Horizon BCBSNJ Health Insurance Marketplace

Transcription

July 2015
Horizon Blue Cross Blue Shield of New Jersey Drug Guide
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide
Contents
Introduction ...................................................................... I
Drug selection .................................................................. I
Generic drugs .................................................................. I
Member Prescription Benefit .......................................... II
Affordable Care Act ........................................................ II
Utilization Management .................................................. II
Prior Authorization/Medical Necessity Review
and Determination .......................................................... II
Quantity Limits ............................................................... III
“Smart” Prior Authorization ............................................ III
Specialty ........................................................................ III
How to use this list ......................................................... IV
Abbreviation/acronym key .............................................. V
Anti-Infective Drugs ..................................................... 1
Biologicals.................................................................. 14
Antineoplastic Agents ................................................ 14
Endocrine And Metabolic Drugs ................................ 19
Cardiovascular Agents .............................................. 40
Respiratory Agents .................................................... 61
Gastrointestinal Agents ............................................. 70
Genitourinary Agents ................................................. 78
Central Nervous System Drugs ................................. 82
Analgesics and Anesthetics..................................... 102
Neuromuscular Drugs .............................................. 117
Nutritional Products ................................................. 127
Hematological Agents .............................................. 142
Topical Products ...................................................... 149
Miscellaneous Products........................................... 175
Index ....................................................................... 237
Please consider talking to your doctor about prescribing generic and preferred brand medicines, which may help
reduce your out-of-pocket costs. This Drug Guide may help you and your doctor to choose an appropriate medicine.
The Drug Guide is regularly updated. Please visit http://www.HorizonBlue.com/formulary or
https://www.myprime.com/v/HBCBSNJ/COMMERCIAL/NJIADVANT/en/find-medicine.html, for the most up-to-date
Drug Guide.
To search for a medicine 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.
An Independent Licensee of the Blue Cross and Blue Shield Association
A=$0 PREVENTIVE DRUGS
THIS FORMULARY (DRUG LIST) APPLIES TO HORIZON BCBSNJ’S HEALTH INSURANCE MARKETPLACE INDIVIDUAL AND SMALL
GROUP MEDICAL PRODUCTS. THE APPLICABLE PRODUCTS FOR THE INDIVIDUAL MARKET ARE: HORIZON ADVANCE EPO GOLD,
HORIZON ADVANTAGE EPO GOLD, HORIZON ADVANCE EPO SILVER, HORIZON ADVANCE EPO SILVER 40/70%, HORIZON
ADVANTAGE EPO SILVER, PATIENT CENTERED ADVANTAGE EPO SILVER 20/30/30%, HORIZON ADVANCE EPO BRONZE, HORIZON
ADVANTAGE EPO BRONZE, AND HORIZON ADVANTAGE EPO ESSENTIALS. THE APPLICABLE PRODUCTS FOR THE SMALL GROUP
MARKET ARE: DIRECT ACCESS GOLD 100/80/60 BLUECARD, ADVANTAGE EPO GOLD 100 $20/$40, PATIENT CENTERED ADVANTAGE
EPO GOLD 5/20/40, ADVANTAGE EPO GOLD 100/80, ADVANTAGE EPO SILVER 100/70, ADVANTAGE EPO HSA SILVER 100
COMPATIBLE $750 CONTRIB., PATIENT CENTERED ADVANTAGE EPO SILVER 20/30/70%, ADVANTAGE EPO HSA BRONZE 100
COMPATIBLE, AND PATIENT CENTERED ADVANTAGE EPO BRONZE 40/50%/50%.
5517-E NJ IVL © Prime Therapeutics LLC 07/15
Introduction
Horizon Blue Cross Blue Shield of New Jersey is pleased to present the Advantage Drug Guide for the Health
Insurance Marketplace. Your plan’s covered drug list, or formulary, is a list of medicines that your prescription drug
plan covers. At Horizon BCBSNJ, our goal is to give members access to safe and effective prescription drugs.
Please refer to this guide for information and present the guide to your doctor if you require a prescription.
The drug list in this guide applies to Horizon BCBSNJ’s Health Insurance Marketplace individual and small group
products. The applicable products for the individual market are: Horizon Advance EPO Gold, Horizon Advantage
EPO Gold, Horizon Advance EPO Silver, Horizon Advance EPO Silver 40/70%, Horizon Advantage EPO Silver,
Patient Centered Advantage EPO Silver 20/30/30%, Horizon Advance EPO Bronze, Horizon Advantage EPO
Bronze, and Horizon Advantage EPO Essentials. The applicable products for the small group market are: Direct
Access Gold 100/80/60 BlueCard, Advantage EPO Gold 100 $20/$40, Patient Centered Advantage EPO Gold
5/20/40, Advantage EPO Gold 100/80, Advantage EPO Silver 100/70, Advantage EPO HSA Silver 100 Compatible
$750 Contrib., Patient Centered Advantage EPO Silver 20/30/70%, Advantage EPO HSA Bronze 100 Compatible,
and Patient Centered Advantage EPO Bronze 40/50%/50%.
Drug selection
Each medicine chosen for the drug list was analyzed for its safety, efficacy and value by our Pharmacy and
Therapeutics (P&T) Committee. The P&T Committee is made up of local, independent practicing doctors and
pharmacists and meets at least quarterly. Decisions to add or remove medicines from the Advantage Drug List for
the Health Insurance Marketplace are based on safety, efficacy, uniqueness and cost. You can find recent changes
and the most current version of this Drug Guide at https://www.myprime.com/content/myprime/en/findmedicine.html or by logging into Member On-Line Services at http://www.HorizonBlue.com. New medicines are
considered Non-Preferred (Tier 3) until reviewed and approved for inclusion on the drug list by the P&T Committee.
Horizon BCBSNJ encourages doctors to prescribe Generic (Tier 1) and Preferred (Tier 2) medicines. While
coverage is provided for Non-Preferred drugs (Tier 3), members pay more for them.
Generic drugs
We encourage the use of generics as a way to provide high-quality at a lower cost. Generics are as safe and
effective as their brand counterparts, but are usually less expensive. Generics are manufactured under the same
strict requirements of the Food and Drug Administration’s (FDA’s) current Good Manufacturing Practice regulations
required for brand drugs in manufacturing, strength, purity and quality.
An FDA-approved generic drug may be substituted for the brand equivalent when 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 use of generics, Tier 2 Preferred brand drugs typically move to Tier 3 after an equivalent generic drug
becomes available.
If you choose to receive a brand name prescription drug and a generic equivalent is available, you may be subject
to a reduced benefit and a higher out-of-pocket expense.
I
Horizon BCBSNJ Health Insurance Marketplace Advantage Formulary Drug Guide July 2015
Member prescription benefit
The Horizon BCBSNJ prescription benefit is tiered, placing medicine into one of three copayment/costshare levels:
Generic drugs (Tier 1), Preferred brand drugs (Tier 2) and Non-Preferred brand drugs (Tier 3).
Tier 1 – Lowest copayment/costshare – Generic drugs. Tier 1 includes all generic medicines, although not all
generics are listed in the Drug Guide.
Tier 2 – Middle copayment/costshare – Preferred brand drugs.
Tier 3 – Highest copayment/costshare – Non-Preferred brand drugs.
The Advantage Drug List for the Health Insurance Marketplace is an open formulary. This means all FDA approved
medicines are included. However, certain drug classes are excluded from coverage. Investigational , cosmetic
(such as Propecia for hair growth) and erectile dysfunction (such as Viagra) drugs are excluded (not covered).
Coverage, copayment, and additional restrictions and exclusions may vary depending on the individual plan design.
Please refer to the policy and benefit information you received from Horizon BCBSNJ.
Affordable Care Act
Please note, some medicines may have limited or $0 cost-sharing under the Affordable Care Act. These are
indicated on the drug list with the letter A. Examples of categories that may be subject to limited or $0 cost share
include aspirin, breast cancer preventive, fluoride supplements, folic acid supplements, gonorrhea prophylaxis
(newborn), iron supplements, some tobacco cessation, vitamin D supplements, and some contraceptive (birth
control) drugs and devices. If you do not find the medicine you are searching for, call Pharmacy Member Services
to find out if the drug is available over-the-counter, or is covered under your medical benefit.
Utilization management (UM)
Some medicines have special requirements where your doctor must provide clinical information to Horizon BCBSNJ
before the medicine will be approved and covered by the plan. This is called utilization management. Medicines
that require Prior Authorization (PA), Medical Necessity Review and Determination (MND), a “Smart” Prior
Authorization process (“Smart” PA) or that are subject to a Quantity Limit (QL) are noted on the drug list.
Prior Authorization/Medical Necessity Review and Determination
Prior Authorization (PA) means that specific clinical criteria must be met to demonstrate the medical necessity of the
medicine before coverage can be approved. Only medicines that are medically necessary are approved. This
ensures safe and proper use of the medicine. If this drug list shows that you need a PA for a medicine, your doctor
must send a PA request to Horizon BCBSNJ for review. You and your doctor will be notified in writing of the
decision. If the PA request is approved, your medicine will be covered by your plan. If the PA request is not
approved, there is an appeals process available, or you may choose to buy the medicine at your own expense.
Also, some medicines may be reviewed for medical necessity from time to time, even though they are not subject to
our PA requirements. If so, your prescribing doctor may be asked for clinical information to support your use of the
medicine. In instances where the medical necessity determination (MND) results in an unfavorable decision, please
remember such determinations may also be eligible for the appeals process or you may choose to buy the medicine
at your own expense.
Detailed PA/MND information can be found here.
II
Quantity Limits
A Quantity Limit (QL) controls the maximum amount of medicine covered per prescription. It can also identify
gender or age restrictions and amount of medicine. Quantity limits are placed in certain categories and are based
upon FDA-approved drug labeling. These limits help encourage safe and proper use. If the drug list shows that
there is a QL, your doctor must submit a PA request to Horizon BCBSNJ for review if he/she wants to exceed the
QL for your medicine. Clinical information will be required to be submitted with the PA request to explain why you
need to exceed the quantity limit. If the PA request is approved, your medicine will be covered by your plan. If the
request is not approved, there is an appeals process available to you or you may choose to buy the medicine at
your own expense.
Detailed QL information can be found here.
“Smart” Prior Authorization
The “Smart” Prior Authorization (“Smart” PA) process applies to certain therapeutic drug classes. If the drug list
shows that “Smart” PA is used for a certain medicine, it requires the previous use of one or more medicines (usually
a generic drug) before a different medicine (usually a brand name drug) is covered. The “Smart” PA process will
automatically search for the previous use of one or more of the required generic drugs before the brand name drug
will be covered. If that previous use history is present, the request for the brand name drug will be approved
automatically.
If the “Smart” PA process applies, you must first use a generic. Or your doctor must submit a PA request to Horizon
BCBSNJ stating the clinical reason(s) why you cannot use the generic and that the brand is medically necessary If
the PA request is approved, your medicine will be covered by your plan. If the request is not approved, there is an
appeals process available to you or you may choose to buy the medicine at your own expense.
Detailed “Smart” PA information can be found here.
Specialty
Specialty pharmaceuticals require special patient monitoring and handling, and unique education prior to use.
These specialty medicines also require your doctor to submit a Prior Authorization (PA) request to Horizon BCBSNJ
for review.
Horizon BCBSNJ has contracted with select specialty pharmacies that specialize in these therapies. Members who
want to minimize their cost-sharing are required to obtain the specialty medicines from a participating specialty
pharmacy. To find out more information about our Specialty Rx Program and to see the list and phone numbers of
the participating specialty pharmacies, please refer to the following webpage:
http://www.horizonblue.com/specialtyrx
III
How to use this list
The drug list is organized into broad categories (e.g. ANTINEOPLASTIC AGENTS AND RELATED DRUGS).
The graphic below shows the information that is provided in each column of the drug list and is an example only.
Please use the drug search function to find current information for drugs on the drug 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 the drug tier.
These columns indicate the Utilization Management (UM) program(s) that apply to the prescription drug
(e.g., Prior Authorization/Medical Necessity Determination (PA/MND), “Smart” Prior Authorization (“Smart” PA)
and Quantity Limits. If an indicator is present in the column(s), then the UM program applies.
The last column indicates if the drug is a specialty drug.
IV
Abbreviation/acronym key
cap .............................................................. capsules
chew .......................................................... chewable
conc ........................................................concentrate
cr ................................................... controlled release
dr ...................................................... delayed release
ec ......................................................... enteric coated
effe ......................................................... effervescent
equiv ......................................................... equivalent
er ....................................................extended release
inhal ........................................................... inhalation
inj.................................................................. injection
liq....................................................................... liquid
lotn .................................................................... lotion
nebu ............................................................ nebulizer
odt ...................................... orally disintegrating tabs
oint ..............................................................ointment
ophth.......................................................... opthalmic
osm .................................................. osmotic release
powd ..............................................................powder
sa ..................................................... sustained action
sl ............................................................... sublingual
soln ............................................................... solution
sr ................................................... sustained release
suppose .............................................. suppositories
susp ....................................................... suspension
tab…................................................................ tablets
td… ......................................................... transdermal
This guide is subject to change. Please visit our web site, https://www.myprime.com/content/myprime/en/findmedicine.html, for the most current information.
V
ANTI-INFECTIVE AGENTS
PENICILLINS
amoxicillin & k clavulanate tab
250-125 mg
1
AMOXICILLIN - amoxicillin
(trihydrate) chew tab 125 mg
1
500-125 mg (Augmentin)
1
AMOXICILLIN - amoxicillin
(trihydrate) chew tab 250 mg
1
875-125 mg (Augmentin)
1
amoxicillin (trihydrate) cap
250 mg
1
AMOXICILLIN ER - amoxicillin
(trihydrate) tab sr 24hr 775 mg
1
amoxicillin (trihydrate) cap
500 mg
1
AMPICILLIN - ampicillin for susp
125 mg/5ml
1
amoxicillin (trihydrate) for susp
125 mg/5ml
1
AMPICILLIN - ampicillin for susp
250 mg/5ml
1
200 mg/5ml
1
ampicillin cap 250 mg
1
ampicillin cap 500 mg
1
250 mg/5ml
1
AUGMENTIN - amoxicillin & k
clavulanate tab 500-125 mg
3
400 mg/5ml
1
clavulanate tab 875-125 mg
3
amoxicillin (trihydrate) tab
500 mg
1
3
amoxicillin (trihydrate) tab
875 mg
1
clavulanate chew tab 200-28.5
mg
3
amoxicillin & k clavulanate chew
tab 200-28.5 mg
1
clavulanate for susp 125-31.25
mg/5ml
amoxicillin & k clavulanate chew
tab 400-57 mg
1
3
amoxicillin & k clavulanate for
susp 200-28.5 mg/5ml
1
clavulanate for susp 250-62.5
mg/5ml
3
amoxicillin & k clavulanate
for susp 250-62.5 mg/5ml
(Augmentin)
1
AUGMENTIN ES-600 - amoxicillin
& k clavulanate for susp 600-42.9
mg/5ml
3
amoxicillin & k clavulanate for
susp 400-57 mg/5ml
1
AUGMENTIN XR - amoxicillin
& k clavulanate tab sr 12hr
1000-62.5 mg
1
dicloxacillin sodium cap 250 mg
1
amoxicillin & k clavulanate
for susp 600-42.9 mg/5ml
(Augmentin es-600)
dicloxacillin sodium cap 500 mg
1
amoxicillin & k clavulanate tab sr
12hr 1000-62.5 mg (Augmentin
xr)
1
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
MOXATAG - amoxicillin (trihydrate) 3
tab sr 24hr 775 mg
1
penicillin v potassium tab
250 mg
1
penicillin v potassium tab
500 mg
1
CEPHALOSPORINS
cefpodoxime proxetil for susp
100 mg/5ml
1
1
CEDAX - ceftibuten cap 400 mg
3
cefpodoxime proxetil for susp
50 mg/5ml
CEDAX - ceftibuten for susp 90
mg/5ml
3
cefpodoxime proxetil tab 100 mg
1
cefpodoxime proxetil tab 200 mg
1
CEDAX - ceftibuten for susp 180
mg/5ml
3
cefprozil for susp 125 mg/5ml
1
cefprozil for susp 250 mg/5ml
1
cefprozil tab 250 mg
1
cefprozil tab 500 mg
1
CEFTIBUTEN - ceftibuten cap 400
mg
1
CEFTIBUTEN - ceftibuten for susp
180 mg/5ml
1
CEFACLOR - cefaclor for susp 125 1
mg/5ml
mg/5ml
mg/5ml
1
cefaclor cap 250 mg
cefaclor cap 500 mg
1
CEFACLOR ER - cefaclor
monohydrate tab sr 12hr 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
cefazolin sodium for inj 1 gm
1
cefazolin sodium for inj 500 mg
1
cefdinir cap 300 mg
1
cefdinir for susp 125 mg/5ml
1
cefdinir for susp 250 mg/5ml
1
CEFDITOREN PIVOXIL cefditoren pivoxil tab 200 mg
(base equivalent)
1
CEFDITOREN PIVOXIL cefditoren pivoxil tab 400 mg
(base equivalent)
1
cefixime for susp 100 mg/5ml
(Suprax)
1
cefixime for susp 200 mg/5ml
(Suprax)
1
2
CEFTIN - cefuroxime axetil tab 250 3
mg
CEFTIN - cefuroxime axetil tab 500 3
mg
3
CEFTIN - cefuroxime axetil for
susp 125 mg/5ml
3
CEFTIN - cefuroxime axetil for
susp 250 mg/5ml
1
cefuroxime axetil tab 250 mg
(Ceftin)
1
cefuroxime axetil tab 500 mg
(Ceftin)
CEPHALEXIN - cephalexin tab 250 1
mg
CEPHALEXIN - cephalexin tab 500 1
mg
1
cephalexin cap 250 mg (Keflex)
1
1
cephalexin for susp 125 mg/5ml
1
cephalexin for susp 250 mg/5ml
1
KEFLEX - cephalexin cap 250 mg
3
3
3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
SPECTRACEF - cefditoren pivoxil
tab 200 mg (base equivalent)
3
clarithromycin tab sr 24hr
500 mg (Biaxin xl pac)
1
•
SPECTRACEF - cefditoren pivoxil
3
clarithromycin tab 250 mg
(Biaxin)
1
•
SUPRAX - cefixime cap 400 mg
3
1
•
SUPRAX - cefixime chew tab 100
mg
3
clarithromycin tab 500 mg
(Biaxin)
DIFICID - fidaxomicin tab 200 mg
3
•
SUPRAX - cefixime chew tab 200
mg
3
3
SUPRAX - cefixime for susp 100
mg/5ml
3
E.E.S. GRANULES - erythromycin
ethylsuccinate for susp 200
mg/5ml
3
mg/5ml
3
E.E.S. 400 - erythromycin
ethylsuccinate tab 400 mg
2
mg/5ml
3
ERY-TAB - erythromycin tab
delayed release 250 mg
2
2
ERYPED 200 - erythromycin
mg/5ml
3
ERYPED 400 - erythromycin
mg/5ml
3
ERYTHROCIN STEARATE erythromycin stearate tab 250
mg
3
ERYTHROMYCIN BASE erythromycin tab 250 mg
1
ERYTHROMYCIN BASE erythromycin tab 500 mg
1
ERYTHROMYCIN
ETHYLSUCCINA - erythromycin
ethylsuccinate tab 400 mg
1
ERYTHROMYCIN STEARATE erythromycin stearate tab 250
mg
1
MACROLIDES
•
AZITHROMYCIN - azithromycin
powd pack for susp 1 gm
1
azithromycin for susp
100 mg/5ml (Zithromax)
1
azithromycin for susp
200 mg/5ml (Zithromax)
1
azithromycin tab 250 mg
(Zithromax)
1
•
(Zithromax)
1
•
(Zithromax)
1
•
BIAXIN - clarithromycin tab 250 mg 3
BIAXIN - clarithromycin tab 500 mg 3
•
•
BIAXIN - clarithromycin for susp
250 mg/5ml
3
BIAXIN XL - clarithromycin tab sr
24hr 500 mg
3
BIAXIN XL PAC - clarithromycin
tab sr 24hr 500 mg
3
clarithromycin for susp
125 mg/5ml
1
erythromycin w/ delayed release
particles cap 250 mg
1
clarithromycin for susp
250 mg/5ml (Biaxin)
1
PCE - erythromycin w/ enteric
coated particles tab 333 mg
3
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
3
1
DORYX - doxycycline hyclate tab
3
•
DORYX - doxycycline hyclate tab
3
3
ZITHROMAX - azithromycin for
susp 200 mg/5ml
doxycycline hyclate cap 100 mg
(Vibramycin)
1
3
1
ZITHROMAX - azithromycin powd
pack for susp 1 gm
•
doxycycline hyclate cap 50 mg
3
ZITHROMAX TRI-PAK azithromycin tab 500 mg
3
•
doxycycline hyclate tab delayed
release 100 mg
ZITHROMAX Z-PAK - azithromycin 3
tab 250 mg
3
ZMAX - azithromycin extended
release for oral susp 2 gm
•
3
ZITHROMAX - azithromycin tab
600 mg
3
ZITHROMAX - azithromycin for
susp 100 mg/5ml
•
TETRACYCLINES
•
•
1
•
•
release 150 mg (Doryx)
1
•
•
release 75 mg
1
•
•
doxycycline hyclate tab 100 mg
1
doxycycline hyclate tab 20 mg
1
•
•
3
•
•
doxycycline monohydrate cap
100 mg (Monodox)
1
ACTICLATE - doxycycline hyclate
tab 75 mg
3
•
•
150 mg (Adoxa)
1
ACTICLATE - doxycycline hyclate
tab 150 mg
ADOXA - doxycycline monohydrate 3
cap 150 mg
tab 50 mg
tab 75 mg
tab 100 mg
3
ADOXA PAK 1/100 - doxycycline
monohydrate tab 100 mg
3
3
•
•
50 mg
1
•
•
75 mg (Monodox)
1
•
•
doxycycline monohydrate for
susp 25 mg/5ml (Vibramycin)
1
•
•
doxycycline monohydrate tab
100 mg (Adoxa pak 1/100)
1
•
•
•
•
150 mg (Adoxa pak 1/150)
1
•
•
•
•
50 mg (Adoxa)
1
•
•
•
•
75 mg (Adoxa)
1
•
•
MINOCIN - minocycline hcl cap 50
mg
3
•
4
Specialty
demeclocycline hcl tab 300 mg
500 mg
•
Quantity Limits
Prior Authorization
•
3
Drug Name
"Smart" PA
Drug Tier
1
250 mg
Specialty
demeclocycline hcl tab 150 mg
3
Quantity Limits
•
PCE - erythromycin w/ enteric
coated particles tab 500 mg
"Smart" PA
3
Drug Tier
AVIDOXY DK - doxycycline tab
100 mg & suncreen & sal acid
wash 2% kit
Drug Name
Prior Authorization
2015
•
•
MINOCIN - minocycline hcl cap
100 mg
3
•
SOLODYN - minocycline hcl tab sr
24hr 105 mg
3
•
•
MINOCIN KIT - minocycline hcl cap 3
50 mg w/ acne care products kit
MINOCIN KIT - minocycline hcl cap 3
100 mg w/ acne care products kit
1
minocycline hcl cap 100 mg
(Minocin)
1
(Minocin)
1
(Minocin)
1
minocycline hcl tab sr 24hr
135 mg
1
45 mg
1
90 mg
1
minocycline hcl tab 100 mg
•
24hr 115 mg
3
•
•
•
TETRACYCLINE HCL tetracycline hcl cap 250 mg
1
TETRACYCLINE HCL tetracycline hcl cap 500 mg
1
VIBRAMYCIN - doxycycline
monohydrate for susp 25 mg/5ml
3
•
VIBRAMYCIN - doxycycline hyclate 3
cap 100 mg
3
VIBRAMYCIN - doxycycline
calcium syrup 50 mg/5ml
•
•
•
•
•
FLUOROQUINOLONES
•
•
AVELOX - moxifloxacin hcl tab 400
mg (base equiv)
1
1
MONODOX - doxycycline
monohydrate cap 75 mg
3
•
MONODOX - doxycycline
monohydrate cap 100 mg
3
•
MORGIDOX 1X100MG doxycycline hyclate cap 1 x 100
mg w/ cleanser kit
3
•
•
MORGIDOX 2X100MG doxycycline hyclate cap 2 x 100
mg w/ cleanser kit
3
•
•
NUTRIDOX - doxycycline monohyd 3
cap 75 mg w/ omega 3-vit e cap
kit
SOLODYN - minocycline hcl tab sr 3
24hr 55 mg
SOLODYN - minocycline hcl tab sr 3
24hr 65 mg
•
•
•
•
•
•
3
•
AVELOX ABC PACK - moxifloxacin 3
hcl tab 400 mg (base equiv)
CIPRO - ciprofloxacin for oral susp 3
250 mg/5ml (5%) (5 gm/100ml)
3
CIPRO - ciprofloxacin for oral
susp 500 mg/5ml (10%) (10
gm/100ml)
3
CIPRO - ciprofloxacin hcl tab 250
mg (base equiv)
3
CIPRO - ciprofloxacin hcl tab 500
mg (base equiv)
3
CIPRO XR - ciprofloxacinciprofloxacin hcl tab sr 24hr 500
mg (base eq)
3
CIPRO XR - ciprofloxacinciprofloxacin hcl tab sr 24hr 1000
mg(base eq)
1
ciprofloxacin for oral susp
250 mg/5ml (5%) (5 gm/100ml)
(Cipro)
•
Specialty
3
Quantity Limits
Prior Authorization
24hr 80 mg
Drug Name
"Smart" PA
Drug Tier
•
Specialty
3
Quantity Limits
Prior Authorization
MINOCIN - minocycline hcl cap 75
mg
Drug Name
"Smart" PA
Drug Tier
2015
•
•
5
ciprofloxacin for oral
susp 500 mg/5ml (10%)
(10 gm/100ml) (Cipro)
1
CIPROFLOXACIN HCL ciprofloxacin hcl tab 100 mg
(base equiv)
1
ciprofloxacin hcl tab 250 mg
(base equiv) (Cipro)
1
(base equiv) (Cipro)
1
(base equiv)
1
ciprofloxacin-ciprofloxacin hcl
tab sr 24hr 1000 mg(base eq)
(Cipro xr)
1
ciprofloxacin-ciprofloxacin hcl
tab sr 24hr 500 mg (base eq)
(Cipro xr)
1
FACTIVE - gemifloxacin mesylate
tab 320 mg (base equiv)
3
•
LEVAQUIN - levofloxacin tab 250
mg
3
• •
SULFONAMIDES
mg
3
• •
SULFADIAZINE - sulfadiazine tab
500 mg
mg
3
• •
LEVAQUIN - levofloxacin oral soln
25 mg/ml
3
•
levofloxacin oral soln 25 mg/ml
(Levaquin)
1
levofloxacin tab 250 mg
(Levaquin)
1
•
(Levaquin)
1
•
(Levaquin)
1
•
moxifloxacin hcl tab 400 mg
(base equiv) (Avelox)
1
OFLOXACIN - ofloxacin tab 400
mg
1
AMINOGLYCOSIDES
6
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
amikacin sulfate inj 1 gm/4ml
(250 mg/ml)
1
amikacin sulfate inj 500 mg/2ml
(250 mg/ml)
1
BETHKIS - tobramycin nebu soln
300 mg/4ml
3
gentamicin sulfate inj 10 mg/ml
1
gentamicin sulfate inj 40 mg/ml
1
KITABIS PAK - tobramycin nebu
soln 300 mg/5ml
3
neomycin sulfate tab 500 mg
1
paromomycin sulfate cap
250 mg
1
TOBI - tobramycin nebu soln 300
mg/5ml
3
• • •
TOBI PODHALER - tobramycin
inhal cap 28 mg
2
• • •
tobramycin nebu soln
300 mg/5ml (Tobi)
1
• • •
• • •
• • •
1
ANTIMYCOBACTERIAL AGENTS
CYCLOSERINE - cycloserine cap
250 mg
1
ethambutol hcl tab 100 mg
(Myambutol)
1
ethambutol hcl tab 400 mg
(Myambutol)
1
ISONIAZID - isoniazid syrup 50
mg/5ml
1
isoniazid tab 100 mg
1
isoniazid tab 300 mg
1
MYAMBUTOL - ethambutol hcl tab
100 mg
3
MYAMBUTOL - ethambutol hcl tab
400 mg
3
MYCOBUTIN - rifabutin cap 150
mg
3
PASER - aminosalicylic acid cr
granules packet 4 gm
3
PRIFTIN - rifapentine tab 150 mg
3
pyrazinamide tab 500 mg
1
rifabutin cap 150 mg (Mycobutin)
1
RIFADIN - rifampin cap 150 mg
3
RIFADIN - rifampin cap 300 mg
3
RIFAMATE - isoniazid & rifampin
cap 150-300 mg
3
rifampin cap 150 mg (Rifadin)
1
rifampin cap 300 mg (Rifadin)
1
RIFATER - isoniazid-rifampin w/
pyrazinamide tab 50-120-300 mg
3
SEROMYCIN - cycloserine cap
250 mg
2
SIRTURO - bedaquiline fumarate
3
TRECATOR - ethionamide tab 250
mg
3
ANTIFUNGALS
nystatin oral powder
1
ANCOBON - flucytosine cap 250
mg
3
ANCOBON - flucytosine cap 500
mg
3
BIO-STATIN - nystatin cap 500000
unit
3
BIO-STATIN - nystatin cap
1000000 unit
3
CRESEMBA - isavuconazonium
sulfate cap 186 mg
3
DIFLUCAN - fluconazole tab 50 mg 3
3
DIFLUCAN - fluconazole tab 100
mg
3
mg
3
mg
•
•
•
DIFLUCAN - fluconazole for susp
10 mg/ml
3
DIFLUCAN - fluconazole for susp
40 mg/ml
3
fluconazole for susp 10 mg/ml
(Diflucan)
1
fluconazole for susp 40 mg/ml
(Diflucan)
1
fluconazole tab 100 mg (Diflucan)
1
1
1
1
flucytosine cap 250 mg
(Ancobon)
1
flucytosine cap 500 mg
(Ancobon)
1
GRIFULVIN V - griseofulvin
microsize tab 500 mg
3
GRIS-PEG - griseofulvin
ultramicrosize tab 125 mg
3
GRIS-PEG - griseofulvin
ultramicrosize tab 250 mg
3
griseofulvin microsize susp
125 mg/5ml
1
griseofulvin microsize tab
500 mg (Grifulvin v)
1
griseofulvin ultramicrosize tab
125 mg (Gris-peg)
1
griseofulvin ultramicrosize tab
250 mg (Gris-peg)
1
itraconazole cap 100 mg
(Sporanox)
1
ketoconazole tab 200 mg
1
LAMISIL - terbinafine hcl tab 250
mg
3
•
LAMISIL - terbinafine hcl oral
granules packet 125 mg
3
•
LAMISIL - terbinafine hcl oral
granules packet 187.5 mg
3
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
7
NOXAFIL - posaconazole tab
3
•
ATRIPLA - efavirenz-emtricitabinetenofovir df tab 600-200-300 mg
2
NOXAFIL - posaconazole susp 40
mg/ml
2
•
BARACLUDE - entecavir tab 0.5
mg
3
nystatin tab 500000 unit
1
BARACLUDE - entecavir tab 1 mg
3
ONMEL - itraconazole tab 200 mg
3
2
SPORANOX - itraconazole cap
100 mg
3
BARACLUDE - entecavir oral soln
0.05 mg/ml
SPORANOX - itraconazole oral
soln 10 mg/ml
3
SPORANOX PULSEPAK itraconazole cap 100 mg
3
terbinafine hcl tab 250 mg
(Lamisil)
1
VFEND - voriconazole tab 50 mg
3
VFEND - voriconazole tab 200 mg
3
VFEND - voriconazole for susp 40
mg/ml
3
voriconazole for susp 40 mg/ml
(Vfend)
1
voriconazole tab 200 mg (Vfend)
1
voriconazole tab 50 mg (Vfend)
COMBIVIR - lamivudine-zidovudine 3
tab 150-300 mg
2
COMPLERA - emtricitabinerilpivirine-tenofovir df tab
200-25-300 mg
3
COPEGUS - ribavirin tab 200 mg
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
•
•
•
CRIXIVAN - indinavir sulfate cap
200 mg
2
• •
•
CRIXIVAN - indinavir sulfate cap
400 mg
2
•
didanosine delayed release
capsule 125 mg (Videx ec)
1
•
1
•
1
1
•
1
1
•
•
abacavir sulfate tab 300 mg
(base equiv) (Ziagen)
•
•
1
EDURANT - rilpivirine hcl tab 25
mg (base equivalent)
2
abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg
(Trizivir)
EMTRIVA - emtricitabine caps 200
mg
2
•
acyclovir cap 200 mg (Zovirax)
1
•
acyclovir susp 200 mg/5ml
(Zovirax)
EMTRIVA - emtricitabine soln 10
mg/ml
2
1
entecavir tab 0.5 mg (Baraclude)
1
acyclovir tab 400 mg (Zovirax)
1
entecavir tab 1 mg (Baraclude)
1
acyclovir tab 800 mg (Zovirax)
1
EPIVIR - lamivudine tab 150 mg
3
adefovir dipivoxil tab 10 mg
(Hepsera)
1
EPIVIR - lamivudine tab 300 mg
3
2
EPIVIR - lamivudine oral soln 10
mg/ml
3
APTIVUS - tipranavir cap 250 mg
APTIVUS - tipranavir oral soln 100
mg/ml
2
EPIVIR HBV - lamivudine tab 100
mg (hbv)
3
•
•
•
ANTIVIRALS
8
•
•
•
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
2
•
•
ISENTRESS - raltegravir
potassium packet for susp 100
mg (base equiv)
2
•
•
KALETRA - lopinavir-ritonavir tab
100-25 mg
KALETRA - lopinavir-ritonavir tab
200-50 mg
2
•
KALETRA - lopinavir-ritonavir soln
400-100 mg/5ml (80-20 mg/ml)
2
•
lamivudine oral soln 10 mg/ml
(Epivir)
1
•
lamivudine tab 100 mg (hbv)
(Epivir hbv)
1
lamivudine tab 150 mg (Epivir)
1
lamivudine tab 300 mg (Epivir)
1
lamivudine-zidovudine tab
150-300 mg (Combivir)
1
•
•
•
LEXIVA - fosamprenavir calcium
2
•
LEXIVA - fosamprenavir calcium
susp 50 mg/ml (base equiv)
2
•
MODERIBA - ribavirin tab 200 mg
& ribavirin tab 400 mg dose pack
3
•
• •
3
•
MODERIBA - ribavirin tab 400 mg
& ribavirin tab 600 mg dose pack
•
• •
•
MODERIBA 1200 DOSE PACK ribavirin tab 600 mg
3
•
• •
2
•
• •
INVIRASE - saquinavir mesylate
tab 500 mg
•
MODERIBA 800 DOSE PACK ribavirin tab 400 mg
3
2
•
•
potassium tab 400 mg (base
equiv)
NEVIRAPINE - nevirapine susp 50
mg/5ml
1
2
1
•
potassium chew tab 25 mg (base
equiv)
2
•
nevirapine tab sr 24hr 400 mg
(Viramune xr)
nevirapine tab 200 mg (Viramune) 1
2
NORVIR - ritonavir cap 100 mg
potassium chew tab 100 mg
(base equiv)
2
•
•
•
•
•
EPIVIR HBV - lamivudine oral soln
5 mg/ml (hbv)
2
EPZICOM - abacavir sulfatelamivudine tab 600-300 mg
2
EVOTAZ - atazanavir sulfatecobicistat tab 300-150 mg (base
equiv)
2
famciclovir tab 125 mg (Famvir)
1
1
1
FAMVIR - famciclovir tab 125 mg
3
3
3
FLUMADINE - rimantadine
hydrochloride tab 100 mg
3
FUZEON - enfuvirtide for inj 90 mg
2
HARVONI - ledipasvir-sofosbuvir
tab 90-400 mg
2
HEPSERA - adefovir dipivoxil tab
10 mg
3
INTELENCE - etravirine tab 25 mg
2
INTELENCE - etravirine tab 100
mg
2
INTELENCE - etravirine tab 200
mg
2
INVIRASE - saquinavir mesylate
cap 200 mg
•
•
•
•
•
• •
• •
•
•
NORVIR - ritonavir tab 100 mg
2
NORVIR - ritonavir oral soln 80 mg/ 2
ml
3
OLYSIO - simeprevir sodium cap
150 mg (base equivalent)
•
• •
9
3
•
• •
PEG-INTRON - peginterferon
alfa-2b for inj kit 80 mcg/0.5ml
3
•
• •
PEGINTRON - peginterferon
3
•
• •
3
•
• •
3
•
• •
3
•
• •
3
•
• •
PEG-INTRON REDIPEN peginterferon alfa-2b for inj kit 50
mcg/0.5ml
3
•
• •
PREZCOBIX - darunavir-cobicistat
tab 800-150 mg
2
•
• •
•
PEG-INTRON REDIPEN peginterferon alfa-2b for inj kit 80
mcg/0.5ml
•
PREZISTA - darunavir ethanolate
2
3
2
•
PEG-INTRON REDIPEN peginterferon alfa-2b for inj kit
120 mcg/0.5ml
3
•
• •
2
•
3
•
• •
2
PEG-INTRON REDIPEN peginterferon alfa-2b for inj kit
150 mcg/0.5ml
•
2
•
PEG-INTRON REDIPEN PAK 4 peginterferon alfa-2b for inj kit 50
mcg/0.5ml
3
susp 100 mg/ml (base equiv)
REBETOL - ribavirin cap 200 mg
3
REBETOL - ribavirin soln 40 mg/ml
3
PEG-INTRON REDIPEN PAK 4 peginterferon alfa-2b for inj kit 80
mcg/0.5ml
3
•
• •
PEG-INTRON REDIPEN PAK 4
- peginterferon alfa-2b for inj kit
120 mcg/0.5ml
3
•
• •
PEG-INTRON REDIPEN PAK 4
- peginterferon alfa-2b for inj kit
150 mcg/0.5ml
3
•
• •
PEGASYS - peginterferon alfa-2a
inj 180 mcg/ml
2
•
• •
PEGASYS - peginterferon alfa-2a
inj 180 mcg/0.5ml
2
•
• •
PEGASYS PROCLICK peginterferon alfa-2a inj 135
mcg/0.5ml
2
•
• •
PEGASYS PROCLICK peginterferon alfa-2a inj 180
mcg/0.5ml
2
•
• •
10
•
• •
RELENZA DISKHALER - zanamivir 3
aero powder breath activated 5
mg/blister
2
RESCRIPTOR - delavirdine
mesylate tab 100 mg
2
RESCRIPTOR - delavirdine
mesylate tab 200 mg
3
RETROVIR - zidovudine cap 100
mg
3
RETROVIR - zidovudine syrup 10
mg/ml
REYATAZ - atazanavir sulfate cap 2
150 mg (base equiv)
200 mg (base equiv)
300 mg (base equiv)
•
•
Specialty
Quantity Limits
Prior Authorization
• •
Drug Name
"Smart" PA
Drug Tier
•
Specialty
3
Quantity Limits
Prior Authorization
Drug Name
"Smart" PA
Drug Tier
2015
• •
• •
•
•
• •
• •
•
•
•
•
stavudine for oral soln 1 mg/ml
(Zerit)
1
•
2
• •
STRIBILD - elvitegrav-cobicisemtricitab-tenofov tab
150-150-200-300 mg
•
•
• •
SUSTIVA - efavirenz cap 50 mg
2
2
•
• •
SUSTIVA - efavirenz cap 200 mg
3
SUSTIVA - efavirenz tab 600 mg
2
3
•
• •
TAMIFLU - oseltamivir phosphate
cap 30 mg (base equiv)
3
RIBASPHERE RIBAPAK - ribavirin
tab 600 mg
•
•
•
•
3
•
• •
3
tab 200 mg & ribavirin tab 400
mg dose pack
•
3
•
tab 400 mg & ribavirin tab 600
mg dose pack
3
for susp 6 mg/ml (base equiv)
3
•
RIBATAB - ribavirin tab 400 mg
3
RIBATAB - ribavirin tab 600 mg
3
RIBATAB - ribavirin tab 400 mg &
ribavirin tab 600 mg dose pack
3
ribavirin cap 200 mg (Rebetol)
1
ribavirin tab 200 mg (Copegus)
1
rimantadine hydrochloride tab
100 mg (Flumadine)
1
RIMANTALIST - rimantadine tab
100 mg & dietary management
cap pack
3
SELZENTRY - maraviroc tab 150
mg
2
•
SELZENTRY - maraviroc tab 300
mg
2
•
SITAVIG - acyclovir buccal tab 50
mg
3
SOVALDI - sofosbuvir tab 400 mg
2
stavudine cap 15 mg (Zerit)
1
1
1
1
REYATAZ - atazanavir sulfate
oral powder packet 50 mg (base
equiv)
2
RIBASPHERE - ribavirin tab 400
mg
3
•
RIBASPHERE - ribavirin tab 600
mg
3
tab 400 mg
•
• •
•
•
•
• •
• •
• •
TIVICAY - dolutegravir sodium tab
50 mg (base equiv)
2
•
TRIUMEQ - abacavir-dolutegravirlamivudine tab 600-50-300 mg
2
•
•
•
• •
• •
TRIZIVIR - abacavir sulfatelamivudine-zidovudine tab
300-150-300 mg
3
•
TRUVADA - emtricitabine-tenofovir
disoproxil fumarate tab 200-300
mg
2
•
TYBOST - cobicistat tab 150 mg
2
TYZEKA - telbivudine tab 600 mg
2
•
•
valacyclovir hcl tab 1 gm
(Valtrex)
1
valacyclovir hcl tab 500 mg
(Valtrex)
1
VALCYTE - valganciclovir hcl tab
450 mg
3
VALCYTE - valganciclovir hcl for
soln 50 mg/ml (base equiv)
2
valganciclovir hcl tab 450 mg
(Valcyte)
1
VALTREX - valacyclovir hcl tab
500 mg
3
•
• •
•
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
11
VITEKTA - elvitegravir tab 85 mg
2
VITEKTA - elvitegravir tab 150 mg
2
ZERIT - stavudine cap 15 mg
3
3
3
3
ZERIT - stavudine for oral soln 1
mg/ml
3
•
•
•
•
•
•
•
ZIAGEN - abacavir sulfate tab 300
mg (base equiv)
2
•
ZIAGEN - abacavir sulfate soln 20
mg/ml (base equiv)
2
•
zidovudine cap 100 mg (Retrovir)
1
zidovudine syrup 10 mg/ml
(Retrovir)
1
•
•
zidovudine tab 300 mg
1
•
ZOVIRAX - acyclovir cap 200 mg
3
ZOVIRAX - acyclovir tab 400 mg
3
ZOVIRAX - acyclovir tab 800 mg
3
•
ZOVIRAX - acyclovir susp 200
mg/5ml
3
•
ANTIMALARIALS
3
VIDEX - didanosine for soln 2 gm
2
VIDEX - didanosine for soln 4 gm
2
VIDEX EC - didanosine delayed
release capsule 125 mg
3
•
•
• •
3
• •
3
3
VIEKIRA PAK - ombitas-paritapreriton & dasab tab pak 12.5-75-50
& 250 mg
3
VIRACEPT - nelfinavir mesylate
tab 250 mg
2
VIRACEPT - nelfinavir mesylate
tab 625 mg
2
VIRAMUNE - nevirapine tab 200
mg
3
•
VIRAMUNE - nevirapine susp 50
mg/5ml
3
VIRAMUNE XR - nevirapine tab sr
24hr 100 mg
2
VIRAMUNE XR - nevirapine tab sr
24hr 400 mg
3
VIRAZOLE - ribavirin for inhal soln
6 gm
• •
• •
• •
• •
•
•
ARALEN - chloroquine phosphate
tab 500 mg
3
1
3
atovaquone-proguanil hcl tab
250-100 mg (Malarone)
1
VIREAD - tenofovir disoproxil
fumarate tab 150 mg
2
atovaquone-proguanil hcl tab
62.5-25 mg (Malarone)
1
fumarate tab 200 mg
2
chloroquine phosphate tab
250 mg
1
fumarate tab 250 mg
2
chloroquine phosphate tab
500 mg (Aralen)
2
fumarate tab 300 mg
2
COARTEM - artemetherlumefantrine tab 20-120 mg
DARAPRIM - pyrimethamine tab
25 mg
2
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Specialty
Quantity Limits
"Smart" PA
•
VICTRELIS - boceprevir cap 200
mg
12
Prior Authorization
Drug Tier
2
3
•
Drug Name
fumarate oral powder 40 mg/gm
VALTREX - valacyclovir hcl tab 1
gm
•
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
hydroxychloroquine sulfate tab
200 mg (Plaquenil)
1
BACTRIM - sulfamethoxazoletrimethoprim tab 400-80 mg
3
MALARONE - atovaquoneproguanil hcl tab 62.5-25 mg
3
BACTRIM DS - sulfamethoxazoletrimethoprim tab 800-160 mg
3
MALARONE - atovaquoneproguanil hcl tab 250-100 mg
3
2
mefloquine hcl tab 250 mg
1
CAYSTON - aztreonam lysine
for inhal soln 75 mg (base
equivalent)
PLAQUENIL - hydroxychloroquine
sulfate tab 200 mg
3
CLEOCIN - clindamycin hcl cap 75
mg
2
PRIMAQUINE PHOSPHATE primaquine phosphate tab 26.3
mg
1
CLEOCIN - clindamycin hcl cap
150 mg
2
2
QUALAQUIN - quinine sulfate cap
324 mg
3
CLEOCIN - clindamycin hcl cap
300 mg
2
quinine sulfate cap 324 mg
(Qualaquin)
1
CLEOCIN PEDIATRIC GRANULE
- clindamycin palmitate hcl for
soln 75 mg/5ml (base equiv)
clindamycin hcl cap 150 mg
(Cleocin)
1
•
AMEBICIDES
YODOXIN - iodoquinol tab 210 mg
3
3
(Cleocin)
1
YODOXIN - iodoquinol tab 650 mg
ALBENZA - albendazole tab 200
mg
(Cleocin)
1
3
BILTRICIDE - praziquantel tab 600
mg
clindamycin palmitate hcl for
(Cleocin pediatric gr)
1
2
ivermectin tab 3 mg (Stromectol)
1
DAPSONE - dapsone tab 25 mg
1
STROMECTOL - ivermectin tab 3
mg
3
DAPSONE - dapsone tab 100 mg
1
FLAGYL - metronidazole cap 375
mg
3
•
•
FLAGYL - metronidazole tab 250
mg
3
3
•
FLAGYL - metronidazole tab 500
mg
FLAGYL ER - metronidazole tab sr
24hr 750 mg
3
KETEK - telithromycin tab 300 mg
3
ANTHELMINTICS
•
ANTI-INFECTIVE AGENTS - MISC.
ALINIA - nitazoxanide tab 500 mg
2
ALINIA - nitazoxanide for susp 100
mg/5ml
2
atovaquone susp 750 mg/5ml
(Mepron)
1
AZACTAM - aztreonam for inj 1 gm 3
AZACTAM - aztreonam for inj 2 gm 3
aztreonam for inj 1 gm (Azactam)
1
KETEK - telithromycin tab 400 mg
3
aztreonam for inj 2 gm (Azactam)
1
LINCOCIN - lincomycin hcl inj 300
mg/ml
3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
• • •
•
•
13
MEPRON - atovaquone susp 750
mg/5ml
3
metronidazole cap 375 mg
(Flagyl)
1
metronidazole tab 250 mg
(Flagyl)
1
metronidazole tab 500 mg
(Flagyl)
1
NEBUPENT - pentamidine
isethionate for nebulization soln
300 mg
2
PRIMSOL - trimethoprim hcl oral
3
SIVEXTRO - tedizolid phosphate
tab 200 mg
3
sulfamethoxazole-trimethoprim
susp 200-40 mg/5ml
1
tab 400-80 mg (Bactrim)
1
tab 800-160 mg (Bactrim ds)
1
TINDAMAX - tinidazole tab 250 mg
3
TINDAMAX - tinidazole tab 500 mg
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
BIOLOGICALS
VACCINES
BCG VACCINE - bcg vaccine inj
1
VIVOTIF BERNA - typhoid vaccine
cap delayed release
3
TOXOIDS
DAPTACEL - diph, acellular pert &
tet tox inj 15 lf-10 mcg-5 lf/0.5ml
3
DIPHTHERIA/TETANUS TOXOID
- diphtheria-tetanus tox adsorbed
(dt) im inj 25-5 unit/0.5ml
1
INFANRIX - diph, acellular pert &
tet tox inj 25 lf-58 mcg-10 lf/0.5ml
3
KINRIX - diph-tetanus tox ad-acell
pert & polio virus, ipv vac inj
3
PEDIARIX - diph-tetanus tox-acell
pert-hepatitis b-polio ipv vac inj
3
PENTACEL - diph-ac per-tet tox
ad-poliov-haemoph b poly vac for
im susp
3
3
3
QUADRACEL - diph-tetanus tox
ad-acell pert & polio virus, ipv
vac inj
tinidazole tab 250 mg (Tindamax)
1
BIOLOGICALS MISC
tinidazole tab 500 mg (Tindamax)
1
3
•
•
trimethoprim tab 100 mg
1
GRASTEK - timothy grass pollen
allergen ext tab sl 2800 bau
VANCOCIN HCL - vancomycin hcl
cap 125 mg
3
ORALAIR - grass mixed pollen ext
tab sl 300 ir (index of reactivity)
3
•
•
VANCOCIN HCL - vancomycin hcl
cap 250 mg
3
3
•
•
vancomycin hcl cap 125 mg
(Vancocin hcl)
1
RAGWITEK - short ragweed pollen
allergen extract tab sl 12 amb a
1-u
vancomycin hcl cap 250 mg
(Vancocin hcl)
1
ANTINEOPLASTICS
2
•
• •
XIFAXAN - rifaximin tab 200 mg
3
XIFAXAN - rifaximin tab 550 mg
2
ACTIMMUNE - interferon
gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)
3
AFINITOR - everolimus tab 2.5 mg
2
ZYVOX - linezolid tab 600 mg
3
AFINITOR - everolimus tab 5 mg
2
ZYVOX - linezolid for susp 100
mg/5ml
AFINITOR - everolimus tab 7.5 mg
2
•
•
•
• •
• •
• •
14
ANTINEOPLASTIC AGENTS
•
•
ALFERON N - interferon alfa-n3 inj
5000000 unit/ml
2
ALKERAN - melphalan tab 2 mg
2
anastrozole tab 1 mg (Arimidex)
1
ARIMIDEX - anastrozole tab 1 mg
3
AROMASIN - exemestane tab 25
mg
3
bicalutamide tab 50 mg
(Casodex)
1
BOSULIF - bosutinib tab 100 mg
2
BOSULIF - bosutinib tab 500 mg
2
•
CAPRELSA - vandetanib tab 100
mg
2
CAPRELSA - vandetanib tab 300
mg
2
•
CASODEX - bicalutamide tab 50
mg
3
CEENU - lomustine cap 10 mg
2
2
2
COMETRIQ - cabozantinib smalate cap 3 x 20 mg (60 mg
dose) kit
2
COMETRIQ - cabozantinib s-mal
cap 1 x 80 mg & 1 x 20 mg (100
dose) kit
2
COMETRIQ - cabozantinib s-mal
cap 1 x 80 mg & 3 x 20 mg (140
dose) kit
2
capecitabine tab 150 mg (Xeloda) 1
capecitabine tab 500 mg (Xeloda) 1
• •
• •
CYCLOPHOSPHAMIDE cyclophosphamide cap 25 mg
1
1
• •
CYCLOPHOSPHAMIDE cyclophosphamide cap 50 mg
3
• •
• •
ELIGARD - leuprolide acetate for
subcutaneous inj kit 7.5 mg
ELIGARD - leuprolide acetate (3
month) for subcutaneous inj kit
22.5mg
3
• •
30 mg
3
• •
45 mg
3
• •
EMCYT - estramustine phosphate
sodium cap 140 mg
2
ERIVEDGE - vismodegib cap 150
mg
2
•
• •
ETOPOSIDE - etoposide cap 50
mg
1
•
•
exemestane tab 25 mg
(Aromasin)
1
•
• •
•
• •
•
• •
•
•
•
•
•
•
•
•
•
Specialty
2
Quantity Limits
AFINITOR DISPERZ - everolimus
tab for oral susp 5 mg
•
"Smart" PA
2
Prior Authorization
Drug Name
Drug Tier
2
Specialty
•
•
Quantity Limits
2
"Smart" PA
AFINITOR - everolimus tab 10 mg
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
•
•
•
•
•
•
• •
• •
• •
• •
FARESTON - toremifene citrate tab 2
3
FARYDAK - panobinostat lactate
cap 10 mg (base equivalent)
3
3
3
FEMARA - letrozole tab 2.5 mg
•
flutamide cap 125 mg
1
GILOTRIF - afatinib dimaleate tab
2
•
• •
2
•
• •
2
•
• •
15
• •
GLEOSTINE - lomustine cap 10
mg
3
mg
3
mg
3
HEXALEN - altretamine cap 50 mg
2
HYCAMTIN - topotecan hcl cap
0.25 mg (base equiv)
2
HYCAMTIN - topotecan hcl cap 1
mg (base equiv)
2
HYDREA - hydroxyurea cap 500
mg
3
hydroxyurea cap 500 mg
(Hydrea)
1
IBRANCE - palbociclib cap 75 mg
2
2
2
ICLUSIG - ponatinib hcl tab 15 mg
(base equiv)
•
•
•
•
•
•
2
•
•
•
•
•
•
•
•
ICLUSIG - ponatinib hcl tab 45 mg
(base equiv)
2
•
• •
IMBRUVICA - ibrutinib cap 140 mg
2
INLYTA - axitinib tab 1 mg
2
INLYTA - axitinib tab 5 mg
2
INTRON A - interferon alfa-2b for
inj 10000000 unit
2
•
•
•
•
• •
• •
• •
•
inj 18000000 unit
2
•
•
inj 50000000 unit
2
•
INTRON-A - interferon alfa-2b inj
6000000 unit/ml
2
INTRON-A - interferon alfa-2b inj
10000000 unit/ml
2
16
•
•
•
•
•
•
LEUCOVORIN CALCIUM leucovorin calcium tab 10 mg
1
LEUCOVORIN CALCIUM leucovorin calcium tab 15 mg
1
leucovorin calcium tab 25 mg
1
•
leucovorin calcium tab 5 mg
1
2
•
LEUKERAN - chlorambucil tab 2
mg
leuprolide acetate inj kit 5 mg/ml
1
LOMUSTINE - lomustine cap 10
mg
1
•
Specialty
•
Quantity Limits
2
"Smart" PA
GLEEVEC - imatinib mesylate tab
INTRON-A W/DILUENT - interferon 2
alfa-2b for inj 10000000 unit
JAKAFI - ruxolitinib phosphate tab 2
3
LENVIMA 10MG DAILY DOSE lenvatinib cap therapy pak 10 mg
(10 mg daily dose)
3
LENVIMA 14MG DAILY DOSE lenvatinib cap therapy pack 10 &
4 mg (14 mg daily dose)
3
LENVIMA 20MG DAILY DOSE lenvatinib cap therapy pack 10
(2) mg (20 mg daily dose)
3
LENVIMA 24MG DAILY DOSE lenvatinib cap therapy pack 10
(2) & 4 mg (24 mg daily dose)
1
letrozole tab 2.5 mg (Femara)
Prior Authorization
• •
Drug Name
Drug Tier
•
Specialty
2
Quantity Limits
Prior Authorization
GLEEVEC - imatinib mesylate tab
Drug Name
"Smart" PA
Drug Tier
2015
•
•
•
•
•
•
•
• •
•
• •
•
• •
•
• •
•
• •
•
• •
•
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•
• •
•
• •
• •
mg
1
methotrexate sodium inj pf
25 mg/ml
1
mg
1
methotrexate sodium inj 25 mg/
ml
1
LUPRON DEPOT - leuprolide
acetate for inj kit 3.75 mg
2
• •
methotrexate sodium tab 2.5 mg
(base equiv)
1
acetate for inj kit 7.5 mg
2
• •
MYLERAN - busulfan tab 2 mg
2
2
• •
NEXAVAR - sorafenib tosylate tab
2
acetate (3 month) for inj kit 11.25
mg
2
acetate (3 month) for inj kit 22.5
mg
2
• •
NILANDRON - nilutamide tab 150
mg
POMALYST - pomalidomide cap 1
mg
acetate (4 month) for inj kit 30
mg
2
• •
acetate (6 month) for inj kit 45
mg
2
LYNPARZA - olaparib cap 50 mg
2
LYSODREN - mitotane tab 500 mg
2
MATULANE - procarbazine hcl cap
50 mg
2
MEGACE ORAL - megestrol
acetate susp 40 mg/ml
3
megestrol acetate susp 40 mg/ml
(Megace oral)
1
megestrol acetate tab 20 mg
• •
•
•
•
• •
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
• •
2
•
• •
mg
2
•
• •
mg
2
•
• •
mg
2
•
• •
PURIXAN - mercaptopurine susp
2000 mg/100ml (20 mg/ml)
3
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
• •
•
• •
•
• •
SOLTAMOX - tamoxifen citrate oral A
soln 10 mg/5ml (base equivalent)
2
SPRYCEL - dasatinib tab 20 mg
2
2
2
1
2
megestrol acetate tab 40 mg
1
2
MEKINIST - trametinib dimethyl
sulfoxide tab 0.5 mg (base
equivalent)
2
•
• •
MEKINIST - trametinib dimethyl
sulfoxide tab 2 mg (base
equivalent)
2
•
• •
mercaptopurine tab 50 mg
(Purinethol)
1
MESNEX - mesna tab 400 mg
2
STIVARGA - regorafenib tab 40 mg 2
2
SUTENT - sunitinib malate cap
12.5 mg (base equivalent)
SUTENT - sunitinib malate cap 25 2
2
SUTENT - sunitinib malate cap
SUTENT - sunitinib malate cap 50 2
•
•
•
•
•
•
•
•
17
3
•
• •
SYLATRON - peginterferon alfa-2b
for inj kit 444 mcg
2
•
• •
TEMODAR - temozolomide cap
250 mg
3
•
• •
for inj kit 888 mcg
2
•
• •
temozolomide cap 100 mg
(Temodar)
1
•
• •
for inj kit 4 x 296 mcg
2
•
• •
(Temodar)
1
•
• •
for inj kit 4 x 444 mcg
2
•
• •
(Temodar)
1
•
• •
TABLOID - thioguanine tab 40 mg
2
1
•
• •
TAFINLAR - dabrafenib mesylate
2
• •
(Temodar)
1
•
• •
TAFINLAR - dabrafenib mesylate
2
• •
(Temodar)
1
•
• •
tamoxifen citrate tab 10 mg
(base equivalent)
A
(Temodar)
3
tamoxifen citrate tab 20 mg
(base equivalent)
A
THERACYS - bcg live intravesical
for susp 81 mg/vial
TARCEVA - erlotinib hcl tab 25 mg
(base equivalent)
2
TARCEVA - erlotinib hcl tab 100
2
TARCEVA - erlotinib hcl tab 150
2
TARGRETIN - bexarotene cap 75
mg
2
TASIGNA - nilotinib hcl cap 150 mg 2
(base equivalent)
TASIGNA - nilotinib hcl cap 200 mg 2
(base equivalent)
3
TEMODAR - temozolomide cap 5
mg
TEMODAR - temozolomide cap 20 3
mg
3
100 mg
3
140 mg
18
•
•
TICE BCG - bcg live intravesical for 3
susp 50 mg
3
TRELSTAR - triptorelin pamoate
for im susp 3.75 mg
3
TRELSTAR - triptorelin pamoate
for im susp 11.25 mg
3
TRELSTAR MIXJECT - triptorelin
pamoate for im susp 3.75 mg
3
3
1
tretinoin cap 10 mg
•
• •
•
• •
•
• •
•
•
•
• •
•
• •
•
• •
TREXALL - methotrexate sodium
3
•
• •
tab 7.5 mg (base equiv)
3
•
• •
3
•
• •
3
Specialty
180 mg
Quantity Limits
Prior Authorization
• •
Drug Name
"Smart" PA
Drug Tier
•
Specialty
2
Quantity Limits
Prior Authorization
for inj kit 296 mcg
Drug Name
"Smart" PA
Drug Tier
2015
• •
• •
• •
• •
• •
•
• •
dexamethasone elixir 0.5 mg/5ml
1
DEXAMETHASONE INTENSOL dexamethasone conc 1 mg/ml
1
dexamethasone tab 0.5 mg
1
1
1
dexamethasone tab 4 mg
1
dexamethasone tab 6 mg
1
DEXPAK 10 DAY dexamethasone tab 1.5 mg taper
pack
3
DEXPAK 13 DAY dexamethasone tab 1.5 mg taper
pack
3
DEXPAK 6 DAY - dexamethasone
tab 1.5 mg taper pack
3
ENTOCORT EC - budesonide cap
sr 24hr 3 mg
3
FLO-PRED - prednisolone acetate
oral susp 16.7 mg/5ml (15
mg/5ml base)
3
fludrocortisone acetate tab
0.1 mg
1
hydrocortisone tab 10 mg
(Cortef)
1
hydrocortisone tab 20 mg
(Cortef)
1
hydrocortisone tab 5 mg (Cortef)
1
MEDROL - methylprednisolone tab
2 mg
3
4 mg
3
8 mg
3
16 mg
3
32 mg
3
XALKORI - crizotinib cap 250 mg
2
XELODA - capecitabine tab 150
mg
3
•
•
•
XELODA - capecitabine tab 500
mg
3
•
• •
XTANDI - enzalutamide cap 40 mg
2
ZELBORAF - vemurafenib tab 240
2
•
•
• •
• •
ZOLADEX - goserelin acetate
implant 3.6 mg
3
• •
ZOLADEX - goserelin acetate
implant 10.8 mg
3
• •
ZOLINZA - vorinostat cap 100 mg
2
ZYDELIG - idelalisib tab 100 mg
2
ZYDELIG - idelalisib tab 150 mg
2
ZYKADIA - ceritinib cap 150 mg
2
ZYTIGA - abiraterone acetate tab
250 mg
2
ENDOCRINE AND METABOLIC DRUGS
CORTICOSTEROIDS
budesonide cap sr 24hr 3 mg
(Entocort ec)
1
CORTEF - hydrocortisone tab 5 mg 3
3
CORTEF - hydrocortisone tab 10
mg
3
CORTEF - hydrocortisone tab 20
mg
1
CORTISONE ACETATE cortisone acetate tab 25 mg
1
DEXAMETHASONE dexamethasone tab 1 mg
1
DEXAMETHASONE dexamethasone tab 2 mg
•
•
•
•
•
• •
• •
• •
•
•
•
•
•
•
•
•
•
•
Specialty
•
Quantity Limits
VOTRIENT - pazopanib hcl tab 200 2
mg (base equiv)
2
XALKORI - crizotinib cap 200 mg
"Smart" PA
1
Prior Authorization
DEXAMETHASONE dexamethasone soln 0.5 mg/5ml
Drug Name
Drug Tier
• •
Specialty
•
TYKERB - lapatinib ditosylate tab
250 mg (base equiv)
Quantity Limits
Prior Authorization
2
Drug Name
"Smart" PA
Drug Tier
2015
•
19
MEDROL DOSEPAK methylprednisolone tab 4 mg
dose pack
3
prednisolone sod phosph oral
soln 6.7 mg/5ml (5 mg/5ml
base) (Pediapred)
1
methylprednisolone tab 16 mg
(Medrol)
1
1
(Medrol)
1
prednisolone sod phosphate
oral soln 15 mg/5ml (base
equiv)
1
(Medrol)
1
dose pack (Medrol dosepak)
1
PREDNISOLONE SODIUM
PHOSP - prednisolone sodium
phosphate oral soln 25 mg/5ml
(base eq)
1
(Medrol)
1
prednisolone syrup 15 mg/5ml
(usp solution equivalent)
(Prelone)
3
PREDNISONE - prednisone tab 50
mg
1
MILLIPRED - prednisolone tab 5
mg
3
PREDNISONE - prednisone oral
soln 5 mg/5ml
1
MILLIPRED - prednisolone sod
(base equiv)
1
MILLIPRED DP - prednisolone tab
5 mg dose pack
3
mg dose pack
1
ORAPRED ODT - prednisolone
sod phos orally disintegr tab 10
mg (base eq)
3
mg dose pack
PREDNISONE INTENSOL prednisone conc 5 mg/ml
1
mg (base eq)
3
prednisone tab 1 mg
1
prednisone tab 10 mg
1
prednisone tab 2.5 mg
1
mg (base eq)
3
prednisone tab 20 mg
1
prednisone tab 5 mg
1
PEDIAPRED - prednisolone sod
phosph oral soln 6.7 mg/5ml (5
mg/5ml base)
3
RAYOS - prednisone tab delayed
release 1 mg
3
3
prednisolone sod phos orally
disintegr tab 10 mg (base eq)
(Orapred odt)
1
release 2 mg
release 5 mg
3
(Orapred odt)
1
(Orapred odt)
1
20
UCERIS - budesonide tab sr 24hr 9 3
mg
3
VERIPRED 20 - prednisolone sod
(base equiv)
ANDROGEN-ANABOLIC
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
•
ANDRODERM - testosterone td
patch 24hr 2 mg/24hr
2
•
•
NATESTO - testosterone nasal gel
5.5 mg/act
3
•
ANDRODERM - testosterone td
patch 24hr 4 mg/24hr
2
•
•
OXANDRIN - oxandrolone tab 2.5
mg
3
•
ANDROGEL - testosterone td gel
25 mg/2.5gm (1%)
2
•
•
OXANDRIN - oxandrolone tab 10
mg
3
•
50 mg/5gm (1%)
2
•
•
oxandrolone tab 10 mg
(Oxandrin)
1
•
20.25 mg/1.25gm (1.62%)
2
•
•
oxandrolone tab 2.5 mg
(Oxandrin)
1
•
40.5 mg/2.5gm (1.62%)
2
•
•
STRIANT - testosterone buccal
mucoadhesive system 30 mg
3
•
•
ANDROGEL PUMP - testosterone
td gel 12.5 mg/act (1%)
2
•
•
TESTIM - testosterone td gel 50
mg/5gm (1%)
3
•
•
ANDROGEL PUMP - testosterone
td gel 20.25 mg/act (1.62%)
2
•
•
3
ANDROID - methyltestosterone
cap 10 mg
3
•
TESTONE CIK - testosterone
cypionate im inj in oil 200 mg/ml
kit
•
•
AXIRON - testosterone td soln 30
mg/act
3
•
•
danazol cap 100 mg
1
danazol cap 200 mg
1
•
•
danazol cap 50 mg
1
DEPO-TESTOSTERONE testosterone cypionate im in oil
100 mg/ml
3
DEPO-TESTOSTERONE testosterone cypionate im in oil
200 mg/ml
3
FIRST-TESTOSTERONE testosterone propionate td
ointment 2%
3
3
FIRST-TESTOSTERONE MC
COM - testosterone propionate td
cream 2%
3
FORTESTA - testosterone td gel
10mg/act (2%)
•
•
•
•
•
•
•
•
•
•
•
•
•
TESTOSTERONE - testosterone td 1
gel 25 mg/2.5gm (1%)
gel 50 mg/5gm (1%)
gel 10mg/act (2%)
3
TESTOSTERONE - testosterone
cypionate im inj in oil 250 mg/ml
1
testosterone cypionate im
inj in oil 100 mg/ml (Depotestosterone)
1
testosterone cypionate im
inj in oil 200 mg/ml (Depotestosterone)
1
testosterone enanthate im inj in
oil 200 mg/ml
1
TESTOSTERONE PUMP testosterone td gel 12.5 mg/act
(1%)
3
TESTRED - methyltestosterone
cap 10 mg
Specialty
3
Quantity Limits
Prior Authorization
METHITEST - methyltestosterone
oral tab 10 mg
Drug Name
"Smart" PA
Drug Tier
•
Specialty
3
Quantity Limits
Prior Authorization
ANADROL-50 - oxymetholone tab
50 mg
Drug Name
"Smart" PA
Drug Tier
2015
•
•
•
•
•
•
•
21
•
COMBIPATCH - estradiolnorethindrone ace td pttw
0.05-0.14 mg/day
3
•
COMBIPATCH - estradiolnorethindrone ace td pttw
0.05-0.25 mg/day
3
•
DELESTROGEN - estradiol
valerate im in oil 10 mg/ml
3
•
3
•
3
•
•
3
•
DEPO-ESTRADIOL - estradiol
cypionate im in oil 5 mg/ml
3
•
•
DIVIGEL - estradiol td gel 0.25
mg/0.25gm (0.1%)
3
•
•
DIVIGEL - estradiol td gel 0.5
mg/0.5gm (0.1%)
3
•
ESTROGENS
ACTIVELLA - estradiol &
norethindrone acetate tab 0.5-0.1
mg
3
ACTIVELLA - estradiol &
norethindrone acetate tab 1-0.5
mg
3
ALORA - estradiol td patch
biweekly 0.025 mg/24hr
3
3
3
3
ANGELIQ - drospirenone-estradiol
tab 0.25-0.5 mg
3
DIVIGEL - estradiol td gel 1 mg/gm
(0.1%)
3
ANGELIQ - drospirenone-estradiol
tab 0.5-1 mg
3
DUAVEE - conjugated estrogensbazedoxifene tab 0.45-20 mg
3
CLIMARA - estradiol td patch
weekly 0.025 mg/24hr
3
•
ELESTRIN - estradiol gel 0.06%
(0.52 mg/0.87 gm metered-dose
pump)
weekly 0.0375 mg/24hr (37.5
mcg/24hr)
3
•
ENJUVIA - estrogens, conjugated
synthetic b tab 0.3 mg
2
2
weekly 0.05 mg/24hr
3
•
2
weekly 0.06 mg/24hr
3
•
2
weekly 0.075 mg/24hr
3
•
2
weekly 0.1 mg/24hr
3
•
1
CLIMARA PRO - estradiollevonorgestrel td patch weekly
0.045-0.015 mg/day
2
esterified estrogens &
methyltestosterone tab
0.625-1.25 mg
esterified estrogens &
methyltestosterone tab
1.25-2.5 mg
1
22
Specialty
•
Quantity Limits
3
"Smart" PA
VOGELXO PUMP - testosterone td
gel 12.5 mg/act (1%)
Prior Authorization
•
Drug Name
Drug Tier
•
Specialty
3
Quantity Limits
Prior Authorization
VOGELXO - testosterone td gel 50
mg/5gm (1%)
Drug Name
"Smart" PA
Drug Tier
2015
•
•
estradiol & norethindrone
acetate tab 1-0.5 mg (Activella)
•
ESTROGEL - estradiol gel 0.06%
(0.75 mg/1.25 gm metered-dose
pump)
3
ESTROPIPATE - estropipate tab 3
mg
1
estropipate tab 0.75 mg
1
1
estropipate tab 1.5 mg
1
3
estradiol tab 0.5 mg (Estrace)
1
EVAMIST - estradiol transdermal
spray 1.53 mg/spray
estradiol tab 1 mg (Estrace)
1
3
estradiol tab 2 mg (Estrace)
1
estradiol td patch twice weekly
0.025 mg/24hr (Vivelle-dot)
1
•
FEMHRT LOW DOSE norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg
3
1
•
MENEST - esterified estrogens tab
0.3 mg
3
1
•
0.625 mg
3
1
•
1.25 mg
3
1
•
2.5 mg
3
•
estradiol td patch weekly
0.025 mg/24hr (Climara)
1
•
MENOSTAR - estradiol td patch
weekly 14 mcg/24hr
3
•
0.0375 mg/24hr (37.5 mcg/24hr)
(Climara)
1
•
MINIVELLE - estradiol td patch
twice weekly 0.025 mg/24hr
3
•
1
•
3
•
1
•
3
•
1
•
3
•
1
•
norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg
(Femhrt low dose)
1
estradiol valerate im in oil 10 mg/
ml
1
3
ml (Delestrogen)
1
PREFEST - estradiol tab 1
mg(15)/estrad-norgestimate tab
1-0.09mg(15)
ml (Delestrogen)
PREMARIN - estrogens,
conjugated tab 0.3 mg
2
1
Specialty
1
Quantity Limits
estradiol & norethindrone
acetate tab 0.5-0.1 mg
(Activella)
"Smart" PA
3
Prior Authorization
ESTRACE - estradiol tab 2 mg
Drug Name
Drug Tier
3
•
•
•
Specialty
ESTRACE - estradiol tab 1 mg
Quantity Limits
3
"Smart" PA
ESTRACE - estradiol tab 0.5 mg
Prior Authorization
Drug Name
Drug Tier
2015
•
23
2
2
2
2
PREMPHASE - conj est 0.625(14)/
conj est-medroxypro ac tab
0.625-5mg(14)
2
PREMPRO - conjugated estrogenmedroxyprogest acetate tab
0.3-1.5 mg
2
0.45-1.5 mg
2
0.625-2.5 mg
2
0.625-5 mg
2
VIVELLE-DOT - estradiol td patch
3
•
3
•
3
•
3
•
3
CONTRACEPTIVES
BEYAZ - drospirenone-ethinyl
estrad-levomefolate tab
3-0.02-0.451 mg
A
BREVICON-28 - norethindrone &
ethinyl estradiol tab 0.5 mg-35
mcg
3
24
•
3
CYCLESSA - desogestethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mgmg
3
DEPO-PROVERA
CONTRACEPTIV medroxyprogesterone acetate im
susp 150 mg/ml
A
DEPO-SUBQ PROVERA 104 medroxyprogesterone acetate
subcutaneous susp 104
mg/0.65ml
DESOGEN - desogestrel & ethinyl 3
estradiol tab 0.15 mg-30 mcg
desogest-eth estrad & eth estrad A
tab 0.15-0.02/0.01 mg(21/5)
(Mircette)
A
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mgmg (Cyclessa)
A
desogestrel & ethinyl estradiol
tab 0.15 mg-30 mcg (Desogen)
A
drospirenone-ethinyl estradiol
tab 3-0.02 mg (Yaz)
A
drospirenone-ethinyl estradiol
tab 3-0.03 mg (Yasmin 28)
ELLA - ulipristal acetate tab 30 mg A
•
ESTROSTEP FE - norethindrone
ac-ethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg
3
•
ethynodiol diacetate & ethinyl
estradiol tab 1 mg-35 mcg
A
FALESSA - levonorgest-eth estrad
tab 0.1 mg-20 mcg & fa tab 1 mg
kit
A
FEMCON FE - norethindrone &
ethinyl estradiol-fe chew tab 0.4
mg-35 mcg
3
GENERESS FE - norethindrone &
ethinyl estradiol-fe chew tab 0.8
mg-25 mcg
A
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
IMPLANON - etonogestrel
subdermal implant 68 mg
A
levonorg-eth est tab
0.1-0.02mg(84) & eth est tab
0.01mg(7) (Loseasonique)
A
levonorg-eth est tab
0.15-0.03mg(84) & eth est tab
0.01mg(7) (Seasonique)
A
LEVONORGESTREL levonorgestrel tab 0.75 mg
A
levonorgestrel & ethinyl
estradiol (91-day) tab
0.15-0.03 mg
A
A
A
levonorgestrel tab 1.5 mg (Plan b A
one-step)
A
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mgmcg
A
levonorgestrel-ethinyl estradiol
(continuous) tab 90-20 mcg
LILETTA - levonorgestrel releasing 3
iud 18.6 mcg/day (52 mg total)
A
LO LOESTRIN FE - norethin-eth
estradiol-fe tab 1 mg-10 mcg
(24)/10 mcg (2)
3
LO/OVRAL - norgestrel & ethinyl
3
LO/OVRAL-28 - norgestrel &
mcg
3
LOESTRIN FE 1.5/30 norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg
3
LOESTRIN FE 1/20 norethindrone ace & ethinyl
LOESTRIN 1.5/30-21 norethindrone ace & ethinyl
•
•
Specialty
Quantity Limits
"Smart" PA
3
LOESTRIN 1/20-21 - norethindrone 3
ace & ethinyl estradiol tab 1
mg-20 mcg
3
LOSEASONIQUE - levonorg-eth
est tab 0.1-0.02mg(84) & eth est
tab 0.01mg(7)
medroxyprogesterone acetate im A
susp 150 mg/ml (Depo-provera
contrac)
MINASTRIN 24 FE - norethindrone A
ace-eth estradiol-fe chew tab 1
mg-20 mcg (24)
3
MIRCETTE - desogest-eth estrad
& eth estrad tab 0.15-0.02/0.01
mg(21/5)
MIRENA - levonorgestrel releasing A
iud 20 mcg/24hr (52 mg total)
3
MODICON - norethindrone &
mcg
A
NATAZIA - estradiol valeratedienogest tab 3 mg /2-2 mg/2-3
mg/1 mg
NECON 1/50-28 - norethindrone & A
mestranol tab 1 mg-50 mcg
NECON 10/11-28 - norethindrone- A
eth estradiol tab 0.5-35/1-35 mgmcg (10/11)
A
NEXPLANON - etonogestrel
subdermal implant 68 mg
3
NOR-QD - norethindrone tab 0.35
mg
3
NORDETTE-28 - levonorgestrel &
mcg
A
norelgestromin-ethinyl estradiol
td ptwk 150-35 mcg/24hr (Ortho
evra)
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
25
norethindrone & ethinyl estradiol
tab 0.4 mg-35 mcg (Ovcon-35)
A
norethindrone & ethinyl
(Brevicon-28)
A
norethindrone & ethinyl estradiol
tab 1 mg-35 mcg (Norinyl 1+35)
norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mgmcg (Ortho tri-cyclen)
A
norgestrel & ethinyl estradiol tab
0.3 mg-30 mcg
A
A
NORINYL 1+35 - norethindrone &
ethinyl estradiol tab 1 mg-35 mcg
3
estradiol-fe chew tab
0.4 mg-35 mcg (Femcon fe)
A
NORINYL 1+50 - norethindrone &
mestranol tab 1 mg-50 mcg
A
estradiol-fe chew tab
0.8 mg-25 mcg (Generess fe)
NUVARING - etonogestrel-ethinyl
estradiol va ring 0.120-0.015
mg/24hr
A
A
norethindrone ac-ethinyl estradfe tab 1-20/1-30/1-35 mg-mcg
(Estrostep fe)
OGESTREL - norgestrel & ethinyl
A
A
3
norethindrone ace & ethinyl
estradiol tab 1 mg-20 mcg
(Loestrin 1/20-21)
A
ORTHO EVRA - norelgestrominethinyl estradiol td ptwk 150-35
mcg/24hr
ORTHO MICRONOR norethindrone tab 0.35 mg
3
(Loestrin 1.5/30-21)
A
3
(Loestrin fe 1/20)
A
ORTHO TRI-CYCLEN norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mgmcg
A
estradiol-fe tab 1.5 mg-30 mcg
(Loestrin fe 1.5/30)
A
ORTHO TRI-CYCLEN LO norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mgmcg
•
A
ORTHO-CEPT - desogestrel &
mcg
3
norethindrone ace-ethinyl
(24) (Lomedia 24 fe)
norethindrone tab 0.35 mg (Norqd)
norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg
(Ortho-novum 7/7/7)
A
norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg (Trinorinyl 28)
A
norgestimate & ethinyl estradiol
tab 0.25 mg-35 mcg (Orthocyclen)
A
ORTHO-CYCLEN - norgestimate & 3
mcg
3
ORTHO-NOVUM 1/35 norethindrone & ethinyl estradiol
tab 1 mg-35 mcg
3
ORTHO-NOVUM 7/7/7 norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg
3
OVCON-35 - norethindrone &
mcg
•
A
26
•
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
PARAGARD INTRAUTERINE COP
- copper iud
A
norethindrone acetate tab 5 mg
(Aygestin)
1
PLAN B - levonorgestrel tab 0.75
mg
3
progesterone im in oil 50 mg/ml
1
PLAN B ONE-STEP levonorgestrel tab 1.5 mg
progesterone micronized cap
100 mg (Prometrium)
1
3
A
progesterone micronized cap
200 mg (Prometrium)
1
QUARTETTE - levonor-eth est tab
0.15-0.02/0.025/0.03 mg &eth est
0.01 mg
PROMETRIUM - progesterone
micronized cap 100 mg
3
SAFYRAL - drospirenoneethinyl estrad-levomefolate tab
3-0.03-0.451 mg
A
PROMETRIUM - progesterone
micronized cap 200 mg
3
3
PROVERA - medroxyprogesterone
acetate tab 2.5 mg
3
SEASONALE - levonorgestrel &
ethinyl estradiol (91-day) tab
0.15-0.03 mg
3
SEASONIQUE - levonorg-eth est
tab 0.15-0.03mg(84) & eth est
tab 0.01mg(7)
3
acetate tab 5 mg
acetate tab 10 mg
3
SKYLA - levonorgestrel releasing
iud 13.5 mg
A
TRI-NORINYL 28 norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg
3
YASMIN 28 - drospirenone-ethinyl
estradiol tab 3-0.03 mg
YAZ - drospirenone-ethinyl
estradiol tab 3-0.02 mg
ANTIDIABETICS
acarbose tab 100 mg (Precose)
1
1
1
3
ACTOPLUS MET - pioglitazone
hcl-metformin hcl tab 15-500 mg
3
•
•
•
• •
3
ACTOPLUS MET - pioglitazone
hcl-metformin hcl tab 15-850 mg
3
• •
ACTOPLUS MET XR - pioglitazone 3
hcl-metformin hcl tab sr 24hr
15-1000 mg
ACTOPLUS MET XR - pioglitazone 3
hcl-metformin hcl tab sr 24hr
30-1000 mg
3
ACTOS - pioglitazone hcl tab 15
mg (base equiv)
3
mg (base equiv)
3
mg (base equiv)
3
AMARYL - glimepiride tab 1 mg
• •
ZOVIA 1/50E - ethynodiol diacetate A
& ethinyl estradiol tab 1 mg-50
mcg
PROGESTINS
AYGESTIN - norethindrone acetate 3
tab 5 mg
1
medroxyprogesterone acetate
tab 10 mg (Provera)
1
tab 2.5 mg (Provera)
1
tab 5 mg (Provera)
2
MEGACE ES - megestrol acetate
susp 625 mg/5ml
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
3
• •
• •
• •
• •
• •
• •
27
3
• •
3
3
• •
APPFORMIN-D - metformin hcl tab
cap pack
3
FARXIGA - dapagliflozin
propanediol tab 5 mg (base
equivalent)
3
• •
AVANDAMET - rosiglitazone
maleate-metformin hcl tab
2-1000 mg
3
FARXIGA - dapagliflozin
propanediol tab 10 mg (base
equivalent)
FORTAMET - metformin hcl tab sr
24hr osmotic 500 mg
3
• •
AVANDAMET - rosiglitazone
maleate-metformin hcl tab 4-500
mg
3
FORTAMET - metformin hcl tab sr
24hr osmotic 1000 mg
3
• •
1
AVANDIA - rosiglitazone maleate
• •
glimepiride tab 1 mg (Amaryl)
3
1
3
• •
1
1
3
glipizide tab sr 24hr 10 mg
(Glucotrol xl)
•
•
•
•
1
•
BYDUREON - exenatide extended
release for susp pen-injector 2
mg
2
glipizide tab sr 24hr 2.5 mg
(Glucotrol xl)
glipizide tab sr 24hr 5 mg
(Glucotrol xl)
1
•
BYDUREON - exenatide extended
release for inj susp 2 mg
2
glipizide tab 10 mg (Glucotrol)
1
glipizide tab 5 mg (Glucotrol)
1
BYETTA - exenatide soln peninjector 5 mcg/0.02ml
2
• •
glipizide-metformin hcl tab
2.5-250 mg
1
•
•
•
BYETTA - exenatide soln peninjector 10 mcg/0.04ml
2
• •
2.5-500 mg
1
•
CHLORPROPAMIDE chlorpropamide tab 100 mg
1
•
5-500 mg
1
•
CHLORPROPAMIDE chlorpropamide tab 250 mg
1
•
2
CYCLOSET - bromocriptine
mesylate tab 0.8 mg (base
equivalent)
3
•
GLUCAGEN HYPOKIT - glucagon
hcl (rdna) for inj 1 mg (base
equiv)
GLUCAGON EMERGENCY KIT glucagon (rdna) for inj kit 1 mg
2
DIABETA - glyburide tab 1.25 mg
3
DIABETA - glyburide tab 2.5 mg
3
DIABETA - glyburide tab 5 mg
3
DUETACT - pioglitazone hclglimepiride tab 30-2 mg
3
• •
• •
• •
• •
• •
•
•
•
•
•
•
•
•
GLUCOPHAGE - metformin hcl tab 3
500 mg
850 mg
1000 mg
• •
• •
• •
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Tier
Drug Name
DUETACT - pioglitazone hclglimepiride tab 30-4 mg
28
• •
Specialty
APPFORMIN - metformin hcl tab
cap pack
Quantity Limits
3
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
GLUCOPHAGE XR - metformin hcl 3
tab sr 24hr 500 mg
GLUCOPHAGE XR - metformin hcl 3
tab sr 24hr 750 mg
3
GLUCOTROL - glipizide tab 5 mg
• •
glyburide-metformin tab
5-500 mg (Glucovance)
1
•
• •
GLYNASE - glyburide micronized
tab 1.5 mg
3
• •
tab 3 mg
3
• •
tab 6 mg
3
• •
GLYSET - miglitol tab 25 mg
2
2
• •
2
3
• •
GLYXAMBI - empagliflozinlinagliptin tab 10-5 mg
•
•
•
• •
3
• •
GLUCOTROL - glipizide tab 10 mg
3
GLUCOTROL XL - glipizide tab sr
24hr 2.5 mg
3
• •
• •
• •
24hr 5 mg
3
• •
24hr 10 mg
3
GLUCOVANCE - glyburidemetformin tab 1.25-250 mg
3
GLUCOVANCE - glyburidemetformin tab 2.5-500 mg
3
• •
GLYXAMBI - empagliflozinlinagliptin tab 25-5 mg
• •
• •
3
INVOKAMET - canagliflozinmetformin hcl tab 50-500 mg
2
GLUCOVANCE - glyburidemetformin tab 5-500 mg
• •
GLUMETZA - metformin hcl tab sr
24hr modified release 500 mg
•
2
3
• •
GLUMETZA - metformin hcl tab sr
24hr modified release 1000 mg
•
2
3
• •
GLYBURIDE - glyburide tab 1.25
mg
2
1
INVOKANA - canagliflozin tab 100
mg
2
• •
INVOKANA - canagliflozin tab 300
mg
2
• •
2
• •
•
JANUMET - sitagliptin-metformin
hcl tab 50-500 mg
2
• •
•
JANUMET - sitagliptin-metformin
hcl tab 50-1000 mg
JANUMET XR - sitagliptinmetformin hcl tab sr 24hr 50-500
mg
2
• •
JANUMET XR - sitagliptinmetformin hcl tab sr 24hr
50-1000 mg
2
• •
JANUMET XR - sitagliptinmetformin hcl tab sr 24hr
100-1000 mg
2
• •
GLYBURIDE - glyburide tab 2.5 mg 1
1
GLYBURIDE - glyburide tab 5 mg
• •
• •
• •
•
glyburide micronized tab 1.5 mg
(Glynase)
1
glyburide micronized tab 3 mg
(Glynase)
1
glyburide micronized tab 6 mg
(Glynase)
1
glyburide tab 1.25 mg
1
glyburide tab 2.5 mg
1
glyburide tab 5 mg
1
1.25-250 mg (Glucovance)
1
•
•
•
•
2.5-500 mg (Glucovance)
1
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
29
JANUVIA - sitagliptin phosphate
2
• •
metformin hcl tab 500 mg
(Glucophage)
1
•
2
• •
(Glucophage)
1
•
2
• •
nateglinide tab 120 mg (Starlix)
1
1
2
• •
nateglinide tab 60 mg (Starlix)
JARDIANCE - empagliflozin tab 10
mg
3
JARDIANCE - empagliflozin tab 25
mg
2
• •
NESINA - alogliptin benzoate tab
•
•
• •
3
• •
JENTADUETO - linagliptinmetformin hcl tab 2.5-500 mg
3
• •
3
• •
3
• •
25 mg (base equiv)
2
• •
3
• •
ONGLYZA - saxagliptin hcl tab 2.5
mg (base equiv)
2
• •
KAZANO - alogliptin-metformin hcl
tab 12.5-500 mg
3
• •
ONGLYZA - saxagliptin hcl tab 5
mg (base equiv)
3
• •
KAZANO - alogliptin-metformin hcl
tab 12.5-1000 mg
3
• •
OSENI - alogliptin-pioglitazone tab
12.5-15 mg
3
• •
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr
2.5-1000 mg
2
• •
12.5-30 mg
12.5-45 mg
3
• •
2
• •
25-15 mg
3
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 5-500
mg
• •
3
• •
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 5-1000
mg
2
25-30 mg
25-45 mg
3
• •
KORLYM - mifepristone tab 300
mg
2
• •
pioglitazone hcl tab 15 mg (base
equiv) (Actos)
1
• •
metformin hcl tab sr 24hr
osmotic 1000 mg (Fortamet)
1
•
equiv) (Actos)
1
• •
metformin hcl tab sr 24hr
osmotic 500 mg (Fortamet)
1
•
equiv) (Actos)
1
• •
metformin hcl tab sr 24hr 500 mg
(Glucophage xr)
1
•
pioglitazone hcl-glimepiride tab
30-2 mg (Duetact)
1
•
metformin hcl tab sr 24hr 750 mg
(Glucophage xr)
1
•
pioglitazone hcl-glimepiride tab
30-4 mg (Duetact)
1
•
(Glucophage)
1
•
pioglitazone hcl-metformin hcl
tab 15-500 mg (Actoplus met)
1
•
30
• •
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
pioglitazone hcl-metformin hcl
tab 15-850 mg (Actoplus met)
1
•
TRULICITY - dulaglutide soln peninjector 0.75 mg/0.5ml
3
• •
PRANDIMET - repaglinidemetformin hcl tab 1-500 mg
3
•
TRULICITY - dulaglutide soln peninjector 1.5 mg/0.5ml
3
• •
PRANDIMET - repaglinidemetformin hcl tab 2-500 mg
3
•
VICTOZA - liraglutide soln peninjector 18 mg/3ml (6 mg/ml)
2
• •
PRANDIN - repaglinide tab 0.5 mg
3
• •
3
PRANDIN - repaglinide tab 2 mg
3
XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr 5-500
mg
3
PRANDIN - repaglinide tab 1 mg
3
• •
PRECOSE - acarbose tab 50 mg
3
mg
3
3
•
•
•
•
•
•
3
• •
PROGLYCEM - diazoxide susp 50
mg/ml
3
mg
repaglinide tab 0.5 mg (Prandin)
1
• •
1
XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr
10-1000 mg
3
repaglinide tab 1 mg (Prandin)
repaglinide tab 2 mg (Prandin)
1
RIOMET - metformin hcl oral soln
500 mg/5ml
3
•
•
•
•
APIDRA - insulin glulisine inj 100
unit/ml
3
•
STARLIX - nateglinide tab 60 mg
3
•
STARLIX - nateglinide tab 120 mg
SYMLINPEN 120 - pramlintide
acetate pen-inj 2700 mcg/2.7ml
(1000 mcg/ml)
2
APIDRA SOLOSTAR - insulin
glulisine soln pen-injector inj 100
unit/ml
3
3
HUMALOG - insulin lispro (human)
soln cartridge 100 unit/ml
3
•
SYMLINPEN 60 - pramlintide
acetate pen-inj 1500 mcg/1.5ml
(1000 mcg/ml)
2
•
HUMALOG - insulin lispro (human)
inj 100 unit/ml
3
•
•
TANZEUM - albiglutide for soln
pen-injector 30 mg
• •
HUMALOG KWIKPEN - insulin
lispro (human) soln pen-injector
100 unit/ml
3
3
TANZEUM - albiglutide for soln
pen-injector 50 mg
3
• •
NOVOLOG - insulin aspart inj 100
unit/ml
2
•
TOLAZAMIDE - tolazamide tab 500 1
mg
1
tolazamide tab 250 mg
•
NOVOLOG FLEXPEN - insulin
aspart soln pen-injector 100 unit/
ml
2
•
NOVOLOG PENFILL - insulin
aspart soln cartridge 100 unit/ml
2
•
NOVOLOG PENFILL - insulin
aspart inj 100 unit/ml
2
•
•
•
•
TOLBUTAMIDE - tolbutamide tab
500 mg
1
•
•
TRADJENTA - linagliptin tab 5 mg
3
• •
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
Rapid-Acting Insulins
Short-Acting Insulins
31
AFREZZA - insulin regular (human) 3
inhalation powder 4 unit/cartridge
AFREZZA - insulin regular (human) 3
inhalation powd 4 & 8 unit/
cartridge
3
HUMULIN R - insulin regular
(human) inj 100 unit/ml
3
HUMULIN R U-500 (CONCENTR
- insulin regular (human) inj 500
unit/ml
2
NOVOLIN R - insulin regular
2
NOVOLIN R RELION - insulin
regular (human) inj 100 unit/ml
2
RELION R - insulin regular
•
•
•
3
HUMALOG MIX 50/50 KWIKPEN
- insulin lispro prot & lispro sus
pen-inj 100 unit/ml (50-50)
3
HUMALOG MIX 75/25 - insulin
lispro prot & lispro (human) inj
100 unit/ml (75-25)
3
HUMALOG MIX 75/25 KWIKPEN
- insulin lispro prot & lispro sus
3
HUMULIN N - insulin isophane
3
HUMULIN N KWIKPEN - insulin
isophane (human) susp peninjector 100 unit/ml
3
HUMULIN N U-100 PEN - insulin
isophane (human) susp peninjector 100 unit/ml
3
HUMULIN 70/30 - insulin isophane
& regular (human) inj 100 unit/ml
(70-30)
3
32
3
•
•
3
•
•
HUMULIN 70/30 PEN - insulin
isophane & regular susp pen-inj
100 unit/ml (70-30)
2
•
•
NOVOLIN N - insulin isophane
NOVOLIN N RELION - insulin
isophane (human) inj 100 unit/ml
2
•
•
NOVOLIN N U-100 - insulin
isophane (human) inj 100 unit/ml
2
•
•
NOVOLIN 70/30 - insulin isophane
& regular (human) inj 100 unit/ml
(70-30)
2
•
NOVOLIN 70/30 RELION - insulin
isophane & regular (human) inj
100 unit/ml (70-30)
2
•
NOVOLOG MIX 70/30 - insulin
aspart prot & aspart (human) inj
100 unit/ml (70-30)
2
•
NOVOLOG MIX 70/30 PREFILL insulin aspart prot & aspart sus
2
•
2
•
•
LANTUS - insulin glargine inj 100
unit/ml
2
•
•
LANTUS SOLOSTAR - insulin
glargine soln pen-injector 100
unit/ml
2
•
•
LEVEMIR - insulin detemir inj 100
unit/ml
2
•
•
LEVEMIR FLEXPEN - insulin
detemir soln pen-injector 100
unit/ml
2
•
•
LEVEMIR FLEXTOUCH - insulin
detemir soln pen-injector 100
unit/ml
TOUJEO SOLOSTAR - insulin
glargine soln pen-injector 300
unit/ml
2
•
•
•
•
•
Basal Insulins
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Tier
Drug Name
HUMULIN 70/30 KWIKPEN insulin isophane & regular susp
Intermediate-Acting Insulins
HUMALOG MIX 50/50 - insulin
lispro prot & lispro (human) inj
100 unit/ml (50-50)
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
THYROID AGENTS
1
ARMOUR THYROID - thyroid tab
15 mg (1/4 grain)
2
levothyroxine sodium tab
300 mcg (Synthroid)
1
30 mg (1/2 grain)
2
50 mcg (Synthroid)
1
60 mg (1 grain)
2
75 mcg (Synthroid)
1
90 mg (1 1/2 grain)
2
88 mcg (Synthroid)
1
120 mg (2 grain)
2
liothyronine sodium tab 25 mcg
(Cytomel)
1
180 mg (3 grain)
2
(Cytomel)
1
240 mg (4 grain)
2
(Cytomel)
1
300 mg (5 grain)
2
methimazole tab 10 mg
(Tapazole)
methimazole tab 5 mg (Tapazole)
1
CYTOMEL - liothyronine sodium
tab 5 mcg
2
NATURE-THROID - thyroid tab
16.25 mg
3
tab 25 mcg
2
32.5 mg
3
tab 50 mcg
2
48.75 mg (3/4 grain)
3
100 mcg (Synthroid)
1
NATURE-THROID - thyroid tab 65
mg
3
112 mcg (Synthroid)
1
81.25 mg
3
125 mcg (Synthroid)
1
97.5 mg
3
137 mcg (Synthroid)
1
113.75 mg
3
150 mcg (Synthroid)
1
130 mg
3
175 mcg (Synthroid)
1
195 mg
3
200 mcg (Synthroid)
1
260 mg
3
25 mcg (Synthroid)
1
325 mg (5 grain)
3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
33
146.25 mg
3
THYROLAR-1 - liotrix (t3-t4) tab 60
mg (12.5-50 mcg)
2
NATURE-THROID NT-2.5 - thyroid
tab 162.5 mg (2 1/2 grain)
3
THYROLAR-1/2 - liotrix (t3-t4) tab
30 mg (6.25-25 mcg)
2
propylthiouracil tab 50 mg
1
2
SYNTHROID - levothyroxine
sodium tab 25 mcg
2
THYROLAR-1/4 - liotrix (t3-t4) tab
15 mg (3.1-12.5 mcg)
2
sodium tab 50 mcg
2
THYROLAR-2 - liotrix (t3-t4) tab
120 mg (25-100 mcg)
2
sodium tab 75 mcg
2
THYROLAR-3 - liotrix (t3-t4) tab
180 mg (37.5-150 mcg)
3
sodium tab 88 mcg
2
TIROSINT - levothyroxine sodium
cap 13 mcg
3
sodium tab 100 mcg
2
cap 25 mcg
3
sodium tab 112 mcg
2
cap 50 mcg
3
sodium tab 125 mcg
2
cap 75 mcg
3
sodium tab 137 mcg
2
cap 88 mcg
3
sodium tab 150 mcg
2
cap 100 mcg
3
sodium tab 175 mcg
2
cap 112 mcg
3
sodium tab 200 mcg
2
cap 125 mcg
3
sodium tab 300 mcg
2
cap 137 mcg
3
TAPAZOLE - methimazole tab 5
mg
3
cap 150 mcg
3
TAPAZOLE - methimazole tab 10
mg
3
WESTHROID - thyroid tab 16.25
mg
WESTHROID - thyroid tab 32.5 mg
3
thyroid tab 30 mg (1/2 grain)
(Armour thyroid)
1
mg (3/4 grain)
3
thyroid tab 60 mg (1 grain)
(Armour thyroid)
1
WESTHROID - thyroid tab 65 mg
3
thyroid tab 90 mg (1 1/2 grain)
(Armour thyroid)
mg
3
1
WESTHROID - thyroid tab 97.5 mg
3
34
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
mg
3
METHERGINE - methylergonovine
maleate tab 0.2 mg
2
3
3
mg (2 1/2 grain)
3
METHERGINE - methylergonovine
maleate inj 0.2 mg/ml
1
3
methylergonovine maleate inj
0.2 mg/ml
3
1
(5 grain)
3
methylergonovine maleate tab
0.2 mg
3
mg
3
PREPIDIL - dinoprostone cervical
gel 0.5 mg/3gm
3
WESTHROID-P - thyroid tab 16.25
mg
3
PROSTIN E2 - dinoprostone
vaginal suppos 20 mg
mg
3
mg (3/4 grain)
3
WESTHROID-P - thyroid tab 65 mg 3
3
mg
3
WESTHROID-P - thyroid tab 130
mg
3
WP THYROID - thyroid tab 16.25
mg
3
mg
3
mg (3/4 grain)
3
WP THYROID - thyroid tab 65 mg
ENDOCRINE and METABOLIC AGENTS - MISC.
2
ACTONEL - risedronate sodium
tab 5 mg
2
tab 30 mg
2
tab 35 mg
2
tab 150 mg
1
•
ALENDRONATE SODIUM alendronate sodium tab 40 mg
1
•
ALENDRONATE SODIUM alendronate sodium oral soln 70
mg/75ml
1
alendronate sodium tab 10 mg
•
•
•
•
•
•
mg
3
(Fosamax)
1
•
•
•
•
mg
3
ATELVIA - risedronate sodium tab
3
• •
mg
3
BINOSTO - alendronate sodium
effervescent tab 70 mg
3
• •
WP THYROID - thyroid tab 130 mg
3
BONIVA - ibandronate sodium tab
3
• •
3
BRAVELLE - urofollitropin purified
for inj 75 unit
2
OXYTOCICS
CERVIDIL - dinoprostone vaginal
inserts 10 mg
1
1
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
• •
35
3
•
•
desmopressin acetate nasal
spray soln 0.01% (Ddavp)
1
cabergoline tab 0.5 mg
desmopressin acetate nasal
spray soln 0.01% (refrigerated)
1
1
calcitonin (salmon) nasal soln
200 unit/act (Miacalcin)
1
desmopressin acetate tab 0.1 mg
(Ddavp)
1
calcitriol cap 0.25 mcg (Rocaltrol)
1
1
calcitriol cap 0.5 mcg (Rocaltrol)
1
desmopressin acetate tab 0.2 mg
(Ddavp)
calcitriol oral soln 1 mcg/ml
(Rocaltrol)
1
DIDRONEL - etidronate disodium
tab 400 mg
3
CARBAGLU - carglumic acid tab
200 mg
3
doxercalciferol cap 0.5 mcg
(Hectorol)
1
CARNITOR - levocarnitine tab 330
mg
3
doxercalciferol cap 1 mcg
(Hectorol)
1
CARNITOR - levocarnitine oral
soln 1 gm/10ml (10%)
3
doxercalciferol cap 2.5 mcg
(Hectorol)
1
CARNITOR SF - levocarnitine oral
soln 1 gm/10ml (10%)
3
EGRIFTA - tesamorelin acetate for
inj 1 mg (base equiv)
2
•
• •
•
• •
CETROTIDE - cetrorelix acetate for 3
inj kit 0.25 mg
1
chorionic gonadotropin for inj
10000 unit
1
clomiphene citrate tab 50 mg
•
•
•
• •
EGRIFTA - tesamorelin acetate for
2
•
• •
ETIDRONATE DISODIUM etidronate disodium tab 200 mg
1
• •
ETIDRONATE DISODIUM etidronate disodium tab 400 mg
1
EVISTA - raloxifene hcl tab 60 mg
A
Specialty
BUPHENYL - sodium
phenylbutyrate oral powder 3 gm/
teaspoonful
Quantity Limits
1
"Smart" PA
desmopressin acetate nasal soln
0.01% (refrigerated) (Ddavp)
•
Prior Authorization
•
Drug Name
Drug Tier
•
Specialty
3
Quantity Limits
Prior Authorization
BUPHENYL - sodium
phenylbutyrate tab 500 mg
Drug Name
"Smart" PA
Drug Tier
2015
CYSTADANE - betaine powder for
oral solution
3
DDAVP - desmopressin acetate
tab 0.1 mg
3
FOLLISTIM AQ - follitropin beta inj
75 unit/0.5ml
2
•
• •
tab 0.2 mg
3
150 unit/0.5ml
2
•
• •
DDAVP - desmopressin acetate inj
4 mcg/ml
3
300 unit/0.36ml
2
•
• •
nasal soln 0.01% (refrigerated)
3
600 unit/0.72ml
2
•
• •
nasal spray soln 0.01%
3
900 unit/1.08ml
2
•
• •
desmopressin acetate inj 4 mcg/
ml (Ddavp)
1
FORTEO - teriparatide
(recombinant) inj 600 mcg/2.4ml
2
•
• •
36
•
• •
3
• •
GONAL-F RFF PEN - follitropin
alfa inj 450 unit/0.75ml
3
•
• •
• •
•
• •
3
3
FOSAMAX PLUS D - alendronate
sodium-cholecalciferol tab
70-5600 mg-unit
3
•
• •
GANIRELIX ACETATE - ganirelix
acetate inj 250 mcg/0.5ml
1
•
• •
GONAL-F RFF REDIJECT follitropin alfa inj 300 unit/0.5ml
3
•
• •
GENOTROPIN - somatropin for
subcutaneous inj 5 mg
3
•
•
3
•
• •
GENOTROPIN - somatropin for inj
12 mg (13.8 mg overfill)
3
•
•
3
GENOTROPIN MINIQUICK somatropin for inj 0.2 mg
3
•
•
HECTOROL - doxercalciferol cap
0.5 mcg
3
•
•
3
•
•
•
•
3
•
•
•
•
GENOTROPIN MINIQUICK somatropin for inj 1 mg
3
•
•
•
•
3
•
•
•
•
3
•
•
•
•
3
•
•
3
•
•
GENOTROPIN MINIQUICK somatropin for inj 2 mg
3
•
•
GONAL-F - follitropin alfa for inj
450 unit
3
•
• •
GONAL-F - follitropin alfa for inj
1050 unit
3
•
• •
FOSAMAX PLUS D - alendronate
sodium-cholecalciferol tab
70-2800 mg-unit
HECTOROL - doxercalciferol cap 1 3
mcg
3
HECTOROL - doxercalciferol cap
2.5 mcg
3
HUMATROPE - somatropin for inj
5 mg
3
6 mg (18 unit)
3
12 mg (36 unit)
3
24 mg
3
HUMATROPE COMBO PACK somatropin for inj 5 mg
1
ibandronate sodium tab 150 mg
(base equivalent) (Boniva)
3
INCRELEX - mecasermin inj 40
mg/4ml (10 mg/ml)
2
KUVAN - sapropterin
dihydrochloride powder packet
100 mg
2
KUVAN - sapropterin
dihydrochloride soluble tab 100
mg
Specialty
3
Quantity Limits
Prior Authorization
3
Drug Name
"Smart" PA
Drug Tier
• •
FOSAMAX - alendronate sodium
tab 70 mg
Specialty
• •
2
Quantity Limits
•
FORTICAL - calcitonin (salmon)
nasal soln 200 unit/act
"Smart" PA
3
Drug Tier
GONAL-F RFF - follitropin alfa for
inj 75 unit
Drug Name
Prior Authorization
2015
•
•
•
•
• •
•
• •
37
levocarnitine oral soln
1 gm/10ml (10%) (Carnitor)
1
levocarnitine tab 330 mg
(Carnitor)
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
•
3
1
NATPARA - parathyroid hormone
(recombinant) for inj cartridge
100 mcg
2
•
•
LUPANETA PACK - leuprolide (1
mon) inj 3.75 mg & norethindrone
tab 5 mg kit
3
NORDITROPIN CARTRIDGE somatropin inj 5 mg/1.5ml
NORDITROPIN FLEXPRO somatropin inj 5 mg/1.5ml
2
•
•
LUPANETA PACK - leuprolide
(3 mon) inj 11.25 mg &
norethindrone tab 5 mg kit
3
• •
2
•
•
•
•
LUPRON DEPOT-PED - leuprolide
acetate for inj pediatric kit 7.5 mg
• •
2
2
•
•
acetate for inj pediatric kit 11.25
mg
• •
NORDITROPIN FLEXPRO somatropin inj 30 mg/3ml
2
2
2
•
•
acetate for inj pediatric kit 15 mg
2
• •
NORDITROPIN NORDIFLEX PEN
- somatropin inj 30 mg/3ml
3
•
•
acetate (3 month) for inj pediatric
kit 11.25 mg
2
• •
NUTROPIN AQ NUSPIN 10 somatropin inj 10 mg/2ml
3
•
•
2
• •
3
acetate (3 month) for inj pediatric
kit 30 mg
•
•
3
•
•
MENOPUR - menotropins for
subcutaneous inj 75 unit
2
NUTROPIN AQ PEN - somatropin
inj 10 mg/2ml
3
•
•
MIACALCIN - calcitonin (salmon)
inj 200 unit/ml
3
NUTROPIN AQ PEN - somatropin
inj 20 mg/2ml
1
• •
MIACALCIN - calcitonin (salmon)
nasal soln 200 unit/act
3
octreotide acetate inj 100 mcg/ml
(0.1 mg/ml) (Sandostatin)
1
• •
MYALEPT - metreleptin for
subcutaneous inj 11.3 mg
3
octreotide acetate inj 1000 mcg/
ml (1 mg/ml) (Sandostatin)
1
• •
(recombinant) for inj cartridge 25
mcg
3
1
• •
mcg
3
1
• •
3
•
•
mcg
3
OMNITROPE - somatropin inj 5
mg/1.5ml
OMNITROPE - somatropin inj 10
mg/1.5ml
3
•
•
38
• •
•
•
• •
• •
•
•
•
ORFADIN - nitisinone cap 2 mg
3
3
3
•
•
•
•
•
•
•
• •
paricalcitol cap 2 mcg (Zemplar)
1
1
raloxifene hcl tab 60 mg (Evista)
1
RAVICTI - glycerol phenylbutyrate
liquid 1.1 gm/ml
3
•
•
REPRONEX - menotropins for inj
75 unit
2
•
• •
risedronate sodium tab delayed
release 35 mg (Atelvia)
1
•
risedronate sodium tab 150 mg
(Actonel)
1
•
(Actonel)
1
(Actonel)
1
(Actonel)
1
ROCALTROL - calcitriol cap 0.25
mcg
3
ROCALTROL - calcitriol cap 0.5
mcg
3
ROCALTROL - calcitriol oral soln 1
mcg/ml
3
SAIZEN - somatropin (nonrefrigerated) for inj 5 mg
3
•
•
SAIZEN - somatropin (nonrefrigerated) for inj 8.8 mg
3
•
•
•
•
•
• •
SAIZEN CLICK.EASY - somatropin 3
(non-refrigerated) for inj 8.8 mg
2
SAMSCA - tolvaptan tab 15 mg
2
•
SANDOSTATIN - octreotide
acetate inj 50 mcg/ml (0.05 mg/
ml)
3
• •
• •
ml)
3
• •
ml)
3
• •
ml)
3
• •
acetate inj 1000 mcg/ml (1 mg/
ml)
3
• •
SENSIPAR - cinacalcet hcl tab 30
mg (base equiv)
2
mg (base equiv)
2
mg (base equiv)
2
SEROSTIM - somatropin (nonrefrigerated) for subcutaneous inj
4 mg
2
•
• •
5 mg
2
•
• •
6 mg
2
•
• •
SIGNIFOR - pasireotide
diaspartate inj 0.3 mg/ml (base
equiv)
3
•
• •
equiv)
3
•
• •
equiv)
3
•
• •
Specialty
SAMSCA - tolvaptan tab 30 mg
Quantity Limits
•
"Smart" PA
•
•
•
•
Prior Authorization
3
OSPHENA - ospemifene tab 60 mg 3
OVIDREL - choriogonadotropin alfa 3
inj 250 mcg/0.5ml
1
Drug Tier
Specialty
OMNITROPE - somatropin for inj
5.8 mg
Quantity Limits
Prior Authorization
Drug Name
Drug Name
"Smart" PA
Drug Tier
2015
39
3
•
• •
sodium phenylbutyrate oral
powder 3 gm/teaspoonful
(Buphenyl)
1
SOMATULINE DEPOT - lanreotide
acetate extended release inj 60
mg/0.2ml
2
mg/0.3ml
2
mg/0.5ml
2
• •
SOMAVERT - pegvisomant for inj
10 mg (as protein)
2
• •
15 mg (as protein)
2
• •
20 mg (as protein)
2
• •
25 mg (as protein)
2
• •
30 mg (as protein)
2
• •
STIMATE - desmopressin acetate
nasal soln 1.5 mg/ml
3
SYNAREL - nafarelin acetate nasal 2
soln 2 mg/ml
3
TEV-TROPIN - somatropin for
ZEMPLAR - paricalcitol cap 1 mcg 3
ZEMPLAR - paricalcitol cap 2 mcg
3
ZOMACTON - somatropin for
3
40
•
•
• •
• •
•
•
•
•
•
•
•
•
•
• •
CARDIOVASCULAR AGENTS
CARDIOTONICS
DIGOXIN - digoxin oral soln 0.05
mg/ml
1
digoxin tab 125 mcg (0.125 mg)
(Lanoxin)
1
digoxin tab 250 mcg (0.25 mg)
(Lanoxin)
1
LANOXIN - digoxin tab 62.5 mcg
(0.0625 mg)
2
LANOXIN - digoxin tab 125 mcg
(0.125 mg)
2
LANOXIN - digoxin tab 187.5 mcg
(0.1875 mg)
2
LANOXIN - digoxin tab 250 mcg
(0.25 mg)
2
ANTIANGINAL AGENTS
DILATRATE SR - isosorbide
dinitrate cap cr 40 mg
3
IMDUR - isosorbide mononitrate
tab sr 24hr 30 mg
3
ISORDIL TITRADOSE - isosorbide
dinitrate tab 5 mg
3
ISORDIL TITRADOSE - isosorbide
dinitrate tab 40 mg
3
ISOSORBIDE DINITRATE isosorbide dinitrate tab 30 mg
1
isosorbide dinitrate tab cr 40 mg
1
isosorbide dinitrate tab 10 mg
1
1
(Isordil titradose)
1
isosorbide mononitrate tab sr
24hr 120 mg (Imdur)
1
Specialty
SIGNIFOR LAR - pasireotide
pamoate for im er susp 60 mg
(base equiv)
Quantity Limits
• •
"Smart" PA
•
ZOMACTON - somatropin for inj 10 3
mg
2
ZORBTIVE - somatropin (nonrefrigerated) for subcutaneous inj
8.8 mg
Prior Authorization
(base equiv)
3
• •
Drug Name
Drug Tier
•
Specialty
3
Quantity Limits
Prior Authorization
(base equiv)
Drug Name
"Smart" PA
Drug Tier
2015
24hr 30 mg (Imdur)
1
24hr 60 mg (Imdur)
3
1
NITROLINGUAL PUMPSPRAY nitroglycerin tl soln 0.4 mg/spray
(400 mcg/spray)
3
isosorbide mononitrate tab
10 mg
1
NITROMIST - nitroglycerin lingual
aerosol 400 mcg/spray
2
isosorbide mononitrate tab
20 mg
1
NITROSTAT - nitroglycerin sl tab
0.3 mg
2
NITRO-BID - nitroglycerin oint 2%
3
0.4 mg
0.6 mg
2
RANEXA - ranolazine tab sr 12hr
500 mg
3
•
RANEXA - ranolazine tab sr 12hr
1000 mg
3
•
NITRO-DUR - nitroglycerin td patch 3
24hr 0.1 mg/hr
24hr 0.2 mg/hr
24hr 0.3 mg/hr
24hr 0.4 mg/hr
24hr 0.6 mg/hr
24hr 0.8 mg/hr
1
nitroglycerin cap cr 2.5 mg
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
BETA BLOCKERS
acebutolol hcl cap 200 mg
(Sectral)
1
acebutolol hcl cap 400 mg
(Sectral)
1
atenolol tab 100 mg (Tenormin)
1
1
nitroglycerin cap cr 6.5 mg
1
1
nitroglycerin cap cr 9 mg
1
BETAPACE - sotalol hcl tab 80 mg
3
NITROGLYCERIN LINGUAL nitroglycerin lingual aerosol 400
mcg/spray
1
BETAPACE - sotalol hcl tab 120
mg
3
•
•
•
nitroglycerin td patch 24hr
0.1 mg/hr (Nitro-dur)
BETAPACE - sotalol hcl tab 160
mg
3
1
•
BETAPACE AF - sotalol hcl (afib/
afl) tab 80 mg
3
1
•
afl) tab 120 mg
3
1
3
•
1
afl) tab 160 mg
betaxolol hcl tab 10 mg (Kerlone)
1
nitroglycerin tl soln 0.4 mg/spray
(400 mcg/spray) (Nitrolingual
pumpspr)
1
betaxolol hcl tab 20 mg (Kerlone)
1
bisoprolol fumarate tab 10 mg
(Zebeta)
1
41
INDERAL LA - propranolol hcl cap
sr 24hr 120 mg
3
•
•
sr 24hr 160 mg
3
•
3
•
3
BYSTOLIC - nebivolol hcl tab 10
3
•
INDERAL XL - propranolol hcl
sustained-release beads cap sr
24hr 80 mg
3
BYSTOLIC - nebivolol hcl tab 20
3
INDERAL XL - propranolol hcl
24hr 120 mg
carvedilol tab 12.5 mg (Coreg)
1
3
carvedilol tab 25 mg (Coreg)
1
INNOPRAN XL - propranolol hcl
24hr 80 mg
1
COREG - carvedilol tab 3.125 mg
3
INNOPRAN XL - propranolol hcl
24hr 120 mg
3
1
3
3
•
3
KERLONE - betaxolol hcl tab 10
mg
3
KERLONE - betaxolol hcl tab 20
mg
3
COREG - carvedilol tab 25 mg
•
COREG CR - carvedilol phosphate
cap sr 24hr 10 mg
3
labetalol hcl tab 100 mg
(Trandate)
1
cap sr 24hr 20 mg
3
(Trandate)
1
cap sr 24hr 40 mg
3
(Trandate)
1
cap sr 24hr 80 mg
3
LEVATOL - penbutolol sulfate tab
20 mg
3
CORGARD - nadolol tab 20 mg
3
•
LOPRESSOR - metoprolol tartrate
tab 50 mg
3
3
3
3
•
HEMANGEOL - propranolol hcl
oral soln 4.28 mg/ml
3
LOPRESSOR - metoprolol tartrate
tab 100 mg
1
HYPERTENEVIDE-12.5 carvedilol tab 12.5 mg & dietary
management cap pack
3
metoprolol succinate tab sr 24hr
100 mg (Toprol xl)
200 mg (Toprol xl)
1
sr 24hr 60 mg
3
•
25 mg (Toprol xl)
1
sr 24hr 80 mg
3
•
50 mg (Toprol xl)
1
bisoprolol fumarate tab 5 mg
(Zebeta)
1
BYSTOLIC - nebivolol hcl tab 2.5
3
BYSTOLIC - nebivolol hcl tab 5 mg
(base equivalent)
42
•
•
•
•
•
•
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
metoprolol tartrate tab 100 mg
(Lopressor)
1
1
(Lopressor)
1
nadolol tab 20 mg (Corgard)
1
1
1
pindolol tab 10 mg
1
pindolol tab 5 mg
1
PROPRANOLOL HCL propranolol hcl oral soln 20
mg/5ml
1
PROPRANOLOL HCL propranolol hcl oral soln 40
mg/5ml
1
propranolol hcl cap sr 24hr
120 mg (Inderal la)
1
160 mg (Inderal la)
1
60 mg (Inderal la)
1
80 mg (Inderal la)
1
propranolol hcl tab 10 mg
1
1
1
1
1
SECTRAL - acebutolol hcl cap 200
mg
3
•
SECTRAL - acebutolol hcl cap 400
mg
3
•
sotalol hcl (afib/afl) tab 120 mg
(Betapace af)
1
CALCIUM CHANNEL BLOCKERS
3
•
(Betapace af)
1
ADALAT CC - nifedipine tab sr
24hr 30 mg
3
•
(Betapace af)
1
24hr 60 mg
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
sotalol hcl tab 120 mg (Betapace) 1
sotalol hcl tab 160 mg (Betapace) 1
sotalol hcl tab 240 mg
1
sotalol hcl tab 80 mg (Betapace)
1
SOTYLIZE - sotalol hcl oral
solution 5 mg/ml
3
TENORMIN - atenolol tab 25 mg
3
3
3
TIMOLOL MALEATE - timolol
maleate tab 5 mg
1
maleate tab 10 mg
1
maleate tab 20 mg
1
TOPROL XL - metoprolol succinate 3
tab sr 24hr 25 mg
tab sr 24hr 50 mg
tab sr 24hr 100 mg
tab sr 24hr 200 mg
TRANDATE - labetalol hcl tab 100 3
mg
mg
mg
3
ZEBETA - bisoprolol fumarate tab
5 mg
3
ZEBETA - bisoprolol fumarate tab
10 mg
•
•
•
•
•
•
•
•
•
•
•
•
43
24hr 90 mg
3
amlodipine besylate tab 10 mg
(Norvasc)
•
CARDIZEM LA - diltiazem hcl
coated beads tab sr 24hr 240 mg
3
1
3
amlodipine besylate tab 2.5 mg
(Norvasc)
1
3
amlodipine besylate tab 5 mg
(Norvasc)
1
3
CALAN - verapamil hcl tab 80 mg
3
diltiazem hcl cap sr 12hr 120 mg
1
CALAN - verapamil hcl tab 120 mg
3
1
CALAN SR - verapamil hcl tab cr
120 mg
3
1
1
180 mg
•
3
1
3
•
1
240 mg
1
CARDIZEM - diltiazem hcl tab 30
mg
3
diltiazem hcl coated beads cap
sr 24hr 120 mg (Cardizem cd)
1
mg
3
1
mg
3
1
CARDIZEM CD - diltiazem hcl
coated beads cap sr 24hr 120
mg
3
1
mg
3
diltiazem hcl coated beads tab sr
24hr 180 mg (Cardizem la)
1
1
mg
3
1
mg
3
•
1
3
•
1
mg
1
3
diltiazem hcl extended release
beads cap sr 24hr 120 mg
(Tiazac)
(Tiazac)
1
3
44
•
•
•
•
•
•
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
(Tiazac)
1
(Tiazac)
1
(Tiazac)
1
(Tiazac)
1
diltiazem hcl tab 120 mg
(Cardizem)
nifedipine tab sr 24hr osmotic
60 mg (Procardia xl)
1
1
nifedipine tab sr 24hr 30 mg
(Adalat cc)
1
(Adalat cc)
1
(Adalat cc)
1
nimodipine cap 30 mg
1
1
NISOLDIPINE - nisoldipine tab sr
24hr 20 mg
1
(Cardizem)
1
24hr 30 mg
1
(Cardizem)
1
24hr 40 mg
1
1
1
felodipine tab sr 24hr 10 mg
1
NISOLDIPINE ER - nisoldipine tab
sr 24hr 25.5 mg
1
nisoldipine tab sr 24hr 17 mg
(Sular)
1
felodipine tab sr 24hr 2.5 mg
felodipine tab sr 24hr 5 mg
1
HYPERTENIPINE-2.5 amlodipine tab 2.5 mg & dietary
management cap pack
nisoldipine tab sr 24hr 34 mg
(Sular)
1
3
1
ISOPTIN SR - verapamil hcl tab cr
120 mg
3
•
nisoldipine tab sr 24hr 8.5 mg
(Sular)
3
•
180 mg
3
•
NORVASC - amlodipine besylate
tab 2.5 mg
3
•
240 mg
3
•
tab 5 mg
tab 10 mg
3
•
isradipine cap 2.5 mg
1
isradipine cap 5 mg
NYMALIZE - nimodipine oral soln
60 mg/20ml
3
1
nicardipine hcl cap 20 mg
1
3
•
nicardipine hcl cap 30 mg
1
PROCARDIA - nifedipine cap 10
mg
nifedipine cap 10 mg (Procardia)
1
3
•
nifedipine cap 20 mg
1
PROCARDIA XL - nifedipine tab sr
24hr osmotic 30 mg
1
24hr osmotic 60 mg
3
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
45
24hr osmotic 90 mg
3
SULAR - nisoldipine tab sr 24hr 8.5 3
mg
SULAR - nisoldipine tab sr 24hr 17 3
mg
SULAR - nisoldipine tab sr 24hr 34 3
mg
3
TIAZAC - diltiazem hcl extended
release beads cap sr 24hr 120
mg
3
mg
3
mg
3
mg
3
mg
3
mg
1
VERAPAMIL HCL - verapamil hcl
tab 40 mg
1
verapamil hcl cap sr 24hr
100 mg (Verelan pm)
1
120 mg (Verelan)
1
180 mg (Verelan)
1
200 mg (Verelan pm)
1
240 mg (Verelan)
1
300 mg (Verelan pm)
46
•
•
•
•
•
•
•
360 mg (Verelan)
1
verapamil hcl tab cr 120 mg
(Calan sr)
1
(Calan sr)
1
(Calan sr)
1
verapamil hcl tab 120 mg (Calan)
1
verapamil hcl tab 80 mg (Calan)
1
VERELAN - verapamil hcl cap sr
24hr 120 mg
3
•
24hr 180 mg
3
•
24hr 240 mg
3
•
24hr 360 mg
3
•
VERELAN PM - verapamil hcl cap
sr 24hr 100 mg
3
•
sr 24hr 200 mg
3
•
sr 24hr 300 mg
3
•
ANTIARRHYTHMICS
amiodarone hcl tab 100 mg
1
(Cordarone)
1
1
CORDARONE - amiodarone hcl
tab 200 mg
3
disopyramide phosphate cap
100 mg (Norpace)
1
disopyramide phosphate cap
150 mg (Norpace)
1
flecainide acetate tab 100 mg
1
1
1
mexiletine hcl cap 150 mg
1
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
TIKOSYN - dofetilide cap 250 mcg
(0.25 mg)
3
3
(0.5 mg)
3
NORPACE - disopyramide
phosphate cap 150 mg
3
ANTIHYPERTENSIVES
NORPACE CR - disopyramide
phosphate cap sr 12hr 100 mg
•
ACCUPRIL - quinapril hcl tab 5 mg
3
3
ACCUPRIL - quinapril hcl tab 10
mg
3
•
•
NORPACE CR - disopyramide
phosphate cap sr 12hr 150 mg
3
mg
3
•
propafenone hcl cap sr 12hr
225 mg (Rythmol sr)
1
mg
3
•
325 mg (Rythmol sr)
1
3
•
425 mg (Rythmol sr)
1
ACCURETIC - quinaprilhydrochlorothiazide tab 10-12.5
mg
3
•
propafenone hcl tab 150 mg
(Rythmol)
1
ACCURETIC - quinaprilhydrochlorothiazide tab 20-12.5
mg
(Rythmol)
1
ACCURETIC - quinaprilhydrochlorothiazide tab 20-25 mg
3
•
1
3
•
quinidine gluconate tab cr
324 mg
1
ACEON - perindopril erbumine tab
4 mg
3
•
QUINIDINE SULFATE - quinidine
sulfate tab 200 mg
1
ACEON - perindopril erbumine tab
8 mg
ALTACE - ramipril cap 1.25 mg
3
QUINIDINE SULFATE ER quinidine sulfate tab cr 300 mg
1
ALTACE - ramipril cap 2.5 mg
3
ALTACE - ramipril cap 5 mg
3
quinidine sulfate tab 300 mg
1
ALTACE - ramipril cap 10 mg
3
•
•
•
•
RYTHMOL - propafenone hcl tab
150 mg
3
amlodipine besylate-benazepril
hcl cap 10-20 mg (Lotrel)
1
RYTHMOL - propafenone hcl tab
225 mg
3
1
RYTHMOL SR - propafenone hcl
cap sr 12hr 225 mg
3
hcl cap 2.5-10 mg (Lotrel)
1
cap sr 12hr 325 mg
3
1
cap sr 12hr 425 mg
3
1
Specialty
Quantity Limits
NORPACE - disopyramide
phosphate cap 100 mg
3
"Smart" PA
2
(0.125 mg)
Prior Authorization
MULTAQ - dronedarone hcl tab
Drug Name
Drug Tier
1
Specialty
Quantity Limits
1
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
47
1
amlodipine besylate-valsartan
tab 10-160 mg (Exforge)
3
1
ATACAND HCT - candesartan
cilexetil-hydrochlorothiazide tab
32-25 mg
1
1
atenolol & chlorthalidone tab
100-25 mg (Tenoretic 100)
1
1
atenolol & chlorthalidone tab
50-25 mg (Tenoretic 50)
3
•
1
AVALIDE - irbesartanhydrochlorothiazide tab 150-12.5
mg
amlodipine-valsartanhydrochlorothiazide tab
10-160-12.5 mg (Exforge hct)
1
AVALIDE - irbesartanhydrochlorothiazide tab 300-12.5
mg
3
•
10-160-25 mg (Exforge hct)
1
AVAPRO - irbesartan tab 75 mg
3
3
3
•
•
•
1
AZOR - amlodipine besylateolmesartan medoxomil tab 5-20
mg
3
5-160-12.5 mg (Exforge hct)
1
mg
3
1
mg
3
ATACAND - candesartan cilexetil
tab 4 mg
3
3
tab 8 mg
3
mg
tab 16 mg
benazepril &
hydrochlorothiazide tab
10-12.5 mg (Lotensin hct)
1
3
tab 32 mg
3
1
16-12.5 mg
3
benazepril &
20-12.5 mg (Lotensin hct)
1
32-12.5 mg
3
benazepril &
20-25 mg (Lotensin hct)
benazepril &
5-6.25 mg
1
48
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
benazepril hcl tab 10 mg
(Lotensin)
1
(Lotensin)
1
(Lotensin)
candesartan cilexetilhydrochlorothiazide tab
32-12.5 mg (Atacand hct)
1
1
1
32-25 mg (Atacand hct)
1
captopril tab 100 mg
1
BENICAR - olmesartan medoxomil
tab 5 mg
3
captopril tab 12.5 mg
1
captopril tab 25 mg
1
tab 20 mg
3
captopril tab 50 mg
1
tab 40 mg
3
BENICAR HCT - olmesartan
medoxomil-hydrochlorothiazide
tab 20-12.5 mg
3
tab 40-12.5 mg
3
tab 40-25 mg
3
bisoprolol & hydrochlorothiazide
tab 10-6.25 mg (Ziac)
1
tab 2.5-6.25 mg (Ziac)
1
tab 5-6.25 mg (Ziac)
1
candesartan cilexetil tab 16 mg
(Atacand)
1
(Atacand)
1
(Atacand)
1
(Atacand)
1
16-12.5 mg (Atacand hct)
1
1
CAPTOPRIL/
HYDROCHLOROTHIA - captopril
& hydrochlorothiazide tab 25-15
mg
1
CAPTOPRIL/
mg
1
CAPTOPRIL/
mg
1
CAPTOPRIL/
mg
3
CARDURA - doxazosin mesylate
tab 1 mg
3
tab 2 mg
3
tab 4 mg
3
tab 8 mg
CATAPRES - clonidine hcl tab 0.1 3
mg
mg
mg
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
49
2
•
CATAPRES-TTS-2 - clonidine hcl
td patch weekly 0.2 mg/24hr
2
•
2
•
clonidine hcl tab 0.1 mg
(Catapres)
1
(Catapres)
1
(Catapres)
1
clonidine hcl td patch weekly
0.1 mg/24hr (Catapres-tts-1)
1
•
1
•
1
•
CLORPRES - clonidine &
chlorthalidone tab 0.1-15 mg
3
3
3
CORZIDE - nadolol &
bendroflumethiazide tab 40-5 mg
3
CORZIDE - nadolol &
bendroflumethiazide tab 80-5 mg
3
•
COZAAR - losartan potassium tab
25 mg
3
•
50 mg
3
•
100 mg
3
•
DEMSER - metyrosine cap 250 mg
2
DIBENZYLINE phenoxybenzamine hcl cap 10
mg
2
DIOVAN - valsartan tab 40 mg
3
3
50
•
3
DIOVAN HCT - valsartanhydrochlorothiazide tab 80-12.5
mg
3
mg
3
DIOVAN HCT - valsartanhydrochlorothiazide tab 160-25
mg
3
mg
3
DIOVAN HCT - valsartanhydrochlorothiazide tab 320-25
mg
3
doxazosin mesylate tab 1 mg
(Cardura)
1
(Cardura)
1
(Cardura)
1
(Cardura)
1
DUTOPROL - metoprolol &
hydrochlorothiazide tab sr 24hr
25-12.5 mg
2
50-12.5 mg
2
100-12.5 mg
2
EDARBI - azilsartan medoxomil tab 3
40 mg
EDARBI - azilsartan medoxomil tab 3
80 mg
3
EDARBYCLOR - azilsartan
medoxomil-chlorthalidone tab
40-12.5 mg
Specialty
Quantity Limits
3
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
EDARBYCLOR - azilsartan
medoxomil-chlorthalidone tab
40-25 mg
3
EXFORGE HCT - amlodipinevalsartan-hydrochlorothiazide tab
10-160-25 mg
3
enalapril maleate &
10-25 mg (Vaseretic)
1
10-320-25 mg
3
enalapril maleate &
5-12.5 mg
1
fosinopril sodium &
10-12.5 mg
1
enalapril maleate tab 10 mg
(Vasotec)
1
1
enalapril maleate tab 2.5 mg
(Vasotec)
1
fosinopril sodium &
20-12.5 mg
fosinopril sodium tab 10 mg
1
(Vasotec)
1
1
1
(Vasotec)
1
guanfacine hcl tab 1 mg (Tenex)
1
3
guanfacine hcl tab 2 mg (Tenex)
1
EPANED - enalapril maleate for
oral soln 1 mg/ml
hydralazine hcl tab 10 mg
1
eplerenone tab 25 mg (Inspra)
1
1
eplerenone tab 50 mg (Inspra)
1
1
eprosartan mesylate tab 600 mg
(Teveten)
1
1
3
EXFORGE - amlodipine besylatevalsartan tab 5-160 mg
3
HYPERTENSOLOL - metoprolol
tab 50 mg & dietary management
cap pack
3
3
•
3
HYZAAR - losartan potassium &
hydrochlorothiazide tab 50-12.5
mg
3
•
3
mg
3
hydrochlorothiazide tab 100-25
mg
3
5-160-12.5 mg
•
3
INSPRA - eplerenone tab 25 mg
3
5-160-25 mg
INSPRA - eplerenone tab 50 mg
3
irbesartan tab 150 mg (Avapro)
1
10-160-12.5 mg
3
1
1
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
51
irbesartan-hydrochlorothiazide
tab 150-12.5 mg (Avalide)
1
LOTENSIN - benazepril hcl tab 40
mg
3
•
irbesartan-hydrochlorothiazide
tab 300-12.5 mg (Avalide)
1
3
•
lisinopril & hydrochlorothiazide
tab 10-12.5 mg (Zestoretic)
1
LOTENSIN HCT - benazepril &
mg
3
•
tab 20-12.5 mg (Zestoretic)
1
mg
tab 20-25 mg (Zestoretic)
1
hydrochlorothiazide tab 20-25 mg
3
•
lisinopril tab 10 mg (Prinivil)
1
3
•
lisinopril tab 2.5 mg (Zestril)
1
LOTREL - amlodipine besylatebenazepril hcl cap 2.5-10 mg
1
LOTREL - amlodipine besylatebenazepril hcl cap 5-10 mg
3
•
lisinopril tab 30 mg (Zestril)
1
3
•
lisinopril tab 40 mg (Zestril)
1
1
3
•
LOPRESSOR HCT - metoprolol &
3
•
3
•
LOPRESSOR HCT - metoprolol &
mg
3
•
3
•
losartan potassium &
100-12.5 mg (Hyzaar)
1
LYTENSOPRIL KIT - lisinopril tab
cap pack
3
100-25 mg (Hyzaar)
1
LYTENSOPRIL-90 - lisinopril tab
cap pack
3
50-12.5 mg (Hyzaar)
1
LYTENSOPRIL-90 KIT - lisinopril
cap pack
3
losartan potassium tab 100 mg
(Cozaar)
1
MAVIK - trandolapril tab 1 mg
3
3
(Cozaar)
1
3
1
methyldopa tab 250 mg
1
(Cozaar)
methyldopa tab 500 mg
1
mg
3
•
1
mg
3
•
METHYLDOPA/
HYDROCHLOROTHI
- methyldopa &
mg
52
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
METHYLDOPA/
HYDROCHLOROTHI
- methyldopa &
mg
1
metoprolol &
100-25 mg (Lopressor hct)
1
metoprolol &
100-50 mg
1
metoprolol &
50-25 mg (Lopressor hct)
1
MICARDIS - telmisartan tab 20 mg
3
3
3
MICARDIS HCT - telmisartanhydrochlorothiazide tab 40-12.5
mg
3
MICARDIS HCT - telmisartanhydrochlorothiazide tab 80-12.5
mg
moexipril-hydrochlorothiazide
tab 7.5-12.5 mg
1
nadolol & bendroflumethiazide
tab 40-5 mg (Corzide)
1
nadolol & bendroflumethiazide
tab 80-5 mg (Corzide)
1
perindopril erbumine tab 2 mg
1
(Aceon)
1
(Aceon)
1
Specialty
Quantity Limits
"Smart" PA
prazosin hcl cap 1 mg (Minipress) 1
3
PRINIVIL - lisinopril tab 5 mg
3
3
3
3
PRINZIDE - lisinopril &
mg
1
MICARDIS HCT - telmisartanhydrochlorothiazide tab 80-25 mg
3
MINIPRESS - prazosin hcl cap 1
mg
3
•
PROPRANOLOL/
HYDROCHLOROTH
- propranolol &
1
mg
3
•
PROPRANOLOL/
HYDROCHLOROTH
- propranolol &
mg
3
•
quinapril hcl tab 10 mg (Accupril)
1
1
minoxidil tab 10 mg
1
1
minoxidil tab 2.5 mg
1
1
quinapril-hydrochlorothiazide
tab 10-12.5 mg (Accuretic)
1
tab 20-12.5 mg (Accuretic)
1
tab 20-25 mg (Accuretic)
1
ramipril cap 1.25 mg (Altace)
1
moexipril hcl tab 15 mg (Univasc) 1
1
moexipril hcl tab 7.5 mg
(Univasc)
1
tab 15-12.5 mg (Uniretic)
1
tab 15-25 mg
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
53
RESERPINE - reserpine tab 0.25
mg
1
TARKA - trandolapril-verapamil hcl
tab cr 1-240 mg
3
tab cr 2-180 mg
1
telmisartan-hydrochlorothiazide
tab 40-12.5 mg (Micardis hct)
1
tab 80-12.5 mg (Micardis hct)
1
tab 80-25 mg (Micardis hct)
1
TENEX - guanfacine hcl tab 1 mg
3
3
TENEX - guanfacine hcl tab 2 mg
3
3
•
tab cr 2-240 mg
3
TENORETIC 100 - atenolol &
chlorthalidone tab 100-25 mg
3
•
tab cr 4-240 mg
3
TENORETIC 50 - atenolol &
chlorthalidone tab 50-25 mg
terazosin hcl cap 1 mg
1
TEKTURNA - aliskiren fumarate
3
•
1
1
3
•
TEKTURNA - aliskiren fumarate
1
3
•
TEVETEN - eprosartan mesylate
tab 600 mg
3
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 150-12.5
mg
3
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 150-25
mg
3
•
TEVETEN HCT - eprosartan
mesylate-hydrochlorothiazide tab
600-12.5 mg
3
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 300-12.5
mg
3
•
TEVETEN HCT - eprosartan
mesylate-hydrochlorothiazide tab
600-25 mg
trandolapril tab 1 mg (Mavik)
1
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 300-25
mg
3
1
1
telmisartan tab 20 mg (Micardis)
trandolapril-verapamil hcl tab cr
1-240 mg (Tarka)
1
1
1
1
1
2-180 mg (Tarka)
telmisartan-amlodipine tab
40-10 mg (Twynsta)
1
2-240 mg (Tarka)
1
40-5 mg (Twynsta)
1
4-240 mg (Tarka)
1
80-10 mg (Twynsta)
1
54
•
•
Specialty
1
80-5 mg (Twynsta)
Quantity Limits
RESERPINE - reserpine tab 0.1
mg
"Smart" PA
1
Prior Authorization
ramipril cap 5 mg (Altace)
Drug Name
Drug Tier
1
Specialty
ramipril cap 2.5 mg (Altace)
Quantity Limits
1
"Smart" PA
ramipril cap 10 mg (Altace)
Prior Authorization
Drug Name
Drug Tier
2015
TRIBENZOR - olmesartanamlodipine-hydrochlorothiazide
tab 20-5-12.5 mg
3
tab 40-5-12.5 mg
3
tab 40-5-25 mg
3
tab 40-10-12.5 mg
3
tab 40-10-25 mg
3
TWYNSTA - telmisartanamlodipine tab 40-5 mg
3
3
3
3
valsartan tab 160 mg (Diovan)
VASOTEC - enalapril maleate tab
2.5 mg
3
•
5 mg
3
•
10 mg
3
•
20 mg
3
•
VECAMYL - mecamylamine hcl tab 3
2.5 mg
3
ZESTORETIC - lisinopril &
mg
3
mg
3
3
ZESTRIL - lisinopril tab 2.5 mg
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
ZESTRIL - lisinopril tab 5 mg
3
3
3
1
3
1
3
1
3
1
valsartan-hydrochlorothiazide
tab 160-12.5 mg (Diovan hct)
1
ZIAC - bisoprolol &
hydrochlorothiazide tab 2.5-6.25
mg
•
•
•
•
•
•
•
3
•
tab 160-25 mg (Diovan hct)
1
ZIAC - bisoprolol &
mg
1
ZIAC - bisoprolol &
mg
3
•
tab 320-25 mg (Diovan hct)
1
1
VASERETIC - enalapril maleate &
3
DIURETICS
•
ACETAZOLAMIDE acetazolamide tab 125 mg
1
acetazolamide cap sr 12hr
500 mg (Diamox)
1
acetazolamide sodium for inj
500 mg
1
55
3
3
DYRENIUM - triamterene cap 100
mg
3
ALDACTAZIDE - spironolactone &
3
EDECRIN - ethacrynic acid tab 25
mg
1
ALDACTONE - spironolactone tab
25 mg
3
FUROSEMIDE - furosemide oral
soln 8 mg/ml
furosemide oral soln 10 mg/ml
1
50 mg
3
furosemide tab 20 mg (Lasix)
1
1
100 mg
3
1
1
hydrochlorothiazide cap 12.5 mg
(Microzide)
1
amiloride & hydrochlorothiazide
tab 5-50 mg
1
hydrochlorothiazide tab 12.5 mg
1
amiloride hcl tab 5 mg
1
hydrochlorothiazide tab 25 mg
1
bumetanide tab 0.5 mg
1
hydrochlorothiazide tab 50 mg
1
bumetanide tab 1 mg
1
indapamide tab 1.25 mg
1
bumetanide tab 2 mg
1
indapamide tab 2.5 mg
1
CHLOROTHIAZIDE chlorothiazide tab 250 mg
INTROL - glycerin soln 75%
3
chlorothiazide tab 500 mg
1
LASIX - furosemide tab 20 mg
3
CHLORTHALIDONE chlorthalidone tab 25 mg
1
3
3
1
MAXZIDE - triamterene &
3
1
3
DEMADEX - torsemide tab 5 mg
3
MAXZIDE-25 - triamterene &
hydrochlorothiazide tab 37.5-25
mg
3
1
3
methazolamide tab 25 mg
(Neptazane)
3
methazolamide tab 50 mg
(Neptazane)
1
DIAMOX - acetazolamide cap sr
12hr 500 mg
3
METHYCLOTHIAZIDE methyclothiazide tab 5 mg
1
DIURIL - chlorothiazide susp 250
mg/5ml
3
metolazone tab 10 mg
1
3
metolazone tab 2.5 mg
(Zaroxolyn)
1
DYAZIDE - triamterene &
hydrochlorothiazide cap 37.5-25
mg
metolazone tab 5 mg (Zaroxolyn)
1
DYRENIUM - triamterene cap 50
mg
3
MICROZIDE - hydrochlorothiazide
cap 12.5 mg
3
56
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
ALDACTAZIDE - spironolactone &
Quantity Limits
1
"Smart" PA
acetazolamide tab 250 mg
Prior Authorization
Drug Name
Drug Tier
2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
AUVI-Q - epinephrine solution
auto-injector 0.3 mg/0.3ml
(1:1000)
2
•
1
•
spironolactone &
25-25 mg (Aldactazide)
1
EPINEPHRINE - epinephrine
solution auto-injector 0.15
mg/0.15ml (1:1000)
1
•
spironolactone tab 100 mg
(Aldactone)
1
EPINEPHRINE - epinephrine
mg/0.3ml (1:1000)
(Aldactone)
1
2
•
(Aldactone)
1
EPIPEN 2-PAK - epinephrine
mg/0.3ml (1:1000)
2
•
torsemide tab 10 mg (Demadex)
1
EPIPEN-JR 2-PAK - epinephrine
mg/0.3ml (1:2000)
1
midodrine hcl tab 10 mg
1
1
midodrine hcl tab 2.5 mg
1
1
midodrine hcl tab 5 mg
1
triamterene &
hydrochlorothiazide cap
37.5-25 mg (Dyazide)
1
NORTHERA - droxidopa cap 100
mg
3
•
• •
1
mg
3
triamterene &
37.5-25 mg (Maxzide-25)
•
• •
3
•
• •
triamterene &
75-50 mg (Maxzide)
1
mg
TRIAMTERENE/
HYDROCHLOROTH
- triamterene &
hydrochlorothiazide cap 50-25
mg
1
NEPTAZANE - methazolamide tab
25 mg
3
NEPTAZANE - methazolamide tab
50 mg
3
ANTIHYPERLIPIDEMICS
VASOPRESSORS
•
ADRENACLICK - epinephrine
mg/0.15ml (1:1000)
3
ADRENACLICK - epinephrine
mg/0.3ml (1:1000)
3
•
AUVI-Q - epinephrine solution
(1:1000)
2
•
ADVICOR - niacin-lovastatin tab sr
24hr 500-20 mg
3
•
24hr 750-20 mg
3
•
24hr 1000-20 mg
3
•
24hr 1000-40 mg
3
•
ALTOPREV - lovastatin tab sr 24hr
20 mg
3
•
40 mg
3
•
60 mg
3
•
57
ANTARA - fenofibrate micronized
cap 30 mg
3
•
CRESTOR - rosuvastatin calcium
tab 5 mg
2
•
ANTARA - fenofibrate micronized
cap 90 mg
3
•
tab 10 mg
2
•
atorvastatin calcium tab 10 mg
(base equivalent) (Lipitor)
1
tab 20 mg
2
•
1
tab 40 mg
2
•
1
FENOFIBRATE - fenofibrate cap
50 mg
1
•
1
FENOFIBRATE - fenofibrate cap
150 mg
1
•
cholestyramine light powder
packets 4 gm
1
fenofibrate micronized cap
130 mg
1
cholestyramine light powder
4 gm/dose (Questran light)
1
134 mg (Lofibra)
1
cholestyramine powder packets
4 gm (Questran)
1
200 mg (Lofibra)
1
cholestyramine powder 4 gm/
dose (Questran)
1
43 mg
1
choline fenofibrate cap dr
135 mg (fenofibric acid equiv)
(Trilipix)
1
67 mg (Lofibra)
1
fenofibrate tab 145 mg (Tricor)
1
choline fenofibrate cap dr 45 mg
(fenofibric acid equiv) (Trilipix)
1
fenofibrate tab 160 mg (Lofibra)
1
3
fenofibrate tab 48 mg (Tricor)
1
COLESTID - colestipol hcl tab 1
gm
fenofibrate tab 54 mg (Lofibra)
1
FENOFIBRIC ACID - fenofibric
acid tab 35 mg
1
•
FENOFIBRIC ACID - fenofibric
acid tab 105 mg
1
•
FENOGLIDE - fenofibrate tab 40
mg
3
•
FENOGLIDE - fenofibrate tab 120
mg
3
•
FIBRICOR - fenofibric acid tab 35
mg
3
•
FIBRICOR - fenofibric acid tab 105
mg
3
•
fluvastatin sodium cap 20 mg
(Lescol)
1
COLESTID - colestipol hcl granules 3
5 gm
COLESTID - colestipol hcl granule 3
packets 5 gm
COLESTID FLAVORED - colestipol 3
hcl granules 5 gm
COLESTID FLAVORED - colestipol 3
hcl granule packets 5 gm
1
colestipol hcl granule packets
5 gm (Colestid flavored)
1
colestipol hcl granules 5 gm
(Colestid flavored)
colestipol hcl tab 1 gm (Colestid) 1
58
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
fluvastatin sodium cap 40 mg
(Lescol)
1
LIPTRUZET - ezetimibeatorvastatin tab 10-80 mg
3
•
gemfibrozil tab 600 mg (Lopid)
1
•
JUXTAPID - lomitapide mesylate
2
2
2
LIVALO - pitavastatin calcium tab 1 3
mg (base equiv)
mg (base equiv)
mg (base equiv)
3
LOFIBRA - fenofibrate tab 54 mg
•
• •
•
• •
•
• •
2
•
• •
LOFIBRA - fenofibrate tab 160 mg
3
• •
LOFIBRA - fenofibrate micronized
cap 67 mg
3
2
•
•
•
•
•
• •
•
cap 134 mg
3
2
•
• •
•
3
cap 200 mg
3
KYNAMRO - mipomersen sodium
soln prefilled syringe 200 mg/ml
3
3
•
LOPID - gemfibrozil tab 600 mg
LESCOL - fluvastatin sodium cap
20 mg
lovastatin tab 10 mg
1
3
•
lovastatin tab 20 mg (Mevacor)
1
LESCOL - fluvastatin sodium cap
40 mg
lovastatin tab 40 mg (Mevacor)
1
LESCOL XL - fluvastatin sodium
tab sr 24 hr 80 mg
3
•
LOVAZA - omega-3-acid ethyl
esters cap 1 gm
3
LIPITOR - atorvastatin calcium tab
3
•
MEVACOR - lovastatin tab 40 mg
3
1
3
•
niacin tab cr 1000 mg
(antihyperlipidemic) (Niaspan)
1
3
•
1
3
•
3
LIPOFEN - fenofibrate cap 50 mg
3
NIACOR - niacin
(antihyperlipidemic) tab 500 mg
LIPOFEN - fenofibrate cap 150 mg
3
3
3
NIASPAN - niacin tab cr 500 mg
(antihyperlipidemic)
3
3
3
3
omega-3-acid ethyl esters cap
1 gm (Lovaza)
1
•
•
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
•
•
•
59
PRAVACHOL - pravastatin sodium
tab 20 mg
3
•
TRILIPIX - choline fenofibrate cap
dr 45 mg (fenofibric acid equiv)
3
•
tab 40 mg
3
•
TRILIPIX - choline fenofibrate cap
dr 135 mg (fenofibric acid equiv)
3
•
tab 80 mg
3
•
VASCEPA - icosapent ethyl cap 1
gm
3
pravastatin sodium tab 10 mg
1
3
•
(Pravachol)
1
VYTORIN - ezetimibe-simvastatin
tab 10-10 mg
3
•
(Pravachol)
1
tab 10-20 mg
3
•
(Pravachol)
1
tab 10-40 mg
3
•
QUESTRAN - cholestyramine
powder 4 gm/dose
3
tab 10-80 mg
2
QUESTRAN - cholestyramine
powder packets 4 gm
3
WELCHOL - colesevelam hcl tab
625 mg
2
QUESTRAN LIGHT cholestyramine light powder 4
gm/dose
3
WELCHOL - colesevelam hcl
packet for susp 3.75 gm
ZETIA - ezetimibe tab 10 mg
3
ZOCOR - simvastatin tab 5 mg
3
3
•
3
3
•
3
SIMCOR - niacin-simvastatin tab sr 3
24hr 500-20 mg
24hr 500-40 mg
24hr 750-20 mg
24hr 1000-20 mg
24hr 1000-40 mg
1
simvastatin tab 10 mg (Zocor)
1
1
1
1
TRICOR - fenofibrate tab 48 mg
3
TRICOR - fenofibrate tab 145 mg
3
TRIGLIDE - fenofibrate tab 160 mg
3
60
•
•
•
•
•
•
CARDIOVASCULAR AGENTS - MISC.
2
ADCIRCA - tadalafil tab 20 mg
(pah)
3
ADEMPAS - riociguat tab 0.5 mg
ADEMPAS - riociguat tab 1 mg
3
3
ADEMPAS - riociguat tab 2 mg
3
3
amlodipine besylate-atorvastatin
calcium tab 10-10 mg (Caduet)
1
1
1
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
•
•
•
•
•
•
•
• •
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
1
calcium tab 2.5-10 mg (Caduet)
1
CADUET - amlodipine besylateatorvastatin calcium tab 10-40
mg
3
3
1
mg
1
CIALIS - tadalafil tab 5 mg
3
1
CORLANOR - ivabradine hcl tab 5
mg (base equiv)
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
3
•
•
•
3
•
•
1
CORLANOR - ivabradine hcl tab
7.5 mg (base equiv)
1
1
ISOXSUPRINE HCL - isoxsuprine
hcl tab 20 mg
isoxsuprine hcl tab 10 mg
1
1
LETAIRIS - ambrisentan tab 5 mg
2
LETAIRIS - ambrisentan tab 10 mg
2
BIDIL - isosorbide dinitratehydralazine hcl tab 20-37.5 mg
2
OPSUMIT - macitentan tab 10 mg
2
3
ORENITRAM - treprostinil
diolamine tab cr 0.125 mg (base
equiv)
3
CADUET - amlodipine besylateatorvastatin calcium tab 2.5-10
mg
•
•
•
•
•
•
•
•
3
equiv)
3
mg
•
• •
3
diolamine tab cr 1 mg (base
equiv)
3
mg
•
• •
3
equiv)
3
CADUET - amlodipine besylateatorvastatin calcium tab 5-10 mg
•
• •
3
REVATIO - sildenafil citrate tab 20
mg
3
•
• •
3
REVATIO - sildenafil citrate for
suspension 10 mg/ml
3
•
• •
3
sildenafil citrate tab 20 mg
(Revatio)
1
•
• •
mg
3
TRACLEER - bosentan tab 62.5
mg
2
•
• •
mg
3
TRACLEER - bosentan tab 125 mg 2
•
• •
•
•
•
•
RESPIRATORY AGENTS
ANTIHISTAMINES
61
•
brompheniramine maleate tab sr
12hr 6 mg
1
fexofenadine hcl tab 60 mg
1
BROMPHENIRAMINE TANNATE
- brompheniramine tannate chew
tab 12 mg
KARBINAL ER - carbinoxamine
maleate er susp 4 mg/5ml
3
1
1
•
carbinoxamine maleate soln
4 mg/5ml
1
levocetirizine dihydrochloride
soln 2.5 mg/5ml (0.5 mg/ml)
(Xyzal)
•
1
levocetirizine dihydrochloride
tab 5 mg (Xyzal)
1
carbinoxamine maleate tab 4 mg
cetirizine hcl oral soln 1 mg/ml
(5 mg/5ml)
1
•
promethazine hcl suppos
12.5 mg
1
CLARINEX - desloratadine tab 5
mg
3
• •
promethazine hcl suppos 25 mg
1
1
CLARINEX - desloratadine syrup
0.5 mg/ml
• •
promethazine hcl suppos 50 mg
3
1
CLARINEX REDITABS desloratadine tab orally
disintegrating 2.5 mg
3
• •
promethazine hcl syrup
6.25 mg/5ml
promethazine hcl tab 12.5 mg
1
promethazine hcl tab 25 mg
1
CLARINEX REDITABS desloratadine tab orally
disintegrating 5 mg
3
promethazine hcl tab 50 mg
1
RESPA-BR - brompheniramine
maleate tab sr 12hr 11 mg
3
CLEMASTINE FUMARATE clemastine fumarate syrup 0.67
mg/5ml (0.5 mg/5ml base eq)
1
XYZAL - levocetirizine
dihydrochloride tab 5 mg
3
• •
• •
clemastine fumarate tab 2.68 mg
cyproheptadine hcl syrup
2 mg/5ml
1
XYZAL - levocetirizine
dihydrochloride soln 2.5 mg/5ml
(0.5 mg/ml)
3
1
cyproheptadine hcl tab 4 mg
1
desloratadine tab orally
disintegrating 2.5 mg (Clarinex
reditabs)
1
desloratadine tab orally
disintegrating 5 mg (Clarinex
reditabs)
1
•
desloratadine tab 5 mg (Clarinex)
1
•
diphenhydramine hcl cap 25 mg
1
diphenhydramine hcl cap 50 mg
1
diphenhydramine hcl elixir
12.5 mg/5ml
1
diphenhydramine hcl inj 50 mg/
ml
1
62
• •
•
NASAL AGENTS - SYSTEMIC and TOPICAL
3
ASTEPRO - azelastine hcl nasal
spray 0.15% (205.5 mcg/spray)
ATROVENT - ipratropium bromide 3
nasal soln 0.03% (21 mcg/spray)
ATROVENT - ipratropium bromide 3
nasal soln 0.06% (42 mcg/spray)
azelastine hcl nasal spray 0.15% 1
(205.5 mcg/spray) (Astepro)
1
azelastine hcl nasal spray
137 mcg/spray (1 mg/ml)
3
BACTROBAN NASAL - mupirocin
calcium nasal oint 2%
•
BECONASE AQ - beclomethasone 3
dipropionate monohyd nasal
susp 42 mcg/spray
•
•
•
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
budesonide nasal susp 32 mcg/
act (Rhinocort aqua)
1
•
DYMISTA - azelastine hclfluticasone prop nasal spray
137-50 mcg/act
3
• •
FLUNISOLIDE - flunisolide nasal
soln 25 mcg/act (0.025%)
1
•
flunisolide nasal soln 25 mcg/act
(0.025%) (Flunisolide)
1
fluticasone propionate nasal
susp 50 mcg/act (Flonase)
ZETONNA - ciclesonide nasal
aerosol soln 37 mcg/act (50 mcg/
valve)
3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
• •
COUGH/COLD/ALLERGY
acetylcysteine inhal soln 10%
1
acetylcysteine inhal soln 20%
1
•
benzonatate cap 100 mg
(Tessalon perles)
1
1
•
(Zonatuss)
1
1
ipratropium bromide nasal soln
0.03% (21 mcg/spray) (Atrovent)
1
ipratropium bromide nasal soln
0.06% (42 mcg/spray) (Atrovent)
2
NASONEX - mometasone furoate
nasal susp 50 mcg/act
1
olopatadine hcl nasal soln 0.6%
(Patanase)
OMNARIS - ciclesonide nasal susp 3
50 mcg/act
PATANASE - olopatadine hcl nasal 3
soln 0.6%
1
pseudoephedrine hcl tab 30 mg
•
1
brompheniramine &
pseudoephedrine tab sr 12hr
6-45 mg
1
CAPCOF - phenylephrinechlorphen w/ codeine syrup
5-2-10 mg/5ml
3
CARBAPHEN 12 - phenylephchlorphen-carbetapentane liqd
10-4-27.5 mg/5ml
3
CARBAPHEN 12 PED phenyleph-chlorphencarbetapentane susp
2.5-1.25-7.5 mg/ml
3
chlorpheniramine w/ codeine
liquid 2-10 mg/5ml
1
CLARINEX-D 12 HOUR
- desloratadine &
pseudoephedrine tab sr 12hr
2.5-120 mg
3
CODAR AR - chlorpheniramine w/
codeine liquid 2-8 mg/5ml
3
CODAR D - pseudoephedrine w/
3
CPB WC - pseudoephedrinebromphen-codeine liq 10-1.3-6.3
mg/5ml
3
DECON-A - brompheniramine &
phenylephrine elixir 2-5 mg/5ml
3
pseudoephedrine hcl tab 60 mg
1
QNASL - beclomethasone
dipropionate nasal aerosol 80
mcg/act
3
QNASL CHILDRENS beclomethasone dipropionate
nasal aerosol 40 mcg/act
3
RHINOCORT AQUA - budesonide
nasal susp 32 mcg/act
3
TYZINE - tetrahydrozoline hcl
nasal soln 0.1%
3
TYZINE PEDIATRIC NASAL DR
- tetrahydrozoline hcl nasal soln
0.05%
3
VERAMYST - fluticasone furoate
nasal susp 27.5 mcg/spray
3
•
•
•
• •
•
• •
• •
• •
• •
• •
63
DECON-G - phenylephrinebrompheniramine-guaifenesin
liqd 2-1-40 mg/ml
3
HYPERSAL - sodium chloride soln
nebu 3.5%
3
DEX-TUSS - guaifenesin-codeine
liquid 300-10 mg/5ml
HYPERSAL - sodium chloride soln
nebu 7%
3
3
DEXTROMETHORPHAN
HBR/CHLO - phenylephrinechlorphen-dm liquid
1.75-0.75-2.75 mg/ml
LORTUSS EX - pseudoephedrine
w/ cod-gg liquid 30-10-100
mg/5ml
3
1
EXACTUSS - phenylephrine w/
dm-gg liqd 10-28-388 mg/5ml
3
GILPHEX TR - phenylephrineguaifenesin tab 10-388 mg
3
GILTUSS - phenylephrine w/ dmgg liqd 10-28-388 mg/5ml
3
GILTUSS PED-C - phenylephrine
w/ codeine-gg liquid 2.5-3-50 mg/
ml
3
GILTUSS TR - phenylephrine w/
dm-gg cap 7-14-288 mg
3
dm-gg tab 10-28-388 mg
3
dm-gg tab sr 12hr 20-30-600 mg
3
guaifenesin-codeine liquid
200-8 mg/5ml
1
guaifenesin-codeine liquid
225-7.5 mg/5ml
1
guaifenesin-codeine soln
100-10 mg/5ml
1
guaifenesin-codeine soln
100-6.3 mg/5ml
1
1
hydrocod polst-chlorphen polst
cr susp 10-8 mg/5ml (Tussionex
pennkineti)
1
hydrocodone w/ homatropine
syrup 5-1.5 mg/5ml
1
hydrocodone w/ homatropine
tab 5-1.5 mg
HYPER-SAL - sodium chloride soln 3
nebu 7%
64
M-END MAX D - pseudoephedrine- 3
dexbromphen-codeine liqd
20-0.667-6 mg/5ml
3
M-END PE - phenylephrinebromphen w/ codeine liqd
3.33-1.33-6.33 mg/5ml
MAR-COF BP - pseudoephedrine- 3
bromphen-codeine liqd 30-2-7.5
mg/5ml
3
MAR-COF CG EXPECTORANT
- guaifenesin-codeine liquid
225-7.5 mg/5ml
3
MUCINEX D - pseudoephedrineguaifenesin tab sr 12hr 60-600
mg
3
MUCINEX DM dextromethorphan-guaifenesin
tab sr 12hr 30-600 mg
3
NEBUSAL - sodium chloride soln
nebu 6%
NEOTUSS PLUS - phenylephrine- 3
chlorphen-dm liquid 7.5-4-30
mg/5ml
3
NEOTUSS-D - pseudoephedchlorphen w/ dm-gg liqd
30-2-30-200 mg/5ml
3
NORTUSS-EX dextromethorphan-guaifenesin
liquid 20-200 mg/5ml
3
NOTUSS-NX - codeinechlorcyclizine liquid 10-9.375
mg/5ml
3
NOTUSS-NXD - codeinepseudoephedrine-chlorcyclizine
liq 10-30-9.375mg/5ml
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
OBREDON - hydrocodoneguaifenesin soln 2.5-200 mg/5ml
3
PANATUSS DXP - phenylephrinedexbromphen-dm-gg liquid
5-1-15-100 mg/5ml
1
3
PROMETHAZINE VC PLAIN promethazine & phenylephrine
syrup 6.25-5 mg/5ml
1
PEDIATEX TDM - pseudoephedtriprolidine-dm susp 10-0.938-4
mg/ml
3
PROMETHAZINE VC/CODEINE phenylephrine-promethazine w/
codeine syrup 5-6.25-10 mg/5ml
promethazine w/ codeine syrup
6.25-10 mg/5ml
1
phenylephrine w/ dm-gg liqd
10-15-300 mg/5ml
1
promethazine-dm syrup
6.25-15 mg/5ml
1
10-30-200 mg/5ml
1
2.5-5-50 mg/ml
1
2.5-7.5-88 mg/ml
1
phenylephrine-chlorphen-dm
liquid 10-4-15 mg/5ml
1
phenylephrine-guaifenesin liqd
7.5-100 mg/5ml (1.5-20 mg/ml)
1
PHENYLHISTINE DH pseudoephedrine-chlorphen w/
codeine liq 30-2-10 mg/5ml
3
POLY-TUSSIN - codeinechlorcyclizine liquid 10-9.375
mg/5ml
3
POLY-TUSSIN AC phenylephrine-bromphen w/
codeine liquid 10-4-10 mg/5ml
3
POLY-TUSSIN D - codeinepseudoephedrine-chlorcyclizine
liq 10-30-9.375mg/5ml
3
PRO-CLEAR AC - codeinepyrilamine syrup 9-8.33 mg/5ml
3
PRO-RED AC - phenylephrinedexchlorphenir-codeine syrup
5-1-9 mg/5ml
3
PROMETHAZINE VC promethazine & phenylephrine
syrup 6.25-5 mg/5ml
1
1
PROMETHAZINE/
PHENYLEPHRIN - promethazine
& phenylephrine syrup 6.25-5
mg/5ml
1
pseudoeph-chlorphen
w/ hydrocodone soln
60-4-5 mg/5ml (Zutripro)
1
pseudoephed-bromphen-dm
syrup 30-2-10 mg/5ml
pseudoephedrine w/ cod-gg soln 1
30-10-100 mg/5ml
1
pseudoephedrine w/ cod-gg
(Suttar-sf)
1
pseudoephedrinebromphen-codeine liq
10-1.33-6.33 mg/5ml
1
pseudoephedrine-guaifenesin
tab 60-400 mg
3
RELHIST - bromphen tanphenyleph tan chew tab 6-15 mg
3
RESCON-MX dexchlorpheniraminephenylephrine tab sr 12hr 6-40
mg
3
REZIRA - pseudoephedrine w/
hydrocodone soln 60-5 mg/5ml
3
RYDEX - pseudoephedrinebromphen-codeine liq
10-1.33-6.33 mg/5ml
3
SEMPREX-D - acrivastine &
pseudoephedrine cap 8-60 mg
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
65
STATUSS GREEN - codeinepseudoephedrine-chlorcyclizine
liq 9-30-12.5 mg/5ml
3
SUTTAR-SF - pseudoephedrine w/
cod-gg syrup 30-10-100 mg/5ml
3
SUTTAR-2 - pseudoephedrine w/
cod-gg syrup 30-10-100 mg/5ml
3
TESSALON PERLES benzonatate cap 100 mg
3
TGQ 15DM/5PEH/2CPM phenylephrine-chlorphen-dm
syrup 5-2-15 mg/5ml
3
TGQ 30PSE/150GFN/15DM pseudoephedrine w/ dm-gg syrup
30-15-150 mg/5ml
3
TGQ 30PSE/3BRM/15DM pseudoephed-bromphen-dm
•
ANTIASTHMATIC and BRONCHODILATOR AGENTS
• •
ACCOLATE - zafirlukast tab 10 mg 3
ACCOLATE - zafirlukast tab 20 mg
3
2
3
ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 100-50
mcg/dose
• •
•
2
•
TGQ 50PSE/3BRM/30DM pseudoephed-bromphen-dm
1
mcg/dose
2
•
TRICODE AR - pseudoephedrinechlorphen w/ codeine liq 30-2-8
mg/5ml
3
mcg/dose
2
•
TRICODE GF - pseudoephedrine
w/ cod-gg liquid 30-8-200 mg/5ml
3
ADVAIR HFA - fluticasonesalmeterol inhal aerosol 45-21
mcg/act
TUSNEL - brompheniramine w/
dm-gg cap 2-15-200 mg
3
2
•
TUSSICAPS - hydrocod polstchlorphen polst cap sr 12hr 5-4
mg
3
mcg/act
2
•
TUSSICAPS - hydrocod polstchlorphen polst cap sr 12hr 10-8
mg
3
mcg/act
AEROSPAN - flunisolide hfa inhal
aerosol 80 mcg/act
3
•
albuterol sulfate soln nebu
0.083% (2.5 mg/3ml)
1
66
Specialty
1
Quantity Limits
sodium chloride soln nebu 7%
(Hyper-sal)
"Smart" PA
1
TUSSIONEX PENNKINETIC EXT - 3
hydrocod polst-chlorphen polst cr
susp 10-8 mg/5ml
3
VANACOF CD - phenylephrinedexchlorphenir-codeine liquid
5-1-10 mg/5ml
3
VITUZ - hydrocodonechlorpheniramine soln 5-4
mg/5ml
Z-TUSS AC - chlorpheniramine w/ 3
ZONATUSS - benzonatate cap 150 3
mg
ZUTRIPRO - pseudoeph-chlorphen 3
w/ hydrocodone soln 60-4-5
mg/5ml
Prior Authorization
Drug Name
Drug Tier
1
Specialty
Quantity Limits
1
"Smart" PA
sodium chloride soln nebu 0.9%
Prior Authorization
Drug Name
Drug Tier
2015
ASMANEX TWISTHALER 30 MET
- mometasone furoate inhal powd
110 mcg/inh (breath activated)
2
•
2
•
2
•
ASMANEX TWISTHALER 7 METE
3
•
ASMANEX 14 METERED DOSES
2
•
ASMANEX 60 METERED DOSES
2
•
•
ATROVENT HFA - ipratropium
bromide hfa inhal aerosol 17
mcg/act
2
•
3
•
BREO ELLIPTA - fluticasone
furoate-vilanterol aero powd ba
100-25 mcg/inh
2
•
ARNUITY ELLIPTA - fluticasone
furoate aerosol powder breath
activ 100 mcg/act
3
•
BROVANA - arformoterol tartrate
soln nebu 15 mcg/2ml (base
equiv)
3
•
ARNUITY ELLIPTA - fluticasone
furoate aerosol powder breath
activ 200 mcg/act
3
•
budesonide inhalation susp
0.25 mg/2ml (Pulmicort)
1
•
1
•
ASMANEX HFA - mometasone
furoate inhal aerosol suspension
100 mcg/act
2
•
budesonide inhalation susp
0.5 mg/2ml (Pulmicort)
2
•
ASMANEX HFA - mometasone
furoate inhal aerosol suspension
200 mcg/act
2
•
COMBIVENT RESPIMAT ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act
CROMOLYN SODIUM - cromolyn
sodium soln nebu 20 mg/2ml
1
•
ASMANEX TWISTHALER 120 ME
2
•
DALIRESP - roflumilast tab 500
mcg
3
•
•
•
2
DULERA - mometasone furoateformoterol fumarate aerosol
100-5 mcg/act
2
albuterol sulfate soln nebu 0.5%
(5 mg/ml)
1
0.63 mg/3ml (base equiv)
1
1
albuterol sulfate syrup 2 mg/5ml
1
albuterol sulfate tab sr 12hr 4 mg
(Vospire er)
1
albuterol sulfate tab sr 12hr 8 mg
(Vospire er)
1
albuterol sulfate tab 2 mg
1
albuterol sulfate tab 4 mg
1
ALVESCO - ciclesonide inhal
aerosol 80 mcg/act
3
ALVESCO - ciclesonide inhal
aerosol 160 mcg/act
3
•
ANORO ELLIPTA - umeclidiniumvilanterol aero powd ba 62.5-25
mcg/inh
2
ARCAPTA NEOHALER indacaterol maleate inhal powder
cap 75 mcg (base equiv)
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
67
DULERA - mometasone furoateformoterol fumarate aerosol
200-5 mcg/act
2
dyphylline-guaifenesin liqd
100-100 mg/5ml
1
ELIXOPHYLLIN - theophylline elixir 3
80 mg/15ml
2
FLOVENT DISKUS - fluticasone
propionate aer pow ba 50 mcg/
blister
2
blister
2
blister
2
FLOVENT HFA - fluticasone
propionate hfa inhal aero 44
mcg/act (50/valve)
2
propionate hfa inhal aer 110
mcg/act (125/valve)
2
propionate hfa inhal aer 220
mcg/act (250/valve)
FORADIL AEROLIZER - formoterol 2
fumarate inhal cap 12 mcg
INCRUSE ELLIPTA - umeclidinium 2
br aero powd breath act 62.5
mcg/inh (base eq)
1
ipratropium bromide inhal soln
0.02%
1
ipratropium-albuterol nebu soln
0.5-2.5(3) mg/3ml
1
levalbuterol hcl soln nebu conc
1.25 mg/0.5ml (base equiv)
1
levalbuterol hcl soln nebu
(Xopenex)
1
(Xopenex)
68
•
(Xopenex)
1
LUFYLLIN - dyphylline tab 400 mg
3
METAPROTERENOL SULFATE metaproterenol sulfate tab 10 mg
1
METAPROTERENOL SULFATE metaproterenol sulfate tab 20 mg
1
•
1
•
METAPROTERENOL SULFATE metaproterenol sulfate syrup 10
mg/5ml
montelukast sodium chew tab
4 mg (base equiv) (Singulair)
1
•
montelukast sodium chew tab
5 mg (base equiv) (Singulair)
1
•
•
montelukast sodium
oral granules packet 4 mg
(base equiv) (Singulair)
1
•
•
montelukast sodium tab 10 mg
(base equiv) (Singulair)
1
•
PERFOROMIST - formoterol
fumarate soln nebu 20 mcg/2ml
3
•
PROAIR HFA - albuterol sulfate
inhal aero 108 mcg/act (90mcg
base equiv)
2
•
2
•
•
PROAIR RESPICLICK - albuterol
sulfate aer pow ba 108 mcg/act
(90 mcg base equiv)
3
•
•
PROVENTIL HFA - albuterol
sulfate inhal aero 108 mcg/act
(90mcg base equiv)
PULMICORT - budesonide
inhalation susp 0.25 mg/2ml
3
•
inhalation susp 0.5 mg/2ml
3
•
inhalation susp 1 mg/2ml
2
•
PULMICORT FLEXHALER budesonide inhal aero powd 90
mcg/act (breath activated)
3
•
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
3
PULMOPHYLLINE - theophylline
cap pack
3
QVAR - beclomethasone
dipropionate inhal aero soln 40
mcg/act
2
•
QVAR - beclomethasone
dipropionate inhal aero soln 80
mcg/act
2
•
SEREVENT DISKUS - salmeterol
xinafoate aer pow ba 50 mcg/
dose (base equiv)
2
•
SINGULAIR - montelukast sodium
3
•
chew tab 4 mg (base equiv)
3
chew tab 5 mg (base equiv)
3
oral granules packet 4 mg (base
equiv)
3
•
SPIRIVA HANDIHALER tiotropium bromide monohydrate
inhal cap 18 mcg (base equiv)
2
•
SPIRIVA RESPIMAT - tiotropium
bromide monohydrate inhal
aerosol 2.5 mcg/act
2
•
STIOLTO RESPIMAT - tiotropium
br-olodaterol inhal aero soln
2.5-2.5 mcg/act
3
STRIVERDI RESPIMAT olodaterol hcl inhal aerosol soln
2.5 mcg/act (base equiv)
3
SYMBICORT - budesonideformoterol fumarate dihyd
aerosol 80-4.5 mcg/act
2
SYMBICORT - budesonideformoterol fumarate dihyd
aerosol 160-4.5 mcg/act
2
1
THEO-24 - theophylline cap sr 24hr 2
100 mg
200 mg
300 mg
400 mg
1
THEOPHYLLINE - theophylline
elixir 80 mg/15ml
1
theophylline soln 80 mg/15ml
theophylline tab sr 12hr 100 mg
1
1
•
1
1
•
1
1
TUDORZA PRESSAIR - aclidinium
bromide aerosol powd breath
activated 400 mcg/act
3
•
VENTOLIN HFA - albuterol sulfate
inhal aero 108 mcg/act (90mcg
base equiv)
2
•
•
•
•
Specialty
terbutaline sulfate tab 5 mg
Quantity Limits
1
"Smart" PA
terbutaline sulfate tab 2.5 mg
Prior Authorization
Drug Name
Drug Tier
•
PULMICORT FLEXHALER budesonide inhal aero powd 180
mcg/act (breath activated)
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
VOSPIRE ER - albuterol sulfate tab 3
sr 12hr 4 mg
VOSPIRE ER - albuterol sulfate tab 3
sr 12hr 8 mg
3
XOPENEX HFA - levalbuterol
tartrate inhal aerosol 45 mcg/act
(base equiv)
1
zafirlukast tab 10 mg (Accolate)
zafirlukast tab 20 mg (Accolate)
1
ZYFLO - zileuton tab 600 mg
3
ZYFLO CR - zileuton tab sr 12hr
600 mg
3
•
•
•
•
•
RESPIRATORY AGENTS - MISC.
69
KALYDECO - ivacaftor packet 50
mg
2
•
•
•
KALYDECO - ivacaftor packet 75
mg
2
•
• •
OFEV - nintedanib esylate cap 100
3
•
• •
OFEV - nintedanib esylate cap 150
3
•
• •
PULMOZYME - dornase alfa inhal
soln 1 mg/ml
2
ESBRIET - pirfenidone cap 267 mg 3
KALYDECO - ivacaftor tab 150 mg 2
GASTROINTESTINAL AGENTS
LAXATIVES
• •
• •
• •
• •
1
CASCARA SAGRADA - cascara
sagrada fl ext 1 gm/ml
1
COLYTE-FLAVOR PACKS - peg
3350-kcl-na bicarb-nacl-na
sulfate for soln 227.1 gm
3
COLYTE-FLAVOR PACKS - peg
3350-kcl-na bicarb-nacl-na
sulfate for soln 240 gm
3
GOLYTELY - peg 3350-kcl-na
bicarb-nacl-na sulfate for soln
236 gm
3
GOLYTELY - peg 3350-kcl-na
bicarb-nacl-na sulfate packet
227.1 gm
3
KRISTALOSE - lactulose oral
crystal packet 10 gm
3
diphenoxylate w/ atropine tab
2.5-0.025 mg (Lomotil)
1
KRISTALOSE - lactulose oral
crystal packet 20 gm
3
1
lactulose solution 10 gm/15ml
1
DIPHENOXYLATE/ATROPINE
- diphenoxylate w/ atropine liq
2.5-0.025 mg/5ml
MOVIPREP - peg 3350-kcl-naclna sulfate-na acorbate-c for soln
100 gm
2
ANTIDIARRHEALS
FULYZAQ - crofelemer tab delayed 3
release 125 mg
3
LOMOTIL - diphenoxylate w/
atropine tab 2.5-0.025 mg
1
loperamide hcl cap 2 mg
•
•
Specialty
Quantity Limits
"Smart" PA
NULYTELY/FLAVOR PACKS - peg 3
3350-kcl-sod bicarb-nacl for soln
420 gm
2
OSMOPREP - sod phos monosod phos di tabs 1.102-0.398
gm(1.5gm na phos)
3
PCP 100 - mag cit-bisacodylpetrolat-peg-metoclopramideelectrol kit
1
peg 3350-kcl-na bicarb-naclna sulfate for soln 236 gm
(Golytely)
1
peg 3350-kcl-na bicarb-nacl-na
sulfate for soln 240 gm (Colyteflavor packs)
1
peg 3350-kcl-sod bicarb-nacl
for soln 420 gm (Nulytely/flavor
pack)
1
polyethylene glycol 3350 oral
packet
1
polyethylene glycol 3350 oral
powder
3
PREPOPIK - sod picosulfate-mg
oxide-citric acid pack 10 mg-3.5
gm-12 gm
SUCLEAR - na sulf-k sulf-mg sulf & 3
peg 3350-nacl-na bicarb-kcl kit
SUPREP BOWEL PREP - sodium 2
sulfate-potassium sulfatemagnesium sulfate oral soln
bisacodyl tab & peg 3350-kclsod bicarb-nacl for soln kit
70
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
REZYST IM - probiotic product chew tab
3
VSL#3 DS - probiotic product packet
3
ANTACIDS
SODIUM BICARBONATE - sodium
bicarbonate powder
1
ULCER DRUGS
1
BELLADONNA ALKALOIDS & OP
- belladonna alkaloids & opium
suppos 16.2-60 mg
1
BENTYL - dicyclomine hcl cap 10
mg
3
•
BENTYL - dicyclomine hcl tab 20
mg
3
•
BENTYL - dicyclomine hcl oral soln 3
10 mg/5ml
CANTIL - mepenzolate bromide tab 3
25 mg
3
CARAFATE - sucralfate tab 1 gm
•
3
• •
CARAFATE - sucralfate susp 1
gm/10ml
2
ACIPHEX - rabeprazole sodium ec
tab 20 mg
3
• •
cimetidine hcl soln 300 mg/5ml
1
ACIPHEX SPRINKLE rabeprazole sodium capsule
sprinkle dr 5 mg
cimetidine tab 200 mg
1
1
ACIPHEX SPRINKLE rabeprazole sodium capsule
sprinkle dr 10 mg
3
1
1
1
clidinium & chlordiazepoxide
cap 2.5-5 mg (Librax)
1
amoxicillin cap-clarithro tablansopraz cap dr therapy pack
(Prevpac)
2
•
ANASPAZ - hyoscyamine sulfate
tab disp 0.125 mg
3
CUVPOSA - glycopyrrolate oral
soln 1 mg/5ml
3
•
ATROPEN - atropine sulfate im inj
device 0.25 mg/0.3ml
3
CYTOTEC - misoprostol tab 100
mcg
3
•
device 0.5 mg/0.7ml
3
CYTOTEC - misoprostol tab 200
mcg
3
• •
device 1 mg/0.7ml
3
DEXILANT - dexlansoprazole cap
3
• •
device 2 mg/0.7ml
3
DEXILANT - dexlansoprazole cap
1
AXID - nizatidine cap 300 mg
3
DICYCLOMINE HCL - dicyclomine
hcl oral soln 10 mg/5ml
3
dicyclomine hcl cap 10 mg
(Bentyl)
1
AXID - nizatidine oral soln 15 mg/
ml
dicyclomine hcl tab 20 mg
(Bentyl)
1
• •
•
•
•
Specialty
3
BELLADONNA & OPIUM belladonna alkaloids & opium
suppos 16.2-30 mg
Quantity Limits
RESTORA RX - lactobacillus
casei-folic acid cap 60-1.25 mg
"Smart" PA
1
Prior Authorization
opium tincture 1% (10 mg/ml)
(morphine equiv)
Drug Name
Drug Tier
3
Specialty
MOTOFEN - difenoxin w/ atropine
tab 1-0.025 mg
Quantity Limits
1
"Smart" PA
loperamide hcl tab 2 mg
Prior Authorization
Drug Name
Drug Tier
2015
71
DIGEX NF - hyoscyaminephenyltoloxamine cap 0.0625-15
mg
3
DONNATAL - pb-hyoscyatrop-scopol tab
16.2-0.1037-0.0194-0.0065 mg
3
DONNATAL - pb-hyoscyatrop-scopol elix
16.2-0.1037-0.0194-0.0065
mg/5ml
3
DONNATAL EXTENTABS - pbhyoscy-atrop-scopol tab cr
48.6-0.3111-0.0582-0.0195 mg
3
esomeprazole magnesium cap
delayed release 40 mg (base
eq) (Nexium)
1
•
hyoscyamine sulfate soln
0.125 mg/ml
1
hyoscyamine sulfate tab disp
0.125 mg (Anaspaz)
1
hyoscyamine sulfate tab sl
0.125 mg (Levsin/sl)
1
hyoscyamine sulfate tab sr 12hr
0.375 mg (Levbid)
1
hyoscyamine sulfate tab
0.125 mg (Levsin)
1
lansoprazole cap delayed
release 15 mg (Prevacid)
1
lansoprazole cap delayed
release 30 mg (Prevacid)
1
3
•
famotidine for susp 40 mg/5ml
(Pepcid)
1
LEVBID - hyoscyamine sulfate tab
sr 12hr 0.375 mg
3
•
famotidine tab 20 mg (Pepcid)
1
LEVSIN - hyoscyamine sulfate tab
0.125 mg
famotidine tab 40 mg (Pepcid)
1
3
•
GABITIDINE - ranitidine hcl tab
cap pack
3
LEVSIN/SL - hyoscyamine sulfate
tab sl 0.125 mg
LIBRAX - clidinium &
chlordiazepoxide cap 2.5-5 mg
3
•
GASTRINEX NF - hyoscyaminephenyltoloxamine cap 0.0625-15
mg
1
methscopolamine bromide tab
2.5 mg (Pamine)
1
1
GLYCATE - glycopyrrolate tab 1.5
mg
3
methscopolamine bromide tab
5 mg (Pamine forte)
1
glycopyrrolate inj 0.2 mg/ml
(Robinul)
1
misoprostol tab 100 mcg
(Cytotec)
1
glycopyrrolate inj 0.4 mg/2ml
(0.2 mg/ml) (Robinul)
1
misoprostol tab 200 mcg
(Cytotec)
3
• •
glycopyrrolate inj 1 mg/5ml
1
NEXIUM - esomeprazole
magnesium for delayed release
susp pack 2.5 mg
glycopyrrolate inj 4 mg/20ml
1
susp packet 5 mg
3
• •
susp packet 10 mg
3
• •
glycopyrrolate tab 1 mg (Robinul) 1
glycopyrrolate tab 2 mg (Robinul 1
forte)
1
hyoscyamine sulfate elixir
0.125 mg/5ml
72
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
• •
susp packet 20 mg
3
susp packet 40 mg
3
magnesium cap delayed release
40 mg
3
nizatidine cap 150 mg
1
nizatidine cap 300 mg (Axid)
1
nizatidine oral soln 15 mg/ml
(Axid)
1
OMECLAMOX-PAK - amoxicillin
cap-clarithro tab w/ omepraz cap
dr therapy pack
3
omeprazole cap delayed release
10 mg (Prilosec)
1
20 mg (Prilosec)
1
40 mg (Prilosec)
1
•
omeprazole-sodium bicarbonate
cap 20-1100 mg (Zegerid)
1
•
omeprazole-sodium bicarbonate
cap 40-1100 mg (Zegerid)
1
•
PAMINE - methscopolamine
bromide tab 2.5 mg
3
PAMINE FORTE methscopolamine bromide tab 5
mg
3
PAMINE FQ - methscopolamine
tab 5 mg & misc intestinal flora
reg cap
3
pantoprazole sodium ec tab
20 mg (base equiv) (Protonix)
1
•
pantoprazole sodium ec tab
40 mg (base equiv) (Protonix)
1
•
PEPCID - famotidine tab 20 mg
3
PEPCID - famotidine tab 40 mg
3
• •
• •
•
•
•
•
PEPCID - famotidine for susp 40
mg/5ml
3
PREVACID - lansoprazole cap
3
PREVACID - lansoprazole cap
3
• •
PREVACID SOLUTAB lansoprazole tab delayed release
orally disintegrating 15 mg
3
• •
PREVACID SOLUTAB lansoprazole tab delayed release
orally disintegrating 30 mg
3
• •
PREVPAC - amoxicillin capclarithro tab-lansopraz cap dr
therapy pack
3
•
PRILOSEC - omeprazole cap
3
• •
PRILOSEC - omeprazole cap
3
• •
PRILOSEC - omeprazole
susp packet 2.5 mg
3
• •
PRILOSEC - omeprazole
susp packet 10 mg
3
• •
PROPANTHELINE BROMIDE propantheline bromide tab 15 mg
1
PROTONIX - pantoprazole sodium
ec tab 20 mg (base equiv)
3
• •
ec tab 40 mg (base equiv)
3
• •
for delayed release susp packet
40 mg
3
• •
PYLERA - bismuth subcitmetronidazole-tetracycline cap
140-125-125 mg
3
•
rabeprazole sodium ec tab
20 mg (Aciphex)
1
•
ranitidine hcl cap 150 mg
1
ranitidine hcl cap 300 mg
1
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
73
ranitidine hcl syrup 15 mg/ml
(75 mg/5ml)
3
ZANTAC - ranitidine hcl tab 150
mg
3
ZANTAC - ranitidine hcl tab 300
mg
3
ZEGERID - omeprazole-sodium
bicarbonate cap 20-1100 mg
3
•
ANZEMET - dolasetron mesylate
tab 50 mg
3
•
•
•
ANZEMET - dolasetron mesylate
tab 100 mg
3
•
CESAMET - nabilone cap 1 mg
3
•
DICLEGIS - doxylamine-pyridoxine
tab delayed release 10-10 mg
3
•
•
•
dimenhydrinate tab 50 mg
1
dronabinol cap 10 mg (Marinol)
1
dronabinol cap 2.5 mg (Marinol)
1
dronabinol cap 5 mg (Marinol)
1
•
•
•
• •
EMEND - aprepitant capsule 125
mg
2
•
•
•
EMEND - aprepitant capsule
therapy pack 80 & 125 mg
2
•
granisetron hcl tab 1 mg
1
•
MARINOL - dronabinol cap 2.5 mg
3
MARINOL - dronabinol cap 5 mg
3
MARINOL - dronabinol cap 10 mg
3
meclizine hcl tab 12.5 mg
1
meclizine hcl tab 25 mg
1
ondansetron hcl oral soln
4 mg/5ml (Zofran)
1
•
ondansetron hcl tab 24 mg
1
•
•
EMEND - aprepitant capsule 40 mg 2
EMEND - aprepitant capsule 80 mg 2
bicarbonate cap 40-1100 mg
3
• •
(Zofran)
1
bicarbonate powd pack for susp
20-1680 mg
3
• •
(Zofran)
1
•
1
•
bicarbonate powd pack for susp
40-1680 mg
3
ondansetron orally
disintegrating tab 4 mg (Zofran
odt)
ondansetron orally
disintegrating tab 8 mg (Zofran
odt)
1
•
ANTIEMETICS
74
• •
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Tier
3
ranitidine hcl tab 150 mg (Zantac) 1
ranitidine hcl tab 300 mg (Zantac) 1
SYMAX DUOTAB - hyoscyamine
sulfate tab cr 0.375 mg (0.125
mg ir/0.25 mg cr)
Drug Name
AKYNZEO - netupitantpalonosetron cap 300-0.5 mg
1
ROBINUL - glycopyrrolate tab 1 mg 3
3
ROBINUL - glycopyrrolate inj 0.2
mg/ml
3
ROBINUL - glycopyrrolate inj 0.4
mg/2ml (0.2 mg/ml)
3
ROBINUL - glycopyrrolate inj 1
mg/5ml (0.2 mg/ml)
3
ROBINUL - glycopyrrolate inj 4
mg/20ml (0.2 mg/ml)
ROBINUL FORTE - glycopyrrolate 3
tab 2 mg
3
SENTRADINE - ranitidine hcl tab
cap pack
1
SUCRALFATE - sucralfate susp 1
gm/10ml
1
sucralfate tab 1 gm (Carafate)
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
•
SANCUSO - granisetron td patch
3.1 mg/24hr (contains 34.3 mg)
2
TIGAN - trimethobenzamide hcl
cap 300 mg
3
TRANSDERM-SCOP scopolamine td patch 72hr 1.5
mg
2
trimethobenzamide hcl cap
300 mg (Tigan)
1
ZOFRAN - ondansetron hcl tab 4
mg
3
•
ZOFRAN - ondansetron hcl tab 8
mg
3
•
ZOFRAN - ondansetron hcl oral
soln 4 mg/5ml
3
•
ZOFRAN ODT - ondansetron orally 3
disintegrating tab 4 mg
ZOFRAN ODT - ondansetron orally 3
3
ZUPLENZ - ondansetron oral
soluble film 4 mg
3
ZUPLENZ - ondansetron oral
soluble film 8 mg
•
PANCREAZE - pancrelipase
(lip-prot-amyl) dr cap
4200-10000-17500 unit
3
10500-25000-43750 unit
3
16800-40000-70000 unit
3
21000-37000-61000 unit
3
PANCRELIPASE - pancrelipase
5000-17000-27000 unit
3
PERTZYE - pancrelipase (lip-protamyl) dr cap 8000-28750-30250
unit
3
3
•
PERTZYE - pancrelipase (lip-protamyl) dr cap 16000-57500-60500
unit
SUCRAID - sacrosidase soln 8500
unit/ml
3
•
3
•
•
CREON - pancrelipase (lip-protamyl) dr cap 3000-9500-15000
unit
2
ULTRESA - pancrelipase (lip-protamyl) dr cap 13800-27600-27600
unit
3
unit
2
unit
3
unit
2
unit
3
CREON - pancrelipase
24000-76000-120000 unit
2
VIOKACE - pancrelipase (lip-protamyl) tab 10440-39150-39150
unit
3
CREON - pancrelipase
36000-114000-180000 unit
2
VIOKACE - pancrelipase (lip-protamyl) tab 20880-78300-78300
unit
ZENPEP - pancrelipase (lip-protamyl) dr cap 3000-10000-16000
unit
2
DIGESTIVE AIDS
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
75
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
unit
2
calcium acetate (phosphate
binder) cap 667 mg (169 mg
ca) (Phoslo)
1
unit
2
calcium acetate (phosphate
binder) tab 667 mg (Eliphos)
1
2
unit
2
CANASA - mesalamine suppos
1000 mg
CHENODAL - chenodiol tab 250
mg
3
ZENPEP - pancrelipase
20000-68000-109000 unit
2
CHOLBAM - cholic acid cap 50 mg
3
3
25000-85000-136000 unit
2
CHOLBAM - cholic acid cap 250
mg
CIMZIA - certolizumab pegol for inj
kit 2 x 200 mg
3
•
• •
40000-136000-218000 unit
2
CIMZIA - certolizumab pegol inj kit
2 x 200 mg/ml
3
•
• •
CIMZIA STARTER KIT certolizumab pegol inj kit 6 x 200
mg/ml
3
•
• •
COLAZAL - balsalazide disodium
cap 750 mg
3
GASTROINTESTINAL AGENTS- MISC.
mesalamine rectal enema 4 gm & 1
cleanser wipe kit (Rowasa)
3
ACTIGALL - ursodiol cap 300 mg
1
cromolyn sodium oral conc
100 mg/5ml (Gastrocrom)
1
alosetron hcl tab 0.5 mg (base
equiv) (Lotronex)
1
DELZICOL - mesalamine cap dr
400 mg
2
alosetron hcl tab 1 mg (base
equiv) (Lotronex)
3
DIPENTUM - olsalazine sodium
cap 250 mg
3
AMITIZA - lubiprostone cap 8 mcg
ELIPHOS - calcium acetate
(phosphate binder) tab 667 mg
3
ENTEREG - alvimopan cap 12 mg
3
FOSRENOL - lanthanum
carbonate chew tab 500 mg
2
2
2
carbonate oral powder pack 750
mg (elemental)
2
AMITIZA - lubiprostone cap 24 mcg 3
APRISO - mesalamine cap sr 24hr 3
0.375 gm
2
ASACOL HD - mesalamine tab
3
AURYXIA - ferric citrate tab 1 gm
(210 mg ferric iron)
3
AZULFIDINE - sulfasalazine tab
500 mg
3
AZULFIDINE EN-TABS sulfasalazine tab delayed release
500 mg
1
balsalazide disodium cap
750 mg (Colazal)
76
•
•
•
•
•
•
carbonate oral powder pack 1000
mg (elemental)
2
GASTROCROM - cromolyn sodium 3
oral conc 100 mg/5ml
GATTEX - teduglutide (rdna) for inj 3
kit 5 mg
3
GIAZO - balsalazide disodium tab
1.1 gm
1
lactulose (encephalopathy)
solution 10 gm/15ml
LIALDA - mesalamine tab delayed 2
release 1.2 gm
LINZESS - linaclotide cap 145 mcg 2
LINZESS - linaclotide cap 290 mcg
2
LOTRONEX - alosetron hcl tab 0.5
mg (base equiv)
3
LOTRONEX - alosetron hcl tab 1
mg (base equiv)
3
mesalamine enema 4 gm
1
metoclopramide hcl orally
(Metozolv odt)
1
metoclopramide hcl soln
5 mg/5ml (10 mg/10ml)
1
metoclopramide hcl tab 10 mg
(Reglan)
1
metoclopramide hcl tab 5 mg
(Reglan)
1
METOZOLV ODT metoclopramide hcl orally
3
MOVANTIK - naloxegol oxalate tab
3
MOVANTIK - naloxegol oxalate tab
3
PENTASA - mesalamine cap cr
250 mg
2
PENTASA - mesalamine cap cr
500 mg
2
•
•
•
•
PHOSLO - calcium acetate
(phosphate binder) cap 667 mg
(169 mg ca)
3
PHOSLYRA - calcium acetate
(phosphate binder) oral soln 667
mg/5ml
2
REGLAN - metoclopramide hcl tab
5 mg
3
REGLAN - metoclopramide hcl tab
10 mg
3
RELISTOR - methylnaltrexone
bromide inj 8 mg/0.4ml (20 mg/
ml)
2
bromide inj 12 mg/0.6ml (20 mg/
ml)
2
bromide inj kit 12 mg/0.6ml
2
RENAGEL - sevelamer hcl tab 400
mg
3
RENAGEL - sevelamer hcl tab 800
mg
3
RENVELA - sevelamer carbonate
tab 800 mg
2
packet 0.8 gm
2
packet 2.4 gm
2
ROWASA - mesalamine rectal
enema 4 gm & cleanser wipe kit
3
SEVELAMER CARBONATE sevelamer carbonate tab 800 mg
1
SFROWASA - mesalamine sulfitefree (sf) enema 4 gm/60ml
3
sulfasalazine tab delayed
release 500 mg (Azulfidine entabs)
1
sulfasalazine tab 500 mg
(Azulfidine)
1
URSO FORTE - ursodiol tab 500
mg
3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
77
VELPHORO - sucroferric
oxyhydroxide chew tab 500 mg
3
GENITOURINARY AGENTS
URINARY ANTI-INFECTIVES
methenamine-hyos-meth bluesod phos-phen sal tab 81.6 mg
1
methenamine-hyosamine-meth
blue-sod phos tab 81.6 mg
(Urogesic-blue)
1
methenamine-hyosc-meth bluesod phos-phen sal cap 118 mg
1
methenamine-hyosc-meth bluesod phos-phen sal cap 120 mg
1
methenamine-hyosc-meth bluesod phos-phen sal tab 81 mg
1
FURADANTIN - nitrofurantoin susp
25 mg/5ml
3
HIPREX - methenamine hippurate
tab 1 gm
3
MACROBID - nitrofurantoin
monohydrate macrocrystalline
cap 100 mg
3
MACRODANTIN - nitrofurantoin
macrocrystalline cap 25 mg
3
3
3
methenamine hippurate tab 1 gm
(Hiprex)
1
METHENAMINE MANDELATE methenamine mandelate tab 0.5
gm
1
methenamine mandelate tab
1 gm
1
78
•
MONUROL - fosfomycin
tromethamine powd pack 3 gm
(base equivalent)
3
nitrofurantoin macrocrystalline
cap 100 mg (Macrodantin)
1
nitrofurantoin macrocrystalline
cap 50 mg (Macrodantin)
1
nitrofurantoin monohydrate
(Macrobid)
1
nitrofurantoin susp 25 mg/5ml
(Furadantin)
1
PROSED/DS - methenaminehyosc-meth blue-benz acidphenyl sal tab 81.6mg
3
URETRON D/S - methenaminehyosc-meth blue-sod phos-phen
sal tab 120 mg
3
UREX - methenamine hippurate
tab 1 gm
3
URIMAR-T - methenamine-hyoscmeth blue-sod phos-phen sal tab
120 mg
3
UROGESIC-BLUE - methenaminehyosamine-meth blue-sod phos
tab 81.6 mg
3
UROQID #2 - methenamine
mandelate-sod phosphate
monobasic tab 500-500 mg
3
UTA - methenamine-hyoscyaminemeth blue-sod phos cap 120 mg
3
URINARY ANTISPASMODICS
bethanechol chloride tab 10 mg
(Urecholine)
1
(Urecholine)
1
(Urecholine)
1
Specialty
1
Quantity Limits
ursodiol tab 500 mg (Urso forte)
1
"Smart" PA
1
methenamine-hyosc-meth bluebenz acid-phenyl sal tab
81.6mg (Prosed/ds)
Prior Authorization
ursodiol tab 250 mg (Urso 250)
Drug Name
Drug Tier
1
Specialty
ursodiol cap 300 mg (Actigall)
Quantity Limits
3
"Smart" PA
URSO 250 - ursodiol tab 250 mg
Prior Authorization
Drug Name
Drug Tier
2015
tolterodine tartrate cap sr 24hr
2 mg (Detrol la)
1
•
• •
tolterodine tartrate cap sr 24hr
4 mg (Detrol la)
1
•
3
• •
tolterodine tartrate tab 1 mg
(Detrol)
1
•
DETROL LA - tolterodine tartrate
cap sr 24hr 2 mg
3
•
tolterodine tartrate tab 2 mg
(Detrol)
1
•
DETROL LA - tolterodine tartrate
cap sr 24hr 4 mg
3
•
TOVIAZ - fesoterodine fumarate
tab sr 24hr 4 mg
3
• •
DITROPAN XL - oxybutynin
chloride tab sr 24hr 5 mg
3
• •
TOVIAZ - fesoterodine fumarate
tab sr 24hr 8 mg
3
• •
3
• •
trospium chloride cap sr 24hr
60 mg
1
•
3
• •
trospium chloride tab 20 mg
1
•
3
• •
URECHOLINE - bethanechol
chloride tab 5 mg
3
ENABLEX - darifenacin
hydrobromide tab sr 24hr 7.5 mg
(base equiv)
3
ENABLEX - darifenacin
hydrobromide tab sr 24hr 15 mg
(base equiv)
3
• •
chloride tab 10 mg
chloride tab 25 mg
3
1
chloride tab 50 mg
GELNIQUE - oxybutynin td gel 3%
(28 mg/act metered-dose pump)
3
•
• •
3
flavoxate hcl tab 100 mg
VESICARE - solifenacin succinate
tab 5 mg
3
• •
VESICARE - solifenacin succinate
tab 10 mg
3
• •
(Urecholine)
1
DETROL - tolterodine tartrate tab 1
mg
3
DETROL - tolterodine tartrate tab 2
mg
GELNIQUE - oxybutynin chloride td 3
gel 10%
3
MYRBETRIQ - mirabegron tab sr
24 hr 25 mg
3
MYRBETRIQ - mirabegron tab sr
24 hr 50 mg
1
oxybutynin chloride syrup
5 mg/5ml
1
oxybutynin chloride tab sr 24hr
10 mg (Ditropan xl)
1
15 mg (Ditropan xl)
1
5 mg (Ditropan xl)
1
oxybutynin chloride tab 5 mg
• •
• •
VAGINAL PRODUCTS
• •
AVC - sulfanilamide vaginal cream
15%
2
•
CLEOCIN - clindamycin phosphate
vaginal cream 2%
3
•
CLEOCIN - clindamycin phosphate
vaginal suppos 100 mg
3
•
clindamycin phosphate vaginal
cream 2% (Cleocin)
1
•
CLINDESSE - clindamycin
phosphate (one dose) vaginal
cream 2%
3
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
79
CRINONE - progesterone vaginal
gel 4%
3
SHUR-SEAL - nonoxynol-9 gel 2%
A
CRINONE - progesterone vaginal
gel 8%
TERAZOL 3 - terconazole vaginal
cream 0.8%
3
3
ENCARE - nonoxynol-9 vaginal
suppos 100 mg
TERAZOL 7 - terconazole vaginal
cream 0.4%
3
A
2
terconazole vaginal cream 0.4%
(Terazol 7)
1
ENDOMETRIN - progesterone
vaginal insert 100 mg
3
terconazole vaginal cream 0.8%
(Terazol 3)
1
ESTRACE - estradiol vaginal
cream 0.1 mg/gm
ESTRING - estradiol vaginal ring 2
mg (7.5 mcg/24hrs)
terconazole vaginal suppos
80 mg
1
2
FEM PH - acetic acid-oxyquinoline
vaginal gel 0.9-0.025%
TODAY SPONGE - nonoxynol-9
vaginal sponge 1000 mg
A
3
FEMRING - estradiol acetate
vaginal ring 0.05 mg/24hr
3
•
FEMRING - estradiol acetate
vaginal ring 0.1 mg/24hr
3
•
GYNAZOLE-1 - butoconazole
nitrate (one dose) vaginal cream
2%
3
METROGEL-VAGINAL metronidazole vaginal gel 0.75%
3
metronidazole vaginal gel 0.75%
(Metrogel-vaginal)
1
miconazole nitrate vaginal supp
200 mg & 2% cream 9 gm kit
1
MICONAZOLE 3 - miconazole
nitrate vaginal suppos 200 mg
3
NUVESSA - metronidazole vaginal
gel 1.3%
3
OPTIONS CONCEPTROL
VAGINA - nonoxynol-9 gel 4%
A
OPTIONS GYNOL II VAGINAL nonoxynol-9 gel 3%
A
conjugated vaginal cream 0.625
mg/gm
2
RELAGARD - acetic acidoxyquinoline vaginal gel
0.9-0.025%
3
80
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
VAGIFEM - estradiol vaginal tab 10 2
mcg
VCF VAGINAL CONTRACEPTIVE A
- nonoxynol-9 foam 12.5%
VCF VAGINAL CONTRACEPTIVE A
- nonoxynol-9 film 28%
GENITOURINARY AGENTS - MISC.
acetic acid irrigation soln 0.25%
1
alfuzosin hcl tab sr 24hr 10 mg
(Uroxatral)
1
AVODART - dutasteride cap 0.5
mg
3
• •
CARDURA XL - doxazosin
mesylate tab sr 24 hr 4 mg (base
equiv)
3
•
CARDURA XL - doxazosin
mesylate tab sr 24 hr 8 mg (base
equiv)
3
•
CITROLITH - potassium & sodium
citrates tab 50-950 mg
3
CYSTAGON - cysteamine
bitartrate cap 50 mg
3
•
CYSTAGON - cysteamine
bitartrate cap 150 mg
3
•
CYTRA-3 - pot & sod citrates w/ cit
ac syrup 550-500-334 mg/5ml
3
finasteride tab 5 mg (Proscar)
1
FLOMAX - tamsulosin hcl cap 0.4
mg
3
glycine irrigation soln 1.5%
1
JALYN - dutasteride-tamsulosin hcl 3
cap 0.5-0.4 mg
3
K-PHOS NO 2 - potassium &
sodium acid phosphates tab
305-700 mg
3
LITHOSTAT - acetohydroxamic
acid tab 250 mg
1
neomycin-polymyxin b gu
irrigation soln (Neosporin gu
irrigan)
3
NEOSPORIN GU IRRIGANT
- neomycin-polymyxin b gu
irrigation soln
3
ORACIT - sodium citrate & citric
acid soln 490-640 mg/5ml
1
phenazopyridine hcl tab 100 mg
(Pyridium)
1
phenazopyridine hcl tab 200 mg
(Pyridium)
1
pot & sod citrates w/ cit ac soln
550-500-334 mg/5ml
1
potassium citrate & citric acid
powder pack 3300-1002 mg
1
potassium citrate & citric acid
soln 1100-334 mg/5ml
1
potassium citrate tab cr 10 meq
(1080 mg) (Urocit-k 10)
1
(1620 mg) (Urocit-k 15)
1
(540 mg) (Urocit-k 5)
PROCYSBI - cysteamine bitartrate 3
cap delayed release 25 mg (base
equiv)
•
• •
•
PROSCAR - finasteride tab 5 mg
3
PYRIDIUM - phenazopyridine hcl
tab 100 mg
3
PYRIDIUM - phenazopyridine hcl
tab 200 mg
3
RAPAFLO - silodosin cap 4 mg
3
RAPAFLO - silodosin cap 8 mg
3
RENACIDIN - citric acid & dgluconic acid soln
3
Specialty
3
Quantity Limits
PROCYSBI - cysteamine bitartrate
cap delayed release 75 mg (base
equiv)
Drug Name
"Smart" PA
Specialty
Quantity Limits
"Smart" PA
•
Prior Authorization
2
Drug Tier
ELMIRON - pentosan polysulfate
sodium caps 100 mg
Prior Authorization
Drug Name
Drug Tier
2015
•
• •
• •
• •
RIMSO-50 - dimethyl sulfoxide soln 3
50%
3
SHOHLS SOLUTION MODIFIED
- sodium citrate & citric acid soln
500-334 mg/5ml
1
sodium chloride irrigation soln
0.9%
1
sodium citrate & citric acid soln
500-334 mg/5ml (Shohls solution
modi)
SORBITOL - sorbitol irrigation soln 1
3%
SORBITOL - sorbitol irrigation soln 1
3.3%
1
SORBITOL-MANNITOL - sorbitolmannitol irrigation soln 2.7-0.54
gm/100ml
1
tamsulosin hcl cap 0.4 mg
(Flomax)
3
THIOLA - tiopronin tab 100 mg
•
•
UROCIT-K 10 - potassium citrate
tab cr 10 meq (1080 mg)
3
3
3
UROXATRAL - alfuzosin hcl tab sr
24hr 10 mg
3
•
81
CENTRAL NERVOUS SYSTEM DRUGS
ANTIANXIETY AGENTS
clorazepate dipotassium tab
3.75 mg (Tranxene t)
1
ALPRAZOLAM INTENSOL alprazolam conc 1 mg/ml
1
7.5 mg (Tranxene t)
1
alprazolam orally disintegrating
tab 0.25 mg (Niravam)
1
DIAZEPAM - diazepam soln 1 mg/
ml
1
tab 0.5 mg
1
DIAZEPAM - diazepam inj 5 mg/ml
1
diazepam conc 5 mg/ml
1
tab 1 mg
1
diazepam tab 10 mg (Valium)
1
1
tab 2 mg
1
1
alprazolam tab sr 24hr 0.5 mg
(Xanax xr)
1
alprazolam tab sr 24hr 1 mg
(Xanax xr)
1
(Xanax xr)
1
(Xanax xr)
1
alprazolam tab 0.25 mg (Xanax)
1
alprazolam tab 0.5 mg (Xanax)
1
alprazolam tab 1 mg (Xanax)
1
alprazolam tab 2 mg (Xanax)
1
ATIVAN - lorazepam tab 0.5 mg
3
ATIVAN - lorazepam tab 1 mg
3
ATIVAN - lorazepam tab 2 mg
3
buspirone hcl tab 10 mg
1
1
1
1
buspirone hcl tab 7.5 mg
1
chlordiazepoxide hcl cap 10 mg
1
hydroxyzine hcl tab 25 mg
1
1
HYDROXYZINE PAMOATE hydroxyzine pamoate cap 100
mg
1
hydroxyzine pamoate cap 25 mg
(Vistaril)
1
hydroxyzine pamoate cap 50 mg
(Vistaril)
1
lorazepam conc 2 mg/ml
(Lorazepam intensol)
1
1
1
LORAZEPAM INTENSOL lorazepam conc 2 mg/ml
1
lorazepam tab 0.5 mg (Ativan)
1
1
lorazepam tab 1 mg (Ativan)
1
15 mg (Tranxene t)
1
lorazepam tab 2 mg (Ativan)
1
meprobamate tab 200 mg
1
•
•
•
Specialty
Quantity Limits
"Smart" PA
GABAVALE-5 - diazepam tab 5 mg 3
& dietary management cap pack
GABAZOLAMINE - alprazolam tab 3
0.25 mg & dietary management
cap pack
3
GABAZOLAMINE-0.5 alprazolam tab 0.5 mg & dietary
management cap pack
hydroxyzine hcl syrup 10 mg/5ml 1
82
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
1
amitriptyline hcl tab 50 mg
1
1
oxazepam cap 15 mg
1
AMOXAPINE - amoxapine tab 25
mg
1
oxazepam cap 30 mg
1
mg
1
SENTRAZOLAM AM 0.25 alprazolam tab 0.25 mg & dietary
management cap pack
3
mg
1
TRANXENE T - clorazepate
dipotassium tab 3.75 mg
3
•
mg
1
dipotassium tab 7.5 mg
3
•
ANAFRANIL - clomipramine hcl
cap 25 mg
3
•
dipotassium tab 15 mg
3
•
cap 50 mg
3
•
VALIUM - diazepam tab 2 mg
3
•
3
cap 75 mg
3
3
•
3
APLENZIN - bupropion hbr tab sr
24hr 174 mg
3
VISTARIL - hydroxyzine pamoate
cap 25 mg
•
•
•
•
3
•
VISTARIL - hydroxyzine pamoate
cap 50 mg
3
24hr 348 mg
3
•
XANAX - alprazolam tab 0.25 mg
3
3
XANAX - alprazolam tab 1 mg
3
APPBUTAMONE - bupropion hcl
cap pack
3
XANAX - alprazolam tab 0.5 mg
XANAX - alprazolam tab 2 mg
3
XANAX XR - alprazolam tab sr
24hr 0.5 mg
3
•
•
•
•
•
24hr 522 mg
24hr 1 mg
3
•
24hr 2 mg
3
•
24hr 3 mg
3
•
ANTIDEPRESSANTS
1
1
1
•
•
APPBUTAMONE-D - bupropion hcl 3
cap pack
BRINTELLIX - vortioxetine hbr tab 3
5 mg (base equiv)
10 mg (base equiv)
20 mg (base equiv)
1
bupropion hcl tab sr 12hr
100 mg (Wellbutrin sr)
1
Specialty
Quantity Limits
oxazepam cap 10 mg
1
"Smart" PA
Drug Tier
3
Prior Authorization
Drug Name
Specialty
NIRAVAM - alprazolam orally
disintegrating tab 0.25 mg
Quantity Limits
1
"Smart" PA
meprobamate tab 400 mg
Prior Authorization
Drug Name
Drug Tier
2015
• •
• •
• •
83
1
desipramine hcl tab 100 mg
(Norpramin)
1
150 mg (Wellbutrin xl)
1
(Norpramin)
1
300 mg (Wellbutrin xl)
1
(Norpramin)
1
bupropion hcl tab 100 mg
(Wellbutrin)
1
(Norpramin)
1
bupropion hcl tab 75 mg
(Wellbutrin)
1
(Norpramin)
1
CELEXA - citalopram
hydrobromide tab 10 mg (base
equiv)
3
DESVENLAFAXINE ER desvenlafaxine tab sr 24hr 50 mg
1
• •
•
• •
CELEXA - citalopram
equiv)
DESVENLAFAXINE ER desvenlafaxine tab sr 24hr 100
mg
1
3
•
• •
3
DESVENLAFAXINE ER desvenlafaxine fumarate tab sr
24hr 50 mg (base equiv)
1
CELEXA - citalopram
equiv)
• •
citalopram hydrobromide oral
soln 10 mg/5ml
DESVENLAFAXINE ER desvenlafaxine fumarate tab sr
1
1
citalopram hydrobromide tab
10 mg (base equiv) (Celexa)
1
DOXEPIN HCL - doxepin hcl cap
75 mg
1
1
doxepin hcl cap 10 mg
1
1
1
1
1
1
clomipramine hcl cap 25 mg
(Anafranil)
1
(Anafranil)
1
doxepin hcl conc 10 mg/ml
1
1
(Anafranil)
1
duloxetine hcl enteric coated
pellets cap 20 mg (Cymbalta)
1
• •
1
• •
EFFEXOR XR - venlafaxine hcl
cap sr 24hr 37.5 mg (base
equivalent)
3
CYMBALTA - duloxetine hcl enteric 3
coated pellets cap 20 mg
1
(Norpramin)
84
•
• •
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
EFFEXOR XR - venlafaxine
hcl cap sr 24hr 75 mg (base
equivalent)
3
EFFEXOR XR - venlafaxine
hcl cap sr 24hr 150 mg (base
equivalent)
3
EMSAM - selegiline td patch 24hr 6 3
mg/24hr
EMSAM - selegiline td patch 24hr 9 3
mg/24hr
3
EMSAM - selegiline td patch 24hr
12 mg/24hr
1
escitalopram oxalate soln
5 mg/5ml (base equiv)
(Lexapro)
1
escitalopram oxalate tab 10 mg
(base equiv) (Lexapro)
1
1
FETZIMA - levomilnacipran hcl cap 3
sr 24hr 20 mg (base equivalent)
3
FETZIMA TITRATION PACK levomilnacipran hcl cap sr 24hr
20 & 40 mg therapy pack
FLUOXETINE HCL - fluoxetine hcl 1
tab 60 mg
1
fluoxetine hcl cap delayed
release 90 mg (Prozac weekly)
fluoxetine hcl cap 10 mg (Prozac) 1
•
•
•
•
•
• •
• •
• •
• •
• •
•
•
fluoxetine hcl solution
20 mg/5ml
1
fluoxetine hcl tab 10 mg
1
fluoxetine hcl tab 20 mg
1
fluvoxamine maleate cap sr 24hr
100 mg (Luvox cr)
1
fluvoxamine maleate cap sr 24hr
150 mg (Luvox cr)
1
fluvoxamine maleate tab 100 mg
1
1
1
FORFIVO XL - bupropion hcl tab sr 3
24hr 450 mg
GABOXETINE - fluoxetine hcl cap 3
cap pack
1
imipramine hcl tab 10 mg
(Tofranil)
1
(Tofranil)
1
(Tofranil)
imipramine pamoate cap 100 mg 1
(Tofranil-pm)
(Tofranil-pm)
(Tofranil-pm)
1
imipramine pamoate cap 75 mg
(Tofranil-pm)
3
IRENKA - duloxetine hcl enteric
KHEDEZLA - desvenlafaxine tab sr 3
24hr 50 mg
KHEDEZLA - desvenlafaxine tab sr 3
24hr 100 mg
3
LEXAPRO - escitalopram oxalate
3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
• •
• •
•
•
85
•
3
3
MAPROTILINE HCL - maprotiline
hcl tab 25 mg
1
•
hcl tab 50 mg
1
•
hcl tab 75 mg
1
•
MARPLAN - isocarboxazid tab 10
mg
3
mirtazapine orally disintegrating
tab 15 mg (Remeron soltab)
1
1
1
mirtazapine tab 15 mg (Remeron)
1
1
1
mirtazapine tab 7.5 mg
1
NARDIL - phenelzine sulfate tab 15 2
mg
NEFAZODONE HCL - nefazodone 1
hcl tab 50 mg
hcl tab 100 mg
hcl tab 150 mg
hcl tab 200 mg
1
nefazodone hcl tab 250 mg
NORPRAMIN - desipramine hcl tab 3
10 mg
25 mg
50 mg
86
•
•
•
75 mg
100 mg
150 mg
1
NORTRIPTYLINE HCL nortriptyline hcl soln 10 mg/5ml
1
nortriptyline hcl cap 10 mg
(Pamelor)
1
(Pamelor)
1
(Pamelor)
1
(Pamelor)
3
OLEPTRO - trazodone hcl tab sr
24hr 150 mg
3
OLEPTRO - trazodone hcl tab sr
24hr 300 mg
3
PAMELOR - nortriptyline hcl cap
10 mg
3
25 mg
3
50 mg
3
75 mg
3
PARNATE - tranylcypromine
sulfate tab 10 mg
1
paroxetine hcl tab sr 24hr
12.5 mg (Paxil cr)
1
paroxetine hcl tab sr 24hr 25 mg
(Paxil cr)
1
paroxetine hcl tab sr 24hr
37.5 mg (Paxil cr)
1
paroxetine hcl tab 10 mg (Paxil)
1
1
1
•
•
•
• •
• •
•
•
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
PAXIL - paroxetine hcl oral susp 10 3
mg/5ml (base equiv)
3
PAXIL CR - paroxetine hcl tab sr
24hr 12.5 mg
3
24hr 25 mg
3
24hr 37.5 mg
PEXEVA - paroxetine mesylate tab 3
10 mg (base equiv)
20 mg (base equiv)
30 mg (base equiv)
40 mg (base equiv)
1
phenelzine sulfate tab 15 mg
(Nardil)
3
PRISTIQ - desvenlafaxine
succinate tab sr 24hr 25 mg
(base equiv)
3
(base equiv)
3
(base equiv)
1
protriptyline hcl tab 10 mg
(Vivactil)
1
protriptyline hcl tab 5 mg
(Vivactil)
3
PROZAC - fluoxetine hcl cap 10
mg
3
mg
mg
3
PROZAC WEEKLY - fluoxetine hcl
cap delayed release 90 mg
3
REMERON - mirtazapine tab 15
mg
3
•
•
mg
3
•
•
mg
3
•
•
REMERON SOLTAB - mirtazapine
orally disintegrating tab 15 mg
3
•
•
3
•
•
3
•
•
SENTRAFLOX AM-10 - fluoxetine
hcl cap 10 mg & dietary
management cap pack
3
SENTRALOPRAM AM-10 citalopram tab 10 mg & dietary
management cap pack
3
3
• •
SENTRAVIL PM-25 - amitriptyline
hcl tab 25 mg & diet manage
prod cap pack
SENTROXATINE - fluoxetine
hcl cap 10 mg & dietary
management cap pack
3
• •
sertraline hcl oral conc 20 mg/ml
(Zoloft)
1
• •
sertraline hcl tab 100 mg (Zoloft)
1
1
1
SURMONTIL - trimipramine
maleate cap 25 mg
3
•
•
maleate cap 50 mg
3
•
•
maleate cap 100 mg
3
•
•
Specialty
3
•
•
•
•
•
Quantity Limits
PAXIL - paroxetine hcl tab 40 mg
"Smart" PA
3
Prior Authorization
Drug Name
Drug Tier
3
Specialty
Quantity Limits
3
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
•
87
TOFRANIL - imipramine hcl tab 10
mg
3
•
mg
3
•
mg
3
•
TOFRANIL-PM - imipramine
pamoate cap 75 mg
3
•
pamoate cap 100 mg
3
•
pamoate cap 125 mg
3
•
pamoate cap 150 mg
3
•
tranylcypromine sulfate tab
10 mg (Parnate)
1
TRAZAMINE - trazodone hcl tab 50 3
mg & dietary management cap
pack
1
trazodone hcl tab 100 mg
VENLAFAXINE HCL ER venlafaxine hcl tab sr 24hr 225
1
•
venlafaxine hcl tab sr 24hr
(Venlafaxine hcl er)
1
•
venlafaxine hcl tab sr 24hr
(Venlafaxine hcl er)
1
•
venlafaxine hcl tab sr 24hr 75 mg
(base equivalent) (Venlafaxine
hcl er)
1
•
venlafaxine hcl tab 100 mg
1
1
venlafaxine hcl tab 37.5 mg
1
1
1
•
•
•
•
•
VIIBRYD - vilazodone hcl tab 10
mg
3
•
mg
3
•
mg
3
•
1
1
1
venlafaxine hcl cap sr 24hr
(Effexor xr)
1
•
VIIBRYD - vilazodone hcl tab
starter kit 10 (7) & 20 (7) & 40
(16) mg
3
•
(Effexor xr)
1
•
WELLBUTRIN - bupropion hcl tab
75 mg
3
•
3
•
(Effexor xr)
1
WELLBUTRIN - bupropion hcl tab
100 mg
WELLBUTRIN SR - bupropion hcl
tab sr 12hr 100 mg
3
•
VENLAFAXINE HCL ER venlafaxine hcl tab sr 24hr 37.5
1
•
tab sr 12hr 150 mg
3
•
•
•
1
tab sr 12hr 200 mg
3
VENLAFAXINE HCL ER venlafaxine hcl tab sr 24hr 75 mg
(base equivalent)
WELLBUTRIN XL - bupropion hcl
tab sr 24hr 150 mg
3
•
VENLAFAXINE HCL ER venlafaxine hcl tab sr 24hr 150
1
WELLBUTRIN XL - bupropion hcl
tab sr 24hr 300 mg
3
•
88
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
chlorpromazine hcl tab 50 mg
1
ZOLOFT - sertraline hcl tab 100
mg
CLOZAPINE ODT - clozapine
orally disintegrating tab 12.5 mg
1
ZOLOFT - sertraline hcl oral conc
20 mg/ml
3
•
1
1
3
3
clozapine tab 100 mg (Clozaril)
1
clozapine tab 200 mg
1
clozapine tab 25 mg (Clozaril)
1
clozapine tab 50 mg
1
CLOZARIL - clozapine tab 25 mg
3
ANTIPSYCHOTICS
ABILIFY - aripiprazole tab 2 mg
3
3
3
3
3
3
ABILIFY - aripiprazole oral solution
1 mg/ml
2
ABILIFY - aripiprazole im inj 9.75
mg/1.3ml (7.5 mg/ml)
2
ABILIFY DISCMELT - aripiprazole
2
CLOZARIL - clozapine tab 100 mg
3
3
ABILIFY DISCMELT - aripiprazole
2
COMPAZINE - prochlorperazine
maleate tab 5 mg
3
ABILIFY MAINTENA - aripiprazole
im for extended release susp 300
mg
3
COMPAZINE - prochlorperazine
maleate tab 10 mg
3
ABILIFY MAINTENA - aripiprazole
im for extended release susp 400
mg
3
EQUETRO - carbamazepine
(antipsychotic) cap sr 12hr 100
mg
3
aripiprazole tab 10 mg (Abilify)
1
mg
1
3
1
mg
1
FANAPT - iloperidone tab 1 mg
3
1
3
1
3
CHLORPROMAZINE HCL chlorpromazine hcl inj 25 mg/ml
1
3
1
3
1
3
1
3
Specialty
3
Quantity Limits
1
"Smart" PA
Drug Tier
3
•
•
•
Prior Authorization
Drug Name
Specialty
ZOLOFT - sertraline hcl tab 50 mg
Quantity Limits
3
"Smart" PA
ZOLOFT - sertraline hcl tab 25 mg
Prior Authorization
Drug Name
Drug Tier
2015
89
FANAPT TITRATION PACK iloperidone tab 1 mg & 2 mg & 4
mg & 6 mg titration pak
3
HALDOL DECANOATE 100 haloperidol decanoate im soln
100 mg/ml
3
FAZACLO - clozapine orally
3
3
3
HALDOL DECANOATE 50 haloperidol decanoate im soln 50
mg/ml
1
3
haloperidol decanoate im soln
100 mg/ml (Haldol decanoate
100)
3
haloperidol decanoate im soln
50 mg/ml (Haldol decanoate 50)
1
3
haloperidol lactate inj 5 mg/ml
(Haldol)
1
fluphenazine decanoate inj
25 mg/ml
1
haloperidol lactate oral conc
2 mg/ml
1
FLUPHENAZINE HCL fluphenazine hcl elixir 2.5 mg/5ml
1
haloperidol tab 0.5 mg
1
haloperidol tab 1 mg
1
FLUPHENAZINE HCL fluphenazine hcl oral conc 5 mg/
ml
1
1
1
1
1
FLUPHENAZINE HCL fluphenazine hcl inj 2.5 mg/ml
1
fluphenazine hcl tab 1 mg
1
3
1
INVEGA - paliperidone tab sr 24hr
1.5 mg
1
3 mg
3
fluphenazine hcl tab 2.5 mg
1
3
•
6 mg
3
GEODON - ziprasidone hcl cap 20
mg
mg
•
9 mg
3
3
mg
•
mg
3
•
INVEGA SUSTENNA paliperidone palmitate im
extended-release susp 39
mg/0.25ml
3
3
3
GEODON - ziprasidone mesylate
for inj 20 mg (base equivalent)
3
HALDOL - haloperidol lactate inj 5
mg/ml
3
mg/0.5ml
INVEGA SUSTENNA paliperidone palmitate im extendrelease susp 117 mg/0.75ml
3
90
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
loxapine succinate cap 10 mg
1
1
1
1
olanzapine for im inj 10 mg
(Zyprexa)
1
olanzapine orally disintegrating
tab 10 mg (Zyprexa zydis)
1
1
1
1
olanzapine tab 10 mg (Zyprexa)
1
LATUDA - lurasidone hcl tab 20 mg 3
1
olanzapine tab 2.5 mg (Zyprexa)
1
1
1
LATUDA - lurasidone hcl tab 120
mg
3
olanzapine tab 7.5 mg (Zyprexa)
1
1
1
perphenazine tab 16 mg
LITHIUM - lithium oral solution 8
meq/5ml
1
1
1
LITHIUM CARBONATE - lithium
carbonate cap 150 mg
1
LITHIUM CARBONATE - lithium
carbonate cap 600 mg
1
prochlorperazine edisylate inj
5 mg/ml
1
lithium carbonate cap 150 mg
(Lithium carbonate)
1
prochlorperazine maleate tab
10 mg (Compazine)
1
1
1
(Lithium carbonate)
1
prochlorperazine maleate tab
5 mg (Compazine)
prochlorperazine suppos 25 mg
1
lithium carbonate tab cr 300 mg
(Lithobid)
1
quetiapine fumarate tab 100 mg
(Seroquel)
1
lithium carbonate tab cr 450 mg
1
(Seroquel)
1
mg/1.5ml
3
INVEGA TRINZA - paliperidone
palmitate im extend-release susp
273 mg/0.875ml
3
410 mg/1.315ml
3
546 mg/1.75ml
3
819 mg/2.625ml
3
Specialty
3
Quantity Limits
LITHOBID - lithium carbonate tab
cr 300 mg
"Smart" PA
1
3
Prior Authorization
lithium carbonate tab 300 mg
extended-release susp 156 mg/
ml
Specialty
Drug Tier
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Name
Drug Tier
2015
91
(Seroquel)
1
risperidone orally disintegrating
tab 0.25 mg
1
(Seroquel)
1
tab 0.5 mg (Risperdal m-tab)
1
(Seroquel)
1
tab 1 mg (Risperdal m-tab)
1
(Seroquel)
1
1
RISPERDAL - risperidone tab 0.25
mg
3
1
RISPERDAL - risperidone tab 0.5
mg
3
1
RISPERDAL - risperidone tab 1 mg 3
risperidone soln 1 mg/ml
(Risperdal)
1
risperidone tab 0.25 mg
(Risperdal)
1
risperidone tab 0.5 mg
(Risperdal)
1
risperidone tab 1 mg (Risperdal)
1
1
1
1
SAPHRIS - asenapine maleate sl
tab 2.5 mg (base equiv)
3
3
3
SEROQUEL - quetiapine fumarate
tab 25 mg
3
tab 50 mg
3
tab 100 mg
3
tab 200 mg
3
tab 300 mg
3
tab 400 mg
3
RISPERDAL - risperidone soln 1
mg/ml
3
RISPERDAL CONSTA risperidone microspheres for inj
12.5 mg
3
25 mg
3
37.5 mg
3
50 mg
3
RISPERDAL M-TAB - risperidone
orally disintegrating tab 0.5 mg
3
3
3
3
3
92
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
SEROQUEL XR - quetiapine
fumarate tab sr 24hr 50 mg
2
ZYPREXA - olanzapine tab 20 mg
3
ZYPREXA - olanzapine for im inj
10 mg
3
2
ZYPREXA RELPREVV olanzapine pamoate for extended
rel im susp 210 mg (base eq)
3
2
2
3
2
3
thioridazine hcl tab 10 mg
1
1
1
ZYPREXA ZYDIS - olanzapine
3
•
1
3
•
thiothixene cap 1 mg
1
1
3
•
1
1
3
•
trifluoperazine hcl tab 1 mg
1
1
1
AMBIEN - zolpidem tartrate tab 5
mg
3
• •
1
3
• •
VERSACLOZ - clozapine susp 50
mg/ml
3
AMBIEN - zolpidem tartrate tab 10
mg
• •
ziprasidone hcl cap 20 mg
(Geodon)
AMBIEN CR - zolpidem tartrate tab
cr 6.25 mg
3
1
• •
(Geodon)
AMBIEN CR - zolpidem tartrate tab
cr 12.5 mg
3
1
BELSOMRA - suvorexant tab 5 mg
3
(Geodon)
1
BELSOMRA - suvorexant tab 10
mg
3
• •
• •
(Geodon)
1
mg
3
• •
ZYPREXA - olanzapine tab 2.5 mg
3
• •
3
mg
3
ZYPREXA - olanzapine tab 7.5 mg
3
3
3
BUTISOL SODIUM - butabarbital
sodium tab 30 mg
3
BUTISOL SODIUM - butabarbital
sodium tab 50 mg
3
HYPNOTICS
•
•
•
•
•
93
phenobarbital tab 64.8 mg
1
• •
1
1
• •
QUAZEPAM - quazepam tab 15
mg
RESTORIL - temazepam cap 7.5
mg
3
1
estazolam tab 2 mg
1
RESTORIL - temazepam cap 15
mg
3
eszopiclone tab 1 mg (Lunesta)
1
1
RESTORIL - temazepam cap 22.5
mg
3
1
FLURAZEPAM HCL - flurazepam
hcl cap 15 mg
1
RESTORIL - temazepam cap 30
mg
3
FLURAZEPAM HCL - flurazepam
hcl cap 30 mg
1
ROZEREM - ramelteon tab 8 mg
3
SECONAL - secobarbital sodium
cap 100 mg
3
GABAZOLPIDEM-5 - zolpidem tab
5 mg & dietary management cap
pack
3
SENTRAZOLPIDEM PM-5 zolpidem tab 5 mg & dietary
management cap pack
3
HALCION - triazolam tab 0.25 mg
3
HETLIOZ - tasimelteon capsule 20
mg
3
•
SILENOR - doxepin hcl (sleep) tab
3 mg (base equiv)
3
• •
INTERMEZZO - zolpidem tartrate
sl tab 1.75 mg
3
• •
SILENOR - doxepin hcl (sleep) tab
6 mg (base equiv)
3
• •
3
• •
SONATA - zaleplon cap 5 mg
3
INTERMEZZO - zolpidem tartrate
sl tab 3.5 mg
SONATA - zaleplon cap 10 mg
3
• •
• •
LUNESTA - eszopiclone tab 1 mg
3
3
STRAZEPAM - temazepam cap
15mg & dietary management cap
pack
3
3
• •
• •
• •
temazepam cap 15 mg (Restoril)
1
PHENOBARBITAL - phenobarbital
tab 15 mg
1
temazepam cap 22.5 mg
(Restoril)
1
tab 30 mg
1
temazepam cap 30 mg (Restoril)
1
1
temazepam cap 7.5 mg (Restoril)
1
tab 60 mg
triazolam tab 0.125 mg
1
tab 100 mg
1
triazolam tab 0.25 mg (Halcion)
1
zaleplon cap 10 mg (Sonata)
1
phenobarbital elixir 20 mg/5ml
1
zaleplon cap 5 mg (Sonata)
1
1
1
1
zolpidem tartrate tab cr 12.5 mg
(Ambien cr)
94
•
•
•
•
• •
•
•
•
Specialty
estazolam tab 1 mg
Quantity Limits
EDLUAR - zolpidem tartrate sl tab
10 mg
3
"Smart" PA
Drug Tier
3
Prior Authorization
Drug Name
Specialty
EDLUAR - zolpidem tartrate sl tab
5 mg
Quantity Limits
3
"Smart" PA
DORAL - quazepam tab 15 mg
Prior Authorization
Drug Name
Drug Tier
2015
1
•
amphetaminedextroamphetamine cap sr
24hr 15 mg (Adderall xr)
1
•
1
•
1
•
1
•
1
•
amphetaminedextroamphetamine tab 10 mg
(Adderall)
1
•
1
•
•
amphetaminedextroamphetamine tab
12.5 mg (Adderall)
1
•
•
(Adderall)
1
•
•
(Adderall)
1
•
•
(Adderall)
1
•
•
(Adderall)
amphetaminedextroamphetamine tab 7.5 mg
(Adderall)
1
•
zolpidem tartrate tab 10 mg
(Ambien)
1
•
zolpidem tartrate tab 5 mg
(Ambien)
1
•
ZOLPIMIST - zolpidem tartrate oral
spray 5 mg/act
3
• •
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/
ANOREXIANTS
3 •
ADDERALL - amphetaminedextroamphetamine tab 5 mg
3 •
ADDERALL - amphetaminedextroamphetamine tab 7.5 mg
3 •
3 •
ADDERALL - amphetaminedextroamphetamine tab 12.5 mg
3 •
3 •
3 •
3 •
ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr
5 mg
3 •
10 mg
3 •
15 mg
3 •
20 mg
3 •
25 mg
•
•
•
•
•
•
•
Specialty
•
Quantity Limits
Prior Authorization
•
1
Drug Name
"Smart" PA
Drug Tier
3
zolpidem tartrate tab cr 6.25 mg
(Ambien cr)
Specialty
30 mg
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
95
3
•
•
APTENSIO XR - methylphenidate
hcl cap er 24hr 15 mg (xr)
3
•
•
DEXEDRINE - dextroamphetamine
sulfate cap sr 24hr 15 mg
3
•
•
3
•
•
dexmethylphenidate hcl cap sr
24 hr 10 mg (Focalin xr)
1
•
3
•
•
1
•
3
•
•
1
•
3
•
•
1
•
3
•
•
1
•
caffeine citrate oral soln
60 mg/3ml (10 mg/ml base
equiv) (Cafcit)
1
dexmethylphenidate hcl tab
10 mg (Focalin)
1
•
•
•
1
2.5 mg (Focalin)
1
clonidine hcl tab sr 12hr 0.1 mg
(Kapvay)
•
•
CONCERTA - methylphenidate hcl
tab sa osm 18 mg
•
5 mg (Focalin)
1
3
•
•
tab sa osm 27 mg
•
dextroamphetamine sulfate cap
sr 24hr 10 mg (Dexedrine)
1
3
•
•
•
tab sa osm 36 mg
1
3
•
•
•
3
1
tab sa osm 54 mg
•
•
•
3
dextroamphetamine sulfate oral
solution 5 mg/5ml (Procentra)
1
DAYTRANA - methylphenidate td
patch 10 mg/9hr
•
•
patch 15 mg/9hr
•
dextroamphetamine sulfate tab
10 mg
1
3
•
•
patch 20 mg/9hr
dextroamphetamine sulfate tab
5 mg
1
3
•
•
•
•
patch 30 mg/9hr
EVEKEO - amphetamine sulfate
tab 5 mg
3
3
•
•
EVEKEO - amphetamine sulfate
tab 10 mg
3
•
•
DESOXYN - methamphetamine hcl 3
tab 5 mg
DEXEDRINE - dextroamphetamine 3
•
•
FOCALIN - dexmethylphenidate hcl 3
tab 2.5 mg
tab 5 mg
•
•
•
•
96
•
Specialty
DEXEDRINE - dextroamphetamine
Quantity Limits
Prior Authorization
•
Drug Name
"Smart" PA
Drug Tier
•
Specialty
3
Quantity Limits
Prior Authorization
Drug Name
"Smart" PA
Drug Tier
2015
•
•
•
KAPVAY - clonidine hcl tab sr 12hr
0.1 mg
3
•
•
METADATE CD - methylphenidate
hcl cap cr 10 mg
3
•
•
hcl cap cr 20 mg
3
•
•
hcl cap cr 30 mg
3
•
•
hcl cap cr 40 mg
3
•
•
hcl cap cr 50 mg
3
•
•
hcl cap cr 60 mg
3
•
•
methamphetamine hcl tab 5 mg
(Desoxyn)
1
METHYLIN - methylphenidate hcl
chew tab 2.5 mg
3
•
•
chew tab 5 mg
3
•
•
chew tab 10 mg
3
•
•
soln 5 mg/5ml
3
•
•
•
soln 10 mg/5ml
3
•
•
•
methylphenidate hcl cap cr
10 mg (Metadate cd)
1
•
•
20 mg (Metadate cd)
1
•
•
1
•
•
30 mg (Metadate cd)
•
•
40 mg (Metadate cd)
1
•
•
•
50 mg (Metadate cd)
1
•
•
60 mg (Metadate cd)
1
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Specialty
•
Quantity Limits
3
Drug Name
"Smart" PA
Prior Authorization
INTUNIV - guanfacine hcl tab sr
Specialty
•
Quantity Limits
•
"Smart" PA
Drug Tier
tab 10 mg
3
FOCALIN XR dexmethylphenidate hcl cap sr
24 hr 5 mg
3
24 hr 10 mg
3
24 hr 15 mg
3
24 hr 20 mg
3
24 hr 25 mg
3
24 hr 30 mg
3
24 hr 35 mg
3
24 hr 40 mg
1
guanfacine hcl tab sr 24hr 1 mg
(base equiv) (Intuniv)
1
1
1
3
3
3
Prior Authorization
Drug Name
Drug Tier
2015
•
97
3
NUVIGIL - armodafinil tab 200 mg
3
3
PROCENTRA dextroamphetamine sulfate oral
solution 5 mg/5ml
3
methylphenidate hcl cap sr 24hr
30 mg (Ritalin la)
1
•
40 mg (Ritalin la)
1
•
methylphenidate hcl chew tab
10 mg (Methylin)
1
•
1
•
PROVIGIL - modafinil tab 100 mg
3
2.5 mg (Methylin)
PROVIGIL - modafinil tab 200 mg
3
5 mg (Methylin)
1
•
METHYLPHENIDATE HCL ER methylphenidate hcl tab cr 10 mg
1
•
•
METHYLPHENIDATE HCL ER methylphenidate hcl tab sa osm
18 mg
1
•
•
27 mg
1
•
•
36 mg
1
54 mg
1
methylphenidate hcl soln
10 mg/5ml (Methylin)
1
•
methylphenidate hcl soln
5 mg/5ml (Methylin)
1
•
methylphenidate hcl tab cr
20 mg (Ritalin sr)
1
•
methylphenidate hcl tab 10 mg
(Ritalin)
1
•
(Ritalin)
1
•
(Ritalin)
1
•
modafinil tab 100 mg (Provigil)
1
modafinil tab 200 mg (Provigil)
1
QUILLIVANT XR - methylphenidate 3
hcl for er susp 25 mg/5ml (5 mg/
ml)
RITALIN - methylphenidate hcl tab 3
5 mg
10 mg
20 mg
RITALIN LA - methylphenidate hcl 3
cap sr 24hr 10 mg
cap sr 24hr 20 mg
cap sr 24hr 30 mg
cap sr 24hr 40 mg
cap sr 24hr 60 mg (la)
3
SENTRAMODAFIN AM-100 modafinil tab 100 mg & dietary
management cap pack
STRATTERA - atomoxetine hcl cap 3
10 mg (base equiv)
18 mg (base equiv)
25 mg (base equiv)
40 mg (base equiv)
98
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Specialty
•
Quantity Limits
3
1
"Smart" PA
20 mg (Ritalin la)
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
60 mg (base equiv)
80 mg (base equiv)
100 mg (base equiv)
3
VYVANSE - lisdexamfetamine
dimesylate cap 10 mg
3
3
3
3
3
3
3
ZENZEDI - dextroamphetamine
sulfate tab 2.5 mg
3
sulfate tab 7.5 mg
3
sulfate tab 15 mg
3
sulfate tab 20 mg
3
sulfate tab 30 mg
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
•
ANTABUSE - disulfiram tab 500
mg
3
•
•
ARICEPT - donepezil
3
• •
•
•
ARICEPT - donepezil
3
• •
•
•
ARICEPT - donepezil
3
• •
•
•
AUBAGIO - teriflunomide tab 7 mg
3
•
AUBAGIO - teriflunomide tab 14
mg
3
•
2
•
•
AVONEX - interferon beta-1a for
im inj kit 30mcg (33mcg(6.6 mu)/
vial)
• •
•
•
AVONEX - interferon beta-1a im inj
kit 30 mcg/0.5ml
2
• •
•
•
AVONEX PEN - interferon beta-1a
im inj kit 30 mcg/0.5ml
2
• •
•
•
BETASERON - interferon beta-1b
for inj kit 0.3 mg
3
• •
•
•
BRISDELLE - paroxetine mesylate
cap 7.5 mg (base equiv)
3
•
•
A
•
•
bupropion hcl (smoking
deterrent) tab sr 12hr 150 mg
(Zyban)
A
•
•
CHANTIX - varenicline tartrate tab
0.5 mg (base equiv)
A
•
•
CHANTIX - varenicline tartrate tab
1 mg (base equiv)
CHANTIX - varenicline tartrate
tab 0.5 mg x 11 & tab 1 mg x 42
pack
A
•
CHANTIX CONTINUING MONTH
- varenicline tartrate tab 1 mg
(base equiv)
A
•
CHANTIX STARTING MONTH PA
- varenicline tartrate tab 0.5 mg x
11 & tab 1 mg x 42 pack
A
•
CHLORDIAZEPOXIDE/AMITRIPT
- chlordiazepoxide-amitriptyline
tab 5-12.5 mg
1
•
•
PSYCHOTHERAPEUTIC and NEUROLOGICAL
AGENTS - MISC.
1
acamprosate calcium tab
(Campral)
3 •
AMPYRA - dalfampridine tab sr
12hr 10 mg
3
ANTABUSE - disulfiram tab 250
mg
• •
•
•
• •
• •
99
galantamine hydrobromide cap
sr 24hr 16 mg (Razadyne er)
1
•
• •
1
•
1
•
galantamine hydrobromide tab
12 mg (Razadyne)
1
•
1
•
•
4 mg (Razadyne)
1
•
•
8 mg (Razadyne)
3
•
GILENYA - fingolimod hcl cap 0.5
mg (base equiv)
3
•
•
GRALISE - gabapentin (phn) tab
300 mg
GRALISE - gabapentin (phn) tab
600 mg
3
•
GRALISE STARTER - gabapentin
(phn) tab starter pack 300 mg (9)
& 600 mg (69)
3
•
HORIZANT - gabapentin enacarbil
tab cr 300 mg
3
•
HORIZANT - gabapentin enacarbil
tab cr 600 mg
3
•
NAMENDA - memantine hcl tab 5
mg
2
•
NAMENDA - memantine hcl tab 10
mg
2
•
NAMENDA - memantine hcl oral
solution 2 mg/ml
2
•
NAMENDA TITRATION PAK memantine hcl tab 5 mg (28) &
10 mg (21) titration pak
2
•
NAMENDA XR - memantine hcl
cap sr 24hr 7 mg
2
•
cap sr 24hr 14 mg
2
•
COPAXONE - glatiramer acetate
2
disulfiram tab 250 mg (Antabuse)
1
disulfiram tab 500 mg (Antabuse)
1
donepezil hydrochloride orally
(Aricept odt)
1
donepezil hydrochloride orally
1
donepezil hydrochloride tab
10 mg (Aricept)
1
23 mg (Aricept)
1
5 mg (Aricept)
1
ergoloid mesylates tab 1 mg
1
EXELON - rivastigmine td patch
24hr 4.6 mg/24hr
3
• •
24hr 9.5 mg/24hr
3
• •
24hr 13.3 mg/24hr
3
•
• •
• •
• •
• •
• •
• •
•
Specialty
Quantity Limits
"Smart" PA
• •
2
100
Prior Authorization
• •
COPAXONE - glatiramer acetate
1
Drug Tier
1
1
fluoxetine hcl (pmdd) cap 20 mg
Drug Name
GALANTAMINE HYDROBROMIDE
- galantamine hydrobromide oral
soln 4 mg/ml
CHLORDIAZEPOXIDE/AMITRIPT
- chlordiazepoxide-amitriptyline
tab 10-25 mg
EXELON - rivastigmine tartrate cap 3
1.5 mg
3 mg
4.5 mg
6 mg
EXTAVIA - interferon beta-1b for inj 3
kit 0.3 mg
1
fluoxetine hcl (pmdd) cap 10 mg
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
• •
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
cap sr 24hr 21 mg
2
•
olanzapine-fluoxetine hcl cap
6-25 mg (Symbyax)
1
cap sr 24hr 28 mg
2
•
6-50 mg (Symbyax)
1
NAMENDA XR TITRATION PACK
- memantine hcl cap sr 24hr 7
mg & 14 mg & 21 mg & 28 mg
pack
2
•
ORAP - pimozide tab 1 mg
3
ORAP - pimozide tab 2 mg
3
1
NAMZARIC - memantine hcldonepezil hcl cap sr 24hr 14-10
mg
3
• •
PERPHENAZINE/AMITRIPTYLIN
- perphenazine-amitriptyline tab
2-10 mg
1
NAMZARIC - memantine hcldonepezil hcl cap sr 24hr 28-10
mg
3
• •
2-25 mg
1
nicotine polacrilex gum 2 mg
A
4-10 mg
nicotine polacrilex gum 4 mg
A
A
nicotine polacrilex lozenge 4 mg
A
4-25 mg
1
nicotine polacrilex lozenge 2 mg
nicotine td patch 24hr
14 mg/24hr
A
1
nicotine td patch 24hr
21 mg/24hr
A
4-50 mg
2
• •
nicotine td patch 24hr 7 mg/24hr
A
PLEGRIDY - peginterferon beta-1a
soln pen-injector 125 mcg/0.5ml
A
PLEGRIDY - peginterferon beta-1a
soln prefilled syringe 125
mcg/0.5ml
2
NICOTINE TRANSDERMAL
SYST - nicotine td patch 24 hr kit
21-14-7 mg/24hr
• •
A
PLEGRIDY STARTER PACK peginterferon beta-1a soln peninj 63 & 94 mcg/0.5ml pack
2
NICOTROL INHALER - nicotine
inhaler system 10 mg (4 mg
delivered)
• •
A
PLEGRIDY STARTER PACK peginterferon beta-1a soln pref
syr 63 & 94 mcg/0.5ml pack
2
NICOTROL NS - nicotine nasal
spray 10 mg/ml (0.5 mg/spray)
• •
NUEDEXTA - dextromethorphan
hbr-quinidine sulfate cap 20-10
mg
2
RAZADYNE - galantamine
hydrobromide tab 4 mg
3
• •
1
3
12-25 mg (Symbyax)
• •
1
3
12-50 mg (Symbyax)
• •
1
hydrobromide oral soln 4 mg/ml
3
3-25 mg (Symbyax)
• •
•
•
101
RAZADYNE ER - galantamine
hydrobromide cap sr 24hr 8 mg
3
• •
SAVELLA - milnacipran hcl tab 50
mg
3
•
3
• •
•
3
• •
REBIF - interferon beta-1a inj 22
mcg/0.5ml (12mu/ml) (44 mcg/
ml)
2
• •
REBIF - interferon beta-1a inj 44
mcg/0.5ml (24mu/ml) (88 mcg/
ml)
2
• •
REBIF REBIDOSE - interferon
beta-1a inj 22 mcg/0.5ml (12mu/
ml) (44 mcg/ml)
2
• •
REBIF REBIDOSE - interferon
beta-1a inj 44 mcg/0.5ml (24mu/
ml) (88 mcg/ml)
2
• •
REBIF REBIDOSE TITRATION
- interferon beta-1a inj 6 x 8.8
mcg/0.2ml & 6 x 22 mcg/0.5ml
2
• •
REBIF TITRATION PACK interferon beta-1a inj 6 x 8.8
mcg/0.2ml & 6 x 22 mcg/0.5ml
2
• •
rivastigmine tartrate cap 1.5 mg
(Exelon)
1
•
rivastigmine tartrate cap 3 mg
(Exelon)
1
•
rivastigmine tartrate cap 4.5 mg
(Exelon)
1
•
rivastigmine tartrate cap 6 mg
(Exelon)
1
•
SARAFEM - fluoxetine hcl (pmdd)
tab 10 mg
3
SAVELLA - milnacipran hcl tab 100 3
mg
3
SAVELLA TITRATION PACK milnacipran hcl tab 12.5 mg (5) &
25 mg (8) & 50 mg (42) pak
SYMBYAX - olanzapine-fluoxetine 3
hcl cap 3-25 mg
hcl cap 6-25 mg
hcl cap 6-50 mg
hcl cap 12-25 mg
hcl cap 12-50 mg
2
TECFIDERA - dimethyl fumarate
capsule delayed release 120 mg
2
TECFIDERA - dimethyl fumarate
capsule delayed release 240 mg
2
TECFIDERA STARTER PACK dimethyl fumarate capsule dr
starter pack 120 mg & 240 mg
2
XENAZINE - tetrabenazine tab
12.5 mg
2
XENAZINE - tetrabenazine tab 25
mg
3
XYREM - sodium oxybate oral
solution 500 mg/ml
A
ZYBAN - bupropion hcl (smoking
deterrent) tab sr 12hr 150 mg
SARAFEM - fluoxetine hcl (pmdd)
tab 20 mg
3
ANALGESICS - NON-NARCOTIC
1
SAVELLA - milnacipran hcl tab
12.5 mg
3
•
acetaminophen-salicylamidephenyltoloxamine cap
300-200-20mg
SAVELLA - milnacipran hcl tab 25
mg
3
•
ASPIRIN - aspirin tab 81 mg
A
aspirin chew tab 81 mg
A
102
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
•
•
• •
•
• •
•
• •
•
• •
•
• •
•
• •
ANALGESICS AND ANESTHETICS
3
•
A
ORBIVAN - butalbitalacetaminophen-caffeine cap
50-300-40 mg
3
•
BUPAP - butalbital-acetaminophen
tab 50-300 mg
3
ORBIVAN CF - butalbitalacetaminophen tab 50-300 mg
salsalate tab 500 mg
1
butalbital-acetaminophen tab
50-325 mg
1
•
salsalate tab 750 mg
1
1
•
VANATOL LQ - butalbitalacetaminophen-caffeine soln
50-325-40 mg/15ml
1
butalbital-acetaminophencaffeine cap 50-300-40 mg
(Fioricet)
butalbital-acetaminophencaffeine cap 50-325-40 mg
1
•
butalbital-acetaminophencaffeine tab 50-325-40 mg
(Esgic)
1
•
butalbital-aspirin-caffeine cap
50-325-40 mg (Fiorinal)
1
•
choline & magnesium salicylates
liq 500 mg/5ml
ASPIRIN LOW DOSE - aspirin tab
81 mg
A
aspirin tab delayed release
81 mg
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
ANALGESICS - NARCOTIC
ABSTRAL - fentanyl citrate sl tab
100 mcg (base equiv)
3
•
•
3
•
•
3
•
•
1
3
•
•
1
3
CHOLINE MAGNESIUM TRISALI choline & magnesium salicylates
tab 1000 mg
•
•
3
•
•
diflunisal tab 500 mg
1
3
acetaminophen w/ codeine soln
120-12 mg/5ml
1
DISALCID - salsalate tab 500 mg
DISALCID - salsalate tab 750 mg
3
•
3
acetaminophen w/ codeine tab
300-15 mg (Tylenol/codeine)
1
EQUAGESIC - meprobamateaspirin tab 200-325 mg
•
ESGIC - butalbital-acetaminophencaffeine tab 50-325-40 mg
• •
300-30 mg (Tylenol/codeine #3)
1
3
•
FIORICET - butalbitalacetaminophen-caffeine cap
50-300-40 mg
•
300-60 mg (Tylenol/codeine #4)
1
3
3
•
•
FIORICET - butalbitalacetaminophen-caffeine tab
50-325-40 mg
3
• •
ACTIQ - fentanyl citrate lollipop
200 mcg
400 mcg
3
•
•
3
• •
600 mcg
3
FIORINAL - butalbital-aspirincaffeine cap 50-325-40 mg
•
•
3
800 mcg
3
LEVACET - aspirin-apapsalicylamide-caffeine tab
500-250-150-32.5 mg
•
•
103
•
ASPIRIN-CAFFEINE-DIHYDROC
- aspirin-caffeine-dihydrocodeine
cap 356.4-30-16 mg
1
AVINZA - morphine sulfate beads
cap sr 24hr 30 mg
3
•
cap sr 24hr 45 mg
3
•
cap sr 24hr 60 mg
3
•
cap sr 24hr 90 mg
3
•
cap sr 24hr 120 mg
3
•
BUNAVAIL - buprenorphinenaloxone buccal film 2.1-0.3 mg
(base equiv)
3
•
•
BUNAVAIL - buprenorphinenaloxone buccal film 4.2-0.7 mg
(base equiv)
3
•
•
BUNAVAIL - buprenorphinenaloxone buccal film 6.3-1 mg
(base equiv)
3
•
•
buprenorphine hcl sl tab 2 mg
(base equiv)
1
buprenorphine hcl sl tab 8 mg
(base equiv)
1
buprenorphine hcl-naloxone hcl
sl tab 2-0.5 mg (base equiv)
1
buprenorphine hcl-naloxone hcl
sl tab 8-2 mg (base equiv)
1
butalbital-acetaminophen-caff
w/ cod cap 50-300-40-30 mg
(Fioricet/codeine)
1
butalbital-acetaminophen-caff w/
cod cap 50-325-40-30 mg
1
104
•
•
butalbital-aspirin-caff w/ codeine
cap 50-325-40-30 mg (Fiorinal/
codeine #3)
1
butorphanol tartrate inj 1 mg/ml
1
butorphanol tartrate inj 2 mg/ml
1
butorphanol tartrate nasal soln
10 mg/ml
1
•
BUTRANS - buprenorphine td
patch weekly 5 mcg/hr
3
•
patch weekly 7.5 mcg/hr
3
•
3
•
3
•
3
•
CAPITAL/CODEINE acetaminophen w/ codeine susp
120-12 mg/5ml
3
•
CODEINE SULFATE - codeine
sulfate tab 15 mg
1
•
sulfate tab 30 mg
1
•
sulfate tab 60 mg
1
•
codeine sulfate tab 15 mg
(Codeine sulfate)
1
•
1
•
•
•
•
•
•
1
3
•
CONZIP - tramadol hcl cap sr 24hr
biphasic release 100 mg
•
•
•
3
•
•
3
•
DEMEROL - meperidine hcl tab 50
mg
3
•
DEMEROL - meperidine hcl tab
100 mg
3
•
•
•
Specialty
•
Quantity Limits
3
"Smart" PA
1600 mcg
Prior Authorization
•
Drug Name
Drug Tier
•
Specialty
3
Quantity Limits
Prior Authorization
1200 mcg
Drug Name
"Smart" PA
Drug Tier
2015
DILAUDID - hydromorphone hcl
tab 2 mg
3
• •
EXALGO - hydromorphone hcl tab
er 24hr deter 32 mg
3
•
tab 4 mg
3
• •
•
tab 8 mg
3
• •
liqd 1 mg/ml
3
•
DOLOPHINE - methadone hcl tab
10 mg
3
• •
DOLOPHINE HCL - methadone hcl 3
tab 5 mg
3
DURAGESIC - fentanyl td patch
72hr 12 mcg/hr
3
72hr 25 mcg/hr
3
72hr 50 mcg/hr
3
72hr 75 mcg/hr
3
72hr 100 mcg/hr
3
EMBEDA - morphine-naltrexone
cap cr 20-0.8 mg
3
cap cr 30-1.2 mg
3
cap cr 50-2 mg
3
cap cr 60-2.4 mg
3
cap cr 80-3.2 mg
3
cap cr 100-4 mg
EXALGO - hydromorphone hcl tab 3
er 24hr deter 8 mg
er 24hr deter 12 mg
er 24hr deter 16 mg
• •
FENTANYL - fentanyl td patch 72hr 3
37.5 mcg/hr
62.5 mcg/hr
87.5 mcg/hr
1
fentanyl citrate lollipop
1200 mcg (Actiq)
1
fentanyl citrate lollipop
1600 mcg (Actiq)
1
fentanyl citrate lollipop 200 mcg
(Actiq)
1
(Actiq)
1
(Actiq)
1
(Actiq)
1
fentanyl td patch 72hr 100 mcg/
hr (Duragesic)
fentanyl td patch 72hr 12 mcg/hr 1
(Duragesic)
(Duragesic)
(Duragesic)
(Duragesic)
FENTORA - fentanyl citrate buccal 3
tab 100 mcg (base equiv)
•
• •
• •
• •
• •
•
•
•
•
•
•
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
105
•
FIORICET/CODEINE - butalbitalacetaminophen-caff w/ cod cap
50-300-40-30 mg
3
FIORINAL/CODEINE #3 butalbital-aspirin-caff w/ codeine
cap 50-325-40-30 mg
3
HYCET - hydrocodoneacetaminophen soln 7.5-325
mg/15ml
3
hydrocodone-acetaminophen
soln 7.5-325 mg/15ml (Hycet)
1
•
tab 10-300 mg (Xodol)
1
•
tab 10-325 mg (Norco)
1
•
tab 2.5-325 mg
1
•
tab 5-300 mg (Xodol)
1
•
tab 5-325 mg (Norco)
1
•
tab 7.5-300 mg (Xodol)
1
•
tab 7.5-325 mg (Norco)
1
•
hydrocodone-ibuprofen tab
10-200 mg (Ibudone)
1
•
2.5-200 mg (Reprexain)
1
•
5-200 mg (Reprexain)
1
•
7.5-200 mg (Vicoprofen)
1
•
HYDROCODONE/
ACETAMINOPHEN hydrocodone-acetaminophen
soln 7.5-500 mg/15ml
1
HYDROCODONE/
ACETAMINOPHEN hydrocodone-acetaminophen
soln 10-325 mg/15ml
1
106
HYDROMORPHONE HCL hydromorphone hcl suppos 3 mg
1
1
• •
HYDROMORPHONE HCL ER hydromorphone hcl tab er 24hr
deter 32 mg
•
1
• •
hydromorphone hcl liqd 1 mg/ml
(Dilaudid)
•
hydromorphone hcl tab er 24hr
deter 12 mg (Exalgo)
1
•
deter 16 mg (Exalgo)
1
•
deter 8 mg (Exalgo)
1
•
hydromorphone hcl tab 2 mg
(Dilaudid)
1
•
(Dilaudid)
1
•
(Dilaudid)
1
•
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter 20 mg
3
•
3
•
3
•
3
•
3
•
bitartrate tab er 24hr deter 100
mg
3
•
3
•
bitartrate tab er 24hr deter 120
mg
•
•
•
IBUDONE - hydrocodone-ibuprofen 3
tab 10-200 mg
IONSYS - fentanyl hcl iontophoretic 3
td system 40 mcg/act (base
equiv)
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
KADIAN - morphine sulfate cap sr
24hr 10 mg
3
•
METHADONE HCL - methadone
hcl soln 10 mg/5ml
1
•
24hr 20 mg
3
•
methadone hcl conc 10 mg/ml
(Methadose)
1
•
24hr 30 mg
3
•
methadone hcl soln 10 mg/5ml
(Methadone hcl)
1
•
24hr 40 mg
3
•
methadone hcl soln 5 mg/5ml
(Methadone hcl)
1
•
24hr 50 mg
3
•
methadone hcl tab for oral susp
40 mg
1
•
24hr 60 mg
3
•
methadone hcl tab 10 mg
(Dolophine)
1
•
24hr 80 mg
3
•
methadone hcl tab 5 mg
(Dolophine hcl)
1
•
24hr 100 mg
3
•
METHADOSE - methadone hcl
conc 10 mg/ml
3
•
24hr 200 mg
3
•
METHADOSE SUGAR-FREE methadone hcl conc 10 mg/ml
3
•
LAZANDA - fentanyl citrate nasal
spray 100 mcg/act (base equiv)
3
•
•
MORPHINE SULFATE - morphine
sulfate tab 15 mg
1
•
LAZANDA - fentanyl citrate nasal
spray 400 mcg/act (base equiv)
3
•
•
sulfate tab 30 mg
1
•
LEVORPHANOL TARTRATE levorphanol tartrate tab 2 mg
1
•
sulfate suppos 5 mg
1
LORTAB - hydrocodoneacetaminophen soln 7.5-500
mg/15ml
3
•
sulfate suppos 10 mg
1
3
•
1
MEPERIDINE HCL - meperidine
hcl oral soln 50 mg/5ml
meperidine hcl tab 100 mg
(Demerol)
•
1
1
•
•
meperidine hcl tab 50 mg
(Demerol)
morphine sulfate (concentrate)
oral soln 20 mg/ml
1
1
•
•
MEPERIDINE HCL/PROMETHAZI
- meperidine w/ promethazine
cap 50-25 mg
morphine sulfate beads cap sr
24hr 120 mg (Avinza)
1
1
24hr 30 mg (Avinza)
1
•
hcl inj 10 mg/ml
1
24hr 45 mg (Avinza)
1
•
hcl soln 5 mg/5ml
1
24hr 60 mg (Avinza)
1
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
107
24hr 75 mg (Avinza)
1
•
MS CONTIN - morphine sulfate tab
cr 200 mg
3
• •
24hr 90 mg (Avinza)
1
•
NORCO - hydrocodoneacetaminophen tab 10-325 mg
3
• •
morphine sulfate cap sr 24hr
10 mg (Kadian)
1
•
NORCO - hydrocodoneacetaminophen tab 5-325 mg
3
• •
100 mg (Kadian)
1
•
NORCO - hydrocodoneacetaminophen tab 7.5-325 mg
3
• •
20 mg (Kadian)
1
•
NUCYNTA - tapentadol hcl tab 50
mg
3
•
30 mg (Kadian)
1
•
mg
3
•
50 mg (Kadian)
1
•
mg
3
•
60 mg (Kadian)
1
•
NUCYNTA ER - tapentadol hcl tab
sr 12hr 50 mg
3
•
80 mg (Kadian)
1
•
sr 12hr 100 mg
3
•
morphine sulfate oral soln
10 mg/5ml
1
•
sr 12hr 150 mg
3
•
morphine sulfate oral soln
20 mg/5ml
1
•
sr 12hr 200 mg
3
•
morphine sulfate tab cr 100 mg
(Ms contin)
1
•
sr 12hr 250 mg
3
•
(Ms contin)
1
•
OPANA - oxymorphone hcl tab 5
mg
3
•
(Ms contin)
1
•
OPANA - oxymorphone hcl tab 10
mg
3
•
(Ms contin)
1
•
2
•
(Ms contin)
1
•
OPANA ER (CRUSH RESISTANT
- oxymorphone hcl tab er 12hr
deter 5 mg
2
•
cr 15 mg
3
• •
deter 7.5 mg
cr 30 mg
3
• •
2
•
cr 60 mg
3
• •
deter 10 mg
2
•
cr 100 mg
3
deter 15 mg
108
• •
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
•
oxycodone w/ acetaminophen
tab 2.5-325 mg (Percocet)
1
•
tab 5-325 mg (Percocet)
1
•
tab 7.5-325 mg (Percocet)
1
•
oxycodone-aspirin tab
4.8355-325 mg (Percodan)
1
•
•
oxycodone-ibuprofen tab
5-400 mg
1
•
1
•
OXYCONTIN - oxycodone hcl tab
er 12hr deter 10 mg
2
•
1
er 12hr deter 15 mg
•
oxycodone hcl conc 100 mg/5ml
(20 mg/ml) (Oxycodone hcl)
1
•
•
2
oxycodone hcl cap 5 mg
2
•
OXYCODONE HCL ER oxycodone hcl tab er 12hr deter
10 mg
1
•
er 12hr deter 20 mg
er 12hr deter 30 mg
2
•
1
•
er 12hr deter 40 mg
2
20 mg
•
2
•
40 mg
1
er 12hr deter 60 mg
er 12hr deter 80 mg
2
•
80 mg
1
oxymorphone hcl tab sr 12hr
10 mg
1
•
1
•
oxycodone hcl soln 5 mg/5ml
(Oxycodone hcl)
1
15 mg
1
•
oxycodone hcl tab 10 mg
1
20 mg
(Roxicodone)
1
30 mg
1
•
1
1
•
(Roxicodone)
1
40 mg
1
•
(Roxicodone)
1
5 mg
1
•
tab 10-325 mg (Percocet)
1
7.5 mg
oxymorphone hcl tab 10 mg
(Opana)
1
•
deter 20 mg
2
deter 30 mg
2
deter 40 mg
2
•
OXYCODONE HCL - oxycodone
hcl conc 100 mg/5ml (20 mg/ml)
1
OXYCODONE HCL - oxycodone
hcl soln 5 mg/5ml
•
•
•
•
•
•
•
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
109
•
• •
SUBSYS - fentanyl sublingual
spray 100 mcg
3
•
•
3
• •
spray 200 mcg
3
•
•
PERCOCET - oxycodone w/
acetaminophen tab 10-325 mg
3
• •
spray 400 mcg
3
•
•
PERCODAN - oxycodone-aspirin
tab 4.8355-325 mg
3
•
spray 600 mcg
3
•
•
PRIMLEV - oxycodone w/
3
•
spray 800 mcg
3
•
•
acetaminophen tab 7.5-300 mg
3
•
spray 1200 mcg (600 mcg x 2)
3
•
•
3
•
spray 1600 mcg (800 mcg x 2)
3
•
•
REPREXAIN - hydrocodoneibuprofen tab 2.5-200 mg
3
•
3
REPREXAIN - hydrocodoneibuprofen tab 5-200 mg
3
•
SYNALGOS-DC - aspirin-caffeinedihydrocodeine cap 356.4-30-16
mg
3
ROXICET - oxycodone w/
acetaminophen soln 5-325
mg/5ml
3
THERACODEINE-300 - apapcodeine tab 300-30 mg & dietary
management cap pack
3
ROXICODONE - oxycodone hcl
tab 5 mg
3
• •
THERACODOPHEN-325 hydrocodone-apap tab 10-325
mg & dietary manage cap pack
3
• •
tab 30 mg
3
• •
THERATRAMADOL-60 - tramadol
hcl tab 50 mg & dietary
management cap pack
3
tab 15 mg
3
SUBOXONE - buprenorphine hclnaloxone hcl sl film 2-0.5 mg
(base equiv)
2
•
THERATRAMADOL-90 - tramadol
hcl tab 50 mg & dietary
management cap pack
1
•
SUBOXONE - buprenorphine hclnaloxone hcl sl film 4-1 mg (base
equiv)
2
•
TRAMADOL HCL ER - tramadol
hcl cap sr 24hr biphasic release
150 mg
tramadol hcl tab sr 24hr biphasic
release 100 mg
1
•
1
3
•
3
110
•
•
•
•
Specialty
•
pentazocine w/ naloxone tab
50-0.5 mg
Quantity Limits
Prior Authorization
2
1
Drug Name
"Smart" PA
Drug Tier
SUBOXONE - buprenorphine hclnaloxone hcl sl film 12-3 mg
(base equiv)
•
oxymorphone hcl tab 5 mg
(Opana)
Specialty
•
Quantity Limits
•
"Smart" PA
2
Drug Tier
SUBOXONE - buprenorphine hclnaloxone hcl sl film 8-2 mg (base
equiv)
Drug Name
Prior Authorization
2015
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
release 200 mg
1
•
XODOL - hydrocodoneacetaminophen tab 7.5-300 mg
3
•
release 300 mg
1
•
XODOL - hydrocodoneacetaminophen tab 10-300 mg
3
•
tramadol hcl tab sr 24hr 100 mg
(Ultram er)
1
•
3
•
(Ultram er)
1
•
ZAMICET - hydrocodoneacetaminophen soln 10-325
mg/15ml
3
•
•
(Ultram er)
1
•
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr abusedeterrent 10 mg
tramadol hcl tab 50 mg (Ultram)
1
•
•
1
3
tramadol-acetaminophen tab
37.5-325 mg (Ultracet)
•
•
3
•
3
TREZIX - acetaminophen-caffeinedihydrocodeine cap 320.5-30-16
mg
•
•
3
• •
3
TYLENOL/CODEINE acetaminophen w/ codeine tab
300-15 mg
•
•
3
• •
3
TYLENOL/CODEINE #3 acetaminophen w/ codeine tab
300-30 mg
•
•
3
• •
3
TYLENOL/CODEINE #4 acetaminophen w/ codeine tab
300-60 mg
•
•
3
•
•
•
ULTRAM - tramadol hcl tab 50 mg
3
•
•
3
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 5.7-1.4 mg
(base eq)
3
ULTRAM ER - tramadol hcl tab sr
24hr 100 mg
•
• •
(base eq)
3
ULTRACET - tramadolacetaminophen tab 37.5-325 mg
24hr 200 mg
3
• •
3
•
•
24hr 300 mg
3
• •
(base eq)
VICOPROFEN - hydrocodoneibuprofen tab 7.5-200 mg
3
•
• •
XARTEMIS XR - oxycodone w/
acetaminophen tab cr 7.5-325
mg
3
XODOL - hydrocodoneacetaminophen tab 5-300 mg
3
• •
•
•
•
ANALGESICS - ANTI-INFLAMMATORY
3
ACTEMRA - tocilizumab
subcutaneous soln prefilled
syringe 162 mg/0.9ml
ANAPROX - naproxen sodium tab 3
275 mg
ANAPROX DS - naproxen sodium 3
tab 550 mg
•
•
111
2
ARTHROTEC 50 - diclofenac w/
misoprostol tab delayed release
50-0.2 mg
3
ARTHROTEC 75 - diclofenac w/
misoprostol tab delayed release
75-0.2 mg
3
CELEBREX - celecoxib cap 50 mg
3
CELEBREX - celecoxib cap 100
mg
3
mg
3
• •
mg
3
• •
celecoxib cap 100 mg (Celebrex)
1
1
1
1
•
•
•
•
DAYPRO - oxaprozin tab 600 mg
3
DERMACINRX ANALGESIC
COMB - diclofenac sod tab dr 75
mg & lido-men-methyl sal ptch kit
3
DERMACINRX INFLAMMATRAL P
- diclofen dr tab 75mg-ranitidine
tab 150mg-capsaicin cr thpk
3
diclofenac potassium tab 50 mg
(Cataflam)
1
diclofenac sodium tab delayed
release 25 mg
1
release 50 mg
1
release 75 mg
diclofenac sodium tab sr 24hr
100 mg (Voltaren-xr)
112
•
•
•
•
• •
• •
•
Specialty
ARCALYST - rilonacept for inj 220
mg
Quantity Limits
3
"Smart" PA
ARAVA - leflunomide tab 20 mg
Prior Authorization
3
Drug Name
Drug Tier
ARAVA - leflunomide tab 10 mg
Specialty
Quantity Limits
"Smart" PA
Drug Name
Drug Tier
Prior Authorization
2015
diclofenac w/ misoprostol tab
delayed release 50-0.2 mg
(Arthrotec 50)
1
diclofenac w/ misoprostol tab
delayed release 75-0.2 mg
(Arthrotec 75)
1
DUEXIS - ibuprofen-famotidine tab
800-26.6 mg
3
• •
EC-NAPROSYN - naproxen tab ec
375 mg
3
•
EC-NAPROSYN - naproxen tab ec
500 mg
3
•
ENBREL - etanercept
syringe 25 mg/0.5ml
2
•
• •
ENBREL - etanercept
syringe 50 mg/ml
2
•
• •
ENBREL - etanercept for
subcutaneous inj kit 25 mg
2
•
• •
ENBREL SURECLICK - etanercept 2
subcutaneous solution autoinjector 50 mg/ml
1
etodolac cap 200 mg
•
• •
etodolac cap 300 mg
1
etodolac tab sr 24hr 400 mg
1
1
1
etodolac tab 400 mg
1
etodolac tab 500 mg
1
FELDENE - piroxicam cap 10 mg
3
FELDENE - piroxicam cap 20 mg
3
FENOPROFEN CALCIUM fenoprofen calcium cap 400 mg
1
•
•
•
1
FENOPROFEN CALCIUM fenoprofen calcium tab 600 mg
1
•
1
flurbiprofen tab 100 mg
1
flurbiprofen tab 50 mg
1
2
•
• •
3
HUMIRA - adalimumab prefilled
syringe kit 40 mg/0.8ml
2
•
• •
KINERET - anakinra subcutaneous
soln prefilled syringe 100
mg/0.67ml
leflunomide tab 10 mg (Arava)
1
HUMIRA PEDIATRIC CROHNS D
- adalimumab prefilled syringe kit
40 mg/0.8ml
2
• •
leflunomide tab 20 mg (Arava)
1
1
HUMIRA PEN - adalimumab peninjector kit 40 mg/0.8ml
2
•
• •
MECLOFENAMATE SODIUM meclofenamate sodium cap 50
mg
HUMIRA PEN-CROHNS DISEASE
- adalimumab pen-injector kit 40
mg/0.8ml
•
• •
MECLOFENAMATE SODIUM meclofenamate sodium cap 100
mg
1
2
HUMIRA PEN-PSORIASIS STAR
- adalimumab pen-injector kit 40
mg/0.8ml
• •
mefenamic acid cap 250 mg
(Ponstel)
1
2
IBUPROFEN COMFORT PAC ibuprofen tab 800 mg & liniment
topical gel kit
3
ibuprofen susp 100 mg/5ml
1
ibuprofen tab 400 mg
1
1
1
IC 400 - ibuprofen tab 400 mg &
caffeine-vitamins cap kit
3
IC 800 - ibuprofen tab 800 mg &
caffeine-vitamins cap kit
3
INDOCIN - indomethacin susp 25
mg/5ml
3
INDOCIN - indomethacin suppos
50 mg
3
indomethacin cap cr 75 mg
1
indomethacin cap 25 mg
1
indomethacin cap 50 mg
1
ketoprofen cap 50 mg
1
ketoprofen cap 75 mg
1
KETOPROFEN ER - ketoprofen
cap sr 24hr 200 mg
1
•
•
MELOXICAM - meloxicam susp 7.5 1
mg/5ml
3
MELOXICAM COMFORT PAC meloxicam tab 15 mg & liniment
topical gel kit
1
meloxicam tab 15 mg (Mobic)
•
•
•
•
• •
• •
• •
•
•
• •
• •
• •
meloxicam tab 7.5 mg (Mobic)
1
MOBIC - meloxicam tab 7.5 mg
3
MOBIC - meloxicam tab 15 mg
3
MOBIC - meloxicam susp 7.5
mg/5ml
3
nabumetone tab 500 mg
1
nabumetone tab 750 mg
1
NALFON - fenoprofen calcium cap
400 mg
3
•
NAPRELAN - naproxen sodium tab 3
sr 24hr 375 mg (base equiv)
3
NAPROSYN - naproxen tab 250
mg
3
mg
•
Specialty
Quantity Limits
1
"Smart" PA
ketorolac tromethamine tab
10 mg
Prior Authorization
• •
Drug Name
Drug Tier
•
Specialty
2
Quantity Limits
Prior Authorization
Drug Name
"Smart" PA
Drug Tier
2015
•
•
•
•
113
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
mg
3
•
piroxicam cap 20 mg (Feldene)
1
NAPROSYN - naproxen susp 125
mg/5ml
•
PONSTEL - mefenamic acid cap
250 mg
3
3
NAPROXEN - naproxen susp 125
mg/5ml
•
PRASTERA - prasterone cap 200
mg & ibuprofen tab 400 mg kit
3
1
•
•
3
RASUVO - methotrexate soln pf
3
NAPROXEN COMFORT PAC naproxen tab 500 mg & liniment
topical gel kit
auto-injector 10 mg/0.2ml
3
•
naproxen sodium tab sr 24hr
500 mg (base equiv) (Naprelan)
1
3
•
naproxen sodium tab 220 mg
1
•
(Anaprox)
3
1
•
(Anaprox ds)
3
1
•
1
3
naproxen tab ec 375 mg (Ecnaprosyn)
•
1
3
naproxen tab ec 500 mg (Ecnaprosyn)
•
naproxen tab 250 mg (Naprosyn)
3
1
1
3
•
1
ORENCIA - abatacept
syringe 125 mg/ml
3
• •
3
•
3
OTEZLA - apremilast tab starter
therapy pack 10 mg & 20 mg &
30 mg
3
• •
RHEUMATREX - methotrexate
sodium tab 2.5 mg
(antirheumatic)
RIDAURA - auranofin cap 3 mg
2
OTEZLA - apremilast tab 30 mg
3
•
• •
3
SIMPONI - golimumab
subcutaneous soln auto-injector
50 mg/0.5ml
3
OTREXUP - methotrexate soln pf
auto-injector 10mg/0.4ml
•
•
3
•
3
•
• •
3
•
SIMPONI - golimumab
subcutaneous soln auto-injector
100 mg/ml
3
•
• •
3
SIMPONI - golimumab
syringe 50 mg/0.5ml
1
•
• •
piroxicam cap 10 mg (Feldene)
1
SIMPONI - golimumab
syringe 100 mg/ml
3
oxaprozin tab 600 mg (Daypro)
114
•
•
•
• •
•
SPRIX - ketorolac tromethamine
nasal spray 15.75 mg/spray
3
sulindac tab 150 mg
1
sulindac tab 200 mg
1
THERAFELDAMINE - piroxicam
cap 20 mg & dietary
management cap pack
3
THERAPROFEN-60 - ibuprofen tab 3
cap pack
3
THERAPROFEN-800 ibuprofen tab 800 mg & dietary
management cap pack
THERAPROFEN-90 - ibuprofen tab 3
cap pack
3
THERAPROXEN-500 naproxen tab 500 mg & dietary
management cap pack
3
THERAPROXEN-60 - naproxen
tab 250 mg & dietary
management cap pack
3
THERAPROXEN-90 - naproxen
tab 250 mg & dietary
management cap pack
TIVORBEX - indomethacin cap 20 3
mg
TIVORBEX - indomethacin cap 40 3
mg
1
TOLMETIN SODIUM - tolmetin
sodium tab 200 mg
1
TOLMETIN SODIUM - tolmetin
sodium tab 600 mg
1
tolmetin sodium cap 400 mg
TREPADICLOFEN-25 - diclofenac
tab dr 25 mg & dietary
management cap pack
3
TREPOXEN-250 - naproxen tab
cap pack
3
•
TREPOXICAM-7.5 - meloxicam tab 3
7.5 mg & dietary management
cap pack
VIMOVO - naproxen-esomeprazole 3
magnesium tab dr 375-20 mg
VIMOVO - naproxen-esomeprazole 3
magnesium tab dr 500-20 mg
3
VOLTAREN-XR - diclofenac
sodium tab sr 24hr 100 mg
3
XELJANZ - tofacitinib citrate tab 5
3
ZIPSOR - diclofenac potassium
cap 25 mg
3
ZORVOLEX - diclofenac cap 18
mg
3
ZORVOLEX - diclofenac cap 35
mg
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
• •
• •
•
•
• •
•
•
•
MIGRAINE PRODUCTS
•
•
acetaminophen-isometheptenecaffeine tab 325-65-20 mg
(Prodrin)
1
acetaminophen-isometheptenedichloral cap 325-65-100 mg
1
ALSUMA - sumatriptan succinate
solution auto-injector 6 mg/0.5ml
3
• •
AMERGE - naratriptan hcl tab 1 mg 3
(base equiv)
3
AMERGE - naratriptan hcl tab 2.5
mg (base equiv)
3
AXERT - almotriptan malate tab
6.25 mg
3
AXERT - almotriptan malate tab
12.5 mg
3
CAFERGOT - ergotamine w/
caffeine tab 1-100 mg
3
CAMBIA - diclofenac potassium
packet 50 mg
3
D.H.E. 45 - dihydroergotamine
mesylate inj 1 mg/ml
• •
• •
• •
• •
• •
115
DIHYDROERGOTAMINE
MESYLAT - dihydroergotamine
mesylate nasal spray 4 mg/ml
1
dihydroergotamine mesylate inj
1 mg/ml (D.h.e. 45)
•
•
MAXALT-MLT - rizatriptan
benzoate orally disintegrating tab
10 mg
3
1
MIGERGOT - ergotamine w/
caffeine suppos 2-100 mg
3
ERGOMAR - ergotamine tartrate sl
tab 2 mg
2
MIGRANAL - dihydroergotamine
mesylate nasal spray 4 mg/ml
3
•
FROVA - frovatriptan succinate tab
3
• •
naratriptan hcl tab 1 mg (base
equiv) (Amerge)
1
•
IMITREX - sumatriptan nasal spray
5 mg/act
2
• •
naratriptan hcl tab 2.5 mg (base
equiv) (Amerge)
1
•
IMITREX - sumatriptan nasal spray
20 mg/act
2
• •
3
IMITREX - sumatriptan succinate
tab 25 mg
3
• •
PRODRIN - acetaminophenisometheptene-caffeine tab
325-65-20 mg
3
• •
tab 50 mg
3
• •
RELPAX - eletriptan hydrobromide
3
• •
tab 100 mg
3
• •
RELPAX - eletriptan hydrobromide
1
•
inj 6 mg/0.5ml
3
• •
rizatriptan benzoate orally
(Maxalt-mlt)
IMITREX STATDOSE REFILL sumatriptan succinate solution
cartridge 4 mg/0.5ml
3
• •
rizatriptan benzoate orally
(Maxalt-mlt)
1
•
IMITREX STATDOSE REFILL sumatriptan succinate solution
cartridge 6 mg/0.5ml
3
• •
rizatriptan benzoate tab 10 mg
(Maxalt)
1
•
1
•
IMITREX STATDOSE SYSTEM sumatriptan succinate solution
3
rizatriptan benzoate tab 5 mg
(Maxalt)
SUMATRIPTAN - sumatriptan
nasal spray 5 mg/act
1
• •
IMITREX STATDOSE SYSTEM sumatriptan succinate solution
3
SUMATRIPTAN - sumatriptan
nasal spray 20 mg/act
1
• •
•
• •
MAXALT - rizatriptan benzoate tab
5 mg
SUMATRIPTAN SUCCINATE sumatriptan succinate solution
prefilled syringe 6 mg/0.5ml
1
3
MAXALT - rizatriptan benzoate tab
10 mg
3
•
1
• •
MAXALT-MLT - rizatriptan
benzoate orally disintegrating tab
5 mg
3
•
SUMATRIPTAN SUCCINATE
- sumatriptan succinate inj 4
mg/0.5ml
sumatriptan succinate inj
6 mg/0.5ml (Imitrex)
1
•
116
• •
• •
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
•
sumatriptan succinate solution
(Imitrex statdose sys)
1
(Imitrex statdose sys)
1
cartridge 4 mg/0.5ml (Imitrex
statdose ref)
1
cartridge 6 mg/0.5ml (Imitrex
statdose ref)
1
sumatriptan succinate tab
100 mg (Imitrex)
1
•
sumatriptan succinate tab 25 mg
(Imitrex)
1
•
sumatriptan succinate tab 50 mg
(Imitrex)
1
•
SUMAVEL DOSEPRO sumatriptan succinate solution
jet-injector 4 mg/0.5ml
3
• •
SUMAVEL DOSEPRO sumatriptan succinate solution
jet-injector 6 mg/0.5ml
3
•
ZOMIG ZMT - zolmitriptan orally
3
• •
ZOMIG ZMT - zolmitriptan orally
3
• •
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
GOUT AGENTS
TREXIMET - sumatriptan-naproxen 3
sodium tab 85-500 mg
zolmitriptan orally disintegrating 1
tab 2.5 mg (Zomig zmt)
zolmitriptan orally disintegrating 1
tab 5 mg (Zomig zmt)
1
zolmitriptan tab 2.5 mg (Zomig)
•
•
• •
• •
•
•
•
•
• •
• •
• •
zolmitriptan tab 5 mg (Zomig)
1
ZOMIG - zolmitriptan tab 2.5 mg
3
ZOMIG - zolmitriptan tab 5 mg
3
ZOMIG - zolmitriptan nasal spray
2.5 mg/spray unit
3
ZOMIG - zolmitriptan nasal spray 5
mg/spray unit
3
• •
ZOMIG NASAL SPRAY zolmitriptan nasal spray 5 mg/
spray unit
3
• •
allopurinol tab 100 mg (Zyloprim)
1
allopurinol tab 300 mg (Zyloprim)
1
COLCHICINE - colchicine cap 0.6
mg
3
COLCHICINE - colchicine tab 0.6
mg
3
colchicine w/ probenecid tab
0.5-500 mg
1
COLCRYS - colchicine tab 0.6 mg
2
MITIGARE - colchicine cap 0.6 mg
3
probenecid tab 500 mg
1
ULORIC - febuxostat tab 40 mg
3
ULORIC - febuxostat tab 80 mg
3
ZYLOPRIM - allopurinol tab 100
mg
3
ZYLOPRIM - allopurinol tab 300
mg
3
•
•
NEUROMUSCULAR DRUGS
ANTICONVULSANTS
APTIOM - eslicarbazepine acetate
tab 200 mg
3
tab 400 mg
3
tab 600 mg
3
tab 800 mg
3
BANZEL - rufinamide tab 200 mg
2
BANZEL - rufinamide tab 400 mg
2
BANZEL - rufinamide susp 40 mg/
ml
2
carbamazepine cap sr 12hr
100 mg (Carbatrol)
1
117
200 mg (Carbatrol)
1
DEPAKOTE - divalproex sodium
tab delayed release 125 mg
3
300 mg (Carbatrol)
1
3
carbamazepine chew tab 100 mg
1
3
carbamazepine susp 100 mg/5ml
(Tegretol)
1
3
carbamazepine tab sr 12hr
200 mg (Tegretol-xr)
1
DEPAKOTE ER - divalproex
sodium tab sr 24 hr 250 mg
3
carbamazepine tab sr 12hr
400 mg (Tegretol-xr)
1
DEPAKOTE ER - divalproex
sodium tab sr 24 hr 500 mg
3
carbamazepine tab 200 mg
(Tegretol)
1
DEPAKOTE SPRINKLES divalproex sodium cap sprinkle
125 mg
DIASTAT ACUDIAL - diazepam
rectal gel delivery system 10 mg
2
DIASTAT ACUDIAL - diazepam
rectal gel delivery system 20 mg
2
DIASTAT PEDIATRIC - diazepam
rectal gel delivery system 2.5 mg
2
DIAZEPAM - diazepam rectal gel
delivery system 2.5 mg
1
delivery system 10 mg
1
delivery system 20 mg
1
DILANTIN - phenytoin sodium
extended cap 30 mg
2
DILANTIN - phenytoin sodium
extended cap 100 mg
2
DILANTIN INFATABS - phenytoin
chew tab 50 mg
2
DILANTIN-125 - phenytoin susp
125 mg/5ml
3
divalproex sodium cap sprinkle
125 mg (Depakote sprinkles)
1
divalproex sodium tab delayed
release 125 mg (Depakote)
1
1
CARBATROL - carbamazepine cap 2
sr 12hr 100 mg
sr 12hr 200 mg
sr 12hr 300 mg
3
CELONTIN - methsuximide cap
300 mg
clonazepam orally disintegrating 1
tab 0.125 mg
tab 0.25 mg
tab 0.5 mg
tab 1 mg
tab 2 mg
1
clonazepam tab 0.5 mg
(Klonopin)
1
clonazepam tab 1 mg (Klonopin)
clonazepam tab 2 mg (Klonopin)
1
DEPAKENE - valproate sodium
syrup 250 mg/5ml (base equiv)
3
DEPAKENE - valproic acid cap 250 3
mg
118
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
1
GABITRIL - tiagabine hcl tab 4 mg
3
divalproex sodium tab sr 24 hr
250 mg (Depakote er)
GABITRIL - tiagabine hcl tab 12
mg
2
1
divalproex sodium tab sr 24 hr
500 mg (Depakote er)
GABITRIL - tiagabine hcl tab 16
mg
2
1
1
KEPPRA - levetiracetam tab 250
mg
3
ethosuximide cap 250 mg
(Zarontin)
1
mg
3
ethosuximide soln 250 mg/5ml
(Zarontin)
felbamate susp 600 mg/5ml
(Felbatol)
mg
3
1
felbamate tab 400 mg (Felbatol)
mg
3
1
felbamate tab 600 mg (Felbatol)
1
KEPPRA - levetiracetam oral soln
100 mg/ml
3
KEPPRA XR - levetiracetam tab sr
24hr 500 mg
3
•
KEPPRA XR - levetiracetam tab sr
24hr 750 mg
3
•
KLONOPIN - clonazepam tab 0.5
mg
3
FELBATOL - felbamate tab 400 mg 3
FELBATOL - felbamate tab 600 mg 3
FELBATOL - felbamate susp 600
mg/5ml
3
FYCOMPA - perampanel tab 2 mg
3
3
3
3
FYCOMPA - perampanel tab 10
mg
3
FYCOMPA - perampanel tab 12
mg
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
KLONOPIN - clonazepam tab 1 mg 3
KLONOPIN - clonazepam tab 2 mg 3
LAMICTAL - lamotrigine tab 25 mg
3
3
LAMICTAL - lamotrigine tab 100
mg
3
1
mg
3
gabapentin cap 100 mg
(Neurontin)
1
mg
3
(Neurontin)
1
LAMICTAL CHEWABLE DISPERS
- lamotrigine tab chewable
dispersible 5 mg
3
(Neurontin)
gabapentin oral soln 250 mg/5ml
(Neurontin)
1
3
gabapentin tab 600 mg
(Neurontin)
1
LAMICTAL CHEWABLE DISPERS
- lamotrigine tab chewable
dispersible 25 mg
gabapentin tab 800 mg
(Neurontin)
LAMICTAL ODT - lamotrigine tab
disp 25 mg (21) & 50 mg (7)
titration kit
3
1
GABITRIL - tiagabine hcl tab 2 mg
3
119
disp 50 mg (42) & 100 mg (14)
titration kit
3
disp 25 (14) & 50 mg (14) & 100
mg (7) kit
3
LAMICTAL ODT - lamotrigine orally 3
LAMICTAL STARTER/NOT TAKI - 3
lamotrigine tab 25 mg (42) & 100
mg (7) starter kit
LAMICTAL STARTER/TAKING C - 3
lamotrigine tab 25 mg (84) & 100
mg (14) starter kit
LAMICTAL STARTER/TAKING V - 3
lamotrigine tab 25 mg (35) starter
kit
3
LAMICTAL XR - lamotrigine tab
sr 24hr 25 mg (21) & 50 mg (7)
titration kit
LAMICTAL XR - lamotrigine tab sr 3
24hr 25 (14) & 50 mg (14) & 100
mg(7) kit
24hr 50 (14) & 100 mg(14) & 200
mg(7) kit
24hr 25 mg
24hr 50 mg
24hr 100 mg
24hr 200 mg
120
LAMICTAL XR - lamotrigine tab sr
24hr 250 mg
3
LAMICTAL XR - lamotrigine tab sr
24hr 300 mg
3
lamotrigine orally disintegrating
tab 100 mg (Lamictal odt)
1
1
1
1
lamotrigine tab chewable
dispersible 25 mg (Lamictal
chewable di)
1
lamotrigine tab chewable
dispersible 5 mg (Lamictal
chewable di)
1
lamotrigine tab sr 24hr 100 mg
(Lamictal xr)
1
(Lamictal xr)
1
(Lamictal xr)
1
(Lamictal xr)
1
(Lamictal xr)
1
(Lamictal xr)
1
lamotrigine tab 100 mg (Lamictal)
1
1
1
1
levetiracetam oral soln 100 mg/
ml (Keppra)
1
levetiracetam tab sr 24hr 500 mg
(Keppra xr)
1
levetiracetam tab sr 24hr 750 mg
(Keppra xr)
1
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
levetiracetam tab 1000 mg
(Keppra)
1
oxcarbazepine tab 150 mg
(Trileptal)
1
(Keppra)
1
(Trileptal)
1
(Keppra)
1
(Trileptal)
1
(Keppra)
1
OXTELLAR XR - oxcarbazepine
tab sr 24hr 150 mg
3
LYRICA - pregabalin cap 25 mg
3
3
3
tab sr 24hr 300 mg
3
3
3
tab sr 24hr 600 mg
3
PEGANONE - ethotoin tab 250 mg
2
3
PHENYTEK - phenytoin sodium
extended cap 200 mg
3
3
3
PHENYTEK - phenytoin sodium
extended cap 300 mg
3
LYRICA - pregabalin soln 20 mg/ml 3
MYSOLINE - primidone tab 50 mg 3
phenytoin chew tab 50 mg
(Dilantin infatabs)
1
MYSOLINE - primidone tab 250 mg 3
NEURONTIN - gabapentin cap 100 3
mg
mg
mg
NEURONTIN - gabapentin tab 600 3
mg
NEURONTIN - gabapentin tab 800 3
mg
3
NEURONTIN - gabapentin oral
soln 250 mg/5ml
2
ONFI - clobazam tab 10 mg
phenytoin sodium extended cap
100 mg (Dilantin)
1
200 mg (Phenytek)
1
300 mg (Phenytek)
1
phenytoin susp 125 mg/5ml
(Dilantin)
1
POTIGA - ezogabine tab 50 mg
2
2
2
2
primidone tab 250 mg (Mysoline)
1
primidone tab 50 mg (Mysoline)
1
ONFI - clobazam tab 20 mg
2
3
QUDEXY XR - topiramate cap er
24hr sprinkle 25 mg
3
ONFI - clobazam suspension 2.5
mg/ml
oxcarbazepine susp 300 mg/5ml
(60 mg/ml) (Trileptal)
24hr sprinkle 50 mg
3
1
24hr sprinkle 100 mg
3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
121
3
3
SABRIL - vigabatrin tab 500 mg
2
SABRIL - vigabatrin powd pack
500 mg
2
STAVZOR - valproic acid cap
3
3
3
TEGRETOL - carbamazepine tab
200 mg
3
TEGRETOL - carbamazepine susp
100 mg/5ml
3
TEGRETOL-XR - carbamazepine
tab sr 12hr 100 mg
2
tab sr 12hr 200 mg
3
tab sr 12hr 400 mg
• •
• •
topiramate tab 200 mg (Topamax) 1
1
3
TRILEPTAL - oxcarbazepine tab
150 mg
3
3
300 mg
3
THERAPENTIN-60 - gabapentin
cap 300 mg & dietary
management cap pack
3
THERAPENTIN-90 - gabapentin
cap 300 mg & dietary
management cap pack
3
600 mg
TRILEPTAL - oxcarbazepine susp
300 mg/5ml (60 mg/ml)
3
tiagabine hcl tab 2 mg (Gabitril)
1
3
tiagabine hcl tab 4 mg (Gabitril)
1
TROKENDI XR - topiramate cap sr
24hr 25 mg
3
24hr 50 mg
3
TOPAMAX - topiramate tab 25 mg
TOPAMAX - topiramate tab 50 mg
3
3
TOPAMAX - topiramate tab 100
mg
3
24hr 100 mg
3
24hr 200 mg
3
TOPAMAX - topiramate tab 200
mg
valproate sodium syrup
250 mg/5ml (base equiv)
(Depakene)
1
122
Specialty
Quantity Limits
"Smart" PA
TOPAMAX SPRINKLE - topiramate 3
sprinkle cap 25 mg
TOPIRAMATE ER - topiramate cap 1
er 24hr sprinkle 25 mg
1
topiramate sprinkle cap 15 mg
(Topamax sprinkle)
1
topiramate sprinkle cap 25 mg
(Topamax sprinkle)
topiramate tab 50 mg (Topamax)
TOPAMAX SPRINKLE - topiramate 3
sprinkle cap 15 mg
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
valproic acid cap 250 mg
(Depakene)
1
bromocriptine mesylate cap
5 mg (Parlodel)
1
VIMPAT - lacosamide tab 50 mg
2
1
2
bromocriptine mesylate tab
2.5 mg
2
1
2
carbidopa & levodopa orally
disintegrating tab 10-100 mg
2
1
VIMPAT - lacosamide oral solution
10 mg/ml
1
carbidopa & levodopa tab cr
25-100 mg (Sinemet cr)
1
carbidopa & levodopa tab cr
50-200 mg (Sinemet cr)
1
carbidopa & levodopa tab
10-100 mg (Sinemet)
1
25-100 mg (Sinemet)
1
25-250 mg (Sinemet)
1
carbidopa tab 25 mg (Lodosyn)
1
CARBIDOPA/LEVODOPA/
ENTACA - carbidopa-levodopaentacapone tabs 12.5-50-200 mg
1
CARBIDOPA/LEVODOPA/
ENTACA - carbidopa-levodopaentacapone tabs 18.75-75-200
mg
1
CARBIDOPA/LEVODOPA/
ENTACA - carbidopa-levodopaentacapone tabs 25-100-200 mg
1
CARBIDOPA/LEVODOPA/
mg
1
CARBIDOPA/LEVODOPA/
mg
1
ZARONTIN - ethosuximide cap 250 3
mg
3
ZARONTIN - ethosuximide soln
250 mg/5ml
3
ZONEGRAN - zonisamide cap 25
mg
ZONEGRAN - zonisamide cap 100 3
mg
1
zonisamide cap 100 mg
(Zonegran)
1
(Zonegran)
1
ANTIPARKINSON AGENTS
AMANTADINE HCL - amantadine
hcl tab 100 mg
1
amantadine hcl cap 100 mg
1
amantadine hcl syrup 50 mg/5ml
1
APOKYN - apomorphine
hydrochloride inj 10 mg/ml
2
AZILECT - rasagiline mesylate tab
0.5 mg (base equiv)
2
•
AZILECT - rasagiline mesylate tab
1 mg (base equiv)
2
•
benztropine mesylate inj 1 mg/ml
(Cogentin)
1
benztropine mesylate tab 0.5 mg
1
benztropine mesylate tab 1 mg
1
benztropine mesylate tab 2 mg
1
• •
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
123
CARBIDOPA/LEVODOPA/
ENTACA - carbidopa-levodopaentacapone tabs 50-200-200 mg
1
COGENTIN - benztropine mesylate 3
inj 1 mg/ml
COMTAN - entacapone tab 200 mg 2
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr 4.5
mg
3
NEUPRO - rotigotine td patch 24hr
1 mg/24hr
2
•
2
•
DUOPA - carbidopa-levodopa
enteral susp 4.63-20 mg/ml
3
2 mg/24hr
2
•
ELDEPRYL - selegiline hcl cap 5
mg
3
3 mg/24hr
2
•
entacapone tab 200 mg (Comtan)
1
4 mg/24hr
LODOSYN - carbidopa tab 25 mg
3
2
•
MIRAPEX - pramipexole
dihydrochloride tab 0.125 mg
3
6 mg/24hr
2
•
3
8 mg/24hr
3
3
PARLODEL - bromocriptine
mesylate cap 5 mg
1
3
pramipexole dihydrochloride tab
sr 24hr 0.375 mg (Mirapex er)
1
dihydrochloride tab 1 mg
3
1
3
1
mg
3
0.125 mg (Mirapex)
0.25 mg (Mirapex)
1
mg
3
0.5 mg (Mirapex)
1
1
mg
3
0.75 mg (Mirapex)
1 mg (Mirapex)
1
mg
3
1.5 mg (Mirapex)
1
3
REQUIP - ropinirole hydrochloride
tab 0.25 mg
3
dihydrochloride tab sr 24hr 3 mg
mg
tab 0.5 mg
3
3
124
•
•
•
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
tab 1 mg
3
ropinirole hydrochloride tab
0.5 mg (Requip)
1
tab 2 mg
3
1 mg (Requip)
1
tab 3 mg
3
2 mg (Requip)
1
tab 4 mg
3
3 mg (Requip)
1
tab 5 mg
3
4 mg (Requip)
1
REQUIP XL - ropinirole
hydrochloride tab sr 24hr 2 mg
(base equivalent)
3
5 mg (Requip)
1
(base equivalent)
RYTARY - carbidopa & levodopa
cap cr 23.75-95 mg
3
3
cap cr 36.25-145 mg
3
(base equivalent)
3
cap cr 48.75-195 mg
3
3
cap cr 61.25-245 mg
3
(base equivalent)
selegiline hcl cap 5 mg (Eldepryl)
1
(base equivalent)
3
selegiline hcl tab 5 mg
1
SINEMET - carbidopa & levodopa
tab 10-100 mg
3
ropinirole hydrochloride tab sr
24hr 12 mg (base equivalent)
(Requip xl)
1
tab 25-100 mg
3
1
tab 25-250 mg
3
(Requip xl)
3
(Requip xl)
1
SINEMET CR - carbidopa &
levodopa tab cr 25-100 mg
SINEMET CR - carbidopa &
levodopa tab cr 50-200 mg
3
1
STALEVO 100 - carbidopalevodopa-entacapone tabs
25-100-200 mg
3
(Requip xl)
1
31.25-125-200 mg
3
(Requip xl)
0.25 mg (Requip)
1
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
125
37.5-150-200 mg
3
CYCLOBENZAPRINE COMFORT
P - cyclobenzaprine hcl tab 10
mg & liniment topical gel kit
3
•
50-200-200 mg
3
cyclobenzaprine hcl tab 10 mg
1
cyclobenzaprine hcl tab 5 mg
1
3
cyclobenzaprine hcl tab 7.5 mg
(Fexmid)
1
12.5-50-200 mg
•
•
•
3
18.75-75-200 mg
3
DANTRIUM - dantrolene sodium
cap 25 mg
cap 50 mg
3
TASMAR - tolcapone tab 100 mg
3
3
tolcapone tab 100 mg (Tasmar)
1
cap 100 mg
1
DANTROLENE SODIUM dantrolene sodium cap 100 mg
1
trihexyphenidyl hcl elixir 0.4 mg/
ml
1
dantrolene sodium cap 25 mg
(Dantrium)
1
trihexyphenidyl hcl tab 2 mg
trihexyphenidyl hcl tab 5 mg
1
3
dantrolene sodium cap 50 mg
(Dantrium)
1
ZELAPAR - selegiline hcl orally
FEXMID - cyclobenzaprine hcl tab
7.5 mg
3
• •
LORZONE - chlorzoxazone tab
375 mg
3
•
LORZONE - chlorzoxazone tab
750 mg
3
•
METAXALONE - metaxalone tab
400 mg
3
NEUROMUSCULAR AGENTS
RILUTEK - riluzole tab 50 mg
2
riluzole tab 50 mg (Rilutek)
1
MUSCULOSKELETAL THERAPY AGENTS
3
AMRIX - cyclobenzaprine hcl cap
sr 24hr 15 mg
3
AMRIX - cyclobenzaprine hcl cap
sr 24hr 30 mg
1
baclofen tab 10 mg
• •
• •
baclofen tab 20 mg
1
CARISOPRODOL - carisoprodol
tab 250 mg
1
•
carisoprodol tab 350 mg (Soma)
1
carisoprodol w/ aspirin &
codeine tab 200-325-16 mg
1
•
•
carisoprodol w/ aspirin tab
200-325 mg
1
•
chlorzoxazone tab 500 mg
(Parafon forte dsc)
1
•
126
metaxalone tab 800 mg (Skelaxin) 1
1
methocarbamol tab 500 mg
(Robaxin)
1
methocarbamol tab 750 mg
(Robaxin-750)
1
orphenadrine citrate tab sr 12hr
100 mg
1
orphenadrine w/ aspirin &
caffeine tab 25-385-30 mg
3
PARAFON FORTE DSC chlorzoxazone tab 500 mg
•
• •
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
PRAZOLAMINE - carisoprodol tab
cap pack
3
ROBAXIN - methocarbamol tab
500 mg
3
MESTINON - pyridostigmine
bromide tab 60 mg
3
3
•
MESTINON - pyridostigmine
bromide syrup 60 mg/5ml
ROBAXIN-750 - methocarbamol
tab 750 mg
•
MESTINON TIMESPAN pyridostigmine bromide tab cr
180 mg
3
3
SKELAXIN - metaxalone tab 800
mg
3
• •
pyridostigmine bromide tab
60 mg (Mestinon)
1
SOMA - carisoprodol tab 250 mg
3
NUTRITIONAL PRODUCTS
SOMA - carisoprodol tab 350 mg
3
•
• •
THERABENZAPRINE-60 cyclobenzaprine tab 10 mg &
dietary management cap pack
3
AMINOBENZOATE POTASSIUM
- potassium aminobenzoate
packet 2 gm
1
THERABENZAPRINE-90 cyclobenzaprine tab 10 mg &
3
BABY DDROPS - cholecalciferol
drops 400 unit/0.03ml (per drop)
A
cholecalciferol cap 1000 unit
A
THERABENZAPRINE-90-5 cyclobenzaprine tab 5 mg &
3
cholecalciferol cap 400 unit
A
A
TIZANIDINE COMFORT PAC tizanidine tab 4 mg & liniment
topical gel pack
3
cholecalciferol chew tab 1000
unit
cholecalciferol chew tab 400 unit
A
cholecalciferol drops 400
unit/0.03ml (per drop)
A
cholecalciferol drops 5000 unit/
ml (1000 unit/0.2ml)
A
cholecalciferol oral liquid 400
unit/ml
A
cholecalciferol tab 1000 unit
A
cholecalciferol tab 400 unit
A
tizanidine hcl cap 2 mg (Zanaflex) 1
1
tizanidine hcl tab 2 mg
1
ZANAFLEX - tizanidine hcl cap 2
mg
3
•
3
•
D-VI-SOL - cholecalciferol oral
liquid 400 unit/ml
A
mg
3
•
DDROPS - cholecalciferol drops
1000 unit/0.03ml (per drop)
A
mg
3
•
DECARA - cholecalciferol cap
25000 unit
3
ZANAFLEX - tizanidine hcl tab 4
mg
DRISDOL - ergocalciferol cap
50000 unit
3
ergocalciferol cap 50000 unit
(Drisdol)
1
GUANIDINE HCL - guanidine hcl
tab 125 mg
1
Specialty
Quantity Limits
"Smart" PA
VITAMINS
tizanidine hcl tab 4 mg (Zanaflex)
ANTIMYASTHENIC AGENTS
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
127
MEPHYTON - phytonadione tab 5
mg
2
pediatric multiple vitamins w/
fluoride chew tab 0.5 mg
1
POTABA - potassium
aminobenzoate cap 500 mg
3
fluoride chew tab 1 mg
1
POTABA - potassium
aminobenzoate tab 500 mg
3
fluoride soln 0.25 mg/ml
1
SUPER DAILY D3 - cholecalciferol
drops 1000 unit/0.03ml (per drop)
A
1
VITAMIN D - cholecalciferol cap
400 unit
A
pediatric vitamins acd w/
1
VITAMIN D2 - ergocalciferol tab
400 unit
A
pediatric vitamins acd w/
1
VITAMIN D3 - cholecalciferol spray A
1000 unit/spray
A
WELLESSE VITAMIN D3 cholecalciferol oral liquid 1000
unit/10ml
speciality vitamin product tab
1
ACTIVE OB - prenatal w/o a w/fe
cbn-fa-dha cap 20-1-320 mg
3
ADRENAL C FORMULA bioflavonoid products tab
3
MULTIVITAMINS
1
ADVANCED AM/PM - multiple
vitamins w/ calcium therapy pack
3
b-complex w/ c & folic acid cap
1 mg (Nephrocaps)
b-complex w/ c & folic acid tab
1 mg (Nephro-vite rx)
AP-ZEL - multiple vitamins w/
minerals tab
3
1
5 mg
ATABEX EC - prenatal vit w/ dssiron carbonyl-fa tab dr 29-1 mg
3
1
3
1
B-NEXA - prenatal w/ calcium-vit
b6-fa-ginger tab 1.22 mg
b-complex w/ c-biotin-minerals &
folic acid tab 5 mg (Diatx zn)
1
BACMIN - multiple vitamins w/
minerals tab
3
multiple vitamins w/ minerals &
fa tab 1.25 mg (Corvite)
1
multiple vitamins w/ minerals
cap
1
multiple vitamins w/ minerals tab
(Strovite forte)
1
pediatric multiple vitamin w/
minerals & c drops 45 mg/ml
1
pediatric multiple vitamins w/ flfe drops 0.25-10 mg/ml
1
fluoride chew tab 0.25 mg
1
BAL-CARE DHA - prenat w/fe poly- 3
na fered-fa tab 27-1 & omega
cap dr 430mg
BP FOLINATAL PLUS B - prenatal 3
w/ calcium carbonate-b6-b12-fa
tab 1 mg
BP MULTINATAL PLUS - prenatal 3
w/o a vit w/ fe fumarate-fa tab
30-1 mg
BP MULTINATAL PLUS - prenatal 3
w/o a vit w/ fe fum-fa tab chew
40-1 mg
128
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
C-NATE DHA - prenatal vit w/ fe
fum-fa-omega 3 cap 28-1-200
mg
3
CONCEPT DHA - prenatal w/fe
fum-fe poly -fa-omega 3 cap
53.5-38-1 mg
3
CALCIUM PNV - prenatal w/o
vit a w/ fe fum-fa-omega 3 cap
28-1-250 mg
3
CONCEPT OB - prenatal w/o a w/
fe fum-fe poly-fa cap 130-92.4-1
mg
3
CHOICE-OB+DHA - prenatal mv
w/fe poly-fa chw 29-1 mg & dha
cap 250 mg pak
3
CORVITE - multiple vitamins w/
minerals & fa tab 1.25 mg
3
CITRANATAL ASSURE - prenat w/ 3
o a w/fecbn-fegl-dss-fa tab & dha
cap 300 mg pack
CITRANATAL B-CALM - prenat w/ 3
o a w/ fe cbnyl-fa tab 20-1 mg &
vit b6 tab pak
CITRANATAL B-CALM - prenat w/ 3
o a w/fecbn-feglu-fa tab 20-1 mg
& vit b6 tab pak
3
CITRANATAL DHA - prenat w/o
a w/fecbn-fegl-dss-fa tab & dha
cap 250 mg pack
3
CITRANATAL HARMONY prenatal w/o a w/fe cbn-dss-fadha cap 29-1-265 mg
CITRANATAL HARMONY - prenat 3
w/o a w/fe fum-fe cbn-dss-fa-dha
cap 27-1-260 mg
3
CITRANATAL RX - prenatal w/o a
w/ fe carbonyl-fe gluc-dss-fa tab
27-1mg
3
CITRANATAL 90 DHA - prenat w/
o a w/fecbn-fegl-dss-fa tab 90
&dha cap 300mg pak
3
CO-NATAL FA - prenatal vit w/ fe
fumarate-fa tab 29-1 mg
COMPLETE NATAL DHA - prenat- 3
fe bis-fe prot succ-fa-ca tab &
omega 3 cap 250 pk
COMPLETENATE - prenatal vit w/ 3
fe fumarate-fa chew tab 29-1 mg
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
DIALYVITE SUPREME D - multiple 3
vitamins w/ minerals & fa tab 3
mg
DIALYVITE 3000 - b-complex w/ c- 3
biotin-e-minerals & folic acid tab
3 mg
DIALYVITE 5000 - b-complex w/ c- 3
biotin-e-minerals & folic acid tab
5 mg
DIALYVITE/ZINC - b-complex w/ c- 3
zn & folic acid tab 1 mg
DIATX ZN - b-complex w/ c-biotin- 3
minerals & folic acid tab 5 mg
3
DUET DHA - prenat w/fe poly-na
fered-fa tab 25-1 & omega cap
400 mg
3
DUET DHA BALANCED - prenat
w/fe poly-na fered-fa tab 25-1 &
omega cap 267 mg
3
DUET DHA BALANCED - prenat
w/fe poly-na fered-fa tab 27-1 &
omega cap dr 380mg
DUET DHA 400 - prenat w/fe poly- 3
cap 400 mg
3
ELITE-OB - prenatal vit w/ iron
carbonyl-fa tab 50-1.25 mg
3
ENBRACE HR - prenatal vit w/ fe
gly cys-fa-omega 3 fatty acids
cap
3
ESCAVITE - pediatric multiple
vitamins w/ fl-fe chew tab
0.25-7.5 mg
129
ESCAVITE D - pediatric multiple
vitamins w/ fl-fe chew tab 0.25-6
mg
3
ESCAVITE LQ - pediatric multiple
vitamins w/ fl-fe drops 0.25-6 mg/
ml
1
EXTRA-VIRT PLUS DHA - prenatal 3
w/o vit a w/ fe fum-doc-fa-dha
cap 29-1.25-350 mg
FLORIVA - ped multiple vitamins & 3
minerals w/ fl chew tab 0.5 mg
FLORIVA - ped multiple vitamins & 3
minerals w/ fl chew tab 1 mg
3
FOCALGIN CA - prenat w/o a w/
fecbn-fegl-dss-fa tab & dha cap
300 mg pack
FOCALGIN 90 DHA - prenat w/o a 3
w/fecbn-fegl-dss-fa tab 90 &dha
cap 300mg pak
3
FOCALGIN-B - prenatal w/
calcium-vit b6-fa-ginger tab 1.22
mg
3
FOLBECAL - prenatal w/ calcium
carbonate-b6-b12-fa tab 1 mg
3
FOLCAL DHA - prenatal w/o vit
a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg
FOLCAPS OMEGA 3 - prenatal vit 3
w/ fe cbn-fe asp glyc-fa-omega 3
cap 27-1mg
FOLET DHA - prenat w/fecbn-bisg- 3
methylf-dss tab dr & dha cap pak
3
FOLET ONE - prenat w/o a w/
fecbn-bisg-methylf-dss-dha cap
38-1-225 mg
FOLGARD OS - multiple vit w/ min 3
& calcium-folic acid tab 500-1.1
mg
FOLIVANE-OB - prenatal w/o a w/ 3
fe fum-fe poly-fa cap 130-92.4-1
mg
130
FORTAVIT - multiple vitamins w/
minerals cap
3
HEMENATAL OB - prenat vit-fe
poly cmplx-fe heme poly-fa tab
28-6-1 mg
3
HEMENATAL OB + DHA - prenatfe poly cmplx-fe heme poly-fa tab
& omega 3 cap pck
3
INATAL ADVANCE - prenatal vit w/ 3
dss-iron carbonyl-fa tab 90-1 mg
3
INATAL GT - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
3
INATAL ULTRA - prenatal vit w/
3
INFANATE BALANCE - prenatal
w/o a w/fe cbn-dss-fa-dha cap
29-1-265 mg
3
INFANATE PLUS - prenat w/o a
w/fe fum-fe cbn-dss-fa-dha cap
27-1-260 mg
3
L-METHYLFOLATE PNV DHA prenat w/fe fum-l methylfolate-fadha cap 27-1.13-0.4 mg
LEVOMEFOLATE DHA - prenat w/ 3
fe fum-l methylfolate-fa-dha cap
27-1.13-0.4 mg
M-VIT - prenatal vit w/ fe fumarate- 3
fa tab 27-1 mg
3
MACNATAL CN DHA - prenatal
28-1-250 mg
3
MARNATAL-F - prenatal w/o vit a
w/ fe polysac cmplx-fa cap 60-1
mg
3
MYKIDZ IRON FL - pediatric
vitamins acd fluoride & fe susp
0.25-10 mg/2ml
MYNATAL - prenatal multivitamins 3
& minerals w/ iron & fa cap 1 mg
MYNATAL ADVANCE - prenatal vit 3
w/ dss-iron carbonyl-fa tab 90-1
mg
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
MYNATAL PLUS - prenatal vit w/
fe fumarate-fa tab 65-1 mg
3
MYNATAL ULTRACAPLET prenatal vit w/ dss-iron carbonylfa tab 90-1 mg
3
3
NESTABS ABC - prenatal w/o vit a
w/fe polysac-fa-ca tab & omega 3
cap
3
MYNATAL-Z - prenatal vit w/ fe
3
NESTABS DHA - prenat w/o a
w/ fe bisglyc-fa tab 32-1 mg &
omega cap pack
3
MYNATE 90 PLUS - prenatal vit w/
dss-fe fumarate-fa tab cr 90-1 mg
3
NEWGEN - prenatal vit w/o vit a w/
fe bisglycinate-fa tab 32-1 mg
3
NATACHEW - prenatal vit w/ fe
fum-fe bisglycin-fa chew tab 28-1
mg
3
NEXA PLUS - prenatal w/o vit
a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg
3
NATAL-V RX - prenatal vit w/ iron
carbonyl-fa tab 29-1 mg
3
NEXA SELECT - prenatal w/o
vit a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg
NATALVIRT CA - prenat w/o a w/
300 mg pack
3
NICADAN - multiple vitamins w/
minerals tab
3
NICAZEL - multiple vitamins w/
minerals tab
3
NICAZEL FORTE - multiple
vitamins w/ minerals tab
3
NICOMIDE - niacinamide w/ zn-cumethylfol-se-cr tab 750-27-2-0.5
mg
3
NIVA-PLUS - prenatal vit w/ fe
3
NUTRI-TAB OB - prenatal vit w/o
vit a w/ fe bisglycinate-fa tab 32-1
mg
3
NUTRI-TAB OB + DHA - prenat w/
o a w/ fe bisglyc-fa tab 32-1 mg &
omega cap pack
3
NUTRICAP - multiple vitamins w/
minerals tab
3
NUTRIVIT - b-complex w/ lysinemin-fe & fa liqd 800-15-1
mg/15ml
3
O-CAL FA - prenatal vit w/ fe
3
NATALVIRT 90 DHA - prenat w/o a 3
w/fecbn-fegl-dss-fa tab 90 &dha
cap 300mg pak
3
NATALVIT - prenatal vit w/ fe
3
NATELLE ONE - prenatal w/o
vit a w/ fe fum-fa-omega 3 cap
28-1-250 mg
3
NEEVO DHA - prenat w/o a w/
fefum-methylfol-omegas cap
27-1.13 mg
3
NEPHPLEX RX - b-complex w/ czn & folic acid tab 1 mg
NEPHRO-VITE RX - b-complex w/ 3
c & folic acid tab 1 mg
NEPHROCAPS - b-complex w/ c & 3
folic acid cap 1 mg
NEPHROCAPS QT - b-complex w/ 3
c-biotin-d & folic acid tab disp 1
mg
NESTABS - prenatal vit w/o vit a w/ 3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
O-CAL PRENATAL - prenatal vit w/ 3
131
OB COMPLETE - prenatal vit w/
iron carbonyl-fa tab 50-1.25 mg
3
OB COMPLETE ONE - prenatal
w/o a w/fecbn-fe asp glyc-fa-fish
cap 50-1-476 mg
3
3
PNV-DHA - prenat w/o a w/
fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
3
OB COMPLETE PETITE - prenat
w/o a w/fecbn-feaspglyc-faomega cap 35-5-1-200 mg
3
PNV-DHA+DOCUSATE - prenatal
w/o vit a w/ fe fum-dss-fa-dha
cap 27-1.25-300 mg
3
OB COMPLETE PREMIER prenatal vit w/ fe cbn-fe asp glycfa tab 30-20-1 mg
3
PNV-FIRST - prenatal mv w/
fe polysac cmplx-fa-dha cap
29-1-200 mg
3
OB COMPLETE/DHA - prenat w/
iron cbn-fe asp glyc-fa-omega
cap 30-10-1-200 mg
3
PNV-OB/DHA - prenatal mv w/fe
fum-fa tab 65-1 mg & dha cap
250 mg pack
PNV-OMEGA - prenat w/o a w/ fe
fumerate-methylfolate-fa-omega
3 cap
3
PNV-SELECT - prenatal vit w/
fe fum-methylfolate-fa tab
27-0.6-0.4 mg
3
PNV-TOTAL - prenat w/ fe cbn-fe
bisglyc-fa-fish oil cap 35-5-1.2
mg
3
OB-NATAL ONE - prenatal vit w/ fe 3
cbn-fe asp glyc-fa-omega 3 cap
27-1mg
3
OBSTETRIX DHA - prenat w/
fecbn-fa-dss tab 29-1 mg &
omega 3 cap 387 mg pak
3
OBSTETRIX EC - prenatal vit w/
3
OCUVEL - multiple vitamins w/
minerals & fa cap 0.5 mg
3
PAIRE OB - prenat w/ fe poly
cmplx-fe asp-fe gly-fa tab & dha
cap pak
3
PNV FERROUS FUMARATE/
DOCU - prenatal vit w/ dss-fe
3
PNV FOLIC ACID + IRON MUL prenatal vit w/ fe fumarate-fa tab
27-1 mg
3
PNV OB+DHA - prenat w/o a w/
250 mg pack
PNV PRENATAL PLUS MULTIVI - 3
prenatal vit w/ fe fumarate-fa tab
27-1 mg
3
PNV TABS 29-1 - prenatal vit w/
iron carbonyl-fa tab 29-1 mg
132
PNV-VP-U - prenatal w/o a vit w/ fe 3
fumarate-fa cap 106.5-1 mg
3
POLY-VI-FLOR - ped multiple vit
w/ fluoride biphasic chew tab
0.25 mg
3
w/ fluoride biphasic chew tab 0.5
mg
3
w/ fluoride biphasic chew tab 1
mg
3
w/ fluoride biphasic susp 0.25
mg/ml
3
POLY-VI-FLOR FS - pediatric
multiple vitamins w/ fluoride oral
strip 1 mg
3
POLY-VI-FLOR/IRON - ped
multiple vit w/ fl-fe biphasic chew
tab 0.5-10 mg
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
POLY-VI-FLOR/IRON - ped
multiple vitamin w/ fl-fe biphasic
susp 0.25-7 mg/ml
3
PRENAISSANCE NEXT - prenatal
w/ calcium-vit b6-fa-ginger tab
1.2 mg
3
PR NATAL 400 - prenat-fe bis-fe
prot succ-fa-ca tab & omega 3
cap 400 pk
3
PRENAISSANCE NEXT-B prenatal w/ calcium-vit b6-faginger tab 1.22 mg
3
PR NATAL 400 EC - prenat-fe bisfe prot succ-fa-ca tab & omega
cap dr 400 pk
3
PRENAISSANCE PLUS - prenatal
28-1-250 mg
3
PR NATAL 430 - prenat-fe bis-fe
prot succ-fa-ca tab & omega 3
cap 430 pk
3
PRENAISSANCE PROMISE prenat w/o a w/fecbn-fegl-dss-fa
tab & dha cap 300 mg pack
3
PR NATAL 430 EC - prenat-fe bisfe prot succ-fa-ca tab & omega
cap dr 430 pk
3
PRENAISSANCE 90 DHA - prenat
w/o a w/fecbn-fegl-dss-fa tab 90
&dha cap 300mg pak
3
PREFERA OB - prenat vit-fe poly
cmplx-fe heme poly-fa tab 28-6-1
mg
3
PRENAPLUS - prenatal vit w/ fe
3
3
PRENATA - prenatal w/o a vit w/ fe
fum-fa tab chew 29-1 mg
3
PREFERA OB + DHA - prenat-fe
poly cmplx-fe heme poly-fa tab &
omega 3 cap pck
PRENATABS FA - prenatal vit w/
3
PREFERAOB +DHA - prenat-fe
poly cmplx 28mg-fe heme poly-fa
tab&dha cap pack
3
PRENATABS RX - prenatal vit w/
3
PRENATAL - prenatal vit w/ fe
fumarate-fa tab 27-0.8 mg
3
PRENATAL - prenatal vit w/ fe
3
PRENATAL + DHA - prenat w/o
a w/fecbn-fegl-dss-fa tab & dha
cap 250 mg pack
3
PRENATAL AD - prenatal vit w/
3
PRENATAL FORMULA - prenatal
vit w/ fe fumarate-fa tab 27-1 mg
3
PRENATAL LOW IRON - prenatal
3
PRENATAL MULTIVITAMIN-ULT prenatal vit w/ dss-iron carbonylfa tab 90-1 mg
3
PRENATAL PLUS - prenatal vit w/
3
PREFERAOB ONE - prenat-fe poly 3
cmplx-fe heme poly-fa-dha cap
22-6-1-200 mg
3
PREFOL-DHA - prenatal w/o
26-1.2-300 mg
3
PRENAISSANCE - prenatal w/o
29-1.25-325 mg
3
PRENAISSANCE BALANCE prenatal w/o vit a w/ fe cbn-dssfa-dha cap 30-1-260 mg
PRENAISSANCE DHA - prenat w/ 3
o a w/fecbn-fegl-dss-fa tab & dha
cap 250 mg pack
PRENAISSANCE HARMONY DHA 3
- prenat w/fe poly-na fered-fa tab
27-1 & omega cap dr 380mg
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
133
PRENATAL PLUS IRON - prenatal
vit w/ iron carbonyl-fa tab 29-1
mg
3
PRENATE ESSENTIAL - prenat w/
o a w/feaspg-methfol-fa-dha cap
18-0.6-0.4-300 mg
3
PRENATAL PLUS/IRON - prenatal
3
3
PRENATAL VITAMINS PLUS prenatal vit w/ fe fumarate-fa tab
27-1 mg
3
PRENATE MINI - prenat w/oa
w/fecb-feasp-meth-fa-dha cap
18-0.6-0.4-350 mg
3
PRENATAL 19 - prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
3
PRENATE PIXIE - prenat w/o a
w/feaspg-methfol-fa-dha cap
10-0.6-0.4-200 mg
3
PRENATAL 19 - prenatal vit w/
dss-fe fumarate-fa tab 29-1 mg
3
PRENATE RESTORE - prenat w/
o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-400 mg
PRENATAL-U - prenatal w/o a vit
w/ fe fumarate-fa cap 106.5-1 mg
3
PRENATE STAR - prenatal vit w/
fe asparto glycinate-fa tab 20-1
mg
3
PRENA1 CHEW - prenat w/ b2-b6b12-d3-folic acid chew tab 1.4
mg
3
PRENA1 PEARL - prenat w/oa
w/fefum-na fered-fa-dha cap cr
30-1.4-200 mg
3
PRENA1 PLUS/QUATREFOLIC
- prenat w/o a w/ fe chelate-l
methylfol-fa tab & dha cap pk
3
PRENA1/QUATREFOLIC - prenat
w/o a w/fefum-methfol-fa-dha cap
30-0.6-0.4-200 mg
3
PRENATAL/FOLIC ACID - prenatal 3
3
PRENATE - prenat mv & min w/ lmethylfolate-fa chew tab 0.6-0.4
mg
3
PRENATE AM - prenatal w/
calcium-vit b6-vit b12-fa-ginger
tab 1 mg
3
PRENATE DHA - prenat w/o a
w/fefum-methfol-fa-dha cap
28-0.6-0.4-300 mg
3
PRENATE DHA - prenat w/o a
w/feaspg-methfol-fa-dha cap
18-0.6-0.4-300 mg
3
PRENATE ELITE - prenatal w/
fe asp gly-l methylfol-fa tab
20-0.6-0.4 mg
3
PRENATE ELITE - prenatal vit
w/ fe fum-methylfolate-fa tab
26-0.6-0.4 mg
3
PRENATE ENHANCE - prenat w/
o a w/fefum-methfol-fa-dha cap
28-0.6-0.4-400 mg
PRENATE ESSENTIAL - prenat w/ 3
o a w/feasp-methylf-fa-omeg cap
29-0.6-0.4-340 mg
134
PRENEXA - prenatal w/o vit a w/ fe 3
fum-dss-fa-dha cap 27-1.25-300
mg
3
PREPLUS - prenatal vit w/ fe
3
PREQUE 10 - prenatal mv w/
fe carbonyl-dss-fa-dha tab
15-25-0.5-50 mg
3
PRETAB - prenatal vit w/ fe
3
PROTECT PLUS - multiple
vitamins w/ minerals cap
3
PROTECT PLUS - multiple
vitamins w/ minerals liquid
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
PROVIDA DHA - prenat w/o a
w/fe fum-fe poly-fa-dha cap
16-16-1.25-110 mg
3
SELECT-OB - prenatal vit w/ fe
polysac cmplx-fa chew tab 29-1
mg
3
PROVIDA OB - prenatal w/o a w/fe
fum-fe poly-fa cap 20-20-1.25 mg
3
3
PUREFE OB PLUS - prenatal
w/o a w/fe fum-fe poly-fa cap
162.115.2-1 mg
3
SELECT-OB - prenat w/
fepolycmplx-methylfol-fa chew
tab 29-0.6-0.4 mg
3
QUFLORA PEDIATRIC - pediatric
multiple vitamins w/ fluoride chew
tab 0.25 mg
1
SELECT-OB+DHA - prenatal mv
w/fe poly-fa chw 29-1 mg & dha
cap 250 mg pak
3
tab 0.5 mg
1
SETON ET-EC - prenat-fe bis-fe
prot succ-fa-ca tab & omega cap
dr 430 pk
3
tab 1 mg
1
SETONET - prenat-fe bis-fe prot
succ-fa-ca tab & omega 3 cap
430 pk
SIDEROL - multiple vitamins w/
minerals tab
3
multiple vitamins w/ fluoride soln
0.25 mg/ml
1
SM B-COMPLEX/VITAMIN C - bcomplex w/ c & folic acid tab
3
multiple vitamins w/ fluoride soln
0.5 mg/ml
STROVITE - b-complex w/ c & folic
acid tab
3
1
STROVITE FORTE - multiple
3
R-NATAL OB - prenatal w/o a w/fe
cbn-fa-dha cap 20-1-320 mg
3
3
RELNATE DHA - prenatal vit w/ fe
fum-fa-omega 3 cap 28-1-200
mg
3
STROVITE FORTE - multiple
vitamins w/ minerals & fa syrup 1
mg/15ml
RENATABS - b-complex w/ cbiotin-vit e & folic acid tab 1 mg
3
RENATABS WITH IRON - b
complex-c-biotin-e-fa tab 1mg &
fe cbn tab 100 mg pack
3
REQ 49+ - multiple vitamins w/
minerals tab
3
SE-NATAL 19 - prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
3
SE-NATAL 19 - prenatal vit w/ dssfe fumarate-fa tab 29-1 mg
3
SE-TAN DHA - prenatal w/fe fumfe poly -fa-omega 3 cap 15-15-1
mg
3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
STROVITE ONE - multiple vitamins 3
w/ minerals tab
SUPERVITE - b-complex w/ lysine- 3
zn & folic acid liquid
SUPERVITE EC - multiple vitamins 3
w/ minerals & fa tab dr 1 mg
3
SUPPORT - multiple vitamins w/
minerals liquid
SUPPORT-500 - speciality vitamin 3
product cap
3
SYNAGEX - multiple vitamins w/
3
SYNATEK - multiple vitamins w/
135
TARON-BC - prenat w/o a w/ fe
cbnyl-fa tab 20-1 mg & vit b6 tab
pak
3
TRI-VI-FLORO - ped vit acd & lmethylfol w/ fl biphasic susp 0.5
mg/ml
3
TARON-C DHA - prenatal w/fe
fum-fe poly -fa-omega 3 cap
53.5-38-1 mg
3
TRI-VIT/FLUORIDE/IRON pediatric vitamins acd fluoride &
fe drops 0.25-10 mg/ml
3
TARON-DUO EC - prenat-fe bis-fe
prot succ-fa-ca tab & omega cap
dr 400 pk
3
TRI-ZEL - multiple vitamins w/
minerals tab
3
TARON-PREX - prenatal w/o
30-1.2-265 mg
3
TL FOLATE - prenatal vit w/
27-0.5-0.5 mg
3
TL G-FOL OS - multiple vit w/ min
& calcium-folic acid tab 500-1.1
mg
3
TL-CARE DHA - prenatal w/fe
fumarate-fa-dss-fish oil cap
27-1-500 mg
3
TL-FLUORIVITE - pediatric
multiple vitamins w/ fl-fe chew
tab 0.25-7.5 mg
3
TL-SELECT - prenatal w/o vit
a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg
3
TL-SELECT DHA - prenatal w/o
vit a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg
3
TRI-TABS DHA - prenat w/o a w/ fe 3
bisglyc-fa tab 32-1 mg & omega
cap pack
3
TRI-VI-FLOR - ped vit acd & lmethylfol w/ fl biphasic susp 0.25
mg/ml
3
TRI-VI-FLOR - ped vit acd & lmethylfol w/ fl biphasic susp 0.5
mg/ml
3
TRI-VI-FLORO - ped vit acd & lmethylfol w/ fl biphasic susp 0.25
mg/ml
136
TRIADVANCE - prenatal vit w/ dss- 3
3
TRICARE - prenatal vit w/ fe
TRICARE PRENATAL COMPLEAT 3
- prenat w/o a fefum-fa tab 27-1
mg & fish oil chew cap pak
3
TRICARE PRENATAL DHA ONE
- prenatal w/fe fumarate-fa-dssfish oil cap 27-1-500 mg
TRINATAL GT - prenatal vit w/ dss- 3
TRINATAL RX 1 - prenatal vit w/ fe 3
TRINATAL ULTRA - prenatal vit w/ 3
3
TRINATE - prenatal vit w/ fe
3
TRIVEEN-DUO DHA - prenatfe bis-fe prot succ-fa-ca tab &
omega 3 cap 400 pk
3
TRIVEEN-PRX RNF - prenatal w/
o vit a w/ fe fum-dss-fa-dha cap
26-1.2-300 mg
UDAMIN SP - multiple vitamins w/ 3
minerals & fa tab 1 mg
ULTIMATE OB DHA - prenat w/ fe 3
poly cmplx-fe asp-fe gly-fa tab &
dha cap pak
3
ULTIMATECARE ONE - prenatal
vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
ULTIMATECARE ONE NF prenatal w/fe cbnyl-fe asp glycfa-dss-omega cap 20-7-1 mg
3
VINATE IC - prenatal w/o a w/fe
fum-fe poly-fa cap 162.115.2-1
mg
3
ULTRA NATALCARE - prenatal vit
w/ dss-iron carbonyl-fa tab 90-1
mg
3
VINATE II - prenatal vit w/ fe
bisglycinate chelate-fa tab 29-1
mg
3
ULTRA TABS - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
3
VINATE M - prenatal vit w/ sel-fe
3
V-NATAL - prenatal vit w/o vit a w/
3
VINATE ONE - prenatal vit w/ fe
3
V-NATAL DHA - prenat w/o a w/ fe
bisglyc-fa tab 32-1 mg & omega
cap pack
3
VINATE ULTRA - prenatal vit w/
3
VEMAVITE-PRX 2 - prenatal w/
o vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg
VIRT NATE - prenatal vit w/ fe
3
3
VIRT-ADVANCE - prenatal vit w/
3
VIRT-BAL DHA PLUS - prenat w/
fe poly-na fered-fa tab 27-1 &
omega cap dr 380mg
3
VIRT-C DHA - prenatal w/fe fum-fe
poly -fa-omega 3 cap 53.5-38-1
mg
3
VIRT-CARE ONE - prenatal vit w/
fe cbn-fe asp glyc-fa-omega 3
cap 27-1mg
3
VIRT-PN - prenatal vit w/ fe fummethylfolate-fa tab 27-0.6-0.4 mg
3
VIRT-PN DHA - prenat w/o a
27-0.6-0.4-300 mg
3
VENA-BAL DHA - prenat w/fe poly- 3
cap dr 430mg
3
VENATAL-FA - prenatal vit w/ fe
3
VINACAL - prenatal w/o a w/
fe carbonyl-fe gluc-dss-fa tab
27-1mg
VINACAL B - prenat w/o a w/fecbn- 3
feglu-fa tab 20-1 mg & vit b6 tab
pak
3
VINATE AZ EXTRA - prenatal vit
w/ fe bisglycinate chelate-fa tab
29-1 mg
VINATE C - prenatal w/o a vit w/ fe 3
VINATE CALCIUM - prenatal vit w/ 3
iron carbonyl-fe gluc-fa tab 27-1
mg
VINATE CARE - prenatal w/o a vit 3
w/ fe fum-fa tab chew 40-1 mg
3
VINATE DHA RF - prenat w/o a
w/fefum-methylfol-omegas cap
27-1.13 mg
3
VINATE GT - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
VIRT-PN PLUS - prenat w/o a w/ fe 3
fumerate-methylfolate-fa-omega
3 cap
3
VIRT-SELECT - prenatal w/o
29-1.25-325 mg
VIRT-VITE GT - prenatal vit w/ dss- 3
3
VIRTPREX - prenatal w/o vit a w/
fe fum-dss-fa-dha cap 26-1.2-300
mg
137
VITA-PREN - prenatal vit w/
docusate-iron-fa tab 65-1 mg
3
VOL-PLUS - prenatal vit w/ fe
3
VITAFOL - iron w/ vitamin tab
2
3
VITAFOL ULTRA - prenat w/
fe poly-methylfol-fa-dha cap
29-0.6-0.4-200 mg
2
VOL-TAB RX - prenatal vit w/ iron
carbonyl-fa tab 29-1 mg
3
VITAFOL-NANO - prenatal w/
o a w/ fefum-l methylfol-fa tab
18-0.6-0.4 mg
2
VP CH ULTRA - prenat w/o a w/
fe fum-fe cbn-dss-fa-dha cap
27-1-260 mg
VP-CH PLUS - prenatal w/o a w/fe
cbn-dss-fa-dha cap 29-1-265 mg
3
VITAFOL-OB - prenatal vit w/ fe
2
3
VITAFOL-OB+DHA - prenatal mv
w/fe fum-fa tab 65-1 mg & dha
cap 250 mg pack
2
VP-CH-PNV - prenatal w/o vit a w/
fe cbn-dss-fa-dha cap 30-1-260
mg
3
VITAFOL-ONE - prenatal mv w/
fe polysac cmplx-fa-dha cap
29-1-200 mg
2
VP-GGR-B6 PRENATAL - prenatal
w/ calcium-vit b6-fa-ginger tab
1.2 mg
3
VITAFOL-PN - prenatal vit w/ fe
2
VP-HEME OB - prenat vit-fe poly
cmplx-fe heme poly-fa tab 28-6-1
mg
3
VITAL-D RX - b-complex w/ cbiotin-d-zinc & folic acid tab 1 mg
3
VP-HEME OB + DHA - prenat-fe
poly cmplx-fe heme poly-fa tab &
omega 3 cap pck
VITAMEDMD ONE RX/
QUATREFO - prenat w/o a
30-0.6-0.4-200 mg
3
VP-HEME ONE - prenat-fe poly
cmplx-fe heme poly-fa-dha cap
22-6-1-200 mg
3
3
VITAMEDMD PLUS RX/QUATRE
- prenat w/o a w/ fe chelate-l
methylfol-fa tab & dha cap pk
3
VP-PNV-DHA - prenatal vit w/ fe
fum-fa-omega 3 cap 28-1-215.8
mg
3
VITAMEDMD REDICHEW RX prenat w/ b2-b6-b12-d3-folic acid
chew tab 1.4 mg
3
VP-ZEL - multiple vitamins w/
minerals tab
ZATEAN-CH - prenatal w/o a w/fe
cbn-dss-fa-dha cap 27-1-250 mg
3
VITAPEARL - prenat w/oa w/
fefum-na fered-fa-dha cap cr
30-1.4-200 mg
3
ZATEAN-PN - prenatal vit w/
27-0.6-0.4 mg
3
VITAROCA PLUS - multiple
3
3
VIVA DHA - prenatal vit w/ fe fumfa-omega 3 cap 28-1-200 mg
3
ZATEAN-PN DHA - prenat w/o
a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
3
VOL-NATE - prenatal vit w/ fe
3
ZATEAN-PN PLUS - prenat w/o a
w/ fe fumerate-methylfolate-faomega 3 cap
ZINGIBER - prenatal w/ calcium-vit
b6-fa-ginger tab 1.2 mg
3
138
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
MINERALS and ELECTROLYTES
IODINE STRONG - iodine solution
strong 5% (lugol's)
1
K-PHOS - potassium phosphate
monobasic tab 500 mg
3
CALCIFOL - ca carb-folic acidvit d-b6-b12-boron-mag wafer
1342-1.6 mg
3
CALCIUM-FOLIC ACID PLUS D
- ca carb-folic acid-vit d-b6-b12boron-mag wafer 1342-1 mg
3
K-PHOS NEUTRAL - pot phos
monobasic w/sod phos di &
monobas tab 155-852-130mg
3
EFFER-K - potassium bicarbonatecitric acid effer tab 10 meq
3
K-TAB - potassium chloride tab cr
10 meq
3
EFFER-K - potassium bicarbonatecitric acid effer tab 20 meq
3
K-TAB - potassium chloride tab cr
20 meq (1500 mg)
3
FLORICAL - sodium fluoride w/
calcium carb cap 8.3-364 mg
A
3
FLORICAL - sodium fluoride w/
calcium carb tab 8.3-364 mg
A
KLOR-CON M15 - potassium
chloride microencapsulated crys
cr tab 15 meq
3
FLORIVA - sodium fluoride-vitamin
d liqd drops 0.25 mg/ml-400 unit/
ml
3
KLOR-CON 25 - potassium
chloride powder packet 25 meq
KLOR-CON/25 - potassium
chloride powder packet 25 meq
3
FLUOR-A-DAY - sodium fluoridexylitol chew tab 0.55 (0.25 mg
f)-236.79 mg
A
LOZI-FLUR - sodium fluoride
lozenge 1 mg f (from 2.2 mg naf)
A
FLUOR-A-DAY - sodium fluoridexylitol chew tab 1.1 (0.5 mg
f)-236.79 mg
A
FLUOR-A-DAY - sodium fluoridexylitol chew tab 2.2 (1 mg
f)-236.79 mg
A
FLUORABON - sodium fluoride
soln 0.25 mg/0.6ml (from 0.55
mg/0.6ml naf)
A
FLURA-DROPS - sodium fluoride
soln 0.25 mg/drop f (from 0.55
mg/drop naf)
A
GALZIN - zinc acetate cap 25 mg
(elemental zinc)
3
GALZIN - zinc acetate cap 50 mg
(elemental zinc)
3
GNP VITAMIN D-400 - calcium
carbonate-cholecalciferol tab 90
mg-400 unit
1
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
LURIDE - sodium fluoride chew tab A
0.25 mg f (from 0.55 mg naf)
1 mg f (from 2.2 mg naf)
LURIDE - sodium fluoride soln 0.5 A
mg/ml f (from 1.1 mg/ml naf)
3
MAGNEBIND 400 - magnesiumcalcium-folic acid tab 400-200-1
mg
MICRO-K - potassium chloride cap 3
cr 8 meq
MICRO-K - potassium chloride cap 3
cr 10 meq
A
MONOCAL - sodium
monofluorophosphate-calcium
carb tab 22.75-625 mg
1
pot bicarbonate & chloride effer
tab 25 meq
139
pot phos monobasic w/sod
phos di & monobas tab
155-852-130mg (K-phos neutral)
1
sodium fluoride soln 0.125 mg/
drop f (0.275 mg/drop naf)
A
potassium bicarbonate effer tab
25 meq
sodium fluoride soln 0.5 mg/ml f
(from 1.1 mg/ml naf) (Luride)
A
1
potassium chloride cap cr 10
meq (Micro-k)
zinc sulfate cap 220 mg (50 mg
elemental zn)
1
1
potassium chloride cap cr 8 meq
(Micro-k)
1
POTASSIUM CHLORIDE ER potassium chloride tab cr 20 meq
(1500 mg)
1
potassium chloride
microencapsulated crys cr tab
10 meq
1
potassium chloride
microencapsulated crys cr tab
20 meq
1
potassium chloride oral liq 10%
(20 meq/15ml)
acetylcysteine cap 600 mg
1
CARDIOVID PLUS - dha-epavit b6-b12-folic acid cap
240-360-20-0.5-0.8 mg
3
NUTRESTORE - glutamine powd
pack 5 gm
3
TRYPTOPHAN - tryptophan cap
500 mg
1
DIETARY PRODUCTS
3
1
potassium chloride oral liq 20%
(40 meq/15ml)
1
AVAILNEX - carbocysteine chew
tab 750 mg
3
potassium chloride powder
packet 20 meq
1
CARDIOTEK-RX - folic acid-b12b6-arginine-black pepper tab
3
potassium chloride tab cr 10
meq (K-tab)
1
CEREFOLIN - l-methylfolate w/ vit
b12-vit b6-vit b2 tab 6-1-50-5 mg
3
potassium chloride tab cr 8 meq
(600 mg)
1
3
SODIUM FLUORIDE - sodium
fluoride tab 0.5 mg f (from 1.1 mg
naf)
A
CEREFOLIN NAC - l-methylfolatemethylcobalamin-acetylcyst tab
6-2-600 mg
3
SODIUM FLUORIDE - sodium
fluoride tab 1 mg f (from 2.2 mg
naf)
A
CEREFOLIN NAC - l-methylfolatealgae-b12-acetylcyst tab
6-90.314-2-600mg
1
sodium fluoride chew tab
(Luride)
A
CYANOCOBALAMIN/
LEVOMEFOLA - l-methylfolate
w/ vit b6-vit b12 tab 1.13-25-2 mg
DEPLIN - l-methylfolate tab 7.5 mg
3
DEPLIN - l-methylfolate tab 15 mg
3
sodium fluoride chew tab 0.5 mg
f (from 1.1 mg naf) (Luride)
A
DEPLIN 15 - l-methylfolate-algae
cap 15-90.314 mg
3
sodium fluoride chew tab 1 mg f
(from 2.2 mg naf) (Luride)
A
DEPLIN 7.5 - l-methylfolate-algae
cap 7.5-90.314 mg
3
Specialty
Quantity Limits
"Smart" PA
NUTRIENTS
ALZ-NAC - l-methylfolatemethylcobalamin-acetylcyst tab
6-2-600 mg
140
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
ENTERAGAM - serum-derived
bovine immunoglob/protein
isolate 5 gm packet
3
L-METHYLFOLATE CA MECBL - l-methylfolate-algae-b12acetylcyst tab 6-90.314-2-600mg
3
FALESSA - levomefolate
glucosamine tab 1 mg (folate
equivalent)
3
L-METHYLFOLATE CA/ME-CBL/ l-methylfolate-methylcobalaminacetylcyst tab 6-2-600 mg
1
flaxseed oil-evening primrosebilberry cap 1000-500-40 mg
(Tears again hydrate)
1
L-METHYLFOLATE CA/P-5-P/M l-methylfolate w/ vit b6-vit b12 tab
3-35-2 mg
1
FOLBEE AR - folic acid-b12-b6arginine-black pepper tab
3
1
FOLBIC RF - l-methylfolate w/ vit
b6-vit b12 tab 1.13-25-2 mg
3
L-METHYLFOLATE CA/P-5-P/M
- l-methylfolate-algae-vit b12-b6
cap 3-90.314-2-35 mg
1
folic acid-pyridoxinecyanocobalamin tab
2.5-25-2 mg
1
L-METHYLFOLATE CALCIUM - lmethylfolate tab 7.5 mg
L-METHYLFOLATE CALCIUM - lmethylfolate tab 15 mg
1
L-METHYLFOLATE FORMULA
15 - l-methylfolate-algae cap
15-90.314 mg
3
L-METHYLFOLATE FORMULA
7. - l-methylfolate-algae cap
7.5-90.314 mg
3
L-METHYLFOLATE FORTE
- l-methylfolate-algae cap
7.5-90.314 mg
3
L-METHYLFOLATE FORTE - lmethylfolate-algae cap 15-90.314
mg
3
LEVOMEFOLATE CALCIUM/
ACET - l-methylfolate-algae-b12acetylcyst tab 6-90.314-2-600mg
1
ALGA - l-methylfolate-algae cap
7.5-90.314 mg
1
ALGA - l-methylfolate-algae cap
15-90.314 mg
1
LEVOMEFOLATE CALCIUM/PYRI
- l-methylfolate-algae-vit b12-b6
cap 3-90.314-2-35 mg
1
LIMBREL - flavocoxid cap 250 mg
3
LIMBREL - flavocoxid cap 500 mg
3
FOLTANX - l-methylfolate w/ vit b6- 3
vit b12 tab 3-35-2 mg
3
FOLTANX RF - l-methylfolatealgae-vit b12-b6 cap
3-90.314-2-35 mg
3
FOLTX - folic acid-pyridoxinecyanocobalamin tab 2.5-25-2 mg
FOLTX - l-methylfolate w/ vit b6-vit 3
b12 tab 1.13-25-2 mg
3
FOSTEUM - genistein-zinc amino
acid chelate-vitamin d cap
L-METHYL-B6-B12 - l-methylfolate 1
w/ vit b6-vit b12 tab 3-35-2 mg
3
L-METHYL-MC - l-methylfolate w/
vit b12-vit b6-vit b2 tab 6-1-50-5
mg
3
L-METHYL-MC NAC - lmethylfolate-methylcobalaminacetylcyst tab 6-2-600 mg
L-METHYLFOLATE - l-methylfolate 1
tab 7.5 mg
L-METHYLFOLATE - l-methylfolate 1
tab 15 mg
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
141
LIMBREL250 - flavocoxid-citrated
zinc bisglycinate cap 250-50 mg
3
VAYARIN - phosphatidylserinedha-epa cap 75-21.5-8.5 mg
3
LIMBREL500 - flavocoxid-citrated
zinc bisglycinate cap 500-50 mg
3
VAYAROL - phytosterol estersdha-epa cap 630-232.5-92.5 mg
3
VITA-RESPA - folic acidpyridoxine-cyanocobalamin tab
2.2-25-1.3 mg
3
VITACIRC-B - l-methylfolate w/ vit
b6-vit b12 tab 3-35-2 mg
3
VP-GSTN - genistein-zinc amino
acid chelate-vitamin d cap
3
LMTHF/PYRIDOXINE HCL/CYAN - 1
l-methylfolate w/ vit b6-vit b12 tab
1.13-25-2 mg
3
METAFOLBIC - l-methylfolate w/
vit b12-vit b6-vit b2 tab 6-1-50-5
mg
3
METAFOLBIC PLUS - lmethylfolate-methylcobalaminacetylcyst tab 6-2-600 mg
3
METAFOLBIC PLUS RF - lmethylfolate-algae-b12acetylcyst tab 6-90.314-2-600mg
METANX - l-methylfolate w/ vit b6- 3
vit b12 tab 3-35-2 mg
METANX - l-methylfolate-algae-vit 3
b12-b6 cap 3-90.314-2-35 mg
METHYLFOL-ALGAE-B12-ACETY 1
- l-methylfolate-algae-b12acetylcyst tab 6-90.314-2-600mg
PODIAPN - l-methylfolate-b12-b6- 3
alpha lipoic ac cap 5-2-35-300
mg
3
Q-TABS - levomefolate
glucosamine tab 1 mg (folate
equivalent)
1
SACCHARIN SODIUM - sodium
saccharin powder
SODIUM SACCHARIN DIHYDRAT 1
- sodium saccharin powder
3
TEARS AGAIN HYDRATE flaxseed oil-evening primrosebilberry cap 1000-500-40 mg
3
VASCAZEN - omega-3-acid ethyl
esters (dietary management) cap
1 gm
3
VAYACOG - phosphatidylserinedha-epa cap 100-19.5-6.5 mg
142
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
HEMATOLOGICAL AGENTS
HEMATOPOIETIC AGENTS
fe fum-iron polysacch complexfa-b cmplx-c-zn-mn-cu cap
(Tandem plus)
1
ferrous fumarate-fa-b complex-czn-mg-mn-cu tab 106-1 mg
1
iron combination cap
1
iron-docusate-b12-folic acidc-e-cu-biotin tab 150-1 mg
(Hematron-af)
1
ACTIVE FE - fe carbonyl-fa-b
complex-a-c-d-e-min tab 75-1.25
mg
3
ANIMI-3 - folic acid-vit b6-vit b12omega 3-phytosterols cap 1 mg
3
ANIMI-3 - folic acid-b6-b12-domega 3-phytosterols cap 1 mg
3
ANIMI-3/VITAMIN D - folic acid-b6b12-d-omega 3-phytosterols cap
1 mg
3
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80
soln inj 10 mcg/0.4ml
2
•
• •
soln inj 25 mcg/ml
2
•
• •
2
•
• •
2
•
• •
soln inj 100 mcg/ml
2
•
• •
2
•
• •
2
•
• •
soln inj 200 mcg/ml
2
•
• •
2
•
• •
soln inj 300 mcg/ml
2
2
•
• •
soln inj 500 mcg/ml
2
•
• •
B-6 FOLIC ACID - cobalamine
combination cap
1
BIFERARX - polysacch fe
cmplx-fe heme poly-fa-b12 tab
22-6-1-0.025 mg
3
•
A
• •
carbonyl iron susp 15 mg/1.25ml
(elemental iron)
CENFOL - folic acid-vitamin b6vitamin b12 tab 2.3-24.5-2 mg
3
CENTRATEX - ferrous fumaratefa-b complex-c-zn-mg-mn-cu cap
106-1 mg
3
• •
CERDELGA - eliglustat tartrate cap 2
3
CIFEREX - folic acidcholecalciferol cap 1 mg-3775
unit
3
CORVITE FE - iron combination
tab
3
CORVITE 150 - iron combination
tab
CORVITE 150 - iron-folic acid-vit c- 3
vit b6-vit b12-zinc tab 150-1.25
mg
cyanocobalamin inj 1000 mcg/ml 1
DIVISTA - folic acid-vit b6-vit b12omega 3-biotin-cr cap 1 mg
Specialty
•
3
• •
BP VIT 3 PLUS - folic acid-b6-b12d-omega 3-phytosterols cap 1
mg
Quantity Limits
2
3
"Smart" PA
soln inj 60 mcg/ml
•
BP VIT 3 - folic acid-vit b6-vit b12omega 3-phytosterols cap 1 mg
Prior Authorization
2
• •
Drug Name
Drug Tier
•
Specialty
2
Quantity Limits
Prior Authorization
soln inj 40 mcg/ml
Drug Name
"Smart" PA
Drug Tier
2015
•
• •
•
• •
•
• •
3
DROXIA - hydroxyurea cap 200 mg 3
3
DURACHOL - folic acidcholecalciferol cap 1 mg-3775
unit
3
ED CYTE F - ferrous fumaratefolic acid-docusate sodium tab
324-1-50 mg
3
EPOGEN - epoetin alfa inj 2000
unit/ml
3
unit/ml
143
unit/ml
3
FA-8 - folic acid cap 0.8 mg
A
fe fumarate w/ b12-vit c-fa-ifc
cap 110-0.015-75-0.5-240 mg
1
fe fumarate-vit c-vit b12-fa cap
460 (151 fe)-60-0.01-1 mg
1
FE 90 PLUS - fe carbonyl-fe
gluconate-fa-vit b12-vit c-dss tab
90-1 mg
3
FER-IN-SOL - ferrous sulfate soln
75 mg/ml (15 mg/ml elemental
fe)
A
FERIVA - fe bisglycin-fe carbonylc-fa-b12-biotin-dss cap 75-1 mg
3
FERIVA 21/7 - fe asparto gly-b12fa-c-dss-succinic acid-zn tab
75-1 mg
3
FERIVAFA - iron-c-fa-b12-biotincopper-docusate cap 110-1 mg
3
FERRALET 90 - fe carbonyl-fe
90-1 mg
3
FERRAPLUS 90 - iron-folic acid-vit
b12-vit c-docusate sod tab 90-1
mg
3
FERRETTS CHEWABLE IRON
- carbonyl iron chew tab 18 mg
(elemental iron)
A
FERREX 150 FORTE PLUS - fe
asp gly-fe polysacch-succ ac-cthreon ac-b12-fa cap
3
FERREX 28 - fe asparto gly-fe
fum-b12-fa-c-succinic ac tab ther
pack
3
144
•
• •
3
• •
FERROTRIN - iron w/ b12-vit c-faifc cap 36-0.015-75-0.5-240 mg
ferrous fumarate-folic acid tab
324-1 mg
1
FERROUS SULFATE - ferrous
sulfate liquid 220 mg/5ml (44
mg/5ml elemental fe)
A
FERROUS SULFATE - ferrous
sulfate syrup 300 mg/5ml (60
mg/5ml elemental fe)
A
ferrous sulfate elixir 220 mg/5ml
(44 mg/5ml elemental fe)
A
ferrous sulfate soln 75 mg/ml
(15 mg/ml elemental fe)
A
FOCALGIN DSS - fe carbonyl-fe
90-1 mg
3
FOLGARD RX - folic acid-vitamin
b6-vitamin b12 tab 2.2-25-1 mg
3
folic acid tab 1 mg
1
folic acid tab 400 mcg
A
folic acid tab 800 mcg
A
folic acid-vitamin b6-vitamin b12
tab 2.2-25-0.5 mg
1
tab 2.2-25-1 mg (Folgard rx)
1
tab 2.5-25-1 mg
1
FOLIVANE-F - fe fum-fe poly-fa-cb3 cap 62.5-62.5-1-40-3mg(125
mg fe)
3
FOLIVANE-PLUS - fe fum-iron
polysacch complex-fa-b complexc-biotin cap
3
FOLTRATE - cobalamine
combination tab
3
Specialty
•
Quantity Limits
3
3
"Smart" PA
unit/ml
FERRO-PLEX HEMATINIC - fe
fum-dss-vit c-vit e-vit b12-if-fa tab
115-1 mg
Prior Authorization
• •
Drug Name
Drug Tier
•
Specialty
3
Quantity Limits
Prior Authorization
unit/ml
Drug Name
"Smart" PA
Drug Tier
2015
FUSION PLUS - fe fum-iron
poly cmplx-fa-b cmplx-c-biotinprobiotic cap
3
GRANIX - tbo-filgrastim soln
prefilled syringe 300 mcg/0.5ml
3
•
•
GRANIX - tbo-filgrastim soln
prefilled syringe 480 mcg/0.8ml
3
•
•
HEMATOGEN FA - fe fumarate-vit
c-vit b12-fa cap 200-250-0.01-1
mg
3
HEMATRON-AF - iron-docusateb12-folic acid-c-e-cu-biotin tab
150-1 mg
3
HEMETAB - polysacch fe cmplxfe heme poly-fa-b12 tab
22-6-1-0.025 mg
3
HEMOCYTE PLUS - ferrous
fumarate-fa-b complex-c-zn-mgmn-cu cap 106-1 mg
3
HEMOCYTE-F - iron combination
elixir
3
ICAR - carbonyl iron chew tab 15
mg (elemental iron)
A
ICAR PEDIATRIC - carbonyl iron
susp 15 mg/1.25ml (elemental
iron)
A
ICAR-C PLUS - iron-vit c-vit b12folic acid tab 100-250-0.025-1
mg
3
INTEGRA F - fe fum-fe poly-fa-c-b3 3
cap 62.5-62.5-1-40-3mg(125 mg
fe)
3
INTEGRA PLUS - fe fum-iron
polysacch complex-fa-b complexc-biotin cap
IRON ASP GLY/ POLYSACCH C - 1
fe asp gly-fe polysacch-succ acc-threon ac-b12-fa cap
A
IRON CHEWS PEDIATRIC carbonyl iron chew tab 15 mg
(elemental iron)
iron polysacch complex-vit b12fa cap 150-0.025-1 mg
1
iron-folic acid-vit c-vit b6-vit b12zinc tab 150-1.25 mg (Corvite
150)
1
1
iron-vit c-vit b12-folic acid tab
100-250-0.025-1 mg (Icar-c plus)
3
IROSPAN 24/6 - fe asp gly-fe
polys-succ acd-b cmplx-c-ca-fa
tab ther pk
3
IS 24/6 - fe asp gly-fe polys-succ
acd-b cmplx-c-ca-fa tab ther pk
2
LEUKINE - sargramostim inj 500
mcg/ml
2
LEUKINE - sargramostim
lyophilized for inj 250 mcg
MAXARON FORTE - fe gly-fe fum- 3
vit c-vit b12-methylfolate tab
MAXFE - iron-fa-vit b12-biotin-vit c- 3
docusate-mg-zn tab 160-1 mg
MIRCERA - methoxy polyethylene 3
glycol-epoetin beta inj 50
mcg/0.3ml
mcg/0.3ml
mcg/0.3ml
mcg/0.3ml
3
MULTIGEN - fe asparto gly-succ
acd-c-threonic acd-b12-des stom
tab
MULTIGEN FOLIC - fe asparto gly- 3
succinic acd-vit c-threonic acdb12-fa tab
3
MULTIGEN PLUS - fe aspart glyfe fum-succ acd-c-threonic acdb12-fa tab
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
• •
•
• •
•
• •
•
• •
•
• •
•
• •
145
1
MV FE ASPARTO GLY/VIT C/
V - fe asparto gly-succ acd-cthreonic acd-b12-des stom tab
1
MYKIDZ IRON 10 - iron susp 15
mg/1.5ml
A
NASCOBAL - cyanocobalamin
nasal spray 500 mcg/0.1ml
3
NATALVIRT FLT - fe carbonyl-fe
90-1 mg
3
NEPHRON FA - ferrous fumarate
w/ fa-dss-b complex-vit c tab
3
NEULASTA - pegfilgrastim inj 6
mg/0.6ml
3
•
• •
NEULASTA DELIVERY KIT pegfilgrastim inj 6 mg/0.6ml
3
•
• •
NEUMEGA - oprelvekin for inj 5 mg 2
2
NEUPOGEN - filgrastim inj 300
mcg/ml
2
mcg/1.6ml (300 mcg/ml)
2
2
3
NEURIN-SL - cyanocobalaminmethylcobalamin tab sl 600-600
mcg
3
NOVAFERRUM - polysacch iron
complex-vit c-fa for soln 100-60-1
mg/5ml
3
PRE-FOLIC - folic acid-vitamin c
tab 1-100 mg
2
PROCRIT - epoetin alfa inj 2000
unit/ml
2
unit/ml
•
•
• •
• •
•
• •
•
• •
•
• •
•
• •
•
• •
•
• •
unit/ml
2
•
• •
unit/ml
2
•
• •
unit/ml
2
•
• •
PROFERRIN-FORTE - iron heme
polypeptide-folic acid tab 12-1
mg (fe equiv)
3
PROMACTA - eltrombopag
olamine tab 12.5 mg (base equiv)
3
•
• •
olamine tab 25 mg (base equiv)
3
•
• •
3
•
• •
3
•
• •
PROTECTIRON - iron polysacchfa-b complex-vit c-e & minerals
tab 60-1 mg
3
PUREFE PLUS - ferrous fumaratefa-b complex-c-zn-mg-mn-cu cap
106-1 mg
3
REVESTA - folic acidcholecalciferol cap 1 mg-5750
unit
3
SPATONE PUR-ABSORB IRON ferrous sulfate liquid 5 mg/20ml
(elemental iron)
A
TANDEM F - ferrous fum-iron
polysacch-fa cap 162-115.2-1 mg
(106 mg fe)
3
TANDEM PLUS - fe fum-iron
polysacch complex-fa-b cmplx-czn-mn-cu cap
3
TARON FORTE - fe bisglycinate-fe
polysacch-vit c-vit b12-fa cap
3
ZAVESCA - miglustat cap 100 mg
3
ANTICOAGULANTS
146
Specialty
2
Quantity Limits
unit/ml
Drug Name
"Smart" PA
Prior Authorization
MV FE ASPARTO GLY/FE FUM/ fe aspart gly-fe fum-succ acd-cthreonic acd-b12-fa tab
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
• •
ARIXTRA - fondaparinux sodium
inj 2.5 mg/0.5ml
3
•
enoxaparin sodium inj
60 mg/0.6ml (Lovenox)
1
•
inj 5 mg/0.4ml
3
•
1
•
inj 7.5 mg/0.6ml
3
•
fondaparinux sodium inj
10 mg/0.8ml (Arixtra)
1
•
inj 10 mg/0.8ml
3
•
2.5 mg/0.5ml (Arixtra)
1
•
COUMADIN - warfarin sodium tab
1 mg
2
5 mg/0.4ml (Arixtra)
1
•
2 mg
2
7.5 mg/0.6ml (Arixtra)
1
•
2.5 mg
2
FRAGMIN - dalteparin sodium inj
10000 unit/ml
3
•
3 mg
2
2500 unit/0.2ml
3
•
4 mg
2
5000 unit/0.2ml
3
•
5 mg
2
12500 unit/0.5ml
3
•
6 mg
2
15000 unit/0.6ml
3
•
7.5 mg
2
18000 unit/0.72ml
3
•
10 mg
2
95000 unit/3.8ml
3
•
ELIQUIS - apixaban tab 2.5 mg
2
1
ELIQUIS - apixaban tab 5 mg
2
enoxaparin sodium inj 100 mg/
ml (Lovenox)
1
HEPARIN LOCK FLUSH - heparin
sodium (porcine) lock flush iv
soln 1 unit/ml
1
1
•
HEPARIN LOCK FLUSH - heparin
sodium (porcine) lock flush iv
soln 2 unit/ml
1
•
heparin sod lock flush & nacl
lock flush 10 unt/ml-0.9% kit
1
enoxaparin sodium inj 150 mg/
ml (Lovenox)
1
•
heparin sod lock flush & nacl
lock flush 100 unt/ml-0.9% kit
1
1
•
HEPARIN SODIUM - heparin
sodium (porcine) inj 2000 unit/ml
1
300 mg/3ml (Lovenox)
1
•
HEPARIN SODIUM - heparin
sodium (porcine) inj 2500 unit/ml
1
•
•
•
•
•
•
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147
heparin sodium (porcine) inj
1000 unit/ml
1
SAVAYSA - edoxaban tosylate tab
3
•
10000 unit/ml
1
3
•
20000 unit/ml
1
warfarin sodium tab 1 mg
(Coumadin)
1
5000 unit/ml
1
(Coumadin)
1
heparin sodium (porcine) lock
flush iv soln 1 unit/ml (Heparin
lock flush)
1
(Coumadin)
1
flush iv soln 10 unit/ml
warfarin sodium tab 2.5 mg
(Coumadin)
1
1
flush iv soln 100 unit/ml
(Coumadin)
1
1
1
heparin sodium (porcine) pf inj
5000 unit/0.5ml
1
(Coumadin)
3
•
(Coumadin)
1
LOVENOX - enoxaparin sodium inj
30 mg/0.3ml
40 mg/0.4ml
•
(Coumadin)
1
3
60 mg/0.6ml
•
warfarin sodium tab 7.5 mg
(Coumadin)
1
3
2
80 mg/0.8ml
•
XARELTO - rivaroxaban tab 10 mg
3
2
3
•
2
100 mg/ml
2
120 mg/0.8ml
3
•
XARELTO STARTER PACK rivaroxaban tab starter therapy
pack 15 mg & 20 mg
150 mg/ml
3
•
300 mg/3ml
3
PRADAXA - dabigatran etexilate
mesylate cap 75 mg (etexilate
base eq)
2
PRADAXA - dabigatran etexilate
mesylate cap 150 mg (etexilate
base eq)
2
3
148
•
•
•
•
•
•
•
•
•
•
HEMOSTATICS
AMICAR - aminocaproic acid tab
500 mg
3
AMICAR - aminocaproic acid tab
1000 mg
3
AMICAR - aminocaproic acid syrup
25%
3
AMINOCAPROIC ACID aminocaproic acid tab 1000 mg
1
aminocaproic acid syrup 25%
(Amicar)
1
•
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aminocaproic acid tab 500 mg
(Amicar)
1
PERSANTINE - dipyridamole tab
25 mg
3
•
ASTRINGYN - ferric subsulfate
soln 259 mg/gm
3
50 mg
3
•
LYSTEDA - tranexamic acid tab
650 mg
3
75 mg
3
•
MONSELS FERRIC SUBSULFATE
- ferric subsulfate soln
3
PLAVIX - clopidogrel bisulfate tab
75 mg (base equiv)
3
• •
tranexamic acid tab 650 mg
(Lysteda)
1
PLAVIX - clopidogrel bisulfate tab
300 mg (base equiv)
3
• •
PLETAL - cilostazol tab 50 mg
3
PLETAL - cilostazol tab 100 mg
3
ticlopidine hcl tab 250 mg
1
ZONTIVITY - vorapaxar sulfate tab
3
•
•
•
•
HEMATOLOGICAL AGENTS - MISC.
AGGRENOX - aspirin-dipyridamole 3
cap sr 12hr 25-200 mg
3
AGRYLIN - anagrelide hcl cap 0.5
mg
1
anagrelide hcl cap 0.5 mg
(Agrylin)
1
anagrelide hcl cap 1 mg
•
•
•
BRILINTA - ticagrelor tab 90 mg
3
cilostazol tab 100 mg (Pletal)
1
cilostazol tab 50 mg (Pletal)
1
clopidogrel bisulfate tab 300 mg
(base equiv) (Plavix)
1
•
•
•
•
•
clopidogrel bisulfate tab 75 mg
(base equiv) (Plavix)
1
•
dipyridamole tab 25 mg
(Persantine)
1
•
(Persantine)
1
•
(Persantine)
1
•
EFFIENT - prasugrel hcl tab 5 mg
(base equiv)
3
•
•
EFFIENT - prasugrel hcl tab 10 mg
(base equiv)
3
•
•
FIRAZYR - icatibant acetate inj 30
mg/3ml (base equivalent)
2
•
• •
pentoxifylline tab cr 400 mg
1
•
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TOPICAL PRODUCTS
OPHTHALMIC AGENTS
ACUVAIL - ketorolac tromethamine 3
ophth soln 0.45%
3
AKTEN - lidocaine hcl ophth gel
3.5%
ALCAINE - proparacaine hcl ophth 3
soln 0.5%
2
ALOCRIL - nedocromil sodium
ophth soln 2%
3
ALOMIDE - lodoxamide
tromethamine ophth soln 0.1%
2
ALPHAGAN P - brimonidine
tartrate ophth soln 0.1%
3
ALPHAGAN P - brimonidine
tartrate ophth soln 0.15%
2
ALREX - loteprednol etabonate
ophth susp 0.2%
ophthalmic irrigation solution intraocular (Bss plus)
1
ACULAR - ketorolac tromethamine
ophth soln 0.5%
3
ACULAR LS - ketorolac
tromethamine ophth soln 0.4%
3
•
149
apraclonidine hcl ophth soln
0.5% (base equivalent)
(Iopidine)
1
BLEPHAMIDE - sulfacetamide
sodium-prednisolone ophth susp
10-0.2%
3
ATROPINE SULFATE - atropine
sulfate ophth oint 1%
1
3
atropine sulfate ophth soln 1%
(Isopto atropine)
1
BLEPHAMIDE LIQUIFILM
- sulfacetamide sodiumprednisolone ophth susp
10-0.2%
AZASITE - azithromycin ophth soln
1%
3
2
azelastine hcl ophth soln 0.05%
(Optivar)
1
BLEPHAMIDE S.O.P. sulfacetamide sodiumprednisolone ophth oint 10-0.2%
1
AZOPT - brinzolamide ophth susp
1%
3
brimonidine tartrate ophth soln
0.15% (Alphagan p)
1
BACITRACIN - bacitracin ophth
oint 500 unit/gm
1
brimonidine tartrate ophth soln
0.2%
1
bacitracin-polymyxin b ophth
oint
1
bromfenac sodium ophth soln
0.09% (base equiv) (once-daily)
1
bacitracin-polymyxin-neomycinhc ophth oint 1%
1
bromfenac sodium ophth soln
0.09% (base equivalent)
carteolol hcl ophth soln 1%
1
BEPREVE - bepotastine besilate
ophth soln 1.5%
3
CILOXAN - ciprofloxacin hcl ophth
soln 0.3%
3
BESIVANCE - besifloxacin hcl
ophth susp 0.6% (base equiv)
3
CILOXAN - ciprofloxacin hcl ophth
oint 0.3%
3
BETADINE OPHTHALMIC PREP povidone-iodine ophth soln 5%
3
ciprofloxacin hcl ophth soln
0.3% (Ciloxan)
1
BETAGAN - levobunolol hcl ophth
soln 0.5%
3
3
•
BETAGAN C CAP QD levobunolol hcl ophth soln 0.5%
3
COMBIGAN - brimonidine tartratetimolol maleate ophth soln
0.2-0.5%
3
•
betaxolol hcl ophth soln 0.5%
1
COSOPT - dorzolamide hcl-timolol
maleate ophth soln 22.3-6.8 mg/
ml
BETIMOL - timolol ophth soln
0.25%
3
COSOPT PF - dorzolamide
hcl-timolol maleate ophth sol
22.3-6.8 mg/ml pf
3
•
cromolyn sodium ophth soln 4%
1
CYCLOGYL - cyclopentolate hcl
ophth soln 0.5%
3
ophth soln 1%
3
ophth soln 2%
3
BETIMOL - timolol ophth soln 0.5% 3
BETOPTIC-S - betaxolol hcl ophth 2
susp 0.25%
3
BIMATOPROST - bimatoprost
ophth soln 0.03%
BLEPH-10 - sulfacetamide sodium 3
ophth soln 10%
150
•
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CYCLOMYDRIL - cyclopentolate
w/ phenylephrine ophth soln
0.2-1%
3
GARAMYCIN - gentamicin sulfate
ophth soln 0.3%
3
cyclopentolate hcl ophth soln
1% (Cyclogyl)
gatifloxacin ophth soln 0.5%
(Zymaxid)
1
1
cyclopentolate hcl ophth soln
2% (Cyclogyl)
GELFILM OP - gelatin adsorbable
ophth film
3
1
gentamicin sulfate ophth oint
0.3%
1
gentamicin sulfate ophth soln
0.3% (Garamycin)
1
homatropine hbr ophth soln 5%
(Isopto homatropine)
1
ILEVRO - nepafenac ophth susp
0.3%
3
IOPIDINE - apraclonidine hcl ophth
soln 0.5% (base equivalent)
3
IOPIDINE - apraclonidine hcl ophth
soln 1% (base equivalent)
2
ISOPTO ATROPINE - atropine
sulfate ophth soln 1%
3
ISOPTO CARBACHOL - carbachol
ophth soln 1.5%
2
ISOPTO CARBACHOL - carbachol
ophth soln 3%
2
ISOPTO CARPINE - pilocarpine
hcl ophth soln 1%
3
hcl ophth soln 2%
3
hcl ophth soln 4%
3
ISOPTO HOMATROPINE homatropine hbr ophth soln 2%
3
ISOPTO HOMATROPINE homatropine hbr ophth soln 5%
3
ISOPTO HYOSCINE scopolamine hbr ophth soln
0.25%
2
ISTALOL - timolol maleate ophth
soln 0.5% (once-daily)
3
CYSTARAN - cysteamine hcl ophth 3
1
dexamethasone sodium
phosphate ophth soln 0.1%
1
diclofenac sodium ophth soln
0.1%
1
dorzolamide hcl ophth soln 2%
(Trusopt)
1
dorzolamide hcl-timolol maleate
ophth soln 22.3-6.8 mg/ml
(Cosopt)
3
DUREZOL - difluprednate ophth
emulsion 0.05%
3
ELESTAT - epinastine hcl ophth
soln 0.05%
EMADINE - emedastine difumarate 3
ophth soln 0.05% (base equiv)
1
epinastine hcl ophth soln 0.05%
(Elestat)
1
erythromycin ophth oint 5 mg/
gm
FLAREX - fluorometholone acetate 3
ophth susp 0.1%
1
fluorometholone ophth susp
0.1% (Fml liquifilm)
1
flurbiprofen sodium ophth soln
0.03% (Ocufen)
2
FML - fluorometholone ophth oint
0.1%
3
FML FORTE - fluorometholone
ophth susp 0.25%
FML LIQUIFILM - fluorometholone 3
ophth susp 0.1%
•
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•
151
ketorolac tromethamine ophth
soln 0.4% (Acular ls)
1
ketorolac tromethamine ophth
soln 0.5% (Acular)
1
ketotifen fumarate ophth soln
0.025% (base equiv)
1
•
LASTACAFT - alcaftadine ophth
soln 0.25%
3
•
latanoprost ophth soln 0.005%
(Xalatan)
1
•
LEVOBUNOLOL HCL - levobunolol 1
hcl ophth soln 0.25%
1
levobunolol hcl ophth soln 0.5%
(Betagan)
1
levofloxacin ophth soln 0.5%
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op
oin
1
neomycin-polymy-gramicid op
sol 1.75-10000-0.025mg-untmg/ml (Neosporin)
1
neomycin-polymyxindexamethasone ophth oint
0.1% (Maxitrol)
1
neomycin-polymyxindexamethasone ophth susp
0.1% (Maxitrol)
1
NEOMYCIN/POLYMYXIN/
HYDROC - neomycin-polymyxinhc ophth susp
1
NEOSPORIN - neomycinpolymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml
3
LOTEMAX - loteprednol etabonate
ophth susp 0.5%
2
ophth gel 0.5%
3
NEVANAC - nepafenac ophth susp
0.1%
2
ophth oint 0.5%
2
OCUFEN - flurbiprofen sodium
ophth soln 0.03%
3
LUMIGAN - bimatoprost ophth soln
0.01%
3
OCUFLOX - ofloxacin ophth soln
0.3%
3
MAXIDEX - dexamethasone ophth
susp 0.1%
2
ofloxacin ophth soln 0.3%
(Ocuflox)
1
MAXITROL - neomycin-polymyxindexamethasone ophth susp 0.1%
3
OMNIPRED - prednisolone acetate
ophth susp 1%
3
MAXITROL - neomycin-polymyxindexamethasone ophth oint 0.1%
3
PATADAY - olopatadine hcl ophth
soln 0.2%
3
•
METIPRANOLOL - metipranolol
ophth soln 0.3%
1
PATANOL - olopatadine hcl ophth
soln 0.1%
3
•
MITOSOL - mitomycin for ophth
soln kit 0.2 mg
3
PAZEO - olopatadine hcl ophth
3
MOXEZA - moxifloxacin hcl ophth
soln 0.5% (base eq) (2 times
daily)
3
phenylephrine hcl ophth soln
10%
1
phenylephrine hcl ophth soln
2.5%
1
PHOSPHOLINE IODIDE echothiophate iodide ophth for
soln 0.125%
2
NAPHAZOLINE HCL - naphazoline 1
hcl ophth soln 0.1%
NATACYN - natamycin ophth susp 2
5%
152
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pilocarpine hcl ophth soln 1%
(Isopto carpine)
1
sulfacetamide sodium ophth
soln 10% (Bleph-10)
1
(Isopto carpine)
1
1
(Isopto carpine)
1
sulfacetamide sodiumprednisolone ophth soln
10-0.23(0.25)%
1
polymyxin b-trimethoprim
ophth soln 10000 unit/ml-0.1%
(Polytrim)
1
SULFACETAMIDE/
PREDNISOLON - sulfacetamide
sodium-prednisolone ophth susp
10-0.2%
POLYTRIM - polymyxin btrimethoprim ophth soln 10000
unit/ml-0.1%
3
tetracaine hcl ophth soln 0.5%
1
1
PRED FORTE - prednisolone
acetate ophth susp 1%
3
timolol maleate ophth gel
forming soln 0.25% (Timopticxe)
PRED MILD - prednisolone acetate 3
ophth susp 0.12%
PRED-G - gentamicin-prednisolone 2
ace ophth susp 0.3-1%
2
PRED-G S.O.P. - gentamicinprednisolone ace ophth oint
0.3-0.6%
prednisolone acetate ophth susp 1
1% (Pred forte)
1
PREDNISOLONE SODIUM
PHOSP - prednisolone sodium
phosphate ophth soln 1%
3
PROLENSA - bromfenac sodium
ophth soln 0.07% (base
equivalent)
1
proparacaine hcl ophth soln
0.5% (Alcaine)
RESCULA - unoprostone isopropyl 3
ophth soln 0.15%
2
RESTASIS - cyclosporine (ophth)
emulsion 0.05%
2
SIMBRINZA - brinzolamidebrimonidine tartrate ophth susp
1-0.2%
1
SULFACETAMIDE SODIUM sulfacetamide sodium ophth oint
10%
• •
•
•
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1
timolol maleate ophth gel
forming soln 0.5% (Timoptic-xe)
1
timolol maleate ophth soln
0.25% (Timoptic)
1
timolol maleate ophth soln 0.5%
(Timoptic)
TIMOPTIC - timolol maleate ophth 3
soln 0.25%
TIMOPTIC - timolol maleate ophth 3
soln 0.5%
3
TIMOPTIC OCUDOSE - timolol
maleate preservative free ophth
soln 0.25%
3
TIMOPTIC OCUDOSE - timolol
maleate preservative free ophth
soln 0.5%
3
TIMOPTIC-XE - timolol maleate
ophth gel forming soln 0.25%
3
TIMOPTIC-XE - timolol maleate
ophth gel forming soln 0.5%
3
TOBRADEX - tobramycindexamethasone ophth susp
0.3-0.1%
3
TOBRADEX - tobramycindexamethasone ophth oint
0.3-0.1%
153
TOBRADEX ST - tobramycindexamethasone ophth susp
0.3-0.05%
3
acetic acid otic soln 2%
1
1
tobramycin ophth soln 0.3%
(Tobrex)
1
ACETIC ACID/ALUMINUM ACET
- acetic acid 2% in aluminum
acetate otic soln
tobramycin-dexamethasone
ophth susp 0.3-0.1% (Tobradex)
antipyrine-benzocaine otic soln
54-14 mg/ml (5.4-1.4%)
1
1
3
ANTIPYRINE/BENZOCAINE antipyrine-benzocaine otic soln
55-14 mg/ml (5.5-1.4%)
1
TOBREX - tobramycin ophth soln
0.3%
TOBREX - tobramycin ophth oint
0.3%
3
3
TRAVATAN Z - travoprost ophth
soln 0.004% (benzalkonium free)
(bak free)
3
AURALGAN - antipyrinebenzocaine otic soln 55-14 mg/
ml (5.5-1.4%)
CETRAXAL - ciprofloxacin hcl otic
3
TRAVOPROST - travoprost ophth
soln 0.004%
1
CIPRO HC - ciprofloxacinhydrocortisone otic susp 0.2-1%
3
trifluridine ophth soln 1%
(Viroptic)
1
2
TRUSOPT - dorzolamide hcl ophth
soln 2%
3
CIPRODEX - ciprofloxacindexamethasone otic susp
0.3-0.1%
1
VEXOL - rimexolone ophth susp
1%
3
CIPROFLOXACIN - ciprofloxacin
hcl otic soln 0.2% (base
equivalent)
VIGAMOX - moxifloxacin hcl ophth
soln 0.5% (base equiv)
2
3
VIROPTIC - trifluridine ophth soln
1%
3
COLY-MYCIN S - neomycincolistin-hc-thonzonium otic susp
3.3-3-10-0.5 mg/ml
3
XALATAN - latanoprost ophth soln
0.005%
3
• •
CORTANE-B AQUEOUS pramoxine-hc-chloroxylenol
aqueous otic soln 10-10-1 mg/ml
3
• •
CORTANE-B-OTIC - pramoxinehc-chloroxylenol otic soln
10-10-1 mg/ml
3
ZIOPTAN - tafluprost ophth soln
0.0015%
ZIRGAN - ganciclovir ophth gel
0.15%
3
CORTISPORIN - neomycinpolymyxin-hc otic soln 1%
3
ZYLET - loteprednol etabonatetobramycin ophth susp 0.5-0.3%
3
3
ZYMAXID - gatifloxacin ophth soln
0.5%
3
CORTISPORIN-TC - neomycincolistin-hc-thonzonium otic susp
3.3-3-10-0.5 mg/ml
DERMOTIC - fluocinolone
acetonide (otic) oil 0.01%
3
fluocinolone acetonide (otic) oil
0.01% (Dermotic)
1
OTIC AGENTS
antipyrine-benzocainepolycosanol otic sol
5.4-1.4-0.0097% (Treagan otic)
154
1
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hydrocortisone w/ acetic acid
otic soln 1-2% (Vosol hc)
1
MYOXIN - benzocainechloroxylenol-hc otic soln
15-1-10 mg/ml
3
neomycin-polymyxin-hc otic
soln 1% (Cortisporin)
1
neomycin-polymyxin-hc otic
susp 3.5 mg/ml-10000 unit/
ml-1%
1
ofloxacin otic soln 0.3%
1
OTICIN HC NR - pramoxine-hcchloroxylenol otic soln 10-10-1
mg/ml
DEBACTEROL - sulfuric acidsulfonated phenolics soln
30-50%
3
EVOXAC - cevimeline hcl cap 30
mg
3
FLUORIDEX DAILY DEFENSE S sodium fluoride-potassium nitrate
gel 1.1-5%
A
GEL-KAM - stannous fluoride gel
0.4%
A
A
3
GEL-KAM ORAL CARE RINSE stannous fluoride conc 0.63%
3
OTOZIN - antipyrine-benzocaineglycerin-zinc ace otic liqd
5.4-1-2-1%
3
GELCLAIR - povidone-sodium
hyaluronate-glycyrrhetinic acid
gel
GELX - oral wound care products gel
3
PINNACAINE OTIC - benzocaine
otic soln 20%
3
lidocaine hcl viscous soln 2%
1
PRAMOTIC - pramoxinechloroxylenol otic liquid 1-0.1%
LISTERINE ESSENTIAL CARE sod monofluorophosph-eucalmen-methyl sal-thymol gel 0.76%
A
3
pramoxine-chloroxylenol otic
liquid 1-0.1% (Pramotic)
1
A
pramoxine-hc-chloroxylenol otic
soln 10-10-1 mg/ml (Cortane-botic)
1
LISTERINE ESSENTIAL CARE sod monofluorophos-eucal-menmethyl sal-thymol paste 0.76%
LISTERINE RESTORING - sodium
fluoride rinse 0.0221% (0.01% f)
A
TREAGAN OTIC - antipyrinebenzocaine-polycosanol otic sol
5.4-1.4-0.0097%
3
LISTERINE SMART RINSE sodium fluoride rinse 0.0221%
(0.01% f)
A
LISTERINE SMART RINSE ANT sodium fluoride rinse 0.02%
A
LISTERINE TOOTH DEFENSE sodium fluoride rinse 0.0221%
(0.01% f)
A
LISTERINE TOTAL CARE sodium fluoride rinse 0.0221%
(0.01% f)
A
LISTERINE TOTAL CARE PLUS
- sodium fluoride rinse 0.0221%
(0.01% f)
A
MOUTH/THROAT/DENTAL AGENTS
ACT TOTAL CARE DRY MOUTH - A
sodium fluoride rinse 0.02%
1
benzocaine dental soln 20%
cevimeline hcl cap 30 mg
(Evoxac)
1
chlorhexidine gluconate soln
0.12% (Peridex)
1
clotrimazole troche 10 mg
1
COLGATE DRY MOUTH RELIEF
- sodium fluoride mouthwash 2.1
mg/10ml
A
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
155
LISTERINE TOTAL CARE ZERO sodium fluoride rinse 0.02%
A
PREVIDENT 5000 BOOSTER sodium fluoride paste 1.1%
A
LISTERINE WHITENING/RESTO
- sodium fluoride rinse 0.0221%
(0.01% f)
A
PREVIDENT 5000 BOOSTER PL sodium fluoride paste 1.1%
A
MUCOTROL - oral wound care
products - wafer
PREVIDENT 5000 DRY MOUTH sodium fluoride gel 1.1% (0.5% f)
A
3
NAFRINSE DAILY/ACIDULATED sodium fluoride-phosphoric acid
for soln 1 mg/5ml (f equiv)
A
NAFRINSE DAILY/NEUTRAL sodium fluoride for soln rinse
0.05%
A
NAFRINSE WEEKLY - sodium
fluoride for soln rinse 0.2%
A
nystatin susp 100000 unit/ml
1
OMNI GEL - stannous fluoride gel
0.4%
A
ORAFATE - sucralfate-malate
paste 10%
3
ORAMAGICRX - oral wound care
products - for susp rinse
3
ORAVIG - miconazole buccal tab
50 mg (mouth-throat)
3
PERIDEX - chlorhexidine
gluconate soln 0.12%
3
PHOS FLUR - sodium fluoride
rinse 0.044%
A
PHOS-FLUR ORTHO DEFENSE sodium fluoride rinse 0.044%
A
pilocarpine hcl tab 5 mg
(Salagen)
1
pilocarpine hcl tab 7.5 mg
(Salagen)
1
PREVIDENT - sodium fluoride
rinse 0.2%
A
PREVIDENT - sodium fluoride gel
1.1% (0.5% f)
A
PREVIDENT FLUORIDE - sodium
fluoride gel 1.1% (0.5% f)
A
156
PREVIDENT 5000 ENAMEL PRO - A
sodium fluoride-potassium nitrate
paste 1.1-5%
PREVIDENT 5000 PLUS - sodium A
fluoride cream 1.1%
A
PREVIDENT 5000 SENSITIVE sodium fluoride-potassium nitrate
paste 1.1-5%
3
PROTHELIAL - sucralfate-malate
paste 10%
A
REACH KIDS - sodium fluoride
paste 0.15%
A
REMBRANDT CANKER SORE sodium fluoride paste 0.243%
A
REMBRANDT DEEPLY
WHITE+PE - sodium
monofluorophosphate paste
0.884%
A
REMBRANDT INTENSE STAIN sodium fluoride paste 0.243%
A
REMBRANDT WHITENING sodium fluoride rinse 0.02%
3
SALAGEN - pilocarpine hcl tab 5
mg
SALAGEN - pilocarpine hcl tab 7.5 3
mg
3
SALICEPT - oral wound care
products - for susp rinse
A
sodium fluoride cream 1.1%
(Prevident 5000 plus)
sodium fluoride gel 1.1% (0.5% f) A
(Prevident fluoride)
A
sodium fluoride paste 1.1%
(Prevident 5000 boost)
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
(0.01% f)
A
A
(Prevident)
ANALPRAM-HC SINGLES hydrocortisone acetate w/
pramoxine rectal cream 2.5-1%
3
A
ANUSOL-HC - hydrocortisone
rectal cream 2.5%
3
sodium fluoride-potassium
nitrate paste 1.1-5% (Prevident
5000 sensi)
A
ANUSOL-HC - hydrocortisone
acetate suppos 25 mg
3
3
stannous fluoride conc 0.63%
(Gel-kam oral care ri)
A
CORTENEMA - hydrocortisone
enema 100 mg/60ml
2
stannous fluoride gel 0.4%
A
CORTIFOAM - hydrocortisone
acetate rectal foam 90 mg/dose
STANNOUS FLUORIDE RINSE stannous fluoride liq 0.1%
3
hydrocortisone acetate suppos
25 mg (Anusol-hc)
1
THERA-FLUR-N - sodium fluoride
gel 1.1% (0.5% f)
A
hydrocortisone acetate suppos
30 mg (Proctocort)
1
triamcinolone acetonide dental
paste 0.1%
1
hydrocortisone acetate w/
pramoxine rectal cream 1-1%
(Analpram-hc)
1
hydrocortisone acetate w/
pramoxine rectal cream 2.5-1%
(Analpram-hc)
1
hydrocortisone enema
100 mg/60ml (Cortenema)
1
hydrocortisone rectal cream 1%
(Proctocort)
1
hydrocortisone rectal cream
2.5% (Anusol-hc)
1
ANORECTAL AGENTS
hc-pramoxine emol cream
2.5-1% & pramoxine wipe 1%
kit (Analpram e)
1
ANALPRAM ADVANCED - hcpramoxine cr & diet manage prod
tab & cleans wipe kit
3
ANALPRAM E - hc-pramoxine
emol cream 2.5-1% & pramoxine
wipe 1% kit
3
ANALPRAM-HC - hydrocortisone
acetate w/ pramoxine rectal
cream 1-1%
3
LIDOCAINE HCL-HYDROCORTIS
- lidocaine-hydrocortisone
acetate rectal gel 2.8-0.55%
1
cream 2.5-1%
3
lidocaine-hydrocortisone acetate
rectal cream kit 2-2%
1
1
acetate w/ pramoxine rectal lotn
2.5-1%
2
rectal cream kit 3-0.5%
rectal cream kit 3-1%
1
ANALPRAM-HC SINGLES hydrocortisone acetate w/
pramoxine rectal cream 1-1%
3
rectal cream 3-0.5%
1
rectal gel kit 3-2.5%
1
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
157
1
acitretin cap 25 mg (Soriatane)
1
ACLOVATE - alclometasone
dipropionate cream 0.05%
3
acyclovir oint 5% (Zovirax)
1
ACZONE - dapsone gel 5%
3
ADAPALENE - adapalene lotion
0.1%
3
•
•
•
•
PROCTOCORT - hydrocortisone
rectal cream 1%
3
PROCTOCORT - hydrocortisone
acetate suppos 30 mg
3
PROCTOFOAM HC hydrocortisone acetate w/
pramoxine rectal foam 1-1%
2
RECTIV - nitroglycerin oint 0.4%
3
adapalene cream 0.1% (Differin)
1
UCERIS - budesonide rectal foam
2 mg/act
3
adapalene gel 0.1% (Differin)
1
adapalene gel 0.3% (Differin)
1
3
nystatin topical powder
1
salicylic acid cream 6% &
cleanser liqd kit (Salex cream)
1
ADAZIN - benzo-capsaicinlido-methyl salicylate cream
2-0.035-2-10%
3
salicylic acid lotion 6% &
cleanser liqd kit (Salex lotion)
1
ALA QUIN - clioquinol-hc cream
3-0.5%
3
scar treatment products - gel
1
ALA SCALP - hydrocortisone lotion
2%
sulfacetamide sod-sulfur wash
9-4.5% & skin cleanser kit
(Sumadan kit)
1
alclometasone dipropionate
cream 0.05% (Aclovate)
1
1
sulfacetamide sod-sulfur
wash 9-4.5% & sunscreen kit
(Sumadan xlt)
1
alclometasone dipropionate oint
0.05%
3
ABSORICA - isotretinoin cap 10
mg
3
ALCORTIN A - iodoquinolhydrocortisone-aloe
polysaccharide gel 1-2-1%
ALDARA - imiquimod cream 5%
3
mg
3
•
ALOQUIN - iodoquinol-aloe
polysaccharides gel 1.25-1%
3
mg
3
•
ALTABAX - retapamulin oint 1%
3
mg
•
ALUVEA - urea cream 39%
3
3
1
mg
3
•
AMCINONIDE - amcinonide cream
0.1%
1
mg
3
•
AMCINONIDE - amcinonide lotion
0.1%
1
ACANYA - clindamycin phosphatebenzoyl peroxide gel 1.2-2.5%
3
AMCINONIDE - amcinonide oint
0.1%
ANACAINE - benzocaine oint 10%
3
158
•
•
•
•
•
•
Specialty
acitretin cap 17.5 mg (Soriatane)
Quantity Limits
1
3
"Smart" PA
acitretin cap 10 mg (Soriatane)
PROCORT - hydrocortisone
cream 1.85-1.15%
DERMATOLOGICALS
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
BENZAC W WASH - benzoyl
peroxide liq 5%
3
•
BENZACLIN - clindamycin
phosphate-benzoyl peroxide gel
1-5%
3
•
BENZACLIN WITH PUMP clindamycin phosphate-benzoyl
peroxide gel 1-5%
3
•
BENZAMYCIN - benzoyl peroxideerythromycin gel 5-3%
3
•
BENZAMYCINPAK - benzoyl
peroxide-erythromycin gel pack
5-3%
3
•
BENZEFOAM - benzoyl peroxide
foam 5.3%
3
•
BENZEFOAMULTRA - benzoyl
peroxide foam 9.8%
3
•
BENZIQ - benzoyl peroxide gel
5.25 %
3
•
BENZIQ LS - benzoyl peroxide gel
2.75%
3
•
BENZOIN COMPOUND
TINCTURE - benzoin compound
tincture
1
•
BENZOIN TINCTURE - benzoin
tincture
1
3
•
benzoyl peroxide creamy wash
8% &benzoyl peroxide bar 5%
kit (Bpo creamy wash comp)
1
AVAR-E LS - sulfacetamide
sodium w/ sulfur cream 10-2%
3
•
benzoyl peroxide foam 5.3%
(Benzefoam)
1
AVENOVA - hypochlorous acid
cleanser soln 0.01%
3
benzoyl peroxide foam 9.8%
(Benzefoamultra)
1
AZELEX - azelaic acid cream 20%
3
benzoyl peroxide gel 10%
1
BACTROBAN - mupirocin oint 2%
3
benzoyl peroxide gel 5%
1
BACTROBAN - mupirocin calcium
cream 2%
3
benzoyl peroxide liq 10%
1
benzoyl peroxide liq 2.5%
1
BENSAL HP - salicylic acid &
benzoic acid oint 3-6%
3
benzoyl peroxide liq 5.25%
1
3
benzoyl peroxide liq 7%
1
BENZAC AC WASH - benzoyl
peroxide liq 5%
benzoyl peroxide lotion 6%
1
ANODYNERX - capsaicinlidocaine-menthol patch
0.05-2.5-5%
3
ANODYNZ - capsaicin-menthol
disk 0.0375-5%
3
APEXICON E - diflorasone
diacetate emollient base cream
0.05%
3
ARZOL SILVER NITRATE APP silver nitrate-potassium nitrate
applicator 75-25%
3
ATENDIA - lidocaine-menthol
patch 4-3%
3
ATOPICLAIR - dermatological
products misc - cream
3
ATRALIN - tretinoin gel 0.05%
3
AURSTAT ANTI-ITCH HYDROGE
- dermatological products misc gel
3
AURSTAT ANTI-ITCH HYDROGE
- dermatological products misc kit
3
AVAR - sulfacetamide sodium w/
sulfur cleansing pad 9.5-5%
3
•
AVAR LS - sulfacetamide sodium
w/ sulfur cleansing pad 10-2%
3
AVAR LS CLEANSER sulfacetamide sodium w/ sulfur
cleanser 10-2%
•
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
159
3
BPO 9% FOAMING CLOTHS benzoyl peroxide cloth 9%
3
•
calcipotriene cream 0.005%
(Dovonex)
1
calcipotriene oint 0.005%
1
calcipotriene soln 0.005%
(50 mcg/ml)
1
betamethasone dipropionate
augmented cream 0.05%
(Diprolene af)
1
augmented gel 0.05%
1
augmented lotion 0.05%
(Diprolene)
1
augmented oint 0.05%
(Diprolene)
1
calcipotriene-betamethasone
dipropionate oint 0.005-0.064%
(Taclonex)
1
cream 0.05%
1
CALCITRIOL - calcitriol oint 3 mcg/
gm
1
lotion 0.05%
1
3
oint 0.05%
1
CAMPHOMEX - camphorhistamine-menthol liqd spray
4-0.025-10%
3
betamethasone valerate aerosol
foam 0.12% (Luxiq)
1
CAPEX - fluocinolone acetonide
shampoo 0.01%
CARAC - fluorouracil cream 0.5%
2
betamethasone valerate cream
0.1%
1
CEM-UREA - urea soln 45%
3
CENTANY - mupirocin oint 2%
3
betamethasone valerate lotion
0.1%
1
CENTANY AT - mupirocin oint kit
2%
3
betamethasone valerate oint
0.1%
1
3
BIONECT - hyaluronate sodium
spray 0.2%
3
CETACAINE - butambentetracaine-benzocaine aerosol
spray 2-2-14%
3
cream 0.2%
3
CICLODAN CREAM KIT ciclopirox olamine cream 0.77%
(base equiv) & cleanser kit
foam 0.2%
3
CICLODAN SOLUTION KIT ciclopirox solution kit 8%
3
ciclopirox gel 0.77%
1
ciclopirox olamine cream 0.77%
(base equiv)
1
ciclopirox olamine susp 0.77%
(base equiv)
1
ciclopirox shampoo 1% (Loprox
shampoo)
1
1
BPO - benzoyl peroxide gel 4%
3
160
•
Specialty
BPO 3% FOAMING CLOTHS benzoyl peroxide cloth 3%
•
•
Quantity Limits
3
1
BP CLEANSING WASH sulfacetamide sodium-sulfur in
urea emulsion 10-4%
"Smart" PA
BPO - benzoyl peroxide gel 8%
benzoyl peroxideerythromycin gel 5-3%
(Benzamycin)
BIONECT - hyaluronate sodium gel 3
0.2%
BORIC ACID - boric acid granules 1
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
ciclopirox solution kit 8%
(Ciclodan solution ki)
1
clindamycin phosphate soln 1%
(Cleocin-t)
1
ciclopirox solution 8% (Penlac
Nail Lacquer)
1
clindamycin phosphate swab 1%
(Cleocin-t)
1
CICLOPIROX TOPICAL SOLUTI ciclopirox solution 8% & vitamin e
5% topical kit
1
clindamycin phosphate-benzoyl
peroxide gel 1-5% (Benzaclin)
1
clobetasol propionate cream
0.05% (Temovate)
1
CLARAVIS - isotretinoin cap 30 mg 3
3
CLARIFOAM EF - sulfacetamide
sodium w/ sulfur foam 10-5%
3
CLEOCIN-T - clindamycin
phosphate soln 1%
3
phosphate gel 1%
3
phosphate lotion 1%
3
phosphate swab 1%
3
CLEVER CHOICE COMFORT
EZ - methyl salicylate-lidocainementhol patch 2-4-1%
3
CLEVER CHOICE COMFORT
EZ - methyl salicylate-lidocainementhol patch 20-4-1%
3
CLINDACIN ETZ - clindamycin
phosphate swab 1% & cleanser
kit
3
CLINDACIN PAC - clindamycin
phosphate swab 1% & cleanser
kit
3
CLINDAGEL - clindamycin
phosphate gel 1%
1
clindamycin phosph-benzoyl
peroxide (refrig) gel 1.2 (1)-5%
(Duac)
clindamycin phosphate foam 1% 1
(Evoclin)
1
clindamycin phosphate gel 1%
(Cleocin-t)
1
clindamycin phosphate lotion
1% (Cleocin-t)
•
•
•
•
•
•
•
•
•
1
clobetasol propionate emollient
base cream 0.05% (Temovate e)
1
clobetasol propionate emulsion
foam 0.05% (Olux-e)
1
clobetasol propionate foam
0.05% (Olux)
1
clobetasol propionate gel 0.05%
(Temovate)
1
clobetasol propionate lotion
0.05% (Clobex)
clobetasol propionate oint 0.05% 1
(Temovate)
1
clobetasol propionate shampoo
0.05% (Clobex)
1
clobetasol propionate soln
0.05% (Temovate)
1
clobetasol propionate spray
0.05% (Clobex)
3
CLOBEX - clobetasol propionate
spray 0.05%
3
lotion 0.05%
3
shampoo 0.05%
1
CLOCORTOLONE PIVALATE clocortolone pivalate cream 0.1%
1
CLOCORTOLONE PIVALATE
PUM - clocortolone pivalate
cream 0.1%
3
CLODAN KIT - clobetasol
propionate shampoo 0.05% &
cleanser kit
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
•
•
161
clotrimazole soln 1%
1
clotrimazole w/ betamethasone
cream 1-0.05% (Lotrisone)
1
clotrimazole w/ betamethasone
lotion 1-0.05%
1
CNL8 NAIL KIT - ciclopirox soln
8% & lacquer removal pads kit
3
COAL TAR - coal tar soln 20%
1
CONDYLOX - podofilox soln 0.5%
3
CONDYLOX - podofilox gel 0.5%
2
CORDRAN - flurandrenolide cream 3
0.05%
CORDRAN - flurandrenolide lotion 2
0.05%
3
CORDRAN - flurandrenolide oint
0.05%
CORDRAN TAPE - flurandrenolide 2
tape 4 mcg/sqcm
3
CORTALO - hydrocortisone
acetate-aloe vera gel 2%
3
CORTANE-B - hydrocortisonepramoxine-chloroxylenol lot
10-10-1mg/ml
3
CORTISPORIN - neomycinpolymyxin-hc cream 0.5%
3
CORTISPORIN - bacitracinpolymyxin-neomycin hc oint 1%
3
COSENTYX - secukinumab
syringe 150 mg/ml
COSENTYX SENSOREADY PEN - 3
secukinumab subcutaneous soln
auto-injector 150 mg/ml
CUTIVATE - fluticasone propionate 3
cream 0.05%
162
•
•
•
•
•
• •
•
• •
•
DENDRACIN
NEURODENDRAXCIN capsaicin-menthol-methyl
salicylate lotion 0.025-10-30%
3
DERMA-SMOOTHE/FS BODY fluocinolone acetonide oil 0.01%
(body oil)
3
•
DERMA-SMOOTHE/FS BODY
OIL - fluocinolone acetonide oil
0.01% (body oil)
3
•
DERMA-SMOOTHE/FS SCALP fluocinolone acetonide oil 0.01%
(scalp oil)
3
•
DERMA-SMOOTHE/FS SCALP
OI - fluocinolone acetonide oil
0.01% (scalp oil)
3
•
DERMACINRX SILAPAK triamcinolone acet cr 0.1% &
dimeth cr 5% & silicone tape
3
DERMASORB AF - clioquinol-hc
cream 3-0.5% & emollient liqd kit
3
DERMASORB HC - hydrocortisone 3
lot 2% & cleanser liq kit
3
DERMASORB TA - triamcinolone
cream 0.1% & emollient cream
kit
DERMATOP - prednicarbate cream 3
0.1%
3
DERMATOP - prednicarbate oint
0.1%
DESONATE - desonide gel 0.05% 3
desonide cream 0.05%
(Desowen)
•
•
•
1
desonide lotion 0.05% (Desowen) 1
1
desonide oint 0.05% (Desowen)
DESOWEN - desonide cream
0.05%
3
•
Specialty
clotrimazole cream 1%
1
CUTIVATE - fluticasone propionate 3
lotion 0.05%
2
DENAVIR - penciclovir cream 1%
Quantity Limits
•
"Smart" PA
3
Prior Authorization
CLODERM PUMP - clocortolone
pivalate cream 0.1%
Drug Name
Drug Tier
•
Specialty
3
Quantity Limits
Prior Authorization
CLODERM - clocortolone pivalate
cream 0.1%
Drug Name
"Smart" PA
Drug Tier
2015
DRYSOL - aluminum chloride soln
20%
3
DUAC - clindamycin phosphbenzoyl peroxide (refrig) gel 1.2
(1)-5%
3
econazole nitrate cream 1%
1
1
ECOZA - econazole nitrate foam
1%
3
diclofenac sodium (actinic
keratoses) gel 3% (Solaraze)
1
EFUDEX - fluorouracil cream 5%
3
3
diclofenac sodium soln 1.5%
(Pennsaid)
1
ELETONE - dermatological
3
DIFFERIN - adapalene cream
0.1%
3
•
ELETONE TWINPACK dermatological products misc cream
DIFFERIN - adapalene gel 0.1%
3
ELIDEL - pimecrolimus cream 1%
3
DIFFERIN - adapalene gel 0.3%
3
ELIMITE - permethrin cream 5%
3
DIFFERIN - adapalene lotion 0.1%
3
•
•
•
3
•
DIFLORASONE DIACETATE diflorasone diacetate cream
0.05%
1
ELOCON - mometasone furoate
solution 0.1% (lotion)
cream 0.1%
3
•
DIFLORASONE DIACETATE diflorasone diacetate oint 0.05%
1
oint 0.1%
3
•
DIPROLENE - betamethasone
dipropionate augmented lotion
0.05%
3
EMLA - lidocaine-prilocaine cream
2.5-2.5%
3
3
DIPROLENE - betamethasone
dipropionate augmented oint
0.05%
3
EMULSION SB - dermatological
products misc - emulsion
EPICERAM - dermatological
3
DIPROLENE AF - betamethasone
dipropionate augmented cream
0.05%
3
EPIDUO - adapalene-benzoyl
peroxide gel 0.1-2.5%
3
3
EPIFOAM - pramoxine-hc aerosol
foam 1-1%
3
DOVONEX - calcipotriene cream
0.005%
ERTACZO - sertaconazole nitrate
cream 2%
3
ERYGEL - erythromycin gel 2%
3
3
•
DESOXIMETASONE desoximetasone cream 0.05%
1
DESOXIMETASONE desoximetasone oint 0.05%
1
desoximetasone cream 0.25%
(Topicort)
1
desoximetasone gel 0.05%
(Topicort)
1
desoximetasone oint 0.25%
(Topicort)
•
•
•
•
Specialty
•
DESOWEN - desonide oint 0.05%
Quantity Limits
Prior Authorization
3
•
Drug Name
"Smart" PA
Drug Tier
DRITHO-CREME HP - anthralin
cream 1%
3
Specialty
•
DESOWEN - desonide lotion
0.05%
Quantity Limits
•
"Smart" PA
3
Drug Tier
DOXYCYCLINE - doxycycline
(rosacea) cap delayed release 40
mg
Drug Name
Prior Authorization
2015
•
•
•
•
163
ETHYL CHLORIDE/FINE PINPO ethyl chloride aerosol spray
ETHYL CHLORIDE/FINE STREA ethyl chloride aerosol spray
1
fluocinonide cream 0.05%
1
1
fluocinonide cream 0.1% (Vanos)
1
1
1
fluocinonide emulsified base
cream 0.05%
fluocinonide gel 0.05%
1
fluocinonide oint 0.05%
1
fluocinonide soln 0.05%
1
FLUORAC - fluorouracil-diclofenac
sodium cream 5-1%
3
FLUOROPLEX - fluorouracil cream
1%
3
ETHYL CHLORIDE/MEDIUM JET - 1
ethyl chloride aerosol spray
1
ETHYL CHLORIDE/MEDIUM STR
- ethyl chloride aerosol spray
1
ETHYL CHLORIDE/MIST - ethyl
chloride aerosol spray
3
EURAX - crotamiton cream 10%
3
FLUOROURACIL - fluorouracil
cream 0.5%
3
EURAX - crotamiton lotion 10%
EVOCLIN - clindamycin phosphate
foam 1%
3
fluorouracil cream 5% (Efudex)
1
fluorouracil soln 2%
1
EXELDERM - sulconazole nitrate
solution 1%
3
fluorouracil soln 5%
1
3
fluticasone propionate cream
0.05% (Cutivate)
1
EXELDERM - sulconazole nitrate
cream 1%
3
fluticasone propionate lotion
0.05% (Cutivate)
1
EXTINA - ketoconazole foam 2%
FABIOR - tazarotene (acne) foam
0.1%
3
fluticasone propionate oint
0.005% (Cutivate)
1
FINACEA - azelaic acid gel 15%
3
FLECTOR - diclofenac epolamine
patch 1.3%
GEBAUERS PAIN EASE
- pentafluoropropanetetrafluoroethane aero spray
3
3
fluocinolone acetonide cream
0.01%
1
3
fluocinolone acetonide cream
0.025% (Synalar)
1
GEBAUERS SPRAY AND
STRETC - pentafluoropropanetetrafluoroethane aero spray
3
fluocinolone acetonide oil 0.01%
(body oil) (Derma-smoothe/fs
bod)
1
GENADUR - dermatological
products misc - liquid
GENADUR KIT - dermatological
products misc topical/oral - kit
3
fluocinolone acetonide oil 0.01%
(scalp oil) (Derma-smoothe/fs
sca)
1
GENTAMICIN SULFATE gentamicin sulfate cream 0.1%
1
164
•
•
• •
Specialty
1
fluocinolone acetonide soln
0.01% (Synalar)
Quantity Limits
ETHYL CHLORIDE - ethyl chloride
aerosol spray
1
"Smart" PA
1
fluocinolone acetonide oint
0.025% (Synalar)
Prior Authorization
erythromycin soln 2%
Drug Name
Drug Tier
1
Specialty
erythromycin pads 2%
Quantity Limits
1
"Smart" PA
erythromycin gel 2% (Erygel)
Prior Authorization
Drug Name
Drug Tier
2015
GENTAMICIN SULFATE gentamicin sulfate oint 0.1%
1
hydrocortisone lotion 2.5%
1
GORDOFILM - salicylic & lactic
acids soln 16.7-16.7%
hydrocortisone lotion 2% (Ala
scalp)
1
3
hydrocortisone oint 1%
1
GORDONS UREA - urea ointment
40%
3
hydrocortisone oint 2.5%
1
3
hydrocortisone valerate cream
0.2%
1
HALAC - halobetasol prop oint
0.05% & ammonium lactate lot
12% kit
1
halobetasol propionate cream
0.05% (Ultravate)
1
hydrocortisone valerate oint
0.2% (Westcort)
3
halobetasol propionate oint
0.05% (Ultravate)
1
HYLASE WOUND - hyaluronate
sodium gel
3
HALOG - halcinonide cream 0.1%
3
HYLATOPIC - emollient - aerosol
foam
HYLATOPIC PLUS - emollient aerosol foam
3
HALOG - halcinonide oint 0.1%
3
HALOTIN - haloprogin cream 1%
3
3
HPR PLUS - emollient - aerosol
foam
3
HYLATOPIC PLUS dermatological products misc cream
3
HPR - emollient - aerosol foam
3
HPR PLUS - dermatological
3
HYLIRA - hyaluronate sodium
(emollient) gel 0.2%
3
HPR PLUS HYDROGEL KIT dermatological products misc - kit
3
HYLIRA - hyaluronate sodium
(emollient) lotion 0.1%
imiquimod cream 5% (Aldara)
1
hyaluronate sodium
(emollient) gel 0.2% (Hylira)
1
INOVA - benzoyl peroxide pad 4%
& vitamin e topical 5% kit
3
•
HYDRO 35 - urea in lactic acid
vehicle foam 35%
3
INOVA - benzoyl peroxide pad 8%
& vitamin e topical 5% kit
3
•
HYDRO 40 FOAM - urea foam
40%
3
3
•
hydrocortisone butyrate cream
0.1% (Locoid)
1
INOVA 4/1 ACNE CONTROL TH benzoyl perox pad 4% & salicylic
ac pad 1% & vit e 5% kit
3
•
hydrocortisone butyrate
hydrophilic lipo base cream
0.1% (Locoid lipocream)
1
INOVA 8/2 ACNE CONTROL TH benzoyl perox pad 8% & salicylic
ac pad 2% & vit e 5% kit
iodoquinol-hc cream 1%
1
hydrocortisone butyrate oint
0.1% (Locoid)
1
1
hydrocortisone butyrate soln
0.1% (Locoid)
1
iodoquinol-hydrocortisone in
aloe vehicle cream 1-1.9%
(Vytone)
isotretinoin cap 10 mg
1
hydrocortisone cream 1%
1
1
hydrocortisone cream 2.5%
1
1
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
165
•
•
3
3
LAVOCLEN-8 CREAMY WASH benzoyl peroxide liq 8%
3
KERAFOAM - urea foam 30%
3
LIDOCAINE AND TETRACAINE lidocaine-tetracaine cream 7-7%
KERAFOAM 42 - urea foam 42%
3
1
KERALAC - urea cream 47%
3
LIDOCAINE HCL - lidocaine hcl
lotion 3%
3
lidocaine hcl cream 3%
1
KERALYT - salicylic acid gel 6%
3
lidocaine hcl gel 2%
1
KERALYT SCALP - salicylic acid
shampoo 6% & salicylic acid gel
6% kit
lidocaine hcl soln 4% (Xylocaine)
1
lidocaine oint 5%
1
KERYDIN - tavaborole soln 5%
3
lidocaine patch 5% (Lidoderm)
1
ketoconazole cream 2%
1
1
ketoconazole foam 2% (Extina)
1
lidocaine-prilocaine cream
2.5-2.5% (Emla)
ketoconazole shampoo 2%
(Nizoral)
1
LIDOCAINE/PRILOCAINE lidocaine-prilocaine kit 2.5-2.5%
1
KETODAN KIT - ketoconazole
foam 2% & cleanser kit
3
LIDOCIN - lidocaine hcl gel 3%
3
LIDODERM - lidocaine patch 5%
3
KLARON - sulfacetamide sodium
lotion 10% (acne)
3
LIDOPIN - lidocaine hcl cream
3.25%
3
LAC-HYDRIN - lactic acid
(ammonium lactate) cream 12%
3
LIDORX - lidocaine hcl gel 3%
3
LIDOVEX - lidocaine cream 3.75%
3
LAC-HYDRIN - lactic acid
(ammonium lactate) lotion 12%
3
LIDOVIN - lidocaine hcl cream
3.95%
3
lactic acid (ammonium lactate)
cream 12% (Lac-hydrin)
1
LIDOZOL - lidocaine hcl cream
3.75%
3
lotion 10%
1
lindane lotion 1%
1
1
lindane shampoo 1%
1
lotion 12% (Lac-hydrin)
3
•
lactic acid w/ vitamin e cream
10%-3500 unit/30gm
1
LOCOID - hydrocortisone butyrate
soln 0.1%
3
•
LAMISIL SPRAY - terbinafine hcl
soln 1%
3
cream 0.1%
3
LATRIX XM - urea in zinc
undecylenate-lactic acid vehicle
emulsion 45%
3
lotion 0.1%
oint 0.1%
3
•
LAVOCLEN-4 CREAMY WASH benzoyl peroxide liq 4%
3
LOCOID LIPOCREAM hydrocortisone butyrate
hydrophilic lipo base cream 0.1%
3
•
166
•
•
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
KENALOG - triamcinolone
acetonide aerosol soln
Quantity Limits
3
"Smart" PA
JUBLIA - efinaconazole soln 10%
Prior Authorization
Drug Name
Drug Tier
2015
LOPROX SHAMPOO - ciclopirox
shampoo 1%
3
LOTRISONE - clotrimazole w/
betamethasone cream 1-0.05%
•
METROLOTION - metronidazole
lotion 0.75%
3
3
metronidazole cream 0.75%
(Metrocream)
1
LOUTREX - antiseborrheic
3
metronidazole gel 0.75%
1
metronidazole gel 1% (Metrogel)
1
LUXIQ - betamethasone valerate
aerosol foam 0.12%
3
metronidazole lotion 0.75%
(Metrolotion)
1
LUZU - luliconazole cream 1%
3
LYCELLE - nit remover - gel
3
MAL PATCH - lidocaine-menthol
patch 4-5%
3
malathion lotion 0.5% (Ovide)
1
MB HYDROGEL - dermatological
products misc - kit
3
MEDI-DERM-RX - capsaicinmenthol-methyl salicylate cream
0.035-5-20%
3
MEDI-DERM/L-RX - lidocainecapsaicin-menthol-methyl sal
cream 2-0.035-5-20%
3
MEDROX-RX - capsaicin-mentholmethyl salicylate oint 0.05-7-20%
3
MEGRIX - capsaicin-menthol disk
0.0375-5%
3
MENTAX - butenafine hcl cream
1%
3
MENTHOCIN PATCH/LIDOCAINE
- lidocaine-capsaicin-men-methyl
sal patch 0.5-0.0375-5-20%
3
MENTHOLIX - lidocaine-menthol
liquid spray 4-1%
3
methoxsalen rapid cap 10 mg
(Oxsoralen ultra)
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
METVIXIA - methyl aminolevulinate 3
hcl cream 16.8% (base equiv)
3
MIGRYL - capsaicin-menthol disk
0.0375-5%
mometasone furoate cream 0.1% 1
(Elocon)
1
mometasone furoate oint 0.1%
(Elocon)
1
mometasone furoate solution
0.1% (lotion) (Elocon)
1
mupirocin calcium cream 2%
(Bactroban)
1
mupirocin oint 2% (Bactroban)
naftifine hcl cream 1% (Naftin)
1
NAFTIN - naftifine hcl cream 1%
3
NAFTIN - naftifine hcl cream 2%
3
NAFTIN - naftifine hcl gel 1%
3
NAFTIN - naftifine hcl gel 2%
3
NATROBA - spinosad susp 0.9%
3
NEO-SYNALAR - neomycinfluocinolone cream 0.35-0.025%
3
3
1
NEO-SYNALAR KIT - neomycinfluocinolone cream 0.35-0.025%
& emollient cr kit
1
NEOSALUS - emollient - aerosol
foam
3
METHYL SALICYLATE - methyl
salicylate liquid
3
3
•
NEOSALUS - emollient - lotion
METROCREAM - metronidazole
cream 0.75%
3
METROGEL - metronidazole gel
1%
3
•
NEOSALUS - dermatological
NEOSALUS CP - dermatological
3
167
3
•
OVACE PLUS WASH sulfacetamide sodium liquid 10%
3
•
OVACE PLUS WASH sulfacetamide sodium cleansing
gel 10%
3
•
OVACE WASH - sulfacetamide
sodium liquid 10%
3
•
OVIDE - malathion lotion 0.5%
3
OXISTAT - oxiconazole nitrate
cream 1%
3
OXISTAT - oxiconazole nitrate
lotion 1%
3
OXSORALEN - methoxsalen lotion
1%
3
OXSORALEN ULTRA methoxsalen rapid cap 10 mg
3
PAIN RELIEF PATCH - lidocainementhol patch 5-1%
3
nystatin oint 100000 unit/gm
PANDEL - hydrocortisone
probutate cream 0.1%
3
1
nystatin-triamcinolone cream
100000-0.1 unit/gm-%
1
PANRETIN - alitretinoin gel 0.1%
3
nystatin-triamcinolone oint
100000-0.1 unit/gm-%
1
3
NIVATOPIC PLUS - dermatological 3
NIZORAL - ketoconazole shampoo 3
2%
NORITATE - metronidazole cream 3
1%
NOVACORT - hydrocortisone ace- 3
pramoxine-aloe polysacch gel
2-1-1%
NUCORT - hydrocortisone acetate 3
lotion 2%
NUOX - benzoyl peroxide-sulfur gel 3
6-3%
NUVAIL - dermatological products 3
misc - solution
3
NUZON - hydrocortisone acetatealoe vera gel 2%
1
nystatin cream 100000 unit/gm
OLUX - clobetasol propionate foam 3
0.05%
3
OLUX-E - clobetasol propionate
emulsion foam 0.05%
3
ONEXTON - clindamycin
phosphate-benzoyl peroxide gel
1.2-3.75%
3
ORACEA - doxycycline (rosacea)
cap delayed release 40 mg
3
OVACE PLUS - sulfacetamide
sodium cream 10%
3
sodium lotion 9.8%
168
•
•
•
•
•
•
•
•
PEDIADERM AF COMPLETE KIT - 3
nystatin cream 100000 unit/gm &
diaper rash cream kit
PEDIADERM HC - hydrocortisone 3
lot 2% & emollient cream kit
3
PEDIADERM TA - triamcinolone
cream 0.1% & emollient cream
kit
3
PENLAC NAIL LACQUER ciclopirox solution 8%
3
PENNSAID - diclofenac sodium
soln 1.5%
3
PENNSAID - diclofenac sodium
soln 2%
PERMAVAN EXTERNAL PATCH - 3
lidocaine-dm-trolamine salicylate
patch 4-4-10%
•
•
• •
• •
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Tier
Drug Name
sodium shampoo 10%
NEUAC KIT - clindamycin-benzoyl
perox gel 1.2-5% & moisturizer cr
kit
•
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
1
3
pramoxine-hc cream 1-2.5%
(Pramosone)
1
PICATO - ingenol mebutate gel
0.015%
3
PRASCION RA WITH SUNSCREE
- sulfacetamide sodium-sulfursunscreen cream 10-5%
1
PICATO - ingenol mebutate gel
0.05%
3
prednicarbate cream 0.1%
(Dermatop)
1
PLEXION - sulfacetamide sodium
w/ sulfur cream 9.8-4.8%
3
•
prednicarbate oint 0.1%
(Dermatop)
3
PLEXION - sulfacetamide sodium
w/ sulfur lotion 9.8-4.8%
3
•
PRESERA - emollient - aerosol
foam
3
PLEXION CLEANSER sulfacetamide sodium w/ sulfur
cleanser 9.8-4.8%
3
•
PROMISEB - antiseborrheic
PROMISEB COMPLETE antiseborrheic products misc - kit
3
PLEXION CLEANSING CLOTHS
- sulfacetamide sodium w/ sulfur
cleansing cloth 9.8-4.8%
3
PLIAGLIS - lidocaine-tetracaine
cream 7-7%
3
PODOCON 25 IN BENZOIN TIN podophyllum resin soln 25%
3
podofilox soln 0.5% (Condylox)
1
PR CREAM - dermatological
products misc - kit
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
PHARMACIST CHOICE TSX PAT
- methyl salicylate-lidocainementhol patch 2-4-1%
Quantity Limits
1
"Smart" PA
permethrin cream 5% (Elimite)
Prior Authorization
Drug Name
Drug Tier
2015
PROTOPIC - tacrolimus oint 0.03% 3
PROTOPIC - tacrolimus oint 0.1% 3
PROZENA - lidocaine patch 4%
3
PRUCLAIR - dermatological
3
PRUDOXIN - doxepin hcl cream
5%
3
3
PRUMYX - dermatological
3
3
PYROGALLIC ACID - pyrogallolchlorobutanol oint 25-2%
1
PRAMOSONE - pramoxine-hc
cream 1-1%
3
QUTENZA - capsaicin patch 8% &
cleansing gel kit
3
cream 1-2.5%
3
REGENECARE - lidocaine hclcollagen-aloe vera gel 2%
3
lotion 1-1%
3
REGRANEX - becaplermin gel
0.01%
2
lotion 1-2.5%
3
RELYYKS - lidocaine-menthol
patch 4-5%
3
PRAMOSONE - pramoxine-hc oint
1-1%
3
REMAXAZON EXTERNAL PATCH
- lidocaine-capsaicin-chondroitinglucos patch 4-0.0285-3-5%
3
PRAMOSONE - pramoxine-hc oint
1-2.5%
PRAMOSONE E - pramoxine-hc
emollient base cream 1-2.5%
3
RENOVO LIDO 5 - lidocainecapsaicin cream 5-0.05%
3
pramoxine hcl gel 1%
1
•
169
1
salicylic acid foam 6% (Salvax)
1
salicylic acid gel 6% (Keralyt)
1
SALICYLIC ACID IN AMMONIU
- salicylic acid in ammonium
lactate vehicle foam 6%
1
salicylic acid lotion 6%
1
RETIN-A - tretinoin cream 0.025%
3
3
RETIN-A - tretinoin gel 0.01%
3
RETIN-A - tretinoin gel 0.025%
3
RETIN-A MICRO - tretinoin
microsphere gel 0.04%
3
RETIN-A MICRO - tretinoin
3
•
salicylic acid shampoo 6%
(Salex)
1
RETIN-A MICRO PUMP - tretinoin
3
•
3
3
•
SALKERA - salicylic acid in
ammonium lactate vehicle foam
6%
SALVAX - salicylic acid foam 6%
3
3
RIAX - benzoyl peroxide foam
5.5%
3
•
RIAX - benzoyl peroxide foam
9.5%
3
•
ROSADAN KIT - metronidazole gel
0.75% w/ cleanser kit
3
•
ROSADAN KIT - metronidazole
cream 0.75% w/ cleanser kit
3
•
ROSANIL - sulfacetamide sodsulfur emul 10-5% & skin
cleanser kit
3
ROSULA - sulfacetamide sodium
w/ sulfur wash 10-4.5%
3
SALEX - salicylic acid shampoo
6%
3
SALEX CREAM - salicylic acid
cream 6% & cleanser liqd kit
3
SALEX LOTION - salicylic acid
lotion 6% & cleanser liqd kit
3
SALICYLIC ACID - salicylic acid
soln 26%
1
SALICYLIC ACID - salicylic acid
film-forming soln 28.5%
3
170
•
•
•
•
•
•
•
•
•
SALVAX DUO PLUS - salicylic acid 3
foam 6% & urea in lactic acid
foam 35% kit
2
SANTYL - collagenase oint 250
unit/gm
3
SCALACORT DK - hc lot 2% &
sal acid-sulfur shampoo 2-2% &
shampoo kit
1
selenium sulfide lotion 2.5%
SELRX - selenium sulfidepyrithione zinc in urea shampoo
2.3%
3
SILVADENE - silver sulfadiazine
cream 1%
3
SILVER NITRATE - silver nitrate
soln 0.5%
1
soln 10%
1
soln 25%
1
soln 50%
1
oint 10%
1
Specialty
salicylic acid film forming liquid
27.5% (Virasal)
3
Quantity Limits
1
3
"Smart" PA
salicylic acid cream 6%
RENUU NL - allantoin-petrolatum
patch 2-30%
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
sulfacetamide sodium lotion
10% (acne) (Klaron)
1
3
SKLICE - ivermectin lotion 0.5%
sulfacetamide sodium shampoo
10% (Ovace plus)
1
3
SODIUM SULFACETAMIDE
WASH - sulfacetamide sodium in
bakuchiol vehicle wash 10%
3
sulfacetamide sodium w/
sulfur cleanser 10-2% (Avar ls
cleanser)
1
SODIUM SULFACETAMIDE/SULF
- sulfacetamide sodium w/ sulfur
susp 10-5%
1
•
sulfacetamide sodium w/ sulfur
cleanser 9.8-4.8% (Plexion
cleanser)
1
- sulfacetamide sodium-sulfur in
urea emulsion 10-5%
1
•
cleansing cloth 10-5%
1
- sulfacetamide sodium-sulfur in
urea gel 10-5%
•
cleansing pad 10-4% (Sumaxin)
1
1
cream 10-2% (Avar-e ls)
1
sodium thiosulfate-salicylic acid
lotion 25-1%
1
cream 10-5%
1
SOLAICE - capsaicin-menthol
topical patch 0.05-5%
3
cream 9.8-4.8% (Plexion)
1
SOLARAZE - diclofenac sodium
(actinic keratoses) gel 3%
3
emulsion 10-1%
1
SOOLANTRA - ivermectin cream
1%
3
emulsion 10-5%
1
SORIATANE - acitretin cap 10 mg
3
SORIATANE - acitretin cap 17.5
mg
foam 10-5% (Clarifoam ef)
1
3
SORIATANE - acitretin cap 25 mg
lotion 10-5%
1
3
SORILUX - calcipotriene foam
0.005%
3
lotion 9.8-4.8% (Plexion)
1
SPINOSAD - spinosad susp 0.9%
1
1
STELARA - ustekinumab soln
prefilled syringe 45 mg/0.5ml
3
susp 8-4% (Sumaxin ts)
wash 9-4.5% (Sumadan wash)
1
3
SINELEE - capsaicin-menthol
topical patch 0.05-5%
•
• •
Specialty
1
SILVERA PAIN RELIEF capsaicin-lidocaine-menthol
patch 0.0375-1-5%
Quantity Limits
Prior Authorization
sulfacetamide sodium liquid 10%
(Ovace wash)
silver sulfadiazine cream 1%
(Silvadene)
Drug Name
"Smart" PA
Drug Tier
1
1
Specialty
sulfacetamide sodium
cleansing gel 10% (Ovace plus
wash)
1
Quantity Limits
•
silver nitrate-potassium nitrate
applicator 75-25% (Arzol silver
nitrate)
"Smart" PA
3
Drug Tier
STELARA - ustekinumab soln
prefilled syringe 90 mg/ml
Drug Name
Prior Authorization
2015
• •
171
wash 9-4% (Sumaxin wash)
1
SULFAMYLON - mafenide acetate
packet for topical soln 5% (50
gm)
3
SULFAMYLON - mafenide acetate
cream 85 mg/gm
SYNALAR TS - fluocinolone
acetonide soln 0.01% & cleanser
kit
3
SYNERA - lidocaine-tetracaine
topical patch 70-70 mg
3
3
SYNVEXIA TC - lidocaine-menthol
cream 4-1%
3
SULFOAM - sulfur shampoo 2%
3
3
SULFURATED LIME - sulfurated
lime solution
1
TACLONEX - calcipotrienebetamethasone dipropionate
susp 0.005-0.064%
SUMADAN KIT - sulfacetamide
sod-sulfur wash 9-4.5% & skin
cleanser kit
3
•
TACLONEX - calcipotrienebetamethasone dipropionate oint
0.005-0.064%
3
SUMADAN WASH - sulfacetamide
sodium w/ sulfur wash 9-4.5%
3
•
tacrolimus oint 0.03% (Protopic)
1
tacrolimus oint 0.1% (Protopic)
1
SUMADAN XLT - sulfacetamide
sod-sulfur wash 9-4.5% &
sunscreen kit
3
TARGRETIN - bexarotene gel 1%
2
2
•
SUMAXIN - sulfacetamide sodium
w/ sulfur cleansing pad 10-4%
3
•
TAZORAC - tazarotene cream
0.05%
2
•
SUMAXIN CP KIT - sulfacetamide
sod-sulfur pad 10-4% & skin
cleanser kit
3
•
TAZORAC - tazarotene cream
0.1%
TAZORAC - tazarotene gel 0.05%
2
TAZORAC - tazarotene gel 0.1%
2
•
•
SUMAXIN TS - sulfacetamide
sodium w/ sulfur susp 8-4%
3
•
TEMOVATE - clobetasol
propionate soln 0.05%
3
•
SUMAXIN WASH - sulfacetamide
sodium w/ sulfur wash 9-4%
3
•
propionate cream 0.05%
3
•
SYNALAR - fluocinolone acetonide
soln 0.01%
3
propionate gel 0.05%
3
•
cream 0.025%
3
propionate oint 0.05%
3
•
oint 0.025%
3
3
•
SYNALAR CREAM KIT fluocinolone cream 0.025%emollient cream kit
3
TEMOVATE E - clobetasol
propionate emollient base cream
0.05%
TERSI FOAM - selenium sulfide
foam 2.25%
3
SYNALAR OINTMENT KIT fluocinolone oint 0.025%emollient cream kit
3
TETRAMEX - tetracaine-mentholcamphor liqd spray 2-1-3%
3
TETRIX - dermatological products
misc - kit
3
172
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
1
3
TRIAMCINOLONE ACETONIDE
- triamcinolone acetonide oint
0.5%
1
TL-CERMIDE - dermatological
3
triamcinolone acetonide aerosol
soln (Kenalog)
1
TOPICORT - desoximetasone
spray 0.25%
3
•
triamcinolone acetonide cream
0.025%
1
cream 0.05%
3
•
0.1%
1
cream 0.25%
3
•
0.5%
1
TOPICORT - desoximetasone gel
0.05%
3
•
triamcinolone acetonide lotion
0.025%
1
TOPICORT - desoximetasone oint
0.05%
3
triamcinolone acetonide lotion
0.1%
1
TOPICORT - desoximetasone oint
0.25%
3
triamcinolone acetonide oint
0.025%
1
TRETIN-X - tretinoin cream
0.075%
3
•
triamcinolone acetonide oint
0.1%
3
TRETIN-X - tretinoin cream
0.025% w/ cleanser & moisturizer
kit
3
•
TRIANEX - triamcinolone
acetonide oint 0.05%
TROPAZONE - emollient - lotion
3
TRETIN-X - tretinoin cream 0.05%
w/ cleanser & moisturizer kit
•
ULESFIA - benzyl alcohol lotion
5%
2
3
3
•
ULTRASAL-ER - salicylic acid filmforming soln 28.5%
3
TRETIN-X - tretinoin cream 0.1%
w/ cleanser & moisturizer kit
tretinoin cream 0.05% (Retin-a)
1
•
1
ULTRAVATE - halobetasol
propionate oint 0.05%
3
tretinoin gel 0.01% (Retin-a)
1
•
1
ULTRAVATE X - halobetasol prop
cream 0.05% & lactic acid cream
10% kit
3
tretinoin gel 0.025% (Retin-a)
tretinoin microsphere gel 0.04%
(Retin-a micro)
1
•
•
•
•
•
•
•
1
ULTRAVATE - halobetasol
propionate cream 0.05%
3
3
•
tretinoin microsphere gel 0.1%
(Retin-a micro)
1
•
ULTRAVATE X - halobetasol prop
oint 0.05% & lactic acid cream
10% kit
UMECTA - urea emulsion 40%
3
TRI-CHLOR - trichloroacetic acid
liqd 80%
3
UMECTA - urea suspension 40%
3
UMECTA NAIL FILM - urea
suspension 40%
3
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
TL TRISEB - antiseborrheic
Drug Name
Drug Tier
•
Specialty
3
Quantity Limits
Prior Authorization
TEXACORT - hydrocortisone soln
2.5%
Drug Name
"Smart" PA
Drug Tier
2015
•
173
UMECTA PD - urea-hyaluronate
sodium emulsion 40-0.3%
3
UMECTA PD - urea-hyaluronate
sodium susp 40-0.3%
3
URAMAXIN - urea cream 45%
3
URAMAXIN - urea gel 45%
3
URAMAXIN - urea lotion 45%
3
URAMAXIN - urea in ammonium
lactate vehicle foam 20%
3
URAMAXIN GT - urea gel 45%
3
urea cream 39% (Aluvea)
1
urea cream 40%
1
urea cream 45% (Uramaxin)
1
urea cream 47% (Keralac)
1
urea cream 50%
1
urea foam 40% (Hydro 40 foam)
1
urea gel 40%
1
urea gel 45% (Uramaxin)
1
urea in lactic acid vehicle foam
35% (Hydro 35)
1
urea in lactic acid-salicylic acid
vehicle susp 50%
1
urea in zinc undecylenate-lactic
acid vehicle emulsion 50%
1
urea lotion 40%
1
urea lotion 45% (Uramaxin)
1
UREA NAIL - urea in zinc
undecylenate-lactic acid vehicle
stick 50%
3
VANOXIDE-HC - benzoyl peroxide- 3
hc lotion 5-0.5%
3
VECTICAL - calcitriol oint 3 mcg/
gm
3
VELMA PAIN RELIEF - methyl
salicylate-lidocaine-menthol
patch 16-4-2%
3
VELTIN - clindamycin phosphatetretinoin gel 1.2-0.025%
VENELEX - balsam peru-castor oil 3
oint
VERDESO - desonide foam 0.05% 3
3
UTOPIC - urea cream 41%
3
VALCHLOR - mechlorethamine hcl
gel 0.016% (base equivalent)
2
VANOS - fluocinonide cream 0.1%
3
174
VEREGEN - sinecatechins oint
15%
3
VEXA - allantoin-lidocainepetrolatum patch 2-4-30%
3
VIRASAL - salicylic acid film
forming liquid 27.5%
3
VOLTAREN - diclofenac sodium
gel 1%
3
VUSION - miconazole-zinc
oxide-white petrolatum oint
0.25-15-81.35%
3
VYTONE - iodoquinolhydrocortisone in aloe vehicle
cream 1-1.9%
3
WESTCORT - hydrocortisone
valerate oint 0.2%
3
XCLAIR - dermatological products
misc - cream
3
•
•
•
XOLEGEL COREPAK ketoconazole gel 2% &
hydrocortisone gel 1% kit
3
XOLEGEL DUO/HEAD & SHOULD
- ketoconazole gel 2% &
pyrithione zinc shampoo 1% kit
3
•
•
• •
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
•
XERESE - acyclovir-hydrocortisone 3
cream 5-1%
3
XOLEGEL - ketoconazole gel 2%
UREA NAIL KIT - urea susp 40% & 3
hyaluronate sodium gel 0.2% kit
1
urea suspension 40% (Umecta)
UREVAZ - urea cream 44%
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
XOLEGEL DUO/XOLEX ketoconazole gel 2% & pyrithione
zinc shampoo 1% kit
3
CHLORHEXIDINE GLUCONATE
- chlorhexidine gluconate soln
20%
1
XYLOCAINE - lidocaine hcl soln
4%
3
FORMA-RAY - formaldehyde
solution 20%
3
ZACARE 4% KIT - benzoyl
peroxide lotion 4% & hyaluronate
sodium gel 0.2% kit
3
•
FORMALDEHYDE - formaldehyde
solution 37%
1
1
3
•
formaldehyde solution 10%
ZACARE 8% KIT - benzoyl
peroxide lotion 8% & hyaluronate
sodium gel 0.2% kit
ZACLIR CLEANSING - benzoyl
peroxide lotion 8%
3
•
ZENATANE - isotretinoin cap 30
mg
3
•
ZIANA - clindamycin phosphatetretinoin gel 1.2-0.025%
3
•
ZITHRANOL - anthralin shampoo
1%
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
GLUTARALDEHYDE - glutaral soln 1
25%
1
IODINE TINCTURE - iodine
tincture
1
LUGOLS STRONG IODINE iodine solution
ANTIDOTES
CHEMET - succimer cap 100 mg
2
3
EVZIO - naloxone hcl solution
2
ZITHRANOL-RR - anthralin cream
1.2%
3
EXJADE - deferasirox tab for oral
susp 125 mg
2
•
•
ZONALON - doxepin hcl cream 5%
3
2
•
•
ZOVIRAX - acyclovir cream 5%
3
susp 250 mg
3
susp 500 mg
2
ZOVIRAX - acyclovir oint 5%
•
•
ZYCLARA - imiquimod cream
3.75%
3
FERRIPROX - deferiprone tab 500
mg
3
•
• •
ZYCLARA PUMP - imiquimod
cream 2.5%
3
JADENU - deferasirox tab 90 mg
3
3
3
ZYCLARA PUMP - imiquimod
cream 3.75%
3
•
•
•
•
•
•
8-MOP - methoxsalen cap 10 mg
3
naltrexone hcl tab 50 mg (Revia)
1
RADIOGARDASE - prussian blue
insoluble cap 0.5 gm
3
REVIA - naltrexone hcl tab 50 mg
3
MISCELLANEOUS PRODUCTS
ANTISEPTICS & DISINFECTANTS
•
ANASEPT - sodium hypochlorite
liquid 0.057%
3
BENZALKONIUM CHLORIDE benzalkonium chloride soln
1
ACCU-CHEK ACTIVE STRIPS glucose blood test strip
2
•
BENZALKONIUM CHLORIDE benzalkonium chloride soln 50%
1
ACCU-CHEK AVIVA - glucose
blood test strip
2
•
DIAGNOSTIC PRODUCTS
175
ACCU-CHEK AVIVA PLUS glucose blood test strip
2
•
ASSURE II TEST STRIPS glucose blood test strip
3
•
ACCU-CHEK COMFORT CURVE
T - glucose blood test strip
2
•
ASSURE PLATINUM TEST STRI glucose blood test strip
3
•
ACCU-CHEK COMPACT PLUS glucose blood test strip
2
•
ASSURE PRISM MULTI TEST S glucose blood test strip
3
•
ACCU-CHEK COMPACT STRIPS - 2
glucose blood test strip
2
ACCU-CHEK COMPACT TEST
DR - glucose blood test strip
ACCU-CHEK SMARTVIEW STRIP 2
- glucose blood test strip
2
ACCUTREND GLUCOSE glucose blood test strip
3
ACURA BLOOD GLUCOSE TEST
ADVANCE INTUITION TEST ST - 3
ADVANCE MICRO-DRAW TEST S 3
ADVOCATE REDI-CODE - glucose 3
blood test strip
ADVOCATE REDI-CODE+ TEST - 3
3
ADVOCATE TEST STRIPS glucose blood test strip
AGAMATRIX AMP NO CODE TES 3
AGAMATRIX JAZZ TEST STRIP - 3
3
AGAMATRIX KEYNOTE TEST ST
AGAMATRIX PRESTO TEST STR 3
ASCENSIA AUTODISC TEST ST - 3
glucose blood test disk
3
ASSURE II - glucose blood test
strip
3
ASSURE II CHECK STRIP glucose blood test strip
•
ASSURE PRO TEST STRIPS glucose blood test strip
3
•
•
ASSURE 3 TEST STRIPS glucose blood test strip
3
•
•
ASSURE 4 TEST STRIPS glucose blood test strip
3
•
•
AT LAST TEST STRIPS - glucose
blood test strip
3
•
•
BAYER BREEZE 2 TEST DISC glucose blood test disk
3
•
•
BAYER CONTOUR BLOOD
GLUCO - glucose blood test strip
3
•
•
BAYER CONTOUR NEXT BLOOD
3
•
•
BD TEST STRIPS - glucose blood
test strip
3
•
•
BG STAR BLOOD GLUCOSE TES
3
•
•
BIOSCANNER GLUCOSE TEST S
3
•
•
BLOOD GLUCOSE TEST STRIPS
3
•
•
CAREONE BLOOD GLUCOSE
TES - glucose blood test strip
3
•
•
CARESENS N BLOOD GLUCOSE
3
•
•
CHOICE DM FORA G20 TEST S glucose blood test strip
3
•
•
CLEVER CHEK AUTO-CODE TES
3
•
•
CLEVER CHEK AUTO-CODE VOI
3
•
•
CLEVER CHEK TEST STRIPS glucose blood test strip
3
•
176
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
CLEVER CHOICE AUTO-CODE P
3
•
EASYPRO PLUS - glucose blood
test strip
3
•
CLEVER CHOICE MICRO TEST glucose blood test strip
3
•
ECLIPSE TEST STRIPS - glucose
blood test strip
3
•
CONTROL AST - glucose blood
test strip
3
•
ELEMENT COMPACT TEST STRI
3
•
CONTROL TEST STRIPS glucose blood test strip
3
•
ELEMENT PLUS TEST STRIPS glucose blood test strip
3
•
CVS ADVANCED GLUCOSE
METE - glucose blood test strip
3
•
ELEMENT TEST STRIPS glucose blood test strip
3
•
DIATRUE PLUS BLOOD GLUCOS
3
•
EMBRACE BLOOD GLUCOSE
3
•
DUO-CARE TEST STRIPS glucose blood test strip
3
•
3
•
EASY PLUS BLOOD GLUCOSE T
3
•
EMBRACE EVO BLOOD
GLUCOSE - glucose blood test
strip
3
•
EASY PLUS II BLOOD GLUCOS glucose blood test strip
3
•
EMBRACE PRO BLOOD
strip
EASY STEP TEST STRIPS glucose blood test strip
3
•
•
EASY TALK BLOOD GLUCOSE T
3
•
EASY TOUCH GLUCOSE TEST S
3
•
EASY TOUCH HEALTHPRO
GLUC - glucose blood test strip
3
•
EASY TRAK BLOOD GLUCOSE T
3
•
EASYGLUCO - glucose blood test
strip
3
•
EASYGLUCO PLUS - glucose
blood test strip
3
•
EASYMAX TEST STRIPS glucose blood test strip
3
•
EASYMAX 15 TEST STRIPS glucose blood test strip
3
•
EASYPLUS BLOOD GLUCOSE
TE - glucose blood test strip
3
•
EASYPRO BLOOD GLUCOSE
3
•
ENVISION AUTOCODE TEST ST - 3
EQ BLOOD GLUCOSE TEST STR 3
3
EQL TRUETEST BLOOD
GLUCOS - glucose blood test
strip
EQL TRUETRACK TEST - glucose 3
blood test strip
3
EVENCARE + BLOOD GLUCOSE
3
EVENCARE BLOOD GLUCOSE
3
EVENCARE G2 TEST STRIPS glucose blood test strip
3
EVENCARE G3 TEST STRIPS glucose blood test strip
3
EVOLUTION AUTOCODE glucose blood test strip
EXACTECH R-S-G TEST STRIP - 3
3
EXACTECH TEST STRIPS glucose blood test strip
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
•
•
•
•
•
•
177
EZ SMART BLOOD GLUCOSE TE
3
•
FORA V30A BLOOD GLUCOSE T
3
•
EZ SMART PLUS BLOOD GLUCO
3
•
FORACARE GD40 - glucose blood
test strip
3
•
FASTTAKE TEST STRIPS glucose blood test strip
2
•
FORACARE PREMIUM V10 TEST
3
•
FIFTY50 GLUCOSE TEST STRI glucose blood test strip
3
•
•
FORA D10 BLOOD GLUCOSE TE
3
•
FORA D15C BLOOD GLUCOSE T
3
•
FORA D15G BLOOD GLUCOSE T
3
•
FORA D15Z BLOOD GLUCOSE T
3
•
FORA D20 BLOOD GLUCOSE TE
3
•
FORA GD20 TEST STRIPS glucose blood test strip
3
•
FORA GD50 BLOOD GLUCOSE T
3
•
FORA G20 BLOOD GLUCOSE TE
3
•
FORA G30A BLOOD GLUCOSE T
3
FORA G71A BLOOD GLUCOSE T
3
FORA G90 BLOOD GLUCOSE TE
3
FORA TEST N' GO BLOOD GLU glucose blood test strip
3
FORA V10 BLOOD GLUCOSE TE
3
3
3
3
FORACARE TEST N GO TEST S - 3
FORTISCARE BLOOD GLUCOSE 3
FREESTYLE INSULINX BLOOD - 3
3
FREESTYLE LITE TEST STRIP glucose blood test strip
3
FREESTYLE TEST STRIPS glucose blood test strip
GE100 BLOOD GLUCOSE TEST - 3
3
GHT TEST STRIPS - glucose
blood test strip
2
GLUCAGEN DIAGNOSTIC glucagon hcl (rdna) diagnostic for
GLUCO PERFECT 3 TEST STRI - 3
3
GLUCOCARD EXPRESSION
BLOO - glucose blood test strip
GLUCOCARD SHINE TEST STRI - 3
GLUCOCARD VITAL TEST STRI - 3
3
GLUCOCARD X-SENSOR glucose blood test strip
3
GLUCOCARD 01 SENSOR PLUS
3
GLUCOCOM TEST STRIPS glucose blood test strip
3
GLUCOLAB TEST STRIPS glucose blood test strip
178
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
GLUCONAVII BLOOD GLUCOSE - 3
3
GMATE BLOOD GLUCOSE TEST
INFINITY BLOOD GLUCOSE TE - 3
3
KROGER BLOOD GLUCOSE
TEST - glucose blood test strip
3
KROGER PREMIUM BLOOD
GLUC - glucose blood test strip
KROGER TEST STRIPS - glucose 3
blood test strip
LIBERTY NEXT GENERATION B - 3
LIBERTY TEST STRIPS - glucose 3
blood test strip
MAXIMA BLOOD GLUCOSE TEST 3
MEIJER BLOOD GLUCOSE TEST 3
MEIJER PREMIUM BLOOD GLUC 3
3
MEIJER TRUETEST BLOOD GLU
MEIJER TRUETRACK BLOOD GL 3
3
MICRODOT TEST STRIPS glucose blood test strip
3
MYGLUCOHEALTH BLOOD
3
NEUTEK 2TEK TEST STRIPS glucose blood test strip
NEXGEN TEST STRIPS - glucose 3
blood test strip
NOVA MAX GLUCOSE TEST STR 3
ON CALL EXPRESS BLOOD GLU 3
ON CALL PLUS BLOOD GLUCOS 3
•
ON CALL VIVID BLOOD GLUCO glucose blood test strip
3
•
•
ONETOUCH BASIC/PROFILE TE - 2
2
ONETOUCH ULTRA BLUE glucose blood test strip
2
ONETOUCH ULTRA TEST STRIP
2
ONETOUCH VERIO TEST STRIP
3
OPTIUM TEST STRIPS - glucose
blood test strip
3
OPTIUMEZ TEST STRIPS glucose blood test strip
3
OPTUMRX BLOOD GLUCOSE
3
PHARMACIST CHOICE
AUTOCOD - glucose blood test
strip
3
POCKETCHEM EZ BLOOD
3
PRECISION PCX - glucose blood
test strip
PRECISION PCX PLUS TEST S - 3
3
PRECISION POINT OF CARE T glucose blood test strip
3
PRECISION QID TEST STRIPS glucose blood test strip
PRECISION SOF-TACT TEST S - 3
3
PRECISION XTRA BLOOD GLUC
3
PRESTIGE TEST STRIPS glucose blood test strip
PRODIGY NO CODING BLOOD G 3
3
PTS PANELS GLUCOSE TEST glucose blood test strip
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
179
3
•
SOLUS V2 AUDIBLE TEST glucose blood test strip
3
•
QUINTET AC BLOOD GLUCOSE - 3
QUINTET BLOOD GLUCOSE TES 3
RA TRUETEST STRIPS - glucose 3
blood test strip
3
REFUAH PLUS BLOOD
strip
RELION BLOOD GLUCOSE TEST 3
RELION CONFIRM/MICRO TEST - 3
RELION PRIME BLOOD GLUCOS 3
3
RELION ULTIMA BLOOD GLUCO
3
RELION ULTIMA TEST STRIPS glucose blood test strip
REVEAL BLOOD GLUCOSE TEST 3
REXALL BLOOD GLUCOSE TEST 3
3
RIGHTEST GS100 BLOOD GLUC
3
3
SMART DIABETES XPRES BLOO 3
3
SMART SENSE PREMIUM
BLOOD - glucose blood test strip
SMART SENSE VALUE BLOOD G 3
3
SMARTEST BLOOD GLUCOSE
•
SUPREME TEST STRIPS glucose blood test strip
3
•
•
SURE EDGE BLOOD GLUCOSE T
3
•
•
SURE-TEST EASYPLUS MINI B glucose blood test strip
3
•
•
SURECHEK BLOOD GLUCOSE
3
•
SURESTEP PRO TEST STRIPS glucose blood test strip
2
•
•
2
•
SURESTEP TEST STRIPS glucose blood test strip
•
3
•
TELCARE BLOOD GLUCOSE
•
TGT BLOOD GLUCOSE TEST ST
3
•
•
TRUE METRIX BLOOD GLUCOSE
3
•
•
TRUE METRIX SELF MONITORI glucose blood test strip
3
•
•
TRUETEST BLOOD GLUCOSE T - 3
3
TRUETEST STRIPS - glucose
blood test strip
3
TRUETRACK BLOOD GLUCOSE
T - glucose blood test strip
3
TRUETRACK TEST - glucose
blood test strip
3
ULTIMA TEST STRIPS - glucose
blood test strip
ULTRATRAK PRO TEST STRIPS - 3
ULTRATRAK ULTIMATE TEST S - 3
3
UNISTRIP1 GENERIC - glucose
blood test strip
VICTORY AGM-4000 TEST STR - 3
•
QUICKTEK TEST STRIPS glucose blood test strip
180
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
VOCAL POINT BLOOD GLUCOSE
3
•
ACCU-CHEK SAFE-T-PRO LANC
- lancets
3
WAVESENSE PRESTO TEST
STR - glucose blood test strip
3
•
ACCU-CHEK SAFE-T-PRO PLUS
- lancets
2
ACCU-CHEK SAFE-T-PRO PLUS
- lancets
3
ACCU-CHEK SMARTVIEW
CONTR - blood glucose
calibration - liquid
3
ACCU-CHEK SOFT TOUCH LANC
- lancets
2
ACCU-CHEK SOFT TOUCH LANC
- lancets
3
ACCU-CHEK SOFTCLIX LANCET
- lancets
2
- lancets
3
- lancet devices
3
ACCU-CHEK VOICEMATE - blood
glucose monitoring kit w/ device
2
ACCUTREND GLUCOSE
CONTROL - blood glucose
3
ACTI-LANCE LANCETS 28G lancets
3
ACTI-LANCE LITE SAFETY LA lancets
3
ACTI-LANCE SPECIAL SAFETY lancets
3
ACTI-LANCE UNIVERSAL SAFE lancets
3
ACURA BLOOD GLUCOSE
MONIT - blood glucose
monitoring kit w/ device
3
ACURA CONTROL SOLUTION HI
- blood glucose calibration - liquid
- high
3
ACURA CONTROL SOLUTION LO
- low
3
CHEMICALS
MEDICAL DEVICES
ACCU-CHEK ACTIVE GLUCOSE - 2
blood glucose calibration - liquid
3
ACCU-CHEK AVIVA - blood
glucose calibration - liquid
ACCU-CHEK AVIVA PLUS - blood 2
2
C - blood glucose calibration liquid
2
L - blood glucose calibration liquid
3
ACCU-CHEK COMPACT BLUE
CO - blood glucose calibration liquid
2
ACCU-CHEK COMPACT PLUS
CA - blood glucose monitoring kit
ACCU-CHEK COMPACT PLUS CL 2
3
ACCU-CHEK FASTCLIX LANCET
- lancets
ACCU-CHEK INSTANT GLUCOSE 2
ACCU-CHEK INSTANT GLUCOSE 3
ACCU-CHEK MULTICLIX LANCE - 2
lancets
ACCU-CHEK MULTICLIX LANCE - 3
lancets
ACCU-CHEK NANO SMARTVIEW 2
- blood glucose monitoring kit w/
device
2
ACCU-CHEK SAFE-T-PRO LANC
- lancets
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
181
ACURA CONTROL SOLUTION
NO - blood glucose calibration liquid - normal
3
ADVOCATE INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
ACURA PLUS BLOOD GLUCOSE
device
3
ADVOCATE INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
ADJUSTABLE LANCING DEVICE
- lancet devices
1
2
ADVANCE INTUITION BLOOD G
device
3
ml 29 x 1/2"
2
ADVANCE INTUITION CONTROL
- normal
3
ml 30 x 5/16"
2
ADVANCE MICRO-DRAW
CONTRO - blood glucose
3
ADVOCATE INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
29 x 1/2"
2
ADVANCE MICRO-DRAW
NORMAL - blood glucose
3
30 x 5/16"
2
ADVOCATE BLOOD GLUCOSE
MO - blood glucose monitoring
kit w/ device
3
31 x 5/16"
2
ADVOCATE CONTROL
SOLUTION - blood glucose
calibration - liquid - high
3
ml 31 x 5/16"
ADVOCATE LANCETS - lancets
3
ADVOCATE CONTROL
calibration - liquid - low
ADVOCATE LANCETS 30G lancets
3
3
ADVOCATE LANCING DEVICE lancet devices
3
ADVOCATE INSULIN PEN NEED
- insulin pen needle 29 g x 12.7
mm
2
- insulin pen needle 31 g x 5 mm
(3/16")
2
(1/3" or 5/16")
2
ml 29 x 1/2"
2
182
ADVOCATE RAPID-SAFE LANCI - 3
lancet devices
3
ADVOCATE REDI-CODE
+ CONTR - blood glucose
3
ADVOCATE REDI-CODE
+ CONTR - blood glucose
3
ADVOCATE REDI-CODE+/ TALK
device
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
ADVOCATE REDI-CODE/TALKIN
device
3
AEROCHAMBER Z-STAT PLUS/
M - spacer/aerosol-holding
chambers - device
3
ADVOCATE SAFETY LANCETS lancets
3
3
ADVOCATE SAFETY LANCETS 2
- lancets
3
S - spacer/aerosol-holding
chambers - device
3
AEROCHAMBER MINI AEROSOL
- spacer/aerosol-holding
chambers - device
3
AEROCHAMBER/FLOWSIGNAL spacer/aerosol-holding chambers
- device
3
AEROCHAMBER MV - spacer/
aerosol-holding chambers device
3
AEROVENT PLUS HOLDING
CHA - spacer/aerosol-holding
chambers - device
3
AEROCHAMBER PLUS - spacer/
3
AF LANCETS SUPER THIN lancets
3
AEROCHAMBER PLUS FLOW
VU - spacer/aerosol-holding
chambers - device
3
AGAMATRIX CONTROL HIGH blood glucose calibration - liquid
- high
AGAMATRIX CONTROL NORMAL
3
AEROCHAMBER PLUS FLOWVU - spacer/aerosol-holding
chambers - device
3
AGAMATRIX CONTROL NORMAL
- normal
3
AEROCHAMBER PLUS FLOWVU/ - spacer/aerosol-holding
chambers - device
3
AEROCHAMBER PLUS/MASK spacer/aerosol-holding chambers
- device
3
AEROCHAMBER PLUS/SMALL
MA - spacer/aerosol-holding
chambers - device
3
AEROCHAMBER Z-STAT PLUS
V - spacer/aerosol-holding
chambers - device
3
F - spacer/aerosol-holding
chambers - device
3
L - spacer/aerosol-holding
chambers - device
3
AGAMATRIX JAZZ - blood glucose 3
3
AGAMATRIX PRESTO - blood
AGAMATRIX ULTRA-THIN LANC - 3
lancets
ALTERNATE SITE LANCING DE - 1
lancet devices
2
ANTI-STICK INSULIN SYRING insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
ANTI-STICK INSULIN SYRING insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
ANTI-STICK INSULIN SYRING insulin syringe/needle u-100 1 ml
29 x 1/2"
AQUA LANCE ADJUSTABLE LAN 3
- lancet devices
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
183
3
ASSURE 3 CONTROL LEVEL 1/ blood glucose calibration - liquid
3
ASCENSIA AUTODISC NORMAL - 3
blood glucose calibration - liquid normal
3
ASSURE COMFORT LANCETS
UL - lancets
3
ASSURE DOSE NORMAL
calibration - liquid - normal
ASSURE DOSE NORMAL/HIGH C 3
ASSURE HAEMOLANCE PLUS HI 3
- lancets
3
ASSURE HAEMOLANCE PLUS
LO - lancets
ASSURE HAEMOLANCE PLUS MI 3
- lancets
3
NO - lancets
3
PE - lancets
2
ASSURE ID INSULIN SAFETY insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
ASSURE ID INSULIN SAFETY insulin syringe/needle u-100 1 ml
29 x 1/2"
3
ASSURE II CONTROL LEVEL 1 blood glucose calibration - liquid
3
ASSURE LANCE LANCETS lancets
ASSURE LANCE LANCETS 21G - 3
lancets
ASSURE LANCE PLUS SAFETY - 3
lancets
3
ASSURE LANCETS - lancets
ASSURE 4 CONTROL LEVEL 1/ blood glucose calibration - liquid
3
AT LAST CONTROL SOLUTION blood glucose calibration - liquid
3
AT LAST LANCETS - lancets
3
AURORA LANCET SUPER THIN lancets
3
AURORA LANCET THIN 23G lancets
3
AURORA PEN NEEDLES 29GX12
- insulin pen needle 29 g x 12
mm (1/2")
2
AURORA PEN NEEDLES 31G X insulin pen needle 31 g x 6 mm
(1/4")
2
AURORA PEN NEEDLES 31G X insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
AURORA UNIFINE PENTIPS/MI insulin pen needle 31 g x 5 mm
(3/16")
2
AURORA UNIFINE PENTIPS/32 insulin pen needle 32 g x 4 mm
(5/32")
2
AUTO-LANCET - lancet devices
3
AUTO-LANCET MINI - lancet
devices
3
AUTOLET IMPRESSION - lancet
devices
3
ASCENSIA AUTODISC LOW AND
ASSURE PRISM CONTROL LEV blood glucose calibration - liquid
3
ASSURE PRO CONTROL LEVEL - 3
184
AUTOLET IMPRESSION LANCIN - 3
lancet devices
3
AUTOLET MINI - lancet devices
AUTOPEN - injection device for
insulin
1
AUTOPEN - injection device for
insulin
3
B-D INSULIN SYRINGE MICRO insulin syringe/needle u-100 1 ml
28 x 1/2"
2
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
B-D INSULIN SYRINGE ULTRA insulin syringe/needle u-100 0.3
ml 30 x 1/2"
2
BAYER CONTOUR NEXT EZ BLO
device
3
B-D INSULIN SYRINGE ULTRA insulin syringe/needle u-100 1 ml
31 x 5/16"
2
BAYER CONTOUR NEXT LINK B
device
3
B-D INSULIN SYRINGE ULTRA insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
BAYER CONTOUR NEXT USB BL
device
3
BAYER BREEZE 2 BLOOD GLUC
device
3
BAYER BREEZE 2 HIGH CONTR
- high
3
BAYER BREEZE 2 LOW CONTRO
- low
3
BAYER BREEZE 2 NORMAL CON
- normal
3
BAYER CONTOUR BLOOD
GLUCO - blood glucose
3
BAYER CONTOUR HIGH
3
BAYER CONTOUR LINK BLOOD
device
3
BAYER CONTOUR LOW
3
BAYER CONTOUR NEXT BLOOD
device
3
BAYER CONTOUR NEXT
3
BAYER CONTOUR NEXT
3
3
BAYER CONTOUR NORMAL
CONT - blood glucose calibration
- liquid - normal
3
BAYER CONTOUR USB BLOOD
G - blood glucose monitoring kit
w/ device
3
BAYER MICROLET LANCETS lancets
3
BAYER MICROLET 2 LANCING lancet devices
2
BD LO-DOSE INSULIN SYRIN insulin syringe/needle u-100 1/2
ml 28 x 1/2"
BD AUTOSHIELD DUO 30G X 3 - 2
insulin pen needle 30 g x 5 mm
(3/16")
2
BD AUTOSHIELD 29G X 3/16" insulin pen needle 29 g x 5 mm
(3/16")
2
BD AUTOSHIELD 29G X 5/16" insulin pen needle 29 g x 8 mm
(5/16")
2
BD INSULIN SYRINGE LUER-L insulin syringe (disp) u-100 1 ml
BD INSULIN SYRINGE MICROF - 2
insulin syringe/needle u-100 0.3
ml 28 x 1/2"
insulin syringe/needle u-100 1/2
ml 28 x 1/2"
insulin syringe/needle u-100 1 ml
27 x 5/8"
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
185
BD INSULIN SYRINGE MICROF insulin syringe/needle u-100 1 ml
28 x 1/2"
2
BD INSULIN SYRINGE ULTRAF insulin syringe/needle u-100 1 ml
31 x 5/16"
2
BD INSULIN SYRINGE SAFETY insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
BD INSULIN SYRINGE ULTRAF insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
BD INSULIN SYRINGE SAFETY insulin syringe/needle u-100 1 ml
29 x 1/2"
2
BD INSULIN SYRINGE ULTRAF insulin syringe/needle u-100 1/2
ml 31 x 15/64"
2
BD INSULIN SYRINGE SAFETY insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
31 x 15/64"
2
BD INSULIN SYRINGE SLIP T insulin syringe (disp) u-100 1 ml
2
2
BD INSULIN SYRINGE U-40/1 insulin syringe/needle u-40 1 ml
25 x 5/8"
2
BD INSULIN SYRINGE/DETACH insulin syringe/needle u-100 1 ml
25 x 5/8"
2
ml 29 x 1/2"
2
25 x 1"
2
ml 30 x 1/2"
2
26 x 1/2"
2
ml 31 x 5/16"
2
BD INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
ml 29 x 1/2"
2
BD INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml
27 x 1/2"
2
ml 30 x 1/2"
2
28 x 1/2"
2
ml 31 x 15/64"
2
27.5 x 5/8"
2
29 x 1/2"
2
29 x 1/2"
2
30 x 1/2"
2
BD INTEGRA INSULIN SYRING insulin syringe/needle u-100 1 ml
29 x 1/2"
BD INTEGRA SYRINGE/RETRAC
- insulin syringe/needle u-100 1
ml 25 x 1"
2
186
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
BD LANCET DEVICE - lancet
devices
3
BD LANCET ULTRAFINE 30G lancets
3
BD LANCET ULTRAFINE 33G lancets
BLOOD GLUCOSE MONITORING
device
1
1
3
BLOOD GLUCOSE SYSTEM PAK
device
BD LATITUDE DIABETES MANA
device
3
BREATHERITE - spacer/aerosolholding chambers - device
3
3
BD LOGIC BLOOD GLUCOSE MO
device
3
BREATHERITE COLLAPSIBLE spacer/aerosol-holding chambers
- device
3
BD MICROTAINER LANCETS lancets
3
BREATHERITE RIGID SPACER spacer/aerosol-holding chambers
- device
BD PEN - injection device for
insulin
3
BD PEN MINI - injection device for
insulin
3
BD PEN NEEDLE/MINI/ULTRAF insulin pen needle 31 g x 5 mm
(3/16")
2
BD PEN NEEDLE/NANO/ULTRA
(5/32")
2
BD PEN NEEDLE/SHORT/ULTRA
(1/3" or 5/16")
2
BD PEN NEEDLE/ULTRAFINE/2
mm
2
BD PEN NEEDLES SHORT/ULTR
(1/3" or 5/16")
2
BD SAFETY-LOK INSULIN SYR insulin syringe/needle u-100 1 ml
29 x 1/2"
2
BD SAFETYGLIDE INSULIN SY insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
BD ULTRA FINE LANCETS lancets
3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
BREATHERITE W/LARGE MASK - 3
spacer/aerosol-holding chambers
- device
3
BREATHERITE W/MEDIUM
MASK - spacer/aerosol-holding
chambers - device
BREATHERITE W/SMALL MASK - 3
spacer/aerosol-holding chambers
- device
BULLSEYE MINI SAFETY LANC - 3
lancets
3
BULLSEYE SAFETY LANCETS lancets
CARDIOCOM LANCING DEVICE - 3
lancet devices
2
CAREFINE PEN NEEDLE 32GX4
(5/32")
2
CAREFINE PEN NEEDLES 29GX
mm (1/2")
2
(1/3" or 5/16")
2
(1/4")
187
(1/3" or 5/16")
2
CAREONE ULTIGUARD INSULIN
- insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
(1/5" or 3/16")
2
ml 30 x 5/16"
2
(1/4")
2
ml 29 x 1/2"
2
CAREONE ADVANCED LANCING
- lancet devices
3
2
CAREONE BLOOD GLUCOSE
MON - blood glucose monitoring
kit w/ device
3
ml 30 x 5/16"
2
CAREONE INSULIN SYRINGES/ insulin syringe/needle u-100 0.3
ml 30 x 1/2"
2
CAREONE UNIFINE PENTIPS P insulin pen needle 29 g x 12 mm
(1/2")
2
CAREONE INSULIN SYRINGES/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
CAREONE UNIFINE PENTIPS P
(3/16")
2
CAREONE INSULIN SYRINGES/ insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
(1/4")
2
CAREONE INSULIN SYRINGES/ insulin syringe/needle u-100 1 ml
30 x 1/2"
2
(1/3" or 5/16")
2
CAREONE INSULIN SYRINGES/ insulin syringe/needle u-100 1 ml
31 x 5/16"
2
(5/32")
2
CAREONE INSULIN SYRINGES/ insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
CAREONE UNIFINE PENTIPS 2 insulin pen needle 29 g x 12 mm
(1/2")
2
CAREONE LANCET THIN lancets
3
(3/16")
2
CAREONE LANCET ULTRA THIN
- lancets
3
(1/4")
- insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
(1/3" or 5/16")
2
ml 30 x 5/16"
2
CARESENS CONTROL A SOLUTI
3
CAYA - diaphragm arc-spring
3
188
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
CLEANLET LANCETS 28G lancets
3
CLEVER CHEK BLOOD
GLUCOSE - blood glucose
3
CLEVER CHEK LANCETS ULTRA
- lancets
3
CLEVER CHOICE COMFORT EZ
ml 29 x 1/2"
2
ml 30 x 5/16"
2
ml 30 x 1/2"
2
ml 31 x 5/16"
2
ml 28 x 1/2"
2
ml 29 x 1/2"
2
ml 30 x 5/16"
2
ml 30 x 1/2"
2
CLEVER CHOICE COMFORT EZ - 2
28 x 1/2"
29 x 1/2"
30 x 5/16"
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
30 x 1/2"
31 x 5/16"
2
ml 31 x 5/16"
2
(3/16")
2
(1/4")
2
(1/3" or 5/16")
2
(5/32")
2
(1/5" or 3/16")
2
(1/4")
2
(5/32")
2
(1/5" or 3/16")
2
(1/4")
2
(1/3" or 5/16")
189
3
CLEVER CHOICE GLUCOSE
CON - blood glucose calibration liquid - high
3
CLEVER CHOICE GLUCOSE
CON - blood glucose calibration liquid - low
CLEVER CHOICE MICRO BLOOD 3
device
CLICKFINE PEN NEEDLE UNIV - 2
(1/4")
CLICKFINE PEN NEEDLE UNIV - 2
(1/3" or 5/16")
CLICKFINE PEN NEEDLE 32GX - 2
(5/32")
CLICKFINE PEN NEEDLES/31G - 2
(1/4")
CLICKFINE PEN NEEDLES/31G - 2
(1/3" or 5/16")
CLICKFINE UNIVERSAL PEN N - 2
(1/4")
CLICKFINE UNIVERSAL PEN N - 2
(1/3" or 5/16")
3
CLOSERCARE - lancet devices
COAGUCHEK LANCETS - lancets
2
COAGUCHEK LANCETS - lancets
3
COMFORT ASSIST INSULIN SY insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ml 30 x 5/16"
2
COMFORT ASSIST INSULIN SY insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
190
ml 29 x 1/2"
2
ml 30 x 5/16"
2
COMFORT ASSIST INSULIN SY insulin syringe/needle u-100 1 ml
29 x 1/2"
2
30 x 5/16"
2
31 x 5/16"
2
ml 31 x 5/16"
2
COMFORT ASSURED LANCETS
M - lancets
3
COMFORT ASSURED LANCETS
S - lancets
3
COMFORT LANCETS - lancets
3
CONTROL BLOOD GLUCOSE
kit w/ device
3
CONTROL SOLUTION NORMAL blood glucose calibration - liquid normal
3
3
CVS ADVANCED GLUCOSE
METE - blood glucose monitoring
kit w/ device
2
CVS INSULIN SYRINGE/0.3ML insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
CVS INSULIN SYRINGE/0.3ML insulin syringe/needle u-100 0.3
ml 30 x 1/2"
2
CVS INSULIN SYRINGE/0.5ML insulin syringe/needle u-100 1/2
ml 29 x 1/2"
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
CVS INSULIN SYRINGE/0.5ML insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
CVS INSULIN SYRINGE/1ML/2 insulin syringe/needle u-100 1 ml
29 x 1/2"
2
CVS LANCETS MICRO THIN 33 lancets
3
CVS LANCETS ORIGINAL lancets
3
CVS LANCETS THIN 26G lancets
3
CVS LANCETS ULTRA THIN 30 lancets
3
CVS LANCETS 21G - lancets
3
CVS LANCING DEVICE - lancet
devices
3
CVS ULTRA THIN LANCETS lancets
3
DIASTAR EASY TEST II LANC lancets
3
DIASTAR EASY TEST LANCETS - 3
lancets
DIATRUE GLUCOSE CONTROL S 3
- high
- normal
- low
3
DIDGET - blood glucose
DROPLET LANCETS ULTRA THI - 3
lancets
3
DROPLET LANCING DEVICE lancet devices
DRUG MART ADJUSTABLE LANC 3
- lancet devices
DRUG MART LANCETS THIN lancets
3
DRUG MART LANCETS ULTRA T
- lancets
3
DRUG MART ON-THE-GO LANCE
- lancets
3
DRUG MART ULTRA COMFORT I
ml 29 x 1/2"
2
ml 30 x 5/16"
2
ml 31 x 5/16"
2
ml 30 x 5/16"
2
DRUG MART ULTRA COMFORT
I - insulin syringe/needle u-100 1
ml 29 x 1/2"
2
DRUG MART ULTRA COMFORT
I - insulin syringe/needle u-100 1
ml 30 x 5/16"
2
ml 31 x 5/16"
2
DRUG MART UNIFINE PENTIPS insulin pen needle 29 g x 12 mm
(1/2")
2
DRUG MART UNIFINE PENTIPS
(3/16")
2
(1/4")
2
(1/3" or 5/16")
2
(5/32")
2
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
191
DRUG MART UNILET LANCETS lancets
3
DUANE READE LANCET ALTERN
- lancets
3
DUANE READE LANCET SUPER
- lancets
3
DUANE READE LANCET ULTRA - 3
lancets
DUANE READE UNIFINE PENTI - 2
(1/2")
2
DUANE READE UNIFINE PENTI
(1/4")
2
DUANE READE UNIFINE PENTI
(1/3" or 5/16")
3
DUO-CARE CONTROL
3
E-Z JECT LANCETS - lancets
EASIVENT/MASK-MEDIUM spacer/aerosol-holding chambers
- device
3
EASIVENT/MASK-SMALL spacer/aerosol-holding chambers
- device
3
EASY COMFORT INSULIN SYRI insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
EASY COMFORT INSULIN SYRI insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
EASY COMFORT INSULIN SYRI insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
EASY COMFORT INSULIN SYRI insulin syringe/needle u-100 1 ml
30 x 5/16"
2
EASY COMFORT INSULIN SYRI insulin syringe/needle u-100 1 ml
30 x 1/2"
2
3
EASY COMFORT LANCETS lancets
3
E-Z JECT LANCETS COLOR lancets
3
EASY COMFORT LANCETS 30G/
- lancets
3
E-Z JECT LANCETS SUPER TH lancets
3
EASY COMFORT PEN NEEDLES
(3/16")
2
E-Z JECT LANCETS THIN 26G lancets
E-Z JECT LANCETS 21G - lancets
3
3
(1/4")
2
E-Z SPACER - spacer/aerosolholding chambers - device
E-Z SPACER THE BODY GUARD
- spacer/aerosol-holding
chambers - device
3
(1/3" or 5/16")
2
E-ZJECT LANCETS MICRO-THI lancets
3
2
EASIVENT - spacer/aerosolholding chambers - device
3
(5/32")
3
EASIVENT/MASK-LARGE spacer/aerosol-holding chambers
- device
3
EASY MINI LANCING DEVICE lancet devices
EASY PLUS BLOOD GLUCOSE M
device
3
192
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
EASY PLUS II CONTROL SOLU blood glucose calibration - liquid
- high
3
EASY TOUCH INSULIN SYRING insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
EASY PLUS II CONTROL SOLU blood glucose calibration - liquid
- low
3
ml 30 x 1/2"
2
EASY STEP BLOOD GLUCOSE M
device
3
EASY TOUCH INSULIN SYRING insulin syringe/needle u-100 1/2
ml 27 x 1/2"
2
EASY STEP CONTROL SOLUTIO
- high
3
ml 31 x 5/16"
2
- normal
3
ml 28 x 1/2"
2
- low
3
ml 29 x 1/2"
2
EASY TALK BLOOD GLUCOSE M
device
3
ml 30 x 5/16"
2
EASY TALK CONTROL SOLUTIO
- high
3
ml 30 x 1/2"
2
- normal
3
EASY TOUCH INSULIN SYRING insulin syringe/needle u-100 1 ml
27 x 1/2"
2
- low
3
28 x 1/2"
2
EASY TOUCH CONTROL SOLUTI
3
2
EASY TOUCH GLUCOSE
MONITO - blood glucose
3
29 x 1/2"
30 x 5/16"
2
30 x 1/2"
2
31 x 5/16"
2
3
- liquid
3
GLUC - blood glucose monitoring
kit w/ device
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
193
ml 31 x 5/16"
2
EASY TOUCH PEN NEEDLES 31
(1/4")
2
EASY TOUCH LANCETS 21G/PR
- lancets
3
2
- lancets
3
(1/3" or 5/16")
2
- lancets
3
(5/32")
EASY TOUCH LANCETS 26G/PU
- lancets
3
2
EASY TOUCH LANCETS 26G/TW
- lancets
3
(1/5" or 3/16")
2
- lancets
3
(1/4")
3
EASY TOUCH PEN NEEDLES/31
(3/16")
2
- lancets
- lancets
3
EASY TOUCH SAFETY LANCETS
- lancets
3
EASY TOUCH LANCETS 30G/BU
- lancets
3
2
- lancets
3
EASY TOUCH 32GX5MM - insulin
pen needle 32 g x 5 mm (1/5" or
3/16")
- lancets
EASY TOUCH 32GX6MM - insulin
pen needle 32 g x 6 mm (1/4")
2
3
3
- lancets
3
EASY TRAK BLOOD GLUCOSE M
device
- lancets
3
3
- lancets
3
EASY TRAK GLUCOSE
3
- lancets
3
EASY TRAK GLUCOSE
- lancets
3
3
EASY TOUCH LANCING DEVICE
- lancet devices
3
EASY TRAK GLUCOSE
3
mm (1/2")
2
EASY TWIST & CAP LANCETS lancets
EASYGLUCO CONTROL
SOLUTIO - blood glucose
3
194
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
EASYGLUCO CONTROL
3
EASYPRO BLOOD GLUCOSE
kit w/ device
3
EASYGLUCO CONTROL
3
EASYPRO PLUS - blood glucose
3
EASYTEST II LANCETS - lancets
3
EASYMAX CONTROL SOLUTION
- high
3
EASYTEST LANCETS - lancets
3
3
- normal
3
ECLIPSE BLOOD GLUCOSE
kit w/ device
3
- low
3
ECLIPSE HIGH CONTROL - blood
glucose calibration - liquid - high
ECLIPSE LOW CONTROL - blood
glucose calibration - liquid - low
3
EASYMAX L BLOOD GLUCOSE S
device
3
ECLIPSE NORMAL CONTROL blood glucose calibration - liquid
- normal
3
EASYMAX N BLOOD GLUCOSE S
device
3
ELEMENT AUTOCODE SYSTEM
device
3
EASYMAX NG SELF-MONITORIN
device
3
ELEMENT COMPACT CONTROL
S - blood glucose calibration liquid
3
EASYMAX V BLOOD GLUCOSE S
device
3
ELEMENT HIGH CONTROL blood glucose calibration - liquid
- high
3
EASYMAX V2 SELF-MONITORIN
device
3
ELEMENT LOW CONTROL blood glucose calibration - liquid
- low
3
EASYMAX 15 LEVEL 1 GLUCOS blood glucose calibration - liquid
3
3
EASYMAX 15 LEVEL 2 GLUCOS blood glucose calibration - liquid
3
ELEMENT NORMAL CONTROL blood glucose calibration - liquid normal
3
EASYPLUS R13N SELF-MONITO
device
3
ELEMENT PLUS CONTROL
SOLU - blood glucose calibration
- liquid - high
3
EASYPLUS V SELF-MONITORIN
device
3
- liquid - normal
- liquid - low
3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
195
ELITE-THIN INSULIN SYRING insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
EMBRACE EVO BLOOD
3
ml 28 x 5/16"
2
EMBRACE EVO GLUCOSE
3
ml 28 x 1/2"
2
EMBRACE EVO GLUCOSE
3
ml 29 x 5/16"
2
EMBRACE GLUCOSE CONTROL
S - blood glucose calibration liquid - high
3
ml 29 x 1/2"
2
EMBRACE LANCETS ULTRA THI
- lancets
3
ml 30 x 5/16"
EMBRACE PRO GLUCOSE
3
2
2
ENVISION AUTOCODE - blood
3
ELITE-THIN INSULIN SYRING insulin syringe/needle u-100 1 ml
28 x 5/16"
3
28 x 1/2"
2
ENVISION CONTROL HIGH blood glucose calibration - liquid
- high
3
29 x 1/2"
2
ENVISION CONTROL LOW blood glucose calibration - liquid
- low
3
29 x 5/16"
2
ENVISION CONTROL NORMAL blood glucose calibration - liquid normal
EQL COLOR LANCETS MICRO T
- lancets
3
30 x 5/16"
2
EQL COLOR LANCETS 21G lancets
3
2
EQL INSULIN SYRINGE/U-100 insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
31 x 5/16"
2
EQL INSULIN SYRINGE/U-100 insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
ELITE-THIN INSULIN SYRING insulin syringe/needle u-100 0.3
ml 31 x 5/16"
3
EQL INSULIN SYRINGE/U-100 insulin syringe/needle u-100 1 ml
29 x 1/2"
2
EMBRACE CONTROL SOLUTION
- low
196
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
EQL INSULIN SYRINGE/0.3ML insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
EQL ULTRA SHORT PEN NEEDL
(1/4")
2
ml 30 x 5/16"
2
EVENCARE CONTROL
3
ml 31 x 5/16"
2
EVENCARE G2 GLUCOSE
3
EQL INSULIN SYRINGE/0.5ML insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
EVENCARE G3 GLUCOSE
3
ml 29 x 1/2"
2
EVOLUTION CONTROL SOLUTIO
- normal
3
ml 30 x 5/16"
2
EXEL INSULIN PEN NEEDLES insulin pen needle 29 g x 12 mm
(1/2")
2
EQL INSULIN SYRINGE/1ML/2 insulin syringe/needle u-100 1 ml
29 x 1/2"
2
(1/4")
2
30 x 5/16"
2
(1/3" or 5/16")
2
31 x 5/16"
2
EXEL INSULIN SYRINGE/0.3M insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
EQL SHORT PEN NEEDLES 31G
(1/3" or 5/16")
2
EXEL INSULIN SYRINGE/0.3M insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
EQL SUPER THIN LANCETS 30 lancets
3
EXEL INSULIN SYRINGE/0.5M insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
ml 29 x 1/2"
2
ml 30 x 5/16"
2
EXEL INSULIN SYRINGE/1ML/ insulin syringe/needle u-100 1 ml
28 x 1/2"
2
EQL THIN LANCETS 26G - lancets 3
3
EQL TRUE2GO BLOOD
EQL ULTRA COMFORT INSULIN - 2
30 x 5/16"
2
EQL ULTRA COMFORT INSULIN
ml 31 x 5/16"
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
197
29 x 1/2"
2
FIFTY50 SUPERIOR COMFORT insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
30 x 5/16"
2
FIFTY50 SUPERIOR COMFORT insulin syringe/needle u-100 1 ml
31 x 5/16"
2
EZ SMART BLOOD GLUCOSE LA
- lancets
3
2
EZ-LETS LANCETS 21G - lancets
3
FIFTY50 SUPERIOR COMFORT insulin syringe/needle u-100 0.3
ml 31 x 5/16"
3
FINE 30 - lancets
3
EZ-LETS LANCETS 26G SUPER lancets
3
FINGERSTIX LANCETS - lancets
3
3
EZ-LETS LANCETS 28G ULTRA lancets
3
FORA CONTROL SOLUTION HIG
- high
3
FASTTAKE COMPACT MONITORI
device
2
FC FEMALE CONDOM - condoms
- female
A
FC2 FEMALE CONDOM condoms - female
A
FEMCAP - cervical cap 22 mm
A
A
A
FIFTY50 CONTROL SOLUTION blood glucose calibration - liquid
3
3
FORA CONTROL SOLUTION
LOW - blood glucose calibration liquid - low
3
FORA CONTROL SOLUTION
NOR - blood glucose calibration liquid - normal
3
FORA G20 BLOOD GLUCOSE
kit w/ device
FORA G71A BLOOD GLUCOSE M 3
device
3
FORA LANCETS - lancets
3
FIFTY50 GLUCOSE METER 2.0 blood glucose monitoring kit w/
device
3
FORA LANCING DEVICE - lancet
devices
3
FIFTY50 LANCING DEVICE lancet devices
3
FORA V22 BLOOD GLUCOSE MO
device
3
FIFTY50 PEN NEEDLES 31G X insulin pen needle 31 g x 5 mm
(3/16")
2
FORA V30A BLOOD GLUCOSE M
device
3
FIFTY50 PEN NEEDLES 31G X insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
FORACARE GDH CONTROL
- liquid - high
3
FIFTY50 SAFETY SEAL LANCE lancets
3
- liquid - normal
198
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
- liquid - low
3
FREESTYLE PRECISION INSUL insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
FORTISCARE CONTROL SOLUTI
- high
3
FREESTYLE PRECISION INSUL insulin syringe/needle u-100 1 ml
30 x 5/16"
2
- normal
3
FREESTYLE PRECISION INSUL insulin syringe/needle u-100 1 ml
31 x 5/16"
2
- low
3
FREESTYLE SIDEKICK II VAL blood glucose monitoring kit w/
device
3
FORTISCARE SELF-MONITORIN
device
3
FREESTYLE UNISTICK II LAN lancets
3
FREDS PHARMACY AUTOLET LA
- lancet devices
GENTLE-LET GP LANCETS lancets
3
3
2
GENTLE-LET LANCETS GENERA
- lancets
3
FREDS PHARMACY UNIFINE PE
(3/16")
GENTLE-LET LANCETS SAFETY
- lancets
3
(1/3" or 5/16")
2
GE100 BLOOD GLUCOSE MONIT
device
3
(5/32")
2
GE100 CONTROL SOLUTION NO
- normal
3
FREDS PHARMACY UNILET LAN
- lancets
3
3
FREESTYLE CONTROL SOLUTIO
3
GHT BLOOD GLUCOSE MONITO
device
FREESTYLE FREEDOM - blood
GLOBAL EASE INJECT PEN NE insulin pen needle 29 g x 12 mm
(1/2")
2
3
FREESTYLE FREEDOM LITE blood glucose monitoring kit w/
device
3
GLOBAL EASE INJECT PEN NE
(3/16")
2
FREESTYLE INSULINX BLOOD blood glucose monitoring kit w/
device
3
(1/3" or 5/16")
2
FREESTYLE LANCETS - lancets
3
2
FREESTYLE PRECISION INSUL insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
(5/32")
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
199
GLOBAL INJECT EASE INSULI insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
GLOBAL INJECT EASE LANCET lancets
3
ml 30 x 5/16"
GLOBAL LANCING DEVICE lancet devices
3
2
3
ml 30 x 1/2"
2
AUDI - blood glucose monitoring
kit w/ device
GLOBAL INJECT EASE INSULI insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
ml 28 x 1/2"
2
ml 29 x 1/2"
2
ml 30 x 5/16"
2
ml 30 x 1/2"
2
GLOBAL INJECT EASE INSULI insulin syringe/needle u-100 1 ml
28 x 1/2"
2
29 x 1/2"
2
30 x 5/16"
2
30 x 1/2"
2
31 x 5/16"
2
ml 31 x 5/16"
2
200
3
- liquid
3
GLUCOCARD SHINE - blood
3
GLUCOCARD SHINE CONTROL
GLUCOCARD VITAL BLOOD GLU 3
device
3
GLUCOCARD X-METER - blood
3
GLUCOCARD X-METER
3
GLUCOCARD 01 BLOOD
GLUCOS - blood glucose
3
GLUCOCARD 01 CONTROL
- liquid
3
GLUCOCARD 01 CONTROL
- liquid - normal
3
GLUCOCARD 01-MINI BLOOD G
device
3
GLUCOCOM BLOOD GLUCOSE
kit w/ device
3
GLUCOCOM HIGH CONTROL blood glucose calibration - liquid
- high
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
GLUCOCOM LANCETS 28G lancets
3
3
3
GLUCOCOM NORMAL CONTROL
- normal
3
GLUCOLAB HIGH CONTROL blood glucose calibration - liquid
- high
3
GLUCOLAB LOW CONTROL blood glucose calibration - liquid
- low
3
GLUCOLAB NORMAL CONTROL
- normal
3
GLUCOLET 2 AUTOMATIC LANC
- lancet devices
3
GLUCONAVII BLOOD GLUCOSE
device
3
GLUCOPRO INSULIN SYRINGE/
ml 30 x 5/16"
2
ml 30 x 1/2"
2
ml 31 x 5/16"
2
ml 30 x 5/16"
2
ml 30 x 1/2"
2
GLUCOPRO INSULIN SYRINGE/ - 2
30 x 5/16"
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
30 x 1/2"
31 x 5/16"
2
ml 31 x 5/16"
GLUCOSE CONTROL NORMAL - 1
blood glucose calibration - liquid normal
GLUCOSE CONTROL SOLUTION 1
3
GLUCOSOURCE LANCET
DEVICE - lancet devices
3
GLUCOSOURCE LANCETS lancets
GMATE CONTROL SOLUTION LE 3
3
GMATE LANCETS 30G - lancets
GMATE LANCING DEVICE lancet devices
3
GMATE SMART STARTER KIT blood glucose monitoring kit w/
device
3
GNP CLICKFINE PEN NEEDLE insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
GNP CLICKFINE UNIVERSAL P insulin pen needle 31 g x 6 mm
(1/4")
2
GNP CLICKFINE UNIVERSAL P insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
GNP INSULIN SYRINGE/0.3ML insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ml 30 x 5/16"
2
201
ml 31 x 5/16"
2
GNP ULTRA COMFORT INSULIN
ml 29 x 1/2"
2
GNP INSULIN SYRINGE/0.5ML insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
ml 30 x 5/16"
2
ml 28 x 1/2"
2
ml 31 x 5/16"
2
ml 29 x 1/2"
2
ml 28 x 1/2"
2
ml 30 x 5/16"
2
ml 29 x 1/2"
2
GNP INSULIN SYRINGE/1ML/2 insulin syringe/needle u-100 1 ml
28 x 1/2"
2
ml 30 x 5/16"
2
29 x 1/2"
2
ml 28 x 1/2"
2
30 x 5/16"
2
ml 29 x 1/2"
2
31 x 5/16"
2
ml 30 x 5/16"
2
GNP LANCETS - lancets
3
2
GNP LANCETS MICRO THIN 33 lancets
3
ml 31 x 5/16"
GNP LANCETS SUPER THIN 30 lancets
3
2
GNP LANCETS THIN - lancets
3
ml 31 x 5/16"
3
H&H THINLET LANCETS 26G lancets
3
GNP LANCETS THIN 26G lancets
3
H&H THINLET SUPER THIN LA lancets
3
GNP LANCETS 21G - lancets
GNP MICRO THIN LANCETS 33 lancets
3
2
GNP SUPER THIN LANCETS/30 lancets
3
H-E-B IN CONTROL PEN NEED insulin pen needle 31 g x 5 mm
(3/16")
202
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
(1/4")
2
HEALTHWISE PEN NEEDLES 29
mm (1/2")
2
(1/3" or 5/16")
2
HEALTHWISE SHORT PEN NEED
(1/3" or 5/16")
2
(5/32")
2
HEALTHWISE UNIFINE PENTIP insulin pen needle 32 g x 4 mm
(5/32")
2
H-E-B INCONTROL ADVANCED lancet devices
3
H-E-B INCONTROL LANCETS S lancets
3
H-E-B INCONTROL LANCETS U lancets
3
H-E-B INCONTROL PEN NEEDL insulin pen needle 29 g x 12 mm
(1/2")
2
HAEMOLANCE - lancets
3
HAEMOLANCE LOW FLOW
LANCE - lancets
3
HAEMOLANCE PLUS - lancets
3
HAEMOLANCE PLUS HIGH
FLOW - lancets
3
HAEMOLANCE PLUS LOW FLOW
- lancets
3
HAEMOLANCE PLUS MAX FLOW
- lancets
3
HAEMOLANCE PLUS PEDIATRIC
- lancets
3
HEALTHY ACCENTS AUTOLET I - 3
lancet devices
HEALTHY ACCENTS UNIFINE P - 2
(1/2")
2
HEALTHY ACCENTS UNIFINE P
(3/16")
2
(1/4")
2
(1/3" or 5/16")
2
(5/32")
HEALTHY ACCENTS UNILET LA - 3
lancets
HM LANCETS MICRO THIN 33G - 3
lancets
HM LANCETS ULTRA THIN 30G - 3
lancets
HUMAPEN LUXURA HD - injection 3
device for insulin
3
HY-VEE LANCETS - lancets
HEALTH CARE LANCING DEVIC - 3
lancet devices
3
HEALTHWISE LANCETS 30G lancets
3
HEALTHWISE LANCING PEN lancet devices
2
HEALTHWISE MINI PEN NEEDL
(1/4")
HY-VEE THIN LANCETS - lancets
3
IBG STAR BLOOD GLUCOSE MO
device
3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
203
INFINITY BLOOD GLUCOSE MO
device
3
INSULIN SYRINGE/U-100/1ML insulin syringe/needle u-100 1 ml
31 x 5/16"
2
INFINITY CONTROL SOLUTION blood glucose calibration - liquid
- high
3
INSULIN SYRINGE/0.3ML/29G insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
INFINITY CONTROL SOLUTION blood glucose calibration - liquid normal
3
ml 29 x 1"
2
INFINITY CONTROL SOLUTION blood glucose calibration - liquid
- low
3
ml 30 x 5/16"
2
INSPIRACHAMBER/ANTI-STATI spacer/aerosol-holding chambers
- device
3
ml 31 x 5/16"
2
INSPIRACHAMBER/
SOOTHERMAS - spacer/
3
INSULIN SYRINGE/0.5ML/27G insulin syringe/needle u-100 1/2
ml 27 x 1/2"
2
3
ml 28 x 1/2"
2
INSPIREASE DRUG DELIVERY spacer/aerosol-holding chambers
- device
INSULIN SYRINGE/U-100/0.3 insulin syringe/needle u-100 0.3
ml 29 x 1/2"
ml 29 x 1/2"
2
2
INSULIN SYRINGE/U-100/0.5 insulin syringe/needle u-100 1/2
ml 28 x 1/2"
ml 30 x 5/16"
2
2
2
ml 30 x 1/2"
2
INSULIN SYRINGE/U-100/0.5 insulin syringe/needle u-100 1/2
ml 29 x 1/2"
28 x 1/2"
ml 31 x 5/16"
2
2
29 x 1/2"
INSULIN SYRINGE/1ML/28G X insulin syringe/needle u-100 1 ml
28 x 1/2"
2
2
30 x 5/16"
29 x 1/2"
2
2
30 x 5/16"
2
204
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
31 x 5/16"
2
KMART VALU PLUS INSULIN S insulin syringe (disp) u-100 1/2
ml
2
INSUPEN PEN NEEDLES 32G X
(5/32")
2
KMART VALU PLUS INSULIN S insulin syringe (disp) u-100 1 ml
2
3
INSUPEN SENSITIVE 32GX6MM
(1/4")
2
KROGER BLOOD GLUCOSE
MONI - blood glucose monitoring
kit w/ device
KROGER INSULIN SYRINGE/U- insulin syringe/needle u-100 0.3
ml 30 x 1/2"
2
KROGER INSULIN SYRINGE/0. insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ml 30 x 5/16"
2
KROGER INSULIN SYRINGE/0. insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
ml 29 x 1/2"
2
ml 30 x 5/16"
2
ml 31 x 5/16"
2
INSUPEN SENSITIVE 32GX8MM - 2
2
INSUPEN ULTRAFIN 29GX12MM
mm (1/2")
INSUPEN ULTRAFIN 30GX8MM - 2
(1/3" or 5/16")
(1/4")
(1/3" or 5/16")
INSUPEN 33GX4MM - insulin pen 2
needle 33 g x 4 mm (5/32")
3
KINNEY LANCETS - lancets
KINNEY THIN LANCETS - lancets
3
KINRAY INSULIN SYRINGE PR insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
KINRAY INSULIN SYRINGE PR insulin syringe/needle u-100 1 ml
31 x 5/16"
2
KINRAY INSULIN SYRINGE PR insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
KINRAY INSULIN SYRINGE/0. insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
KMART VALU PLUS INSULIN S insulin syringe (disp) u-100 0.3
ml
2
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
KROGER INSULIN SYRINGE/1M - 2
29 x 1/2"
30 x 5/16"
31 x 5/16"
3
KROGER LANCETS - lancets
KROGER LANCETS MICRO THIN
- lancets
3
205
KROGER LANCETS SUPER THIN
- lancets
3
LANCETS SUPER THIN 28G lancets
3
KROGER LANCETS THIN lancets
3
LANCETS THIN - lancets
1
LANCETS THIN - lancets
3
KROGER LANCETS THIN 26G lancets
3
LANCETS TWIST TOP - lancets
1
LANCETS ULTRA FINE - lancets
3
LANCETS ULTRA THIN - lancets
3
LANCETS ULTRA THIN 30G lancets
3
LANCETS 26G TWIST TOP lancets
1
LANCETS 28G - lancets
1
LANCETS 30G - lancets
1
1
LANCETS 30G/TWIST TOP lancets
3
1
KROGER LANCETS ULTRATHIN - 3
lancets
KROGER LANCETS 21G - lancets 3
KROGER LANCING DEVICE lancet devices
3
KROGER PEN NEEDLES 29G X insulin pen needle 29 g x 12 mm
(1/2")
2
KROGER PEN NEEDLES 31G X
(1/3" or 5/16")
2
KROGER PEN NEEDLES 31GX1/
(1/4")
2
3
KROGER PREMIUM BLOOD
kit w/ device
3
LADY LITE LANCETS - lancets
LANCET DEVICE ADJUSTABLE lancet devices
1
LANCET DEVICE WITH EJECTO - 3
lancet devices
1
LANCETS - lancets
LANCETS MICRO THIN 33G lancets
3
LANCETS SAFETY SEAL 21G lancets
1
1
1
1
206
LANCETS 33G UNIVERSAL DES - 3
lancets
LANCING DEVICE - lancet devices 1
LANCING DEVICE ADJUSTABLE
- lancet devices
1
LANZO - lancet devices
3
LDR BLOOD GLUCOSE
TRUETES - blood glucose
3
LEADER ADVANCED LANCING D
- lancet devices
3
LEADER INSULIN SYRINGE/0. insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ml 30 x 5/16"
2
LEADER INSULIN SYRINGE/0. insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
ml 28 x 1/2"
2
LEADER UNIFINE PENTIPS/PL insulin pen needle 32 g x 4 mm
(5/32")
2
ml 29 x 1/2"
2
LIBERTY CONTROL SOLUTION blood glucose calibration - liquid
- high
3
ml 30 x 5/16"
2
LIBERTY CONTROL SOLUTION blood glucose calibration - liquid normal
3
ml 31 x 5/16"
2
LIBERTY GLUCOSE CONTROL L
3
LEADER INSULIN SYRINGE/1M insulin syringe/needle u-100 1 ml
28 x 1/2"
LIBERTY GLUCOSE CONTROL M
3
2
3
29 x 1/2"
2
LIBERTY GLUCOSE CONTROL N
- normal
LIBERTY MEDICAL LANCETS 3 lancets
3
30 x 5/16"
2
LIBERTY MINI LANCING DEVI lancet devices
3
2
LIFESCAN UNISTIK II LANCE lancets
2
31 x 5/16"
2
LEADER LANCETS COLORED lancets
3
LIFESCAN UNISTIK 2 DEEP P lancets
LITE TOUCH LANCETS - lancets
3
LEADER SUPER THIN LANCET lancets
3
LITE TOUCH LANCING DEVICE lancet devices
3
LEADER THIN LANCETS - lancets
3
3
LEADER UNIFINE PENTIPS PL insulin pen needle 31 g x 5 mm
(3/16")
2
LITE TOUCH LANCING PEN lancet devices
2
LEADER UNIFINE PENTIPS PL insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
LITE TOUCH PEN NEEDLES/31 insulin pen needle 31 g x 5 mm
(3/16")
LITEAIRE - spacer/aerosol-holding
chambers - device
3
LEADER UNIFINE PENTIPS/MI insulin pen needle 31 g x 5 mm
(3/16")
2
LITETOUCH INSULIN SYRINGE insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
LEADER UNIFINE PENTIPS/NA insulin pen needle 32 g x 4 mm
(5/32")
2
ml 30 x 5/16"
2
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
207
LITETOUCH INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
LIVE BETTER LANCET ULTRA lancets
3
ml 28 x 1/2"
LIVE BETTER PEN NEEDLES 2 insulin pen needle 29 g x 12 mm
(1/2")
2
2
2
ml 29 x 1/2"
2
(1/4")
2
(1/3" or 5/16")
2
ml 30 x 5/16"
LITETOUCH INSULIN SYRINGE insulin syringe/needle u-100 1 ml
28 x 1/2"
LONGS INSULIN SYRINGE/0.5 insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
2
29 x 1/2"
LONGS LANCETS STANDARD lancets
3
2
LONGS LANCETS THIN - lancets
3
2
LONGS LANCETS ULTRA THIN lancets
3
30 x 5/16"
2
31 x 5/16"
2
MAGELLAN INSULIN SAFETY S insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ml 31 x 5/16"
2
MAGELLAN INSULIN SAFETY S insulin syringe/needle u-100 0.3
ml 30 x 5/16"
MAGELLAN INSULIN SAFETY S insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
MAGELLAN INSULIN SAFETY S insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
MAGELLAN INSULIN SAFETY S insulin syringe/needle u-100 1 ml
29 x 1/2"
2
MAGELLAN INSULIN SAFETY S insulin syringe/needle u-100 1 ml
30 x 5/16"
2
MAXI-COMFORT INSULIN SYRI insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
LITETOUCH LANCETS MICRO T - 3
lancets
2
LITETOUCH PEN NEEDLES 29G
mm
2
(1/4")
2
(1/3" or 5/16")
3
LIVE BETTER ADVANCED LANC
- lancet devices
3
LIVE BETTER LANCET SUPER lancets
208
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
MAXI-COMFORT INSULIN SYRI insulin syringe/needle u-100 1 ml
28 x 1/2"
2
MEDISENSE HIGH/LOW
MAXIMA BLOOD GLUCOSE
kit w/ device
3
MAXIMA CONTROL SOLUTION blood glucose calibration - liquid
3
MAXIMA CONTROL SOLUTION/N
- normal
3
MAXIMA METER KIT - blood
3
MAXIMA STARTER KIT - blood
3
MEDI-LANCE LANCETS - lancets
3
MEDIC INSULIN SYRINGE/0.3 insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
MEDIC INSULIN SYRINGE/0.5 insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
MEDICHOICE PRE-SET SAFETY
- lancets
3
MEDICHOICE SAFETY LANCET lancets
3
MEDICINE SHOPPE LANCETS lancets
3
MEDISENSE HIGH/MID/LOW CO - 3
MEDISENSE MID CONTROL SOL 3
3
MEDISENSE THIN LANCETS lancets
MEDLANCE PLUS EXTRA LANCE 3
- lancets
3
MEDLANCE PLUS LANCETS lancets
MEDLANCE PLUS LANCETS LIT - 3
lancets
MEDLANCE PLUS LITE LANCET - 3
lancets
3
MEDLANCE PLUS SPECIAL LAN
- lancets
MEDLANCE PLUS SUPERLITE 3 - 3
lancets
3
MEDLANCE PLUS UNIVERSAL L
- lancets
3
MEDLANCE PLUS/LITE 25G lancets
3
MEDLANCE/EXTRA - lancets
MEDICINE SHOPPE LANCETS T - 3
lancets
2
MEDICINE SHOPPE PEN NEEDL
mm (1/2")
2
(1/4")
2
(1/3" or 5/16")
MEDISENSE GLUCOSE KETONE 3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
3
MEDLANCE/LITE - lancets
3
MEDLANCE/UNIVERSAL - lancets
3
MEIJER BLOOD GLUCOSE MONI
device
3
MEIJER COLOR LANCETS UNIV - 3
lancets
3
MEIJER LANCETS - lancets
MEIJER LANCETS THIN - lancets
3
MEIJER LANCETS UNIVERSAL lancets
3
MEIJER PEN NEEDLES 29G X insulin pen needle 29 g x 12 mm
(1/2")
2
209
(1/4")
2
MONOJECT INSULIN SYRINGE/ insulin syringe (disp) u-100 1 ml
2
(1/3" or 5/16")
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
2
2
MEIJER PREMIUM BLOOD GLUC
device
3
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 30 x 5/16"
3
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
MEIJER SUPER THIN LANCETS lancets
MEIJER TRUERESULT BLOOD G
device
3
ml 29 x 1/2"
2
MEIJER TRUETRACK BLOOD GL
device
3
ml 30 x 5/16"
2
MEIJER TRUE2GO BLOOD GLUC
device
3
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
25 x 5/8"
2
MI PASTE - dentifrices - paste
3
2
MI PASTE PLUS - dentifrices paste
3
27 x 1/2"
MICROCHAMBER - spacer/
3
28 x 1/2"
2
MICRODOT BLOOD GLUCOSE
kit w/ device
3
29 x 1/2"
2
MICRODOT CONTROL
3
30 x 5/16"
2
MICROLET LANCETS - lancets
3
2
MICROSPACER - spacer/aerosolholding chambers - device
3
31 x 5/16"
3
MONOJECT ULTRA COMFORT
IN - insulin syringe/needle u-100
0.3 ml 29 x 1/2"
2
MICROTAINER SAFETY FLOW L
- lancets
MINI LANCING DEVICE - lancet
devices
3
2
MONOJECT INSULIN SYRINGE insulin syringe (disp) u-100 1 ml
2
0.3 ml 30 x 5/16"
210
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
1/2 ml 31 x 5/16"
2
MS INSULIN SYRINGE/0.3ML/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
1/2 ml 28 x 1/2"
2
ml 30 x 5/16"
2
1/2 ml 29 x 1/2"
2
ml 31 x 5/16"
2
1/2 ml 30 x 5/16"
2
MS INSULIN SYRINGE/0.5ML/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
1 ml 28 x 1/2"
2
ml 29 x 1/2"
2
1 ml 29 x 1/2"
2
ml 30 x 5/16"
2
1 ml 30 x 5/16"
2
MS INSULIN SYRINGE/1ML/29 insulin syringe/needle u-100 1 ml
29 x 1/2"
2
0.3 ml 31 x 5/16"
2
30 x 5/16"
2
MONOLET LANCETS - lancets
3
2
MONOLET OPD LANCETS lancets
3
31 x 5/16"
MONOLETTOR SAFETY
LANCETS - lancets
3
MULTI-LANCET DEVICE - lancet
devices
1
MOORE MED MONOJECT INSULI
ml 28 x 1/2"
2
MYGLUCOHEALTH BLOOD
3
ml 29 x 1/2"
2
ml 28 x 1/2"
2
3
MYGLUCOHEALTH CONTROL
LOW - blood glucose calibration liquid
3
MYGLUCOHEALTH MGH
SOFTLAN - lancets
3
NETGROUP LANCETS - lancets
ml 29 x 1/2"
2
NEUTEK 2TEK CONTROL SOLUT
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
3
211
NEXGEN NORMAL CONTROL blood glucose calibration - liquid
- normal
3
NOVOTWIST 30GX8MM - insulin
5/16")
2
NORDIPEN 5 INJECTION DEVI injection device - misc
3
2
NOVA MAX BLOOD GLUCOSE
kit w/ device
3
NOVOTWIST 32GX5MM - insulin
3/16")
OMNIFLEX DIAPHRAGM diaphragms
A
NOVA MAX PLUS GLU/KET CON
3
OMNITROPE PEN 5 INJECTION injection device - misc
3
NOVA SAFETY LANCETS 23G lancets
3
3
NOVA SAFETY LANCETS 28G lancets
3
ON CALL EXPRESS BLOOD GLU
device
3
NOVA SUREFLEX LANCETS lancets
3
ON CALL EXPRESS GLUCOSE C
ON CALL LANCETS - lancets
3
NOVA SUREFLEX LANCING DEV
- lancet devices
3
ON CALL LANCING DEVICE lancet devices
3
NOVOFINE AUTOCOVER
30GX8M - insulin pen needle 30
g x 8 mm (1/3" or 5/16")
2
ON CALL PLUS BLOOD GLUCOS
device
3
NOVOFINE PLUS 32GX4MM insulin pen needle 32 g x 4 mm
(5/32")
2
ON CALL PLUS GLUCOSE CONT
3
NOVOFINE 30GX8MM - insulin
5/16")
ON CALL PLUS LANCETS lancets
3
2
ON CALL PLUS LANCING DEVI lancet devices
3
NOVOFINE 32GX6MM - insulin
2
3
NOVOPEN ECHO - injection
device for insulin
2
ON CALL VIVID BLOOD GLUCO
device
NOVOPEN JR (GREEN) - injection
device for insulin
ON CALL VIVID GLUCOSE CON blood glucose calibration - liquid
3
2
NOVOPEN JR (YELLOW) injection device for insulin
ON CALL VIVID PAL BLOOD G blood glucose monitoring kit w/
device
3
2
NOVOPEN 3 INSULIN DELIVER injection device for insulin
2
2
NOVOPEN 3 PENMATE - injection
device for insulin
2
ONETOUCH BASIC SYSTEM blood glucose monitoring kit w/
device
ONETOUCH CLUB LANCETS FIN
- lancets
2
212
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
ONETOUCH COMBO PACK lancets
2
ONETOUCH DELICA LANCETS E
- lancets
2
ONETOUCH DELICA LANCETS F
- lancets
ONETOUCH VERIO MID
3
2
2
ONETOUCH VERIO SYNC
BLOOD - blood glucose
ONETOUCH DELICA LANCING D
- lancet devices
3
OPTICHAMBER - spacer/aerosolholding chambers - device
3
ONETOUCH FINEPOINT LANCET
- lancets
2
3
ONETOUCH LANCETS - lancets
2
OPTICHAMBER ADVANTAGE spacer/aerosol-holding chambers
- device
2
OPTICHAMBER ADVANTAGE/
LAR - spacer/aerosol-holding
chambers - device
3
ONETOUCH PROFILE SYSTEM
device
3
MED - spacer/aerosol-holding
chambers - device
3
ONETOUCH ULTRA CONTROL blood glucose calibration - liquid
ONETOUCH ULTRA MINI - blood
2
3
ONETOUCH ULTRA SYSTEM KIT
device
2
SMA - spacer/aerosol-holding
chambers - device
3
ONETOUCH ULTRA 2 - blood
2
OPTICHAMBER DIAMOND spacer/aerosol-holding chambers
- device
ONETOUCH ULTRALINK
SYSTEM - blood glucose
OPTICHAMBER DIAMOND/
LARGE - spacer/aerosol-holding
chambers - device
3
2
3
ONETOUCH ULTRASMART blood glucose monitoring kit w/
device
2
MEDIU - spacer/aerosol-holding
chambers - device
ONETOUCH ULTRASOFT
LANCET - lancets
SMALL - spacer/aerosol-holding
chambers - device
3
2
ONETOUCH ULTRASOFT
LANCET - lancets
3
OPTIHALER - spacer/aerosolholding chambers - device
3
ONETOUCH VERIO - blood
2
3
ONETOUCH VERIO CONTROL
SO - blood glucose calibration liquid - high
3
OPTIHALER MDI DRUG DELIVE spacer/aerosol-holding chambers
- device
3
ONETOUCH VERIO IQ BLOOD G
device
2
OPTIUM BLOOD GLUCOSE MONI
device
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
213
MET - blood glucose monitoring
kit w/ device
3
kit w/ device
3
OPTUMRX GLUCOSE CONTROL
L - blood glucose calibration liquid
3
ORSINI INSULIN SYRINGE/U- insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
ORSINI INSULIN SYRINGE/U- insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
ORSINI INSULIN SYRINGE/U- insulin syringe/needle u-100 1 ml
30 x 5/16"
2
ORTHO DIAPHRAGM ALL-FLEX/ - A
diaphragm arc-spring 65 mm
A
ORTHO DIAPHRAGM COIL SPRI
- diaphragm coil spring kit 50 mm
A
- diaphragm coil spring kit 100
mm
A
- diaphragm coil spring kit 105
mm
A
ORTHO DIAPHRAGM FLAT SPRI
- diaphragm flat spring kit 55 mm
A
A
214
A
A
A
A
A
A
PARADIGM LINK BLOOD GLUCO
device
3
PC LANCETS SUPER THIN 30G lancets
3
PC UNIFINE PENTIPS 29G X insulin pen needle 29 g x 12 mm
(1/2")
2
(3/16")
2
(1/4")
2
(1/3" or 5/16")
2
PCA INJECTOR - injection device - 1
misc
2
PEN NEEDLES 29G X 12MM insulin pen needle 29 g x 12 mm
(1/2")
PEN NEEDLES 29GX1/2" - insulin 2
2
PEN NEEDLES 30GX5/16" insulin pen needle 30 g x 8 mm
(1/3" or 5/16")
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
PEN NEEDLES 31G X 1/4" SH insulin pen needle 31 g x 6 mm
(1/4")
2
PRECISION LINK - blood glucose
3
PEN NEEDLES 31G X 3/16" insulin pen needle 31 g x 5 mm
(3/16")
PRECISION SURE-DOSE INSUL insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
2
2
PEN NEEDLES 31G X 6MM insulin pen needle 31 g x 6 mm
(1/4")
2
PRECISION SURE-DOSE INSUL insulin syringe/needle u-100 1/2
ml 30 x 3/8"
2
ml 28 x 1/2"
2
PEN NEEDLES 31GX5/16" insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
PERFECT LANCETS 30G lancets
ml 29 x 1/2"
2
3
PERFECT PRESSURE ACTIVATE
- lancets
3
2
PHARMACIST CHOICE
AUTOCOD - blood glucose
3
PRECISION SURE-DOSE INSUL insulin syringe/needle u-100 1 ml
28 x 1/2"
2
PHARMACIST CHOICE ULTRA T
- lancets
3
PRECISION SURE-DOSE PLUS insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
PHARMACY COUNTER
LANCETS - lancets
3
PRECISION SURE-DOSE PLUS insulin syringe/needle u-100 1 ml
29 x 1/2"
POCKET CHAMBER - spacer/
3
PRECISION THIN LANCETS lancets
3
3
POCKET SPACER - spacer/
3
PRECISION THINS GP LANCET lancets
PRECISION ULTRA LANCET lancets
3
POCKETCHEM EZ BLOOD
3
PREFERRED PLUS INSULIN SY insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
POCKETCHEM EZ CONTROL
LEV - blood glucose calibration liquid
3
PREFERRED PLUS INSULIN SY insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
PRECISION GLUCOSE
3
PREFERRED PLUS INSULIN SY insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
PRECISION GLUCOSE KETONE - 3
PRECISION GLUCOSE/KETONE - 3
ml 29 x 1/2"
2
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
215
ml 30 x 5/16"
2
PREFERRED PLUS INSULIN SY insulin syringe/needle u-100 1 ml
28 x 1/2"
2
29 x 1/2"
2
30 x 5/16"
2
PREFERRED PLUS LANCETS CO
- lancets
3
PREFERRED PLUS LANCETS SU
- lancets
3
PREFERRED PLUS LANCETS TH
- lancets
3
PREFERRED PLUS UNIFINE PE insulin pen needle 29 g x 12 mm
(1/2")
2
PREFERRED PLUS UNIFINE PE
(3/16")
2
(1/4")
2
(1/3" or 5/16")
2
(5/32")
2
PRENTIF CAVITY-RIM CERVIC cervical cap 22 mm
A
A
A
A
216
PRENTIF FITTING SET - cervical
caps
A
PRODIGY AUTOCODE BLOOD
GL - blood glucose monitoring kit
w/ device
3
3
PRODIGY AUTOCODE PRO
BLOO - blood glucose monitoring
kit w/ device
3
PRODIGY CONTROL SOLUTION
- high
3
PRODIGY CONTROL SOLUTION
- low
2
PRODIGY INSULIN MINI PEN insulin pen needle 31 g x 5 mm
(3/16")
2
PRODIGY INSULIN SHORT PEN
(1/3" or 5/16")
2
PRODIGY INSULIN SYRING/U- insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
PRODIGY INSULIN SYRINGE/1 insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
PRODIGY INSULIN SYRINGE/1 insulin syringe/needle u-100 1 ml
28 x 1/2"
3
PRODIGY LANCING DEVICE lancet devices
3
PRODIGY POCKET BLOOD
kit w/ device
3
PRODIGY POCKET PRO BLOOD
device
PRODIGY PRESSURE ACTIVATE 3
- lancets
3
PRODIGY TWIST TOP LANCETS
- lancets
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
PRODIGY VOICE BLOOD GLUCO
device
3
PX PEN NEEDLE 31GX8MM insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
PSS SELECT GP LANCETS lancets
3
2
PSS SELECT SAFETY LANCETS
- lancets
3
PX SHORTLENGTH PEN
NEEDLE - insulin pen needle 31
g x 8 mm (1/3" or 5/16")
3
PX ADVANCED LANCING DEVIC
- lancet devices
3
Q-CARE Q2 ORAL CLEANSING/ oral hygiene products - kit
3
PX EXTRA SHORT PEN NEEDLE
(1/4")
2
Q-CARE Q4 ORAL CLEANSING/ oral hygiene products - kit
QC ADVANCED LANCING DEVIC
- lancet devices
3
PX INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 0.3
ml 30 x 1/2"
2
QC INSULIN SYRINGE 0.5ML/ insulin syringe/needle u-100 1/2
ml 29 g
2
PX INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
QC INSULIN SYRINGE 0.5ML/ insulin syringe/needle u-100 1/2
ml 30 g
2
PX INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
QC INSULIN SYRINGE/0.3ML/ insulin syringe/needle u-100 0.3
ml 29 g
2
PX INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml
30 x 1/2"
2
QC INSULIN SYRINGE/0.3ML/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
PX INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml
31 x 5/16"
2
QC INSULIN SYRINGE/0.5ML/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
PX INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
QC INSULIN SYRINGE/0.5ML/ insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
PX LANCET AUTO INJECTOR lancet devices
3
2
PX LANCETS - lancets
3
QC INSULIN SYRINGE/1ML/29 insulin syringe/needle u-100 1 ml
29 x 1/2"
PX LANCETS ULTRA THIN lancets
3
2
PX MINI PEN NEEDLES 31GX5 insulin pen needle 31 g x 5 mm
(3/16")
2
30 g
2
PX PEN NEEDLE 29GX12MM insulin pen needle 29 g x 12 mm
(1/2")
2
31 x 5/16"
QC LANCETS SUPER THIN lancets
3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
217
QC LANCETS ULTRA THIN lancets
3
RA LANCING DEVICE - lancet
devices
3
QC PEN NEEDLES 29G X 12MM insulin pen needle 29 g x 12 mm
(1/2")
2
RA PEN NEEDLES 31G X 5MM insulin pen needle 31 g x 5 mm
(3/16")
2
(1/4")
2
RA PEN NEEDLES 31G X 8MM insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
(1/3" or 5/16")
2
RA TRUERESULT BLOOD
3
QC UNIFINE PENTIPS 32GX4M insulin pen needle 32 g x 4 mm
(5/32")
2
RA TRUE2GO BLOOD GLUCOSE
device
3
QUICKTEK - blood glucose
3
2
QUICKTEK CONTROL SOLUTION
3
REALITY INSULIN SYRINGE/U insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
QUINTET GLUCOSE CONTROL/H
3
REALITY INSULIN SYRINGE/U insulin syringe/needle u-100 1/2
ml 29 x 1/2"
RA E-ZJECT COLOR LANCETS lancets
3
2
RA E-ZJECT LANCETS THIN 2 lancets
3
REALITY INSULIN SYRINGE/U insulin syringe/needle u-100 1 ml
28 x 1/2"
2
RA E-ZJECT LANCETS ULTRA lancets
3
REALITY INSULIN SYRINGE/U insulin syringe/needle u-100 1 ml
29 x 1/2"
3
REALITY LANCETS - lancets
3
RA E-ZJECT LANCETS 28G lancets
3
RA INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
REALITY TRIGGER LANCETS lancets
3
RA INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml
30 x 5/16"
2
REFUAH PLUS BLOOD
3
RA INSULIN SYRINGE/0.5ML/ insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
REFUAH PLUS GLUCOSE
3
RA INSULIN SYRINGE/1ML/29 insulin syringe/needle u-100 1 ml
29 x 1/2"
2
RELION CONFIRM BLOOD GLUC
device
RELION INSULIN SYRINGE/U insulin syringe/needle u-100 1/2
ml 29 g
2
218
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
RELION INSULIN SYRINGE/U- insulin syringe/needle u-100 0.3
ml 29 g
2
ml 30 g
2
ml 29 x 1/2"
2
ml 30 x 5/16"
2
RELION INSULIN SYRINGE/U- insulin syringe/needle u-100 1/2
ml 30 g
2
ml 31 x 5/16"
2
ml 29 x 1/2"
2
ml 30 x 5/16"
2
RELION INSULIN SYRINGE/U- insulin syringe/needle u-100 1 ml
29 x 1/2"
2
30 g
2
30 x 5/16"
2
31 x 5/16"
2
ml 31 x 5/16"
2
RELION LANCETS - lancets
3
RELION LANCETS MICRO-THIN lancets
3
RELION LANCETS STANDARD 2
- lancets
3
RELION LANCETS THIN 26G lancets
3
RELION LANCETS ULTRA-THIN lancets
3
RELION LANCING DEVICE lancet devices
3
RELION MICRO BLOOD GLUCOS
device
3
RELION MINI PEN NEEDLES 3 insulin pen needle 31 g x 6 mm
(1/4")
2
RELION PEN NEEDLES 29GX12 insulin pen needle 29 g x 12 mm
(1/2")
2
RELION PEN NEEDLES 31GX8M
(1/3" or 5/16")
2
RELION PEN NEEDLES 32GX4M
(5/32")
2
RELION SHORT PEN NEEDLES
(1/3" or 5/16")
2
RELION THIN LANCETS - lancets
3
RELION ULTIMA BLOOD GLUCO
device
3
RELION ULTRA THIN LANCETS lancets
3
RELION ULTRA THIN PLUS LA lancets
3
REMESENSE - dental
desensitizing product - misc
3
RENEW ADVANCED LANCING
CA - lancets
3
RENEW ADVANCED LANCING
DE - lancet devices
3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
219
REVEAL BLOOD GLUCOSE
kit w/ device
3
SAFESNAP INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
REXALL BLOOD GLUCOSE MONI
device
3
SAFESNAP INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
28 x 1/2"
2
REXALL LANCETS ULTRA THIN lancets
3
2
RIGHTEST GC300 HIGH CONTR
- high
3
SAFESNAP INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
29 x 1/2"
SAFETY LANCET 2MM - lancets
3
RIGHTEST GC300 NORMAL CON
- normal
SAFETY LANCET 21G/PRESSUR
- lancets
1
3
SAFETY LANCET 28G/PRESSUR
- lancets
1
RIGHTEST GD500 LANCING DE lancet devices
3
SAFETY LANCETS - lancets
3
3
SAFETY LANCETS 21G - lancets
3
RIGHTEST GL300 LANCETS lancets
SAFETY LANCETS 28G - lancets
1
RIGHTEST GM100 BLOOD GLUC
device
3
SAFETY LET LANCETS - lancets
3
SAFETY SEAL LANCETS 28G lancets
3
device
3
SAFETY SEAL LANCETS 30G lancets
3
device
SAFETY-GLIDE INSULIN SYRI insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
3
3
SAPSCARE TWIST TOP LANCET
- lancets
3
RITEFLO - spacer/aerosol-holding
chambers - device
SB INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
SB INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
SB INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml
29 x 1/2"
2
30 x 5/16"
2
SAFE-T-LANCE LOW FLOW 25G - 3
lancets
SAFE-T-LANCE NORMAL FLOW - 3
lancets
3
SAFE-T-LANCE PLUS SAFETY lancets
SAFESNAP INSULIN SYRINGE/ - 2
insulin syringe/needle u-100 0.3
ml 30 x 5/16"
SAFESNAP INSULIN SYRINGE/ - 2
insulin syringe/needle u-100 1/2
ml 29 x 1/2"
220
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
31 x 5/16"
2
SM INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
SB LANCETS THIN - lancets
3
2
SB LANCETS ULTRA THIN lancets
3
SM INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2
ml 28 x 1/2"
SCHNUCKS INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
ml 29 x 1/2"
2
SCHNUCKS INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
ml 30 x 5/16"
2
SELECT-LITE LANCING DEVIC lancet devices
3
2
SHOPKO AUTOLET LANCING DE
- lancet devices
3
SM INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml
28 x 1/2"
2
SHOPKO ON-THE-GO COMFORT
- lancets
3
29 x 1/2"
2
30 x 5/16"
2
SHOPKO UNIFINE PENTIPS PE insulin pen needle 29 g x 12 mm
(1/2")
2
SM INSULIN SYRINGE/0.3ML/ insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
SHOPKO UNIFINE PENTIPS PE
(3/16")
2
SM INSULIN SYRINGE/0.5ML/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
(1/3" or 5/16")
2
SM INSULIN SYRINGE/1ML/31 insulin syringe/needle u-100 1 ml
31 x 5/16"
2
(5/32")
3
SM LANCETS 21G - lancets
3
SHOPKO UNILET LANCETS SUP
- lancets
3
SHOPKO UNILET LANCETS ULT
- lancets
3
SM MICRO THIN LANCETS 33G lancets
3
SIMPLE DIAGNOSTICS LANCIN lancet devices
3
SM SUPER THIN LANCETS 30G lancets
SM THIN LANCETS 26G - lancets
3
SINGLE-LET - lancets
3
2
SM INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
SM ULTRA COMFORT INSULIN insulin syringe/needle u-100 1 ml
30 x 5/16"
SMART DIABETES VANTAGE LA
- lancet devices
3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
221
SMART DIABETES VANTAGE UN
- lancets
3
SMART DIABETES XPRES BLOO
device
3
3
SOLUS V2 CONTROL HIGH blood glucose calibration - liquid
- high
3
SMART SENSE COLOR
LANCETS - lancets
3
SOLUS V2 CONTROL LOW blood glucose calibration - liquid
- low
3
SMART SENSE PREMIUM
BLOOD - blood glucose
3
SOLUS V2 LANCING DEVICE lancet devices
SOLUS V2 PRESSURE ACTIVAT
- lancets
3
SMART SENSE STANDARD
LANC - lancets
3
SOLUS V2 TWIST LANCETS 30 lancets
3
STERILANCE TL - lancets
3
SUPER THIN LANCETS - lancets
3
SURE COMFORT INSULIN SYRI insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ml 30 x 5/16"
2
ml 30 x 1/2"
2
SURE COMFORT INSULIN SYRI insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
ml 28 x 1/2"
2
ml 29 x 1/2"
2
ml 30 x 5/16"
2
ml 30 x 1/2"
2
SURE COMFORT INSULIN SYRI insulin syringe/needle u-100 1 ml
28 x 1/2"
2
SMART SENSE SUPER THIN LA - 3
lancets
SMART SENSE THIN LANCETS - 3
lancets
SMART SENSE VALUE BLOOD - 3
blood glucose monitoring kit w/
device
3
SMARTEST CONTROL
3
SMARTEST EJECT STARTER KI
device
3
SMARTEST LANCETS 28G lancets
SMARTEST PERSONA STARTER 3
device
3
SMARTEST PRONTO STARTER
device
SMARTEST PROTEGE STARTER 3
device
SOLARTEK GLUCOSE CONTROL 3
3
SOLUS V2 AUDIBLE BLOOD GL
device
222
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
29 x 1/2"
2
SURE EDGE GLUCOSE
3
30 x 5/16"
2
SURE EDGE GLUCOSE
3
30 x 1/2"
2
SURE-FINE PEN NEEDLES 29G
mm
2
31 x 5/16"
2
(3/16")
2
ml 31 x 5/16"
2
(1/3" or 5/16")
2
SURE COMFORT LANCETS 28G
- lancets
3
2
SURE COMFORT LANCETS 30G
- lancets
3
SURE-JECT INSULIN SYRINGE insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
SURE COMFORT LANCING PEN
- lancet devices
3
ml 30 x 5/16"
SURE COMFORT PEN NEEDLES
mm
2
SURE-JECT INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
(1/3" or 5/16")
2
ml 28 x 1/2"
2
(3/16")
2
ml 29 x 1/2"
2
(1/3" or 5/16")
2
ml 30 x 5/16"
2
(5/32")
2
SURE-JECT INSULIN SYRINGE insulin syringe/needle u-100 1 ml
28 x 1/2"
2
(1/4")
2
29 x 1/2"
2
SURE EDGE GLUCOSE
3
30 x 5/16"
2
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
223
31 x 5/16"
2
TAI DOC CONTROL - blood
glucose calibration - liquid normal
3
ml 31 x 5/16"
2
TECHLITE AST LANCETS lancets
3
TECHLITE LANCETS - lancets
3
SURE-LANCE FLAT LANCETS lancets
3
TECHLITE LANCETS 30G lancets
3
SURE-LANCE LANCETS 26G lancets
3
3
SURE-LANCE THIN LANCETS 2 lancets
3
TELCARE BLOOD GLUCOSE
kit w/ device
SURE-LANCE ULTRA THIN LAN lancets
TELCARE GLUCOSE CONTROL
3
3
SURE-PEN - lancet devices
3
2
SURE-TOUCH LANCETS UNIVER
- lancets
3
TERUMO INSULIN SYRINGE/U- insulin syringe/needle u-100 0.3
ml 29 x 1/2"
SURECHEK BLOOD GLUCOSE
kit w/ device
3
TERUMO INSULIN SYRINGE/U- insulin syringe/needle u-100 1/2
ml 27 x 1/2"
2
SURECHEK GLUCOSE
3
TERUMO INSULIN SYRINGE/U- insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
SURECHEK GLUCOSE
3
TERUMO INSULIN SYRINGE/U- insulin syringe/needle u-100 1 ml
28 x 1/2"
2
SURECHEK GLUCOSE
3
TERUMO INSULIN SYRINGE/0. insulin syringe/needle u-100 1/2
ml 30 x 3/8"
2
SURELITE LANCETS - lancets
3
2
SURESTEP GLUCOSE CONTROL
3
TERUMO INSULIN SYRINGE/0. insulin syringe/needle u-100 1/2
ml 29 x 1/2"
SURESTEP PRO HIGH
3
SURESTEP PRO LOW GLUCOSE
- low
3
SURESTEP PRO NORMAL
3
224
TERUMO INSULIN SYRINGE/1M - 2
27 x 1/2"
TERUMO INSULIN SYRINGE/1M - 2
29 x 1/2"
TERUMO SURGUARD INSULIN S 2
ml 29 x 1/2"
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
TERUMO SURGUARD INSULIN S
ml 28 x 1/2"
2
THINPRO INSULIN SYRINGE/0 insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
ml 29 x 1/2"
2
ml 29 x 1/2"
2
ml 28 x 1/2"
2
THINPRO INSULIN SYRINGE/1 insulin syringe/needle u-100 1 ml
28 x 1/2"
2
ml 29 x 1/2"
2
THINPRO INSULIN SYRINGE/1 insulin syringe/needle u-100 1 ml
29 x 1/2"
2
TGT ADVANCED LANCING DEVI
- lancet devices
3
TODAYS HEALTH ADVANCED LA
- lancet devices
3
TGT BLOOD GLUCOSE
MONITOR - blood glucose
3
TODAYS HEALTH MINI PEN NE
(1/4")
2
TGT LANCET ALTERNATE SITE lancets
3
TGT LANCET MICRO THIN 33G lancets
3
TGT LANCET SUPER THIN 30G lancets
3
TGT LANCET THIN 23G - lancets
3
TGT LANCET THIN 26G - lancets
3
TGT LANCET ULTRA THIN 28G lancets
3
TGT LANCET ULTRA THIN 30G lancets
3
TGT LANCING DEVICE - lancet
devices
3
THINLETS GP LANCETS - lancets
3
THINLETS LANCET - lancets
3
THINPRO INSULIN SYRINGE/0 insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ml 30 x 3/8"
2
TODAYS HEALTH ORIGINAL PE - 2
(1/2")
TODAYS HEALTH SHORT PEN N 2
(1/3" or 5/16")
TODAYS HEALTH SUPER THIN - 3
lancets
TODAYS HEALTH ULTRA THIN - 3
lancets
2
TOPCARE CLICKFINE UNIVERS
(1/4")
2
TOPCARE CLICKFINE UNIVERS
(1/3" or 5/16")
TOPCARE ULTRA COMFORT INS 2
ml 29 x 1/2"
ml 30 x 5/16"
ml 31 x 5/16"
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
225
TOPCARE ULTRA COMFORT INS
ml 29 x 1/2"
2
TRUE METRIX CONTROL SOLUT
- normal
3
ml 30 x 5/16"
2
- low
3
ml 29 x 1/2"
2
TRUECONTROL GLUCOSE
3
ml 30 x 5/16"
2
TRUEDRAW LANCING DEVICE lancet devices
3
ml 31 x 5/16"
TRUEPLUS INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
2
ml 31 x 5/16"
ml 30 x 5/16"
2
2
2
TRUEPLUS INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
TOPCO INSULIN SYRINGE/U-1 insulin syringe/needle u-100 0.3
ml 29 x 1/2"
TOPCO INSULIN SYRINGE/U-1 insulin syringe/needle u-100 1/2
ml 28 x 1/2"
ml 28 x 1/2"
2
2
TOPCO INSULIN SYRINGE/U-1 insulin syringe/needle u-100 1/2
ml 29 x 1/2"
ml 29 x 1/2"
2
2
2
TOPCO INSULIN SYRINGE/U-1 insulin syringe/needle u-100 1 ml
28 x 1/2"
2
ml 30 x 5/16"
2
TRUEPLUS INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
28 x 1/2"
2
TOPCO INSULIN SYRINGE/U-1 insulin syringe/needle u-100 1 ml
29 x 1/2"
TRAVEL LANCETS 30G - lancets
TRUE METRIX AIR - blood
3
29 x 1/2"
2
3
2
TRUE METRIX BLOOD GLUCOSE
device
3
30 x 5/16"
2
- high
3
31 x 5/16"
226
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
ml 31 x 5/16"
2
ULTICARE INSULIN SAFETY S insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
TRUEPLUS LANCETS 26G lancets
3
2
3
ULTICARE INSULIN SAFETY S insulin syringe/needle u-100 1 ml
29 x 1/2"
2
TRUEPLUS LANCETS 28G SUPE
- lancets
3
ULTICARE INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 31 x 5/16"
3
2
TRUEPLUS LANCETS 30G ULTR
- lancets
3
ULTICARE INSULIN SYRINGE insulin syringe/needle u-100 1 ml
31 x 5/16"
2
3
ULTICARE INSULIN SYRINGE insulin syringe/needle u-100 0.3
ml 31 x 5/16"
3
ULTICARE INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
TRUEPLUS LANCETS 33G MICR
- lancets
TRUEPLUS SAFETY LANCETS 2
- lancets
3
2
TRUERESULT BLOOD GLUCOSE
device
3
ml 30 x 5/16"
2
TRUETEST GLUCOSE CONTROL
3
ml 30 x 1/2"
TRUETRACK BLOOD GLUCOSE
M - blood glucose monitoring kit
w/ device
ULTICARE INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
3
3
ml 28 x 1/2"
2
TRUETRACK SMART SYSTEM blood glucose monitoring kit w/
device
TRUE2GO BLOOD GLUCOSE
kit w/ device
ml 29 x 1/2"
2
3
ULTI-LANCE AUTO-ADJUST DE lancet devices
ml 30 x 5/16"
2
3
ULTI-LANCE AUTOMATIC/ CLE lancet devices
3
2
ULTI-LANCE MINI ADJUSTABL lancet devices
3
ml 30 x 1/2"
ULTICARE INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
28 x 1/2"
2
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
227
29 x 1/2"
2
ULTIGUARD INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
30 x 5/16"
2
ULTIGUARD INSULIN SYRINGE insulin syringe/needle u-100 1 ml
29 x 1/2"
2
30 x 1/2"
2
ULTIGUARD INSULIN SYRINGE insulin syringe/needle u-100 1 ml
30 x 5/16"
2
31 x 5/16"
2
ULTILET BASIC LANCETS 30G lancets
3
ml 31 x 5/16"
ULTILET CLASSIC LANCETS lancets
3
2
2
ULTICARE MICRO PEN NEEDLE
(5/32")
2
ULTILET INSULIN SYRINGE/S insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
ULTICARE MINI PEN NEEDLES insulin pen needle 31 g x 6 mm
(1/4")
2
ULTILET INSULIN SYRINGE/S insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
ULTICARE ORIGINAL PEN NEE insulin pen needle 29 g x 12 mm
(1/2")
2
ULTILET INSULIN SYRINGE/S insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
ULTICARE PEN NEEDLES/29G
mm
2
ULTILET INSULIN SYRINGE/S insulin syringe/needle u-100 1 ml
30 x 5/16"
2
ULTICARE SHORT PEN NEEDLE
(1/3" or 5/16")
2
ULTILET INSULIN SYRINGE/S insulin syringe/needle u-100 1 ml
31 x 5/16"
2
ULTICARE THIN LANCETS 30G lancets
3
ULTILET INSULIN SYRINGE/S insulin syringe/needle u-100 0.3
ml 31 x 5/16"
ULTILET LANCETS - lancets
3
ULTIGUARD INSULIN SYRINGE insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ULTILET LANCETS 33G - lancets
3
3
ULTIGUARD INSULIN SYRINGE insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
ULTILET OPERATING DEVICE lancet devices
2
ULTIGUARD INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
ULTILET PEN NEEDLE 32GX4M
(5/32")
ULTILET SAFETY LANCETS 23 lancets
3
228
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
ULTILET SHORT PEN NEEDLES
(3/16")
2
ULTRA-COMFORT INSULIN SYR
ml 29 x 1/2"
2
ULTILET SHORT PEN NEEDLES
(1/3" or 5/16")
2
ml 30 x 5/16"
2
ULTILET ULTI-LANCE ADJ DE lancet devices
3
2
ULTRA COMFORT INSULIN SYR
ml 30 x 5/16"
2
ml 31 x 5/16"
2
ml 31 x 5/16"
2
ml 28 x 1/2"
2
ml 28 x 1/2"
2
ml 29 x 1/2"
2
ml 29 x 1/2"
2
ml 30 x 5/16"
2
ml 30 x 1/2"
2
ml 28 x 1/2"
2
ml 29 x 1/2"
2
ml 29 x 1/2"
2
ml 30 x 1/2"
2
ml 30 x 5/16"
2
ml 31 x 5/16"
2
ml 31 x 5/16"
2
ULTRA INSULIN SYRINGE/U-1 insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
ml 31 x 5/16"
ULTRA-THIN II AUTO LANCET lancets
3
ULTRA THIN LANCETS 28G lancets
3
2
ULTRA THIN LANCETS 30G lancets
3
ULTRA-THIN II INSULIN SYR insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ULTRA TRAK PRO BLOOD GLUC
device
3
ml 30 x 5/16"
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
229
ULTRA-THIN II INSULIN SYR insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
ULTRATRAK ULTIMATE
3
ml 29 x 1/2"
2
UNIFINE PENTIPS PLUS 29GX insulin pen needle 29 g x 12 mm
(1/2")
2
ml 30 x 5/16"
2
(3/16")
2
ULTRA-THIN II INSULIN SYR insulin syringe/needle u-100 1 ml
29 x 1/2"
2
(1/4")
2
30 x 5/16"
2
(1/3" or 5/16")
2
31 x 5/16"
2
(5/32")
2
ml 31 x 5/16"
2
UNIFINE PENTIPS 29GX12MM insulin pen needle 29 g x 12 mm
(1/2")
2
ULTRA-THIN II LANCETS 28G lancets
3
2
ULTRA-THIN II LANCETS 30G lancets
3
UNIFINE PENTIPS 31G X 3/1 insulin pen needle 31 g x 5 mm
(3/16")
2
ULTRA-THIN II MINI PEN NE insulin pen needle 31 g x 5 mm
(3/16")
2
UNIFINE PENTIPS 31G X 6MM insulin pen needle 31 g x 6 mm
(1/4")
2
ULTRA-THIN II PEN NEEDLES insulin pen needle 29 g x 12.7
mm
2
UNIFINE PENTIPS 31G X 8MM insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
ULTRA-THIN II PEN NEEDLES insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
(3/16")
2
ULTRA-THIN II SAFETY AUTO lancets
3
(1/4")
ULTRATRAK PRO CONTROL
SOL - blood glucose calibration liquid
3
(1/3" or 5/16")
2
3
ULTRATRAK PRO NORMAL
- liquid - normal
(5/32")
2
230
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
UNILET COMFORTOUCH
LANCET - lancets
3
UNILET EXCELITE - lancets
3
UNILET EXCELITE II - lancets
3
UNILET G.P. LANCET - lancets
3
UNILET G.P. SUPERLITE LAN lancets
3
UNILET GP 28 ULTRA THIN lancets
3
UNILET LANCET - lancets
3
UNILET LANCETS MICRO-THIN lancets
3
UNILET LANCETS SUPER-THIN lancets
V-R MONOJECT INSULIN SYRI insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
V-R MONOJECT INSULIN SYRI insulin syringe/needle u-100 1 ml
28 x 1/2"
2
V-R MONOJECT INSULIN SYRI insulin syringe/needle u-100 1 ml
29 x 1/2"
2
VALUE HEALTH INSULIN SYRI insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
2
3
VALUE HEALTH INSULIN SYRI insulin syringe/needle u-100 1 ml
29 x 1/2"
UNILET LANCETS ULTRA-THIN lancets
3
VALUE PLUS LANCETS STANDA
- lancets
3
UNILET SUPERLITE LANCET lancets
3
VALUE PLUS LANCETS SUPER lancets
3
UNISTIK SAFETY LANCETS 28 lancets
3
VALUE PLUS LANCETS THIN 2 lancets
3
UNISTIK SAFETY LANCETS 30 lancets
3
VALUE PLUS LANCING DEVICE lancet devices
3
UNISTIK 3 GENTLE - lancets
3
3
UNISTRIP CONTROL SOLUTION
- high
3
VALUMARK LANCET SUPER THI
- lancets
VALUMARK LANCET ULTRA THI
- lancets
3
UNISTRIP CONTROL SOLUTION
- low
3
VALUMARK PEN NEEDLES 29GX
mm (1/2")
2
UNIVERSAL 1 LANCETS THIN lancets
3
2
UNIVERSAL 1 LANCETS ULTRA lancets
3
VALUMARK PEN NEEDLES 31G
(1/4")
2
V-R MONOJECT INSULIN SYRI insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
VALUMARK PEN NEEDLES 31G
(1/3" or 5/16")
3
V-R MONOJECT INSULIN SYRI insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
VALVED HOLDING CHAMBER spacer/aerosol-holding chambers
- device
VANISHPOINT INSULIN SYRIN insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
231
VANISHPOINT INSULIN SYRIN insulin syringe/needle u-100 1 ml
29 x 1/2"
2
VICTORY CONTROL LEVEL 1/2 blood glucose calibration - liquid
3
VIDA MIA AUTOLET LANCING lancet devices
3
VIDA MIA UNIFINE PENTIPS insulin pen needle 29 g x 12 mm
(1/2")
2
(1/4")
2
(5/32")
2
VIDA MIA UNILET LANCETS S lancets
3
VIDA MIA UNILET LANCETS U lancets
3
VIDA MIA UNIPFINE PENTIPS insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
VITALET PRO LANCETS - lancets
3
VITALET PRO PLUS LANCETS lancets
3
VOCAL POINT GLUCOSE CONTR
- high
WALGREENS ADVANCED
TRAVEL - lancets
3
WALGREENS COMFORT
ASSURED - lancets
3
WALGREENS LANCETS - lancets
3
WALGREENS THIN LANCETS lancets
3
WALGREENS ULTRA THIN LANC
- lancets
3
WATCHHALER - spacer/aerosolholding chambers - device
3
WAVESENSE AMP - blood
3
WAVESENSE KEYNOTE - blood
3
WD MEDIC INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
WD MEDIC INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
WD MEDIC INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
2
3
WD MEDIC INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
VOCAL POINT GLUCOSE CONTR
- low
3
WD MEDIC INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
29 x 1/2"
2
VORTEX VALVED HOLDING
CHA - spacer/aerosol-holding
chambers - device
3
WD MEDIC INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
30 x 5/16"
2
VP INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
WEGMANS UNIFINE PENTIPS P
(3/16")
2
W&F LANCETS COLORED 21G lancets
3
(1/4")
W&F LANCETS 26G - lancets
3
232
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
(1/3" or 5/16")
2
1ST TIER UNIFINE PENTIPS insulin pen needle 31 g x 5 mm
(3/16")
2
(5/32")
2
(1/4")
2
WIDE-SEAL SILICONE DIAPHR diaphragm wide seal 60 mm
A
2
A
(1/3" or 5/16")
2
A
(5/32")
A
1ST TIER UNILET COMFORTOU - 3
lancets
A
PHARMACEUTICAL ADJUVANTS
A
ANHYDROUS CREAM BASE anhydrous cream base
A
A
XPRES CONTROL SOLUTION NO
- normal
3
1ST CHOICE LANCETS SUPER lancets
3
1ST CHOICE LANCETS THIN lancets
3
1ST CHOICE LANCETS ULTRA lancets
3
APOTHEDERM - transdermal base 3
cream
CAPS 0 CLEAR DELAYED RELE - 1
non gelatin capsules (empty)
CAPSULE #0 CLEAR/LOCKING/ - 1
CAPSULE CONI-SNAP #0 CLEA - 1
1
CHERRY SYRUP - cherry syrup
1ST CHOICE PEN NEEDLES 31 insulin pen needle 31 g x 6 mm
(1/4")
DERMACINRX TOPICAL SOLUTI
- external vehicles - solution
3
2
EMPTY CAPSULE SIZE 1 VEGE non gelatin capsules (empty)
1
1ST CHOICE PEN NEEDLES 31 insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
EXYDERM - transdermal patch
3
FLAVOR BLEND - oral vehicles
3
(1/2")
2
FLAVOR PLUS - oral vehicles
3
FLAVOR SWEET - oral vehicles
3
FLAVOR SWEET-SF - oral
vehicles
3
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
3
233
1
PLO20 BASE - premium lecithin
organogel base gel
3
1
POLYETHYLENE GLYCOL 8000 polyethylene glycol 8000 oint
1
LECITHIN ORGANOGEL premium lecithin organogel base
gel
PURIFIED WATER - distilled water
1
ORA-BLEND - oral vehicles
3
1
ORA-BLEND SF - oral vehicles
3
RASPBERRY SYRUP - raspberry
syrup
3
SALINE/PHENOL - saline w/
phenol inj
1
ORA-PLUS - oral vehicles
ORA-SWEET - oral vehicles
3
SIMPLE SYRUP - simple - syrup
1
ORA-SWEET SF - oral vehicles
3
SYRPALTA - oral vehicles
3
ORAL MIX FLAVORED SUSPEND
- oral vehicles
3
SYRPALTA - simple - syrup
3
3
SYRSPEND SF - oral vehicles
3
ORAL MIX SF - oral vehicles
1
VEGETABLE CAPSULE #0 GREE
- non gelatin capsules (empty)
1
ORAL SUSPEND - oral vehicles
ORAL SYRUP FLAVORED VEHIC
- oral vehicles
1
ORAL SYRUP SF - oral vehicles
1
PCCA ACACIA SYRUP BASE acacia syrup
3
PCCA COBASE #1 - cobase #1
ointment base
3
PCCA POLYPEG BASE polyethylene glycol ointment
3
PCCA SWEET-SF - oral vehicles
3
PCCA SYRUP VEHICLE - oral
vehicles
3
PCCA-PLUS - oral vehicles
3
VEGETABLE CAPSULE #0 WHIT - 1
VEGETABLE CAPSULE #00 WHI - 1
3
VERSAFREE - oral vehicles
PETROLATUM YELLOW petrolatum ointment
1
VERSAPLUS - oral vehicles
3
1
YELLOW PETROLATUM petrolatum ointment
1
PLACEBO #00 - placebo - cap
PLO GEL - MEDIFLO KIT premium lecithin organogel base
kit
3
ASSORTED CLASSES
234
sodium polystyrene sulfonate
powder (Kayexalate)
1
ASTAGRAF XL - tacrolimus cap sr
24hr 0.5 mg
3
Specialty
Quantity Limits
LANOLIN ANHYDROUS - lanolin
anhydrous
3
"Smart" PA
1
PLO GEL - MEDIFLO PRE-MIX premium lecithin organogel base
gel
Prior Authorization
LANOLIN - lanolin anhydrous oil
Drug Name
Drug Tier
1
Specialty
lanolin
Quantity Limits
3
"Smart" PA
KRISGEL 100 - krisgel 100 gel
Prior Authorization
Drug Name
Drug Tier
2015
•
24hr 1 mg
3
•
24hr 5 mg
3
•
AZASAN - azathioprine tab 75 mg
3
AZASAN - azathioprine tab 100 mg 3
1
azathioprine tab 50 mg (Imuran)
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
Specialty
Quantity Limits
"Smart" PA
Prior Authorization
Drug Name
Drug Tier
2015
mycophenolate sodium tab dr
180 mg (mycophenolic acid
equiv) (Myfortic)
1
•
mycophenolate sodium tab dr
360 mg (mycophenolic acid
equiv) (Myfortic)
1
•
MYFORTIC - mycophenolate
sodium tab dr 180 mg
(mycophenolic acid equiv)
3
•
MYFORTIC - mycophenolate
sodium tab dr 360 mg
(mycophenolic acid equiv)
3
•
NEORAL - cyclosporine modified
cap 25 mg
3
•
cap 100 mg
3
•
CELLCEPT - mycophenolate
mofetil cap 250 mg
3
•
mofetil tab 500 mg
3
•
mofetil for oral susp 200 mg/ml
3
•
CUPRIMINE - penicillamine cap
250 mg
3
cyclosporine cap 100 mg
(Sandimmune)
1
•
oral soln 100 mg/ml
3
•
cyclosporine cap 25 mg
(Sandimmune)
1
•
CYCLOSPORINE MODIFIED cyclosporine modified cap 50 mg
1
•
PROGRAF - tacrolimus cap 0.5 mg 3
3
PROGRAF - tacrolimus cap 1 mg
cyclosporine modified cap
100 mg (Neoral)
1
cyclosporine modified cap
25 mg (Neoral)
1
•
•
•
•
•
•
•
cyclosporine modified oral soln
100 mg/ml (Neoral)
1
DEPEN TITRATABS penicillamine tab 250 mg
3
IMURAN - azathioprine tab 50 mg
3
KAYEXALATE - sodium
polystyrene sulfonate powder
3
lactated ringer's for irrigation
1
mycophenolate mofetil cap
250 mg (Cellcept)
1
•
mycophenolate mofetil for oral
susp 200 mg/ml (Cellcept)
1
•
mycophenolate mofetil tab
500 mg (Cellcept)
1
•
PROGRAF - tacrolimus cap 5 mg
3
•
RAPAMUNE - sirolimus tab 0.5 mg
3
RAPAMUNE - sirolimus tab 1 mg
3
•
RAPAMUNE - sirolimus tab 2 mg
3
2
•
RAPAMUNE - sirolimus oral soln 1
mg/ml
REVLIMID - lenalidomide caps 2.5
mg
2
•
• •
REVLIMID - lenalidomide cap 5 mg 2
2
REVLIMID - lenalidomide cap 10
mg
2
mg
2
mg
2
mg
1
ringer's solution for irrigation
•
•
• •
• •
•
• •
•
• •
•
• •
SANDIMMUNE - cyclosporine cap
25 mg
3
•
235
Specialty
Quantity Limits
"Smart" PA
Drug Name
Prior Authorization
Drug Tier
2015
SANDIMMUNE - cyclosporine cap
100 mg
3
•
SANDIMMUNE - cyclosporine oral
soln 100 mg/ml
3
•
sirolimus tab 0.5 mg (Rapamune)
1
sirolimus tab 1 mg (Rapamune)
1
sirolimus tab 2 mg (Rapamune)
1
•
•
•
oral susp 15 gm/60ml (Sps)
1
rectal susp 30 gm/120ml
1
SPS - sodium polystyrene
sulfonate oral susp 15 gm/60ml
3
SYPRINE - trientine hcl cap 250
mg
3
tacrolimus cap 0.5 mg (Prograf)
1
tacrolimus cap 1 mg (Prograf)
1
tacrolimus cap 5 mg (Prograf)
1
THALOMID - thalidomide cap 50
mg
•
• •
2
•
•
•
•
• •
mg
2
•
• •
mg
2
•
• •
mg
2
•
• •
ZORTRESS - everolimus tab 0.25
mg
3
•
mg
3
•
mg
3
•
236
2015
INDEX
1ST CHOICE LANCETS SUPER - lancets .................... 233
1ST CHOICE LANCETS THIN - lancets ........................ 233
1ST CHOICE LANCETS ULTRA - lancets .....................233
1ST CHOICE PEN NEEDLES 31 - insulin pen needle 31 g
x 6 mm (1/4").................................................................233
1ST CHOICE PEN NEEDLES 31 - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................233
1ST TIER UNIFINE PENTIPS - insulin pen needle 29 g x
12 mm (1/2")..................................................................233
5 mm (3/16")..................................................................233
6 mm (1/4")....................................................................233
8 mm (1/3" or 5/16")......................................................233
4 mm (5/32")..................................................................233
1ST TIER UNILET COMFORTOU - lancets ...................233
8-MOP - methoxsalen cap 10 mg................................... 175
A
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg (Trizivir).................................................8
abacavir sulfate tab 300 mg (base equiv) (Ziagen).........8
ABILIFY - aripiprazole im inj 9.75 mg/1.3ml (7.5 mg/
ml).................................................................................... 89
ABILIFY - aripiprazole oral solution 1 mg/ml.....................89
ABILIFY - aripiprazole tab 10 mg......................................89
ABILIFY - aripiprazole tab 2 mg........................................89
ABILIFY - aripiprazole tab 5 mg........................................89
ABILIFY DISCMELT - aripiprazole orally disintegrating tab
10 mg...............................................................................89
ABILIFY DISCMELT - aripiprazole orally disintegrating tab
15 mg...............................................................................89
ABILIFY MAINTENA - aripiprazole im for extended release
susp 300 mg....................................................................89
ABILIFY MAINTENA - aripiprazole im for extended release
susp 400 mg....................................................................89
ABSORICA - isotretinoin cap 10 mg............................... 158
ABSTRAL - fentanyl citrate sl tab 100 mcg (base
equiv)............................................................................. 103
equiv)............................................................................. 103
equiv)............................................................................. 103
equiv)............................................................................. 103
equiv)............................................................................. 103
equiv)............................................................................. 103
acamprosate calcium tab delayed release 333 mg
(Campral)........................................................................ 99
ACANYA - clindamycin phosphate-benzoyl peroxide gel
1.2-2.5%.........................................................................158
acarbose tab 100 mg (Precose)..................................... 27
acarbose tab 25 mg (Precose)....................................... 27
acarbose tab 50 mg (Precose)....................................... 27
ACCOLATE - zafirlukast tab 10 mg.................................. 66
ACCOLATE - zafirlukast tab 20 mg.................................. 66
ACCU-CHEK ACTIVE GLUCOSE - blood glucose
calibration - liquid ......................................................... 181
ACCU-CHEK ACTIVE STRIPS - glucose blood test
strip................................................................................ 175
ACCU-CHEK AVIVA - blood glucose calibration - liquid
....................................................................................... 181
ACCU-CHEK AVIVA - glucose blood test strip............... 175
ACCU-CHEK AVIVA PLUS - blood glucose monitoring kit
w/ device ...................................................................... 181
ACCU-CHEK AVIVA PLUS - glucose blood test strip..... 176
ACCU-CHEK COMFORT CURVE C - blood glucose
ACCU-CHEK COMFORT CURVE L - blood glucose
ACCU-CHEK COMFORT CURVE T - glucose blood test
strip................................................................................ 176
ACCU-CHEK COMPACT BLUE CO - blood glucose
ACCU-CHEK COMPACT PLUS CA - blood glucose
monitoring kit ................................................................ 181
ACCU-CHEK COMPACT PLUS CL - blood glucose
ACCU-CHEK COMPACT PLUS - glucose blood test
strip................................................................................ 176
ACCU-CHEK COMPACT STRIPS - glucose blood test
strip................................................................................ 176
ACCU-CHEK COMPACT TEST DR - glucose blood test
strip................................................................................ 176
ACCU-CHEK FASTCLIX LANCET - lancets .................. 181
ACCU-CHEK INSTANT GLUCOSE - blood glucose
ACCU-CHEK INSTANT GLUCOSE - blood glucose
ACCU-CHEK MULTICLIX LANCE - lancets ...................181
ACCU-CHEK MULTICLIX LANCE - lancets ...................181
ACCU-CHEK NANO SMARTVIEW - blood glucose
monitoring kit w/ device ................................................181
ACCU-CHEK SAFE-T-PRO LANC - lancets .................. 181
ACCU-CHEK SAFE-T-PRO LANC - lancets .................. 181
ACCU-CHEK SAFE-T-PRO PLUS - lancets .................. 181
ACCU-CHEK SAFE-T-PRO PLUS - lancets .................. 181
237
2015
ACCU-CHEK SMARTVIEW CONTR - blood glucose
ACCU-CHEK SMARTVIEW STRIP - glucose blood test
strip................................................................................ 176
ACCU-CHEK SOFTCLIX LANCET - lancet devices .......181
ACCU-CHEK SOFTCLIX LANCET - lancets ..................181
ACCU-CHEK SOFTCLIX LANCET - lancets ..................181
ACCU-CHEK SOFT TOUCH LANC - lancets ................ 181
ACCU-CHEK SOFT TOUCH LANC - lancets ................ 181
ACCU-CHEK VOICEMATE - blood glucose monitoring kit
w/ device ...................................................................... 181
ACCUPRIL - quinapril hcl tab 10 mg................................ 47
ACCUPRIL - quinapril hcl tab 5 mg.................................. 47
ACCURETIC - quinapril-hydrochlorothiazide tab 10-12.5
mg.................................................................................... 47
ACCURETIC - quinapril-hydrochlorothiazide tab 20-12.5
mg.................................................................................... 47
ACCURETIC - quinapril-hydrochlorothiazide tab 20-25
mg.................................................................................... 47
ACCUTREND GLUCOSE CONTROL - blood glucose
ACCUTREND GLUCOSE - glucose blood test strip........176
acebutolol hcl cap 200 mg (Sectral)..............................41
acebutolol hcl cap 400 mg (Sectral)..............................41
ACEON - perindopril erbumine tab 4 mg.......................... 47
ACEON - perindopril erbumine tab 8 mg.......................... 47
acetaminophen-isometheptene-caffeine tab 325-65-20
mg (Prodrin)................................................................. 115
acetaminophen-isometheptene-dichloral cap
325-65-100 mg.............................................................. 115
acetaminophen-salicylamide-phenyltoloxamine cap
300-200-20mg............................................................... 102
acetaminophen w/ codeine soln 120-12 mg/5ml.........103
acetaminophen w/ codeine tab 300-15 mg (Tylenol/
codeine)........................................................................ 103
codeine #3)...................................................................103
codeine #4)...................................................................103
ACETAZOLAMIDE - acetazolamide tab 125 mg...............55
acetazolamide cap sr 12hr 500 mg (Diamox)................55
acetazolamide sodium for inj 500 mg........................... 55
acetazolamide tab 250 mg..............................................56
ACETIC ACID/ALUMINUM ACET - acetic acid 2% in
aluminum acetate otic soln............................................154
acetic acid irrigation soln 0.25%................................... 80
acetic acid otic soln 2%............................................... 154
acetylcysteine cap 600 mg........................................... 140
acetylcysteine inhal soln 10%........................................63
acetylcysteine inhal soln 20%........................................63
ACIPHEX - rabeprazole sodium ec tab 20 mg..................71
ACIPHEX SPRINKLE - rabeprazole sodium capsule
sprinkle dr 10 mg............................................................ 71
238
ACIPHEX SPRINKLE - rabeprazole sodium capsule
sprinkle dr 5 mg.............................................................. 71
acitretin cap 10 mg (Soriatane)....................................158
acitretin cap 17.5 mg (Soriatane).................................158
acitretin cap 25 mg (Soriatane)....................................158
ACLOVATE - alclometasone dipropionate cream
0.05%.............................................................................158
ACTEMRA - tocilizumab subcutaneous soln prefilled
syringe 162 mg/0.9ml.................................................... 111
ACTICLATE - doxycycline hyclate tab 150 mg................... 4
ACTICLATE - doxycycline hyclate tab 75 mg..................... 4
ACTIGALL - ursodiol cap 300 mg.....................................76
ACTI-LANCE LANCETS 28G - lancets ..........................181
ACTI-LANCE LITE SAFETY LA - lancets ...................... 181
ACTI-LANCE SPECIAL SAFETY - lancets .................... 181
ACTI-LANCE UNIVERSAL SAFE - lancets ....................181
ACTIMMUNE - interferon gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)........................................................14
ACTIQ - fentanyl citrate lollipop 1200 mcg......................104
ACTIQ - fentanyl citrate lollipop 1600 mcg......................104
ACTIQ - fentanyl citrate lollipop 200 mcg........................103
ACTIVE FE - fe carbonyl-fa-b complex-a-c-d-e-min tab
75-1.25 mg ................................................................... 142
ACTIVELLA - estradiol & norethindrone acetate tab
0.5-0.1 mg....................................................................... 22
ACTIVELLA - estradiol & norethindrone acetate tab 1-0.5
mg.................................................................................... 22
ACTIVE OB - prenatal w/o a w/fe cbn-fa-dha cap 20-1-320
mg .................................................................................128
ACTONEL - risedronate sodium tab 150 mg.................... 35
ACTONEL - risedronate sodium tab 30 mg...................... 35
ACTONEL - risedronate sodium tab 35 mg...................... 35
ACTONEL - risedronate sodium tab 5 mg........................ 35
ACTOPLUS MET - pioglitazone hcl-metformin hcl tab
15-500 mg....................................................................... 27
ACTOPLUS MET - pioglitazone hcl-metformin hcl tab
15-850 mg....................................................................... 27
ACTOPLUS MET XR - pioglitazone hcl-metformin hcl tab
sr 24hr 15-1000 mg.........................................................27
ACTOPLUS MET XR - pioglitazone hcl-metformin hcl tab
sr 24hr 30-1000 mg.........................................................27
ACTOS - pioglitazone hcl tab 15 mg (base equiv)............ 27
ACT TOTAL CARE DRY MOUTH - sodium fluoride rinse
0.02%.............................................................................155
ACULAR - ketorolac tromethamine ophth soln 0.5%.......149
ACULAR LS - ketorolac tromethamine ophth soln
0.4%...............................................................................149
ACURA BLOOD GLUCOSE MONIT - blood glucose
ACURA BLOOD GLUCOSE TEST - glucose blood test
strip................................................................................ 176
2015
ACURA CONTROL SOLUTION HI - blood glucose
calibration - liquid - high ...............................................181
ACURA CONTROL SOLUTION LO - blood glucose
calibration - liquid - low ................................................ 181
ACURA CONTROL SOLUTION NO - blood glucose
calibration - liquid - normal ...........................................182
ACURA PLUS BLOOD GLUCOSE - blood glucose
ACUVAIL - ketorolac tromethamine ophth soln
0.45%.............................................................................149
acyclovir cap 200 mg (Zovirax)........................................8
acyclovir oint 5% (Zovirax)...........................................158
acyclovir susp 200 mg/5ml (Zovirax).............................. 8
acyclovir tab 400 mg (Zovirax)........................................ 8
acyclovir tab 800 mg (Zovirax)........................................ 8
ACZONE - dapsone gel 5%............................................ 158
ADALAT CC - nifedipine tab sr 24hr 30 mg...................... 43
ADAPALENE - adapalene lotion 0.1%............................158
adapalene cream 0.1% (Differin).................................. 158
adapalene gel 0.1% (Differin)....................................... 158
adapalene gel 0.3% (Differin)....................................... 158
ADAZIN - benzo-capsaicin-lido-methyl salicylate cream
2-0.035-2-10%............................................................... 158
ADCIRCA - tadalafil tab 20 mg (pah)................................60
ADDERALL - amphetamine-dextroamphetamine tab 10
mg.................................................................................... 95
ADDERALL - amphetamine-dextroamphetamine tab 12.5
mg.................................................................................... 95
mg.................................................................................... 95
mg.................................................................................... 95
mg.................................................................................... 95
mg.................................................................................... 95
ADDERALL - amphetamine-dextroamphetamine tab 7.5
mg.................................................................................... 95
ADDERALL XR - amphetamine-dextroamphetamine cap
sr 24hr 10 mg..................................................................95
sr 24hr 15 mg..................................................................95
sr 24hr 20 mg..................................................................95
sr 24hr 25 mg..................................................................95
sr 24hr 30 mg..................................................................95
sr 24hr 5 mg....................................................................95
adefovir dipivoxil tab 10 mg (Hepsera)........................... 8
ADEMPAS - riociguat tab 0.5 mg..................................... 60
ADEMPAS - riociguat tab 1 mg........................................ 60
ADEMPAS - riociguat tab 2 mg........................................ 60
ADJUSTABLE LANCING DEVICE - lancet devices ....... 182
ADOXA - doxycycline monohydrate cap 150 mg................ 4
ADOXA - doxycycline monohydrate tab 100 mg................. 4
ADOXA - doxycycline monohydrate tab 50 mg................... 4
ADOXA - doxycycline monohydrate tab 75 mg................... 4
ADOXA PAK 1/100 - doxycycline monohydrate tab 100
mg...................................................................................... 4
mg...................................................................................... 4
mg...................................................................................... 4
ADRENACLICK - epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)..........................................................57
ADRENACLICK - epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................57
ADRENAL C FORMULA - bioflavonoid products tab ..... 128
ADVAIR DISKUS - fluticasone-salmeterol aer powder ba
100-50 mcg/dose............................................................. 66
250-50 mcg/dose............................................................. 66
500-50 mcg/dose............................................................. 66
ADVAIR HFA - fluticasone-salmeterol inhal aerosol 115-21
mcg/act............................................................................ 66
mcg/act............................................................................ 66
mcg/act............................................................................ 66
ADVANCED AM/PM - multiple vitamins w/ calcium therapy
pack .............................................................................. 128
ADVANCE INTUITION BLOOD G - blood glucose
ADVANCE INTUITION CONTROL - blood glucose
ADVANCE INTUITION TEST ST - glucose blood test
strip................................................................................ 176
ADVANCE MICRO-DRAW CONTRO - blood glucose
ADVANCE MICRO-DRAW NORMAL - blood glucose
ADVANCE MICRO-DRAW TEST S - glucose blood test
strip................................................................................ 176
ADVICOR - niacin-lovastatin tab sr 24hr 1000-20 mg....... 57
ADVICOR - niacin-lovastatin tab sr 24hr 1000-40 mg....... 57
ADVICOR - niacin-lovastatin tab sr 24hr 500-20 mg.........57
ADVICOR - niacin-lovastatin tab sr 24hr 750-20 mg.........57
ADVOCATE BLOOD GLUCOSE MO - blood glucose
ADVOCATE CONTROL SOLUTION - blood glucose
ADVOCATE CONTROL SOLUTION - blood glucose
ADVOCATE INSULIN PEN NEED - insulin pen needle 29
g x 12.7 mm.................................................................. 182
239
2015
g x 5 mm (3/16")........................................................... 182
g x 8 mm (1/3" or 5/16")................................................182
ADVOCATE INSULIN SYRINGE/ - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................182
u-100 0.3 ml 30 x 5/16".................................................182
u-100 0.3 ml 31 x 5/16".................................................182
u-100 1/2 ml 29 x 1/2"...................................................182
u-100 1/2 ml 30 x 5/16".................................................182
u-100 1/2 ml 31 x 5/16".................................................182
u-100 1 ml 29 x 1/2"......................................................182
u-100 1 ml 30 x 5/16"....................................................182
u-100 1 ml 31 x 5/16"....................................................182
ADVOCATE LANCETS 30G - lancets ........................... 182
ADVOCATE LANCETS - lancets ................................... 182
ADVOCATE LANCING DEVICE - lancet devices .......... 182
ADVOCATE RAPID-SAFE LANCI - lancet devices ........182
ADVOCATE REDI-CODE/TALKIN - blood glucose
ADVOCATE REDI-CODE+/ TALK - blood glucose
ADVOCATE REDI-CODE+ CONTR - blood glucose
ADVOCATE REDI-CODE+ CONTR - blood glucose
ADVOCATE REDI-CODE+ TEST - glucose blood test
strip................................................................................ 176
ADVOCATE REDI-CODE - glucose blood test strip........176
ADVOCATE SAFETY LANCETS 2 - lancets ................. 183
ADVOCATE SAFETY LANCETS - lancets .................... 183
ADVOCATE TEST STRIPS - glucose blood test strip.....176
AEROCHAMBER/FLOWSIGNAL - spacer/aerosol-holding
chambers - device ........................................................183
AEROCHAMBER MINI AEROSOL - spacer/aerosolholding chambers - device ........................................... 183
AEROCHAMBER MV - spacer/aerosol-holding chambers device ........................................................................... 183
AEROCHAMBER PLUS/MASK - spacer/aerosol-holding
chambers - device ........................................................183
AEROCHAMBER PLUS/SMALL MA - spacer/aerosolholding chambers - device ........................................... 183
AEROCHAMBER PLUS FLOW-VU/ - spacer/aerosolholding chambers - device ........................................... 183
AEROCHAMBER PLUS FLOW VU - spacer/aerosolholding chambers - device ........................................... 183
AEROCHAMBER PLUS FLOW-VU - spacer/aerosolholding chambers - device ........................................... 183
240
AEROCHAMBER PLUS - spacer/aerosol-holding
chambers - device ........................................................183
AEROCHAMBER Z-STAT PLUS/F - spacer/aerosolholding chambers - device ........................................... 183
AEROCHAMBER Z-STAT PLUS/L - spacer/aerosolholding chambers - device ........................................... 183
AEROCHAMBER Z-STAT PLUS/M - spacer/aerosolholding chambers - device ........................................... 183
AEROCHAMBER Z-STAT PLUS/S - spacer/aerosolholding chambers - device ........................................... 183
AEROCHAMBER Z-STAT PLUS V - spacer/aerosolholding chambers - device ........................................... 183
AEROSPAN - flunisolide hfa inhal aerosol 80 mcg/act......66
AEROVENT PLUS HOLDING CHA - spacer/aerosolholding chambers - device ........................................... 183
AFINITOR DISPERZ - everolimus tab for oral susp 2
mg.................................................................................... 15
mg.................................................................................... 15
mg.................................................................................... 15
AFINITOR - everolimus tab 10 mg....................................15
AFINITOR - everolimus tab 2.5 mg...................................14
AFINITOR - everolimus tab 5 mg..................................... 14
AFINITOR - everolimus tab 7.5 mg...................................14
AF LANCETS SUPER THIN - lancets ........................... 183
AFREZZA - insulin regular (human) inhalation powd 4 & 8
unit/cartridge.................................................................... 32
AFREZZA - insulin regular (human) inhalation powder 4
unit/cartridge.................................................................... 32
AGAMATRIX AMP NO CODE TES - glucose blood test
strip................................................................................ 176
AGAMATRIX CONTROL HIGH - blood glucose calibration
- liquid - high ................................................................ 183
AGAMATRIX CONTROL NORMAL - blood glucose
AGAMATRIX CONTROL NORMAL - blood glucose
AGAMATRIX JAZZ - blood glucose monitoring kit w/
device ........................................................................... 183
AGAMATRIX JAZZ TEST STRIP - glucose blood test
strip................................................................................ 176
AGAMATRIX KEYNOTE TEST ST - glucose blood test
strip................................................................................ 176
AGAMATRIX PRESTO - blood glucose monitoring kit w/
device ........................................................................... 183
AGAMATRIX PRESTO TEST STR - glucose blood test
strip................................................................................ 176
AGAMATRIX ULTRA-THIN LANC - lancets ...................183
AGGRENOX - aspirin-dipyridamole cap sr 12hr 25-200
mg.................................................................................. 149
AGRYLIN - anagrelide hcl cap 0.5 mg............................149
AKTEN - lidocaine hcl ophth gel 3.5%............................ 149
AKYNZEO - netupitant-palonosetron cap 300-0.5 mg.......74
ALA QUIN - clioquinol-hc cream 3-0.5%.........................158
ALA SCALP - hydrocortisone lotion 2%.......................... 158
2015
ALBENZA - albendazole tab 200 mg................................ 13
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)..........66
albuterol sulfate soln nebu 0.5% (5 mg/ml).................. 67
albuterol sulfate soln nebu 0.63 mg/3ml (base
equiv).............................................................................. 67
albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv).............................................................................. 67
albuterol sulfate syrup 2 mg/5ml................................... 67
albuterol sulfate tab 2 mg.............................................. 67
albuterol sulfate tab 4 mg.............................................. 67
albuterol sulfate tab sr 12hr 4 mg (Vospire er).............67
albuterol sulfate tab sr 12hr 8 mg (Vospire er).............67
ALCAINE - proparacaine hcl ophth soln 0.5%................ 149
alclometasone dipropionate cream 0.05%
(Aclovate)......................................................................158
alclometasone dipropionate oint 0.05%...................... 158
ALCORTIN A - iodoquinol-hydrocortisone-aloe
polysaccharide gel 1-2-1% ........................................... 158
ALDACTAZIDE - spironolactone & hydrochlorothiazide tab
25-25 mg......................................................................... 56
ALDACTAZIDE - spironolactone & hydrochlorothiazide tab
50-50 mg......................................................................... 56
ALDACTONE - spironolactone tab 100 mg.......................56
ALDACTONE - spironolactone tab 25 mg.........................56
ALDACTONE - spironolactone tab 50 mg.........................56
ALDARA - imiquimod cream 5%.....................................158
ALENDRONATE SODIUM - alendronate sodium oral soln
70 mg/75ml......................................................................35
ALENDRONATE SODIUM - alendronate sodium tab 40
mg.................................................................................... 35
alendronate sodium tab 10 mg...................................... 35
alendronate sodium tab 35 mg...................................... 35
alendronate sodium tab 5 mg........................................ 35
alendronate sodium tab 70 mg (Fosamax)................... 35
ALFERON N - interferon alfa-n3 inj 5000000 unit/ml........ 15
alfuzosin hcl tab sr 24hr 10 mg (Uroxatral).................. 80
ALINIA - nitazoxanide for susp 100 mg/5ml......................13
ALINIA - nitazoxanide tab 500 mg.................................... 13
ALKERAN - melphalan tab 2 mg...................................... 15
allopurinol tab 100 mg (Zyloprim)............................... 117
allopurinol tab 300 mg (Zyloprim)............................... 117
ALOCRIL - nedocromil sodium ophth soln 2%................149
ALOMIDE - lodoxamide tromethamine ophth soln
0.1%...............................................................................149
ALOQUIN - iodoquinol-aloe polysaccharides gel 1.25-1%
....................................................................................... 158
ALORA - estradiol td patch biweekly 0.025 mg/24hr.........22
ALORA - estradiol td patch biweekly 0.05 mg/24hr...........22
ALORA - estradiol td patch biweekly 0.075 mg/24hr.........22
ALORA - estradiol td patch biweekly 0.1 mg/24hr.............22
alosetron hcl tab 0.5 mg (base equiv) (Lotronex).........76
alosetron hcl tab 1 mg (base equiv) (Lotronex)............76
ALPHAGAN P - brimonidine tartrate ophth soln 0.1%.....149
ALPHAGAN P - brimonidine tartrate ophth soln
0.15%.............................................................................149
ALPRAZOLAM INTENSOL - alprazolam conc 1 mg/
ml..................................................................................... 82
alprazolam orally disintegrating tab 0.25 mg
(Niravam)........................................................................ 82
alprazolam orally disintegrating tab 0.5 mg................. 82
alprazolam orally disintegrating tab 1 mg.................... 82
alprazolam orally disintegrating tab 2 mg.................... 82
alprazolam tab 0.25 mg (Xanax).................................... 82
alprazolam tab 0.5 mg (Xanax)...................................... 82
alprazolam tab 1 mg (Xanax)......................................... 82
alprazolam tab 2 mg (Xanax)......................................... 82
alprazolam tab sr 24hr 0.5 mg (Xanax xr)..................... 82
alprazolam tab sr 24hr 1 mg (Xanax xr)........................ 82
ALREX - loteprednol etabonate ophth susp 0.2%........... 149
ALSUMA - sumatriptan succinate solution auto-injector 6
mg/0.5ml........................................................................ 115
ALTABAX - retapamulin oint 1%.....................................158
ALTACE - ramipril cap 1.25 mg........................................ 47
ALTACE - ramipril cap 10 mg........................................... 47
ALTACE - ramipril cap 2.5 mg.......................................... 47
ALTACE - ramipril cap 5 mg.............................................47
ALTERNATE SITE LANCING DE - lancet devices ........ 183
ALTOPREV - lovastatin tab sr 24hr 20 mg....................... 57
ALUVEA - urea cream 39%............................................ 158
ALVESCO - ciclesonide inhal aerosol 160 mcg/act...........67
ALVESCO - ciclesonide inhal aerosol 80 mcg/act.............67
ALZ-NAC - l-methylfolate-methylcobalamin-acetylcyst tab
6-2-600 mg ................................................................... 140
AMANTADINE HCL - amantadine hcl tab 100 mg.......... 123
amantadine hcl cap 100 mg......................................... 123
amantadine hcl syrup 50 mg/5ml.................................123
AMARYL - glimepiride tab 1 mg....................................... 27
AMBIEN CR - zolpidem tartrate tab cr 12.5 mg................ 93
AMBIEN CR - zolpidem tartrate tab cr 6.25 mg................ 93
AMBIEN - zolpidem tartrate tab 10 mg............................. 93
AMBIEN - zolpidem tartrate tab 5 mg............................... 93
AMCINONIDE - amcinonide cream 0.1%........................158
AMCINONIDE - amcinonide lotion 0.1%......................... 158
AMCINONIDE - amcinonide oint 0.1%............................158
AMERGE - naratriptan hcl tab 1 mg (base equiv)........... 115
AMERGE - naratriptan hcl tab 2.5 mg (base equiv)........ 115
AMICAR - aminocaproic acid syrup 25%........................ 148
AMICAR - aminocaproic acid tab 1000 mg..................... 148
AMICAR - aminocaproic acid tab 500 mg....................... 148
amikacin sulfate inj 1 gm/4ml (250 mg/ml)..................... 6
amikacin sulfate inj 500 mg/2ml (250 mg/ml)..................6
amiloride & hydrochlorothiazide tab 5-50 mg...............56
amiloride hcl tab 5 mg....................................................56
AMINOBENZOATE POTASSIUM - potassium
aminobenzoate packet 2 gm......................................... 127
241
2015
AMINOCAPROIC ACID - aminocaproic acid tab 1000
mg.................................................................................. 148
aminocaproic acid syrup 25% (Amicar)...................... 148
aminocaproic acid tab 500 mg (Amicar)..................... 149
amiodarone hcl tab 100 mg........................................... 46
amiodarone hcl tab 200 mg (Cordarone)...................... 46
amiodarone hcl tab 400 mg........................................... 46
AMITIZA - lubiprostone cap 24 mcg................................. 76
AMITIZA - lubiprostone cap 8 mcg................................... 76
amitriptyline hcl tab 100 mg...........................................83
amitriptyline hcl tab 10 mg............................................ 83
amitriptyline hcl tab 150 mg...........................................83
amlodipine besylate-atorvastatin calcium tab 10-10 mg
(Caduet).......................................................................... 60
(Caduet).......................................................................... 60
(Caduet).......................................................................... 60
(Caduet).......................................................................... 61
amlodipine besylate-atorvastatin calcium tab 2.5-10
mg (Caduet)....................................................................61
mg (Caduet)....................................................................61
mg (Caduet)....................................................................61
(Caduet).......................................................................... 61
(Caduet).......................................................................... 61
(Caduet).......................................................................... 61
(Caduet).......................................................................... 61
amlodipine besylate-benazepril hcl cap 10-20 mg
(Lotrel).............................................................................47
(Lotrel).............................................................................47
amlodipine besylate-benazepril hcl cap 2.5-10 mg
(Lotrel).............................................................................47
(Lotrel).............................................................................47
(Lotrel).............................................................................47
(Lotrel).............................................................................48
amlodipine besylate tab 10 mg (Norvasc).....................44
amlodipine besylate tab 2.5 mg (Norvasc)....................44
amlodipine besylate tab 5 mg (Norvasc)...................... 44
amlodipine besylate-valsartan tab 10-160 mg
(Exforge)......................................................................... 48
(Exforge)......................................................................... 48
242
(Exforge)......................................................................... 48
(Exforge)......................................................................... 48
amlodipine-valsartan-hydrochlorothiazide tab
10-160-12.5 mg (Exforge hct)....................................... 48
10-160-25 mg (Exforge hct).......................................... 48
10-320-25 mg (Exforge hct).......................................... 48
5-160-12.5 mg (Exforge hct)......................................... 48
amlodipine-valsartan-hydrochlorothiazide tab 5-160-25
mg (Exforge hct)............................................................48
AMOXAPINE - amoxapine tab 100 mg............................. 83
AMOXAPINE - amoxapine tab 150 mg............................. 83
AMOXAPINE - amoxapine tab 25 mg...............................83
AMOXAPINE - amoxapine tab 50 mg...............................83
amoxicillin (trihydrate) cap 250 mg................................. 1
amoxicillin (trihydrate) cap 500 mg................................. 1
amoxicillin (trihydrate) for susp 125 mg/5ml.................. 1
amoxicillin (trihydrate) tab 500 mg..................................1
amoxicillin (trihydrate) tab 875 mg..................................1
amoxicillin & k clavulanate chew tab 200-28.5 mg.........1
amoxicillin & k clavulanate chew tab 400-57 mg............1
amoxicillin & k clavulanate for susp 200-28.5
mg/5ml.............................................................................. 1
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
(Augmentin)......................................................................1
amoxicillin & k clavulanate for susp 400-57 mg/5ml...... 1
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
(Augmentin es-600)......................................................... 1
amoxicillin & k clavulanate tab 250-125 mg................... 1
amoxicillin & k clavulanate tab 500-125 mg
(Augmentin)......................................................................1
amoxicillin & k clavulanate tab 875-125 mg
(Augmentin)......................................................................1
amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg
(Augmentin xr)................................................................. 1
AMOXICILLIN - amoxicillin (trihydrate) chew tab 125
mg...................................................................................... 1
AMOXICILLIN - amoxicillin (trihydrate) chew tab 250
mg...................................................................................... 1
amoxicillin cap-clarithro tab-lansopraz cap dr therapy
pack (Prevpac)............................................................... 71
AMOXICILLIN ER - amoxicillin (trihydrate) tab sr 24hr 775
mg...................................................................................... 1
amphetamine-dextroamphetamine cap sr 24hr 10 mg
(Adderall xr)................................................................... 95
(Adderall xr)................................................................... 95
(Adderall xr)................................................................... 95
2015
(Adderall xr)................................................................... 95
(Adderall xr)................................................................... 95
(Adderall xr)................................................................... 95
amphetamine-dextroamphetamine tab 10 mg
(Adderall)........................................................................ 95
amphetamine-dextroamphetamine tab 12.5 mg
(Adderall)........................................................................ 95
(Adderall)........................................................................ 95
(Adderall)........................................................................ 95
(Adderall)........................................................................ 95
(Adderall)........................................................................ 95
amphetamine-dextroamphetamine tab 7.5 mg
(Adderall)........................................................................ 95
AMPICILLIN - ampicillin for susp 125 mg/5ml.....................1
AMPICILLIN - ampicillin for susp 250 mg/5ml.....................1
ampicillin cap 250 mg.......................................................1
ampicillin cap 500 mg.......................................................1
AMPYRA - dalfampridine tab sr 12hr 10 mg..................... 99
AMRIX - cyclobenzaprine hcl cap sr 24hr 15 mg............ 126
AMRIX - cyclobenzaprine hcl cap sr 24hr 30 mg............ 126
ANACAINE - benzocaine oint 10%................................. 158
ANADROL-50 - oxymetholone tab 50 mg......................... 21
ANAFRANIL - clomipramine hcl cap 25 mg...................... 83
anagrelide hcl cap 0.5 mg (Agrylin).............................149
anagrelide hcl cap 1 mg............................................... 149
ANALPRAM ADVANCED - hc-pramoxine cr & diet
manage prod tab & cleans wipe kit............................... 157
ANALPRAM E - hc-pramoxine emol cream 2.5-1% &
pramoxine wipe 1% kit.................................................. 157
ANALPRAM-HC - hydrocortisone acetate w/ pramoxine
rectal cream 1-1%......................................................... 157
rectal cream 2.5-1%...................................................... 157
rectal lotn 2.5-1%.......................................................... 157
ANALPRAM-HC SINGLES - hydrocortisone acetate w/
pramoxine rectal cream 1-1%....................................... 157
ANALPRAM-HC SINGLES - hydrocortisone acetate w/
pramoxine rectal cream 2.5-1%.................................... 157
ANAPROX DS - naproxen sodium tab 550 mg............... 111
ANAPROX - naproxen sodium tab 275 mg.....................111
ANASEPT - sodium hypochlorite liquid 0.057%.............. 175
ANASPAZ - hyoscyamine sulfate tab disp 0.125 mg........ 71
anastrozole tab 1 mg (Arimidex)................................... 15
ANCOBON - flucytosine cap 250 mg..................................7
ANCOBON - flucytosine cap 500 mg..................................7
ANDRODERM - testosterone td patch 24hr 2 mg/24hr..... 21
ANDRODERM - testosterone td patch 24hr 4 mg/24hr..... 21
ANDROGEL PUMP - testosterone td gel 12.5 mg/act
(1%)................................................................................. 21
ANDROGEL PUMP - testosterone td gel 20.25 mg/act
(1.62%)............................................................................ 21
ANDROGEL - testosterone td gel 20.25 mg/1.25gm
(1.62%)............................................................................ 21
ANDROGEL - testosterone td gel 25 mg/2.5gm (1%)....... 21
ANDROGEL - testosterone td gel 40.5 mg/2.5gm
(1.62%)............................................................................ 21
ANDROGEL - testosterone td gel 50 mg/5gm (1%).......... 21
ANDROID - methyltestosterone cap 10 mg...................... 21
ANGELIQ - drospirenone-estradiol tab 0.25-0.5 mg......... 22
ANGELIQ - drospirenone-estradiol tab 0.5-1 mg.............. 22
ANHYDROUS CREAM BASE - anhydrous cream
base............................................................................... 233
ANIMI-3/VITAMIN D - folic acid-b6-b12-d-omega 3phytosterols cap 1 mg ..................................................142
ANIMI-3 - folic acid-b6-b12-d-omega 3-phytosterols cap 1
mg .................................................................................142
ANIMI-3 - folic acid-vit b6-vit b12-omega 3-phytosterols
cap 1 mg ...................................................................... 142
ANODYNERX - capsaicin-lidocaine-menthol patch
0.05-2.5-5%................................................................... 159
ANODYNZ - capsaicin-menthol disk 0.0375-5%............. 159
ANORO ELLIPTA - umeclidinium-vilanterol aero powd ba
62.5-25 mcg/inh............................................................... 67
ANTABUSE - disulfiram tab 250 mg................................. 99
ANTABUSE - disulfiram tab 500 mg................................. 99
ANTARA - fenofibrate micronized cap 30 mg................... 58
ANTARA - fenofibrate micronized cap 90 mg................... 58
ANTIPYRINE/BENZOCAINE - antipyrine-benzocaine otic
soln 55-14 mg/ml (5.5-1.4%)......................................... 154
antipyrine-benzocaine otic soln 54-14 mg/ml
(5.4-1.4%)...................................................................... 154
antipyrine-benzocaine-polycosanol otic sol
5.4-1.4-0.0097% (Treagan otic)................................... 154
ANTI-STICK INSULIN SYRING - insulin syringe/needle
u-100 1/2 ml 28 x 1/2"...................................................183
u-100 1/2 ml 29 x 1/2"...................................................183
u-100 1 ml 29 x 1/2"......................................................183
ANUSOL-HC - hydrocortisone acetate suppos 25
mg.................................................................................. 157
ANUSOL-HC - hydrocortisone rectal cream 2.5%...........157
ANZEMET - dolasetron mesylate tab 100 mg...................74
ANZEMET - dolasetron mesylate tab 50 mg.....................74
APEXICON E - diflorasone diacetate emollient base
cream 0.05%................................................................. 159
APIDRA - insulin glulisine inj 100 unit/ml.......................... 31
APIDRA SOLOSTAR - insulin glulisine soln pen-injector inj
100 unit/ml....................................................................... 31
APLENZIN - bupropion hbr tab sr 24hr 174 mg................ 83
243
2015
APOKYN - apomorphine hydrochloride inj 10 mg/ml.......123
APOTHEDERM - transdermal base cream .................... 233
APPBUTAMONE - bupropion hcl tab 75 mg & dietary
management cap pack.................................................... 83
APPBUTAMONE-D - bupropion hcl tab 75 mg & dietary
APPFORMIN-D - metformin hcl tab 500 mg & dietary
APPFORMIN - metformin hcl tab 500 mg & dietary
apraclonidine hcl ophth soln 0.5% (base equivalent)
(Iopidine).......................................................................150
APRISO - mesalamine cap sr 24hr 0.375 gm................... 76
APTENSIO XR - methylphenidate hcl cap er 24hr 10 mg
(xr)....................................................................................96
(xr)....................................................................................96
(xr)....................................................................................96
(xr)....................................................................................96
(xr)....................................................................................96
(xr)....................................................................................96
(xr)....................................................................................96
APTIOM - eslicarbazepine acetate tab 200 mg...............117
APTIVUS - tipranavir cap 250 mg.......................................8
APTIVUS - tipranavir oral soln 100 mg/ml.......................... 8
AP-ZEL - multiple vitamins w/ minerals tab ....................128
AQUA LANCE ADJUSTABLE LAN - lancet devices ...... 183
ARALEN - chloroquine phosphate tab 500 mg................. 12
ARANESP ALBUMIN FREE - darbepoetin alfapolysorbate 80 soln inj 100 mcg/0.5ml.......................... 143
ARANESP ALBUMIN FREE - darbepoetin alfapolysorbate 80 soln inj 100 mcg/ml............................... 143
ARANESP ALBUMIN FREE - darbepoetin alfapolysorbate 80 soln inj 10 mcg/0.4ml............................ 142
ARANESP ALBUMIN FREE - darbepoetin alfapolysorbate 80 soln inj 25 mcg/ml.................................142
244
ARAVA - leflunomide tab 10 mg..................................... 112
ARAVA - leflunomide tab 20 mg..................................... 112
ARCALYST - rilonacept for inj 220 mg........................... 112
ARCAPTA NEOHALER - indacaterol maleate inhal
powder cap 75 mcg (base equiv).................................... 67
ARICEPT - donepezil hydrochloride tab 10 mg.................99
ARICEPT - donepezil hydrochloride tab 23 mg.................99
ARICEPT - donepezil hydrochloride tab 5 mg...................99
ARIMIDEX - anastrozole tab 1 mg....................................15
aripiprazole tab 10 mg (Abilify)......................................89
aripiprazole tab 2 mg (Abilify)........................................89
aripiprazole tab 5 mg (Abilify)........................................89
ARIXTRA - fondaparinux sodium inj 10 mg/0.8ml........... 147
ARIXTRA - fondaparinux sodium inj 2.5 mg/0.5ml.......... 147
ARIXTRA - fondaparinux sodium inj 5 mg/0.4ml............. 147
ARIXTRA - fondaparinux sodium inj 7.5 mg/0.6ml.......... 147
ARMOUR THYROID - thyroid tab 120 mg (2 grain).......... 33
ARMOUR THYROID - thyroid tab 15 mg (1/4 grain)......... 33
ARMOUR THYROID - thyroid tab 30 mg (1/2 grain)......... 33
ARMOUR THYROID - thyroid tab 60 mg (1 grain)............ 33
ARMOUR THYROID - thyroid tab 90 mg (1 1/2 grain)...... 33
ARNUITY ELLIPTA - fluticasone furoate aerosol powder
breath activ 100 mcg/act................................................. 67
ARNUITY ELLIPTA - fluticasone furoate aerosol powder
breath activ 200 mcg/act................................................. 67
AROMASIN - exemestane tab 25 mg............................... 15
ARTHROTEC 50 - diclofenac w/ misoprostol tab delayed
release 50-0.2 mg......................................................... 112
ARTHROTEC 75 - diclofenac w/ misoprostol tab delayed
release 75-0.2 mg......................................................... 112
ARZOL SILVER NITRATE APP - silver nitrate-potassium
nitrate applicator 75-25%...............................................159
ASACOL HD - mesalamine tab delayed release 800
mg.................................................................................... 76
ASCENSIA AUTODISC LOW AND - blood glucose
ASCENSIA AUTODISC NORMAL - blood glucose
ASCENSIA AUTODISC TEST ST - glucose blood test
disk.................................................................................176
2015
ASMANEX 14 METERED DOSES - mometasone furoate
inhal powd 220 mcg/inh (breath activated)......................67
ASMANEX 60 METERED DOSES - mometasone furoate
ASMANEX HFA - mometasone furoate inhal aerosol
suspension 100 mcg/act..................................................67
ASMANEX HFA - mometasone furoate inhal aerosol
suspension 200 mcg/act..................................................67
ASMANEX TWISTHALER 120 ME - mometasone furoate
ASMANEX TWISTHALER 14 MET - mometasone furoate
ASMANEX TWISTHALER 7 METE - mometasone furoate
ASPIRIN - aspirin tab 81 mg.......................................... 102
ASPIRIN-CAFFEINE-DIHYDROC - aspirin-caffeinedihydrocodeine cap 356.4-30-16 mg............................. 104
aspirin chew tab 81 mg................................................ 102
ASPIRIN LOW DOSE - aspirin tab 81 mg...................... 103
aspirin tab delayed release 81 mg...............................103
ASSURE 3 CONTROL LEVEL 1/ - blood glucose
ASSURE 3 TEST STRIPS - glucose blood test strip.......176
ASSURE 4 CONTROL LEVEL 1/ - blood glucose
ASSURE 4 TEST STRIPS - glucose blood test strip.......176
ASSURE COMFORT LANCETS UL - lancets ................184
ASSURE DOSE NORMAL/HIGH C - blood glucose
ASSURE DOSE NORMAL CONTRO - blood glucose
ASSURE HAEMOLANCE PLUS HI - lancets .................184
ASSURE HAEMOLANCE PLUS LO - lancets ................184
ASSURE HAEMOLANCE PLUS MI - lancets ................ 184
ASSURE HAEMOLANCE PLUS NO - lancets ............... 184
ASSURE HAEMOLANCE PLUS PE - lancets ................184
ASSURE ID INSULIN SAFETY - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"...................................................184
ASSURE ID INSULIN SAFETY - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................184
ASSURE II CHECK STRIP - glucose blood test strip......176
ASSURE II CONTROL LEVEL 1 - blood glucose
ASSURE II - glucose blood test strip.............................. 176
ASSURE II TEST STRIPS - glucose blood test strip.......176
ASSURE LANCE LANCETS 21G - lancets ................... 184
ASSURE LANCE LANCETS - lancets ........................... 184
ASSURE LANCE PLUS SAFETY - lancets ................... 184
ASSURE LANCETS - lancets ........................................ 184
ASSURE PLATINUM TEST STRI - glucose blood test
strip................................................................................ 176
ASSURE PRISM CONTROL LEV - blood glucose
ASSURE PRISM MULTI TEST S - glucose blood test
strip................................................................................ 176
ASSURE PRO CONTROL LEVEL - blood glucose
ASSURE PRO TEST STRIPS - glucose blood test
strip................................................................................ 176
ASTAGRAF XL - tacrolimus cap sr 24hr 0.5 mg............. 234
ASTAGRAF XL - tacrolimus cap sr 24hr 1 mg................ 235
ASTAGRAF XL - tacrolimus cap sr 24hr 5 mg................ 235
ASTEPRO - azelastine hcl nasal spray 0.15% (205.5 mcg/
spray)............................................................................... 62
ASTRINGYN - ferric subsulfate soln 259 mg/gm............ 149
ATABEX EC - prenatal vit w/ dss-iron carbonyl-fa tab dr
29-1 mg ........................................................................ 128
ATACAND - candesartan cilexetil tab 16 mg.................... 48
ATACAND - candesartan cilexetil tab 32 mg.................... 48
ATACAND - candesartan cilexetil tab 4 mg...................... 48
ATACAND - candesartan cilexetil tab 8 mg...................... 48
ATACAND HCT - candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg................................ 48
ATACAND HCT - candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg................................ 48
ATACAND HCT - candesartan cilexetilhydrochlorothiazide tab 32-25 mg................................... 48
ATELVIA - risedronate sodium tab delayed release 35
mg.................................................................................... 35
ATENDIA - lidocaine-menthol patch 4-3%...................... 159
atenolol & chlorthalidone tab 100-25 mg (Tenoretic
100)..................................................................................48
atenolol & chlorthalidone tab 50-25 mg (Tenoretic
50)....................................................................................48
atenolol tab 100 mg (Tenormin).....................................41
atenolol tab 25 mg (Tenormin).......................................41
atenolol tab 50 mg (Tenormin).......................................41
ATIVAN - lorazepam tab 0.5 mg.......................................82
ATIVAN - lorazepam tab 1 mg..........................................82
ATIVAN - lorazepam tab 2 mg..........................................82
AT LAST CONTROL SOLUTION - blood glucose
AT LAST LANCETS - lancets ........................................ 184
AT LAST TEST STRIPS - glucose blood test strip..........176
ATOPICLAIR - dermatological products misc - cream
....................................................................................... 159
atorvastatin calcium tab 10 mg (base equivalent)
(Lipitor)........................................................................... 58
(Lipitor)........................................................................... 58
(Lipitor)........................................................................... 58
(Lipitor)........................................................................... 58
245
2015
atovaquone-proguanil hcl tab 250-100 mg
(Malarone).......................................................................12
atovaquone-proguanil hcl tab 62.5-25 mg
(Malarone).......................................................................12
atovaquone susp 750 mg/5ml (Mepron)........................13
ATRALIN - tretinoin gel 0.05%........................................159
ATRIPLA - efavirenz-emtricitabine-tenofovir df tab
600-200-300 mg................................................................ 8
ATROPEN - atropine sulfate im inj device 0.25
mg/0.3ml.......................................................................... 71
ATROPEN - atropine sulfate im inj device 0.5
mg/0.7ml.......................................................................... 71
ATROPEN - atropine sulfate im inj device 1 mg/0.7ml...... 71
ATROPEN - atropine sulfate im inj device 2 mg/0.7ml...... 71
ATROPINE SULFATE - atropine sulfate ophth oint
1%..................................................................................150
atropine sulfate ophth soln 1% (Isopto atropine)....... 150
ATROVENT HFA - ipratropium bromide hfa inhal aerosol
17 mcg/act....................................................................... 67
ATROVENT - ipratropium bromide nasal soln 0.03% (21
mcg/spray)....................................................................... 62
ATROVENT - ipratropium bromide nasal soln 0.06% (42
mcg/spray)....................................................................... 62
AUBAGIO - teriflunomide tab 14 mg.................................99
AUBAGIO - teriflunomide tab 7 mg...................................99
AUGMENTIN - amoxicillin & k clavulanate chew tab
200-28.5 mg...................................................................... 1
AUGMENTIN - amoxicillin & k clavulanate for susp
125-31.25 mg/5ml..............................................................1
AUGMENTIN - amoxicillin & k clavulanate for susp
250-62.5 mg/5ml................................................................1
AUGMENTIN - amoxicillin & k clavulanate tab 500-125
mg...................................................................................... 1
AUGMENTIN - amoxicillin & k clavulanate tab 875-125
mg...................................................................................... 1
AUGMENTIN ES-600 - amoxicillin & k clavulanate for
susp 600-42.9 mg/5ml.......................................................1
AUGMENTIN XR - amoxicillin & k clavulanate tab sr 12hr
1000-62.5 mg.................................................................... 1
AURALGAN - antipyrine-benzocaine otic soln 55-14 mg/ml
(5.5-1.4%)...................................................................... 154
AURORA LANCET SUPER THIN - lancets ................... 184
AURORA LANCET THIN 23G - lancets .........................184
AURORA PEN NEEDLES 29GX12 - insulin pen needle 29
g x 12 mm (1/2")........................................................... 184
AURORA PEN NEEDLES 31G X - insulin pen needle 31 g
x 6 mm (1/4").................................................................184
AURORA PEN NEEDLES 31G X - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................184
AURORA UNIFINE PENTIPS/32 - insulin pen needle 32 g
x 4 mm (5/32")...............................................................184
AURORA UNIFINE PENTIPS/MI - insulin pen needle 31 g
x 5 mm (3/16")...............................................................184
AURSTAT ANTI-ITCH HYDROGE - dermatological
products misc - gel .......................................................159
246
AURSTAT ANTI-ITCH HYDROGE - dermatological
products misc - kit ........................................................159
AURYXIA - ferric citrate tab 1 gm (210 mg ferric iron)...... 76
AUTO-LANCET - lancet devices ....................................184
AUTO-LANCET MINI - lancet devices ........................... 184
AUTOLET IMPRESSION - lancet devices ..................... 184
AUTOLET IMPRESSION LANCIN - lancet devices ....... 184
AUTOLET MINI - lancet devices ....................................184
AUTOPEN - injection device for insulin...........................184
AUTOPEN - injection device for insulin...........................184
AUVI-Q - epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)..........................................................57
AUVI-Q - epinephrine solution auto-injector 0.3 mg/0.3ml
(1:1000)............................................................................57
AVAILNEX - carbocysteine chew tab 750 mg................. 140
AVALIDE - irbesartan-hydrochlorothiazide tab 150-12.5
mg.................................................................................... 48
AVALIDE - irbesartan-hydrochlorothiazide tab 300-12.5
mg.................................................................................... 48
AVANDAMET - rosiglitazone maleate-metformin hcl tab
2-1000 mg....................................................................... 28
AVANDAMET - rosiglitazone maleate-metformin hcl tab
4-500 mg......................................................................... 28
AVANDIA - rosiglitazone maleate tab 2 mg (base
equiv)............................................................................... 28
equiv)............................................................................... 28
equiv)............................................................................... 28
AVAPRO - irbesartan tab 150 mg.....................................48
AVAPRO - irbesartan tab 300 mg.....................................48
AVAPRO - irbesartan tab 75 mg.......................................48
AVAR-E LS - sulfacetamide sodium w/ sulfur cream
10-2%.............................................................................159
AVAR LS CLEANSER - sulfacetamide sodium w/ sulfur
cleanser 10-2%..............................................................159
AVAR LS - sulfacetamide sodium w/ sulfur cleansing pad
10-2%.............................................................................159
AVAR - sulfacetamide sodium w/ sulfur cleansing pad
9.5-5%............................................................................159
AVC - sulfanilamide vaginal cream 15%........................... 79
AVELOX ABC PACK - moxifloxacin hcl tab 400 mg (base
equiv)................................................................................. 5
AVELOX - moxifloxacin hcl tab 400 mg (base equiv)..........5
AVENOVA - hypochlorous acid cleanser soln 0.01%......159
AVIDOXY DK - doxycycline tab 100 mg & suncreen & sal
acid wash 2% kit............................................................... 4
AVINZA - morphine sulfate beads cap sr 24hr 120
mg.................................................................................. 104
AVINZA - morphine sulfate beads cap sr 24hr 30 mg..... 104
AVODART - dutasteride cap 0.5 mg.................................80
AVONEX - interferon beta-1a for im inj kit 30mcg
(33mcg(6.6 mu)/vial)........................................................99
2015
AVONEX - interferon beta-1a im inj kit 30 mcg/0.5ml....... 99
AVONEX PEN - interferon beta-1a im inj kit 30
mcg/0.5ml........................................................................ 99
AXERT - almotriptan malate tab 12.5 mg....................... 115
AXERT - almotriptan malate tab 6.25 mg....................... 115
AXID - nizatidine cap 300 mg........................................... 71
AXID - nizatidine oral soln 15 mg/ml.................................71
AXIRON - testosterone td soln 30 mg/act......................... 21
AYGESTIN - norethindrone acetate tab 5 mg................... 27
AZACTAM - aztreonam for inj 1 gm..................................13
AZACTAM - aztreonam for inj 2 gm..................................13
AZASAN - azathioprine tab 100 mg................................235
AZASAN - azathioprine tab 75 mg..................................235
AZASITE - azithromycin ophth soln 1%.......................... 150
azathioprine tab 50 mg (Imuran)..................................235
azelastine hcl nasal spray 0.15% (205.5 mcg/spray)
(Astepro)......................................................................... 62
azelastine hcl nasal spray 137 mcg/spray (1 mg/
ml)....................................................................................62
azelastine hcl ophth soln 0.05% (Optivar).................. 150
AZELEX - azelaic acid cream 20%................................. 159
AZILECT - rasagiline mesylate tab 0.5 mg (base
equiv)............................................................................. 123
AZILECT - rasagiline mesylate tab 1 mg (base
equiv)............................................................................. 123
AZITHROMYCIN - azithromycin powd pack for susp 1
gm...................................................................................... 3
azithromycin for susp 100 mg/5ml (Zithromax)..............3
azithromycin for susp 200 mg/5ml (Zithromax)..............3
azithromycin tab 250 mg (Zithromax)............................. 3
AZOPT - brinzolamide ophth susp 1%............................150
AZOR - amlodipine besylate-olmesartan medoxomil tab
10-20 mg......................................................................... 48
10-40 mg......................................................................... 48
5-20 mg........................................................................... 48
5-40 mg........................................................................... 48
aztreonam for inj 1 gm (Azactam)................................. 13
aztreonam for inj 2 gm (Azactam)................................. 13
AZULFIDINE EN-TABS - sulfasalazine tab delayed
release 500 mg................................................................76
AZULFIDINE - sulfasalazine tab 500 mg.......................... 76
B
B-6 FOLIC ACID - cobalamine combination cap ............ 143
BABY DDROPS - cholecalciferol drops 400 unit/0.03ml
(per drop).......................................................................127
BACITRACIN - bacitracin ophth oint 500 unit/gm............150
bacitracin-polymyxin b ophth oint...............................150
bacitracin-polymyxin-neomycin-hc ophth oint 1%.....150
baclofen tab 10 mg....................................................... 126
baclofen tab 20 mg....................................................... 126
BACMIN - multiple vitamins w/ minerals tab .................. 128
BACTRIM DS - sulfamethoxazole-trimethoprim tab
800-160 mg..................................................................... 13
BACTRIM - sulfamethoxazole-trimethoprim tab 400-80
mg.................................................................................... 13
BACTROBAN - mupirocin calcium cream 2%.................159
BACTROBAN - mupirocin oint 2%.................................. 159
BACTROBAN NASAL - mupirocin calcium nasal oint
2%....................................................................................62
BAL-CARE DHA - prenat w/fe poly-na fered-fa tab 27-1 &
omega cap dr 430mg.................................................... 128
balsalazide disodium cap 750 mg (Colazal)..................76
BANZEL - rufinamide susp 40 mg/ml..............................117
BANZEL - rufinamide tab 200 mg................................... 117
BANZEL - rufinamide tab 400 mg................................... 117
BARACLUDE - entecavir oral soln 0.05 mg/ml................... 8
BARACLUDE - entecavir tab 0.5 mg.................................. 8
BARACLUDE - entecavir tab 1 mg..................................... 8
BAYER BREEZE 2 BLOOD GLUC - blood glucose
BAYER BREEZE 2 HIGH CONTR - blood glucose
BAYER BREEZE 2 LOW CONTRO - blood glucose
BAYER BREEZE 2 NORMAL CON - blood glucose
BAYER BREEZE 2 TEST DISC - glucose blood test
disk.................................................................................176
BAYER CONTOUR BLOOD GLUCO - blood glucose
BAYER CONTOUR BLOOD GLUCO - glucose blood test
strip................................................................................ 176
BAYER CONTOUR HIGH CONTRO - blood glucose
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................................................................................ 176
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 USB BL - blood glucose
BAYER CONTOUR NORMAL CONT - blood glucose
BAYER CONTOUR USB BLOOD G - blood glucose
247
2015
BAYER MICROLET 2 LANCING - lancet devices ..........185
BAYER MICROLET LANCETS - lancets ....................... 185
BCG VACCINE - bcg vaccine inj...................................... 14
b-complex w/ c & folic acid cap 1 mg
(Nephrocaps)................................................................128
b-complex w/ c & folic acid tab................................... 128
b-complex w/ c & folic acid tab 1 mg (Nephro-vite
rx).................................................................................. 128
b-complex w/ c & folic acid tab 5 mg.......................... 128
b-complex w/ c-biotin-minerals & folic acid tab 5 mg
(Diatx zn)...................................................................... 128
BD AUTOSHIELD 29G X 3/16" - insulin pen needle 29 g x
5 mm (3/16")..................................................................185
BD AUTOSHIELD 29G X 5/16" - insulin pen needle 29 g x
8 mm (5/16")..................................................................185
BD AUTOSHIELD DUO 30G X 3 - insulin pen needle 30 g
x 5 mm (3/16")...............................................................185
BD INSULIN SYRINGE/DETACH - insulin syringe/needle
u-100 1 ml 25 x 1"........................................................ 186
u-100 1 ml 25 x 5/8"......................................................186
u-100 1 ml 26 x 1/2"......................................................186
BD INSULIN SYRINGE/U-100/ - insulin syringe/needle
u-100 1/2 ml 30 x 1/2"...................................................186
u-100 1 ml 27 x 1/2"......................................................186
u-100 1 ml 28 x 1/2"......................................................186
u-100 2 ml 27.5 x 5/8"...................................................186
u-100 2 ml 29 x 1/2"......................................................186
BD INSULIN SYRINGE LUER-L - insulin syringe (disp)
u-100 1 ml..................................................................... 185
BD INSULIN SYRINGE MICROF - insulin syringe/needle
u-100 0.3 ml 28 x 1/2"...................................................185
u-100 1/2 ml 28 x 1/2"...................................................185
u-100 1 ml 27 x 5/8"......................................................185
u-100 1 ml 28 x 1/2"......................................................186
B-D INSULIN SYRINGE MICRO - insulin syringe/needle
u-100 1 ml 28 x 1/2"......................................................184
BD INSULIN SYRINGE SAFETY - insulin syringe/needle
u-100 0.3 ml 31 x 5/16".................................................186
u-100 1/2 ml 29 x 1/2"...................................................186
u-100 1 ml 29 x 1/2"......................................................186
BD INSULIN SYRINGE SLIP T - insulin syringe (disp)
u-100 1 ml..................................................................... 186
BD INSULIN SYRINGE U-40/1 - insulin syringe/needle
u-40 1 ml 25 x 5/8"....................................................... 186
248
BD INSULIN SYRINGE ULTRAF - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................186
u-100 0.3 ml 30 x 1/2"...................................................186
u-100 0.3 ml 31 x 15/64"...............................................186
u-100 0.3 ml 31 x 5/16".................................................186
u-100 1/2 ml 29 x 1/2"...................................................186
u-100 1/2 ml 30 x 1/2"...................................................186
u-100 1/2 ml 31 x 15/64"...............................................186
u-100 1/2 ml 31 x 5/16".................................................186
u-100 1 ml 29 x 1/2"......................................................186
u-100 1 ml 30 x 1/2"......................................................186
u-100 1 ml 31 x 15/64"..................................................186
u-100 1 ml 31 x 5/16"....................................................186
B-D INSULIN SYRINGE ULTRA - insulin syringe/needle
u-100 0.3 ml 30 x 1/2"...................................................185
u-100 0.3 ml 31 x 5/16".................................................185
u-100 1 ml 31 x 5/16"....................................................185
BD INTEGRA INSULIN SYRING - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................186
BD INTEGRA SYRINGE/RETRAC - insulin syringe/needle
u-100 1 ml 25 x 1"........................................................ 186
BD LANCET DEVICE - lancet devices .......................... 187
BD LANCET ULTRAFINE 30G - lancets ........................187
BD LANCET ULTRAFINE 33G - lancets ........................187
BD LATITUDE DIABETES MANA - blood glucose
BD LO-DOSE INSULIN SYRIN - insulin syringe/needle
u-100 1/2 ml 28 x 1/2"...................................................185
BD LOGIC BLOOD GLUCOSE MO - blood glucose
BD MICROTAINER LANCETS - lancets ........................187
BD PEN - injection device for insulin.............................. 187
BD PEN MINI - injection device for insulin...................... 187
BD PEN NEEDLE/MINI/ULTRAF - insulin pen needle 31 g
x 5 mm (3/16")...............................................................187
BD PEN NEEDLE/NANO/ULTRA - insulin pen needle 32 g
x 4 mm (5/32")...............................................................187
BD PEN NEEDLE/SHORT/ULTRA - insulin pen needle 31
g x 8 mm (1/3" or 5/16")................................................187
BD PEN NEEDLE/ULTRAFINE/2 - insulin pen needle 29 g
x 12.7 mm..................................................................... 187
BD PEN NEEDLES SHORT/ULTR - insulin pen needle 31
g x 8 mm (1/3" or 5/16")................................................187
2015
BD SAFETYGLIDE INSULIN SY - insulin syringe/needle
u-100 1/2 ml 30 x 5/16".................................................187
BD SAFETY-LOK INSULIN SYR - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................187
BD TEST STRIPS - glucose blood test strip................... 176
BD ULTRA FINE LANCETS - lancets ............................187
BECONASE AQ - beclomethasone dipropionate monohyd
nasal susp 42 mcg/spray................................................ 62
BELLADONNA & OPIUM - belladonna alkaloids & opium
suppos 16.2-30 mg..........................................................71
BELLADONNA ALKALOIDS & OP - belladonna alkaloids
& opium suppos 16.2-60 mg........................................... 71
BELSOMRA - suvorexant tab 10 mg................................ 93
BELSOMRA - suvorexant tab 5 mg.................................. 93
benazepril & hydrochlorothiazide tab 10-12.5 mg
(Lotensin hct)................................................................. 48
benazepril & hydrochlorothiazide tab 20-12.5 mg
(Lotensin hct)................................................................. 48
benazepril & hydrochlorothiazide tab 20-25 mg
(Lotensin hct)................................................................. 48
benazepril & hydrochlorothiazide tab 5-6.25 mg..........48
benazepril hcl tab 10 mg (Lotensin).............................. 49
benazepril hcl tab 5 mg.................................................. 49
BENICAR HCT - olmesartan medoxomilhydrochlorothiazide tab 20-12.5 mg................................ 49
BENICAR HCT - olmesartan medoxomilhydrochlorothiazide tab 40-12.5 mg................................ 49
BENICAR HCT - olmesartan medoxomilhydrochlorothiazide tab 40-25 mg................................... 49
BENICAR - olmesartan medoxomil tab 20 mg.................. 49
BENICAR - olmesartan medoxomil tab 40 mg.................. 49
BENICAR - olmesartan medoxomil tab 5 mg.................... 49
BENSAL HP - salicylic acid & benzoic acid oint 3-6%.....159
BENTYL - dicyclomine hcl cap 10 mg.............................. 71
BENTYL - dicyclomine hcl oral soln 10 mg/5ml................ 71
BENTYL - dicyclomine hcl tab 20 mg............................... 71
BENZAC AC WASH - benzoyl peroxide liq 5%...............159
BENZACLIN - clindamycin phosphate-benzoyl peroxide
gel 1-5%........................................................................ 159
BENZACLIN WITH PUMP - clindamycin phosphatebenzoyl peroxide gel 1-5%............................................ 159
BENZAC W WASH - benzoyl peroxide liq 5%................ 159
BENZALKONIUM CHLORIDE - benzalkonium chloride
soln................................................................................ 175
BENZALKONIUM CHLORIDE - benzalkonium chloride
soln 50%........................................................................175
BENZAMYCIN - benzoyl peroxide-erythromycin gel
5-3%...............................................................................159
BENZAMYCINPAK - benzoyl peroxide-erythromycin gel
pack 5-3%......................................................................159
BENZEFOAM - benzoyl peroxide foam 5.3%................. 159
BENZEFOAMULTRA - benzoyl peroxide foam 9.8%...... 159
BENZIQ - benzoyl peroxide gel 5.25 %.......................... 159
BENZIQ LS - benzoyl peroxide gel 2.75%...................... 159
benzocaine dental soln 20%........................................ 155
BENZOIN COMPOUND TINCTURE - benzoin compound
tincture........................................................................... 159
BENZOIN TINCTURE - benzoin tincture.........................159
benzonatate cap 100 mg (Tessalon perles).................. 63
benzonatate cap 150 mg (Zonatuss)............................. 63
benzonatate cap 200 mg................................................ 63
benzoyl peroxide creamy wash 8% &benzoyl peroxide
bar 5% kit (Bpo creamy wash comp).........................159
benzoyl peroxide-erythromycin gel 5-3%
(Benzamycin)................................................................160
benzoyl peroxide foam 5.3% (Benzefoam)..................159
benzoyl peroxide foam 9.8% (Benzefoamultra).......... 159
benzoyl peroxide gel 10%............................................ 159
benzoyl peroxide gel 5%.............................................. 159
benzoyl peroxide liq 10%............................................. 159
benzoyl peroxide liq 2.5%............................................ 159
benzoyl peroxide liq 5.25%.......................................... 159
benzoyl peroxide liq 7%............................................... 159
benzoyl peroxide lotion 6%..........................................159
benztropine mesylate inj 1 mg/ml (Cogentin)............. 123
benztropine mesylate tab 0.5 mg.................................123
benztropine mesylate tab 1 mg................................... 123
benztropine mesylate tab 2 mg................................... 123
BEPREVE - bepotastine besilate ophth soln 1.5%..........150
BESIVANCE - besifloxacin hcl ophth susp 0.6% (base
equiv)............................................................................. 150
BETADINE OPHTHALMIC PREP - povidone-iodine ophth
soln 5%..........................................................................150
BETAGAN C CAP QD - levobunolol hcl ophth soln
0.5%...............................................................................150
BETAGAN - levobunolol hcl ophth soln 0.5%................. 150
betamethasone dipropionate augmented cream 0.05%
(Diprolene af)............................................................... 160
betamethasone dipropionate augmented gel
0.05%.............................................................................160
betamethasone dipropionate augmented lotion 0.05%
(Diprolene).................................................................... 160
betamethasone dipropionate augmented oint 0.05%
(Diprolene).................................................................... 160
betamethasone dipropionate cream 0.05%.................160
betamethasone dipropionate lotion 0.05%................. 160
betamethasone dipropionate oint 0.05%.....................160
betamethasone valerate aerosol foam 0.12%
(Luxiq)........................................................................... 160
betamethasone valerate cream 0.1%...........................160
betamethasone valerate lotion 0.1%........................... 160
betamethasone valerate oint 0.1%...............................160
BETAPACE AF - sotalol hcl (afib/afl) tab 120 mg............. 41
BETAPACE AF - sotalol hcl (afib/afl) tab 160 mg............. 41
BETAPACE AF - sotalol hcl (afib/afl) tab 80 mg............... 41
BETAPACE - sotalol hcl tab 120 mg................................ 41
BETAPACE - sotalol hcl tab 160 mg................................ 41
BETAPACE - sotalol hcl tab 80 mg.................................. 41
249
2015
BETASERON - interferon beta-1b for inj kit 0.3 mg.......... 99
betaxolol hcl ophth soln 0.5%..................................... 150
betaxolol hcl tab 10 mg (Kerlone)................................. 41
betaxolol hcl tab 20 mg (Kerlone)................................. 41
bethanechol chloride tab 10 mg (Urecholine)...............78
bethanechol chloride tab 5 mg (Urecholine)................ 78
BETHKIS - tobramycin nebu soln 300 mg/4ml....................6
BETIMOL - timolol ophth soln 0.25%..............................150
BETIMOL - timolol ophth soln 0.5%................................150
BETOPTIC-S - betaxolol hcl ophth susp 0.25%.............. 150
BEYAZ - drospirenone-ethinyl estrad-levomefolate tab
3-0.02-0.451 mg.............................................................. 24
BG STAR BLOOD GLUCOSE TES - glucose blood test
strip................................................................................ 176
BIAXIN - clarithromycin for susp 250 mg/5ml..................... 3
BIAXIN - clarithromycin tab 250 mg....................................3
BIAXIN - clarithromycin tab 500 mg....................................3
BIAXIN XL - clarithromycin tab sr 24hr 500 mg.................. 3
BIAXIN XL PAC - clarithromycin tab sr 24hr 500 mg.......... 3
bicalutamide tab 50 mg (Casodex)................................ 15
BIDIL - isosorbide dinitrate-hydralazine hcl tab 20-37.5
mg.................................................................................... 61
BIFERARX - polysacch fe cmplx-fe heme poly-fa-b12 tab
22-6-1-0.025 mg............................................................ 143
BILTRICIDE - praziquantel tab 600 mg.............................13
BIMATOPROST - bimatoprost ophth soln 0.03%............150
BINOSTO - alendronate sodium effervescent tab 70
mg.................................................................................... 35
BIONECT - hyaluronate sodium cream 0.2%..................160
BIONECT - hyaluronate sodium foam 0.2%....................160
BIONECT - hyaluronate sodium gel 0.2%.......................160
BIONECT - hyaluronate sodium spray 0.2%...................160
BIOSCANNER GLUCOSE TEST S - glucose blood test
strip................................................................................ 176
BIO-STATIN - nystatin cap 1000000 unit............................7
BIO-STATIN - nystatin cap 500000 unit..............................7
bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln
kit.....................................................................................70
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
(Ziac)............................................................................... 49
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
(Ziac)............................................................................... 49
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
(Ziac)............................................................................... 49
bisoprolol fumarate tab 10 mg (Zebeta)........................41
bisoprolol fumarate tab 5 mg (Zebeta)..........................42
BLEPH-10 - sulfacetamide sodium ophth soln 10%........ 150
BLEPHAMIDE LIQUIFILM - sulfacetamide sodiumprednisolone ophth susp 10-0.2%................................. 150
BLEPHAMIDE S.O.P. - sulfacetamide sodiumprednisolone ophth oint 10-0.2%...................................150
BLEPHAMIDE - sulfacetamide sodium-prednisolone ophth
susp 10-0.2%.................................................................150
250
BLOOD GLUCOSE MONITORING - blood glucose
BLOOD GLUCOSE SYSTEM PAK - blood glucose
BLOOD GLUCOSE TEST STRIPS - glucose blood test
strip................................................................................ 176
B-NEXA - prenatal w/ calcium-vit b6-fa-ginger tab 1.22 mg
....................................................................................... 128
BONIVA - ibandronate sodium tab 150 mg (base
equivalent)....................................................................... 35
BORIC ACID - boric acid granules..................................160
BOSULIF - bosutinib tab 100 mg......................................15
BOSULIF - bosutinib tab 500 mg......................................15
BP CLEANSING WASH - sulfacetamide sodium-sulfur in
urea emulsion 10-4%.................................................... 160
BP FOLINATAL PLUS B - prenatal w/ calcium carbonateb6-b12-fa tab 1 mg ...................................................... 128
BP MULTINATAL PLUS - prenatal w/o a vit w/ fe
fumarate-fa tab 30-1 mg .............................................. 128
BP MULTINATAL PLUS - prenatal w/o a vit w/ fe fum-fa
tab chew 40-1 mg ........................................................ 128
BPO 3% FOAMING CLOTHS - benzoyl peroxide cloth
3%..................................................................................160
BPO 9% FOAMING CLOTHS - benzoyl peroxide cloth
9%..................................................................................160
BPO - benzoyl peroxide gel 4%......................................160
BPO - benzoyl peroxide gel 8%......................................160
BP VIT 3 - folic acid-vit b6-vit b12-omega 3-phytosterols
cap 1 mg ...................................................................... 143
BP VIT 3 PLUS - folic acid-b6-b12-d-omega 3-phytosterols
cap 1 mg ...................................................................... 143
BRAVELLE - urofollitropin purified for inj 75 unit...............35
BREATHERITE COLLAPSIBLE - spacer/aerosol-holding
chambers - device ........................................................187
BREATHERITE RIGID SPACER - spacer/aerosol-holding
chambers - device ........................................................187
BREATHERITE - spacer/aerosol-holding chambers device ........................................................................... 187
BREATHERITE W/LARGE MASK - spacer/aerosolholding chambers - device ........................................... 187
BREATHERITE W/MEDIUM MASK - spacer/aerosolholding chambers - device ........................................... 187
BREATHERITE W/SMALL MASK - spacer/aerosol-holding
chambers - device ........................................................187
BREO ELLIPTA - fluticasone furoate-vilanterol aero powd
ba 100-25 mcg/inh...........................................................67
BREVICON-28 - norethindrone & ethinyl estradiol tab 0.5
mg-35 mcg.......................................................................24
BRILINTA - ticagrelor tab 90 mg.....................................149
brimonidine tartrate ophth soln 0.15% (Alphagan
p)....................................................................................150
brimonidine tartrate ophth soln 0.2%..........................150
BRINTELLIX - vortioxetine hbr tab 10 mg (base equiv).....83
BRINTELLIX - vortioxetine hbr tab 20 mg (base equiv).....83
BRINTELLIX - vortioxetine hbr tab 5 mg (base equiv).......83
2015
BRISDELLE - paroxetine mesylate cap 7.5 mg (base
equiv)............................................................................... 99
bromfenac sodium ophth soln 0.09% (base equiv)
(once-daily)...................................................................150
bromfenac sodium ophth soln 0.09% (base
equivalent).................................................................... 150
bromocriptine mesylate cap 5 mg (Parlodel)..............123
bromocriptine mesylate tab 2.5 mg.............................123
brompheniramine & pseudoephedrine tab sr 12hr 6-45
mg....................................................................................63
brompheniramine maleate tab sr 12hr 6 mg.................62
BROMPHENIRAMINE TANNATE - brompheniramine
tannate chew tab 12 mg..................................................62
BROVANA - arformoterol tartrate soln nebu 15 mcg/2ml
(base equiv).....................................................................67
budesonide cap sr 24hr 3 mg (Entocort ec)................. 19
budesonide inhalation susp 0.25 mg/2ml
(Pulmicort)...................................................................... 67
budesonide inhalation susp 0.5 mg/2ml
(Pulmicort)...................................................................... 67
budesonide nasal susp 32 mcg/act (Rhinocort
aqua)............................................................................... 63
BULLSEYE MINI SAFETY LANC - lancets .................... 187
BULLSEYE SAFETY LANCETS - lancets ......................187
bumetanide tab 0.5 mg................................................... 56
bumetanide tab 1 mg...................................................... 56
bumetanide tab 2 mg...................................................... 56
BUNAVAIL - buprenorphine-naloxone buccal film 2.1-0.3
mg (base equiv).............................................................104
BUNAVAIL - buprenorphine-naloxone buccal film 4.2-0.7
mg (base equiv).............................................................104
BUNAVAIL - buprenorphine-naloxone buccal film 6.3-1 mg
(base equiv)...................................................................104
BUPAP - butalbital-acetaminophen tab 50-300 mg......... 103
BUPHENYL - sodium phenylbutyrate oral powder 3 gm/
teaspoonful...................................................................... 36
BUPHENYL - sodium phenylbutyrate tab 500 mg.............36
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base
equiv)............................................................................ 104
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
equiv)............................................................................ 104
buprenorphine hcl sl tab 2 mg (base equiv)............... 104
buprenorphine hcl sl tab 8 mg (base equiv)............... 104
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
(Zyban)............................................................................ 99
bupropion hcl tab 100 mg (Wellbutrin)......................... 84
bupropion hcl tab 75 mg (Wellbutrin)........................... 84
bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr)........ 83
bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl).........84
bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl).........84
buspirone hcl tab 10 mg................................................ 82
buspirone hcl tab 5 mg.................................................. 82
buspirone hcl tab 7.5 mg............................................... 82
butalbital-acetaminophen-caffeine cap 50-300-40 mg
(Fioricet)........................................................................103
butalbital-acetaminophen-caffeine cap 50-325-40
mg..................................................................................103
butalbital-acetaminophen-caffeine tab 50-325-40 mg
(Esgic)........................................................................... 103
butalbital-acetaminophen-caff w/ cod cap 50-300-40-30
mg (Fioricet/codeine).................................................. 104
butalbital-acetaminophen-caff w/ cod cap 50-325-40-30
mg..................................................................................104
butalbital-acetaminophen tab 50-325 mg.................... 103
butalbital-aspirin-caffeine cap 50-325-40 mg
(Fiorinal)........................................................................103
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
(Fiorinal/codeine #3)....................................................104
BUTISOL SODIUM - butabarbital sodium tab 30 mg........ 93
BUTISOL SODIUM - butabarbital sodium tab 50 mg........ 93
butorphanol tartrate inj 1 mg/ml.................................. 104
butorphanol tartrate inj 2 mg/ml.................................. 104
butorphanol tartrate nasal soln 10 mg/ml...................104
BUTRANS - buprenorphine td patch weekly 10 mcg/
hr....................................................................................104
hr....................................................................................104
hr....................................................................................104
hr....................................................................................104
BUTRANS - buprenorphine td patch weekly 7.5 mcg/
hr....................................................................................104
BYDUREON - exenatide extended release for inj susp 2
mg.................................................................................... 28
BYDUREON - exenatide extended release for susp peninjector 2 mg....................................................................28
BYETTA - exenatide soln pen-injector 10 mcg/0.04ml...... 28
BYETTA - exenatide soln pen-injector 5 mcg/0.02ml........ 28
BYSTOLIC - nebivolol hcl tab 10 mg (base
equivalent)....................................................................... 42
BYSTOLIC - nebivolol hcl tab 2.5 mg (base
equivalent)....................................................................... 42
BYSTOLIC - nebivolol hcl tab 20 mg (base
equivalent)....................................................................... 42
BYSTOLIC - nebivolol hcl tab 5 mg (base equivalent)...... 42
C
cabergoline tab 0.5 mg................................................... 36
CADUET - amlodipine besylate-atorvastatin calcium tab
10-10 mg......................................................................... 61
10-20 mg......................................................................... 61
10-40 mg......................................................................... 61
10-80 mg......................................................................... 61
251
2015
2.5-10 mg........................................................................ 61
2.5-20 mg........................................................................ 61
2.5-40 mg........................................................................ 61
5-10 mg........................................................................... 61
5-20 mg........................................................................... 61
5-40 mg........................................................................... 61
5-80 mg........................................................................... 61
CAFERGOT - ergotamine w/ caffeine tab 1-100 mg....... 115
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base
equiv) (Cafcit).................................................................96
CALAN SR - verapamil hcl tab cr 120 mg........................ 44
CALAN - verapamil hcl tab 120 mg.................................. 44
CALAN - verapamil hcl tab 80 mg.................................... 44
CALCIFOL - ca carb-folic acid-vit d-b6-b12-boron-mag
wafer 1342-1.6 mg........................................................ 139
calcipotriene-betamethasone dipropionate oint
0.005-0.064% (Taclonex)............................................. 160
calcipotriene cream 0.005% (Dovonex)....................... 160
calcipotriene oint 0.005%............................................. 160
calcipotriene soln 0.005% (50 mcg/ml)........................160
calcitonin (salmon) nasal soln 200 unit/act
(Miacalcin)...................................................................... 36
CALCITRIOL - calcitriol oint 3 mcg/gm........................... 160
calcitriol cap 0.25 mcg (Rocaltrol).................................36
calcitriol cap 0.5 mcg (Rocaltrol)...................................36
calcitriol oral soln 1 mcg/ml (Rocaltrol)........................36
calcium acetate (phosphate binder) cap 667 mg (169
mg ca) (Phoslo)............................................................. 76
calcium acetate (phosphate binder) tab 667 mg
(Eliphos)..........................................................................76
CALCIUM-FOLIC ACID PLUS D - ca carb-folic acid-vit db6-b12-boron-mag wafer 1342-1 mg.............................139
CALCIUM PNV - prenatal w/o vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg .......................................................... 129
CAMBIA - diclofenac potassium packet 50 mg............... 115
CAMPHOMEX - camphor-histamine-menthol liqd spray
4-0.025-10%.................................................................. 160
CANASA - mesalamine suppos 1000 mg......................... 76
candesartan cilexetil-hydrochlorothiazide tab 16-12.5
mg (Atacand hct)........................................................... 49
candesartan cilexetil-hydrochlorothiazide tab 32-12.5
mg (Atacand hct)........................................................... 49
candesartan cilexetil-hydrochlorothiazide tab 32-25
mg (Atacand hct)........................................................... 49
candesartan cilexetil tab 16 mg (Atacand)....................49
candesartan cilexetil tab 32 mg (Atacand)....................49
candesartan cilexetil tab 4 mg (Atacand)......................49
252
candesartan cilexetil tab 8 mg (Atacand)......................49
CANTIL - mepenzolate bromide tab 25 mg.......................71
CAPCOF - phenylephrine-chlorphen w/ codeine syrup
5-2-10 mg/5ml................................................................. 63
capecitabine tab 150 mg (Xeloda)................................. 15
capecitabine tab 500 mg (Xeloda)................................. 15
CAPEX - fluocinolone acetonide shampoo 0.01%.......... 160
CAPITAL/CODEINE - acetaminophen w/ codeine susp
120-12 mg/5ml...............................................................104
CAPRELSA - vandetanib tab 100 mg............................... 15
CAPRELSA - vandetanib tab 300 mg............................... 15
CAPS 0 CLEAR DELAYED RELE - non gelatin capsules
(empty) ......................................................................... 233
CAPSULE #0 CLEAR/LOCKING/ - non gelatin capsules
(empty) ......................................................................... 233
CAPSULE CONI-SNAP #0 CLEA - non gelatin capsules
(empty) ......................................................................... 233
(empty) ......................................................................... 233
(empty) ......................................................................... 233
CAPTOPRIL/HYDROCHLOROTHIA - captopril &
hydrochlorothiazide tab 25-15 mg................................... 49
captopril tab 100 mg....................................................... 49
captopril tab 12.5 mg...................................................... 49
captopril tab 25 mg......................................................... 49
captopril tab 50 mg......................................................... 49
CARAC - fluorouracil cream 0.5%...................................160
CARAFATE - sucralfate susp 1 gm/10ml..........................71
CARAFATE - sucralfate tab 1 gm.....................................71
CARBAGLU - carglumic acid tab 200 mg......................... 36
carbamazepine cap sr 12hr 100 mg (Carbatrol)..........117
carbamazepine chew tab 100 mg................................ 118
carbamazepine susp 100 mg/5ml (Tegretol)............... 118
carbamazepine tab 200 mg (Tegretol)......................... 118
carbamazepine tab sr 12hr 200 mg (Tegretol-xr)........118
carbamazepine tab sr 12hr 400 mg (Tegretol-xr)........118
CARBAPHEN 12 PED - phenyleph-chlorphencarbetapentane susp 2.5-1.25-7.5 mg/ml........................ 63
CARBAPHEN 12 - phenyleph-chlorphen-carbetapentane
liqd 10-4-27.5 mg/5ml......................................................63
CARBATROL - carbamazepine cap sr 12hr 100 mg....... 118
CARBIDOPA/LEVODOPA/ENTACA - carbidopalevodopa-entacapone tabs 12.5-50-200 mg.................. 123
CARBIDOPA/LEVODOPA/ENTACA - carbidopalevodopa-entacapone tabs 18.75-75-200 mg................ 123
2015
CARBIDOPA/LEVODOPA/ENTACA - carbidopalevodopa-entacapone tabs 25-100-200 mg................... 123
CARBIDOPA/LEVODOPA/ENTACA - carbidopalevodopa-entacapone tabs 31.25-125-200 mg.............. 123
CARBIDOPA/LEVODOPA/ENTACA - carbidopalevodopa-entacapone tabs 37.5-150-200 mg................ 123
CARBIDOPA/LEVODOPA/ENTACA - carbidopalevodopa-entacapone tabs 50-200-200 mg................... 124
carbidopa & levodopa orally disintegrating tab 10-100
mg..................................................................................123
mg..................................................................................123
mg..................................................................................123
carbidopa & levodopa tab 10-100 mg (Sinemet).........123
carbidopa & levodopa tab cr 25-100 mg (Sinemet
cr).................................................................................. 123
carbidopa & levodopa tab cr 50-200 mg (Sinemet
cr).................................................................................. 123
carbidopa tab 25 mg (Lodosyn)...................................123
carbinoxamine maleate soln 4 mg/5ml..........................62
carbinoxamine maleate tab 4 mg...................................62
carbonyl iron susp 15 mg/1.25ml (elemental iron)..... 143
CARDIOCOM LANCING DEVICE - lancet devices ........ 187
CARDIOTEK-RX - folic acid-b12-b6-arginine-black pepper
tab .................................................................................140
CARDIOVID PLUS - dha-epa-vit b6-b12-folic acid cap
240-360-20-0.5-0.8 mg.................................................. 140
CARDIZEM CD - diltiazem hcl coated beads cap sr 24hr
120 mg.............................................................................44
180 mg.............................................................................44
240 mg.............................................................................44
300 mg.............................................................................44
360 mg.............................................................................44
CARDIZEM - diltiazem hcl tab 120 mg............................. 44
CARDIZEM - diltiazem hcl tab 30 mg............................... 44
CARDIZEM - diltiazem hcl tab 60 mg............................... 44
CARDIZEM LA - diltiazem hcl coated beads tab sr 24hr
120 mg.............................................................................44
180 mg.............................................................................44
240 mg.............................................................................44
300 mg.............................................................................44
360 mg.............................................................................44
420 mg.............................................................................44
CARDURA - doxazosin mesylate tab 1 mg.......................49
CARDURA XL - doxazosin mesylate tab sr 24 hr 4 mg
(base equiv).....................................................................80
CARDURA XL - doxazosin mesylate tab sr 24 hr 8 mg
(base equiv).....................................................................80
CAREFINE PEN NEEDLE 32GX4 - insulin pen needle 32
g x 4 mm (5/32")........................................................... 187
CAREFINE PEN NEEDLES 29GX - insulin pen needle 29
g x 12 mm (1/2")........................................................... 187
g x 8 mm (1/3" or 5/16")................................................187
g x 6 mm (1/4")............................................................. 187
g x 8 mm (1/3" or 5/16")................................................188
g x 5 mm (1/5" or 3/16")................................................188
g x 6 mm (1/4")............................................................. 188
CAREONE ADVANCED LANCING - lancet devices ...... 188
CAREONE BLOOD GLUCOSE MON - blood glucose
CAREONE BLOOD GLUCOSE TES - glucose blood test
strip................................................................................ 176
CAREONE INSULIN SYRINGES/ - insulin syringe/needle
u-100 0.3 ml 30 x 1/2"...................................................188
u-100 0.3 ml 31 x 5/16".................................................188
u-100 1/2 ml 30 x 1/2"...................................................188
u-100 1/2 ml 31 x 5/16".................................................188
u-100 1 ml 30 x 1/2"......................................................188
u-100 1 ml 31 x 5/16"....................................................188
CAREONE LANCET THIN - lancets .............................. 188
CAREONE LANCET ULTRA THIN - lancets ..................188
CAREONE ULTIGUARD INSULIN - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................188
u-100 0.3 ml 30 x 5/16".................................................188
u-100 1/2 ml 29 x 1/2"...................................................188
u-100 1/2 ml 30 x 5/16".................................................188
u-100 1 ml 29 x 1/2"......................................................188
u-100 1 ml 30 x 5/16"....................................................188
CAREONE UNIFINE PENTIPS 2 - insulin pen needle 29 g
x 12 mm (1/2")...............................................................188
x 5 mm (3/16")...............................................................188
253
2015
x 6 mm (1/4").................................................................188
x 8 mm (1/3" or 5/16")...................................................188
CAREONE UNIFINE PENTIPS P - insulin pen needle 29 g
x 12 mm (1/2")...............................................................188
x 5 mm (3/16")...............................................................188
x 6 mm (1/4").................................................................188
x 8 mm (1/3" or 5/16")...................................................188
x 4 mm (5/32")...............................................................188
CARESENS CONTROL A SOLUTI - blood glucose
CARESENS N BLOOD GLUCOSE - glucose blood test
strip................................................................................ 176
CARISOPRODOL - carisoprodol tab 250 mg..................126
carisoprodol tab 350 mg (Soma)................................. 126
carisoprodol w/ aspirin & codeine tab 200-325-16
mg..................................................................................126
carisoprodol w/ aspirin tab 200-325 mg...................... 126
CARNITOR - levocarnitine oral soln 1 gm/10ml (10%)......36
CARNITOR - levocarnitine tab 330 mg............................. 36
CARNITOR SF - levocarnitine oral soln 1 gm/10ml
(10%)............................................................................... 36
carteolol hcl ophth soln 1%......................................... 150
carvedilol tab 12.5 mg (Coreg).......................................42
carvedilol tab 25 mg (Coreg)..........................................42
carvedilol tab 3.125 mg (Coreg).....................................42
carvedilol tab 6.25 mg (Coreg).......................................42
CASCARA SAGRADA - cascara sagrada fl ext 1 gm/
ml..................................................................................... 70
CASODEX - bicalutamide tab 50 mg................................ 15
CATAPRES - clonidine hcl tab 0.1 mg..............................49
CATAPRES-TTS-1 - clonidine hcl td patch weekly 0.1
mg/24hr............................................................................50
mg/24hr............................................................................50
mg/24hr............................................................................50
CAYA - diaphragm arc-spring ........................................ 188
CAYSTON - aztreonam lysine for inhal soln 75 mg (base
equivalent)....................................................................... 13
CEDAX - ceftibuten cap 400 mg.........................................2
CEDAX - ceftibuten for susp 180 mg/5ml........................... 2
CEDAX - ceftibuten for susp 90 mg/5ml............................. 2
CEENU - lomustine cap 100 mg.......................................15
CEENU - lomustine cap 10 mg.........................................15
CEENU - lomustine cap 40 mg.........................................15
cefaclor cap 250 mg......................................................... 2
cefaclor cap 500 mg......................................................... 2
CEFACLOR - cefaclor for susp 125 mg/5ml....................... 2
254
CEFACLOR ER - cefaclor monohydrate tab sr 12hr 500
mg...................................................................................... 2
cefadroxil cap 500 mg...................................................... 2
cefadroxil for susp 250 mg/5ml....................................... 2
cefadroxil for susp 500 mg/5ml....................................... 2
cefadroxil tab 1 gm........................................................... 2
cefazolin sodium for inj 1 gm.......................................... 2
cefazolin sodium for inj 500 mg...................................... 2
cefdinir cap 300 mg.......................................................... 2
cefdinir for susp 125 mg/5ml........................................... 2
cefdinir for susp 250 mg/5ml........................................... 2
CEFDITOREN PIVOXIL - cefditoren pivoxil tab 200 mg
(base equivalent)............................................................... 2
CEFDITOREN PIVOXIL - cefditoren pivoxil tab 400 mg
(base equivalent)............................................................... 2
cefixime for susp 100 mg/5ml (Suprax).......................... 2
cefixime for susp 200 mg/5ml (Suprax).......................... 2
cefpodoxime proxetil for susp 100 mg/5ml.................... 2
cefpodoxime proxetil for susp 50 mg/5ml...................... 2
cefpodoxime proxetil tab 100 mg.................................... 2
cefpodoxime proxetil tab 200 mg.................................... 2
cefprozil for susp 125 mg/5ml......................................... 2
cefprozil for susp 250 mg/5ml......................................... 2
cefprozil tab 250 mg......................................................... 2
cefprozil tab 500 mg......................................................... 2
CEFTIBUTEN - ceftibuten cap 400 mg...............................2
CEFTIBUTEN - ceftibuten for susp 180 mg/5ml................. 2
CEFTIN - cefuroxime axetil for susp 125 mg/5ml................2
CEFTIN - cefuroxime axetil for susp 250 mg/5ml................2
CEFTIN - cefuroxime axetil tab 250 mg..............................2
CEFTIN - cefuroxime axetil tab 500 mg..............................2
cefuroxime axetil tab 250 mg (Ceftin)............................. 2
cefuroxime axetil tab 500 mg (Ceftin)............................. 2
CELEBREX - celecoxib cap 100 mg...............................112
CELEBREX - celecoxib cap 50 mg.................................112
celecoxib cap 100 mg (Celebrex).................................112
celecoxib cap 50 mg (Celebrex).................................. 112
CELEXA - citalopram hydrobromide tab 10 mg (base
equiv)............................................................................... 84
equiv)............................................................................... 84
equiv)............................................................................... 84
CELLCEPT - mycophenolate mofetil cap 250 mg........... 235
CELLCEPT - mycophenolate mofetil for oral susp 200 mg/
ml................................................................................... 235
CELLCEPT - mycophenolate mofetil tab 500 mg............235
CELONTIN - methsuximide cap 300 mg.........................118
CEM-UREA - urea soln 45%...........................................160
2015
CENFOL - folic acid-vitamin b6-vitamin b12 tab 2.3-24.5-2
mg.................................................................................. 143
CENTANY AT - mupirocin oint kit 2%.............................160
CENTANY - mupirocin oint 2%....................................... 160
CENTRATEX - ferrous fumarate-fa-b complex-c-zn-mgmn-cu cap 106-1 mg .................................................... 143
cephalexin cap 250 mg (Keflex).......................................2
CEPHALEXIN - cephalexin tab 250 mg..............................2
CEPHALEXIN - cephalexin tab 500 mg..............................2
cephalexin for susp 125 mg/5ml......................................2
cephalexin for susp 250 mg/5ml......................................2
CERDELGA - eliglustat tartrate cap 84 mg (base
equivalent)..................................................................... 143
CEREFOLIN - l-methylfolate w/ vit b12-vit b6-vit b2 tab
6-1-50-5 mg ..................................................................140
CEREFOLIN NAC - l-methylfolate-algae-b12-acetylcyst
tab 6-90.314-2-600mg .................................................. 140
CEREFOLIN NAC - l-methylfolate-methylcobalaminacetylcyst tab 6-2-600 mg ............................................ 140
CERVIDIL - dinoprostone vaginal inserts 10 mg...............35
CESAMET - nabilone cap 1 mg........................................74
CETACAINE - butamben-tetracaine-benzocaine aerosol
spray 2-2-14%............................................................... 160
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)...................62
CETRAXAL - ciprofloxacin hcl otic soln 0.2% (base
equivalent)..................................................................... 154
CETROTIDE - cetrorelix acetate for inj kit 0.25 mg...........36
cevimeline hcl cap 30 mg (Evoxac)............................. 155
CHANTIX CONTINUING MONTH - varenicline tartrate tab
1 mg (base equiv)........................................................... 99
CHANTIX STARTING MONTH PA - varenicline tartrate
tab 0.5 mg x 11 & tab 1 mg x 42 pack............................ 99
CHANTIX - varenicline tartrate tab 0.5 mg (base
equiv)............................................................................... 99
CHANTIX - varenicline tartrate tab 0.5 mg x 11 & tab 1 mg
x 42 pack.........................................................................99
CHANTIX - varenicline tartrate tab 1 mg (base equiv)...... 99
CHEMET - succimer cap 100 mg................................... 175
CHENODAL - chenodiol tab 250 mg................................ 76
CHERRY SYRUP - cherry syrup.................................... 233
CHLORDIAZEPOXIDE/AMITRIPT - chlordiazepoxideamitriptyline tab 10-25 mg............................................. 100
CHLORDIAZEPOXIDE/AMITRIPT - chlordiazepoxideamitriptyline tab 5-12.5 mg.............................................. 99
chlordiazepoxide hcl cap 10 mg.................................... 82
chlordiazepoxide hcl cap 25 mg.................................... 82
chlordiazepoxide hcl cap 5 mg......................................82
CHLORHEXIDINE GLUCONATE - chlorhexidine
gluconate soln 20%....................................................... 175
chlorhexidine gluconate soln 0.12% (Peridex)........... 155
chloroquine phosphate tab 250 mg...............................12
chloroquine phosphate tab 500 mg (Aralen)................ 12
CHLOROTHIAZIDE - chlorothiazide tab 250 mg.............. 56
chlorothiazide tab 500 mg.............................................. 56
chlorpheniramine w/ codeine liquid 2-10 mg/5ml.........63
CHLORPROMAZINE HCL - chlorpromazine hcl inj 25 mg/
ml..................................................................................... 89
chlorpromazine hcl tab 100 mg..................................... 89
chlorpromazine hcl tab 10 mg....................................... 89
chlorpromazine hcl tab 200 mg..................................... 89
CHLORPROPAMIDE - chlorpropamide tab 100 mg......... 28
CHLORPROPAMIDE - chlorpropamide tab 250 mg......... 28
CHLORTHALIDONE - chlorthalidone tab 100 mg.............56
CHLORTHALIDONE - chlorthalidone tab 25 mg...............56
CHLORTHALIDONE - chlorthalidone tab 50 mg...............56
chlorzoxazone tab 500 mg (Parafon forte dsc)...........126
CHOICE DM FORA G20 TEST S - glucose blood test
strip................................................................................ 176
CHOICE-OB+DHA - prenatal mv w/fe poly-fa chw 29-1 mg
& dha cap 250 mg pak .................................................129
CHOLBAM - cholic acid cap 250 mg................................ 76
CHOLBAM - cholic acid cap 50 mg.................................. 76
cholecalciferol cap 1000 unit....................................... 127
cholecalciferol cap 400 unit......................................... 127
cholecalciferol chew tab 1000 unit.............................. 127
cholecalciferol chew tab 400 unit................................ 127
cholecalciferol drops 400 unit/0.03ml (per drop)........127
cholecalciferol drops 5000 unit/ml (1000
unit/0.2ml)..................................................................... 127
cholecalciferol oral liquid 400 unit/ml......................... 127
cholecalciferol tab 1000 unit........................................ 127
cholecalciferol tab 400 unit.......................................... 127
cholestyramine light powder 4 gm/dose (Questran
light)................................................................................ 58
cholestyramine light powder packets 4 gm..................58
cholestyramine powder 4 gm/dose (Questran)............ 58
cholestyramine powder packets 4 gm (Questran)........58
choline & magnesium salicylates liq 500 mg/5ml.......103
choline fenofibrate cap dr 135 mg (fenofibric acid
equiv) (Trilipix)............................................................... 58
choline fenofibrate cap dr 45 mg (fenofibric acid
equiv) (Trilipix)............................................................... 58
CHOLINE MAGNESIUM TRISALI - choline & magnesium
salicylates tab 1000 mg.................................................103
chorionic gonadotropin for inj 10000 unit.................... 36
CIALIS - tadalafil tab 5 mg................................................61
CICLODAN CREAM KIT - ciclopirox olamine cream 0.77%
(base equiv) & cleanser kit............................................160
CICLODAN SOLUTION KIT - ciclopirox solution kit
8%..................................................................................160
ciclopirox gel 0.77%......................................................160
ciclopirox olamine cream 0.77% (base equiv)............ 160
ciclopirox olamine susp 0.77% (base equiv).............. 160
ciclopirox shampoo 1% (Loprox shampoo)................160
ciclopirox solution 8% (Penlac Nail Lacquer).............161
ciclopirox solution kit 8% (Ciclodan solution ki)........161
CICLOPIROX TOPICAL SOLUTI - ciclopirox solution 8%
& vitamin e 5% topical kit..............................................161
255
2015
CIFEREX - folic acid-cholecalciferol cap 1 mg-3775
unit................................................................................. 143
cilostazol tab 100 mg (Pletal).......................................149
cilostazol tab 50 mg (Pletal).........................................149
CILOXAN - ciprofloxacin hcl ophth oint 0.3%..................150
CILOXAN - ciprofloxacin hcl ophth soln 0.3%................. 150
cimetidine hcl soln 300 mg/5ml..................................... 71
cimetidine tab 200 mg.................................................... 71
CIMZIA - certolizumab pegol for inj kit 2 x 200 mg............76
CIMZIA - certolizumab pegol inj kit 2 x 200 mg/ml............ 76
CIMZIA STARTER KIT - certolizumab pegol inj kit 6 x 200
mg/ml............................................................................... 76
CIPRO - ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml).......................................................................... 5
CIPRO - ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml).......................................................................... 5
CIPRO - ciprofloxacin hcl tab 250 mg (base equiv)............ 5
CIPRO - ciprofloxacin hcl tab 500 mg (base equiv)............ 5
CIPRODEX - ciprofloxacin-dexamethasone otic susp
0.3-0.1%.........................................................................154
CIPROFLOXACIN - ciprofloxacin hcl otic soln 0.2% (base
equivalent)..................................................................... 154
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000
mg(base eq) (Cipro xr)....................................................6
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg
(base eq) (Cipro xr)......................................................... 6
ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml) (Cipro)............................................................ 5
ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml) (Cipro)............................................................ 6
CIPROFLOXACIN HCL - ciprofloxacin hcl tab 100 mg
(base equiv).......................................................................6
ciprofloxacin hcl ophth soln 0.3% (Ciloxan)............... 150
ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)......... 6
ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)......... 6
ciprofloxacin hcl tab 750 mg (base equiv)......................6
CIPRO HC - ciprofloxacin-hydrocortisone otic susp
0.2-1%............................................................................154
CIPRO XR - ciprofloxacin-ciprofloxacin hcl tab sr 24hr
1000 mg(base eq)............................................................. 5
CIPRO XR - ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500
mg (base eq)..................................................................... 5
citalopram hydrobromide oral soln 10 mg/5ml.............84
citalopram hydrobromide tab 10 mg (base equiv)
(Celexa)........................................................................... 84
(Celexa)........................................................................... 84
(Celexa)........................................................................... 84
CITRANATAL 90 DHA - prenat w/o a w/fecbn-fegl-dss-fa
tab 90 &dha cap 300mg pak......................................... 129
CITRANATAL ASSURE - prenat w/o a w/fecbn-fegl-dss-fa
tab & dha cap 300 mg pack.......................................... 129
256
CITRANATAL B-CALM - prenat w/o a w/fecbn-feglu-fa tab
20-1 mg & vit b6 tab pak...............................................129
CITRANATAL B-CALM - prenat w/o a w/ fe cbnyl-fa tab
20-1 mg & vit b6 tab pak...............................................129
CITRANATAL DHA - prenat w/o a w/fecbn-fegl-dss-fa tab
& dha cap 250 mg pack................................................ 129
CITRANATAL HARMONY - prenatal w/o a w/fe cbn-dssfa-dha cap 29-1-265 mg ...............................................129
CITRANATAL HARMONY - prenat w/o a w/fe fum-fe cbndss-fa-dha cap 27-1-260 mg ........................................ 129
CITRANATAL RX - prenatal w/o a w/ fe carbonyl-fe glucdss-fa tab 27-1mg ........................................................ 129
CITROLITH - potassium & sodium citrates tab 50-950
mg.................................................................................... 80
CLARAVIS - isotretinoin cap 30 mg................................161
CLARIFOAM EF - sulfacetamide sodium w/ sulfur foam
10-5%.............................................................................161
CLARINEX-D 12 HOUR - desloratadine &
pseudoephedrine tab sr 12hr 2.5-120 mg....................... 63
CLARINEX - desloratadine syrup 0.5 mg/ml..................... 62
CLARINEX - desloratadine tab 5 mg................................ 62
CLARINEX REDITABS - desloratadine tab orally
disintegrating 2.5 mg....................................................... 62
CLARINEX REDITABS - desloratadine tab orally
disintegrating 5 mg.......................................................... 62
clarithromycin for susp 125 mg/5ml................................3
clarithromycin for susp 250 mg/5ml (Biaxin)..................3
clarithromycin tab 250 mg (Biaxin)................................. 3
clarithromycin tab 500 mg (Biaxin)................................. 3
clarithromycin tab sr 24hr 500 mg (Biaxin xl pac)..........3
CLEANLET LANCETS 28G - lancets .............................189
CLEMASTINE FUMARATE - clemastine fumarate syrup
0.67 mg/5ml (0.5 mg/5ml base eq)................................. 62
clemastine fumarate tab 2.68 mg...................................62
CLEOCIN - clindamycin hcl cap 150 mg...........................13
CLEOCIN - clindamycin hcl cap 300 mg...........................13
CLEOCIN - clindamycin hcl cap 75 mg.............................13
CLEOCIN - clindamycin phosphate vaginal cream 2%..... 79
CLEOCIN - clindamycin phosphate vaginal suppos 100
mg.................................................................................... 79
CLEOCIN PEDIATRIC GRANULE - clindamycin palmitate
hcl for soln 75 mg/5ml (base equiv)................................ 13
CLEOCIN-T - clindamycin phosphate gel 1%................. 161
CLEOCIN-T - clindamycin phosphate lotion 1%..............161
CLEOCIN-T - clindamycin phosphate soln 1%............... 161
CLEOCIN-T - clindamycin phosphate swab 1%..............161
CLEVER CHEK AUTO-CODE TES - glucose blood test
strip................................................................................ 176
CLEVER CHEK AUTO-CODE VOI - glucose blood test
strip................................................................................ 176
CLEVER CHEK BLOOD GLUCOSE - blood glucose
CLEVER CHEK LANCETS ULTRA - lancets ................. 189
CLEVER CHEK TEST STRIPS - glucose blood test
strip................................................................................ 176
2015
CLEVER CHOICE AUTO-CODE P - glucose blood test
strip................................................................................ 177
CLEVER CHOICE COMFORT EZ - insulin pen needle 31
g x 5 mm (3/16")........................................................... 189
g x 6 mm (1/4")............................................................. 189
g x 8 mm (1/3" or 5/16")................................................189
g x 4 mm (5/32")........................................................... 189
g x 5 mm (1/5" or 3/16")................................................189
g x 6 mm (1/4")............................................................. 189
g x 8 mm....................................................................... 189
g x 4 mm (5/32")........................................................... 189
g x 5 mm (1/5" or 3/16")................................................189
g x 6 mm (1/4")............................................................. 189
g x 8 mm (1/3" or 5/16")................................................189
CLEVER CHOICE COMFORT EZ - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................189
u-100 0.3 ml 30 x 1/2"...................................................189
u-100 0.3 ml 30 x 5/16".................................................189
u-100 0.3 ml 31 x 5/16".................................................189
u-100 1/2 ml 28 x 1/2"...................................................189
u-100 1/2 ml 29 x 1/2"...................................................189
u-100 1/2 ml 30 x 1/2"...................................................189
u-100 1/2 ml 30 x 5/16".................................................189
u-100 1/2 ml 31 x 5/16".................................................189
u-100 1 ml 28 x 1/2"......................................................189
u-100 1 ml 29 x 1/2"......................................................189
u-100 1 ml 30 x 1/2"......................................................189
u-100 1 ml 30 x 5/16"....................................................189
u-100 1 ml 31 x 5/16"....................................................189
CLEVER CHOICE COMFORT EZ - methyl salicylatelidocaine-menthol patch 20-4-1%.................................. 161
CLEVER CHOICE COMFORT EZ - methyl salicylatelidocaine-menthol patch 2-4-1%.................................... 161
CLEVER CHOICE GLUCOSE CON - blood glucose
CLEVER CHOICE GLUCOSE CON - blood glucose
CLEVER CHOICE MICRO BLOOD - blood glucose
CLEVER CHOICE MICRO TEST - glucose blood test
strip................................................................................ 177
CLICKFINE PEN NEEDLE 32GX - insulin pen needle 32 g
x 4 mm (5/32")...............................................................190
CLICKFINE PEN NEEDLES/31G - insulin pen needle 31 g
x 6 mm (1/4").................................................................190
CLICKFINE PEN NEEDLES/31G - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................190
CLICKFINE PEN NEEDLE UNIV - insulin pen needle 31 g
x 6 mm (1/4").................................................................190
CLICKFINE PEN NEEDLE UNIV - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................190
CLICKFINE UNIVERSAL PEN N - insulin pen needle 31 g
x 6 mm (1/4").................................................................190
CLICKFINE UNIVERSAL PEN N - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................190
clidinium & chlordiazepoxide cap 2.5-5 mg
(Librax)............................................................................71
CLIMARA - estradiol td patch weekly 0.025 mg/24hr........ 22
CLIMARA - estradiol td patch weekly 0.0375 mg/24hr
(37.5 mcg/24hr)............................................................... 22
CLIMARA - estradiol td patch weekly 0.05 mg/24hr..........22
CLIMARA - estradiol td patch weekly 0.06 mg/24hr..........22
CLIMARA - estradiol td patch weekly 0.075 mg/24hr........ 22
CLIMARA - estradiol td patch weekly 0.1 mg/24hr............22
CLIMARA PRO - estradiol-levonorgestrel td patch weekly
0.045-0.015 mg/day.........................................................22
CLINDACIN ETZ - clindamycin phosphate swab 1% &
cleanser kit.................................................................... 161
CLINDACIN PAC - clindamycin phosphate swab 1% &
cleanser kit.................................................................... 161
CLINDAGEL - clindamycin phosphate gel 1%................ 161
clindamycin hcl cap 150 mg (Cleocin).......................... 13
clindamycin hcl cap 300 mg (Cleocin).......................... 13
clindamycin hcl cap 75 mg (Cleocin)............................ 13
clindamycin palmitate hcl for soln 75 mg/5ml (base
equiv) (Cleocin pediatric gr).........................................13
clindamycin phosphate-benzoyl peroxide gel 1-5%
(Benzaclin)....................................................................161
clindamycin phosphate foam 1% (Evoclin).................161
clindamycin phosphate gel 1% (Cleocin-t)................. 161
clindamycin phosphate lotion 1% (Cleocin-t).............161
clindamycin phosphate soln 1% (Cleocin-t)............... 161
clindamycin phosphate swab 1% (Cleocin-t)..............161
clindamycin phosphate vaginal cream 2%
(Cleocin)..........................................................................79
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2
(1)-5% (Duac)................................................................161
CLINDESSE - clindamycin phosphate (one dose) vaginal
cream 2%........................................................................ 79
257
2015
clobetasol propionate cream 0.05% (Temovate)........ 161
clobetasol propionate emollient base cream 0.05%
(Temovate e)................................................................ 161
clobetasol propionate emulsion foam 0.05% (Oluxe)....................................................................................161
clobetasol propionate foam 0.05% (Olux)................... 161
clobetasol propionate gel 0.05% (Temovate)..............161
clobetasol propionate lotion 0.05% (Clobex)..............161
clobetasol propionate oint 0.05% (Temovate)............ 161
clobetasol propionate shampoo 0.05% (Clobex)........161
clobetasol propionate soln 0.05% (Temovate)........... 161
clobetasol propionate spray 0.05% (Clobex).............. 161
CLOBEX - clobetasol propionate lotion 0.05%................161
CLOBEX - clobetasol propionate shampoo 0.05%..........161
CLOBEX - clobetasol propionate spray 0.05%............... 161
CLOCORTOLONE PIVALATE - clocortolone pivalate
cream 0.1%................................................................... 161
CLOCORTOLONE PIVALATE PUM - clocortolone pivalate
cream 0.1%................................................................... 161
CLODAN KIT - clobetasol propionate shampoo 0.05% &
cleanser kit.................................................................... 161
CLODERM - clocortolone pivalate cream 0.1%.............. 162
CLODERM PUMP - clocortolone pivalate cream
0.1%...............................................................................162
clomiphene citrate tab 50 mg........................................ 36
clomipramine hcl cap 25 mg (Anafranil)....................... 84
clonazepam orally disintegrating tab 0.125 mg..........118
clonazepam orally disintegrating tab 0.25 mg............118
clonazepam orally disintegrating tab 0.5 mg..............118
clonazepam orally disintegrating tab 1 mg.................118
clonazepam orally disintegrating tab 2 mg.................118
clonazepam tab 0.5 mg (Klonopin)..............................118
clonazepam tab 1 mg (Klonopin).................................118
clonazepam tab 2 mg (Klonopin).................................118
clonidine hcl tab 0.1 mg (Catapres).............................. 50
clonidine hcl tab sr 12hr 0.1 mg (Kapvay).................... 96
clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1)................................................................................ 50
clopidogrel bisulfate tab 300 mg (base equiv)
(Plavix).......................................................................... 149
clopidogrel bisulfate tab 75 mg (base equiv)
(Plavix).......................................................................... 149
clorazepate dipotassium tab 15 mg (Tranxene t)......... 82
clorazepate dipotassium tab 3.75 mg (Tranxene t)...... 82
clorazepate dipotassium tab 7.5 mg (Tranxene t)........ 82
CLORPRES - clonidine & chlorthalidone tab 0.1-15
mg.................................................................................... 50
258
mg.................................................................................... 50
mg.................................................................................... 50
CLOSERCARE - lancet devices .................................... 190
clotrimazole cream 1%................................................. 162
clotrimazole soln 1%.....................................................162
clotrimazole troche 10 mg............................................155
clotrimazole w/ betamethasone cream 1-0.05%
(Lotrisone).................................................................... 162
clotrimazole w/ betamethasone lotion 1-0.05%.......... 162
CLOZAPINE ODT - clozapine orally disintegrating tab 100
mg.................................................................................... 89
CLOZAPINE ODT - clozapine orally disintegrating tab 12.5
mg.................................................................................... 89
mg.................................................................................... 89
mg.................................................................................... 89
mg.................................................................................... 89
clozapine tab 100 mg (Clozaril)..................................... 89
clozapine tab 200 mg......................................................89
clozapine tab 25 mg (Clozaril)....................................... 89
clozapine tab 50 mg........................................................89
CLOZARIL - clozapine tab 100 mg................................... 89
CLOZARIL - clozapine tab 25 mg.....................................89
C-NATE DHA - prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg ................................................................. 129
CNL8 NAIL KIT - ciclopirox soln 8% & lacquer removal
pads kit.......................................................................... 162
COAGUCHEK LANCETS - lancets ................................190
COAGUCHEK LANCETS - lancets ................................190
COAL TAR - coal tar soln 20%.......................................162
COARTEM - artemether-lumefantrine tab 20-120 mg....... 12
CODAR AR - chlorpheniramine w/ codeine liquid 2-8
mg/5ml............................................................................. 63
CODAR D - pseudoephedrine w/ codeine liquid 30-8
mg/5ml............................................................................. 63
CODEINE SULFATE - codeine sulfate tab 15 mg...........104
codeine sulfate tab 15 mg (Codeine sulfate).............. 104
codeine sulfate tab 30 mg............................................ 104
codeine sulfate tab 60 mg............................................ 104
COGENTIN - benztropine mesylate inj 1 mg/ml..............124
COLAZAL - balsalazide disodium cap 750 mg..................76
COLCHICINE - colchicine cap 0.6 mg............................ 117
COLCHICINE - colchicine tab 0.6 mg............................. 117
colchicine w/ probenecid tab 0.5-500 mg....................117
COLCRYS - colchicine tab 0.6 mg..................................117
COLESTID - colestipol hcl granule packets 5 gm............. 58
COLESTID - colestipol hcl granules 5 gm.........................58
COLESTID - colestipol hcl tab 1 gm................................. 58
COLESTID FLAVORED - colestipol hcl granule packets 5
gm.................................................................................... 58
2015
COLESTID FLAVORED - colestipol hcl granules 5 gm.....58
colestipol hcl granule packets 5 gm (Colestid
flavored)..........................................................................58
colestipol hcl granules 5 gm (Colestid flavored)..........58
colestipol hcl tab 1 gm (Colestid)..................................58
COLGATE DRY MOUTH RELIEF - sodium fluoride
mouthwash 2.1 mg/10ml............................................... 155
COLY-MYCIN S - neomycin-colistin-hc-thonzonium otic
susp 3.3-3-10-0.5 mg/ml................................................154
COLYTE-FLAVOR PACKS - peg 3350-kcl-na bicarb-naclna sulfate for soln 227.1 gm............................................70
COLYTE-FLAVOR PACKS - peg 3350-kcl-na bicarb-naclna sulfate for soln 240 gm.............................................. 70
COMBIGAN - brimonidine tartrate-timolol maleate ophth
soln 0.2-0.5%.................................................................150
COMBIPATCH - estradiol-norethindrone ace td pttw
0.05-0.14 mg/day.............................................................22
COMBIPATCH - estradiol-norethindrone ace td pttw
0.05-0.25 mg/day.............................................................22
COMBIVENT RESPIMAT - ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act........................................... 67
COMBIVIR - lamivudine-zidovudine tab 150-300 mg..........8
COMETRIQ - cabozantinib s-malate cap 3 x 20 mg (60 mg
dose) kit........................................................................... 15
COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 1 x 20
mg (100 dose) kit............................................................ 15
COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 3 x 20
mg (140 dose) kit............................................................ 15
COMFORT ASSIST INSULIN SY - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................190
u-100 0.3 ml 30 x 5/16".................................................190
u-100 0.3 ml 31 x 5/16".................................................190
u-100 1/2 ml 29 x 1/2"...................................................190
u-100 1/2 ml 30 x 5/16".................................................190
u-100 1/2 ml 31 x 5/16".................................................190
u-100 1 ml 29 x 1/2"......................................................190
u-100 1 ml 30 x 5/16"....................................................190
u-100 1 ml 31 x 5/16"....................................................190
COMFORT ASSURED LANCETS M - lancets ...............190
COMFORT ASSURED LANCETS S - lancets ............... 190
COMFORT LANCETS - lancets .....................................190
COMPAZINE - prochlorperazine maleate tab 10 mg........ 89
COMPAZINE - prochlorperazine maleate tab 5 mg.......... 89
COMPLERA - emtricitabine-rilpivirine-tenofovir df tab
200-25-300 mg.................................................................. 8
COMPLETE NATAL DHA - prenat-fe bis-fe prot succ-fa-ca
tab & omega 3 cap 250 pk............................................129
COMPLETENATE - prenatal vit w/ fe fumarate-fa chew
tab 29-1 mg ..................................................................129
COMTAN - entacapone tab 200 mg............................... 124
CO-NATAL FA - prenatal vit w/ fe fumarate-fa tab 29-1 mg
....................................................................................... 129
CONCEPT DHA - prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg ......................................................... 129
CONCEPT OB - prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg .............................................................. 129
CONCERTA - methylphenidate hcl tab sa osm 18 mg......96
CONDYLOX - podofilox gel 0.5%................................... 162
CONDYLOX - podofilox soln 0.5%..................................162
CONTROL AST - glucose blood test strip.......................177
CONTROL BLOOD GLUCOSE MON - blood glucose
CONTROL SOLUTION NORMAL - blood glucose
CONTROL TEST STRIPS - glucose blood test strip....... 177
CONZIP - tramadol hcl cap sr 24hr biphasic release 100
mg.................................................................................. 104
mg.................................................................................. 104
mg.................................................................................. 104
COPAXONE - glatiramer acetate soln prefilled syringe 20
mg/ml............................................................................. 100
COPAXONE - glatiramer acetate soln prefilled syringe 40
mg/ml............................................................................. 100
COPEGUS - ribavirin tab 200 mg....................................... 8
CORDARONE - amiodarone hcl tab 200 mg.................... 46
CORDRAN - flurandrenolide cream 0.05%..................... 162
CORDRAN - flurandrenolide lotion 0.05%...................... 162
CORDRAN - flurandrenolide oint 0.05%......................... 162
CORDRAN TAPE - flurandrenolide tape 4 mcg/sqcm.....162
COREG - carvedilol tab 12.5 mg...................................... 42
COREG - carvedilol tab 25 mg......................................... 42
COREG - carvedilol tab 3.125 mg.................................... 42
COREG - carvedilol tab 6.25 mg...................................... 42
COREG CR - carvedilol phosphate cap sr 24hr 10 mg..... 42
CORGARD - nadolol tab 20 mg........................................42
CORLANOR - ivabradine hcl tab 5 mg (base equiv)......... 61
CORLANOR - ivabradine hcl tab 7.5 mg (base equiv)...... 61
CORTALO - hydrocortisone acetate-aloe vera gel
2%..................................................................................162
CORTANE-B AQUEOUS - pramoxine-hc-chloroxylenol
aqueous otic soln 10-10-1 mg/ml.................................. 154
CORTANE-B - hydrocortisone-pramoxine-chloroxylenol lot
10-10-1mg/ml.................................................................162
259
2015
CORTANE-B-OTIC - pramoxine-hc-chloroxylenol otic soln
10-10-1 mg/ml............................................................... 154
CORTEF - hydrocortisone tab 10 mg............................... 19
CORTEF - hydrocortisone tab 20 mg............................... 19
CORTEF - hydrocortisone tab 5 mg................................. 19
CORTENEMA - hydrocortisone enema 100 mg/60ml..... 157
CORTIFOAM - hydrocortisone acetate rectal foam 90 mg/
dose............................................................................... 157
CORTISONE ACETATE - cortisone acetate tab 25
mg.................................................................................... 19
CORTISPORIN - bacitracin-polymyxin-neomycin hc oint
1%..................................................................................162
CORTISPORIN - neomycin-polymyxin-hc cream
0.5%...............................................................................162
CORTISPORIN - neomycin-polymyxin-hc otic soln
1%..................................................................................154
CORTISPORIN-TC - neomycin-colistin-hc-thonzonium otic
susp 3.3-3-10-0.5 mg/ml................................................154
CORVITE 150 - iron combination tab ............................ 143
CORVITE 150 - iron-folic acid-vit c-vit b6-vit b12-zinc tab
150-1.25 mg.................................................................. 143
CORVITE FE - iron combination tab ..............................143
CORVITE - multiple vitamins w/ minerals & fa tab 1.25
mg.................................................................................. 129
CORZIDE - nadolol & bendroflumethiazide tab 40-5
mg.................................................................................... 50
CORZIDE - nadolol & bendroflumethiazide tab 80-5
mg.................................................................................... 50
COSENTYX - secukinumab subcutaneous soln prefilled
syringe 150 mg/ml......................................................... 162
COSENTYX SENSOREADY PEN - secukinumab
subcutaneous soln auto-injector 150 mg/ml.................. 162
COSOPT - dorzolamide hcl-timolol maleate ophth soln
22.3-6.8 mg/ml...............................................................150
COSOPT PF - dorzolamide hcl-timolol maleate ophth sol
22.3-6.8 mg/ml pf.......................................................... 150
COUMADIN - warfarin sodium tab 10 mg....................... 147
COUMADIN - warfarin sodium tab 1 mg......................... 147
COUMADIN - warfarin sodium tab 2.5 mg...................... 147
COUMADIN - warfarin sodium tab 7.5 mg...................... 147
COZAAR - losartan potassium tab 100 mg.......................50
COZAAR - losartan potassium tab 25 mg.........................50
COZAAR - losartan potassium tab 50 mg.........................50
CPB WC - pseudoephedrine-bromphen-codeine liq
10-1.3-6.3 mg/5ml............................................................63
CREON - pancrelipase (lip-prot-amyl) dr cap
12000-38000-60000 unit..................................................75
24000-76000-120000 unit................................................75
3000-9500-15000 unit......................................................75
260
36000-114000-180000 unit..............................................75
6000-19000-30000 unit....................................................75
CRESEMBA - isavuconazonium sulfate cap 186 mg.......... 7
CRESTOR - rosuvastatin calcium tab 10 mg.................... 58
CRESTOR - rosuvastatin calcium tab 5 mg......................58
CRINONE - progesterone vaginal gel 4%.........................80
CRINONE - progesterone vaginal gel 8%.........................80
CRIXIVAN - indinavir sulfate cap 200 mg........................... 8
CRIXIVAN - indinavir sulfate cap 400 mg........................... 8
CROMOLYN SODIUM - cromolyn sodium soln nebu 20
mg/2ml............................................................................. 67
cromolyn sodium ophth soln 4%.................................150
cromolyn sodium oral conc 100 mg/5ml
(Gastrocrom).................................................................. 76
CUPRIMINE - penicillamine cap 250 mg........................ 235
CUTIVATE - fluticasone propionate cream 0.05%.......... 162
CUTIVATE - fluticasone propionate lotion 0.05%............162
CUVPOSA - glycopyrrolate oral soln 1 mg/5ml.................71
CVS ADVANCED GLUCOSE METE - blood glucose
CVS ADVANCED GLUCOSE METE - glucose blood test
strip................................................................................ 177
CVS INSULIN SYRINGE/0.3ML - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................190
u-100 0.3 ml 30 x 1/2"...................................................190
u-100 1/2 ml 29 x 1/2"...................................................190
u-100 1/2 ml 30 x 1/2"...................................................191
CVS INSULIN SYRINGE/1ML/2 - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................191
CVS LANCETS 21G - lancets ....................................... 191
CVS LANCETS MICRO THIN 33 - lancets .................... 191
CVS LANCETS ORIGINAL - lancets ............................. 191
CVS LANCETS THIN 26G - lancets .............................. 191
CVS LANCETS ULTRA THIN 30 - lancets .................... 191
CVS LANCING DEVICE - lancet devices ...................... 191
CVS ULTRA THIN LANCETS - lancets ......................... 191
CYANOCOBALAMIN/LEVOMEFOLA - l-methylfolate w/ vit
b6-vit b12 tab 1.13-25-2 mg .........................................140
cyanocobalamin inj 1000 mcg/ml................................ 143
CYCLESSA - desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg........................ 24
CYCLOBENZAPRINE COMFORT P - cyclobenzaprine hcl
tab 10 mg & liniment topical gel kit............................... 126
cyclobenzaprine hcl tab 10 mg.................................... 126
cyclobenzaprine hcl tab 5 mg......................................126
cyclobenzaprine hcl tab 7.5 mg (Fexmid)................... 126
CYCLOGYL - cyclopentolate hcl ophth soln 0.5%.......... 150
CYCLOGYL - cyclopentolate hcl ophth soln 1%............. 150
CYCLOGYL - cyclopentolate hcl ophth soln 2%............. 150
2015
CYCLOMYDRIL - cyclopentolate w/ phenylephrine ophth
soln 0.2-1%....................................................................151
cyclopentolate hcl ophth soln 1% (Cyclogyl)............. 151
cyclopentolate hcl ophth soln 2% (Cyclogyl)............. 151
CYCLOPHOSPHAMIDE - cyclophosphamide cap 25
mg.................................................................................... 15
CYCLOPHOSPHAMIDE - cyclophosphamide cap 50
mg.................................................................................... 15
CYCLOSERINE - cycloserine cap 250 mg......................... 6
CYCLOSET - bromocriptine mesylate tab 0.8 mg (base
equivalent)....................................................................... 28
cyclosporine cap 100 mg (Sandimmune)....................235
cyclosporine cap 25 mg (Sandimmune)......................235
cyclosporine modified cap 100 mg (Neoral)............... 235
cyclosporine modified cap 25 mg (Neoral)................. 235
CYCLOSPORINE MODIFIED - cyclosporine modified cap
50 mg.............................................................................235
cyclosporine modified oral soln 100 mg/ml
(Neoral)......................................................................... 235
CYMBALTA - duloxetine hcl enteric coated pellets cap 20
mg.................................................................................... 84
mg.................................................................................... 84
mg.................................................................................... 84
cyproheptadine hcl syrup 2 mg/5ml..............................62
cyproheptadine hcl tab 4 mg......................................... 62
CYSTADANE - betaine powder for oral solution .............. 36
CYSTAGON - cysteamine bitartrate cap 150 mg.............. 80
CYSTAGON - cysteamine bitartrate cap 50 mg................80
CYSTARAN - cysteamine hcl ophth soln 0.44% (base
equivalent)..................................................................... 151
CYTOMEL - liothyronine sodium tab 25 mcg.................... 33
CYTOMEL - liothyronine sodium tab 50 mcg.................... 33
CYTOMEL - liothyronine sodium tab 5 mcg......................33
CYTOTEC - misoprostol tab 100 mcg.............................. 71
CYTOTEC - misoprostol tab 200 mcg.............................. 71
CYTRA-3 - pot & sod citrates w/ cit ac syrup 550-500-334
mg/5ml............................................................................. 80
D
D.H.E. 45 - dihydroergotamine mesylate inj 1 mg/ml...... 115
DALIRESP - roflumilast tab 500 mcg................................67
danazol cap 100 mg........................................................ 21
danazol cap 200 mg........................................................ 21
danazol cap 50 mg..........................................................21
DANTRIUM - dantrolene sodium cap 100 mg.................126
DANTRIUM - dantrolene sodium cap 25 mg...................126
DANTRIUM - dantrolene sodium cap 50 mg...................126
dantrolene sodium cap 25 mg (Dantrium).................. 126
dantrolene sodium cap 50 mg (Dantrium).................. 126
DANTROLENE SODIUM - dantrolene sodium cap 100
mg.................................................................................. 126
DAPSONE - dapsone tab 100 mg.................................... 13
DAPSONE - dapsone tab 25 mg...................................... 13
DAPTACEL - diph, acellular pert & tet tox inj 15 lf-10
mcg-5 lf/0.5ml.................................................................. 14
DARAPRIM - pyrimethamine tab 25 mg........................... 12
DAYPRO - oxaprozin tab 600 mg................................... 112
DAYTRANA - methylphenidate td patch 10 mg/9hr.......... 96
DDAVP - desmopressin acetate inj 4 mcg/ml................... 36
DDAVP - desmopressin acetate nasal soln 0.01%
(refrigerated).................................................................... 36
DDAVP - desmopressin acetate nasal spray soln
0.01%...............................................................................36
DDAVP - desmopressin acetate tab 0.1 mg..................... 36
DDAVP - desmopressin acetate tab 0.2 mg..................... 36
DDROPS - cholecalciferol drops 1000 unit/0.03ml (per
drop)...............................................................................127
DEBACTEROL - sulfuric acid-sulfonated phenolics soln
30-50%...........................................................................155
DECARA - cholecalciferol cap 25000 unit.......................127
DECON-A - brompheniramine & phenylephrine elixir 2-5
mg/5ml............................................................................. 63
DECON-G - phenylephrine-brompheniramine-guaifenesin
liqd 2-1-40 mg/ml.............................................................64
DELESTROGEN - estradiol valerate im in oil 10 mg/
ml..................................................................................... 22
ml..................................................................................... 22
ml..................................................................................... 22
DELZICOL - mesalamine cap dr 400 mg..........................76
DEMADEX - torsemide tab 100 mg.................................. 56
DEMADEX - torsemide tab 10 mg.................................... 56
DEMADEX - torsemide tab 20 mg.................................... 56
DEMADEX - torsemide tab 5 mg...................................... 56
demeclocycline hcl tab 150 mg....................................... 4
demeclocycline hcl tab 300 mg....................................... 4
DEMEROL - meperidine hcl tab 100 mg.........................104
DEMEROL - meperidine hcl tab 50 mg...........................104
DEMSER - metyrosine cap 250 mg.................................. 50
DENAVIR - penciclovir cream 1%...................................162
DENDRACIN NEURODENDRAXCIN - capsaicin-mentholmethyl salicylate lotion 0.025-10-30%........................... 162
DEPAKENE - valproate sodium syrup 250 mg/5ml (base
equiv)............................................................................. 118
DEPAKENE - valproic acid cap 250 mg......................... 118
DEPAKOTE - divalproex sodium tab delayed release 125
mg.................................................................................. 118
mg.................................................................................. 118
mg.................................................................................. 118
DEPAKOTE ER - divalproex sodium tab sr 24 hr 250
mg.................................................................................. 118
DEPAKOTE ER - divalproex sodium tab sr 24 hr 500
mg.................................................................................. 118
261
2015
DEPAKOTE SPRINKLES - divalproex sodium cap sprinkle
125 mg...........................................................................118
DEPEN TITRATABS - penicillamine tab 250 mg............ 235
DEPLIN 15 - l-methylfolate-algae cap 15-90.314 mg ..... 140
DEPLIN 7.5 - l-methylfolate-algae cap 7.5-90.314 mg
....................................................................................... 140
DEPLIN - l-methylfolate tab 15 mg ................................ 140
DEPLIN - l-methylfolate tab 7.5 mg ............................... 140
DEPO-ESTRADIOL - estradiol cypionate im in oil 5 mg/
ml..................................................................................... 22
DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp 150 mg/ml.......... 24
DEPO-SUBQ PROVERA 104 - medroxyprogesterone
acetate subcutaneous susp 104 mg/0.65ml.................... 24
DEPO-TESTOSTERONE - testosterone cypionate im in oil
100 mg/ml........................................................................21
DEPO-TESTOSTERONE - testosterone cypionate im in oil
200 mg/ml........................................................................21
DERMACINRX ANALGESIC COMB - diclofenac sod tab
dr 75 mg & lido-men-methyl sal ptch kit........................ 112
DERMACINRX INFLAMMATRAL P - diclofen dr tab 75mgranitidine tab 150mg-capsaicin cr thpk.......................... 112
DERMACINRX SILAPAK - triamcinolone acet cr 0.1% &
dimeth cr 5% & silicone tape.........................................162
DERMACINRX TOPICAL SOLUTI - external vehicles solution ......................................................................... 233
DERMA-SMOOTHE/FS BODY - fluocinolone acetonide oil
0.01% (body oil)............................................................ 162
DERMA-SMOOTHE/FS BODY OIL - fluocinolone
acetonide oil 0.01% (body oil)....................................... 162
DERMA-SMOOTHE/FS SCALP - fluocinolone acetonide
oil 0.01% (scalp oil)....................................................... 162
DERMA-SMOOTHE/FS SCALP OI - fluocinolone
acetonide oil 0.01% (scalp oil)...................................... 162
DERMASORB AF - clioquinol-hc cream 3-0.5% &
emollient liqd kit.............................................................162
DERMASORB HC - hydrocortisone lot 2% & cleanser liq
kit................................................................................... 162
DERMASORB TA - triamcinolone cream 0.1% & emollient
cream kit........................................................................ 162
DERMATOP - prednicarbate cream 0.1%.......................162
DERMATOP - prednicarbate oint 0.1%...........................162
DERMOTIC - fluocinolone acetonide (otic) oil 0.01%......154
desipramine hcl tab 100 mg (Norpramin)......................84
desipramine hcl tab 10 mg (Norpramin)....................... 84
desipramine hcl tab 150 mg (Norpramin)......................84
desloratadine tab 5 mg (Clarinex)................................. 62
desloratadine tab orally disintegrating 2.5 mg
(Clarinex reditabs)......................................................... 62
desloratadine tab orally disintegrating 5 mg (Clarinex
reditabs)..........................................................................62
desmopressin acetate inj 4 mcg/ml (Ddavp)................ 36
262
desmopressin acetate nasal soln 0.01% (refrigerated)
(Ddavp)............................................................................36
desmopressin acetate nasal spray soln 0.01%
(Ddavp)............................................................................36
desmopressin acetate nasal spray soln 0.01%
(refrigerated)...................................................................36
desmopressin acetate tab 0.1 mg (Ddavp)................... 36
desmopressin acetate tab 0.2 mg (Ddavp)................... 36
DESOGEN - desogestrel & ethinyl estradiol tab 0.15
mg-30 mcg.......................................................................24
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01
mg(21/5) (Mircette).........................................................24
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg
(Cyclessa)....................................................................... 24
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg
(Desogen)....................................................................... 24
DESONATE - desonide gel 0.05%..................................162
desonide cream 0.05% (Desowen)...............................162
desonide lotion 0.05% (Desowen)............................... 162
desonide oint 0.05% (Desowen).................................. 162
DESOWEN - desonide cream 0.05%..............................162
DESOWEN - desonide lotion 0.05%............................... 163
DESOWEN - desonide oint 0.05%..................................163
desoximetasone cream 0.25% (Topicort)....................163
DESOXIMETASONE - desoximetasone cream
0.05%.............................................................................163
DESOXIMETASONE - desoximetasone oint 0.05%........163
desoximetasone gel 0.05% (Topicort)......................... 163
desoximetasone oint 0.25% (Topicort)........................163
DESOXYN - methamphetamine hcl tab 5 mg................... 96
DESVENLAFAXINE ER - desvenlafaxine fumarate tab sr
24hr 100 mg (base equiv)............................................... 84
DESVENLAFAXINE ER - desvenlafaxine fumarate tab sr
24hr 50 mg (base equiv)................................................. 84
DESVENLAFAXINE ER - desvenlafaxine tab sr 24hr 100
mg.................................................................................... 84
DESVENLAFAXINE ER - desvenlafaxine tab sr 24hr 50
mg.................................................................................... 84
DETROL LA - tolterodine tartrate cap sr 24hr 2 mg.......... 79
DETROL LA - tolterodine tartrate cap sr 24hr 4 mg.......... 79
DETROL - tolterodine tartrate tab 1 mg............................ 79
DETROL - tolterodine tartrate tab 2 mg............................ 79
DEXAMETHASONE - dexamethasone soln 0.5
mg/5ml............................................................................. 19
DEXAMETHASONE - dexamethasone tab 1 mg.............. 19
DEXAMETHASONE - dexamethasone tab 2 mg.............. 19
dexamethasone elixir 0.5 mg/5ml.................................. 19
DEXAMETHASONE INTENSOL - dexamethasone conc 1
mg/ml............................................................................... 19
dexamethasone sodium phosphate ophth soln
0.1%...............................................................................151
dexamethasone tab 0.5 mg............................................ 19
dexamethasone tab 0.75 mg.......................................... 19
dexamethasone tab 1.5 mg............................................ 19
dexamethasone tab 4 mg............................................... 19
2015
dexamethasone tab 6 mg............................................... 19
DEXEDRINE - dextroamphetamine sulfate cap sr 24hr 10
mg.................................................................................... 96
mg.................................................................................... 96
mg.................................................................................... 96
DEXILANT - dexlansoprazole cap delayed release 30
mg.................................................................................... 71
DEXILANT - dexlansoprazole cap delayed release 60
mg.................................................................................... 71
dexmethylphenidate hcl cap sr 24 hr 10 mg (Focalin
xr).................................................................................... 96
xr).................................................................................... 96
xr).................................................................................... 96
xr).................................................................................... 96
xr).................................................................................... 96
dexmethylphenidate hcl tab 10 mg (Focalin)................96
dexmethylphenidate hcl tab 2.5 mg (Focalin)...............96
dexmethylphenidate hcl tab 5 mg (Focalin)..................96
DEXPAK 10 DAY - dexamethasone tab 1.5 mg taper
pack................................................................................. 19
pack................................................................................. 19
pack................................................................................. 19
dextroamphetamine sulfate cap sr 24hr 10 mg
(Dexedrine)..................................................................... 96
(Dexedrine)..................................................................... 96
(Dexedrine)..................................................................... 96
dextroamphetamine sulfate oral solution 5 mg/5ml
(Procentra)......................................................................96
dextroamphetamine sulfate tab 10 mg..........................96
dextroamphetamine sulfate tab 5 mg............................96
DEXTROMETHORPHAN HBR/CHLO - phenylephrinechlorphen-dm liquid 1.75-0.75-2.75 mg/ml...................... 64
DEX-TUSS - guaifenesin-codeine liquid 300-10
mg/5ml............................................................................. 64
DIABETA - glyburide tab 1.25 mg.....................................28
DIABETA - glyburide tab 2.5 mg.......................................28
DIABETA - glyburide tab 5 mg..........................................28
DIALYVITE/ZINC - b-complex w/ c-zn & folic acid tab 1
mg.................................................................................. 129
DIALYVITE 3000 - b-complex w/ c-biotin-e-minerals & folic
acid tab 3 mg................................................................ 129
DIALYVITE 5000 - b-complex w/ c-biotin-e-minerals & folic
acid tab 5 mg................................................................ 129
DIALYVITE SUPREME D - multiple vitamins w/ minerals &
fa tab 3 mg.................................................................... 129
DIAMOX - acetazolamide cap sr 12hr 500 mg..................56
DIASTAR EASY TEST II LANC - lancets ...................... 191
DIASTAR EASY TEST LANCETS - lancets ...................191
DIASTAT ACUDIAL - diazepam rectal gel delivery system
10 mg.............................................................................118
DIASTAT ACUDIAL - diazepam rectal gel delivery system
20 mg.............................................................................118
DIASTAT PEDIATRIC - diazepam rectal gel delivery
system 2.5 mg............................................................... 118
DIATRUE GLUCOSE CONTROL S - blood glucose
DIATRUE PLUS BLOOD GLUCOS - glucose blood test
strip................................................................................ 177
DIATX ZN - b-complex w/ c-biotin-minerals & folic acid tab
5 mg...............................................................................129
diazepam conc 5 mg/ml..................................................82
DIAZEPAM - diazepam inj 5 mg/ml.................................. 82
DIAZEPAM - diazepam rectal gel delivery system 10
mg.................................................................................. 118
DIAZEPAM - diazepam rectal gel delivery system 2.5
mg.................................................................................. 118
DIAZEPAM - diazepam rectal gel delivery system 20
mg.................................................................................. 118
DIAZEPAM - diazepam soln 1 mg/ml............................... 82
diazepam tab 10 mg (Valium).........................................82
diazepam tab 2 mg (Valium)...........................................82
diazepam tab 5 mg (Valium)...........................................82
DIBENZYLINE - phenoxybenzamine hcl cap 10 mg......... 50
DICLEGIS - doxylamine-pyridoxine tab delayed release
10-10 mg......................................................................... 74
diclofenac potassium tab 50 mg (Cataflam)............... 112
diclofenac sodium (actinic keratoses) gel 3%
(Solaraze)......................................................................163
diclofenac sodium ophth soln 0.1%............................ 151
diclofenac sodium soln 1.5% (Pennsaid)....................163
diclofenac sodium tab delayed release 25 mg........... 112
diclofenac sodium tab sr 24hr 100 mg (Voltarenxr).................................................................................. 112
diclofenac w/ misoprostol tab delayed release 50-0.2
mg (Arthrotec 50)........................................................ 112
diclofenac w/ misoprostol tab delayed release 75-0.2
mg (Arthrotec 75)........................................................ 112
dicloxacillin sodium cap 250 mg..................................... 1
dicloxacillin sodium cap 500 mg..................................... 1
dicyclomine hcl cap 10 mg (Bentyl).............................. 71
DICYCLOMINE HCL - dicyclomine hcl oral soln 10
mg/5ml............................................................................. 71
dicyclomine hcl tab 20 mg (Bentyl)...............................71
didanosine delayed release capsule 125 mg (Videx
ec)......................................................................................8
263
2015
ec)......................................................................................8
ec)......................................................................................8
ec)......................................................................................8
DIDGET - blood glucose monitoring kit w/ device .......... 191
DIDRONEL - etidronate disodium tab 400 mg.................. 36
DIFFERIN - adapalene cream 0.1%............................... 163
DIFFERIN - adapalene gel 0.1%.................................... 163
DIFFERIN - adapalene gel 0.3%.................................... 163
DIFFERIN - adapalene lotion 0.1%.................................163
DIFICID - fidaxomicin tab 200 mg.......................................3
DIFLORASONE DIACETATE - diflorasone diacetate
cream 0.05%................................................................. 163
DIFLORASONE DIACETATE - diflorasone diacetate oint
0.05%.............................................................................163
DIFLUCAN - fluconazole for susp 10 mg/ml....................... 7
DIFLUCAN - fluconazole for susp 40 mg/ml....................... 7
DIFLUCAN - fluconazole tab 100 mg..................................7
DIFLUCAN - fluconazole tab 50 mg....................................7
diflunisal tab 500 mg.................................................... 103
DIGEX NF - hyoscyamine-phenyltoloxamine cap
0.0625-15 mg.................................................................. 72
DIGOXIN - digoxin oral soln 0.05 mg/ml...........................40
digoxin tab 125 mcg (0.125 mg) (Lanoxin)....................40
digoxin tab 250 mcg (0.25 mg) (Lanoxin)......................40
DIHYDROERGOTAMINE MESYLAT - dihydroergotamine
mesylate nasal spray 4 mg/ml.......................................116
dihydroergotamine mesylate inj 1 mg/ml (D.h.e.
45)..................................................................................116
DILANTIN-125 - phenytoin susp 125 mg/5ml..................118
DILANTIN INFATABS - phenytoin chew tab 50 mg........ 118
DILANTIN - phenytoin sodium extended cap 100 mg..... 118
DILANTIN - phenytoin sodium extended cap 30 mg....... 118
DILATRATE SR - isosorbide dinitrate cap cr 40 mg..........40
DILAUDID - hydromorphone hcl liqd 1 mg/ml................. 105
DILAUDID - hydromorphone hcl tab 2 mg...................... 105
diltiazem hcl cap sr 12hr 120 mg...................................44
diltiazem hcl cap sr 12hr 60 mg.................................... 44
diltiazem hcl cap sr 12hr 90 mg.................................... 44
diltiazem hcl coated beads cap sr 24hr 120 mg
(Cardizem cd)................................................................. 44
(Cardizem cd)................................................................. 44
(Cardizem cd)................................................................. 44
(Cardizem cd)................................................................. 44
264
(Cardizem cd)................................................................. 44
diltiazem hcl coated beads tab sr 24hr 180 mg
(Cardizem la).................................................................. 44
(Cardizem la).................................................................. 44
(Cardizem la).................................................................. 44
(Cardizem la).................................................................. 44
(Cardizem la).................................................................. 44
diltiazem hcl extended release beads cap sr 24hr 120
mg (Tiazac).....................................................................44
mg (Tiazac).....................................................................44
mg (Tiazac).....................................................................45
mg (Tiazac).....................................................................45
mg (Tiazac).....................................................................45
mg (Tiazac).....................................................................45
diltiazem hcl tab 120 mg (Cardizem)............................. 45
diltiazem hcl tab 30 mg (Cardizem)............................... 45
diltiazem hcl tab 60 mg (Cardizem)............................... 45
diltiazem hcl tab 90 mg.................................................. 45
dimenhydrinate tab 50 mg............................................. 74
DIOVAN HCT - valsartan-hydrochlorothiazide tab
160-12.5 mg.................................................................... 50
DIOVAN HCT - valsartan-hydrochlorothiazide tab 160-25
mg.................................................................................... 50
DIOVAN HCT - valsartan-hydrochlorothiazide tab
320-12.5 mg.................................................................... 50
DIOVAN HCT - valsartan-hydrochlorothiazide tab 320-25
mg.................................................................................... 50
DIOVAN HCT - valsartan-hydrochlorothiazide tab 80-12.5
mg.................................................................................... 50
DIOVAN - valsartan tab 160 mg....................................... 50
DIOVAN - valsartan tab 320 mg....................................... 50
DIOVAN - valsartan tab 40 mg......................................... 50
DIOVAN - valsartan tab 80 mg......................................... 50
DIPENTUM - olsalazine sodium cap 250 mg.................... 76
diphenhydramine hcl cap 25 mg................................... 62
diphenhydramine hcl cap 50 mg................................... 62
diphenhydramine hcl elixir 12.5 mg/5ml....................... 62
diphenhydramine hcl inj 50 mg/ml................................ 62
DIPHENOXYLATE/ATROPINE - diphenoxylate w/
atropine liq 2.5-0.025 mg/5ml..........................................70
diphenoxylate w/ atropine tab 2.5-0.025 mg
(Lomotil)..........................................................................70
DIPHTHERIA/TETANUS TOXOID - diphtheria-tetanus tox
adsorbed (dt) im inj 25-5 unit/0.5ml.................................14
DIPROLENE AF - betamethasone dipropionate
augmented cream 0.05%.............................................. 163
2015
DIPROLENE - betamethasone dipropionate augmented
lotion 0.05%...................................................................163
DIPROLENE - betamethasone dipropionate augmented
oint 0.05%......................................................................163
dipyridamole tab 25 mg (Persantine).......................... 149
DISALCID - salsalate tab 500 mg................................... 103
DISALCID - salsalate tab 750 mg................................... 103
disopyramide phosphate cap 100 mg (Norpace)..........46
disopyramide phosphate cap 150 mg (Norpace)..........46
disulfiram tab 250 mg (Antabuse)............................... 100
disulfiram tab 500 mg (Antabuse)............................... 100
DITROPAN XL - oxybutynin chloride tab sr 24hr 10
mg.................................................................................... 79
DITROPAN XL - oxybutynin chloride tab sr 24hr 15
mg.................................................................................... 79
DITROPAN XL - oxybutynin chloride tab sr 24hr 5 mg......79
DIURIL - chlorothiazide susp 250 mg/5ml.........................56
divalproex sodium cap sprinkle 125 mg (Depakote
sprinkles)...................................................................... 118
divalproex sodium tab delayed release 125 mg
(Depakote).................................................................... 118
(Depakote).................................................................... 118
(Depakote).................................................................... 119
divalproex sodium tab sr 24 hr 250 mg (Depakote
er).................................................................................. 119
divalproex sodium tab sr 24 hr 500 mg (Depakote
er).................................................................................. 119
DIVIGEL - estradiol td gel 0.25 mg/0.25gm (0.1%)........... 22
DIVIGEL - estradiol td gel 0.5 mg/0.5gm (0.1%)............... 22
DIVIGEL - estradiol td gel 1 mg/gm (0.1%).......................22
DIVISTA - folic acid-vit b6-vit b12-omega 3-biotin-cr cap 1
mg .................................................................................143
DOLOPHINE HCL - methadone hcl tab 5 mg................. 105
DOLOPHINE - methadone hcl tab 10 mg....................... 105
donepezil hydrochloride orally disintegrating tab 10
mg (Aricept odt)...........................................................100
donepezil hydrochloride orally disintegrating tab 5
mg..................................................................................100
donepezil hydrochloride tab 10 mg (Aricept)............. 100
donepezil hydrochloride tab 23 mg (Aricept)............. 100
donepezil hydrochloride tab 5 mg (Aricept)............... 100
DONNATAL EXTENTABS - pb-hyoscy-atrop-scopol tab cr
48.6-0.3111-0.0582-0.0195 mg....................................... 72
DONNATAL - pb-hyoscy-atrop-scopol elix
16.2-0.1037-0.0194-0.0065 mg/5ml................................ 72
DONNATAL - pb-hyoscy-atrop-scopol tab
16.2-0.1037-0.0194-0.0065 mg....................................... 72
DORAL - quazepam tab 15 mg........................................ 94
DORYX - doxycycline hyclate tab delayed release 200
mg...................................................................................... 4
DORYX - doxycycline hyclate tab delayed release 50
mg...................................................................................... 4
dorzolamide hcl ophth soln 2% (Trusopt)...................151
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8
mg/ml (Cosopt)............................................................ 151
DOVONEX - calcipotriene cream 0.005%.......................163
doxazosin mesylate tab 1 mg (Cardura)....................... 50
doxepin hcl cap 100 mg................................................. 84
doxepin hcl cap 10 mg................................................... 84
doxepin hcl cap 150 mg................................................. 84
doxepin hcl conc 10 mg/ml............................................ 84
DOXEPIN HCL - doxepin hcl cap 75 mg.......................... 84
doxercalciferol cap 0.5 mcg (Hectorol)......................... 36
doxercalciferol cap 1 mcg (Hectorol)............................ 36
doxercalciferol cap 2.5 mcg (Hectorol)......................... 36
DOXYCYCLINE - doxycycline (rosacea) cap delayed
release 40 mg................................................................163
doxycycline hyclate cap 100 mg (Vibramycin)............... 4
doxycycline hyclate cap 50 mg....................................... 4
doxycycline hyclate tab 100 mg...................................... 4
doxycycline hyclate tab 20 mg........................................ 4
doxycycline hyclate tab delayed release 100 mg........... 4
doxycycline hyclate tab delayed release 150 mg
(Doryx).............................................................................. 4
doxycycline hyclate tab delayed release 75 mg............. 4
doxycycline monohydrate cap 100 mg (Monodox)........ 4
doxycycline monohydrate cap 150 mg (Adoxa)............. 4
doxycycline monohydrate cap 50 mg............................. 4
doxycycline monohydrate cap 75 mg (Monodox).......... 4
doxycycline monohydrate for susp 25 mg/5ml
(Vibramycin)..................................................................... 4
doxycycline monohydrate tab 100 mg (Adoxa pak
1/100).................................................................................4
doxycycline monohydrate tab 150 mg (Adoxa pak
1/150).................................................................................4
doxycycline monohydrate tab 50 mg (Adoxa)................ 4
doxycycline monohydrate tab 75 mg (Adoxa)................ 4
DRISDOL - ergocalciferol cap 50000 unit....................... 127
DRITHO-CREME HP - anthralin cream 1%.................... 163
dronabinol cap 10 mg (Marinol).....................................74
dronabinol cap 2.5 mg (Marinol)....................................74
dronabinol cap 5 mg (Marinol).......................................74
DROPLET LANCETS ULTRA THI - lancets ...................191
DROPLET LANCING DEVICE - lancet devices ............. 191
drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)..... 24
drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin
28)....................................................................................24
DROXIA - hydroxyurea cap 200 mg............................... 143
DRUG MART ADJUSTABLE LANC - lancet devices ..... 191
DRUG MART LANCETS THIN - lancets ........................191
DRUG MART LANCETS ULTRA T - lancets ................. 191
265
2015
DRUG MART ON-THE-GO LANCE - lancets ................ 191
DRUG MART ULTRA COMFORT I - insulin syringe/
needle u-100 0.3 ml 29 x 1/2"....................................... 191
needle u-100 0.3 ml 30 x 5/16"..................................... 191
needle u-100 0.3 ml 31 x 5/16"..................................... 191
needle u-100 1/2 ml 30 x 5/16"..................................... 191
needle u-100 1/2 ml 31 x 5/16"..................................... 191
needle u-100 1 ml 29 x 1/2"..........................................191
needle u-100 1 ml 30 x 5/16"........................................ 191
DRUG MART UNIFINE PENTIPS - insulin pen needle 29
g x 12 mm (1/2")........................................................... 191
g x 5 mm (3/16")........................................................... 191
g x 6 mm (1/4")............................................................. 191
g x 8 mm (1/3" or 5/16")................................................191
g x 4 mm (5/32")........................................................... 191
DRUG MART UNILET LANCETS - lancets ................... 192
DRYSOL - aluminum chloride soln 20%......................... 163
DUAC - clindamycin phosph-benzoyl peroxide (refrig) gel
1.2 (1)-5%......................................................................163
DUANE READE LANCET ALTERN - lancets ................ 192
DUANE READE LANCET SUPER - lancets .................. 192
DUANE READE LANCET ULTRA - lancets ...................192
DUANE READE UNIFINE PENTI - insulin pen needle 29 g
x 12 mm (1/2")...............................................................192
x 6 mm (1/4").................................................................192
x 8 mm (1/3" or 5/16")...................................................192
DUAVEE - conjugated estrogens-bazedoxifene tab
0.45-20 mg...................................................................... 22
DUETACT - pioglitazone hcl-glimepiride tab 30-2 mg....... 28
DUETACT - pioglitazone hcl-glimepiride tab 30-4 mg....... 28
DUET DHA 400 - prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 400 mg....................................................... 129
DUET DHA BALANCED - prenat w/fe poly-na fered-fa tab
25-1 & omega cap 267 mg............................................129
DUET DHA BALANCED - prenat w/fe poly-na fered-fa tab
27-1 & omega cap dr 380mg........................................ 129
DUET DHA - prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 400 mg....................................................... 129
DUEXIS - ibuprofen-famotidine tab 800-26.6 mg............ 112
DULERA - mometasone furoate-formoterol fumarate
aerosol 100-5 mcg/act..................................................... 67
DULERA - mometasone furoate-formoterol fumarate
aerosol 200-5 mcg/act..................................................... 68
266
duloxetine hcl enteric coated pellets cap 20 mg
(Cymbalta)...................................................................... 84
(Cymbalta)...................................................................... 84
(Cymbalta)...................................................................... 84
DUO-CARE CONTROL SOLUTION - blood glucose
DUO-CARE TEST STRIPS - glucose blood test strip..... 177
DUOPA - carbidopa-levodopa enteral susp 4.63-20 mg/
ml................................................................................... 124
DURACHOL - folic acid-cholecalciferol cap 1 mg-3775
unit................................................................................. 143
DURAGESIC - fentanyl td patch 72hr 100 mcg/hr.......... 105
DURAGESIC - fentanyl td patch 72hr 12 mcg/hr............ 105
DUREZOL - difluprednate ophth emulsion 0.05%...........151
DUTOPROL - metoprolol & hydrochlorothiazide tab sr
24hr 100-12.5 mg............................................................ 50
24hr 25-12.5 mg.............................................................. 50
24hr 50-12.5 mg.............................................................. 50
D-VI-SOL - cholecalciferol oral liquid 400 unit/ml............ 127
DYAZIDE - triamterene & hydrochlorothiazide cap 37.5-25
mg.................................................................................... 56
DYMISTA - azelastine hcl-fluticasone prop nasal spray
137-50 mcg/act................................................................ 63
dyphylline-guaifenesin liqd 100-100 mg/5ml................ 68
DYRENIUM - triamterene cap 100 mg..............................56
DYRENIUM - triamterene cap 50 mg................................56
E
E.E.S. 400 - erythromycin ethylsuccinate tab 400 mg.........3
E.E.S. GRANULES - erythromycin ethylsuccinate for susp
200 mg/5ml........................................................................3
EASIVENT/MASK-LARGE - spacer/aerosol-holding
chambers - device ........................................................192
EASIVENT/MASK-MEDIUM - spacer/aerosol-holding
chambers - device ........................................................192
EASIVENT/MASK-SMALL - spacer/aerosol-holding
chambers - device ........................................................192
EASIVENT - spacer/aerosol-holding chambers - device
....................................................................................... 192
EASY COMFORT INSULIN SYRI - insulin syringe/needle
u-100 0.3 ml 30 x 5/16".................................................192
u-100 1/2 ml 30 x 1/2"...................................................192
u-100 1/2 ml 30 x 5/16".................................................192
u-100 1 ml 30 x 1/2"......................................................192
u-100 1 ml 30 x 5/16"....................................................192
2015
EASY COMFORT LANCETS 30G/ - lancets ..................192
EASY COMFORT LANCETS - lancets .......................... 192
EASY COMFORT PEN NEEDLES - insulin pen needle 31
g x 5 mm (3/16")........................................................... 192
g x 6 mm (1/4")............................................................. 192
g x 8 mm (1/3" or 5/16")................................................192
g x 4 mm (5/32")........................................................... 192
EASYGLUCO CONTROL SOLUTIO - blood glucose
EASYGLUCO - glucose blood test strip..........................177
EASYGLUCO PLUS - glucose blood test strip................177
EASYMAX 15 LEVEL 1 GLUCOS - blood glucose
EASYMAX 15 LEVEL 2 GLUCOS - blood glucose
EASYMAX 15 TEST STRIPS - glucose blood test
strip................................................................................ 177
EASYMAX CONTROL SOLUTION - blood glucose
EASYMAX L BLOOD GLUCOSE S - blood glucose
EASYMAX N BLOOD GLUCOSE S - blood glucose
EASYMAX NG SELF-MONITORIN - blood glucose
EASYMAX TEST STRIPS - glucose blood test strip....... 177
EASYMAX V2 SELF-MONITORIN - blood glucose
EASYMAX V BLOOD GLUCOSE S - blood glucose
EASY MINI LANCING DEVICE - lancet devices ............ 192
EASY PLUS BLOOD GLUCOSE M - blood glucose
EASYPLUS BLOOD GLUCOSE TE - glucose blood test
strip................................................................................ 177
EASY PLUS BLOOD GLUCOSE T - glucose blood test
strip................................................................................ 177
EASY PLUS II BLOOD GLUCOS - glucose blood test
strip................................................................................ 177
EASY PLUS II CONTROL SOLU - blood glucose
EASY PLUS II CONTROL SOLU - blood glucose
EASYPLUS R13N SELF-MONITO - blood glucose
EASYPLUS V SELF-MONITORIN - blood glucose
EASYPRO BLOOD GLUCOSE MON - blood glucose
EASYPRO BLOOD GLUCOSE TES - glucose blood test
strip................................................................................ 177
EASYPRO PLUS - blood glucose monitoring kit w/ device
....................................................................................... 195
EASYPRO PLUS - glucose blood test strip.................... 177
EASY STEP BLOOD GLUCOSE M - blood glucose
EASY STEP CONTROL SOLUTIO - blood glucose
EASY STEP TEST STRIPS - glucose blood test strip.....177
EASY TALK BLOOD GLUCOSE M - blood glucose
EASY TALK BLOOD GLUCOSE T - glucose blood test
strip................................................................................ 177
EASY TALK CONTROL SOLUTIO - blood glucose
EASYTEST II LANCETS - lancets ................................. 195
EASYTEST LANCETS - lancets .................................... 195
EASY TOUCH 32GX5MM - insulin pen needle 32 g x 5
mm (1/5" or 3/16")......................................................... 194
EASY TOUCH 32GX6MM - insulin pen needle 32 g x 6
mm (1/4")....................................................................... 194
EASY TOUCH CONTROL SOLUTI - blood glucose
EASY TOUCH GLUCOSE MONITO - blood glucose
EASY TOUCH GLUCOSE TEST S - glucose blood test
strip................................................................................ 177
EASY TOUCH HEALTHPRO CONT - blood glucose
EASY TOUCH HEALTHPRO GLUC - blood glucose
EASY TOUCH HEALTHPRO GLUC - glucose blood test
strip................................................................................ 177
EASY TOUCH INSULIN SYRING - insulin syringe/needle
u-100 0.3 ml 30 x 1/2"...................................................193
u-100 0.3 ml 30 x 5/16".................................................193
u-100 0.3 ml 31 x 5/16".................................................194
u-100 1/2 ml 27 x 1/2"...................................................193
u-100 1/2 ml 28 x 1/2"...................................................193
267
2015
u-100 1/2 ml 29 x 1/2"...................................................193
u-100 1/2 ml 30 x 1/2"...................................................193
u-100 1/2 ml 30 x 5/16".................................................193
u-100 1/2 ml 31 x 5/16".................................................193
u-100 1 ml 27 x 1/2"......................................................193
u-100 1 ml 28 x 1/2"......................................................193
u-100 1 ml 29 x 1/2"......................................................193
u-100 1 ml 30 x 1/2"......................................................193
u-100 1 ml 30 x 5/16"....................................................193
u-100 1 ml 31 x 5/16"....................................................193
EASY TOUCH LANCETS 21G/PR - lancets .................. 194
EASY TOUCH LANCETS 26G/PU - lancets .................. 194
EASY TOUCH LANCETS 26G/TW - lancets ................. 194
EASY TOUCH LANCETS 30G/BU - lancets .................. 194
EASY TOUCH LANCING DEVICE - lancet devices ....... 194
EASY TOUCH PEN NEEDLES/31 - insulin pen needle 31
g x 5 mm (3/16")........................................................... 194
EASY TOUCH PEN NEEDLES 29 - insulin pen needle 29
g x 12 mm (1/2")........................................................... 194
g x 6 mm (1/4")............................................................. 194
g x 8 mm (1/3" or 5/16")................................................194
g x 4 mm (5/32")........................................................... 194
g x 5 mm (1/5" or 3/16")................................................194
g x 6 mm (1/4")............................................................. 194
EASY TOUCH SAFETY LANCETS - lancets .................194
EASY TRAK BLOOD GLUCOSE M - blood glucose
EASY TRAK BLOOD GLUCOSE T - glucose blood test
strip................................................................................ 177
268
EASY TRAK GLUCOSE CONTROL - blood glucose
EASY TWIST & CAP LANCETS - lancets...................... 194
ECLIPSE BLOOD GLUCOSE MON - blood glucose
ECLIPSE HIGH CONTROL - blood glucose calibration liquid - high ...................................................................195
ECLIPSE LOW CONTROL - blood glucose calibration liquid - low .................................................................... 195
ECLIPSE NORMAL CONTROL - blood glucose calibration
- liquid - normal ............................................................ 195
ECLIPSE TEST STRIPS - glucose blood test strip......... 177
EC-NAPROSYN - naproxen tab ec 375 mg.................... 112
EC-NAPROSYN - naproxen tab ec 500 mg.................... 112
econazole nitrate cream 1%......................................... 163
ECOZA - econazole nitrate foam 1%..............................163
EDARBI - azilsartan medoxomil tab 40 mg.......................50
EDARBI - azilsartan medoxomil tab 80 mg.......................50
EDARBYCLOR - azilsartan medoxomil-chlorthalidone tab
40-12.5 mg...................................................................... 50
EDARBYCLOR - azilsartan medoxomil-chlorthalidone tab
40-25 mg......................................................................... 51
ED CYTE F - ferrous fumarate-folic acid-docusate sodium
tab 324-1-50 mg............................................................ 143
EDECRIN - ethacrynic acid tab 25 mg..............................56
EDLUAR - zolpidem tartrate sl tab 10 mg.........................94
EDLUAR - zolpidem tartrate sl tab 5 mg...........................94
EDURANT - rilpivirine hcl tab 25 mg (base equivalent).......8
EFFER-K - potassium bicarbonate-citric acid effer tab 10
meq................................................................................ 139
EFFER-K - potassium bicarbonate-citric acid effer tab 20
meq................................................................................ 139
EFFEXOR XR - venlafaxine hcl cap sr 24hr 150 mg (base
equivalent)....................................................................... 85
EFFEXOR XR - venlafaxine hcl cap sr 24hr 37.5 mg (base
equivalent)....................................................................... 84
EFFEXOR XR - venlafaxine hcl cap sr 24hr 75 mg (base
equivalent)....................................................................... 85
EFFIENT - prasugrel hcl tab 10 mg (base equiv)............149
EFFIENT - prasugrel hcl tab 5 mg (base equiv)..............149
EFUDEX - fluorouracil cream 5%................................... 163
EGRIFTA - tesamorelin acetate for inj 1 mg (base
equiv)............................................................................... 36
EGRIFTA - tesamorelin acetate for inj 2 mg (base
equiv)............................................................................... 36
ELDEPRYL - selegiline hcl cap 5 mg..............................124
ELEMENT AUTOCODE SYSTEM - blood glucose
ELEMENT COMPACT CONTROL S - blood glucose
ELEMENT COMPACT TEST STRI - glucose blood test
strip................................................................................ 177
2015
ELEMENT HIGH CONTROL - blood glucose calibration liquid - high ...................................................................195
ELEMENT LOW CONTROL - blood glucose calibration liquid - low .................................................................... 195
ELEMENT NORMAL CONTROL - blood glucose
ELEMENT PLUS CONTROL SOLU - blood glucose
ELEMENT PLUS TEST STRIPS - glucose blood test
strip................................................................................ 177
ELEMENT TEST STRIPS - glucose blood test strip....... 177
ELESTAT - epinastine hcl ophth soln 0.05%.................. 151
ELESTRIN - estradiol gel 0.06% (0.52 mg/0.87 gm
metered-dose pump)....................................................... 22
ELETONE - dermatological products misc - cream ........ 163
ELETONE TWINPACK - dermatological products misc cream ............................................................................163
ELIDEL - pimecrolimus cream 1%.................................. 163
ELIGARD - leuprolide acetate (3 month) for subcutaneous
inj kit 22.5mg................................................................... 15
inj kit 30 mg.....................................................................15
inj kit 45 mg.....................................................................15
ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5
mg.................................................................................... 15
ELIMITE - permethrin cream 5%.................................... 163
ELIPHOS - calcium acetate (phosphate binder) tab 667
mg.................................................................................... 76
ELIQUIS - apixaban tab 2.5 mg......................................147
ELIQUIS - apixaban tab 5 mg.........................................147
ELITE-OB - prenatal vit w/ iron carbonyl-fa tab 50-1.25 mg
....................................................................................... 129
ELITE-THIN INSULIN SYRING - insulin syringe/needle
u-100 0.3 ml 31 x 5/16".................................................196
u-100 1/2 ml 28 x 1/2"...................................................196
u-100 1/2 ml 28 x 5/16".................................................196
u-100 1/2 ml 29 x 1/2"...................................................196
u-100 1/2 ml 29 x 5/16".................................................196
u-100 1/2 ml 30 x 5/16".................................................196
u-100 1/2 ml 31 x 5/16".................................................196
u-100 1 ml 28 x 1/2"......................................................196
u-100 1 ml 28 x 5/16"....................................................196
u-100 1 ml 29 x 1/2"......................................................196
u-100 1 ml 29 x 5/16"....................................................196
u-100 1 ml 30 x 5/16"....................................................196
u-100 1 ml 31 x 5/16"....................................................196
ELIXOPHYLLIN - theophylline elixir 80 mg/15ml.............. 68
ELLA - ulipristal acetate tab 30 mg...................................24
ELMIRON - pentosan polysulfate sodium caps 100
mg.................................................................................... 81
ELOCON - mometasone furoate cream 0.1%.................163
ELOCON - mometasone furoate oint 0.1%..................... 163
ELOCON - mometasone furoate solution 0.1%
(lotion)............................................................................ 163
EMADINE - emedastine difumarate ophth soln 0.05%
(base equiv)...................................................................151
EMBEDA - morphine-naltrexone cap cr 100-4 mg.......... 105
EMBEDA - morphine-naltrexone cap cr 20-0.8 mg......... 105
EMBEDA - morphine-naltrexone cap cr 50-2 mg............ 105
EMBRACE BLOOD GLUCOSE TES - glucose blood test
strip................................................................................ 177
EMBRACE CONTROL SOLUTION - blood glucose
EMBRACE EVO BLOOD GLUCOSE - blood glucose
EMBRACE EVO BLOOD GLUCOSE - glucose blood test
strip................................................................................ 177
EMBRACE EVO GLUCOSE CONTR - blood glucose
EMBRACE EVO GLUCOSE CONTR - blood glucose
EMBRACE GLUCOSE CONTROL S - blood glucose
EMBRACE LANCETS ULTRA THI - lancets ..................196
EMBRACE PRO BLOOD GLUCOSE - glucose blood test
strip................................................................................ 177
EMBRACE PRO GLUCOSE CONTR - blood glucose
EMCYT - estramustine phosphate sodium cap 140
mg.................................................................................... 15
EMEND - aprepitant capsule 125 mg............................... 74
EMEND - aprepitant capsule 40 mg................................. 74
EMEND - aprepitant capsule 80 mg................................. 74
EMEND - aprepitant capsule therapy pack 80 & 125
mg.................................................................................... 74
EMLA - lidocaine-prilocaine cream 2.5-2.5%.................. 163
EMPTY CAPSULE SIZE 1 VEGE - non gelatin capsules
(empty) ......................................................................... 233
EMSAM - selegiline td patch 24hr 12 mg/24hr..................85
EMSAM - selegiline td patch 24hr 6 mg/24hr....................85
EMSAM - selegiline td patch 24hr 9 mg/24hr....................85
269
2015
EMTRIVA - emtricitabine caps 200 mg...............................8
EMTRIVA - emtricitabine soln 10 mg/ml............................. 8
EMULSION SB - dermatological products misc - emulsion
....................................................................................... 163
ENABLEX - darifenacin hydrobromide tab sr 24hr 15 mg
(base equiv).....................................................................79
ENABLEX - darifenacin hydrobromide tab sr 24hr 7.5 mg
(base equiv).....................................................................79
enalapril maleate & hydrochlorothiazide tab 10-25 mg
(Vaseretic).......................................................................51
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg....................................................................................51
enalapril maleate tab 10 mg (Vasotec).......................... 51
enalapril maleate tab 2.5 mg (Vasotec)......................... 51
enalapril maleate tab 20 mg (Vasotec).......................... 51
enalapril maleate tab 5 mg (Vasotec)............................ 51
ENBRACE HR - prenatal vit w/ fe gly cys-fa-omega 3 fatty
acids cap ...................................................................... 129
ENBREL - etanercept for subcutaneous inj kit 25 mg..... 112
ENBREL - etanercept subcutaneous soln prefilled syringe
25 mg/0.5ml...................................................................112
ENBREL - etanercept subcutaneous soln prefilled syringe
50 mg/ml........................................................................112
ENBREL SURECLICK - etanercept subcutaneous solution
auto-injector 50 mg/ml................................................... 112
ENCARE - nonoxynol-9 vaginal suppos 100 mg...............80
ENDOMETRIN - progesterone vaginal insert 100 mg....... 80
ENJUVIA - estrogens, conjugated synthetic b tab 0.3
mg.................................................................................... 22
mg.................................................................................... 22
mg.................................................................................... 22
mg.................................................................................... 22
mg.................................................................................... 22
enoxaparin sodium inj 100 mg/ml (Lovenox)..............147
enoxaparin sodium inj 120 mg/0.8ml (Lovenox).........147
enoxaparin sodium inj 150 mg/ml (Lovenox)..............147
enoxaparin sodium inj 300 mg/3ml (Lovenox)............147
enoxaparin sodium inj 30 mg/0.3ml (Lovenox)...........147
entacapone tab 200 mg (Comtan)................................124
entecavir tab 0.5 mg (Baraclude).....................................8
entecavir tab 1 mg (Baraclude)........................................8
ENTERAGAM - serum-derived bovine immunoglob/protein
isolate 5 gm packet....................................................... 141
ENTEREG - alvimopan cap 12 mg................................... 76
ENTOCORT EC - budesonide cap sr 24hr 3 mg.............. 19
ENVISION AUTOCODE - blood glucose monitoring kit w/
device ........................................................................... 196
ENVISION AUTOCODE TEST ST - glucose blood test
strip................................................................................ 177
270
ENVISION CONTROL HIGH - blood glucose calibration liquid - high ...................................................................196
ENVISION CONTROL LOW - blood glucose calibration liquid - low .................................................................... 196
ENVISION CONTROL NORMAL - blood glucose
EPANED - enalapril maleate for oral soln 1 mg/ml........... 51
EPICERAM - dermatological products misc - emulsion
....................................................................................... 163
EPIDUO - adapalene-benzoyl peroxide gel 0.1-2.5%..... 163
EPIFOAM - pramoxine-hc aerosol foam 1-1%................ 163
epinastine hcl ophth soln 0.05% (Elestat)...................151
EPINEPHRINE - epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)..........................................................57
EPINEPHRINE - epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................57
EPIPEN 2-PAK - epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................57
EPIPEN-JR 2-PAK - epinephrine solution auto-injector
0.15 mg/0.3ml (1:2000)................................................... 57
EPIVIR HBV - lamivudine oral soln 5 mg/ml (hbv).............. 9
EPIVIR HBV - lamivudine tab 100 mg (hbv)....................... 8
EPIVIR - lamivudine oral soln 10 mg/ml............................. 8
EPIVIR - lamivudine tab 150 mg.........................................8
EPIVIR - lamivudine tab 300 mg.........................................8
eplerenone tab 25 mg (Inspra).......................................51
eplerenone tab 50 mg (Inspra).......................................51
EPOGEN - epoetin alfa inj 10000 unit/ml........................144
EPOGEN - epoetin alfa inj 20000 unit/ml........................144
EPOGEN - epoetin alfa inj 2000 unit/ml..........................143
eprosartan mesylate tab 600 mg (Teveten)...................51
EPZICOM - abacavir sulfate-lamivudine tab 600-300
mg...................................................................................... 9
EQ BLOOD GLUCOSE TEST STR - glucose blood test
strip................................................................................ 177
EQL COLOR LANCETS 21G - lancets .......................... 196
EQL COLOR LANCETS MICRO T - lancets .................. 196
EQL INSULIN SYRINGE/0.3ML - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................197
u-100 0.3 ml 30 x 5/16".................................................197
u-100 0.3 ml 31 x 5/16".................................................197
u-100 1/2 ml 29 x 1/2"...................................................197
u-100 1/2 ml 30 x 5/16".................................................197
u-100 1/2 ml 31 x 5/16".................................................197
EQL INSULIN SYRINGE/1ML/2 - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................197
u-100 1 ml 30 x 5/16"....................................................197
2015
u-100 1 ml 31 x 5/16"....................................................197
EQL INSULIN SYRINGE/U-100 - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................196
u-100 1/2 ml 29 x 1/2"...................................................196
u-100 1 ml 29 x 1/2"......................................................196
EQL SHORT PEN NEEDLES 31G - insulin pen needle 31
g x 8 mm (1/3" or 5/16")................................................197
EQL SUPER THIN LANCETS 30 - lancets .................... 197
EQL THIN LANCETS 26G - lancets .............................. 197
EQL TRUE2GO BLOOD GLUCOSE - blood glucose
EQL TRUETEST BLOOD GLUCOS - glucose blood test
strip................................................................................ 177
EQL TRUETRACK TEST - glucose blood test strip........ 177
EQL ULTRA COMFORT INSULIN - insulin syringe/needle
u-100 0.3 ml 31 x 5/16".................................................197
EQL ULTRA COMFORT INSULIN - insulin syringe/needle
u-100 1 ml 30 x 5/16"....................................................197
EQL ULTRA SHORT PEN NEEDL - insulin pen needle 31
g x 6 mm (1/4")............................................................. 197
EQUAGESIC - meprobamate-aspirin tab 200-325
mg.................................................................................. 103
EQUETRO - carbamazepine (antipsychotic) cap sr 12hr
100 mg.............................................................................89
200 mg.............................................................................89
300 mg.............................................................................89
ergocalciferol cap 50000 unit (Drisdol)....................... 127
ergoloid mesylates tab 1 mg........................................100
ERGOMAR - ergotamine tartrate sl tab 2 mg................. 116
ERIVEDGE - vismodegib cap 150 mg.............................. 15
ERTACZO - sertaconazole nitrate cream 2%................. 163
ERYGEL - erythromycin gel 2%......................................163
ERYPED 200 - erythromycin ethylsuccinate for susp 200
mg/5ml............................................................................... 3
ERYPED 400 - erythromycin ethylsuccinate for susp 400
mg/5ml............................................................................... 3
ERY-TAB - erythromycin tab delayed release 250 mg........ 3
ERYTHROCIN STEARATE - erythromycin stearate tab
250 mg...............................................................................3
ERYTHROMYCIN BASE - erythromycin tab 250 mg.......... 3
ERYTHROMYCIN BASE - erythromycin tab 500 mg.......... 3
ERYTHROMYCIN ETHYLSUCCINA - erythromycin
ethylsuccinate tab 400 mg................................................ 3
erythromycin gel 2% (Erygel).......................................164
erythromycin ophth oint 5 mg/gm............................... 151
erythromycin pads 2%.................................................. 164
erythromycin soln 2%...................................................164
ERYTHROMYCIN STEARATE - erythromycin stearate tab
250 mg...............................................................................3
erythromycin w/ delayed release particles cap 250
mg......................................................................................3
ESBRIET - pirfenidone cap 267 mg..................................70
ESCAVITE D - pediatric multiple vitamins w/ fl-fe chew tab
0.25-6 mg ..................................................................... 130
ESCAVITE LQ - pediatric multiple vitamins w/ fl-fe drops
0.25-6 mg/ml ................................................................ 130
ESCAVITE - pediatric multiple vitamins w/ fl-fe chew tab
0.25-7.5 mg .................................................................. 129
escitalopram oxalate soln 5 mg/5ml (base equiv)
(Lexapro).........................................................................85
escitalopram oxalate tab 10 mg (base equiv)
(Lexapro).........................................................................85
(Lexapro).........................................................................85
(Lexapro).........................................................................85
ESGIC - butalbital-acetaminophen-caffeine tab 50-325-40
mg.................................................................................. 103
esomeprazole magnesium cap delayed release 40 mg
(base eq) (Nexium)........................................................ 72
estazolam tab 1 mg.........................................................94
estazolam tab 2 mg.........................................................94
esterified estrogens & methyltestosterone tab
0.625-1.25 mg................................................................. 22
esterified estrogens & methyltestosterone tab 1.25-2.5
mg....................................................................................22
ESTRACE - estradiol tab 0.5 mg...................................... 23
ESTRACE - estradiol tab 1 mg......................................... 23
ESTRACE - estradiol tab 2 mg......................................... 23
ESTRACE - estradiol vaginal cream 0.1 mg/gm............... 80
estradiol & norethindrone acetate tab 0.5-0.1 mg
(Activella)........................................................................23
estradiol & norethindrone acetate tab 1-0.5 mg
(Activella)........................................................................23
estradiol tab 0.5 mg (Estrace)........................................23
estradiol tab 1 mg (Estrace)...........................................23
estradiol tab 2 mg (Estrace)...........................................23
estradiol td patch twice weekly 0.025 mg/24hr (Vivelledot).................................................................................. 23
estradiol td patch twice weekly 0.0375 mg/24hr
(Vivelle-dot).................................................................... 23
estradiol td patch weekly 0.025 mg/24hr (Climara)...... 23
estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr) (Climara)....................................................... 23
estradiol td patch weekly 0.05 mg/24hr (Climara)........ 23
estradiol td patch weekly 0.06 mg/24hr (Climara)........ 23
estradiol td patch weekly 0.075 mg/24hr (Climara)...... 23
estradiol td patch weekly 0.1 mg/24hr (Climara).......... 23
estradiol valerate im in oil 10 mg/ml............................. 23
271
2015
estradiol valerate im in oil 20 mg/ml (Delestrogen)......23
estradiol valerate im in oil 40 mg/ml (Delestrogen)......23
ESTRING - estradiol vaginal ring 2 mg (7.5
mcg/24hrs)....................................................................... 80
ESTROGEL - estradiol gel 0.06% (0.75 mg/1.25 gm
metered-dose pump)....................................................... 23
ESTROPIPATE - estropipate tab 3 mg............................. 23
estropipate tab 0.75 mg..................................................23
estropipate tab 1.5 mg....................................................23
ESTROSTEP FE - norethindrone ac-ethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg................................................... 24
eszopiclone tab 1 mg (Lunesta).................................... 94
ethambutol hcl tab 100 mg (Myambutol)........................ 6
ethambutol hcl tab 400 mg (Myambutol)........................ 6
ethosuximide cap 250 mg (Zarontin)...........................119
ethosuximide soln 250 mg/5ml (Zarontin).................. 119
ETHYL CHLORIDE/FINE PINPO - ethyl chloride aerosol
spray.............................................................................. 164
ETHYL CHLORIDE/FINE STREA - ethyl chloride aerosol
spray.............................................................................. 164
ETHYL CHLORIDE/MEDIUM JET - ethyl chloride aerosol
spray.............................................................................. 164
ETHYL CHLORIDE/MEDIUM STR - ethyl chloride aerosol
spray.............................................................................. 164
ETHYL CHLORIDE/MIST - ethyl chloride aerosol
spray.............................................................................. 164
ETHYL CHLORIDE - ethyl chloride aerosol spray.......... 164
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35
mcg..................................................................................24
ETIDRONATE DISODIUM - etidronate disodium tab 200
mg.................................................................................... 36
ETIDRONATE DISODIUM - etidronate disodium tab 400
mg.................................................................................... 36
etodolac cap 200 mg.....................................................112
etodolac cap 300 mg.....................................................112
etodolac tab 400 mg..................................................... 112
etodolac tab 500 mg..................................................... 112
etodolac tab sr 24hr 400 mg........................................ 112
ETOPOSIDE - etoposide cap 50 mg................................ 15
EURAX - crotamiton cream 10%.................................... 164
EURAX - crotamiton lotion 10%......................................164
EVAMIST - estradiol transdermal spray 1.53 mg/spray.....23
EVEKEO - amphetamine sulfate tab 10 mg......................96
EVEKEO - amphetamine sulfate tab 5 mg........................96
EVENCARE + BLOOD GLUCOSE - glucose blood test
strip................................................................................ 177
EVENCARE BLOOD GLUCOSE TE - glucose blood test
strip................................................................................ 177
EVENCARE CONTROL SOLUTION - blood glucose
EVENCARE G2 GLUCOSE CONTR - blood glucose
272
EVENCARE G2 TEST STRIPS - glucose blood test
strip................................................................................ 177
EVENCARE G3 GLUCOSE CONTR - blood glucose
EVENCARE G3 TEST STRIPS - glucose blood test
strip................................................................................ 177
EVISTA - raloxifene hcl tab 60 mg....................................36
EVOCLIN - clindamycin phosphate foam 1%..................164
EVOLUTION AUTOCODE - glucose blood test strip.......177
EVOLUTION CONTROL SOLUTIO - blood glucose
EVOTAZ - atazanavir sulfate-cobicistat tab 300-150 mg
(base equiv).......................................................................9
EVOXAC - cevimeline hcl cap 30 mg............................. 155
EVZIO - naloxone hcl solution auto-injector 0.4
mg/0.4ml........................................................................ 175
EXACTECH R-S-G TEST STRIP - glucose blood test
strip................................................................................ 177
EXACTECH TEST STRIPS - glucose blood test strip..... 177
EXACTUSS - phenylephrine w/ dm-gg liqd 10-28-388
mg/5ml............................................................................. 64
EXALGO - hydromorphone hcl tab er 24hr deter 12
mg.................................................................................. 105
mg.................................................................................. 105
mg.................................................................................. 105
mg.................................................................................. 105
EXELDERM - sulconazole nitrate cream 1%.................. 164
EXELDERM - sulconazole nitrate solution 1%................ 164
EXEL INSULIN PEN NEEDLES - insulin pen needle 29 g
x 12 mm (1/2")...............................................................197
x 6 mm (1/4").................................................................197
x 8 mm (1/3" or 5/16")...................................................197
EXEL INSULIN SYRINGE/0.3M - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................197
u-100 0.3 ml 30 x 5/16".................................................197
u-100 1/2 ml 28 x 1/2"...................................................197
u-100 1/2 ml 29 x 1/2"...................................................197
u-100 1/2 ml 30 x 5/16".................................................197
EXEL INSULIN SYRINGE/1ML/ - insulin syringe/needle
u-100 1 ml 28 x 1/2"......................................................197
u-100 1 ml 29 x 1/2"......................................................198
u-100 1 ml 30 x 5/16"....................................................198
EXELON - rivastigmine tartrate cap 1.5 mg.................... 100
EXELON - rivastigmine tartrate cap 3 mg....................... 100
EXELON - rivastigmine tartrate cap 4.5 mg.................... 100
2015
EXELON - rivastigmine tartrate cap 6 mg....................... 100
EXELON - rivastigmine td patch 24hr 13.3 mg/24hr....... 100
EXELON - rivastigmine td patch 24hr 4.6 mg/24hr......... 100
EXELON - rivastigmine td patch 24hr 9.5 mg/24hr......... 100
exemestane tab 25 mg (Aromasin)................................15
EXFORGE - amlodipine besylate-valsartan tab 10-160
mg.................................................................................... 51
mg.................................................................................... 51
mg.................................................................................... 51
mg.................................................................................... 51
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 10-160-12.5 mg......................... 51
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 10-160-25 mg............................ 51
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 10-320-25 mg............................ 51
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5 mg........................... 51
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg.............................. 51
EXJADE - deferasirox tab for oral susp 125 mg..............175
EXTAVIA - interferon beta-1b for inj kit 0.3 mg............... 100
EXTINA - ketoconazole foam 2%................................... 164
EXTRA-VIRT PLUS DHA - prenatal w/o vit a w/ fe fumdoc-fa-dha cap 29-1.25-350 mg ................................... 130
EXYDERM - transdermal patch ..................................... 233
E-Z JECT LANCETS 21G - lancets ............................... 192
E-Z JECT LANCETS COLOR - lancets ......................... 192
E-Z JECT LANCETS - lancets .......................................192
E-ZJECT LANCETS MICRO-THI - lancets .................... 192
E-Z JECT LANCETS SUPER TH - lancets .................... 192
E-Z JECT LANCETS THIN 26G - lancets ...................... 192
EZ-LETS LANCETS 21G - lancets ................................ 198
EZ-LETS LANCETS 26G SUPER - lancets ................... 198
EZ-LETS LANCETS 28G ULTRA - lancets ....................198
EZ SMART BLOOD GLUCOSE LA - lancets ................. 198
EZ SMART BLOOD GLUCOSE TE - glucose blood test
strip................................................................................ 178
EZ SMART PLUS BLOOD GLUCO - glucose blood test
strip................................................................................ 178
E-Z SPACER - spacer/aerosol-holding chambers - device
....................................................................................... 192
E-Z SPACER THE BODY GUARD - spacer/aerosolholding chambers - device ........................................... 192
F
FA-8 - folic acid cap 0.8 mg............................................144
FABIOR - tazarotene (acne) foam 0.1%......................... 164
FACTIVE - gemifloxacin mesylate tab 320 mg (base
equiv)................................................................................. 6
FALESSA - levomefolate glucosamine tab 1 mg (folate
equivalent)..................................................................... 141
FALESSA - levonorgest-eth estrad tab 0.1 mg-20 mcg &
fa tab 1 mg kit................................................................. 24
famciclovir tab 125 mg (Famvir)...................................... 9
famotidine for susp 40 mg/5ml (Pepcid)....................... 72
famotidine tab 20 mg (Pepcid).......................................72
famotidine tab 40 mg (Pepcid).......................................72
FAMVIR - famciclovir tab 125 mg....................................... 9
FANAPT - iloperidone tab 10 mg......................................89
FANAPT - iloperidone tab 12 mg......................................89
FANAPT - iloperidone tab 1 mg........................................89
FANAPT TITRATION PACK - iloperidone tab 1 mg & 2 mg
& 4 mg & 6 mg titration pak............................................ 90
FARESTON - toremifene citrate tab 60 mg (base
equivalent)....................................................................... 15
FARXIGA - dapagliflozin propanediol tab 10 mg (base
equivalent)....................................................................... 28
FARXIGA - dapagliflozin propanediol tab 5 mg (base
equivalent)....................................................................... 28
FARYDAK - panobinostat lactate cap 10 mg (base
equivalent)....................................................................... 15
equivalent)....................................................................... 15
equivalent)....................................................................... 15
FASTTAKE COMPACT MONITORI - blood glucose
FASTTAKE TEST STRIPS - glucose blood test strip...... 178
FAZACLO - clozapine orally disintegrating tab 100 mg.....90
FAZACLO - clozapine orally disintegrating tab 12.5
mg.................................................................................... 90
FAZACLO - clozapine orally disintegrating tab 25 mg.......90
FC2 FEMALE CONDOM - condoms - female ................ 198
FC FEMALE CONDOM - condoms - female .................. 198
FE 90 PLUS - fe carbonyl-fe gluconate-fa-vit b12-vit c-dss
tab 90-1 mg ..................................................................144
fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1
mg..................................................................................144
fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240
mg..................................................................................144
fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu
cap (Tandem plus).......................................................142
felbamate susp 600 mg/5ml (Felbatol)........................ 119
273
2015
felbamate tab 400 mg (Felbatol).................................. 119
felbamate tab 600 mg (Felbatol).................................. 119
FELBATOL - felbamate susp 600 mg/5ml...................... 119
FELBATOL - felbamate tab 400 mg................................119
FELBATOL - felbamate tab 600 mg................................119
FELDENE - piroxicam cap 10 mg................................... 112
FELDENE - piroxicam cap 20 mg................................... 112
felodipine tab sr 24hr 10 mg.......................................... 45
felodipine tab sr 24hr 2.5 mg......................................... 45
felodipine tab sr 24hr 5 mg............................................45
FEMARA - letrozole tab 2.5 mg........................................ 15
FEMCAP - cervical cap 22 mm.......................................198
FEMCON FE - norethindrone & ethinyl estradiol-fe chew
tab 0.4 mg-35 mcg.......................................................... 24
FEMHRT LOW DOSE - norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg...........................................23
FEM PH - acetic acid-oxyquinoline vaginal gel
0.9-0.025%.......................................................................80
FEMRING - estradiol acetate vaginal ring 0.05
mg/24hr............................................................................80
FEMRING - estradiol acetate vaginal ring 0.1 mg/24hr..... 80
FENOFIBRATE - fenofibrate cap 150 mg......................... 58
FENOFIBRATE - fenofibrate cap 50 mg........................... 58
fenofibrate micronized cap 130 mg............................... 58
fenofibrate micronized cap 134 mg (Lofibra)................58
fenofibrate micronized cap 200 mg (Lofibra)................58
fenofibrate micronized cap 43 mg................................. 58
fenofibrate micronized cap 67 mg (Lofibra)..................58
fenofibrate tab 145 mg (Tricor)...................................... 58
fenofibrate tab 160 mg (Lofibra).................................... 58
fenofibrate tab 48 mg (Tricor)........................................ 58
fenofibrate tab 54 mg (Lofibra)...................................... 58
FENOFIBRIC ACID - fenofibric acid tab 105 mg...............58
FENOFIBRIC ACID - fenofibric acid tab 35 mg.................58
FENOGLIDE - fenofibrate tab 120 mg.............................. 58
FENOGLIDE - fenofibrate tab 40 mg................................ 58
FENOPROFEN CALCIUM - fenoprofen calcium cap 400
mg.................................................................................. 112
FENOPROFEN CALCIUM - fenoprofen calcium tab 600
mg.................................................................................. 112
fentanyl citrate lollipop 1200 mcg (Actiq)................... 105
fentanyl citrate lollipop 1600 mcg (Actiq)................... 105
fentanyl citrate lollipop 200 mcg (Actiq)..................... 105
FENTANYL - fentanyl td patch 72hr 37.5 mcg/hr............ 105
fentanyl td patch 72hr 100 mcg/hr (Duragesic).......... 105
fentanyl td patch 72hr 12 mcg/hr (Duragesic)............ 105
274
FENTORA - fentanyl citrate buccal tab 100 mcg (base
equiv)............................................................................. 105
equiv)............................................................................. 105
equiv)............................................................................. 105
equiv)............................................................................. 105
equiv)............................................................................. 105
FER-IN-SOL - ferrous sulfate soln 75 mg/ml (15 mg/ml
elemental fe)..................................................................144
FERIVA 21/7 - fe asparto gly-b12-fa-c-dss-succinic acidzn tab 75-1 mg .............................................................144
FERIVAFA - iron-c-fa-b12-biotin-copper-docusate cap
110-1 mg ...................................................................... 144
FERIVA - fe bisglycin-fe carbonyl-c-fa-b12-biotin-dss cap
75-1 mg ........................................................................ 144
FERRALET 90 - fe carbonyl-fe gluconate-fa-vit b12-vit cdss tab 90-1 mg ........................................................... 144
FERRAPLUS 90 - iron-folic acid-vit b12-vit c-docusate sod
tab 90-1 mg ..................................................................144
FERRETTS CHEWABLE IRON - carbonyl iron chew tab
18 mg (elemental iron).................................................. 144
FERREX 150 FORTE PLUS - fe asp gly-fe polysacchsucc ac-c-threon ac-b12-fa cap ....................................144
FERREX 28 - fe asparto gly-fe fum-b12-fa-c-succinic ac
tab ther pack ................................................................ 144
FERRIPROX - deferiprone tab 500 mg...........................175
FERRO-PLEX HEMATINIC - fe fum-dss-vit c-vit e-vit b12if-fa tab 115-1 mg .........................................................144
FERROTRIN - iron w/ b12-vit c-fa-ifc cap
36-0.015-75-0.5-240 mg................................................ 144
ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab
106-1 mg ......................................................................142
ferrous fumarate-folic acid tab 324-1 mg.................... 144
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental
fe)...................................................................................144
FERROUS SULFATE - ferrous sulfate liquid 220 mg/5ml
(44 mg/5ml elemental fe)...............................................144
FERROUS SULFATE - ferrous sulfate syrup 300 mg/5ml
(60 mg/5ml elemental fe)...............................................144
ferrous sulfate soln 75 mg/ml (15 mg/ml elemental
fe)...................................................................................144
FETZIMA - levomilnacipran hcl cap sr 24hr 120 mg (base
equivalent)....................................................................... 85
equivalent)....................................................................... 85
equivalent)....................................................................... 85
equivalent)....................................................................... 85
FETZIMA TITRATION PACK - levomilnacipran hcl cap sr
24hr 20 & 40 mg therapy pack........................................85
FEXMID - cyclobenzaprine hcl tab 7.5 mg......................126
fexofenadine hcl tab 60 mg............................................62
2015
FIBRICOR - fenofibric acid tab 105 mg............................ 58
FIBRICOR - fenofibric acid tab 35 mg.............................. 58
FIFTY50 CONTROL SOLUTION - blood glucose
FIFTY50 GLUCOSE METER 2.0 - blood glucose
FIFTY50 GLUCOSE TEST STRI - glucose blood test
strip................................................................................ 178
FIFTY50 LANCING DEVICE - lancet devices ................ 198
FIFTY50 PEN NEEDLES 31G X - insulin pen needle 31 g
x 5 mm (3/16")...............................................................198
FIFTY50 PEN NEEDLES 31G X - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................198
FIFTY50 SAFETY SEAL LANCE - lancets .................... 198
FIFTY50 SUPERIOR COMFORT - insulin syringe/needle
u-100 0.3 ml 31 x 5/16".................................................198
u-100 1/2 ml 31 x 5/16".................................................198
u-100 1 ml 31 x 5/16"....................................................198
FINACEA - azelaic acid gel 15%.................................... 164
finasteride tab 5 mg (Proscar)....................................... 81
FINE 30 - lancets ...........................................................198
FINGERSTIX LANCETS - lancets ................................. 198
FIORICET/CODEINE - butalbital-acetaminophen-caff w/
cod cap 50-300-40-30 mg............................................. 106
FIORICET - butalbital-acetaminophen-caffeine cap
50-300-40 mg................................................................ 103
FIORICET - butalbital-acetaminophen-caffeine tab
50-325-40 mg................................................................ 103
FIORINAL/CODEINE #3 - butalbital-aspirin-caff w/
codeine cap 50-325-40-30 mg...................................... 106
FIORINAL - butalbital-aspirin-caffeine cap 50-325-40
mg.................................................................................. 103
FIRAZYR - icatibant acetate inj 30 mg/3ml (base
equivalent)..................................................................... 149
FIRST-TESTOSTERONE MC COM - testosterone
propionate td cream 2%.................................................. 21
FIRST-TESTOSTERONE - testosterone propionate td
ointment 2%.....................................................................21
FLAGYL ER - metronidazole tab sr 24hr 750 mg..............13
FLAGYL - metronidazole cap 375 mg...............................13
FLAGYL - metronidazole tab 250 mg............................... 13
FLAGYL - metronidazole tab 500 mg............................... 13
FLAREX - fluorometholone acetate ophth susp 0.1%..... 151
FLAVOR BLEND - oral vehicles .................................... 233
FLAVOR PLUS - oral vehicles .......................................233
FLAVOR SWEET - oral vehicles ....................................233
FLAVOR SWEET-SF - oral vehicles .............................. 233
flavoxate hcl tab 100 mg................................................ 79
flaxseed oil-evening primrose-bilberry cap
1000-500-40 mg (Tears again hydrate)...................... 141
flecainide acetate tab 100 mg........................................ 46
flecainide acetate tab 150 mg........................................ 46
flecainide acetate tab 50 mg.......................................... 46
FLECTOR - diclofenac epolamine patch 1.3%................164
FLOMAX - tamsulosin hcl cap 0.4 mg.............................. 81
FLO-PRED - prednisolone acetate oral susp 16.7 mg/5ml
(15 mg/5ml base)............................................................ 19
FLORICAL - sodium fluoride w/ calcium carb cap 8.3-364
mg.................................................................................. 139
FLORICAL - sodium fluoride w/ calcium carb tab 8.3-364
mg.................................................................................. 139
FLORIVA - ped multiple vitamins & minerals w/ fl chew tab
0.5 mg............................................................................130
FLORIVA - ped multiple vitamins & minerals w/ fl chew tab
1 mg...............................................................................130
FLORIVA - sodium fluoride-vitamin d liqd drops 0.25 mg/
ml-400 unit/ml................................................................ 139
FLOVENT DISKUS - fluticasone propionate aer pow ba
100 mcg/blister................................................................ 68
FLOVENT DISKUS - fluticasone propionate aer pow ba
250 mcg/blister................................................................ 68
FLOVENT DISKUS - fluticasone propionate aer pow ba 50
mcg/blister........................................................................68
FLOVENT HFA - fluticasone propionate hfa inhal aer 110
mcg/act (125/valve)......................................................... 68
FLOVENT HFA - fluticasone propionate hfa inhal aer 220
mcg/act (250/valve)......................................................... 68
FLOVENT HFA - fluticasone propionate hfa inhal aero 44
mcg/act (50/valve)........................................................... 68
fluconazole for susp 10 mg/ml (Diflucan)....................... 7
fluconazole for susp 40 mg/ml (Diflucan)....................... 7
fluconazole tab 100 mg (Diflucan)................................... 7
fluconazole tab 50 mg (Diflucan).....................................7
flucytosine cap 250 mg (Ancobon)..................................7
flucytosine cap 500 mg (Ancobon)..................................7
fludrocortisone acetate tab 0.1 mg................................19
FLUMADINE - rimantadine hydrochloride tab 100 mg........ 9
FLUNISOLIDE - flunisolide nasal soln 25 mcg/act
(0.025%).......................................................................... 63
flunisolide nasal soln 25 mcg/act (0.025%)
(Flunisolide)....................................................................63
fluocinolone acetonide (otic) oil 0.01%
(Dermotic)..................................................................... 154
fluocinolone acetonide cream 0.01%.......................... 164
fluocinolone acetonide cream 0.025% (Synalar)........ 164
fluocinolone acetonide oil 0.01% (body oil) (Dermasmoothe/fs bod)...........................................................164
fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca)........................................................... 164
fluocinolone acetonide oint 0.025% (Synalar)............ 164
fluocinolone acetonide soln 0.01% (Synalar)............. 164
fluocinonide cream 0.05%............................................ 164
fluocinonide cream 0.1% (Vanos)................................ 164
fluocinonide emulsified base cream 0.05%................ 164
fluocinonide gel 0.05%................................................. 164
fluocinonide oint 0.05%................................................ 164
fluocinonide soln 0.05%............................................... 164
275
2015
FLUORABON - sodium fluoride soln 0.25 mg/0.6ml (from
0.55 mg/0.6ml naf)........................................................ 139
FLUORAC - fluorouracil-diclofenac sodium cream
5-1%...............................................................................164
FLUOR-A-DAY - sodium fluoride-xylitol chew tab 0.55
(0.25 mg f)-236.79 mg...................................................139
FLUOR-A-DAY - sodium fluoride-xylitol chew tab 1.1 (0.5
mg f)-236.79 mg............................................................ 139
FLUOR-A-DAY - sodium fluoride-xylitol chew tab 2.2 (1
mg f)-236.79 mg............................................................ 139
FLUORIDEX DAILY DEFENSE S - sodium fluoridepotassium nitrate gel 1.1-5%.........................................155
fluorometholone ophth susp 0.1% (Fml liquifilm)...... 151
FLUOROPLEX - fluorouracil cream 1%.......................... 164
fluorouracil cream 5% (Efudex)................................... 164
FLUOROURACIL - fluorouracil cream 0.5%................... 164
fluorouracil soln 2%......................................................164
fluorouracil soln 5%......................................................164
fluoxetine hcl (pmdd) cap 10 mg................................. 100
fluoxetine hcl (pmdd) cap 20 mg................................. 100
fluoxetine hcl cap 10 mg (Prozac)................................. 85
fluoxetine hcl cap delayed release 90 mg (Prozac
weekly)............................................................................ 85
FLUOXETINE HCL - fluoxetine hcl tab 60 mg.................. 85
fluoxetine hcl solution 20 mg/5ml................................. 85
fluoxetine hcl tab 10 mg.................................................85
fluoxetine hcl tab 20 mg.................................................85
fluphenazine decanoate inj 25 mg/ml............................90
FLUPHENAZINE HCL - fluphenazine hcl elixir 2.5
mg/5ml............................................................................. 90
FLUPHENAZINE HCL - fluphenazine hcl inj 2.5 mg/ml.....90
FLUPHENAZINE HCL - fluphenazine hcl oral conc 5 mg/
ml..................................................................................... 90
fluphenazine hcl tab 10 mg............................................ 90
fluphenazine hcl tab 1 mg..............................................90
fluphenazine hcl tab 2.5 mg........................................... 90
fluphenazine hcl tab 5 mg..............................................90
FLURA-DROPS - sodium fluoride soln 0.25 mg/drop f
(from 0.55 mg/drop naf)................................................ 139
FLURAZEPAM HCL - flurazepam hcl cap 15 mg..............94
FLURAZEPAM HCL - flurazepam hcl cap 30 mg..............94
flurbiprofen sodium ophth soln 0.03% (Ocufen)........ 151
flurbiprofen tab 100 mg................................................ 112
flurbiprofen tab 50 mg.................................................. 112
flutamide cap 125 mg..................................................... 15
fluticasone propionate cream 0.05% (Cutivate)..........164
fluticasone propionate lotion 0.05% (Cutivate).......... 164
fluticasone propionate nasal susp 50 mcg/act
(Flonase)......................................................................... 63
fluticasone propionate oint 0.005% (Cutivate)............164
fluvastatin sodium cap 20 mg (Lescol)......................... 58
fluvastatin sodium cap 40 mg (Lescol)......................... 59
fluvoxamine maleate cap sr 24hr 100 mg (Luvox
cr).................................................................................... 85
276
fluvoxamine maleate cap sr 24hr 150 mg (Luvox
cr).................................................................................... 85
fluvoxamine maleate tab 100 mg................................... 85
fluvoxamine maleate tab 25 mg.....................................85
fluvoxamine maleate tab 50 mg.....................................85
FML - fluorometholone ophth oint 0.1%.......................... 151
FML FORTE - fluorometholone ophth susp 0.25%......... 151
FML LIQUIFILM - fluorometholone ophth susp 0.1%...... 151
FOCALGIN 90 DHA - prenat w/o a w/fecbn-fegl-dss-fa tab
90 &dha cap 300mg pak............................................... 130
FOCALGIN-B - prenatal w/ calcium-vit b6-fa-ginger tab
1.22 mg ........................................................................ 130
FOCALGIN CA - prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 300 mg pack....................................................130
FOCALGIN DSS - fe carbonyl-fe gluconate-fa-vit b12-vit cdss tab 90-1 mg ........................................................... 144
FOCALIN - dexmethylphenidate hcl tab 10 mg.................97
FOCALIN - dexmethylphenidate hcl tab 2.5 mg................96
FOCALIN - dexmethylphenidate hcl tab 5 mg...................96
FOCALIN XR - dexmethylphenidate hcl cap sr 24 hr 10
mg.................................................................................... 97
mg.................................................................................... 97
mg.................................................................................... 97
mg.................................................................................... 97
mg.................................................................................... 97
mg.................................................................................... 97
mg.................................................................................... 97
mg.................................................................................... 97
FOLBECAL - prenatal w/ calcium carbonate-b6-b12-fa tab
1 mg ............................................................................. 130
FOLBEE AR - folic acid-b12-b6-arginine-black pepper tab
....................................................................................... 141
FOLBIC RF - l-methylfolate w/ vit b6-vit b12 tab 1.13-25-2
mg .................................................................................141
FOLCAL DHA - prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 27-1.25-300 mg ..................................................... 130
FOLCAPS OMEGA 3 - prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg ...............................................130
FOLET DHA - prenat w/fecbn-bisg-methylf-dss tab dr &
dha cap pak...................................................................130
FOLET ONE - prenat w/o a w/fecbn-bisg-methylf-dss-dha
cap 38-1-225 mg .......................................................... 130
FOLGARD OS - multiple vit w/ min & calcium-folic acid tab
500-1.1 mg.................................................................... 130
FOLGARD RX - folic acid-vitamin b6-vitamin b12 tab
2.2-25-1 mg................................................................... 144
folic acid-pyridoxine-cyanocobalamin tab 2.5-25-2
mg..................................................................................141
folic acid tab 1 mg........................................................ 144
2015
folic acid tab 400 mcg.................................................. 144
folic acid tab 800 mcg.................................................. 144
folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5
mg..................................................................................144
folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg
(Folgard rx)...................................................................144
folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg...... 144
FOLIVANE-F - fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe) ................................... 144
FOLIVANE-OB - prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg .............................................................. 130
FOLIVANE-PLUS - fe fum-iron polysacch complex-fa-b
complex-c-biotin cap .................................................... 144
FOLLISTIM AQ - follitropin beta inj 150 unit/0.5ml............ 36
FOLLISTIM AQ - follitropin beta inj 300 unit/0.36ml.......... 36
FOLLISTIM AQ - follitropin beta inj 75 unit/0.5ml..............36
FOLTANX - l-methylfolate w/ vit b6-vit b12 tab 3-35-2 mg
....................................................................................... 141
FOLTANX RF - l-methylfolate-algae-vit b12-b6 cap
3-90.314-2-35 mg .........................................................141
FOLTRATE - cobalamine combination tab .....................144
FOLTX - folic acid-pyridoxine-cyanocobalamin tab
2.5-25-2 mg................................................................... 141
FOLTX - l-methylfolate w/ vit b6-vit b12 tab 1.13-25-2 mg
....................................................................................... 141
fondaparinux sodium inj 10 mg/0.8ml (Arixtra).......... 147
fondaparinux sodium inj 2.5 mg/0.5ml (Arixtra)......... 147
fondaparinux sodium inj 5 mg/0.4ml (Arixtra)............ 147
fondaparinux sodium inj 7.5 mg/0.6ml (Arixtra)......... 147
FORACARE GD40 - glucose blood test strip.................. 178
FORACARE GDH CONTROL SOLU - blood glucose
FORACARE PREMIUM V10 TEST - glucose blood test
strip................................................................................ 178
FORACARE TEST N GO TEST S - glucose blood test
strip................................................................................ 178
FORA CONTROL SOLUTION HIG - blood glucose
FORA CONTROL SOLUTION LOW - blood glucose
FORA CONTROL SOLUTION NOR - blood glucose
FORA D10 BLOOD GLUCOSE TE - glucose blood test
strip................................................................................ 178
FORA D15C BLOOD GLUCOSE T - glucose blood test
strip................................................................................ 178
FORA D15G BLOOD GLUCOSE T - glucose blood test
strip................................................................................ 178
FORA D15Z BLOOD GLUCOSE T - glucose blood test
strip................................................................................ 178
FORA D20 BLOOD GLUCOSE TE - glucose blood test
strip................................................................................ 178
FORADIL AEROLIZER - formoterol fumarate inhal cap 12
mcg.................................................................................. 68
FORA G20 BLOOD GLUCOSE MO - blood glucose
FORA G20 BLOOD GLUCOSE TE - glucose blood test
strip................................................................................ 178
FORA G30A BLOOD GLUCOSE T - glucose blood test
strip................................................................................ 178
FORA G71A BLOOD GLUCOSE M - blood glucose
FORA G71A BLOOD GLUCOSE T - glucose blood test
strip................................................................................ 178
FORA G90 BLOOD GLUCOSE TE - glucose blood test
strip................................................................................ 178
FORA GD20 TEST STRIPS - glucose blood test
strip................................................................................ 178
FORA GD50 BLOOD GLUCOSE T - glucose blood test
strip................................................................................ 178
FORA LANCETS - lancets .............................................198
FORA LANCING DEVICE - lancet devices .................... 198
FORA TEST N' GO BLOOD GLU - glucose blood test
strip................................................................................ 178
FORA V10 BLOOD GLUCOSE TE - glucose blood test
strip................................................................................ 178
strip................................................................................ 178
strip................................................................................ 178
FORA V22 BLOOD GLUCOSE MO - blood glucose
strip................................................................................ 178
FORA V30A BLOOD GLUCOSE M - blood glucose
FORA V30A BLOOD GLUCOSE T - glucose blood test
strip................................................................................ 178
FORFIVO XL - bupropion hcl tab sr 24hr 450 mg............. 85
FORMALDEHYDE - formaldehyde solution 37%............ 175
formaldehyde solution 10%..........................................175
FORMA-RAY - formaldehyde solution 20%.................... 175
FORTAMET - metformin hcl tab sr 24hr osmotic 1000
mg.................................................................................... 28
FORTAMET - metformin hcl tab sr 24hr osmotic 500
mg.................................................................................... 28
FORTAVIT - multiple vitamins w/ minerals cap ..............130
FORTEO - teriparatide (recombinant) inj 600
mcg/2.4ml........................................................................ 36
FORTESTA - testosterone td gel 10mg/act (2%).............. 21
FORTICAL - calcitonin (salmon) nasal soln 200 unit/
act.................................................................................... 37
FORTISCARE BLOOD GLUCOSE - glucose blood test
strip................................................................................ 178
FORTISCARE CONTROL SOLUTI - blood glucose
277
2015
FORTISCARE SELF-MONITORIN - blood glucose
FOSAMAX - alendronate sodium tab 70 mg.....................37
FOSAMAX PLUS D - alendronate sodium-cholecalciferol
tab 70-2800 mg-unit........................................................ 37
FOSAMAX PLUS D - alendronate sodium-cholecalciferol
tab 70-5600 mg-unit........................................................ 37
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg....................................................................................51
fosinopril sodium & hydrochlorothiazide tab 20-12.5
mg....................................................................................51
fosinopril sodium tab 10 mg.......................................... 51
FOSRENOL - lanthanum carbonate chew tab 1000
mg.................................................................................... 76
FOSRENOL - lanthanum carbonate chew tab 500 mg......76
FOSRENOL - lanthanum carbonate chew tab 750 mg......76
FOSRENOL - lanthanum carbonate oral powder pack
1000 mg (elemental)....................................................... 77
FOSRENOL - lanthanum carbonate oral powder pack 750
mg (elemental).................................................................76
FOSTEUM - genistein-zinc amino acid chelate-vitamin d
cap ................................................................................141
FRAGMIN - dalteparin sodium inj 10000 unit/ml............. 147
FRAGMIN - dalteparin sodium inj 12500 unit/0.5ml........ 147
FRAGMIN - dalteparin sodium inj 18000 unit/0.72ml...... 147
FRAGMIN - dalteparin sodium inj 2500 unit/0.2ml.......... 147
FRAGMIN - dalteparin sodium inj 5000 unit/0.2ml.......... 147
FREDS PHARMACY AUTOLET LA - lancet devices ..... 199
FREDS PHARMACY UNIFINE PE - insulin pen needle 31
g x 5 mm (3/16")........................................................... 199
g x 8 mm (1/3" or 5/16")................................................199
g x 4 mm (5/32")........................................................... 199
FREDS PHARMACY UNILET LAN - lancets ................. 199
FREESTYLE CONTROL SOLUTIO - blood glucose
FREESTYLE FREEDOM - blood glucose monitoring kit w/
device ........................................................................... 199
FREESTYLE FREEDOM LITE - blood glucose monitoring
kit w/ device ................................................................. 199
FREESTYLE INSULINX BLOOD - blood glucose
FREESTYLE INSULINX BLOOD - glucose blood test
strip................................................................................ 178
FREESTYLE LANCETS - lancets .................................. 199
FREESTYLE LITE TEST STRIP - glucose blood test
strip................................................................................ 178
278
FREESTYLE PRECISION INSUL - insulin syringe/needle
u-100 1/2 ml 30 x 5/16".................................................199
u-100 1/2 ml 31 x 5/16".................................................199
u-100 1 ml 30 x 5/16"....................................................199
u-100 1 ml 31 x 5/16"....................................................199
FREESTYLE SIDEKICK II VAL - blood glucose monitoring
kit w/ device ................................................................. 199
FREESTYLE TEST STRIPS - glucose blood test
strip................................................................................ 178
FREESTYLE UNISTICK II LAN - lancets .......................199
FROVA - frovatriptan succinate tab 2.5 mg (base
equivalent)..................................................................... 116
FULYZAQ - crofelemer tab delayed release 125 mg........ 70
FURADANTIN - nitrofurantoin susp 25 mg/5ml.................78
FUROSEMIDE - furosemide oral soln 8 mg/ml................. 56
furosemide oral soln 10 mg/ml...................................... 56
furosemide tab 20 mg (Lasix)........................................ 56
FUSION PLUS - fe fum-iron poly cmplx-fa-b cmplx-cbiotin-probiotic cap ....................................................... 145
FUZEON - enfuvirtide for inj 90 mg.................................... 9
FYCOMPA - perampanel tab 10 mg............................... 119
FYCOMPA - perampanel tab 12 mg............................... 119
FYCOMPA - perampanel tab 2 mg................................. 119
G
gabapentin cap 100 mg (Neurontin)............................ 119
gabapentin oral soln 250 mg/5ml (Neurontin)............ 119
gabapentin tab 600 mg (Neurontin).............................119
gabapentin tab 800 mg (Neurontin).............................119
GABAVALE-5 - diazepam tab 5 mg & dietary management
cap pack.......................................................................... 82
GABAZOLAMINE-0.5 - alprazolam tab 0.5 mg & dietary
GABAZOLAMINE - alprazolam tab 0.25 mg & dietary
GABAZOLPIDEM-5 - zolpidem tab 5 mg & dietary
GABITIDINE - ranitidine hcl tab 150 mg & dietary
GABITRIL - tiagabine hcl tab 12 mg............................... 119
GABITRIL - tiagabine hcl tab 16 mg............................... 119
GABITRIL - tiagabine hcl tab 2 mg................................. 119
GABITRIL - tiagabine hcl tab 4 mg................................. 119
GABOXETINE - fluoxetine hcl cap 10 mg & dietary
2015
galantamine hydrobromide cap sr 24hr 16 mg
(Razadyne er)............................................................... 100
(Razadyne er)............................................................... 100
(Razadyne er)............................................................... 100
GALANTAMINE HYDROBROMIDE - galantamine
hydrobromide oral soln 4 mg/ml.................................... 100
galantamine hydrobromide tab 12 mg (Razadyne).....100
galantamine hydrobromide tab 4 mg (Razadyne).......100
galantamine hydrobromide tab 8 mg (Razadyne).......100
GALZIN - zinc acetate cap 25 mg (elemental zinc)......... 139
GALZIN - zinc acetate cap 50 mg (elemental zinc)......... 139
GANIRELIX ACETATE - ganirelix acetate inj 250
mcg/0.5ml........................................................................ 37
GARAMYCIN - gentamicin sulfate ophth soln 0.3%........ 151
GASTRINEX NF - hyoscyamine-phenyltoloxamine cap
0.0625-15 mg.................................................................. 72
GASTROCROM - cromolyn sodium oral conc 100
mg/5ml............................................................................. 77
gatifloxacin ophth soln 0.5% (Zymaxid)......................151
GATTEX - teduglutide (rdna) for inj kit 5 mg.....................77
GE100 BLOOD GLUCOSE MONIT - blood glucose
GE100 BLOOD GLUCOSE TEST - glucose blood test
strip................................................................................ 178
GE100 CONTROL SOLUTION NO - blood glucose
GEBAUERS PAIN EASE - pentafluoropropanetetrafluoroethane aero spray......................................... 164
GEBAUERS SPRAY AND STRETC - pentafluoropropanetetrafluoroethane aero spray......................................... 164
GELCLAIR - povidone-sodium hyaluronate-glycyrrhetinic
acid gel .........................................................................155
GELFILM OP - gelatin adsorbable ophth film..................151
GEL-KAM ORAL CARE RINSE - stannous fluoride conc
0.63%.............................................................................155
GEL-KAM - stannous fluoride gel 0.4%.......................... 155
GELNIQUE - oxybutynin chloride td gel 10%....................79
GELNIQUE - oxybutynin td gel 3% (28 mg/act metereddose pump)......................................................................79
GELX - oral wound care products - gel ..........................155
gemfibrozil tab 600 mg (Lopid)......................................59
GENADUR - dermatological products misc - liquid ........ 164
GENADUR KIT - dermatological products misc topical/oral
- kit ............................................................................... 164
GENERESS FE - norethindrone & ethinyl estradiol-fe
chew tab 0.8 mg-25 mcg.................................................24
GENOTROPIN MINIQUICK - somatropin for inj 0.2
mg.................................................................................... 37
mg.................................................................................... 37
mg.................................................................................... 37
mg.................................................................................... 37
mg.................................................................................... 37
mg.................................................................................... 37
mg.................................................................................... 37
mg.................................................................................... 37
GENOTROPIN MINIQUICK - somatropin for inj 1 mg.......37
GENOTROPIN MINIQUICK - somatropin for inj 2 mg.......37
GENOTROPIN - somatropin for inj 12 mg (13.8 mg
overfill)............................................................................. 37
GENOTROPIN - somatropin for subcutaneous inj 5
mg.................................................................................... 37
GENTAMICIN SULFATE - gentamicin sulfate cream
0.1%...............................................................................164
GENTAMICIN SULFATE - gentamicin sulfate oint
0.1%...............................................................................165
gentamicin sulfate inj 10 mg/ml.......................................6
gentamicin sulfate inj 40 mg/ml.......................................6
gentamicin sulfate ophth oint 0.3%.............................151
gentamicin sulfate ophth soln 0.3% (Garamycin).......151
GENTLE-LET GP LANCETS - lancets ...........................199
GENTLE-LET LANCETS GENERA - lancets .................199
GENTLE-LET LANCETS SAFETY - lancets .................. 199
GEODON - ziprasidone hcl cap 20 mg............................. 90
GEODON - ziprasidone mesylate for inj 20 mg (base
equivalent)....................................................................... 90
GHT BLOOD GLUCOSE MONITO - blood glucose
GHT TEST STRIPS - glucose blood test strip.................178
GIAZO - balsalazide disodium tab 1.1 gm........................ 77
GILENYA - fingolimod hcl cap 0.5 mg (base equiv)........ 100
GILOTRIF - afatinib dimaleate tab 20 mg (base
equivalent)....................................................................... 15
equivalent)....................................................................... 15
equivalent)....................................................................... 15
GILPHEX TR - phenylephrine-guaifenesin tab 10-388
mg.................................................................................... 64
GILTUSS PED-C - phenylephrine w/ codeine-gg liquid
2.5-3-50 mg/ml................................................................ 64
GILTUSS - phenylephrine w/ dm-gg liqd 10-28-388
mg/5ml............................................................................. 64
GILTUSS TR - phenylephrine w/ dm-gg cap 7-14-288
mg.................................................................................... 64
GILTUSS TR - phenylephrine w/ dm-gg tab 10-28-388
mg.................................................................................... 64
GILTUSS TR - phenylephrine w/ dm-gg tab sr 12hr
20-30-600 mg.................................................................. 64
GLEEVEC - imatinib mesylate tab 100 mg (base
equivalent)....................................................................... 16
279
2015
GLEEVEC - imatinib mesylate tab 400 mg (base
equivalent)....................................................................... 16
GLEOSTINE - lomustine cap 100 mg............................... 16
GLEOSTINE - lomustine cap 10 mg................................. 16
GLEOSTINE - lomustine cap 40 mg................................. 16
glimepiride tab 1 mg (Amaryl)....................................... 28
glipizide-metformin hcl tab 2.5-250 mg......................... 28
glipizide-metformin hcl tab 2.5-500 mg......................... 28
glipizide-metformin hcl tab 5-500 mg............................ 28
glipizide tab 10 mg (Glucotrol)...................................... 28
glipizide tab 5 mg (Glucotrol)........................................ 28
glipizide tab sr 24hr 10 mg (Glucotrol xl)......................28
glipizide tab sr 24hr 2.5 mg (Glucotrol xl).....................28
glipizide tab sr 24hr 5 mg (Glucotrol xl)....................... 28
GLOBAL EASE INJECT PEN NE - insulin pen needle 29 g
x 12 mm (1/2")...............................................................199
x 5 mm (3/16")...............................................................199
x 8 mm (1/3" or 5/16")...................................................199
x 4 mm (5/32")...............................................................199
GLOBAL INJECT EASE INSULI - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................200
u-100 0.3 ml 30 x 1/2"...................................................200
u-100 0.3 ml 30 x 5/16".................................................200
u-100 0.3 ml 31 x 5/16".................................................200
u-100 1/2 ml 28 x 1/2"...................................................200
u-100 1/2 ml 29 x 1/2"...................................................200
u-100 1/2 ml 30 x 1/2"...................................................200
u-100 1/2 ml 30 x 5/16".................................................200
u-100 1/2 ml 31 x 5/16".................................................200
u-100 1 ml 28 x 1/2"......................................................200
u-100 1 ml 29 x 1/2"......................................................200
u-100 1 ml 30 x 1/2"......................................................200
u-100 1 ml 30 x 5/16"....................................................200
u-100 1 ml 31 x 5/16"....................................................200
GLOBAL INJECT EASE LANCET - lancets ................... 200
GLOBAL LANCING DEVICE - lancet devices ................200
GLUCAGEN DIAGNOSTIC - glucagon hcl (rdna)
diagnostic for inj 1 mg (base equiv).............................. 178
280
GLUCAGEN HYPOKIT - glucagon hcl (rdna) for inj 1 mg
(base equiv).....................................................................28
GLUCAGON EMERGENCY KIT - glucagon (rdna) for inj
kit 1 mg............................................................................28
GLUCOCARD 01 BLOOD GLUCOS - blood glucose
GLUCOCARD 01 CONTROL SOLU - blood glucose
GLUCOCARD 01 CONTROL SOLU - blood glucose
GLUCOCARD 01-MINI BLOOD G - blood glucose
GLUCOCARD 01 SENSOR PLUS - glucose blood test
strip................................................................................ 178
GLUCOCARD EXPRESSION AUDI - blood glucose
GLUCOCARD EXPRESSION BLOO - glucose blood test
strip................................................................................ 178
GLUCOCARD EXPRESSION CONT - blood glucose
GLUCOCARD SHINE - blood glucose monitoring kit w/
device ........................................................................... 200
GLUCOCARD SHINE CONTROL S - blood glucose
GLUCOCARD SHINE TEST STRI - glucose blood test
strip................................................................................ 178
GLUCOCARD VITAL BLOOD GLU - blood glucose
GLUCOCARD VITAL TEST STRI - glucose blood test
strip................................................................................ 178
GLUCOCARD X-METER - blood glucose monitoring kit w/
device ........................................................................... 200
GLUCOCARD X-METER CONTROL - blood glucose
GLUCOCARD X-SENSOR - glucose blood test strip...... 178
GLUCOCOM BLOOD GLUCOSE MO - blood glucose
GLUCOCOM HIGH CONTROL - blood glucose calibration
- liquid - high ................................................................ 200
GLUCOCOM LANCETS 28G - lancets .......................... 201
GLUCOCOM NORMAL CONTROL - blood glucose
GLUCOCOM TEST STRIPS - glucose blood test
strip................................................................................ 178
GLUCOLAB HIGH CONTROL - blood glucose calibration liquid - high ...................................................................201
GLUCOLAB LOW CONTROL - blood glucose calibration liquid - low .................................................................... 201
GLUCOLAB NORMAL CONTROL - blood glucose
GLUCOLAB TEST STRIPS - glucose blood test strip..... 178
GLUCOLET 2 AUTOMATIC LANC - lancet devices .......201
GLUCONAVII BLOOD GLUCOSE - blood glucose
2015
GLUCONAVII BLOOD GLUCOSE - glucose blood test
strip................................................................................ 179
GLUCO PERFECT 3 TEST STRI - glucose blood test
strip................................................................................ 178
GLUCOPHAGE - metformin hcl tab 1000 mg................... 28
GLUCOPHAGE - metformin hcl tab 500 mg..................... 28
GLUCOPHAGE - metformin hcl tab 850 mg..................... 28
GLUCOPHAGE XR - metformin hcl tab sr 24hr 500
mg.................................................................................... 29
GLUCOPHAGE XR - metformin hcl tab sr 24hr 750
mg.................................................................................... 29
GLUCOPRO INSULIN SYRINGE/ - insulin syringe/needle
u-100 0.3 ml 30 x 1/2"...................................................201
u-100 0.3 ml 30 x 5/16".................................................201
u-100 0.3 ml 31 x 5/16".................................................201
u-100 1/2 ml 30 x 1/2"...................................................201
u-100 1/2 ml 30 x 5/16".................................................201
u-100 1/2 ml 31 x 5/16".................................................201
u-100 1 ml 30 x 1/2"......................................................201
u-100 1 ml 30 x 5/16"....................................................201
u-100 1 ml 31 x 5/16"....................................................201
GLUCOSE CONTROL NORMAL - blood glucose
GLUCOSE CONTROL SOLUTION - blood glucose
GLUCOSOURCE LANCET DEVICE - lancet devices
....................................................................................... 201
GLUCOSOURCE LANCETS - lancets ........................... 201
GLUCOTROL - glipizide tab 10 mg.................................. 29
GLUCOTROL - glipizide tab 5 mg.................................... 29
GLUCOTROL XL - glipizide tab sr 24hr 10 mg................. 29
GLUCOTROL XL - glipizide tab sr 24hr 2.5 mg................ 29
GLUCOTROL XL - glipizide tab sr 24hr 5 mg................... 29
GLUCOVANCE - glyburide-metformin tab 1.25-250
mg.................................................................................... 29
GLUCOVANCE - glyburide-metformin tab 2.5-500 mg..... 29
GLUCOVANCE - glyburide-metformin tab 5-500 mg........ 29
GLUMETZA - metformin hcl tab sr 24hr modified release
1000 mg...........................................................................29
GLUMETZA - metformin hcl tab sr 24hr modified release
500 mg.............................................................................29
GLUTARALDEHYDE - glutaral soln 25%........................175
GLYBURIDE - glyburide tab 1.25 mg............................... 29
GLYBURIDE - glyburide tab 2.5 mg................................. 29
GLYBURIDE - glyburide tab 5 mg.................................... 29
glyburide-metformin tab 1.25-250 mg
(Glucovance).................................................................. 29
glyburide-metformin tab 2.5-500 mg (Glucovance)...... 29
glyburide-metformin tab 5-500 mg (Glucovance)......... 29
glyburide micronized tab 1.5 mg (Glynase).................. 29
glyburide micronized tab 3 mg (Glynase)..................... 29
glyburide micronized tab 6 mg (Glynase)..................... 29
glyburide tab 1.25 mg..................................................... 29
glyburide tab 2.5 mg....................................................... 29
glyburide tab 5 mg..........................................................29
GLYCATE - glycopyrrolate tab 1.5 mg..............................72
glycine irrigation soln 1.5%............................................81
glycopyrrolate inj 0.2 mg/ml (Robinul).......................... 72
glycopyrrolate inj 0.4 mg/2ml (0.2 mg/ml)
(Robinul)......................................................................... 72
glycopyrrolate inj 1 mg/5ml (0.2 mg/ml) (Robinul)....... 72
glycopyrrolate inj 4 mg/20ml (0.2 mg/ml) (Robinul)..... 72
glycopyrrolate tab 1 mg (Robinul).................................72
glycopyrrolate tab 2 mg (Robinul forte)........................72
GLYNASE - glyburide micronized tab 1.5 mg................... 29
GLYNASE - glyburide micronized tab 3 mg...................... 29
GLYNASE - glyburide micronized tab 6 mg...................... 29
GLYSET - miglitol tab 100 mg.......................................... 29
GLYSET - miglitol tab 25 mg............................................ 29
GLYSET - miglitol tab 50 mg............................................ 29
GLYXAMBI - empagliflozin-linagliptin tab 10-5 mg............29
GLYXAMBI - empagliflozin-linagliptin tab 25-5 mg............29
GMATE BLOOD GLUCOSE TEST - glucose blood test
strip................................................................................ 179
GMATE CONTROL SOLUTION LE - blood glucose
GMATE LANCETS 30G - lancets .................................. 201
GMATE LANCING DEVICE - lancet devices ................. 201
GMATE SMART STARTER KIT - blood glucose
GNP CLICKFINE PEN NEEDLE - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................201
GNP CLICKFINE UNIVERSAL P - insulin pen needle 31 g
x 6 mm (1/4").................................................................201
GNP CLICKFINE UNIVERSAL P - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................201
GNP INSULIN SYRINGE/0.3ML - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................201
u-100 0.3 ml 30 x 5/16".................................................201
u-100 0.3 ml 31 x 5/16".................................................202
u-100 1/2 ml 28 x 1/2"...................................................202
u-100 1/2 ml 29 x 1/2"...................................................202
u-100 1/2 ml 30 x 5/16".................................................202
u-100 1/2 ml 31 x 5/16".................................................202
GNP INSULIN SYRINGE/1ML/2 - insulin syringe/needle
u-100 1 ml 28 x 1/2"......................................................202
u-100 1 ml 29 x 1/2"......................................................202
281
2015
u-100 1 ml 30 x 5/16"....................................................202
u-100 1 ml 31 x 5/16"....................................................202
GNP LANCETS 21G - lancets ....................................... 202
GNP LANCETS - lancets ...............................................202
GNP LANCETS MICRO THIN 33 - lancets ....................202
GNP LANCETS SUPER THIN 30 - lancets ................... 202
GNP LANCETS THIN 26G - lancets ..............................202
GNP LANCETS THIN - lancets ..................................... 202
GNP MICRO THIN LANCETS 33 - lancets ....................202
GNP SUPER THIN LANCETS/30 - lancets ................... 202
GNP ULTRA COMFORT INSULIN - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................202
u-100 0.3 ml 30 x 5/16".................................................202
u-100 0.3 ml 31 x 5/16".................................................202
u-100 1/2 ml 28 x 1/2"...................................................202
u-100 1/2 ml 29 x 1/2"...................................................202
u-100 1/2 ml 30 x 5/16".................................................202
u-100 1/2 ml 31 x 5/16".................................................202
u-100 1 ml 28 x 1/2"......................................................202
u-100 1 ml 29 x 1/2"......................................................202
u-100 1 ml 30 x 5/16"....................................................202
u-100 1 ml 31 x 5/16"....................................................202
GNP VITAMIN D-400 - calcium carbonate-cholecalciferol
tab 90 mg-400 unit........................................................ 139
GOLYTELY - peg 3350-kcl-na bicarb-nacl-na sulfate for
soln 236 gm.....................................................................70
GOLYTELY - peg 3350-kcl-na bicarb-nacl-na sulfate
packet 227.1 gm..............................................................70
GONAL-F - follitropin alfa for inj 1050 unit........................ 37
GONAL-F - follitropin alfa for inj 450 unit.......................... 37
GONAL-F RFF - follitropin alfa for inj 75 unit.................... 37
GONAL-F RFF PEN - follitropin alfa inj 300 unit/0.5ml......37
GONAL-F RFF PEN - follitropin alfa inj 450
unit/0.75ml....................................................................... 37
GONAL-F RFF PEN - follitropin alfa inj 900 unit/1.5ml......37
GONAL-F RFF REDIJECT - follitropin alfa inj 300
unit/0.5ml......................................................................... 37
unit/0.75ml....................................................................... 37
unit/1.5ml......................................................................... 37
GORDOFILM - salicylic & lactic acids soln
16.7-16.7%.....................................................................165
GORDONS UREA - urea ointment 40%......................... 165
282
GRALISE - gabapentin (phn) tab 300 mg....................... 100
GRALISE - gabapentin (phn) tab 600 mg....................... 100
GRALISE STARTER - gabapentin (phn) tab starter pack
300 mg (9) & 600 mg (69)............................................ 100
granisetron hcl tab 1 mg................................................ 74
GRANIX - tbo-filgrastim soln prefilled syringe 300
mcg/0.5ml...................................................................... 145
GRANIX - tbo-filgrastim soln prefilled syringe 480
mcg/0.8ml...................................................................... 145
GRASTEK - timothy grass pollen allergen ext tab sl 2800
bau................................................................................... 14
GRIFULVIN V - griseofulvin microsize tab 500 mg............. 7
griseofulvin microsize susp 125 mg/5ml........................ 7
griseofulvin microsize tab 500 mg (Grifulvin v)............. 7
griseofulvin ultramicrosize tab 125 mg (Gris-peg)......... 7
griseofulvin ultramicrosize tab 250 mg (Gris-peg)......... 7
GRIS-PEG - griseofulvin ultramicrosize tab 125 mg........... 7
GRIS-PEG - griseofulvin ultramicrosize tab 250 mg........... 7
guaifenesin-codeine liquid 200-8 mg/5ml..................... 64
guaifenesin-codeine liquid 225-7.5 mg/5ml.................. 64
guaifenesin-codeine soln 100-10 mg/5ml......................64
guaifenesin-codeine soln 100-6.3 mg/5ml.....................64
guanfacine hcl tab 1 mg (Tenex)................................... 51
guanfacine hcl tab 2 mg (Tenex)................................... 51
guanfacine hcl tab sr 24hr 1 mg (base equiv)
(Intuniv)...........................................................................97
(Intuniv)...........................................................................97
(Intuniv)...........................................................................97
(Intuniv)...........................................................................97
GUANIDINE HCL - guanidine hcl tab 125 mg.................127
GYNAZOLE-1 - butoconazole nitrate (one dose) vaginal
cream 2%........................................................................ 80
H
H&H THINLET LANCETS 26G - lancets.........................202
H&H THINLET SUPER THIN LA - lancets......................202
HAEMOLANCE - lancets ............................................... 203
HAEMOLANCE LOW FLOW LANCE - lancets .............. 203
HAEMOLANCE PLUS HIGH FLOW - lancets ................203
HAEMOLANCE PLUS - lancets .....................................203
HAEMOLANCE PLUS LOW FLOW - lancets .................203
HAEMOLANCE PLUS MAX FLOW - lancets ................. 203
HAEMOLANCE PLUS PEDIATRIC - lancets ................. 203
HALAC - halobetasol prop oint 0.05% & ammonium
lactate lot 12% kit.......................................................... 165
HALCION - triazolam tab 0.25 mg.................................... 94
HALDOL DECANOATE 100 - haloperidol decanoate im
soln 100 mg/ml................................................................ 90
HALDOL DECANOATE 50 - haloperidol decanoate im
soln 50 mg/ml.................................................................. 90
HALDOL - haloperidol lactate inj 5 mg/ml......................... 90
halobetasol propionate cream 0.05% (Ultravate)........165
halobetasol propionate oint 0.05% (Ultravate)........... 165
2015
HALOG - halcinonide cream 0.1%.................................. 165
HALOG - halcinonide oint 0.1%...................................... 165
haloperidol decanoate im soln 100 mg/ml (Haldol
decanoate 100)...............................................................90
haloperidol decanoate im soln 50 mg/ml (Haldol
decanoate 50).................................................................90
haloperidol lactate inj 5 mg/ml (Haldol)........................ 90
haloperidol lactate oral conc 2 mg/ml...........................90
haloperidol tab 0.5 mg....................................................90
haloperidol tab 10 mg.....................................................90
haloperidol tab 1 mg.......................................................90
haloperidol tab 20 mg.....................................................90
HALOTIN - haloprogin cream 1%................................... 165
HARVONI - ledipasvir-sofosbuvir tab 90-400 mg................ 9
hc-pramoxine emol cream 2.5-1% & pramoxine wipe
1% kit (Analpram e).....................................................157
HEALTH CARE LANCING DEVIC - lancet devices ....... 203
HEALTHWISE LANCETS 30G - lancets ........................203
HEALTHWISE LANCING PEN - lancet devices .............203
HEALTHWISE MINI PEN NEEDL - insulin pen needle 31
g x 6 mm (1/4")............................................................. 203
HEALTHWISE PEN NEEDLES 29 - insulin pen needle 29
g x 12 mm (1/2")........................................................... 203
HEALTHWISE SHORT PEN NEED - insulin pen needle
31 g x 8 mm (1/3" or 5/16")...........................................203
HEALTHWISE UNIFINE PENTIP - insulin pen needle 32 g
x 4 mm (5/32")...............................................................203
HEALTHY ACCENTS AUTOLET I - lancet devices ....... 203
HEALTHY ACCENTS UNIFINE P - insulin pen needle 29
g x 12 mm (1/2")........................................................... 203
g x 5 mm (3/16")........................................................... 203
g x 6 mm (1/4")............................................................. 203
g x 8 mm (1/3" or 5/16")................................................203
g x 4 mm (5/32")........................................................... 203
HEALTHY ACCENTS UNILET LA - lancets ...................203
H-E-B INCONTROL ADVANCED - lancet devices .........203
H-E-B INCONTROL LANCETS S - lancets ....................203
H-E-B INCONTROL LANCETS U - lancets ................... 203
H-E-B IN CONTROL PEN NEED - insulin pen needle 31 g
x 5 mm (3/16")...............................................................202
x 6 mm (1/4").................................................................203
x 8 mm (1/3" or 5/16")...................................................203
x 4 mm (5/32")...............................................................203
H-E-B INCONTROL PEN NEEDL - insulin pen needle 29
g x 12 mm (1/2")........................................................... 203
HECTOROL - doxercalciferol cap 0.5 mcg....................... 37
HECTOROL - doxercalciferol cap 1 mcg.......................... 37
HECTOROL - doxercalciferol cap 2.5 mcg....................... 37
HEMANGEOL - propranolol hcl oral soln 4.28 mg/ml....... 42
HEMATOGEN FA - fe fumarate-vit c-vit b12-fa cap
200-250-0.01-1 mg........................................................ 145
HEMATRON-AF - iron-docusate-b12-folic acid-c-e-cubiotin tab 150-1 mg ...................................................... 145
HEMENATAL OB + DHA - prenat-fe poly cmplx-fe heme
poly-fa tab & omega 3 cap pck..................................... 130
HEMENATAL OB - prenat vit-fe poly cmplx-fe heme polyfa tab 28-6-1 mg .......................................................... 130
HEMETAB - polysacch fe cmplx-fe heme poly-fa-b12 tab
22-6-1-0.025 mg............................................................ 145
HEMOCYTE-F - iron combination elixir ......................... 145
HEMOCYTE PLUS - ferrous fumarate-fa-b complex-c-znmg-mn-cu cap 106-1 mg .............................................. 145
HEPARIN LOCK FLUSH - heparin sodium (porcine) lock
flush iv soln 1 unit/ml.....................................................147
HEPARIN LOCK FLUSH - heparin sodium (porcine) lock
flush iv soln 2 unit/ml.....................................................147
heparin sodium (porcine) inj 10000 unit/ml................ 148
heparin sodium (porcine) inj 1000 unit/ml.................. 148
heparin sodium (porcine) inj 20000 unit/ml................ 148
heparin sodium (porcine) inj 5000 unit/ml.................. 148
heparin sodium (porcine) lock flush iv soln 100 unit/
ml...................................................................................148
heparin sodium (porcine) lock flush iv soln 10 unit/
ml...................................................................................148
heparin sodium (porcine) lock flush iv soln 1 unit/ml
(Heparin lock flush)..................................................... 148
heparin sodium (porcine) pf inj 5000 unit/0.5ml......... 148
HEPARIN SODIUM - heparin sodium (porcine) inj 2000
unit/ml............................................................................ 147
HEPARIN SODIUM - heparin sodium (porcine) inj 2500
unit/ml............................................................................ 147
heparin sod lock flush & nacl lock flush 100 unt/
ml-0.9% kit....................................................................147
heparin sod lock flush & nacl lock flush 10 unt/
ml-0.9% kit....................................................................147
HEPSERA - adefovir dipivoxil tab 10 mg............................ 9
HETLIOZ - tasimelteon capsule 20 mg............................. 94
HEXALEN - altretamine cap 50 mg.................................. 16
HIPREX - methenamine hippurate tab 1 gm.....................78
HM LANCETS MICRO THIN 33G - lancets ................... 203
HM LANCETS ULTRA THIN 30G - lancets ................... 203
homatropine hbr ophth soln 5% (Isopto
homatropine)................................................................ 151
HORIZANT - gabapentin enacarbil tab cr 300 mg...........100
HORIZANT - gabapentin enacarbil tab cr 600 mg...........100
HPR - emollient - aerosol foam ..................................... 165
HPR PLUS - dermatological products misc - cream .......165
HPR PLUS - emollient - aerosol foam ........................... 165
HPR PLUS HYDROGEL KIT - dermatological products
misc - kit .......................................................................165
HUMALOG - insulin lispro (human) inj 100 unit/ml............31
HUMALOG - insulin lispro (human) soln cartridge 100 unit/
ml..................................................................................... 31
283
2015
HUMALOG KWIKPEN - insulin lispro (human) soln peninjector 100 unit/ml.......................................................... 31
HUMALOG MIX 50/50 - insulin lispro prot & lispro (human)
inj 100 unit/ml (50-50)..................................................... 32
HUMALOG MIX 50/50 KWIKPEN - insulin lispro prot &
lispro sus pen-inj 100 unit/ml (50-50).............................. 32
HUMALOG MIX 75/25 - insulin lispro prot & lispro (human)
inj 100 unit/ml (75-25)..................................................... 32
HUMALOG MIX 75/25 KWIKPEN - insulin lispro prot &
lispro sus pen-inj 100 unit/ml (75-25).............................. 32
HUMAPEN LUXURA HD - injection device for insulin.....203
HUMATROPE COMBO PACK - somatropin for inj 5
mg.................................................................................... 37
HUMATROPE - somatropin for inj 12 mg (36 unit)........... 37
HUMATROPE - somatropin for inj 24 mg......................... 37
HUMATROPE - somatropin for inj 5 mg........................... 37
HUMATROPE - somatropin for inj 6 mg (18 unit)............. 37
HUMIRA - adalimumab prefilled syringe kit 10
mg/0.2ml........................................................................ 113
mg/0.4ml........................................................................ 113
mg/0.8ml........................................................................ 113
HUMIRA PEDIATRIC CROHNS D - adalimumab prefilled
syringe kit 40 mg/0.8ml................................................. 113
HUMIRA PEN - adalimumab pen-injector kit 40
mg/0.8ml........................................................................ 113
HUMIRA PEN-CROHNS DISEASE - adalimumab peninjector kit 40 mg/0.8ml................................................. 113
HUMIRA PEN-PSORIASIS STAR - adalimumab peninjector kit 40 mg/0.8ml................................................. 113
HUMULIN 70/30 - insulin isophane & regular (human) inj
100 unit/ml (70-30).......................................................... 32
HUMULIN 70/30 KWIKPEN - insulin isophane & regular
susp pen-inj 100 unit/ml (70-30)......................................32
HUMULIN 70/30 PEN - insulin isophane & regular susp
pen-inj 100 unit/ml (70-30).............................................. 32
HUMULIN N - insulin isophane (human) inj 100 unit/
ml..................................................................................... 32
HUMULIN N KWIKPEN - insulin isophane (human) susp
pen-injector 100 unit/ml................................................... 32
HUMULIN N U-100 PEN - insulin isophane (human) susp
pen-injector 100 unit/ml................................................... 32
HUMULIN R - insulin regular (human) inj 100 unit/ml....... 32
HUMULIN R U-500 (CONCENTR - insulin regular (human)
inj 500 unit/ml.................................................................. 32
hyaluronate sodium (emollient) gel 0.2% (Hylira).......165
HYCAMTIN - topotecan hcl cap 0.25 mg (base equiv)......16
HYCAMTIN - topotecan hcl cap 1 mg (base equiv)...........16
HYCET - hydrocodone-acetaminophen soln 7.5-325
mg/15ml......................................................................... 106
hydralazine hcl tab 100 mg............................................ 51
hydralazine hcl tab 10 mg.............................................. 51
HYDREA - hydroxyurea cap 500 mg................................ 16
284
HYDRO 35 - urea in lactic acid vehicle foam 35%.......... 165
HYDRO 40 FOAM - urea foam 40%............................... 165
hydrochlorothiazide cap 12.5 mg (Microzide)...............56
hydrochlorothiazide tab 12.5 mg................................... 56
hydrochlorothiazide tab 25 mg...................................... 56
hydrochlorothiazide tab 50 mg...................................... 56
HYDROCODONE/ACETAMINOPHEN - hydrocodoneacetaminophen soln 10-325 mg/15ml........................... 106
HYDROCODONE/ACETAMINOPHEN - hydrocodoneacetaminophen soln 7.5-500 mg/15ml.......................... 106
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
(Hycet)...........................................................................106
hydrocodone-acetaminophen tab 10-300 mg
(Xodol)...........................................................................106
(Norco).......................................................................... 106
hydrocodone-acetaminophen tab 2.5-325 mg............ 106
(Xodol)...........................................................................106
(Norco).......................................................................... 106
hydrocodone-acetaminophen tab 7.5-300 mg
(Xodol)...........................................................................106
hydrocodone-acetaminophen tab 7.5-325 mg
(Norco).......................................................................... 106
hydrocodone-ibuprofen tab 10-200 mg (Ibudone)......106
hydrocodone-ibuprofen tab 2.5-200 mg
(Reprexain)................................................................... 106
hydrocodone-ibuprofen tab 5-200 mg
(Reprexain)................................................................... 106
hydrocodone-ibuprofen tab 7.5-200 mg
(Vicoprofen)..................................................................106
hydrocodone w/ homatropine syrup 5-1.5 mg/5ml.......64
hydrocodone w/ homatropine tab 5-1.5 mg.................. 64
hydrocod polst-chlorphen polst cr susp 10-8 mg/5ml
(Tussionex pennkineti)..................................................64
hydrocortisone acetate suppos 25 mg (Anusolhc)..................................................................................157
hydrocortisone acetate suppos 30 mg
(Proctocort).................................................................. 157
hydrocortisone acetate w/ pramoxine rectal cream
1-1% (Analpram-hc)..................................................... 157
hydrocortisone acetate w/ pramoxine rectal cream
2.5-1% (Analpram-hc).................................................. 157
hydrocortisone butyrate cream 0.1% (Locoid)........... 165
hydrocortisone butyrate hydrophilic lipo base cream
0.1% (Locoid lipocream)............................................. 165
hydrocortisone butyrate oint 0.1% (Locoid)............... 165
hydrocortisone butyrate soln 0.1% (Locoid).............. 165
hydrocortisone cream 1%............................................ 165
hydrocortisone cream 2.5%......................................... 165
hydrocortisone enema 100 mg/60ml (Cortenema)..... 157
hydrocortisone lotion 2.5%.......................................... 165
hydrocortisone lotion 2% (Ala scalp).......................... 165
hydrocortisone oint 1%................................................ 165
hydrocortisone oint 2.5%............................................. 165
2015
hydrocortisone rectal cream 1% (Proctocort)............ 157
hydrocortisone rectal cream 2.5% (Anusol-hc).......... 157
hydrocortisone tab 10 mg (Cortef)................................ 19
hydrocortisone tab 20 mg (Cortef)................................ 19
hydrocortisone tab 5 mg (Cortef).................................. 19
hydrocortisone valerate cream 0.2%...........................165
hydrocortisone valerate oint 0.2% (Westcort)............ 165
hydrocortisone w/ acetic acid otic soln 1-2% (Vosol
hc)..................................................................................155
HYDROMORPHONE HCL ER - hydromorphone hcl tab er
24hr deter 32 mg...........................................................106
HYDROMORPHONE HCL - hydromorphone hcl suppos 3
mg.................................................................................. 106
hydromorphone hcl liqd 1 mg/ml (Dilaudid)............... 106
hydromorphone hcl tab 2 mg (Dilaudid)..................... 106
hydromorphone hcl tab er 24hr deter 12 mg
(Exalgo).........................................................................106
(Exalgo).........................................................................106
(Exalgo).........................................................................106
hydroxychloroquine sulfate tab 200 mg
(Plaquenil).......................................................................13
hydroxyurea cap 500 mg (Hydrea)................................ 16
hydroxyzine hcl syrup 10 mg/5ml..................................82
hydroxyzine hcl tab 10 mg.............................................82
hydroxyzine pamoate cap 25 mg (Vistaril)....................82
hydroxyzine pamoate cap 50 mg (Vistaril)....................82
HYDROXYZINE PAMOATE - hydroxyzine pamoate cap
100 mg.............................................................................82
HYLASE WOUND - hyaluronate sodium gel ..................165
HYLATOPIC - emollient - aerosol foam ......................... 165
HYLATOPIC PLUS - dermatological products misc cream ............................................................................165
HYLATOPIC PLUS - emollient - aerosol foam ............... 165
HYLIRA - hyaluronate sodium (emollient) gel 0.2%........ 165
HYLIRA - hyaluronate sodium (emollient) lotion 0.1%.....165
hyoscyamine sulfate elixir 0.125 mg/5ml...................... 72
hyoscyamine sulfate soln 0.125 mg/ml......................... 72
hyoscyamine sulfate tab 0.125 mg (Levsin)................. 72
hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)...... 72
hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl)..........72
hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid).....72
HYPERSAL - sodium chloride soln nebu 3.5%................. 64
HYPERSAL - sodium chloride soln nebu 7%.................... 64
HYPER-SAL - sodium chloride soln nebu 7%...................64
HYPERTENEVIDE-12.5 - carvedilol tab 12.5 mg & dietary
HYPERTENIPINE-2.5 - amlodipine tab 2.5 mg & dietary
HYPERTENSOLOL - metoprolol tab 50 mg & dietary
HYSINGLA ER - hydrocodone bitartrate tab er 24hr deter
100 mg...........................................................................106
120 mg...........................................................................106
20 mg.............................................................................106
30 mg.............................................................................106
40 mg.............................................................................106
60 mg.............................................................................106
80 mg.............................................................................106
HY-VEE LANCETS - lancets ......................................... 203
HY-VEE THIN LANCETS - lancets ................................ 203
HYZAAR - losartan potassium & hydrochlorothiazide tab
100-12.5 mg.................................................................... 51
100-25 mg....................................................................... 51
50-12.5 mg...................................................................... 51
I
ibandronate sodium tab 150 mg (base equivalent)
(Boniva)...........................................................................37
IBG STAR BLOOD GLUCOSE MO - blood glucose
IBRANCE - palbociclib cap 100 mg.................................. 16
IBRANCE - palbociclib cap 125 mg.................................. 16
IBRANCE - palbociclib cap 75 mg.................................... 16
IBUDONE - hydrocodone-ibuprofen tab 10-200 mg........ 106
IBUPROFEN COMFORT PAC - ibuprofen tab 800 mg &
liniment topical gel kit.................................................... 113
ibuprofen susp 100 mg/5ml..........................................113
ibuprofen tab 400 mg....................................................113
ibuprofen tab 600 mg....................................................113
ibuprofen tab 800 mg....................................................113
IC 400 - ibuprofen tab 400 mg & caffeine-vitamins cap
kit................................................................................... 113
IC 800 - ibuprofen tab 800 mg & caffeine-vitamins cap
kit................................................................................... 113
ICAR - carbonyl iron chew tab 15 mg (elemental
iron)................................................................................145
ICAR-C PLUS - iron-vit c-vit b12-folic acid tab
100-250-0.025-1 mg...................................................... 145
ICAR PEDIATRIC - carbonyl iron susp 15 mg/1.25ml
(elemental iron)..............................................................145
ICLUSIG - ponatinib hcl tab 15 mg (base equiv)...............16
ICLUSIG - ponatinib hcl tab 45 mg (base equiv)...............16
ILEVRO - nepafenac ophth susp 0.3%........................... 151
IMBRUVICA - ibrutinib cap 140 mg.................................. 16
IMDUR - isosorbide mononitrate tab sr 24hr 30 mg.......... 40
imipramine hcl tab 10 mg (Tofranil).............................. 85
285
2015
imipramine pamoate cap 100 mg (Tofranil-pm)............85
imipramine pamoate cap 75 mg (Tofranil-pm)..............85
imiquimod cream 5% (Aldara)......................................165
IMITREX STATDOSE REFILL - sumatriptan succinate
solution cartridge 4 mg/0.5ml........................................ 116
IMITREX STATDOSE REFILL - sumatriptan succinate
solution cartridge 6 mg/0.5ml........................................ 116
IMITREX STATDOSE SYSTEM - sumatriptan succinate
solution auto-injector 4 mg/0.5ml...................................116
IMITREX STATDOSE SYSTEM - sumatriptan succinate
solution auto-injector 6 mg/0.5ml...................................116
IMITREX - sumatriptan nasal spray 20 mg/act................116
IMITREX - sumatriptan nasal spray 5 mg/act..................116
IMITREX - sumatriptan succinate inj 6 mg/0.5ml............ 116
IMITREX - sumatriptan succinate tab 100 mg.................116
IMITREX - sumatriptan succinate tab 25 mg...................116
IMITREX - sumatriptan succinate tab 50 mg...................116
IMPLANON - etonogestrel subdermal implant 68 mg....... 25
IMURAN - azathioprine tab 50 mg.................................. 235
INATAL ADVANCE - prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg ..................................................................130
INATAL GT - prenatal vit w/ dss-iron carbonyl-fa tab 90-1
mg .................................................................................130
INATAL ULTRA - prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg ........................................................................ 130
INCRELEX - mecasermin inj 40 mg/4ml (10 mg/ml)......... 37
INCRUSE ELLIPTA - umeclidinium br aero powd breath
act 62.5 mcg/inh (base eq)............................................. 68
indapamide tab 1.25 mg................................................. 56
indapamide tab 2.5 mg................................................... 56
INDERAL LA - propranolol hcl cap sr 24hr 120 mg...........42
INDERAL LA - propranolol hcl cap sr 24hr 160 mg...........42
INDERAL LA - propranolol hcl cap sr 24hr 60 mg.............42
INDERAL LA - propranolol hcl cap sr 24hr 80 mg.............42
INDERAL XL - propranolol hcl sustained-release beads
cap sr 24hr 120 mg.........................................................42
INDERAL XL - propranolol hcl sustained-release beads
cap sr 24hr 80 mg...........................................................42
INDOCIN - indomethacin suppos 50 mg.........................113
INDOCIN - indomethacin susp 25 mg/5ml...................... 113
indomethacin cap 25 mg.............................................. 113
indomethacin cap 50 mg.............................................. 113
indomethacin cap cr 75 mg..........................................113
INFANATE BALANCE - prenatal w/o a w/fe cbn-dss-fadha cap 29-1-265 mg ...................................................130
INFANATE PLUS - prenat w/o a w/fe fum-fe cbn-dss-fadha cap 27-1-260 mg ...................................................130
INFANRIX - diph, acellular pert & tet tox inj 25 lf-58
mcg-10 lf/0.5ml................................................................ 14
INFINITY BLOOD GLUCOSE MO - blood glucose
INFINITY BLOOD GLUCOSE TE - glucose blood test
strip................................................................................ 179
286
INFINITY CONTROL SOLUTION - blood glucose
INLYTA - axitinib tab 1 mg................................................16
INLYTA - axitinib tab 5 mg................................................16
INNOPRAN XL - propranolol hcl sustained-release beads
cap sr 24hr 120 mg.........................................................42
INNOPRAN XL - propranolol hcl sustained-release beads
cap sr 24hr 80 mg...........................................................42
INOVA 4/1 ACNE CONTROL TH - benzoyl perox pad 4%
& salicylic ac pad 1% & vit e 5% kit.............................. 165
INOVA 8/2 ACNE CONTROL TH - benzoyl perox pad 8%
& salicylic ac pad 2% & vit e 5% kit.............................. 165
INOVA - benzoyl peroxide pad 4% & vitamin e topical 5%
kit................................................................................... 165
INOVA - benzoyl peroxide pad 8% & vitamin e topical 5%
kit................................................................................... 165
INSPIRACHAMBER/ANTI-STATI - spacer/aerosol-holding
chambers - device ........................................................204
INSPIRACHAMBER/SOOTHERMAS - spacer/aerosolholding chambers - device ........................................... 204
INSPIREASE DRUG DELIVERY - spacer/aerosol-holding
chambers - device ........................................................204
INSPRA - eplerenone tab 25 mg...................................... 51
INSPRA - eplerenone tab 50 mg...................................... 51
INSULIN SYRINGE/0.3ML/29G - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................204
u-100 0.3 ml 29 x 1"......................................................204
u-100 0.3 ml 30 x 5/16".................................................204
u-100 0.3 ml 31 x 5/16".................................................204
u-100 1/2 ml 27 x 1/2"...................................................204
u-100 1/2 ml 28 x 1/2"...................................................204
u-100 1/2 ml 29 x 1/2"...................................................204
u-100 1/2 ml 30 x 1/2"...................................................204
u-100 1/2 ml 30 x 5/16".................................................204
u-100 1/2 ml 31 x 5/16".................................................204
INSULIN SYRINGE/1ML/28G X - insulin syringe/needle
u-100 1 ml 28 x 1/2"......................................................204
u-100 1 ml 29 x 1/2"......................................................204
u-100 1 ml 30 x 5/16"....................................................204
u-100 1 ml 31 x 5/16"....................................................205
2015
INSULIN SYRINGE/U-100/0.3 - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................204
u-100 1/2 ml 28 x 1/2"...................................................204
u-100 1/2 ml 29 x 1/2"...................................................204
INSULIN SYRINGE/U-100/1ML - insulin syringe/needle
u-100 1 ml 28 x 1/2"......................................................204
u-100 1 ml 29 x 1/2"......................................................204
u-100 1 ml 30 x 5/16"....................................................204
u-100 1 ml 31 x 5/16"....................................................204
INSUPEN 33GX4MM - insulin pen needle 33 g x 4 mm
(5/32")............................................................................ 205
INSUPEN PEN NEEDLES 32G X - insulin pen needle 32
g x 4 mm (5/32")........................................................... 205
INSUPEN SENSITIVE 32GX6MM - insulin pen needle 32
g x 6 mm (1/4")............................................................. 205
INSUPEN SENSITIVE 32GX8MM - insulin pen needle 32
g x 8 mm....................................................................... 205
INSUPEN ULTRAFIN 29GX12MM - insulin pen needle 29
g x 12 mm (1/2")........................................................... 205
INSUPEN ULTRAFIN 30GX8MM - insulin pen needle 30 g
x 8 mm (1/3" or 5/16")...................................................205
x 6 mm (1/4").................................................................205
x 8 mm (1/3" or 5/16")...................................................205
INTEGRA F - fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe) ................................... 145
INTEGRA PLUS - fe fum-iron polysacch complex-fa-b
complex-c-biotin cap .................................................... 145
INTELENCE - etravirine tab 100 mg...................................9
INTELENCE - etravirine tab 200 mg...................................9
INTELENCE - etravirine tab 25 mg.....................................9
INTERMEZZO - zolpidem tartrate sl tab 1.75 mg............. 94
INTERMEZZO - zolpidem tartrate sl tab 3.5 mg............... 94
INTROL - glycerin soln 75%............................................. 56
INTRON A - interferon alfa-2b for inj 10000000 unit......... 16
INTRON-A - interferon alfa-2b inj 10000000 unit/ml..........16
INTRON-A - interferon alfa-2b inj 6000000 unit/ml............16
INTRON-A W/DILUENT - interferon alfa-2b for inj
10000000 unit..................................................................16
18000000 unit..................................................................16
50000000 unit..................................................................16
INTUNIV - guanfacine hcl tab sr 24hr 1 mg (base
equiv)............................................................................... 97
equiv)............................................................................... 97
equiv)............................................................................... 97
equiv)............................................................................... 97
INVEGA - paliperidone tab sr 24hr 1.5 mg....................... 90
INVEGA - paliperidone tab sr 24hr 3 mg.......................... 90
INVEGA SUSTENNA - paliperidone palmitate im
extended-release susp 156 mg/ml.................................. 91
extended-release susp 234 mg/1.5ml............................. 91
extended-release susp 39 mg/0.25ml............................. 90
extended-release susp 78 mg/0.5ml............................... 90
INVEGA SUSTENNA - paliperidone palmitate im extendrelease susp 117 mg/0.75ml........................................... 90
INVEGA TRINZA - paliperidone palmitate im extendrelease susp 273 mg/0.875ml......................................... 91
INVEGA TRINZA - paliperidone palmitate im extendrelease susp 546 mg/1.75ml........................................... 91
INVIRASE - saquinavir mesylate cap 200 mg.....................9
INVIRASE - saquinavir mesylate tab 500 mg..................... 9
INVOKAMET - canagliflozin-metformin hcl tab 150-1000
mg.................................................................................... 29
mg.................................................................................... 29
mg.................................................................................... 29
mg.................................................................................... 29
INVOKANA - canagliflozin tab 100 mg............................. 29
INVOKANA - canagliflozin tab 300 mg............................. 29
IODINE STRONG - iodine solution strong 5%
(lugol's)...........................................................................139
IODINE TINCTURE - iodine tincture .............................. 175
iodoquinol-hc cream 1%...............................................165
iodoquinol-hydrocortisone in aloe vehicle cream
1-1.9% (Vytone)............................................................ 165
IONSYS - fentanyl hcl iontophoretic td system 40 mcg/act
(base equiv)...................................................................106
IOPIDINE - apraclonidine hcl ophth soln 0.5% (base
equivalent)..................................................................... 151
IOPIDINE - apraclonidine hcl ophth soln 1% (base
equivalent)..................................................................... 151
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml...... 68
ipratropium bromide inhal soln 0.02%.......................... 68
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
(Atrovent)........................................................................63
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
(Atrovent)........................................................................63
287
2015
irbesartan-hydrochlorothiazide tab 150-12.5 mg
(Avalide)..........................................................................52
irbesartan-hydrochlorothiazide tab 300-12.5 mg
(Avalide)..........................................................................52
irbesartan tab 150 mg (Avapro)..................................... 51
irbesartan tab 300 mg (Avapro)..................................... 51
irbesartan tab 75 mg (Avapro)....................................... 51
IRENKA - duloxetine hcl enteric coated pellets cap 40
mg.................................................................................... 85
IRON ASP GLY/ POLYSACCH C - fe asp gly-fe
polysacch-succ ac-c-threon ac-b12-fa cap ................... 145
IRON CHEWS PEDIATRIC - carbonyl iron chew tab 15
mg (elemental iron)....................................................... 145
iron combination cap ...................................................142
iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1
mg (Hematron-af).........................................................142
iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg
(Corvite 150)................................................................. 145
iron polysacch complex-vit b12-fa cap 150-0.025-1
mg..................................................................................145
iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg
(Icar-c plus).................................................................. 145
IROSPAN 24/6 - fe asp gly-fe polys-succ acd-b cmplx-cca-fa tab ther pk ...........................................................145
IS 24/6 - fe asp gly-fe polys-succ acd-b cmplx-c-ca-fa tab
ther pk .......................................................................... 145
ISENTRESS - raltegravir potassium chew tab 100 mg
(base equiv).......................................................................9
ISENTRESS - raltegravir potassium chew tab 25 mg (base
equiv)................................................................................. 9
ISENTRESS - raltegravir potassium packet for susp 100
mg (base equiv).................................................................9
ISENTRESS - raltegravir potassium tab 400 mg (base
equiv)................................................................................. 9
ISONIAZID - isoniazid syrup 50 mg/5ml............................. 6
isoniazid tab 100 mg.........................................................6
isoniazid tab 300 mg.........................................................6
ISOPTIN SR - verapamil hcl tab cr 120 mg...................... 45
ISOPTO ATROPINE - atropine sulfate ophth soln
1%..................................................................................151
ISOPTO CARBACHOL - carbachol ophth soln 1.5%...... 151
ISOPTO CARBACHOL - carbachol ophth soln 3%......... 151
ISOPTO CARPINE - pilocarpine hcl ophth soln 1%........ 151
ISOPTO HOMATROPINE - homatropine hbr ophth soln
2%..................................................................................151
ISOPTO HOMATROPINE - homatropine hbr ophth soln
5%..................................................................................151
ISOPTO HYOSCINE - scopolamine hbr ophth soln
0.25%.............................................................................151
ISORDIL TITRADOSE - isosorbide dinitrate tab 40
mg.................................................................................... 40
ISORDIL TITRADOSE - isosorbide dinitrate tab 5 mg...... 40
288
ISOSORBIDE DINITRATE - isosorbide dinitrate tab 30
mg.................................................................................... 40
isosorbide dinitrate tab 10 mg.......................................40
isosorbide dinitrate tab 20 mg.......................................40
isosorbide dinitrate tab 5 mg (Isordil titradose)........... 40
isosorbide dinitrate tab cr 40 mg.................................. 40
isosorbide mononitrate tab 10 mg................................ 41
isosorbide mononitrate tab 20 mg................................ 41
isosorbide mononitrate tab sr 24hr 120 mg (Imdur).....40
isosorbide mononitrate tab sr 24hr 30 mg (Imdur).......41
isosorbide mononitrate tab sr 24hr 60 mg (Imdur).......41
isotretinoin cap 10 mg..................................................165
ISOXSUPRINE HCL - isoxsuprine hcl tab 20 mg..............61
isoxsuprine hcl tab 10 mg..............................................61
isradipine cap 2.5 mg..................................................... 45
isradipine cap 5 mg........................................................ 45
ISTALOL - timolol maleate ophth soln 0.5% (oncedaily).............................................................................. 151
itraconazole cap 100 mg (Sporanox)...............................7
ivermectin tab 3 mg (Stromectol).................................. 13
J
JADENU - deferasirox tab 180 mg..................................175
JADENU - deferasirox tab 360 mg..................................175
JADENU - deferasirox tab 90 mg....................................175
JAKAFI - ruxolitinib phosphate tab 10 mg (base
equivalent)....................................................................... 16
equivalent)....................................................................... 16
equivalent)....................................................................... 16
equivalent)....................................................................... 16
equivalent)....................................................................... 16
JALYN - dutasteride-tamsulosin hcl cap 0.5-0.4 mg......... 81
JANUMET - sitagliptin-metformin hcl tab 50-1000 mg.......29
JANUMET - sitagliptin-metformin hcl tab 50-500 mg........ 29
JANUMET XR - sitagliptin-metformin hcl tab sr 24hr
100-1000 mg................................................................... 29
50-1000 mg..................................................................... 29
50-500 mg....................................................................... 29
JANUVIA - sitagliptin phosphate tab 100 mg (base
equiv)............................................................................... 30
equiv)............................................................................... 30
equiv)............................................................................... 30
JARDIANCE - empagliflozin tab 10 mg.............................30
JARDIANCE - empagliflozin tab 25 mg.............................30
JENTADUETO - linagliptin-metformin hcl tab 2.5-1000
mg.................................................................................... 30
2015
mg.................................................................................... 30
mg.................................................................................... 30
JUBLIA - efinaconazole soln 10%...................................166
JUXTAPID - lomitapide mesylate cap 10 mg (base
equiv)............................................................................... 59
equiv)............................................................................... 59
equiv)............................................................................... 59
equiv)............................................................................... 59
equiv)............................................................................... 59
equiv)............................................................................... 59
K
KADIAN - morphine sulfate cap sr 24hr 100 mg............. 107
KADIAN - morphine sulfate cap sr 24hr 10 mg............... 107
KADIAN - morphine sulfate cap sr 24hr 200 mg............. 107
KALETRA - lopinavir-ritonavir soln 400-100 mg/5ml (80-20
mg/ml)................................................................................ 9
KALETRA - lopinavir-ritonavir tab 100-25 mg..................... 9
KALETRA - lopinavir-ritonavir tab 200-50 mg..................... 9
KALYDECO - ivacaftor packet 50 mg............................... 70
KALYDECO - ivacaftor packet 75 mg............................... 70
KALYDECO - ivacaftor tab 150 mg...................................70
KAPVAY - clonidine hcl tab sr 12hr 0.1 mg...................... 97
KARBINAL ER - carbinoxamine maleate er susp 4
mg/5ml............................................................................. 62
KAYEXALATE - sodium polystyrene sulfonate powder
....................................................................................... 235
KAZANO - alogliptin-metformin hcl tab 12.5-1000 mg.......30
KAZANO - alogliptin-metformin hcl tab 12.5-500 mg........ 30
KEFLEX - cephalexin cap 250 mg......................................2
KENALOG - triamcinolone acetonide aerosol soln..........166
KEPPRA - levetiracetam oral soln 100 mg/ml.................119
KEPPRA - levetiracetam tab 1000 mg............................ 119
KEPPRA - levetiracetam tab 250 mg..............................119
KEPPRA XR - levetiracetam tab sr 24hr 500 mg............ 119
KEPPRA XR - levetiracetam tab sr 24hr 750 mg............ 119
KERAFOAM 42 - urea foam 42%................................... 166
KERAFOAM - urea foam 30%........................................ 166
KERALAC - urea cream 47%..........................................166
KERALYT - salicylic acid gel 6%.................................... 166
KERALYT SCALP - salicylic acid shampoo 6% & salicylic
acid gel 6% kit...............................................................166
KERLONE - betaxolol hcl tab 10 mg................................ 42
KERLONE - betaxolol hcl tab 20 mg................................ 42
KERYDIN - tavaborole soln 5%...................................... 166
KETEK - telithromycin tab 300 mg....................................13
KETEK - telithromycin tab 400 mg....................................13
ketoconazole cream 2%................................................166
ketoconazole foam 2% (Extina)................................... 166
ketoconazole shampoo 2% (Nizoral)........................... 166
ketoconazole tab 200 mg................................................. 7
KETODAN KIT - ketoconazole foam 2% & cleanser
kit................................................................................... 166
ketoprofen cap 50 mg...................................................113
ketoprofen cap 75 mg...................................................113
KETOPROFEN ER - ketoprofen cap sr 24hr 200 mg......113
ketorolac tromethamine ophth soln 0.4% (Acular
ls)...................................................................................152
ketorolac tromethamine ophth soln 0.5% (Acular).....152
ketorolac tromethamine tab 10 mg..............................113
ketotifen fumarate ophth soln 0.025% (base
equiv)............................................................................ 152
KHEDEZLA - desvenlafaxine tab sr 24hr 100 mg............. 85
KHEDEZLA - desvenlafaxine tab sr 24hr 50 mg............... 85
KINERET - anakinra subcutaneous soln prefilled syringe
100 mg/0.67ml............................................................... 113
KINNEY LANCETS - lancets ......................................... 205
KINNEY THIN LANCETS - lancets ................................ 205
KINRAY INSULIN SYRINGE/0. - insulin syringe/needle
u-100 1/2 ml 29 x 1/2"...................................................205
KINRAY INSULIN SYRINGE PR - insulin syringe/needle
u-100 0.3 ml 31 x 5/16".................................................205
u-100 1/2 ml 31 x 5/16".................................................205
u-100 1 ml 31 x 5/16"....................................................205
KINRIX - diph-tetanus tox ad-acell pert & polio virus, ipv
vac inj.............................................................................. 14
KITABIS PAK - tobramycin nebu soln 300 mg/5ml............. 6
KLARON - sulfacetamide sodium lotion 10% (acne)....... 166
KLONOPIN - clonazepam tab 0.5 mg............................. 119
KLONOPIN - clonazepam tab 1 mg................................119
KLONOPIN - clonazepam tab 2 mg................................119
KLOR-CON/25 - potassium chloride powder packet 25
meq................................................................................ 139
KLOR-CON 25 - potassium chloride powder packet 25
meq................................................................................ 139
KLOR-CON M15 - potassium chloride microencapsulated
crys cr tab 15 meq........................................................ 139
KMART VALU PLUS INSULIN S - insulin syringe (disp)
u-100 0.3 ml.................................................................. 205
u-100 1/2 ml.................................................................. 205
u-100 1 ml..................................................................... 205
289
2015
KOMBIGLYZE XR - saxagliptin-metformin hcl tab sr 24hr
2.5-1000 mg.................................................................... 30
5-1000 mg....................................................................... 30
5-500 mg......................................................................... 30
KORLYM - mifepristone tab 300 mg................................. 30
K-PHOS NEUTRAL - pot phos monobasic w/sod phos di &
monobas tab 155-852-130mg....................................... 139
K-PHOS NO 2 - potassium & sodium acid phosphates tab
305-700 mg..................................................................... 81
K-PHOS - potassium phosphate monobasic tab 500
mg.................................................................................. 139
KRISGEL 100 - krisgel 100 gel.......................................234
KRISTALOSE - lactulose oral crystal packet 10 gm..........70
KRISTALOSE - lactulose oral crystal packet 20 gm..........70
KROGER BLOOD GLUCOSE MONI - blood glucose
KROGER BLOOD GLUCOSE TEST - glucose blood test
strip................................................................................ 179
KROGER INSULIN SYRINGE/0. - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................205
u-100 0.3 ml 30 x 5/16".................................................205
u-100 0.3 ml 31 x 5/16".................................................205
u-100 1/2 ml 29 x 1/2"...................................................205
u-100 1/2 ml 30 x 5/16".................................................205
u-100 1/2 ml 31 x 5/16".................................................205
KROGER INSULIN SYRINGE/1M - insulin syringe/needle
u-100 1 ml 29 x 1/2"......................................................205
u-100 1 ml 30 x 5/16"....................................................205
u-100 1 ml 31 x 5/16"....................................................205
KROGER INSULIN SYRINGE/U- - insulin syringe/needle
u-100 0.3 ml 30 x 1/2"...................................................205
KROGER LANCETS 21G - lancets ............................... 206
KROGER LANCETS - lancets ....................................... 205
KROGER LANCETS MICRO THIN - lancets ................. 205
KROGER LANCETS SUPER THIN - lancets .................206
KROGER LANCETS THIN 26G - lancets ...................... 206
KROGER LANCETS THIN - lancets .............................. 206
KROGER LANCETS ULTRATHIN - lancets .................. 206
KROGER LANCING DEVICE - lancet devices .............. 206
KROGER PEN NEEDLES 29G X - insulin pen needle 29 g
x 12 mm (1/2")...............................................................206
KROGER PEN NEEDLES 31GX1/ - insulin pen needle 31
g x 6 mm (1/4")............................................................. 206
KROGER PEN NEEDLES 31G X - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................206
KROGER PREMIUM BLOOD GLUC - blood glucose
290
KROGER PREMIUM BLOOD GLUC - glucose blood test
strip................................................................................ 179
KROGER TEST STRIPS - glucose blood test strip.........179
K-TAB - potassium chloride tab cr 10 meq..................... 139
K-TAB - potassium chloride tab cr 20 meq (1500 mg).....139
KUVAN - sapropterin dihydrochloride powder packet 100
mg.................................................................................... 37
KUVAN - sapropterin dihydrochloride soluble tab 100
mg.................................................................................... 37
KYNAMRO - mipomersen sodium soln prefilled syringe
200 mg/ml........................................................................59
L
labetalol hcl tab 100 mg (Trandate)...............................42
LAC-HYDRIN - lactic acid (ammonium lactate) cream
12%................................................................................166
LAC-HYDRIN - lactic acid (ammonium lactate) lotion
12%................................................................................166
lactated ringer's for irrigation...................................... 235
lactic acid (ammonium lactate) cream 12% (Lachydrin)...........................................................................166
lactic acid (ammonium lactate) lotion 10%................. 166
lactic acid (ammonium lactate) lotion 12% (Lachydrin)...........................................................................166
lactic acid w/ vitamin e cream 10%-3500
unit/30gm...................................................................... 166
lactulose (encephalopathy) solution 10 gm/15ml.........77
lactulose solution 10 gm/15ml....................................... 70
LADY LITE LANCETS - lancets .....................................206
LAMICTAL CHEWABLE DISPERS - lamotrigine tab
chewable dispersible 25 mg.......................................... 119
LAMICTAL CHEWABLE DISPERS - lamotrigine tab
chewable dispersible 5 mg............................................ 119
LAMICTAL - lamotrigine tab 100 mg...............................119
LAMICTAL - lamotrigine tab 25 mg.................................119
LAMICTAL ODT - lamotrigine orally disintegrating tab 100
mg.................................................................................. 120
mg.................................................................................. 120
mg.................................................................................. 120
mg.................................................................................. 120
LAMICTAL ODT - lamotrigine tab disp 25 (14) & 50 mg
(14) & 100 mg (7) kit.....................................................120
LAMICTAL ODT - lamotrigine tab disp 25 mg (21) & 50 mg
(7) titration kit.................................................................119
LAMICTAL ODT - lamotrigine tab disp 50 mg (42) & 100
mg (14) titration kit........................................................ 120
LAMICTAL STARTER/NOT TAKI - lamotrigine tab 25 mg
(42) & 100 mg (7) starter kit..........................................120
2015
LAMICTAL STARTER/TAKING C - lamotrigine tab 25 mg
(84) & 100 mg (14) starter kit........................................120
LAMICTAL STARTER/TAKING V - lamotrigine tab 25 mg
(35) starter kit................................................................ 120
LAMICTAL XR - lamotrigine tab sr 24hr 100 mg.............120
LAMICTAL XR - lamotrigine tab sr 24hr 25 (14) & 50 mg
(14) & 100 mg(7) kit...................................................... 120
LAMICTAL XR - lamotrigine tab sr 24hr 25 mg...............120
LAMICTAL XR - lamotrigine tab sr 24hr 25 mg (21) & 50
mg (7) titration kit.......................................................... 120
LAMICTAL XR - lamotrigine tab sr 24hr 50 (14) & 100
mg(14) & 200 mg(7) kit................................................. 120
LAMICTAL XR - lamotrigine tab sr 24hr 50 mg...............120
LAMISIL SPRAY - terbinafine hcl soln 1%......................166
LAMISIL - terbinafine hcl oral granules packet 125 mg....... 7
LAMISIL - terbinafine hcl oral granules packet 187.5
mg...................................................................................... 7
LAMISIL - terbinafine hcl tab 250 mg................................. 7
lamivudine oral soln 10 mg/ml (Epivir)........................... 9
lamivudine tab 100 mg (hbv) (Epivir hbv)....................... 9
lamivudine tab 150 mg (Epivir)........................................ 9
lamivudine tab 300 mg (Epivir)........................................ 9
lamivudine-zidovudine tab 150-300 mg (Combivir)........ 9
lamotrigine orally disintegrating tab 100 mg (Lamictal
odt)................................................................................ 120
odt)................................................................................ 120
odt)................................................................................ 120
odt)................................................................................ 120
lamotrigine tab 100 mg (Lamictal)............................... 120
lamotrigine tab 25 mg (Lamictal)................................. 120
lamotrigine tab chewable dispersible 25 mg (Lamictal
chewable di)................................................................. 120
lamotrigine tab chewable dispersible 5 mg (Lamictal
chewable di)................................................................. 120
lamotrigine tab sr 24hr 100 mg (Lamictal xr)..............120
lamotrigine tab sr 24hr 25 mg (Lamictal xr)................120
lamotrigine tab sr 24hr 50 mg (Lamictal xr)................120
LANCET DEVICE ADJUSTABLE - lancet devices .........206
LANCET DEVICE WITH EJECTO - lancet devices ........206
LANCETS 26G TWIST TOP - lancets ........................... 206
LANCETS 28G - lancets ................................................206
LANCETS 30G/TWIST TOP - lancets ............................206
LANCETS 30G - lancets ................................................206
LANCETS 33G UNIVERSAL DES - lancets ...................206
LANCETS - lancets ........................................................206
LANCETS MICRO THIN 33G - lancets ..........................206
LANCETS SAFETY SEAL 21G - lancets ....................... 206
LANCETS SUPER THIN 28G - lancets ......................... 206
LANCETS THIN - lancets .............................................. 206
LANCETS THIN - lancets .............................................. 206
LANCETS TWIST TOP - lancets ................................... 206
LANCETS ULTRA FINE - lancets ..................................206
LANCETS ULTRA THIN 30G - lancets ..........................206
LANCETS ULTRA THIN - lancets ..................................206
LANCING DEVICE ADJUSTABLE - lancet devices ....... 206
LANCING DEVICE - lancet devices ...............................206
lanolin............................................................................. 234
LANOLIN ANHYDROUS - lanolin anhydrous..................234
LANOLIN - lanolin anhydrous oil.....................................234
LANOXIN - digoxin tab 125 mcg (0.125 mg).....................40
LANOXIN - digoxin tab 187.5 mcg (0.1875 mg)................40
LANOXIN - digoxin tab 250 mcg (0.25 mg)...................... 40
LANOXIN - digoxin tab 62.5 mcg (0.0625 mg)..................40
lansoprazole cap delayed release 15 mg
(Prevacid)........................................................................72
lansoprazole cap delayed release 30 mg
(Prevacid)........................................................................72
LANTUS - insulin glargine inj 100 unit/ml......................... 32
LANTUS SOLOSTAR - insulin glargine soln pen-injector
100 unit/ml....................................................................... 32
LANZO - lancet devices .................................................206
LASIX - furosemide tab 20 mg..........................................56
LASTACAFT - alcaftadine ophth soln 0.25%.................. 152
latanoprost ophth soln 0.005% (Xalatan).................... 152
LATRIX XM - urea in zinc undecylenate-lactic acid vehicle
emulsion 45%................................................................ 166
LATUDA - lurasidone hcl tab 120 mg............................... 91
LATUDA - lurasidone hcl tab 20 mg................................. 91
LAVOCLEN-4 CREAMY WASH - benzoyl peroxide liq
4%..................................................................................166
LAVOCLEN-8 CREAMY WASH - benzoyl peroxide liq
8%..................................................................................166
LAZANDA - fentanyl citrate nasal spray 100 mcg/act (base
equiv)............................................................................. 107
LAZANDA - fentanyl citrate nasal spray 400 mcg/act (base
equiv)............................................................................. 107
LDR BLOOD GLUCOSE TRUETES - blood glucose
LEADER ADVANCED LANCING D - lancet devices ......206
LEADER INSULIN SYRINGE/0. - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................206
291
2015
u-100 0.3 ml 30 x 5/16".................................................206
u-100 0.3 ml 31 x 5/16".................................................207
u-100 1/2 ml 28 x 1/2"...................................................207
u-100 1/2 ml 29 x 1/2"...................................................207
u-100 1/2 ml 30 x 5/16".................................................207
u-100 1/2 ml 31 x 5/16".................................................206
LEADER INSULIN SYRINGE/1M - insulin syringe/needle
u-100 1 ml 28 x 1/2"......................................................207
u-100 1 ml 29 x 1/2"......................................................207
u-100 1 ml 30 x 5/16"....................................................207
u-100 1 ml 31 x 5/16"....................................................207
LEADER LANCETS COLORED - lancets ...................... 207
LEADER SUPER THIN LANCET - lancets .................... 207
LEADER THIN LANCETS - lancets ............................... 207
LEADER UNIFINE PENTIPS/MI - insulin pen needle 31 g
x 5 mm (3/16")...............................................................207
LEADER UNIFINE PENTIPS/NA - insulin pen needle 32 g
x 4 mm (5/32")...............................................................207
LEADER UNIFINE PENTIPS/PL - insulin pen needle 32 g
x 4 mm (5/32")...............................................................207
LEADER UNIFINE PENTIPS PL - insulin pen needle 31 g
x 5 mm (3/16")...............................................................207
LEADER UNIFINE PENTIPS PL - insulin pen needle 31 g
x 8 mm (1/3" or 5/16")...................................................207
LECITHIN ORGANOGEL - premium lecithin organogel
base gel......................................................................... 234
leflunomide tab 10 mg (Arava).....................................113
leflunomide tab 20 mg (Arava).....................................113
LENVIMA 10MG DAILY DOSE - lenvatinib cap therapy
pak 10 mg (10 mg daily dose)........................................ 16
pack 10 & 4 mg (14 mg daily dose)................................ 16
pack 10 (2) mg (20 mg daily dose)................................. 16
pack 10 (2) & 4 mg (24 mg daily dose)........................... 16
LESCOL - fluvastatin sodium cap 20 mg.......................... 59
LESCOL - fluvastatin sodium cap 40 mg.......................... 59
LESCOL XL - fluvastatin sodium tab sr 24 hr 80 mg.........59
LETAIRIS - ambrisentan tab 10 mg.................................. 61
LETAIRIS - ambrisentan tab 5 mg.................................... 61
letrozole tab 2.5 mg (Femara)........................................ 16
LEUCOVORIN CALCIUM - leucovorin calcium tab 10
mg.................................................................................... 16
LEUCOVORIN CALCIUM - leucovorin calcium tab 15
mg.................................................................................... 16
leucovorin calcium tab 25 mg........................................16
292
leucovorin calcium tab 5 mg..........................................16
LEUKERAN - chlorambucil tab 2 mg................................ 16
LEUKINE - sargramostim inj 500 mcg/ml........................145
LEUKINE - sargramostim lyophilized for inj 250 mcg...... 145
leuprolide acetate inj kit 5 mg/ml.................................. 16
LEVACET - aspirin-apap-salicylamide-caffeine tab
500-250-150-32.5 mg.................................................... 103
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
(Xopenex)........................................................................68
(Xopenex)........................................................................68
(Xopenex)........................................................................68
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base
equiv).............................................................................. 68
LEVAQUIN - levofloxacin oral soln 25 mg/ml......................6
LEVAQUIN - levofloxacin tab 250 mg.................................6
LEVATOL - penbutolol sulfate tab 20 mg......................... 42
LEVBID - hyoscyamine sulfate tab sr 12hr 0.375 mg........72
LEVEMIR FLEXPEN - insulin detemir soln pen-injector
100 unit/ml....................................................................... 32
LEVEMIR FLEXTOUCH - insulin detemir soln pen-injector
100 unit/ml....................................................................... 32
LEVEMIR - insulin detemir inj 100 unit/ml.........................32
levetiracetam oral soln 100 mg/ml (Keppra)............... 120
levetiracetam tab 1000 mg (Keppra)............................121
levetiracetam tab 250 mg (Keppra)..............................121
levetiracetam tab sr 24hr 500 mg (Keppra xr)............ 120
levetiracetam tab sr 24hr 750 mg (Keppra xr)............ 120
LEVOBUNOLOL HCL - levobunolol hcl ophth soln
0.25%.............................................................................152
levobunolol hcl ophth soln 0.5% (Betagan)................ 152
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 38
levocarnitine tab 330 mg (Carnitor)...............................38
levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5
mg/ml) (Xyzal)................................................................ 62
levocetirizine dihydrochloride tab 5 mg (Xyzal)........... 62
levofloxacin ophth soln 0.5%.......................................152
levofloxacin oral soln 25 mg/ml (Levaquin)....................6
levofloxacin tab 250 mg (Levaquin)................................ 6
LEVOMEFOLATE CALCIUM/ACET - l-methylfolate-algaeb12-acetylcyst tab 6-90.314-2-600mg .......................... 141
LEVOMEFOLATE CALCIUM/ALGA - l-methylfolate-algae
cap 15-90.314 mg ........................................................ 141
LEVOMEFOLATE CALCIUM/ALGA - l-methylfolate-algae
cap 7.5-90.314 mg ....................................................... 141
LEVOMEFOLATE CALCIUM/PYRI - l-methylfolate-algaevit b12-b6 cap 3-90.314-2-35 mg ................................. 141
LEVOMEFOLATE DHA - prenat w/fe fum-l methylfolate-fadha cap 27-1.13-0.4 mg ...............................................130
2015
levonorgestrel & ethinyl estradiol (91-day) tab
0.15-0.03 mg................................................................... 25
levonorgestrel & ethinyl estradiol tab 0.15 mg-30
mcg..................................................................................25
levonorgestrel & ethinyl estradiol tab 0.1 mg-20
mcg..................................................................................25
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg................................ 25
levonorgestrel-ethinyl estradiol (continuous) tab 90-20
mcg..................................................................................25
LEVONORGESTREL - levonorgestrel tab 0.75 mg.......... 25
levonorgestrel tab 1.5 mg (Plan b one-step).................25
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab
0.01mg(7) (Loseasonique)............................................ 25
levonorg-eth est tab 0.15-0.03mg(84) & eth est tab
0.01mg(7) (Seasonique)................................................ 25
LEVORPHANOL TARTRATE - levorphanol tartrate tab 2
mg.................................................................................. 107
levothyroxine sodium tab 100 mcg (Synthroid)........... 33
levothyroxine sodium tab 25 mcg (Synthroid)............. 33
LEVSIN/SL - hyoscyamine sulfate tab sl 0.125 mg........... 72
LEVSIN - hyoscyamine sulfate tab 0.125 mg....................72
LEXAPRO - escitalopram oxalate soln 5 mg/5ml (base
equiv)............................................................................... 86
LEXAPRO - escitalopram oxalate tab 10 mg (base
equiv)............................................................................... 85
equiv)............................................................................... 86
equiv)............................................................................... 85
LEXIVA - fosamprenavir calcium susp 50 mg/ml (base
equiv)................................................................................. 9
LEXIVA - fosamprenavir calcium tab 700 mg (base
equiv)................................................................................. 9
LIALDA - mesalamine tab delayed release 1.2 gm........... 77
LIBERTY CONTROL SOLUTION - blood glucose
LIBERTY CONTROL SOLUTION - blood glucose
LIBERTY GLUCOSE CONTROL L - blood glucose
LIBERTY GLUCOSE CONTROL M - blood glucose
LIBERTY GLUCOSE CONTROL N - blood glucose
LIBERTY MEDICAL LANCETS 3 - lancets .................... 207
LIBERTY MINI LANCING DEVI - lancet devices ............207
LIBERTY NEXT GENERATION B - glucose blood test
strip................................................................................ 179
LIBERTY TEST STRIPS - glucose blood test strip......... 179
LIBRAX - clidinium & chlordiazepoxide cap 2.5-5 mg....... 72
LIDOCAINE/PRILOCAINE - lidocaine-prilocaine kit
2.5-2.5%.........................................................................166
LIDOCAINE AND TETRACAINE - lidocaine-tetracaine
cream 7-7%................................................................... 166
lidocaine hcl cream 3%................................................ 166
lidocaine hcl gel 2%......................................................166
LIDOCAINE HCL-HYDROCORTIS - lidocainehydrocortisone acetate rectal gel 2.8-0.55%................. 157
LIDOCAINE HCL - lidocaine hcl lotion 3%......................166
lidocaine hcl soln 4% (Xylocaine)................................166
lidocaine hcl viscous soln 2%..................................... 155
lidocaine-hydrocortisone acetate rectal cream
3-0.5%............................................................................157
lidocaine-hydrocortisone acetate rectal cream kit
2-2%...............................................................................157
3-0.5%............................................................................157
3-1%...............................................................................157
lidocaine-hydrocortisone acetate rectal gel kit
3-2.5%............................................................................157
lidocaine oint 5%...........................................................166
lidocaine patch 5% (Lidoderm).................................... 166
lidocaine-prilocaine cream 2.5-2.5% (Emla)................166
LIDOCIN - lidocaine hcl gel 3%...................................... 166
LIDODERM - lidocaine patch 5%....................................166
LIDOPIN - lidocaine hcl cream 3.25%.............................166
LIDORX - lidocaine hcl gel 3%....................................... 166
LIDOVEX - lidocaine cream 3.75%................................. 166
LIDOVIN - lidocaine hcl cream 3.95%.............................166
LIDOZOL - lidocaine hcl cream 3.75%............................166
LIFESCAN UNISTIK 2 DEEP P - lancets ...................... 207
LIFESCAN UNISTIK II LANCE - lancets ........................207
LILETTA - levonorgestrel releasing iud 18.6 mcg/day (52
mg total)...........................................................................25
LIMBREL250 - flavocoxid-citrated zinc bisglycinate cap
250-50 mg..................................................................... 142
LIMBREL500 - flavocoxid-citrated zinc bisglycinate cap
500-50 mg..................................................................... 142
LIMBREL - flavocoxid cap 250 mg..................................141
LIMBREL - flavocoxid cap 500 mg..................................141
LINCOCIN - lincomycin hcl inj 300 mg/ml......................... 13
lindane lotion 1%...........................................................166
lindane shampoo 1%.................................................... 166
LINZESS - linaclotide cap 145 mcg.................................. 77
LINZESS - linaclotide cap 290 mcg.................................. 77
liothyronine sodium tab 25 mcg (Cytomel)...................33
liothyronine sodium tab 50 mcg (Cytomel)...................33
liothyronine sodium tab 5 mcg (Cytomel).....................33
LIPITOR - atorvastatin calcium tab 10 mg (base
equivalent)....................................................................... 59
293
2015
equivalent)....................................................................... 59
equivalent)....................................................................... 59
equivalent)....................................................................... 59
LIPOFEN - fenofibrate cap 150 mg...................................59
LIPOFEN - fenofibrate cap 50 mg.................................... 59
LIPTRUZET - ezetimibe-atorvastatin tab 10-10 mg.......... 59
lisinopril & hydrochlorothiazide tab 10-12.5 mg
(Zestoretic)..................................................................... 52
lisinopril & hydrochlorothiazide tab 20-12.5 mg
(Zestoretic)..................................................................... 52
lisinopril & hydrochlorothiazide tab 20-25 mg
(Zestoretic)..................................................................... 52
lisinopril tab 10 mg (Prinivil)..........................................52
lisinopril tab 2.5 mg (Zestril).......................................... 52
lisinopril tab 20 mg (Prinivil)..........................................52
lisinopril tab 30 mg (Zestril)........................................... 52
lisinopril tab 40 mg (Zestril)........................................... 52
lisinopril tab 5 mg (Prinivil)............................................52
LISTERINE ESSENTIAL CARE - sod monofluorophoseucal-men-methyl sal-thymol paste 0.76% ...................155
LISTERINE ESSENTIAL CARE - sod monofluorophospheucal-men-methyl sal-thymol gel 0.76% .......................155
LISTERINE RESTORING - sodium fluoride rinse 0.0221%
(0.01% f)........................................................................ 155
LISTERINE SMART RINSE ANT - sodium fluoride rinse
0.02%.............................................................................155
LISTERINE SMART RINSE - sodium fluoride rinse
0.0221% (0.01% f).........................................................155
LISTERINE TOOTH DEFENSE - sodium fluoride rinse
0.0221% (0.01% f).........................................................155
LISTERINE TOTAL CARE PLUS - sodium fluoride rinse
0.0221% (0.01% f).........................................................155
LISTERINE TOTAL CARE - sodium fluoride rinse
0.0221% (0.01% f).........................................................155
LISTERINE TOTAL CARE ZERO - sodium fluoride rinse
0.02%.............................................................................156
LISTERINE WHITENING/RESTO - sodium fluoride rinse
0.0221% (0.01% f).........................................................156
LITEAIRE - spacer/aerosol-holding chambers - device
....................................................................................... 207
LITETOUCH INSULIN SYRINGE - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................207
u-100 0.3 ml 30 x 5/16".................................................207
u-100 0.3 ml 31 x 5/16".................................................208
u-100 1/2 ml 28 x 1/2"...................................................208
u-100 1/2 ml 29 x 1/2"...................................................208
294
u-100 1/2 ml 30 x 5/16".................................................208
u-100 1/2 ml 31 x 5/16".................................................208
u-100 1 ml 28 x 1/2"......................................................208
u-100 1 ml 29 x 1/2"......................................................208
u-100 1 ml 30 x 5/16"....................................................208
u-100 1 ml 31 x 5/16"....................................................208
LITE TOUCH LANCETS - lancets ................................. 207
LITETOUCH LANCETS MICRO T - lancets ...................208
LITE TOUCH LANCING DEVICE - lancet devices .........207
LITE TOUCH LANCING PEN - lancet devices ...............207
LITE TOUCH PEN NEEDLES/31 - insulin pen needle 31 g
x 5 mm (3/16")...............................................................207
LITETOUCH PEN NEEDLES 29G - insulin pen needle 29
g x 12.7 mm.................................................................. 208
g x 6 mm (1/4")............................................................. 208
g x 8 mm (1/3" or 5/16")................................................208
lithium carbonate cap 150 mg (Lithium carbonate)......91
lithium carbonate cap 300 mg....................................... 91
lithium carbonate cap 600 mg (Lithium carbonate)......91
LITHIUM CARBONATE - lithium carbonate cap 150
mg.................................................................................... 91
LITHIUM CARBONATE - lithium carbonate cap 600
mg.................................................................................... 91
lithium carbonate tab 300 mg........................................ 91
lithium carbonate tab cr 300 mg (Lithobid)...................91
lithium carbonate tab cr 450 mg....................................91
LITHIUM - lithium oral solution 8 meq/5ml........................ 91
LITHOBID - lithium carbonate tab cr 300 mg.................... 91
LITHOSTAT - acetohydroxamic acid tab 250 mg..............81
LIVALO - pitavastatin calcium tab 1 mg (base equiv)........59
LIVE BETTER ADVANCED LANC - lancet devices ....... 208
LIVE BETTER LANCET SUPER - lancets ..................... 208
LIVE BETTER LANCET ULTRA - lancets ......................208
LIVE BETTER PEN NEEDLES 2 - insulin pen needle 29 g
x 12 mm (1/2")...............................................................208
x 6 mm (1/4").................................................................208
x 8 mm (1/3" or 5/16")...................................................208
L-METHYL-B6-B12 - l-methylfolate w/ vit b6-vit b12 tab
3-35-2 mg ..................................................................... 141
L-METHYLFOLATE CA/ME-CBL/ - l-methylfolatemethylcobalamin-acetylcyst tab 6-2-600 mg ................ 141
L-METHYLFOLATE CA/P-5-P/M - l-methylfolate-algae-vit
b12-b6 cap 3-90.314-2-35 mg ......................................141
2015
L-METHYLFOLATE CA/P-5-P/M - l-methylfolate w/ vit b6vit b12 tab 3-35-2 mg ...................................................141
L-METHYLFOLATE CALCIUM - l-methylfolate tab 15 mg
....................................................................................... 141
L-METHYLFOLATE CALCIUM - l-methylfolate tab 7.5 mg
....................................................................................... 141
L-METHYLFOLATE CA ME-CBL - l-methylfolate-algaeb12-acetylcyst tab 6-90.314-2-600mg .......................... 141
L-METHYLFOLATE FORMULA 15 - l-methylfolate-algae
cap 15-90.314 mg ........................................................ 141
L-METHYLFOLATE FORMULA 7. - l-methylfolate-algae
cap 7.5-90.314 mg ....................................................... 141
L-METHYLFOLATE FORTE - l-methylfolate-algae cap
15-90.314 mg ............................................................... 141
L-METHYLFOLATE FORTE - l-methylfolate-algae cap
7.5-90.314 mg .............................................................. 141
L-METHYLFOLATE - l-methylfolate tab 15 mg .............. 141
L-METHYLFOLATE - l-methylfolate tab 7.5 mg ............. 141
L-METHYLFOLATE PNV DHA - prenat w/fe fum-l
methylfolate-fa-dha cap 27-1.13-0.4 mg .......................130
L-METHYL-MC - l-methylfolate w/ vit b12-vit b6-vit b2 tab
6-1-50-5 mg ..................................................................141
L-METHYL-MC NAC - l-methylfolate-methylcobalaminacetylcyst tab 6-2-600 mg ............................................ 141
LMTHF/PYRIDOXINE HCL/CYAN - l-methylfolate w/ vit
b6-vit b12 tab 1.13-25-2 mg .........................................142
LO/OVRAL-28 - norgestrel & ethinyl estradiol tab 0.3
mg-30 mcg.......................................................................25
LO/OVRAL - norgestrel & ethinyl estradiol tab 0.3 mg-30
mcg.................................................................................. 25
LOCOID - hydrocortisone butyrate cream 0.1%..............166
LOCOID - hydrocortisone butyrate lotion 0.1%............... 166
LOCOID - hydrocortisone butyrate oint 0.1%..................166
LOCOID - hydrocortisone butyrate soln 0.1%................. 166
LOCOID LIPOCREAM - hydrocortisone butyrate
hydrophilic lipo base cream 0.1%..................................166
LODOSYN - carbidopa tab 25 mg.................................. 124
LOESTRIN 1/20-21 - norethindrone ace & ethinyl estradiol
tab 1 mg-20 mcg............................................................. 25
LOESTRIN 1.5/30-21 - norethindrone ace & ethinyl
estradiol tab 1.5 mg-30 mcg............................................25
LOESTRIN FE 1/20 - norethindrone ace & ethinyl
estradiol-fe tab 1 mg-20 mcg.......................................... 25
LOESTRIN FE 1.5/30 - norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg....................................... 25
LOFIBRA - fenofibrate micronized cap 134 mg.................59
LOFIBRA - fenofibrate micronized cap 200 mg.................59
LOFIBRA - fenofibrate micronized cap 67 mg...................59
LOFIBRA - fenofibrate tab 160 mg................................... 59
LOFIBRA - fenofibrate tab 54 mg..................................... 59
LO LOESTRIN FE - norethin-eth estradiol-fe tab 1 mg-10
mcg (24)/10 mcg (2)........................................................25
LOMOTIL - diphenoxylate w/ atropine tab 2.5-0.025
mg.................................................................................... 70
LOMUSTINE - lomustine cap 100 mg...............................17
LOMUSTINE - lomustine cap 10 mg.................................16
LOMUSTINE - lomustine cap 40 mg.................................17
LONGS INSULIN SYRINGE/0.5 - insulin syringe/needle
u-100 1/2 ml 31 x 5/16".................................................208
LONGS LANCETS STANDARD - lancets ......................208
LONGS LANCETS THIN - lancets .................................208
LONGS LANCETS ULTRA THIN - lancets .................... 208
loperamide hcl cap 2 mg................................................70
loperamide hcl tab 2 mg.................................................71
LOPID - gemfibrozil tab 600 mg....................................... 59
LOPRESSOR HCT - metoprolol & hydrochlorothiazide tab
100-25 mg....................................................................... 52
LOPRESSOR HCT - metoprolol & hydrochlorothiazide tab
50-25 mg......................................................................... 52
LOPRESSOR - metoprolol tartrate tab 100 mg.................42
LOPRESSOR - metoprolol tartrate tab 50 mg...................42
LOPROX SHAMPOO - ciclopirox shampoo 1%.............. 167
lorazepam conc 2 mg/ml (Lorazepam intensol)............82
LORAZEPAM INTENSOL - lorazepam conc 2 mg/ml....... 82
lorazepam tab 0.5 mg (Ativan)....................................... 82
lorazepam tab 1 mg (Ativan).......................................... 82
lorazepam tab 2 mg (Ativan).......................................... 82
LORTAB - hydrocodone-acetaminophen soln 7.5-500
mg/15ml......................................................................... 107
LORTUSS EX - pseudoephedrine w/ cod-gg liquid
30-10-100 mg/5ml............................................................64
LORZONE - chlorzoxazone tab 375 mg......................... 126
LORZONE - chlorzoxazone tab 750 mg......................... 126
losartan potassium & hydrochlorothiazide tab
100-12.5 mg (Hyzaar).....................................................52
losartan potassium & hydrochlorothiazide tab 100-25
mg (Hyzaar).................................................................... 52
losartan potassium & hydrochlorothiazide tab 50-12.5
mg (Hyzaar).................................................................... 52
losartan potassium tab 100 mg (Cozaar)...................... 52
losartan potassium tab 25 mg (Cozaar)........................ 52
losartan potassium tab 50 mg (Cozaar)........................ 52
LOSEASONIQUE - levonorg-eth est tab 0.1-0.02mg(84) &
eth est tab 0.01mg(7)...................................................... 25
LOTEMAX - loteprednol etabonate ophth gel 0.5%........ 152
LOTEMAX - loteprednol etabonate ophth oint 0.5%....... 152
LOTEMAX - loteprednol etabonate ophth susp 0.5%......152
LOTENSIN - benazepril hcl tab 10 mg..............................52
LOTENSIN HCT - benazepril & hydrochlorothiazide tab
10-12.5 mg...................................................................... 52
20-12.5 mg...................................................................... 52
20-25 mg......................................................................... 52
LOTREL - amlodipine besylate-benazepril hcl cap 10-20
mg.................................................................................... 52
mg.................................................................................... 52
LOTREL - amlodipine besylate-benazepril hcl cap 2.5-10
mg.................................................................................... 52
295
2015
mg.................................................................................... 52
mg.................................................................................... 52
mg.................................................................................... 52
LOTRISONE - clotrimazole w/ betamethasone cream
1-0.05%..........................................................................167
LOTRONEX - alosetron hcl tab 0.5 mg (base equiv)........ 77
LOTRONEX - alosetron hcl tab 1 mg (base equiv)........... 77
LOUTREX - antiseborrheic products misc - cream ........ 167
lovastatin tab 10 mg....................................................... 59
lovastatin tab 20 mg (Mevacor)..................................... 59
lovastatin tab 40 mg (Mevacor)..................................... 59
LOVAZA - omega-3-acid ethyl esters cap 1 gm................59
LOVENOX - enoxaparin sodium inj 100 mg/ml............... 148
LOVENOX - enoxaparin sodium inj 120 mg/0.8ml.......... 148
LOVENOX - enoxaparin sodium inj 150 mg/ml............... 148
LOVENOX - enoxaparin sodium inj 300 mg/3ml............. 148
LOVENOX - enoxaparin sodium inj 30 mg/0.3ml............ 148
loxapine succinate cap 10 mg....................................... 91
loxapine succinate cap 5 mg......................................... 91
LOZI-FLUR - sodium fluoride lozenge 1 mg f (from 2.2 mg
naf).................................................................................139
LUFYLLIN - dyphylline tab 400 mg................................... 68
LUGOLS STRONG IODINE - iodine solution .................175
LUMIGAN - bimatoprost ophth soln 0.01%..................... 152
LUNESTA - eszopiclone tab 1 mg.................................... 94
LUPANETA PACK - leuprolide (1 mon) inj 3.75 mg &
norethindrone tab 5 mg kit.............................................. 38
LUPANETA PACK - leuprolide (3 mon) inj 11.25 mg &
norethindrone tab 5 mg kit.............................................. 38
LUPRON DEPOT - leuprolide acetate (3 month) for inj kit
11.25 mg..........................................................................17
22.5 mg............................................................................17
30 mg...............................................................................17
45 mg...............................................................................17
LUPRON DEPOT - leuprolide acetate for inj kit 3.75
mg.................................................................................... 17
LUPRON DEPOT - leuprolide acetate for inj kit 7.5
mg.................................................................................... 17
LUPRON DEPOT-PED - leuprolide acetate (3 month) for
inj pediatric kit 11.25 mg................................................. 38
LUPRON DEPOT-PED - leuprolide acetate (3 month) for
inj pediatric kit 30 mg...................................................... 38
296
LUPRON DEPOT-PED - leuprolide acetate for inj pediatric
kit 11.25 mg.....................................................................38
kit 15 mg..........................................................................38
kit 7.5 mg.........................................................................38
LURIDE - sodium fluoride chew tab 0.25 mg f (from 0.55
mg naf).......................................................................... 139
LURIDE - sodium fluoride chew tab 0.5 mg f (from 1.1 mg
naf).................................................................................139
LURIDE - sodium fluoride chew tab 1 mg f (from 2.2 mg
naf).................................................................................139
LURIDE - sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml
naf).................................................................................139
LUXIQ - betamethasone valerate aerosol foam
0.12%.............................................................................167
LUZU - luliconazole cream 1%....................................... 167
LYCELLE - nit remover - gel ..........................................167
LYNPARZA - olaparib cap 50 mg..................................... 17
LYRICA - pregabalin cap 100 mg................................... 121
LYRICA - pregabalin cap 25 mg..................................... 121
LYRICA - pregabalin soln 20 mg/ml................................121
LYSODREN - mitotane tab 500 mg.................................. 17
LYSTEDA - tranexamic acid tab 650 mg........................ 149
LYTENSOPRIL-90 KIT - lisinopril tab 20 mg & dietary
LYTENSOPRIL-90 - lisinopril tab 20 mg & dietary
LYTENSOPRIL KIT - lisinopril tab 20 mg & dietary
M
MACNATAL CN DHA - prenatal w/o a w/fe cbn-dss-fa-dha
cap 28-1-250 mg .......................................................... 130
MACROBID - nitrofurantoin monohydrate macrocrystalline
cap 100 mg..................................................................... 78
MACRODANTIN - nitrofurantoin macrocrystalline cap 100
mg.................................................................................... 78
mg.................................................................................... 78
mg.................................................................................... 78
MAGELLAN INSULIN SAFETY S - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................208
u-100 0.3 ml 30 x 5/16".................................................208
u-100 1/2 ml 29 x 1/2"...................................................208
u-100 1/2 ml 30 x 5/16".................................................208
2015
u-100 1 ml 29 x 1/2"......................................................208
u-100 1 ml 30 x 5/16"....................................................208
MAGNEBIND 400 - magnesium-calcium-folic acid tab
400-200-1 mg................................................................ 139
MALARONE - atovaquone-proguanil hcl tab 250-100
mg.................................................................................... 13
MALARONE - atovaquone-proguanil hcl tab 62.5-25
mg.................................................................................... 13
malathion lotion 0.5% (Ovide)......................................167
MAL PATCH - lidocaine-menthol patch 4-5%................. 167
MAPROTILINE HCL - maprotiline hcl tab 25 mg.............. 86
MAR-COF BP - pseudoephedrine-bromphen-codeine liqd
30-2-7.5 mg/5ml.............................................................. 64
MAR-COF CG EXPECTORANT - guaifenesin-codeine
liquid 225-7.5 mg/5ml...................................................... 64
MARINOL - dronabinol cap 10 mg....................................74
MARINOL - dronabinol cap 2.5 mg...................................74
MARINOL - dronabinol cap 5 mg......................................74
MARNATAL-F - prenatal w/o vit a w/ fe polysac cmplx-fa
cap 60-1 mg ................................................................. 130
MARPLAN - isocarboxazid tab 10 mg.............................. 86
MATULANE - procarbazine hcl cap 50 mg....................... 17
MAVIK - trandolapril tab 1 mg.......................................... 52
MAXALT-MLT - rizatriptan benzoate orally disintegrating
tab 10 mg...................................................................... 116
MAXALT-MLT - rizatriptan benzoate orally disintegrating
tab 5 mg........................................................................ 116
MAXALT - rizatriptan benzoate tab 10 mg...................... 116
MAXALT - rizatriptan benzoate tab 5 mg........................ 116
MAXARON FORTE - fe gly-fe fum-vit c-vit b12methylfolate tab ............................................................ 145
MAXFE - iron-fa-vit b12-biotin-vit c-docusate-mg-zn tab
160-1 mg ...................................................................... 145
MAXI-COMFORT INSULIN SYRI - insulin syringe/needle
u-100 1/2 ml 28 x 1/2"...................................................208
MAXI-COMFORT INSULIN SYRI - insulin syringe/needle
u-100 1 ml 28 x 1/2"......................................................209
MAXIDEX - dexamethasone ophth susp 0.1%................152
MAXIMA BLOOD GLUCOSE MONI - blood glucose
MAXIMA BLOOD GLUCOSE TEST - glucose blood test
strip................................................................................ 179
MAXIMA CONTROL SOLUTION/N - blood glucose
MAXIMA CONTROL SOLUTION - blood glucose
MAXIMA METER KIT - blood glucose monitoring kit w/
device ........................................................................... 209
MAXIMA STARTER KIT - blood glucose monitoring kit w/
device ........................................................................... 209
MAXITROL - neomycin-polymyxin-dexamethasone ophth
oint 0.1%........................................................................152
MAXITROL - neomycin-polymyxin-dexamethasone ophth
susp 0.1%......................................................................152
MAXZIDE-25 - triamterene & hydrochlorothiazide tab
37.5-25 mg...................................................................... 56
MAXZIDE - triamterene & hydrochlorothiazide tab 75-50
mg.................................................................................... 56
MB HYDROGEL - dermatological products misc - kit .....167
meclizine hcl tab 12.5 mg...............................................74
meclizine hcl tab 25 mg..................................................74
MECLOFENAMATE SODIUM - meclofenamate sodium
cap 100 mg................................................................... 113
MECLOFENAMATE SODIUM - meclofenamate sodium
cap 50 mg..................................................................... 113
MEDICHOICE PRE-SET SAFETY - lancets .................. 209
MEDICHOICE SAFETY LANCET - lancets ....................209
MEDICINE SHOPPE LANCETS - lancets ......................209
MEDICINE SHOPPE LANCETS T - lancets .................. 209
MEDICINE SHOPPE PEN NEEDL - insulin pen needle 29
g x 12 mm (1/2")........................................................... 209
g x 6 mm (1/4")............................................................. 209
g x 8 mm (1/3" or 5/16")................................................209
MEDIC INSULIN SYRINGE/0.3 - insulin syringe/needle
u-100 0.3 ml 30 x 5/16".................................................209
MEDIC INSULIN SYRINGE/0.5 - insulin syringe/needle
u-100 1/2 ml 30 x 5/16".................................................209
MEDI-DERM/L-RX - lidocaine-capsaicin-menthol-methyl
sal cream 2-0.035-5-20%.............................................. 167
MEDI-DERM-RX - capsaicin-menthol-methyl salicylate
cream 0.035-5-20%....................................................... 167
MEDI-LANCE LANCETS - lancets .................................209
MEDISENSE GLUCOSE KETONE - blood glucose
MEDISENSE HIGH/LOW CONTRO - blood glucose
MEDISENSE HIGH/MID/LOW CO - blood glucose
MEDISENSE MID CONTROL SOL - blood glucose
MEDISENSE THIN LANCETS - lancets ........................ 209
MEDLANCE/EXTRA - lancets ........................................209
MEDLANCE/LITE - lancets ............................................ 209
MEDLANCE/UNIVERSAL - lancets ............................... 209
MEDLANCE PLUS/LITE 25G - lancets ..........................209
MEDLANCE PLUS EXTRA LANCE - lancets ................ 209
MEDLANCE PLUS LANCETS - lancets .........................209
MEDLANCE PLUS LANCETS LIT - lancets ...................209
MEDLANCE PLUS LITE LANCET - lancets ...................209
MEDLANCE PLUS SPECIAL LAN - lancets .................. 209
MEDLANCE PLUS SUPERLITE 3 - lancets .................. 209
MEDLANCE PLUS UNIVERSAL L - lancets .................. 209
MEDROL DOSEPAK - methylprednisolone tab 4 mg dose
pack................................................................................. 20
297
2015
MEDROL - methylprednisolone tab 16 mg....................... 19
MEDROL - methylprednisolone tab 2 mg......................... 19
MEDROL - methylprednisolone tab 32 mg....................... 19
MEDROX-RX - capsaicin-menthol-methyl salicylate oint
0.05-7-20%.................................................................... 167
medroxyprogesterone acetate im susp 150 mg/ml
(Depo-provera contrac)................................................. 25
medroxyprogesterone acetate tab 10 mg (Provera).....27
medroxyprogesterone acetate tab 2.5 mg
(Provera)......................................................................... 27
medroxyprogesterone acetate tab 5 mg (Provera).......27
mefenamic acid cap 250 mg (Ponstel)........................ 113
mefloquine hcl tab 250 mg.............................................13
MEGACE ES - megestrol acetate susp 625 mg/5ml......... 27
MEGACE ORAL - megestrol acetate susp 40 mg/ml........ 17
megestrol acetate susp 40 mg/ml (Megace oral)..........17
megestrol acetate tab 20 mg..........................................17
megestrol acetate tab 40 mg..........................................17
MEGRIX - capsaicin-menthol disk 0.0375-5%................ 167
MEIJER BLOOD GLUCOSE MONI - blood glucose
MEIJER BLOOD GLUCOSE TEST - glucose blood test
strip................................................................................ 179
MEIJER COLOR LANCETS UNIV - lancets ...................209
MEIJER LANCETS - lancets ..........................................209
MEIJER LANCETS THIN - lancets ................................ 209
MEIJER LANCETS UNIVERSAL - lancets .....................209
MEIJER PEN NEEDLES 29G X - insulin pen needle 29 g
x 12 mm (1/2")...............................................................209
x 6 mm (1/4").................................................................210
x 8 mm (1/3" or 5/16")...................................................210
MEIJER PREMIUM BLOOD GLUC - blood glucose
MEIJER PREMIUM BLOOD GLUC - glucose blood test
strip................................................................................ 179
MEIJER SUPER THIN LANCETS - lancets ................... 210
MEIJER TRUE2GO BLOOD GLUC - blood glucose
MEIJER TRUERESULT BLOOD G - blood glucose
MEIJER TRUETEST BLOOD GLU - glucose blood test
strip................................................................................ 179
MEIJER TRUETRACK BLOOD GL - blood glucose
MEIJER TRUETRACK BLOOD GL - glucose blood test
strip................................................................................ 179
MEKINIST - trametinib dimethyl sulfoxide tab 0.5 mg
(base equivalent)............................................................. 17
MEKINIST - trametinib dimethyl sulfoxide tab 2 mg (base
equivalent)....................................................................... 17
MELOXICAM COMFORT PAC - meloxicam tab 15 mg &
liniment topical gel kit.................................................... 113
298
MELOXICAM - meloxicam susp 7.5 mg/5ml................... 113
meloxicam tab 15 mg (Mobic)......................................113
meloxicam tab 7.5 mg (Mobic).....................................113
M-END MAX D - pseudoephedrine-dexbromphen-codeine
liqd 20-0.667-6 mg/5ml....................................................64
M-END PE - phenylephrine-bromphen w/ codeine liqd
3.33-1.33-6.33 mg/5ml.....................................................64
MENEST - esterified estrogens tab 0.3 mg.......................23
MENEST - esterified estrogens tab 0.625 mg...................23
MENEST - esterified estrogens tab 1.25 mg.....................23
MENEST - esterified estrogens tab 2.5 mg.......................23
MENOPUR - menotropins for subcutaneous inj 75
unit................................................................................... 38
MENOSTAR - estradiol td patch weekly 14 mcg/24hr.......23
MENTAX - butenafine hcl cream 1%.............................. 167
MENTHOCIN PATCH/LIDOCAINE - lidocaine-capsaicinmen-methyl sal patch 0.5-0.0375-5-20%.......................167
MENTHOLIX - lidocaine-menthol liquid spray 4-1%........167
MEPERIDINE HCL/PROMETHAZI - meperidine w/
promethazine cap 50-25 mg..........................................107
MEPERIDINE HCL - meperidine hcl oral soln 50
mg/5ml........................................................................... 107
meperidine hcl tab 100 mg (Demerol)......................... 107
meperidine hcl tab 50 mg (Demerol)........................... 107
MEPHYTON - phytonadione tab 5 mg............................ 128
meprobamate tab 200 mg...............................................82
meprobamate tab 400 mg...............................................83
MEPRON - atovaquone susp 750 mg/5ml........................ 14
mercaptopurine tab 50 mg (Purinethol)........................ 17
mesalamine enema 4 gm................................................77
mesalamine rectal enema 4 gm & cleanser wipe kit
(Rowasa)......................................................................... 76
MESNEX - mesna tab 400 mg..........................................17
MESTINON - pyridostigmine bromide syrup 60
mg/5ml........................................................................... 127
MESTINON - pyridostigmine bromide tab 60 mg............ 127
MESTINON TIMESPAN - pyridostigmine bromide tab cr
180 mg...........................................................................127
METADATE CD - methylphenidate hcl cap cr 10 mg........97
METAFOLBIC - l-methylfolate w/ vit b12-vit b6-vit b2 tab
6-1-50-5 mg ..................................................................142
METAFOLBIC PLUS - l-methylfolate-methylcobalaminacetylcyst tab 6-2-600 mg ............................................ 142
METAFOLBIC PLUS RF - l-methylfolate-algae-b12acetylcyst tab 6-90.314-2-600mg ................................. 142
METANX - l-methylfolate-algae-vit b12-b6 cap
3-90.314-2-35 mg .........................................................142
METANX - l-methylfolate w/ vit b6-vit b12 tab 3-35-2 mg
....................................................................................... 142
METAPROTERENOL SULFATE - metaproterenol sulfate
syrup 10 mg/5ml..............................................................68
2015
tab 10 mg........................................................................ 68
tab 20 mg........................................................................ 68
METAXALONE - metaxalone tab 400 mg.......................126
metaxalone tab 800 mg (Skelaxin)...............................126
metformin hcl tab 1000 mg (Glucophage).....................30
metformin hcl tab 500 mg (Glucophage)...................... 30
metformin hcl tab 850 mg (Glucophage)...................... 30
metformin hcl tab sr 24hr 500 mg (Glucophage xr)......30
metformin hcl tab sr 24hr 750 mg (Glucophage xr)......30
metformin hcl tab sr 24hr osmotic 1000 mg
(Fortamet)....................................................................... 30
metformin hcl tab sr 24hr osmotic 500 mg
(Fortamet)....................................................................... 30
methadone hcl conc 10 mg/ml (Methadose)............... 107
METHADONE HCL - methadone hcl inj 10 mg/ml.......... 107
METHADONE HCL - methadone hcl soln 10 mg/5ml..... 107
METHADONE HCL - methadone hcl soln 5 mg/5ml....... 107
methadone hcl soln 10 mg/5ml (Methadone hcl)........107
methadone hcl soln 5 mg/5ml (Methadone hcl)..........107
methadone hcl tab 10 mg (Dolophine)........................ 107
methadone hcl tab 5 mg (Dolophine hcl).................... 107
methadone hcl tab for oral susp 40 mg...................... 107
METHADOSE - methadone hcl conc 10 mg/ml.............. 107
METHADOSE SUGAR-FREE - methadone hcl conc 10
mg/ml............................................................................. 107
methamphetamine hcl tab 5 mg (Desoxyn).................. 97
methazolamide tab 25 mg (Neptazane)......................... 56
methazolamide tab 50 mg (Neptazane)......................... 56
methenamine hippurate tab 1 gm (Hiprex)................... 78
methenamine-hyosamine-meth blue-sod phos tab 81.6
mg (Urogesic-blue)........................................................ 78
methenamine-hyosc-meth blue-benz acid-phenyl sal
tab 81.6mg (Prosed/ds)................................................. 78
methenamine-hyosc-meth blue-sod phos-phen sal cap
118 mg ...........................................................................78
methenamine-hyosc-meth blue-sod phos-phen sal cap
120 mg ...........................................................................78
methenamine-hyosc-meth blue-sod phos-phen sal tab
81 mg .............................................................................78
methenamine-hyos-meth blue-sod phos-phen sal tab
81.6 mg ..........................................................................78
METHENAMINE MANDELATE - methenamine mandelate
tab 0.5 gm....................................................................... 78
methenamine mandelate tab 1 gm................................ 78
METHERGINE - methylergonovine maleate inj 0.2 mg/
ml..................................................................................... 35
METHERGINE - methylergonovine maleate tab 0.2
mg.................................................................................... 35
methimazole tab 10 mg (Tapazole)................................33
methimazole tab 5 mg (Tapazole)..................................33
METHITEST - methyltestosterone oral tab 10 mg.............21
methocarbamol tab 500 mg (Robaxin)........................ 126
methocarbamol tab 750 mg (Robaxin-750)................. 126
methotrexate sodium inj 25 mg/ml................................ 17
methotrexate sodium inj pf 25 mg/ml............................17
methotrexate sodium tab 2.5 mg (base equiv)............. 17
methoxsalen rapid cap 10 mg (Oxsoralen ultra)........ 167
methscopolamine bromide tab 2.5 mg (Pamine)..........72
methscopolamine bromide tab 5 mg (Pamine
forte)................................................................................72
METHYCLOTHIAZIDE - methyclothiazide tab 5 mg......... 56
METHYLDOPA/HYDROCHLOROTHI - methyldopa &
hydrochlorothiazide tab 250-15 mg................................. 52
METHYLDOPA/HYDROCHLOROTHI - methyldopa &
hydrochlorothiazide tab 250-25 mg................................. 53
methyldopa tab 250 mg.................................................. 52
methyldopa tab 500 mg.................................................. 52
methylergonovine maleate inj 0.2 mg/ml...................... 35
methylergonovine maleate tab 0.2 mg.......................... 35
METHYLFOL-ALGAE-B12-ACETY - l-methylfolate-algaeb12-acetylcyst tab 6-90.314-2-600mg .......................... 142
METHYLIN - methylphenidate hcl chew tab 10 mg...........97
METHYLIN - methylphenidate hcl chew tab 2.5 mg..........97
METHYLIN - methylphenidate hcl chew tab 5 mg.............97
METHYLIN - methylphenidate hcl soln 10 mg/5ml............97
METHYLIN - methylphenidate hcl soln 5 mg/5ml..............97
methylphenidate hcl cap cr 10 mg (Metadate cd).........97
methylphenidate hcl cap sr 24hr 20 mg (Ritalin la)...... 98
methylphenidate hcl chew tab 10 mg (Methylin).......... 98
methylphenidate hcl chew tab 2.5 mg (Methylin)......... 98
methylphenidate hcl chew tab 5 mg (Methylin)............ 98
METHYLPHENIDATE HCL ER - methylphenidate hcl tab
cr 10 mg.......................................................................... 98
sa osm 18 mg................................................................. 98
sa osm 27 mg................................................................. 98
sa osm 36 mg................................................................. 98
sa osm 54 mg................................................................. 98
methylphenidate hcl soln 10 mg/5ml (Methylin)...........98
methylphenidate hcl soln 5 mg/5ml (Methylin).............98
methylphenidate hcl tab 10 mg (Ritalin)....................... 98
methylphenidate hcl tab 20 mg (Ritalin)....................... 98
methylphenidate hcl tab 5 mg (Ritalin)......................... 98
methylphenidate hcl tab cr 20 mg (Ritalin sr)...............98
methylprednisolone tab 16 mg (Medrol)....................... 20
methylprednisolone tab 32 mg (Medrol)....................... 20
methylprednisolone tab 4 mg (Medrol)......................... 20
methylprednisolone tab 4 mg dose pack (Medrol
dosepak)......................................................................... 20
methylprednisolone tab 8 mg (Medrol)......................... 20
299
2015
METHYL SALICYLATE - methyl salicylate liquid ........... 167
METIPRANOLOL - metipranolol ophth soln 0.3%...........152
metoclopramide hcl orally disintegrating tab 5 mg
(Metozolv odt)................................................................ 77
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml).........77
metoclopramide hcl tab 10 mg (Reglan)....................... 77
metoclopramide hcl tab 5 mg (Reglan)......................... 77
metolazone tab 10 mg.................................................... 56
metolazone tab 2.5 mg (Zaroxolyn)............................... 56
metolazone tab 5 mg (Zaroxolyn).................................. 56
metoprolol & hydrochlorothiazide tab 100-25 mg
(Lopressor hct).............................................................. 53
metoprolol & hydrochlorothiazide tab 100-50 mg........ 53
metoprolol & hydrochlorothiazide tab 50-25 mg
(Lopressor hct).............................................................. 53
metoprolol succinate tab sr 24hr 100 mg (Toprol
xl).....................................................................................42
metoprolol succinate tab sr 24hr 200 mg (Toprol
xl).....................................................................................42
metoprolol succinate tab sr 24hr 25 mg (Toprol xl)..... 42
metoprolol succinate tab sr 24hr 50 mg (Toprol xl)..... 42
metoprolol tartrate tab 100 mg (Lopressor)..................43
metoprolol tartrate tab 25 mg........................................ 43
metoprolol tartrate tab 50 mg (Lopressor)....................43
METOZOLV ODT - metoclopramide hcl orally
disintegrating tab 5 mg....................................................77
METROCREAM - metronidazole cream 0.75%...............167
METROGEL - metronidazole gel 1%.............................. 167
METROGEL-VAGINAL - metronidazole vaginal gel
0.75%...............................................................................80
METROLOTION - metronidazole lotion 0.75%................167
metronidazole cap 375 mg (Flagyl)............................... 14
metronidazole cream 0.75% (Metrocream)..................167
metronidazole gel 0.75%...............................................167
metronidazole gel 1% (Metrogel)................................. 167
metronidazole lotion 0.75% (Metrolotion)................... 167
metronidazole tab 250 mg (Flagyl)................................ 14
metronidazole tab 500 mg (Flagyl)................................ 14
metronidazole vaginal gel 0.75% (Metrogelvaginal)........................................................................... 80
METVIXIA - methyl aminolevulinate hcl cream 16.8%
(base equiv)...................................................................167
MEVACOR - lovastatin tab 40 mg.................................... 59
mexiletine hcl cap 150 mg............................................. 46
MIACALCIN - calcitonin (salmon) inj 200 unit/ml.............. 38
MIACALCIN - calcitonin (salmon) nasal soln 200 unit/
act.................................................................................... 38
MICARDIS HCT - telmisartan-hydrochlorothiazide tab
40-12.5 mg...................................................................... 53
80-12.5 mg...................................................................... 53
80-25 mg......................................................................... 53
MICARDIS - telmisartan tab 20 mg...................................53
300
MICONAZOLE 3 - miconazole nitrate vaginal suppos 200
mg.................................................................................... 80
miconazole nitrate vaginal supp 200 mg & 2% cream 9
gm kit.............................................................................. 80
MICROCHAMBER - spacer/aerosol-holding chambers device ........................................................................... 210
MICRODOT BLOOD GLUCOSE MO - blood glucose
MICRODOT CONTROL SOLUTION - blood glucose
MICRODOT TEST STRIPS - glucose blood test strip..... 179
MICRO-K - potassium chloride cap cr 10 meq................139
MICRO-K - potassium chloride cap cr 8 meq..................139
MICROLET LANCETS - lancets .................................... 210
MICROSPACER - spacer/aerosol-holding chambers device ........................................................................... 210
MICROTAINER SAFETY FLOW L - lancets .................. 210
MICROZIDE - hydrochlorothiazide cap 12.5 mg............... 56
midodrine hcl tab 10 mg................................................ 57
midodrine hcl tab 2.5 mg............................................... 57
midodrine hcl tab 5 mg.................................................. 57
MIGERGOT - ergotamine w/ caffeine suppos 2-100
mg.................................................................................. 116
MIGRANAL - dihydroergotamine mesylate nasal spray 4
mg/ml............................................................................. 116
MIGRYL - capsaicin-menthol disk 0.0375-5%.................167
MILLIPRED DP - prednisolone tab 5 mg dose pack......... 20
MILLIPRED - prednisolone sod phosphate oral soln 10
mg/5ml (base equiv)........................................................20
MILLIPRED - prednisolone tab 5 mg................................ 20
MINASTRIN 24 FE - norethindrone ace-eth estradiol-fe
chew tab 1 mg-20 mcg (24)............................................ 25
MINI LANCING DEVICE - lancet devices ...................... 210
MINIPRESS - prazosin hcl cap 1 mg................................53
MINIVELLE - estradiol td patch biweekly 0.0375
mg/24hr............................................................................23
mg/24hr............................................................................23
mg/24hr............................................................................23
MINIVELLE - estradiol td patch biweekly 0.1 mg/24hr...... 23
MINIVELLE - estradiol td patch twice weekly 0.025
mg/24hr............................................................................23
MINOCIN KIT - minocycline hcl cap 100 mg w/ acne care
products kit .......................................................................5
MINOCIN KIT - minocycline hcl cap 50 mg w/ acne care
products kit .......................................................................5
MINOCIN - minocycline hcl cap 100 mg............................. 5
MINOCIN - minocycline hcl cap 50 mg............................... 4
MINOCIN - minocycline hcl cap 75 mg............................... 5
minocycline hcl cap 100 mg (Minocin)............................5
minocycline hcl cap 50 mg (Minocin)............................. 5
2015
minocycline hcl cap 75 mg (Minocin)............................. 5
minocycline hcl tab 100 mg............................................. 5
minocycline hcl tab 50 mg............................................... 5
minocycline hcl tab 75 mg............................................... 5
minocycline hcl tab sr 24hr 135 mg................................ 5
minocycline hcl tab sr 24hr 45 mg.................................. 5
minocycline hcl tab sr 24hr 90 mg.................................. 5
minoxidil tab 10 mg........................................................ 53
minoxidil tab 2.5 mg....................................................... 53
MI PASTE - dentifrices - paste ...................................... 210
MI PASTE PLUS - dentifrices - paste ............................ 210
MIRAPEX ER - pramipexole dihydrochloride tab sr 24hr
0.375 mg........................................................................124
0.75 mg..........................................................................124
1.5 mg............................................................................124
2.25 mg..........................................................................124
3.75 mg..........................................................................124
MIRAPEX ER - pramipexole dihydrochloride tab sr 24hr 3
mg.................................................................................. 124
4.5 mg............................................................................124
MIRAPEX - pramipexole dihydrochloride tab 0.125
mg.................................................................................. 124
mg.................................................................................. 124
MIRAPEX - pramipexole dihydrochloride tab 0.5 mg...... 124
mg.................................................................................. 124
MIRAPEX - pramipexole dihydrochloride tab 1.5 mg...... 124
MIRAPEX - pramipexole dihydrochloride tab 1 mg......... 124
MIRCERA - methoxy polyethylene glycol-epoetin beta inj
100 mcg/0.3ml............................................................... 145
200 mcg/0.3ml............................................................... 145
50 mcg/0.3ml................................................................. 145
75 mcg/0.3ml................................................................. 145
MIRCETTE - desogest-eth estrad & eth estrad tab
0.15-0.02/0.01 mg(21/5).................................................. 25
MIRENA - levonorgestrel releasing iud 20 mcg/24hr (52
mg total)...........................................................................25
mirtazapine orally disintegrating tab 15 mg (Remeron
soltab)............................................................................. 86
soltab)............................................................................. 86
soltab)............................................................................. 86
mirtazapine tab 15 mg (Remeron)................................. 86
mirtazapine tab 7.5 mg................................................... 86
misoprostol tab 100 mcg (Cytotec)............................... 72
misoprostol tab 200 mcg (Cytotec)............................... 72
MITIGARE - colchicine cap 0.6 mg.................................117
MITOSOL - mitomycin for ophth soln kit 0.2 mg............. 152
MOBIC - meloxicam susp 7.5 mg/5ml.............................113
MOBIC - meloxicam tab 15 mg.......................................113
MOBIC - meloxicam tab 7.5 mg......................................113
modafinil tab 100 mg (Provigil)......................................98
modafinil tab 200 mg (Provigil)......................................98
MODERIBA 1200 DOSE PACK - ribavirin tab 600 mg........9
MODERIBA 800 DOSE PACK - ribavirin tab 400 mg..........9
MODERIBA - ribavirin tab 200 mg & ribavirin tab 400 mg
dose pack.......................................................................... 9
MODERIBA - ribavirin tab 400 mg & ribavirin tab 600 mg
dose pack.......................................................................... 9
MODICON - norethindrone & ethinyl estradiol tab 0.5
mg-35 mcg.......................................................................25
moexipril hcl tab 15 mg (Univasc).................................53
moexipril hcl tab 7.5 mg (Univasc)................................53
moexipril-hydrochlorothiazide tab 15-12.5 mg
(Uniretic)......................................................................... 53
moexipril-hydrochlorothiazide tab 15-25 mg................ 53
moexipril-hydrochlorothiazide tab 7.5-12.5 mg............ 53
mometasone furoate cream 0.1% (Elocon)................. 167
mometasone furoate oint 0.1% (Elocon).....................167
mometasone furoate solution 0.1% (lotion)
(Elocon).........................................................................167
MONOCAL - sodium monofluorophosphate-calcium carb
tab 22.75-625 mg.......................................................... 139
MONODOX - doxycycline monohydrate cap 100 mg.......... 5
MONODOX - doxycycline monohydrate cap 75 mg............ 5
MONOJECT INSULIN SYRINGE/ - insulin syringe/needle
u-100 0.3 ml 29 x 1/2"...................................................210
u-100 0.3 ml 30 x 5/16".................................................210
u-100 1/2 ml 28 x 1/2"...................................................210
u-100 1/2 ml 29 x 1/2"...................................................210
u-100 1/2 ml 30 x 5/16".................................................210
u-100 1 ml 25 x 5/8"......................................................210
u-100 1 ml 27 x 1/2"......................................................210
u-100 1 ml 28 x 1/2"......................................................210
u-100 1 ml 29 x 1/2"......................................................210
u-100 1 ml 30 x 5/16"....................................................210
u-100 1 ml 31 x 5/16"....................................................210
MONOJECT INSULIN SYRINGE/ - insulin syringe (disp)
u-100 1 ml..................................................................... 210
301
2015
MONOJECT INSULIN SYRINGE - insulin syringe (disp)
u-100 1 ml..................................................................... 210
MONOJECT ULTRA COMFORT IN - insulin syringe/
needle u-100 0.3 ml 29 x 1/2"....................................... 210
needle u-100 0.3 ml 30 x 5/16"..................................... 210
needle u-100 0.3 ml 31 x 5/16"..................................... 211
needle u-100 1/2 ml 28 x 1/2"....................................... 211
needle u-100 1/2 ml 29 x 1/2"....................................... 211
needle u-100 1/2 ml 30 x 5/16"..................................... 211
needle u-100 1/2 ml 31 x 5/16"..................................... 211
needle u-100 1 ml 28 x 1/2"..........................................211
needle u-100 1 ml 29 x 1/2"..........................................211
needle u-100 1 ml 30 x 5/16"........................................ 211
MONOLET LANCETS - lancets ..................................... 211
MONOLET OPD LANCETS - lancets ............................ 211
MONOLETTOR SAFETY LANCETS - lancets ............... 211
MONSELS FERRIC SUBSULFATE - ferric subsulfate soln
....................................................................................... 149
montelukast sodium chew tab 4 mg (base equiv)
(Singulair)....................................................................... 68
montelukast sodium chew tab 5 mg (base equiv)
(Singulair)....................................................................... 68
montelukast sodium oral granules packet 4 mg (base
equiv) (Singulair)........................................................... 68
montelukast sodium tab 10 mg (base equiv)
(Singulair)....................................................................... 68
MONUROL - fosfomycin tromethamine powd pack 3 gm
(base equivalent)............................................................. 78
MOORE MED MONOJECT INSULI - insulin syringe/
needle u-100 1/2 ml 28 x 1/2"....................................... 211
needle u-100 1/2 ml 29 x 1/2"....................................... 211
needle u-100 1 ml 28 x 1/2"..........................................211
needle u-100 1 ml 29 x 1/2".............................

Horizon BCBSNJ Health Insurance Marketplace

Transcription

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