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

Transcription

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January 2016
Blue Cross Blue Shield of Wyoming Standard Drug List
Contents
Therapeutic Class Drug List
Introduction .................................................................... I Anti-Infective Agents ....................................................... 1
Member prescription benefit ............................................ I Cancer Drugs .................................................................. 7
Prior Authorization ........................................................... I Hormones, Diabetes and Related Drugs ...................... 10
How to use this list .......................................................... II Heart and Circulatory Drugs ......................................... 17
Specialty Products ........................................................ III Respiratory Agents ....................................................... 26
Generic substitution ...................................................... III Gastrointestinal Drugs .................................................. 28
Abbreviation Key............................................................ III Genitourinary Drugs ...................................................... 31
Central Nervous System Drugs .................................... 32
Pain Relief Drugs .......................................................... 40
Neuromuscular Drugs ................................................... 45
Blood Modifying Drugs .................................................. 50
Topical Products ........................................................... 52
Miscellaneous Categories (includes Supplies
and Devices) ............................................................. 58
Index............................................................................. 62
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.
Prime Therapeutics LLC (Prime) is an independent company that manages pharmacy benefits for Blue Cross Blue Shield of Wyoming
members
2278 WY © Prime Therapeutics LLC 01/16
Introduction
This Blue Cross Blue Shield of Wyoming (BCBSWY) Standard Drug List, also called a patient medication guide,
includes Brand drugs and Generic drugs. This guide, current at time of printing and subject to change, is updated
quarterly. Members and physicians can review the most up-to-date version of the Standard Drug List at
www.wyomingblue.com/pharmacy.
The Standard Drug List includes a list of prescription drugs, insulin, and diabetic supplies that reflect the current
recommendations of BCBSWY. The Standard Drug List is developed in conjunction with Prime Therapeutics’
National Pharmacy & Therapeutics Committee, which includes practicing physicians and pharmacists dedicated to
providing patients with high-quality, cost-effective drug therapy. The Committee includes physicians and
pharmacists from throughout the country. Prime Therapeutics does not have voting privileges. Drugs are reviewed
in terms of safety, efficacy, and clinical uniqueness.
Member prescription benefit
Medications and supplies on this list are Preferred products. Drugs or supplies not listed are Non-Preferred (NP).
Coverage of Preferred and Non-Preferred drugs will vary depending on your individual prescription benefit.
Some drugs may be excluded from coverage. For example, drugs indicated for cosmetic purposes, e.g., Propecia, for hair
growth, are not covered. Prescription drugs may be excluded from coverage if there are over-the-counter (OTC) versions
marketed. OTC drugs are not covered with the exception of insulin and selected diabetic supplies.
Prior Authorization
Drugs are selected for prior authorization (PA) because of actual or potential misuse or overuse that may be of
clinical and/or economic concern. Drugs selected for PA require that specific clinical criteria are met before the
drugs will be covered under a member’s prescription benefit.
Not all drugs selected for PA are on the Standard Drug List. Coverage of Preferred and Non-Preferred drugs will
vary depending on your individual prescription benefit. Drugs selected for PA are subject to change. For information
about benefit coverage on specific drugs, please call 800.442.2376.
I
How to use this list
This list is organized into broad therapeutic categories (e.g. Hormones, Diabetes and Related Drugs).Within most
categories, drugs are sub-grouped based upon drug class (e.g Corticosteroids). All drugs listed, whether generic or
brand, are Preferred drugs. The graphic below shows the information that is provided in each column of the
medication list and is an example only. Please use the drug search function to find current information for drugs on
the medication list.
The first column of the chart lists the drug name.
Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference
brand drug in (parentheses). Some generic products have no reference brand.
Brand prescription drugs are shown in capital letters followed by the generic name.
The second column indicates if the drug is a specialty drug. Note: Additional information about specialty
drugs can be found in this document under the header for Specialty Products.
The columns indicate the Utilization Management (UM) program(s) that apply to the prescription drug
(e.g., Prior Authorization and Quantity Limits). If an indicator is present in the column(s), then the
UM program noted is possibly applied to your benefit. Some plans may have UM on additional
medications beyond those noted in this document.
II
Specialty Products
Specialty drugs are used in the treatment of medical conditions such as hepatitis, multiple sclerosis and rheumatoid
arthritis. Specialty drugs may be oral or injectable medications that can either be self-administered or administered
by a health care professional. These high cost medications also have one or more of the following characteristics:
•
Unique storage or shipment requirements
•
Additional education and support required from a health care professional
•
Usually not stocked at retail pharmacies
Generic substitution
BCBSWY encourages generic utilization as a way to provide high-quality drugs at a reduced cost. Generic drugs
are as safe and effective as their brand-name counterparts, but are usually less expensive. Generic drugs are
manufactured under the same strict standards of FDA’s Good Manufacturing Practice regulations that are required
for brand products including batch requirements for identity, strength, purity, and quality.
An FDA-approved generic drug may be substituted for the brand counterpart because it:
•
Contains the same active ingredient(s) as the brand drug
•
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
To encourage the use of generic drugs, Preferred brand drugs usually become Non-Preferred after the generic
equivalent version is added to the drug guide. If the brand drug you are looking for does not appear on this list,
it may be present under the generic name. You can ask your pharmacist for assistance.
Abbreviation/acronym key
cap ...................................................................... capsules
chew .................................................................. chewable
odt ......................................... orally disintegrating tablets
oint ..................................................................... ointment
conc .............................................................. concentrate
cr .......................................................... controlled release
ophth ............................................................... ophthalmic
osm .......................................................... osmotic release
dr ............................................................. delayed release
ec ................................................................ enteric coated
powd..................................................................... powder
sa ............................................................ sustained action
effe................................................................. effervescent
equiv ................................................................ equivalent
sl ...................................................................... sublingual
soln ....................................................................... solution
er ...........................................................extended release
inhal................................................................... inhalation
sr .......................................................... sustained release
suppos ........................................................ suppositories
inj ......................................................................... injection
liq .............................................................................. liquid
susp ................................................................ suspension
tab ...........................................................................tablets
lotn ........................................................................... lotion
nebu ................................................................... nebulizer
td ................................................................... transdermal
III
ANTI-INFECTIVE AGENTS
PENICILLINS
AMOXICILLIN – amoxicillin (trihydrate)
chew tab 125 mg
AMOXICILLIN – amoxicillin (trihydrate)
chew tab 250 mg
amoxicillin (trihydrate) cap 250 mg
amoxicillin (trihydrate) cap 500 mg
amoxicillin (trihydrate) for susp
125 mg/5ml
200 mg/5ml
250 mg/5ml
400 mg/5ml
amoxicillin (trihydrate) tab 500 mg
AMPICILLIN – ampicillin for susp 125
mg/5ml
AMPICILLIN – ampicillin for susp 250
mg/5ml
ampicillin cap 250 mg
ampicillin cap 500 mg
AUGMENTIN – amoxicillin & k
clavulanate for susp 125-31.25 mg/5ml
dicloxacillin sodium cap 250 mg
dicloxacillin sodium cap 500 mg
penicillin v potassium for soln
125 mg/5ml
penicillin v potassium for soln
250 mg/5ml
penicillin v potassium tab 250 mg
amoxicillin & k clavulanate for susp
200-28.5 mg/5ml
penicillin v potassium tab 500 mg
CEPHALOSPORINS
250-62.5 mg/5ml (Augmentin)
cefaclor cap 250 mg
400-57 mg/5ml
cefadroxil cap 500 mg
cefaclor cap 500 mg
cefadroxil for susp 250 mg/5ml
cefadroxil for susp 500 mg/5ml
amoxicillin & k clavulanate tab sr 12hr
1000-62.5 mg (Augmentin xr)
cefadroxil tab 1 gm
amoxicillin & k clavulanate tab
250-125 mg
cefdinir for susp 125 mg/5ml
500-125 mg (Augmentin)
cefixime for susp 100 mg/5ml (Suprax)
875-125 mg (Augmentin)
AMOXICILLIN/CLAVULANATE P –
amoxicillin & k clavulanate chew tab
200-28.5 mg
Quantity Limits
AMOXICILLIN/CLAVULANATE P –
amoxicillin & k clavulanate chew tab
400-57 mg
amoxicillin (trihydrate) tab 875 mg
600-42.9 mg/5ml (Augmentin es-600)
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
cefdinir cap 300 mg
cefdinir for susp 250 mg/5ml
cefixime for susp 200 mg/5ml (Suprax)
cefpodoxime proxetil for susp
50 mg/5ml
cefpodoxime proxetil for susp
100 mg/5ml
cefpodoxime proxetil tab 100 mg
cefpodoxime proxetil tab 200 mg
1
cefprozil for susp 125 mg/5ml
clarithromycin tab 500 mg (Biaxin)
cefprozil for susp 250 mg/5ml
E.E.S. 400 – erythromycin ethylsuccinate
tab 400 mg
cefprozil tab 250 mg
cefprozil tab 500 mg
CEFTIN – cefuroxime axetil for susp 125
mg/5ml
ceftriaxone sodium for inj 10 gm
cefuroxime axetil tab 250 mg (Ceftin)
cefuroxime axetil tab 500 mg (Ceftin)
cephalexin cap 250 mg (Keflex)
cephalexin for susp 125 mg/5ml
cephalexin for susp 250 mg/5ml
SUPRAX – cefixime cap 400 mg
SUPRAX – cefixime chew tab 100 mg
ERY-TAB – erythromycin tab delayed
release 333 mg
release 500 mg
ERYTHROCIN STEARATE –
erythromycin stearate tab 250 mg
ERYTHROMYCIN BASE – erythromycin
tab 250 mg
ERYTHROMYCIN BASE – erythromycin
tab 500 mg
ERYTHROMYCIN ETHYLSUCCINA –
erythromycin ethylsuccinate tab 400 mg
SUPRAX – cefixime chew tab 200 mg
SUPRAX – cefixime for susp 100 mg/5ml
TETRACYCLINES
demeclocycline hcl tab 150 mg
demeclocycline hcl tab 300 mg
MACROLIDES
doxycycline hyclate cap 50 mg
AZITHROMYCIN – azithromycin powd
pack for susp 1 gm
doxycycline hyclate cap 100 mg
(Vibramycin)
azithromycin for susp 100 mg/5ml
(Zithromax)
doxycycline hyclate tab delayed
release 75 mg
azithromycin for susp 200 mg/5ml
(Zithromax)
release 100 mg
azithromycin tab 250 mg (Zithromax)
release 150 mg (Doryx)
clarithromycin for susp 125 mg/5ml
clarithromycin for susp 250 mg/5ml
(Biaxin)
clarithromycin tab sr 24hr 500 mg
(Biaxin xl pac)
clarithromycin tab 250 mg (Biaxin)
2
Quantity Limits
release 250 mg
erythromycin w/ delayed release
particles cap 250 mg
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
doxycycline hyclate tab 20 mg
doxycycline hyclate tab 100 mg
doxycycline monohydrate cap 50 mg
(Monodox)
(Monodox)
(Adoxa)
ciprofloxacin-ciprofloxacin hcl tab sr
24hr 500 mg (base eq) (Cipro xr)
doxycycline monohydrate for susp
25 mg/5ml (Vibramycin)
ciprofloxacin-ciprofloxacin hcl tab sr
24hr 1000 mg(base eq) (Cipro xr)
doxycycline monohydrate tab 50 mg
(Adoxa)
levofloxacin oral soln 25 mg/ml
(Levaquin)
(Adoxa)
levofloxacin tab 250 mg (Levaquin)
(Adoxa pak 1/100)
(Adoxa pak 1/150)
minocycline hcl cap 50 mg (Minocin)
minocycline hcl tab sr 24hr 45 mg
minocycline hcl tab 50 mg
TETRACYCLINE HCL – tetracycline hcl
cap 250 mg
TETRACYCLINE HCL – tetracycline hcl
cap 500 mg
FLUOROQUINOLONES
ciprofloxacin for oral susp 250 mg/5ml
(5%) (5 gm/100ml) (Cipro)
ciprofloxacin for oral susp 500 mg/5ml
(10%) (10 gm/100ml) (Cipro)
Quantity Limits
•
moxifloxacin hcl tab 400 mg (base
equiv) (Avelox)
OFLOXACIN – ofloxacin tab 400 mg
AMINOGLYCOSIDES
neomycin sulfate tab 500 mg
paromomycin sulfate cap 250 mg
tobramycin nebu soln 300 mg/5ml
(Tobi)
TUBERCULOSIS
ethambutol hcl tab 100 mg (Myambutol)
ethambutol hcl tab 400 mg (Myambutol)
ISONIAZID – isoniazid syrup 50 mg/5ml
isoniazid tab 100 mg
isoniazid tab 300 mg
PRIFTIN – rifapentine tab 150 mg
pyrazinamide tab 500 mg
rifabutin cap 150 mg (Mycobutin)
RIFAMATE – isoniazid & rifampin cap
150-300 mg
rifampin cap 150 mg (Rifadin)
rifampin cap 300 mg (Rifadin)
ciprofloxacin hcl tab 250 mg (base
equiv) (Cipro)
fluconazole for susp 10 mg/ml
(Diflucan)
equiv)
•
CIPROFLOXACIN HCL – ciprofloxacin
hcl tab 100 mg (base equiv)
equiv) (Cipro)
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
FUNGAL INFECTIONS
fluconazole for susp 40 mg/ml
(Diflucan)
fluconazole tab 50 mg (Diflucan)
3
DAKLINZA – daclatasvir dihydrochloride
tab 60 mg (base equivalent)
flucytosine cap 250 mg (Ancobon)
flucytosine cap 500 mg (Ancobon)
EPIVIR HBV – lamivudine oral soln 5 mg/
ml (hbv)
HARVONI – ledipasvir-sofosbuvir tab
90-400 mg
griseofulvin ultramicrosize tab 125 mg
(Gris-peg)
lamivudine tab 100 mg (hbv) (Epivir
hbv)
griseofulvin ultramicrosize tab 250 mg
(Gris-peg)
PEGASYS – peginterferon alfa-2a inj 180
mcg/ml
itraconazole cap 100 mg (Sporanox)
LAMISIL – terbinafine hcl oral granules
packet 125 mg
PEGASYS – peginterferon alfa-2a inj 180
mcg/0.5ml
•
•
nystatin oral powder
voriconazole tab 50 mg (Vfend)
voriconazole tab 200 mg (Vfend)
PEGASYS PROCLICK – peginterferon
alfa-2a inj 180 mcg/0.5ml
ribavirin cap 200 mg (Rebetol)
SOVALDI – sofosbuvir tab 400 mg
SPORANOX – itraconazole oral soln 10
mg/ml
voriconazole for susp 40 mg/ml (Vfend)
PEGASYS PROCLICK – peginterferon
alfa-2a inj 135 mcg/0.5ml
ribavirin tab 200 mg (Copegus)
nystatin tab 500000 unit
terbinafine hcl tab 250 mg (Lamisil)
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Quantity Limits
acyclovir tab 400 mg (Zovirax)
acyclovir tab 800 mg (Zovirax)
famciclovir tab 125 mg (Famvir)
VALCYTE – valganciclovir hcl for soln 50
mg/ml (base equiv)
valacyclovir hcl tab 500 mg (Valtrex)
valganciclovir hcl tab 450 mg (base
equivalent) (Valcyte)
valacyclovir hcl tab 1 gm (Valtrex)
4
•
acyclovir susp 200 mg/5ml (Zovirax)
BARACLUDE – entecavir oral soln 0.05
mg/ml
•
•
acyclovir cap 200 mg (Zovirax)
Cytomegalovirus
adefovir dipivoxil tab 10 mg (Hepsera)
•
Herpes
VIRAL INFECTIONS
Hepatitis
•
entecavir tab 1 mg (Baraclude)
griseofulvin microsize tab 500 mg
(Grifulvin v)
NOXAFIL – posaconazole susp 40 mg/ml
•
•
entecavir tab 0.5 mg (Baraclude)
griseofulvin microsize susp
125 mg/5ml
NOXAFIL – posaconazole tab delayed
release 100 mg
Prior Authorization
DAKLINZA – daclatasvir dihydrochloride
LAMISIL – terbinafine hcl oral granules
packet 187.5 mg
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
HIV/AIDS
•
•
abacavir sulfate tab 300 mg (base
equiv) (Ziagen)
abacavir sulfate-lamivudine-zidovudine
tab 300-150-300 mg (Trizivir)
APTIVUS – tipranavir cap 250 mg
APTIVUS – tipranavir oral soln 100 mg/ml
ATRIPLA – efavirenz-emtricitabinetenofovir df tab 600-200-300 mg
COMPLERA – emtricitabine-rilpivirinetenofovir df tab 200-25-300 mg
CRIXIVAN – indinavir sulfate cap 200 mg
CRIXIVAN – indinavir sulfate cap 400 mg
didanosine delayed release capsule
125 mg (Videx ec)
200 mg (Videx ec)
250 mg (Videx ec)
400 mg (Videx ec)
EDURANT – rilpivirine hcl tab 25 mg
(base equivalent)
EMTRIVA – emtricitabine caps 200 mg
KALETRA – lopinavir-ritonavir soln
400-100 mg/5ml (80-20 mg/ml)
KALETRA – lopinavir-ritonavir tab 100-25
mg
KALETRA – lopinavir-ritonavir tab 200-50
mg
lamivudine oral soln 10 mg/ml (Epivir)
lamivudine tab 150 mg (Epivir)
lamivudine tab 300 mg (Epivir)
lamivudine-zidovudine tab 150-300 mg
(Combivir)
LEXIVA – fosamprenavir calcium tab 700
mg (base equiv)
LEXIVA – fosamprenavir calcium susp 50
mg/ml (base equiv)
nevirapine tab sr 24hr 400 mg
(Viramune xr)
nevirapine tab 200 mg (Viramune)
EPZICOM – abacavir sulfate-lamivudine
tab 600-300 mg
NORVIR – ritonavir cap 100 mg
NORVIR – ritonavir tab 100 mg
EVOTAZ – atazanavir sulfate-cobicistat
tab 300-150 mg (base equiv)
NORVIR – ritonavir oral soln 80 mg/ml
INTELENCE – etravirine tab 25 mg
INVIRASE – saquinavir mesylate cap 200
mg
INVIRASE – saquinavir mesylate tab 500
mg
ISENTRESS – raltegravir potassium tab
400 mg (base equiv)
ISENTRESS – raltegravir potassium
packet for susp 100 mg (base equiv)
chew tab 25 mg (base equiv)
Quantity Limits
chew tab 100 mg (base equiv)
EMTRIVA – emtricitabine soln 10 mg/ml
FUZEON – enfuvirtide for inj 90 mg
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
PREZCOBIX – darunavir-cobicistat tab
800-150 mg
PREZISTA – darunavir ethanolate susp
100 mg/ml (base equiv)
PREZISTA – darunavir ethanolate tab 75
mg (base equiv)
mg (base equiv)
mg (base equiv)
mg (base equiv)
RESCRIPTOR – delavirdine mesylate tab
100 mg
RESCRIPTOR – delavirdine mesylate tab
200 mg
5
REYATAZ – atazanavir sulfate oral
powder packet 50 mg (base equiv)
VIREAD – tenofovir disoproxil fumarate
tab 150 mg
REYATAZ – atazanavir sulfate cap 150
mg (base equiv)
tab 200 mg
mg (base equiv)
tab 250 mg
mg (base equiv)
tab 300 mg
SELZENTRY – maraviroc tab 150 mg
VITEKTA – elvitegravir tab 85 mg
SELZENTRY – maraviroc tab 300 mg
VITEKTA – elvitegravir tab 150 mg
stavudine cap 15 mg (Zerit)
ZIAGEN – abacavir sulfate soln 20 mg/ml
(base equiv)
stavudine for oral soln 1 mg/ml (Zerit)
STRIBILD – elvitegrav-cobicis-emtricitabtenofov tab 150-150-200-300 mg
SUSTIVA – efavirenz tab 600 mg
SUSTIVA – efavirenz cap 50 mg
SUSTIVA – efavirenz cap 200 mg
TIVICAY – dolutegravir sodium tab 50 mg
(base equiv)
TRIUMEQ – abacavir-dolutegravirlamivudine tab 600-50-300 mg
TRUVADA – emtricitabine-tenofovir
disoproxil fumarate tab 200-300 mg
TYBOST – cobicistat tab 150 mg
VIDEX – didanosine for soln 2 gm
VIDEX – didanosine for soln 4 gm
VIRACEPT – nelfinavir mesylate tab 250
mg
VIRACEPT – nelfinavir mesylate tab 625
mg
VIRAMUNE – nevirapine susp 50 mg/5ml
VIRAMUNE XR – nevirapine tab sr 24hr
100 mg
oral powder 40 mg/gm
6
Quantity Limits
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
zidovudine cap 100 mg (Retrovir)
zidovudine syrup 10 mg/ml (Retrovir)
zidovudine tab 300 mg
Influenza
RELENZA DISKHALER – zanamivir aero
powder breath activated 5 mg/blister
rimantadine hydrochloride tab 100 mg
(Flumadine)
TAMIFLU – oseltamivir phosphate for
susp 6 mg/ml (base equiv)
TAMIFLU – oseltamivir phosphate cap 30
mg (base equiv)
mg (base equiv)
mg (base equiv)
MALARIA
atovaquone-proguanil hcl tab
62.5-25 mg (Malarone)
atovaquone-proguanil hcl tab
250-100 mg (Malarone)
chloroquine phosphate tab 250 mg
chloroquine phosphate tab 500 mg
(Aralen)
COARTEM – artemether-lumefantrine tab
20-120 mg
DARAPRIM – pyrimethamine tab 25 mg
ZYVOX – linezolid for susp 100 mg/5ml
ivermectin tab 3 mg (Stromectol)
OTHER ANTI-INFECTIVES
atovaquone susp 750 mg/5ml (Mepron)
clindamycin hcl cap 75 mg (Cleocin)
clindamycin palmitate hcl for soln
75 mg/5ml (base equiv) (Cleocin
pediatric gr)
ACTIMMUNE – interferon gamma-1b inj
100 mcg/0.5ml (2000000 unit/0.5ml)
AFINITOR – everolimus tab 2.5 mg
AFINITOR – everolimus tab 5 mg
AFINITOR – everolimus tab 7.5 mg
AFINITOR – everolimus tab 10 mg
AFINITOR DISPERZ – everolimus tab for
oral susp 2 mg
oral susp 3 mg
DAPSONE – dapsone tab 100 mg
ALKERAN – melphalan tab 2 mg
linezolid tab 600 mg (Zyvox)
anastrozole tab 1 mg (Arimidex)
metronidazole cap 375 mg (Flagyl)
bexarotene cap 75 mg (Targretin)
metronidazole tab 250 mg (Flagyl)
bicalutamide tab 50 mg (Casodex)
metronidazole tab 500 mg (Flagyl)
BOSULIF – bosutinib tab 100 mg
NEBUPENT – pentamidine isethionate for
nebulization soln 300 mg
BOSULIF – bosutinib tab 500 mg
SIVEXTRO – tedizolid phosphate tab 200
mg
capecitabine tab 500 mg (Xeloda)
sulfamethoxazole-trimethoprim tab
800-160 mg (Bactrim ds)
tinidazole tab 250 mg (Tindamax)
tinidazole tab 500 mg (Tindamax)
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CANCER DRUGS
oral susp 5 mg
sulfamethoxazole-trimethoprim tab
400-80 mg (Bactrim)
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XIFAXAN – rifaximin tab 550 mg
DAPSONE – dapsone tab 25 mg
sulfamethoxazole-trimethoprim susp
200-40 mg/5ml
•
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Quantity Limits
Quantity Limits
quinine sulfate cap 324 mg (Qualaquin)
BILTRICIDE – praziquantel tab 600 mg
•
vancomycin hcl cap 125 mg (Vancocin
hcl)
vancomycin hcl cap 250 mg (Vancocin
hcl)
ALBENZA – albendazole tab 200 mg
•
trimethoprim tab 100 mg
PRIMAQUINE PHOSPHATE –
primaquine phosphate tab 26.3 mg (15
mg base)
WORM INFECTIONS
Prior Authorization
mefloquine hcl tab 250 mg
Drug Name
Specialty
hydroxychloroquine sulfate tab 200 mg
(Plaquenil)
Prior Authorization
Drug Name
Specialty
2016
capecitabine tab 150 mg (Xeloda)
CAPRELSA – vandetanib tab 100 mg
CAPRELSA – vandetanib tab 300 mg
COMETRIQ – cabozantinib s-malate cap
3 x 20 mg (60 mg dose) kit
COMETRIQ – cabozantinib s-mal cap 1 x
80 mg & 1 x 20 mg (100 dose) kit
COMETRIQ – cabozantinib s-mal cap 1 x
80 mg & 3 x 20 mg (140 dose) kit
7
CYCLOPHOSPHAMIDE –
cyclophosphamide cap 25 mg
IBRANCE – palbociclib cap 75 mg
CYCLOPHOSPHAMIDE –
cyclophosphamide cap 50 mg
EMCYT – estramustine phosphate
sodium cap 140 mg
ERIVEDGE – vismodegib cap 150 mg
ICLUSIG – ponatinib hcl tab 15 mg (base
equiv)
•
•
ETOPOSIDE – etoposide cap 50 mg
IMBRUVICA – ibrutinib cap 140 mg
exemestane tab 25 mg (Aromasin)
FARESTON – toremifene citrate tab 60
mg (base equivalent)
FARYDAK – panobinostat lactate cap 10
flutamide cap 125 mg
GILOTRIF – afatinib dimaleate tab 20 mg
(base equivalent)
(base equivalent)
(base equivalent)
GLEEVEC – imatinib mesylate tab 100
GLEEVEC – imatinib mesylate tab 400
INLYTA – axitinib tab 1 mg
INLYTA – axitinib tab 5 mg
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JAKAFI – ruxolitinib phosphate tab 20 mg
(base equivalent)
•
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(base equivalent)
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LENVIMA 10MG DAILY DOSE –
lenvatinib cap therapy pack 10 mg (10
mg daily dose)
•
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GLEOSTINE – lomustine cap 40 mg
HYCAMTIN – topotecan hcl cap 0.25 mg
(base equiv)
HYCAMTIN – topotecan hcl cap 1 mg
(base equiv)
hydroxyurea cap 500 mg (Hydrea)
8
(base equivalent)
(base equivalent)
(base equivalent)
lenvatinib cap therapy pack 10 & 4 mg
(14 mg daily dose)
lenvatinib cap therapy pack 10 (2) mg
(20 mg daily dose)
HEXALEN – altretamine cap 50 mg
IRESSA – gefitinib tab 250 mg
•
ICLUSIG – ponatinib hcl tab 45 mg (base
equiv)
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lenvatinib cap therapy pack 10 (2) & 4
mg (24 mg daily dose)
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Quantity Limits
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
letrozole tab 2.5 mg (Femara)
LEUCOVORIN CALCIUM – leucovorin
calcium tab 10 mg
LEUCOVORIN CALCIUM – leucovorin
calcium tab 15 mg
leucovorin calcium tab 5 mg
SPRYCEL – dasatinib tab 20 mg
LOMUSTINE – lomustine cap 10 mg
LONSURF – trifluridine-tipiracil tab
15-6.14 mg
LONSURF – trifluridine-tipiracil tab
20-8.19 mg
LYNPARZA – olaparib cap 50 mg
LYSODREN – mitotane tab 500 mg
MATULANE – procarbazine hcl cap 50
mg
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STIVARGA – regorafenib tab 40 mg
SUTENT – sunitinib malate cap 12.5 mg
(base equivalent)
SUTENT – sunitinib malate cap 25 mg
(base equivalent)
megestrol acetate susp 40 mg/ml
(Megace oral)
SUTENT – sunitinib malate cap 37.5 mg
(base equivalent)
megestrol acetate tab 20 mg
SUTENT – sunitinib malate cap 50 mg
(base equivalent)
megestrol acetate tab 40 mg
MEKINIST – trametinib dimethyl sulfoxide
tab 0.5 mg (base equivalent)
MEKINIST – trametinib dimethyl sulfoxide
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SYLATRON – peginterferon alfa-2b for inj
kit 200 mcg
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kit 300 mcg
kit 600 mcg
mercaptopurine tab 50 mg (Purinethol)
MESNEX – mesna tab 400 mg
TABLOID – thioguanine tab 40 mg
methotrexate sodium tab 2.5 mg (base
equiv)
MYLERAN – busulfan tab 2 mg
NEXAVAR – sorafenib tosylate tab 200
NILANDRON – nilutamide tab 150 mg
ODOMZO – sonidegib phosphate cap
200 mg (base equivalent)
POMALYST – pomalidomide cap 1 mg
PURIXAN – mercaptopurine susp 2000
mg/100ml (20 mg/ml)
TAFINLAR – dabrafenib mesylate cap 50
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TAFINLAR – dabrafenib mesylate cap 75
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Quantity Limits
Prior Authorization
SOLTAMOX – tamoxifen citrate oral soln
10 mg/5ml (base equivalent)
LEUKERAN – chlorambucil tab 2 mg
Drug Name
Specialty
leucovorin calcium tab 25 mg
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
tamoxifen citrate tab 10 mg (base
equivalent)
tamoxifen citrate tab 20 mg (base
equivalent)
TARCEVA – erlotinib hcl tab 25 mg (base
equivalent)
TARCEVA – erlotinib hcl tab 100 mg
(base equivalent)
TARCEVA – erlotinib hcl tab 150 mg
(base equivalent)
9
TASIGNA – nilotinib hcl cap 150 mg (base
equivalent)
TASIGNA – nilotinib hcl cap 200 mg (base
equivalent)
temozolomide cap 5 mg (Temodar)
tretinoin cap 10 mg
TYKERB – lapatinib ditosylate tab 250 mg
(base equiv)
VOTRIENT – pazopanib hcl tab 200 mg
(base equiv)
XALKORI – crizotinib cap 200 mg
XALKORI – crizotinib cap 250 mg
XTANDI – enzalutamide cap 40 mg
ZELBORAF – vemurafenib tab 240 mg
ZOLINZA – vorinostat cap 100 mg
ZYDELIG – idelalisib tab 100 mg
ZYDELIG – idelalisib tab 150 mg
ZYKADIA – ceritinib cap 150 mg
ZYTIGA – abiraterone acetate tab 250 mg
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HORMONES, DIABETES AND RELATED DRUGS
CORTICOSTEROIDS
budesonide cap sr 24hr 3 mg (Entocort
ec)
CORTISONE ACETATE – cortisone
acetate tab 25 mg
DEXAMETHASONE – dexamethasone
soln 0.5 mg/5ml
tab 1 mg
tab 2 mg
dexamethasone elixir 0.5 mg/5ml
10
Quantity Limits
Prior Authorization
Drug Name
Specialty
•
Quantity Limits
•
Prior Authorization
Drug Name
Specialty
2016
DEXAMETHASONE INTENSOL –
dexamethasone conc 1 mg/ml
dexamethasone tab 0.5 mg
dexamethasone tab 4 mg
dexamethasone tab 6 mg
fludrocortisone acetate tab 0.1 mg
hydrocortisone tab 5 mg (Cortef)
methylprednisolone tab 4 mg dose
pack (Medrol dosepak)
methylprednisolone tab 4 mg (Medrol)
prednisolone sod phos orally disintegr
tab 10 mg (base eq) (Orapred odt)
prednisolone sod phosph oral
soln 6.7 mg/5ml (5 mg/5ml base)
(Pediapred)
prednisolone sod phosphate oral soln
15 mg/5ml (base equiv)
prednisolone syrup 15 mg/5ml (usp
solution equivalent) (Prelone)
PREDNISONE – prednisone tab 50 mg
PREDNISONE – prednisone oral soln 5
mg/5ml
dose pack
dose pack
prednisone tab 1 mg
prednisone tab 2.5 mg
prednisone tab 5 mg
prednisone tab 10 mg
prednisone tab 20 mg
MALE HORMONES
ANDRODERM – testosterone td patch
24hr 2 mg/24hr
ANDRODERM – testosterone td patch
24hr 4 mg/24hr
ANDROGEL – testosterone td gel 20.25
mg/1.25gm (1.62%)
ANDROGEL – testosterone td gel 40.5
mg/2.5gm (1.62%)
ANDROGEL PUMP – testosterone td gel
20.25 mg/act (1.62%)
ANDROXY – fluoxymesterone tab 10 mg
danazol cap 50 mg
danazol cap 100 mg
danazol cap 200 mg
oxandrolone tab 2.5 mg (Oxandrin)
oxandrolone tab 10 mg (Oxandrin)
testosterone td gel 25 mg/2.5gm (1%)
(Androgel)
testosterone td gel 50 mg/5gm (1%)
(Androgel)
testosterone td gel 12.5 mg/act (1%)
(Androgel pump)
ESTROGENS
Quantity Limits
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
estradiol & norethindrone acetate tab
1-0.5 mg (Activella)
estradiol tab 0.5 mg (Estrace)
estradiol tab 1 mg (Estrace)
estradiol tab 2 mg (Estrace)
estradiol td patch twice weekly
0.025 mg/24hr (Vivelle-dot)
estradiol td patch weekly
0.025 mg/24hr (Climara)
0.0375 mg/24hr (37.5 mcg/24hr)
(Climara)
estradiol td patch weekly 0.05 mg/24hr
(Climara)
(Climara)
0.075 mg/24hr (Climara)
(Climara)
ESTROPIPATE – estropipate tab 3 mg
CLIMARA PRO – estradiol-levonorgestrel
td patch weekly 0.045-0.015 mg/day
estropipate tab 0.75 mg
DIVIGEL – estradiol td gel 0.25
mg/0.25gm (0.1%)
norethindrone acetate-ethinyl estradiol
tab 0.5 mg-2.5 mcg (Femhrt low dose)
DIVIGEL – estradiol td gel 0.5 mg/0.5gm
(0.1%)
norethindrone acetate-ethinyl estradiol
tab 1 mg-5 mcg
DIVIGEL – estradiol td gel 1 mg/gm
(0.1%)
PREMARIN – estrogens, conjugated tab
0.3 mg
estradiol & norethindrone acetate tab
0.5-0.1 mg (Activella)
0.45 mg
estropipate tab 1.5 mg
11
0.625 mg
desogestrel & ethinyl estradiol tab
0.15 mg-30 mcg (Desogen)
0.9 mg
drospirenone-ethinyl estradiol tab
3-0.02 mg (Yaz)
1.25 mg
drospirenone-ethinyl estradiol tab
3-0.03 mg (Yasmin 28)
PREMPHASE – conj est 0.625(14)/conj
est-medroxypro ac tab 0.625-5mg(14)
ELLA – ulipristal acetate tab 30 mg
PREMPRO – conjugated estrogenmedroxyprogest acetate tab 0.3-1.5 mg
PREMPRO – conjugated estrogenmedroxyprogest acetate tab 0.45-1.5
mg
PREMPRO – conjugated estrogenmedroxyprogest acetate tab 0.625-2.5
mg
PREMPRO – conjugated estrogenmedroxyprogest acetate tab 0.625-5 mg
PROGESTINS
medroxyprogesterone acetate tab
2.5 mg (Provera)
5 mg (Provera)
10 mg (Provera)
megestrol acetate susp 625 mg/5ml
(Megace es)
norethindrone acetate tab 5 mg
(Aygestin)
progesterone micronized cap 100 mg
(Prometrium)
(Prometrium)
Quantity Limits
ethynodiol diacetate & ethinyl estradiol
tab 1 mg-35 mcg
levonorg-eth est tab 0.1-0.02mg(84) &
eth est tab 0.01mg(7) (Loseasonique)
levonorg-eth est tab 0.15-0.03mg(84) &
eth est tab 0.01mg(7) (Seasonique)
levonorgestrel & ethinyl estradiol (91day) tab 0.15-0.03 mg
levonorgestrel & ethinyl estradiol tab
0.1 mg-20 mcg
levonorgestrel & ethinyl estradiol tab
0.15 mg-30 mcg
levonorgestrel tab 1.5 mg (Plan b onestep)
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg
levonorgestrel-ethinyl estradiol
(continuous) tab 90-20 mcg
medroxyprogesterone acetate im susp
150 mg/ml (Depo-provera contrac)
NECON 1/50-28 – norethindrone &
mestranol tab 1 mg-50 mcg
NECON 10/11-28 – norethindrone-eth
estradiol tab 0.5-35/1-35 mg-mcg
(10/11)
BIRTH CONTROL
norethindrone & ethinyl estradiol tab
0.4 mg-35 mcg (Ovcon-35)
desogest-eth estrad & eth estrad tab
0.15-0.02/0.01 mg(21/5) (Mircette)
0.5 mg-35 mcg (Brevicon-28)
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mgmg (Cyclessa)
1 mg-35 mcg (Norinyl 1+35)
12
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
norethindrone & ethinyl estradiol-fe
chew tab 0.4 mg-35 mcg (Femcon fe)
norethindrone & ethinyl estradiol-fe
chew tab 0.8 mg-25 mcg (Generess
fe)
INFERTILITY
norethindrone ac-ethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg (Estrostep fe)
chorionic gonadotropin for inj 10000
unit
norethindrone ace & ethinyl estradiol
tab 1 mg-20 mcg (Loestrin 1/20-21)
norethindrone ace & ethinyl estradiol
tab 1.5 mg-30 mcg (Loestrin 1.5/30-21)
norethindrone ace & ethinyl estradiolfe tab 1 mg-20 mcg (Loestrin fe 1/20)
norethindrone ace & ethinyl estradiolfe tab 1.5 mg-30 mcg (Loestrin fe
1.5/30)
norethindrone ace-ethinyl estradiol-fe
tab 1 mg-20 mcg (24)
norethindrone tab 0.35 mg (Nor-qd)
norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg (Orthonovum 7/7/7)
norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg (Tri-norinyl
28)
CETROTIDE – cetrorelix acetate for inj kit
0.25 mg
clomiphene citrate tab 50 mg (Clomid)
FOLLISTIM AQ – follitropin beta inj 75
unit/0.5ml
unit/0.36ml
unit/0.72ml
unit/1.08ml
GONAL-F – follitropin alfa for inj 450 unit
GONAL-F – follitropin alfa for inj 1050 unit
GONAL-F RFF – follitropin alfa for inj 75
unit
GONAL-F RFF PEN – follitropin alfa inj
300 unit/0.5ml
450 unit/0.75ml
norgestimate & ethinyl estradiol tab
0.25 mg-35 mcg (Ortho-cyclen)
900 unit/1.5ml
norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg
(Ortho tri-cyclen)
GONAL-F RFF REDIJECT – follitropin
alfa inj 300 unit/0.5ml
norgestrel & ethinyl estradiol tab
0.3 mg-30 mcg
NUVARING – etonogestrel-ethinyl
estradiol va ring 0.120-0.015 mg/24hr
OGESTREL – norgestrel & ethinyl
estradiol tab 0.5 mg-50 mcg
ORTHO TRI-CYCLEN LO –
norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg
OVIDREL – choriogonadotropin alfa inj
250 mcg/0.5ml
REPRONEX – menotropins for inj 75 unit
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Quantity Limits
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
DIABETES
acarbose tab 25 mg (Precose)
XULANE – norelgestromin-ethinyl
estradiol td ptwk 150-35 mcg/24hr
ZOVIA 1/50E – ethynodiol diacetate &
ethinyl estradiol tab 1 mg-50 mcg
BYDUREON – exenatide extended
release for susp pen-injector 2 mg
13
BYDUREON – exenatide extended
release for inj susp 2 mg
INVOKAMET – canagliflozin-metformin
hcl tab 50-500 mg
BYETTA – exenatide soln pen-injector 5
mcg/0.02ml
hcl tab 50-1000 mg
BYETTA – exenatide soln pen-injector 10
mcg/0.04ml
hcl tab 150-500 mg
glimepiride tab 1 mg (Amaryl)
hcl tab 150-1000 mg
glipizide tab sr 24hr 2.5 mg (Glucotrol
xl)
glipizide tab sr 24hr 5 mg (Glucotrol xl)
glipizide tab sr 24hr 10 mg (Glucotrol xl)
glipizide tab 5 mg (Glucotrol)
glipizide tab 10 mg (Glucotrol)
glipizide-metformin hcl tab 2.5-250 mg
glipizide-metformin hcl tab 2.5-500 mg
glipizide-metformin hcl tab 5-500 mg
GLUCAGON EMERGENCY KIT –
glucagon (rdna) for inj kit 1 mg
GLYBURIDE – glyburide tab 1.25 mg
GLYBURIDE – glyburide tab 2.5 mg
GLYBURIDE – glyburide tab 5 mg
glyburide micronized tab 1.5 mg
(Glynase)
glyburide micronized tab 3 mg
(Glynase)
glyburide micronized tab 6 mg
(Glynase)
glyburide tab 1.25 mg
glyburide tab 2.5 mg
glyburide tab 5 mg
glyburide-metformin tab 1.25-250 mg
(Glucovance)
(Glucovance)
glyburide-metformin tab 5-500 mg
(Glucovance)
14
Quantity Limits
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
INVOKANA – canagliflozin tab 100 mg
INVOKANA – canagliflozin tab 300 mg
JANUMET – sitagliptin-metformin hcl tab
50-500 mg
JANUMET – sitagliptin-metformin hcl tab
50-1000 mg
JANUMET XR – sitagliptin-metformin hcl
tab sr 24hr 50-500 mg
tab sr 24hr 50-1000 mg
tab sr 24hr 100-1000 mg
JANUVIA – sitagliptin phosphate tab 25
mg (base equiv)
mg (base equiv)
mg (base equiv)
JARDIANCE – empagliflozin tab 10 mg
JARDIANCE – empagliflozin tab 25 mg
KOMBIGLYZE XR – saxagliptinmetformin hcl tab sr 24hr 2.5-1000 mg
KOMBIGLYZE XR – saxagliptinmetformin hcl tab sr 24hr 5-500 mg
KOMBIGLYZE XR – saxagliptinmetformin hcl tab sr 24hr 5-1000 mg
metformin hcl tab sr 24hr 500 mg
(Glucophage xr)
metformin hcl tab sr 24hr 750 mg
(Glucophage xr)
metformin hcl tab sr 24hr osmotic
500 mg (Fortamet)
metformin hcl tab sr 24hr osmotic
1000 mg (Fortamet)
NOVOLOG PENFILL – insulin aspart soln
cartridge 100 unit/ml
metformin hcl tab 500 mg (Glucophage)
NOVOLOG PENFILL – insulin aspart inj
100 unit/ml
metformin hcl tab 850 mg (Glucophage)
metformin hcl tab 1000 mg
(Glucophage)
nateglinide tab 60 mg (Starlix)
nateglinide tab 120 mg (Starlix)
ONGLYZA – saxagliptin hcl tab 2.5 mg
(base equiv)
ONGLYZA – saxagliptin hcl tab 5 mg
(base equiv)
pioglitazone hcl tab 15 mg (base equiv)
(Actos)
(Actos)
(Actos)
pioglitazone hcl-glimepiride tab
30-2 mg (Duetact)
pioglitazone hcl-glimepiride tab
30-4 mg (Duetact)
pioglitazone hcl-metformin hcl tab
15-500 mg (Actoplus met)
pioglitazone hcl-metformin hcl tab
15-850 mg (Actoplus met)
repaglinide tab 0.5 mg (Prandin)
repaglinide tab 1 mg (Prandin)
repaglinide tab 2 mg (Prandin)
tolazamide tab 250 mg
VICTOZA – liraglutide soln pen-injector
18 mg/3ml (6 mg/ml)
DIABETES - INSULINS
Rapid-Acting Insulins
Quantity Limits
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
Short-Acting Insulins
HUMULIN R U-500 (CONCENTR –
insulin regular (human) inj 500 unit/ml
NOVOLIN R – insulin regular (human) inj
100 unit/ml
Intermediate-Acting Insulins
NOVOLIN N – insulin nph (human)
(isophane) inj 100 unit/ml
NOVOLIN 70/30 – insulin nph isophane &
regular human inj 100 unit/ml (70-30)
NOVOLOG MIX 70/30 – insulin aspart
prot & aspart (human) inj 100 unit/ml
(70-30)
NOVOLOG MIX 70/30 PREFILL – insulin
aspart prot & aspart sus pen-inj 100
unit/ml (70-30)
Basal Insulins
LANTUS – insulin glargine inj 100 unit/ml
LANTUS SOLOSTAR – insulin glargine
soln pen-injector 100 unit/ml
LEVEMIR – insulin detemir inj 100 unit/ml
LEVEMIR FLEXPEN – insulin detemir
LEVEMIR FLEXTOUCH – insulin detemir
TOUJEO SOLOSTAR – insulin glargine
THYROID REGULATION
levothyroxine sodium tab 25 mcg
(Synthroid)
NOVOLOG – insulin aspart inj 100 unit/ml
(Synthroid)
NOVOLOG FLEXPEN – insulin aspart
(Synthroid)
(Synthroid)
15
(Synthroid)
ACTONEL – risedronate sodium tab 150
mg
(Synthroid)
ALENDRONATE SODIUM – alendronate
sodium tab 40 mg
(Synthroid)
alendronate sodium tab 5 mg
(Synthroid)
liothyronine sodium tab 5 mcg
(Cytomel)
desmopressin acetate nasal soln
0.01% (refrigerated) (Ddavp)
(Cytomel)
desmopressin acetate nasal spray soln
0.01% (Ddavp)
(Cytomel)
desmopressin acetate nasal spray soln
0.01% (refrigerated)
methimazole tab 5 mg (Tapazole)
desmopressin acetate tab 0.1 mg
(Ddavp)
calcitriol oral soln 1 mcg/ml (Rocaltrol)
methimazole tab 10 mg (Tapazole)
desmopressin acetate tab 0.2 mg
(Ddavp)
propylthiouracil tab 50 mg
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doxercalciferol cap 0.5 mcg (Hectorol)
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doxercalciferol cap 2.5 mcg (Hectorol)
OTHER HORMONES AND RELATED DRUGS
ACTONEL – risedronate sodium tab 5 mg
mg
mg
16
Quantity Limits
calcitriol cap 0.25 mcg (Rocaltrol)
calcitriol cap 0.5 mcg (Rocaltrol)
OMNITROPE – somatropin inj 10
mg/1.5ml
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calcitonin (salmon) nasal soln 200 unit/
act (Miacalcin)
(Synthroid)
OMNITROPE – somatropin inj 5 mg/1.5ml
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cabergoline tab 0.5 mg
(Synthroid)
OMNITROPE – somatropin for inj 5.8 mg
•
(Fosamax)
(Synthroid)
INCRELEX – mecasermin inj 40 mg/4ml
(10 mg/ml)
•
(Synthroid)
GROWTH HORMONE
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
doxercalciferol cap 1 mcg (Hectorol)
FORTEO – teriparatide (recombinant) inj
600 mcg/2.4ml
ibandronate sodium tab 150 mg (base
equivalent) (Boniva)
levocarnitine oral soln 1 gm/10ml
(10%) (Carnitor)
levocarnitine tab 330 mg (Carnitor)
methylergonovine maleate tab 0.2 mg
ORFADIN – nitisinone cap 2 mg
captopril tab 100 mg
paricalcitol cap 2 mcg (Zemplar)
CAPTOPRIL/HYDROCHLOROTHIA –
captopril & hydrochlorothiazide tab
25-15 mg
•
PROLIA – denosumab inj 60 mg/ml
raloxifene hcl tab 60 mg (Evista)
risedronate sodium tab 5 mg (Actonel)
risedronate sodium tab 150 mg
(Actonel)
50-25 mg
SENSIPAR – cinacalcet hcl tab 30 mg
(base equiv)
enalapril maleate &
hydrochlorothiazide tab 5-12.5 mg
(base equiv)
sodium phenylbutyrate oral powder
3 gm/teaspoonful (Buphenyl)
25-25 mg
50-15 mg
(base equiv)
•
STIMATE – desmopressin acetate nasal
soln 1.5 mg/ml
HEART AND CIRCULATORY DRUGS
ANGIOTENSIN CONVERTING ENZYME (ACE)
INHIBITORS AND COMBINATI
•
enalapril maleate &
hydrochlorothiazide tab 10-25 mg
(Vaseretic)
enalapril maleate tab 2.5 mg (Vasotec)
enalapril maleate tab 5 mg (Vasotec)
fosinopril sodium &
benazepril & hydrochlorothiazide tab
5-6.25 mg
fosinopril sodium &
10-12.5 mg (Lotensin hct)
fosinopril sodium tab 10 mg
20-12.5 mg (Lotensin hct)
20-25 mg (Lotensin hct)
benazepril hcl tab 5 mg
benazepril hcl tab 10 mg (Lotensin)
captopril tab 12.5 mg
captopril tab 25 mg
Quantity Limits
captopril tab 50 mg
Prior Authorization
Drug Name
Specialty
•
Quantity Limits
•
Prior Authorization
Drug Name
Specialty
2016
lisinopril & hydrochlorothiazide tab
10-12.5 mg (Zestoretic)
20-12.5 mg (Zestoretic)
20-25 mg (Zestoretic)
lisinopril tab 2.5 mg (Zestril)
lisinopril tab 5 mg (Prinivil)
17
lisinopril tab 40 mg (Zestril)
Quantity Limits
amlodipine-valsartanhydrochlorothiazide tab
10-160-12.5 mg (Exforge hct)
moexipril hcl tab 7.5 mg (Univasc)
moexipril hcl tab 15 mg (Univasc)
10-160-25 mg (Exforge hct)
moexipril-hydrochlorothiazide tab
7.5-12.5 mg
15-12.5 mg (Uniretic)
10-320-25 mg (Exforge hct)
15-25 mg
candesartan cilexetil tab 4 mg
(Atacand)
perindopril erbumine tab 2 mg
perindopril erbumine tab 4 mg (Aceon)
(Atacand)
perindopril erbumine tab 8 mg (Aceon)
quinapril hcl tab 5 mg (Accupril)
(Atacand)
(Atacand)
candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg
(Atacand hct)
quinapril-hydrochlorothiazide tab
10-12.5 mg (Accuretic)
20-12.5 mg (Accuretic)
candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg
(Atacand hct)
20-25 mg (Accuretic)
candesartan cilexetilhydrochlorothiazide tab 32-25 mg
(Atacand hct)
ramipril cap 1.25 mg (Altace)
ramipril cap 2.5 mg (Altace)
EPROSARTAN MESYLATE – eprosartan
mesylate tab 600 mg
ramipril cap 5 mg (Altace)
ramipril cap 10 mg (Altace)
irbesartan tab 75 mg (Avapro)
trandolapril tab 1 mg (Mavik)
ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS)
AND COMBINATIONS
18
Prior Authorization
amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg
(Exforge hct)
lisinopril tab 30 mg (Zestril)
5-160-12.5 mg (Exforge hct)
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
irbesartan-hydrochlorothiazide tab
150-12.5 mg (Avalide)
irbesartan-hydrochlorothiazide tab
300-12.5 mg (Avalide)
losartan potassium &
(Hyzaar)
(Hyzaar)
atenolol & chlorthalidone tab
100-25 mg (Tenoretic 100)
hydrochlorothiazide tab 100-25 mg
(Hyzaar)
atenolol tab 50 mg (Tenormin)
losartan potassium tab 25 mg (Cozaar)
losartan potassium tab 50 mg (Cozaar)
losartan potassium tab 100 mg
(Cozaar)
telmisartan tab 20 mg (Micardis)
telmisartan-hydrochlorothiazide tab
40-12.5 mg (Micardis hct)
80-12.5 mg (Micardis hct)
betaxolol hcl tab 10 mg (Kerlone)
betaxolol hcl tab 20 mg (Kerlone)
bisoprolol & hydrochlorothiazide tab
2.5-6.25 mg (Ziac)
5-6.25 mg (Ziac)
10-6.25 mg (Ziac)
bisoprolol fumarate tab 5 mg (Zebeta)
bisoprolol fumarate tab 10 mg (Zebeta)
carvedilol tab 3.125 mg (Coreg)
valsartan tab 40 mg (Diovan)
carvedilol tab 25 mg (Coreg)
DUTOPROL – metoprolol &
hydrochlorothiazide tab sr 24hr 25-12.5
mg
valsartan-hydrochlorothiazide tab
80-12.5 mg (Diovan hct)
160-25 mg (Diovan hct)
320-25 mg (Diovan hct)
BETA BLOCKERS AND COMBINATIONS
acebutolol hcl cap 200 mg (Sectral)
acebutolol hcl cap 400 mg (Sectral)
atenolol & chlorthalidone tab 50-25 mg
(Tenoretic 50)
Quantity Limits
80-25 mg (Micardis hct)
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
hydrochlorothiazide tab sr 24hr 50-12.5
mg
hydrochlorothiazide tab sr 24hr
100-12.5 mg
labetalol hcl tab 100 mg (Trandate)
metoprolol & hydrochlorothiazide tab
50-25 mg (Lopressor hct)
100-25 mg (Lopressor hct)
100-50 mg
19
metoprolol succinate tab sr 24hr 25 mg
(Toprol xl)
metoprolol succinate tab sr 24hr 50 mg
(Toprol xl)
metoprolol succinate tab sr 24hr
100 mg (Toprol xl)
metoprolol succinate tab sr 24hr
200 mg (Toprol xl)
metoprolol tartrate tab 25 mg
(Lopressor)
(Lopressor)
nadolol & bendroflumethiazide tab
40-5 mg (Corzide)
nadolol & bendroflumethiazide tab
80-5 mg (Corzide)
nadolol tab 20 mg (Corgard)
pindolol tab 5 mg
pindolol tab 10 mg
PROPRANOLOL HCL – propranolol hcl
oral soln 20 mg/5ml
PROPRANOLOL HCL – propranolol hcl
oral soln 40 mg/5ml
propranolol hcl cap sr 24hr 60 mg
(Inderal la)
(Inderal la)
(Inderal la)
(Inderal la)
propranolol hcl tab 10 mg
20
Quantity Limits
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
PROPRANOLOL/HYDROCHLOROTH –
propranolol & hydrochlorothiazide tab
40-25 mg
PROPRANOLOL/HYDROCHLOROTH –
propranolol & hydrochlorothiazide tab
80-25 mg
TIMOLOL MALEATE – timolol maleate
tab 5 mg
tab 10 mg
tab 20 mg
CALCIUM CHANNEL BLOCKERS AND
COMBINATIONS
amlodipine besylate tab 2.5 mg
(Norvasc)
amlodipine besylate tab 5 mg (Norvasc)
amlodipine besylate tab 10 mg
(Norvasc)
amlodipine besylate-atorvastatin
calcium tab 2.5-10 mg (Caduet)
calcium tab 5-10 mg (Caduet)
diltiazem hcl coated beads tab sr 24hr
180 mg (Cardizem la)
amlodipine besylate-benazepril hcl cap
2.5-10 mg (Lotrel)
5-10 mg (Lotrel)
5-20 mg (Lotrel)
5-40 mg (Lotrel)
10-20 mg (Lotrel)
diltiazem hcl extended release beads
cap sr 24hr 120 mg (Tiazac)
10-40 mg (Lotrel)
amlodipine besylate-valsartan tab
5-160 mg (Exforge)
5-320 mg (Exforge)
10-160 mg (Exforge)
10-320 mg (Exforge)
diltiazem hcl cap sr 12hr 60 mg
diltiazem hcl tab 30 mg (Cardizem)
diltiazem hcl tab 90 mg
felodipine tab sr 24hr 2.5 mg
felodipine tab sr 24hr 5 mg
diltiazem hcl coated beads cap sr 24hr
120 mg (Cardizem cd)
felodipine tab sr 24hr 10 mg
nicardipine hcl cap 30 mg
Quantity Limits
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
nicardipine hcl cap 20 mg
nifedipine cap 10 mg (Procardia)
nifedipine cap 20 mg
nifedipine tab sr 24hr 30 mg (Adalat cc)
nifedipine tab sr 24hr osmotic release
30 mg (Procardia xl)
21
ISOSORBIDE DINITRATE – isosorbide
dinitrate tab 30 mg
ISOSORBIDE DINITRATE ER –
isosorbide dinitrate tab cr 40 mg
nimodipine cap 30 mg
isosorbide dinitrate tab 5 mg (Isordil
titradose)
nisoldipine tab sr 24hr 8.5 mg (Sular)
nisoldipine tab sr 24hr 17 mg (Sular)
nisoldipine tab sr 24hr 34 mg (Sular)
telmisartan-amlodipine tab 40-5 mg
(Twynsta)
(Twynsta)
isosorbide dinitrate tab 20 mg
isosorbide mononitrate tab sr 24hr
30 mg (Imdur)
60 mg (Imdur)
120 mg (Imdur)
(Twynsta)
isosorbide mononitrate tab 10 mg
isosorbide mononitrate tab 20 mg
VERAPAMIL HCL – verapamil hcl tab 40
mg
NITRO-BID – nitroglycerin oint 2%
verapamil hcl cap sr 24hr 100 mg
(Verelan pm)
nitroglycerin cap cr 6.5 mg
(Verelan)
(Verelan pm)
(Verelan)
(Verelan pm)
nitroglycerin cap cr 2.5 mg
nitroglycerin cap cr 9 mg
nitroglycerin td patch 24hr 0.1 mg/hr
(Nitro-dur)
(Nitro-dur)
(Nitro-dur)
(Nitro-dur)
NITROSTAT – nitroglycerin sl tab 0.3 mg
(Verelan)
verapamil hcl tab cr 120 mg (Calan sr)
CHOLESTEROL LOWERING
atorvastatin calcium tab 10 mg (base
equivalent) (Lipitor)
verapamil hcl tab 80 mg (Calan)
verapamil hcl tab 120 mg (Calan)
CHEST PAIN
22
Quantity Limits
isosorbide dinitrate tab 10 mg
(Twynsta)
(Verelan)
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
fenofibrate tab 160 mg (Lofibra)
cholestyramine light powder packets
4 gm
fluvastatin sodium cap 40 mg (Lescol)
cholestyramine light powder 4 gm/
dose (Questran light)
gemfibrozil tab 600 mg (Lopid)
lovastatin tab 10 mg
lovastatin tab 20 mg (Mevacor)
cholestyramine powder 4 gm/dose
(Questran)
niacin tab cr 500 mg
(antihyperlipidemic) (Niaspan)
choline fenofibrate cap dr 45 mg
(fenofibric acid equiv) (Trilipix)
choline fenofibrate cap dr 135 mg
(fenofibric acid equiv) (Trilipix)
colestipol hcl granule packets 5 gm
(Colestid flavored)
pravastatin sodium tab 10 mg
lovastatin tab 40 mg (Mevacor)
(Pravachol)
colestipol hcl tab 1 gm (Colestid)
(Pravachol)
CRESTOR – rosuvastatin calcium tab 5
mg
(Pravachol)
mg
simvastatin tab 5 mg (Zocor)
mg
mg
fenofibrate micronized cap 43 mg
(Antara)
(Lofibra)
Quantity Limits
fluvastatin sodium cap 20 mg (Lescol)
cholestyramine powder packets 4 gm
(Questran)
colestipol hcl granules 5 gm (Colestid
flavored)
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
WELCHOL – colesevelam hcl tab 625 mg
WELCHOL – colesevelam hcl packet for
susp 3.75 gm
FLUID RETENTION
(Antara)
ACETAZOLAMIDE – acetazolamide tab
125 mg
(Lofibra)
acetazolamide cap sr 12hr 500 mg
(Diamox)
(Lofibra)
acetazolamide tab 250 mg
fenofibrate tab 48 mg (Tricor)
amiloride & hydrochlorothiazide tab
5-50 mg
fenofibrate tab 54 mg (Lofibra)
amiloride hcl tab 5 mg
fenofibrate tab 145 mg (Tricor)
23
bumetanide tab 0.5 mg
bumetanide tab 1 mg
bumetanide tab 2 mg
CHLOROTHIAZIDE – chlorothiazide tab
250 mg
chlorothiazide tab 500 mg
CHLORTHALIDONE – chlorthalidone tab
25 mg
CHLORTHALIDONE – chlorthalidone tab
50 mg
furosemide oral soln 10 mg/ml
furosemide tab 20 mg (Lasix)
hydrochlorothiazide cap 12.5 mg
(Microzide)
hydrochlorothiazide tab 12.5 mg
hydrochlorothiazide tab 25 mg
hydrochlorothiazide tab 50 mg
indapamide tab 1.25 mg
indapamide tab 2.5 mg
methazolamide tab 25 mg (Neptazane)
methazolamide tab 50 mg (Neptazane)
metolazone tab 2.5 mg (Zaroxolyn)
metolazone tab 5 mg (Zaroxolyn)
metolazone tab 10 mg
spironolactone & hydrochlorothiazide
tab 25-25 mg (Aldactazide)
spironolactone tab 25 mg (Aldactone)
torsemide tab 5 mg (Demadex)
Quantity Limits
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
triamterene & hydrochlorothiazide cap
37.5-25 mg (Dyazide)
triamterene & hydrochlorothiazide tab
37.5-25 mg (Maxzide-25)
triamterene & hydrochlorothiazide tab
75-50 mg (Maxzide)
TRIAMTERENE/HYDROCHLOROTH –
triamterene & hydrochlorothiazide cap
50-25 mg
HEART RHYTHM
amiodarone hcl tab 100 mg
amiodarone hcl tab 200 mg (Cordarone)
amiodarone hcl tab 400 mg
disopyramide phosphate cap 100 mg
(Norpace)
disopyramide phosphate cap 150 mg
(Norpace)
flecainide acetate tab 50 mg
mexiletine hcl cap 150 mg
propafenone hcl cap sr 12hr 225 mg
(Rythmol sr)
(Rythmol sr)
(Rythmol sr)
propafenone hcl tab 150 mg (Rythmol)
propafenone hcl tab 225 mg (Rythmol)
propafenone hcl tab 300 mg
quinidine gluconate tab cr 324 mg
QUINIDINE SULFATE – quinidine sulfate
tab 200 mg
QUINIDINE SULFATE ER – quinidine
sulfate tab cr 300 mg
quinidine sulfate tab 300 mg
24
LETAIRIS – ambrisentan tab 5 mg
sotalol hcl tab 240 mg
LETAIRIS – ambrisentan tab 10 mg
•
•
midodrine hcl tab 10 mg
minoxidil tab 2.5 mg
clonidine hcl td patch weekly
0.2 mg/24hr (Catapres-tts-2)
minoxidil tab 10 mg
phenoxybenzamine hcl cap 10 mg
(Dibenzyline)
doxazosin mesylate tab 2 mg (Cardura)
eplerenone tab 25 mg (Inspra)
eplerenone tab 50 mg (Inspra)
guanfacine hcl tab 1 mg (Tenex)
guanfacine hcl tab 2 mg (Tenex)
hydralazine hcl tab 10 mg
•
•
Quantity Limits
•
•
midodrine hcl tab 2.5 mg
•
methyldopa tab 500 mg
midodrine hcl tab 5 mg
digoxin tab 250 mcg (0.25 mg)
(Lanoxin)
•
methyldopa tab 250 mg
clonidine hcl tab 0.3 mg (Catapres)
digoxin tab 125 mcg (0.125 mg)
(Lanoxin)
Prior Authorization
LANOXIN – digoxin tab 250 mcg (0.25
mg)
sotalol hcl tab 160 mg (Betapace)
DIGOXIN – digoxin oral soln 0.05 mg/ml
•
LANOXIN – digoxin tab 187.5 mcg
(0.1875 mg)
•
LANOXIN – digoxin tab 125 mcg (0.125
mg)
•
•
LANOXIN – digoxin tab 62.5 mcg (0.0625
mg)
sotalol hcl (afib/afl) tab 160 mg
(Betapace af)
ADCIRCA – tadalafil tab 20 mg (pah)
•
•
(Betapace af)
OTHER HEART RELATED DRUGS
Drug Name
Specialty
(Betapace af)
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
OPSUMIT – macitentan tab 10 mg
prazosin hcl cap 1 mg (Minipress)
sildenafil citrate tab 20 mg (Revatio)
terazosin hcl cap 1 mg
TRACLEER – bosentan tab 62.5 mg
TRACLEER – bosentan tab 125 mg
ERECTILE DYSFUNCTION
VIAGRA – sildenafil citrate tab 25 mg
•
•
•
BEE STING KITS
25
EPIPEN 2-PAK – epinephrine solution
auto-injector 0.3 mg/0.3ml (1:1000)
fluticasone propionate nasal susp
50 mcg/act (Flonase)
EPIPEN-JR 2-PAK – epinephrine solution
auto-injector 0.15 mg/0.3ml (1:2000)
ipratropium bromide nasal soln 0.03%
(21 mcg/spray) (Atrovent)
RESPIRATORY AGENTS
ipratropium bromide nasal soln 0.06%
(42 mcg/spray) (Atrovent)
ANTIHISTAMINES
cyproheptadine hcl syrup 2 mg/5ml
cyproheptadine hcl tab 4 mg
desloratadine tab orally disintegrating
2.5 mg (Clarinex reditabs)
desloratadine tab orally disintegrating
5 mg (Clarinex reditabs)
triamcinolone acetonide nasal aerosol
suspension 55 mcg/act (Nasacort aq)
COUGH/COLD/ALLERGY
acetylcysteine inhal soln 10%
acetylcysteine inhal soln 20%
levocetirizine dihydrochloride soln
2.5 mg/5ml (0.5 mg/ml) (Xyzal)
SSKI – potassium iodide soln 1 gm/ml
ASTHMA/COPD
levocetirizine dihydrochloride tab 5 mg
(Xyzal)
ADVAIR DISKUS – fluticasone-salmeterol
aer powder ba 100-50 mcg/dose
promethazine hcl suppos 12.5 mg
promethazine hcl suppos 50 mg
promethazine hcl syrup 6.25 mg/5ml
promethazine hcl tab 12.5 mg
promethazine hcl tab 25 mg
promethazine hcl tab 50 mg
NASAL PRODUCTS
ASTEPRO – azelastine hcl nasal spray
0.15% (205.5 mcg/spray)
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%
budesonide nasal susp 32 mcg/act
(Rhinocort aqua)
flunisolide nasal soln 25 mcg/act
(0.025%) (Flunisolide)
26
Quantity Limits
olopatadine hcl nasal soln 0.6%
(Patanase)
desloratadine tab 5 mg (Clarinex)
promethazine hcl suppos 25 mg
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
ADVAIR HFA – fluticasone-salmeterol
inhal aerosol 45-21 mcg/act
albuterol sulfate soln nebu 0.083%
(2.5 mg/3ml)
albuterol sulfate soln nebu 0.5% (5 mg/
ml)
albuterol sulfate soln nebu
0.63 mg/3ml (base equiv)
albuterol sulfate soln nebu
1.25 mg/3ml (base equiv)
albuterol sulfate syrup 2 mg/5ml
albuterol sulfate tab sr 12hr 4 mg
(Vospire er)
albuterol sulfate tab sr 12hr 8 mg
(Vospire er)
budesonide inhalation susp 0.5 mg/2ml
(Pulmicort)
albuterol sulfate tab 2 mg
budesonide inhalation susp 1 mg/2ml
(Pulmicort)
albuterol sulfate tab 4 mg
ANORO ELLIPTA – umeclidiniumvilanterol aero powd ba 62.5-25 mcg/
inh
ARNUITY ELLIPTA – fluticasone furoate
aerosol powder breath activ 100 mcg/
act
ARNUITY ELLIPTA – fluticasone furoate
aerosol powder breath activ 200 mcg/
act
ASMANEX HFA – mometasone furoate
inhal aerosol suspension 100 mcg/act
ASMANEX HFA – mometasone furoate
inhal aerosol suspension 200 mcg/act
ASMANEX TWISTHALER 120 ME –
mometasone furoate inhal powd 220
mcg/inh (breath activated)
ASMANEX TWISTHALER 14 MET –
ATROVENT HFA – ipratropium bromide
hfa inhal aerosol 17 mcg/act
BREO ELLIPTA – fluticasone furoatevilanterol aero powd ba 100-25 mcg/inh
BREO ELLIPTA – fluticasone furoatevilanterol aero powd ba 200-25 mcg/inh
budesonide inhalation susp
0.25 mg/2ml (Pulmicort)
Quantity Limits
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
COMBIVENT RESPIMAT – ipratropiumalbuterol inhal aerosol soln 20-100 mcg/
act
CROMOLYN SODIUM – cromolyn sodium
soln nebu 20 mg/2ml
DULERA – mometasone furoateformoterol fumarate aerosol 100-5 mcg/
act
DULERA – mometasone furoateformoterol fumarate aerosol 200-5 mcg/
act
dyphylline-guaifenesin liqd
100-100 mg/5ml
FLOVENT DISKUS – fluticasone
propionate aer pow ba 50 mcg/blister
FLOVENT HFA – fluticasone propionate
hfa inhal aero 44 mcg/act (50/valve)
hfa inhal aer 110 mcg/act (125/valve)
hfa inhal aer 220 mcg/act (250/valve)
FORADIL AEROLIZER – formoterol
fumarate inhal cap 12 mcg
INCRUSE ELLIPTA – umeclidinium br
aero powd breath act 62.5 mcg/inh
(base eq)
ipratropium bromide inhal soln 0.02%
ipratropium-albuterol nebu soln
0.5-2.5(3) mg/3ml (Duoneb)
levalbuterol hcl soln nebu conc
1.25 mg/0.5ml (base equiv)
levalbuterol hcl soln nebu 0.31 mg/3ml
(base equiv) (Xopenex)
27
theophylline tab sr 12hr 200 mg
montelukast sodium chew tab 4 mg
(base equiv) (Singulair)
zafirlukast tab 10 mg (Accolate)
zafirlukast tab 20 mg (Accolate)
montelukast sodium tab 10 mg (base
equiv) (Singulair)
OTHER RESPIRATORY DRUGS
PROAIR HFA – albuterol sulfate inhal
aero 108 mcg/act (90mcg base equiv)
KALYDECO – ivacaftor packet 50 mg
KALYDECO – ivacaftor tab 150 mg
KALYDECO – ivacaftor packet 75 mg
PULMOZYME – dornase alfa inhal soln 1
mg/ml
QVAR – beclomethasone diprop inhal
aero soln 40 mcg/act (50/valve)
GASTROINTESTINAL DRUGS
QVAR – beclomethasone diprop inhal
aero soln 80 mcg/act (100/valve)
bisacodyl tab & peg 3350-kcl-sod
bicarb-nacl for soln kit
SEREVENT DISKUS – salmeterol
xinafoate aer pow ba 50 mcg/dose
(base equiv)
lactulose solution 10 gm/15ml
SPIRIVA HANDIHALER – tiotropium
bromide monohydrate inhal cap 18 mcg
(base equiv)
peg 3350-kcl-na bicarb-nacl-na sulfate
for soln 236 gm (Golytely)
LAXATIVES
peg 3350-kcl-sod bicarb-nacl for soln
420 gm (Nulytely/flavor pack)
peg 3350-kcl-na bicarb-nacl-na sulfate
for soln 240 gm (Colyte-flavor packs)
polyethylene glycol 3350 oral packet
SPIRIVA RESPIMAT – tiotropium bromide
monohydrate inhal aerosol 2.5 mcg/act
polyethylene glycol 3350 oral powder
SYMBICORT – budesonide-formoterol
fumarate dihyd aerosol 80-4.5 mcg/act
diphenoxylate w/ atropine tab
2.5-0.025 mg (Lomotil)
SYMBICORT – budesonide-formoterol
fumarate dihyd aerosol 160-4.5 mcg/act
DIPHENOXYLATE/ATROPINE –
diphenoxylate w/ atropine liq 2.5-0.025
mg/5ml
terbutaline sulfate tab 5 mg
theophylline soln 80 mg/15ml
Quantity Limits
montelukast sodium oral granules
packet 4 mg (base equiv) (Singulair)
terbutaline sulfate tab 2.5 mg
•
•
•
•
VENTOLIN HFA – albuterol sulfate inhal
aero 108 mcg/act (90mcg base equiv)
SPIRIVA RESPIMAT – tiotropium bromide
monohydrate inhal aerosol 1.25 mcg/
act
•
•
•
•
montelukast sodium chew tab 5 mg
(base equiv) (Singulair)
PROAIR RESPICLICK – albuterol sulfate
aer pow ba 108 mcg/act (90 mcg base
equiv)
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
ANTIDIARRHEALS
loperamide hcl cap 2 mg
ULCER/GERD
28
amoxicillin cap-clarithro tab-lansopraz
cap dr therapy pack (Prevpac)
methscopolamine bromide tab 5 mg
(Pamine forte)
CARAFATE – sucralfate susp 1 gm/10ml
misoprostol tab 100 mcg (Cytotec)
cimetidine hcl soln 300 mg/5ml
misoprostol tab 200 mcg (Cytotec)
cimetidine tab 200 mg
NEXIUM – esomeprazole magnesium for
delayed release susp pack 2.5 mg
dicyclomine hcl cap 10 mg (Bentyl)
dicyclomine hcl oral soln 10 mg/5ml
delayed release susp packet 10 mg
esomeprazole magnesium cap delayed
release 20 mg (base eq) (Nexium)
esomeprazole magnesium cap delayed
release 40 mg (base eq) (Nexium)
nizatidine cap 150 mg
famotidine for susp 40 mg/5ml (Pepcid)
nizatidine oral soln 15 mg/ml (Axid)
famotidine tab 40 mg (Pepcid)
glycopyrrolate tab 1 mg (Robinul)
glycopyrrolate tab 2 mg (Robinul forte)
hyoscyamine sulfate elixir
0.125 mg/5ml
hyoscyamine sulfate soln 0.125 mg/ml
hyoscyamine sulfate tab disp 0.125 mg
(Anaspaz)
hyoscyamine sulfate tab sl 0.125 mg
(Levsin/sl)
hyoscyamine sulfate tab sr 12hr
0.375 mg (Levbid)
hyoscyamine sulfate tab 0.125 mg
(Levsin)
lansoprazole cap delayed release
15 mg (Prevacid)
lansoprazole cap delayed release
30 mg (Prevacid)
methscopolamine bromide tab 2.5 mg
(Pamine)
Quantity Limits
dicyclomine hcl tab 20 mg (Bentyl)
famotidine tab 20 mg (Pepcid)
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
nizatidine cap 300 mg (Axid)
omeprazole cap delayed release 10 mg
(Prilosec)
(Prilosec)
(Prilosec)
omeprazole-sodium bicarbonate cap
20-1100 mg (Zegerid)
omeprazole-sodium bicarbonate cap
40-1100 mg (Zegerid)
pantoprazole sodium ec tab 20 mg
(base equiv) (Protonix)
pantoprazole sodium ec tab 40 mg
(base equiv) (Protonix)
PROPANTHELINE BROMIDE –
propantheline bromide tab 15 mg
rabeprazole sodium ec tab 20 mg
(Aciphex)
ranitidine hcl cap 150 mg
ranitidine hcl cap 300 mg
ranitidine hcl syrup 15 mg/ml
(75 mg/5ml)
29
sucralfate tab 1 gm (Carafate)
NAUSEA AND VOMITING
dronabinol cap 2.5 mg (Marinol)
dronabinol cap 5 mg (Marinol)
ZENPEP – pancrelipase (lip-prot-amyl) dr
cap 5000-17000-27000 unit
EMEND – aprepitant capsule 40 mg
cap 10000-34000-55000 unit
granisetron hcl inj 1 mg/ml
granisetron hcl inj 4 mg/4ml (1 mg/ml)
granisetron hcl tab 1 mg
meclizine hcl tab 12.5 mg
meclizine hcl tab 25 mg
ondansetron hcl oral soln 4 mg/5ml
(Zofran)
ondansetron hcl tab 4 mg (Zofran)
ondansetron hcl tab 8 mg (Zofran)
ondansetron hcl tab 24 mg
ondansetron orally disintegrating tab
4 mg (Zofran odt)
ondansetron orally disintegrating tab
8 mg (Zofran odt)
TRANSDERM-SCOP – scopolamine td
patch 72hr 1 mg/3days
trimethobenzamide hcl cap 300 mg
(Tigan)
DIGESTIVE ENZYMES
CREON – pancrelipase (lip-prot-amyl) dr
cap 3000-9500-15000 unit
cap 6000-19000-30000 unit
30
Quantity Limits
Quantity Limits
cap 36000-114000-180000 unit
EMEND – aprepitant capsule therapy
pack 80 & 125 mg
granisetron hcl inj 0.1 mg/ml
•
cap 24000-76000-120000 unit
cap 3000-10000-16000 unit
•
cap 12000-38000-60000 unit
dronabinol cap 10 mg (Marinol)
Prior Authorization
ranitidine hcl tab 300 mg (Zantac)
Drug Name
Specialty
ranitidine hcl tab 150 mg (Zantac)
Prior Authorization
Drug Name
Specialty
2016
cap 15000-51000-82000 unit
cap 20000-68000-109000 unit
cap 25000-85000-136000 unit
cap 40000-136000-218000 unit
OTHER GASTROINTESTINAL DRUGS
alosetron hcl tab 0.5 mg (base equiv)
(Lotronex)
alosetron hcl tab 1 mg (base equiv)
(Lotronex)
ASACOL HD – mesalamine tab delayed
release 800 mg
balsalazide disodium cap 750 mg
(Colazal)
calcium acetate (phosphate binder)
cap 667 mg (169 mg ca) (Phoslo)
calcium acetate (phosphate binder) tab
667 mg (Eliphos)
CANASA – mesalamine suppos 1000 mg
CHENODAL – chenodiol tab 250 mg
cromolyn sodium oral conc
100 mg/5ml (Gastrocrom)
DELZICOL – mesalamine cap dr 400 mg
lactulose (encephalopathy) solution
10 gm/15ml
LIALDA – mesalamine tab delayed
release 1.2 gm
methenamine-hyosc-meth blue-sod
phos-phen sal cap 118 mg
mesalamine enema 4 gm
phos-phen sal cap 120 mg
mesalamine rectal enema 4 gm &
cleanser wipe kit (Rowasa)
metoclopramide hcl inj 5 mg/ml
metoclopramide hcl orally
disintegrating tab 5 mg (Metozolv odt)
metoclopramide hcl soln 5 mg/5ml
(10 mg/10ml)
metoclopramide hcl tab 5 mg (Reglan)
metoclopramide hcl tab 10 mg (Reglan)
PENTASA – mesalamine cap cr 250 mg
PENTASA – mesalamine cap cr 500 mg
methenamine-hyoscamine-meth bluesod phos tab 81.6 mg (Urogesic-blue)
nitrofurantoin macrocrystalline cap
25 mg (Macrodantin)
50 mg (Macrodantin)
100 mg (Macrodantin)
nitrofurantoin monohydrate
macrocrystalline cap 100 mg
(Macrobid)
RENVELA – sevelamer carbonate packet
0.8 gm
nitrofurantoin susp 25 mg/5ml
(Furadantin)
RENVELA – sevelamer carbonate packet
2.4 gm
URINARY TRACT SPASMS
sulfasalazine tab 500 mg (Azulfidine)
ursodiol cap 300 mg (Actigall)
ursodiol tab 250 mg (Urso 250)
ursodiol tab 500 mg (Urso forte)
GENITOURINARY DRUGS
URINARY TRACT INFECTIONS
MACRODANTIN – nitrofurantoin
macrocrystalline cap 25 mg
methenamine hippurate tab 1 gm
(Hiprex)
methenamine mandelate tab 1 gm
methenamine-hyos-meth blue-sod
phos-phen sal tab 81.6 mg
methenamine-hyosc-meth blue-benz
acid-phenyl sal tab 81.6mg (Prosed/
ds)
Quantity Limits
phos-phen sal tab 81 mg
RENVELA – sevelamer carbonate tab
800 mg
sulfasalazine tab delayed release
500 mg (Azulfidine en-tabs)
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
bethanechol chloride tab 5 mg
(Urecholine)
(Urecholine)
(Urecholine)
(Urecholine)
MYRBETRIQ – mirabegron tab sr 24 hr
25 mg
MYRBETRIQ – mirabegron tab sr 24 hr
50 mg
oxybutynin chloride syrup 5 mg/5ml
oxybutynin chloride tab sr 24hr 5 mg
(Ditropan xl)
(Ditropan xl)
(Ditropan xl)
oxybutynin chloride tab 5 mg
31
tolterodine tartrate cap sr 24hr 2 mg
(Detrol la)
ELMIRON – pentosan polysulfate sodium
caps 100 mg
tolterodine tartrate cap sr 24hr 4 mg
(Detrol la)
finasteride tab 5 mg (Proscar)
tolterodine tartrate tab 2 mg (Detrol)
phenazopyridine hcl tab 100 mg
(Pyridium)
trospium chloride cap sr 24hr 60 mg
phenazopyridine hcl tab 200 mg
(Pyridium)
trospium chloride tab 20 mg (Sanctura)
VESICARE – solifenacin succinate tab 5
mg
pot & sod citrates w/ cit ac soln
550-500-334 mg/5ml
VESICARE – solifenacin succinate tab 10
mg
potassium citrate & citric acid powder
pack 3300-1002 mg
VAGINAL PRODUCTS
potassium citrate & citric acid soln
1100-334 mg/5ml
CLEOCIN – clindamycin phosphate
vaginal suppos 100 mg
potassium citrate tab cr 5 meq
(540 mg) (Urocit-k 5)
clindamycin phosphate vaginal cream
2% (Cleocin)
(1080 mg) (Urocit-k 10)
metronidazole vaginal gel 0.75%
(Metrogel-vaginal)
(1620 mg) (Urocit-k 15)
PREMARIN – estrogens, conjugated
vaginal cream 0.625 mg/gm
sodium citrate & citric acid soln
500-334 mg/5ml (Shohls solution modi)
terconazole vaginal cream 0.4%
(Terazol 7)
tamsulosin hcl cap 0.4 mg (Flomax)
terconazole vaginal cream 0.8%
(Terazol 3)
CENTRAL NERVOUS SYSTEM DRUGS
ANXIETY
terconazole vaginal suppos 80 mg
alprazolam orally disintegrating tab
0.25 mg (Niravam)
VAGIFEM – estradiol vaginal tab 10 mcg
OTHER GENITOURINARY DRUGS
0.5 mg
alfuzosin hcl tab sr 24hr 10 mg
(Uroxatral)
CYSTAGON – cysteamine bitartrate cap
50 mg
CYSTAGON – cysteamine bitartrate cap
150 mg
CYTRA-3 – pot & sod citrates w/ cit ac
syrup 550-500-334 mg/5ml
dutasteride cap 0.5 mg (Avodart)
32
Quantity Limits
K-PHOS NO 2 – potassium & sodium
acid phosphates tab 305-700 mg
tolterodine tartrate tab 1 mg (Detrol)
AVODART – dutasteride cap 0.5 mg
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
•
•
•
•
1 mg
2 mg
alprazolam tab sr 24hr 0.5 mg (Xanax
xr)
alprazolam tab sr 24hr 1 mg (Xanax xr)
alprazolam tab 0.25 mg (Xanax)
oxazepam cap 10 mg
alprazolam tab 0.5 mg (Xanax)
oxazepam cap 15 mg
alprazolam tab 1 mg (Xanax)
oxazepam cap 30 mg
alprazolam tab 2 mg (Xanax)
DEPRESSION
buspirone hcl tab 5 mg
amitriptyline hcl tab 10 mg
buspirone hcl tab 7.5 mg
chlordiazepoxide hcl cap 5 mg
bupropion hcl tab sr 12hr 100 mg
(Wellbutrin sr)
clorazepate dipotassium tab 3.75 mg
(Tranxene t)
clorazepate dipotassium tab 7.5 mg
(Tranxene t)
clorazepate dipotassium tab 15 mg
(Tranxene t)
DIAZEPAM – diazepam soln 1 mg/ml
diazepam tab 2 mg (Valium)
hydroxyzine hcl syrup 10 mg/5ml
hydroxyzine hcl tab 10 mg
HYDROXYZINE PAMOATE –
hydroxyzine pamoate cap 100 mg
(Vistaril)
(Wellbutrin sr)
(Wellbutrin xl)
(Wellbutrin xl)
bupropion hcl tab 75 mg (Wellbutrin)
bupropion hcl tab 100 mg (Wellbutrin)
citalopram hydrobromide oral soln
10 mg/5ml
citalopram hydrobromide tab 10 mg
(base equiv) (Celexa)
clomipramine hcl cap 25 mg (Anafranil)
lorazepam conc 2 mg/ml (Lorazepam
intensol)
desipramine hcl tab 10 mg (Norpramin)
lorazepam tab 1 mg (Ativan)
lorazepam tab 2 mg (Ativan)
Quantity Limits
(Wellbutrin sr)
(Vistaril)
lorazepam tab 0.5 mg (Ativan)
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
33
desipramine hcl tab 100 mg
(Norpramin)
fluvoxamine maleate tab 50 mg
desipramine hcl tab 150 mg
(Norpramin)
imipramine hcl tab 10 mg (Tofranil)
DOXEPIN HCL – doxepin hcl cap 75 mg
doxepin hcl cap 10 mg
doxepin hcl conc 10 mg/ml
duloxetine hcl enteric coated pellets
cap 20 mg (Cymbalta)
imipramine pamoate cap 75 mg
(Tofranil-pm)
(Tofranil-pm)
(Tofranil-pm)
(Tofranil-pm)
mirtazapine orally disintegrating tab
15 mg (Remeron soltab)
escitalopram oxalate tab 5 mg (base
equiv) (Lexapro)
mirtazapine tab 7.5 mg
mirtazapine tab 15 mg (Remeron)
equiv) (Lexapro)
equiv) (Lexapro)
NORTRIPTYLINE HCL – nortriptyline hcl
soln 10 mg/5ml
fluoxetine hcl cap 10 mg (Prozac)
fluoxetine hcl solution 20 mg/5ml
fluoxetine hcl tab 10 mg
nortriptyline hcl cap 10 mg (Pamelor)
paroxetine hcl tab sr 24hr 12.5 mg
(Paxil cr)
fluoxetine hcl tab 20 mg
paroxetine hcl tab sr 24hr 25 mg (Paxil
cr)
fluvoxamine maleate cap sr 24hr
100 mg (Luvox cr)
paroxetine hcl tab sr 24hr 37.5 mg
(Paxil cr)
fluvoxamine maleate cap sr 24hr
150 mg (Luvox cr)
paroxetine hcl tab 10 mg (Paxil)
34
Quantity Limits
escitalopram oxalate soln 5 mg/5ml
(base equiv) (Lexapro)
fluoxetine hcl cap delayed release
90 mg (Prozac weekly)
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
aripiprazole tab 15 mg (Abilify)
phenelzine sulfate tab 15 mg (Nardil)
protriptyline hcl tab 5 mg (Vivactil)
protriptyline hcl tab 10 mg (Vivactil)
chlorpromazine hcl tab 10 mg
sertraline hcl oral conc 20 mg/ml
(Zoloft)
sertraline hcl tab 25 mg (Zoloft)
tranylcypromine sulfate tab 10 mg
(Parnate)
trazodone hcl tab 50 mg
venlafaxine hcl cap sr 24hr 37.5 mg
(base equivalent) (Effexor xr)
venlafaxine hcl cap sr 24hr 75 mg
venlafaxine hcl cap sr 24hr 150 mg
clozapine tab 25 mg (Clozaril)
clozapine tab 50 mg
clozapine tab 100 mg (Clozaril)
clozapine tab 200 mg
FLUPHENAZINE HCL – fluphenazine hcl
elixir 2.5 mg/5ml
FLUPHENAZINE HCL – fluphenazine hcl
oral conc 5 mg/ml
fluphenazine hcl tab 1 mg
fluphenazine hcl tab 2.5 mg
haloperidol lactate oral conc 2 mg/ml
venlafaxine hcl tab sr 24hr 75 mg (base
equivalent) (Venlafaxine hcl er)
haloperidol tab 1 mg
venlafaxine hcl tab sr 24hr 150 mg
(base equivalent) (Venlafaxine hcl er)
venlafaxine hcl tab 37.5 mg
venlafaxine hcl tab 50 mg
haloperidol tab 0.5 mg
LITHIUM – lithium oral solution 8 meq/5ml
LITHIUM CARBONATE – lithium
carbonate cap 150 mg
PSYCHOTIC AND BIPOLAR DISORDERS
lithium carbonate cap 150 mg (Lithium
carbonate)
aripiprazole oral solution 1 mg/ml
lithium carbonate cap 300 mg
lithium carbonate cap 600 mg (Lithium
carbonate)
Quantity Limits
venlafaxine hcl tab sr 24hr 37.5 mg
(base equivalent) (Venlafaxine hcl er)
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
35
lithium carbonate tab cr 300 mg
(Lithobid)
quetiapine fumarate tab 25 mg
(Seroquel)
lithium carbonate tab cr 450 mg
(Seroquel)
lithium carbonate tab 300 mg
loxapine succinate cap 5 mg (Loxitane)
loxapine succinate cap 10 mg
olanzapine orally disintegrating tab
5 mg (Zyprexa zydis)
olanzapine tab 2.5 mg (Zyprexa)
olanzapine tab 5 mg (Zyprexa)
olanzapine tab 7.5 mg (Zyprexa)
paliperidone tab sr 24hr 1.5 mg
(Invega)
paliperidone tab sr 24hr 3 mg (Invega)
perphenazine tab 2 mg
prochlorperazine maleate tab 5 mg
(base equivalent) (Compazine)
prochlorperazine maleate tab 10 mg
(base equivalent) (Compazine)
prochlorperazine suppos 25 mg
36
Quantity Limits
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
(Seroquel)
(Seroquel)
(Seroquel)
(Seroquel)
risperidone orally disintegrating tab
0.25 mg
0.5 mg (Risperdal m-tab)
1 mg (Risperdal m-tab)
risperidone soln 1 mg/ml (Risperdal)
risperidone tab 0.25 mg (Risperdal)
risperidone tab 0.5 mg (Risperdal)
risperidone tab 1 mg (Risperdal)
SEROQUEL XR – quetiapine fumarate
tab sr 24hr 50 mg
tab sr 24hr 150 mg
tab sr 24hr 200 mg
tab sr 24hr 300 mg
tab sr 24hr 400 mg
phenobarbital tab 64.8 mg
thiothixene cap 1 mg
temazepam cap 7.5 mg (Restoril)
trifluoperazine hcl tab 1 mg
ziprasidone hcl cap 20 mg (Geodon)
SLEEP AIDS
estazolam tab 1 mg
estazolam tab 2 mg
eszopiclone tab 1 mg (Lunesta)
Quantity Limits
temazepam cap 15 mg (Restoril)
temazepam cap 22.5 mg (Restoril)
temazepam cap 30 mg (Restoril)
zaleplon cap 5 mg (Sonata)
zaleplon cap 10 mg (Sonata)
zolpidem tartrate tab cr 6.25 mg
(Ambien cr)
zolpidem tartrate tab cr 12.5 mg
(Ambien cr)
zolpidem tartrate tab 5 mg (Ambien)
zolpidem tartrate tab 10 mg (Ambien)
HYPERACTIVITY/NARCOLEPSY
amphetamine-dextroamphetamine cap
sr 24hr 5 mg (Adderall xr)
FLURAZEPAM HCL – flurazepam hcl cap
15 mg
FLURAZEPAM HCL – flurazepam hcl cap
30 mg
midazolam hcl syrup 2 mg/ml (base
equivalent)
PHENOBARBITAL – phenobarbital tab 15
mg
amphetamine-dextroamphetamine tab
5 mg (Adderall)
mg
7.5 mg (Adderall)
mg
10 mg (Adderall)
PHENOBARBITAL – phenobarbital tab
100 mg
12.5 mg (Adderall)
phenobarbital elixir 20 mg/5ml
15 mg (Adderall)
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
37
20 mg (Adderall)
methylphenidate hcl cap cr 10 mg
(Metadate cd)
30 mg (Adderall)
(Metadate cd)
caffeine citrate oral soln 60 mg/3ml
(10 mg/ml base equiv) (Cafcit)
(Metadate cd)
clonidine hcl tab sr 12hr 0.1 mg
(Kapvay)
(Metadate cd)
dexmethylphenidate hcl cap sr 24 hr
5 mg (Focalin xr)
(Metadate cd)
15 mg (Focalin xr)
(Metadate cd)
30 mg (Focalin xr)
methylphenidate hcl cap sr 24hr 20 mg
(la) (Ritalin la)
40 mg (Focalin xr)
(la) (Ritalin la)
dexmethylphenidate hcl tab 2.5 mg
(Focalin)
(la) (Ritalin la)
dexmethylphenidate hcl tab 5 mg
(Focalin)
methylphenidate hcl soln 5 mg/5ml
(Methylin)
dexmethylphenidate hcl tab 10 mg
(Focalin)
methylphenidate hcl soln 10 mg/5ml
(Methylin)
dextroamphetamine sulfate cap sr 24hr
5 mg (Dexedrine)
methylphenidate hcl tab cr 10 mg
10 mg (Dexedrine)
15 mg (Dexedrine)
dextroamphetamine sulfate oral
solution 5 mg/5ml (Procentra)
dextroamphetamine sulfate tab 5 mg
dextroamphetamine sulfate tab 10 mg
guanfacine hcl tab sr 24hr 1 mg (base
equiv) (Intuniv)
equiv) (Intuniv)
equiv) (Intuniv)
equiv) (Intuniv)
38
Quantity Limits
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
•
•
•
methylphenidate hcl tab cr 20 mg
(Ritalin sr)
methylphenidate hcl tab 5 mg (Ritalin)
modafinil tab 100 mg (Provigil)
modafinil tab 200 mg (Provigil)
STRATTERA – atomoxetine hcl cap 10
mg (base equiv)
mg (base equiv)
mg (base equiv)
mg (base equiv)
mg (base equiv)
REBIF – interferon beta-1a soln pref syr
22 mcg/0.5ml (12mu/ml)
mg (base equiv)
REBIF – interferon beta-1a soln pref syr
44 mcg/0.5ml (24mu/ml)
mg (base equiv)
REBIF REBIDOSE – interferon beta-1a
soln auto-inj 22 mcg/0.5ml (12mu/ml)
VYVANSE – lisdexamfetamine dimesylate
cap 10 mg
REBIF REBIDOSE – interferon beta-1a
soln auto-inj 44 mcg/0.5ml (24mu/ml)
cap 20 mg
REBIF REBIDOSE TITRATION –
interferon beta-1a auto-inj 6x8.8
mcg/0.2ml & 6x22 mcg/0.5ml
cap 30 mg
REBIF TITRATION PACK – interferon
beta-1a pref syr 6x8.8 mcg/0.2ml &
6x22 mcg/0.5ml
cap 40 mg
TECFIDERA – dimethyl fumarate capsule
delayed release 120 mg
cap 50 mg
TECFIDERA – dimethyl fumarate capsule
cap 60 mg
TECFIDERA STARTER PACK – dimethyl
fumarate capsule dr starter pack 120
mg & 240 mg
cap 70 mg
MULTIPLE SCLEROSIS
BETASERON – interferon beta-1b for inj
kit 0.3 mg
COPAXONE – glatiramer acetate soln
prefilled syringe 20 mg/ml
COPAXONE – glatiramer acetate soln
glatiramer acetate soln prefilled
syringe 20 mg/ml (Copaxone)
PLEGRIDY – peginterferon beta-1a soln
pen-injector 125 mcg/0.5ml
PLEGRIDY – peginterferon beta-1a soln
prefilled syringe 125 mcg/0.5ml
PLEGRIDY STARTER PACK –
peginterferon beta-1a soln pen-inj 63 &
94 mcg/0.5ml pack
PLEGRIDY STARTER PACK –
peginterferon beta-1a soln pref syr 63 &
94 mcg/0.5ml pack
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Quantity Limits
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
OTHER CENTRAL NERVOUS SYSTEM DRUGS
•
•
•
•
•
•
•
•
•
•
•
•
•
•
CHANTIX STARTING MONTH PA –
varenicline tartrate tab 0.5 mg x 11 &
tab 1 mg x 42 pack
•
•
disulfiram tab 250 mg (Antabuse)
•
•
acamprosate calcium tab delayed
release 333 mg (Campral)
bupropion hcl (smoking deterrent) tab
sr 12hr 150 mg (Zyban)
CHANTIX – varenicline tartrate tab 0.5
mg (base equiv)
CHANTIX – varenicline tartrate tab 1 mg
(base equiv)
CHANTIX CONTINUING MONTH –
varenicline tartrate tab 1 mg (base
equiv)
disulfiram tab 500 mg (Antabuse)
donepezil hydrochloride orally
disintegrating tab 5 mg (Aricept odt)
39
donepezil hydrochloride orally
disintegrating tab 10 mg (Aricept odt)
olanzapine-fluoxetine hcl cap 6-25 mg
(Symbyax)
donepezil hydrochloride tab 5 mg
(Aricept)
(Symbyax)
(Aricept)
(Symbyax)
(Aricept)
(Symbyax)
fluoxetine hcl (pmdd) cap 10 mg
pimozide tab 1 mg (Orap)
fluoxetine hcl (pmdd) cap 20 mg
pimozide tab 2 mg (Orap)
GALANTAMINE HYDROBROMIDE –
galantamine hydrobromide oral soln 4
mg/ml
rivastigmine tartrate cap 1.5 mg
(Exelon)
galantamine hydrobromide cap sr 24hr
8 mg (Razadyne er)
rivastigmine tartrate cap 4.5 mg
(Exelon)
16 mg (Razadyne er)
24 mg (Razadyne er)
rivastigmine tartrate cap 6 mg (Exelon)
tetrabenazine tab 12.5 mg (Xenazine)
tetrabenazine tab 25 mg (Xenazine)
PAIN RELIEF DRUGS
galantamine hydrobromide tab 8 mg
(Razadyne)
butalbital-acetaminophen tab
50-325 mg
(Razadyne)
butalbital-acetaminophen-caffeine cap
50-300-40 mg (Fioricet)
memantine hcl oral solution 2 mg/ml
(Namenda)
butalbital-acetaminophen-caffeine cap
50-325-40 mg
memantine hcl tab 5 mg (Namenda)
butalbital-acetaminophen-caffeine tab
50-325-40 mg
memantine hcl tab 5 mg (28) & 10 mg
(21) titration pak (Namenda titration
pa)
NAMENDA – memantine hcl oral solution
2 mg/ml
Quantity Limits
butalbital-aspirin-caffeine cap
50-325-40 mg (Fiorinal)
choline & magnesium salicylates liq
500 mg/5ml
diflunisal tab 500 mg
salsalate tab 500 mg
NICOTROL NS – nicotine nasal spray 10
mg/ml (0.5 mg/spray)
NARCOTIC DRUGS
40
•
•
NON-NARCOTIC DRUGS
NICOTROL INHALER – nicotine inhaler
system 10 mg (4 mg delivered)
(Symbyax)
•
•
rivastigmine tartrate cap 3 mg (Exelon)
(Razadyne)
memantine hcl tab 10 mg (Namenda)
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
salsalate tab 750 mg
acetaminophen w/ codeine soln
120-12 mg/5ml
acetaminophen w/ codeine tab
300-15 mg (Tylenol/codeine)
fentanyl td patch 72hr 75 mcg/hr
(Duragesic)
300-30 mg (Tylenol/codeine #3)
(Duragesic)
300-60 mg (Tylenol/codeine #4)
hydrocodone-acetaminophen soln
7.5-325 mg/15ml (Hycet)
buprenorphine hcl sl tab 2 mg (base
equiv)
hydrocodone-acetaminophen tab
2.5-325 mg
buprenorphine hcl sl tab 8 mg (base
equiv)
10-325 mg (Norco)
butalbital-acetaminophen-caff w/ cod
cap 50-300-40-30 mg (Fioricet/codeine)
5-300 mg (Xodol)
butalbital-acetaminophen-caff w/ cod
cap 50-325-40-30 mg
7.5-300 mg (Xodol)
butalbital-aspirin-caff w/ codeine cap
50-325-40-30 mg (Fiorinal/codeine #3)
5-325 mg (Norco)
butorphanol tartrate nasal soln 10 mg/
ml
7.5-325 mg (Norco)
codeine sulfate tab 15 mg (Codeine
sulfate)
10-300 mg (Xodol)
codeine sulfate tab 30 mg
hydrocodone-ibuprofen tab 5-200 mg
(Reprexain)
codeine sulfate tab 60 mg
fentanyl citrate lozenge on a handle
200 mcg (Actiq)
400 mcg (Actiq)
600 mcg (Actiq)
800 mcg (Actiq)
1200 mcg (Actiq)
1600 mcg (Actiq)
(Duragesic)
(Duragesic)
(Duragesic)
•
hydrocodone-ibuprofen tab 7.5-200 mg
(Vicoprofen)
•
hydrocodone-ibuprofen tab 10-200 mg
(Ibudone)
•
HYDROMORPHONE HCL –
hydromorphone hcl suppos 3 mg
•
hydromorphone hcl liqd 1 mg/ml
(Dilaudid)
•
hydromorphone hcl tab er 24hr deter
8 mg (Exalgo)
•
12 mg (Exalgo)
•
16 mg (Exalgo)
•
hydromorphone hcl tab 2 mg (Dilaudid)
•
Quantity Limits
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
•
•
41
methadone hcl conc 10 mg/ml
(Methadose)
MORPHINE SULFATE ER – morphine
sulfate beads cap sr 24hr 60 mg
methadone hcl soln 5 mg/5ml
(Methadone hcl)
methadone hcl soln 10 mg/5ml
(Methadone hcl)
methadone hcl tab for oral susp 40 mg
methadone hcl tab 5 mg (Dolophine hcl)
methadone hcl tab 10 mg (Dolophine)
MORPHINE SULFATE – morphine sulfate
tab 15 mg
tab 30 mg
suppos 5 mg
suppos 10 mg
suppos 20 mg
suppos 30 mg
morphine sulfate cap sr 24hr 10 mg
(Kadian)
(Kadian)
(Kadian)
(Kadian)
(Kadian)
(Kadian)
(Kadian)
Quantity Limits
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
morphine sulfate oral soln 10 mg/5ml
(20 mg/ml)
morphine sulfate tab cr 15 mg (Ms
contin)
contin)
contin)
contin)
contin)
NUCYNTA ER – tapentadol hcl tab sr
12hr 50 mg
12hr 100 mg
12hr 150 mg
12hr 200 mg
12hr 250 mg
OXYCODONE HCL – oxycodone hcl
conc 100 mg/5ml (20 mg/ml)
oxycodone hcl cap 5 mg
oxycodone hcl conc 100 mg/5ml
(20 mg/ml) (Oxycodone hcl)
oxycodone hcl soln 5 mg/5ml
(Oxycodone hcl)
oxycodone hcl tab 5 mg (Roxicodone)
42
tramadol hcl tab sr 24hr biphasic
release 300 mg
oxycodone w/ acetaminophen tab
10-325 mg (Percocet)
tramadol hcl tab 50 mg (Ultram)
oxycodone-aspirin tab 4.8355-325 mg
(Percodan)
OXYCONTIN – oxycodone hcl tab er 12hr
deter 40 mg
deter 60 mg
deter 80 mg
oxymorphone hcl tab sr 12hr 5 mg
oxymorphone hcl tab sr 12hr 7.5 mg
oxymorphone hcl tab 5 mg (Opana)
Quantity Limits
release 200 mg
7.5-325 mg (Percocet)
deter 30 mg
•
release 100 mg
5-325 mg (Percocet)
deter 20 mg
•
tramadol hcl tab sr 24hr 300 mg (Ultram
er)
2.5-325 mg (Percocet)
deter 15 mg
•
er)
oxycodone hcl tab 20 mg
deter 10 mg
•
er)
oxycodone-ibuprofen tab 5-400 mg
Prior Authorization
oxycodone hcl tab 10 mg
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
tramadol-acetaminophen tab
37.5-325 mg (Ultracet)
•
RHEUMATOID AND OSTEOARTHRITIS
•
celecoxib cap 100 mg (Celebrex)
•
•
diclofenac potassium tab 50 mg
(Cataflam)
•
diclofenac sodium tab delayed release
25 mg
•
50 mg
•
75 mg
diclofenac sodium tab sr 24hr 100 mg
(Voltaren-xr)
diclofenac w/ misoprostol tab delayed
release 50-0.2 mg (Arthrotec 50)
diclofenac w/ misoprostol tab delayed
release 75-0.2 mg (Arthrotec 75)
ENBREL – etanercept for subcutaneous
inj kit 25 mg
ENBREL – etanercept subcutaneous soln
prefilled syringe 25 mg/0.5ml
oxymorphone hcl tab 10 mg (Opana)
43
•
•
•
•
•
•
•
naproxen tab ec 500 mg (Ec-naprosyn)
•
•
naproxen tab 375 mg (Naprosyn)
indomethacin cap 25 mg
44
Quantity Limits
•
naproxen sodium tab 550 mg (Anaprox
ds)
naproxen tab ec 375 mg (Ec-naprosyn)
•
•
oxaprozin tab 600 mg (Daypro)
•
•
piroxicam cap 20 mg (Feldene)
•
•
piroxicam cap 10 mg (Feldene)
SIMPONI – golimumab subcutaneous
soln auto-injector 50 mg/0.5ml
soln auto-injector 100 mg/ml
soln prefilled syringe 50 mg/0.5ml
soln prefilled syringe 100 mg/ml
ibuprofen tab 600 mg
indomethacin cap cr 75 mg
•
naproxen sodium tab 275 mg (Anaprox)
•
ILARIS – canakinumab for inj 180 mg
•
NAPROXEN – naproxen susp 125
mg/5ml
ibuprofen susp 100 mg/5ml
•
nabumetone tab 750 mg
flurbiprofen tab 50 mg
HUMIRA PEN-PSORIASIS STAR
– adalimumab pen-injector kit 40
mg/0.8ml
•
nabumetone tab 500 mg
etodolac tab 500 mg
HUMIRA PEN-CROHNS DISEASE
– adalimumab pen-injector kit 40
mg/0.8ml
•
meloxicam tab 15 mg (Mobic)
etodolac tab 400 mg
HUMIRA PEN – adalimumab pen-injector
kit 40 mg/0.8ml
•
meloxicam tab 7.5 mg (Mobic)
etodolac tab sr 24hr 600 mg
HUMIRA PEDIATRIC CROHNS D –
adalimumab prefilled syringe kit 40
mg/0.8ml
•
mefenamic acid cap 250 mg (Ponstel)
HUMIRA – adalimumab prefilled syringe
kit 40 mg/0.8ml
ketoprofen cap 75 mg
leflunomide tab 20 mg (Arava)
kit 20 mg/0.4ml
ketoprofen cap 50 mg
leflunomide tab 10 mg (Arava)
etodolac cap 300 mg
kit 10 mg/0.2ml
indomethacin cap 50 mg
ketorolac tromethamine tab 10 mg
etodolac cap 200 mg
flurbiprofen tab 100 mg
Quantity Limits
•
Prior Authorization
ENBREL SURECLICK – etanercept
subcutaneous solution auto-injector 50
mg/ml
•
Drug Name
Specialty
ENBREL – etanercept subcutaneous soln
Prior Authorization
Drug Name
Specialty
2016
•
•
sulindac tab 150 mg
sulindac tab 200 mg
tolmetin sodium cap 400 mg
MIGRAINE HEADACHES
acetaminophen-isometheptenedichloral cap 325-65-100 mg
sumatriptan succinate tab 25 mg
(Imitrex)
IMITREX – sumatriptan nasal spray 5 mg/
act
(Imitrex)
IMITREX – sumatriptan nasal spray 20
mg/act
(Imitrex)
isometheptene-caffeineacetaminophen tab 65-20-325 mg
(Prodrin)
zolmitriptan orally disintegrating tab
2.5 mg (Zomig zmt)
MIGRANAL – dihydroergotamine
mesylate nasal spray 4 mg/ml
naratriptan hcl tab 1 mg (base equiv)
(Amerge)
naratriptan hcl tab 2.5 mg (base equiv)
(Amerge)
rizatriptan benzoate orally
disintegrating tab 5 mg (Maxalt-mlt)
rizatriptan benzoate orally
disintegrating tab 10 mg (Maxalt-mlt)
zolmitriptan tab 2.5 mg (Zomig)
zolmitriptan tab 5 mg (Zomig)
GOUT
allopurinol tab 100 mg (Zyloprim)
allopurinol tab 300 mg (Zyloprim)
colchicine w/ probenecid tab
0.5-500 mg
probenecid tab 500 mg
NEUROMUSCULAR DRUGS
rizatriptan benzoate tab 10 mg (Maxalt)
SEIZURES
SUMATRIPTAN SUCCINATE –
sumatriptan succinate solution prefilled
syringe 6 mg/0.5ml
carbamazepine cap sr 12hr 100 mg
(Carbatrol)
sumatriptan succinate inj 6 mg/0.5ml
(Imitrex)
sumatriptan succinate solution autoinjector 4 mg/0.5ml (Imitrex statdose
sys)
sumatriptan succinate solution autoinjector 6 mg/0.5ml (Imitrex statdose
sys)
sumatriptan succinate solution
cartridge 4 mg/0.5ml (Imitrex statdose
ref)
sumatriptan succinate solution
cartridge 6 mg/0.5ml (Imitrex statdose
ref)
Quantity Limits
zolmitriptan orally disintegrating tab
5 mg (Zomig zmt)
rizatriptan benzoate tab 5 mg (Maxalt)
SUMATRIPTAN SUCCINATE –
sumatriptan succinate inj 4 mg/0.5ml
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
(Carbatrol)
(Carbatrol)
carbamazepine chew tab 100 mg
carbamazepine susp 100 mg/5ml
(Tegretol)
carbamazepine tab sr 12hr 200 mg
(Tegretol-xr)
carbamazepine tab sr 12hr 400 mg
(Tegretol-xr)
carbamazepine tab 200 mg (Tegretol)
CELONTIN – methsuximide cap 300 mg
clonazepam orally disintegrating tab
0.125 mg
45
0.25 mg
felbamate tab 400 mg (Felbatol)
0.5 mg
gabapentin cap 100 mg (Neurontin)
1 mg
2 mg
clonazepam tab 0.5 mg (Klonopin)
clonazepam tab 1 mg (Klonopin)
clonazepam tab 2 mg (Klonopin)
DIASTAT ACUDIAL – diazepam rectal gel
delivery system 10 mg
DIASTAT ACUDIAL – diazepam rectal gel
delivery system 20 mg
DIASTAT PEDIATRIC – diazepam rectal
gel delivery system 2.5 mg
DILANTIN – phenytoin sodium extended
cap 30 mg
DILANTIN – phenytoin sodium extended
cap 100 mg
DILANTIN-125 – phenytoin susp 125
mg/5ml
divalproex sodium cap sprinkle 125 mg
(Depakote sprinkles)
divalproex sodium tab delayed release
125 mg (Depakote)
gabapentin oral soln 250 mg/5ml
(Neurontin)
gabapentin tab 600 mg (Neurontin)
gabapentin tab 800 mg (Neurontin)
lamotrigine tab chewable dispersible
5 mg (Lamictal chewable di)
lamotrigine tab chewable dispersible
25 mg (Lamictal chewable di)
lamotrigine tab sr 24hr 25 mg (Lamictal
xr)
lamotrigine tab sr 24hr 50 mg (Lamictal
xr)
lamotrigine tab sr 24hr 100 mg
(Lamictal xr)
(Lamictal xr)
(Lamictal xr)
(Lamictal xr)
lamotrigine tab 25 mg (Lamictal)
500 mg (Depakote)
divalproex sodium tab sr 24 hr 500 mg
(Depakote er)
ethosuximide cap 250 mg (Zarontin)
levetiracetam oral soln 100 mg/ml
(Keppra)
levetiracetam tab sr 24hr 500 mg
(Keppra xr)
levetiracetam tab sr 24hr 750 mg
(Keppra xr)
ethosuximide soln 250 mg/5ml
(Zarontin)
levetiracetam tab 250 mg (Keppra)
felbamate susp 600 mg/5ml (Felbatol)
46
Quantity Limits
felbamate tab 600 mg (Felbatol)
250 mg (Depakote)
divalproex sodium tab sr 24 hr 250 mg
(Depakote er)
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
zonisamide cap 25 mg (Zonegran)
oxcarbazepine susp 300 mg/5ml
(60 mg/ml) (Trileptal)
zonisamide cap 50 mg
oxcarbazepine tab 150 mg (Trileptal)
PARKINSON'S DISEASE
PHENYTEK – phenytoin sodium
extended cap 200 mg
PHENYTEK – phenytoin sodium
extended cap 300 mg
phenytoin chew tab 50 mg (Dilantin
infatabs)
phenytoin sodium extended cap
100 mg (Dilantin)
200 mg (Phenytek)
300 mg (Phenytek)
phenytoin susp 125 mg/5ml (Dilantin)
primidone tab 50 mg (Mysoline)
primidone tab 250 mg (Mysoline)
SABRIL – vigabatrin tab 500 mg
amantadine hcl cap 100 mg
amantadine hcl syrup 50 mg/5ml
AZILECT – rasagiline mesylate tab 0.5
mg (base equiv)
AZILECT – rasagiline mesylate tab 1 mg
(base equiv)
benztropine mesylate tab 0.5 mg
benztropine mesylate tab 1 mg
benztropine mesylate tab 2 mg
bromocriptine mesylate cap 5 mg
(Parlodel)
bromocriptine mesylate tab 2.5 mg
(Parlodel)
carbidopa & levodopa orally
disintegrating tab 10-100 mg
TEGRETOL-XR – carbamazepine tab sr
12hr 100 mg
carbidopa & levodopa tab cr 25-100 mg
(Sinemet cr)
tiagabine hcl tab 2 mg (Gabitril)
carbidopa & levodopa tab cr 50-200 mg
(Sinemet cr)
topiramate sprinkle cap 15 mg
(Topamax sprinkle)
topiramate sprinkle cap 25 mg
(Topamax sprinkle)
topiramate tab 25 mg (Topamax)
valproate sodium syrup 250 mg/5ml
(base equiv) (Depakene)
Quantity Limits
zonisamide cap 100 mg (Zonegran)
SABRIL – vigabatrin powd pack 500 mg
tiagabine hcl tab 4 mg (Gabitril)
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
carbidopa & levodopa tab 10-100 mg
(Sinemet)
(Sinemet)
(Sinemet)
carbidopa tab 25 mg (Lodosyn)
CARBIDOPA/LEVODOPA/ENTACA –
carbidopa-levodopa-entacapone tabs
12.5-50-200 mg
valproic acid cap 250 mg (Depakene)
47
18.75-75-200 mg
25-100-200 mg
31.25-125-200 mg
37.5-150-200 mg
50-200-200 mg
ropinirole hydrochloride tab 1 mg
(Requip)
(Requip)
(Requip)
(Requip)
(Requip)
selegiline hcl cap 5 mg (Eldepryl)
selegiline hcl tab 5 mg
trihexyphenidyl hcl elixir 0.4 mg/ml
pramipexole dihydrochloride tab
0.125 mg (Mirapex)
trihexyphenidyl hcl tab 2 mg
0.25 mg (Mirapex)
MUSCLE RELAXANTS
0.75 mg (Mirapex)
pramipexole dihydrochloride tab 1 mg
(Mirapex)
1.5 mg (Mirapex)
trihexyphenidyl hcl tab 5 mg
baclofen tab 10 mg
baclofen tab 20 mg
chlorzoxazone tab 500 mg (Parafon
forte dsc)
cyclobenzaprine hcl tab 5 mg
cyclobenzaprine hcl tab 7.5 mg
(Fexmid)
cyclobenzaprine hcl tab 10 mg
ropinirole hydrochloride tab sr 24hr
2 mg (base equivalent) (Requip xl)
DANTROLENE SODIUM – dantrolene
sodium cap 100 mg
dantrolene sodium cap 25 mg
(Dantrium)
dantrolene sodium cap 50 mg
(Dantrium)
metaxalone tab 800 mg (Skelaxin)
ropinirole hydrochloride tab 0.25 mg
(Requip)
48
Quantity Limits
ropinirole hydrochloride tab 0.5 mg
(Requip)
entacapone tab 200 mg (Comtan)
0.5 mg (Mirapex)
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
methocarbamol tab 500 mg (Robaxin)
methocarbamol tab 750 mg
(Robaxin-750)
orphenadrine citrate tab sr 12hr
100 mg
orphenadrine w/ aspirin & caffeine tab
25-385-30 mg
PRENAPLUS – prenatal vit w/ fe
fumarate-fa tab 27-1 mg
tizanidine hcl cap 2 mg (base
equivalent) (Zanaflex)
PRENATABS FA – prenatal vit w/ fe
PRENATABS RX – prenatal vit w/ iron
carbonyl-fa tab 29-1 mg
PRENATAL PLUS – prenatal vit w/ fe
tizanidine hcl tab 2 mg (base
equivalent)
PRENATAL 19 – prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
tizanidine hcl tab 4 mg (base
PRENATAL 19 – prenatal vit w/ dss-fe
OTHER NEUROMUSCULAR DRUGS
PRENATAL-U – prenatal w/o a vit w/ fe
fumarate-fa cap 106.5-1 mg
pyridostigmine bromide tab 60 mg
(Mestinon)
riluzole tab 50 mg (Rilutek)
VITAMINS
ergocalciferol cap 50000 unit (Drisdol)
MEPHYTON – phytonadione tab 5 mg
Quantity Limits
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
TRI-VIT/FLUORIDE/IRON – pediatric
vitamins acd fluoride & fe drops 0.25-10
mg/ml
TRINATE – prenatal vit w/ fe fumarate-fa
tab 28-1 mg
MULTIVITAMINS
VINACAL B – prenat w/o a w/fecbn-feglufa tab 20-1 mg & vit b6 tab pak
ESCAVITE LQ – pediatric multiple
vitamins w/ fl-fe drops 0.25-6 mg/ml
VINATE AZ EXTRA – prenatal vit w/ fe
bisglycinate chelate-fa tab 29-1 mg
pediatric multiple vitamins w/ fl-fe
drops 0.25-10 mg/ml
VINATE C – prenatal w/o a vit w/ fe
pediatric multiple vitamins w/ fluoride
chew tab 0.25 mg
VINATE CALCIUM – prenatal vit w/ iron
carbonyl-fe gluc-fa tab 27-1 mg
chew tab 0.5 mg
VINATE CARE – prenatal w/o a vit w/ fe
fum-fa tab chew 40-1 mg
chew tab 1 mg
VINATE DHA RF – prenat w/o a w/fefummethylfol-omegas cap 27-1.13 mg
soln 0.25 mg/ml
VINATE IC – prenatal w/o a w/fe fum-fe
poly-fa cap 162.115.2-1 mg
soln 0.5 mg/ml
VINATE II – prenatal vit w/ fe bisglycinate
chelate-fa tab 29-1 mg
pediatric vitamins acd w/ fluoride soln
0.25 mg/ml
VINATE M – prenatal vit w/ sel-fe
pediatric vitamins acd w/ fluoride soln
0.5 mg/ml
VINATE ONE – prenatal vit w/ fe
MINERALS AND ELECTROLYTES
49
FLUOR-A-DAY – sodium fluoride-xylitol
chew tab 0.55 (0.25 mg f)-236.79 mg
SODIUM FLUORIDE – sodium fluoride
tab 1 mg f (from 2.2 mg naf)
chew tab 1.1 (0.5 mg f)-236.79 mg
sodium fluoride chew tab 0.25 mg f
(from 0.55 mg naf) (Luride)
chew tab 2.2 (1 mg f)-236.79 mg
sodium fluoride chew tab 0.5 mg f
(from 1.1 mg naf) (Luride)
FLURA-DROPS – sodium fluoride soln
0.25 mg/drop f (from 0.55 mg/drop naf)
sodium fluoride chew tab 1 mg f (from
2.2 mg naf) (Luride)
K-PHOS – potassium phosphate
monobasic tab 500 mg
sodium fluoride soln 0.125 mg/drop f
(0.275 mg/drop naf)
pot bicarbonate & chloride effer tab 25
meq
sodium fluoride soln 0.5 mg/ml f (from
1.1 mg/ml naf) (Luride)
pot phos monobasic w/sod phos di &
monobas tab 155-852-130mg (K-phos
neutral)
SSKI – potassium iodide soln 1 gm/ml
potassium bicarbonate effer tab 25
meq
ARANESP ALBUMIN FREE –
darbepoetin alfa soln prefilled syringe
10 mcg/0.4ml
potassium chloride oral soln 10% (20
meq/15ml)
potassium chloride oral soln 20% (40
meq/15ml)
potassium chloride powder packet 20
meq
potassium chloride tab cr 8 meq
(600 mg)
potassium chloride tab cr 10 meq (Ktab)
SODIUM FLUORIDE – sodium fluoride
tab 0.5 mg f (from 1.1 mg naf)
50
•
•
•
•
•
•
•
•
•
•
•
Quantity Limits
•
AMICAR – aminocaproic acid syrup 25%
potassium chloride cap cr 10 meq
(Micro-k)
potassium chloride microencapsulated
crys cr tab 20 meq
•
AMICAR – aminocaproic acid tab 500 mg
anagrelide hcl cap 0.5 mg (Agrylin)
potassium chloride microencapsulated
crys cr tab 10 meq
•
BLOOD MODIFYING DRUGS
potassium chloride cap cr 8 meq
(Micro-k)
POTASSIUM CHLORIDE ER – potassium
chloride tab cr 8 meq (600 mg)
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
anagrelide hcl cap 1 mg
25 mcg/0.42ml
40 mcg/0.4ml
60 mcg/0.3ml
100 mcg/0.5ml
150 mcg/0.3ml
200 mcg/0.4ml
darbepoetin alfa soln inj 25 mcg/ml
cilostazol tab 50 mg (Pletal)
cilostazol tab 100 mg (Pletal)
clopidogrel bisulfate tab 75 mg (base
equiv) (Plavix)
clopidogrel bisulfate tab 300 mg (base
equiv) (Plavix)
dipyridamole tab 25 mg (Persantine)
EFFIENT – prasugrel hcl tab 5 mg (base
equiv)
EFFIENT – prasugrel hcl tab 10 mg (base
equiv)
enoxaparin sodium inj 30 mg/0.3ml
(Lovenox)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Quantity Limits
Quantity Limits
•
Prior Authorization
500 mcg/ml
•
Drug Name
Specialty
300 mcg/0.6ml
Prior Authorization
Drug Name
Specialty
2016
enoxaparin sodium inj 100 mg/ml
(Lovenox)
(Lovenox)
enoxaparin sodium inj 150 mg/ml
(Lovenox)
•
•
•
•
•
•
•
•
fondaparinux sodium subcutaneous inj
2.5 mg/0.5ml (Arixtra)
•
•
5 mg/0.4ml (Arixtra)
•
•
7.5 mg/0.6ml (Arixtra)
enoxaparin sodium inj 300 mg/3ml
(Lovenox)
FIRAZYR – icatibant acetate inj 30
mg/3ml (base equivalent)
folic acid tab 1 mg
10 mg/0.8ml (Arixtra)
GRANIX – tbo-filgrastim soln prefilled
syringe 300 mcg/0.5ml
GRANIX – tbo-filgrastim soln prefilled
NEULASTA – pegfilgrastim soln prefilled
syringe 6 mg/0.6ml
NEULASTA DELIVERY KIT –
pegfilgrastim soln prefilled syringe kit 6
mg/0.6ml
NEUPOGEN – filgrastim soln prefilled
NEUPOGEN – filgrastim soln prefilled
syringe 480 mcg/0.8ml (600 mcg/ml)
NEUPOGEN – filgrastim inj 300 mcg/ml
(Lovenox)
NEUPOGEN – filgrastim inj 480
mcg/1.6ml (300 mcg/ml)
(Lovenox)
pentoxifylline tab cr 400 mg
PROCRIT – epoetin alfa inj 2000 unit/ml
(Lovenox)
51
tranexamic acid tab 650 mg (Lysteda)
warfarin sodium tab 1 mg (Coumadin)
warfarin sodium tab 2.5 mg (Coumadin)
warfarin sodium tab 7.5 mg (Coumadin)
XARELTO – rivaroxaban tab 10 mg
XARELTO STARTER PACK –
rivaroxaban tab starter therapy pack 15
mg & 20 mg
TOPICAL PRODUCTS
EYE
Anti-infectives
BACITRACIN – bacitracin ophth oint 500
unit/gm
bacitracin-polymyxin b ophth oint
CILOXAN – ciprofloxacin hcl ophth oint
0.3%
ciprofloxacin hcl ophth soln 0.3%
(Ciloxan)
erythromycin ophth oint 5 mg/gm
gatifloxacin ophth soln 0.5% (Zymaxid)
gentamicin sulfate ophth oint 0.3%
gentamicin sulfate ophth soln 0.3%
(Garamycin)
levofloxacin ophth soln 0.5%
NATACYN – natamycin ophth susp 5%
52
Quantity Limits
Prior Authorization
Drug Name
Specialty
•
•
•
Quantity Limits
•
•
•
Prior Authorization
Drug Name
Specialty
2016
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml
(Neosporin)
ofloxacin ophth soln 0.3% (Ocuflox)
polymyxin b-trimethoprim ophth soln
10000 unit/ml-0.1% (Polytrim)
sulfacetamide sodium ophth soln 10%
(Bleph-10)
tobramycin ophth soln 0.3% (Tobrex)
TOBREX – tobramycin ophth oint 0.3%
trifluridine ophth soln 1% (Viroptic)
VIGAMOX – moxifloxacin hcl ophth soln
0.5% (base equiv)
Steroids and Combination Products
ALREX – loteprednol etabonate ophth
susp 0.2%
bacitracin-polymyxin-neomycin-hc
ophth oint 1%
DEXAMETHASONE SODIUM PHOS –
dexamethasone sodium phosphate
ophth soln 0.1%
fluorometholone ophth susp 0.1% (Fml
liquifilm)
LOTEMAX – loteprednol etabonate ophth
gel 0.5%
oint 0.5%
susp 0.5%
neomycin-polymyxin-dexamethasone
ophth oint 0.1% (Maxitrol)
neomycin-polymyxin-dexamethasone
ophth susp 0.1% (Maxitrol)
prednisolone acetate ophth susp 1%
(Pred forte)
sulfacetamide sodium-prednisolone
ophth soln 10-0.23(0.25)%
tobramycin-dexamethasone ophth
susp 0.3-0.1% (Tobradex)
timolol maleate ophth gel forming soln
0.5% (Timoptic-xe)
ZYLET – loteprednol etabonatetobramycin ophth susp 0.5-0.3%
timolol maleate ophth soln 0.25%
(Timoptic)
Glaucoma
timolol maleate ophth soln 0.5%
(Timoptic)
ALPHAGAN P – brimonidine tartrate
ophth soln 0.1%
apraclonidine hcl ophth soln 0.5%
(base equivalent) (Iopidine)
AZOPT – brinzolamide ophth susp 1%
betaxolol hcl ophth soln 0.5%
brimonidine tartrate ophth soln 0.15%
(Alphagan p)
brimonidine tartrate ophth soln 0.2%
carteolol hcl ophth soln 1%
dorzolamide hcl ophth soln 2%
(Trusopt)
dorzolamide hcl-timolol maleate ophth
soln 22.3-6.8 mg/ml (Cosopt)
latanoprost ophth soln 0.005%
(Xalatan)
LEVOBUNOLOL HCL – levobunolol hcl
ophth soln 0.25%
levobunolol hcl ophth soln 0.5%
(Betagan)
LUMIGAN – bimatoprost ophth soln
0.01%
METIPRANOLOL – metipranolol ophth
soln 0.3%
pilocarpine hcl ophth soln 1% (Isopto
carpine)
carpine)
carpine)
SIMBRINZA – brinzolamide-brimonidine
tartrate ophth susp 1-0.2%
timolol maleate ophth gel forming soln
0.25% (Timoptic-xe)
Quantity Limits
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
TRAVATAN Z – travoprost ophth soln
0.004% (benzalkonium free) (bak free)
Other Eye Products
ATROPINE SULFATE – atropine sulfate
ophth oint 1%
atropine sulfate ophth soln 1% (Isopto
atropine)
azelastine hcl ophth soln 0.05%
(Optivar)
bromfenac sodium ophth soln 0.09%
(base equivalent)
bromfenac sodium ophth soln 0.09%
(base equiv) (once-daily)
cromolyn sodium ophth soln 4%
cyclopentolate hcl ophth soln 1%
(Cyclogyl)
cyclopentolate hcl ophth soln 2%
(Cyclogyl)
diclofenac sodium ophth soln 0.1%
epinastine hcl ophth soln 0.05%
(Elestat)
flurbiprofen sodium ophth soln 0.03%
(Ocufen)
homatropine hbr ophth soln 5% (Isopto
homatropine)
ketorolac tromethamine ophth soln
0.4% (Acular ls)
ketorolac tromethamine ophth soln
0.5% (Acular)
PATADAY – olopatadine hcl ophth soln
0.2% (base equivalent)
PAZEO – olopatadine hcl ophth soln 0.7%
(base equivalent)
phenylephrine hcl ophth soln 2.5%
53
phenylephrine hcl ophth soln 10%
pilocarpine hcl tab 5 mg (Salagen)
tropicamide ophth soln 0.5%
pilocarpine hcl tab 7.5 mg (Salagen)
tropicamide ophth soln 1% (Mydriacyl)
sodium fluoride cream 1.1% (Prevident
5000 plus)
EAR
acetic acid otic soln 2%
antipyrine-benzocaine otic soln
54-14 mg/ml (5.4-1.4%)
antipyrine-benzocaine-polycosanol
otic sol 5.4-1.4-0.0097% (Treagan otic)
CIPRO HC – ciprofloxacin-hydrocortisone
otic susp 0.2-1%
CIPRODEX – ciprofloxacindexamethasone otic susp 0.3-0.1%
CORTANE-B AQUEOUS – pramoxine-hcchloroxylenol aqueous otic soln 10-10-1
mg/ml
fluocinolone acetonide (otic) oil 0.01%
(Dermotic)
hydrocortisone w/ acetic acid otic soln
1-2% (Vosol hc)
neomycin-polymyxin-hc otic soln 1%
(Cortisporin)
triamcinolone acetonide dental paste
0.1%
ANORECTAL AGENTS
CORTIFOAM – hydrocortisone acetate
rectal foam 10% (90 mg/dose)
hydrocortisone acetate suppos 25 mg
(Anusol-hc)
hydrocortisone acetate suppos 30 mg
(Proctocort)
hydrocortisone enema 100 mg/60ml
(Cortenema)
hydrocortisone rectal cream 1%
(Proctocort)
hydrocortisone rectal cream 2.5%
(Anusol-hc)
SKIN CONDITIONS/PRODUCTS
Acne
ofloxacin otic soln 0.3%
adapalene gel 0.1% (Differin)
pramoxine-hc-chloroxylenol otic soln
10-10-1 mg/ml (Cortane-b-otic)
MOUTH AND THROAT (LOCAL)
cevimeline hcl cap 30 mg (Evoxac)
chlorhexidine gluconate soln 0.12%
(Peridex)
adapalene cream 0.1% (Differin)
adapalene gel 0.3% (Differin)
benzoyl peroxide-erythromycin gel
5-3% (Benzamycin)
BP CLEANSING WASH – sulfacetamide
sodium-sulfur in urea emulsion 10-4%
clindamycin phosph-benzoyl peroxide
(refrig) gel 1.2 (1)-5% (Duac)
clotrimazole troche 10 mg
clindamycin phosphate foam 1%
(Evoclin)
lidocaine hcl laryngotracheal soln 4%
(Lta 360 kit)
clindamycin phosphate gel 1%
(Cleocin-t)
lidocaine hcl viscous soln 2%
clindamycin phosphate lotion 1%
(Cleocin-t)
nystatin susp 100000 unit/ml
54
Quantity Limits
sodium fluoride gel 1.1% (0.5% f)
(Prevident fluoride)
neomycin-polymyxin-hc otic susp
3.5 mg/ml-10000 unit/ml-1%
pramoxine-chloroxylenol otic liquid
1-0.1% (Pramotic)
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
clindamycin phosphate soln 1%
(Cleocin-t)
sulfacetamide sodium w/ sulfur cream
10-5%
clindamycin phosphate swab 1%
(Cleocin-t)
sulfacetamide sodium w/ sulfur
emulsion 10-1%
clindamycin phosphate-benzoyl
peroxide gel 1-5% (Benzaclin)
emulsion 10-5%
erythromycin gel 2% (Erygel)
sulfacetamide sodium w/ sulfur foam
10-5% (Clarifoam ef)
erythromycin pads 2%
erythromycin soln 2%
FINACEA – azelaic acid foam 15%
FINACEA – azelaic acid gel 15%
isotretinoin cap 10 mg
sulfacetamide sodium w/ sulfur susp
8-4% (Sumaxin ts)
sulfacetamide sodium w/ sulfur wash
9-4% (Sumaxin wash)
metronidazole cream 0.75%
(Metrocream)
TAZORAC – tazarotene cream 0.05%
TAZORAC – tazarotene cream 0.1%
metronidazole gel 0.75%
TAZORAC – tazarotene gel 0.05%
metronidazole gel 1% (Metrogel)
TAZORAC – tazarotene gel 0.1%
metronidazole lotion 0.75%
(Metrolotion)
tretinoin cream 0.025% (Retin-a)
ORACEA – doxycycline (rosacea) cap
PRASCION RA WITH SUNSCREE –
sulfacetamide sodium-sulfur-sunscreen
cream 10-5%
tretinoin gel 0.01% (Retin-a)
tretinoin gel 0.025%, (Retin-a)
tretinoin gel 0.05% (Atralin)
sulfacetamide sod-sulfur wash 9-4.5%
& skin cleanser kit (Sumadan kit)
tretinoin microsphere gel 0.04% (Retina micro)
sulfacetamide sodium lotion 10%
(acne) (Klaron)
tretinoin microsphere gel 0.1% (Retin-a
micro)
cleanser 10-2% (Avar ls cleanser)
Anti-infectives
cleansing cloth 10-5%
ciclopirox gel 0.77% (Loprox)
cleansing pad 10-4% (Sumaxin)
sulfacetamide sodium w/ sulfur cream
10-2% (Avar-e ls)
Quantity Limits
sulfacetamide sodium w/ sulfur lotion
10-5%
sulfacetamide sodium w/ sulfur wash
9-4.5% (Sumadan wash)
isotretinoin cap 30 mg (Claravis)
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
acyclovir oint 5% (Zovirax)
ciclopirox olamine cream 0.77% (base
equiv)
ciclopirox olamine susp 0.77% (base
equiv)
55
ciclopirox shampoo 1% (Loprox
shampoo)
betamethasone dipropionate
augmented gel 0.05%
ciclopirox solution kit 8% (Ciclodan
solution ki)
augmented lotion 0.05% (Diprolene)
ciclopirox solution 8% (Penlac nail
lacquer)
augmented oint 0.05% (Diprolene)
clotrimazole w/ betamethasone cream
1-0.05% (Lotrisone)
betamethasone dipropionate cream
0.05%
clotrimazole w/ betamethasone lotion
1-0.05%
betamethasone dipropionate lotion
0.05%
diclofenac sodium soln 1.5%
(Pennsaid)
betamethasone dipropionate oint
0.05%
econazole nitrate cream 1%
betamethasone valerate aerosol foam
0.12% (Luxiq)
GENTAMICIN SULFATE – gentamicin
sulfate cream 0.1%
betamethasone valerate lotion 0.1%
iodoquinol-hydrocortisone in aloe
vehicle cream 1-1.9% (Vytone)
clobetasol propionate cream 0.05%
(Temovate)
ketoconazole foam 2% (Extina)
ketoconazole shampoo 2% (Nizoral)
mupirocin calcium cream 2%
(Bactroban)
mupirocin oint 2% (Bactroban)
nystatin cream 100000 unit/gm
nystatin oint 100000 unit/gm
nystatin topical powder
silver sulfadiazine cream 1%
(Silvadene)
Corticosteroids
alclometasone dipropionate cream
0.05% (Aclovate)
betamethasone valerate oint 0.1%
clobetasol propionate emollient base
cream 0.05% (Temovate e)
clobetasol propionate emulsion foam
0.05% (Olux-e)
clobetasol propionate foam 0.05%
(Olux)
clobetasol propionate gel 0.05%
(Temovate)
clobetasol propionate lotion 0.05%
(Clobex)
clobetasol propionate oint 0.05%
(Temovate)
clobetasol propionate shampoo 0.05%
(Clobex)
alclometasone dipropionate oint 0.05%
clobetasol propionate soln 0.05%
(Temovate)
AMCINONIDE – amcinonide cream 0.1%
desonide cream 0.05% (Desowen)
augmented cream 0.05% (Diprolene
af)
desonide lotion 0.05% (Desowen)
56
Quantity Limits
betamethasone valerate cream 0.1%
GENTAMICIN SULFATE – gentamicin
sulfate oint 0.1%
ketoconazole cream 2%
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
desonide oint 0.05% (Desowen)
DESOXIMETASONE – desoximetasone
cream 0.05%
desoximetasone cream 0.25% (Topicort)
desoximetasone gel 0.05% (Topicort)
desoximetasone oint 0.25% (Topicort)
DIFLORASONE DIACETATE –
diflorasone diacetate cream 0.05%
DIFLORASONE DIACETATE –
diflorasone diacetate oint 0.05%
hydrocortisone butyrate oint 0.1%
(Locoid)
hydrocortisone butyrate soln 0.1%
(Locoid)
hydrocortisone cream 1%
hydrocortisone cream 2.5%
hydrocortisone lotion 2% (Ala scalp)
fluocinolone acetonide cream 0.025%
(Synalar)
hydrocortisone lotion 2.5%
hydrocortisone oint 2.5%
fluocinolone acetonide oil 0.01% (body
oil) (Derma-smoothe/fs bod)
hydrocortisone valerate cream 0.2%
fluocinolone acetonide oint 0.025%
(Synalar)
fluocinolone acetonide soln 0.01%
(Synalar)
fluocinonide cream 0.05%
hydrocortisone valerate oint 0.2%
(Westcort)
mometasone furoate cream 0.1%
(Elocon)
mometasone furoate oint 0.1% (Elocon)
mometasone furoate solution 0.1%
(lotion) (Elocon)
fluocinonide cream 0.1% (Vanos)
nystatin-triamcinolone cream
100000-0.1 unit/gm-%
fluocinonide emulsified base cream
0.05%
nystatin-triamcinolone oint 100000-0.1
unit/gm-%
fluocinonide gel 0.05%
prednicarbate cream 0.1% (Dermatop)
fluocinonide oint 0.05%
prednicarbate oint 0.1% (Dermatop)
fluocinonide soln 0.05%
TRIAMCINOLONE ACETONIDE –
triamcinolone acetonide oint 0.5%
fluticasone propionate cream 0.05%
(Cutivate)
triamcinolone acetonide cream 0.025%
fluticasone propionate lotion 0.05%
(Cutivate)
fluticasone propionate oint 0.005%
(Cutivate)
triamcinolone acetonide lotion 0.025%
halobetasol propionate cream 0.05%
(Ultravate)
Quantity Limits
hydrocortisone butyrate hydrophilic
lipo base cream 0.1% (Locoid
lipocream)
fluocinolone acetonide cream 0.01%
fluocinolone acetonide oil 0.01% (scalp
oil) (Derma-smoothe/fs sca)
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
triamcinolone acetonide lotion 0.1%
halobetasol propionate oint 0.05%
(Ultravate)
hydrocortisone butyrate cream 0.1%
(Locoid)
acitretin cap 10 mg (Soriatane)
Other Skin Products
57
calcipotriene cream 0.005% (Dovonex)
calcipotriene oint 0.005%
calcipotriene soln 0.005% (50 mcg/ml)
CARAC – fluorouracil cream 0.5%
diclofenac sodium (actinic
keratoses) gel 3% (Solaraze)
DRYSOL – aluminum chloride soln 20%
ELIDEL – pimecrolimus cream 1%
FLUOROPLEX – fluorouracil cream 1%
fluorouracil cream 5% (Efudex)
STELARA – ustekinumab soln prefilled
syringe 90 mg/ml
•
•
•
•
•
•
Quantity Limits
Quantity Limits
STELARA – ustekinumab soln prefilled
syringe 45 mg/0.5ml
Prior Authorization
acitretin cap 25 mg (Soriatane)
Drug Name
Specialty
acitretin cap 17.5 mg (Soriatane)
Prior Authorization
Drug Name
Specialty
2016
tacrolimus oint 0.03% (Protopic)
tacrolimus oint 0.1% (Protopic)
VALCHLOR – mechlorethamine hcl gel
0.016% (base equivalent)
VOLTAREN – diclofenac sodium gel 1%
ZYCLARA – imiquimod cream 3.75%
ZYCLARA PUMP – imiquimod cream
2.5%
fluorouracil soln 2%
ZYCLARA PUMP – imiquimod cream
3.75%
fluorouracil soln 5%
MISCELLANEOUS CATEGORIES
imiquimod cream 5% (Aldara)
DIABETIC SUPPLIES
Many other diabetic supplies including Insulin Syringes,
Lancets and Lancet Devices are Preferred for plans
that cover them, however, only commonly prescribed
products are shown on the Preferred Drug List.
lactic acid (ammonium lactate) lotion
10%
lidocaine hcl cream 3%
lidocaine hcl gel 2%
lidocaine hcl soln 4% (Xylocaine)
lidocaine oint 5%
lidocaine patch 5% (Lidoderm)
lidocaine-prilocaine cream 2.5-2.5%
(Emla)
lidocaine-prilocaine kit 2.5-2.5%
lindane lotion 1%
lindane shampoo 1%
malathion lotion 0.5% (Ovide)
methoxsalen rapid cap 10 mg
(Oxsoralen ultra)
permethrin cream 5% (Elimite)
PICATO – ingenol mebutate gel 0.015%
PICATO – ingenol mebutate gel 0.05%
podofilox soln 0.5% (Condylox)
selenium sulfide lotion 2.5%
58
Blood Glucose Monitors, Test Strips, and Monitor
Calibration Liquids
ACCU-CHEK ACTIVE GLUCOSE – blood
glucose calibration - liquid
ACCU-CHEK ACTIVE STRIPS – glucose
blood test strip
ACCU-CHEK AVIVA – glucose blood test
strip
ACCU-CHEK AVIVA – blood glucose
calibration - liquid
ACCU-CHEK AVIVA CONNECT – blood
glucose monitoring kit w/ device
ACCU-CHEK AVIVA PLUS – glucose
blood test strip
ACCU-CHEK AVIVA PLUS – blood
ACCU-CHEK COMFORT CURVE C –
blood glucose calibration - liquid
ACCU-CHEK COMFORT CURVE L –
ACCU-CHEK COMPACT BLUE CO –
BAYER BREEZE 2 TEST DISC – glucose
blood test disk
ACCU-CHEK COMPACT PLUS – glucose
blood test strip
BAYER CONTOUR BLOOD GLUCO –
glucose blood test strip
ACCU-CHEK COMPACT PLUS CA –
blood glucose monitoring kit
blood glucose monitoring devices
ACCU-CHEK COMPACT PLUS CL –
blood glucose monitoring kit w/ device
ACCU-CHEK COMPACT TEST DR –
BAYER CONTOUR HIGH CONTRO –
blood glucose calibration - liquid - high
ACCU-CHEK INSTANT GLUCOSE –
BAYER CONTOUR LINK BLOOD – blood
ACCU-CHEK NANO SMARTVIEW –
BAYER CONTOUR LOW CONTROL –
blood glucose calibration - liquid - low
ACCU-CHEK SMARTVIEW CONTR –
BAYER CONTOUR NEXT BLOOD –
ACCU-CHEK SMARTVIEW STRIP –
BAYER CONTOUR NEXT BLOOD –
ACCU-CHEK VOICEMATE – blood
BAYER CONTOUR NEXT CONTRO
– blood glucose calibration - liquid normal
ACCUTREND GLUCOSE – glucose
blood test strip
ACCUTREND GLUCOSE CONTROL –
ACETEST – acetone (urine) test tab
ASCENSIA AUTODISC LOW AND –
ASCENSIA AUTODISC NORMAL – blood
glucose calibration - liquid - normal
ASCENSIA AUTODISC TEST ST –
glucose blood test disk
BAYER BREEZE 2 BLOOD GLUC –
BAYER BREEZE 2 HIGH CONTR – blood
glucose calibration - liquid - high
BAYER BREEZE 2 LOW CONTRO –
BAYER BREEZE 2 NORMAL CON –
blood glucose calibration - liquid normal
Quantity Limits
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
BAYER CONTOUR NEXT CONTRO –
BAYER CONTOUR NEXT EZ BLO –
BAYER CONTOUR NEXT LINK B – blood
BAYER CONTOUR NEXT LINK W –
BAYER CONTOUR NEXT USB BL –
BAYER CONTOUR NORMAL CONT
– blood glucose calibration - liquid normal
BAYER CONTOUR USB BLOOD G –
BREEZE 2 BLOOD GLUCOSE MO –
blood glucose monitoring devices
CHEMSTRIP UGK – urine glucoseketones test strips
59
CHEMSTRIP-K – acetone (urine) test
strip
cyclosporine modified cap 100 mg
(Neoral)
DIDGET – blood glucose monitoring kit w/
device
cyclosporine modified oral soln
100 mg/ml (Neoral)
KETO-DIASTIX – urine glucose-ketones
test strips
mycophenolate mofetil cap 250 mg
(Cellcept)
KETOSTIX – acetone (urine) test strip
mycophenolate mofetil for oral susp
200 mg/ml (Cellcept)
PRECISION XTRA – ketone blood test
strip
INJECTION DEVICE FOR INSULIN VARIOUS
naloxone hcl inj 0.4 mg/ml
INSULIN PEN NEEDLES - NOVOTWIST
naltrexone hcl tab 50 mg (Revia)
INSULIN PEN NEEDLES - VARIOUS
RAPAMUNE – sirolimus oral soln 1 mg/ml
INSULIN SYRINGES - VARIOUS
REVLIMID – lenalidomide caps 2.5 mg
LANCET DEVICES - VARIOUS
REVLIMID – lenalidomide cap 5 mg
LANCETS - VARIOUS
RESPIRATORY INHALER-ASSIST DEVICES
The Preferred Drug List includes most spacer
devices. The most commonly prescribed products
are AEROCHAMBER, EASIVENT, E-Z SPACER,
INSPIREASE, and MICROCHAMBER.
SANDIMMUNE – cyclosporine oral soln
100 mg/ml
INHALER-ASSIST DEVICES - VARIOUS
MISCELLANEOUS DRUGS
SANDIMMUNE – cyclosporine cap 25 mg
azathioprine tab 50 mg (Imuran)
SANDIMMUNE – cyclosporine cap 100
mg
buprenorphine hcl-naloxone hcl sl tab
2-0.5 mg (base equiv)
sirolimus tab 0.5 mg (Rapamune)
buprenorphine hcl-naloxone hcl sl tab
8-2 mg (base equiv)
cyclosporine cap 100 mg
(Sandimmune)
cyclosporine modified cap 25 mg
(Neoral)
60
Quantity Limits
mycophenolate sodium tab dr 360 mg
(mycophenolic acid equiv) (Myfortic)
INSULIN PEN NEEDLES - NOVOFINE
cyclosporine cap 25 mg (Sandimmune)
•
•
•
•
•
•
mycophenolate sodium tab dr 180 mg
(mycophenolic acid equiv) (Myfortic)
ALCOHOL SWABS - VARIOUS
CUPRIMINE – penicillamine cap 250 mg
•
•
•
•
•
•
mycophenolate mofetil tab 500 mg
(Cellcept)
Other Diabetic Supplies
CHEMET – succimer cap 100 mg
Prior Authorization
Drug Name
Specialty
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
sirolimus tab 1 mg (Rapamune)
sirolimus tab 2 mg (Rapamune)
•
•
sodium polystyrene sulfonate oral
susp 15 gm/60ml (Sps)
sodium polystyrene sulfonate powder
(Kayexalate)
sodium polystyrene sulfonate rectal
susp 30 gm/120ml
•
•
•
•
•
•
•
•
Quantity Limits
Prior Authorization
Drug Name
Specialty
2016
SUBOXONE – buprenorphine hclnaloxone hcl sl film 2-0.5 mg (base
equiv)
SUBOXONE – buprenorphine hclnaloxone hcl sl film 4-1 mg (base equiv)
SUBOXONE – buprenorphine hclnaloxone hcl sl film 8-2 mg (base equiv)
SUBOXONE – buprenorphine hclnaloxone hcl sl film 12-3 mg (base
equiv)
tacrolimus cap 0.5 mg (Prograf)
tacrolimus cap 1 mg (Prograf)
tacrolimus cap 5 mg (Prograf)
THALOMID – thalidomide cap 50 mg
ZORTRESS – everolimus tab 0.25 mg
61
2016
INDEX
A
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg (Trizivir).................................................. 4
abacavir sulfate tab 300 mg (base equiv) (Ziagen)......... 4
acamprosate calcium tab delayed release 333 mg
(Campral).......................................................................... 39
acarbose tab 25 mg (Precose)........................................ 13
acarbose tab 50 mg (Precose)........................................ 13
acarbose tab 100 mg (Precose)...................................... 13
ACCU-CHEK ACTIVE GLUCOSE – blood glucose
calibration - liquid.............................................................. 58
ACCU-CHEK ACTIVE STRIPS – glucose blood test
strip.....................................................................................58
ACCU-CHEK AVIVA – blood glucose calibration liquid................................................................................... 58
ACCU-CHEK AVIVA CONNECT – blood glucose
monitoring kit w/ device.................................................... 58
ACCU-CHEK AVIVA – glucose blood test strip.................. 58
ACCU-CHEK AVIVA PLUS – blood glucose monitoring kit
w/ device............................................................................ 58
ACCU-CHEK AVIVA PLUS – glucose blood test strip....... 58
ACCU-CHEK COMFORT CURVE C – blood glucose
ACCU-CHEK COMFORT CURVE L – blood glucose
ACCU-CHEK COMPACT BLUE CO – blood glucose
ACCU-CHEK COMPACT PLUS CA – blood glucose
monitoring kit..................................................................... 59
ACCU-CHEK COMPACT PLUS CL – blood glucose
ACCU-CHEK COMPACT PLUS – glucose blood test
strip.....................................................................................59
ACCU-CHEK COMPACT TEST DR – glucose blood test
strip.....................................................................................59
ACCU-CHEK INSTANT GLUCOSE – blood glucose
ACCU-CHEK NANO SMARTVIEW – blood glucose
ACCU-CHEK SMARTVIEW CONTR – blood glucose
ACCU-CHEK SMARTVIEW STRIP – glucose blood test
strip.....................................................................................59
ACCU-CHEK VOICEMATE – blood glucose monitoring kit
w/ device............................................................................ 59
ACCUTREND GLUCOSE CONTROL – blood glucose
ACCUTREND GLUCOSE – glucose blood test strip......... 59
acebutolol hcl cap 200 mg (Sectral)............................... 19
acebutolol hcl cap 400 mg (Sectral)............................... 19
acetaminophen-isometheptene-dichloral cap
325-65-100 mg.................................................................. 45
62
acetaminophen w/ codeine soln 120-12 mg/5ml........... 40
acetaminophen w/ codeine tab 300-15 mg (Tylenol/
codeine)............................................................................ 41
codeine #3)....................................................................... 41
codeine #4)....................................................................... 41
ACETAZOLAMIDE – acetazolamide tab 125 mg............... 23
acetazolamide cap sr 12hr 500 mg (Diamox)................ 23
acetazolamide tab 250 mg............................................... 23
ACETEST – acetone (urine) test tab................................. 59
acetic acid otic soln 2%................................................... 54
acetylcysteine inhal soln 10%......................................... 26
acetylcysteine inhal soln 20%......................................... 26
acitretin cap 10 mg (Soriatane)....................................... 57
acitretin cap 17.5 mg (Soriatane).................................... 58
acitretin cap 25 mg (Soriatane)....................................... 58
ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)........................................................... 7
ACTONEL – risedronate sodium tab 5 mg........................ 16
ACTONEL – risedronate sodium tab 30 mg...................... 16
ACTONEL – risedronate sodium tab 35 mg...................... 16
ACTONEL – risedronate sodium tab 150 mg.................... 16
acyclovir cap 200 mg (Zovirax)......................................... 4
acyclovir oint 5% (Zovirax).............................................. 55
acyclovir susp 200 mg/5ml (Zovirax)............................... 4
acyclovir tab 400 mg (Zovirax)..........................................4
acyclovir tab 800 mg (Zovirax)..........................................4
adapalene cream 0.1% (Differin)..................................... 54
adapalene gel 0.1% (Differin).......................................... 54
adapalene gel 0.3% (Differin).......................................... 54
ADCIRCA – tadalafil tab 20 mg (pah)................................ 25
adefovir dipivoxil tab 10 mg (Hepsera)............................ 4
ADVAIR DISKUS – fluticasone-salmeterol aer powder ba
100-50 mcg/dose............................................................... 26
250-50 mcg/dose............................................................... 26
500-50 mcg/dose............................................................... 26
ADVAIR HFA – fluticasone-salmeterol inhal aerosol 45-21
mcg/act............................................................................... 26
ADVAIR HFA – fluticasone-salmeterol inhal aerosol 115-21
mcg/act............................................................................... 26
ADVAIR HFA – fluticasone-salmeterol inhal aerosol
230-21 mcg/act.................................................................. 26
AFINITOR DISPERZ – everolimus tab for oral susp 2
mg........................................................................................ 7
mg........................................................................................ 7
mg........................................................................................ 7
AFINITOR – everolimus tab 2.5 mg..................................... 7
AFINITOR – everolimus tab 5 mg........................................ 7
AFINITOR – everolimus tab 7.5 mg..................................... 7
AFINITOR – everolimus tab 10 mg...................................... 7
ALBENZA – albendazole tab 200 mg.................................. 7
2016
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml).......... 26
albuterol sulfate soln nebu 0.5% (5 mg/ml)................... 26
albuterol sulfate soln nebu 0.63 mg/3ml (base
equiv)................................................................................. 26
albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv)................................................................................. 26
albuterol sulfate syrup 2 mg/5ml.................................... 26
albuterol sulfate tab 2 mg................................................ 27
albuterol sulfate tab 4 mg................................................ 27
albuterol sulfate tab sr 12hr 4 mg (Vospire er)..............26
albuterol sulfate tab sr 12hr 8 mg (Vospire er)..............27
alclometasone dipropionate cream 0.05%
(Aclovate).......................................................................... 56
alclometasone dipropionate oint 0.05%......................... 56
ALCOHOL SWABS - VARIOUS......................................... 60
ALENDRONATE SODIUM – alendronate sodium tab 40
mg...................................................................................... 16
alendronate sodium tab 5 mg......................................... 16
alendronate sodium tab 10 mg....................................... 16
alendronate sodium tab 35 mg....................................... 16
alendronate sodium tab 70 mg (Fosamax).................... 16
alfuzosin hcl tab sr 24hr 10 mg (Uroxatral)................... 32
ALKERAN – melphalan tab 2 mg.........................................7
allopurinol tab 100 mg (Zyloprim).................................. 45
allopurinol tab 300 mg (Zyloprim).................................. 45
alosetron hcl tab 0.5 mg (base equiv) (Lotronex)......... 30
alosetron hcl tab 1 mg (base equiv) (Lotronex)............ 30
ALPHAGAN P – brimonidine tartrate ophth soln 0.1%...... 53
alprazolam orally disintegrating tab 0.5 mg.................. 32
alprazolam orally disintegrating tab 1 mg..................... 32
alprazolam orally disintegrating tab 2 mg..................... 32
alprazolam orally disintegrating tab 0.25 mg
(Niravam)...........................................................................32
alprazolam tab 0.25 mg (Xanax)......................................33
alprazolam tab 0.5 mg (Xanax)........................................33
alprazolam tab 1 mg (Xanax)...........................................33
alprazolam tab 2 mg (Xanax)...........................................33
alprazolam tab sr 24hr 0.5 mg (Xanax xr)...................... 32
alprazolam tab sr 24hr 1 mg (Xanax xr)......................... 32
ALREX – loteprednol etabonate ophth susp 0.2%.............52
amantadine hcl cap 100 mg............................................ 47
amantadine hcl syrup 50 mg/5ml....................................47
AMCINONIDE – amcinonide cream 0.1%......................... 56
AMICAR – aminocaproic acid syrup 25%.......................... 50
AMICAR – aminocaproic acid tab 500 mg......................... 50
amiloride & hydrochlorothiazide tab 5-50 mg............... 23
amiloride hcl tab 5 mg..................................................... 23
amiodarone hcl tab 100 mg............................................. 24
amiodarone hcl tab 400 mg............................................. 24
amiodarone hcl tab 200 mg (Cordarone)....................... 24
amitriptyline hcl tab 10 mg.............................................. 33
amitriptyline hcl tab 100 mg............................................ 33
amitriptyline hcl tab 150 mg............................................ 33
amlodipine besylate-atorvastatin calcium tab 2.5-10
mg (Caduet)...................................................................... 20
mg (Caduet)...................................................................... 20
mg (Caduet)...................................................................... 20
amlodipine besylate-atorvastatin calcium tab 5-10 mg
(Caduet).............................................................................20
(Caduet).............................................................................20
(Caduet).............................................................................20
(Caduet).............................................................................20
(Caduet).............................................................................20
(Caduet).............................................................................20
(Caduet).............................................................................20
(Caduet).............................................................................21
amlodipine besylate-benazepril hcl cap 2.5-10 mg
(Lotrel)............................................................................... 21
amlodipine besylate-benazepril hcl cap 5-10 mg
(Lotrel)............................................................................... 21
(Lotrel)............................................................................... 21
(Lotrel)............................................................................... 21
(Lotrel)............................................................................... 21
(Lotrel)............................................................................... 21
amlodipine besylate tab 2.5 mg (Norvasc).................... 20
amlodipine besylate tab 5 mg (Norvasc)....................... 20
amlodipine besylate tab 10 mg (Norvasc)..................... 20
amlodipine besylate-valsartan tab 5-160 mg
(Exforge)........................................................................... 21
(Exforge)........................................................................... 21
(Exforge)........................................................................... 21
(Exforge)........................................................................... 21
amlodipine-valsartan-hydrochlorothiazide tab
5-160-12.5 mg (Exforge hct)........................................... 18
amlodipine-valsartan-hydrochlorothiazide tab 5-160-25
mg (Exforge hct)..............................................................18
10-160-12.5 mg (Exforge hct).........................................18
10-160-25 mg (Exforge hct)............................................ 18
63
2016
10-320-25 mg (Exforge hct)............................................ 18
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)................................................................. 29
amoxicillin (trihydrate) cap 250 mg.................................. 1
amoxicillin (trihydrate) cap 500 mg.................................. 1
amoxicillin (trihydrate) for susp 125 mg/5ml................... 1
amoxicillin (trihydrate) tab 500 mg................................... 1
amoxicillin (trihydrate) tab 875 mg................................... 1
amphetamine-dextroamphetamine cap sr 24hr 5 mg
(Adderall xr)..................................................................... 37
(Adderall xr)..................................................................... 37
(Adderall xr)..................................................................... 37
(Adderall xr)..................................................................... 37
(Adderall xr)..................................................................... 37
(Adderall xr)..................................................................... 37
amphetamine-dextroamphetamine tab 5 mg
(Adderall).......................................................................... 37
amphetamine-dextroamphetamine tab 7.5 mg
(Adderall).......................................................................... 37
(Adderall).......................................................................... 37
amphetamine-dextroamphetamine tab 12.5 mg
(Adderall).......................................................................... 37
(Adderall).......................................................................... 37
64
(Adderall).......................................................................... 38
(Adderall).......................................................................... 38
AMPICILLIN – ampicillin for susp 125 mg/5ml.................... 1
AMPICILLIN – ampicillin for susp 250 mg/5ml.................... 1
ampicillin cap 250 mg........................................................ 1
ampicillin cap 500 mg........................................................ 1
anagrelide hcl cap 1 mg.................................................. 50
anagrelide hcl cap 0.5 mg (Agrylin)............................... 50
anastrozole tab 1 mg (Arimidex).......................................7
ANDRODERM – testosterone td patch 24hr 2
mg/24hr.............................................................................. 11
ANDRODERM – testosterone td patch 24hr 4
mg/24hr.............................................................................. 11
ANDROGEL PUMP – testosterone td gel 20.25 mg/act
(1.62%)............................................................................... 11
ANDROGEL – testosterone td gel 20.25 mg/1.25gm
(1.62%)............................................................................... 11
ANDROGEL – testosterone td gel 40.5 mg/2.5gm
(1.62%)............................................................................... 11
ANDROXY – fluoxymesterone tab 10 mg.......................... 11
ANORO ELLIPTA – umeclidinium-vilanterol aero powd ba
62.5-25 mcg/inh................................................................. 27
antipyrine-benzocaine otic soln 54-14 mg/ml
(5.4-1.4%).......................................................................... 54
antipyrine-benzocaine-polycosanol otic sol
5.4-1.4-0.0097% (Treagan otic).......................................54
apraclonidine hcl ophth soln 0.5% (base equivalent)
(Iopidine)........................................................................... 53
APTIVUS – tipranavir cap 250 mg....................................... 5
APTIVUS – tipranavir oral soln 100 mg/ml.......................... 5
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25
mcg/ml................................................................................ 51
mcg/ml................................................................................ 51
mcg/ml................................................................................ 51
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj
100 mcg/ml........................................................................ 51
200 mcg/ml........................................................................ 51
300 mcg/ml........................................................................ 51
ARANESP ALBUMIN FREE – darbepoetin alfa soln
prefilled syringe 10 mcg/0.4ml.......................................... 50
prefilled syringe 25 mcg/0.42ml........................................ 50
2016
prefilled syringe 500 mcg/ml............................................. 51
aripiprazole oral solution 1 mg/ml.................................. 35
aripiprazole tab 2 mg (Abilify)......................................... 35
aripiprazole tab 5 mg (Abilify)......................................... 35
aripiprazole tab 10 mg (Abilify)....................................... 35
ARNUITY ELLIPTA – fluticasone furoate aerosol powder
breath activ 100 mcg/act.................................................. 27
ARNUITY ELLIPTA – fluticasone furoate aerosol powder
breath activ 200 mcg/act.................................................. 27
ASACOL HD – mesalamine tab delayed release 800
mg...................................................................................... 30
ASCENSIA AUTODISC LOW AND – blood glucose
ASCENSIA AUTODISC NORMAL – blood glucose
calibration - liquid - normal............................................... 59
ASCENSIA AUTODISC TEST ST – glucose blood test
disk..................................................................................... 59
ASMANEX HFA – mometasone furoate inhal aerosol
suspension 100 mcg/act................................................... 27
ASMANEX HFA – mometasone furoate inhal aerosol
suspension 200 mcg/act................................................... 27
ASMANEX TWISTHALER 120 ME – mometasone furoate
inhal powd 220 mcg/inh (breath activated)...................... 27
ASMANEX TWISTHALER 14 MET – mometasone furoate
inhal powd 110 mcg/inh (breath activated)....................... 27
ASTEPRO – azelastine hcl nasal spray 0.15% (205.5 mcg/
spray)................................................................................. 26
atenolol & chlorthalidone tab 50-25 mg (Tenoretic
50)...................................................................................... 19
atenolol & chlorthalidone tab 100-25 mg (Tenoretic
100).................................................................................... 19
atenolol tab 25 mg (Tenormin)........................................ 19
atenolol tab 50 mg (Tenormin)........................................ 19
atenolol tab 100 mg (Tenormin)...................................... 19
atorvastatin calcium tab 10 mg (base equivalent)
(Lipitor).............................................................................. 22
(Lipitor).............................................................................. 22
(Lipitor).............................................................................. 22
(Lipitor).............................................................................. 23
atovaquone-proguanil hcl tab 62.5-25 mg
(Malarone)........................................................................... 6
atovaquone-proguanil hcl tab 250-100 mg
(Malarone)........................................................................... 6
atovaquone susp 750 mg/5ml (Mepron)...........................7
ATRIPLA – efavirenz-emtricitabine-tenofovir df tab
600-200-300 mg.................................................................. 5
ATROPINE SULFATE – atropine sulfate ophth oint
1%...................................................................................... 53
atropine sulfate ophth soln 1% (Isopto atropine)......... 53
ATROVENT HFA – ipratropium bromide hfa inhal aerosol
17 mcg/act......................................................................... 27
AUGMENTIN – amoxicillin & k clavulanate for susp
125-31.25 mg/5ml............................................................... 1
AVODART – dutasteride cap 0.5 mg................................. 32
azathioprine tab 50 mg (Imuran)..................................... 60
azelastine hcl nasal spray 0.1% (137 mcg/spray)......... 26
azelastine hcl nasal spray 0.15% (205.5 mcg/spray)
(Astepro)........................................................................... 26
azelastine hcl ophth soln 0.05% (Optivar)..................... 53
AZILECT – rasagiline mesylate tab 0.5 mg (base
equiv)................................................................................. 47
AZILECT – rasagiline mesylate tab 1 mg (base equiv)......47
AZITHROMYCIN – azithromycin powd pack for susp 1
gm........................................................................................ 2
azithromycin for susp 100 mg/5ml (Zithromax).............. 2
azithromycin for susp 200 mg/5ml (Zithromax).............. 2
azithromycin tab 250 mg (Zithromax).............................. 2
AZOPT – brinzolamide ophth susp 1%.............................. 53
B
BACITRACIN – bacitracin ophth oint 500 unit/gm............. 52
bacitracin-polymyxin b ophth oint..................................52
bacitracin-polymyxin-neomycin-hc ophth oint 1%....... 52
baclofen tab 10 mg........................................................... 48
baclofen tab 20 mg........................................................... 48
BACTROBAN NASAL – mupirocin calcium nasal oint
2%...................................................................................... 26
balsalazide disodium cap 750 mg (Colazal).................. 30
BARACLUDE – entecavir oral soln 0.05 mg/ml................... 4
BAYER BREEZE 2 BLOOD GLUC – blood glucose
BAYER BREEZE 2 HIGH CONTR – blood glucose
calibration - liquid - high................................................... 59
BAYER BREEZE 2 LOW CONTRO – blood glucose
calibration - liquid - low..................................................... 59
BAYER BREEZE 2 NORMAL CON – blood glucose
BAYER BREEZE 2 TEST DISC – glucose blood test
disk..................................................................................... 59
BAYER CONTOUR BLOOD GLUCO – blood glucose
monitoring devices............................................................ 59
BAYER CONTOUR BLOOD GLUCO – blood glucose
65
2016
BAYER CONTOUR BLOOD GLUCO – glucose blood test
strip.....................................................................................59
BAYER CONTOUR HIGH CONTRO – blood glucose
calibration - liquid - high................................................... 59
BAYER CONTOUR LINK BLOOD – blood glucose
BAYER CONTOUR LOW CONTROL – blood glucose
BAYER CONTOUR NEXT BLOOD – blood glucose
BAYER CONTOUR NEXT BLOOD – glucose blood test
strip.....................................................................................59
BAYER CONTOUR NEXT CONTRO – blood glucose
BAYER CONTOUR NEXT CONTRO – blood glucose
BAYER CONTOUR NEXT EZ BLO – blood glucose
BAYER CONTOUR NEXT LINK B – blood glucose
BAYER CONTOUR NEXT LINK W – blood glucose
BAYER CONTOUR NEXT USB BL – blood glucose
BAYER CONTOUR NORMAL CONT – blood glucose
BAYER CONTOUR USB BLOOD G – blood glucose
benazepril & hydrochlorothiazide tab 5-6.25 mg.......... 17
benazepril & hydrochlorothiazide tab 10-12.5 mg
(Lotensin hct)................................................................... 17
benazepril & hydrochlorothiazide tab 20-12.5 mg
(Lotensin hct)................................................................... 17
benazepril & hydrochlorothiazide tab 20-25 mg
(Lotensin hct)................................................................... 17
benazepril hcl tab 5 mg................................................... 17
benazepril hcl tab 10 mg (Lotensin)............................... 17
benzoyl peroxide-erythromycin gel 5-3%
(Benzamycin)....................................................................54
benztropine mesylate tab 0.5 mg....................................47
benztropine mesylate tab 1 mg.......................................47
benztropine mesylate tab 2 mg.......................................47
betamethasone dipropionate augmented cream 0.05%
(Diprolene af)................................................................... 56
betamethasone dipropionate augmented gel
0.05%................................................................................. 56
betamethasone dipropionate augmented lotion 0.05%
(Diprolene)........................................................................ 56
betamethasone dipropionate augmented oint 0.05%
(Diprolene)........................................................................ 56
betamethasone dipropionate cream 0.05%................... 56
betamethasone dipropionate lotion 0.05%.................... 56
betamethasone dipropionate oint 0.05%....................... 56
66
betamethasone valerate aerosol foam 0.12%
(Luxiq)............................................................................... 56
betamethasone valerate cream 0.1%............................. 56
betamethasone valerate lotion 0.1%.............................. 56
betamethasone valerate oint 0.1%................................. 56
BETASERON – interferon beta-1b for inj kit 0.3 mg.......... 39
betaxolol hcl ophth soln 0.5%.........................................53
betaxolol hcl tab 10 mg (Kerlone).................................. 19
betaxolol hcl tab 20 mg (Kerlone).................................. 19
bethanechol chloride tab 5 mg (Urecholine)................. 31
bethanechol chloride tab 10 mg (Urecholine)............... 31
bexarotene cap 75 mg (Targretin)..................................... 7
bicalutamide tab 50 mg (Casodex)................................... 7
BILTRICIDE – praziquantel tab 600 mg............................... 7
bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln
kit....................................................................................... 28
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
(Ziac).................................................................................. 19
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
(Ziac).................................................................................. 19
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
(Ziac).................................................................................. 19
bisoprolol fumarate tab 5 mg (Zebeta)...........................19
bisoprolol fumarate tab 10 mg (Zebeta).........................19
BOSULIF – bosutinib tab 100 mg........................................ 7
BOSULIF – bosutinib tab 500 mg........................................ 7
BP CLEANSING WASH – sulfacetamide sodium-sulfur in
urea emulsion 10-4%........................................................ 54
BREEZE 2 BLOOD GLUCOSE MO – blood glucose
monitoring devices............................................................ 59
BREO ELLIPTA – fluticasone furoate-vilanterol aero powd
ba 100-25 mcg/inh............................................................ 27
BREO ELLIPTA – fluticasone furoate-vilanterol aero powd
ba 200-25 mcg/inh............................................................ 27
brimonidine tartrate ophth soln 0.2%.............................53
brimonidine tartrate ophth soln 0.15% (Alphagan
p)........................................................................................ 53
bromfenac sodium ophth soln 0.09% (base
equivalent)........................................................................ 53
bromfenac sodium ophth soln 0.09% (base equiv)
(once-daily)....................................................................... 53
bromocriptine mesylate cap 5 mg (Parlodel)................ 47
bromocriptine mesylate tab 2.5 mg (Parlodel).............. 47
budesonide cap sr 24hr 3 mg (Entocort ec).................. 10
(Pulmicort)........................................................................ 27
(Pulmicort)........................................................................ 27
budesonide inhalation susp 1 mg/2ml (Pulmicort)....... 27
budesonide nasal susp 32 mcg/act (Rhinocort
aqua).................................................................................. 26
bumetanide tab 0.5 mg.................................................... 24
bumetanide tab 1 mg........................................................24
bumetanide tab 2 mg........................................................24
2016
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base
equiv)................................................................................. 60
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
equiv)................................................................................. 60
buprenorphine hcl sl tab 2 mg (base equiv)................. 41
buprenorphine hcl sl tab 8 mg (base equiv)................. 41
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
(Zyban).............................................................................. 39
bupropion hcl tab 75 mg (Wellbutrin)............................ 33
bupropion hcl tab 100 mg (Wellbutrin).......................... 33
bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr)......... 33
bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl)......... 33
bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl)......... 33
buspirone hcl tab 5 mg.................................................... 33
buspirone hcl tab 7.5 mg................................................. 33
buspirone hcl tab 10 mg.................................................. 33
butalbital-acetaminophen-caffeine cap 50-325-40
mg...................................................................................... 40
butalbital-acetaminophen-caffeine cap 50-300-40 mg
(Fioricet)............................................................................ 40
butalbital-acetaminophen-caffeine tab 50-325-40
mg...................................................................................... 40
butalbital-acetaminophen-caff w/ cod cap 50-325-40-30
mg...................................................................................... 41
butalbital-acetaminophen-caff w/ cod cap 50-300-40-30
mg (Fioricet/codeine)...................................................... 41
butalbital-acetaminophen tab 50-325 mg.......................40
butalbital-aspirin-caffeine cap 50-325-40 mg
(Fiorinal)............................................................................ 40
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
(Fiorinal/codeine #3)....................................................... 41
butorphanol tartrate nasal soln 10 mg/ml..................... 41
BYDUREON – exenatide extended release for inj susp 2
mg...................................................................................... 14
BYDUREON – exenatide extended release for susp peninjector 2 mg...................................................................... 13
BYETTA – exenatide soln pen-injector 5 mcg/0.02ml........ 14
BYETTA – exenatide soln pen-injector 10 mcg/0.04ml...... 14
C
cabergoline tab 0.5 mg.................................................... 16
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base
equiv) (Cafcit)...................................................................38
calcipotriene cream 0.005% (Dovonex).......................... 58
calcipotriene oint 0.005%................................................. 58
calcipotriene soln 0.005% (50 mcg/ml).......................... 58
calcitonin (salmon) nasal soln 200 unit/act
(Miacalcin)........................................................................ 16
calcitriol cap 0.25 mcg (Rocaltrol).................................. 16
calcitriol cap 0.5 mcg (Rocaltrol).................................... 16
calcitriol oral soln 1 mcg/ml (Rocaltrol)......................... 16
calcium acetate (phosphate binder) cap 667 mg (169
mg ca) (Phoslo)............................................................... 30
calcium acetate (phosphate binder) tab 667 mg
(Eliphos)............................................................................ 30
CANASA – mesalamine suppos 1000 mg......................... 30
candesartan cilexetil-hydrochlorothiazide tab 16-12.5
mg (Atacand hct)............................................................. 18
candesartan cilexetil-hydrochlorothiazide tab 32-12.5
mg (Atacand hct)............................................................. 18
candesartan cilexetil-hydrochlorothiazide tab 32-25
mg (Atacand hct)............................................................. 18
candesartan cilexetil tab 4 mg (Atacand)...................... 18
candesartan cilexetil tab 8 mg (Atacand)...................... 18
candesartan cilexetil tab 16 mg (Atacand).................... 18
candesartan cilexetil tab 32 mg (Atacand).................... 18
capecitabine tab 150 mg (Xeloda).................................... 7
capecitabine tab 500 mg (Xeloda).................................... 7
CAPRELSA – vandetanib tab 100 mg................................. 7
CAPRELSA – vandetanib tab 300 mg................................. 7
CAPTOPRIL/HYDROCHLOROTHIA – captopril &
hydrochlorothiazide tab 25-15 mg.................................... 17
captopril tab 12.5 mg........................................................17
captopril tab 25 mg...........................................................17
captopril tab 50 mg...........................................................17
captopril tab 100 mg.........................................................17
CARAC – fluorouracil cream 0.5%..................................... 58
CARAFATE – sucralfate susp 1 gm/10ml.......................... 29
carbamazepine cap sr 12hr 100 mg (Carbatrol)............ 45
carbamazepine chew tab 100 mg................................... 45
carbamazepine susp 100 mg/5ml (Tegretol).................. 45
carbamazepine tab 200 mg (Tegretol)............................ 45
carbamazepine tab sr 12hr 200 mg (Tegretol-xr).......... 45
carbamazepine tab sr 12hr 400 mg (Tegretol-xr).......... 45
CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopaentacapone tabs 12.5-50-200 mg.....................................47
CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopaentacapone tabs 18.75-75-200 mg...................................48
CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopaentacapone tabs 25-100-200 mg......................................48
CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopaentacapone tabs 31.25-125-200 mg................................ 48
CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopaentacapone tabs 37.5-150-200 mg...................................48
CARBIDOPA/LEVODOPA/ENTACA – carbidopa-levodopaentacapone tabs 50-200-200 mg......................................48
carbidopa & levodopa orally disintegrating tab 10-100
mg...................................................................................... 47
67
2016
mg...................................................................................... 47
mg...................................................................................... 47
carbidopa & levodopa tab cr 25-100 mg (Sinemet
cr)....................................................................................... 47
carbidopa & levodopa tab cr 50-200 mg (Sinemet
cr)....................................................................................... 47
carbidopa & levodopa tab 10-100 mg (Sinemet)........... 47
carbidopa tab 25 mg (Lodosyn)...................................... 47
carteolol hcl ophth soln 1%............................................ 53
carvedilol tab 3.125 mg (Coreg)...................................... 19
carvedilol tab 6.25 mg (Coreg)........................................ 19
carvedilol tab 12.5 mg (Coreg)........................................ 19
carvedilol tab 25 mg (Coreg)........................................... 19
cefaclor cap 250 mg........................................................... 1
cefaclor cap 500 mg........................................................... 1
cefadroxil cap 500 mg........................................................ 1
cefadroxil for susp 250 mg/5ml........................................ 1
cefadroxil for susp 500 mg/5ml........................................ 1
cefadroxil tab 1 gm............................................................. 1
cefdinir cap 300 mg............................................................ 1
cefdinir for susp 125 mg/5ml............................................ 1
cefdinir for susp 250 mg/5ml............................................ 1
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..................... 1
cefpodoxime proxetil tab 100 mg..................................... 1
cefpodoxime proxetil tab 200 mg..................................... 1
cefprozil for susp 125 mg/5ml...........................................2
cefprozil for susp 250 mg/5ml...........................................2
cefprozil tab 250 mg........................................................... 2
cefprozil tab 500 mg........................................................... 2
CEFTIN – cefuroxime axetil for susp 125 mg/5ml............... 2
ceftriaxone sodium for inj 10 gm......................................2
cefuroxime axetil tab 250 mg (Ceftin).............................. 2
cefuroxime axetil tab 500 mg (Ceftin).............................. 2
celecoxib cap 50 mg (Celebrex)......................................43
celecoxib cap 100 mg (Celebrex)....................................43
CELONTIN – methsuximide cap 300 mg........................... 45
cephalexin cap 250 mg (Keflex)........................................ 2
cephalexin for susp 125 mg/5ml....................................... 2
cephalexin for susp 250 mg/5ml....................................... 2
CETROTIDE – cetrorelix acetate for inj kit 0.25 mg.......... 13
cevimeline hcl cap 30 mg (Evoxac)................................ 54
CHANTIX CONTINUING MONTH – varenicline tartrate tab
1 mg (base equiv)............................................................. 39
CHANTIX STARTING MONTH PA – varenicline tartrate
tab 0.5 mg x 11 & tab 1 mg x 42 pack............................. 39
68
CHANTIX – varenicline tartrate tab 0.5 mg (base
equiv)................................................................................. 39
CHANTIX – varenicline tartrate tab 1 mg (base equiv)...... 39
CHEMET – succimer cap 100 mg......................................60
CHEMSTRIP-K – acetone (urine) test strip....................... 60
CHEMSTRIP UGK – urine glucose-ketones test strips..... 59
CHENODAL – chenodiol tab 250 mg.................................30
chlordiazepoxide hcl cap 5 mg....................................... 33
chlordiazepoxide hcl cap 10 mg..................................... 33
chlordiazepoxide hcl cap 25 mg..................................... 33
chlorhexidine gluconate soln 0.12% (Peridex).............. 54
chloroquine phosphate tab 250 mg..................................6
chloroquine phosphate tab 500 mg (Aralen)................... 6
CHLOROTHIAZIDE – chlorothiazide tab 250 mg.............. 24
chlorothiazide tab 500 mg............................................... 24
chlorpromazine hcl tab 10 mg........................................ 35
chlorpromazine hcl tab 100 mg...................................... 35
chlorpromazine hcl tab 200 mg...................................... 35
CHLORTHALIDONE – chlorthalidone tab 25 mg.............. 24
CHLORTHALIDONE – chlorthalidone tab 50 mg.............. 24
chlorzoxazone tab 500 mg (Parafon forte dsc)............. 48
cholestyramine light powder 4 gm/dose (Questran
light)...................................................................................23
cholestyramine light powder packets 4 gm.................. 23
cholestyramine powder 4 gm/dose (Questran)............. 23
cholestyramine powder packets 4 gm (Questran)........ 23
choline & magnesium salicylates liq 500 mg/5ml......... 40
choline fenofibrate cap dr 45 mg (fenofibric acid
equiv) (Trilipix)................................................................. 23
choline fenofibrate cap dr 135 mg (fenofibric acid
equiv) (Trilipix)................................................................. 23
chorionic gonadotropin for inj 10000 unit..................... 13
ciclopirox gel 0.77% (Loprox)......................................... 55
ciclopirox olamine cream 0.77% (base equiv)...............55
ciclopirox olamine susp 0.77% (base equiv)................. 55
ciclopirox shampoo 1% (Loprox shampoo).................. 56
ciclopirox solution kit 8% (Ciclodan solution ki).......... 56
ciclopirox solution 8% (Penlac nail lacquer)................. 56
cilostazol tab 50 mg (Pletal)............................................ 51
cilostazol tab 100 mg (Pletal).......................................... 51
CILOXAN – ciprofloxacin hcl ophth oint 0.3%................... 52
cimetidine hcl soln 300 mg/5ml...................................... 29
cimetidine tab 200 mg...................................................... 29
CIPRODEX – ciprofloxacin-dexamethasone otic susp
0.3-0.1%............................................................................. 54
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000
mg(base eq) (Cipro xr)..................................................... 3
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg
(base eq) (Cipro xr)........................................................... 3
ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml) (Cipro).............................................................. 3
2016
ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml) (Cipro).............................................................. 3
CIPROFLOXACIN HCL – ciprofloxacin hcl tab 100 mg
(base equiv)......................................................................... 3
ciprofloxacin hcl ophth soln 0.3% (Ciloxan)................. 52
ciprofloxacin hcl tab 750 mg (base equiv).......................3
ciprofloxacin hcl tab 250 mg (base equiv) (Cipro).......... 3
ciprofloxacin hcl tab 500 mg (base equiv) (Cipro).......... 3
CIPRO HC – ciprofloxacin-hydrocortisone otic susp
0.2-1%................................................................................ 54
citalopram hydrobromide oral soln 10 mg/5ml............. 33
citalopram hydrobromide tab 10 mg (base equiv)
(Celexa)............................................................................. 33
(Celexa)............................................................................. 33
(Celexa)............................................................................. 33
clarithromycin for susp 125 mg/5ml.................................2
clarithromycin for susp 250 mg/5ml (Biaxin).................. 2
clarithromycin tab 250 mg (Biaxin).................................. 2
clarithromycin tab 500 mg (Biaxin).................................. 2
clarithromycin tab sr 24hr 500 mg (Biaxin xl pac).......... 2
CLEOCIN – clindamycin phosphate vaginal suppos 100
mg...................................................................................... 32
CLIMARA PRO – estradiol-levonorgestrel td patch weekly
0.045-0.015 mg/day.......................................................... 11
clindamycin hcl cap 75 mg (Cleocin)............................... 7
clindamycin hcl cap 150 mg (Cleocin)............................. 7
clindamycin hcl cap 300 mg (Cleocin)............................. 7
clindamycin palmitate hcl for soln 75 mg/5ml (base
equiv) (Cleocin pediatric gr)............................................ 7
clindamycin phosphate-benzoyl peroxide gel 1-5%
(Benzaclin)........................................................................ 55
clindamycin phosphate foam 1% (Evoclin)................... 54
clindamycin phosphate gel 1% (Cleocin-t).................... 54
clindamycin phosphate lotion 1% (Cleocin-t)............... 54
clindamycin phosphate soln 1% (Cleocin-t).................. 55
clindamycin phosphate swab 1% (Cleocin-t)................ 55
clindamycin phosphate vaginal cream 2%
(Cleocin)............................................................................ 32
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2
(1)-5% (Duac)....................................................................54
clobetasol propionate cream 0.05% (Temovate)........... 56
clobetasol propionate emollient base cream 0.05%
(Temovate e)..................................................................... 56
clobetasol propionate emulsion foam 0.05% (Oluxe)........................................................................................ 56
clobetasol propionate foam 0.05% (Olux)......................56
clobetasol propionate gel 0.05% (Temovate)................ 56
clobetasol propionate lotion 0.05% (Clobex)................ 56
clobetasol propionate oint 0.05% (Temovate)............... 56
clobetasol propionate shampoo 0.05% (Clobex).......... 56
clobetasol propionate soln 0.05% (Temovate).............. 56
clomiphene citrate tab 50 mg (Clomid).......................... 13
clomipramine hcl cap 25 mg (Anafranil)........................ 33
clonazepam orally disintegrating tab 0.125 mg............ 45
clonazepam orally disintegrating tab 0.25 mg.............. 46
clonazepam orally disintegrating tab 0.5 mg................ 46
clonazepam orally disintegrating tab 1 mg................... 46
clonazepam orally disintegrating tab 2 mg................... 46
clonazepam tab 0.5 mg (Klonopin)................................. 46
clonazepam tab 1 mg (Klonopin).................................... 46
clonazepam tab 2 mg (Klonopin).................................... 46
clonidine hcl tab 0.1 mg (Catapres)............................... 25
clonidine hcl tab sr 12hr 0.1 mg (Kapvay)..................... 38
clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1)...................................................................................25
clopidogrel bisulfate tab 75 mg (base equiv)
(Plavix).............................................................................. 51
clopidogrel bisulfate tab 300 mg (base equiv)
(Plavix).............................................................................. 51
clorazepate dipotassium tab 3.75 mg (Tranxene t)....... 33
clorazepate dipotassium tab 7.5 mg (Tranxene t)......... 33
clorazepate dipotassium tab 15 mg (Tranxene t).......... 33
clotrimazole troche 10 mg............................................... 54
clotrimazole w/ betamethasone cream 1-0.05%
(Lotrisone)........................................................................ 56
clotrimazole w/ betamethasone lotion 1-0.05%............. 56
clozapine tab 50 mg......................................................... 35
clozapine tab 200 mg....................................................... 35
clozapine tab 25 mg (Clozaril).........................................35
clozapine tab 100 mg (Clozaril).......................................35
COARTEM – artemether-lumefantrine tab 20-120 mg........ 6
codeine sulfate tab 30 mg............................................... 41
codeine sulfate tab 60 mg............................................... 41
codeine sulfate tab 15 mg (Codeine sulfate)................. 41
colchicine w/ probenecid tab 0.5-500 mg...................... 45
colestipol hcl granule packets 5 gm (Colestid
flavored)............................................................................ 23
colestipol hcl granules 5 gm (Colestid flavored).......... 23
colestipol hcl tab 1 gm (Colestid)...................................23
COMBIVENT RESPIMAT – ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act............................................ 27
COMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60
mg dose) kit......................................................................... 7
COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20
mg (100 dose) kit................................................................ 7
COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20
mg (140 dose) kit................................................................ 7
COMPLERA – emtricitabine-rilpivirine-tenofovir df tab
200-25-300 mg.................................................................... 5
COPAXONE – glatiramer acetate soln prefilled syringe 20
mg/ml..................................................................................39
69
2016
COPAXONE – glatiramer acetate soln prefilled syringe 40
mg/ml..................................................................................39
CORTANE-B AQUEOUS – pramoxine-hc-chloroxylenol
aqueous otic soln 10-10-1 mg/ml..................................... 54
CORTIFOAM – hydrocortisone acetate rectal foam 10%
(90 mg/dose)..................................................................... 54
CORTISONE ACETATE – cortisone acetate tab 25
mg...................................................................................... 10
CREON – pancrelipase (lip-prot-amyl) dr cap
3000-9500-15000 unit....................................................... 30
6000-19000-30000 unit..................................................... 30
12000-38000-60000 unit................................................... 30
24000-76000-120000 unit................................................. 30
36000-114000-180000 unit............................................... 30
CRESTOR – rosuvastatin calcium tab 5 mg...................... 23
CRESTOR – rosuvastatin calcium tab 10 mg.................... 23
CRIXIVAN – indinavir sulfate cap 200 mg........................... 5
CRIXIVAN – indinavir sulfate cap 400 mg........................... 5
CROMOLYN SODIUM – cromolyn sodium soln nebu 20
mg/2ml............................................................................... 27
cromolyn sodium ophth soln 4%....................................53
cromolyn sodium oral conc 100 mg/5ml
(Gastrocrom).................................................................... 30
CUPRIMINE – penicillamine cap 250 mg.......................... 60
cyclobenzaprine hcl tab 5 mg......................................... 48
cyclobenzaprine hcl tab 10 mg....................................... 48
cyclobenzaprine hcl tab 7.5 mg (Fexmid)...................... 48
cyclopentolate hcl ophth soln 1% (Cyclogyl)................ 53
cyclopentolate hcl ophth soln 2% (Cyclogyl)................ 53
CYCLOPHOSPHAMIDE – cyclophosphamide cap 25
mg........................................................................................ 8
CYCLOPHOSPHAMIDE – cyclophosphamide cap 50
mg........................................................................................ 8
cyclosporine cap 25 mg (Sandimmune)........................ 60
cyclosporine cap 100 mg (Sandimmune)...................... 60
cyclosporine modified cap 25 mg (Neoral).................... 60
cyclosporine modified cap 100 mg (Neoral).................. 60
cyclosporine modified oral soln 100 mg/ml
(Neoral)..............................................................................60
cyproheptadine hcl syrup 2 mg/5ml............................... 26
cyproheptadine hcl tab 4 mg.......................................... 26
CYSTAGON – cysteamine bitartrate cap 50 mg................ 32
CYSTAGON – cysteamine bitartrate cap 150 mg.............. 32
CYTRA-3 – pot & sod citrates w/ cit ac syrup 550-500-334
mg/5ml............................................................................... 32
D
DAKLINZA – daclatasvir dihydrochloride tab 30 mg (base
equivalent)............................................................................4
70
DAKLINZA – daclatasvir dihydrochloride tab 60 mg (base
equivalent)............................................................................4
danazol cap 50 mg............................................................11
danazol cap 100 mg..........................................................11
danazol cap 200 mg..........................................................11
dantrolene sodium cap 25 mg (Dantrium)..................... 48
dantrolene sodium cap 50 mg (Dantrium)..................... 48
DANTROLENE SODIUM – dantrolene sodium cap 100
mg...................................................................................... 48
DAPSONE – dapsone tab 25 mg.........................................7
DAPSONE – dapsone tab 100 mg.......................................7
DARAPRIM – pyrimethamine tab 25 mg............................. 6
DELZICOL – mesalamine cap dr 400 mg.......................... 30
demeclocycline hcl tab 150 mg........................................ 2
demeclocycline hcl tab 300 mg........................................ 2
desipramine hcl tab 10 mg (Norpramin)........................ 33
desipramine hcl tab 100 mg (Norpramin)...................... 34
desipramine hcl tab 150 mg (Norpramin)...................... 34
desloratadine tab 5 mg (Clarinex).................................. 26
desloratadine tab orally disintegrating 2.5 mg
(Clarinex reditabs)........................................................... 26
desloratadine tab orally disintegrating 5 mg (Clarinex
reditabs)............................................................................ 26
desmopressin acetate nasal soln 0.01% (refrigerated)
(Ddavp).............................................................................. 16
desmopressin acetate nasal spray soln 0.01%
(Ddavp).............................................................................. 16
desmopressin acetate nasal spray soln 0.01%
(refrigerated).....................................................................16
desmopressin acetate tab 0.1 mg (Ddavp).................... 16
desmopressin acetate tab 0.2 mg (Ddavp).................... 16
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01
mg(21/5) (Mircette).......................................................... 12
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg (Cyclessa)..... 12
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg
(Desogen)......................................................................... 12
desonide cream 0.05% (Desowen)................................. 56
desonide lotion 0.05% (Desowen).................................. 56
desonide oint 0.05% (Desowen)......................................56
desoximetasone cream 0.25% (Topicort)....................... 57
DESOXIMETASONE – desoximetasone cream 0.05%..... 57
desoximetasone gel 0.05% (Topicort)............................ 57
desoximetasone oint 0.25% (Topicort)........................... 57
DEXAMETHASONE – dexamethasone soln 0.5
mg/5ml............................................................................... 10
DEXAMETHASONE – dexamethasone tab 1 mg.............. 10
DEXAMETHASONE – dexamethasone tab 2 mg.............. 10
dexamethasone elixir 0.5 mg/5ml................................... 10
DEXAMETHASONE INTENSOL – dexamethasone conc 1
mg/ml..................................................................................10
DEXAMETHASONE SODIUM PHOS – dexamethasone
sodium phosphate ophth soln 0.1%................................. 52
2016
dexamethasone tab 0.5 mg............................................. 10
dexamethasone tab 0.75 mg........................................... 10
dexamethasone tab 1.5 mg............................................. 10
dexamethasone tab 4 mg................................................ 10
dexamethasone tab 6 mg................................................ 10
dexmethylphenidate hcl cap sr 24 hr 5 mg (Focalin
xr)....................................................................................... 38
xr)....................................................................................... 38
xr)....................................................................................... 38
xr)....................................................................................... 38
dexmethylphenidate hcl tab 2.5 mg (Focalin)............... 38
dexmethylphenidate hcl tab 5 mg (Focalin).................. 38
dexmethylphenidate hcl tab 10 mg (Focalin)................ 38
dextroamphetamine sulfate cap sr 24hr 5 mg
(Dexedrine)....................................................................... 38
(Dexedrine)....................................................................... 38
(Dexedrine)....................................................................... 38
dextroamphetamine sulfate oral solution 5 mg/5ml
(Procentra)........................................................................ 38
dextroamphetamine sulfate tab 5 mg.............................38
dextroamphetamine sulfate tab 10 mg...........................38
DIASTAT ACUDIAL – diazepam rectal gel delivery system
10 mg................................................................................. 46
DIASTAT ACUDIAL – diazepam rectal gel delivery system
20 mg................................................................................. 46
DIASTAT PEDIATRIC – diazepam rectal gel delivery
system 2.5 mg................................................................... 46
DIAZEPAM – diazepam soln 1 mg/ml................................ 33
diazepam tab 2 mg (Valium)............................................ 33
diazepam tab 5 mg (Valium)............................................ 33
diazepam tab 10 mg (Valium).......................................... 33
diclofenac potassium tab 50 mg (Cataflam).................. 43
diclofenac sodium (actinic keratoses) gel 3%
(Solaraze).......................................................................... 58
diclofenac sodium ophth soln 0.1%............................... 53
diclofenac sodium soln 1.5% (Pennsaid).......................56
diclofenac sodium tab delayed release 25 mg.............. 43
diclofenac sodium tab sr 24hr 100 mg (Voltarenxr)....................................................................................... 43
diclofenac w/ misoprostol tab delayed release 50-0.2
mg (Arthrotec 50)............................................................ 43
diclofenac w/ misoprostol tab delayed release 75-0.2
mg (Arthrotec 75)............................................................ 43
dicloxacillin sodium cap 250 mg...................................... 1
dicloxacillin sodium cap 500 mg...................................... 1
dicyclomine hcl cap 10 mg (Bentyl)............................... 29
dicyclomine hcl oral soln 10 mg/5ml............................. 29
dicyclomine hcl tab 20 mg (Bentyl)................................ 29
didanosine delayed release capsule 125 mg (Videx
ec)........................................................................................ 5
ec)........................................................................................ 5
ec)........................................................................................ 5
ec)........................................................................................ 5
DIDGET – blood glucose monitoring kit w/ device............. 60
DIFLORASONE DIACETATE – diflorasone diacetate
cream 0.05%..................................................................... 57
DIFLORASONE DIACETATE – diflorasone diacetate oint
0.05%................................................................................. 57
diflunisal tab 500 mg........................................................ 40
DIGOXIN – digoxin oral soln 0.05 mg/ml........................... 25
digoxin tab 125 mcg (0.125 mg) (Lanoxin).................... 25
digoxin tab 250 mcg (0.25 mg) (Lanoxin)...................... 25
DILANTIN – phenytoin sodium extended cap 30 mg......... 46
DILANTIN – phenytoin sodium extended cap 100 mg....... 46
DILANTIN-125 – phenytoin susp 125 mg/5ml................... 46
diltiazem hcl cap sr 12hr 60 mg......................................21
diltiazem hcl cap sr 12hr 90 mg......................................21
diltiazem hcl cap sr 12hr 120 mg....................................21
diltiazem hcl coated beads cap sr 24hr 120 mg
(Cardizem cd)................................................................... 21
(Cardizem cd)................................................................... 21
(Cardizem cd)................................................................... 21
(Cardizem cd)................................................................... 21
(Cardizem cd)................................................................... 21
diltiazem hcl coated beads tab sr 24hr 180 mg
(Cardizem la).................................................................... 21
(Cardizem la).................................................................... 21
(Cardizem la).................................................................... 21
(Cardizem la).................................................................... 21
(Cardizem la).................................................................... 21
diltiazem hcl extended release beads cap sr 24hr 120
mg (Tiazac)....................................................................... 21
mg (Tiazac)....................................................................... 21
mg (Tiazac)....................................................................... 21
mg (Tiazac)....................................................................... 21
mg (Tiazac)....................................................................... 21
71
2016
mg (Tiazac)....................................................................... 21
diltiazem hcl tab 90 mg.................................................... 21
diltiazem hcl tab 30 mg (Cardizem)................................ 21
diltiazem hcl tab 60 mg (Cardizem)................................ 21
diltiazem hcl tab 120 mg (Cardizem).............................. 21
DIPHENOXYLATE/ATROPINE – diphenoxylate w/
atropine liq 2.5-0.025 mg/5ml........................................... 28
diphenoxylate w/ atropine tab 2.5-0.025 mg
(Lomotil)............................................................................ 28
dipyridamole tab 25 mg (Persantine)............................. 51
disopyramide phosphate cap 100 mg (Norpace).......... 24
disopyramide phosphate cap 150 mg (Norpace).......... 24
disulfiram tab 250 mg (Antabuse).................................. 39
disulfiram tab 500 mg (Antabuse).................................. 39
divalproex sodium cap sprinkle 125 mg (Depakote
sprinkles).......................................................................... 46
divalproex sodium tab delayed release 125 mg
(Depakote)........................................................................ 46
(Depakote)........................................................................ 46
(Depakote)........................................................................ 46
divalproex sodium tab sr 24 hr 250 mg (Depakote
er)....................................................................................... 46
divalproex sodium tab sr 24 hr 500 mg (Depakote
er)....................................................................................... 46
DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%)........... 11
DIVIGEL – estradiol td gel 0.5 mg/0.5gm (0.1%)............... 11
DIVIGEL – estradiol td gel 1 mg/gm (0.1%).......................11
donepezil hydrochloride orally disintegrating tab 5 mg
(Aricept odt)..................................................................... 39
donepezil hydrochloride orally disintegrating tab 10
mg (Aricept odt).............................................................. 40
donepezil hydrochloride tab 5 mg (Aricept).................. 40
donepezil hydrochloride tab 10 mg (Aricept)................ 40
donepezil hydrochloride tab 23 mg (Aricept)................ 40
dorzolamide hcl ophth soln 2% (Trusopt)..................... 53
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8
mg/ml (Cosopt)................................................................ 53
doxazosin mesylate tab 1 mg (Cardura)........................ 25
doxepin hcl cap 10 mg..................................................... 34
doxepin hcl cap 100 mg................................................... 34
doxepin hcl cap 150 mg................................................... 34
doxepin hcl conc 10 mg/ml............................................. 34
DOXEPIN HCL – doxepin hcl cap 75 mg.......................... 34
doxercalciferol cap 0.5 mcg (Hectorol).......................... 16
doxercalciferol cap 1 mcg (Hectorol)............................. 16
doxercalciferol cap 2.5 mcg (Hectorol).......................... 16
72
doxycycline hyclate cap 50 mg.........................................2
doxycycline hyclate cap 100 mg (Vibramycin)................ 2
doxycycline hyclate tab delayed release 75 mg............. 2
doxycycline hyclate tab delayed release 100 mg........... 2
doxycycline hyclate tab delayed release 150 mg
(Doryx)................................................................................. 2
doxycycline hyclate tab 20 mg......................................... 2
doxycycline hyclate tab 100 mg....................................... 2
doxycycline monohydrate cap 50 mg.............................. 2
doxycycline monohydrate cap 150 mg (Adoxa).............. 3
doxycycline monohydrate cap 75 mg (Monodox)........... 2
doxycycline monohydrate cap 100 mg (Monodox)......... 2
doxycycline monohydrate for susp 25 mg/5ml
(Vibramycin)....................................................................... 3
doxycycline monohydrate tab 50 mg (Adoxa)................ 3
doxycycline monohydrate tab 75 mg (Adoxa)................ 3
doxycycline monohydrate tab 100 mg (Adoxa pak
1/100)................................................................................... 3
doxycycline monohydrate tab 150 mg (Adoxa pak
1/150)................................................................................... 3
dronabinol cap 2.5 mg (Marinol)..................................... 30
dronabinol cap 5 mg (Marinol)........................................ 30
dronabinol cap 10 mg (Marinol)...................................... 30
drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin
28)...................................................................................... 12
drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)...... 12
DRYSOL – aluminum chloride soln 20%........................... 58
DULERA – mometasone furoate-formoterol fumarate
aerosol 100-5 mcg/act...................................................... 27
DULERA – mometasone furoate-formoterol fumarate
aerosol 200-5 mcg/act...................................................... 27
duloxetine hcl enteric coated pellets cap 20 mg
(Cymbalta)........................................................................ 34
(Cymbalta)........................................................................ 34
(Cymbalta)........................................................................ 34
dutasteride cap 0.5 mg (Avodart)................................... 32
DUTOPROL – metoprolol & hydrochlorothiazide tab sr
24hr 25-12.5 mg................................................................ 19
24hr 50-12.5 mg................................................................ 19
24hr 100-12.5 mg.............................................................. 19
dyphylline-guaifenesin liqd 100-100 mg/5ml................. 27
E
econazole nitrate cream 1%............................................ 56
EDURANT – rilpivirine hcl tab 25 mg (base equivalent)...... 5
E.E.S. 400 – erythromycin ethylsuccinate tab 400 mg........ 2
EFFIENT – prasugrel hcl tab 5 mg (base equiv)............... 51
EFFIENT – prasugrel hcl tab 10 mg (base equiv)............. 51
ELIDEL – pimecrolimus cream 1%.................................... 58
ELLA – ulipristal acetate tab 30 mg................................... 12
ELMIRON – pentosan polysulfate sodium caps 100
mg...................................................................................... 32
2016
EMCYT – estramustine phosphate sodium cap 140 mg......8
EMEND – aprepitant capsule 40 mg..................................30
EMEND – aprepitant capsule 80 mg..................................30
EMEND – aprepitant capsule 125 mg................................30
EMEND – aprepitant capsule therapy pack 80 & 125
mg...................................................................................... 30
EMTRIVA – emtricitabine caps 200 mg............................... 5
EMTRIVA – emtricitabine soln 10 mg/ml............................. 5
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg...................................................................................... 17
enalapril maleate & hydrochlorothiazide tab 10-25 mg
(Vaseretic)......................................................................... 17
enalapril maleate tab 2.5 mg (Vasotec).......................... 17
enalapril maleate tab 5 mg (Vasotec)............................. 17
enalapril maleate tab 10 mg (Vasotec)........................... 17
enalapril maleate tab 20 mg (Vasotec)........................... 17
ENBREL – etanercept for subcutaneous inj kit 25 mg....... 43
ENBREL – etanercept subcutaneous soln prefilled syringe
25 mg/0.5ml....................................................................... 43
ENBREL – etanercept subcutaneous soln prefilled syringe
50 mg/ml............................................................................ 44
ENBREL SURECLICK – etanercept subcutaneous
solution auto-injector 50 mg/ml.........................................44
enoxaparin sodium inj 30 mg/0.3ml (Lovenox)............. 51
enoxaparin sodium inj 100 mg/ml (Lovenox)................ 51
enoxaparin sodium inj 120 mg/0.8ml (Lovenox)........... 51
enoxaparin sodium inj 150 mg/ml (Lovenox)................ 51
enoxaparin sodium inj 300 mg/3ml (Lovenox).............. 51
entacapone tab 200 mg (Comtan)...................................48
entecavir tab 0.5 mg (Baraclude)...................................... 4
entecavir tab 1 mg (Baraclude)......................................... 4
epinastine hcl ophth soln 0.05% (Elestat)..................... 53
EPIPEN-JR 2-PAK – epinephrine solution auto-injector
0.15 mg/0.3ml (1:2000)..................................................... 26
EPIPEN 2-PAK – epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................. 26
EPIVIR HBV – lamivudine oral soln 5 mg/ml (hbv).............. 4
eplerenone tab 25 mg (Inspra)........................................ 25
eplerenone tab 50 mg (Inspra)........................................ 25
EPROSARTAN MESYLATE – eprosartan mesylate tab
600 mg............................................................................... 18
EPZICOM – abacavir sulfate-lamivudine tab 600-300
mg........................................................................................ 5
ergocalciferol cap 50000 unit (Drisdol).......................... 49
ERIVEDGE – vismodegib cap 150 mg................................ 8
ERY-TAB – erythromycin tab delayed release 250 mg........ 2
ERYTHROCIN STEARATE – erythromycin stearate tab
250 mg................................................................................. 2
ERYTHROMYCIN BASE – erythromycin tab 250 mg.......... 2
ERYTHROMYCIN BASE – erythromycin tab 500 mg.......... 2
ERYTHROMYCIN ETHYLSUCCINA – erythromycin
ethylsuccinate tab 400 mg.................................................. 2
erythromycin gel 2% (Erygel).......................................... 55
erythromycin ophth oint 5 mg/gm.................................. 52
erythromycin pads 2%..................................................... 55
erythromycin soln 2%...................................................... 55
erythromycin w/ delayed release particles cap 250
mg........................................................................................ 2
ESCAVITE LQ – pediatric multiple vitamins w/ fl-fe drops
0.25-6 mg/ml...................................................................... 49
escitalopram oxalate soln 5 mg/5ml (base equiv)
(Lexapro)........................................................................... 34
escitalopram oxalate tab 5 mg (base equiv)
(Lexapro)........................................................................... 34
(Lexapro)........................................................................... 34
(Lexapro)........................................................................... 34
esomeprazole magnesium cap delayed release 20 mg
(base eq) (Nexium).......................................................... 29
esomeprazole magnesium cap delayed release 40 mg
(base eq) (Nexium).......................................................... 29
estazolam tab 1 mg.......................................................... 37
estazolam tab 2 mg.......................................................... 37
estradiol & norethindrone acetate tab 0.5-0.1 mg
(Activella).......................................................................... 11
estradiol & norethindrone acetate tab 1-0.5 mg
(Activella).......................................................................... 11
estradiol tab 0.5 mg (Estrace)......................................... 11
estradiol tab 1 mg (Estrace)............................................ 11
estradiol tab 2 mg (Estrace)............................................ 11
estradiol td patch twice weekly 0.025 mg/24hr (Vivelledot).....................................................................................11
estradiol td patch twice weekly 0.0375 mg/24hr
(Vivelle-dot)...................................................................... 11
estradiol td patch weekly 0.025 mg/24hr (Climara).......11
estradiol td patch weekly 0.05 mg/24hr (Climara).........11
estradiol td patch weekly 0.06 mg/24hr (Climara).........11
estradiol td patch weekly 0.075 mg/24hr (Climara).......11
estradiol td patch weekly 0.1 mg/24hr (Climara)...........11
estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr) (Climara).........................................................11
ESTROPIPATE – estropipate tab 3 mg..............................11
estropipate tab 0.75 mg................................................... 11
estropipate tab 1.5 mg..................................................... 11
eszopiclone tab 1 mg (Lunesta)......................................37
ethambutol hcl tab 100 mg (Myambutol)......................... 3
ethambutol hcl tab 400 mg (Myambutol)......................... 3
73
2016
ethosuximide cap 250 mg (Zarontin)..............................46
ethosuximide soln 250 mg/5ml (Zarontin)..................... 46
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35
mcg.................................................................................... 12
etodolac cap 200 mg........................................................ 44
etodolac cap 300 mg........................................................ 44
etodolac tab 400 mg......................................................... 44
etodolac tab 500 mg......................................................... 44
etodolac tab sr 24hr 400 mg........................................... 44
ETOPOSIDE – etoposide cap 50 mg................................... 8
EVOTAZ – atazanavir sulfate-cobicistat tab 300-150 mg
(base equiv)......................................................................... 5
exemestane tab 25 mg (Aromasin)................................... 8
F
famciclovir tab 125 mg (Famvir)....................................... 4
famotidine for susp 40 mg/5ml (Pepcid)........................ 29
famotidine tab 20 mg (Pepcid)........................................ 29
famotidine tab 40 mg (Pepcid)........................................ 29
FARESTON – toremifene citrate tab 60 mg (base
equivalent)............................................................................8
FARYDAK – panobinostat lactate cap 10 mg (base
equivalent)............................................................................8
equivalent)............................................................................8
equivalent)............................................................................8
felbamate susp 600 mg/5ml (Felbatol)........................... 46
felbamate tab 400 mg (Felbatol)..................................... 46
felbamate tab 600 mg (Felbatol)..................................... 46
felodipine tab sr 24hr 2.5 mg.......................................... 21
felodipine tab sr 24hr 5 mg............................................. 21
felodipine tab sr 24hr 10 mg........................................... 21
fenofibrate micronized cap 43 mg (Antara)................... 23
fenofibrate micronized cap 130 mg (Antara)................. 23
fenofibrate micronized cap 67 mg (Lofibra).................. 23
fenofibrate micronized cap 134 mg (Lofibra)................ 23
fenofibrate micronized cap 200 mg (Lofibra)................ 23
fenofibrate tab 54 mg (Lofibra)....................................... 23
fenofibrate tab 160 mg (Lofibra)..................................... 23
fenofibrate tab 48 mg (Tricor)......................................... 23
fenofibrate tab 145 mg (Tricor)....................................... 23
fentanyl citrate lozenge on a handle 200 mcg
(Actiq)................................................................................ 41
(Actiq)................................................................................ 41
(Actiq)................................................................................ 41
(Actiq)................................................................................ 41
(Actiq)................................................................................ 41
74
(Actiq)................................................................................ 41
fentanyl td patch 72hr 12 mcg/hr (Duragesic)............... 41
fentanyl td patch 72hr 100 mcg/hr (Duragesic)............. 41
FINACEA – azelaic acid foam 15%................................... 55
FINACEA – azelaic acid gel 15%.......................................55
finasteride tab 5 mg (Proscar)........................................ 32
FIRAZYR – icatibant acetate inj 30 mg/3ml (base
equivalent)......................................................................... 51
flecainide acetate tab 50 mg........................................... 24
flecainide acetate tab 100 mg......................................... 24
flecainide acetate tab 150 mg......................................... 24
FLOVENT DISKUS – fluticasone propionate aer pow ba
50 mcg/blister.................................................................... 27
100 mcg/blister.................................................................. 27
250 mcg/blister.................................................................. 27
FLOVENT HFA – fluticasone propionate hfa inhal aer 110
mcg/act (125/valve)........................................................... 27
FLOVENT HFA – fluticasone propionate hfa inhal aer 220
mcg/act (250/valve)........................................................... 27
FLOVENT HFA – fluticasone propionate hfa inhal aero 44
mcg/act (50/valve)............................................................. 27
fluconazole for susp 10 mg/ml (Diflucan)........................ 3
fluconazole for susp 40 mg/ml (Diflucan)........................ 3
fluconazole tab 50 mg (Diflucan)...................................... 3
fluconazole tab 100 mg (Diflucan).................................... 3
flucytosine cap 250 mg (Ancobon)...................................4
flucytosine cap 500 mg (Ancobon)...................................4
fludrocortisone acetate tab 0.1 mg.................................10
flunisolide nasal soln 25 mcg/act (0.025%)
(Flunisolide)......................................................................26
fluocinolone acetonide cream 0.01%............................. 57
fluocinolone acetonide cream 0.025% (Synalar)........... 57
fluocinolone acetonide oil 0.01% (body oil) (Dermasmoothe/fs bod).............................................................. 57
fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca)............................................................... 57
fluocinolone acetonide oint 0.025% (Synalar)............... 57
fluocinolone acetonide (otic) oil 0.01% (Dermotic)....... 54
fluocinolone acetonide soln 0.01% (Synalar)................ 57
fluocinonide cream 0.05%............................................... 57
fluocinonide cream 0.1% (Vanos)................................... 57
fluocinonide emulsified base cream 0.05%................... 57
fluocinonide gel 0.05%..................................................... 57
fluocinonide oint 0.05%....................................................57
fluocinonide soln 0.05%................................................... 57
FLUOR-A-DAY – sodium fluoride-xylitol chew tab 0.55
(0.25 mg f)-236.79 mg...................................................... 50
2016
FLUOR-A-DAY – sodium fluoride-xylitol chew tab 1.1 (0.5
mg f)-236.79 mg................................................................ 50
FLUOR-A-DAY – sodium fluoride-xylitol chew tab 2.2 (1
mg f)-236.79 mg................................................................ 50
fluorometholone ophth susp 0.1% (Fml liquifilm)........ 52
FLUOROPLEX – fluorouracil cream 1%............................ 58
fluorouracil cream 5% (Efudex)...................................... 58
fluorouracil soln 2%......................................................... 58
fluorouracil soln 5%......................................................... 58
fluoxetine hcl cap delayed release 90 mg (Prozac
weekly).............................................................................. 34
fluoxetine hcl cap 10 mg (Prozac).................................. 34
fluoxetine hcl (pmdd) cap 10 mg.................................... 40
fluoxetine hcl (pmdd) cap 20 mg.................................... 40
fluoxetine hcl solution 20 mg/5ml.................................. 34
fluoxetine hcl tab 10 mg.................................................. 34
fluoxetine hcl tab 20 mg.................................................. 34
FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5
mg/5ml............................................................................... 35
FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/
ml........................................................................................ 35
fluphenazine hcl tab 1 mg............................................... 35
fluphenazine hcl tab 2.5 mg............................................ 35
fluphenazine hcl tab 5 mg............................................... 35
fluphenazine hcl tab 10 mg............................................. 35
FLURA-DROPS – sodium fluoride soln 0.25 mg/drop f
(from 0.55 mg/drop naf).................................................... 50
FLURAZEPAM HCL – flurazepam hcl cap 15 mg..............37
FLURAZEPAM HCL – flurazepam hcl cap 30 mg..............37
flurbiprofen sodium ophth soln 0.03% (Ocufen)........... 53
flurbiprofen tab 50 mg......................................................44
flurbiprofen tab 100 mg................................................... 44
flutamide cap 125 mg......................................................... 8
fluticasone propionate cream 0.05% (Cutivate)............ 57
fluticasone propionate lotion 0.05% (Cutivate)............. 57
fluticasone propionate nasal susp 50 mcg/act
(Flonase)........................................................................... 26
fluticasone propionate oint 0.005% (Cutivate).............. 57
fluvastatin sodium cap 20 mg (Lescol).......................... 23
fluvastatin sodium cap 40 mg (Lescol).......................... 23
fluvoxamine maleate cap sr 24hr 100 mg (Luvox
cr)....................................................................................... 34
fluvoxamine maleate cap sr 24hr 150 mg (Luvox
cr)....................................................................................... 34
fluvoxamine maleate tab 25 mg...................................... 34
fluvoxamine maleate tab 50 mg...................................... 34
fluvoxamine maleate tab 100 mg.................................... 34
folic acid tab 1 mg............................................................ 51
FOLLISTIM AQ – follitropin beta inj 75 unit/0.5ml..............13
FOLLISTIM AQ – follitropin beta inj 300 unit/0.36ml..........13
fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml
(Arixtra)............................................................................. 51
fondaparinux sodium subcutaneous inj 5 mg/0.4ml
(Arixtra)............................................................................. 51
fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml
(Arixtra)............................................................................. 51
fondaparinux sodium subcutaneous inj 10 mg/0.8ml
(Arixtra)............................................................................. 51
FORADIL AEROLIZER – formoterol fumarate inhal cap 12
mcg.....................................................................................27
FORTEO – teriparatide (recombinant) inj 600
mcg/2.4ml...........................................................................16
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg...................................................................................... 17
fosinopril sodium & hydrochlorothiazide tab 20-12.5
mg...................................................................................... 17
fosinopril sodium tab 10 mg........................................... 17
furosemide oral soln 10 mg/ml....................................... 24
furosemide tab 20 mg (Lasix)......................................... 24
FUZEON – enfuvirtide for inj 90 mg.....................................5
G
gabapentin cap 100 mg (Neurontin)............................... 46
gabapentin oral soln 250 mg/5ml (Neurontin)............... 46
gabapentin tab 600 mg (Neurontin)................................ 46
gabapentin tab 800 mg (Neurontin)................................ 46
galantamine hydrobromide cap sr 24hr 8 mg
(Razadyne er)................................................................... 40
(Razadyne er)................................................................... 40
(Razadyne er)................................................................... 40
GALANTAMINE HYDROBROMIDE – galantamine
hydrobromide oral soln 4 mg/ml....................................... 40
galantamine hydrobromide tab 4 mg (Razadyne)......... 40
galantamine hydrobromide tab 8 mg (Razadyne)......... 40
galantamine hydrobromide tab 12 mg (Razadyne)....... 40
gatifloxacin ophth soln 0.5% (Zymaxid).........................52
gemfibrozil tab 600 mg (Lopid)....................................... 23
GENTAMICIN SULFATE – gentamicin sulfate cream
0.1%................................................................................... 56
GENTAMICIN SULFATE – gentamicin sulfate oint
0.1%................................................................................... 56
gentamicin sulfate ophth oint 0.3%................................ 52
gentamicin sulfate ophth soln 0.3% (Garamycin)......... 52
GILOTRIF – afatinib dimaleate tab 20 mg (base
equivalent)............................................................................8
equivalent)............................................................................8
equivalent)............................................................................8
75
2016
glatiramer acetate soln prefilled syringe 20 mg/ml
(Copaxone)....................................................................... 39
GLEEVEC – imatinib mesylate tab 100 mg (base
equivalent)............................................................................8
GLEEVEC – imatinib mesylate tab 400 mg (base
equivalent)............................................................................8
GLEOSTINE – lomustine cap 5 mg..................................... 8
GLEOSTINE – lomustine cap 10 mg................................... 8
GLEOSTINE – lomustine cap 40 mg................................... 8
GLEOSTINE – lomustine cap 100 mg................................. 8
glimepiride tab 1 mg (Amaryl).........................................14
glipizide-metformin hcl tab 2.5-250 mg.......................... 14
glipizide-metformin hcl tab 2.5-500 mg.......................... 14
glipizide-metformin hcl tab 5-500 mg............................. 14
glipizide tab 5 mg (Glucotrol)..........................................14
glipizide tab 10 mg (Glucotrol)........................................14
glipizide tab sr 24hr 2.5 mg (Glucotrol xl)..................... 14
glipizide tab sr 24hr 5 mg (Glucotrol xl)........................ 14
glipizide tab sr 24hr 10 mg (Glucotrol xl)...................... 14
GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj
kit 1 mg.............................................................................. 14
GLYBURIDE – glyburide tab 1.25 mg................................ 14
GLYBURIDE – glyburide tab 2.5 mg.................................. 14
GLYBURIDE – glyburide tab 5 mg..................................... 14
(Glucovance).................................................................... 14
glyburide-metformin tab 2.5-500 mg (Glucovance)...... 14
glyburide-metformin tab 5-500 mg (Glucovance)......... 14
glyburide micronized tab 1.5 mg (Glynase)................... 14
glyburide micronized tab 3 mg (Glynase)...................... 14
glyburide micronized tab 6 mg (Glynase)...................... 14
glyburide tab 1.25 mg.......................................................14
glyburide tab 2.5 mg.........................................................14
glyburide tab 5 mg............................................................14
glycopyrrolate tab 1 mg (Robinul).................................. 29
glycopyrrolate tab 2 mg (Robinul forte)......................... 29
GONAL-F – follitropin alfa for inj 450 unit.......................... 13
GONAL-F – follitropin alfa for inj 1050 unit........................ 13
GONAL-F RFF – follitropin alfa for inj 75 unit.................... 13
GONAL-F RFF PEN – follitropin alfa inj 300 unit/0.5ml..... 13
GONAL-F RFF PEN – follitropin alfa inj 450
unit/0.75ml......................................................................... 13
GONAL-F RFF PEN – follitropin alfa inj 900 unit/1.5ml..... 13
GONAL-F RFF REDIJECT – follitropin alfa inj 300
unit/0.5ml............................................................................13
unit/0.75ml......................................................................... 13
unit/1.5ml............................................................................13
granisetron hcl inj 0.1 mg/ml.......................................... 30
granisetron hcl inj 1 mg/ml............................................. 30
granisetron hcl inj 4 mg/4ml (1 mg/ml).......................... 30
granisetron hcl tab 1 mg................................................. 30
76
GRANIX – tbo-filgrastim soln prefilled syringe 300
mcg/0.5ml...........................................................................51
GRANIX – tbo-filgrastim soln prefilled syringe 480
mcg/0.8ml...........................................................................51
griseofulvin microsize susp 125 mg/5ml......................... 4
griseofulvin microsize tab 500 mg (Grifulvin v).............. 4
griseofulvin ultramicrosize tab 125 mg (Gris-peg)......... 4
griseofulvin ultramicrosize tab 250 mg (Gris-peg)......... 4
guanfacine hcl tab 1 mg (Tenex).................................... 25
guanfacine hcl tab 2 mg (Tenex).................................... 25
guanfacine hcl tab sr 24hr 1 mg (base equiv)
(Intuniv)............................................................................. 38
(Intuniv)............................................................................. 38
(Intuniv)............................................................................. 38
(Intuniv)............................................................................. 38
H
halobetasol propionate cream 0.05% (Ultravate).......... 57
halobetasol propionate oint 0.05% (Ultravate).............. 57
haloperidol lactate oral conc 2 mg/ml............................35
haloperidol tab 0.5 mg..................................................... 35
haloperidol tab 1 mg........................................................ 35
haloperidol tab 10 mg...................................................... 35
haloperidol tab 20 mg...................................................... 35
HARVONI – ledipasvir-sofosbuvir tab 90-400 mg................ 4
HEXALEN – altretamine cap 50 mg.....................................8
homatropine hbr ophth soln 5% (Isopto
homatropine).................................................................... 53
HUMIRA – adalimumab prefilled syringe kit 10
mg/0.2ml............................................................................ 44
mg/0.4ml............................................................................ 44
mg/0.8ml............................................................................ 44
HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled
syringe kit 40 mg/0.8ml..................................................... 44
HUMIRA PEN – adalimumab pen-injector kit 40
mg/0.8ml............................................................................ 44
HUMIRA PEN-CROHNS DISEASE – adalimumab peninjector kit 40 mg/0.8ml..................................................... 44
HUMIRA PEN-PSORIASIS STAR – adalimumab peninjector kit 40 mg/0.8ml..................................................... 44
HUMULIN R U-500 (CONCENTR – insulin regular
(human) inj 500 unit/ml..................................................... 15
HYCAMTIN – topotecan hcl cap 0.25 mg (base equiv)....... 8
HYCAMTIN – topotecan hcl cap 1 mg (base equiv)............ 8
hydralazine hcl tab 10 mg............................................... 25
hydralazine hcl tab 100 mg............................................. 25
hydrochlorothiazide cap 12.5 mg (Microzide)............... 24
2016
hydrochlorothiazide tab 12.5 mg.................................... 24
hydrochlorothiazide tab 25 mg....................................... 24
hydrochlorothiazide tab 50 mg....................................... 24
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
(Hycet)............................................................................... 41
hydrocodone-acetaminophen tab 2.5-325 mg............... 41
hydrocodone-acetaminophen tab 7.5-325 mg
(Norco).............................................................................. 41
hydrocodone-acetaminophen tab 5-325 mg
(Norco).............................................................................. 41
(Norco).............................................................................. 41
hydrocodone-acetaminophen tab 7.5-300 mg
(Xodol)............................................................................... 41
(Xodol)............................................................................... 41
(Xodol)............................................................................... 41
hydrocodone-ibuprofen tab 10-200 mg (Ibudone)........ 41
hydrocodone-ibuprofen tab 5-200 mg (Reprexain)....... 41
hydrocodone-ibuprofen tab 7.5-200 mg
(Vicoprofen)...................................................................... 41
hydrocortisone acetate suppos 25 mg (Anusol-hc)..... 54
hydrocortisone acetate suppos 30 mg (Proctocort)..... 54
hydrocortisone butyrate cream 0.1% (Locoid).............. 57
hydrocortisone butyrate hydrophilic lipo base cream
0.1% (Locoid lipocream).................................................57
hydrocortisone butyrate oint 0.1% (Locoid).................. 57
hydrocortisone butyrate soln 0.1% (Locoid)................. 57
hydrocortisone cream 1%................................................ 57
hydrocortisone cream 2.5%............................................. 57
hydrocortisone enema 100 mg/60ml (Cortenema)........ 54
hydrocortisone lotion 2.5%............................................. 57
hydrocortisone lotion 2% (Ala scalp)............................. 57
hydrocortisone oint 2.5%................................................. 57
hydrocortisone rectal cream 2.5% (Anusol-hc)............ 54
hydrocortisone rectal cream 1% (Proctocort)............... 54
hydrocortisone tab 5 mg (Cortef)................................... 10
hydrocortisone tab 10 mg (Cortef)................................. 10
hydrocortisone tab 20 mg (Cortef)................................. 10
hydrocortisone valerate cream 0.2%.............................. 57
hydrocortisone valerate oint 0.2% (Westcort)............... 57
hydrocortisone w/ acetic acid otic soln 1-2% (Vosol
hc)...................................................................................... 54
HYDROMORPHONE HCL – hydromorphone hcl suppos 3
mg...................................................................................... 41
hydromorphone hcl liqd 1 mg/ml (Dilaudid).................. 41
hydromorphone hcl tab er 24hr deter 8 mg
(Exalgo)............................................................................. 41
(Exalgo)............................................................................. 41
(Exalgo)............................................................................. 41
hydromorphone hcl tab 2 mg (Dilaudid)........................ 41
hydroxychloroquine sulfate tab 200 mg (Plaquenil)....... 7
hydroxyurea cap 500 mg (Hydrea)................................... 8
hydroxyzine hcl syrup 10 mg/5ml...................................33
hydroxyzine hcl tab 10 mg.............................................. 33
hydroxyzine pamoate cap 25 mg (Vistaril).................... 33
hydroxyzine pamoate cap 50 mg (Vistaril).................... 33
HYDROXYZINE PAMOATE – hydroxyzine pamoate cap
100 mg............................................................................... 33
hyoscyamine sulfate elixir 0.125 mg/5ml....................... 29
hyoscyamine sulfate soln 0.125 mg/ml.......................... 29
hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)...... 29
hyoscyamine sulfate tab 0.125 mg (Levsin).................. 29
hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl).......... 29
hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid)..... 29
I
ibandronate sodium tab 150 mg (base equivalent)
(Boniva)............................................................................. 16
IBRANCE – palbociclib cap 75 mg...................................... 8
IBRANCE – palbociclib cap 100 mg.................................... 8
IBRANCE – palbociclib cap 125 mg.................................... 8
ibuprofen susp 100 mg/5ml............................................. 44
ibuprofen tab 400 mg....................................................... 44
ibuprofen tab 600 mg....................................................... 44
ibuprofen tab 800 mg....................................................... 44
ICLUSIG – ponatinib hcl tab 15 mg (base equiv)................ 8
ICLUSIG – ponatinib hcl tab 45 mg (base equiv)................ 8
ILARIS – canakinumab for inj 180 mg............................... 44
IMBRUVICA – ibrutinib cap 140 mg.....................................8
imipramine hcl tab 10 mg (Tofranil)............................... 34
imipramine pamoate cap 75 mg (Tofranil-pm).............. 34
imipramine pamoate cap 100 mg (Tofranil-pm)............ 34
imiquimod cream 5% (Aldara)......................................... 58
IMITREX – sumatriptan nasal spray 5 mg/act................... 45
IMITREX – sumatriptan nasal spray 20 mg/act................. 45
INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml)......... 16
INCRUSE ELLIPTA – umeclidinium br aero powd breath
act 62.5 mcg/inh (base eq)............................................... 27
indapamide tab 1.25 mg................................................... 24
indapamide tab 2.5 mg..................................................... 24
indomethacin cap cr 75 mg............................................. 44
indomethacin cap 25 mg................................................. 44
indomethacin cap 50 mg................................................. 44
INHALER-ASSIST DEVICES - VARIOUS.......................... 60
INJECTION DEVICE FOR INSULIN -VARIOUS................ 60
INLYTA – axitinib tab 1 mg................................................... 8
INLYTA – axitinib tab 5 mg................................................... 8
INSULIN PEN NEEDLES - NOVOFINE............................. 60
INSULIN PEN NEEDLES - NOVOTWIST.......................... 60
INSULIN PEN NEEDLES - VARIOUS................................ 60
77
2016
INSULIN SYRINGES - VARIOUS...................................... 60
INTELENCE – etravirine tab 25 mg..................................... 5
INTELENCE – etravirine tab 100 mg................................... 5
INTELENCE – etravirine tab 200 mg................................... 5
INVIRASE – saquinavir mesylate cap 200 mg.................... 5
INVIRASE – saquinavir mesylate tab 500 mg..................... 5
INVOKAMET – canagliflozin-metformin hcl tab 50-500
mg...................................................................................... 14
mg...................................................................................... 14
mg...................................................................................... 14
mg...................................................................................... 14
INVOKANA – canagliflozin tab 100 mg..............................14
INVOKANA – canagliflozin tab 300 mg..............................14
iodoquinol-hydrocortisone in aloe vehicle cream
1-1.9% (Vytone)................................................................ 56
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml
(Duoneb)........................................................................... 27
ipratropium bromide inhal soln 0.02%........................... 27
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
(Atrovent).......................................................................... 26
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
(Atrovent).......................................................................... 26
irbesartan-hydrochlorothiazide tab 150-12.5 mg
(Avalide)............................................................................ 18
irbesartan-hydrochlorothiazide tab 300-12.5 mg
(Avalide)............................................................................ 18
irbesartan tab 75 mg (Avapro)........................................ 18
irbesartan tab 150 mg (Avapro)...................................... 18
irbesartan tab 300 mg (Avapro)...................................... 18
IRESSA – gefitinib tab 250 mg............................................ 8
ISENTRESS – raltegravir potassium chew tab 25 mg
(base equiv)......................................................................... 5
ISENTRESS – raltegravir potassium chew tab 100 mg
(base equiv)......................................................................... 5
ISENTRESS – raltegravir potassium packet for susp 100
mg (base equiv).................................................................. 5
ISENTRESS – raltegravir potassium tab 400 mg (base
equiv)....................................................................................5
isometheptene-caffeine-acetaminophen tab 65-20-325
mg (Prodrin)..................................................................... 45
ISONIAZID – isoniazid syrup 50 mg/5ml............................. 3
isoniazid tab 100 mg.......................................................... 3
isoniazid tab 300 mg.......................................................... 3
ISOSORBIDE DINITRATE ER – isosorbide dinitrate tab cr
40 mg................................................................................. 22
ISOSORBIDE DINITRATE – isosorbide dinitrate tab 30
mg...................................................................................... 22
isosorbide dinitrate tab 10 mg........................................ 22
isosorbide dinitrate tab 20 mg........................................ 22
isosorbide dinitrate tab 5 mg (Isordil titradose)........... 22
isosorbide mononitrate tab 10 mg................................. 22
isosorbide mononitrate tab 20 mg................................. 22
isosorbide mononitrate tab sr 24hr 30 mg (Imdur)....... 22
78
isosorbide mononitrate tab sr 24hr 60 mg (Imdur)....... 22
isosorbide mononitrate tab sr 24hr 120 mg (Imdur)..... 22
isotretinoin cap 10 mg..................................................... 55
isotretinoin cap 30 mg (Claravis)....................................55
itraconazole cap 100 mg (Sporanox)................................4
ivermectin tab 3 mg (Stromectol)..................................... 7
J
JAKAFI – ruxolitinib phosphate tab 5 mg (base
equivalent)............................................................................8
equivalent)............................................................................8
equivalent)............................................................................8
equivalent)............................................................................8
equivalent)............................................................................8
JANUMET – sitagliptin-metformin hcl tab 50-500 mg........ 14
JANUMET – sitagliptin-metformin hcl tab 50-1000 mg...... 14
JANUMET XR – sitagliptin-metformin hcl tab sr 24hr
50-500 mg......................................................................... 14
50-1000 mg....................................................................... 14
100-1000 mg..................................................................... 14
JANUVIA – sitagliptin phosphate tab 25 mg (base
equiv)................................................................................. 14
equiv)................................................................................. 14
equiv)................................................................................. 14
JARDIANCE – empagliflozin tab 10 mg.............................14
JARDIANCE – empagliflozin tab 25 mg.............................14
K
KALETRA – lopinavir-ritonavir soln 400-100 mg/5ml
(80-20 mg/ml)...................................................................... 5
KALETRA – lopinavir-ritonavir tab 100-25 mg..................... 5
KALETRA – lopinavir-ritonavir tab 200-50 mg..................... 5
KALYDECO – ivacaftor packet 50 mg............................... 28
KALYDECO – ivacaftor packet 75 mg............................... 28
KALYDECO – ivacaftor tab 150 mg................................... 28
ketoconazole cream 2%................................................... 56
ketoconazole foam 2% (Extina).......................................56
ketoconazole shampoo 2% (Nizoral).............................. 56
KETO-DIASTIX – urine glucose-ketones test strips.......... 60
ketoprofen cap 50 mg...................................................... 44
ketoprofen cap 75 mg...................................................... 44
ketorolac tromethamine ophth soln 0.5% (Acular)....... 53
ketorolac tromethamine ophth soln 0.4% (Acular
ls)....................................................................................... 53
ketorolac tromethamine tab 10 mg.................................44
KETOSTIX – acetone (urine) test strip.............................. 60
2016
KOMBIGLYZE XR – saxagliptin-metformin hcl tab sr 24hr
2.5-1000 mg...................................................................... 14
5-500 mg............................................................................14
5-1000 mg......................................................................... 14
K-PHOS NO 2 – potassium & sodium acid phosphates tab
305-700 mg....................................................................... 32
K-PHOS – potassium phosphate monobasic tab 500
mg...................................................................................... 50
L
labetalol hcl tab 100 mg (Trandate)................................ 19
lactic acid (ammonium lactate) lotion 10%....................58
lactulose (encephalopathy) solution 10 gm/15ml......... 30
lactulose solution 10 gm/15ml........................................ 28
LAMISIL – terbinafine hcl oral granules packet 125 mg...... 4
LAMISIL – terbinafine hcl oral granules packet 187.5
mg........................................................................................ 4
lamivudine oral soln 10 mg/ml (Epivir)............................ 5
lamivudine tab 150 mg (Epivir)......................................... 5
lamivudine tab 300 mg (Epivir)......................................... 5
lamivudine tab 100 mg (hbv) (Epivir hbv)........................ 4
lamivudine-zidovudine tab 150-300 mg (Combivir)........ 5
lamotrigine tab chewable dispersible 5 mg (Lamictal
chewable di)..................................................................... 46
lamotrigine tab chewable dispersible 25 mg (Lamictal
chewable di)..................................................................... 46
lamotrigine tab 25 mg (Lamictal).................................... 46
lamotrigine tab 100 mg (Lamictal).................................. 46
lamotrigine tab sr 24hr 25 mg (Lamictal xr).................. 46
lamotrigine tab sr 24hr 50 mg (Lamictal xr).................. 46
lamotrigine tab sr 24hr 100 mg (Lamictal xr)................ 46
LANCET DEVICES - VARIOUS......................................... 60
LANCETS - VARIOUS........................................................ 60
LANOXIN – digoxin tab 62.5 mcg (0.0625 mg)................. 25
LANOXIN – digoxin tab 125 mcg (0.125 mg).................... 25
LANOXIN – digoxin tab 187.5 mcg (0.1875 mg)............... 25
LANOXIN – digoxin tab 250 mcg (0.25 mg)...................... 25
lansoprazole cap delayed release 15 mg
(Prevacid).......................................................................... 29
lansoprazole cap delayed release 30 mg
(Prevacid).......................................................................... 29
LANTUS – insulin glargine inj 100 unit/ml......................... 15
LANTUS SOLOSTAR – insulin glargine soln pen-injector
100 unit/ml......................................................................... 15
latanoprost ophth soln 0.005% (Xalatan)....................... 53
leflunomide tab 10 mg (Arava)........................................ 44
leflunomide tab 20 mg (Arava)........................................ 44
LENVIMA 14MG DAILY DOSE – lenvatinib cap therapy
pack 10 & 4 mg (14 mg daily dose)................................... 8
pack 10 (2) & 4 mg (24 mg daily dose).............................. 8
pack 10 mg (10 mg daily dose).......................................... 8
pack 10 (2) mg (20 mg daily dose).................................... 8
LETAIRIS – ambrisentan tab 5 mg.................................... 25
LETAIRIS – ambrisentan tab 10 mg.................................. 25
letrozole tab 2.5 mg (Femara)........................................... 8
LEUCOVORIN CALCIUM – leucovorin calcium tab 10
mg........................................................................................ 8
LEUCOVORIN CALCIUM – leucovorin calcium tab 15
mg........................................................................................ 8
leucovorin calcium tab 5 mg............................................. 8
leucovorin calcium tab 25 mg........................................... 9
LEUKERAN – chlorambucil tab 2 mg.................................. 9
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base
equiv)................................................................................. 27
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
(Xopenex).......................................................................... 27
(Xopenex).......................................................................... 28
(Xopenex).......................................................................... 28
LEVEMIR FLEXPEN – insulin detemir soln pen-injector
100 unit/ml......................................................................... 15
LEVEMIR FLEXTOUCH – insulin detemir soln pen-injector
100 unit/ml......................................................................... 15
LEVEMIR – insulin detemir inj 100 unit/ml......................... 15
levetiracetam oral soln 100 mg/ml (Keppra)..................46
levetiracetam tab 250 mg (Keppra).................................46
levetiracetam tab 1000 mg (Keppra)...............................47
levetiracetam tab sr 24hr 500 mg (Keppra xr)............... 46
levetiracetam tab sr 24hr 750 mg (Keppra xr)............... 46
LEVOBUNOLOL HCL – levobunolol hcl ophth soln
0.25%................................................................................. 53
levobunolol hcl ophth soln 0.5% (Betagan).................. 53
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 16
levocarnitine tab 330 mg (Carnitor)................................ 16
levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/
ml) (Xyzal)......................................................................... 26
levocetirizine dihydrochloride tab 5 mg (Xyzal)............ 26
levofloxacin ophth soln 0.5%.......................................... 52
levofloxacin oral soln 25 mg/ml (Levaquin).................... 3
levofloxacin tab 250 mg (Levaquin)................................. 3
levonorgestrel & ethinyl estradiol (91-day) tab
0.15-0.03 mg..................................................................... 12
levonorgestrel & ethinyl estradiol tab 0.1 mg-20
mcg.................................................................................... 12
79
2016
levonorgestrel & ethinyl estradiol tab 0.15 mg-30
mcg.................................................................................... 12
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg................................. 12
levonorgestrel-ethinyl estradiol (continuous) tab 90-20
mcg.................................................................................... 12
levonorgestrel tab 1.5 mg (Plan b one-step)................. 12
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab
0.01mg(7) (Loseasonique).............................................. 12
levonorg-eth est tab 0.15-0.03mg(84) & eth est tab
0.01mg(7) (Seasonique).................................................. 12
levothyroxine sodium tab 25 mcg (Synthroid).............. 15
levothyroxine sodium tab 100 mcg (Synthroid)............ 16
LEXIVA – fosamprenavir calcium susp 50 mg/ml (base
equiv)....................................................................................5
LEXIVA – fosamprenavir calcium tab 700 mg (base
equiv)....................................................................................5
LIALDA – mesalamine tab delayed release 1.2 gm........... 31
lidocaine hcl cream 3%.................................................... 58
lidocaine hcl gel 2%......................................................... 58
lidocaine hcl laryngotracheal soln 4% (Lta 360 kit)...... 54
lidocaine hcl soln 4% (Xylocaine)...................................58
lidocaine hcl viscous soln 2%........................................ 54
lidocaine oint 5%...............................................................58
lidocaine patch 5% (Lidoderm)....................................... 58
lidocaine-prilocaine cream 2.5-2.5% (Emla).................. 58
lidocaine-prilocaine kit 2.5-2.5%..................................... 58
lindane lotion 1%.............................................................. 58
lindane shampoo 1%........................................................ 58
linezolid tab 600 mg (Zyvox)............................................. 7
liothyronine sodium tab 5 mcg (Cytomel)..................... 16
liothyronine sodium tab 25 mcg (Cytomel)................... 16
liothyronine sodium tab 50 mcg (Cytomel)................... 16
lisinopril & hydrochlorothiazide tab 10-12.5 mg
(Zestoretic)....................................................................... 17
lisinopril & hydrochlorothiazide tab 20-12.5 mg
(Zestoretic)....................................................................... 17
lisinopril & hydrochlorothiazide tab 20-25 mg
(Zestoretic)....................................................................... 17
lisinopril tab 5 mg (Prinivil)............................................. 17
lisinopril tab 10 mg (Prinivil)........................................... 17
lisinopril tab 20 mg (Prinivil)........................................... 18
lisinopril tab 2.5 mg (Zestril)........................................... 17
lisinopril tab 30 mg (Zestril)............................................ 18
lisinopril tab 40 mg (Zestril)............................................ 18
lithium carbonate cap 300 mg.........................................35
80
lithium carbonate cap 150 mg (Lithium carbonate)...... 35
lithium carbonate cap 600 mg (Lithium carbonate)...... 35
LITHIUM CARBONATE – lithium carbonate cap 150
mg...................................................................................... 35
lithium carbonate tab cr 450 mg..................................... 36
lithium carbonate tab cr 300 mg (Lithobid)................... 36
lithium carbonate tab 300 mg......................................... 36
LITHIUM – lithium oral solution 8 meq/5ml........................ 35
LOMUSTINE – lomustine cap 10 mg................................... 9
LOMUSTINE – lomustine cap 40 mg................................... 9
LOMUSTINE – lomustine cap 100 mg................................. 9
LONSURF – trifluridine-tipiracil tab 15-6.14 mg...................9
LONSURF – trifluridine-tipiracil tab 20-8.19 mg...................9
loperamide hcl cap 2 mg................................................. 28
lorazepam conc 2 mg/ml (Lorazepam intensol)............ 33
lorazepam tab 0.5 mg (Ativan)........................................ 33
lorazepam tab 1 mg (Ativan)........................................... 33
lorazepam tab 2 mg (Ativan)........................................... 33
losartan potassium & hydrochlorothiazide tab 50-12.5
mg (Hyzaar)...................................................................... 18
losartan potassium & hydrochlorothiazide tab 100-12.5
mg (Hyzaar)...................................................................... 19
losartan potassium & hydrochlorothiazide tab 100-25
mg (Hyzaar)...................................................................... 19
losartan potassium tab 25 mg (Cozaar)......................... 19
losartan potassium tab 50 mg (Cozaar)......................... 19
losartan potassium tab 100 mg (Cozaar)....................... 19
LOTEMAX – loteprednol etabonate ophth gel 0.5%.......... 52
LOTEMAX – loteprednol etabonate ophth oint 0.5%......... 52
LOTEMAX – loteprednol etabonate ophth susp 0.5%....... 52
lovastatin tab 10 mg......................................................... 23
lovastatin tab 20 mg (Mevacor).......................................23
lovastatin tab 40 mg (Mevacor).......................................23
loxapine succinate cap 10 mg........................................ 36
loxapine succinate cap 5 mg (Loxitane)........................ 36
LUMIGAN – bimatoprost ophth soln 0.01%....................... 53
LYNPARZA – olaparib cap 50 mg........................................ 9
LYSODREN – mitotane tab 500 mg..................................... 9
M
MACRODANTIN – nitrofurantoin macrocrystalline cap 25
mg...................................................................................... 31
malathion lotion 0.5% (Ovide)......................................... 58
MATULANE – procarbazine hcl cap 50 mg......................... 9
meclizine hcl tab 12.5 mg................................................ 30
meclizine hcl tab 25 mg................................................... 30
medroxyprogesterone acetate im susp 150 mg/ml
(Depo-provera contrac).................................................. 12
medroxyprogesterone acetate tab 2.5 mg
(Provera)........................................................................... 12
medroxyprogesterone acetate tab 5 mg (Provera)....... 12
medroxyprogesterone acetate tab 10 mg (Provera)..... 12
mefenamic acid cap 250 mg (Ponstel)........................... 44
mefloquine hcl tab 250 mg................................................ 7
2016
megestrol acetate susp 625 mg/5ml (Megace es)......... 12
megestrol acetate susp 40 mg/ml (Megace oral)............ 9
megestrol acetate tab 20 mg............................................. 9
megestrol acetate tab 40 mg............................................. 9
MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg
(base equivalent)................................................................. 9
MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (base
equivalent)............................................................................9
meloxicam tab 7.5 mg (Mobic)........................................ 44
meloxicam tab 15 mg (Mobic)......................................... 44
memantine hcl oral solution 2 mg/ml (Namenda)......... 40
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak
(Namenda titration pa).................................................... 40
memantine hcl tab 5 mg (Namenda).............................. 40
memantine hcl tab 10 mg (Namenda)............................ 40
MEPHYTON – phytonadione tab 5 mg.............................. 49
mercaptopurine tab 50 mg (Purinethol)........................... 9
mesalamine enema 4 gm................................................. 31
mesalamine rectal enema 4 gm & cleanser wipe kit
(Rowasa)........................................................................... 31
MESNEX – mesna tab 400 mg............................................ 9
metaxalone tab 800 mg (Skelaxin)..................................48
metformin hcl tab 500 mg (Glucophage)....................... 15
metformin hcl tab 850 mg (Glucophage)....................... 15
metformin hcl tab 1000 mg (Glucophage)..................... 15
metformin hcl tab sr 24hr 500 mg (Glucophage xr)...... 14
metformin hcl tab sr 24hr 750 mg (Glucophage xr)...... 14
metformin hcl tab sr 24hr osmotic 500 mg
(Fortamet)......................................................................... 14
metformin hcl tab sr 24hr osmotic 1000 mg
(Fortamet)......................................................................... 15
methadone hcl conc 10 mg/ml (Methadose)................. 42
methadone hcl soln 5 mg/5ml (Methadone hcl)............ 42
methadone hcl soln 10 mg/5ml (Methadone hcl).......... 42
methadone hcl tab for oral susp 40 mg......................... 42
methadone hcl tab 10 mg (Dolophine)........................... 42
methadone hcl tab 5 mg (Dolophine hcl).......................42
methazolamide tab 25 mg (Neptazane).......................... 24
methazolamide tab 50 mg (Neptazane).......................... 24
methenamine hippurate tab 1 gm (Hiprex).................... 31
methenamine-hyoscamine-meth blue-sod phos tab
81.6 mg (Urogesic-blue)................................................. 31
methenamine-hyosc-meth blue-benz acid-phenyl sal
tab 81.6mg (Prosed/ds).................................................. 31
methenamine-hyosc-meth blue-sod phos-phen sal cap
118 mg...............................................................................31
methenamine-hyosc-meth blue-sod phos-phen sal cap
120 mg.............................................................................. 31
methenamine-hyosc-meth blue-sod phos-phen sal tab
81 mg................................................................................ 31
methenamine-hyos-meth blue-sod phos-phen sal tab
81.6 mg............................................................................. 31
methenamine mandelate tab 1 gm................................. 31
methimazole tab 5 mg (Tapazole)................................... 16
methimazole tab 10 mg (Tapazole)................................. 16
methocarbamol tab 750 mg (Robaxin-750).................... 48
methocarbamol tab 500 mg (Robaxin)........................... 48
methotrexate sodium tab 2.5 mg (base equiv)................ 9
methoxsalen rapid cap 10 mg (Oxsoralen ultra)........... 58
methscopolamine bromide tab 2.5 mg (Pamine).......... 29
methscopolamine bromide tab 5 mg (Pamine
forte).................................................................................. 29
methyldopa tab 250 mg................................................... 25
methyldopa tab 500 mg................................................... 25
methylergonovine maleate tab 0.2 mg........................... 16
methylphenidate hcl cap cr 10 mg (Metadate cd)......... 38
methylphenidate hcl cap sr 24hr 20 mg (la) (Ritalin
la)....................................................................................... 38
la)....................................................................................... 38
la)....................................................................................... 38
methylphenidate hcl soln 5 mg/5ml (Methylin)............. 38
methylphenidate hcl soln 10 mg/5ml (Methylin)........... 38
methylphenidate hcl tab cr 10 mg.................................. 38
methylphenidate hcl tab cr 20 mg (Ritalin sr)............... 38
methylphenidate hcl tab 5 mg (Ritalin).......................... 38
methylphenidate hcl tab 10 mg (Ritalin)........................ 38
methylphenidate hcl tab 20 mg (Ritalin)........................ 38
methylprednisolone tab 4 mg dose pack (Medrol
dosepak)........................................................................... 10
methylprednisolone tab 4 mg (Medrol).......................... 10
methylprednisolone tab 8 mg (Medrol).......................... 10
methylprednisolone tab 16 mg (Medrol)........................ 10
methylprednisolone tab 32 mg (Medrol)........................ 10
METIPRANOLOL – metipranolol ophth soln 0.3%............ 53
metoclopramide hcl inj 5 mg/ml..................................... 31
metoclopramide hcl orally disintegrating tab 5 mg
(Metozolv odt).................................................................. 31
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)......... 31
metoclopramide hcl tab 5 mg (Reglan).......................... 31
metoclopramide hcl tab 10 mg (Reglan)........................ 31
metolazone tab 10 mg...................................................... 24
metolazone tab 2.5 mg (Zaroxolyn)................................ 24
metolazone tab 5 mg (Zaroxolyn)................................... 24
metoprolol & hydrochlorothiazide tab 100-50 mg........ 19
metoprolol & hydrochlorothiazide tab 50-25 mg
(Lopressor hct)................................................................ 19
metoprolol & hydrochlorothiazide tab 100-25 mg
(Lopressor hct)................................................................ 19
metoprolol succinate tab sr 24hr 25 mg (Toprol xl)...... 20
metoprolol succinate tab sr 24hr 50 mg (Toprol xl)...... 20
metoprolol succinate tab sr 24hr 100 mg (Toprol
xl)....................................................................................... 20
metoprolol succinate tab sr 24hr 200 mg (Toprol
xl)....................................................................................... 20
metoprolol tartrate tab 25 mg......................................... 20
81
2016
metoprolol tartrate tab 50 mg (Lopressor).................... 20
metoprolol tartrate tab 100 mg (Lopressor).................. 20
metronidazole cap 375 mg (Flagyl).................................. 7
metronidazole cream 0.75% (Metrocream).................... 55
metronidazole gel 0.75%.................................................. 55
metronidazole gel 1% (Metrogel).................................... 55
metronidazole lotion 0.75% (Metrolotion)...................... 55
metronidazole tab 250 mg (Flagyl)................................... 7
metronidazole tab 500 mg (Flagyl)................................... 7
metronidazole vaginal gel 0.75% (Metrogelvaginal)..............................................................................32
mexiletine hcl cap 150 mg............................................... 24
midazolam hcl syrup 2 mg/ml (base equivalent).......... 37
midodrine hcl tab 2.5 mg................................................. 25
midodrine hcl tab 5 mg.................................................... 25
midodrine hcl tab 10 mg.................................................. 25
MIGRANAL – dihydroergotamine mesylate nasal spray 4
mg/ml..................................................................................45
minocycline hcl cap 50 mg (Minocin).............................. 3
minocycline hcl cap 75 mg (Minocin).............................. 3
minocycline hcl cap 100 mg (Minocin)............................ 3
minocycline hcl tab 50 mg................................................ 3
minocycline hcl tab 75 mg................................................ 3
minocycline hcl tab 100 mg.............................................. 3
minocycline hcl tab sr 24hr 45 mg................................... 3
minocycline hcl tab sr 24hr 90 mg................................... 3
minocycline hcl tab sr 24hr 135 mg................................. 3
minoxidil tab 2.5 mg......................................................... 25
minoxidil tab 10 mg.......................................................... 25
mirtazapine orally disintegrating tab 15 mg (Remeron
soltab)............................................................................... 34
soltab)............................................................................... 34
soltab)............................................................................... 34
mirtazapine tab 7.5 mg..................................................... 34
mirtazapine tab 15 mg (Remeron).................................. 34
misoprostol tab 100 mcg (Cytotec)................................ 29
misoprostol tab 200 mcg (Cytotec)................................ 29
modafinil tab 100 mg (Provigil)....................................... 38
modafinil tab 200 mg (Provigil)....................................... 38
moexipril hcl tab 7.5 mg (Univasc)................................. 18
moexipril hcl tab 15 mg (Univasc).................................. 18
moexipril-hydrochlorothiazide tab 7.5-12.5 mg.............18
moexipril-hydrochlorothiazide tab 15-25 mg.................18
moexipril-hydrochlorothiazide tab 15-12.5 mg
(Uniretic)........................................................................... 18
mometasone furoate cream 0.1% (Elocon)................... 57
mometasone furoate oint 0.1% (Elocon)........................57
mometasone furoate solution 0.1% (lotion)
(Elocon)............................................................................. 57
82
montelukast sodium chew tab 4 mg (base equiv)
(Singulair)......................................................................... 28
montelukast sodium chew tab 5 mg (base equiv)
(Singulair)......................................................................... 28
montelukast sodium oral granules packet 4 mg (base
equiv) (Singulair)............................................................. 28
montelukast sodium tab 10 mg (base equiv)
(Singulair)......................................................................... 28
morphine sulfate cap sr 24hr 10 mg (Kadian)............... 42
morphine sulfate cap sr 24hr 100 mg (Kadian)............. 42
MORPHINE SULFATE ER – morphine sulfate beads cap
sr 24hr 30 mg.................................................................... 42
sr 24hr 45 mg.................................................................... 42
sr 24hr 60 mg.................................................................... 42
sr 24hr 75 mg.................................................................... 42
sr 24hr 90 mg.................................................................... 42
sr 24hr 120 mg.................................................................. 42
MORPHINE SULFATE – morphine sulfate suppos 5
mg...................................................................................... 42
mg...................................................................................... 42
mg...................................................................................... 42
mg...................................................................................... 42
MORPHINE SULFATE – morphine sulfate tab 15 mg....... 42
MORPHINE SULFATE – morphine sulfate tab 30 mg....... 42
morphine sulfate oral soln 10 mg/5ml........................... 42
morphine sulfate oral soln 20 mg/5ml........................... 42
morphine sulfate oral soln 100 mg/5ml (20 mg/ml)...... 42
morphine sulfate tab cr 15 mg (Ms contin)................... 42
morphine sulfate tab cr 100 mg (Ms contin)................. 42
morphine sulfate tab cr 200 mg (Ms contin)................. 42
moxifloxacin hcl tab 400 mg (base equiv) (Avelox)........ 3
mupirocin calcium cream 2% (Bactroban).................... 56
mupirocin oint 2% (Bactroban)....................................... 56
mycophenolate mofetil cap 250 mg (Cellcept).............. 60
mycophenolate mofetil for oral susp 200 mg/ml
(Cellcept)........................................................................... 60
mycophenolate mofetil tab 500 mg (Cellcept)............... 60
mycophenolate sodium tab dr 180 mg (mycophenolic
acid equiv) (Myfortic)...................................................... 60
mycophenolate sodium tab dr 360 mg (mycophenolic
acid equiv) (Myfortic)...................................................... 60
2016
MYLERAN – busulfan tab 2 mg........................................... 9
MYRBETRIQ – mirabegron tab sr 24 hr 25 mg................. 31
MYRBETRIQ – mirabegron tab sr 24 hr 50 mg................. 31
N
nabumetone tab 500 mg.................................................. 44
nabumetone tab 750 mg.................................................. 44
nadolol & bendroflumethiazide tab 40-5 mg
(Corzide)............................................................................20
nadolol & bendroflumethiazide tab 80-5 mg
(Corzide)............................................................................20
nadolol tab 20 mg (Corgard)........................................... 20
naloxone hcl inj 0.4 mg/ml.............................................. 60
naltrexone hcl tab 50 mg (Revia).................................... 60
NAMENDA – memantine hcl oral solution 2 mg/ml........... 40
NAPROXEN – naproxen susp 125 mg/5ml....................... 44
naproxen sodium tab 275 mg (Anaprox)....................... 44
naproxen sodium tab 550 mg (Anaprox ds).................. 44
naproxen tab ec 375 mg (Ec-naprosyn)......................... 44
naproxen tab ec 500 mg (Ec-naprosyn)......................... 44
naproxen tab 250 mg (Naprosyn)................................... 44
naratriptan hcl tab 1 mg (base equiv) (Amerge)........... 45
naratriptan hcl tab 2.5 mg (base equiv) (Amerge)........ 45
NATACYN – natamycin ophth susp 5%............................. 52
nateglinide tab 60 mg (Starlix)........................................ 15
nateglinide tab 120 mg (Starlix)...................................... 15
NEBUPENT – pentamidine isethionate for nebulization
soln 300 mg......................................................................... 7
NECON 1/50-28 – norethindrone & mestranol tab 1 mg-50
mcg.....................................................................................12
NECON 10/11-28 – norethindrone-eth estradiol tab
0.5-35/1-35 mg-mcg (10/11)............................................. 12
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin..................................52
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml (Neosporin)................ 52
neomycin-polymyxin-dexamethasone ophth oint 0.1%
(Maxitrol)........................................................................... 52
neomycin-polymyxin-dexamethasone ophth susp
0.1% (Maxitrol)................................................................. 52
neomycin-polymyxin-hc otic soln 1% (Cortisporin)..... 54
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000
unit/ml-1%......................................................................... 54
neomycin sulfate tab 500 mg............................................ 3
NEULASTA DELIVERY KIT – pegfilgrastim soln prefilled
syringe kit 6 mg/0.6ml....................................................... 51
NEULASTA – pegfilgrastim soln prefilled syringe 6
mg/0.6ml............................................................................ 51
NEUPOGEN – filgrastim inj 300 mcg/ml............................ 51
NEUPOGEN – filgrastim inj 480 mcg/1.6ml (300 mcg/
ml)...................................................................................... 51
NEUPOGEN – filgrastim soln prefilled syringe 300
mcg/0.5ml...........................................................................51
NEUPOGEN – filgrastim soln prefilled syringe 480
mcg/0.8ml (600 mcg/ml)................................................... 51
nevirapine tab 200 mg (Viramune).................................... 5
nevirapine tab sr 24hr 400 mg (Viramune xr).................. 5
NEXAVAR – sorafenib tosylate tab 200 mg (base
equivalent)............................................................................9
NEXIUM – esomeprazole magnesium for delayed release
susp packet 5 mg..............................................................29
susp packet 10 mg............................................................29
susp packet 20 mg............................................................29
susp packet 40 mg............................................................29
susp pack 2.5 mg..............................................................29
niacin tab cr 500 mg (antihyperlipidemic)
(Niaspan)........................................................................... 23
(Niaspan)........................................................................... 23
(Niaspan)........................................................................... 23
nicardipine hcl cap 20 mg............................................... 21
nicardipine hcl cap 30 mg............................................... 21
NICOTROL INHALER – nicotine inhaler system 10 mg (4
mg delivered)..................................................................... 40
NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/
spray)................................................................................. 40
nifedipine cap 20 mg........................................................ 21
nifedipine cap 10 mg (Procardia)....................................21
nifedipine tab sr 24hr 30 mg (Adalat cc)........................21
nifedipine tab sr 24hr osmotic release 30 mg
(Procardia xl)....................................................................21
(Procardia xl)....................................................................22
(Procardia xl)....................................................................22
NILANDRON – nilutamide tab 150 mg................................ 9
nimodipine cap 30 mg...................................................... 22
nisoldipine tab sr 24hr 8.5 mg (Sular)............................ 22
nisoldipine tab sr 24hr 17 mg (Sular)............................. 22
nisoldipine tab sr 24hr 34 mg (Sular)............................. 22
NITRO-BID – nitroglycerin oint 2%.................................... 22
nitrofurantoin macrocrystalline cap 25 mg
(Macrodantin)................................................................... 31
(Macrodantin)................................................................... 31
(Macrodantin)................................................................... 31
nitrofurantoin monohydrate macrocrystalline cap 100
mg (Macrobid).................................................................. 31
nitrofurantoin susp 25 mg/5ml (Furadantin)..................31
83
2016
nitroglycerin cap cr 2.5 mg............................................. 22
nitroglycerin cap cr 6.5 mg............................................. 22
nitroglycerin cap cr 9 mg................................................ 22
nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur).......... 22
NITROSTAT – nitroglycerin sl tab 0.3 mg.......................... 22
nizatidine cap 150 mg...................................................... 29
nizatidine cap 300 mg (Axid)........................................... 29
nizatidine oral soln 15 mg/ml (Axid)............................... 29
norethindrone & ethinyl estradiol-fe chew tab 0.4
mg-35 mcg (Femcon fe)................................................. 12
norethindrone & ethinyl estradiol-fe chew tab 0.8
mg-25 mcg (Generess fe)............................................... 13
norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg
(Brevicon-28).................................................................... 12
norethindrone & ethinyl estradiol tab 1 mg-35 mcg
(Norinyl 1+35)................................................................... 12
norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg
(Ovcon-35)........................................................................ 12
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20
mcg (Loestrin fe 1/20).....................................................13
norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30
mcg (Loestrin fe 1.5/30)..................................................13
norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg
(Loestrin 1/20-21)............................................................. 13
norethindrone ace & ethinyl estradiol tab 1.5 mg-30
mcg (Loestrin 1.5/30-21)................................................. 13
norethindrone ace-ethinyl estradiol-fe tab 1 mg-20
mcg (24)............................................................................ 13
norethindrone acetate-ethinyl estradiol tab 1 mg-5
mcg.................................................................................... 11
norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5
mcg (Femhrt low dose).................................................. 11
norethindrone acetate tab 5 mg (Aygestin)................... 12
norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35
mg-mcg (Estrostep fe).................................................... 13
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mgmcg (Ortho-novum 7/7/7)............................................... 13
norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28)......................................................... 13
norethindrone tab 0.35 mg (Nor-qd)............................... 13
norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg
(Ortho-cyclen).................................................................. 13
norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35
mg-mcg (Ortho tri-cyclen).............................................. 13
norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg......... 13
nortriptyline hcl cap 10 mg (Pamelor)............................34
NORTRIPTYLINE HCL – nortriptyline hcl soln 10
mg/5ml............................................................................... 34
84
NORVIR – ritonavir cap 100 mg.......................................... 5
NORVIR – ritonavir oral soln 80 mg/ml................................ 5
NORVIR – ritonavir tab 100 mg........................................... 5
NOVOLIN 70/30 – insulin nph isophane & regular human
inj 100 unit/ml (70-30)....................................................... 15
NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/
ml........................................................................................ 15
NOVOLIN R – insulin regular (human) inj 100 unit/ml....... 15
NOVOLOG FLEXPEN – insulin aspart soln pen-injector
100 unit/ml......................................................................... 15
NOVOLOG – insulin aspart inj 100 unit/ml........................ 15
NOVOLOG MIX 70/30 – insulin aspart prot & aspart
(human) inj 100 unit/ml (70-30)........................................ 15
NOVOLOG MIX 70/30 PREFILL – insulin aspart prot &
aspart sus pen-inj 100 unit/ml (70-30)..............................15
NOVOLOG PENFILL – insulin aspart inj 100 unit/ml......... 15
NOVOLOG PENFILL – insulin aspart soln cartridge 100
unit/ml................................................................................. 15
NOXAFIL – posaconazole susp 40 mg/ml........................... 4
NOXAFIL – posaconazole tab delayed release 100 mg...... 4
NUCYNTA ER – tapentadol hcl tab sr 12hr 50 mg............ 42
NUCYNTA ER – tapentadol hcl tab sr 12hr 100 mg.......... 42
NUVARING – etonogestrel-ethinyl estradiol va ring
0.120-0.015 mg/24hr......................................................... 13
nystatin cream 100000 unit/gm....................................... 56
nystatin oint 100000 unit/gm........................................... 56
nystatin oral powder........................................................... 4
nystatin susp 100000 unit/ml.......................................... 54
nystatin tab 500000 unit..................................................... 4
nystatin topical powder....................................................56
nystatin-triamcinolone cream 100000-0.1 unit/gm%........................................................................................ 57
nystatin-triamcinolone oint 100000-0.1 unit/gm-%....... 57
O
ODOMZO – sonidegib phosphate cap 200 mg (base
equivalent)............................................................................9
OFLOXACIN – ofloxacin tab 400 mg................................... 3
ofloxacin ophth soln 0.3% (Ocuflox).............................. 52
ofloxacin otic soln 0.3%................................................... 54
OGESTREL – norgestrel & ethinyl estradiol tab 0.5 mg-50
mcg.....................................................................................13
olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax)....... 40
olanzapine-fluoxetine hcl cap 12-25 mg (Symbyax)..... 40
olanzapine-fluoxetine hcl cap 12-50 mg (Symbyax)..... 40
olanzapine orally disintegrating tab 5 mg (Zyprexa
zydis)................................................................................. 36
zydis)................................................................................. 36
zydis)................................................................................. 36
2016
zydis)................................................................................. 36
olanzapine tab 2.5 mg (Zyprexa).....................................36
olanzapine tab 5 mg (Zyprexa)........................................36
olanzapine tab 7.5 mg (Zyprexa).....................................36
olanzapine tab 10 mg (Zyprexa)......................................36
olopatadine hcl nasal soln 0.6% (Patanase).................. 26
omeprazole cap delayed release 10 mg (Prilosec)....... 29
omeprazole-sodium bicarbonate cap 20-1100 mg
(Zegerid)............................................................................ 29
omeprazole-sodium bicarbonate cap 40-1100 mg
(Zegerid)............................................................................ 29
OMNITROPE – somatropin for inj 5.8 mg......................... 16
OMNITROPE – somatropin inj 5 mg/1.5ml........................ 16
OMNITROPE – somatropin inj 10 mg/1.5ml...................... 16
ondansetron hcl oral soln 4 mg/5ml (Zofran)................ 30
ondansetron hcl tab 24 mg............................................. 30
ondansetron hcl tab 4 mg (Zofran).................................30
ondansetron hcl tab 8 mg (Zofran).................................30
ondansetron orally disintegrating tab 4 mg (Zofran
odt).....................................................................................30
ondansetron orally disintegrating tab 8 mg (Zofran
odt).....................................................................................30
ONGLYZA – saxagliptin hcl tab 2.5 mg (base equiv).........15
ONGLYZA – saxagliptin hcl tab 5 mg (base equiv)............15
OPSUMIT – macitentan tab 10 mg.................................... 25
ORACEA – doxycycline (rosacea) cap delayed release 40
mg...................................................................................... 55
ORFADIN – nitisinone cap 2 mg........................................ 16
ORFADIN – nitisinone cap 5 mg........................................ 16
ORFADIN – nitisinone cap 10 mg...................................... 17
orphenadrine citrate tab sr 12hr 100 mg....................... 48
orphenadrine w/ aspirin & caffeine tab 25-385-30
mg...................................................................................... 49
ORTHO TRI-CYCLEN LO – norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg................................... 13
OVIDREL – choriogonadotropin alfa inj 250
mcg/0.5ml...........................................................................13
oxandrolone tab 2.5 mg (Oxandrin)................................11
oxandrolone tab 10 mg (Oxandrin).................................11
oxaprozin tab 600 mg (Daypro).......................................44
oxazepam cap 10 mg........................................................33
oxazepam cap 15 mg........................................................33
oxazepam cap 30 mg........................................................33
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
(Trileptal)........................................................................... 47
oxcarbazepine tab 150 mg (Trileptal)............................. 47
oxybutynin chloride syrup 5 mg/5ml..............................31
oxybutynin chloride tab 5 mg......................................... 31
oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)...... 31
oxybutynin chloride tab sr 24hr 10 mg (Ditropan
xl)....................................................................................... 31
oxybutynin chloride tab sr 24hr 15 mg (Ditropan
xl)....................................................................................... 31
oxycodone-aspirin tab 4.8355-325 mg (Percodan)....... 43
oxycodone hcl cap 5 mg................................................. 42
oxycodone hcl conc 100 mg/5ml (20 mg/ml)
(Oxycodone hcl).............................................................. 42
OXYCODONE HCL – oxycodone hcl conc 100 mg/5ml (20
mg/ml)................................................................................ 42
oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)............42
oxycodone hcl tab 10 mg................................................ 43
oxycodone hcl tab 20 mg................................................ 43
oxycodone hcl tab 5 mg (Roxicodone).......................... 42
oxycodone hcl tab 15 mg (Roxicodone)........................ 43
oxycodone hcl tab 30 mg (Roxicodone)........................ 43
oxycodone-ibuprofen tab 5-400 mg............................... 43
oxycodone w/ acetaminophen tab 2.5-325 mg
(Percocet)......................................................................... 43
oxycodone w/ acetaminophen tab 5-325 mg
(Percocet)......................................................................... 43
oxycodone w/ acetaminophen tab 7.5-325 mg
(Percocet)......................................................................... 43
oxycodone w/ acetaminophen tab 10-325 mg
(Percocet)......................................................................... 43
OXYCONTIN – oxycodone hcl tab er 12hr deter 10
mg...................................................................................... 43
mg...................................................................................... 43
mg...................................................................................... 43
mg...................................................................................... 43
mg...................................................................................... 43
mg...................................................................................... 43
mg...................................................................................... 43
oxymorphone hcl tab 5 mg (Opana)...............................43
oxymorphone hcl tab 10 mg (Opana).............................43
oxymorphone hcl tab sr 12hr 5 mg................................ 43
oxymorphone hcl tab sr 12hr 7.5 mg............................. 43
oxymorphone hcl tab sr 12hr 10 mg.............................. 43
P
paliperidone tab sr 24hr 1.5 mg (Invega)....................... 36
paliperidone tab sr 24hr 3 mg (Invega).......................... 36
pantoprazole sodium ec tab 20 mg (base equiv)
(Protonix).......................................................................... 29
85
2016
pantoprazole sodium ec tab 40 mg (base equiv)
(Protonix).......................................................................... 29
paricalcitol cap 1 mcg (Zemplar).................................... 17
paromomycin sulfate cap 250 mg.................................... 3
paroxetine hcl tab 10 mg (Paxil)..................................... 34
paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)................ 34
paroxetine hcl tab sr 24hr 25 mg (Paxil cr)................... 34
paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)................ 34
PATADAY – olopatadine hcl ophth soln 0.2% (base
equivalent)......................................................................... 53
PAZEO – olopatadine hcl ophth soln 0.7% (base
equivalent)......................................................................... 53
pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/
ml....................................................................................... 49
pediatric multiple vitamins w/ fluoride chew tab 0.25
mg...................................................................................... 49
pediatric multiple vitamins w/ fluoride chew tab 0.5
mg...................................................................................... 49
pediatric multiple vitamins w/ fluoride chew tab 1
mg...................................................................................... 49
pediatric multiple vitamins w/ fluoride soln 0.25 mg/
ml....................................................................................... 49
pediatric multiple vitamins w/ fluoride soln 0.5 mg/
ml....................................................................................... 49
pediatric vitamins acd w/ fluoride soln 0.25 mg/ml...... 49
pediatric vitamins acd w/ fluoride soln 0.5 mg/ml........ 49
PEGASYS – peginterferon alfa-2a inj 180 mcg/ml.............. 4
PEGASYS – peginterferon alfa-2a inj 180 mcg/0.5ml......... 4
PEGASYS PROCLICK – peginterferon alfa-2a inj 135
mcg/0.5ml.............................................................................4
PEGASYS PROCLICK – peginterferon alfa-2a inj 180
mcg/0.5ml.............................................................................4
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm
(Colyte-flavor packs)....................................................... 28
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm
(Golytely)...........................................................................28
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
(Nulytely/flavor pack)...................................................... 28
penicillin v potassium for soln 125 mg/5ml.....................1
penicillin v potassium for soln 250 mg/5ml.....................1
penicillin v potassium tab 250 mg....................................1
penicillin v potassium tab 500 mg....................................1
PENTASA – mesalamine cap cr 250 mg........................... 31
PENTASA – mesalamine cap cr 500 mg........................... 31
pentoxifylline tab cr 400 mg............................................ 51
perindopril erbumine tab 2 mg....................................... 18
perindopril erbumine tab 4 mg (Aceon)......................... 18
perindopril erbumine tab 8 mg (Aceon)......................... 18
permethrin cream 5% (Elimite)........................................58
perphenazine tab 2 mg.................................................... 36
86
perphenazine tab 16 mg.................................................. 36
phenazopyridine hcl tab 100 mg (Pyridium).................. 32
phenazopyridine hcl tab 200 mg (Pyridium).................. 32
phenelzine sulfate tab 15 mg (Nardil)............................ 35
phenobarbital elixir 20 mg/5ml........................................37
PHENOBARBITAL – phenobarbital tab 15 mg.................. 37
PHENOBARBITAL – phenobarbital tab 100 mg................ 37
phenobarbital tab 16.2 mg............................................... 37
phenoxybenzamine hcl cap 10 mg (Dibenzyline)......... 25
phenylephrine hcl ophth soln 2.5%................................ 53
phenylephrine hcl ophth soln 10%................................. 54
PHENYTEK – phenytoin sodium extended cap 200
mg...................................................................................... 47
PHENYTEK – phenytoin sodium extended cap 300
mg...................................................................................... 47
phenytoin chew tab 50 mg (Dilantin infatabs)...............47
phenytoin sodium extended cap 100 mg (Dilantin)...... 47
phenytoin sodium extended cap 200 mg
(Phenytek)......................................................................... 47
phenytoin sodium extended cap 300 mg
(Phenytek)......................................................................... 47
phenytoin susp 125 mg/5ml (Dilantin)........................... 47
PICATO – ingenol mebutate gel 0.015%........................... 58
PICATO – ingenol mebutate gel 0.05%............................. 58
pilocarpine hcl ophth soln 1% (Isopto carpine)............ 53
pilocarpine hcl tab 5 mg (Salagen).................................54
pilocarpine hcl tab 7.5 mg (Salagen)..............................54
pimozide tab 1 mg (Orap)................................................ 40
pimozide tab 2 mg (Orap)................................................ 40
pindolol tab 5 mg.............................................................. 20
pindolol tab 10 mg............................................................ 20
pioglitazone hcl-glimepiride tab 30-2 mg (Duetact)...... 15
pioglitazone hcl-glimepiride tab 30-4 mg (Duetact)...... 15
pioglitazone hcl-metformin hcl tab 15-500 mg
(Actoplus met)................................................................. 15
pioglitazone hcl-metformin hcl tab 15-850 mg
(Actoplus met)................................................................. 15
pioglitazone hcl tab 15 mg (base equiv) (Actos)...........15
piroxicam cap 10 mg (Feldene).......................................44
piroxicam cap 20 mg (Feldene).......................................44
PLEGRIDY – peginterferon beta-1a soln pen-injector 125
mcg/0.5ml...........................................................................39
PLEGRIDY – peginterferon beta-1a soln prefilled syringe
125 mcg/0.5ml................................................................... 39
PLEGRIDY STARTER PACK – peginterferon beta-1a soln
pen-inj 63 & 94 mcg/0.5ml pack....................................... 39
2016
PLEGRIDY STARTER PACK – peginterferon beta-1a soln
pref syr 63 & 94 mcg/0.5ml pack..................................... 39
podofilox soln 0.5% (Condylox)...................................... 58
polyethylene glycol 3350 oral packet............................. 28
polyethylene glycol 3350 oral powder........................... 28
polymyxin b-trimethoprim ophth soln 10000 unit/
ml-0.1% (Polytrim)........................................................... 52
POMALYST – pomalidomide cap 1 mg............................... 9
pot & sod citrates w/ cit ac soln 550-500-334
mg/5ml............................................................................... 32
potassium bicarbonate effer tab 25 meq....................... 50
potassium chloride cap cr 8 meq (Micro-k)................... 50
potassium chloride cap cr 10 meq (Micro-k)................. 50
POTASSIUM CHLORIDE ER – potassium chloride tab cr 8
meq (600 mg).................................................................... 50
potassium chloride microencapsulated crys cr tab 10
meq.................................................................................... 50
potassium chloride microencapsulated crys cr tab 20
meq.................................................................................... 50
potassium chloride oral soln 10% (20 meq/15ml)......... 50
potassium chloride oral soln 20% (40 meq/15ml)......... 50
potassium chloride powder packet 20 meq.................. 50
potassium chloride tab cr 10 meq (K-tab)..................... 50
potassium chloride tab cr 8 meq (600 mg).................... 50
potassium citrate & citric acid powder pack 3300-1002
mg...................................................................................... 32
potassium citrate & citric acid soln 1100-334
mg/5ml............................................................................... 32
potassium citrate tab cr 5 meq (540 mg) (Urocit-k
5)........................................................................................ 32
10)...................................................................................... 32
15)...................................................................................... 32
pot bicarbonate & chloride effer tab 25 meq................. 50
pot phos monobasic w/sod phos di & monobas tab
155-852-130mg (K-phos neutral)................................... 50
pramipexole dihydrochloride tab 0.125 mg
(Mirapex)........................................................................... 48
(Mirapex)........................................................................... 48
pramipexole dihydrochloride tab 0.5 mg (Mirapex)...... 48
(Mirapex)........................................................................... 48
pramipexole dihydrochloride tab 1 mg (Mirapex)......... 48
pramipexole dihydrochloride tab 1.5 mg (Mirapex)...... 48
pramoxine-chloroxylenol otic liquid 1-0.1%
(Pramotic)......................................................................... 54
pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml
(Cortane-b-otic)................................................................ 54
PRASCION RA WITH SUNSCREE – sulfacetamide
sodium-sulfur-sunscreen cream 10-5%............................ 55
pravastatin sodium tab 10 mg........................................ 23
pravastatin sodium tab 20 mg (Pravachol)....................23
prazosin hcl cap 1 mg (Minipress)................................. 25
PRECISION XTRA – ketone blood test strip..................... 60
prednicarbate cream 0.1% (Dermatop).......................... 57
prednicarbate oint 0.1% (Dermatop).............................. 57
prednisolone acetate ophth susp 1% (Pred forte)........ 52
prednisolone sod phos orally disintegr tab 10 mg
(base eq) (Orapred odt).................................................. 10
prednisolone sod phosphate oral soln 15 mg/5ml
(base equiv)...................................................................... 10
prednisolone sod phosph oral soln 6.7 mg/5ml (5
mg/5ml base) (Pediapred).............................................. 10
prednisolone syrup 15 mg/5ml (usp solution
equivalent) (Prelone)....................................................... 10
PREDNISONE – prednisone oral soln 5 mg/5ml............... 10
PREDNISONE – prednisone tab 50 mg............................ 10
PREDNISONE – prednisone tab 5 mg dose pack............. 10
PREDNISONE – prednisone tab 10 mg dose pack........... 10
prednisone tab 1 mg........................................................ 10
prednisone tab 2.5 mg..................................................... 11
prednisone tab 5 mg........................................................ 11
prednisone tab 10 mg...................................................... 11
prednisone tab 20 mg...................................................... 11
PREMARIN – estrogens, conjugated tab 0.3 mg...............11
PREMARIN – estrogens, conjugated tab 0.45 mg.............11
PREMARIN – estrogens, conjugated tab 0.625 mg...........12
PREMARIN – estrogens, conjugated tab 0.9 mg...............12
PREMARIN – estrogens, conjugated tab 1.25 mg.............12
PREMARIN – estrogens, conjugated vaginal cream 0.625
mg/gm................................................................................ 32
PREMPHASE – conj est 0.625(14)/conj est-medroxypro
ac tab 0.625-5mg(14)........................................................ 12
PREMPRO – conjugated estrogen-medroxyprogest
acetate tab 0.3-1.5 mg...................................................... 12
acetate tab 0.45-1.5 mg.................................................... 12
acetate tab 0.625-2.5 mg.................................................. 12
acetate tab 0.625-5 mg..................................................... 12
PRENAPLUS – prenatal vit w/ fe fumarate-fa tab 27-1
mg...................................................................................... 49
PRENATABS FA – prenatal vit w/ fe fumarate-fa tab 29-1
mg...................................................................................... 49
PRENATABS RX – prenatal vit w/ iron carbonyl-fa tab 29-1
mg...................................................................................... 49
PRENATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1
mg...................................................................................... 49
87
2016
PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab
29-1 mg..............................................................................49
PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab
29-1 mg..............................................................................49
PRENATAL-U – prenatal w/o a vit w/ fe fumarate-fa cap
106.5-1 mg........................................................................ 49
PREZCOBIX – darunavir-cobicistat tab 800-150 mg........... 5
PREZISTA – darunavir ethanolate susp 100 mg/ml (base
equiv)....................................................................................5
PREZISTA – darunavir ethanolate tab 75 mg (base
equiv)....................................................................................5
equiv)....................................................................................5
equiv)....................................................................................5
equiv)....................................................................................5
PRIFTIN – rifapentine tab 150 mg....................................... 3
PRIMAQUINE PHOSPHATE – primaquine phosphate tab
26.3 mg (15 mg base)........................................................ 7
primidone tab 50 mg (Mysoline)..................................... 47
primidone tab 250 mg (Mysoline)................................... 47
PROAIR HFA – albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv).......................................................... 28
PROAIR RESPICLICK – albuterol sulfate aer pow ba 108
mcg/act (90 mcg base equiv)........................................... 28
probenecid tab 500 mg.................................................... 45
prochlorperazine maleate tab 5 mg (base equivalent)
(Compazine)..................................................................... 36
prochlorperazine maleate tab 10 mg (base equivalent)
(Compazine)..................................................................... 36
prochlorperazine suppos 25 mg..................................... 36
PROCRIT – epoetin alfa inj 2000 unit/ml........................... 51
PROCRIT – epoetin alfa inj 10000 unit/ml......................... 52
(Prometrium).................................................................... 12
(Prometrium).................................................................... 12
PROLIA – denosumab inj 60 mg/ml...................................17
promethazine hcl suppos 12.5 mg................................. 26
promethazine hcl suppos 25 mg.................................... 26
promethazine hcl suppos 50 mg.................................... 26
promethazine hcl syrup 6.25 mg/5ml............................. 26
promethazine hcl tab 12.5 mg......................................... 26
promethazine hcl tab 25 mg............................................ 26
promethazine hcl tab 50 mg............................................ 26
propafenone hcl cap sr 12hr 225 mg (Rythmol sr)....... 24
propafenone hcl tab 300 mg........................................... 24
propafenone hcl tab 150 mg (Rythmol)......................... 24
propafenone hcl tab 225 mg (Rythmol)......................... 24
88
PROPANTHELINE BROMIDE – propantheline bromide
tab 15 mg.......................................................................... 29
PROPRANOLOL/HYDROCHLOROTH – propranolol &
PROPRANOLOL/HYDROCHLOROTH – propranolol &
propranolol hcl cap sr 24hr 60 mg (Inderal la).............. 20
propranolol hcl cap sr 24hr 80 mg (Inderal la).............. 20
propranolol hcl cap sr 24hr 120 mg (Inderal la)............ 20
propranolol hcl cap sr 24hr 160 mg (Inderal la)............ 20
PROPRANOLOL HCL – propranolol hcl oral soln 20
mg/5ml............................................................................... 20
PROPRANOLOL HCL – propranolol hcl oral soln 40
mg/5ml............................................................................... 20
propranolol hcl tab 10 mg............................................... 20
propylthiouracil tab 50 mg.............................................. 16
protriptyline hcl tab 5 mg (Vivactil)................................ 35
protriptyline hcl tab 10 mg (Vivactil).............................. 35
PULMOZYME – dornase alfa inhal soln 1 mg/ml.............. 28
PURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/
ml)........................................................................................ 9
pyrazinamide tab 500 mg................................................... 3
pyridostigmine bromide tab 60 mg (Mestinon)............. 49
Q
quetiapine fumarate tab 25 mg (Seroquel).................... 36
quetiapine fumarate tab 50 mg (Seroquel).................... 36
quetiapine fumarate tab 100 mg (Seroquel).................. 36
quinapril hcl tab 5 mg (Accupril).................................... 18
quinapril hcl tab 10 mg (Accupril).................................. 18
quinapril-hydrochlorothiazide tab 10-12.5 mg
(Accuretic)........................................................................ 18
quinapril-hydrochlorothiazide tab 20-12.5 mg
(Accuretic)........................................................................ 18
quinapril-hydrochlorothiazide tab 20-25 mg
(Accuretic)........................................................................ 18
quinidine gluconate tab cr 324 mg................................. 24
QUINIDINE SULFATE ER – quinidine sulfate tab cr 300
mg...................................................................................... 24
QUINIDINE SULFATE – quinidine sulfate tab 200 mg....... 24
quinidine sulfate tab 300 mg........................................... 24
quinine sulfate cap 324 mg (Qualaquin).......................... 7
QVAR – beclomethasone diprop inhal aero soln 40 mcg/
act (50/valve)..................................................................... 28
QVAR – beclomethasone diprop inhal aero soln 80 mcg/
act (100/valve)................................................................... 28
2016
R
rabeprazole sodium ec tab 20 mg (Aciphex)................. 29
raloxifene hcl tab 60 mg (Evista).................................... 17
ramipril cap 1.25 mg (Altace).......................................... 18
ramipril cap 2.5 mg (Altace)............................................ 18
ramipril cap 5 mg (Altace)............................................... 18
ramipril cap 10 mg (Altace)............................................. 18
ranitidine hcl cap 150 mg................................................ 29
ranitidine hcl cap 300 mg................................................ 29
ranitidine hcl syrup 15 mg/ml (75 mg/5ml).................... 29
ranitidine hcl tab 150 mg (Zantac).................................. 30
ranitidine hcl tab 300 mg (Zantac).................................. 30
RAPAMUNE – sirolimus oral soln 1 mg/ml........................ 60
REBIF – interferon beta-1a soln pref syr 22 mcg/0.5ml
(12mu/ml)........................................................................... 39
REBIF – interferon beta-1a soln pref syr 44 mcg/0.5ml
(24mu/ml)........................................................................... 39
REBIF REBIDOSE – interferon beta-1a soln auto-inj 22
mcg/0.5ml (12mu/ml).........................................................39
REBIF REBIDOSE – interferon beta-1a soln auto-inj 44
mcg/0.5ml (24mu/ml).........................................................39
REBIF REBIDOSE TITRATION – interferon beta-1a autoinj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml............................ 39
REBIF TITRATION PACK – interferon beta-1a pref syr
6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml................................. 39
RELENZA DISKHALER – zanamivir aero powder breath
activated 5 mg/blister.......................................................... 6
RENVELA – sevelamer carbonate packet 0.8 gm............. 31
RENVELA – sevelamer carbonate packet 2.4 gm............. 31
RENVELA – sevelamer carbonate tab 800 mg..................31
repaglinide tab 0.5 mg (Prandin).................................... 15
repaglinide tab 1 mg (Prandin)....................................... 15
repaglinide tab 2 mg (Prandin)....................................... 15
REPRONEX – menotropins for inj 75 unit......................... 13
RESCRIPTOR – delavirdine mesylate tab 100 mg..............5
RESCRIPTOR – delavirdine mesylate tab 200 mg..............5
REVLIMID – lenalidomide cap 5 mg.................................. 60
REVLIMID – lenalidomide cap 10 mg................................ 60
REVLIMID – lenalidomide caps 2.5 mg............................. 60
REYATAZ – atazanavir sulfate cap 150 mg (base
equiv)....................................................................................6
equiv)....................................................................................6
equiv)....................................................................................6
REYATAZ – atazanavir sulfate oral powder packet 50 mg
(base equiv)......................................................................... 6
ribavirin cap 200 mg (Rebetol).......................................... 4
ribavirin tab 200 mg (Copegus)........................................ 4
rifabutin cap 150 mg (Mycobutin)..................................... 3
RIFAMATE – isoniazid & rifampin cap 150-300 mg............. 3
rifampin cap 150 mg (Rifadin)........................................... 3
rifampin cap 300 mg (Rifadin)........................................... 3
riluzole tab 50 mg (Rilutek)............................................. 49
rimantadine hydrochloride tab 100 mg (Flumadine)...... 6
risedronate sodium tab 5 mg (Actonel)......................... 17
risedronate sodium tab 30 mg (Actonel)....................... 17
risedronate sodium tab 35 mg (Actonel)....................... 17
risedronate sodium tab 150 mg (Actonel)..................... 17
risperidone orally disintegrating tab 0.25 mg............... 36
risperidone orally disintegrating tab 0.5 mg (Risperdal
m-tab)................................................................................ 36
risperidone orally disintegrating tab 1 mg (Risperdal
m-tab)................................................................................ 36
m-tab)................................................................................ 36
m-tab)................................................................................ 36
m-tab)................................................................................ 36
risperidone soln 1 mg/ml (Risperdal)............................. 36
risperidone tab 0.25 mg (Risperdal)............................... 36
risperidone tab 0.5 mg (Risperdal)................................. 36
risperidone tab 1 mg (Risperdal).................................... 36
rivastigmine tartrate cap 1.5 mg (Exelon)......................40
rivastigmine tartrate cap 3 mg (Exelon).........................40
rivastigmine tartrate cap 4.5 mg (Exelon)......................40
rivastigmine tartrate cap 6 mg (Exelon).........................40
rizatriptan benzoate orally disintegrating tab 5 mg
(Maxalt-mlt)....................................................................... 45
rizatriptan benzoate orally disintegrating tab 10 mg
(Maxalt-mlt)....................................................................... 45
rizatriptan benzoate tab 5 mg (Maxalt)...........................45
rizatriptan benzoate tab 10 mg (Maxalt).........................45
ropinirole hydrochloride tab 0.25 mg (Requip)............. 48
ropinirole hydrochloride tab 0.5 mg (Requip)............... 48
ropinirole hydrochloride tab 1 mg (Requip).................. 48
ropinirole hydrochloride tab sr 24hr 2 mg (base
equivalent) (Requip xl)................................................... 48
S
SABRIL – vigabatrin powd pack 500 mg........................... 47
SABRIL – vigabatrin tab 500 mg........................................47
89
2016
salsalate tab 500 mg.........................................................40
salsalate tab 750 mg.........................................................40
SANDIMMUNE – cyclosporine cap 25 mg.........................60
SANDIMMUNE – cyclosporine cap 100 mg.......................60
SANDIMMUNE – cyclosporine oral soln 100 mg/ml.......... 60
selegiline hcl cap 5 mg (Eldepryl).................................. 48
selegiline hcl tab 5 mg..................................................... 48
selenium sulfide lotion 2.5%........................................... 58
SELZENTRY – maraviroc tab 150 mg................................. 6
SELZENTRY – maraviroc tab 300 mg................................. 6
SENSIPAR – cinacalcet hcl tab 30 mg (base equiv)..........17
SEREVENT DISKUS – salmeterol xinafoate aer pow ba
50 mcg/dose (base equiv)................................................ 28
SEROQUEL XR – quetiapine fumarate tab sr 24hr 50
mg...................................................................................... 36
mg...................................................................................... 36
mg...................................................................................... 36
mg...................................................................................... 36
mg...................................................................................... 37
sertraline hcl oral conc 20 mg/ml (Zoloft)......................35
sertraline hcl tab 25 mg (Zoloft)..................................... 35
sertraline hcl tab 50 mg (Zoloft)..................................... 35
sertraline hcl tab 100 mg (Zoloft)................................... 35
sildenafil citrate tab 20 mg (Revatio)............................. 25
silver sulfadiazine cream 1% (Silvadene)...................... 56
SIMBRINZA – brinzolamide-brimonidine tartrate ophth
susp 1-0.2%....................................................................... 53
SIMPONI – golimumab subcutaneous soln auto-injector
50 mg/0.5ml....................................................................... 44
SIMPONI – golimumab subcutaneous soln auto-injector
100 mg/ml.......................................................................... 44
SIMPONI – golimumab subcutaneous soln prefilled
syringe 50 mg/0.5ml.......................................................... 44
SIMPONI – golimumab subcutaneous soln prefilled
syringe 100 mg/ml............................................................. 44
simvastatin tab 5 mg (Zocor).......................................... 23
simvastatin tab 10 mg (Zocor)........................................ 23
sirolimus tab 0.5 mg (Rapamune)...................................60
sirolimus tab 1 mg (Rapamune)......................................60
sirolimus tab 2 mg (Rapamune)......................................60
SIVEXTRO – tedizolid phosphate tab 200 mg..................... 7
sodium citrate & citric acid soln 500-334 mg/5ml
(Shohls solution modi)................................................... 32
sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)
(Luride).............................................................................. 50
sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)
(Luride).............................................................................. 50
90
sodium fluoride chew tab 1 mg f (from 2.2 mg naf)
(Luride).............................................................................. 50
sodium fluoride cream 1.1% (Prevident 5000 plus)...... 54
sodium fluoride gel 1.1% (0.5% f) (Prevident
fluoride)............................................................................. 54
SODIUM FLUORIDE – sodium fluoride tab 0.5 mg f (from
1.1 mg naf)........................................................................ 50
SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from
2.2 mg naf)........................................................................ 50
sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop
naf)..................................................................................... 50
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)
(Luride).............................................................................. 50
sodium phenylbutyrate oral powder 3 gm/teaspoonful
(Buphenyl)........................................................................ 17
sodium polystyrene sulfonate oral susp 15 gm/60ml
(Sps).................................................................................. 60
sodium polystyrene sulfonate powder
(Kayexalate)...................................................................... 60
sodium polystyrene sulfonate rectal susp 30
gm/120ml...........................................................................60
SOLTAMOX – tamoxifen citrate oral soln 10 mg/5ml (base
equivalent)............................................................................9
sotalol hcl (afib/afl) tab 80 mg (Betapace af)................. 25
sotalol hcl (afib/afl) tab 120 mg (Betapace af)............... 25
sotalol hcl (afib/afl) tab 160 mg (Betapace af)............... 25
sotalol hcl tab 240 mg...................................................... 25
sotalol hcl tab 80 mg (Betapace).................................... 25
sotalol hcl tab 120 mg (Betapace).................................. 25
sotalol hcl tab 160 mg (Betapace).................................. 25
SOVALDI – sofosbuvir tab 400 mg...................................... 4
SPIRIVA HANDIHALER – tiotropium bromide
monohydrate inhal cap 18 mcg (base equiv)................... 28
SPIRIVA RESPIMAT – tiotropium bromide monohydrate
inhal aerosol 1.25 mcg/act................................................ 28
SPIRIVA RESPIMAT – tiotropium bromide monohydrate
inhal aerosol 2.5 mcg/act.................................................. 28
spironolactone & hydrochlorothiazide tab 25-25 mg
(Aldactazide).....................................................................24
spironolactone tab 25 mg (Aldactone)........................... 24
spironolactone tab 50 mg (Aldactone)........................... 24
spironolactone tab 100 mg (Aldactone)......................... 24
SPORANOX – itraconazole oral soln 10 mg/ml................... 4
SPRYCEL – dasatinib tab 20 mg......................................... 9
SPRYCEL – dasatinib tab 100 mg....................................... 9
SPRYCEL – dasatinib tab 140 mg....................................... 9
SSKI – potassium iodide soln 1 gm/ml......................... 26,50
stavudine cap 15 mg (Zerit)...............................................6
stavudine for oral soln 1 mg/ml (Zerit)............................ 6
2016
STELARA – ustekinumab soln prefilled syringe 45
mg/0.5ml............................................................................ 58
STELARA – ustekinumab soln prefilled syringe 90 mg/
ml........................................................................................ 58
STIMATE – desmopressin acetate nasal soln 1.5 mg/
ml........................................................................................ 17
STIVARGA – regorafenib tab 40 mg.................................... 9
STRATTERA – atomoxetine hcl cap 10 mg (base
equiv)................................................................................. 38
equiv)................................................................................. 38
equiv)................................................................................. 38
equiv)................................................................................. 38
equiv)................................................................................. 39
equiv)................................................................................. 39
equiv)................................................................................. 39
STRIBILD – elvitegrav-cobicis-emtricitab-tenofov tab
150-150-200-300 mg........................................................... 6
SUBOXONE – buprenorphine hcl-naloxone hcl sl film
2-0.5 mg (base equiv)....................................................... 61
SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1
mg (base equiv)................................................................ 61
mg (base equiv)................................................................ 61
mg (base equiv)................................................................ 61
sucralfate tab 1 gm (Carafate).........................................30
sulfacetamide sodium lotion 10% (acne) (Klaron)........ 55
sulfacetamide sodium ophth soln 10% (Bleph-10)....... 52
sulfacetamide sodium-prednisolone ophth soln
10-0.23(0.25)%.................................................................. 52
sulfacetamide sodium w/ sulfur cleanser 10-2% (Avar
ls cleanser)....................................................................... 55
sulfacetamide sodium w/ sulfur cleansing cloth
10-5%................................................................................. 55
sulfacetamide sodium w/ sulfur cleansing pad 10-4%
(Sumaxin).......................................................................... 55
sulfacetamide sodium w/ sulfur cream 10-5%.............. 55
sulfacetamide sodium w/ sulfur cream 10-2% (Avar-e
ls)....................................................................................... 55
sulfacetamide sodium w/ sulfur emulsion 10-1%......... 55
sulfacetamide sodium w/ sulfur emulsion 10-5%......... 55
sulfacetamide sodium w/ sulfur foam 10-5% (Clarifoam
ef)....................................................................................... 55
sulfacetamide sodium w/ sulfur lotion 10-5%............... 55
sulfacetamide sodium w/ sulfur susp 8-4% (Sumaxin
ts)....................................................................................... 55
sulfacetamide sodium w/ sulfur wash 9-4.5%
(Sumadan wash).............................................................. 55
sulfacetamide sodium w/ sulfur wash 9-4% (Sumaxin
wash)................................................................................. 55
sulfacetamide sod-sulfur wash 9-4.5% & skin cleanser
kit (Sumadan kit)............................................................. 55
sulfamethoxazole-trimethoprim susp 200-40
mg/5ml................................................................................. 7
sulfamethoxazole-trimethoprim tab 400-80 mg
(Bactrim)............................................................................. 7
sulfamethoxazole-trimethoprim tab 800-160 mg
(Bactrim ds)........................................................................ 7
sulfasalazine tab delayed release 500 mg (Azulfidine
en-tabs)............................................................................. 31
sulfasalazine tab 500 mg (Azulfidine)............................ 31
sulindac tab 150 mg......................................................... 44
sulindac tab 200 mg......................................................... 44
sumatriptan succinate inj 6 mg/0.5ml (Imitrex)............. 45
sumatriptan succinate solution auto-injector 4
mg/0.5ml (Imitrex statdose sys).................................... 45
sumatriptan succinate solution auto-injector 6
mg/0.5ml (Imitrex statdose sys).................................... 45
sumatriptan succinate solution cartridge 4 mg/0.5ml
(Imitrex statdose ref)...................................................... 45
sumatriptan succinate solution cartridge 6 mg/0.5ml
(Imitrex statdose ref)...................................................... 45
SUMATRIPTAN SUCCINATE – sumatriptan succinate inj 4
mg/0.5ml............................................................................ 45
SUMATRIPTAN SUCCINATE – sumatriptan succinate
solution prefilled syringe 6 mg/0.5ml................................ 45
sumatriptan succinate tab 25 mg (Imitrex).................... 45
sumatriptan succinate tab 50 mg (Imitrex).................... 45
sumatriptan succinate tab 100 mg (Imitrex).................. 45
SUPRAX – cefixime cap 400 mg......................................... 2
SUPRAX – cefixime chew tab 100 mg................................ 2
SUPRAX – cefixime chew tab 200 mg................................ 2
SUPRAX – cefixime for susp 100 mg/5ml........................... 2
SUSTIVA – efavirenz cap 50 mg......................................... 6
SUSTIVA – efavirenz cap 200 mg....................................... 6
SUSTIVA – efavirenz tab 600 mg........................................ 6
SUTENT – sunitinib malate cap 12.5 mg (base
equivalent)............................................................................9
SUTENT – sunitinib malate cap 25 mg (base
equivalent)............................................................................9
SUTENT – sunitinib malate cap 37.5 mg (base
equivalent)............................................................................9
SUTENT – sunitinib malate cap 50 mg (base
equivalent)............................................................................9
SYLATRON – peginterferon alfa-2b for inj kit 200 mcg....... 9
SYMBICORT – budesonide-formoterol fumarate dihyd
aerosol 80-4.5 mcg/act..................................................... 28
SYMBICORT – budesonide-formoterol fumarate dihyd
aerosol 160-4.5 mcg/act................................................... 28
T
TABLOID – thioguanine tab 40 mg...................................... 9
91
2016
tacrolimus cap 0.5 mg (Prograf)..................................... 61
tacrolimus cap 1 mg (Prograf)........................................ 61
tacrolimus cap 5 mg (Prograf)........................................ 61
tacrolimus oint 0.03% (Protopic).................................... 58
tacrolimus oint 0.1% (Protopic)...................................... 58
TAFINLAR – dabrafenib mesylate cap 50 mg (base
equivalent)............................................................................9
TAFINLAR – dabrafenib mesylate cap 75 mg (base
equivalent)............................................................................9
TAMIFLU – oseltamivir phosphate cap 30 mg (base
equiv)....................................................................................6
equiv)....................................................................................6
equiv)....................................................................................6
TAMIFLU – oseltamivir phosphate for susp 6 mg/ml (base
equiv)....................................................................................6
tamoxifen citrate tab 10 mg (base equivalent)................ 9
tamoxifen citrate tab 20 mg (base equivalent)................ 9
tamsulosin hcl cap 0.4 mg (Flomax).............................. 32
TARCEVA – erlotinib hcl tab 25 mg (base equivalent)......... 9
TARCEVA – erlotinib hcl tab 100 mg (base equivalent)....... 9
TARCEVA – erlotinib hcl tab 150 mg (base equivalent)....... 9
TASIGNA – nilotinib hcl cap 150 mg (base equivalent)..... 10
TASIGNA – nilotinib hcl cap 200 mg (base equivalent)..... 10
TAZORAC – tazarotene cream 0.05%............................... 55
TAZORAC – tazarotene cream 0.1%................................. 55
TAZORAC – tazarotene gel 0.05%.................................... 55
TAZORAC – tazarotene gel 0.1%...................................... 55
TECFIDERA – dimethyl fumarate capsule delayed release
120 mg............................................................................... 39
TECFIDERA – dimethyl fumarate capsule delayed release
240 mg............................................................................... 39
TECFIDERA STARTER PACK – dimethyl fumarate
capsule dr starter pack 120 mg & 240 mg....................... 39
TEGRETOL-XR – carbamazepine tab sr 12hr 100 mg...... 47
telmisartan-amlodipine tab 40-5 mg (Twynsta)............. 22
telmisartan-amlodipine tab 80-5 mg (Twynsta)............. 22
telmisartan-amlodipine tab 40-10 mg (Twynsta)........... 22
telmisartan-amlodipine tab 80-10 mg (Twynsta)........... 22
telmisartan-hydrochlorothiazide tab 40-12.5 mg
(Micardis hct)................................................................... 19
telmisartan-hydrochlorothiazide tab 80-12.5 mg
(Micardis hct)................................................................... 19
telmisartan-hydrochlorothiazide tab 80-25 mg
(Micardis hct)................................................................... 19
telmisartan tab 20 mg (Micardis).................................... 19
temazepam cap 7.5 mg (Restoril)................................... 37
temazepam cap 15 mg (Restoril).................................... 37
temazepam cap 22.5 mg (Restoril)................................. 37
temazepam cap 30 mg (Restoril).................................... 37
temozolomide cap 5 mg (Temodar)................................ 10
temozolomide cap 20 mg (Temodar).............................. 10
temozolomide cap 100 mg (Temodar)............................ 10
92
terazosin hcl cap 1 mg..................................................... 25
terazosin hcl cap 10 mg................................................... 25
terbinafine hcl tab 250 mg (Lamisil)................................. 4
terbutaline sulfate tab 2.5 mg......................................... 28
terbutaline sulfate tab 5 mg............................................ 28
terconazole vaginal cream 0.4% (Terazol 7).................. 32
terconazole vaginal cream 0.8% (Terazol 3).................. 32
terconazole vaginal suppos 80 mg.................................32
testosterone td gel 12.5 mg/act (1%) (Androgel
pump)................................................................................ 11
testosterone td gel 25 mg/2.5gm (1%) (Androgel)........ 11
testosterone td gel 50 mg/5gm (1%) (Androgel)........... 11
tetrabenazine tab 12.5 mg (Xenazine)............................ 40
tetrabenazine tab 25 mg (Xenazine)............................... 40
TETRACYCLINE HCL – tetracycline hcl cap 250 mg.......... 3
TETRACYCLINE HCL – tetracycline hcl cap 500 mg.......... 3
THALOMID – thalidomide cap 50 mg................................ 61
THALOMID – thalidomide cap 100 mg.............................. 61
theophylline soln 80 mg/15ml......................................... 28
theophylline tab sr 12hr 100 mg..................................... 28
thiothixene cap 1 mg........................................................ 37
thiothixene cap 10 mg...................................................... 37
tiagabine hcl tab 2 mg (Gabitril)..................................... 47
tiagabine hcl tab 4 mg (Gabitril)..................................... 47
timolol maleate ophth gel forming soln 0.25%
(Timoptic-xe).................................................................... 53
timolol maleate ophth gel forming soln 0.5%
(Timoptic-xe).................................................................... 53
timolol maleate ophth soln 0.25% (Timoptic)................ 53
timolol maleate ophth soln 0.5% (Timoptic).................. 53
TIMOLOL MALEATE – timolol maleate tab 5 mg.............. 20
TIMOLOL MALEATE – timolol maleate tab 10 mg............ 20
TIMOLOL MALEATE – timolol maleate tab 20 mg............ 20
tinidazole tab 250 mg (Tindamax)..................................... 7
tinidazole tab 500 mg (Tindamax)..................................... 7
TIVICAY – dolutegravir sodium tab 50 mg (base equiv)...... 6
tizanidine hcl cap 2 mg (base equivalent)
(Zanaflex).......................................................................... 49
(Zanaflex).......................................................................... 49
(Zanaflex).......................................................................... 49
2016
tizanidine hcl tab 2 mg (base equivalent)...................... 49
tizanidine hcl tab 4 mg (base equivalent)
(Zanaflex).......................................................................... 49
tobramycin-dexamethasone ophth susp 0.3-0.1%
(Tobradex)......................................................................... 53
tobramycin nebu soln 300 mg/5ml (Tobi)........................ 3
tobramycin ophth soln 0.3% (Tobrex)............................ 52
TOBREX – tobramycin ophth oint 0.3%............................. 52
tolazamide tab 250 mg..................................................... 15
tolmetin sodium cap 400 mg........................................... 44
tolterodine tartrate cap sr 24hr 2 mg (Detrol la)............32
tolterodine tartrate cap sr 24hr 4 mg (Detrol la)............32
tolterodine tartrate tab 1 mg (Detrol)............................. 32
tolterodine tartrate tab 2 mg (Detrol)............................. 32
topiramate sprinkle cap 15 mg (Topamax sprinkle)..... 47
topiramate sprinkle cap 25 mg (Topamax sprinkle)..... 47
topiramate tab 25 mg (Topamax).................................... 47
topiramate tab 50 mg (Topamax).................................... 47
topiramate tab 100 mg (Topamax).................................. 47
topiramate tab 200 mg (Topamax).................................. 47
torsemide tab 5 mg (Demadex)....................................... 24
torsemide tab 10 mg (Demadex)..................................... 24
torsemide tab 20 mg (Demadex)..................................... 24
torsemide tab 100 mg (Demadex)................................... 24
TOUJEO SOLOSTAR – insulin glargine soln pen-injector
300 unit/ml......................................................................... 15
TRACLEER – bosentan tab 62.5 mg................................. 25
TRACLEER – bosentan tab 125 mg.................................. 25
tramadol-acetaminophen tab 37.5-325 mg
(Ultracet)........................................................................... 43
tramadol hcl tab 50 mg (Ultram)..................................... 43
tramadol hcl tab sr 24hr biphasic release 100 mg........ 43
tramadol hcl tab sr 24hr 100 mg (Ultram er)................. 43
trandolapril tab 1 mg (Mavik).......................................... 18
tranexamic acid tab 650 mg (Lysteda)........................... 52
TRANSDERM-SCOP – scopolamine td patch 72hr 1
mg/3days............................................................................30
tranylcypromine sulfate tab 10 mg (Parnate)................ 35
TRAVATAN Z – travoprost ophth soln 0.004%
(benzalkonium free) (bak free)......................................... 53
trazodone hcl tab 50 mg.................................................. 35
trazodone hcl tab 100 mg................................................ 35
tretinoin cap 10 mg...........................................................10
tretinoin cream 0.025% (Retin-a).....................................55
tretinoin cream 0.05% (Retin-a).......................................55
tretinoin cream 0.1% (Retin-a).........................................55
tretinoin gel 0.025%, (Retin-a)......................................... 55
tretinoin gel 0.05% (Atralin)............................................. 55
tretinoin gel 0.01% (Retin-a)............................................ 55
tretinoin microsphere gel 0.04% (Retin-a micro).......... 55
tretinoin microsphere gel 0.1% (Retin-a micro)............ 55
triamcinolone acetonide cream 0.025%......................... 57
triamcinolone acetonide cream 0.1%............................. 57
triamcinolone acetonide cream 0.5%............................. 57
triamcinolone acetonide dental paste 0.1%.................. 54
triamcinolone acetonide lotion 0.025%.......................... 57
triamcinolone acetonide lotion 0.1%.............................. 57
triamcinolone acetonide nasal aerosol suspension 55
mcg/act (Nasacort aq).................................................... 26
triamcinolone acetonide oint 0.025%............................. 57
triamcinolone acetonide oint 0.1%................................. 57
TRIAMCINOLONE ACETONIDE – triamcinolone
acetonide oint 0.5%.......................................................... 57
TRIAMTERENE/HYDROCHLOROTH – triamterene &
hydrochlorothiazide cap 50-25 mg................................... 24
triamterene & hydrochlorothiazide cap 37.5-25 mg
(Dyazide)........................................................................... 24
triamterene & hydrochlorothiazide tab 37.5-25 mg
(Maxzide-25)..................................................................... 24
triamterene & hydrochlorothiazide tab 75-50 mg
(Maxzide)........................................................................... 24
trifluoperazine hcl tab 1 mg............................................ 37
trifluoperazine hcl tab 10 mg.......................................... 37
trifluridine ophth soln 1% (Viroptic)............................... 52
trihexyphenidyl hcl elixir 0.4 mg/ml............................... 48
trihexyphenidyl hcl tab 2 mg...........................................48
trihexyphenidyl hcl tab 5 mg...........................................48
trimethobenzamide hcl cap 300 mg (Tigan).................. 30
trimethoprim tab 100 mg................................................... 7
TRINATE – prenatal vit w/ fe fumarate-fa tab 28-1 mg...... 49
TRIUMEQ – abacavir-dolutegravir-lamivudine tab
600-50-300 mg.................................................................... 6
TRI-VIT/FLUORIDE/IRON – pediatric vitamins acd fluoride
& fe drops 0.25-10 mg/ml................................................. 49
tropicamide ophth soln 0.5%.......................................... 54
tropicamide ophth soln 1% (Mydriacyl)......................... 54
trospium chloride cap sr 24hr 60 mg............................. 32
trospium chloride tab 20 mg (Sanctura)........................ 32
TRUVADA – emtricitabine-tenofovir disoproxil fumarate
tab 200-300 mg................................................................... 6
TYBOST – cobicistat tab 150 mg.........................................6
TYKERB – lapatinib ditosylate tab 250 mg (base
equiv)................................................................................. 10
U
ursodiol cap 300 mg (Actigall)........................................ 31
ursodiol tab 250 mg (Urso 250)...................................... 31
ursodiol tab 500 mg (Urso forte).................................... 31
V
VAGIFEM – estradiol vaginal tab 10 mcg.......................... 32
valacyclovir hcl tab 1 gm (Valtrex)................................... 4
93
2016
valacyclovir hcl tab 500 mg (Valtrex)............................... 4
VALCHLOR – mechlorethamine hcl gel 0.016% (base
equivalent)......................................................................... 58
VALCYTE – valganciclovir hcl for soln 50 mg/ml (base
equiv)....................................................................................4
valganciclovir hcl tab 450 mg (base equivalent)
(Valcyte).............................................................................. 4
valproate sodium syrup 250 mg/5ml (base equiv)
(Depakene)........................................................................ 47
valproic acid cap 250 mg (Depakene)............................ 47
valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan
hct)..................................................................................... 19
hct)..................................................................................... 19
valsartan-hydrochlorothiazide tab 160-25 mg (Diovan
hct)..................................................................................... 19
hct)..................................................................................... 19
valsartan-hydrochlorothiazide tab 320-25 mg (Diovan
hct)..................................................................................... 19
valsartan tab 40 mg (Diovan).......................................... 19
valsartan tab 80 mg (Diovan).......................................... 19
valsartan tab 160 mg (Diovan)........................................ 19
valsartan tab 320 mg (Diovan)........................................ 19
vancomycin hcl cap 125 mg (Vancocin hcl).................... 7
vancomycin hcl cap 250 mg (Vancocin hcl).................... 7
venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent)
(Effexor xr)....................................................................... 35
venlafaxine hcl cap sr 24hr 75 mg (base equivalent)
(Effexor xr)....................................................................... 35
venlafaxine hcl cap sr 24hr 150 mg (base equivalent)
(Effexor xr)....................................................................... 35
venlafaxine hcl tab 25 mg................................................35
venlafaxine hcl tab 37.5 mg.............................................35
venlafaxine hcl tab 100 mg..............................................35
venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent)
(Venlafaxine hcl er)......................................................... 35
venlafaxine hcl tab sr 24hr 75 mg (base equivalent)
venlafaxine hcl tab sr 24hr 150 mg (base equivalent)
VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv).......................................................... 28
verapamil hcl cap sr 24hr 120 mg (Verelan).................. 22
verapamil hcl cap sr 24hr 100 mg (Verelan pm)............ 22
verapamil hcl tab cr 120 mg (Calan sr).......................... 22
verapamil hcl tab 80 mg (Calan)..................................... 22
94
verapamil hcl tab 120 mg (Calan)................................... 22
VERAPAMIL HCL – verapamil hcl tab 40 mg.................... 22
VESICARE – solifenacin succinate tab 5 mg.................... 32
VESICARE – solifenacin succinate tab 10 mg...................32
VIAGRA – sildenafil citrate tab 25 mg............................... 25
VIAGRA – sildenafil citrate tab 50 mg............................... 25
VIAGRA – sildenafil citrate tab 100 mg............................. 25
VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/
ml)...................................................................................... 15
VIDEX – didanosine for soln 2 gm....................................... 6
VIDEX – didanosine for soln 4 gm....................................... 6
VIGAMOX – moxifloxacin hcl ophth soln 0.5% (base
equiv)................................................................................. 52
VINACAL B – prenat w/o a w/fecbn-feglu-fa tab 20-1 mg &
vit b6 tab pak.................................................................... 49
VINATE AZ EXTRA – prenatal vit w/ fe bisglycinate
chelate-fa tab 29-1 mg...................................................... 49
VINATE CALCIUM – prenatal vit w/ iron carbonyl-fe glucfa tab 27-1 mg................................................................... 49
VINATE CARE – prenatal w/o a vit w/ fe fum-fa tab chew
40-1 mg..............................................................................49
VINATE C – prenatal w/o a vit w/ fe fumarate-fa tab 30-1
mg...................................................................................... 49
VINATE DHA RF – prenat w/o a w/fefum-methylfolomegas cap 27-1.13 mg................................................... 49
VINATE IC – prenatal w/o a w/fe fum-fe poly-fa cap
162.115.2-1 mg..................................................................49
VINATE II – prenatal vit w/ fe bisglycinate chelate-fa tab
29-1 mg..............................................................................49
VINATE M – prenatal vit w/ sel-fe fumarate-fa tab 27-1
mg...................................................................................... 49
VINATE ONE – prenatal vit w/ fe fumarate-fa tab 60-1
mg...................................................................................... 49
VIRACEPT – nelfinavir mesylate tab 250 mg...................... 6
VIRACEPT – nelfinavir mesylate tab 625 mg...................... 6
VIRAMUNE – nevirapine susp 50 mg/5ml........................... 6
VIRAMUNE XR – nevirapine tab sr 24hr 100 mg................ 6
VIREAD – tenofovir disoproxil fumarate oral powder 40
mg/gm.................................................................................. 6
VIREAD – tenofovir disoproxil fumarate tab 150 mg........... 6
VITEKTA – elvitegravir tab 85 mg........................................ 6
VITEKTA – elvitegravir tab 150 mg...................................... 6
VOLTAREN – diclofenac sodium gel 1%........................... 58
voriconazole for susp 40 mg/ml (Vfend).......................... 4
voriconazole tab 50 mg (Vfend)........................................ 4
voriconazole tab 200 mg (Vfend)...................................... 4
VOTRIENT – pazopanib hcl tab 200 mg (base equiv)....... 10
VYVANSE – lisdexamfetamine dimesylate cap 10 mg...... 39
2016
W
warfarin sodium tab 1 mg (Coumadin).......................... 52
warfarin sodium tab 2.5 mg (Coumadin)....................... 52
warfarin sodium tab 7.5 mg (Coumadin)....................... 52
warfarin sodium tab 10 mg (Coumadin)........................ 52
WELCHOL – colesevelam hcl packet for susp 3.75
gm...................................................................................... 23
WELCHOL – colesevelam hcl tab 625 mg........................ 23
X
XALKORI – crizotinib cap 200 mg..................................... 10
XALKORI – crizotinib cap 250 mg..................................... 10
XARELTO – rivaroxaban tab 10 mg................................... 52
XARELTO STARTER PACK – rivaroxaban tab starter
therapy pack 15 mg & 20 mg........................................... 52
XIFAXAN – rifaximin tab 550 mg......................................... 7
XTANDI – enzalutamide cap 40 mg................................... 10
XULANE – norelgestromin-ethinyl estradiol td ptwk 150-35
mcg/24hr............................................................................ 13
Y
Z
zafirlukast tab 10 mg (Accolate)..................................... 28
zafirlukast tab 20 mg (Accolate)..................................... 28
zaleplon cap 5 mg (Sonata)............................................. 37
zaleplon cap 10 mg (Sonata)........................................... 37
ZELBORAF – vemurafenib tab 240 mg............................. 10
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
3000-10000-16000 unit..................................................... 30
5000-17000-27000 unit..................................................... 30
10000-34000-55000 unit................................................... 30
15000-51000-82000 unit................................................... 30
20000-68000-109000 unit................................................. 30
25000-85000-136000 unit................................................. 30
40000-136000-218000 unit............................................... 30
ZIAGEN – abacavir sulfate soln 20 mg/ml (base equiv)...... 6
zidovudine cap 100 mg (Retrovir).....................................6
zidovudine syrup 10 mg/ml (Retrovir).............................. 6
zidovudine tab 300 mg....................................................... 6
ziprasidone hcl cap 20 mg (Geodon)............................. 37
ZOLINZA – vorinostat cap 100 mg.................................... 10
zolmitriptan orally disintegrating tab 2.5 mg (Zomig
zmt).................................................................................... 45
zolmitriptan orally disintegrating tab 5 mg (Zomig
zmt).................................................................................... 45
zolmitriptan tab 2.5 mg (Zomig)...................................... 45
zolmitriptan tab 5 mg (Zomig)......................................... 45
zolpidem tartrate tab cr 6.25 mg (Ambien cr)................ 37
zolpidem tartrate tab cr 12.5 mg (Ambien cr)................ 37
zolpidem tartrate tab 5 mg (Ambien)..............................37
zolpidem tartrate tab 10 mg (Ambien)............................37
zonisamide cap 50 mg..................................................... 47
zonisamide cap 25 mg (Zonegran)................................. 47
zonisamide cap 100 mg (Zonegran)............................... 47
ZORTRESS – everolimus tab 0.25 mg.............................. 61
ZORTRESS – everolimus tab 0.5 mg................................ 61
ZORTRESS – everolimus tab 0.75 mg.............................. 61
ZOVIA 1/50E – ethynodiol diacetate & ethinyl estradiol tab
1 mg-50 mcg..................................................................... 13
ZYCLARA – imiquimod cream 3.75%................................ 58
ZYCLARA PUMP – imiquimod cream 2.5%...................... 58
ZYCLARA PUMP – imiquimod cream 3.75%.................... 58
ZYDELIG – idelalisib tab 100 mg....................................... 10
ZYDELIG – idelalisib tab 150 mg....................................... 10
ZYKADIA – ceritinib cap 150 mg....................................... 10
ZYLET – loteprednol etabonate-tobramycin ophth susp
0.5-0.3%............................................................................. 53
ZYTIGA – abiraterone acetate tab 250 mg........................ 10
ZYVOX – linezolid for susp 100 mg/5ml.............................. 7
95

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

Transcription

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