CHEWABLE DISPERS – lamotrigine tab
chewable dispersible 25 mg........................................... 111
LAMICTAL – lamotrigine tab 25 mg................................. 111
LAMICTAL – lamotrigine tab 100 mg............................... 111
LAMICTAL ODT – lamotrigine orally disintegrating tab 25
mg.................................................................................... 111
mg.................................................................................... 111
mg.................................................................................... 111
mg.................................................................................... 111
LAMICTAL ODT – lamotrigine tab disp 25 (14) & 50 mg
(14) & 100 mg (7) kit...................................................... 111
LAMICTAL ODT – lamotrigine tab disp 25 mg (21) & 50
mg (7) titration kit............................................................ 111
LAMICTAL ODT – lamotrigine tab disp 50 mg (42) & 100
mg (14) titration kit.......................................................... 111
LAMICTAL STARTER/NOT TAKI – lamotrigine tab 25 mg
(42) & 100 mg (7) starter kit........................................... 111
LAMICTAL STARTER/TAKING C – lamotrigine tab 25 mg
(84) & 100 mg (14) starter kit......................................... 111
LAMICTAL STARTER/TAKING V – lamotrigine tab 25 mg
(35) starter kit.................................................................. 111
LAMICTAL XR – lamotrigine tab sr 24hr 25 (14) & 50 mg
(14) & 100 mg(7) kit........................................................ 111
LAMICTAL XR – lamotrigine tab sr 24hr 50 (14) & 100
mg(14) & 200 mg(7) kit................................................... 111
LAMICTAL XR – lamotrigine tab sr 24hr 25 mg............... 112
LAMICTAL XR – lamotrigine tab sr 24hr 50 mg............... 112
LAMICTAL XR – lamotrigine tab sr 24hr 100 mg............. 112
LAMICTAL XR – lamotrigine tab sr 24hr 25 mg (21) & 50
mg (7) titration kit............................................................ 111
LAMISIL SPRAY – terbinafine hcl soln 1%...................... 146
LAMISIL – terbinafine hcl tab 250 mg..................................7
lamivudine oral soln 10 mg/ml (Epivir).......................... 11
lamivudine tab 150 mg (Epivir)....................................... 11
lamivudine tab 300 mg (Epivir)....................................... 11
lamivudine tab 100 mg (hbv) (Epivir hbv)........................ 8
lamivudine-zidovudine tab 150-300 mg (Combivir)...... 11
lamotrigine orally disintegrating tab 25 mg (Lamictal
odt)...................................................................................112
odt)...................................................................................112
odt)...................................................................................112
odt)...................................................................................112
189
2016
lamotrigine tab chewable dispersible 5 mg (Lamictal
chewable di)................................................................... 112
lamotrigine tab chewable dispersible 25 mg (Lamictal
chewable di)................................................................... 112
lamotrigine tab disp 25 (14) & 50 mg (14) & 100 mg (7)
kit (Lamictal odt)........................................................... 112
lamotrigine tab disp 25 mg (21) & 50 mg (7) titration kit
(Lamictal odt)................................................................. 112
lamotrigine tab disp 50 mg (42) & 100 mg (14) titration
kit (Lamictal odt)........................................................... 112
lamotrigine tab 25 mg (Lamictal).................................. 112
lamotrigine tab 100 mg (Lamictal)................................ 112
lamotrigine tab sr 24hr 25 mg (Lamictal xr)................ 112
lamotrigine tab sr 24hr 50 mg (Lamictal xr)................ 112
lamotrigine tab sr 24hr 100 mg (Lamictal xr).............. 112
LANCET DEVICES – VARIOUS MANUFACTURERS..... 153
LANCETS – VARIOUS MANUFACTURERS................... 153
LANOXIN – digoxin tab 62.5 mcg (0.0625 mg)................. 62
LANOXIN – digoxin tab 125 mcg (0.125 mg).................... 62
LANOXIN – digoxin tab 187.5 mcg (0.1875 mg)............... 62
LANOXIN – digoxin tab 250 mcg (0.25 mg)...................... 62
lansoprazole cap delayed release 15 mg
(Prevacid).......................................................................... 71
lansoprazole cap delayed release 30 mg
(Prevacid).......................................................................... 71
LANTUS – insulin glargine inj 100 unit/ml......................... 35
LANTUS SOLOSTAR – insulin glargine soln pen-injector
100 unit/ml......................................................................... 35
LASIX – furosemide tab 20 mg.......................................... 58
LASTACAFT – alcaftadine ophth soln 0.25%.................. 142
latanoprost ophth soln 0.005% (Xalatan)..................... 140
LATUDA – lurasidone hcl tab 20 mg.................................. 86
LATUDA – lurasidone hcl tab 120 mg................................ 86
LECITHIN – lecithin granules........................................... 128
leflunomide tab 10 mg (Arava)...................................... 106
leflunomide tab 20 mg (Arava)...................................... 106
LENVIMA 14 MG DAILY DOSE – lenvatinib cap therapy
pack 10 & 4 mg (14 mg daily dose)................................. 19
pack 10 & 4 (2) mg (18 mg daily dose)............................ 19
pack 10 (2) & 4 mg (24 mg daily dose)............................ 19
pack 10 mg (10 mg daily dose)........................................ 19
pack 10 (2) mg (20 mg daily dose).................................. 19
pack 4 (2) mg (8 mg daily dose)...................................... 19
LESCOL XL – fluvastatin sodium tab sr 24 hr 80 mg........ 55
LETAIRIS – ambrisentan tab 5 mg.................................... 62
LETAIRIS – ambrisentan tab 10 mg.................................. 62
letrozole tab 2.5 mg (Femara)......................................... 19
LEUCOVORIN CALCIUM – leucovorin calcium tab 10
mg...................................................................................... 19
LEUCOVORIN CALCIUM – leucovorin calcium tab 15
mg...................................................................................... 19
leucovorin calcium tab 5 mg........................................... 19
leucovorin calcium tab 25 mg......................................... 19
LEUKERAN – chlorambucil tab 2 mg................................ 19
LEUKINE – sargramostim lyophilized for inj 250 mcg..... 131
leuprolide acetate inj kit 5 mg/ml................................... 19
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base
equiv) (Xopenex concentrate)....................................... 68
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
(Xopenex).......................................................................... 68
(Xopenex).......................................................................... 68
(Xopenex).......................................................................... 68
LEVAQUIN – levofloxacin tab 250 mg................................. 5
LEVATOL – penbutolol sulfate tab 20 mg.......................... 48
LEVBID – hyoscyamine sulfate tab sr 12hr 0.375 mg....... 71
LEVEMIR FLEXTOUCH – insulin detemir soln pen-injector
100 unit/ml......................................................................... 35
LEVEMIR – insulin detemir inj 100 unit/ml......................... 35
levetiracetam oral soln 100 mg/ml (Keppra)................112
levetiracetam tab 250 mg (Keppra)...............................112
levetiracetam tab 1000 mg (Keppra).............................112
levetiracetam tab sr 24hr 500 mg (Keppra xr)............. 112
levetiracetam tab sr 24hr 750 mg (Keppra xr)............. 112
LEVITRA – vardenafil hcl tab 2.5 mg................................. 64
LEVITRA – vardenafil hcl tab 5 mg....................................64
LEVITRA – vardenafil hcl tab 10 mg..................................64
LEVITRA – vardenafil hcl tab 20 mg..................................64
levobunolol hcl ophth soln 0.5% (Betagan)................ 140
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 40
levocarnitine tab 330 mg (Carnitor)................................ 40
levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/
ml) (Xyzal)......................................................................... 64
levocetirizine dihydrochloride tab 5 mg (Xyzal)............ 64
levofloxacin ophth soln 0.5%........................................ 137
levofloxacin oral soln 25 mg/ml........................................ 5
levofloxacin tab 250 mg (Levaquin)................................. 6
LEVOMEFOLATE DHA – prenat w/fe fum-l methylfolatefa-dha cap 27-1.13-0.4 mg............................................. 121
levonorgestrel tab 1.5 mg................................................ 28
190
2016
levothyroxine sodium tab 25 mcg (Synthroid).............. 35
levothyroxine sodium tab 100 mcg (Synthroid)............ 35
LEVSIN/SL – hyoscyamine sulfate tab sl 0.125 mg...........71
LEVSIN – hyoscyamine sulfate tab 0.125 mg................... 71
LEVULAN KERASTICK – aminolevulinic acid hcl for soln
20% (stick applicator)......................................................152
LEXAPRO – escitalopram oxalate soln 5 mg/5ml (base
equiv)................................................................................. 82
LEXIVA – fosamprenavir calcium susp 50 mg/ml (base
equiv)................................................................................. 11
LEXIVA – fosamprenavir calcium tab 700 mg (base
equiv)................................................................................. 11
LEXUSS 210 – chlorpheniramine w/ codeine liquid 2-10
mg/5ml............................................................................... 65
LIALDA – mesalamine tab delayed release 1.2 gm........... 75
lidocaine hcl gel 2%....................................................... 152
LIDOCAINE HCL-HYDROCORTIS – lidocainehydrocortisone acetate rectal gel 2.8-0.55%.................. 143
LIDOCAINE HCL – lidocaine hcl laryngotracheal soln
4%.................................................................................... 143
lidocaine hcl soln 4% (Xylocaine).................................152
lidocaine hcl viscous soln 2%...................................... 143
lidocaine patch 5% (Lidoderm)..................................... 152
lidocaine-prilocaine cream 2.5-2.5%.............................152
LIDODERM – lidocaine patch 5%.................................... 152
lindane shampoo 1%...................................................... 152
linezolid for susp 100 mg/5ml (Zyvox)........................... 14
linezolid tab 600 mg (Zyvox)........................................... 14
LINZESS – linaclotide cap 145 mcg.................................. 75
LINZESS – linaclotide cap 290 mcg.................................. 75
liothyronine sodium tab 5 mcg (Cytomel)..................... 36
liothyronine sodium tab 25 mcg (Cytomel)................... 36
liothyronine sodium tab 50 mcg (Cytomel)................... 36
LIPOFEN – fenofibrate cap 50 mg..................................... 55
LIPOFEN – fenofibrate cap 150 mg................................... 56
lisinopril & hydrochlorothiazide tab 10-12.5 mg
(Zestoretic)....................................................................... 43
lisinopril & hydrochlorothiazide tab 20-12.5 mg
(Zestoretic)....................................................................... 43
lisinopril & hydrochlorothiazide tab 20-25 mg
(Zestoretic)....................................................................... 43
lisinopril tab 5 mg (Prinivil)............................................. 43
lisinopril tab 10 mg (Prinivil)........................................... 43
lisinopril tab 20 mg (Prinivil)........................................... 43
lisinopril tab 2.5 mg (Zestril)........................................... 43
lisinopril tab 30 mg (Zestril)............................................ 43
lisinopril tab 40 mg (Zestril)............................................ 43
lithium carbonate cap 300 mg.........................................86
lithium carbonate cap 150 mg (Lithium carbonate)...... 86
lithium carbonate cap 600 mg (Lithium carbonate)...... 86
LITHIUM CARBONATE – lithium carbonate cap 150
mg...................................................................................... 86
LITHIUM CARBONATE – lithium carbonate cap 600
mg...................................................................................... 86
lithium carbonate tab cr 450 mg..................................... 86
lithium carbonate tab cr 300 mg (Lithobid)................... 86
lithium carbonate tab 300 mg......................................... 86
LITHIUM – lithium oral solution 8 meq/5ml........................ 86
LITHOBID – lithium carbonate tab cr 300 mg.................... 86
LITHOSTAT – acetohydroxamic acid tab 250 mg.............. 78
LIVALO – pitavastatin calcium tab 1 mg (base equiv)....... 56
LOCOID – hydrocortisone butyrate cream 0.1%............. 150
LOCOID – hydrocortisone butyrate lotion 0.1%............... 150
LOCOID – hydrocortisone butyrate oint 0.1%..................150
LOCOID – hydrocortisone butyrate soln 0.1%................. 150
LOCOID LIPOCREAM – hydrocortisone butyrate
hydrophilic lipo base cream 0.1%...................................150
LODOSYN – carbidopa tab 25 mg...................................115
LOESTRIN FE 1.5/30 – norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg.........................................28
LOESTRIN FE 1/20 – norethindrone ace & ethinyl
estradiol-fe tab 1 mg-20 mcg............................................28
LOFIBRA – fenofibrate micronized cap 67 mg.................. 56
LOFIBRA – fenofibrate micronized cap 134 mg................ 56
LOFIBRA – fenofibrate micronized cap 200 mg................ 56
LOFIBRA – fenofibrate tab 54 mg......................................56
LOFIBRA – fenofibrate tab 160 mg....................................56
LO LOESTRIN FE – norethin-eth estradiol-fe tab 1 mg-10
mcg (24)/10 mcg (2)......................................................... 28
LOMOTIL – diphenoxylate w/ atropine tab 2.5-0.025
mg...................................................................................... 70
LONSURF – trifluridine-tipiracil tab 15-6.14 mg.................20
LONSURF – trifluridine-tipiracil tab 20-8.19 mg.................20
loperamide hcl cap 2 mg................................................. 70
LOPID – gemfibrozil tab 600 mg........................................ 56
LOPRESSOR HCT – metoprolol & hydrochlorothiazide tab
50-25 mg............................................................................48
LOPRESSOR HCT – metoprolol & hydrochlorothiazide tab
100-25 mg......................................................................... 48
LOPRESSOR – metoprolol tartrate tab 50 mg.................. 48
LOPRESSOR – metoprolol tartrate tab 100 mg................ 48
LOPROX SHAMPOO – ciclopirox shampoo 1%..............146
loratadine & pseudoephedrine tab sr 12hr 5-120
mg...................................................................................... 65
loratadine & pseudoephedrine tab sr 24hr 10-240
mg...................................................................................... 65
loratadine rapidly-disintegrating tab 10 mg
(Claritin)............................................................................ 64
loratadine syrup 5 mg/5ml............................................... 64
loratadine tab 10 mg.........................................................64
191
2016
lorazepam conc 2 mg/ml.................................................. 80
lorazepam tab 0.5 mg (Ativan)........................................ 80
lorazepam tab 1 mg (Ativan)........................................... 80
lorazepam tab 2 mg (Ativan)........................................... 80
losartan potassium & hydrochlorothiazide tab 50-12.5
mg (Hyzaar)...................................................................... 46
losartan potassium & hydrochlorothiazide tab 100-12.5
mg (Hyzaar)...................................................................... 46
losartan potassium & hydrochlorothiazide tab 100-25
mg (Hyzaar)...................................................................... 46
losartan potassium tab 25 mg (Cozaar)......................... 46
losartan potassium tab 50 mg (Cozaar)......................... 46
losartan potassium tab 100 mg (Cozaar)....................... 46
LOSEASONIQUE – levonorg-eth est tab 0.1-0.02mg(84) &
eth est tab 0.01mg(7)........................................................28
LOTEMAX – loteprednol etabonate ophth gel 0.5%........ 138
LOTEMAX – loteprednol etabonate ophth oint 0.5%....... 138
LOTEMAX – loteprednol etabonate ophth susp 0.5%..... 139
LOTENSIN – benazepril hcl tab 10 mg.............................. 43
LOTENSIN HCT – benazepril & hydrochlorothiazide tab
10-12.5 mg........................................................................ 43
20-12.5 mg........................................................................ 43
20-25 mg............................................................................43
LOTREL – amlodipine besylate-benazepril hcl cap 5-10
mg...................................................................................... 51
mg...................................................................................... 51
mg...................................................................................... 51
mg...................................................................................... 51
LOTRISONE – clotrimazole w/ betamethasone cream
1-0.05%............................................................................ 146
lovastatin tab 10 mg......................................................... 56
lovastatin tab 20 mg......................................................... 56
lovastatin tab 40 mg (Mevacor).......................................56
LOVAZA – omega-3-acid ethyl esters cap 1 gm................ 56
LOVENOX – enoxaparin sodium inj 30 mg/0.3ml............ 131
LOVENOX – enoxaparin sodium inj 100 mg/ml............... 131
LOVENOX – enoxaparin sodium inj 120 mg/0.8ml.......... 131
LOVENOX – enoxaparin sodium inj 150 mg/ml............... 131
LOVENOX – enoxaparin sodium inj 300 mg/3ml............. 131
loxapine succinate cap 5 mg.......................................... 86
loxapine succinate cap 10 mg........................................ 86
LOZI-FLUR – sodium fluoride lozenge 1 mg f (from 2.2 mg
naf)................................................................................... 127
LUMIGAN – bimatoprost ophth soln 0.01%..................... 140
LURIDE – sodium fluoride chew tab 0.25 mg f (from 0.55
mg naf).............................................................................127
LURIDE – sodium fluoride chew tab 0.5 mg f (from 1.1 mg
naf)................................................................................... 127
LURIDE – sodium fluoride chew tab 1 mg f (from 2.2 mg
naf)................................................................................... 127
LURIDE – sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/
ml naf).............................................................................. 127
LUXIQ – betamethasone valerate aerosol foam
0.12%............................................................................... 150
LYNPARZA – olaparib cap 50 mg...................................... 20
LYRICA – pregabalin cap 25 mg...................................... 112
LYRICA – pregabalin cap 100 mg.................................... 112
LYRICA – pregabalin soln 20 mg/ml................................ 112
LYSODREN – mitotane tab 500 mg................................... 20
LYSTEDA – tranexamic acid tab 650 mg.........................131
M
MACNATAL CN DHA – prenatal w/o a w/fe cbn-dss-fa-dha
cap 28-1-250 mg............................................................. 121
MACROBID – nitrofurantoin monohydrate macrocrystalline
cap 100 mg....................................................................... 76
MACRODANTIN – nitrofurantoin macrocrystalline cap 25
mg...................................................................................... 76
mg...................................................................................... 76
mg...................................................................................... 76
MALARONE – atovaquone-proguanil hcl tab 62.5-25
mg...................................................................................... 13
MALARONE – atovaquone-proguanil hcl tab 250-100
mg...................................................................................... 13
malathion lotion 0.5% (Ovide)....................................... 152
MAPROTILINE HCL – maprotiline hcl tab 25 mg.............. 82
MARINOL – dronabinol cap 2.5 mg................................... 73
MARINOL – dronabinol cap 5 mg...................................... 73
MARINOL – dronabinol cap 10 mg.................................... 73
MARNATAL-F – prenatal w/o vit a w/ fe polysac cmplx-fa
cap 60-1 mg.................................................................... 121
MARPLAN – isocarboxazid tab 10 mg...............................82
MATULANE – procarbazine hcl cap 50 mg....................... 20
MAVIK – trandolapril tab 1 mg........................................... 43
MAVIK – trandolapril tab 2 mg........................................... 43
MAXIDEX – dexamethasone ophth susp 0.1%............... 139
MAXITROL – neomycin-polymyxin-dexamethasone ophth
oint 0.1%.......................................................................... 139
MAXITROL – neomycin-polymyxin-dexamethasone ophth
susp 0.1%........................................................................ 139
192
2016
MAXZIDE – triamterene & hydrochlorothiazide tab 75-50
mg...................................................................................... 58
MAXZIDE-25 – triamterene & hydrochlorothiazide tab
37.5-25 mg........................................................................ 58
meclizine hcl tab 12.5 mg................................................ 73
meclizine hcl tab 25 mg................................................... 73
MECLOFENAMATE SODIUM – meclofenamate sodium
cap 50 mg....................................................................... 106
MECLOFENAMATE SODIUM – meclofenamate sodium
cap 100 mg..................................................................... 106
MEDROL DOSEPAK – methylprednisolone tab therapy
pack 4 mg (21).................................................................. 23
MEDROL – methylprednisolone tab 2 mg......................... 23
MEDROL – methylprednisolone tab 16 mg....................... 23
MEDROL – methylprednisolone tab 32 mg....................... 23
medroxyprogesterone acetate tab 2.5 mg
(Provera)........................................................................... 27
medroxyprogesterone acetate tab 5 mg (Provera)....... 27
medroxyprogesterone acetate tab 10 mg (Provera)..... 27
mefenamic acid cap 250 mg (Ponstel)......................... 106
mefloquine hcl tab 250 mg.............................................. 13
MEGACE ES – megestrol acetate susp 625 mg/5ml.........27
MEGACE ORAL – megestrol acetate susp 40 mg/ml........20
megestrol acetate susp 625 mg/5ml (Megace es)......... 27
megestrol acetate susp 40 mg/ml (Megace oral).......... 20
megestrol acetate tab 20 mg........................................... 20
megestrol acetate tab 40 mg........................................... 20
MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg
(base equivalent)............................................................... 20
MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (base
equivalent)......................................................................... 20
meloxicam tab 7.5 mg (Mobic)...................................... 106
meloxicam tab 15 mg (Mobic)....................................... 106
memantine hcl oral solution 2 mg/ml (Namenda)......... 96
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak
(Namenda titration pa).................................................... 96
memantine hcl tab 5 mg (Namenda).............................. 96
memantine hcl tab 10 mg (Namenda)............................ 96
MENACTRA – meningococcal (a, c, y, and w-135)
conjugate vaccine inj......................................................... 16
MENEST – esterified estrogens tab 0.3 mg...................... 26
MENEST – esterified estrogens tab 0.625 mg...................26
MENEST – esterified estrogens tab 1.25 mg.................... 26
MENEST – esterified estrogens tab 2.5 mg...................... 26
MENHIBRIX – meningococcal (c & y)-haemophilus b tet
tox conj vac for inj............................................................. 16
MENOMUNE-A/C/Y/W-135 – meningococcal vaccine a, c,
y, and w-135 inj................................................................. 16
MENOSTAR – estradiol td patch weekly 14 mcg/24hr...... 26
MENTAX – butenafine hcl cream 1%............................... 146
MENVEO – meningococcal (a, c, y, and w-135) oligo conj
vac for inj........................................................................... 16
MEPERIDINE HCL/PROMETHAZI – meperidine w/
promethazine cap 50-25 mg........................................... 101
MEPERIDINE HCL – meperidine hcl oral soln 50
mg/5ml............................................................................. 101
meperidine hcl tab 50 mg.............................................. 101
meperidine hcl tab 100 mg............................................ 101
MEPHYTON – phytonadione tab 5 mg............................ 119
meprobamate tab 200 mg................................................ 80
meprobamate tab 400 mg................................................ 80
MEPRON – atovaquone susp 750 mg/5ml........................ 14
mercaptopurine tab 50 mg.............................................. 20
mesalamine enema 4 gm................................................. 75
MESNEX – mesna tab 400 mg.......................................... 20
MESTINON – pyridostigmine bromide syrup 60
mg/5ml............................................................................. 119
MESTINON – pyridostigmine bromide tab 60 mg............ 119
MESTINON TIMESPAN – pyridostigmine bromide tab cr
180 mg............................................................................. 119
METADATE CD – methylphenidate hcl cap cr 10 mg
(cd)..................................................................................... 91
(cd)..................................................................................... 91
(cd)..................................................................................... 91
(cd)..................................................................................... 92
(cd)..................................................................................... 92
(cd)..................................................................................... 92
METAPROTERENOL SULFATE – metaproterenol sulfate
syrup 10 mg/5ml................................................................68
tab 10 mg.......................................................................... 68
tab 20 mg.......................................................................... 68
METAXALONE – metaxalone tab 400 mg....................... 118
metaxalone tab 800 mg (Skelaxin)................................118
metformin hcl tab 500 mg (Glucophage)....................... 33
metformin hcl tab 850 mg (Glucophage)....................... 33
metformin hcl tab 1000 mg (Glucophage)..................... 33
metformin hcl tab sr 24hr 500 mg (Glucophage xr)...... 33
metformin hcl tab sr 24hr 750 mg (Glucophage xr)...... 33
methadone hcl conc 10 mg/ml (Methadose)............... 101
METHADONE HCL – methadone hcl soln 5 mg/5ml....... 101
METHADONE HCL – methadone hcl soln 10 mg/5ml..... 101
methadone hcl soln 5 mg/5ml (Methadone hcl).......... 101
methadone hcl soln 10 mg/5ml (Methadone hcl)........ 101
methadone hcl tab for oral susp 40 mg....................... 101
methadone hcl tab 5 mg (Dolophine)........................... 101
methadone hcl tab 10 mg (Dolophine)......................... 101
METHADOSE – methadone hcl conc 10 mg/ml.............. 101
METHADOSE SUGAR-FREE – methadone hcl conc 10
mg/ml............................................................................... 101
methamphetamine hcl tab 5 mg (Desoxyn)................... 92
methazolamide tab 25 mg (Neptazane).......................... 58
methazolamide tab 50 mg (Neptazane).......................... 58
methenamine hippurate tab 1 gm (Hiprex).................... 76
193
2016
methimazole tab 5 mg (Tapazole)................................... 36
methimazole tab 10 mg (Tapazole)................................. 36
METHITEST – methyltestosterone oral tab 10 mg............ 24
methocarbamol tab 750 mg (Robaxin-750).................. 118
methocarbamol tab 500 mg (Robaxin)......................... 118
methotrexate sodium for inj 1 gm.................................. 20
methotrexate sodium inj 50 mg/2ml (25 mg/ml)............ 20
methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)....... 20
methotrexate sodium inj pf 100 mg/4ml (25 mg/ml)..... 20
methotrexate sodium inj pf 200 mg/8ml (25 mg/ml)..... 20
methotrexate sodium inj pf 250 mg/10ml (25 mg/
ml)...................................................................................... 20
methotrexate sodium inj pf 1000 mg/40ml (25 mg/
ml)...................................................................................... 20
METHOTREXATE SODIUM – methotrexate sodium inj
250 mg/10ml (25 mg/ml)................................................... 20
methotrexate sodium tab 2.5 mg (base equiv).............. 20
methoxsalen rapid cap 10 mg (Oxsoralen ultra)......... 152
methscopolamine bromide tab 2.5 mg (Pamine).......... 71
methscopolamine bromide tab 5 mg (Pamine
forte).................................................................................. 71
METHYCLOTHIAZIDE – methyclothiazide tab 5 mg......... 58
METHYLDOPA/HYDROCHLOROTHI – methyldopa &
hydrochlorothiazide tab 250-15 mg.................................. 62
METHYLDOPA/HYDROCHLOROTHI – methyldopa &
hydrochlorothiazide tab 250-25 mg.................................. 62
methyldopa tab 250 mg................................................... 62
methyldopa tab 500 mg................................................... 62
methylergonovine maleate tab 0.2 mg........................... 40
METHYLIN – methylphenidate hcl chew tab 2.5 mg......... 92
METHYLIN – methylphenidate hcl chew tab 5 mg............ 92
METHYLIN – methylphenidate hcl chew tab 10 mg.......... 92
METHYLIN – methylphenidate hcl soln 5 mg/5ml............. 92
METHYLIN – methylphenidate hcl soln 10 mg/5ml........... 92
methylphenidate hcl cap cr 10 mg (cd) (Metadate
cd)...................................................................................... 92
cd)...................................................................................... 92
cd)...................................................................................... 92
cd)...................................................................................... 92
cd)...................................................................................... 92
cd)...................................................................................... 92
methylphenidate hcl cap sr 24hr 20 mg (la) (Ritalin
la)....................................................................................... 92
la)....................................................................................... 92
la)....................................................................................... 92
methylphenidate hcl chew tab 2.5 mg (Methylin)......... 92
methylphenidate hcl chew tab 5 mg (Methylin)............ 92
methylphenidate hcl chew tab 10 mg (Methylin).......... 92
METHYLPHENIDATE HCL ER – methylphenidate hcl tab
sa osm 18 mg................................................................... 92
sa osm 27 mg................................................................... 92
sa osm 36 mg................................................................... 92
sa osm 54 mg................................................................... 92
sr 24hr 18 mg.................................................................... 92
sr 24hr 27 mg.................................................................... 92
sr 24hr 36 mg.................................................................... 92
sr 24hr 54 mg.................................................................... 92
methylphenidate hcl soln 5 mg/5ml (Methylin)............. 92
methylphenidate hcl soln 10 mg/5ml (Methylin)........... 92
methylphenidate hcl tab cr 10 mg.................................. 92
methylphenidate hcl tab cr 20 mg.................................. 92
methylphenidate hcl tab 5 mg (Ritalin).......................... 93
methylphenidate hcl tab 10 mg (Ritalin)........................ 93
methylphenidate hcl tab 20 mg (Ritalin)........................ 93
methylprednisolone tab 4 mg (Medrol).......................... 23
methylprednisolone tab 8 mg (Medrol).......................... 23
methylprednisolone tab 16 mg (Medrol)........................ 23
methylprednisolone tab 32 mg (Medrol)........................ 23
methylprednisolone tab therapy pack 4 mg (21)
(Medrol dosepak)............................................................. 23
methyltestosterone cap 10 mg (Testred)....................... 24
METIPRANOLOL – metipranolol ophth soln 0.3%.......... 140
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)......... 75
metoclopramide hcl tab 5 mg (Reglan).......................... 75
metoclopramide hcl tab 10 mg (Reglan)........................ 75
metolazone tab 2.5 mg..................................................... 58
metolazone tab 5 mg........................................................ 58
metolazone tab 10 mg...................................................... 58
metoprolol & hydrochlorothiazide tab 100-50 mg........ 48
metoprolol & hydrochlorothiazide tab 50-25 mg
(Lopressor hct)................................................................ 48
metoprolol & hydrochlorothiazide tab 100-25 mg
(Lopressor hct)................................................................ 48
metoprolol succinate tab sr 24hr 25 mg (tartrate equiv)
(Toprol xl)......................................................................... 48
metoprolol succinate tab sr 24hr 50 mg (tartrate equiv)
(Toprol xl)......................................................................... 48
metoprolol succinate tab sr 24hr 100 mg (tartrate
equiv) (Toprol xl)............................................................. 48
metoprolol succinate tab sr 24hr 200 mg (tartrate
equiv) (Toprol xl)............................................................. 48
METOPROLOL TARTRATE – metoprolol tartrate tab 37.5
mg...................................................................................... 48
METOPROLOL TARTRATE – metoprolol tartrate tab 75
mg...................................................................................... 48
metoprolol tartrate tab 25 mg......................................... 48
metoprolol tartrate tab 50 mg (Lopressor).................... 49
194
2016
metoprolol tartrate tab 100 mg (Lopressor).................. 49
METROCREAM – metronidazole cream 0.75%.............. 145
METROGEL – metronidazole gel 1%.............................. 145
METROGEL-VAGINAL – metronidazole vaginal gel
0.75%................................................................................. 78
METROLOTION – metronidazole lotion 0.75%............... 145
metronidazole cap 375 mg (Flagyl)................................ 14
metronidazole cream 0.75% (Metrocream).................. 145
metronidazole gel 0.75%................................................ 145
metronidazole gel 1% (Metrogel).................................. 145
metronidazole lotion 0.75% (Metrolotion).................... 145
metronidazole tab 250 mg (Flagyl)................................. 14
metronidazole tab 500 mg (Flagyl)................................. 14
metronidazole vaginal gel 0.75% (Metrogelvaginal)..............................................................................78
MEVACOR – lovastatin tab 40 mg..................................... 56
mexiletine hcl cap 150 mg............................................... 59
MIACALCIN – calcitonin (salmon) inj 200 unit/ml.............. 40
MIACALCIN – calcitonin (salmon) nasal soln 200 unit/
act....................................................................................... 40
MICARDIS HCT – telmisartan-hydrochlorothiazide tab
40-12.5 mg........................................................................ 46
80-12.5 mg........................................................................ 46
80-25 mg............................................................................46
MICARDIS – telmisartan tab 20 mg................................... 46
MICONAZOLE 3 – miconazole nitrate vaginal suppos 200
mg...................................................................................... 78
MICRO-K – potassium chloride cap cr 8 meq................. 127
MICRO-K – potassium chloride cap cr 10 meq............... 127
MICROZIDE – hydrochlorothiazide cap 12.5 mg............... 58
midodrine hcl tab 2.5 mg................................................. 62
midodrine hcl tab 5 mg.................................................... 62
midodrine hcl tab 10 mg.................................................. 62
MIGERGOT – ergotamine w/ caffeine suppos 2-100
mg.................................................................................... 107
miglitol tab 25 mg (Glyset).............................................. 33
miglitol tab 50 mg (Glyset).............................................. 33
miglitol tab 100 mg (Glyset)............................................ 33
MIGRANAL – dihydroergotamine mesylate nasal spray 4
mg/ml............................................................................... 108
MILLIPRED DP – prednisolone tab therapy pack 5 mg
(21)..................................................................................... 23
MILLIPRED DP – prednisolone tab therapy pack 5 mg
(48)..................................................................................... 23
MILLIPRED – prednisolone sod phosphate oral soln 10
mg/5ml (base equiv)......................................................... 23
MILLIPRED – prednisolone tab 5 mg................................ 23
MINASTRIN 24 FE – norethindrone ace-eth estradiol-fe
chew tab 1 mg-20 mcg (24)............................................. 28
MINIPRESS – prazosin hcl cap 1 mg................................ 62
MINIVELLE – estradiol td patch twice weekly 0.025
mg/24hr.............................................................................. 26
mg/24hr.............................................................................. 26
mg/24hr.............................................................................. 26
mg/24hr.............................................................................. 26
mg/24hr.............................................................................. 26
minocycline hcl cap 50 mg (Minocin).............................. 4
minocycline hcl cap 75 mg (Minocin).............................. 4
minocycline hcl cap 100 mg (Minocin)............................ 5
minocycline hcl tab 50 mg................................................ 5
minocycline hcl tab 75 mg................................................ 5
minocycline hcl tab 100 mg.............................................. 5
minocycline hcl tab sr 24hr 45 mg................................... 5
minocycline hcl tab sr 24hr 90 mg................................... 5
minocycline hcl tab sr 24hr 135 mg................................. 5
minoxidil tab 2.5 mg......................................................... 62
minoxidil tab 10 mg.......................................................... 62
MIRAPEX ER – pramipexole dihydrochloride tab sr 24hr
0.375 mg.......................................................................... 116
0.75 mg............................................................................ 116
1.5 mg.............................................................................. 116
2.25 mg............................................................................ 116
MIRAPEX ER – pramipexole dihydrochloride tab sr 24hr 3
mg.................................................................................... 116
3.75 mg............................................................................ 116
4.5 mg.............................................................................. 116
MIRAPEX – pramipexole dihydrochloride tab 0.125
mg.................................................................................... 116
mg.................................................................................... 116
MIRAPEX – pramipexole dihydrochloride tab 0.5 mg...... 116
mg.................................................................................... 116
MIRAPEX – pramipexole dihydrochloride tab 1 mg......... 116
MIRAPEX – pramipexole dihydrochloride tab 1.5 mg...... 116
MIRCERA – methoxy peg-epoetin beta soln prefilled syr
50 mcg/0.3ml................................................................... 131
75 mcg/0.3ml................................................................... 131
100 mcg/0.3ml................................................................. 131
200 mcg/0.3ml................................................................. 131
mirtazapine orally disintegrating tab 15 mg (Remeron
soltab)............................................................................... 82
195
2016
soltab)............................................................................... 82
soltab)............................................................................... 82
mirtazapine tab 7.5 mg..................................................... 82
mirtazapine tab 15 mg (Remeron).................................. 82
misoprostol tab 100 mcg (Cytotec)................................ 71
misoprostol tab 200 mcg (Cytotec)................................ 71
MITIGARE – colchicine cap 0.6 mg................................. 109
MITOSOL – mitomycin for ophth soln kit 0.2 mg............. 137
M-M-R II – measles, mumps & rubella virus vaccines for
inj........................................................................................ 16
modafinil tab 100 mg (Provigil)....................................... 93
modafinil tab 200 mg (Provigil)....................................... 93
MODERIBA 1200 DOSE PACK – ribavirin tab 600 mg....... 8
MODERIBA 800 DOSE PACK – ribavirin tab 400 mg......... 8
MODERIBA – ribavirin tab 200 mg & ribavirin tab 400 mg
dose pack............................................................................ 8
MODERIBA – ribavirin tab 400 mg & ribavirin tab 600 mg
dose pack............................................................................ 8
MODICON – norethindrone & ethinyl estradiol tab 0.5
mg-35 mcg......................................................................... 28
moexipril hcl tab 7.5 mg.................................................. 43
moexipril hcl tab 15 mg................................................... 43
moexipril-hydrochlorothiazide tab 7.5-12.5 mg.............43
moexipril-hydrochlorothiazide tab 15-12.5 mg..............43
moexipril-hydrochlorothiazide tab 15-25 mg.................44
MOLINDONE HYDROCHLORIDE – molindone hcl tab 5
mg...................................................................................... 86
mg...................................................................................... 86
mg...................................................................................... 86
mometasone furoate cream 0.1% (Elocon)................. 150
mometasone furoate oint 0.1% (Elocon)......................150
mometasone furoate solution 0.1% (lotion)
(Elocon)........................................................................... 150
MONOCLATE-P – antihemophilic factor (human) for inj kit
250 unit............................................................................ 135
1000 unit.......................................................................... 135
1500 unit.......................................................................... 135
MONONINE – coagulation factor ix for inj 500 unit..........135
MONONINE – coagulation factor ix for inj 1000 unit........135
montelukast sodium chew tab 4 mg (base equiv)
(Singulair)......................................................................... 68
montelukast sodium chew tab 5 mg (base equiv)
(Singulair)......................................................................... 68
montelukast sodium oral granules packet 4 mg (base
equiv) (Singulair)............................................................. 68
montelukast sodium tab 10 mg (base equiv)
(Singulair)......................................................................... 68
MONUROL – fosfomycin tromethamine powd pack 3 gm
(base equivalent)............................................................... 76
8-MOP – methoxsalen cap 10 mg................................... 153
morphine sulfate cap sr 24hr 10 mg (Kadian)............. 101
morphine sulfate cap sr 24hr 100 mg (Kadian)........... 101
MORPHINE SULFATE ER – morphine sulfate beads cap
sr 24hr 30 mg.................................................................. 101
sr 24hr 45 mg.................................................................. 101
sr 24hr 60 mg.................................................................. 101
sr 24hr 75 mg.................................................................. 101
sr 24hr 90 mg.................................................................. 101
sr 24hr 120 mg................................................................ 102
MORPHINE SULFATE – morphine sulfate suppos 5
mg.................................................................................... 101
mg.................................................................................... 101
mg.................................................................................... 101
mg.................................................................................... 101
MORPHINE SULFATE – morphine sulfate tab 15 mg..... 101
MORPHINE SULFATE – morphine sulfate tab 30 mg..... 101
morphine sulfate oral soln 10 mg/5ml......................... 102
morphine sulfate oral soln 20 mg/5ml......................... 102
morphine sulfate oral soln 100 mg/5ml (20 mg/
ml).................................................................................... 102
morphine sulfate tab cr 15 mg (Ms contin)................. 102
morphine sulfate tab cr 100 mg (Ms contin)............... 102
morphine sulfate tab cr 200 mg (Ms contin)............... 102
MOTOFEN – difenoxin w/ atropine tab 1-0.025 mg........... 70
MOVANTIK – naloxegol oxalate tab 12.5 mg (base
equivalent)......................................................................... 75
MOVANTIK – naloxegol oxalate tab 25 mg (base
equivalent)......................................................................... 75
MOVIPREP – peg 3350-kcl-nacl-na sulfate-na ascorbate-c
for soln 100 gm................................................................. 70
MOXATAG – amoxicillin (trihydrate) tab sr 24hr 775 mg..... 2
MOXEZA – moxifloxacin hcl ophth soln 0.5% (base eq) (2
times daily)...................................................................... 137
moxifloxacin hcl tab 400 mg (base equiv) (Avelox)........ 6
MULTAQ – dronedarone hcl tab 400 mg (base
equivalent)......................................................................... 59
mupirocin calcium cream 2% (Bactroban).................. 146
mupirocin oint 2%........................................................... 146
196
2016
M-VIT – prenatal vit w/ fe fumarate-fa tab 27-1 mg......... 121
MYALEPT – metreleptin for subcutaneous inj 11.3 mg...... 40
MYAMBUTOL – ethambutol hcl tab 100 mg........................ 6
MYAMBUTOL – ethambutol hcl tab 400 mg........................ 6
MYCOBUTIN – rifabutin cap 150 mg................................... 6
mycophenolate mofetil cap 250 mg (Cellcept)............ 154
mycophenolate mofetil for oral susp 200 mg/ml
(Cellcept)......................................................................... 155
mycophenolate mofetil tab 500 mg (Cellcept)............. 155
mycophenolate sodium tab dr 180 mg (mycophenolic
acid equiv) (Myfortic).................................................... 155
mycophenolate sodium tab dr 360 mg (mycophenolic
acid equiv) (Myfortic).................................................... 155
MYDRIACYL – tropicamide ophth soln 1%......................142
MYFORTIC – mycophenolate sodium tab dr 180 mg
(mycophenolic acid equiv).............................................. 155
MYFORTIC – mycophenolate sodium tab dr 360 mg
(mycophenolic acid equiv).............................................. 155
MYLERAN – busulfan tab 2 mg......................................... 20
MYNATAL ADVANCE – prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg..................................................................... 121
MYNATAL PLUS – prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................... 121
MYNATAL – prenatal multivitamins & minerals w/ iron & fa
cap 1 mg..........................................................................121
MYNATAL ULTRACAPLET – prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg.................................................. 121
MYNATAL-Z – prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................... 121
MYNATE 90 PLUS – prenatal vit w/ dss-fe fumarate-fa tab
cr 90-1 mg....................................................................... 121
MYRBETRIQ – mirabegron tab sr 24 hr 25 mg................. 77
MYRBETRIQ – mirabegron tab sr 24 hr 50 mg................. 77
N
nabumetone tab 500 mg................................................ 106
nabumetone tab 750 mg................................................ 106
nadolol & bendroflumethiazide tab 40-5 mg
(Corzide)............................................................................49
nadolol & bendroflumethiazide tab 80-5 mg
(Corzide)............................................................................49
nadolol tab 20 mg (Corgard)........................................... 49
naftifine hcl cream 2% (Naftin)......................................146
NALFON – fenoprofen calcium cap 400 mg.................... 106
naloxone hcl inj 0.4 mg/ml............................................ 155
NALOXONE HCL – naloxone hcl inj 1 mg/ml.................. 155
naltrexone hcl tab 50 mg................................................. 96
NAMENDA – memantine hcl oral solution 2 mg/ml........... 96
NAMENDA – memantine hcl tab 5 mg.............................. 96
NAMENDA – memantine hcl tab 10 mg............................ 96
NAMENDA TITRATION PAK – memantine hcl tab 5 mg
(28) & 10 mg (21) titration pak......................................... 96
NAMENDA XR – memantine hcl cap sr 24hr 7 mg........... 96
NAMENDA XR – memantine hcl cap sr 24hr 14 mg......... 96
NAMENDA XR TITRATION PACK – memantine hcl cap sr
24hr 7 mg & 14 mg & 21 mg & 28 mg pack.....................96
NAMZARIC – memantine hcl-donepezil hcl cap sr 24hr
14-10 mg............................................................................96
NAMZARIC – memantine hcl-donepezil hcl cap sr 24hr
28-10 mg............................................................................96
NAPROSYN – naproxen susp 125 mg/5ml..................... 106
NAPROSYN – naproxen tab 500 mg............................... 106
naproxen sodium tab 275 mg....................................... 106
naproxen sodium tab 550 mg (Anaprox ds)................ 106
naproxen susp 125 mg/5ml (Naprosyn)....................... 106
naproxen tab ec 375 mg (Ec-naprosyn)....................... 106
naproxen tab ec 500 mg (Ec-naprosyn)....................... 106
naproxen tab 250 mg..................................................... 106
naproxen tab 375 mg..................................................... 106
naproxen tab 500 mg (Naprosyn)................................. 106
naratriptan hcl tab 1 mg (base equiv) (Amerge)......... 108
naratriptan hcl tab 2.5 mg (base equiv) (Amerge)...... 108
NARCAN – naloxone hcl nasal spray 4 mg/0.1ml........... 155
NARDIL – phenelzine sulfate tab 15 mg............................ 83
NASCOBAL – cyanocobalamin nasal spray 500
mcg/0.1ml........................................................................ 131
NATACHEW – prenatal vit w/ fe fum-fe bisglycin-fa chew
tab 28-1 mg..................................................................... 121
NATACYN – natamycin ophth susp 5%........................... 138
NATALVIT – prenatal vit w/ fe fumarate-fa tab 75-1
mg.................................................................................... 121
NATAZIA – estradiol valerate-dienogest tab 3 mg /2-2
mg/2-3 mg/1 mg................................................................ 28
nateglinide tab 60 mg (Starlix)........................................ 33
nateglinide tab 120 mg (Starlix)...................................... 33
NATELLE ONE – prenatal w/o vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg............................................................. 121
NATPARA – parathyroid hormone (recombinant) for inj
cartridge 25 mcg............................................................... 40
cartridge 50 mcg............................................................... 40
cartridge 75 mcg............................................................... 40
cartridge 100 mcg............................................................. 40
NATROBA – spinosad susp 0.9%.................................... 152
NATURE-THROID NT-2.5 – thyroid tab 162.5 mg (2 1/2
grain).................................................................................. 36
NATURE-THROID – thyroid tab 16.25 mg......................... 36
NATURE-THROID – thyroid tab 32.5 mg........................... 36
NATURE-THROID – thyroid tab 65 mg.............................. 36
NATURE-THROID – thyroid tab 81.25 mg......................... 36
NATURE-THROID – thyroid tab 97.5 mg........................... 36
NATURE-THROID – thyroid tab 113.75 mg....................... 36
NATURE-THROID – thyroid tab 130 mg............................ 36
NATURE-THROID – thyroid tab 146.25 mg....................... 36
197
2016
NATURE-THROID – thyroid tab 48.75 mg (3/4 grain)....... 36
NATURE-THROID – thyroid tab 325 mg (5 grain)............. 36
NEBUPENT – pentamidine isethionate for nebulization
soln 300 mg....................................................................... 14
NEBUSAL – sodium chloride soln nebu 6%...................... 65
NECON 1/50-28 – norethindrone & mestranol tab 1 mg-50
mcg.....................................................................................28
NECON 10/11-28 – norethindrone-eth estradiol tab
0.5-35/1-35 mg-mcg (10/11)............................................. 28
NEEVO DHA – prenat w/o a w/fefum-methylfol-omegas
cap 27-1.13 mg............................................................... 121
NEFAZODONE HCL – nefazodone hcl tab 100 mg...........83
nefazodone hcl tab 50 mg............................................... 83
nefazodone hcl tab 250 mg............................................. 83
NEOMYCIN/POLYMYXIN/HYDROC – neomycinpolymyxin-hc ophth susp................................................ 139
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin............................... 138
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml (Neosporin).............. 138
neomycin-polymyxin-dexamethasone ophth oint 0.1%
(Maxitrol)......................................................................... 139
neomycin-polymyxin-dexamethasone ophth susp
0.1% (Maxitrol)............................................................... 139
neomycin-polymyxin-hc otic soln 1%.......................... 142
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000
unit/ml-1%....................................................................... 142
neomycin sulfate tab 500 mg............................................ 6
NEORAL – cyclosporine modified cap 25 mg.................. 155
NEORAL – cyclosporine modified cap 100 mg................ 155
NEORAL – cyclosporine modified oral soln 100 mg/
ml...................................................................................... 155
NEOSPORIN – neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml......................................138
NEPHROCAPS QT – b-complex w/ c-biotin-d & folic acid
tab disp 1 mg.................................................................. 121
NEPTAZANE – methazolamide tab 25 mg........................ 58
NEPTAZANE – methazolamide tab 50 mg........................ 58
NESINA – alogliptin benzoate tab 6.25 mg (base
equiv)................................................................................. 33
NESINA – alogliptin benzoate tab 12.5 mg (base
equiv)................................................................................. 33
NESINA – alogliptin benzoate tab 25 mg (base equiv)...... 33
NESTABS ABC – prenatal w/o vit a w/fe polysac-fa-ca tab
& omega 3 cap................................................................ 121
NESTABS DHA – prenat w/o a w/ fe bisglyc-fa tab 32-1
mg & omega cap pack.................................................... 121
NESTABS – prenatal vit w/o vit a w/ fe bisglycinate-fa tab
32-1 mg............................................................................121
NEULASTA ONPRO KIT – pegfilgrastim soln prefilled
syringe kit 6 mg/0.6ml..................................................... 132
NEULASTA – pegfilgrastim soln prefilled syringe 6
mg/0.6ml.......................................................................... 132
NEUPOGEN – filgrastim inj 300 mcg/ml.......................... 132
NEUPOGEN – filgrastim inj 480 mcg/1.6ml (300 mcg/
ml).................................................................................... 132
NEUPOGEN – filgrastim soln prefilled syringe 300
mcg/0.5ml........................................................................ 132
NEUPOGEN – filgrastim soln prefilled syringe 480
mcg/0.8ml (600 mcg/ml)................................................. 132
NEUPRO – rotigotine td patch 24hr 1 mg/24hr............... 116
NEURONTIN – gabapentin cap 100 mg.......................... 113
NEURONTIN – gabapentin oral soln 250 mg/5ml........... 113
NEURONTIN – gabapentin tab 600 mg........................... 113
NEURONTIN – gabapentin tab 800 mg........................... 113
NEVANAC – nepafenac ophth susp 0.1%....................... 142
NEVIRAPINE – nevirapine susp 50 mg/5ml...................... 11
nevirapine tab 200 mg (Viramune).................................. 11
nevirapine tab sr 24hr 100 mg (Viramune xr)................ 11
nevirapine tab sr 24hr 400 mg (Viramune xr)................ 11
NEWGEN – prenatal vit w/o vit a w/ fe bisglycinate-fa tab
32-1 mg............................................................................121
NEXA PLUS – prenatal w/o vit a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg............................................................... 121
NEXAVAR – sorafenib tosylate tab 200 mg (base
equivalent)......................................................................... 20
NEXIUM – esomeprazole magnesium for delayed release
susp packet 5 mg..............................................................72
susp packet 10 mg............................................................72
susp packet 20 mg............................................................72
susp packet 40 mg............................................................72
susp pack 2.5 mg..............................................................72
niacin tab cr 500 mg (antihyperlipidemic)
(Niaspan)........................................................................... 56
(Niaspan)........................................................................... 56
(Niaspan)........................................................................... 56
NIACOR – niacin (antihyperlipidemic) tab 500 mg............ 56
NIASPAN – niacin tab cr 500 mg (antihyperlipidemic)....... 56
NIASPAN – niacin tab cr 750 mg (antihyperlipidemic)....... 56
NIASPAN – niacin tab cr 1000 mg (antihyperlipidemic)..... 56
nicardipine hcl cap 20 mg............................................... 51
nicardipine hcl cap 30 mg............................................... 51
nicotine polacrilex gum 2 mg..........................................98
nicotine polacrilex gum 4 mg..........................................98
nicotine td patch 24hr 7 mg/24hr....................................98
nicotine td patch 24hr 14 mg/24hr..................................98
nicotine td patch 24hr 21 mg/24hr..................................98
198
2016
NICOTROL INHALER – nicotine inhaler system 10 mg (4
mg delivered)..................................................................... 98
NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/
spray)................................................................................. 98
nifedipine cap 20 mg........................................................ 51
nifedipine cap 10 mg (Procardia)....................................51
nifedipine tab sr 24hr 30 mg (Adalat cc)........................51
nifedipine tab sr 24hr osmotic release 30 mg
(Procardia xl)....................................................................52
(Procardia xl)....................................................................52
(Procardia xl)....................................................................52
NILANDRON – nilutamide tab 150 mg.............................. 20
nimodipine cap 30 mg...................................................... 52
NINLARO – ixazomib citrate cap 2.3 mg (base
equivalent)......................................................................... 20
NINLARO – ixazomib citrate cap 3 mg (base
equivalent)......................................................................... 20
NINLARO – ixazomib citrate cap 4 mg (base
equivalent)......................................................................... 20
NISOLDIPINE ER – nisoldipine tab sr 24hr 25.5 mg......... 52
NISOLDIPINE – nisoldipine tab sr 24hr 20 mg.................. 52
nisoldipine tab sr 24hr 8.5 mg (Sular)............................ 52
nisoldipine tab sr 24hr 17 mg (Sular)............................. 52
nisoldipine tab sr 24hr 34 mg (Sular)............................. 52
NITRO-BID – nitroglycerin oint 2%.................................... 53
NITRO-DUR – nitroglycerin td patch 24hr 0.1 mg/hr......... 53
nitrofurantoin macrocrystalline cap 25 mg
(Macrodantin)................................................................... 76
(Macrodantin)................................................................... 76
(Macrodantin)................................................................... 76
nitrofurantoin monohydrate macrocrystalline cap 100
mg (Macrobid).................................................................. 76
nitrofurantoin susp 25 mg/5ml........................................ 76
nitroglycerin cap cr 2.5 mg............................................. 54
nitroglycerin cap cr 6.5 mg............................................. 54
nitroglycerin cap cr 9 mg................................................ 54
NITROGLYCERIN LINGUAL – nitroglycerin lingual aerosol
400 mcg/spray................................................................... 54
nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur).......... 54
nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)
(Nitrolingual pumpspr)................................................... 54
NITROLINGUAL PUMPSPRAY – nitroglycerin tl soln 0.4
mg/spray (400 mcg/spray)................................................ 54
NITROMIST – nitroglycerin lingual aerosol 400 mcg/
spray...................................................................................54
NITROSTAT – nitroglycerin sl tab 0.3 mg.......................... 54
NIVA-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................... 121
nizatidine cap 150 mg...................................................... 72
nizatidine cap 300 mg...................................................... 72
NIZORAL – ketoconazole shampoo 2%.......................... 146
nonoxynol-9 gel 4%.......................................................... 28
NORDITROPIN FLEXPRO – somatropin inj 5
mg/1.5ml............................................................................ 38
mg/1.5ml............................................................................ 38
mg/1.5ml............................................................................ 38
mg/3ml............................................................................... 38
norethindrone acetate-ethinyl estradiol tab 1 mg-5
mcg.................................................................................... 26
norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5
mcg (Femhrt low dose).................................................. 26
norethindrone acetate tab 5 mg (Aygestin)................... 27
NORINYL 1+35 – norethindrone & ethinyl estradiol tab 1
mg-35 mcg......................................................................... 28
NORPACE CR – disopyramide phosphate cap sr 12hr 100
mg...................................................................................... 59
NORPACE CR – disopyramide phosphate cap sr 12hr 150
mg...................................................................................... 59
NORPACE – disopyramide phosphate cap 100 mg.......... 59
NORPACE – disopyramide phosphate cap 150 mg.......... 59
NOR-QD – norethindrone tab 0.35 mg.............................. 28
nortriptyline hcl cap 10 mg (Pamelor)............................83
NORTRIPTYLINE HCL – nortriptyline hcl soln 10
mg/5ml............................................................................... 83
NORVASC – amlodipine besylate tab 2.5 mg.................... 52
NORVASC – amlodipine besylate tab 5 mg.......................52
NORVASC – amlodipine besylate tab 10 mg..................... 52
NORVIR – ritonavir cap 100 mg........................................ 11
NORVIR – ritonavir oral soln 80 mg/ml.............................. 11
NORVIR – ritonavir tab 100 mg......................................... 11
NOVOEIGHT – antihemophilic factor (recombinant) for inj
250 unit............................................................................ 135
500 unit............................................................................ 135
1000 unit.......................................................................... 135
199
2016
1500 unit.......................................................................... 135
2000 unit.......................................................................... 136
3000 unit.......................................................................... 136
NOVOLIN 70/30 – insulin nph isophane & regular human
inj 100 unit/ml (70-30)....................................................... 35
NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/
ml........................................................................................ 35
NOVOLIN R – insulin regular (human) inj 100 unit/ml....... 34
NOVOLOG FLEXPEN – insulin aspart soln pen-injector
100 unit/ml......................................................................... 34
NOVOLOG – insulin aspart inj 100 unit/ml........................ 34
NOVOLOG MIX 70/30 – insulin aspart prot & aspart
(human) inj 100 unit/ml (70-30)........................................ 35
NOVOLOG MIX 70/30 PREFILL – insulin aspart prot &
aspart sus pen-inj 100 unit/ml (70-30)..............................35
NOVOLOG PENFILL – insulin aspart soln cartridge 100
unit/ml................................................................................. 34
NOVOSEVEN RT – coagulation factor viia (recomb) for inj
1 mg (1000 mcg).............................................................136
2 mg (2000 mcg).............................................................136
5 mg (5000 mcg).............................................................136
8 mg (8000 mcg).............................................................136
NOXAFIL – posaconazole susp 40 mg/ml........................... 7
NOXAFIL – posaconazole tab delayed release 100 mg...... 7
NUCORT – hydrocortisone acetate lotion 2%................. 150
NUCYNTA ER – tapentadol hcl tab sr 12hr 50 mg.......... 102
NUCYNTA ER – tapentadol hcl tab sr 12hr 100 mg........ 102
NUCYNTA – tapentadol hcl tab 50 mg............................ 102
NUCYNTA – tapentadol hcl tab 75 mg............................ 102
NUCYNTA – tapentadol hcl tab 100 mg.......................... 102
NUEDEXTA – dextromethorphan hbr-quinidine sulfate cap
20-10 mg............................................................................96
NULYTELY/FLAVOR PACKS – peg 3350-kcl-sod bicarbnacl for soln 420 gm......................................................... 70
NUOX – benzoyl peroxide-sulfur gel 6-3%...................... 145
NUTRESTORE – glutamine powd pack 5 gm................. 128
NUTROPIN AQ NUSPIN 10 – somatropin inj 10
mg/2ml............................................................................... 38
NUTROPIN AQ NUSPIN 20 – somatropin inj 20
mg/2ml............................................................................... 38
NUTROPIN AQ NUSPIN 5 – somatropin inj 5 mg/2ml...... 38
NUTROPIN AQ PEN – somatropin inj 10 mg/2ml............. 38
NUVARING – etonogestrel-ethinyl estradiol va ring
0.120-0.015 mg/24hr......................................................... 28
NUVIGIL – armodafinil tab 50 mg...................................... 93
NUVIGIL – armodafinil tab 150 mg.................................... 93
NUWIQ – antihemophilic factor (recombinant) for inj kit
250 unit............................................................................ 136
500 unit............................................................................ 136
1000 unit.......................................................................... 136
2000 unit.......................................................................... 136
NUWIQ – antihemophilic factor (recombinant) for inj 250
unit....................................................................................136
unit....................................................................................136
unit....................................................................................136
unit....................................................................................136
NYMALIZE – nimodipine oral soln 60 mg/20ml................. 52
nystatin cream 100000 unit/gm..................................... 146
nystatin oint 100000 unit/gm......................................... 146
nystatin susp 100000 unit/ml........................................ 143
nystatin tab 500000 unit..................................................... 7
nystatin topical powder..................................................146
nystatin-triamcinolone cream 100000-0.1 unit/gm%...................................................................................... 150
nystatin-triamcinolone oint 100000-0.1 unit/gm-%..... 150
O
OB COMPLETE/DHA – prenat w/ iron cbn-fe asp glyc-faomega cap 30-10-1-200 mg........................................... 122
OB COMPLETE GOLD – prenat w/o a w/fecbn-methfol-fadha cap 27.5-1-200 mg.................................................. 121
OB COMPLETE ONE – prenatal w/o a w/fecbn-fe asp
glyc-fa-fish cap 50-1-476 mg.......................................... 121
OB COMPLETE PETITE – prenat w/o a w/fecbnfeaspglyc-fa-omega cap 35-5-1-200 mg........................ 122
OB COMPLETE PREMIER – prenatal vit w/ fe cbn-fe asp
glyc-fa tab 30-20-1 mg.................................................... 122
OB COMPLETE – prenatal vit w/ iron carbonyl-fa tab
50-1.25 mg...................................................................... 121
OBIZUR – antihemophilic factor (recomb porc) rpfviii for inj
500 unit............................................................................ 136
OBSTETRIX DHA – prenat w/fecbn-fa-dss tab 29-1 mg &
omega 3 cap 387 mg pak...............................................122
OBSTETRIX EC – prenatal vit w/ dss-iron carbonyl-fa tab
29-1 mg............................................................................122
O-CAL FA – prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................... 121
O-CAL PRENATAL – prenatal vit w/ fe fumarate-fa tab
15-1 mg............................................................................121
octreotide acetate inj 50 mcg/ml (0.05 mg/ml)
(Sandostatin).................................................................... 40
(Sandostatin).................................................................... 40
(Sandostatin).................................................................... 40
200
2016
(Sandostatin).................................................................... 40
octreotide acetate inj 1000 mcg/ml (1 mg/ml)
(Sandostatin).................................................................... 40
OCUFEN – flurbiprofen sodium ophth soln 0.03%.......... 142
OCUFLOX – ofloxacin ophth soln 0.3%...........................138
ODEFSEY – emtricitabine-rilpivirine-tenofovir af tab
200-25-25 mg.................................................................... 11
ODOMZO – sonidegib phosphate cap 200 mg (base
equivalent)......................................................................... 20
OFEV – nintedanib esylate cap 100 mg (base
equivalent)......................................................................... 69
OFEV – nintedanib esylate cap 150 mg (base
equivalent)......................................................................... 69
OFLOXACIN – ofloxacin tab 400 mg................................... 6
ofloxacin ophth soln 0.3% (Ocuflox)............................ 138
ofloxacin otic soln 0.3%................................................. 142
OGESTREL – norgestrel & ethinyl estradiol tab 0.5 mg-50
mcg.....................................................................................28
olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax)....... 96
olanzapine-fluoxetine hcl cap 12-25 mg (Symbyax)..... 96
olanzapine-fluoxetine hcl cap 12-50 mg (Symbyax)..... 96
olanzapine orally disintegrating tab 5 mg (Zyprexa
zydis)................................................................................. 86
zydis)................................................................................. 86
zydis)................................................................................. 86
zydis)................................................................................. 86
olanzapine tab 2.5 mg (Zyprexa).....................................86
olanzapine tab 5 mg (Zyprexa)........................................86
olanzapine tab 7.5 mg (Zyprexa).....................................86
olanzapine tab 10 mg (Zyprexa)......................................86
olopatadine hcl nasal soln 0.6% (Patanase).................. 65
olopatadine hcl ophth soln 0.1% (base equivalent)
(Patanol).......................................................................... 142
OLUX – clobetasol propionate foam 0.05%..................... 150
OLUX-E – clobetasol propionate emulsion foam
0.05%............................................................................... 150
OLYSIO – simeprevir sodium cap 150 mg (base
equivalent)............................................................................8
OMECLAMOX-PAK – amoxicillin cap-clarithro tab w/
omepraz cap dr therapy pack........................................... 72
omega-3-acid ethyl esters cap 1 gm (Lovaza)...............56
omeprazole cap delayed release 10 mg (Prilosec)....... 72
omeprazole-sodium bicarbonate cap 20-1100 mg
(Zegerid)............................................................................ 72
omeprazole-sodium bicarbonate cap 40-1100 mg
(Zegerid)............................................................................ 72
OMNIFLEX DIAPHRAGM – diaphragms........................... 28
OMNIPRED – prednisolone acetate ophth susp 1%....... 139
OMNITROPE – somatropin for inj 5.8 mg......................... 38
OMNITROPE – somatropin inj 5 mg/1.5ml........................ 38
OMNITROPE – somatropin inj 10 mg/1.5ml...................... 38
ondansetron hcl oral soln 4 mg/5ml (Zofran)................ 73
ondansetron hcl tab 24 mg............................................. 73
ondansetron hcl tab 4 mg (Zofran).................................73
ondansetron hcl tab 8 mg (Zofran).................................73
ondansetron orally disintegrating tab 4 mg (Zofran
odt).....................................................................................73
ondansetron orally disintegrating tab 8 mg (Zofran
odt).....................................................................................73
ONFI – clobazam suspension 2.5 mg/ml......................... 113
ONFI – clobazam tab 10 mg............................................ 113
ONFI – clobazam tab 20 mg............................................ 113
ONGLYZA – saxagliptin hcl tab 2.5 mg (base equiv).........33
ONGLYZA – saxagliptin hcl tab 5 mg (base equiv)............33
OPANA ER (CRUSH RESISTANT – oxymorphone hcl tab
er 12hr deter 5 mg.......................................................... 102
er 12hr deter 7.5 mg....................................................... 102
er 12hr deter 10 mg........................................................ 102
er 12hr deter 15 mg........................................................ 102
er 12hr deter 20 mg........................................................ 102
er 12hr deter 30 mg........................................................ 102
er 12hr deter 40 mg........................................................ 102
OPANA – oxymorphone hcl tab 5 mg.............................. 102
OPANA – oxymorphone hcl tab 10 mg............................ 102
OPSUMIT – macitentan tab 10 mg.................................... 62
OPTIONS CONCEPTROL VAGINA – nonoxynol-9 gel
4%...................................................................................... 28
OPTIONS GYNOL II VAGINAL – nonoxynol-9 gel 3%...... 28
ORACIT – sodium citrate & citric acid soln 490-640
mg/5ml............................................................................... 79
oral contraceptives – all generics.................................. 28
ORAP – pimozide tab 1 mg............................................... 96
ORAP – pimozide tab 2 mg............................................... 96
ORAPRED ODT – prednisolone sod phos orally disintegr
tab 10 mg (base eq)......................................................... 23
tab 15 mg (base eq)......................................................... 23
tab 30 mg (base eq)......................................................... 23
ORAVIG – miconazole buccal tab 50 mg (mouththroat)............................................................................... 143
ORENCIA – abatacept subcutaneous soln prefilled syringe
125 mg/ml........................................................................ 106
ORENITRAM – treprostinil diolamine tab cr 0.125 mg
(base equiv)....................................................................... 62
201
2016
ORENITRAM – treprostinil diolamine tab cr 0.25 mg (base
equiv)................................................................................. 62
ORENITRAM – treprostinil diolamine tab cr 1 mg (base
equiv)................................................................................. 63
ORENITRAM – treprostinil diolamine tab cr 2.5 mg (base
equiv)................................................................................. 63
ORFADIN – nitisinone cap 2 mg........................................ 41
ORFADIN – nitisinone cap 5 mg........................................ 41
ORFADIN – nitisinone cap 10 mg...................................... 41
ORFADIN – nitisinone susp 4 mg/ml................................. 41
ORKAMBI – lumacaftor-ivacaftor tab 200-125 mg.............70
orphenadrine citrate tab sr 12hr 100 mg..................... 118
ORTHO-CYCLEN – norgestimate & ethinyl estradiol tab
0.25 mg-35 mcg................................................................ 29
ORTHO DIAPHRAGM COIL SPRI – diaphragm coil spring
kit 50 mm........................................................................... 28
kit 100 mm......................................................................... 28
kit 105 mm......................................................................... 28
ORTHO DIAPHRAGM FLAT SPRI – diaphragm flat spring
kit 55 mm........................................................................... 28
kit 60 mm........................................................................... 28
kit 65 mm........................................................................... 28
kit 70 mm........................................................................... 29
kit 75 mm........................................................................... 29
kit 80 mm........................................................................... 29
kit 85 mm........................................................................... 29
kit 90 mm........................................................................... 29
kit 95 mm........................................................................... 29
ORTHO MICRONOR – norethindrone tab 0.35 mg........... 29
ORTHO-NOVUM 7/7/7 – norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg............................................ 29
ORTHO-NOVUM 1/35 – norethindrone & ethinyl estradiol
tab 1 mg-35 mcg............................................................... 29
ORTHO TRI-CYCLEN LO – norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg................................... 29
ORTHO TRI-CYCLEN – norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg................................... 29
OSENI – alogliptin-pioglitazone tab 12.5-15 mg................ 33
OSENI – alogliptin-pioglitazone tab 25-15 mg................... 33
OSMOPREP – sod phos mono-sod phos di tabs
1.102-0.398 gm(1.5gm na phos)...................................... 70
OSPHENA – ospemifene tab 60 mg.................................. 41
OTEZLA – apremilast tab 30 mg..................................... 106
OTEZLA – apremilast tab starter therapy pack 10 mg & 20
mg & 30 mg.................................................................... 106
OTREXUP – methotrexate soln pf auto-injector 7.5
mg/0.4ml.......................................................................... 106
OTREXUP – methotrexate soln pf auto-injector 10
mg/0.4ml.......................................................................... 106
mg/0.4ml.......................................................................... 106
mg/0.4ml.......................................................................... 106
mg/0.4ml.......................................................................... 106
mg/0.4ml.......................................................................... 106
mg/0.4ml.......................................................................... 106
OVIDE – malathion lotion 0.5%........................................152
OXANDRIN – oxandrolone tab 2.5 mg.............................. 24
OXANDRIN – oxandrolone tab 10 mg............................... 24
oxandrolone tab 2.5 mg (Oxandrin)................................24
oxandrolone tab 10 mg (Oxandrin).................................24
oxaprozin tab 600 mg (Daypro).....................................106
oxazepam cap 10 mg........................................................80
oxazepam cap 15 mg........................................................80
oxazepam cap 30 mg........................................................80
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
(Trileptal)......................................................................... 113
oxcarbazepine tab 150 mg (Trileptal)........................... 113
oxiconazole nitrate cream 1% (Oxistat)....................... 146
OXSORALEN – methoxsalen lotion 1%.......................... 152
OXSORALEN ULTRA – methoxsalen rapid cap 10
mg.................................................................................... 152
OXTELLAR XR – oxcarbazepine tab sr 24hr 150 mg......113
oxybutynin chloride syrup 5 mg/5ml..............................77
oxybutynin chloride tab 5 mg......................................... 77
oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)...... 77
oxybutynin chloride tab sr 24hr 10 mg (Ditropan
xl)....................................................................................... 77
oxybutynin chloride tab sr 24hr 15 mg (Ditropan
xl)....................................................................................... 77
OXYCODONE/ACETAMINOPHEN – oxycodone w/
acetaminophen soln 5-325 mg/5ml................................ 103
OXYCODONE/IBUPROFEN – oxycodone-ibuprofen tab
5-400 mg......................................................................... 103
oxycodone-aspirin tab 4.8355-325 mg (Percodan)..... 103
oxycodone hcl cap 5 mg............................................... 102
oxycodone hcl conc 100 mg/5ml (20 mg/ml)............... 102
OXYCODONE HCL ER – oxycodone hcl tab er 12hr deter
10 mg............................................................................... 102
15 mg............................................................................... 102
202
2016
20 mg............................................................................... 102
30 mg............................................................................... 102
40 mg............................................................................... 103
60 mg............................................................................... 103
80 mg............................................................................... 103
oxycodone hcl soln 5 mg/5ml....................................... 103
oxycodone hcl tab 10 mg.............................................. 103
oxycodone hcl tab 20 mg.............................................. 103
oxycodone hcl tab 5 mg (Roxicodone)........................ 103
oxycodone hcl tab 15 mg (Roxicodone)...................... 103
oxycodone hcl tab 30 mg (Roxicodone)...................... 103
oxycodone w/ acetaminophen tab 2.5-325 mg
(Percocet)....................................................................... 103
oxycodone w/ acetaminophen tab 5-325 mg
(Percocet)....................................................................... 103
oxycodone w/ acetaminophen tab 7.5-325 mg
(Percocet)....................................................................... 103
oxycodone w/ acetaminophen tab 10-325 mg
(Percocet)....................................................................... 103
OXYCONTIN – oxycodone hcl tab er 12hr deter 10
mg.................................................................................... 103
mg.................................................................................... 103
mg.................................................................................... 103
mg.................................................................................... 103
mg.................................................................................... 103
mg.................................................................................... 103
mg.................................................................................... 103
oxymorphone hcl tab 5 mg (Opana).............................103
oxymorphone hcl tab 10 mg (Opana)...........................103
oxymorphone hcl tab sr 12hr 5 mg.............................. 103
oxymorphone hcl tab sr 12hr 7.5 mg........................... 103
oxymorphone hcl tab sr 12hr 10 mg............................ 103
P
paliperidone tab sr 24hr 1.5 mg (Invega)....................... 86
paliperidone tab sr 24hr 3 mg (Invega).......................... 86
PAMELOR – nortriptyline hcl cap 10 mg............................83
PAMINE FORTE – methscopolamine bromide tab 5
mg...................................................................................... 72
PAMINE – methscopolamine bromide tab 2.5 mg............. 72
PANCREAZE – pancrelipase (lip-prot-amyl) dr cap
4200-10000-17500 unit..................................................... 73
10500-25000-43750 unit................................................... 74
16800-40000-70000 unit................................................... 74
21000-37000-61000 unit................................................... 74
PANRETIN – alitretinoin gel 0.1%.................................... 152
pantoprazole sodium ec tab 20 mg (base equiv)
(Protonix).......................................................................... 72
pantoprazole sodium ec tab 40 mg (base equiv)
(Protonix).......................................................................... 72
PARAFON FORTE DSC – chlorzoxazone tab 500
mg.................................................................................... 118
PAREGORIC – paregoric tincture 2 mg/5ml...................... 70
paricalcitol cap 4 mcg...................................................... 41
paricalcitol cap 1 mcg (Zemplar).................................... 41
paricalcitol cap 2 mcg (Zemplar).................................... 41
PARLODEL – bromocriptine mesylate cap 5 mg............. 116
PARNATE – tranylcypromine sulfate tab 10 mg................ 83
paromomycin sulfate cap 250 mg.................................... 6
paroxetine hcl tab 10 mg (Paxil)..................................... 83
paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)................ 83
paroxetine hcl tab sr 24hr 25 mg (Paxil cr)................... 83
paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)................ 83
PASER – aminosalicylic acid cr granules packet 4 gm........ 6
PATADAY – olopatadine hcl ophth soln 0.2% (base
equivalent)....................................................................... 142
PATANASE – olopatadine hcl nasal soln 0.6%.................. 65
PATANOL – olopatadine hcl ophth soln 0.1% (base
equivalent)....................................................................... 142
PAXIL – paroxetine hcl oral susp 10 mg/5ml (base
equiv)................................................................................. 83
PAZEO – olopatadine hcl ophth soln 0.7% (base
equivalent)....................................................................... 142
PCE – erythromycin w/ enteric coated particles tab 333
mg........................................................................................ 4
PCE – erythromycin w/ enteric coated particles tab 500
mg........................................................................................ 4
PEDIAPRED – prednisolone sod phosph oral soln 6.7
mg/5ml (5 mg/5ml base)................................................... 23
PEDIARIX – diph-tetanus tox-acell pert-hepatitis b-polio
ipv vac inj...........................................................................16
PEDVAX HIB – haemophilus b polysaccharide conj vac im
susp 7.5 mcg/0.5 ml..........................................................17
PEGANONE – ethotoin tab 250 mg................................. 113
PEGASYS – peginterferon alfa-2a inj 180 mcg/ml.............. 9
PEGASYS – peginterferon alfa-2a inj 180 mcg/0.5ml......... 9
203
2016
PEGASYS PROCLICK – peginterferon alfa-2a inj 135
mcg/0.5ml.............................................................................9
PEGASYS PROCLICK – peginterferon alfa-2a inj 180
mcg/0.5ml.............................................................................9
PEGINTRON – peginterferon alfa-2b for inj kit 50
mcg/0.5ml.............................................................................9
mcg/0.5ml.............................................................................9
mcg/0.5ml.............................................................................9
mcg/0.5ml.............................................................................9
PEG-INTRON REDIPEN PAK 4 – peginterferon alfa-2b for
inj kit 120 mcg/0.5ml........................................................... 8
PEG-INTRON REDIPEN – peginterferon alfa-2b for inj kit
50 mcg/0.5ml....................................................................... 8
80 mcg/0.5ml....................................................................... 8
120 mcg/0.5ml..................................................................... 8
150 mcg/0.5ml..................................................................... 8
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm
(Colyte-flavor packs)....................................................... 70
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm
(Golytely)...........................................................................70
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
(Nulytely/flavor pack)...................................................... 70
penicillin v potassium for soln 125 mg/5ml.....................2
penicillin v potassium for soln 250 mg/5ml.....................2
penicillin v potassium tab 250 mg....................................2
penicillin v potassium tab 500 mg....................................2
PENLAC NAIL LACQUER – ciclopirox solution 8%.........146
PENTACEL – diph-ac per-tet tox ad-poliov-haemoph b
poly vac for im susp.......................................................... 17
PENTASA – mesalamine cap cr 250 mg........................... 75
PENTASA – mesalamine cap cr 500 mg........................... 75
pentazocine w/ naloxone tab 50-0.5 mg.......................103
pentoxifylline tab cr 400 mg.......................................... 132
PERFOROMIST – formoterol fumarate soln nebu 20
mcg/2ml..............................................................................68
PERIDEX – chlorhexidine gluconate soln 0.12%.............143
perindopril erbumine tab 2 mg....................................... 44
perindopril erbumine tab 4 mg (Aceon)......................... 44
perindopril erbumine tab 8 mg (Aceon)......................... 44
permethrin cream 5% (Elimite)......................................152
PERPHENAZINE/AMITRIPTYLIN – perphenazineamitriptyline tab 2-10 mg.................................................. 96
perphenazine tab 2 mg.................................................... 87
perphenazine tab 16 mg.................................................. 87
PERTZYE – pancrelipase (lip-prot-amyl) dr cap
8000-28750-30250 unit..................................................... 74
PERTZYE – pancrelipase (lip-prot-amyl) dr cap
16000-57500-60500 unit................................................... 74
PEXEVA – paroxetine mesylate tab 10 mg (base
equiv)................................................................................. 83
equiv)................................................................................. 83
equiv)................................................................................. 83
equiv)................................................................................. 83
phenazopyridine hcl tab 100 mg (Pyridium).................. 79
phenazopyridine hcl tab 200 mg (Pyridium).................. 79
phenelzine sulfate tab 15 mg (Nardil)............................ 83
phenobarbital elixir 20 mg/5ml........................................88
PHENOBARBITAL – phenobarbital tab 15 mg.................. 88
PHENOBARBITAL – phenobarbital tab 100 mg................ 88
phenobarbital tab 16.2 mg............................................... 88
phenoxybenzamine hcl cap 10 mg (Dibenzyline)......... 63
phenylephrine hcl ophth soln 2.5%.............................. 142
phenylephrine hcl ophth soln 10%............................... 142
phenylephrine-promethazine w/ codeine syrup
5-6.25-10 mg/5ml............................................................. 65
PHENYTEK – phenytoin sodium extended cap 200
mg.................................................................................... 113
PHENYTEK – phenytoin sodium extended cap 300
mg.................................................................................... 113
phenytoin chew tab 50 mg (Dilantin infatabs).............113
phenytoin sodium extended cap 100 mg
(Dilantin)..........................................................................113
(Phenytek)....................................................................... 113
(Phenytek).......................................................................113
phenytoin susp 125 mg/5ml (Dilantin-125).................. 113
PHOSLO – calcium acetate (phosphate binder) cap 667
mg (169 mg ca)................................................................. 75
PHOSLYRA – calcium acetate (phosphate binder) oral
soln 667 mg/5ml................................................................ 75
PHOSPHOLINE IODIDE – echothiophate iodide ophth for
soln 0.125%..................................................................... 140
PICATO – ingenol mebutate gel 0.015%......................... 152
PICATO – ingenol mebutate gel 0.05%........................... 152
pilocarpine hcl ophth soln 1% (Isopto carpine).......... 140
204
2016
pilocarpine hcl tab 5 mg (Salagen)...............................143
pilocarpine hcl tab 7.5 mg (Salagen)............................143
pimozide tab 1 mg (Orap)................................................ 96
pimozide tab 2 mg (Orap)................................................ 97
pindolol tab 5 mg.............................................................. 49
pindolol tab 10 mg............................................................ 49
pioglitazone hcl-glimepiride tab 30-2 mg (Duetact)...... 33
pioglitazone hcl-glimepiride tab 30-4 mg (Duetact)...... 33
pioglitazone hcl-metformin hcl tab 15-500 mg
(Actoplus met)................................................................. 33
pioglitazone hcl-metformin hcl tab 15-850 mg
(Actoplus met)................................................................. 33
pioglitazone hcl tab 15 mg (base equiv) (Actos)...........33
piroxicam cap 10 mg (Feldene).....................................106
piroxicam cap 20 mg (Feldene).....................................106
PLAN B ONE-STEP – levonorgestrel tab 1.5 mg.............. 29
PLAQUENIL – hydroxychloroquine sulfate tab 200 mg..... 13
PLEGRIDY – peginterferon beta-1a soln pen-injector 125
mcg/0.5ml...........................................................................94
PLEGRIDY – peginterferon beta-1a soln prefilled syringe
125 mcg/0.5ml................................................................... 94
PLEGRIDY STARTER PACK – peginterferon beta-1a soln
pen-inj 63 & 94 mcg/0.5ml pack....................................... 94
PLEGRIDY STARTER PACK – peginterferon beta-1a soln
pref syr 63 & 94 mcg/0.5ml pack..................................... 94
PNEUMOVAX 23/1 DOSE – pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml.............................................. 17
PNEUMOVAX 23 – pneumococcal vaccine polyvalent inj
25 mcg/0.5ml..................................................................... 17
PNV-DHA+DOCUSATE – prenatal w/o vit a w/ fe fum-dssfa-dha cap 27-1.25-300 mg............................................ 122
PNV-DHA – prenat w/o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg........................................................... 122
PNV FERROUS FUMARATE/DOCU – prenatal vit w/ dssfe fumarate-fa tab 29-1 mg............................................. 122
PNV FOLIC ACID + IRON MUL – prenatal vit w/ fe
PNV OB+DHA – prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 250 mg pack..................................................... 122
PNV-OMEGA – prenat w/o a w/ fe fumerate-methylfolatefa-omega 3 cap............................................................... 122
PNV PRENATAL PLUS MULTIVI – prenatal vit w/ fe
PNV-SELECT – prenatal vit w/ fe fum-methylfolate-fa tab
27-0.6-0.4 mg.................................................................. 122
PNV TABS 29-1 – prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................... 122
PNV-TOTAL – prenat w/ fe cbn-fe bisglyc-fa-fish oil cap
35-5-1.2 mg..................................................................... 122
PNV-VP-U – prenatal w/o a vit w/ fe fumarate-fa cap
106.5-1 mg...................................................................... 122
podofilox soln 0.5% (Condylox).................................... 152
polyethylene glycol 3350 oral packet............................. 70
polyethylene glycol 3350 oral powder........................... 70
polymyxin b-trimethoprim ophth soln 10000 unit/
ml-0.1% (Polytrim)......................................................... 138
POLYTRIM – polymyxin b-trimethoprim ophth soln 10000
unit/ml-0.1%..................................................................... 138
POMALYST – pomalidomide cap 1 mg............................. 20
PONSTEL – mefenamic acid cap 250 mg....................... 106
pot & sod citrates w/ cit ac soln 550-500-334
mg/5ml............................................................................... 79
potassium bicarbonate effer tab 25 meq..................... 128
potassium chloride cap cr 8 meq (Micro-k)................. 128
potassium chloride cap cr 10 meq (Micro-k)............... 128
POTASSIUM CHLORIDE ER – potassium chloride tab cr 8
meq (600 mg).................................................................. 128
POTASSIUM CHLORIDE ER – potassium chloride tab cr
20 meq (1500 mg).......................................................... 128
potassium chloride microencapsulated crys cr tab 10
meq.................................................................................. 128
potassium chloride microencapsulated crys cr tab 20
meq.................................................................................. 128
potassium chloride oral soln 10% (20 meq/15ml)....... 128
potassium chloride oral soln 20% (40 meq/15ml)....... 128
potassium chloride powder packet 20 meq................ 128
potassium chloride tab cr 10 meq (K-tab)................... 128
potassium chloride tab cr 8 meq (600 mg).................. 128
potassium citrate & citric acid powder pack 3300-1002
mg...................................................................................... 79
potassium citrate tab cr 5 meq (540 mg) (Urocit-k
5)........................................................................................ 79
10)...................................................................................... 79
15)...................................................................................... 79
pot bicarbonate & chloride effer tab 25 meq............... 127
POTIGA – ezogabine tab 50 mg...................................... 113
POTIGA – ezogabine tab 200 mg.................................... 113
pot phos monobasic w/sod phos di & monobas tab
155-852-130mg (K-phos neutral)................................. 128
PRADAXA – dabigatran etexilate mesylate cap 75 mg
(etexilate base eq).......................................................... 132
PRALUENT – alirocumab subcutaneous soln pen-injector
75 mg/ml............................................................................ 56
PRALUENT – alirocumab subcutaneous soln pen-injector
150 mg/ml.......................................................................... 56
PRALUENT – alirocumab subcutaneous soln prefilled
syringe 75 mg/ml............................................................... 56
PRALUENT – alirocumab subcutaneous soln prefilled
syringe 150 mg/ml............................................................. 56
205
2016
pramipexole dihydrochloride tab 0.125 mg
(Mirapex)......................................................................... 116
(Mirapex)......................................................................... 116
(Mirapex)......................................................................... 116
(Mirapex)......................................................................... 116
pramipexole dihydrochloride tab 1 mg (Mirapex)....... 116
(Mirapex)......................................................................... 116
pramipexole dihydrochloride tab sr 24hr 0.375 mg
(Mirapex er).................................................................... 116
(Mirapex er).................................................................... 116
(Mirapex er).................................................................... 116
(Mirapex er).................................................................... 116
pramipexole dihydrochloride tab sr 24hr 3 mg
(Mirapex er).................................................................... 116
(Mirapex er).................................................................... 116
PRAMOSONE – pramoxine-hc cream 1-1%................... 150
PRAMOSONE – pramoxine-hc lotion 1-1%..................... 150
PRAMOSONE – pramoxine-hc lotion 1-2.5%.................. 150
PRAMOSONE – pramoxine-hc oint 1-2.5%..................... 150
PRANDIN – repaglinide tab 0.5 mg................................... 33
PRANDIN – repaglinide tab 1 mg...................................... 33
PRANDIN – repaglinide tab 2 mg...................................... 33
PRAVACHOL – pravastatin sodium tab 20 mg.................. 56
pravastatin sodium tab 10 mg........................................ 56
pravastatin sodium tab 20 mg (Pravachol)....................56
prazosin hcl cap 1 mg (Minipress)................................. 63
PRECOSE – acarbose tab 25 mg......................................33
PRECOSE – acarbose tab 50 mg......................................33
PRECOSE – acarbose tab 100 mg....................................33
PRED FORTE – prednisolone acetate ophth susp
1%.................................................................................... 139
PRED-G – gentamicin-prednisolone ace ophth susp
0.3-1%.............................................................................. 139
PRED-G S.O.P. – gentamicin-prednisolone ace ophth oint
0.3-0.6%........................................................................... 139
PRED MILD – prednisolone acetate ophth susp
0.12%............................................................................... 139
prednicarbate cream 0.1% (Dermatop)........................ 150
prednicarbate oint 0.1% (Dermatop)............................ 150
prednisolone acetate ophth susp 1% (Pred forte)...... 139
PREDNISOLONE SODIUM PHOSP – prednisolone
sodium phosphate ophth soln 1%.................................. 139
PREDNISOLONE SODIUM PHOSP – prednisolone
sodium phosphate oral soln 25 mg/5ml (base eq)........... 23
prednisolone sod phos orally disintegr tab 10 mg
(base eq) (Orapred odt).................................................. 23
prednisolone sod phosphate oral soln 15 mg/5ml
(base equiv)...................................................................... 23
prednisolone sod phosph oral soln 6.7 mg/5ml (5
mg/5ml base) (Pediapred).............................................. 23
prednisolone syrup 15 mg/5ml (usp solution
equivalent)........................................................................ 23
PREDNISONE INTENSOL – prednisone conc 5 mg/
ml........................................................................................ 24
PREDNISONE – prednisone oral soln 5 mg/5ml............... 23
PREDNISONE – prednisone tab 50 mg............................ 23
PREDNISONE – prednisone tab therapy pack 5 mg
(21)..................................................................................... 23
(48)..................................................................................... 23
(21)..................................................................................... 24
(48)..................................................................................... 24
prednisone tab 1 mg........................................................ 24
prednisone tab 2.5 mg..................................................... 24
prednisone tab 5 mg........................................................ 24
prednisone tab 10 mg...................................................... 24
prednisone tab 20 mg...................................................... 24
PREFERAOB +DHA – prenat-fe poly cmplx 28mg-fe heme
poly-fa tab&dha cap pack............................................... 122
PREFERAOB ONE – prenat-fe poly cmplx-fe heme polyfa-dha cap 22-6-1-200 mg.............................................. 122
PREFERA OB – prenat vit-fe poly cmplx-fe heme poly-fa
tab 34-1 mg..................................................................... 122
PREFEST – estradiol tab 1 mg(15)/estrad-norgestimate
tab 1-0.09mg(15)............................................................... 26
PREMARIN – estrogens, conjugated tab 0.3 mg...............26
PREMARIN – estrogens, conjugated tab 0.45 mg.............26
PREMARIN – estrogens, conjugated tab 0.625 mg...........26
PREMARIN – estrogens, conjugated tab 0.9 mg...............26
PREMARIN – estrogens, conjugated tab 1.25 mg.............26
PREMARIN – estrogens, conjugated vaginal cream 0.625
mg/gm................................................................................ 78
PREMPHASE – conj est 0.625(14)/conj est-medroxypro
ac tab 0.625-5mg(14)........................................................ 27
PREMPRO – conjugated estrogen-medroxyprogest
acetate tab 0.3-1.5 mg...................................................... 27
acetate tab 0.45-1.5 mg.................................................... 27
acetate tab 0.625-2.5 mg.................................................. 27
acetate tab 0.625-5 mg..................................................... 27
206
2016
PRENA1 CHEW – prenat w/ b2-b6-b12-d3-folic acid chew
tab 1.4 mg....................................................................... 124
PRENAISSANCE BALANCE – prenatal w/o vit a w/ fe
cbn-dss-fa-dha cap 30-1-260 mg................................... 122
PRENAISSANCE HARMONY DHA – prenat w/fe poly-na
fered-fa tab 27-1 & omega cap dr 380mg...................... 122
PRENAISSANCE NEXT-B – prenatal w/ calcium-vit b6-faginger tab 1.22 mg.......................................................... 123
PRENAISSANCE NEXT – prenatal w/ calcium-vit b6-faginger tab 1.2 mg............................................................ 123
PRENAISSANCE PLUS – prenatal w/o a w/fe cbn-dss-fadha cap 28-1-250 mg......................................................123
PRENAISSANCE – prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg........................................................ 122
PRENA1 PEARL – prenat w/oa w/fefum-na fered-fa-dha
cap cr 30-1.4-200 mg......................................................124
PRENATABS FA – prenatal vit w/ fe fumarate-fa tab 29-1
mg.................................................................................... 123
PRENATABS RX – prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................... 123
PRENATAL PLUS IRON – prenatal vit w/ iron carbonyl-fa
tab 29-1 mg..................................................................... 123
PRENATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................... 123
PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab
29-1 mg............................................................................123
PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab
29-1 mg............................................................................123
PRENATAL – prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................... 123
PRENATAL-U – prenatal w/o a vit w/ fe fumarate-fa cap
106.5-1 mg...................................................................... 123
PRENATAL VITAMINS PLUS LO – prenatal vit w/ fe
PRENATA – prenatal w/o a vit w/ fe fum-fa tab chew 29-1
mg.................................................................................... 123
PRENATE AM – prenatal w/ calcium-vit b6-vit b12-faginger tab 1 mg............................................................... 123
PRENATE DHA – prenat w/o a w/feaspg-methfol-fa-dha
cap 18-0.6-0.4-300 mg....................................................123
PRENATE DHA – prenat w/o a w/fefum-methfol-fa-dha
cap 28-0.6-0.4-300 mg....................................................123
PRENATE ELITE – prenatal vit w/ fe fum-methylfolate-fa
tab 26-0.6-0.4 mg............................................................ 123
PRENATE ELITE – prenatal w/ fe asp gly-l methylfol-fa tab
20-0.6-0.4 mg.................................................................. 123
PRENATE ENHANCE – prenat w/o a w/fefum-methfol-fadha cap 28-0.6-0.4-400 mg............................................ 123
PRENATE ESSENTIAL – prenat w/o a w/feaspg-methfolfa-dha cap 18-0.6-0.4-300 mg........................................ 123
PRENATE ESSENTIAL – prenat w/o a w/feasp-methylf-faomeg cap 29-0.6-0.4-340 mg......................................... 123
PRENATE MINI – prenat w/oa w/fecb-feasp-meth-fa-dha
cap 18-0.6-0.4-350 mg....................................................123
PRENATE MINI – prenat w/o a w/fecbn-methylf-fa-dha cap
29-0.6-0.4-350 mg........................................................... 123
PRENATE PIXIE – prenat w/o a w/feaspg-methfol-fa-dha
cap 10-0.6-0.4-200 mg....................................................123
PRENATE – prenat mv & min w/ l-methylfolate-fa chew tab
0.6-0.4 mg....................................................................... 123
PRENATE RESTORE – prenat w/o a w/fefum-methfol-fadha cap 27-0.6-0.4-400 mg............................................ 123
PRENATE STAR – prenatal vit w/ fe asparto glycinate-fa
tab 20-1 mg..................................................................... 123
PRENTIF CAVITY-RIM CERVIC – cervical cap 22
mm..................................................................................... 29
mm..................................................................................... 29
mm..................................................................................... 29
mm..................................................................................... 29
PRENTIF FITTING SET – cervical caps............................ 29
PREPLUS – prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................... 124
PREPOPIK – sod picosulfate-mg oxide-citric acid pack 10
mg-3.5 gm-12 gm.............................................................. 70
PREQUE 10 – prenatal mv w/fe carbonyl-dss-fa-dha tab
15-25-0.5-50 mg.............................................................. 124
PRETAB – prenatal vit w/ fe fumarate-fa tab 29-1 mg..... 124
PREVNAR 13 – pneumococcal 13-valent conjugate
vaccine inj.......................................................................... 17
PREVPAC – amoxicillin cap-clarithro tab-lansopraz cap dr
therapy pack...................................................................... 72
PREZCOBIX – darunavir-cobicistat tab 800-150 mg......... 11
PREZISTA – darunavir ethanolate susp 100 mg/ml (base
equiv)................................................................................. 11
PREZISTA – darunavir ethanolate tab 75 mg (base
equiv)................................................................................. 11
equiv)................................................................................. 11
equiv)................................................................................. 11
equiv)................................................................................. 11
PRIFTIN – rifapentine tab 150 mg....................................... 6
PRILOSEC OTC – omeprazole magnesium delayed
release tab 20 mg (base equiv)........................................72
PRIMAQUINE PHOSPHATE – primaquine phosphate tab
26.3 mg (15 mg base)...................................................... 13
primidone tab 50 mg (Mysoline)................................... 113
primidone tab 250 mg (Mysoline)................................. 113
PRIMSOL – trimethoprim hcl oral soln 50 mg/5ml (base
equiv)................................................................................. 14
PRISTIQ – desvenlafaxine succinate tab sr 24hr 25 mg
(base equiv)....................................................................... 83
(base equiv)....................................................................... 83
(base equiv)....................................................................... 83
PR NATAL 400 EC – prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 400 pk...................................................... 122
207
2016
PR NATAL 430 EC – prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 430 pk...................................................... 122
PR NATAL 400 – prenat-fe bis-fe prot succ-fa-ca tab &
omega 3 cap 400 pk....................................................... 122
PR NATAL 430 – prenat-fe bis-fe prot succ-fa-ca tab &
omega 3 cap 430 pk....................................................... 122
PROAIR HFA – albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv).......................................................... 68
PROAIR RESPICLICK – albuterol sulfate aer pow ba 108
mcg/act (90 mcg base equiv)........................................... 68
probenecid tab 500 mg.................................................. 109
PROCARDIA – nifedipine cap 10 mg................................ 52
PROCARDIA XL – nifedipine tab sr 24hr osmotic release
30 mg................................................................................. 52
60 mg................................................................................. 52
90 mg................................................................................. 52
PROCENTRA – dextroamphetamine sulfate oral solution 5
mg/5ml............................................................................... 93
prochlorperazine maleate tab 5 mg (base equivalent)
(Compazine)..................................................................... 87
prochlorperazine maleate tab 10 mg (base equivalent)
(Compazine)..................................................................... 87
prochlorperazine suppos 25 mg..................................... 87
PROCRIT – epoetin alfa inj 2000 unit/ml......................... 132
PROCRIT – epoetin alfa inj 10000 unit/ml....................... 132
PROCTOCORT – hydrocortisone rectal cream 1%......... 143
PROCTOFOAM HC – hydrocortisone acetate w/
pramoxine rectal foam 1-1%........................................... 144
PROCYSBI – cysteamine bitartrate cap delayed release
25 mg (base equiv)........................................................... 79
PROCYSBI – cysteamine bitartrate cap delayed release
75 mg (base equiv)........................................................... 79
PRODRIN – isometheptene-caffeine-acetaminophen tab
65-20-325 mg.................................................................. 108
PROFILNINE – factor ix complex for inj 500 unit............. 136
PROFILNINE – factor ix complex for inj 1000 unit........... 136
PROFILNINE – factor ix complex for inj 1500 unit........... 136
PROFILNINE SD – factor ix complex for inj 500 unit....... 136
PROFILNINE SD – factor ix complex for inj 1000 unit..... 136
PROFILNINE SD – factor ix complex for inj 1500 unit..... 136
progesterone micronized cap 100 mg
(Prometrium).................................................................... 27
progesterone micronized cap 200 mg
(Prometrium).................................................................... 27
PROGLYCEM – diazoxide susp 50 mg/ml......................... 33
PROGRAF – tacrolimus cap 0.5 mg................................ 155
PROGRAF – tacrolimus cap 1 mg................................... 155
PROGRAF – tacrolimus cap 5 mg................................... 155
PROLENSA – bromfenac sodium ophth soln 0.07% (base
equivalent)....................................................................... 142
PROMACTA – eltrombopag olamine tab 12.5 mg (base
equiv)............................................................................... 132
PROMACTA – eltrombopag olamine tab 25 mg (base
equiv)............................................................................... 132
equiv)............................................................................... 132
equiv)............................................................................... 132
promethazine & phenylephrine syrup 6.25-5
mg/5ml............................................................................... 65
promethazine-dm syrup 6.25-15 mg/5ml........................65
promethazine hcl suppos 12.5 mg................................. 64
promethazine hcl suppos 25 mg.................................... 64
promethazine hcl suppos 50 mg.................................... 64
promethazine hcl syrup 6.25 mg/5ml............................. 64
promethazine hcl tab 12.5 mg......................................... 64
promethazine hcl tab 25 mg............................................ 64
promethazine hcl tab 50 mg............................................ 64
promethazine w/ codeine syrup 6.25-10 mg/5ml........... 65
propafenone hcl cap sr 12hr 225 mg (Rythmol sr)....... 59
propafenone hcl tab 150 mg........................................... 59
propafenone hcl tab 300 mg........................................... 60
propafenone hcl tab 225 mg (Rythmol)......................... 59
PROPANTHELINE BROMIDE – propantheline bromide
tab 15 mg.......................................................................... 72
proparacaine hcl ophth soln 0.5% (Alcaine)............... 142
PROPRANOLOL/HYDROCHLOROTH – propranolol &
PROPRANOLOL/HYDROCHLOROTH – propranolol &
propranolol hcl cap sr 24hr 60 mg (Inderal la).............. 49
propranolol hcl cap sr 24hr 80 mg (Inderal la).............. 49
propranolol hcl cap sr 24hr 120 mg (Inderal la)............ 49
propranolol hcl cap sr 24hr 160 mg (Inderal la)............ 49
PROPRANOLOL HCL – propranolol hcl oral soln 20
mg/5ml............................................................................... 49
PROPRANOLOL HCL – propranolol hcl oral soln 40
mg/5ml............................................................................... 49
propranolol hcl tab 10 mg............................................... 49
propylthiouracil tab 50 mg.............................................. 36
PROQUAD – measles-mumps-rubella-varicella virus
vaccines for inj.................................................................. 17
PROSCAR – finasteride tab 5 mg......................................79
PROTOPIC – tacrolimus oint 0.03%................................ 152
PROTOPIC – tacrolimus oint 0.1%.................................. 152
protriptyline hcl tab 5 mg................................................ 83
protriptyline hcl tab 10 mg.............................................. 83
PROVENTIL HFA – albuterol sulfate inhal aero 108 mcg/
act (90mcg base equiv).................................................... 68
208
2016
PROVERA – medroxyprogesterone acetate tab 2.5
mg...................................................................................... 27
PROVERA – medroxyprogesterone acetate tab 5 mg.......27
PROVERA – medroxyprogesterone acetate tab 10
mg...................................................................................... 27
PROVIDA DHA – prenat w/o a w/fe fum-fe poly-fa-dha cap
16-16-1.25-110 mg.......................................................... 124
PROVIDA OB – prenatal w/o a w/fe fum-fe poly-fa cap
20-20-1.25 mg................................................................. 124
PRUDOXIN – doxepin hcl cream 5%...............................152
pseudoeph-chlorphen w/ hydrocodone soln 60-4-5
mg/5ml (Zutripro)............................................................. 65
pseudoephed-bromphen-dm syrup 30-2-10
mg/5ml............................................................................... 65
PSORCON – diflorasone diacetate cream 0.05%........... 150
PULMICORT – budesonide inhalation susp 0.25
mg/2ml............................................................................... 68
PULMICORT – budesonide inhalation susp 0.5
mg/2ml............................................................................... 68
PULMICORT – budesonide inhalation susp 1 mg/2ml...... 68
PULMICORT FLEXHALER – budesonide inhal aero powd
90 mcg/act (breath activated)........................................... 68
PULMICORT FLEXHALER – budesonide inhal aero powd
180 mcg/act (breath activated)......................................... 68
PULMOZYME – dornase alfa inhal soln 1 mg/ml.............. 70
PUREFE OB PLUS – prenatal w/o a w/fe fum-fe poly-fa
cap 162.115.2-1 mg........................................................ 124
PURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/
ml)...................................................................................... 20
PYLERA – bismuth subcit-metronidazole-tetracycline cap
140-125-125 mg................................................................ 72
pyrazinamide tab 500 mg................................................... 6
PYRIDIUM – phenazopyridine hcl tab 100 mg.................. 79
PYRIDIUM – phenazopyridine hcl tab 200 mg.................. 79
pyridostigmine bromide tab cr 180 mg (Mestinon
timespan)........................................................................ 119
pyridostigmine bromide tab 60 mg (Mestinon)........... 119
PYROGALLIC ACID – pyrogallol-chlorobutanol oint
25-2%............................................................................... 147
Q
QUADRACEL – diph-tetanus tox ad-acell pert & polio
virus, ipv vac inj................................................................ 17
QUALAQUIN – quinine sulfate cap 324 mg....................... 13
QUARTETTE – levonor-eth est tab 0.15-0.02/0.025/0.03
mg &eth est 0.01 mg........................................................ 29
QUDEXY XR – topiramate cap er 24hr sprinkle 25
mg.................................................................................... 113
mg.................................................................................... 113
mg.................................................................................... 113
mg.................................................................................... 113
mg.................................................................................... 113
QUESTRAN – cholestyramine powder 4 gm/dose............ 56
QUESTRAN – cholestyramine powder packets 4 gm........56
QUESTRAN LIGHT – cholestyramine light powder 4 gm/
dose....................................................................................56
quetiapine fumarate tab 25 mg (Seroquel).................... 87
quetiapine fumarate tab 50 mg (Seroquel).................... 87
quetiapine fumarate tab 100 mg (Seroquel).................. 87
QUILLICHEW ER – methylphenidate hcl chew tab
extended release 20 mg................................................... 93
QUILLIVANT XR – methylphenidate hcl for er susp 25
mg/5ml (5 mg/ml).............................................................. 93
quinapril hcl tab 5 mg (Accupril).................................... 44
quinapril hcl tab 10 mg (Accupril).................................. 44
quinapril-hydrochlorothiazide tab 10-12.5 mg
(Accuretic)........................................................................ 44
quinapril-hydrochlorothiazide tab 20-12.5 mg
(Accuretic)........................................................................ 44
quinapril-hydrochlorothiazide tab 20-25 mg
(Accuretic)........................................................................ 44
quinidine gluconate tab cr 324 mg................................. 60
QUINIDINE SULFATE – quinidine sulfate tab 200 mg....... 60
QUINIDINE SULFATE – quinidine sulfate tab 300 mg....... 60
quinine sulfate cap 324 mg (Qualaquin)........................ 13
QVAR – beclomethasone diprop inhal aero soln 40 mcg/
act (50/valve)..................................................................... 68
QVAR – beclomethasone diprop inhal aero soln 80 mcg/
act (100/valve)................................................................... 68
R
rabeprazole sodium ec tab 20 mg (Aciphex)................. 72
RADIOGARDASE – prussian blue insoluble cap 0.5
gm.................................................................................... 155
raloxifene hcl tab 60 mg (Evista).................................... 41
ramipril cap 1.25 mg (Altace).......................................... 44
ramipril cap 2.5 mg (Altace)............................................ 44
ramipril cap 5 mg (Altace)............................................... 44
ramipril cap 10 mg (Altace)............................................. 44
RANEXA – ranolazine tab sr 12hr 500 mg........................ 54
RANEXA – ranolazine tab sr 12hr 1000 mg...................... 54
ranitidine hcl cap 150 mg................................................ 72
ranitidine hcl cap 300 mg................................................ 72
ranitidine hcl syrup 15 mg/ml (75 mg/5ml).................... 72
ranitidine hcl tab 150 mg (Zantac).................................. 72
ranitidine hcl tab 300 mg (Zantac).................................. 72
RAPAFLO – silodosin cap 4 mg......................................... 79
RAPAFLO – silodosin cap 8 mg......................................... 79
RAPAMUNE – sirolimus oral soln 1 mg/ml...................... 155
209
2016
RAPAMUNE – sirolimus tab 0.5 mg................................. 155
RAPAMUNE – sirolimus tab 1 mg.................................... 155
RAPAMUNE – sirolimus tab 2 mg.................................... 155
RASUVO – methotrexate soln pf auto-injector 7.5
mg/0.15ml........................................................................ 106
RASUVO – methotrexate soln pf auto-injector 10
mg/0.2ml.......................................................................... 106
mg/0.25ml........................................................................ 106
mg/0.3ml.......................................................................... 106
mg/0.35ml........................................................................ 106
mg/0.4ml.......................................................................... 107
mg/0.45ml........................................................................ 107
mg/0.5ml.......................................................................... 107
mg/0.55ml........................................................................ 107
mg/0.6ml.......................................................................... 107
RAVICTI – glycerol phenylbutyrate liquid 1.1 gm/ml.......... 41
RAZADYNE ER – galantamine hydrobromide cap sr 24hr
8 mg................................................................................... 97
16 mg................................................................................. 97
24 mg................................................................................. 97
RAZADYNE – galantamine hydrobromide tab 4 mg.......... 97
RAZADYNE – galantamine hydrobromide tab 8 mg.......... 97
RAZADYNE – galantamine hydrobromide tab 12 mg........ 97
REBETOL – ribavirin cap 200 mg........................................ 9
REBETOL – ribavirin soln 40 mg/ml.................................... 9
REBIF – interferon beta-1a soln pref syr 22 mcg/0.5ml
(12mu/ml)........................................................................... 94
REBIF – interferon beta-1a soln pref syr 44 mcg/0.5ml
(24mu/ml)........................................................................... 94
REBIF REBIDOSE – interferon beta-1a soln auto-inj 22
mcg/0.5ml (12mu/ml).........................................................94
REBIF REBIDOSE – interferon beta-1a soln auto-inj 44
mcg/0.5ml (24mu/ml).........................................................94
REBIF REBIDOSE TITRATION – interferon beta-1a autoinj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml............................ 94
REBIF TITRATION PACK – interferon beta-1a pref syr
6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml................................. 94
RECOMBINATE – antihemophilic factor (recombinant) for
inj 220-400 unit................................................................136
inj 401-800 unit................................................................136
inj 801-1240 unit..............................................................136
inj 1241-1800 unit........................................................... 136
inj 1801-2400 unit........................................................... 136
RECOMBIVAX HB – hepatitis b vaccine (recombinant)
susp 5 mcg/0.5ml.............................................................. 17
susp 10 mcg/ml................................................................. 17
susp 40 mcg/ml................................................................. 17
RECTIV – nitroglycerin oint 0.4%.....................................144
REGENECARE – lidocaine hcl-collagen-aloe vera gel
2%.................................................................................... 152
REGLAN – metoclopramide hcl tab 5 mg.......................... 75
REGLAN – metoclopramide hcl tab 10 mg........................ 75
REGRANEX – becaplermin gel 0.01%............................ 152
RELAGARD – acetic acid-oxyquinoline vaginal gel
0.9-0.025%......................................................................... 78
RELENZA DISKHALER – zanamivir aero powder breath
activated 5 mg/blister........................................................ 13
RELISTOR – methylnaltrexone bromide inj 8 mg/0.4ml (20
mg/ml)................................................................................ 76
RELISTOR – methylnaltrexone bromide inj 12 mg/0.6ml
(20 mg/ml)..........................................................................76
RELNATE DHA – prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg.................................................................... 124
RELPAX – eletriptan hydrobromide tab 20 mg (base
equivalent)....................................................................... 108
RELPAX – eletriptan hydrobromide tab 40 mg (base
equivalent)....................................................................... 108
REMODULIN – treprostinil sodium inj 1 mg/ml (base
equiv)................................................................................. 63
REMODULIN – treprostinil sodium inj 2.5 mg/ml (base
equiv)................................................................................. 63
equiv)................................................................................. 63
equiv)................................................................................. 63
RENAGEL – sevelamer hcl tab 400 mg............................ 76
RENAGEL – sevelamer hcl tab 800 mg............................ 76
RENVELA – sevelamer carbonate packet 0.8 gm............. 76
RENVELA – sevelamer carbonate packet 2.4 gm............. 76
RENVELA – sevelamer carbonate tab 800 mg..................76
REPAGLINIDE/METFORMIN HYD – repaglinidemetformin hcl tab 1-500 mg.............................................. 34
REPAGLINIDE/METFORMIN HYD – repaglinidemetformin hcl tab 2-500 mg.............................................. 34
repaglinide tab 0.5 mg (Prandin).................................... 33
repaglinide tab 1 mg (Prandin)....................................... 34
repaglinide tab 2 mg (Prandin)....................................... 34
REPATHA – evolocumab subcutaneous soln prefilled
syringe 140 mg/ml............................................................. 57
REPATHA SURECLICK – evolocumab subcutaneous soln
auto-injector 140 mg/ml.................................................... 57
REQUIP – ropinirole hydrochloride tab 0.25 mg.............. 116
REQUIP – ropinirole hydrochloride tab 0.5 mg................ 117
REQUIP – ropinirole hydrochloride tab 1 mg................... 117
210
2016
REQUIP XL – ropinirole hydrochloride tab sr 24hr 2 mg
(base equivalent)............................................................. 117
(base equivalent)............................................................. 117
(base equivalent)............................................................. 117
(base equivalent)............................................................. 117
(base equivalent)............................................................. 117
RESCRIPTOR – delavirdine mesylate tab 100 mg............ 11
RESCRIPTOR – delavirdine mesylate tab 200 mg............ 11
RESCULA – unoprostone isopropyl ophth soln
0.15%............................................................................... 140
RESTASIS – cyclosporine (ophth) emulsion 0.05%........ 142
RESTORA RX – lactobacillus casei-folic acid cap 60-1.25
mg...................................................................................... 70
RETIN-A – tretinoin cream 0.025%.................................. 145
RETIN-A – tretinoin cream 0.05%.................................... 145
RETIN-A – tretinoin cream 0.1%...................................... 145
RETIN-A – tretinoin gel 0.01%......................................... 145
RETIN-A – tretinoin gel 0.025%....................................... 145
RETROVIR – zidovudine cap 100 mg............................... 11
RETROVIR – zidovudine syrup 10 mg/ml..........................11
REVATIO – sildenafil citrate for suspension 10 mg/ml....... 63
REVLIMID – lenalidomide cap 5 mg................................ 155
REVLIMID – lenalidomide cap 10 mg.............................. 155
REVLIMID – lenalidomide caps 2.5 mg........................... 155
REXULTI – brexpiprazole tab 0.25 mg.............................. 87
REXULTI – brexpiprazole tab 0.5 mg................................ 87
REXULTI – brexpiprazole tab 1 mg................................... 87
REYATAZ – atazanavir sulfate cap 150 mg (base
equiv)................................................................................. 11
equiv)................................................................................. 11
equiv)................................................................................. 11
REYATAZ – atazanavir sulfate oral powder packet 50 mg
(base equiv)....................................................................... 11
REZIRA – pseudoephedrine w/ hydrocodone soln 60-5
mg/5ml............................................................................... 65
RHEUMATREX – methotrexate sodium tab 2.5 mg
(antirheumatic)................................................................. 107
RIBASPHERE RIBAPAK – ribavirin tab 400 mg.................. 9
RIBASPHERE RIBAPAK – ribavirin tab 600 mg.................. 9
RIBASPHERE RIBAPAK – ribavirin tab 200 mg & ribavirin
tab 400 mg dose pack........................................................ 9
RIBASPHERE RIBAPAK – ribavirin tab 400 mg & ribavirin
tab 600 mg dose pack........................................................ 9
RIBASPHERE – ribavirin tab 400 mg.................................. 9
RIBASPHERE – ribavirin tab 600 mg.................................. 9
ribavirin cap 200 mg (Rebetol).......................................... 9
ribavirin tab 200 mg (Copegus)........................................ 9
RIDAURA – auranofin cap 3 mg...................................... 107
rifabutin cap 150 mg (Mycobutin)..................................... 6
RIFADIN – rifampin cap 150 mg.......................................... 6
RIFADIN – rifampin cap 300 mg.......................................... 6
RIFAMATE – isoniazid & rifampin cap 150-300 mg............. 6
rifampin cap 150 mg (Rifadin)........................................... 6
rifampin cap 300 mg (Rifadin)........................................... 6
RIFATER – isoniazid-rifampin w/ pyrazinamide tab
50-120-300 mg.................................................................... 6
RILUTEK – riluzole tab 50 mg......................................... 119
riluzole tab 50 mg (Rilutek)........................................... 119
rimantadine hydrochloride tab 100 mg
(Flumadine)....................................................................... 13
ringer's solution for irrigation....................................... 155
RIOMET – metformin hcl oral soln 500 mg/5ml................. 34
risedronate sodium tab delayed release 35 mg
(Atelvia)............................................................................. 41
risedronate sodium tab 5 mg (Actonel)......................... 41
risedronate sodium tab 30 mg (Actonel)....................... 41
risedronate sodium tab 35 mg (Actonel)....................... 41
risedronate sodium tab 150 mg (Actonel)..................... 41
risperidone orally disintegrating tab 0.25 mg............... 87
risperidone orally disintegrating tab 0.5 mg (Risperdal
m-tab)................................................................................ 87
risperidone orally disintegrating tab 1 mg (Risperdal
m-tab)................................................................................ 87
m-tab)................................................................................ 87
m-tab)................................................................................ 87
m-tab)................................................................................ 87
risperidone soln 1 mg/ml (Risperdal)............................. 87
risperidone tab 0.25 mg (Risperdal)............................... 87
risperidone tab 0.5 mg (Risperdal)................................. 87
risperidone tab 1 mg (Risperdal).................................... 87
RITALIN LA – methylphenidate hcl cap sr 24hr 10 mg
(la)...................................................................................... 93
(la)...................................................................................... 93
(la)...................................................................................... 93
(la)...................................................................................... 93
(la)...................................................................................... 93
RITALIN – methylphenidate hcl tab 5 mg.......................... 93
211
2016
RITALIN – methylphenidate hcl tab 10 mg........................ 93
RITALIN – methylphenidate hcl tab 20 mg........................ 93
rivastigmine tartrate cap 1.5 mg (Exelon)......................97
rivastigmine tartrate cap 3 mg (Exelon).........................97
rivastigmine tartrate cap 4.5 mg (Exelon)......................97
rivastigmine tartrate cap 6 mg (Exelon).........................97
rivastigmine td patch 24hr 4.6 mg/24hr (Exelon).......... 97
rivastigmine td patch 24hr 9.5 mg/24hr (Exelon).......... 97
rivastigmine td patch 24hr 13.3 mg/24hr (Exelon)........ 97
RIXUBIS – coagulation factor ix (recombinant) for inj 250
unit....................................................................................136
unit....................................................................................136
unit....................................................................................136
unit....................................................................................136
unit....................................................................................136
rizatriptan benzoate oral disintegrating tab 5 mg (base
eq) (Maxalt-mlt).............................................................. 108
rizatriptan benzoate oral disintegrating tab 10 mg
(base eq) (Maxalt-mlt)................................................... 108
rizatriptan benzoate tab 5 mg (base equivalent)
(Maxalt)............................................................................108
rizatriptan benzoate tab 10 mg (base equivalent)
(Maxalt)............................................................................108
R-NATAL OB – prenatal w/o a w/fe cbn-fa-dha cap
20-1-320 mg.................................................................... 124
ROBAXIN – methocarbamol tab 500 mg......................... 118
ROBAXIN-750 – methocarbamol tab 750 mg.................. 118
ROBINUL FORTE – glycopyrrolate tab 2 mg.................... 72
ROBINUL – glycopyrrolate tab 1 mg..................................72
ROCALTROL – calcitriol cap 0.25 mcg.............................. 41
ROCALTROL – calcitriol cap 0.5 mcg................................ 41
ROCALTROL – calcitriol oral soln 1 mcg/ml...................... 41
ropinirole hydrochloride tab 0.25 mg (Requip)........... 117
ropinirole hydrochloride tab 0.5 mg (Requip)............. 117
ropinirole hydrochloride tab 1 mg (Requip)................ 117
ropinirole hydrochloride tab sr 24hr 2 mg (base
equivalent) (Requip xl)................................................. 117
rosuvastatin calcium tab 5 mg (Crestor)....................... 57
rosuvastatin calcium tab 10 mg (Crestor)..................... 57
ROZEREM – ramelteon tab 8 mg...................................... 88
RUCONEST – c1 esterase inhibitor (recombinant) for iv inj
2100 unit.......................................................................... 132
RULAVITE DHA – prenat w/o a w/fefum-methfol-fa-dha
cap 27-0.6-0.4-300 mg....................................................124
RYTHMOL – propafenone hcl tab 225 mg.........................60
RYTHMOL SR – propafenone hcl cap sr 12hr 225 mg...... 60
S
SABRIL – vigabatrin powd pack 500 mg......................... 113
SABRIL – vigabatrin tab 500 mg......................................113
SAFYRAL – drospirenone-ethinyl estrad-levomefolate tab
3-0.03-0.451 mg................................................................ 29
SAIZEN CLICK.EASY – somatropin (non-refrigerated) for
inj 8.8 mg........................................................................... 38
SAIZEN – somatropin (non-refrigerated) for inj 5 mg........ 38
SAIZEN – somatropin (non-refrigerated) for inj 8.8 mg..... 38
SALAGEN – pilocarpine hcl tab 5 mg.............................. 143
SALAGEN – pilocarpine hcl tab 7.5 mg........................... 143
SALEX – salicylic acid shampoo 6%............................... 147
salicylic acid cream 6%................................................. 147
salicylic acid gel 6% (Keralyt)....................................... 147
SALICYLIC ACID IN AMMONIU – salicylic acid in
ammonium lactate vehicle foam 6%...............................147
salicylic acid lotion 6%.................................................. 147
SALICYLIC ACID – salicylic acid soln 26%..................... 147
salicylic acid shampoo 6% (Salex)............................... 147
salsalate tab 500 mg (Disalcid)....................................... 98
salsalate tab 750 mg (Disalcid)....................................... 98
SAMSCA – tolvaptan tab 15 mg........................................ 41
SAMSCA – tolvaptan tab 30 mg........................................ 41
SANCUSO – granisetron td patch 3.1 mg/24hr (contains
34.3 mg).............................................................................73
SANDIMMUNE – cyclosporine cap 25 mg.......................155
SANDIMMUNE – cyclosporine cap 100 mg.....................155
SANDIMMUNE – cyclosporine oral soln 100 mg/ml........ 155
SANDOSTATIN – octreotide acetate inj 50 mcg/ml (0.05
mg/ml)................................................................................ 41
mg/ml)................................................................................ 41
mg/ml)................................................................................ 41
mg/ml)................................................................................ 41
SANDOSTATIN – octreotide acetate inj 1000 mcg/ml (1
mg/ml)................................................................................ 41
SANTYL – collagenase oint 250 unit/gm......................... 152
SAPHRIS – asenapine maleate sl tab 2.5 mg (base
equiv)................................................................................. 87
SAPHRIS – asenapine maleate sl tab 5 mg (base
equiv)................................................................................. 87
SAPHRIS – asenapine maleate sl tab 10 mg (base
equiv)................................................................................. 87
212
2016
SARAFEM – fluoxetine hcl (pmdd) tab 10 mg................... 97
SARAFEM – fluoxetine hcl (pmdd) tab 20 mg................... 97
SAVAYSA – edoxaban tosylate tab 15 mg (base
equivalent)....................................................................... 132
equivalent)....................................................................... 132
equivalent)....................................................................... 132
SAVELLA – milnacipran hcl tab 12.5 mg........................... 97
SAVELLA – milnacipran hcl tab 25 mg.............................. 97
SAVELLA – milnacipran hcl tab 50 mg.............................. 97
SAVELLA – milnacipran hcl tab 100 mg............................ 97
SAVELLA TITRATION PACK – milnacipran hcl tab 12.5
mg (5) & 25 mg (8) & 50 mg (42) pak.............................. 97
SEASONIQUE – levonorg-eth est tab 0.15-0.03mg(84) &
eth est tab 0.01mg(7)........................................................29
SECONAL SODIUM – secobarbital sodium cap 100
mg...................................................................................... 88
SECTRAL – acebutolol hcl cap 200 mg............................ 49
SECTRAL – acebutolol hcl cap 400 mg............................ 49
SELECT-OB+DHA – prenatal mv w/fe poly-fa chw 29-1
mg & dha cap 250 mg pak............................................. 124
SELECT-OB – prenatal vit w/ fe polysac cmplx-fa chew
tab 29-1 mg..................................................................... 124
SELECT-OB – prenat w/ fepolycmplx-methylfol-fa chew
tab 29-0.6-0.4 mg............................................................ 124
selegiline hcl cap 5 mg (Eldepryl)................................ 117
selegiline hcl tab 5 mg................................................... 117
selenium sulfide lotion 2.5%......................................... 152
selenium sulfide-pyrithione zinc in urea shampoo
2.25%............................................................................... 152
SELZENTRY – maraviroc tab 150 mg............................... 11
SELZENTRY – maraviroc tab 300 mg............................... 11
SE-NATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg.................................................................................... 124
SE-NATAL 19 – prenatal vit w/ fe fumarate-fa chew tab
29-1 mg............................................................................124
SENSIPAR – cinacalcet hcl tab 30 mg (base equiv)..........41
SEREVENT DISKUS – salmeterol xinafoate aer pow ba
50 mcg/dose (base equiv)................................................ 68
SEROQUEL XR – quetiapine fumarate tab sr 24hr 50
mg...................................................................................... 87
mg...................................................................................... 87
mg...................................................................................... 87
mg...................................................................................... 87
mg...................................................................................... 88
SEROSTIM – somatropin (non-refrigerated) for
subcutaneous inj 4 mg...................................................... 38
sertraline hcl oral conc 20 mg/ml (Zoloft)......................83
sertraline hcl tab 25 mg (Zoloft)..................................... 83
sertraline hcl tab 50 mg (Zoloft)..................................... 83
sertraline hcl tab 100 mg (Zoloft)................................... 83
SE-TAN DHA – prenatal w/fe fum-fe poly -fa-omega 3 cap
15-15-1 mg...................................................................... 124
SFROWASA – mesalamine sulfite-free (sf) enema 4
gm/60ml............................................................................. 76
SHOHLS SOLUTION MODIFIED – sodium citrate & citric
acid soln 500-334 mg/5ml................................................ 79
SHUR-SEAL – nonoxynol-9 gel 2%................................... 29
SIGNIFOR – pasireotide diaspartate inj 0.3 mg/ml (base
equiv)................................................................................. 41
equiv)................................................................................. 41
equiv)................................................................................. 41
sildenafil citrate tab 20 mg (Revatio)............................. 63
SILVADENE – silver sulfadiazine cream 1%.................... 147
silver nitrate-potassium nitrate applicator 75-25%
(Arzol silver nitrate)...................................................... 152
SILVER NITRATE – silver nitrate oint 10%...................... 152
SILVER NITRATE – silver nitrate soln 0.5%.................... 152
SILVER NITRATE – silver nitrate soln 10%..................... 152
silver sulfadiazine cream 1% (Silvadene).................... 147
SIMBRINZA – brinzolamide-brimonidine tartrate ophth
susp 1-0.2%.....................................................................140
SIMPONI – golimumab subcutaneous soln auto-injector
50 mg/0.5ml..................................................................... 107
SIMPONI – golimumab subcutaneous soln auto-injector
100 mg/ml........................................................................ 107
SIMPONI – golimumab subcutaneous soln prefilled
syringe 50 mg/0.5ml........................................................ 107
SIMPONI – golimumab subcutaneous soln prefilled
syringe 100 mg/ml........................................................... 107
simvastatin tab 5 mg (Zocor).......................................... 57
simvastatin tab 10 mg (Zocor)........................................ 57
SINEMET – carbidopa & levodopa tab 10-100 mg.......... 117
SINEMET CR – carbidopa & levodopa tab cr 25-100
mg.................................................................................... 117
SINEMET CR – carbidopa & levodopa tab cr 50-200
mg.................................................................................... 117
SINGULAIR – montelukast sodium oral granules packet 4
mg (base equiv)................................................................ 68
sirolimus tab 0.5 mg (Rapamune).................................155
sirolimus tab 1 mg (Rapamune)....................................155
sirolimus tab 2 mg (Rapamune)....................................155
213
2016
SIRTURO – bedaquiline fumarate tab 100 mg (base
equiv)....................................................................................6
SIVEXTRO – tedizolid phosphate tab 200 mg................... 14
SKELAXIN – metaxalone tab 800 mg.............................. 118
sodium chloride irrigation soln 0.9%............................. 79
sodium chloride soln nebu 0.9%.................................... 66
sodium chloride soln nebu 3%....................................... 66
sodium chloride soln nebu 10%..................................... 66
sodium chloride soln nebu 7% (Hyper-sal)................... 66
sodium citrate & citric acid soln 500-334 mg/5ml
(Shohls solution modi)................................................... 79
sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)
(Luride)............................................................................ 128
sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)
(Luride)............................................................................ 128
sodium fluoride chew tab 1 mg f (from 2.2 mg naf)
(Luride)............................................................................ 128
SODIUM FLUORIDE – sodium fluoride tab 0.5 mg f (from
1.1 mg naf)...................................................................... 128
SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from
2.2 mg naf)...................................................................... 128
sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop
naf)................................................................................... 128
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)
(Luride)............................................................................ 128
sodium phenylbutyrate oral powder 3 gm/teaspoonful
(Buphenyl)........................................................................ 41
sodium polystyrene sulfonate oral susp 15
gm/60ml...........................................................................155
sodium polystyrene sulfonate powder
(Kayexalate).................................................................... 155
sodium polystyrene sulfonate rectal susp 30
gm/120ml........................................................................ 155
SODIUM SULFACETAMIDE/SULF – sulfacetamide
sodium-sulfur in urea gel 10-5%.....................................145
SODIUM SULFACETAMIDE WASH – sulfacetamide
sodium in bakuchiol vehicle wash 10%.......................... 153
SOLARAZE – diclofenac sodium (actinic keratoses) gel
3%.................................................................................... 153
SOLTAMOX – tamoxifen citrate oral soln 10 mg/5ml (base
equivalent)......................................................................... 20
SOMAVERT – pegvisomant for inj 10 mg (as protein)....... 41
SONATA – zaleplon cap 5 mg........................................... 88
SONATA – zaleplon cap 10 mg......................................... 88
SOOLANTRA – ivermectin cream 1%............................. 145
SORIATANE – acitretin cap 10 mg.................................. 153
SORIATANE – acitretin cap 17.5 mg............................... 153
SORIATANE – acitretin cap 25 mg.................................. 153
SORILUX – calcipotriene foam 0.005%........................... 153
sotalol hcl (afib/afl) tab 80 mg (Betapace af)................. 60
sotalol hcl (afib/afl) tab 120 mg (Betapace af)............... 60
sotalol hcl (afib/afl) tab 160 mg (Betapace af)............... 60
sotalol hcl tab 240 mg...................................................... 60
sotalol hcl tab 80 mg (Betapace).................................... 60
sotalol hcl tab 120 mg (Betapace).................................. 60
sotalol hcl tab 160 mg (Betapace).................................. 60
SOTYLIZE – sotalol hcl oral solution 5 mg/ml................... 60
SOVALDI – sofosbuvir tab 400 mg...................................... 9
SPECTRACEF – cefditoren pivoxil tab 200 mg (base
equivalent)............................................................................3
SPECTRACEF – cefditoren pivoxil tab 400 mg (base
equivalent)............................................................................3
SPINOSAD – spinosad susp 0.9%.................................. 153
SPIRIVA HANDIHALER – tiotropium bromide
monohydrate inhal cap 18 mcg (base equiv)................... 68
SPIRIVA RESPIMAT – tiotropium bromide monohydrate
inhal aerosol 1.25 mcg/act................................................ 69
SPIRIVA RESPIMAT – tiotropium bromide monohydrate
inhal aerosol 2.5 mcg/act.................................................. 69
spironolactone & hydrochlorothiazide tab 25-25 mg
(Aldactazide).....................................................................58
spironolactone tab 25 mg (Aldactone)........................... 58
spironolactone tab 50 mg (Aldactone)........................... 58
spironolactone tab 100 mg (Aldactone)......................... 58
SPORANOX – itraconazole cap 100 mg............................. 7
SPORANOX – itraconazole oral soln 10 mg/ml................... 7
SPORANOX PULSEPAK – itraconazole cap 100 mg.......... 7
SPRYCEL – dasatinib tab 20 mg....................................... 20
SPRYCEL – dasatinib tab 100 mg..................................... 21
SPRYCEL – dasatinib tab 140 mg..................................... 21
SSKI – potassium iodide soln 1 gm/ml.............................. 66
STALEVO 100 – carbidopa-levodopa-entacapone tabs
25-100-200 mg................................................................ 117
31.25-125-200 mg........................................................... 118
37.5-150-200 mg............................................................. 118
50-200-200 mg................................................................ 118
12.5-50-200 mg............................................................... 118
18.75-75-200 mg............................................................. 118
STARLIX – nateglinide tab 60 mg...................................... 34
STARLIX – nateglinide tab 120 mg.................................... 34
stavudine cap 15 mg (Zerit).............................................11
stavudine for oral soln 1 mg/ml (Zerit).......................... 11
STELARA – ustekinumab soln prefilled syringe 45
mg/0.5ml.......................................................................... 153
STELARA – ustekinumab soln prefilled syringe 90 mg/
ml...................................................................................... 153
214
2016
STIMATE – desmopressin acetate nasal soln 1.5 mg/
ml........................................................................................ 42
STIVARGA – regorafenib tab 40 mg.................................. 21
STRATTERA – atomoxetine hcl cap 10 mg (base
equiv)................................................................................. 93
equiv)................................................................................. 93
equiv)................................................................................. 93
equiv)................................................................................. 93
equiv)................................................................................. 93
equiv)................................................................................. 93
equiv)................................................................................. 93
STRENSIQ – asfotase alfa subcutaneous inj 18
mg/0.45ml.......................................................................... 42
mg/0.7ml............................................................................ 42
STRENSIQ – asfotase alfa subcutaneous inj 40 mg/
ml........................................................................................ 42
mg/0.8ml............................................................................ 42
STRIBILD – elvitegrav-cobic-emtricitab-tenofovdf tab
150-150-200-300 mg......................................................... 11
STRIVERDI RESPIMAT – olodaterol hcl inhal aerosol soln
2.5 mcg/act (base equiv).................................................. 69
STROMECTOL – ivermectin tab 3 mg............................... 13
SUBOXONE – buprenorphine hcl-naloxone hcl sl film
2-0.5 mg (base equiv)..................................................... 155
SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1
mg (base equiv).............................................................. 155
mg (base equiv).............................................................. 156
mg (base equiv).............................................................. 156
SUCRAID – sacrosidase soln 8500 unit/ml....................... 74
sucralfate tab 1 gm (Carafate).........................................72
SULAR – nisoldipine tab sr 24hr 8.5 mg............................52
SULAR – nisoldipine tab sr 24hr 17 mg............................ 52
SULAR – nisoldipine tab sr 24hr 34 mg............................ 52
sulfacetamide sodium lotion 10% (acne) (Klaron)...... 145
sulfacetamide sodium ophth soln 10% (Bleph-10)..... 138
sulfacetamide sodium-prednisolone ophth soln
10-0.23(0.25)%................................................................ 139
SULFACETAMIDE SODIUM – sulfacetamide sodium
ophth oint 10%................................................................ 138
SULFADIAZINE – sulfadiazine tab 500 mg......................... 6
sulfamethoxazole-trimethoprim susp 200-40
mg/5ml............................................................................... 14
sulfamethoxazole-trimethoprim tab 400-80 mg
(Bactrim)........................................................................... 14
sulfamethoxazole-trimethoprim tab 800-160 mg
(Bactrim ds)...................................................................... 14
SULFAMYLON – mafenide acetate cream 85 mg/gm..... 147
SULFAMYLON – mafenide acetate packet for topical soln
5% (50 gm)...................................................................... 147
sulfasalazine tab delayed release 500 mg (Azulfidine
en-tabs)............................................................................. 76
sulfasalazine tab 500 mg (Azulfidine)............................ 76
SULFOAM – sulfur shampoo 2%..................................... 145
sulindac tab 150 mg....................................................... 107
sulindac tab 200 mg....................................................... 107
sumatriptan nasal spray 5 mg/act (Imitrex)................. 108
sumatriptan nasal spray 20 mg/act (Imitrex)............... 108
sumatriptan succinate inj 6 mg/0.5ml (Imitrex)........... 108
sumatriptan succinate solution auto-injector 4
mg/0.5ml (Imitrex statdose sys).................................. 108
sumatriptan succinate solution auto-injector 6
mg/0.5ml (Imitrex statdose sys).................................. 108
sumatriptan succinate solution cartridge 4 mg/0.5ml
(Imitrex statdose ref).................................................... 108
sumatriptan succinate solution cartridge 6 mg/0.5ml
(Imitrex statdose ref).................................................... 108
SUMATRIPTAN SUCCINATE – sumatriptan succinate
solution prefilled syringe 6 mg/0.5ml.............................. 108
sumatriptan succinate tab 25 mg (Imitrex).................. 108
sumatriptan succinate tab 50 mg (Imitrex).................. 108
sumatriptan succinate tab 100 mg (Imitrex)................ 108
SUPRAX – cefixime cap 400 mg......................................... 3
SUPRAX – cefixime chew tab 100 mg................................ 3
SUPRAX – cefixime chew tab 200 mg................................ 3
SUPRAX – cefixime for susp 100 mg/5ml........................... 3
SUPREP BOWEL PREP – sodium sulfate-potassium
sulfate-magnesium sulfate oral soln................................. 70
SURMONTIL – trimipramine maleate cap 25 mg.............. 84
SURMONTIL – trimipramine maleate cap 50 mg.............. 84
SURMONTIL – trimipramine maleate cap 100 mg............ 84
SUSTIVA – efavirenz cap 50 mg....................................... 11
SUSTIVA – efavirenz cap 200 mg..................................... 11
SUSTIVA – efavirenz tab 600 mg...................................... 11
SUTENT – sunitinib malate cap 12.5 mg (base
equivalent)......................................................................... 21
SUTENT – sunitinib malate cap 25 mg (base
equivalent)......................................................................... 21
SUTENT – sunitinib malate cap 37.5 mg (base
equivalent)......................................................................... 21
SUTENT – sunitinib malate cap 50 mg (base
equivalent)......................................................................... 21
SYLATRON – peginterferon alfa-2b for inj kit 200 mcg..... 21
SYMAX DUOTAB – hyoscyamine sulfate tab cr 0.375 mg
(0.125 mg ir/0.25 mg cr)................................................... 72
SYMBICORT – budesonide-formoterol fumarate dihyd
aerosol 80-4.5 mcg/act..................................................... 69
SYMBICORT – budesonide-formoterol fumarate dihyd
aerosol 160-4.5 mcg/act................................................... 69
215
2016
SYMBYAX – olanzapine-fluoxetine hcl cap 3-25 mg......... 97
SYMBYAX – olanzapine-fluoxetine hcl cap 12-25 mg....... 97
SYMBYAX – olanzapine-fluoxetine hcl cap 12-50 mg....... 97
SYMLINPEN 120 – pramlintide acetate pen-inj 2700
mcg/2.7ml (1000 mcg/ml)................................................. 34
SYMLINPEN 60 – pramlintide acetate pen-inj 1500
mcg/1.5ml (1000 mcg/ml)................................................. 34
SYNALAR – fluocinolone acetonide cream 0.025%........ 150
SYNALAR – fluocinolone acetonide oint 0.025%............ 150
SYNALAR – fluocinolone acetonide soln 0.01%..............150
SYNALGOS-DC – aspirin-caffeine-dihydrocodeine cap
356.4-30-16 mg............................................................... 103
SYNAREL – nafarelin acetate nasal soln 2 mg/ml (200
mcg/act) (base eq)............................................................ 42
SYNRIBO – omacetaxine mepesuccinate for inj 3.5
mg...................................................................................... 21
SYNTHROID – levothyroxine sodium tab 25 mcg............. 36
SYNTHROID – levothyroxine sodium tab 100 mcg........... 36
SYPRINE – trientine hcl cap 250 mg............................... 156
SYRINGES/NEEDLES – VARIOUS MANUFACTURERS –
for self-injectable drug administration............................. 153
T
TABLOID – thioguanine tab 40 mg.................................... 21
tacrolimus cap 0.5 mg (Prograf)................................... 156
tacrolimus cap 1 mg (Prograf)...................................... 156
tacrolimus cap 5 mg (Prograf)...................................... 156
tacrolimus oint 0.03% (Protopic).................................. 153
tacrolimus oint 0.1% (Protopic).................................... 153
TAFINLAR – dabrafenib mesylate cap 50 mg (base
equivalent)......................................................................... 21
TAFINLAR – dabrafenib mesylate cap 75 mg (base
equivalent)......................................................................... 21
TAGRISSO – osimertinib mesylate tab 40 mg (base
equivalent)......................................................................... 21
TAGRISSO – osimertinib mesylate tab 80 mg (base
equivalent)......................................................................... 21
TAMIFLU – oseltamivir phosphate cap 30 mg (base
equiv)................................................................................. 13
equiv)................................................................................. 13
equiv)................................................................................. 13
TAMIFLU – oseltamivir phosphate for susp 6 mg/ml (base
equiv)................................................................................. 13
tamoxifen citrate tab 10 mg (base equivalent).............. 21
tamoxifen citrate tab 20 mg (base equivalent).............. 21
tamsulosin hcl cap 0.4 mg (Flomax).............................. 79
TANZEUM – albiglutide for soln pen-injector 30 mg.......... 34
TANZEUM – albiglutide for soln pen-injector 50 mg.......... 34
TAPAZOLE – methimazole tab 5 mg................................. 36
TAPAZOLE – methimazole tab 10 mg............................... 36
TARCEVA – erlotinib hcl tab 25 mg (base equivalent)....... 21
TARCEVA – erlotinib hcl tab 100 mg (base equivalent)..... 21
TARCEVA – erlotinib hcl tab 150 mg (base equivalent)..... 21
TARGRETIN – bexarotene cap 75 mg............................... 21
TARGRETIN – bexarotene gel 1%...................................153
TARKA – trandolapril-verapamil hcl tab cr 1-240 mg......... 52
TARON-BC – prenat w/o a w/ fe cbnyl-fa tab 20-1 mg & vit
b6 tab pak....................................................................... 124
TARON-C DHA – prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg............................................................ 124
TARON-PREX – prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 30-1.2-265 mg.......................................................... 124
TASIGNA – nilotinib hcl cap 150 mg (base equivalent)..... 21
TASIGNA – nilotinib hcl cap 200 mg (base equivalent)..... 21
TASMAR – tolcapone tab 100 mg.................................... 118
TAZORAC – tazarotene cream 0.05%............................. 145
TAZORAC – tazarotene cream 0.1%............................... 145
TAZORAC – tazarotene gel 0.05%.................................. 145
TAZORAC – tazarotene gel 0.1%.................................... 145
TBC – trypsin w/ castor oil & peruvian balsam spray.......153
TECFIDERA – dimethyl fumarate capsule delayed release
120 mg............................................................................... 94
TECFIDERA – dimethyl fumarate capsule delayed release
240 mg............................................................................... 94
TECFIDERA STARTER PACK – dimethyl fumarate
capsule dr starter pack 120 mg & 240 mg....................... 94
TECHNIVIE – ombitasvir-paritaprevir-ritonavir tab
12.5-75-50 mg..................................................................... 9
TEGRETOL – carbamazepine susp 100 mg/5ml............. 114
TEGRETOL – carbamazepine tab 200 mg...................... 113
TEGRETOL-XR – carbamazepine tab sr 12hr 100
mg.................................................................................... 114
mg.................................................................................... 114
mg.................................................................................... 114
TEKTURNA – aliskiren fumarate tab 150 mg (base
equivalent)......................................................................... 63
TEKTURNA – aliskiren fumarate tab 300 mg (base
equivalent)......................................................................... 63
TEKTURNA HCT – aliskiren-hydrochlorothiazide tab
150-12.5 mg...................................................................... 63
150-25 mg......................................................................... 63
216
2016
300-12.5 mg...................................................................... 63
300-25 mg......................................................................... 63
telmisartan-amlodipine tab 40-5 mg (Twynsta)............. 52
telmisartan-amlodipine tab 80-5 mg (Twynsta)............. 52
telmisartan-amlodipine tab 40-10 mg (Twynsta)........... 52
telmisartan-amlodipine tab 80-10 mg (Twynsta)........... 52
telmisartan-hydrochlorothiazide tab 40-12.5 mg
(Micardis hct)................................................................... 46
telmisartan-hydrochlorothiazide tab 80-12.5 mg
(Micardis hct)................................................................... 46
telmisartan-hydrochlorothiazide tab 80-25 mg
(Micardis hct)................................................................... 46
telmisartan tab 20 mg (Micardis).................................... 46
temazepam cap 7.5 mg (Restoril)................................... 88
temazepam cap 15 mg (Restoril).................................... 89
temazepam cap 22.5 mg (Restoril)................................. 89
temazepam cap 30 mg (Restoril).................................... 89
TEMODAR – temozolomide cap 5 mg............................... 21
TEMODAR – temozolomide cap 20 mg............................. 21
TEMODAR – temozolomide cap 100 mg........................... 21
TEMOVATE – clobetasol propionate cream 0.05%......... 150
TEMOVATE – clobetasol propionate gel 0.05%...............150
TEMOVATE – clobetasol propionate oint 0.05%..............150
TEMOVATE – clobetasol propionate soln 0.05%............. 150
TEMOVATE E – clobetasol propionate emollient base
cream 0.05%................................................................... 150
temozolomide cap 5 mg (Temodar)................................ 21
temozolomide cap 20 mg (Temodar).............................. 21
temozolomide cap 100 mg (Temodar)............................ 21
TENEX – guanfacine hcl tab 1 mg.....................................63
TENEX – guanfacine hcl tab 2 mg.....................................63
TENIVAC – tetanus-diphtheria toxoids (td) inj 5-2 lfu........ 17
TENORETIC 100 – atenolol & chlorthalidone tab 100-25
mg...................................................................................... 49
TENORETIC 50 – atenolol & chlorthalidone tab 50-25
mg...................................................................................... 49
TERAZOL 3 – terconazole vaginal cream 0.8%................ 78
TERAZOL 7 – terconazole vaginal cream 0.4%................ 78
terazosin hcl cap 1 mg..................................................... 63
terazosin hcl cap 10 mg................................................... 63
terbinafine hcl tab 250 mg (Lamisil)................................. 7
terbutaline sulfate tab 2.5 mg......................................... 69
terbutaline sulfate tab 5 mg............................................ 69
terconazole vaginal cream 0.4% (Terazol 7).................. 78
terconazole vaginal cream 0.8% (Terazol 3).................. 78
terconazole vaginal suppos 80 mg.................................78
TESSALON PERLES – benzonatate cap 100 mg............. 66
TEST DISCS – BAYER BREEZE 2................................. 153
TEST DISCS – VARIOUS MANUFACTURERS...............153
testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone).................................................................... 24
testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone).................................................................... 24
testosterone enanthate im inj in oil 200 mg/ml............. 24
testosterone td gel 12.5 mg/act (1%) (Androgel
pump)................................................................................ 25
testosterone td gel 25 mg/2.5gm (1%) (Androgel)........ 24
testosterone td gel 50 mg/5gm (1%) (Androgel)........... 24
TEST STRIPS – BAYER CONTOUR/NEXT.................... 153
TEST STRIPS – VARIOUS MANUFACTURERS – glucose
blood test strip................................................................. 153
TETANUS/DIPHTHERIA TOXOID – tetanus-diphtheria
toxoids (td) inj 2-2 lf/0.5ml................................................ 17
tetrabenazine tab 12.5 mg (Xenazine)............................ 97
tetrabenazine tab 25 mg (Xenazine)............................... 97
tetracaine hcl ophth soln 0.5%..................................... 142
tetracycline hcl cap 250 mg (Tetracycline hcl)................ 5
tetracycline hcl cap 500 mg (Tetracycline hcl)................ 5
TETRACYCLINE HCL – tetracycline hcl cap 250 mg.......... 5
TETRACYCLINE HCL – tetracycline hcl cap 500 mg.......... 5
TEXACORT – hydrocortisone soln 2.5%......................... 150
THALOMID – thalidomide cap 50 mg.............................. 156
THALOMID – thalidomide cap 100 mg............................ 156
theophylline soln 80 mg/15ml......................................... 69
theophylline tab sr 12hr 100 mg..................................... 69
THEO-24 – theophylline cap sr 24hr 100 mg.................... 69
THIOLA – tiopronin tab 100 mg......................................... 79
thioridazine hcl tab 10 mg............................................... 88
thioridazine hcl tab 100 mg............................................. 88
thiothixene cap 1 mg........................................................ 88
thiothixene cap 10 mg...................................................... 88
THRIVITE 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg.................................................................................... 124
THRIVITE RX – prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................... 124
thyroid tab 30 mg (1/2 grain) (Armour thyroid)............. 37
217
2016
thyroid tab 90 mg (1 1/2 grain) (Armour thyroid).......... 37
thyroid tab 60 mg (1 grain) (Armour thyroid)................ 37
THYROLAR-1/2 – liotrix (t3-t4) tab 30 mg (6.25-25
mcg)................................................................................... 37
THYROLAR-1/4 – liotrix (t3-t4) tab 15 mg (3.1-12.5
mcg)................................................................................... 37
THYROLAR-1 – liotrix (t3-t4) tab 60 mg (12.5-50 mcg)..... 37
THYROLAR-2 – liotrix (t3-t4) tab 120 mg (25-100
mcg)................................................................................... 37
THYROLAR-3 – liotrix (t3-t4) tab 180 mg (37.5-150
mcg)................................................................................... 37
tiagabine hcl tab 2 mg (Gabitril)................................... 114
tiagabine hcl tab 4 mg (Gabitril)................................... 114
TIGAN – trimethobenzamide hcl cap 300 mg.................... 73
TIKOSYN – dofetilide cap 125 mcg (0.125 mg)................. 60
TIKOSYN – dofetilide cap 250 mcg (0.25 mg)................... 60
TIKOSYN – dofetilide cap 500 mcg (0.5 mg).....................60
timolol maleate ophth gel forming soln 0.25%
(Timoptic-xe).................................................................. 140
timolol maleate ophth gel forming soln 0.5%
(Timoptic-xe).................................................................. 140
timolol maleate ophth soln 0.25% (Timoptic).............. 140
timolol maleate ophth soln 0.5% (Timoptic)................ 140
TIMOLOL MALEATE – timolol maleate tab 5 mg.............. 49
TIMOLOL MALEATE – timolol maleate tab 10 mg............ 49
TIMOLOL MALEATE – timolol maleate tab 20 mg............ 49
TIMOPTIC OCUDOSE – timolol maleate preservative free
ophth soln 0.25%............................................................ 140
TIMOPTIC OCUDOSE – timolol maleate preservative free
ophth soln 0.5%.............................................................. 140
TIMOPTIC – timolol maleate ophth soln 0.25%............... 140
TIMOPTIC – timolol maleate ophth soln 0.5%................. 140
TIMOPTIC-XE – timolol maleate ophth gel forming soln
0.25%............................................................................... 141
TIMOPTIC-XE – timolol maleate ophth gel forming soln
0.5%................................................................................. 141
TINDAMAX – tinidazole tab 250 mg.................................. 14
TINDAMAX – tinidazole tab 500 mg.................................. 14
tinidazole tab 250 mg (Tindamax)................................... 14
tinidazole tab 500 mg (Tindamax)................................... 14
TIROSINT – levothyroxine sodium cap 13 mcg................. 37
TIROSINT – levothyroxine sodium cap 100 mcg............... 37
TIVICAY – dolutegravir sodium tab 10 mg (base
equiv)................................................................................. 11
equiv)................................................................................. 12
equiv)................................................................................. 12
tizanidine hcl cap 2 mg (base equivalent)
(Zanaflex)........................................................................ 118
(Zanaflex)........................................................................ 118
(Zanaflex)........................................................................ 118
tizanidine hcl tab 2 mg (base equivalent).................... 118
tizanidine hcl tab 4 mg (base equivalent)
(Zanaflex)........................................................................ 118
TL-CARE DHA – prenatal w/fe fumarate-fa-dss-fish oil cap
27-1-500 mg.................................................................... 124
TL FOLATE – prenatal vit w/ fe fum-methylfolate-fa tab
27-0.5-0.5 mg.................................................................. 124
TL-SELECT – prenatal w/o vit a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg............................................................... 124
TOBI PODHALER – tobramycin inhal cap 28 mg................ 6
TOBI – tobramycin nebu soln 300 mg/5ml...........................6
TOBRADEX ST – tobramycin-dexamethasone ophth susp
0.3-0.05%......................................................................... 139
TOBRADEX – tobramycin-dexamethasone ophth oint
0.3-0.1%........................................................................... 139
TOBRADEX – tobramycin-dexamethasone ophth susp
0.3-0.1%........................................................................... 139
tobramycin-dexamethasone ophth susp 0.3-0.1%
(Tobradex)....................................................................... 139
tobramycin nebu soln 300 mg/5ml (Tobi)........................ 6
tobramycin ophth soln 0.3% (Tobrex).......................... 138
TOBREX – tobramycin ophth oint 0.3%........................... 138
TOBREX – tobramycin ophth soln 0.3%.......................... 138
TODAY SPONGE – nonoxynol-9 vaginal sponge 1000
mg...................................................................................... 29
TOLAK – fluorouracil cream 4%....................................... 153
TOLAZAMIDE – tolazamide tab 250 mg............................ 34
TOLAZAMIDE – tolazamide tab 500 mg............................ 34
TOLBUTAMIDE – tolbutamide tab 500 mg........................ 34
tolcapone tab 100 mg (Tasmar).................................... 118
tolmetin sodium cap 400 mg......................................... 107
TOLMETIN SODIUM – tolmetin sodium tab 200 mg....... 107
TOLMETIN SODIUM – tolmetin sodium tab 600 mg....... 107
tolterodine tartrate cap sr 24hr 2 mg (Detrol la)............77
tolterodine tartrate cap sr 24hr 4 mg (Detrol la)............77
tolterodine tartrate tab 1 mg (Detrol)............................. 77
tolterodine tartrate tab 2 mg (Detrol)............................. 77
TOPAMAX SPRINKLE – topiramate sprinkle cap 15
mg.................................................................................... 114
TOPAMAX SPRINKLE – topiramate sprinkle cap 25
mg.................................................................................... 114
TOPAMAX – topiramate tab 25 mg.................................. 114
TOPAMAX – topiramate tab 50 mg.................................. 114
TOPAMAX – topiramate tab 100 mg................................ 114
TOPAMAX – topiramate tab 200 mg................................ 114
TOPICORT – desoximetasone cream 0.05%.................. 150
TOPICORT – desoximetasone cream 0.25%.................. 150
TOPICORT – desoximetasone gel 0.05%....................... 150
TOPICORT – desoximetasone oint 0.05%...................... 151
TOPICORT – desoximetasone oint 0.25%...................... 151
218
2016
TOPICORT – desoximetasone spray 0.25%................... 150
TOPIRAMATE ER – topiramate cap er 24hr sprinkle 25
mg.................................................................................... 114
mg.................................................................................... 114
mg.................................................................................... 114
mg.................................................................................... 114
mg.................................................................................... 114
topiramate sprinkle cap 15 mg (Topamax
sprinkle).......................................................................... 114
topiramate sprinkle cap 25 mg (Topamax
sprinkle).......................................................................... 114
topiramate tab 25 mg (Topamax).................................. 114
topiramate tab 50 mg (Topamax).................................. 114
topiramate tab 100 mg (Topamax)................................ 114
topiramate tab 200 mg (Topamax)................................ 114
TOPROL XL – metoprolol succinate tab sr 24hr 25 mg
(tartrate equiv)................................................................... 49
(tartrate equiv)................................................................... 49
(tartrate equiv)................................................................... 49
(tartrate equiv)................................................................... 49
torsemide tab 100 mg.......................................................59
torsemide tab 5 mg (Demadex)....................................... 59
torsemide tab 10 mg (Demadex)..................................... 59
torsemide tab 20 mg (Demadex)..................................... 59
TOUJEO SOLOSTAR – insulin glargine soln pen-injector
300 unit/ml......................................................................... 35
TOVIAZ – fesoterodine fumarate tab sr 24hr 4 mg............ 77
TOVIAZ – fesoterodine fumarate tab sr 24hr 8 mg............ 77
TRACLEER – bosentan tab 62.5 mg................................. 63
TRACLEER – bosentan tab 125 mg.................................. 63
TRADJENTA – linagliptin tab 5 mg.................................... 34
tramadol-acetaminophen tab 37.5-325 mg
(Ultracet)......................................................................... 104
tramadol hcl tab 50 mg (Ultram)................................... 104
tramadol hcl tab sr 24hr biphasic release 100 mg...... 104
tramadol hcl tab sr 24hr 100 mg...................................103
tramadol hcl tab sr 24hr 200 mg...................................104
tramadol hcl tab sr 24hr 300 mg (Ultram er)............... 104
trandolapril tab 4 mg........................................................ 44
trandolapril tab 1 mg (Mavik).......................................... 44
trandolapril tab 2 mg (Mavik).......................................... 44
trandolapril-verapamil hcl tab cr 1-240 mg (Tarka)....... 52
tranexamic acid tab 650 mg (Lysteda)......................... 132
TRANSDERM-SCOP – scopolamine td patch 72hr 1
mg/3days............................................................................73
tranylcypromine sulfate tab 10 mg (Parnate)................ 84
TRAVATAN Z – travoprost ophth soln 0.004%
(benzalkonium free) (bak free)....................................... 141
TRAVOPROST – travoprost ophth soln 0.004%.............. 141
trazodone hcl tab 50 mg.................................................. 84
trazodone hcl tab 100 mg................................................ 84
TRECATOR – ethionamide tab 250 mg............................... 6
TRESIBA FLEXTOUCH – insulin degludec soln peninjector 100 unit/ml............................................................ 35
TRESIBA FLEXTOUCH – insulin degludec soln peninjector 200 unit/ml............................................................ 35
tretinoin cap 10 mg...........................................................21
tretinoin cream 0.025% (Retin-a)...................................145
tretinoin cream 0.05% (Retin-a).....................................145
tretinoin cream 0.1% (Retin-a).......................................145
tretinoin gel 0.05% (Atralin)........................................... 145
tretinoin gel 0.01% (Retin-a).......................................... 145
tretinoin gel 0.025% (Retin-a)........................................ 145
TRETTEN – coagulation factor xiii a-subunit for inj
2000-3125 unit................................................................ 137
TREXALL – methotrexate sodium tab 5 mg (base
equiv)................................................................................. 22
TREXALL – methotrexate sodium tab 7.5 mg (base
equiv)................................................................................. 22
equiv)................................................................................. 22
equiv)................................................................................. 22
TREZIX – acetaminophen-caffeine-dihydrocodeine cap
320.5-30-16 mg............................................................... 104
TRIADVANCE – prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg............................................................................124
triamcinolone acetonide aerosol soln 0.147 mg/gm
(Kenalog)........................................................................ 151
triamcinolone acetonide cream 0.025%....................... 151
triamcinolone acetonide cream 0.1%........................... 151
triamcinolone acetonide cream 0.5%........................... 151
triamcinolone acetonide dental paste 0.1%................ 143
triamcinolone acetonide lotion 0.025%........................ 151
triamcinolone acetonide lotion 0.1%............................ 151
triamcinolone acetonide nasal aerosol suspension 55
mcg/act..............................................................................65
triamcinolone acetonide oint 0.025%........................... 151
triamcinolone acetonide oint 0.1%............................... 151
TRIAMCINOLONE ACETONIDE – triamcinolone
acetonide oint 0.5%........................................................ 151
TRIAMTERENE/HYDROCHLOROTH – triamterene &
hydrochlorothiazide cap 50-25 mg................................... 59
triamterene & hydrochlorothiazide cap 37.5-25 mg
(Dyazide)........................................................................... 59
triamterene & hydrochlorothiazide tab 37.5-25 mg
(Maxzide-25)..................................................................... 59
219
2016
triamterene & hydrochlorothiazide tab 75-50 mg
(Maxzide)........................................................................... 59
triazolam tab 0.25 mg (Halcion)...................................... 89
TRIAZOLAM – triazolam tab 0.125 mg.............................. 89
TRIBENZOR – olmesartan-amlodipinehydrochlorothiazide tab 20-5-12.5 mg.............................. 46
TRIBENZOR – olmesartan-amlodipinehydrochlorothiazide tab 40-5-12.5 mg.............................. 46
TRIBENZOR – olmesartan-amlodipinehydrochlorothiazide tab 40-5-25 mg................................. 46
TRIBENZOR – olmesartan-amlodipinehydrochlorothiazide tab 40-10-12.5 mg............................ 46
TRIBENZOR – olmesartan-amlodipinehydrochlorothiazide tab 40-10-25 mg............................... 46
TRICARE PRENATAL COMPLEAT – prenat w/o a fefumfa tab 27-1 mg & fish oil chew cap pak.......................... 125
TRICARE PRENATAL DHA ONE – prenatal w/fe
fumarate-fa-dss-fish oil cap 27-1-500 mg.......................125
TRICARE PRENATAL – prenat w/o a w/fepyro-mfol chw
4.5-1 mg & dha cap 150 thpk......................................... 125
TRICARE – prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................... 124
trifluoperazine hcl tab 1 mg............................................ 88
trifluoperazine hcl tab 10 mg.......................................... 88
trifluridine ophth soln 1% (Viroptic)............................. 138
TRIGLIDE – fenofibrate tab 160 mg.................................. 57
trihexyphenidyl hcl elixir 0.4 mg/ml............................. 118
trihexyphenidyl hcl tab 2 mg.........................................118
trihexyphenidyl hcl tab 5 mg.........................................118
TRILEPTAL – oxcarbazepine susp 300 mg/5ml (60 mg/
ml).................................................................................... 114
TRILEPTAL – oxcarbazepine tab 150 mg........................ 114
TRILIPIX – choline fenofibrate cap dr 45 mg (fenofibric
acid equiv)......................................................................... 57
TRILIPIX – choline fenofibrate cap dr 135 mg (fenofibric
acid equiv)......................................................................... 57
trimethobenzamide hcl cap 300 mg (Tigan).................. 73
trimethoprim tab 100 mg................................................. 14
trimipramine maleate cap 25 mg (Surmontil)................ 84
trimipramine maleate cap 50 mg (Surmontil)................ 84
trimipramine maleate cap 100 mg (Surmontil).............. 84
TRINATAL GT – prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg............................................................................125
TRINATAL RX 1 – prenatal vit w/ fe fumarate-fa tab 60-1
mg.................................................................................... 125
TRINATE – prenatal vit w/ fe fumarate-fa tab 28-1
mg.................................................................................... 125
TRI-NORINYL 28 – norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg...............................................29
TRINTELLIX – vortioxetine hbr tab 5 mg (base equiv)...... 84
TRINTELLIX – vortioxetine hbr tab 10 mg (base
equiv)................................................................................. 84
TRINTELLIX – vortioxetine hbr tab 20 mg (base
equiv)................................................................................. 84
TRISTART DHA – prenat w/o a w/fecbn-methylf-fa-dha
cap 31-0.6-0.4-200 mg....................................................125
TRI-TABS DHA – prenat w/o a w/ fe bisglyc-fa tab 32-1 mg
& omega cap pack.......................................................... 124
TRIUMEQ – abacavir-dolutegravir-lamivudine tab
600-50-300 mg.................................................................. 12
TRIVEEN-DUO DHA – prenat-fe bis-fe prot succ-fa-ca tab
& omega 3 cap 400 pk................................................... 125
TRIVEEN-PRX RNF – prenatal w/o vit a w/ fe fum-dss-fadha cap 26-1.2-300 mg.................................................. 125
TRIZIVIR – abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg................................................................ 12
TROKENDI XR – topiramate cap sr 24hr 25 mg............. 114
TROKENDI XR – topiramate cap sr 24hr 50 mg............. 114
TROKENDI XR – topiramate cap sr 24hr 100 mg........... 114
TROKENDI XR – topiramate cap sr 24hr 200 mg........... 114
tropicamide ophth soln 0.5%........................................ 142
tropicamide ophth soln 1% (Mydriacyl)....................... 142
trospium chloride cap sr 24hr 60 mg............................. 77
trospium chloride tab 20 mg........................................... 77
TRULICITY – dulaglutide soln pen-injector 0.75
mg/0.5ml............................................................................ 34
TRULICITY – dulaglutide soln pen-injector 1.5
mg/0.5ml............................................................................ 34
TRUMENBA – meningococcal group b vaccine im susp
prefilled syringe................................................................. 17
TRUSOPT – dorzolamide hcl ophth soln 2%................... 141
TRUVADA – emtricitabine-tenofovir disoproxil fumarate
tab 100-150 mg................................................................. 12
tab 133-200 mg................................................................. 12
tab 167-250 mg................................................................. 12
tab 200-300 mg................................................................. 12
TUDORZA PRESSAIR – aclidinium bromide aerosol powd
breath activated 400 mcg/act........................................... 69
TUSSIONEX PENNKINETIC EXT – hydrocod polstchlorphen polst er susp 10-8 mg/5ml............................... 66
TWINRIX – hepatitis a (inact)-hep b (recomb) vac inj
720-20 elu-mcg/ml............................................................. 17
TWYNSTA – telmisartan-amlodipine tab 40-5 mg............. 53
TWYNSTA – telmisartan-amlodipine tab 40-10 mg........... 53
TWYNSTA – telmisartan-amlodipine tab 80-5 mg............. 53
TWYNSTA – telmisartan-amlodipine tab 80-10 mg........... 53
TYBOST – cobicistat tab 150 mg.......................................12
TYKERB – lapatinib ditosylate tab 250 mg (base
equiv)................................................................................. 22
TYLENOL/CODEINE #3 – acetaminophen w/ codeine tab
300-30 mg....................................................................... 104
TYLENOL/CODEINE #4 – acetaminophen w/ codeine tab
300-60 mg....................................................................... 104
TYLENOL/CODEINE – acetaminophen w/ codeine tab
300-15 mg....................................................................... 104
220
2016
TYVASO REFILL – treprostinil inhalation solution 0.6 mg/
ml........................................................................................ 63
TYVASO STARTER – treprostinil inhalation solution 0.6
mg/ml..................................................................................63
TYVASO – treprostinil inhalation solution 0.6 mg/ml......... 63
TYZEKA – telbivudine tab 600 mg....................................... 9
TYZINE PEDIATRIC NASAL DR – tetrahydrozoline hcl
nasal soln 0.05%............................................................... 65
TYZINE – tetrahydrozoline hcl nasal soln 0.1%.................65
U
UCERIS – budesonide rectal foam 2 mg/act................... 144
UCERIS – budesonide tab sr 24hr 9 mg........................... 24
ULESFIA – benzyl alcohol lotion 5%............................... 153
ULORIC – febuxostat tab 40 mg...................................... 109
ULORIC – febuxostat tab 80 mg...................................... 109
ULTIMATECARE ONE NF – prenatal w/fe cbnyl-fe asp
glyc-fa-dss-omega cap 20-7-1 mg.................................. 125
ULTIMATECARE ONE – prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg................................................. 125
ULTRAVATE – halobetasol propionate cream 0.05%...... 151
ULTRAVATE – halobetasol propionate oint 0.05%.......... 151
UPTRAVI – selexipag tab 200 mcg.................................... 63
UPTRAVI – selexipag tab 1000 mcg.................................. 63
UPTRAVI – selexipag tab therapy pack 200 mcg (140) &
800 mcg (60)..................................................................... 63
URAMAXIN – urea in ammonium lactate vehicle foam
20%.................................................................................. 153
URECHOLINE – bethanechol chloride tab 5 mg............... 77
URECHOLINE – bethanechol chloride tab 10 mg............. 77
UROCIT-K 10 – potassium citrate tab cr 10 meq (1080
mg)..................................................................................... 79
mg)..................................................................................... 79
mg)..................................................................................... 79
UROGESIC-BLUE – methenamine-hyoscamine-meth
blue-sod phos tab 81.6 mg............................................... 76
ursodiol cap 300 mg (Actigall)........................................ 76
ursodiol tab 250 mg (Urso 250)...................................... 76
ursodiol tab 500 mg (Urso forte).................................... 76
URSO FORTE – ursodiol tab 500 mg................................ 76
URSO 250 – ursodiol tab 250 mg...................................... 76
V
VAGIFEM – estradiol vaginal tab 10 mcg.......................... 78
valacyclovir hcl tab 1 gm (Valtrex)................................... 9
valacyclovir hcl tab 500 mg (Valtrex)............................... 9
VALCHLOR – mechlorethamine hcl gel 0.016% (base
equivalent)....................................................................... 153
VALCYTE – valganciclovir hcl for soln 50 mg/ml (base
equiv)....................................................................................7
valganciclovir hcl tab 450 mg (base equivalent)
(Valcyte).............................................................................. 7
valproate sodium syrup 250 mg/5ml (base equiv)
(Depakene)......................................................................114
valproic acid cap 250 mg (Depakene).......................... 114
valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan
hct)..................................................................................... 47
hct)..................................................................................... 47
valsartan-hydrochlorothiazide tab 160-25 mg (Diovan
hct)..................................................................................... 47
hct)..................................................................................... 47
valsartan-hydrochlorothiazide tab 320-25 mg (Diovan
hct)..................................................................................... 47
valsartan tab 40 mg (Diovan).......................................... 46
valsartan tab 80 mg (Diovan).......................................... 47
valsartan tab 160 mg (Diovan)........................................ 47
valsartan tab 320 mg (Diovan)........................................ 47
VANCOCIN HCL – vancomycin hcl cap 125 mg................14
VANCOCIN HCL – vancomycin hcl cap 250 mg................14
vancomycin hcl cap 125 mg (Vancocin hcl).................. 14
vancomycin hcl cap 250 mg (Vancocin hcl).................. 14
VAQTA – hepatitis a vaccine inj susp 25 unit/0.5ml........... 17
VAQTA – hepatitis a vaccine inj susp 50 unit/ml................ 17
VARIVAX – varicella virus vac live for subcutaneous inj
1350 pfu/0.5ml................................................................... 17
VARUBI – rolapitant hcl tab 90 mg (base equiv)............... 73
VASCEPA – icosapent ethyl cap 1 gm...............................57
VCF VAGINAL CONTRACEPTIVE – nonoxynol-9 film
28%.................................................................................... 29
VCF VAGINAL CONTRACEPTIVE – nonoxynol-9 foam
12.5%................................................................................. 29
VECAMYL – mecamylamine hcl tab 2.5 mg...................... 64
VECTICAL – calcitriol oint 3 mcg/gm............................... 153
VELPHORO – sucroferric oxyhydroxide chew tab 500
mg...................................................................................... 76
VELTASSA – patiromer sorbitex calcium for susp packet
8.4 gm (base eq).............................................................156
16.8 gm (base eq)...........................................................156
25.2 gm (base eq)...........................................................156
VEMAVITE-PRX 2 – prenatal w/o vit a w/ fe fum-dss-fadha cap 27-1.25-300 mg................................................ 125
VENA-BAL DHA – prenat w/fe poly-na fered-fa tab 27-1 &
omega cap dr 430mg...................................................... 125
venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent)
(Effexor xr)....................................................................... 84
venlafaxine hcl cap sr 24hr 75 mg (base equivalent)
(Effexor xr)....................................................................... 84
221
2016
venlafaxine hcl cap sr 24hr 150 mg (base equivalent)
(Effexor xr)....................................................................... 84
VENLAFAXINE HCL ER – venlafaxine hcl tab sr 24hr 37.5
mg (base equivalent)........................................................ 84
VENLAFAXINE HCL ER – venlafaxine hcl tab sr 24hr 75
venlafaxine hcl tab 25 mg................................................84
venlafaxine hcl tab 37.5 mg.............................................84
venlafaxine hcl tab 100 mg..............................................84
venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent)
(Venlafaxine hcl er)......................................................... 84
venlafaxine hcl tab sr 24hr 75 mg (base equivalent)
venlafaxine hcl tab sr 24hr 150 mg (base equivalent)
VENTAVIS – iloprost inhalation solution 10 mcg/ml........... 64
VENTAVIS – iloprost inhalation solution 20 mcg/ml........... 64
VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv).......................................................... 69
verapamil hcl cap sr 24hr 120 mg (Verelan).................. 53
verapamil hcl cap sr 24hr 100 mg (Verelan pm)............ 53
verapamil hcl tab cr 120 mg (Calan sr).......................... 53
verapamil hcl tab 40 mg.................................................. 53
verapamil hcl tab 80 mg (Calan)..................................... 53
verapamil hcl tab 120 mg (Calan)................................... 53
VERDESO – desonide foam 0.05%................................. 151
VEREGEN – sinecatechins oint 15%............................... 153
VERELAN PM – verapamil hcl cap sr 24hr 100 mg.......... 53
VERELAN – verapamil hcl cap sr 24hr 120 mg................. 53
VERIPRED 20 – prednisolone sod phosphate oral soln 20
mg/5ml (base equiv)......................................................... 24
VERSACLOZ – clozapine susp 50 mg/ml..........................88
VESICARE – solifenacin succinate tab 5 mg.................... 77
VESICARE – solifenacin succinate tab 10 mg...................77
VEXOL – rimexolone ophth susp 1%...............................139
VFEND – voriconazole for susp 40 mg/ml........................... 7
VFEND – voriconazole tab 50 mg........................................7
VFEND – voriconazole tab 200 mg......................................7
VIBERZI – eluxadoline tab 75 mg...................................... 76
VIBERZI – eluxadoline tab 100 mg.................................... 76
VIBRAMYCIN – doxycycline calcium syrup 50 mg/5ml....... 5
VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/
ml)...................................................................................... 34
VIDEX – didanosine for soln 2 gm..................................... 12
VIDEX – didanosine for soln 4 gm..................................... 12
VIDEX EC – didanosine delayed release capsule 125
mg...................................................................................... 12
mg...................................................................................... 12
mg...................................................................................... 12
mg...................................................................................... 12
VIEKIRA PAK – ombitas-paritapre-riton & dasab tab pak
12.5-75-50 & 250 mg.......................................................... 9
VIGAMOX – moxifloxacin hcl ophth soln 0.5% (base
equiv)............................................................................... 138
VIIBRYD STARTER PACK – vilazodone hcl tab starter kit
10 (7) & 20 (23) mg.......................................................... 84
VIIBRYD – vilazodone hcl tab 10 mg................................. 84
VIMPAT – lacosamide oral solution 10 mg/ml.................. 114
VIMPAT – lacosamide tab 50 mg..................................... 114
VIMPAT – lacosamide tab 100 mg................................... 114
VINACAL B – prenat w/o a w/fecbn-feglu-fa tab 20-1 mg &
vit b6 tab pak.................................................................. 125
VINATE AZ EXTRA – prenatal vit w/ fe bisglycinate
chelate-fa tab 29-1 mg.................................................... 125
VINATE CALCIUM – prenatal vit w/ iron carbonyl-fe glucfa tab 27-1 mg................................................................. 125
VINATE CARE – prenatal w/o a vit w/ fe fum-fa tab chew
40-1 mg............................................................................125
VINATE C – prenatal w/o a vit w/ fe fumarate-fa tab 30-1
mg.................................................................................... 125
VINATE DHA RF – prenat w/o a w/fefum-methylfolomegas cap 27-1.13 mg................................................. 125
VINATE IC – prenatal w/o a w/fe fum-fe poly-fa cap
162.115.2-1 mg................................................................125
VINATE II – prenatal vit w/ fe bisglycinate chelate-fa tab
29-1 mg............................................................................125
VINATE M – prenatal vit w/ sel-fe fumarate-fa tab 27-1
mg.................................................................................... 125
VINATE ONE – prenatal vit w/ fe fumarate-fa tab 60-1
mg.................................................................................... 125
VIOKACE – pancrelipase (lip-prot-amyl) tab
10440-39150-39150 unit................................................... 74
VIOKACE – pancrelipase (lip-prot-amyl) tab
20880-78300-78300 unit................................................... 74
VIRACEPT – nelfinavir mesylate tab 250 mg.................... 12
VIRACEPT – nelfinavir mesylate tab 625 mg.................... 12
VIRAMUNE – nevirapine susp 50 mg/5ml......................... 12
222
2016
VIRAMUNE – nevirapine tab 200 mg................................ 12
VIRAMUNE XR – nevirapine tab sr 24hr 100 mg.............. 12
VIRAMUNE XR – nevirapine tab sr 24hr 400 mg.............. 12
VIRAZOLE – ribavirin for inhal soln 6 gm.......................... 14
VIREAD – tenofovir disoproxil fumarate oral powder 40
mg/gm................................................................................ 12
VIREAD – tenofovir disoproxil fumarate tab 150 mg......... 12
VIROPTIC – trifluridine ophth soln 1%.............................138
VIRT-ADVANCE – prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg............................................................................125
VIRT-CARE ONE – prenatal vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg...................................................... 125
VIRT-C DHA – prenatal w/fe fum-fe poly -fa-omega 3 cap
53.5-38-1 mg................................................................... 125
VIRT-NATE DHA – prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg.................................................................... 126
VIRT NATE – prenatal vit w/ fe fumarate-fa tab 28-1
mg.................................................................................... 125
VIRT-PN DHA – prenat w/o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg........................................................... 126
VIRT-PN PLUS – prenat w/o a w/ fe fumeratemethylfolate-fa-omega 3 cap.......................................... 126
VIRT-PN – prenatal vit w/ fe fum-methylfolate-fa tab
27-0.6-0.4 mg.................................................................. 126
VIRTPREX – prenatal w/o vit a w/ fe fum-dss-fa-dha cap
26-1.2-300 mg................................................................. 126
VIRT-SELECT – prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg........................................................ 126
VIRT-VITE GT – prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg............................................................................126
VISTARIL – hydroxyzine pamoate cap 25 mg................... 80
VISTARIL – hydroxyzine pamoate cap 50 mg................... 80
VITAFOL FE+ – prenat-fepoly-methol-fa-dha cap 90-1-200
mg & dss 50mg cap........................................................ 126
VITAFOL GUMMIES – prenat vit w/ fe phos-fa-omega
chew tab 3.33-0.333-34.8 mg......................................... 126
VITAFOL-NANO – prenatal w/o a w/ fefum-l methylfol-fa
tab 18-0.6-0.4 mg............................................................ 126
VITAFOL-OB+DHA – prenatal mv w/fe fum-fa tab 65-1 mg
& dha cap 250 mg pack................................................. 126
VITAFOL-OB – prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................... 126
VITAFOL-ONE – prenatal mv w/ fe polysac cmplx-fa-dha
cap 29-1-200 mg............................................................. 126
VITAFOL ULTRA – prenat w/fe poly-methylfol-fa-dha cap
29-0.6-0.4-200 mg........................................................... 126
VITAMEDMD ONE RX/QUATREFO – prenat w/o a w/
fefum-methfol-fa-dha cap 30-0.6-0.4-200 mg.................126
VITAMEDMD PLUS RX/QUATRE – prenat w/o a w/ fe
chelate-l methylfol-fa tab & dha cap pk.......................... 126
VITAMEDMD REDICHEW RX – prenat w/ b2-b6-b12-d3folic acid chew tab 1.4 mg.............................................. 126
VITAPEARL – prenat w/oa w/fefum-na fered-fa-dha cap cr
30-1.4-200 mg................................................................. 126
VITA-PREN – prenatal vit w/ docusate-iron-fa tab 65-1
mg.................................................................................... 126
VITATRUE – prenat w/o a w/fe chel-fa tab 30-1.4 mg &
dha cap 300mg pk.......................................................... 126
VITEKTA – elvitegravir tab 85 mg...................................... 12
VITEKTA – elvitegravir tab 150 mg.................................... 12
VITUZ – hydrocodone-chlorpheniramine soln 5-4
mg/5ml............................................................................... 66
VIVA DHA – prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg.................................................................... 126
VIVELLE-DOT – estradiol td patch twice weekly 0.025
mg/24hr.............................................................................. 27
mg/24hr.............................................................................. 27
mg/24hr.............................................................................. 27
mg/24hr.............................................................................. 27
mg/24hr.............................................................................. 27
VOL-NATE – prenatal vit w/ fe fumarate-fa tab 28-1
mg.................................................................................... 126
VOL-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................... 126
VOL-TAB RX – prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................... 126
VOLTAREN – diclofenac sodium gel 1%......................... 147
voriconazole for susp 40 mg/ml (Vfend).......................... 7
voriconazole tab 50 mg (Vfend)........................................ 7
voriconazole tab 200 mg (Vfend)...................................... 7
VOSPIRE ER – albuterol sulfate tab sr 12hr 4 mg............ 69
VOSPIRE ER – albuterol sulfate tab sr 12hr 8 mg............ 69
VOTRIENT – pazopanib hcl tab 200 mg (base equiv)....... 22
VP-CH PLUS – prenatal w/o a w/fe cbn-dss-fa-dha cap
29-1-265 mg.................................................................... 126
VP-CH-PNV – prenatal w/o vit a w/ fe cbn-dss-fa-dha cap
30-1-260 mg.................................................................... 126
VP-GGR-B6 PRENATAL – prenatal w/ calcium-vit b6-faginger tab 1.2 mg............................................................ 126
VP-HEME OB + DHA – prenat-fe poly cmplx-fe heme
poly-fa tab & omega 3 cap pck...................................... 127
VP-HEME OB – prenat vit-fe poly cmplx-fe heme poly-fa
tab 28-6-1 mg.................................................................. 126
VP-HEME ONE – prenat-fe poly cmplx-fe heme poly-fadha cap 22-6-1-200 mg.................................................. 127
VP-PNV-DHA – prenatal vit w/ fe fum-fa-omega 3 cap
28-1-215.8 mg................................................................. 127
VRAYLAR – cariprazine hcl cap 1.5 mg (base
equivalent)......................................................................... 88
VRAYLAR – cariprazine hcl cap 3 mg (base
equivalent)......................................................................... 88
VRAYLAR – cariprazine hcl cap 4.5 mg (base
equivalent)......................................................................... 88
223
2016
VRAYLAR – cariprazine hcl cap 6 mg (base
equivalent)......................................................................... 88
VRAYLAR – cariprazine hcl cap therapy pack 1.5 mg (1) &
3 mg (6)............................................................................. 88
VYTORIN – ezetimibe-simvastatin tab 10-10 mg.............. 57
VYVANSE – lisdexamfetamine dimesylate cap 10 mg...... 93
W
warfarin sodium tab 1 mg (Coumadin)........................ 132
warfarin sodium tab 2.5 mg (Coumadin)..................... 132
warfarin sodium tab 7.5 mg (Coumadin)..................... 132
warfarin sodium tab 10 mg (Coumadin)...................... 132
water for irrigation, sterile irrigation soln.................... 156
WELCHOL – colesevelam hcl packet for susp 3.75
gm...................................................................................... 57
WELCHOL – colesevelam hcl tab 625 mg........................ 57
WESTCORT – hydrocortisone valerate oint 0.2%........... 151
WESTHROID – thyroid tab 32.5 mg.................................. 37
WESTHROID – thyroid tab 65 mg..................................... 37
WESTHROID – thyroid tab 97.5 mg.................................. 37
WESTHROID – thyroid tab 130 mg................................... 37
WESTHROID – thyroid tab 195 mg................................... 37
WIDE-SEAL SILICONE DIAPHR – diaphragm wide seal
60 mm................................................................................ 29
65 mm................................................................................ 29
70 mm................................................................................ 29
75 mm................................................................................ 29
80 mm................................................................................ 29
85 mm................................................................................ 29
90 mm................................................................................ 30
95 mm................................................................................ 30
WILATE – antihemophilic factor/vwf (human) for inj
500-500 unit kit................................................................137
WILATE – antihemophilic factor/vwf (human) for inj
1000-1000 unit kit........................................................... 137
WP THYROID – thyroid tab 16.25 mg............................... 37
WP THYROID – thyroid tab 32.5 mg................................. 37
WP THYROID – thyroid tab 65 mg.................................... 37
WP THYROID – thyroid tab 81.25 mg............................... 37
WP THYROID – thyroid tab 97.5 mg................................. 37
WP THYROID – thyroid tab 113.75 mg............................. 37
WP THYROID – thyroid tab 130 mg.................................. 37
WP THYROID – thyroid tab 48.75 mg (3/4 grain).............. 37
X
XALATAN – latanoprost ophth soln 0.005%.....................141
XALKORI – crizotinib cap 200 mg..................................... 22
XALKORI – crizotinib cap 250 mg..................................... 22
XARELTO – rivaroxaban tab 10 mg................................. 133
XARELTO STARTER PACK – rivaroxaban tab starter
therapy pack 15 mg & 20 mg......................................... 133
XELJANZ – tofacitinib citrate tab 5 mg (base
equivalent)....................................................................... 107
XELODA – capecitabine tab 150 mg................................. 22
XELODA – capecitabine tab 500 mg................................. 22
XENAZINE – tetrabenazine tab 12.5 mg........................... 97
XENAZINE – tetrabenazine tab 25 mg.............................. 97
XIFAXAN – rifaximin tab 200 mg....................................... 14
XIFAXAN – rifaximin tab 550 mg....................................... 14
XIGDUO XR – dapagliflozin-metformin hcl tab sr 24hr
5-500 mg............................................................................34
5-1000 mg......................................................................... 34
10-500 mg......................................................................... 34
10-1000 mg....................................................................... 34
XOPENEX CONCENTRATE – levalbuterol hcl soln nebu
conc 1.25 mg/0.5ml (base equiv)..................................... 69
XOPENEX HFA – levalbuterol tartrate inhal aerosol 45
mcg/act (base equiv)......................................................... 69
XOPENEX – levalbuterol hcl soln nebu 0.31 mg/3ml (base
equiv)................................................................................. 69
equiv)................................................................................. 69
equiv)................................................................................. 69
XTANDI – enzalutamide cap 40 mg................................... 22
XULANE – norelgestromin-ethinyl estradiol td ptwk 150-35
mcg/24hr............................................................................ 30
XURIDEN – uridine triacetate oral granules packet 2
gm...................................................................................... 42
XYLOCAINE – lidocaine hcl soln 4%............................... 153
XYNTHA – antihemophilic factor recombinant paf for inj kit
250 unit............................................................................ 137
500 unit............................................................................ 137
1000 unit.......................................................................... 137
224
2016
2000 unit.......................................................................... 137
XYNTHA SOLOFUSE – antihemophilic factor recombinant
paf for inj kit 250 unit...................................................... 137
paf for inj kit 500 unit...................................................... 137
paf for inj kit 1000 unit.................................................... 137
XYREM – sodium oxybate oral solution 500 mg/ml........... 97
Y
YASMIN 28 – drospirenone-ethinyl estradiol tab 3-0.03
mg...................................................................................... 30
YAZ – drospirenone-ethinyl estradiol tab 3-0.02 mg.......... 30
Z
ZACLIR CLEANSING – benzoyl peroxide lotion 8%....... 145
zafirlukast tab 10 mg (Accolate)..................................... 69
zafirlukast tab 20 mg (Accolate)..................................... 69
zaleplon cap 5 mg (Sonata)............................................. 89
zaleplon cap 10 mg (Sonata)........................................... 89
ZAMICET – hydrocodone-acetaminophen soln 10-325
mg/15ml........................................................................... 104
ZANAFLEX – tizanidine hcl cap 2 mg (base
equivalent)....................................................................... 119
equivalent)....................................................................... 119
equivalent)....................................................................... 119
ZANAFLEX – tizanidine hcl tab 4 mg (base
equivalent)....................................................................... 119
ZARONTIN – ethosuximide cap 250 mg..........................114
ZARONTIN – ethosuximide soln 250 mg/5ml.................. 114
ZARXIO – filgrastim-sndz soln prefilled syringe 300
mcg/0.5ml........................................................................ 133
ZARXIO – filgrastim-sndz soln prefilled syringe 480
mcg/0.8ml........................................................................ 133
ZATEAN-CH – prenatal w/o a w/fe cbn-dss-fa-dha cap
27-1-250 mg.................................................................... 127
ZATEAN-PN DHA – prenat w/o a w/fefum-methfol-fa-dha
cap 27-0.6-0.4-300 mg....................................................127
ZATEAN-PN PLUS – prenat w/o a w/ fe fumeratemethylfolate-fa-omega 3 cap.......................................... 127
ZAVESCA – miglustat cap 100 mg.................................. 133
ZEBETA – bisoprolol fumarate tab 5 mg............................49
ZEBETA – bisoprolol fumarate tab 10 mg..........................49
ZELBORAF – vemurafenib tab 240 mg............................. 22
ZEMPLAR – paricalcitol cap 1 mcg................................... 42
ZEMPLAR – paricalcitol cap 2 mcg................................... 42
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
3000-10000-16000 unit..................................................... 74
5000-17000-27000 unit..................................................... 74
10000-34000-55000 unit................................................... 74
15000-51000-82000 unit................................................... 74
20000-68000-109000 unit................................................. 74
25000-85000-136000 unit................................................. 74
40000-136000-218000 unit............................................... 74
ZENZEDI – dextroamphetamine sulfate tab 2.5 mg.......... 94
ZENZEDI – dextroamphetamine sulfate tab 7.5 mg.......... 94
ZENZEDI – dextroamphetamine sulfate tab 15 mg........... 94
ZEPATIER – elbasvir-grazoprevir tab 50-100 mg................ 9
ZERIT – stavudine cap 15 mg........................................... 12
ZERIT – stavudine for oral soln 1 mg/ml........................... 12
ZETIA – ezetimibe tab 10 mg............................................ 57
ZIAC – bisoprolol & hydrochlorothiazide tab 2.5-6.25
mg...................................................................................... 50
ZIAC – bisoprolol & hydrochlorothiazide tab 5-6.25
mg...................................................................................... 50
ZIAC – bisoprolol & hydrochlorothiazide tab 10-6.25
mg...................................................................................... 50
ZIAGEN – abacavir sulfate soln 20 mg/ml (base
equiv)................................................................................. 12
ZIAGEN – abacavir sulfate tab 300 mg (base equiv).........12
zidovudine cap 100 mg (Retrovir)...................................12
zidovudine syrup 10 mg/ml (Retrovir)............................ 12
zidovudine tab 300 mg..................................................... 12
ZIOPTAN – tafluprost ophth soln 0.0015%...................... 141
ziprasidone hcl cap 20 mg (Geodon)............................. 88
ZIRGAN – ganciclovir ophth gel 0.15%........................... 138
ZITHROMAX – azithromycin for susp 100 mg/5ml.............. 4
ZITHROMAX – azithromycin for susp 200 mg/5ml.............. 4
ZITHROMAX – azithromycin powd pack for susp 1 gm.......4
ZITHROMAX – azithromycin tab 250 mg.............................4
ZITHROMAX TRI-PAK – azithromycin tab 500 mg.............. 4
ZITHROMAX Z-PAK – azithromycin tab 250 mg................. 4
ZMAX – azithromycin extended release for oral susp 2
gm........................................................................................ 4
ZOCOR – simvastatin tab 5 mg......................................... 57
ZOCOR – simvastatin tab 10 mg....................................... 57
225
2016
ZOFRAN ODT – ondansetron orally disintegrating tab 4
mg...................................................................................... 73
ZOFRAN ODT – ondansetron orally disintegrating tab 8
mg...................................................................................... 73
ZOFRAN – ondansetron hcl oral soln 4 mg/5ml................ 73
ZOFRAN – ondansetron hcl tab 4 mg............................... 73
ZOFRAN – ondansetron hcl tab 8 mg............................... 73
ZOLINZA – vorinostat cap 100 mg.................................... 22
zolmitriptan orally disintegrating tab 2.5 mg (Zomig
zmt).................................................................................. 108
zolmitriptan orally disintegrating tab 5 mg (Zomig
zmt).................................................................................. 108
zolmitriptan tab 2.5 mg (Zomig).................................... 108
zolmitriptan tab 5 mg (Zomig)....................................... 108
ZOLOFT – sertraline hcl oral conc 20 mg/ml..................... 84
zolpidem tartrate tab cr 6.25 mg (Ambien cr)................ 89
zolpidem tartrate tab cr 12.5 mg (Ambien cr)................ 89
zolpidem tartrate tab 5 mg (Ambien)..............................89
zolpidem tartrate tab 10 mg (Ambien)............................89
ZOMACTON – somatropin for inj 10 mg............................ 38
ZOMACTON – somatropin for subcutaneous inj 5 mg...... 38
ZOMIG NASAL SPRAY – zolmitriptan nasal spray 5 mg/
spray unit......................................................................... 108
ZOMIG – zolmitriptan nasal spray 2.5 mg/spray unit....... 108
ZONALON – doxepin hcl cream 5%................................ 153
ZONEGRAN – zonisamide cap 25 mg.............................115
ZONEGRAN – zonisamide cap 100 mg...........................115
zonisamide cap 50 mg................................................... 115
zonisamide cap 25 mg (Zonegran)............................... 115
zonisamide cap 100 mg (Zonegran)............................. 115
ZONTIVITY – vorapaxar sulfate tab 2.08 mg (base
equivalent)....................................................................... 133
ZORBTIVE – somatropin (non-refrigerated) for
subcutaneous inj 8.8 mg................................................... 38
ZORTRESS – everolimus tab 0.25 mg............................ 156
ZORTRESS – everolimus tab 0.5 mg.............................. 156
ZORTRESS – everolimus tab 0.75 mg............................ 156
ZOSTAVAX – zoster vaccine live for inj 19400
unit/0.65ml......................................................................... 17
ZOVIA 1/50E – ethynodiol diacetate & ethinyl estradiol tab
1 mg-50 mcg..................................................................... 30
ZOVIRAX – acyclovir cap 200 mg....................................... 9
ZOVIRAX – acyclovir susp 200 mg/5ml............................... 9
ZOVIRAX – acyclovir tab 400 mg........................................ 9
ZOVIRAX – acyclovir tab 800 mg........................................ 9
ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab
1.4-0.36 mg (base eq).................................................... 156
2.9-0.71 mg (base eq).................................................... 156
ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab 5.7-1.4
mg (base eq)................................................................... 156
ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab 8.6-2.1
mg (base eq)................................................................... 156
11.4-2.9 mg (base eq).....................................................156
ZUTRIPRO – pseudoeph-chlorphen w/ hydrocodone soln
60-4-5 mg/5ml................................................................... 66
ZYDELIG – idelalisib tab 100 mg....................................... 22
ZYDELIG – idelalisib tab 150 mg....................................... 22
ZYFLO CR – zileuton tab sr 12hr 600 mg......................... 69
ZYKADIA – ceritinib cap 150 mg....................................... 22
ZYLET – loteprednol etabonate-tobramycin ophth susp
0.5-0.3%........................................................................... 139
ZYLOPRIM – allopurinol tab 100 mg............................... 109
ZYLOPRIM – allopurinol tab 300 mg............................... 109
ZYMAXID – gatifloxacin ophth soln 0.5%........................ 138
ZYTIGA – abiraterone acetate tab 250 mg........................ 22
ZYVOX – linezolid for susp 100 mg/5ml............................ 15
ZYVOX – linezolid tab 600 mg........................................... 15
226

Florida Blue July 2016 Medication Guide

Transcription

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