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

Transcription

September 2016
Blue Cross and Blue Shield of North Carolina
Open Basic 5 Tier Formulary
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 medication formulary is regularly updated. Please visit www.bcbsnc.com for the most
up-to-date information.
Contents
Therapeutic Class Medication List
Preface................................................................. I
Member guide to covered medications on the
Open Basic 5 Tier Formulary................................. I
Formulary tiers ...................................................... I
5-Tier formulary...................................................... I
Generic medications ............................................... I
Compounded prescriptions ..................................... II
Prior review, quantity limitations and
restricted-access medications ................................. II
Specialty medications ............................................ II
Affordable Care Act ............................................. III
Limited Distribution medications.............................. III
Using the member guide to the Open Basic
Formulary..........................................................IV
Abbreviation/acronym key........................................V
Anti-Infective Agents ............................................... 1
Biologicals ............................................................13
Antineoplastic Agents .............................................14
Endocrine and Metabolic Medications .......................18
Cardiovascular Agents ...........................................39
Respiratory Agents ................................................60
Gastrointestinal Agents...........................................68
Genitourinary Agents..............................................75
Central Nervous System Medications .......................78
Analgesics and Anesthetics.....................................98
Neuromuscular Medications .................................. 113
Nutritional Products.............................................. 122
Hematological Agents .......................................... 133
Topical Products.................................................. 143
Miscellaneous Products ........................................ 166
Index ................................................................. 174
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-I NC HIM © Prime Therapeutics LLC 09/16
Member guide to covered medications on the Open Basic 5 Tier Formulary
This guide lists the approved brand name and generic prescription medications that have been reviewed by
Blue Cross and Blue Shield of North Carolina (BCBSNC). Please refer to this formulary guide for information
about medications covered by this formulary, and present this guide to your doctor if you require a prescription.
This guide was current at the time of printing and is subject to change.
The prescription medications listed in the formulary or their tier placement may change from time to time due t o
a change in the cost of the medication and/or in the classification of the medication by the U.S. Food and Drug
Administration (FDA) or nationally-recognized medication databases (e.g., Medispan). For a more complete
listing of medication coverage and costs, you may use our medication search at www.bcbsnc.com. You may
also call BCBSNC Customer Service at the number listed on the back of your ID card to verify prescription
medication benefits.
A formulary is a list of prescription medications covered by a health plan. BCBSNC Pharmacy & Therapeutics (P&T)
Committee reviews medications at least quarterly. This includes ongoing reviews of clinical information about new
medications and reviews of new safety and efficacy information about older medications. The majority of BCBSNC’s
P&T Committee is composed of practicing physicians and pharmacists independent of BCBSNC. Tier placement of
prescription medications in the formulary may be determined by: the effectiveness and safety of the medication, the
cost of the medication, and /or the classification of the medications by the U.S. Food and Drug Administration (FDA)
or nationally-recognized medication databases (e.g., Medispan).
Please refer to your member guide for detailed information regarding your pharmacy benefits, including your benefit
design, out-of-pocket costs, prior review and restricted access medication requests, and applicable exclusions.
Formulary tiers
The Open Basic 5 Tier Formulary covers most medications approved by the United States Food &
DrugAdministration (FDA), within existing benefits. The plan design determines the member’s payment obligation.
Definitions for the five-tiered benefit structure:

Tier 1: The prescription medication tier which consists of the lowest cost tier of prescription medications,
most are generic.

Tier 2: The prescription medication tier which consists of medium-cost prescription medications, most are
generic, and some brand-name medications.

Tier 3: The prescription medication tier which consists of high-cost prescription medications, most are
brand-name prescription medications.

Tier 4: The prescription medication tier which consists of the higher-cost prescription medications, most
are brand-name prescription medications, and some specialty medications.

Tier 5: The prescription medication tier which consists of the highest-cost prescription medications, most
are specialty medications.
Generic medications
In most cases choosing a generic medication equivalent, when available, may mean significant savings to
you. We encourage you to discuss with your physician whether a generic alternative is available as these
medications represent safe, effective treatment options. Especially for medications that are taken daily and refilled
frequently, you will experience the long-term savings of a lower medication payment month after month. If you
choose a brand name prescription medication and a generic equivalent is available, you may be subject to
a reduced benefit and a higher out-of-pocket expense.
Blue Cross and Blue Shield of North Carolina (BCBSNC) September 2016 Open Basic 5 Tier Formulary
I
Compounded prescriptions
Compounded prescriptions contain two or more medications mixed together. Compounded prescriptions are
processed according to member benefits. To be eligible for coverage, compounded medications must contain at
least one ingredient that is defined as a prescription medication and must not be a copy of a commercially available
product. Compounded medications may be subject to prior review and benefit exclusion.
Prior review, quantity limitations and restricted-access medications
Certain medications may be subject to prior review, quantity limitations, or restricted-access programs. BCBSNC’s
P&T Committee reviews the clinical criteria for these programs.

Medications 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 medications, BCBSNC requires that the member has tried non-restrictedaccess formulary medications first. Coverage for restricted-access medications may be provided without the
use of a non-restricted-access medication if the provider certifies in writing that the member has previously
used non-restricted-access medications and the non-restricted-access medications have been detrimental
to the member's health or have been ineffective in treating the same condition and, in the opinion of the
provider, are likely to be detrimental to the member's health or ineffective in treating the condition in the
future. Clinical rationale and documentation for exception requests may be required.
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 medications. However, BCBSNC recognizes that in many cases, “off-label” (non-FDA approved) uses of
prescription medications 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 Medication 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 medications
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 medications or
therapies. Most specialty medications can be found on Tier 5, but some may be found on a lower tier.
Some of these specialty medications will need to be filled at a participating specialty pharmacy in our network.
These medications are identified in the specialty column of the formulary guide. Call the customer service number
on the back of your ID card to determine which pharmacy can fill your specialty medication prescription.
II
Affordable Care Act
Please note, some medications may have limited or $0 cost-sharing under the Affordable Care Act (ACA);
examples of categories of medications that may be subject to limited or $0 cost share include aspirin, breast cancer
preventive, fluoride supplements, folic acid supplements, gonorrhea prophylaxis (newborn), iron supplements,
tobacco cessation, vaccines, vitamin D supplements, and some contraceptive medications and devices. You may
find additional information about these medications at: www.bcbsnc.com/preventive. These medications are
identified in the ACA column of the formulary guide. If you do not find the medication you are searching for, consult
or contact the customer service number on the back of your ID card to find out if the medication is available over the
counter or is covered under your medical and/or pharmacy benefit.
Limited Distribution medications
Limited Distribution medications (LD) are medications where the manufacturer chooses to limit the distribution of the
medication to only a few pharmacies, or the Food and Drug Administration (FDA) requires this restriction during the
medication approval process. This type of restricted distribution helps the manufacturer keep track of medication
inventory and ensure that special dosing or lab monitoring requirements are followed to minimize any risks
associated with the LD medication. Medications which have restrictions on where the member may obtain them are
identified in the LD column of the formulary guide.
III
Using the member guide to the Basic Formulary
The Medication List is organized into broad categories (e.g., ANALGESICS AND ANESTHETICS). The graphic below
shows the information that is provided in each column of the medication list and is an example only. P lease use the
medication search function to find current information for medications 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.
Note: If a medication displays an “A” in the Medication Tier column, this indicates the medication may only be
covered if a member meets the criteria for $0 copay under the Affordable Care Act (ACA).
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 next three 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.
The seventh column indicates if the medication may have limited or $0 cost-sharing under the Affordable Care
Act (ACA). Benefits may apply.
The last column indicates if the medication is considered Limited Distribution.
IV
Abbreviation/acronym key
cap .........................................................capsules
chew ..................................................... chewable
conc .................................................. concentrate
cr...............................................controlled release
dr ................................................ delayed release
ec ................................................... enteric coated
effe .................................................... effervescent
equiv ....................................................equivalent
er............................................... extended release
inhal ......................................................inhalation
inj ............................................................injection
liq................................................................ liquid
lotn.............................................................. lotion
nebu...................................................... nebulizer
odt ................................... orally disintegrating tabs
oint ........................................................ ointment
ophth .................................................... opthalmic
osm ............................................. osmotic release
powd ........................................................powder
sa ................................................sustained action
sl ......................................................... sublingual
soln ......................................................... solution
sr ...............................................sustained release
suppos ........................................... suppositories
susp .................................................. suspension
tab…..........................................................tablets
td… ................................................... transdermal
V
amoxicillin (trihydrate) tab
875 mg
amoxicillin & k clavulanate for
susp 200-28.5 mg/5ml
AMPICILLIN - ampicillin for susp
125 mg/5ml
4
1
AMPICILLIN - ampicillin for susp
250 mg/5ml
4
ampicillin cap 250 mg
1
1
ampicillin cap 500 mg
4
AUGMENTIN - amoxicillin & k
clavulanate for susp 250-62.5
mg/5ml
4
1
clavulanate tab 500-125 mg
4
1
clavulanate tab 875-125 mg
4
1
1
2
amoxicillin & k clavulanate for
susp 400-57 mg/5ml
1
1
amoxicillin & k clavulanate tab sr 2
12hr 1000-62.5 mg (Augmentin
xr)
2
amoxicillin & k clavulanate tab
250-125 mg
1
500-125 mg (Augmentin)
1
875-125 mg (Augmentin)
Limited Distribution
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
1
clavulanate for susp 125-31.25
mg/5ml
1
amoxicillin & k clavulanate
for susp 250-62.5 mg/5ml
(Augmentin)
amoxicillin & k clavulanate
for susp 600-42.9 mg/5ml
(Augmentin es-600)
Drug Tier
1
1
amoxicillin (trihydrate) tab
500 mg
4
amoxicillin (trihydrate) cap
250 mg
amoxicillin (trihydrate) for susp
400 mg/5ml
ACA
AMOXICILLIN/CLAVULANATE P amoxicillin & k clavulanate chew
tab 400-57 mg
4
250 mg/5ml
Quantity Limits
4
AMOXICILLIN - amoxicillin
(trihydrate) chew tab 250 mg
200 mg/5ml
Restricted Access
AMOXICILLIN/CLAVULANATE P amoxicillin & k clavulanate chew
tab 200-28.5 mg
4
125 mg/5ml
Prior Review
4
AMOXICILLIN - amoxicillin
(trihydrate) chew tab 125 mg
amoxicillin (trihydrate) cap
500 mg
Drug Name
AMOXICILLIN ER - amoxicillin
(trihydrate) tab sr 24hr 775 mg
ANTI-INFECTIVE AGENTS
PENICILLINS
Specialty
Drug Name
Drug Tier
2016
4
AUGMENTIN ES-600 - amoxicillin
& k clavulanate for susp 600-42.9
mg/5ml
4
AUGMENTIN XR - amoxicillin
& k clavulanate tab sr 12hr
1000-62.5 mg
dicloxacillin sodium cap 250 mg 1
dicloxacillin sodium cap 500 mg
1
MOXATAG - amoxicillin (trihydrate)
tab sr 24hr 775 mg
4
penicillin v potassium for soln
125 mg/5ml
1
penicillin v potassium for soln
250 mg/5ml
penicillin v potassium tab
250 mg
1
1
1
penicillin v potassium tab
500 mg
CEPHALOSPORINS
1
CEDAX - ceftibuten cap 400 mg
CEDAX - ceftibuten for susp 180
mg/5ml
4
CEFACLOR - cefaclor for susp 125
mg/5ml
4
mg/5ml
4
mg/5ml
4
cefaclor cap 250 mg
1
2
CEFACLOR ER - cefaclor
monohydrate tab sr 12hr 500 mg
4
cefadroxil cap 500 mg
1
cefadroxil for susp 250 mg/5ml
cefadroxil for susp 500 mg/5ml
cefadroxil tab 1 gm
cefdinir cap 300 mg
cefdinir for susp 125 mg/5ml
cefdinir for susp 250 mg/5ml
2
2
2
1
2
2
CEFDITOREN PIVOXIL - cefditoren 4
pivoxil tab 200 mg (base
equivalent)
CEFDITOREN PIVOXIL - cefditoren 4
pivoxil tab 400 mg (base
equivalent)
2
cefixime for susp 100 mg/5ml
(Suprax)
2
cefixime for susp 200 mg/5ml
(Suprax)
2
cefpodoxime proxetil for susp
50 mg/5ml
2
cefpodoxime proxetil for susp
100 mg/5ml
cefpodoxime proxetil tab 100 mg 2
cefpodoxime proxetil tab 200 mg
cefprozil for susp 125 mg/5ml
2
cefprozil tab 250 mg
cefprozil tab 500 mg
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Drug Name
cefprozil for susp 250 mg/5ml
4
cefaclor cap 500 mg
Specialty
Drug Name
Drug Tier
2016
1
2
2
2
CEFTIBUTEN - ceftibuten cap 400
mg
4
CEFTIBUTEN - ceftibuten for susp
180 mg/5ml
4
CEFTIN - cefuroxime axetil for susp 4
125 mg/5ml
CEFTIN - cefuroxime axetil for susp 4
250 mg/5ml
CEFTIN - cefuroxime axetil tab 500 4
mg
1
cefuroxime axetil tab 250 mg
(Ceftin)
2
cefuroxime axetil tab 500 mg
(Ceftin)
CEPHALEXIN - cephalexin tab 250 4
mg
CEPHALEXIN - cephalexin tab 500 4
mg
1
cephalexin cap 250 mg (Keflex)
cephalexin for susp 125 mg/5ml
cephalexin for susp 250 mg/5ml
1
2
1
1
KEFLEX - cephalexin cap 250 mg
4
4
4
SPECTRACEF - cefditoren pivoxil
tab 200 mg (base equivalent)
4
SPECTRACEF - cefditoren pivoxil
4
SUPRAX - cefixime cap 400 mg
4
SUPRAX - cefixime chew tab 100
mg
4
SUPRAX - cefixime chew tab 200
mg
4
2
SUPRAX - cefixime for susp 100
mg/5ml
4
ERY-TAB - erythromycin tab
delayed release 333 mg
4
mg/5ml
4
4
mg/5ml
4
ERYPED 200 - erythromycin
ethylsuccinate for susp 200
mg/5ml
4
AZITHROMYCIN - azithromycin
powd pack for susp 1 gm
4
4
azithromycin for susp
100 mg/5ml (Zithromax)
1
ERYPED 400 - erythromycin
mg/5ml
ERYTHROCIN STEARATE erythromycin stearate tab 250
mg
4
MACROLIDES
azithromycin for susp
200 mg/5ml (Zithromax)
1
azithromycin tab 250 mg
(Zithromax)
1
ERYTHROMYCIN BASE erythromycin tab 250 mg
4
(Zithromax)
1
ERYTHROMYCIN BASE erythromycin tab 500 mg
4
(Zithromax)
1
4
BIAXIN - clarithromycin for susp
250 mg/5ml
4
ERYTHROMYCIN
ETHYLSUCCINA - erythromycin
ethylsuccinate tab 400 mg
2
BIAXIN - clarithromycin tab 250 mg
4
erythromycin w/ delayed release
particles cap 250 mg
BIAXIN - clarithromycin tab 500 mg
4
clarithromycin for susp
125 mg/5ml
PCE - erythromycin w/ enteric
coated particles tab 333 mg
4
2
PCE - erythromycin w/ enteric
coated particles tab 500 mg
4
2
ZITHROMAX - azithromycin for
susp 100 mg/5ml
4
2
ZITHROMAX - azithromycin for
susp 200 mg/5ml
4
clarithromycin tab 250 mg
(Biaxin)
2
ZITHROMAX - azithromycin powd
pack for susp 1 gm
4
clarithromycin tab 500 mg
(Biaxin)
2
DIFICID - fidaxomicin tab 200 mg
5
E.E.S. GRANULES - erythromycin
mg/5ml
4
E.E.S. 400 - erythromycin
ethylsuccinate tab 400 mg
4
4
ZITHROMAX - azithromycin tab 250 4
mg
mg
mg
4
ZITHROMAX TRI-PAK azithromycin tab 500 mg
ZITHROMAX Z-PAK - azithromycin 4
tab 250 mg
clarithromycin for susp
250 mg/5ml (Biaxin)
clarithromycin tab sr 24hr
500 mg
•
•
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
3
ZMAX - azithromycin extended
release for oral susp 2 gm
TETRACYCLINES
4
• •
doxycycline hyclate tab delayed
release 200 mg (Doryx)
doxycycline hyclate tab 20 mg
ACTICLATE - doxycycline hyclate
tab 75 mg
4
ACTICLATE - doxycycline hyclate
tab 150 mg
4
ADOXA - doxycycline monohydrate
cap 150 mg
4
doxycycline monohydrate cap
75 mg (Monodox)
tab 50 mg
4
100 mg (Monodox)
tab 75 mg
4
150 mg (Adoxa)
tab 100 mg
4
doxycycline monohydrate for
susp 25 mg/5ml (Vibramycin)
ADOXA PAK 1/100 - doxycycline
monohydrate tab 100 mg
4
doxycycline monohydrate tab
50 mg (Adoxa)
4
75 mg (Adoxa)
4
100 mg (Adoxa pak 1/100)
AVIDOXY DK - doxycycline tab 100 4
mg & suncreen & sal acid wash
2% kit
2
demeclocycline hcl tab 150 mg
demeclocycline hcl tab 300 mg
2
• •
• •
DORYX - doxycycline hyclate tab
4
• •
DORYX - doxycycline hyclate tab
4
• •
doxycycline hyclate cap 50 mg
2
doxycycline hyclate cap 100 mg
(Vibramycin)
2
release 50 mg (Doryx)
2
release 75 mg
release 100 mg
release 150 mg
2
2
2
doxycycline hyclate tab 100 mg
50 mg
150 mg (Adoxa pak 1/150)
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
• •
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
2
2
2
2
2
2
2
2
2
2
2
2
MINOCIN - minocycline hcl cap 50
mg
4
MINOCIN - minocycline hcl cap 75
mg
4
MINOCIN - minocycline hcl cap 100 4
mg
1
minocycline hcl cap 50 mg
(Minocin)
1
(Minocin)
1
(Minocin)
2
minocycline hcl tab sr 24hr
45 mg
2
90 mg
2
135 mg
2
minocycline hcl tab 50 mg
4
2
FLUOROQUINOLONES
2
4
MONODOX - doxycycline
monohydrate cap 75 mg
4
AVELOX - moxifloxacin hcl tab 400
mg (base equiv)
4
MONODOX - doxycycline
monohydrate cap 100 mg
4
AVELOX ABC PACK - moxifloxacin
hcl tab 400 mg (base equiv)
4
MORGIDOX 1X100MG doxycycline hyclate cap 1 x 100
mg w/ cleanser kit
4
CIPRO - ciprofloxacin for oral susp
250 mg/5ml (5%) (5 gm/100ml)
4
MORGIDOX 2X100MG doxycycline hyclate cap 2 x 100
mg w/ cleanser kit
4
CIPRO - ciprofloxacin for oral
susp 500 mg/5ml (10%) (10
gm/100ml)
CIPRO - ciprofloxacin hcl tab 250
mg (base equiv)
4
NUTRIDOX - doxycycline monohyd
cap 75 mg w/ omega 3-vit e cap
kit
4
CIPRO - ciprofloxacin hcl tab 500
mg (base equiv)
4
4
• •
4
SOLODYN - minocycline hcl tab sr
24hr 55 mg
24hr 65 mg
4
• •
CIPRO XR - ciprofloxacinciprofloxacin hcl tab sr 24hr 500
mg (base eq)
4
24hr 80 mg
4
• •
CIPRO XR - ciprofloxacinciprofloxacin hcl tab sr 24hr 1000
mg(base eq)
4
• •
2
24hr 105 mg
ciprofloxacin for oral susp
250 mg/5ml (5%) (5 gm/100ml)
(Cipro)
24hr 115 mg
4
• •
2
TARGADOX - doxycycline hyclate
tab 50 mg
4
• •
ciprofloxacin for oral
susp 500 mg/5ml (10%)
(10 gm/100ml) (Cipro)
TETRACYCLINE HCL - tetracycline 4
hcl cap 250 mg
TETRACYCLINE HCL - tetracycline 4
hcl cap 500 mg
2
tetracycline hcl cap 250 mg
(Tetracycline hcl)
2
tetracycline hcl cap 500 mg
(Tetracycline hcl)
VIBRAMYCIN - doxycycline calcium 4
syrup 50 mg/5ml
VIBRAMYCIN - doxycycline hyclate 4
cap 100 mg
4
VIBRAMYCIN - doxycycline
monohydrate for susp 25 mg/5ml
• •
• •
• •
CIPROFLOXACIN HCL ciprofloxacin hcl tab 100 mg
(base equiv)
4
ciprofloxacin hcl tab 250 mg
(base equiv) (Cipro)
1
(base equiv) (Cipro)
(base equiv)
• •
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
1
1
ciprofloxacin-ciprofloxacin hcl
tab sr 24hr 500 mg (base eq)
(Cipro xr)
2
ciprofloxacin-ciprofloxacin hcl
tab sr 24hr 1000 mg(base eq)
(Cipro xr)
2
5
FACTIVE - gemifloxacin mesylate
tab 320 mg (base equiv)
4
ethambutol hcl tab 100 mg
(Myambutol)
2
LEVAQUIN - levofloxacin tab 250
mg
4
ethambutol hcl tab 400 mg
(Myambutol)
2
mg
4
ISONIAZID - isoniazid syrup 50
mg/5ml
4
mg
4
isoniazid tab 100 mg
1
levofloxacin oral soln 25 mg/ml
(Levaquin)
2
levofloxacin tab 250 mg
(Levaquin)
1
(Levaquin)
1
(Levaquin)
1
moxifloxacin hcl tab 400 mg
(base equiv) (Avelox)
2
isoniazid tab 300 mg
AMINOGLYCOSIDES
BETHKIS - tobramycin nebu soln
300 mg/4ml
5
KITABIS PAK - tobramycin nebu
soln 300 mg/5ml
5
neomycin sulfate tab 500 mg
1
paromomycin sulfate cap
250 mg
• •
•
•
•
•
2
•
•
TOBI PODHALER - tobramycin
inhal cap 28 mg
5
•
•
tobramycin nebu soln
300 mg/5ml (Tobi)
5
•
•
ANTIMYCOBACTERIAL AGENTS
CYCLOSERINE - cycloserine cap
250 mg
4
4
4
ACA
Quantity Limits
Restricted Access
Prior Review
2
4
RIFADIN - rifampin cap 300 mg
4
RIFAMATE - isoniazid & rifampin
cap 150-300 mg
4
rifampin cap 150 mg (Rifadin)
2
2
RIFATER - isoniazid-rifampin w/
pyrazinamide tab 50-120-300 mg
4
SIRTURO - bedaquiline fumarate
4
TRECATOR - ethionamide tab 250
mg
4
ANTIFUNGALS
• •
2
RIFADIN - rifampin cap 150 mg
rifampin cap 300 mg (Rifadin)
5
SULFADIAZINE - sulfadiazine tab
500 mg
MYAMBUTOL - ethambutol hcl tab
400 mg
rifabutin cap 150 mg (Mycobutin)
TOBI - tobramycin nebu soln 300
mg/5ml
SULFONAMIDES
4
MYCOBUTIN - rifabutin cap 150 mg 4
4
PASER - aminosalicylic acid cr
granules packet 4 gm
4
PRIFTIN - rifapentine tab 150 mg
OFLOXACIN - ofloxacin tab 400 mg 4
• •
1
MYAMBUTOL - ethambutol hcl tab
100 mg
pyrazinamide tab 500 mg
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
• •
•
• •
ANCOBON - flucytosine cap 250
mg
4
ANCOBON - flucytosine cap 500
mg
4
BIO-STATIN - nystatin cap 500000
unit
4
• •
BIO-STATIN - nystatin cap 1000000 4
unit
• •
6
4
LAMISIL - terbinafine hcl oral
granules packet 187.5 mg
4
• •
DIFLUCAN - fluconazole for susp
40 mg/ml
4
LAMISIL - terbinafine hcl tab 250
mg
4
DIFLUCAN - fluconazole tab 50 mg
4
5
• •
DIFLUCAN - fluconazole tab 100
mg
4
NOXAFIL - posaconazole susp 40
mg/ml
5
• •
mg
4
NOXAFIL - posaconazole tab
2
mg
4
nystatin oral powder
fluconazole for susp 10 mg/ml
(Diflucan)
1
fluconazole for susp 40 mg/ml
(Diflucan)
2
fluconazole tab 50 mg (Diflucan)
1
flucytosine cap 250 mg
(Ancobon)
2
flucytosine cap 500 mg
(Ancobon)
2
GRIS-PEG - griseofulvin
ultramicrosize tab 125 mg
DIFLUCAN - fluconazole for susp
10 mg/ml
nystatin tab 500000 unit
ONMEL - itraconazole tab 200 mg
2
VFEND - voriconazole tab 200 mg
5
4
voriconazole for susp 40 mg/ml
(Vfend)
5
GRIS-PEG - griseofulvin
ultramicrosize tab 250 mg
4
voriconazole tab 50 mg (Vfend)
5
griseofulvin microsize susp
125 mg/5ml
2
griseofulvin microsize tab
500 mg (Grifulvin v)
griseofulvin ultramicrosize tab
125 mg (Gris-peg)
griseofulvin ultramicrosize tab
250 mg (Gris-peg)
voriconazole tab 200 mg (Vfend)
ANTIVIRALS
2
2
2
ketoconazole tab 200 mg
1
•
•
•
• •
• •
• •
• •
• •
• •
5
2
•
abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg
(Trizivir)
5
•
acyclovir cap 200 mg (Zovirax)
1
abacavir sulfate tab 300 mg
(base equiv) (Ziagen)
2
itraconazole cap 100 mg
(Sporanox)
•
•
4
SPORANOX - itraconazole cap 100 4
mg
SPORANOX - itraconazole oral soln 4
10 mg/ml
4
SPORANOX PULSEPAK itraconazole cap 100 mg
1
terbinafine hcl tab 250 mg
(Lamisil)
5
VFEND - voriconazole for susp 40
mg/ml
5
VFEND - voriconazole tab 50 mg
fluconazole tab 100 mg (Diflucan) 1
acyclovir susp 200 mg/5ml
(Zovirax)
2
acyclovir tab 400 mg (Zovirax)
1
acyclovir tab 800 mg (Zovirax)
• •
ACA
4
5
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Tier
ACA
Quantity Limits
Drug Name
LAMISIL - terbinafine hcl oral
granules packet 125 mg
CRESEMBA - isavuconazonium
sulfate cap 186 mg
•
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
1
7
5
•
BARACLUDE - entecavir tab 0.5
mg
5
•
BARACLUDE - entecavir tab 1 mg
5
•
•
COMBIVIR - lamivudine-zidovudine 5
tab 150-300 mg
5
COMPLERA - emtricitabinerilpivirine-tenofovir df tab
200-25-300 mg
5
COPEGUS - ribavirin tab 200 mg
•
CRIXIVAN - indinavir sulfate cap
200 mg
5
•
•
CRIXIVAN - indinavir sulfate cap
400 mg
5
•
DAKLINZA - daclatasvir
dihydrochloride tab 30 mg (base
equivalent)
5
• •
equivalent)
5
• •
equivalent)
5
DESCOVY - emtricitabine-tenofovir
alafenamide fumarate tab 200-25
mg
5
didanosine delayed release
capsule 125 mg (Videx ec)
2
•
2
•
2
•
•
•
EPCLUSA - sofosbuvir-velpatasvir
tab 400-100 mg
5
EPIVIR - lamivudine oral soln 10
mg/ml
5
•
EPIVIR - lamivudine tab 150 mg
5
EPIVIR - lamivudine tab 300 mg
5
EPIVIR HBV - lamivudine oral soln
5 mg/ml (hbv)
5
•
•
•
EPIVIR HBV - lamivudine tab 100
mg (hbv)
5
•
EPZICOM - abacavir sulfatelamivudine tab 600-300 mg
5
•
EVOTAZ - atazanavir sulfatecobicistat tab 300-150 mg (base
equiv)
5
•
famciclovir tab 125 mg (Famvir)
2
• •
•
•
•
• •
entecavir tab 1 mg (Baraclude)
5
BARACLUDE - entecavir oral soln
0.05 mg/ml
•
ACA
•
EDURANT - rilpivirine hcl tab 25 mg 5
(base equivalent)
EMTRIVA - emtricitabine caps 200 5
mg
5
EMTRIVA - emtricitabine soln 10
mg/ml
entecavir tab 0.5 mg (Baraclude) 5
Quantity Limits
5
•
Restricted Access
ATRIPLA - efavirenz-emtricitabinetenofovir df tab 600-200-300 mg
2
Prior Review
5
Specialty
APTIVUS - tipranavir oral soln 100
mg/ml
•
•
Drug Name
Drug Tier
5
APTIVUS - tipranavir cap 250 mg
ACA
•
Quantity Limits
5
Restricted Access
adefovir dipivoxil tab 10 mg
(Hepsera)
Prior Review
Specialty
Drug Name
Drug Tier
2016
2
2
FAMVIR - famciclovir tab 125 mg
4
4
4
FLUMADINE - rimantadine
hydrochloride tab 100 mg
4
FUZEON - enfuvirtide for inj 90 mg
5
GENVOYA - elvitegrav-cobicemtricitab-tenofov af tab
150-150-200-10 mg
5
•
•
HARVONI - ledipasvir-sofosbuvir
tab 90-400 mg
5
• •
8
INVIRASE - saquinavir mesylate
cap 200 mg
5
•
•
•
•
INVIRASE - saquinavir mesylate
tab 500 mg
5
•
ISENTRESS - raltegravir potassium 5
chew tab 25 mg (base equiv)
packet for susp 100 mg (base
equiv)
5
KALETRA - lopinavir-ritonavir soln
400-100 mg/5ml (80-20 mg/ml)
5
KALETRA - lopinavir-ritonavir tab
100-25 mg
5
KALETRA - lopinavir-ritonavir tab
200-50 mg
2
lamivudine oral soln 10 mg/ml
(Epivir)
5
lamivudine tab 100 mg (hbv)
(Epivir hbv)
2
lamivudine tab 150 mg (Epivir)
•
INTELENCE - etravirine tab 100 mg 5
INTELENCE - etravirine tab 200 mg 5
•
•
•
•
•
•
•
•
5
•
•
•
5
•
LEXIVA - fosamprenavir calcium tab 5
700 mg (base equiv)
MODERIBA - ribavirin tab 200 mg & 5
ribavirin tab 400 mg dose pack
MODERIBA - ribavirin tab 400 mg & 5
ribavirin tab 600 mg dose pack
•
lamivudine tab 300 mg (Epivir)
lamivudine-zidovudine tab
150-300 mg (Combivir)
LEXIVA - fosamprenavir calcium
susp 50 mg/ml (base equiv)
2
•
•
5
•
NEVIRAPINE - nevirapine susp 50
mg/5ml
5
•
nevirapine tab sr 24hr 100 mg
(Viramune xr)
2
•
nevirapine tab sr 24hr 400 mg
(Viramune xr)
2
•
nevirapine tab 200 mg (Viramune) 2
5
NORVIR - ritonavir cap 100 mg
•
•
•
NORVIR - ritonavir oral soln 80 mg/ 5
ml
5
NORVIR - ritonavir tab 100 mg
ODEFSEY - emtricitabine-rilpivirine- 5
tenofovir af tab 200-25-25 mg
5
OLYSIO - simeprevir sodium cap
150 mg (base equivalent)
5
PEG-INTRON REDIPEN peginterferon alfa-2b for inj kit 50
mcg/0.5ml
5
PEG-INTRON REDIPEN peginterferon alfa-2b for inj kit 80
mcg/0.5ml
5
PEG-INTRON REDIPEN peginterferon alfa-2b for inj kit
120 mcg/0.5ml
5
PEG-INTRON REDIPEN peginterferon alfa-2b for inj kit
150 mcg/0.5ml
5
PEG-INTRON REDIPEN PAK 4 peginterferon alfa-2b for inj kit
120 mcg/0.5ml
5
PEGASYS - peginterferon alfa-2a
inj 180 mcg/ml
5
PEGASYS - peginterferon alfa-2a
inj 180 mcg/0.5ml
5
PEGASYS PROCLICK peginterferon alfa-2a inj 135
mcg/0.5ml
MODERIBA 800 DOSE PACK ribavirin tab 400 mg
ACA
•
Quantity Limits
5
Restricted Access
MODERIBA 1200 DOSE PACK ribavirin tab 600 mg
Prior Review
Specialty
Drug Name
Drug Tier
5
INTELENCE - etravirine tab 25 mg
ACA
•
Quantity Limits
5
Restricted Access
HEPSERA - adefovir dipivoxil tab
10 mg
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
•
• •
• •
• •
• •
• •
• •
• •
• •
• •
9
•
RIBASPHERE - ribavirin tab 400
mg
5
•
RIBASPHERE - ribavirin tab 600
mg
5
•
RIBASPHERE RIBAPAK - ribavirin
tab 400 mg
5
•
tab 600 mg
5
•
tab 200 mg & ribavirin tab 400
mg dose pack
5
•
•
tab 400 mg & ribavirin tab 600
mg dose pack
5
•
•
ribavirin cap 200 mg (Rebetol)
5
•
•
PEGINTRON - peginterferon
alfa-2b for inj kit 50 mcg/0.5ml
• •
5
• •
5
• •
5
• •
PREZCOBIX - darunavir-cobicistat
tab 800-150 mg
5
•
PREZISTA - darunavir ethanolate
susp 100 mg/ml (base equiv)
5
•
5
•
5
5
5
•
REBETOL - ribavirin cap 200 mg
5
REBETOL - ribavirin soln 40 mg/ml
5
•
•
ribavirin tab 200 mg (Copegus)
rimantadine hydrochloride tab
100 mg (Flumadine)
5
2
SELZENTRY - maraviroc tab 150
mg
5
•
SELZENTRY - maraviroc tab 300
mg
5
•
•
SITAVIG - acyclovir buccal tab 50
mg
4
•
SOVALDI - sofosbuvir tab 400 mg
5
stavudine cap 15 mg (Zerit)
2
•
•
•
•
• •
stavudine for oral soln 1 mg/ml
(Zerit)
2
• •
•
•
•
•
•
STRIBILD - elvitegrav-cobicemtricitab-tenofovdf tab
150-150-200-300 mg
5
•
SUSTIVA - efavirenz cap 50 mg
5
•
5
ACA
REYATAZ - atazanavir sulfate oral
powder packet 50 mg (base
equiv)
5
Quantity Limits
•
Restricted Access
5
5
Prior Review
Specialty
Drug Tier
ACA
Drug Name
REYATAZ - atazanavir sulfate cap
300 mg (base equiv)
PEGASYS PROCLICK peginterferon alfa-2a inj 180
mcg/0.5ml
RELENZA DISKHALER - zanamivir 4
aero powder breath activated 5
mg/blister
5
RESCRIPTOR - delavirdine
mesylate tab 100 mg
5
RESCRIPTOR - delavirdine
mesylate tab 200 mg
5
RETROVIR - zidovudine cap 100
mg
5
RETROVIR - zidovudine syrup 10
mg/ml
5
150 mg (base equiv)
5
200 mg (base equiv)
Quantity Limits
• •
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
2
2
2
10
SUSTIVA - efavirenz cap 200 mg
5
SUSTIVA - efavirenz tab 600 mg
5
TAMIFLU - oseltamivir phosphate
cap 30 mg (base equiv)
valacyclovir hcl tab 1 gm
(Valtrex)
2
4
VALCYTE - valganciclovir hcl for
soln 50 mg/ml (base equiv)
5
4
VALCYTE - valganciclovir hcl tab
5
4
valganciclovir hcl tab 450 mg
(base equivalent) (Valcyte)
5
for susp 6 mg/ml (base equiv)
4
VALTREX - valacyclovir hcl tab 500
mg
4
TECHNIVIE - ombitasvirparitaprevir-ritonavir tab
12.5-75-50 mg
5
VALTREX - valacyclovir hcl tab 1
gm
4
5
TIVICAY - dolutegravir sodium tab
10 mg (base equiv)
5
•
VIDEX - didanosine for soln 2 gm
VIDEX - didanosine for soln 4 gm
5
5
•
VIDEX EC - didanosine delayed
release capsule 125 mg
5
25 mg (base equiv)
•
•
•
5
•
5
50 mg (base equiv)
•
•
5
TRIUMEQ - abacavir-dolutegravirlamivudine tab 600-50-300 mg
5
•
•
5
TRIZIVIR - abacavir sulfatelamivudine-zidovudine tab
300-150-300 mg
5
•
5
• •
TRUVADA - emtricitabine-tenofovir
disoproxil fumarate tab 100-150
mg
5
•
VIEKIRA PAK - ombitas-paritapreriton & dasab tab pak 12.5-75-50
& 250 mg
mg
5
•
mg
5
•
mg
5
•
TYBOST - cobicistat tab 150 mg
5
TYZEKA - telbivudine tab 600 mg
5
•
•
valacyclovir hcl tab 500 mg
(Valtrex)
2
• •
VIRACEPT - nelfinavir mesylate tab 5
250 mg
VIRACEPT - nelfinavir mesylate tab 5
625 mg
5
VIRAMUNE - nevirapine susp 50
mg/5ml
5
VIRAMUNE - nevirapine tab 200
mg
VIRAMUNE XR - nevirapine tab sr 5
24hr 100 mg
VIRAMUNE XR - nevirapine tab sr 5
24hr 400 mg
VIRAZOLE - ribavirin for inhal soln 5
6 gm
5
VIREAD - tenofovir disoproxil
fumarate oral powder 40 mg/gm
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
•
•
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
•
•
•
•
•
• • •
•
11
5
•
VITEKTA - elvitegravir tab 85 mg
5
VITEKTA - elvitegravir tab 150 mg
5
ZEPATIER - elbasvir-grazoprevir
tab 50-100 mg
5
•
•
• •
ZERIT - stavudine cap 15 mg
5
5
5
5
ZERIT - stavudine for oral soln 1
mg/ml
5
•
•
•
•
•
ZIAGEN - abacavir sulfate soln 20
mg/ml (base equiv)
5
ZIAGEN - abacavir sulfate tab 300
mg (base equiv)
5
zidovudine cap 100 mg (Retrovir)
2
1
1
4
4
4
•
PRIMAQUINE PHOSPHATE primaquine phosphate tab 26.3
mg (15 mg base)
•
QUALAQUIN - quinine sulfate cap
324 mg
4
quinine sulfate cap 324 mg
(Qualaquin)
2
zidovudine syrup 10 mg/ml
(Retrovir)
2
zidovudine tab 300 mg
2
•
ANTHELMINTICS
ALBENZA - albendazole tab 200
mg
4
4
ZOVIRAX - acyclovir cap 200 mg
4
ZOVIRAX - acyclovir susp 200
mg/5ml
4
BILTRICIDE - praziquantel tab 600
mg
4
ZOVIRAX - acyclovir tab 400 mg
4
EMVERM - mebendazole chew tab
100 mg
ZOVIRAX - acyclovir tab 800 mg
4
ivermectin tab 3 mg (Stromectol)
2
ANTIMALARIALS
•
DARAPRIM - pyrimethamine tab 25 4
mg
1
hydroxychloroquine sulfate tab
200 mg (Plaquenil)
4
MALARONE - atovaquoneproguanil hcl tab 62.5-25 mg
4
MALARONE - atovaquoneproguanil hcl tab 250-100 mg
1
mefloquine hcl tab 250 mg
PLAQUENIL - hydroxychloroquine
sulfate tab 200 mg
•
•
STROMECTOL - ivermectin tab 3
mg
4
ARALEN - chloroquine phosphate
tab 500 mg
4
atovaquone-proguanil hcl tab
62.5-25 mg (Malarone)
2
ALINIA - nitazoxanide for susp 100
mg/5ml
4
• •
2
ALINIA - nitazoxanide tab 500 mg
4
• •
atovaquone susp 750 mg/5ml
(Mepron)
2
atovaquone-proguanil hcl tab
250-100 mg (Malarone)
ANTI-INFECTIVE AGENTS - MISC.
fumarate tab 300 mg
COARTEM - artemetherlumefantrine tab 20-120 mg
ACA
•
Quantity Limits
5
Restricted Access
fumarate tab 250 mg
chloroquine phosphate tab
500 mg (Aralen)
Prior Review
•
chloroquine phosphate tab
250 mg
Specialty
5
Drug Name
Drug Tier
fumarate tab 200 mg
•
ACA
5
Quantity Limits
fumarate tab 150 mg
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
12
BACTRIM - sulfamethoxazoletrimethoprim tab 400-80 mg
4
MEPRON - atovaquone susp 750
mg/5ml
4
BACTRIM DS - sulfamethoxazoletrimethoprim tab 800-160 mg
4
metronidazole cap 375 mg
(Flagyl)
2
CAYSTON - aztreonam lysine
for inhal soln 75 mg (base
equivalent)
5
metronidazole tab 250 mg
(Flagyl)
1
4
metronidazole tab 500 mg
(Flagyl)
1
CLEOCIN - clindamycin hcl cap 75
mg
NEBUPENT - pentamidine
isethionate for nebulization soln
300 mg
4
PRIMSOL - trimethoprim hcl oral
soln 50 mg/5ml (base equiv)
4
SIVEXTRO - tedizolid phosphate
tab 200 mg
4
sulfamethoxazole-trimethoprim
susp 200-40 mg/5ml
1
•
•
CLEOCIN - clindamycin hcl cap 150 4
mg
CLEOCIN - clindamycin hcl cap 300 4
mg
CLEOCIN PEDIATRIC GRANULE - 4
clindamycin palmitate hcl for soln
75 mg/5ml (base equiv)
1
clindamycin hcl cap 75 mg
(Cleocin)
1
(Cleocin)
1
(Cleocin)
2
clindamycin palmitate hcl for
(Cleocin pediatric gr)
2
dapsone tab 25 mg
tab 400-80 mg (Bactrim)
tab 800-160 mg (Bactrim ds)
ACA
Quantity Limits
• •
1
1
TINDAMAX - tinidazole tab 250 mg
4
TINDAMAX - tinidazole tab 500 mg
4
tinidazole tab 250 mg (Tindamax) 2
tinidazole tab 500 mg (Tindamax) 2
1
2
trimethoprim tab 100 mg
FLAGYL - metronidazole cap 375
mg
4
VANCOCIN HCL - vancomycin hcl
cap 125 mg
4
FLAGYL - metronidazole tab 250
mg
4
VANCOCIN HCL - vancomycin hcl
cap 250 mg
4
FLAGYL - metronidazole tab 500
mg
4
vancomycin hcl cap 125 mg
(Vancocin hcl)
2
FLAGYL ER - metronidazole tab sr
24hr 750 mg
4
vancomycin hcl cap 250 mg
(Vancocin hcl)
2
IMPAVIDO - miltefosine cap 50 mg
4
XIFAXAN - rifaximin tab 200 mg
4
KETEK - telithromycin tab 300 mg
4
XIFAXAN - rifaximin tab 550 mg
4
KETEK - telithromycin tab 400 mg
4
4
•
linezolid for susp 100 mg/5ml
(Zyvox)
2
•
ZYVOX - linezolid for susp 100
mg/5ml
ZYVOX - linezolid tab 600 mg
4
•
linezolid tab 600 mg (Zyvox)
2
•
dapsone tab 100 mg
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
BIOLOGICALS
13
BIOLOGICALS MISC
• • •
•
ADAGEN - pegademase bovine inj
250 unit/ml
5
GRASTEK - timothy grass pollen
allergen ext tab sl 2800 bau
4
• •
ORALAIR - grass mixed pollen ext
tab sl 300 ir (index of reactivity)
4
• •
•
ORALAIR ADULT SAMPLE KIT grass mixed pollen ext tab sl 300
ir (index of reactivity)
4
• •
•
ORALAIR ADULT STARTER PAC grass mixed pollen ext tab sl 300
ir (index of reactivity)
4
ORALAIR CHILDREN/
ADOLESCE - grass mixed
pollen ext tab sl 100 ir (index of
reactivity)
4
• •
•
ORALAIR CHILDREN/
ADOLESCE - grass mixed pollen
tab sl therpak 100 (3) ir & 300 (6)
ir
4
• •
•
RAGWITEK - short ragweed pollen
allergen extract tab sl 12 amb a
1-u
4
• •
•
• •
ACTIMMUNE - interferon
gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)
5
•
•
AFINITOR - everolimus tab 2.5 mg
5
AFINITOR - everolimus tab 5 mg
5
AFINITOR - everolimus tab 7.5 mg
5
AFINITOR - everolimus tab 10 mg
5
AFINITOR DISPERZ - everolimus
tab for oral susp 2 mg
5
•
•
•
•
•
•
•
•
•
•
5
•
•
5
•
•
ALECENSA - alectinib hcl cap 150
mg (base equivalent)
5
• •
•
5
•
bexarotene cap 75 mg (Targretin)
5
•
•
bicalutamide tab 50 mg
(Casodex)
1
BOSULIF - bosutinib tab 100 mg
5
BOSULIF - bosutinib tab 500 mg
5
CABOMETYX - cabozantinib
s-malate tab 20 mg (base
equivalent)
azacitidine for inj 100 mg
(Vidaza)
ACA
5
1
Quantity Limits
AROMASIN - exemestane tab 25
mg
anastrozole tab 1 mg (Arimidex)
Restricted Access
5
5
Prior Review
Specialty
ARIMIDEX - anastrozole tab 1 mg
•
•
•
•
ALKERAN - melphalan tab 2 mg
5
•
•
• •
•
•
•
•
equivalent)
5
• •
•
•
equivalent)
5
• •
•
•
CAPRELSA - vandetanib tab 100
mg
5
•
•
•
CAPRELSA - vandetanib tab 300
mg
5
•
CASODEX - bicalutamide tab 50
mg
5
•
COMETRIQ - cabozantinib s-mal
cap 1 x 80 mg & 1 x 20 mg (100
dose) kit
5
•
•
COMETRIQ - cabozantinib s-mal
cap 1 x 80 mg & 3 x 20 mg (140
dose) kit
5
•
•
COMETRIQ - cabozantinib s-malate 5
cap 3 x 20 mg (60 mg dose) kit
5
COTELLIC - cobimetinib fumarate
5
CYCLOPHOSPHAMIDE cyclophosphamide cap 25 mg
•
•
capecitabine tab 150 mg (Xeloda) 5
capecitabine tab 500 mg (Xeloda) 5
ANTINEOPLASTIC AGENTS
ANTINEOPLASTICS
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
•
•
•
•
•
14
•
ELIGARD - leuprolide acetate for
subcutaneous inj kit 7.5 mg
5
•
EMCYT - estramustine phosphate
sodium cap 140 mg
5
•
ERIVEDGE - vismodegib cap 150
mg
5
•
ETOPOSIDE - etoposide cap 50 mg 5
2
exemestane tab 25 mg
(Aromasin)
FARESTON - toremifene citrate tab 5
5
FARYDAK - panobinostat lactate
cap 10 mg (base equivalent)
5
5
5
FASLODEX - fulvestrant inj 250
mg/5ml
5
FEMARA - letrozole tab 2.5 mg
•
•
5
•
•
•
•
GLEOSTINE - lomustine cap 10 mg 5
GLEOSTINE - lomustine cap 40 mg 5
•
•
• •
•
• •
•
• •
•
•
•
GLEOSTINE - lomustine cap 100
mg
5
HEXALEN - altretamine cap 50 mg
5
HYCAMTIN - topotecan hcl cap
0.25 mg (base equiv)
5
GLEOSTINE - lomustine cap 5 mg
ACA
ELIGARD - leuprolide acetate (6
month) for subcutaneous inj kit
45 mg
•
Quantity Limits
•
5
Restricted Access
5
GLEEVEC - imatinib mesylate tab
Prior Review
30 mg
Specialty
•
Drug Name
Drug Tier
5
22.5mg
ACA
•
Quantity Limits
5
Restricted Access
CYCLOPHOSPHAMIDE cyclophosphamide cap 50 mg
Prior Review
Specialty
Drug Name
Drug Tier
2016
5
•
•
•
HYCAMTIN - topotecan hcl cap 1
mg (base equiv)
5
•
•
HYDREA - hydroxyurea cap 500
mg
5
•
hydroxyurea cap 500 mg
(Hydrea)
5
•
IBRANCE - palbociclib cap 75 mg
5
5
5
ICLUSIG - ponatinib hcl tab 15 mg
(base equiv)
5
• •
• •
• •
•
•
•
•
•
ICLUSIG - ponatinib hcl tab 45 mg
(base equiv)
5
•
•
imatinib mesylate tab 100 mg
(base equivalent) (Gleevec)
5
•
5
•
IMBRUVICA - ibrutinib cap 140 mg
5
INLYTA - axitinib tab 1 mg
5
INLYTA - axitinib tab 5 mg
5
•
•
•
•
imatinib mesylate tab 400 mg
(base equivalent) (Gleevec)
•
INTRON A - interferon alfa-2b inj
6000000 unit/ml
5
•
•
•
•
GILOTRIF - afatinib dimaleate tab
5
•
•
•
5
•
•
INTRON A - interferon alfa-2b inj
10000000 unit/ml
5
•
•
5
•
•
•
•
GLEEVEC - imatinib mesylate tab
5
•
INTRON A - interferon alfa-2b for inj 5
10000000 unit
18000000 unit
50000000 unit
•
•
•
•
flutamide cap 125 mg
2
15
•
•
IRESSA - gefitinib tab 250 mg
5
•
•
•
•
•
•
•
•
•
•
•
•
•
•
LEUCOVORIN CALCIUM leucovorin calcium tab 10 mg
4
LEUCOVORIN CALCIUM leucovorin calcium tab 15 mg
4
leucovorin calcium tab 5 mg
2
LEUKERAN - chlorambucil tab 2
mg
5
•
leuprolide acetate inj kit 5 mg/ml
2
LONSURF - trifluridine-tipiracil tab
15-6.14 mg
5
•
•
•
LONSURF - trifluridine-tipiracil tab
20-8.19 mg
5
•
•
LUPRON DEPOT - leuprolide
acetate (3 month) for inj kit 11.25
mg
5
•
acetate (3 month) for inj kit 22.5
mg
5
•
acetate (4 month) for inj kit 30
mg
5
•
•
acetate (6 month) for inj kit 45
mg
5
•
•
acetate for inj kit 3.75 mg
5
•
acetate for inj kit 7.5 mg
5
•
LYNPARZA - olaparib cap 50 mg
5
LYSODREN - mitotane tab 500 mg
5
MATULANE - procarbazine hcl cap
50 mg
5
• •
•
•
4
•
•
•
•
•
•
•
MEGACE ORAL - megestrol
acetate susp 40 mg/ml
•
megestrol acetate susp 40 mg/ml 2
(Megace oral)
1
megestrol acetate tab 20 mg
•
•
INTRON A W/DILUENT - interferon
alfa-2b for inj 50000000 unit
5
2
ACA
•
leucovorin calcium tab 25 mg
Quantity Limits
5
JAKAFI - ruxolitinib phosphate tab 5 5
5
JAKAFI - ruxolitinib phosphate tab
5
5
5
5
LENVIMA 10MG DAILY DOSE lenvatinib cap therapy pack 10
mg (10 mg daily dose)
5
LENVIMA 14MG DAILY DOSE lenvatinib cap therapy pack 10 &
4 mg (14 mg daily dose)
5
LENVIMA 18MG DAILY DOSE lenvatinib cap therapy pack 10 &
4 (2) mg (18 mg daily dose)
5
(2) mg (20 mg daily dose)
5
(2) & 4 mg (24 mg daily dose)
5
LENVIMA 8MG DAILY DOSE lenvatinib cap therapy pack 4 (2)
mg (8 mg daily dose)
1
letrozole tab 2.5 mg (Femara)
•
Restricted Access
•
Prior Review
5
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
megestrol acetate tab 40 mg
1
•
•
MEKINIST - trametinib dimethyl
sulfoxide tab 0.5 mg (base
equivalent)
5
• •
•
•
MEKINIST - trametinib dimethyl
sulfoxide tab 2 mg (base
equivalent)
5
• •
•
•
mercaptopurine tab 50 mg
2
•
16
MESNEX - mesna tab 400 mg
5
METHOTREXATE SODIUM methotrexate sodium inj 250
mg/10ml (25 mg/ml)
4
methotrexate sodium for inj
1 gm
2
methotrexate sodium inj pf
50 mg/2ml (25 mg/ml)
100 mg/4ml (25 mg/ml)
200 mg/8ml (25 mg/ml)
250 mg/10ml (25 mg/ml)
1000 mg/40ml (25 mg/ml)
methotrexate sodium inj
50 mg/2ml (25 mg/ml)
methotrexate sodium tab 2.5 mg
(base equiv)
1
1
1
1
1
1
2
MYLERAN - busulfan tab 2 mg
5
NEXAVAR - sorafenib tosylate tab
5
•
•
NILANDRON - nilutamide tab 150
mg
5
•
NINLARO - ixazomib citrate cap 2.3 5
5
NINLARO - ixazomib citrate cap 3
5
NINLARO - ixazomib citrate cap 4
5
ODOMZO - sonidegib phosphate
POMALYST - pomalidomide cap 1 5
mg
mg
mg
mg
•
• •
•
• •
•
• •
•
•
•
• • •
•
• • •
•
• • •
•
• • •
•
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
•
Prior Review
Specialty
Drug Name
Drug Tier
2016
PURIXAN - mercaptopurine susp
2000 mg/100ml (20 mg/ml)
5
•
SOLTAMOX - tamoxifen citrate oral
soln 10 mg/5ml (base equivalent)
5
•
SPRYCEL - dasatinib tab 20 mg
5
5
5
5
5
5
STIVARGA - regorafenib tab 40 mg
5
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
SUTENT - sunitinib malate cap 12.5 5
5
SUTENT - sunitinib malate cap 25
SUTENT - sunitinib malate cap 37.5 5
5
SUTENT - sunitinib malate cap 50
SYLATRON - peginterferon alfa-2b 5
for inj kit 200 mcg
for inj kit 300 mcg
for inj kit 600 mcg
5
SYNRIBO - omacetaxine
mepesuccinate for inj 3.5 mg
5
TABLOID - thioguanine tab 40 mg
•
TAFINLAR - dabrafenib mesylate
5
•
• •
TAFINLAR - dabrafenib mesylate
5
• •
TAGRISSO - osimertinib mesylate
5
• •
•
TAGRISSO - osimertinib mesylate
5
• •
•
tamoxifen citrate tab 10 mg
(base equivalent)
1
•
1
•
tamoxifen citrate tab 20 mg
(base equivalent)
•
•
•
•
17
•
4
TREXALL - methotrexate sodium
tab 7.5 mg (base equiv)
4
•
ACA
•
Quantity Limits
•
Restricted Access
TARCEVA - erlotinib hcl tab 100 mg 5
(base equivalent)
TARCEVA - erlotinib hcl tab 150 mg 5
(base equivalent)
5
TARGRETIN - bexarotene cap 75
mg
TASIGNA - nilotinib hcl cap 150 mg 5
(base equivalent)
TASIGNA - nilotinib hcl cap 200 mg 5
(base equivalent)
5
TEMODAR - temozolomide cap 5
mg
TEMODAR - temozolomide cap 20 5
mg
mg
mg
mg
mg
5
temozolomide cap 5 mg
(Temodar)
5
(Temodar)
5
(Temodar)
5
(Temodar)
5
(Temodar)
5
(Temodar)
5
tretinoin cap 10 mg
•
Prior Review
•
Specialty
5
TARCEVA - erlotinib hcl tab 25 mg
(base equivalent)
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
4
4
TYKERB - lapatinib ditosylate tab
250 mg (base equiv)
5
•
VENCLEXTA - venetoclax tab 10
mg
5
• •
•
•
mg
5
• •
•
•
mg
5
• •
•
•
5
• •
•
•
•
VENCLEXTA STARTING PACK venetoclax tab therapy starter
pack 10 & 50 & 100 mg
•
VIDAZA - azacitidine for inj 100 mg
5
XALKORI - crizotinib cap 200 mg
5
XALKORI - crizotinib cap 250 mg
5
•
•
•
•
•
• • •
• •
•
•
•
•
•
•
•
•
•
XELODA - capecitabine tab 150 mg 5
XELODA - capecitabine tab 500 mg 5
XTANDI - enzalutamide cap 40 mg
5
•
ZELBORAF - vemurafenib tab 240
mg
5
•
ZOLINZA - vorinostat cap 100 mg
5
•
ZYDELIG - idelalisib tab 100 mg
5
ZYDELIG - idelalisib tab 150 mg
5
ZYKADIA - ceritinib cap 150 mg
5
ZYTIGA - abiraterone acetate tab
250 mg
5
•
•
•
•
•
•
•
•
•
• •
•
•
•
•
•
•
•
•
•
ENDOCRINE AND METABOLIC DRUGS
CORTICOSTEROIDS
2
budesonide delayed release
particles cap 3 mg (Entocort ec)
CORTEF - hydrocortisone tab 5 mg 4
CORTEF - hydrocortisone tab 10
mg
4
CORTEF - hydrocortisone tab 20
mg
4
18
CORTISONE ACETATE - cortisone
acetate tab 25 mg
4
DEXAMETHASONE dexamethasone soln 0.5 mg/5ml
4
DEXAMETHASONE dexamethasone tab 1 mg
4
DEXAMETHASONE dexamethasone tab 2 mg
dexamethasone elixir 0.5 mg/5ml
1
methylprednisolone tab 4 mg
(Medrol)
1
(Medrol)
1
(Medrol)
1
(Medrol)
2
4
• •
• •
1
1
1
1
DEXPAK 10 DAY - dexamethasone
tab therapy pack 1.5 mg (35)
4
4
MILLIPRED - prednisolone tab 5
mg
4
4
MILLIPRED DP - prednisolone tab
therapy pack 5 mg (21)
4
ENTOCORT EC - budesonide
delayed release particles cap 3
mg
4
MILLIPRED DP - prednisolone tab
4
fludrocortisone acetate tab
0.1 mg
1
1
hydrocortisone tab 10 mg
(Cortef)
1
hydrocortisone tab 20 mg
(Cortef)
1
MEDROL - methylprednisolone tab
2 mg
4
4 mg
4
8 mg
4
16 mg
4
ACA
Quantity Limits
Restricted Access
1
4
methylprednisolone tab therapy
pack 4 mg (21) (Medrol
dosepak)
MILLIPRED - prednisolone sod
phosphate oral soln 10 mg/5ml
(base equiv)
hydrocortisone tab 5 mg (Cortef)
Prior Review
4
1
dexamethasone tab 6 mg
Specialty
Drug Tier
ACA
Quantity Limits
Restricted Access
MEDROL DOSEPAK methylprednisolone tab therapy
pack 4 mg (21)
dexamethasone tab 0.5 mg
dexamethasone tab 4 mg
Prior Review
4
4
• •
Drug Name
32 mg
DEXAMETHASONE INTENSOL dexamethasone conc 1 mg/ml
Specialty
Drug Name
Drug Tier
2016
ORAPRED ODT - prednisolone sod 4
phos orally disintegr tab 10 mg
(base eq)
(base eq)
(base eq)
4
PEDIAPRED - prednisolone sod
phosph oral soln 6.7 mg/5ml (5
mg/5ml base)
2
prednisolone sod phos orally
disintegr tab 10 mg (base eq)
(Orapred odt)
19
(Orapred odt)
2
(Orapred odt)
2
prednisolone sod phosph oral
soln 6.7 mg/5ml (5 mg/5ml
base) (Pediapred)
1
prednisolone sod phosphate
oral soln 15 mg/5ml (base
equiv)
ANDROGEN-ANABOLIC
• •
ANADROL-50 - oxymetholone tab
50 mg
4
•
ANDRODERM - testosterone td
patch 24hr 2 mg/24hr
3
•
ANDRODERM - testosterone td
patch 24hr 4 mg/24hr
3
•
4
•
4
prednisolone syrup 15 mg/5ml
(usp solution equivalent)
1
ANDROGEL - testosterone td gel
25 mg/2.5gm (1%)
4
4
•
PREDNISONE - prednisone oral
soln 5 mg/5ml
50 mg/5gm (1%)
3
4
•
PREDNISONE - prednisone tab
20.25 mg/1.25gm (1.62%)
3
4
•
40.5 mg/2.5gm (1.62%)
4
•
4
ANDROGEL PUMP - testosterone
td gel 12.5 mg/act (1%)
3
4
•
ANDROGEL PUMP - testosterone
td gel 20.25 mg/act (1.62%)
4
•
PREDNISONE - prednisone tab 50
mg
PREDNISONE INTENSOL prednisone conc 5 mg/ml
4
prednisone tab 1 mg
1
ANDROID - methyltestosterone cap 4
10 mg
4
ANDROXY - fluoxymesterone tab
10 mg
AVEED - testosterone undecanoate 5
im inj in oil 750 mg/3ml (250mg/
ml)
4
AXIRON - testosterone td soln 30
mg/act
2
danazol cap 50 mg
prednisone tab 5 mg
prednisone tab 10 mg
prednisone tab 20 mg
1
1
1
1
RAYOS - prednisone tab delayed
release 1 mg
4
• •
release 2 mg
4
• •
danazol cap 100 mg
danazol cap 200 mg
DEPO-TESTOSTERONE testosterone cypionate im inj in
oil 100 mg/ml
• •
ACA
UCERIS - budesonide tab sr 24hr 9 4
mg
4
VERIPRED 20 - prednisolone sod
(base equiv)
Quantity Limits
• •
PREDNISOLONE SODIUM
PHOSP - prednisolone sodium
(base eq)
prednisone tab 2.5 mg
Restricted Access
Prior Review
4
release 5 mg
1
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
• •
•
• •
2
2
4
•
20
DEPO-TESTOSTERONE testosterone cypionate im inj in
oil 200 mg/ml
4
FORTESTA - testosterone td gel
10mg/act (2%)
4
METHITEST - methyltestosterone
oral tab 10 mg
4
•
methyltestosterone cap 10 mg
(Testred)
2
•
NATESTO - testosterone nasal gel
5.5 mg/act
4
• •
OXANDRIN - oxandrolone tab 2.5
mg
4
•
OXANDRIN - oxandrolone tab 10
mg
4
•
oxandrolone tab 2.5 mg
(Oxandrin)
2
•
oxandrolone tab 10 mg
(Oxandrin)
2
•
STRIANT - testosterone buccal
mucoadhesive system 30 mg
4
•
TESTIM - testosterone td gel 50
mg/5gm (1%)
4
• •
TESTOSTERONE - testosterone td
gel 25 mg/2.5gm (1%)
4
• •
gel 50 mg/5gm (1%)
4
• •
gel 10mg/act (2%)
4
• •
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
• •
•
TESTRED - methyltestosterone cap 4
10 mg
VOGELXO - testosterone td gel 50 4
mg/5gm (1%)
VOGELXO PUMP - testosterone td 4
gel 12.5 mg/act (1%)
•
ESTROGENS
• •
• •
ACTIVELLA - estradiol &
norethindrone acetate tab 0.5-0.1
mg
4
ACTIVELLA - estradiol &
norethindrone acetate tab 1-0.5
mg
4
ALORA - estradiol td patch twice
weekly 0.025 mg/24hr
4
• •
weekly 0.05 mg/24hr
4
• •
4
• •
weekly 0.1 mg/24hr
4
• •
ANGELIQ - drospirenone-estradiol
tab 0.25-0.5 mg
4
• •
ANGELIQ - drospirenone-estradiol
tab 0.5-1 mg
4
• •
CLIMARA - estradiol td patch
4
•
weekly 0.0375 mg/24hr (37.5
mcg/24hr)
4
1
•
weekly 0.05 mg/24hr
4
4
• •
weekly 0.06 mg/24hr
4
TESTOSTERONE PUMP testosterone td gel 12.5 mg/act
(1%)
4
testosterone td gel 25 mg/2.5gm
(1%) (Androgel)
2
•
2
testosterone td gel 12.5 mg/act
(1%) (Androgel pump)
ACA
•
Quantity Limits
2
testosterone td gel 50 mg/5gm
(1%) (Androgel)
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
•
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
21
weekly 0.1 mg/24hr
4
CLIMARA PRO - estradiollevonorgestrel td patch weekly
0.045-0.015 mg/day
4
COMBIPATCH - estradiolnorethindrone ace td pttw
0.05-0.14 mg/day
4
• •
estradiol tab 2 mg (Estrace)
COMBIPATCH - estradiolnorethindrone ace td pttw
0.05-0.25 mg/day
4
• •
estradiol td patch twice weekly
0.0375 mg/24hr (Vivelle-dot)
DELESTROGEN - estradiol
valerate im in oil 10 mg/ml
4
4
4
DEPO-ESTRADIOL - estradiol
cypionate im in oil 5 mg/ml
4
• •
estradiol td patch weekly
0.025 mg/24hr (Climara)
DIVIGEL - estradiol td gel 0.25
mg/0.25gm (0.1%)
4
• •
DIVIGEL - estradiol td gel 0.5
mg/0.5gm (0.1%)
4
• •
DIVIGEL - estradiol td gel 1 mg/gm
(0.1%)
4
• •
DUAVEE - conjugated estrogensbazedoxifene tab 0.45-20 mg
4
• •
ELESTRIN - estradiol gel 0.06%
(0.52 mg/0.87 gm metered-dose
pump)
4
• •
esterified estrogens &
methyltestosterone tab
0.625-1.25 mg
2
esterified estrogens &
methyltestosterone tab
1.25-2.5 mg
• •
estradiol & norethindrone
acetate tab 1-0.5 mg (Activella)
estradiol tab 0.5 mg (Estrace)
estradiol tab 1 mg (Estrace)
2
ESTRACE - estradiol tab 0.5 mg
4
ESTRACE - estradiol tab 1 mg
4
ESTRACE - estradiol tab 2 mg
4
estradiol & norethindrone
acetate tab 0.5-0.1 mg
(Activella)
2
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
2
1
1
1
2
2
2
2
2
2
2
0.0375 mg/24hr (37.5 mcg/24hr)
(Climara)
2
2
2
2
estradiol valerate im in oil 20 mg/ 2
ml (Delestrogen)
estradiol valerate im in oil 40 mg/ 2
ml (Delestrogen)
4
ESTROGEL - estradiol gel 0.06%
(0.75 mg/1.25 gm metered-dose
pump)
1
ESTROPIPATE - estropipate tab
0.75 mg
1
ESTROPIPATE - estropipate tab
1.5 mg
ESTROPIPATE - estropipate tab 3 4
mg
• •
22
4
FEMHRT LOW DOSE norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg
4
MENEST - esterified estrogens tab
0.3 mg
4
• •
0.625 mg
4
• •
1.25 mg
4
• •
2.5 mg
4
• •
MENOSTAR - estradiol td patch
weekly 14 mcg/24hr
4
• •
MINIVELLE - estradiol td patch
twice weekly 0.025 mg/24hr
4
• •
4
• •
4
• •
4
• •
4
• •
norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg
(Femhrt low dose)
2
norethindrone acetate-ethinyl
estradiol tab 1 mg-5 mcg
2
PREFEST - estradiol tab 1
mg(15)/estrad-norgestimate tab
1-0.09mg(15)
PREMARIN - estrogens, conjugated 3
tab 0.3 mg
tab 0.45 mg
tab 0.625 mg
tab 0.9 mg
• •
ACA
Quantity Limits
Restricted Access
Prior Review
tab 1.25 mg
PREMPHASE - conj est 0.625(14)/ 3
conj est-medroxypro ac tab
0.625-5mg(14)
PREMPRO - conjugated estrogen- 3
medroxyprogest acetate tab
0.3-1.5 mg
0.45-1.5 mg
0.625-2.5 mg
0.625-5 mg
4
VIVELLE-DOT - estradiol td patch
4
4
4
4
CONTRACEPTIVES
4
Specialty
Drug Name
Drug Tier
ACA
• •
EVAMIST - estradiol transdermal
spray 1.53 mg/spray
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
BEYAZ - drospirenone-ethinyl
estrad-levomefolate tab
3-0.02-0.451 mg
4
BREVICON-28 - norethindrone &
ethinyl estradiol tab 0.5 mg-35
mcg
4
• •
4
CYCLESSA - desogestethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mgmg
4
DEPO-PROVERA
CONTRACEPTIV medroxyprogesterone acetate im
susp 150 mg/ml
23
DEPO-SUBQ PROVERA 104 medroxyprogesterone acetate
subcutaneous susp 104
mg/0.65ml
4
DESOGEN - desogestrel & ethinyl
estradiol tab 0.15 mg-30 mcg
4
desogest-eth estrad & eth estrad
tab 0.15-0.02/0.01 mg(21/5)
(Mircette)
A
4
ethynodiol diacetate & ethinyl
A
levonorgestrel tab 1.5 mg
A
•
•
LOESTRIN FE 1.5/30 norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg
4
FEMCON FE - norethindrone &
ethinyl estradiol-fe chew tab 0.4
mg-35 mcg
4
GENERESS FE - norethindrone &
ethinyl estradiol-fe chew tab 0.8
mg-25 mcg
4
levonorg-eth est tab
0.1-0.02mg(84) & eth est tab
0.01mg(7) (Loseasonique)
A
•
A
•
A
•
LOESTRIN FE 1/20 - norethindrone 4
ace & ethinyl estradiol-fe tab 1
mg-20 mcg
4
LOESTRIN 1.5/30-21 norethindrone ace & ethinyl
LOESTRIN 1/20-21 - norethindrone 4
ace & ethinyl estradiol tab 1
mg-20 mcg
LOSEASONIQUE - levonorg-eth est 4
tab 0.1-0.02mg(84) & eth est tab
0.01mg(7)
medroxyprogesterone acetate im A
susp 150 mg/ml (Depo-provera
contrac)
MINASTRIN 24 FE - norethindrone 4
ace-eth estradiol-fe chew tab 1
mg-20 mcg (24)
4
MIRCETTE - desogest-eth estrad
& eth estrad tab 0.15-0.02/0.01
mg(21/5)
MODICON - norethindrone & ethinyl 4
4
NATAZIA - estradiol valeratedienogest tab 3 mg /2-2 mg/2-3
mg/1 mg
A
•
•
4
• •
ACA
A
LO LOESTRIN FE - norethin-eth
estradiol-fe tab 1 mg-10 mcg
(24)/10 mcg (2)
•
Quantity Limits
•
levonorgestrel-ethinyl estradiol
(continuous) tab 90-20 mcg
•
Restricted Access
A
•
•
Prior Review
•
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mgmcg
•
Specialty
Drug Tier
A
•
4
levonorgestrel & ethinyl
estradiol (91-day) tab
0.15-0.03 mg
FALESSA - levonorgest-eth estrad
tab 0.1 mg-20 mcg & fa tab 1 mg
kit
levonorg-eth est tab
0.15-0.03mg(84) & eth est tab
0.01mg(7) (Seasonique)
Drug Name
A
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mgmg (Cyclessa)
A
desogestrel & ethinyl estradiol
tab 0.15 mg-30 mcg (Desogen)
A
drospirenone-ethinyl estradiol
tab 3-0.02 mg (Yaz)
A
drospirenone-ethinyl estradiol
tab 3-0.03 mg (Yasmin 28)
ELLA - ulipristal acetate tab 30 mg A
ESTROSTEP FE - norethindrone
ac-ethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg
ACA
• •
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
•
• •
• •
24
norethindrone & ethinyl estradiol A
tab 0.4 mg-35 mcg (Ovcon-35)
A
norethindrone & ethinyl
(Brevicon-28)
norethindrone & ethinyl estradiol A
tab 1 mg-35 mcg (Norinyl 1+35)
A
estradiol-fe chew tab
0.4 mg-35 mcg (Femcon fe)
A
estradiol-fe chew tab
0.8 mg-25 mcg (Generess fe)
norethindrone ac-ethinyl estrad- A
fe tab 1-20/1-30/1-35 mg-mcg
(Estrostep fe)
A
norethindrone ace & ethinyl
(Loestrin 1/20-21)
A
(Loestrin 1.5/30-21)
A
(Loestrin fe 1/20)
A
estradiol-fe tab 1.5 mg-30 mcg
(Loestrin fe 1.5/30)
A
norethindrone ace-ethinyl
(24)
norethindrone tab 0.35 mg (Nor- A
qd)
A
norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg
(Ortho-novum 7/7/7)
•
A
•
norgestimate & ethinyl estradiol
tab 0.25 mg-35 mcg (Orthocyclen)
A
•
norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mgmcg (Ortho tri-cyclen lo)
A
•
A
•
A
•
norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mgmcg (Ortho tri-cyclen)
•
norgestrel & ethinyl estradiol tab
0.3 mg-30 mcg
•
NORINYL 1+35 - norethindrone &
ethinyl estradiol tab 1 mg-35 mcg
4
•
NUVARING - etonogestrel-ethinyl
estradiol va ring 0.120-0.015
mg/24hr
A
OGESTREL - norgestrel & ethinyl
4
ORTHO EVRA - norelgestrominethinyl estradiol td ptwk 150-35
mcg/24hr
A
ORTHO MICRONOR norethindrone tab 0.35 mg
4
ORTHO TRI-CYCLEN norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mgmcg
4
ORTHO TRI-CYCLEN LO norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mgmcg
4
•
ORTHO-CYCLEN - norgestimate &
mcg
4
•
ORTHO-NOVUM 1/35 norethindrone & ethinyl estradiol
tab 1 mg-35 mcg
4
ORTHO-NOVUM 7/7/7 norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg
4
•
•
•
•
•
norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg (Trinorinyl 28)
•
•
ACA
4
Quantity Limits
NOR-QD - norethindrone tab 0.35
mg
Restricted Access
• •
Prior Review
4
Specialty
NECON 10/11-28 - norethindroneeth estradiol tab 0.5-35/1-35 mgmcg (10/11)
Drug Name
Drug Tier
• •
4
ACA
NECON 1/50-28 - norethindrone &
mestranol tab 1 mg-50 mcg
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
• •
•
25
OVCON-35 - norethindrone &
mcg
4
QUARTETTE - levonor-eth est tab
0.15-0.02/0.025/0.03 mg &eth est
0.01 mg
4
SAFYRAL - drospirenoneethinyl estrad-levomefolate tab
3-0.03-0.451 mg
4
SEASONIQUE - levonorg-eth est
tab 0.15-0.03mg(84) & eth est
tab 0.01mg(7)
4
TRI-NORINYL 28 norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg
4
XULANE - norelgestrominethinyl estradiol td ptwk 150-35
mcg/24hr
A
YASMIN 28 - drospirenone-ethinyl
estradiol tab 3-0.03 mg
4
YAZ - drospirenone-ethinyl estradiol 4
tab 3-0.02 mg
ZOVIA 1/50E - ethynodiol diacetate 4
& ethinyl estradiol tab 1 mg-50
mcg
PROGESTINS
AYGESTIN - norethindrone acetate
tab 5 mg
4
medroxyprogesterone acetate
tab 2.5 mg (Provera)
1
tab 5 mg (Provera)
tab 10 mg (Provera)
1
1
MEGACE ES - megestrol acetate
susp 625 mg/5ml
4
megestrol acetate susp
625 mg/5ml (Megace es)
2
norethindrone acetate tab 5 mg
(Aygestin)
2
progesterone im in oil 50 mg/ml
2
progesterone micronized cap
100 mg (Prometrium)
progesterone micronized cap
200 mg (Prometrium)
• •
• •
•
ACA
Quantity Limits
Restricted Access
Prior Review
2
2
PROMETRIUM - progesterone
micronized cap 100 mg
4
PROMETRIUM - progesterone
micronized cap 200 mg
4
PROVERA - medroxyprogesterone
acetate tab 2.5 mg
4
acetate tab 5 mg
4
acetate tab 10 mg
4
ANTIDIABETICS
Antidiabetics
acarbose tab 25 mg (Precose)
• •
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
2
2
2
ACTOPLUS MET - pioglitazone hcl- 4
metformin hcl tab 15-500 mg
ACTOPLUS MET - pioglitazone hcl- 4
metformin hcl tab 15-850 mg
ACTOPLUS MET XR - pioglitazone 4
hcl-metformin hcl tab sr 24hr
15-1000 mg
ACTOPLUS MET XR - pioglitazone 4
hcl-metformin hcl tab sr 24hr
30-1000 mg
ACTOS - pioglitazone hcl tab 15 mg 4
(base equiv)
(base equiv)
(base equiv)
4
ALOGLIPTIN - alogliptin benzoate
4
4
•
•
• • •
• • •
•
•
•
• •
• •
• •
26
4
ALOGLIPTIN/METFORMIN HCL alogliptin-metformin hcl tab
12.5-1000 mg
4
ALOGLIPTIN/PIOGLITAZONE alogliptin-pioglitazone tab
12.5-15 mg
4
12.5-30 mg
4
• •
12.5-45 mg
4
ALOGLIPTIN/PIOGLITAZONE alogliptin-pioglitazone tab 25-15
mg
4
mg
4
mg
4
AMARYL - glimepiride tab 1 mg
CHLORPROPAMIDE chlorpropamide tab 250 mg
4
• •
CYCLOSET - bromocriptine
mesylate tab 0.8 mg (base
equivalent)
4
• •
DEX4 FAST ACTING GLUCOSE glucose oral liquid 15 gm/59ml
4
DEX4 GLUCOSE - glucose oral
liquid 15 gm/59ml
4
DUETACT - pioglitazone hclglimepiride tab 30-2 mg
4
•
• •
DUETACT - pioglitazone hclglimepiride tab 30-4 mg
4
•
4
• •
• •
FARXIGA - dapagliflozin
propanediol tab 5 mg (base
equivalent)
4
• •
• •
FARXIGA - dapagliflozin
propanediol tab 10 mg (base
equivalent)
FORTAMET - metformin hcl tab sr
24hr osmotic 500 mg
4
FORTAMET - metformin hcl tab sr
24hr osmotic 1000 mg
4
4
glimepiride tab 1 mg (Amaryl)
1
4
4
AVANDIA - rosiglitazone maleate
4
• • •
glipizide tab sr 24hr 2.5 mg
(Glucotrol xl)
1
AVANDIA - rosiglitazone maleate
4
• • •
glipizide tab sr 24hr 5 mg
(Glucotrol xl)
1
BYDUREON - exenatide extended
release for susp pen-injector 2
mg
4
• • •
glipizide tab sr 24hr 10 mg
(Glucotrol xl)
1
BYDUREON - exenatide for inj
extended release susp 2 mg
• • •
1
4
glipizide tab 5 mg (Glucotrol)
BYETTA - exenatide soln peninjector 5 mcg/0.02ml
4
• • •
glipizide-metformin hcl tab
2.5-250 mg
BYETTA - exenatide soln peninjector 10 mcg/0.04ml
4
• • •
2.5-500 mg
CHLORPROPAMIDE chlorpropamide tab 100 mg
4
• •
glipizide tab 10 mg (Glucotrol)
5-500 mg
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
• •
ALOGLIPTIN/METFORMIN HCL alogliptin-metformin hcl tab
12.5-500 mg
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
1
1
1
2
2
2
27
GLYXAMBI - empagliflozinlinagliptin tab 25-5 mg
4
• •
GLUCOTROL XL - glipizide tab sr
24hr 10 mg
4
INSTA-GLUCOSE - glucose gel
77.4%
4
GLUCOVANCE - glyburidemetformin tab 1.25-250 mg
4
INVOKAMET - canagliflozinmetformin hcl tab 50-500 mg
3
GLUCOVANCE - glyburidemetformin tab 2.5-500 mg
4
3
GLUCOVANCE - glyburidemetformin tab 5-500 mg
4
3
GLUMETZA - metformin hcl tab sr
24hr modified release 500 mg
4
• •
3
GLUMETZA - metformin hcl tab sr
24hr modified release 1000 mg
4
• •
INVOKANA - canagliflozin tab 100
mg
3
glyburide micronized tab 1.5 mg
(Glynase)
1
INVOKANA - canagliflozin tab 300
mg
3
glyburide micronized tab 3 mg
(Glynase)
1
JANUMET - sitagliptin-metformin
hcl tab 50-500 mg
4
• •
glyburide micronized tab 6 mg
(Glynase)
1
JANUMET - sitagliptin-metformin
hcl tab 50-1000 mg
4
• •
GLUCOPHAGE - metformin hcl tab
1000 mg
4
GLUCOPHAGE XR - metformin hcl
tab sr 24hr 500 mg
4
GLUCOPHAGE XR - metformin hcl
tab sr 24hr 750 mg
4
glucose gel 40%
2
glucose oral liquid 15 gm/59ml
glyburide-metformin tab
1.25-250 mg (Glucovance)
2.5-500 mg (Glucovance)
5-500 mg (Glucovance)
2
4
4
glyburide tab 5 mg
ACA
24hr 5 mg
850 mg
glyburide tab 2.5 mg
Quantity Limits
Restricted Access
4
4
glyburide tab 1.25 mg
Specialty
GLYXAMBI - empagliflozinlinagliptin tab 10-5 mg
500 mg
Drug Name
Drug Tier
Prior Review
4
4
ACA
24hr 2.5 mg
GLUCAGON EMERGENCY KIT glucagon (rdna) for inj kit 1 mg
Quantity Limits
4
3
Prior Review
GLUCOTROL - glipizide tab 10 mg
GLUCAGEN HYPOKIT - glucagon
hcl (rdna) for inj 1 mg (base
equiv)
Specialty
4
•
•
•
•
Drug Tier
GLUCOTROL - glipizide tab 5 mg
•
•
•
•
Drug Name
Restricted Access
2016
1
1
1
1
1
1
GLYNASE - glyburide micronized
tab 1.5 mg
4
tab 3 mg
4
tab 6 mg
4
GLYSET - miglitol tab 25 mg
4
4
4
28
JANUVIA - sitagliptin phosphate tab 4
25 mg (base equiv)
50 mg (base equiv)
100 mg (base equiv)
JARDIANCE - empagliflozin tab 10 4
mg
JARDIANCE - empagliflozin tab 25 4
mg
4
JENTADUETO - linagliptinmetformin hcl tab 2.5-500 mg
4
4
4
JENTADUETO XR - linagliptinmetformin hcl tab sr 24hr
2.5-1000 mg
4
JENTADUETO XR - linagliptinmetformin hcl tab sr 24hr 5-1000
mg
KAZANO - alogliptin-metformin hcl 4
tab 12.5-500 mg
KAZANO - alogliptin-metformin hcl 4
tab 12.5-1000 mg
3
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr
2.5-1000 mg
3
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 5-500
mg
• •
• •
• •
• •
• •
• •
• •
• •
• •
3
KORLYM - mifepristone tab 300 mg 5
metformin hcl tab sr 24hr 500 mg 1
(Glucophage xr)
metformin hcl tab sr 24hr 750 mg 1
(Glucophage xr)
2
metformin hcl tab sr 24hr
osmotic 500 mg (Fortamet)
2
osmotic 1000 mg (Fortamet)
2
modified release 500 mg
(Glumetza)
2
modified release 1000 mg
(Glumetza)
1
metformin hcl tab 500 mg
(Glucophage)
1
(Glucophage)
1
(Glucophage)
2
miglitol tab 25 mg (Glyset)
• •
•
• •
• •
2
2
2
• •
nateglinide tab 60 mg (Starlix)
• •
NESINA - alogliptin benzoate tab
4
• •
• •
NESINA - alogliptin benzoate tab
4
• •
NESINA - alogliptin benzoate tab 25 4
mg (base equiv)
ONGLYZA - saxagliptin hcl tab 2.5 3
mg (base equiv)
3
ONGLYZA - saxagliptin hcl tab 5
mg (base equiv)
OSENI - alogliptin-pioglitazone tab 4
12.5-15 mg
• •
nateglinide tab 120 mg (Starlix)
• •
ACA
4
Quantity Limits
JANUMET XR - sitagliptinmetformin hcl tab sr 24hr
100-1000 mg
Restricted Access
• •
Prior Review
4
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 5-1000
mg
Specialty
JANUMET XR - sitagliptinmetformin hcl tab sr 24hr
50-1000 mg
Drug Name
Drug Tier
• •
4
ACA
JANUMET XR - sitagliptinmetformin hcl tab sr 24hr 50-500
mg
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
2
• •
29
OSENI - alogliptin-pioglitazone tab
25-30 mg
4
• •
25-45 mg
4
• •
pioglitazone hcl tab 15 mg (base
equiv) (Actos)
1
•
1
•
equiv) (Actos)
equiv) (Actos)
pioglitazone hcl-glimepiride tab
30-2 mg (Duetact)
pioglitazone hcl-glimepiride tab
30-4 mg (Duetact)
pioglitazone hcl-metformin hcl
tab 15-500 mg (Actoplus met)
pioglitazone hcl-metformin hcl
tab 15-850 mg (Actoplus met)
1
2
2
•
•
2
•
4
PRANDIN - repaglinide tab 1 mg
4
PRANDIN - repaglinide tab 2 mg
4
PRECOSE - acarbose tab 25 mg
4
4
4
PROGLYCEM - diazoxide susp 50
mg/ml
4
repaglinide tab 0.5 mg (Prandin)
2
repaglinide tab 2 mg (Prandin)
•
2
PRANDIN - repaglinide tab 0.5 mg
repaglinide tab 1 mg (Prandin)
•
2
2
REPAGLINIDE/METFORMIN HYD - 4
repaglinide-metformin hcl tab
1-500 mg
• •
STARLIX - nateglinide tab 120 mg
4
SYMLINPEN 120 - pramlintide
acetate pen-inj 2700 mcg/2.7ml
(1000 mcg/ml)
4
• •
SYMLINPEN 60 - pramlintide
acetate pen-inj 1500 mcg/1.5ml
(1000 mcg/ml)
4
• •
SYNJARDY - empagliflozinmetformin hcl tab 5-500 mg
4
• •
SYNJARDY - empagliflozinmetformin hcl tab 5-1000 mg
4
• •
SYNJARDY - empagliflozinmetformin hcl tab 12.5-500 mg
4
• •
SYNJARDY - empagliflozinmetformin hcl tab 12.5-1000 mg
4
• •
TANZEUM - albiglutide for soln pen- 4
injector 30 mg
TANZEUM - albiglutide for soln pen- 4
injector 50 mg
TOLAZAMIDE - tolazamide tab 250 1
mg
TOLAZAMIDE - tolazamide tab 500 4
mg
4
TOLBUTAMIDE - tolbutamide tab
500 mg
4
TRADJENTA - linagliptin tab 5 mg
• • •
• • •
TRULICITY - dulaglutide soln peninjector 0.75 mg/0.5ml
4
• •
• • •
TRULICITY - dulaglutide soln peninjector 1.5 mg/0.5ml
4
• • •
VICTOZA - liraglutide soln peninjector 18 mg/3ml (6 mg/ml)
3
•
XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr 5-500
mg
4
• •
ACA
25-15 mg
4
Quantity Limits
• •
Restricted Access
4
Prior Review
12.5-45 mg
REPAGLINIDE/METFORMIN HYD - 4
repaglinide-metformin hcl tab
2-500 mg
4
RIOMET - metformin hcl oral soln
500 mg/5ml
4
STARLIX - nateglinide tab 60 mg
Specialty
• •
Drug Name
Drug Tier
4
12.5-30 mg
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
30
mg
4
mg
4
XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr
10-1000 mg
4
Rapid-Acting Insulins
• •
• •
NOVOLIN R - insulin regular
(human) inj 100 unit/ml
3
NOVOLIN R RELION - insulin
regular (human) inj 100 unit/ml
3
Intermediate-Acting Insulins
HUMALOG MIX 50/50 - insulin
lispro prot & lispro (human) inj
100 unit/ml (50-50)
4
•
4
•
4
•
APIDRA SOLOSTAR - insulin
glulisine soln pen-injector inj 100
unit/ml
4
•
HUMALOG MIX 50/50 KWIKPEN insulin lispro prot & lispro sus
pen-inj 100 unit/ml (50-50)
4
•
HUMALOG - insulin lispro (human)
inj 100 unit/ml
4
•
HUMALOG MIX 75/25 - insulin
lispro prot & lispro (human) inj
100 unit/ml (75-25)
4
•
•
HUMALOG KWIKPEN - insulin
lispro (human) soln pen-injector
100 unit/ml
4
•
HUMALOG MIX 75/25 KWIKPEN insulin lispro prot & lispro sus
4
HUMALOG - insulin lispro (human)
soln cartridge 100 unit/ml
HUMULIN N - insulin nph (human)
(isophane) inj 100 unit/ml
4
•
•
HUMULIN N KWIKPEN - insulin
nph (human) (isophane) susp
pen-injector 100 unit/ml
4
HUMALOG KWIKPEN - insulin
lispro (human) soln pen-injector
200 unit/ml
4
•
HUMULIN 70/30 - insulin nph
isophane & regular human inj
100 unit/ml (70-30)
4
NOVOLOG - insulin aspart inj 100
unit/ml
3
•
NOVOLOG FLEXPEN - insulin
aspart soln pen-injector 100 unit/
ml
3
•
NOVOLOG PENFILL - insulin
aspart soln cartridge 100 unit/ml
3
HUMULIN 70/30 KWIKPEN - insulin 4
nph & regular susp pen-inj 100
unit/ml (70-30)
3
NOVOLIN N - insulin nph (human)
(isophane) inj 100 unit/ml
3
NOVOLIN N RELION - insulin nph
(human) (isophane) inj 100 unit/
ml
3
NOVOLIN 70/30 - insulin nph
isophane & regular human inj
100 unit/ml (70-30)
3
NOVOLIN 70/30 RELION - insulin
nph isophane & regular human
inj 100 unit/ml (70-30)
HUMULIN R - insulin regular
(human) inj 100 unit/ml
4
•
HUMULIN R U-500 (CONCENTR insulin regular (human) inj 500
unit/ml
4
•
HUMULIN R U-500 KWIKPEN insulin regular (human) soln peninjector 500 unit/ml
4
•
ACA
Quantity Limits
RELION R - insulin regular (human) 3
inj 100 unit/ml
APIDRA - insulin glulisine inj 100
unit/ml
Short-Acting Insulins
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
• •
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
31
NOVOLOG MIX 70/30 - insulin
aspart prot & aspart (human) inj
100 unit/ml (70-30)
3
NOVOLOG MIX 70/30 PREFILL insulin aspart prot & aspart sus
3
Basal Insulins
3
•
LANTUS SOLOSTAR - insulin
glargine soln pen-injector 100
unit/ml
3
•
LEVEMIR - insulin detemir inj 100
unit/ml
4
• • •
LEVEMIR FLEXTOUCH - insulin
detemir soln pen-injector 100
unit/ml
4
• • •
TOUJEO SOLOSTAR - insulin
glargine soln pen-injector 300
unit/ml
3
•
TRESIBA FLEXTOUCH - insulin
degludec soln pen-injector 100
unit/ml
3
• • •
TRESIBA FLEXTOUCH - insulin
degludec soln pen-injector 200
unit/ml
3
• • •
ARMOUR THYROID - thyroid tab
15 mg (1/4 grain)
4
30 mg (1/2 grain)
4
60 mg (1 grain)
4
90 mg (1 1/2 grain)
4
120 mg (2 grain)
4
180 mg (3 grain)
4
240 mg (4 grain)
4
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Tier
Drug Name
300 mg (5 grain)
LANTUS - insulin glargine inj 100
unit/ml
THYROID AGENTS
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
4
CYTOMEL - liothyronine sodium tab 4
5 mcg
25 mcg
50 mcg
1
levothyroxine sodium tab
25 mcg (Synthroid)
1
50 mcg (Synthroid)
1
75 mcg (Synthroid)
1
88 mcg (Synthroid)
1
100 mcg (Synthroid)
1
112 mcg (Synthroid)
1
125 mcg (Synthroid)
1
137 mcg (Synthroid)
1
150 mcg (Synthroid)
1
175 mcg (Synthroid)
1
200 mcg (Synthroid)
1
300 mcg (Synthroid)
1
liothyronine sodium tab 5 mcg
(Cytomel)
1
(Cytomel)
1
(Cytomel)
methimazole tab 5 mg (Tapazole) 1
methimazole tab 10 mg
(Tapazole)
1
32
4
SYNTHROID - levothyroxine
sodium tab 137 mcg
4
NATURE-THROID - thyroid tab 32.5 4
mg
4
NATURE-THROID - thyroid tab
48.75 mg (3/4 grain)
4
NATURE-THROID - thyroid tab 65
mg
4
81.25 mg
NATURE-THROID - thyroid tab 97.5 4
mg
4
113.75 mg
NATURE-THROID - thyroid tab 130 4
mg
mg
mg
mg (5 grain)
4
146.25 mg
NATURE-THROID NT-2.5 - thyroid 4
tab 162.5 mg (2 1/2 grain)
2
propylthiouracil tab 50 mg
sodium tab 150 mcg
4
sodium tab 175 mcg
4
sodium tab 200 mcg
4
sodium tab 300 mcg
4
16.25 mg
sodium tab 25 mcg
4
sodium tab 50 mcg
4
sodium tab 75 mcg
4
sodium tab 88 mcg
4
sodium tab 100 mcg
4
sodium tab 112 mcg
4
sodium tab 125 mcg
4
TAPAZOLE - methimazole tab 5 mg 4
4
TAPAZOLE - methimazole tab 10
mg
1
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)
THYROLAR-1 - liotrix (t3-t4) tab 60 4
mg (12.5-50 mcg)
4
THYROLAR-1/2 - liotrix (t3-t4) tab
30 mg (6.25-25 mcg)
4
THYROLAR-1/4 - liotrix (t3-t4) tab
15 mg (3.1-12.5 mcg)
4
THYROLAR-2 - liotrix (t3-t4) tab
120 mg (25-100 mcg)
4
THYROLAR-3 - liotrix (t3-t4) tab
180 mg (37.5-150 mcg)
4
TIROSINT - levothyroxine sodium
cap 13 mcg
4
cap 25 mcg
4
cap 50 mcg
4
cap 75 mcg
4
cap 88 mcg
4
cap 100 mcg
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
• •
• •
• •
• •
• •
33
• •
cap 137 mcg
4
• •
cap 150 mcg
4
• •
WESTHROID - thyroid tab 32.5 mg
4
WESTHROID - thyroid tab 65 mg
4
WESTHROID - thyroid tab 97.5 mg
4
alendronate sodium tab 10 mg
4
4
1
WP THYROID - thyroid tab 16.25
mg
4
(Fosamax)
ATELVIA - risedronate sodium tab
4
BINOSTO - alendronate sodium
effervescent tab 70 mg
4
BONIVA - ibandronate sodium tab
4
WP THYROID - thyroid tab 32.5 mg 4
4
mg (3/4 grain)
4
WP THYROID - thyroid tab 65 mg
mg
4
WP THYROID - thyroid tab 97.5 mg 4
WP THYROID - thyroid tab 113.75 4
mg
WP THYROID - thyroid tab 130 mg 4
OXYTOCICS
CERVIDIL - dinoprostone vaginal
inserts 10 mg
4
methylergonovine maleate tab
0.2 mg
2
• •
1
1
5
BRAVELLE– Benefit Limits may
apply - urofollitropin purified for inj
75 unit
5
BUPHENYL - sodium
phenylbutyrate oral powder 3 gm/
teaspoonful
5
BUPHENYL - sodium
phenylbutyrate tab 500 mg
2
cabergoline tab 0.5 mg
calcitonin (salmon) nasal soln
200 unit/act (Miacalcin)
2
PREPIDIL - dinoprostone cervical
gel 0.5 mg/3gm
4
calcitriol cap 0.25 mcg (Rocaltrol) 1
calcitriol cap 0.5 mcg (Rocaltrol) 2
PROSTIN E2 - dinoprostone
vaginal suppos 20 mg
4
calcitriol oral soln 1 mcg/ml
(Rocaltrol)
2
CARBAGLU - carglumic acid tab
200 mg
5
ENDOCRINE and METABOLIC AGENTS - MISC.
ACTONEL - risedronate sodium tab 4
5 mg
30 mg
4
ACA
cap 125 mcg
35 mg
150 mg
4
ALENDRONATE SODIUM alendronate sodium oral soln 70
mg/75ml
4
ALENDRONATE SODIUM alendronate sodium tab 40 mg
1
Quantity Limits
• •
Restricted Access
4
Prior Review
cap 112 mcg
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
• •
•
• •
•
•
CARNITOR - levocarnitine oral soln 4
1 gm/10ml (10%)
CARNITOR - levocarnitine tab 330 4
mg
34
• •
5
CETROTIDE– Benefit Limits may
apply - cetrorelix acetate for inj kit
0.25 mg
2
chorionic gonadotropin for inj
10000 unit– Benefit Limits may
apply
1
clomiphene citrate tab 50 mg–
Benefit Limits may apply
CYSTADANE - betaine powder for 5
oral solution
DDAVP - desmopressin acetate inj 4
4 mcg/ml
4
DDAVP - desmopressin acetate
nasal soln 0.01% (refrigerated)
4
DDAVP - desmopressin acetate
nasal spray soln 0.01%
DDAVP - desmopressin acetate tab 4
0.1 mg
DDAVP - desmopressin acetate tab 4
0.2 mg
desmopressin acetate inj 4 mcg/ 2
ml (Ddavp)
desmopressin acetate nasal soln 2
0.01% (refrigerated) (Ddavp)
2
desmopressin acetate nasal
spray soln 0.01% (Ddavp)
2
desmopressin acetate nasal
spray soln 0.01% (refrigerated)
desmopressin acetate tab 0.1 mg 2
(Ddavp)
desmopressin acetate tab 0.2 mg 2
(Ddavp)
2
doxercalciferol cap 0.5 mcg
(Hectorol)
2
doxercalciferol cap 1 mcg
(Hectorol)
2
doxercalciferol cap 2.5 mcg
(Hectorol)
EGRIFTA - tesamorelin acetate for
inj 2 mg (base equiv)
5
• •
ETIDRONATE DISODIUM etidronate disodium tab 200 mg
4
ETIDRONATE DISODIUM etidronate disodium tab 400 mg
4
EVISTA - raloxifene hcl tab 60 mg
4
FOLLISTIM AQ– Benefit Limits
may apply - follitropin beta inj 75
unit/0.5ml
5
• •
•
5
unit/0.36ml
5
unit/0.72ml
5
unit/1.08ml
5
FORTEO - teriparatide
(recombinant) inj 600 mcg/2.4ml
4
FORTICAL - calcitonin (salmon)
nasal soln 200 unit/act
4
FOSAMAX - alendronate sodium
tab 70 mg
4
FOSAMAX PLUS D - alendronate
sodium-cholecalciferol tab
70-2800 mg-unit
4
FOSAMAX PLUS D - alendronate
sodium-cholecalciferol tab
70-5600 mg-unit
5
GANIRELIX ACETATE– Benefit
Limits may apply - ganirelix
acetate inj 250 mcg/0.5ml
GENOTROPIN - somatropin for inj 5
12 mg (13.8 mg overfill)
5
GENOTROPIN - somatropin for
subcutaneous inj 5 mg
5
GENOTROPIN MINIQUICK somatropin for inj 0.2 mg
5
ACA
EGRIFTA - tesamorelin acetate for
inj 1 mg (base equiv)
Quantity Limits
4
CARNITOR SF - levocarnitine oral
soln 1 gm/10ml (10%)
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
•
• • • •
• •
• •
• •
• • •
• • •
• • •
35
5
5
• • •
5
• • •
5
• • •
GENOTROPIN MINIQUICK somatropin for inj 2 mg
5
• • •
GONAL-F– Benefit Limits may
apply - follitropin alfa for inj 450
unit
5
GONAL-F– Benefit Limits may
unit
5
GONAL-F RFF– Benefit Limits may
unit
5
GONAL-F RFF PEN– Benefit
Limits may apply - follitropin alfa
inj 300 unit/0.5ml
5
inj 450 unit/0.75ml
5
inj 900 unit/1.5ml
5
GONAL-F RFF REDIJECT–
Benefit Limits may apply follitropin alfa inj 300 unit/0.5ml
5
5
• • •
• • •
4
HECTOROL - doxercalciferol cap 1
mcg
4
HECTOROL - doxercalciferol cap
2.5 mcg
4
HUMATROPE - somatropin for inj 5 5
mg
HUMATROPE - somatropin for inj 6 5
mg (18 unit)
5
HUMATROPE - somatropin for inj
12 mg (36 unit)
5
HUMATROPE - somatropin for inj
24 mg
5
HUMATROPE COMBO PACK somatropin for inj 5 mg
2
ibandronate sodium tab 150 mg
(base equivalent) (Boniva)
5
INCRELEX - mecasermin inj 40
mg/4ml (10 mg/ml)
5
KUVAN - sapropterin
dihydrochloride powder packet
100 mg
5
KUVAN - sapropterin
dihydrochloride powder packet
500 mg
5
KUVAN - sapropterin
dihydrochloride soluble tab 100
mg
2
levocarnitine oral soln
1 gm/10ml (10%) (Carnitor)
2
levocarnitine tab 330 mg
(Carnitor)
5
LUPANETA PACK - leuprolide (1
mon) inj 3.75 mg & norethindrone
tab 5 mg kit
5
HECTOROL - doxercalciferol cap
0.5 mcg
• • •
ACA
GENOTROPIN MINIQUICK somatropin for inj 1 mg
• • •
5
Quantity Limits
5
H.P. ACTHAR - corticotropin inj gel
80 unit/ml
Restricted Access
• • •
5
Prior Review
5
Specialty
Drug Name
Drug Tier
• • •
5
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
• • •
• • •
• • •
• • •
• • •
•
•
• • •
•
• • •
•
• • •
•
36
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
NORDITROPIN FLEXPRO somatropin inj 15 mg/1.5ml
5
• • •
NORDITROPIN FLEXPRO somatropin inj 30 mg/3ml
5
• • •
•
NUTROPIN AQ NUSPIN 10 somatropin inj 10 mg/2ml
5
• • •
•
5
• • •
•
•
5
• • •
•
•
NUTROPIN AQ PEN - somatropin
inj 10 mg/2ml
5
• • •
•
NUTROPIN AQ PEN - somatropin
inj 20 mg/2ml
5
• • •
•
octreotide acetate inj 50 mcg/ml
(0.05 mg/ml) (Sandostatin)
5
• •
octreotide acetate inj 100 mcg/ml 5
5
octreotide acetate inj 1000 mcg/
ml (1 mg/ml) (Sandostatin)
5
OMNITROPE - somatropin for inj
5.8 mg
5
OMNITROPE - somatropin inj 5
mg/1.5ml
5
OMNITROPE - somatropin inj 10
mg/1.5ml
5
ORFADIN - nitisinone cap 2 mg
• •
LUPANETA PACK - leuprolide
(3 mon) inj 11.25 mg &
norethindrone tab 5 mg kit
5
LUPRON DEPOT-PED - leuprolide
acetate (3 month) for inj pediatric
kit 11.25 mg
5
acetate (3 month) for inj pediatric
kit 30 mg
5
•
acetate for inj pediatric kit 7.5 mg
5
acetate for inj pediatric kit 11.25
mg
5
acetate for inj pediatric kit 15 mg
5
MENOPUR– Benefit Limits
may apply - menotropins for
subcutaneous inj 75 unit
5
MIACALCIN - calcitonin (salmon)
nasal soln 200 unit/act
4
MYALEPT - metreleptin for
subcutaneous inj 11.3 mg
5
• •
•
NATPARA - parathyroid hormone
(recombinant) for inj cartridge 25
mcg
5
• •
•
mcg
5
• •
•
mcg
5
• •
•
(recombinant) for inj cartridge
100 mcg
5
• •
•
NORDITROPIN CARTRIDGE somatropin inj 5 mg/1.5ml
5
• • •
•
5
• • •
•
5
• • •
•
•
•
5
5
ORFADIN - nitisinone susp 4 mg/ml 5
OSPHENA - ospemifene tab 60 mg 4
•
• •
• •
• •
• •
•
• •
•
• •
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
5
OVIDREL– Benefit Limits may
apply - choriogonadotropin alfa inj
250 mcg/0.5ml
paricalcitol cap 1 mcg (Zemplar) 2
paricalcitol cap 2 mcg (Zemplar)
2
37
paricalcitol cap 4 mcg
raloxifene hcl tab 60 mg (Evista)
2
2
RAVICTI - glycerol phenylbutyrate
liquid 1.1 gm/ml
5
REPRONEX– Benefit Limits may
apply - menotropins for inj 75 unit
5
risedronate sodium tab delayed
release 35 mg (Atelvia)
2
2
risedronate sodium tab 30 mg
(Actonel)
2
(Actonel)
2
(Actonel)
2
ROCALTROL - calcitriol cap 0.25
mcg
4
ROCALTROL - calcitriol cap 0.5
mcg
4
ROCALTROL - calcitriol oral soln 1
mcg/ml
4
SAIZEN - somatropin (nonrefrigerated) for inj 5 mg
5
• • •
SAIZEN - somatropin (nonrefrigerated) for inj 8.8 mg
5
• • •
SAIZEN CLICK.EASY - somatropin
(non-refrigerated) for inj 8.8 mg
5
• • •
SAMSCA - tolvaptan tab 15 mg
5
SAMSCA - tolvaptan tab 30 mg
5
• •
• •
• •
SANDOSTATIN - octreotide acetate 5
inj 50 mcg/ml (0.05 mg/ml)
inj 1000 mcg/ml (1 mg/ml)
•
• •
(Actonel)
• •
• •
• •
• •
•
•
•
•
•
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
SANDOSTATIN LAR DEPOT octreotide acetate for im inj kit 10
mg
5
• •
mg
5
• •
mg
5
• •
SENSIPAR - cinacalcet hcl tab 30
mg (base equiv)
5
• • •
mg (base equiv)
5
• • •
mg (base equiv)
5
• • •
SEROSTIM - somatropin (nonrefrigerated) for subcutaneous inj
4 mg
5
• • •
•
5 mg
5
• • •
•
6 mg
5
• • •
•
• • • •
•
• • • •
•
• • • •
•
SIGNIFOR - pasireotide diaspartate 5
inj 0.3 mg/ml (base equiv)
2
sodium phenylbutyrate oral
powder 3 gm/teaspoonful
(Buphenyl)
SOMATULINE DEPOT - lanreotide 5
acetate extended release inj 60
mg/0.2ml
mg/0.3ml
mg/0.5ml
• •
• •
•
• •
•
• •
•
38
• • •
•
SOMAVERT - pegvisomant for inj
20 mg (as protein)
5
• • •
•
25 mg (as protein)
5
• • •
•
30 mg (as protein)
5
• • •
•
STIMATE - desmopressin acetate
nasal soln 1.5 mg/ml
5
• • •
STRENSIQ - asfotase alfa
subcutaneous inj 18 mg/0.45ml
5
5
subcutaneous inj 40 mg/ml
LANOXIN - digoxin tab 62.5 mcg
(0.0625 mg)
4
LANOXIN - digoxin tab 125 mcg
(0.125 mg)
4
LANOXIN - digoxin tab 187.5 mcg
(0.1875 mg)
4
LANOXIN - digoxin tab 250 mcg
(0.25 mg)
4
ANTIANGINAL AGENTS
•
DILATRATE SR - isosorbide
dinitrate cap cr 40 mg
4
• •
•
ISORDIL TITRADOSE - isosorbide
dinitrate tab 5 mg
4
5
• •
•
ISORDIL TITRADOSE - isosorbide
dinitrate tab 40 mg
4
• •
•
ISOSORBIDE DINITRATE isosorbide dinitrate tab 30 mg
4
5
ISOSORBIDE DINITRATE ER isosorbide dinitrate tab cr 40 mg
4
SYNAREL - nafarelin acetate nasal
soln 2 mg/ml (200 mcg/act) (base
eq)
5
2
XURIDEN - uridine triacetate oral
granules packet 2 gm
5
isosorbide dinitrate tab 5 mg
(Isordil titradose)
2
ZEMPLAR - paricalcitol cap 1 mcg
4
ZEMPLAR - paricalcitol cap 2 mcg
4
ZOMACTON - somatropin for inj 10
mg
5
• • •
•
ZOMACTON - somatropin for
5
• • •
•
ZORBTIVE - somatropin (nonrefrigerated) for subcutaneous inj
8.8 mg
5
• • •
• •
•
•
isosorbide mononitrate tab sr
24hr 60 mg
24hr 120 mg
isosorbide mononitrate tab
10 mg
isosorbide mononitrate tab
20 mg
CARDIOVASCULAR AGENTS
CARDIOTONICS
24hr 30 mg
DIGOXIN - digoxin oral soln 0.05
mg/ml
4
digoxin tab 125 mcg (0.125 mg)
(Lanoxin)
1
• •
NITRO-BID - nitroglycerin oint 2%
5
1
ACA
15 mg (as protein)
digoxin tab 250 mcg (0.25 mg)
(Lanoxin)
Quantity Limits
•
Restricted Access
• • •
Prior Review
5
Specialty
10 mg (as protein)
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
• •
2
1
1
1
1
1
4
NITRO-DUR - nitroglycerin td patch 4
24hr 0.1 mg/hr
24hr 0.2 mg/hr
39
24hr 0.3 mg/hr
24hr 0.4 mg/hr
24hr 0.6 mg/hr
24hr 0.8 mg/hr
1
nitroglycerin cap cr 2.5 mg
nitroglycerin cap cr 6.5 mg
nitroglycerin cap cr 9 mg
NITROGLYCERIN LINGUAL nitroglycerin lingual aerosol 400
mcg/spray
4
nitroglycerin td patch 24hr
0.1 mg/hr (Nitro-dur)
1
4
NITROMIST - nitroglycerin lingual
aerosol 400 mcg/spray
4
NITROSTAT - nitroglycerin sl tab
0.3 mg
4
0.4 mg
4
0.6 mg
4
RANEXA - ranolazine tab sr 12hr
500 mg
4
RANEXA - ranolazine tab sr 12hr
1000 mg
4
BETA BLOCKERS
1
atenolol tab 25 mg (Tenormin)
1
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
ACA
Drug Tier
acebutolol hcl cap 400 mg
(Sectral)
1
1
4
BETAPACE - sotalol hcl tab 120 mg 4
BETAPACE - sotalol hcl tab 160 mg 4
• •
1
NITROLINGUAL PUMPSPRAY nitroglycerin tl soln 0.4 mg/spray
(400 mcg/spray)
1
BETAPACE - sotalol hcl tab 80 mg
1
2
acebutolol hcl cap 200 mg
(Sectral)
1
nitroglycerin tl soln 0.4 mg/spray
(400 mcg/spray) (Nitrolingual
pumpspr)
Drug Name
1
1
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
BETAPACE AF - sotalol hcl (afib/afl) 4
tab 80 mg
tab 120 mg
tab 160 mg
betaxolol hcl tab 10 mg (Kerlone) 1
betaxolol hcl tab 20 mg (Kerlone) 1
1
bisoprolol fumarate tab 5 mg
(Zebeta)
1
bisoprolol fumarate tab 10 mg
(Zebeta)
4
BYSTOLIC - nebivolol hcl tab 2.5
BYSTOLIC - nebivolol hcl tab 5 mg 4
(base equivalent)
4
BYSTOLIC - nebivolol hcl tab 10
4
BYSTOLIC - nebivolol hcl tab 20
1
carvedilol tab 3.125 mg (Coreg)
• •
• •
carvedilol tab 25 mg (Coreg)
• •
• •
• •
• •
1
1
1
COREG - carvedilol tab 3.125 mg
4
4
4
COREG - carvedilol tab 25 mg
4
40
COREG CR - carvedilol phosphate
cap sr 24hr 80 mg
4
• •
CORGARD - nadolol tab 20 mg
4
4
4
HEMANGEOL - propranolol hcl oral 4
soln 4.28 mg/ml
4
INDERAL LA - propranolol hcl cap
sr 24hr 60 mg
4
sr 24hr 80 mg
4
sr 24hr 120 mg
4
sr 24hr 160 mg
4
INDERAL XL - propranolol hcl
sustained-release beads cap sr
24hr 80 mg
4
INDERAL XL - propranolol hcl
24hr 120 mg
4
INNOPRAN XL - propranolol hcl
24hr 80 mg
4
INNOPRAN XL - propranolol hcl
24hr 120 mg
KERLONE - betaxolol hcl tab 10 mg 4
KERLONE - betaxolol hcl tab 20 mg 4
1
labetalol hcl tab 100 mg
(Trandate)
1
(Trandate)
2
(Trandate)
• •
• •
• •
• •
•
LOPRESSOR - metoprolol tartrate
tab 100 mg
4
metoprolol succinate tab sr 24hr 1
25 mg (tartrate equiv) (Toprol xl)
50 mg (tartrate equiv) (Toprol xl)
100 mg (tartrate equiv) (Toprol
xl)
200 mg (tartrate equiv) (Toprol
xl)
4
METOPROLOL TARTRATE metoprolol tartrate tab 37.5 mg
4
METOPROLOL TARTRATE metoprolol tartrate tab 75 mg
1
metoprolol tartrate tab 25 mg
(Lopressor)
1
(Lopressor)
1
nadolol tab 20 mg (Corgard)
2
pindolol tab 5 mg
• •
pindolol tab 10 mg
• •
ACA
4
4
• •
Quantity Limits
cap sr 24hr 40 mg
LOPRESSOR - metoprolol tartrate
tab 50 mg
Restricted Access
• •
4
Prior Review
4
LEVATOL - penbutolol sulfate tab
20 mg
Specialty
cap sr 24hr 20 mg
Drug Name
Drug Tier
• •
4
ACA
cap sr 24hr 10 mg
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
• •
2
2
2
2
PROPRANOLOL HCL - propranolol 4
hcl oral soln 20 mg/5ml
PROPRANOLOL HCL - propranolol 4
hcl oral soln 40 mg/5ml
2
propranolol hcl cap sr 24hr
60 mg (Inderal la)
2
80 mg (Inderal la)
2
120 mg (Inderal la)
• •
• •
41
160 mg (Inderal la)
propranolol hcl tab 10 mg
2
TOPROL XL - metoprolol succinate
tab sr 24hr 200 mg (tartrate
equiv)
1
1
1
1
4
SECTRAL - acebutolol hcl cap 400
mg
4
sotalol hcl (afib/afl) tab 80 mg
(Betapace af)
1
(Betapace af)
1
(Betapace af)
1
sotalol hcl tab 80 mg (Betapace)
1
sotalol hcl tab 120 mg (Betapace) 1
sotalol hcl tab 160 mg (Betapace) 1
ADALAT CC - nifedipine tab sr 24hr 4
30 mg
60 mg
90 mg
1
amlodipine besylate tab 2.5 mg
(Norvasc)
1
amlodipine besylate tab 5 mg
(Norvasc)
1
amlodipine besylate tab 10 mg
(Norvasc)
4
CALAN - verapamil hcl tab 80 mg
sotalol hcl tab 240 mg
1
CALAN - verapamil hcl tab 120 mg
4
CALAN SR - verapamil hcl tab cr
120 mg
4
180 mg
4
240 mg
4
CARDIZEM - diltiazem hcl tab 30
mg
4
mg
4
mg
4
CARDIZEM CD - diltiazem hcl
coated beads cap sr 24hr 120
mg
4
mg
4
4
TENORMIN - atenolol tab 100 mg
4
TIMOLOL MALEATE - timolol
maleate tab 5 mg
4
maleate tab 10 mg
4
maleate tab 20 mg
4
tab sr 24hr 25 mg (tartrate equiv)
4
tab sr 24hr 50 mg (tartrate equiv)
4
tab sr 24hr 100 mg (tartrate
equiv)
4
ACA
Quantity Limits
Restricted Access
CALCIUM CHANNEL BLOCKERS
SECTRAL - acebutolol hcl cap 200
mg
Prior Review
4
ZEBETA - bisoprolol fumarate tab 5 4
mg
4
ZEBETA - bisoprolol fumarate tab
10 mg
1
SOTYLIZE - sotalol hcl oral solution 4
5 mg/ml
4
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
42
mg
4
mg
4
mg
4
CARDIZEM LA - diltiazem hcl
coated beads tab sr 24hr 120 mg
4
4
4
4
4
4
diltiazem hcl cap sr 12hr 60 mg
2
diltiazem hcl coated beads cap
sr 24hr 120 mg (Cardizem cd)
diltiazem hcl coated beads tab sr
24hr 180 mg (Cardizem la)
1
diltiazem hcl extended release
beads cap sr 24hr 240 mg
(Tiazac)
1
(Tiazac)
1
(Tiazac)
1
(Tiazac)
2
diltiazem hcl tab 30 mg
(Cardizem)
1
1
1
(Cardizem)
1
1
1
1
(Cardizem)
felodipine tab sr 24hr 2.5 mg
1
1
1
1
2
2
2
felodipine tab sr 24hr 5 mg
felodipine tab sr 24hr 10 mg
isradipine cap 2.5 mg
isradipine cap 5 mg
nicardipine hcl cap 20 mg
nicardipine hcl cap 30 mg
nifedipine cap 10 mg (Procardia)
nifedipine cap 20 mg
ACA
Quantity Limits
2
(Tiazac)
1
Restricted Access
2
1
2
Prior Review
2
(Tiazac)
2
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
1
1
2
2
2
2
2
2
43
nifedipine tab sr 24hr 30 mg
(Adalat cc)
1
PROCARDIA XL - nifedipine tab sr
24hr osmotic release 90 mg
4
(Adalat cc)
1
SULAR - nisoldipine tab sr 24hr 8.5
mg
4
(Adalat cc)
2
SULAR - nisoldipine tab sr 24hr 17
mg
4
nifedipine tab sr 24hr osmotic
release 30 mg (Procardia xl)
1
SULAR - nisoldipine tab sr 24hr 34
mg
4
1
TIAZAC - diltiazem hcl extended
release beads cap sr 24hr 120
mg
4
mg
4
mg
4
mg
4
mg
4
mg
4
nimodipine cap 30 mg
2
2
NISOLDIPINE - nisoldipine tab sr
24hr 20 mg
4
24hr 30 mg
4
24hr 40 mg
4
NISOLDIPINE ER - nisoldipine tab
sr 24hr 25.5 mg
4
nisoldipine tab sr 24hr 8.5 mg
(Sular)
2
nisoldipine tab sr 24hr 17 mg
(Sular)
2
nisoldipine tab sr 24hr 34 mg
(Sular)
2
NORVASC - amlodipine besylate
tab 2.5 mg
4
tab 5 mg
4
tab 10 mg
4
NYMALIZE - nimodipine oral soln
60 mg/20ml
5
PROCARDIA - nifedipine cap 10
mg
4
4
4
• •
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
verapamil hcl cap sr 24hr 100 mg 2
(Verelan pm)
(Verelan)
(Verelan)
(Verelan pm)
(Verelan)
(Verelan pm)
(Verelan)
1
verapamil hcl tab cr 120 mg
(Calan sr)
44
(Calan sr)
1
(Calan sr)
1
verapamil hcl tab 40 mg
2
verapamil hcl tab 80 mg (Calan)
1
verapamil hcl tab 120 mg (Calan) 1
4
VERELAN - verapamil hcl cap sr
24hr 120 mg
4
24hr 180 mg
4
24hr 240 mg
4
24hr 360 mg
4
VERELAN PM - verapamil hcl cap
sr 24hr 100 mg
4
sr 24hr 200 mg
4
sr 24hr 300 mg
ANTIARRHYTHMICS
amiodarone hcl tab 100 mg
2
(Cordarone)
1
2
CORDARONE - amiodarone hcl tab 4
200 mg
1
disopyramide phosphate cap
100 mg (Norpace)
1
disopyramide phosphate cap
150 mg (Norpace)
2
dofetilide cap 125 mcg
(0.125 mg) (Tikosyn)
dofetilide cap 250 mcg (0.25 mg) 2
(Tikosyn)
2
dofetilide cap 500 mcg (0.5 mg)
(Tikosyn)
1
flecainide acetate tab 50 mg
mexiletine hcl cap 150 mg
ACA
Quantity Limits
Restricted Access
Prior Review
2
2
2
2
MULTAQ - dronedarone hcl tab 400 4
4
NORPACE - disopyramide
phosphate cap 100 mg
4
NORPACE - disopyramide
phosphate cap 150 mg
4
NORPACE CR - disopyramide
phosphate cap sr 12hr 100 mg
4
NORPACE CR - disopyramide
phosphate cap sr 12hr 150 mg
2
propafenone hcl cap sr 12hr
225 mg (Rythmol sr)
2
325 mg (Rythmol sr)
2
425 mg (Rythmol sr)
1
propafenone hcl tab 150 mg
(Rythmol)
1
(Rythmol)
2
quinidine gluconate tab cr
324 mg
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
• •
2
QUINIDINE SULFATE - quinidine
sulfate tab 200 mg
4
QUINIDINE SULFATE - quinidine
sulfate tab 300 mg
4
RYTHMOL - propafenone hcl tab
225 mg
4
RYTHMOL SR - propafenone hcl
cap sr 12hr 225 mg
4
cap sr 12hr 325 mg
4
cap sr 12hr 425 mg
4
1
45
TIKOSYN - dofetilide cap 125 mcg
(0.125 mg)
4
(0.25 mg)
4
(0.5 mg)
4
ANTIHYPERTENSIVES
ACCUPRIL - quinapril hcl tab 5 mg
4
ACCUPRIL - quinapril hcl tab 10 mg 4
4
ACCURETIC - quinaprilhydrochlorothiazide tab 10-12.5
mg
4
ACCURETIC - quinaprilhydrochlorothiazide tab 20-12.5
mg
4
ACCURETIC - quinaprilhydrochlorothiazide tab 20-25 mg
ACEON - perindopril erbumine tab 4
4 mg
ACEON - perindopril erbumine tab 4
8 mg
4
ALTACE - ramipril cap 1.25 mg
ALTACE - ramipril cap 2.5 mg
4
ALTACE - ramipril cap 5 mg
4
ALTACE - ramipril cap 10 mg
4
amlodipine besylate-benazepril
hcl cap 2.5-10 mg (Lotrel)
1
hcl cap 5-10 mg (Lotrel)
1
1
1
1
1
•
2
•
2
•
2
•
2
•
2
•
2
•
2
•
2
•
ATACAND - candesartan cilexetil
tab 4 mg
4
• •
tab 8 mg
4
• •
tab 16 mg
4
• •
tab 32 mg
4
• •
ATACAND HCT - candesartan
cilexetil-hydrochlorothiazide tab
16-12.5 mg
4
• •
32-12.5 mg
4
• •
32-25 mg
4
• •
atenolol & chlorthalidone tab
50-25 mg (Tenoretic 50)
1
amlodipine besylate-valsartan
tab 5-320 mg (Exforge)
amlodipine-valsartanhydrochlorothiazide tab
5-160-12.5 mg (Exforge hct)
5-160-25 mg (Exforge hct)
10-160-12.5 mg (Exforge hct)
2
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
46
atenolol & chlorthalidone tab
100-25 mg (Tenoretic 100)
1
• •
AVALIDE - irbesartanhydrochlorothiazide tab 150-12.5
mg
4
AVALIDE - irbesartanhydrochlorothiazide tab 300-12.5
mg
4
AVAPRO - irbesartan tab 75 mg
4
4
4
AZOR - amlodipine besylateolmesartan medoxomil tab 5-20
mg
4
•
•
•
•
mg
4
• •
mg
4
• •
mg
4
benazepril &
hydrochlorothiazide tab
5-6.25 mg
1
benazepril &
10-12.5 mg (Lotensin hct)
benazepril &
20-12.5 mg (Lotensin hct)
benazepril &
20-25 mg (Lotensin hct)
benazepril hcl tab 5 mg
1
1
1
1
(Lotensin)
1
(Lotensin)
1
(Lotensin)
1
• •
•
•
•
•
• •
4
• •
BENICAR - olmesartan medoxomil
tab 20 mg
4
• •
tab 40 mg
4
• •
BENICAR HCT - olmesartan
medoxomil-hydrochlorothiazide
tab 20-12.5 mg
4
• •
tab 40-12.5 mg
4
• •
tab 40-25 mg
4
• •
bisoprolol & hydrochlorothiazide
tab 2.5-6.25 mg (Ziac)
1
tab 5-6.25 mg (Ziac)
tab 10-6.25 mg (Ziac)
1
1
candesartan cilexetil tab 4 mg
(Atacand)
2
•
(Atacand)
2
•
(Atacand)
2
•
(Atacand)
2
•
candesartan cilexetilhydrochlorothiazide tab
16-12.5 mg (Atacand hct)
2
•
2
•
2
•
32-12.5 mg (Atacand hct)
32-25 mg (Atacand hct)
captopril tab 12.5 mg
captopril tab 25 mg
captopril tab 50 mg
tab 5 mg
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
2
2
2
47
captopril tab 100 mg
2
4
CAPTOPRIL/
HYDROCHLOROTHIA - captopril
& hydrochlorothiazide tab 25-15
mg
4
CAPTOPRIL/
mg
4
CAPTOPRIL/
mg
4
CAPTOPRIL/
mg
4
CARDURA - doxazosin mesylate
tab 1 mg
4
tab 2 mg
4
tab 4 mg
4
tab 8 mg
4
CATAPRES - clonidine hcl tab 0.1
mg
4
mg
4
mg
CATAPRES-TTS-1 - clonidine hcl td 4
patch weekly 0.1 mg/24hr
1
clonidine hcl tab 0.1 mg
(Catapres)
1
(Catapres)
(Catapres)
1
clonidine hcl td patch weekly
0.1 mg/24hr (Catapres-tts-1)
2
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
2
2
CLORPRES - clonidine &
chlorthalidone tab 0.1-15 mg
4
• •
4
• •
4
• •
CORZIDE - nadolol &
bendroflumethiazide tab 40-5 mg
4
CORZIDE - nadolol &
bendroflumethiazide tab 80-5 mg
4
COZAAR - losartan potassium tab
25 mg
4
• •
50 mg
4
• •
100 mg
4
• •
DEMSER - metyrosine cap 250 mg
4
DIBENZYLINE phenoxybenzamine hcl cap 10
mg
4
DIOVAN - valsartan tab 40 mg
4
4
4
4
DIOVAN HCT - valsartanhydrochlorothiazide tab 80-12.5
mg
4
•
•
•
•
•
mg
4
• •
DIOVAN HCT - valsartanhydrochlorothiazide tab 160-25
mg
4
• •
• •
•
•
•
•
•
48
4
DIOVAN HCT - valsartanhydrochlorothiazide tab 320-25
mg
4
doxazosin mesylate tab 1 mg
(Cardura)
1
(Cardura)
1
(Cardura)
1
(Cardura)
1
DUTOPROL - metoprolol &
hydrochlorothiazide tab sr 24hr
25-12.5 mg
4
• •
50-12.5 mg
4
• •
100-12.5 mg
4
EDARBI - azilsartan medoxomil tab
40 mg
4
EDARBI - azilsartan medoxomil tab
80 mg
4
• •
EDARBYCLOR - azilsartan
medoxomil-chlorthalidone tab
40-12.5 mg
4
EDARBYCLOR - azilsartan
medoxomil-chlorthalidone tab
40-25 mg
4
enalapril maleate &
5-12.5 mg
enalapril maleate &
10-25 mg (Vaseretic)
enalapril maleate tab 2.5 mg
(Vasotec)
• •
enalapril maleate tab 5 mg
(Vasotec)
1
(Vasotec)
1
(Vasotec)
1
EPANED - enalapril maleate for oral 4
soln 1 mg/ml
2
eplerenone tab 25 mg (Inspra)
eplerenone tab 50 mg (Inspra)
2
4
• •
EXFORGE - amlodipine besylatevalsartan tab 5-160 mg
4
• •
4
• •
4
• •
4
• •
EXFORGE HCT - amlodipinevalsartan-hydrochlorothiazide tab
5-160-12.5 mg
4
• •
5-160-25 mg
4
• •
• •
10-160-12.5 mg
4
• •
• •
10-160-25 mg
4
• •
1
10-320-25 mg
4
• •
1
fosinopril sodium &
10-12.5 mg
2
1
fosinopril sodium &
20-12.5 mg
• •
fosinopril sodium tab 10 mg
• •
EPROSARTAN MESYLATE eprosartan mesylate tab 600 mg
• •
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
• •
mg
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
2
1
49
guanfacine hcl tab 1 mg (Tenex)
guanfacine hcl tab 2 mg (Tenex)
hydralazine hcl tab 10 mg
1
1
1
1
1
4
HYZAAR - losartan potassium &
hydrochlorothiazide tab 100-25
mg
4
INSPRA - eplerenone tab 25 mg
4
INSPRA - eplerenone tab 50 mg
4
irbesartan tab 75 mg (Avapro)
1
irbesartan-hydrochlorothiazide
tab 300-12.5 mg (Avalide)
lisinopril & hydrochlorothiazide
tab 10-12.5 mg (Zestoretic)
tab 20-12.5 mg (Zestoretic)
tab 20-25 mg (Zestoretic)
lisinopril tab 2.5 mg (Zestril)
lisinopril tab 5 mg (Prinivil)
lisinopril tab 30 mg (Zestril)
lisinopril tab 40 mg (Zestril)
• •
• •
• •
1
•
•
•
•
1
•
1
1
1
1
1
1
1
1
1
1
1
4
LOPRESSOR HCT - metoprolol &
hydrochlorothiazide tab 50-25 mg
4
LOPRESSOR HCT - metoprolol &
mg
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
(Cozaar)
1
(Cozaar)
4
LOTENSIN - benazepril hcl tab 10
mg
4
mg
4
mg
4
LOTENSIN HCT - benazepril &
hydrochlorothiazide tab 10-12.5
mg
4
mg
4
4
LOTREL - amlodipine besylatebenazepril hcl cap 5-10 mg
4
4
4
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
1
mg
irbesartan-hydrochlorothiazide
tab 150-12.5 mg (Avalide)
Restricted Access
1
4
Prior Review
1
mg
Specialty
Drug Name
Drug Tier
2016
•
•
•
•
•
•
50
MAVIK - trandolapril tab 1 mg
4
MAVIK - trandolapril tab 2 mg
4
methyldopa tab 250 mg
1
methyldopa tab 500 mg
4
METHYLDOPA/
HYDROCHLOROTHI methyldopa &
mg
4
metoprolol &
50-25 mg (Lopressor hct)
1
metoprolol &
100-50 mg
moexipril hcl tab 7.5 mg
moexipril hcl tab 15 mg
moexipril-hydrochlorothiazide
tab 7.5-12.5 mg
tab 15-12.5 mg
tab 15-25 mg
nadolol & bendroflumethiazide
tab 40-5 mg (Corzide)
nadolol & bendroflumethiazide
tab 80-5 mg (Corzide)
perindopril erbumine tab 2 mg
1
1
MICARDIS - telmisartan tab 20 mg
4
4
4
MICARDIS HCT - telmisartanhydrochlorothiazide tab 40-12.5
mg
4
•
•
•
•
•
•
•
•
MICARDIS HCT - telmisartanhydrochlorothiazide tab 80-12.5
mg
4
• •
4
MICARDIS HCT - telmisartanhydrochlorothiazide tab 80-25 mg
4
MINIPRESS - prazosin hcl cap 1
mg
4
mg
4
mg
1
minoxidil tab 2.5 mg
• •
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Drug Name
minoxidil tab 10 mg
1
METHYLDOPA/
HYDROCHLOROTHI methyldopa &
mg
metoprolol &
100-25 mg (Lopressor hct)
Specialty
Drug Name
Drug Tier
2016
1
1
1
1
1
1
2
2
1
(Aceon)
1
(Aceon)
1
phenoxybenzamine hcl cap
10 mg (Dibenzyline)
2
prazosin hcl cap 1 mg (Minipress) 1
4
PRESTALIA - perindopril arginineamlodipine besylate tab 3.5-2.5
mg
4
PRESTALIA - perindopril arginineamlodipine besylate tab 7-5 mg
4
PRESTALIA - perindopril arginineamlodipine besylate tab 14-10
mg
4
PRINIVIL - lisinopril tab 5 mg
4
4
• •
• •
• •
4
PROPRANOLOL/
HYDROCHLOROTH - propranolol
mg
4
PROPRANOLOL/
HYDROCHLOROTH - propranolol
51
quinapril hcl tab 5 mg (Accupril)
quinapril-hydrochlorothiazide
tab 10-12.5 mg (Accuretic)
tab 20-12.5 mg (Accuretic)
tab 20-25 mg (Accuretic)
ramipril cap 1.25 mg (Altace)
ramipril cap 2.5 mg (Altace)
ramipril cap 5 mg (Altace)
ramipril cap 10 mg (Altace)
telmisartan tab 40 mg (Micardis)
telmisartan tab 80 mg (Micardis)
1
telmisartan-amlodipine tab
40-5 mg (Twynsta)
1
1
40-10 mg (Twynsta)
1
1
80-5 mg (Twynsta)
1
80-10 mg (Twynsta)
1
telmisartan-hydrochlorothiazide
tab 40-12.5 mg (Micardis hct)
1
tab 80-12.5 mg (Micardis hct)
1
tab 80-25 mg (Micardis hct)
1
1
2
•
2
•
2
•
2
•
4
TENORETIC 100 - atenolol &
chlorthalidone tab 100-25 mg
4
TARKA - trandolapril-verapamil hcl
tab cr 2-240 mg
4
TENORETIC 50 - atenolol &
chlorthalidone tab 50-25 mg
4
tab cr 4-240 mg
4
terazosin hcl cap 1 mg
1
TEKTURNA - aliskiren fumarate tab 4
TEKTURNA - aliskiren fumarate tab 4
4
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 150-12.5
mg
4
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 150-25
mg
4
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 300-12.5
mg
4
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 300-25
mg
telmisartan tab 20 mg (Micardis) 2
• •
• •
• •
• •
• •
• •
•
trandolapril tab 1 mg (Mavik)
trandolapril-verapamil hcl tab cr
1-240 mg (Tarka)
2-180 mg (Tarka)
2-240 mg (Tarka)
4-240 mg (Tarka)
TRIBENZOR - olmesartanamlodipine-hydrochlorothiazide
tab 20-5-12.5 mg
•
ACA
2
4
Quantity Limits
•
TENEX - guanfacine hcl tab 2 mg
tab cr 2-180 mg
Restricted Access
2
2
4
4
Prior Review
2
•
•
•
2
TENEX - guanfacine hcl tab 1 mg
tab cr 1-240 mg
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
mg
Drug Tier
2016
1
1
1
1
1
1
2
2
2
2
4
• •
52
4
tab 40-5-25 mg
4
tab 40-10-12.5 mg
4
• •
tab 40-10-25 mg
4
• •
TWYNSTA - telmisartan-amlodipine 4
tab 40-5 mg
tab 40-10 mg
tab 80-5 mg
tab 80-10 mg
2
valsartan tab 40 mg (Diovan)
• •
valsartan-hydrochlorothiazide
tab 80-12.5 mg (Diovan hct)
tab 160-25 mg (Diovan hct)
tab 320-25 mg (Diovan hct)
• •
• •
4
VECAMYL - mecamylamine hcl tab
2.5 mg
4
ZESTORETIC - lisinopril &
mg
4
mg
4
• •
ZESTRIL - lisinopril tab 20 mg
4
4
4
ZIAC - bisoprolol &
hydrochlorothiazide tab 2.5-6.25
mg
4
ZIAC - bisoprolol &
mg
4
ZIAC - bisoprolol &
mg
4
•
1
•
1
•
ACA
Quantity Limits
Restricted Access
Prior Review
•
•
4
4
ZESTRIL - lisinopril tab 2.5 mg
4
1
Specialty
Drug Tier
VASOTEC - enalapril maleate tab
20 mg
•
4
VASERETIC - enalapril maleate &
4
2.5 mg
VASOTEC - enalapril maleate tab 5 4
mg
4
4
1
2
10 mg
1
2
Drug Name
• •
•
•
•
•
•
2
• •
tab 40-5-12.5 mg
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
DIURETICS
ACETAZOLAMIDE - acetazolamide 4
tab 125 mg
2
acetazolamide cap sr 12hr
500 mg (Diamox)
2
acetazolamide tab 250 mg
4
ALDACTAZIDE - spironolactone &
4
ALDACTAZIDE - spironolactone &
4
ALDACTONE - spironolactone tab
25 mg
53
50 mg
4
FUROSEMIDE - furosemide oral
soln 8 mg/ml
4
100 mg
4
furosemide oral soln 10 mg/ml
1
amiloride & hydrochlorothiazide
tab 5-50 mg
1
amiloride hcl tab 5 mg
bumetanide tab 0.5 mg
bumetanide tab 1 mg
bumetanide tab 2 mg
furosemide tab 20 mg (Lasix)
1
1
1
1
BUMEX - bumetanide tab 0.5 mg
4
BUMEX - bumetanide tab 1 mg
4
BUMEX - bumetanide tab 2 mg
4
CHLORTHALIDONE chlorthalidone tab 50 mg
4
CHLORTHALIDONE chlorthalidone tab 100 mg
4
chlorthalidone tab 25 mg
2
DEMADEX - torsemide tab 5 mg
4
4
4
DIAMOX - acetazolamide cap sr
12hr 500 mg
4
DIURIL - chlorothiazide susp 250
mg/5ml
4
DYAZIDE - triamterene &
hydrochlorothiazide cap 37.5-25
mg
4
DYRENIUM - triamterene cap 50
mg
4
DYRENIUM - triamterene cap 100
mg
4
EDECRIN - ethacrynic acid tab 25
mg
4
ethacrynic acid tab 25 mg
2
1
indapamide tab 2.5 mg
ACA
Quantity Limits
Restricted Access
1
1
1
5
LASIX - furosemide tab 20 mg
4
4
4
4
MAXZIDE - triamterene &
4
MAXZIDE-25 - triamterene &
hydrochlorothiazide tab 37.5-25
mg
2
methazolamide tab 25 mg
(Neptazane)
2
methazolamide tab 50 mg
(Neptazane)
4
METHYCLOTHIAZIDE methyclothiazide tab 5 mg
1
metolazone tab 2.5 mg
metolazone tab 10 mg
Prior Review
1
KEVEYIS - dichlorphenamide tab
50 mg
metolazone tab 5 mg
• •
1
hydrochlorothiazide tab 12.5 mg
indapamide tab 1.25 mg
• •
1
1
hydrochlorothiazide tab 50 mg
CHLOROTHIAZIDE - chlorothiazide 4
tab 250 mg
1
chlorothiazide tab 500 mg
1
hydrochlorothiazide cap 12.5 mg
(Microzide)
hydrochlorothiazide tab 25 mg
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
•
• •
1
2
MICROZIDE - hydrochlorothiazide
cap 12.5 mg
4
NEPTAZANE - methazolamide tab
25 mg
4
NEPTAZANE - methazolamide tab
50 mg
4
54
1
EPIPEN 2-PAK - epinephrine
solution auto-injector 0.3
mg/0.3ml (1:1000)
3
spironolactone tab 25 mg
(Aldactone)
1
3
(Aldactone)
1
EPIPEN-JR 2-PAK - epinephrine
mg/0.3ml (1:2000)
2
(Aldactone)
1
midodrine hcl tab 2.5 mg
torsemide tab 5 mg (Demadex)
1
spironolactone &
25-25 mg (Aldactazide)
midodrine hcl tab 5 mg
midodrine hcl tab 10 mg
1
1
torsemide tab 100 mg (Demadex) 1
1
triamterene &
hydrochlorothiazide cap
37.5-25 mg (Dyazide)
1
triamterene &
37.5-25 mg (Maxzide-25)
1
triamterene &
75-50 mg (Maxzide)
4
TRIAMTERENE/
HYDROCHLOROTH triamterene &
hydrochlorothiazide cap 50-25
mg
VASOPRESSORS
4
• •
ADRENACLICK - epinephrine
mg/0.3ml (1:1000)
4
• •
EPINEPHRINE - epinephrine
mg/0.15ml (1:1000)
4
EPINEPHRINE - epinephrine
mg/0.3ml (1:1000)
4
• •
• •
ACA
Quantity Limits
Restricted Access
Prior Review
2
2
NORTHERA - droxidopa cap 100
mg
5
• • •
•
mg
5
• • •
•
mg
5
• • •
•
ALTOPREV - lovastatin tab sr 24hr
20 mg
4
• •
40 mg
4
• •
60 mg
4
• •
ANTARA - fenofibrate micronized
cap 30 mg
4
ANTARA - fenofibrate micronized
cap 90 mg
4
atorvastatin calcium tab 10 mg
(base equivalent) (Lipitor)
1
ANTIHYPERLIPIDEMICS
ADRENACLICK - epinephrine
mg/0.15ml (1:1000)
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
cholestyramine light powder
packets 4 gm
cholestyramine light powder
4 gm/dose (Questran light)
cholestyramine powder packets
4 gm (Questran)
1
1
1
2
2
2
55
cholestyramine powder 4 gm/
dose (Questran)
choline fenofibrate cap dr 45 mg
(fenofibric acid equiv) (Trilipix)
2
2
choline fenofibrate cap dr
135 mg (fenofibric acid equiv)
(Trilipix)
2
COLESTID - colestipol hcl granule
packets 5 gm
4
4
COLESTID FLAVORED - colestipol
hcl granules 5 gm
4
colestipol hcl granule packets
5 gm (Colestid flavored)
2
colestipol hcl granules 5 gm
(Colestid flavored)
2
colestipol hcl tab 1 gm (Colestid)
2
CRESTOR - rosuvastatin calcium
tab 5 mg
2
tab 10 mg
2
tab 20 mg
2
tab 40 mg
2
FENOFIBRATE - fenofibrate cap 50 4
mg
4
FENOFIBRATE - fenofibrate cap
150 mg
2
fenofibrate micronized cap
43 mg
1
67 mg (Lofibra)
2
130 mg
1
134 mg (Lofibra)
200 mg (Lofibra)
2
fenofibrate tab 54 mg (Lofibra)
1
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Tier
ACA
Drug Name
fenofibrate tab 40 mg (Fenoglide) 2
1
fenofibrate tab 48 mg (Tricor)
fenofibrate tab 120 mg
(Fenoglide)
2
fenofibrate tab 145 mg (Tricor)
2
fenofibrate tab 160 mg (Lofibra)
COLESTID - colestipol hcl granules 4
5 gm
COLESTID - colestipol hcl tab 1 gm 4
COLESTID FLAVORED - colestipol
hcl granule packets 5 gm
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
2
FENOFIBRIC ACID - fenofibric acid 4
tab 35 mg
FENOFIBRIC ACID - fenofibric acid 4
tab 105 mg
4
FENOGLIDE - fenofibrate tab 40
mg
4
FENOGLIDE - fenofibrate tab 120
mg
4
FIBRICOR - fenofibric acid tab 35
mg
FIBRICOR - fenofibric acid tab 105 4
mg
2
fluvastatin sodium cap 20 mg
(Lescol)
2
fluvastatin sodium cap 40 mg
(Lescol)
2
fluvastatin sodium tab sr 24 hr
80 mg (Lescol xl)
1
gemfibrozil tab 600 mg (Lopid)
• •
• •
• •
• •
• •
JUXTAPID - lomitapide mesylate
5
• •
•
•
• •
5
• •
•
•
5
• •
•
•
5
• •
•
•
5
• •
•
•
5
• •
•
•
56
KYNAMRO - mipomersen sodium
soln prefilled syringe 200 mg/ml
5
LESCOL XL - fluvastatin sodium tab 4
sr 24 hr 80 mg
LIPITOR - atorvastatin calcium tab 4
4
LIPOFEN - fenofibrate cap 50 mg
LIPOFEN - fenofibrate cap 150 mg
4
LIVALO - pitavastatin calcium tab 1
mg (base equiv)
4
• •
• •
• •
mg (base equiv)
4
• •
mg (base equiv)
4
• •
LOFIBRA - fenofibrate micronized
cap 67 mg
4
cap 134 mg
4
cap 200 mg
4
LOFIBRA - fenofibrate tab 54 mg
4
LOFIBRA - fenofibrate tab 160 mg
4
LOPID - gemfibrozil tab 600 mg
4
lovastatin tab 10 mg
1
lovastatin tab 20 mg
lovastatin tab 40 mg (Mevacor)
MEVACOR - lovastatin tab 40 mg
4
niacin tab cr 500 mg
(antihyperlipidemic) (Niaspan)
2
2
2
• •
NIACOR - niacin
(antihyperlipidemic) tab 500 mg
4
NIASPAN - niacin tab cr 500 mg
(antihyperlipidemic)
4
•
4
•
4
•
omega-3-acid ethyl esters cap
1 gm (Lovaza)
2
pravastatin sodium tab 20 mg
(Pravachol)
1
•
(Pravachol)
1
•
(Pravachol)
1
QUESTRAN - cholestyramine
powder packets 4 gm
4
•
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Tier
•
Drug Name
OMEGA-3/D-3 WELLNESS PACK - 4
omega-3-acid ethyl esters cap
1gm & vit d3 cap 1000 unit kit
5
PRALUENT - alirocumab
subcutaneous soln pen-injector
75 mg/ml
5
subcutaneous soln pen-injector
150 mg/ml
5
subcutaneous soln prefilled
syringe 75 mg/ml
5
syringe 150 mg/ml
PRAVACHOL - pravastatin sodium 4
tab 20 mg
tab 40 mg
tab 80 mg
1
1
4
ACA
•
1
LOVAZA - omega-3-acid ethyl
esters cap 1 gm
Quantity Limits
• •
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
• •
•
• •
•
• •
•
• •
•
57
VYTORIN - ezetimibe-simvastatin
tab 10-80 mg
4
• •
QUESTRAN LIGHT cholestyramine light powder 4
gm/dose
4
WELCHOL - colesevelam hcl
packet for susp 3.75 gm
4
• •
WELCHOL - colesevelam hcl tab
625 mg
4
REPATHA - evolocumab
syringe 140 mg/ml
5
• •
ZETIA - ezetimibe tab 10 mg
4
REPATHA PUSHTRONEX
SYSTEM - evolocumab
subcutaneous soln cartridge/
infusor 420 mg/3.5ml
5
ZOCOR - simvastatin tab 5 mg
4
4
4
4
REPATHA SURECLICK evolocumab subcutaneous soln
auto-injector 140 mg/ml
5
4
rosuvastatin calcium tab 5 mg
(Crestor)
2
•
(Crestor)
2
•
CARDIOVASCULAR AGENTS - MISC.
5
ADCIRCA - tadalafil tab 20 mg
(pah)
5
ADEMPAS - riociguat tab 0.5 mg
(Crestor)
•
5
2
ADEMPAS - riociguat tab 1 mg
5
•
ADEMPAS - riociguat tab 2 mg
5
(Crestor)
2
5
simvastatin tab 5 mg (Zocor)
1
• •
• •
• •
1
1
1
1
TRILIPIX - choline fenofibrate cap
dr 45 mg (fenofibric acid equiv)
4
TRILIPIX - choline fenofibrate cap
dr 135 mg (fenofibric acid equiv)
4
VASCEPA - icosapent ethyl cap 1
gm
4
• •
tab 10-10 mg
4
• •
tab 10-20 mg
4
• •
tab 10-40 mg
4
• •
•
•
•
4
ACA
QUESTRAN - cholestyramine
powder 4 gm/dose
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• • •
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
amlodipine besylate-atorvastatin 2
calcium tab 2.5-10 mg (Caduet)
calcium tab 5-10 mg (Caduet)
58
amlodipine besylate-atorvastatin
amlodipine besylate-atorvastatin
4
•
2
ENTRESTO - sacubitril-valsartan
tab 97-103 mg
4
•
ISOXSUPRINE HCL - isoxsuprine
hcl tab 20 mg
4
• •
isoxsuprine hcl tab 10 mg
2
BIDIL - isosorbide dinitratehydralazine hcl tab 20-37.5 mg
4
CADUET - amlodipine besylateatorvastatin calcium tab 2.5-10
mg
4
mg
4
mg
• •
5
•
•
•
•
•
•
•
•
•
•
•
•
ORENITRAM - treprostinil
diolamine tab cr 0.25 mg (base
equiv)
5
• • •
•
diolamine tab cr 1 mg (base
equiv)
5
• • •
•
equiv)
5
• • •
•
REVATIO - sildenafil citrate for
suspension 10 mg/ml
5
• • •
REVATIO - sildenafil citrate tab 20
mg
5
• • •
sildenafil citrate tab 20 mg
(Revatio)
5
• •
LETAIRIS - ambrisentan tab 5 mg
5
LETAIRIS - ambrisentan tab 10 mg
5
OPSUMIT - macitentan tab 10 mg
5
4
equiv)
CADUET - amlodipine besylateatorvastatin calcium tab 5-10 mg
4
4
4
4
CADUET - amlodipine besylateatorvastatin calcium tab 10-10
mg
4
mg
4
mg
4
mg
4
CORLANOR - ivabradine hcl tab 5
mg (base equiv)
4
•
CORLANOR - ivabradine hcl tab
7.5 mg (base equiv)
4
tab 24-26 mg
4
TRACLEER - bosentan tab 62.5 mg 5
TRACLEER - bosentan tab 125 mg 5
UPTRAVI - selexipag tab therapy
pack 200 mcg (140) & 800 mcg
(60)
5
UPTRAVI - selexipag tab 200 mcg
5
5
•
5
5
•
UPTRAVI - selexipag tab 1000 mcg 5
•
•
•
•
tab 49-51 mg
ACA
2
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• • •
• • •
• • •
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
59
ERECTILE DYSFUNCTION
• •
MUSE– Benefit Limits may apply alprostadil urethral pellet 1000
mcg
4
• •
CAVERJECT– Benefit Limits may
apply - alprostadil for inj 20 mcg
4
• •
CAVERJECT– Benefit Limits may
apply - alprostadil for inj 40 mcg
4
• •
CAVERJECT IMPULSE– Benefit
Limits may apply - alprostadil for
inj kit 10 mcg
4
• •
STAXYN– Benefit Limits may
apply - vardenafil hcl orally
disintegrating tab 10 mg
4
• •
CAVERJECT IMPULSE– Benefit
Limits may apply - alprostadil for
inj kit 20 mcg
4
• •
STENDRA– Benefit Limits may
apply - avanafil tab 50 mg
4
• •
4
• •
CIALIS– Benefit Limits may apply tadalafil tab 2.5 mg
4
• •
4
• •
CIALIS– Benefit Limits may apply tadalafil tab 5 mg
4
• •
4
• •
4
• •
EDEX– Benefit Limits may apply alprostadil for inj kit 10 mcg
4
• •
4
• •
RESPIRATORY AGENTS
4
• •
brompheniramine maleate tab sr
12hr 6 mg
LEVITRA– Benefit Limits may
apply - vardenafil hcl tab 2.5 mg
4
• •
4
apply - vardenafil hcl tab 5 mg
4
• •
BROMPHENIRAMINE TANNATE brompheniramine tannate chew
tab 12 mg
1
4
• •
carbinoxamine maleate soln
4 mg/5ml
4
• •
CLARINEX - desloratadine syrup
0.5 mg/ml
4
mcg
4
• •
CLARINEX - desloratadine tab 5
mg
4
1
mcg
4
clemastine fumarate tab 2.68 mg
• •
4
ACA
mcg
Quantity Limits
Restricted Access
Prior Review
Specialty
•
Drug Name
Drug Tier
ACA
• • •
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
3
VIAGRA– Benefit Limits may
apply - sildenafil citrate tab 25 mg
3
apply - sildenafil citrate tab 50 mg
3
apply - sildenafil citrate tab 100
mg
ANTIHISTAMINES
carbinoxamine maleate tab 4 mg
cyproheptadine hcl syrup
2 mg/5ml
cyproheptadine hcl tab 4 mg
1
1
• •
• •
1
1
60
DESLORATADINE ODT desloratadine tab orally
disintegrating 2.5 mg
2
DESLORATADINE ODT desloratadine tab orally
disintegrating 5 mg
2
1
KARBINAL ER - carbinoxamine
maleate extended release susp 4
mg/5ml
4
levocetirizine dihydrochloride
soln 2.5 mg/5ml (0.5 mg/ml)
(Xyzal)
2
levocetirizine dihydrochloride
tab 5 mg (Xyzal)
1
promethazine hcl suppos
12.5 mg
promethazine hcl suppos 25 mg
promethazine hcl suppos 50 mg
promethazine hcl syrup
6.25 mg/5ml
promethazine hcl tab 12.5 mg
promethazine hcl tab 25 mg
promethazine hcl tab 50 mg
• •
2
2
1
1
1
RESPA-BR - brompheniramine
maleate tab sr 12hr 11 mg
4
XYZAL - levocetirizine
dihydrochloride soln 2.5 mg/5ml
(0.5 mg/ml)
4
XYZAL - levocetirizine
dihydrochloride tab 5 mg
4
• •
NASAL AGENTS - SYSTEMIC and TOPICAL
4
•
ADRENALIN - epinephrine hcl
nasal soln 0.1%
4
ASTEPRO - azelastine hcl nasal
spray 0.15% (205.5 mcg/spray)
2
azelastine hcl nasal spray 0.1%
(137 mcg/spray)
•
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
ACA
Drug Tier
2
BACTROBAN NASAL - mupirocin
calcium nasal oint 2%
4
BECONASE AQ - beclomethasone
dipropionate monohyd nasal
susp 42 mcg/spray
4
budesonide nasal susp 32 mcg/
act (Rhinocort aqua)
2
DYMISTA - azelastine hclfluticasone prop nasal spray
137-50 mcg/act
4
flunisolide nasal soln 25 mcg/act
(0.025%) (Flunisolide)
1
fluticasone propionate nasal
susp 50 mcg/act
2
1
Drug Name
azelastine hcl nasal spray 0.15%
(205.5 mcg/spray) (Astepro)
desloratadine tab 5 mg (Clarinex) 1
diphenhydramine hcl cap 50 mg 1
diphenhydramine hcl elixir
12.5 mg/5ml
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
1
1
ipratropium bromide nasal soln
0.03% (21 mcg/spray) (Atrovent)
1
ipratropium bromide nasal soln
0.06% (42 mcg/spray) (Atrovent)
mometasone furoate nasal susp 2
50 mcg/act (Nasonex)
2
NASONEX - mometasone furoate
nasal susp 50 mcg/act
2
olopatadine hcl nasal soln 0.6%
(Patanase)
OMNARIS - ciclesonide nasal susp 4
50 mcg/act
PATANASE - olopatadine hcl nasal 4
soln 0.6%
4
QNASL - beclomethasone
dipropionate nasal aerosol 80
mcg/act
4
QNASL CHILDRENS beclomethasone dipropionate
nasal aerosol 40 mcg/act
RHINOCORT AQUA - budesonide 4
nasal susp 32 mcg/act
2
triamcinolone acetonide nasal
aerosol suspension 55 mcg/act
TYZINE - tetrahydrozoline hcl nasal 4
soln 0.1%
•
• •
61
TYZINE PEDIATRIC NASAL DR tetrahydrozoline hcl nasal soln
0.05%
4
VERAMYST - fluticasone furoate
nasal susp 27.5 mcg/spray
4
ZETONNA - ciclesonide nasal
aerosol soln 37 mcg/act (50 mcg/
valve)
4
COUGH/COLD/ALLERGY
acetylcysteine inhal soln 10%
acetylcysteine inhal soln 20%
2
2
benzonatate cap 100 mg
(Tessalon perles)
1
benzonatate cap 200 mg
1
1
CAPCOF - phenylephrinechlorphen w/ codeine syrup
5-2-10 mg/5ml
4
• •
CARBAPHEN 12 - phenylephchlorphen-carbetapentane liqd
10-4-27.5 mg/5ml
4
• •
CARBAPHEN 12 PED - phenyleph- 4
chlorphen-carbetapentane susp
2.5-1.25-7.5 mg/ml
4
CLARINEX-D 12 HOUR desloratadine &
pseudoephedrine tab sr 12hr
2.5-120 mg
4
CODAR AR - chlorpheniramine w/
codeine liquid 2-8 mg/5ml
4
CODAR D - pseudoephedrine w/
4
DECON-A - brompheniramine &
phenylephrine elixir 2-5 mg/5ml
4
DECON-G - phenylephrinebrompheniramine-guaifenesin
liqd 2-1-40 mg/ml
• •
• •
• •
• •
• •
• •
DEX-TUSS - guaifenesin-codeine
liquid 300-10 mg/5ml
4
4
DEXTROMETHORPHAN HBR/
CHLO - phenylephrine-chlorphendm liquid 1.75-0.75-2.75 mg/ml
EXACTUSS - phenylephrine w/ dm- 4
gg liqd 10-28-388 mg/5ml
4
FLOWTUSS - hydrocodoneguaifenesin soln 2.5-200 mg/5ml
4
GILPHEX TR - phenylephrineguaifenesin tab 10-388 mg
GILTUSS - phenylephrine w/ dm-gg 4
liqd 10-28-388 mg/5ml
4
GILTUSS PED-C - phenylephrine
w/ codeine-gg liquid 2.5-3-50 mg/
ml
4
GILTUSS TR - phenylephrine w/
dm-gg tab 10-28-388 mg
2
guaifenesin-codeine liquid
200-8 mg/5ml
2
guaifenesin-codeine liquid
225-7.5 mg/5ml
1
guaifenesin-codeine soln
100-6.3 mg/5ml
1
guaifenesin-codeine soln
100-10 mg/5ml
4
HISTEX-AC - phenylephrinetriprolidine-codeine syrup
10-2.5-10 mg/5ml
HYCOFENIX - pseudoephedrine w/ 4
hydrocodone-gg soln 30-2.5-200
mg/5ml
2
hydrocod polst-chlorphen polst
er susp 10-8 mg/5ml (Tussionex
pennkineti)
1
hydrocodone w/ homatropine
syrup 5-1.5 mg/5ml
1
hydrocodone w/ homatropine
tab 5-1.5 mg
HYPER-SAL - sodium chloride soln 4
nebu 7%
ACA
• •
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
• •
2
BENZONATATE - benzonatate cap
150 mg
brompheniramine &
pseudoephedrine tab sr 12hr
6-45 mg
Specialty
Drug Name
Drug Tier
2016
• •
• •
• •
• •
• •
• •
62
HYPERSAL - sodium chloride soln
nebu 3.5%
4
HYPERSAL - sodium chloride soln
nebu 7%
4
LEXUSS 210 - chlorpheniramine w/ 4
4
LORTUSS EX - pseudoephedrine
w/ cod-gg liquid 30-10-100
mg/5ml
M-END MAX D - pseudoephedrine- 4
dexbromphen-codeine liqd
20-0.667-6 mg/5ml
4
M-END PE - phenylephrinebromphen w/ codeine liqd
3.33-1.33-6.33 mg/5ml
MAR-COF BP - pseudoephedrine- 4
bromphen-codeine liqd 30-2-7.5
mg/5ml
4
MAR-COF CG EXPECTORANT guaifenesin-codeine liquid
225-7.5 mg/5ml
4
NEBUSAL - sodium chloride soln
nebu 6%
NEOTUSS PLUS - phenylephrine- 4
chlorphen-dm liquid 7.5-4-30
mg/5ml
NORTUSS-EX - dextromethorphan- 4
guaifenesin liquid 20-200 mg/5ml
4
OBREDON - hydrocodoneguaifenesin soln 2.5-200 mg/5ml
4
PANATUSS DXP - phenylephrinedexbromphen-dm-gg liquid
5-1-15-100 mg/5ml
2
phenylephrine w/ dm-gg liqd
10-15-300 mg/5ml
2
2.5-5-50 mg/ml
2
2.5-7.5-88 mg/ml
2
phenylephrinebrompheniramine-dm liquid
7.5-4-15 mg/5ml
phenylephrine-guaifenesin liqd
7.5-100 mg/5ml (1.5-20 mg/ml)
phenylephrine-promethazine
w/ codeine syrup
5-6.25-10 mg/5ml
• •
• •
• •
• •
• •
• •
• •
• •
• •
ACA
2
2
4
• •
POLY-TUSSIN AC - phenylephrine- 4
bromphen w/ codeine liquid
10-4-10 mg/5ml
4
PRO-CLEAR AC - codeinepyrilamine syrup 9-8.33 mg/5ml
4
PRO-RED AC - phenylephrinedexchlorphenir-codeine syrup
5-1-9 mg/5ml
1
promethazine & phenylephrine
syrup 6.25-5 mg/5ml
1
promethazine w/ codeine syrup
6.25-10 mg/5ml
1
promethazine-dm syrup
6.25-15 mg/5ml
2
pseudoeph-chlorphen
w/ hydrocodone soln
60-4-5 mg/5ml (Zutripro)
1
pseudoephed-bromphen-dm
syrup 30-2-10 mg/5ml
pseudoephedrine w/ cod-gg soln 1
30-10-100 mg/5ml
2
pseudoephedrine w/ cod-gg
(Suttar-sf)
1
pseudoephedrinebromphen-codeine liq
10-1.33-6.33 mg/5ml
4
RELHIST - bromphen tanphenyleph tan chew tab 6-15 mg
4
REZIRA - pseudoephedrine w/
hydrocodone soln 60-5 mg/5ml
4
RYDEX - pseudoephedrinebromphen-codeine liq
10-1.33-6.33 mg/5ml
• •
PHENYLHISTINE DH pseudoephedrine-chlorphen w/
codeine liq 30-2-10 mg/5ml
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
• •
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
• •
• •
• •
63
SEMPREX-D - acrivastine &
pseudoephedrine cap 8-60 mg
4
sodium chloride soln nebu 0.9%
1
sodium chloride soln nebu 3%
1
(Hyper-sal)
1
1
• •
TUZISTRA XR - codeine polistchlorphen polist er susp 14.7-2.8
mg/5ml
4
• •
VANACOF CD - phenylephrinedexchlorphenir-codeine liquid
5-1-10 mg/5ml
4
• •
4
• •
• •
SUTTAR-SF - pseudoephedrine w/
cod-gg syrup 30-10-100 mg/5ml
4
VITUZ - hydrocodonechlorpheniramine soln 5-4
mg/5ml
Z-TUSS AC - chlorpheniramine w/
4
SUTTAR-2 - pseudoephedrine w/
cod-gg syrup 30-10-100 mg/5ml
4
ZUTRIPRO - pseudoeph-chlorphen
w/ hydrocodone soln 60-4-5
mg/5ml
4
4
ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 100-50
mcg/dose
3
mcg/dose
3
mcg/dose
3
ADVAIR HFA - fluticasonesalmeterol inhal aerosol 45-21
mcg/act
3
mcg/act
3
• •
mcg/act
3
• •
AEROSPAN - flunisolide hfa inhal
aerosol 80 mcg/act
4
albuterol sulfate soln nebu
0.083% (2.5 mg/3ml)
1
• •
• •
• •
• •
• •
ACA
Quantity Limits
ANTIASTHMATIC and BRONCHODILATOR AGENTS
•
ACCOLATE - zafirlukast tab 10 mg 4
ACCOLATE - zafirlukast tab 20 mg
• •
Restricted Access
4
4
• •
Prior Review
TUSSIONEX PENNKINETIC EXT hydrocod polst-chlorphen polst er
susp 10-8 mg/5ml
STATUSS GREEN - codeinepseudoephedrine-chlorcyclizine
liq 9-30-12.5 mg/5ml
TESSALON PERLES - benzonatate 4
cap 100 mg
4
TGQ 15DM/5PEH/2CPM phenylephrine-chlorphen-dm
syrup 5-2-15 mg/5ml
4
TGQ 30PSE/150GFN/15DM pseudoephedrine w/ dm-gg syrup
30-15-150 mg/5ml
4
TGQ 30PSE/3BRM/15DM pseudoephed-bromphen-dm
4
TGQ 50PSE/3BRM/30DM pseudoephed-bromphen-dm
4
TRICODE AR - pseudoephedrinechlorphen w/ codeine liq 30-2-8
mg/5ml
4
TRICODE GF - pseudoephedrine
w/ cod-gg liquid 30-8-200 mg/5ml
TUSNEL - brompheniramine w/ dm- 4
gg cap 2-15-200 mg
4
TUSSICAPS - hydrocod polstchlorphen polst cap sr 12hr 5-4
mg
4
TUSSICAPS - hydrocod polstchlorphen polst cap sr 12hr 10-8
mg
Specialty
Drug Name
Drug Tier
ACA
• •
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
• •
64
albuterol sulfate soln nebu 0.5%
(5 mg/ml)
0.63 mg/3ml (base equiv)
1
2
2
albuterol sulfate syrup 2 mg/5ml
1
albuterol sulfate tab 4 mg
2
albuterol sulfate tab sr 12hr 4 mg 2
(Vospire er)
albuterol sulfate tab sr 12hr 8 mg 2
(Vospire er)
2
albuterol sulfate tab 2 mg
ALVESCO - ciclesonide inhal
aerosol 80 mcg/act
4
• •
ALVESCO - ciclesonide inhal
aerosol 160 mcg/act
4
• •
ANORO ELLIPTA - umeclidiniumvilanterol aero powd ba 62.5-25
mcg/inh
3
ARCAPTA NEOHALER indacaterol maleate inhal powder
cap 75 mcg (base equiv)
4
• •
ARNUITY ELLIPTA - fluticasone
furoate aerosol powder breath
activ 100 mcg/act
4
• •
ARNUITY ELLIPTA - fluticasone
furoate aerosol powder breath
activ 200 mcg/act
4
• •
ASMANEX HFA - mometasone
furoate inhal aerosol suspension
100 mcg/act
3
ASMANEX HFA - mometasone
furoate inhal aerosol suspension
200 mcg/act
3
ASMANEX TWISTHALER 120 ME - 3
mometasone furoate inhal powd
220 mcg/inh (breath activated)
ASMANEX TWISTHALER 14 MET - 3
3
ASMANEX TWISTHALER 7
METE - mometasone furoate
inhal powd 110 mcg/inh (breath
activated)
4
ATROVENT HFA - ipratropium
bromide hfa inhal aerosol 17
mcg/act
4
BEVESPI AEROSPHERE glycopyrrolate-formoterol
fumarate aerosol 9-4.8 mcg/act
3
BREO ELLIPTA - fluticasone
furoate-vilanterol aero powd ba
100-25 mcg/inh
3
BREO ELLIPTA - fluticasone
furoate-vilanterol aero powd ba
200-25 mcg/inh
4
BROVANA - arformoterol tartrate
soln nebu 15 mcg/2ml (base
equiv)
2
budesonide inhalation susp
0.25 mg/2ml (Pulmicort)
2
0.5 mg/2ml (Pulmicort)
2
1 mg/2ml (Pulmicort)
3
COMBIVENT RESPIMAT ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act
4
CROMOLYN SODIUM - cromolyn
sodium soln nebu 20 mg/2ml
4
DALIRESP - roflumilast tab 500
mcg
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
• •
• •
• • •
65
4
ELIXOPHYLLIN - theophylline elixir
80 mg/15ml
4
METAPROTERENOL SULFATE metaproterenol sulfate syrup 10
mg/5ml
4
FLOVENT DISKUS - fluticasone
propionate aer pow ba 50 mcg/
blister
3
METAPROTERENOL SULFATE metaproterenol sulfate tab 10 mg
METAPROTERENOL SULFATE metaproterenol sulfate tab 20 mg
4
blister
3
montelukast sodium chew tab
4 mg (base equiv) (Singulair)
1
•
3
1
blister
montelukast sodium chew tab
5 mg (base equiv) (Singulair)
•
2
•
FLOVENT HFA - fluticasone
propionate hfa inhal aero 44
mcg/act (50/valve)
3
montelukast sodium
oral granules packet 4 mg
(base equiv) (Singulair)
1
•
3
propionate hfa inhal aer 110 mcg/
act (125/valve)
3
propionate hfa inhal aer 220
mcg/act (250/valve)
INCRUSE ELLIPTA - umeclidinium 3
br aero powd breath act 62.5
mcg/inh (base eq)
1
ipratropium bromide inhal soln
0.02%
2
ipratropium-albuterol nebu soln
0.5-2.5(3) mg/3ml
2
levalbuterol hcl soln nebu conc
1.25 mg/0.5ml (base equiv)
(Xopenex concentrate)
2
levalbuterol hcl soln nebu
(Xopenex)
montelukast sodium tab 10 mg
(base equiv) (Singulair)
PERFOROMIST - formoterol
fumarate soln nebu 20 mcg/2ml
4
PROAIR HFA - albuterol sulfate
inhal aero 108 mcg/act (90mcg
base equiv)
3
PROAIR RESPICLICK - albuterol
sulfate aer pow ba 108 mcg/act
(90 mcg base equiv)
3
PROVENTIL HFA - albuterol sulfate 4
base equiv)
4
PULMICORT - budesonide
inhalation susp 0.25 mg/2ml
4
inhalation susp 0.5 mg/2ml
4
inhalation susp 1 mg/2ml
4
PULMICORT FLEXHALER budesonide inhal aero powd 90
mcg/act (breath activated)
ACA
2
2
Quantity Limits
dyphylline-guaifenesin liqd
100-100 mg/5ml
(Xopenex)
Restricted Access
• •
2
Prior Review
4
(Xopenex)
Specialty
DULERA - mometasone furoateformoterol fumarate aerosol
200-5 mcg/act
Drug Name
Drug Tier
• •
4
ACA
DULERA - mometasone furoateformoterol fumarate aerosol
100-5 mcg/act
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
• •
• •
66
4
QVAR - beclomethasone diprop
inhal aero soln 40 mcg/act (50/
valve)
4
• •
QVAR - beclomethasone diprop
inhal aero soln 80 mcg/act (100/
valve)
4
• •
SEREVENT DISKUS - salmeterol
xinafoate aer pow ba 50 mcg/
dose (base equiv)
3
SINGULAIR - montelukast sodium
4
4
•
oral granules packet 4 mg (base
equiv)
4
•
theophylline tab sr 24hr 400 mg
4
•
4
• •
TUDORZA PRESSAIR - aclidinium
bromide aerosol powd breath
activated 400 mcg/act
VENTOLIN HFA - albuterol sulfate
base equiv)
4
• •
SPIRIVA HANDIHALER - tiotropium 3
bromide monohydrate inhal cap
18 mcg (base equiv)
3
SPIRIVA RESPIMAT - tiotropium
bromide monohydrate inhal
aerosol 1.25 mcg/act
3
SPIRIVA RESPIMAT - tiotropium
bromide monohydrate inhal
aerosol 2.5 mcg/act
4
STIOLTO RESPIMAT - tiotropium
br-olodaterol inhal aero soln
2.5-2.5 mcg/act
STRIVERDI RESPIMAT - olodaterol 4
hcl inhal aerosol soln 2.5 mcg/act
(base equiv)
4
SYMBICORT - budesonideformoterol fumarate dihyd
aerosol 80-4.5 mcg/act
4
SYMBICORT - budesonideformoterol fumarate dihyd
aerosol 160-4.5 mcg/act
2
terbutaline sulfate tab 2.5 mg
THEO-24 - theophylline cap sr 24hr 4
100 mg
200 mg
300 mg
400 mg
2
theophylline soln 80 mg/15ml
•
• •
• •
• •
• •
ACA
• •
• •
• •
• •
1
1
1
1
1
1
VOSPIRE ER - albuterol sulfate tab 4
sr 12hr 4 mg
VOSPIRE ER - albuterol sulfate tab 4
sr 12hr 8 mg
4
XOPENEX - levalbuterol hcl soln
nebu 0.31 mg/3ml (base equiv)
4
4
4
XOPENEX CONCENTRATE levalbuterol hcl soln nebu conc
1.25 mg/0.5ml (base equiv)
4
XOPENEX HFA - levalbuterol
tartrate inhal aerosol 45 mcg/act
(base equiv)
2
zafirlukast tab 10 mg (Accolate)
zafirlukast tab 20 mg (Accolate)
Quantity Limits
Restricted Access
Prior Review
PULMICORT FLEXHALER budesonide inhal aero powd 180
mcg/act (breath activated)
terbutaline sulfate tab 5 mg
2
Specialty
Drug Name
Drug Tier
ACA
• •
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
2
• •
•
•
67
ZYFLO - zileuton tab 600 mg
4
ZYFLO CR - zileuton tab sr 12hr
600 mg
4
RESPIRATORY AGENTS - MISC.
OSMOPREP - sod phos monosod phos di tabs 1.102-0.398
gm(1.5gm na phos)
4
• •
4
• •
5
KALYDECO - ivacaftor packet 75
mg
5
• •
•
PCP 100 - mag cit-bisacodylpetrolat-peg-metoclopramideelectrol kit
OFEV - nintedanib esylate cap 100
5
• •
• •
•
•
peg 3350-kcl-sod bicarb-nacl
for soln 420 gm (Nulytely/flavor
pack)
1
KALYDECO - ivacaftor tab 150 mg
5
5
• •
•
1
OFEV - nintedanib esylate cap 150
peg 3350-kcl-na bicarb-naclna sulfate for soln 236 gm
(Golytely)
ORKAMBI - lumacaftor-ivacaftor tab 5
200-125 mg
5
PULMOZYME - dornase alfa inhal
soln 1 mg/ml
• •
•
KALYDECO - ivacaftor packet 50
mg
•
GASTROINTESTINAL AGENTS
LAXATIVES
bisacodyl tab & peg 3350-kclsod bicarb-nacl for soln kit
2
COLYTE-FLAVOR PACKS - peg
3350-kcl-na bicarb-nacl-na
sulfate for soln 240 gm
4
GOLYTELY - peg 3350-kcl-na
bicarb-nacl-na sulfate packet
227.1 gm
4
GOLYTELY - peg 3350-kcl-na
bicarb-nacl-na sulfate for soln
236 gm
4
KRISTALOSE - lactulose oral
crystal packet 10 gm
4
KRISTALOSE - lactulose oral
crystal packet 20 gm
4
lactulose solution 10 gm/15ml
1
• •
1
peg 3350-kcl-na bicarb-nacl-na
sulfate for soln 240 gm (Colyteflavor packs)
1
polyethylene glycol 3350 oral
packet
1
polyethylene glycol 3350 oral
powder
4
PREPOPIK - sod picosulfate-mg
oxide-citric acid pack 10 mg-3.5
gm-12 gm
4
SUPREP BOWEL PREP - sodium
sulfate-potassium sulfatemagnesium sulfate oral soln
ANTIDIARRHEALS
MINERAL OIL HEAVY - mineral oil
4
MOVIPREP - peg 3350-kcl-nacl-na
sulfate-na ascorbate-c for soln
100 gm
4
diphenoxylate w/ atropine tab
2.5-0.025 mg (Lomotil)
4
• •
• •
FULYZAQ - crofelemer tab delayed
release 125 mg
4
LOMOTIL - diphenoxylate w/
atropine tab 2.5-0.025 mg
4
loperamide hcl cap 2 mg
1
MOTOFEN - difenoxin w/ atropine
tab 1-0.025 mg
ACA
Quantity Limits
• •
• •
1
DIPHENOXYLATE/ATROPINE diphenoxylate w/ atropine liq
2.5-0.025 mg/5ml
• •
Restricted Access
4
•
•
5
Prior Review
NULYTELY/FLAVOR PACKS - peg
3350-kcl-sod bicarb-nacl for soln
420 gm
• •
• •
ESBRIET - pirfenidone cap 267 mg
Specialty
Drug Name
Drug Tier
• • •
• • •
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
4
• •
• •
68
opium tincture 1% (10 mg/ml)
(morphine equiv)
PAREGORIC - paregoric tincture 2
mg/5ml
ANTACIDS
SODIUM BICARBONATE - sodium
bicarbonate powder
ULCER DRUGS
ACIPHEX - rabeprazole sodium ec
tab 20 mg
cimetidine hcl soln 300 mg/5ml
cimetidine tab 200 mg
4
4
1
1
1
1
1
CYTOTEC - misoprostol tab 100
mcg
4
CYTOTEC - misoprostol tab 200
mcg
4
DEXILANT - dexlansoprazole cap
4
• •
DEXILANT - dexlansoprazole cap
4
• •
• •
dicyclomine hcl cap 10 mg
(Bentyl)
1
• •
dicyclomine hcl oral soln
10 mg/5ml
2
• •
• •
dicyclomine hcl tab 20 mg
(Bentyl)
1
DONNATAL - pb-hyoscyatrop-scopol elix
16.2-0.1037-0.0194-0.0065
mg/5ml
4
• •
DONNATAL - pb-hyoscyatrop-scopol tab
16.2-0.1037-0.0194-0.0065 mg
4
• •
esomeprazole magnesium cap
delayed release 20 mg (base
eq) (Nexium)
2
esomeprazole magnesium cap
delayed release 40 mg (base
eq) (Nexium)
• •
2
famotidine tab 20 mg (Pepcid)
1
GASTRINEX NF - hyoscyaminephenyltoloxamine cap 0.0625-15
mg
• •
2
famotidine for susp 40 mg/5ml
(Pepcid)
famotidine tab 40 mg (Pepcid)
ACA
• •
4
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Tier
ACA
Drug Name
CUVPOSA - glycopyrrolate oral
soln 1 mg/5ml
4
2
Quantity Limits
Restricted Access
Prior Review
2
ACIPHEX SPRINKLE - rabeprazole 4
sodium capsule sprinkle dr 5 mg
ACIPHEX SPRINKLE - rabeprazole 4
sodium capsule sprinkle dr 10
mg
2
amoxicillin cap-clarithro tablansopraz cap dr therapy pack
(Prevpac)
4
ANASPAZ - hyoscyamine sulfate
tab disp 0.125 mg
4
BELLADONNA & OPIUM belladonna alkaloids & opium
suppos 16.2-30 mg
BELLADONNA ALKALOIDS & OP - 4
belladonna alkaloids & opium
suppos 16.2-60 mg
4
BENTYL - dicyclomine hcl cap 10
mg
4
BENTYL - dicyclomine hcl tab 20
mg
4
CARAFATE - sucralfate susp 1
gm/10ml
4
CARAFATE - sucralfate tab 1 gm
chlordiazepoxide hcl-clidinium
bromide cap 5-2.5 mg (Librax)
Specialty
Drug Name
Drug Tier
2016
1
4
• •
glycopyrrolate tab 1 mg (Robinul) 1
glycopyrrolate tab 2 mg (Robinul 2
forte)
1
hyoscyamine sulfate elixir
0.125 mg/5ml
69
hyoscyamine sulfate soln
0.125 mg/ml
hyoscyamine sulfate tab disp
0.125 mg (Anaspaz)
hyoscyamine sulfate tab sl
0.125 mg (Levsin/sl)
hyoscyamine sulfate tab sr 12hr
0.375 mg (Levbid)
hyoscyamine sulfate tab
0.125 mg (Levsin)
lansoprazole cap delayed
release 15 mg (Prevacid)
1
1
1
1
1
1
NEXIUM - esomeprazole
magnesium for delayed release
susp packet 20 mg
3
susp packet 40 mg
3
susp pack 2.5 mg
3
NIZATIDINE - nizatidine oral soln
15 mg/ml
4
nizatidine cap 150 mg
1
1
1
nizatidine cap 300 mg (Axid)
4
LEVBID - hyoscyamine sulfate tab
sr 12hr 0.375 mg
4
OMECLAMOX-PAK - amoxicillin
cap-clarithro tab w/ omepraz cap
dr therapy pack
LEVSIN - hyoscyamine sulfate tab
0.125 mg
4
omeprazole cap delayed release
10 mg (Prilosec)
1
LEVSIN/SL - hyoscyamine sulfate
tab sl 0.125 mg
4
20 mg (Prilosec)
LIBRAX - chlordiazepoxide hclclidinium bromide cap 5-2.5 mg
4
40 mg (Prilosec)
methscopolamine bromide tab
2.5 mg (Pamine)
2
omeprazole-sodium bicarbonate
cap 20-1100 mg (Zegerid)
2
omeprazole-sodium bicarbonate
cap 40-1100 mg (Zegerid)
misoprostol tab 100 mcg
(Cytotec)
1
PAMINE - methscopolamine
bromide tab 2.5 mg
4
misoprostol tab 200 mcg
(Cytotec)
1
4
magnesium cap delayed release
20 mg (base eq)
4
PAMINE FORTE methscopolamine bromide tab 5
mg
magnesium cap delayed release
40 mg (base eq)
4
susp packet 5 mg
3
susp packet 10 mg
3
lansoprazole cap delayed
release 30 mg (Prevacid)
methscopolamine bromide tab
5 mg (Pamine forte)
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
1
1
2
• •
2
• •
PAMINE FQ - methscopolamine tab 4
5 mg & misc intestinal flora reg
cap
1
pantoprazole sodium ec tab
20 mg (base equiv) (Protonix)
1
pantoprazole sodium ec tab
40 mg (base equiv) (Protonix)
2
pb-hyoscy-atrop-scopol tab
16.2-0.1037-0.0194-0.0065 mg
(Donnatal)
• •
70
PEPCID - famotidine for susp 40
mg/5ml
4
PEPCID - famotidine tab 20 mg
4
PEPCID - famotidine tab 40 mg
4
PREVACID - lansoprazole cap
4
PREVACID - lansoprazole cap
4
PREVACID SOLUTAB lansoprazole tab delayed release
orally disintegrating 15 mg
4
PREVACID SOLUTAB lansoprazole tab delayed release
orally disintegrating 30 mg
4
PREVPAC - amoxicillin cap-clarithro 4
tab-lansopraz cap dr therapy
pack
4
PRILOSEC - omeprazole cap
4
4
4
PRILOSEC - omeprazole
susp packet 2.5 mg
4
PRILOSEC - omeprazole
susp packet 10 mg
4
PROPANTHELINE BROMIDE propantheline bromide tab 15 mg
PROTONIX - pantoprazole sodium 4
ec tab 20 mg (base equiv)
ec tab 40 mg (base equiv)
for delayed release susp packet
40 mg
4
PYLERA - bismuth subcitmetronidazole-tetracycline cap
140-125-125 mg
rabeprazole sodium ec tab
20 mg (Aciphex)
ranitidine hcl cap 150 mg
ranitidine hcl cap 300 mg
• •
• •
• •
• •
• •
• •
ACA
Quantity Limits
Restricted Access
Prior Review
1
2
2
ranitidine hcl syrup 15 mg/ml
(75 mg/5ml)
1
sucralfate tab 1 gm (Carafate)
1
ranitidine hcl tab 150 mg (Zantac) 1
ranitidine hcl tab 300 mg (Zantac) 1
SYMAX DUOTAB - hyoscyamine
sulfate tab cr 0.375 mg (0.125
mg ir/0.25 mg cr)
4
ZANTAC - ranitidine hcl tab 150 mg 4
ZANTAC - ranitidine hcl tab 300 mg 4
• •
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
ZEGERID - omeprazole-sodium
bicarbonate cap 20-1100 mg
4
• •
bicarbonate cap 40-1100 mg
4
• •
bicarbonate powd pack for susp
20-1680 mg
4
• • •
bicarbonate powd pack for susp
40-1680 mg
4
• • •
AKYNZEO - netupitantpalonosetron cap 300-0.5 mg
5
• • •
ANZEMET - dolasetron mesylate
tab 50 mg
5
• • • •
ANZEMET - dolasetron mesylate
tab 100 mg
5
• • • •
CESAMET - nabilone cap 1 mg
4
• • •
DICLEGIS - doxylamine-pyridoxine
tab delayed release 10-10 mg
4
dronabinol cap 2.5 mg (Marinol)
2
ANTIEMETICS
dronabinol cap 5 mg (Marinol)
dronabinol cap 10 mg (Marinol)
2
2
4
• • •
EMEND - aprepitant capsule 40 mg 4
• • •
EMEND - aprepitant capsule
therapy pack 80 & 125 mg
71
EMEND - aprepitant capsule 80 mg 4
4
EMEND - aprepitant capsule 125
mg
2
granisetron hcl tab 1 mg
MARINOL - dronabinol cap 2.5 mg
4
MARINOL - dronabinol cap 5 mg
4
MARINOL - dronabinol cap 10 mg
4
meclizine hcl tab 12.5 mg
1
meclizine hcl tab 25 mg
ondansetron hcl oral soln
4 mg/5ml (Zofran)
2
1
ondansetron hcl tab 8 mg
(Zofran)
1
2
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)
5
TIGAN - trimethobenzamide hcl cap 4
300 mg
TRANSDERM-SCOP - scopolamine 4
td patch 72hr 1 mg/3days
2
trimethobenzamide hcl cap
300 mg (Tigan)
5
VARUBI - rolapitant hcl tab 90 mg
(base equiv)
4
ZOFRAN - ondansetron hcl oral
soln 4 mg/5ml
4
ZOFRAN - ondansetron hcl tab 4
mg
4
ZOFRAN - ondansetron hcl tab 8
mg
ZOFRAN ODT - ondansetron orally 4
• • •
• • • •
•
4
ZUPLENZ - ondansetron oral
soluble film 4 mg
4
• • •
ZUPLENZ - ondansetron oral
soluble film 8 mg
4
• • •
CREON - pancrelipase (lip-protamyl) dr cap 3000-9500-15000
unit
4
• •
unit
4
• •
unit
4
• •
CREON - pancrelipase
(lip-prot-amyl) dr cap
24000-76000-120000 unit
4
• •
CREON - pancrelipase
36000-114000-180000 unit
4
• •
PANCREAZE - pancrelipase
4200-10000-17500 unit
4
• •
10500-25000-43750 unit
4
• •
16800-40000-70000 unit
4
• •
21000-37000-61000 unit
4
• •
PERTZYE - pancrelipase (lip-protamyl) dr cap 8000-28750-30250
unit
4
• •
PERTZYE - pancrelipase (lip-protamyl) dr cap 16000-57500-60500
unit
4
• •
SUCRAID - sacrosidase soln 8500
unit/ml
5
• •
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
ZOFRAN ODT - ondansetron orally
DIGESTIVE AIDS
1
(Zofran)
Drug Name
Drug Tier
• • •
• • •
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
72
VIOKACE - pancrelipase (lip-protamyl) tab 10440-39150-39150
unit
4
VIOKACE - pancrelipase (lip-protamyl) tab 20880-78300-78300
unit
4
ZENPEP - pancrelipase (lip-protamyl) dr cap 3000-10000-16000
unit
AZULFIDINE - sulfasalazine tab
500 mg
4
AZULFIDINE EN-TABS sulfasalazine tab delayed release
500 mg
4
3
balsalazide disodium cap
750 mg (Colazal)
2
unit
3
calcium acetate (phosphate
binder) cap 667 mg (169 mg
ca) (Phoslo)
unit
3
unit
3
ZENPEP - pancrelipase
20000-68000-109000 unit
3
25000-85000-136000 unit
3
40000-136000-218000 unit
3
• •
calcium acetate (phosphate
binder) tab 667 mg (Eliphos)
CANASA - mesalamine suppos
1000 mg
alosetron hcl tab 0.5 mg (base
equiv) (Lotronex)
alosetron hcl tab 1 mg (base
equiv) (Lotronex)
AMITIZA - lubiprostone cap 8 mcg
2
2
4
AMITIZA - lubiprostone cap 24 mcg 4
APRISO - mesalamine cap sr 24hr 4
0.375 gm
4
ASACOL HD - mesalamine tab
4
AURYXIA - ferric citrate tab 1 gm
(210 mg ferric iron)
• •
• •
• •
• •
• •
ACA
Quantity Limits
Restricted Access
Prior Review
2
2
4
CHENODAL - chenodiol tab 250 mg 4
CHOLBAM - cholic acid cap 50 mg 5
GASTROINTESTINAL AGENTS- MISC.
4
ACTIGALL - ursodiol cap 300 mg
Specialty
Drug Name
Drug Tier
ACA
• •
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
CHOLBAM - cholic acid cap 250 mg 5
CIMZIA - certolizumab pegol for inj 5
kit 2 x 200 mg
CIMZIA - certolizumab pegol inj kit 5
2 x 200 mg/ml
5
CIMZIA STARTER KIT certolizumab pegol inj kit 6 x 200
mg/ml
4
COLAZAL - balsalazide disodium
cap 750 mg
5
cromolyn sodium oral conc
100 mg/5ml (Gastrocrom)
3
DELZICOL - mesalamine cap dr
400 mg
DIPENTUM - olsalazine sodium cap 4
250 mg
4
ELIPHOS - calcium acetate
(phosphate binder) tab 667 mg
ENTEREG - alvimopan cap 12 mg 5
FOSRENOL - lanthanum carbonate 4
chew tab 500 mg (elemental)
• •
• •
• •
• • • •
•
•
•
• • • •
• • • •
•
• •
• •
• •
• •
• •
73
oral powder pack 750 mg
(elemental)
oral powder pack 1000 mg
(elemental)
GASTROCROM - cromolyn sodium 5
oral conc 100 mg/5ml
GATTEX - teduglutide (rdna) for inj 5
kit 5 mg
4
GIAZO - balsalazide disodium tab
1.1 gm
1
lactulose (encephalopathy)
solution 10 gm/15ml
4
LIALDA - mesalamine tab delayed
release 1.2 gm
LINZESS - linaclotide cap 145 mcg 3
LINZESS - linaclotide cap 290 mcg
3
mesalamine enema 4 gm
2
mesalamine rectal enema 4 gm & 2
cleanser wipe kit (Rowasa)
2
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)
4
METOCLOPRAMIDE ODT metoclopramide hcl orally
METOZOLV ODT - metoclopramide 4
hcl orally disintegrating tab 5 mg
MOVANTIK - naloxegol oxalate tab 4
12.5 mg (base equivalent)
MOVANTIK - naloxegol oxalate tab 4
5
OCALIVA - obeticholic acid tab 5
mg
OCALIVA - obeticholic acid tab 10
mg
•
•
•
• •
• •
• •
• •
•
•
5
PENTASA - mesalamine cap cr 250 4
mg
PENTASA - mesalamine cap cr 500 4
mg
4
PHOSLO - calcium acetate
(phosphate binder) cap 667 mg
(169 mg ca)
4
PHOSLYRA - calcium acetate
(phosphate binder) oral soln 667
mg/5ml
REGLAN - metoclopramide hcl tab 4
5 mg
REGLAN - metoclopramide hcl tab 4
10 mg
5
RELISTOR - methylnaltrexone
bromide inj 8 mg/0.4ml (20 mg/
ml)
5
RELISTOR - methylnaltrexone
bromide inj 12 mg/0.6ml (20 mg/
ml)
RENAGEL - sevelamer hcl tab 400 4
mg
RENAGEL - sevelamer hcl tab 800 4
mg
4
RENVELA - sevelamer carbonate
packet 0.8 gm
4
packet 2.4 gm
4
tab 800 mg
4
ROWASA - mesalamine rectal
enema 4 gm & cleanser wipe kit
SFROWASA - mesalamine sulfite- 4
free (sf) enema 4 gm/60ml
sulfasalazine tab delayed release 1
500 mg (Azulfidine en-tabs)
1
sulfasalazine tab 500 mg
(Azulfidine)
4
URSO FORTE - ursodiol tab 500
mg
•
ACA
Quantity Limits
• •
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
• •
• •
• •
• •
• •
• •
• •
• •
74
URSO 250 - ursodiol tab 250 mg
4
ursodiol cap 300 mg (Actigall)
2
ursodiol tab 250 mg (Urso 250)
ursodiol tab 500 mg (Urso forte)
VELPHORO - sucroferric
oxyhydroxide chew tab 500 mg
4
• •
VIBERZI - eluxadoline tab 75 mg
4
VIBERZI - eluxadoline tab 100 mg
4
• •
• •
GENITOURINARY AGENTS
URINARY ANTI-INFECTIVES
HIPREX - methenamine hippurate
tab 1 gm
4
MACROBID - nitrofurantoin
monohydrate macrocrystalline
cap 100 mg
4
MACRODANTIN - nitrofurantoin
macrocrystalline cap 25 mg
4
4
4
methenamine hippurate tab 1 gm
(Hiprex)
2
METHENAMINE MANDELATE methenamine mandelate tab 0.5
gm
4
methenamine mandelate tab
1 gm
2
methenamine-hyos-meth bluesod phos-phen sal tab 81.6 mg
methenamine-hyosc-meth bluebenz acid-phenyl sal tab
81.6mg (Prosed/ds)
methenamine-hyosc-meth bluesod phos-phen sal cap 118 mg
methenamine-hyosc-meth bluesod phos-phen sal cap 120 mg
methenamine-hyosc-meth bluesod phos-phen sal tab 81 mg
2
2
2
2
2
2
MONUROL - fosfomycin
tromethamine powd pack 3 gm
(base equivalent)
4
nitrofurantoin macrocrystalline
cap 25 mg (Macrodantin)
2
ACA
Quantity Limits
Restricted Access
• •
1
2
nitrofurantoin monohydrate
(Macrobid)
1
nitrofurantoin susp 25 mg/5ml
(Furadantin)
2
URIMAR-T - methenamine-hyoscmeth blue-sod phos-phen sal tab
120 mg
4
UROGESIC-BLUE - methenaminehyoscamine-meth blue-sod phos
tab 81.6 mg
4
URINARY ANTISPASMODICS
Prior Review
2
methenamine-hyoscamine-meth
blue-sod phos tab 81.6 mg
(Urogesic-blue)
Specialty
Drug Tier
ACA
Drug Name
methenamine-hyoscamine-meth
blue-sod phos cap 120 mg
2
2
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
bethanechol chloride tab 5 mg
(Urecholine)
1
(Urecholine)
1
(Urecholine)
1
(Urecholine)
2
darifenacin hydrobromide tab
sr 24hr 7.5 mg (base equiv)
(Enablex)
2
•
darifenacin hydrobromide tab
sr 24hr 15 mg (base equiv)
(Enablex)
2
•
DETROL - tolterodine tartrate tab 1
mg
4
• •
75
2
•
tolterodine tartrate tab 2 mg
(Detrol)
2
•
• •
• •
• •
TOVIAZ - fesoterodine fumarate tab 4
sr 24hr 4 mg
TOVIAZ - fesoterodine fumarate tab 4
sr 24hr 8 mg
2
trospium chloride cap sr 24hr
60 mg
2
trospium chloride tab 20 mg
DITROPAN XL - oxybutynin
chloride tab sr 24hr 5 mg
4
• •
4
• •
4
ENABLEX - darifenacin
hydrobromide tab sr 24hr 7.5 mg
(base equiv)
4
• •
URECHOLINE - bethanechol
chloride tab 5 mg
4
chloride tab 10 mg
4
ENABLEX - darifenacin
hydrobromide tab sr 24hr 15 mg
(base equiv)
4
chloride tab 25 mg
4
flavoxate hcl tab 100 mg
2
chloride tab 50 mg
4
VESICARE - solifenacin succinate
tab 5 mg
4
• •
VESICARE - solifenacin succinate
tab 10 mg
4
• •
• •
• •
• •
• •
VAGINAL PRODUCTS
•
AVC - sulfanilamide vaginal cream
15%
4
•
CLEOCIN - clindamycin phosphate
vaginal cream 2%
4
•
CLEOCIN - clindamycin phosphate
vaginal suppos 100 mg
4
•
clindamycin phosphate vaginal
cream 2% (Cleocin)
2
CLINDESSE - clindamycin
phosphate (one dose) vaginal
cream 2%
4
OXYTROL - oxybutynin td patch
4
•
• •
2
•
CRINONE - progesterone vaginal
gel 4%
4
tolterodine tartrate cap sr 24hr
2 mg (Detrol la)
2
•
CRINONE - progesterone vaginal
gel 8%
4
ENCARE - nonoxynol-9 vaginal
suppos 100 mg
A
tolterodine tartrate cap sr 24hr
4 mg (Detrol la)
4
GELNIQUE - oxybutynin chloride td 4
gel 10%
4
MYRBETRIQ - mirabegron tab sr
24 hr 25 mg
4
MYRBETRIQ - mirabegron tab sr
24 hr 50 mg
1
oxybutynin chloride syrup
5 mg/5ml
2
oxybutynin chloride tab sr 24hr
5 mg (Ditropan xl)
2
10 mg (Ditropan xl)
2
15 mg (Ditropan xl)
1
oxybutynin chloride tab 5 mg
tolterodine tartrate tab 1 mg
(Detrol)
ACA
DETROL LA - tolterodine tartrate
cap sr 24hr 4 mg
Quantity Limits
• •
Restricted Access
4
Prior Review
DETROL LA - tolterodine tartrate
cap sr 24hr 2 mg
Specialty
• •
Drug Name
Drug Tier
4
DETROL - tolterodine tartrate tab 2
mg
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
•
•
• •
• •
• •
•
76
ENDOMETRIN - progesterone
vaginal insert 100 mg
5
ESTRACE - estradiol vaginal cream 4
0.1 mg/gm
ESTRING - estradiol vaginal ring 2 4
mg (7.5 mcg/24hrs)
FEM PH - acetic acid-oxyquinoline 4
vaginal gel 0.9-0.025%
4
FEMRING - estradiol acetate
vaginal ring 0.05 mg/24hr
4
FEMRING - estradiol acetate
vaginal ring 0.1 mg/24hr
4
GYNAZOLE-1 - butoconazole
nitrate (one dose) vaginal cream
2%
4
METROGEL-VAGINAL metronidazole vaginal gel 0.75%
metronidazole vaginal gel 0.75% 1
(Metrogel-vaginal)
4
MICONAZOLE 3 - miconazole
nitrate vaginal suppos 200 mg
NUVESSA - metronidazole vaginal 4
gel 1.3%
A
OPTIONS CONCEPTROL
VAGINA - nonoxynol-9 gel 4%
A
OPTIONS GYNOL II VAGINAL nonoxynol-9 gel 3%
vaginal cream 0.625 mg/gm
4
RELAGARD - acetic acidoxyquinoline vaginal gel
0.9-0.025%
SHUR-SEAL - nonoxynol-9 gel 2% A
terconazole vaginal suppos
80 mg
• •
• •
• •
• •
TODAY SPONGE - nonoxynol-9
vaginal sponge 1000 mg
A
VAGIFEM - estradiol vaginal tab 10
mcg
3
GENITOURINARY AGENTS - MISC.
alfuzosin hcl tab sr 24hr 10 mg
(Uroxatral)
• •
• •
• •
•
•
• •
•
•
•
•
1
AVODART - dutasteride cap 0.5 mg 4
4
CARDURA XL - doxazosin
mesylate tab sr 24 hr 4 mg (base
equiv)
4
CARDURA XL - doxazosin
mesylate tab sr 24 hr 8 mg (base
equiv)
CYSTAGON - cysteamine bitartrate 4
cap 50 mg
CYSTAGON - cysteamine bitartrate 4
cap 150 mg
CYTRA-3 - pot & sod citrates w/ cit 4
ac syrup 550-500-334 mg/5ml
dutasteride cap 0.5 mg (Avodart) 2
dutasteride-tamsulosin hcl cap
0.5-0.4 mg (Jalyn)
ACA
2
VCF VAGINAL CONTRACEPTIVE - A
nonoxynol-9 film 28%
VCF VAGINAL CONTRACEPTIVE - A
nonoxynol-9 foam 12.5%
• •
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
• •
• •
•
• •
•
• •
2
ELMIRON - pentosan polysulfate
sodium caps 100 mg
4
finasteride tab 5 mg (Proscar)
1
TERAZOL 3 - terconazole vaginal
cream 0.8%
4
FLOMAX - tamsulosin hcl cap 0.4
mg
4
TERAZOL 7 - terconazole vaginal
cream 0.4%
4
JALYN - dutasteride-tamsulosin hcl
cap 0.5-0.4 mg
4
terconazole vaginal cream 0.4%
(Terazol 7)
1
4
terconazole vaginal cream 0.8%
(Terazol 3)
1
K-PHOS NO 2 - potassium &
sodium acid phosphates tab
305-700 mg
• •
LITHOSTAT - acetohydroxamic acid 4
tab 250 mg
77
ORACIT - sodium citrate & citric
acid soln 490-640 mg/5ml
4
THIOLA - tiopronin tab 100 mg
4
UROCIT-K 10 - potassium citrate
tab cr 10 meq (1080 mg)
4
phenazopyridine hcl tab 100 mg
(Pyridium)
1
UROCIT-K 15 - potassium citrate
tab cr 15 meq (1620 mg)
4
phenazopyridine hcl tab 200 mg
(Pyridium)
1
pot & sod citrates w/ cit ac soln
550-500-334 mg/5ml
2
potassium citrate & citric acid
powder pack 3300-1002 mg
potassium citrate & citric acid
soln 1100-334 mg/5ml
potassium citrate tab cr 5 meq
(540 mg) (Urocit-k 5)
(1080 mg) (Urocit-k 10)
(1620 mg) (Urocit-k 15)
ANTIANXIETY AGENTS
2
ALPRAZOLAM INTENSOL alprazolam conc 1 mg/ml
4
2
alprazolam orally disintegrating
tab 0.25 mg (Niravam)
2
2
tab 0.5 mg
PROCYSBI - cysteamine bitartrate
cap delayed release 75 mg (base
equiv)
5
PROSCAR - finasteride tab 5 mg
4
PYRIDIUM - phenazopyridine hcl
tab 100 mg
4
PYRIDIUM - phenazopyridine hcl
tab 200 mg
4
RAPAFLO - silodosin cap 4 mg
4
RAPAFLO - silodosin cap 8 mg
4
SHOHLS SOLUTION MODIFIED sodium citrate & citric acid soln
500-334 mg/5ml
4
sodium chloride irrigation soln
0.9%
1
1
sodium citrate & citric acid soln
500-334 mg/5ml (Shohls solution
modi)
1
tamsulosin hcl cap 0.4 mg
(Flomax)
ACA
Quantity Limits
Restricted Access
Prior Review
•
CENTRAL NERVOUS SYSTEM DRUGS
2
5
• •
UROCIT-K 5 - potassium citrate tab 4
cr 5 meq (540 mg)
UROXATRAL - alfuzosin hcl tab sr 4
24hr 10 mg
1
PROCYSBI - cysteamine bitartrate
cap delayed release 25 mg (base
equiv)
Specialty
Drug Name
Drug Tier
ACA
• •
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
• •
• •
• •
•
•
tab 1 mg
tab 2 mg
2
2
2
alprazolam tab sr 24hr 0.5 mg
(Xanax xr)
1
alprazolam tab sr 24hr 1 mg
(Xanax xr)
1
(Xanax xr)
1
(Xanax xr)
1
alprazolam tab 0.25 mg (Xanax)
1
alprazolam tab 0.5 mg (Xanax)
alprazolam tab 1 mg (Xanax)
alprazolam tab 2 mg (Xanax)
1
1
1
ATIVAN - lorazepam tab 0.5 mg
4
ATIVAN - lorazepam tab 1 mg
4
ATIVAN - lorazepam tab 2 mg
4
buspirone hcl tab 5 mg
1
buspirone hcl tab 7.5 mg
• •
2
1
78
chlordiazepoxide hcl cap 5 mg
clorazepate dipotassium tab
3.75 mg (Tranxene t)
7.5 mg (Tranxene t)
15 mg (Tranxene t)
VALIUM - diazepam tab 2 mg
4
4
4
VISTARIL - hydroxyzine pamoate
cap 25 mg
4
4
1
VISTARIL - hydroxyzine pamoate
cap 50 mg
1
XANAX - alprazolam tab 0.25 mg
4
1
XANAX - alprazolam tab 0.5 mg
4
XANAX - alprazolam tab 1 mg
4
XANAX - alprazolam tab 2 mg
4
1
1
1
1
hydroxyzine pamoate cap 50 mg
(Vistaril)
1
lorazepam conc 2 mg/ml
(Lorazepam intensol)
1
lorazepam tab 0.5 mg (Ativan)
1
1
1
2
2
• •
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Tier
4
1
meprobamate tab 400 mg
ACA
TRANXENE T - clorazepate
dipotassium tab 15 mg
1
hydroxyzine pamoate cap 25 mg
(Vistaril)
meprobamate tab 200 mg
Quantity Limits
4
1
4
lorazepam tab 2 mg (Ativan)
Restricted Access
dipotassium tab 7.5 mg
1
HYDROXYZINE PAMOATE hydroxyzine pamoate cap 100
mg
lorazepam tab 1 mg (Ativan)
1
4
hydroxyzine hcl syrup 10 mg/5ml 1
1
hydroxyzine hcl tab 10 mg
1
dipotassium tab 3.75 mg
2
oxazepam cap 30 mg
1
diazepam conc 5 mg/ml
diazepam tab 10 mg (Valium)
Drug Name
oxazepam cap 15 mg
1
4
Prior Review
1
DIAZEPAM - diazepam oral soln 1
mg/ml
Specialty
Drug Name
Drug Tier
2016
XANAX XR - alprazolam tab sr 24hr 4
0.5 mg
1 mg
2 mg
3 mg
ANTIDEPRESSANTS
amitriptyline hcl tab 10 mg
NIRAVAM - alprazolam orally
disintegrating tab 0.25 mg
4
AMOXAPINE - amoxapine tab 25
mg
oxazepam cap 10 mg
1
mg
1
1
1
1
1
1
4
• •
4
• •
79
mg
4
mg
4
ANAFRANIL - clomipramine hcl cap 4
25 mg
50 mg
75 mg
4
APLENZIN - bupropion hbr tab sr
24hr 174 mg
4
24hr 348 mg
4
24hr 522 mg
1
bupropion hcl tab sr 12hr
100 mg (Wellbutrin sr)
1
1
1
150 mg (Wellbutrin xl)
1
300 mg (Wellbutrin xl)
1
bupropion hcl tab 75 mg
(Wellbutrin)
1
bupropion hcl tab 100 mg
(Wellbutrin)
CELEXA - citalopram hydrobromide 4
2
citalopram hydrobromide oral
soln 10 mg/5ml
1
citalopram hydrobromide tab
10 mg (base equiv) (Celexa)
•
•
•
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
1
1
clomipramine hcl cap 25 mg
(Anafranil)
2
(Anafranil)
2
(Anafranil)
2
CYMBALTA - duloxetine hcl enteric
coated pellets cap 20 mg
4
4
4
desipramine hcl tab 10 mg
(Norpramin)
2
(Norpramin)
2
(Norpramin)
2
(Norpramin)
2
(Norpramin)
2
(Norpramin)
2
DESVENLAFAXINE ER desvenlafaxine fumarate tab sr
24hr 50 mg (base equiv)
4
•
DESVENLAFAXINE ER desvenlafaxine fumarate tab sr
4
•
DESVENLAFAXINE ER desvenlafaxine tab sr 24hr 50 mg
4
•
DESVENLAFAXINE ER desvenlafaxine tab sr 24hr 100
mg
4
•
DOXEPIN HCL - doxepin hcl cap 75 4
mg
80
doxepin hcl cap 10 mg
doxepin hcl conc 10 mg/ml
1
1
1
1
1
1
•
•
FETZIMA - levomilnacipran hcl cap
sr 24hr 120 mg (base equivalent)
4
•
FETZIMA TITRATION PACK levomilnacipran hcl cap sr 24hr
20 & 40 mg therapy pack
4
•
•
2
FLUOXETINE HCL - fluoxetine hcl
tab 60 mg
4
2
fluoxetine hcl cap delayed
release 90 mg (Prozac weekly)
2
fluoxetine hcl cap 10 mg (Prozac) 1
2
4
EFFEXOR XR - venlafaxine hcl cap 4
EFFEXOR XR - venlafaxine hcl cap 4
ELAVIL - amitriptyline hcl tab 25 mg 4
1
fluoxetine hcl solution
20 mg/5ml
1
fluoxetine hcl tab 10 mg
fluoxetine hcl tab 20 mg
fluvoxamine maleate cap sr 24hr
100 mg
EMSAM - selegiline td patch 24hr 6
mg/24hr
4
• •
fluvoxamine maleate cap sr 24hr
150 mg
EMSAM - selegiline td patch 24hr 9
mg/24hr
4
• •
fluvoxamine maleate tab 25 mg
EMSAM - selegiline td patch 24hr
12 mg/24hr
4
• •
escitalopram oxalate soln
(Lexapro)
2
escitalopram oxalate tab 5 mg
(base equiv) (Lexapro)
1
1
1
4
4
ACA
Quantity Limits
•
duloxetine hcl enteric coated
pellets cap 20 mg (Cymbalta)
EFFEXOR XR - venlafaxine hcl
cap sr 24hr 37.5 mg (base
equivalent)
Restricted Access
4
4
Prior Review
DULOXETINE HCL - duloxetine hcl
enteric coated pellets cap 40 mg
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
1
2
2
1
1
1
FORFIVO XL - bupropion hcl tab sr
24hr 450 mg
4
imipramine hcl tab 10 mg
(Tofranil)
1
(Tofranil)
1
(Tofranil)
1
imipramine pamoate cap 75 mg
(Tofranil-pm)
2
(Tofranil-pm)
2
•
81
(Tofranil-pm)
2
NEFAZODONE HCL - nefazodone
hcl tab 150 mg
4
(Tofranil-pm)
2
4
IRENKA - duloxetine hcl enteric
4
•
NEFAZODONE HCL - nefazodone
hcl tab 200 mg
nefazodone hcl tab 50 mg
2
KHEDEZLA - desvenlafaxine tab sr
24hr 50 mg
4
•
KHEDEZLA - desvenlafaxine tab sr
24hr 100 mg
4
•
LEXAPRO - escitalopram oxalate
4
4
4
4
MAPROTILINE HCL - maprotiline
hcl tab 25 mg
4
hcl tab 50 mg
4
hcl tab 75 mg
4
MARPLAN - isocarboxazid tab 10
mg
4
mirtazapine orally disintegrating
tab 15 mg (Remeron soltab)
2
mirtazapine tab 7.5 mg
2
2
1
mirtazapine tab 15 mg (Remeron) 1
NARDIL - phenelzine sulfate tab 15 4
mg
NEFAZODONE HCL - nefazodone 4
hcl tab 100 mg
• •
nefazodone hcl tab 250 mg
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
2
NORPRAMIN - desipramine hcl tab
10 mg
4
NORPRAMIN - desipramine hcl tab
25 mg
4
NORTRIPTYLINE HCL nortriptyline hcl soln 10 mg/5ml
4
nortriptyline hcl cap 10 mg
(Pamelor)
1
(Pamelor)
1
(Pamelor)
1
(Pamelor)
1
• •
PAMELOR - nortriptyline hcl cap 10 4
mg
mg
mg
mg
PARNATE - tranylcypromine sulfate 4
tab 10 mg
2
paroxetine hcl tab sr 24hr
12.5 mg (Paxil cr)
paroxetine hcl tab sr 24hr 25 mg 2
(Paxil cr)
2
paroxetine hcl tab sr 24hr
37.5 mg (Paxil cr)
1
paroxetine hcl tab 10 mg (Paxil)
1
1
1
82
4
PAXIL - paroxetine hcl tab 10 mg
4
4
4
4
PAXIL CR - paroxetine hcl tab sr
24hr 12.5 mg
4
24hr 25 mg
4
24hr 37.5 mg
4
PEXEVA - paroxetine mesylate tab
10 mg (base equiv)
4
•
20 mg (base equiv)
4
•
30 mg (base equiv)
4
•
40 mg (base equiv)
4
•
phenelzine sulfate tab 15 mg
(Nardil)
2
PRISTIQ - desvenlafaxine
succinate tab sr 24hr 25 mg
(base equiv)
4
•
(base equiv)
4
•
(base equiv)
4
protriptyline hcl tab 5 mg
2
protriptyline hcl tab 10 mg
sertraline hcl tab 100 mg (Zoloft)
PROZAC - fluoxetine hcl cap 10 mg 4
PROZAC WEEKLY - fluoxetine hcl 4
cap delayed release 90 mg
REMERON - mirtazapine tab 15 mg 4
ACA
Quantity Limits
Restricted Access
1
1
SURMONTIL - trimipramine
maleate cap 25 mg
4
• •
maleate cap 50 mg
4
• •
maleate cap 100 mg
4
• •
TOFRANIL - imipramine hcl tab 10
mg
4
mg
4
mg
4
tranylcypromine sulfate tab
10 mg (Parnate)
2
trazodone hcl tab 50 mg
2
Prior Review
REMERON SOLTAB - mirtazapine 4
orally disintegrating tab 15 mg
sertraline hcl oral conc 20 mg/ml 2
(Zoloft)
1
•
Specialty
Drug Name
Drug Tier
ACA
•
PAXIL - paroxetine hcl oral susp 10
mg/5ml (base equiv)
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
trimipramine maleate cap 25 mg
trimipramine maleate cap 50 mg
trimipramine maleate cap
100 mg
1
1
1
2
2
2
2
TRINTELLIX - vortioxetine hbr tab 5 4
mg (base equiv)
4
TRINTELLIX - vortioxetine hbr tab
10 mg (base equiv)
4
TRINTELLIX - vortioxetine hbr tab
20 mg (base equiv)
•
•
•
83
venlafaxine hcl cap sr 24hr
(Effexor xr)
1
(Effexor xr)
1
(Effexor xr)
1
VENLAFAXINE HCL ER venlafaxine hcl tab sr 24hr 37.5
4
VENLAFAXINE HCL ER venlafaxine hcl tab sr 24hr 75 mg
(base equivalent)
4
VENLAFAXINE HCL ER venlafaxine hcl tab sr 24hr 150
4
VENLAFAXINE HCL ER venlafaxine hcl tab sr 24hr 225
4
venlafaxine hcl tab sr 24hr
(Venlafaxine hcl er)
2
venlafaxine hcl tab 50 mg
WELLBUTRIN SR - bupropion hcl
tab sr 12hr 100 mg
4
tab sr 12hr 150 mg
4
tab sr 12hr 200 mg
4
WELLBUTRIN XL - bupropion hcl
tab sr 24hr 150 mg
4
WELLBUTRIN XL - bupropion hcl
tab sr 24hr 300 mg
4
ZOLOFT - sertraline hcl oral conc
20 mg/ml
4
ZOLOFT - sertraline hcl tab 25 mg
4
ZOLOFT - sertraline hcl tab 50 mg
4
ANTIPSYCHOTICS
ABILIFY - aripiprazole tab 2 mg
4
4
4
4
4
4
aripiprazole oral solution 1 mg/
ml
2
aripiprazole orally disintegrating
tab 10 mg
aripiprazole orally disintegrating
tab 15 mg
aripiprazole tab 2 mg (Abilify)
1
1
1
1
VIIBRYD - vilazodone hcl tab 10 mg 4
4
VIIBRYD STARTER PACK vilazodone hcl tab starter kit 10
(7) & 20 (23) mg
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Tier
ACA
Drug Name
ZOLOFT - sertraline hcl tab 100 mg 4
venlafaxine hcl tab sr 24hr 75 mg 2
(base equivalent) (Venlafaxine
hcl er)
2
venlafaxine hcl tab sr 24hr
(Venlafaxine hcl er)
1
venlafaxine hcl tab 37.5 mg
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
•
•
•
chlorpromazine hcl tab 10 mg
•
•
•
•
•
•
•
2
2
2
2
2
2
2
2
•
•
•
•
•
•
2
2
2
2
84
2
CLOZAPINE ODT - clozapine orally 4
2
clozapine orally disintegrating
tab 25 mg (Fazaclo)
2
clozapine orally disintegrating
tab 100 mg (Fazaclo)
2
clozapine tab 25 mg (Clozaril)
clozapine tab 50 mg
clozapine tab 100 mg (Clozaril)
clozapine tab 200 mg
• • •
• • •
• • •
•
•
2
2
2
•
•
•
•
•
•
CLOZARIL - clozapine tab 25 mg
4
CLOZARIL - clozapine tab 100 mg
4
EQUETRO - carbamazepine
(antipsychotic) cap sr 12hr 100
mg
4
mg
4
• •
mg
4
• •
FANAPT - iloperidone tab 2 mg
4
4
4
4
4
4
FANAPT TITRATION PACK iloperidone tab 1 mg & 2 mg & 4
mg & 6 mg titration pak
4
•
•
•
•
•
•
•
FAZACLO - clozapine orally
4
• • •
4
•
• •
•
•
•
•
•
•
•
4
•
4
• • •
4
• • •
FLUPHENAZINE HCL fluphenazine hcl elixir 2.5 mg/5ml
4
• •
FLUPHENAZINE HCL fluphenazine hcl oral conc 5 mg/
ml
4
• •
fluphenazine hcl tab 1 mg
1
fluphenazine hcl tab 2.5 mg
1
1
1
GEODON - ziprasidone hcl cap 20
mg
4
•
mg
4
•
mg
4
•
mg
4
•
haloperidol lactate oral conc
2 mg/ml
2
haloperidol tab 0.5 mg
haloperidol tab 1 mg
1
1
1
1
1
2
4
•
INVEGA - paliperidone tab sr 24hr 3 4
mg
mg
mg
LATUDA - lurasidone hcl tab 20 mg 4
•
INVEGA - paliperidone tab sr 24hr
1.5 mg
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
•
• •
85
2
•
paliperidone tab sr 24hr 6 mg
(Invega)
2
•
(Invega)
2
•
perphenazine tab 2 mg
2
4
LATUDA - lurasidone hcl tab 120
mg
4
LITHIUM - lithium oral solution 8
meq/5ml
4
LITHIUM CARBONATE - lithium
carbonate cap 150 mg
4
LITHIUM CARBONATE - lithium
carbonate cap 600 mg
4
paliperidone tab sr 24hr 1.5 mg
(Invega)
lithium carbonate cap 150 mg
(Lithium carbonate)
1
1
lithium carbonate tab cr 450 mg
1
lithium carbonate tab 300 mg
olanzapine tab 2.5 mg (Zyprexa)
olanzapine tab 5 mg (Zyprexa)
olanzapine tab 7.5 mg (Zyprexa)
1
LITHOBID - lithium carbonate tab cr 4
300 mg
1
loxapine succinate cap 5 mg
1
2
2
MOLINDONE HYDROCHLORIDE - 4
molindone hcl tab 5 mg
NUPLAZID - pimavanserin tartrate 5
2
olanzapine orally disintegrating
tab 5 mg (Zyprexa zydis)
2
2
• •
• •
• •
• • • •
•
•
•
•
1
1
1
1
1
(Invega)
LATUDA - lurasidone hcl tab 80 mg
ACA
2
•
•
•
•
•
•
•
4
1
Quantity Limits
1
lithium carbonate tab cr 300 mg
(Lithobid)
Restricted Access
•
4
1
Prior Review
2
(Lithium carbonate)
Specialty
Drug Name
Drug Tier
•
•
•
•
ACA
•
•
•
•
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
2
2
2
prochlorperazine maleate
(Compazine)
1
prochlorperazine maleate tab
(Compazine)
1
prochlorperazine suppos 25 mg
2
quetiapine fumarate tab 25 mg
(Seroquel)
1
•
(Seroquel)
1
•
(Seroquel)
1
•
(Seroquel)
1
•
(Seroquel)
1
•
(Seroquel)
1
•
86
REXULTI - brexpiprazole tab 2 mg
4
4
4
•
•
•
•
RISPERDAL - risperidone soln 1
mg/ml
4
RISPERDAL - risperidone tab 0.25
mg
4
•
RISPERDAL - risperidone tab 0.5
mg
4
•
RISPERDAL - risperidone tab 1 mg
4
4
4
4
RISPERDAL M-TAB - risperidone
orally disintegrating tab 0.5 mg
4
•
•
•
•
•
4
•
•
•
•
•
1
•
risperidone tab 0.25 mg
(Risperdal)
1
•
risperidone tab 0.5 mg
(Risperdal)
1
•
risperidone tab 1 mg (Risperdal)
1
SAPHRIS - asenapine maleate sl
4
•
•
•
•
• •
4
• •
4
• •
SEROQUEL - quetiapine fumarate
tab 25 mg
4
•
tab 50 mg
4
•
•
tab 100 mg
4
•
4
•
tab 200 mg
4
•
4
•
tab 300 mg
4
•
4
•
tab 400 mg
4
•
risperidone orally disintegrating
tab 0.25 mg
2
•
SEROQUEL XR - quetiapine
fumarate tab sr 24hr 50 mg
4
• •
2
•
4
• •
2
•
4
• •
2
•
4
• •
2
•
4
• •
2
•
thioridazine hcl tab 10 mg
1
tab 0.5 mg (Risperdal m-tab)
tab 1 mg (Risperdal m-tab)
1
1
1
4
risperidone soln 1 mg/ml
(Risperdal)
ACA
Quantity Limits
• •
Restricted Access
4
Prior Review
REXULTI - brexpiprazole tab 0.5
mg
Specialty
• •
Drug Name
Drug Tier
4
REXULTI - brexpiprazole tab 0.25
mg
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
1
87
thiothixene cap 1 mg
trifluoperazine hcl tab 1 mg
1
1
1
1
2
2
2
2
4
•
ZYPREXA ZYDIS - olanzapine
4
•
4
•
AMBIEN - zolpidem tartrate tab 5
mg
4
AMBIEN - zolpidem tartrate tab 10
mg
4
VERSACLOZ - clozapine susp 50
mg/ml
4
• • •
AMBIEN CR - zolpidem tartrate tab
cr 6.25 mg
4
VRAYLAR - cariprazine hcl cap
therapy pack 1.5 mg (1) & 3 mg
(6)
4
• •
AMBIEN CR - zolpidem tartrate tab
cr 12.5 mg
4
4
VRAYLAR - cariprazine hcl cap 1.5
4
• •
BELSOMRA - suvorexant tab 5 mg
4
VRAYLAR - cariprazine hcl cap 3
4
• •
BELSOMRA - suvorexant tab 10
mg
• •
• •
4
• •
VRAYLAR - cariprazine hcl cap 4.5
4
• •
mg
4
• •
VRAYLAR - cariprazine hcl cap 6
4
• •
mg
4
• •
ziprasidone hcl cap 20 mg
(Geodon)
2
•
BUTISOL SODIUM - butabarbital
sodium tab 30 mg
DORAL - quazepam tab 15 mg
4
(Geodon)
2
•
• •
• •
(Geodon)
2
•
(Geodon)
2
•
ZYPREXA - olanzapine tab 2.5 mg
4
ZYPREXA - olanzapine tab 5 mg
4
ZYPREXA - olanzapine tab 7.5 mg
4
4
4
4
4
•
•
•
•
•
•
•
EDLUAR - zolpidem tartrate sl tab 5 4
mg
4
EDLUAR - zolpidem tartrate sl tab
10 mg
1
estazolam tab 1 mg
estazolam tab 2 mg
eszopiclone tab 1 mg (Lunesta)
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Tier
Drug Name
HYPNOTICS
1
1
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
1
1
1
1
FLURAZEPAM HCL - flurazepam
hcl cap 15 mg
4
FLURAZEPAM HCL - flurazepam
hcl cap 30 mg
4
HALCION - triazolam tab 0.25 mg
4
88
HETLIOZ - tasimelteon capsule 20
mg
5
INTERMEZZO - zolpidem tartrate sl 4
tab 1.75 mg
INTERMEZZO - zolpidem tartrate sl 4
tab 3.5 mg
4
LUNESTA - eszopiclone tab 1 mg
4
4
PHENOBARBITAL - phenobarbital
tab 15 mg
4
tab 30 mg
4
tab 60 mg
4
tab 100 mg
4
phenobarbital elixir 20 mg/5ml
2
phenobarbital tab 16.2 mg
4
temazepam cap 7.5 mg (Restoril)
2
• •
SECONAL SODIUM - secobarbital
sodium cap 100 mg
4
• •
• •
SILENOR - doxepin hcl (sleep) tab
3 mg (base equiv)
4
• •
SILENOR - doxepin hcl (sleep) tab
6 mg (base equiv)
4
• •
SONATA - zaleplon cap 5 mg
4
ACA
Quantity Limits
Restricted Access
Prior Review
ACA
Specialty
1
temazepam cap 22.5 mg
(Restoril)
2
temazepam cap 30 mg (Restoril)
1
TRIAZOLAM - triazolam tab 0.125
mg
4
triazolam tab 0.25 mg (Halcion)
1
zaleplon cap 10 mg (Sonata)
1
Drug Tier
SONATA - zaleplon cap 10 mg
zaleplon cap 5 mg (Sonata)
1
QUAZEPAM - quazepam tab 15 mg 4
4
RESTORIL - temazepam cap 7.5
mg
4
RESTORIL - temazepam cap 15
mg
RESTORIL - temazepam cap 22.5 4
mg
4
RESTORIL - temazepam cap 30
mg
4
ROZEREM - ramelteon tab 8 mg
•
Drug Name
temazepam cap 15 mg (Restoril)
1
1
Quantity Limits
•
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
1
1
zolpidem tartrate sl tab 1.75 mg
(Intermezzo)
2
zolpidem tartrate sl tab 3.5 mg
(Intermezzo)
2
zolpidem tartrate tab cr 6.25 mg
(Ambien cr)
2
zolpidem tartrate tab cr 12.5 mg
(Ambien cr)
2
zolpidem tartrate tab 5 mg
(Ambien)
1
zolpidem tartrate tab 10 mg
(Ambien)
1
ZOLPIMIST - zolpidem tartrate oral
spray 5 mg/act
4
• •
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/
ANOREXIANTS
4
ADDERALL - amphetaminedextroamphetamine tab 5 mg
4
ADDERALL - amphetaminedextroamphetamine tab 7.5 mg
4
4
ADDERALL - amphetaminedextroamphetamine tab 12.5 mg
4
4
•
•
•
•
•
•
89
ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr
15 mg
2
20 mg
2
25 mg
2
30 mg
2
ADIPEX-P - phentermine hcl cap
37.5 mg
4
ADIPEX-P - phentermine hcl tab
37.5 mg
4
ADZENYS XR-ODT - amphetamine 4
tab extended release dispersible
3.1 mg
6.3 mg
9.4 mg
12.5 mg
15.7 mg
18.8 mg
•
•
•
•
•
amphetaminedextroamphetamine cap sr
24hr 15 mg (Adderall xr)
•
•
2
•
•
2
•
•
2
•
•
2
•
•
2
•
•
amphetaminedextroamphetamine tab 5 mg
(Adderall)
2
•
amphetaminedextroamphetamine tab 7.5 mg
(Adderall)
2
•
• • •
(Adderall)
2
•
• • •
amphetaminedextroamphetamine tab
12.5 mg (Adderall)
2
•
• • •
(Adderall)
2
•
• • •
(Adderall)
2
•
• • •
(Adderall)
2
•
• • •
APTENSIO XR - methylphenidate
hcl cap er 24hr 10 mg (xr)
4
• • •
4
• • •
•
•
2
2
ACA
10 mg
Quantity Limits
•
Restricted Access
2
Prior Review
5 mg
Specialty
•
Drug Name
Drug Tier
4
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
90
• • •
4
• • •
4
• • •
ARMODAFINIL - armodafinil tab
200 mg
2
•
•
armodafinil tab 50 mg (Nuvigil)
2
•
•
•
•
•
•
•
•
•
2
2
BELVIQ - lorcaserin hcl tab 10 mg
4
benzphetamine hcl tab 25 mg
2
benzphetamine hcl tab 50 mg
caffeine citrate oral soln
60 mg/3ml (10 mg/ml base
equiv)
2
4
• • •
DESOXYN - methamphetamine hcl
tab 5 mg
4
•
DEXEDRINE - dextroamphetamine
sulfate cap sr 24hr 5 mg
4
•
4
•
4
•
dexmethylphenidate hcl cap sr
24 hr 5 mg (Focalin xr)
2
•
2
•
2
•
2
•
2
•
2
•
1
•
1
•
2
•
2
•
2
•
2
•
2
•
2
•
2
•
2
clonidine hcl tab sr 12hr 0.1 mg
(Kapvay)
2
•
CONCERTA - methylphenidate hcl
tab sa osm 18 mg
3
•
tab sa osm 27 mg
3
•
tab sa osm 36 mg
3
•
tab sa osm 54 mg
3
•
CONTRAVE - naltrexone hclbupropion hcl tab sr 12hr 8-90
mg
4
•
DAYTRANA - methylphenidate td
patch 10 mg/9hr
4
• • •
dextroamphetamine sulfate oral
solution 5 mg/5ml (Procentra)
patch 15 mg/9hr
4
• • •
dextroamphetamine sulfate tab
5 mg
patch 20 mg/9hr
4
• • •
dextroamphetamine sulfate tab
10 mg
dexmethylphenidate hcl tab
2.5 mg (Focalin)
5 mg (Focalin)
10 mg (Focalin)
dextroamphetamine sulfate cap
sr 24hr 5 mg (Dexedrine)
4
patch 30 mg/9hr
ACA
Quantity Limits
• • •
Restricted Access
4
Prior Review
Specialty
• • •
Drug Name
Drug Tier
4
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
91
•
DYANAVEL XR - amphetamine
extended release susp 2.5 mg/ml
4
• • •
EVEKEO - amphetamine sulfate tab 4
5 mg
EVEKEO - amphetamine sulfate tab 4
10 mg
FOCALIN - dexmethylphenidate hcl 4
tab 2.5 mg
tab 5 mg
tab 10 mg
FOCALIN XR - dexmethylphenidate 4
hcl cap sr 24 hr 5 mg
2
guanfacine hcl tab sr 24hr 1 mg
(base equiv) (Intuniv)
2
2
• • •
•
INTUNIV - guanfacine hcl tab sr
4
•
4
•
4
•
4
•
• • •
KAPVAY - clonidine hcl tab sr 12hr
0.1 mg
4
•
•
METADATE CD - methylphenidate
hcl cap cr 10 mg (cd)
4
•
•
4
•
•
4
•
•
4
•
•
4
•
•
4
•
•
methamphetamine hcl tab 5 mg
(Desoxyn)
2
•
METHYLIN - methylphenidate hcl
chew tab 2.5 mg
4
•
•
chew tab 5 mg
4
•
•
chew tab 10 mg
4
•
•
soln 5 mg/5ml
4
•
•
soln 10 mg/5ml
4
•
•
methylphenidate hcl cap cr
10 mg (cd) (Metadate cd)
2
•
•
2
•
•
1
2
ACA
diethylpropion hcl tab 25 mg
(Diethylpropion hcl)
Quantity Limits
•
Restricted Access
1
Prior Review
diethylpropion hcl tab sr 24hr
75 mg
Specialty
•
Drug Name
Drug Tier
4
DIETHYLPROPION HCL diethylpropion hcl tab 25 mg
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
92
•
2
•
2
•
2
•
methylphenidate hcl tab 5 mg
(Ritalin)
1
•
(Ritalin)
1
•
•
(Ritalin)
2
•
•
2
2
modafinil tab 100 mg (Provigil)
modafinil tab 200 mg (Provigil)
METHYLPHENIDATE HCL ER methylphenidate hcl tab sa osm
18 mg
3
•
27 mg
3
36 mg
3
54 mg
3
METHYLPHENIDATE HCL ER methylphenidate hcl tab sr 24hr
18 mg
3
27 mg
3
•
36 mg
3
•
methylphenidate hcl cap sr 24hr
20 mg (la) (Ritalin la)
methylphenidate hcl chew tab
2.5 mg (Methylin)
5 mg (Methylin)
10 mg (Methylin)
2
2
2
2
2
2
2
•
•
•
•
•
•
methylphenidate hcl soln
10 mg/5ml (Methylin)
methylphenidate hcl tab cr
10 mg
methylphenidate hcl tab cr
20 mg
NUVIGIL - armodafinil tab 50 mg
4
4
4
4
4
•
PHENDIMETRAZINE TARTRATE phendimetrazine tartrate cap sr
24hr 105 mg
•
•
•
•
•
•
•
1
•
•
phendimetrazine tartrate tab
35 mg (Bontril pdm)
phentermine hcl cap 15 mg
1
•
phentermine hcl cap 37.5 mg
(Adipex-p)
1
•
•
•
phentermine hcl tab 37.5 mg
(Adipex-p)
1
•
phentermine hcl cap 30 mg
•
2
1
PROCENTRA - dextroamphetamine 4
sulfate oral solution 5 mg/5ml
4
PROVIGIL - modafinil tab 100 mg
PROVIGIL - modafinil tab 200 mg
4
2
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
methylphenidate hcl soln
5 mg/5ml (Methylin)
•
Drug Tier
•
2
3
•
Drug Name
54 mg
2
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
•
•
•
•
•
•
•
•
•
•
93
4
•
STRATTERA - atomoxetine hcl cap
10 mg (base equiv)
4
• • •
4
•
18 mg (base equiv)
4
• • •
QSYMIA - phentermine hcltopiramate cap sr 24hr 15-92 mg
4
•
25 mg (base equiv)
4
• • •
QUILLICHEW ER methylphenidate hcl chew tab
extended release 20 mg
4
• • •
40 mg (base equiv)
4
• • •
60 mg (base equiv)
4
• • •
4
• • •
80 mg (base equiv)
4
• • •
4
• • •
100 mg (base equiv)
4
• • •
VYVANSE - lisdexamfetamine
dimesylate cap 10 mg
4
• • •
QUILLIVANT XR - methylphenidate
hcl for er susp 25 mg/5ml (5 mg/
ml)
4
• • •
4
• • •
REGIMEX - benzphetamine hcl tab
25 mg
4
•
4
• • •
RITALIN - methylphenidate hcl tab
5 mg
4
•
4
• • •
10 mg
4
•
4
• • •
20 mg
4
•
4
• • •
RITALIN LA - methylphenidate hcl
cap sr 24hr 10 mg (la)
4
•
4
• • •
4
•
XENICAL - orlistat cap 120 mg
4
4
• • •
4
ZENZEDI - dextroamphetamine
sulfate tab 2.5 mg
4
4
• • •
sulfate tab 7.5 mg
4
4
• • •
sulfate tab 15 mg
sulfate tab 20 mg
4
• • •
•
•
•
SAXENDA - liraglutide (weight
management) soln pen-injector
18 mg/3ml
ACA
QSYMIA - phentermine hcltopiramate cap sr 24hr 11.25-69
mg
Quantity Limits
•
Restricted Access
4
Prior Review
QSYMIA - phentermine hcltopiramate cap sr 24hr 7.5-46 mg
Specialty
•
Drug Name
Drug Tier
4
QSYMIA - phentermine hcltopiramate cap sr 24hr 3.75-23
mg
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
94
sulfate tab 30 mg
4
PSYCHOTHERAPEUTIC and NEUROLOGICAL AGENTS
- MISC.
2
acamprosate calcium tab
4
•
•
ADDYI - flibanserin tab 100 mg
AMPYRA - dalfampridine tab sr
12hr 10 mg
5
• •
•
•
ANTABUSE - disulfiram tab 250 mg 4
ANTABUSE - disulfiram tab 500 mg 4
ARICEPT - donepezil hydrochloride 4
tab 5 mg
tab 10 mg
tab 23 mg
AUBAGIO - teriflunomide tab 7 mg 5
AUBAGIO - teriflunomide tab 14 mg 5
AVONEX - interferon beta-1a for im 5
inj kit 30mcg (33mcg(6.6 mu)/
vial)
5
AVONEX - interferon beta-1a im
prefilled syringe kit 30 mcg/0.5ml
AVONEX PEN - interferon beta-1a 5
im auto-injector kit 30 mcg/0.5ml
5
BETASERON - interferon beta-1b
for inj kit 0.3 mg
BRISDELLE - paroxetine mesylate 4
cap 7.5 mg (base equiv)
A
bupropion hcl (smoking
deterrent) tab sr 12hr 150 mg
(Zyban)
CHANTIX - varenicline tartrate tab A
0.5 mg (base equiv)
CHANTIX - varenicline tartrate tab 1 A
mg (base equiv)
CHANTIX CONTINUING MONTH - A
varenicline tartrate tab 1 mg
(base equiv)
• • • •
• • • •
• • • •
•
•
• • • •
• • • •
• •
•
• •
•
•
•
•
CHANTIX STARTING MONTH PA - A
varenicline tartrate tab 0.5 mg x
11 & tab 1 mg x 42 pack
CHLORDIAZEPOXIDE/AMITRIPT - 4
chlordiazepoxide-amitriptyline tab
5-12.5 mg
CHLORDIAZEPOXIDE/AMITRIPT - 4
chlordiazepoxide-amitriptyline tab
10-25 mg
A
COMMIT - nicotine polacrilex
lozenge 2 mg
A
COMMIT - nicotine polacrilex
lozenge 4 mg
5
COPAXONE - glatiramer acetate
5
COPAXONE - glatiramer acetate
disulfiram tab 250 mg (Antabuse) 2
•
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
• • •
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
• •
•
•
• •
•
• •
•
disulfiram tab 500 mg (Antabuse) 2
1
donepezil hydrochloride orally
1
donepezil hydrochloride orally
1
donepezil hydrochloride tab
5 mg (Aricept)
1
10 mg (Aricept)
2
23 mg (Aricept)
ERGOLOID MESYLATES - ergoloid 4
mesylates tab 1 mg
EXELON - rivastigmine tartrate cap 4
1.5 mg
3 mg
4.5 mg
6 mg
4
EXELON - rivastigmine td patch
24hr 4.6 mg/24hr
95
24hr 9.5 mg/24hr
4
24hr 13.3 mg/24hr
4
EXTAVIA - interferon beta-1b for inj
kit 0.3 mg
5
FLUOXETINE - fluoxetine hcl
(pmdd) cap 10 mg
2
FLUOXETINE - fluoxetine hcl
(pmdd) cap 20 mg
memantine hcl oral solution
2 mg/ml (Namenda)
2
memantine hcl tab 10 mg
(Namenda)
2
2
2
memantine hcl tab 5 mg (28)
& 10 mg (21) titration pak
(Namenda titration pa)
4
GALANTAMINE
HYDROBROMIDE - galantamine
hydrobromide oral soln 4 mg/ml
4
NAMENDA - memantine hcl oral
solution 2 mg/ml
NAMENDA - memantine hcl tab 5
mg
4
galantamine hydrobromide cap
sr 24hr 8 mg (Razadyne er)
2
NAMENDA - memantine hcl tab 10
mg
4
2
NAMENDA TITRATION PAK memantine hcl tab 5 mg (28) &
10 mg (21) titration pak
4
galantamine hydrobromide tab
4 mg (Razadyne)
8 mg (Razadyne)
12 mg (Razadyne)
2
2
2
2
GILENYA - fingolimod hcl cap 0.5
mg (base equiv)
5
• • • •
glatiramer acetate soln prefilled
syringe 20 mg/ml (Copaxone)
5
• •
•
GRALISE - gabapentin (once-daily)
tab 300 mg
4
• • •
GRALISE - gabapentin (once-daily)
tab 600 mg
4
• • •
GRALISE STARTER - gabapentin
(once-daily) tab pack 300 mg (9)
& 600 mg (69)
4
• • •
HORIZANT - gabapentin enacarbil
tab cr 300 mg
4
• • •
HORIZANT - gabapentin enacarbil
tab cr 600 mg
4
• • •
•
ACA
Quantity Limits
Restricted Access
Prior Review
2
memantine hcl tab 5 mg
(Namenda)
• • • •
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
NAMENDA XR - memantine hcl cap 4
sr 24hr 7 mg
sr 24hr 14 mg
sr 24hr 21 mg
sr 24hr 28 mg
NAMENDA XR TITRATION PACK - 4
memantine hcl cap sr 24hr 7 mg
& 14 mg & 21 mg & 28 mg pack
4
NAMZARIC - memantine hcldonepezil hcl cap sr 24hr 14-10
mg
4
NAMZARIC - memantine hcldonepezil hcl cap sr 24hr 28-10
mg
NICODERM CQ - nicotine td patch A
24hr 7 mg/24hr
24hr 14 mg/24hr
24hr 21 mg/24hr
• •
• •
• •
• •
• •
•
•
•
96
A
•
NICORETTE - nicotine polacrilex
lozenge 4 mg
A
•
NICORETTE MINI - nicotine
polacrilex lozenge 2 mg
A
•
NICORETTE MINI - nicotine
polacrilex lozenge 4 mg
A
•
NICORETTE STARTER KIT nicotine polacrilex gum 2 mg
A
•
NICORETTE STARTER KIT nicotine polacrilex gum 4 mg
A
•
nicotine polacrilex gum 2 mg
A
•
•
•
•
•
•
nicotine polacrilex gum 4 mg
nicotine polacrilex lozenge 2 mg
nicotine polacrilex lozenge 4 mg
nicotine td patch 24hr 7 mg/24hr
nicotine td patch 24hr
14 mg/24hr
A
A
A
A
A
olanzapine-fluoxetine hcl cap
12-50 mg (Symbyax)
lozenge 2 mg
12-25 mg (Symbyax)
ACA
•
Quantity Limits
A
Restricted Access
gum 4 mg
6-50 mg (Symbyax)
Prior Review
•
Specialty
A
Drug Name
Drug Tier
gum 2 mg
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
2
2
2
ORAP - pimozide tab 1 mg
4
ORAP - pimozide tab 2 mg
4
PERPHENAZINE/AMITRIPTYLIN perphenazine-amitriptyline tab
2-10 mg
4
• •
2-25 mg
4
• •
4-10 mg
4
• •
4-25 mg
4
• •
4-50 mg
4
• •
pimozide tab 1 mg (Orap)
2
A
•
A
•
PLEGRIDY - peginterferon beta-1a
soln pen-injector 125 mcg/0.5ml
5
NICOTINE TRANSDERMAL
SYST - nicotine td patch 24 hr kit
21-14-7 mg/24hr
• •
•
•
5
• •
•
•
NICOTROL INHALER - nicotine
inhaler system 10 mg (4 mg
delivered)
A
•
PLEGRIDY - peginterferon beta-1a
soln prefilled syringe 125
mcg/0.5ml
5
• •
•
•
NICOTROL NS - nicotine nasal
spray 10 mg/ml (0.5 mg/spray)
A
•
PLEGRIDY STARTER PACK peginterferon beta-1a soln peninj 63 & 94 mcg/0.5ml pack
5
5
NUEDEXTA - dextromethorphan
hbr-quinidine sulfate cap 20-10
mg
PLEGRIDY STARTER PACK peginterferon beta-1a soln pref
syr 63 & 94 mcg/0.5ml pack
• •
•
•
2
RAZADYNE - galantamine
hydrobromide tab 4 mg
4
3-25 mg (Symbyax)
2
4
4
nicotine td patch 24hr
21 mg/24hr
6-25 mg (Symbyax)
•
pimozide tab 2 mg (Orap)
2
97
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
RAZADYNE ER - galantamine
hydrobromide cap sr 24hr 8 mg
4
SAVELLA - milnacipran hcl tab 25
mg
4
• •
4
mg
4
• •
4
mg
4
• •
SAVELLA TITRATION PACK milnacipran hcl tab 12.5 mg (5) &
25 mg (8) & 50 mg (42) pak
4
• •
SYMBYAX - olanzapine-fluoxetine
hcl cap 3-25 mg
4
hcl cap 6-25 mg
4
hcl cap 6-50 mg
4
hcl cap 12-25 mg
4
hcl cap 12-50 mg
4
TECFIDERA - dimethyl fumarate
capsule delayed release 120 mg
5
• •
•
•
TECFIDERA - dimethyl fumarate
capsule delayed release 240 mg
5
• •
•
•
TECFIDERA STARTER PACK dimethyl fumarate capsule dr
starter pack 120 mg & 240 mg
5
• •
•
•
tetrabenazine tab 12.5 mg
(Xenazine)
5
• •
tetrabenazine tab 25 mg
(Xenazine)
5
• •
XENAZINE - tetrabenazine tab 12.5 5
mg
5
XENAZINE - tetrabenazine tab 25
mg
5
XYREM - sodium oxybate oral
solution 500 mg/ml
5
ZINBRYTA - daclizumab soln
prefilled syringe 150 mg/ml
A
ZYBAN - bupropion hcl (smoking
deterrent) tab sr 12hr 150 mg
• •
•
• •
•
• •
•
• • • •
•
REBIF - interferon beta-1a soln pref 5
syr 22 mcg/0.5ml (12mu/ml)
REBIF - interferon beta-1a soln pref 5
syr 44 mcg/0.5ml (24mu/ml)
5
REBIF REBIDOSE - interferon
beta-1a soln auto-inj 22
mcg/0.5ml (12mu/ml)
5
REBIF REBIDOSE - interferon
beta-1a soln auto-inj 44
mcg/0.5ml (24mu/ml)
5
REBIF REBIDOSE TITRATION interferon beta-1a auto-inj 6x8.8
mcg/0.2ml & 6x22 mcg/0.5ml
5
REBIF TITRATION PACK interferon beta-1a pref syr 6x8.8
mcg/0.2ml & 6x22 mcg/0.5ml
2
rivastigmine tartrate cap 1.5 mg
(Exelon)
2
rivastigmine tartrate cap 3 mg
(Exelon)
2
rivastigmine tartrate cap 4.5 mg
(Exelon)
2
rivastigmine tartrate cap 6 mg
(Exelon)
2
rivastigmine td patch 24hr
4.6 mg/24hr (Exelon)
2
2
4
SARAFEM - fluoxetine hcl (pmdd)
tab 10 mg
4
SARAFEM - fluoxetine hcl (pmdd)
tab 20 mg
SAVELLA - milnacipran hcl tab 12.5 4
mg
• •
•
• •
•
• •
•
• •
•
• •
•
• •
• •
• •
• •
•
•
ANALGESICS AND ANESTHETICS
98
ANALGESICS - NON-NARCOTIC
acetaminophen-salicylamidephenyltoloxamine cap
300-200-20mg
4
aspirin chew tab 81 mg
A
aspirin tab delayed release
325 mg
aspirin tab 325 mg
• •
A
•
•
A
•
A
• •
•
FIORICET - butalbitalacetaminophen-caffeine cap
50-300-40 mg
4
FIORINAL - butalbital-aspirincaffeine cap 50-325-40 mg
4
LEVACET - aspirin-apapsalicylamide-caffeine tab
500-250-150-32.5 mg
4
salsalate tab 500 mg (Disalcid)
2
salsalate tab 750 mg (Disalcid)
VANATOL LQ - butalbitalacetaminophen-caffeine soln
50-325-40 mg/15ml
2
4
• •
4
butalbital-acetaminophen tab
50-325 mg
1
ABSTRAL - fentanyl citrate sl tab
100 mcg (base equiv)
5
• • •
butalbital-acetaminophencaffeine cap 50-300-40 mg
(Fioricet)
2
5
• • •
5
• • •
butalbital-acetaminophencaffeine cap 50-325-40 mg
2
5
• • •
butalbital-acetaminophencaffeine tab 50-325-40 mg
(Esgic)
1
5
• • •
butalbital-aspirin-caffeine cap
50-325-40 mg (Fiorinal)
2
5
• • •
2
acetaminophen w/ codeine soln
120-12 mg/5ml
1
choline & magnesium salicylates
liq 500 mg/5ml
CHOLINE MAGNESIUM TRISALI choline & magnesium salicylates
tab 1000 mg
4
diflunisal tab 500 mg
2
DISALCID - salsalate tab 500 mg
4
DISALCID - salsalate tab 750 mg
4
ECOTRIN REGULAR STRENGTH - A
aspirin tab delayed release 325
mg
4
EQUAGESIC - meprobamateaspirin tab 200-325 mg
ESGIC - butalbital-acetaminophen- 4
caffeine tab 50-325-40 mg
acetaminophen w/ codeine tab
300-15 mg (Tylenol/codeine)
300-30 mg (Tylenol/codeine #3)
300-60 mg (Tylenol/codeine #4)
•
• •
acetaminophen-caffeinedihydrocodeine cap
320.5-30-16 mg (Trezix)
• •
BUPAP - butalbital-acetaminophen
tab 50-300 mg
ANALGESICS - NARCOTIC
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
2
ALLZITAL - butalbitalacetaminophen tab 25-325 mg
aspirin tab delayed release
81 mg
Specialty
Drug Name
Drug Tier
2016
1
1
1
2
ACTIQ - fentanyl citrate lozenge on
a handle 200 mcg
5
•
•
a handle 400 mcg
5
•
•
99
a handle 1200 mcg
5
•
•
a handle 1600 mcg
5
•
•
ASPIRIN-CAFFEINE-DIHYDROC aspirin-caffeine-dihydrocodeine
cap 356.4-30-16 mg
4
• •
BELBUCA - buprenorphine hcl
buccal film 75 mcg (base
equivalent)
4
• • •
equivalent)
4
• • •
equivalent)
4
• • •
equivalent)
4
• • •
equivalent)
4
• • •
equivalent)
4
• • •
equivalent)
4
• • •
BUNAVAIL - buprenorphinenaloxone buccal film 2.1-0.3 mg
(base equiv)
4
• • •
BUNAVAIL - buprenorphinenaloxone buccal film 4.2-0.7 mg
(base equiv)
4
• • •
BUNAVAIL - buprenorphinenaloxone buccal film 6.3-1 mg
(base equiv)
4
• • •
buprenorphine hcl sl tab 2 mg
(base equiv)
2
•
•
buprenorphine hcl-naloxone hcl
sl tab 2-0.5 mg (base equiv)
buprenorphine hcl-naloxone hcl
sl tab 8-2 mg (base equiv)
•
2
•
•
2
•
•
butalbital-acetaminophen-caff
w/ cod cap 50-300-40-30 mg
(Fioricet/codeine)
2
butalbital-acetaminophen-caff w/
cod cap 50-325-40-30 mg
2
butalbital-aspirin-caff w/ codeine
cap 50-325-40-30 mg (Fiorinal/
codeine #3)
2
butorphanol tartrate nasal soln
10 mg/ml
2
BUTRANS - buprenorphine td patch 4
weekly 5 mcg/hr
weekly 7.5 mcg/hr
weekly 10 mcg/hr
weekly 15 mcg/hr
weekly 20 mcg/hr
4
CAPITAL/CODEINE acetaminophen w/ codeine susp
120-12 mg/5ml
4
CODEINE SULFATE - codeine
sulfate tab 15 mg
4
sulfate tab 30 mg
4
sulfate tab 60 mg
1
codeine sulfate tab 15 mg
(Codeine sulfate)
2
(Codeine sulfate)
2
(Codeine sulfate)
•
•
2
ACA
•
Quantity Limits
5
Restricted Access
a handle 800 mcg
buprenorphine hcl sl tab 8 mg
(base equiv)
Prior Review
•
Specialty
•
Drug Name
Drug Tier
5
a handle 600 mcg
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• • •
• • •
• • •
• • •
• • •
• •
100
• • •
DILAUDID - hydromorphone hcl liqd 4
1 mg/ml
DILAUDID - hydromorphone hcl tab 4
2 mg
4 mg
8 mg
DOLOPHINE - methadone hcl tab 5 4
mg
4
DOLOPHINE - methadone hcl tab
10 mg
4
DURAGESIC - fentanyl td patch
72hr 12 mcg/hr
4
72hr 25 mcg/hr
4
72hr 50 mcg/hr
4
72hr 75 mcg/hr
4
72hr 100 mcg/hr
4
EMBEDA - morphine-naltrexone
cap cr 20-0.8 mg
4
cap cr 30-1.2 mg
4
cap cr 50-2 mg
4
cap cr 60-2.4 mg
4
cap cr 80-3.2 mg
4
cap cr 100-4 mg
•
•
•
•
•
• • •
• • •
• • •
• • •
• • •
• • •
4
•
EXALGO - hydromorphone hcl tab
er 24hr deter 12 mg
4
•
er 24hr deter 16 mg
4
•
er 24hr deter 32 mg
4
•
FENTANYL - fentanyl td patch 72hr
37.5 mcg/hr
4
• • •
62.5 mcg/hr
4
• • •
87.5 mcg/hr
4
• • •
fentanyl citrate lozenge on a
handle 200 mcg (Actiq)
5
•
•
5
•
•
5
•
•
5
•
•
5
•
•
5
•
•
fentanyl td patch 72hr 12 mcg/hr
(Duragesic)
2
•
(Duragesic)
2
•
(Duragesic)
2
•
(Duragesic)
2
•
fentanyl td patch 72hr 100 mcg/
hr (Duragesic)
2
•
FENTORA - fentanyl citrate buccal
tab 100 mcg (base equiv)
5
• • •
5
• • •
4
er 24hr deter 8 mg
ACA
CONZIP - tramadol hcl cap sr 24hr
biphasic release 300 mg
Quantity Limits
• • •
Restricted Access
4
Prior Review
Specialty
• • •
Drug Name
Drug Tier
4
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
101
FIORICET/CODEINE - butalbitalacetaminophen-caff w/ cod cap
50-300-40-30 mg
4
FIORINAL/CODEINE #3 butalbital-aspirin-caff w/ codeine
cap 50-325-40-30 mg
4
HYCET - hydrocodoneacetaminophen soln 7.5-325
mg/15ml
4
hydrocodone-acetaminophen
soln 7.5-325 mg/15ml (Hycet)
2
soln 10-325 mg/15ml (Zamicet)
tab 2.5-325 mg
tab 10-325 mg (Norco)
tab 5-300 mg (Xodol)
tab 7.5-300 mg (Xodol)
tab 5-325 mg (Norco)
tab 7.5-325 mg (Norco)
tab 10-300 mg (Xodol)
hydrocodone-ibuprofen tab
5-200 mg (Reprexain)
7.5-200 mg (Vicoprofen)
10-200 mg (Ibudone)
HYDROMORPHONE HCL hydromorphone hcl suppos 3 mg
2
2
1
1
2
1
1
2
2
1
2
4
• • •
4
hydromorphone hcl liqd 1 mg/ml
(Dilaudid)
2
hydromorphone hcl tab er 24hr
deter 8 mg (Exalgo)
2
•
2
•
2
•
deter 12 mg (Exalgo)
deter 16 mg (Exalgo)
hydromorphone hcl tab 2 mg
(Dilaudid)
1
(Dilaudid)
1
(Dilaudid)
2
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter 20 mg
4
• • •
4
• • •
4
• • •
4
• • •
4
• • •
bitartrate tab er 24hr deter 100
mg
4
• • •
bitartrate tab er 24hr deter 120
mg
4
• • •
IBUDONE - hydrocodone-ibuprofen 4
tab 10-200 mg
4
KADIAN - morphine sulfate cap sr
24hr 10 mg
4
24hr 20 mg
4
24hr 30 mg
5
•
HYDROMORPHONE HCL ER hydromorphone hcl tab er 24hr
deter 32 mg
ACA
Quantity Limits
• • •
Restricted Access
5
Prior Review
Specialty
• • •
Drug Name
Drug Tier
5
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
•
•
102
•
24hr 80 mg
4
•
24hr 100 mg
4
•
24hr 200 mg
4
• • •
LAZANDA - fentanyl citrate nasal
spray 100 mcg/act (base equiv)
5
• • •
5
• • •
5
• • •
LEVORPHANOL TARTRATE levorphanol tartrate tab 2 mg
4
• •
LORTAB - hydrocodoneacetaminophen soln 10-300
mg/15ml
4
• •
MEPERIDINE HCL - meperidine hcl 4
oral soln 50 mg/5ml
1
meperidine hcl tab 50 mg
(Demerol)
2
meperidine hcl tab 100 mg
(Demerol)
MEPERIDINE HCL/PROMETHAZI - 4
meperidine w/ promethazine cap
50-25 mg
4
METHADONE HCL - methadone
hcl soln 5 mg/5ml
4
METHADONE HCL - methadone
hcl soln 10 mg/5ml
1
methadone hcl conc 10 mg/ml
(Methadose)
2
methadone hcl soln 5 mg/5ml
(Methadone hcl)
• •
methadone hcl tab 5 mg
(Dolophine hcl)
1
methadone hcl tab 10 mg
(Dolophine)
1
METHADOSE - methadone hcl
conc 10 mg/ml
4
METHADOSE SUGAR-FREE methadone hcl conc 10 mg/ml
4
MORPHINE SULFATE - morphine
sulfate suppos 5 mg
4
sulfate suppos 10 mg
4
4
4
sulfate tab 15 mg
4
sulfate tab 30 mg
4
morphine sulfate cap sr 24hr
10 mg (Kadian)
2
•
2
•
2
•
2
•
2
•
2
•
2
•
4
• • •
20 mg (Kadian)
• •
30 mg (Kadian)
50 mg (Kadian)
60 mg (Kadian)
80 mg (Kadian)
100 mg (Kadian)
MORPHINE SULFATE ER morphine sulfate beads cap sr
24hr 30 mg
4
2
ACA
24hr 60 mg
methadone hcl tab for oral susp
40 mg
Quantity Limits
•
Restricted Access
4
2
Prior Review
24hr 50 mg
methadone hcl soln 10 mg/5ml
(Methadone hcl)
Specialty
• • •
Drug Name
Drug Tier
4
24hr 40 mg
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
103
4
24hr 60 mg
4
24hr 75 mg
4
• • •
24hr 90 mg
4
• • •
24hr 120 mg
4
morphine sulfate oral soln
10 mg/5ml
20 mg/5ml
100 mg/5ml (20 mg/ml)
NORCO - hydrocodoneacetaminophen tab 10-325 mg
4
NORCO - hydrocodoneacetaminophen tab 5-325 mg
4
NORCO - hydrocodoneacetaminophen tab 7.5-325 mg
4
NUCYNTA - tapentadol hcl tab 50
mg
4
• •
mg
4
• •
mg
4
• •
NUCYNTA ER - tapentadol hcl tab
sr 12hr 50 mg
4
• • •
1
sr 12hr 100 mg
4
• • •
1
sr 12hr 150 mg
4
• • •
2
sr 12hr 200 mg
4
• • •
• • •
• • •
• • •
morphine sulfate tab cr 15 mg
(Ms contin)
2
•
sr 12hr 250 mg
4
(Ms contin)
2
•
OPANA - oxymorphone hcl tab 5
mg
4
(Ms contin)
2
•
OPANA - oxymorphone hcl tab 10
mg
4
(Ms contin)
2
•
4
• • •
(Ms contin)
2
•
OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr
deter 5 mg
4
• • •
MS CONTIN - morphine sulfate tab
cr 15 mg
4
•
deter 7.5 mg
cr 30 mg
4
•
4
• • •
cr 60 mg
4
•
deter 10 mg
4
• • •
cr 100 mg
4
•
deter 15 mg
•
deter 20 mg
4
cr 200 mg
4
• • •
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
• • •
24hr 45 mg
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
104
4
deter 40 mg
4
OXAYDO - oxycodone hcl tab
abuse deter 5 mg
4
• •
OXAYDO - oxycodone hcl tab
abuse deter 7.5 mg
4
• •
oxycodone hcl cap 5 mg
2
• • •
oxycodone hcl tab 30 mg
(Roxicodone)
2
oxycodone w/ acetaminophen
soln 5-325 mg/5ml (Roxicet)
2
tab 2.5-325 mg (Percocet)
tab 5-325 mg (Percocet)
tab 7.5-325 mg (Percocet)
2
tab 10-325 mg (Percocet)
OXYCODONE HCL ER oxycodone hcl tab er 12hr deter
10 mg
4
oxycodone-aspirin tab
4.8355-325 mg (Percodan)
15 mg
4
20 mg
4
•
30 mg
4
• • •
40 mg
4
•
60 mg
4
• • •
80 mg
4
oxycodone hcl soln 5 mg/5ml
(Oxycodone hcl)
2
(Roxicodone)
2
2
oxycodone hcl conc 100 mg/5ml
(20 mg/ml) (Oxycodone hcl)
•
• • •
•
1
2
2
2
1
OXYCONTIN - oxycodone hcl tab
er 12hr deter 10 mg
4
•
er 12hr deter 15 mg
4
• • •
er 12hr deter 20 mg
4
•
er 12hr deter 30 mg
4
• • •
er 12hr deter 40 mg
4
•
er 12hr deter 60 mg
4
• • •
er 12hr deter 80 mg
4
•
oxymorphone hcl tab sr 12hr
5 mg
2
•
2
•
2
•
2
•
2
•
10 mg
(Roxicodone)
2
15 mg
2
20 mg
2
OXYCODONE/IBUPROFEN oxycodone-ibuprofen tab 5-400
mg
7.5 mg
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
• • •
deter 30 mg
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
105
30 mg
40 mg
oxymorphone hcl tab 5 mg
(Opana)
2
oxymorphone hcl tab 10 mg
(Opana)
2
pentazocine w/ naloxone tab
50-0.5 mg
2
PERCOCET - oxycodone w/
acetaminophen tab 2.5-325 mg
4
acetaminophen tab 5-325 mg
4
4
4
PERCODAN - oxycodone-aspirin
tab 4.8355-325 mg
4
PRIMLEV - oxycodone w/
4
• •
4
• •
4
• •
REPREXAIN - hydrocodoneibuprofen tab 5-200 mg
4
ROXICET - oxycodone w/
acetaminophen soln 5-325
mg/5ml
4
ROXICODONE - oxycodone hcl tab 4
5 mg
15 mg
30 mg
3
SUBOXONE - buprenorphine hclnaloxone hcl sl film 2-0.5 mg
(base equiv)
•
•
3
•
SUBOXONE - buprenorphine hclnaloxone hcl sl film 8-2 mg (base
equiv)
3
•
•
SUBOXONE - buprenorphine hclnaloxone hcl sl film 12-3 mg
(base equiv)
3
•
•
SUBSYS - fentanyl sublingual spray 5
100 mcg
200 mcg
400 mcg
600 mcg
800 mcg
1200 mcg (600 mcg x 2)
1600 mcg (800 mcg x 2)
SYNALGOS-DC - aspirin-caffeine- 4
dihydrocodeine cap 356.4-30-16
mg
TRAMADOL HCL ER - tramadol hcl 4
cap sr 24hr biphasic release 100
mg
mg
mg
mg
2
tramadol hcl tab sr 24hr 100 mg
(Ultram er)
2
(Ultram er)
•
SUBOXONE - buprenorphine hclnaloxone hcl sl film 4-1 mg (base
equiv)
ACA
Quantity Limits
Restricted Access
Prior Review
•
Specialty
2
Drug Name
Drug Tier
•
2
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• • •
• • •
• • •
• • •
• • •
• • •
• • •
• •
• • •
• • •
• • •
• • •
•
•
106
2
•
tramadol hcl tab sr 24hr biphasic
release 300 mg
tramadol hcl tab 50 mg (Ultram)
tramadol-acetaminophen tab
37.5-325 mg (Ultracet)
1
1
TREZIX - acetaminophen-caffeinedihydrocodeine cap 320.5-30-16
mg
4
TYLENOL/CODEINE acetaminophen w/ codeine tab
300-15 mg
4
TYLENOL/CODEINE #3 acetaminophen w/ codeine tab
300-30 mg
4
TYLENOL/CODEINE #4 acetaminophen w/ codeine tab
300-60 mg
4
ULTRACET - tramadolacetaminophen tab 37.5-325 mg
4
ULTRAM - tramadol hcl tab 50 mg
4
ULTRAM ER - tramadol hcl tab sr
24hr 300 mg
4
•
XARTEMIS XR - oxycodone w/
acetaminophen tab cr 7.5-325
mg
4
• • •
XODOL - hydrocodoneacetaminophen tab 5-300 mg
4
XODOL - hydrocodoneacetaminophen tab 7.5-300 mg
4
XODOL - hydrocodoneacetaminophen tab 10-300 mg
4
XTAMPZA ER - oxycodone cap er
12hr abuse-deterrent 9 mg
4
12hr abuse-deterrent 13.5 mg
4
• • •
• • •
4
• • •
4
• • •
4
• • •
ZAMICET - hydrocodoneacetaminophen soln 10-325
mg/15ml
4
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr abusedeterrent 10 mg
4
• • •
4
• • •
4
• • •
4
• • •
4
• • •
4
• • •
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 1.4-0.36 mg
(base eq)
4
• • •
(base eq)
4
• • •
(base eq)
4
• • •
(base eq)
4
• • •
(base eq)
4
• • •
•
ACA
2
release 200 mg
Quantity Limits
•
Restricted Access
2
Prior Review
release 100 mg
Specialty
•
Drug Name
Drug Tier
2
(Ultram er)
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
ANALGESICS - ANTI-INFLAMMATORY
107
ACTEMRA - tocilizumab
syringe 162 mg/0.9ml
5
DUEXIS - ibuprofen-famotidine tab
800-26.6 mg
4
EC-NAPROSYN - naproxen tab ec
375 mg
4
ANAPROX DS - naproxen sodium
tab 550 mg
4
EC-NAPROSYN - naproxen tab ec
500 mg
4
ARAVA - leflunomide tab 10 mg
5
ARAVA - leflunomide tab 20 mg
5
5
• •
•
ARCALYST - rilonacept for inj 220
mg
5
ENBREL - etanercept for
5
• •
•
ARTHROTEC 50 - diclofenac w/
misoprostol tab delayed release
50-0.2 mg
4
ENBREL - etanercept
syringe 25 mg/0.5ml
5
• •
•
ARTHROTEC 75 - diclofenac w/
misoprostol tab delayed release
75-0.2 mg
4
ENBREL - etanercept
syringe 50 mg/ml
5
• •
•
CELEBREX - celecoxib cap 50 mg
4
ENBREL SURECLICK - etanercept
subcutaneous solution autoinjector 50 mg/ml
etodolac cap 200 mg
2
CELEBREX - celecoxib cap 100 mg 4
2
celecoxib cap 50 mg (Celebrex)
2
2
2
DAYPRO - oxaprozin tab 600 mg
4
diclofenac potassium tab 50 mg
1
diclofenac sodium tab delayed
release 25 mg
release 50 mg
release 75 mg
diclofenac sodium tab sr 24hr
100 mg (Voltaren-xr)
1
1
1
1
diclofenac w/ misoprostol tab
delayed release 50-0.2 mg
(Arthrotec 50)
2
diclofenac w/ misoprostol tab
delayed release 75-0.2 mg
(Arthrotec 75)
2
• • •
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
etodolac cap 300 mg
etodolac tab sr 24hr 400 mg
etodolac tab 400 mg
etodolac tab 500 mg
ACA
• •
Quantity Limits
Restricted Access
Prior Review
Specialty
•
Drug Name
Drug Tier
• • • •
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
2
2
2
2
2
2
FELDENE - piroxicam cap 10 mg
4
FELDENE - piroxicam cap 20 mg
4
FENOPROFEN CALCIUM fenoprofen calcium cap 200 mg
4
• •
FENOPROFEN CALCIUM fenoprofen calcium cap 400 mg
4
• •
FENOPROFEN CALCIUM fenoprofen calcium tab 600 mg
4
• •
FENORTHO - fenoprofen calcium
cap 200 mg
4
• •
FENORTHO - fenoprofen calcium
cap 400 mg
4
• •
FLANAX PAIN RELIEF KIT naproxen tab 500 mg & liniment
topical gel kit
4
• •
flurbiprofen tab 50 mg
1
108
flurbiprofen tab 100 mg
1
• •
•
5
• •
•
leflunomide tab 10 mg (Arava)
• •
•
• •
•
• •
•
• •
•
HUMIRA - adalimumab prefilled
syringe kit 40 mg/0.8ml
HUMIRA PEDIATRIC CROHNS D - 5
adalimumab prefilled syringe kit
40 mg/0.8ml
5
HUMIRA PEN - adalimumab peninjector kit 40 mg/0.8ml
5
HUMIRA PEN-CROHNS
DISEASE - adalimumab peninjector kit 40 mg/0.8ml
HUMIRA PEN-PSORIASIS STAR - 5
adalimumab pen-injector kit 40
mg/0.8ml
4
IBUPROFEN COMFORT PAC ibuprofen tab 800 mg & liniment
topical gel kit
1
ibuprofen susp 100 mg/5ml
• •
1
1
• •
MECLOFENAMATE SODIUM meclofenamate sodium cap 100
mg
4
• •
mefenamic acid cap 250 mg
(Ponstel)
2
MELOXICAM COMFORT PAC meloxicam tab 15 mg & liniment
topical gel kit
4
meloxicam tab 7.5 mg (Mobic)
1
MOBIC - meloxicam tab 7.5 mg
4
MOBIC - meloxicam tab 15 mg
4
nabumetone tab 500 mg
1
1
4
IC 800 - ibuprofen tab 800 mg &
caffeine-vitamins cap kit
4
• •
NAPRELAN - naproxen sodium tab
4
INDOCIN - indomethacin suppos 50 4
mg
4
INDOCIN - indomethacin susp 25
mg/5ml
2
indomethacin cap cr 75 mg
• •
4
• •
4
NAPROSYN - naproxen susp 125
mg/5ml
4
ketoprofen cap 50 mg
ketoprofen cap 75 mg
KETOPROFEN ER - ketoprofen
cap sr 24hr 200 mg
1
4
• •
•
• •
1
NALFON - fenoprofen calcium cap
400 mg
1
ACA
1
• •
1
Quantity Limits
• • • •
4
indomethacin cap 50 mg
Restricted Access
5
4
nabumetone tab 750 mg
1
Prior Review
•
IC 400 - ibuprofen tab 400 mg &
caffeine-vitamins cap kit
indomethacin cap 25 mg
Specialty
1
MECLOFENAMATE SODIUM meclofenamate sodium cap 50
mg
meloxicam tab 15 mg (Mobic)
1
1
•
leflunomide tab 20 mg (Arava)
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
5
KINERET - anakinra subcutaneous
soln prefilled syringe 100
mg/0.67ml
ibuprofen tab 800 mg
ketorolac tromethamine tab
10 mg
•
5
Drug Name
• •
Specialty
Drug Name
Drug Tier
2016
NAPROSYN - naproxen tab 500 mg 4
4
NAPROXEN COMFORT PAC naproxen tab 500 mg & liniment
topical gel kit
2
naproxen sodium tab sr 24hr
375 mg (base equiv) (Naprelan)
• •
• •
• •
109
2
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 susp 125 mg/5ml
piroxicam cap 20 mg (Feldene)
naproxen tab ec 375 mg (Ecnaprosyn)
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
2
PONSTEL - mefenamic acid cap
250 mg
4
RASUVO - methotrexate soln pf
auto-injector 7.5 mg/0.15ml
5
• •
auto-injector 10 mg/0.2ml
5
• •
1
5
• •
naproxen tab ec 500 mg (Ecnaprosyn)
1
5
• •
naproxen tab 250 mg (Naprosyn)
1
5
• •
5
• •
5
• •
5
• •
5
• •
5
• •
RHEUMATREX - methotrexate
sodium tab 2.5 mg
(antirheumatic)
4
• •
RIDAURA - auranofin cap 3 mg
4
SIMPONI - golimumab
subcutaneous soln auto-injector
50 mg/0.5ml
5
• •
• •
•
•
SIMPONI - golimumab
100 mg/ml
5
• •
•
•
SIMPONI - golimumab
syringe 50 mg/0.5ml
5
• •
•
•
SIMPONI - golimumab
syringe 100 mg/ml
5
• •
•
•
SPRIX - ketorolac tromethamine
nasal spray 15.75 mg/spray
4
1
1
ORENCIA - abatacept
syringe 125 mg/ml
5
• • • •
ORENCIA CLICKJET - abatacept
125 mg/ml
5
• • • •
OTEZLA - apremilast tab starter
therapy pack 10 mg & 20 mg &
30 mg
5
OTEZLA - apremilast tab 30 mg
5
OTREXUP - methotrexate soln pf
• • • •
•
•
5
• • • •
• •
5
• •
5
• •
5
• •
5
• •
5
• •
5
• •
oxaprozin tab 600 mg (Daypro)
2
piroxicam cap 10 mg (Feldene)
2
• • •
110
sulindac tab 150 mg
sulindac tab 200 mg
1
1
• •
TIVORBEX - indomethacin cap 20
mg
4
• •
CAMBIA - diclofenac potassium
packet 50 mg
4
• • •
TIVORBEX - indomethacin cap 40
mg
4
• •
D.H.E. 45 - dihydroergotamine
mesylate inj 1 mg/ml
5
• • • •
TOLMETIN SODIUM - tolmetin
sodium tab 200 mg
4
• •
4
• • •
TOLMETIN SODIUM - tolmetin
sodium tab 600 mg
4
• •
DIHYDROERGOTAMINE
MESYLAT - dihydroergotamine
mesylate nasal spray 4 mg/ml
2
• • • •
tolmetin sodium cap 400 mg
2
dihydroergotamine mesylate inj
1 mg/ml (D.h.e. 45)
VIMOVO - naproxen-esomeprazole
magnesium tab dr 375-20 mg
4
• •
ERGOMAR - ergotamine tartrate sl
tab 2 mg
4
• •
VIMOVO - naproxen-esomeprazole
magnesium tab dr 500-20 mg
4
• •
FROVA - frovatriptan succinate tab
4
• • •
VIVLODEX - meloxicam cap 5 mg
4
•
4
frovatriptan succinate tab 2.5 mg
(base equivalent) (Frova)
2
VIVLODEX - meloxicam cap 10 mg
IMITREX - sumatriptan nasal spray
5 mg/act
4
XELJANZ - tofacitinib citrate tab 5
5
• •
• •
• • • •
• •
IMITREX - sumatriptan nasal spray
20 mg/act
4
• •
IMITREX - sumatriptan succinate inj 4
6 mg/0.5ml
4
IMITREX - sumatriptan succinate
tab 25 mg
4
tab 50 mg
4
tab 100 mg
4
IMITREX STATDOSE REFILL sumatriptan succinate solution
cartridge 4 mg/0.5ml
4
IMITREX STATDOSE REFILL sumatriptan succinate solution
cartridge 6 mg/0.5ml
4
IMITREX STATDOSE SYSTEM sumatriptan succinate solution
4
IMITREX STATDOSE SYSTEM sumatriptan succinate solution
• •
XELJANZ XR - tofacitinib citrate tab 5
ZIPSOR - diclofenac potassium cap 4
25 mg
ZORVOLEX - diclofenac cap 18 mg 4
ZORVOLEX - diclofenac cap 35 mg 4
MIGRAINE PRODUCTS
• • • •
• •
• •
• •
almotriptan malate tab 6.25 mg
(Axert)
2
•
almotriptan malate tab 12.5 mg
(Axert)
2
•
ALSUMA - sumatriptan succinate
solution auto-injector 6 mg/0.5ml
4
• •
AMERGE - naratriptan hcl tab 1 mg 4
(base equiv)
4
AMERGE - naratriptan hcl tab 2.5
mg (base equiv)
4
AXERT - almotriptan malate tab
6.25 mg
4
AXERT - almotriptan malate tab
12.5 mg
• •
• •
• •
• •
4
ACA
CAFERGOT - ergotamine w/
caffeine tab 1-100 mg
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
• •
• •
• •
• •
• •
• •
111
isometheptene-caffeineacetaminophen tab
65-20-325 mg (Prodrin)
isometheptene-dichloralacetaminophen cap
65-100-325 mg
2
MAXALT - rizatriptan benzoate tab
4
• •
MAXALT - rizatriptan benzoate tab
4
• •
MAXALT-MLT - rizatriptan benzoate 4
oral disintegrating tab 5 mg (base
eq)
MAXALT-MLT - rizatriptan benzoate 4
oral disintegrating tab 10 mg
(base eq)
4
MIGERGOT - ergotamine w/
caffeine suppos 2-100 mg
4
MIGRANAL - dihydroergotamine
mesylate nasal spray 4 mg/ml
2
naratriptan hcl tab 1 mg (base
equiv) (Amerge)
2
naratriptan hcl tab 2.5 mg (base
equiv) (Amerge)
4
ONZETRA XSAIL - sumatriptan
succinate exhaler powder 11 mg/
nosepiece
4
PRODRIN - isometheptenecaffeine-acetaminophen tab
65-20-325 mg
RELPAX - eletriptan hydrobromide 4
RELPAX - eletriptan hydrobromide 4
2
rizatriptan benzoate oral
disintegrating tab 5 mg (base
eq) (Maxalt-mlt)
2
rizatriptan benzoate oral
disintegrating tab 10 mg (base
eq) (Maxalt-mlt)
1
rizatriptan benzoate tab 5 mg
(base equivalent) (Maxalt)
• •
• •
• •
• • •
•
•
• •
• •
• •
•
•
•
SUMATRIPTAN - sumatriptan nasal 4
spray 5 mg/act
SUMATRIPTAN - sumatriptan nasal 4
spray 20 mg/act
4
SUMATRIPTAN SUCCINATE sumatriptan succinate solution
prefilled syringe 6 mg/0.5ml
2
sumatriptan succinate inj
6 mg/0.5ml (Imitrex)
2
sumatriptan succinate solution
(Imitrex statdose sys)
2
(Imitrex statdose sys)
2
cartridge 4 mg/0.5ml (Imitrex
statdose ref)
2
cartridge 6 mg/0.5ml (Imitrex
statdose ref)
sumatriptan succinate tab 25 mg 1
(Imitrex)
sumatriptan succinate tab 50 mg 1
(Imitrex)
1
sumatriptan succinate tab
100 mg (Imitrex)
4
SUMAVEL DOSEPRO sumatriptan succinate solution
jet-injector 4 mg/0.5ml
4
SUMAVEL DOSEPRO sumatriptan succinate solution
jet-injector 6 mg/0.5ml
TREXIMET - sumatriptan-naproxen 4
sodium tab 85-500 mg
4
ZEMBRACE SYMTOUCH sumatriptan succinate solution
zolmitriptan orally disintegrating 2
tab 2.5 mg (Zomig zmt)
•
•
ACA
Quantity Limits
Restricted Access
Prior Review
1
rizatriptan benzoate tab 10 mg
(base equivalent) (Maxalt)
2
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
• •
•
•
•
•
•
•
•
•
• •
• •
• •
•
•
112
zolmitriptan orally disintegrating
tab 5 mg (Zomig zmt)
zolmitriptan tab 2.5 mg (Zomig)
zolmitriptan tab 5 mg (Zomig)
2
BANZEL - rufinamide susp 40 mg/
ml
4
• •
BANZEL - rufinamide tab 200 mg
4
BANZEL - rufinamide tab 400 mg
4
BRIVIACT - brivaracetam oral soln
10 mg/ml
4
• •
• •
• • •
ZOMIG - zolmitriptan tab 2.5 mg
4
ZOMIG - zolmitriptan tab 5 mg
4
ZOMIG NASAL SPRAY zolmitriptan nasal spray 5 mg/
spray unit
4
ZOMIG ZMT - zolmitriptan orally
4
• •
BRIVIACT - brivaracetam tab 50 mg 4
ZOMIG ZMT - zolmitriptan orally
4
• •
BRIVIACT - brivaracetam tab 100
mg
4
carbamazepine cap sr 12hr
100 mg (Carbatrol)
2
allopurinol tab 100 mg (Zyloprim)
allopurinol tab 300 mg (Zyloprim)
1
1
• •
200 mg (Carbatrol)
4
COLCHICINE - colchicine tab 0.6
mg
4
carbamazepine susp 100 mg/5ml
(Tegretol)
2
colchicine w/ probenecid tab
0.5-500 mg
1
3
MITIGARE - colchicine cap 0.6 mg
4
carbamazepine tab sr 12hr
100 mg (Tegretol-xr)
2
COLCRYS - colchicine tab 0.6 mg
probenecid tab 500 mg
1
ULORIC - febuxostat tab 40 mg
4
ULORIC - febuxostat tab 80 mg
4
ZYLOPRIM - allopurinol tab 100 mg 4
ZYLOPRIM - allopurinol tab 300 mg 4
NEUROMUSCULAR DRUGS
300 mg (Carbatrol)
carbamazepine chew tab 100 mg
• •
• •
4
4
APTIOM - eslicarbazepine acetate
tab 400 mg
4
tab 600 mg
4
2
4
CARBATROL - carbamazepine cap
sr 12hr 300 mg
ACA
2
sr 12hr 100 mg
4
•
•
•
•
•
1
1
tab 200 mg
•
•
•
•
•
2
carbamazepine tab 200 mg
(Tegretol)
sr 12hr 200 mg
ANTICONVULSANTS
•
•
•
•
•
2
COLCHICINE - colchicine cap 0.6
mg
• •
Quantity Limits
4
4
GOUT AGENTS
Restricted Access
tab 800 mg
ZOMIG - zolmitriptan nasal spray
2.5 mg/spray unit
• •
• •
• •
Prior Review
•
•
• •
Specialty
2
Drug Name
Drug Tier
•
2
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
CELONTIN - methsuximide cap 300 4
mg
113
2
DIAZEPAM - diazepam rectal gel
delivery system 20 mg
4
2
DILANTIN - phenytoin sodium
extended cap 30 mg
4
2
DILANTIN - phenytoin sodium
extended cap 100 mg
4
2
DILANTIN INFATABS - phenytoin
chew tab 50 mg
4
2
DILANTIN-125 - phenytoin susp
125 mg/5ml
4
clonazepam tab 0.5 mg
(Klonopin)
1
2
clonazepam tab 1 mg (Klonopin)
1
divalproex sodium cap delayed
release sprinkle 125 mg
(Depakote sprinkles)
divalproex sodium tab delayed
release 125 mg (Depakote)
1
clonazepam orally disintegrating
tab 0.125 mg
tab 0.25 mg
tab 0.5 mg
tab 1 mg
tab 2 mg
clonazepam tab 2 mg (Klonopin)
1
DEPAKENE - valproate sodium
syrup 250 mg/5ml (base equiv)
4
DEPAKENE - valproic acid cap 250
mg
4
DEPAKOTE - divalproex sodium tab 4
DEPAKOTE ER - divalproex sodium 4
tab sr 24 hr 250 mg
DEPAKOTE ER - divalproex sodium 4
tab sr 24 hr 500 mg
4
DEPAKOTE SPRINKLES divalproex sodium cap delayed
release sprinkle 125 mg
4
DIASTAT ACUDIAL - diazepam
rectal gel delivery system 10 mg
4
DIASTAT ACUDIAL - diazepam
rectal gel delivery system 20 mg
4
DIASTAT PEDIATRIC - diazepam
rectal gel delivery system 2.5 mg
4
delivery system 2.5 mg
4
delivery system 10 mg
divalproex sodium tab sr 24 hr
250 mg (Depakote er)
divalproex sodium tab sr 24 hr
500 mg (Depakote er)
ACA
Quantity Limits
Restricted Access
Prior Review
1
1
2
2
ethosuximide cap 250 mg
(Zarontin)
2
ethosuximide soln 250 mg/5ml
(Zarontin)
2
felbamate susp 600 mg/5ml
(Felbatol)
2
felbamate tab 400 mg (Felbatol)
2
felbamate tab 600 mg (Felbatol)
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
2
FELBATOL - felbamate susp 600
mg/5ml
4
FELBATOL - felbamate tab 400 mg
4
FELBATOL - felbamate tab 600 mg
4
FYCOMPA - perampanel susp 0.5
mg/ml
4
FYCOMPA - perampanel tab 2 mg
4
4
4
114
4
FYCOMPA - perampanel tab 10 mg 4
FYCOMPA - perampanel tab 12 mg 4
gabapentin cap 100 mg
(Neurontin)
1
(Neurontin)
1
(Neurontin)
1
gabapentin oral soln 250 mg/5ml
(Neurontin)
2
gabapentin tab 600 mg
(Neurontin)
1
gabapentin tab 800 mg
(Neurontin)
1
GABITRIL - tiagabine hcl tab 2 mg
4
GABITRIL - tiagabine hcl tab 4 mg
4
GABITRIL - tiagabine hcl tab 12 mg 4
GABITRIL - tiagabine hcl tab 16 mg 4
KEPPRA - levetiracetam oral soln
100 mg/ml
4
KEPPRA - levetiracetam tab 250
mg
4
mg
4
mg
4
mg
4
KEPPRA XR - levetiracetam tab sr
24hr 500 mg
4
KEPPRA XR - levetiracetam tab sr
24hr 750 mg
4
KLONOPIN - clonazepam tab 0.5
mg
4
KLONOPIN - clonazepam tab 1 mg
4
KLONOPIN - clonazepam tab 2 mg
4
LAMICTAL - lamotrigine tab 25 mg
4
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
LAMICTAL - lamotrigine tab 150 mg 4
LAMICTAL CHEWABLE DISPERS - 4
lamotrigine tab chewable
dispersible 5 mg
LAMICTAL CHEWABLE DISPERS - 4
dispersible 25 mg
LAMICTAL ODT - lamotrigine orally 4
4
LAMICTAL ODT - lamotrigine tab
disp 25 mg (21) & 50 mg (7)
titration kit
4
disp 50 mg (42) & 100 mg (14)
titration kit
4
disp 25 (14) & 50 mg (14) & 100
mg (7) kit
4
LAMICTAL STARTER/NOT TAKI lamotrigine tab 25 mg (42) & 100
mg (7) starter kit
LAMICTAL STARTER/TAKING C - 4
lamotrigine tab 25 mg (84) & 100
mg (14) starter kit
4
LAMICTAL STARTER/TAKING V lamotrigine tab 25 mg (35) starter
kit
4
LAMICTAL XR - lamotrigine tab
sr 24hr 25 mg (21) & 50 mg (7)
titration kit
4
LAMICTAL XR - lamotrigine tab sr
24hr 25 (14) & 50 mg (14) & 100
mg(7) kit
115
24hr 50 (14) & 100 mg(14) & 200
mg(7) kit
4
lamotrigine tab sr 24hr 100 mg
(Lamictal xr)
2
(Lamictal xr)
2
24hr 25 mg
4
(Lamictal xr)
2
24hr 50 mg
4
4
(Lamictal xr)
2
24hr 100 mg
lamotrigine tab 25 mg (Lamictal)
1
24hr 200 mg
4
24hr 250 mg
4
24hr 300 mg
4
lamotrigine orally disintegrating
tab 25 mg (Lamictal odt)
2
2
2
2
dispersible 5 mg (Lamictal
chewable di)
2
dispersible 25 mg (Lamictal
chewable di)
2
lamotrigine tab disp 25 mg
(21) & 50 mg (7) titration kit
(LAMICTAL ODT)
2
lamotrigine tab disp 50 mg (42)
& 100 mg (14) titration kit
(LAMICTAL ODT)
2
lamotrigine tab disp 25 (14) &
50 mg (14) & 100 mg (7) kit
(LAMICTAL ODT)
2
(Lamictal xr)
(Lamictal xr)
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
lamotrigine tab 100 mg (Lamictal) 1
1
levetiracetam oral soln 100 mg/
ml (Keppra)
levetiracetam tab sr 24hr 500 mg 2
(Keppra xr)
levetiracetam tab sr 24hr 750 mg 2
(Keppra xr)
1
levetiracetam tab 250 mg
(Keppra)
1
(Keppra)
1
(Keppra)
2
(Keppra)
4
LYRICA - pregabalin cap 25 mg
4
4
4
4
4
4
4
LYRICA - pregabalin soln 20 mg/ml
4
2
MYSOLINE - primidone tab 50 mg
4
2
MYSOLINE - primidone tab 250 mg 4
NEURONTIN - gabapentin cap 100 4
mg
116
NEURONTIN - gabapentin cap 300
mg
4
phenytoin susp 125 mg/5ml
(Dilantin-125)
2
NEURONTIN - gabapentin cap 400
mg
4
POTIGA - ezogabine tab 50 mg
4
4
4
4
primidone tab 50 mg (Mysoline)
1
NEURONTIN - gabapentin oral soln 4
250 mg/5ml
NEURONTIN - gabapentin tab 600 4
mg
NEURONTIN - gabapentin tab 800 4
mg
4
ONFI - clobazam suspension 2.5
mg/ml
4
ONFI - clobazam tab 10 mg
ONFI - clobazam tab 20 mg
4
oxcarbazepine susp 300 mg/5ml
(60 mg/ml) (Trileptal)
2
oxcarbazepine tab 150 mg
(Trileptal)
1
(Trileptal)
1
(Trileptal)
2
OXTELLAR XR - oxcarbazepine tab 4
sr 24hr 150 mg
sr 24hr 300 mg
sr 24hr 600 mg
PEGANONE - ethotoin tab 250 mg 4
PHENYTEK - phenytoin sodium
extended cap 200 mg
4
PHENYTEK - phenytoin sodium
extended cap 300 mg
4
phenytoin chew tab 50 mg
(Dilantin infatabs)
1
phenytoin sodium extended cap
100 mg (Dilantin)
1
200 mg (Phenytek)
300 mg (Phenytek)
1
1
primidone tab 250 mg (Mysoline)
• •
• •
• •
1
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
QUDEXY XR - topiramate cap er
24hr sprinkle 25 mg
4
• •
24hr sprinkle 50 mg
4
• •
24hr sprinkle 100 mg
4
• •
4
• •
4
• •
SABRIL - vigabatrin powd pack 500 5
mg
5
SABRIL - vigabatrin tab 500 mg
• • •
•
• • •
• •
•
• •
SPRITAM - levetiracetam tab
disintegrating soluble 250 mg
4
• •
4
• •
• •
4
• •
4
• •
TEGRETOL - carbamazepine susp
100 mg/5ml
4
TEGRETOL - carbamazepine tab
200 mg
4
TEGRETOL-XR - carbamazepine
tab sr 12hr 100 mg
4
tab sr 12hr 200 mg
4
tab sr 12hr 400 mg
4
tiagabine hcl tab 2 mg (Gabitril)
2
117
tiagabine hcl tab 4 mg (Gabitril)
2
TOPAMAX - topiramate tab 25 mg
4
TOPAMAX - topiramate tab 50 mg
4
TOPAMAX - topiramate tab 100 mg 4
TOPAMAX - topiramate tab 200 mg 4
• •
1
4
valproic acid cap 250 mg
(Depakene)
1
TOPAMAX SPRINKLE - topiramate
sprinkle cap 25 mg
VIMPAT - lacosamide oral solution
10 mg/ml
4
TOPIRAMATE ER - topiramate cap
er 24hr sprinkle 25 mg
4
• •
VIMPAT - lacosamide tab 50 mg
4
4
4
4
• •
4
4
4
• •
4
• •
topiramate sprinkle cap 15 mg
(Topamax sprinkle)
2
topiramate sprinkle cap 25 mg
(Topamax sprinkle)
2
topiramate tab 25 mg (Topamax)
1
ZARONTIN - ethosuximide cap 250 4
mg
ZARONTIN - ethosuximide soln 250 4
mg/5ml
4
ZONEGRAN - zonisamide cap 25
mg
ZONEGRAN - zonisamide cap 100 4
mg
1
zonisamide cap 25 mg
(Zonegran)
1
topiramate tab 100 mg (Topamax) 1
topiramate tab 200 mg (Topamax) 1
TRILEPTAL - oxcarbazepine susp
300 mg/5ml (60 mg/ml)
4
TRILEPTAL - oxcarbazepine tab
150 mg
4
300 mg
4
600 mg
4
TROKENDI XR - topiramate cap sr
24hr 25 mg
4
24hr 50 mg
4
(Zonegran)
ANTIPARKINSON AGENTS
2
AMANTADINE HCL - amantadine
hcl tab 100 mg
4
amantadine hcl cap 100 mg
2
amantadine hcl syrup 50 mg/5ml
4
ACA
24hr 200 mg
Quantity Limits
• •
4
1
Restricted Access
4
TOPAMAX SPRINKLE - topiramate
sprinkle cap 15 mg
topiramate tab 50 mg (Topamax)
Prior Review
24hr 100 mg
valproate sodium syrup
(Depakene)
• •
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
1
APOKYN - apomorphine
hydrochloride inj 10 mg/ml
5
• •
AZILECT - rasagiline mesylate tab
0.5 mg (base equiv)
4
• •
AZILECT - rasagiline mesylate tab
1 mg (base equiv)
4
benztropine mesylate tab 0.5 mg
1
• •
•
118
benztropine mesylate tab 1 mg
benztropine mesylate tab 2 mg
bromocriptine mesylate cap
5 mg (Parlodel)
bromocriptine mesylate tab
2.5 mg
carbidopa & levodopa orally
disintegrating tab 10-100 mg
carbidopa & levodopa tab cr
25-100 mg (Sinemet cr)
carbidopa & levodopa tab cr
50-200 mg (Sinemet cr)
carbidopa & levodopa tab
10-100 mg (Sinemet)
25-100 mg (Sinemet)
25-250 mg (Sinemet)
carbidopa tab 25 mg (Lodosyn)
1
CARBIDOPA/LEVODOPA/
ENTACA - carbidopa-levodopaentacapone tabs 50-200-200 mg
4
COMTAN - entacapone tab 200 mg
4
2
ELDEPRYL - selegiline hcl cap 5
mg
4
1
entacapone tab 200 mg (Comtan) 2
4
LODOSYN - carbidopa tab 25 mg
2
MIRAPEX - pramipexole
dihydrochloride tab 0.125 mg
4
2
4
1
4
1
4
1
dihydrochloride tab 1 mg
4
1
4
1
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr 0.375
mg
4
1
2
2
CARBIDOPA/LEVODOPA/
ENTACA - carbidopa-levodopaentacapone tabs 12.5-50-200 mg
4
mg
4
CARBIDOPA/LEVODOPA/
ENTACA - carbidopa-levodopaentacapone tabs 18.75-75-200
mg
4
mg
4
4
CARBIDOPA/LEVODOPA/
ENTACA - carbidopa-levodopaentacapone tabs 25-100-200 mg
4
mg
4
CARBIDOPA/LEVODOPA/
mg
4
dihydrochloride tab sr 24hr 3 mg
mg
4
CARBIDOPA/LEVODOPA/
mg
4
mg
4
NEUPRO - rotigotine td patch 24hr
1 mg/24hr
4
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
119
6 mg/24hr
4
• •
8 mg/24hr
4
• •
PARLODEL - bromocriptine
mesylate cap 5 mg
pramipexole dihydrochloride tab
sr 24hr 0.375 mg (Mirapex er)
sr 24hr 3 mg (Mirapex er)
0.125 mg (Mirapex)
0.25 mg (Mirapex)
0.5 mg (Mirapex)
0.75 mg (Mirapex)
1 mg (Mirapex)
1.5 mg (Mirapex)
REQUIP - ropinirole hydrochloride
tab 0.25 mg
tab 2 mg
4
tab 3 mg
4
tab 4 mg
4
4
tab 5 mg
4
2
REQUIP XL - ropinirole
hydrochloride tab sr 24hr 2 mg
(base equivalent)
4
(base equivalent)
4
(base equivalent)
4
(base equivalent)
4
(base equivalent)
4
ropinirole hydrochloride tab sr
24hr 2 mg (base equivalent)
(Requip xl)
2
(Requip xl)
2
(Requip xl)
2
(Requip xl)
2
(Requip xl)
2
2
2
2
2
2
2
1
1
1
1
1
1
4
• •
ACA
4
4
Quantity Limits
4 mg/24hr
tab 1 mg
Restricted Access
• •
4
Prior Review
4
tab 0.5 mg
Specialty
3 mg/24hr
Drug Name
Drug Tier
• •
4
ACA
2 mg/24hr
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
120
ropinirole hydrochloride tab
0.25 mg (Requip)
0.5 mg (Requip)
1 mg (Requip)
2 mg (Requip)
3 mg (Requip)
4 mg (Requip)
1
1
1
1
1
1
STALEVO 150 - carbidopalevodopa-entacapone tabs
37.5-150-200 mg
4
50-200-200 mg
4
tolcapone tab 100 mg (Tasmar)
RYTARY - carbidopa & levodopa
cap cr 23.75-95 mg
4
trihexyphenidyl hcl elixir 0.4 mg/
ml
cap cr 36.25-145 mg
4
cap cr 48.75-195 mg
4
cap cr 61.25-245 mg
4
selegiline hcl cap 5 mg (Eldepryl) 2
2
selegiline hcl tab 5 mg
ACA
Quantity Limits
Restricted Access
Prior Review
STALEVO 50 - carbidopa-levodopa- 4
entacapone tabs 12.5-50-200 mg
STALEVO 75 - carbidopa-levodopa- 4
entacapone tabs 18.75-75-200
mg
4
TASMAR - tolcapone tab 100 mg
1
5 mg (Requip)
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
trihexyphenidyl hcl tab 2 mg
trihexyphenidyl hcl tab 5 mg
ZELAPAR - selegiline hcl orally
NEUROMUSCULAR AGENTS
2
1
1
1
• •
4
RILUTEK - riluzole tab 50 mg
5
riluzole tab 50 mg (Rilutek)
5
•
•
SINEMET - carbidopa & levodopa
tab 10-100 mg
4
tab 25-100 mg
4
tab 25-250 mg
4
MUSCULOSKELETAL THERAPY AGENTS
•
AMRIX - cyclobenzaprine hcl cap sr 4
24hr 15 mg
•
AMRIX - cyclobenzaprine hcl cap sr 4
24hr 30 mg
1
baclofen tab 10 mg
SINEMET CR - carbidopa &
levodopa tab cr 25-100 mg
4
carisoprodol tab 250 mg (Soma)
SINEMET CR - carbidopa &
levodopa tab cr 50-200 mg
4
25-100-200 mg
4
31.25-125-200 mg
4
baclofen tab 20 mg
carisoprodol tab 350 mg (Soma)
carisoprodol w/ aspirin &
codeine tab 200-325-16 mg
carisoprodol w/ aspirin tab
200-325 mg
chlorzoxazone tab 500 mg
(Parafon forte dsc)
•
•
1
2
1
2
2
1
4
CYCLOBENZAPRINE COMFORT
P - cyclobenzaprine hcl tab 10 mg
& liniment topical gel kit
• •
121
cyclobenzaprine hcl tab 5 mg
1
cyclobenzaprine hcl tab 7.5 mg
(Fexmid)
2
tizanidine hcl cap 2 mg (base
equivalent) (Zanaflex)
cyclobenzaprine hcl tab 10 mg
1
DANTRIUM - dantrolene sodium
cap 50 mg
4
tizanidine hcl tab 2 mg (base
equivalent)
dantrolene sodium cap 25 mg
(Dantrium)
2
tizanidine hcl tab 4 mg (base
(Dantrium)
2
ZANAFLEX - tizanidine hcl cap 2
4
2
4
4
methocarbamol tab 500 mg
(Robaxin)
1
methocarbamol tab 750 mg
(Robaxin-750)
1
orphenadrine citrate tab sr 12hr
100 mg
1
PARAFON FORTE DSC chlorzoxazone tab 500 mg
• •
4
ROBAXIN - methocarbamol tab 500 4
mg
ROBAXIN-750 - methocarbamol tab 4
750 mg
4
SKELAXIN - metaxalone tab 800
mg
4
SOMA - carisoprodol tab 250 mg
SOMA - carisoprodol tab 350 mg
4
TIZANIDINE COMFORT PAC tizanidine tab 4 mg & liniment
topical gel pack
4
ACA
Quantity Limits
2
• •
Restricted Access
2
4
• •
Prior Review
2
DANTRIUM - dantrolene sodium
cap 25 mg
LORZONE - chlorzoxazone tab 375 4
mg
LORZONE - chlorzoxazone tab 750 4
mg
4
METAXALONE - metaxalone tab
400 mg
metaxalone tab 800 mg (Skelaxin) 2
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
1
1
ZANAFLEX - tizanidine hcl tab 4 mg 4
(base equivalent)
ANTIMYASTHENIC AGENTS
GUANIDINE HCL - guanidine hcl
tab 125 mg
4
• •
MESTINON - pyridostigmine
bromide syrup 60 mg/5ml
4
• •
MESTINON - pyridostigmine
bromide tab 60 mg
4
MESTINON TIMESPAN pyridostigmine bromide tab cr
180 mg
4
pyridostigmine bromide tab cr
180 mg (Mestinon timespan)
2
pyridostigmine bromide tab
60 mg (Mestinon)
1
NUTRITIONAL PRODUCTS
VITAMINS
• •
• •
AMINOBENZOATE POTASSIUM potassium aminobenzoate
packet 2 gm
4
BABY DDROPS - cholecalciferol
drops 400 unit/0.03ml (per drop)
A
•
cholecalciferol cap 400 unit
A
•
•
A
122
cholecalciferol chew tab 400 unit
cholecalciferol chew tab 1000
unit
cholecalciferol drops 5000 unit/
ml (1000 unit/0.2ml)
cholecalciferol drops 400
unit/0.03ml (per drop)
cholecalciferol oral liquid 400
unit/ml
cholecalciferol tab 400 unit
1
• •
ATABEX EC - prenatal vit w/ dssiron carbonyl-fa tab dr 29-1 mg
4
A
•
b-complex w/ c & folic acid cap
1 mg (Nephrocaps)
1
A
•
b-complex w/ c & folic acid tab
1
A
DDROPS - cholecalciferol drops
1000 unit/0.03ml (per drop)
A
• •
DECARA - cholecalciferol cap
25000 unit
4
• •
ergocalciferol cap 50000 unit
(Drisdol)
1
MEPHYTON - phytonadione tab 5
mg
4
POTABA - potassium
aminobenzoate cap 500 mg
4
• •
SUPER DAILY D3 - cholecalciferol A
drops 1000 unit/0.03ml (per drop)
A
VITAMELTS VITAMIN D cholecalciferol orally
disintegrating tab 1000 unit
VITAMIN D2 - ergocalciferol tab 400 A
unit
A
VITAMIN D3 - cholecalciferol oral
liquid 1200 unit/15ml
VITAMIN D3 - cholecalciferol spray A
1000 unit/spray
A
WELLESSE VITAMIN D3 cholecalciferol oral liquid 1000
unit/10ml
• •
1 mg (Nephro-vite rx)
5 mg
1
1
1
•
BACMIN - multiple vitamins w/
minerals tab
4
•
BAL-CARE DHA - prenat w/fe polyna fered-fa tab 27-1 & omega
cap dr 430mg
4
BP FOLINATAL PLUS B - prenatal
w/ calcium carbonate-b6-b12-fa
tab 1 mg
4
BP MULTINATAL PLUS - prenatal
w/o a vit w/ fe fum-fa tab chew
40-1 mg
4
BP MULTINATAL PLUS - prenatal
w/o a vit w/ fe fumarate-fa tab
30-1 mg
4
•
C-NATE DHA - prenatal vit w/ fe
fum-fa-omega 3 cap 28-1-200
mg
4
•
CALCIUM PNV - prenatal w/o vit
a w/ fe fum-fa-omega 3 cap
28-1-250 mg
4
CITRANATAL ASSURE - prenat w/
o a w/fecbn-fegl-dss-fa tab & dha
cap 300 mg pack
4
•
•
• •
•
• •
•
4
ACA
AP-ZEL - multiple vitamins w/
minerals tab
Quantity Limits
• •
•
A
Restricted Access
4
A
•
•
Prior Review
ADVANCED AM/PM - multiple
vitamins w/ calcium therapy pack
A
A
Specialty
Drug Tier
ACA
Drug Name
•
•
A
D-VI-SOL - cholecalciferol oral
liquid 400 unit/ml
MULTIVITAMINS
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
CITRANATAL B-CALM - prenat w/o 4
a w/fecbn-feglu-fa tab 20-1 mg &
vit b6 tab pak
4
CITRANATAL DHA - prenat w/o a
w/fecbn-fegl-dss-fa tab & dha
cap 250 mg pack
123
ESCAVITE - pediatric multiple
vitamins w/ fl-fe chew tab
0.25-7.5 mg
4
• •
CITRANATAL RX - prenatal w/o a
w/ fe carbonyl-fe gluc-dss-fa tab
27-1mg
4
ESCAVITE D - pediatric multiple
vitamins w/ fl-fe chew tab 0.25-6
mg
4
• •
CITRANATAL 90 DHA - prenat w/
o a w/fecbn-fegl-dss-fa tab 90
&dha cap 300mg pak
4
ESCAVITE LQ - pediatric multiple
vitamins w/ fl-fe drops 0.25-6 mg/
ml
4
CO-NATAL FA - prenatal vit w/ fe
fumarate-fa tab 29-1 mg
4
COMPLETE NATAL DHA - prenatfe bis-fe prot succ-fa-ca tab &
omega 3 cap 250 pk
4
COMPLETENATE - prenatal vit w/
fe fumarate-fa chew tab 29-1 mg
4
CONCEPT DHA - prenatal w/fe
fum-fe poly -fa-omega 3 cap
53.5-38-1 mg
4
EXTRA-VIRT PLUS DHA - prenatal 4
w/o vit a w/ fe fum-doc-fa-dha
cap 29-1.25-350 mg
FLORIVA - ped multiple vitamins & 4
minerals w/ fl chew tab 0.5 mg
FLORIVA - ped multiple vitamins & 4
minerals w/ fl chew tab 1 mg
4
FOCALGIN CA - prenat w/o a w/
fecbn-fegl-dss-fa tab & dha cap
300 mg pack
FOCALGIN 90 DHA - prenat w/o a 4
w/fecbn-fegl-dss-fa tab 90 &dha
cap 300mg pak
4
FOLCAL DHA - prenatal w/o vit
a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg
FOLCAPS OMEGA 3 - prenatal vit 4
w/ fe cbn-fe asp glyc-fa-omega 3
cap 27-1mg
FOLET DHA - prenat w/fecbn-bisg- 4
methylf-dss tab dr & dha cap pak
4
FOLET ONE - prenat w/o a w/
fecbn-bisg-methylf-dss-dha cap
38-1-225 mg
FOLGARD OS - multiple vit w/ min 4
& calcium-folic acid tab 500-1.1
mg
FOLIVANE-OB - prenatal w/o a w/fe 4
fum-fe poly-fa cap 130-92.4-1 mg
4
FORTAVIT - multiple vitamins w/
minerals cap
HEMENATAL OB - prenat vit-fe poly 4
cmplx-fe heme poly-fa tab 28-6-1
mg
CONCEPT OB - prenatal w/o a w/fe 4
fum-fe poly-fa cap 130-92.4-1 mg
4
CORVITE - multiple vitamins w/
minerals & fa tab 1.25 mg
DIALYVITE SUPREME D - multiple 4
vitamins w/ minerals & fa tab 3
mg
DIALYVITE 3000 - b-complex w/ c- 4
biotin-e-minerals & folic acid tab
3 mg
DIALYVITE 5000 - b-complex w/ c- 4
biotin-e-minerals & folic acid tab
5 mg
DIALYVITE/ZINC - b-complex w/ c- 4
zn & folic acid tab 1 mg
4
DOTHELLE DHA - prenatal w/fe
53.5-38-1 mg
4
ELITE-OB - prenatal vit w/ iron
carbonyl-fa tab 50-1.25 mg
4
ENBRACE HR - prenatal vit w/ fe
gly cys-fa-omega 3 fatty acids
cap
• •
• •
• •
• •
4
ACA
CITRANATAL HARMONY - prenat
w/o a w/fe fum-fe cbn-dss-fa-dha
cap 27-1-260 mg
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
• •
• •
• •
124
HEMENATAL OB + DHA - prenat-fe 4
poly cmplx-fe heme poly-fa tab &
omega 3 cap pck
INATAL ADVANCE - prenatal vit w/ 4
dss-iron carbonyl-fa tab 90-1 mg
INATAL GT - prenatal vit w/ dss-iron 4
carbonyl-fa tab 90-1 mg
4
INATAL ULTRA - prenatal vit w/
4
INFANATE BALANCE - prenatal
w/o a w/fe cbn-dss-fa-dha cap
29-1-265 mg
4
MACNATAL CN DHA - prenatal
28-1-250 mg
MARNATAL-F - prenatal w/o vit a w/ 4
fe polysac cmplx-fa cap 60-1 mg
2
multiple vitamins w/ minerals &
fa tab 1.25 mg (Corvite)
1
multiple vitamins w/ minerals
cap
multiple vitamins w/ minerals tab 2
(Strovite forte)
4
MYKIDZ IRON FL - pediatric
vitamins acd fluoride & fe susp
0.25-10 mg/2ml
4
MYNATAL - prenatal multivitamins
& minerals w/ iron & fa cap 1 mg
MYNATAL ADVANCE - prenatal vit 4
w/ dss-iron carbonyl-fa tab 90-1
mg
MYNATAL PLUS - prenatal vit w/ fe 4
4
MYNATAL ULTRACAPLET prenatal vit w/ dss-iron carbonylfa tab 90-1 mg
4
MYNATAL-Z - prenatal vit w/ fe
MYNATE 90 PLUS - prenatal vit w/ 4
dss-fe fumarate-fa tab cr 90-1 mg
NATACHEW - prenatal vit w/ fe fum- 4
fe bisglycin-fa chew tab 28-1 mg
• •
NATALVIT - prenatal vit w/ fe
4
NATELLE ONE - prenatal w/o vit
a w/ fe fum-fa-omega 3 cap
28-1-250 mg
4
NEPHPLEX RX - b-complex w/ c-zn 4
& folic acid tab 1 mg
NEPHRO-VITE RX - b-complex w/ 4
c & folic acid tab 1 mg
NEPHROCAPS - b-complex w/ c & 4
folic acid cap 1 mg
NEPHROCAPS QT - b-complex w/ 4
c-biotin-d & folic acid tab disp 1
mg
NESTABS - prenatal vit w/o vit a w/ 4
fe bisglycinate-fa tab 32-1 mg
NESTABS DHA - prenat w/o a w/ fe 4
bisglyc-fa tab 32-1 mg & omega
cap pack
NEWGEN - prenatal vit w/o vit a w/ 4
fe bisglycinate-fa tab 32-1 mg
4
NEXA PLUS - prenatal w/o vit
a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg
4
NICADAN - multiple vitamins w/
minerals tab
4
NICAZEL - multiple vitamins w/
minerals tab
4
NICAZEL FORTE - multiple
vitamins w/ minerals tab
NICOMIDE - niacinamide w/ zn-cu- 4
methylfol-se-cr tab 750-27-2-0.5
mg
NICOMIDE - niacinamide w/ zn-cu- 4
methylfolate tab 750-25-1.5-0.5
mg
4
NUTRICAP - multiple vitamins w/
minerals tab
4
NUTRIVIT - b-complex w/ lysinemin-fe & fa liqd 800-15-1
mg/15ml
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
• •
• •
• •
• •
• •
• •
• •
• •
125
O-CAL PRENATAL - prenatal vit w/
fe fumarate-fa tab 15-1 mg
4
OB COMPLETE - prenatal vit w/
iron carbonyl-fa tab 50-1.25 mg
4
OB COMPLETE GOLD - prenat w/
o a w/fecbn-methfol-fa-dha cap
27.5-1-200 mg
4
OB COMPLETE ONE - prenatal w/o 4
a w/fecbn-fe asp glyc-fa-fish cap
50-1-476 mg
OB COMPLETE PETITE - prenat w/ 4
o a w/fecbn-feaspglyc-fa-omega
cap 35-5-1-200 mg
4
OB COMPLETE PREMIER prenatal vit w/ fe cbn-fe asp glycfa tab 30-20-1 mg
4
OB COMPLETE/DHA - prenat w/
iron cbn-fe asp glyc-fa-omega
cap 30-10-1-200 mg
OBSTETRIX DHA - prenat w/fecbn- 4
fa-dss tab 29-1 mg & omega 3
cap 387 mg pak
4
OBSTETRIX EC - prenatal vit w/
4
OCUVEL - multiple vitamins w/
minerals & fa cap 0.5 mg
2
pediatric multiple vitamin w/
minerals & c drops 45 mg/ml
1
pediatric multiple vitamins w/ flfe drops 0.25-10 mg/ml
1
pediatric multiple vitamins w/
fluoride chew tab 0.25 mg
1
fluoride chew tab 1 mg
1
fluoride soln 0.25 mg/ml
1
1
pediatric vitamins acd w/
1
pediatric vitamins acd w/
• •
PNV FERROUS FUMARATE/
DOCU - prenatal vit w/ dss-fe
4
PNV OB+DHA - prenat w/o a w/
fecbn-fegl-dss-fa tab & dha cap
250 mg pack
4
PNV TABS 29-1 - prenatal vit w/
iron carbonyl-fa tab 29-1 mg
4
PNV-DHA - prenat w/o a w/
fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
4
PNV-DHA+DOCUSATE - prenatal
w/o vit a w/ fe fum-dss-fa-dha
cap 27-1.25-300 mg
4
PNV-OMEGA - prenat w/o a w/ fe
fumerate-methylfolate-fa-omega
3 cap
4
PNV-SELECT - prenatal vit w/
fe fum-methylfolate-fa tab
27-0.6-0.4 mg
4
PNV-TOTAL - prenat w/ fe cbn-fe
bisglyc-fa-fish oil cap 35-5-1.2
mg
4
PNV-VP-U - prenatal w/o a vit w/ fe
fumarate-fa cap 106.5-1 mg
4
POLY-VI-FLOR - ped multiple vit w/ 4
fluoride biphasic chew tab 0.25
mg
fluoride biphasic chew tab 0.5 mg
fluoride biphasic chew tab 1 mg
fluoride biphasic susp 0.25 mg/ml
4
POLY-VI-FLOR FS - pediatric
multiple vit w/ fluoride oral strip
0.25 mg
4
multiple vit w/ fluoride oral strip
0.5 mg
4
multiple vitamins w/ fluoride oral
strip 1 mg
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
• •
• •
• •
• •
• •
• •
126
POLY-VI-FLOR/IRON - ped multiple 4
vit w/ fl-fe biphasic chew tab
0.5-10 mg
POLY-VI-FLOR/IRON - ped multiple 4
vitamin w/ fl-fe biphasic susp
0.25-7 mg/ml
4
PR NATAL 400 - prenat-fe bis-fe
prot succ-fa-ca tab & omega 3
cap 400 pk
PR NATAL 400 EC - prenat-fe bis-fe 4
prot succ-fa-ca tab & omega cap
dr 400 pk
4
PR NATAL 430 - prenat-fe bis-fe
prot succ-fa-ca tab & omega 3
cap 430 pk
PR NATAL 430 EC - prenat-fe bis-fe 4
prot succ-fa-ca tab & omega cap
dr 430 pk
4
PREFERAOB +DHA - prenat-fe
poly cmplx 28mg-fe heme poly-fa
tab&dha cap pack
PREFERAOB ONE - prenat-fe poly 4
cmplx-fe heme poly-fa-dha cap
22-6-1-200 mg
4
PRENAISSANCE - prenatal w/o
vit a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg
4
PRENAISSANCE BALANCE prenatal w/o vit a w/ fe cbn-dssfa-dha cap 30-1-260 mg
4
PRENAISSANCE HARMONY
DHA - prenat w/fe poly-na feredfa tab 27-1 & omega cap dr
380mg
PRENAISSANCE NEXT - prenatal 4
w/ calcium-vit b6-fa-ginger tab
1.2 mg
4
PRENAISSANCE NEXT-B prenatal w/ calcium-vit b6-faginger tab 1.22 mg
PRENAISSANCE PLUS - prenatal 4
28-1-250 mg
• •
PRENATABS FA - prenatal vit w/ fe
4
PRENATABS RX - prenatal vit w/
4
PRENATAL PLUS IRON - prenatal
vit w/ iron carbonyl-fa tab 29-1
mg
4
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
• •
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
PRENATAL 19 - prenatal vit w/ dss- 4
fe fumarate-fa tab 29-1 mg
4
PRENATAL 19 - prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
PRENATAL-U - prenatal w/o a vit w/ 4
fe fumarate-fa cap 106.5-1 mg
4
PRENATE - prenat mv & min w/ lmethylfolate-fa chew tab 0.6-0.4
mg
4
PRENATE DHA - prenat w/o a
w/feaspg-methfol-fa-dha cap
18-0.6-0.4-300 mg
4
PRENATE DHA - prenat w/o a
w/fefum-methfol-fa-dha cap
28-0.6-0.4-300 mg
4
PRENATE ELITE - prenatal vit
w/ fe fum-methylfolate-fa tab
26-0.6-0.4 mg
4
PRENATE ELITE - prenatal w/
fe asp gly-l methylfol-fa tab
20-0.6-0.4 mg
4
PRENATE ENHANCE - prenat w/
o a w/fefum-methfol-fa-dha cap
28-0.6-0.4-400 mg
PRENATE ESSENTIAL - prenat w/ 4
o a w/feasp-methylf-fa-omeg cap
29-0.6-0.4-340 mg
PRENATE ESSENTIAL - prenat w/ 4
o a w/feaspg-methfol-fa-dha cap
18-0.6-0.4-300 mg
4
PRENATE MINI - prenat w/o a
w/fecbn-methylf-fa-dha cap
29-0.6-0.4-350 mg
4
PRENATE MINI - prenat w/oa w/
fecb-feasp-meth-fa-dha cap
18-0.6-0.4-350 mg
127
PRENATE PIXIE - prenat w/o a
w/feaspg-methfol-fa-dha cap
10-0.6-0.4-200 mg
4
RULAVITE DHA - prenat w/o a
27-0.6-0.4-300 mg
4
PRENATE RESTORE - prenat w/
o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-400 mg
4
SE-NATAL 19 - prenatal vit w/ dssfe fumarate-fa tab 29-1 mg
4
4
4
PRENATE STAR - prenatal vit w/ fe
asparto glycinate-fa tab 20-1 mg
SE-NATAL 19 - prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
PRENA1 CHEW - prenat w/ b2-b6b12-d3-folic acid chew tab 1.4
mg
4
PRENA1 PEARL - prenat w/oa w/
fefum-na fered-fa-dha cap cr
30-1.4-200 mg
4
PREQUE 10 - prenatal mv w/
fe carbonyl-dss-fa-dha tab
15-25-0.5-50 mg
4
PROTECT PLUS - multiple vitamins 4
w/ minerals cap
4
PROVIDA DHA - prenat w/o a
w/fe fum-fe poly-fa-dha cap
16-16-1.25-110 mg
PROVIDA OB - prenatal w/o a w/fe 4
fum-fe poly-fa cap 20-20-1.25 mg
4
PUREFE OB PLUS - prenatal
w/o a w/fe fum-fe poly-fa cap
162.115.2-1 mg
4
QUFLORA PEDIATRIC - pediatric
multiple vitamins w/ fluoride soln
0.25 mg/ml
4
QUFLORA PEDIATRIC - pediatric
multiple vitamins w/ fluoride soln
0.5 mg/ml
4
RELNATE DHA - prenatal vit w/ fe
fum-fa-omega 3 cap 28-1-200
mg
RENATABS - b-complex w/ c-biotin- 4
vit e & folic acid tab 1 mg
4
RENATABS WITH IRON - b
complex-c-biotin-e-fa tab 1mg &
fe cbn tab 100 mg pack
4
REQ 49+ - multiple vitamins w/
minerals tab
• •
• •
• •
• •
SE-TAN DHA - prenatal w/fe fum-fe 4
poly -fa-omega 3 cap 15-15-1 mg
4
SELECT-OB - prenat w/
fepolycmplx-methylfol-fa chew
tab 29-0.6-0.4 mg
4
SELECT-OB - prenatal vit w/ fe
polysac cmplx-fa chew tab 29-1
mg
4
SELECT-OB+DHA - prenatal mv
w/fe poly-fa chw 29-1 mg & dha
cap 250 mg pak
4
SIDEROL - multiple vitamins w/
minerals tab
4
SM B-COMPLEX/VITAMIN C - bcomplex w/ c & folic acid tab
4
STROVITE FORTE - multiple
vitamins w/ minerals & fa syrup 1
mg/15ml
4
STROVITE FORTE - multiple
STROVITE ONE - multiple vitamins 4
w/ minerals tab
SUPERVITE - b-complex w/ lysine- 4
zn & folic acid liquid
SUPERVITE EC - multiple vitamins 4
w/ minerals & fa tab dr 1 mg
4
SUPPORT - multiple vitamins w/
minerals liquid
SUPPORT-500 - speciality vitamin 4
product cap
4
SYNAGEX - multiple vitamins w/
4
SYNATEK - multiple vitamins w/
ACA
Quantity Limits
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2016
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
128
TRI-VI-FLORO - ped vit acd & lmethylfol w/ fl biphasic susp 0.5
mg/ml
4
• •
TARON-C DHA - prenatal w/fe
53.5-38-1 mg
4
TRI-VIT/FLUORIDE/IRON pediatric vitamins acd fluoride &
fe drops 0.25-10 mg/ml
4
• •
TARON-PREX - prenatal w/o vit
30-1.2-265 mg
4
TRIADVANCE - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
4
4
TRICARE PRENATAL - prenat w/o
a w/fepyro-mfol chw 4.5-1 mg &
dha cap 150 thpk
4
TEXAVITE LQ - pediatric
multivitamins w/fl-fe-zn drops
0.25-7-3 mg/ml
TRICARE PRENATAL DHA ONE prenatal w/fe fumarate-fa-dssfish oil cap 27-1-500 mg
4
THRIVITE RX - prenatal vit w/ iron
4
TRINATAL GT - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
4
TRINATAL RX 1 - prenatal vit w/ fe
4
TRINATE - prenatal vit w/ fe
4
TRISTART DHA - prenat w/o a
w/fecbn-methylf-fa-dha cap
31-0.6-0.4-200 mg
4
TRIVEEN-DUO DHA - prenatfe bis-fe prot succ-fa-ca tab &
omega 3 cap 400 pk
4
TRIVEEN-PRX RNF - prenatal w/
o vit a w/ fe fum-dss-fa-dha cap
26-1.2-300 mg
4
UDAMIN SP - multiple vitamins w/
minerals & fa tab 1 mg
4
THRIVITE 19 - prenatal vit w/ dss-fe 4
TL FOLATE - prenatal vit w/ fe fum- 4
methylfolate-fa tab 27-0.5-0.5 mg
TL G-FOL OS - multiple vit w/ min & 4
calcium-folic acid tab 500-1.1 mg
4
TL-CARE DHA - prenatal w/fe
fumarate-fa-dss-fish oil cap
27-1-500 mg
TL-FLUORIVITE - pediatric multiple 4
vitamins w/ fl-fe chew tab
0.25-7.5 mg
4
TL-SELECT - prenatal w/o vit
29-1.25-325 mg
TRI-TABS DHA - prenat w/o a w/ fe 4
bisglyc-fa tab 32-1 mg & omega
cap pack
4
TRI-VI-FLOR - ped vit acd & lmethylfol w/ fl biphasic susp 0.25
mg/ml
4
TRI-VI-FLOR - ped vit acd & lmethylfol w/ fl biphasic susp 0.5
mg/ml
4
TRI-VI-FLORO - ped vit acd & lmethylfol w/ fl biphasic susp 0.25
mg/ml
• •
• •
• •
• •
• •
• •
4
ACA
TARON-BC - prenat w/o a w/ fe
cbnyl-fa tab 20-1 mg & vit b6 tab
pak
Quantity Limits
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2016
• •
ULTIMATECARE ONE - prenatal vit 4
w/ fe cbn-fe asp glyc-fa-omega 3
cap 27-1mg
4
ULTIMATECARE ONE NF prenatal w/fe cbnyl-fe asp glycfa-dss-omega cap 20-7-1 mg
4
VEMAVITE-PRX 2 - prenatal w/o
vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg
VENA-BAL DHA - prenat w/fe poly- 4
na fered-fa tab 27-1 & omega
cap dr 430mg
129
VINACAL B - prenat w/o a w/fecbnfeglu-fa tab 20-1 mg & vit b6 tab
pak
4
VIRT-PN PLUS - prenat w/o a w/ fe
fumerate-methylfolate-fa-omega
3 cap
4
VINATE AZ EXTRA - prenatal vit
w/ fe bisglycinate chelate-fa tab
29-1 mg
4
VIRT-SELECT - prenatal w/o vit
29-1.25-325 mg
4
VINATE C - prenatal w/o a vit w/ fe
4
VINATE CALCIUM - prenatal vit w/
iron carbonyl-fe gluc-fa tab 27-1
mg
4
VINATE CARE - prenatal w/o a vit
w/ fe fum-fa tab chew 40-1 mg
4
VINATE IC - prenatal w/o a w/fe
fum-fe poly-fa cap 162.115.2-1
mg
4
VINATE II - prenatal vit w/ fe
bisglycinate chelate-fa tab 29-1
mg
4
VIRT-VITE GT - prenatal vit w/ dss- 4
VIRTPREX - prenatal w/o vit a w/ fe 4
fum-dss-fa-dha cap 26-1.2-300
mg
4
VITA-PREN - prenatal vit w/
docusate-iron-fa tab 65-1 mg
4
VITA-RX DIABETIC VITAMIN speciality vitamin product cap
4
VITAFOL - iron w/ vitamin tab
VINATE M - prenatal vit w/ sel-fe
4
VINATE ONE - prenatal vit w/ fe
4
VIRT NATE - prenatal vit w/ fe
4
VIRT-ADVANCE - prenatal vit w/
VIRT-C DHA - prenatal w/fe fum-fe
poly -fa-omega 3 cap 53.5-38-1
mg
VITAFOL FE+ - prenat-fepolymethol-fa-dha cap 90-1-200 mg
& dss 50mg cap
4
VITAFOL GUMMIES - prenat vit
w/ fe phos-fa-omega chew tab
3.33-0.333-34.8 mg
4
VITAFOL-NANO - prenatal w/o
a w/ fefum-l methylfol-fa tab
18-0.6-0.4 mg
4
4
VITAFOL-OB - prenatal vit w/ fe
4
4
VITAFOL-OB+DHA - prenatal mv w/ 4
fe fum-fa tab 65-1 mg & dha cap
250 mg pack
4
VITAFOL-ONE - prenatal mv w/
fe polysac cmplx-fa-dha cap
29-1-200 mg
4
VITAL-D RX - b-complex w/ cbiotin-d-zinc & folic acid tab 1 mg
4
VITAMEDMD ONE RX/
QUATREFO - prenat w/o a
30-0.6-0.4-200 mg
VITAMEDMD PLUS RX/QUATRE - 4
prenat w/o a w/ fe chelate-l
methylfol-fa tab & dha cap pk
VIRT-CARE ONE - prenatal vit w/ fe 4
cbn-fe asp glyc-fa-omega 3 cap
27-1mg
4
VIRT-NATE DHA - prenatal vit w/
fe fum-fa-omega 3 cap 28-1-200
mg
4
VIRT-PN - prenatal vit w/ fe fummethylfolate-fa tab 27-0.6-0.4 mg
4
VIRT-PN DHA - prenat w/o a
27-0.6-0.4-300 mg
ACA
Quantity Limits
Restricted Access
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ACA
Quantity Limits
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Drug Name
Drug Tier
2016
• •
• •
130
VITAMEDMD REDICHEW RX prenat w/ b2-b6-b12-d3-folic acid
chew tab 1.4 mg
4
ZATEAN-PN PLUS - prenat w/o a
w/ fe fumerate-methylfolate-faomega 3 cap
VITAPEARL - prenat w/oa w/
fefum-na fered-fa-dha cap cr
30-1.4-200 mg
4
MINERALS and ELECTROLYTES
4
• •
VITAROCA PLUS - multiple
4
CALCIFOL - ca carb-folic acidvit d-b6-b12-boron-mag wafer
1342-1.6 mg
4
CALCIUM-FOLIC ACID PLUS D ca carb-folic acid-vit d-b6-b12boron-mag wafer 1342-1 mg
4
VIVA DHA - prenatal vit w/ fe fumfa-omega 3 cap 28-1-200 mg
• •
VOL-NATE - prenatal vit w/ fe
4
EFFER-K - potassium bicarbonatecitric acid effer tab 10 meq
4
VOL-TAB RX - prenatal vit w/ iron
4
EFFER-K - potassium bicarbonatecitric acid effer tab 20 meq
4
VP-CH PLUS - prenatal w/o a w/fe
cbn-dss-fa-dha cap 29-1-265 mg
4
FLORICAL - sodium fluoride w/
calcium carb cap 8.3-364 mg
A
•
VP-CH-PNV - prenatal w/o vit a w/
fe cbn-dss-fa-dha cap 30-1-260
mg
4
FLORICAL - sodium fluoride w/
calcium carb tab 8.3-364 mg
A
•
FLORIVA - sodium fluoride-vitamin
d liqd drops 0.25 mg/ml-400 unit/
ml
4
VP-GGR-B6 PRENATAL - prenatal
w/ calcium-vit b6-fa-ginger tab
1.2 mg
4
FLUOR-A-DAY - sodium fluoridexylitol chew tab 0.55 (0.25 mg
f)-236.79 mg
4
VP-HEME OB - prenat vit-fe poly
cmplx-fe heme poly-fa tab 28-6-1
mg
4
•
FLUOR-A-DAY - sodium fluoridexylitol chew tab 1.1 (0.5 mg
f)-236.79 mg
4
VP-HEME OB + DHA - prenat-fe
poly cmplx-fe heme poly-fa tab &
omega 3 cap pck
4
•
4
FLUOR-A-DAY - sodium fluoridexylitol chew tab 2.2 (1 mg
f)-236.79 mg
4
VP-HEME ONE - prenat-fe poly
cmplx-fe heme poly-fa-dha cap
22-6-1-200 mg
•
FLUORABON - sodium fluoride
soln 0.25 mg/0.6ml (from 0.55
mg/0.6ml naf)
4
VP-PNV-DHA - prenatal vit w/ fe
fum-fa-omega 3 cap 28-1-215.8
mg
4
•
FLURA-DROPS - sodium fluoride
soln 0.25 mg/drop f (from 0.55
mg/drop naf)
4
VP-ZEL - multiple vitamins w/
minerals tab
4
•
ZATEAN-CH - prenatal w/o a w/fe
cbn-dss-fa-dha cap 27-1-250 mg
4
GALZIN - zinc acetate cap 25 mg
(elemental zinc)
4
• •
ZATEAN-PN DHA - prenat w/o
a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
4
GALZIN - zinc acetate cap 50 mg
(elemental zinc)
4
• •
• •
• •
ACA
Quantity Limits
Restricted Access
Prior Review
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Drug Name
Drug Tier
ACA
Quantity Limits
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Specialty
Drug Name
Drug Tier
2016
4
• •
•
131
GNP VITAMIN D-400 - calcium
carbonate-cholecalciferol tab 90
mg-400 unit
4
IODINE STRONG - iodine solution
strong 5% (lugol's)
4
• •
K-PHOS - potassium phosphate
monobasic tab 500 mg
4
• •
K-PHOS NEUTRAL - pot phos
monobasic w/sod phos di &
monobas tab 155-852-130mg
4
K-TAB - potassium chloride tab cr 8 4
meq (600 mg)
4
K-TAB - potassium chloride tab cr
10 meq
4
K-TAB - potassium chloride tab cr
20 meq (1500 mg)
4
KLOR-CON M15 - potassium
chloride microencapsulated crys
cr tab 15 meq
KLOR-CON/25 - potassium chloride 4
powder packet 25 meq
4
LOZI-FLUR - sodium fluoride
lozenge 1 mg f (from 2.2 mg naf)
LURIDE - sodium fluoride chew tab 4
0.25 mg f (from 0.55 mg naf)
1 mg f (from 2.2 mg naf)
4
LURIDE - sodium fluoride soln 0.5
mg/ml f (from 1.1 mg/ml naf)
4
MAGNEBIND 400 - magnesiumcalcium-folic acid tab 400-200-1
mg
MICRO-K - potassium chloride cap 4
cr 8 meq
MICRO-K - potassium chloride cap 4
cr 10 meq
A
MONOCAL - sodium
monofluorophosphate-calcium
carb tab 22.75-625 mg
pot bicarbonate & chloride effer
tab 25 meq
•
•
•
•
•
• •
•
ACA
Quantity Limits
Restricted Access
Prior Review
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ACA
Quantity Limits
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Drug Name
Drug Tier
2016
2
1
pot phos monobasic w/sod
phos di & monobas tab
155-852-130mg (K-phos neutral)
1
potassium bicarbonate effer tab
25 meq
potassium chloride cap cr 8 meq 1
(Micro-k)
1
potassium chloride cap cr 10
meq (Micro-k)
4
POTASSIUM CHLORIDE ER potassium chloride tab cr 8 meq
(600 mg)
4
POTASSIUM CHLORIDE ER potassium chloride tab cr 20 meq
(1500 mg)
1
potassium chloride
microencapsulated crys cr tab
10 meq
1
potassium chloride
microencapsulated crys cr tab
20 meq
1
potassium chloride oral soln
10% (20 meq/15ml)
2
potassium chloride oral soln
20% (40 meq/15ml)
2
potassium chloride powder
packet 20 meq
potassium chloride tab cr 8 meq 1
(600 mg)
1
potassium chloride tab cr 10
meq (K-tab)
4
SODIUM FLUORIDE - sodium
fluoride tab 0.5 mg f (from 1.1 mg
naf)
4
SODIUM FLUORIDE - sodium
fluoride tab 1 mg f (from 2.2 mg
naf)
1
sodium fluoride chew tab
(Luride)
•
•
•
132
sodium fluoride chew tab 0.5 mg
f (from 1.1 mg naf) (Luride)
sodium fluoride chew tab 1 mg f
(from 2.2 mg naf) (Luride)
sodium fluoride soln 0.125 mg/
drop f (0.275 mg/drop naf)
sodium fluoride soln 0.5 mg/ml f
(from 1.1 mg/ml naf) (Luride)
SSKI - potassium iodide soln 1 gm/
ml
NUTRIENTS
acetylcysteine cap 600 mg
NUTRESTORE - glutamine powd
pack 5 gm
2
•
1
•
• •
4
2
• •
4
ABANEU-SL - cyanocobalaminmethylcobalamin tab sl 600-600
mcg
4
• •
ACTIVE FE - fe carbonyl-fa-b
complex-a-c-d-e-min tab 75-1.25
mg
4
• •
ANIMI-3 - folic acid-b6-b12-domega 3-phytosterols cap 1 mg
4
• •
ANIMI-3/VITAMIN D - folic acid-b6b12-d-omega 3-phytosterols cap
1 mg
4
• •
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 25 mcg/
ml
5
ml
5
•
ml
5
•
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 100
mcg/ml
5
•
mcg/ml
5
•
•
•
ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled
syringe 10 mcg/0.4ml
5
•
5
•
5
•
5
•
5
•
5
•
5
•
5
•
syringe 500 mcg/ml
5
•
B-6 FOLIC ACID - cobalamine
combination cap
4
• •
BIFERARX - polysacch fe cmplxfe heme poly-fa-b12 tab
22-6-1-0.025 mg
4
• •
BP VIT 3 - folic acid-vit b6-vit b12omega 3-phytosterols cap 1 mg
4
carbonyl iron susp 15 mg/1.25ml
(elemental iron)
A
CENTRATEX - ferrous fumarate-fa- 4
b complex-c-zn-mg-mn-cu cap
106-1 mg
5
ACA
mcg/ml
Quantity Limits
Restricted Access
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•
Specialty
1
Drug Name
Drug Tier
•
ACA
1
HEMATOLOGICAL AGENTS
HEMATOPOIETIC AGENTS
Quantity Limits
Restricted Access
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Specialty
Drug Name
Drug Tier
2016
•
• •
133
CERDELGA - eliglustat tartrate cap
5
4
CORVITE 150 - iron-folic acid-vit cvit b6-vit b12-zinc tab 150-1.25
mg
4
cyanocobalamin inj 1000 mcg/ml
1
DIVISTA - folic acid-vit b6-vit b12omega 3-biotin-cr cap 1 mg
DROXIA - hydroxyurea cap 400 mg 5
4
DURACHOL - folic acidcholecalciferol cap 1 mg-3775
unit
4
ED CYTE F - ferrous fumaratefolic acid-docusate sodium tab
324-1-50 mg
5
EPOGEN - epoetin alfa inj 2000
unit/ml
5
unit/ml
5
unit/ml
5
unit/ml
5
unit/ml
A
FA-8 - folic acid cap 0.8 mg
fe fum-iron polysacch complexfa-b cmplx-c-zn-mn-cu cap
(Tandem plus)
1
fe fumarate w/ b12-vit c-fa-ifc
cap 110-0.015-75-0.5-240 mg
1
fe fumarate-vit c-vit b12-fa cap
460 (151 fe)-60-0.01-1 mg
1
• •
• •
• •
•
•
•
• •
• •
•
•
•
•
•
•
FER-IN-SOL - ferrous sulfate soln
75 mg/ml (15 mg/ml elemental
fe)
A
FERIVA - fe bisglycin-fe carbonyl-c- 4
fa-b12-biotin-dss cap 75-1 mg
4
FERIVA 21/7 - fe asparto gly-b12fa-c-dss-succinic acid-zn tab
75-1 mg
4
FERIVAFA - iron-c-fa-b12-biotincopper-docusate cap 110-1 mg
4
FERRALET 90 - fe carbonyl-fe
gluconate-fa-vit b12-vit c-dss tab
90-1 mg
FERRAPLUS 90 - iron-folic acid-vit 4
b12-vit c-docusate sod tab 90-1
mg
A
FERRETTS CHEWABLE IRON carbonyl iron chew tab 18 mg
(elemental iron)
4
FERREX 150 FORTE PLUS - fe
asp gly-fe polysacch-succ ac-cthreon ac-b12-fa cap
FERREX 28 - fe asparto gly-fe fum- 4
b12-fa-c-succinic ac tab ther
pack
4
FERRO-PLEX HEMATINIC - fe
fum-dss-vit c-vit e-vit b12-if-fa tab
115-1 mg
FERROTRIN - iron w/ b12-vit c-fa- 4
ifc cap 36-0.015-75-0.5-240 mg
1
ferrous fumarate-folic acid tab
324-1 mg
A
FERROUS SULFATE - ferrous
sulfate liquid 220 mg/5ml (44
mg/5ml elemental fe)
A
FERROUS SULFATE - ferrous
sulfate syrup 300 mg/5ml (60
mg/5ml elemental fe)
ferrous sulfate elixir 220 mg/5ml A
(44 mg/5ml elemental fe)
A
ferrous sulfate soln 75 mg/ml
(15 mg/ml elemental fe)
•
ACA
Quantity Limits
Restricted Access
Prior Review
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•
Drug Name
Drug Tier
ACA
Quantity Limits
• •
4
Restricted Access
• •
CIFEREX - folic acid-cholecalciferol 4
cap 1 mg-3775 unit
CORVITE FE - iron combination tab 4
CORVITE 150 - iron combination
tab
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
• •
• •
• •
• •
•
• •
• •
• •
• •
•
•
•
•
134
FOCALGIN DSS - fe carbonyl-fe
gluconate-fa-vit b12-vit c-dss tab
90-1 mg
4
FOLGARD RX - folic acid-vitamin
b6-vitamin b12 tab 2.2-25-1 mg
4
folic acid tab 400 mcg
A
folic acid tab 800 mcg
folic acid tab 1 mg
folic acid-vitamin b6-vitamin b12
tab 2.2-25-0.5 mg
folic acid-vitamin b6-vitamin b12
tab 2.2-25-1 mg (Folgard rx)
•
•
A
1
1
1
4
• •
4
FOLIVANE-PLUS - fe fum-iron
polysacch complex-fa-b complexc-biotin cap
4
FOLTRATE - cobalamine
combination tab
4
FUSION PLUS - fe fum-iron poly
cmplx-fa-b cmplx-c-biotinprobiotic cap
5
GRANIX - tbo-filgrastim soln
prefilled syringe 300 mcg/0.5ml
5
GRANIX - tbo-filgrastim soln
4
HEMATOGEN FA - fe fumarate-vit
c-vit b12-fa cap 200-250-0.01-1
mg
4
HEMATRON-AF - iron-docusateb12-folic acid-c-e-cu-biotin tab
150-1 mg
4
HEMETAB - polysacch fe cmplxfe heme poly-fa-b12 tab
22-6-1-0.025 mg
4
HEMOCYTE PLUS - ferrous
fumarate-fa-b complex-c-zn-mgmn-cu cap 106-1 mg
4
HEMOCYTE-F - iron combination
elixir
• •
FOLIVANE-F - fe fum-fe poly-fa-cb3 cap 62.5-62.5-1-40-3mg(125
mg fe)
• •
• •
•
•
• •
• •
• •
• •
HYDROXOCOBALAMIN hydroxocobalamin inj 1000 mcg/
ml
4
ICAR - carbonyl iron chew tab 15
mg (elemental iron)
A
•
ICAR PEDIATRIC - carbonyl iron
susp 15 mg/1.25ml (elemental
iron)
A
•
ICAR-C PLUS - iron-vit c-vit b12folic acid tab 100-250-0.025-1
mg
4
• •
INTEGRA F - fe fum-fe poly-fa-c-b3 4
cap 62.5-62.5-1-40-3mg(125 mg
fe)
4
INTEGRA PLUS - fe fum-iron
polysacch complex-fa-b complexc-biotin cap
A
IRON CHEWS PEDIATRIC carbonyl iron chew tab 15 mg
(elemental iron)
1
iron combination cap
iron-docusate-b12-folic acidc-e-cu-biotin tab 150-1 mg
(Hematron-af)
1
iron-folic acid-vit c-vit b6-vit b12zinc tab 150-1.25 mg (Corvite
150)
2
IROSPAN 24/6 - fe bisglyc-fe polys- 4
succ acd-b cmplx-c-ca-fa tab ther
pk
4
IS 24/6 - fe bisglyc-fe polys-succ
acd-b cmplx-c-ca-fa tab ther pk
5
LEUKINE - sargramostim
lyophilized for inj 250 mcg
MAXFE - iron-fa-vit b12-biotin-vit c- 4
docusate-mg-zn tab 160-1 mg
MOZOBIL - plerixafor subcutaneous 5
inj 24 mg/1.2ml (20 mg/ml)
4
MULTIGEN - fe asparto gly-succ
acd-c-threonic acd-b12-des stom
tab
ACA
Quantity Limits
Restricted Access
Prior Review
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ACA
• •
Quantity Limits
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Drug Name
Drug Tier
2016
• •
•
• •
• •
•
• •
• • •
• •
135
4
MULTIGEN PLUS - fe aspart glyfe fum-succ acd-c-threonic acdb12-fa tab
4
MYKIDZ IRON 10 - iron susp 15
mg/1.5ml
A
NASCOBAL - cyanocobalamin
nasal spray 500 mcg/0.1ml
4
• •
NEPHRON FA - ferrous fumarate w/ 4
fa-dss-b complex-vit c tab
5
NEULASTA - pegfilgrastim soln
5
NEULASTA ONPRO KIT pegfilgrastim soln prefilled
5
NEUPOGEN - filgrastim inj 300
mcg/ml
5
NEUPOGEN - filgrastim inj 480
mcg/1.6ml (300 mcg/ml)
5
NEUPOGEN - filgrastim soln
5
NEUPOGEN - filgrastim soln
(600 mcg/ml)
4
NEURIN-SL - cyanocobalaminmethylcobalamin tab sl 600-600
mcg
5
NPLATE - romiplostim for inj 250
mcg
5
NPLATE - romiplostim for inj 500
mcg
4
ORTHO D - folic acidcholecalciferol cap 1 mg-3775
unit
4
PRE-FOLIC - folic acid-vitamin c
tab 1-100 mg
5
PROCRIT - epoetin alfa inj 2000
unit/ml
5
unit/ml
• •
• •
•
•
•
•
•
•
•
• •
• •
•
• •
•
• •
• •
•
•
5
•
unit/ml
5
•
unit/ml
5
•
PROFERRIN-FORTE - iron heme
polypeptide-folic acid tab 12-1
mg (fe equiv)
4
PROMACTA - eltrombopag olamine 5
4
PROTECTIRON - iron polysacchfa-b complex-vit c-e & minerals
tab 60-1 mg
PUREFE PLUS - ferrous fumarate- 4
fa-b complex-c-zn-mg-mn-cu cap
106-1 mg
4
SPATONE PUR-ABSORB IRON ferrous sulfate liquid 5 mg/20ml
(elemental iron)
4
TANDEM F - ferrous fum-iron
polysacch-fa cap 162-115.2-1 mg
(106 mg fe)
4
TANDEM PLUS - fe fum-iron
polysacch complex-fa-b cmplx-czn-mn-cu cap
TARON FORTE - fe bisglycinate-fe 4
polysacch-vit c-vit b12-fa cap
5
ZARXIO - filgrastim-sndz soln
5
ZARXIO - filgrastim-sndz soln
5
ZAVESCA - miglustat cap 100 mg
unit/ml
ACA
•
Quantity Limits
5
Restricted Access
unit/ml
Prior Review
Specialty
Drug Name
Drug Tier
ACA
• •
MULTIGEN FOLIC - fe asparto glysuccinic acd-vit c-threonic acdb12-fa tab
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
• •
•
• •
•
• •
•
• •
•
• •
• •
• •
• •
•
•
• •
•
ANTICOAGULANTS
136
ARIXTRA - fondaparinux sodium
subcutaneous inj 2.5 mg/0.5ml
5
5
5
5
COUMADIN - warfarin sodium tab 1 4
mg
mg
4
COUMADIN - warfarin sodium tab
2.5 mg
mg
mg
mg
mg
4
7.5 mg
4
10 mg
4
ELIQUIS - apixaban tab 2.5 mg
enoxaparin sodium inj 150 mg/
ml (Lovenox)
enoxaparin sodium inj
300 mg/3ml (Lovenox)
fondaparinux sodium
(Arixtra)
2
fondaparinux sodium
(Arixtra)
2
fondaparinux sodium
(Arixtra)
2
fondaparinux sodium
(Arixtra)
2
FRAGMIN - dalteparin sodium inj
10000 unit/ml
5
2500 unit/0.2ml
5
5000 unit/0.2ml
5
7500 unit/0.3ml
5
12500 unit/0.5ml
5
15000 unit/0.6ml
5
18000 unit/0.72ml
5
30 mg/0.3ml (Lovenox)
2
2
95000 unit/3.8ml
5
IPRIVASK - desirudin for inj 15 mg
5
LOVENOX - enoxaparin sodium inj
30 mg/0.3ml
4
40 mg/0.4ml
4
60 mg/0.6ml
4
80 mg/0.8ml
4
enoxaparin sodium inj 100 mg/
ml (Lovenox)
2
2
2
ACA
Quantity Limits
Restricted Access
2
4
2
Prior Review
2
ELIQUIS - apixaban tab 5 mg
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
137
100 mg/ml
4
120 mg/0.8ml
4
150 mg/ml
4
300 mg/3ml
4
PRADAXA - dabigatran etexilate
mesylate cap 75 mg (etexilate
base eq)
4
base eq)
4
base eq)
4
SAVAYSA - edoxaban tosylate tab
4
4
4
warfarin sodium tab 1 mg
(Coumadin)
1
(Coumadin)
1
warfarin sodium tab 2.5 mg
(Coumadin)
1
(Coumadin)
1
(Coumadin)
1
(Coumadin)
1
(Coumadin)
1
warfarin sodium tab 7.5 mg
(Coumadin)
1
(Coumadin)
1
XARELTO - rivaroxaban tab 10 mg
3
3
3
XARELTO STARTER PACK rivaroxaban tab starter therapy
pack 15 mg & 20 mg
3
HEMOSTATICS
AMICAR - aminocaproic acid oral
soln 0.25 gm/ml
4
AMICAR - aminocaproic acid tab
500 mg
4
AMICAR - aminocaproic acid tab
1000 mg
4
ARTISS - fibrin sealant component
solution
4
ASTRINGYN - ferric subsulfate soln 4
259 mg/gm
EVICEL - fibrin sealant component 4
kit 2 ml
EVICEL - fibrin sealant component 4
kit 5 ml
4
EVITHROM - thrombin (human)
topical soln 800-1200 unit/ml
LYSTEDA - tranexamic acid tab 650 4
mg
4
MONSELS FERRIC
SUBSULFATE - ferric subsulfate
soln
4
RECOTHROM - thrombin
(recombinant) for soln 5000 unit
4
RECOTHROM - thrombin
(recombinant) for soln 20000 unit
4
RECOTHROM SPRAY KIT thrombin (recombinant) for soln
20000 unit
4
THROMBIN-JMI DILUENT thrombin for soln 5000 unit
4
THROMBIN-JMI DILUENT thrombin for soln 20000 unit
4
THROMBIN-JMI EPISTAXIS thrombin for soln kit 5000 unit
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
• •
138
THROMBIN-JMI SYRINGE SPRA thrombin for soln kit 5000 unit
4
THROMBIN-JMI SYRINGE SPRA thrombin for soln kit 20000 unit
4
THROMBIN-JMI W/DIL SPRAY thrombin for soln kit 20000 unit
4
THROMBOGEN - thrombin for soln
kit 10000 unit
4
1000 unit
4
10000 unit
4
•
ADYNOVATE - antihemophilic
factor recomb pegylated for inj
2000 unit
5
•
AFSTYLA - antihemophilic fact
rcmb single chain for inj kit 250
unit
5
unit
5
unit
5
unit
5
unit
5
•
AGGRENOX - aspirin-dipyridamole
cap sr 12hr 25-200 mg
4
•
AGRYLIN - anagrelide hcl cap 0.5
mg
4
•
ALPHANATE/VON WILLEBRAND - 5
antihemophilic factor/vwf
(human) for inj 250 unit
•
•
•
•
•
5
ACA
1000 unit
Quantity Limits
•
Restricted Access
5
Prior Review
Specialty
Drug Tier
ACA
Quantity Limits
Restricted Access
Drug Name
500 unit
TISSEEL - fibrin sealant component 4
solution
4
TISSEEL VH - fibrin sealant
component kit 2 ml
4
component kit 4 ml
4
component kit 10 ml
2
tranexamic acid tab 650 mg
(Lysteda)
HEMATOLOGICAL AGENTS - MISC.
5
ADVATE - antihemophilic factor
rahf-pfm for inj 250 unit
5
5
5
5
5
5
5
250 unit
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
•
•
•
•
139
ALPHANINE SD - coagulation
factor ix for inj 1500 unit
5
•
ALPROLIX - coagulation factor ix
(recomb) (rfixfc) for inj 250 unit
5
•
•
5
•
•
5
•
•
5
•
•
5
•
•
anagrelide hcl cap 0.5 mg
(Agrylin)
anagrelide hcl cap 1 mg
5
•
•
COAGADEX - coagulation factor x
5
•
•
CORIFACT - factor xiii concentrate
(human) for inj kit 1000-1600 unit
5
•
•
dipyridamole tab 25 mg
(Persantine)
1
(Persantine)
1
(Persantine)
1
DURLAZA - aspirin capsule sr 24hr
162.5 mg
4
2
EFFIENT - prasugrel hcl tab 5 mg
(base equiv)
4
2
EFFIENT - prasugrel hcl tab 10 mg
(base equiv)
4
ELOCTATE - antihemophilic factor
(recomb) rfviiifc for inj 250 unit
5
•
•
5
•
•
5
•
•
5
•
•
5
•
•
5
•
•
5
•
•
FEIBA - antiinhibitor coagulant
complex for inj
5
•
FIRAZYR - icatibant acetate inj 30
mg/3ml (base equivalent)
5
• •
HELIXATE FS - antihemophilic
factor (recombinant) for inj kit
250 unit
5
•
BRILINTA - ticagrelor tab 90 mg
4
cilostazol tab 50 mg (Pletal)
1
clopidogrel bisulfate tab 75 mg
(base equiv) (Plavix)
1
COAGADEX - coagulation factor x
ASPIRIN/DIPYRIDAMOLE - aspirin- 4
dipyridamole cap sr 12hr 25-200
mg
BEBULIN - factor ix complex for inj 5
200-1200 unit
5
BENEFIX - coagulation factor ix
(recombinant) for inj 250 unit
5
5
5
5
4
BRILINTA - ticagrelor tab 60 mg
cilostazol tab 100 mg (Pletal)
•
ACA
5
Quantity Limits
clopidogrel bisulfate tab 300 mg
(base equiv) (Plavix)
Restricted Access
•
Prior Review
5
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
1
1
•
•
•
•
•
•
•
•
140
5
•
KOATE-DVI - antihemophilic factor
5
•
KOGENATE FS - antihemophilic
250 unit
5
•
500 unit
5
•
1000 unit
5
•
2000 unit
5
•
3000 unit
5
•
KOGENATE FS BIO-SET antihemophilic factor
(recombinant) for inj kit 250 unit
5
•
•
5
•
5
•
5
•
IDELVION - coagulation factor ix
(recomb) (rix-fp) for inj 500 unit
5
•
5
•
5
•
5
•
5
•
IXINITY - coagulation factor ix
5
•
•
5
•
5
•
•
KOVALTRY - antihemophilic factor
5
•
5
•
•
5
•
1000 unit
2000 unit
5
•
3000 unit
5
•
HEMOFIL M - antihemophilic factor
5
•
5
•
5
•
5
•
HUMATE-P - antihemophilic factor/
vwf (human) for inj 250-600 unit
5
•
vwf (human) for inj 500-1200 unit
5
•
vwf (human) for inj 1000-2400
unit
5
•
5
ACA
•
Quantity Limits
5
5
Restricted Access
500 unit
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
•
Prior Review
Specialty
Drug Name
Drug Tier
2016
141
5
•
NUWIQ - antihemophilic factor
5
•
MONOCLATE-P - antihemophilic
factor (human) for inj kit 1000
unit
5
5
•
factor (human) for inj kit 1500
unit
5
•
5
•
MONONINE - coagulation factor ix
for inj 500 unit
5
•
5
•
•
5
MONONINE - coagulation factor ix
for inj 1000 unit
5
•
5
•
5
NOVOEIGHT - antihemophilic
factor (recombinant) for inj 250
unit
•
5
•
unit
5
•
•
5
•
unit
5
•
•
OBIZUR - antihemophilic factor
(recomb porc) rpfviii for inj 500
unit
pentoxifylline tab cr 400 mg
1
unit
5
•
•
unit
5
•
•
unit
5
•
•
NOVOSEVEN RT - coagulation
factor viia (recomb) for inj 1 mg
(1000 mcg)
5
•
•
(2000 mcg)
5
•
•
(5000 mcg)
5
•
•
•
•
•
PLAVIX - clopidogrel bisulfate tab
75 mg (base equiv)
4
PLAVIX - clopidogrel bisulfate tab
300 mg (base equiv)
4
PROFILNINE - factor ix complex for 5
inj 500 unit
inj 1000 unit
inj 1500 unit
5
PROFILNINE SD - factor ix
complex for inj 500 unit
5
5
ACA
•
Quantity Limits
5
Restricted Access
(8000 mcg)
Prior Review
factor (human) for inj kit 250 unit
5
Specialty
•
Drug Name
Drug Tier
5
ACA
•
Quantity Limits
5
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
•
•
•
•
•
•
•
142
•
RECOMBINATE - antihemophilic
factor (recombinant) for inj
1801-2400 unit
5
•
RIASTAP - fibrinogen conc (human) 5
inj approximately 1 gm (900-1300
mg)
5
RIXUBIS - coagulation factor ix
5
5
5
5
TRETTEN - coagulation factor xiii a- 5
subunit for inj 2000-3125 unit
VONVENDI - von willebrand factor 5
VONVENDI - von willebrand factor 5
WILATE - antihemophilic factor/vwf 5
(human) for inj 500-500 unit kit
WILATE - antihemophilic factor/vwf 5
(human) for inj 1000-1000 unit kit
5
XYNTHA - antihemophilic factor
recombinant paf for inj kit 250
unit
•
•
•
•
•
•
•
•
•
5
•
unit
5
•
XYNTHA SOLOFUSE antihemophilic factor
unit
5
•
unit
5
•
unit
5
•
unit
5
•
unit
5
•
ZONTIVITY - vorapaxar sulfate tab
4
5
unit
ACA
1241-1800 unit
•
Quantity Limits
•
5
Restricted Access
5
unit
Prior Review
801-1240 unit
Specialty
•
Drug Name
Drug Tier
5
401-800 unit
ACA
•
Quantity Limits
5
Restricted Access
220-400 unit
Prior Review
Specialty
Drug Name
Drug Tier
2016
TOPICAL PRODUCTS
OPHTHALMIC AGENTS
•
•
•
ACULAR - ketorolac tromethamine
ophth soln 0.5%
4
ACULAR LS - ketorolac
tromethamine ophth soln 0.4%
4
ACUVAIL - ketorolac tromethamine
ophth soln 0.45%
4
• •
AKTEN - lidocaine hcl ophth gel
3.5%
4
• •
ALCAINE - proparacaine hcl ophth
soln 0.5%
4
143
4
BACITRACIN - bacitracin ophth oint 4
500 unit/gm
1
bacitracin-polymyxin b ophth
oint
bacitracin-polymyxin-neomycin- 1
hc ophth oint 1%
4
BEPREVE - bepotastine besilate
ophth soln 1.5%
4
BESIVANCE - besifloxacin hcl
ophth susp 0.6% (base equiv)
BETADINE OPHTHALMIC PREP - 4
povidone-iodine ophth soln 5%
4
BETAGAN - levobunolol hcl ophth
soln 0.5%
1
betaxolol hcl ophth soln 0.5%
• •
BIMATOPROST - bimatoprost
ophth soln 0.03%
4
• •
BLEPH-10 - sulfacetamide sodium
ophth soln 10%
4
4
• •
• •
BLEPHAMIDE - sulfacetamide
sodium-prednisolone ophth susp
10-0.2%
BLEPHAMIDE S.O.P. sulfacetamide sodiumprednisolone ophth oint 10-0.2%
4
• •
• •
brimonidine tartrate ophth soln
0.15% (Alphagan p)
2
brimonidine tartrate ophth soln
0.2%
1
4
• •
BROMFENAC - bromfenac
sodium ophth soln 0.09% (base
equivalent)
• •
2
bromfenac sodium ophth soln
0.09% (base equiv) (once-daily)
1
carteolol hcl ophth soln 1%
• •
• •
BETIMOL - timolol ophth soln
0.25%
4
• •
BETIMOL - timolol ophth soln 0.5%
4
• •
4
ACA
• •
AZOPT - brinzolamide ophth susp
1%
BETOPTIC-S - betaxolol hcl ophth
susp 0.25%
Quantity Limits
ALPHAGAN P - brimonidine tartrate 4
ophth soln 0.1%
ALPHAGAN P - brimonidine tartrate 4
ophth soln 0.15%
4
ALREX - loteprednol etabonate
ophth susp 0.2%
2
apraclonidine hcl ophth soln
0.5% (base equivalent)
(Iopidine)
4
ATROPINE SULFATE - atropine
sulfate ophth oint 1%
1
atropine sulfate ophth soln 1%
(Isopto atropine)
AZASITE - azithromycin ophth soln 4
1%
2
azelastine hcl ophth soln 0.05%
Restricted Access
• •
Prior Review
4
Specialty
ALOMIDE - lodoxamide
tromethamine ophth soln 0.1%
Drug Name
Drug Tier
• •
4
ACA
ALOCRIL - nedocromil sodium
ophth soln 2%
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
CILOXAN - ciprofloxacin hcl ophth
oint 0.3%
4
CILOXAN - ciprofloxacin hcl ophth
soln 0.3%
4
ciprofloxacin hcl ophth soln
0.3% (Ciloxan)
1
COMBIGAN - brimonidine tartratetimolol maleate ophth soln
0.2-0.5%
4
COSOPT - dorzolamide hcl-timolol
maleate ophth soln 22.3-6.8 mg/
ml
4
COSOPT PF - dorzolamide hcltimolol maleate ophth sol
22.3-6.8 mg/ml pf
4
cromolyn sodium ophth soln 4%
1
CYCLOGYL - cyclopentolate hcl
ophth soln 0.5%
4
ophth soln 1%
4
• •
• •
• •
144
ophth soln 2%
4
CYCLOMYDRIL - cyclopentolate w/ 4
phenylephrine ophth soln 0.2-1%
2
cyclopentolate hcl ophth soln
0.5% (Cyclogyl)
1
1% (Cyclogyl)
1
2% (Cyclogyl)
CYSTARAN - cysteamine hcl ophth 5
soln 0.44% (base equivalent)
4
DEXAMETHASONE SODIUM
PHOS - dexamethasone sodium
phosphate ophth soln 0.1%
1
diclofenac sodium ophth soln
0.1%
1
dorzolamide hcl ophth soln 2%
(Trusopt)
dorzolamide hcl-timolol maleate 1
ophth soln 22.3-6.8 mg/ml
(Cosopt)
4
DUREZOL - difluprednate ophth
emulsion 0.05%
4
ELESTAT - epinastine hcl ophth
soln 0.05%
EMADINE - emedastine difumarate 4
ophth soln 0.05% (base equiv)
2
epinastine hcl ophth soln 0.05%
(Elestat)
1
erythromycin ophth oint 5 mg/
gm
FLAREX - fluorometholone acetate 4
ophth susp 0.1%
1
fluorometholone ophth susp
0.1% (Fml liquifilm)
1
flurbiprofen sodium ophth soln
0.03% (Ocufen)
4
FML - fluorometholone ophth oint
0.1%
• •
• •
• •
• •
• •
• •
•
FML FORTE - fluorometholone
ophth susp 0.25%
4
FML LIQUIFILM - fluorometholone
ophth susp 0.1%
4
gatifloxacin ophth soln 0.5%
(Zymaxid)
2
GELFILM OP - gelatin adsorbable
ophth film
4
gentamicin sulfate ophth oint
0.3%
1
gentamicin sulfate ophth soln
0.3% (Garamycin)
ACA
• •
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
1
homatropine hbr ophth soln 5%
(Isopto homatropine)
1
ILEVRO - nepafenac ophth susp
0.3%
4
IOPIDINE - apraclonidine hcl ophth
4
IOPIDINE - apraclonidine hcl ophth
soln 1% (base equivalent)
4
• •
ISOPTO CARBACHOL - carbachol
ophth soln 1.5%
4
• •
ISOPTO CARBACHOL - carbachol
ophth soln 3%
4
• •
ISOPTO CARPINE - pilocarpine hcl 4
ophth soln 1%
ophth soln 2%
ophth soln 4%
4
ISOPTO HOMATROPINE homatropine hbr ophth soln 2%
4
ISOPTO HOMATROPINE homatropine hbr ophth soln 5%
ISOPTO HYOSCINE - scopolamine 4
hbr ophth soln 0.25%
4
ISTALOL - timolol maleate ophth
soln 0.5% (once-daily)
1
ketorolac tromethamine ophth
soln 0.4% (Acular ls)
• •
• •
• •
145
ketorolac tromethamine ophth
soln 0.5% (Acular)
1
LACRISERT - artificial tear ophth
insert
4
LASTACAFT - alcaftadine ophth
soln 0.25%
4
latanoprost ophth soln 0.005%
(Xalatan)
1
levobunolol hcl ophth soln 0.5%
(Betagan)
1
levofloxacin ophth soln 0.5%
2
• •
• •
LOTEMAX - loteprednol etabonate
ophth gel 0.5%
3
• •
ophth oint 0.5%
4
• •
ophth susp 0.5%
4
• •
LUMIGAN - bimatoprost ophth soln
0.01%
4
• •
MAXIDEX - dexamethasone ophth
susp 0.1%
4
• •
MAXITROL - neomycin-polymyxindexamethasone ophth oint 0.1%
4
MAXITROL - neomycin-polymyxin- 4
dexamethasone ophth susp 0.1%
4
METIPRANOLOL - metipranolol
ophth soln 0.3%
4
MITOSOL - mitomycin for ophth
soln kit 0.2 mg
4
MOXEZA - moxifloxacin hcl ophth
soln 0.5% (base eq) (2 times
daily)
NATACYN - natamycin ophth susp 4
5%
1
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op
oin
1
neomycin-polymy-gramicid op
sol 1.75-10000-0.025mg-untmg/ml (Neosporin)
• •
• •
• •
neomycin-polymyxindexamethasone ophth oint
0.1% (Maxitrol)
neomycin-polymyxindexamethasone ophth susp
0.1% (Maxitrol)
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
1
1
NEOMYCIN/POLYMYXIN/
HYDROC - neomycin-polymyxinhc ophth susp
4
NEOSPORIN - neomycinpolymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml
4
NEVANAC - nepafenac ophth susp
0.1%
4
OCUFEN - flurbiprofen sodium
ophth soln 0.03%
4
OCUFLOX - ofloxacin ophth soln
0.3%
4
ofloxacin ophth soln 0.3%
(Ocuflox)
1
olopatadine hcl ophth soln 0.1%
(base equivalent) (Patanol)
2
OMNIPRED - prednisolone acetate
ophth susp 1%
4
ophthalmic irrigation solution intraocular (Bss plus)
2
PATADAY - olopatadine hcl ophth
4
PATANOL - olopatadine hcl ophth
4
PAZEO - olopatadine hcl ophth soln 4
2
phenylephrine hcl ophth soln
2.5%
1
phenylephrine hcl ophth soln
10%
4
PHOSPHOLINE IODIDE echothiophate iodide ophth for
soln 0.125%
1
pilocarpine hcl ophth soln 1%
(Isopto carpine)
• •
• •
• •
• •
146
(Isopto carpine)
1
(Isopto carpine)
2
polymyxin b-trimethoprim
ophth soln 10000 unit/ml-0.1%
(Polytrim)
1
POLYTRIM - polymyxin btrimethoprim ophth soln 10000
unit/ml-0.1%
4
PRED FORTE - prednisolone
acetate ophth susp 1%
4
PRED MILD - prednisolone acetate
ophth susp 0.12%
4
PRED-G - gentamicin-prednisolone
ace ophth susp 0.3-1%
4
• •
PRED-G S.O.P. - gentamicinprednisolone ace ophth oint
0.3-0.6%
4
• •
prednisolone acetate ophth susp
1% (Pred forte)
2
PREDNISOLONE SODIUM
PHOSP - prednisolone sodium
phosphate ophth soln 1%
4
PROLENSA - bromfenac sodium
ophth soln 0.07% (base
equivalent)
4
proparacaine hcl ophth soln
0.5% (Alcaine)
1
sulfacetamide sodiumprednisolone ophth soln
10-0.23(0.25)%
tetracaine hcl ophth soln 0.5%
timolol maleate ophth gel
forming soln 0.25% (Timopticxe)
• •
RESCULA - unoprostone isopropyl
ophth soln 0.15%
4
• •
RESTASIS - cyclosporine (ophth)
emulsion 0.05%
4
•
SIMBRINZA - brinzolamidebrimonidine tartrate ophth susp
1-0.2%
3
SULFACETAMIDE SODIUM sulfacetamide sodium ophth oint
10%
4
sulfacetamide sodium ophth
soln 10% (Bleph-10)
1
ACA
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ACA
Quantity Limits
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Drug Tier
2016
1
1
2
2
timolol maleate ophth gel
forming soln 0.5% (Timoptic-xe)
1
timolol maleate ophth soln
0.25% (Timoptic)
timolol maleate ophth soln 0.5% 1
(Timoptic)
4
TIMOPTIC - timolol maleate ophth
soln 0.25%
4
TIMOPTIC - timolol maleate ophth
soln 0.5%
4
TIMOPTIC OCUDOSE - timolol
maleate preservative free ophth
soln 0.25%
4
TIMOPTIC OCUDOSE - timolol
maleate preservative free ophth
soln 0.5%
4
TIMOPTIC-XE - timolol maleate
ophth gel forming soln 0.25%
4
TIMOPTIC-XE - timolol maleate
ophth gel forming soln 0.5%
4
TOBRADEX - tobramycindexamethasone ophth oint
0.3-0.1%
4
TOBRADEX - tobramycindexamethasone ophth susp
0.3-0.1%
4
TOBRADEX ST - tobramycindexamethasone ophth susp
0.3-0.05%
1
tobramycin ophth soln 0.3%
(Tobrex)
2
tobramycin-dexamethasone
ophth susp 0.3-0.1% (Tobradex)
4
TOBREX - tobramycin ophth oint
0.3%
• •
• •
• •
• •
• •
147
TOBREX - tobramycin ophth soln
0.3%
4
TRAVATAN Z - travoprost ophth
soln 0.004% (benzalkonium free)
(bak free)
4
TRAVOPROST - travoprost ophth
soln 0.004%
4
trifluridine ophth soln 1%
(Viroptic)
2
TRUSOPT - dorzolamide hcl ophth
soln 2%
4
VEXOL - rimexolone ophth susp 1% 4
VIGAMOX - moxifloxacin hcl ophth 4
soln 0.5% (base equiv)
4
VIROPTIC - trifluridine ophth soln
1%
4
XALATAN - latanoprost ophth soln
0.005%
4
XIIDRA - lifitegrast ophth soln 5%
• •
• •
• •
• •
ZIOPTAN - tafluprost ophth soln
0.0015%
4
• •
ZIRGAN - ganciclovir ophth gel
0.15%
4
• •
ZYLET - loteprednol etabonatetobramycin ophth susp 0.5-0.3%
4
• •
ZYMAXID - gatifloxacin ophth soln
0.5%
4
OTIC AGENTS
acetic acid otic soln 2%
1
ACETIC ACID/ALUMINUM ACET acetic acid 2% in aluminum
acetate otic soln
4
antipyrine-benzocaine otic soln
54-14 mg/ml (5.4-1.4%)
1
CETRAXAL - ciprofloxacin hcl otic
4
CIPRO HC - ciprofloxacinhydrocortisone otic susp 0.2-1%
4
• •
CIPRODEX - ciprofloxacindexamethasone otic susp
0.3-0.1%
4
• •
CIPROFLOXACIN - ciprofloxacin
hcl otic soln 0.2% (base
equivalent)
4
COLY-MYCIN S - neomycincolistin-hc-thonzonium otic susp
3.3-3-10-0.5 mg/ml
4
CORTANE-B AQUEOUS pramoxine-hc-chloroxylenol
aqueous otic soln 10-10-1 mg/ml
4
ACA
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ACA
Quantity Limits
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Drug Tier
2016
• •
CORTANE-B-OTIC - pramoxine-hc- 4
chloroxylenol otic soln 10-10-1
mg/ml
4
DERMOTIC - fluocinolone
acetonide (otic) oil 0.01%
2
fluocinolone acetonide (otic) oil
0.01% (Dermotic)
2
hydrocortisone w/ acetic acid
otic soln 1-2%
1
neomycin-polymyxin-hc otic
soln 1% (Cortisporin)
1
neomycin-polymyxin-hc otic
susp 3.5 mg/ml-10000 unit/
ml-1%
1
ofloxacin otic soln 0.3%
OTICIN HC NR - pramoxine-hcchloroxylenol otic soln 10-10-1
mg/ml
4
PRAMOTIC - pramoxinechloroxylenol otic liquid 1-0.1%
4
pramoxine-hc-chloroxylenol otic
soln 10-10-1 mg/ml (Cortane-botic)
1
MOUTH/THROAT/DENTAL AGENTS
ACT TOTAL CARE DRY MOUTH - A
sodium fluoride rinse 0.02%
4
AQUORAL - artificial saliva - aero
soln
4
ARESTIN - minocycline hcl
subgingival powder cartridge 1
mg
2
benzocaine dental soln 20%
•
• •
• •
148
•
2
A
•
1
LISTERINE TOTAL CARE ZERO sodium fluoride rinse 0.02%
LISTERINE WHITENING/RESTO sodium fluoride rinse 0.0221%
(0.01% f)
A
•
NAFRINSE DAILY/ACIDULATED sodium fluoride-phosphoric acid
for soln 1 mg/5ml (f equiv)
4
•
NAFRINSE DAILY/NEUTRAL sodium fluoride for soln rinse
0.05%
4
•
NAFRINSE WEEKLY - sodium
fluoride for soln rinse 0.2%
4
•
NEUTRASAL - artificial saliva packet
4
NUMOISYN - artificial saliva lozenge
4
cevimeline hcl cap 30 mg
(Evoxac)
chlorhexidine gluconate soln
0.12% (Peridex)
1
COLGATE DRY MOUTH RELIEF sodium fluoride mouthwash 2.1
mg/10ml
A
•
CREST COMPLETE - sodium
fluoride paste 0.243%
A
•
DEBACTEROL - sulfuric acidsulfonated phenolics soln
30-50%
4
EVOXAC - cevimeline hcl cap 30
mg
4
FLUORIDEX DAILY DEFENSE S sodium fluoride-potassium nitrate
gel 1.1-5%
4
•
GEL-KAM - stannous fluoride gel
0.4%
A
•
NUMOISYN - artificial saliva solution
4
GEL-KAM ORAL CARE RINSE stannous fluoride conc 0.63%
4
•
nystatin susp 100000 unit/ml
1
GELCLAIR - povidone-sodium
hyaluronate-glycyrrhetinic acid
gel
4
LIDOCAINE HCL - lidocaine hcl
laryngotracheal soln 4%
1
lidocaine hcl viscous soln 2%
1
A
LISTERINE ESSENTIAL CARE sod monofluorophosph-eucalmen-methyl sal-thymol gel 0.76%
LISTERINE RESTORING - sodium A
fluoride rinse 0.0221% (0.01% f)
A
LISTERINE SMART RINSE sodium fluoride rinse 0.0221%
(0.01% f)
LISTERINE TOTAL CARE - sodium A
fluoride rinse 0.0221% (0.01% f)
• •
• •
•
•
•
•
OMNI GEL - stannous fluoride gel
0.4%
• •
• •
•
A
ORAFATE - sucralfate-malate paste 4
10%
ORAVIG - miconazole buccal tab 50 4
mg (mouth-throat)
PERIDEX - chlorhexidine gluconate 4
soln 0.12%
PHOS FLUR - sodium fluoride rinse A
0.044%
PHOS-FLUR ORTHO DEFENSE - A
2
pilocarpine hcl tab 5 mg
(Salagen)
2
pilocarpine hcl tab 7.5 mg
(Salagen)
PREVIDENT - sodium fluoride rinse 4
0.2%
ACA
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Drug Tier
ACA
Quantity Limits
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A
4
• •
Drug Name
LISTERINE TOTAL CARE PLUS sodium fluoride rinse 0.0221%
(0.01% f)
CAPHOSOL - artificial saliva solution
clotrimazole troche 10 mg
Specialty
Drug Name
Drug Tier
2016
•
• •
•
•
•
149
•
PREVIDENT 5000 BOOSTER PL sodium fluoride paste 1.1%
4
•
PREVIDENT 5000 DRY MOUTH sodium fluoride gel 1.1% (0.5% f)
4
•
(Prevident)
PREVIDENT 5000 ENAMEL PRO sodium fluoride-potassium nitrate
paste 1.1-5%
4
•
PREVIDENT 5000 PLUS - sodium
fluoride cream 1.1%
4
•
PREVIDENT 5000 SENSITIVE sodium fluoride-potassium nitrate
paste 1.1-5%
4
1
•
(0.01% f)
A
•
A
1
•
•
sodium fluoride-potassium
nitrate paste 1.1-5% (Prevident
5000 sensi)
1
•
stannous fluoride conc 0.63%
(Gel-kam oral care ri)
1
•
stannous fluoride gel 0.4%
A
STANNOUS FLUORIDE RINSE stannous fluoride liq 0.1%
A
•
•
PROTHELIAL - sucralfate-malate
paste 10%
4
THERA-FLUR-N - sodium fluoride
gel 1.1% (0.5% f)
4
•
REMBRANDT DEEPLY
WHITE+PE - sodium
monofluorophosphate paste
0.884%
A
triamcinolone acetonide dental
paste 0.1%
2
REMBRANDT INTENSE STAIN sodium fluoride paste 0.243%
A
•
REMBRANDT WHITENING sodium fluoride rinse 0.02%
A
•
SALAGEN - pilocarpine hcl tab 5
mg
4
SALAGEN - pilocarpine hcl tab 7.5
mg
4
SALIVAMAX - artificial saliva packet
4
• •
SALIVATE RX - artificial saliva packet
4
• •
SENSODYNE REPAIR &
PROTEC - stannous fluoride
paste 0.454%
A
•
sodium fluoride cream 1.1%
(Prevident 5000 plus)
1
•
sodium fluoride gel 1.1% (0.5% f)
(Prevident fluoride)
1
•
•
•
•
sodium fluoride paste 1.1%
(Prevident 5000 boost)
4
ACA
PREVIDENT 5000 BOOSTER sodium fluoride paste 1.1%
Quantity Limits
•
Restricted Access
4
Prior Review
PREVIDENT FLUORIDE - sodium
fluoride gel 1.1% (0.5% f)
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
ANORECTAL AGENTS
ANALPRAM E - hc-pramoxine emol 4
cream 2.5-1% & pramoxine wipe
1% kit
4
ANALPRAM HC - hydrocortisone
acetate w/ pramoxine rectal
cream 2.5-1%
4
ANALPRAM HC SINGLES hydrocortisone acetate w/
pramoxine rectal cream 2.5-1%
4
ANALPRAM-HC - hydrocortisone
acetate w/ pramoxine rectal
cream 1-1%
4
ANALPRAM-HC - hydrocortisone
acetate w/ pramoxine rectal lotn
2.5-1%
4
ANALPRAM-HC SINGLES hydrocortisone acetate w/
pramoxine rectal cream 1-1%
4
ANALPRAM-HC SINGLES hydrocortisone acetate w/
• •
150
ANUSOL-HC - hydrocortisone
rectal cream 2.5%
4
PROCTOCORT - hydrocortisone
rectal cream 1%
4
CORTENEMA - hydrocortisone
enema 100 mg/60ml
4
4
• •
CORTIFOAM - hydrocortisone
acetate rectal foam 10% (90 mg/
dose)
4
PROCTOFOAM HC hydrocortisone acetate w/
pramoxine rectal foam 1-1%
RECTIV - nitroglycerin oint 0.4%
4
hydrocortisone acetate suppos
25 mg (Anusol-hc)
1
•
• •
hydrocortisone acetate suppos
30 mg (Proctocort)
• •
UCERIS - budesonide rectal foam 2 4
mg/act
DERMATOLOGICALS
2
ABSORICA - isotretinoin cap 10 mg 5
hydrocortisone acetate w/
pramoxine rectal cream 1-1%
(Analpram-hc)
2
hydrocortisone acetate w/
(Analpram-hc)
2
hydrocortisone enema
100 mg/60ml (Cortenema)
2
ACANYA - clindamycin phosphatebenzoyl peroxide gel 1.2-2.5%
4
hydrocortisone rectal cream 1%
(Proctocort)
1
acitretin cap 10 mg (Soriatane)
2
hydrocortisone rectal cream
2.5% (Anusol-hc)
1
acitretin cap 25 mg (Soriatane)
LIDOCAINE HCL-HYDROCORTIS - 4
lidocaine-hydrocortisone acetate
rectal gel 2.8-0.55%
lidocaine-hydrocortisone acetate 2
rectal cream kit 2-2%
rectal cream kit 3-0.5%
rectal cream kit 3-1%
rectal cream 3-0.5%
rectal gel kit 3-2.5%
PROCORT - hydrocortisone acetate 4
w/ pramoxine rectal cream
1.85-1.15%
4
PROCTOCORT - hydrocortisone
acetate suppos 30 mg
acitretin cap 17.5 mg (Soriatane)
• •
• •
ACA
2
4
ACUICYN DAILY EYELID & EY eyelid cleansers - liquid
4
acyclovir oint 5% (Zovirax)
2
ACZONE - dapsone gel 5%
4
ACZONE - dapsone gel 7.5%
4
ADAPALENE - adapalene lotion
0.1%
4
adapalene cream 0.1% (Differin)
2
adapalene gel 0.3% (Differin)
•
•
•
•
•
•
•
2
ACLOVATE - alclometasone
dipropionate cream 0.05%
adapalene gel 0.1% (Differin)
•
•
•
•
•
•
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
2
2
ALA SCALP - hydrocortisone lotion
2%
4
ALA-QUIN - clioquinol-hc cream
3-0.5%
4
alclometasone dipropionate
cream 0.05% (Aclovate)
2
•
•
• •
•
•
•
• •
151
alclometasone dipropionate oint
0.05%
• •
AVAR-E LS - sulfacetamide sodium
w/ sulfur cream 10-2%
4
•
AVENOVA - eyelid cleansers - liquid 4
AZELEX - azelaic acid cream 20% 4
•
ALCORTIN A - iodoquinolhydrocortisone-aloe
polysaccharide gel 1-2-1%
4
ALDARA - imiquimod cream 5%
4
ALEVICYN ANTIPRURITIC GEL wound dressings - gel
4
• • •
• •
ALEVICYN DERMAL SPRAY wound dressings - soln
4
• •
ALOQUIN - iodoquinol-aloe
polysaccharides gel 1.25-1%
4
• •
ALTABAX - retapamulin oint 1%
4
• •
ALUVEA - urea cream 39%
4
AMCINONIDE - amcinonide cream
0.1%
4
AMCINONIDE - amcinonide lotion
0.1%
4
AMCINONIDE - amcinonide oint
0.1%
4
APEXICON E - diflorasone
diacetate emollient base cream
0.05%
4
ARZOL SILVER NITRATE APP silver nitrate-potassium nitrate
applicator 75-25%
4
ATOPICLAIR - dermatological
products misc - cream
4
• •
ATRALIN - tretinoin gel 0.05%
4
• •
• •
• •
• •
• •
•
•
•
•
BACTROBAN - mupirocin calcium
cream 2%
4
BEAU RX - scar treatment products 4
- gel
4
BENSAL HP - salicylic acid &
benzoic acid oint 3-6%
4
BENZAC AC WASH - benzoyl
peroxide liq 5%
4
BENZACLIN - clindamycin
phosphate-benzoyl peroxide gel
1-5%
4
BENZACLIN WITH PUMP clindamycin phosphate-benzoyl
peroxide gel 1-5%
BENZAMYCIN - benzoyl peroxide- 4
erythromycin gel 5-3%
4
BENZAMYCINPAK - benzoyl
peroxide-erythromycin gel pack
5-3%
4
BENZEFOAM - benzoyl peroxide
foam 5.3%
4
BENZEFOAM ULTRA - benzoyl
peroxide foam 9.8%
BENZIQ - benzoyl peroxide gel 5.25 4
%
BENZIQ LS - benzoyl peroxide gel 4
2.75%
2
benzoyl peroxide cloth 6%
benzoyl peroxide creamy wash
8% &benzoyl peroxide bar 5%
kit
benzoyl peroxide foam 5.3%
(Benzefoam)
•
ACA
4
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Tier
Drug Name
AVAR LS CLEANSER sulfacetamide sodium w/ sulfur
cleanser 10-2%
2
ATRAPRO ANTIPRURITIC HYDR - 4
wound dressings - gel
4
ATRAPRO DERMAL SPRAY wound cleansers - liquid
4
AVAR - sulfacetamide sodium w/
sulfur cleansing pad 9.5-5%
4
AVAR - sulfacetamide sodium w/
sulfur foam 9.5-5%
AVAR LS - sulfacetamide sodium w/ 4
sulfur cleansing pad 10-2%
AVAR LS - sulfacetamide sodium w/ 4
sulfur foam 10-2%
ACA
Quantity Limits
Restricted Access
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Specialty
Drug Name
Drug Tier
2016
• •
•
•
•
•
•
•
•
•
•
2
2
152
benzoyl peroxide foam 9.8%
(Benzefoamultra)
2
calcipotriene cream 0.005%
(Dovonex)
2
benzoyl peroxide gel 10%
1
calcipotriene oint 0.005%
2
benzoyl peroxide liq 2.5%
benzoyl peroxide liq 7%
2
calcipotriene soln 0.005%
(50 mcg/ml)
2
2
CALCITRIOL - calcitriol oint 3 mcg/
gm
4
benzoyl peroxideerythromycin gel 5-3%
(Benzamycin)
2
• •
4
• •
betamethasone dipropionate
augmented cream 0.05%
(Diprolene af)
1
CAMPHOMEX - camphorhistamine-menthol liqd spray
4-0.025-10%
4
• •
augmented gel 0.05%
2
CAPEX - fluocinolone acetonide
shampoo 0.01%
CARAC - fluorouracil cream 0.5%
4
CARRASYN HYDROGEL WOUND
D - wound dressings - gel
4
• •
• •
CEM-UREA - urea soln 45%
4
• •
CENTANY - mupirocin oint 2%
4
CENTANY AT - mupirocin oint kit
2%
4
• •
CICLODAN CREAM KIT - ciclopirox 4
olamine cream 0.77% (base
equiv) & cleanser kit
4
CICLODAN SOLUTION KIT ciclopirox solution kit 8%
2
ciclopirox gel 0.77%
• •
benzoyl peroxide liq 5.25%
benzoyl peroxide lotion 6%
2
2
2
augmented lotion 0.05%
(Diprolene)
2
augmented oint 0.05%
(Diprolene)
2
cream 0.05%
2
lotion 0.05%
oint 0.05%
betamethasone valerate aerosol
foam 0.12% (Luxiq)
betamethasone valerate cream
0.1%
betamethasone valerate lotion
0.1%
betamethasone valerate oint
0.1%
2
2
2
ciclopirox olamine cream 0.77%
(base equiv)
1
ciclopirox olamine susp 0.77%
(base equiv)
2
1
BP CLEANSING WASH sulfacetamide sodium-sulfur in
urea emulsion 10-4%
4
•
BPO - benzoyl peroxide gel 4%
4
BPO - benzoyl peroxide gel 8%
4
•
•
ACA
2
calcipotriene-betamethasone
dipropionate oint 0.005-0.064%
(Taclonex)
benzoyl peroxide liq 10%
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
1
1
ciclopirox shampoo 1% (Loprox
shampoo)
2
ciclopirox solution kit 8%
(Ciclodan solution ki)
2
ciclopirox solution 8% (Penlac
Nail Lacquer)
1
CICLOPIROX TOPICAL SOLUTI - 4
ciclopirox solution 8% & vitamin e
5% topical kit
• •
153
CLEOCIN-T - clindamycin
phosphate swab 1%
4
•
CLINDACIN ETZ - clindamycin
phosphate swab 1% & cleanser
kit
4
•
CLINDACIN PAC - clindamycin
phosphate swab 1% & cleanser
kit
4
•
CLINDAGEL - clindamycin
phosphate gel 1%
4
clindamycin phosph-benzoyl
peroxide (refrig) gel 1.2 (1)-5%
(Duac)
2
clindamycin phosphate foam 1%
(Evoclin)
2
clindamycin phosphate gel 1%
(Cleocin-t)
2
clindamycin phosphate lotion
1% (Cleocin-t)
2
•
clobetasol propionate oint 0.05%
(Temovate)
2
clobetasol propionate shampoo
0.05% (Clobex)
2
clobetasol propionate soln
0.05% (Temovate)
clobetasol propionate spray
0.05% (Clobex)
2
2
CLOBEX - clobetasol propionate
lotion 0.05%
4
shampoo 0.05%
4
spray 0.05%
4
CLOCORTOLONE PIVALATE clocortolone pivalate cream 0.1%
4
• •
CLOCORTOLONE PIVALATE
PUM - clocortolone pivalate
cream 0.1%
4
• •
4
• •
clindamycin phosphate soln 1%
(Cleocin-t)
2
CLODAN KIT - clobetasol
propionate shampoo 0.05% &
cleanser kit
1
CLODERM - clocortolone pivalate
cream 0.1%
4
clindamycin phosphate swab 1%
(Cleocin-t)
• •
CLODERM PUMP - clocortolone
pivalate cream 0.1%
4
clindamycin phosphate-benzoyl
peroxide gel 1-5% (Benzaclin)
2
• •
2
clotrimazole w/ betamethasone
cream 1-0.05% (Lotrisone)
2
2
clotrimazole w/ betamethasone
lotion 1-0.05%
clindamycin phosphatetretinoin gel 1.2-0.025% (Ziana)
clobetasol propionate cream
0.05% (Temovate)
2
clobetasol propionate emollient
base cream 0.05% (Temovate e)
2
clobetasol propionate emulsion
foam 0.05% (Olux-e)
2
clobetasol propionate foam
0.05% (Olux)
•
ACA
4
2
Quantity Limits
phosphate soln 1%
clobetasol propionate lotion
0.05% (Clobex)
Restricted Access
•
2
Prior Review
4
clobetasol propionate gel 0.05%
(Temovate)
Specialty
phosphate lotion 1%
Drug Name
Drug Tier
•
4
ACA
phosphate gel 1%
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
2
CNL8 NAIL KIT - ciclopirox soln 8% 4
& lacquer removal pads kit
4
COAL TAR - coal tar soln 20%
• •
COCAINE HCL - cocaine hcl soln
4%
4
• •
• •
COCAINE HCL - cocaine hcl soln
10%
4
• •
154
DERMASORB XM - urea cream
39% & emollient cream kit
4
• •
• •
dermatological products misc cream
2
4
• •
DERMATOP - prednicarbate cream
0.1%
4
CORDRAN TAPE - flurandrenolide
tape 4 mcg/sqcm
4
• •
DERMATOP - prednicarbate oint
0.1%
4
CORTANE-B - hydrocortisonepramoxine-chloroxylenol lot
10-10-1mg/ml
4
• •
DESONATE - desonide gel 0.05%
4
desonide cream 0.05%
(Desowen)
2
CORTISPORIN - bacitracinpolymyxin-neomycin hc oint 1%
4
• •
CORTISPORIN - neomycinpolymyxin-hc crm 3.5 mg/
gm-10000 unt/gm-0.5%
4
• •
desonide lotion 0.05% (Desowen) 2
2
desonide oint 0.05% (Desowen)
COSENTYX - secukinumab
syringe 150 mg/ml
5
• • • •
•
COSENTYX SENSOREADY PEN secukinumab subcutaneous soln
auto-injector 150 mg/ml
5
• • • •
•
CUTIVATE - fluticasone propionate
cream 0.05%
4
CUTIVATE - fluticasone propionate
lotion 0.05%
4
DENAVIR - penciclovir cream 1%
4
DERMA-SMOOTHE/FS BODY fluocinolone acetonide oil 0.01%
(body oil)
4
DERMA-SMOOTHE/FS SCALP fluocinolone acetonide oil 0.01%
(scalp oil)
4
DERMASORB AF - clioquinol-hc
cream 3-0.5% & emollient liqd kit
4
DERMASORB HC - hydrocortisone
lot 2% & cleanser liq kit
4
CONDYLOX - podofilox soln 0.5%
4
COPASIL - emollient - gel
4
CORDRAN - flurandrenolide cream
0.05%
4
CORDRAN - flurandrenolide lotion
0.05%
4
CORDRAN - flurandrenolide oint
0.05%
• •
• •
• •
DESOWEN - desonide cream
0.05%
• •
ACA
4
4
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Tier
ACA
Drug Name
DERMASORB TA - triamcinolone
cream 0.1% & emollient cream
kit
CONDYLOX - podofilox gel 0.5%
• •
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
4
DESOWEN - desonide lotion 0.05% 4
4
DESOXIMETASONE desoximetasone cream 0.05%
4
DESOXIMETASONE desoximetasone oint 0.05%
2
desoximetasone cream 0.25%
(Topicort)
2
desoximetasone gel 0.05%
(Topicort)
2
desoximetasone oint 0.25%
(Topicort)
4
DIAB - wound dressings - gel
• •
• •
DIAB F.D.G. FREEZE-DRIED wound dressings - gel
4
• •
• •
diclofenac sodium (actinic
keratoses) gel 3% (Solaraze)
2
• •
diclofenac sodium gel 1%
(Voltaren)
2
•
diclofenac sodium soln 1.5%
(Pennsaid)
2
•
DIFFERIN - adapalene cream 0.1% 4
4
DIFFERIN - adapalene gel 0.1%
• •
• •
155
4
DIFFERIN - adapalene lotion 0.1%
4
DIFLORASONE DIACETATE diflorasone diacetate cream
0.05%
4
DIFLORASONE DIACETATE diflorasone diacetate oint 0.05%
4
DIPROLENE - betamethasone
dipropionate augmented lotion
0.05%
4
DIPROLENE - betamethasone
dipropionate augmented oint
0.05%
4
DIPROLENE AF - betamethasone
dipropionate augmented cream
0.05%
4
DOVONEX - calcipotriene cream
0.005%
4
DOXEPIN HYDROCHLORIDE doxepin hcl cream 5%
4
• •
4
DOXYCYCLINE - doxycycline
(rosacea) cap delayed release 40
mg
4
DRITHO-CREME HP - anthralin
cream 1%
DRYSOL - aluminum chloride soln 4
20%
4
DUAC - clindamycin phosphbenzoyl peroxide (refrig) gel 1.2
(1)-5%
2
econazole nitrate cream 1%
• •
• •
•
• •
ECOZA - econazole nitrate foam
1%
4
EFUDEX - fluorouracil cream 5%
4
ELETONE - dermatological
4
• •
ELETONE TWINPACK dermatological products misc cream
4
• •
ELIDEL - pimecrolimus cream 1%
4
ELIMITE - permethrin cream 5%
4
•
ELOCON - mometasone furoate
cream 0.1%
4
oint 0.1%
4
solution 0.1% (lotion)
4
ENSTILAR - calcipotrienebetamethasone dipropionate
foam 0.005-0.064%
4
• •
EPIDUO - adapalene-benzoyl
peroxide gel 0.1-2.5%
4
• •
EPIDUO FORTE - adapalenebenzoyl peroxide gel 0.3-2.5%
4
• •
EPIFOAM - pramoxine-hc aerosol
foam 1-1%
4
• •
ERTACZO - sertaconazole nitrate
cream 2%
4
• •
ERYGEL - erythromycin gel 2%
4
•
erythromycin gel 2% (Erygel)
1
erythromycin pads 2%
erythromycin soln 2%
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
• •
• •
DIFFERIN - adapalene gel 0.3%
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
2
1
ESSENTRA WIPES 9X9" CLEAN isopropyl alcohol wipes 70%
4
EURAX - crotamiton cream 10%
4
EURAX - crotamiton lotion 10%
4
EVOCLIN - clindamycin phosphate
foam 1%
4
• •
• •
•
EXELDERM - sulconazole nitrate
cream 1%
4
• •
EXELDERM - sulconazole nitrate
solution 1%
4
• •
EXODERM - sodium thiosulfatesalicylic acid lotion 25-1%
4
EXTINA - ketoconazole foam 2%
4
FABIOR - tazarotene (acne) foam
0.1%
4
• •
FINACEA - azelaic acid foam 15%
4
FINACEA - azelaic acid gel 15%
4
•
•
FLECTOR - diclofenac epolamine
patch 1.3%
4
•
156
4
• •
2
GORDONS UREA - urea ointment
40%
4
• •
fluocinolone acetonide oil 0.01%
(body oil) (Derma-smoothe/fs
bod)
2
HALAC - halobetasol prop oint
0.05% & ammonium lactate lot
12% kit
4
fluocinolone acetonide oil 0.01%
(scalp oil) (Derma-smoothe/fs
sca)
2
halobetasol propionate cream
0.05% (Ultravate)
2
fluocinolone acetonide oint
0.025% (Synalar)
2
fluocinolone acetonide cream
0.025% (Synalar)
fluocinolone acetonide soln
0.01% (Synalar)
fluocinonide cream 0.05%
halobetasol propionate oint
0.05% (Ultravate)
2
2
fluocinonide cream 0.1% (Vanos) 2
2
fluocinonide emulsified base
cream 0.05%
2
fluocinonide gel 0.05%
fluocinonide oint 0.05%
fluocinonide soln 0.05%
2
2
4
HALOG - halcinonide oint 0.1%
4
HALOTIN - haloprogin cream 1%
4
HPR - dermatological products,
misc. - aerosol foam
4
•
•
•
•
HPR PLUS - dermatological
4
• •
HPR PLUS - dermatological
products, misc. - aerosol foam
4
• •
4
• •
2
FLUOROPLEX - fluorouracil cream
1%
4
• •
FLUOROURACIL - fluorouracil
cream 0.5%
4
• •
hyaluronate sodium
(emollient) gel 0.2% (Hylira)
fluorouracil cream 5% (Efudex)
2
fluorouracil soln 2%
fluorouracil soln 5%
flurandrenolide cream 0.05%
fluticasone propionate cream
0.05% (Cutivate)
fluticasone propionate lotion
0.05% (Cutivate)
fluticasone propionate oint
0.005%
2
2
2
1
2
1
GENTAMICIN SULFATE gentamicin sulfate cream 0.1%
4
GENTAMICIN SULFATE gentamicin sulfate oint 0.1%
4
2
HALOG - halcinonide cream 0.1%
HPR PLUS/MB HYDROGEL emollient foam & wound dressing
gel kit
HYDRO 35 - urea in lactic acid
vehicle foam 35%
GORDOFILM - salicylic & lactic
acids soln 16.7-16.7%
ACA
2
fluocinolone acetonide cream
0.01%
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
•
•
•
4
HYDRO 40 FOAM - urea foam 40% 4
2
hydrocortisone butyrate cream
0.1% (Locoid)
2
hydrocortisone butyrate
hydrophilic lipo base cream
0.1% (Locoid lipocream)
2
hydrocortisone butyrate oint
0.1% (Locoid)
2
hydrocortisone butyrate soln
0.1% (Locoid)
1
hydrocortisone cream 1%
hydrocortisone cream 2.5%
hydrocortisone lotion 2% (Ala
scalp)
1
2
157
hydrocortisone lotion 2.5%
hydrocortisone oint 1%
hydrocortisone oint 2.5%
hydrocortisone valerate cream
0.2%
hydrocortisone valerate oint
0.2% (Westcort)
1
1
1
2
2
4
• •
HYLATOPIC PLUS - dermatological 4
HYLATOPIC PLUS - dermatological 4
4
HYLIRA - hyaluronate sodium
(emollient) gel 0.2%
4
HYLIRA - hyaluronate sodium
(emollient) lotion 0.1%
2
imiquimod cream 5% (Aldara)
• •
HYLATOPIC - dermatological
• •
•
•
INOVA - benzoyl peroxide pad 4%
& vitamin e topical 5% kit
4
•
INOVA - benzoyl peroxide pad 8%
& vitamin e topical 5% kit
4
•
INOVA 4/1 ACNE CONTROL TH benzoyl perox pad 4% & salicylic
ac pad 1% & vit e 5% kit
4
•
INOVA 8/2 ACNE CONTROL TH benzoyl perox pad 8% & salicylic
ac pad 2% & vit e 5% kit
4
•
iodoquinol-hc cream 1%
2
2
isotretinoin cap 10 mg
2
JUBLIA - efinaconazole soln 10%
2
2
2
4
4
KENDALL AMORPHOUS
HYDROGE - wound dressings gel
4
KERALAC - urea cream 47%
4
KERALYT - salicylic acid gel 6%
4
KERALYT SCALP - salicylic acid
shampoo 6% & salicylic acid gel
6% kit
4
• •
KERYDIN - tavaborole soln 5%
4
• •
ketoconazole cream 2%
1
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
ACA
Drug Tier
KENALOG - triamcinolone
acetonide aerosol soln 0.147 mg/
gm
ketoconazole shampoo 2%
(Nizoral)
• •
4
iodoquinol-hydrocortisone in
aloe vehicle cream 1-1.9%
(Vytone)
Drug Name
ketoconazole foam 2% (Extina)
INFLAMMA-K KIT - diclofenac td
soln 1.5% & camph-men-methyl
sal patch kit
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
2
1
KETODAN KIT - ketoconazole foam 4
2% & cleanser kit
4
KLARON - sulfacetamide sodium
lotion 10% (acne)
4
LAC-HYDRIN - lactic acid
(ammonium lactate) cream 12%
4
LAC-HYDRIN - lactic acid
(ammonium lactate) lotion 12%
1
lactic acid (ammonium lactate)
cream 12% (Lac-hydrin)
1
lotion 10%
1
lotion 12% (Lac-hydrin)
1
lactic acid w/ vitamin e cream
10%-3500 unit/30gm
4
LAMISIL SPRAY - terbinafine hcl
soln 1%
4
LATRIX XM - urea in zinc
undecylenate-lactic acid vehicle
emulsion 45%
4
LAVARE WOUND WASH - wound
cleansers - gel
• •
•
• •
• •
• •
• •
158
LEVULAN KERASTICK aminolevulinic acid hcl for soln
20% (stick applicator)
4
lidocaine hcl gel 2%
1
lidocaine hcl soln 4% (Xylocaine)
lidocaine oint 5%
lidocaine patch 5% (Lidoderm)
lidocaine-prilocaine cream kit
2.5-2.5%
1
2
2
•
•
2
•
METROGEL - metronidazole gel
1%
4
•
METROLOTION - metronidazole
lotion 0.75%
4
•
metronidazole cream 0.75%
(Metrocream)
2
metronidazole gel 0.75%
2
2
1
metronidazole gel 1% (Metrogel)
2
LIDODERM - lidocaine patch 5%
4
metronidazole lotion 0.75%
(Metrolotion)
lindane shampoo 1%
2
MICROCYN - wound cleansers gel
4
• •
MICROCYN - wound cleansers liquid
4
• •
MICROCYN SKIN AND WOUND
H - wound cleansers - gel
4
• •
MIRVASO - brimonidine tartrate gel
4
• •
mometasone furoate cream 0.1%
(Elocon)
1
mometasone furoate oint 0.1%
(Elocon)
1
1
lidocaine-prilocaine cream
2.5-2.5% (Emla)
•
•
LOCOID - hydrocortisone butyrate
cream 0.1%
4
lotion 0.1%
4
oint 0.1%
4
soln 0.1%
4
LOCOID LIPOCREAM hydrocortisone butyrate
hydrophilic lipo base cream 0.1%
4
LOPROX SHAMPOO - ciclopirox
shampoo 1%
4
mometasone furoate solution
0.1% (lotion) (Elocon)
LOTRISONE - clotrimazole w/
betamethasone cream 1-0.05%
4
mupirocin calcium cream 2%
(Bactroban)
2
mupirocin oint 2% (Bactroban)
1
LOUTREX - antiseborrheic products 4
misc - cream
4
LUXIQ - betamethasone valerate
aerosol foam 0.12%
4
LUZU - luliconazole cream 1%
malathion lotion 0.5% (Ovide)
2
• •
• •
• •
NAFTIFINE HCL - naftifine hcl
cream 1%
4
• •
naftifine hcl cream 2% (Naftin)
2
NAFTIN - naftifine hcl cream 2%
4
NAFTIN - naftifine hcl gel 1%
4
NAFTIN - naftifine hcl gel 2%
4
NATROBA - spinosad susp 0.9%
4
NEO-SYNALAR - neomycinfluocinolone cream 0.35-0.025%
4
4
• •
MENTAX - butenafine hcl cream 1% 4
2
methoxsalen rapid cap 10 mg
(Oxsoralen ultra)
• •
MB HYDROGEL - dermatological
products misc - kit
4
ACA
METROCREAM - metronidazole
cream 0.75%
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
• •
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
• •
• •
159
• •
OVACE PLUS - sulfacetamide
sodium cream 10%
4
• •
• •
sodium foam 9.8%
4
NEOSALUS - dermatological
4
• •
4
sodium lotion 9.8%
• •
NEOSALUS CP - dermatological
4
• •
• •
4
NEOSALUS - emollient - lotion
4
NEUAC KIT - clindamycin-benzoyl
perox gel 1.2-5% & moisturizer cr
kit
4
•
sodium shampoo 10%
4
NIVATOPIC PLUS - dermatological
4
• •
OVACE PLUS WASH sulfacetamide sodium cleansing
gel 10%
OVACE PLUS WASH sulfacetamide sodium liquid 10%
4
NIZORAL - ketoconazole shampoo
2%
4
4
NORITATE - metronidazole cream
1%
4
•
OVACE WASH - sulfacetamide
sodium liquid 10%
OVIDE - malathion lotion 0.5%
4
• •
oxiconazole nitrate cream 1%
(Oxistat)
2
NOVACORT - hydrocortisone acepramoxine-aloe polysacch gel
2-1-1%
4
4
NUCORT - hydrocortisone acetate
lotion 2%
4
• •
OXISTAT - oxiconazole nitrate
cream 1%
4
• •
NUOX - benzoyl peroxide-sulfur gel 4
6-3%
1
nystatin cream 100000 unit/gm
•
OXISTAT - oxiconazole nitrate
lotion 1%
OXSORALEN - methoxsalen lotion
1%
4
• •
OXSORALEN ULTRA methoxsalen rapid cap 10 mg
4
NEOSALUS - dermatological
4
nystatin oint 100000 unit/gm
nystatin topical powder
nystatin-triamcinolone cream
100000-0.1 unit/gm-%
1
2
PANDEL - hydrocortisone probutate 4
cream 0.1%
5
PANRETIN - alitretinoin gel 0.1%
2
2
PENLAC NAIL LACQUER ciclopirox solution 8%
4
OLUX - clobetasol propionate foam
0.05%
4
PENNSAID - diclofenac sodium
soln 2%
4
OLUX-E - clobetasol propionate
emulsion foam 0.05%
4
permethrin cream 5% (Elimite)
2
ONEXTON - clindamycin
phosphate-benzoyl peroxide gel
1.2-3.75%
4
nystatin-triamcinolone oint
100000-0.1 unit/gm-%
•
• •
• • •
•
PICATO - ingenol mebutate gel
0.015%
4
• • •
PICATO - ingenol mebutate gel
0.05%
4
• • •
• •
ACA
4
4
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Tier
ACA
Drug Name
ORACEA - doxycycline (rosacea)
cap delayed release 40 mg
NEO-SYNALAR KIT - neomycinfluocinolone cream 0.35-0.025%
& emollient cr kit
• •
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
160
4
•
PLIAGLIS - lidocaine-tetracaine
cream 7-7%
4
• •
podofilox soln 0.5% (Condylox)
2
PRAMOSONE - pramoxine-hc
cream 1-1%
4
cream 1-2.5%
4
lotion 1-1%
4
lotion 1-2.5%
• •
• •
PROTOPIC - tacrolimus oint 0.03%
4
PROTOPIC - tacrolimus oint 0.1%
4
PRUCLAIR - dermatological
4
•
•
• •
PRUDOXIN - doxepin hcl cream 5% 4
PRUMYX - dermatological products 4
misc - cream
4
PSORCON - diflorasone diacetate
cream 0.05%
4
PYROGALLIC ACID - pyrogallolchlorobutanol oint 25-2%
RADIAGEL - wound dressings - gel 4
• •
• •
• •
• •
• •
RADIAPLEXRX - wound dressings
- gel
4
• •
RECEDO - scar treatment products
- gel
4
4
• •
REGENECARE - lidocaine hclcollagen-aloe vera gel 2%
4
• •
PRAMOSONE - pramoxine-hc oint
1-1%
4
• •
REGRANEX - becaplermin gel
0.01%
5
• •
PRAMOSONE - pramoxine-hc oint
1-2.5%
4
• •
RETIN-A - tretinoin cream 0.025%
4
PRAMOSONE E - pramoxine-hc
emollient base cream 1-2.5%
• •
4
4
4
2
RETIN-A - tretinoin gel 0.01%
4
pramoxine-hc cream 1-2.5%
(Pramosone)
RETIN-A - tretinoin gel 0.025%
4
PRASCION RA WITH
SUNSCREE - sulfacetamide
sodium-sulfur-sunscreen cream
10-5%
4
RETIN-A MICRO - tretinoin
microsphere gel 0.04%
4
•
•
•
•
•
•
RETIN-A MICRO - tretinoin
4
• •
prednicarbate cream 0.1%
(Dermatop)
2
RETIN-A MICRO PUMP - tretinoin
4
• •
prednicarbate oint 0.1%
(Dermatop)
1
4
• •
PRESERA - dermatological
4
• •
4
• •
PROMISEB - antiseborrheic
4
• •
RIAX - benzoyl peroxide foam 5.5% 4
RIAX - benzoyl peroxide foam 9.5% 4
•
•
•
PLEXION CLEANSING CLOTHS sulfacetamide sodium w/ sulfur
cleansing cloth 9.8-4.8%
4
ACA
•
PROMISEB COMPLETE antiseborrheic products misc - kit
Quantity Limits
PLEXION CLEANSER sulfacetamide sodium w/ sulfur
cleanser 9.8-4.8%
4
Restricted Access
•
Prior Review
4
Specialty
PLEXION - sulfacetamide sodium
w/ sulfur lotion 9.8-4.8%
Drug Name
Drug Tier
•
4
ACA
PLEXION - sulfacetamide sodium
w/ sulfur cream 9.8-4.8%
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
•
•
•
•
•
161
ROSULA - sulfacetamide sodium w/ 2
sulfur cleansing cloth 10-5%
ROSULA - sulfacetamide sodium w/ 4
sulfur wash 10-4.5%
SALEX - salicylic acid shampoo 6% 4
SALEX CREAM - salicylic acid
cream 6% & cleanser liqd kit
4
SALEX LOTION - salicylic acid
lotion 6% & cleanser liqd kit
4
SALICYLIC ACID - salicylic acid
soln 26%
4
salicylic acid cream 6%
2
salicylic acid cream 6% &
cleanser liqd kit (Salex cream)
salicylic acid film forming liquid
27.5% (Virasal)
salicylic acid foam 6% (Salvax)
salicylic acid gel 6% (Keralyt)
• •
2
2
2
2
SALICYLIC ACID IN AMMONIU salicylic acid in ammonium
lactate vehicle foam 6%
4
salicylic acid lotion 6%
2
salicylic acid lotion 6% &
cleanser liqd kit (Salex lotion)
•
• •
2
salicylic acid shampoo 6%
(Salex)
2
SALVAX - salicylic acid foam 6%
4
SALVAX DUO PLUS - salicylic acid
foam 6% & urea in lactic acid
foam 35% kit
4
• •
SANTYL - collagenase oint 250
unit/gm
4
• •
SCALACORT DK - hc lot 2% & sal
acid-sulfur shampoo 2-2% &
shampoo kit
4
• •
scar treatment products - gel
2
selenium sulfide-pyrithione zinc
in urea shampoo 2.25%
ACA
Quantity Limits
Restricted Access
Prior Review
•
selenium sulfide lotion 2.5%
Specialty
ROSADAN KIT - metronidazole gel
0.75% w/ cleanser kit
4
Drug Name
Drug Tier
•
4
ACA
ROSADAN KIT - metronidazole
cream 0.75% w/ cleanser kit
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
1
2
SELRX - selenium sulfide-pyrithione 4
zinc in urea shampoo 2.3%
4
SERNIVO - betamethasone
dipropionate spray emulsion
0.05% (base equiv)
4
SILVADENE - silver sulfadiazine
cream 1%
4
SILVASORB - wound dressings gel
4
SILVER NITRATE - silver nitrate
oint 10%
4
soln 0.5%
4
soln 10%
4
soln 25%
4
soln 50%
1
silver nitrate-potassium nitrate
applicator 75-25% (Arzol silver
nitrate)
1
silver sulfadiazine cream 1%
(Silvadene)
4
SODIUM SULFACETAMIDE
WASH - sulfacetamide sodium in
bakuchiol vehicle wash 10%
SODIUM SULFACETAMIDE/SULF - 4
sulfacetamide sodium w/ sulfur
susp 10-5%
sulfacetamide sodium-sulfur in
urea emulsion 10-5%
sulfacetamide sodium-sulfur in
urea gel 10-5%
4
SOLARAZE - diclofenac sodium
(actinic keratoses) gel 3%
• •
• •
• •
• •
• •
• •
• •
• •
• •
•
•
•
• •
162
SOOLANTRA - ivermectin cream
1%
4
SORIATANE - acitretin cap 10 mg
4
SORIATANE - acitretin cap 17.5 mg 4
4
SORIATANE - acitretin cap 25 mg
• •
SPECTRAGEL - wound dressings - 4
gel
4
SPINOSAD - spinosad susp 0.9%
• •
emulsion 10-5%
foam 10-5% (Clarifoam ef)
STELARA - ustekinumab soln
5
STELARA - ustekinumab soln
prefilled syringe 90 mg/ml
5
• •
sulfacetamide sod-sulfur wash
9-4.5% & skin cleanser kit
(Sumadan kit)
2
sulfacetamide sod-sulfur
wash 9-4.5% & sunscreen kit
(Sumadan xlt)
2
sulfacetamide sodium
cleansing gel 10% (Ovace plus
wash)
2
•
lotion 9.8-4.8% (Plexion)
lotion 10-5%
susp 8-4% (Sumaxin ts)
wash 9-4% (Sumaxin wash)
wash 9-4.5% (Sumadan wash)
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Tier
cream 10-5%
• •
• •
•
sulfacetamide sodium liquid 10% 2
(Ovace wash)
2
sulfacetamide sodium lotion
10% (acne) (Klaron)
sulfacetamide sodium shampoo 2
10% (Ovace plus)
2
cleanser 9.8-4.8% (Plexion
cleanser)
2
sulfacetamide sodium w/
sulfur cleanser 10-2% (Avar ls
cleanser)
2
cleansing pad 10-4% (Sumaxin)
2
cream 9.8-4.8% (Plexion)
2
cream 10-2% (Avar-e ls)
Drug Name
emulsion 10-1%
4
SORILUX - calcipotriene foam
0.005%
ACA
• •
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
2
1
1
2
2
2
2
2
2
• •
SULFAMYLON - mafenide acetate
cream 85 mg/gm
4
SULFAMYLON - mafenide acetate
packet for topical soln 5% (50
gm)
4
SULFOAM - sulfur shampoo 2%
4
SULFURATED LIME - sulfurated
lime solution
4
• •
• •
SUMADAN KIT - sulfacetamide
sod-sulfur wash 9-4.5% & skin
cleanser kit
4
•
SUMADAN WASH - sulfacetamide
sodium w/ sulfur wash 9-4.5%
4
•
SUMADAN XLT - sulfacetamide
sod-sulfur wash 9-4.5% &
sunscreen kit
4
•
SUMAXIN - sulfacetamide sodium
w/ sulfur cleansing pad 10-4%
4
•
SUMAXIN CP KIT - sulfacetamide
sod-sulfur pad 10-4% & skin
cleanser kit
4
•
SUMAXIN TS - sulfacetamide
sodium w/ sulfur susp 8-4%
4
•
163
4
SYNALAR - fluocinolone acetonide
cream 0.025%
4
oint 0.025%
4
soln 0.01%
4
SYNALAR CREAM KIT fluocinolone cream 0.025%emollient cream kit
4
• •
SYNALAR OINTMENT KIT fluocinolone oint 0.025%emollient cream kit
4
• •
SYNALAR TS - fluocinolone
acetonide soln 0.01% & cleanser
kit
4
• •
SYNERA - lidocaine-tetracaine
topical patch 70-70 mg
4
• •
TACLONEX - calcipotrienebetamethasone dipropionate oint
0.005-0.064%
4
TACLONEX - calcipotrienebetamethasone dipropionate
susp 0.005-0.064%
4
• •
tacrolimus oint 0.03% (Protopic)
2
TALTZ - ixekizumab subcutaneous
soln auto-injector 80 mg/ml
5
•
•
• • • •
TALTZ - ixekizumab subcutaneous
5
• • • •
TARGRETIN - bexarotene gel 1%
5
TAZORAC - tazarotene cream
0.05%
4
• • •
• •
tacrolimus oint 0.1% (Protopic)
2
TAZORAC - tazarotene cream 0.1% 4
4
TAZORAC - tazarotene gel 0.05%
TAZORAC - tazarotene gel 0.1%
4
TBC - trypsin w/ castor oil &
peruvian balsam spray
4
TEMOVATE - clobetasol propionate 4
cream 0.05%
• •
• •
• •
gel 0.05%
oint 0.05%
soln 0.05%
4
TEMOVATE E - clobetasol
propionate emollient base cream
0.05%
4
TERSI FOAM - selenium sulfide
foam 2.25%
4
TEXACORT - hydrocortisone soln
2.5%
THERAHONEY - wound dressings 4
- gel
4
TOLAK - fluorouracil cream 4%
• •
• •
• •
TOPICORT - desoximetasone
cream 0.25%
4
TOPICORT - desoximetasone gel
0.05%
4
TOPICORT - desoximetasone oint
0.05%
4
TOPICORT - desoximetasone oint
0.25%
4
•
spray 0.25%
4
• •
•
TRETIN-X - tretinoin cream
0.0375%
4
• •
TRETIN-X - tretinoin cream 0.075% 4
TRETIN-X - tretinoin cream 0.05% 4
w/ cleanser & moisturizer kit
tretinoin cream 0.025% (Retin-a) 2
• •
• •
tretinoin cream 0.1% (Retin-a)
tretinoin gel 0.01% (Retin-a)
tretinoin gel 0.025% (Retin-a)
tretinoin gel 0.05% (Atralin)
2
2
2
2
• •
4
2
ACA
• •
cream 0.05%
tretinoin cream 0.05% (Retin-a)
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
•
SUMAXIN WASH - sulfacetamide
sodium w/ sulfur wash 9-4%
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
•
•
•
•
•
•
164
triamcinolone acetonide cream
0.5%
triamcinolone acetonide lotion
0.025%
triamcinolone acetonide lotion
0.1%
triamcinolone acetonide oint
0.025%
triamcinolone acetonide oint
0.1%
• •
UMECTA - urea emulsion 40%
4
• •
UMECTA NAIL FILM - urea
suspension 40%
4
UMECTA PD - urea-hyaluronate
sodium emulsion 40-0.3%
4
• •
UMECTA PD - urea-hyaluronate
sodium susp 40-0.3%
4
• •
URAMAXIN - urea cream 45%
4
URAMAXIN - urea gel 45%
4
URAMAXIN - urea in ammonium
lactate vehicle foam 20%
4
URAMAXIN - urea lotion 45%
4
URAMAXIN GT - urea gel 45%
4
2
URAMAXIN GT KIT - urea gel 45%
& emollient cream kit
4
2
urea cream 39% (Aluvea)
2
• •
1
1
1
urea cream 40%
1
urea cream 45% (Uramaxin)
urea cream 47% (Keralac)
1
TRIANEX - triamcinolone acetonide 4
oint 0.05%
4
TROPAZONE - emollient - lotion
ULESFIA - benzyl alcohol lotion 5% 4
4
ULTRASAL-ER - salicylic acid er
film-forming soln 28.5%
4
ULTRAVATE - halobetasol
propionate cream 0.05%
4
propionate lotion 0.05%
4
propionate oint 0.05%
4
ULTRAVATE X - halobetasol prop
cream 0.05% & lactic acid cream
10% kit
urea cream 50%
• •
urea foam 40% (Hydro 40 foam)
• •
• •
• •
urea gel 45% (Uramaxin)
• •
urea gel 40%
urea in lactic acid vehicle foam
35% (Hydro 35)
urea in lactic acid-salicylic acid
vehicle susp 50%
urea in zinc undecylenate-lactic
acid vehicle emulsion 50%
urea lotion 40%
urea lotion 45% (Uramaxin)
• •
triamcinolone acetonide aerosol
soln 0.147 mg/gm (Kenalog)
2
0.1%
4
ACA
4
0.025%
ULTRAVATE X - halobetasol prop
oint 0.05% & lactic acid cream
10% kit
Quantity Limits
TRIAMCINOLONE ACETONIDE triamcinolone acetonide oint
0.5%
Restricted Access
TRI-CHLOR - trichloroacetic acid
liqd 80%
4
Prior Review
•
Specialty
2
Drug Name
Drug Tier
tretinoin microsphere gel 0.1%
(Retin-a micro pump)
•
ACA
2
Quantity Limits
tretinoin microsphere gel 0.04%
(Retin-a micro)
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
• •
2
2
2
2
2
2
2
2
2
2
2
2
UREA NAIL - urea in zinc
undecylenate-lactic acid vehicle
stick 50%
4
• •
UREA NAIL KIT - urea susp 40% &
hyaluronate sodium gel 0.2% kit
4
• •
165
urea suspension 40% (Umecta)
2
• •
• •
• • •
UREVAZ - urea cream 44%
4
UTOPIC - urea cream 41%
4
VALCHLOR - mechlorethamine hcl
gel 0.016% (base equivalent)
5
VANOS - fluocinonide cream 0.1%
4
VANOXIDE-HC - benzoyl peroxidehc lotion 5-0.5%
4
•
VASCUDERM HYDROGEL
WOUND - wound dressings - gel
4
• •
VECTICAL - calcitriol oint 3 mcg/gm 4
4
VELTIN - clindamycin phosphatetretinoin gel 1.2-0.025%
VENELEX - balsam peru-castor oil 4
oint
VERDESO - desonide foam 0.05% 4
• •
• •
VEREGEN - sinecatechins oint 15% 4
4
VIRASAL - salicylic acid film
forming liquid 27.5%
VOLTAREN - diclofenac sodium gel 3
1%
4
VUSION - miconazole-zinc
oxide-white petrolatum oint
0.25-15-81.35%
4
VYTONE - iodoquinolhydrocortisone in aloe vehicle
cream 1-1.9%
4
WESTCORT - hydrocortisone
valerate oint 0.2%
XERESE - acyclovir-hydrocortisone 4
cream 5-1%
4
XOLEGEL - ketoconazole gel 2%
• •
• •
• •
•
• •
•
XYLOCAINE - lidocaine hcl soln 4% 4
4
ZACARE 4% KIT - benzoyl
peroxide lotion 4% & hyaluronate
sodium gel 0.2% kit
4
ZACARE 8% KIT - benzoyl
peroxide lotion 8% & hyaluronate
sodium gel 0.2% kit
4
ZACLIR CLEANSING - benzoyl
peroxide lotion 8%
ZANABIN ANTIPRURITIC HYDR - 4
wound dressings - gel
4
ZIANA - clindamycin phosphatetretinoin gel 1.2-0.025%
4
ZITHRANOL - anthralin shampoo
1%
ZITHRANOL-RR - anthralin cream 4
1.2%
ZONALON - doxepin hcl cream 5% 4
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
•
•
• •
• •
• •
• •
• •
• •
ZOVIRAX - acyclovir cream 5%
4
ZOVIRAX - acyclovir oint 5%
4
ZYCLARA - imiquimod cream
3.75%
4
• • •
ZYCLARA PUMP - imiquimod
cream 2.5%
4
• • •
ZYCLARA PUMP - imiquimod
cream 3.75%
4
• • •
8-MOP - methoxsalen cap 10 mg
5
• • •
MISCELLANEOUS PRODUCTS
• •
• •
• •
XOLEGEL COREPAK ketoconazole gel 2% &
hydrocortisone gel 1% kit
4
XOLEGEL DUO/HEAD &
SHOULD - ketoconazole gel 2%
& pyrithione zinc shampoo 1% kit
4
• •
XOLEGEL DUO/XOLEX ketoconazole gel 2% & pyrithione
zinc shampoo 1% kit
4
• •
ANTISEPTICS & DISINFECTANTS
ANASEPT - sodium hypochlorite
liquid 0.057%
4
BENZALKONIUM CHLORIDE benzalkonium chloride soln 50%
4
BUCALSEP - antiseptic products
misc - liquid
4
BUCALSEP - antiseptic products
misc - solution
4
CHLORHEXIDINE GLUCONATE chlorhexidine gluconate soln
20%
4
166
HYDROGEN PEROXIDE hydrogen peroxide soln 30%
4
CETYLEV - acetylcysteine
effervescent tab 2.5 gm
4
CHEMET - succimer cap 100 mg
4
EVZIO - naloxone hcl solution auto- 4
injector 0.4 mg/0.4ml
5
EXJADE - deferasirox tab for oral
susp 125 mg
5
susp 250 mg
5
susp 500 mg
FERRIPROX - deferiprone oral soln 5
100 mg/ml
FERRIPROX - deferiprone tab 500 5
mg
5
JADENU - deferasirox tab 90 mg
5
5
naltrexone hcl tab 50 mg (Revia)
1
ASCENSIA AUTODISC TEST ST glucose blood test disk
4
CETYLEV - acetylcysteine
effervescent tab 500 mg
•
DIAGNOSTIC PRODUCTS
All Brand Diabetic Supplies 25% coinsurance
BAYER BREEZE 2 TEST DISC glucose blood test disk
IODINE TINCTURE - iodine tincture 4
LUGOLS STRONG IODINE - iodine 4
solution
ANTIDOTES
ACA
1
Quantity Limits
formaldehyde solution 10%
•
Restricted Access
• •
5
Prior Review
4
VISTOGARD - uridine triacetate
oral granules packet 10 gm
Specialty
FORMALDEHYDE - formaldehyde
solution 37%
Drug Name
Drug Tier
• •
4
ACA
FORMA-RAY - formaldehyde
solution 20%
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
BAYER CONTOUR BLOOD
GLUCO - glucose blood test strip
BAYER CONTOUR NEXT BLOOD glucose blood test strip
•
BLOOD GLUCOSE TEST STRIPS
– VARIOUS
NOVA MAX PLUS KETONE TEST ketone blood test strip
ONETOUCH ULTRA BLUE glucose blood test strip
• • •
•
ONETOUCH ULTRA TEST STRIP glucose blood test strip
• • •
•
ONETOUCH VERIO TEST STRIP glucose blood test strip
• • •
•
PRECISION XTRA - ketone blood
test strip
• •
•
PTS PANELS KETONE TEST ketone blood test strip
• •
•
URINE TEST STRIPS – VARIOUS
•
•
•
ACE AEROSOL CLOUD
ENHANCE - respiratory therapy
supplies - misc
4
ACTIVITY POUCH - respiratory
therapy supplies - misc
4
•
•
•
MEDICAL DEVICES
NARCAN - naloxone hcl nasal
spray 4 mg/0.1ml
4
ADULT MASK - respiratory therapy
supplies - devices
4
PENTETATE CALCIUM TRISODI pentetate calcium trisodium iv or
inhalation soln 200 mg/ml
4
ADULT MASK - respiratory therapy
supplies - misc
4
ADULT MASK LARGE - respiratory
4
PENTETATE ZINC TRISODIUM pentetate zinc trisodium iv or
inhalation soln 200 mg/ml
4
AEROBIKA - respiratory therapy
supplies - devices
4
167
AEROGEAR ASTHMA ACTION peak flow meter w/inhaler assist
device kit
4
ASSESS PEAK FLOW METER
FU - peak flow meter
4
ASTHMAPACK I - peak flow meter
w/inhaler assist device kit
4
AEROTRACH PLUS - respiratory
4
ASTHMAPACK II - peak flow meter
4
AIRS DISPOSABLE NEBULIZER respiratory therapy supplies - kit
4
ALL FLOW 1000 PFT FILTER respiratory therapy supplies devices
4
ALL FLOW 1000 PFT FILTER respiratory therapy supplies - kit
4
ALL FLOW 1000 PULMONARY
F - respiratory therapy supplies misc
4
4
4
4
4
4
4
4
4
4
4
ASTHMAPACK III - peak flow meter 4
BREATHERITE VALVED MDI CH - 4
respiratory therapy supplies devices
A
CAYA - diaphragm arc-spring
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
CO MONITOR - respiratory therapy 4
supplies - devices
4
CO MONITOR CALIBRATION respiratory therapy supplies - kit
4
CO MONITOR REPLACEMENT
T - respiratory therapy supplies misc
4
DEVILBISS TRAVEL-AIRE COM respiratory therapy supplies devices
4
DISPOSABLE MOUTHPIECE
FUL - respiratory therapy supplies
- mouthpieces
4
DISPOSABLE MOUTHPIECE
LOW - respiratory therapy
supplies - mouthpieces
4
DISPOSABLE MOUTHPIECE/
LOW - respiratory therapy
supplies - mouthpieces
DISPOSABLE MOUTHPIECE/UNI - 4
respiratory therapy supplies mouthpieces
4
EBASE CONTROLLER KIT respiratory therapy supplies misc
4
EFLOW SCF AEROSOL HEAD respiratory therapy supplies misc
168
ELITE DC AUTO ADAPTER respiratory therapy supplies misc
4
LITETOUCH MASK SMALL respiratory therapy supplies misc
4
FACE MASK EARLOOP-STYLE masks
4
MINIELITE RECHARGEABLE BA respiratory therapy supplies misc
4
MISC NEEDLES – VARIOUS
4
MISTASSIST - respiratory therapy
supplies - devices
4
NEBULIZER AIR TUBE/PLUGS respiratory therapy supplies misc
4
NEBULIZER COMPRESSOR/
DUAL - respiratory therapy
supplies - kit
4
NEBULIZER KIT/TUBING/MOUT respiratory therapy supplies - kit
4
NEBULIZER PEDIATRIC MASK respiratory therapy supplies misc
4
NEBULIZER/ADULT MASK respiratory therapy supplies - kit
4
NEBULIZER/PEDIATRIC MASK respiratory therapy supplies - kit
4
OMNIFLEX DIAPHRAGM diaphragms
A
ONE FLOW FVC MONITORING
S - respiratory therapy supplies devices
4
•
FC FEMALE CONDOM - condoms - A
female
FC2 FEMALE CONDOM - condoms A
- female
A
FEMCAP - cervical cap 22 mm
A
A
FILTER AIR PP - respiratory
4
FLUTTER - respiratory therapy
supplies - devices
4
FULL KIT NEBULIZER SET respiratory therapy supplies misc
4
HURRISEAL - dental desensitizing
product - solution
4
IN-CHECK DIAL INSPIRATORY respiratory therapy supplies devices
4
IN-CHECK INSPIRATORY FLOW respiratory therapy supplies devices
4
INNOSPIRE REPLACEMENT FIL respiratory therapy supplies misc
4
INSULIN PEN NEEDLES –
VARIOUS
4
INSULIN SYRINGES – VARIOUS
4
LANCETS – VARIOUS
4
LITETOUCH MASK LARGE respiratory therapy supplies misc
4
LITETOUCH MASK MEDIUM respiratory therapy supplies misc
4
•
•
•
•
• •
ONE FLOW FVC MONITORING S - 4
respiratory therapy supplies - kit
ORTHO DIAPHRAGM COIL SPRI - A
diaphragm coil spring kit 50 mm
ORTHO DIAPHRAGM FLAT SPRI - A
diaphragm flat spring kit 55 mm
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
•
•
•
•
•
169
PARI ALTERA NEBULIZER HAN - 4
respiratory therapy supplies misc
4
PARI ERAPID NEBULIZER HAN respiratory therapy supplies misc
4
PARI EXPIRATORY FILTER VA respiratory therapy supplies misc
4
PARI LC PLUS PEDIATRIC KI respiratory therapy supplies - kit
4
PARI MANUAL INTERRUPTER respiratory therapy supplies devices
4
PARI MASK SET - respiratory
4
PARI SOFT PLASTIC ADULT M respiratory therapy supplies misc
4
PARI SOFT PLASTIC PEDIATR respiratory therapy supplies misc
4
PARI TREK S COMBO PACK respiratory therapy supplies devices
PARI TREK S PORTABLE POWE - 4
PEDIATRIC AEROSOL MASK respiratory therapy supplies misc
4
•
PEDIATRIC COMPRESSOR
NEBU - respiratory therapy
supplies - kit
4
•
PFLEX - respiratory therapy
supplies - misc
4
•
PILLOW MASK/ADULT - respiratory 4
PILLOW MASK/CHILD - respiratory 4
4
PILLOW MASK/PEDIATRIC respiratory therapy supplies misc
A
PRENTIF CAVITY-RIM CERVIC cervical cap 22 mm
A
A
A
A
PRENTIF FITTING SET - cervical
caps
PRIMEAIRE DUAL-VALVED HOL - 4
4
PULMO-AIDE COMPRESSOR/
PUL - respiratory therapy supplies
- devices
PULMO-AIDE LT COMPRESSOR/ - 4
4
PULMO-AIDE TRAVELER
COMPR - respiratory therapy
supplies - devices
4
PULMONEB LT COMPRESSOR
NE - respiratory therapy supplies
- devices
•
•
•
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
•
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
•
•
•
•
170
PULMONEB LT COMPRESSOR/
NE - respiratory therapy supplies
- devices
4
QUAKE - respiratory therapy
supplies - devices
4
REMESENSE - dental desensitizing 4
product - misc
4
REPLACEMENT AIR FILTER respiratory therapy supplies misc
SAMI THE SEAL COMPRESSOR - 4
SIDESTREAM ADULT FACE MAS - 4
4
SIDESTREAM CUSTOM
NEBULIZ - respiratory therapy
supplies - kit
SIDESTREAM PEDIATRIC FACE - 4
SILICONE MASK FOR BREATHE - 4
SILICONE MASK FOR BREATHR - 4
4
SPIRO PD - respiratory therapy
supplies - devices
4
THRESHOLD IMT - respiratory
4
THRESHOLD PEP - respiratory
therapy supplies - devices
TRUZONE PEAK FLOW METER - 4
peak flow meter
4
URINE GLUCOSE MONITORING
– VARIOUS
4
VORTEX HOLDING CHAMBER/
MA - respiratory therapy supplies
- devices
A
WIDE-SEAL SILICONE DIAPHR diaphragm wide seal 60 mm
•
A
•
A
•
A
•
A
•
A
•
A
•
A
•
WINDMILL TRAINER - respiratory
4
PHARMACY ADJUVANTS –
VARIOUS
ASSORTED CLASSES
ACA
Quantity Limits
Restricted Access
Prior Review
PHARMACEUTICAL ADJUVANTS
•
Specialty
Drug Name
Drug Tier
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
4
ASTAGRAF XL - tacrolimus cap sr
24hr 0.5 mg
5
•
24hr 1 mg
5
•
24hr 5 mg
5
•
AZASAN - azathioprine tab 75 mg
5
AZASAN - azathioprine tab 100 mg
5
azathioprine tab 50 mg (Imuran)
5
CELLCEPT - mycophenolate
mofetil cap 250 mg
5
•
mofetil for oral susp 200 mg/ml
5
•
mofetil tab 500 mg
5
•
CUPRIMINE - penicillamine cap
250 mg
4
cyclosporine cap 25 mg
(Sandimmune)
5
•
171
5
•
5
•
cyclosporine modified cap
100 mg (Neoral)
cyclosporine modified oral soln
100 mg/ml (Neoral)
DEPEN TITRATABS - penicillamine 4
tab 250 mg
ENVARSUS XR - tacrolimus tab sr 5
24hr 0.75 mg
24hr 1 mg
24hr 4 mg
5
IMURAN - azathioprine tab 50 mg
KAYEXALATE - sodium polystyrene 4
sulfonate powder
5
mycophenolate mofetil cap
250 mg (Cellcept)
5
mycophenolate mofetil for oral
susp 200 mg/ml (Cellcept)
5
mycophenolate mofetil tab
500 mg (Cellcept)
5
mycophenolate sodium tab dr
180 mg (mycophenolic acid
equiv) (Myfortic)
5
mycophenolate sodium tab dr
360 mg (mycophenolic acid
equiv) (Myfortic)
5
MYFORTIC - mycophenolate
sodium tab dr 180 mg
(mycophenolic acid equiv)
5
MYFORTIC - mycophenolate
sodium tab dr 360 mg
(mycophenolic acid equiv)
•
•
•
•
•
•
•
•
•
•
5
•
NEORAL - cyclosporine modified
oral soln 100 mg/ml
5
•
PROGRAF - tacrolimus cap 0.5 mg
5
PROGRAF - tacrolimus cap 1 mg
5
PROGRAF - tacrolimus cap 5 mg
5
RAPAMUNE - sirolimus oral soln 1
mg/ml
5
•
•
•
•
RAPAMUNE - sirolimus tab 0.5 mg
5
RAPAMUNE - sirolimus tab 1 mg
5
RAPAMUNE - sirolimus tab 2 mg
5
REVLIMID - lenalidomide caps 2.5
mg
5
REVLIMID - lenalidomide cap 5 mg
5
REVLIMID - lenalidomide cap 10
mg
•
cap 100 mg
ACA
5
50 mg (Cyclosporine modifie)
•
Quantity Limits
•
5
Restricted Access
5
cap 25 mg
Prior Review
25 mg (Neoral)
Specialty
•
Drug Name
Drug Tier
5
CYCLOSPORINE MODIFIED cyclosporine modified cap 50 mg
ACA
•
Quantity Limits
5
Restricted Access
cyclosporine cap 100 mg
(Sandimmune)
Prior Review
Specialty
Drug Name
Drug Tier
2016
•
•
•
• •
•
5
• •
• •
•
•
mg
5
• •
•
mg
5
• •
•
mg
5
• •
•
ringer's solution for irrigation
2
SANDIMMUNE - cyclosporine cap
25 mg
5
•
SANDIMMUNE - cyclosporine cap
100 mg
5
•
SANDIMMUNE - cyclosporine oral
soln 100 mg/ml
5
•
sirolimus tab 0.5 mg (Rapamune) 5
5
sirolimus tab 1 mg (Rapamune)
•
•
•
sirolimus tab 2 mg (Rapamune)
sodium polystyrene sulfonate
oral susp 15 gm/60ml (Sps)
powder (Kayexalate)
5
2
2
172
rectal susp 30 gm/120ml
2
tacrolimus cap 1 mg (Prograf)
5
SYPRINE - trientine hcl cap 250 mg 4
5
tacrolimus cap 0.5 mg (Prograf)
ACA
Quantity Limits
Restricted Access
Prior Review
Specialty
Drug Name
Drug Tier
2016
• •
THALOMID - thalidomide cap 50
mg
5
•
•
•
• •
mg
5
• •
•
mg
5
• •
•
mg
5
• •
•
VELTASSA - patiromer sorbitex
calcium for susp packet 8.4 gm
(base eq)
4
•
(base eq)
4
•
(base eq)
4
•
ZORTRESS - everolimus tab 0.25
mg
5
mg
5
mg
5
tacrolimus cap 5 mg (Prograf)
5
•
173
2016
INDEX
A
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg (Trizivir)................................................ 7
abacavir sulfate tab 300 mg (base equiv) (Ziagen)........ 7
ABANEU-SL -cyanocobalamin-methylcobalamin tab sl
600-600 mcg................................................................. 133
ABILIFY -aripiprazole tab 2 mg......................................... 84
ABILIFY -aripiprazole tab 5 mg......................................... 84
ABILIFY -aripiprazole tab 10 mg....................................... 84
ABSORICA -isotretinoin cap 10 mg................................ 151
ABSTRAL -fentanyl citrate sl tab 100 mcg (base
equiv)............................................................................... 99
equiv)............................................................................... 99
equiv)............................................................................... 99
equiv)............................................................................... 99
equiv)............................................................................... 99
equiv)............................................................................... 99
acamprosate calcium tab delayed release 333 mg...... 95
ACANYA -clindamycin phosphate-benzoyl peroxide gel
1.2-2.5%........................................................................ 151
acarbose tab 25 mg (Precose)....................................... 26
acarbose tab 50 mg (Precose)....................................... 26
acarbose tab 100 mg (Precose)..................................... 26
ACCOLATE -zafirlukast tab 10 mg....................................64
ACCOLATE -zafirlukast tab 20 mg....................................64
ACCUPRIL -quinapril hcl tab 5 mg................................... 46
ACCUPRIL -quinapril hcl tab 10 mg................................. 46
ACCURETIC -quinapril-hydrochlorothiazide tab 10-12.5
mg.................................................................................... 46
ACCURETIC -quinapril-hydrochlorothiazide tab 20-12.5
mg.................................................................................... 46
ACCURETIC -quinapril-hydrochlorothiazide tab 20-25
mg.................................................................................... 46
ACE AEROSOL CLOUD ENHANCE -respiratory therapy
supplies - misc.............................................................. 167
acebutolol hcl cap 200 mg (Sectral).............................. 40
acebutolol hcl cap 400 mg (Sectral).............................. 40
ACEON -perindopril erbumine tab 4 mg........................... 46
ACEON -perindopril erbumine tab 8 mg........................... 46
acetaminophen-caffeine-dihydrocodeine cap
320.5-30-16 mg (Trezix)................................................ 99
acetaminophen-salicylamide-phenyltoloxamine cap
300-200-20mg.................................................................99
acetaminophen w/ codeine soln 120-12 mg/5ml.......... 99
acetaminophen w/ codeine tab 300-15 mg (Tylenol/
codeine).......................................................................... 99
codeine #3).................................................................... 99
codeine #4).................................................................... 99
ACETAZOLAMIDE -acetazolamide tab 125 mg............... 53
acetazolamide cap sr 12hr 500 mg (Diamox)............... 53
acetazolamide tab 250 mg.............................................. 53
ACETIC ACID/ALUMINUM ACET -acetic acid 2% in
aluminum acetate otic soln...........................................148
acetic acid otic soln 2%................................................ 148
acetylcysteine cap 600 mg........................................... 133
acetylcysteine inhal soln 10%........................................ 62
acetylcysteine inhal soln 20%........................................ 62
ACIPHEX -rabeprazole sodium ec tab 20 mg.................. 69
ACIPHEX SPRINKLE -rabeprazole sodium capsule
sprinkle dr 5 mg.............................................................. 69
ACIPHEX SPRINKLE -rabeprazole sodium capsule
sprinkle dr 10 mg............................................................ 69
acitretin cap 10 mg (Soriatane).................................... 151
acitretin cap 17.5 mg (Soriatane)................................. 151
acitretin cap 25 mg (Soriatane).................................... 151
ACLOVATE -alclometasone dipropionate cream
0.05%.............................................................................151
ACTEMRA -tocilizumab subcutaneous soln prefilled
syringe 162 mg/0.9ml................................................... 108
ACTICLATE -doxycycline hyclate tab 75 mg...................... 4
ACTICLATE -doxycycline hyclate tab 150 mg.................... 4
ACTIGALL -ursodiol cap 300 mg...................................... 73
ACTIMMUNE -interferon gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)....................................................... 14
ACTIQ -fentanyl citrate lozenge on a handle 200 mcg..... 99
ACTIQ -fentanyl citrate lozenge on a handle 400 mcg..... 99
ACTIQ -fentanyl citrate lozenge on a handle 600
mcg................................................................................ 100
mcg................................................................................ 100
mcg................................................................................ 100
mcg................................................................................ 100
ACTIVE FE -fe carbonyl-fa-b complex-a-c-d-e-min tab
75-1.25 mg.................................................................... 133
ACTIVELLA -estradiol & norethindrone acetate tab
0.5-0.1 mg....................................................................... 21
ACTIVELLA -estradiol & norethindrone acetate tab 1-0.5
mg.................................................................................... 21
ACTIVITY POUCH -respiratory therapy supplies misc............................................................................... 167
ACTONEL -risedronate sodium tab 5 mg......................... 34
174
2016
ACTONEL -risedronate sodium tab 30 mg....................... 34
ACTONEL -risedronate sodium tab 35 mg....................... 34
ACTONEL -risedronate sodium tab 150 mg..................... 34
ACTOPLUS MET -pioglitazone hcl-metformin hcl tab
15-500 mg....................................................................... 26
ACTOPLUS MET -pioglitazone hcl-metformin hcl tab
15-850 mg....................................................................... 26
ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab
sr 24hr 15-1000 mg........................................................ 26
ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab
sr 24hr 30-1000 mg........................................................ 26
ACTOS -pioglitazone hcl tab 15 mg (base equiv)............. 26
ACT TOTAL CARE DRY MOUTH -sodium fluoride rinse
0.02%.............................................................................148
ACUICYN DAILY EYELID & EY -eyelid cleansers liquid.............................................................................. 151
ACULAR -ketorolac tromethamine ophth soln 0.5%....... 143
ACULAR LS -ketorolac tromethamine ophth soln
0.4%...............................................................................143
ACUVAIL -ketorolac tromethamine ophth soln
0.45%.............................................................................143
acyclovir cap 200 mg (Zovirax)........................................ 7
acyclovir oint 5% (Zovirax)........................................... 151
acyclovir susp 200 mg/5ml (Zovirax).............................. 7
acyclovir tab 400 mg (Zovirax)........................................ 7
acyclovir tab 800 mg (Zovirax)........................................ 7
ACZONE -dapsone gel 5%............................................. 151
ACZONE -dapsone gel 7.5%.......................................... 151
ADAGEN -pegademase bovine inj 250 unit/ml................. 14
ADALAT CC -nifedipine tab sr 24hr 30 mg....................... 42
ADAPALENE -adapalene lotion 0.1%............................. 151
adapalene cream 0.1% (Differin).................................. 151
adapalene gel 0.1% (Differin)....................................... 151
adapalene gel 0.3% (Differin)....................................... 151
ADCIRCA -tadalafil tab 20 mg (pah)................................. 58
ADDERALL -amphetamine-dextroamphetamine tab 5
mg.................................................................................... 89
ADDERALL -amphetamine-dextroamphetamine tab 7.5
mg.................................................................................... 89
mg.................................................................................... 89
ADDERALL -amphetamine-dextroamphetamine tab 12.5
mg.................................................................................... 89
mg.................................................................................... 89
mg.................................................................................... 89
mg.................................................................................... 90
ADDERALL XR -amphetamine-dextroamphetamine cap
sr 24hr 5 mg................................................................... 90
sr 24hr 10 mg................................................................. 90
sr 24hr 15 mg................................................................. 90
sr 24hr 20 mg................................................................. 90
sr 24hr 25 mg................................................................. 90
sr 24hr 30 mg................................................................. 90
ADDYI -flibanserin tab 100 mg......................................... 95
adefovir dipivoxil tab 10 mg (Hepsera)........................... 8
ADEMPAS -riociguat tab 0.5 mg....................................... 58
ADEMPAS -riociguat tab 1 mg.......................................... 58
ADEMPAS -riociguat tab 2 mg.......................................... 58
ADIPEX-P -phentermine hcl cap 37.5 mg.........................90
ADIPEX-P -phentermine hcl tab 37.5 mg......................... 90
ADOXA -doxycycline monohydrate cap 150 mg................. 4
ADOXA -doxycycline monohydrate tab 50 mg....................4
ADOXA -doxycycline monohydrate tab 75 mg....................4
ADOXA -doxycycline monohydrate tab 100 mg..................4
ADOXA PAK 1/100 -doxycycline monohydrate tab 100
mg...................................................................................... 4
mg...................................................................................... 4
mg...................................................................................... 4
ADRENACLICK -epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)......................................................... 55
ADRENACLICK -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)........................................................... 55
ADRENALIN -epinephrine hcl nasal soln 0.1%................ 61
ADULT MASK LARGE -respiratory therapy supplies misc............................................................................... 167
ADULT MASK -respiratory therapy supplies devices.......................................................................... 167
ADULT MASK -respiratory therapy supplies - misc........ 167
ADVAIR DISKUS -fluticasone-salmeterol aer powder ba
100-50 mcg/dose............................................................ 64
250-50 mcg/dose............................................................ 64
500-50 mcg/dose............................................................ 64
ADVAIR HFA -fluticasone-salmeterol inhal aerosol 45-21
mcg/act............................................................................ 64
mcg/act............................................................................ 64
mcg/act............................................................................ 64
ADVANCED AM/PM -multiple vitamins w/ calcium therapy
pack............................................................................... 123
ADVATE -antihemophilic factor rahf-pfm for inj 250
unit................................................................................. 139
unit................................................................................. 139
unit................................................................................. 139
175
2016
unit................................................................................. 139
unit................................................................................. 139
unit................................................................................. 139
unit................................................................................. 139
ADYNOVATE -antihemophilic factor recomb pegylated for
inj 250 unit.................................................................... 139
inj 500 unit.................................................................... 139
inj 1000 unit.................................................................. 139
inj 2000 unit.................................................................. 139
ADZENYS XR-ODT -amphetamine tab extended release
dispersible 3.1 mg.......................................................... 90
dispersible 6.3 mg.......................................................... 90
dispersible 9.4 mg.......................................................... 90
dispersible 12.5 mg........................................................ 90
dispersible 15.7 mg........................................................ 90
dispersible 18.8 mg........................................................ 90
AEROBIKA -respiratory therapy supplies - devices........ 167
AEROGEAR ASTHMA ACTION -peak flow meter w/
inhaler assist device kit................................................ 168
AEROSPAN -flunisolide hfa inhal aerosol 80 mcg/act...... 64
AEROTRACH PLUS -respiratory therapy supplies misc............................................................................... 168
AFINITOR DISPERZ -everolimus tab for oral susp 2
mg.................................................................................... 14
mg.................................................................................... 14
mg.................................................................................... 14
AFINITOR -everolimus tab 2.5 mg.................................... 14
AFINITOR -everolimus tab 5 mg....................................... 14
AFINITOR -everolimus tab 7.5 mg.................................... 14
AFINITOR -everolimus tab 10 mg..................................... 14
AFSTYLA -antihemophilic fact rcmb single chain for inj kit
250 unit......................................................................... 139
500 unit......................................................................... 139
1000 unit....................................................................... 139
2000 unit....................................................................... 139
3000 unit....................................................................... 139
AGGRENOX -aspirin-dipyridamole cap sr 12hr 25-200
mg.................................................................................. 139
AGRYLIN -anagrelide hcl cap 0.5 mg............................. 139
AIRS DISPOSABLE NEBULIZER -respiratory therapy
supplies - kit.................................................................. 168
AKTEN -lidocaine hcl ophth gel 3.5%............................. 143
AKYNZEO -netupitant-palonosetron cap 300-0.5 mg....... 71
ALA-QUIN -clioquinol-hc cream 3-0.5%..........................151
ALA SCALP -hydrocortisone lotion 2%........................... 151
ALBENZA -albendazole tab 200 mg................................. 12
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)......... 64
albuterol sulfate soln nebu 0.5% (5 mg/ml).................. 65
albuterol sulfate soln nebu 0.63 mg/3ml (base
equiv).............................................................................. 65
albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv).............................................................................. 65
albuterol sulfate syrup 2 mg/5ml................................... 65
albuterol sulfate tab 2 mg...............................................65
albuterol sulfate tab 4 mg...............................................65
albuterol sulfate tab sr 12hr 4 mg (Vospire er)............ 65
albuterol sulfate tab sr 12hr 8 mg (Vospire er)............ 65
ALCAINE -proparacaine hcl ophth soln 0.5%................. 143
alclometasone dipropionate cream 0.05%
(Aclovate)..................................................................... 151
alclometasone dipropionate oint 0.05%......................152
ALCORTIN A -iodoquinol-hydrocortisone-aloe
polysaccharide gel 1-2-1%........................................... 152
ALDACTAZIDE -spironolactone & hydrochlorothiazide tab
25-25 mg......................................................................... 53
ALDACTAZIDE -spironolactone & hydrochlorothiazide tab
50-50 mg......................................................................... 53
ALDACTONE -spironolactone tab 25 mg......................... 53
ALDACTONE -spironolactone tab 50 mg......................... 54
ALDACTONE -spironolactone tab 100 mg....................... 54
ALDARA -imiquimod cream 5%...................................... 152
ALECENSA -alectinib hcl cap 150 mg (base
equivalent)....................................................................... 14
ALENDRONATE SODIUM -alendronate sodium oral soln
70 mg/75ml..................................................................... 34
ALENDRONATE SODIUM -alendronate sodium tab 40
mg.................................................................................... 34
alendronate sodium tab 5 mg........................................ 34
alendronate sodium tab 10 mg...................................... 34
alendronate sodium tab 35 mg...................................... 34
alendronate sodium tab 70 mg (Fosamax)................... 34
ALEVICYN ANTIPRURITIC GEL -wound dressings gel.................................................................................. 152
ALEVICYN DERMAL SPRAY -wound dressings soln................................................................................ 152
alfuzosin hcl tab sr 24hr 10 mg (Uroxatral).................. 77
ALINIA -nitazoxanide for susp 100 mg/5ml.......................12
ALINIA -nitazoxanide tab 500 mg..................................... 12
ALKERAN -melphalan tab 2 mg....................................... 14
ALL FLOW 1000 PFT FILTER -respiratory therapy
supplies - devices......................................................... 168
176
2016
supplies - kit.................................................................. 168
supplies - kit.................................................................. 168
supplies - kit.................................................................. 168
supplies - kit.................................................................. 168
supplies - kit.................................................................. 168
ALL FLOW 1000 PULMONARY F -respiratory therapy
supplies - misc.............................................................. 168
allopurinol tab 100 mg (Zyloprim)............................... 113
allopurinol tab 300 mg (Zyloprim)............................... 113
ALLZITAL -butalbital-acetaminophen tab 25-325 mg....... 99
almotriptan malate tab 6.25 mg (Axert).......................111
almotriptan malate tab 12.5 mg (Axert).......................111
ALOCRIL -nedocromil sodium ophth soln 2%................ 144
ALOGLIPTIN/METFORMIN HCL -alogliptin-metformin hcl
tab 12.5-500 mg............................................................. 27
ALOGLIPTIN/METFORMIN HCL -alogliptin-metformin hcl
tab 12.5-1000 mg........................................................... 27
ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab
12.5-15 mg...................................................................... 27
12.5-30 mg...................................................................... 27
12.5-45 mg...................................................................... 27
25-15 mg......................................................................... 27
25-30 mg......................................................................... 27
25-45 mg......................................................................... 27
ALOGLIPTIN -alogliptin benzoate tab 6.25 mg (base
equiv)............................................................................... 26
ALOGLIPTIN -alogliptin benzoate tab 12.5 mg (base
equiv)............................................................................... 26
ALOGLIPTIN -alogliptin benzoate tab 25 mg (base
equiv)............................................................................... 26
ALOMIDE -lodoxamide tromethamine ophth soln
0.1%...............................................................................144
ALOQUIN -iodoquinol-aloe polysaccharides gel
1.25-1%......................................................................... 152
ALORA -estradiol td patch twice weekly 0.025
mg/24hr........................................................................... 21
ALORA -estradiol td patch twice weekly 0.05 mg/24hr..... 21
ALORA -estradiol td patch twice weekly 0.075
mg/24hr........................................................................... 21
ALORA -estradiol td patch twice weekly 0.1 mg/24hr....... 21
alosetron hcl tab 0.5 mg (base equiv) (Lotronex)........ 73
alosetron hcl tab 1 mg (base equiv) (Lotronex)........... 73
ALPHAGAN P -brimonidine tartrate ophth soln 0.1%..... 144
ALPHAGAN P -brimonidine tartrate ophth soln
0.15%.............................................................................144
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 250 unit......................................... 139
vwf (human) for inj 500 unit......................................... 139
vwf (human) for inj 1000 unit....................................... 139
ALPHANINE SD -coagulation factor ix for inj 500
unit................................................................................. 140
unit................................................................................. 140
unit................................................................................. 140
ALPRAZOLAM INTENSOL -alprazolam conc 1 mg/
ml..................................................................................... 78
alprazolam orally disintegrating tab 0.5 mg................. 78
alprazolam orally disintegrating tab 1 mg.................... 78
alprazolam orally disintegrating tab 2 mg.................... 78
alprazolam orally disintegrating tab 0.25 mg
(Niravam)........................................................................ 78
alprazolam tab 0.25 mg (Xanax).................................... 78
alprazolam tab 0.5 mg (Xanax)...................................... 78
alprazolam tab 1 mg (Xanax)..........................................78
alprazolam tab 2 mg (Xanax)..........................................78
alprazolam tab sr 24hr 0.5 mg (Xanax xr)..................... 78
alprazolam tab sr 24hr 1 mg (Xanax xr)........................ 78
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
250 unit......................................................................... 140
500 unit......................................................................... 140
1000 unit....................................................................... 140
2000 unit....................................................................... 140
3000 unit....................................................................... 140
ALREX -loteprednol etabonate ophth susp 0.2%........... 144
ALSUMA -sumatriptan succinate solution auto-injector 6
mg/0.5ml........................................................................ 111
ALTABAX -retapamulin oint 1%.......................................152
ALTACE -ramipril cap 1.25 mg.......................................... 46
ALTACE -ramipril cap 2.5 mg............................................ 46
ALTACE -ramipril cap 5 mg............................................... 46
ALTACE -ramipril cap 10 mg............................................. 46
ALTOPREV -lovastatin tab sr 24hr 20 mg........................ 55
177
2016
ALUVEA -urea cream 39%..............................................152
ALVESCO -ciclesonide inhal aerosol 80 mcg/act............. 65
ALVESCO -ciclesonide inhal aerosol 160 mcg/act........... 65
AMANTADINE HCL -amantadine hcl tab 100 mg........... 118
amantadine hcl cap 100 mg......................................... 118
amantadine hcl syrup 50 mg/5ml................................ 118
AMARYL -glimepiride tab 1 mg......................................... 27
AMBIEN CR -zolpidem tartrate tab cr 6.25 mg................. 88
AMBIEN CR -zolpidem tartrate tab cr 12.5 mg................. 88
AMBIEN -zolpidem tartrate tab 5 mg................................ 88
AMBIEN -zolpidem tartrate tab 10 mg.............................. 88
AMCINONIDE -amcinonide cream 0.1%........................ 152
AMCINONIDE -amcinonide lotion 0.1%.......................... 152
AMCINONIDE -amcinonide oint 0.1%.............................152
AMERGE -naratriptan hcl tab 1 mg (base equiv)........... 111
AMERGE -naratriptan hcl tab 2.5 mg (base equiv)........ 111
AMICAR -aminocaproic acid oral soln 0.25 gm/ml......... 138
AMICAR -aminocaproic acid tab 500 mg........................ 138
AMICAR -aminocaproic acid tab 1000 mg...................... 138
amiloride & hydrochlorothiazide tab 5-50 mg.............. 54
amiloride hcl tab 5 mg.................................................... 54
AMINOBENZOATE POTASSIUM -potassium
aminobenzoate packet 2 gm........................................ 122
amiodarone hcl tab 100 mg............................................ 45
amiodarone hcl tab 400 mg............................................ 45
amiodarone hcl tab 200 mg (Cordarone)...................... 45
AMITIZA -lubiprostone cap 8 mcg.................................... 73
AMITIZA -lubiprostone cap 24 mcg.................................. 73
amitriptyline hcl tab 10 mg............................................. 79
amitriptyline hcl tab 100 mg........................................... 79
amitriptyline hcl tab 150 mg........................................... 79
amlodipine besylate-atorvastatin calcium tab 2.5-10
mg (Caduet)................................................................... 58
mg (Caduet)................................................................... 58
mg (Caduet)................................................................... 58
amlodipine besylate-atorvastatin calcium tab 5-10 mg
(Caduet).......................................................................... 58
(Caduet).......................................................................... 58
(Caduet).......................................................................... 58
(Caduet).......................................................................... 58
amlodipine besylate-atorvastatin calcium tab 10-10
mg (Caduet)................................................................... 58
mg (Caduet)................................................................... 58
mg (Caduet)................................................................... 59
mg (Caduet)................................................................... 59
amlodipine besylate-benazepril hcl cap 2.5-10 mg
(Lotrel)............................................................................ 46
amlodipine besylate-benazepril hcl cap 5-10 mg
(Lotrel)............................................................................ 46
(Lotrel)............................................................................ 46
(Lotrel)............................................................................ 46
(Lotrel)............................................................................ 46
(Lotrel)............................................................................ 46
amlodipine besylate tab 2.5 mg (Norvasc)................... 42
amlodipine besylate tab 5 mg (Norvasc)...................... 42
amlodipine besylate tab 10 mg (Norvasc).................... 42
amlodipine besylate-valsartan tab 5-160 mg
(Exforge)......................................................................... 46
(Exforge)......................................................................... 46
(Exforge)......................................................................... 46
(Exforge)......................................................................... 46
amlodipine-valsartan-hydrochlorothiazide tab
5-160-12.5 mg (Exforge hct)........................................ 46
5-160-25 mg (Exforge hct)........................................... 46
10-160-12.5 mg (Exforge hct)...................................... 46
10-160-25 mg (Exforge hct)......................................... 46
10-320-25 mg (Exforge hct)......................................... 46
AMOXAPINE -amoxapine tab 25 mg................................ 79
AMOXAPINE -amoxapine tab 50 mg................................ 79
AMOXAPINE -amoxapine tab 100 mg.............................. 80
AMOXAPINE -amoxapine tab 150 mg.............................. 80
AMOXICILLIN/CLAVULANATE P -amoxicillin & k
clavulanate chew tab 200-28.5 mg.................................. 1
AMOXICILLIN/CLAVULANATE P -amoxicillin & k
clavulanate chew tab 400-57 mg..................................... 1
amoxicillin & k clavulanate for susp 200-28.5
mg/5ml.............................................................................. 1
amoxicillin & k clavulanate for susp 400-57 mg/5ml..... 1
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
(Augmentin)..................................................................... 1
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
(Augmentin es-600)........................................................ 1
amoxicillin & k clavulanate tab 250-125 mg................... 1
amoxicillin & k clavulanate tab 500-125 mg
(Augmentin)..................................................................... 1
amoxicillin & k clavulanate tab 875-125 mg
(Augmentin)..................................................................... 1
amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg
(Augmentin xr)................................................................ 1
178
2016
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).............................................................. 69
AMOXICILLIN ER -amoxicillin (trihydrate) tab sr 24hr 775
mg...................................................................................... 1
amoxicillin (trihydrate) cap 250 mg................................. 1
amoxicillin (trihydrate) cap 500 mg................................. 1
amoxicillin (trihydrate) for susp 125 mg/5ml..................1
amoxicillin (trihydrate) tab 500 mg.................................. 1
amoxicillin (trihydrate) tab 875 mg.................................. 1
amphetamine-dextroamphetamine cap sr 24hr 5 mg
(Adderall xr)................................................................... 90
(Adderall xr)................................................................... 90
(Adderall xr)................................................................... 90
(Adderall xr)................................................................... 90
(Adderall xr)................................................................... 90
(Adderall xr)................................................................... 90
amphetamine-dextroamphetamine tab 5 mg
(Adderall)........................................................................ 90
amphetamine-dextroamphetamine tab 7.5 mg
(Adderall)........................................................................ 90
(Adderall)........................................................................ 90
amphetamine-dextroamphetamine tab 12.5 mg
(Adderall)........................................................................ 90
(Adderall)........................................................................ 90
(Adderall)........................................................................ 90
(Adderall)........................................................................ 90
AMPICILLIN -ampicillin for susp 125 mg/5ml..................... 1
AMPICILLIN -ampicillin for susp 250 mg/5ml..................... 1
ampicillin cap 250 mg....................................................... 1
ampicillin cap 500 mg....................................................... 1
AMPYRA -dalfampridine tab sr 12hr 10 mg...................... 95
AMRIX -cyclobenzaprine hcl cap sr 24hr 15 mg............. 121
AMRIX -cyclobenzaprine hcl cap sr 24hr 30 mg............. 121
ANADROL-50 -oxymetholone tab 50 mg.......................... 20
ANAFRANIL -clomipramine hcl cap 25 mg....................... 80
anagrelide hcl cap 1 mg............................................... 140
anagrelide hcl cap 0.5 mg (Agrylin)............................ 140
ANALPRAM E -hc-pramoxine emol cream 2.5-1% &
pramoxine wipe 1% kit................................................. 150
ANALPRAM-HC -hydrocortisone acetate w/ pramoxine
rectal cream 1-1%........................................................ 150
ANALPRAM HC -hydrocortisone acetate w/ pramoxine
rectal cream 2.5-1%..................................................... 150
ANALPRAM-HC -hydrocortisone acetate w/ pramoxine
rectal lotn 2.5-1%..........................................................150
ANALPRAM-HC SINGLES -hydrocortisone acetate w/
pramoxine rectal cream 1-1%...................................... 150
ANALPRAM-HC SINGLES -hydrocortisone acetate w/
pramoxine rectal cream 2.5-1%................................... 150
ANALPRAM HC SINGLES -hydrocortisone acetate w/
pramoxine rectal cream 2.5-1%................................... 150
ANAPROX DS -naproxen sodium tab 550 mg............... 108
ANASEPT -sodium hypochlorite liquid 0.057%.............. 166
ANASPAZ -hyoscyamine sulfate tab disp 0.125 mg......... 69
anastrozole tab 1 mg (Arimidex)................................... 14
ANCOBON -flucytosine cap 250 mg................................... 6
ANCOBON -flucytosine cap 500 mg................................... 6
ANDRODERM -testosterone td patch 24hr 2 mg/24hr..... 20
ANDRODERM -testosterone td patch 24hr 4 mg/24hr..... 20
ANDROGEL PUMP -testosterone td gel 12.5 mg/act
(1%)................................................................................. 20
ANDROGEL PUMP -testosterone td gel 20.25 mg/act
(1.62%)............................................................................ 20
ANDROGEL -testosterone td gel 25 mg/2.5gm (1%)....... 20
ANDROGEL -testosterone td gel 50 mg/5gm (1%).......... 20
ANDROGEL -testosterone td gel 20.25 mg/1.25gm
(1.62%)............................................................................ 20
ANDROGEL -testosterone td gel 40.5 mg/2.5gm
(1.62%)............................................................................ 20
ANDROID -methyltestosterone cap 10 mg....................... 20
ANDROXY -fluoxymesterone tab 10 mg........................... 20
ANGELIQ -drospirenone-estradiol tab 0.25-0.5 mg.......... 21
ANGELIQ -drospirenone-estradiol tab 0.5-1 mg............... 21
ANIMI-3/VITAMIN D -folic acid-b6-b12-d-omega 3phytosterols cap 1 mg.................................................. 133
ANIMI-3 -folic acid-b6-b12-d-omega 3-phytosterols cap 1
mg.................................................................................. 133
ANORO ELLIPTA -umeclidinium-vilanterol aero powd ba
62.5-25 mcg/inh.............................................................. 65
ANTABUSE -disulfiram tab 250 mg.................................. 95
ANTABUSE -disulfiram tab 500 mg.................................. 95
ANTARA -fenofibrate micronized cap 30 mg.................... 55
ANTARA -fenofibrate micronized cap 90 mg.................... 55
antipyrine-benzocaine otic soln 54-14 mg/ml
(5.4-1.4%)...................................................................... 148
ANUSOL-HC -hydrocortisone rectal cream 2.5%........... 151
ANZEMET -dolasetron mesylate tab 50 mg..................... 71
ANZEMET -dolasetron mesylate tab 100 mg................... 71
APEXICON E -diflorasone diacetate emollient base
cream 0.05%................................................................. 152
APIDRA -insulin glulisine inj 100 unit/ml........................... 31
APIDRA SOLOSTAR -insulin glulisine soln pen-injector inj
100 unit/ml.......................................................................31
APLENZIN -bupropion hbr tab sr 24hr 174 mg.................80
179
2016
APOKYN -apomorphine hydrochloride inj 10 mg/ml....... 118
apraclonidine hcl ophth soln 0.5% (base equivalent)
(Iopidine)...................................................................... 144
APRISO -mesalamine cap sr 24hr 0.375 gm.................... 73
APTENSIO XR -methylphenidate hcl cap er 24hr 10 mg
(xr)................................................................................... 90
(xr)................................................................................... 90
(xr)................................................................................... 91
(xr)................................................................................... 91
(xr)................................................................................... 91
(xr)................................................................................... 91
(xr)................................................................................... 91
APTIOM -eslicarbazepine acetate tab 200 mg............... 113
APTIVUS -tipranavir cap 250 mg........................................ 8
APTIVUS -tipranavir oral soln 100 mg/ml........................... 8
AP-ZEL -multiple vitamins w/ minerals tab..................... 123
AQUORAL -artificial saliva - aero soln............................ 148
ARALEN -chloroquine phosphate tab 500 mg.................. 12
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 25
mcg/ml........................................................................... 133
mcg/ml........................................................................... 133
mcg/ml........................................................................... 133
mcg/ml........................................................................... 133
mcg/ml........................................................................... 133
mcg/ml........................................................................... 133
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 10 mcg/0.4ml..................................... 133
prefilled syringe 25 mcg/0.42ml................................... 133
prefilled syringe 500 mcg/ml........................................ 133
ARAVA -leflunomide tab 10 mg....................................... 108
ARAVA -leflunomide tab 20 mg....................................... 108
ARCALYST -rilonacept for inj 220 mg.............................108
ARCAPTA NEOHALER -indacaterol maleate inhal powder
cap 75 mcg (base equiv)................................................65
ARESTIN -minocycline hcl subgingival powder cartridge 1
mg.................................................................................. 148
ARICEPT -donepezil hydrochloride tab 5 mg................... 95
ARICEPT -donepezil hydrochloride tab 10 mg................. 95
ARICEPT -donepezil hydrochloride tab 23 mg................. 95
ARIMIDEX -anastrozole tab 1 mg..................................... 14
aripiprazole orally disintegrating tab 10 mg.................84
aripiprazole orally disintegrating tab 15 mg.................84
aripiprazole oral solution 1 mg/ml................................. 84
aripiprazole tab 2 mg (Abilify)........................................ 84
aripiprazole tab 5 mg (Abilify)........................................ 84
aripiprazole tab 10 mg (Abilify)...................................... 84
ARIXTRA -fondaparinux sodium subcutaneous inj 2.5
mg/0.5ml........................................................................ 137
ARIXTRA -fondaparinux sodium subcutaneous inj 5
mg/0.4ml........................................................................ 137
ARIXTRA -fondaparinux sodium subcutaneous inj 7.5
mg/0.6ml........................................................................ 137
ARIXTRA -fondaparinux sodium subcutaneous inj 10
mg/0.8ml........................................................................ 137
ARMODAFINIL -armodafinil tab 200 mg........................... 91
armodafinil tab 50 mg (Nuvigil)......................................91
armodafinil tab 150 mg (Nuvigil)................................... 91
armodafinil tab 250 mg (Nuvigil)................................... 91
ARMOUR THYROID -thyroid tab 15 mg (1/4 grain)......... 32
ARMOUR THYROID -thyroid tab 30 mg (1/2 grain)......... 32
ARMOUR THYROID -thyroid tab 90 mg (1 1/2 grain)...... 32
ARMOUR THYROID -thyroid tab 60 mg (1 grain)............ 32
ARMOUR THYROID -thyroid tab 120 mg (2 grain).......... 32
ARNUITY ELLIPTA -fluticasone furoate aerosol powder
breath activ 100 mcg/act................................................ 65
ARNUITY ELLIPTA -fluticasone furoate aerosol powder
breath activ 200 mcg/act................................................ 65
AROMASIN -exemestane tab 25 mg................................ 14
ARTHROTEC 50 -diclofenac w/ misoprostol tab delayed
release 50-0.2 mg.........................................................108
ARTHROTEC 75 -diclofenac w/ misoprostol tab delayed
release 75-0.2 mg.........................................................108
ARTISS -fibrin sealant component solution.................... 138
ARZOL SILVER NITRATE APP -silver nitrate-potassium
nitrate applicator 75-25%............................................. 152
ASACOL HD -mesalamine tab delayed release 800
mg.................................................................................... 73
ASCENSIA AUTODISC TEST ST -glucose blood test
disk................................................................................ 167
180
2016
ASMANEX HFA -mometasone furoate inhal aerosol
suspension 100 mcg/act................................................. 65
ASMANEX HFA -mometasone furoate inhal aerosol
suspension 200 mcg/act................................................. 65
ASMANEX TWISTHALER 120 ME -mometasone furoate
inhal powd 220 mcg/inh (breath activated).................... 65
ASMANEX TWISTHALER 7 METE -mometasone furoate
ASMANEX TWISTHALER 14 MET -mometasone furoate
ASPIRIN/DIPYRIDAMOLE -aspirin-dipyridamole cap sr
12hr 25-200 mg............................................................ 140
ASPIRIN-CAFFEINE-DIHYDROC -aspirin-caffeinedihydrocodeine cap 356.4-30-16 mg........................... 100
aspirin chew tab 81 mg...................................................99
aspirin tab delayed release 81 mg.................................99
aspirin tab delayed release 325 mg...............................99
aspirin tab 325 mg........................................................... 99
ASSESS PEAK FLOW METER FU -peak flow
meter..............................................................................168
ASTAGRAF XL -tacrolimus cap sr 24hr 0.5 mg.............. 171
ASTAGRAF XL -tacrolimus cap sr 24hr 1 mg................. 171
ASTAGRAF XL -tacrolimus cap sr 24hr 5 mg................. 171
ASTEPRO -azelastine hcl nasal spray 0.15% (205.5 mcg/
spray)............................................................................... 61
ASTHMAPACK III -peak flow meter w/inhaler assist
device kit....................................................................... 168
ASTHMAPACK II -peak flow meter w/inhaler assist device
kit................................................................................... 168
ASTHMAPACK I -peak flow meter w/inhaler assist device
kit................................................................................... 168
ASTRINGYN -ferric subsulfate soln 259 mg/gm............. 138
ATABEX EC -prenatal vit w/ dss-iron carbonyl-fa tab dr
29-1 mg......................................................................... 123
ATACAND -candesartan cilexetil tab 4 mg....................... 46
ATACAND -candesartan cilexetil tab 8 mg....................... 46
ATACAND -candesartan cilexetil tab 16 mg..................... 46
ATACAND -candesartan cilexetil tab 32 mg..................... 46
ATACAND HCT -candesartan cilexetil-hydrochlorothiazide
tab 16-12.5 mg............................................................... 46
tab 32-12.5 mg............................................................... 46
tab 32-25 mg...................................................................46
ATELVIA -risedronate sodium tab delayed release 35
mg.................................................................................... 34
atenolol & chlorthalidone tab 50-25 mg (Tenoretic
50).................................................................................... 46
atenolol & chlorthalidone tab 100-25 mg (Tenoretic
100).................................................................................. 47
atenolol tab 25 mg (Tenormin)....................................... 40
atenolol tab 50 mg (Tenormin)....................................... 40
atenolol tab 100 mg (Tenormin)..................................... 40
ATIVAN -lorazepam tab 0.5 mg......................................... 78
ATIVAN -lorazepam tab 1 mg............................................ 78
ATIVAN -lorazepam tab 2 mg............................................ 78
ATOPICLAIR -dermatological products misc - cream..... 152
atorvastatin calcium tab 10 mg (base equivalent)
(Lipitor)........................................................................... 55
(Lipitor)........................................................................... 55
(Lipitor)........................................................................... 55
(Lipitor)........................................................................... 55
atovaquone-proguanil hcl tab 62.5-25 mg
(Malarone)...................................................................... 12
atovaquone-proguanil hcl tab 250-100 mg
(Malarone)...................................................................... 12
atovaquone susp 750 mg/5ml (Mepron)....................... 12
ATRALIN -tretinoin gel 0.05%......................................... 152
ATRAPRO ANTIPRURITIC HYDR -wound dressings gel.................................................................................. 152
ATRAPRO DERMAL SPRAY -wound cleansers liquid.............................................................................. 152
ATRIPLA -efavirenz-emtricitabine-tenofovir df tab
600-200-300 mg................................................................8
ATROPINE SULFATE -atropine sulfate ophth oint
1%.................................................................................. 144
atropine sulfate ophth soln 1% (Isopto atropine)...... 144
ATROVENT HFA -ipratropium bromide hfa inhal aerosol
17 mcg/act.......................................................................65
AUBAGIO -teriflunomide tab 7 mg.................................... 95
AUBAGIO -teriflunomide tab 14 mg.................................. 95
AUGMENTIN -amoxicillin & k clavulanate for susp
125-31.25 mg/5ml............................................................. 1
AUGMENTIN -amoxicillin & k clavulanate for susp
250-62.5 mg/5ml............................................................... 1
AUGMENTIN -amoxicillin & k clavulanate tab 500-125
mg...................................................................................... 1
AUGMENTIN -amoxicillin & k clavulanate tab 875-125
mg...................................................................................... 1
AUGMENTIN ES-600 -amoxicillin & k clavulanate for
susp 600-42.9 mg/5ml...................................................... 1
AUGMENTIN XR -amoxicillin & k clavulanate tab sr 12hr
1000-62.5 mg.................................................................... 1
AURYXIA -ferric citrate tab 1 gm (210 mg ferric iron)....... 73
AVALIDE -irbesartan-hydrochlorothiazide tab 150-12.5
mg.................................................................................... 47
AVALIDE -irbesartan-hydrochlorothiazide tab 300-12.5
mg.................................................................................... 47
AVANDIA -rosiglitazone maleate tab 2 mg (base
equiv)............................................................................... 27
AVANDIA -rosiglitazone maleate tab 4 mg (base
equiv)............................................................................... 27
AVAPRO -irbesartan tab 75 mg........................................ 47
AVAPRO -irbesartan tab 150 mg...................................... 47
AVAPRO -irbesartan tab 300 mg...................................... 47
181
2016
AVAR-E LS -sulfacetamide sodium w/ sulfur cream
10-2%............................................................................ 152
AVAR LS CLEANSER -sulfacetamide sodium w/ sulfur
cleanser 10-2%............................................................. 152
AVAR LS -sulfacetamide sodium w/ sulfur cleansing pad
10-2%............................................................................ 152
AVAR LS -sulfacetamide sodium w/ sulfur foam
10-2%............................................................................ 152
AVAR -sulfacetamide sodium w/ sulfur cleansing pad
9.5-5%........................................................................... 152
AVAR -sulfacetamide sodium w/ sulfur foam 9.5-5%...... 152
AVC -sulfanilamide vaginal cream 15%............................ 76
AVEED -testosterone undecanoate im inj in oil 750
mg/3ml (250mg/ml)......................................................... 20
AVELOX ABC PACK -moxifloxacin hcl tab 400 mg (base
equiv)................................................................................. 5
AVELOX -moxifloxacin hcl tab 400 mg (base equiv).......... 5
AVENOVA -eyelid cleansers - liquid................................152
AVIDOXY DK -doxycycline tab 100 mg & suncreen & sal
acid wash 2% kit...............................................................4
AVODART -dutasteride cap 0.5 mg.................................. 77
AVONEX -interferon beta-1a for im inj kit 30mcg
(33mcg(6.6 mu)/vial)....................................................... 95
AVONEX -interferon beta-1a im prefilled syringe kit 30
mcg/0.5ml........................................................................ 95
AVONEX PEN -interferon beta-1a im auto-injector kit 30
mcg/0.5ml........................................................................ 95
AXERT -almotriptan malate tab 6.25 mg........................ 111
AXERT -almotriptan malate tab 12.5 mg........................ 111
AXIRON -testosterone td soln 30 mg/act.......................... 20
AYGESTIN -norethindrone acetate tab 5 mg.................... 26
azacitidine for inj 100 mg (Vidaza)................................ 14
AZASAN -azathioprine tab 75 mg................................... 171
AZASAN -azathioprine tab 100 mg................................. 171
AZASITE -azithromycin ophth soln 1%........................... 144
azathioprine tab 50 mg (Imuran).................................. 171
azelastine hcl nasal spray 0.1% (137 mcg/spray)........ 61
azelastine hcl nasal spray 0.15% (205.5 mcg/spray)
(Astepro).........................................................................61
azelastine hcl ophth soln 0.05%.................................. 144
AZELEX -azelaic acid cream 20%.................................. 152
AZILECT -rasagiline mesylate tab 0.5 mg (base
equiv)............................................................................. 118
AZILECT -rasagiline mesylate tab 1 mg (base
equiv)............................................................................. 118
AZITHROMYCIN -azithromycin powd pack for susp 1
gm...................................................................................... 3
azithromycin for susp 100 mg/5ml (Zithromax)............. 3
azithromycin for susp 200 mg/5ml (Zithromax)............. 3
azithromycin tab 250 mg (Zithromax)............................. 3
AZOPT -brinzolamide ophth susp 1%............................. 144
AZOR -amlodipine besylate-olmesartan medoxomil tab
5-20 mg........................................................................... 47
5-40 mg........................................................................... 47
10-20 mg......................................................................... 47
10-40 mg......................................................................... 47
AZULFIDINE EN-TABS -sulfasalazine tab delayed
release 500 mg............................................................... 73
AZULFIDINE -sulfasalazine tab 500 mg........................... 73
B
BABY DDROPS -cholecalciferol drops 400 unit/0.03ml
(per drop)...................................................................... 122
BACITRACIN -bacitracin ophth oint 500 unit/gm............ 144
bacitracin-polymyxin b ophth oint.............................. 144
bacitracin-polymyxin-neomycin-hc ophth oint
1%.................................................................................. 144
baclofen tab 10 mg........................................................ 121
baclofen tab 20 mg........................................................ 121
BACMIN -multiple vitamins w/ minerals tab.................... 123
BACTRIM DS -sulfamethoxazole-trimethoprim tab
800-160 mg..................................................................... 13
BACTRIM -sulfamethoxazole-trimethoprim tab 400-80
mg.................................................................................... 13
BACTROBAN -mupirocin calcium cream 2%................. 152
BACTROBAN NASAL -mupirocin calcium nasal oint
2%.................................................................................... 61
BAL-CARE DHA -prenat w/fe poly-na fered-fa tab 27-1 &
omega cap dr 430mg................................................... 123
balsalazide disodium cap 750 mg (Colazal)................. 73
BANZEL -rufinamide susp 40 mg/ml............................... 113
BANZEL -rufinamide tab 200 mg.................................... 113
BANZEL -rufinamide tab 400 mg.................................... 113
BARACLUDE -entecavir oral soln 0.05 mg/ml.................... 8
BARACLUDE -entecavir tab 0.5 mg................................... 8
BARACLUDE -entecavir tab 1 mg...................................... 8
BAYER BREEZE 2 TEST DISC -glucose blood test
disk................................................................................ 167
BAYER CONTOUR BLOOD GLUCO -glucose blood test
strip................................................................................ 167
BAYER CONTOUR NEXT BLOOD -glucose blood test
strip................................................................................ 167
b-complex w/ c & folic acid cap 1 mg
(Nephrocaps)............................................................... 123
b-complex w/ c & folic acid tab................................... 123
b-complex w/ c & folic acid tab 5 mg.......................... 123
b-complex w/ c & folic acid tab 1 mg (Nephro-vite
rx).................................................................................. 123
BEAU RX -scar treatment products - gel........................ 152
BEBULIN -factor ix complex for inj 200-1200 unit.......... 140
BECONASE AQ -beclomethasone dipropionate monohyd
nasal susp 42 mcg/spray............................................... 61
BELBUCA -buprenorphine hcl buccal film 75 mcg (base
equivalent)..................................................................... 100
equivalent)..................................................................... 100
equivalent)..................................................................... 100
182
2016
equivalent)..................................................................... 100
equivalent)..................................................................... 100
equivalent)..................................................................... 100
equivalent)..................................................................... 100
BELLADONNA & OPIUM -belladonna alkaloids & opium
suppos 16.2-30 mg......................................................... 69
BELLADONNA ALKALOIDS & OP -belladonna alkaloids
& opium suppos 16.2-60 mg.......................................... 69
BELSOMRA -suvorexant tab 5 mg................................... 88
BELSOMRA -suvorexant tab 10 mg................................. 88
BELVIQ -lorcaserin hcl tab 10 mg..................................... 91
benazepril & hydrochlorothiazide tab 5-6.25 mg......... 47
benazepril & hydrochlorothiazide tab 10-12.5 mg
(Lotensin hct)................................................................ 47
benazepril & hydrochlorothiazide tab 20-12.5 mg
(Lotensin hct)................................................................ 47
benazepril & hydrochlorothiazide tab 20-25 mg
(Lotensin hct)................................................................ 47
benazepril hcl tab 5 mg.................................................. 47
benazepril hcl tab 10 mg (Lotensin).............................. 47
BENEFIX -coagulation factor ix (recombinant) for inj 250
unit................................................................................. 140
unit................................................................................. 140
unit................................................................................. 140
unit................................................................................. 140
unit................................................................................. 140
BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 20-12.5 mg...............................47
BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 40-12.5 mg...............................47
BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 40-25 mg.................................. 47
BENICAR -olmesartan medoxomil tab 5 mg.....................47
BENICAR -olmesartan medoxomil tab 20 mg...................47
BENICAR -olmesartan medoxomil tab 40 mg...................47
BENSAL HP -salicylic acid & benzoic acid oint 3-6%..... 152
BENTYL -dicyclomine hcl cap 10 mg............................... 69
BENTYL -dicyclomine hcl tab 20 mg................................ 69
BENZAC AC WASH -benzoyl peroxide liq 5%............... 152
BENZACLIN -clindamycin phosphate-benzoyl peroxide
gel 1-5%........................................................................ 152
BENZACLIN WITH PUMP -clindamycin phosphatebenzoyl peroxide gel 1-5%........................................... 152
BENZALKONIUM CHLORIDE -benzalkonium chloride
soln 50%....................................................................... 166
BENZAMYCIN -benzoyl peroxide-erythromycin gel
5-3%.............................................................................. 152
BENZAMYCINPAK -benzoyl peroxide-erythromycin gel
pack 5-3%..................................................................... 152
BENZEFOAM -benzoyl peroxide foam 5.3%.................. 152
BENZEFOAM ULTRA -benzoyl peroxide foam 9.8%..... 152
BENZIQ -benzoyl peroxide gel 5.25 %........................... 152
BENZIQ LS -benzoyl peroxide gel 2.75%....................... 152
benzocaine dental soln 20%.........................................148
BENZONATATE -benzonatate cap 150 mg...................... 62
benzonatate cap 200 mg................................................. 62
benzonatate cap 100 mg (Tessalon perles).................. 62
benzoyl peroxide cloth 6%........................................... 152
benzoyl peroxide creamy wash 8% &benzoyl peroxide
bar 5% kit..................................................................... 152
benzoyl peroxide-erythromycin gel 5-3%
(Benzamycin)............................................................... 153
benzoyl peroxide foam 5.3% (Benzefoam)................. 152
benzoyl peroxide foam 9.8% (Benzefoamultra)......... 153
benzoyl peroxide gel 10%.............................................153
benzoyl peroxide liq 2.5%.............................................153
benzoyl peroxide liq 5.25%...........................................153
benzoyl peroxide liq 7%................................................153
benzoyl peroxide liq 10%..............................................153
benzoyl peroxide lotion 6%.......................................... 153
benzphetamine hcl tab 25 mg........................................ 91
benzphetamine hcl tab 50 mg........................................ 91
benztropine mesylate tab 0.5 mg................................ 118
benztropine mesylate tab 1 mg................................... 119
benztropine mesylate tab 2 mg................................... 119
BEPREVE -bepotastine besilate ophth soln 1.5%.......... 144
BESIVANCE -besifloxacin hcl ophth susp 0.6% (base
equiv)............................................................................. 144
BETADINE OPHTHALMIC PREP -povidone-iodine ophth
soln 5%......................................................................... 144
BETAGAN -levobunolol hcl ophth soln 0.5%.................. 144
betamethasone dipropionate augmented cream 0.05%
(Diprolene af)............................................................... 153
betamethasone dipropionate augmented gel
0.05%.............................................................................153
betamethasone dipropionate augmented lotion 0.05%
(Diprolene)................................................................... 153
betamethasone dipropionate augmented oint 0.05%
(Diprolene)................................................................... 153
betamethasone dipropionate cream 0.05%................ 153
betamethasone dipropionate lotion 0.05%................. 153
betamethasone dipropionate oint 0.05%.................... 153
betamethasone valerate aerosol foam 0.12%
(Luxiq)........................................................................... 153
betamethasone valerate cream 0.1%.......................... 153
betamethasone valerate lotion 0.1%........................... 153
betamethasone valerate oint 0.1%.............................. 153
BETAPACE AF -sotalol hcl (afib/afl) tab 80 mg................ 40
BETAPACE AF -sotalol hcl (afib/afl) tab 120 mg.............. 40
BETAPACE AF -sotalol hcl (afib/afl) tab 160 mg.............. 40
BETAPACE -sotalol hcl tab 80 mg.................................... 40
BETAPACE -sotalol hcl tab 120 mg.................................. 40
183
2016
BETAPACE -sotalol hcl tab 160 mg.................................. 40
BETASERON -interferon beta-1b for inj kit 0.3 mg........... 95
betaxolol hcl ophth soln 0.5%......................................144
betaxolol hcl tab 10 mg (Kerlone)................................. 40
betaxolol hcl tab 20 mg (Kerlone)................................. 40
bethanechol chloride tab 5 mg (Urecholine)................ 75
bethanechol chloride tab 10 mg (Urecholine).............. 75
BETHKIS -tobramycin nebu soln 300 mg/4ml.................... 6
BETIMOL -timolol ophth soln 0.25%............................... 144
BETIMOL -timolol ophth soln 0.5%................................. 144
BETOPTIC-S -betaxolol hcl ophth susp 0.25%.............. 144
BEVESPI AEROSPHERE -glycopyrrolate-formoterol
fumarate aerosol 9-4.8 mcg/act..................................... 65
bexarotene cap 75 mg (Targretin)..................................14
BEYAZ -drospirenone-ethinyl estrad-levomefolate tab
3-0.02-0.451 mg..............................................................23
B-6 FOLIC ACID -cobalamine combination cap............. 133
BIAXIN -clarithromycin for susp 250 mg/5ml...................... 3
BIAXIN -clarithromycin tab 250 mg..................................... 3
BIAXIN -clarithromycin tab 500 mg..................................... 3
bicalutamide tab 50 mg (Casodex)................................ 14
BIDIL -isosorbide dinitrate-hydralazine hcl tab 20-37.5
mg.................................................................................... 59
BIFERARX -polysacch fe cmplx-fe heme poly-fa-b12 tab
22-6-1-0.025 mg........................................................... 133
BILTRICIDE -praziquantel tab 600 mg.............................. 12
BIMATOPROST -bimatoprost ophth soln 0.03%............ 144
BINOSTO -alendronate sodium effervescent tab 70
mg.................................................................................... 34
BIO-STATIN -nystatin cap 500000 unit............................... 6
BIO-STATIN -nystatin cap 1000000 unit............................. 6
bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln
kit..................................................................................... 68
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
(Ziac)............................................................................... 47
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
(Ziac)............................................................................... 47
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
(Ziac)............................................................................... 47
bisoprolol fumarate tab 5 mg (Zebeta)..........................40
bisoprolol fumarate tab 10 mg (Zebeta)........................40
BLEPHAMIDE S.O.P. -sulfacetamide sodiumprednisolone ophth oint 10-0.2%................................. 144
BLEPHAMIDE -sulfacetamide sodium-prednisolone ophth
susp 10-0.2%................................................................ 144
BLEPH-10 -sulfacetamide sodium ophth soln 10%........ 144
BLOOD GLUCOSE TEST STRIPS – VARIOUS............. 167
BONIVA -ibandronate sodium tab 150 mg (base
equivalent)....................................................................... 34
BOSULIF -bosutinib tab 100 mg....................................... 14
BOSULIF -bosutinib tab 500 mg....................................... 14
BP CLEANSING WASH -sulfacetamide sodium-sulfur in
urea emulsion 10-4%................................................... 153
BP FOLINATAL PLUS B -prenatal w/ calcium carbonateb6-b12-fa tab 1 mg....................................................... 123
BP MULTINATAL PLUS -prenatal w/o a vit w/ fe fumaratefa tab 30-1 mg.............................................................. 123
BP MULTINATAL PLUS -prenatal w/o a vit w/ fe fum-fa
tab chew 40-1 mg......................................................... 123
BPO -benzoyl peroxide gel 4%....................................... 153
BPO -benzoyl peroxide gel 8%....................................... 153
BP VIT 3 -folic acid-vit b6-vit b12-omega 3-phytosterols
cap 1 mg....................................................................... 133
BRAVELLE– Benefit Limits may apply -urofollitropin
purified for inj 75 unit......................................................34
BREATHERITE VALVED MDI CH -respiratory therapy
BREO ELLIPTA -fluticasone furoate-vilanterol aero powd
ba 100-25 mcg/inh.......................................................... 65
BREO ELLIPTA -fluticasone furoate-vilanterol aero powd
ba 200-25 mcg/inh.......................................................... 65
BREVICON-28 -norethindrone & ethinyl estradiol tab 0.5
mg-35 mcg...................................................................... 23
BRILINTA -ticagrelor tab 60 mg...................................... 140
BRILINTA -ticagrelor tab 90 mg...................................... 140
brimonidine tartrate ophth soln 0.2%......................... 144
brimonidine tartrate ophth soln 0.15% (Alphagan
p)................................................................................... 144
BRISDELLE -paroxetine mesylate cap 7.5 mg (base
equiv)............................................................................... 95
BRIVIACT -brivaracetam oral soln 10 mg/ml.................. 113
BRIVIACT -brivaracetam tab 10 mg............................... 113
BRIVIACT -brivaracetam tab 100 mg............................. 113
BROMFENAC -bromfenac sodium ophth soln 0.09%
(base equivalent).......................................................... 144
bromfenac sodium ophth soln 0.09% (base equiv)
(once-daily).................................................................. 144
bromocriptine mesylate cap 5 mg (Parlodel)............. 119
bromocriptine mesylate tab 2.5 mg............................. 119
brompheniramine & pseudoephedrine tab sr 12hr
6-45 mg........................................................................... 62
brompheniramine maleate tab sr 12hr 6 mg................ 60
BROMPHENIRAMINE TANNATE -brompheniramine
tannate chew tab 12 mg.................................................60
BROVANA -arformoterol tartrate soln nebu 15 mcg/2ml
(base equiv).................................................................... 65
BUCALSEP -antiseptic products misc - liquid.................166
BUCALSEP -antiseptic products misc - solution.............166
budesonide delayed release particles cap 3 mg
(Entocort ec).................................................................. 18
budesonide inhalation susp 0.25 mg/2ml
(Pulmicort)......................................................................65
budesonide inhalation susp 0.5 mg/2ml
(Pulmicort)......................................................................65
budesonide inhalation susp 1 mg/2ml (Pulmicort)...... 65
budesonide nasal susp 32 mcg/act (Rhinocort
aqua)............................................................................... 61
bumetanide tab 0.5 mg................................................... 54
bumetanide tab 1 mg...................................................... 54
184
2016
bumetanide tab 2 mg...................................................... 54
BUMEX -bumetanide tab 0.5 mg...................................... 54
BUMEX -bumetanide tab 1 mg......................................... 54
BUMEX -bumetanide tab 2 mg......................................... 54
BUNAVAIL -buprenorphine-naloxone buccal film 2.1-0.3
mg (base equiv)............................................................ 100
BUNAVAIL -buprenorphine-naloxone buccal film 4.2-0.7
mg (base equiv)............................................................ 100
BUNAVAIL -buprenorphine-naloxone buccal film 6.3-1 mg
(base equiv).................................................................. 100
BUPAP -butalbital-acetaminophen tab 50-300 mg........... 99
BUPHENYL -sodium phenylbutyrate oral powder 3 gm/
teaspoonful...................................................................... 34
BUPHENYL -sodium phenylbutyrate tab 500 mg............. 34
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base
equiv)............................................................................ 100
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
equiv)............................................................................ 100
buprenorphine hcl sl tab 2 mg (base equiv).............. 100
buprenorphine hcl sl tab 8 mg (base equiv).............. 100
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
(Zyban)............................................................................ 95
bupropion hcl tab 75 mg (Wellbutrin)........................... 80
bupropion hcl tab 100 mg (Wellbutrin)......................... 80
bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr)........ 80
bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl)........ 80
bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl)........ 80
buspirone hcl tab 5 mg................................................... 78
buspirone hcl tab 7.5 mg................................................ 78
buspirone hcl tab 10 mg................................................. 78
butalbital-acetaminophen-caffeine cap 50-325-40
mg................................................................................... 99
butalbital-acetaminophen-caffeine cap 50-300-40 mg
(Fioricet)......................................................................... 99
butalbital-acetaminophen-caffeine tab 50-325-40 mg
(Esgic)............................................................................. 99
butalbital-acetaminophen-caff w/ cod cap
50-325-40-30 mg.......................................................... 100
butalbital-acetaminophen-caff w/ cod cap
50-300-40-30 mg (Fioricet/codeine).......................... 100
butalbital-acetaminophen tab 50-325 mg......................99
butalbital-aspirin-caffeine cap 50-325-40 mg
(Fiorinal)......................................................................... 99
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
(Fiorinal/codeine #3)................................................... 100
BUTISOL SODIUM -butabarbital sodium tab 30 mg.........88
butorphanol tartrate nasal soln 10 mg/ml.................. 100
BUTRANS -buprenorphine td patch weekly 5 mcg/
hr.................................................................................... 100
BUTRANS -buprenorphine td patch weekly 7.5 mcg/
hr.................................................................................... 100
hr.................................................................................... 100
hr.................................................................................... 100
hr.................................................................................... 100
BYDUREON -exenatide extended release for susp peninjector 2 mg................................................................... 27
BYDUREON -exenatide for inj extended release susp 2
mg.................................................................................... 27
BYETTA -exenatide soln pen-injector 5 mcg/0.02ml........ 27
BYETTA -exenatide soln pen-injector 10 mcg/0.04ml...... 27
BYSTOLIC -nebivolol hcl tab 2.5 mg (base
equivalent)....................................................................... 40
BYSTOLIC -nebivolol hcl tab 5 mg (base equivalent).......40
BYSTOLIC -nebivolol hcl tab 10 mg (base
equivalent)....................................................................... 40
BYSTOLIC -nebivolol hcl tab 20 mg (base
equivalent)....................................................................... 40
C
cabergoline tab 0.5 mg................................................... 34
CABOMETYX -cabozantinib s-malate tab 20 mg (base
equivalent)....................................................................... 14
equivalent)....................................................................... 14
equivalent)....................................................................... 14
CADUET -amlodipine besylate-atorvastatin calcium tab
2.5-10 mg........................................................................ 59
2.5-20 mg........................................................................ 59
2.5-40 mg........................................................................ 59
5-10 mg........................................................................... 59
5-20 mg........................................................................... 59
5-40 mg........................................................................... 59
5-80 mg........................................................................... 59
10-10 mg......................................................................... 59
10-20 mg......................................................................... 59
10-40 mg......................................................................... 59
10-80 mg......................................................................... 59
CAFERGOT -ergotamine w/ caffeine tab 1-100 mg....... 111
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base
equiv).............................................................................. 91
CALAN SR -verapamil hcl tab cr 120 mg......................... 42
CALAN -verapamil hcl tab 80 mg..................................... 42
CALAN -verapamil hcl tab 120 mg................................... 42
185
2016
CALCIFOL -ca carb-folic acid-vit d-b6-b12-boron-mag
wafer 1342-1.6 mg........................................................131
calcipotriene-betamethasone dipropionate oint
0.005-0.064% (Taclonex)............................................ 153
calcipotriene cream 0.005% (Dovonex).......................153
calcipotriene oint 0.005%..............................................153
calcipotriene soln 0.005% (50 mcg/ml)....................... 153
calcitonin (salmon) nasal soln 200 unit/act
(Miacalcin)...................................................................... 34
CALCITRIOL -calcitriol oint 3 mcg/gm............................ 153
calcitriol cap 0.25 mcg (Rocaltrol)................................. 34
calcitriol cap 0.5 mcg (Rocaltrol)................................... 34
calcitriol oral soln 1 mcg/ml (Rocaltrol)........................34
calcium acetate (phosphate binder) cap 667 mg (169
mg ca) (Phoslo)............................................................. 73
calcium acetate (phosphate binder) tab 667 mg
(Eliphos)......................................................................... 73
CALCIUM-FOLIC ACID PLUS D -ca carb-folic acid-vit db6-b12-boron-mag wafer 1342-1 mg........................... 131
CALCIUM PNV -prenatal w/o vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg.......................................................... 123
CAMBIA -diclofenac potassium packet 50 mg................ 111
CAMPHOMEX -camphor-histamine-menthol liqd spray
4-0.025-10%.................................................................. 153
CANASA -mesalamine suppos 1000 mg.......................... 73
candesartan cilexetil-hydrochlorothiazide tab 16-12.5
mg (Atacand hct).......................................................... 47
candesartan cilexetil-hydrochlorothiazide tab 32-12.5
mg (Atacand hct).......................................................... 47
candesartan cilexetil-hydrochlorothiazide tab 32-25
mg (Atacand hct).......................................................... 47
candesartan cilexetil tab 4 mg (Atacand)..................... 47
candesartan cilexetil tab 8 mg (Atacand)..................... 47
candesartan cilexetil tab 16 mg (Atacand)................... 47
candesartan cilexetil tab 32 mg (Atacand)................... 47
CAPCOF -phenylephrine-chlorphen w/ codeine syrup
5-2-10 mg/5ml................................................................. 62
capecitabine tab 150 mg (Xeloda)................................. 14
capecitabine tab 500 mg (Xeloda)................................. 14
CAPEX -fluocinolone acetonide shampoo 0.01%........... 153
CAPHOSOL -artificial saliva - solution............................ 149
CAPITAL/CODEINE -acetaminophen w/ codeine susp
120-12 mg/5ml.............................................................. 100
CAPRELSA -vandetanib tab 100 mg................................ 14
CAPRELSA -vandetanib tab 300 mg................................ 14
CAPTOPRIL/HYDROCHLOROTHIA -captopril &
hydrochlorothiazide tab 25-15 mg.................................. 48
captopril tab 12.5 mg...................................................... 47
captopril tab 25 mg......................................................... 47
captopril tab 50 mg......................................................... 47
captopril tab 100 mg....................................................... 48
CARAC -fluorouracil cream 0.5%.................................... 153
CARAFATE -sucralfate susp 1 gm/10ml........................... 69
CARAFATE -sucralfate tab 1 gm.......................................69
CARBAGLU -carglumic acid tab 200 mg.......................... 34
carbamazepine cap sr 12hr 100 mg (Carbatrol)......... 113
carbamazepine chew tab 100 mg................................ 113
carbamazepine susp 100 mg/5ml (Tegretol)............... 113
carbamazepine tab 200 mg (Tegretol)......................... 113
carbamazepine tab sr 12hr 100 mg (Tegretol-xr)....... 113
CARBAPHEN 12 PED -phenyleph-chlorphencarbetapentane susp 2.5-1.25-7.5 mg/ml...................... 62
CARBAPHEN 12 -phenyleph-chlorphen-carbetapentane
liqd 10-4-27.5 mg/5ml..................................................... 62
CARBATROL -carbamazepine cap sr 12hr 100 mg....... 113
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 12.5-50-200 mg................................ 119
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 18.75-75-200 mg.............................. 119
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 25-100-200 mg................................. 119
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 31.25-125-200 mg............................ 119
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 37.5-150-200 mg.............................. 119
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 50-200-200 mg................................. 119
carbidopa & levodopa orally disintegrating tab 10-100
mg................................................................................. 119
mg................................................................................. 119
mg................................................................................. 119
carbidopa & levodopa tab cr 25-100 mg (Sinemet
cr).................................................................................. 119
carbidopa & levodopa tab cr 50-200 mg (Sinemet
cr).................................................................................. 119
carbidopa & levodopa tab 10-100 mg (Sinemet)........ 119
carbidopa tab 25 mg (Lodosyn)................................... 119
carbinoxamine maleate soln 4 mg/5ml......................... 60
carbinoxamine maleate tab 4 mg.................................. 60
carbonyl iron susp 15 mg/1.25ml (elemental
iron)............................................................................... 133
CARDIZEM CD -diltiazem hcl coated beads cap sr 24hr
120 mg............................................................................ 42
180 mg............................................................................ 42
240 mg............................................................................ 43
186
2016
300 mg............................................................................ 43
360 mg............................................................................ 43
CARDIZEM -diltiazem hcl tab 30 mg................................ 42
CARDIZEM -diltiazem hcl tab 60 mg................................ 42
CARDIZEM -diltiazem hcl tab 120 mg.............................. 42
CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr
120 mg............................................................................ 43
180 mg............................................................................ 43
240 mg............................................................................ 43
300 mg............................................................................ 43
360 mg............................................................................ 43
420 mg............................................................................ 43
CARDURA -doxazosin mesylate tab 1 mg....................... 48
CARDURA XL -doxazosin mesylate tab sr 24 hr 4 mg
(base equiv).................................................................... 77
CARDURA XL -doxazosin mesylate tab sr 24 hr 8 mg
(base equiv).................................................................... 77
carisoprodol tab 250 mg (Soma)................................. 121
carisoprodol tab 350 mg (Soma)................................. 121
carisoprodol w/ aspirin & codeine tab 200-325-16
mg................................................................................. 121
carisoprodol w/ aspirin tab 200-325 mg......................121
CARNITOR -levocarnitine oral soln 1 gm/10ml (10%)...... 34
CARNITOR -levocarnitine tab 330 mg.............................. 34
CARNITOR SF -levocarnitine oral soln 1 gm/10ml
(10%)............................................................................... 35
CARRASYN HYDROGEL WOUND D -wound dressings gel.................................................................................. 153
carteolol hcl ophth soln 1%......................................... 144
carvedilol tab 3.125 mg (Coreg)..................................... 40
carvedilol tab 6.25 mg (Coreg)....................................... 40
carvedilol tab 12.5 mg (Coreg)....................................... 40
carvedilol tab 25 mg (Coreg).......................................... 40
CASODEX -bicalutamide tab 50 mg................................. 14
CATAPRES -clonidine hcl tab 0.1 mg............................... 48
CATAPRES-TTS-1 -clonidine hcl td patch weekly 0.1
mg/24hr........................................................................... 48
mg/24hr........................................................................... 48
mg/24hr........................................................................... 48
CAVERJECT– Benefit Limits may apply -alprostadil for inj
20 mcg............................................................................ 60
CAVERJECT– Benefit Limits may apply -alprostadil for inj
40 mcg............................................................................ 60
CAVERJECT IMPULSE– Benefit Limits may apply alprostadil for inj kit 10 mcg........................................... 60
CAVERJECT IMPULSE– Benefit Limits may apply alprostadil for inj kit 20 mcg........................................... 60
CAYA -diaphragm arc-spring........................................... 168
CAYSTON -aztreonam lysine for inhal soln 75 mg (base
equivalent)....................................................................... 13
CEDAX -ceftibuten cap 400 mg.......................................... 2
CEDAX -ceftibuten for susp 180 mg/5ml............................ 2
cefaclor cap 250 mg.......................................................... 2
cefaclor cap 500 mg.......................................................... 2
CEFACLOR -cefaclor for susp 125 mg/5ml........................ 2
CEFACLOR ER -cefaclor monohydrate tab sr 12hr 500
mg...................................................................................... 2
cefadroxil cap 500 mg....................................................... 2
cefadroxil for susp 250 mg/5ml....................................... 2
cefadroxil for susp 500 mg/5ml....................................... 2
cefadroxil tab 1 gm............................................................ 2
cefdinir cap 300 mg........................................................... 2
cefdinir for susp 125 mg/5ml........................................... 2
cefdinir for susp 250 mg/5ml........................................... 2
CEFDITOREN PIVOXIL -cefditoren pivoxil tab 200 mg
(base equivalent).............................................................. 2
CEFDITOREN PIVOXIL -cefditoren pivoxil tab 400 mg
(base equivalent).............................................................. 2
cefixime for susp 100 mg/5ml (Suprax).......................... 2
cefixime for susp 200 mg/5ml (Suprax).......................... 2
cefpodoxime proxetil for susp 50 mg/5ml...................... 2
cefpodoxime proxetil for susp 100 mg/5ml.................... 2
cefpodoxime proxetil tab 100 mg.................................... 2
cefpodoxime proxetil tab 200 mg.................................... 2
cefprozil for susp 125 mg/5ml..........................................2
cefprozil for susp 250 mg/5ml..........................................2
cefprozil tab 250 mg.......................................................... 2
cefprozil tab 500 mg.......................................................... 2
CEFTIBUTEN -ceftibuten cap 400 mg................................ 2
CEFTIBUTEN -ceftibuten for susp 180 mg/5ml.................. 2
CEFTIN -cefuroxime axetil for susp 125 mg/5ml................ 2
CEFTIN -cefuroxime axetil for susp 250 mg/5ml................ 2
CEFTIN -cefuroxime axetil tab 500 mg............................... 2
cefuroxime axetil tab 250 mg (Ceftin)............................. 2
cefuroxime axetil tab 500 mg (Ceftin)............................. 2
CELEBREX -celecoxib cap 50 mg.................................. 108
CELEBREX -celecoxib cap 100 mg................................ 108
celecoxib cap 50 mg (Celebrex).................................. 108
celecoxib cap 100 mg (Celebrex)................................ 108
CELEXA -citalopram hydrobromide tab 10 mg (base
equiv)............................................................................... 80
equiv)............................................................................... 80
187
2016
equiv)............................................................................... 80
CELLCEPT -mycophenolate mofetil cap 250 mg........... 171
CELLCEPT -mycophenolate mofetil for oral susp 200 mg/
ml................................................................................... 171
CELLCEPT -mycophenolate mofetil tab 500 mg............ 171
CELONTIN -methsuximide cap 300 mg.......................... 113
CEM-UREA -urea soln 45%............................................ 153
CENTANY AT -mupirocin oint kit 2%.............................. 153
CENTANY -mupirocin oint 2%.........................................153
CENTRATEX -ferrous fumarate-fa-b complex-c-zn-mgmn-cu cap 106-1 mg.................................................... 133
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)..................................................................... 134
CERVIDIL -dinoprostone vaginal inserts 10 mg............... 34
CESAMET -nabilone cap 1 mg......................................... 71
CETRAXAL -ciprofloxacin hcl otic soln 0.2% (base
equivalent)..................................................................... 148
CETROTIDE– Benefit Limits may apply -cetrorelix acetate
for inj kit 0.25 mg............................................................35
CETYLEV -acetylcysteine effervescent tab 2.5 gm........ 167
CETYLEV -acetylcysteine effervescent tab 500 mg....... 167
cevimeline hcl cap 30 mg (Evoxac)............................. 149
CHANTIX CONTINUING MONTH -varenicline tartrate tab
1 mg (base equiv).......................................................... 95
CHANTIX STARTING MONTH PA -varenicline tartrate tab
0.5 mg x 11 & tab 1 mg x 42 pack.................................95
CHANTIX -varenicline tartrate tab 0.5 mg (base
equiv)............................................................................... 95
CHANTIX -varenicline tartrate tab 1 mg (base equiv).......95
CHEMET -succimer cap 100 mg.................................... 167
CHENODAL -chenodiol tab 250 mg................................. 73
CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 5-12.5 mg............................................. 95
CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 10-25 mg.............................................. 95
chlordiazepoxide hcl cap 5 mg...................................... 79
chlordiazepoxide hcl cap 10 mg.................................... 79
chlordiazepoxide hcl cap 25 mg.................................... 79
chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg
(Librax)........................................................................... 69
CHLORHEXIDINE GLUCONATE -chlorhexidine
gluconate soln 20%...................................................... 166
chlorhexidine gluconate soln 0.12% (Peridex)...........149
chloroquine phosphate tab 250 mg.............................. 12
chloroquine phosphate tab 500 mg (Aralen)................ 12
CHLOROTHIAZIDE -chlorothiazide tab 250 mg............... 54
chlorothiazide tab 500 mg.............................................. 54
chlorpromazine hcl tab 10 mg....................................... 84
chlorpromazine hcl tab 100 mg..................................... 84
chlorpromazine hcl tab 200 mg..................................... 85
CHLORPROPAMIDE -chlorpropamide tab 100 mg.......... 27
CHLORPROPAMIDE -chlorpropamide tab 250 mg.......... 27
CHLORTHALIDONE -chlorthalidone tab 50 mg............... 54
CHLORTHALIDONE -chlorthalidone tab 100 mg............. 54
chlorthalidone tab 25 mg................................................ 54
chlorzoxazone tab 500 mg (Parafon forte dsc).......... 121
CHOLBAM -cholic acid cap 50 mg................................... 73
CHOLBAM -cholic acid cap 250 mg................................. 73
cholecalciferol cap 400 unit......................................... 122
cholecalciferol cap 1000 unit....................................... 122
cholecalciferol cap 50000 unit..................................... 123
cholecalciferol chew tab 400 unit................................ 123
cholecalciferol chew tab 1000 unit.............................. 123
cholecalciferol drops 400 unit/0.03ml (per drop)....... 123
cholecalciferol drops 5000 unit/ml (1000
unit/0.2ml).....................................................................123
cholecalciferol oral liquid 400 unit/ml......................... 123
cholecalciferol tab 400 unit.......................................... 123
cholecalciferol tab 1000 unit........................................ 123
cholecalciferol tab 50000 unit...................................... 123
cholestyramine light powder 4 gm/dose (Questran
light)................................................................................ 55
cholestyramine light powder packets 4 gm................. 55
cholestyramine powder 4 gm/dose (Questran)............ 56
cholestyramine powder packets 4 gm (Questran)....... 55
choline & magnesium salicylates liq 500 mg/5ml........ 99
choline fenofibrate cap dr 45 mg (fenofibric acid
equiv) (Trilipix).............................................................. 56
choline fenofibrate cap dr 135 mg (fenofibric acid
equiv) (Trilipix).............................................................. 56
CHOLINE MAGNESIUM TRISALI -choline & magnesium
salicylates tab 1000 mg..................................................99
chorionic gonadotropin for inj 10000 unit– Benefit
Limits may apply.......................................................... 35
CIALIS– Benefit Limits may apply -tadalafil tab 2.5
mg.................................................................................... 60
CIALIS– Benefit Limits may apply -tadalafil tab 5 mg....... 60
CIALIS– Benefit Limits may apply -tadalafil tab 10 mg..... 60
CIALIS– Benefit Limits may apply -tadalafil tab 20 mg..... 60
CICLODAN CREAM KIT -ciclopirox olamine cream 0.77%
(base equiv) & cleanser kit...........................................153
CICLODAN SOLUTION KIT -ciclopirox solution kit
8%.................................................................................. 153
ciclopirox gel 0.77%...................................................... 153
ciclopirox olamine cream 0.77% (base equiv)............153
ciclopirox olamine susp 0.77% (base equiv).............. 153
ciclopirox shampoo 1% (Loprox shampoo)............... 153
ciclopirox solution kit 8% (Ciclodan solution ki)....... 153
ciclopirox solution 8% (Penlac Nail Lacquer)............ 153
CICLOPIROX TOPICAL SOLUTI -ciclopirox solution 8%
& vitamin e 5% topical kit............................................. 153
CIFEREX -folic acid-cholecalciferol cap 1 mg-3775
unit................................................................................. 134
cilostazol tab 50 mg (Pletal)......................................... 140
188
2016
cilostazol tab 100 mg (Pletal)....................................... 140
CILOXAN -ciprofloxacin hcl ophth oint 0.3%.................. 144
CILOXAN -ciprofloxacin hcl ophth soln 0.3%..................144
cimetidine hcl soln 300 mg/5ml..................................... 69
cimetidine tab 200 mg..................................................... 69
CIMZIA -certolizumab pegol for inj kit 2 x 200 mg............ 73
CIMZIA -certolizumab pegol inj kit 2 x 200 mg/ml............ 73
CIMZIA STARTER KIT -certolizumab pegol inj kit 6 x 200
mg/ml............................................................................... 73
CIPRO -ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml).......................................................................... 5
CIPRO -ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml).......................................................................... 5
CIPRO -ciprofloxacin hcl tab 250 mg (base equiv)............. 5
CIPRO -ciprofloxacin hcl tab 500 mg (base equiv)............. 5
CIPRODEX -ciprofloxacin-dexamethasone otic susp
0.3-0.1%........................................................................ 148
CIPROFLOXACIN -ciprofloxacin hcl otic soln 0.2% (base
equivalent)..................................................................... 148
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000
mg(base eq) (Cipro xr)................................................... 5
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg
(base eq) (Cipro xr)........................................................ 5
ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml) (Cipro)........................................................... 5
ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml) (Cipro)........................................................... 5
CIPROFLOXACIN HCL -ciprofloxacin hcl tab 100 mg
(base equiv)...................................................................... 5
ciprofloxacin hcl ophth soln 0.3% (Ciloxan).............. 144
ciprofloxacin hcl tab 750 mg (base equiv)..................... 5
ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)......... 5
ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)......... 5
CIPRO HC -ciprofloxacin-hydrocortisone otic susp
0.2-1%........................................................................... 148
CIPRO XR -ciprofloxacin-ciprofloxacin hcl tab sr 24hr
1000 mg(base eq)............................................................ 5
CIPRO XR -ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500
mg (base eq).....................................................................5
citalopram hydrobromide oral soln 10 mg/5ml............ 80
citalopram hydrobromide tab 10 mg (base equiv)
(Celexa)........................................................................... 80
(Celexa)........................................................................... 80
(Celexa)........................................................................... 80
CITRANATAL ASSURE -prenat w/o a w/fecbn-fegl-dss-fa
tab & dha cap 300 mg pack......................................... 123
CITRANATAL B-CALM -prenat w/o a w/fecbn-feglu-fa tab
20-1 mg & vit b6 tab pak............................................. 123
CITRANATAL DHA -prenat w/o a w/fecbn-fegl-dss-fa tab
& dha cap 250 mg pack............................................... 123
CITRANATAL 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa
tab 90 &dha cap 300mg pak........................................ 124
CITRANATAL HARMONY -prenat w/o a w/fe fum-fe cbndss-fa-dha cap 27-1-260 mg........................................ 124
CITRANATAL RX -prenatal w/o a w/ fe carbonyl-fe glucdss-fa tab 27-1mg.........................................................124
CLARINEX -desloratadine syrup 0.5 mg/ml......................60
CLARINEX -desloratadine tab 5 mg................................. 60
CLARINEX-D 12 HOUR -desloratadine &
pseudoephedrine tab sr 12hr 2.5-120 mg......................62
clarithromycin for susp 125 mg/5ml............................... 3
clarithromycin for susp 250 mg/5ml (Biaxin)................. 3
clarithromycin tab 250 mg (Biaxin)................................. 3
clarithromycin tab 500 mg (Biaxin)................................. 3
clarithromycin tab sr 24hr 500 mg.................................. 3
clemastine fumarate tab 2.68 mg.................................. 60
CLEOCIN -clindamycin hcl cap 75 mg............................. 13
CLEOCIN -clindamycin hcl cap 150 mg........................... 13
CLEOCIN -clindamycin hcl cap 300 mg........................... 13
CLEOCIN -clindamycin phosphate vaginal cream 2%......76
CLEOCIN -clindamycin phosphate vaginal suppos 100
mg.................................................................................... 76
CLEOCIN PEDIATRIC GRANULE -clindamycin palmitate
hcl for soln 75 mg/5ml (base equiv)...............................13
CLEOCIN-T -clindamycin phosphate gel 1%.................. 154
CLEOCIN-T -clindamycin phosphate lotion 1%.............. 154
CLEOCIN-T -clindamycin phosphate soln 1%................ 154
CLEOCIN-T -clindamycin phosphate swab 1%.............. 154
CLIMARA -estradiol td patch weekly 0.025 mg/24hr........ 21
CLIMARA -estradiol td patch weekly 0.05 mg/24hr.......... 21
CLIMARA -estradiol td patch weekly 0.06 mg/24hr.......... 21
CLIMARA -estradiol td patch weekly 0.075 mg/24hr........ 21
CLIMARA -estradiol td patch weekly 0.1 mg/24hr............ 22
CLIMARA -estradiol td patch weekly 0.0375 mg/24hr
(37.5 mcg/24hr)...............................................................21
CLIMARA PRO -estradiol-levonorgestrel td patch weekly
0.045-0.015 mg/day........................................................ 22
CLINDACIN ETZ -clindamycin phosphate swab 1% &
cleanser kit.................................................................... 154
CLINDACIN PAC -clindamycin phosphate swab 1% &
cleanser kit.................................................................... 154
CLINDAGEL -clindamycin phosphate gel 1%................. 154
clindamycin hcl cap 75 mg (Cleocin)............................ 13
clindamycin hcl cap 150 mg (Cleocin).......................... 13
clindamycin hcl cap 300 mg (Cleocin).......................... 13
clindamycin palmitate hcl for soln 75 mg/5ml (base
equiv) (Cleocin pediatric gr)........................................13
clindamycin phosphate-benzoyl peroxide gel 1-5%
(Benzaclin)................................................................... 154
clindamycin phosphate foam 1% (Evoclin)................ 154
clindamycin phosphate gel 1% (Cleocin-t)................. 154
clindamycin phosphate lotion 1% (Cleocin-t)............ 154
clindamycin phosphate soln 1% (Cleocin-t)............... 154
clindamycin phosphate swab 1% (Cleocin-t)............. 154
clindamycin phosphate-tretinoin gel 1.2-0.025%
(Ziana)........................................................................... 154
clindamycin phosphate vaginal cream 2%
(Cleocin)......................................................................... 76
189
2016
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2
(1)-5% (Duac)............................................................... 154
CLINDESSE -clindamycin phosphate (one dose) vaginal
cream 2%........................................................................ 76
clobetasol propionate cream 0.05% (Temovate)........ 154
clobetasol propionate emollient base cream 0.05%
(Temovate e)................................................................ 154
clobetasol propionate emulsion foam 0.05% (Oluxe).................................................................................... 154
clobetasol propionate foam 0.05% (Olux).................. 154
clobetasol propionate gel 0.05% (Temovate)............. 154
clobetasol propionate lotion 0.05% (Clobex)............. 154
clobetasol propionate oint 0.05% (Temovate)............ 154
clobetasol propionate shampoo 0.05% (Clobex)....... 154
clobetasol propionate soln 0.05% (Temovate)........... 154
clobetasol propionate spray 0.05% (Clobex)............. 154
CLOBEX -clobetasol propionate lotion 0.05%................ 154
CLOBEX -clobetasol propionate shampoo 0.05%.......... 154
CLOBEX -clobetasol propionate spray 0.05%................ 154
CLOCORTOLONE PIVALATE -clocortolone pivalate
cream 0.1%................................................................... 154
CLOCORTOLONE PIVALATE PUM -clocortolone pivalate
cream 0.1%................................................................... 154
CLODAN KIT -clobetasol propionate shampoo 0.05% &
cleanser kit.................................................................... 154
CLODERM -clocortolone pivalate cream 0.1%............... 154
CLODERM PUMP -clocortolone pivalate cream
0.1%...............................................................................154
clomiphene citrate tab 50 mg– Benefit Limits may
apply............................................................................... 35
clomipramine hcl cap 25 mg (Anafranil)....................... 80
clonazepam orally disintegrating tab 0.125 mg......... 114
clonazepam orally disintegrating tab 0.25 mg........... 114
clonazepam orally disintegrating tab 0.5 mg............. 114
clonazepam orally disintegrating tab 1 mg................ 114
clonazepam orally disintegrating tab 2 mg................ 114
clonazepam tab 0.5 mg (Klonopin).............................. 114
clonazepam tab 1 mg (Klonopin)................................. 114
clonazepam tab 2 mg (Klonopin)................................. 114
clonidine hcl tab 0.1 mg (Catapres).............................. 48
clonidine hcl tab sr 12hr 0.1 mg (Kapvay).................... 91
clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1)................................................................................ 48
clopidogrel bisulfate tab 75 mg (base equiv)
(Plavix).......................................................................... 140
clopidogrel bisulfate tab 300 mg (base equiv)
(Plavix).......................................................................... 140
clorazepate dipotassium tab 3.75 mg (Tranxene t)...... 79
clorazepate dipotassium tab 7.5 mg (Tranxene t)........ 79
clorazepate dipotassium tab 15 mg (Tranxene t)......... 79
CLORPRES -clonidine & chlorthalidone tab 0.1-15
mg.................................................................................... 48
mg.................................................................................... 48
mg.................................................................................... 48
clotrimazole troche 10 mg............................................ 149
clotrimazole w/ betamethasone cream 1-0.05%
(Lotrisone).................................................................... 154
clotrimazole w/ betamethasone lotion 1-0.05%..........154
CLOZAPINE ODT -clozapine orally disintegrating tab 12.5
mg.................................................................................... 85
CLOZAPINE ODT -clozapine orally disintegrating tab 150
mg.................................................................................... 85
CLOZAPINE ODT -clozapine orally disintegrating tab 200
mg.................................................................................... 85
clozapine orally disintegrating tab 25 mg
(Fazaclo)......................................................................... 85
clozapine orally disintegrating tab 100 mg
(Fazaclo)......................................................................... 85
clozapine tab 50 mg........................................................ 85
clozapine tab 200 mg...................................................... 85
clozapine tab 25 mg (Clozaril)........................................85
clozapine tab 100 mg (Clozaril)..................................... 85
CLOZARIL -clozapine tab 25 mg...................................... 85
CLOZARIL -clozapine tab 100 mg.................................... 85
C-NATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg.................................................................. 123
CNL8 NAIL KIT -ciclopirox soln 8% & lacquer removal
pads kit.......................................................................... 154
COAGADEX -coagulation factor x (human) for inj 250
unit................................................................................. 140
COAGADEX -coagulation factor x (human) for inj 500
unit................................................................................. 140
COAL TAR -coal tar soln 20%........................................ 154
COARTEM -artemether-lumefantrine tab 20-120 mg....... 12
COCAINE HCL -cocaine hcl soln 4%............................. 154
COCAINE HCL -cocaine hcl soln 10%........................... 154
CODAR AR -chlorpheniramine w/ codeine liquid 2-8
mg/5ml............................................................................. 62
CODAR D -pseudoephedrine w/ codeine liquid 30-8
mg/5ml............................................................................. 62
CODEINE SULFATE -codeine sulfate tab 15 mg........... 100
codeine sulfate tab 15 mg (Codeine sulfate).............. 100
COLAZAL -balsalazide disodium cap 750 mg.................. 73
COLCHICINE -colchicine cap 0.6 mg............................. 113
COLCHICINE -colchicine tab 0.6 mg.............................. 113
colchicine w/ probenecid tab 0.5-500 mg................... 113
COLCRYS -colchicine tab 0.6 mg................................... 113
COLESTID -colestipol hcl granule packets 5 gm.............. 56
COLESTID -colestipol hcl granules 5 gm......................... 56
COLESTID -colestipol hcl tab 1 gm.................................. 56
190
2016
COLESTID FLAVORED -colestipol hcl granule packets 5
gm.................................................................................... 56
COLESTID FLAVORED -colestipol hcl granules 5 gm..... 56
colestipol hcl granule packets 5 gm (Colestid
flavored)......................................................................... 56
colestipol hcl granules 5 gm (Colestid flavored)......... 56
colestipol hcl tab 1 gm (Colestid)..................................56
COLGATE DRY MOUTH RELIEF -sodium fluoride
mouthwash 2.1 mg/10ml.............................................. 149
COLY-MYCIN S -neomycin-colistin-hc-thonzonium otic
susp 3.3-3-10-0.5 mg/ml.............................................. 148
COLYTE-FLAVOR PACKS -peg 3350-kcl-na bicarb-naclna sulfate for soln 240 gm............................................. 68
COMBIGAN -brimonidine tartrate-timolol maleate ophth
soln 0.2-0.5%................................................................ 144
COMBIPATCH -estradiol-norethindrone ace td pttw
0.05-0.14 mg/day............................................................ 22
COMBIPATCH -estradiol-norethindrone ace td pttw
0.05-0.25 mg/day............................................................ 22
COMBIVENT RESPIMAT -ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act.......................................... 65
COMBIVIR -lamivudine-zidovudine tab 150-300 mg.......... 8
COMETRIQ -cabozantinib s-malate cap 3 x 20 mg (60 mg
dose) kit........................................................................... 14
COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 1 x 20
mg (100 dose) kit............................................................14
COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 3 x 20
mg (140 dose) kit............................................................14
COMMIT -nicotine polacrilex lozenge 2 mg...................... 95
COMMIT -nicotine polacrilex lozenge 4 mg...................... 95
CO MONITOR CALIBRATION -respiratory therapy
supplies - kit.................................................................. 168
CO MONITOR REPLACEMENT T -respiratory therapy
supplies - misc.............................................................. 168
CO MONITOR -respiratory therapy supplies devices.......................................................................... 168
COMPLERA -emtricitabine-rilpivirine-tenofovir df tab
200-25-300 mg.................................................................. 8
COMPLETE NATAL DHA -prenat-fe bis-fe prot succ-fa-ca
tab & omega 3 cap 250 pk.......................................... 124
COMPLETENATE -prenatal vit w/ fe fumarate-fa chew tab
29-1 mg......................................................................... 124
COMTAN -entacapone tab 200 mg................................. 119
CO-NATAL FA -prenatal vit w/ fe fumarate-fa tab 29-1
mg.................................................................................. 124
CONCEPT DHA -prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg......................................................... 124
CONCEPT OB -prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg...............................................................124
CONCERTA -methylphenidate hcl tab sa osm 18 mg...... 91
CONDYLOX -podofilox gel 0.5%.................................... 155
CONDYLOX -podofilox soln 0.5%................................... 155
CONTRAVE -naltrexone hcl-bupropion hcl tab sr 12hr
8-90 mg........................................................................... 91
CONZIP -tramadol hcl cap sr 24hr biphasic release 100
mg.................................................................................. 101
mg.................................................................................. 101
mg.................................................................................. 101
COPASIL -emollient - gel................................................ 155
COPAXONE -glatiramer acetate soln prefilled syringe 20
mg/ml............................................................................... 95
COPAXONE -glatiramer acetate soln prefilled syringe 40
mg/ml............................................................................... 95
COPEGUS -ribavirin tab 200 mg........................................ 8
CORDARONE -amiodarone hcl tab 200 mg..................... 45
CORDRAN -flurandrenolide cream 0.05%...................... 155
CORDRAN -flurandrenolide lotion 0.05%....................... 155
CORDRAN -flurandrenolide oint 0.05%.......................... 155
CORDRAN TAPE -flurandrenolide tape 4 mcg/sqcm..... 155
COREG -carvedilol tab 3.125 mg..................................... 40
COREG -carvedilol tab 6.25 mg....................................... 40
COREG -carvedilol tab 12.5 mg....................................... 40
COREG -carvedilol tab 25 mg.......................................... 40
COREG CR -carvedilol phosphate cap sr 24hr 10 mg..... 41
CORGARD -nadolol tab 20 mg......................................... 41
CORIFACT -factor xiii concentrate (human) for inj kit
1000-1600 unit.............................................................. 140
CORLANOR -ivabradine hcl tab 5 mg (base equiv)......... 59
CORLANOR -ivabradine hcl tab 7.5 mg (base equiv)...... 59
CORTANE-B AQUEOUS -pramoxine-hc-chloroxylenol
aqueous otic soln 10-10-1 mg/ml................................. 148
CORTANE-B -hydrocortisone-pramoxine-chloroxylenol lot
10-10-1mg/ml................................................................ 155
CORTANE-B-OTIC -pramoxine-hc-chloroxylenol otic soln
10-10-1 mg/ml............................................................... 148
CORTEF -hydrocortisone tab 5 mg...................................18
CORTEF -hydrocortisone tab 10 mg.................................18
CORTEF -hydrocortisone tab 20 mg.................................18
CORTENEMA -hydrocortisone enema 100 mg/60ml..... 151
CORTIFOAM -hydrocortisone acetate rectal foam 10%
(90 mg/dose)................................................................. 151
CORTISONE ACETATE -cortisone acetate tab 25 mg..... 19
CORTISPORIN -bacitracin-polymyxin-neomycin hc oint
1%.................................................................................. 155
CORTISPORIN -neomycin-polymyxin-hc crm 3.5 mg/
gm-10000 unt/gm-0.5%................................................ 155
CORVITE FE -iron combination tab................................ 134
CORVITE 150 -iron combination tab...............................134
CORVITE 150 -iron-folic acid-vit c-vit b6-vit b12-zinc tab
150-1.25 mg.................................................................. 134
CORVITE -multiple vitamins w/ minerals & fa tab 1.25
mg.................................................................................. 124
CORZIDE -nadolol & bendroflumethiazide tab 40-5
mg.................................................................................... 48
191
2016
CORZIDE -nadolol & bendroflumethiazide tab 80-5
mg.................................................................................... 48
COSENTYX -secukinumab subcutaneous soln prefilled
syringe 150 mg/ml........................................................ 155
COSENTYX SENSOREADY PEN -secukinumab
subcutaneous soln auto-injector 150 mg/ml................ 155
COSOPT -dorzolamide hcl-timolol maleate ophth soln
22.3-6.8 mg/ml.............................................................. 144
COSOPT PF -dorzolamide hcl-timolol maleate ophth sol
22.3-6.8 mg/ml pf..........................................................144
COTELLIC -cobimetinib fumarate tab 20 mg (base
equivalent)....................................................................... 14
COUMADIN -warfarin sodium tab 1 mg.......................... 137
COUMADIN -warfarin sodium tab 2.5 mg....................... 137
COUMADIN -warfarin sodium tab 7.5 mg....................... 137
COUMADIN -warfarin sodium tab 10 mg........................ 137
COZAAR -losartan potassium tab 25 mg..........................48
COZAAR -losartan potassium tab 50 mg..........................48
COZAAR -losartan potassium tab 100 mg........................48
CREON -pancrelipase (lip-prot-amyl) dr cap
3000-9500-15000 unit.....................................................72
6000-19000-30000 unit...................................................72
12000-38000-60000 unit................................................ 72
24000-76000-120000 unit.............................................. 72
36000-114000-180000 unit............................................. 72
CRESEMBA -isavuconazonium sulfate cap 186 mg.......... 7
CREST COMPLETE -sodium fluoride paste 0.243%..... 149
CRESTOR -rosuvastatin calcium tab 5 mg.......................56
CRESTOR -rosuvastatin calcium tab 10 mg.....................56
CRINONE -progesterone vaginal gel 4%.......................... 76
CRINONE -progesterone vaginal gel 8%.......................... 76
CRIXIVAN -indinavir sulfate cap 200 mg............................ 8
CRIXIVAN -indinavir sulfate cap 400 mg............................ 8
CROMOLYN SODIUM -cromolyn sodium soln nebu 20
mg/2ml............................................................................. 65
cromolyn sodium ophth soln 4%................................ 144
cromolyn sodium oral conc 100 mg/5ml
(Gastrocrom).................................................................. 73
CUPRIMINE -penicillamine cap 250 mg......................... 171
CUTIVATE -fluticasone propionate cream 0.05%........... 155
CUTIVATE -fluticasone propionate lotion 0.05%.............155
CUVPOSA -glycopyrrolate oral soln 1 mg/5ml................. 69
cyanocobalamin inj 1000 mcg/ml................................ 134
CYCLESSA -desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg...................... 23
CYCLOBENZAPRINE COMFORT P -cyclobenzaprine hcl
tab 10 mg & liniment topical gel kit.............................. 121
cyclobenzaprine hcl tab 5 mg...................................... 122
cyclobenzaprine hcl tab 10 mg.................................... 122
cyclobenzaprine hcl tab 7.5 mg (Fexmid)................... 122
CYCLOGYL -cyclopentolate hcl ophth soln 0.5%........... 144
CYCLOGYL -cyclopentolate hcl ophth soln 1%.............. 144
CYCLOGYL -cyclopentolate hcl ophth soln 2%.............. 145
CYCLOMYDRIL -cyclopentolate w/ phenylephrine ophth
soln 0.2-1%................................................................... 145
cyclopentolate hcl ophth soln 0.5% (Cyclogyl)..........145
cyclopentolate hcl ophth soln 1% (Cyclogyl).............145
cyclopentolate hcl ophth soln 2% (Cyclogyl).............145
CYCLOPHOSPHAMIDE -cyclophosphamide cap 25
mg.................................................................................... 14
CYCLOPHOSPHAMIDE -cyclophosphamide cap 50
mg.................................................................................... 15
CYCLOSERINE -cycloserine cap 250 mg.......................... 6
CYCLOSET -bromocriptine mesylate tab 0.8 mg (base
equivalent)....................................................................... 27
cyclosporine cap 25 mg (Sandimmune)..................... 171
cyclosporine cap 100 mg (Sandimmune)................... 172
cyclosporine modified cap 50 mg (Cyclosporine
modifie)......................................................................... 172
cyclosporine modified cap 25 mg (Neoral).................172
cyclosporine modified cap 100 mg (Neoral)...............172
CYCLOSPORINE MODIFIED -cyclosporine modified cap
50 mg............................................................................ 172
cyclosporine modified oral soln 100 mg/ml
(Neoral)......................................................................... 172
CYMBALTA -duloxetine hcl enteric coated pellets cap 20
mg.................................................................................... 80
mg.................................................................................... 80
mg.................................................................................... 80
cyproheptadine hcl syrup 2 mg/5ml.............................. 60
cyproheptadine hcl tab 4 mg......................................... 60
CYSTADANE -betaine powder for oral solution................ 35
CYSTAGON -cysteamine bitartrate cap 50 mg.................77
CYSTAGON -cysteamine bitartrate cap 150 mg...............77
CYSTARAN -cysteamine hcl ophth soln 0.44% (base
equivalent)..................................................................... 145
CYTOMEL -liothyronine sodium tab 5 mcg.......................32
CYTOMEL -liothyronine sodium tab 25 mcg.....................32
CYTOMEL -liothyronine sodium tab 50 mcg.....................32
CYTOTEC -misoprostol tab 100 mcg................................69
CYTOTEC -misoprostol tab 200 mcg................................69
CYTRA-3 -pot & sod citrates w/ cit ac syrup 550-500-334
mg/5ml............................................................................. 77
D
DAKLINZA -daclatasvir dihydrochloride tab 30 mg (base
equivalent)......................................................................... 8
equivalent)......................................................................... 8
192
2016
equivalent)......................................................................... 8
DALIRESP -roflumilast tab 500 mcg................................. 65
danazol cap 50 mg.......................................................... 20
danazol cap 100 mg........................................................ 20
danazol cap 200 mg........................................................ 20
DANTRIUM -dantrolene sodium cap 25 mg................... 122
DANTRIUM -dantrolene sodium cap 50 mg................... 122
dantrolene sodium cap 100 mg................................... 122
dantrolene sodium cap 25 mg (Dantrium).................. 122
dantrolene sodium cap 50 mg (Dantrium).................. 122
dapsone tab 25 mg.......................................................... 13
dapsone tab 100 mg........................................................ 13
DARAPRIM -pyrimethamine tab 25 mg............................ 12
darifenacin hydrobromide tab sr 24hr 7.5 mg (base
equiv) (Enablex)............................................................ 75
darifenacin hydrobromide tab sr 24hr 15 mg (base
equiv) (Enablex)............................................................ 75
DAYPRO -oxaprozin tab 600 mg.................................... 108
DAYTRANA -methylphenidate td patch 10 mg/9hr........... 91
DDAVP -desmopressin acetate inj 4 mcg/ml.................... 35
DDAVP -desmopressin acetate nasal soln 0.01%
(refrigerated).................................................................... 35
DDAVP -desmopressin acetate nasal spray soln
0.01%...............................................................................35
DDAVP -desmopressin acetate tab 0.1 mg...................... 35
DDAVP -desmopressin acetate tab 0.2 mg...................... 35
DDROPS -cholecalciferol drops 1000 unit/0.03ml (per
drop).............................................................................. 123
DEBACTEROL -sulfuric acid-sulfonated phenolics soln
30-50%.......................................................................... 149
DECARA -cholecalciferol cap 25000 unit....................... 123
DECON-A -brompheniramine & phenylephrine elixir 2-5
mg/5ml............................................................................. 62
DECON-G -phenylephrine-brompheniramine-guaifenesin
liqd 2-1-40 mg/ml............................................................ 62
DELESTROGEN -estradiol valerate im in oil 10 mg/
ml..................................................................................... 22
ml..................................................................................... 22
ml..................................................................................... 22
DELZICOL -mesalamine cap dr 400 mg........................... 73
DEMADEX -torsemide tab 5 mg....................................... 54
DEMADEX -torsemide tab 10 mg..................................... 54
DEMADEX -torsemide tab 20 mg..................................... 54
demeclocycline hcl tab 150 mg....................................... 4
demeclocycline hcl tab 300 mg....................................... 4
DEMSER -metyrosine cap 250 mg................................... 48
DENAVIR -penciclovir cream 1%.................................... 155
DEPAKENE -valproate sodium syrup 250 mg/5ml (base
equiv)............................................................................. 114
DEPAKENE -valproic acid cap 250 mg...........................114
DEPAKOTE -divalproex sodium tab delayed release 125
mg.................................................................................. 114
mg.................................................................................. 114
mg.................................................................................. 114
DEPAKOTE ER -divalproex sodium tab sr 24 hr 250
mg.................................................................................. 114
DEPAKOTE ER -divalproex sodium tab sr 24 hr 500
mg.................................................................................. 114
DEPAKOTE SPRINKLES -divalproex sodium cap delayed
release sprinkle 125 mg............................................... 114
DEPEN TITRATABS -penicillamine tab 250 mg............. 172
DEPO-ESTRADIOL -estradiol cypionate im in oil 5 mg/
ml..................................................................................... 22
DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp 150 mg/ml........ 23
DEPO-SUBQ PROVERA 104 -medroxyprogesterone
acetate subcutaneous susp 104 mg/0.65ml.................. 24
DEPO-TESTOSTERONE -testosterone cypionate im inj in
oil 100 mg/ml.................................................................. 20
DEPO-TESTOSTERONE -testosterone cypionate im inj in
oil 200 mg/ml.................................................................. 21
DERMA-SMOOTHE/FS BODY -fluocinolone acetonide oil
0.01% (body oil)............................................................ 155
DERMA-SMOOTHE/FS SCALP -fluocinolone acetonide
oil 0.01% (scalp oil)...................................................... 155
DERMASORB AF -clioquinol-hc cream 3-0.5% &
emollient liqd kit............................................................ 155
DERMASORB HC -hydrocortisone lot 2% & cleanser liq
kit................................................................................... 155
DERMASORB TA -triamcinolone cream 0.1% & emollient
cream kit........................................................................155
DERMASORB XM -urea cream 39% & emollient cream
kit................................................................................... 155
dermatological products misc - cream....................... 155
DERMATOP -prednicarbate cream 0.1%........................ 155
DERMATOP -prednicarbate oint 0.1%............................ 155
DERMOTIC -fluocinolone acetonide (otic) oil 0.01%...... 148
DESCOVY -emtricitabine-tenofovir alafenamide fumarate
tab 200-25 mg...................................................................8
desipramine hcl tab 10 mg (Norpramin)....................... 80
desipramine hcl tab 100 mg (Norpramin)..................... 80
desipramine hcl tab 150 mg (Norpramin)..................... 80
DESLORATADINE ODT -desloratadine tab orally
disintegrating 2.5 mg...................................................... 61
DESLORATADINE ODT -desloratadine tab orally
disintegrating 5 mg......................................................... 61
desloratadine tab 5 mg (Clarinex)................................. 61
desmopressin acetate inj 4 mcg/ml (Ddavp)................ 35
desmopressin acetate nasal soln 0.01% (refrigerated)
(Ddavp)........................................................................... 35
desmopressin acetate nasal spray soln 0.01%
(Ddavp)........................................................................... 35
193
2016
desmopressin acetate nasal spray soln 0.01%
(refrigerated).................................................................. 35
desmopressin acetate tab 0.1 mg (Ddavp)................... 35
desmopressin acetate tab 0.2 mg (Ddavp)................... 35
DESOGEN -desogestrel & ethinyl estradiol tab 0.15
mg-30 mcg...................................................................... 24
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01
mg(21/5) (Mircette)........................................................ 24
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg
(Cyclessa).......................................................................24
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg
(Desogen)....................................................................... 24
DESONATE -desonide gel 0.05%................................... 155
desonide cream 0.05% (Desowen).............................. 155
desonide lotion 0.05% (Desowen)............................... 155
desonide oint 0.05% (Desowen).................................. 155
DESOWEN -desonide cream 0.05%...............................155
DESOWEN -desonide lotion 0.05%................................ 155
desoximetasone cream 0.25% (Topicort)....................155
DESOXIMETASONE -desoximetasone cream
0.05%.............................................................................155
DESOXIMETASONE -desoximetasone oint 0.05%........ 155
desoximetasone gel 0.05% (Topicort)......................... 155
desoximetasone oint 0.25% (Topicort)........................ 155
DESOXYN -methamphetamine hcl tab 5 mg.................... 91
DESVENLAFAXINE ER -desvenlafaxine fumarate tab sr
24hr 50 mg (base equiv)................................................ 80
DESVENLAFAXINE ER -desvenlafaxine fumarate tab sr
24hr 100 mg (base equiv).............................................. 80
DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 50
mg.................................................................................... 80
DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 100
mg.................................................................................... 80
DETROL LA -tolterodine tartrate cap sr 24hr 2 mg.......... 76
DETROL LA -tolterodine tartrate cap sr 24hr 4 mg.......... 76
DETROL -tolterodine tartrate tab 1 mg............................. 75
DETROL -tolterodine tartrate tab 2 mg............................. 76
DEVILBISS TRAVEL-AIRE COM -respiratory therapy
DEXAMETHASONE -dexamethasone soln 0.5
mg/5ml............................................................................. 19
DEXAMETHASONE -dexamethasone tab 1 mg...............19
DEXAMETHASONE -dexamethasone tab 2 mg...............19
dexamethasone elixir 0.5 mg/5ml.................................. 19
DEXAMETHASONE INTENSOL -dexamethasone conc 1
mg/ml............................................................................... 19
DEXAMETHASONE SODIUM PHOS -dexamethasone
sodium phosphate ophth soln 0.1%............................. 145
dexamethasone tab 0.5 mg............................................ 19
dexamethasone tab 0.75 mg.......................................... 19
dexamethasone tab 1.5 mg............................................ 19
dexamethasone tab 4 mg............................................... 19
dexamethasone tab 6 mg............................................... 19
DEXEDRINE -dextroamphetamine sulfate cap sr 24hr 5
mg.................................................................................... 91
mg.................................................................................... 91
mg.................................................................................... 91
DEX4 FAST ACTING GLUCOSE -glucose oral liquid 15
gm/59ml........................................................................... 27
DEX4 GLUCOSE -glucose oral liquid 15 gm/59ml........... 27
DEXILANT -dexlansoprazole cap delayed release 30
mg.................................................................................... 69
DEXILANT -dexlansoprazole cap delayed release 60
mg.................................................................................... 69
dexmethylphenidate hcl cap sr 24 hr 5 mg (Focalin
xr).................................................................................... 91
xr).................................................................................... 91
xr).................................................................................... 91
xr).................................................................................... 91
xr).................................................................................... 91
xr).................................................................................... 91
dexmethylphenidate hcl tab 2.5 mg (Focalin).............. 91
dexmethylphenidate hcl tab 5 mg (Focalin)................. 91
dexmethylphenidate hcl tab 10 mg (Focalin)............... 91
DEXPAK 10 DAY -dexamethasone tab therapy pack 1.5
mg (35)............................................................................ 19
mg (51)............................................................................ 19
mg (21)............................................................................ 19
dextroamphetamine sulfate cap sr 24hr 5 mg
(Dexedrine)..................................................................... 91
(Dexedrine)..................................................................... 91
(Dexedrine)..................................................................... 91
dextroamphetamine sulfate oral solution 5 mg/5ml
(Procentra)..................................................................... 91
dextroamphetamine sulfate tab 5 mg........................... 91
dextroamphetamine sulfate tab 10 mg......................... 91
DEXTROMETHORPHAN HBR/CHLO -phenylephrinechlorphen-dm liquid 1.75-0.75-2.75 mg/ml.................... 62
DEX-TUSS -guaifenesin-codeine liquid 300-10
mg/5ml............................................................................. 62
D.H.E. 45 -dihydroergotamine mesylate inj 1 mg/ml.......111
DIAB F.D.G. FREEZE-DRIED -wound dressings gel.................................................................................. 155
DIAB -wound dressings - gel.......................................... 155
DIALYVITE/ZINC -b-complex w/ c-zn & folic acid tab 1
mg.................................................................................. 124
DIALYVITE 3000 -b-complex w/ c-biotin-e-minerals & folic
acid tab 3 mg................................................................ 124
DIALYVITE 5000 -b-complex w/ c-biotin-e-minerals & folic
acid tab 5 mg................................................................ 124
194
2016
DIALYVITE SUPREME D -multiple vitamins w/ minerals &
fa tab 3 mg................................................................... 124
DIAMOX -acetazolamide cap sr 12hr 500 mg.................. 54
DIASTAT ACUDIAL -diazepam rectal gel delivery system
10 mg............................................................................ 114
DIASTAT ACUDIAL -diazepam rectal gel delivery system
20 mg............................................................................ 114
DIASTAT PEDIATRIC -diazepam rectal gel delivery
system 2.5 mg.............................................................. 114
diazepam conc 5 mg/ml.................................................. 79
DIAZEPAM -diazepam oral soln 1 mg/ml..........................79
DIAZEPAM -diazepam rectal gel delivery system 2.5
mg.................................................................................. 114
DIAZEPAM -diazepam rectal gel delivery system 10
mg.................................................................................. 114
DIAZEPAM -diazepam rectal gel delivery system 20
mg.................................................................................. 114
diazepam tab 2 mg (Valium)........................................... 79
diazepam tab 5 mg (Valium)........................................... 79
diazepam tab 10 mg (Valium)......................................... 79
DIBENZYLINE -phenoxybenzamine hcl cap 10 mg..........48
DICLEGIS -doxylamine-pyridoxine tab delayed release
10-10 mg......................................................................... 71
diclofenac potassium tab 50 mg................................. 108
diclofenac sodium (actinic keratoses) gel 3%
(Solaraze)..................................................................... 155
diclofenac sodium gel 1% (Voltaren)...........................155
diclofenac sodium ophth soln 0.1%............................ 145
diclofenac sodium soln 1.5% (Pennsaid)................... 155
diclofenac sodium tab delayed release 25 mg........... 108
diclofenac sodium tab sr 24hr 100 mg (Voltarenxr).................................................................................. 108
diclofenac w/ misoprostol tab delayed release 50-0.2
mg (Arthrotec 50)........................................................108
diclofenac w/ misoprostol tab delayed release 75-0.2
mg (Arthrotec 75)........................................................108
dicloxacillin sodium cap 250 mg..................................... 1
dicloxacillin sodium cap 500 mg..................................... 1
dicyclomine hcl cap 10 mg (Bentyl).............................. 69
dicyclomine hcl oral soln 10 mg/5ml............................ 69
dicyclomine hcl tab 20 mg (Bentyl)............................... 69
didanosine delayed release capsule 125 mg (Videx
ec)...................................................................................... 8
ec)...................................................................................... 8
ec)...................................................................................... 8
ec)...................................................................................... 8
DIETHYLPROPION HCL -diethylpropion hcl tab 25
mg.................................................................................... 92
diethylpropion hcl tab 25 mg (Diethylpropion hcl)...... 92
diethylpropion hcl tab sr 24hr 75 mg............................ 92
DIFFERIN -adapalene cream 0.1%................................ 155
DIFFERIN -adapalene gel 0.1%...................................... 155
DIFFERIN -adapalene gel 0.3%...................................... 156
DIFFERIN -adapalene lotion 0.1%.................................. 156
DIFICID -fidaxomicin tab 200 mg........................................ 3
DIFLORASONE DIACETATE -diflorasone diacetate
cream 0.05%................................................................. 156
DIFLORASONE DIACETATE -diflorasone diacetate oint
0.05%.............................................................................156
DIFLUCAN -fluconazole for susp 10 mg/ml........................ 7
DIFLUCAN -fluconazole for susp 40 mg/ml........................ 7
DIFLUCAN -fluconazole tab 50 mg..................................... 7
DIFLUCAN -fluconazole tab 100 mg................................... 7
diflunisal tab 500 mg....................................................... 99
DIGOXIN -digoxin oral soln 0.05 mg/ml............................ 39
digoxin tab 125 mcg (0.125 mg) (Lanoxin)................... 39
digoxin tab 250 mcg (0.25 mg) (Lanoxin)..................... 39
DIHYDROERGOTAMINE MESYLAT -dihydroergotamine
mesylate nasal spray 4 mg/ml..................................... 111
dihydroergotamine mesylate inj 1 mg/ml (D.h.e.
45).................................................................................. 111
DILANTIN INFATABS -phenytoin chew tab 50 mg......... 114
DILANTIN -phenytoin sodium extended cap 30 mg........114
DILANTIN -phenytoin sodium extended cap 100 mg......114
DILANTIN-125 -phenytoin susp 125 mg/5ml.................. 114
DILATRATE SR -isosorbide dinitrate cap cr 40 mg.......... 39
DILAUDID -hydromorphone hcl liqd 1 mg/ml.................. 101
DILAUDID -hydromorphone hcl tab 2 mg....................... 101
diltiazem hcl cap sr 12hr 60 mg.....................................43
diltiazem hcl cap sr 12hr 90 mg.....................................43
diltiazem hcl cap sr 12hr 120 mg...................................43
diltiazem hcl coated beads cap sr 24hr 120 mg
(Cardizem cd)................................................................ 43
(Cardizem cd)................................................................ 43
(Cardizem cd)................................................................ 43
(Cardizem cd)................................................................ 43
(Cardizem cd)................................................................ 43
diltiazem hcl coated beads tab sr 24hr 180 mg
(Cardizem la)................................................................. 43
(Cardizem la)................................................................. 43
(Cardizem la)................................................................. 43
(Cardizem la)................................................................. 43
(Cardizem la)................................................................. 43
195
2016
diltiazem hcl extended release beads cap sr 24hr 120
mg (Tiazac).................................................................... 43
mg (Tiazac).................................................................... 43
mg (Tiazac).................................................................... 43
mg (Tiazac).................................................................... 43
mg (Tiazac).................................................................... 43
mg (Tiazac).................................................................... 43
diltiazem hcl tab 90 mg................................................... 43
diltiazem hcl tab 30 mg (Cardizem)............................... 43
diltiazem hcl tab 60 mg (Cardizem)............................... 43
diltiazem hcl tab 120 mg (Cardizem)............................. 43
DIOVAN HCT -valsartan-hydrochlorothiazide tab 80-12.5
mg.................................................................................... 48
mg.................................................................................... 48
DIOVAN HCT -valsartan-hydrochlorothiazide tab 160-25
mg.................................................................................... 48
mg.................................................................................... 49
DIOVAN HCT -valsartan-hydrochlorothiazide tab 320-25
mg.................................................................................... 49
DIOVAN -valsartan tab 40 mg........................................... 48
DIOVAN -valsartan tab 80 mg........................................... 48
DIOVAN -valsartan tab 160 mg......................................... 48
DIOVAN -valsartan tab 320 mg......................................... 48
DIPENTUM -olsalazine sodium cap 250 mg.....................73
diphenhydramine hcl cap 50 mg................................... 61
diphenhydramine hcl elixir 12.5 mg/5ml....................... 61
DIPHENOXYLATE/ATROPINE -diphenoxylate w/ atropine
liq 2.5-0.025 mg/5ml....................................................... 68
diphenoxylate w/ atropine tab 2.5-0.025 mg
(Lomotil)......................................................................... 68
DIPROLENE AF -betamethasone dipropionate
augmented cream 0.05%............................................. 156
DIPROLENE -betamethasone dipropionate augmented
lotion 0.05%.................................................................. 156
DIPROLENE -betamethasone dipropionate augmented
oint 0.05%..................................................................... 156
dipyridamole tab 25 mg (Persantine).......................... 140
DISALCID -salsalate tab 500 mg...................................... 99
DISALCID -salsalate tab 750 mg...................................... 99
disopyramide phosphate cap 100 mg (Norpace)......... 45
disopyramide phosphate cap 150 mg (Norpace)......... 45
DISPOSABLE MOUTHPIECE/LOW -respiratory therapy
supplies - mouthpieces................................................. 168
DISPOSABLE MOUTHPIECE/UNI -respiratory therapy
DISPOSABLE MOUTHPIECE FUL -respiratory therapy
DISPOSABLE MOUTHPIECE LOW -respiratory therapy
disulfiram tab 250 mg (Antabuse)................................. 95
disulfiram tab 500 mg (Antabuse)................................. 95
DITROPAN XL -oxybutynin chloride tab sr 24hr 5 mg...... 76
DITROPAN XL -oxybutynin chloride tab sr 24hr 10
mg.................................................................................... 76
DITROPAN XL -oxybutynin chloride tab sr 24hr 15
mg.................................................................................... 76
DIURIL -chlorothiazide susp 250 mg/5ml......................... 54
divalproex sodium cap delayed release sprinkle 125
mg (Depakote sprinkles)............................................114
divalproex sodium tab delayed release 125 mg
(Depakote).................................................................... 114
(Depakote).................................................................... 114
(Depakote).................................................................... 114
divalproex sodium tab sr 24 hr 250 mg (Depakote
er).................................................................................. 114
divalproex sodium tab sr 24 hr 500 mg (Depakote
er).................................................................................. 114
DIVIGEL -estradiol td gel 0.25 mg/0.25gm (0.1%)........... 22
DIVIGEL -estradiol td gel 0.5 mg/0.5gm (0.1%)............... 22
DIVIGEL -estradiol td gel 1 mg/gm (0.1%)....................... 22
DIVISTA -folic acid-vit b6-vit b12-omega 3-biotin-cr cap 1
mg.................................................................................. 134
dofetilide cap 125 mcg (0.125 mg) (Tikosyn)................45
dofetilide cap 250 mcg (0.25 mg) (Tikosyn)..................45
dofetilide cap 500 mcg (0.5 mg) (Tikosyn)....................45
DOLOPHINE -methadone hcl tab 5 mg.......................... 101
DOLOPHINE -methadone hcl tab 10 mg........................ 101
donepezil hydrochloride orally disintegrating tab 5
mg................................................................................... 95
donepezil hydrochloride orally disintegrating tab 10
mg................................................................................... 95
donepezil hydrochloride tab 5 mg (Aricept)................. 95
donepezil hydrochloride tab 10 mg (Aricept)............... 95
donepezil hydrochloride tab 23 mg (Aricept)............... 95
DONNATAL -pb-hyoscy-atrop-scopol elix
16.2-0.1037-0.0194-0.0065 mg/5ml............................... 69
DONNATAL -pb-hyoscy-atrop-scopol tab
16.2-0.1037-0.0194-0.0065 mg...................................... 69
DORAL -quazepam tab 15 mg.......................................... 88
DORYX -doxycycline hyclate tab delayed release 50
mg...................................................................................... 4
DORYX -doxycycline hyclate tab delayed release 200
mg...................................................................................... 4
dorzolamide hcl ophth soln 2% (Trusopt).................. 145
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8
mg/ml (Cosopt)............................................................145
DOTHELLE DHA -prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg......................................................... 124
DOVONEX -calcipotriene cream 0.005%........................156
doxazosin mesylate tab 1 mg (Cardura)....................... 49
196
2016
doxepin hcl cap 10 mg....................................................81
doxepin hcl cap 100 mg..................................................81
doxepin hcl cap 150 mg..................................................81
doxepin hcl conc 10 mg/ml............................................ 81
DOXEPIN HCL -doxepin hcl cap 75 mg........................... 80
DOXEPIN HYDROCHLORIDE -doxepin hcl cream
5%.................................................................................. 156
doxercalciferol cap 0.5 mcg (Hectorol)......................... 35
doxercalciferol cap 1 mcg (Hectorol)............................ 35
doxercalciferol cap 2.5 mcg (Hectorol)......................... 35
DOXYCYCLINE -doxycycline (rosacea) cap delayed
release 40 mg............................................................... 156
doxycycline hyclate cap 50 mg....................................... 4
doxycycline hyclate cap 100 mg (Vibramycin)...............4
doxycycline hyclate tab delayed release 75 mg............ 4
doxycycline hyclate tab delayed release 100 mg.......... 4
doxycycline hyclate tab delayed release 150 mg.......... 4
doxycycline hyclate tab delayed release 50 mg
(Doryx).............................................................................. 4
doxycycline hyclate tab delayed release 200 mg
(Doryx).............................................................................. 4
doxycycline hyclate tab 20 mg........................................ 4
doxycycline hyclate tab 100 mg...................................... 4
doxycycline monohydrate cap 50 mg............................. 4
doxycycline monohydrate cap 150 mg (Adoxa).............4
doxycycline monohydrate cap 75 mg (Monodox)..........4
doxycycline monohydrate cap 100 mg (Monodox)........4
doxycycline monohydrate for susp 25 mg/5ml
(Vibramycin)..................................................................... 4
doxycycline monohydrate tab 50 mg (Adoxa)............... 4
doxycycline monohydrate tab 75 mg (Adoxa)............... 4
doxycycline monohydrate tab 100 mg (Adoxa pak
1/100)................................................................................. 4
doxycycline monohydrate tab 150 mg (Adoxa pak
1/150)................................................................................. 4
DRITHO-CREME HP -anthralin cream 1%..................... 156
dronabinol cap 2.5 mg (Marinol).................................... 71
dronabinol cap 5 mg (Marinol)....................................... 71
dronabinol cap 10 mg (Marinol)..................................... 71
drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin
28).................................................................................... 24
drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)..... 24
DROXIA -hydroxyurea cap 200 mg................................ 134
DRYSOL -aluminum chloride soln 20%.......................... 156
DUAC -clindamycin phosph-benzoyl peroxide (refrig) gel
1.2 (1)-5%..................................................................... 156
DUAVEE -conjugated estrogens-bazedoxifene tab
0.45-20 mg...................................................................... 22
DUETACT -pioglitazone hcl-glimepiride tab 30-2 mg....... 27
DUETACT -pioglitazone hcl-glimepiride tab 30-4 mg....... 27
DUEXIS -ibuprofen-famotidine tab 800-26.6 mg............ 108
DULERA -mometasone furoate-formoterol fumarate
aerosol 100-5 mcg/act.................................................... 66
DULERA -mometasone furoate-formoterol fumarate
aerosol 200-5 mcg/act.................................................... 66
DULOXETINE HCL -duloxetine hcl enteric coated pellets
cap 40 mg....................................................................... 81
duloxetine hcl enteric coated pellets cap 20 mg
(Cymbalta)...................................................................... 81
(Cymbalta)...................................................................... 81
(Cymbalta)...................................................................... 81
DURACHOL -folic acid-cholecalciferol cap 1 mg-3775
unit................................................................................. 134
DURAGESIC -fentanyl td patch 72hr 12 mcg/hr............. 101
DURAGESIC -fentanyl td patch 72hr 100 mcg/hr........... 101
DUREZOL -difluprednate ophth emulsion 0.05%........... 145
DURLAZA -aspirin capsule sr 24hr 162.5 mg................. 140
dutasteride cap 0.5 mg (Avodart).................................. 77
dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn)...... 77
DUTOPROL -metoprolol & hydrochlorothiazide tab sr
24hr 25-12.5 mg............................................................. 49
24hr 50-12.5 mg............................................................. 49
24hr 100-12.5 mg........................................................... 49
D-VI-SOL -cholecalciferol oral liquid 400 unit/ml............ 123
DYANAVEL XR -amphetamine extended release susp 2.5
mg/ml............................................................................... 92
DYAZIDE -triamterene & hydrochlorothiazide cap 37.5-25
mg.................................................................................... 54
DYMISTA -azelastine hcl-fluticasone prop nasal spray
137-50 mcg/act............................................................... 61
dyphylline-guaifenesin liqd 100-100 mg/5ml................ 66
DYRENIUM -triamterene cap 50 mg................................. 54
DYRENIUM -triamterene cap 100 mg............................... 54
E
EBASE CONTROLLER KIT -respiratory therapy supplies
- misc............................................................................. 168
EC-NAPROSYN -naproxen tab ec 375 mg.....................108
EC-NAPROSYN -naproxen tab ec 500 mg.....................108
econazole nitrate cream 1%......................................... 156
ECOTRIN REGULAR STRENGTH -aspirin tab delayed
release 325 mg............................................................... 99
ECOZA -econazole nitrate foam 1%............................... 156
EDARBI -azilsartan medoxomil tab 40 mg........................49
EDARBI -azilsartan medoxomil tab 80 mg........................49
EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab
40-12.5 mg...................................................................... 49
EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab
40-25 mg......................................................................... 49
ED CYTE F -ferrous fumarate-folic acid-docusate sodium
tab 324-1-50 mg........................................................... 134
197
2016
EDECRIN -ethacrynic acid tab 25 mg.............................. 54
EDEX– Benefit Limits may apply -alprostadil for inj kit 10
mcg.................................................................................. 60
mcg.................................................................................. 60
mcg.................................................................................. 60
EDLUAR -zolpidem tartrate sl tab 5 mg............................88
EDLUAR -zolpidem tartrate sl tab 10 mg..........................88
EDURANT -rilpivirine hcl tab 25 mg (base equivalent)....... 8
E.E.S. 400 -erythromycin ethylsuccinate tab 400 mg......... 3
E.E.S. GRANULES -erythromycin ethylsuccinate for susp
200 mg/5ml....................................................................... 3
EFFER-K -potassium bicarbonate-citric acid effer tab 10
meq................................................................................ 131
EFFER-K -potassium bicarbonate-citric acid effer tab 20
meq................................................................................ 131
EFFEXOR XR -venlafaxine hcl cap sr 24hr 37.5 mg (base
equivalent)....................................................................... 81
EFFEXOR XR -venlafaxine hcl cap sr 24hr 75 mg (base
equivalent)....................................................................... 81
EFFEXOR XR -venlafaxine hcl cap sr 24hr 150 mg (base
equivalent)....................................................................... 81
EFFIENT -prasugrel hcl tab 5 mg (base equiv).............. 140
EFFIENT -prasugrel hcl tab 10 mg (base equiv)............ 140
EFLOW SCF AEROSOL HEAD -respiratory therapy
supplies - misc.............................................................. 168
EFUDEX -fluorouracil cream 5%..................................... 156
EGRIFTA -tesamorelin acetate for inj 1 mg (base
equiv)............................................................................... 35
EGRIFTA -tesamorelin acetate for inj 2 mg (base
equiv)............................................................................... 35
ELAVIL -amitriptyline hcl tab 25 mg.................................. 81
ELDEPRYL -selegiline hcl cap 5 mg...............................119
ELESTAT -epinastine hcl ophth soln 0.05%................... 145
ELESTRIN -estradiol gel 0.06% (0.52 mg/0.87 gm
metered-dose pump)...................................................... 22
ELETONE -dermatological products misc - cream......... 156
ELETONE TWINPACK -dermatological products misc cream............................................................................. 156
ELIDEL -pimecrolimus cream 1%................................... 156
ELIGARD -leuprolide acetate for subcutaneous inj kit 7.5
mg.................................................................................... 15
ELIGARD -leuprolide acetate (3 month) for subcutaneous
inj kit 22.5mg...................................................................15
inj kit 30 mg.................................................................... 15
inj kit 45 mg.................................................................... 15
ELIMITE -permethrin cream 5%...................................... 156
ELIPHOS -calcium acetate (phosphate binder) tab 667
mg.................................................................................... 73
ELIQUIS -apixaban tab 2.5 mg....................................... 137
ELIQUIS -apixaban tab 5 mg.......................................... 137
ELITE DC AUTO ADAPTER -respiratory therapy supplies
- misc............................................................................. 169
ELITE-OB -prenatal vit w/ iron carbonyl-fa tab 50-1.25
mg.................................................................................. 124
ELIXOPHYLLIN -theophylline elixir 80 mg/15ml............... 66
ELLA -ulipristal acetate tab 30 mg.................................... 24
ELMIRON -pentosan polysulfate sodium caps 100
mg.................................................................................... 77
ELOCON -mometasone furoate cream 0.1%................. 156
ELOCON -mometasone furoate oint 0.1%......................156
ELOCON -mometasone furoate solution 0.1%
(lotion)............................................................................ 156
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
250 unit......................................................................... 140
500 unit......................................................................... 140
750 unit......................................................................... 140
1000 unit....................................................................... 140
1500 unit....................................................................... 140
2000 unit....................................................................... 140
3000 unit....................................................................... 140
EMADINE -emedastine difumarate ophth soln 0.05%
(base equiv).................................................................. 145
EMBEDA -morphine-naltrexone cap cr 20-0.8 mg..........101
EMBEDA -morphine-naltrexone cap cr 50-2 mg.............101
EMBEDA -morphine-naltrexone cap cr 100-4 mg...........101
EMCYT -estramustine phosphate sodium cap 140
mg.................................................................................... 15
EMEND -aprepitant capsule 40 mg.................................. 71
EMEND -aprepitant capsule 80 mg.................................. 72
EMEND -aprepitant capsule 125 mg................................ 72
EMEND -aprepitant capsule therapy pack 80 & 125
mg.................................................................................... 71
EMSAM -selegiline td patch 24hr 6 mg/24hr.................... 81
EMSAM -selegiline td patch 24hr 9 mg/24hr.................... 81
EMSAM -selegiline td patch 24hr 12 mg/24hr.................. 81
EMTRIVA -emtricitabine caps 200 mg................................ 8
EMTRIVA -emtricitabine soln 10 mg/ml.............................. 8
EMVERM -mebendazole chew tab 100 mg...................... 12
ENABLEX -darifenacin hydrobromide tab sr 24hr 7.5 mg
(base equiv).................................................................... 76
ENABLEX -darifenacin hydrobromide tab sr 24hr 15 mg
(base equiv).................................................................... 76
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg................................................................................... 49
enalapril maleate & hydrochlorothiazide tab 10-25 mg
(Vaseretic)...................................................................... 49
enalapril maleate tab 2.5 mg (Vasotec)......................... 49
enalapril maleate tab 5 mg (Vasotec)............................ 49
enalapril maleate tab 10 mg (Vasotec).......................... 49
enalapril maleate tab 20 mg (Vasotec).......................... 49
198
2016
ENBRACE HR -prenatal vit w/ fe gly cys-fa-omega 3 fatty
acids cap....................................................................... 124
ENBREL -etanercept for subcutaneous inj 25 mg.......... 108
ENBREL -etanercept subcutaneous soln prefilled syringe
25 mg/0.5ml.................................................................. 108
ENBREL -etanercept subcutaneous soln prefilled syringe
50 mg/ml....................................................................... 108
ENBREL SURECLICK -etanercept subcutaneous solution
auto-injector 50 mg/ml.................................................. 108
ENCARE -nonoxynol-9 vaginal suppos 100 mg............... 76
ENDOMETRIN -progesterone vaginal insert 100 mg....... 77
enoxaparin sodium inj 30 mg/0.3ml (Lovenox).......... 137
enoxaparin sodium inj 100 mg/ml (Lovenox)............. 137
enoxaparin sodium inj 120 mg/0.8ml (Lovenox)........ 137
enoxaparin sodium inj 150 mg/ml (Lovenox)............. 137
enoxaparin sodium inj 300 mg/3ml (Lovenox)........... 137
ENSTILAR -calcipotriene-betamethasone dipropionate
foam 0.005-0.064%...................................................... 156
entacapone tab 200 mg (Comtan)............................... 119
entecavir tab 0.5 mg (Baraclude)..................................... 8
entecavir tab 1 mg (Baraclude)........................................ 8
ENTEREG -alvimopan cap 12 mg.................................... 73
ENTOCORT EC -budesonide delayed release particles
cap 3 mg......................................................................... 19
ENTRESTO -sacubitril-valsartan tab 24-26 mg................ 59
ENTRESTO -sacubitril-valsartan tab 49-51 mg................ 59
ENTRESTO -sacubitril-valsartan tab 97-103 mg.............. 59
ENVARSUS XR -tacrolimus tab sr 24hr 0.75 mg............172
ENVARSUS XR -tacrolimus tab sr 24hr 1 mg................ 172
ENVARSUS XR -tacrolimus tab sr 24hr 4 mg................ 172
EPANED -enalapril maleate for oral soln 1 mg/ml............ 49
EPCLUSA -sofosbuvir-velpatasvir tab 400-100 mg............ 8
EPIDUO -adapalene-benzoyl peroxide gel 0.1-2.5%......156
EPIDUO FORTE -adapalene-benzoyl peroxide gel
0.3-2.5%........................................................................ 156
EPIFOAM -pramoxine-hc aerosol foam 1-1%.................156
epinastine hcl ophth soln 0.05% (Elestat).................. 145
EPINEPHRINE -epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)......................................................... 55
EPINEPHRINE -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)........................................................... 55
EPIPEN-JR 2-PAK -epinephrine solution auto-injector
0.15 mg/0.3ml (1:2000).................................................. 55
EPIPEN 2-PAK -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)........................................................... 55
EPIVIR HBV -lamivudine oral soln 5 mg/ml (hbv)............... 8
EPIVIR HBV -lamivudine tab 100 mg (hbv)........................ 8
EPIVIR -lamivudine oral soln 10 mg/ml.............................. 8
EPIVIR -lamivudine tab 150 mg.......................................... 8
EPIVIR -lamivudine tab 300 mg.......................................... 8
eplerenone tab 25 mg (Inspra)....................................... 49
eplerenone tab 50 mg (Inspra)....................................... 49
EPOGEN -epoetin alfa inj 2000 unit/ml...........................134
EPOGEN -epoetin alfa inj 10000 unit/ml.........................134
EPOGEN -epoetin alfa inj 20000 unit/ml.........................134
EPROSARTAN MESYLATE -eprosartan mesylate tab 600
mg.................................................................................... 49
EPZICOM -abacavir sulfate-lamivudine tab 600-300
mg...................................................................................... 8
EQUAGESIC -meprobamate-aspirin tab 200-325 mg...... 99
EQUETRO -carbamazepine (antipsychotic) cap sr 12hr
100 mg............................................................................ 85
200 mg............................................................................ 85
300 mg............................................................................ 85
ergocalciferol cap 50000 unit (Drisdol)....................... 123
ERGOLOID MESYLATES -ergoloid mesylates tab 1
mg.................................................................................... 95
ERGOMAR -ergotamine tartrate sl tab 2 mg.................. 111
ERIVEDGE -vismodegib cap 150 mg............................... 15
ERTACZO -sertaconazole nitrate cream 2%.................. 156
ERYGEL -erythromycin gel 2%....................................... 156
ERYPED 200 -erythromycin ethylsuccinate for susp 200
mg/5ml............................................................................... 3
ERYPED 400 -erythromycin ethylsuccinate for susp 400
mg/5ml............................................................................... 3
ERY-TAB -erythromycin tab delayed release 250 mg........ 3
ERYTHROCIN STEARATE -erythromycin stearate tab
250 mg.............................................................................. 3
ERYTHROMYCIN BASE -erythromycin tab 250 mg.......... 3
ERYTHROMYCIN BASE -erythromycin tab 500 mg.......... 3
ERYTHROMYCIN ETHYLSUCCINA -erythromycin
ethylsuccinate tab 400 mg............................................... 3
erythromycin gel 2% (Erygel)....................................... 156
erythromycin ophth oint 5 mg/gm............................... 145
erythromycin pads 2%.................................................. 156
erythromycin soln 2%................................................... 156
erythromycin w/ delayed release particles cap 250
mg......................................................................................3
ESBRIET -pirfenidone cap 267 mg................................... 68
ESCAVITE D -pediatric multiple vitamins w/ fl-fe chew tab
0.25-6 mg...................................................................... 124
ESCAVITE LQ -pediatric multiple vitamins w/ fl-fe drops
0.25-6 mg/ml................................................................. 124
ESCAVITE -pediatric multiple vitamins w/ fl-fe chew tab
0.25-7.5 mg................................................................... 124
escitalopram oxalate soln 5 mg/5ml (base equiv)
(Lexapro)........................................................................ 81
escitalopram oxalate tab 5 mg (base equiv)
(Lexapro)........................................................................ 81
(Lexapro)........................................................................ 81
(Lexapro)........................................................................ 81
ESGIC -butalbital-acetaminophen-caffeine tab 50-325-40
mg.................................................................................... 99
199
2016
esomeprazole magnesium cap delayed release 20 mg
(base eq) (Nexium)....................................................... 69
esomeprazole magnesium cap delayed release 40 mg
(base eq) (Nexium)....................................................... 69
ESSENTRA WIPES 9X9" CLEAN -isopropyl alcohol
wipes 70%..................................................................... 156
estazolam tab 1 mg......................................................... 88
estazolam tab 2 mg......................................................... 88
esterified estrogens & methyltestosterone tab
0.625-1.25 mg................................................................ 22
esterified estrogens & methyltestosterone tab
1.25-2.5 mg.....................................................................22
ESTRACE -estradiol tab 0.5 mg....................................... 22
ESTRACE -estradiol tab 1 mg.......................................... 22
ESTRACE -estradiol tab 2 mg.......................................... 22
ESTRACE -estradiol vaginal cream 0.1 mg/gm................ 77
estradiol & norethindrone acetate tab 0.5-0.1 mg
(Activella)....................................................................... 22
estradiol & norethindrone acetate tab 1-0.5 mg
(Activella)....................................................................... 22
estradiol tab 0.5 mg (Estrace)........................................ 22
estradiol tab 1 mg (Estrace)........................................... 22
estradiol tab 2 mg (Estrace)........................................... 22
estradiol td patch twice weekly 0.025 mg/24hr (Vivelledot).................................................................................. 22
estradiol td patch twice weekly 0.0375 mg/24hr
(Vivelle-dot).................................................................... 22
estradiol td patch weekly 0.025 mg/24hr (Climara)......22
estradiol td patch weekly 0.05 mg/24hr (Climara)........22
estradiol td patch weekly 0.06 mg/24hr (Climara)........22
estradiol td patch weekly 0.075 mg/24hr (Climara)......22
estradiol td patch weekly 0.1 mg/24hr (Climara)..........22
estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr) (Climara)...................................................... 22
estradiol valerate im in oil 20 mg/ml (Delestrogen)..... 22
estradiol valerate im in oil 40 mg/ml (Delestrogen)..... 22
ESTRING -estradiol vaginal ring 2 mg (7.5
mcg/24hrs).......................................................................77
ESTROGEL -estradiol gel 0.06% (0.75 mg/1.25 gm
metered-dose pump)...................................................... 22
ESTROPIPATE -estropipate tab 0.75 mg......................... 22
ESTROPIPATE -estropipate tab 1.5 mg........................... 22
ESTROPIPATE -estropipate tab 3 mg.............................. 22
ESTROSTEP FE -norethindrone ac-ethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg.................................................. 24
eszopiclone tab 1 mg (Lunesta).................................... 88
ethacrynic acid tab 25 mg.............................................. 54
ethambutol hcl tab 100 mg (Myambutol)........................ 6
ethambutol hcl tab 400 mg (Myambutol)........................ 6
ethosuximide cap 250 mg (Zarontin).......................... 114
ethosuximide soln 250 mg/5ml (Zarontin).................. 114
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35
mcg................................................................................. 24
ETIDRONATE DISODIUM -etidronate disodium tab 200
mg.................................................................................... 35
ETIDRONATE DISODIUM -etidronate disodium tab 400
mg.................................................................................... 35
etodolac cap 200 mg..................................................... 108
etodolac cap 300 mg..................................................... 108
etodolac tab 400 mg...................................................... 108
etodolac tab 500 mg...................................................... 108
etodolac tab sr 24hr 400 mg........................................ 108
ETOPOSIDE -etoposide cap 50 mg..................................15
EURAX -crotamiton cream 10%...................................... 156
EURAX -crotamiton lotion 10%....................................... 156
EVAMIST -estradiol transdermal spray 1.53 mg/spray..... 23
EVEKEO -amphetamine sulfate tab 5 mg.........................92
EVEKEO -amphetamine sulfate tab 10 mg.......................92
EVICEL -fibrin sealant component kit 2 ml..................... 138
EVICEL -fibrin sealant component kit 5 ml..................... 138
EVISTA -raloxifene hcl tab 60 mg..................................... 35
EVITHROM -thrombin (human) topical soln 800-1200
unit/ml............................................................................ 138
EVOCLIN -clindamycin phosphate foam 1%.................. 156
EVOTAZ -atazanavir sulfate-cobicistat tab 300-150 mg
(base equiv)...................................................................... 8
EVOXAC -cevimeline hcl cap 30 mg.............................. 149
EVZIO -naloxone hcl solution auto-injector 0.4
mg/0.4ml........................................................................ 167
EXACTUSS -phenylephrine w/ dm-gg liqd 10-28-388
mg/5ml............................................................................. 62
EXALGO -hydromorphone hcl tab er 24hr deter 8
mg.................................................................................. 101
mg.................................................................................. 101
mg.................................................................................. 101
mg.................................................................................. 101
EXELDERM -sulconazole nitrate cream 1%................... 156
EXELDERM -sulconazole nitrate solution 1%................ 156
EXELON -rivastigmine tartrate cap 1.5 mg....................... 95
EXELON -rivastigmine tartrate cap 3 mg.......................... 95
EXELON -rivastigmine tartrate cap 4.5 mg....................... 95
EXELON -rivastigmine tartrate cap 6 mg.......................... 95
EXELON -rivastigmine td patch 24hr 4.6 mg/24hr............ 95
EXELON -rivastigmine td patch 24hr 9.5 mg/24hr............ 96
EXELON -rivastigmine td patch 24hr 13.3 mg/24hr.......... 96
exemestane tab 25 mg (Aromasin)................................ 15
EXFORGE -amlodipine besylate-valsartan tab 5-160
mg.................................................................................... 49
mg.................................................................................... 49
200
2016
mg.................................................................................... 49
mg.................................................................................... 49
EXFORGE HCT -amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5 mg......................... 49
EXFORGE HCT -amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg............................ 49
EXFORGE HCT -amlodipine-valsartanhydrochlorothiazide tab 10-160-12.5 mg....................... 49
EXFORGE HCT -amlodipine-valsartanhydrochlorothiazide tab 10-160-25 mg.......................... 49
EXFORGE HCT -amlodipine-valsartanhydrochlorothiazide tab 10-320-25 mg.......................... 49
EXJADE -deferasirox tab for oral susp 125 mg.............. 167
EXODERM -sodium thiosulfate-salicylic acid lotion
25-1%............................................................................ 156
EXTAVIA -interferon beta-1b for inj kit 0.3 mg.................. 96
EXTINA -ketoconazole foam 2%..................................... 156
EXTRA-VIRT PLUS DHA -prenatal w/o vit a w/ fe fumdoc-fa-dha cap 29-1.25-350 mg................................... 124
F
FABIOR -tazarotene (acne) foam 0.1%.......................... 156
FACE MASK EARLOOP-STYLE -masks........................ 169
FACTIVE -gemifloxacin mesylate tab 320 mg (base
equiv)................................................................................. 6
FA-8 -folic acid cap 0.8 mg............................................. 134
FALESSA -levonorgest-eth estrad tab 0.1 mg-20 mcg & fa
tab 1 mg kit..................................................................... 24
famciclovir tab 125 mg (Famvir)...................................... 8
famotidine for susp 40 mg/5ml (Pepcid)....................... 69
famotidine tab 20 mg (Pepcid)....................................... 69
famotidine tab 40 mg (Pepcid)....................................... 69
FAMVIR -famciclovir tab 125 mg........................................ 8
FANAPT -iloperidone tab 2 mg......................................... 85
FANAPT -iloperidone tab 10 mg....................................... 85
FANAPT -iloperidone tab 12 mg....................................... 85
FANAPT TITRATION PACK -iloperidone tab 1 mg & 2 mg
& 4 mg & 6 mg titration pak........................................... 85
FARESTON -toremifene citrate tab 60 mg (base
equivalent)....................................................................... 15
FARXIGA -dapagliflozin propanediol tab 5 mg (base
equivalent)....................................................................... 27
FARXIGA -dapagliflozin propanediol tab 10 mg (base
equivalent)....................................................................... 27
FARYDAK -panobinostat lactate cap 10 mg (base
equivalent)....................................................................... 15
equivalent)....................................................................... 15
equivalent)....................................................................... 15
FASLODEX -fulvestrant inj 250 mg/5ml............................ 15
FAZACLO -clozapine orally disintegrating tab 12.5
mg.................................................................................... 85
FAZACLO -clozapine orally disintegrating tab 25 mg....... 85
FAZACLO -clozapine orally disintegrating tab 100 mg..... 85
FC FEMALE CONDOM -condoms - female....................169
FC2 FEMALE CONDOM -condoms - female..................169
fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1
mg................................................................................. 134
fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240
mg................................................................................. 134
fe fum-iron polysacch complex-fa-b cmplx-c-zn-mncu cap (Tandem plus)................................................ 134
FEIBA -antiinhibitor coagulant complex for inj................ 140
felbamate susp 600 mg/5ml (Felbatol)........................ 114
felbamate tab 400 mg (Felbatol).................................. 114
felbamate tab 600 mg (Felbatol).................................. 114
FELBATOL -felbamate susp 600 mg/5ml........................114
FELBATOL -felbamate tab 400 mg................................. 114
FELBATOL -felbamate tab 600 mg................................. 114
FELDENE -piroxicam cap 10 mg.................................... 108
FELDENE -piroxicam cap 20 mg.................................... 108
felodipine tab sr 24hr 2.5 mg......................................... 43
felodipine tab sr 24hr 5 mg............................................ 43
felodipine tab sr 24hr 10 mg.......................................... 43
FEMARA -letrozole tab 2.5 mg......................................... 15
FEMCAP -cervical cap 22 mm........................................ 169
FEMCON FE -norethindrone & ethinyl estradiol-fe chew
tab 0.4 mg-35 mcg......................................................... 24
FEMHRT LOW DOSE -norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg......................................... 23
FEM PH -acetic acid-oxyquinoline vaginal gel
0.9-0.025%...................................................................... 77
FEMRING -estradiol acetate vaginal ring 0.05
mg/24hr........................................................................... 77
FEMRING -estradiol acetate vaginal ring 0.1 mg/24hr..... 77
FENOFIBRATE -fenofibrate cap 50 mg............................ 56
FENOFIBRATE -fenofibrate cap 150 mg.......................... 56
fenofibrate micronized cap 43 mg................................. 56
fenofibrate micronized cap 130 mg............................... 56
fenofibrate micronized cap 67 mg (Lofibra)................. 56
fenofibrate micronized cap 134 mg (Lofibra)............... 56
fenofibrate micronized cap 200 mg (Lofibra)............... 56
fenofibrate tab 40 mg (Fenoglide)................................. 56
fenofibrate tab 120 mg (Fenoglide)............................... 56
fenofibrate tab 54 mg (Lofibra)...................................... 56
fenofibrate tab 160 mg (Lofibra).................................... 56
fenofibrate tab 48 mg (Tricor)........................................ 56
fenofibrate tab 145 mg (Tricor)...................................... 56
201
2016
FENOFIBRIC ACID -fenofibric acid tab 35 mg................. 56
FENOFIBRIC ACID -fenofibric acid tab 105 mg............... 56
FENOGLIDE -fenofibrate tab 40 mg................................. 56
FENOGLIDE -fenofibrate tab 120 mg............................... 56
FENOPROFEN CALCIUM -fenoprofen calcium cap 200
mg.................................................................................. 108
FENOPROFEN CALCIUM -fenoprofen calcium cap 400
mg.................................................................................. 108
FENOPROFEN CALCIUM -fenoprofen calcium tab 600
mg.................................................................................. 108
FENORTHO -fenoprofen calcium cap 200 mg............... 108
FENORTHO -fenoprofen calcium cap 400 mg............... 108
fentanyl citrate lozenge on a handle 200 mcg
(Actiq)........................................................................... 101
(Actiq)........................................................................... 101
(Actiq)........................................................................... 101
(Actiq)........................................................................... 101
(Actiq)........................................................................... 101
(Actiq)........................................................................... 101
FENTANYL -fentanyl td patch 72hr 37.5 mcg/hr.............101
fentanyl td patch 72hr 12 mcg/hr (Duragesic)............ 101
fentanyl td patch 72hr 100 mcg/hr (Duragesic).......... 101
FENTORA -fentanyl citrate buccal tab 100 mcg (base
equiv)............................................................................. 101
equiv)............................................................................. 101
equiv)............................................................................. 102
equiv)............................................................................. 102
equiv)............................................................................. 102
FER-IN-SOL -ferrous sulfate soln 75 mg/ml (15 mg/ml
elemental fe)................................................................. 134
FERIVA 21/7 -fe asparto gly-b12-fa-c-dss-succinic acid-zn
tab 75-1 mg...................................................................134
FERIVAFA -iron-c-fa-b12-biotin-copper-docusate cap
110-1 mg....................................................................... 134
FERIVA -fe bisglycin-fe carbonyl-c-fa-b12-biotin-dss cap
75-1 mg......................................................................... 134
FERRALET 90 -fe carbonyl-fe gluconate-fa-vit b12-vit cdss tab 90-1 mg........................................................... 134
FERRAPLUS 90 -iron-folic acid-vit b12-vit c-docusate sod
tab 90-1 mg...................................................................134
FERRETTS CHEWABLE IRON -carbonyl iron chew tab
18 mg (elemental iron)................................................. 134
FERREX 28 -fe asparto gly-fe fum-b12-fa-c-succinic ac
tab ther pack................................................................. 134
FERREX 150 FORTE PLUS -fe asp gly-fe polysacch-succ
ac-c-threon ac-b12-fa cap............................................ 134
FERRIPROX -deferiprone oral soln 100 mg/ml.............. 167
FERRIPROX -deferiprone tab 500 mg............................ 167
FERRO-PLEX HEMATINIC -fe fum-dss-vit c-vit e-vit b12if-fa tab 115-1 mg......................................................... 134
FERROTRIN -iron w/ b12-vit c-fa-ifc cap
36-0.015-75-0.5-240 mg............................................... 134
ferrous fumarate-folic acid tab 324-1 mg....................134
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental
fe).................................................................................. 134
FERROUS SULFATE -ferrous sulfate liquid 220 mg/5ml
(44 mg/5ml elemental fe)............................................. 134
FERROUS SULFATE -ferrous sulfate syrup 300 mg/5ml
(60 mg/5ml elemental fe)............................................. 134
ferrous sulfate soln 75 mg/ml (15 mg/ml elemental
fe).................................................................................. 134
FETZIMA -levomilnacipran hcl cap sr 24hr 20 mg (base
equivalent)....................................................................... 81
equivalent)....................................................................... 81
equivalent)....................................................................... 81
equivalent)....................................................................... 81
FETZIMA TITRATION PACK -levomilnacipran hcl cap sr
24hr 20 & 40 mg therapy pack...................................... 81
FIBRICOR -fenofibric acid tab 35 mg............................... 56
FIBRICOR -fenofibric acid tab 105 mg............................. 56
FILTER AIR PP -respiratory therapy supplies - misc...... 169
FINACEA -azelaic acid foam 15%.................................. 156
FINACEA -azelaic acid gel 15%..................................... 156
finasteride tab 5 mg (Proscar)....................................... 77
FIORICET/CODEINE -butalbital-acetaminophen-caff w/
cod cap 50-300-40-30 mg............................................ 102
FIORICET -butalbital-acetaminophen-caffeine cap
50-300-40 mg.................................................................. 99
FIORINAL/CODEINE #3 -butalbital-aspirin-caff w/ codeine
cap 50-325-40-30 mg................................................... 102
FIORINAL -butalbital-aspirin-caffeine cap 50-325-40
mg.................................................................................... 99
FIRAZYR -icatibant acetate inj 30 mg/3ml (base
equivalent)..................................................................... 140
FLAGYL ER -metronidazole tab sr 24hr 750 mg.............. 13
FLAGYL -metronidazole cap 375 mg................................ 13
FLAGYL -metronidazole tab 250 mg................................ 13
FLAGYL -metronidazole tab 500 mg................................ 13
FLANAX PAIN RELIEF KIT -naproxen tab 500 mg &
liniment topical gel kit................................................... 108
FLAREX -fluorometholone acetate ophth susp 0.1%..... 145
flavoxate hcl tab 100 mg.................................................76
flecainide acetate tab 50 mg.......................................... 45
flecainide acetate tab 100 mg........................................ 45
flecainide acetate tab 150 mg........................................ 45
FLECTOR -diclofenac epolamine patch 1.3%................ 156
202
2016
FLOMAX -tamsulosin hcl cap 0.4 mg............................... 77
FLORICAL -sodium fluoride w/ calcium carb cap 8.3-364
mg.................................................................................. 131
FLORICAL -sodium fluoride w/ calcium carb tab 8.3-364
mg.................................................................................. 131
FLORIVA -ped multiple vitamins & minerals w/ fl chew tab
0.5 mg........................................................................... 124
FLORIVA -ped multiple vitamins & minerals w/ fl chew tab
1 mg.............................................................................. 124
FLORIVA -sodium fluoride-vitamin d liqd drops 0.25 mg/
ml-400 unit/ml............................................................... 131
FLOVENT DISKUS -fluticasone propionate aer pow ba 50
mcg/blister....................................................................... 66
FLOVENT DISKUS -fluticasone propionate aer pow ba
100 mcg/blister................................................................ 66
FLOVENT DISKUS -fluticasone propionate aer pow ba
250 mcg/blister................................................................ 66
FLOVENT HFA -fluticasone propionate hfa inhal aer 110
mcg/act (125/valve)........................................................ 66
FLOVENT HFA -fluticasone propionate hfa inhal aer 220
mcg/act (250/valve)........................................................ 66
FLOVENT HFA -fluticasone propionate hfa inhal aero 44
mcg/act (50/valve)...........................................................66
FLOWTUSS -hydrocodone-guaifenesin soln 2.5-200
mg/5ml............................................................................. 62
fluconazole for susp 10 mg/ml (Diflucan)....................... 7
fluconazole for susp 40 mg/ml (Diflucan)....................... 7
fluconazole tab 50 mg (Diflucan)..................................... 7
fluconazole tab 100 mg (Diflucan)................................... 7
flucytosine cap 250 mg (Ancobon)................................. 7
flucytosine cap 500 mg (Ancobon)................................. 7
fludrocortisone acetate tab 0.1 mg............................... 19
FLUMADINE -rimantadine hydrochloride tab 100 mg.........8
flunisolide nasal soln 25 mcg/act (0.025%)
(Flunisolide)................................................................... 61
fluocinolone acetonide cream 0.01%.......................... 157
fluocinolone acetonide cream 0.025% (Synalar)........157
fluocinolone acetonide oil 0.01% (body oil) (Dermasmoothe/fs bod).......................................................... 157
fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca)...........................................................157
fluocinolone acetonide oint 0.025% (Synalar)............ 157
fluocinolone acetonide (otic) oil 0.01%
(Dermotic).................................................................... 148
fluocinolone acetonide soln 0.01% (Synalar)............. 157
fluocinonide cream 0.05%............................................ 157
fluocinonide cream 0.1% (Vanos)................................ 157
fluocinonide emulsified base cream 0.05%................ 157
fluocinonide gel 0.05%.................................................. 157
fluocinonide oint 0.05%................................................ 157
fluocinonide soln 0.05%................................................ 157
FLUORABON -sodium fluoride soln 0.25 mg/0.6ml (from
0.55 mg/0.6ml naf)........................................................131
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 0.55
(0.25 mg f)-236.79 mg..................................................131
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 1.1 (0.5
mg f)-236.79 mg........................................................... 131
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 2.2 (1 mg
f)-236.79 mg.................................................................. 131
FLUORIDEX DAILY DEFENSE S -sodium fluoridepotassium nitrate gel 1.1-5%........................................149
fluorometholone ophth susp 0.1% (Fml liquifilm)..... 145
FLUOROPLEX -fluorouracil cream 1%........................... 157
fluorouracil cream 5% (Efudex)................................... 157
FLUOROURACIL -fluorouracil cream 0.5%.................... 157
fluorouracil soln 2%...................................................... 157
fluorouracil soln 5%...................................................... 157
FLUOXETINE -fluoxetine hcl (pmdd) cap 10 mg.............. 96
FLUOXETINE -fluoxetine hcl (pmdd) cap 20 mg.............. 96
fluoxetine hcl cap delayed release 90 mg (Prozac
weekly)............................................................................ 81
fluoxetine hcl cap 10 mg (Prozac)................................. 81
FLUOXETINE HCL -fluoxetine hcl tab 60 mg................... 81
fluoxetine hcl solution 20 mg/5ml................................. 81
fluoxetine hcl tab 10 mg................................................. 81
fluoxetine hcl tab 20 mg................................................. 81
FLUPHENAZINE HCL -fluphenazine hcl elixir 2.5
mg/5ml............................................................................. 85
FLUPHENAZINE HCL -fluphenazine hcl oral conc 5 mg/
ml..................................................................................... 85
fluphenazine hcl tab 1 mg.............................................. 85
fluphenazine hcl tab 2.5 mg........................................... 85
fluphenazine hcl tab 5 mg.............................................. 85
fluphenazine hcl tab 10 mg............................................ 85
FLURA-DROPS -sodium fluoride soln 0.25 mg/drop f
(from 0.55 mg/drop naf)............................................... 131
flurandrenolide cream 0.05%....................................... 157
FLURAZEPAM HCL -flurazepam hcl cap 15 mg.............. 88
FLURAZEPAM HCL -flurazepam hcl cap 30 mg.............. 88
flurbiprofen sodium ophth soln 0.03% (Ocufen)........145
flurbiprofen tab 50 mg.................................................. 108
flurbiprofen tab 100 mg................................................ 109
flutamide cap 125 mg...................................................... 15
fluticasone propionate cream 0.05% (Cutivate)......... 157
fluticasone propionate lotion 0.05% (Cutivate).......... 157
fluticasone propionate nasal susp 50 mcg/act............ 61
fluticasone propionate oint 0.005%............................. 157
FLUTTER -respiratory therapy supplies - devices.......... 169
fluvastatin sodium cap 20 mg (Lescol)......................... 56
fluvastatin sodium cap 40 mg (Lescol)......................... 56
fluvastatin sodium tab sr 24 hr 80 mg (Lescol xl)........56
fluvoxamine maleate cap sr 24hr 100 mg..................... 81
fluvoxamine maleate cap sr 24hr 150 mg..................... 81
fluvoxamine maleate tab 25 mg..................................... 81
fluvoxamine maleate tab 50 mg..................................... 81
fluvoxamine maleate tab 100 mg................................... 81
FML -fluorometholone ophth oint 0.1%........................... 145
FML FORTE -fluorometholone ophth susp 0.25%.......... 145
FML LIQUIFILM -fluorometholone ophth susp 0.1%...... 145
203
2016
FOCALGIN CA -prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 300 mg pack...................................................124
FOCALGIN 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa tab
90 &dha cap 300mg pak.............................................. 124
FOCALGIN DSS -fe carbonyl-fe gluconate-fa-vit b12-vit cdss tab 90-1 mg........................................................... 135
FOCALIN -dexmethylphenidate hcl tab 2.5 mg................ 92
FOCALIN -dexmethylphenidate hcl tab 5 mg................... 92
FOCALIN -dexmethylphenidate hcl tab 10 mg................. 92
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 5
mg.................................................................................... 92
mg.................................................................................... 92
mg.................................................................................... 92
mg.................................................................................... 92
mg.................................................................................... 92
mg.................................................................................... 92
mg.................................................................................... 92
mg.................................................................................... 92
FOLCAL DHA -prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 27-1.25-300 mg..................................................... 124
FOLCAPS OMEGA 3 -prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg............................................... 124
FOLET DHA -prenat w/fecbn-bisg-methylf-dss tab dr &
dha cap pak.................................................................. 124
FOLET ONE -prenat w/o a w/fecbn-bisg-methylf-dss-dha
cap 38-1-225 mg.......................................................... 124
FOLGARD OS -multiple vit w/ min & calcium-folic acid tab
500-1.1 mg.................................................................... 124
FOLGARD RX -folic acid-vitamin b6-vitamin b12 tab
2.2-25-1 mg................................................................... 135
folic acid tab 400 mcg................................................... 135
folic acid tab 800 mcg................................................... 135
folic acid tab 1 mg......................................................... 135
folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5
mg................................................................................. 135
folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg
(Folgard rx).................................................................. 135
FOLIVANE-F -fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe)................................... 135
FOLIVANE-OB -prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg...............................................................124
FOLIVANE-PLUS -fe fum-iron polysacch complex-fa-b
complex-c-biotin cap..................................................... 135
FOLLISTIM AQ– Benefit Limits may apply -follitropin beta
inj 75 unit/0.5ml.............................................................. 35
inj 300 unit/0.36ml.......................................................... 35
inj 600 unit/0.72ml.......................................................... 35
inj 900 unit/1.08ml.......................................................... 35
FOLTRATE -cobalamine combination tab....................... 135
fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml
(Arixtra).........................................................................137
fondaparinux sodium subcutaneous inj 5 mg/0.4ml
(Arixtra).........................................................................137
fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml
(Arixtra).........................................................................137
fondaparinux sodium subcutaneous inj 10 mg/0.8ml
(Arixtra).........................................................................137
FORFIVO XL -bupropion hcl tab sr 24hr 450 mg............. 81
FORMALDEHYDE -formaldehyde solution 37%............ 167
formaldehyde solution 10%.......................................... 167
FORMA-RAY -formaldehyde solution 20%..................... 167
FORTAMET -metformin hcl tab sr 24hr osmotic 500
mg.................................................................................... 27
FORTAMET -metformin hcl tab sr 24hr osmotic 1000
mg.................................................................................... 27
FORTAVIT -multiple vitamins w/ minerals cap................ 124
FORTEO -teriparatide (recombinant) inj 600
mcg/2.4ml........................................................................ 35
FORTESTA -testosterone td gel 10mg/act (2%)............... 21
FORTICAL -calcitonin (salmon) nasal soln 200 unit/
act.................................................................................... 35
FOSAMAX -alendronate sodium tab 70 mg......................35
FOSAMAX PLUS D -alendronate sodium-cholecalciferol
tab 70-2800 mg-unit....................................................... 35
FOSAMAX PLUS D -alendronate sodium-cholecalciferol
tab 70-5600 mg-unit....................................................... 35
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg................................................................................... 49
fosinopril sodium & hydrochlorothiazide tab 20-12.5
mg................................................................................... 49
fosinopril sodium tab 10 mg.......................................... 49
FOSRENOL -lanthanum carbonate chew tab 500 mg
(elemental).......................................................................73
(elemental).......................................................................73
(elemental).......................................................................73
FOSRENOL -lanthanum carbonate oral powder pack 750
mg (elemental)................................................................ 74
FOSRENOL -lanthanum carbonate oral powder pack
1000 mg (elemental).......................................................74
FRAGMIN -dalteparin sodium inj 10000 unit/ml..............137
FRAGMIN -dalteparin sodium inj 2500 unit/0.2ml...........137
FRAGMIN -dalteparin sodium inj 12500 unit/0.5ml.........137
FRAGMIN -dalteparin sodium inj 18000 unit/0.72ml.......137
FROVA -frovatriptan succinate tab 2.5 mg (base
equivalent)..................................................................... 111
204
2016
frovatriptan succinate tab 2.5 mg (base equivalent)
(Frova).......................................................................... 111
FULL KIT NEBULIZER SET -respiratory therapy supplies
- misc............................................................................. 169
FULYZAQ -crofelemer tab delayed release 125 mg......... 68
FUROSEMIDE -furosemide oral soln 8 mg/ml..................54
furosemide oral soln 10 mg/ml...................................... 54
furosemide tab 20 mg (Lasix)........................................ 54
FUSION PLUS -fe fum-iron poly cmplx-fa-b cmplx-cbiotin-probiotic cap........................................................ 135
FUZEON -enfuvirtide for inj 90 mg..................................... 8
FYCOMPA -perampanel susp 0.5 mg/ml........................ 114
FYCOMPA -perampanel tab 2 mg.................................. 114
FYCOMPA -perampanel tab 10 mg................................ 115
FYCOMPA -perampanel tab 12 mg................................ 115
G
gabapentin cap 100 mg (Neurontin)............................ 115
gabapentin oral soln 250 mg/5ml (Neurontin)............ 115
gabapentin tab 600 mg (Neurontin)............................. 115
gabapentin tab 800 mg (Neurontin)............................. 115
GABITRIL -tiagabine hcl tab 2 mg.................................. 115
GABITRIL -tiagabine hcl tab 4 mg.................................. 115
GABITRIL -tiagabine hcl tab 12 mg................................ 115
GABITRIL -tiagabine hcl tab 16 mg................................ 115
galantamine hydrobromide cap sr 24hr 8 mg
(Razadyne er)................................................................ 96
(Razadyne er)................................................................ 96
(Razadyne er)................................................................ 96
GALANTAMINE HYDROBROMIDE -galantamine
hydrobromide oral soln 4 mg/ml.................................... 96
galantamine hydrobromide tab 4 mg (Razadyne)........ 96
galantamine hydrobromide tab 8 mg (Razadyne)........ 96
galantamine hydrobromide tab 12 mg (Razadyne)...... 96
GALZIN -zinc acetate cap 25 mg (elemental zinc)......... 131
GALZIN -zinc acetate cap 50 mg (elemental zinc)......... 131
GANIRELIX ACETATE– Benefit Limits may apply ganirelix acetate inj 250 mcg/0.5ml............................... 35
GASTRINEX NF -hyoscyamine-phenyltoloxamine cap
0.0625-15 mg.................................................................. 69
GASTROCROM -cromolyn sodium oral conc 100
mg/5ml............................................................................. 74
gatifloxacin ophth soln 0.5% (Zymaxid)..................... 145
GATTEX -teduglutide (rdna) for inj kit 5 mg...................... 74
GELCLAIR -povidone-sodium hyaluronate-glycyrrhetinic
acid gel.......................................................................... 149
GELFILM OP -gelatin adsorbable ophth film.................. 145
GEL-KAM ORAL CARE RINSE -stannous fluoride conc
0.63%.............................................................................149
GEL-KAM -stannous fluoride gel 0.4%........................... 149
GELNIQUE -oxybutynin chloride td gel 10%.................... 76
gemfibrozil tab 600 mg (Lopid)...................................... 56
GENERESS FE -norethindrone & ethinyl estradiol-fe
chew tab 0.8 mg-25 mcg................................................24
GENOTROPIN MINIQUICK -somatropin for inj 0.2
mg.................................................................................... 35
mg.................................................................................... 36
mg.................................................................................... 36
mg.................................................................................... 36
GENOTROPIN MINIQUICK -somatropin for inj 1 mg....... 36
mg.................................................................................... 36
mg.................................................................................... 36
mg.................................................................................... 36
mg.................................................................................... 36
GENOTROPIN MINIQUICK -somatropin for inj 2 mg....... 36
GENOTROPIN -somatropin for inj 12 mg (13.8 mg
overfill)............................................................................. 35
GENOTROPIN -somatropin for subcutaneous inj 5
mg.................................................................................... 35
GENTAMICIN SULFATE -gentamicin sulfate cream
0.1%...............................................................................157
GENTAMICIN SULFATE -gentamicin sulfate oint
0.1%...............................................................................157
gentamicin sulfate ophth oint 0.3%............................. 145
gentamicin sulfate ophth soln 0.3% (Garamycin)...... 145
GENVOYA -elvitegrav-cobic-emtricitab-tenofov af tab
150-150-200-10 mg.......................................................... 8
GEODON -ziprasidone hcl cap 20 mg.............................. 85
GIAZO -balsalazide disodium tab 1.1 gm......................... 74
GILENYA -fingolimod hcl cap 0.5 mg (base equiv)........... 96
GILOTRIF -afatinib dimaleate tab 20 mg (base
equivalent)....................................................................... 15
equivalent)....................................................................... 15
equivalent)....................................................................... 15
GILPHEX TR -phenylephrine-guaifenesin tab 10-388
mg.................................................................................... 62
GILTUSS PED-C -phenylephrine w/ codeine-gg liquid
2.5-3-50 mg/ml................................................................ 62
GILTUSS -phenylephrine w/ dm-gg liqd 10-28-388
mg/5ml............................................................................. 62
GILTUSS TR -phenylephrine w/ dm-gg tab 10-28-388
mg.................................................................................... 62
205
2016
glatiramer acetate soln prefilled syringe 20 mg/ml
(Copaxone)..................................................................... 96
GLEEVEC -imatinib mesylate tab 100 mg (base
equivalent)....................................................................... 15
GLEEVEC -imatinib mesylate tab 400 mg (base
equivalent)....................................................................... 15
GLEOSTINE -lomustine cap 5 mg.................................... 15
GLEOSTINE -lomustine cap 10 mg.................................. 15
GLEOSTINE -lomustine cap 40 mg.................................. 15
GLEOSTINE -lomustine cap 100 mg................................ 15
glimepiride tab 1 mg (Amaryl)........................................27
glipizide-metformin hcl tab 2.5-250 mg......................... 27
glipizide-metformin hcl tab 2.5-500 mg......................... 27
glipizide-metformin hcl tab 5-500 mg............................ 27
glipizide tab 5 mg (Glucotrol).........................................27
glipizide tab 10 mg (Glucotrol).......................................27
glipizide tab sr 24hr 2.5 mg (Glucotrol xl).................... 27
glipizide tab sr 24hr 5 mg (Glucotrol xl)....................... 27
glipizide tab sr 24hr 10 mg (Glucotrol xl)..................... 27
GLUCAGEN HYPOKIT -glucagon hcl (rdna) for inj 1 mg
(base equiv).................................................................... 28
GLUCAGON EMERGENCY KIT -glucagon (rdna) for inj
kit 1 mg........................................................................... 28
GLUCOPHAGE -metformin hcl tab 500 mg...................... 28
GLUCOPHAGE -metformin hcl tab 850 mg...................... 28
GLUCOPHAGE -metformin hcl tab 1000 mg.................... 28
GLUCOPHAGE XR -metformin hcl tab sr 24hr 500
mg.................................................................................... 28
GLUCOPHAGE XR -metformin hcl tab sr 24hr 750
mg.................................................................................... 28
glucose gel 40%............................................................... 28
glucose oral liquid 15 gm/59ml...................................... 28
GLUCOTROL -glipizide tab 5 mg..................................... 28
GLUCOTROL -glipizide tab 10 mg................................... 28
GLUCOTROL XL -glipizide tab sr 24hr 2.5 mg.................28
GLUCOTROL XL -glipizide tab sr 24hr 5 mg....................28
GLUCOTROL XL -glipizide tab sr 24hr 10 mg..................28
GLUCOVANCE -glyburide-metformin tab 1.25-250
mg.................................................................................... 28
GLUCOVANCE -glyburide-metformin tab 2.5-500 mg...... 28
GLUCOVANCE -glyburide-metformin tab 5-500 mg......... 28
GLUMETZA -metformin hcl tab sr 24hr modified release
500 mg............................................................................ 28
GLUMETZA -metformin hcl tab sr 24hr modified release
1000 mg.......................................................................... 28
glyburide-metformin tab 1.25-250 mg
(Glucovance).................................................................. 28
glyburide-metformin tab 2.5-500 mg (Glucovance)..... 28
glyburide-metformin tab 5-500 mg (Glucovance)........ 28
glyburide micronized tab 1.5 mg (Glynase)..................28
glyburide micronized tab 3 mg (Glynase).....................28
glyburide micronized tab 6 mg (Glynase).....................28
glyburide tab 1.25 mg..................................................... 28
glyburide tab 2.5 mg....................................................... 28
glyburide tab 5 mg.......................................................... 28
glycopyrrolate tab 1 mg (Robinul)................................. 69
glycopyrrolate tab 2 mg (Robinul forte)........................69
GLYNASE -glyburide micronized tab 1.5 mg.................... 28
GLYNASE -glyburide micronized tab 3 mg....................... 28
GLYNASE -glyburide micronized tab 6 mg....................... 28
GLYSET -miglitol tab 25 mg.............................................. 28
GLYSET -miglitol tab 50 mg.............................................. 28
GLYSET -miglitol tab 100 mg............................................ 28
GLYXAMBI -empagliflozin-linagliptin tab 10-5 mg............ 28
GLYXAMBI -empagliflozin-linagliptin tab 25-5 mg............ 28
GNP VITAMIN D-400 -calcium carbonate-cholecalciferol
tab 90 mg-400 unit....................................................... 132
GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate for
soln 236 gm.................................................................... 68
GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate
packet 227.1 gm............................................................. 68
GONAL-F– Benefit Limits may apply -follitropin alfa for inj
450 unit........................................................................... 36
GONAL-F– Benefit Limits may apply -follitropin alfa for inj
1050 unit......................................................................... 36
GONAL-F RFF– Benefit Limits may apply -follitropin alfa
for inj 75 unit................................................................... 36
GONAL-F RFF PEN– Benefit Limits may apply -follitropin
alfa inj 300 unit/0.5ml..................................................... 36
alfa inj 450 unit/0.75ml................................................... 36
alfa inj 900 unit/1.5ml..................................................... 36
GONAL-F RFF REDIJECT– Benefit Limits may apply follitropin alfa inj 300 unit/0.5ml......................................36
GONAL-F RFF REDIJECT– Benefit Limits may apply follitropin alfa inj 450 unit/0.75ml....................................36
GONAL-F RFF REDIJECT– Benefit Limits may apply follitropin alfa inj 900 unit/1.5ml......................................36
GORDOFILM -salicylic & lactic acids soln
16.7-16.7%.................................................................... 157
GORDONS UREA -urea ointment 40%.......................... 157
GRALISE -gabapentin (once-daily) tab 300 mg................96
GRALISE -gabapentin (once-daily) tab 600 mg................96
GRALISE STARTER -gabapentin (once-daily) tab pack
300 mg (9) & 600 mg (69)............................................. 96
granisetron hcl tab 1 mg................................................ 72
GRANIX -tbo-filgrastim soln prefilled syringe 300
mcg/0.5ml...................................................................... 135
GRANIX -tbo-filgrastim soln prefilled syringe 480
mcg/0.8ml...................................................................... 135
GRASTEK -timothy grass pollen allergen ext tab sl 2800
bau................................................................................... 14
griseofulvin microsize susp 125 mg/5ml........................ 7
griseofulvin microsize tab 500 mg (Grifulvin v)............. 7
griseofulvin ultramicrosize tab 125 mg (Gris-peg)........ 7
griseofulvin ultramicrosize tab 250 mg (Gris-peg)........ 7
GRIS-PEG -griseofulvin ultramicrosize tab 125 mg............ 7
GRIS-PEG -griseofulvin ultramicrosize tab 250 mg............ 7
guaifenesin-codeine liquid 200-8 mg/5ml..................... 62
guaifenesin-codeine liquid 225-7.5 mg/5ml.................. 62
guaifenesin-codeine soln 100-6.3 mg/5ml.................... 62
206
2016
guaifenesin-codeine soln 100-10 mg/5ml..................... 62
guanfacine hcl tab 1 mg (Tenex)................................... 50
guanfacine hcl tab 2 mg (Tenex)................................... 50
guanfacine hcl tab sr 24hr 1 mg (base equiv)
(Intuniv).......................................................................... 92
(Intuniv).......................................................................... 92
(Intuniv).......................................................................... 92
(Intuniv).......................................................................... 92
GUANIDINE HCL -guanidine hcl tab 125 mg................. 122
GYNAZOLE-1 -butoconazole nitrate (one dose) vaginal
cream 2%........................................................................ 77
H
HALAC -halobetasol prop oint 0.05% & ammonium
lactate lot 12% kit......................................................... 157
HALCION -triazolam tab 0.25 mg..................................... 88
halobetasol propionate cream 0.05% (Ultravate)....... 157
halobetasol propionate oint 0.05% (Ultravate)........... 157
HALOG -halcinonide cream 0.1%................................... 157
HALOG -halcinonide oint 0.1%....................................... 157
haloperidol lactate oral conc 2 mg/ml...........................85
haloperidol tab 0.5 mg.................................................... 85
haloperidol tab 1 mg....................................................... 85
haloperidol tab 10 mg..................................................... 85
haloperidol tab 20 mg..................................................... 85
HALOTIN -haloprogin cream 1%.................................... 157
HARVONI -ledipasvir-sofosbuvir tab 90-400 mg................ 8
HECTOROL -doxercalciferol cap 0.5 mcg........................ 36
HECTOROL -doxercalciferol cap 1 mcg........................... 36
HECTOROL -doxercalciferol cap 2.5 mcg........................ 36
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 250 unit.................................................................... 140
kit 500 unit.................................................................... 141
kit 1000 unit.................................................................. 141
kit 2000 unit.................................................................. 141
kit 3000 unit.................................................................. 141
HEMANGEOL -propranolol hcl oral soln 4.28 mg/ml........ 41
HEMATOGEN FA -fe fumarate-vit c-vit b12-fa cap
200-250-0.01-1 mg....................................................... 135
HEMATRON-AF -iron-docusate-b12-folic acid-c-e-cubiotin tab 150-1 mg...................................................... 135
HEMENATAL OB + DHA -prenat-fe poly cmplx-fe heme
poly-fa tab & omega 3 cap pck.................................... 125
HEMENATAL OB -prenat vit-fe poly cmplx-fe heme polyfa tab 28-6-1 mg........................................................... 124
HEMETAB -polysacch fe cmplx-fe heme poly-fa-b12 tab
22-6-1-0.025 mg........................................................... 135
HEMOCYTE-F -iron combination elixir........................... 135
HEMOCYTE PLUS -ferrous fumarate-fa-b complex-c-znmg-mn-cu cap 106-1 mg.............................................. 135
HEMOFIL M -antihemophilic factor (human) for inj 250
unit................................................................................. 141
unit................................................................................. 141
unit................................................................................. 141
unit................................................................................. 141
HEPSERA -adefovir dipivoxil tab 10 mg............................. 9
HETLIOZ -tasimelteon capsule 20 mg.............................. 89
HEXALEN -altretamine cap 50 mg................................... 15
HIPREX -methenamine hippurate tab 1 gm......................75
HISTEX-AC -phenylephrine-triprolidine-codeine syrup
10-2.5-10 mg/5ml............................................................ 62
homatropine hbr ophth soln 5% (Isopto
homatropine)............................................................... 145
HORIZANT -gabapentin enacarbil tab cr 300 mg............. 96
HORIZANT -gabapentin enacarbil tab cr 600 mg............. 96
H.P. ACTHAR -corticotropin inj gel 80 unit/ml................... 36
HPR -dermatological products, misc. - aerosol foam......157
HPR PLUS/MB HYDROGEL -emollient foam & wound
dressing gel kit.............................................................. 157
HPR PLUS -dermatological products, misc. - aerosol
foam............................................................................... 157
HPR PLUS -dermatological products misc - cream........ 157
HUMALOG -insulin lispro (human) inj 100 unit/ml............ 31
HUMALOG -insulin lispro (human) soln cartridge 100 unit/
ml..................................................................................... 31
HUMALOG KWIKPEN -insulin lispro (human) soln peninjector 100 unit/ml......................................................... 31
HUMALOG KWIKPEN -insulin lispro (human) soln peninjector 200 unit/ml......................................................... 31
HUMALOG MIX 50/50 -insulin lispro prot & lispro (human)
inj 100 unit/ml (50-50).................................................... 31
HUMALOG MIX 75/25 -insulin lispro prot & lispro (human)
inj 100 unit/ml (75-25).................................................... 31
HUMALOG MIX 50/50 KWIKPEN -insulin lispro prot &
lispro sus pen-inj 100 unit/ml (50-50).............................31
HUMALOG MIX 75/25 KWIKPEN -insulin lispro prot &
lispro sus pen-inj 100 unit/ml (75-25).............................31
HUMATE-P -antihemophilic factor/vwf (human) for inj
250-600 unit.................................................................. 141
500-1200 unit................................................................ 141
1000-2400 unit.............................................................. 141
HUMATROPE COMBO PACK -somatropin for inj 5
mg.................................................................................... 36
HUMATROPE -somatropin for inj 5 mg............................ 36
HUMATROPE -somatropin for inj 24 mg.......................... 36
HUMATROPE -somatropin for inj 6 mg (18 unit).............. 36
HUMATROPE -somatropin for inj 12 mg (36 unit)............ 36
HUMIRA -adalimumab prefilled syringe kit 10
mg/0.2ml........................................................................ 109
207
2016
mg/0.4ml........................................................................ 109
mg/0.8ml........................................................................ 109
HUMIRA PEDIATRIC CROHNS D -adalimumab prefilled
syringe kit 40 mg/0.8ml................................................ 109
HUMIRA PEN -adalimumab pen-injector kit 40
mg/0.8ml........................................................................ 109
HUMIRA PEN-CROHNS DISEASE -adalimumab peninjector kit 40 mg/0.8ml................................................ 109
HUMIRA PEN-PSORIASIS STAR -adalimumab peninjector kit 40 mg/0.8ml................................................ 109
HUMULIN 70/30 -insulin nph isophane & regular human
inj 100 unit/ml (70-30).................................................... 31
HUMULIN 70/30 KWIKPEN -insulin nph & regular susp
pen-inj 100 unit/ml (70-30)............................................. 31
HUMULIN N -insulin nph (human) (isophane) inj 100 unit/
ml..................................................................................... 31
HUMULIN N KWIKPEN -insulin nph (human) (isophane)
susp pen-injector 100 unit/ml......................................... 31
HUMULIN R -insulin regular (human) inj 100 unit/ml........ 31
HUMULIN R U-500 (CONCENTR -insulin regular (human)
inj 500 unit/ml..................................................................31
HUMULIN R U-500 KWIKPEN -insulin regular (human)
soln pen-injector 500 unit/ml.......................................... 31
HURRISEAL -dental desensitizing product - solution..... 169
hyaluronate sodium (emollient) gel 0.2% (Hylira)...... 157
HYCAMTIN -topotecan hcl cap 0.25 mg (base equiv)...... 15
HYCAMTIN -topotecan hcl cap 1 mg (base equiv)........... 15
HYCET -hydrocodone-acetaminophen soln 7.5-325
mg/15ml......................................................................... 102
HYCOFENIX -pseudoephedrine w/ hydrocodone-gg soln
30-2.5-200 mg/5ml.......................................................... 62
hydralazine hcl tab 10 mg.............................................. 50
hydralazine hcl tab 100 mg............................................ 50
HYDREA -hydroxyurea cap 500 mg................................. 15
hydrochlorothiazide cap 12.5 mg (Microzide).............. 54
hydrochlorothiazide tab 12.5 mg................................... 54
hydrochlorothiazide tab 25 mg...................................... 54
hydrochlorothiazide tab 50 mg...................................... 54
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
(Hycet).......................................................................... 102
hydrocodone-acetaminophen soln 10-325 mg/15ml
(Zamicet).......................................................................102
hydrocodone-acetaminophen tab 2.5-325 mg............ 102
hydrocodone-acetaminophen tab 7.5-325 mg
(Norco).......................................................................... 102
hydrocodone-acetaminophen tab 5-325 mg
(Norco).......................................................................... 102
(Norco).......................................................................... 102
hydrocodone-acetaminophen tab 7.5-300 mg
(Xodol).......................................................................... 102
(Xodol).......................................................................... 102
(Xodol).......................................................................... 102
hydrocodone-ibuprofen tab 10-200 mg (Ibudone)..... 102
hydrocodone-ibuprofen tab 5-200 mg
(Reprexain)................................................................... 102
hydrocodone-ibuprofen tab 7.5-200 mg
(Vicoprofen)................................................................. 102
hydrocodone w/ homatropine syrup 5-1.5 mg/5ml...... 62
hydrocodone w/ homatropine tab 5-1.5 mg..................62
hydrocod polst-chlorphen polst er susp 10-8 mg/5ml
(Tussionex pennkineti)................................................. 62
hydrocortisone acetate suppos 25 mg (Anusolhc)................................................................................. 151
hydrocortisone acetate suppos 30 mg
(Proctocort).................................................................. 151
hydrocortisone acetate w/ pramoxine rectal cream
1-1% (Analpram-hc).................................................... 151
hydrocortisone acetate w/ pramoxine rectal cream
2.5-1% (Analpram-hc)................................................. 151
hydrocortisone butyrate cream 0.1% (Locoid)...........157
hydrocortisone butyrate hydrophilic lipo base cream
0.1% (Locoid lipocream)............................................ 157
hydrocortisone butyrate oint 0.1% (Locoid)............... 157
hydrocortisone butyrate soln 0.1% (Locoid).............. 157
hydrocortisone cream 1%.............................................157
hydrocortisone cream 2.5%..........................................157
hydrocortisone enema 100 mg/60ml
(Cortenema)................................................................. 151
hydrocortisone lotion 2.5%.......................................... 158
hydrocortisone lotion 2% (Ala scalp).......................... 157
hydrocortisone oint 1%................................................. 158
hydrocortisone oint 2.5%..............................................158
hydrocortisone rectal cream 2.5% (Anusol-hc)......... 151
hydrocortisone rectal cream 1% (Proctocort)............ 151
hydrocortisone tab 5 mg (Cortef).................................. 19
hydrocortisone tab 10 mg (Cortef)................................ 19
hydrocortisone tab 20 mg (Cortef)................................ 19
hydrocortisone valerate cream 0.2%...........................158
hydrocortisone valerate oint 0.2% (Westcort)............ 158
hydrocortisone w/ acetic acid otic soln 1-2%............ 148
HYDRO 40 FOAM -urea foam 40%................................ 157
HYDROGEN PEROXIDE -hydrogen peroxide soln
30%................................................................................167
HYDROMORPHONE HCL ER -hydromorphone hcl tab er
24hr deter 32 mg.......................................................... 102
HYDROMORPHONE HCL -hydromorphone hcl suppos 3
mg.................................................................................. 102
hydromorphone hcl liqd 1 mg/ml (Dilaudid)...............102
hydromorphone hcl tab er 24hr deter 8 mg
(Exalgo)........................................................................ 102
(Exalgo)........................................................................ 102
(Exalgo)........................................................................ 102
hydromorphone hcl tab 2 mg (Dilaudid)..................... 102
208
2016
HYDRO 35 -urea in lactic acid vehicle foam 35%.......... 157
HYDROXOCOBALAMIN -hydroxocobalamin inj 1000
mcg/ml........................................................................... 135
hydroxychloroquine sulfate tab 200 mg
(Plaquenil)...................................................................... 12
hydroxyurea cap 500 mg (Hydrea)................................ 15
hydroxyzine hcl syrup 10 mg/5ml................................. 79
hydroxyzine hcl tab 10 mg............................................. 79
hydroxyzine pamoate cap 25 mg (Vistaril)................... 79
hydroxyzine pamoate cap 50 mg (Vistaril)................... 79
HYDROXYZINE PAMOATE -hydroxyzine pamoate cap
100 mg............................................................................ 79
HYLATOPIC -dermatological products, misc. - aerosol
foam............................................................................... 158
HYLATOPIC PLUS -dermatological products, misc. aerosol foam................................................................. 158
HYLATOPIC PLUS -dermatological products misc cream............................................................................. 158
HYLIRA -hyaluronate sodium (emollient) gel 0.2%.........158
HYLIRA -hyaluronate sodium (emollient) lotion 0.1%..... 158
hyoscyamine sulfate elixir 0.125 mg/5ml...................... 69
hyoscyamine sulfate soln 0.125 mg/ml......................... 70
hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)..... 70
hyoscyamine sulfate tab 0.125 mg (Levsin)................. 70
hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl)......... 70
hyoscyamine sulfate tab sr 12hr 0.375 mg
(Levbid)........................................................................... 70
HYPERSAL -sodium chloride soln nebu 3.5%..................63
HYPER-SAL -sodium chloride soln nebu 7%................... 62
HYPERSAL -sodium chloride soln nebu 7%.....................63
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
20 mg............................................................................ 102
30 mg............................................................................ 102
40 mg............................................................................ 102
60 mg............................................................................ 102
80 mg............................................................................ 102
100 mg.......................................................................... 102
120 mg.......................................................................... 102
HYZAAR -losartan potassium & hydrochlorothiazide tab
50-12.5 mg...................................................................... 50
100-12.5 mg.................................................................... 50
100-25 mg....................................................................... 50
I
ibandronate sodium tab 150 mg (base equivalent)
(Boniva).......................................................................... 36
IBRANCE -palbociclib cap 75 mg..................................... 15
IBRANCE -palbociclib cap 100 mg................................... 15
IBRANCE -palbociclib cap 125 mg................................... 15
IBUDONE -hydrocodone-ibuprofen tab 10-200 mg........ 102
IBUPROFEN COMFORT PAC -ibuprofen tab 800 mg &
ibuprofen susp 100 mg/5ml.......................................... 109
ibuprofen tab 400 mg.................................................... 109
ibuprofen tab 600 mg.................................................... 109
ibuprofen tab 800 mg.................................................... 109
ICAR -carbonyl iron chew tab 15 mg (elemental
iron)................................................................................135
ICAR-C PLUS -iron-vit c-vit b12-folic acid tab
100-250-0.025-1 mg..................................................... 135
ICAR PEDIATRIC -carbonyl iron susp 15 mg/1.25ml
(elemental iron)............................................................. 135
IC 400 -ibuprofen tab 400 mg & caffeine-vitamins cap
kit................................................................................... 109
IC 800 -ibuprofen tab 800 mg & caffeine-vitamins cap
kit................................................................................... 109
ICLUSIG -ponatinib hcl tab 15 mg (base equiv)............... 15
ICLUSIG -ponatinib hcl tab 45 mg (base equiv)............... 15
IDELVION -coagulation factor ix (recomb) (rix-fp) for inj
250 unit......................................................................... 141
500 unit......................................................................... 141
1000 unit....................................................................... 141
2000 unit....................................................................... 141
ILEVRO -nepafenac ophth susp 0.3%............................ 145
imatinib mesylate tab 100 mg (base equivalent)
(Gleevec)........................................................................ 15
imatinib mesylate tab 400 mg (base equivalent)
(Gleevec)........................................................................ 15
IMBRUVICA -ibrutinib cap 140 mg................................... 15
imipramine hcl tab 10 mg (Tofranil).............................. 81
imipramine pamoate cap 75 mg (Tofranil-pm)............. 81
imipramine pamoate cap 100 mg (Tofranil-pm)........... 81
imiquimod cream 5% (Aldara)...................................... 158
IMITREX STATDOSE REFILL -sumatriptan succinate
solution cartridge 4 mg/0.5ml....................................... 111
IMITREX STATDOSE REFILL -sumatriptan succinate
solution cartridge 6 mg/0.5ml....................................... 111
IMITREX STATDOSE SYSTEM -sumatriptan succinate
solution auto-injector 4 mg/0.5ml................................. 111
IMITREX STATDOSE SYSTEM -sumatriptan succinate
solution auto-injector 6 mg/0.5ml................................. 111
IMITREX -sumatriptan nasal spray 5 mg/act.................. 111
IMITREX -sumatriptan nasal spray 20 mg/act................ 111
IMITREX -sumatriptan succinate inj 6 mg/0.5ml............. 111
IMITREX -sumatriptan succinate tab 25 mg................... 111
IMITREX -sumatriptan succinate tab 50 mg................... 111
IMITREX -sumatriptan succinate tab 100 mg................. 111
209
2016
IMPAVIDO -miltefosine cap 50 mg.................................... 13
IMURAN -azathioprine tab 50 mg................................... 172
INATAL ADVANCE -prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg...................................................................125
INATAL GT -prenatal vit w/ dss-iron carbonyl-fa tab 90-1
mg.................................................................................. 125
INATAL ULTRA -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg......................................................................... 125
IN-CHECK DIAL INSPIRATORY -respiratory therapy
IN-CHECK INSPIRATORY FLOW -respiratory therapy
INCRELEX -mecasermin inj 40 mg/4ml (10 mg/ml)..........36
INCRUSE ELLIPTA -umeclidinium br aero powd breath
act 62.5 mcg/inh (base eq)............................................ 66
indapamide tab 1.25 mg..................................................54
indapamide tab 2.5 mg.................................................... 54
INDERAL LA -propranolol hcl cap sr 24hr 60 mg............. 41
INDERAL LA -propranolol hcl cap sr 24hr 80 mg............. 41
INDERAL LA -propranolol hcl cap sr 24hr 120 mg........... 41
INDERAL LA -propranolol hcl cap sr 24hr 160 mg........... 41
INDERAL XL -propranolol hcl sustained-release beads
cap sr 24hr 80 mg.......................................................... 41
INDERAL XL -propranolol hcl sustained-release beads
cap sr 24hr 120 mg........................................................ 41
INDOCIN -indomethacin suppos 50 mg..........................109
INDOCIN -indomethacin susp 25 mg/5ml....................... 109
indomethacin cap cr 75 mg.......................................... 109
indomethacin cap 25 mg.............................................. 109
indomethacin cap 50 mg.............................................. 109
INFANATE BALANCE -prenatal w/o a w/fe cbn-dss-fa-dha
cap 29-1-265 mg.......................................................... 125
INFLAMMA-K KIT -diclofenac td soln 1.5% & camphmen-methyl sal patch kit.............................................. 158
INLYTA -axitinib tab 1 mg.................................................. 15
INLYTA -axitinib tab 5 mg.................................................. 15
INNOPRAN XL -propranolol hcl sustained-release beads
cap sr 24hr 80 mg.......................................................... 41
INNOPRAN XL -propranolol hcl sustained-release beads
cap sr 24hr 120 mg........................................................ 41
INNOSPIRE REPLACEMENT FIL -respiratory therapy
supplies - misc.............................................................. 169
INOVA 4/1 ACNE CONTROL TH -benzoyl perox pad 4%
& salicylic ac pad 1% & vit e 5% kit.............................158
INOVA 8/2 ACNE CONTROL TH -benzoyl perox pad 8%
& salicylic ac pad 2% & vit e 5% kit.............................158
INOVA -benzoyl peroxide pad 4% & vitamin e topical 5%
kit................................................................................... 158
INOVA -benzoyl peroxide pad 8% & vitamin e topical 5%
kit................................................................................... 158
INSPRA -eplerenone tab 25 mg....................................... 50
INSPRA -eplerenone tab 50 mg....................................... 50
INSTA-GLUCOSE -glucose gel 77.4%............................. 28
INSULIN PEN NEEDLES – VARIOUS............................ 169
INSULIN SYRINGES – VARIOUS...................................169
INTEGRA F -fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe)................................... 135
INTEGRA PLUS -fe fum-iron polysacch complex-fa-b
complex-c-biotin cap..................................................... 135
INTELENCE -etravirine tab 25 mg...................................... 9
INTELENCE -etravirine tab 100 mg.................................... 9
INTELENCE -etravirine tab 200 mg.................................... 9
INTERMEZZO -zolpidem tartrate sl tab 1.75 mg.............. 89
INTERMEZZO -zolpidem tartrate sl tab 3.5 mg................ 89
INTRON A -interferon alfa-2b for inj 10000000 unit.......... 15
INTRON A -interferon alfa-2b inj 6000000 unit/ml............ 15
INTRON A -interferon alfa-2b inj 10000000 unit/ml.......... 15
INTRON A W/DILUENT -interferon alfa-2b for inj
10000000 unit................................................................. 16
18000000 unit................................................................. 16
50000000 unit................................................................. 16
INTUNIV -guanfacine hcl tab sr 24hr 1 mg (base
equiv)............................................................................... 92
equiv)............................................................................... 92
equiv)............................................................................... 92
equiv)............................................................................... 92
INVEGA -paliperidone tab sr 24hr 1.5 mg........................ 85
INVEGA -paliperidone tab sr 24hr 3 mg........................... 85
INVIRASE -saquinavir mesylate cap 200 mg..................... 9
INVIRASE -saquinavir mesylate tab 500 mg...................... 9
INVOKAMET -canagliflozin-metformin hcl tab 50-500
mg.................................................................................... 28
mg.................................................................................... 28
mg.................................................................................... 28
mg.................................................................................... 28
INVOKANA -canagliflozin tab 100 mg.............................. 28
INVOKANA -canagliflozin tab 300 mg.............................. 28
IODINE STRONG -iodine solution strong 5%
(lugol's).......................................................................... 132
IODINE TINCTURE -iodine tincture................................ 167
iodoquinol-hc cream 1%............................................... 158
iodoquinol-hydrocortisone in aloe vehicle cream
1-1.9% (Vytone)........................................................... 158
IOPIDINE -apraclonidine hcl ophth soln 0.5% (base
equivalent)..................................................................... 145
IOPIDINE -apraclonidine hcl ophth soln 1% (base
equivalent)..................................................................... 145
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml..... 66
ipratropium bromide inhal soln 0.02%.......................... 66
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
(Atrovent)....................................................................... 61
210
2016
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
(Atrovent)....................................................................... 61
IPRIVASK -desirudin for inj 15 mg.................................. 137
irbesartan-hydrochlorothiazide tab 150-12.5 mg
(Avalide)..........................................................................50
irbesartan-hydrochlorothiazide tab 300-12.5 mg
(Avalide)..........................................................................50
irbesartan tab 75 mg (Avapro)....................................... 50
irbesartan tab 150 mg (Avapro)..................................... 50
irbesartan tab 300 mg (Avapro)..................................... 50
IRENKA -duloxetine hcl enteric coated pellets cap 40
mg.................................................................................... 82
IRESSA -gefitinib tab 250 mg........................................... 16
IRON CHEWS PEDIATRIC -carbonyl iron chew tab 15 mg
(elemental iron)............................................................. 135
iron combination cap.................................................... 135
iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1
mg (Hematron-af)........................................................ 135
iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg
(Corvite 150)................................................................ 135
IROSPAN 24/6 -fe bisglyc-fe polys-succ acd-b cmplx-cca-fa tab ther pk........................................................... 135
IS 24/6 -fe bisglyc-fe polys-succ acd-b cmplx-c-ca-fa tab
ther pk........................................................................... 135
ISENTRESS -raltegravir potassium chew tab 25 mg (base
equiv)................................................................................. 9
ISENTRESS -raltegravir potassium chew tab 100 mg
(base equiv)...................................................................... 9
ISENTRESS -raltegravir potassium packet for susp 100
mg (base equiv)................................................................ 9
ISENTRESS -raltegravir potassium tab 400 mg (base
equiv)................................................................................. 9
isometheptene-caffeine-acetaminophen tab 65-20-325
mg (Prodrin)................................................................ 112
isometheptene-dichloral-acetaminophen cap
65-100-325 mg............................................................. 112
ISONIAZID -isoniazid syrup 50 mg/5ml.............................. 6
isoniazid tab 100 mg......................................................... 6
isoniazid tab 300 mg......................................................... 6
ISOPTO CARBACHOL -carbachol ophth soln 1.5%...... 145
ISOPTO CARBACHOL -carbachol ophth soln 3%......... 145
ISOPTO CARPINE -pilocarpine hcl ophth soln 1%........ 145
ISOPTO HOMATROPINE -homatropine hbr ophth soln
2%.................................................................................. 145
ISOPTO HOMATROPINE -homatropine hbr ophth soln
5%.................................................................................. 145
ISOPTO HYOSCINE -scopolamine hbr ophth soln
0.25%.............................................................................145
ISORDIL TITRADOSE -isosorbide dinitrate tab 5 mg.......39
ISORDIL TITRADOSE -isosorbide dinitrate tab 40
mg.................................................................................... 39
ISOSORBIDE DINITRATE ER -isosorbide dinitrate tab cr
40 mg.............................................................................. 39
ISOSORBIDE DINITRATE -isosorbide dinitrate tab 30
mg.................................................................................... 39
isosorbide dinitrate tab 10 mg....................................... 39
isosorbide dinitrate tab 20 mg....................................... 39
isosorbide dinitrate tab 5 mg (Isordil titradose).......... 39
isosorbide mononitrate tab 10 mg................................ 39
isosorbide mononitrate tab 20 mg................................ 39
isosorbide mononitrate tab sr 24hr 30 mg................... 39
isosorbide mononitrate tab sr 24hr 60 mg................... 39
isosorbide mononitrate tab sr 24hr 120 mg................. 39
isotretinoin cap 10 mg.................................................. 158
ISOXSUPRINE HCL -isoxsuprine hcl tab 20 mg.............. 59
isoxsuprine hcl tab 10 mg.............................................. 59
isradipine cap 2.5 mg...................................................... 43
isradipine cap 5 mg......................................................... 43
ISTALOL -timolol maleate ophth soln 0.5% (oncedaily).............................................................................. 145
itraconazole cap 100 mg (Sporanox).............................. 7
ivermectin tab 3 mg (Stromectol).................................. 12
IXINITY -coagulation factor ix (recombinant) for inj 500
unit................................................................................. 141
unit................................................................................. 141
unit................................................................................. 141
J
JADENU -deferasirox tab 90 mg..................................... 167
JADENU -deferasirox tab 180 mg................................... 167
JADENU -deferasirox tab 360 mg................................... 167
JAKAFI -ruxolitinib phosphate tab 5 mg (base
equivalent)....................................................................... 16
equivalent)....................................................................... 16
equivalent)....................................................................... 16
equivalent)....................................................................... 16
equivalent)....................................................................... 16
JALYN -dutasteride-tamsulosin hcl cap 0.5-0.4 mg.......... 77
JANUMET -sitagliptin-metformin hcl tab 50-500 mg......... 28
JANUMET -sitagliptin-metformin hcl tab 50-1000 mg....... 28
JANUMET XR -sitagliptin-metformin hcl tab sr 24hr
50-500 mg....................................................................... 29
50-1000 mg..................................................................... 29
100-1000 mg................................................................... 29
JANUVIA -sitagliptin phosphate tab 25 mg (base
equiv)............................................................................... 29
equiv)............................................................................... 29
equiv)............................................................................... 29
JARDIANCE -empagliflozin tab 10 mg............................. 29
211
2016
JARDIANCE -empagliflozin tab 25 mg............................. 29
JENTADUETO -linagliptin-metformin hcl tab 2.5-1000
mg.................................................................................... 29
mg.................................................................................... 29
mg.................................................................................... 29
JENTADUETO XR -linagliptin-metformin hcl tab sr 24hr
2.5-1000 mg.................................................................... 29
JENTADUETO XR -linagliptin-metformin hcl tab sr 24hr
5-1000 mg....................................................................... 29
JUBLIA -efinaconazole soln 10%.................................... 158
JUXTAPID -lomitapide mesylate cap 5 mg (base
equiv)............................................................................... 56
equiv)............................................................................... 56
equiv)............................................................................... 56
equiv)............................................................................... 56
equiv)............................................................................... 56
equiv)............................................................................... 56
K
KADIAN -morphine sulfate cap sr 24hr 10 mg................102
KADIAN -morphine sulfate cap sr 24hr 100 mg.............. 103
KADIAN -morphine sulfate cap sr 24hr 200 mg.............. 103
KALETRA -lopinavir-ritonavir soln 400-100 mg/5ml (80-20
mg/ml)................................................................................ 9
KALETRA -lopinavir-ritonavir tab 100-25 mg...................... 9
KALETRA -lopinavir-ritonavir tab 200-50 mg...................... 9
KALYDECO -ivacaftor packet 50 mg................................ 68
KALYDECO -ivacaftor packet 75 mg................................ 68
KALYDECO -ivacaftor tab 150 mg.................................... 68
KAPVAY -clonidine hcl tab sr 12hr 0.1 mg........................ 92
KARBINAL ER -carbinoxamine maleate extended release
susp 4 mg/5ml................................................................ 61
KAYEXALATE -sodium polystyrene sulfonate
powder........................................................................... 172
KAZANO -alogliptin-metformin hcl tab 12.5-1000 mg....... 29
KAZANO -alogliptin-metformin hcl tab 12.5-500 mg......... 29
KEFLEX -cephalexin cap 250 mg....................................... 2
KENALOG -triamcinolone acetonide aerosol soln 0.147
mg/gm............................................................................ 158
KENDALL AMORPHOUS HYDROGE -wound dressings gel.................................................................................. 158
KEPPRA -levetiracetam oral soln 100 mg/ml................. 115
KEPPRA -levetiracetam tab 250 mg............................... 115
KEPPRA -levetiracetam tab 1000 mg............................. 115
KEPPRA XR -levetiracetam tab sr 24hr 500 mg............ 115
KEPPRA XR -levetiracetam tab sr 24hr 750 mg............ 115
KERALAC -urea cream 47%........................................... 158
KERALYT -salicylic acid gel 6%...................................... 158
KERALYT SCALP -salicylic acid shampoo 6% & salicylic
acid gel 6% kit.............................................................. 158
KERLONE -betaxolol hcl tab 10 mg................................. 41
KERLONE -betaxolol hcl tab 20 mg................................. 41
KERYDIN -tavaborole soln 5%........................................158
KETEK -telithromycin tab 300 mg..................................... 13
KETEK -telithromycin tab 400 mg..................................... 13
ketoconazole cream 2%................................................ 158
ketoconazole foam 2% (Extina)................................... 158
ketoconazole shampoo 2% (Nizoral)........................... 158
ketoconazole tab 200 mg.................................................. 7
KETODAN KIT -ketoconazole foam 2% & cleanser
kit................................................................................... 158
ketoprofen cap 50 mg................................................... 109
ketoprofen cap 75 mg................................................... 109
KETOPROFEN ER -ketoprofen cap sr 24hr 200 mg...... 109
ketorolac tromethamine ophth soln 0.5%
(Acular)......................................................................... 146
ketorolac tromethamine ophth soln 0.4% (Acular
ls)................................................................................... 145
ketorolac tromethamine tab 10 mg............................. 109
KEVEYIS -dichlorphenamide tab 50 mg........................... 54
KHEDEZLA -desvenlafaxine tab sr 24hr 50 mg............... 82
KHEDEZLA -desvenlafaxine tab sr 24hr 100 mg............. 82
KINERET -anakinra subcutaneous soln prefilled syringe
100 mg/0.67ml.............................................................. 109
KITABIS PAK -tobramycin nebu soln 300 mg/5ml.............. 6
KLARON -sulfacetamide sodium lotion 10% (acne)....... 158
KLONOPIN -clonazepam tab 0.5 mg.............................. 115
KLONOPIN -clonazepam tab 1 mg................................. 115
KLONOPIN -clonazepam tab 2 mg................................. 115
KLOR-CON/25 -potassium chloride powder packet 25
meq................................................................................ 132
KLOR-CON M15 -potassium chloride microencapsulated
crys cr tab 15 meq....................................................... 132
KOATE-DVI -antihemophilic factor (human) for inj 250
unit................................................................................. 141
unit................................................................................. 141
unit................................................................................. 141
KOGENATE FS -antihemophilic factor (recombinant) for
inj kit 250 unit............................................................... 141
inj kit 500 unit............................................................... 141
inj kit 1000 unit............................................................. 141
inj kit 2000 unit............................................................. 141
212
2016
inj kit 3000 unit............................................................. 141
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 250 unit.................................. 141
(recombinant) for inj kit 500 unit.................................. 141
(recombinant) for inj kit 1000 unit................................ 141
KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr
2.5-1000 mg.................................................................... 29
5-500 mg......................................................................... 29
5-1000 mg....................................................................... 29
KORLYM -mifepristone tab 300 mg.................................. 29
KOVALTRY -antihemophilic factor (recombinant) for inj
250 unit......................................................................... 141
500 unit......................................................................... 141
1000 unit....................................................................... 141
2000 unit....................................................................... 142
3000 unit....................................................................... 142
K-PHOS NEUTRAL -pot phos monobasic w/sod phos di &
monobas tab 155-852-130mg...................................... 132
K-PHOS NO 2 -potassium & sodium acid phosphates tab
305-700 mg..................................................................... 77
K-PHOS -potassium phosphate monobasic tab 500
mg.................................................................................. 132
KRISTALOSE -lactulose oral crystal packet 10 gm.......... 68
KRISTALOSE -lactulose oral crystal packet 20 gm.......... 68
K-TAB -potassium chloride tab cr 10 meq...................... 132
K-TAB -potassium chloride tab cr 8 meq (600 mg)......... 132
K-TAB -potassium chloride tab cr 20 meq (1500 mg)..... 132
KUVAN -sapropterin dihydrochloride powder packet 100
mg.................................................................................... 36
KUVAN -sapropterin dihydrochloride powder packet 500
mg.................................................................................... 36
KUVAN -sapropterin dihydrochloride soluble tab 100
mg.................................................................................... 36
KYNAMRO -mipomersen sodium soln prefilled syringe
200 mg/ml....................................................................... 57
L
labetalol hcl tab 100 mg (Trandate)............................... 41
LAC-HYDRIN -lactic acid (ammonium lactate) cream
12%................................................................................158
LAC-HYDRIN -lactic acid (ammonium lactate) lotion
12%................................................................................158
LACRISERT -artificial tear ophth insert...........................146
lactic acid (ammonium lactate) cream 12% (Lachydrin).......................................................................... 158
lactic acid (ammonium lactate) lotion 10%.................158
lactic acid (ammonium lactate) lotion 12% (Lachydrin).......................................................................... 158
lactic acid w/ vitamin e cream 10%-3500
unit/30gm......................................................................158
lactulose (encephalopathy) solution 10 gm/15ml........ 74
lactulose solution 10 gm/15ml....................................... 68
LAMICTAL CHEWABLE DISPERS -lamotrigine tab
chewable dispersible 5 mg........................................... 115
LAMICTAL CHEWABLE DISPERS -lamotrigine tab
chewable dispersible 25 mg......................................... 115
LAMICTAL -lamotrigine tab 25 mg.................................. 115
LAMICTAL -lamotrigine tab 100 mg................................ 115
LAMICTAL ODT -lamotrigine orally disintegrating tab 25
mg.................................................................................. 115
mg.................................................................................. 115
mg.................................................................................. 115
mg.................................................................................. 115
LAMICTAL ODT -lamotrigine tab disp 25 (14) & 50 mg
(14) & 100 mg (7) kit.................................................... 115
LAMICTAL ODT -lamotrigine tab disp 25 mg (21) & 50 mg
(7) titration kit................................................................ 115
LAMICTAL ODT -lamotrigine tab disp 50 mg (42) & 100
mg (14) titration kit....................................................... 115
LAMICTAL STARTER/NOT TAKI -lamotrigine tab 25 mg
(42) & 100 mg (7) starter kit.........................................115
LAMICTAL STARTER/TAKING C -lamotrigine tab 25 mg
(84) & 100 mg (14) starter kit.......................................115
LAMICTAL STARTER/TAKING V -lamotrigine tab 25 mg
(35) starter kit............................................................... 115
LAMICTAL XR -lamotrigine tab sr 24hr 25 (14) & 50 mg
(14) & 100 mg(7) kit..................................................... 115
LAMICTAL XR -lamotrigine tab sr 24hr 50 (14) & 100
mg(14) & 200 mg(7) kit................................................ 116
LAMICTAL XR -lamotrigine tab sr 24hr 25 mg............... 116
LAMICTAL XR -lamotrigine tab sr 24hr 50 mg............... 116
LAMICTAL XR -lamotrigine tab sr 24hr 100 mg............. 116
LAMICTAL XR -lamotrigine tab sr 24hr 25 mg (21) & 50
mg (7) titration kit......................................................... 115
LAMISIL SPRAY -terbinafine hcl soln 1%....................... 158
LAMISIL -terbinafine hcl oral granules packet 125 mg....... 7
LAMISIL -terbinafine hcl oral granules packet 187.5
mg...................................................................................... 7
LAMISIL -terbinafine hcl tab 250 mg.................................. 7
lamivudine oral soln 10 mg/ml (Epivir)........................... 9
lamivudine tab 150 mg (Epivir)........................................ 9
213
2016
lamivudine tab 300 mg (Epivir)........................................ 9
lamivudine tab 100 mg (hbv) (Epivir hbv)....................... 9
lamivudine-zidovudine tab 150-300 mg (Combivir)....... 9
lamotrigine orally disintegrating tab 25 mg (Lamictal
odt)................................................................................ 116
odt)................................................................................ 116
odt)................................................................................ 116
odt)................................................................................ 116
lamotrigine tab chewable dispersible 5 mg (Lamictal
chewable di)................................................................ 116
lamotrigine tab chewable dispersible 25 mg (Lamictal
chewable di)................................................................ 116
lamotrigine tab disp 25 (14) & 50 mg (14) & 100 mg (7)
kit (LAMICTAL ODT)................................................... 116
lamotrigine tab disp 25 mg (21) & 50 mg (7) titration
kit (LAMICTAL ODT)................................................... 116
lamotrigine tab disp 50 mg (42) & 100 mg (14) titration
kit (LAMICTAL ODT)................................................... 116
lamotrigine tab 25 mg (Lamictal)................................. 116
lamotrigine tab 100 mg (Lamictal)............................... 116
lamotrigine tab sr 24hr 25 mg (Lamictal xr)............... 116
lamotrigine tab sr 24hr 50 mg (Lamictal xr)............... 116
lamotrigine tab sr 24hr 100 mg (Lamictal xr)............. 116
LANCETS – VARIOUS.................................................... 169
LANOXIN -digoxin tab 62.5 mcg (0.0625 mg).................. 39
LANOXIN -digoxin tab 125 mcg (0.125 mg)..................... 39
LANOXIN -digoxin tab 187.5 mcg (0.1875 mg)................ 39
LANOXIN -digoxin tab 250 mcg (0.25 mg)....................... 39
lansoprazole cap delayed release 15 mg
(Prevacid)....................................................................... 70
lansoprazole cap delayed release 30 mg
(Prevacid)....................................................................... 70
LANTUS -insulin glargine inj 100 unit/ml.......................... 32
LANTUS SOLOSTAR -insulin glargine soln pen-injector
100 unit/ml.......................................................................32
LASIX -furosemide tab 20 mg........................................... 54
LASTACAFT -alcaftadine ophth soln 0.25%................... 146
latanoprost ophth soln 0.005% (Xalatan).................... 146
LATRIX XM -urea in zinc undecylenate-lactic acid vehicle
emulsion 45%............................................................... 158
LATUDA -lurasidone hcl tab 20 mg...................................85
LATUDA -lurasidone hcl tab 120 mg.................................86
LAVARE WOUND WASH -wound cleansers - gel.......... 158
LAZANDA -fentanyl citrate nasal spray 100 mcg/act (base
equiv)............................................................................. 103
equiv)............................................................................. 103
equiv)............................................................................. 103
leflunomide tab 10 mg (Arava)..................................... 109
leflunomide tab 20 mg (Arava)..................................... 109
LENVIMA 14MG DAILY DOSE -lenvatinib cap therapy
pack 10 & 4 mg (14 mg daily dose)............................... 16
pack 10 & 4 (2) mg (18 mg daily dose)......................... 16
pack 10 (2) & 4 mg (24 mg daily dose)......................... 16
pack 10 mg (10 mg daily dose)..................................... 16
pack 10 (2) mg (20 mg daily dose)................................ 16
pack 4 (2) mg (8 mg daily dose).................................... 16
LESCOL XL -fluvastatin sodium tab sr 24 hr 80 mg......... 57
LETAIRIS -ambrisentan tab 5 mg..................................... 59
LETAIRIS -ambrisentan tab 10 mg................................... 59
letrozole tab 2.5 mg (Femara)........................................ 16
LEUCOVORIN CALCIUM -leucovorin calcium tab 10
mg.................................................................................... 16
LEUCOVORIN CALCIUM -leucovorin calcium tab 15
mg.................................................................................... 16
leucovorin calcium tab 5 mg.......................................... 16
leucovorin calcium tab 25 mg........................................ 16
LEUKERAN -chlorambucil tab 2 mg................................. 16
LEUKINE -sargramostim lyophilized for inj 250 mcg...... 135
leuprolide acetate inj kit 5 mg/ml.................................. 16
LEVACET -aspirin-apap-salicylamide-caffeine tab
500-250-150-32.5 mg..................................................... 99
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base
equiv) (Xopenex concentrate)..................................... 66
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
(Xopenex)....................................................................... 66
(Xopenex)....................................................................... 66
(Xopenex)....................................................................... 66
LEVAQUIN -levofloxacin tab 250 mg.................................. 6
LEVATOL -penbutolol sulfate tab 20 mg........................... 41
LEVBID -hyoscyamine sulfate tab sr 12hr 0.375 mg........ 70
LEVEMIR FLEXTOUCH -insulin detemir soln pen-injector
100 unit/ml.......................................................................32
LEVEMIR -insulin detemir inj 100 unit/ml..........................32
levetiracetam oral soln 100 mg/ml (Keppra)...............116
levetiracetam tab 250 mg (Keppra)............................. 116
levetiracetam tab 1000 mg (Keppra)........................... 116
levetiracetam tab sr 24hr 500 mg (Keppra xr)............ 116
214
2016
levetiracetam tab sr 24hr 750 mg (Keppra xr)............ 116
LEVITRA– Benefit Limits may apply -vardenafil hcl tab 2.5
mg.................................................................................... 60
LEVITRA– Benefit Limits may apply -vardenafil hcl tab 5
mg.................................................................................... 60
mg.................................................................................... 60
mg.................................................................................... 60
levobunolol hcl ophth soln 0.5% (Betagan)............... 146
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)..... 36
levocarnitine tab 330 mg (Carnitor)............................... 36
levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5
mg/ml) (Xyzal)................................................................ 61
levocetirizine dihydrochloride tab 5 mg (Xyzal)...........61
levofloxacin ophth soln 0.5%....................................... 146
levofloxacin oral soln 25 mg/ml (Levaquin)................... 6
levofloxacin tab 250 mg (Levaquin)................................ 6
levonorgestrel & ethinyl estradiol (91-day) tab
0.15-0.03 mg.................................................................. 24
levonorgestrel & ethinyl estradiol tab 0.1 mg-20
mcg................................................................................. 24
levonorgestrel & ethinyl estradiol tab 0.15 mg-30
mcg................................................................................. 24
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg............................... 24
levonorgestrel-ethinyl estradiol (continuous) tab
90-20 mcg.......................................................................24
levonorgestrel tab 1.5 mg............................................... 24
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab
0.01mg(7) (Loseasonique)........................................... 24
levonorg-eth est tab 0.15-0.03mg(84) & eth est tab
0.01mg(7) (Seasonique)............................................... 24
LEVORPHANOL TARTRATE -levorphanol tartrate tab 2
mg.................................................................................. 103
levothyroxine sodium tab 25 mcg (Synthroid)............. 32
levothyroxine sodium tab 100 mcg (Synthroid)........... 32
LEVSIN/SL -hyoscyamine sulfate tab sl 0.125 mg........... 70
LEVSIN -hyoscyamine sulfate tab 0.125 mg.................... 70
LEVULAN KERASTICK -aminolevulinic acid hcl for soln
20% (stick applicator)................................................... 159
LEXAPRO -escitalopram oxalate soln 5 mg/5ml (base
equiv)............................................................................... 82
LEXAPRO -escitalopram oxalate tab 5 mg (base
equiv)............................................................................... 82
equiv)............................................................................... 82
equiv)............................................................................... 82
LEXIVA -fosamprenavir calcium susp 50 mg/ml (base
equiv)................................................................................. 9
LEXIVA -fosamprenavir calcium tab 700 mg (base
equiv)................................................................................. 9
LEXUSS 210 -chlorpheniramine w/ codeine liquid 2-10
mg/5ml............................................................................. 63
LIALDA -mesalamine tab delayed release 1.2 gm........... 74
LIBRAX -chlordiazepoxide hcl-clidinium bromide cap
5-2.5 mg.......................................................................... 70
lidocaine hcl gel 2%...................................................... 159
LIDOCAINE HCL-HYDROCORTIS -lidocainehydrocortisone acetate rectal gel 2.8-0.55%............... 151
LIDOCAINE HCL -lidocaine hcl laryngotracheal soln
4%.................................................................................. 149
lidocaine hcl soln 4% (Xylocaine)............................... 159
lidocaine hcl viscous soln 2%..................................... 149
lidocaine-hydrocortisone acetate rectal cream
3-0.5%........................................................................... 151
lidocaine-hydrocortisone acetate rectal cream kit
2-2%.............................................................................. 151
3-0.5%........................................................................... 151
3-1%.............................................................................. 151
lidocaine-hydrocortisone acetate rectal gel kit
3-2.5%........................................................................... 151
lidocaine oint 5%........................................................... 159
lidocaine patch 5% (Lidoderm).................................... 159
lidocaine-prilocaine cream 2.5-2.5% (Emla)............... 159
lidocaine-prilocaine cream kit 2.5-2.5%...................... 159
LIDODERM -lidocaine patch 5%..................................... 159
lindane shampoo 1%..................................................... 159
linezolid for susp 100 mg/5ml (Zyvox).......................... 13
linezolid tab 600 mg (Zyvox).......................................... 13
LINZESS -linaclotide cap 145 mcg................................... 74
LINZESS -linaclotide cap 290 mcg................................... 74
liothyronine sodium tab 5 mcg (Cytomel).................... 32
liothyronine sodium tab 25 mcg (Cytomel).................. 32
liothyronine sodium tab 50 mcg (Cytomel).................. 32
LIPITOR -atorvastatin calcium tab 10 mg (base
equivalent)....................................................................... 57
equivalent)....................................................................... 57
equivalent)....................................................................... 57
equivalent)....................................................................... 57
LIPOFEN -fenofibrate cap 50 mg...................................... 57
LIPOFEN -fenofibrate cap 150 mg.................................... 57
lisinopril & hydrochlorothiazide tab 10-12.5 mg
(Zestoretic)..................................................................... 50
lisinopril & hydrochlorothiazide tab 20-12.5 mg
(Zestoretic)..................................................................... 50
215
2016
lisinopril & hydrochlorothiazide tab 20-25 mg
(Zestoretic)..................................................................... 50
lisinopril tab 5 mg (Prinivil)............................................ 50
lisinopril tab 10 mg (Prinivil).......................................... 50
lisinopril tab 20 mg (Prinivil).......................................... 50
lisinopril tab 2.5 mg (Zestril).......................................... 50
lisinopril tab 30 mg (Zestril)........................................... 50
lisinopril tab 40 mg (Zestril)........................................... 50
LISTERINE ESSENTIAL CARE -sod monofluorophospheucal-men-methyl sal-thymol gel 0.76%...................... 149
LISTERINE RESTORING -sodium fluoride rinse 0.0221%
(0.01% f)........................................................................149
LISTERINE SMART RINSE -sodium fluoride rinse
0.0221% (0.01% f)........................................................ 149
LISTERINE TOTAL CARE PLUS -sodium fluoride rinse
0.0221% (0.01% f)........................................................ 149
LISTERINE TOTAL CARE -sodium fluoride rinse 0.0221%
(0.01% f)........................................................................149
LISTERINE TOTAL CARE ZERO -sodium fluoride rinse
0.02%.............................................................................149
LISTERINE WHITENING/RESTO -sodium fluoride rinse
0.0221% (0.01% f)........................................................ 149
LITETOUCH MASK LARGE -respiratory therapy supplies
- misc............................................................................. 169
LITETOUCH MASK MEDIUM -respiratory therapy
supplies - misc.............................................................. 169
LITETOUCH MASK SMALL -respiratory therapy supplies
- misc............................................................................. 169
lithium carbonate cap 300 mg....................................... 86
lithium carbonate cap 150 mg (Lithium carbonate)..... 86
lithium carbonate cap 600 mg (Lithium carbonate)..... 86
LITHIUM CARBONATE -lithium carbonate cap 150
mg.................................................................................... 86
LITHIUM CARBONATE -lithium carbonate cap 600
mg.................................................................................... 86
lithium carbonate tab cr 450 mg.................................... 86
lithium carbonate tab cr 300 mg (Lithobid).................. 86
lithium carbonate tab 300 mg........................................ 86
LITHIUM -lithium oral solution 8 meq/5ml......................... 86
LITHOBID -lithium carbonate tab cr 300 mg..................... 86
LITHOSTAT -acetohydroxamic acid tab 250 mg............... 77
LIVALO -pitavastatin calcium tab 1 mg (base equiv)........ 57
LOCOID -hydrocortisone butyrate cream 0.1%.............. 159
LOCOID -hydrocortisone butyrate lotion 0.1%................159
LOCOID -hydrocortisone butyrate oint 0.1%.................. 159
LOCOID -hydrocortisone butyrate soln 0.1%..................159
LOCOID LIPOCREAM -hydrocortisone butyrate
hydrophilic lipo base cream 0.1%................................ 159
LODOSYN -carbidopa tab 25 mg................................... 119
LOESTRIN 1.5/30-21 -norethindrone ace & ethinyl
estradiol tab 1.5 mg-30 mcg.......................................... 24
LOESTRIN 1/20-21 -norethindrone ace & ethinyl estradiol
tab 1 mg-20 mcg............................................................ 24
LOESTRIN FE 1.5/30 -norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg...................................... 24
LOESTRIN FE 1/20 -norethindrone ace & ethinyl
estradiol-fe tab 1 mg-20 mcg......................................... 24
LOFIBRA -fenofibrate micronized cap 67 mg................... 57
LOFIBRA -fenofibrate micronized cap 134 mg................. 57
LOFIBRA -fenofibrate micronized cap 200 mg................. 57
LOFIBRA -fenofibrate tab 54 mg...................................... 57
LOFIBRA -fenofibrate tab 160 mg.................................... 57
LO LOESTRIN FE -norethin-eth estradiol-fe tab 1 mg-10
mcg (24)/10 mcg (2)....................................................... 24
LOMOTIL -diphenoxylate w/ atropine tab 2.5-0.025
mg.................................................................................... 68
LONSURF -trifluridine-tipiracil tab 15-6.14 mg................. 16
LONSURF -trifluridine-tipiracil tab 20-8.19 mg................. 16
loperamide hcl cap 2 mg................................................ 68
LOPID -gemfibrozil tab 600 mg......................................... 57
LOPRESSOR HCT -metoprolol & hydrochlorothiazide tab
50-25 mg......................................................................... 50
LOPRESSOR HCT -metoprolol & hydrochlorothiazide tab
100-25 mg....................................................................... 50
LOPRESSOR -metoprolol tartrate tab 50 mg................... 41
LOPRESSOR -metoprolol tartrate tab 100 mg................. 41
LOPROX SHAMPOO -ciclopirox shampoo 1%.............. 159
lorazepam conc 2 mg/ml (Lorazepam intensol)........... 79
lorazepam tab 0.5 mg (Ativan)....................................... 79
lorazepam tab 1 mg (Ativan).......................................... 79
lorazepam tab 2 mg (Ativan).......................................... 79
LORTAB -hydrocodone-acetaminophen soln 10-300
mg/15ml......................................................................... 103
LORTUSS EX -pseudoephedrine w/ cod-gg liquid
30-10-100 mg/5ml........................................................... 63
LORZONE -chlorzoxazone tab 375 mg.......................... 122
LORZONE -chlorzoxazone tab 750 mg.......................... 122
losartan potassium & hydrochlorothiazide tab 50-12.5
mg (Hyzaar)....................................................................50
losartan potassium & hydrochlorothiazide tab
100-12.5 mg (Hyzaar).................................................... 50
losartan potassium & hydrochlorothiazide tab 100-25
mg (Hyzaar)....................................................................50
losartan potassium tab 25 mg (Cozaar)........................ 50
losartan potassium tab 50 mg (Cozaar)........................ 50
losartan potassium tab 100 mg (Cozaar)...................... 50
LOSEASONIQUE -levonorg-eth est tab 0.1-0.02mg(84) &
eth est tab 0.01mg(7)..................................................... 24
LOTEMAX -loteprednol etabonate ophth gel 0.5%......... 146
LOTEMAX -loteprednol etabonate ophth oint 0.5%........ 146
LOTEMAX -loteprednol etabonate ophth susp 0.5%...... 146
LOTENSIN -benazepril hcl tab 10 mg.............................. 50
LOTENSIN HCT -benazepril & hydrochlorothiazide tab
10-12.5 mg...................................................................... 50
20-12.5 mg...................................................................... 50
20-25 mg......................................................................... 50
LOTREL -amlodipine besylate-benazepril hcl cap 5-10
mg.................................................................................... 50
216
2016
mg.................................................................................... 50
mg.................................................................................... 50
mg.................................................................................... 50
LOTRISONE -clotrimazole w/ betamethasone cream
1-0.05%......................................................................... 159
LOUTREX -antiseborrheic products misc - cream.......... 159
lovastatin tab 10 mg........................................................ 57
lovastatin tab 20 mg........................................................ 57
lovastatin tab 40 mg (Mevacor)..................................... 57
LOVAZA -omega-3-acid ethyl esters cap 1 gm.................57
LOVENOX -enoxaparin sodium inj 30 mg/0.3ml.............137
LOVENOX -enoxaparin sodium inj 100 mg/ml................138
LOVENOX -enoxaparin sodium inj 120 mg/0.8ml...........138
LOVENOX -enoxaparin sodium inj 150 mg/ml................138
LOVENOX -enoxaparin sodium inj 300 mg/3ml..............138
loxapine succinate cap 5 mg......................................... 86
loxapine succinate cap 10 mg....................................... 86
LOZI-FLUR -sodium fluoride lozenge 1 mg f (from 2.2 mg
naf)................................................................................. 132
LUGOLS STRONG IODINE -iodine solution.................. 167
LUMIGAN -bimatoprost ophth soln 0.01%...................... 146
LUNESTA -eszopiclone tab 1 mg......................................89
LUPANETA PACK -leuprolide (1 mon) inj 3.75 mg &
norethindrone tab 5 mg kit............................................. 36
LUPANETA PACK -leuprolide (3 mon) inj 11.25 mg &
norethindrone tab 5 mg kit............................................. 37
LUPRON DEPOT -leuprolide acetate for inj kit 3.75
mg.................................................................................... 16
LUPRON DEPOT -leuprolide acetate for inj kit 7.5
mg.................................................................................... 16
LUPRON DEPOT -leuprolide acetate (3 month) for inj kit
11.25 mg......................................................................... 16
22.5 mg........................................................................... 16
30 mg.............................................................................. 16
45 mg.............................................................................. 16
LUPRON DEPOT-PED -leuprolide acetate for inj pediatric
kit 7.5 mg........................................................................ 37
kit 11.25 mg.................................................................... 37
kit 15 mg......................................................................... 37
LUPRON DEPOT-PED -leuprolide acetate (3 month) for
inj pediatric kit 11.25 mg................................................ 37
LUPRON DEPOT-PED -leuprolide acetate (3 month) for
inj pediatric kit 30 mg..................................................... 37
LURIDE -sodium fluoride chew tab 0.25 mg f (from 0.55
mg naf).......................................................................... 132
LURIDE -sodium fluoride chew tab 0.5 mg f (from 1.1 mg
naf)................................................................................. 132
LURIDE -sodium fluoride chew tab 1 mg f (from 2.2 mg
naf)................................................................................. 132
LURIDE -sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml
naf)................................................................................. 132
LUXIQ -betamethasone valerate aerosol foam
0.12%.............................................................................159
LUZU -luliconazole cream 1%......................................... 159
LYNPARZA -olaparib cap 50 mg....................................... 16
LYRICA -pregabalin cap 25 mg.......................................116
LYRICA -pregabalin cap 100 mg.....................................116
LYRICA -pregabalin soln 20 mg/ml................................. 116
LYSODREN -mitotane tab 500 mg....................................16
LYSTEDA -tranexamic acid tab 650 mg......................... 138
M
MACNATAL CN DHA -prenatal w/o a w/fe cbn-dss-fa-dha
cap 28-1-250 mg.......................................................... 125
MACROBID -nitrofurantoin monohydrate macrocrystalline
cap 100 mg..................................................................... 75
MACRODANTIN -nitrofurantoin macrocrystalline cap 25
mg.................................................................................... 75
mg.................................................................................... 75
mg.................................................................................... 75
MAGNEBIND 400 -magnesium-calcium-folic acid tab
400-200-1 mg................................................................132
MALARONE -atovaquone-proguanil hcl tab 62.5-25
mg.................................................................................... 12
MALARONE -atovaquone-proguanil hcl tab 250-100
mg.................................................................................... 12
malathion lotion 0.5% (Ovide)...................................... 159
MAPROTILINE HCL -maprotiline hcl tab 25 mg............... 82
MAR-COF BP -pseudoephedrine-bromphen-codeine liqd
30-2-7.5 mg/5ml.............................................................. 63
MAR-COF CG EXPECTORANT -guaifenesin-codeine
liquid 225-7.5 mg/5ml..................................................... 63
MARINOL -dronabinol cap 2.5 mg.................................... 72
MARINOL -dronabinol cap 5 mg....................................... 72
MARINOL -dronabinol cap 10 mg..................................... 72
MARNATAL-F -prenatal w/o vit a w/ fe polysac cmplx-fa
cap 60-1 mg.................................................................. 125
MARPLAN -isocarboxazid tab 10 mg............................... 82
217
2016
MATULANE -procarbazine hcl cap 50 mg........................ 16
MAVIK -trandolapril tab 1 mg............................................ 51
MAVIK -trandolapril tab 2 mg............................................ 51
MAXALT-MLT -rizatriptan benzoate oral disintegrating tab
5 mg (base eq)............................................................. 112
MAXALT-MLT -rizatriptan benzoate oral disintegrating tab
10 mg (base eq)........................................................... 112
MAXALT -rizatriptan benzoate tab 5 mg (base
equivalent)..................................................................... 112
MAXALT -rizatriptan benzoate tab 10 mg (base
equivalent)..................................................................... 112
MAXFE -iron-fa-vit b12-biotin-vit c-docusate-mg-zn tab
160-1 mg....................................................................... 135
MAXIDEX -dexamethasone ophth susp 0.1%................ 146
MAXITROL -neomycin-polymyxin-dexamethasone ophth
oint 0.1%....................................................................... 146
MAXITROL -neomycin-polymyxin-dexamethasone ophth
susp 0.1%..................................................................... 146
MAXZIDE -triamterene & hydrochlorothiazide tab 75-50
mg.................................................................................... 54
MAXZIDE-25 -triamterene & hydrochlorothiazide tab
37.5-25 mg...................................................................... 54
MB HYDROGEL -dermatological products misc - kit...... 159
meclizine hcl tab 12.5 mg............................................... 72
meclizine hcl tab 25 mg.................................................. 72
MECLOFENAMATE SODIUM -meclofenamate sodium
cap 50 mg..................................................................... 109
MECLOFENAMATE SODIUM -meclofenamate sodium
cap 100 mg................................................................... 109
MEDROL DOSEPAK -methylprednisolone tab therapy
pack 4 mg (21)............................................................... 19
MEDROL -methylprednisolone tab 2 mg.......................... 19
MEDROL -methylprednisolone tab 16 mg........................ 19
MEDROL -methylprednisolone tab 32 mg........................ 19
medroxyprogesterone acetate im susp 150 mg/ml
(Depo-provera contrac)................................................ 24
medroxyprogesterone acetate tab 2.5 mg
(Provera)......................................................................... 26
medroxyprogesterone acetate tab 5 mg (Provera)...... 26
medroxyprogesterone acetate tab 10 mg
(Provera)......................................................................... 26
mefenamic acid cap 250 mg (Ponstel)........................ 109
mefloquine hcl tab 250 mg............................................. 12
MEGACE ES -megestrol acetate susp 625 mg/5ml......... 26
MEGACE ORAL -megestrol acetate susp 40 mg/ml........ 16
megestrol acetate susp 625 mg/5ml (Megace es)........ 26
megestrol acetate susp 40 mg/ml (Megace oral)......... 16
megestrol acetate tab 20 mg.......................................... 16
megestrol acetate tab 40 mg.......................................... 16
MEKINIST -trametinib dimethyl sulfoxide tab 0.5 mg
(base equivalent)............................................................ 16
MEKINIST -trametinib dimethyl sulfoxide tab 2 mg (base
equivalent)....................................................................... 16
MELOXICAM COMFORT PAC -meloxicam tab 15 mg &
meloxicam tab 7.5 mg (Mobic)..................................... 109
meloxicam tab 15 mg (Mobic)...................................... 109
memantine hcl oral solution 2 mg/ml (Namenda)........ 96
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak
(Namenda titration pa)................................................. 96
memantine hcl tab 5 mg (Namenda)............................. 96
memantine hcl tab 10 mg (Namenda)........................... 96
M-END MAX D -pseudoephedrine-dexbromphen-codeine
liqd 20-0.667-6 mg/5ml................................................... 63
M-END PE -phenylephrine-bromphen w/ codeine liqd
3.33-1.33-6.33 mg/5ml....................................................63
MENEST -esterified estrogens tab 0.3 mg....................... 23
MENEST -esterified estrogens tab 0.625 mg................... 23
MENEST -esterified estrogens tab 1.25 mg..................... 23
MENEST -esterified estrogens tab 2.5 mg....................... 23
MENOPUR– Benefit Limits may apply -menotropins for
subcutaneous inj 75 unit................................................ 37
MENOSTAR -estradiol td patch weekly 14 mcg/24hr....... 23
MENTAX -butenafine hcl cream 1%................................159
MEPERIDINE HCL/PROMETHAZI -meperidine w/
promethazine cap 50-25 mg........................................ 103
MEPERIDINE HCL -meperidine hcl oral soln 50
mg/5ml........................................................................... 103
meperidine hcl tab 50 mg (Demerol)........................... 103
meperidine hcl tab 100 mg (Demerol)......................... 103
MEPHYTON -phytonadione tab 5 mg............................. 123
meprobamate tab 200 mg............................................... 79
meprobamate tab 400 mg............................................... 79
MEPRON -atovaquone susp 750 mg/5ml......................... 13
mercaptopurine tab 50 mg............................................. 16
mesalamine enema 4 gm................................................ 74
mesalamine rectal enema 4 gm & cleanser wipe kit
(Rowasa).........................................................................74
MESNEX -mesna tab 400 mg........................................... 17
MESTINON -pyridostigmine bromide syrup 60
mg/5ml........................................................................... 122
MESTINON -pyridostigmine bromide tab 60 mg.............122
MESTINON TIMESPAN -pyridostigmine bromide tab cr
180 mg.......................................................................... 122
METADATE CD -methylphenidate hcl cap cr 10 mg
(cd)................................................................................... 92
(cd)................................................................................... 92
(cd)................................................................................... 92
(cd)................................................................................... 92
(cd)................................................................................... 92
(cd)................................................................................... 92
METAPROTERENOL SULFATE -metaproterenol sulfate
syrup 10 mg/5ml............................................................. 66
tab 10 mg........................................................................ 66
tab 20 mg........................................................................ 66
218
2016
METAXALONE -metaxalone tab 400 mg........................ 122
metaxalone tab 800 mg (Skelaxin).............................. 122
metformin hcl tab 500 mg (Glucophage)...................... 29
metformin hcl tab 850 mg (Glucophage)...................... 29
metformin hcl tab 1000 mg (Glucophage).................... 29
metformin hcl tab sr 24hr 500 mg (Glucophage xr)..... 29
metformin hcl tab sr 24hr 750 mg (Glucophage xr)..... 29
metformin hcl tab sr 24hr modified release 500 mg
(Glumetza)...................................................................... 29
metformin hcl tab sr 24hr modified release 1000 mg
(Glumetza)...................................................................... 29
metformin hcl tab sr 24hr osmotic 500 mg
(Fortamet)....................................................................... 29
metformin hcl tab sr 24hr osmotic 1000 mg
(Fortamet)....................................................................... 29
methadone hcl conc 10 mg/ml (Methadose).............. 103
METHADONE HCL -methadone hcl soln 5 mg/5ml........103
METHADONE HCL -methadone hcl soln 10 mg/5ml......103
methadone hcl soln 5 mg/5ml (Methadone hcl)......... 103
methadone hcl soln 10 mg/5ml (Methadone hcl)....... 103
methadone hcl tab for oral susp 40 mg...................... 103
methadone hcl tab 10 mg (Dolophine)........................ 103
methadone hcl tab 5 mg (Dolophine hcl)................... 103
METHADOSE -methadone hcl conc 10 mg/ml............... 103
METHADOSE SUGAR-FREE -methadone hcl conc 10
mg/ml............................................................................. 103
methamphetamine hcl tab 5 mg (Desoxyn).................. 92
methazolamide tab 25 mg (Neptazane)......................... 54
methazolamide tab 50 mg (Neptazane)......................... 54
methenamine hippurate tab 1 gm (Hiprex)................... 75
methenamine-hyoscamine-meth blue-sod phos cap
120 mg............................................................................ 75
methenamine-hyoscamine-meth blue-sod phos tab
81.6 mg (Urogesic-blue)............................................... 75
methenamine-hyosc-meth blue-benz acid-phenyl sal
tab 81.6mg (Prosed/ds)................................................ 75
methenamine-hyosc-meth blue-sod phos-phen sal
cap 118 mg.................................................................... 75
methenamine-hyosc-meth blue-sod phos-phen sal
cap 120 mg.................................................................... 75
methenamine-hyosc-meth blue-sod phos-phen sal tab
81 mg.............................................................................. 75
methenamine-hyos-meth blue-sod phos-phen sal tab
81.6 mg........................................................................... 75
METHENAMINE MANDELATE -methenamine mandelate
tab 0.5 gm....................................................................... 75
methenamine mandelate tab 1 gm................................ 75
methimazole tab 5 mg (Tapazole).................................. 32
methimazole tab 10 mg (Tapazole)................................ 32
METHITEST -methyltestosterone oral tab 10 mg............. 21
methocarbamol tab 750 mg (Robaxin-750).................122
methocarbamol tab 500 mg (Robaxin)........................ 122
methotrexate sodium for inj 1 gm................................. 17
methotrexate sodium inj 50 mg/2ml (25 mg/ml)........... 17
methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)...... 17
methotrexate sodium inj pf 100 mg/4ml (25 mg/
ml)................................................................................... 17
ml)................................................................................... 17
ml)................................................................................... 17
ml)................................................................................... 17
METHOTREXATE SODIUM -methotrexate sodium inj 250
mg/10ml (25 mg/ml)........................................................17
methotrexate sodium tab 2.5 mg (base equiv)............. 17
methoxsalen rapid cap 10 mg (Oxsoralen ultra)........ 159
methscopolamine bromide tab 2.5 mg (Pamine)......... 70
methscopolamine bromide tab 5 mg (Pamine
forte)................................................................................70
METHYCLOTHIAZIDE -methyclothiazide tab 5 mg..........54
METHYLDOPA/HYDROCHLOROTHI -methyldopa &
hydrochlorothiazide tab 250-15 mg................................ 51
METHYLDOPA/HYDROCHLOROTHI -methyldopa &
hydrochlorothiazide tab 250-25 mg................................ 51
methyldopa tab 250 mg.................................................. 51
methyldopa tab 500 mg.................................................. 51
methylergonovine maleate tab 0.2 mg.......................... 34
METHYLIN -methylphenidate hcl chew tab 2.5 mg.......... 92
METHYLIN -methylphenidate hcl chew tab 5 mg............. 92
METHYLIN -methylphenidate hcl chew tab 10 mg........... 92
METHYLIN -methylphenidate hcl soln 5 mg/5ml.............. 92
METHYLIN -methylphenidate hcl soln 10 mg/5ml............ 92
methylphenidate hcl cap cr 10 mg (cd) (Metadate
cd)................................................................................... 92
cd)................................................................................... 92
cd)................................................................................... 93
cd)................................................................................... 93
cd)................................................................................... 93
cd)................................................................................... 93
methylphenidate hcl cap sr 24hr 20 mg (la) (Ritalin
la)..................................................................................... 93
la)..................................................................................... 93
la)..................................................................................... 93
methylphenidate hcl chew tab 2.5 mg (Methylin)........ 93
methylphenidate hcl chew tab 5 mg (Methylin)........... 93
methylphenidate hcl chew tab 10 mg (Methylin)......... 93
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sa osm 18 mg................................................................. 93
sa osm 27 mg................................................................. 93
sa osm 36 mg................................................................. 93
sa osm 54 mg................................................................. 93
sr 24hr 18 mg................................................................. 93
219
2016
sr 24hr 27 mg................................................................. 93
sr 24hr 36 mg................................................................. 93
sr 24hr 54 mg................................................................. 93
methylphenidate hcl soln 5 mg/5ml (Methylin)............ 93
methylphenidate hcl soln 10 mg/5ml (Methylin).......... 93
methylphenidate hcl tab cr 10 mg................................. 93
methylphenidate hcl tab cr 20 mg................................. 93
methylphenidate hcl tab 5 mg (Ritalin)......................... 93
methylphenidate hcl tab 10 mg (Ritalin)....................... 93
methylphenidate hcl tab 20 mg (Ritalin)....................... 93
methylprednisolone tab 4 mg (Medrol)......................... 19
methylprednisolone tab 8 mg (Medrol)......................... 19
methylprednisolone tab 16 mg (Medrol)....................... 19
methylprednisolone tab 32 mg (Medrol)....................... 19
methylprednisolone tab therapy pack 4 mg (21)
(Medrol dosepak).......................................................... 19
methyltestosterone cap 10 mg (Testred)...................... 21
METIPRANOLOL -metipranolol ophth soln 0.3%........... 146
metoclopramide hcl orally disintegrating tab 5 mg
(Metozolv odt)................................................................ 74
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)........ 74
metoclopramide hcl tab 5 mg (Reglan)......................... 74
metoclopramide hcl tab 10 mg (Reglan)....................... 74
METOCLOPRAMIDE ODT -metoclopramide hcl orally
disintegrating tab 10 mg................................................. 74
metolazone tab 2.5 mg.................................................... 54
metolazone tab 5 mg....................................................... 54
metolazone tab 10 mg..................................................... 54
metoprolol & hydrochlorothiazide tab 100-50 mg....... 51
metoprolol & hydrochlorothiazide tab 50-25 mg
(Lopressor hct)..............................................................51
metoprolol & hydrochlorothiazide tab 100-25 mg
(Lopressor hct)..............................................................51
metoprolol succinate tab sr 24hr 25 mg (tartrate
equiv) (Toprol xl)........................................................... 41
equiv) (Toprol xl)........................................................... 41
equiv) (Toprol xl)........................................................... 41
equiv) (Toprol xl)........................................................... 41
METOPROLOL TARTRATE -metoprolol tartrate tab 37.5
mg.................................................................................... 41
METOPROLOL TARTRATE -metoprolol tartrate tab 75
mg.................................................................................... 41
metoprolol tartrate tab 25 mg........................................ 41
metoprolol tartrate tab 50 mg (Lopressor)................... 41
metoprolol tartrate tab 100 mg (Lopressor)................. 41
METOZOLV ODT -metoclopramide hcl orally
disintegrating tab 5 mg................................................... 74
METROCREAM -metronidazole cream 0.75%............... 159
METROGEL -metronidazole gel 1%............................... 159
METROGEL-VAGINAL -metronidazole vaginal gel
0.75%...............................................................................77
METROLOTION -metronidazole lotion 0.75%................ 159
metronidazole cap 375 mg (Flagyl)............................... 13
metronidazole cream 0.75% (Metrocream)................. 159
metronidazole gel 0.75%............................................... 159
metronidazole gel 1% (Metrogel)................................. 159
metronidazole lotion 0.75% (Metrolotion)................... 159
metronidazole tab 250 mg (Flagyl)................................ 13
metronidazole tab 500 mg (Flagyl)................................ 13
metronidazole vaginal gel 0.75% (Metrogelvaginal)........................................................................... 77
MEVACOR -lovastatin tab 40 mg...................................... 57
mexiletine hcl cap 150 mg.............................................. 45
MIACALCIN -calcitonin (salmon) nasal soln 200 unit/
act.................................................................................... 37
MICARDIS HCT -telmisartan-hydrochlorothiazide tab
40-12.5 mg...................................................................... 51
80-12.5 mg...................................................................... 51
80-25 mg......................................................................... 51
MICARDIS -telmisartan tab 20 mg.................................... 51
MICONAZOLE 3 -miconazole nitrate vaginal suppos 200
mg.................................................................................... 77
MICROCYN SKIN AND WOUND H -wound cleansers gel.................................................................................. 159
MICROCYN -wound cleansers - gel............................... 159
MICROCYN -wound cleansers - liquid............................ 159
MICRO-K -potassium chloride cap cr 8 meq.................. 132
MICRO-K -potassium chloride cap cr 10 meq................ 132
MICROZIDE -hydrochlorothiazide cap 12.5 mg................54
midodrine hcl tab 2.5 mg................................................ 55
midodrine hcl tab 5 mg................................................... 55
midodrine hcl tab 10 mg................................................. 55
MIGERGOT -ergotamine w/ caffeine suppos 2-100
mg.................................................................................. 112
miglitol tab 25 mg (Glyset)............................................. 29
miglitol tab 50 mg (Glyset)............................................. 29
miglitol tab 100 mg (Glyset)........................................... 29
MIGRANAL -dihydroergotamine mesylate nasal spray 4
mg/ml............................................................................. 112
MILLIPRED DP -prednisolone tab therapy pack 5 mg
(21).................................................................................. 19
MILLIPRED DP -prednisolone tab therapy pack 5 mg
(48).................................................................................. 19
MILLIPRED -prednisolone sod phosphate oral soln 10
mg/5ml (base equiv)....................................................... 19
MILLIPRED -prednisolone tab 5 mg................................. 19
MINASTRIN 24 FE -norethindrone ace-eth estradiol-fe
chew tab 1 mg-20 mcg (24)........................................... 24
MINERAL OIL HEAVY -mineral oil.................................... 68
MINIELITE RECHARGEABLE BA -respiratory therapy
supplies - misc.............................................................. 169
MINIPRESS -prazosin hcl cap 1 mg................................. 51
220
2016
MINIVELLE -estradiol td patch twice weekly 0.025
mg/24hr........................................................................... 23
mg/24hr........................................................................... 23
mg/24hr........................................................................... 23
mg/24hr........................................................................... 23
mg/24hr........................................................................... 23
MINOCIN -minocycline hcl cap 50 mg................................ 4
MINOCIN -minocycline hcl cap 75 mg................................ 4
MINOCIN -minocycline hcl cap 100 mg.............................. 4
minocycline hcl cap 50 mg (Minocin)............................. 4
minocycline hcl cap 75 mg (Minocin)............................. 4
minocycline hcl cap 100 mg (Minocin)........................... 4
minocycline hcl tab 50 mg............................................... 4
minocycline hcl tab 75 mg............................................... 5
minocycline hcl tab 100 mg............................................. 5
minocycline hcl tab sr 24hr 45 mg.................................. 4
minocycline hcl tab sr 24hr 90 mg.................................. 4
minocycline hcl tab sr 24hr 135 mg................................ 4
minoxidil tab 2.5 mg........................................................ 51
minoxidil tab 10 mg......................................................... 51
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr
0.375 mg....................................................................... 119
0.75 mg......................................................................... 119
1.5 mg........................................................................... 119
2.25 mg......................................................................... 119
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 3
mg.................................................................................. 119
3.75 mg......................................................................... 119
4.5 mg........................................................................... 119
MIRAPEX -pramipexole dihydrochloride tab 0.125
mg.................................................................................. 119
mg.................................................................................. 119
MIRAPEX -pramipexole dihydrochloride tab 0.5 mg.......119
mg.................................................................................. 119
MIRAPEX -pramipexole dihydrochloride tab 1 mg..........119
MIRAPEX -pramipexole dihydrochloride tab 1.5 mg.......119
MIRCETTE -desogest-eth estrad & eth estrad tab
0.15-0.02/0.01 mg(21/5)................................................. 24
mirtazapine orally disintegrating tab 15 mg (Remeron
soltab)............................................................................. 82
soltab)............................................................................. 82
soltab)............................................................................. 82
mirtazapine tab 7.5 mg....................................................82
mirtazapine tab 15 mg (Remeron)................................. 82
MIRVASO -brimonidine tartrate gel 0.33% (base
equivalent)..................................................................... 159
MISC NEEDLES – VARIOUS..........................................169
misoprostol tab 100 mcg (Cytotec)............................... 70
misoprostol tab 200 mcg (Cytotec)............................... 70
MISTASSIST -respiratory therapy supplies - devices..... 169
MITIGARE -colchicine cap 0.6 mg.................................. 113
MITOSOL -mitomycin for ophth soln kit 0.2 mg.............. 146
MOBIC -meloxicam tab 7.5 mg....................................... 109
MOBIC -meloxicam tab 15 mg........................................ 109
modafinil tab 100 mg (Provigil)...................................... 93
modafinil tab 200 mg (Provigil)...................................... 93
MODERIBA 1200 DOSE PACK -ribavirin tab 600 mg........ 9
MODERIBA 800 DOSE PACK -ribavirin tab 400 mg.......... 9
MODERIBA -ribavirin tab 200 mg & ribavirin tab 400 mg
dose pack.......................................................................... 9
MODERIBA -ribavirin tab 400 mg & ribavirin tab 600 mg
dose pack.......................................................................... 9
MODICON -norethindrone & ethinyl estradiol tab 0.5
mg-35 mcg...................................................................... 24
moexipril hcl tab 7.5 mg................................................. 51
moexipril hcl tab 15 mg.................................................. 51
moexipril-hydrochlorothiazide tab 7.5-12.5 mg........... 51
moexipril-hydrochlorothiazide tab 15-12.5 mg............ 51
moexipril-hydrochlorothiazide tab 15-25 mg............... 51
MOLINDONE HYDROCHLORIDE -molindone hcl tab 5
mg.................................................................................... 86
mg.................................................................................... 86
mg.................................................................................... 86
mometasone furoate cream 0.1% (Elocon)................ 159
mometasone furoate nasal susp 50 mcg/act
(Nasonex)....................................................................... 61
mometasone furoate oint 0.1% (Elocon).................... 159
mometasone furoate solution 0.1% (lotion)
(Elocon)........................................................................ 159
MONOCAL -sodium monofluorophosphate-calcium carb
tab 22.75-625 mg......................................................... 132
MONOCLATE-P -antihemophilic factor (human) for inj kit
250 unit......................................................................... 142
1000 unit....................................................................... 142
1500 unit....................................................................... 142
MONODOX -doxycycline monohydrate cap 75 mg............ 5
MONODOX -doxycycline monohydrate cap 100 mg.......... 5
MONONINE -coagulation factor ix for inj 500 unit.......... 142
MONONINE -coagulation factor ix for inj 1000 unit........ 142
MONSELS FERRIC SUBSULFATE -ferric subsulfate
soln................................................................................ 138
montelukast sodium chew tab 4 mg (base equiv)
(Singulair)....................................................................... 66
221
2016
montelukast sodium chew tab 5 mg (base equiv)
(Singulair)....................................................................... 66
montelukast sodium oral granules packet 4 mg (base
equiv) (Singulair)...........................................................66
montelukast sodium tab 10 mg (base equiv)
(Singulair)....................................................................... 66
MONUROL -fosfomycin tromethamine powd pack 3 gm
(base equivalent)............................................................ 75
8-MOP -methoxsalen cap 10 mg.................................... 166
MORGIDOX 1X100MG -doxycycline hyclate cap 1 x 100
mg w/ cleanser kit.............................................................5
MORGIDOX 2X100MG -doxycycline hyclate cap 2 x 100
mg w/ cleanser kit.............................................................5
morphine sulfate cap sr 24hr 10 mg (Kadian)............ 103
morphine sulfate cap sr 24hr 100 mg (Kadian).......... 103
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 30 mg....................................................................103
24hr 45 mg....................................................................104
24hr 60 mg....................................................................104
24hr 75 mg....................................................................104
24hr 90 mg....................................................................104
24hr 120 mg..................................................................104
MORPHINE SULFATE -morphine sulfate suppos 5
mg.................................................................................. 103
mg.................................................................................. 103
mg.................................................................................. 103
mg.................................................................................. 103
MORPHINE SULFATE -morphine sulfate tab 15 mg...... 103
MORPHINE SULFATE -morphine sulfate tab 30 mg...... 103
morphine sulfate oral soln 10 mg/5ml........................ 104
morphine sulfate oral soln 20 mg/5ml........................ 104
morphine sulfate oral soln 100 mg/5ml (20 mg/
ml)................................................................................. 104
morphine sulfate tab cr 15 mg (Ms contin)................ 104
morphine sulfate tab cr 100 mg (Ms contin).............. 104
morphine sulfate tab cr 200 mg (Ms contin).............. 104
MOTOFEN -difenoxin w/ atropine tab 1-0.025 mg............68
MOVANTIK -naloxegol oxalate tab 12.5 mg (base
equivalent)....................................................................... 74
MOVANTIK -naloxegol oxalate tab 25 mg (base
equivalent)....................................................................... 74
MOVIPREP -peg 3350-kcl-nacl-na sulfate-na ascorbate-c
for soln 100 gm...............................................................68
MOXATAG -amoxicillin (trihydrate) tab sr 24hr 775 mg...... 1
MOXEZA -moxifloxacin hcl ophth soln 0.5% (base eq) (2
times daily).................................................................... 146
moxifloxacin hcl tab 400 mg (base equiv) (Avelox)....... 6
MOZOBIL -plerixafor subcutaneous inj 24 mg/1.2ml (20
mg/ml)............................................................................ 135
MS CONTIN -morphine sulfate tab cr 15 mg.................. 104
MS CONTIN -morphine sulfate tab cr 100 mg................ 104
MS CONTIN -morphine sulfate tab cr 200 mg................ 104
MULTAQ -dronedarone hcl tab 400 mg (base
equivalent)....................................................................... 45
MULTIGEN -fe asparto gly-succ acd-c-threonic acd-b12des stom tab................................................................. 135
MULTIGEN FOLIC -fe asparto gly-succinic acd-vit cthreonic acd-b12-fa tab................................................ 136
MULTIGEN PLUS -fe aspart gly-fe fum-succ acd-cthreonic acd-b12-fa tab................................................ 136
multiple vitamins w/ minerals & fa tab 1.25 mg
(Corvite)........................................................................ 125
multiple vitamins w/ minerals cap............................... 125
multiple vitamins w/ minerals tab (Strovite forte)...... 125
mupirocin calcium cream 2% (Bactroban)................. 159
mupirocin oint 2% (Bactroban).................................... 159
MUSE– Benefit Limits may apply -alprostadil urethral
pellet 125 mcg................................................................ 60
pellet 250 mcg................................................................ 60
pellet 500 mcg................................................................ 60
pellet 1000 mcg.............................................................. 60
MYALEPT -metreleptin for subcutaneous inj 11.3 mg...... 37
MYAMBUTOL -ethambutol hcl tab 100 mg......................... 6
MYAMBUTOL -ethambutol hcl tab 400 mg......................... 6
MYCOBUTIN -rifabutin cap 150 mg.................................... 6
mycophenolate mofetil cap 250 mg (Cellcept)........... 172
mycophenolate mofetil for oral susp 200 mg/ml
(Cellcept)...................................................................... 172
mycophenolate mofetil tab 500 mg (Cellcept)............172
mycophenolate sodium tab dr 180 mg (mycophenolic
acid equiv) (Myfortic)................................................. 172
mycophenolate sodium tab dr 360 mg (mycophenolic
acid equiv) (Myfortic)................................................. 172
MYFORTIC -mycophenolate sodium tab dr 180 mg
(mycophenolic acid equiv)............................................ 172
MYFORTIC -mycophenolate sodium tab dr 360 mg
(mycophenolic acid equiv)............................................ 172
MYKIDZ IRON FL -pediatric vitamins acd fluoride & fe
susp 0.25-10 mg/2ml.................................................... 125
MYKIDZ IRON 10 -iron susp 15 mg/1.5ml...................... 136
MYLERAN -busulfan tab 2 mg.......................................... 17
MYNATAL ADVANCE -prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg...................................................................125
222
2016
MYNATAL PLUS -prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................. 125
MYNATAL -prenatal multivitamins & minerals w/ iron & fa
cap 1 mg....................................................................... 125
MYNATAL ULTRACAPLET -prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg............................................... 125
MYNATAL-Z -prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................. 125
MYNATE 90 PLUS -prenatal vit w/ dss-fe fumarate-fa tab
cr 90-1 mg.....................................................................125
MYRBETRIQ -mirabegron tab sr 24 hr 25 mg.................. 76
MYRBETRIQ -mirabegron tab sr 24 hr 50 mg.................. 76
MYSOLINE -primidone tab 50 mg.................................. 116
MYSOLINE -primidone tab 250 mg................................ 116
N
nabumetone tab 500 mg............................................... 109
nabumetone tab 750 mg............................................... 109
nadolol & bendroflumethiazide tab 40-5 mg
(Corzide)......................................................................... 51
nadolol & bendroflumethiazide tab 80-5 mg
(Corzide)......................................................................... 51
nadolol tab 20 mg (Corgard).......................................... 41
NAFRINSE DAILY/ACIDULATED -sodium fluoridephosphoric acid for soln 1 mg/5ml (f equiv)................. 149
NAFRINSE DAILY/NEUTRAL -sodium fluoride for soln
rinse 0.05%................................................................... 149
NAFRINSE WEEKLY -sodium fluoride for soln rinse
0.2%...............................................................................149
naftifine hcl cream 2% (Naftin).................................... 159
NAFTIFINE HCL -naftifine hcl cream 1%........................159
NAFTIN -naftifine hcl cream 2%..................................... 159
NAFTIN -naftifine hcl gel 1%........................................... 159
NAFTIN -naftifine hcl gel 2%........................................... 159
NALFON -fenoprofen calcium cap 400 mg..................... 109
naltrexone hcl tab 50 mg (Revia)................................. 167
NAMENDA -memantine hcl oral solution 2 mg/ml............ 96
NAMENDA -memantine hcl tab 5 mg............................... 96
NAMENDA -memantine hcl tab 10 mg............................. 96
NAMENDA TITRATION PAK -memantine hcl tab 5 mg
(28) & 10 mg (21) titration pak....................................... 96
NAMENDA XR -memantine hcl cap sr 24hr 7 mg............ 96
NAMENDA XR -memantine hcl cap sr 24hr 14 mg.......... 96
NAMENDA XR TITRATION PACK -memantine hcl cap sr
24hr 7 mg & 14 mg & 21 mg & 28 mg pack.................. 96
NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr
14-10 mg......................................................................... 96
NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr
28-10 mg......................................................................... 96
NAPRELAN -naproxen sodium tab sr 24hr 375 mg (base
equiv)............................................................................. 109
equiv)............................................................................. 109
equiv)............................................................................. 109
NAPROSYN -naproxen susp 125 mg/5ml...................... 109
NAPROSYN -naproxen tab 500 mg................................ 109
NAPROXEN COMFORT PAC -naproxen tab 500 mg &
naproxen sodium tab 275 mg (Anaprox).................... 110
naproxen sodium tab 550 mg (Anaprox ds)............... 110
naproxen sodium tab sr 24hr 375 mg (base equiv)
(Naprelan)..................................................................... 109
naproxen sodium tab sr 24hr 500 mg (base equiv)
(Naprelan)..................................................................... 110
naproxen susp 125 mg/5ml.......................................... 110
naproxen tab ec 375 mg (Ec-naprosyn)...................... 110
naproxen tab ec 500 mg (Ec-naprosyn)...................... 110
naproxen tab 250 mg (Naprosyn)................................ 110
naratriptan hcl tab 1 mg (base equiv) (Amerge)........ 112
naratriptan hcl tab 2.5 mg (base equiv) (Amerge)..... 112
NARCAN -naloxone hcl nasal spray 4 mg/0.1ml............ 167
NARDIL -phenelzine sulfate tab 15 mg............................ 82
NASCOBAL -cyanocobalamin nasal spray 500
mcg/0.1ml...................................................................... 136
NASONEX -mometasone furoate nasal susp 50 mcg/
act.................................................................................... 61
NATACHEW -prenatal vit w/ fe fum-fe bisglycin-fa chew
tab 28-1 mg...................................................................125
NATACYN -natamycin ophth susp 5%............................ 146
NATALVIT -prenatal vit w/ fe fumarate-fa tab 75-1
mg.................................................................................. 125
NATAZIA -estradiol valerate-dienogest tab 3 mg /2-2
mg/2-3 mg/1 mg............................................................. 24
nateglinide tab 60 mg (Starlix)....................................... 29
nateglinide tab 120 mg (Starlix)..................................... 29
NATELLE ONE -prenatal w/o vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg.......................................................... 125
NATESTO -testosterone nasal gel 5.5 mg/act.................. 21
NATPARA -parathyroid hormone (recombinant) for inj
cartridge 25 mcg............................................................. 37
cartridge 50 mcg............................................................. 37
cartridge 75 mcg............................................................. 37
cartridge 100 mcg........................................................... 37
NATROBA -spinosad susp 0.9%..................................... 159
NATURE-THROID NT-2.5 -thyroid tab 162.5 mg (2 1/2
grain)................................................................................33
NATURE-THROID -thyroid tab 16.25 mg..........................33
NATURE-THROID -thyroid tab 32.5 mg............................33
NATURE-THROID -thyroid tab 65 mg...............................33
NATURE-THROID -thyroid tab 81.25 mg..........................33
NATURE-THROID -thyroid tab 97.5 mg............................33
NATURE-THROID -thyroid tab 113.75 mg........................ 33
NATURE-THROID -thyroid tab 130 mg.............................33
NATURE-THROID -thyroid tab 146.25 mg....................... 33
223
2016
NATURE-THROID -thyroid tab 48.75 mg (3/4 grain)........ 33
NATURE-THROID -thyroid tab 325 mg (5 grain).............. 33
NEBULIZER/ADULT MASK -respiratory therapy supplies kit................................................................................... 169
NEBULIZER/PEDIATRIC MASK -respiratory therapy
supplies - kit.................................................................. 169
NEBULIZER AIR TUBE/PLUGS -respiratory therapy
supplies - misc.............................................................. 169
NEBULIZER COMPRESSOR/DUAL -respiratory therapy
supplies - kit.................................................................. 169
NEBULIZER KIT/TUBING/MOUT -respiratory therapy
supplies - kit.................................................................. 169
NEBULIZER PEDIATRIC MASK -respiratory therapy
supplies - misc.............................................................. 169
NEBUPENT -pentamidine isethionate for nebulization
soln 300 mg.................................................................... 13
NEBUSAL -sodium chloride soln nebu 6%....................... 63
NECON 1/50-28 -norethindrone & mestranol tab 1 mg-50
mcg.................................................................................. 25
NECON 10/11-28 -norethindrone-eth estradiol tab
0.5-35/1-35 mg-mcg (10/11)........................................... 25
NEFAZODONE HCL -nefazodone hcl tab 100 mg........... 82
nefazodone hcl tab 50 mg.............................................. 82
nefazodone hcl tab 250 mg............................................ 82
NEOMYCIN/POLYMYXIN/HYDROC -neomycinpolymyxin-hc ophth susp.............................................. 146
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin............................. 146
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml (Neosporin)........... 146
neomycin-polymyxin-dexamethasone ophth oint 0.1%
(Maxitrol)...................................................................... 146
neomycin-polymyxin-dexamethasone ophth susp
0.1% (Maxitrol).............................................................146
neomycin-polymyxin-hc otic soln 1%
(Cortisporin).................................................................148
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000
unit/ml-1%.................................................................... 148
neomycin sulfate tab 500 mg........................................... 6
NEORAL -cyclosporine modified cap 25 mg...................172
NEORAL -cyclosporine modified cap 100 mg.................172
NEORAL -cyclosporine modified oral soln 100 mg/
ml................................................................................... 172
NEOSALUS CP -dermatological products misc cream............................................................................. 160
NEOSALUS -dermatological products, misc. - aerosol
foam............................................................................... 160
NEOSALUS -dermatological products misc - cream...... 160
NEOSALUS -emollient - lotion........................................ 160
NEOSPORIN -neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml................................... 146
NEO-SYNALAR KIT -neomycin-fluocinolone cream
0.35-0.025% & emollient cr kit..................................... 160
NEO-SYNALAR -neomycin-fluocinolone cream
0.35-0.025%.................................................................. 159
NEOTUSS PLUS -phenylephrine-chlorphen-dm liquid
7.5-4-30 mg/5ml.............................................................. 63
NEPHPLEX RX -b-complex w/ c-zn & folic acid tab 1
mg.................................................................................. 125
NEPHROCAPS -b-complex w/ c & folic acid cap 1
mg.................................................................................. 125
NEPHROCAPS QT -b-complex w/ c-biotin-d & folic acid
tab disp 1 mg................................................................ 125
NEPHRON FA -ferrous fumarate w/ fa-dss-b complex-vit
c tab...............................................................................136
NEPHRO-VITE RX -b-complex w/ c & folic acid tab 1
mg.................................................................................. 125
NEPTAZANE -methazolamide tab 25 mg......................... 54
NEPTAZANE -methazolamide tab 50 mg......................... 54
NESINA -alogliptin benzoate tab 6.25 mg (base
equiv)............................................................................... 29
NESINA -alogliptin benzoate tab 12.5 mg (base
equiv)............................................................................... 29
NESINA -alogliptin benzoate tab 25 mg (base equiv).......29
NESTABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg
& omega cap pack....................................................... 125
NESTABS -prenatal vit w/o vit a w/ fe bisglycinate-fa tab
32-1 mg......................................................................... 125
NEUAC KIT -clindamycin-benzoyl perox gel 1.2-5% &
moisturizer cr kit........................................................... 160
NEULASTA ONPRO KIT -pegfilgrastim soln prefilled
syringe kit 6 mg/0.6ml.................................................. 136
NEULASTA -pegfilgrastim soln prefilled syringe 6
mg/0.6ml........................................................................ 136
NEUPOGEN -filgrastim inj 300 mcg/ml........................... 136
NEUPOGEN -filgrastim inj 480 mcg/1.6ml (300 mcg/
ml).................................................................................. 136
NEUPOGEN -filgrastim soln prefilled syringe 300
mcg/0.5ml...................................................................... 136
NEUPOGEN -filgrastim soln prefilled syringe 480
mcg/0.8ml (600 mcg/ml)............................................... 136
NEUPRO -rotigotine td patch 24hr 1 mg/24hr................ 119
NEURIN-SL -cyanocobalamin-methylcobalamin tab sl
600-600 mcg................................................................. 136
NEURONTIN -gabapentin cap 100 mg........................... 116
NEURONTIN -gabapentin oral soln 250 mg/5ml............ 117
NEURONTIN -gabapentin tab 600 mg............................ 117
NEURONTIN -gabapentin tab 800 mg............................ 117
NEUTRASAL -artificial saliva - packet............................ 149
NEVANAC -nepafenac ophth susp 0.1%........................ 146
NEVIRAPINE -nevirapine susp 50 mg/5ml......................... 9
nevirapine tab 200 mg (Viramune)...................................9
nevirapine tab sr 24hr 100 mg (Viramune xr)................. 9
224
2016
nevirapine tab sr 24hr 400 mg (Viramune xr)................. 9
NEWGEN -prenatal vit w/o vit a w/ fe bisglycinate-fa tab
32-1 mg......................................................................... 125
NEXA PLUS -prenatal w/o vit a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg.............................................................125
NEXAVAR -sorafenib tosylate tab 200 mg (base
equivalent)....................................................................... 17
NEXIUM -esomeprazole magnesium cap delayed release
20 mg (base eq)............................................................. 70
NEXIUM -esomeprazole magnesium cap delayed release
40 mg (base eq)............................................................. 70
NEXIUM -esomeprazole magnesium for delayed release
susp packet 5 mg........................................................... 70
susp packet 10 mg......................................................... 70
susp packet 20 mg......................................................... 70
susp packet 40 mg......................................................... 70
susp pack 2.5 mg........................................................... 70
niacin tab cr 500 mg (antihyperlipidemic)
(Niaspan)........................................................................ 57
(Niaspan)........................................................................ 57
(Niaspan)........................................................................ 57
NIACOR -niacin (antihyperlipidemic) tab 500 mg............. 57
NIASPAN -niacin tab cr 500 mg (antihyperlipidemic)........57
NIASPAN -niacin tab cr 750 mg (antihyperlipidemic)........57
NIASPAN -niacin tab cr 1000 mg (antihyperlipidemic)......57
NICADAN -multiple vitamins w/ minerals tab.................. 125
nicardipine hcl cap 20 mg.............................................. 43
nicardipine hcl cap 30 mg.............................................. 43
NICAZEL FORTE -multiple vitamins w/ minerals tab...... 125
NICAZEL -multiple vitamins w/ minerals tab................... 125
NICODERM CQ -nicotine td patch 24hr 7 mg/24hr.......... 96
NICODERM CQ -nicotine td patch 24hr 14 mg/24hr........ 96
NICODERM CQ -nicotine td patch 24hr 21 mg/24hr........ 96
NICOMIDE -niacinamide w/ zn-cu-methylfolate tab
750-25-1.5-0.5 mg........................................................ 125
NICOMIDE -niacinamide w/ zn-cu-methylfol-se-cr tab
750-27-2-0.5 mg........................................................... 125
NICORETTE MINI -nicotine polacrilex lozenge 2 mg....... 97
NICORETTE MINI -nicotine polacrilex lozenge 4 mg....... 97
NICORETTE -nicotine polacrilex gum 2 mg..................... 97
NICORETTE -nicotine polacrilex gum 4 mg..................... 97
NICORETTE -nicotine polacrilex lozenge 2 mg................ 97
NICORETTE -nicotine polacrilex lozenge 4 mg................ 97
NICORETTE STARTER KIT -nicotine polacrilex gum 2
mg.................................................................................... 97
NICORETTE STARTER KIT -nicotine polacrilex gum 4
mg.................................................................................... 97
nicotine polacrilex gum 2 mg.........................................97
nicotine polacrilex gum 4 mg.........................................97
nicotine polacrilex lozenge 2 mg................................... 97
nicotine polacrilex lozenge 4 mg................................... 97
nicotine td patch 24hr 7 mg/24hr...................................97
nicotine td patch 24hr 14 mg/24hr.................................97
nicotine td patch 24hr 21 mg/24hr.................................97
NICOTINE TRANSDERMAL SYST -nicotine td patch 24
hr kit 21-14-7 mg/24hr.................................................... 97
NICOTROL INHALER -nicotine inhaler system 10 mg (4
mg delivered).................................................................. 97
NICOTROL NS -nicotine nasal spray 10 mg/ml (0.5 mg/
spray)............................................................................... 97
nifedipine cap 20 mg....................................................... 43
nifedipine cap 10 mg (Procardia).................................. 43
nifedipine tab sr 24hr 30 mg (Adalat cc).......................44
nifedipine tab sr 24hr osmotic release 30 mg
(Procardia xl)................................................................. 44
(Procardia xl)................................................................. 44
(Procardia xl)................................................................. 44
NILANDRON -nilutamide tab 150 mg............................... 17
nimodipine cap 30 mg..................................................... 44
NINLARO -ixazomib citrate cap 2.3 mg (base
equivalent)....................................................................... 17
NINLARO -ixazomib citrate cap 3 mg (base
equivalent)....................................................................... 17
NINLARO -ixazomib citrate cap 4 mg (base
equivalent)....................................................................... 17
NIRAVAM -alprazolam orally disintegrating tab 0.25
mg.................................................................................... 79
NISOLDIPINE ER -nisoldipine tab sr 24hr 25.5 mg.......... 44
NISOLDIPINE -nisoldipine tab sr 24hr 20 mg................... 44
nisoldipine tab sr 24hr 8.5 mg (Sular)........................... 44
nisoldipine tab sr 24hr 17 mg (Sular)............................44
nisoldipine tab sr 24hr 34 mg (Sular)............................44
NITRO-BID -nitroglycerin oint 2%..................................... 39
NITRO-DUR -nitroglycerin td patch 24hr 0.1 mg/hr.......... 39
nitrofurantoin macrocrystalline cap 25 mg
(Macrodantin).................................................................75
(Macrodantin).................................................................75
(Macrodantin).................................................................75
nitrofurantoin monohydrate macrocrystalline cap 100
mg (Macrobid)............................................................... 75
nitrofurantoin susp 25 mg/5ml (Furadantin)................ 75
nitroglycerin cap cr 2.5 mg............................................ 40
nitroglycerin cap cr 6.5 mg............................................ 40
nitroglycerin cap cr 9 mg............................................... 40
225
2016
NITROGLYCERIN LINGUAL -nitroglycerin lingual aerosol
400 mcg/spray................................................................ 40
nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)......... 40
nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)
(Nitrolingual pumpspr)................................................. 40
NITROLINGUAL PUMPSPRAY -nitroglycerin tl soln 0.4
mg/spray (400 mcg/spray)..............................................40
NITROMIST -nitroglycerin lingual aerosol 400 mcg/
spray................................................................................ 40
NITROSTAT -nitroglycerin sl tab 0.3 mg........................... 40
NIVATOPIC PLUS -dermatological products misc cream............................................................................. 160
nizatidine cap 150 mg..................................................... 70
nizatidine cap 300 mg (Axid).......................................... 70
NIZATIDINE -nizatidine oral soln 15 mg/ml...................... 70
NIZORAL -ketoconazole shampoo 2%........................... 160
NORCO -hydrocodone-acetaminophen tab 7.5-325
mg.................................................................................. 104
NORCO -hydrocodone-acetaminophen tab 5-325
mg.................................................................................. 104
NORCO -hydrocodone-acetaminophen tab 10-325
mg.................................................................................. 104
NORDITROPIN CARTRIDGE -somatropin inj 5
mg/1.5ml.......................................................................... 37
NORDITROPIN FLEXPRO -somatropin inj 5
mg/1.5ml.......................................................................... 37
mg/1.5ml.......................................................................... 37
mg/1.5ml.......................................................................... 37
mg/3ml............................................................................. 37
norethindrone & ethinyl estradiol-fe chew tab 0.4
mg-35 mcg (Femcon fe)............................................... 25
norethindrone & ethinyl estradiol-fe chew tab 0.8
mg-25 mcg (Generess fe)............................................ 25
norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg
(Brevicon-28)................................................................. 25
norethindrone & ethinyl estradiol tab 1 mg-35 mcg
(Norinyl 1+35)................................................................ 25
norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg
(Ovcon-35)...................................................................... 25
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20
mcg (Loestrin fe 1/20).................................................. 25
norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30
mcg (Loestrin fe 1.5/30)............................................... 25
norethindrone ace & ethinyl estradiol tab 1 mg-20
mcg (Loestrin 1/20-21)................................................. 25
norethindrone ace & ethinyl estradiol tab 1.5 mg-30
mcg (Loestrin 1.5/30-21).............................................. 25
norethindrone ace-ethinyl estradiol-fe tab 1 mg-20
mcg (24)......................................................................... 25
norethindrone acetate-ethinyl estradiol tab 1 mg-5
mcg................................................................................. 23
norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5
mcg (Femhrt low dose)................................................ 23
norethindrone acetate tab 5 mg (Aygestin).................. 26
norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35
mg-mcg (Estrostep fe)................................................. 25
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35
mg-mcg (Ortho-novum 7/7/7)...................................... 25
norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28)...................................................... 25
norethindrone tab 0.35 mg (Nor-qd).............................. 25
norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg
(Ortho-cyclen)................................................................ 25
norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35
mg-mcg (Ortho tri-cyclen)........................................... 25
norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25
mg-mcg (Ortho tri-cyclen lo)....................................... 25
norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg........ 25
NORINYL 1+35 -norethindrone & ethinyl estradiol tab 1
mg-35 mcg...................................................................... 25
NORITATE -metronidazole cream 1%.............................160
NORPACE CR -disopyramide phosphate cap sr 12hr 100
mg.................................................................................... 45
NORPACE CR -disopyramide phosphate cap sr 12hr 150
mg.................................................................................... 45
NORPACE -disopyramide phosphate cap 100 mg........... 45
NORPACE -disopyramide phosphate cap 150 mg........... 45
NORPRAMIN -desipramine hcl tab 10 mg........................82
NORPRAMIN -desipramine hcl tab 25 mg........................82
NOR-QD -norethindrone tab 0.35 mg............................... 25
NORTHERA -droxidopa cap 100 mg................................ 55
nortriptyline hcl cap 10 mg (Pamelor)...........................82
NORTRIPTYLINE HCL -nortriptyline hcl soln 10
mg/5ml............................................................................. 82
NORTUSS-EX -dextromethorphan-guaifenesin liquid
20-200 mg/5ml................................................................ 63
NORVASC -amlodipine besylate tab 2.5 mg.................... 44
NORVASC -amlodipine besylate tab 5 mg....................... 44
NORVASC -amlodipine besylate tab 10 mg..................... 44
NORVIR -ritonavir cap 100 mg........................................... 9
NORVIR -ritonavir oral soln 80 mg/ml.................................9
NORVIR -ritonavir tab 100 mg............................................ 9
NOVACORT -hydrocortisone ace-pramoxine-aloe
polysacch gel 2-1-1%................................................... 160
NOVA MAX PLUS KETONE TEST -ketone blood test
strip................................................................................ 167
NOVOEIGHT -antihemophilic factor (recombinant) for inj
250 unit......................................................................... 142
500 unit......................................................................... 142
226
2016
1000 unit....................................................................... 142
1500 unit....................................................................... 142
2000 unit....................................................................... 142
3000 unit....................................................................... 142
NOVOLIN 70/30 -insulin nph isophane & regular human
inj 100 unit/ml (70-30).................................................... 31
NOVOLIN 70/30 RELION -insulin nph isophane & regular
human inj 100 unit/ml (70-30)........................................ 31
NOVOLIN N -insulin nph (human) (isophane) inj 100 unit/
ml..................................................................................... 31
NOVOLIN N RELION -insulin nph (human) (isophane) inj
100 unit/ml.......................................................................31
NOVOLIN R -insulin regular (human) inj 100 unit/ml........ 31
NOVOLIN R RELION -insulin regular (human) inj 100
unit/ml.............................................................................. 31
NOVOLOG FLEXPEN -insulin aspart soln pen-injector
100 unit/ml.......................................................................31
NOVOLOG -insulin aspart inj 100 unit/ml......................... 31
NOVOLOG MIX 70/30 -insulin aspart prot & aspart
(human) inj 100 unit/ml (70-30)...................................... 32
NOVOLOG MIX 70/30 PREFILL -insulin aspart prot &
aspart sus pen-inj 100 unit/ml (70-30)........................... 32
NOVOLOG PENFILL -insulin aspart soln cartridge 100
unit/ml.............................................................................. 31
NOVOSEVEN RT -coagulation factor viia (recomb) for inj
1 mg (1000 mcg).......................................................... 142
2 mg (2000 mcg).......................................................... 142
5 mg (5000 mcg).......................................................... 142
8 mg (8000 mcg).......................................................... 142
NOXAFIL -posaconazole susp 40 mg/ml............................ 7
NOXAFIL -posaconazole tab delayed release 100 mg....... 7
NPLATE -romiplostim for inj 250 mcg............................. 136
NPLATE -romiplostim for inj 500 mcg............................. 136
NUCORT -hydrocortisone acetate lotion 2%.................. 160
NUCYNTA ER -tapentadol hcl tab sr 12hr 50 mg........... 104
NUCYNTA ER -tapentadol hcl tab sr 12hr 100 mg......... 104
NUCYNTA -tapentadol hcl tab 50 mg............................. 104
NUCYNTA -tapentadol hcl tab 75 mg............................. 104
NUCYNTA -tapentadol hcl tab 100 mg........................... 104
NUEDEXTA -dextromethorphan hbr-quinidine sulfate cap
20-10 mg......................................................................... 97
NULYTELY/FLAVOR PACKS -peg 3350-kcl-sod bicarbnacl for soln 420 gm.......................................................68
NUMOISYN -artificial saliva - lozenge............................ 149
NUMOISYN -artificial saliva - solution............................ 149
NUOX -benzoyl peroxide-sulfur gel 6-3%....................... 160
NUPLAZID -pimavanserin tartrate tab 17 mg (base
equivalent)....................................................................... 86
NUTRESTORE -glutamine powd pack 5 gm.................. 133
NUTRICAP -multiple vitamins w/ minerals tab................125
NUTRIDOX -doxycycline monohyd cap 75 mg w/ omega
3-vit e cap kit.................................................................... 5
NUTRIVIT -b-complex w/ lysine-min-fe & fa liqd 800-15-1
mg/15ml......................................................................... 125
NUTROPIN AQ NUSPIN 10 -somatropin inj 10
mg/2ml............................................................................. 37
NUTROPIN AQ NUSPIN 20 -somatropin inj 20
mg/2ml............................................................................. 37
NUTROPIN AQ NUSPIN 5 -somatropin inj 5 mg/2ml....... 37
NUTROPIN AQ PEN -somatropin inj 10 mg/2ml.............. 37
NUTROPIN AQ PEN -somatropin inj 20 mg/2ml.............. 37
NUVARING -etonogestrel-ethinyl estradiol va ring
0.120-0.015 mg/24hr...................................................... 25
NUVESSA -metronidazole vaginal gel 1.3%.....................77
NUVIGIL -armodafinil tab 50 mg....................................... 93
NUVIGIL -armodafinil tab 150 mg..................................... 93
NUWIQ -antihemophilic factor (recombinant) for inj kit 250
unit................................................................................. 142
NUWIQ -antihemophilic factor (recombinant) for inj kit 500
unit................................................................................. 142
NUWIQ -antihemophilic factor (recombinant) for inj kit
1000 unit....................................................................... 142
NUWIQ -antihemophilic factor (recombinant) for inj kit
2000 unit....................................................................... 142
NUWIQ -antihemophilic factor (recombinant) for inj 250
unit................................................................................. 142
unit................................................................................. 142
unit................................................................................. 142
unit................................................................................. 142
NYMALIZE -nimodipine oral soln 60 mg/20ml.................. 44
nystatin cream 100000 unit/gm.................................... 160
nystatin oint 100000 unit/gm........................................ 160
nystatin oral powder..........................................................7
nystatin susp 100000 unit/ml....................................... 149
nystatin tab 500000 unit....................................................7
nystatin topical powder................................................ 160
nystatin-triamcinolone cream 100000-0.1 unit/gm%.................................................................................... 160
nystatin-triamcinolone oint 100000-0.1 unit/gm%.................................................................................... 160
O
OB COMPLETE/DHA -prenat w/ iron cbn-fe asp glyc-faomega cap 30-10-1-200 mg......................................... 126
OB COMPLETE GOLD -prenat w/o a w/fecbn-methfol-fadha cap 27.5-1-200 mg................................................ 126
OB COMPLETE ONE -prenatal w/o a w/fecbn-fe asp
glyc-fa-fish cap 50-1-476 mg........................................126
227
2016
OB COMPLETE PETITE -prenat w/o a w/fecbnfeaspglyc-fa-omega cap 35-5-1-200 mg...................... 126
OB COMPLETE PREMIER -prenatal vit w/ fe cbn-fe asp
glyc-fa tab 30-20-1 mg................................................. 126
OB COMPLETE -prenatal vit w/ iron carbonyl-fa tab
50-1.25 mg.................................................................... 126
OBIZUR -antihemophilic factor (recomb porc) rpfviii for inj
500 unit......................................................................... 142
OBREDON -hydrocodone-guaifenesin soln 2.5-200
mg/5ml............................................................................. 63
OBSTETRIX DHA -prenat w/fecbn-fa-dss tab 29-1 mg &
omega 3 cap 387 mg pak............................................ 126
OBSTETRIX EC -prenatal vit w/ dss-iron carbonyl-fa tab
29-1 mg......................................................................... 126
OCALIVA -obeticholic acid tab 5 mg................................. 74
OCALIVA -obeticholic acid tab 10 mg............................... 74
O-CAL PRENATAL -prenatal vit w/ fe fumarate-fa tab 15-1
mg.................................................................................. 126
octreotide acetate inj 50 mcg/ml (0.05 mg/ml)
(Sandostatin)................................................................. 37
(Sandostatin)................................................................. 37
(Sandostatin)................................................................. 37
(Sandostatin)................................................................. 37
octreotide acetate inj 1000 mcg/ml (1 mg/ml)
(Sandostatin)................................................................. 37
OCUFEN -flurbiprofen sodium ophth soln 0.03%........... 146
OCUFLOX -ofloxacin ophth soln 0.3%........................... 146
OCUVEL -multiple vitamins w/ minerals & fa cap 0.5
mg.................................................................................. 126
ODEFSEY -emtricitabine-rilpivirine-tenofovir af tab
200-25-25 mg.................................................................... 9
ODOMZO -sonidegib phosphate cap 200 mg (base
equivalent)....................................................................... 17
OFEV -nintedanib esylate cap 100 mg (base
equivalent)....................................................................... 68
OFEV -nintedanib esylate cap 150 mg (base
equivalent)....................................................................... 68
OFLOXACIN -ofloxacin tab 400 mg.................................... 6
ofloxacin ophth soln 0.3% (Ocuflox)........................... 146
ofloxacin otic soln 0.3%................................................148
OGESTREL -norgestrel & ethinyl estradiol tab 0.5 mg-50
mcg.................................................................................. 25
olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax)...... 97
olanzapine-fluoxetine hcl cap 12-25 mg
(Symbyax)...................................................................... 97
olanzapine-fluoxetine hcl cap 12-50 mg
(Symbyax)...................................................................... 97
olanzapine orally disintegrating tab 5 mg (Zyprexa
zydis)...............................................................................86
zydis)...............................................................................86
zydis)...............................................................................86
zydis)...............................................................................86
olanzapine tab 2.5 mg (Zyprexa)................................... 86
olanzapine tab 5 mg (Zyprexa)...................................... 86
olanzapine tab 7.5 mg (Zyprexa)................................... 86
olanzapine tab 10 mg (Zyprexa).................................... 86
olopatadine hcl nasal soln 0.6% (Patanase).................61
olopatadine hcl ophth soln 0.1% (base equivalent)
(Patanol)....................................................................... 146
OLUX -clobetasol propionate foam 0.05%......................160
OLUX-E -clobetasol propionate emulsion foam
0.05%.............................................................................160
OLYSIO -simeprevir sodium cap 150 mg (base
equivalent)......................................................................... 9
OMECLAMOX-PAK -amoxicillin cap-clarithro tab w/
omepraz cap dr therapy pack........................................ 70
OMEGA-3/D-3 WELLNESS PACK -omega-3-acid ethyl
esters cap 1gm & vit d3 cap 1000 unit kit......................57
omega-3-acid ethyl esters cap 1 gm (Lovaza)............. 57
omeprazole cap delayed release 10 mg (Prilosec)...... 70
omeprazole-sodium bicarbonate cap 20-1100 mg
(Zegerid)......................................................................... 70
omeprazole-sodium bicarbonate cap 40-1100 mg
(Zegerid)......................................................................... 70
OMNARIS -ciclesonide nasal susp 50 mcg/act................ 61
OMNIFLEX DIAPHRAGM -diaphragms.......................... 169
OMNI GEL -stannous fluoride gel 0.4%.......................... 149
OMNIPRED -prednisolone acetate ophth susp 1%........ 146
OMNITROPE -somatropin for inj 5.8 mg.......................... 37
OMNITROPE -somatropin inj 5 mg/1.5ml......................... 37
OMNITROPE -somatropin inj 10 mg/1.5ml....................... 37
ondansetron hcl oral soln 4 mg/5ml (Zofran)............... 72
ondansetron hcl tab 24 mg............................................ 72
ondansetron hcl tab 4 mg (Zofran)................................72
ondansetron hcl tab 8 mg (Zofran)................................72
ondansetron orally disintegrating tab 4 mg (Zofran
odt).................................................................................. 72
ondansetron orally disintegrating tab 8 mg (Zofran
odt).................................................................................. 72
ONE FLOW FVC MONITORING S -respiratory therapy
ONE FLOW FVC MONITORING S -respiratory therapy
supplies - kit.................................................................. 169
ONETOUCH ULTRA BLUE -glucose blood test strip..... 167
ONETOUCH ULTRA TEST STRIP -glucose blood test
strip................................................................................ 167
ONETOUCH VERIO TEST STRIP -glucose blood test
strip................................................................................ 167
ONEXTON -clindamycin phosphate-benzoyl peroxide gel
1.2-3.75%...................................................................... 160
ONFI -clobazam suspension 2.5 mg/ml.......................... 117
228
2016
ONFI -clobazam tab 10 mg............................................. 117
ONFI -clobazam tab 20 mg............................................. 117
ONGLYZA -saxagliptin hcl tab 2.5 mg (base equiv)......... 29
ONGLYZA -saxagliptin hcl tab 5 mg (base equiv)............ 29
ONMEL -itraconazole tab 200 mg....................................... 7
ONZETRA XSAIL -sumatriptan succinate exhaler powder
11 mg/nosepiece........................................................... 112
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 5 mg....................................................... 104
er 12hr deter 7.5 mg.................................................... 104
er 12hr deter 10 mg..................................................... 104
er 12hr deter 15 mg..................................................... 104
er 12hr deter 20 mg..................................................... 104
er 12hr deter 30 mg..................................................... 105
er 12hr deter 40 mg..................................................... 105
OPANA -oxymorphone hcl tab 5 mg............................... 104
OPANA -oxymorphone hcl tab 10 mg............................. 104
ophthalmic irrigation solution - intraocular (Bss
plus).............................................................................. 146
opium tincture 1% (10 mg/ml) (morphine equiv)..........69
OPSUMIT -macitentan tab 10 mg..................................... 59
OPTIONS CONCEPTROL VAGINA -nonoxynol-9 gel
4%.................................................................................... 77
OPTIONS GYNOL II VAGINAL -nonoxynol-9 gel 3%....... 77
ORACEA -doxycycline (rosacea) cap delayed release 40
mg.................................................................................. 160
ORACIT -sodium citrate & citric acid soln 490-640
mg/5ml............................................................................. 78
ORAFATE -sucralfate-malate paste 10%........................ 149
ORALAIR ADULT SAMPLE KIT -grass mixed pollen ext
tab sl 300 ir (index of reactivity)..................................... 14
ORALAIR ADULT STARTER PAC -grass mixed pollen ext
tab sl 300 ir (index of reactivity)..................................... 14
ORALAIR CHILDREN/ADOLESCE -grass mixed pollen
ext tab sl 100 ir (index of reactivity)............................... 14
ORALAIR CHILDREN/ADOLESCE -grass mixed pollen
tab sl therpak 100 (3) ir & 300 (6) ir.............................. 14
ORALAIR -grass mixed pollen ext tab sl 300 ir (index of
reactivity)......................................................................... 14
ORAP -pimozide tab 1 mg................................................ 97
ORAP -pimozide tab 2 mg................................................ 97
ORAPRED ODT -prednisolone sod phos orally disintegr
tab 10 mg (base eq)....................................................... 19
tab 15 mg (base eq)....................................................... 19
tab 30 mg (base eq)....................................................... 19
ORAVIG -miconazole buccal tab 50 mg (mouththroat)............................................................................ 149
ORENCIA -abatacept subcutaneous soln prefilled syringe
125 mg/ml..................................................................... 110
ORENCIA CLICKJET -abatacept subcutaneous soln
auto-injector 125 mg/ml................................................ 110
ORENITRAM -treprostinil diolamine tab cr 0.125 mg
(base equiv).................................................................... 59
ORENITRAM -treprostinil diolamine tab cr 0.25 mg (base
equiv)............................................................................... 59
ORENITRAM -treprostinil diolamine tab cr 1 mg (base
equiv)............................................................................... 59
ORENITRAM -treprostinil diolamine tab cr 2.5 mg (base
equiv)............................................................................... 59
ORFADIN -nitisinone cap 2 mg......................................... 37
ORFADIN -nitisinone cap 5 mg......................................... 37
ORFADIN -nitisinone cap 10 mg....................................... 37
ORFADIN -nitisinone susp 4 mg/ml.................................. 37
ORKAMBI -lumacaftor-ivacaftor tab 200-125 mg............. 68
orphenadrine citrate tab sr 12hr 100 mg.................... 122
ORTHO-CYCLEN -norgestimate & ethinyl estradiol tab
0.25 mg-35 mcg.............................................................. 25
ORTHO D -folic acid-cholecalciferol cap 1 mg-3775
unit................................................................................. 136
ORTHO DIAPHRAGM COIL SPRI -diaphragm coil spring
kit 50 mm...................................................................... 169
kit 100 mm.................................................................... 169
kit 105 mm.................................................................... 169
ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring
kit 55 mm...................................................................... 169
kit 60 mm...................................................................... 169
kit 65 mm...................................................................... 170
kit 70 mm...................................................................... 170
kit 75 mm...................................................................... 170
kit 80 mm...................................................................... 170
kit 85 mm...................................................................... 170
kit 90 mm...................................................................... 170
kit 95 mm...................................................................... 170
ORTHO EVRA -norelgestromin-ethinyl estradiol td ptwk
150-35 mcg/24hr............................................................. 25
ORTHO MICRONOR -norethindrone tab 0.35 mg............25
ORTHO-NOVUM 7/7/7 -norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg.......................................... 25
ORTHO-NOVUM 1/35 -norethindrone & ethinyl estradiol
tab 1 mg-35 mcg............................................................ 25
ORTHO TRI-CYCLEN LO -norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg................................. 25
ORTHO TRI-CYCLEN -norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg................................. 25
OSENI -alogliptin-pioglitazone tab 12.5-15 mg................. 29
229
2016
OSENI -alogliptin-pioglitazone tab 25-15 mg.................... 30
OSMOPREP -sod phos mono-sod phos di tabs
1.102-0.398 gm(1.5gm na phos).................................... 68
OSPHENA -ospemifene tab 60 mg................................... 37
OTEZLA -apremilast tab 30 mg...................................... 110
OTEZLA -apremilast tab starter therapy pack 10 mg & 20
mg & 30 mg.................................................................. 110
OTICIN HC NR -pramoxine-hc-chloroxylenol otic soln
10-10-1 mg/ml............................................................... 148
OTREXUP -methotrexate soln pf auto-injector 7.5
mg/0.4ml........................................................................ 110
OTREXUP -methotrexate soln pf auto-injector 10
mg/0.4ml........................................................................ 110
mg/0.4ml........................................................................ 110
mg/0.4ml........................................................................ 110
mg/0.4ml........................................................................ 110
mg/0.4ml........................................................................ 110
mg/0.4ml........................................................................ 110
OVACE PLUS -sulfacetamide sodium cream 10%......... 160
OVACE PLUS -sulfacetamide sodium foam 9.8%.......... 160
OVACE PLUS -sulfacetamide sodium lotion 9.8%......... 160
OVACE PLUS -sulfacetamide sodium shampoo
10%................................................................................160
OVACE PLUS WASH -sulfacetamide sodium cleansing
gel 10%......................................................................... 160
OVACE PLUS WASH -sulfacetamide sodium liquid
10%................................................................................160
OVACE WASH -sulfacetamide sodium liquid 10%......... 160
OVCON-35 -norethindrone & ethinyl estradiol tab 0.4
mg-35 mcg...................................................................... 26
OVIDE -malathion lotion 0.5%........................................ 160
OVIDREL– Benefit Limits may apply -choriogonadotropin
alfa inj 250 mcg/0.5ml.................................................... 37
OXANDRIN -oxandrolone tab 2.5 mg............................... 21
OXANDRIN -oxandrolone tab 10 mg................................ 21
oxandrolone tab 2.5 mg (Oxandrin).............................. 21
oxandrolone tab 10 mg (Oxandrin)............................... 21
oxaprozin tab 600 mg (Daypro)................................... 110
OXAYDO -oxycodone hcl tab abuse deter 5 mg............ 105
OXAYDO -oxycodone hcl tab abuse deter 7.5 mg..........105
oxazepam cap 10 mg...................................................... 79
oxazepam cap 15 mg...................................................... 79
oxazepam cap 30 mg...................................................... 79
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
(Trileptal)...................................................................... 117
oxcarbazepine tab 150 mg (Trileptal).......................... 117
oxiconazole nitrate cream 1% (Oxistat)...................... 160
OXISTAT -oxiconazole nitrate cream 1%........................ 160
OXISTAT -oxiconazole nitrate lotion 1%......................... 160
OXSORALEN -methoxsalen lotion 1%........................... 160
OXSORALEN ULTRA -methoxsalen rapid cap 10
mg.................................................................................. 160
OXTELLAR XR -oxcarbazepine tab sr 24hr 150 mg...... 117
oxybutynin chloride syrup 5 mg/5ml............................ 76
oxybutynin chloride tab 5 mg........................................ 76
oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)..... 76
oxybutynin chloride tab sr 24hr 10 mg (Ditropan
xl)..................................................................................... 76
oxybutynin chloride tab sr 24hr 15 mg (Ditropan
xl)..................................................................................... 76
OXYCODONE/IBUPROFEN -oxycodone-ibuprofen tab
5-400 mg....................................................................... 105
oxycodone-aspirin tab 4.8355-325 mg
(Percodan).................................................................... 105
oxycodone hcl cap 5 mg.............................................. 105
oxycodone hcl conc 100 mg/5ml (20 mg/ml)
(Oxycodone hcl).......................................................... 105
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
10 mg............................................................................ 105
15 mg............................................................................ 105
20 mg............................................................................ 105
30 mg............................................................................ 105
40 mg............................................................................ 105
60 mg............................................................................ 105
80 mg............................................................................ 105
oxycodone hcl soln 5 mg/5ml (Oxycodone hcl).........105
oxycodone hcl tab 10 mg............................................. 105
oxycodone hcl tab 20 mg............................................. 105
oxycodone hcl tab 5 mg (Roxicodone)....................... 105
oxycodone hcl tab 15 mg (Roxicodone)..................... 105
oxycodone hcl tab 30 mg (Roxicodone)..................... 105
oxycodone w/ acetaminophen soln 5-325 mg/5ml
(Roxicet)....................................................................... 105
oxycodone w/ acetaminophen tab 2.5-325 mg
(Percocet)..................................................................... 105
oxycodone w/ acetaminophen tab 5-325 mg
(Percocet)..................................................................... 105
oxycodone w/ acetaminophen tab 7.5-325 mg
(Percocet)..................................................................... 105
oxycodone w/ acetaminophen tab 10-325 mg
(Percocet)..................................................................... 105
OXYCONTIN -oxycodone hcl tab er 12hr deter 10
mg.................................................................................. 105
mg.................................................................................. 105
230
2016
mg.................................................................................. 105
mg.................................................................................. 105
mg.................................................................................. 105
mg.................................................................................. 105
mg.................................................................................. 105
oxymorphone hcl tab 5 mg (Opana)............................106
oxymorphone hcl tab 10 mg (Opana)..........................106
oxymorphone hcl tab sr 12hr 5 mg............................. 105
oxymorphone hcl tab sr 12hr 7.5 mg.......................... 105
oxymorphone hcl tab sr 12hr 10 mg........................... 105
OXYTROL -oxybutynin td patch twice weekly 3.9
mg/24hr........................................................................... 76
P
paliperidone tab sr 24hr 1.5 mg (Invega)...................... 86
paliperidone tab sr 24hr 3 mg (Invega)......................... 86
PAMELOR -nortriptyline hcl cap 10 mg............................ 82
PAMINE FORTE -methscopolamine bromide tab 5
mg.................................................................................... 70
PAMINE FQ -methscopolamine tab 5 mg & misc intestinal
flora reg cap.................................................................... 70
PAMINE -methscopolamine bromide tab 2.5 mg.............. 70
PANATUSS DXP -phenylephrine-dexbromphen-dm-gg
liquid 5-1-15-100 mg/5ml................................................ 63
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
4200-10000-17500 unit...................................................72
10500-25000-43750 unit................................................ 72
16800-40000-70000 unit................................................ 72
21000-37000-61000 unit................................................ 72
PANDEL -hydrocortisone probutate cream 0.1%............ 160
PANRETIN -alitretinoin gel 0.1%..................................... 160
pantoprazole sodium ec tab 20 mg (base equiv)
(Protonix)........................................................................70
pantoprazole sodium ec tab 40 mg (base equiv)
(Protonix)........................................................................70
PARAFON FORTE DSC -chlorzoxazone tab 500 mg..... 122
PAREGORIC -paregoric tincture 2 mg/5ml....................... 69
PARI ALTERA NEBULIZER HAN -respiratory therapy
supplies - misc.............................................................. 170
paricalcitol cap 4 mcg..................................................... 38
paricalcitol cap 1 mcg (Zemplar)................................... 37
paricalcitol cap 2 mcg (Zemplar)................................... 37
PARI ERAPID NEBULIZER HAN -respiratory therapy
supplies - misc.............................................................. 170
PARI EXPIRATORY FILTER VA -respiratory therapy
supplies - misc.............................................................. 170
PARI LC PLUS PEDIATRIC KI -respiratory therapy
supplies - kit.................................................................. 170
PARI MANUAL INTERRUPTER -respiratory therapy
PARI MASK SET -respiratory therapy supplies misc............................................................................... 170
PARI SOFT PLASTIC ADULT M -respiratory therapy
supplies - misc.............................................................. 170
PARI SOFT PLASTIC PEDIATR -respiratory therapy
supplies - misc.............................................................. 170
PARI TREK S COMBO PACK -respiratory therapy
PARI TREK S PORTABLE POWE -respiratory therapy
supplies - kit.................................................................. 170
PARLODEL -bromocriptine mesylate cap 5 mg.............. 120
PARNATE -tranylcypromine sulfate tab 10 mg................. 82
paromomycin sulfate cap 250 mg................................... 6
paroxetine hcl tab 10 mg (Paxil).................................... 82
paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)............... 82
paroxetine hcl tab sr 24hr 25 mg (Paxil cr).................. 82
paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)............... 82
PASER -aminosalicylic acid cr granules packet 4 gm.........6
PATADAY -olopatadine hcl ophth soln 0.2% (base
equivalent)..................................................................... 146
PATANASE -olopatadine hcl nasal soln 0.6%................... 61
PATANOL -olopatadine hcl ophth soln 0.1% (base
equivalent)..................................................................... 146
PAXIL CR -paroxetine hcl tab sr 24hr 12.5 mg................. 83
PAXIL CR -paroxetine hcl tab sr 24hr 25 mg.................... 83
PAXIL CR -paroxetine hcl tab sr 24hr 37.5 mg................. 83
PAXIL -paroxetine hcl oral susp 10 mg/5ml (base
equiv)............................................................................... 83
PAXIL -paroxetine hcl tab 10 mg...................................... 83
PAZEO -olopatadine hcl ophth soln 0.7% (base
equivalent)..................................................................... 146
pb-hyoscy-atrop-scopol tab 16.2-0.1037-0.0194-0.0065
mg (Donnatal)................................................................ 70
PCE -erythromycin w/ enteric coated particles tab 333
mg...................................................................................... 3
PCE -erythromycin w/ enteric coated particles tab 500
mg...................................................................................... 3
PCP 100 -mag cit-bisacodyl-petrolat-pegmetoclopramide-electrol kit............................................. 68
PEDIAPRED -prednisolone sod phosph oral soln 6.7
mg/5ml (5 mg/5ml base)................................................ 19
231
2016
PEDIATRIC AEROSOL MASK -respiratory therapy
supplies - misc.............................................................. 170
PEDIATRIC COMPRESSOR NEBU -respiratory therapy
supplies - kit.................................................................. 170
pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/
ml................................................................................... 126
pediatric multiple vitamins w/ fluoride chew tab 0.25
mg................................................................................. 126
pediatric multiple vitamins w/ fluoride chew tab 1
mg................................................................................. 126
pediatric multiple vitamins w/ fluoride soln 0.25 mg/
ml................................................................................... 126
pediatric multiple vitamins w/ fluoride soln 0.5 mg/
ml................................................................................... 126
pediatric multiple vitamin w/ minerals & c drops 45
mg/ml............................................................................ 126
pediatric vitamins acd w/ fluoride soln 0.25 mg/
ml................................................................................... 126
pediatric vitamins acd w/ fluoride soln 0.5 mg/ml..... 126
PEGANONE -ethotoin tab 250 mg.................................. 117
PEGASYS -peginterferon alfa-2a inj 180 mcg/ml............... 9
PEGASYS -peginterferon alfa-2a inj 180 mcg/0.5ml.......... 9
PEGASYS PROCLICK -peginterferon alfa-2a inj 135
mcg/0.5ml.......................................................................... 9
PEGASYS PROCLICK -peginterferon alfa-2a inj 180
mcg/0.5ml........................................................................ 10
PEGINTRON -peginterferon alfa-2b for inj kit 50
mcg/0.5ml........................................................................ 10
mcg/0.5ml........................................................................ 10
mcg/0.5ml........................................................................ 10
mcg/0.5ml........................................................................ 10
PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for
inj kit 120 mcg/0.5ml........................................................ 9
PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit
50 mcg/0.5ml.....................................................................9
80 mcg/0.5ml.....................................................................9
120 mcg/0.5ml.................................................................. 9
150 mcg/0.5ml.................................................................. 9
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240
gm (Colyte-flavor packs)............................................. 68
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236
gm (Golytely)................................................................. 68
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
(Nulytely/flavor pack)................................................... 68
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...................................2
PENLAC NAIL LACQUER -ciclopirox solution 8%......... 160
PENNSAID -diclofenac sodium soln 2%......................... 160
PENTASA -mesalamine cap cr 250 mg............................ 74
PENTASA -mesalamine cap cr 500 mg............................ 74
pentazocine w/ naloxone tab 50-0.5 mg......................106
PENTETATE CALCIUM TRISODI -pentetate calcium
trisodium iv or inhalation soln 200 mg/ml.................... 167
PENTETATE ZINC TRISODIUM -pentetate zinc trisodium
iv or inhalation soln 200 mg/ml.................................... 167
pentoxifylline tab cr 400 mg......................................... 142
PEPCID -famotidine for susp 40 mg/5ml.......................... 71
PEPCID -famotidine tab 20 mg......................................... 71
PEPCID -famotidine tab 40 mg......................................... 71
PERCOCET -oxycodone w/ acetaminophen tab 2.5-325
mg.................................................................................. 106
PERCOCET -oxycodone w/ acetaminophen tab 5-325
mg.................................................................................. 106
PERCOCET -oxycodone w/ acetaminophen tab 7.5-325
mg.................................................................................. 106
PERCOCET -oxycodone w/ acetaminophen tab 10-325
mg.................................................................................. 106
PERCODAN -oxycodone-aspirin tab 4.8355-325 mg..... 106
PERFOROMIST -formoterol fumarate soln nebu 20
mcg/2ml........................................................................... 66
PERIDEX -chlorhexidine gluconate soln 0.12%............. 149
perindopril erbumine tab 2 mg...................................... 51
perindopril erbumine tab 4 mg (Aceon)........................ 51
perindopril erbumine tab 8 mg (Aceon)........................ 51
permethrin cream 5% (Elimite).................................... 160
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-10 mg................................................ 97
perphenazine tab 2 mg................................................... 86
perphenazine tab 16 mg................................................. 86
PERTZYE -pancrelipase (lip-prot-amyl) dr cap
8000-28750-30250 unit...................................................72
PERTZYE -pancrelipase (lip-prot-amyl) dr cap
16000-57500-60500 unit................................................ 72
PEXEVA -paroxetine mesylate tab 10 mg (base
equiv)............................................................................... 83
equiv)............................................................................... 83
equiv)............................................................................... 83
equiv)............................................................................... 83
PFLEX -respiratory therapy supplies - misc....................170
PHARMACY ADJUVANTS – VARIOUS.......................... 171
phenazopyridine hcl tab 100 mg (Pyridium).................78
phenazopyridine hcl tab 200 mg (Pyridium).................78
232
2016
PHENDIMETRAZINE TARTRATE -phendimetrazine
tartrate cap sr 24hr 105 mg........................................... 93
phendimetrazine tartrate tab 35 mg (Bontril pdm).......93
phenelzine sulfate tab 15 mg (Nardil)........................... 83
phenobarbital elixir 20 mg/5ml...................................... 89
PHENOBARBITAL -phenobarbital tab 15 mg................... 89
PHENOBARBITAL -phenobarbital tab 100 mg................. 89
phenobarbital tab 16.2 mg.............................................. 89
phenoxybenzamine hcl cap 10 mg (Dibenzyline)........ 51
phentermine hcl cap 15 mg............................................ 93
phentermine hcl cap 30 mg............................................ 93
phentermine hcl cap 37.5 mg (Adipex-p)...................... 93
phentermine hcl tab 37.5 mg (Adipex-p).......................93
phenylephrine-brompheniramine-dm liquid 7.5-4-15
mg/5ml............................................................................ 63
phenylephrine-guaifenesin liqd 7.5-100 mg/5ml (1.5-20
mg/ml)............................................................................. 63
phenylephrine hcl ophth soln 2.5%............................. 146
phenylephrine hcl ophth soln 10%.............................. 146
phenylephrine-promethazine w/ codeine syrup
5-6.25-10 mg/5ml........................................................... 63
phenylephrine w/ dm-gg liqd 10-15-300 mg/5ml.......... 63
phenylephrine w/ dm-gg liqd 2.5-5-50 mg/ml............... 63
phenylephrine w/ dm-gg liqd 2.5-7.5-88 mg/ml............ 63
PHENYLHISTINE DH -pseudoephedrine-chlorphen w/
codeine liq 30-2-10 mg/5ml............................................ 63
PHENYTEK -phenytoin sodium extended cap 200
mg.................................................................................. 117
PHENYTEK -phenytoin sodium extended cap 300
mg.................................................................................. 117
phenytoin chew tab 50 mg (Dilantin infatabs)............117
phenytoin sodium extended cap 100 mg
(Dilantin)....................................................................... 117
(Phenytek).................................................................... 117
(Phenytek).................................................................... 117
phenytoin susp 125 mg/5ml (Dilantin-125)................. 117
PHOS-FLUR ORTHO DEFENSE -sodium fluoride rinse
0.044%.......................................................................... 149
PHOS FLUR -sodium fluoride rinse 0.044%................... 149
PHOSLO -calcium acetate (phosphate binder) cap 667
mg (169 mg ca).............................................................. 74
PHOSLYRA -calcium acetate (phosphate binder) oral soln
667 mg/5ml..................................................................... 74
PHOSPHOLINE IODIDE -echothiophate iodide ophth for
soln 0.125%.................................................................. 146
PICATO -ingenol mebutate gel 0.015%.......................... 160
PICATO -ingenol mebutate gel 0.05%............................ 160
PILLOW MASK/ADULT -respiratory therapy supplies misc............................................................................... 170
PILLOW MASK/CHILD -respiratory therapy supplies misc............................................................................... 170
PILLOW MASK/PEDIATRIC -respiratory therapy supplies
- misc............................................................................. 170
pilocarpine hcl ophth soln 1% (Isopto carpine)......... 146
pilocarpine hcl tab 5 mg (Salagen)..............................149
pilocarpine hcl tab 7.5 mg (Salagen)...........................149
pimozide tab 1 mg (Orap)............................................... 97
pimozide tab 2 mg (Orap)............................................... 97
pindolol tab 5 mg............................................................. 41
pindolol tab 10 mg........................................................... 41
pioglitazone hcl-glimepiride tab 30-2 mg (Duetact)..... 30
pioglitazone hcl-glimepiride tab 30-4 mg (Duetact)..... 30
pioglitazone hcl-metformin hcl tab 15-500 mg
(Actoplus met)............................................................... 30
pioglitazone hcl-metformin hcl tab 15-850 mg
(Actoplus met)............................................................... 30
pioglitazone hcl tab 15 mg (base equiv) (Actos)..........30
piroxicam cap 10 mg (Feldene)................................... 110
piroxicam cap 20 mg (Feldene)................................... 110
PLAQUENIL -hydroxychloroquine sulfate tab 200 mg...... 12
PLAVIX -clopidogrel bisulfate tab 75 mg (base
equiv)............................................................................. 142
PLAVIX -clopidogrel bisulfate tab 300 mg (base
equiv)............................................................................. 142
PLEGRIDY -peginterferon beta-1a soln pen-injector 125
mcg/0.5ml........................................................................ 97
PLEGRIDY -peginterferon beta-1a soln prefilled syringe
125 mcg/0.5ml................................................................ 97
PLEGRIDY STARTER PACK -peginterferon beta-1a soln
pen-inj 63 & 94 mcg/0.5ml pack.................................... 97
PLEGRIDY STARTER PACK -peginterferon beta-1a soln
pref syr 63 & 94 mcg/0.5ml pack................................... 97
PLEXION CLEANSER -sulfacetamide sodium w/ sulfur
cleanser 9.8-4.8%......................................................... 161
PLEXION CLEANSING CLOTHS -sulfacetamide sodium
w/ sulfur cleansing cloth 9.8-4.8%............................... 161
PLEXION -sulfacetamide sodium w/ sulfur cream
9.8-4.8%........................................................................ 161
PLEXION -sulfacetamide sodium w/ sulfur lotion
9.8-4.8%........................................................................ 161
PLIAGLIS -lidocaine-tetracaine cream 7-7%.................. 161
PNV-DHA+DOCUSATE -prenatal w/o vit a w/ fe fum-dssfa-dha cap 27-1.25-300 mg.......................................... 126
PNV-DHA -prenat w/o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg........................................................ 126
PNV FERROUS FUMARATE/DOCU -prenatal vit w/ dssfe fumarate-fa tab 29-1 mg.......................................... 126
PNV OB+DHA -prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 250 mg pack...................................................126
PNV-OMEGA -prenat w/o a w/ fe fumerate-methylfolatefa-omega 3 cap............................................................. 126
233
2016
PNV-SELECT -prenatal vit w/ fe fum-methylfolate-fa tab
27-0.6-0.4 mg................................................................ 126
PNV TABS 29-1 -prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................. 126
PNV-TOTAL -prenat w/ fe cbn-fe bisglyc-fa-fish oil cap
35-5-1.2 mg................................................................... 126
PNV-VP-U -prenatal w/o a vit w/ fe fumarate-fa cap
106.5-1 mg.................................................................... 126
podofilox soln 0.5% (Condylox)................................... 161
polyethylene glycol 3350 oral packet............................ 68
polyethylene glycol 3350 oral powder.......................... 68
polymyxin b-trimethoprim ophth soln 10000 unit/
ml-0.1% (Polytrim)...................................................... 147
POLYTRIM -polymyxin b-trimethoprim ophth soln 10000
unit/ml-0.1%.................................................................. 147
POLY-TUSSIN AC -phenylephrine-bromphen w/ codeine
liquid 10-4-10 mg/5ml..................................................... 63
POLY-VI-FLOR/IRON -ped multiple vitamin w/ fl-fe
biphasic susp 0.25-7 mg/ml......................................... 127
POLY-VI-FLOR/IRON -ped multiple vit w/ fl-fe biphasic
chew tab 0.5-10 mg...................................................... 127
POLY-VI-FLOR FS -pediatric multiple vitamins w/ fluoride
oral strip 1 mg...............................................................126
POLY-VI-FLOR FS -pediatric multiple vit w/ fluoride oral
strip 0.25 mg................................................................. 126
POLY-VI-FLOR FS -pediatric multiple vit w/ fluoride oral
strip 0.5 mg................................................................... 126
POLY-VI-FLOR -ped multiple vit w/ fluoride biphasic chew
tab 0.25 mg................................................................... 126
tab 0.5 mg..................................................................... 126
tab 1 mg........................................................................ 126
POLY-VI-FLOR -ped multiple vit w/ fluoride biphasic susp
0.25 mg/ml.................................................................... 126
POMALYST -pomalidomide cap 1 mg.............................. 17
PONSTEL -mefenamic acid cap 250 mg........................ 110
pot & sod citrates w/ cit ac soln 550-500-334
mg/5ml............................................................................ 78
POTABA -potassium aminobenzoate cap 500 mg..........123
potassium bicarbonate effer tab 25 meq.................... 132
potassium chloride cap cr 8 meq (Micro-k)................ 132
potassium chloride cap cr 10 meq (Micro-k).............. 132
POTASSIUM CHLORIDE ER -potassium chloride tab cr 8
meq (600 mg)............................................................... 132
POTASSIUM CHLORIDE ER -potassium chloride tab cr
20 meq (1500 mg)........................................................ 132
potassium chloride microencapsulated crys cr tab 10
meq............................................................................... 132
potassium chloride microencapsulated crys cr tab 20
meq............................................................................... 132
potassium chloride oral soln 10% (20 meq/15ml)...... 132
potassium chloride oral soln 20% (40 meq/15ml)...... 132
potassium chloride powder packet 20 meq............... 132
potassium chloride tab cr 10 meq (K-tab).................. 132
potassium chloride tab cr 8 meq (600 mg)................. 132
potassium citrate & citric acid powder pack 3300-1002
mg................................................................................... 78
potassium citrate & citric acid soln 1100-334
mg/5ml............................................................................ 78
potassium citrate tab cr 5 meq (540 mg) (Urocit-k
5)...................................................................................... 78
10).................................................................................... 78
15).................................................................................... 78
pot bicarbonate & chloride effer tab 25 meq.............. 132
POTIGA -ezogabine tab 50 mg....................................... 117
POTIGA -ezogabine tab 200 mg..................................... 117
pot phos monobasic w/sod phos di & monobas tab
155-852-130mg (K-phos neutral)...............................132
PRADAXA -dabigatran etexilate mesylate cap 75 mg
(etexilate base eq)........................................................ 138
PRALUENT -alirocumab subcutaneous soln pen-injector
75 mg/ml......................................................................... 57
PRALUENT -alirocumab subcutaneous soln pen-injector
150 mg/ml....................................................................... 57
PRALUENT -alirocumab subcutaneous soln prefilled
syringe 75 mg/ml............................................................ 57
PRALUENT -alirocumab subcutaneous soln prefilled
syringe 150 mg/ml.......................................................... 57
pramipexole dihydrochloride tab 0.125 mg
(Mirapex).......................................................................120
(Mirapex).......................................................................120
(Mirapex).......................................................................120
(Mirapex).......................................................................120
pramipexole dihydrochloride tab 1 mg (Mirapex)...... 120
(Mirapex).......................................................................120
pramipexole dihydrochloride tab sr 24hr 0.375 mg
(Mirapex er).................................................................. 120
(Mirapex er).................................................................. 120
(Mirapex er).................................................................. 120
(Mirapex er).................................................................. 120
pramipexole dihydrochloride tab sr 24hr 3 mg
(Mirapex er).................................................................. 120
(Mirapex er).................................................................. 120
234
2016
(Mirapex er).................................................................. 120
PRAMOSONE E -pramoxine-hc emollient base cream
1-2.5%........................................................................... 161
PRAMOSONE -pramoxine-hc cream 1-1%.................... 161
PRAMOSONE -pramoxine-hc cream 1-2.5%................. 161
PRAMOSONE -pramoxine-hc lotion 1-1%...................... 161
PRAMOSONE -pramoxine-hc lotion 1-2.5%................... 161
PRAMOSONE -pramoxine-hc oint 1-1%.........................161
PRAMOSONE -pramoxine-hc oint 1-2.5%......................161
PRAMOTIC -pramoxine-chloroxylenol otic liquid
1-0.1%........................................................................... 148
pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml
(Cortane-b-otic)........................................................... 148
pramoxine-hc cream 1-2.5% (Pramosone)................. 161
PRANDIN -repaglinide tab 0.5 mg.................................... 30
PRANDIN -repaglinide tab 1 mg....................................... 30
PRANDIN -repaglinide tab 2 mg....................................... 30
PRASCION RA WITH SUNSCREE -sulfacetamide
sodium-sulfur-sunscreen cream 10-5%....................... 161
PRAVACHOL -pravastatin sodium tab 20 mg................... 57
pravastatin sodium tab 10 mg....................................... 57
pravastatin sodium tab 20 mg (Pravachol)...................57
prazosin hcl cap 1 mg (Minipress)................................ 51
PRECISION XTRA -ketone blood test strip.................... 167
PRECOSE -acarbose tab 25 mg...................................... 30
PRECOSE -acarbose tab 50 mg...................................... 30
PRECOSE -acarbose tab 100 mg.................................... 30
PRED FORTE -prednisolone acetate ophth susp
1%.................................................................................. 147
PRED-G -gentamicin-prednisolone ace ophth susp
0.3-1%........................................................................... 147
PRED-G S.O.P. -gentamicin-prednisolone ace ophth oint
0.3-0.6%........................................................................ 147
PRED MILD -prednisolone acetate ophth susp
0.12%.............................................................................147
prednicarbate cream 0.1% (Dermatop)....................... 161
prednicarbate oint 0.1% (Dermatop)........................... 161
prednisolone acetate ophth susp 1% (Pred forte)..... 147
PREDNISOLONE SODIUM PHOSP -prednisolone
sodium phosphate ophth soln 1%................................ 147
PREDNISOLONE SODIUM PHOSP -prednisolone
sodium phosphate oral soln 25 mg/5ml (base eq)......... 20
prednisolone sod phos orally disintegr tab 10 mg
(base eq) (Orapred odt)............................................... 19
prednisolone sod phosphate oral soln 15 mg/5ml
(base equiv)................................................................... 20
prednisolone sod phosph oral soln 6.7 mg/5ml (5
mg/5ml base) (Pediapred)............................................20
prednisolone syrup 15 mg/5ml (usp solution
equivalent)......................................................................20
PREDNISONE INTENSOL -prednisone conc 5 mg/ml..... 20
PREDNISONE -prednisone oral soln 5 mg/5ml................ 20
PREDNISONE -prednisone tab 50 mg............................. 20
PREDNISONE -prednisone tab therapy pack 5 mg
(21).................................................................................. 20
(48).................................................................................. 20
(21).................................................................................. 20
(48).................................................................................. 20
prednisone tab 1 mg....................................................... 20
prednisone tab 2.5 mg.................................................... 20
prednisone tab 5 mg....................................................... 20
prednisone tab 10 mg..................................................... 20
prednisone tab 20 mg..................................................... 20
PREFERAOB +DHA -prenat-fe poly cmplx 28mg-fe heme
poly-fa tab&dha cap pack.............................................127
PREFERAOB ONE -prenat-fe poly cmplx-fe heme polyfa-dha cap 22-6-1-200 mg............................................127
PREFEST -estradiol tab 1 mg(15)/estrad-norgestimate
tab 1-0.09mg(15)............................................................ 23
PRE-FOLIC -folic acid-vitamin c tab 1-100 mg............... 136
PREMARIN -estrogens, conjugated tab 0.3 mg............... 23
PREMARIN -estrogens, conjugated tab 0.45 mg............. 23
PREMARIN -estrogens, conjugated tab 0.625 mg........... 23
PREMARIN -estrogens, conjugated tab 0.9 mg............... 23
PREMARIN -estrogens, conjugated tab 1.25 mg............. 23
PREMARIN -estrogens, conjugated vaginal cream 0.625
mg/gm.............................................................................. 77
PREMPHASE -conj est 0.625(14)/conj est-medroxypro ac
tab 0.625-5mg(14).......................................................... 23
PREMPRO -conjugated estrogen-medroxyprogest
acetate tab 0.3-1.5 mg................................................... 23
acetate tab 0.45-1.5 mg................................................. 23
acetate tab 0.625-2.5 mg............................................... 23
acetate tab 0.625-5 mg.................................................. 23
PRENA1 CHEW -prenat w/ b2-b6-b12-d3-folic acid chew
tab 1.4 mg..................................................................... 128
PRENAISSANCE BALANCE -prenatal w/o vit a w/ fe cbndss-fa-dha cap 30-1-260 mg........................................ 127
PRENAISSANCE HARMONY DHA -prenat w/fe poly-na
fered-fa tab 27-1 & omega cap dr 380mg....................127
PRENAISSANCE NEXT-B -prenatal w/ calcium-vit b6-faginger tab 1.22 mg....................................................... 127
PRENAISSANCE NEXT -prenatal w/ calcium-vit b6-faginger tab 1.2 mg......................................................... 127
PRENAISSANCE PLUS -prenatal w/o a w/fe cbn-dss-fadha cap 28-1-250 mg................................................... 127
235
2016
PRENAISSANCE -prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg..................................................... 127
PRENA1 PEARL -prenat w/oa w/fefum-na fered-fa-dha
cap cr 30-1.4-200 mg................................................... 128
PRENATABS FA -prenatal vit w/ fe fumarate-fa tab 29-1
mg.................................................................................. 127
PRENATABS RX -prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................. 127
PRENATAL PLUS IRON -prenatal vit w/ iron carbonyl-fa
tab 29-1 mg...................................................................127
PRENATAL 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg.................................................................................. 127
PRENATAL 19 -prenatal vit w/ fe fumarate-fa chew tab
29-1 mg......................................................................... 127
PRENATAL-U -prenatal w/o a vit w/ fe fumarate-fa cap
106.5-1 mg.................................................................... 127
PRENATE DHA -prenat w/o a w/feaspg-methfol-fa-dha
cap 18-0.6-0.4-300 mg................................................. 127
PRENATE DHA -prenat w/o a w/fefum-methfol-fa-dha cap
28-0.6-0.4-300 mg........................................................ 127
PRENATE ELITE -prenatal vit w/ fe fum-methylfolate-fa
tab 26-0.6-0.4 mg......................................................... 127
PRENATE ELITE -prenatal w/ fe asp gly-l methylfol-fa tab
20-0.6-0.4 mg................................................................ 127
PRENATE ENHANCE -prenat w/o a w/fefum-methfol-fadha cap 28-0.6-0.4-400 mg.......................................... 127
PRENATE ESSENTIAL -prenat w/o a w/feaspg-methfolfa-dha cap 18-0.6-0.4-300 mg..................................... 127
PRENATE ESSENTIAL -prenat w/o a w/feasp-methylf-faomeg cap 29-0.6-0.4-340 mg....................................... 127
PRENATE MINI -prenat w/oa w/fecb-feasp-meth-fa-dha
cap 18-0.6-0.4-350 mg................................................. 127
PRENATE MINI -prenat w/o a w/fecbn-methylf-fa-dha cap
29-0.6-0.4-350 mg........................................................ 127
PRENATE PIXIE -prenat w/o a w/feaspg-methfol-fa-dha
cap 10-0.6-0.4-200 mg................................................. 128
PRENATE -prenat mv & min w/ l-methylfolate-fa chew tab
0.6-0.4 mg..................................................................... 127
PRENATE RESTORE -prenat w/o a w/fefum-methfol-fadha cap 27-0.6-0.4-400 mg.......................................... 128
PRENATE STAR -prenatal vit w/ fe asparto glycinate-fa
tab 20-1 mg...................................................................128
PRENTIF CAVITY-RIM CERVIC -cervical cap 22
mm................................................................................. 170
mm................................................................................. 170
mm................................................................................. 170
mm................................................................................. 170
PRENTIF FITTING SET -cervical caps........................... 170
PREPIDIL -dinoprostone cervical gel 0.5 mg/3gm............34
PREPOPIK -sod picosulfate-mg oxide-citric acid pack 10
mg-3.5 gm-12 gm........................................................... 68
PREQUE 10 -prenatal mv w/fe carbonyl-dss-fa-dha tab
15-25-0.5-50 mg........................................................... 128
PRESERA -dermatological products, misc. - aerosol
foam............................................................................... 161
PRESTALIA -perindopril arginine-amlodipine besylate tab
3.5-2.5 mg....................................................................... 51
7-5 mg............................................................................. 51
14-10 mg......................................................................... 51
PREVACID -lansoprazole cap delayed release 15 mg..... 71
PREVACID -lansoprazole cap delayed release 30 mg..... 71
PREVACID SOLUTAB -lansoprazole tab delayed release
orally disintegrating 15 mg............................................. 71
PREVACID SOLUTAB -lansoprazole tab delayed release
orally disintegrating 30 mg............................................. 71
PREVIDENT 5000 BOOSTER PL -sodium fluoride paste
1.1%...............................................................................150
PREVIDENT 5000 BOOSTER -sodium fluoride paste
1.1%...............................................................................150
PREVIDENT 5000 DRY MOUTH -sodium fluoride gel
1.1% (0.5% f)................................................................ 150
PREVIDENT 5000 ENAMEL PRO -sodium fluoridepotassium nitrate paste 1.1-5%................................... 150
PREVIDENT FLUORIDE -sodium fluoride gel 1.1% (0.5%
f)..................................................................................... 150
PREVIDENT 5000 PLUS -sodium fluoride cream
1.1%...............................................................................150
PREVIDENT 5000 SENSITIVE -sodium fluoridepotassium nitrate paste 1.1-5%................................... 150
PREVIDENT -sodium fluoride rinse 0.2%....................... 149
PREVPAC -amoxicillin cap-clarithro tab-lansopraz cap dr
therapy pack................................................................... 71
PREZCOBIX -darunavir-cobicistat tab 800-150 mg..........10
PREZISTA -darunavir ethanolate susp 100 mg/ml (base
equiv)............................................................................... 10
PREZISTA -darunavir ethanolate tab 75 mg (base
equiv)............................................................................... 10
equiv)............................................................................... 10
equiv)............................................................................... 10
equiv)............................................................................... 10
PRIFTIN -rifapentine tab 150 mg........................................ 6
PRILOSEC -omeprazole cap delayed release 10 mg.......71
PRILOSEC -omeprazole magnesium for delayed release
susp packet 2.5 mg........................................................ 71
PRILOSEC -omeprazole magnesium for delayed release
susp packet 10 mg......................................................... 71
PRIMAQUINE PHOSPHATE -primaquine phosphate tab
26.3 mg (15 mg base).................................................... 12
PRIMEAIRE DUAL-VALVED HOL -respiratory therapy
primidone tab 50 mg (Mysoline).................................. 117
primidone tab 250 mg (Mysoline)................................ 117
236
2016
PRIMLEV -oxycodone w/ acetaminophen tab 5-300
mg.................................................................................. 106
PRIMLEV -oxycodone w/ acetaminophen tab 7.5-300
mg.................................................................................. 106
PRIMLEV -oxycodone w/ acetaminophen tab 10-300
mg.................................................................................. 106
PRIMSOL -trimethoprim hcl oral soln 50 mg/5ml (base
equiv)............................................................................... 13
PRINIVIL -lisinopril tab 5 mg............................................. 51
PRINIVIL -lisinopril tab 10 mg........................................... 51
PRINIVIL -lisinopril tab 20 mg........................................... 51
PRISTIQ -desvenlafaxine succinate tab sr 24hr 25 mg
(base equiv).................................................................... 83
(base equiv).................................................................... 83
(base equiv).................................................................... 83
PR NATAL 400 EC -prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 400 pk................................................... 127
PR NATAL 430 EC -prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 430 pk................................................... 127
PR NATAL 400 -prenat-fe bis-fe prot succ-fa-ca tab &
omega 3 cap 400 pk.................................................... 127
PR NATAL 430 -prenat-fe bis-fe prot succ-fa-ca tab &
omega 3 cap 430 pk.................................................... 127
PROAIR HFA -albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv)........................................................ 66
PROAIR RESPICLICK -albuterol sulfate aer pow ba 108
mcg/act (90 mcg base equiv)......................................... 66
probenecid tab 500 mg................................................. 113
PROCARDIA -nifedipine cap 10 mg................................. 44
PROCARDIA XL -nifedipine tab sr 24hr osmotic release
30 mg.............................................................................. 44
60 mg.............................................................................. 44
90 mg.............................................................................. 44
PROCENTRA -dextroamphetamine sulfate oral solution 5
mg/5ml............................................................................. 93
prochlorperazine maleate tab 5 mg (base equivalent)
(Compazine)................................................................... 86
prochlorperazine maleate tab 10 mg (base equivalent)
(Compazine)................................................................... 86
prochlorperazine suppos 25 mg.................................... 86
PRO-CLEAR AC -codeine-pyrilamine syrup 9-8.33
mg/5ml............................................................................. 63
PROCORT -hydrocortisone acetate w/ pramoxine rectal
cream 1.85-1.15%........................................................ 151
PROCRIT -epoetin alfa inj 2000 unit/ml.......................... 136
PROCRIT -epoetin alfa inj 10000 unit/ml........................ 136
PROCTOCORT -hydrocortisone acetate suppos 30
mg.................................................................................. 151
PROCTOCORT -hydrocortisone rectal cream 1%.......... 151
PROCTOFOAM HC -hydrocortisone acetate w/
pramoxine rectal foam 1-1%........................................ 151
PROCYSBI -cysteamine bitartrate cap delayed release 25
mg (base equiv).............................................................. 78
PROCYSBI -cysteamine bitartrate cap delayed release 75
mg (base equiv).............................................................. 78
PRODRIN -isometheptene-caffeine-acetaminophen tab
65-20-325 mg................................................................112
PROFERRIN-FORTE -iron heme polypeptide-folic acid
tab 12-1 mg (fe equiv).................................................. 136
PROFILNINE -factor ix complex for inj 500 unit............. 142
PROFILNINE -factor ix complex for inj 1000 unit........... 142
PROFILNINE -factor ix complex for inj 1500 unit........... 142
PROFILNINE SD -factor ix complex for inj 500 unit........142
PROFILNINE SD -factor ix complex for inj 1000 unit......142
PROFILNINE SD -factor ix complex for inj 1500 unit......142
progesterone im in oil 50 mg/ml.................................... 26
progesterone micronized cap 100 mg
(Prometrium).................................................................. 26
progesterone micronized cap 200 mg
(Prometrium).................................................................. 26
PROGLYCEM -diazoxide susp 50 mg/ml......................... 30
PROGRAF -tacrolimus cap 0.5 mg................................. 172
PROGRAF -tacrolimus cap 1 mg.................................... 172
PROGRAF -tacrolimus cap 5 mg.................................... 172
PROLENSA -bromfenac sodium ophth soln 0.07% (base
equivalent)..................................................................... 147
PROMACTA -eltrombopag olamine tab 12.5 mg (base
equiv)............................................................................. 136
PROMACTA -eltrombopag olamine tab 25 mg (base
equiv)............................................................................. 136
equiv)............................................................................. 136
equiv)............................................................................. 136
promethazine & phenylephrine syrup 6.25-5
mg/5ml............................................................................ 63
promethazine-dm syrup 6.25-15 mg/5ml.......................63
promethazine hcl suppos 12.5 mg................................ 61
promethazine hcl suppos 25 mg................................... 61
promethazine hcl suppos 50 mg................................... 61
promethazine hcl syrup 6.25 mg/5ml............................ 61
promethazine hcl tab 12.5 mg........................................ 61
promethazine hcl tab 25 mg........................................... 61
promethazine hcl tab 50 mg........................................... 61
promethazine w/ codeine syrup 6.25-10 mg/5ml..........63
PROMETRIUM -progesterone micronized cap 100
mg.................................................................................... 26
PROMETRIUM -progesterone micronized cap 200
mg.................................................................................... 26
PROMISEB -antiseborrheic products misc - cream........ 161
PROMISEB COMPLETE -antiseborrheic products misc kit................................................................................... 161
propafenone hcl cap sr 12hr 225 mg (Rythmol sr)...... 45
propafenone hcl tab 300 mg.......................................... 45
237
2016
propafenone hcl tab 150 mg (Rythmol)........................ 45
propafenone hcl tab 225 mg (Rythmol)........................ 45
PROPANTHELINE BROMIDE -propantheline bromide tab
15 mg.............................................................................. 71
proparacaine hcl ophth soln 0.5% (Alcaine).............. 147
PROPRANOLOL/HYDROCHLOROTH -propranolol &
PROPRANOLOL/HYDROCHLOROTH -propranolol &
propranolol hcl cap sr 24hr 60 mg (Inderal la)............. 41
propranolol hcl cap sr 24hr 80 mg (Inderal la)............. 41
propranolol hcl cap sr 24hr 120 mg (Inderal la)........... 41
propranolol hcl cap sr 24hr 160 mg (Inderal la)........... 42
PROPRANOLOL HCL -propranolol hcl oral soln 20
mg/5ml............................................................................. 41
PROPRANOLOL HCL -propranolol hcl oral soln 40
mg/5ml............................................................................. 41
propranolol hcl tab 10 mg.............................................. 42
propylthiouracil tab 50 mg............................................. 33
PRO-RED AC -phenylephrine-dexchlorphenir-codeine
syrup 5-1-9 mg/5ml.........................................................63
PROSCAR -finasteride tab 5 mg...................................... 78
PROSTIN E2 -dinoprostone vaginal suppos 20 mg......... 34
PROTECTIRON -iron polysacch-fa-b complex-vit c-e &
minerals tab 60-1 mg................................................... 136
PROTECT PLUS -multiple vitamins w/ minerals cap......128
PROTHELIAL -sucralfate-malate paste 10%.................. 150
PROTONIX -pantoprazole sodium ec tab 20 mg (base
equiv)............................................................................... 71
PROTONIX -pantoprazole sodium ec tab 40 mg (base
equiv)............................................................................... 71
PROTONIX -pantoprazole sodium for delayed release
susp packet 40 mg......................................................... 71
PROTOPIC -tacrolimus oint 0.03%................................. 161
PROTOPIC -tacrolimus oint 0.1%................................... 161
protriptyline hcl tab 5 mg............................................... 83
protriptyline hcl tab 10 mg............................................. 83
PROVENTIL HFA -albuterol sulfate inhal aero 108 mcg/
act (90mcg base equiv).................................................. 66
PROVERA -medroxyprogesterone acetate tab 2.5
mg.................................................................................... 26
PROVERA -medroxyprogesterone acetate tab 5 mg....... 26
PROVERA -medroxyprogesterone acetate tab 10 mg..... 26
PROVIDA DHA -prenat w/o a w/fe fum-fe poly-fa-dha cap
16-16-1.25-110 mg........................................................128
PROVIDA OB -prenatal w/o a w/fe fum-fe poly-fa cap
20-20-1.25 mg...............................................................128
PROVIGIL -modafinil tab 100 mg..................................... 93
PROVIGIL -modafinil tab 200 mg..................................... 93
PROZAC -fluoxetine hcl cap 10 mg.................................. 83
PROZAC WEEKLY -fluoxetine hcl cap delayed release 90
mg.................................................................................... 83
PRUCLAIR -dermatological products misc - cream........ 161
PRUDOXIN -doxepin hcl cream 5%............................... 161
PRUMYX -dermatological products misc - cream...........161
pseudoeph-chlorphen w/ hydrocodone soln 60-4-5
mg/5ml (Zutripro).......................................................... 63
pseudoephed-bromphen-dm syrup 30-2-10
mg/5ml............................................................................ 63
pseudoephedrine-bromphen-codeine liq 10-1.33-6.33
mg/5ml............................................................................ 63
pseudoephedrine w/ cod-gg soln 30-10-100
mg/5ml............................................................................ 63
pseudoephedrine w/ cod-gg syrup 30-10-100 mg/5ml
(Suttar-sf)....................................................................... 63
PSORCON -diflorasone diacetate cream 0.05%............ 161
PTS PANELS KETONE TEST -ketone blood test
strip................................................................................ 167
PULMICORT -budesonide inhalation susp 0.25
mg/2ml............................................................................. 66
PULMICORT -budesonide inhalation susp 0.5
mg/2ml............................................................................. 66
PULMICORT -budesonide inhalation susp 1 mg/2ml....... 66
PULMICORT FLEXHALER -budesonide inhal aero powd
90 mcg/act (breath activated).........................................66
PULMICORT FLEXHALER -budesonide inhal aero powd
180 mcg/act (breath activated)...................................... 67
PULMO-AIDE COMPRESSOR/PUL -respiratory therapy
PULMO-AIDE LT COMPRESSOR/ -respiratory therapy
PULMO-AIDE TRAVELER COMPR -respiratory therapy
PULMONEB LT COMPRESSOR/NE -respiratory therapy
PULMONEB LT COMPRESSOR NE -respiratory therapy
PULMOZYME -dornase alfa inhal soln 1 mg/ml............... 68
PUREFE OB PLUS -prenatal w/o a w/fe fum-fe poly-fa
cap 162.115.2-1 mg...................................................... 128
PUREFE PLUS -ferrous fumarate-fa-b complex-c-zn-mgmn-cu cap 106-1 mg.................................................... 136
PURIXAN -mercaptopurine susp 2000 mg/100ml (20 mg/
ml).................................................................................... 17
PYLERA -bismuth subcit-metronidazole-tetracycline cap
140-125-125 mg..............................................................71
pyrazinamide tab 500 mg..................................................6
PYRIDIUM -phenazopyridine hcl tab 100 mg................... 78
PYRIDIUM -phenazopyridine hcl tab 200 mg................... 78
pyridostigmine bromide tab cr 180 mg (Mestinon
timespan)......................................................................122
pyridostigmine bromide tab 60 mg (Mestinon).......... 122
PYROGALLIC ACID -pyrogallol-chlorobutanol oint
25-2%............................................................................ 161
238
2016
Q
QNASL -beclomethasone dipropionate nasal aerosol 80
mcg/act............................................................................ 61
QNASL CHILDRENS -beclomethasone dipropionate
nasal aerosol 40 mcg/act............................................... 61
QSYMIA -phentermine hcl-topiramate cap sr 24hr 3.75-23
mg.................................................................................... 94
QSYMIA -phentermine hcl-topiramate cap sr 24hr 7.5-46
mg.................................................................................... 94
QSYMIA -phentermine hcl-topiramate cap sr 24hr
11.25-69 mg.................................................................... 94
QSYMIA -phentermine hcl-topiramate cap sr 24hr 15-92
mg.................................................................................... 94
QUAKE -respiratory therapy supplies - devices..............171
QUALAQUIN -quinine sulfate cap 324 mg........................12
QUARTETTE -levonor-eth est tab 0.15-0.02/0.025/0.03
mg &eth est 0.01 mg...................................................... 26
QUAZEPAM -quazepam tab 15 mg.................................. 89
QUDEXY XR -topiramate cap er 24hr sprinkle 25
mg.................................................................................. 117
mg.................................................................................. 117
mg.................................................................................. 117
mg.................................................................................. 117
mg.................................................................................. 117
QUESTRAN -cholestyramine powder 4 gm/dose............. 58
QUESTRAN -cholestyramine powder packets 4 gm........ 57
QUESTRAN LIGHT -cholestyramine light powder 4 gm/
dose................................................................................. 58
quetiapine fumarate tab 25 mg (Seroquel)................... 86
quetiapine fumarate tab 50 mg (Seroquel)................... 86
quetiapine fumarate tab 100 mg (Seroquel)................. 86
QUFLORA PEDIATRIC -pediatric multiple vitamins w/
fluoride soln 0.25 mg/ml............................................... 128
QUFLORA PEDIATRIC -pediatric multiple vitamins w/
fluoride soln 0.5 mg/ml................................................. 128
QUILLICHEW ER -methylphenidate hcl chew tab
extended release 20 mg.................................................94
QUILLIVANT XR -methylphenidate hcl for er susp 25
mg/5ml (5 mg/ml)............................................................ 94
quinapril hcl tab 5 mg (Accupril)................................... 52
quinapril hcl tab 10 mg (Accupril)................................. 52
quinapril-hydrochlorothiazide tab 10-12.5 mg
(Accuretic)...................................................................... 52
quinapril-hydrochlorothiazide tab 20-12.5 mg
(Accuretic)...................................................................... 52
quinapril-hydrochlorothiazide tab 20-25 mg
(Accuretic)...................................................................... 52
quinidine gluconate tab cr 324 mg................................ 45
QUINIDINE SULFATE -quinidine sulfate tab 200 mg....... 45
QUINIDINE SULFATE -quinidine sulfate tab 300 mg....... 45
quinine sulfate cap 324 mg (Qualaquin)....................... 12
QVAR -beclomethasone diprop inhal aero soln 40 mcg/act
(50/valve)......................................................................... 67
QVAR -beclomethasone diprop inhal aero soln 80 mcg/act
(100/valve)....................................................................... 67
R
rabeprazole sodium ec tab 20 mg (Aciphex)................ 71
RADIAGEL -wound dressings - gel................................. 161
RADIAPLEXRX -wound dressings - gel.......................... 161
RAGWITEK -short ragweed pollen allergen extract tab sl
12 amb a 1-u.................................................................. 14
raloxifene hcl tab 60 mg (Evista)................................... 38
ramipril cap 1.25 mg (Altace)......................................... 52
ramipril cap 2.5 mg (Altace)........................................... 52
ramipril cap 5 mg (Altace).............................................. 52
ramipril cap 10 mg (Altace)............................................ 52
RANEXA -ranolazine tab sr 12hr 500 mg......................... 40
RANEXA -ranolazine tab sr 12hr 1000 mg....................... 40
ranitidine hcl cap 150 mg............................................... 71
ranitidine hcl cap 300 mg............................................... 71
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)................... 71
ranitidine hcl tab 150 mg (Zantac)................................. 71
ranitidine hcl tab 300 mg (Zantac)................................. 71
RAPAFLO -silodosin cap 4 mg..........................................78
RAPAFLO -silodosin cap 8 mg..........................................78
RAPAMUNE -sirolimus oral soln 1 mg/ml....................... 172
RAPAMUNE -sirolimus tab 0.5 mg..................................172
RAPAMUNE -sirolimus tab 1 mg.....................................172
RAPAMUNE -sirolimus tab 2 mg.....................................172
RASUVO -methotrexate soln pf auto-injector 7.5
mg/0.15ml...................................................................... 110
RASUVO -methotrexate soln pf auto-injector 10
mg/0.2ml........................................................................ 110
mg/0.25ml...................................................................... 110
mg/0.3ml........................................................................ 110
mg/0.35ml...................................................................... 110
mg/0.4ml........................................................................ 110
mg/0.45ml...................................................................... 110
mg/0.5ml........................................................................ 110
mg/0.55ml...................................................................... 110
mg/0.6ml........................................................................ 110
239
2016
RAVICTI -glycerol phenylbutyrate liquid 1.1 gm/ml...........38
RAYOS -prednisone tab delayed release 1 mg................ 20
RAZADYNE ER -galantamine hydrobromide cap sr 24hr 8
mg.................................................................................... 98
RAZADYNE ER -galantamine hydrobromide cap sr 24hr
16 mg.............................................................................. 98
RAZADYNE ER -galantamine hydrobromide cap sr 24hr
24 mg.............................................................................. 98
RAZADYNE -galantamine hydrobromide tab 4 mg...........97
RAZADYNE -galantamine hydrobromide tab 8 mg...........97
RAZADYNE -galantamine hydrobromide tab 12 mg.........97
REBETOL -ribavirin cap 200 mg....................................... 10
REBETOL -ribavirin soln 40 mg/ml................................... 10
REBIF -interferon beta-1a soln pref syr 22 mcg/0.5ml
(12mu/ml)........................................................................ 98
REBIF -interferon beta-1a soln pref syr 44 mcg/0.5ml
(24mu/ml)........................................................................ 98
REBIF REBIDOSE -interferon beta-1a soln auto-inj 22
mcg/0.5ml (12mu/ml)...................................................... 98
REBIF REBIDOSE -interferon beta-1a soln auto-inj 44
mcg/0.5ml (24mu/ml)...................................................... 98
REBIF REBIDOSE TITRATION -interferon beta-1a autoinj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml.......................... 98
REBIF TITRATION PACK -interferon beta-1a pref syr
6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml............................... 98
RECEDO -scar treatment products - gel.........................161
RECOMBINATE -antihemophilic factor (recombinant) for
inj 220-400 unit............................................................. 143
inj 401-800 unit............................................................. 143
inj 801-1240 unit........................................................... 143
inj 1241-1800 unit......................................................... 143
inj 1801-2400 unit......................................................... 143
RECOTHROM SPRAY KIT -thrombin (recombinant) for
soln 20000 unit............................................................. 138
RECOTHROM -thrombin (recombinant) for soln 5000
unit................................................................................. 138
RECOTHROM -thrombin (recombinant) for soln 20000
unit................................................................................. 138
RECTIV -nitroglycerin oint 0.4%..................................... 151
REGENECARE -lidocaine hcl-collagen-aloe vera gel
2%.................................................................................. 161
REGIMEX -benzphetamine hcl tab 25 mg........................ 94
REGLAN -metoclopramide hcl tab 5 mg........................... 74
REGLAN -metoclopramide hcl tab 10 mg......................... 74
REGRANEX -becaplermin gel 0.01%............................. 161
RELAGARD -acetic acid-oxyquinoline vaginal gel
0.9-0.025%...................................................................... 77
RELENZA DISKHALER -zanamivir aero powder breath
activated 5 mg/blister......................................................10
RELHIST -bromphen tan-phenyleph tan chew tab 6-15
mg.................................................................................... 63
RELION R -insulin regular (human) inj 100 unit/ml........... 31
RELISTOR -methylnaltrexone bromide inj 8 mg/0.4ml (20
mg/ml).............................................................................. 74
RELISTOR -methylnaltrexone bromide inj 12 mg/0.6ml
(20 mg/ml)....................................................................... 74
RELNATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg.................................................................. 128
RELPAX -eletriptan hydrobromide tab 20 mg (base
equivalent)..................................................................... 112
RELPAX -eletriptan hydrobromide tab 40 mg (base
equivalent)..................................................................... 112
REMBRANDT DEEPLY WHITE+PE -sodium
monofluorophosphate paste 0.884%........................... 150
REMBRANDT INTENSE STAIN -sodium fluoride paste
0.243%.......................................................................... 150
REMBRANDT WHITENING -sodium fluoride rinse
0.02%.............................................................................150
REMERON -mirtazapine tab 15 mg.................................. 83
REMERON SOLTAB -mirtazapine orally disintegrating tab
15 mg.............................................................................. 83
30 mg.............................................................................. 83
45 mg.............................................................................. 83
REMESENSE -dental desensitizing product - misc........ 171
RENAGEL -sevelamer hcl tab 400 mg............................. 74
RENAGEL -sevelamer hcl tab 800 mg............................. 74
RENATABS -b-complex w/ c-biotin-vit e & folic acid tab 1
mg.................................................................................. 128
RENATABS WITH IRON -b complex-c-biotin-e-fa tab 1mg
& fe cbn tab 100 mg pack............................................ 128
RENVELA -sevelamer carbonate packet 0.8 gm.............. 74
RENVELA -sevelamer carbonate packet 2.4 gm.............. 74
RENVELA -sevelamer carbonate tab 800 mg.................. 74
REPAGLINIDE/METFORMIN HYD -repaglinide-metformin
hcl tab 1-500 mg.............................................................30
REPAGLINIDE/METFORMIN HYD -repaglinide-metformin
hcl tab 2-500 mg.............................................................30
repaglinide tab 0.5 mg (Prandin)................................... 30
repaglinide tab 1 mg (Prandin)...................................... 30
repaglinide tab 2 mg (Prandin)...................................... 30
REPATHA -evolocumab subcutaneous soln prefilled
syringe 140 mg/ml.......................................................... 58
REPATHA PUSHTRONEX SYSTEM -evolocumab
subcutaneous soln cartridge/infusor 420 mg/3.5ml....... 58
REPATHA SURECLICK -evolocumab subcutaneous soln
auto-injector 140 mg/ml.................................................. 58
REPLACEMENT AIR FILTER -respiratory therapy
supplies - misc.............................................................. 171
REPREXAIN -hydrocodone-ibuprofen tab 5-200 mg...... 106
REPRONEX– Benefit Limits may apply -menotropins for
inj 75 unit........................................................................ 38
REQ 49+ -multiple vitamins w/ minerals tab................... 128
REQUIP -ropinirole hydrochloride tab 0.25 mg...............120
REQUIP -ropinirole hydrochloride tab 0.5 mg.................120
240
2016
REQUIP -ropinirole hydrochloride tab 1 mg....................120
REQUIP XL -ropinirole hydrochloride tab sr 24hr 2 mg
(base equivalent).......................................................... 120
(base equivalent).......................................................... 120
(base equivalent).......................................................... 120
(base equivalent).......................................................... 120
(base equivalent).......................................................... 120
RESCRIPTOR -delavirdine mesylate tab 100 mg............ 10
RESCRIPTOR -delavirdine mesylate tab 200 mg............ 10
RESCULA -unoprostone isopropyl ophth soln
0.15%.............................................................................147
RESPA-BR -brompheniramine maleate tab sr 12hr 11
mg.................................................................................... 61
RESTASIS -cyclosporine (ophth) emulsion 0.05%......... 147
RESTORIL -temazepam cap 7.5 mg................................ 89
RESTORIL -temazepam cap 15 mg................................. 89
RESTORIL -temazepam cap 22.5 mg.............................. 89
RESTORIL -temazepam cap 30 mg................................. 89
RETIN-A MICRO PUMP -tretinoin microsphere gel
0.04%.............................................................................161
0.08%.............................................................................161
0.1%...............................................................................161
RETIN-A MICRO -tretinoin microsphere gel 0.04%........ 161
RETIN-A MICRO -tretinoin microsphere gel 0.1%.......... 161
RETIN-A -tretinoin cream 0.025%................................... 161
RETIN-A -tretinoin cream 0.05%..................................... 161
RETIN-A -tretinoin cream 0.1%....................................... 161
RETIN-A -tretinoin gel 0.01%.......................................... 161
RETIN-A -tretinoin gel 0.025%........................................ 161
RETROVIR -zidovudine cap 100 mg................................ 10
RETROVIR -zidovudine syrup 10 mg/ml.......................... 10
REVATIO -sildenafil citrate for suspension 10 mg/ml....... 59
REVATIO -sildenafil citrate tab 20 mg............................... 59
REVLIMID -lenalidomide cap 5 mg................................. 172
REVLIMID -lenalidomide cap 10 mg............................... 172
REVLIMID -lenalidomide caps 2.5 mg............................ 172
REXULTI -brexpiprazole tab 0.25 mg............................... 87
REXULTI -brexpiprazole tab 0.5 mg................................. 87
REXULTI -brexpiprazole tab 1 mg.................................... 87
REYATAZ -atazanavir sulfate cap 150 mg (base
equiv)............................................................................... 10
equiv)............................................................................... 10
equiv)............................................................................... 10
REYATAZ -atazanavir sulfate oral powder packet 50 mg
(base equiv).................................................................... 10
REZIRA -pseudoephedrine w/ hydrocodone soln 60-5
mg/5ml............................................................................. 63
RHEUMATREX -methotrexate sodium tab 2.5 mg
(antirheumatic).............................................................. 110
RHINOCORT AQUA -budesonide nasal susp 32 mcg/
act.................................................................................... 61
RIASTAP -fibrinogen conc (human) inj approximately 1
gm (900-1300 mg)........................................................ 143
RIAX -benzoyl peroxide foam 5.5%................................ 161
RIAX -benzoyl peroxide foam 9.5%................................ 161
RIBASPHERE RIBAPAK -ribavirin tab 400 mg................. 10
RIBASPHERE RIBAPAK -ribavirin tab 600 mg................. 10
RIBASPHERE RIBAPAK -ribavirin tab 200 mg & ribavirin
tab 400 mg dose pack....................................................10
RIBASPHERE RIBAPAK -ribavirin tab 400 mg & ribavirin
tab 600 mg dose pack....................................................10
RIBASPHERE -ribavirin tab 400 mg................................. 10
RIBASPHERE -ribavirin tab 600 mg................................. 10
ribavirin cap 200 mg (Rebetol)....................................... 10
ribavirin tab 200 mg (Copegus)..................................... 10
RIDAURA -auranofin cap 3 mg....................................... 110
rifabutin cap 150 mg (Mycobutin).................................... 6
RIFADIN -rifampin cap 150 mg........................................... 6
RIFADIN -rifampin cap 300 mg........................................... 6
RIFAMATE -isoniazid & rifampin cap 150-300 mg.............. 6
rifampin cap 150 mg (Rifadin).......................................... 6
rifampin cap 300 mg (Rifadin).......................................... 6
RIFATER -isoniazid-rifampin w/ pyrazinamide tab
50-120-300 mg.................................................................. 6
RILUTEK -riluzole tab 50 mg.......................................... 121
riluzole tab 50 mg (Rilutek).......................................... 121
rimantadine hydrochloride tab 100 mg
(Flumadine).................................................................... 10
ringer's solution for irrigation...................................... 172
RIOMET -metformin hcl oral soln 500 mg/5ml.................. 30
risedronate sodium tab delayed release 35 mg
(Atelvia).......................................................................... 38
risedronate sodium tab 5 mg (Actonel)........................ 38
risedronate sodium tab 30 mg (Actonel)...................... 38
risedronate sodium tab 35 mg (Actonel)...................... 38
risedronate sodium tab 150 mg (Actonel).................... 38
RISPERDAL M-TAB -risperidone orally disintegrating tab
0.5 mg............................................................................. 87
1 mg................................................................................ 87
2 mg................................................................................ 87
3 mg................................................................................ 87
4 mg................................................................................ 87
241
2016
RISPERDAL -risperidone soln 1 mg/ml............................ 87
RISPERDAL -risperidone tab 0.25 mg.............................. 87
RISPERDAL -risperidone tab 0.5 mg................................ 87
RISPERDAL -risperidone tab 1 mg................................... 87
risperidone orally disintegrating tab 0.25 mg.............. 87
risperidone orally disintegrating tab 0.5 mg (Risperdal
m-tab).............................................................................. 87
risperidone orally disintegrating tab 1 mg (Risperdal
m-tab).............................................................................. 87
m-tab).............................................................................. 87
m-tab).............................................................................. 87
m-tab).............................................................................. 87
risperidone soln 1 mg/ml (Risperdal)............................ 87
risperidone tab 0.25 mg (Risperdal).............................. 87
risperidone tab 0.5 mg (Risperdal)................................ 87
risperidone tab 1 mg (Risperdal)................................... 87
RITALIN LA -methylphenidate hcl cap sr 24hr 10 mg
(la).................................................................................... 94
(la).................................................................................... 94
(la).................................................................................... 94
(la).................................................................................... 94
(la).................................................................................... 94
RITALIN -methylphenidate hcl tab 5 mg........................... 94
RITALIN -methylphenidate hcl tab 10 mg......................... 94
RITALIN -methylphenidate hcl tab 20 mg......................... 94
rivastigmine tartrate cap 1.5 mg (Exelon).....................98
rivastigmine tartrate cap 3 mg (Exelon)........................98
rivastigmine tartrate cap 4.5 mg (Exelon).....................98
rivastigmine tartrate cap 6 mg (Exelon)........................98
rivastigmine td patch 24hr 4.6 mg/24hr (Exelon)......... 98
rivastigmine td patch 24hr 9.5 mg/24hr (Exelon)......... 98
rivastigmine td patch 24hr 13.3 mg/24hr (Exelon)....... 98
RIXUBIS -coagulation factor ix (recombinant) for inj 250
unit................................................................................. 143
unit................................................................................. 143
unit................................................................................. 143
unit................................................................................. 143
unit................................................................................. 143
rizatriptan benzoate oral disintegrating tab 5 mg (base
eq) (Maxalt-mlt)........................................................... 112
rizatriptan benzoate oral disintegrating tab 10 mg
(base eq) (Maxalt-mlt)................................................ 112
rizatriptan benzoate tab 5 mg (base equivalent)
(Maxalt)......................................................................... 112
rizatriptan benzoate tab 10 mg (base equivalent)
(Maxalt)......................................................................... 112
ROBAXIN-750 -methocarbamol tab 750 mg...................122
ROBAXIN -methocarbamol tab 500 mg.......................... 122
ROCALTROL -calcitriol cap 0.25 mcg...............................38
ROCALTROL -calcitriol cap 0.5 mcg.................................38
ROCALTROL -calcitriol oral soln 1 mcg/ml....................... 38
ropinirole hydrochloride tab 0.25 mg (Requip).......... 121
ropinirole hydrochloride tab 0.5 mg (Requip)............ 121
ropinirole hydrochloride tab 1 mg (Requip)............... 121
ropinirole hydrochloride tab sr 24hr 2 mg (base
equivalent) (Requip xl)............................................... 120
ROSADAN KIT -metronidazole cream 0.75% w/ cleanser
kit................................................................................... 162
ROSADAN KIT -metronidazole gel 0.75% w/ cleanser
kit................................................................................... 162
ROSULA -sulfacetamide sodium w/ sulfur cleansing cloth
10-5%............................................................................ 162
ROSULA -sulfacetamide sodium w/ sulfur wash
10-4.5%......................................................................... 162
rosuvastatin calcium tab 5 mg (Crestor)...................... 58
rosuvastatin calcium tab 10 mg (Crestor).................... 58
ROWASA -mesalamine rectal enema 4 gm & cleanser
wipe kit............................................................................ 74
ROXICET -oxycodone w/ acetaminophen soln 5-325
mg/5ml........................................................................... 106
ROXICODONE -oxycodone hcl tab 5 mg....................... 106
ROXICODONE -oxycodone hcl tab 15 mg..................... 106
ROXICODONE -oxycodone hcl tab 30 mg..................... 106
ROZEREM -ramelteon tab 8 mg....................................... 89
RULAVITE DHA -prenat w/o a w/fefum-methfol-fa-dha
cap 27-0.6-0.4-300 mg................................................. 128
RYDEX -pseudoephedrine-bromphen-codeine liq
10-1.33-6.33 mg/5ml....................................................... 63
RYTARY -carbidopa & levodopa cap cr 23.75-95 mg..... 121
RYTARY -carbidopa & levodopa cap cr 36.25-145
mg.................................................................................. 121
mg.................................................................................. 121
242
2016
mg.................................................................................. 121
RYTHMOL -propafenone hcl tab 225 mg......................... 45
RYTHMOL SR -propafenone hcl cap sr 12hr 225 mg...... 45
S
SABRIL -vigabatrin powd pack 500 mg.......................... 117
SABRIL -vigabatrin tab 500 mg...................................... 117
SAFYRAL -drospirenone-ethinyl estrad-levomefolate tab
3-0.03-0.451 mg..............................................................26
SAIZEN CLICK.EASY -somatropin (non-refrigerated) for
inj 8.8 mg........................................................................ 38
SAIZEN -somatropin (non-refrigerated) for inj 5 mg......... 38
SAIZEN -somatropin (non-refrigerated) for inj 8.8 mg...... 38
SALAGEN -pilocarpine hcl tab 5 mg............................... 150
SALAGEN -pilocarpine hcl tab 7.5 mg............................ 150
SALEX CREAM -salicylic acid cream 6% & cleanser liqd
kit................................................................................... 162
SALEX LOTION -salicylic acid lotion 6% & cleanser liqd
kit................................................................................... 162
SALEX -salicylic acid shampoo 6%................................ 162
salicylic acid cream 6%................................................ 162
salicylic acid cream 6% & cleanser liqd kit (Salex
cream)........................................................................... 162
salicylic acid film forming liquid 27.5% (Virasal)....... 162
salicylic acid foam 6% (Salvax)................................... 162
salicylic acid gel 6% (Keralyt)...................................... 162
SALICYLIC ACID IN AMMONIU -salicylic acid in
ammonium lactate vehicle foam 6%............................ 162
salicylic acid lotion 6%................................................. 162
salicylic acid lotion 6% & cleanser liqd kit (Salex
lotion)............................................................................ 162
SALICYLIC ACID -salicylic acid soln 26%...................... 162
salicylic acid shampoo 6% (Salex).............................. 162
SALIVAMAX -artificial saliva - packet..............................150
SALIVATE RX -artificial saliva - packet........................... 150
salsalate tab 500 mg (Disalcid)...................................... 99
salsalate tab 750 mg (Disalcid)...................................... 99
SALVAX DUO PLUS -salicylic acid foam 6% & urea in
lactic acid foam 35% kit............................................... 162
SALVAX -salicylic acid foam 6%..................................... 162
SAMI THE SEAL COMPRESSOR -respiratory therapy
supplies - kit.................................................................. 171
SAMSCA -tolvaptan tab 15 mg......................................... 38
SAMSCA -tolvaptan tab 30 mg......................................... 38
SANCUSO -granisetron td patch 3.1 mg/24hr (contains
34.3 mg).......................................................................... 72
SANDIMMUNE -cyclosporine cap 25 mg....................... 172
SANDIMMUNE -cyclosporine cap 100 mg..................... 172
SANDIMMUNE -cyclosporine oral soln 100 mg/ml......... 172
SANDOSTATIN LAR DEPOT -octreotide acetate for im inj
kit 10 mg......................................................................... 38
kit 20 mg......................................................................... 38
kit 30 mg......................................................................... 38
SANDOSTATIN -octreotide acetate inj 50 mcg/ml (0.05
mg/ml).............................................................................. 38
mg/ml).............................................................................. 38
mg/ml).............................................................................. 38
mg/ml).............................................................................. 38
SANDOSTATIN -octreotide acetate inj 1000 mcg/ml (1
mg/ml).............................................................................. 38
SANTYL -collagenase oint 250 unit/gm.......................... 162
SAPHRIS -asenapine maleate sl tab 2.5 mg (base
equiv)............................................................................... 87
SAPHRIS -asenapine maleate sl tab 5 mg (base
equiv)............................................................................... 87
SAPHRIS -asenapine maleate sl tab 10 mg (base
equiv)............................................................................... 87
SARAFEM -fluoxetine hcl (pmdd) tab 10 mg.................... 98
SARAFEM -fluoxetine hcl (pmdd) tab 20 mg.................... 98
SAVAYSA -edoxaban tosylate tab 15 mg (base
equivalent)..................................................................... 138
equivalent)..................................................................... 138
equivalent)..................................................................... 138
SAVELLA -milnacipran hcl tab 12.5 mg............................ 98
SAVELLA -milnacipran hcl tab 25 mg............................... 98
SAVELLA -milnacipran hcl tab 50 mg............................... 98
SAVELLA -milnacipran hcl tab 100 mg............................. 98
SAVELLA TITRATION PACK -milnacipran hcl tab 12.5 mg
(5) & 25 mg (8) & 50 mg (42) pak................................. 98
SAXENDA -liraglutide (weight management) soln peninjector 18 mg/3ml.......................................................... 94
SCALACORT DK -hc lot 2% & sal acid-sulfur shampoo
2-2% & shampoo kit..................................................... 162
scar treatment products - gel...................................... 162
SEASONIQUE -levonorg-eth est tab 0.15-0.03mg(84) &
eth est tab 0.01mg(7)..................................................... 26
SECONAL SODIUM -secobarbital sodium cap 100
mg.................................................................................... 89
SECTRAL -acebutolol hcl cap 200 mg............................. 42
SECTRAL -acebutolol hcl cap 400 mg............................. 42
SELECT-OB+DHA -prenatal mv w/fe poly-fa chw 29-1 mg
& dha cap 250 mg pak................................................. 128
SELECT-OB -prenatal vit w/ fe polysac cmplx-fa chew tab
29-1 mg......................................................................... 128
SELECT-OB -prenat w/ fepolycmplx-methylfol-fa chew
tab 29-0.6-0.4 mg......................................................... 128
selegiline hcl cap 5 mg (Eldepryl)............................... 121
selegiline hcl tab 5 mg.................................................. 121
selenium sulfide lotion 2.5%........................................ 162
selenium sulfide-pyrithione zinc in urea shampoo
2.25%.............................................................................162
SELRX -selenium sulfide-pyrithione zinc in urea shampoo
2.3%...............................................................................162
243
2016
SELZENTRY -maraviroc tab 150 mg................................ 10
SELZENTRY -maraviroc tab 300 mg................................ 10
SEMPREX-D -acrivastine & pseudoephedrine cap 8-60
mg.................................................................................... 64
SE-NATAL 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg.................................................................................. 128
SE-NATAL 19 -prenatal vit w/ fe fumarate-fa chew tab
29-1 mg......................................................................... 128
SENSIPAR -cinacalcet hcl tab 30 mg (base equiv).......... 38
SENSODYNE REPAIR & PROTEC -stannous fluoride
paste 0.454%................................................................ 150
SEREVENT DISKUS -salmeterol xinafoate aer pow ba 50
mcg/dose (base equiv)................................................... 67
SERNIVO -betamethasone dipropionate spray emulsion
0.05% (base equiv).......................................................162
SEROQUEL -quetiapine fumarate tab 25 mg................... 87
SEROQUEL -quetiapine fumarate tab 50 mg................... 87
SEROQUEL -quetiapine fumarate tab 100 mg................. 87
SEROQUEL XR -quetiapine fumarate tab sr 24hr 50
mg.................................................................................... 87
mg.................................................................................... 87
mg.................................................................................... 87
mg.................................................................................... 87
mg.................................................................................... 87
SEROSTIM -somatropin (non-refrigerated) for
subcutaneous inj 4 mg................................................... 38
sertraline hcl oral conc 20 mg/ml (Zoloft).................... 83
sertraline hcl tab 25 mg (Zoloft).................................... 83
sertraline hcl tab 50 mg (Zoloft).................................... 83
sertraline hcl tab 100 mg (Zoloft).................................. 83
SE-TAN DHA -prenatal w/fe fum-fe poly -fa-omega 3 cap
15-15-1 mg.................................................................... 128
SFROWASA -mesalamine sulfite-free (sf) enema 4
gm/60ml........................................................................... 74
SHOHLS SOLUTION MODIFIED -sodium citrate & citric
acid soln 500-334 mg/5ml.............................................. 78
SHUR-SEAL -nonoxynol-9 gel 2%.................................... 77
SIDEROL -multiple vitamins w/ minerals tab.................. 128
SIDESTREAM ADULT FACE MAS -respiratory therapy
supplies - misc.............................................................. 171
SIDESTREAM CUSTOM NEBULIZ -respiratory therapy
supplies - kit.................................................................. 171
SIDESTREAM PEDIATRIC FACE -respiratory therapy
supplies - misc.............................................................. 171
SIGNIFOR -pasireotide diaspartate inj 0.3 mg/ml (base
equiv)............................................................................... 38
equiv)............................................................................... 38
equiv)............................................................................... 38
sildenafil citrate tab 20 mg (Revatio)............................ 59
SILENOR -doxepin hcl (sleep) tab 3 mg (base equiv)...... 89
SILENOR -doxepin hcl (sleep) tab 6 mg (base equiv)...... 89
SILICONE MASK FOR BREATHE -respiratory therapy
supplies - misc.............................................................. 171
SILICONE MASK FOR BREATHR -respiratory therapy
supplies - misc.............................................................. 171
SILVADENE -silver sulfadiazine cream 1%.....................162
SILVASORB -wound dressings - gel............................... 162
silver nitrate-potassium nitrate applicator 75-25%
(Arzol silver nitrate).................................................... 162
SILVER NITRATE -silver nitrate oint 10%....................... 162
SILVER NITRATE -silver nitrate soln 0.5%..................... 162
SILVER NITRATE -silver nitrate soln 10%...................... 162
silver sulfadiazine cream 1% (Silvadene)................... 162
SIMBRINZA -brinzolamide-brimonidine tartrate ophth
susp 1-0.2%.................................................................. 147
SIMPONI -golimumab subcutaneous soln auto-injector 50
mg/0.5ml........................................................................ 110
SIMPONI -golimumab subcutaneous soln auto-injector
100 mg/ml..................................................................... 110
SIMPONI -golimumab subcutaneous soln prefilled syringe
50 mg/0.5ml.................................................................. 110
SIMPONI -golimumab subcutaneous soln prefilled syringe
100 mg/ml..................................................................... 110
simvastatin tab 5 mg (Zocor)......................................... 58
simvastatin tab 10 mg (Zocor)....................................... 58
SINEMET -carbidopa & levodopa tab 10-100 mg........... 121
SINEMET CR -carbidopa & levodopa tab cr 25-100
mg.................................................................................. 121
SINEMET CR -carbidopa & levodopa tab cr 50-200
mg.................................................................................. 121
SINGULAIR -montelukast sodium chew tab 4 mg (base
equiv)............................................................................... 67
SINGULAIR -montelukast sodium chew tab 5 mg (base
equiv)............................................................................... 67
SINGULAIR -montelukast sodium oral granules packet 4
mg (base equiv).............................................................. 67
SINGULAIR -montelukast sodium tab 10 mg (base
equiv)............................................................................... 67
sirolimus tab 0.5 mg (Rapamune)............................... 172
sirolimus tab 1 mg (Rapamune).................................. 172
sirolimus tab 2 mg (Rapamune).................................. 172
244
2016
SIRTURO -bedaquiline fumarate tab 100 mg (base
equiv)................................................................................. 6
SITAVIG -acyclovir buccal tab 50 mg................................ 10
SIVEXTRO -tedizolid phosphate tab 200 mg....................13
SKELAXIN -metaxalone tab 800 mg............................... 122
SM B-COMPLEX/VITAMIN C -b-complex w/ c & folic acid
tab.................................................................................. 128
SODIUM BICARBONATE -sodium bicarbonate
powder............................................................................. 69
sodium chloride irrigation soln 0.9%............................ 78
sodium chloride soln nebu 0.9%................................... 64
sodium chloride soln nebu 3%...................................... 64
sodium chloride soln nebu 10%.................................... 64
sodium chloride soln nebu 7% (Hyper-sal).................. 64
sodium citrate & citric acid soln 500-334 mg/5ml
(Shohls solution modi)................................................ 78
sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)
(Luride)......................................................................... 132
sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)
(Luride)......................................................................... 133
sodium fluoride chew tab 1 mg f (from 2.2 mg naf)
(Luride)......................................................................... 133
sodium fluoride cream 1.1% (Prevident 5000
plus).............................................................................. 150
sodium fluoride gel 1.1% (0.5% f) (Prevident
fluoride)........................................................................ 150
sodium fluoride paste 1.1% (Prevident 5000
boost)............................................................................ 150
sodium fluoride-potassium nitrate paste 1.1-5%
(Prevident 5000 sensi)............................................... 150
sodium fluoride rinse 0.05%.........................................150
sodium fluoride rinse 0.0221% (0.01% f).................... 150
sodium fluoride rinse 0.2% (Prevident)...................... 150
SODIUM FLUORIDE -sodium fluoride tab 0.5 mg f (from
1.1 mg naf)....................................................................132
SODIUM FLUORIDE -sodium fluoride tab 1 mg f (from
2.2 mg naf)....................................................................132
sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop
naf)................................................................................ 133
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)
(Luride)......................................................................... 133
sodium phenylbutyrate oral powder 3 gm/teaspoonful
(Buphenyl)...................................................................... 38
sodium polystyrene sulfonate oral susp 15 gm/60ml
(Sps).............................................................................. 172
sodium polystyrene sulfonate powder
(Kayexalate)................................................................. 172
sodium polystyrene sulfonate rectal susp 30
gm/120ml...................................................................... 173
SODIUM SULFACETAMIDE/SULF -sulfacetamide
sodium-sulfur in urea emulsion 10-5%........................ 162
SODIUM SULFACETAMIDE/SULF -sulfacetamide
sodium-sulfur in urea gel 10-5%.................................. 162
SODIUM SULFACETAMIDE/SULF -sulfacetamide sodium
w/ sulfur susp 10-5%.................................................... 162
SODIUM SULFACETAMIDE WASH -sulfacetamide
sodium in bakuchiol vehicle wash 10%....................... 162
SOLARAZE -diclofenac sodium (actinic keratoses) gel
3%.................................................................................. 162
SOLODYN -minocycline hcl tab sr 24hr 55 mg.................. 5
SOLODYN -minocycline hcl tab sr 24hr 105 mg................ 5
SOLODYN -minocycline hcl tab sr 24hr 115 mg................. 5
SOLTAMOX -tamoxifen citrate oral soln 10 mg/5ml (base
equivalent)....................................................................... 17
SOMA -carisoprodol tab 250 mg..................................... 122
SOMA -carisoprodol tab 350 mg..................................... 122
SOMATULINE DEPOT -lanreotide acetate extended
release inj 60 mg/0.2ml.................................................. 38
release inj 90 mg/0.3ml.................................................. 38
release inj 120 mg/0.5ml................................................ 38
SOMAVERT -pegvisomant for inj 10 mg (as protein)....... 39
SONATA -zaleplon cap 5 mg............................................ 89
SONATA -zaleplon cap 10 mg.......................................... 89
SOOLANTRA -ivermectin cream 1%.............................. 163
SORIATANE -acitretin cap 10 mg................................... 163
SORIATANE -acitretin cap 17.5 mg................................ 163
SORIATANE -acitretin cap 25 mg................................... 163
SORILUX -calcipotriene foam 0.005%............................ 163
sotalol hcl (afib/afl) tab 80 mg (Betapace af)................ 42
sotalol hcl (afib/afl) tab 120 mg (Betapace af).............. 42
sotalol hcl (afib/afl) tab 160 mg (Betapace af).............. 42
sotalol hcl tab 240 mg.....................................................42
sotalol hcl tab 80 mg (Betapace)................................... 42
sotalol hcl tab 120 mg (Betapace)................................. 42
sotalol hcl tab 160 mg (Betapace)................................. 42
SOTYLIZE -sotalol hcl oral solution 5 mg/ml.................... 42
SOVALDI -sofosbuvir tab 400 mg..................................... 10
SPATONE PUR-ABSORB IRON -ferrous sulfate liquid 5
mg/20ml (elemental iron)..............................................136
SPECTRACEF -cefditoren pivoxil tab 200 mg (base
equivalent)......................................................................... 2
SPECTRACEF -cefditoren pivoxil tab 400 mg (base
equivalent)......................................................................... 2
SPECTRAGEL -wound dressings - gel........................... 163
SPINOSAD -spinosad susp 0.9%................................... 163
SPIRIVA HANDIHALER -tiotropium bromide monohydrate
inhal cap 18 mcg (base equiv)....................................... 67
SPIRIVA RESPIMAT -tiotropium bromide monohydrate
inhal aerosol 1.25 mcg/act............................................. 67
SPIRIVA RESPIMAT -tiotropium bromide monohydrate
inhal aerosol 2.5 mcg/act............................................... 67
spironolactone & hydrochlorothiazide tab 25-25 mg
(Aldactazide).................................................................. 55
spironolactone tab 25 mg (Aldactone).......................... 55
spironolactone tab 50 mg (Aldactone).......................... 55
spironolactone tab 100 mg (Aldactone)........................ 55
245
2016
SPIRO PD -respiratory therapy supplies - devices......... 171
SPORANOX -itraconazole cap 100 mg.............................. 7
SPORANOX -itraconazole oral soln 10 mg/ml....................7
SPORANOX PULSEPAK -itraconazole cap 100 mg.......... 7
SPRITAM -levetiracetam tab disintegrating soluble 250
mg.................................................................................. 117
mg.................................................................................. 117
mg.................................................................................. 117
mg.................................................................................. 117
SPRIX -ketorolac tromethamine nasal spray 15.75 mg/
spray.............................................................................. 110
SPRYCEL -dasatinib tab 20 mg........................................ 17
SPRYCEL -dasatinib tab 100 mg...................................... 17
SPRYCEL -dasatinib tab 140 mg...................................... 17
SSKI -potassium iodide soln 1 gm/ml............................. 133
STALEVO 100 -carbidopa-levodopa-entacapone tabs
25-100-200 mg..............................................................121
31.25-125-200 mg........................................................ 121
37.5-150-200 mg.......................................................... 121
50-200-200 mg..............................................................121
12.5-50-200 mg.............................................................121
18.75-75-200 mg.......................................................... 121
stannous fluoride conc 0.63% (Gel-kam oral care
ri)................................................................................... 150
stannous fluoride gel 0.4%........................................... 150
STANNOUS FLUORIDE RINSE -stannous fluoride liq
0.1%...............................................................................150
STARLIX -nateglinide tab 60 mg....................................... 30
STARLIX -nateglinide tab 120 mg..................................... 30
STATUSS GREEN -codeine-pseudoephedrinechlorcyclizine liq 9-30-12.5 mg/5ml................................ 64
stavudine cap 15 mg (Zerit)............................................10
stavudine for oral soln 1 mg/ml (Zerit)......................... 10
STAXYN– Benefit Limits may apply -vardenafil hcl orally
disintegrating tab 10 mg................................................. 60
STELARA -ustekinumab soln prefilled syringe 45
mg/0.5ml........................................................................ 163
STELARA -ustekinumab soln prefilled syringe 90 mg/
ml................................................................................... 163
STENDRA– Benefit Limits may apply -avanafil tab 50
mg.................................................................................... 60
mg.................................................................................... 60
mg.................................................................................... 60
STIMATE -desmopressin acetate nasal soln 1.5 mg/
ml..................................................................................... 39
STIOLTO RESPIMAT -tiotropium br-olodaterol inhal aero
soln 2.5-2.5 mcg/act....................................................... 67
STIVARGA -regorafenib tab 40 mg................................... 17
STRATTERA -atomoxetine hcl cap 10 mg (base
equiv)............................................................................... 94
equiv)............................................................................... 94
equiv)............................................................................... 94
equiv)............................................................................... 94
equiv)............................................................................... 94
equiv)............................................................................... 94
equiv)............................................................................... 94
STRENSIQ -asfotase alfa subcutaneous inj 18
mg/0.45ml........................................................................ 39
mg/0.7ml.......................................................................... 39
STRENSIQ -asfotase alfa subcutaneous inj 40 mg/ml..... 39
mg/0.8ml.......................................................................... 39
STRIANT -testosterone buccal mucoadhesive system 30
mg.................................................................................... 21
STRIBILD -elvitegrav-cobic-emtricitab-tenofovdf tab
150-150-200-300 mg...................................................... 10
STRIVERDI RESPIMAT -olodaterol hcl inhal aerosol soln
2.5 mcg/act (base equiv)................................................ 67
STROMECTOL -ivermectin tab 3 mg................................12
STROVITE FORTE -multiple vitamins w/ minerals & fa
syrup 1 mg/15ml........................................................... 128
STROVITE FORTE -multiple vitamins w/ minerals
tab.................................................................................. 128
STROVITE ONE -multiple vitamins w/ minerals tab....... 128
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 2-0.5
mg (base equiv)............................................................ 106
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 4-1
mg (base equiv)............................................................ 106
mg (base equiv)............................................................ 106
mg (base equiv)............................................................ 106
SUBSYS -fentanyl sublingual spray 100 mcg................. 106
SUBSYS -fentanyl sublingual spray 1200 mcg (600 mcg x
2).................................................................................... 106
SUBSYS -fentanyl sublingual spray 1600 mcg (800 mcg x
2).................................................................................... 106
246
2016
SUCRAID -sacrosidase soln 8500 unit/ml........................ 72
sucralfate tab 1 gm (Carafate)....................................... 71
SULAR -nisoldipine tab sr 24hr 8.5 mg............................ 44
SULAR -nisoldipine tab sr 24hr 17 mg............................. 44
SULAR -nisoldipine tab sr 24hr 34 mg............................. 44
sulfacetamide sodium cleansing gel 10% (Ovace plus
wash).............................................................................163
sulfacetamide sodium liquid 10% (Ovace wash)....... 163
sulfacetamide sodium lotion 10% (acne) (Klaron)..... 163
sulfacetamide sodium ophth soln 10%
(Bleph-10)..................................................................... 147
sulfacetamide sodium-prednisolone ophth soln
10-0.23(0.25)%............................................................. 147
sulfacetamide sodium shampoo 10% (Ovace
plus).............................................................................. 163
SULFACETAMIDE SODIUM -sulfacetamide sodium ophth
oint 10%........................................................................ 147
sulfacetamide sodium w/ sulfur cleanser 10-2% (Avar
ls cleanser).................................................................. 163
sulfacetamide sodium w/ sulfur cleanser 9.8-4.8%
(Plexion cleanser)....................................................... 163
sulfacetamide sodium w/ sulfur cleansing pad 10-4%
(Sumaxin)..................................................................... 163
sulfacetamide sodium w/ sulfur cream 10-5%........... 163
sulfacetamide sodium w/ sulfur cream 10-2% (Avar-e
ls)................................................................................... 163
sulfacetamide sodium w/ sulfur cream 9.8-4.8%
(Plexion)....................................................................... 163
sulfacetamide sodium w/ sulfur emulsion 10-1%...... 163
sulfacetamide sodium w/ sulfur emulsion 10-5%...... 163
sulfacetamide sodium w/ sulfur foam 10-5%
(Clarifoam ef)............................................................... 163
sulfacetamide sodium w/ sulfur lotion 10-5%............ 163
sulfacetamide sodium w/ sulfur lotion 9.8-4.8%
(Plexion)....................................................................... 163
sulfacetamide sodium w/ sulfur susp 8-4% (Sumaxin
ts).................................................................................. 163
sulfacetamide sodium w/ sulfur wash 9-4.5%
(Sumadan wash)......................................................... 163
sulfacetamide sodium w/ sulfur wash 9-4% (Sumaxin
wash).............................................................................163
sulfacetamide sod-sulfur wash 9-4.5% & skin cleanser
kit (Sumadan kit).........................................................163
sulfacetamide sod-sulfur wash 9-4.5% & sunscreen
kit (Sumadan xlt).........................................................163
SULFADIAZINE -sulfadiazine tab 500 mg.......................... 6
sulfamethoxazole-trimethoprim susp 200-40
mg/5ml............................................................................ 13
sulfamethoxazole-trimethoprim tab 400-80 mg
(Bactrim)......................................................................... 13
sulfamethoxazole-trimethoprim tab 800-160 mg
(Bactrim ds)................................................................... 13
SULFAMYLON -mafenide acetate cream 85 mg/gm...... 163
SULFAMYLON -mafenide acetate packet for topical soln
5% (50 gm)................................................................... 163
sulfasalazine tab delayed release 500 mg (Azulfidine
en-tabs)........................................................................... 74
sulfasalazine tab 500 mg (Azulfidine)........................... 74
SULFOAM -sulfur shampoo 2%...................................... 163
SULFURATED LIME -sulfurated lime solution................ 163
sulindac tab 150 mg...................................................... 111
sulindac tab 200 mg...................................................... 111
SUMADAN KIT -sulfacetamide sod-sulfur wash 9-4.5% &
skin cleanser kit............................................................ 163
SUMADAN WASH -sulfacetamide sodium w/ sulfur wash
9-4.5%........................................................................... 163
SUMADAN XLT -sulfacetamide sod-sulfur wash 9-4.5% &
sunscreen kit................................................................. 163
sumatriptan succinate inj 6 mg/0.5ml (Imitrex).......... 112
sumatriptan succinate solution auto-injector 4
mg/0.5ml (Imitrex statdose sys)............................... 112
sumatriptan succinate solution auto-injector 6
mg/0.5ml (Imitrex statdose sys)............................... 112
sumatriptan succinate solution cartridge 4 mg/0.5ml
(Imitrex statdose ref).................................................. 112
sumatriptan succinate solution cartridge 6 mg/0.5ml
(Imitrex statdose ref).................................................. 112
SUMATRIPTAN SUCCINATE -sumatriptan succinate
solution prefilled syringe 6 mg/0.5ml........................... 112
sumatriptan succinate tab 25 mg (Imitrex)................. 112
sumatriptan succinate tab 50 mg (Imitrex)................. 112
sumatriptan succinate tab 100 mg (Imitrex)............... 112
SUMATRIPTAN -sumatriptan nasal spray 5 mg/act....... 112
SUMATRIPTAN -sumatriptan nasal spray 20 mg/act..... 112
SUMAVEL DOSEPRO -sumatriptan succinate solution jetinjector 4 mg/0.5ml....................................................... 112
SUMAVEL DOSEPRO -sumatriptan succinate solution jetinjector 6 mg/0.5ml....................................................... 112
SUMAXIN CP KIT -sulfacetamide sod-sulfur pad 10-4% &
skin cleanser kit............................................................ 163
SUMAXIN -sulfacetamide sodium w/ sulfur cleansing pad
10-4%............................................................................ 163
SUMAXIN TS -sulfacetamide sodium w/ sulfur susp
8-4%.............................................................................. 163
SUMAXIN WASH -sulfacetamide sodium w/ sulfur wash
9-4%.............................................................................. 164
SUPER DAILY D3 -cholecalciferol drops 1000 unit/0.03ml
(per drop)...................................................................... 123
SUPERVITE -b-complex w/ lysine-zn & folic acid
liquid.............................................................................. 128
SUPERVITE EC -multiple vitamins w/ minerals & fa tab dr
1 mg.............................................................................. 128
SUPPORT -multiple vitamins w/ minerals liquid............. 128
SUPPORT-500 -speciality vitamin product cap.............. 128
SUPRAX -cefixime cap 400 mg.......................................... 2
SUPRAX -cefixime chew tab 100 mg................................. 2
SUPRAX -cefixime chew tab 200 mg................................. 2
SUPRAX -cefixime for susp 100 mg/5ml............................ 3
SUPREP BOWEL PREP -sodium sulfate-potassium
sulfate-magnesium sulfate oral soln.............................. 68
SURMONTIL -trimipramine maleate cap 25 mg............... 83
SURMONTIL -trimipramine maleate cap 50 mg............... 83
247
2016
SURMONTIL -trimipramine maleate cap 100 mg............. 83
SUSTIVA -efavirenz cap 50 mg........................................ 10
SUSTIVA -efavirenz cap 200 mg...................................... 11
SUSTIVA -efavirenz tab 600 mg....................................... 11
SUTENT -sunitinib malate cap 12.5 mg (base
equivalent)....................................................................... 17
SUTENT -sunitinib malate cap 25 mg (base
equivalent)....................................................................... 17
SUTENT -sunitinib malate cap 37.5 mg (base
equivalent)....................................................................... 17
SUTENT -sunitinib malate cap 50 mg (base
equivalent)....................................................................... 17
SUTTAR-2 -pseudoephedrine w/ cod-gg syrup 30-10-100
mg/5ml............................................................................. 64
SUTTAR-SF -pseudoephedrine w/ cod-gg syrup
30-10-100 mg/5ml........................................................... 64
SYLATRON -peginterferon alfa-2b for inj kit 200 mcg...... 17
SYMAX DUOTAB -hyoscyamine sulfate tab cr 0.375 mg
(0.125 mg ir/0.25 mg cr).................................................71
SYMBICORT -budesonide-formoterol fumarate dihyd
aerosol 80-4.5 mcg/act................................................... 67
SYMBICORT -budesonide-formoterol fumarate dihyd
aerosol 160-4.5 mcg/act................................................. 67
SYMBYAX -olanzapine-fluoxetine hcl cap 3-25 mg.......... 98
SYMBYAX -olanzapine-fluoxetine hcl cap 12-25 mg........ 98
SYMBYAX -olanzapine-fluoxetine hcl cap 12-50 mg........ 98
SYMLINPEN 120 -pramlintide acetate pen-inj 2700
mcg/2.7ml (1000 mcg/ml)............................................... 30
SYMLINPEN 60 -pramlintide acetate pen-inj 1500
mcg/1.5ml (1000 mcg/ml)............................................... 30
SYNAGEX -multiple vitamins w/ minerals & fa cap 1.25
mg.................................................................................. 128
SYNALAR CREAM KIT -fluocinolone cream 0.025%emollient cream kit........................................................164
SYNALAR -fluocinolone acetonide cream 0.025%......... 164
SYNALAR -fluocinolone acetonide oint 0.025%............. 164
SYNALAR -fluocinolone acetonide soln 0.01%.............. 164
SYNALAR OINTMENT KIT -fluocinolone oint 0.025%emollient cream kit........................................................164
SYNALAR TS -fluocinolone acetonide soln 0.01% &
cleanser kit.................................................................... 164
SYNALGOS-DC -aspirin-caffeine-dihydrocodeine cap
356.4-30-16 mg.............................................................106
SYNAREL -nafarelin acetate nasal soln 2 mg/ml (200
mcg/act) (base eq)..........................................................39
SYNATEK -multiple vitamins w/ minerals & fa cap 1.25
mg.................................................................................. 128
SYNERA -lidocaine-tetracaine topical patch 70-70
mg.................................................................................. 164
SYNJARDY -empagliflozin-metformin hcl tab 12.5-1000
mg.................................................................................... 30
SYNJARDY -empagliflozin-metformin hcl tab 12.5-500
mg.................................................................................... 30
SYNJARDY -empagliflozin-metformin hcl tab 5-500
mg.................................................................................... 30
SYNJARDY -empagliflozin-metformin hcl tab 5-1000
mg.................................................................................... 30
SYNRIBO -omacetaxine mepesuccinate for inj 3.5
mg.................................................................................... 17
SYNTHROID -levothyroxine sodium tab 25 mcg.............. 33
SYNTHROID -levothyroxine sodium tab 100 mcg............ 33
SYPRINE -trientine hcl cap 250 mg................................ 173
T
TABLOID -thioguanine tab 40 mg..................................... 17
TACLONEX -calcipotriene-betamethasone dipropionate
oint 0.005-0.064%......................................................... 164
TACLONEX -calcipotriene-betamethasone dipropionate
susp 0.005-0.064%....................................................... 164
tacrolimus cap 0.5 mg (Prograf).................................. 173
tacrolimus cap 1 mg (Prograf)..................................... 173
tacrolimus cap 5 mg (Prograf)..................................... 173
tacrolimus oint 0.03% (Protopic)................................. 164
tacrolimus oint 0.1% (Protopic)................................... 164
TAFINLAR -dabrafenib mesylate cap 50 mg (base
equivalent)....................................................................... 17
TAFINLAR -dabrafenib mesylate cap 75 mg (base
equivalent)....................................................................... 17
TAGRISSO -osimertinib mesylate tab 40 mg (base
equivalent)....................................................................... 17
TAGRISSO -osimertinib mesylate tab 80 mg (base
equivalent)....................................................................... 17
TALTZ -ixekizumab subcutaneous soln auto-injector 80
mg/ml............................................................................. 164
TALTZ -ixekizumab subcutaneous soln prefilled syringe
80 mg/ml....................................................................... 164
TAMIFLU -oseltamivir phosphate cap 30 mg (base
equiv)............................................................................... 11
equiv)............................................................................... 11
equiv)............................................................................... 11
TAMIFLU -oseltamivir phosphate for susp 6 mg/ml (base
equiv)............................................................................... 11
tamoxifen citrate tab 10 mg (base equivalent)............. 17
tamoxifen citrate tab 20 mg (base equivalent)............. 17
tamsulosin hcl cap 0.4 mg (Flomax)............................. 78
TANDEM F -ferrous fum-iron polysacch-fa cap
162-115.2-1 mg (106 mg fe)........................................ 136
248
2016
TANDEM PLUS -fe fum-iron polysacch complex-fa-b
cmplx-c-zn-mn-cu cap.................................................. 136
TANZEUM -albiglutide for soln pen-injector 30 mg........... 30
TANZEUM -albiglutide for soln pen-injector 50 mg........... 30
TAPAZOLE -methimazole tab 5 mg.................................. 33
TAPAZOLE -methimazole tab 10 mg................................ 33
TARCEVA -erlotinib hcl tab 25 mg (base equivalent)....... 18
TARCEVA -erlotinib hcl tab 100 mg (base equivalent)..... 18
TARCEVA -erlotinib hcl tab 150 mg (base equivalent)..... 18
TARGADOX -doxycycline hyclate tab 50 mg...................... 5
TARGRETIN -bexarotene cap 75 mg................................18
TARGRETIN -bexarotene gel 1%....................................164
TARKA -trandolapril-verapamil hcl tab cr 1-240 mg..........52
TARON-BC -prenat w/o a w/ fe cbnyl-fa tab 20-1 mg & vit
b6 tab pak..................................................................... 129
TARON-C DHA -prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg......................................................... 129
TARON FORTE -fe bisglycinate-fe polysacch-vit c-vit b12fa cap............................................................................ 136
TARON-PREX -prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 30-1.2-265 mg....................................................... 129
TASIGNA -nilotinib hcl cap 150 mg (base equivalent)...... 18
TASIGNA -nilotinib hcl cap 200 mg (base equivalent)...... 18
TASMAR -tolcapone tab 100 mg.....................................121
TAZORAC -tazarotene cream 0.05%.............................. 164
TAZORAC -tazarotene cream 0.1%................................ 164
TAZORAC -tazarotene gel 0.05%................................... 164
TAZORAC -tazarotene gel 0.1%..................................... 164
TBC -trypsin w/ castor oil & peruvian balsam spray....... 164
TECFIDERA -dimethyl fumarate capsule delayed release
120 mg............................................................................ 98
TECFIDERA -dimethyl fumarate capsule delayed release
240 mg............................................................................ 98
TECFIDERA STARTER PACK -dimethyl fumarate
capsule dr starter pack 120 mg & 240 mg..................... 98
TECHNIVIE -ombitasvir-paritaprevir-ritonavir tab
12.5-75-50 mg................................................................. 11
TEGRETOL -carbamazepine susp 100 mg/5ml............. 117
TEGRETOL -carbamazepine tab 200 mg....................... 117
TEGRETOL-XR -carbamazepine tab sr 12hr 100
mg.................................................................................. 117
mg.................................................................................. 117
mg.................................................................................. 117
TEKTURNA -aliskiren fumarate tab 150 mg (base
equivalent)....................................................................... 52
TEKTURNA -aliskiren fumarate tab 300 mg (base
equivalent)....................................................................... 52
TEKTURNA HCT -aliskiren-hydrochlorothiazide tab
150-12.5 mg.................................................................... 52
150-25 mg....................................................................... 52
300-12.5 mg.................................................................... 52
300-25 mg....................................................................... 52
telmisartan-amlodipine tab 40-5 mg (Twynsta)............ 52
telmisartan-amlodipine tab 80-5 mg (Twynsta)............ 52
telmisartan-amlodipine tab 40-10 mg (Twynsta).......... 52
telmisartan-amlodipine tab 80-10 mg (Twynsta).......... 52
telmisartan-hydrochlorothiazide tab 40-12.5 mg
(Micardis hct)................................................................. 52
telmisartan-hydrochlorothiazide tab 80-12.5 mg
(Micardis hct)................................................................. 52
telmisartan-hydrochlorothiazide tab 80-25 mg
(Micardis hct)................................................................. 52
telmisartan tab 20 mg (Micardis)................................... 52
temazepam cap 7.5 mg (Restoril).................................. 89
temazepam cap 15 mg (Restoril)................................... 89
temazepam cap 22.5 mg (Restoril)................................ 89
temazepam cap 30 mg (Restoril)................................... 89
TEMODAR -temozolomide cap 5 mg................................ 18
TEMODAR -temozolomide cap 20 mg.............................. 18
TEMODAR -temozolomide cap 100 mg............................ 18
TEMOVATE -clobetasol propionate cream 0.05%.......... 164
TEMOVATE -clobetasol propionate gel 0.05%............... 164
TEMOVATE -clobetasol propionate oint 0.05%.............. 164
TEMOVATE -clobetasol propionate soln 0.05%..............164
TEMOVATE E -clobetasol propionate emollient base
cream 0.05%................................................................. 164
temozolomide cap 5 mg (Temodar)............................... 18
temozolomide cap 20 mg (Temodar)............................. 18
temozolomide cap 100 mg (Temodar)........................... 18
TENEX -guanfacine hcl tab 1 mg..................................... 52
TENEX -guanfacine hcl tab 2 mg..................................... 52
TENORETIC 100 -atenolol & chlorthalidone tab 100-25
mg.................................................................................... 52
TENORETIC 50 -atenolol & chlorthalidone tab 50-25
mg.................................................................................... 52
TENORMIN -atenolol tab 25 mg....................................... 42
TENORMIN -atenolol tab 50 mg....................................... 42
TENORMIN -atenolol tab 100 mg..................................... 42
TERAZOL 3 -terconazole vaginal cream 0.8%................. 77
TERAZOL 7 -terconazole vaginal cream 0.4%................. 77
terazosin hcl cap 1 mg....................................................52
terazosin hcl cap 10 mg..................................................52
terbinafine hcl tab 250 mg (Lamisil)................................ 7
terbutaline sulfate tab 2.5 mg........................................ 67
terbutaline sulfate tab 5 mg........................................... 67
249
2016
terconazole vaginal cream 0.4% (Terazol 7)................. 77
terconazole vaginal cream 0.8% (Terazol 3)................. 77
terconazole vaginal suppos 80 mg............................... 77
TERSI FOAM -selenium sulfide foam 2.25%.................. 164
TESSALON PERLES -benzonatate cap 100 mg.............. 64
TESTIM -testosterone td gel 50 mg/5gm (1%)................. 21
testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone).................................................................. 21
testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone).................................................................. 21
testosterone enanthate im inj in oil 200 mg/ml............ 21
TESTOSTERONE PUMP -testosterone td gel 12.5 mg/act
(1%)................................................................................. 21
testosterone td gel 12.5 mg/act (1%) (Androgel
pump).............................................................................. 21
testosterone td gel 25 mg/2.5gm (1%) (Androgel)....... 21
testosterone td gel 50 mg/5gm (1%) (Androgel).......... 21
TESTOSTERONE -testosterone td gel 10mg/act
(2%)................................................................................. 21
TESTOSTERONE -testosterone td gel 25 mg/2.5gm
(1%)................................................................................. 21
TESTOSTERONE -testosterone td gel 50 mg/5gm
(1%)................................................................................. 21
TESTRED -methyltestosterone cap 10 mg....................... 21
tetrabenazine tab 12.5 mg (Xenazine)........................... 98
tetrabenazine tab 25 mg (Xenazine).............................. 98
tetracaine hcl ophth soln 0.5%.................................... 147
tetracycline hcl cap 250 mg (Tetracycline hcl)............... 5
tetracycline hcl cap 500 mg (Tetracycline hcl)............... 5
TETRACYCLINE HCL -tetracycline hcl cap 250 mg...........5
TETRACYCLINE HCL -tetracycline hcl cap 500 mg...........5
TEXACORT -hydrocortisone soln 2.5%.......................... 164
TEXAVITE LQ -pediatric multivitamins w/fl-fe-zn drops
0.25-7-3 mg/ml.............................................................. 129
TGQ 15DM/5PEH/2CPM -phenylephrine-chlorphen-dm
syrup 5-2-15 mg/5ml.......................................................64
TGQ 30PSE/3BRM/15DM -pseudoephed-bromphen-dm
syrup 30-3-15 mg/5ml.....................................................64
TGQ 50PSE/3BRM/30DM -pseudoephed-bromphen-dm
syrup 50-3-30 mg/5ml.....................................................64
TGQ 30PSE/150GFN/15DM -pseudoephedrine w/ dm-gg
syrup 30-15-150 mg/5ml................................................ 64
THALOMID -thalidomide cap 50 mg............................... 173
THALOMID -thalidomide cap 100 mg............................. 173
theophylline soln 80 mg/15ml........................................ 67
theophylline tab sr 12hr 100 mg.................................... 67
THEO-24 -theophylline cap sr 24hr 100 mg..................... 67
THERA-FLUR-N -sodium fluoride gel 1.1% (0.5% f)...... 150
THERAHONEY -wound dressings - gel.......................... 164
THIOLA -tiopronin tab 100 mg.......................................... 78
thioridazine hcl tab 10 mg.............................................. 87
thioridazine hcl tab 100 mg............................................ 88
thiothixene cap 1 mg....................................................... 88
thiothixene cap 10 mg..................................................... 88
THRESHOLD IMT -respiratory therapy supplies misc............................................................................... 171
THRESHOLD PEP -respiratory therapy supplies devices.......................................................................... 171
THRIVITE 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg.................................................................................. 129
THRIVITE RX -prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................. 129
THROMBIN-JMI DILUENT -thrombin for soln 5000
unit................................................................................. 138
THROMBIN-JMI DILUENT -thrombin for soln 20000
unit................................................................................. 138
THROMBIN-JMI EPISTAXIS -thrombin for soln kit 5000
unit................................................................................. 138
THROMBIN-JMI SYRINGE SPRA -thrombin for soln kit
5000 unit....................................................................... 139
THROMBIN-JMI SYRINGE SPRA -thrombin for soln kit
20000 unit..................................................................... 139
THROMBIN-JMI W/DIL SPRAY -thrombin for soln kit
20000 unit..................................................................... 139
THROMBOGEN -thrombin for soln kit 10000 unit.......... 139
THROMBOGEN -thrombin for soln 1000 unit................. 139
THROMBOGEN -thrombin for soln 10000 unit............... 139
thyroid tab 30 mg (1/2 grain) (Armour thyroid)............ 33
thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)......... 33
thyroid tab 60 mg (1 grain) (Armour thyroid)............... 33
THYROLAR-1/2 -liotrix (t3-t4) tab 30 mg (6.25-25
mcg)................................................................................. 33
THYROLAR-1/4 -liotrix (t3-t4) tab 15 mg (3.1-12.5
mcg)................................................................................. 33
THYROLAR-1 -liotrix (t3-t4) tab 60 mg (12.5-50 mcg)......33
THYROLAR-2 -liotrix (t3-t4) tab 120 mg (25-100
mcg)................................................................................. 33
THYROLAR-3 -liotrix (t3-t4) tab 180 mg (37.5-150
mcg)................................................................................. 33
tiagabine hcl tab 2 mg (Gabitril).................................. 117
tiagabine hcl tab 4 mg (Gabitril).................................. 118
TIAZAC -diltiazem hcl extended release beads cap sr
24hr 120 mg....................................................................44
24hr 180 mg....................................................................44
24hr 240 mg....................................................................44
24hr 300 mg....................................................................44
250
2016
24hr 360 mg....................................................................44
24hr 420 mg....................................................................44
TIGAN -trimethobenzamide hcl cap 300 mg..................... 72
TIKOSYN -dofetilide cap 125 mcg (0.125 mg)................. 46
TIKOSYN -dofetilide cap 250 mcg (0.25 mg)................... 46
TIKOSYN -dofetilide cap 500 mcg (0.5 mg)..................... 46
timolol maleate ophth gel forming soln 0.25%
(Timoptic-xe)................................................................ 147
timolol maleate ophth gel forming soln 0.5%
(Timoptic-xe)................................................................ 147
timolol maleate ophth soln 0.25% (Timoptic)............. 147
timolol maleate ophth soln 0.5% (Timoptic)............... 147
TIMOLOL MALEATE -timolol maleate tab 5 mg............... 42
TIMOLOL MALEATE -timolol maleate tab 10 mg............. 42
TIMOLOL MALEATE -timolol maleate tab 20 mg............. 42
TIMOPTIC OCUDOSE -timolol maleate preservative free
ophth soln 0.25%.......................................................... 147
TIMOPTIC OCUDOSE -timolol maleate preservative free
ophth soln 0.5%............................................................ 147
TIMOPTIC -timolol maleate ophth soln 0.25%................147
TIMOPTIC -timolol maleate ophth soln 0.5%..................147
TIMOPTIC-XE -timolol maleate ophth gel forming soln
0.25%.............................................................................147
TIMOPTIC-XE -timolol maleate ophth gel forming soln
0.5%...............................................................................147
TINDAMAX -tinidazole tab 250 mg................................... 13
TINDAMAX -tinidazole tab 500 mg................................... 13
tinidazole tab 250 mg (Tindamax)..................................13
tinidazole tab 500 mg (Tindamax)..................................13
TIROSINT -levothyroxine sodium cap 13 mcg..................33
TIROSINT -levothyroxine sodium cap 100 mcg................33
TIROSINT -levothyroxine sodium cap 112 mcg................ 34
TISSEEL -fibrin sealant component solution.................. 139
TISSEEL VH -fibrin sealant component kit 2 ml............. 139
TISSEEL VH -fibrin sealant component kit 4 ml............. 139
TISSEEL VH -fibrin sealant component kit 10 ml........... 139
TIVICAY -dolutegravir sodium tab 10 mg (base equiv)..... 11
TIVORBEX -indomethacin cap 20 mg............................ 111
TIVORBEX -indomethacin cap 40 mg............................ 111
TIZANIDINE COMFORT PAC -tizanidine tab 4 mg &
liniment topical gel pack............................................... 122
tizanidine hcl cap 2 mg (base equivalent)
(Zanaflex)......................................................................122
(Zanaflex)......................................................................122
(Zanaflex)......................................................................122
tizanidine hcl tab 2 mg (base equivalent)................... 122
tizanidine hcl tab 4 mg (base equivalent)
(Zanaflex)......................................................................122
TL-CARE DHA -prenatal w/fe fumarate-fa-dss-fish oil cap
27-1-500 mg.................................................................. 129
TL-FLUORIVITE -pediatric multiple vitamins w/ fl-fe chew
tab 0.25-7.5 mg............................................................ 129
TL FOLATE -prenatal vit w/ fe fum-methylfolate-fa tab
27-0.5-0.5 mg................................................................ 129
TL G-FOL OS -multiple vit w/ min & calcium-folic acid tab
500-1.1 mg.................................................................... 129
TL-SELECT -prenatal w/o vit a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg.............................................................129
TOBI PODHALER -tobramycin inhal cap 28 mg.................6
TOBI -tobramycin nebu soln 300 mg/5ml........................... 6
TOBRADEX ST -tobramycin-dexamethasone ophth susp
0.3-0.05%...................................................................... 147
TOBRADEX -tobramycin-dexamethasone ophth oint
0.3-0.1%........................................................................ 147
TOBRADEX -tobramycin-dexamethasone ophth susp
0.3-0.1%........................................................................ 147
tobramycin-dexamethasone ophth susp 0.3-0.1%
(Tobradex).................................................................... 147
tobramycin nebu soln 300 mg/5ml (Tobi)....................... 6
tobramycin ophth soln 0.3% (Tobrex)......................... 147
TOBREX -tobramycin ophth oint 0.3%........................... 147
TOBREX -tobramycin ophth soln 0.3%........................... 148
TODAY SPONGE -nonoxynol-9 vaginal sponge 1000
mg.................................................................................... 77
TOFRANIL -imipramine hcl tab 10 mg.............................. 83
TOLAK -fluorouracil cream 4%........................................164
TOLAZAMIDE -tolazamide tab 250 mg.............................30
TOLAZAMIDE -tolazamide tab 500 mg.............................30
TOLBUTAMIDE -tolbutamide tab 500 mg......................... 30
tolcapone tab 100 mg (Tasmar)................................... 121
tolmetin sodium cap 400 mg........................................ 111
TOLMETIN SODIUM -tolmetin sodium tab 200 mg........ 111
TOLMETIN SODIUM -tolmetin sodium tab 600 mg........ 111
tolterodine tartrate cap sr 24hr 2 mg (Detrol la).......... 76
tolterodine tartrate cap sr 24hr 4 mg (Detrol la).......... 76
tolterodine tartrate tab 1 mg (Detrol)............................ 76
tolterodine tartrate tab 2 mg (Detrol)............................ 76
TOPAMAX SPRINKLE -topiramate sprinkle cap 15
mg.................................................................................. 118
TOPAMAX SPRINKLE -topiramate sprinkle cap 25
mg.................................................................................. 118
TOPAMAX -topiramate tab 25 mg...................................118
TOPAMAX -topiramate tab 50 mg...................................118
TOPAMAX -topiramate tab 100 mg.................................118
TOPAMAX -topiramate tab 200 mg.................................118
TOPICORT -desoximetasone cream 0.05%................... 164
TOPICORT -desoximetasone cream 0.25%................... 164
TOPICORT -desoximetasone gel 0.05%........................ 164
251
2016
TOPICORT -desoximetasone oint 0.05%....................... 164
TOPICORT -desoximetasone oint 0.25%....................... 164
TOPICORT -desoximetasone spray 0.25%.................... 164
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 25
mg.................................................................................. 118
mg.................................................................................. 118
mg.................................................................................. 118
mg.................................................................................. 118
mg.................................................................................. 118
topiramate sprinkle cap 15 mg (Topamax
sprinkle)........................................................................118
topiramate sprinkle cap 25 mg (Topamax
sprinkle)........................................................................118
topiramate tab 25 mg (Topamax)................................. 118
topiramate tab 50 mg (Topamax)................................. 118
topiramate tab 100 mg (Topamax)............................... 118
topiramate tab 200 mg (Topamax)............................... 118
TOPROL XL -metoprolol succinate tab sr 24hr 25 mg
(tartrate equiv)................................................................. 42
(tartrate equiv)................................................................. 42
(tartrate equiv)................................................................. 42
(tartrate equiv)................................................................. 42
torsemide tab 5 mg (Demadex)...................................... 55
torsemide tab 10 mg (Demadex).................................... 55
torsemide tab 20 mg (Demadex).................................... 55
torsemide tab 100 mg (Demadex).................................. 55
TOUJEO SOLOSTAR -insulin glargine soln pen-injector
300 unit/ml.......................................................................32
TOVIAZ -fesoterodine fumarate tab sr 24hr 4 mg.............76
TOVIAZ -fesoterodine fumarate tab sr 24hr 8 mg.............76
TRACLEER -bosentan tab 62.5 mg.................................. 59
TRACLEER -bosentan tab 125 mg................................... 59
TRADJENTA -linagliptin tab 5 mg..................................... 30
tramadol-acetaminophen tab 37.5-325 mg
(Ultracet)....................................................................... 107
TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic
release 100 mg............................................................. 106
release 150 mg............................................................. 106
release 200 mg............................................................. 106
release 300 mg............................................................. 106
tramadol hcl tab 50 mg (Ultram).................................. 107
tramadol hcl tab sr 24hr biphasic release 100 mg..... 107
tramadol hcl tab sr 24hr 100 mg (Ultram er).............. 106
trandolapril tab 1 mg (Mavik)......................................... 52
trandolapril-verapamil hcl tab cr 1-240 mg (Tarka)...... 52
tranexamic acid tab 650 mg (Lysteda)........................ 139
TRANSDERM-SCOP -scopolamine td patch 72hr 1
mg/3days......................................................................... 72
TRANXENE T -clorazepate dipotassium tab 3.75 mg...... 79
TRANXENE T -clorazepate dipotassium tab 7.5 mg........ 79
TRANXENE T -clorazepate dipotassium tab 15 mg......... 79
tranylcypromine sulfate tab 10 mg (Parnate)............... 83
TRAVATAN Z -travoprost ophth soln 0.004%
(benzalkonium free) (bak free)..................................... 148
TRAVOPROST -travoprost ophth soln 0.004%.............. 148
trazodone hcl tab 50 mg................................................. 83
trazodone hcl tab 100 mg............................................... 83
TRECATOR -ethionamide tab 250 mg................................ 6
TRESIBA FLEXTOUCH -insulin degludec soln peninjector 100 unit/ml......................................................... 32
TRESIBA FLEXTOUCH -insulin degludec soln peninjector 200 unit/ml......................................................... 32
tretinoin cap 10 mg......................................................... 18
tretinoin cream 0.025% (Retin-a)................................. 164
tretinoin cream 0.05% (Retin-a)................................... 164
tretinoin cream 0.1% (Retin-a)..................................... 164
tretinoin gel 0.05% (Atralin).......................................... 164
tretinoin gel 0.01% (Retin-a)......................................... 164
tretinoin gel 0.025% (Retin-a)....................................... 164
tretinoin microsphere gel 0.04% (Retin-a micro)....... 165
tretinoin microsphere gel 0.1% (Retin-a micro
pump)............................................................................ 165
TRETIN-X -tretinoin cream 0.0375%.............................. 164
TRETIN-X -tretinoin cream 0.075%................................ 164
TRETIN-X -tretinoin cream 0.05% w/ cleanser &
moisturizer kit................................................................ 164
TRETTEN -coagulation factor xiii a-subunit for inj
2000-3125 unit.............................................................. 143
TREXALL -methotrexate sodium tab 5 mg (base
equiv)............................................................................... 18
TREXALL -methotrexate sodium tab 7.5 mg (base
equiv)............................................................................... 18
equiv)............................................................................... 18
equiv)............................................................................... 18
TREXIMET -sumatriptan-naproxen sodium tab 85-500
mg.................................................................................. 112
TREZIX -acetaminophen-caffeine-dihydrocodeine cap
320.5-30-16 mg.............................................................107
TRIADVANCE -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg......................................................................... 129
252
2016
triamcinolone acetonide aerosol soln 0.147 mg/gm
(Kenalog)...................................................................... 165
triamcinolone acetonide cream 0.025%...................... 165
triamcinolone acetonide cream 0.1%.......................... 165
triamcinolone acetonide cream 0.5%.......................... 165
triamcinolone acetonide dental paste 0.1%............... 150
triamcinolone acetonide lotion 0.025%....................... 165
triamcinolone acetonide lotion 0.1%........................... 165
triamcinolone acetonide nasal aerosol suspension 55
mcg/act........................................................................... 61
triamcinolone acetonide oint 0.025%.......................... 165
triamcinolone acetonide oint 0.1%.............................. 165
TRIAMCINOLONE ACETONIDE -triamcinolone acetonide
oint 0.5%....................................................................... 165
TRIAMTERENE/HYDROCHLOROTH -triamterene &
hydrochlorothiazide cap 50-25 mg................................. 55
triamterene & hydrochlorothiazide cap 37.5-25 mg
(Dyazide).........................................................................55
triamterene & hydrochlorothiazide tab 37.5-25 mg
(Maxzide-25)................................................................... 55
triamterene & hydrochlorothiazide tab 75-50 mg
(Maxzide)........................................................................ 55
TRIANEX -triamcinolone acetonide oint 0.05%.............. 165
triazolam tab 0.25 mg (Halcion)..................................... 89
TRIAZOLAM -triazolam tab 0.125 mg............................... 89
TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide
tab 20-5-12.5 mg............................................................ 52
tab 40-5-12.5 mg............................................................ 53
tab 40-5-25 mg............................................................... 53
tab 40-10-12.5 mg.......................................................... 53
tab 40-10-25 mg............................................................. 53
TRICARE PRENATAL DHA ONE -prenatal w/fe fumaratefa-dss-fish oil cap 27-1-500 mg................................... 129
TRICARE PRENATAL -prenat w/o a w/fepyro-mfol chw
4.5-1 mg & dha cap 150 thpk...................................... 129
TRI-CHLOR -trichloroacetic acid liqd 80%......................165
TRICODE AR -pseudoephedrine-chlorphen w/ codeine liq
30-2-8 mg/5ml................................................................. 64
TRICODE GF -pseudoephedrine w/ cod-gg liquid
30-8-200 mg/5ml............................................................. 64
trifluoperazine hcl tab 1 mg........................................... 88
trifluoperazine hcl tab 10 mg......................................... 88
trifluridine ophth soln 1% (Viroptic)............................ 148
trihexyphenidyl hcl elixir 0.4 mg/ml............................ 121
trihexyphenidyl hcl tab 2 mg........................................121
trihexyphenidyl hcl tab 5 mg........................................121
TRILEPTAL -oxcarbazepine susp 300 mg/5ml (60 mg/
ml).................................................................................. 118
TRILEPTAL -oxcarbazepine tab 150 mg........................ 118
TRILIPIX -choline fenofibrate cap dr 45 mg (fenofibric
acid equiv)....................................................................... 58
TRILIPIX -choline fenofibrate cap dr 135 mg (fenofibric
acid equiv)....................................................................... 58
trimethobenzamide hcl cap 300 mg (Tigan)................. 72
trimethoprim tab 100 mg................................................ 13
trimipramine maleate cap 25 mg................................... 83
trimipramine maleate cap 50 mg................................... 83
trimipramine maleate cap 100 mg................................. 83
TRINATAL GT -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg......................................................................... 129
TRINATAL RX 1 -prenatal vit w/ fe fumarate-fa tab 60-1
mg.................................................................................. 129
TRINATE -prenatal vit w/ fe fumarate-fa tab 28-1 mg..... 129
TRI-NORINYL 28 -norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg............................................ 26
TRINTELLIX -vortioxetine hbr tab 5 mg (base equiv)....... 83
TRINTELLIX -vortioxetine hbr tab 10 mg (base equiv)..... 83
TRINTELLIX -vortioxetine hbr tab 20 mg (base equiv)..... 83
TRISTART DHA -prenat w/o a w/fecbn-methylf-fa-dha cap
31-0.6-0.4-200 mg........................................................ 129
TRI-TABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg
& omega cap pack....................................................... 129
TRIUMEQ -abacavir-dolutegravir-lamivudine tab
600-50-300 mg................................................................11
TRIVEEN-DUO DHA -prenat-fe bis-fe prot succ-fa-ca tab
& omega 3 cap 400 pk................................................. 129
TRIVEEN-PRX RNF -prenatal w/o vit a w/ fe fum-dss-fadha cap 26-1.2-300 mg................................................ 129
TRI-VI-FLORO -ped vit acd & l-methylfol w/ fl biphasic
susp 0.25 mg/ml........................................................... 129
TRI-VI-FLORO -ped vit acd & l-methylfol w/ fl biphasic
susp 0.5 mg/ml............................................................. 129
TRI-VI-FLOR -ped vit acd & l-methylfol w/ fl biphasic susp
0.25 mg/ml.................................................................... 129
TRI-VI-FLOR -ped vit acd & l-methylfol w/ fl biphasic susp
0.5 mg/ml...................................................................... 129
TRI-VIT/FLUORIDE/IRON -pediatric vitamins acd fluoride
& fe drops 0.25-10 mg/ml.............................................129
TRIZIVIR -abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg..............................................................11
TROKENDI XR -topiramate cap sr 24hr 25 mg.............. 118
TROKENDI XR -topiramate cap sr 24hr 50 mg.............. 118
TROKENDI XR -topiramate cap sr 24hr 100 mg............ 118
TROKENDI XR -topiramate cap sr 24hr 200 mg............ 118
TROPAZONE -emollient - lotion...................................... 165
trospium chloride cap sr 24hr 60 mg............................ 76
trospium chloride tab 20 mg.......................................... 76
TRULICITY -dulaglutide soln pen-injector 0.75
mg/0.5ml.......................................................................... 30
TRULICITY -dulaglutide soln pen-injector 1.5
mg/0.5ml.......................................................................... 30
TRUSOPT -dorzolamide hcl ophth soln 2%....................148
TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab
100-150 mg..................................................................... 11
TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab
133-200 mg.......

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

Transcription

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