Blue Cross and Blue Shield of North Carolina (BCBSNC)

Transcription

October 2015
Blue Cross and Blue Shield of North Carolina Enhanced 4 Tier Formulary
Click to search for a drug name in this document
Contents
Preferred Medication List
Preface ............................................................................ I
Anti-Infective Agents.................................................... 1
Member guide to commonly prescribed
Biologicals ................................................................. 10
Medications On The Enhanced Formulary .............. I
Antineoplastic Agents ................................................ 10
Enhanced Formulary tiers .......................................... I
Endocrine and Metabolic Drugs ................................ 15
4-Tier Formulary ...................................................... I
Cardiovascular Agents .............................................. 29
3-Tier Formulary .................................................... II
Respiratory Agents .................................................... 43
2-Tier Formulary .................................................... II
Gastrointestinal Agents ............................................. 48
Generic Drugs ............................................................ II
Genitourinary Agents ................................................. 53
Compounded Prescriptions ........................................ II
Central Nervous System Drugs ................................. 56
Prior review, quantity limitations and
Analgesics and Anesthetics ...................................... 69
restricted-access drugs ......................................... II
Neuromuscular Drugs................................................ 79
Specialty drugs .......................................................... III
Nutritional Products ................................................... 84
Using the member guide to the
Hematological Agents................................................ 86
Enhanced Formulary ............................................ III
Topical Products ........................................................ 90
Abbreviation/acronym Key ........................................ IV
Miscellaneous Products........................................... 102
Index ....................................................................... 105
Please consider talking to your doctor about prescribing formulary medications, which may help reduce your
out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you.
The drug formulary is regularly updated. Please visit bcbsnc.com for the most up-to-date information.
To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to
Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click
on Search.
5154 NC © Prime Therapeutics LLC 10/15
Member guide to commonly prescribed medications on the Enhanced Formulary
This guide lists common brand name and generic prescription drugs that have been reviewed by Blue Cross and
Blue Shield of North Carolina (BCBSNC). Please refer to this formulary benefit guide for information about the
availability of frequently prescribed medications covered by BCBSNC’s Enhanced Formulary and present this
guide to your doctor if you or another covered family member requires a prescription. This guide is not meant to
be comprehensive but to provide a list of the most commonly prescribed drugs.
This guide was current at the time of printing and is subject to change. If you are unable to find a particular
drug in this guide, it does not necessarily mean that it is not covered. For a more complete listing of drug
coverage and costs, you may use our Prescription Drug Search at bcbsnc.com. You may also call BCBSNC
Customer Service at the number listed on your ID card to confirm a drug’s tier status or verify prescription
drug benefits.
A formulary is a list of prescription drugs recommended by a health plan. BCBSNC Pharmacy & Therapeutics (P&T)
Committee reviews medications listed on the formulary at least quarterly. This includes ongoing reviews of clinical
information about new drugs and reviews of new safety and efficacy information about older drugs. The majority of
BCBSNC’s P&T Committee is composed of practicing physicians and pharmacists independent of BCBSNC.
Please refer to your benefit booklet for detailed information regarding your pharmacy benefits, including your tiered
benefit structure, out-of-pocket costs and applicable exclusions.
Enhanced Formulary tiers
The 3-Tier and 4-Tier Formularies cover most medications approved by the United States Food & Drug
Administration (FDA), within existing benefits. The plan design determines the member’s payment obligation.
Some members have a two-tiered benefit structure (Tier 1 and Tier 2), some members have a three-tiered benefit
structure (Tier 1, Tier 2, and Tier 3), and some members have a four-tiered benefit structure (Tier 1, Tier 2, Tier 3,
and Tier 4) depending on the plan in which they are enrolled.
Note: Drugs listed as covered on Tier 1 are generics only. Listed brand names for Tier 1 drugs are for reference
only. Brands for which generic equivalents are available are covered on Tier 3 unless indicated otherwise.
4-Tier Formulary
Here are the definitions of each tier for a four-tiered benefit structure:
I

Tier 1: Generic medications. Medications listed in Tier 1 have the lowest co-payment.

Tier 2: Includes select brand-name drugs recommended by the BCBSNC P&T Committee as preferred
brand-name products based on safety, efficacy, and cost. Medications listed in Tier 2 have the
second-lowest co-payment.

Tier 3: Contains 1) brand-name products that, as recommended by the P&T Committee, usually have
preferred and often less costly therapeutic alternatives at a lower tier, 2) brands with therapeutically
equivalent generics, 3) new non-specialty drugs not yet reviewed by the P&T Committee, and 4) preferred
specialty brand-name drugs. Medications listed in Tier 3 have the second-highest co-payment.

Tier 4: Most specialty drugs: Those medications, as classified by the P&T Committee, that generally have
unique uses, require special dosing or administration, are typically prescribed by a specialist provider and
are significantly more costly than alternative drugs or therapies. Medications listed in Tier 4 generally
have the highest co-payment or co-insurance amount.
Blue Cross and Blue Shield of North Carolina (BCBSNC) October 2015 Enhanced 4 Tier Formulary
3-Tier Formulary
Definitions for a three-tiered benefit structure:

Tier 1: Generic medications. Medications listed in Tier 1 have the lowest co-payment.

Tier 2: Includes select brand-name drugs determined by the BCBSNC P&T Committee to be
preferred products based on safety, efficacy, and cost. Medications listed in Tier 2 have the
second-lowest co-payment.

Tier 3: Contains brand-name products that often have preferred and less costly therapeutic
alternatives at a lower tier, brands with therapeutically equivalent generics, and certain specialty
drugs. Medications listed in Tier 3 have the highest co-payment.
2-Tier Formulary
For a two-tiered benefit structure, the following definitions apply:

Tier 1: Generic medications. Medications listed in Tier 1 have a lower co-payment.

Tier 2: Includes all brand-name products.

For BCBSNC members participating in the 2-Tier Formulary, there is no distinction or preference
between Tier 2, Tier 3, and Tier 4 drugs.
Generic drugs
In most cases choosing a generic drug equivalent, when available, will mean significant savings to you.
We encourage you to discuss with your physician whether a generic alternative is available as these drugs
represent safe, effective treatment options. Especially for drugs that are taken daily and refilled frequently, you will
experience the long-term savings of a lower drug co-payment month after month. For some benefit plans, if you
choose 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.
Compounded prescriptions
Compounded prescriptions contain two or more drugs mixed together. Compounded prescriptions are processed
according to member benefits. To be eligible for coverage, compounded medications must contain at least one
FDA-approved prescription ingredient and must not be a copy of a commercially available product. Compounded
medications may be subject to prior review.
Prior review, quantity limitations and restricted-access drugs
Under some benefit plans, certain medications may be subject to prior review, quantity limitations, or restrictedaccess programs. BCBSNC’s P&T Committee reviews the clinical criteria for these programs.

Drugs that have prior review requirements must be reviewed by BCBSNC before coverage can be
authorized.

Certain medications may also have limitations on the quantity and days’ supply coverage. Quantities in
excess of the coverage limit must be reviewed and approved by BCBSNC before coverage can be
authorized for amounts in excess of the limits.

For coverage of restricted-access drugs, BCBSNC requires that the member has tried a preferred drug
first. Coverage for restricted-access drugs may be provided without the use of a preferred drug if the
provider certifies in writing that the member has previously used a preferred drug and the preferred drug
has been detrimental to the member's health or has been ineffective in treating the same condition and,
in the opinion of the provider, is likely to be detrimental to the member's health or ineffective in treating
the condition in the future.
II
The FDA is responsible for approving medications for use based on clinical data proving the medication is safe and
effective for that specific use. BCBSNC’s prior review and quantity limitations programs follow FDA-approved uses for
these drugs. However, BCBSNC recognizes that in many cases, “off-label” (non-FDA approved) uses of prescription
drugs may be acceptable. In determining the acceptability of off-label uses, BCBSNC utilizes several sources of
clinical information including but not limited to 1) nationally recognized clinical references including American Hospital
Formulary Service Drug Information; 2) the results of at least two randomized controlled clinical studies that support a
specific off-label use, and that are published in peer-reviewed professional medical journals; and 3) consultations with
internal and external physician experts regarding community standards. Additional searches for current supporting
medical literature may be performed utilizing standard electronic databases.
Specialty drugs
These medications, as classified by BCBSNC, generally have unique uses, require special dosing or administration,
are typically prescribed by a specialist provider and are significantly more costly than alternative drugs or therapies.
Most specialty drugs can be found on Tier 4, but there are some specialty drugs that are on Tiers 1, 2 and 3.
Some of these specialty drugs will need to be filled at a participating specialty pharmacy in our network. These drugs
are identified in the specialty column of the formulary guide. Call the customer service number on the back of your
BCBSNC ID card to determine which pharmacy can fill your specialty drug prescription.
Using the member guide to the Enhanced Formulary
The Medication List is organized into broad categories (e.g., ANTI-INFECTIVE AGENTS). The graphic below shows
the information that is provided in each column of the medication list and is an example only. Please use the drug
search function to find current information for drugs on the medication list.
The first column of the chart lists the medication name. Generic medications are listed in lowercase boldface .
Brand name medications are capitalized.
Separate medication entries are required for some dosage forms such as extended-release and
delayed-release.
The second column indicates the Tier level.
The third column indicates if the medication is a Specialty medication and needs to be filled at a participating
specialty pharmacy in our network.
The remaining columns indicate the Pharmacy Program(s) that apply to the prescription medication
(e.g., Prior Review, Restricted Access and Quantity Limitations). If an indicator is present in the column(s),
then the Pharmacy Program applies.
III
Abbreviation/acronym key
cap ................................................................ capsules
chew ............................................................ chewable
odt ........................................ orally disintegrating tabs
oint ................................................................ ointment
conc .........................................................concentrate
cr .................................................... controlled release
ophth .......................................................... ophthalmic
osm ..................................................... osmotic release
dr ........................................................ delayed release
ec ........................................................... enteric coated
powd ................................................................ powder
sa ....................................................... sustained action
effe............................................................ effervescent
equiv ........................................................... equivalent
sl ................................................................. sublingual
soln .................................................................. solution
er ...................................................... extended release
inhal............................................................. inhalation
sr ..................................................... sustained release
suppos ................................................... suppositories
inj .................................................................... injection
liq ......................................................................... liquid
susp ........................................................... suspension
tab ...................................................................... tablets
lotn ...................................................................... lotion
nebu .............................................................. nebulizer
td .............................................................. transdermal
IV
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
AMPICILLIN – ampicillin for susp
125 mg/5ml
1
amoxicillin (trihydrate) cap
500 mg
1
AMPICILLIN – ampicillin for susp
250 mg/5ml
1
amoxicillin (trihydrate) for susp
125 mg/5ml
1
ampicillin cap 250 mg
1
ampicillin cap 500 mg
1
200 mg/5ml
1
dicloxacillin sodium cap 250 mg
1
dicloxacillin sodium cap 500 mg
1
250 mg/5ml
1
MOXATAG – amoxicillin
(trihydrate) tab sr 24hr 775 mg
3
400 mg/5ml
1
penicillin v potassium for soln
125 mg/5ml
1
amoxicillin (trihydrate) tab
500 mg
1
penicillin v potassium for soln
250 mg/5ml
1
amoxicillin (trihydrate) tab
875 mg
1
penicillin v potassium tab
250 mg
1
amoxicillin & k clavulanate chew
tab 200-28.5 mg
1
penicillin v potassium tab
500 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 sr
12hr 1000-62.5 mg (Augmentin
xr)
1
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
CEPHALOSPORINS
cefaclor cap 250 mg
1
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
cefdinir cap 300 mg
1
cefdinir for susp 125 mg/5ml
1
cefdinir for susp 250 mg/5ml
1
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
1
AZITHROMYCIN – azithromycin
powd pack for susp 1 gm
1
cefixime for susp 200 mg/5ml
(Suprax)
1
azithromycin for susp
100 mg/5ml (Zithromax)
1
cefpodoxime proxetil for susp
50 mg/5ml
1
azithromycin for susp
200 mg/5ml (Zithromax)
1
cefpodoxime proxetil for susp
100 mg/5ml
1
azithromycin tab 250 mg
(Zithromax)
1
cefpodoxime proxetil tab 100 mg
cefpodoxime proxetil tab 200 mg
1
1
(Zithromax)
1
cefprozil for susp 125 mg/5ml
cefprozil for susp 250 mg/5ml
1
1
cefprozil tab 250 mg
1
(Zithromax)
cefprozil tab 500 mg
1
1
cefuroxime axetil tab 250 mg
(Ceftin)
1
clarithromycin for susp
125 mg/5ml
1
cefuroxime axetil tab 500 mg
(Ceftin)
1
clarithromycin for susp
250 mg/5ml (Biaxin)
1
CEPHALEXIN – cephalexin tab
250 mg
1
clarithromycin tab sr 24hr
500 mg (Biaxin xl pac)
1
CEPHALEXIN – cephalexin tab
500 mg
1
clarithromycin tab 250 mg
(Biaxin)
1
cephalexin cap 250 mg (Keflex)
1
clarithromycin tab 500 mg
(Biaxin)
1
DIFICID – fidaxomicin tab 200 mg
4
1
E.E.S. 400 – erythromycin
ethylsuccinate tab 400 mg
1
cephalexin for susp 125 mg/5ml
1
1
cephalexin for susp 250 mg/5ml
1
ERY-TAB – erythromycin tab
delayed release 250 mg
SPECTRACEF – cefditoren pivoxil
tab 200 mg (base equivalent)
3
ERY-TAB – erythromycin tab
1
SPECTRACEF – cefditoren pivoxil
3
1
SUPRAX – cefixime cap 400 mg
2
ERYTHROCIN STEARATE –
erythromycin stearate tab 250
mg
2
SUPRAX – cefixime for susp 500
mg/5ml
2
SUPRAX – cefixime chew tab 100
mg
3
SUPRAX – cefixime chew tab 200
mg
3
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
MACROLIDES
•
•
ERYTHROMYCIN
ETHYLSUCCINA – erythromycin
ethylsuccinate tab 400 mg
1
doxycycline monohydrate tab
50 mg (Adoxa)
1
erythromycin w/ delayed release
particles cap 250 mg
75 mg (Adoxa)
1
1
PCE – erythromycin w/ enteric
coated particles tab 333 mg
100 mg (Adoxa pak 1/100)
1
3
3
150 mg (Adoxa pak 1/150)
1
PCE – erythromycin w/ enteric
coated particles tab 500 mg
ZMAX – azithromycin extended
release for oral susp 2 gm
minocycline hcl cap 50 mg
(Minocin)
1
3
(Minocin)
1
(Minocin)
1
TETRACYCLINES
demeclocycline hcl tab 150 mg
1
demeclocycline hcl tab 300 mg
1
DORYX – doxycycline hyclate tab
3
• •
minocycline hcl tab sr 24hr
45 mg
1
DORYX – doxycycline hyclate tab
3
• •
90 mg
1
doxycycline hyclate cap 50 mg
1
1
doxycycline hyclate cap 100 mg
(Vibramycin)
1
135 mg
minocycline hcl tab 50 mg
1
doxycycline hyclate tab delayed
release 75 mg
1
1
1
release 100 mg
1
SOLODYN – minocycline hcl tab sr
24hr 55 mg
3
• •
release 150 mg
1
24hr 65 mg
3
• •
doxycycline hyclate tab 20 mg
1
3
• •
doxycycline hyclate tab 100 mg
1
24hr 80 mg
doxycycline monohydrate cap
50 mg
1
24hr 105 mg
3
• •
75 mg (Monodox)
1
24hr 115 mg
3
• •
100 mg (Monodox)
1
TETRACYCLINE HCL –
tetracycline hcl cap 250 mg
1
150 mg (Adoxa)
1
TETRACYCLINE HCL –
tetracycline hcl cap 500 mg
1
doxycycline monohydrate for
susp 25 mg/5ml (Vibramycin)
1
FLUOROQUINOLONES
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
3
ciprofloxacin for oral susp
250 mg/5ml (5%) (5 gm/100ml)
(Cipro)
1
ciprofloxacin for oral
susp 500 mg/5ml (10%)
(10 gm/100ml) (Cipro)
1
CIPROFLOXACIN HCL –
ciprofloxacin hcl tab 100 mg
(base equiv)
1
(base equiv) (Cipro)
1
(base equiv) (Cipro)
1
(base equiv)
1
ethambutol hcl tab 100 mg
(Myambutol)
1
ciprofloxacin-ciprofloxacin hcl
tab sr 24hr 500 mg (base eq)
(Cipro xr)
1
ethambutol hcl tab 400 mg
(Myambutol)
1
isoniazid tab 100 mg
1
ciprofloxacin-ciprofloxacin hcl
tab sr 24hr 1000 mg(base eq)
(Cipro xr)
1
isoniazid tab 300 mg
1
pyrazinamide tab 500 mg
1
3
rifabutin cap 150 mg (Mycobutin)
1
FACTIVE – gemifloxacin mesylate
tab 320 mg (base equiv)
rifampin cap 150 mg (Rifadin)
1
levofloxacin oral soln 25 mg/ml
(Levaquin)
1
rifampin cap 300 mg (Rifadin)
1
levofloxacin tab 250 mg
(Levaquin)
SIRTURO – bedaquiline fumarate
4
1
(Levaquin)
1
CRESEMBA – isavuconazonium
sulfate cap 186 mg
4
(Levaquin)
1
fluconazole for susp 10 mg/ml
(Diflucan)
1
moxifloxacin hcl tab 400 mg
(base equiv) (Avelox)
1
fluconazole for susp 40 mg/ml
(Diflucan)
1
OFLOXACIN – ofloxacin tab 400
mg
1
fluconazole tab 50 mg (Diflucan)
1
1
1
1
flucytosine cap 250 mg
(Ancobon)
1
paromomycin sulfate cap
250 mg
1
TOBI – tobramycin nebu soln 300
mg/5ml
3
•
TOBI PODHALER – tobramycin
inhal cap 28 mg
4
•
tobramycin nebu soln
300 mg/5ml (Tobi)
1
•
SULFADIAZINE – sulfadiazine tab
500 mg
1
ANTIMYCOBACTERIAL AGENTS
ANTIFUNGALS
BETHKIS – tobramycin nebu soln
300 mg/4ml
4
•
KITABIS PAK – tobramycin nebu
soln 300 mg/5ml
4
•
neomycin sulfate tab 500 mg
1
•
Quantity Limits
Restricted Access
Prior Review
SULFONAMIDES
AMINOGLYCOSIDES
4
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
1
1
acyclovir susp 200 mg/5ml
(Zovirax)
1
griseofulvin ultramicrosize tab
125 mg (Gris-peg)
1
acyclovir tab 400 mg (Zovirax)
1
acyclovir tab 800 mg (Zovirax)
1
griseofulvin ultramicrosize tab
250 mg (Gris-peg)
1
adefovir dipivoxil tab 10 mg
(Hepsera)
1
itraconazole cap 100 mg
(Sporanox)
1
APTIVUS – tipranavir cap 250 mg
2
1
APTIVUS – tipranavir oral soln 100
mg/ml
2
ketoconazole tab 200 mg
LAMISIL – terbinafine hcl oral
granules packet 125 mg
3
LAMISIL – terbinafine hcl oral
granules packet 187.5 mg
3
NOXAFIL – posaconazole tab
4
NOXAFIL – posaconazole susp 40
mg/ml
4
nystatin oral powder
1
nystatin tab 500000 unit
1
ONMEL – itraconazole tab 200 mg
3
terbinafine hcl tab 250 mg
(Lamisil)
1
VFEND – voriconazole for susp 40
mg/ml
4
VFEND – voriconazole tab 50 mg
4
VFEND – voriconazole tab 200 mg
4
voriconazole for susp 40 mg/ml
(Vfend)
1
voriconazole tab 50 mg (Vfend)
1
voriconazole tab 200 mg (Vfend)
1
•
•
1
•
1
griseofulvin microsize tab
500 mg (Grifulvin v)
•
ATRIPLA – efavirenz-emtricitabine- 2
tenofovir df tab 600-200-300 mg
BARACLUDE – entecavir oral soln 3
0.05 mg/ml
3
BARACLUDE – entecavir tab 0.5
mg
BARACLUDE – entecavir tab 1 mg 3
•
•
•
•
COMBIVIR – lamivudinezidovudine tab 150-300 mg
3
•
•
COMPLERA – emtricitabinerilpivirine-tenofovir df tab
200-25-300 mg
2
•
COPEGUS – ribavirin tab 200 mg
4
•
CRIXIVAN – indinavir sulfate cap
200 mg
2
•
•
•
•
•
CRIXIVAN – indinavir sulfate cap
400 mg
2
•
DAKLINZA – daclatasvir
dihydrochloride tab 30 mg (base
equivalent)
4
• •
•
DAKLINZA – daclatasvir
dihydrochloride tab 60 mg (base
equivalent)
4
• •
•
didanosine delayed release
capsule 125 mg (Videx ec)
1
•
1
•
•
ANTIVIRALS
abacavir sulfate tab 300 mg
(base equiv) (Ziagen)
Quantity Limits
acyclovir cap 200 mg (Zovirax)
griseofulvin microsize susp
125 mg/5ml
Restricted Access
Specialty
•
1
Drug Name
Prior Review
Drug Tier
Quantity Limits
Restricted Access
Prior Review
1
flucytosine cap 500 mg
(Ancobon)
Specialty
abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg
(Trizivir)
Drug Name
Drug Tier
2015
5
•
INVIRASE – saquinavir mesylate
cap 200 mg
2
•
1
•
INVIRASE – saquinavir mesylate
tab 500 mg
2
•
EDURANT – rilpivirine hcl tab 25
mg (base equivalent)
2
2
•
EMTRIVA – emtricitabine caps 200
mg
2
ISENTRESS – raltegravir
potassium tab 400 mg (base
equiv)
2
•
EMTRIVA – emtricitabine soln 10
mg/ml
2
•
potassium packet for susp 100
mg (base equiv)
entecavir tab 0.5 mg (Baraclude)
1
•
1
potassium chew tab 25 mg (base
equiv)
2
entecavir tab 1 mg (Baraclude)
EPIVIR – lamivudine tab 150 mg
3
•
EPIVIR – lamivudine tab 300 mg
EPIVIR – lamivudine oral soln 10
mg/ml
3
potassium chew tab 100 mg
(base equiv)
2
3
•
•
•
•
•
2
•
EPIVIR HBV – lamivudine tab 100
mg (hbv)
3
•
KALETRA – lopinavir-ritonavir soln
400-100 mg/5ml (80-20 mg/ml)
2
•
EPIVIR HBV – lamivudine oral soln
5 mg/ml (hbv)
3
•
KALETRA – lopinavir-ritonavir tab
100-25 mg
2
•
EPZICOM – abacavir sulfatelamivudine tab 600-300 mg
2
•
KALETRA – lopinavir-ritonavir tab
200-50 mg
1
•
EVOTAZ – atazanavir sulfatecobicistat tab 300-150 mg (base
equiv)
4
•
lamivudine oral soln 10 mg/ml
(Epivir)
lamivudine tab 100 mg (hbv)
(Epivir hbv)
1
•
famciclovir tab 125 mg (Famvir)
1
lamivudine tab 150 mg (Epivir)
1
1
lamivudine tab 300 mg (Epivir)
1
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
4
•
MODERIBA – ribavirin tab 400 mg
& ribavirin tab 600 mg dose pack
4
•
MODERIBA 1200 DOSE PACK –
ribavirin tab 600 mg
4
•
FUZEON – enfuvirtide for inj 90 mg 3
4
HARVONI – ledipasvir-sofosbuvir
tab 90-400 mg
3
HEPSERA – adefovir dipivoxil tab
10 mg
INTELENCE – etravirine tab 25 mg 2
INTELENCE – etravirine tab 100
mg
2
INTELENCE – etravirine tab 200
mg
2
6
•
•
• •
•
Quantity Limits
1
Drug Name
Restricted Access
Specialty
Drug Name
Prior Review
Drug Tier
Quantity Limits
Specialty
Restricted Access
Drug Tier
Prior Review
2015
•
nevirapine tab 200 mg (Viramune) 1
2
NORVIR – ritonavir cap 100 mg
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
3
• •
PEGASYS – peginterferon alfa-2a
inj 180 mcg/0.5ml
3
• •
PEGASYS PROCLICK –
peginterferon alfa-2a inj 135
mcg/0.5ml
3
• •
PEGASYS PROCLICK –
peginterferon alfa-2a inj 180
mcg/0.5ml
3
• •
NORVIR – ritonavir tab 100 mg
2
NORVIR – ritonavir oral soln 80
mg/ml
2
•
•
•
•
OLYSIO – simeprevir sodium cap
150 mg (base equivalent)
4
• •
PEG-INTRON – peginterferon
alfa-2b for inj kit 50 mcg/0.5ml
3
• •
3
• •
PEGINTRON – peginterferon
3
• •
3
• •
3
• •
3
• •
3
• •
PEG-INTRON REDIPEN –
peginterferon alfa-2b for inj kit 50
mcg/0.5ml
3
• •
3
• •
4
•
mcg/0.5ml
3
PREZCOBIX – darunavir-cobicistat
tab 800-150 mg
2
•
peginterferon alfa-2b for inj kit
120 mcg/0.5ml
3
• •
PREZISTA – darunavir ethanolate
susp 100 mg/ml (base equiv)
2
•
3
• •
2
peginterferon alfa-2b for inj kit
150 mcg/0.5ml
•
2
•
PEG-INTRON REDIPEN PAK 4 –
mcg/0.5ml
3
2
•
PEG-INTRON REDIPEN PAK 4 –
mcg/0.5ml
3
REBETOL – ribavirin cap 200 mg
4
REBETOL – ribavirin soln 40 mg/
ml
3
•
•
• •
• •
• •
Quantity Limits
nevirapine tab sr 24hr 400 mg
(Viramune xr)
1
PEG-INTRON REDIPEN PAK 4
– peginterferon alfa-2b for inj kit
120 mcg/0.5ml
Drug Name
Restricted Access
•
Prior Review
3
Specialty
NEVIRAPINE – nevirapine susp 50
mg/5ml
Drug Tier
•
Quantity Limits
4
Restricted Access
Specialty
MODERIBA 800 DOSE PACK –
ribavirin tab 400 mg
Drug Name
Prior Review
Drug Tier
2015
7
RELENZA DISKHALER –
zanamivir aero powder breath
activated 5 mg/blister
3
RESCRIPTOR – delavirdine
mesylate tab 100 mg
2
rimantadine hydrochloride tab
100 mg (Flumadine)
1
2
•
SELZENTRY – maraviroc tab 150
mg
•
•
•
RESCRIPTOR – delavirdine
mesylate tab 200 mg
SELZENTRY – maraviroc tab 300
mg
2
2
4
3
•
SOVALDI – sofosbuvir tab 400 mg
RETROVIR – zidovudine cap 100
mg
stavudine cap 15 mg (Zerit)
1
3
•
1
RETROVIR – zidovudine syrup 10
mg/ml
1
REYATAZ – atazanavir sulfate
oral powder packet 50 mg (base
equiv)
2
•
1
stavudine for oral soln 1 mg/ml
(Zerit)
1
• •
•
•
•
•
•
REYATAZ – atazanavir sulfate cap
150 mg (base equiv)
2
•
2
•
200 mg (base equiv)
2
•
STRIBILD – elvitegrav-cobicisemtricitab-tenofov tab
150-150-200-300 mg
SUSTIVA – efavirenz tab 600 mg
2
300 mg (base equiv)
2
•
SUSTIVA – efavirenz cap 50 mg
2
SUSTIVA – efavirenz cap 200 mg
2
RIBASPHERE – ribavirin tab 400
mg
1
•
•
•
•
3
RIBASPHERE – ribavirin tab 600
mg
1
•
TAMIFLU – oseltamivir phosphate
for susp 6 mg/ml (base equiv)
3
RIBASPHERE RIBAPAK – ribavirin 1
tab 400 mg
tab 600 mg
tab 200 mg & ribavirin tab 400
mg dose pack
tab 400 mg & ribavirin tab 600
mg dose pack
3
RIBATAB – ribavirin tab 400 mg
•
cap 30 mg (base equiv)
3
3
TECHNIVIE – ombitasvirparitaprevir-ritonavir tab
12.5-75-50 mg
4
• •
TIVICAY – dolutegravir sodium tab
50 mg (base equiv)
2
•
•
•
•
TRIUMEQ – abacavir-dolutegravirlamivudine tab 600-50-300 mg
4
•
TRIZIVIR – abacavir sulfatelamivudine-zidovudine tab
300-150-300 mg
3
•
•
•
TRUVADA – emtricitabine-tenofovir 2
disoproxil fumarate tab 200-300
mg
•
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
8
•
•
•
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
•
3
valacyclovir hcl tab 500 mg
(Valtrex)
1
VIREAD – tenofovir disoproxil
fumarate oral powder 40 mg/gm
2
•
valacyclovir hcl tab 1 gm
(Valtrex)
1
fumarate tab 150 mg
2
•
VALCYTE – valganciclovir hcl tab
3
•
fumarate tab 200 mg
2
•
VALCYTE – valganciclovir hcl for
soln 50 mg/ml (base equiv)
3
•
fumarate tab 250 mg
2
•
valganciclovir hcl tab 450 mg
(base equivalent) (Valcyte)
1
•
fumarate tab 300 mg
2
•
VICTRELIS – boceprevir cap 200
mg
4
• •
VITEKTA – elvitegravir tab 85 mg
4
VITEKTA – elvitegravir tab 150 mg
4
VIDEX – didanosine for soln 2 gm
2
2
VIDEX – didanosine for soln 4 gm
2
ZERIT – stavudine for oral soln 1
mg/ml
•
•
•
VIDEX EC – didanosine delayed
release capsule 125 mg
3
ZERIT – stavudine cap 15 mg
3
3
3
3
3
•
3
3
3
•
ZIAGEN – abacavir sulfate tab 300
mg (base equiv)
•
•
•
•
•
2
•
VIEKIRA PAK – ombitas-paritapreriton & dasab tab pak 12.5-75-50
& 250 mg
4
• •
ZIAGEN – abacavir sulfate soln 20
mg/ml (base equiv)
zidovudine cap 100 mg (Retrovir)
1
1
VIRACEPT – nelfinavir mesylate
tab 250 mg
2
zidovudine syrup 10 mg/ml
(Retrovir)
•
•
zidovudine tab 300 mg
1
•
VIRACEPT – nelfinavir mesylate
tab 625 mg
2
VIRAMUNE – nevirapine tab 200
mg
3
VIRAMUNE – nevirapine susp 50
mg/5ml
2
VIRAMUNE XR – nevirapine tab sr
24hr 100 mg
2
VIRAMUNE XR – nevirapine tab sr
24hr 400 mg
3
•
•
•
•
•
•
ANTIMALARIALS
1
•
atovaquone-proguanil hcl tab
62.5-25 mg (Malarone)
1
•
atovaquone-proguanil hcl tab
250-100 mg (Malarone)
1
•
chloroquine phosphate tab
250 mg
1
•
chloroquine phosphate tab
500 mg (Aralen)
COARTEM – artemetherlumefantrine tab 20-120 mg
2
Quantity Limits
4
Restricted Access
Specialty
VIRAZOLE – ribavirin for inhal soln
6 gm
Drug Name
Prior Review
Drug Tier
TYZEKA – telbivudine tab 600 mg
•
•
Quantity Limits
4
Restricted Access
Specialty
TYBOST – cobicistat tab 150 mg
Prior Review
Drug Name
Drug Tier
2015
9
hydroxychloroquine sulfate tab
200 mg (Plaquenil)
1
metronidazole tab 500 mg
(Flagyl)
1
mefloquine hcl tab 250 mg
1
2
PRIMAQUINE PHOSPHATE –
primaquine phosphate tab 26.3
mg (15 mg base)
2
PRIMSOL – trimethoprim hcl oral
soln 50 mg/5ml (base equiv)
sulfamethoxazole-trimethoprim
susp 200-40 mg/5ml
1
quinine sulfate cap 324 mg
(Qualaquin)
1
tab 400-80 mg (Bactrim)
1
tab 800-160 mg (Bactrim ds)
1
tinidazole tab 250 mg (Tindamax)
1
tinidazole tab 500 mg (Tindamax)
1
ANTI-INFECTIVE AGENTS - MISC.
trimethoprim tab 100 mg
1
ALINIA – nitazoxanide for susp 100 2
mg/5ml
1
atovaquone susp 750 mg/5ml
(Mepron)
4
CAYSTON – aztreonam lysine
for inhal soln 75 mg (base
equivalent)
1
clindamycin hcl cap 75 mg
(Cleocin)
1
(Cleocin)
1
(Cleocin)
1
clindamycin palmitate hcl for
soln 75 mg/5ml (base equiv)
(Cleocin pediatric gr)
2
DAPSONE – dapsone tab 25 mg
vancomycin hcl cap 125 mg
(Vancocin hcl)
1
vancomycin hcl cap 250 mg
(Vancocin hcl)
1
XIFAXAN – rifaximin tab 200 mg
3
XIFAXAN – rifaximin tab 550 mg
3
ZYVOX – linezolid tab 600 mg
3
ZYVOX – linezolid for susp 100
mg/5ml
3
ANTHELMINTICS
ALBENZA – albendazole tab 200
mg
2
ivermectin tab 3 mg (Stromectol)
1
•
ADAGEN – pegademase bovine inj 3
250 unit/ml
•
ANTINEOPLASTIC AGENTS
3
•
AFINITOR – everolimus tab 2.5 mg 4
4
AFINITOR – everolimus tab 5 mg
ACTIMMUNE – interferon
gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)
2
KETEK – telithromycin tab 300 mg
3
KETEK – telithromycin tab 400 mg
3
linezolid tab 600 mg (Zyvox)
1
metronidazole cap 375 mg
(Flagyl)
1
AFINITOR DISPERZ – everolimus
tab for oral susp 2 mg
4
•
•
•
•
•
metronidazole tab 250 mg
(Flagyl)
1
4
•
AFINITOR – everolimus tab 7.5 mg 4
AFINITOR – everolimus tab 10 mg 4
Quantity Limits
Restricted Access
BIOLOGICALS
DAPSONE – dapsone tab 100 mg
10
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
3
•
•
anastrozole tab 1 mg (Arimidex)
1
EMCYT – estramustine phosphate
sodium cap 140 mg
2
azacitidine for inj 100 mg
(Vidaza)
4
ERIVEDGE – vismodegib cap 150
mg
4
•
bexarotene cap 75 mg (Targretin)
1
bicalutamide tab 50 mg
(Casodex)
1
ETOPOSIDE – etoposide cap 50
mg
1
•
BOSULIF – bosutinib tab 100 mg
4
exemestane tab 25 mg
(Aromasin)
1
BOSULIF – bosutinib tab 500 mg
4
FARESTON – toremifene citrate
3
FARYDAK – panobinostat lactate
cap 10 mg (base equivalent)
4
• •
4
• •
4
• •
FASLODEX – fulvestrant inj 250
mg/5ml
4
•
flutamide cap 125 mg
1
GILOTRIF – afatinib dimaleate tab
4
•
•
4
•
•
4
•
•
GLEEVEC – imatinib mesylate tab
3
•
•
GLEEVEC – imatinib mesylate tab
3
•
•
GLEOSTINE – lomustine cap 10
mg
4
•
mg
4
•
mg
4
•
•
•
•
•
•
•
•
•
•
•
Quantity Limits
ELIGARD – leuprolide acetate (6
month) for subcutaneous inj kit
45 mg
Drug Name
Restricted Access
3
Prior Review
Specialty
ALKERAN – melphalan tab 2 mg
capecitabine tab 150 mg (Xeloda) 1
capecitabine tab 500 mg (Xeloda) 1
4
CAPRELSA – vandetanib tab 100
mg
4
CAPRELSA – vandetanib tab 300
mg
4
COMETRIQ – cabozantinib smalate cap 3 x 20 mg (60 mg
dose) kit
4
COMETRIQ – cabozantinib s-mal
cap 1 x 80 mg & 1 x 20 mg (100
dose) kit
4
COMETRIQ – cabozantinib s-mal
cap 1 x 80 mg & 3 x 20 mg (140
dose) kit
1
CYCLOPHOSPHAMIDE –
cyclophosphamide cap 25 mg
1
CYCLOPHOSPHAMIDE –
cyclophosphamide cap 50 mg
3
ELIGARD – leuprolide acetate for
subcutaneous inj kit 7.5 mg
3
22.5mg
3
30 mg
Drug Tier
•
Quantity Limits
4
Restricted Access
Specialty
Drug Name
Prior Review
Drug Tier
2015
HEXALEN – altretamine cap 50 mg 2
11
•
JAKAFI – ruxolitinib phosphate tab
4
•
hydroxyurea cap 500 mg
(Hydrea)
1
•
4
•
IBRANCE – palbociclib cap 75 mg
4
• •
• •
• •
•
KADCYLA – ado-trastuzumab
emtansine for iv soln 100 mg
4
KADCYLA – ado-trastuzumab
emtansine for iv soln 160 mg
4
KYPROLIS – carfilzomib for inj 60
mg
4
LENVIMA 10MG DAILY DOSE –
lenvatinib cap therapy pack 10
mg (10 mg daily dose)
4
•
lenvatinib cap therapy pack 10 &
4 mg (14 mg daily dose)
4
•
(2) mg (20 mg daily dose)
4
•
(2) & 4 mg (24 mg daily dose)
4
•
letrozole tab 2.5 mg (Femara)
1
IBRANCE – palbociclib cap 100 mg 4
IBRANCE – palbociclib cap 125 mg 4
ICLUSIG – ponatinib hcl tab 15 mg
(base equiv)
4
ICLUSIG – ponatinib hcl tab 45 mg
(base equiv)
4
IMBRUVICA – ibrutinib cap 140 mg 4
4
INLYTA – axitinib tab 1 mg
•
•
•
•
•
INLYTA – axitinib tab 5 mg
4
INTRON A – interferon alfa-2b inj
6000000 unit/ml
2
INTRON A – interferon alfa-2b inj
10000000 unit/ml
2
•
INTRON A – interferon alfa-2b for
inj 10000000 unit
2
•
inj 18000000 unit
2
•
inj 50000000 unit
2
•
LEUCOVORIN CALCIUM –
leucovorin calcium tab 10 mg
3
•
INTRON A W/DILUENT –
interferon alfa-2b for inj
10000000 unit
2
•
LEUCOVORIN CALCIUM –
3
•
1
18000000 unit
2
1
3
50000000 unit
2
•
LEUKERAN – chlorambucil tab 2
mg
•
•
•
LOMUSTINE – lomustine cap 10
mg
1
•
4
mg
•
4
•
•
1
IRESSA – gefitinib tab 250 mg
1
•
4
•
mg
2
•
4
•
LUPRON DEPOT – leuprolide
acetate for inj kit 3.75 mg
12
•
Quantity Limits
3
Drug Name
Restricted Access
Specialty
HYDREA – hydroxyurea cap 500
mg
Drug Name
Prior Review
Drug Tier
Quantity Limits
Specialty
Restricted Access
Drug Tier
Prior Review
2015
methotrexate sodium tab 2.5 mg
(base equiv)
1
acetate (3 month) for inj kit 11.25
mg
2
•
MYLERAN – busulfan tab 2 mg
2
3
acetate (3 month) for inj kit 22.5
mg
2
•
NEXAVAR – sorafenib tosylate tab
NILANDRON – nilutamide tab 150
mg
2
2
•
PERJETA – pertuzumab soln for iv
infusion 420 mg/14ml (30 mg/ml)
4
acetate (4 month) for inj kit 30
mg
4
• •
acetate (6 month) for inj kit 45
mg
2
POMALYST – pomalidomide cap 1
mg
mg
4
• •
LYNPARZA – olaparib cap 50 mg
4
mg
4
• •
mg
4
• •
SPRYCEL – dasatinib tab 20 mg
3
3
3
3
3
3
STIVARGA – regorafenib tab 40
mg
4
•
•
•
•
•
•
•
SUTENT – sunitinib malate cap
12.5 mg (base equivalent)
3
•
SUTENT – sunitinib malate cap 25
3
•
SUTENT – sunitinib malate cap
3
•
SUTENT – sunitinib malate cap 50
3
•
SYLATRON – peginterferon alfa-2b 4
for inj kit 200 mcg
for inj kit 300 mcg
for inj kit 600 mcg
•
LYSODREN – mitotane tab 500 mg 2
4
MARQIBO – vincristine sulfate
liposome iv susp 5 mg/31ml
(0.16 mg/ml)
2
MATULANE – procarbazine hcl
cap 50 mg
megestrol acetate susp 40 mg/ml 1
(Megace oral)
1
megestrol acetate tab 20 mg
megestrol acetate tab 40 mg
1
MEKINIST – trametinib dimethyl
sulfoxide tab 0.5 mg (base
equivalent)
4
MEKINIST – trametinib dimethyl
sulfoxide tab 2 mg (base
equivalent)
4
mercaptopurine tab 50 mg
(Purinethol)
1
MESNEX – mesna tab 400 mg
3
methotrexate sodium for inj
1 gm
1
methotrexate sodium inj pf
25 mg/ml
1
methotrexate sodium inj 25 mg/
ml
1
•
• •
•
•
•
• •
• •
•
Quantity Limits
•
Restricted Access
Prior Review
2
Drug Name
Specialty
acetate for inj kit 7.5 mg
Drug Name
Drug Tier
Quantity Limits
Specialty
Restricted Access
Drug Tier
Prior Review
2015
•
•
•
13
•
temozolomide cap 100 mg
(Temodar)
1
•
TABLOID – thioguanine tab 40 mg
2
•
4
(Temodar)
1
TAFINLAR – dabrafenib mesylate
•
• •
1
•
TAFINLAR – dabrafenib mesylate
4
• •
(Temodar)
1
•
tamoxifen citrate tab 10 mg
(base equivalent)
1
(Temodar)
tretinoin cap 10 mg
1
•
tamoxifen citrate tab 20 mg
(base equivalent)
1
TREXALL – methotrexate sodium
3
•
tab 7.5 mg (base equiv)
3
•
3
•
3
•
TYKERB – lapatinib ditosylate tab
250 mg (base equiv)
3
•
•
VIDAZA – azacitidine for inj 100
mg
3
•
•
VOTRIENT – pazopanib hcl tab
200 mg (base equiv)
4
•
•
XALKORI – crizotinib cap 200 mg
4
XALKORI – crizotinib cap 250 mg
4
XELODA – capecitabine tab 150
mg
3
•
•
•
XELODA – capecitabine tab 500
mg
3
•
TARCEVA – erlotinib hcl tab 25 mg 3
(base equivalent)
3
TARCEVA – erlotinib hcl tab 100
3
TARCEVA – erlotinib hcl tab 150
TARGRETIN – bexarotene cap 75 3
mg
4
TASIGNA – nilotinib hcl cap 150
4
TASIGNA – nilotinib hcl cap 200
3
TEMODAR – temozolomide cap 5
mg
TEMODAR – temozolomide cap 20 3
mg
3
TEMODAR – temozolomide cap
100 mg
3
140 mg
3
180 mg
3
250 mg
1
(Temodar)
1
(Temodar)
14
•
•
•
•
•
•
•
XOFIGO – radium ra 223 dichloride 4
inj 27 microcurie/ml (1000 kbq/
ml)
XTANDI – enzalutamide cap 40 mg 4
• • •
ZALTRAP – ziv-aflibercept iv soln
100 mg/4ml (for infusion)
4
ZALTRAP – ziv-aflibercept iv soln
200 mg/8ml (for infusion)
4
ZELBORAF – vemurafenib tab 240
mg
4
• •
ZOLINZA – vorinostat cap 100 mg
4
•
Quantity Limits
4
Drug Name
Restricted Access
Specialty
SYNRIBO – omacetaxine
mepesuccinate for inj 3.5 mg
Drug Name
Prior Review
Drug Tier
Quantity Limits
Specialty
Restricted Access
Drug Tier
Prior Review
2015
ZYTIGA – abiraterone acetate tab
250 mg
4
ENDOCRINE AND METABOLIC DRUGS
CORTICOSTEROIDS
methylprednisolone tab 8 mg
(Medrol)
1
(Medrol)
1
(Medrol)
1
MILLIPRED – prednisolone tab 5
mg
1
3
budesonide cap sr 24hr 3 mg
(Entocort ec)
1
CORTISONE ACETATE –
cortisone acetate tab 25 mg
1
DEXAMETHASONE –
dexamethasone tab 1 mg
1
MILLIPRED – prednisolone sod
phosphate oral soln 10 mg/5ml
(base equiv)
DEXAMETHASONE –
MILLIPRED DP – prednisolone tab
5 mg dose pack
1
1
1
dexamethasone tab 0.5 mg
1
prednisolone sod phos orally
disintegr tab 10 mg (base eq)
(Orapred odt)
1
dexamethasone elixir 0.5 mg/5ml
1
1
1
(Orapred odt)
1
DEXPAK 10 DAY –
dexamethasone tab 1.5 mg taper
pack
3
(Orapred odt)
1
1
1
DEXPAK 13 DAY –
dexamethasone tab 1.5 mg taper
pack
3
prednisolone sod phosph oral
soln 6.7 mg/5ml (5 mg/5ml
base) (Pediapred)
1
DEXPAK 6 DAY – dexamethasone
tab 1.5 mg taper pack
3
prednisolone sod phosphate
oral soln 15 mg/5ml (base
equiv)
1
fludrocortisone acetate tab
0.1 mg
1
prednisolone syrup 15 mg/5ml
(usp solution equivalent)
(Prelone)
hydrocortisone tab 5 mg (Cortef)
1
hydrocortisone tab 10 mg
(Cortef)
1
hydrocortisone tab 20 mg
(Cortef)
1
dose pack (Medrol dosepak)
1
Quantity Limits
4
Restricted Access
ZYKADIA – ceritinib cap 150 mg
1
Prior Review
4
(Medrol)
Specialty
ZYDELIG – idelalisib tab 150 mg
•
•
•
• •
Drug Name
Drug Tier
4
Quantity Limits
Specialty
ZYDELIG – idelalisib tab 100 mg
Restricted Access
Drug Name
Drug Tier
Prior Review
2015
PREDNISONE – prednisone tab 50 1
mg
1
PREDNISONE – prednisone oral
soln 5 mg/5ml
mg dose pack
mg dose pack
15
prednisone tab 20 mg
1
UCERIS – budesonide tab sr 24hr
9 mg
3
3
• •
• •
ANADROL-50 – oxymetholone tab
50 mg
3
ANDRODERM – testosterone td
patch 24hr 2 mg/24hr
2
•
ANDRODERM – testosterone td
patch 24hr 4 mg/24hr
2
•
ANDROGEL – testosterone td gel
25 mg/2.5gm (1%)
2
•
50 mg/5gm (1%)
2
•
20.25 mg/1.25gm (1.62%)
2
•
40.5 mg/2.5gm (1.62%)
2
•
ANDROGEL PUMP – testosterone
td gel 12.5 mg/act (1%)
2
•
ANDROGEL PUMP – testosterone
td gel 20.25 mg/act (1.62%)
2
•
ANDROID – methyltestosterone
cap 10 mg
3
ANDROXY – fluoxymesterone tab
10 mg
1
•
AVEED – testosterone
undecanoate im inj in oil 750
mg/3ml (250mg/ml)
3
•
AXIRON – testosterone td soln 30
mg/act
3
danazol cap 50 mg
1
NATESTO – testosterone nasal gel 3
5.5 mg/act
1
oxandrolone tab 2.5 mg
(Oxandrin)
1
oxandrolone tab 10 mg
(Oxandrin)
3
STRIANT – testosterone buccal
mucoadhesive system 30 mg
3
TESTIM – testosterone td gel 50
mg/5gm (1%)
3
TESTOSTERONE – testosterone
td gel 25 mg/2.5gm (1%)
3
td gel 50 mg/5gm (1%)
3
td gel 25 mg/2.5gm (1%)
3
td gel 10mg/act (2%)
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
3
TESTOSTERONE PUMP –
testosterone td gel 12.5 mg/act
(1%)
3
TESTRED – methyltestosterone
cap 10 mg
VOGELXO – testosterone td gel 50 3
mg/5gm (1%)
3
VOGELXO PUMP – testosterone
td gel 12.5 mg/act (1%)
danazol cap 100 mg
1
ESTROGENS
danazol cap 200 mg
1
ALORA – estradiol td patch twice
weekly 0.025 mg/24hr
ANDROGEN-ANABOLIC
16
•
•
• •
•
•
•
• •
• •
• •
• •
• •
•
•
•
• •
•
• •
• •
3
Quantity Limits
1
Restricted Access
prednisone tab 10 mg
Prior Review
1
FORTESTA – testosterone td gel
10mg/act (2%)
Specialty
prednisone tab 5 mg
Drug Name
Drug Tier
1
Quantity Limits
prednisone tab 2.5 mg
Restricted Access
1
Prior Review
prednisone tab 1 mg
Specialty
Drug Name
Drug Tier
2015
weekly 0.05 mg/24hr
3
weekly 0.075 mg/24hr
3
weekly 0.1 mg/24hr
esterified estrogens &
methyltestosterone tab
1.25-2.5 mg
1
1
3
estradiol & norethindrone
acetate tab 0.5-0.1 mg
(Activella)
ANGELIQ – drospirenone-estradiol
tab 0.25-0.5 mg
3
estradiol & norethindrone
acetate tab 1-0.5 mg (Activella)
1
ANGELIQ – drospirenone-estradiol
tab 0.5-1 mg
3
estradiol tab 0.5 mg (Estrace)
1
estradiol tab 1 mg (Estrace)
1
CLIMARA PRO – estradiollevonorgestrel td patch weekly
0.045-0.015 mg/day
3
estradiol tab 2 mg (Estrace)
1
estradiol td patch twice weekly
0.025 mg/24hr (Vivelle-dot)
1
COMBIPATCH – estradiolnorethindrone ace td pttw
0.05-0.14 mg/day
3
1
3
1
COMBIPATCH – estradiolnorethindrone ace td pttw
0.05-0.25 mg/day
1
DIVIGEL – estradiol td gel 0.25
mg/0.25gm (0.1%)
3
1
DIVIGEL – estradiol td gel 0.5
mg/0.5gm (0.1%)
3
estradiol td patch weekly
0.025 mg/24hr (Climara)
1
0.0375 mg/24hr (37.5 mcg/24hr)
(Climara)
1
1
1
1
1
estradiol valerate im in oil 20 mg/
ml (Delestrogen)
1
estradiol valerate im in oil 40 mg/
ml (Delestrogen)
1
DIVIGEL – estradiol td gel 1 mg/gm 3
(0.1%)
3
ELESTRIN – estradiol gel 0.06%
(0.52 mg/0.87 gm metered-dose
pump)
ENJUVIA – estrogens, conjugated 3
synthetic b tab 0.3 mg
1
esterified estrogens &
methyltestosterone tab
0.625-1.25 mg
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
17
ESTROGEL – estradiol gel 0.06%
(0.75 mg/1.25 gm metered-dose
pump)
3
PREMPRO – conjugated estrogenmedroxyprogest acetate tab
0.3-1.5 mg
2
ESTROPIPATE – estropipate tab 3
mg
1
2
estropipate tab 0.75 mg
1
0.45-1.5 mg
estropipate tab 1.5 mg
1
2
EVAMIST – estradiol transdermal
spray 1.53 mg/spray
3
0.625-2.5 mg
3
0.625-5 mg
2
MENOSTAR – estradiol td patch
weekly 14 mcg/24hr
MINIVELLE – estradiol td patch
twice weekly 0.0375 mg/24hr
3
3
3
3
norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg
(Femhrt low dose)
1
norethindrone acetate-ethinyl
estradiol tab 1 mg-5 mcg
1
PREFEST – estradiol tab 1
mg(15)/estrad-norgestimate tab
1-0.09mg(15)
3
PREMARIN – estrogens,
conjugated tab 0.3 mg
2
2
2
2
2
PREMPHASE – conj est 0.625(14)/ 2
conj est-medroxypro ac tab
0.625-5mg(14)
18
CONTRACEPTIVES
BEYAZ – drospirenone-ethinyl
estrad-levomefolate tab
3-0.02-0.451 mg
3
ELLA – ulipristal acetate tab 30 mg
3
levonorgestrel tab 1.5 mg (Plan b
one-step)
1
LO LOESTRIN FE – norethin-eth
estradiol-fe tab 1 mg-10 mcg
(24)/10 mcg (2)
2
medroxyprogesterone acetate im
susp 150 mg/ml (Depo-provera
contrac)
1
NATAZIA – estradiol valeratedienogest tab 3 mg /2-2 mg/2-3
mg/1 mg
3
NECON 1/50-28 – norethindrone &
mestranol tab 1 mg-50 mcg
1
NECON 10/11-28 – norethindroneeth estradiol tab 0.5-35/1-35 mgmcg (10/11)
1
1
norelgestromin-ethinyl estradiol
td ptwk 150-35 mcg/24hr (Ortho
evra)
NUVARING – etonogestrel-ethinyl 2
estradiol va ring 0.120-0.015
mg/24hr
OGESTREL – norgestrel & ethinyl 1
estradiol tab 0.5 mg-50 mcg
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
oral contraceptives –
all generics
1
BYDUREON – exenatide extended
release for inj susp 2 mg
2
ORTHO TRI-CYCLEN LO –
norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mgmcg
3
BYETTA – exenatide soln peninjector 5 mcg/0.02ml
2
BYETTA – exenatide soln peninjector 10 mcg/0.04ml
2
SAFYRAL – drospirenoneethinyl estrad-levomefolate tab
3-0.03-0.451 mg
3
CHLORPROPAMIDE –
chlorpropamide tab 100 mg
1
2
CHLORPROPAMIDE –
chlorpropamide tab 250 mg
1
YAZ – drospirenone-ethinyl
estradiol tab 3-0.02 mg
1
CYCLOSET – bromocriptine
mesylate tab 0.8 mg (base
equivalent)
3
ZOVIA 1/50E – ethynodiol
diacetate & ethinyl estradiol tab 1
mg-50 mcg
glimepiride tab 1 mg (Amaryl)
1
1
1
PROGESTINS
medroxyprogesterone acetate
tab 2.5 mg (Provera)
1
tab 5 mg (Provera)
1
glipizide tab sr 24hr 2.5 mg
(Glucotrol xl)
1
tab 10 mg (Provera)
1
glipizide tab sr 24hr 5 mg
(Glucotrol xl)
1
MEGACE ES – megestrol acetate
susp 625 mg/5ml
3
glipizide tab sr 24hr 10 mg
(Glucotrol xl)
1
megestrol acetate susp
625 mg/5ml (Megace es)
1
glipizide tab 5 mg (Glucotrol)
1
glipizide tab 10 mg (Glucotrol)
1
norethindrone acetate tab 5 mg
(Aygestin)
1
glipizide-metformin hcl tab
2.5-250 mg
1
progesterone im in oil 50 mg/ml
1
1
progesterone micronized cap
100 mg (Prometrium)
1
2.5-500 mg
1
progesterone micronized cap
200 mg (Prometrium)
1
5-500 mg
GLUCAGEN HYPOKIT – glucagon
hcl (rdna) for inj 1 mg (base
equiv)
2
GLUCAGON EMERGENCY KIT –
glucagon (rdna) for inj kit 1 mg
2
GLUMETZA – metformin hcl tab sr
24hr modified release 500 mg
3
GLUMETZA – metformin hcl tab sr
24hr modified release 1000 mg
3
ANTIDIABETICS
acarbose tab 25 mg (Precose)
1
1
1
BYDUREON – exenatide extended
release for susp pen-injector 2
mg
2
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
19
GLYBURIDE – glyburide tab 1.25
mg
1
GLYBURIDE – glyburide tab 2.5
mg
1
GLYBURIDE – glyburide tab 5 mg
1
glyburide micronized tab 1.5 mg
(Glynase)
1
glyburide micronized tab 3 mg
(Glynase)
1
glyburide micronized tab 6 mg
(Glynase)
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
1
JANUVIA – sitagliptin phosphate
2
1
2
glyburide tab 1.25 mg
glyburide tab 2.5 mg
1
glyburide tab 5 mg
2
1
glyburide-metformin tab
1.25-250 mg (Glucovance)
1
JENTADUETO – linagliptinmetformin hcl tab 2.5-500 mg
3
2.5-500 mg (Glucovance)
1
3
5-500 mg (Glucovance)
1
3
GLYSET – miglitol tab 25 mg
3
3
3
KAZANO – alogliptin-metformin hcl
tab 12.5-500 mg
3
3
INVOKAMET – canagliflozinmetformin hcl tab 50-500 mg
2
KAZANO – alogliptin-metformin hcl
tab 12.5-1000 mg
2
2
KOMBIGLYZE XR – saxagliptinmetformin hcl tab sr 24hr
2.5-1000 mg
2
KOMBIGLYZE XR – saxagliptinmetformin hcl tab sr 24hr 5-500
mg
2
2
2
INVOKANA – canagliflozin tab 100
mg
2
KOMBIGLYZE XR – saxagliptinmetformin hcl tab sr 24hr 5-1000
mg
4
INVOKANA – canagliflozin tab 300
mg
2
KORLYM – mifepristone tab 300
mg
JANUMET – sitagliptin-metformin
hcl tab 50-500 mg
metformin hcl tab sr 24hr 500 mg
(Glucophage xr)
1
2
JANUMET – sitagliptin-metformin
hcl tab 50-1000 mg
metformin hcl tab sr 24hr 750 mg
(Glucophage xr)
1
2
20
• •
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
metformin hcl tab sr 24hr
osmotic 500 mg (Fortamet)
1
pioglitazone hcl-glimepiride tab
30-2 mg (Duetact)
1
metformin hcl tab sr 24hr
osmotic 1000 mg (Fortamet)
1
pioglitazone hcl-glimepiride tab
30-4 mg (Duetact)
1
metformin hcl tab 500 mg
(Glucophage)
1
pioglitazone hcl-metformin hcl
tab 15-500 mg (Actoplus met)
1
(Glucophage)
1
pioglitazone hcl-metformin hcl
tab 15-850 mg (Actoplus met)
1
(Glucophage)
1
PRANDIMET – repaglinidemetformin hcl tab 1-500 mg
3
nateglinide tab 60 mg (Starlix)
1
3
nateglinide tab 120 mg (Starlix)
1
PRANDIMET – repaglinidemetformin hcl tab 2-500 mg
NESINA – alogliptin benzoate tab
6.25 mg (base equiv)
3
repaglinide tab 0.5 mg (Prandin)
1
repaglinide tab 1 mg (Prandin)
1
12.5 mg (base equiv)
3
repaglinide tab 2 mg (Prandin)
1
3
RIOMET – metformin hcl oral soln
500 mg/5ml
3
25 mg (base equiv)
ONGLYZA – saxagliptin hcl tab 2.5
mg (base equiv)
SYMLINPEN 120 – pramlintide
acetate pen-inj 2700 mcg/2.7ml
(1000 mcg/ml)
3
2
ONGLYZA – saxagliptin hcl tab 5
mg (base equiv)
2
3
OSENI – alogliptin-pioglitazone tab
12.5-15 mg
3
SYMLINPEN 60 – pramlintide
acetate pen-inj 1500 mcg/1.5ml
(1000 mcg/ml)
1
12.5-30 mg
3
TOLAZAMIDE – tolazamide tab
500 mg
tolazamide tab 250 mg
1
12.5-45 mg
3
TOLBUTAMIDE – tolbutamide tab
500 mg
1
25-15 mg
3
TRADJENTA – linagliptin tab 5 mg
3
25-30 mg
VICTOZA – liraglutide soln peninjector 18 mg/3ml (6 mg/ml)
2
3
25-45 mg
3
pioglitazone hcl tab 15 mg (base
equiv) (Actos)
1
equiv) (Actos)
equiv) (Actos)
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
Rapid-Acting Insulins
APIDRA – insulin glulisine inj 100
unit/ml
3
•
3
•
1
APIDRA SOLOSTAR – insulin
glulisine soln pen-injector inj 100
unit/ml
HUMALOG – insulin lispro (human) 3
soln cartridge 100 unit/ml
•
1
21
HUMALOG – insulin lispro (human) 3
inj 100 unit/ml
3
HUMALOG KWIKPEN – insulin
lispro (human) soln pen-injector
100 unit/ml
3
HUMALOG KWIKPEN – insulin
lispro (human) soln pen-injector
200 unit/ml
NOVOLOG – insulin aspart inj 100 2
unit/ml
2
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
•
•
•
3
•
HUMULIN N – insulin nph (human)
(isophane) inj 100 unit/ml
3
•
HUMULIN N KWIKPEN – insulin
nph (human) (isophane) susp
pen-injector 100 unit/ml
3
•
HUMULIN N U-100 PEN – insulin
nph (human) (isophane) susp
pen-injector 100 unit/ml
3
•
HUMULIN 70/30 – insulin nph
isophane & regular human inj
100 unit/ml (70-30)
3
•
HUMULIN 70/30 KWIKPEN –
insulin nph & regular susp pen-inj
100 unit/ml (70-30)
3
•
3
•
HUMULIN R – insulin regular
(human) inj 100 unit/ml
3
•
3
•
NOVOLIN N – insulin nph (human)
(isophane) inj 100 unit/ml
2
HUMULIN R U-500 (CONCENTR
– insulin regular (human) inj 500
unit/ml
2
NOVOLIN R – insulin regular
2
NOVOLIN N RELION – insulin nph
(human) (isophane) inj 100 unit/
ml
2
NOVOLIN 70/30 – insulin nph
isophane & regular human inj
100 unit/ml (70-30)
2
NOVOLIN R RELION – insulin
regular (human) inj 100 unit/ml
RELION R – insulin regular
2
NOVOLIN 70/30 RELION – insulin
nph isophane & regular human
inj 100 unit/ml (70-30)
2
Intermediate-Acting Insulins
HUMALOG MIX 50/50 – insulin
lispro prot & lispro (human) inj
100 unit/ml (50-50)
3
•
NOVOLOG MIX 70/30 – insulin
aspart prot & aspart (human) inj
100 unit/ml (70-30)
2
HUMALOG MIX 50/50 KWIKPEN
– insulin lispro prot & lispro sus
pen-inj 100 unit/ml (50-50)
3
•
NOVOLOG MIX 70/30 PREFILL –
insulin aspart prot & aspart sus
2
HUMALOG MIX 75/25 – insulin
lispro prot & lispro (human) inj
100 unit/ml (75-25)
3
•
Basal Insulins
22
LANTUS – insulin glargine inj 100
unit/ml
2
Quantity Limits
Restricted Access
Prior Review
HUMALOG MIX 75/25 KWIKPEN
– insulin lispro prot & lispro sus
HUMULIN 70/30 PEN – insulin nph
& regular susp pen-inj 100 unit/
ml (70-30)
Short-Acting Insulins
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
LANTUS SOLOSTAR – insulin
glargine soln pen-injector 100
unit/ml
2
levothyroxine sodium tab
112 mcg (Synthroid)
1
LEVEMIR – insulin detemir inj 100
unit/ml
125 mcg (Synthroid)
1
2
LEVEMIR FLEXPEN – insulin
detemir soln pen-injector 100
unit/ml
137 mcg (Synthroid)
1
2
150 mcg (Synthroid)
1
LEVEMIR FLEXTOUCH – insulin
detemir soln pen-injector 100
unit/ml
2
175 mcg (Synthroid)
1
2
200 mcg (Synthroid)
1
TOUJEO SOLOSTAR – insulin
glargine soln pen-injector 300
unit/ml
300 mcg (Synthroid)
1
THYROID AGENTS
3
liothyronine sodium tab 5 mcg
(Cytomel)
1
ARMOUR THYROID – thyroid tab
15 mg (1/4 grain)
3
(Cytomel)
1
30 mg (1/2 grain)
3
(Cytomel)
1
60 mg (1 grain)
3
methimazole tab 5 mg (Tapazole)
1
90 mg (1 1/2 grain)
1
120 mg (2 grain)
3
methimazole tab 10 mg
(Tapazole)
propylthiouracil tab 50 mg
1
180 mg (3 grain)
3
SYNTHROID – levothyroxine
sodium tab 25 mcg
2
240 mg (4 grain)
3
sodium tab 50 mcg
2
300 mg (5 grain)
3
sodium tab 75 mcg
2
25 mcg (Synthroid)
1
sodium tab 88 mcg
2
50 mcg (Synthroid)
1
sodium tab 100 mcg
2
75 mcg (Synthroid)
1
sodium tab 112 mcg
2
88 mcg (Synthroid)
1
sodium tab 125 mcg
2
100 mcg (Synthroid)
1
sodium tab 137 mcg
2
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
23
sodium tab 150 mcg
2
TIROSINT – levothyroxine sodium
cap 137 mcg
2
sodium tab 175 mcg
2
cap 150 mcg
2
sodium tab 200 mcg
2
OXYTOCICS
sodium tab 300 mcg
2
methylergonovine maleate tab
0.2 mg
thyroid tab 30 mg (1/2 grain)
(Armour thyroid)
1
thyroid tab 60 mg (1 grain)
(Armour thyroid)
1
thyroid tab 90 mg (1 1/2 grain)
(Armour thyroid)
1
THYROLAR-1 – liotrix (t3-t4) tab
60 mg (12.5-50 mcg)
3
THYROLAR-1/2 – liotrix (t3-t4) tab
30 mg (6.25-25 mcg)
3
THYROLAR-1/4 – liotrix (t3-t4) tab
15 mg (3.1-12.5 mcg)
3
120 mg (25-100 mcg)
3
180 mg (37.5-150 mcg)
ENDOCRINE and METABOLIC AGENTS - MISC.
3
ACTONEL – risedronate sodium
tab 5 mg
3
tab 30 mg
3
tab 35 mg
3
tab 150 mg
1
ALENDRONATE SODIUM –
alendronate sodium tab 40 mg
1
1
1
3
(Fosamax)
1
cap 13 mcg
2
ATELVIA – risedronate sodium tab
3
cap 25 mcg
2
BINOSTO – alendronate sodium
effervescent tab 70 mg
3
cap 50 mcg
2
4
cap 75 mcg
2
BRAVELLE – Benefit Limits may
apply – urofollitropin purified for
inj 75 unit
3
•
cap 88 mcg
2
BUPHENYL – sodium
phenylbutyrate tab 500 mg
3
•
cap 100 mcg
2
BUPHENYL – sodium
phenylbutyrate oral powder 3 gm/
teaspoonful
2
cabergoline tab 0.5 mg
1
cap 112 mcg
1
cap 125 mcg
2
calcitonin (salmon) nasal soln
200 unit/act (Miacalcin)
calcitriol cap 0.25 mcg (Rocaltrol)
1
•
Quantity Limits
Restricted Access
1
24
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
ETIDRONATE DISODIUM –
etidronate disodium tab 400 mg
1
FOLLISTIM AQ – Benefit Limits
may apply – follitropin beta inj 75
unit/0.5ml
3
4
may apply – follitropin beta inj
300 unit/0.36ml
3
chorionic gonadotropin for inj
10000 unit – Benefit Limits
may apply
1
600 unit/0.72ml
3
clomiphene citrate tab 50 mg –
Benefit Limits may apply
1
3
CYSTADANE – betaine powder for
oral solution
3
900 unit/1.08ml
4
desmopressin acetate inj 4 mcg/
ml (Ddavp)
1
FORTEO – teriparatide
(recombinant) inj 600 mcg/2.4ml
1
desmopressin acetate nasal soln
0.01% (refrigerated) (Ddavp)
1
FORTICAL – calcitonin (salmon)
nasal soln 200 unit/act
2
desmopressin acetate nasal
spray soln 0.01% (Ddavp)
1
FOSAMAX PLUS D – alendronate
sodium-cholecalciferol tab
70-2800 mg-unit
1
FOSAMAX PLUS D – alendronate
sodium-cholecalciferol tab
70-5600 mg-unit
2
desmopressin acetate nasal
spray soln 0.01% (refrigerated)
desmopressin acetate tab 0.1 mg
(Ddavp)
1
4
desmopressin acetate tab 0.2 mg
(Ddavp)
1
GANIRELIX ACETATE – Benefit
Limits may apply – ganirelix
acetate inj 250 mcg/0.5ml
• • •
1
GENOTROPIN – somatropin for
subcutaneous inj 5 mg
4
doxercalciferol cap 0.5 mcg
(Hectorol)
• • •
doxercalciferol cap 1 mcg
(Hectorol)
GENOTROPIN – somatropin for inj
12 mg (13.8 mg overfill)
4
1
• • •
doxercalciferol cap 2.5 mcg
(Hectorol)
GENOTROPIN MINIQUICK –
somatropin for inj 0.2 mg
4
1
4
• •
• • •
4
• •
• • •
4
• • •
somatropin for inj 1 mg
4
• • •
EGRIFTA – tesamorelin acetate for 4
inj 1 mg (base equiv)
EGRIFTA – tesamorelin acetate for 4
inj 2 mg (base equiv)
1
ETIDRONATE DISODIUM –
etidronate disodium tab 200 mg
•
Quantity Limits
Restricted Access
CETROTIDE – Benefit Limits may
apply – cetrorelix acetate for inj
kit 0.25 mg
Prior Review
4
Specialty
CARBAGLU – carglumic acid tab
200 mg
Drug Name
Drug Tier
1
Quantity Limits
calcitriol oral soln 1 mcg/ml
(Rocaltrol)
Restricted Access
1
Prior Review
calcitriol cap 0.5 mcg (Rocaltrol)
Specialty
Drug Name
Drug Tier
2015
• •
25
4
• • •
HUMATROPE – somatropin for inj
6 mg (18 unit)
4
• • •
4
• • •
12 mg (36 unit)
4
• • •
4
• • •
24 mg
4
• • •
4
• • •
HUMATROPE COMBO PACK –
4
• • •
4
• • •
ibandronate sodium tab 150 mg
(base equivalent) (Boniva)
1
GONAL-F – Benefit Limits may
apply – follitropin alfa for inj 450
unit
3
INCRELEX – mecasermin inj 40
mg/4ml (10 mg/ml)
4
• •
•
GONAL-F – Benefit Limits may
apply – follitropin alfa for inj 1050
unit
KUVAN – sapropterin
dihydrochloride soluble tab 100
mg
4
3
•
3
dihydrochloride powder packet
100 mg
4
GONAL-F RFF – Benefit Limits
may apply – follitropin alfa for inj
75 unit
•
GONAL-F RFF PEN – Benefit
Limits may apply – follitropin alfa
inj 300 unit/0.5ml
dihydrochloride powder packet
500 mg
4
3
inj 450 unit/0.75ml
levocarnitine oral soln
1 gm/10ml (10%) (Carnitor)
1
3
levocarnitine tab 330 mg
(Carnitor)
1
inj 900 unit/1.5ml
3
LUPANETA PACK – leuprolide (1
mon) inj 3.75 mg & norethindrone
tab 5 mg kit
4
GONAL-F RFF REDIJECT –
Benefit Limits may apply –
follitropin alfa inj 300 unit/0.5ml
3
LUPANETA PACK – leuprolide
(3 mon) inj 11.25 mg &
norethindrone tab 5 mg kit
4
3
3
H.P. ACTHAR – corticotropin inj
gel 80 unit/ml
4
• • •
5 mg
4
• • •
Drug Name
26
Drug Name
LUPRON DEPOT-PED – leuprolide 2
acetate for inj pediatric kit 7.5 mg
acetate for inj pediatric kit 11.25
mg
acetate for inj pediatric kit 15 mg
acetate (3 month) for inj pediatric
kit 11.25 mg
•
•
•
•
Quantity Limits
Restricted Access
Specialty
Prior Review
Drug Tier
Quantity Limits
Specialty
Restricted Access
Drug Tier
Prior Review
2015
NUTROPIN AQ PEN – somatropin
inj 20 mg/2ml
4
• • •
octreotide acetate inj 50 mcg/ml
(0.05 mg/ml) (Sandostatin)
1
•
1
•
1
•
1
•
octreotide acetate inj 1000 mcg/
ml (1 mg/ml) (Sandostatin)
1
•
OMNITROPE – somatropin inj 5
mg/1.5ml
3
• •
OMNITROPE – somatropin inj 10
mg/1.5ml
3
• •
OMNITROPE – somatropin for inj
5.8 mg
3
• •
ORFADIN – nitisinone cap 2 mg
4
4
4
•
•
•
OVIDREL – Benefit Limits may
apply – choriogonadotropin alfa
inj 250 mcg/0.5ml
4
paricalcitol cap 1 mcg (Zemplar)
1
1
• • •
1
raloxifene hcl tab 60 mg (Evista)
1
• • •
RAVICTI – glycerol phenylbutyrate
liquid 1.1 gm/ml
4
• • •
REPRONEX – Benefit Limits may
apply – menotropins for inj 75
unit
4
risedronate sodium tab delayed
release 35 mg (Atelvia)
1
risedronate sodium tab 5 mg
(Actonel)
1
(Actonel)
1
• •
• •
• •
• •
• •
• • •
• • •
• • •
• • •
• • •
• • •
• • •
Drug Name
Quantity Limits
Restricted Access
Specialty
Prior Review
Drug Tier
Quantity Limits
•
Restricted Access
Specialty
acetate (3 month) for inj pediatric
kit 30 mg
4
MENOPUR – Benefit Limits
may apply – menotropins for
subcutaneous inj 75 unit
4
MYALEPT – metreleptin for
subcutaneous inj 11.3 mg
4
NATPARA – parathyroid hormone
(recombinant) for inj cartridge 25
mcg
4
mcg
4
mcg
4
(recombinant) for inj cartridge
100 mcg
4
NORDITROPIN CARTRIDGE –
somatropin inj 5 mg/1.5ml
4
NORDITROPIN FLEXPRO –
4
4
4
somatropin inj 30 mg/3ml
4
NORDITROPIN NORDIFLEX PEN
– somatropin inj 30 mg/3ml
4
NUTROPIN AQ NUSPIN 10 –
4
4
NUTROPIN AQ PEN – somatropin 4
inj 10 mg/2ml
Drug Name
Prior Review
Drug Tier
2015
•
27
(Actonel)
1
SAIZEN – somatropin (nonrefrigerated) for inj 5 mg
4
• • •
SAIZEN – somatropin (nonrefrigerated) for inj 8.8 mg
4
• • •
SAIZEN CLICK.EASY –
somatropin (non-refrigerated) for
inj 8.8 mg
4
• • •
SAMSCA – tolvaptan tab 15 mg
4
SAMSCA – tolvaptan tab 30 mg
4
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)
3
•
mg (base equiv)
3
•
mg (base equiv)
3
•
SEROSTIM – somatropin (nonrefrigerated) for subcutaneous inj
4 mg
4
• • •
5 mg
4
28
•
•
•
•
•
•
• • •
6 mg
4
• • •
SIGNIFOR – pasireotide
diaspartate inj 0.3 mg/ml (base
equiv)
4
•
equiv)
4
•
equiv)
4
•
sodium phenylbutyrate oral
powder 3 gm/teaspoonful
(Buphenyl)
1
•
SOMATULINE DEPOT – lanreotide 4
acetate extended release inj 60
mg/0.2ml
mg/0.3ml
mg/0.5ml
SOMAVERT – pegvisomant for inj 3
10 mg (as protein)
15 mg (as protein)
20 mg (as protein)
25 mg (as protein)
30 mg (as protein)
STIMATE – desmopressin acetate 3
nasal soln 1.5 mg/ml
4
SYNAREL – nafarelin acetate
nasal soln 2 mg/ml
4
TEV-TROPIN – somatropin for
•
Drug Name
•
•
•
•
•
•
•
•
•
• • •
Quantity Limits
Restricted Access
Prior Review
Specialty
1
Drug Tier
(Actonel)
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
1
ZOMACTON – somatropin for inj
10 mg
4
• • •
NITRO-BID – nitroglycerin oint 2%
1
ZORBTIVE – somatropin (nonrefrigerated) for subcutaneous inj
8.8 mg
• • •
NITRO-DUR – nitroglycerin td
patch 24hr 0.1 mg/hr
2
4
2
2
CARDIOVASCULAR AGENTS
CARDIOTONICS
DIGOXIN – digoxin oral soln 0.05
mg/ml
1
2
digoxin tab 125 mcg (0.125 mg)
(Lanoxin)
1
2
digoxin tab 250 mcg (0.25 mg)
(Lanoxin)
1
2
LANOXIN – digoxin tab 62.5 mcg
(0.0625 mg)
2
nitroglycerin cap cr 2.5 mg
1
nitroglycerin cap cr 6.5 mg
1
LANOXIN – digoxin tab 125 mcg
(0.125 mg)
2
nitroglycerin cap cr 9 mg
1
2
nitroglycerin td patch 24hr
0.1 mg/hr (Nitro-dur)
1
LANOXIN – digoxin tab 187.5 mcg
(0.1875 mg)
2
1
LANOXIN – digoxin tab 250 mcg
(0.25 mg)
1
1
nitroglycerin tl soln 0.4 mg/spray
(400 mcg/spray) (Nitrolingual
pumpspr)
1
NITROMIST – nitroglycerin lingual
aerosol 400 mcg/spray
3
ANTIANGINAL AGENTS
ISOSORBIDE DINITRATE –
isosorbide dinitrate tab 30 mg
1
isosorbide dinitrate tab cr 40 mg
1
(Isordil titradose)
1
1
1
isosorbide mononitrate tab sr
24hr 30 mg (Imdur)
1
NITROSTAT – nitroglycerin sl tab
0.3 mg
2
24hr 60 mg (Imdur)
1
0.4 mg
2
24hr 120 mg (Imdur)
1
0.6 mg
2
isosorbide mononitrate tab
10 mg
1
RANEXA – ranolazine tab sr 12hr
500 mg
2
Quantity Limits
isosorbide mononitrate tab
20 mg
Restricted Access
• • •
Prior Review
4
Drug Name
Specialty
ZOMACTON – somatropin for
Drug Name
Drug Tier
Quantity Limits
Specialty
Restricted Access
Drug Tier
Prior Review
2015
29
2
INNOPRAN XL – propranolol hcl
sustained-release beads cap sr
24hr 120 mg
3
acebutolol hcl cap 200 mg
(Sectral)
1
labetalol hcl tab 100 mg
(Trandate)
1
acebutolol hcl cap 400 mg
(Sectral)
1
(Trandate)
1
atenolol tab 25 mg (Tenormin)
1
1
1
(Trandate)
1
LEVATOL – penbutolol sulfate tab
20 mg
3
betaxolol hcl tab 10 mg (Kerlone)
1
betaxolol hcl tab 20 mg (Kerlone)
metoprolol succinate tab sr 24hr
25 mg (Toprol xl)
1
1
bisoprolol fumarate tab 5 mg
(Zebeta)
1
50 mg (Toprol xl)
1
bisoprolol fumarate tab 10 mg
(Zebeta)
1
100 mg (Toprol xl)
1
BYSTOLIC – nebivolol hcl tab 2.5
3
200 mg (Toprol xl)
1
metoprolol tartrate tab 25 mg
1
(Lopressor)
1
(Lopressor)
1
nadolol tab 20 mg (Corgard)
1
1
1
pindolol tab 5 mg
1
pindolol tab 10 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
60 mg (Inderal la)
1
80 mg (Inderal la)
1
RANEXA – ranolazine tab sr 12hr
1000 mg
BETA BLOCKERS
BYSTOLIC – nebivolol hcl tab 5 mg 3
(base equivalent)
3
BYSTOLIC – nebivolol hcl tab 10
3
BYSTOLIC – nebivolol hcl tab 20
1
carvedilol tab 3.125 mg (Coreg)
1
1
carvedilol tab 25 mg (Coreg)
1
COREG CR – carvedilol phosphate 3
cap sr 24hr 10 mg
cap sr 24hr 20 mg
cap sr 24hr 40 mg
cap sr 24hr 80 mg
3
INNOPRAN XL – propranolol hcl
sustained-release beads cap sr
24hr 80 mg
30
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
1
diltiazem hcl cap sr 24hr 120 mg
1
1
1
diltiazem hcl coated beads cap
sr 24hr 120 mg (Cardizem cd)
1
1
160 mg (Inderal la)
propranolol hcl tab 10 mg
1
1
1
1
1
sotalol hcl (afib/afl) tab 80 mg
(Betapace af)
1
1
(Betapace af)
1
1
(Betapace af)
1
1
sotalol hcl tab 80 mg (Betapace)
1
diltiazem hcl coated beads tab sr
24hr 180 mg (Cardizem la)
1
1
sotalol hcl tab 120 mg (Betapace) 1
sotalol hcl tab 160 mg (Betapace) 1
sotalol hcl tab 240 mg
1
1
1
TIMOLOL MALEATE – timolol
maleate tab 5 mg
1
1
maleate tab 10 mg
1
1
maleate tab 20 mg
diltiazem hcl extended release
beads cap sr 24hr 120 mg
(Tiazac)
1
(Tiazac)
1
1
CALCIUM CHANNEL BLOCKERS
amlodipine besylate tab 2.5 mg
(Norvasc)
1
amlodipine besylate tab 5 mg
(Norvasc)
1
amlodipine besylate tab 10 mg
(Norvasc)
1
CARDIZEM CD – diltiazem hcl
coated beads cap sr 24hr 360
mg
2
(Tiazac)
1
CARDIZEM LA – diltiazem hcl
coated beads tab sr 24hr 120 mg
2
(Tiazac)
1
1
(Tiazac)
Quantity Limits
1
Restricted Access
1
1
Prior Review
120 mg (Inderal la)
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
31
(Tiazac)
1
NISOLDIPINE ER – nisoldipine tab
sr 24hr 25.5 mg
1
diltiazem hcl tab 30 mg
(Cardizem)
nisoldipine tab sr 24hr 8.5 mg
(Sular)
1
1
(Cardizem)
nisoldipine tab sr 24hr 17 mg
(Sular)
1
1
1
nisoldipine tab sr 24hr 34 mg
(Sular)
1
(Cardizem)
1
NYMALIZE – nimodipine oral soln
60 mg/20ml
4
felodipine tab sr 24hr 2.5 mg
1
1
felodipine tab sr 24hr 5 mg
1
VERAPAMIL HCL – verapamil hcl
tab 40 mg
felodipine tab sr 24hr 10 mg
1
1
isradipine cap 2.5 mg
1
verapamil hcl cap sr 24hr
100 mg (Verelan pm)
1
120 mg (Verelan)
1
isradipine cap 5 mg
nicardipine hcl cap 20 mg
1
1
180 mg (Verelan)
1
nicardipine hcl cap 30 mg
nifedipine cap 10 mg (Procardia)
1
1
nifedipine cap 20 mg
1
200 mg (Verelan pm)
nifedipine tab sr 24hr 30 mg
(Adalat cc)
1
240 mg (Verelan)
1
(Adalat cc)
1
300 mg (Verelan pm)
1
(Adalat cc)
1
360 mg (Verelan)
1
nifedipine tab sr 24hr osmotic
30 mg (Procardia xl)
1
verapamil hcl tab cr 120 mg
(Calan sr)
1
1
(Calan sr)
1
1
(Calan sr)
1
nimodipine cap 30 mg
1
verapamil hcl tab 80 mg (Calan)
1
NISOLDIPINE – nisoldipine tab sr
24hr 20 mg
1
verapamil hcl tab 120 mg (Calan)
1
24hr 30 mg
1
amiodarone hcl tab 100 mg
1
24hr 40 mg
(Cordarone)
1
1
1
32
ANTIARRHYTHMICS
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
disopyramide phosphate cap
100 mg (Norpace)
1
TIKOSYN – dofetilide cap 500 mcg
(0.5 mg)
disopyramide phosphate cap
150 mg (Norpace)
1
ANTIHYPERTENSIVES
flecainide acetate tab 50 mg
amlodipine besylate-benazepril
hcl cap 2.5-10 mg (Lotrel)
1
1
1
1
1
hcl cap 5-10 mg (Lotrel)
mexiletine hcl cap 150 mg
1
1
1
1
1
MULTAQ – dronedarone hcl tab
3
1
NORPACE CR – disopyramide
phosphate cap sr 12hr 100 mg
2
1
NORPACE CR – disopyramide
phosphate cap sr 12hr 150 mg
2
amlodipine besylate-valsartan
tab 5-160 mg (Exforge)
1
propafenone hcl cap sr 12hr
225 mg (Rythmol sr)
1
1
325 mg (Rythmol sr)
1
1
425 mg (Rythmol sr)
1
1
propafenone hcl tab 150 mg
(Rythmol)
1
1
(Rythmol)
1
amlodipine-valsartanhydrochlorothiazide tab
5-160-12.5 mg (Exforge hct)
quinidine gluconate tab cr
324 mg
1
5-160-25 mg (Exforge hct)
1
1
1
QUINIDINE SULFATE – quinidine
sulfate tab 200 mg
1
10-160-12.5 mg (Exforge hct)
QUINIDINE SULFATE ER –
quinidine sulfate tab cr 300 mg
1
1
quinidine sulfate tab 300 mg
1
3
1
(0.125 mg)
(0.25 mg)
3
atenolol & chlorthalidone tab
50-25 mg (Tenoretic 50)
1
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
3
33
atenolol & chlorthalidone tab
100-25 mg (Tenoretic 100)
1
AZOR – amlodipine besylateolmesartan medoxomil tab 5-20
mg
2
mg
2
mg
2
mg
2
benazepril &
hydrochlorothiazide tab
5-6.25 mg
1
benazepril &
10-12.5 mg (Lotensin hct)
1
benazepril &
20-12.5 mg (Lotensin hct)
1
benazepril &
20-25 mg (Lotensin hct)
1
benazepril hcl tab 5 mg
1
(Lotensin)
1
(Lotensin)
1
(Lotensin)
1
BENICAR – olmesartan medoxomil 2
tab 5 mg
tab 20 mg
tab 40 mg
34
2
•
•
BENICAR HCT – olmesartan
medoxomil-hydrochlorothiazide
tab 20-12.5 mg
2
•
•
tab 40-12.5 mg
2
•
•
tab 40-25 mg
bisoprolol & hydrochlorothiazide
tab 2.5-6.25 mg (Ziac)
1
tab 5-6.25 mg (Ziac)
1
tab 10-6.25 mg (Ziac)
1
candesartan cilexetil tab 4 mg
(Atacand)
1
(Atacand)
1
(Atacand)
1
(Atacand)
1
candesartan cilexetilhydrochlorothiazide tab
16-12.5 mg (Atacand hct)
1
32-12.5 mg (Atacand hct)
1
32-25 mg (Atacand hct)
1
captopril tab 12.5 mg
1
captopril tab 25 mg
1
•
captopril tab 50 mg
1
captopril tab 100 mg
1
•
CAPTOPRIL/
HYDROCHLOROTHIA –
captopril & hydrochlorothiazide
tab 25-15 mg
1
•
•
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
CAPTOPRIL/
HYDROCHLOROTHIA –
tab 25-25 mg
1
CAPTOPRIL/
HYDROCHLOROTHIA –
tab 50-15 mg
1
CAPTOPRIL/
HYDROCHLOROTHIA –
tab 50-25 mg
1
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
DUTOPROL – metoprolol &
hydrochlorothiazide tab sr 24hr
50-12.5 mg
2
100-12.5 mg
2
EDARBI – azilsartan medoxomil
tab 40 mg
3
•
EDARBI – azilsartan medoxomil
tab 80 mg
3
•
EDARBYCLOR – azilsartan
medoxomil-chlorthalidone tab
40-12.5 mg
3
•
EDARBYCLOR – azilsartan
medoxomil-chlorthalidone tab
40-25 mg
3
•
enalapril maleate &
5-12.5 mg
1
enalapril maleate &
10-25 mg (Vaseretic)
1
1
enalapril maleate tab 2.5 mg
(Vasotec)
1
CLORPRES – clonidine &
chlorthalidone tab 0.1-15 mg
1
enalapril maleate tab 5 mg
(Vasotec)
1
1
(Vasotec)
1
3
(Vasotec)
1
doxazosin mesylate tab 1 mg
(Cardura)
1
eplerenone tab 25 mg (Inspra)
1
eplerenone tab 50 mg (Inspra)
1
(Cardura)
1
EPROSARTAN MESYLATE –
eprosartan mesylate tab 600 mg
1
(Cardura)
1
1
(Cardura)
1
fosinopril sodium &
10-12.5 mg
2
fosinopril sodium &
20-12.5 mg
1
25-12.5 mg
fosinopril sodium tab 10 mg
1
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
35
hydralazine hcl tab 10 mg
1
1
1
1
irbesartan tab 75 mg (Avapro)
1
1
1
irbesartan-hydrochlorothiazide
tab 150-12.5 mg (Avalide)
1
irbesartan-hydrochlorothiazide
tab 300-12.5 mg (Avalide)
1
lisinopril & hydrochlorothiazide
tab 10-12.5 mg (Zestoretic)
1
tab 20-12.5 mg (Zestoretic)
1
tab 20-25 mg (Zestoretic)
1
lisinopril tab 2.5 mg (Zestril)
1
lisinopril tab 5 mg (Prinivil)
1
1
1
lisinopril tab 30 mg (Zestril)
1
lisinopril tab 40 mg (Zestril)
1
losartan potassium &
50-12.5 mg (Hyzaar)
1
100-12.5 mg (Hyzaar)
1
100-25 mg (Hyzaar)
1
losartan potassium tab 25 mg
(Cozaar)
1
36
1
methyldopa tab 250 mg
1
methyldopa tab 500 mg
1
METHYLDOPA/
HYDROCHLOROTHI
– methyldopa &
hydrochlorothiazide tab 250-15
mg
1
METHYLDOPA/
HYDROCHLOROTHI
– methyldopa &
hydrochlorothiazide tab 250-25
mg
1
metoprolol &
50-25 mg (Lopressor hct)
1
metoprolol &
100-25 mg (Lopressor hct)
1
metoprolol &
100-50 mg
1
minoxidil tab 2.5 mg
1
minoxidil tab 10 mg
1
moexipril hcl tab 7.5 mg
(Univasc)
1
moexipril hcl tab 15 mg (Univasc) 1
1
moexipril-hydrochlorothiazide
tab 7.5-12.5 mg
1
tab 15-12.5 mg (Uniretic)
1
tab 15-25 mg
1
nadolol & bendroflumethiazide
tab 40-5 mg (Corzide)
1
nadolol & bendroflumethiazide
tab 80-5 mg (Corzide)
1
perindopril erbumine tab 2 mg
Quantity Limits
1
(Cozaar)
Restricted Access
guanfacine hcl tab 2 mg (Tenex)
1
Prior Review
1
(Cozaar)
Specialty
guanfacine hcl tab 1 mg (Tenex)
Drug Name
Drug Tier
1
Quantity Limits
Restricted Access
1
Prior Review
Specialty
Drug Name
Drug Tier
2015
(Aceon)
1
(Aceon)
1
phenoxybenzamine hcl cap
10 mg (Dibenzyline)
1
prazosin hcl cap 1 mg (Minipress) 1
1
PROPRANOLOL/
HYDROCHLOROTH
– propranolol &
hydrochlorothiazide tab 40-25 mg
1
PROPRANOLOL/
HYDROCHLOROTH
– propranolol &
1
quinapril hcl tab 5 mg (Accupril)
TEKTURNA HCT – aliskirenhydrochlorothiazide tab 150-12.5
mg
3
•
TEKTURNA HCT – aliskirenhydrochlorothiazide tab 150-25
mg
3
•
TEKTURNA HCT – aliskirenhydrochlorothiazide tab 300-12.5
mg
3
•
TEKTURNA HCT – aliskirenhydrochlorothiazide tab 300-25
mg
3
•
telmisartan tab 20 mg (Micardis)
1
1
1
telmisartan-amlodipine tab
40-5 mg (Twynsta)
1
40-10 mg (Twynsta)
1
80-5 mg (Twynsta)
1
1
1
1
1
80-10 mg (Twynsta)
1
quinapril-hydrochlorothiazide
tab 10-12.5 mg (Accuretic)
1
telmisartan-hydrochlorothiazide
tab 40-12.5 mg (Micardis hct)
1
tab 20-12.5 mg (Accuretic)
1
tab 80-12.5 mg (Micardis hct)
1
tab 20-25 mg (Accuretic)
1
tab 80-25 mg (Micardis hct)
1
ramipril cap 1.25 mg (Altace)
ramipril cap 2.5 mg (Altace)
1
terazosin hcl cap 1 mg
1
ramipril cap 5 mg (Altace)
1
1
ramipril cap 10 mg (Altace)
1
1
RESERPINE – reserpine tab 0.1
mg
1
1
1
TEKTURNA – aliskiren fumarate
3
•
TEVETEN HCT – eprosartan
mesylate-hydrochlorothiazide tab
600-25 mg
3
RESERPINE – reserpine tab 0.25
mg
trandolapril tab 1 mg (Mavik)
1
3
•
1
TEKTURNA – aliskiren fumarate
1
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
•
37
trandolapril-verapamil hcl tab cr
1-240 mg (Tarka)
1
ACETAZOLAMIDE –
acetazolamide tab 125 mg
1
2-180 mg (Tarka)
1
acetazolamide cap sr 12hr
500 mg (Diamox)
1
2-240 mg (Tarka)
1
acetazolamide tab 250 mg
1
1
ALDACTAZIDE – spironolactone &
2
4-240 mg (Tarka)
2
amiloride & hydrochlorothiazide
tab 5-50 mg
1
TRIBENZOR – olmesartanamlodipine-hydrochlorothiazide
tab 20-5-12.5 mg
amiloride hcl tab 5 mg
1
2
bumetanide tab 0.5 mg
1
tab 40-5-12.5 mg
bumetanide tab 1 mg
1
bumetanide tab 2 mg
1
tab 40-5-25 mg
2
•
CHLOROTHIAZIDE –
chlorothiazide tab 250 mg
1
1
2
•
chlorothiazide tab 500 mg
tab 40-10-12.5 mg
CHLORTHALIDONE –
chlorthalidone tab 25 mg
1
2
•
CHLORTHALIDONE –
chlorthalidone tab 50 mg
1
tab 40-10-25 mg
2
valsartan tab 40 mg (Diovan)
1
DIURIL – chlorothiazide susp 250
mg/5ml
1
1
DYRENIUM – triamterene cap 50
mg
2
1
DYRENIUM – triamterene cap 100
mg
2
valsartan-hydrochlorothiazide
tab 80-12.5 mg (Diovan hct)
1
EDECRIN – ethacrynic acid tab 25
mg
2
1
FUROSEMIDE – furosemide oral
soln 8 mg/ml
2
tab 160-25 mg (Diovan hct)
1
furosemide oral soln 10 mg/ml
1
furosemide tab 20 mg (Lasix)
1
1
1
1
1
tab 320-25 mg (Diovan hct)
1
VECAMYL – mecamylamine hcl
tab 2.5 mg
3
hydrochlorothiazide cap 12.5 mg
(Microzide)
hydrochlorothiazide tab 12.5 mg
1
hydrochlorothiazide tab 25 mg
1
DIURETICS
38
•
•
•
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
1
methazolamide tab 25 mg
(Neptazane)
1
3
methazolamide tab 50 mg
(Neptazane)
1
AUVI-Q – epinephrine solution
auto-injector 0.15 mg/0.15ml
(1:1000)
1
AUVI-Q – epinephrine solution
(1:1000)
3
METHYCLOTHIAZIDE –
methyclothiazide tab 5 mg
metolazone tab 2.5 mg
(Zaroxolyn)
1
3
metolazone tab 5 mg (Zaroxolyn)
1
EPINEPHRINE – epinephrine
solution auto-injector 0.15
mg/0.15ml (1:1000)
metolazone tab 10 mg
1
3
spironolactone &
25-25 mg (Aldactazide)
1
EPINEPHRINE – epinephrine
mg/0.3ml (1:1000)
2
spironolactone tab 25 mg
(Aldactone)
1
EPIPEN 2-PAK – epinephrine
mg/0.3ml (1:1000)
(Aldactone)
1
2
(Aldactone)
1
EPIPEN-JR 2-PAK – epinephrine
mg/0.3ml (1:2000)
midodrine hcl tab 2.5 mg
1
torsemide tab 5 mg (Demadex)
1
midodrine hcl tab 5 mg
1
1
midodrine hcl tab 10 mg
1
1
4
1
NORTHERA – droxidopa cap 100
mg
1
mg
4
triamterene &
hydrochlorothiazide cap
37.5-25 mg (Dyazide)
4
triamterene &
37.5-25 mg (Maxzide-25)
1
mg
triamterene &
75-50 mg (Maxzide)
1
TRIAMTERENE/
HYDROCHLOROTH
– triamterene &
hydrochlorothiazide cap 50-25
mg
1
Quantity Limits
3
indapamide tab 2.5 mg
ADRENACLICK – epinephrine
mg/0.15ml (1:1000)
Restricted Access
indapamide tab 1.25 mg
Prior Review
VASOPRESSORS
1
Specialty
1
Drug Name
Drug Tier
Quantity Limits
Restricted Access
hydrochlorothiazide tab 50 mg
Specialty
Drug Name
Drug Tier
Prior Review
2015
ANTIHYPERLIPIDEMICS
ADVICOR – niacin-lovastatin tab sr 3
24hr 500-20 mg
24hr 750-20 mg
24hr 1000-20 mg
24hr 1000-40 mg
• •
• •
• •
• •
39
ALTOPREV – lovastatin tab sr 24hr 3
20 mg
40 mg
60 mg
1
atorvastatin calcium tab 10 mg
(base equivalent) (Lipitor)
1
1
1
1
cholestyramine light powder
packets 4 gm
1
cholestyramine light powder
4 gm/dose (Questran light)
1
cholestyramine powder packets
4 gm (Questran)
1
cholestyramine powder 4 gm/
dose (Questran)
choline fenofibrate cap dr 45 mg 1
(fenofibric acid equiv) (Trilipix)
1
choline fenofibrate cap dr
135 mg (fenofibric acid equiv)
(Trilipix)
1
colestipol hcl granule packets
5 gm (Colestid flavored)
1
colestipol hcl granules 5 gm
(Colestid flavored)
colestipol hcl tab 1 gm (Colestid) 1
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
fenofibrate micronized cap
43 mg
1
67 mg (Lofibra)
1
130 mg
1
134 mg (Lofibra)
1
200 mg (Lofibra)
1
fenofibrate tab 48 mg (Tricor)
1
fenofibrate tab 54 mg (Lofibra)
1
fenofibrate tab 145 mg (Tricor)
1
fenofibrate tab 160 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
fluvastatin sodium cap 20 mg
(Lescol)
1
fluvastatin sodium cap 40 mg
(Lescol)
1
gemfibrozil tab 600 mg (Lopid)
1
JUXTAPID – lomitapide mesylate
4
• •
•
4
• •
•
CRESTOR – rosuvastatin calcium
tab 5 mg
2
4
• •
•
tab 10 mg
2
4
• •
•
tab 20 mg
2
4
• •
•
tab 40 mg
2
4
• •
•
40
3
LIPOFEN – fenofibrate cap 150 mg 3
3
LIVALO – pitavastatin calcium tab
1 mg (base equiv)
3
2 mg (base equiv)
3
4 mg (base equiv)
1
lovastatin tab 10 mg
pravastatin sodium tab 40 mg
(Pravachol)
1
(Pravachol)
1
SIMCOR – niacin-simvastatin tab
sr 24hr 500-20 mg
3
• •
• •
sr 24hr 500-40 mg
3
• •
• •
sr 24hr 750-20 mg
3
• •
• •
sr 24hr 1000-20 mg
3
• •
sr 24hr 1000-40 mg
3
• •
simvastatin tab 5 mg (Zocor)
1
1
1
1
1
• •
lovastatin tab 20 mg (Mevacor)
1
lovastatin tab 40 mg (Mevacor)
1
niacin tab cr 500 mg
(antihyperlipidemic) (Niaspan)
1
1
1
TRIGLIDE – fenofibrate tab 160
mg
3
NIACOR – niacin
(antihyperlipidemic) tab 500 mg
1
VYTORIN – ezetimibe-simvastatin
tab 10-10 mg
3
• •
omega-3-acid ethyl esters cap
1 gm (Lovaza)
1
tab 10-20 mg
3
• •
PRALUENT – alirocumab
subcutaneous soln pen-injector
75 mg/ml
4
• •
•
tab 10-40 mg
3
• •
•
• •
subcutaneous soln pen-injector
150 mg/ml
• •
tab 10-80 mg
3
4
3
subcutaneous soln prefilled
syringe 75 mg/ml
4
• •
•
WELCHOL – colesevelam hcl tab
625 mg
WELCHOL – colesevelam hcl
packet for susp 3.75 gm
3
4
• •
•
ZETIA – ezetimibe tab 10 mg
2
syringe 150 mg/ml
1
(Pravachol)
1
CARDIOVASCULAR AGENTS - MISC.
3
ADCIRCA – tadalafil tab 20 mg
(pah)
4
ADEMPAS – riociguat tab 0.5 mg
ADEMPAS – riociguat tab 1 mg
4
Quantity Limits
LIPOFEN – fenofibrate cap 50 mg
Restricted Access
3
Prior Review
LESCOL XL – fluvastatin sodium
tab sr 24 hr 80 mg
•
Specialty
• •
Drug Name
Drug Tier
4
Quantity Limits
Specialty
KYNAMRO – mipomersen sodium
soln prefilled syringe 200 mg/ml
Drug Name
Restricted Access
Drug Tier
Prior Review
2015
• •
• •
• •
41
4
ADEMPAS – riociguat tab 2 mg
4
4
• •
• •
• •
4
• •
amlodipine besylate-atorvastatin
calcium tab 2.5-10 mg (Caduet)
1
ORENITRAM – treprostinil
diolamine tab cr 2.5 mg (base
equiv)
4
• •
1
REVATIO – sildenafil citrate tab 20
mg
3
• •
1
REVATIO – sildenafil citrate for
suspension 10 mg/ml
3
• •
calcium tab 5-10 mg (Caduet)
1
sildenafil citrate tab 20 mg
(Revatio)
1
• •
1
TRACLEER – bosentan tab 62.5
mg
3
• •
1
TRACLEER – bosentan tab 125
mg
3
• •
1
1
CAVERJECT – Benefit Limits may
apply – alprostadil for inj 20 mcg
3
1
CAVERJECT – Benefit Limits may
apply – alprostadil for inj 40 mcg
3
1
CAVERJECT IMPULSE – Benefit
Limits may apply – alprostadil for
inj kit 10 mcg
3
1
3
BIDIL – isosorbide dinitratehydralazine hcl tab 20-37.5 mg
2
CAVERJECT IMPULSE – Benefit
Limits may apply – alprostadil for
inj kit 20 mcg
•
ISOXSUPRINE HCL – isoxsuprine
hcl tab 20 mg
CIALIS – Benefit Limits may apply
– tadalafil tab 2.5 mg
3
1
•
isoxsuprine hcl tab 10 mg
– tadalafil tab 5 mg
3
1
LETAIRIS – ambrisentan tab 5 mg
3
3
•
LETAIRIS – ambrisentan tab 10
mg
3
3
•
OPSUMIT – macitentan tab 10 mg
3
equiv)
4
EDEX – Benefit Limits may apply –
alprostadil for inj kit 10 mcg
3
3
equiv)
4
3
Drug Name
ERECTLIE DYSFUNCTION
• •
• •
• •
• •
• •
Quantity Limits
diolamine tab cr 1 mg (base
equiv)
Restricted Access
Prior Review
Specialty
42
Drug Tier
Quantity Limits
Specialty
Restricted Access
Drug Name
Drug Tier
Prior Review
2015
LEVITRA – Benefit Limits may
apply – vardenafil hcl tab 2.5 mg
3
•
apply – vardenafil hcl tab 5 mg
3
•
3
3
MUSE – Benefit Limits may apply
– alprostadil urethral pellet 125
mcg
CLEMASTINE FUMARATE –
clemastine fumarate syrup 0.67
mg/5ml (0.5 mg/5ml base eq)
1
clemastine fumarate tab 2.68 mg
1
•
cyproheptadine hcl syrup
2 mg/5ml
1
•
cyproheptadine hcl tab 4 mg
1
desloratadine tab orally
disintegrating 2.5 mg (Clarinex
reditabs)
1
3
mcg
desloratadine tab orally
disintegrating 5 mg (Clarinex
reditabs)
1
3
desloratadine tab 5 mg (Clarinex)
1
mcg
3
diphenhydramine hcl cap 50 mg
1
1
mcg
3
diphenhydramine hcl elixir
12.5 mg/5ml
1
STAXYN – Benefit Limits may
apply – vardenafil hcl orally
disintegrating tab 10 mg
3
levocetirizine dihydrochloride
soln 2.5 mg/5ml (0.5 mg/ml)
(Xyzal)
levocetirizine dihydrochloride
tab 5 mg (Xyzal)
1
VIAGRA – Benefit Limits may apply
– sildenafil citrate tab 25 mg
2
promethazine hcl suppos
12.5 mg
1
2
promethazine hcl suppos 25 mg
1
promethazine hcl suppos 50 mg
1
2
promethazine hcl syrup
6.25 mg/5ml
1
RESPIRATORY AGENTS
promethazine hcl tab 12.5 mg
1
ANTIHISTAMINES
promethazine hcl tab 25 mg
1
promethazine hcl tab 50 mg
1
brompheniramine maleate tab sr
12hr 6 mg
1
BROMPHENIRAMINE TANNATE
– brompheniramine tannate chew
tab 12 mg
1
carbinoxamine maleate soln
4 mg/5ml
1
carbinoxamine maleate tab 4 mg
1
•
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
NASAL AGENTS - SYSTEMIC and TOPICAL
2
ASTEPRO – azelastine hcl nasal
spray 0.15% (205.5 mcg/spray)
1
azelastine hcl nasal spray 0.1%
(137 mcg/spray)
azelastine hcl nasal spray 0.15% 1
(205.5 mcg/spray) (Astepro)
43
BECONASE AQ – beclomethasone 3
dipropionate monohyd nasal
susp 42 mcg/spray
1
budesonide nasal susp 32 mcg/
act (Rhinocort aqua)
3
DYMISTA – azelastine hclfluticasone prop nasal spray
137-50 mcg/act
1
FLUNISOLIDE – flunisolide nasal
soln 25 mcg/act (0.025%)
flunisolide nasal soln 25 mcg/act 1
(0.025%) (Flunisolide)
1
fluticasone propionate nasal
susp 50 mcg/act (Flonase)
1
ipratropium bromide nasal soln
0.03% (21 mcg/spray) (Atrovent)
1
ipratropium bromide nasal soln
0.06% (42 mcg/spray) (Atrovent)
NASONEX – mometasone furoate 2
nasal susp 50 mcg/act
1
olopatadine hcl nasal soln 0.6%
(Patanase)
3
OMNARIS – ciclesonide nasal
susp 50 mcg/act
3
QNASL – beclomethasone
dipropionate nasal aerosol 80
mcg/act
3
QNASL CHILDRENS –
beclomethasone dipropionate
nasal aerosol 40 mcg/act
1
triamcinolone acetonide nasal
aerosol suspension 55 mcg/act
(Nasacort aq)
3
VERAMYST – fluticasone furoate
nasal susp 27.5 mcg/spray
3
ZETONNA – ciclesonide nasal
aerosol soln 37 mcg/act (50 mcg/
valve)
COUGH/COLD/ALLERGY
acetylcysteine inhal soln 10%
1
acetylcysteine inhal soln 20%
1
44
•
benzonatate cap 100 mg
(Tessalon perles)
1
(Zonatuss)
1
1
brompheniramine &
pseudoephedrine tab sr 12hr
6-45 mg
1
CLARINEX-D 12 HOUR
– desloratadine &
pseudoephedrine tab sr 12hr
2.5-120 mg
3
DEXTROMETHORPHAN HBR/
CHLO – phenylephrinechlorphen-dm liquid
1.75-0.75-2.75 mg/ml
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
1
LEXUSS 210 – chlorpheniramine
w/ codeine liquid 2-10 mg/5ml
1
phenylephrine w/ dm-gg liqd
10-15-300 mg/5ml
1
10-30-200 mg/5ml
1
2.5-5-50 mg/ml
1
2.5-7.5-88 mg/ml
1
phenylephrinebrompheniramine-dm liquid
7.5-4-15 mg/5ml
1
phenylephrine-guaifenesin liqd
7.5-100 mg/5ml (1.5-20 mg/ml)
1
PROMETHAZINE VC PLAIN –
promethazine & phenylephrine
syrup 6.25-5 mg/5ml
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
promethazine w/ codeine syrup
6.25-10 mg/5ml
1
promethazine-dm syrup
6.25-15 mg/5ml
1
pseudoeph-chlorphen
w/ hydrocodone soln
60-4-5 mg/5ml (Zutripro)
1
pseudoephed-bromphen-dm
syrup 30-2-10 mg/5ml
ADVAIR HFA – fluticasonesalmeterol inhal aerosol 115-21
mcg/act
2
mcg/act
2
1
1
albuterol sulfate soln nebu
0.083% (2.5 mg/3ml)
1
RELHIST – bromphen tanphenyleph tan chew tab 6-15 mg
1
albuterol sulfate soln nebu 0.5%
(5 mg/ml)
1
sodium chloride soln nebu 0.9%
1
0.63 mg/3ml (base equiv)
sodium chloride soln nebu 3%
1
1
(Hyper-sal)
1
albuterol sulfate syrup 2 mg/5ml
1
1
1
TGQ 15DM/5PEH/2CPM –
phenylephrine-chlorphen-dm
syrup 5-2-15 mg/5ml
1
albuterol sulfate tab sr 12hr 4 mg
(Vospire er)
albuterol sulfate tab sr 12hr 8 mg
(Vospire er)
1
TGQ 30PSE/150GFN/15DM –
pseudoephedrine w/ dm-gg syrup
30-15-150 mg/5ml
1
albuterol sulfate tab 2 mg
1
albuterol sulfate tab 4 mg
1
TGQ 30PSE/3BRM/15DM –
ALVESCO – ciclesonide inhal
aerosol 80 mcg/act
3
1
ALVESCO – ciclesonide inhal
aerosol 160 mcg/act
3
TGQ 50PSE/3BRM/30DM –
1
ANORO ELLIPTA – umeclidiniumvilanterol aero powd ba 62.5-25
mcg/inh
2
ARCAPTA NEOHALER –
indacaterol maleate inhal powder
cap 75 mcg (base equiv)
3
ARNUITY ELLIPTA – fluticasone
furoate aerosol powder breath
activ 100 mcg/act
2
ARNUITY ELLIPTA – fluticasone
furoate aerosol powder breath
activ 200 mcg/act
2
ASMANEX HFA – mometasone
furoate inhal aerosol suspension
100 mcg/act
2
ANTIASTHMATIC and BRONCHODILATOR AGENTS
2
ADVAIR DISKUS – fluticasonesalmeterol aer powder ba 100-50
mcg/dose
2
mcg/dose
2
mcg/dose
2
mcg/act
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
45
ASMANEX HFA – mometasone
furoate inhal aerosol suspension
200 mcg/act
2
ASMANEX TWISTHALER 120
ME – mometasone furoate
inhal powd 220 mcg/inh (breath
activated)
2
MET – mometasone furoate
activated)
2
activated)
2
activated)
2
activated)
2
METE – mometasone furoate
activated)
2
budesonide inhalation susp
1 mg/2ml (Pulmicort)
1
COMBIVENT RESPIMAT –
ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act
2
CROMOLYN SODIUM – cromolyn
sodium soln nebu 20 mg/2ml
1
DALIRESP – roflumilast tab 500
mcg
3
DULERA – mometasone furoateformoterol fumarate aerosol
100-5 mcg/act
2
DULERA – mometasone furoateformoterol fumarate aerosol
200-5 mcg/act
2
dyphylline-guaifenesin liqd
100-100 mg/5ml
1
ELIXOPHYLLIN – theophylline
elixir 80 mg/15ml
2
FLOVENT DISKUS – fluticasone
propionate aer pow ba 50 mcg/
blister
2
blister
2
ATROVENT HFA – ipratropium
bromide hfa inhal aerosol 17
mcg/act
blister
2
2
2
FLOVENT HFA – fluticasone
propionate hfa inhal aero 44
mcg/act (50/valve)
2
BREO ELLIPTA – fluticasone
furoate-vilanterol aero powd ba
100-25 mcg/inh
BREO ELLIPTA – fluticasone
furoate-vilanterol aero powd ba
200-25 mcg/inh
propionate hfa inhal aer 110
mcg/act (125/valve)
2
2
BROVANA – arformoterol tartrate
soln nebu 15 mcg/2ml (base
equiv)
propionate hfa inhal aer 220
mcg/act (250/valve)
2
3
1
FORADIL AEROLIZER –
formoterol fumarate inhal cap 12
mcg
2
0.25 mg/2ml (Pulmicort)
0.5 mg/2ml (Pulmicort)
1
ipratropium bromide inhal soln
0.02%
1
46
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
ipratropium-albuterol nebu soln
0.5-2.5(3) mg/3ml
1
PULMICORT – budesonide
inhalation susp 1 mg/2ml
2
levalbuterol hcl soln nebu conc
1.25 mg/0.5ml (base equiv)
(Xopenex concentrate)
1
QVAR – beclomethasone
dipropionate inhal aero soln 40
mcg/act
2
levalbuterol hcl soln nebu
(Xopenex)
1
QVAR – beclomethasone
dipropionate inhal aero soln 80
mcg/act
2
(Xopenex)
1
SEREVENT DISKUS – salmeterol
xinafoate aer pow ba 50 mcg/
dose (base equiv)
2
(Xopenex)
1
SPIRIVA HANDIHALER –
tiotropium bromide monohydrate
inhal cap 18 mcg (base equiv)
2
METAPROTERENOL SULFATE –
metaproterenol sulfate syrup 10
mg/5ml
1
SPIRIVA RESPIMAT – tiotropium
bromide monohydrate inhal
aerosol 2.5 mcg/act
2
metaproterenol sulfate tab 10 mg
1
2
metaproterenol sulfate tab 20 mg
1
SYMBICORT – budesonideformoterol fumarate dihyd
aerosol 80-4.5 mcg/act
2
montelukast sodium chew tab
4 mg (base equiv) (Singulair)
1
SYMBICORT – budesonideformoterol fumarate dihyd
aerosol 160-4.5 mcg/act
montelukast sodium chew tab
5 mg (base equiv) (Singulair)
1
terbutaline sulfate tab 2.5 mg
1
terbutaline sulfate tab 5 mg
1
montelukast sodium
oral granules packet 4 mg
(base equiv) (Singulair)
1
THEO-24 – theophylline cap sr
24hr 100 mg
3
1
24hr 200 mg
3
montelukast sodium tab 10 mg
(base equiv) (Singulair)
PERFOROMIST – formoterol
fumarate soln nebu 20 mcg/2ml
24hr 300 mg
3
3
PROAIR HFA – albuterol sulfate
inhal aero 108 mcg/act (90mcg
base equiv)
24hr 400 mg
3
2
theophylline soln 80 mg/15ml
1
2
theophylline tab sr 12hr 100 mg
1
PROAIR RESPICLICK – albuterol
sulfate aer pow ba 108 mcg/act
(90 mcg base equiv)
1
1
PROVENTIL HFA – albuterol
sulfate inhal aero 108 mcg/act
(90mcg base equiv)
3
1
1
1
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
47
TUDORZA PRESSAIR – aclidinium 3
bromide aerosol powd breath
activated 400 mcg/act
VENTOLIN HFA – albuterol sulfate 2
inhal aero 108 mcg/act (90mcg
base equiv)
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 CR – zileuton tab sr 12hr
600 mg
3
RESPIRATORY AGENTS - MISC.
4
• •
KALYDECO – ivacaftor tab 150 mg 4
4
KALYDECO – ivacaftor packet 50
mg
4
KALYDECO – ivacaftor packet 75
mg
4
OFEV – nintedanib esylate cap
4
OFEV – nintedanib esylate cap
4
ORKAMBI – lumacaftor-ivacaftor
tab 200-125 mg
PULMOZYME – dornase alfa inhal 3
soln 1 mg/ml
2
SCLEROSOL INTRAPLEURAL –
talc intrapleural aerosol powder 4
gm (0.4 gm/second)
• •
• •
ESBRIET – pirfenidone cap 267
mg
GASTROINTESTINAL AGENTS
LAXATIVES
bisacodyl tab & peg 3350-kclsod bicarb-nacl for soln kit
1
COLYTE-FLAVOR PACKS –
peg 3350-kcl-na bicarb-nacl-na
sulfate for soln 227.1 gm
2
lactulose solution 10 gm/15ml
1
48
• •
• •
MOVIPREP – peg 3350-kcl-naclna sulfate-na ascorbate-c for soln
100 gm
3
OSMOPREP – sod phos monosod phos di tabs 1.102-0.398
gm(1.5gm na phos)
3
peg 3350-kcl-sod bicarb-nacl
for soln 420 gm (Nulytely/flavor
pack)
1
peg 3350-kcl-na bicarb-naclna sulfate for soln 236 gm
(Golytely)
1
peg 3350-kcl-na bicarb-nacl-na
sulfate for soln 240 gm (Colyteflavor packs)
1
polyethylene glycol 3350 oral
packet
1
PREPOPIK – sod picosulfate-mg
oxide-citric acid pack 10 mg-3.5
gm-12 gm
3
SUPREP BOWEL PREP – sodium
sulfate-potassium sulfatemagnesium sulfate oral soln
3
ANTIDIARRHEALS
• •
diphenoxylate w/ atropine tab
2.5-0.025 mg (Lomotil)
1
• •
DIPHENOXYLATE/ATROPINE
– diphenoxylate w/ atropine liq
2.5-0.025 mg/5ml
1
FULYZAQ – crofelemer tab
4
loperamide hcl cap 2 mg
1
OPIUM TINCTURE (PAREGORIC
– paregoric 2 mg/5ml
1
opium tincture 1% (10 mg/ml)
(morphine equiv)
1
•
ULCER DRUGS
ACIPHEX SPRINKLE –
rabeprazole sodium capsule
sprinkle dr 5 mg
3
•
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
•
ACIPHEX SPRINKLE –
rabeprazole sodium capsule
sprinkle dr 10 mg
3
amoxicillin cap-clarithro tablansopraz cap dr therapy pack
(Prevpac)
1
ANASPAZ – hyoscyamine sulfate
tab disp 0.125 mg
1
BELLADONNA & OPIUM –
belladonna alkaloids & opium
suppos 16.2-30 mg
1
BELLADONNA ALKALOIDS & OP
– belladonna alkaloids & opium
suppos 16.2-60 mg
1
chlordiazepoxide hcl-clidinium
bromide cap 5-2.5 mg (Librax)
1
cimetidine hcl soln 300 mg/5ml
1
cimetidine tab 200 mg
1
1
1
1
CUVPOSA – glycopyrrolate oral
soln 1 mg/5ml
3
DEXILANT – dexlansoprazole cap
3
•
DEXILANT – dexlansoprazole cap
3
•
dicyclomine hcl cap 10 mg
(Bentyl)
1
dicyclomine hcl oral soln
10 mg/5ml
1
dicyclomine hcl tab 20 mg
(Bentyl)
1
esomeprazole magnesium cap
delayed release 20 mg (base
eq) (Nexium)
1
•
esomeprazole magnesium cap
delayed release 40 mg (base
eq) (Nexium)
1
•
famotidine for susp 40 mg/5ml
(Pepcid)
1
famotidine tab 20 mg – is not
covered, it is available OTC
(Pepcid)
1
famotidine tab 40 mg (Pepcid)
1
GASTRINEX NF – hyoscyaminephenyltoloxamine cap 0.0625-15
mg
1
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
glycopyrrolate tab 1 mg (Robinul) 1
glycopyrrolate tab 2 mg (Robinul 1
forte)
1
hyoscyamine sulfate elixir
0.125 mg/5ml
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
methscopolamine bromide tab
2.5 mg (Pamine)
1
methscopolamine bromide tab
5 mg (Pamine forte)
1
misoprostol tab 100 mcg
(Cytotec)
1
misoprostol tab 200 mcg
(Cytotec)
2
NEXIUM – esomeprazole
magnesium for delayed release
susp packet 10 mg
49
susp packet 20 mg
2
susp packet 40 mg
2
magnesium cap delayed release
20 mg (base eq)
1
magnesium cap delayed release
40 mg (base eq)
1
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
pantoprazole sodium ec tab
20 mg (base equiv) (Protonix)
1
pantoprazole sodium ec tab
40 mg (base equiv) (Protonix)
1
PRILOSEC – omeprazole
susp packet 2.5 mg
3
PRILOSEC – omeprazole
susp packet 10 mg
3
PROPANTHELINE BROMIDE –
propantheline bromide tab 15 mg
1
50
1
ranitidine hcl tab 150 mg – is not
(Zantac)
1
ranitidine hcl tab 300 mg (Zantac) 1
1
sucralfate tab 1 gm (Carafate)
ZANTAC – ranitidine hcl tab 300
mg
3
ZEGERID – omeprazole-sodium
bicarbonate powd pack for susp
20-1680 mg
3
•
ZEGERID – omeprazole-sodium
bicarbonate powd pack for susp
40-1680 mg
3
•
ANTIEMETICS
•
•
AKYNZEO – netupitantpalonosetron cap 300-0.5 mg
4
ANZEMET – dolasetron mesylate
tab 50 mg
4
•
ANZEMET – dolasetron mesylate
tab 100 mg
4
•
CESAMET – nabilone cap 1 mg
3
DICLEGIS – doxylamine-pyridoxine 3
tab delayed release 10-10 mg
1
dronabinol cap 2.5 mg (Marinol)
dronabinol cap 5 mg (Marinol)
1
dronabinol cap 10 mg (Marinol)
1
Quantity Limits
Restricted Access
•
PROTONIX – pantoprazole sodium 3
for delayed release susp packet
40 mg
2
PYLERA – bismuth subcitmetronidazole-tetracycline cap
140-125-125 mg
1
rabeprazole sodium ec tab
20 mg (Aciphex)
ranitidine hcl cap 150 mg – is not 1
1
ranitidine hcl cap 300 mg
ranitidine hcl syrup 15 mg/ml
(75 mg/5ml)
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
EMEND – aprepitant capsule
therapy pack 80 & 125 mg
3
EMEND – aprepitant capsule 40
mg
3
mg
3
mg
3
granisetron hcl tab 1 mg
1
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 4 mg
(Zofran)
1
(Zofran)
1
1
ondansetron orally
disintegrating tab 4 mg (Zofran
odt)
1
ondansetron orally
disintegrating tab 8 mg (Zofran
odt)
1
SANCUSO – granisetron td patch
3.1 mg/24hr (contains 34.3 mg)
4
TRANSDERM-SCOP –
scopolamine td patch 72hr 1
mg/3days
3
trimethobenzamide hcl cap
300 mg (Tigan)
1
ZUPLENZ – ondansetron oral
soluble film 4 mg
3
ZUPLENZ – ondansetron oral
soluble film 8 mg
3
DIGESTIVE AIDS
CREON – pancrelipase (lip-protamyl) dr cap 3000-9500-15000
unit
2
•
unit
2
unit
2
CREON – pancrelipase
(lip-prot-amyl) dr cap
24000-76000-120000 unit
2
CREON – pancrelipase
36000-114000-180000 unit
2
PANCREAZE – pancrelipase
4200-10000-17500 unit
3
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
PERTZYE – pancrelipase (lip-protamyl) dr cap 16000-57500-60500
unit
3
SUCRAID – sacrosidase soln 8500
unit/ml
3
ULTRESA – pancrelipase (lip-protamyl) dr cap 13800-27600-27600
unit
3
unit
3
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
•
51
unit
3
ASACOL HD – mesalamine tab
2
VIOKACE – pancrelipase (lip-protamyl) tab 10440-39150-39150
unit
balsalazide disodium cap
750 mg (Colazal)
1
3
1
VIOKACE – pancrelipase (lip-protamyl) tab 20880-78300-78300
unit
3
calcium acetate (phosphate
binder) cap 667 mg (169 mg
ca) (Phoslo)
calcium acetate (phosphate
binder) tab 667 mg (Eliphos)
1
ZENPEP – pancrelipase (lip-protamyl) dr cap 3000-10000-16000
unit
2
CANASA – mesalamine suppos
1000 mg
2
unit
2
unit
2
unit
2
ZENPEP – pancrelipase
20000-68000-109000 unit
2
25000-85000-136000 unit
2
40000-136000-218000 unit
2
GASTROINTESTINAL AGENTS- MISC.
1
alosetron hcl tab 0.5 mg (base
equiv) (Lotronex)
1
alosetron hcl tab 1 mg (base
equiv) (Lotronex)
AMITIZA – lubiprostone cap 8 mcg 3
AMITIZA – lubiprostone cap 24
mcg
3
APRISO – mesalamine cap sr 24hr
0.375 gm
3
52
CHOLBAM – cholic acid cap 50 mg 4
4
CHOLBAM – cholic acid cap 250
mg
CIMZIA – certolizumab pegol for inj 4
kit 2 x 200 mg
CIMZIA – certolizumab pegol inj kit 4
2 x 200 mg/ml
4
CIMZIA STARTER KIT –
certolizumab pegol inj kit 6 x 200
mg/ml
1
cromolyn sodium oral conc
100 mg/5ml (Gastrocrom)
2
DELZICOL – mesalamine cap dr
400 mg
2
DIPENTUM – olsalazine sodium
cap 250 mg
1
ELIPHOS – calcium acetate
(phosphate binder) tab 667 mg
ENTEREG – alvimopan cap 12 mg 4
FOSRENOL – lanthanum
carbonate chew tab 500 mg
(elemental)
2
(elemental)
2
(elemental)
2
GASTROCROM – cromolyn
sodium oral conc 100 mg/5ml
3
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
• •
• •
• • • •
• • • •
• • •
•
•
LINZESS – linaclotide cap 290 mcg 2
1
mesalamine enema 4 gm
mesalamine rectal enema 4 gm &
cleanser wipe kit (Rowasa)
1
metoclopramide hcl orally
(Metozolv odt)
1
metoclopramide hcl soln
5 mg/5ml (10 mg/10ml)
1
metoclopramide hcl tab 5 mg
(Reglan)
1
metoclopramide hcl tab 10 mg
(Reglan)
1
METOZOLV ODT –
metoclopramide hcl orally
3
PENTASA – mesalamine cap cr
250 mg
2
PENTASA – mesalamine cap cr
500 mg
2
PHOSLYRA – calcium acetate
(phosphate binder) oral soln 667
mg/5ml
3
RELISTOR – methylnaltrexone
bromide inj 8 mg/0.4ml (20 mg/
ml)
4
RELISTOR – methylnaltrexone
bromide inj 12 mg/0.6ml (20 mg/
ml)
4
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
•
Restricted Access
Specialty
GATTEX – teduglutide (rdna) for inj 4
kit 5 mg
GIAZO – balsalazide disodium tab 3
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
Drug Name
Prior Review
Drug Tier
2015
RENAGEL – sevelamer hcl tab 800 2
mg
RENVELA – sevelamer carbonate 2
tab 800 mg
packet 0.8 gm
packet 2.4 gm
1
sulfasalazine tab delayed
release 500 mg (Azulfidine entabs)
1
sulfasalazine tab 500 mg
(Azulfidine)
1
ursodiol cap 300 mg (Actigall)
ursodiol tab 250 mg (Urso 250)
1
ursodiol tab 500 mg (Urso forte)
1
GENITOURINARY AGENTS
URINARY ANTI-INFECTIVES
RENAGEL – sevelamer hcl tab 400 2
mg
methenamine hippurate tab 1 gm
(Hiprex)
1
METHENAMINE MANDELATE –
methenamine mandelate tab 0.5
gm
1
methenamine mandelate tab
1 gm
1
methenamine-hyos-meth bluesod phos-phen sal tab 81.6 mg
1
methenamine-hyosc-meth bluebenz acid-phenyl sal tab
81.6mg (Prosed/ds)
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
methenamine-hyoscamine-meth
blue-sod phos tab 81.6 mg
(Urogesic-blue)
1
53
nitrofurantoin macrocrystalline
cap 50 mg (Macrodantin)
1
oxybutynin chloride tab sr 24hr
5 mg (Ditropan xl)
1
nitrofurantoin macrocrystalline
cap 100 mg (Macrodantin)
1
10 mg (Ditropan xl)
1
nitrofurantoin monohydrate
macrocrystalline cap 100 mg
(Macrobid)
1
15 mg (Ditropan xl)
1
oxybutynin chloride tab 5 mg
1
nitrofurantoin susp 25 mg/5ml
(Furadantin)
1
OXYTROL – oxybutynin td patch
3
URETRON D/S – methenaminehyosc-meth blue-sod phos-phen
sal tab 120 mg
1
tolterodine tartrate cap sr 24hr
2 mg (Detrol la)
1
1
tolterodine tartrate cap sr 24hr
4 mg (Detrol la)
1
UROGESIC-BLUE –
methenamine-hyoscamine-meth
blue-sod phos tab 81.6 mg
tolterodine tartrate tab 1 mg
(Detrol)
1
URINARY ANTISPASMODICS
1
tolterodine tartrate tab 2 mg
(Detrol)
1
bethanechol chloride tab 5 mg
(Urecholine)
1
TOVIAZ – fesoterodine fumarate
tab sr 24hr 4 mg
3
(Urecholine)
1
TOVIAZ – fesoterodine fumarate
tab sr 24hr 8 mg
3
(Urecholine)
1
trospium chloride cap sr 24hr
60 mg
1
(Urecholine)
3
trospium chloride tab 20 mg
1
ENABLEX – darifenacin
hydrobromide tab sr 24hr 7.5 mg
(base equiv)
VESICARE – solifenacin succinate
tab 5 mg
2
ENABLEX – darifenacin
hydrobromide tab sr 24hr 15 mg
(base equiv)
3
VESICARE – solifenacin succinate
tab 10 mg
2
flavoxate hcl tab 100 mg
1
GELNIQUE – oxybutynin td gel 3%
(28 mg/act metered-dose pump)
3
GELNIQUE – oxybutynin chloride
td gel 10%
3
MYRBETRIQ – mirabegron tab sr
24 hr 25 mg
2
MYRBETRIQ – mirabegron tab sr
24 hr 50 mg
2
oxybutynin chloride syrup
5 mg/5ml
1
54
VAGINAL PRODUCTS
AVC – sulfanilamide vaginal cream
15%
2
CLEOCIN – clindamycin phosphate 2
vaginal suppos 100 mg
1
clindamycin phosphate vaginal
cream 2% (Cleocin)
3
CLINDESSE – clindamycin
phosphate (one dose) vaginal
cream 2%
4
ENDOMETRIN – progesterone
vaginal insert 100 mg
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
ESTRING – estradiol vaginal ring 2
mg (7.5 mcg/24hrs)
3
ELMIRON – pentosan polysulfate
sodium caps 100 mg
3
FEM PH – acetic acid-oxyquinoline
vaginal gel 0.9-0.025%
1
finasteride tab 5 mg (Proscar)
1
glycine irrigation soln 1.5%
1
FEMRING – estradiol acetate
vaginal ring 0.05 mg/24hr
3
JALYN – dutasteride-tamsulosin
hcl cap 0.5-0.4 mg
3
FEMRING – estradiol acetate
vaginal ring 0.1 mg/24hr
3
1
GYNAZOLE-1 – butoconazole
nitrate (one dose) vaginal cream
2%
3
neomycin-polymyxin b gu
irrigation soln (Neosporin gu
irrigan)
phenazopyridine hcl tab 100 mg
(Pyridium)
1
metronidazole vaginal gel 0.75%
(Metrogel-vaginal)
1
phenazopyridine hcl tab 200 mg
(Pyridium)
1
MICONAZOLE 3 – miconazole
nitrate vaginal suppos 200 mg
1
pot & sod citrates w/ cit ac soln
550-500-334 mg/5ml
1
conjugated vaginal cream 0.625
mg/gm
2
potassium citrate & citric acid
powder pack 3300-1002 mg
1
1
potassium citrate & citric acid
soln 1100-334 mg/5ml
1
terconazole vaginal cream 0.4%
(Terazol 7)
1
potassium citrate tab cr 5 meq
(540 mg) (Urocit-k 5)
1
terconazole vaginal cream 0.8%
(Terazol 3)
1
(1080 mg) (Urocit-k 10)
1
terconazole vaginal suppos
80 mg
2
(1620 mg) (Urocit-k 15)
1
VAGIFEM – estradiol vaginal tab
10 mcg
PROCYSBI – cysteamine bitartrate
cap delayed release 25 mg (base
equiv)
4
•
PROCYSBI – cysteamine bitartrate
cap delayed release 75 mg (base
equiv)
4
•
RAPAFLO – silodosin cap 4 mg
3
RAPAFLO – silodosin cap 8 mg
3
sodium chloride irrigation soln
0.9%
1
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
2
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
CYTRA-3 – pot & sod citrates w/ cit 1
ac syrup 550-500-334 mg/5ml
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
1
sodium citrate & citric acid soln
500-334 mg/5ml (Shohls solution
modi)
1
tamsulosin hcl cap 0.4 mg
(Flomax)
55
ANTIANXIETY AGENTS
diazepam tab 10 mg (Valium)
1
hydroxyzine hcl syrup 10 mg/5ml
1
hydroxyzine hcl tab 10 mg
1
1
1
HYDROXYZINE PAMOATE –
hydroxyzine pamoate cap 100
mg
1
alprazolam orally disintegrating
tab 0.25 mg (Niravam)
1
tab 0.5 mg
1
tab 1 mg
1
tab 2 mg
1
1
hydroxyzine pamoate cap 25 mg
(Vistaril)
1
alprazolam tab sr 24hr 0.5 mg
(Xanax xr)
1
hydroxyzine pamoate cap 50 mg
(Vistaril)
1
alprazolam tab sr 24hr 1 mg
(Xanax xr)
1
lorazepam conc 2 mg/ml
(Lorazepam intensol)
1
(Xanax xr)
1
lorazepam tab 0.5 mg (Ativan)
1
(Xanax xr)
lorazepam tab 1 mg (Ativan)
1
alprazolam tab 0.25 mg (Xanax)
1
lorazepam tab 2 mg (Ativan)
1
alprazolam tab 0.5 mg (Xanax)
1
meprobamate tab 200 mg
1
alprazolam tab 1 mg (Xanax)
1
meprobamate tab 400 mg
1
alprazolam tab 2 mg (Xanax)
1
oxazepam cap 10 mg
1
buspirone hcl tab 5 mg
1
oxazepam cap 15 mg
1
buspirone hcl tab 7.5 mg
1
oxazepam cap 30 mg
1
1
ANTIDEPRESSANTS
1
amitriptyline hcl tab 10 mg
1
1
1
chlordiazepoxide hcl cap 5 mg
1
1
1
1
1
1
clorazepate dipotassium tab
3.75 mg (Tranxene t)
1
1
1
7.5 mg (Tranxene t)
1
AMOXAPINE – amoxapine tab 25
mg
1
15 mg (Tranxene t)
1
mg
1
diazepam conc 5 mg/ml
1
mg
1
56
Quantity Limits
1
Restricted Access
Prior Review
CENTRAL NERVOUS SYSTEM DRUGS
Specialty
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Drug Name
Specialty
Drug Tier
2015
mg
1
clomipramine hcl cap 75 mg
(Anafranil)
1
APLENZIN – bupropion hbr tab sr
24hr 174 mg
3
desipramine hcl tab 10 mg
(Norpramin)
1
24hr 348 mg
3
(Norpramin)
1
24hr 522 mg
3
(Norpramin)
1
BRINTELLIX – vortioxetine hbr tab
5 mg (base equiv)
3
•
(Norpramin)
1
10 mg (base equiv)
3
•
(Norpramin)
1
20 mg (base equiv)
3
•
(Norpramin)
1
bupropion hcl tab sr 12hr
100 mg (Wellbutrin sr)
1
DOXEPIN HCL – doxepin hcl cap
75 mg
1
1
doxepin hcl cap 10 mg
1
1
1
1
1
1
150 mg (Wellbutrin xl)
1
300 mg (Wellbutrin xl)
1
doxepin hcl conc 10 mg/ml
1
1
bupropion hcl tab 75 mg
(Wellbutrin)
1
duloxetine hcl enteric coated
pellets cap 20 mg (Cymbalta)
1
bupropion hcl tab 100 mg
(Wellbutrin)
1
1
citalopram hydrobromide oral
soln 10 mg/5ml
1
3
citalopram hydrobromide tab
10 mg (base equiv) (Celexa)
1
EMSAM – selegiline td patch 24hr
6 mg/24hr
3
1
9 mg/24hr
3
1
12 mg/24hr
1
(Anafranil)
1
escitalopram oxalate soln
5 mg/5ml (base equiv)
(Lexapro)
(Anafranil)
1
escitalopram oxalate tab 5 mg
(base equiv) (Lexapro)
1
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
57
1
imipramine hcl tab 25 mg
(Tofranil)
1
1
(Tofranil)
1
FETZIMA – levomilnacipran
hcl cap sr 24hr 20 mg (base
equivalent)
3
•
imipramine pamoate cap 75 mg
(Tofranil-pm)
1
3
•
(Tofranil-pm)
1
equivalent)
1
equivalent)
3
•
(Tofranil-pm)
(Tofranil-pm)
1
3
•
MAPROTILINE HCL – maprotiline
hcl tab 25 mg
1
equivalent)
1
FETZIMA TITRATION PACK –
levomilnacipran hcl cap sr 24hr
20 & 40 mg therapy pack
3
hcl tab 50 mg
hcl tab 75 mg
1
FLUOXETINE HCL – fluoxetine hcl
tab 60 mg
3
mirtazapine orally disintegrating
tab 15 mg (Remeron soltab)
1
fluoxetine hcl cap delayed
release 90 mg (Prozac weekly)
1
1
fluoxetine hcl cap 10 mg (Prozac) 1
1
mirtazapine tab 7.5 mg
1
mirtazapine tab 15 mg (Remeron)
1
1
1
NEFAZODONE HCL – nefazodone
hcl tab 50 mg
1
hcl tab 100 mg
1
hcl tab 150 mg
1
hcl tab 200 mg
1
nefazodone hcl tab 250 mg
1
NORTRIPTYLINE HCL –
nortriptyline hcl soln 10 mg/5ml
1
1
fluoxetine hcl solution
20 mg/5ml
1
fluoxetine hcl tab 10 mg
fluoxetine hcl tab 20 mg
1
fluvoxamine maleate cap sr 24hr
100 mg (Luvox cr)
1
fluvoxamine maleate cap sr 24hr
150 mg
1
fluvoxamine maleate tab 25 mg
1
1
1
(Tofranil)
1
58
•
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
nortriptyline hcl cap 10 mg
(Pamelor)
1
(Pamelor)
1
(Pamelor)
PRISTIQ – desvenlafaxine
succinate tab sr 24hr 100 mg
(base equiv)
3
protriptyline hcl tab 5 mg
1
1
protriptyline hcl tab 10 mg
1
1
sertraline hcl oral conc 20 mg/ml
(Zoloft)
1
(Pamelor)
sertraline hcl tab 25 mg (Zoloft)
1
OLEPTRO – trazodone hcl tab sr
24hr 150 mg
3
1
3
1
OLEPTRO – trazodone hcl tab sr
24hr 300 mg
1
paroxetine hcl tab sr 24hr
12.5 mg (Paxil cr)
1
tranylcypromine sulfate tab
10 mg (Parnate)
trazodone hcl tab 50 mg
1
paroxetine hcl tab sr 24hr 25 mg
(Paxil cr)
1
1
1
paroxetine hcl tab sr 24hr
37.5 mg (Paxil cr)
1
1
1
paroxetine hcl tab 20 mg (Paxil)
1
venlafaxine hcl cap sr 24hr
(Effexor xr)
1
1
1
1
(Effexor xr)
PAXIL – paroxetine hcl oral susp
2
1
PEXEVA – paroxetine mesylate
3
•
(Effexor xr)
3
•
VENLAFAXINE HCL ER –
venlafaxine hcl tab sr 24hr 37.5
1
3
•
1
3
•
venlafaxine hcl tab sr 24hr 75 mg
(base equivalent)
1
phenelzine sulfate tab 15 mg
(Nardil)
1
venlafaxine hcl tab sr 24hr 150
(base equiv)
3
•
venlafaxine hcl tab sr 24hr 225
1
(base equiv)
3
•
venlafaxine hcl tab sr 24hr
(Venlafaxine hcl er)
1
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
•
59
venlafaxine hcl tab sr 24hr 75 mg
(base equivalent) (Venlafaxine
hcl er)
1
EQUETRO – carbamazepine
(antipsychotic) cap sr 12hr 100
mg
3
venlafaxine hcl tab sr 24hr
(Venlafaxine hcl er)
1
mg
3
venlafaxine hcl tab 25 mg
1
3
venlafaxine hcl tab 37.5 mg
1
1
mg
1
FANAPT – iloperidone tab 1 mg
3
1
3
3
3
VIIBRYD – vilazodone hcl tab
starter kit 10 (7) & 20 (7) & 40
(16) mg
3
3
VIIBRYD – vilazodone hcl tab 10
mg
3
3
3
mg
3
3
mg
3
FANAPT TITRATION PACK –
iloperidone tab 1 mg & 2 mg & 4
mg & 6 mg titration pak
FAZACLO – clozapine orally
disintegrating tab 12.5 mg
3
3
3
3
3
FLUPHENAZINE HCL –
fluphenazine hcl elixir 2.5 mg/5ml
1
FLUPHENAZINE HCL –
fluphenazine hcl oral conc 5 mg/
ml
1
fluphenazine hcl tab 1 mg
1
fluphenazine hcl tab 2.5 mg
1
1
1
ANTIPSYCHOTICS
aripiprazole tab 2 mg (Abilify)
1
1
1
1
1
1
chlorpromazine hcl tab 10 mg
1
1
1
1
1
clozapine tab 25 mg (Clozaril)
1
clozapine tab 50 mg
1
clozapine tab 100 mg (Clozaril)
1
clozapine tab 200 mg
1
60
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
1
haloperidol tab 0.5 mg
haloperidol tab 1 mg
LITHOBID – lithium carbonate tab
cr 300 mg
2
1
1
loxapine succinate cap 5 mg
1
1
1
1
1
1
1
INVEGA – paliperidone tab sr 24hr
1.5 mg
3
olanzapine orally disintegrating
tab 5 mg (Zyprexa zydis)
1
3 mg
3
1
6 mg
3
1
9 mg
3
1
LATUDA – lurasidone hcl tab 20
mg
3
olanzapine tab 2.5 mg (Zyprexa)
1
olanzapine tab 5 mg (Zyprexa)
1
mg
3
olanzapine tab 7.5 mg (Zyprexa)
1
3
1
mg
1
mg
3
1
perphenazine tab 2 mg
1
mg
3
1
1
LITHIUM – lithium oral solution 8
meq/5ml
1
1
1
LITHIUM CARBONATE – lithium
carbonate cap 600 mg
1
prochlorperazine maleate
(Compazine)
1
LITHIUM CARBONATE – lithium
carbonate cap 150 mg
1
lithium carbonate cap 150 mg
(Lithium carbonate)
1
prochlorperazine maleate tab
(Compazine)
1
1
prochlorperazine suppos 25 mg
(Lithium carbonate)
quetiapine fumarate tab 25 mg
(Seroquel)
1
1
lithium carbonate tab cr 300 mg
(Lithobid)
(Seroquel)
1
1
Quantity Limits
lithium carbonate tab 300 mg
1
Restricted Access
1
1
Prior Review
lithium carbonate tab cr 450 mg
haloperidol lactate oral conc
2 mg/ml
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
61
(Seroquel)
1
SEROQUEL XR – quetiapine
fumarate tab sr 24hr 200 mg
3
(Seroquel)
1
3
(Seroquel)
1
3
(Seroquel)
1
thioridazine hcl tab 10 mg
1
1
risperidone orally disintegrating
tab 0.25 mg
1
1
1
1
tab 0.5 mg (Risperdal m-tab)
thiothixene cap 1 mg
1
tab 1 mg (Risperdal m-tab)
1
1
1
1
1
1
1
trifluoperazine hcl tab 1 mg
1
1
1
1
risperidone soln 1 mg/ml
(Risperdal)
1
ziprasidone hcl cap 20 mg
(Geodon)
1
risperidone tab 0.25 mg
(Risperdal)
1
(Geodon)
1
risperidone tab 0.5 mg
(Risperdal)
1
(Geodon)
1
risperidone tab 1 mg (Risperdal)
1
1
1
(Geodon)
1
HYPNOTICS
1
•
SAPHRIS – asenapine maleate sl
tab 2.5 mg (base equiv)
3
EDLUAR – Benefit Limits may
apply – zolpidem tartrate sl tab 5
mg
3
•
3
EDLUAR – Benefit Limits may
apply – zolpidem tartrate sl tab
10 mg
3
3
estazolam tab 1 mg
1
estazolam tab 2 mg
1
3
1
3
eszopiclone tab 1 mg – Benefit
Limits may apply (Lunesta)
62
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
1
temazepam cap 15 mg (Restoril)
1
temazepam cap 22.5 mg
(Restoril)
1
1
temazepam cap 30 mg (Restoril)
1
FLURAZEPAM HCL – flurazepam
hcl cap 15 mg
1
triazolam tab 0.125 mg
1
1
triazolam tab 0.25 mg (Halcion)
1
FLURAZEPAM HCL – flurazepam
hcl cap 30 mg
1
HETLIOZ – tasimelteon capsule 20
mg
4
zaleplon cap 5 mg – Benefit
Limits may apply (Sonata)
1
INTERMEZZO – Benefit Limits
may apply – zolpidem tartrate sl
tab 1.75 mg
3
zaleplon cap 10 mg – Benefit
Limits may apply (Sonata)
1
INTERMEZZO – Benefit Limits
may apply – zolpidem tartrate sl
tab 3.5 mg
3
zolpidem tartrate tab cr 6.25 mg
– Benefit Limits may apply
(Ambien cr)
1
midazolam hcl syrup 2 mg/ml
(base equivalent)
1
zolpidem tartrate tab cr 12.5 mg
(Ambien cr)
1
PHENOBARBITAL – phenobarbital
tab 15 mg
1
zolpidem tartrate tab 5 mg –
Benefit Limits may apply
(Ambien)
1
zolpidem tartrate tab 10 mg
(Ambien)
1
tab 30 mg
tab 60 mg
1
3
tab 100 mg
1
ZOLPIMIST – Benefit Limits may
apply – zolpidem tartrate oral
spray 5 mg/act
phenobarbital elixir 20 mg/5ml
1
phenobarbital tab 16.2 mg
1
1
1
1
ROZEREM – Benefit Limits may
apply – ramelteon tab 8 mg
3
•
SILENOR – Benefit Limits may
apply – doxepin hcl (sleep) tab 3
mg (base equiv)
3
•
SILENOR – Benefit Limits may
apply – doxepin hcl (sleep) tab 6
mg (base equiv)
3
•
temazepam cap 7.5 mg (Restoril)
1
•
•
•
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/
ANOREXIANTS
1
amphetaminedextroamphetamine cap sr
24hr 5 mg (Adderall xr)
1
1
1
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
•
•
•
•
•
63
•
1
1
amphetaminedextroamphetamine tab 5 mg
(Adderall)
1
•
amphetaminedextroamphetamine tab 7.5 mg
(Adderall)
1
•
(Adderall)
1
amphetaminedextroamphetamine tab
12.5 mg (Adderall)
1
(Adderall)
1
(Adderall)
1
(Adderall)
1
BELVIQ – lorcaserin hcl tab 10 mg
3
caffeine citrate oral soln
60 mg/3ml (10 mg/ml base
equiv) (Cafcit)
1
clonidine hcl tab sr 12hr 0.1 mg
(Kapvay)
1
•
CONCERTA – methylphenidate hcl 2
tab sa osm 18 mg
tab sa osm 27 mg
tab sa osm 36 mg
tab sa osm 54 mg
•
64
•
•
•
•
•
•
•
•
•
•
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
DAYTRANA – methylphenidate td
patch 10 mg/9hr
3
•
patch 15 mg/9hr
3
•
patch 20 mg/9hr
3
•
patch 30 mg/9hr
3
•
dexmethylphenidate hcl cap sr
24 hr 5 mg (Focalin xr)
1
•
1
•
1
•
1
•
1
•
1
•
dexmethylphenidate hcl tab
2.5 mg (Focalin)
1
•
5 mg (Focalin)
1
•
10 mg (Focalin)
1
•
dextroamphetamine sulfate cap
sr 24hr 5 mg (Dexedrine)
1
•
1
•
1
•
dextroamphetamine sulfate oral
solution 5 mg/5ml (Procentra)
1
•
dextroamphetamine sulfate tab
5 mg
1
•
dextroamphetamine sulfate tab
10 mg
1
•
•
FOCALIN XR –
24 hr 5 mg
3
FOCALIN XR –
24 hr 10 mg
3
FOCALIN XR –
24 hr 15 mg
3
•
FOCALIN XR –
24 hr 20 mg
3
•
FOCALIN XR –
24 hr 25 mg
3
•
FOCALIN XR –
24 hr 30 mg
3
•
FOCALIN XR –
24 hr 35 mg
3
FOCALIN XR –
24 hr 40 mg
3
•
guanfacine hcl tab sr 24hr 1 mg
(base equiv) (Intuniv)
1
•
1
•
1
•
1
•
INTUNIV – guanfacine hcl tab sr
24hr 1 mg (base equiv)
3
•
3
•
3
•
3
•
•
•
KAPVAY – clonidine hcl tab sr 12hr 3
0.1 mg
1
methamphetamine hcl tab 5 mg
(Desoxyn)
1
methylphenidate hcl cap cr
10 mg (Metadate cd)
1
20 mg (Metadate cd)
1
30 mg (Metadate cd)
1
40 mg (Metadate cd)
1
50 mg (Metadate cd)
1
60 mg (Metadate cd)
1
methylphenidate hcl cap sr 24hr
20 mg (la) (Ritalin la)
1
1
1
methylphenidate hcl chew tab
2.5 mg (Methylin)
1
5 mg (Methylin)
1
10 mg (Methylin)
2
METHYLPHENIDATE HCL ER –
methylphenidate hcl tab sa osm
18 mg
2
27 mg
2
36 mg
2
54 mg
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
65
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
methylphenidate hcl soln
5 mg/5ml (Methylin)
1
•
STRATTERA – atomoxetine hcl
3
•
methylphenidate hcl soln
10 mg/5ml (Methylin)
1
•
3
•
methylphenidate hcl tab cr
10 mg
1
•
3
•
methylphenidate hcl tab cr
20 mg (Ritalin sr)
1
•
3
•
methylphenidate hcl tab 5 mg
(Ritalin)
1
•
VYVANSE – lisdexamfetamine
dimesylate cap 10 mg
2
•
(Ritalin)
1
•
2
•
(Ritalin)
1
•
2
•
modafinil tab 100 mg (Provigil)
1
•
1
2
modafinil tab 200 mg (Provigil)
NUVIGIL – armodafinil tab 50 mg
3
•
3
2
3
2
•
3
•
•
•
•
•
•
•
QSYMIA – phentermine hcltopiramate cap sr 24hr 3.75-23
mg
2
3
3
•
QSYMIA – phentermine hcltopiramate cap sr 24hr 7.5-46 mg
3
•
ZENZEDI – dextroamphetamine
sulfate tab 2.5 mg
3
•
QSYMIA – phentermine hcltopiramate cap sr 24hr 11.25-69
mg
3
•
sulfate tab 7.5 mg
sulfate tab 15 mg
3
•
3
•
sulfate tab 20 mg
3
QSYMIA – phentermine hcltopiramate cap sr 24hr 15-92 mg
•
3
sulfate tab 30 mg
3
QUILLIVANT XR –
methylphenidate hcl for er susp
25 mg/5ml (5 mg/ml)
•
3
•
3
•
3
•
66
•
•
•
•
•
•
•
•
PSYCHOTHERAPEUTIC and NEUROLOGICAL
AGENTS - MISC.
1
acamprosate calcium tab
(Campral)
4 • •
AMPYRA – dalfampridine tab sr
12hr 10 mg
AUBAGIO – teriflunomide tab 7 mg 4 • •
•
1
AVONEX – interferon beta-1a for
im inj kit 30mcg (33mcg(6.6 mu)/
vial)
4
• • •
donepezil hydrochloride orally
(Aricept odt)
1
AVONEX – interferon beta-1a im
inj kit 30 mcg/0.5ml
4
• • •
donepezil hydrochloride tab
5 mg (Aricept)
1
AVONEX PEN – interferon beta-1a
im inj kit 30 mcg/0.5ml
4
• • •
10 mg (Aricept)
1
BETASERON – interferon beta-1b
for inj kit 0.3 mg
3
• •
23 mg (Aricept)
1
bupropion hcl (smoking
deterrent) tab sr 12hr 150 mg
(Zyban)
1
ergoloid mesylates tab 1 mg
1
EXELON – rivastigmine td patch
24hr 4.6 mg/24hr
2
2
24hr 9.5 mg/24hr
2
CHANTIX – Benefit Limits may
apply – varenicline tartrate tab
0.5 mg (base equiv)
2
CHANTIX – Benefit Limits may
apply – varenicline tartrate tab 1
mg (base equiv)
2
24hr 13.3 mg/24hr
EXTAVIA – interferon beta-1b for
inj kit 0.3 mg
4
CHANTIX CONTINUING MONTH
– Benefit Limits may apply –
varenicline tartrate tab 1 mg
(base equiv)
2
fluoxetine hcl (pmdd) cap 10 mg
1
fluoxetine hcl (pmdd) cap 20 mg
1
1
CHANTIX STARTING MONTH
PA – Benefit Limits may apply –
varenicline tartrate tab 0.5 mg x
11 & tab 1 mg x 42 pack
2
GALANTAMINE HYDROBROMIDE
– galantamine hydrobromide oral
soln 4 mg/ml
galantamine hydrobromide cap
sr 24hr 8 mg (Razadyne er)
1
1
1
CHLORDIAZEPOXIDE/AMITRIPT
– chlordiazepoxide-amitriptyline
tab 5-12.5 mg
1
CHLORDIAZEPOXIDE/AMITRIPT
– chlordiazepoxide-amitriptyline
tab 10-25 mg
1
galantamine hydrobromide tab
4 mg (Razadyne)
1
COPAXONE – glatiramer acetate
3
• •
8 mg (Razadyne)
1
COPAXONE – glatiramer acetate
3
• •
12 mg (Razadyne)
1
disulfiram tab 250 mg (Antabuse)
1
4
disulfiram tab 500 mg (Antabuse)
1
GILENYA – fingolimod hcl cap 0.5
mg (base equiv)
Quantity Limits
donepezil hydrochloride orally
Restricted Access
• • •
Prior Review
4
Drug Name
Specialty
AUBAGIO – teriflunomide tab 14
mg
Drug Name
Drug Tier
Quantity Limits
Specialty
Restricted Access
Drug Tier
Prior Review
2015
• • •
• • •
67
3
HORIZANT – gabapentin enacarbil
tab cr 300 mg
3
HORIZANT – gabapentin enacarbil
tab cr 600 mg
3
NUEDEXTA – dextromethorphan
hbr-quinidine sulfate cap 20-10
mg
4
3
olanzapine-fluoxetine hcl cap
3-25 mg (Symbyax)
1
1
6-25 mg (Symbyax)
1
memantine hcl tab 5 mg
(Namenda)
1
6-50 mg (Symbyax)
1
memantine hcl tab 10 mg
(Namenda)
1
12-25 mg (Symbyax)
1
memantine hcl tab 5 mg (28)
& 10 mg (21) titration pak
(Namenda titration pa)
1
NAMENDA – memantine hcl oral
solution 2 mg/ml
3
12-50 mg (Symbyax)
ORAP – pimozide tab 1 mg
3
NAMENDA – memantine hcl tab 5
mg
3
ORAP – pimozide tab 2 mg
3
PERPHENAZINE/AMITRIPTYLIN
– perphenazine-amitriptyline tab
2-10 mg
1
2-25 mg
1
4-10 mg
1
4-25 mg
1
4-50 mg
1
PLEGRIDY – peginterferon
beta-1a soln pen-injector 125
mcg/0.5ml
3
• •
PLEGRIDY – peginterferon
beta-1a soln prefilled syringe 125
mcg/0.5ml
3
• •
NAMENDA – memantine hcl tab 10 3
mg
3
NAMENDA TITRATION PAK –
memantine hcl tab 5 mg (28) &
10 mg (21) titration pak
3
NAMENDA XR – memantine hcl
cap sr 24hr 7 mg
3
cap sr 24hr 14 mg
3
cap sr 24hr 21 mg
3
cap sr 24hr 28 mg
3
NAMENDA XR TITRATION PACK
– memantine hcl cap sr 24hr 7
mg & 14 mg & 21 mg & 28 mg
pack
3
NICOTROL INHALER – Benefit
Limits may apply – nicotine
68
Quantity Limits
GRALISE – gabapentin (phn) tab
600 mg
NICOTROL NS – Benefit Limits
may apply – nicotine nasal spray
10 mg/ml (0.5 mg/spray)
Restricted Access
3
Prior Review
GRALISE – gabapentin (phn) tab
300 mg
Specialty
• •
Drug Name
inhaler system 10 mg (4 mg
delivered)
Drug Tier
4
Quantity Limits
Specialty
glatiramer acetate soln prefilled
syringe 20 mg/ml (Copaxone)
Drug Name
Restricted Access
Drug Tier
Prior Review
2015
REBIF – interferon beta-1a inj 44
mcg/0.5ml (24mu/ml) (88 mcg/
ml)
3
• •
REBIF REBIDOSE – interferon
beta-1a inj 22 mcg/0.5ml (12mu/
ml) (44 mcg/ml)
3
REBIF REBIDOSE – interferon
beta-1a inj 44 mcg/0.5ml (24mu/
ml) (88 mcg/ml)
3
REBIF REBIDOSE TITRATION
– interferon beta-1a inj 6 x 8.8
mcg/0.2ml & 6 x 22 mcg/0.5ml
3
REBIF TITRATION PACK –
interferon beta-1a inj 6 x 8.8
mcg/0.2ml & 6 x 22 mcg/0.5ml
3
rivastigmine tartrate cap 1.5 mg
(Exelon)
1
rivastigmine tartrate cap 3 mg
(Exelon)
3
3
• •
SAVELLA – milnacipran hcl tab
100 mg
3
• •
SAVELLA TITRATION PACK –
milnacipran hcl tab 12.5 mg (5) &
25 mg (8) & 50 mg (42) pak
TECFIDERA – dimethyl fumarate
capsule delayed release 120 mg
3
• •
TECFIDERA – dimethyl fumarate
capsule delayed release 240 mg
3
• •
• •
TECFIDERA STARTER PACK –
dimethyl fumarate capsule dr
starter pack 120 mg & 240 mg
3
• •
• •
XENAZINE – tetrabenazine tab
12.5 mg
4
•
XENAZINE – tetrabenazine tab 25
mg
4
•
XYREM – sodium oxybate oral
solution 500 mg/ml
3
• •
• •
• •
Quantity Limits
3
SAVELLA – milnacipran hcl tab 50
mg
Restricted Access
REBIF – interferon beta-1a inj 22
mcg/0.5ml (12mu/ml) (44 mcg/
ml)
Prior Review
PLEGRIDY STARTER PACK –
peginterferon beta-1a soln pref
syr 63 & 94 mcg/0.5ml pack
3
Specialty
• •
Drug Name
Drug Tier
3
Quantity Limits
Specialty
PLEGRIDY STARTER PACK –
peginterferon beta-1a soln peninj 63 & 94 mcg/0.5ml pack
Drug Name
Restricted Access
Drug Tier
Prior Review
2015
ANALGESICS AND ANESTHETICS
ANALGESICS - NON-NARCOTIC
acetaminophen-salicylamidephenyltoloxamine cap
300-200-20mg
1
1
butalbital-acetaminophen tab
50-325 mg
1
rivastigmine tartrate cap 4.5 mg
(Exelon)
1
1
rivastigmine tartrate cap 6 mg
(Exelon)
1
butalbital-acetaminophencaffeine cap 50-300-40 mg
(Fioricet)
1
SARAFEM – fluoxetine hcl (pmdd)
tab 10 mg
3
butalbital-acetaminophencaffeine cap 50-325-40 mg
1
SARAFEM – fluoxetine hcl (pmdd)
tab 20 mg
3
butalbital-acetaminophencaffeine tab 50-325-40 mg
(Esgic)
SAVELLA – milnacipran hcl tab
12.5 mg
3
butalbital-aspirin-caffeine cap
50-325-40 mg (Fiorinal)
1
SAVELLA – milnacipran hcl tab 25
mg
3
choline & magnesium salicylates
liq 500 mg/5ml
1
69
CHOLINE MAGNESIUM TRISALI
– choline & magnesium
salicylates tab 1000 mg
1
diflunisal tab 500 mg
1
LEVACET – aspirin-apapsalicylamide-caffeine tab
500-250-150-32.5 mg
1
salsalate tab 500 mg
1
salsalate tab 750 mg
1
VANATOL LQ – butalbitalacetaminophen-caffeine soln
50-325-40 mg/15ml
1
Quantity Limits
Restricted Access
•
•
ACTIQ – fentanyl citrate lozenge
on a handle 800 mcg
4
•
•
on a handle 1200 mcg
4
•
•
on a handle 1600 mcg
4
•
•
buprenorphine hcl sl tab 2 mg
(base equiv)
1
•
•
buprenorphine hcl sl tab 8 mg
(base equiv)
1
•
•
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
ABSTRAL – fentanyl citrate sl tab
100 mcg (base equiv)
4
4
•
•
butalbital-acetaminophen-caff
w/ cod cap 50-300-40-30 mg
(Fioricet/codeine)
4
•
•
butalbital-acetaminophen-caff w/
cod cap 50-325-40-30 mg
1
4
•
•
1
4
•
•
butalbital-aspirin-caff w/ codeine
cap 50-325-40-30 mg (Fiorinal/
codeine #3)
butorphanol tartrate inj 1 mg/ml
1
acetaminophen w/ codeine soln
120-12 mg/5ml
1
butorphanol tartrate inj 2 mg/ml
1
1
acetaminophen w/ codeine tab
300-15 mg (Tylenol/codeine)
1
butorphanol tartrate nasal soln
10 mg/ml
3
300-30 mg (Tylenol/codeine #3)
1
BUTRANS – buprenorphine td
patch weekly 5 mcg/hr
3
300-60 mg (Tylenol/codeine #4)
1
patch weekly 7.5 mcg/hr
3
acetaminophen-caffeinedihydrocodeine cap
320.5-30-16 mg (Trezix)
1
3
on a handle 200 mcg
4
•
•
3
on a handle 400 mcg
4
•
•
codeine sulfate tab 15 mg
(Codeine sulfate)
1
70
Prior Review
4
4
•
Specialty
on a handle 600 mcg
ANALGESICS - NARCOTIC
•
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
CONZIP – tramadol hcl cap sr 24hr 3
biphasic release 100 mg
EXALGO – hydromorphone hcl tab 3
er 24hr deter 8 mg
er 24hr deter 12 mg
er 24hr deter 16 mg
er 24hr deter 32 mg
1
fentanyl citrate lozenge on a
handle 200 mcg (Actiq)
1
1
1
1
1
fentanyl td patch 72hr 12 mcg/hr 1
(Duragesic)
(Duragesic)
(Duragesic)
(Duragesic)
1
fentanyl td patch 72hr 100 mcg/
hr (Duragesic)
FENTORA – fentanyl citrate buccal 4
tab 100 mcg (base equiv)
Quantity Limits
Restricted Access
4
•
•
FENTORA – fentanyl citrate buccal
4
•
•
4
•
•
4
•
•
hydrocodone-acetaminophen
soln 7.5-325 mg/15ml (Hycet)
1
tab 2.5-325 mg
1
tab 10-325 mg (Norco)
1
tab 5-300 mg (Xodol)
1
•
tab 7.5-300 mg (Xodol)
1
•
•
tab 5-325 mg (Norco)
1
•
•
tab 7.5-325 mg (Norco)
1
•
•
tab 10-300 mg (Xodol)
1
•
•
hydrocodone-ibuprofen tab
2.5-200 mg (Reprexain)
1
•
•
5-200 mg (Reprexain)
1
7.5-200 mg (Vicoprofen)
1
10-200 mg (Ibudone)
1
HYDROCODONE/
ACETAMINOPHEN –
soln 10-325 mg/15ml
1
HYDROMORPHONE HCL –
hydromorphone hcl suppos 3 mg
1
hydromorphone hcl liqd 1 mg/ml
(Dilaudid)
1
•
Prior Review
•
•
Specialty
Drug Name
Drug Tier
1
Quantity Limits
Restricted Access
1
Prior Review
Specialty
Drug Name
Drug Tier
2015
71
hydromorphone hcl tab er 24hr
deter 8 mg (Exalgo)
1
MORPHINE SULFATE – morphine
sulfate tab 30 mg
1
deter 12 mg (Exalgo)
1
sulfate suppos 5 mg
1
deter 16 mg (Exalgo)
1
sulfate suppos 10 mg
1
hydromorphone hcl tab 2 mg
(Dilaudid)
1
1
(Dilaudid)
1
1
(Dilaudid)
1
morphine sulfate (concentrate)
oral soln 20 mg/ml
1
LAZANDA – fentanyl citrate nasal
spray 100 mcg/act (base equiv)
4
•
•
morphine sulfate cap sr 24hr
10 mg (Kadian)
1
LAZANDA – fentanyl citrate nasal
spray 400 mcg/act (base equiv)
4
•
•
20 mg (Kadian)
1
LEVORPHANOL TARTRATE –
levorphanol tartrate tab 2 mg
1
30 mg (Kadian)
1
MEPERIDINE HCL – meperidine
hcl oral soln 50 mg/5ml
1
50 mg (Kadian)
1
meperidine hcl tab 50 mg
(Demerol)
1
60 mg (Kadian)
1
meperidine hcl tab 100 mg
(Demerol)
1
80 mg (Kadian)
1
METHADONE HCL – methadone
hcl soln 5 mg/5ml
1
100 mg (Kadian)
1
methadone hcl conc 10 mg/ml
(Methadose)
1
1
methadone hcl soln 5 mg/5ml
(Methadone hcl)
1
MORPHINE SULFATE ER –
morphine sulfate beads cap sr
24hr 30 mg
1
methadone hcl soln 10 mg/5ml
(Methadone hcl)
1
24hr 45 mg
methadone hcl tab for oral susp
40 mg
1
1
methadone hcl tab 5 mg
(Dolophine hcl)
1
24hr 60 mg
1
methadone hcl tab 10 mg
(Dolophine)
1
24hr 75 mg
1
24hr 90 mg
1
sulfate tab 15 mg
72
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
24hr 120 mg
1
OPANA ER (CRUSH RESISTANT
– oxymorphone hcl tab er 12hr
deter 10 mg
3
morphine sulfate oral soln
10 mg/5ml
1
3
morphine sulfate oral soln
20 mg/5ml
1
deter 15 mg
3
morphine sulfate tab cr 15 mg
(Ms contin)
1
deter 20 mg
(Ms contin)
1
3
(Ms contin)
1
deter 30 mg
3
(Ms contin)
1
deter 40 mg
1
OXYCODONE HCL – oxycodone
hcl conc 100 mg/5ml (20 mg/ml)
1
(Ms contin)
3
oxycodone hcl cap 5 mg
1
NUCYNTA – tapentadol hcl tab 50
mg
1
NUCYNTA – tapentadol hcl tab 75
mg
3
oxycodone hcl conc 100 mg/5ml
(20 mg/ml) (Oxycodone hcl)
1
NUCYNTA – tapentadol hcl tab
100 mg
3
oxycodone hcl soln 5 mg/5ml
(Oxycodone hcl)
1
NUCYNTA ER – tapentadol hcl tab
sr 12hr 50 mg
3
oxycodone hcl tab 5 mg
(Roxicodone)
1
sr 12hr 100 mg
3
(Roxicodone)
1
sr 12hr 150 mg
3
1
1
sr 12hr 200 mg
3
(Roxicodone)
1
sr 12hr 250 mg
3
oxycodone w/ acetaminophen
tab 2.5-325 mg (Percocet)
1
deter 5 mg
3
tab 5-325 mg (Percocet)
tab 7.5-325 mg (Percocet)
1
deter 7.5 mg
3
tab 10-325 mg (Percocet)
1
oxycodone-aspirin tab
4.8355-325 mg (Percodan)
1
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
73
•
•
SUBOXONE – buprenorphine hclnaloxone hcl sl film 8-2 mg (base
equiv)
2
•
•
2
•
•
•
SUBOXONE – buprenorphine hclnaloxone hcl sl film 12-3 mg
(base equiv)
2
•
SUBSYS – fentanyl sublingual
spray 100 mcg
4
•
•
2
•
spray 200 mcg
4
OXYCONTIN – oxycodone hcl tab
er 12hr deter 80 mg
•
•
1
spray 400 mcg
4
oxymorphone hcl tab sr 12hr
5 mg
•
•
1
spray 600 mcg
4
7.5 mg
•
•
1
spray 800 mcg
4
10 mg
•
•
1
spray 1200 mcg (600 mcg x 2)
4
15 mg
•
•
1
spray 1600 mcg (800 mcg x 2)
4
20 mg
•
•
1
tramadol hcl tab sr 24hr 100 mg
(Ultram er)
1
30 mg
1
(Ultram er)
1
40 mg
1
(Ultram er)
1
oxymorphone hcl tab 5 mg
(Opana)
1
tramadol hcl tab sr 24hr biphasic
release 100 mg
1
oxymorphone hcl tab 10 mg
(Opana)
1
release 200 mg
1
pentazocine w/ naloxone tab
50-0.5 mg
1
release 300 mg
1
PRIMLEV – oxycodone w/
acetaminophen tab 5-300 mg
1
tramadol hcl tab 50 mg (Ultram)
1
PRIMLEV – oxycodone w/
acetaminophen tab 7.5-300 mg
tramadol-acetaminophen tab
37.5-325 mg (Ultracet)
1
2
er 12hr deter 15 mg
2
•
er 12hr deter 20 mg
2
•
er 12hr deter 30 mg
2
•
er 12hr deter 40 mg
2
er 12hr deter 60 mg
74
Quantity Limits
Restricted Access
2
er 12hr deter 10 mg
Prior Review
SUBOXONE – buprenorphine hclnaloxone hcl sl film 4-1 mg (base
equiv)
1
Specialty
•
oxycodone-ibuprofen tab
5-400 mg
Drug Tier
•
Prior Review
2
•
SUBOXONE – buprenorphine hclnaloxone hcl sl film 2-0.5 mg
(base equiv)
Drug Name
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
2015
TREZIX – acetaminophen-caffeine- 1
dihydrocodeine cap 320.5-30-16
mg
3
ZOHYDRO ER – hydrocodone
bitartrate cap sr 12hr abusedeterrent 10 mg
3
3
3
3
3
ANALGESICS - ANTI-INFLAMMATORY
4
ACTEMRA – tocilizumab
syringe 162 mg/0.9ml
4
ARAVA – leflunomide tab 10 mg
diclofenac potassium tab 50 mg
(Cataflam)
1
diclofenac sodium tab delayed
release 25 mg
1
release 50 mg
1
release 75 mg
1
•
diclofenac sodium tab sr 24hr
100 mg (Voltaren-xr)
1
1
•
diclofenac w/ misoprostol tab
delayed release 50-0.2 mg
(Arthrotec 50)
1
•
diclofenac w/ misoprostol tab
delayed release 75-0.2 mg
(Arthrotec 75)
•
•
•
• • • •
ARAVA – leflunomide tab 20 mg
4
ARCALYST – rilonacept for inj 220
mg
4
CELEBREX – celecoxib cap 50 mg
3
CELEBREX – celecoxib cap 100
mg
3
mg
3
•
mg
3
celecoxib cap 50 mg (Celebrex)
1
1
1
1
•
•
•
DUEXIS – ibuprofen-famotidine tab 3
800-26.6 mg
3
ENBREL – etanercept for
subcutaneous inj kit 25 mg
3
ENBREL – etanercept
syringe 25 mg/0.5ml
3
ENBREL – etanercept
syringe 50 mg/ml
3
ENBREL SURECLICK –
etanercept subcutaneous
solution auto-injector 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
FENOPROFEN CALCIUM –
fenoprofen calcium tab 600 mg
1
flurbiprofen tab 50 mg
1
flurbiprofen tab 100 mg
1
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
•
• •
•
• •
•
• •
•
• •
•
75
HUMIRA – adalimumab prefilled
syringe kit 20 mg/0.4ml
3
• •
•
3
• •
HUMIRA PEDIATRIC CROHNS D
– adalimumab prefilled syringe kit
40 mg/0.8ml
3
• •
HUMIRA PEN – adalimumab peninjector kit 40 mg/0.8ml
3
HUMIRA PEN-CROHNS DISEASE
– adalimumab pen-injector kit 40
mg/0.8ml
3
HUMIRA PEN-PSORIASIS STAR
– adalimumab pen-injector kit 40
mg/0.8ml
3
ibuprofen susp 100 mg/5ml
1
ibuprofen tab 400 mg
1
1
1
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
KETOROLAC TROMETHAMINE
– ketorolac tromethamine inj 300
mg/10ml (30 mg/ml)
Quantity Limits
•
Restricted Access
• •
Prior Review
3
Drug Name
Specialty
Drug Name
Drug Tier
Quantity Limits
Specialty
Restricted Access
Drug Tier
Prior Review
2015
MECLOFENAMATE SODIUM –
meclofenamate sodium cap 50
mg
1
1
•
MECLOFENAMATE SODIUM –
meclofenamate sodium cap 100
mg
•
mefenamic acid cap 250 mg
(Ponstel)
1
MELOXICAM – meloxicam susp
7.5 mg/5ml
1
meloxicam tab 7.5 mg (Mobic)
1
meloxicam tab 15 mg (Mobic)
1
nabumetone tab 500 mg
1
nabumetone tab 750 mg
1
NAPROXEN – naproxen susp 125
mg/5ml
1
naproxen sodium tab sr 24hr
500 mg (base equiv) (Naprelan)
1
naproxen sodium tab 275 mg
(Anaprox)
1
naproxen sodium tab 550 mg
(Anaprox ds)
1
naproxen tab ec 375 mg (Ecnaprosyn)
1
naproxen tab ec 500 mg (Ecnaprosyn)
1
naproxen tab 250 mg (Naprosyn)
1
1
1
1
4
• • • •
ketorolac tromethamine tab
10 mg
1
ORENCIA – abatacept
syringe 125 mg/ml
4
• • • •
KINERET – anakinra
syringe 100 mg/0.67ml
4
OTEZLA – apremilast tab starter
therapy pack 10 mg & 20 mg &
30 mg
OTEZLA – apremilast tab 30 mg
4
• • • •
leflunomide tab 10 mg (Arava)
1
4
leflunomide tab 20 mg (Arava)
1
OTREXUP – methotrexate soln pf
auto-injector 10 mg/0.4ml
4
76
• •
• •
• •
• •
•
•
•
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
4
SPRIX – ketorolac tromethamine
nasal spray 15.75 mg/spray
3
4
sulindac tab 150 mg
1
sulindac tab 200 mg
1
oxaprozin tab 600 mg (Daypro)
1
1
piroxicam cap 10 mg (Feldene)
1
TOLMETIN SODIUM – tolmetin
sodium tab 200 mg
piroxicam cap 20 mg (Feldene)
1
1
RASUVO – methotrexate soln pf
4
TOLMETIN SODIUM – tolmetin
sodium tab 600 mg
tolmetin sodium cap 400 mg
1
4
•
2
•
4
•
VIMOVO – naproxenesomeprazole magnesium tab dr
375-20 mg
2
•
4
•
VIMOVO – naproxenesomeprazole magnesium tab dr
500-20 mg
4
•
XELJANZ – tofacitinib citrate tab 5
4
4
•
ZIPSOR – diclofenac potassium
cap 25 mg
3
4
•
MIGRAINE PRODUCTS
1
4
•
acetaminophen-isometheptenedichloral cap 325-65-100 mg
1
•
4
•
almotriptan malate tab 6.25 mg
(Axert)
1
•
4
•
almotriptan malate tab 12.5 mg
(Axert)
3
• •
RIDAURA – auranofin cap 3 mg
2
AXERT – almotriptan malate tab
6.25 mg
SIMPONI – golimumab
subcutaneous soln auto-injector
50 mg/0.5ml
3
AXERT – almotriptan malate tab
12.5 mg
3
• •
3
subcutaneous soln auto-injector
100 mg/ml
3
CAFERGOT – ergotamine w/
caffeine tab 1-100 mg
CAMBIA – diclofenac potassium
packet 50 mg
3
syringe 50 mg/0.5ml
3
• •
•
D.H.E. 45 – dihydroergotamine
mesylate inj 1 mg/ml
4
•
•
•
syringe 100 mg/ml
• •
dihydroergotamine mesylate inj
1 mg/ml (D.h.e. 45)
1
3
•
• •
• •
•
•
FROVA – frovatriptan succinate tab 3
• • • •
• • •
• •
77
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
isometheptene-caffeineacetaminophen tab
65-20-325 mg (Prodrin)
1
sumatriptan succinate solution
cartridge 6 mg/0.5ml (Imitrex
statdose ref)
1
•
MIGERGOT – ergotamine w/
caffeine suppos 2-100 mg
1
sumatriptan succinate tab 25 mg
(Imitrex)
1
•
MIGRANAL – dihydroergotamine
mesylate nasal spray 4 mg/ml
3
sumatriptan succinate tab 50 mg
(Imitrex)
1
•
naratriptan hcl tab 1 mg (base
equiv) (Amerge)
1
•
sumatriptan succinate tab
100 mg (Imitrex)
1
•
naratriptan hcl tab 2.5 mg (base
equiv) (Amerge)
1
•
3
• •
RELPAX – eletriptan hydrobromide
2
•
SUMAVEL DOSEPRO –
jet-injector 4 mg/0.5ml
3
• •
RELPAX – eletriptan hydrobromide
2
•
SUMAVEL DOSEPRO –
jet-injector 6 mg/0.5ml
rizatriptan benzoate orally
(Maxalt-mlt)
1
•
TREXIMET – sumatriptannaproxen sodium tab 85-500 mg
3
• •
1
•
rizatriptan benzoate orally
(Maxalt-mlt)
1
zolmitriptan orally disintegrating
tab 2.5 mg (Zomig zmt)
zolmitriptan orally disintegrating
tab 5 mg (Zomig zmt)
1
•
rizatriptan benzoate tab 5 mg
(Maxalt)
1
zolmitriptan tab 2.5 mg (Zomig)
1
1
rizatriptan benzoate tab 10 mg
(Maxalt)
•
zolmitriptan tab 5 mg (Zomig)
1
3
SUMATRIPTAN – sumatriptan
nasal spray 5 mg/act
1
•
ZOMIG – zolmitriptan nasal spray
2.5 mg/spray unit
•
•
• •
1
•
allopurinol tab 100 mg (Zyloprim)
1
SUMATRIPTAN – sumatriptan
nasal spray 20 mg/act
allopurinol tab 300 mg (Zyloprim)
1
sumatriptan succinate inj
6 mg/0.5ml (Imitrex)
1
•
colchicine w/ probenecid tab
0.5-500 mg
1
(Imitrex statdose sys)
1
•
COLCRYS – colchicine tab 0.6 mg
2
probenecid tab 500 mg
1
ULORIC – febuxostat tab 40 mg
3
(Imitrex statdose sys)
1
ULORIC – febuxostat tab 80 mg
3
cartridge 4 mg/0.5ml (Imitrex
statdose ref)
1
78
•
•
•
GOUT AGENTS
GENERAL ANESTHETICS
•
FORANE – isoflurane inhal soln
1
isoflurane inhal soln (Forane)
1
sevoflurane inhal soln (Ultane)
1
clonazepam tab 2 mg (Klonopin)
1
BANZEL – rufinamide susp 40 mg/
ml
3
DIAZEPAM – diazepam rectal gel
delivery system 2.5 mg
1
BANZEL – rufinamide tab 200 mg
3
1
BANZEL – rufinamide tab 400 mg
3
delivery system 10 mg
carbamazepine cap sr 12hr
100 mg (Carbatrol)
1
delivery system 20 mg
1
200 mg (Carbatrol)
1
DILANTIN – phenytoin sodium
extended cap 30 mg
2
300 mg (Carbatrol)
1
DILANTIN – phenytoin sodium
extended cap 100 mg
2
carbamazepine chew tab 100 mg
1
2
carbamazepine susp 100 mg/5ml
(Tegretol)
1
DILANTIN INFATABS – phenytoin
chew tab 50 mg
2
carbamazepine tab sr 12hr
200 mg (Tegretol-xr)
1
DILANTIN-125 – phenytoin susp
125 mg/5ml
1
carbamazepine tab sr 12hr
400 mg (Tegretol-xr)
1
divalproex sodium cap sprinkle
125 mg (Depakote sprinkles)
1
carbamazepine tab 200 mg
(Tegretol)
1
divalproex sodium tab delayed
release 125 mg (Depakote)
1
CARBATROL – carbamazepine
cap sr 12hr 100 mg
2
1
cap sr 12hr 200 mg
2
1
cap sr 12hr 300 mg
2
divalproex sodium tab sr 24 hr
250 mg (Depakote er)
1
clonazepam orally disintegrating
tab 0.125 mg
1
divalproex sodium tab sr 24 hr
500 mg (Depakote er)
1
tab 0.25 mg
1
ethosuximide cap 250 mg
(Zarontin)
1
tab 0.5 mg
1
ethosuximide soln 250 mg/5ml
(Zarontin)
1
tab 1 mg
1
felbamate susp 600 mg/5ml
(Felbatol)
felbamate tab 400 mg (Felbatol)
1
tab 2 mg
1
felbamate tab 600 mg (Felbatol)
1
1
clonazepam tab 0.5 mg
(Klonopin)
1
gabapentin cap 100 mg
(Neurontin)
(Neurontin)
1
Quantity Limits
ANTICONVULSANTS
Restricted Access
1
Prior Review
clonazepam tab 1 mg (Klonopin)
Specialty
Drug Tier
Quantity Limits
Restricted Access
Prior Review
NEUROMUSCULAR DRUGS
Specialty
Drug Name
Drug Name
Drug Tier
2015
79
(Neurontin)
1
gabapentin oral soln 250 mg/5ml
(Neurontin)
1
1
lamotrigine tab chewable
dispersible 25 mg (Lamictal
chewable di)
1
gabapentin tab 600 mg
(Neurontin)
1
lamotrigine tab sr 24hr 25 mg
(Lamictal xr)
1
gabapentin tab 800 mg
(Neurontin)
1
(Lamictal xr)
1
GABITRIL – tiagabine hcl tab 12
mg
2
(Lamictal xr)
1
GABITRIL – tiagabine hcl tab 16
mg
2
(Lamictal xr)
1
LAMICTAL ODT – lamotrigine tab
disp 25 mg (21) & 50 mg (7)
titration kit
3
(Lamictal xr)
(Lamictal xr)
1
disp 50 mg (42) & 100 mg (14)
titration kit
3
lamotrigine tab 25 mg (Lamictal)
1
1
3
1
disp 25 (14) & 50 mg (14) & 100
mg (7) kit
1
1
LAMICTAL STARTER/NOT TAKI –
lamotrigine tab 25 mg (42) & 100
mg (7) starter kit
2
levetiracetam oral soln 100 mg/
ml (Keppra)
levetiracetam tab sr 24hr 500 mg
(Keppra xr)
1
levetiracetam tab sr 24hr 750 mg
(Keppra xr)
1
levetiracetam tab 250 mg
(Keppra)
1
(Keppra)
1
(Keppra)
1
(Keppra)
1
LYRICA – pregabalin soln 20 mg/
ml
2
LYRICA – pregabalin cap 25 mg
2
2
2
2
LAMICTAL STARTER/TAKING C – 2
lamotrigine tab 25 mg (84) & 100
mg (14) starter kit
LAMICTAL STARTER/TAKING V – 2
lamotrigine tab 25 mg (35) starter
kit
1
lamotrigine orally disintegrating
tab 25 mg (Lamictal odt)
1
1
1
1
lamotrigine tab chewable
dispersible 5 mg (Lamictal
chewable di)
80
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
3
2
3
2
SABRIL – vigabatrin powd pack
500 mg
•
•
2
3
ONFI – clobazam suspension 2.5
mg/ml
3
STAVZOR – valproic acid cap
3
ONFI – clobazam tab 10 mg
3
3
3
ONFI – clobazam tab 20 mg
oxcarbazepine susp 300 mg/5ml
(60 mg/ml) (Trileptal)
1
TEGRETOL – carbamazepine tab
200 mg
2
oxcarbazepine tab 150 mg
(Trileptal)
1
(Trileptal)
1
(Trileptal)
1
OXTELLAR XR – oxcarbazepine
tab sr 24hr 150 mg
3
tab sr 24hr 300 mg
3
tab sr 24hr 600 mg
3
PHENYTEK – phenytoin sodium
extended cap 200 mg
2
PHENYTEK – phenytoin sodium
extended cap 300 mg
2
phenytoin chew tab 50 mg
(Dilantin infatabs)
Quantity Limits
SABRIL – vigabatrin tab 500 mg
Restricted Access
Specialty
2
Prior Review
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Name
Drug Tier
2015
TEGRETOL – carbamazepine susp 2
100 mg/5ml
2
TEGRETOL-XR – carbamazepine
tab sr 12hr 100 mg
2
tab sr 12hr 200 mg
2
tab sr 12hr 400 mg
1
tiagabine hcl tab 2 mg (Gabitril)
tiagabine hcl tab 4 mg (Gabitril)
1
topiramate sprinkle cap 15 mg
(Topamax sprinkle)
1
topiramate sprinkle cap 25 mg
(Topamax sprinkle)
1
topiramate tab 25 mg (Topamax)
1
1
topiramate tab 50 mg (Topamax)
1
phenytoin sodium extended cap
100 mg (Dilantin)
1
topiramate tab 100 mg (Topamax) 1
topiramate tab 200 mg (Topamax) 1
phenytoin susp 125 mg/5ml
(Dilantin)
1
POTIGA – ezogabine tab 50 mg
3
3
3
3
primidone tab 50 mg (Mysoline)
1
primidone tab 250 mg (Mysoline)
1
valproate sodium syrup
(Depakene)
1
valproic acid cap 250 mg
(Depakene)
1
VIMPAT – lacosamide oral solution
10 mg/ml
3
VIMPAT – lacosamide tab 50 mg
3
3
3
81
carbidopa tab 25 mg (Lodosyn)
1
2
1
CARBIDOPA/LEVODOPA/
ENTACA – carbidopa-levodopaentacapone tabs 12.5-50-200 mg
2
AMANTADINE HCL – amantadine
hcl tab 100 mg
1
CARBIDOPA/LEVODOPA/
ENTACA – carbidopa-levodopaentacapone tabs 18.75-75-200
mg
amantadine hcl cap 100 mg
1
amantadine hcl syrup 50 mg/5ml
APOKYN – apomorphine
hydrochloride inj 10 mg/ml
3
CARBIDOPA/LEVODOPA/
ENTACA – carbidopa-levodopaentacapone tabs 25-100-200 mg
2
1
2
AZILECT – rasagiline mesylate tab
0.5 mg (base equiv)
3
AZILECT – rasagiline mesylate tab
1 mg (base equiv)
3
CARBIDOPA/LEVODOPA/
mg
2
benztropine mesylate tab 0.5 mg
1
benztropine mesylate tab 1 mg
1
CARBIDOPA/LEVODOPA/
mg
benztropine mesylate tab 2 mg
1
2
bromocriptine mesylate cap
5 mg (Parlodel)
1
CARBIDOPA/LEVODOPA/
ENTACA – carbidopa-levodopaentacapone tabs 50-200-200 mg
bromocriptine mesylate tab
2.5 mg
1
entacapone tab 200 mg (Comtan)
1
3
carbidopa & levodopa orally
disintegrating tab 10-100 mg
1
MIRAPEX ER – pramipexole
dihydrochloride tab sr 24hr 0.375
mg
1
3
1
mg
3
carbidopa & levodopa tab cr
25-100 mg (Sinemet cr)
1
mg
1
mg
3
carbidopa & levodopa tab cr
50-200 mg (Sinemet cr)
carbidopa & levodopa tab
10-100 mg (Sinemet)
1
dihydrochloride tab sr 24hr 3 mg
3
25-100 mg (Sinemet)
1
mg
3
ANTIPARKINSON AGENTS
82
•
Quantity Limits
Restricted Access
zonisamide cap 100 mg
(Zonegran)
1
Prior Review
1
25-250 mg (Sinemet)
Specialty
Drug Name
Drug Tier
1
Quantity Limits
(Zonegran)
Restricted Access
3
Prior Review
Specialty
Drug Name
Drug Tier
2015
3
ropinirole hydrochloride tab sr
24hr 4 mg (base equivalent)
(Requip xl)
1
NEUPRO – rotigotine td patch 24hr 3
1 mg/24hr
2 mg/24hr
3 mg/24hr
4 mg/24hr
6 mg/24hr
8 mg/24hr
pramipexole dihydrochloride tab 1
sr 24hr 0.375 mg (Mirapex er)
sr 24hr 3 mg (Mirapex er)
0.125 mg (Mirapex)
0.25 mg (Mirapex)
0.5 mg (Mirapex)
0.75 mg (Mirapex)
1 mg (Mirapex)
1.5 mg (Mirapex)
1
(Requip xl)
(Requip xl)
1
(Requip xl)
1
(Requip xl)
1
ropinirole hydrochloride tab
0.25 mg (Requip)
1
0.5 mg (Requip)
1
1 mg (Requip)
1
2 mg (Requip)
1
3 mg (Requip)
1
4 mg (Requip)
1
5 mg (Requip)
1
selegiline hcl cap 5 mg (Eldepryl)
1
selegiline hcl tab 5 mg
1
STALEVO 100 – carbidopalevodopa-entacapone tabs
25-100-200 mg
3
31.25-125-200 mg
3
37.5-150-200 mg
3
50-200-200 mg
3
mg
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
83
12.5-50-200 mg
3
18.75-75-200 mg
3
tolcapone tab 100 mg (Tasmar)
1
trihexyphenidyl hcl elixir 0.4 mg/
ml
1
trihexyphenidyl hcl tab 2 mg
1
trihexyphenidyl hcl tab 5 mg
1
ZELAPAR – selegiline hcl orally
disintegrating tab 1.25 mg
3
NEUROMUSCULAR AGENTS
RILUTEK – riluzole tab 50 mg
3
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
cyclobenzaprine hcl tab 5 mg
1
cyclobenzaprine hcl tab 7.5 mg
(Fexmid)
1
cyclobenzaprine hcl tab 10 mg
1
DANTROLENE SODIUM –
dantrolene sodium cap 100 mg
1
84
(Dantrium)
1
(Dantrium)
1
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
1
tizanidine hcl cap 2 mg (base
equivalent) (Zanaflex)
1
1
1
tizanidine hcl tab 2 mg (base
equivalent)
1
tizanidine hcl tab 4 mg (base
ANTIMYASTHENIC AGENTS
pyridostigmine bromide tab cr
180 mg (Mestinon timespan)
1
pyridostigmine bromide tab
60 mg (Mestinon)
1
NUTRITIONAL PRODUCTS
VITAMINS
AMINOBENZOATE POTASSIUM
– potassium aminobenzoate
packet 2 gm
1
cholecalciferol cap 50000 unit
1
ergocalciferol cap 50000 unit
(Drisdol)
1
MEPHYTON – phytonadione tab 5
mg
3
VITAMIN K1 – phytonadione inj 10
mg/ml
1
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
ESCAVITE LQ – pediatric multiple
vitamins w/ fl-fe drops 0.25-6 mg/
ml
1
MINERALS and ELECTROLYTES
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)
1
potassium chloride oral liq 20%
(40 meq/15ml)
1
potassium chloride powder
packet 20 meq
1
CALCIUM-FOLIC ACID PLUS D
– ca carb-folic acid-vit d-b6-b12boron-mag wafer 1342-1 mg
1
EFFER-K – potassium
bicarbonate-citric acid effer tab
10 meq
2
EFFER-K – potassium
bicarbonate-citric acid effer tab
20 meq
2
IODINE STRONG – iodine solution
strong 5% (lugol's)
potassium chloride tab cr 8 meq
(600 mg)
1
1
K-PHOS – potassium phosphate
monobasic tab 500 mg
potassium chloride tab cr 10
meq (K-tab)
1
2
1
SODIUM FLUORIDE – sodium
fluoride tab 0.5 mg f (from 1.1 mg
naf)
1
K-PHOS NEUTRAL – pot phos
monobasic w/sod phos di &
monobas tab 155-852-130mg
K-TAB – potassium chloride tab cr
20 meq (1500 mg)
SODIUM FLUORIDE – sodium
fluoride tab 1 mg f (from 2.2 mg
naf)
1
3
KLOR-CON M15 – potassium
chloride microencapsulated crys
cr tab 15 meq
2
sodium fluoride chew tab
0.25 mg f (from 0.55 mg naf)
(Luride)
1
LOZI-FLUR – sodium fluoride
lozenge 1 mg f (from 2.2 mg naf)
1
sodium fluoride chew tab 0.5 mg
f (from 1.1 mg naf) (Luride)
1
pot bicarbonate & chloride effer
tab 25 meq
1
sodium fluoride chew tab 1 mg f
(from 2.2 mg naf) (Luride)
1
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)
1
potassium bicarbonate effer tab
25 meq
sodium fluoride soln 0.5 mg/ml f
(from 1.1 mg/ml naf) (Luride)
1
1
potassium chloride cap cr 8 meq
(Micro-k)
zinc sulfate cap 220 mg (50 mg
elemental zn)
1
1
potassium chloride cap cr 10
meq (Micro-k)
1
POTASSIUM CHLORIDE ER –
potassium chloride tab cr 8 meq
(600 mg)
1
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
NUTRIENTS
acetylcysteine cap 600 mg
1
HEMATOLOGICAL AGENTS
HEMATOPOIETIC AGENTS
85
3
•
ARANESP ALBUMIN FREE –
darbepoetin alfa-polysorbate 80
soln inj 500 mcg/ml
3
•
soln inj 25 mcg/ml
3
•
BP VIT 3 – folic acid-vit b6-vit b12omega 3-phytosterols cap 1 mg
1
4
• •
soln inj 25 mcg/0.42ml
3
CERDELGA – eliglustat tartrate
2
•
soln inj 40 mcg/ml
3
•
DROXIA – hydroxyurea cap 200
mg
mg
2
•
3
•
mg
2
•
4
•
soln inj 60 mcg/ml
3
EPOGEN – epoetin alfa inj 2000
unit/ml
unit/ml
4
•
3
unit/ml
4
•
4
•
soln inj 100 mcg/ml
3
unit/ml
unit/ml
4
•
3
•
fe fum-iron polysacch complexfa-b cmplx-c-zn-mn-cu cap
(Tandem plus)
1
3
•
fe fumarate w/ b12-vit c-fa-ifc
cap 110-0.015-75-0.5-240 mg
1
3
•
fe fumarate-vit c-vit b12-fa cap
460 (151 fe)-60-0.01-1 mg
1
soln inj 200 mcg/ml
3
•
soln inj 300 mcg/ml
3
•
3
•
86
•
•
•
•
Drug Name
FERRAPLUS 90 – iron-folic acid-vit 1
b12-vit c-docusate sod tab 90-1
mg
1
FERREX 150 FORTE PLUS – fe
asp gly-fe polysacch-succ ac-cthreon ac-b12-fa cap
1
FERREX 28 – fe asparto gly-fe
fum-b12-fa-c-succinic ac tab ther
pack
1
ferrous fumarate-folic acid tab
324-1 mg
Quantity Limits
Drug Name
Restricted Access
Specialty
Prior Review
Drug Tier
Quantity Limits
Specialty
Restricted Access
Drug Tier
Prior Review
2015
FOLIVANE-PLUS – fe fum-iron
polysacch complex-fa-b complexc-biotin cap
1
FOLTRATE – cobalamine
combination tab
MULTIGEN PLUS – fe aspart glyfe fum-succ acd-c-threonic acdb12-fa tab
1
NASCOBAL – cyanocobalamin
nasal spray 500 mcg/0.1ml
3
NEULASTA – pegfilgrastim inj 6
mg/0.6ml
4
•
4
•
2
NEULASTA DELIVERY KIT –
pegfilgrastim inj 6 mg/0.6ml
4
•
GRANIX – tbo-filgrastim soln
prefilled syringe 300 mcg/0.5ml
4
•
NEUMEGA – oprelvekin for inj 5
mg
3
•
GRANIX – tbo-filgrastim soln
prefilled syringe 480 mcg/0.8ml
4
•
NEUPOGEN – filgrastim inj 300
mcg/ml
3
•
HEMATOGEN FA – fe fumarate-vit
c-vit b12-fa cap 200-250-0.01-1
mg
1
mcg/1.6ml (300 mcg/ml)
3
•
HYDROXOCOBALAMIN –
hydroxocobalamin inj 1000 mcg/
ml
1
3
•
•
iron combination cap
PROCRIT – epoetin alfa inj 2000
unit/ml
4
1
iron-docusate-b12-folic acidc-e-cu-biotin tab 150-1 mg
(Hematron-af)
1
unit/ml
4
•
•
1
unit/ml
4
iron-folic acid-vit c-vit b6-vit b12zinc tab 150-1.25 mg (Corvite
150)
unit/ml
4
•
unit/ml
4
•
unit/ml
4
•
PROFERRIN-FORTE – iron heme
polypeptide-folic acid tab 12-1
mg (fe equiv)
2
PROMACTA – eltrombopag
olamine tab 12.5 mg (base equiv)
4
•
olamine tab 25 mg (base equiv)
4
•
1
iron-vit c-vit b12-folic acid tab
100-250-0.025-1 mg (Icar-c plus)
4
LEUKINE – sargramostim
lyophilized for inj 250 mcg
4
MOZOBIL – plerixafor
subcutaneous inj 24 mg/1.2ml
(20 mg/ml)
1
MULTIGEN – fe asparto gly-succ
acd-c-threonic acd-b12-des stom
tab
•
•
Quantity Limits
1
1
Restricted Access
FOLIVANE-F – fe fum-fe poly-fa-cb3 cap 62.5-62.5-1-40-3mg(125
mg fe)
MULTIGEN FOLIC – fe asparto
gly-succinic acd-vit c-threonic
acd-b12-fa tab
Prior Review
1
Specialty
folic acid-vitamin b6-vitamin b12
tab 2.2-25-1 mg (Folgard rx)
Drug Name
Drug Tier
1
Quantity Limits
folic acid-vitamin b6-vitamin b12
tab 2.2-25-0.5 mg
Restricted Access
1
Prior Review
folic acid tab 1 mg
Specialty
Drug Name
Drug Tier
2015
87
1
4
•
enoxaparin sodium inj
40 mg/0.4ml (Lovenox)
1
1
1
enoxaparin sodium inj 100 mg/
ml (Lovenox)
1
1
PUREFE PLUS – ferrous fumarate- 2
fa-b complex-c-zn-mg-mn-cu cap
106-1 mg
1
TARON FORTE – fe bisglycinatefe polysacch-vit c-vit b12-fa cap
ZAVESCA – miglustat cap 100 mg 3
ANTICOAGULANTS
• •
ARIXTRA – fondaparinux sodium
subcutaneous inj 2.5 mg/0.5ml
4
1
4
enoxaparin sodium inj 150 mg/
ml (Lovenox)
1
4
300 mg/3ml (Lovenox)
1
4
fondaparinux sodium
(Arixtra)
COUMADIN – warfarin sodium tab
1 mg
2
1
2 mg
2
fondaparinux sodium
(Arixtra)
1
2.5 mg
2
fondaparinux sodium
(Arixtra)
2
fondaparinux sodium
(Arixtra)
1
3 mg
4 mg
2
FRAGMIN – dalteparin sodium inj
10000 unit/ml
4
5 mg
2
2500 unit/0.2ml
4
6 mg
2
5000 unit/0.2ml
4
7.5 mg
2
12500 unit/0.5ml
4
10 mg
2
15000 unit/0.6ml
4
ELIQUIS – apixaban tab 2.5 mg
2
ELIQUIS – apixaban tab 5 mg
18000 unit/0.72ml
4
2
88
Quantity Limits
Restricted Access
•
Prior Review
4
Drug Name
Specialty
Drug Name
Drug Tier
Quantity Limits
Specialty
Restricted Access
Drug Tier
Prior Review
2015
95000 unit/3.8ml
4
AMICAR – aminocaproic acid tab
1000 mg
2
heparin sodium (porcine) 2 unit/
ml in sodium chloride 0.9%
(Heparin sodium/sodiu)
1
tranexamic acid tab 650 mg
(Lysteda)
1
HEPARIN SODIUM/SODIUM CHL
– heparin sodium (porcine) 2
unit/ml in sodium chloride 0.9%
1
IPRIVASK – desirudin for inj 15 mg
4
PRADAXA – dabigatran etexilate
mesylate cap 75 mg (etexilate
base eq)
2
PRADAXA – dabigatran etexilate
mesylate cap 150 mg (etexilate
base eq)
2
warfarin sodium tab 1 mg
(Coumadin)
3
cilostazol tab 50 mg (Pletal)
1
cilostazol tab 100 mg (Pletal)
1
1
clopidogrel bisulfate tab 75 mg
(base equiv) (Plavix)
1
(Coumadin)
1
clopidogrel bisulfate tab 300 mg
(base equiv) (Plavix)
1
warfarin sodium tab 2.5 mg
(Coumadin)
1
dipyridamole tab 25 mg
(Persantine)
1
(Coumadin)
1
(Persantine)
1
(Coumadin)
1
(Persantine)
1
(Coumadin)
1
EFFIENT – prasugrel hcl tab 5 mg
(base equiv)
3
(Coumadin)
1
warfarin sodium tab 7.5 mg
(Coumadin)
1
(Coumadin)
1
EFFIENT – prasugrel hcl tab 10 mg 3
(base equiv)
FIRAZYR – icatibant acetate inj 30 4
mg/3ml (base equivalent)
1
pentoxifylline tab cr 400 mg
XARELTO STARTER PACK –
rivaroxaban tab starter therapy
pack 15 mg & 20 mg
2
Quantity Limits
Restricted Access
Prior Review
HEMATOLOGICAL AGENTS - MISC.
3
AGGRENOX – aspirindipyridamole cap sr 12hr 25-200
mg
1
anagrelide hcl cap 0.5 mg
(Agrylin)
1
anagrelide hcl cap 1 mg
BRILINTA – ticagrelor tab 90 mg
XARELTO – rivaroxaban tab 10 mg 2
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
ticlopidine hcl tab 250 mg
• •
1
TOPICAL PRODUCTS
OPHTHALMIC AGENTS
ACUVAIL – ketorolac
tromethamine ophth soln 0.45%
3
ALOCRIL – nedocromil sodium
ophth soln 2%
3
HEMOSTATICS
89
ALOMIDE – lodoxamide
tromethamine ophth soln 0.1%
3
brimonidine tartrate ophth soln
0.15% (Alphagan p)
1
ALPHAGAN P – brimonidine
tartrate ophth soln 0.1%
2
brimonidine tartrate ophth soln
0.2%
1
apraclonidine hcl ophth soln
0.5% (base equivalent)
(Iopidine)
1
bromfenac sodium ophth soln
0.09% (base equivalent)
1
1
bromfenac sodium ophth soln
0.09% (base equiv) (once-daily)
1
ATROPINE SULFATE – atropine
sulfate ophth oint 1%
carteolol hcl ophth soln 1%
1
atropine sulfate ophth soln 1%
(Isopto atropine)
1
CILOXAN – ciprofloxacin hcl ophth
soln 0.3%
3
AZASITE – azithromycin ophth
soln 1%
3
CILOXAN – ciprofloxacin hcl ophth
oint 0.3%
3
azelastine hcl ophth soln 0.05%
(Optivar)
1
ciprofloxacin hcl ophth soln
0.3% (Ciloxan)
1
AZOPT – brinzolamide ophth susp
1%
2
3
BACITRACIN – bacitracin ophth
oint 500 unit/gm
1
COMBIGAN – brimonidine tartratetimolol maleate ophth soln
0.2-0.5%
bacitracin-polymyxin b ophth
oint
COSOPT PF – dorzolamide
hcl-timolol maleate ophth sol
22.3-6.8 mg/ml pf
3
1
bacitracin-polymyxin-neomycinhc ophth oint 1%
1
cromolyn sodium ophth soln 4%
1
BEPREVE – bepotastine besilate
ophth soln 1.5%
cyclopentolate hcl ophth soln
1% (Cyclogyl)
1
3
3
cyclopentolate hcl ophth soln
2% (Cyclogyl)
1
BESIVANCE – besifloxacin hcl
ophth susp 0.6% (base equiv)
1
dexamethasone sodium
phosphate ophth soln 0.1%
1
betaxolol hcl ophth soln 0.5%
BETIMOL – timolol ophth soln
0.25%
2
diclofenac sodium ophth soln
0.1%
1
BETIMOL – timolol ophth soln
0.5%
2
dorzolamide hcl ophth soln 2%
(Trusopt)
1
BETOPTIC-S – betaxolol hcl ophth
susp 0.25%
2
1
BLEPHAMIDE – sulfacetamide
sodium-prednisolone ophth susp
10-0.2%
3
dorzolamide hcl-timolol maleate
ophth soln 22.3-6.8 mg/ml
(Cosopt)
epinastine hcl ophth soln 0.05%
(Elestat)
1
BLEPHAMIDE S.O.P. –
sulfacetamide sodiumprednisolone ophth oint 10-0.2%
2
erythromycin ophth oint 5 mg/
gm
1
90
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
fluorometholone ophth susp
0.1% (Fml liquifilm)
1
LUMIGAN – bimatoprost ophth
soln 0.01%
2
flurbiprofen sodium ophth soln
0.03% (Ocufen)
1
METIPRANOLOL – metipranolol
ophth soln 0.3%
1
gatifloxacin ophth soln 0.5%
(Zymaxid)
1
3
gentamicin sulfate ophth oint
0.3%
1
MOXEZA – moxifloxacin hcl ophth
soln 0.5% (base eq) (2 times
daily)
1
gentamicin sulfate ophth soln
0.3% (Garamycin)
1
NAPHAZOLINE HCL –
naphazoline hcl ophth soln 0.1%
1
homatropine hbr ophth soln 5%
(Isopto homatropine)
1
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op
oin
ILEVRO – nepafenac ophth susp
0.3%
3
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
ISOPTO CARBACHOL – carbachol 3
ophth soln 1.5%
ISOPTO CARBACHOL – carbachol 3
ophth soln 3%
2
ISOPTO HYOSCINE –
scopolamine hbr ophth soln
0.25%
3
ISTALOL – timolol maleate ophth
soln 0.5% (once-daily)
1
ketorolac tromethamine ophth
soln 0.4% (Acular ls)
1
ketorolac tromethamine ophth
soln 0.5% (Acular)
2
LACRISERT – artificial tear ophth
insert
3
LASTACAFT – alcaftadine ophth
soln 0.25%
1
latanoprost ophth soln 0.005%
(Xalatan)
1
LEVOBUNOLOL HCL –
levobunolol hcl ophth soln 0.25%
1
levobunolol hcl ophth soln 0.5%
(Betagan)
1
levofloxacin ophth soln 0.5%
LOTEMAX – loteprednol etabonate
ophth gel 0.5%
2
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
1
NEOMYCIN/POLYMYXIN/
HYDROC – neomycin-polymyxinhc ophth susp
3
NEVANAC – nepafenac ophth
susp 0.1%
1
ofloxacin ophth soln 0.3%
(Ocuflox)
1
ophthalmic irrigation solution intraocular (Bss plus)
PATADAY – olopatadine hcl ophth 3
soln 0.2%
PATANOL – olopatadine hcl ophth 3
soln 0.1%
1
phenylephrine hcl ophth soln
2.5%
1
phenylephrine hcl ophth soln
10%
2
PHOSPHOLINE IODIDE –
echothiophate iodide ophth for
soln 0.125%
91
pilocarpine hcl ophth soln 1%
(Isopto carpine)
1
timolol maleate ophth soln
0.25% (Timoptic)
1
(Isopto carpine)
1
timolol maleate ophth soln 0.5%
(Timoptic)
1
(Isopto carpine)
1
2
polymyxin b-trimethoprim
ophth soln 10000 unit/ml-0.1%
(Polytrim)
1
TOBRADEX – tobramycindexamethasone ophth oint
0.3-0.1%
2
prednisolone acetate ophth susp
1% (Pred forte)
1
TOBRADEX ST – tobramycindexamethasone ophth susp
0.3-0.05%
1
PREDNISOLONE SODIUM
PHOSP – prednisolone sodium
phosphate ophth soln 1%
1
tobramycin ophth soln 0.3%
(Tobrex)
PROLENSA – bromfenac sodium
ophth soln 0.07% (base
equivalent)
3
proparacaine hcl ophth soln
0.5% (Alcaine)
1
RESCULA – unoprostone isopropyl 3
ophth soln 0.15%
3
RESTASIS – cyclosporine (ophth)
emulsion 0.05%
2
SIMBRINZA – brinzolamidebrimonidine tartrate ophth susp
1-0.2%
1
SULFACETAMIDE SODIUM –
sulfacetamide sodium ophth oint
10%
1
sulfacetamide sodium ophth
soln 10% (Bleph-10)
1
sulfacetamide sodiumprednisolone ophth soln
10-0.23(0.25)%
1
tetracaine hcl ophth soln 0.5%
timolol maleate ophth gel
forming soln 0.25% (Timopticxe)
1
1
timolol maleate ophth gel
forming soln 0.5% (Timoptic-xe)
92
1
tobramycin-dexamethasone
ophth susp 0.3-0.1% (Tobradex)
2
TRAVATAN Z – travoprost ophth
soln 0.004% (benzalkonium free)
(bak free)
1
trifluridine ophth soln 1%
(Viroptic)
1
tropicamide ophth soln 0.5%
•
tropicamide ophth soln 1%
(Mydriacyl)
1
VIGAMOX – moxifloxacin hcl ophth 3
soln 0.5% (base equiv)
3
ZIOPTAN – tafluprost ophth soln
0.0015%
3
ZYLET – loteprednol etabonatetobramycin ophth susp 0.5-0.3%
OTIC AGENTS
acetic acid otic soln 2%
1
ACETIC ACID/ALUMINUM ACET
– acetic acid 2% in aluminum
acetate otic soln
1
antipyrine-benzocaine otic soln
54-14 mg/ml (5.4-1.4%)
1
antipyrine-benzocainepolycosanol otic sol
5.4-1.4-0.0097% (Treagan otic)
1
ANTIPYRINE/BENZOCAINE –
antipyrine-benzocaine otic soln
55-14 mg/ml (5.5-1.4%)
1
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
CETRAXAL – ciprofloxacin hcl otic
soln 0.2% (base equivalent)
3
benzocaine dental soln 20%
1
CIPRO HC – ciprofloxacinhydrocortisone otic susp 0.2-1%
cevimeline hcl cap 30 mg
(Evoxac)
1
3
CIPRODEX – ciprofloxacindexamethasone otic susp
0.3-0.1%
chlorhexidine gluconate soln
0.12% (Peridex)
1
3
clotrimazole troche 10 mg
1
1
lidocaine hcl laryngotracheal
soln 4% (Lta 360 kit)
1
CORTANE-B AQUEOUS –
pramoxine-hc-chloroxylenol
aqueous otic soln 10-10-1 mg/ml
lidocaine hcl viscous soln 2%
1
CORTANE-B-OTIC – pramoxinehc-chloroxylenol otic soln
10-10-1 mg/ml
1
LTA 360 KIT – lidocaine hcl
laryngotracheal soln 4%
1
fluocinolone acetonide (otic) oil
0.01% (Dermotic)
1
hydrocortisone w/ acetic acid
otic soln 1-2%
1
MYOXIN – benzocainechloroxylenol-hc otic susp
15-1-10 mg/ml
1
neomycin-polymyxin-hc otic
soln 1% (Cortisporin)
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
NAFRINSE DAILY/ACIDULATED – 1
sodium fluoride-phosphoric acid
for soln 1 mg/5ml (f equiv)
1
NAFRINSE DAILY/NEUTRAL –
sodium fluoride for soln rinse
0.05%
1
nystatin susp 100000 unit/ml
1
1
pilocarpine hcl tab 5 mg
(Salagen)
1
neomycin-polymyxin-hc otic
susp 3.5 mg/ml-10000 unit/
ml-1%
1
pilocarpine hcl tab 7.5 mg
(Salagen)
sodium fluoride cream 1.1%
(Prevident 5000 plus)
1
ofloxacin otic soln 0.3%
1
1
OTICIN HC NR – pramoxine-hcchloroxylenol otic soln 10-10-1
mg/ml
1
sodium fluoride gel 1.1% (0.5% f)
(Prevident fluoride)
sodium fluoride paste 1.1%
(Prevident 5000 boost)
1
OTOZIN – antipyrine-benzocaineglycerin-zinc ace otic liqd
5.4-1-2-1%
1
sodium fluoride rinse 0.2%
(Prevident)
1
pramoxine-chloroxylenol otic
liquid 1-0.1% (Pramotic)
sodium fluoride-potassium
nitrate paste 1.1-5% (Prevident
5000 sensi)
1
1
pramoxine-hc-chloroxylenol otic
soln 10-10-1 mg/ml (Cortane-botic)
1
stannous fluoride conc 0.63%
(Gel-kam oral care ri)
1
1
triamcinolone acetonide dental
paste 0.1%
1
TREAGAN OTIC – antipyrinebenzocaine-polycosanol otic sol
5.4-1.4-0.0097%
ANORECTAL AGENTS
MOUTH/THROAT/DENTAL AGENTS
93
ANALPRAM-HC – hydrocortisone
acetate w/ pramoxine rectal lotn
2.5-1%
3
ABSORICA – isotretinoin cap 10
mg
4
CORTIFOAM – hydrocortisone
acetate rectal foam 90 mg/dose
mg
4
2
hc-pramoxine emol cream
2.5-1% & pramoxine wipe 1%
kit (Analpram e)
mg
4
1
mg
4
hydrocortisone acetate suppos
25 mg (Anusol-hc)
1
mg
4
hydrocortisone acetate suppos
30 mg (Proctocort)
1
mg
4
hydrocortisone acetate w/
pramoxine rectal cream 1-1%
(Analpram-hc)
1
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
LIDOCAINE HCL-HYDROCORTIS
– lidocaine-hydrocortisone
acetate rectal gel 2.8-0.55%
1
lidocaine-hydrocortisone acetate
rectal cream kit 2-2%
1
rectal cream kit 3-0.5%
1
rectal cream kit 3-1%
1
rectal cream 3-0.5%
1
rectal gel kit 3-2.5%
1
PROCTOFOAM HC –
pramoxine rectal foam 1-1%
2
DERMATOLOGICALS
94
ACANYA – clindamycin phosphate- 3
benzoyl peroxide gel 1.2-2.5%
1
acitretin cap 10 mg (Soriatane)
acitretin cap 17.5 mg (Soriatane)
1
acitretin cap 25 mg (Soriatane)
1
acyclovir oint 5% (Zovirax)
1
ACZONE – dapsone gel 5%
3
adapalene cream 0.1% (Differin)
1
adapalene gel 0.1% (Differin)
1
adapalene gel 0.3% (Differin)
1
alclometasone dipropionate
cream 0.05% (Aclovate)
1
alclometasone dipropionate oint
0.05%
1
ALTABAX – retapamulin oint 1%
3
•
•
•
AMCINONIDE – amcinonide cream 1
0.1%
AMCINONIDE – amcinonide lotion 1
0.1%
1
AMCINONIDE – amcinonide oint
0.1%
1
APEXICON E – diflorasone
diacetate emollient base cream
0.05%
1
ARZOL SILVER NITRATE APP –
silver nitrate-potassium nitrate
applicator 75-25%
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
BPO – benzoyl peroxide gel 8%
1
1
calcipotriene cream 0.005%
(Dovonex)
1
benzoyl peroxide liq 2.5%
1
calcipotriene oint 0.005%
1
benzoyl peroxide liq 7%
1
1
benzoyl peroxide liq 10%
1
calcipotriene soln 0.005%
(50 mcg/ml)
1
benzoyl peroxide lotion 6%
1
calcipotriene-betamethasone
dipropionate oint 0.005-0.064%
(Taclonex)
1
benzoyl peroxide liq 5.25%
benzoyl peroxideerythromycin gel 5-3%
(Benzamycin)
1
CALCITRIOL – calcitriol oint 3
mcg/gm
1
2
betamethasone dipropionate
augmented cream 0.05%
(Diprolene af)
1
CAPEX – fluocinolone acetonide
shampoo 0.01%
CARAC – fluorouracil cream 0.5%
3
1
CEM-UREA – urea soln 45%
1
augmented gel 0.05%
CENTANY – mupirocin oint 2%
1
augmented lotion 0.05%
(Diprolene)
1
ciclopirox gel 0.77%
1
ciclopirox olamine cream 0.77%
(base equiv)
1
augmented oint 0.05%
(Diprolene)
1
ciclopirox olamine susp 0.77%
(base equiv)
1
1
ciclopirox shampoo 1% (Loprox
shampoo)
1
cream 0.05%
lotion 0.05%
ciclopirox solution kit 8%
(Ciclodan solution ki)
1
1
oint 0.05%
ciclopirox solution 8% (Penlac
Nail Lacquer)
1
1
betamethasone valerate aerosol
foam 0.12% (Luxiq)
CICLOPIROX TOPICAL SOLUTI –
ciclopirox solution 8% & vitamin e
5% topical kit
1
1
betamethasone valerate cream
0.1%
1
CLARAVIS – isotretinoin cap 30
mg
1
betamethasone valerate lotion
0.1%
1
1
betamethasone valerate oint
0.1%
1
clindamycin phosph-benzoyl
peroxide (refrig) gel 1.2 (1)-5%
(Duac)
clindamycin phosphate foam 1%
(Evoclin)
1
Quantity Limits
Restricted Access
benzoyl peroxide foam 9.8%
(Benzefoamultra)
1
Prior Review
1
BP CLEANSING WASH –
sulfacetamide sodium-sulfur in
urea emulsion 10-4%
Specialty
benzoyl peroxide foam 5.3%
(Benzefoam)
Drug Name
Drug Tier
3
• •
Quantity Limits
AZELEX – azelaic acid cream 20%
Restricted Access
3
Prior Review
ATRALIN – tretinoin gel 0.05%
Specialty
Drug Name
Drug Tier
2015
95
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
clindamycin phosphate gel 1%
(Cleocin-t)
1
COCAINE HCL – cocaine hcl soln
10%
1
clindamycin phosphate lotion
1% (Cleocin-t)
1
CONDYLOX – podofilox gel 0.5%
3
clindamycin phosphate soln 1%
(Cleocin-t)
CORDRAN – flurandrenolide
cream 0.05%
3
1
1
CORDRAN – flurandrenolide lotion
0.05%
3
clindamycin phosphate swab 1%
(Cleocin-t)
1
CORDRAN – flurandrenolide oint
0.05%
3
clindamycin phosphate-benzoyl
peroxide gel 1-5% (Benzaclin)
clobetasol propionate cream
0.05% (Temovate)
CORTALO – hydrocortisone
acetate-aloe vera gel 2%
1
1
• • • •
clobetasol propionate emollient
base cream 0.05% (Temovate e)
COSENTYX – secukinumab
syringe 150 mg/ml
4
1
clobetasol propionate emulsion
foam 0.05% (Olux-e)
1
4
• • • •
clobetasol propionate foam
0.05% (Olux)
1
COSENTYX SENSOREADY PEN
– secukinumab subcutaneous
soln auto-injector 150 mg/ml
DENAVIR – penciclovir cream 1%
3
clobetasol propionate gel 0.05%
(Temovate)
1
DESONATE – desonide gel 0.05%
3
clobetasol propionate lotion
0.05% (Clobex)
desonide cream 0.05%
(Desowen)
1
1
clobetasol propionate oint 0.05%
(Temovate)
1
desonide lotion 0.05% (Desowen) 1
1
desonide oint 0.05% (Desowen)
1
DESOXIMETASONE –
desoximetasone cream 0.05%
1
clobetasol propionate shampoo
0.05% (Clobex)
1
desoximetasone cream 0.25%
(Topicort)
1
clobetasol propionate soln
0.05% (Temovate)
1
desoximetasone gel 0.05%
(Topicort)
1
clobetasol propionate spray
0.05% (Clobex)
3
desoximetasone oint 0.25%
(Topicort)
1
CLODERM – clocortolone pivalate
cream 0.1%
3
diclofenac sodium (actinic
keratoses) gel 3% (Solaraze)
1
CLODERM PUMP – clocortolone
pivalate cream 0.1%
1
diclofenac sodium soln 1.5%
(Pennsaid)
1
clotrimazole w/ betamethasone
cream 1-0.05% (Lotrisone)
clotrimazole w/ betamethasone
lotion 1-0.05%
1
DIFFERIN – adapalene lotion 0.1% 2
3
DIFFERIN – adapalene gel 0.3%
COCAINE HCL – cocaine hcl soln
4%
1
96
DIFLORASONE DIACETATE –
diflorasone diacetate cream
0.05%
•
• •
• •
1
DIFLORASONE DIACETATE –
diflorasone diacetate oint 0.05%
1
fluocinolone acetonide oint
0.025% (Synalar)
1
econazole nitrate cream 1%
1
1
ELETONE – dermatological
products misc - cream
1
fluocinolone acetonide soln
0.01% (Synalar)
fluocinonide cream 0.05%
1
ELIDEL – pimecrolimus cream 1%
3
fluocinonide cream 0.1% (Vanos)
1
EMULSION SB – dermatological
products misc - emulsion
1
fluocinonide emulsified base
cream 0.05%
1
EPIDUO – adapalene-benzoyl
peroxide gel 0.1-2.5%
3
• •
fluocinonide gel 0.05%
1
1
EPIDUO FORTE – adapalenebenzoyl peroxide gel 0.3-2.5%
• •
fluocinonide oint 0.05%
3
fluocinonide soln 0.05%
1
3
FLUOROPLEX – fluorouracil
cream 1%
2
ERTACZO – sertaconazole nitrate
cream 2%
1
fluorouracil cream 5% (Efudex)
1
erythromycin gel 2% (Erygel)
1
fluorouracil soln 2%
1
erythromycin pads 2%
1
fluorouracil soln 5%
1
erythromycin soln 2%
3
fluticasone propionate cream
0.05% (Cutivate)
1
EURAX – crotamiton cream 10%
EURAX – crotamiton lotion 10%
3
EXELDERM – sulconazole nitrate
solution 1%
fluticasone propionate lotion
0.05% (Cutivate)
1
3
EXELDERM – sulconazole nitrate
cream 1%
fluticasone propionate oint
0.005% (Cutivate)
1
3
1
GENTAMICIN SULFATE –
gentamicin sulfate cream 0.1%
1
EXODERM – sodium thiosulfatesalicylic acid lotion 25-1%
3
GENTAMICIN SULFATE –
gentamicin sulfate oint 0.1%
1
FINACEA – azelaic acid foam 15%
FINACEA – azelaic acid gel 15%
3
1
FLECTOR – diclofenac epolamine
patch 1.3%
3
HALAC – halobetasol prop oint
0.05% & ammonium lactate lot
12% kit
fluocinolone acetonide cream
0.01%
1
halobetasol propionate cream
0.05% (Ultravate)
1
fluocinolone acetonide cream
0.025% (Synalar)
1
halobetasol propionate oint
0.05% (Ultravate)
1
fluocinolone acetonide oil 0.01%
(body oil) (Derma-smoothe/fs
bod)
1
hyaluronate sodium
(emollient) gel 0.2% (Hylira)
1
1
fluocinolone acetonide oil 0.01%
(scalp oil) (Derma-smoothe/fs
sca)
1
hydrocortisone butyrate cream
0.1% (Locoid)
•
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
97
hydrocortisone butyrate
hydrophilic lipo base cream
0.1% (Locoid lipocream)
1
hydrocortisone butyrate oint
0.1% (Locoid)
1
hydrocortisone butyrate soln
0.1% (Locoid)
LAMISIL SPRAY – terbinafine hcl
soln 1%
2
LATRIX XM – urea in zinc
undecylenate-lactic acid vehicle
emulsion 45%
1
1
LIDOCAINE HCL – lidocaine hcl
lotion 3%
1
hydrocortisone cream 1%
1
lidocaine hcl cream 3%
1
hydrocortisone cream 2.5%
1
lidocaine hcl gel 2%
1
hydrocortisone lotion 2% (Ala
scalp)
1
lidocaine hcl soln 4% (Xylocaine)
1
lidocaine oint 5%
1
hydrocortisone lotion 2.5%
1
lidocaine patch 5% (Lidoderm)
1
hydrocortisone oint 1%
1
lidocaine-menthol patch 4-5%
1
hydrocortisone oint 2.5%
1
1
hydrocortisone valerate cream
0.2%
1
lidocaine-prilocaine cream
2.5-2.5% (Emla)
lidocaine-prilocaine kit 2.5-2.5%
1
hydrocortisone valerate oint
0.2% (Westcort)
1
LIDODERM – lidocaine patch 5%
3
1
lindane lotion 1%
1
imiquimod cream 5% (Aldara)
1
lindane shampoo 1%
1
iodoquinol-hc cream 1%
1
malathion lotion 0.5% (Ovide)
1
iodoquinol-hydrocortisone in
aloe vehicle cream 1-1.9%
(Vytone)
methoxsalen rapid cap 10 mg
(Oxsoralen ultra)
1
isotretinoin cap 10 mg
1
1
1
METHYL SALICYLATE – methyl
salicylate liquid
1
metronidazole cream 0.75%
(Metrocream)
1
ketoconazole cream 2%
1
metronidazole gel 0.75%
1
ketoconazole foam 2% (Extina)
1
metronidazole gel 1% (Metrogel)
1
ketoconazole shampoo 2%
(Nizoral)
1
metronidazole lotion 0.75%
(Metrolotion)
1
lactic acid (ammonium lactate)
cream 12% (Lac-hydrin)
1
mometasone furoate cream 0.1%
(Elocon)
1
lotion 10%
1
mometasone furoate oint 0.1%
(Elocon)
1
lotion 12% (Lac-hydrin)
1
mometasone furoate solution
0.1% (lotion) (Elocon)
1
lactic acid w/ vitamin e cream
10%-3500 unit/30gm
1
mupirocin calcium cream 2%
(Bactroban)
1
98
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
•
•
•
•
3
1
PICATO – ingenol mebutate gel
0.05%
NAFTIN – naftifine hcl cream 1%
3
podofilox soln 0.5% (Condylox)
1
NAFTIN – naftifine hcl cream 2%
3
1
NAFTIN – naftifine hcl gel 1%
3
PR CREAM – dermatological
products misc - kit
3
PRAMOSONE – pramoxine-hc
cream 1-1%
3
NAFTIN – naftifine hcl gel 2%
NATROBA – spinosad susp 0.9%
3
NORITATE – metronidazole cream
1%
cream 1-2.5%
3
3
nystatin cream 100000 unit/gm
lotion 1-1%
3
1
nystatin oint 100000 unit/gm
1
3
nystatin topical powder
1
lotion 1-2.5%
nystatin-triamcinolone cream
100000-0.1 unit/gm-%
1
PRAMOSONE – pramoxine-hc oint
1-1%
3
nystatin-triamcinolone oint
100000-0.1 unit/gm-%
1
PRAMOSONE – pramoxine-hc oint
1-2.5%
3
ORACEA – doxycycline (rosacea)
cap delayed release 40 mg
3
pramoxine hcl gel 1%
1
1
OVACE PLUS – sulfacetamide
sodium cream 10%
3
pramoxine-hc cream 1-2.5%
(Pramosone)
1
sodium foam 9.8%
3
prednicarbate cream 0.1%
(Dermatop)
1
sodium lotion 9.8%
3
prednicarbate oint 0.1%
(Dermatop)
1
OXISTAT – oxiconazole nitrate
cream 1%
3
PRUCLAIR – dermatological
1
OXISTAT – oxiconazole nitrate
lotion 1%
3
PRUDOXIN – doxepin hcl cream
5%
PRUMYX – dermatological
1
PRUTECT – wound dressings emulsion
1
REGRANEX – becaplermin gel
0.01%
4
RETIN-A MICRO – tretinoin
microsphere gel 0.04%
3
• •
RETIN-A MICRO – tretinoin
3
• •
RETIN-A MICRO PUMP – tretinoin
3
• •
OXSORALEN – methoxsalen lotion 3
1%
3
PANDEL – hydrocortisone
probutate cream 0.1%
3
PANRETIN – alitretinoin gel 0.1%
PENNSAID – diclofenac sodium
soln 2%
3
permethrin cream 5% (Elimite)
1
PICATO – ingenol mebutate gel
0.015%
3
• •
•
•
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
naftifine hcl cream 1% (Naftin)
Restricted Access
1
Prior Review
mupirocin oint 2% (Bactroban)
Specialty
Drug Name
Drug Tier
2015
99
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
3
• •
SPINOSAD – spinosad susp 0.9%
1
• •
•
• •
STELARA – ustekinumab soln
prefilled syringe 45 mg/0.5ml
3
3
• •
•
SALICYLIC ACID – salicylic acid
soln 26%
STELARA – ustekinumab soln
prefilled syringe 90 mg/ml
3
1
1
salicylic acid cream 6% &
cleanser liqd kit (Salex cream)
1
sulfacetamide sod-sulfur wash
9-4.5% & skin cleanser kit
(Sumadan kit)
1
salicylic acid cream 6%
1
salicylic acid film forming liquid
27.5% (Virasal)
1
sulfacetamide sod-sulfur
wash 9-4.5% & sunscreen kit
(Sumadan xlt)
salicylic acid film-forming soln
28.5% (Ultrasal-er)
1
1
salicylic acid foam 6% (Salvax)
1
sulfacetamide sodium
cleansing gel 10% (Ovace plus
wash)
1
sulfacetamide sodium liquid 10%
(Ovace wash)
1
salicylic acid gel 6% (Keralyt)
SALICYLIC ACID IN AMMONIU
– salicylic acid in ammonium
lactate vehicle foam 6%
1
sulfacetamide sodium lotion
10% (acne) (Klaron)
1
1
sulfacetamide sodium shampoo
10% (Ovace plus)
1
salicylic acid lotion 6%
salicylic acid lotion 6% &
cleanser liqd kit (Salex lotion)
1
1
salicylic acid shampoo 6%
(Salex)
1
sulfacetamide sodium w/ sulfur
cleanser 9.8-4.8% (Plexion
cleanser)
SALVAX – salicylic acid foam 6%
scar treatment products - gel
1
sulfacetamide sodium w/
sulfur cleanser 10-2% (Avar ls
cleanser)
1
1
selenium sulfide lotion 2.5%
1
1
silver nitrate-potassium nitrate
applicator 75-25% (Arzol silver
nitrate)
1
cleansing cloth 10-5%
cleansing pad 10-4% (Sumaxin)
1
silver sulfadiazine cream 1%
(Silvadene)
1
cream 9.8-4.8% (Plexion)
1
SKLICE – ivermectin lotion 0.5%
3
1
SODIUM SULFACETAMIDE/SULF
– sulfacetamide sodium w/ sulfur
susp 10-5%
1
cream 10-2% (Avar-e ls)
cream 10-5%
1
SODIUM SULFACETAMIDE/SULF
– sulfacetamide sodium-sulfur in
urea emulsion 10-5%
1
emulsion 10-1%
1
1
SONAFINE – wound dressings emulsion
1
emulsion 10-5%
100
foam 10-5% (Clarifoam ef)
1
tretinoin microsphere gel 0.04%
(Retin-a micro)
1
•
lotion 9.8-4.8% (Plexion)
1
tretinoin microsphere gel 0.1%
(Retin-a micro)
1
•
lotion 10-5%
1
TRI-CHLOR – trichloroacetic acid
liqd 80%
1
susp 8-4% (Sumaxin ts)
1
1
wash 9-4% (Sumaxin wash)
1
TRIAMCINOLONE ACETONIDE
– triamcinolone acetonide oint
0.5%
1
wash 9-4.5% (Sumadan wash)
1
triamcinolone acetonide aerosol
soln (Kenalog)
1
TACLONEX – calcipotrienebetamethasone dipropionate
susp 0.005-0.064%
3
triamcinolone acetonide cream
0.025%
0.1%
1
tacrolimus oint 0.03% (Protopic)
1
1
tacrolimus oint 0.1% (Protopic)
1
0.5%
TARGRETIN – bexarotene gel 1%
3
1
TAZORAC – tazarotene cream
0.05%
3
triamcinolone acetonide lotion
0.025%
1
TAZORAC – tazarotene cream
0.1%
3
triamcinolone acetonide lotion
0.1%
1
TAZORAC – tazarotene gel 0.05%
3
triamcinolone acetonide oint
0.1%
1
TAZORAC – tazarotene gel 0.1%
3
TRETIN-X – tretinoin cream
0.075%
3
• •
• •
• •
triamcinolone acetonide oint
0.025%
1
TRETIN-X – tretinoin cream
0.025% w/ cleanser & moisturizer
kit
3
• •
TRIANEX – triamcinolone
acetonide oint 0.05%
trypsin w/ castor oil & peruvian
balsam spray (Granulex)
1
3
• •
ULESFIA – benzyl alcohol lotion
5%
3
TRETIN-X – tretinoin cream 0.05%
w/ cleanser & moisturizer kit
3
• •
urea cream 39% (Aluvea)
1
TRETIN-X – tretinoin cream 0.1%
w/ cleanser & moisturizer kit
urea cream 40%
1
tretinoin cream 0.025% (Retin-a)
1
urea cream 45% (Uramaxin)
1
1
urea cream 47% (Keralac)
1
1
urea cream 50%
1
tretinoin gel 0.01% (Retin-a)
1
urea foam 40% (Hydro 40 foam)
1
tretinoin gel 0.025% (Retin-a)
1
•
•
•
•
•
urea gel 40%
1
urea gel 45% (Uramaxin)
1
•
• •
• •
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2015
101
urea in lactic acid vehicle foam
35% (Hydro 35)
1
ZYCLARA PUMP – imiquimod
cream 2.5%
3
urea in lactic acid-salicylic acid
vehicle susp 50%
1
ZYCLARA PUMP – imiquimod
cream 3.75%
3
urea in zinc undecylenate-lactic
acid vehicle emulsion 50%
1
8-MOP – methoxsalen cap 10 mg
2
urea lotion 40%
1
urea lotion 45% (Uramaxin)
1
UREA NAIL – urea in zinc
undecylenate-lactic acid vehicle
stick 50%
1
UREA NAIL KIT – urea susp 40%
& hyaluronate sodium gel 0.2%
kit
1
urea suspension 40% (Umecta)
1
ANTISEPTICS & DISINFECTANTS
FORMA-RAY – formaldehyde
solution 20%
1
formaldehyde solution 10%
1
HYDROGEN PEROXIDE –
hydrogen peroxide soln 30%
2
ANTIDOTES
VEREGEN – sinecatechins oint
15%
3
VOLTAREN – diclofenac sodium
gel 1%
2
VUSION – miconazole-zinc
oxide-white petrolatum oint
0.25-15-81.35%
3
wound dressings - cream
1
XERESE – acyclovirhydrocortisone cream 5-1%
3
XOLEGEL – ketoconazole gel 2%
3
ZIANA – clindamycin phosphatetretinoin gel 1.2-0.025%
3
ZOVIRAX – acyclovir cream 5%
3
ZYCLARA – imiquimod cream
3.75%
3
•
• •
•
CHEMET – succimer cap 100 mg
3
EXJADE – deferasirox tab for oral
susp 125 mg
4
•
susp 250 mg
4
•
susp 500 mg
4
•
FERRIPROX – deferiprone tab 500 4
mg
4
JADENU – deferasirox tab 90 mg
4
4
naltrexone hcl tab 50 mg (Revia)
1
REVIA – naltrexone hcl tab 50 mg
4
•
•
•
DIAGNOSTIC PRODUCTS
All Brand Diabetic Supplies 25% coinsurance
ASCENSIA AUTODISC TEST ST –
glucose blood test disk
BAYER BREEZE 2 TEST DISC –
glucose blood test disk
• •
BAYER CONTOUR BLOOD
GLUCO – glucose blood test
strip
BAYER CONTOUR NEXT BLOOD
– glucose blood test strip
Quantity Limits
Restricted Access
Prior Review
•
MISCELLANEOUS PRODUCTS
VALCHLOR – mechlorethamine hcl 4
gel 0.016% (base equivalent)
3
VANOXIDE-HC – benzoyl
peroxide-hc lotion 5-0.5%
3
VECTICAL – calcitriol oint 3 mcg/
gm
VELTIN – clindamycin phosphate- 3
tretinoin gel 1.2-0.025%
VERDESO – desonide foam 0.05% 3
102
Specialty
Drug Name
Drug Tier
Quantity Limits
Restricted Access
Prior Review
Drug Name
Specialty
Drug Tier
2015
cyclosporine modified cap
100 mg (Neoral)
1
•
ONETOUCH ULTRA BLUE –
glucose blood test strip
cyclosporine modified oral soln
100 mg/ml (Neoral)
1
•
ONETOUCH ULTRA TEST STRIP
DEPEN TITRATABS –
penicillamine tab 250 mg
2
ONETOUCH VERIO TEST STRIP
irrigation solution, physiological
1
lactated ringer's for irrigation
1
SURESTEP PRO TEST STRIPS –
glucose blood test strip
mycophenolate mofetil cap
250 mg (Cellcept)
1
•
mycophenolate mofetil for oral
susp 200 mg/ml (Cellcept)
1
•
4
•
•
•
4
mycophenolate mofetil tab
500 mg (Cellcept)
1
ASTAGRAF XL – tacrolimus cap sr
24hr 0.5 mg
•
•
4
mycophenolate sodium tab dr
180 mg (mycophenolic acid
equiv) (Myfortic)
1
24hr 1 mg
24hr 5 mg
4
•
1
•
AZASAN – azathioprine tab 75 mg
3
mycophenolate sodium tab dr
360 mg (mycophenolic acid
equiv) (Myfortic)
AZASAN – azathioprine tab 100
mg
3
3
•
azathioprine tab 50 mg (Imuran)
1
MYFORTIC – mycophenolate
sodium tab dr 180 mg
(mycophenolic acid equiv)
3
•
•
CELLCEPT – mycophenolate
mofetil tab 500 mg
3
•
MYFORTIC – mycophenolate
sodium tab dr 360 mg
(mycophenolic acid equiv)
3
mofetil cap 250 mg
2
•
mofetil for oral susp 200 mg/ml
3
•
NEORAL – cyclosporine modified
oral soln 100 mg/ml
cap 25 mg
2
•
CUPRIMINE – penicillamine cap
250 mg
2
2
•
cyclosporine cap 25 mg
(Sandimmune)
1
•
cap 100 mg
2
•
cyclosporine cap 100 mg
(Sandimmune)
1
•
PROGRAF – tacrolimus cap 0.5
mg
PROGRAF – tacrolimus cap 1 mg
2
3
•
PROGRAF – tacrolimus cap 5 mg
2
CYCLOSPORINE MODIFIED –
cyclosporine modified cap 50 mg
•
•
•
THYROGEN – thyrotropin alfa for
inj 1.1 mg
ASSORTED CLASSES
RAPAMUNE – sirolimus oral soln 1 2
mg/ml
Quantity Limits
LANCETS – VARIOUS
MANUFACTURERS
Restricted Access
Specialty
•
•
GLUCOSE BLOOD TEST STRIPS
– VARIOUS
Drug Name
Prior Review
Drug Tier
Quantity Limits
Restricted Access
Prior Review
1
Specialty
cyclosporine modified cap
25 mg (Neoral)
Drug Name
Drug Tier
2015
103
RAPAMUNE – sirolimus tab 2 mg
3
REVLIMID – lenalidomide caps 2.5
mg
3
REVLIMID – lenalidomide cap 5
mg
3
mg
3
mg
3
mg
3
• •
mg
3
• •
ringer's solution for irrigation
1
SANDIMMUNE – cyclosporine oral
soln 100 mg/ml
2
•
SANDIMMUNE – cyclosporine cap
25 mg
2
•
SANDIMMUNE – cyclosporine cap
100 mg
2
•
sirolimus tab 0.5 mg (Rapamune)
1
sirolimus tab 1 mg (Rapamune)
1
sirolimus tab 2 mg (Rapamune)
1
•
•
•
sodium polystyrene sulfonate
oral susp 15 gm/60ml (Sps)
1
powder (Kayexalate)
1
rectal susp 30 gm/120ml
1
tacrolimus cap 0.5 mg (Prograf)
1
tacrolimus cap 1 mg (Prograf)
1
tacrolimus cap 5 mg (Prograf)
1
THALOMID – thalidomide cap 50
mg
3
•
•
•
• •
mg
3
• •
104
• •
• •
• •
3
• •
mg
3
• •
water for irrigation, sterile
irrigation soln
1
ZORTRESS – everolimus tab 0.25
mg
3
mg
3
mg
3
Quantity Limits
mg
Drug Name
Restricted Access
Prior Review
Quantity Limits
Restricted Access
Specialty
•
•
•
• •
Drug Tier
RAPAMUNE – sirolimus tab 0.5 mg 3
3
RAPAMUNE – sirolimus tab 1 mg
Prior Review
Drug Name
Specialty
Drug Tier
2015
2015
INDEX
8-MOP – methoxsalen cap 10 mg.................................. 102
A
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg (Trizivir).................................................5
abacavir sulfate tab 300 mg (base equiv) (Ziagen).........5
ABSORICA – isotretinoin cap 10 mg................................ 94
ABSTRAL – fentanyl citrate sl tab 100 mcg (base
equiv)............................................................................... 70
equiv)............................................................................... 70
equiv)............................................................................... 70
equiv)............................................................................... 70
equiv)............................................................................... 70
equiv)............................................................................... 70
acamprosate calcium tab delayed release 333 mg
(Campral)........................................................................ 66
ACANYA – clindamycin phosphate-benzoyl peroxide gel
1.2-2.5%...........................................................................94
acarbose tab 100 mg (Precose)..................................... 19
acarbose tab 25 mg (Precose)....................................... 19
acarbose tab 50 mg (Precose)....................................... 19
acebutolol hcl cap 200 mg (Sectral)..............................30
acebutolol hcl cap 400 mg (Sectral)..............................30
acetaminophen-caffeine-dihydrocodeine cap
320.5-30-16 mg (Trezix)................................................. 70
acetaminophen-isometheptene-dichloral cap
325-65-100 mg................................................................ 77
acetaminophen-salicylamide-phenyltoloxamine cap
300-200-20mg................................................................. 69
acetaminophen w/ codeine soln 120-12 mg/5ml...........70
acetaminophen w/ codeine tab 300-15 mg (Tylenol/
codeine).......................................................................... 70
codeine #3).....................................................................70
codeine #4).....................................................................70
ACETAZOLAMIDE – acetazolamide tab 125 mg.............. 38
acetazolamide cap sr 12hr 500 mg (Diamox)................38
acetazolamide tab 250 mg..............................................38
ACETIC ACID/ALUMINUM ACET – acetic acid 2% in
aluminum acetate otic soln..............................................92
acetic acid irrigation soln 0.25%................................... 55
acetic acid otic soln 2%................................................. 92
acetylcysteine cap 600 mg............................................. 85
acetylcysteine inhal soln 10%........................................44
acetylcysteine inhal soln 20%........................................44
ACIPHEX SPRINKLE – rabeprazole sodium capsule
sprinkle dr 10 mg............................................................ 49
ACIPHEX SPRINKLE – rabeprazole sodium capsule
sprinkle dr 5 mg.............................................................. 48
acitretin cap 10 mg (Soriatane)......................................94
acitretin cap 17.5 mg (Soriatane)...................................94
acitretin cap 25 mg (Soriatane)......................................94
ACTEMRA – tocilizumab subcutaneous soln prefilled
syringe 162 mg/0.9ml...................................................... 75
ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)........................................................10
ACTIQ – fentanyl citrate lozenge on a handle 1200
mcg.................................................................................. 70
mcg.................................................................................. 70
mcg.................................................................................. 70
mcg.................................................................................. 70
mcg.................................................................................. 70
mcg.................................................................................. 70
ACTONEL – risedronate sodium tab 150 mg....................24
ACTONEL – risedronate sodium tab 30 mg......................24
ACTONEL – risedronate sodium tab 35 mg......................24
ACTONEL – risedronate sodium tab 5 mg........................24
ACUVAIL – ketorolac tromethamine ophth soln 0.45%..... 89
acyclovir cap 200 mg (Zovirax)........................................5
acyclovir oint 5% (Zovirax)............................................ 94
acyclovir susp 200 mg/5ml (Zovirax).............................. 5
acyclovir tab 400 mg (Zovirax)........................................ 5
acyclovir tab 800 mg (Zovirax)........................................ 5
ACZONE – dapsone gel 5%............................................. 94
ADAGEN – pegademase bovine inj 250 unit/ml................10
adapalene cream 0.1% (Differin)....................................94
adapalene gel 0.1% (Differin)......................................... 94
adapalene gel 0.3% (Differin)......................................... 94
ADCIRCA – tadalafil tab 20 mg (pah)............................... 41
adefovir dipivoxil tab 10 mg (Hepsera)........................... 5
ADEMPAS – riociguat tab 0.5 mg.....................................41
ADEMPAS – riociguat tab 1 mg........................................41
ADEMPAS – riociguat tab 2 mg........................................42
ADRENACLICK – epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)..........................................................39
ADVAIR DISKUS – fluticasone-salmeterol aer powder ba
100-50 mcg/dose............................................................. 45
250-50 mcg/dose............................................................. 45
500-50 mcg/dose............................................................. 45
105
2015
ADVAIR HFA – fluticasone-salmeterol inhal aerosol
115-21 mcg/act................................................................ 45
ADVAIR HFA – fluticasone-salmeterol inhal aerosol
230-21 mcg/act................................................................ 45
ADVAIR HFA – fluticasone-salmeterol inhal aerosol 45-21
mcg/act............................................................................ 45
ADVICOR – niacin-lovastatin tab sr 24hr 1000-20 mg...... 39
ADVICOR – niacin-lovastatin tab sr 24hr 1000-40 mg...... 39
ADVICOR – niacin-lovastatin tab sr 24hr 500-20 mg........ 39
ADVICOR – niacin-lovastatin tab sr 24hr 750-20 mg........ 39
AFINITOR DISPERZ – everolimus tab for oral susp 2
mg.................................................................................... 10
mg.................................................................................... 10
mg.................................................................................... 11
AFINITOR – everolimus tab 10 mg...................................10
AFINITOR – everolimus tab 2.5 mg..................................10
AFINITOR – everolimus tab 5 mg.....................................10
AFINITOR – everolimus tab 7.5 mg..................................10
AGGRENOX – aspirin-dipyridamole cap sr 12hr 25-200
mg.................................................................................... 89
AKYNZEO – netupitant-palonosetron cap 300-0.5 mg......50
ALBENZA – albendazole tab 200 mg............................... 10
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)..........45
albuterol sulfate soln nebu 0.5% (5 mg/ml).................. 45
albuterol sulfate soln nebu 0.63 mg/3ml (base
equiv).............................................................................. 45
albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv).............................................................................. 45
albuterol sulfate syrup 2 mg/5ml................................... 45
albuterol sulfate tab 2 mg.............................................. 45
albuterol sulfate tab 4 mg.............................................. 45
albuterol sulfate tab sr 12hr 4 mg (Vospire er).............45
albuterol sulfate tab sr 12hr 8 mg (Vospire er).............45
alclometasone dipropionate cream 0.05%
(Aclovate)........................................................................94
alclometasone dipropionate oint 0.05%........................ 94
ALDACTAZIDE – spironolactone & hydrochlorothiazide
tab 50-50 mg................................................................... 38
ALENDRONATE SODIUM – alendronate sodium tab 40
mg.................................................................................... 24
alendronate sodium tab 10 mg...................................... 24
alendronate sodium tab 35 mg...................................... 24
alendronate sodium tab 5 mg........................................ 24
alendronate sodium tab 70 mg (Fosamax)................... 24
alfuzosin hcl tab sr 24hr 10 mg (Uroxatral).................. 55
ALINIA – nitazoxanide for susp 100 mg/5ml..................... 10
ALKERAN – melphalan tab 2 mg..................................... 11
allopurinol tab 100 mg (Zyloprim)................................. 78
allopurinol tab 300 mg (Zyloprim)................................. 78
almotriptan malate tab 12.5 mg (Axert).........................77
almotriptan malate tab 6.25 mg (Axert).........................77
ALOCRIL – nedocromil sodium ophth soln 2%................. 89
ALOMIDE – lodoxamide tromethamine ophth soln
0.1%.................................................................................90
106
ALORA – estradiol td patch twice weekly 0.025
mg/24hr............................................................................16
mg/24hr............................................................................17
mg/24hr............................................................................17
ALORA – estradiol td patch twice weekly 0.1 mg/24hr......17
alosetron hcl tab 0.5 mg (base equiv) (Lotronex).........52
alosetron hcl tab 1 mg (base equiv) (Lotronex)............52
ALPHAGAN P – brimonidine tartrate ophth soln 0.1%...... 90
alprazolam orally disintegrating tab 0.25 mg
(Niravam)........................................................................ 56
alprazolam orally disintegrating tab 0.5 mg................. 56
alprazolam orally disintegrating tab 1 mg.................... 56
alprazolam orally disintegrating tab 2 mg.................... 56
alprazolam tab 0.25 mg (Xanax).................................... 56
alprazolam tab 0.5 mg (Xanax)...................................... 56
alprazolam tab 1 mg (Xanax)......................................... 56
alprazolam tab 2 mg (Xanax)......................................... 56
alprazolam tab sr 24hr 0.5 mg (Xanax xr)..................... 56
alprazolam tab sr 24hr 1 mg (Xanax xr)........................ 56
ALTABAX – retapamulin oint 1%...................................... 94
ALTOPREV – lovastatin tab sr 24hr 20 mg...................... 40
ALVESCO – ciclesonide inhal aerosol 160 mcg/act..........45
ALVESCO – ciclesonide inhal aerosol 80 mcg/act............45
AMANTADINE HCL – amantadine hcl tab 100 mg........... 82
amantadine hcl cap 100 mg........................................... 82
amantadine hcl syrup 50 mg/5ml...................................82
AMCINONIDE – amcinonide cream 0.1%.........................94
AMCINONIDE – amcinonide lotion 0.1%.......................... 94
AMCINONIDE – amcinonide oint 0.1%.............................94
AMICAR – aminocaproic acid tab 1000 mg...................... 89
amiloride & hydrochlorothiazide tab 5-50 mg...............38
amiloride hcl tab 5 mg....................................................38
AMINOBENZOATE POTASSIUM – potassium
aminobenzoate packet 2 gm........................................... 84
amiodarone hcl tab 100 mg........................................... 32
amiodarone hcl tab 200 mg (Cordarone)...................... 32
amiodarone hcl tab 400 mg........................................... 32
AMITIZA – lubiprostone cap 24 mcg.................................52
AMITIZA – lubiprostone cap 8 mcg...................................52
amitriptyline hcl tab 100 mg...........................................56
amitriptyline hcl tab 10 mg............................................ 56
amitriptyline hcl tab 150 mg...........................................56
amlodipine besylate-atorvastatin calcium tab 10-10 mg
(Caduet).......................................................................... 42
(Caduet).......................................................................... 42
2015
(Caduet).......................................................................... 42
(Caduet).......................................................................... 42
amlodipine besylate-atorvastatin calcium tab 2.5-10
mg (Caduet)....................................................................42
mg (Caduet)....................................................................42
mg (Caduet)....................................................................42
(Caduet).......................................................................... 42
(Caduet).......................................................................... 42
(Caduet).......................................................................... 42
(Caduet).......................................................................... 42
amlodipine besylate-benazepril hcl cap 10-20 mg
(Lotrel).............................................................................33
(Lotrel).............................................................................33
amlodipine besylate-benazepril hcl cap 2.5-10 mg
(Lotrel).............................................................................33
(Lotrel).............................................................................33
(Lotrel).............................................................................33
(Lotrel).............................................................................33
amlodipine besylate tab 10 mg (Norvasc).....................31
amlodipine besylate tab 2.5 mg (Norvasc)....................31
amlodipine besylate tab 5 mg (Norvasc)...................... 31
amlodipine besylate-valsartan tab 10-160 mg
(Exforge)......................................................................... 33
(Exforge)......................................................................... 33
(Exforge)......................................................................... 33
(Exforge)......................................................................... 33
amlodipine-valsartan-hydrochlorothiazide tab
10-160-12.5 mg (Exforge hct)....................................... 33
10-160-25 mg (Exforge hct).......................................... 33
10-320-25 mg (Exforge hct).......................................... 33
5-160-12.5 mg (Exforge hct)......................................... 33
amlodipine-valsartan-hydrochlorothiazide tab 5-160-25
mg (Exforge hct)............................................................33
AMOXAPINE – amoxapine tab 100 mg............................ 56
AMOXAPINE – amoxapine tab 150 mg............................ 57
AMOXAPINE – amoxapine tab 25 mg.............................. 56
AMOXAPINE – amoxapine tab 50 mg.............................. 56
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)............................................................... 49
amphetamine-dextroamphetamine cap sr 24hr 10 mg
(Adderall xr)................................................................... 63
(Adderall xr)................................................................... 63
(Adderall xr)................................................................... 63
(Adderall xr)................................................................... 64
(Adderall xr)................................................................... 64
(Adderall xr)................................................................... 63
amphetamine-dextroamphetamine tab 10 mg
(Adderall)........................................................................ 64
amphetamine-dextroamphetamine tab 12.5 mg
(Adderall)........................................................................ 64
(Adderall)........................................................................ 64
(Adderall)........................................................................ 64
(Adderall)........................................................................ 64
(Adderall)........................................................................ 64
amphetamine-dextroamphetamine tab 7.5 mg
(Adderall)........................................................................ 64
AMPICILLIN – ampicillin for susp 125 mg/5ml.................... 1
107
2015
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.................... 66
AMRIX – cyclobenzaprine hcl cap sr 24hr 15 mg............. 84
AMRIX – cyclobenzaprine hcl cap sr 24hr 30 mg............. 84
ANADROL-50 – oxymetholone tab 50 mg........................ 16
anagrelide hcl cap 0.5 mg (Agrylin).............................. 89
anagrelide hcl cap 1 mg................................................. 89
ANALPRAM-HC – hydrocortisone acetate w/ pramoxine
rectal lotn 2.5-1%............................................................ 94
ANASPAZ – hyoscyamine sulfate tab disp 0.125 mg........49
anastrozole tab 1 mg (Arimidex)................................... 11
ANDRODERM – testosterone td patch 24hr 2
mg/24hr............................................................................16
ANDRODERM – testosterone td patch 24hr 4
mg/24hr............................................................................16
ANDROGEL PUMP – testosterone td gel 12.5 mg/act
(1%)................................................................................. 16
ANDROGEL PUMP – testosterone td gel 20.25 mg/act
(1.62%)............................................................................ 16
ANDROGEL – testosterone td gel 20.25 mg/1.25gm
(1.62%)............................................................................ 16
ANDROGEL – testosterone td gel 25 mg/2.5gm (1%)...... 16
ANDROGEL – testosterone td gel 40.5 mg/2.5gm
(1.62%)............................................................................ 16
ANDROGEL – testosterone td gel 50 mg/5gm (1%)......... 16
ANDROID – methyltestosterone cap 10 mg......................16
ANDROXY – fluoxymesterone tab 10 mg......................... 16
ANGELIQ – drospirenone-estradiol tab 0.25-0.5 mg.........17
ANGELIQ – drospirenone-estradiol tab 0.5-1 mg..............17
ANORO ELLIPTA – umeclidinium-vilanterol aero powd ba
62.5-25 mcg/inh............................................................... 45
ANTIPYRINE/BENZOCAINE – antipyrine-benzocaine otic
soln 55-14 mg/ml (5.5-1.4%)........................................... 92
antipyrine-benzocaine otic soln 54-14 mg/ml
(5.4-1.4%)........................................................................ 92
antipyrine-benzocaine-polycosanol otic sol
5.4-1.4-0.0097% (Treagan otic)..................................... 92
ANZEMET – dolasetron mesylate tab 100 mg.................. 50
ANZEMET – dolasetron mesylate tab 50 mg.................... 50
APEXICON E – diflorasone diacetate emollient base
cream 0.05%................................................................... 94
APIDRA – insulin glulisine inj 100 unit/ml......................... 21
APIDRA SOLOSTAR – insulin glulisine soln pen-injector
inj 100 unit/ml.................................................................. 21
APLENZIN – bupropion hbr tab sr 24hr 174 mg............... 57
APOKYN – apomorphine hydrochloride inj 10 mg/ml........82
apraclonidine hcl ophth soln 0.5% (base equivalent)
(Iopidine).........................................................................90
APRISO – mesalamine cap sr 24hr 0.375 gm.................. 52
APTIVUS – tipranavir cap 250 mg......................................5
APTIVUS – tipranavir oral soln 100 mg/ml......................... 5
108
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 100 mcg/0.5ml............................ 86
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 100 mcg/ml.................................86
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 10 mcg/0.4ml.............................. 86
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 25 mcg/ml...................................86
ARAVA – leflunomide tab 10 mg...................................... 75
ARAVA – leflunomide tab 20 mg...................................... 75
ARCALYST – rilonacept for inj 220 mg.............................75
ARCAPTA NEOHALER – indacaterol maleate inhal
powder cap 75 mcg (base equiv).................................... 45
aripiprazole tab 10 mg (Abilify)......................................60
aripiprazole tab 2 mg (Abilify)........................................60
aripiprazole tab 5 mg (Abilify)........................................60
ARIXTRA – fondaparinux sodium subcutaneous inj 10
mg/0.8ml.......................................................................... 88
ARIXTRA – fondaparinux sodium subcutaneous inj 2.5
mg/0.5ml.......................................................................... 88
ARIXTRA – fondaparinux sodium subcutaneous inj 5
mg/0.4ml.......................................................................... 88
ARIXTRA – fondaparinux sodium subcutaneous inj 7.5
mg/0.6ml.......................................................................... 88
ARMOUR THYROID – thyroid tab 120 mg (2 grain)......... 23
ARMOUR THYROID – thyroid tab 15 mg (1/4 grain)........ 23
ARMOUR THYROID – thyroid tab 30 mg (1/2 grain)........ 23
ARMOUR THYROID – thyroid tab 60 mg (1 grain)........... 23
2015
ARMOUR THYROID – thyroid tab 90 mg (1 1/2 grain)..... 23
ARNUITY ELLIPTA – fluticasone furoate aerosol powder
breath activ 100 mcg/act................................................. 45
ARNUITY ELLIPTA – fluticasone furoate aerosol powder
breath activ 200 mcg/act................................................. 45
ARZOL SILVER NITRATE APP – silver nitrate-potassium
nitrate applicator 75-25%.................................................94
ASACOL HD – mesalamine tab delayed release 800
mg.................................................................................... 52
ASCENSIA AUTODISC TEST ST – glucose blood test
disk.................................................................................102
ASMANEX HFA – mometasone furoate inhal aerosol
suspension 100 mcg/act..................................................45
ASMANEX HFA – mometasone furoate inhal aerosol
suspension 200 mcg/act..................................................46
ASMANEX TWISTHALER 120 ME – mometasone furoate
inhal powd 220 mcg/inh (breath activated)......................46
ASMANEX TWISTHALER 14 MET – mometasone furoate
ASMANEX TWISTHALER 7 METE – mometasone furoate
ASTAGRAF XL – tacrolimus cap sr 24hr 0.5 mg............ 103
ASTAGRAF XL – tacrolimus cap sr 24hr 1 mg............... 103
ASTAGRAF XL – tacrolimus cap sr 24hr 5 mg............... 103
ASTEPRO – azelastine hcl nasal spray 0.15% (205.5
mcg/spray)....................................................................... 43
ATELVIA – risedronate sodium tab delayed release 35
mg.................................................................................... 24
atenolol & chlorthalidone tab 100-25 mg (Tenoretic
100)..................................................................................34
atenolol & chlorthalidone tab 50-25 mg (Tenoretic
50)....................................................................................33
atenolol tab 100 mg (Tenormin).....................................30
atenolol tab 25 mg (Tenormin).......................................30
atenolol tab 50 mg (Tenormin).......................................30
atorvastatin calcium tab 10 mg (base equivalent)
(Lipitor)........................................................................... 40
(Lipitor)........................................................................... 40
(Lipitor)........................................................................... 40
(Lipitor)........................................................................... 40
atovaquone-proguanil hcl tab 250-100 mg
(Malarone).........................................................................9
atovaquone-proguanil hcl tab 62.5-25 mg
(Malarone).........................................................................9
atovaquone susp 750 mg/5ml (Mepron)........................10
ATRALIN – tretinoin gel 0.05%......................................... 95
ATRIPLA – efavirenz-emtricitabine-tenofovir df tab
600-200-300 mg................................................................ 5
ATROPINE SULFATE – atropine sulfate ophth oint
1%....................................................................................90
atropine sulfate ophth soln 1% (Isopto atropine)......... 90
ATROVENT HFA – ipratropium bromide hfa inhal aerosol
17 mcg/act....................................................................... 46
AUBAGIO – teriflunomide tab 14 mg................................ 67
AUBAGIO – teriflunomide tab 7 mg.................................. 66
AUVI-Q – epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)..........................................................39
AUVI-Q – epinephrine solution auto-injector 0.3 mg/0.3ml
(1:1000)............................................................................39
AVC – sulfanilamide vaginal cream 15%.......................... 54
AVEED – testosterone undecanoate im inj in oil 750
mg/3ml (250mg/ml)..........................................................16
AVODART – dutasteride cap 0.5 mg................................ 55
AVONEX – interferon beta-1a for im inj kit 30mcg
(33mcg(6.6 mu)/vial)........................................................67
AVONEX – interferon beta-1a im inj kit 30 mcg/0.5ml.......67
AVONEX PEN – interferon beta-1a im inj kit 30
mcg/0.5ml........................................................................ 67
AXERT – almotriptan malate tab 12.5 mg........................ 77
AXERT – almotriptan malate tab 6.25 mg........................ 77
AXIRON – testosterone td soln 30 mg/act........................ 16
azacitidine for inj 100 mg (Vidaza)................................ 11
AZASAN – azathioprine tab 100 mg............................... 103
AZASAN – azathioprine tab 75 mg................................. 103
AZASITE – azithromycin ophth soln 1%........................... 90
azathioprine tab 50 mg (Imuran)..................................103
azelastine hcl nasal spray 0.1% (137 mcg/spray).........43
azelastine hcl nasal spray 0.15% (205.5 mcg/spray)
(Astepro)......................................................................... 43
azelastine hcl ophth soln 0.05% (Optivar).................... 90
AZELEX – azelaic acid cream 20%.................................. 95
AZILECT – rasagiline mesylate tab 0.5 mg (base
equiv)............................................................................... 82
AZILECT – rasagiline mesylate tab 1 mg (base equiv)..... 82
AZITHROMYCIN – azithromycin powd pack for susp 1
gm...................................................................................... 2
azithromycin for susp 100 mg/5ml (Zithromax)..............2
azithromycin for susp 200 mg/5ml (Zithromax)..............2
azithromycin tab 250 mg (Zithromax)............................. 2
AZOPT – brinzolamide ophth susp 1%............................. 90
AZOR – amlodipine besylate-olmesartan medoxomil tab
10-20 mg......................................................................... 34
10-40 mg......................................................................... 34
5-20 mg........................................................................... 34
5-40 mg........................................................................... 34
109
2015
B
BACITRACIN – bacitracin ophth oint 500 unit/gm.............90
bacitracin-polymyxin b ophth oint.................................90
bacitracin-polymyxin-neomycin-hc ophth oint 1%.......90
baclofen tab 10 mg......................................................... 84
baclofen tab 20 mg......................................................... 84
balsalazide disodium cap 750 mg (Colazal)..................52
BANZEL – rufinamide susp 40 mg/ml...............................79
BANZEL – rufinamide tab 200 mg.................................... 79
BANZEL – rufinamide tab 400 mg.................................... 79
BARACLUDE – entecavir oral soln 0.05 mg/ml.................. 5
BARACLUDE – entecavir tab 0.5 mg................................. 5
BARACLUDE – entecavir tab 1 mg.................................... 5
BAYER BREEZE 2 TEST DISC – glucose blood test
disk.................................................................................102
BAYER CONTOUR BLOOD GLUCO – glucose blood test
strip................................................................................ 102
BAYER CONTOUR NEXT BLOOD – glucose blood test
strip................................................................................ 102
BECONASE AQ – beclomethasone dipropionate monohyd
nasal susp 42 mcg/spray................................................ 44
BELLADONNA & OPIUM – belladonna alkaloids & opium
suppos 16.2-30 mg..........................................................49
BELLADONNA ALKALOIDS & OP – belladonna alkaloids
& opium suppos 16.2-60 mg........................................... 49
BELVIQ – lorcaserin hcl tab 10 mg...................................64
benazepril & hydrochlorothiazide tab 10-12.5 mg
(Lotensin hct)................................................................. 34
benazepril & hydrochlorothiazide tab 20-12.5 mg
(Lotensin hct)................................................................. 34
benazepril & hydrochlorothiazide tab 20-25 mg
(Lotensin hct)................................................................. 34
benazepril & hydrochlorothiazide tab 5-6.25 mg..........34
benazepril hcl tab 10 mg (Lotensin).............................. 34
benazepril hcl tab 5 mg.................................................. 34
BENICAR HCT – olmesartan medoxomilhydrochlorothiazide tab 20-12.5 mg................................ 34
BENICAR HCT – olmesartan medoxomilhydrochlorothiazide tab 40-12.5 mg................................ 34
BENICAR HCT – olmesartan medoxomilhydrochlorothiazide tab 40-25 mg................................... 34
BENICAR – olmesartan medoxomil tab 20 mg................. 34
BENICAR – olmesartan medoxomil tab 40 mg................. 34
BENICAR – olmesartan medoxomil tab 5 mg................... 34
benzocaine dental soln 20%.......................................... 93
benzonatate cap 100 mg (Tessalon perles).................. 44
benzonatate cap 150 mg (Zonatuss)............................. 44
benzonatate cap 200 mg................................................ 44
benzoyl peroxide-erythromycin gel 5-3%
(Benzamycin)..................................................................95
benzoyl peroxide foam 5.3% (Benzefoam)....................95
benzoyl peroxide foam 9.8% (Benzefoamultra)............ 95
benzoyl peroxide liq 10%............................................... 95
110
benzoyl peroxide liq 2.5%.............................................. 95
benzoyl peroxide liq 5.25%............................................ 95
benzoyl peroxide liq 7%................................................. 95
benzoyl peroxide lotion 6%............................................95
benztropine mesylate tab 0.5 mg...................................82
benztropine mesylate tab 1 mg..................................... 82
benztropine mesylate tab 2 mg..................................... 82
BEPREVE – bepotastine besilate ophth soln 1.5%...........90
BESIVANCE – besifloxacin hcl ophth susp 0.6% (base
equiv)............................................................................... 90
betamethasone dipropionate augmented cream 0.05%
(Diprolene af)................................................................. 95
betamethasone dipropionate augmented gel
0.05%...............................................................................95
betamethasone dipropionate augmented lotion 0.05%
(Diprolene)...................................................................... 95
betamethasone dipropionate augmented oint 0.05%
(Diprolene)...................................................................... 95
betamethasone dipropionate cream 0.05%...................95
betamethasone dipropionate lotion 0.05%................... 95
betamethasone dipropionate oint 0.05%...................... 95
betamethasone valerate aerosol foam 0.12%
(Luxiq)............................................................................. 95
betamethasone valerate cream 0.1%.............................95
betamethasone valerate lotion 0.1%............................. 95
betamethasone valerate oint 0.1%.................................95
BETASERON – interferon beta-1b for inj kit 0.3 mg..........67
betaxolol hcl ophth soln 0.5%....................................... 90
betaxolol hcl tab 10 mg (Kerlone)................................. 30
betaxolol hcl tab 20 mg (Kerlone)................................. 30
bethanechol chloride tab 10 mg (Urecholine)...............54
bethanechol chloride tab 5 mg (Urecholine)................ 54
BETHKIS – tobramycin nebu soln 300 mg/4ml................... 4
BETIMOL – timolol ophth soln 0.25%............................... 90
BETIMOL – timolol ophth soln 0.5%................................. 90
BETOPTIC-S – betaxolol hcl ophth susp 0.25%............... 90
bexarotene cap 75 mg (Targretin)................................. 11
BEYAZ – drospirenone-ethinyl estrad-levomefolate tab
3-0.02-0.451 mg.............................................................. 18
bicalutamide tab 50 mg (Casodex)................................ 11
BIDIL – isosorbide dinitrate-hydralazine hcl tab 20-37.5
mg.................................................................................... 42
BINOSTO – alendronate sodium effervescent tab 70
mg.................................................................................... 24
bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln
kit.....................................................................................48
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
(Ziac)............................................................................... 34
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
(Ziac)............................................................................... 34
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
(Ziac)............................................................................... 34
bisoprolol fumarate tab 10 mg (Zebeta)........................30
bisoprolol fumarate tab 5 mg (Zebeta)..........................30
2015
BLEPHAMIDE S.O.P. – sulfacetamide sodiumprednisolone ophth oint 10-0.2%.....................................90
BLEPHAMIDE – sulfacetamide sodium-prednisolone
ophth susp 10-0.2%........................................................ 90
BOSULIF – bosutinib tab 100 mg..................................... 11
BOSULIF – bosutinib tab 500 mg..................................... 11
BP CLEANSING WASH – sulfacetamide sodium-sulfur in
urea emulsion 10-4%...................................................... 95
BPO – benzoyl peroxide gel 8%....................................... 95
BP VIT 3 – folic acid-vit b6-vit b12-omega 3-phytosterols
cap 1 mg......................................................................... 86
BRAVELLE – Benefit Limits may apply – urofollitropin
purified for inj 75 unit...................................................... 24
BREO ELLIPTA – fluticasone furoate-vilanterol aero powd
ba 100-25 mcg/inh...........................................................46
BREO ELLIPTA – fluticasone furoate-vilanterol aero powd
ba 200-25 mcg/inh...........................................................46
BRILINTA – ticagrelor tab 90 mg......................................89
brimonidine tartrate ophth soln 0.15% (Alphagan
p)......................................................................................90
brimonidine tartrate ophth soln 0.2%............................90
BRINTELLIX – vortioxetine hbr tab 10 mg (base
equiv)............................................................................... 57
BRINTELLIX – vortioxetine hbr tab 20 mg (base
equiv)............................................................................... 57
BRINTELLIX – vortioxetine hbr tab 5 mg (base equiv)......57
bromfenac sodium ophth soln 0.09% (base equiv)
(once-daily).....................................................................90
bromfenac sodium ophth soln 0.09% (base
equivalent)...................................................................... 90
bromocriptine mesylate cap 5 mg (Parlodel)................82
bromocriptine mesylate tab 2.5 mg...............................82
brompheniramine & pseudoephedrine tab sr 12hr 6-45
mg....................................................................................44
brompheniramine maleate tab sr 12hr 6 mg.................43
BROMPHENIRAMINE TANNATE – brompheniramine
tannate chew tab 12 mg..................................................43
BROVANA – arformoterol tartrate soln nebu 15 mcg/2ml
(base equiv).....................................................................46
budesonide cap sr 24hr 3 mg (Entocort ec)................. 15
budesonide inhalation susp 0.25 mg/2ml
(Pulmicort)...................................................................... 46
budesonide inhalation susp 0.5 mg/2ml
(Pulmicort)...................................................................... 46
budesonide inhalation susp 1 mg/2ml (Pulmicort).......46
budesonide nasal susp 32 mcg/act (Rhinocort
aqua)............................................................................... 44
bumetanide tab 0.5 mg................................................... 38
bumetanide tab 1 mg...................................................... 38
bumetanide tab 2 mg...................................................... 38
BUPHENYL – sodium phenylbutyrate oral powder 3 gm/
teaspoonful...................................................................... 24
BUPHENYL – sodium phenylbutyrate tab 500 mg............ 24
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base
equiv).............................................................................. 70
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
equiv).............................................................................. 70
buprenorphine hcl sl tab 2 mg (base equiv)................. 70
buprenorphine hcl sl tab 8 mg (base equiv)................. 70
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
– Benefit Limits may apply (Zyban)............................. 67
bupropion hcl tab 100 mg (Wellbutrin)......................... 57
bupropion hcl tab 75 mg (Wellbutrin)........................... 57
bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr)........ 57
bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl).........57
bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl).........57
buspirone hcl tab 10 mg................................................ 56
buspirone hcl tab 5 mg.................................................. 56
buspirone hcl tab 7.5 mg............................................... 56
butalbital-acetaminophen-caffeine cap 50-300-40 mg
(Fioricet)..........................................................................69
butalbital-acetaminophen-caffeine cap 50-325-40
mg....................................................................................69
butalbital-acetaminophen-caffeine tab 50-325-40 mg
(Esgic)............................................................................. 69
butalbital-acetaminophen-caff w/ cod cap 50-300-40-30
mg (Fioricet/codeine).................................................... 70
butalbital-acetaminophen-caff w/ cod cap 50-325-40-30
mg....................................................................................70
butalbital-acetaminophen tab 50-325 mg...................... 69
butalbital-aspirin-caffeine cap 50-325-40 mg
(Fiorinal)..........................................................................69
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
(Fiorinal/codeine #3)......................................................70
butorphanol tartrate inj 1 mg/ml.................................... 70
butorphanol tartrate inj 2 mg/ml.................................... 70
butorphanol tartrate nasal soln 10 mg/ml.....................70
BUTRANS – buprenorphine td patch weekly 10 mcg/
hr......................................................................................70
hr......................................................................................70
hr......................................................................................70
BUTRANS – buprenorphine td patch weekly 5 mcg/hr......70
BUTRANS – buprenorphine td patch weekly 7.5 mcg/
hr......................................................................................70
BYDUREON – exenatide extended release for inj susp 2
mg.................................................................................... 19
BYDUREON – exenatide extended release for susp peninjector 2 mg....................................................................19
BYETTA – exenatide soln pen-injector 10 mcg/0.04ml..... 19
BYETTA – exenatide soln pen-injector 5 mcg/0.02ml....... 19
BYSTOLIC – nebivolol hcl tab 10 mg (base
equivalent)....................................................................... 30
BYSTOLIC – nebivolol hcl tab 2.5 mg (base
equivalent)....................................................................... 30
111
2015
BYSTOLIC – nebivolol hcl tab 20 mg (base
equivalent)....................................................................... 30
BYSTOLIC – nebivolol hcl tab 5 mg (base equivalent)......30
C
cabergoline tab 0.5 mg................................................... 24
CAFERGOT – ergotamine w/ caffeine tab 1-100 mg........ 77
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base
equiv) (Cafcit).................................................................64
calcipotriene-betamethasone dipropionate oint
0.005-0.064% (Taclonex)............................................... 95
calcipotriene cream 0.005% (Dovonex).........................95
calcipotriene oint 0.005%............................................... 95
calcipotriene soln 0.005% (50 mcg/ml)..........................95
calcitonin (salmon) nasal soln 200 unit/act
(Miacalcin)...................................................................... 24
CALCITRIOL – calcitriol oint 3 mcg/gm............................ 95
calcitriol cap 0.25 mcg (Rocaltrol).................................24
calcitriol cap 0.5 mcg (Rocaltrol)...................................25
calcitriol oral soln 1 mcg/ml (Rocaltrol)........................25
calcium acetate (phosphate binder) cap 667 mg (169
mg ca) (Phoslo)............................................................. 52
calcium acetate (phosphate binder) tab 667 mg
(Eliphos)..........................................................................52
CALCIUM-FOLIC ACID PLUS D – ca carb-folic acid-vit db6-b12-boron-mag wafer 1342-1 mg...............................85
CAMBIA – diclofenac potassium packet 50 mg................ 77
CANASA – mesalamine suppos 1000 mg........................ 52
candesartan cilexetil-hydrochlorothiazide tab 16-12.5
mg (Atacand hct)........................................................... 34
candesartan cilexetil-hydrochlorothiazide tab 32-12.5
mg (Atacand hct)........................................................... 34
candesartan cilexetil-hydrochlorothiazide tab 32-25
mg (Atacand hct)........................................................... 34
candesartan cilexetil tab 16 mg (Atacand)....................34
candesartan cilexetil tab 32 mg (Atacand)....................34
candesartan cilexetil tab 4 mg (Atacand)......................34
candesartan cilexetil tab 8 mg (Atacand)......................34
capecitabine tab 150 mg (Xeloda)................................. 11
capecitabine tab 500 mg (Xeloda)................................. 11
CAPEX – fluocinolone acetonide shampoo 0.01%............95
CAPRELSA – vandetanib tab 100 mg.............................. 11
CAPRELSA – vandetanib tab 300 mg.............................. 11
CAPTOPRIL/HYDROCHLOROTHIA – captopril &
hydrochlorothiazide tab 25-15 mg................................... 34
captopril tab 100 mg....................................................... 34
captopril tab 12.5 mg...................................................... 34
captopril tab 25 mg......................................................... 34
captopril tab 50 mg......................................................... 34
CARAC – fluorouracil cream 0.5%....................................95
112
CARBAGLU – carglumic acid tab 200 mg........................ 25
carbamazepine cap sr 12hr 100 mg (Carbatrol)............79
carbamazepine chew tab 100 mg.................................. 79
carbamazepine susp 100 mg/5ml (Tegretol)................. 79
carbamazepine tab 200 mg (Tegretol)........................... 79
carbamazepine tab sr 12hr 200 mg (Tegretol-xr)..........79
carbamazepine tab sr 12hr 400 mg (Tegretol-xr)..........79
CARBATROL – carbamazepine cap sr 12hr 100 mg........ 79
CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 12.5-50-200 mg.................... 82
CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 18.75-75-200 mg.................. 82
CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 25-100-200 mg..................... 82
CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 31.25-125-200 mg................ 82
CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 37.5-150-200 mg.................. 82
CARBIDOPA/LEVODOPA/ENTACA – carbidopalevodopa-entacapone tabs 50-200-200 mg..................... 82
carbidopa & levodopa orally disintegrating tab 10-100
mg....................................................................................82
mg....................................................................................82
mg....................................................................................82
carbidopa & levodopa tab 10-100 mg (Sinemet)...........82
carbidopa & levodopa tab cr 25-100 mg (Sinemet
cr).................................................................................... 82
carbidopa & levodopa tab cr 50-200 mg (Sinemet
cr).................................................................................... 82
carbidopa tab 25 mg (Lodosyn).....................................82
carbinoxamine maleate soln 4 mg/5ml..........................43
carbinoxamine maleate tab 4 mg...................................43
CARDIZEM CD – diltiazem hcl coated beads cap sr 24hr
360 mg.............................................................................31
CARDIZEM LA – diltiazem hcl coated beads tab sr 24hr
120 mg.............................................................................31
CARDURA XL – doxazosin mesylate tab sr 24 hr 4 mg
(base equiv).....................................................................55
CARDURA XL – doxazosin mesylate tab sr 24 hr 8 mg
(base equiv).....................................................................55
CARISOPRODOL – carisoprodol tab 250 mg...................84
carisoprodol tab 350 mg (Soma)................................... 84
carisoprodol w/ aspirin & codeine tab 200-325-16
mg....................................................................................84
carisoprodol w/ aspirin tab 200-325 mg........................84
carteolol hcl ophth soln 1%........................................... 90
carvedilol tab 12.5 mg (Coreg).......................................30
carvedilol tab 25 mg (Coreg)..........................................30
2015
carvedilol tab 3.125 mg (Coreg).....................................30
carvedilol tab 6.25 mg (Coreg).......................................30
CAVERJECT – Benefit Limits may apply – alprostadil for
inj 20 mcg........................................................................42
CAVERJECT – Benefit Limits may apply – alprostadil for
inj 40 mcg........................................................................42
CAVERJECT IMPULSE – Benefit Limits may apply –
alprostadil for inj kit 10 mcg............................................ 42
CAVERJECT IMPULSE – Benefit Limits may apply –
alprostadil for inj kit 20 mcg............................................ 42
CAYSTON – aztreonam lysine for inhal soln 75 mg (base
equivalent)....................................................................... 10
cefaclor cap 250 mg......................................................... 1
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
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)............................................................... 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
cefuroxime axetil tab 250 mg (Ceftin)............................. 2
cefuroxime axetil tab 500 mg (Ceftin)............................. 2
CELEBREX – celecoxib cap 100 mg................................ 75
CELEBREX – celecoxib cap 50 mg.................................. 75
celecoxib cap 100 mg (Celebrex).................................. 75
celecoxib cap 50 mg (Celebrex).................................... 75
CELLCEPT – mycophenolate mofetil cap 250 mg.......... 103
CELLCEPT – mycophenolate mofetil for oral susp 200 mg/
ml................................................................................... 103
CELLCEPT – mycophenolate mofetil tab 500 mg........... 103
CEM-UREA – urea soln 45%............................................95
CENTANY – mupirocin oint 2%........................................ 95
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)....................................................................... 86
CESAMET – nabilone cap 1 mg....................................... 50
CETRAXAL – ciprofloxacin hcl otic soln 0.2% (base
equivalent)....................................................................... 93
CETROTIDE – Benefit Limits may apply – cetrorelix
acetate for inj kit 0.25 mg................................................25
cevimeline hcl cap 30 mg (Evoxac)...............................93
CHANTIX – Benefit Limits may apply – varenicline tartrate
tab 0.5 mg (base equiv).................................................. 67
CHANTIX – Benefit Limits may apply – varenicline tartrate
tab 1 mg (base equiv)..................................................... 67
CHANTIX CONTINUING MONTH – Benefit Limits may
apply – varenicline tartrate tab 1 mg (base equiv)...........67
CHANTIX STARTING MONTH PA – Benefit Limits may
apply – varenicline tartrate tab 0.5 mg x 11 & tab 1 mg x
42 pack............................................................................ 67
CHEMET – succimer cap 100 mg...................................102
CHLORDIAZEPOXIDE/AMITRIPT – chlordiazepoxideamitriptyline tab 10-25 mg............................................... 67
CHLORDIAZEPOXIDE/AMITRIPT – chlordiazepoxideamitriptyline tab 5-12.5 mg.............................................. 67
chlordiazepoxide hcl cap 10 mg.................................... 56
chlordiazepoxide hcl cap 25 mg.................................... 56
chlordiazepoxide hcl cap 5 mg......................................56
chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg
(Librax)............................................................................49
chlorhexidine gluconate soln 0.12% (Peridex)............. 93
chloroquine phosphate tab 250 mg.................................9
chloroquine phosphate tab 500 mg (Aralen).................. 9
CHLOROTHIAZIDE – chlorothiazide tab 250 mg..............38
chlorothiazide tab 500 mg.............................................. 38
chlorpromazine hcl tab 100 mg..................................... 60
chlorpromazine hcl tab 10 mg....................................... 60
chlorpromazine hcl tab 200 mg..................................... 60
CHLORPROPAMIDE – chlorpropamide tab 100 mg.........19
CHLORPROPAMIDE – chlorpropamide tab 250 mg.........19
CHLORTHALIDONE – chlorthalidone tab 25 mg.............. 38
CHLORTHALIDONE – chlorthalidone tab 50 mg.............. 38
chlorzoxazone tab 500 mg (Parafon forte dsc).............84
CHOLBAM – cholic acid cap 250 mg............................... 52
CHOLBAM – cholic acid cap 50 mg................................. 52
cholecalciferol cap 50000 unit....................................... 84
cholestyramine light powder 4 gm/dose (Questran
light)................................................................................ 40
cholestyramine light powder packets 4 gm..................40
cholestyramine powder 4 gm/dose (Questran)............ 40
cholestyramine powder packets 4 gm (Questran)........40
choline & magnesium salicylates liq 500 mg/5ml........ 69
113
2015
choline fenofibrate cap dr 135 mg (fenofibric acid
equiv) (Trilipix)............................................................... 40
choline fenofibrate cap dr 45 mg (fenofibric acid
equiv) (Trilipix)............................................................... 40
CHOLINE MAGNESIUM TRISALI – choline & magnesium
salicylates tab 1000 mg...................................................70
chorionic gonadotropin for inj 10000 unit – Benefit
Limits may apply........................................................... 25
CIALIS – Benefit Limits may apply – tadalafil tab 10
mg.................................................................................... 42
CIALIS – Benefit Limits may apply – tadalafil tab 2.5
mg.................................................................................... 42
CIALIS – Benefit Limits may apply – tadalafil tab 20
mg.................................................................................... 42
CIALIS – Benefit Limits may apply – tadalafil tab 5 mg..... 42
ciclopirox gel 0.77%........................................................95
ciclopirox olamine cream 0.77% (base equiv).............. 95
ciclopirox olamine susp 0.77% (base equiv)................ 95
ciclopirox shampoo 1% (Loprox shampoo)..................95
ciclopirox solution 8% (Penlac Nail Lacquer)...............95
ciclopirox solution kit 8% (Ciclodan solution ki)..........95
CICLOPIROX TOPICAL SOLUTI – ciclopirox solution 8%
& vitamin e 5% topical kit................................................95
cilostazol tab 100 mg (Pletal).........................................89
cilostazol tab 50 mg (Pletal)...........................................89
CILOXAN – ciprofloxacin hcl ophth oint 0.3%................... 90
CILOXAN – ciprofloxacin hcl ophth soln 0.3%.................. 90
cimetidine hcl soln 300 mg/5ml..................................... 49
cimetidine tab 200 mg.................................................... 49
CIMZIA – certolizumab pegol for inj kit 2 x 200 mg...........52
CIMZIA – certolizumab pegol inj kit 2 x 200 mg/ml........... 52
CIMZIA STARTER KIT – certolizumab pegol inj kit 6 x 200
mg/ml............................................................................... 52
CIPRODEX – ciprofloxacin-dexamethasone otic susp
0.3-0.1%...........................................................................93
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000
mg(base eq) (Cipro xr)....................................................4
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg
(base eq) (Cipro xr)......................................................... 4
ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml) (Cipro)............................................................ 4
ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml) (Cipro)............................................................ 4
CIPROFLOXACIN HCL – ciprofloxacin hcl tab 100 mg
(base equiv).......................................................................4
ciprofloxacin hcl ophth soln 0.3% (Ciloxan).................90
ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)......... 4
ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)......... 4
ciprofloxacin hcl tab 750 mg (base equiv)......................4
CIPRO HC – ciprofloxacin-hydrocortisone otic susp
0.2-1%..............................................................................93
citalopram hydrobromide oral soln 10 mg/5ml.............57
114
citalopram hydrobromide tab 10 mg (base equiv)
(Celexa)........................................................................... 57
(Celexa)........................................................................... 57
(Celexa)........................................................................... 57
CLARAVIS – isotretinoin cap 30 mg................................. 95
CLARINEX-D 12 HOUR – desloratadine &
pseudoephedrine tab sr 12hr 2.5-120 mg....................... 44
clarithromycin for susp 125 mg/5ml................................2
clarithromycin for susp 250 mg/5ml (Biaxin)..................2
clarithromycin tab 250 mg (Biaxin)................................. 2
clarithromycin tab 500 mg (Biaxin)................................. 2
clarithromycin tab sr 24hr 500 mg (Biaxin xl pac)..........2
CLEMASTINE FUMARATE – clemastine fumarate syrup
0.67 mg/5ml (0.5 mg/5ml base eq)................................. 43
clemastine fumarate tab 2.68 mg...................................43
CLEOCIN – clindamycin phosphate vaginal suppos 100
mg.................................................................................... 54
CLIMARA PRO – estradiol-levonorgestrel td patch weekly
0.045-0.015 mg/day.........................................................17
clindamycin hcl cap 150 mg (Cleocin).......................... 10
clindamycin hcl cap 300 mg (Cleocin).......................... 10
clindamycin hcl cap 75 mg (Cleocin)............................ 10
clindamycin palmitate hcl for soln 75 mg/5ml (base
equiv) (Cleocin pediatric gr).........................................10
clindamycin phosphate-benzoyl peroxide gel 1-5%
(Benzaclin)......................................................................96
clindamycin phosphate foam 1% (Evoclin).................. 95
clindamycin phosphate gel 1% (Cleocin-t)................... 96
clindamycin phosphate lotion 1% (Cleocin-t)...............96
clindamycin phosphate soln 1% (Cleocin-t)................. 96
clindamycin phosphate swab 1% (Cleocin-t)................96
clindamycin phosphate vaginal cream 2%
(Cleocin)..........................................................................54
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2
(1)-5% (Duac)..................................................................95
CLINDESSE – clindamycin phosphate (one dose) vaginal
cream 2%........................................................................ 54
clobetasol propionate cream 0.05% (Temovate).......... 96
clobetasol propionate emollient base cream 0.05%
(Temovate e).................................................................. 96
clobetasol propionate emulsion foam 0.05% (Oluxe)......................................................................................96
clobetasol propionate foam 0.05% (Olux).....................96
clobetasol propionate gel 0.05% (Temovate)................96
clobetasol propionate lotion 0.05% (Clobex)................96
clobetasol propionate oint 0.05% (Temovate).............. 96
clobetasol propionate shampoo 0.05% (Clobex)..........96
clobetasol propionate soln 0.05% (Temovate)............. 96
clobetasol propionate spray 0.05% (Clobex)................ 96
CLODERM – clocortolone pivalate cream 0.1%............... 96
CLODERM PUMP – clocortolone pivalate cream
0.1%.................................................................................96
clomiphene citrate tab 50 mg – Benefit Limits may
apply................................................................................25
2015
clomipramine hcl cap 25 mg (Anafranil)....................... 57
clonazepam orally disintegrating tab 0.125 mg............79
clonazepam orally disintegrating tab 0.25 mg..............79
clonazepam orally disintegrating tab 0.5 mg................79
clonazepam orally disintegrating tab 1 mg...................79
clonazepam orally disintegrating tab 2 mg...................79
clonazepam tab 0.5 mg (Klonopin)................................79
clonazepam tab 1 mg (Klonopin)...................................79
clonazepam tab 2 mg (Klonopin)...................................79
clonidine hcl tab 0.1 mg (Catapres).............................. 35
clonidine hcl tab sr 12hr 0.1 mg (Kapvay).................... 64
clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1)................................................................................ 35
clopidogrel bisulfate tab 300 mg (base equiv)
(Plavix)............................................................................ 89
clopidogrel bisulfate tab 75 mg (base equiv)
(Plavix)............................................................................ 89
clorazepate dipotassium tab 15 mg (Tranxene t)......... 56
clorazepate dipotassium tab 3.75 mg (Tranxene t)...... 56
clorazepate dipotassium tab 7.5 mg (Tranxene t)........ 56
CLORPRES – clonidine & chlorthalidone tab 0.1-15
mg.................................................................................... 35
mg.................................................................................... 35
mg.................................................................................... 35
clotrimazole troche 10 mg..............................................93
clotrimazole w/ betamethasone cream 1-0.05%
(Lotrisone)...................................................................... 96
clotrimazole w/ betamethasone lotion 1-0.05%............ 96
clozapine tab 100 mg (Clozaril)..................................... 60
clozapine tab 200 mg......................................................60
clozapine tab 25 mg (Clozaril)....................................... 60
clozapine tab 50 mg........................................................60
COARTEM – artemether-lumefantrine tab 20-120 mg........ 9
COCAINE HCL – cocaine hcl soln 10%............................96
COCAINE HCL – cocaine hcl soln 4%..............................96
codeine sulfate tab 15 mg (Codeine sulfate)................ 70
codeine sulfate tab 30 mg..............................................71
codeine sulfate tab 60 mg..............................................71
colchicine w/ probenecid tab 0.5-500 mg......................78
COLCRYS – colchicine tab 0.6 mg...................................78
colestipol hcl granule packets 5 gm (Colestid
flavored)..........................................................................40
colestipol hcl granules 5 gm (Colestid flavored)..........40
colestipol hcl tab 1 gm (Colestid)..................................40
COLYTE-FLAVOR PACKS – peg 3350-kcl-na bicarb-naclna sulfate for soln 227.1 gm............................................48
COMBIGAN – brimonidine tartrate-timolol maleate ophth
soln 0.2-0.5%...................................................................90
COMBIPATCH – estradiol-norethindrone ace td pttw
0.05-0.14 mg/day.............................................................17
COMBIPATCH – estradiol-norethindrone ace td pttw
0.05-0.25 mg/day.............................................................17
COMBIVENT RESPIMAT – ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act........................................... 46
COMBIVIR – lamivudine-zidovudine tab 150-300 mg......... 5
COMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60
mg dose) kit.....................................................................11
COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20
mg (100 dose) kit............................................................ 11
COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20
mg (140 dose) kit............................................................ 11
COMPLERA – emtricitabine-rilpivirine-tenofovir df tab
200-25-300 mg.................................................................. 5
CONCERTA – methylphenidate hcl tab sa osm 18 mg..... 64
CONDYLOX – podofilox gel 0.5%.................................... 96
CONZIP – tramadol hcl cap sr 24hr biphasic release 100
mg.................................................................................... 71
mg.................................................................................... 71
mg.................................................................................... 71
COPAXONE – glatiramer acetate soln prefilled syringe 20
mg/ml............................................................................... 67
COPAXONE – glatiramer acetate soln prefilled syringe 40
mg/ml............................................................................... 67
COPEGUS – ribavirin tab 200 mg...................................... 5
CORDRAN – flurandrenolide cream 0.05%...................... 96
CORDRAN – flurandrenolide lotion 0.05%........................96
CORDRAN – flurandrenolide oint 0.05%.......................... 96
COREG CR – carvedilol phosphate cap sr 24hr 10
mg.................................................................................... 30
mg.................................................................................... 30
mg.................................................................................... 30
mg.................................................................................... 30
CORTALO – hydrocortisone acetate-aloe vera gel 2%..... 96
CORTANE-B AQUEOUS – pramoxine-hc-chloroxylenol
aqueous otic soln 10-10-1 mg/ml.................................... 93
CORTANE-B-OTIC – pramoxine-hc-chloroxylenol otic soln
10-10-1 mg/ml................................................................. 93
CORTIFOAM – hydrocortisone acetate rectal foam 90 mg/
dose................................................................................. 94
CORTISONE ACETATE – cortisone acetate tab 25
mg.................................................................................... 15
COSENTYX – secukinumab subcutaneous soln prefilled
syringe 150 mg/ml........................................................... 96
115
2015
COSENTYX SENSOREADY PEN – secukinumab
subcutaneous soln auto-injector 150 mg/ml.................... 96
COSOPT PF – dorzolamide hcl-timolol maleate ophth sol
22.3-6.8 mg/ml pf............................................................ 90
COUMADIN – warfarin sodium tab 10 mg........................ 88
COUMADIN – warfarin sodium tab 1 mg.......................... 88
COUMADIN – warfarin sodium tab 2.5 mg....................... 88
COUMADIN – warfarin sodium tab 7.5 mg....................... 88
CREON – pancrelipase (lip-prot-amyl) dr cap
12000-38000-60000 unit..................................................51
24000-76000-120000 unit................................................51
3000-9500-15000 unit......................................................51
36000-114000-180000 unit..............................................51
6000-19000-30000 unit....................................................51
CRESEMBA – isavuconazonium sulfate cap 186 mg......... 4
CRESTOR – rosuvastatin calcium tab 10 mg................... 40
CRESTOR – rosuvastatin calcium tab 5 mg..................... 40
CRIXIVAN – indinavir sulfate cap 200 mg.......................... 5
CRIXIVAN – indinavir sulfate cap 400 mg.......................... 5
CROMOLYN SODIUM – cromolyn sodium soln nebu 20
mg/2ml............................................................................. 46
cromolyn sodium ophth soln 4%...................................90
cromolyn sodium oral conc 100 mg/5ml
(Gastrocrom).................................................................. 52
CUPRIMINE – penicillamine cap 250 mg....................... 103
CUVPOSA – glycopyrrolate oral soln 1 mg/5ml................ 49
cyclobenzaprine hcl tab 10 mg......................................84
cyclobenzaprine hcl tab 5 mg........................................84
cyclobenzaprine hcl tab 7.5 mg (Fexmid)..................... 84
cyclopentolate hcl ophth soln 1% (Cyclogyl)............... 90
cyclopentolate hcl ophth soln 2% (Cyclogyl)............... 90
CYCLOPHOSPHAMIDE – cyclophosphamide cap 25
mg.................................................................................... 11
CYCLOPHOSPHAMIDE – cyclophosphamide cap 50
mg.................................................................................... 11
CYCLOSET – bromocriptine mesylate tab 0.8 mg (base
equivalent)....................................................................... 19
cyclosporine cap 100 mg (Sandimmune)....................103
cyclosporine cap 25 mg (Sandimmune)......................103
cyclosporine modified cap 100 mg (Neoral)............... 103
cyclosporine modified cap 25 mg (Neoral)................. 103
CYCLOSPORINE MODIFIED – cyclosporine modified cap
50 mg.............................................................................103
cyclosporine modified oral soln 100 mg/ml
(Neoral)......................................................................... 103
116
cyproheptadine hcl syrup 2 mg/5ml..............................43
cyproheptadine hcl tab 4 mg......................................... 43
CYSTADANE – betaine powder for oral solution.............. 25
CYTRA-3 – pot & sod citrates w/ cit ac syrup 550-500-334
mg/5ml............................................................................. 55
D
D.H.E. 45 – dihydroergotamine mesylate inj 1 mg/ml....... 77
DAKLINZA – daclatasvir dihydrochloride tab 30 mg (base
equivalent)......................................................................... 5
DAKLINZA – daclatasvir dihydrochloride tab 60 mg (base
equivalent)......................................................................... 5
DALIRESP – roflumilast tab 500 mcg............................... 46
danazol cap 100 mg........................................................ 16
danazol cap 200 mg........................................................ 16
danazol cap 50 mg.......................................................... 16
dantrolene sodium cap 25 mg (Dantrium).................... 84
dantrolene sodium cap 50 mg (Dantrium).................... 84
DANTROLENE SODIUM – dantrolene sodium cap 100
mg.................................................................................... 84
DAPSONE – dapsone tab 100 mg................................... 10
DAPSONE – dapsone tab 25 mg..................................... 10
DAYTRANA – methylphenidate td patch 10 mg/9hr..........64
DELZICOL – mesalamine cap dr 400 mg......................... 52
demeclocycline hcl tab 150 mg....................................... 3
demeclocycline hcl tab 300 mg....................................... 3
DENAVIR – penciclovir cream 1%.................................... 96
DEPEN TITRATABS – penicillamine tab 250 mg............103
desipramine hcl tab 100 mg (Norpramin)......................57
desipramine hcl tab 10 mg (Norpramin)....................... 57
desipramine hcl tab 150 mg (Norpramin)......................57
desloratadine tab 5 mg (Clarinex)................................. 43
desloratadine tab orally disintegrating 2.5 mg
(Clarinex reditabs)......................................................... 43
desloratadine tab orally disintegrating 5 mg (Clarinex
reditabs)..........................................................................43
desmopressin acetate inj 4 mcg/ml (Ddavp)................ 25
desmopressin acetate nasal soln 0.01% (refrigerated)
(Ddavp)............................................................................25
desmopressin acetate nasal spray soln 0.01%
(Ddavp)............................................................................25
desmopressin acetate nasal spray soln 0.01%
(refrigerated)...................................................................25
desmopressin acetate tab 0.1 mg (Ddavp)................... 25
desmopressin acetate tab 0.2 mg (Ddavp)................... 25
DESONATE – desonide gel 0.05%...................................96
desonide cream 0.05% (Desowen).................................96
desonide lotion 0.05% (Desowen)................................. 96
desonide oint 0.05% (Desowen).................................... 96
desoximetasone cream 0.25% (Topicort)......................96
2015
DESOXIMETASONE – desoximetasone cream 0.05%.....96
desoximetasone gel 0.05% (Topicort)........................... 96
desoximetasone oint 0.25% (Topicort)..........................96
DEXAMETHASONE – dexamethasone tab 1 mg............. 15
DEXAMETHASONE – dexamethasone tab 2 mg............. 15
dexamethasone elixir 0.5 mg/5ml.................................. 15
dexamethasone sodium phosphate ophth soln
0.1%.................................................................................90
dexamethasone tab 0.5 mg............................................ 15
dexamethasone tab 0.75 mg.......................................... 15
dexamethasone tab 1.5 mg............................................ 15
dexamethasone tab 4 mg............................................... 15
dexamethasone tab 6 mg............................................... 15
DEXILANT – dexlansoprazole cap delayed release 30
mg.................................................................................... 49
DEXILANT – dexlansoprazole cap delayed release 60
mg.................................................................................... 49
dexmethylphenidate hcl cap sr 24 hr 10 mg (Focalin
xr).................................................................................... 64
xr).................................................................................... 64
xr).................................................................................... 64
xr).................................................................................... 64
xr).................................................................................... 64
xr).................................................................................... 64
dexmethylphenidate hcl tab 10 mg (Focalin)................64
dexmethylphenidate hcl tab 2.5 mg (Focalin)...............64
dexmethylphenidate hcl tab 5 mg (Focalin)..................64
DEXPAK 10 DAY – dexamethasone tab 1.5 mg taper
pack................................................................................. 15
pack................................................................................. 15
pack................................................................................. 15
dextroamphetamine sulfate cap sr 24hr 10 mg
(Dexedrine)..................................................................... 64
(Dexedrine)..................................................................... 64
(Dexedrine)..................................................................... 64
dextroamphetamine sulfate oral solution 5 mg/5ml
(Procentra)......................................................................64
dextroamphetamine sulfate tab 10 mg..........................64
dextroamphetamine sulfate tab 5 mg............................64
DEXTROMETHORPHAN HBR/CHLO – phenylephrinechlorphen-dm liquid 1.75-0.75-2.75 mg/ml...................... 44
diazepam conc 5 mg/ml..................................................56
DIAZEPAM – diazepam rectal gel delivery system 10
mg.................................................................................... 79
DIAZEPAM – diazepam rectal gel delivery system 2.5
mg.................................................................................... 79
DIAZEPAM – diazepam rectal gel delivery system 20
mg.................................................................................... 79
diazepam tab 10 mg (Valium).........................................56
diazepam tab 2 mg (Valium)...........................................56
diazepam tab 5 mg (Valium)...........................................56
DICLEGIS – doxylamine-pyridoxine tab delayed release
10-10 mg......................................................................... 50
diclofenac potassium tab 50 mg (Cataflam)................. 75
diclofenac sodium (actinic keratoses) gel 3%
(Solaraze)........................................................................96
diclofenac sodium ophth soln 0.1%.............................. 90
diclofenac sodium soln 1.5% (Pennsaid)......................96
diclofenac sodium tab delayed release 25 mg............. 75
diclofenac sodium tab sr 24hr 100 mg (Voltarenxr).................................................................................... 75
diclofenac w/ misoprostol tab delayed release 50-0.2
mg (Arthrotec 50).......................................................... 75
diclofenac w/ misoprostol tab delayed release 75-0.2
mg (Arthrotec 75).......................................................... 75
dicloxacillin sodium cap 250 mg..................................... 1
dicloxacillin sodium cap 500 mg..................................... 1
dicyclomine hcl cap 10 mg (Bentyl).............................. 49
dicyclomine hcl oral soln 10 mg/5ml.............................49
dicyclomine hcl tab 20 mg (Bentyl)...............................49
didanosine delayed release capsule 125 mg (Videx
ec)......................................................................................5
ec)......................................................................................5
ec)......................................................................................6
ec)......................................................................................6
DIFFERIN – adapalene gel 0.3%......................................96
DIFFERIN – adapalene lotion 0.1%.................................. 96
DIFICID – fidaxomicin tab 200 mg......................................2
DIFLORASONE DIACETATE – diflorasone diacetate
cream 0.05%................................................................... 96
DIFLORASONE DIACETATE – diflorasone diacetate oint
0.05%...............................................................................97
diflunisal tab 500 mg...................................................... 70
DIGOXIN – digoxin oral soln 0.05 mg/ml.......................... 29
digoxin tab 125 mcg (0.125 mg) (Lanoxin)....................29
digoxin tab 250 mcg (0.25 mg) (Lanoxin)......................29
dihydroergotamine mesylate inj 1 mg/ml (D.h.e.
45)....................................................................................77
DILANTIN-125 – phenytoin susp 125 mg/5ml...................79
DILANTIN INFATABS – phenytoin chew tab 50 mg..........79
DILANTIN – phenytoin sodium extended cap 100 mg.......79
DILANTIN – phenytoin sodium extended cap 30 mg........ 79
diltiazem hcl cap sr 12hr 120 mg...................................31
diltiazem hcl cap sr 12hr 60 mg.................................... 31
diltiazem hcl cap sr 12hr 90 mg.................................... 31
117
2015
diltiazem hcl coated beads cap sr 24hr 120 mg
(Cardizem cd)................................................................. 31
(Cardizem cd)................................................................. 31
(Cardizem cd)................................................................. 31
(Cardizem cd)................................................................. 31
(Cardizem cd)................................................................. 31
diltiazem hcl coated beads tab sr 24hr 180 mg
(Cardizem la).................................................................. 31
(Cardizem la).................................................................. 31
(Cardizem la).................................................................. 31
(Cardizem la).................................................................. 31
(Cardizem la).................................................................. 31
diltiazem hcl extended release beads cap sr 24hr 120
mg (Tiazac).....................................................................31
mg (Tiazac).....................................................................31
mg (Tiazac).....................................................................31
mg (Tiazac).....................................................................31
mg (Tiazac).....................................................................31
mg (Tiazac).....................................................................32
diltiazem hcl tab 120 mg (Cardizem)............................. 32
diltiazem hcl tab 30 mg (Cardizem)............................... 32
diltiazem hcl tab 60 mg (Cardizem)............................... 32
diltiazem hcl tab 90 mg.................................................. 32
DIPENTUM – olsalazine sodium cap 250 mg................... 52
diphenhydramine hcl cap 50 mg................................... 43
diphenhydramine hcl elixir 12.5 mg/5ml....................... 43
DIPHENOXYLATE/ATROPINE – diphenoxylate w/
atropine liq 2.5-0.025 mg/5ml..........................................48
diphenoxylate w/ atropine tab 2.5-0.025 mg
(Lomotil)..........................................................................48
dipyridamole tab 25 mg (Persantine)............................ 89
disopyramide phosphate cap 100 mg (Norpace)..........33
disopyramide phosphate cap 150 mg (Norpace)..........33
disulfiram tab 250 mg (Antabuse)................................. 67
disulfiram tab 500 mg (Antabuse)................................. 67
DIURIL – chlorothiazide susp 250 mg/5ml........................38
divalproex sodium cap sprinkle 125 mg (Depakote
sprinkles)........................................................................ 79
divalproex sodium tab delayed release 125 mg
(Depakote)...................................................................... 79
118
(Depakote)...................................................................... 79
(Depakote)...................................................................... 79
divalproex sodium tab sr 24 hr 250 mg (Depakote
er).................................................................................... 79
divalproex sodium tab sr 24 hr 500 mg (Depakote
er).................................................................................... 79
DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%).......... 17
DIVIGEL – estradiol td gel 0.5 mg/0.5gm (0.1%).............. 17
DIVIGEL – estradiol td gel 1 mg/gm (0.1%)...................... 17
donepezil hydrochloride orally disintegrating tab 10
mg (Aricept odt).............................................................67
donepezil hydrochloride orally disintegrating tab 5
mg....................................................................................67
donepezil hydrochloride tab 10 mg (Aricept)............... 67
donepezil hydrochloride tab 23 mg (Aricept)............... 67
donepezil hydrochloride tab 5 mg (Aricept)................. 67
DORYX – doxycycline hyclate tab delayed release 200
mg...................................................................................... 3
DORYX – doxycycline hyclate tab delayed release 50
mg...................................................................................... 3
dorzolamide hcl ophth soln 2% (Trusopt).....................90
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8
mg/ml (Cosopt).............................................................. 90
doxazosin mesylate tab 1 mg (Cardura)....................... 35
doxepin hcl cap 100 mg................................................. 57
doxepin hcl cap 10 mg................................................... 57
doxepin hcl cap 150 mg................................................. 57
doxepin hcl conc 10 mg/ml............................................ 57
DOXEPIN HCL – doxepin hcl cap 75 mg..........................57
doxercalciferol cap 0.5 mcg (Hectorol)......................... 25
doxercalciferol cap 1 mcg (Hectorol)............................ 25
doxercalciferol cap 2.5 mcg (Hectorol)......................... 25
doxycycline hyclate cap 100 mg (Vibramycin)............... 3
doxycycline hyclate cap 50 mg....................................... 3
doxycycline hyclate tab 100 mg...................................... 3
doxycycline hyclate tab 20 mg........................................ 3
doxycycline hyclate tab delayed release 100 mg........... 3
doxycycline hyclate tab delayed release 150 mg........... 3
doxycycline hyclate tab delayed release 75 mg............. 3
doxycycline monohydrate cap 100 mg (Monodox)........ 3
doxycycline monohydrate cap 150 mg (Adoxa)............. 3
doxycycline monohydrate cap 50 mg............................. 3
doxycycline monohydrate cap 75 mg (Monodox).......... 3
doxycycline monohydrate for susp 25 mg/5ml
(Vibramycin)..................................................................... 3
doxycycline monohydrate tab 100 mg (Adoxa pak
1/100).................................................................................3
doxycycline monohydrate tab 150 mg (Adoxa pak
1/150).................................................................................3
2015
doxycycline monohydrate tab 50 mg (Adoxa)................ 3
doxycycline monohydrate tab 75 mg (Adoxa)................ 3
dronabinol cap 10 mg (Marinol).....................................50
dronabinol cap 2.5 mg (Marinol)....................................50
dronabinol cap 5 mg (Marinol).......................................50
DROXIA – hydroxyurea cap 200 mg.................................86
DUEXIS – ibuprofen-famotidine tab 800-26.6 mg............. 75
DULERA – mometasone furoate-formoterol fumarate
aerosol 100-5 mcg/act..................................................... 46
DULERA – mometasone furoate-formoterol fumarate
aerosol 200-5 mcg/act..................................................... 46
duloxetine hcl enteric coated pellets cap 20 mg
(Cymbalta)...................................................................... 57
(Cymbalta)...................................................................... 57
(Cymbalta)...................................................................... 57
DUTOPROL – metoprolol & hydrochlorothiazide tab sr
24hr 100-12.5 mg............................................................ 35
24hr 25-12.5 mg.............................................................. 35
24hr 50-12.5 mg.............................................................. 35
DYMISTA – azelastine hcl-fluticasone prop nasal spray
137-50 mcg/act................................................................ 44
dyphylline-guaifenesin liqd 100-100 mg/5ml................ 46
DYRENIUM – triamterene cap 100 mg............................. 38
DYRENIUM – triamterene cap 50 mg...............................38
E
E.E.S. 400 – erythromycin ethylsuccinate tab 400 mg........ 2
econazole nitrate cream 1%........................................... 97
EDARBI – azilsartan medoxomil tab 40 mg...................... 35
EDARBI – azilsartan medoxomil tab 80 mg...................... 35
EDARBYCLOR – azilsartan medoxomil-chlorthalidone tab
40-12.5 mg...................................................................... 35
EDARBYCLOR – azilsartan medoxomil-chlorthalidone tab
40-25 mg......................................................................... 35
EDECRIN – ethacrynic acid tab 25 mg.............................38
EDEX – Benefit Limits may apply – alprostadil for inj kit 10
mcg.................................................................................. 42
mcg.................................................................................. 42
mcg.................................................................................. 42
EDLUAR – Benefit Limits may apply – zolpidem tartrate sl
tab 10 mg........................................................................ 62
EDLUAR – Benefit Limits may apply – zolpidem tartrate sl
tab 5 mg.......................................................................... 62
EDURANT – rilpivirine hcl tab 25 mg (base equivalent)...... 6
EFFER-K – potassium bicarbonate-citric acid effer tab 10
meq.................................................................................. 85
EFFER-K – potassium bicarbonate-citric acid effer tab 20
meq.................................................................................. 85
EFFIENT – prasugrel hcl tab 10 mg (base equiv)............. 89
EFFIENT – prasugrel hcl tab 5 mg (base equiv)............... 89
EGRIFTA – tesamorelin acetate for inj 1 mg (base
equiv)............................................................................... 25
EGRIFTA – tesamorelin acetate for inj 2 mg (base
equiv)............................................................................... 25
ELESTRIN – estradiol gel 0.06% (0.52 mg/0.87 gm
metered-dose pump)....................................................... 17
ELETONE – dermatological products misc - cream.......... 97
ELIDEL – pimecrolimus cream 1%................................... 97
ELIGARD – leuprolide acetate (3 month) for subcutaneous
inj kit 22.5mg................................................................... 11
inj kit 30 mg.....................................................................11
inj kit 45 mg.....................................................................11
ELIGARD – leuprolide acetate for subcutaneous inj kit 7.5
mg.................................................................................... 11
ELIPHOS – calcium acetate (phosphate binder) tab 667
mg.................................................................................... 52
ELIQUIS – apixaban tab 2.5 mg....................................... 88
ELIQUIS – apixaban tab 5 mg.......................................... 88
ELIXOPHYLLIN – theophylline elixir 80 mg/15ml..............46
ELLA – ulipristal acetate tab 30 mg.................................. 18
ELMIRON – pentosan polysulfate sodium caps 100
mg.................................................................................... 55
EMCYT – estramustine phosphate sodium cap 140
mg.................................................................................... 11
EMEND – aprepitant capsule 125 mg...............................51
EMEND – aprepitant capsule 40 mg.................................51
EMEND – aprepitant capsule 80 mg.................................51
EMEND – aprepitant capsule therapy pack 80 & 125
mg.................................................................................... 51
EMSAM – selegiline td patch 24hr 12 mg/24hr................. 57
EMSAM – selegiline td patch 24hr 6 mg/24hr...................57
EMSAM – selegiline td patch 24hr 9 mg/24hr...................57
EMTRIVA – emtricitabine caps 200 mg.............................. 6
EMTRIVA – emtricitabine soln 10 mg/ml............................ 6
EMULSION SB – dermatological products misc emulsion...........................................................................97
ENABLEX – darifenacin hydrobromide tab sr 24hr 15 mg
(base equiv).....................................................................54
ENABLEX – darifenacin hydrobromide tab sr 24hr 7.5 mg
(base equiv).....................................................................54
enalapril maleate & hydrochlorothiazide tab 10-25 mg
(Vaseretic).......................................................................35
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg....................................................................................35
enalapril maleate tab 10 mg (Vasotec).......................... 35
enalapril maleate tab 2.5 mg (Vasotec)......................... 35
enalapril maleate tab 20 mg (Vasotec).......................... 35
enalapril maleate tab 5 mg (Vasotec)............................ 35
ENBREL – etanercept for subcutaneous inj kit 25 mg...... 75
ENBREL – etanercept subcutaneous soln prefilled syringe
25 mg/0.5ml.....................................................................75
119
2015
ENBREL – etanercept subcutaneous soln prefilled syringe
50 mg/ml..........................................................................75
ENBREL SURECLICK – etanercept subcutaneous
solution auto-injector 50 mg/ml....................................... 75
ENDOMETRIN – progesterone vaginal insert 100 mg...... 54
ENJUVIA – estrogens, conjugated synthetic b tab 0.3
mg.................................................................................... 17
mg.................................................................................... 17
mg.................................................................................... 17
mg.................................................................................... 17
mg.................................................................................... 17
enoxaparin sodium inj 100 mg/ml (Lovenox)............... 88
enoxaparin sodium inj 120 mg/0.8ml (Lovenox)...........88
enoxaparin sodium inj 150 mg/ml (Lovenox)............... 88
enoxaparin sodium inj 300 mg/3ml (Lovenox)..............88
enoxaparin sodium inj 30 mg/0.3ml (Lovenox).............88
entacapone tab 200 mg (Comtan)..................................82
entecavir tab 0.5 mg (Baraclude).....................................6
entecavir tab 1 mg (Baraclude)........................................6
ENTEREG – alvimopan cap 12 mg.................................. 52
EPIDUO – adapalene-benzoyl peroxide gel 0.1-2.5%.......97
EPIDUO FORTE – adapalene-benzoyl peroxide gel
0.3-2.5%...........................................................................97
epinastine hcl ophth soln 0.05% (Elestat).....................90
EPINEPHRINE – epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)..........................................................39
EPINEPHRINE – epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................39
EPIPEN 2-PAK – epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................39
EPIPEN-JR 2-PAK – epinephrine solution auto-injector
0.15 mg/0.3ml (1:2000)................................................... 39
EPIVIR HBV – lamivudine oral soln 5 mg/ml (hbv)............. 6
EPIVIR HBV – lamivudine tab 100 mg (hbv)...................... 6
EPIVIR – lamivudine oral soln 10 mg/ml.............................6
EPIVIR – lamivudine tab 150 mg........................................6
EPIVIR – lamivudine tab 300 mg........................................6
eplerenone tab 25 mg (Inspra).......................................35
eplerenone tab 50 mg (Inspra).......................................35
EPOGEN – epoetin alfa inj 10000 unit/ml......................... 86
EPOGEN – epoetin alfa inj 20000 unit/ml......................... 86
EPOGEN – epoetin alfa inj 2000 unit/ml...........................86
EPROSARTAN MESYLATE – eprosartan mesylate tab
600 mg.............................................................................35
EPZICOM – abacavir sulfate-lamivudine tab 600-300
mg...................................................................................... 6
120
EQUETRO – carbamazepine (antipsychotic) cap sr 12hr
100 mg.............................................................................60
200 mg.............................................................................60
300 mg.............................................................................60
ergocalciferol cap 50000 unit (Drisdol)......................... 84
ergoloid mesylates tab 1 mg..........................................67
ERIVEDGE – vismodegib cap 150 mg............................. 11
ERTACZO – sertaconazole nitrate cream 2%...................97
ERY-TAB – erythromycin tab delayed release 250 mg....... 2
ERY-TAB – erythromycin tab delayed release 333 mg....... 2
ERYTHROCIN STEARATE – erythromycin stearate tab
250 mg...............................................................................2
ERYTHROMYCIN ETHYLSUCCINA – erythromycin
ethylsuccinate tab 400 mg................................................ 3
erythromycin gel 2% (Erygel).........................................97
erythromycin ophth oint 5 mg/gm................................. 90
erythromycin pads 2%....................................................97
erythromycin soln 2%.....................................................97
erythromycin w/ delayed release particles cap 250
mg......................................................................................3
ESBRIET – pirfenidone cap 267 mg................................. 48
ESCAVITE LQ – pediatric multiple vitamins w/ fl-fe drops
0.25-6 mg/ml....................................................................85
escitalopram oxalate soln 5 mg/5ml (base equiv)
(Lexapro).........................................................................57
escitalopram oxalate tab 10 mg (base equiv)
(Lexapro).........................................................................58
(Lexapro).........................................................................58
(Lexapro).........................................................................57
esomeprazole magnesium cap delayed release 20 mg
(base eq) (Nexium)........................................................ 49
esomeprazole magnesium cap delayed release 40 mg
(base eq) (Nexium)........................................................ 49
estazolam tab 1 mg.........................................................62
estazolam tab 2 mg.........................................................62
esterified estrogens & methyltestosterone tab
0.625-1.25 mg................................................................. 17
esterified estrogens & methyltestosterone tab 1.25-2.5
mg....................................................................................17
estradiol & norethindrone acetate tab 0.5-0.1 mg
(Activella)........................................................................17
estradiol & norethindrone acetate tab 1-0.5 mg
(Activella)........................................................................17
estradiol tab 0.5 mg (Estrace)........................................17
estradiol tab 1 mg (Estrace)...........................................17
estradiol tab 2 mg (Estrace)...........................................17
estradiol td patch twice weekly 0.025 mg/24hr (Vivelledot).................................................................................. 17
estradiol td patch twice weekly 0.0375 mg/24hr
(Vivelle-dot).................................................................... 17
2015
estradiol td patch weekly 0.025 mg/24hr (Climara)...... 17
estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr) (Climara)....................................................... 17
estradiol td patch weekly 0.05 mg/24hr (Climara)........ 17
estradiol td patch weekly 0.06 mg/24hr (Climara)........ 17
estradiol td patch weekly 0.075 mg/24hr (Climara)...... 17
estradiol td patch weekly 0.1 mg/24hr (Climara).......... 17
estradiol valerate im in oil 20 mg/ml (Delestrogen)......17
estradiol valerate im in oil 40 mg/ml (Delestrogen)......17
ESTRING – estradiol vaginal ring 2 mg (7.5
mcg/24hrs)....................................................................... 55
ESTROGEL – estradiol gel 0.06% (0.75 mg/1.25 gm
metered-dose pump)....................................................... 18
ESTROPIPATE – estropipate tab 3 mg............................ 18
estropipate tab 0.75 mg..................................................18
estropipate tab 1.5 mg....................................................18
eszopiclone tab 1 mg – Benefit Limits may apply
(Lunesta).........................................................................62
(Lunesta).........................................................................63
(Lunesta).........................................................................63
ethambutol hcl tab 100 mg (Myambutol)........................ 4
ethambutol hcl tab 400 mg (Myambutol)........................ 4
ethosuximide cap 250 mg (Zarontin).............................79
ethosuximide soln 250 mg/5ml (Zarontin).................... 79
ETIDRONATE DISODIUM – etidronate disodium tab 200
mg.................................................................................... 25
ETIDRONATE DISODIUM – etidronate disodium tab 400
mg.................................................................................... 25
etodolac cap 200 mg.......................................................75
etodolac cap 300 mg.......................................................75
etodolac tab 400 mg....................................................... 75
etodolac tab 500 mg....................................................... 75
etodolac tab sr 24hr 400 mg.......................................... 75
ETOPOSIDE – etoposide cap 50 mg................................11
EURAX – crotamiton cream 10%......................................97
EURAX – crotamiton lotion 10%....................................... 97
EVAMIST – estradiol transdermal spray 1.53 mg/
spray................................................................................ 18
EVOTAZ – atazanavir sulfate-cobicistat tab 300-150 mg
(base equiv).......................................................................6
EXALGO – hydromorphone hcl tab er 24hr deter 12
mg.................................................................................... 71
mg.................................................................................... 71
mg.................................................................................... 71
EXALGO – hydromorphone hcl tab er 24hr deter 8 mg.....71
EXELDERM – sulconazole nitrate cream 1%................... 97
EXELDERM – sulconazole nitrate solution 1%................. 97
EXELON – rivastigmine td patch 24hr 13.3 mg/24hr.........67
EXELON – rivastigmine td patch 24hr 4.6 mg/24hr...........67
EXELON – rivastigmine td patch 24hr 9.5 mg/24hr...........67
exemestane tab 25 mg (Aromasin)................................11
EXJADE – deferasirox tab for oral susp 125 mg.............102
EXODERM – sodium thiosulfate-salicylic acid lotion
25-1%...............................................................................97
EXTAVIA – interferon beta-1b for inj kit 0.3 mg................ 67
F
FACTIVE – gemifloxacin mesylate tab 320 mg (base
equiv)................................................................................. 4
famciclovir tab 125 mg (Famvir)...................................... 6
famotidine for susp 40 mg/5ml (Pepcid)....................... 49
famotidine tab 20 mg – is not covered, it is available
OTC (Pepcid).................................................................. 49
famotidine tab 40 mg (Pepcid).......................................49
FANAPT – iloperidone tab 10 mg..................................... 60
FANAPT – iloperidone tab 12 mg..................................... 60
FANAPT – iloperidone tab 1 mg....................................... 60
FANAPT TITRATION PACK – iloperidone tab 1 mg & 2
mg & 4 mg & 6 mg titration pak...................................... 60
FARESTON – toremifene citrate tab 60 mg (base
equivalent)....................................................................... 11
FARYDAK – panobinostat lactate cap 10 mg (base
equivalent)....................................................................... 11
equivalent)....................................................................... 11
equivalent)....................................................................... 11
FASLODEX – fulvestrant inj 250 mg/5ml.......................... 11
FAZACLO – clozapine orally disintegrating tab 100
mg.................................................................................... 60
FAZACLO – clozapine orally disintegrating tab 12.5
mg.................................................................................... 60
mg.................................................................................... 60
mg.................................................................................... 60
FAZACLO – clozapine orally disintegrating tab 25 mg...... 60
fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1
mg....................................................................................86
fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240
mg....................................................................................86
fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu
cap (Tandem plus).........................................................86
felbamate susp 600 mg/5ml (Felbatol).......................... 79
121
2015
felbamate tab 400 mg (Felbatol).................................... 79
felbamate tab 600 mg (Felbatol).................................... 79
felodipine tab sr 24hr 10 mg.......................................... 32
felodipine tab sr 24hr 2.5 mg......................................... 32
felodipine tab sr 24hr 5 mg............................................32
FEM PH – acetic acid-oxyquinoline vaginal gel
0.9-0.025%.......................................................................55
FEMRING – estradiol acetate vaginal ring 0.05
mg/24hr............................................................................55
FEMRING – estradiol acetate vaginal ring 0.1
mg/24hr............................................................................55
fenofibrate micronized cap 130 mg............................... 40
fenofibrate micronized cap 134 mg (Lofibra)................40
fenofibrate micronized cap 200 mg (Lofibra)................40
fenofibrate micronized cap 43 mg................................. 40
fenofibrate micronized cap 67 mg (Lofibra)..................40
fenofibrate tab 145 mg (Tricor)...................................... 40
fenofibrate tab 160 mg (Lofibra).................................... 40
fenofibrate tab 48 mg (Tricor)........................................ 40
fenofibrate tab 54 mg (Lofibra)...................................... 40
FENOFIBRIC ACID – fenofibric acid tab 105 mg..............40
FENOFIBRIC ACID – fenofibric acid tab 35 mg................40
FENOGLIDE – fenofibrate tab 120 mg............................. 40
FENOGLIDE – fenofibrate tab 40 mg............................... 40
FENOPROFEN CALCIUM – fenoprofen calcium tab 600
mg.................................................................................... 75
fentanyl citrate lozenge on a handle 1200 mcg
(Actiq)..............................................................................71
(Actiq)..............................................................................71
(Actiq)..............................................................................71
(Actiq)..............................................................................71
(Actiq)..............................................................................71
(Actiq)..............................................................................71
fentanyl td patch 72hr 100 mcg/hr (Duragesic)............ 71
fentanyl td patch 72hr 12 mcg/hr (Duragesic).............. 71
FENTORA – fentanyl citrate buccal tab 100 mcg (base
equiv)............................................................................... 71
equiv)............................................................................... 71
equiv)............................................................................... 71
equiv)............................................................................... 71
equiv)............................................................................... 71
FERRAPLUS 90 – iron-folic acid-vit b12-vit c-docusate
sod tab 90-1 mg.............................................................. 86
122
FERREX 150 FORTE PLUS – fe asp gly-fe polysacchsucc ac-c-threon ac-b12-fa cap.......................................86
FERREX 28 – fe asparto gly-fe fum-b12-fa-c-succinic ac
tab ther pack................................................................... 86
FERRIPROX – deferiprone tab 500 mg.......................... 102
ferrous fumarate-folic acid tab 324-1 mg...................... 86
FETZIMA – levomilnacipran hcl cap sr 24hr 120 mg (base
equivalent)....................................................................... 58
equivalent)....................................................................... 58
equivalent)....................................................................... 58
equivalent)....................................................................... 58
FETZIMA TITRATION PACK – levomilnacipran hcl cap sr
24hr 20 & 40 mg therapy pack........................................58
FINACEA – azelaic acid foam 15%.................................. 97
FINACEA – azelaic acid gel 15%..................................... 97
finasteride tab 5 mg (Proscar)....................................... 55
FIRAZYR – icatibant acetate inj 30 mg/3ml (base
equivalent)....................................................................... 89
flavoxate hcl tab 100 mg................................................ 54
flecainide acetate tab 100 mg........................................ 33
flecainide acetate tab 150 mg........................................ 33
flecainide acetate tab 50 mg.......................................... 33
FLECTOR – diclofenac epolamine patch 1.3%.................97
FLOVENT DISKUS – fluticasone propionate aer pow ba
100 mcg/blister................................................................ 46
250 mcg/blister................................................................ 46
50 mcg/blister.................................................................. 46
FLOVENT HFA – fluticasone propionate hfa inhal aer 110
mcg/act (125/valve)......................................................... 46
FLOVENT HFA – fluticasone propionate hfa inhal aer 220
mcg/act (250/valve)......................................................... 46
FLOVENT HFA – fluticasone propionate hfa inhal aero 44
mcg/act (50/valve)........................................................... 46
fluconazole for susp 10 mg/ml (Diflucan)....................... 4
fluconazole for susp 40 mg/ml (Diflucan)....................... 4
fluconazole tab 100 mg (Diflucan)................................... 4
fluconazole tab 50 mg (Diflucan).....................................4
flucytosine cap 250 mg (Ancobon)..................................4
flucytosine cap 500 mg (Ancobon)..................................5
fludrocortisone acetate tab 0.1 mg................................15
FLUNISOLIDE – flunisolide nasal soln 25 mcg/act
(0.025%).......................................................................... 44
flunisolide nasal soln 25 mcg/act (0.025%)
(Flunisolide)....................................................................44
fluocinolone acetonide (otic) oil 0.01% (Dermotic)...... 93
fluocinolone acetonide cream 0.01%............................ 97
fluocinolone acetonide cream 0.025% (Synalar).......... 97
fluocinolone acetonide oil 0.01% (body oil) (Dermasmoothe/fs bod).............................................................97
2015
fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca)............................................................. 97
fluocinolone acetonide oint 0.025% (Synalar).............. 97
fluocinolone acetonide soln 0.01% (Synalar)............... 97
fluocinonide cream 0.05%.............................................. 97
fluocinonide cream 0.1% (Vanos).................................. 97
fluocinonide emulsified base cream 0.05%.................. 97
fluocinonide gel 0.05%................................................... 97
fluocinonide oint 0.05%.................................................. 97
fluocinonide soln 0.05%................................................. 97
fluorometholone ophth susp 0.1% (Fml liquifilm)........ 91
FLUOROPLEX – fluorouracil cream 1%........................... 97
fluorouracil cream 5% (Efudex)..................................... 97
fluorouracil soln 2%........................................................97
fluorouracil soln 5%........................................................97
fluoxetine hcl (pmdd) cap 10 mg................................... 67
fluoxetine hcl (pmdd) cap 20 mg................................... 67
fluoxetine hcl cap 10 mg (Prozac)................................. 58
fluoxetine hcl cap delayed release 90 mg (Prozac
weekly)............................................................................ 58
FLUOXETINE HCL – fluoxetine hcl tab 60 mg................. 58
fluoxetine hcl solution 20 mg/5ml................................. 58
fluoxetine hcl tab 10 mg.................................................58
fluoxetine hcl tab 20 mg.................................................58
FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5
mg/5ml............................................................................. 60
FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/
ml..................................................................................... 60
fluphenazine hcl tab 10 mg............................................ 60
fluphenazine hcl tab 1 mg..............................................60
fluphenazine hcl tab 2.5 mg........................................... 60
fluphenazine hcl tab 5 mg..............................................60
FLURAZEPAM HCL – flurazepam hcl cap 15 mg............. 63
FLURAZEPAM HCL – flurazepam hcl cap 30 mg............. 63
flurbiprofen sodium ophth soln 0.03% (Ocufen).......... 91
flurbiprofen tab 100 mg.................................................. 75
flurbiprofen tab 50 mg.................................................... 75
flutamide cap 125 mg..................................................... 11
fluticasone propionate cream 0.05% (Cutivate)............97
fluticasone propionate lotion 0.05% (Cutivate)............ 97
fluticasone propionate nasal susp 50 mcg/act
(Flonase)......................................................................... 44
fluticasone propionate oint 0.005% (Cutivate)..............97
fluvastatin sodium cap 20 mg (Lescol)......................... 40
fluvastatin sodium cap 40 mg (Lescol)......................... 40
fluvoxamine maleate cap sr 24hr 100 mg (Luvox
cr).................................................................................... 58
fluvoxamine maleate cap sr 24hr 150 mg..................... 58
fluvoxamine maleate tab 100 mg................................... 58
fluvoxamine maleate tab 25 mg.....................................58
fluvoxamine maleate tab 50 mg.....................................58
FOCALIN XR – dexmethylphenidate hcl cap sr 24 hr 10
mg.................................................................................... 65
mg.................................................................................... 65
mg.................................................................................... 65
mg.................................................................................... 65
mg.................................................................................... 65
mg.................................................................................... 65
mg.................................................................................... 65
mg.................................................................................... 65
folic acid tab 1 mg.......................................................... 87
folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg..... 87
folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg
(Folgard rx).....................................................................87
FOLIVANE-F – fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe)...................................... 87
FOLIVANE-PLUS – fe fum-iron polysacch complex-fa-b
complex-c-biotin cap........................................................87
FOLLISTIM AQ – Benefit Limits may apply – follitropin
beta inj 300 unit/0.36ml................................................... 25
beta inj 600 unit/0.72ml................................................... 25
beta inj 75 unit/0.5ml....................................................... 25
beta inj 900 unit/1.08ml................................................... 25
FOLTRATE – cobalamine combination tab.......................87
fondaparinux sodium subcutaneous inj 10 mg/0.8ml
(Arixtra)........................................................................... 88
fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml
(Arixtra)........................................................................... 88
fondaparinux sodium subcutaneous inj 5 mg/0.4ml
(Arixtra)........................................................................... 88
fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml
(Arixtra)........................................................................... 88
FORADIL AEROLIZER – formoterol fumarate inhal cap 12
mcg.................................................................................. 46
FORANE – isoflurane inhal soln....................................... 78
formaldehyde solution 10%..........................................102
FORMA-RAY – formaldehyde solution 20%................... 102
FORTEO – teriparatide (recombinant) inj 600
mcg/2.4ml........................................................................ 25
FORTESTA – testosterone td gel 10mg/act (2%)............. 16
FORTICAL – calcitonin (salmon) nasal soln 200 unit/
act.................................................................................... 25
FOSAMAX PLUS D – alendronate sodium-cholecalciferol
tab 70-2800 mg-unit........................................................ 25
FOSAMAX PLUS D – alendronate sodium-cholecalciferol
tab 70-5600 mg-unit........................................................ 25
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg....................................................................................35
123
2015
fosinopril sodium & hydrochlorothiazide tab 20-12.5
mg....................................................................................35
fosinopril sodium tab 10 mg.......................................... 35
FOSRENOL – lanthanum carbonate chew tab 1000 mg
(elemental)....................................................................... 52
(elemental)....................................................................... 52
(elemental)....................................................................... 52
FRAGMIN – dalteparin sodium inj 10000 unit/ml.............. 88
FRAGMIN – dalteparin sodium inj 12500 unit/0.5ml......... 88
FRAGMIN – dalteparin sodium inj 18000 unit/0.72ml....... 88
FRAGMIN – dalteparin sodium inj 2500 unit/0.2ml........... 88
FRAGMIN – dalteparin sodium inj 5000 unit/0.2ml........... 88
FROVA – frovatriptan succinate tab 2.5 mg (base
equivalent)....................................................................... 77
FULYZAQ – crofelemer tab delayed release 125 mg........48
FUROSEMIDE – furosemide oral soln 8 mg/ml................ 38
furosemide oral soln 10 mg/ml...................................... 38
furosemide tab 20 mg (Lasix)........................................ 38
FUZEON – enfuvirtide for inj 90 mg....................................6
G
gabapentin cap 100 mg (Neurontin).............................. 79
gabapentin oral soln 250 mg/5ml (Neurontin).............. 80
gabapentin tab 600 mg (Neurontin)...............................80
gabapentin tab 800 mg (Neurontin)...............................80
GABITRIL – tiagabine hcl tab 12 mg................................ 80
GABITRIL – tiagabine hcl tab 16 mg................................ 80
galantamine hydrobromide cap sr 24hr 16 mg
(Razadyne er)................................................................. 67
(Razadyne er)................................................................. 67
(Razadyne er)................................................................. 67
GALANTAMINE HYDROBROMIDE – galantamine
hydrobromide oral soln 4 mg/ml...................................... 67
galantamine hydrobromide tab 12 mg (Razadyne).......67
galantamine hydrobromide tab 4 mg (Razadyne)........ 67
galantamine hydrobromide tab 8 mg (Razadyne)........ 67
GANIRELIX ACETATE – Benefit Limits may apply –
ganirelix acetate inj 250 mcg/0.5ml................................. 25
GASTRINEX NF – hyoscyamine-phenyltoloxamine cap
0.0625-15 mg.................................................................. 49
GASTROCROM – cromolyn sodium oral conc 100
mg/5ml............................................................................. 52
gatifloxacin ophth soln 0.5% (Zymaxid)........................91
GATTEX – teduglutide (rdna) for inj kit 5 mg.................... 53
124
GELNIQUE – oxybutynin chloride td gel 10%................... 54
GELNIQUE – oxybutynin td gel 3% (28 mg/act metereddose pump)......................................................................54
gemfibrozil tab 600 mg (Lopid)......................................40
GENOTROPIN MINIQUICK – somatropin for inj 0.2
mg.................................................................................... 25
mg.................................................................................... 25
mg.................................................................................... 25
mg.................................................................................... 25
mg.................................................................................... 26
mg.................................................................................... 26
mg.................................................................................... 26
mg.................................................................................... 26
GENOTROPIN MINIQUICK – somatropin for inj 1 mg...... 25
GENOTROPIN MINIQUICK – somatropin for inj 2 mg...... 26
GENOTROPIN – somatropin for inj 12 mg (13.8 mg
overfill)............................................................................. 25
GENOTROPIN – somatropin for subcutaneous inj 5
mg.................................................................................... 25
GENTAMICIN SULFATE – gentamicin sulfate cream
0.1%.................................................................................97
GENTAMICIN SULFATE – gentamicin sulfate oint
0.1%.................................................................................97
gentamicin sulfate ophth oint 0.3%...............................91
gentamicin sulfate ophth soln 0.3% (Garamycin)........ 91
GIAZO – balsalazide disodium tab 1.1 gm........................53
GILENYA – fingolimod hcl cap 0.5 mg (base equiv)......... 67
GILOTRIF – afatinib dimaleate tab 20 mg (base
equivalent)....................................................................... 11
equivalent)....................................................................... 11
equivalent)....................................................................... 11
glatiramer acetate soln prefilled syringe 20 mg/ml
(Copaxone)..................................................................... 68
GLEEVEC – imatinib mesylate tab 100 mg (base
equivalent)....................................................................... 11
GLEEVEC – imatinib mesylate tab 400 mg (base
equivalent)....................................................................... 11
GLEOSTINE – lomustine cap 100 mg.............................. 11
GLEOSTINE – lomustine cap 10 mg................................ 11
GLEOSTINE – lomustine cap 40 mg................................ 11
glimepiride tab 1 mg (Amaryl)....................................... 19
glipizide-metformin hcl tab 2.5-250 mg......................... 19
glipizide-metformin hcl tab 2.5-500 mg......................... 19
glipizide-metformin hcl tab 5-500 mg............................ 19
glipizide tab 10 mg (Glucotrol)...................................... 19
2015
glipizide tab 5 mg (Glucotrol)........................................ 19
glipizide tab sr 24hr 10 mg (Glucotrol xl)......................19
glipizide tab sr 24hr 2.5 mg (Glucotrol xl).....................19
glipizide tab sr 24hr 5 mg (Glucotrol xl)....................... 19
GLUCAGEN HYPOKIT – glucagon hcl (rdna) for inj 1 mg
(base equiv).....................................................................19
GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj
kit 1 mg............................................................................19
GLUCOSE BLOOD TEST STRIPS – VARIOUS............. 103
GLUMETZA – metformin hcl tab sr 24hr modified release
1000 mg...........................................................................19
GLUMETZA – metformin hcl tab sr 24hr modified release
500 mg.............................................................................19
GLYBURIDE – glyburide tab 1.25 mg...............................20
GLYBURIDE – glyburide tab 2.5 mg.................................20
GLYBURIDE – glyburide tab 5 mg................................... 20
glyburide-metformin tab 1.25-250 mg
(Glucovance).................................................................. 20
glyburide-metformin tab 2.5-500 mg (Glucovance)...... 20
glyburide-metformin tab 5-500 mg (Glucovance)......... 20
glyburide micronized tab 1.5 mg (Glynase).................. 20
glyburide micronized tab 3 mg (Glynase)..................... 20
glyburide micronized tab 6 mg (Glynase)..................... 20
glyburide tab 1.25 mg..................................................... 20
glyburide tab 2.5 mg....................................................... 20
glyburide tab 5 mg..........................................................20
glycine irrigation soln 1.5%............................................55
glycopyrrolate tab 1 mg (Robinul).................................49
glycopyrrolate tab 2 mg (Robinul forte)........................49
GLYSET – miglitol tab 100 mg......................................... 20
GLYSET – miglitol tab 25 mg........................................... 20
GLYSET – miglitol tab 50 mg........................................... 20
GONAL-F – Benefit Limits may apply – follitropin alfa for
inj 1050 unit..................................................................... 26
GONAL-F – Benefit Limits may apply – follitropin alfa for
inj 450 unit.......................................................................26
GONAL-F RFF – Benefit Limits may apply – follitropin alfa
for inj 75 unit................................................................... 26
GONAL-F RFF PEN – Benefit Limits may apply –
follitropin alfa inj 300 unit/0.5ml.......................................26
follitropin alfa inj 450 unit/0.75ml..................................... 26
GONAL-F RFF REDIJECT – Benefit Limits may apply –
follitropin alfa inj 450 unit/0.75ml..................................... 26
GRALISE – gabapentin (phn) tab 300 mg........................ 68
GRALISE – gabapentin (phn) tab 600 mg........................ 68
granisetron hcl tab 1 mg................................................ 51
GRANIX – tbo-filgrastim soln prefilled syringe 300
mcg/0.5ml........................................................................ 87
GRANIX – tbo-filgrastim soln prefilled syringe 480
mcg/0.8ml........................................................................ 87
griseofulvin microsize susp 125 mg/5ml........................ 5
griseofulvin microsize tab 500 mg (Grifulvin v)............. 5
griseofulvin ultramicrosize tab 125 mg (Gris-peg)......... 5
griseofulvin ultramicrosize tab 250 mg (Gris-peg)......... 5
guanfacine hcl tab 1 mg (Tenex)................................... 36
guanfacine hcl tab 2 mg (Tenex)................................... 36
guanfacine hcl tab sr 24hr 1 mg (base equiv)
(Intuniv)...........................................................................65
(Intuniv)...........................................................................65
(Intuniv)...........................................................................65
(Intuniv)...........................................................................65
GYNAZOLE-1 – butoconazole nitrate (one dose) vaginal
cream 2%........................................................................ 55
H
H.P. ACTHAR – corticotropin inj gel 80 unit/ml................. 26
HALAC – halobetasol prop oint 0.05% & ammonium
lactate lot 12% kit............................................................ 97
halobetasol propionate cream 0.05% (Ultravate)......... 97
halobetasol propionate oint 0.05% (Ultravate)............. 97
haloperidol lactate oral conc 2 mg/ml...........................61
haloperidol tab 0.5 mg....................................................61
haloperidol tab 10 mg.....................................................61
haloperidol tab 1 mg.......................................................61
haloperidol tab 20 mg.....................................................61
HARVONI – ledipasvir-sofosbuvir tab 90-400 mg............... 6
hc-pramoxine emol cream 2.5-1% & pramoxine wipe
1% kit (Analpram e).......................................................94
HEMATOGEN FA – fe fumarate-vit c-vit b12-fa cap
200-250-0.01-1 mg.......................................................... 87
HEPARIN SODIUM/SODIUM CHL – heparin sodium
(porcine) 2 unit/ml in sodium chloride 0.9%.................... 89
heparin sodium (porcine) 2 unit/ml in sodium chloride
0.9% (Heparin sodium/sodiu)....................................... 89
HEPSERA – adefovir dipivoxil tab 10 mg........................... 6
HETLIOZ – tasimelteon capsule 20 mg............................ 63
HEXALEN – altretamine cap 50 mg..................................11
homatropine hbr ophth soln 5% (Isopto
homatropine).................................................................. 91
HORIZANT – gabapentin enacarbil tab cr 300 mg............68
HORIZANT – gabapentin enacarbil tab cr 600 mg............68
HUMALOG – insulin lispro (human) inj 100 unit/ml........... 22
HUMALOG – insulin lispro (human) soln cartridge 100
unit/ml.............................................................................. 21
HUMALOG KWIKPEN – insulin lispro (human) soln peninjector 100 unit/ml.......................................................... 22
HUMALOG KWIKPEN – insulin lispro (human) soln peninjector 200 unit/ml.......................................................... 22
125
2015
HUMALOG MIX 50/50 – insulin lispro prot & lispro
(human) inj 100 unit/ml (50-50)....................................... 22
HUMALOG MIX 50/50 KWIKPEN – insulin lispro prot &
lispro sus pen-inj 100 unit/ml (50-50).............................. 22
HUMALOG MIX 75/25 – insulin lispro prot & lispro
(human) inj 100 unit/ml (75-25)....................................... 22
HUMALOG MIX 75/25 KWIKPEN – insulin lispro prot &
lispro sus pen-inj 100 unit/ml (75-25).............................. 22
HUMATROPE COMBO PACK – somatropin for inj 5
mg.................................................................................... 26
HUMATROPE – somatropin for inj 12 mg (36 unit)...........26
HUMATROPE – somatropin for inj 24 mg.........................26
HUMATROPE – somatropin for inj 5 mg.......................... 26
HUMATROPE – somatropin for inj 6 mg (18 unit).............26
HUMIRA – adalimumab prefilled syringe kit 10
mg/0.2ml.......................................................................... 76
mg/0.4ml.......................................................................... 76
mg/0.8ml.......................................................................... 76
HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled
syringe kit 40 mg/0.8ml................................................... 76
HUMIRA PEN – adalimumab pen-injector kit 40
mg/0.8ml.......................................................................... 76
HUMIRA PEN-CROHNS DISEASE – adalimumab peninjector kit 40 mg/0.8ml................................................... 76
HUMIRA PEN-PSORIASIS STAR – adalimumab peninjector kit 40 mg/0.8ml................................................... 76
HUMULIN 70/30 – insulin nph isophane & regular human
inj 100 unit/ml (70-30)..................................................... 22
HUMULIN 70/30 KWIKPEN – insulin nph & regular susp
pen-inj 100 unit/ml (70-30).............................................. 22
HUMULIN 70/30 PEN – insulin nph & regular susp pen-inj
100 unit/ml (70-30).......................................................... 22
HUMULIN N – insulin nph (human) (isophane) inj 100 unit/
ml..................................................................................... 22
HUMULIN N KWIKPEN – insulin nph (human) (isophane)
susp pen-injector 100 unit/ml.......................................... 22
HUMULIN N U-100 PEN – insulin nph (human) (isophane)
susp pen-injector 100 unit/ml.......................................... 22
HUMULIN R – insulin regular (human) inj 100 unit/ml.......22
HUMULIN R U-500 (CONCENTR – insulin regular
(human) inj 500 unit/ml....................................................22
hyaluronate sodium (emollient) gel 0.2% (Hylira)........ 97
hydralazine hcl tab 100 mg............................................ 36
hydralazine hcl tab 10 mg.............................................. 36
HYDREA – hydroxyurea cap 500 mg............................... 12
hydrochlorothiazide cap 12.5 mg (Microzide)...............38
hydrochlorothiazide tab 12.5 mg................................... 38
hydrochlorothiazide tab 25 mg...................................... 38
hydrochlorothiazide tab 50 mg...................................... 39
HYDROCODONE/ACETAMINOPHEN – hydrocodoneacetaminophen soln 10-325 mg/15ml............................. 71
126
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
(Hycet).............................................................................71
hydrocodone-acetaminophen tab 10-300 mg
(Xodol).............................................................................71
(Norco)............................................................................ 71
hydrocodone-acetaminophen tab 2.5-325 mg.............. 71
(Xodol).............................................................................71
(Norco)............................................................................ 71
hydrocodone-acetaminophen tab 7.5-300 mg
(Xodol).............................................................................71
hydrocodone-acetaminophen tab 7.5-325 mg
(Norco)............................................................................ 71
hydrocodone-ibuprofen tab 10-200 mg (Ibudone)........71
hydrocodone-ibuprofen tab 2.5-200 mg
(Reprexain)..................................................................... 71
hydrocodone-ibuprofen tab 5-200 mg (Reprexain)...... 71
hydrocodone-ibuprofen tab 7.5-200 mg
(Vicoprofen)....................................................................71
hydrocodone w/ homatropine syrup 5-1.5 mg/5ml.......44
hydrocodone w/ homatropine tab 5-1.5 mg.................. 44
hydrocod polst-chlorphen polst cr susp 10-8 mg/5ml
(Tussionex pennkineti)..................................................44
hydrocortisone acetate suppos 25 mg (Anusol-hc)..... 94
hydrocortisone acetate suppos 30 mg
(Proctocort).................................................................... 94
hydrocortisone acetate w/ pramoxine rectal cream
1-1% (Analpram-hc)....................................................... 94
hydrocortisone acetate w/ pramoxine rectal cream
2.5-1% (Analpram-hc).................................................... 94
hydrocortisone butyrate cream 0.1% (Locoid)............. 97
hydrocortisone butyrate hydrophilic lipo base cream
0.1% (Locoid lipocream)............................................... 98
hydrocortisone butyrate oint 0.1% (Locoid)................. 98
hydrocortisone butyrate soln 0.1% (Locoid)................ 98
hydrocortisone cream 1%.............................................. 98
hydrocortisone cream 2.5%........................................... 98
hydrocortisone enema 100 mg/60ml (Cortenema)....... 94
hydrocortisone lotion 2.5%............................................ 98
hydrocortisone lotion 2% (Ala scalp)............................ 98
hydrocortisone oint 1%.................................................. 98
hydrocortisone oint 2.5%............................................... 98
hydrocortisone rectal cream 1% (Proctocort).............. 94
hydrocortisone rectal cream 2.5% (Anusol-hc)............ 94
hydrocortisone tab 10 mg (Cortef)................................ 15
hydrocortisone tab 20 mg (Cortef)................................ 15
hydrocortisone tab 5 mg (Cortef).................................. 15
hydrocortisone valerate cream 0.2%.............................98
hydrocortisone valerate oint 0.2% (Westcort).............. 98
hydrocortisone w/ acetic acid otic soln 1-2%...............93
HYDROGEN PEROXIDE – hydrogen peroxide soln
30%................................................................................102
HYDROMORPHONE HCL – hydromorphone hcl suppos 3
mg.................................................................................... 71
2015
hydromorphone hcl liqd 1 mg/ml (Dilaudid)................. 71
hydromorphone hcl tab 2 mg (Dilaudid)....................... 72
hydromorphone hcl tab er 24hr deter 12 mg
(Exalgo)...........................................................................72
(Exalgo)...........................................................................72
(Exalgo)...........................................................................72
HYDROXOCOBALAMIN – hydroxocobalamin inj 1000
mcg/ml............................................................................. 87
hydroxychloroquine sulfate tab 200 mg
(Plaquenil).......................................................................10
hydroxyurea cap 500 mg (Hydrea)................................ 12
hydroxyzine hcl syrup 10 mg/5ml..................................56
hydroxyzine hcl tab 10 mg.............................................56
hydroxyzine pamoate cap 25 mg (Vistaril)....................56
hydroxyzine pamoate cap 50 mg (Vistaril)....................56
HYDROXYZINE PAMOATE – hydroxyzine pamoate cap
100 mg.............................................................................56
hyoscyamine sulfate elixir 0.125 mg/5ml...................... 49
hyoscyamine sulfate soln 0.125 mg/ml......................... 49
hyoscyamine sulfate tab 0.125 mg (Levsin)................. 49
hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)...... 49
hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl)..........49
hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid).....49
I
ibandronate sodium tab 150 mg (base equivalent)
(Boniva)...........................................................................26
IBRANCE – palbociclib cap 100 mg................................. 12
IBRANCE – palbociclib cap 125 mg................................. 12
IBRANCE – palbociclib cap 75 mg................................... 12
ibuprofen susp 100 mg/5ml............................................76
ibuprofen tab 400 mg......................................................76
ibuprofen tab 600 mg......................................................76
ibuprofen tab 800 mg......................................................76
ICLUSIG – ponatinib hcl tab 15 mg (base equiv).............. 12
ICLUSIG – ponatinib hcl tab 45 mg (base equiv).............. 12
ILEVRO – nepafenac ophth susp 0.3%............................ 91
IMBRUVICA – ibrutinib cap 140 mg..................................12
imipramine hcl tab 10 mg (Tofranil).............................. 58
imipramine pamoate cap 100 mg (Tofranil-pm)............58
imipramine pamoate cap 75 mg (Tofranil-pm)..............58
imiquimod cream 5% (Aldara)........................................98
INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml)........ 26
indapamide tab 1.25 mg................................................. 39
indapamide tab 2.5 mg................................................... 39
indomethacin cap 25 mg................................................ 76
indomethacin cap 50 mg................................................ 76
indomethacin cap cr 75 mg........................................... 76
INLYTA – axitinib tab 1 mg...............................................12
INLYTA – axitinib tab 5 mg...............................................12
INNOPRAN XL – propranolol hcl sustained-release beads
cap sr 24hr 120 mg.........................................................30
INNOPRAN XL – propranolol hcl sustained-release beads
cap sr 24hr 80 mg...........................................................30
INTELENCE – etravirine tab 100 mg.................................. 6
INTELENCE – etravirine tab 200 mg.................................. 6
INTELENCE – etravirine tab 25 mg.................................... 6
INTERMEZZO – Benefit Limits may apply – zolpidem
tartrate sl tab 1.75 mg..................................................... 63
INTERMEZZO – Benefit Limits may apply – zolpidem
tartrate sl tab 3.5 mg.......................................................63
INTRON A – interferon alfa-2b for inj 10000000 unit.........12
INTRON A – interferon alfa-2b inj 10000000 unit/ml......... 12
INTRON A – interferon alfa-2b inj 6000000 unit/ml........... 12
INTRON A W/DILUENT – interferon alfa-2b for inj
10000000 unit..................................................................12
18000000 unit..................................................................12
50000000 unit..................................................................12
INTUNIV – guanfacine hcl tab sr 24hr 1 mg (base
equiv)............................................................................... 65
equiv)............................................................................... 65
equiv)............................................................................... 65
equiv)............................................................................... 65
INVEGA – paliperidone tab sr 24hr 1.5 mg.......................61
INVEGA – paliperidone tab sr 24hr 3 mg..........................61
INVIRASE – saquinavir mesylate cap 200 mg.................... 6
INVIRASE – saquinavir mesylate tab 500 mg.....................6
INVOKAMET – canagliflozin-metformin hcl tab 150-1000
mg.................................................................................... 20
mg.................................................................................... 20
mg.................................................................................... 20
mg.................................................................................... 20
INVOKANA – canagliflozin tab 100 mg.............................20
INVOKANA – canagliflozin tab 300 mg.............................20
IODINE STRONG – iodine solution strong 5%
(lugol's).............................................................................85
iodoquinol-hc cream 1%.................................................98
iodoquinol-hydrocortisone in aloe vehicle cream
1-1.9% (Vytone).............................................................. 98
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml...... 47
127
2015
ipratropium bromide inhal soln 0.02%.......................... 46
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
(Atrovent)........................................................................44
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
(Atrovent)........................................................................44
IPRIVASK – desirudin for inj 15 mg..................................89
irbesartan-hydrochlorothiazide tab 150-12.5 mg
(Avalide)..........................................................................36
irbesartan-hydrochlorothiazide tab 300-12.5 mg
(Avalide)..........................................................................36
irbesartan tab 150 mg (Avapro)..................................... 36
irbesartan tab 300 mg (Avapro)..................................... 36
irbesartan tab 75 mg (Avapro)....................................... 36
IRESSA – gefitinib tab 250 mg......................................... 12
iron combination cap......................................................87
iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1
mg (Hematron-af)...........................................................87
iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg
(Corvite 150)................................................................... 87
iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg
(Icar-c plus).................................................................... 87
irrigation solution, physiological ................................103
ISENTRESS – raltegravir potassium chew tab 100 mg
(base equiv).......................................................................6
ISENTRESS – raltegravir potassium chew tab 25 mg
(base equiv).......................................................................6
ISENTRESS – raltegravir potassium packet for susp 100
mg (base equiv).................................................................6
ISENTRESS – raltegravir potassium tab 400 mg (base
equiv)................................................................................. 6
isoflurane inhal soln (Forane)........................................78
isometheptene-caffeine-acetaminophen tab 65-20-325
mg (Prodrin)................................................................... 78
isoniazid tab 100 mg.........................................................4
isoniazid tab 300 mg.........................................................4
ISOPTO CARBACHOL – carbachol ophth soln 1.5%....... 91
ISOPTO CARBACHOL – carbachol ophth soln 3%.......... 91
ISOPTO HYOSCINE – scopolamine hbr ophth soln
0.25%...............................................................................91
ISOSORBIDE DINITRATE – isosorbide dinitrate tab 30
mg.................................................................................... 29
isosorbide dinitrate tab 10 mg.......................................29
isosorbide dinitrate tab 20 mg.......................................29
isosorbide dinitrate tab 5 mg (Isordil titradose)........... 29
isosorbide dinitrate tab cr 40 mg.................................. 29
isosorbide mononitrate tab 10 mg................................ 29
isosorbide mononitrate tab 20 mg................................ 29
isosorbide mononitrate tab sr 24hr 120 mg (Imdur).....29
isosorbide mononitrate tab sr 24hr 30 mg (Imdur).......29
isosorbide mononitrate tab sr 24hr 60 mg (Imdur).......29
isotretinoin cap 10 mg....................................................98
ISOXSUPRINE HCL – isoxsuprine hcl tab 20 mg............. 42
isoxsuprine hcl tab 10 mg..............................................42
isradipine cap 2.5 mg..................................................... 32
128
isradipine cap 5 mg........................................................ 32
ISTALOL – timolol maleate ophth soln 0.5% (oncedaily)................................................................................ 91
itraconazole cap 100 mg (Sporanox)...............................5
ivermectin tab 3 mg (Stromectol).................................. 10
J
JADENU – deferasirox tab 180 mg.................................102
JADENU – deferasirox tab 360 mg.................................102
JADENU – deferasirox tab 90 mg...................................102
JAKAFI – ruxolitinib phosphate tab 10 mg (base
equivalent)....................................................................... 12
equivalent)....................................................................... 12
equivalent)....................................................................... 12
equivalent)....................................................................... 12
equivalent)....................................................................... 12
JALYN – dutasteride-tamsulosin hcl cap 0.5-0.4 mg.........55
JANUMET – sitagliptin-metformin hcl tab 50-1000 mg......20
JANUMET – sitagliptin-metformin hcl tab 50-500 mg........20
JANUMET XR – sitagliptin-metformin hcl tab sr 24hr
100-1000 mg................................................................... 20
50-1000 mg..................................................................... 20
50-500 mg....................................................................... 20
JANUVIA – sitagliptin phosphate tab 100 mg (base
equiv)............................................................................... 20
equiv)............................................................................... 20
equiv)............................................................................... 20
JENTADUETO – linagliptin-metformin hcl tab 2.5-1000
mg.................................................................................... 20
mg.................................................................................... 20
mg.................................................................................... 20
JUXTAPID – lomitapide mesylate cap 10 mg (base
equiv)............................................................................... 40
equiv)............................................................................... 40
equiv)............................................................................... 40
equiv)............................................................................... 40
equiv)............................................................................... 40
equiv)............................................................................... 40
2015
K
KADCYLA – ado-trastuzumab emtansine for iv soln 100
mg.................................................................................... 12
KADCYLA – ado-trastuzumab emtansine for iv soln 160
mg.................................................................................... 12
KALETRA – lopinavir-ritonavir soln 400-100 mg/5ml
(80-20 mg/ml).................................................................... 6
KALETRA – lopinavir-ritonavir tab 100-25 mg.................... 6
KALETRA – lopinavir-ritonavir tab 200-50 mg.................... 6
KALYDECO – ivacaftor packet 50 mg.............................. 48
KALYDECO – ivacaftor packet 75 mg.............................. 48
KALYDECO – ivacaftor tab 150 mg..................................48
KAPVAY – clonidine hcl tab sr 12hr 0.1 mg......................65
KAZANO – alogliptin-metformin hcl tab 12.5-1000 mg......20
KAZANO – alogliptin-metformin hcl tab 12.5-500 mg........20
KETEK – telithromycin tab 300 mg................................... 10
KETEK – telithromycin tab 400 mg................................... 10
ketoconazole cream 2%..................................................98
ketoconazole foam 2% (Extina)..................................... 98
ketoconazole shampoo 2% (Nizoral)............................. 98
ketoconazole tab 200 mg................................................. 5
ketoprofen cap 50 mg.....................................................76
ketoprofen cap 75 mg.....................................................76
KETOPROFEN ER – ketoprofen cap sr 24hr 200 mg....... 76
KETOROLAC TROMETHAMINE – ketorolac
tromethamine inj 300 mg/10ml (30 mg/ml)...................... 76
ketorolac tromethamine ophth soln 0.4% (Acular
ls).....................................................................................91
ketorolac tromethamine ophth soln 0.5% (Acular).......91
ketorolac tromethamine tab 10 mg................................76
KINERET – anakinra subcutaneous soln prefilled syringe
100 mg/0.67ml................................................................. 76
KITABIS PAK – tobramycin nebu soln 300 mg/5ml............ 4
KLOR-CON M15 – potassium chloride microencapsulated
crys cr tab 15 meq.......................................................... 85
KOMBIGLYZE XR – saxagliptin-metformin hcl tab sr 24hr
2.5-1000 mg.................................................................... 20
5-1000 mg....................................................................... 20
5-500 mg......................................................................... 20
KORLYM – mifepristone tab 300 mg................................ 20
K-PHOS NEUTRAL – pot phos monobasic w/sod phos di
& monobas tab 155-852-130mg......................................85
K-PHOS – potassium phosphate monobasic tab 500
mg.................................................................................... 85
K-TAB – potassium chloride tab cr 20 meq (1500 mg)......85
KUVAN – sapropterin dihydrochloride powder packet 100
mg.................................................................................... 26
KUVAN – sapropterin dihydrochloride powder packet 500
mg.................................................................................... 26
KUVAN – sapropterin dihydrochloride soluble tab 100
mg.................................................................................... 26
KYNAMRO – mipomersen sodium soln prefilled syringe
200 mg/ml........................................................................41
KYPROLIS – carfilzomib for inj 60 mg.............................. 12
L
labetalol hcl tab 100 mg (Trandate)...............................30
LACRISERT – artificial tear ophth insert...........................91
lactated ringer's for irrigation...................................... 103
lactic acid (ammonium lactate) cream 12% (Lachydrin).............................................................................98
lactic acid (ammonium lactate) lotion 10%................... 98
lactic acid (ammonium lactate) lotion 12% (Lachydrin).............................................................................98
lactic acid w/ vitamin e cream 10%-3500 unit/30gm..... 98
lactulose (encephalopathy) solution 10 gm/15ml.........53
lactulose solution 10 gm/15ml....................................... 48
LAMICTAL ODT – lamotrigine tab disp 25 (14) & 50 mg
(14) & 100 mg (7) kit.......................................................80
LAMICTAL ODT – lamotrigine tab disp 25 mg (21) & 50
mg (7) titration kit............................................................ 80
LAMICTAL ODT – lamotrigine tab disp 50 mg (42) & 100
mg (14) titration kit.......................................................... 80
LAMICTAL STARTER/NOT TAKI – lamotrigine tab 25 mg
(42) & 100 mg (7) starter kit............................................80
LAMICTAL STARTER/TAKING C – lamotrigine tab 25 mg
(84) & 100 mg (14) starter kit..........................................80
LAMICTAL STARTER/TAKING V – lamotrigine tab 25 mg
(35) starter kit.................................................................. 80
LAMISIL SPRAY – terbinafine hcl soln 1%....................... 98
LAMISIL – terbinafine hcl oral granules packet 125 mg...... 5
LAMISIL – terbinafine hcl oral granules packet 187.5
mg...................................................................................... 5
lamivudine oral soln 10 mg/ml (Epivir)........................... 6
lamivudine tab 100 mg (hbv) (Epivir hbv)....................... 6
lamivudine tab 150 mg (Epivir)........................................ 6
lamivudine tab 300 mg (Epivir)........................................ 6
lamivudine-zidovudine tab 150-300 mg (Combivir)........ 6
lamotrigine orally disintegrating tab 100 mg (Lamictal
odt).................................................................................. 80
odt).................................................................................. 80
odt).................................................................................. 80
odt).................................................................................. 80
lamotrigine tab 100 mg (Lamictal)................................. 80
lamotrigine tab 25 mg (Lamictal)................................... 80
lamotrigine tab chewable dispersible 25 mg (Lamictal
chewable di)................................................................... 80
lamotrigine tab chewable dispersible 5 mg (Lamictal
chewable di)................................................................... 80
lamotrigine tab sr 24hr 100 mg (Lamictal xr)................80
129
2015
lamotrigine tab sr 24hr 25 mg (Lamictal xr)..................80
lamotrigine tab sr 24hr 50 mg (Lamictal xr)..................80
LANCETS – VARIOUS MANUFACTURERS.................. 103
LANOXIN – digoxin tab 125 mcg (0.125 mg)....................29
LANOXIN – digoxin tab 187.5 mcg (0.1875 mg)............... 29
LANOXIN – digoxin tab 250 mcg (0.25 mg)......................29
LANOXIN – digoxin tab 62.5 mcg (0.0625 mg)................. 29
lansoprazole cap delayed release 15 mg
(Prevacid)........................................................................49
lansoprazole cap delayed release 30 mg
(Prevacid)........................................................................49
LANTUS – insulin glargine inj 100 unit/ml.........................22
LANTUS SOLOSTAR – insulin glargine soln pen-injector
100 unit/ml....................................................................... 23
LASTACAFT – alcaftadine ophth soln 0.25%................... 91
latanoprost ophth soln 0.005% (Xalatan)...................... 91
LATRIX XM – urea in zinc undecylenate-lactic acid vehicle
emulsion 45%.................................................................. 98
LATUDA – lurasidone hcl tab 120 mg.............................. 61
LATUDA – lurasidone hcl tab 20 mg................................ 61
LAZANDA – fentanyl citrate nasal spray 100 mcg/act
(base equiv).....................................................................72
LAZANDA – fentanyl citrate nasal spray 400 mcg/act
(base equiv).....................................................................72
leflunomide tab 10 mg (Arava).......................................76
leflunomide tab 20 mg (Arava).......................................76
LENVIMA 10MG DAILY DOSE – lenvatinib cap therapy
pack 10 mg (10 mg daily dose).......................................12
pack 10 & 4 mg (14 mg daily dose)................................ 12
pack 10 (2) mg (20 mg daily dose)................................. 12
pack 10 (2) & 4 mg (24 mg daily dose)........................... 12
LESCOL XL – fluvastatin sodium tab sr 24 hr 80 mg........ 41
LETAIRIS – ambrisentan tab 10 mg................................. 42
LETAIRIS – ambrisentan tab 5 mg................................... 42
letrozole tab 2.5 mg (Femara)........................................ 12
LEUCOVORIN CALCIUM – leucovorin calcium tab 10
mg.................................................................................... 12
LEUCOVORIN CALCIUM – leucovorin calcium tab 15
mg.................................................................................... 12
leucovorin calcium tab 25 mg........................................12
leucovorin calcium tab 5 mg..........................................12
LEUKERAN – chlorambucil tab 2 mg............................... 12
LEUKINE – sargramostim lyophilized for inj 250 mcg....... 87
LEVACET – aspirin-apap-salicylamide-caffeine tab
500-250-150-32.5 mg...................................................... 70
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
(Xopenex)........................................................................47
(Xopenex)........................................................................47
130
(Xopenex)........................................................................47
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base
equiv) (Xopenex concentrate)...................................... 47
LEVATOL – penbutolol sulfate tab 20 mg.........................30
LEVEMIR FLEXPEN – insulin detemir soln pen-injector
100 unit/ml....................................................................... 23
LEVEMIR FLEXTOUCH – insulin detemir soln pen-injector
100 unit/ml....................................................................... 23
LEVEMIR – insulin detemir inj 100 unit/ml........................ 23
levetiracetam oral soln 100 mg/ml (Keppra)................. 80
levetiracetam tab 1000 mg (Keppra)..............................80
levetiracetam tab 250 mg (Keppra)................................80
levetiracetam tab sr 24hr 500 mg (Keppra xr).............. 80
levetiracetam tab sr 24hr 750 mg (Keppra xr).............. 80
LEVITRA – Benefit Limits may apply – vardenafil hcl tab
10 mg...............................................................................43
2.5 mg..............................................................................43
20 mg...............................................................................43
LEVITRA – Benefit Limits may apply – vardenafil hcl tab 5
mg.................................................................................... 43
LEVOBUNOLOL HCL – levobunolol hcl ophth soln
0.25%...............................................................................91
levobunolol hcl ophth soln 0.5% (Betagan)..................91
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 26
levocarnitine tab 330 mg (Carnitor)...............................26
levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5
mg/ml) (Xyzal)................................................................ 43
levocetirizine dihydrochloride tab 5 mg (Xyzal)........... 43
levofloxacin ophth soln 0.5%.........................................91
levofloxacin oral soln 25 mg/ml (Levaquin)....................4
levofloxacin tab 250 mg (Levaquin)................................ 4
levonorgestrel tab 1.5 mg (Plan b one-step).................18
LEVORPHANOL TARTRATE – levorphanol tartrate tab 2
mg.................................................................................... 72
levothyroxine sodium tab 100 mcg (Synthroid)........... 23
levothyroxine sodium tab 25 mcg (Synthroid)............. 23
LEXIVA – fosamprenavir calcium susp 50 mg/ml (base
equiv)................................................................................. 6
2015
LEXIVA – fosamprenavir calcium tab 700 mg (base
equiv)................................................................................. 6
LEXUSS 210 – chlorpheniramine w/ codeine liquid 2-10
mg/5ml............................................................................. 44
LIALDA – mesalamine tab delayed release 1.2 gm.......... 53
lidocaine hcl cream 3%.................................................. 98
lidocaine hcl gel 2%........................................................98
LIDOCAINE HCL-HYDROCORTIS – lidocainehydrocortisone acetate rectal gel 2.8-0.55%................... 94
lidocaine hcl laryngotracheal soln 4% (Lta 360 kit)......93
LIDOCAINE HCL – lidocaine hcl lotion 3%....................... 98
lidocaine hcl soln 4% (Xylocaine)..................................98
lidocaine hcl viscous soln 2%....................................... 93
lidocaine-hydrocortisone acetate rectal cream
3-0.5%..............................................................................94
lidocaine-hydrocortisone acetate rectal cream kit
2-2%.................................................................................94
3-0.5%..............................................................................94
3-1%.................................................................................94
lidocaine-hydrocortisone acetate rectal gel kit
3-2.5%..............................................................................94
lidocaine-menthol patch 4-5%........................................98
lidocaine oint 5%.............................................................98
lidocaine patch 5% (Lidoderm)...................................... 98
lidocaine-prilocaine cream 2.5-2.5% (Emla)..................98
lidocaine-prilocaine kit 2.5-2.5%.................................... 98
LIDODERM – lidocaine patch 5%.....................................98
lindane lotion 1%.............................................................98
lindane shampoo 1%...................................................... 98
linezolid tab 600 mg (Zyvox).......................................... 10
LINZESS – linaclotide cap 145 mcg................................. 53
LINZESS – linaclotide cap 290 mcg................................. 53
liothyronine sodium tab 25 mcg (Cytomel)...................23
liothyronine sodium tab 50 mcg (Cytomel)...................23
liothyronine sodium tab 5 mcg (Cytomel).....................23
LIPOFEN – fenofibrate cap 150 mg..................................41
LIPOFEN – fenofibrate cap 50 mg....................................41
lisinopril & hydrochlorothiazide tab 10-12.5 mg
(Zestoretic)..................................................................... 36
lisinopril & hydrochlorothiazide tab 20-12.5 mg
(Zestoretic)..................................................................... 36
lisinopril & hydrochlorothiazide tab 20-25 mg
(Zestoretic)..................................................................... 36
lisinopril tab 10 mg (Prinivil)..........................................36
lisinopril tab 2.5 mg (Zestril).......................................... 36
lisinopril tab 20 mg (Prinivil)..........................................36
lisinopril tab 30 mg (Zestril)........................................... 36
lisinopril tab 40 mg (Zestril)........................................... 36
lisinopril tab 5 mg (Prinivil)............................................36
lithium carbonate cap 150 mg (Lithium carbonate)......61
lithium carbonate cap 300 mg....................................... 61
lithium carbonate cap 600 mg (Lithium carbonate)......61
LITHIUM CARBONATE – lithium carbonate cap 150
mg.................................................................................... 61
LITHIUM CARBONATE – lithium carbonate cap 600
mg.................................................................................... 61
lithium carbonate tab 300 mg........................................ 61
lithium carbonate tab cr 300 mg (Lithobid)...................61
lithium carbonate tab cr 450 mg....................................61
LITHIUM – lithium oral solution 8 meq/5ml....................... 61
LITHOBID – lithium carbonate tab cr 300 mg................... 61
LIVALO – pitavastatin calcium tab 1 mg (base equiv)....... 41
LO LOESTRIN FE – norethin-eth estradiol-fe tab 1 mg-10
mcg (24)/10 mcg (2)........................................................18
LOMUSTINE – lomustine cap 100 mg.............................. 12
LOMUSTINE – lomustine cap 10 mg................................12
LOMUSTINE – lomustine cap 40 mg................................12
loperamide hcl cap 2 mg................................................48
lorazepam conc 2 mg/ml (Lorazepam intensol)............56
lorazepam tab 0.5 mg (Ativan)....................................... 56
lorazepam tab 1 mg (Ativan).......................................... 56
lorazepam tab 2 mg (Ativan).......................................... 56
losartan potassium & hydrochlorothiazide tab
100-12.5 mg (Hyzaar).....................................................36
losartan potassium & hydrochlorothiazide tab 100-25
mg (Hyzaar).................................................................... 36
losartan potassium & hydrochlorothiazide tab 50-12.5
mg (Hyzaar).................................................................... 36
losartan potassium tab 100 mg (Cozaar)...................... 36
losartan potassium tab 25 mg (Cozaar)........................ 36
losartan potassium tab 50 mg (Cozaar)........................ 36
LOTEMAX – loteprednol etabonate ophth gel 0.5%..........91
lovastatin tab 10 mg....................................................... 41
lovastatin tab 20 mg (Mevacor)..................................... 41
lovastatin tab 40 mg (Mevacor)..................................... 41
loxapine succinate cap 10 mg....................................... 61
loxapine succinate cap 5 mg......................................... 61
LOZI-FLUR – sodium fluoride lozenge 1 mg f (from 2.2 mg
naf)...................................................................................85
LTA 360 KIT – lidocaine hcl laryngotracheal soln 4%....... 93
LUMIGAN – bimatoprost ophth soln 0.01%...................... 91
LUPANETA PACK – leuprolide (1 mon) inj 3.75 mg &
norethindrone tab 5 mg kit.............................................. 26
LUPANETA PACK – leuprolide (3 mon) inj 11.25 mg &
norethindrone tab 5 mg kit.............................................. 26
LUPRON DEPOT – leuprolide acetate (3 month) for inj kit
11.25 mg..........................................................................13
22.5 mg............................................................................13
30 mg...............................................................................13
45 mg...............................................................................13
LUPRON DEPOT – leuprolide acetate for inj kit 3.75
mg.................................................................................... 12
131
2015
LUPRON DEPOT – leuprolide acetate for inj kit 7.5
mg.................................................................................... 13
LUPRON DEPOT-PED – leuprolide acetate (3 month) for
inj pediatric kit 11.25 mg................................................. 26
LUPRON DEPOT-PED – leuprolide acetate (3 month) for
inj pediatric kit 30 mg...................................................... 27
LUPRON DEPOT-PED – leuprolide acetate for inj
pediatric kit 11.25 mg...................................................... 26
pediatric kit 15 mg........................................................... 26
pediatric kit 7.5 mg.......................................................... 26
LYNPARZA – olaparib cap 50 mg.................................... 13
LYRICA – pregabalin cap 100 mg.................................... 80
LYRICA – pregabalin cap 25 mg...................................... 80
LYRICA – pregabalin soln 20 mg/ml.................................80
LYSODREN – mitotane tab 500 mg................................. 13
M
malathion lotion 0.5% (Ovide)........................................98
MAPROTILINE HCL – maprotiline hcl tab 25 mg..............58
MARQIBO – vincristine sulfate liposome iv susp 5
mg/31ml (0.16 mg/ml)..................................................... 13
MATULANE – procarbazine hcl cap 50 mg...................... 13
meclizine hcl tab 12.5 mg...............................................51
meclizine hcl tab 25 mg..................................................51
MECLOFENAMATE SODIUM – meclofenamate sodium
cap 100 mg..................................................................... 76
MECLOFENAMATE SODIUM – meclofenamate sodium
cap 50 mg....................................................................... 76
medroxyprogesterone acetate im susp 150 mg/ml
(Depo-provera contrac)................................................. 18
medroxyprogesterone acetate tab 10 mg (Provera).....19
medroxyprogesterone acetate tab 2.5 mg
(Provera)......................................................................... 19
medroxyprogesterone acetate tab 5 mg (Provera).......19
mefenamic acid cap 250 mg (Ponstel).......................... 76
mefloquine hcl tab 250 mg.............................................10
MEGACE ES – megestrol acetate susp 625 mg/5ml........ 19
megestrol acetate susp 40 mg/ml (Megace oral)..........13
megestrol acetate susp 625 mg/5ml (Megace es)........ 19
megestrol acetate tab 20 mg..........................................13
megestrol acetate tab 40 mg..........................................13
MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg
(base equivalent)............................................................. 13
MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (base
equivalent)....................................................................... 13
MELOXICAM – meloxicam susp 7.5 mg/5ml.................... 76
132
meloxicam tab 15 mg (Mobic)........................................76
meloxicam tab 7.5 mg (Mobic).......................................76
memantine hcl tab 10 mg (Namenda)............................68
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak
(Namenda titration pa).................................................. 68
memantine hcl tab 5 mg (Namenda)............................. 68
MENOPUR – Benefit Limits may apply – menotropins for
subcutaneous inj 75 unit................................................. 27
MENOSTAR – estradiol td patch weekly 14 mcg/24hr...... 18
MEPERIDINE HCL – meperidine hcl oral soln 50
mg/5ml............................................................................. 72
meperidine hcl tab 100 mg (Demerol)........................... 72
meperidine hcl tab 50 mg (Demerol)............................. 72
MEPHYTON – phytonadione tab 5 mg............................. 84
meprobamate tab 200 mg...............................................56
meprobamate tab 400 mg...............................................56
mercaptopurine tab 50 mg (Purinethol)........................ 13
mesalamine enema 4 gm................................................53
mesalamine rectal enema 4 gm & cleanser wipe kit
(Rowasa)......................................................................... 53
MESNEX – mesna tab 400 mg.........................................13
METAPROTERENOL SULFATE – metaproterenol sulfate
syrup 10 mg/5ml..............................................................47
tab 10 mg........................................................................ 47
tab 20 mg........................................................................ 47
metaxalone tab 800 mg (Skelaxin).................................84
metformin hcl tab 1000 mg (Glucophage).....................21
metformin hcl tab 500 mg (Glucophage)...................... 21
metformin hcl tab 850 mg (Glucophage)...................... 21
metformin hcl tab sr 24hr 500 mg (Glucophage xr)......20
metformin hcl tab sr 24hr 750 mg (Glucophage xr)......20
metformin hcl tab sr 24hr osmotic 1000 mg
(Fortamet)....................................................................... 21
metformin hcl tab sr 24hr osmotic 500 mg
(Fortamet)....................................................................... 21
methadone hcl conc 10 mg/ml (Methadose).................72
METHADONE HCL – methadone hcl soln 5 mg/5ml........ 72
methadone hcl soln 10 mg/5ml (Methadone hcl)..........72
methadone hcl soln 5 mg/5ml (Methadone hcl)............72
methadone hcl tab 10 mg (Dolophine).......................... 72
methadone hcl tab 5 mg (Dolophine hcl)......................72
methadone hcl tab for oral susp 40 mg........................ 72
methamphetamine hcl tab 5 mg (Desoxyn).................. 65
methazolamide tab 25 mg (Neptazane)......................... 39
methazolamide tab 50 mg (Neptazane)......................... 39
methenamine hippurate tab 1 gm (Hiprex)................... 53
methenamine-hyoscamine-meth blue-sod phos tab
81.6 mg (Urogesic-blue)................................................53
methenamine-hyosc-meth blue-benz acid-phenyl sal
tab 81.6mg (Prosed/ds)................................................. 53
methenamine-hyosc-meth blue-sod phos-phen sal cap
118 mg............................................................................ 53
methenamine-hyosc-meth blue-sod phos-phen sal cap
120 mg............................................................................ 53
2015
methenamine-hyosc-meth blue-sod phos-phen sal tab
81 mg.............................................................................. 53
methenamine-hyos-meth blue-sod phos-phen sal tab
81.6 mg........................................................................... 53
METHENAMINE MANDELATE – methenamine mandelate
tab 0.5 gm....................................................................... 53
methenamine mandelate tab 1 gm................................ 53
methimazole tab 10 mg (Tapazole)................................23
methimazole tab 5 mg (Tapazole)..................................23
methocarbamol tab 500 mg (Robaxin).......................... 84
methocarbamol tab 750 mg (Robaxin-750)................... 84
methotrexate sodium for inj 1 gm................................. 13
methotrexate sodium inj 25 mg/ml................................ 13
methotrexate sodium inj pf 25 mg/ml............................13
methotrexate sodium tab 2.5 mg (base equiv)............. 13
methoxsalen rapid cap 10 mg (Oxsoralen ultra).......... 98
methscopolamine bromide tab 2.5 mg (Pamine)..........49
methscopolamine bromide tab 5 mg (Pamine
forte)................................................................................49
METHYCLOTHIAZIDE – methyclothiazide tab 5 mg........ 39
METHYLDOPA/HYDROCHLOROTHI – methyldopa &
hydrochlorothiazide tab 250-15 mg................................. 36
METHYLDOPA/HYDROCHLOROTHI – methyldopa &
hydrochlorothiazide tab 250-25 mg................................. 36
methyldopa tab 250 mg.................................................. 36
methyldopa tab 500 mg.................................................. 36
methylergonovine maleate tab 0.2 mg.......................... 24
methylphenidate hcl cap cr 10 mg (Metadate cd).........65
methylphenidate hcl cap sr 24hr 20 mg (la) (Ritalin
la).....................................................................................65
la).....................................................................................65
la).....................................................................................65
methylphenidate hcl chew tab 10 mg (Methylin).......... 65
methylphenidate hcl chew tab 2.5 mg (Methylin)......... 65
methylphenidate hcl chew tab 5 mg (Methylin)............ 65
METHYLPHENIDATE HCL ER – methylphenidate hcl tab
sa osm 18 mg................................................................. 65
sa osm 27 mg................................................................. 65
sa osm 36 mg................................................................. 65
sa osm 54 mg................................................................. 65
methylphenidate hcl soln 10 mg/5ml (Methylin)...........66
methylphenidate hcl soln 5 mg/5ml (Methylin).............66
methylphenidate hcl tab 10 mg (Ritalin)....................... 66
methylphenidate hcl tab 20 mg (Ritalin)....................... 66
methylphenidate hcl tab 5 mg (Ritalin)......................... 66
methylphenidate hcl tab cr 10 mg................................. 66
methylphenidate hcl tab cr 20 mg (Ritalin sr)...............66
methylprednisolone tab 16 mg (Medrol)....................... 15
methylprednisolone tab 32 mg (Medrol)....................... 15
methylprednisolone tab 4 mg (Medrol)......................... 15
methylprednisolone tab 4 mg dose pack (Medrol
dosepak)......................................................................... 15
methylprednisolone tab 8 mg (Medrol)......................... 15
METHYL SALICYLATE – methyl salicylate liquid............. 98
METIPRANOLOL – metipranolol ophth soln 0.3%............ 91
metoclopramide hcl orally disintegrating tab 5 mg
(Metozolv odt)................................................................ 53
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml).........53
metoclopramide hcl tab 10 mg (Reglan)....................... 53
metoclopramide hcl tab 5 mg (Reglan)......................... 53
metolazone tab 10 mg.................................................... 39
metolazone tab 2.5 mg (Zaroxolyn)............................... 39
metolazone tab 5 mg (Zaroxolyn).................................. 39
metoprolol & hydrochlorothiazide tab 100-25 mg
(Lopressor hct).............................................................. 36
metoprolol & hydrochlorothiazide tab 100-50 mg........ 36
metoprolol & hydrochlorothiazide tab 50-25 mg
(Lopressor hct).............................................................. 36
metoprolol succinate tab sr 24hr 100 mg (Toprol
xl).....................................................................................30
metoprolol succinate tab sr 24hr 200 mg (Toprol
xl).....................................................................................30
metoprolol succinate tab sr 24hr 25 mg (Toprol xl)..... 30
metoprolol succinate tab sr 24hr 50 mg (Toprol xl)..... 30
metoprolol tartrate tab 100 mg (Lopressor)..................30
metoprolol tartrate tab 25 mg........................................ 30
metoprolol tartrate tab 50 mg (Lopressor)....................30
METOZOLV ODT – metoclopramide hcl orally
disintegrating tab 5 mg....................................................53
metronidazole cap 375 mg (Flagyl)............................... 10
metronidazole cream 0.75% (Metrocream)....................98
metronidazole gel 0.75%................................................ 98
metronidazole gel 1% (Metrogel)................................... 98
metronidazole lotion 0.75% (Metrolotion)..................... 98
metronidazole tab 250 mg (Flagyl)................................ 10
metronidazole tab 500 mg (Flagyl)................................ 10
metronidazole vaginal gel 0.75% (Metrogelvaginal)........................................................................... 55
mexiletine hcl cap 150 mg............................................. 33
MICONAZOLE 3 – miconazole nitrate vaginal suppos 200
mg.................................................................................... 55
midazolam hcl syrup 2 mg/ml (base equivalent).......... 63
midodrine hcl tab 10 mg................................................ 39
midodrine hcl tab 2.5 mg............................................... 39
midodrine hcl tab 5 mg.................................................. 39
MIGERGOT – ergotamine w/ caffeine suppos 2-100
mg.................................................................................... 78
MIGRANAL – dihydroergotamine mesylate nasal spray 4
mg/ml............................................................................... 78
MILLIPRED DP – prednisolone tab 5 mg dose pack.........15
133
2015
MILLIPRED – prednisolone sod phosphate oral soln 10
mg/5ml (base equiv)........................................................15
MILLIPRED – prednisolone tab 5 mg............................... 15
MINIVELLE – estradiol td patch twice weekly 0.0375
mg/24hr............................................................................18
mg/24hr............................................................................18
mg/24hr............................................................................18
mg/24hr............................................................................18
minocycline hcl cap 100 mg (Minocin)............................3
minocycline hcl cap 50 mg (Minocin)............................. 3
minocycline hcl cap 75 mg (Minocin)............................. 3
minocycline hcl tab 100 mg............................................. 3
minocycline hcl tab 50 mg............................................... 3
minocycline hcl tab 75 mg............................................... 3
minocycline hcl tab sr 24hr 135 mg................................ 3
minocycline hcl tab sr 24hr 45 mg.................................. 3
minocycline hcl tab sr 24hr 90 mg.................................. 3
minoxidil tab 10 mg........................................................ 36
minoxidil tab 2.5 mg....................................................... 36
MIRAPEX ER – pramipexole dihydrochloride tab sr 24hr
0.375 mg..........................................................................82
0.75 mg............................................................................82
1.5 mg..............................................................................82
2.25 mg............................................................................82
3.75 mg............................................................................82
MIRAPEX ER – pramipexole dihydrochloride tab sr 24hr 3
mg.................................................................................... 82
4.5 mg..............................................................................83
mirtazapine orally disintegrating tab 15 mg (Remeron
soltab)............................................................................. 58
soltab)............................................................................. 58
soltab)............................................................................. 58
mirtazapine tab 15 mg (Remeron)................................. 58
mirtazapine tab 7.5 mg................................................... 58
misoprostol tab 100 mcg (Cytotec)............................... 49
misoprostol tab 200 mcg (Cytotec)............................... 49
modafinil tab 100 mg (Provigil)......................................66
modafinil tab 200 mg (Provigil)......................................66
MODERIBA 1200 DOSE PACK – ribavirin tab 600 mg....... 6
MODERIBA 800 DOSE PACK – ribavirin tab 400 mg.........7
MODERIBA – ribavirin tab 200 mg & ribavirin tab 400 mg
dose pack.......................................................................... 6
MODERIBA – ribavirin tab 400 mg & ribavirin tab 600 mg
dose pack.......................................................................... 6
134
moexipril hcl tab 15 mg (Univasc).................................36
moexipril hcl tab 7.5 mg (Univasc)................................36
moexipril-hydrochlorothiazide tab 15-12.5 mg
(Uniretic)......................................................................... 36
moexipril-hydrochlorothiazide tab 15-25 mg................ 36
moexipril-hydrochlorothiazide tab 7.5-12.5 mg............ 36
mometasone furoate cream 0.1% (Elocon)................... 98
mometasone furoate oint 0.1% (Elocon).......................98
mometasone furoate solution 0.1% (lotion)
(Elocon)...........................................................................98
montelukast sodium chew tab 4 mg (base equiv)
(Singulair)....................................................................... 47
montelukast sodium chew tab 5 mg (base equiv)
(Singulair)....................................................................... 47
montelukast sodium oral granules packet 4 mg (base
equiv) (Singulair)........................................................... 47
montelukast sodium tab 10 mg (base equiv)
(Singulair)....................................................................... 47
morphine sulfate (concentrate) oral soln 20 mg/ml..... 72
morphine sulfate cap sr 24hr 100 mg (Kadian)............ 72
morphine sulfate cap sr 24hr 10 mg (Kadian).............. 72
MORPHINE SULFATE ER – morphine sulfate beads cap
sr 24hr 120 mg................................................................73
sr 24hr 30 mg..................................................................72
sr 24hr 45 mg..................................................................72
sr 24hr 60 mg..................................................................72
sr 24hr 75 mg..................................................................72
sr 24hr 90 mg..................................................................72
MORPHINE SULFATE – morphine sulfate suppos 10
mg.................................................................................... 72
mg.................................................................................... 72
mg.................................................................................... 72
mg.................................................................................... 72
MORPHINE SULFATE – morphine sulfate tab 15 mg.......72
MORPHINE SULFATE – morphine sulfate tab 30 mg.......72
morphine sulfate oral soln 10 mg/5ml...........................73
morphine sulfate oral soln 20 mg/5ml...........................73
morphine sulfate tab cr 100 mg (Ms contin)................. 73
morphine sulfate tab cr 15 mg (Ms contin)...................73
morphine sulfate tab cr 200 mg (Ms contin)................. 73
2015
MOVIPREP – peg 3350-kcl-nacl-na sulfate-na ascorbate-c
for soln 100 gm............................................................... 48
MOXATAG – amoxicillin (trihydrate) tab sr 24hr 775 mg.....1
MOXEZA – moxifloxacin hcl ophth soln 0.5% (base eq) (2
times daily)...................................................................... 91
moxifloxacin hcl tab 400 mg (base equiv) (Avelox)....... 4
MOZOBIL – plerixafor subcutaneous inj 24 mg/1.2ml (20
mg/ml).............................................................................. 87
MULTAQ – dronedarone hcl tab 400 mg (base
equivalent)....................................................................... 33
MULTIGEN – fe asparto gly-succ acd-c-threonic acd-b12des stom tab....................................................................87
MULTIGEN FOLIC – fe asparto gly-succinic acd-vit cthreonic acd-b12-fa tab................................................... 87
MULTIGEN PLUS – fe aspart gly-fe fum-succ acd-cthreonic acd-b12-fa tab................................................... 87
mupirocin calcium cream 2% (Bactroban)....................98
mupirocin oint 2% (Bactroban)......................................99
MUSE – Benefit Limits may apply – alprostadil urethral
pellet 1000 mcg............................................................... 43
pellet 125 mcg................................................................. 43
pellet 250 mcg................................................................. 43
pellet 500 mcg................................................................. 43
MYALEPT – metreleptin for subcutaneous inj 11.3 mg..... 27
mycophenolate mofetil cap 250 mg (Cellcept)........... 103
mycophenolate mofetil for oral susp 200 mg/ml
(Cellcept).......................................................................103
mycophenolate mofetil tab 500 mg (Cellcept)............ 103
mycophenolate sodium tab dr 180 mg (mycophenolic
acid equiv) (Myfortic).................................................. 103
mycophenolate sodium tab dr 360 mg (mycophenolic
acid equiv) (Myfortic).................................................. 103
MYFORTIC – mycophenolate sodium tab dr 180 mg
(mycophenolic acid equiv)............................................. 103
MYFORTIC – mycophenolate sodium tab dr 360 mg
(mycophenolic acid equiv)............................................. 103
MYLERAN – busulfan tab 2 mg........................................13
MYOXIN – benzocaine-chloroxylenol-hc otic susp 15-1-10
mg/ml............................................................................... 93
MYRBETRIQ – mirabegron tab sr 24 hr 25 mg................ 54
MYRBETRIQ – mirabegron tab sr 24 hr 50 mg................ 54
N
nabumetone tab 500 mg.................................................76
nabumetone tab 750 mg.................................................76
nadolol & bendroflumethiazide tab 40-5 mg
(Corzide)......................................................................... 36
nadolol & bendroflumethiazide tab 80-5 mg
(Corzide)......................................................................... 36
nadolol tab 20 mg (Corgard).......................................... 30
NAFRINSE DAILY/ACIDULATED – sodium fluoridephosphoric acid for soln 1 mg/5ml (f equiv).....................93
NAFRINSE DAILY/NEUTRAL – sodium fluoride for soln
rinse 0.05%......................................................................93
naftifine hcl cream 1% (Naftin)...................................... 99
NAFTIN – naftifine hcl cream 1%..................................... 99
NAFTIN – naftifine hcl cream 2%..................................... 99
NAFTIN – naftifine hcl gel 1%.......................................... 99
NAFTIN – naftifine hcl gel 2%.......................................... 99
naltrexone hcl tab 50 mg (Revia).................................102
NAMENDA – memantine hcl oral solution 2 mg/ml........... 68
NAMENDA – memantine hcl tab 10 mg............................68
NAMENDA – memantine hcl tab 5 mg..............................68
NAMENDA TITRATION PAK – memantine hcl tab 5 mg
(28) & 10 mg (21) titration pak........................................ 68
NAMENDA XR – memantine hcl cap sr 24hr 14 mg......... 68
NAMENDA XR – memantine hcl cap sr 24hr 7 mg........... 68
NAMENDA XR TITRATION PACK – memantine hcl cap sr
24hr 7 mg & 14 mg & 21 mg & 28 mg pack.................... 68
NAPHAZOLINE HCL – naphazoline hcl ophth soln
0.1%.................................................................................91
NAPROXEN – naproxen susp 125 mg/5ml.......................76
naproxen sodium tab 275 mg (Anaprox)...................... 76
naproxen sodium tab 550 mg (Anaprox ds)................. 76
naproxen sodium tab sr 24hr 500 mg (base equiv)
(Naprelan)....................................................................... 76
naproxen tab 250 mg (Naprosyn).................................. 76
naproxen tab ec 375 mg (Ec-naprosyn)........................ 76
naproxen tab ec 500 mg (Ec-naprosyn)........................ 76
naratriptan hcl tab 1 mg (base equiv) (Amerge)........... 78
naratriptan hcl tab 2.5 mg (base equiv) (Amerge)........ 78
NASCOBAL – cyanocobalamin nasal spray 500
mcg/0.1ml........................................................................ 87
NASONEX – mometasone furoate nasal susp 50 mcg/
act.................................................................................... 44
NATAZIA – estradiol valerate-dienogest tab 3 mg /2-2
mg/2-3 mg/1 mg.............................................................. 18
nateglinide tab 120 mg (Starlix).....................................21
nateglinide tab 60 mg (Starlix).......................................21
NATESTO – testosterone nasal gel 5.5 mg/act................ 16
NATPARA – parathyroid hormone (recombinant) for inj
cartridge 100 mcg............................................................27
cartridge 25 mcg..............................................................27
cartridge 50 mcg..............................................................27
cartridge 75 mcg..............................................................27
NATROBA – spinosad susp 0.9%.................................... 99
NECON 1/50-28 – norethindrone & mestranol tab 1 mg-50
mcg.................................................................................. 18
135
2015
NECON 10/11-28 – norethindrone-eth estradiol tab
0.5-35/1-35 mg-mcg (10/11)............................................18
NEFAZODONE HCL – nefazodone hcl tab 100 mg.......... 58
NEFAZODONE HCL – nefazodone hcl tab 50 mg............ 58
nefazodone hcl tab 250 mg............................................ 58
NEOMYCIN/POLYMYXIN/HYDROC – neomycinpolymyxin-hc ophth susp................................................. 91
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin.................................91
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml (Neosporin)............... 91
neomycin-polymyxin b gu irrigation soln (Neosporin
gu irrigan).......................................................................55
neomycin-polymyxin-dexamethasone ophth oint 0.1%
(Maxitrol).........................................................................91
neomycin-polymyxin-dexamethasone ophth susp
0.1% (Maxitrol)............................................................... 91
neomycin-polymyxin-hc otic soln 1% (Cortisporin).....93
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000
unit/ml-1%.......................................................................93
neomycin sulfate tab 500 mg...........................................4
NEORAL – cyclosporine modified cap 100 mg............... 103
NEORAL – cyclosporine modified cap 25 mg................. 103
NEORAL – cyclosporine modified oral soln 100 mg/
ml................................................................................... 103
NESINA – alogliptin benzoate tab 12.5 mg (base
equiv)............................................................................... 21
NESINA – alogliptin benzoate tab 25 mg (base equiv)......21
NESINA – alogliptin benzoate tab 6.25 mg (base
equiv)............................................................................... 21
NEULASTA DELIVERY KIT – pegfilgrastim inj 6
mg/0.6ml.......................................................................... 87
NEULASTA – pegfilgrastim inj 6 mg/0.6ml....................... 87
NEUMEGA – oprelvekin for inj 5 mg................................ 87
NEUPOGEN – filgrastim inj 300 mcg/0.5ml (600 mcg/
ml).................................................................................... 87
NEUPOGEN – filgrastim inj 300 mcg/ml........................... 87
ml).................................................................................... 87
ml).................................................................................... 87
NEUPRO – rotigotine td patch 24hr 1 mg/24hr................. 83
NEVANAC – nepafenac ophth susp 0.1%........................ 91
NEVIRAPINE – nevirapine susp 50 mg/5ml....................... 7
nevirapine tab 200 mg (Viramune)...................................7
nevirapine tab sr 24hr 400 mg (Viramune xr)................. 7
NEXAVAR – sorafenib tosylate tab 200 mg (base
equivalent)....................................................................... 13
136
NEXIUM – esomeprazole magnesium cap delayed release
20 mg (base eq)..............................................................50
NEXIUM – esomeprazole magnesium cap delayed release
40 mg (base eq)..............................................................50
NEXIUM – esomeprazole magnesium for delayed release
susp packet 10 mg.......................................................... 49
susp packet 20 mg.......................................................... 50
susp packet 40 mg.......................................................... 50
niacin tab cr 1000 mg (antihyperlipidemic)
(Niaspan).........................................................................41
(Niaspan).........................................................................41
(Niaspan).........................................................................41
NIACOR – niacin (antihyperlipidemic) tab 500 mg............ 41
nicardipine hcl cap 20 mg..............................................32
nicardipine hcl cap 30 mg..............................................32
NICOTROL INHALER – Benefit Limits may apply –
nicotine inhaler system 10 mg (4 mg delivered).............. 68
NICOTROL NS – Benefit Limits may apply – nicotine
nasal spray 10 mg/ml (0.5 mg/spray).............................. 68
nifedipine cap 10 mg (Procardia)...................................32
nifedipine cap 20 mg...................................................... 32
nifedipine tab sr 24hr 30 mg (Adalat cc).......................32
nifedipine tab sr 24hr osmotic 30 mg (Procardia
xl).....................................................................................32
xl).....................................................................................32
xl).....................................................................................32
NILANDRON – nilutamide tab 150 mg............................. 13
nimodipine cap 30 mg.................................................... 32
NISOLDIPINE ER – nisoldipine tab sr 24hr 25.5 mg.........32
NISOLDIPINE – nisoldipine tab sr 24hr 20 mg................. 32
nisoldipine tab sr 24hr 17 mg (Sular)............................32
nisoldipine tab sr 24hr 34 mg (Sular)............................32
nisoldipine tab sr 24hr 8.5 mg (Sular)...........................32
NITRO-BID – nitroglycerin oint 2%................................... 29
NITRO-DUR – nitroglycerin td patch 24hr 0.1 mg/hr.........29
nitrofurantoin macrocrystalline cap 100 mg
(Macrodantin)................................................................. 54
nitrofurantoin macrocrystalline cap 50 mg
(Macrodantin)................................................................. 54
nitrofurantoin monohydrate macrocrystalline cap 100
mg (Macrobid)................................................................ 54
2015
nitrofurantoin susp 25 mg/5ml (Furadantin)................. 54
nitroglycerin cap cr 2.5 mg............................................ 29
nitroglycerin cap cr 6.5 mg............................................ 29
nitroglycerin cap cr 9 mg............................................... 29
nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)......... 29
nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)
(Nitrolingual pumpspr).................................................. 29
NITROMIST – nitroglycerin lingual aerosol 400 mcg/
spray................................................................................ 29
NITROSTAT – nitroglycerin sl tab 0.3 mg.........................29
nizatidine cap 150 mg.....................................................50
nizatidine cap 300 mg (Axid)..........................................50
nizatidine oral soln 15 mg/ml (Axid)..............................50
NORDITROPIN CARTRIDGE – somatropin inj 5
mg/1.5ml.......................................................................... 27
NORDITROPIN FLEXPRO – somatropin inj 10
mg/1.5ml.......................................................................... 27
mg/1.5ml.......................................................................... 27
mg/3ml............................................................................. 27
mg/1.5ml.......................................................................... 27
NORDITROPIN NORDIFLEX PEN – somatropin inj 30
mg/3ml............................................................................. 27
norelgestromin-ethinyl estradiol td ptwk 150-35
mcg/24hr (Ortho evra)................................................... 18
norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5
mcg (Femhrt low dose)................................................. 18
norethindrone acetate-ethinyl estradiol tab 1 mg-5
mcg..................................................................................18
norethindrone acetate tab 5 mg (Aygestin).................. 19
NORITATE – metronidazole cream 1%............................ 99
NORPACE CR – disopyramide phosphate cap sr 12hr 100
mg.................................................................................... 33
NORPACE CR – disopyramide phosphate cap sr 12hr 150
mg.................................................................................... 33
NORTHERA – droxidopa cap 100 mg.............................. 39
nortriptyline hcl cap 10 mg (Pamelor)...........................59
NORTRIPTYLINE HCL – nortriptyline hcl soln 10
mg/5ml............................................................................. 58
NORVIR – ritonavir cap 100 mg......................................... 7
NORVIR – ritonavir oral soln 80 mg/ml...............................7
NORVIR – ritonavir tab 100 mg.......................................... 7
NOVOLIN 70/30 – insulin nph isophane & regular human
inj 100 unit/ml (70-30)..................................................... 22
NOVOLIN 70/30 RELION – insulin nph isophane & regular
human inj 100 unit/ml (70-30)......................................... 22
NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/
ml..................................................................................... 22
NOVOLIN N RELION – insulin nph (human) (isophane) inj
100 unit/ml....................................................................... 22
NOVOLIN R – insulin regular (human) inj 100 unit/ml....... 22
NOVOLIN R RELION – insulin regular (human) inj 100
unit/ml.............................................................................. 22
NOVOLOG FLEXPEN – insulin aspart soln pen-injector
100 unit/ml....................................................................... 22
NOVOLOG – insulin aspart inj 100 unit/ml........................22
NOVOLOG MIX 70/30 – insulin aspart prot & aspart
(human) inj 100 unit/ml (70-30)....................................... 22
NOVOLOG MIX 70/30 PREFILL – insulin aspart prot &
aspart sus pen-inj 100 unit/ml (70-30).............................22
NOVOLOG PENFILL – insulin aspart inj 100 unit/ml........ 22
NOVOLOG PENFILL – insulin aspart soln cartridge 100
unit/ml.............................................................................. 22
NOXAFIL – posaconazole susp 40 mg/ml.......................... 5
NOXAFIL – posaconazole tab delayed release 100 mg......5
NUCYNTA ER – tapentadol hcl tab sr 12hr 100 mg..........73
NUCYNTA ER – tapentadol hcl tab sr 12hr 50 mg........... 73
NUCYNTA – tapentadol hcl tab 100 mg........................... 73
NUCYNTA – tapentadol hcl tab 50 mg............................. 73
NUCYNTA – tapentadol hcl tab 75 mg............................. 73
NUEDEXTA – dextromethorphan hbr-quinidine sulfate cap
20-10 mg......................................................................... 68
NUTROPIN AQ NUSPIN 10 – somatropin inj 10
mg/2ml............................................................................. 27
NUTROPIN AQ NUSPIN 20 – somatropin inj 20
mg/2ml............................................................................. 27
NUTROPIN AQ NUSPIN 5 – somatropin inj 5 mg/2ml...... 27
NUTROPIN AQ PEN – somatropin inj 10 mg/2ml............. 27
NUTROPIN AQ PEN – somatropin inj 20 mg/2ml............. 27
NUVARING – etonogestrel-ethinyl estradiol va ring
0.120-0.015 mg/24hr....................................................... 18
NUVIGIL – armodafinil tab 150 mg................................... 66
NUVIGIL – armodafinil tab 50 mg.....................................66
NYMALIZE – nimodipine oral soln 60 mg/20ml.................32
nystatin cream 100000 unit/gm......................................99
nystatin oint 100000 unit/gm..........................................99
nystatin oral powder......................................................... 5
nystatin susp 100000 unit/ml......................................... 93
nystatin tab 500000 unit................................................... 5
nystatin topical powder .................................................99
nystatin-triamcinolone cream 100000-0.1 unit/gm%......................................................................................99
nystatin-triamcinolone oint 100000-0.1 unit/gm-%....... 99
137
2015
O
octreotide acetate inj 1000 mcg/ml (1 mg/ml)
(Sandostatin).................................................................. 27
octreotide acetate inj 100 mcg/ml (0.1 mg/ml)
(Sandostatin).................................................................. 27
(Sandostatin).................................................................. 27
(Sandostatin).................................................................. 27
(Sandostatin).................................................................. 27
OFEV – nintedanib esylate cap 100 mg (base
equivalent)....................................................................... 48
OFEV – nintedanib esylate cap 150 mg (base
equivalent)....................................................................... 48
OFLOXACIN – ofloxacin tab 400 mg.................................. 4
ofloxacin ophth soln 0.3% (Ocuflox)............................. 91
ofloxacin otic soln 0.3%................................................. 93
OGESTREL – norgestrel & ethinyl estradiol tab 0.5 mg-50
mcg.................................................................................. 18
olanzapine-fluoxetine hcl cap 12-25 mg (Symbyax).....68
olanzapine-fluoxetine hcl cap 12-50 mg (Symbyax).....68
olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax).......68
olanzapine orally disintegrating tab 10 mg (Zyprexa
zydis)...............................................................................61
zydis)...............................................................................61
zydis)...............................................................................61
zydis)...............................................................................61
olanzapine tab 10 mg (Zyprexa).................................... 61
olanzapine tab 2.5 mg (Zyprexa)................................... 61
olanzapine tab 5 mg (Zyprexa)...................................... 61
olanzapine tab 7.5 mg (Zyprexa)................................... 61
OLEPTRO – trazodone hcl tab sr 24hr 150 mg................ 59
OLEPTRO – trazodone hcl tab sr 24hr 300 mg................ 59
olopatadine hcl nasal soln 0.6% (Patanase)................. 44
OLYSIO – simeprevir sodium cap 150 mg (base
equivalent)......................................................................... 7
OMECLAMOX-PAK – amoxicillin cap-clarithro tab w/
omepraz cap dr therapy pack..........................................50
omega-3-acid ethyl esters cap 1 gm (Lovaza).............. 41
omeprazole cap delayed release 10 mg (Prilosec)....... 50
omeprazole-sodium bicarbonate cap 20-1100 mg
(Zegerid)..........................................................................50
omeprazole-sodium bicarbonate cap 40-1100 mg
(Zegerid)..........................................................................50
OMNARIS – ciclesonide nasal susp 50 mcg/act............... 44
138
OMNITROPE – somatropin for inj 5.8 mg.........................27
OMNITROPE – somatropin inj 10 mg/1.5ml..................... 27
OMNITROPE – somatropin inj 5 mg/1.5ml....................... 27
ondansetron hcl oral soln 4 mg/5ml (Zofran)............... 51
ondansetron hcl tab 24 mg............................................ 51
ondansetron hcl tab 4 mg (Zofran)................................51
ondansetron hcl tab 8 mg (Zofran)................................51
ondansetron orally disintegrating tab 4 mg (Zofran
odt).................................................................................. 51
ondansetron orally disintegrating tab 8 mg (Zofran
odt).................................................................................. 51
ONETOUCH ULTRA BLUE – glucose blood test
strip................................................................................ 103
ONETOUCH ULTRA TEST STRIP – glucose blood test
strip................................................................................ 103
ONETOUCH VERIO TEST STRIP – glucose blood test
strip................................................................................ 103
ONFI – clobazam suspension 2.5 mg/ml.......................... 81
ONFI – clobazam tab 10 mg.............................................81
ONFI – clobazam tab 20 mg.............................................81
ONGLYZA – saxagliptin hcl tab 2.5 mg (base equiv)........ 21
ONGLYZA – saxagliptin hcl tab 5 mg (base equiv)........... 21
ONMEL – itraconazole tab 200 mg.....................................5
OPANA ER (CRUSH RESISTANT – oxymorphone hcl tab
er 12hr deter 10 mg........................................................ 73
er 12hr deter 15 mg........................................................ 73
er 12hr deter 20 mg........................................................ 73
er 12hr deter 30 mg........................................................ 73
er 12hr deter 40 mg........................................................ 73
er 12hr deter 5 mg.......................................................... 73
er 12hr deter 7.5 mg....................................................... 73
ophthalmic irrigation solution - intraocular (Bss
plus)................................................................................ 91
OPIUM TINCTURE (PAREGORIC – paregoric 2
mg/5ml............................................................................. 48
opium tincture 1% (10 mg/ml) (morphine equiv).......... 48
OPSUMIT – macitentan tab 10 mg................................... 42
ORACEA – doxycycline (rosacea) cap delayed release 40
mg.................................................................................... 99
oral contraceptives – all generics................................. 19
ORAP – pimozide tab 1 mg.............................................. 68
ORAP – pimozide tab 2 mg.............................................. 68
ORENCIA – abatacept subcutaneous soln prefilled syringe
125 mg/ml........................................................................76
ORENITRAM – treprostinil diolamine tab cr 0.125 mg
(base equiv).....................................................................42
ORENITRAM – treprostinil diolamine tab cr 0.25 mg (base
equiv)............................................................................... 42
ORENITRAM – treprostinil diolamine tab cr 1 mg (base
equiv)............................................................................... 42
2015
ORENITRAM – treprostinil diolamine tab cr 2.5 mg (base
equiv)............................................................................... 42
ORFADIN – nitisinone cap 10 mg.....................................27
ORFADIN – nitisinone cap 2 mg.......................................27
ORFADIN – nitisinone cap 5 mg.......................................27
ORKAMBI – lumacaftor-ivacaftor tab 200-125 mg............ 48
orphenadrine citrate tab sr 12hr 100 mg.......................84
orphenadrine w/ aspirin & caffeine tab 25-385-30
mg....................................................................................84
ORTHO TRI-CYCLEN LO – norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg.................................. 19
OSENI – alogliptin-pioglitazone tab 12.5-15 mg............... 21
OSENI – alogliptin-pioglitazone tab 25-15 mg.................. 21
OSMOPREP – sod phos mono-sod phos di tabs
1.102-0.398 gm(1.5gm na phos)..................................... 48
OTEZLA – apremilast tab 30 mg...................................... 76
OTEZLA – apremilast tab starter therapy pack 10 mg & 20
mg & 30 mg.....................................................................76
OTICIN HC NR – pramoxine-hc-chloroxylenol otic soln
10-10-1 mg/ml................................................................. 93
OTOZIN – antipyrine-benzocaine-glycerin-zinc ace otic
liqd 5.4-1-2-1%................................................................ 93
OTREXUP – methotrexate soln pf auto-injector 10
mg/0.4ml.......................................................................... 76
mg/0.4ml.......................................................................... 76
mg/0.4ml.......................................................................... 77
mg/0.4ml.......................................................................... 77
OVACE PLUS – sulfacetamide sodium cream 10%..........99
OVACE PLUS – sulfacetamide sodium foam 9.8%...........99
OVACE PLUS – sulfacetamide sodium lotion 9.8%.......... 99
OVIDREL – Benefit Limits may apply –
choriogonadotropin alfa inj 250 mcg/0.5ml......................27
oxandrolone tab 10 mg (Oxandrin)................................16
oxandrolone tab 2.5 mg (Oxandrin)...............................16
oxaprozin tab 600 mg (Daypro)..................................... 77
oxazepam cap 10 mg...................................................... 56
oxazepam cap 15 mg...................................................... 56
oxazepam cap 30 mg...................................................... 56
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
(Trileptal).........................................................................81
oxcarbazepine tab 150 mg (Trileptal)............................ 81
OXISTAT – oxiconazole nitrate cream 1%........................99
OXISTAT – oxiconazole nitrate lotion 1%......................... 99
OXSORALEN – methoxsalen lotion 1%............................99
OXTELLAR XR – oxcarbazepine tab sr 24hr 150 mg....... 81
oxybutynin chloride syrup 5 mg/5ml.............................54
oxybutynin chloride tab 5 mg........................................ 54
oxybutynin chloride tab sr 24hr 10 mg (Ditropan
xl).....................................................................................54
oxybutynin chloride tab sr 24hr 15 mg (Ditropan
xl).....................................................................................54
oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)......54
oxycodone-aspirin tab 4.8355-325 mg (Percodan)....... 73
oxycodone hcl cap 5 mg................................................ 73
oxycodone hcl conc 100 mg/5ml (20 mg/ml)
(Oxycodone hcl).............................................................73
OXYCODONE HCL – oxycodone hcl conc 100 mg/5ml (20
mg/ml).............................................................................. 73
oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)........... 73
oxycodone hcl tab 10 mg...............................................73
oxycodone hcl tab 15 mg (Roxicodone)....................... 73
oxycodone hcl tab 20 mg...............................................73
oxycodone hcl tab 30 mg (Roxicodone)....................... 73
oxycodone hcl tab 5 mg (Roxicodone)......................... 73
oxycodone-ibuprofen tab 5-400 mg...............................74
oxycodone w/ acetaminophen tab 10-325 mg
(Percocet)....................................................................... 73
oxycodone w/ acetaminophen tab 2.5-325 mg
(Percocet)....................................................................... 73
oxycodone w/ acetaminophen tab 5-325 mg
(Percocet)....................................................................... 73
oxycodone w/ acetaminophen tab 7.5-325 mg
(Percocet)....................................................................... 73
OXYCONTIN – oxycodone hcl tab er 12hr deter 10
mg.................................................................................... 74
mg.................................................................................... 74
mg.................................................................................... 74
mg.................................................................................... 74
mg.................................................................................... 74
mg.................................................................................... 74
mg.................................................................................... 74
oxymorphone hcl tab 10 mg (Opana)............................74
oxymorphone hcl tab 5 mg (Opana)..............................74
oxymorphone hcl tab sr 12hr 10 mg............................. 74
oxymorphone hcl tab sr 12hr 5 mg............................... 74
oxymorphone hcl tab sr 12hr 7.5 mg............................ 74
OXYTROL – oxybutynin td patch twice weekly 3.9
mg/24hr............................................................................54
139
2015
P
PANCREAZE – pancrelipase (lip-prot-amyl) dr cap
10500-25000-43750 unit..................................................51
16800-40000-70000 unit..................................................51
21000-37000-61000 unit..................................................51
4200-10000-17500 unit....................................................51
PANCRELIPASE – pancrelipase (lip-prot-amyl) dr cap
5000-17000-27000 unit....................................................51
PANDEL – hydrocortisone probutate cream 0.1%............ 99
PANRETIN – alitretinoin gel 0.1%.................................... 99
pantoprazole sodium ec tab 20 mg (base equiv)
(Protonix)........................................................................ 50
pantoprazole sodium ec tab 40 mg (base equiv)
(Protonix)........................................................................ 50
paricalcitol cap 1 mcg (Zemplar)................................... 27
paromomycin sulfate cap 250 mg................................... 4
paroxetine hcl tab 10 mg (Paxil).................................... 59
paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)................ 59
paroxetine hcl tab sr 24hr 25 mg (Paxil cr)...................59
paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)................ 59
PATADAY – olopatadine hcl ophth soln 0.2%...................91
PATANOL – olopatadine hcl ophth soln 0.1%...................91
PAXIL – paroxetine hcl oral susp 10 mg/5ml (base
equiv)............................................................................... 59
PCE – erythromycin w/ enteric coated particles tab 333
mg...................................................................................... 3
PCE – erythromycin w/ enteric coated particles tab 500
mg...................................................................................... 3
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm
(Golytely)........................................................................ 48
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm
(Colyte-flavor packs)..................................................... 48
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
(Nulytely/flavor pack).................................................... 48
PEGASYS – peginterferon alfa-2a inj 180 mcg/0.5ml......... 7
PEGASYS – peginterferon alfa-2a inj 180 mcg/ml.............. 7
PEGASYS PROCLICK – peginterferon alfa-2a inj 135
mcg/0.5ml.......................................................................... 7
PEGASYS PROCLICK – peginterferon alfa-2a inj 180
mcg/0.5ml.......................................................................... 7
PEGINTRON – peginterferon alfa-2b for inj kit 120
mcg/0.5ml.......................................................................... 7
PEG-INTRON – peginterferon alfa-2b for inj kit 120
mcg/0.5ml.......................................................................... 7
mcg/0.5ml.......................................................................... 7
140
mcg/0.5ml.......................................................................... 7
mcg/0.5ml.......................................................................... 7
mcg/0.5ml.......................................................................... 7
mcg/0.5ml.......................................................................... 7
mcg/0.5ml.......................................................................... 7
PEG-INTRON REDIPEN PAK 4 – peginterferon alfa-2b for
inj kit 120 mcg/0.5ml......................................................... 7
inj kit 150 mcg/0.5ml......................................................... 7
inj kit 50 mcg/0.5ml........................................................... 7
inj kit 80 mcg/0.5ml........................................................... 7
PEG-INTRON REDIPEN – peginterferon alfa-2b for inj kit
120 mcg/0.5ml................................................................... 7
150 mcg/0.5ml................................................................... 7
50 mcg/0.5ml..................................................................... 7
80 mcg/0.5ml..................................................................... 7
penicillin v potassium for soln 125 mg/5ml.................... 1
penicillin v potassium for soln 250 mg/5ml.................... 1
penicillin v potassium tab 250 mg...................................1
penicillin v potassium tab 500 mg...................................1
PENNSAID – diclofenac sodium soln 2%......................... 99
PENTASA – mesalamine cap cr 250 mg.......................... 53
PENTASA – mesalamine cap cr 500 mg.......................... 53
pentazocine w/ naloxone tab 50-0.5 mg........................74
pentoxifylline tab cr 400 mg...........................................89
PERFOROMIST – formoterol fumarate soln nebu 20
mcg/2ml........................................................................... 47
perindopril erbumine tab 2 mg...................................... 36
perindopril erbumine tab 4 mg (Aceon)........................ 37
perindopril erbumine tab 8 mg (Aceon)........................ 37
PERJETA – pertuzumab soln for iv infusion 420 mg/14ml
(30 mg/ml)....................................................................... 13
permethrin cream 5% (Elimite)...................................... 99
PERPHENAZINE/AMITRIPTYLIN – perphenazineamitriptyline tab 2-10 mg................................................. 68
PERPHENAZINE/AMITRIPTYLIN – perphenazineamitriptyline tab 2-25 mg.................................................68
PERPHENAZINE/AMITRIPTYLIN – perphenazineamitriptyline tab 4-10 mg................................................. 68
perphenazine tab 16 mg................................................. 61
perphenazine tab 2 mg................................................... 61
2015
PERTZYE – pancrelipase (lip-prot-amyl) dr cap
16000-57500-60500 unit..................................................51
PERTZYE – pancrelipase (lip-prot-amyl) dr cap
8000-28750-30250 unit....................................................51
PEXEVA – paroxetine mesylate tab 10 mg (base
equiv)............................................................................... 59
equiv)............................................................................... 59
equiv)............................................................................... 59
equiv)............................................................................... 59
phenazopyridine hcl tab 100 mg (Pyridium)................. 55
phenazopyridine hcl tab 200 mg (Pyridium)................. 55
phenelzine sulfate tab 15 mg (Nardil)............................59
phenobarbital elixir 20 mg/5ml...................................... 63
PHENOBARBITAL – phenobarbital tab 100 mg............... 63
PHENOBARBITAL – phenobarbital tab 15 mg................. 63
phenobarbital tab 16.2 mg............................................. 63
phenoxybenzamine hcl cap 10 mg (Dibenzyline)......... 37
phenylephrine-brompheniramine-dm liquid 7.5-4-15
mg/5ml............................................................................ 44
phenylephrine-guaifenesin liqd 7.5-100 mg/5ml (1.5-20
mg/ml)............................................................................. 44
phenylephrine hcl ophth soln 10%................................91
phenylephrine hcl ophth soln 2.5%...............................91
phenylephrine w/ dm-gg liqd 10-15-300 mg/5ml...........44
phenylephrine w/ dm-gg liqd 10-30-200 mg/5ml...........44
phenylephrine w/ dm-gg liqd 2.5-5-50 mg/ml................44
phenylephrine w/ dm-gg liqd 2.5-7.5-88 mg/ml.............44
PHENYTEK – phenytoin sodium extended cap 200
mg.................................................................................... 81
PHENYTEK – phenytoin sodium extended cap 300
mg.................................................................................... 81
phenytoin chew tab 50 mg (Dilantin infatabs).............. 81
phenytoin sodium extended cap 100 mg (Dilantin)......81
phenytoin susp 125 mg/5ml (Dilantin).......................... 81
PHOSLYRA – calcium acetate (phosphate binder) oral
soln 667 mg/5ml.............................................................. 53
PHOSPHOLINE IODIDE – echothiophate iodide ophth for
soln 0.125%.....................................................................91
PICATO – ingenol mebutate gel 0.015%.......................... 99
PICATO – ingenol mebutate gel 0.05%............................ 99
pilocarpine hcl ophth soln 1% (Isopto carpine)............92
pilocarpine hcl tab 5 mg (Salagen)................................93
pilocarpine hcl tab 7.5 mg (Salagen).............................93
pindolol tab 10 mg.......................................................... 30
pindolol tab 5 mg............................................................ 30
pioglitazone hcl-glimepiride tab 30-2 mg (Duetact)......21
pioglitazone hcl-glimepiride tab 30-4 mg (Duetact)......21
pioglitazone hcl-metformin hcl tab 15-500 mg
(Actoplus met)............................................................... 21
pioglitazone hcl-metformin hcl tab 15-850 mg
(Actoplus met)............................................................... 21
pioglitazone hcl tab 15 mg (base equiv) (Actos).......... 21
piroxicam cap 10 mg (Feldene)..................................... 77
piroxicam cap 20 mg (Feldene)..................................... 77
PLEGRIDY – peginterferon beta-1a soln pen-injector 125
mcg/0.5ml........................................................................ 68
PLEGRIDY – peginterferon beta-1a soln prefilled syringe
125 mcg/0.5ml................................................................. 68
PLEGRIDY STARTER PACK – peginterferon beta-1a soln
pen-inj 63 & 94 mcg/0.5ml pack......................................69
PLEGRIDY STARTER PACK – peginterferon beta-1a soln
pref syr 63 & 94 mcg/0.5ml pack.................................... 69
podofilox soln 0.5% (Condylox).....................................99
polyethylene glycol 3350 oral packet............................48
polymyxin b-trimethoprim ophth soln 10000 unit/
ml-0.1% (Polytrim)......................................................... 92
POMALYST – pomalidomide cap 1 mg............................ 13
pot & sod citrates w/ cit ac soln 550-500-334
mg/5ml............................................................................ 55
potassium bicarbonate effer tab 25 meq...................... 85
potassium chloride cap cr 10 meq (Micro-k)................ 85
potassium chloride cap cr 8 meq (Micro-k).................. 85
POTASSIUM CHLORIDE ER – potassium chloride tab cr
8 meq (600 mg)...............................................................85
potassium chloride microencapsulated crys cr tab 10
meq..................................................................................85
potassium chloride microencapsulated crys cr tab 20
meq..................................................................................85
potassium chloride oral liq 10% (20 meq/15ml)............85
potassium chloride oral liq 20% (40 meq/15ml)............85
potassium chloride powder packet 20 meq..................85
potassium chloride tab cr 10 meq (K-tab).................... 85
potassium chloride tab cr 8 meq (600 mg)................... 85
potassium citrate & citric acid powder pack 3300-1002
mg....................................................................................55
potassium citrate & citric acid soln 1100-334
mg/5ml............................................................................ 55
potassium citrate tab cr 10 meq (1080 mg) (Urocit-k
10)....................................................................................55
15)....................................................................................55
5)......................................................................................55
pot bicarbonate & chloride effer tab 25 meq................ 85
POTIGA – ezogabine tab 200 mg.....................................81
141
2015
POTIGA – ezogabine tab 50 mg.......................................81
pot phos monobasic w/sod phos di & monobas tab
155-852-130mg (K-phos neutral).................................. 85
PRADAXA – dabigatran etexilate mesylate cap 150 mg
(etexilate base eq)...........................................................89
PRADAXA – dabigatran etexilate mesylate cap 75 mg
(etexilate base eq)...........................................................89
PRALUENT – alirocumab subcutaneous soln pen-injector
150 mg/ml........................................................................41
PRALUENT – alirocumab subcutaneous soln pen-injector
75 mg/ml..........................................................................41
PRALUENT – alirocumab subcutaneous soln prefilled
syringe 150 mg/ml........................................................... 41
PRALUENT – alirocumab subcutaneous soln prefilled
syringe 75 mg/ml............................................................. 41
pramipexole dihydrochloride tab 0.125 mg
(Mirapex)......................................................................... 83
(Mirapex)......................................................................... 83
pramipexole dihydrochloride tab 0.5 mg (Mirapex)......83
(Mirapex)......................................................................... 83
pramipexole dihydrochloride tab 1.5 mg (Mirapex)......83
pramipexole dihydrochloride tab 1 mg (Mirapex)........ 83
pramipexole dihydrochloride tab sr 24hr 0.375 mg
(Mirapex er).................................................................... 83
(Mirapex er).................................................................... 83
(Mirapex er).................................................................... 83
pramipexole dihydrochloride tab sr 24hr 3 mg
(Mirapex er).................................................................... 83
(Mirapex er).................................................................... 83
PRAMOSONE – pramoxine-hc cream 1-1%.....................99
PRAMOSONE – pramoxine-hc cream 1-2.5%.................. 99
PRAMOSONE – pramoxine-hc lotion 1-1%...................... 99
PRAMOSONE – pramoxine-hc lotion 1-2.5%................... 99
PRAMOSONE – pramoxine-hc oint 1-1%......................... 99
PRAMOSONE – pramoxine-hc oint 1-2.5%...................... 99
pramoxine-chloroxylenol otic liquid 1-0.1%
(Pramotic)....................................................................... 93
pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml
(Cortane-b-otic).............................................................. 93
pramoxine-hc cream 1-2.5% (Pramosone).................... 99
pramoxine hcl gel 1%..................................................... 99
PRANDIMET – repaglinide-metformin hcl tab 1-500
mg.................................................................................... 21
PRANDIMET – repaglinide-metformin hcl tab 2-500
mg.................................................................................... 21
pravastatin sodium tab 10 mg....................................... 41
pravastatin sodium tab 20 mg (Pravachol)................... 41
prazosin hcl cap 1 mg (Minipress)................................ 37
142
PR CREAM – dermatological products misc - kit.............. 99
prednicarbate cream 0.1% (Dermatop)..........................99
prednicarbate oint 0.1% (Dermatop)..............................99
prednisolone acetate ophth susp 1% (Pred forte)........92
PREDNISOLONE SODIUM PHOSP – prednisolone
sodium phosphate ophth soln 1%................................... 92
prednisolone sod phos orally disintegr tab 10 mg
(base eq) (Orapred odt)................................................ 15
prednisolone sod phosphate oral soln 15 mg/5ml
(base equiv)....................................................................15
prednisolone sod phosph oral soln 6.7 mg/5ml (5
mg/5ml base) (Pediapred).............................................15
prednisolone syrup 15 mg/5ml (usp solution
equivalent) (Prelone)..................................................... 15
PREDNISONE – prednisone oral soln 5 mg/5ml.............. 15
PREDNISONE – prednisone tab 10 mg dose pack...........15
PREDNISONE – prednisone tab 50 mg............................15
PREDNISONE – prednisone tab 5 mg dose pack............ 15
prednisone tab 10 mg.....................................................16
prednisone tab 1 mg.......................................................16
prednisone tab 2.5 mg....................................................16
prednisone tab 20 mg.....................................................16
prednisone tab 5 mg.......................................................16
PREFEST – estradiol tab 1 mg(15)/estrad-norgestimate
tab 1-0.09mg(15)............................................................. 18
PREMARIN – estrogens, conjugated tab 0.3 mg.............. 18
PREMARIN – estrogens, conjugated tab 0.45 mg............ 18
PREMARIN – estrogens, conjugated tab 0.625 mg.......... 18
PREMARIN – estrogens, conjugated tab 0.9 mg.............. 18
PREMARIN – estrogens, conjugated tab 1.25 mg............ 18
PREMARIN – estrogens, conjugated vaginal cream 0.625
mg/gm.............................................................................. 55
PREMPHASE – conj est 0.625(14)/conj est-medroxypro
ac tab 0.625-5mg(14)...................................................... 18
PREMPRO – conjugated estrogen-medroxyprogest
acetate tab 0.3-1.5 mg.................................................... 18
acetate tab 0.45-1.5 mg.................................................. 18
acetate tab 0.625-2.5 mg................................................ 18
acetate tab 0.625-5 mg................................................... 18
PREPOPIK – sod picosulfate-mg oxide-citric acid pack 10
mg-3.5 gm-12 gm............................................................ 48
PREZCOBIX – darunavir-cobicistat tab 800-150 mg.......... 7
PREZISTA – darunavir ethanolate susp 100 mg/ml (base
equiv)................................................................................. 7
PREZISTA – darunavir ethanolate tab 150 mg (base
equiv)................................................................................. 7
2015
equiv)................................................................................. 7
equiv)................................................................................. 7
equiv)................................................................................. 7
PRILOSEC – omeprazole magnesium for delayed release
susp packet 10 mg.......................................................... 50
PRILOSEC – omeprazole magnesium for delayed release
susp packet 2.5 mg......................................................... 50
PRIMAQUINE PHOSPHATE – primaquine phosphate tab
26.3 mg (15 mg base).....................................................10
primidone tab 250 mg (Mysoline).................................. 81
primidone tab 50 mg (Mysoline).................................... 81
PRIMLEV – oxycodone w/ acetaminophen tab 5-300
mg.................................................................................... 74
PRIMLEV – oxycodone w/ acetaminophen tab 7.5-300
mg.................................................................................... 74
PRIMSOL – trimethoprim hcl oral soln 50 mg/5ml (base
equiv)............................................................................... 10
PRISTIQ – desvenlafaxine succinate tab sr 24hr 100 mg
(base equiv).....................................................................59
(base equiv).....................................................................59
(base equiv).....................................................................59
PROAIR HFA – albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv).........................................................47
PROAIR RESPICLICK – albuterol sulfate aer pow ba 108
mcg/act (90 mcg base equiv).......................................... 47
probenecid tab 500 mg...................................................78
prochlorperazine maleate tab 10 mg (base equivalent)
(Compazine)................................................................... 61
prochlorperazine maleate tab 5 mg (base equivalent)
(Compazine)................................................................... 61
prochlorperazine suppos 25 mg....................................61
PROCRIT – epoetin alfa inj 10000 unit/ml........................ 87
PROCRIT – epoetin alfa inj 2000 unit/ml.......................... 87
PROCTOFOAM HC – hydrocortisone acetate w/
pramoxine rectal foam 1-1%........................................... 94
PROCYSBI – cysteamine bitartrate cap delayed release
25 mg (base equiv)......................................................... 55
PROCYSBI – cysteamine bitartrate cap delayed release
75 mg (base equiv)......................................................... 55
PROFERRIN-FORTE – iron heme polypeptide-folic acid
tab 12-1 mg (fe equiv).....................................................87
progesterone im in oil 50 mg/ml....................................19
progesterone micronized cap 100 mg
(Prometrium).................................................................. 19
progesterone micronized cap 200 mg
(Prometrium).................................................................. 19
PROGRAF – tacrolimus cap 0.5 mg............................... 103
PROGRAF – tacrolimus cap 1 mg.................................. 103
PROGRAF – tacrolimus cap 5 mg.................................. 103
PROLENSA – bromfenac sodium ophth soln 0.07% (base
equivalent)....................................................................... 92
PROMACTA – eltrombopag olamine tab 12.5 mg (base
equiv)............................................................................... 87
PROMACTA – eltrombopag olamine tab 25 mg (base
equiv)............................................................................... 87
equiv)............................................................................... 88
equiv)............................................................................... 88
promethazine-dm syrup 6.25-15 mg/5ml....................... 45
promethazine hcl suppos 12.5 mg................................ 43
promethazine hcl suppos 25 mg................................... 43
promethazine hcl suppos 50 mg................................... 43
promethazine hcl syrup 6.25 mg/5ml............................ 43
promethazine hcl tab 12.5 mg........................................43
promethazine hcl tab 25 mg...........................................43
promethazine hcl tab 50 mg...........................................43
PROMETHAZINE VC PLAIN – promethazine &
phenylephrine syrup 6.25-5 mg/5ml................................ 44
promethazine w/ codeine syrup 6.25-10 mg/5ml.......... 45
propafenone hcl cap sr 12hr 225 mg (Rythmol sr)....... 33
propafenone hcl tab 150 mg (Rythmol).........................33
propafenone hcl tab 225 mg (Rythmol).........................33
propafenone hcl tab 300 mg.......................................... 33
PROPANTHELINE BROMIDE – propantheline bromide
tab 15 mg........................................................................ 50
proparacaine hcl ophth soln 0.5% (Alcaine).................92
PROPRANOLOL/HYDROCHLOROTH – propranolol &
PROPRANOLOL/HYDROCHLOROTH – propranolol &
propranolol hcl cap sr 24hr 120 mg (Inderal la)........... 31
propranolol hcl cap sr 24hr 160 mg (Inderal la)........... 31
propranolol hcl cap sr 24hr 60 mg (Inderal la)............. 30
propranolol hcl cap sr 24hr 80 mg (Inderal la)............. 30
PROPRANOLOL HCL – propranolol hcl oral soln 20
mg/5ml............................................................................. 30
PROPRANOLOL HCL – propranolol hcl oral soln 40
mg/5ml............................................................................. 30
propranolol hcl tab 10 mg..............................................31
propylthiouracil tab 50 mg............................................. 23
PROTONIX – pantoprazole sodium for delayed release
susp packet 40 mg.......................................................... 50
protriptyline hcl tab 10 mg............................................. 59
protriptyline hcl tab 5 mg...............................................59
PROVENTIL HFA – albuterol sulfate inhal aero 108 mcg/
act (90mcg base equiv)...................................................47
143
2015
PRUCLAIR – dermatological products misc - cream.........99
PRUDOXIN – doxepin hcl cream 5%................................99
PRUMYX – dermatological products misc - cream........... 99
PRUTECT – wound dressings - emulsion.........................99
pseudoeph-chlorphen w/ hydrocodone soln 60-4-5
mg/5ml (Zutripro)........................................................... 45
pseudoephed-bromphen-dm syrup 30-2-10
mg/5ml............................................................................ 45
PULMICORT – budesonide inhalation susp 1 mg/2ml...... 47
PULMOZYME – dornase alfa inhal soln 1 mg/ml..............48
PUREFE PLUS – ferrous fumarate-fa-b complex-c-zn-mgmn-cu cap 106-1 mg....................................................... 88
PYLERA – bismuth subcit-metronidazole-tetracycline cap
140-125-125 mg.............................................................. 50
pyrazinamide tab 500 mg................................................. 4
pyridostigmine bromide tab 60 mg (Mestinon).............84
pyridostigmine bromide tab cr 180 mg (Mestinon
timespan)........................................................................ 84
Q
QNASL – beclomethasone dipropionate nasal aerosol 80
mcg/act............................................................................ 44
QNASL CHILDRENS – beclomethasone dipropionate
nasal aerosol 40 mcg/act................................................ 44
QSYMIA – phentermine hcl-topiramate cap sr 24hr
11.25-69 mg.................................................................... 66
QSYMIA – phentermine hcl-topiramate cap sr 24hr 15-92
mg.................................................................................... 66
QSYMIA – phentermine hcl-topiramate cap sr 24hr
3.75-23 mg...................................................................... 66
QSYMIA – phentermine hcl-topiramate cap sr 24hr 7.5-46
mg.................................................................................... 66
quetiapine fumarate tab 100 mg (Seroquel)..................62
quetiapine fumarate tab 25 mg (Seroquel)....................61
quetiapine fumarate tab 50 mg (Seroquel)....................61
QUILLIVANT XR – methylphenidate hcl for er susp 25
mg/5ml (5 mg/ml)............................................................ 66
quinapril hcl tab 10 mg (Accupril)................................. 37
quinapril hcl tab 5 mg (Accupril)................................... 37
quinapril-hydrochlorothiazide tab 10-12.5 mg
(Accuretic)...................................................................... 37
quinapril-hydrochlorothiazide tab 20-12.5 mg
(Accuretic)...................................................................... 37
quinapril-hydrochlorothiazide tab 20-25 mg
(Accuretic)...................................................................... 37
quinidine gluconate tab cr 324 mg................................33
QUINIDINE SULFATE ER – quinidine sulfate tab cr 300
mg.................................................................................... 33
QUINIDINE SULFATE – quinidine sulfate tab 200 mg...... 33
quinidine sulfate tab 300 mg..........................................33
quinine sulfate cap 324 mg (Qualaquin)....................... 10
144
QVAR – beclomethasone dipropionate inhal aero soln 40
mcg/act............................................................................ 47
QVAR – beclomethasone dipropionate inhal aero soln 80
mcg/act............................................................................ 47
R
rabeprazole sodium ec tab 20 mg (Aciphex)................ 50
raloxifene hcl tab 60 mg (Evista)................................... 27
ramipril cap 1.25 mg (Altace)......................................... 37
ramipril cap 10 mg (Altace)............................................ 37
ramipril cap 2.5 mg (Altace)........................................... 37
ramipril cap 5 mg (Altace)..............................................37
RANEXA – ranolazine tab sr 12hr 1000 mg......................30
RANEXA – ranolazine tab sr 12hr 500 mg....................... 29
ranitidine hcl cap 150 mg – is not covered, it is
available OTC................................................................. 50
ranitidine hcl cap 300 mg...............................................50
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)................... 50
ranitidine hcl tab 150 mg – is not covered, it is
available OTC (Zantac)..................................................50
ranitidine hcl tab 300 mg (Zantac).................................50
RAPAFLO – silodosin cap 4 mg....................................... 55
RAPAFLO – silodosin cap 8 mg....................................... 55
RAPAMUNE – sirolimus oral soln 1 mg/ml..................... 103
RAPAMUNE – sirolimus tab 0.5 mg............................... 104
RAPAMUNE – sirolimus tab 1 mg.................................. 104
RAPAMUNE – sirolimus tab 2 mg.................................. 104
RASUVO – methotrexate soln pf auto-injector 10
mg/0.2ml.......................................................................... 77
RASUVO – methotrexate soln pf auto-injector 12.5
mg/0.25ml........................................................................ 77
mg/0.3ml.......................................................................... 77
mg/0.35ml........................................................................ 77
mg/0.4ml.......................................................................... 77
mg/0.45ml........................................................................ 77
mg/0.5ml.......................................................................... 77
mg/0.55ml........................................................................ 77
mg/0.6ml.......................................................................... 77
mg/0.15ml........................................................................ 77
RAVICTI – glycerol phenylbutyrate liquid 1.1 gm/ml......... 27
REBETOL – ribavirin cap 200 mg.......................................7
REBETOL – ribavirin soln 40 mg/ml................................... 7
REBIF – interferon beta-1a inj 22 mcg/0.5ml (12mu/ml)
(44 mcg/ml)......................................................................69
REBIF – interferon beta-1a inj 44 mcg/0.5ml (24mu/ml)
(88 mcg/ml)......................................................................69
REBIF REBIDOSE – interferon beta-1a inj 22 mcg/0.5ml
(12mu/ml) (44 mcg/ml).................................................... 69
2015
REBIF REBIDOSE – interferon beta-1a inj 44 mcg/0.5ml
(24mu/ml) (88 mcg/ml).................................................... 69
REBIF REBIDOSE TITRATION – interferon beta-1a inj 6 x
8.8 mcg/0.2ml & 6 x 22 mcg/0.5ml..................................69
REBIF TITRATION PACK – interferon beta-1a inj 6 x 8.8
mcg/0.2ml & 6 x 22 mcg/0.5ml........................................69
REGRANEX – becaplermin gel 0.01%............................. 99
RELENZA DISKHALER – zanamivir aero powder breath
activated 5 mg/blister........................................................ 8
RELHIST – bromphen tan-phenyleph tan chew tab 6-15
mg.................................................................................... 45
RELION R – insulin regular (human) inj 100 unit/ml..........22
RELISTOR – methylnaltrexone bromide inj 12 mg/0.6ml
(20 mg/ml)....................................................................... 53
RELISTOR – methylnaltrexone bromide inj 8 mg/0.4ml (20
mg/ml).............................................................................. 53
RELPAX – eletriptan hydrobromide tab 20 mg (base
equivalent)....................................................................... 78
RELPAX – eletriptan hydrobromide tab 40 mg (base
equivalent)....................................................................... 78
RENAGEL – sevelamer hcl tab 400 mg............................53
RENAGEL – sevelamer hcl tab 800 mg............................53
RENVELA – sevelamer carbonate packet 0.8 gm.............53
RENVELA – sevelamer carbonate packet 2.4 gm.............53
RENVELA – sevelamer carbonate tab 800 mg................. 53
repaglinide tab 0.5 mg (Prandin)................................... 21
repaglinide tab 1 mg (Prandin)...................................... 21
repaglinide tab 2 mg (Prandin)...................................... 21
REPRONEX – Benefit Limits may apply – menotropins for
inj 75 unit.........................................................................27
RESCRIPTOR – delavirdine mesylate tab 100 mg............. 8
RESCRIPTOR – delavirdine mesylate tab 200 mg............. 8
RESCULA – unoprostone isopropyl ophth soln 0.15%......92
RESERPINE – reserpine tab 0.1 mg................................ 37
RESERPINE – reserpine tab 0.25 mg.............................. 37
RESTASIS – cyclosporine (ophth) emulsion 0.05%..........92
RETIN-A MICRO PUMP – tretinoin microsphere gel
0.04%...............................................................................99
0.08%.............................................................................100
0.1%...............................................................................100
RETIN-A MICRO – tretinoin microsphere gel 0.04%.........99
RETIN-A MICRO – tretinoin microsphere gel 0.1%...........99
RETROVIR – zidovudine cap 100 mg................................ 8
RETROVIR – zidovudine syrup 10 mg/ml...........................8
REVATIO – sildenafil citrate for suspension 10 mg/ml...... 42
REVATIO – sildenafil citrate tab 20 mg............................ 42
REVIA – naltrexone hcl tab 50 mg..................................102
REVLIMID – lenalidomide cap 10 mg............................. 104
REVLIMID – lenalidomide cap 5 mg............................... 104
REVLIMID – lenalidomide caps 2.5 mg.......................... 104
REYATAZ – atazanavir sulfate cap 150 mg (base
equiv)................................................................................. 8
equiv)................................................................................. 8
equiv)................................................................................. 8
REYATAZ – atazanavir sulfate oral powder packet 50 mg
(base equiv).......................................................................8
RIBASPHERE RIBAPAK – ribavirin tab 200 mg & ribavirin
tab 400 mg dose pack...................................................... 8
RIBASPHERE RIBAPAK – ribavirin tab 400 mg................. 8
RIBASPHERE RIBAPAK – ribavirin tab 400 mg & ribavirin
tab 600 mg dose pack...................................................... 8
RIBASPHERE RIBAPAK – ribavirin tab 600 mg................. 8
RIBASPHERE – ribavirin tab 400 mg................................. 8
RIBASPHERE – ribavirin tab 600 mg................................. 8
RIBATAB – ribavirin tab 400 mg.........................................8
RIBATAB – ribavirin tab 400 mg & ribavirin tab 600 mg
dose pack.......................................................................... 8
RIBATAB – ribavirin tab 600 mg.........................................8
ribavirin cap 200 mg (Rebetol).........................................8
ribavirin tab 200 mg (Copegus)....................................... 8
RIDAURA – auranofin cap 3 mg.......................................77
rifabutin cap 150 mg (Mycobutin)....................................4
rifampin cap 150 mg (Rifadin)..........................................4
rifampin cap 300 mg (Rifadin)..........................................4
RILUTEK – riluzole tab 50 mg.......................................... 84
riluzole tab 50 mg (Rilutek)............................................ 84
rimantadine hydrochloride tab 100 mg (Flumadine)...... 8
ringer's solution for irrigation......................................104
RIOMET – metformin hcl oral soln 500 mg/5ml................ 21
risedronate sodium tab 150 mg (Actonel).....................28
risedronate sodium tab 30 mg (Actonel)...................... 27
risedronate sodium tab 35 mg (Actonel)...................... 28
risedronate sodium tab 5 mg (Actonel)........................ 27
risedronate sodium tab delayed release 35 mg
(Atelvia)...........................................................................27
risperidone orally disintegrating tab 0.25 mg...............62
risperidone orally disintegrating tab 0.5 mg (Risperdal
m-tab).............................................................................. 62
risperidone orally disintegrating tab 1 mg (Risperdal
m-tab).............................................................................. 62
m-tab).............................................................................. 62
m-tab).............................................................................. 62
m-tab).............................................................................. 62
risperidone soln 1 mg/ml (Risperdal)............................62
risperidone tab 0.25 mg (Risperdal).............................. 62
risperidone tab 0.5 mg (Risperdal)................................ 62
risperidone tab 1 mg (Risperdal)................................... 62
rivastigmine tartrate cap 1.5 mg (Exelon)..................... 69
145
2015
rivastigmine tartrate cap 3 mg (Exelon)........................69
rivastigmine tartrate cap 4.5 mg (Exelon)..................... 69
rivastigmine tartrate cap 6 mg (Exelon)........................69
rizatriptan benzoate orally disintegrating tab 10 mg
(Maxalt-mlt).....................................................................78
rizatriptan benzoate orally disintegrating tab 5 mg
(Maxalt-mlt).....................................................................78
rizatriptan benzoate tab 10 mg (Maxalt)........................78
rizatriptan benzoate tab 5 mg (Maxalt)..........................78
ropinirole hydrochloride tab 0.25 mg (Requip).............83
ropinirole hydrochloride tab 0.5 mg (Requip)...............83
ropinirole hydrochloride tab 1 mg (Requip)................. 83
ropinirole hydrochloride tab sr 24hr 12 mg (base
equivalent) (Requip xl).................................................. 83
ROZEREM – Benefit Limits may apply – ramelteon tab 8
mg.................................................................................... 63
S
SABRIL – vigabatrin powd pack 500 mg.......................... 81
SABRIL – vigabatrin tab 500 mg...................................... 81
SAFYRAL – drospirenone-ethinyl estrad-levomefolate tab
3-0.03-0.451 mg.............................................................. 19
SAIZEN CLICK.EASY – somatropin (non-refrigerated) for
inj 8.8 mg.........................................................................28
SAIZEN – somatropin (non-refrigerated) for inj 5 mg........ 28
SAIZEN – somatropin (non-refrigerated) for inj 8.8 mg..... 28
salicylic acid cream 6%................................................ 100
salicylic acid cream 6% & cleanser liqd kit (Salex
cream)........................................................................... 100
salicylic acid film forming liquid 27.5% (Virasal)........100
salicylic acid film-forming soln 28.5% (Ultrasaler).................................................................................. 100
salicylic acid foam 6% (Salvax)................................... 100
salicylic acid gel 6% (Keralyt)......................................100
SALICYLIC ACID IN AMMONIU – salicylic acid in
ammonium lactate vehicle foam 6%..............................100
salicylic acid lotion 6%.................................................100
salicylic acid lotion 6% & cleanser liqd kit (Salex
lotion)............................................................................ 100
SALICYLIC ACID – salicylic acid soln 26%.................... 100
salicylic acid shampoo 6% (Salex).............................. 100
salsalate tab 500 mg....................................................... 70
salsalate tab 750 mg....................................................... 70
SALVAX – salicylic acid foam 6%...................................100
146
SAMSCA – tolvaptan tab 15 mg....................................... 28
SAMSCA – tolvaptan tab 30 mg....................................... 28
SANCUSO – granisetron td patch 3.1 mg/24hr (contains
34.3 mg).......................................................................... 51
SANDIMMUNE – cyclosporine cap 100 mg.................... 104
SANDIMMUNE – cyclosporine cap 25 mg...................... 104
SANDIMMUNE – cyclosporine oral soln 100 mg/ml........104
SANDOSTATIN – octreotide acetate inj 1000 mcg/ml (1
mg/ml).............................................................................. 28
SANDOSTATIN – octreotide acetate inj 100 mcg/ml (0.1
mg/ml).............................................................................. 28
mg/ml).............................................................................. 28
mg/ml).............................................................................. 28
mg/ml).............................................................................. 28
SAPHRIS – asenapine maleate sl tab 10 mg (base
equiv)............................................................................... 62
SAPHRIS – asenapine maleate sl tab 2.5 mg (base
equiv)............................................................................... 62
SAPHRIS – asenapine maleate sl tab 5 mg (base
equiv)............................................................................... 62
SARAFEM – fluoxetine hcl (pmdd) tab 10 mg.................. 69
SARAFEM – fluoxetine hcl (pmdd) tab 20 mg.................. 69
SAVELLA – milnacipran hcl tab 100 mg........................... 69
SAVELLA – milnacipran hcl tab 12.5 mg.......................... 69
SAVELLA – milnacipran hcl tab 25 mg............................. 69
SAVELLA – milnacipran hcl tab 50 mg............................. 69
SAVELLA TITRATION PACK – milnacipran hcl tab 12.5
mg (5) & 25 mg (8) & 50 mg (42) pak.............................69
scar treatment products - gel...................................... 100
SCLEROSOL INTRAPLEURAL – talc intrapleural aerosol
powder 4 gm (0.4 gm/second)........................................ 48
selegiline hcl cap 5 mg (Eldepryl)................................. 83
selegiline hcl tab 5 mg................................................... 83
selenium sulfide lotion 2.5%........................................ 100
SELZENTRY – maraviroc tab 150 mg................................ 8
SELZENTRY – maraviroc tab 300 mg................................ 8
SENSIPAR – cinacalcet hcl tab 30 mg (base equiv)......... 28
SEREVENT DISKUS – salmeterol xinafoate aer pow ba
50 mcg/dose (base equiv)............................................... 47
SEROQUEL XR – quetiapine fumarate tab sr 24hr 150
mg.................................................................................... 62
mg.................................................................................... 62
mg.................................................................................... 62
mg.................................................................................... 62
mg.................................................................................... 62
SEROSTIM – somatropin (non-refrigerated) for
subcutaneous inj 4 mg.................................................... 28
2015
sertraline hcl oral conc 20 mg/ml (Zoloft).....................59
sertraline hcl tab 100 mg (Zoloft).................................. 59
sertraline hcl tab 25 mg (Zoloft).................................... 59
sertraline hcl tab 50 mg (Zoloft).................................... 59
sevoflurane inhal soln (Ultane)......................................78
SIGNIFOR – pasireotide diaspartate inj 0.3 mg/ml (base
equiv)............................................................................... 28
equiv)............................................................................... 28
equiv)............................................................................... 28
sildenafil citrate tab 20 mg (Revatio).............................42
SILENOR – Benefit Limits may apply – doxepin hcl (sleep)
tab 3 mg (base equiv)..................................................... 63
SILENOR – Benefit Limits may apply – doxepin hcl (sleep)
tab 6 mg (base equiv)..................................................... 63
silver nitrate-potassium nitrate applicator 75-25%
(Arzol silver nitrate).....................................................100
silver sulfadiazine cream 1% (Silvadene)................... 100
SIMBRINZA – brinzolamide-brimonidine tartrate ophth
susp 1-0.2%.....................................................................92
SIMCOR – niacin-simvastatin tab sr 24hr 1000-20 mg..... 41
SIMCOR – niacin-simvastatin tab sr 24hr 1000-40 mg..... 41
SIMCOR – niacin-simvastatin tab sr 24hr 500-20 mg....... 41
SIMPONI – golimumab subcutaneous soln auto-injector
100 mg/ml........................................................................77
SIMPONI – golimumab subcutaneous soln auto-injector
50 mg/0.5ml.....................................................................77
SIMPONI – golimumab subcutaneous soln prefilled
syringe 100 mg/ml........................................................... 77
SIMPONI – golimumab subcutaneous soln prefilled
syringe 50 mg/0.5ml........................................................ 77
simvastatin tab 10 mg (Zocor)....................................... 41
simvastatin tab 5 mg (Zocor)......................................... 41
sirolimus tab 0.5 mg (Rapamune)................................104
sirolimus tab 1 mg (Rapamune)...................................104
sirolimus tab 2 mg (Rapamune)...................................104
SIRTURO – bedaquiline fumarate tab 100 mg (base
equiv)................................................................................. 4
SKLICE – ivermectin lotion 0.5%.................................... 100
sodium chloride irrigation soln 0.9%............................ 55
sodium chloride soln nebu 0.9%................................... 45
sodium chloride soln nebu 10%.................................... 45
sodium chloride soln nebu 3%...................................... 45
sodium chloride soln nebu 7% (Hyper-sal)...................45
sodium citrate & citric acid soln 500-334 mg/5ml
(Shohls solution modi)..................................................55
sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)
(Luride)............................................................................85
sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)
(Luride)............................................................................85
sodium fluoride chew tab 1 mg f (from 2.2 mg naf)
(Luride)............................................................................85
sodium fluoride cream 1.1% (Prevident 5000 plus)......93
sodium fluoride gel 1.1% (0.5% f) (Prevident
fluoride)...........................................................................93
sodium fluoride paste 1.1% (Prevident 5000 boost).....93
sodium fluoride-potassium nitrate paste 1.1-5%
(Prevident 5000 sensi).................................................. 93
sodium fluoride rinse 0.2% (Prevident).........................93
SODIUM FLUORIDE – sodium fluoride tab 0.5 mg f (from
1.1 mg naf)...................................................................... 85
SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from
2.2 mg naf)...................................................................... 85
sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop
naf).................................................................................. 85
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)
(Luride)............................................................................85
sodium phenylbutyrate oral powder 3 gm/teaspoonful
(Buphenyl)...................................................................... 28
sodium polystyrene sulfonate oral susp 15 gm/60ml
(Sps).............................................................................. 104
sodium polystyrene sulfonate powder
(Kayexalate)..................................................................104
sodium polystyrene sulfonate rectal susp 30
gm/120ml...................................................................... 104
SODIUM SULFACETAMIDE/SULF – sulfacetamide
sodium-sulfur in urea emulsion 10-5%.......................... 100
SODIUM SULFACETAMIDE/SULF – sulfacetamide
sodium w/ sulfur susp 10-5%........................................ 100
SOLODYN – minocycline hcl tab sr 24hr 105 mg............... 3
SOLODYN – minocycline hcl tab sr 24hr 115 mg............... 3
SOLODYN – minocycline hcl tab sr 24hr 55 mg................. 3
SOMATULINE DEPOT – lanreotide acetate extended
release inj 120 mg/0.5ml................................................. 28
release inj 60 mg/0.2ml................................................... 28
release inj 90 mg/0.3ml................................................... 28
SOMAVERT – pegvisomant for inj 10 mg (as protein)...... 28
SONAFINE – wound dressings - emulsion..................... 100
sotalol hcl (afib/afl) tab 120 mg (Betapace af).............. 31
sotalol hcl (afib/afl) tab 160 mg (Betapace af).............. 31
sotalol hcl (afib/afl) tab 80 mg (Betapace af)................ 31
sotalol hcl tab 120 mg (Betapace)................................. 31
sotalol hcl tab 160 mg (Betapace)................................. 31
sotalol hcl tab 240 mg.................................................... 31
147
2015
sotalol hcl tab 80 mg (Betapace)................................... 31
SOVALDI – sofosbuvir tab 400 mg.....................................8
SPECTRACEF – cefditoren pivoxil tab 200 mg (base
equivalent)......................................................................... 2
SPECTRACEF – cefditoren pivoxil tab 400 mg (base
equivalent)......................................................................... 2
SPINOSAD – spinosad susp 0.9%................................. 100
SPIRIVA HANDIHALER – tiotropium bromide
monohydrate inhal cap 18 mcg (base equiv)...................47
SPIRIVA RESPIMAT – tiotropium bromide monohydrate
inhal aerosol 2.5 mcg/act................................................ 47
spironolactone & hydrochlorothiazide tab 25-25 mg
(Aldactazide)...................................................................39
spironolactone tab 100 mg (Aldactone)........................ 39
spironolactone tab 25 mg (Aldactone).......................... 39
spironolactone tab 50 mg (Aldactone).......................... 39
SPRIX – ketorolac tromethamine nasal spray 15.75 mg/
spray................................................................................ 77
SPRYCEL – dasatinib tab 100 mg....................................13
SPRYCEL – dasatinib tab 140 mg....................................13
SPRYCEL – dasatinib tab 20 mg......................................13
STALEVO 100 – carbidopa-levodopa-entacapone tabs
25-100-200 mg................................................................ 83
31.25-125-200 mg........................................................... 83
37.5-150-200 mg............................................................. 83
50-200-200 mg................................................................ 83
12.5-50-200 mg............................................................... 84
18.75-75-200 mg............................................................. 84
stannous fluoride conc 0.63% (Gel-kam oral care
ri)..................................................................................... 93
stavudine cap 15 mg (Zerit)............................................. 8
stavudine for oral soln 1 mg/ml (Zerit)............................8
STAVZOR – valproic acid cap delayed release 125
mg.................................................................................... 81
mg.................................................................................... 81
mg.................................................................................... 81
STAXYN – Benefit Limits may apply – vardenafil hcl orally
disintegrating tab 10 mg..................................................43
STELARA – ustekinumab soln prefilled syringe 45
mg/0.5ml........................................................................ 100
STELARA – ustekinumab soln prefilled syringe 90 mg/
ml................................................................................... 100
148
STIMATE – desmopressin acetate nasal soln 1.5 mg/
ml..................................................................................... 28
STIVARGA – regorafenib tab 40 mg.................................13
STRATTERA – atomoxetine hcl cap 100 mg (base
equiv)............................................................................... 66
equiv)............................................................................... 66
equiv)............................................................................... 66
equiv)............................................................................... 66
equiv)............................................................................... 66
equiv)............................................................................... 66
equiv)............................................................................... 66
STRIANT – testosterone buccal mucoadhesive system 30
mg.................................................................................... 16
STRIBILD – elvitegrav-cobicis-emtricitab-tenofov tab
150-150-200-300 mg......................................................... 8
SUBOXONE – buprenorphine hcl-naloxone hcl sl film 12-3
mg (base equiv)...............................................................74
SUBOXONE – buprenorphine hcl-naloxone hcl sl film
2-0.5 mg (base equiv)..................................................... 74
mg (base equiv)...............................................................74
mg (base equiv)...............................................................74
SUBSYS – fentanyl sublingual spray 100 mcg................. 74
SUBSYS – fentanyl sublingual spray 1200 mcg (600 mcg
x 2)...................................................................................74
SUBSYS – fentanyl sublingual spray 1600 mcg (800 mcg
x 2)...................................................................................74
SUCRAID – sacrosidase soln 8500 unit/ml.......................51
sucralfate tab 1 gm (Carafate)....................................... 50
sulfacetamide sodium cleansing gel 10% (Ovace plus
wash).............................................................................100
sulfacetamide sodium liquid 10% (Ovace wash)........ 100
sulfacetamide sodium lotion 10% (acne) (Klaron)......100
sulfacetamide sodium ophth soln 10% (Bleph-10).......92
sulfacetamide sodium-prednisolone ophth soln
10-0.23(0.25)%................................................................ 92
sulfacetamide sodium shampoo 10% (Ovace
plus).............................................................................. 100
SULFACETAMIDE SODIUM – sulfacetamide sodium
ophth oint 10%................................................................ 92
sulfacetamide sodium w/ sulfur cleanser 10-2% (Avar
ls cleanser)...................................................................100
sulfacetamide sodium w/ sulfur cleanser 9.8-4.8%
(Plexion cleanser)........................................................ 100
2015
sulfacetamide sodium w/ sulfur cleansing cloth
10-5%.............................................................................100
sulfacetamide sodium w/ sulfur cleansing pad 10-4%
(Sumaxin)......................................................................100
sulfacetamide sodium w/ sulfur cream 10-2% (Avar-e
ls)...................................................................................100
sulfacetamide sodium w/ sulfur cream 10-5%............ 100
sulfacetamide sodium w/ sulfur cream 9.8-4.8%
(Plexion)........................................................................100
sulfacetamide sodium w/ sulfur emulsion 10-1%....... 100
sulfacetamide sodium w/ sulfur emulsion 10-5%....... 100
sulfacetamide sodium w/ sulfur foam 10-5% (Clarifoam
ef)...................................................................................101
sulfacetamide sodium w/ sulfur lotion 10-5%.............101
sulfacetamide sodium w/ sulfur lotion 9.8-4.8%
(Plexion)........................................................................101
sulfacetamide sodium w/ sulfur susp 8-4% (Sumaxin
ts)...................................................................................101
sulfacetamide sodium w/ sulfur wash 9-4.5%
(Sumadan wash).......................................................... 101
sulfacetamide sodium w/ sulfur wash 9-4% (Sumaxin
wash).............................................................................101
sulfacetamide sod-sulfur wash 9-4.5% & skin cleanser
kit (Sumadan kit)......................................................... 100
sulfacetamide sod-sulfur wash 9-4.5% & sunscreen kit
(Sumadan xlt)............................................................... 100
SULFADIAZINE – sulfadiazine tab 500 mg........................ 4
sulfamethoxazole-trimethoprim susp 200-40
mg/5ml............................................................................ 10
sulfamethoxazole-trimethoprim tab 400-80 mg
(Bactrim)......................................................................... 10
sulfamethoxazole-trimethoprim tab 800-160 mg
(Bactrim ds)....................................................................10
sulfasalazine tab 500 mg (Azulfidine)........................... 53
sulfasalazine tab delayed release 500 mg (Azulfidine
en-tabs)........................................................................... 53
sulindac tab 150 mg........................................................77
sulindac tab 200 mg........................................................77
sumatriptan succinate inj 6 mg/0.5ml (Imitrex)............ 78
sumatriptan succinate solution auto-injector 4
mg/0.5ml (Imitrex statdose sys)................................... 78
sumatriptan succinate solution auto-injector 6
mg/0.5ml (Imitrex statdose sys)................................... 78
sumatriptan succinate solution cartridge 4 mg/0.5ml
(Imitrex statdose ref)..................................................... 78
sumatriptan succinate solution cartridge 6 mg/0.5ml
(Imitrex statdose ref)..................................................... 78
sumatriptan succinate tab 100 mg (Imitrex)................. 78
sumatriptan succinate tab 25 mg (Imitrex)................... 78
sumatriptan succinate tab 50 mg (Imitrex)................... 78
SUMATRIPTAN – sumatriptan nasal spray 20 mg/act...... 78
SUMATRIPTAN – sumatriptan nasal spray 5 mg/act........ 78
SUMAVEL DOSEPRO – sumatriptan succinate solution
jet-injector 4 mg/0.5ml..................................................... 78
SUMAVEL DOSEPRO – sumatriptan succinate solution
jet-injector 6 mg/0.5ml..................................................... 78
SUPRAX – cefixime cap 400 mg........................................ 2
SUPRAX – cefixime chew tab 100 mg............................... 2
SUPRAX – cefixime chew tab 200 mg............................... 2
SUPRAX – cefixime for susp 500 mg/5ml.......................... 2
SUPREP BOWEL PREP – sodium sulfate-potassium
sulfate-magnesium sulfate oral soln................................ 48
SURESTEP PRO TEST STRIPS – glucose blood test
strip................................................................................ 103
SUSTIVA – efavirenz cap 200 mg...................................... 8
SUSTIVA – efavirenz cap 50 mg........................................ 8
SUSTIVA – efavirenz tab 600 mg.......................................8
SUTENT – sunitinib malate cap 12.5 mg (base
equivalent)....................................................................... 13
SUTENT – sunitinib malate cap 25 mg (base
equivalent)....................................................................... 13
SUTENT – sunitinib malate cap 37.5 mg (base
equivalent)....................................................................... 13
SUTENT – sunitinib malate cap 50 mg (base
equivalent)....................................................................... 13
SYLATRON – peginterferon alfa-2b for inj kit 200 mcg..... 13
SYMBICORT – budesonide-formoterol fumarate dihyd
aerosol 160-4.5 mcg/act.................................................. 47
SYMBICORT – budesonide-formoterol fumarate dihyd
aerosol 80-4.5 mcg/act.................................................... 47
SYMLINPEN 120 – pramlintide acetate pen-inj 2700
mcg/2.7ml (1000 mcg/ml)................................................ 21
SYMLINPEN 60 – pramlintide acetate pen-inj 1500
mcg/1.5ml (1000 mcg/ml)................................................ 21
SYNAREL – nafarelin acetate nasal soln 2 mg/ml............ 28
SYNRIBO – omacetaxine mepesuccinate for inj 3.5
mg.................................................................................... 14
SYNTHROID – levothyroxine sodium tab 100 mcg...........23
SYNTHROID – levothyroxine sodium tab 25 mcg.............23
T
TABLOID – thioguanine tab 40 mg................................... 14
TACLONEX – calcipotriene-betamethasone dipropionate
susp 0.005-0.064%........................................................101
tacrolimus cap 0.5 mg (Prograf).................................. 104
tacrolimus cap 1 mg (Prograf)..................................... 104
tacrolimus cap 5 mg (Prograf)..................................... 104
tacrolimus oint 0.03% (Protopic)................................. 101
tacrolimus oint 0.1% (Protopic)................................... 101
149
2015
TAFINLAR – dabrafenib mesylate cap 50 mg (base
equivalent)....................................................................... 14
TAFINLAR – dabrafenib mesylate cap 75 mg (base
equivalent)....................................................................... 14
TAMIFLU – oseltamivir phosphate cap 30 mg (base
equiv)................................................................................. 8
equiv)................................................................................. 8
equiv)................................................................................. 8
TAMIFLU – oseltamivir phosphate for susp 6 mg/ml (base
equiv)................................................................................. 8
tamoxifen citrate tab 10 mg (base equivalent)............. 14
tamoxifen citrate tab 20 mg (base equivalent)............. 14
tamsulosin hcl cap 0.4 mg (Flomax)............................. 55
TARCEVA – erlotinib hcl tab 100 mg (base
equivalent)....................................................................... 14
TARCEVA – erlotinib hcl tab 150 mg (base
equivalent)....................................................................... 14
TARCEVA – erlotinib hcl tab 25 mg (base equivalent)...... 14
TARGRETIN – bexarotene cap 75 mg............................. 14
TARGRETIN – bexarotene gel 1%................................. 101
TARON FORTE – fe bisglycinate-fe polysacch-vit c-vit
b12-fa cap........................................................................88
TASIGNA – nilotinib hcl cap 150 mg (base equivalent).....14
TASIGNA – nilotinib hcl cap 200 mg (base equivalent).....14
TAZORAC – tazarotene cream 0.05%............................101
TAZORAC – tazarotene cream 0.1%..............................101
TAZORAC – tazarotene gel 0.05%................................. 101
TAZORAC – tazarotene gel 0.1%................................... 101
TECFIDERA – dimethyl fumarate capsule delayed release
120 mg.............................................................................69
TECFIDERA – dimethyl fumarate capsule delayed release
240 mg.............................................................................69
TECFIDERA STARTER PACK – dimethyl fumarate
capsule dr starter pack 120 mg & 240 mg...................... 69
TECHNIVIE – ombitasvir-paritaprevir-ritonavir tab
12.5-75-50 mg................................................................... 8
TEGRETOL – carbamazepine susp 100 mg/5ml.............. 81
TEGRETOL – carbamazepine tab 200 mg....................... 81
TEGRETOL-XR – carbamazepine tab sr 12hr 100 mg..... 81
TEKTURNA – aliskiren fumarate tab 150 mg (base
equivalent)....................................................................... 37
TEKTURNA – aliskiren fumarate tab 300 mg (base
equivalent)....................................................................... 37
TEKTURNA HCT – aliskiren-hydrochlorothiazide tab
150-12.5 mg.................................................................... 37
150-25 mg....................................................................... 37
300-12.5 mg.................................................................... 37
300-25 mg....................................................................... 37
telmisartan-amlodipine tab 40-10 mg (Twynsta).......... 37
150
telmisartan-amlodipine tab 40-5 mg (Twynsta)............ 37
telmisartan-amlodipine tab 80-10 mg (Twynsta).......... 37
telmisartan-amlodipine tab 80-5 mg (Twynsta)............ 37
telmisartan-hydrochlorothiazide tab 40-12.5 mg
(Micardis hct)................................................................. 37
telmisartan-hydrochlorothiazide tab 80-12.5 mg
(Micardis hct)................................................................. 37
telmisartan-hydrochlorothiazide tab 80-25 mg
(Micardis hct)................................................................. 37
telmisartan tab 20 mg (Micardis)................................... 37
temazepam cap 15 mg (Restoril)................................... 63
temazepam cap 22.5 mg (Restoril)................................ 63
temazepam cap 30 mg (Restoril)................................... 63
temazepam cap 7.5 mg (Restoril).................................. 63
TEMODAR – temozolomide cap 100 mg.......................... 14
TEMODAR – temozolomide cap 20 mg............................ 14
TEMODAR – temozolomide cap 5 mg.............................. 14
temozolomide cap 100 mg (Temodar)........................... 14
temozolomide cap 20 mg (Temodar).............................14
temozolomide cap 5 mg (Temodar)...............................14
terazosin hcl cap 10 mg................................................. 37
terazosin hcl cap 1 mg................................................... 37
terbinafine hcl tab 250 mg (Lamisil)................................5
terbutaline sulfate tab 2.5 mg........................................ 47
terbutaline sulfate tab 5 mg........................................... 47
terconazole vaginal cream 0.4% (Terazol 7)................. 55
terconazole vaginal cream 0.8% (Terazol 3)................. 55
terconazole vaginal suppos 80 mg................................55
TESTIM – testosterone td gel 50 mg/5gm (1%)................ 16
testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone).................................................................. 16
testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone).................................................................. 16
testosterone enanthate im inj in oil 200 mg/ml............ 16
TESTOSTERONE PUMP – testosterone td gel 12.5 mg/
act (1%)........................................................................... 16
TESTOSTERONE – testosterone td gel 10mg/act
(2%)................................................................................. 16
TESTOSTERONE – testosterone td gel 25 mg/2.5gm
(1%)................................................................................. 16
TESTOSTERONE – testosterone td gel 25 mg/2.5gm
(1%)................................................................................. 16
TESTOSTERONE – testosterone td gel 50 mg/5gm
(1%)................................................................................. 16
TESTRED – methyltestosterone cap 10 mg..................... 16
tetracaine hcl ophth soln 0.5%...................................... 92
2015
TETRACYCLINE HCL – tetracycline hcl cap 250 mg......... 3
TETRACYCLINE HCL – tetracycline hcl cap 500 mg......... 3
TEVETEN HCT – eprosartan mesylatehydrochlorothiazide tab 600-25 mg................................. 37
TEV-TROPIN – somatropin for subcutaneous inj 5 mg..... 28
TGQ 15DM/5PEH/2CPM – phenylephrine-chlorphen-dm
syrup 5-2-15 mg/5ml....................................................... 45
TGQ 30PSE/150GFN/15DM – pseudoephedrine w/ dm-gg
syrup 30-15-150 mg/5ml..................................................45
TGQ 30PSE/3BRM/15DM – pseudoephed-bromphen-dm
syrup 30-3-15 mg/5ml..................................................... 45
TGQ 50PSE/3BRM/30DM – pseudoephed-bromphen-dm
syrup 50-3-30 mg/5ml..................................................... 45
THALOMID – thalidomide cap 100 mg........................... 104
THALOMID – thalidomide cap 50 mg............................. 104
THEO-24 – theophylline cap sr 24hr 100 mg....................47
theophylline soln 80 mg/15ml........................................ 47
theophylline tab sr 12hr 100 mg.................................... 47
thioridazine hcl tab 100 mg............................................62
thioridazine hcl tab 10 mg..............................................62
thiothixene cap 10 mg.................................................... 62
thiothixene cap 1 mg...................................................... 62
THYROGEN – thyrotropin alfa for inj 1.1 mg.................. 103
thyroid tab 30 mg (1/2 grain) (Armour thyroid).............24
thyroid tab 60 mg (1 grain) (Armour thyroid)................24
thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)..........24
THYROLAR-1/2 – liotrix (t3-t4) tab 30 mg (6.25-25
mcg)................................................................................. 24
THYROLAR-1/4 – liotrix (t3-t4) tab 15 mg (3.1-12.5
mcg)................................................................................. 24
THYROLAR-1 – liotrix (t3-t4) tab 60 mg (12.5-50 mcg).....24
THYROLAR-2 – liotrix (t3-t4) tab 120 mg (25-100
mcg)................................................................................. 24
THYROLAR-3 – liotrix (t3-t4) tab 180 mg (37.5-150
mcg)................................................................................. 24
tiagabine hcl tab 2 mg (Gabitril).................................... 81
tiagabine hcl tab 4 mg (Gabitril).................................... 81
ticlopidine hcl tab 250 mg..............................................89
TIKOSYN – dofetilide cap 125 mcg (0.125 mg)................ 33
TIKOSYN – dofetilide cap 250 mcg (0.25 mg).................. 33
TIKOSYN – dofetilide cap 500 mcg (0.5 mg).................... 33
timolol maleate ophth gel forming soln 0.25%
(Timoptic-xe).................................................................. 92
timolol maleate ophth gel forming soln 0.5%
(Timoptic-xe).................................................................. 92
timolol maleate ophth soln 0.25% (Timoptic)............... 92
timolol maleate ophth soln 0.5% (Timoptic)................. 92
TIMOLOL MALEATE – timolol maleate tab 10 mg............31
TIMOLOL MALEATE – timolol maleate tab 20 mg............31
TIMOLOL MALEATE – timolol maleate tab 5 mg..............31
tinidazole tab 250 mg (Tindamax)..................................10
tinidazole tab 500 mg (Tindamax)..................................10
TIROSINT – levothyroxine sodium cap 100 mcg.............. 24
TIROSINT – levothyroxine sodium cap 13 mcg................ 24
TIVICAY – dolutegravir sodium tab 50 mg (base equiv)......8
tizanidine hcl cap 2 mg (base equivalent)
(Zanaflex)........................................................................ 84
(Zanaflex)........................................................................ 84
(Zanaflex)........................................................................ 84
tizanidine hcl tab 2 mg (base equivalent)..................... 84
tizanidine hcl tab 4 mg (base equivalent)
(Zanaflex)........................................................................ 84
TOBI PODHALER – tobramycin inhal cap 28 mg............... 4
TOBI – tobramycin nebu soln 300 mg/5ml..........................4
TOBRADEX ST – tobramycin-dexamethasone ophth susp
0.3-0.05%.........................................................................92
TOBRADEX – tobramycin-dexamethasone ophth oint
0.3-0.1%...........................................................................92
tobramycin-dexamethasone ophth susp 0.3-0.1%
(Tobradex)...................................................................... 92
tobramycin nebu soln 300 mg/5ml (Tobi)....................... 4
tobramycin ophth soln 0.3% (Tobrex)........................... 92
tolazamide tab 250 mg....................................................21
TOLAZAMIDE – tolazamide tab 500 mg...........................21
TOLBUTAMIDE – tolbutamide tab 500 mg....................... 21
tolcapone tab 100 mg (Tasmar)..................................... 84
tolmetin sodium cap 400 mg..........................................77
TOLMETIN SODIUM – tolmetin sodium tab 200 mg.........77
TOLMETIN SODIUM – tolmetin sodium tab 600 mg.........77
tolterodine tartrate cap sr 24hr 2 mg (Detrol la)........... 54
tolterodine tartrate cap sr 24hr 4 mg (Detrol la)........... 54
tolterodine tartrate tab 1 mg (Detrol).............................54
tolterodine tartrate tab 2 mg (Detrol).............................54
topiramate sprinkle cap 15 mg (Topamax sprinkle)..... 81
topiramate sprinkle cap 25 mg (Topamax sprinkle)..... 81
topiramate tab 100 mg (Topamax).................................81
topiramate tab 200 mg (Topamax).................................81
151
2015
topiramate tab 25 mg (Topamax)...................................81
topiramate tab 50 mg (Topamax)...................................81
torsemide tab 100 mg (Demadex)..................................39
torsemide tab 10 mg (Demadex)....................................39
torsemide tab 20 mg (Demadex)....................................39
torsemide tab 5 mg (Demadex)......................................39
TOUJEO SOLOSTAR – insulin glargine soln pen-injector
300 unit/ml....................................................................... 23
TOVIAZ – fesoterodine fumarate tab sr 24hr 4 mg........... 54
TOVIAZ – fesoterodine fumarate tab sr 24hr 8 mg........... 54
TRACLEER – bosentan tab 125 mg................................. 42
TRACLEER – bosentan tab 62.5 mg................................ 42
TRADJENTA – linagliptin tab 5 mg...................................21
tramadol-acetaminophen tab 37.5-325 mg
(Ultracet)......................................................................... 74
tramadol hcl tab 50 mg (Ultram).................................... 74
tramadol hcl tab sr 24hr 100 mg (Ultram er).................74
tramadol hcl tab sr 24hr biphasic release 100 mg....... 74
trandolapril tab 1 mg (Mavik)......................................... 37
trandolapril-verapamil hcl tab cr 1-240 mg (Tarka)...... 38
tranexamic acid tab 650 mg (Lysteda).......................... 89
TRANSDERM-SCOP – scopolamine td patch 72hr 1
mg/3days......................................................................... 51
tranylcypromine sulfate tab 10 mg (Parnate)............... 59
TRAVATAN Z – travoprost ophth soln 0.004%
(benzalkonium free) (bak free)........................................ 92
trazodone hcl tab 100 mg...............................................59
trazodone hcl tab 50 mg.................................................59
TREAGAN OTIC – antipyrine-benzocaine-polycosanol otic
sol 5.4-1.4-0.0097%.........................................................93
tretinoin cap 10 mg......................................................... 14
tretinoin cream 0.025% (Retin-a)................................. 101
tretinoin cream 0.05% (Retin-a)................................... 101
tretinoin cream 0.1% (Retin-a)..................................... 101
tretinoin gel 0.01% (Retin-a).........................................101
tretinoin gel 0.025% (Retin-a).......................................101
tretinoin microsphere gel 0.04% (Retin-a micro)........ 101
tretinoin microsphere gel 0.1% (Retin-a micro)..........101
TRETIN-X – tretinoin cream 0.025% w/ cleanser &
moisturizer kit................................................................ 101
moisturizer kit................................................................ 101
TRETIN-X – tretinoin cream 0.075%...............................101
moisturizer kit................................................................ 101
152
TREXALL – methotrexate sodium tab 10 mg (base
equiv)............................................................................... 14
equiv)............................................................................... 14
equiv)............................................................................... 14
TREXALL – methotrexate sodium tab 7.5 mg (base
equiv)............................................................................... 14
TREXIMET – sumatriptan-naproxen sodium tab 85-500
mg.................................................................................... 78
TREZIX – acetaminophen-caffeine-dihydrocodeine cap
320.5-30-16 mg............................................................... 75
triamcinolone acetonide aerosol soln (Kenalog)........101
triamcinolone acetonide cream 0.025%...................... 101
triamcinolone acetonide cream 0.1%.......................... 101
triamcinolone acetonide cream 0.5%.......................... 101
triamcinolone acetonide dental paste 0.1%.................. 93
triamcinolone acetonide lotion 0.025%....................... 101
triamcinolone acetonide lotion 0.1%........................... 101
triamcinolone acetonide nasal aerosol suspension 55
mcg/act (Nasacort aq)................................................... 44
triamcinolone acetonide oint 0.025%.......................... 101
triamcinolone acetonide oint 0.1%.............................. 101
TRIAMCINOLONE ACETONIDE – triamcinolone
acetonide oint 0.5%.......................................................101
TRIAMTERENE/HYDROCHLOROTH – triamterene &
hydrochlorothiazide cap 50-25 mg.................................. 39
triamterene & hydrochlorothiazide cap 37.5-25 mg
(Dyazide)......................................................................... 39
triamterene & hydrochlorothiazide tab 37.5-25 mg
(Maxzide-25)................................................................... 39
triamterene & hydrochlorothiazide tab 75-50 mg
(Maxzide).........................................................................39
TRIANEX – triamcinolone acetonide oint 0.05%............. 101
triazolam tab 0.125 mg................................................... 63
triazolam tab 0.25 mg (Halcion)..................................... 63
TRIBENZOR – olmesartan-amlodipinehydrochlorothiazide tab 20-5-12.5 mg............................. 38
TRIBENZOR – olmesartan-amlodipinehydrochlorothiazide tab 40-10-12.5 mg........................... 38
TRIBENZOR – olmesartan-amlodipinehydrochlorothiazide tab 40-10-25 mg.............................. 38
TRIBENZOR – olmesartan-amlodipinehydrochlorothiazide tab 40-5-12.5 mg............................. 38
TRIBENZOR – olmesartan-amlodipinehydrochlorothiazide tab 40-5-25 mg................................ 38
TRI-CHLOR – trichloroacetic acid liqd 80%.................... 101
trifluoperazine hcl tab 10 mg......................................... 62
trifluoperazine hcl tab 1 mg........................................... 62
trifluridine ophth soln 1% (Viroptic).............................. 92
TRIGLIDE – fenofibrate tab 160 mg................................. 41
trihexyphenidyl hcl elixir 0.4 mg/ml.............................. 84
trihexyphenidyl hcl tab 2 mg......................................... 84
trihexyphenidyl hcl tab 5 mg......................................... 84
2015
trimethobenzamide hcl cap 300 mg (Tigan)..................51
trimethoprim tab 100 mg................................................ 10
TRIUMEQ – abacavir-dolutegravir-lamivudine tab
600-50-300 mg.................................................................. 8
TRIZIVIR – abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg................................................................ 8
tropicamide ophth soln 0.5%......................................... 92
tropicamide ophth soln 1% (Mydriacyl)........................ 92
trospium chloride cap sr 24hr 60 mg............................ 54
trospium chloride tab 20 mg..........................................54
TRUVADA – emtricitabine-tenofovir disoproxil fumarate
tab 200-300 mg................................................................. 8
trypsin w/ castor oil & peruvian balsam spray
(Granulex)..................................................................... 101
TUDORZA PRESSAIR – aclidinium bromide aerosol powd
breath activated 400 mcg/act.......................................... 48
TYBOST – cobicistat tab 150 mg....................................... 9
TYKERB – lapatinib ditosylate tab 250 mg (base
equiv)............................................................................... 14
TYZEKA – telbivudine tab 600 mg......................................9
U
UCERIS – budesonide tab sr 24hr 9 mg...........................16
ULESFIA – benzyl alcohol lotion 5%.............................. 101
ULORIC – febuxostat tab 40 mg.......................................78
ULORIC – febuxostat tab 80 mg.......................................78
ULTRESA – pancrelipase (lip-prot-amyl) dr cap
13800-27600-27600 unit..................................................51
20700-41400-41400 unit..................................................51
23000-46000-46000 unit..................................................52
urea cream 39% (Aluvea)............................................. 101
urea cream 40%.............................................................101
urea cream 45% (Uramaxin)......................................... 101
urea cream 47% (Keralac)............................................ 101
urea cream 50%.............................................................101
urea foam 40% (Hydro 40 foam).................................. 101
urea gel 40%.................................................................. 101
urea gel 45% (Uramaxin).............................................. 101
urea in lactic acid-salicylic acid vehicle susp
50%................................................................................102
urea in lactic acid vehicle foam 35% (Hydro 35).........102
urea in zinc undecylenate-lactic acid vehicle emulsion
50%................................................................................102
urea lotion 40%..............................................................102
urea lotion 45% (Uramaxin)..........................................102
UREA NAIL KIT – urea susp 40% & hyaluronate sodium
gel 0.2% kit....................................................................102
UREA NAIL – urea in zinc undecylenate-lactic acid vehicle
stick 50%....................................................................... 102
urea suspension 40% (Umecta)................................... 102
URETRON D/S – methenamine-hyosc-meth blue-sod
phos-phen sal tab 120 mg.............................................. 54
UROGESIC-BLUE – methenamine-hyoscamine-meth
blue-sod phos tab 81.6 mg............................................. 54
ursodiol cap 300 mg (Actigall).......................................53
ursodiol tab 250 mg (Urso 250)..................................... 53
ursodiol tab 500 mg (Urso forte)................................... 53
V
VAGIFEM – estradiol vaginal tab 10 mcg......................... 55
valacyclovir hcl tab 1 gm (Valtrex).................................. 9
valacyclovir hcl tab 500 mg (Valtrex).............................. 9
VALCHLOR – mechlorethamine hcl gel 0.016% (base
equivalent)..................................................................... 102
VALCYTE – valganciclovir hcl for soln 50 mg/ml (base
equiv)................................................................................. 9
VALCYTE – valganciclovir hcl tab 450 mg (base
equivalent)......................................................................... 9
valganciclovir hcl tab 450 mg (base equivalent)
(Valcyte)............................................................................ 9
valproate sodium syrup 250 mg/5ml (base equiv)
(Depakene)......................................................................81
valproic acid cap 250 mg (Depakene)........................... 81
valsartan-hydrochlorothiazide tab 160-12.5 mg
(Diovan hct)....................................................................38
valsartan-hydrochlorothiazide tab 160-25 mg (Diovan
hct).................................................................................. 38
valsartan-hydrochlorothiazide tab 320-12.5 mg
(Diovan hct).................................................................... 38
valsartan-hydrochlorothiazide tab 320-25 mg (Diovan
hct).................................................................................. 38
valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan
hct).................................................................................. 38
valsartan tab 160 mg (Diovan)....................................... 38
valsartan tab 320 mg (Diovan)....................................... 38
valsartan tab 40 mg (Diovan)......................................... 38
valsartan tab 80 mg (Diovan)......................................... 38
VANATOL LQ – butalbital-acetaminophen-caffeine soln
50-325-40 mg/15ml..........................................................70
vancomycin hcl cap 125 mg (Vancocin hcl)................. 10
vancomycin hcl cap 250 mg (Vancocin hcl)................. 10
VANOXIDE-HC – benzoyl peroxide-hc lotion 5-0.5%......102
VECAMYL – mecamylamine hcl tab 2.5 mg..................... 38
VECTICAL – calcitriol oint 3 mcg/gm.............................. 102
VELTIN – clindamycin phosphate-tretinoin gel
1.2-0.025%.....................................................................102
venlafaxine hcl cap sr 24hr 150 mg (base equivalent)
(Effexor xr)..................................................................... 59
venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent)
(Effexor xr)..................................................................... 59
venlafaxine hcl cap sr 24hr 75 mg (base equivalent)
(Effexor xr)..................................................................... 59
VENLAFAXINE HCL ER – venlafaxine hcl tab sr 24hr 150
mg (base equivalent).......................................................59
VENLAFAXINE HCL ER – venlafaxine hcl tab sr 24hr 37.5
153
2015
venlafaxine hcl tab 100 mg............................................ 60
venlafaxine hcl tab 25 mg.............................................. 60
venlafaxine hcl tab 37.5 mg........................................... 60
venlafaxine hcl tab sr 24hr 150 mg (base equivalent)
(Venlafaxine hcl er)....................................................... 60
venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent)
venlafaxine hcl tab sr 24hr 75 mg (base equivalent)
VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv).........................................................48
VERAMYST – fluticasone furoate nasal susp 27.5 mcg/
spray................................................................................ 44
verapamil hcl cap sr 24hr 100 mg (Verelan pm)........... 32
verapamil hcl cap sr 24hr 120 mg (Verelan)................. 32
verapamil hcl tab 120 mg (Calan).................................. 32
verapamil hcl tab 80 mg (Calan).................................... 32
verapamil hcl tab cr 120 mg (Calan sr)......................... 32
VERAPAMIL HCL – verapamil hcl tab 40 mg................... 32
VERDESO – desonide foam 0.05%................................102
VEREGEN – sinecatechins oint 15%..............................102
VESICARE – solifenacin succinate tab 10 mg.................. 54
VESICARE – solifenacin succinate tab 5 mg....................54
VFEND – voriconazole for susp 40 mg/ml.......................... 5
VFEND – voriconazole tab 200 mg.................................... 5
VFEND – voriconazole tab 50 mg...................................... 5
VIAGRA – Benefit Limits may apply – sildenafil citrate tab
100 mg.............................................................................43
25 mg...............................................................................43
50 mg...............................................................................43
VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/
ml).................................................................................... 21
VICTRELIS – boceprevir cap 200 mg.................................9
VIDAZA – azacitidine for inj 100 mg................................. 14
VIDEX – didanosine for soln 2 gm......................................9
VIDEX – didanosine for soln 4 gm......................................9
VIDEX EC – didanosine delayed release capsule 125
mg...................................................................................... 9
mg...................................................................................... 9
mg...................................................................................... 9
mg...................................................................................... 9
154
VIEKIRA PAK – ombitas-paritapre-riton & dasab tab pak
12.5-75-50 & 250 mg........................................................ 9
VIGAMOX – moxifloxacin hcl ophth soln 0.5% (base
equiv)............................................................................... 92
VIIBRYD – vilazodone hcl tab 10 mg................................60
VIIBRYD – vilazodone hcl tab starter kit 10 (7) & 20 (7) &
40 (16) mg.......................................................................60
VIMOVO – naproxen-esomeprazole magnesium tab dr
375-20 mg....................................................................... 77
VIMOVO – naproxen-esomeprazole magnesium tab dr
500-20 mg....................................................................... 77
VIMPAT – lacosamide oral solution 10 mg/ml...................81
VIMPAT – lacosamide tab 100 mg................................... 81
VIMPAT – lacosamide tab 50 mg..................................... 81
VIOKACE – pancrelipase (lip-prot-amyl) tab
10440-39150-39150 unit..................................................52
VIOKACE – pancrelipase (lip-prot-amyl) tab
20880-78300-78300 unit..................................................52
VIRACEPT – nelfinavir mesylate tab 250 mg..................... 9
VIRACEPT – nelfinavir mesylate tab 625 mg..................... 9
VIRAMUNE – nevirapine susp 50 mg/5ml.......................... 9
VIRAMUNE – nevirapine tab 200 mg................................. 9
VIRAMUNE XR – nevirapine tab sr 24hr 100 mg............... 9
VIRAMUNE XR – nevirapine tab sr 24hr 400 mg............... 9
VIRAZOLE – ribavirin for inhal soln 6 gm........................... 9
VIREAD – tenofovir disoproxil fumarate oral powder 40
mg/gm................................................................................ 9
VIREAD – tenofovir disoproxil fumarate tab 150 mg........... 9
VITAMIN K1 – phytonadione inj 10 mg/ml........................ 84
VITEKTA – elvitegravir tab 150 mg.................................... 9
VITEKTA – elvitegravir tab 85 mg...................................... 9
VOGELXO PUMP – testosterone td gel 12.5 mg/act
(1%)................................................................................. 16
VOGELXO – testosterone td gel 50 mg/5gm (1%)............16
VOLTAREN – diclofenac sodium gel 1%........................ 102
voriconazole for susp 40 mg/ml (Vfend)......................... 5
voriconazole tab 200 mg (Vfend).....................................5
voriconazole tab 50 mg (Vfend).......................................5
VOTRIENT – pazopanib hcl tab 200 mg (base equiv).......14
VUSION – miconazole-zinc oxide-white petrolatum oint
0.25-15-81.35%............................................................. 102
VYTORIN – ezetimibe-simvastatin tab 10-10 mg..............41
VYVANSE – lisdexamfetamine dimesylate cap 10 mg......66
2015
W
warfarin sodium tab 10 mg (Coumadin)........................89
warfarin sodium tab 1 mg (Coumadin)..........................89
warfarin sodium tab 2.5 mg (Coumadin).......................89
warfarin sodium tab 7.5 mg (Coumadin).......................89
water for irrigation, sterile irrigation soln................... 104
WELCHOL – colesevelam hcl packet for susp 3.75
gm.................................................................................... 41
WELCHOL – colesevelam hcl tab 625 mg........................41
wound dressings - cream.............................................102
X
XALKORI – crizotinib cap 200 mg.................................... 14
XALKORI – crizotinib cap 250 mg.................................... 14
XARELTO – rivaroxaban tab 10 mg................................. 89
XARELTO STARTER PACK – rivaroxaban tab starter
therapy pack 15 mg & 20 mg..........................................89
XELJANZ – tofacitinib citrate tab 5 mg (base
equivalent)....................................................................... 77
XELODA – capecitabine tab 150 mg................................ 14
XELODA – capecitabine tab 500 mg................................ 14
XENAZINE – tetrabenazine tab 12.5 mg.......................... 69
XENAZINE – tetrabenazine tab 25 mg............................. 69
XERESE – acyclovir-hydrocortisone cream 5-1%...........102
XIFAXAN – rifaximin tab 200 mg...................................... 10
XIFAXAN – rifaximin tab 550 mg...................................... 10
XOFIGO – radium ra 223 dichloride inj 27 microcurie/ml
(1000 kbq/ml)...................................................................14
XOLEGEL – ketoconazole gel 2%.................................. 102
XOPENEX HFA – levalbuterol tartrate inhal aerosol 45
mcg/act (base equiv)....................................................... 48
XTANDI – enzalutamide cap 40 mg..................................14
XYREM – sodium oxybate oral solution 500 mg/ml.......... 69
Y
YAZ – drospirenone-ethinyl estradiol tab 3-0.02 mg......... 19
Z
zafirlukast tab 10 mg (Accolate).................................... 48
zafirlukast tab 20 mg (Accolate).................................... 48
zaleplon cap 10 mg – Benefit Limits may apply
(Sonata)...........................................................................63
zaleplon cap 5 mg – Benefit Limits may apply
(Sonata)...........................................................................63
ZALTRAP – ziv-aflibercept iv soln 100 mg/4ml (for
infusion)........................................................................... 14
ZALTRAP – ziv-aflibercept iv soln 200 mg/8ml (for
infusion)........................................................................... 14
ZANTAC – ranitidine hcl tab 300 mg................................ 50
ZAVESCA – miglustat cap 100 mg................................... 88
ZEGERID – omeprazole-sodium bicarbonate powd pack
for susp 20-1680 mg....................................................... 50
ZEGERID – omeprazole-sodium bicarbonate powd pack
for susp 40-1680 mg....................................................... 50
ZELAPAR – selegiline hcl orally disintegrating tab 1.25
mg.................................................................................... 84
ZELBORAF – vemurafenib tab 240 mg............................ 14
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
10000-34000-55000 unit..................................................52
15000-51000-82000 unit..................................................52
20000-68000-109000 unit................................................52
25000-85000-136000 unit................................................52
3000-10000-16000 unit....................................................52
40000-136000-218000 unit..............................................52
5000-17000-27000 unit....................................................52
ZENZEDI – dextroamphetamine sulfate tab 15 mg...........66
ZENZEDI – dextroamphetamine sulfate tab 2.5 mg..........66
ZENZEDI – dextroamphetamine sulfate tab 7.5 mg..........66
ZERIT – stavudine cap 15 mg............................................ 9
ZERIT – stavudine for oral soln 1 mg/ml............................ 9
ZETIA – ezetimibe tab 10 mg........................................... 41
ZETONNA – ciclesonide nasal aerosol soln 37 mcg/act
(50 mcg/valve)................................................................. 44
ZIAGEN – abacavir sulfate soln 20 mg/ml (base equiv)...... 9
ZIAGEN – abacavir sulfate tab 300 mg (base equiv).......... 9
ZIANA – clindamycin phosphate-tretinoin gel
1.2-0.025%.....................................................................102
zidovudine cap 100 mg (Retrovir)................................... 9
zidovudine syrup 10 mg/ml (Retrovir).............................9
zidovudine tab 300 mg..................................................... 9
zinc sulfate cap 220 mg (50 mg elemental zn)..............85
ZIOPTAN – tafluprost ophth soln 0.0015%....................... 92
ziprasidone hcl cap 20 mg (Geodon)............................ 62
ZIPSOR – diclofenac potassium cap 25 mg..................... 77
ZMAX – azithromycin extended release for oral susp 2
gm...................................................................................... 3
155
2015
ZOHYDRO ER – hydrocodone bitartrate cap sr 12hr
abuse-deterrent 10 mg.................................................... 75
ZOLINZA – vorinostat cap 100 mg................................... 14
zolmitriptan orally disintegrating tab 2.5 mg (Zomig
zmt)..................................................................................78
zolmitriptan orally disintegrating tab 5 mg (Zomig
zmt)..................................................................................78
zolmitriptan tab 2.5 mg (Zomig).....................................78
zolmitriptan tab 5 mg (Zomig)........................................78
zolpidem tartrate tab 10 mg – Benefit Limits may apply
(Ambien)......................................................................... 63
zolpidem tartrate tab 5 mg – Benefit Limits may apply
(Ambien)......................................................................... 63
zolpidem tartrate tab cr 12.5 mg – Benefit Limits may
apply (Ambien cr).......................................................... 63
zolpidem tartrate tab cr 6.25 mg – Benefit Limits may
apply (Ambien cr).......................................................... 63
ZOLPIMIST – Benefit Limits may apply – zolpidem tartrate
oral spray 5 mg/act..........................................................63
ZOMACTON – somatropin for inj 10 mg...........................29
ZOMACTON – somatropin for subcutaneous inj 5 mg...... 29
ZOMIG – zolmitriptan nasal spray 2.5 mg/spray unit........ 78
zonisamide cap 100 mg (Zonegran).............................. 82
zonisamide cap 25 mg (Zonegran)................................ 82
zonisamide cap 50 mg....................................................82
ZORBTIVE – somatropin (non-refrigerated) for
subcutaneous inj 8.8 mg................................................. 29
ZORTRESS – everolimus tab 0.25 mg........................... 104
ZORTRESS – everolimus tab 0.5 mg............................. 104
ZORTRESS – everolimus tab 0.75 mg........................... 104
ZOVIA 1/50E – ethynodiol diacetate & ethinyl estradiol tab
1 mg-50 mcg................................................................... 19
ZOVIRAX – acyclovir cream 5%..................................... 102
ZUPLENZ – ondansetron oral soluble film 4 mg............... 51
ZUPLENZ – ondansetron oral soluble film 8 mg............... 51
ZYCLARA – imiquimod cream 3.75%............................. 102
ZYCLARA PUMP – imiquimod cream 2.5%....................102
ZYCLARA PUMP – imiquimod cream 3.75%..................102
ZYDELIG – idelalisib tab 100 mg......................................15
ZYDELIG – idelalisib tab 150 mg......................................15
ZYFLO CR – zileuton tab sr 12hr 600 mg........................ 48
ZYKADIA – ceritinib cap 150 mg...................................... 15
ZYLET – loteprednol etabonate-tobramycin ophth susp
0.5-0.3%...........................................................................92
ZYTIGA – abiraterone acetate tab 250 mg....................... 15
ZYVOX – linezolid for susp 100 mg/5ml........................... 10
156
ZYVOX – linezolid tab 600 mg..........................................10

Blue Cross and Blue Shield of North Carolina (BCBSNC)

Transcription

Similar documents

Medi-Pak Rx Basic (PDP) 2015 Comprehensive

Blue Medicare Rx Standard

Medi-Pak Rx Premier (PDP) 2015 Comprehensive

Florida Blue July 2016 Medication Guide

Blue Cross and Blue Shield of North Carolina (BCBSNC) September

Horizon BCBSNJ Health Insurance Marketplace

Florida Blue September 2016 Care Choices Medication Guide

BCBSAL Individual Market Standard Drug List for October

BCBSND Formulary - Blue Cross Blue Shield of North Dakota

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

generic drug list - Blue Cross and Blue Shield of Texas

2015 Standard Drug List - Blue Cross and Blue Shield of Texas

Standard Drug Formulary - Blue Cross and Blue Shield of Illinois

MPI 3275 1 2/1 4 - Arkansas Blue Cross and Blue Shield

Buckeye Community Health Plan Preferred Drug List

Blue Cross Blue Shield of North Carolina Open Basic 5 Tier