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

Transcription

October 2015
Standard Drug List
Click to search for a drug name in this document
Contents
Introduction .................................................................... I Therapeutic Class Drug List ........................................ 1
How drugs are selected ................................................... I Anti-Infective Agents ....................................................... 1
How member payment is determined .............................. I Cancer Drugs .................................................................. 7
How to use this list .......................................................... II Hormones, Diabetes and Related Drugs ........................ 8
Generic drugs ................................................................. II Heart and Circulatory Drugs ......................................... 13
Coverage considerations ............................................... III Respiratory Agents ....................................................... 21
Specialty drugs .............................................................. IV Gastrointestinal Drugs .................................................. 24
Abbreviation key ............................................................. V Genitourinary Drugs ...................................................... 26
Central Nervous System Drugs .................................... 27
Pain Relief Drugs .......................................................... 34
Neuromuscular Drugs ................................................... 38
Supplements ................................................................. 41
Blood Modifying Drugs .................................................. 42
Topical Products ........................................................... 46
Miscellaneous Categories (includes Supplies
and Devices) ............................................................... 51
Index............................................................................. 53
Please consider talking to your doctor about prescribing preferred medications, which may help reduce your
out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you.
The drug list, also known as a formulary, is regularly updated. Please visit bcbstx.com for the most up-to-date
information.
To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to
Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click
on Search.
41722-A TX © Prime Therapeutics LLC 10/15
Introduction
Blue Cross and Blue Shield of Texas (BCBSTX) is pleased to present the 2015 Drug List. This is a list of
preferred drugs which includes Brand drugs and a partial listing of generic drugs. Members are encouraged to
show this list to their physicians and pharmacists. Physicians are encouraged to prescribe drugs on this
list, when right for the member. However, decisions regarding therapy and treatment are always between
members and their physician.
Drug List updates – This list is regularly updated as generic drugs become available and changes take place in
the pharmaceuticals market. For the most up-to-date information, visit bcbstx.com and log in to
SM
Blue Access for Members or call the number on the back of your ID card. Physicians can access the list from
the provider portal at bcbstx.com.
How drugs are selected
Drugs on this list are selected based on the recommendations of a committee made up of physicians and
pharmacists from throughout the country. The committee, which includes at least one representative from
BCBSTX, reviews drugs regulated by the U.S. Food and Drug Administration (FDA).
Both drugs that are newly approved by the FDA as well as those that have been on the market for some time are
considered. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs currently on
the list.
How member payment is determined
This list shows prescription drug products in tiers. Generally, each drug is placed into one of three or four member
payment tiers: generic, Preferred Brand or Non-Preferred Brand (not listed in this document). Specialty drugs can
either be within the previous three tiers or can be a separate fourth tier depending on your benefit design. To
verify your payment amount for a drug, visit bcbstx.com and log in to Blue Access for Members or call the
number on the back of your ID card.
Your pharmacy benefit includes coverage for many prescription drugs, although some exclusions may apply. For
example, drugs indicated for cosmetic purposes, e.g., Propecia, for hair growth, may not be covered. Prescription
products that have over-the-counter (OTC) equivalents may not be covered. Drugs that are not FDA-approved for
self-administration may be available through your medical benefit.
I
Blue Cross and Blue Shield of Texas October 2015 Standard Preferred Drug List
How to use this list
Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand
drug in (parentheses). The reference brand drug is a non-preferred (NP) brand and is only included as
a reference to the brand. Some generic products have no reference brand.
Example: atorvastatin (Lipitor)
Brand drugs are listed in all CAPITAL letters.
Example: PROAIR HFA
Drugs used to treat multiple conditions
Some drugs in the same dosage form may be used to treat more than one medical condition. In these instances,
each medication is classified according to its first FDA-approved use. Please check the index if you do not find
your particular medication in the class/condition section that corresponds to your use.
Generic drugs
Using generic drugs, when right for you, can help you save on your out-of-pocket medication costs. Generic drugs
must be approved by the FDA just as brand drugs are, and must meet the same standards.
There are two types of generic drugs:

A generic equivalent is made with the same active ingredient(s) at the same dosage as the reference drug.

A generic alternative is a drug typically used to treat the same condition, but the active ingredient(s)
differs from the brand drug.
According to the FDA, compared to its brand counterpart, an FDA-approved generic drug:

Is chemically the same

Works just as well in the body

Is as safe and effective

Meets the same standards set by the FDA
The main difference between the reference brand drug and the generic equivalent is that the generic often costs
much less.
Preferred brand drugs typically move to a non-preferred brand tier after a generic equivalent becomes available.
You may be responsible for the brand member payment amount plus the difference in cost between the brand
and generic equivalent if you or your doctor requests the reference brand rather than the generic. Generic drugs
have the lowest member payment amount.
Consider talking to your doctor about generic drugs
If your doctor writes a prescription for a brand drug that does not have a generic equivalent, consider asking if an
appropriate generic alternative is available.
You can also let your pharmacist know that you would like a generic equivalent for a brand drug, whenever one is
available. Your pharmacist can usually substitute a generic equivalent for its brand counterpart without a new
prescription from your doctor.
Only your doctor can determine whether a generic alternative is right for you and must prescribe the medication.
II
Coverage considerations
Most prescription drug benefit plans provide coverage for up to a 30-day supply of medication, with some
exceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications.
Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high blood
pressure, diabetes or high cholesterol. Some plans may exclude coverage for certain agents or drug categories,
like those used for erectile dysfunction or weight loss.
Over-the-counter exclusions: Your benefit plan may not provide coverage for prescription medications that
have an over-the-counter version. You should refer to your benefit plan material for details about your particular
benefits.
Compounded medications: Your benefit plan may not provide coverage for compounded medications. Please
see your plan materials or call the number on the back of your ID card to determine whether compounded
medications are covered and/or verify your payment amount.
Repackaged medications: Repackaged versions of medications already available on the market are not covered.
Prior Authorization (PA): Your benefit plan may require prior authorization for certain drugs. This means that
your doctor will need to submit a prior authorization request for coverage of these medications, and the request
will need to be approved, before the medication will be covered under your plan. For the preferred medications
listed in this document, if a prior authorization is commonly required, it will generally be noted next to the
medication with a dot under the prior authorization column. Some plans may have prior authorization on additional
medications beyond those noted in this document. Refer to your benefit plan materials for details about your
particular benefits.
Step Therapy (ST): Your benefit plan may include a step therapy program. This means you may need to try
another proven, cost-effective medication before coverage may be available for the drug included in the program.
Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. For the
preferred medications listed in this document, if a step therapy is commonly required, it will generally be noted
next to the medication with a dot under the step therapy column. Some plans may have step therapy programs on
additional medications beyond those noted in this document. Refer to your benefit plan materials for details about
your particular benefits.
Dispensing Limits (DL): Drug Dispensing limits help encourage medication use as intended by the FDA.
Dispensing limits are placed on medications in certain drug categories. For the preferred medications listed in this
document, if a dispensing limit applies, it will generally be noted next to the medication with a dot under the
dispensing limits column. Limits may include: quantity of covered medication per prescription, quantity of covered
medication in a given time period, coverage only for members within a certain age range, and coverage only for
members of a specific gender. If your doctor prescribes a greater quantity of medication than what the dispensing
limit allows, you can still get the medication. However, you will be responsible for the full cost of the prescription
beyond what your coverage allows.* For a list of medications and their dispensing limits, visit bcbstx.com.
*Please note: For certain controlled substance medications, some state laws may not allow coverage by a health
benefit plan of such medication if dispensed in a quantity beyond what the dispensing limit allows. You will be
responsible for the full cost of the prescription with no benefits applied if the dispensed quantity exceeds the
dispensing limit.
Remember, medication decisions are between you and your doctor. Only you and your doctor can determine
which medication is right for you. Discuss any questions or concerns you have about medications you are taking
or are prescribed with your doctor. BCBSTX does not provide health care services and, therefore, cannot
guarantee any results or outcomes.
III
Specialty drugs
Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, multiple sclerosis
and rheumatoid arthritis. Specialty drugs may be oral, topical or injectable medications that can either be selfadministered or administered by a health care professional. For a current list of specialty medications,
visit myprime.com or bcbstx.com and log in to Blue Access for Members.
Note that some drug classes may be excluded by some plans and therefore may not be covered under your
pharmacy benefit. Your plan may have a different coverage level for self-administered specialty drugs. If you
have questions about your coverage for specialty medications or your prescription drug benefit, call the
number on the back of your ID card.
Prime Therapeutics Specialty Pharmacy Program
Through Prime Therapeutics Specialty Pharmacy, members can have covered specialty medications delivered
directly to them or their doctor’s office. When you receive specialty medications through Prime, you also receive at
no additional charge the following services:

Coordination of coverage between you, your doctor and your health plan

Educational materials about your particular condition and information about managing potential
medication side effects

Syringes, sharps containers and other supplies with every shipment for self-injectables

24/7/365 phone access to a pharmacist for urgent medication issues
To order through Prime Therapeutics Specialty Pharmacy:

Have your doctor call or fax your prescription to Prime Therapeutics Specialty Pharmacy. Your doctor can
call 877-627-6337 or fax to 877-828-3939.

If you have an existing prescription for a covered specialty medication, you can call 877-627-6337 to
transfer your prescription.

A Prime Therapeutics coordinator will contact you to arrange delivery of your medication.

The prescription can be shipped directly to you or your prescribing doctor’s office. Each package is
individually marked for each member. Refrigerated drugs are shipped in temperature-controlled
packaging.
If you have questions, please contact Prime Therapeutics Specialty Pharmacy at 877-627-6337,
visit www.PrimeTherapeutics.com/specialty, or call the number on the back of your ID card.
* Blue Cross and Blue Shield of Texas (BCBSTX) is a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an
Independent Licensee of the Blue Cross and Blue Shield Association. BCBSTX contracts with Prime Therapeutics to provide pharmacy
benefit management, home delivery pharmacy and specialty pharmacy services. BCBSTX, as well as several other independent Blue Cross
and Blue Shield Plans, has an ownership interest in Prime Therapeutics LLC.
IV
Abbreviation key
cap ...................................................................... capsules odt ............................................. orally disintegrating tabs
chew .................................................................. chewable oint ..................................................................... ointment
conc ............................................................. concentrate ophth ............................................................... ophthalmic
cr .......................................................... controlled release osm.......................................................... osmotic release
dr ............................................................. delayed release powd..................................................................... powder
ec ................................................................enteric coated sa ............................................................ sustained action
effe................................................................. effervescent sl ...................................................................... sublingual
equiv ................................................................ equivalent soln ....................................................................... solution
er ...........................................................extended release sr .......................................................... sustained release
inhal................................................................... inhalation suppos ........................................................ suppositories
inj ......................................................................... injection susp................................................................ suspension
liq .............................................................................. liquid tab...........................................................................tablets
lotn ........................................................................... lotion td ................................................................... transdermal
nebu ................................................................... nebulizer
V
ANTI-INFECTIVE AGENTS
PENICILLINS
amoxicillin (trihydrate) cap 250 mg
amoxicillin (trihydrate) cap 500 mg
amoxicillin (trihydrate) for susp
125 mg/5ml
penicillin v potassium tab 250 mg
penicillin v potassium tab 500 mg
250 mg/5ml
cefaclor cap 500 mg
400 mg/5ml
cefadroxil for susp 250 mg/5ml
amoxicillin & k clavulanate chew tab
200-28.5 mg
amoxicillin & k clavulanate chew tab
400-57 mg
amoxicillin & k clavulanate for susp
200-28.5 mg/5ml
250-62.5 mg/5ml (Augmentin)
400-57 mg/5ml
600-42.9 mg/5ml (Augmentin es-600)
cefaclor cap 250 mg
cefadroxil cap 500 mg
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
cefixime for susp 100 mg/5ml
(Suprax)
cefixime for susp 200 mg/5ml
(Suprax)
cefpodoxime proxetil for susp
50 mg/5ml
cefpodoxime proxetil for susp
100 mg/5ml
cefpodoxime proxetil tab 100 mg
amoxicillin & k clavulanate tab sr
12hr 1000-62.5 mg (Augmentin xr)
cefpodoxime proxetil tab 200 mg
amoxicillin & k clavulanate tab
250-125 mg
cefprozil for susp 250 mg/5ml
500-125 mg (Augmentin)
cefprozil tab 500 mg
cefprozil for susp 125 mg/5ml
cefprozil tab 250 mg
875-125 mg (Augmentin)
CEFTIN – cefuroxime axetil for susp
125 mg/5ml
ampicillin cap 250 mg
ceftriaxone sodium for inj 250 mg
ampicillin cap 500 mg
ceftriaxone sodium for inj 500 mg
(Rocephin)
dicloxacillin sodium cap 250 mg
dicloxacillin sodium cap 500 mg
Step Therapy
penicillin v potassium for soln
250 mg/5ml
CEPHALOSPORINS
amoxicillin (trihydrate) tab 875 mg
Dispensing Limits
penicillin v potassium for soln
125 mg/5ml
200 mg/5ml
amoxicillin (trihydrate) tab 500 mg
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
ceftriaxone sodium for inj 1 gm
(Rocephin)
1
ceftriaxone sodium for inj 2 gm
Step Therapy
Dispensing Limits
doxycycline monohydrate cap
100 mg (Monodox)
cefuroxime axetil tab 250 mg (Ceftin)
doxycycline monohydrate cap
150 mg (Adoxa)
cefuroxime axetil tab 500 mg (Ceftin)
cephalexin cap 250 mg (Keflex)
doxycycline monohydrate tab 50 mg
(Adoxa)
cephalexin cap 500 mg (Keflex)
cephalexin for susp 125 mg/5ml
doxycycline monohydrate tab 75 mg
(Adoxa)
cephalexin for susp 250 mg/5ml
doxycycline monohydrate tab
100 mg (Adoxa pak 1/100)
MACROLIDES
AZITHROMYCIN – azithromycin powd
pack for susp 1 gm
doxycycline monohydrate tab
150 mg (Adoxa pak 1/150)
azithromycin for susp 100 mg/5ml
(Zithromax)
minocycline hcl cap 50 mg (Minocin)
azithromycin for susp 200 mg/5ml
(Zithromax)
azithromycin tab 250 mg (Zithromax)
•
•
•
minocycline hcl tab 50 mg
clarithromycin for susp 125 mg/5ml
FLUOROQUINOLONES
clarithromycin for susp 250 mg/5ml
(Biaxin)
ciprofloxacin for oral susp
250 mg/5ml (5%) (5 gm/100ml)
(Cipro)
•
clarithromycin tab sr 24hr 500 mg
(Biaxin xl pac)
clarithromycin tab 500 mg (Biaxin)
ciprofloxacin for oral susp
500 mg/5ml (10%) (10 gm/100ml)
(Cipro)
erythromycin w/ delayed release
particles cap 250 mg
ciprofloxacin hcl tab 250 mg (base
equiv) (Cipro)
TETRACYCLINES
equiv) (Cipro)
clarithromycin tab 250 mg (Biaxin)
demeclocycline hcl tab 150 mg
equiv)
demeclocycline hcl tab 300 mg
doxycycline hyclate cap 50 mg
ciprofloxacin-ciprofloxacin hcl tab sr
24hr 500 mg (base eq) (Cipro xr)
doxycycline hyclate cap 100 mg
(Vibramycin)
ciprofloxacin-ciprofloxacin hcl tab sr
24hr 1000 mg(base eq) (Cipro xr)
doxycycline hyclate tab 20 mg
doxycycline hyclate tab 100 mg
doxycycline monohydrate cap 50 mg
doxycycline monohydrate cap 75 mg
(Monodox)
2
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Drug Name
Prior Authorization
Specialty
2015
levofloxacin oral soln 25 mg/ml
(Levaquin)
levofloxacin tab 250 mg (Levaquin)
terbinafine hcl tab 250 mg (Lamisil)
AMINOGLYCOSIDES
•
neomycin sulfate tab 500 mg
voriconazole for susp 40 mg/ml
(Vfend)
paromomycin sulfate cap 250 mg
voriconazole tab 50 mg (Vfend)
•
•
tobramycin nebu soln 300 mg/5ml
(Tobi)
•
•
voriconazole tab 200 mg (Vfend)
Cytomegalovirus
ethambutol hcl tab 100 mg
(Myambutol)
VALCYTE – valganciclovir hcl tab 450
mg (base equivalent)
ethambutol hcl tab 400 mg
(Myambutol)
VALCYTE – valganciclovir hcl for soln
50 mg/ml (base equiv)
isoniazid tab 100 mg
isoniazid tab 300 mg
valganciclovir hcl tab 450 mg (base
equivalent) (Valcyte)
PRIFTIN – rifapentine tab 150 mg
Hepatitis
pyrazinamide tab 500 mg
adefovir dipivoxil tab 10 mg
(Hepsera)
rifabutin cap 150 mg (Mycobutin)
rifampin cap 150 mg (Rifadin)
BARACLUDE – entecavir oral soln 0.05
mg/ml
rifampin cap 300 mg (Rifadin)
BARACLUDE – entecavir tab 0.5 mg
FUNGAL INFECTIONS
BARACLUDE – entecavir tab 1 mg
fluconazole for susp 10 mg/ml
(Diflucan)
entecavir tab 0.5 mg (Baraclude)
entecavir tab 1 mg (Baraclude)
fluconazole for susp 40 mg/ml
(Diflucan)
HARVONI – ledipasvir-sofosbuvir tab
90-400 mg
fluconazole tab 50 mg (Diflucan)
• •
lamivudine tab 100 mg (hbv) (Epivir
hbv)
OLYSIO – simeprevir sodium cap 150
• •
• •
flucytosine cap 500 mg (Ancobon)
PEGASYS – peginterferon alfa-2a inj
180 mcg/ml
griseofulvin microsize susp
125 mg/5ml
PEGASYS – peginterferon alfa-2a inj
180 mcg/0.5ml
• •
griseofulvin microsize tab 500 mg
(Grifulvin v)
PEGASYS PROCLICK – peginterferon
alfa-2a inj 135 mcg/0.5ml
• •
itraconazole cap 100 mg (Sporanox)
PEGASYS PROCLICK – peginterferon
alfa-2a inj 180 mcg/0.5ml
• •
ribavirin cap 200 mg (Rebetol)
•
•
flucytosine cap 250 mg (Ancobon)
nystatin tab 500000 unit
Step Therapy
VIRAL INFECTIONS
TUBERCULOSIS
NOXAFIL – posaconazole susp 40 mg/
ml
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
•
ribavirin tab 200 mg (Copegus)
3
Herpes
EPZICOM – abacavir sulfatelamivudine tab 600-300 mg
acyclovir cap 200 mg (Zovirax)
FUZEON – enfuvirtide for inj 90 mg
acyclovir susp 200 mg/5ml (Zovirax)
INTELENCE – etravirine tab 25 mg
acyclovir tab 400 mg (Zovirax)
acyclovir tab 800 mg (Zovirax)
famciclovir tab 125 mg (Famvir)
INVIRASE – saquinavir mesylate cap
200 mg
valacyclovir hcl tab 500 mg (Valtrex)
valacyclovir hcl tab 1 gm (Valtrex)
•
•
•
•
•
•
•
INVIRASE – saquinavir mesylate tab
500 mg
•
ISENTRESS – raltegravir potassium
tab 400 mg (base equiv)
•
•
abacavir sulfate tab 300 mg (base
equiv) (Ziagen)
•
packet for susp 100 mg (base equiv)
•
abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg
(Trizivir)
•
chew tab 25 mg (base equiv)
chew tab 100 mg (base equiv)
•
APTIVUS – tipranavir cap 250 mg
•
•
KALETRA – lopinavir-ritonavir soln
400-100 mg/5ml (80-20 mg/ml)
•
•
ATRIPLA – efavirenz-emtricitabinetenofovir df tab 600-200-300 mg
•
KALETRA – lopinavir-ritonavir tab
100-25 mg
•
CRIXIVAN – indinavir sulfate cap 200
mg
•
KALETRA – lopinavir-ritonavir tab
200-50 mg
•
CRIXIVAN – indinavir sulfate cap 400
mg
•
lamivudine oral soln 10 mg/ml
(Epivir)
lamivudine tab 150 mg (Epivir)
didanosine delayed release capsule
125 mg (Videx ec)
•
lamivudine tab 300 mg (Epivir)
200 mg (Videx ec)
•
lamivudine-zidovudine tab
150-300 mg (Combivir)
•
•
•
•
LEXIVA – fosamprenavir calcium tab
700 mg (base equiv)
•
250 mg (Videx ec)
•
LEXIVA – fosamprenavir calcium susp
•
400 mg (Videx ec)
nevirapine tab sr 24hr 400 mg
(Viramune xr)
•
EMTRIVA – emtricitabine caps 200 mg
•
•
nevirapine tab 200 mg (Viramune)
•
•
•
HIV/AIDS
APTIVUS – tipranavir oral soln 100 mg/
ml
EMTRIVA – emtricitabine soln 10 mg/
ml
EPIVIR – lamivudine oral soln 10 mg/ml
4
•
NORVIR – ritonavir cap 100 mg
NORVIR – ritonavir tab 100 mg
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
• •
Step Therapy
SOVALDI – sofosbuvir tab 400 mg
Dispensing Limits
Drug Name
Specialty
Prior Authorization
2015
NORVIR – ritonavir oral soln 80 mg/ml
PREZISTA – darunavir ethanolate susp
•
•
TRUVADA – emtricitabine-tenofovir
disoproxil fumarate tab 200-300 mg
•
VIDEX – didanosine for soln 2 gm
•
•
•
PREZISTA – darunavir ethanolate tab
75 mg (base equiv)
•
VIDEX – didanosine for soln 4 gm
150 mg (base equiv)
•
VIRACEPT – nelfinavir mesylate tab
250 mg
•
VIRACEPT – nelfinavir mesylate tab
625 mg
•
600 mg (base equiv)
VIRAMUNE – nevirapine susp 50
mg/5ml
•
800 mg (base equiv)
•
VIRAMUNE XR – nevirapine tab sr
24hr 100 mg
•
RESCRIPTOR – delavirdine mesylate
tab 100 mg
•
•
VIREAD – tenofovir disoproxil fumarate
oral powder 40 mg/gm
•
RESCRIPTOR – delavirdine mesylate
tab 200 mg
•
tab 150 mg
•
REYATAZ – atazanavir sulfate oral
powder packet 50 mg (base equiv)
•
tab 200 mg
•
REYATAZ – atazanavir sulfate cap 150
mg (base equiv)
tab 250 mg
•
mg (base equiv)
•
•
•
mg (base equiv)
tab 300 mg
•
•
•
•
•
•
•
ZIAGEN – abacavir sulfate soln 20 mg/
ml (base equiv)
•
SELZENTRY – maraviroc tab 150 mg
zidovudine cap 100 mg (Retrovir)
•
•
•
SELZENTRY – maraviroc tab 300 mg
stavudine cap 15 mg (Zerit)
stavudine for oral soln 1 mg/ml
(Zerit)
STRIBILD – elvitegrav-cobicisemtricitab-tenofov tab
150-150-200-300 mg
•
SUSTIVA – efavirenz tab 600 mg
•
•
•
•
SUSTIVA – efavirenz cap 50 mg
SUSTIVA – efavirenz cap 200 mg
TIVICAY – dolutegravir sodium tab 50
mg (base equiv)
zidovudine syrup 10 mg/ml (Retrovir)
zidovudine tab 300 mg
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
MALARIA
atovaquone-proguanil hcl tab
62.5-25 mg (Malarone)
atovaquone-proguanil hcl tab
250-100 mg (Malarone)
chloroquine phosphate tab 250 mg
chloroquine phosphate tab 500 mg
(Aralen)
DARAPRIM – pyrimethamine tab 25 mg
hydroxychloroquine sulfate tab
200 mg (Plaquenil)
mefloquine hcl tab 250 mg
5
AFINITOR – everolimus tab 2.5 mg
AFINITOR – everolimus tab 5 mg
AFINITOR – everolimus tab 7.5 mg
WORM INFECTIONS
AFINITOR – everolimus tab 10 mg
ALBENZA – albendazole tab 200 mg
Step Therapy
Dispensing Limits
•
•
•
•
anastrozole tab 1 mg (Arimidex)
ivermectin tab 3 mg (Stromectol)
bexarotene cap 75 mg (Targretin)
STROMECTOL – ivermectin tab 3 mg
• • •
bicalutamide tab 50 mg (Casodex)
OTHER ANTI-INFECTIVES
capecitabine tab 150 mg (Xeloda)
clindamycin hcl cap 75 mg (Cleocin)
capecitabine tab 500 mg (Xeloda)
• •
• •
EMCYT – estramustine phosphate
sodium cap 140 mg
clindamycin palmitate hcl for soln
75 mg/5ml (base equiv) (Cleocin
pediatric gr)
exemestane tab 25 mg (Aromasin)
FARESTON – toremifene citrate tab 60
DAPSONE – dapsone tab 25 mg
flutamide cap 125 mg
DAPSONE – dapsone tab 100 mg
•
linezolid tab 600 mg (Zyvox)
metronidazole tab 250 mg (Flagyl)
metronidazole tab 500 mg (Flagyl)
GLEEVEC – imatinib mesylate tab 100
• •
GLEEVEC – imatinib mesylate tab 400
• •
SIVEXTRO – tedizolid phosphate tab
200 mg
hydroxyurea cap 500 mg (Hydrea)
sulfamethoxazole-trimethoprim susp
200-40 mg/5ml
IBRANCE – palbociclib cap 100 mg
sulfamethoxazole-trimethoprim tab
400-80 mg (Bactrim)
letrozole tab 2.5 mg (Femara)
sulfamethoxazole-trimethoprim tab
800-160 mg (Bactrim ds)
LEUCOVORIN CALCIUM – leucovorin
calcium tab 10 mg
trimethoprim tab 100 mg
LEUCOVORIN CALCIUM – leucovorin
calcium tab 15 mg
vancomycin hcl cap 125 mg
(Vancocin hcl)
• • •
• • •
• • •
leucovorin calcium tab 5 mg
leucovorin calcium tab 25 mg
vancomycin hcl cap 250 mg
(Vancocin hcl)
LEUKERAN – chlorambucil tab 2 mg
XIFAXAN – rifaximin tab 550 mg
ZYVOX – linezolid tab 600 mg
ZYVOX – linezolid for susp 100 mg/5ml
6
•
•
•
•
ALKERAN – melphalan tab 2 mg
BILTRICIDE – praziquantel tab 600 mg
CANCER DRUGS
Prior Authorization
Drug Name
Specialty
PRIMAQUINE PHOSPHATE –
primaquine phosphate tab 26.3 mg
(15 mg base)
Step Therapy
Dispensing Limits
Drug Name
Prior Authorization
Specialty
2015
•
•
•
megestrol acetate susp 40 mg/ml
(Megace oral)
megestrol acetate tab 20 mg
megestrol acetate tab 40 mg
MEKINIST – trametinib dimethyl
sulfoxide tab 0.5 mg (base
equivalent)
• •
MEKINIST – trametinib dimethyl
sulfoxide tab 2 mg (base equivalent)
• •
SYLATRON – peginterferon alfa-2b for
inj kit 4 x 300 mcg
TABLOID – thioguanine tab 40 mg
• •
mercaptopurine tab 50 mg
(Purinethol)
TAFINLAR – dabrafenib mesylate cap
75 mg (base equivalent)
• •
MESNEX – mesna tab 400 mg
tamoxifen citrate tab 10 mg (base
equivalent)
tamoxifen citrate tab 20 mg (base
equivalent)
MYLERAN – busulfan tab 2 mg
NEXAVAR – sorafenib tosylate tab 200
• •
NILANDRON – nilutamide tab 150 mg
PURIXAN – mercaptopurine susp 2000
mg/100ml (20 mg/ml)
•
SPRYCEL – dasatinib tab 20 mg
•
•
•
•
•
•
•
SUTENT – sunitinib malate cap 12.5
Step Therapy
• •
TAFINLAR – dabrafenib mesylate cap
50 mg (base equivalent)
methotrexate sodium tab 2.5 mg
(base equiv)
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
•
•
•
•
•
•
•
TARCEVA – erlotinib hcl tab 25 mg
(base equivalent)
• •
(base equivalent)
• •
(base equivalent)
• •
TASIGNA – nilotinib hcl cap 150 mg
(base equivalent)
• •
TASIGNA – nilotinib hcl cap 200 mg
(base equivalent)
• •
temozolomide cap 5 mg (Temodar)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
SUTENT – sunitinib malate cap 25 mg
(base equivalent)
• •
SUTENT – sunitinib malate cap 37.5
• •
SUTENT – sunitinib malate cap 50 mg
(base equivalent)
• •
TREXALL – methotrexate sodium tab 5
mg (base equiv)
inj kit 200 mcg
• •
TREXALL – methotrexate sodium tab
7.5 mg (base equiv)
inj kit 300 mcg
• •
10 mg (base equiv)
inj kit 600 mcg
• •
15 mg (base equiv)
inj kit 4 x 200 mcg
• •
VOTRIENT – pazopanib hcl tab 200 mg
(base equiv)
• •
XALKORI – crizotinib cap 200 mg
• •
tretinoin cap 10 mg
7
XALKORI – crizotinib cap 250 mg
ZELBORAF – vemurafenib tab 240 mg
ZYTIGA – abiraterone acetate tab 250
mg
• •
• •
• •
HORMONES, DIABETES AND RELATED DRUGS
prednisolone syrup 15 mg/5ml (usp
solution equivalent) (Prelone)
PREDNISONE – prednisone tab 50 mg
PREDNISONE – prednisone oral soln 5
mg/5ml
PREDNISONE INTENSOL –
prednisone conc 5 mg/ml
CORTICOSTEROIDS
budesonide cap sr 24hr 3 mg
(Entocort ec)
prednisone tab 1 mg
CORTISONE ACETATE – cortisone
acetate tab 25 mg
prednisone tab 2.5 mg
DEXAMETHASONE – dexamethasone
soln 0.5 mg/5ml
prednisone tab 10 mg
dexamethasone elixir 0.5 mg/5ml
MALE HORMONES
dexamethasone tab 0.5 mg
ANDRODERM – testosterone td patch
24hr 2 mg/24hr
• •
ANDRODERM – testosterone td patch
24hr 4 mg/24hr
• •
ANDROGEL – testosterone td gel 25
mg/2.5gm (1%)
• •
ANDROGEL – testosterone td gel 50
mg/5gm (1%)
• •
ANDROGEL – testosterone td gel
20.25 mg/1.25gm (1.62%)
• •
hydrocortisone tab 20 mg (Cortef)
methylprednisolone tab 4 mg dose
pack (Medrol dosepak)
ANDROGEL – testosterone td gel 40.5
mg/2.5gm (1.62%)
• •
methylprednisolone tab 4 mg
(Medrol)
ANDROGEL PUMP – testosterone td
gel 12.5 mg/act (1%)
• •
(Medrol)
ANDROGEL PUMP – testosterone td
gel 20.25 mg/act (1.62%)
• •
(Medrol)
danazol cap 50 mg
(Medrol)
danazol cap 200 mg
•
•
•
• •
dexamethasone tab 4 mg
dexamethasone tab 6 mg
fludrocortisone acetate tab 0.1 mg
prednisolone sod phosph oral
soln 6.7 mg/5ml (5 mg/5ml base)
(Pediapred)
prednisolone sod phosphate oral
soln 15 mg/5ml (base equiv)
8
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Drug Name
Prior Authorization
Specialty
2015
prednisone tab 5 mg
prednisone tab 20 mg
danazol cap 100 mg
testosterone cypionate im inj in oil
100 mg/ml (Depo-testosterone)
testosterone cypionate im inj in oil
200 mg/ml (Depo-testosterone)
• •
testosterone enanthate im inj in oil
200 mg/ml
• •
estradiol td patch weekly
0.025 mg/24hr (Climara)
•
0.0375 mg/24hr (37.5 mcg/24hr)
(Climara)
•
•
DIVIGEL – estradiol td gel 0.25
mg/0.25gm (0.1%)
•
DIVIGEL – estradiol td gel 0.5
mg/0.5gm (0.1%)
•
DIVIGEL – estradiol td gel 1 mg/gm
(0.1%)
•
ENJUVIA – estrogens, conjugated
synthetic b tab 0.3 mg
estropipate tab 0.75 mg
norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg
(Femhrt low dose)
ESTROGENS
COMBIPATCH – estradiolnorethindrone ace td pttw 0.05-0.14
mg/day
COMBIPATCH – estradiolnorethindrone ace td pttw 0.05-0.25
mg/day
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
estropipate tab 1.5 mg
norethindrone acetate-ethinyl
estradiol tab 1 mg-5 mcg
PROGESTINS
medroxyprogesterone acetate tab
2.5 mg (Provera)
estradiol & norethindrone acetate
tab 0.5-0.1 mg (Activella)
5 mg (Provera)
estradiol & norethindrone acetate
tab 1-0.5 mg (Activella)
10 mg (Provera)
estradiol tab 0.5 mg (Estrace)
norethindrone acetate tab 5 mg
(Aygestin)
estradiol tab 1 mg (Estrace)
estradiol tab 2 mg (Estrace)
estradiol td patch twice weekly
0.025 mg/24hr (Vivelle-dot)
•
progesterone micronized cap 100 mg
(Prometrium)
•
progesterone micronized cap 200 mg
(Prometrium)
•
ELLA – ulipristal acetate tab 30 mg
•
levonorgestrel tab 1.5 mg (Plan b
one-step)
•
medroxyprogesterone acetate im
susp 150 mg/ml (Depo-provera
contrac)
BIRTH CONTROL
•
•
9
MIRENA – levonorgestrel releasing iud
20 mcg/24hr (52 mg total)
glipizide tab sr 24hr 2.5 mg (Glucotrol
xl)
norelgestromin-ethinyl estradiol td
ptwk 150-35 mcg/24hr (Ortho evra)
•
glipizide tab sr 24hr 5 mg (Glucotrol
xl)
NUVARING – etonogestrel-ethinyl
estradiol va ring 0.120-0.015 mg/24hr
•
glipizide tab sr 24hr 10 mg (Glucotrol
xl)
oral contraceptives– all generics
•
glipizide tab 5 mg (Glucotrol)
SKYLA – levonorgestrel releasing iud
13.5 mg
glipizide tab 10 mg (Glucotrol)
glipizide-metformin hcl tab
2.5-250 mg
INFERTILITY
chorionic gonadotropin for inj 10000
unit
•
•
clomiphene citrate tab 50 mg
(Clomid)
glipizide-metformin hcl tab
2.5-500 mg
glipizide-metformin hcl tab 5-500 mg
FOLLISTIM AQ – follitropin beta inj 75
unit/0.5ml
•
•
GLUCAGON EMERGENCY KIT –
glucagon (rdna) for inj kit 1 mg
unit/0.36ml
•
•
glyburide micronized tab 1.5 mg
(Glynase)
unit/0.72ml
•
•
glyburide micronized tab 3 mg
(Glynase)
unit/1.08ml
•
•
glyburide micronized tab 6 mg
(Glynase)
GANIRELIX ACETATE – ganirelix
acetate inj 250 mcg/0.5ml
•
•
REPRONEX – menotropins for inj 75
unit
•
•
SYNAREL – nafarelin acetate nasal
soln 2 mg/ml
glyburide tab 1.25 mg
glyburide tab 2.5 mg
glyburide tab 5 mg
glyburide-metformin tab 1.25-250 mg
(Glucovance)
(Glucovance)
DIABETES
glyburide-metformin tab 5-500 mg
(Glucovance)
acarbose tab 25 mg (Precose)
INVOKAMET – canagliflozin-metformin
hcl tab 50-500 mg
•
BYDUREON – exenatide extended
release for susp pen-injector 2 mg
• •
hcl tab 50-1000 mg
•
BYDUREON – exenatide extended
release for inj susp 2 mg
• •
hcl tab 150-500 mg
•
•
glimepiride tab 2 mg (Amaryl)
hcl tab 150-1000 mg
INVOKANA – canagliflozin tab 100 mg
•
10
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Drug Name
Prior Authorization
Specialty
2015
•
•
ONGLYZA – saxagliptin hcl tab 5 mg
(base equiv)
JANUMET – sitagliptin-metformin hcl
tab 50-1000 mg
•
pioglitazone hcl tab 15 mg (base
equiv) (Actos)
JANUMET XR – sitagliptin-metformin
hcl tab sr 24hr 50-500 mg
•
equiv) (Actos)
•
equiv) (Actos)
•
pioglitazone hcl-metformin hcl tab
15-500 mg (Actoplus met)
JANUVIA – sitagliptin phosphate tab 25
mg (base equiv)
•
pioglitazone hcl-metformin hcl tab
15-850 mg (Actoplus met)
JANUVIA – sitagliptin phosphate tab 50
mg (base equiv)
•
JANUVIA – sitagliptin phosphate tab
100 mg (base equiv)
•
JARDIANCE – empagliflozin tab 10 mg
•
•
•
INVOKANA – canagliflozin tab 300 mg
JANUMET – sitagliptin-metformin hcl
tab 50-500 mg
JARDIANCE – empagliflozin tab 25 mg
KOMBIGLYZE XR – saxagliptinmetformin hcl tab sr 24hr 2.5-1000
mg
•
repaglinide tab 0.5 mg (Prandin)
repaglinide tab 1 mg (Prandin)
repaglinide tab 2 mg (Prandin)
VICTOZA – liraglutide soln pen-injector
18 mg/3ml (6 mg/ml)
• •
DIABETES - INSULINS
Rapid-Acting Insulins
NOVOLOG – insulin aspart inj 100 unit/
ml
•
KOMBIGLYZE XR – saxagliptinmetformin hcl tab sr 24hr 5-500 mg
•
NOVOLOG FLEXPEN – insulin aspart
soln pen-injector 100 unit/ml
•
KOMBIGLYZE XR – saxagliptinmetformin hcl tab sr 24hr 5-1000 mg
•
NOVOLOG PENFILL – insulin aspart
soln cartridge 100 unit/ml
•
NOVOLOG PENFILL – insulin aspart inj
100 unit/ml
•
metformin hcl tab sr 24hr 500 mg
(Glucophage xr)
Short-Acting Insulins
metformin hcl tab sr 24hr 750 mg
(Glucophage xr)
NOVOLIN R – insulin regular (human)
inj 100 unit/ml
metformin hcl tab 500 mg
(Glucophage)
•
Intermediate-Acting Insulins
(Glucophage)
NOVOLIN N – insulin nph (human)
(isophane) inj 100 unit/ml
•
(Glucophage)
NOVOLIN 70/30 – insulin nph isophane
& regular human inj 100 unit/ml
(70-30)
•
NOVOLOG MIX 70/30 – insulin aspart
prot & aspart (human) inj 100 unit/ml
(70-30)
•
nateglinide tab 60 mg (Starlix)
nateglinide tab 120 mg (Starlix)
ONGLYZA – saxagliptin hcl tab 2.5 mg
(base equiv)
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
•
11
•
NOVOLOG MIX 70/30 PREFILL –
insulin aspart prot & aspart sus peninj 100 unit/ml (70-30)
LANTUS – insulin glargine inj 100 unit/
ml
•
liothyronine sodium tab 25 mcg
(Cytomel)
LANTUS SOLOSTAR – insulin glargine
•
(Cytomel)
LEVEMIR – insulin detemir inj 100 unit/
ml
•
methimazole tab 5 mg (Tapazole)
LEVEMIR FLEXPEN – insulin detemir
•
LEVEMIR FLEXTOUCH – insulin
detemir soln pen-injector 100 unit/ml
•
TOUJEO SOLOSTAR – insulin glargine
•
levothyroxine sodium tab 25 mcg
(Synthroid)
(Synthroid)
(Synthroid)
(Synthroid)
(Synthroid)
(Synthroid)
(Synthroid)
propylthiouracil tab 50 mg
GROWTH HORMONE
INCRELEX – mecasermin inj 40
mg/4ml (10 mg/ml)
•
OMNITROPE – somatropin for inj 5.8
mg
• •
OMNITROPE – somatropin inj 5
mg/1.5ml
• •
OMNITROPE – somatropin inj 10
mg/1.5ml
• •
OTHER HORMONES AND RELATED DRUGS
ACTONEL – risedronate sodium tab 5
mg
•
mg
•
mg
•
ACTONEL – risedronate sodium tab
150 mg
•
alendronate sodium tab 5 mg
•
•
•
•
(Synthroid)
(Fosamax)
(Synthroid)
cabergoline tab 0.5 mg
12
Step Therapy
methimazole tab 10 mg (Tapazole)
(Synthroid)
(Synthroid)
Dispensing Limits
(Synthroid)
(Cytomel)
Basal Insulins
THYROID REGULATION
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Drug Name
Prior Authorization
Specialty
2015
calcitonin (salmon) nasal soln 200
unit/act (Miacalcin)
calcitriol cap 0.25 mcg (Rocaltrol)
calcitriol cap 0.5 mcg (Rocaltrol)
paricalcitol cap 4 mcg (Zemplar)
calcitriol oral soln 1 mcg/ml
(Rocaltrol)
raloxifene hcl tab 60 mg (Evista)
desmopressin acetate inj 4 mcg/ml
(Ddavp)
desmopressin acetate nasal soln
0.01% (refrigerated) (Ddavp)
desmopressin acetate nasal spray
soln 0.01% (Ddavp)
desmopressin acetate nasal spray
soln 0.01% (refrigerated)
•
risedronate sodium tab 30 mg
(Actonel)
•
(Actonel)
•
(Actonel)
•
• • •
•
ibandronate sodium tab 150 mg
(base equivalent) (Boniva)
SENSIPAR – cinacalcet hcl tab 90 mg
(base equiv)
STIMATE – desmopressin acetate
nasal soln 1.5 mg/ml
HEART AND CIRCULATORY DRUGS
levocarnitine oral soln 1 gm/10ml
(10%) (Carnitor)
ANGIOTENSIN CONVERTING ENZYME (ACE)
INHIBITORS AND COMBINATI
levocarnitine tab 330 mg (Carnitor)
benazepril & hydrochlorothiazide tab
5-6.25 mg
methylergonovine maleate tab
0.2 mg
octreotide acetate inj 50 mcg/ml
(0.05 mg/ml) (Sandostatin)
•
10-12.5 mg (Lotensin hct)
•
20-12.5 mg (Lotensin hct)
•
20-25 mg (Lotensin hct)
•
(1 mg/ml) (Sandostatin)
•
benazepril hcl tab 20 mg (Lotensin)
ORFADIN – nitisinone cap 2 mg
•
•
•
captopril tab 12.5 mg
Step Therapy
(base equiv)
desmopressin acetate tab 0.2 mg
(Ddavp)
Dispensing Limits
(Actonel)
(base equiv)
desmopressin acetate tab 0.1 mg
(Ddavp)
FORTEO – teriparatide (recombinant)
inj 600 mcg/2.4ml
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
benazepril hcl tab 5 mg
captopril tab 25 mg
captopril tab 50 mg
captopril tab 100 mg
13
enalapril maleate &
hydrochlorothiazide tab 5-12.5 mg
perindopril erbumine tab 4 mg
(Aceon)
enalapril maleate &
hydrochlorothiazide tab 10-25 mg
(Vaseretic)
(Aceon)
enalapril maleate tab 2.5 mg
(Vasotec)
quinapril hcl tab 10 mg (Accupril)
enalapril maleate tab 10 mg (Vasotec)
quinapril-hydrochlorothiazide tab
10-12.5 mg (Accuretic)
fosinopril sodium &
20-12.5 mg (Accuretic)
fosinopril sodium &
20-25 mg (Accuretic)
fosinopril sodium tab 10 mg
ramipril cap 1.25 mg (Altace)
ramipril cap 2.5 mg (Altace)
ramipril cap 5 mg (Altace)
lisinopril & hydrochlorothiazide tab
10-12.5 mg (Zestoretic)
ramipril cap 10 mg (Altace)
20-12.5 mg (Zestoretic)
trandolapril tab 2 mg (Mavik)
lisinopril tab 5 mg (Prinivil)
lisinopril tab 30 mg (Zestril)
lisinopril tab 40 mg (Zestril)
moexipril hcl tab 7.5 mg (Univasc)
moexipril hcl tab 15 mg (Univasc)
moexipril-hydrochlorothiazide tab
7.5-12.5 mg
15-12.5 mg (Uniretic)
15-25 mg
Step Therapy
lisinopril tab 2.5 mg (Zestril)
Dispensing Limits
20-25 mg (Zestoretic)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Drug Name
Prior Authorization
Specialty
2015
ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS)
AND COMBINATIONS
amlodipine-valsartanhydrochlorothiazide tab
5-160-12.5 mg (Exforge hct)
5-160-25 mg (Exforge hct)
10-160-12.5 mg (Exforge hct)
14
BENICAR – olmesartan medoxomil tab
5 mg
20 mg
40 mg
BENICAR HCT – olmesartan
medoxomil-hydrochlorothiazide tab
20-12.5 mg
losartan potassium &
(Hyzaar)
40-12.5 mg
losartan potassium tab 25 mg
(Cozaar)
(Cozaar)
telmisartan tab 20 mg (Micardis)
candesartan cilexetil tab 8 mg
(Atacand)
(Atacand)
candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg
(Atacand hct)
telmisartan-hydrochlorothiazide tab
40-12.5 mg (Micardis hct)
80-12.5 mg (Micardis hct)
80-25 mg (Micardis hct)
valsartan tab 40 mg (Diovan)
candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg
(Atacand hct)
candesartan cilexetilhydrochlorothiazide tab 32-25 mg
(Atacand hct)
valsartan-hydrochlorothiazide tab
80-12.5 mg (Diovan hct)
irbesartan tab 75 mg (Avapro)
Step Therapy
(Cozaar)
(Atacand)
(Atacand)
Dispensing Limits
(Hyzaar)
hydrochlorothiazide tab
100-12.5 mg (Hyzaar)
40-25 mg
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
160-25 mg (Diovan hct)
irbesartan-hydrochlorothiazide tab
150-12.5 mg (Avalide)
irbesartan-hydrochlorothiazide tab
300-12.5 mg (Avalide)
320-25 mg (Diovan hct)
BETA BLOCKERS AND COMBINATIONS
15
acebutolol hcl cap 200 mg (Sectral)
metoprolol tartrate tab 50 mg
(Lopressor)
atenolol & chlorthalidone tab
100-25 mg (Tenoretic 100)
atenolol tab 25 mg (Tenormin)
(Lopressor)
nadolol tab 20 mg (Corgard)
bisoprolol & hydrochlorothiazide tab
2.5-6.25 mg (Ziac)
5-6.25 mg (Ziac)
pindolol tab 10 mg
10-6.25 mg (Ziac)
carvedilol tab 3.125 mg (Coreg)
carvedilol tab 25 mg (Coreg)
INNOPRAN XL – propranolol hcl
sustained-release beads cap sr 24hr
80 mg
INNOPRAN XL – propranolol hcl
sustained-release beads cap sr 24hr
120 mg
labetalol hcl tab 100 mg (Trandate)
metoprolol succinate tab sr 24hr
25 mg (Toprol xl)
50 mg (Toprol xl)
100 mg (Toprol xl)
16
Step Therapy
atenolol & chlorthalidone tab
50-25 mg (Tenoretic 50)
bisoprolol fumarate tab 10 mg
(Zebeta)
Dispensing Limits
200 mg (Toprol xl)
acebutolol hcl cap 400 mg (Sectral)
bisoprolol fumarate tab 5 mg
(Zebeta)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Drug Name
Prior Authorization
Specialty
2015
pindolol tab 5 mg
PROPRANOLOL HCL – propranolol hcl
oral soln 20 mg/5ml
PROPRANOLOL HCL – propranolol hcl
oral soln 40 mg/5ml
propranolol hcl cap sr 24hr 60 mg
(Inderal la)
(Inderal la)
(Inderal la)
(Inderal la)
propranolol hcl tab 10 mg
TIMOLOL MALEATE – timolol maleate
tab 5 mg
tab 10 mg
tab 20 mg
CALCIUM CHANNEL BLOCKERS AND
COMBINATIONS
amlodipine besylate tab 2.5 mg
(Norvasc)
amlodipine besylate-valsartan tab
5-160 mg (Exforge)
amlodipine besylate tab 5 mg
(Norvasc)
5-320 mg (Exforge)
amlodipine besylate tab 10 mg
(Norvasc)
10-160 mg (Exforge)
amlodipine besylate-atorvastatin
calcium tab 2.5-10 mg (Caduet)
10-320 mg (Exforge)
diltiazem hcl cap sr 24hr 120 mg
calcium tab 5-10 mg (Caduet)
amlodipine besylate-benazepril hcl
cap 2.5-10 mg (Lotrel)
cap 5-10 mg (Lotrel)
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
diltiazem hcl coated beads cap sr
24hr 120 mg (Cardizem cd)
diltiazem hcl extended release beads
cap sr 24hr 120 mg (Tiazac)
diltiazem hcl tab 30 mg (Cardizem)
diltiazem hcl tab 90 mg
felodipine tab sr 24hr 2.5 mg
felodipine tab sr 24hr 5 mg
17
felodipine tab sr 24hr 10 mg
isosorbide mononitrate tab 20 mg
nitroglycerin td patch 24hr 0.1 mg/hr
(Nitro-dur)
nifedipine tab sr 24hr 90 mg (Adalat
cc)
nifedipine tab sr 24hr osmotic 30 mg
(Procardia xl)
(Procardia xl)
(Procardia xl)
verapamil hcl cap sr 24hr 120 mg
(Verelan)
(Nitro-dur)
(Nitro-dur)
(Nitro-dur)
NITROSTAT – nitroglycerin sl tab 0.3
mg
mg
(Verelan)
mg
(Verelan)
CHOLESTEROL LOWERING
(Verelan)
atorvastatin calcium tab 10 mg (base
equivalent) (Lipitor)
verapamil hcl tab cr 120 mg (Calan
sr)
sr)
sr)
verapamil hcl tab 80 mg (Calan)
cholestyramine light powder packets
4 gm
verapamil hcl tab 120 mg (Calan)
CHEST PAIN
isosorbide dinitrate tab 5 mg (Isordil
titradose)
isosorbide mononitrate tab sr 24hr
30 mg (Imdur)
60 mg (Imdur)
18
Step Therapy
isosorbide mononitrate tab 10 mg
cc)
isosorbide dinitrate tab 20 mg
Dispensing Limits
120 mg (Imdur)
cc)
isosorbide dinitrate tab 10 mg
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Drug Name
Prior Authorization
Specialty
2015
cholestyramine light powder 4 gm/
dose (Questran light)
cholestyramine powder packets
4 gm (Questran)
cholestyramine powder 4 gm/dose
(Questran)
choline fenofibrate cap dr 45 mg
(fenofibric acid equiv) (Trilipix)
choline fenofibrate cap dr 135 mg
(fenofibric acid equiv) (Trilipix)
colestipol hcl granule packets 5 gm
(Colestid flavored)
pravastatin sodium tab 80 mg
(Pravachol)
colestipol hcl granules 5 gm (Colestid
flavored)
simvastatin tab 5 mg (Zocor)
colestipol hcl tab 1 gm (Colestid)
CRESTOR – rosuvastatin calcium tab 5
mg
CRESTOR – rosuvastatin calcium tab
10 mg
20 mg
40 mg
WELCHOL – colesevelam hcl tab 625
mg
WELCHOL – colesevelam hcl packet
for susp 3.75 gm
FLUID RETENTION
fenofibrate micronized cap 134 mg
(Lofibra)
acetazolamide tab 250 mg
amiloride & hydrochlorothiazide tab
5-50 mg
amiloride hcl tab 5 mg
fenofibrate tab 48 mg (Tricor)
bumetanide tab 0.5 mg
fenofibrate tab 54 mg (Lofibra)
bumetanide tab 1 mg
fenofibrate tab 145 mg (Tricor)
bumetanide tab 2 mg
fenofibrate tab 160 mg (Lofibra)
chlorothiazide tab 500 mg
gemfibrozil tab 600 mg (Lopid)
furosemide oral soln 10 mg/ml
lovastatin tab 10 mg
furosemide tab 20 mg (Lasix)
lovastatin tab 20 mg (Mevacor)
lovastatin tab 40 mg (Mevacor)
niacin tab cr 500 mg
(antihyperlipidemic) (Niaspan)
hydrochlorothiazide cap 12.5 mg
(Microzide)
hydrochlorothiazide tab 12.5 mg
hydrochlorothiazide tab 50 mg
(Pravachol)
(Pravachol)
Step Therapy
acetazolamide cap sr 12hr 500 mg
(Diamox)
Dispensing Limits
(Lofibra)
(Lofibra)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
hydrochlorothiazide tab 25 mg
indapamide tab 1.25 mg
indapamide tab 2.5 mg
methazolamide tab 25 mg
(Neptazane)
methazolamide tab 50 mg
(Neptazane)
19
metolazone tab 2.5 mg (Zaroxolyn)
spironolactone &
(Aldactazide)
propafenone hcl cap sr 12hr 425 mg
(Rythmol sr)
spironolactone tab 25 mg (Aldactone)
spironolactone tab 50 mg (Aldactone)
spironolactone tab 100 mg
(Aldactone)
propafenone hcl tab 150 mg
(Rythmol)
(Rythmol)
torsemide tab 5 mg (Demadex)
quinidine gluconate tab cr 324 mg
quinidine sulfate tab 300 mg
sotalol hcl (afib/afl) tab 80 mg
(Betapace af)
triamterene & hydrochlorothiazide
cap 37.5-25 mg (Dyazide)
(Betapace af)
tab 37.5-25 mg (Maxzide-25)
(Betapace af)
tab 75-50 mg (Maxzide)
sotalol hcl tab 80 mg (Betapace)
HEART RHYTHM
amiodarone hcl tab 100 mg
sotalol hcl tab 240 mg
(Cordarone)
OTHER HEART RELATED DRUGS
ADCIRCA – tadalafil tab 20 mg (pah)
disopyramide phosphate cap 100 mg
(Norpace)
clonidine hcl tab 0.1 mg (Catapres)
disopyramide phosphate cap 150 mg
(Norpace)
flecainide acetate tab 150 mg
mexiletine hcl cap 150 mg
• • •
clonidine hcl td patch weekly
0.1 mg/24hr (Catapres-tts-1)
DIBENZYLINE – phenoxybenzamine
hcl cap 10 mg
MULTAQ – dronedarone hcl tab 400
digoxin tab 125 mcg (0.125 mg)
(Lanoxin)
20
Step Therapy
(Rythmol sr)
metolazone tab 10 mg
Dispensing Limits
(Rythmol sr)
metolazone tab 5 mg (Zaroxolyn)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Drug Name
Prior Authorization
Specialty
2015
digoxin tab 250 mcg (0.25 mg)
(Lanoxin)
TRACLEER – bosentan tab 62.5 mg
doxazosin mesylate tab 1 mg
(Cardura)
ERECTILE DYSFUNCTION
(Cardura)
CIALIS – tadalafil tab 5 mg
TRACLEER – bosentan tab 125 mg
CIALIS – tadalafil tab 2.5 mg
(Cardura)
(Cardura)
BEE STING KITS
eplerenone tab 50 mg (Inspra)
guanfacine hcl tab 2 mg (Tenex)
Step Therapy
Dispensing Limits
ANTIHISTAMINES
hydralazine hcl tab 25 mg
cetirizine hcl oral soln 1 mg/ml
(5 mg/5ml)
• • •
• • •
methyldopa tab 250 mg
methyldopa tab 500 mg
cyproheptadine hcl syrup 2 mg/5ml
cyproheptadine hcl tab 4 mg
desloratadine tab orally
disintegrating 2.5 mg (Clarinex
reditabs)
midodrine hcl tab 5 mg
desloratadine tab orally
disintegrating 5 mg (Clarinex
reditabs)
midodrine hcl tab 10 mg
desloratadine tab 5 mg (Clarinex)
minoxidil tab 2.5 mg
levocetirizine dihydrochloride soln
2.5 mg/5ml (0.5 mg/ml) (Xyzal)
midodrine hcl tab 2.5 mg
minoxidil tab 10 mg
• • •
prazosin hcl cap 1 mg (Minipress)
levocetirizine dihydrochloride tab
5 mg (Xyzal)
promethazine hcl suppos 12.5 mg
promethazine hcl suppos 25 mg
sildenafil citrate tab 20 mg (Revatio)
•
•
•
•
RESPIRATORY AGENTS
OPSUMIT – macitentan tab 10 mg
•
•
•
•
EPIPEN-JR 2-PAK – epinephrine
solution auto-injector 0.15 mg/0.3ml
(1:2000)
guanfacine hcl tab 1 mg (Tenex)
LETAIRIS – ambrisentan tab 10 mg
• • •
• • •
EPIPEN 2-PAK – epinephrine solution
auto-injector 0.3 mg/0.3ml (1:1000)
eplerenone tab 25 mg (Inspra)
LETAIRIS – ambrisentan tab 5 mg
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
•
•
promethazine hcl suppos 50 mg
terazosin hcl cap 1 mg
promethazine hcl syrup 6.25 mg/5ml
promethazine hcl tab 12.5 mg
promethazine hcl tab 25 mg
promethazine hcl tab 50 mg
21
NASAL PRODUCTS
•
ASTEPRO – azelastine hcl nasal spray
0.15% (205.5 mcg/spray)
•
albuterol sulfate soln nebu 0.083%
(2.5 mg/3ml)
•
azelastine hcl nasal spray 0.1%
(137 mcg/spray)
•
albuterol sulfate soln nebu 0.5%
(5 mg/ml)
•
azelastine hcl nasal spray 0.15%
(205.5 mcg/spray) (Astepro)
•
albuterol sulfate soln nebu
0.63 mg/3ml (base equiv)
•
flunisolide nasal soln 25 mcg/act
(0.025%) (Flunisolide)
•
albuterol sulfate soln nebu
1.25 mg/3ml (base equiv)
fluticasone propionate nasal susp
50 mcg/act (Flonase)
•
ipratropium bromide nasal soln
0.03% (21 mcg/spray) (Atrovent)
•
ipratropium bromide nasal soln
0.06% (42 mcg/spray) (Atrovent)
•
NASONEX – mometasone furoate
nasal susp 50 mcg/act
•
triamcinolone acetonide nasal
aerosol suspension 55 mcg/act
(Nasacort aq)
•
albuterol sulfate syrup 2 mg/5ml
COUGH/COLD/ALLERGY
acetylcysteine inhal soln 10%
acetylcysteine inhal soln 20%
ASTHMA/COPD
albuterol sulfate tab 2 mg
albuterol sulfate tab 4 mg
ANORO ELLIPTA – umeclidiniumvilanterol aero powd ba 62.5-25 mcg/
inh
•
ARNUITY ELLIPTA – fluticasone
furoate aerosol powder breath activ
100 mcg/act
•
ARNUITY ELLIPTA – fluticasone
furoate aerosol powder breath activ
200 mcg/act
•
ASMANEX HFA – mometasone furoate
inhal aerosol suspension 100 mcg/act
•
ASMANEX HFA – mometasone furoate
inhal aerosol suspension 200 mcg/act
•
ADVAIR DISKUS – fluticasonesalmeterol aer powder ba 100-50
mcg/dose
•
ASMANEX TWISTHALER 120 ME –
mometasone furoate inhal powd 220
mcg/inh (breath activated)
•
mcg/dose
•
ASMANEX TWISTHALER 14 MET –
•
mcg/dose
•
•
ADVAIR HFA – fluticasone-salmeterol
inhal aerosol 45-21 mcg/act
•
•
•
•
•
22
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Drug Name
Prior Authorization
Specialty
2015
ASMANEX TWISTHALER 7 METE –
•
FLOVENT HFA – fluticasone
propionate hfa inhal aer 220 mcg/act
(250/valve)
•
ATROVENT HFA – ipratropium
bromide hfa inhal aerosol 17 mcg/act
•
FORADIL AEROLIZER – formoterol
fumarate inhal cap 12 mcg
•
BREO ELLIPTA – fluticasone furoatevilanterol aero powd ba 100-25 mcg/
inh
•
INCRUSE ELLIPTA – umeclidinium br
aero powd breath act 62.5 mcg/inh
(base eq)
•
BREO ELLIPTA – fluticasone furoatevilanterol aero powd ba 200-25 mcg/
inh
•
ipratropium bromide inhal soln
0.02%
•
ipratropium-albuterol nebu soln
0.5-2.5(3) mg/3ml (Duoneb)
•
budesonide inhalation susp
0.25 mg/2ml (Pulmicort)
•
•
•
0.5 mg/2ml (Pulmicort)
levalbuterol hcl soln nebu conc
1.25 mg/0.5ml (base equiv)
•
levalbuterol hcl soln nebu
0.31 mg/3ml (base equiv) (Xopenex)
•
1 mg/2ml (Pulmicort)
•
•
COMBIVENT RESPIMAT –
ipratropium-albuterol inhal aerosol
soln 20-100 mcg/act
•
DULERA – mometasone furoateformoterol fumarate aerosol 100-5
mcg/act
•
DULERA – mometasone furoateformoterol fumarate aerosol 200-5
mcg/act
•
FLOVENT DISKUS – fluticasone
propionate aer pow ba 50 mcg/blister
•
propionate aer pow ba 100 mcg/
blister
•
propionate aer pow ba 250 mcg/
blister
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
montelukast sodium chew tab 4 mg
(base equiv) (Singulair)
montelukast sodium chew tab 5 mg
(base equiv) (Singulair)
montelukast sodium oral granules
packet 4 mg (base equiv) (Singulair)
montelukast sodium tab 10 mg (base
equiv) (Singulair)
PROAIR HFA – albuterol sulfate inhal
aero 108 mcg/act (90mcg base equiv)
•
•
PROAIR RESPICLICK – albuterol
sulfate aer pow ba 108 mcg/act (90
mcg base equiv)
•
propionate hfa inhal aero 44 mcg/act
(50/valve)
•
QVAR – beclomethasone dipropionate
inhal aero soln 40 mcg/act
•
•
propionate hfa inhal aer 110 mcg/act
(125/valve)
•
QVAR – beclomethasone dipropionate
inhal aero soln 80 mcg/act
SPIRIVA HANDIHALER – tiotropium
bromide monohydrate inhal cap 18
mcg (base equiv)
•
23
SPIRIVA RESPIMAT – tiotropium
bromide monohydrate inhal aerosol
2.5 mcg/act
•
SYMBICORT – budesonide-formoterol
fumarate dihyd aerosol 80-4.5 mcg/
act
•
SYMBICORT – budesonide-formoterol
fumarate dihyd aerosol 160-4.5 mcg/
act
•
loperamide hcl cap 2 mg
ULCER/GERD
cimetidine hcl soln 300 mg/5ml
cimetidine tab 300 mg
dicyclomine hcl cap 10 mg (Bentyl)
theophylline tab sr 12hr 100 mg
dicyclomine hcl tab 20 mg (Bentyl)
DONNATAL – pb-hyoscy-atrop-scopol
tab 16.2-0.1037-0.0194-0.0065 mg
•
•
esomeprazole magnesium cap
delayed release 40 mg (base eq)
(Nexium)
•
famotidine tab 40 mg (Pepcid)
zafirlukast tab 20 mg (Accolate)
glycopyrrolate tab 1 mg (Robinul)
OTHER RESPIRATORY DRUGS
KALYDECO – ivacaftor tab 150 mg
KALYDECO – ivacaftor packet 50 mg
KALYDECO – ivacaftor packet 75 mg
PULMOZYME – dornase alfa inhal soln
1 mg/ml
GASTROINTESTINAL DRUGS
• • •
• • •
• • •
•
glycopyrrolate tab 2 mg (Robinul
forte)
hyoscyamine sulfate elixir
0.125 mg/5ml
hyoscyamine sulfate soln 0.125 mg/
ml
hyoscyamine sulfate tab disp
0.125 mg (Anaspaz)
LAXATIVES
lactulose solution 10 gm/15ml
peg 3350-kcl-sod bicarb-nacl for soln
420 gm (Nulytely/flavor pack)
24
esomeprazole magnesium cap
delayed release 20 mg (base eq)
(Nexium)
famotidine tab 20 mg (Pepcid)
zafirlukast tab 10 mg (Accolate)
peg 3350-kcl-na bicarb-nacl-na
sulfate for soln 240 gm (Colyteflavor packs)
Step Therapy
diphenoxylate w/ atropine tab
2.5-0.025 mg (Lomotil)
terbutaline sulfate tab 5 mg
peg 3350-kcl-na bicarb-nacl-na
sulfate for soln 236 gm (Golytely)
Dispensing Limits
ANTIDIARRHEALS
terbutaline sulfate tab 2.5 mg
VENTOLIN HFA – albuterol sulfate
inhal aero 108 mcg/act (90mcg base
equiv)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Drug Name
Prior Authorization
Specialty
2015
hyoscyamine sulfate tab sl 0.125 mg
(Levsin/sl)
hyoscyamine sulfate tab sr 12hr
0.375 mg (Levbid)
hyoscyamine sulfate tab 0.125 mg
(Levsin)
lansoprazole cap delayed release
15 mg (Prevacid)
•
lansoprazole cap delayed release
30 mg (Prevacid)
•
Step Therapy
Dispensing Limits
ranitidine hcl tab 300 mg (Zantac)
sucralfate tab 1 gm (Carafate)
methscopolamine bromide tab
2.5 mg (Pamine)
NAUSEA AND VOMITING
methscopolamine bromide tab 5 mg
(Pamine forte)
misoprostol tab 100 mcg (Cytotec)
EMEND – aprepitant capsule therapy
pack 80 & 125 mg
•
EMEND – aprepitant capsule 40 mg
•
•
•
•
misoprostol tab 200 mcg (Cytotec)
NEXIUM – esomeprazole magnesium
for delayed release susp pack 2.5 mg
•
for delayed release susp packet 5 mg
•
meclizine hcl tab 12.5 mg
for delayed release susp packet 10
mg
•
mg
•
mg
•
cap delayed release 20 mg (base eq)
•
ondansetron hcl tab 24 mg
cap delayed release 40 mg (base eq)
•
ondansetron orally disintegrating tab
4 mg (Zofran odt)
omeprazole cap delayed release
10 mg (Prilosec)
•
ondansetron orally disintegrating tab
8 mg (Zofran odt)
20 mg (Prilosec)
•
trimethobenzamide hcl cap 300 mg
(Tigan)
40 mg (Prilosec)
•
pantoprazole sodium ec tab 20 mg
(base equiv) (Protonix)
•
pantoprazole sodium ec tab 40 mg
(base equiv) (Protonix)
•
ranitidine hcl cap 150 mg
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
granisetron hcl tab 1 mg
meclizine hcl tab 25 mg
ondansetron hcl inj 4 mg/2ml (2 mg/
ml)
•
ondansetron hcl inj 40 mg/20ml
(2 mg/ml) (Zofran)
•
ondansetron hcl oral soln 4 mg/5ml
(Zofran)
•
ondansetron hcl tab 4 mg (Zofran)
•
•
•
•
ondansetron hcl tab 8 mg (Zofran)
•
DIGESTIVE ENZYMES
CREON – pancrelipase (lip-prot-amyl)
dr cap 3000-9500-15000 unit
dr cap 6000-19000-30000 unit
dr cap 12000-38000-60000 unit
ranitidine hcl cap 300 mg
dr cap 24000-76000-120000 unit
ranitidine hcl syrup 15 mg/ml
(75 mg/5ml)
dr cap 36000-114000-180000 unit
ranitidine hcl tab 150 mg (Zantac)
25
ZENPEP – pancrelipase (lip-prot-amyl)
dr cap 3000-10000-16000 unit
metoclopramide hcl tab 10 mg
(Reglan)
dr cap 5000-17000-27000 unit
PENTASA – mesalamine cap cr 250
mg
dr cap 10000-34000-55000 unit
PENTASA – mesalamine cap cr 500
mg
dr cap 15000-51000-82000 unit
sulfasalazine tab delayed release
500 mg (Azulfidine en-tabs)
dr cap 20000-68000-109000 unit
sulfasalazine tab 500 mg (Azulfidine)
dr cap 25000-85000-136000 unit
ursodiol tab 250 mg (Urso 250)
dr cap 40000-136000-218000 unit
GENITOURINARY DRUGS
ASACOL HD – mesalamine tab
delayed release 800 mg
nitrofurantoin macrocrystalline cap
50 mg (Macrodantin)
balsalazide disodium cap 750 mg
(Colazal)
nitrofurantoin macrocrystalline cap
100 mg (Macrodantin)
calcium acetate (phosphate binder)
cap 667 mg (169 mg ca) (Phoslo)
nitrofurantoin monohydrate
macrocrystalline cap 100 mg
(Macrobid)
calcium acetate (phosphate binder)
tab 667 mg (Eliphos)
nitrofurantoin susp 25 mg/5ml
(Furadantin)
CANASA – mesalamine suppos 1000
mg
URINARY TRACT SPASMS
•
oxybutynin chloride syrup 5 mg/5ml
DELZICOL – mesalamine cap dr 400
mg
oxybutynin chloride tab sr 24hr 5 mg
(Ditropan xl)
lactulose (encephalopathy) solution
10 gm/15ml
oxybutynin chloride tab sr 24hr
10 mg (Ditropan xl)
LIALDA – mesalamine tab delayed
release 1.2 gm
oxybutynin chloride tab sr 24hr
15 mg (Ditropan xl)
LINZESS – linaclotide cap 145 mcg
oxybutynin chloride tab 5 mg
LINZESS – linaclotide cap 290 mcg
tolterodine tartrate cap sr 24hr 2 mg
(Detrol la)
metoclopramide hcl soln 5 mg/5ml
(10 mg/10ml)
metoclopramide hcl tab 5 mg
(Reglan)
26
Step Therapy
ursodiol tab 500 mg (Urso forte)
URINARY TRACT INFECTIONS
mesalamine enema 4 gm
Dispensing Limits
ursodiol cap 300 mg (Actigall)
OTHER GASTROINTESTINAL DRUGS
CHENODAL – chenodiol tab 250 mg
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Drug Name
Prior Authorization
Specialty
2015
tolterodine tartrate cap sr 24hr 4 mg
(Detrol la)
tolterodine tartrate tab 1 mg (Detrol)
tolterodine tartrate tab 2 mg (Detrol)
VESICARE – solifenacin succinate tab
5 mg
potassium citrate tab cr 5 meq
(540 mg) (Urocit-k 5)
VESICARE – solifenacin succinate tab
10 mg
(1080 mg) (Urocit-k 10)
VAGINAL PRODUCTS
(1620 mg) (Urocit-k 15)
CLEOCIN – clindamycin phosphate
vaginal suppos 100 mg
Step Therapy
Dispensing Limits
sodium citrate & citric acid soln
500-334 mg/5ml (Shohls solution
modi)
clindamycin phosphate vaginal
cream 2% (Cleocin)
CRINONE – progesterone vaginal gel
4%
•
CRINONE – progesterone vaginal gel
8%
•
tamsulosin hcl cap 0.4 mg (Flomax)
CENTRAL NERVOUS SYSTEM DRUGS
ANXIETY
alprazolam tab sr 24hr 0.5 mg (Xanax
xr)
ESTRACE – estradiol vaginal cream
0.1 mg/gm
alprazolam tab sr 24hr 1 mg (Xanax
xr)
metronidazole vaginal gel 0.75%
(Metrogel-vaginal)
xr)
terconazole vaginal cream 0.4%
(Terazol 7)
xr)
terconazole vaginal cream 0.8%
(Terazol 3)
alprazolam tab 0.25 mg (Xanax)
terconazole vaginal suppos 80 mg
alprazolam tab 0.5 mg (Xanax)
VAGIFEM – estradiol vaginal tab 10
mcg
alprazolam tab 1 mg (Xanax)
alprazolam tab 2 mg (Xanax)
OTHER GENITOURINARY DRUGS
buspirone hcl tab 5 mg
alfuzosin hcl tab sr 24hr 10 mg
(Uroxatral)
AVODART – dutasteride cap 0.5 mg
CYSTAGON – cysteamine bitartrate
cap 50 mg
•
CYSTAGON – cysteamine bitartrate
cap 150 mg
•
DIAZEPAM – diazepam soln 1 mg/ml
diazepam tab 2 mg (Valium)
finasteride tab 5 mg (Proscar)
pot & sod citrates w/ cit ac soln
550-500-334 mg/5ml
hydroxyzine hcl syrup 10 mg/5ml
potassium citrate & citric acid
powder pack 3300-1002 mg
hydroxyzine hcl tab 25 mg
potassium citrate & citric acid soln
1100-334 mg/5ml
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
27
hydroxyzine pamoate cap 25 mg
(Vistaril)
clomipramine hcl cap 50 mg
(Anafranil)
hydroxyzine pamoate cap 50 mg
(Vistaril)
(Anafranil)
lorazepam conc 2 mg/ml (Lorazepam
intensol)
desipramine hcl tab 10 mg
(Norpramin)
lorazepam tab 0.5 mg (Ativan)
(Norpramin)
lorazepam tab 1 mg (Ativan)
(Norpramin)
lorazepam tab 2 mg (Ativan)
DEPRESSION
(Norpramin)
amitriptyline hcl tab 10 mg
(Norpramin)
(Norpramin)
doxepin hcl cap 10 mg
bupropion hcl tab sr 12hr 100 mg
(Wellbutrin sr)
(Wellbutrin sr)
(Wellbutrin sr)
duloxetine hcl enteric coated pellets
cap 20 mg (Cymbalta)
•
(Wellbutrin xl)
•
(Wellbutrin xl)
•
bupropion hcl tab 75 mg (Wellbutrin)
bupropion hcl tab 100 mg (Wellbutrin)
escitalopram oxalate soln 5 mg/5ml
(base equiv) (Lexapro)
citalopram hydrobromide oral soln
10 mg/5ml
escitalopram oxalate tab 5 mg (base
equiv) (Lexapro)
citalopram hydrobromide tab 10 mg
(base equiv) (Celexa)
escitalopram oxalate tab 10 mg
escitalopram oxalate tab 20 mg
fluoxetine hcl cap 10 mg (Prozac)
(Anafranil)
28
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Drug Name
Prior Authorization
Specialty
2015
doxepin hcl conc 10 mg/ml
fluoxetine hcl solution 20 mg/5ml
fluoxetine hcl tab 10 mg
trazodone hcl tab 150 mg
fluoxetine hcl tab 20 mg
fluvoxamine maleate tab 25 mg
venlafaxine hcl cap sr 24hr 37.5 mg
(base equivalent) (Effexor xr)
imipramine hcl tab 10 mg (Tofranil)
mirtazapine tab 7.5 mg
mirtazapine tab 15 mg (Remeron)
nortriptyline hcl cap 10 mg (Pamelor)
paroxetine hcl tab sr 24hr 12.5 mg
(Paxil cr)
venlafaxine hcl tab sr 24hr 37.5 mg
(base equivalent) (Venlafaxine hcl
er)
venlafaxine hcl tab sr 24hr 75 mg
er)
venlafaxine hcl tab sr 24hr 150 mg
er)
venlafaxine hcl tab 25 mg
venlafaxine hcl tab 37.5 mg
paroxetine hcl tab sr 24hr 37.5 mg
(Paxil cr)
PSYCHOTIC AND BIPOLAR DISORDERS
paroxetine hcl tab 30 mg (Paxil)
phenelzine sulfate tab 15 mg (Nardil)
sertraline hcl oral conc 20 mg/ml
(Zoloft)
chlorpromazine hcl tab 10 mg
clozapine tab 25 mg (Clozaril)
clozapine tab 50 mg
sertraline hcl tab 25 mg (Zoloft)
clozapine tab 100 mg (Clozaril)
clozapine tab 200 mg
fluphenazine decanoate inj 25 mg/ml
tranylcypromine sulfate tab 10 mg
(Parnate)
FLUPHENAZINE HCL – fluphenazine
hcl elixir 2.5 mg/5ml
FLUPHENAZINE HCL – fluphenazine
hcl oral conc 5 mg/ml
Step Therapy
venlafaxine hcl cap sr 24hr 150 mg
Dispensing Limits
venlafaxine hcl cap sr 24hr 75 mg
paroxetine hcl tab sr 24hr 25 mg
(Paxil cr)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
•
•
•
•
fluphenazine hcl tab 1 mg
29
fluphenazine hcl tab 2.5 mg
olanzapine tab 5 mg (Zyprexa)
olanzapine tab 7.5 mg (Zyprexa)
haloperidol decanoate im soln
50 mg/ml (Haldol decanoate 50)
haloperidol decanoate im soln
100 mg/ml (Haldol decanoate 100)
perphenazine tab 2 mg
•
•
•
•
•
haloperidol lactate oral conc 2 mg/ml
haloperidol tab 0.5 mg
haloperidol tab 1 mg
prochlorperazine maleate tab 5 mg
(base equivalent) (Compazine)
prochlorperazine maleate tab 10 mg
(base equivalent) (Compazine)
prochlorperazine suppos 25 mg
lithium carbonate cap 150 mg
(Lithium carbonate)
quetiapine fumarate tab 25 mg
(Seroquel)
•
(Seroquel)
•
(Seroquel)
•
(Seroquel)
•
(Seroquel)
•
(Seroquel)
•
risperidone orally disintegrating tab
0.25 mg
•
(Lithium carbonate)
lithium carbonate tab cr 300 mg
(Lithobid)
lithium carbonate tab cr 450 mg
lithium carbonate tab 300 mg
loxapine succinate cap 5 mg
(Loxitane)
•
0.5 mg (Risperdal m-tab)
•
olanzapine orally disintegrating tab
5 mg (Zyprexa zydis)
•
1 mg (Risperdal m-tab)
•
•
•
•
•
•
•
olanzapine tab 2.5 mg (Zyprexa)
30
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Drug Name
Prior Authorization
Specialty
2015
risperidone soln 1 mg/ml (Risperdal)
risperidone tab 0.25 mg (Risperdal)
risperidone tab 0.5 mg (Risperdal)
risperidone tab 1 mg (Risperdal)
SEROQUEL XR – quetiapine fumarate
tab sr 24hr 50 mg
•
•
•
•
•
•
•
•
phenobarbital tab 16.2 mg
phenobarbital tab 32.4 mg
temazepam cap 7.5 mg (Restoril)
temazepam cap 15 mg (Restoril)
temazepam cap 22.5 mg (Restoril)
temazepam cap 30 mg (Restoril)
zaleplon cap 5 mg (Sonata)
zaleplon cap 10 mg (Sonata)
•
•
•
tab sr 24hr 150 mg
•
zolpidem tartrate tab cr 6.25 mg
(Ambien cr)
•
zolpidem tartrate tab cr 12.5 mg
(Ambien cr)
•
tab sr 24hr 200 mg
•
zolpidem tartrate tab 5 mg (Ambien)
tab sr 24hr 300 mg
•
•
tab sr 24hr 400 mg
•
thiothixene cap 1 mg
trifluoperazine hcl tab 1 mg
ziprasidone hcl cap 20 mg (Geodon)
•
•
•
•
SLEEP AIDS
estazolam tab 1 mg
estazolam tab 2 mg
eszopiclone tab 1 mg (Lunesta)
•
•
•
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
zolpidem tartrate tab 10 mg (Ambien)
HYPERACTIVITY/NARCOLEPSY
amphetamine-dextroamphetamine
cap sr 24hr 5 mg (Adderall xr)
•
•
•
•
•
•
tab 5 mg (Adderall)
•
tab 7.5 mg (Adderall)
•
tab 10 mg (Adderall)
•
tab 12.5 mg (Adderall)
•
•
phenobarbital elixir 20 mg/5ml
31
•
VYVANSE – lisdexamfetamine
dimesylate cap 10 mg
•
•
•
•
caffeine citrate oral soln 60 mg/3ml
(10 mg/ml base equiv) (Cafcit)
dextroamphetamine sulfate cap sr
24hr 5 mg (Dexedrine)
•
•
•
•
•
•
dextroamphetamine sulfate tab 5 mg
•
•
•
guanfacine hcl tab sr 24hr 1 mg
(base equiv) (Intuniv)
MULTIPLE SCLEROSIS
•
BETASERON – interferon beta-1b for
inj kit 0.3 mg
•
•
•
COPAXONE – glatiramer acetate soln
prefilled syringe 20 mg/ml
•
•
•
COPAXONE – glatiramer acetate soln
prefilled syringe 40 mg/ml
•
•
INTUNIV – guanfacine hcl tab sr 24hr 1
mg (base equiv)
•
glatiramer acetate soln prefilled
syringe 20 mg/ml (Copaxone)
•
•
mg (base equiv)
•
PLEGRIDY – peginterferon beta-1a
soln pen-injector 125 mcg/0.5ml
•
•
mg (base equiv)
•
PLEGRIDY – peginterferon beta-1a
soln prefilled syringe 125 mcg/0.5ml
•
•
mg (base equiv)
•
•
•
methylphenidate hcl tab cr 20 mg
(Ritalin sr)
•
PLEGRIDY STARTER PACK –
peginterferon beta-1a soln pen-inj 63
& 94 mcg/0.5ml pack
•
•
methylphenidate hcl tab 5 mg
(Ritalin)
•
PLEGRIDY STARTER PACK –
peginterferon beta-1a soln pref syr 63
& 94 mcg/0.5ml pack
(Ritalin)
•
REBIF – interferon beta-1a inj 22
mcg/0.5ml (12mu/ml) (44 mcg/ml)
•
•
(Ritalin)
•
REBIF – interferon beta-1a inj 44
mcg/0.5ml (24mu/ml) (88 mcg/ml)
•
•
REBIF REBIDOSE – interferon beta-1a
inj 22 mcg/0.5ml (12mu/ml) (44 mcg/
ml)
•
•
modafinil tab 100 mg (Provigil)
modafinil tab 200 mg (Provigil)
32
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Drug Name
Prior Authorization
Specialty
2015
•
•
REBIF REBIDOSE – interferon beta-1a
inj 44 mcg/0.5ml (24mu/ml) (88 mcg/
ml)
•
•
REBIF REBIDOSE TITRATION
– interferon beta-1a inj 6 x 8.8
mcg/0.2ml & 6 x 22 mcg/0.5ml
•
•
REBIF TITRATION PACK – interferon
beta-1a inj 6 x 8.8 mcg/0.2ml & 6 x 22
mcg/0.5ml
•
•
TECFIDERA – dimethyl fumarate
capsule delayed release 120 mg
•
•
galantamine hydrobromide cap sr
24hr 8 mg (Razadyne er)
TECFIDERA – dimethyl fumarate
capsule delayed release 240 mg
•
•
TECFIDERA STARTER PACK –
dimethyl fumarate capsule dr starter
pack 120 mg & 240 mg
•
•
OTHER CENTRAL NERVOUS SYSTEM DRUGS
acamprosate calcium tab delayed
release 333 mg (Campral)
bupropion hcl (smoking deterrent)
tab sr 12hr 150 mg (Zyban)
CHANTIX – varenicline tartrate tab 0.5
mg (base equiv)
CHANTIX – varenicline tartrate tab 1
mg (base equiv)
CHANTIX CONTINUING MONTH –
varenicline tartrate tab 1 mg (base
equiv)
CHANTIX STARTING MONTH PA –
varenicline tartrate tab 0.5 mg x 11 &
tab 1 mg x 42 pack
Step Therapy
EXELON – rivastigmine td patch 24hr
4.6 mg/24hr
9.5 mg/24hr
13.3 mg/24hr
galantamine hydrobromide tab 4 mg
(Razadyne)
galantamine hydrobromide tab 8 mg
(Razadyne)
galantamine hydrobromide tab
12 mg (Razadyne)
memantine hcl tab 5 mg (Namenda)
memantine hcl tab 10 mg (Namenda)
memantine hcl tab 5 mg (28) & 10 mg
(21) titration pak (Namenda titration
pa)
NICOTROL INHALER – nicotine inhaler
system 10 mg (4 mg delivered)
NICOTROL NS – nicotine nasal spray
10 mg/ml (0.5 mg/spray)
disulfiram tab 250 mg (Antabuse)
disulfiram tab 500 mg (Antabuse)
ORAP – pimozide tab 1 mg
donepezil hydrochloride orally
disintegrating tab 5 mg (Aricept odt)
ORAP – pimozide tab 2 mg
donepezil hydrochloride tab 5 mg
(Aricept)
Dispensing Limits
donepezil hydrochloride tab 10 mg
(Aricept)
NUEDEXTA – dextromethorphan hbrquinidine sulfate cap 20-10 mg
donepezil hydrochloride orally
disintegrating tab 10 mg (Aricept
odt)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
rivastigmine tartrate cap 1.5 mg
(Exelon)
rivastigmine tartrate cap 3 mg
(Exelon)
rivastigmine tartrate cap 4.5 mg
(Exelon)
33
rivastigmine tartrate cap 6 mg
(Exelon)
fentanyl citrate lozenge on a handle
400 mcg (Actiq)
• •
PAIN RELIEF DRUGS
• •
NON-NARCOTIC DRUGS
600 mcg (Actiq)
butalbital-acetaminophen tab
50-325 mg
800 mcg (Actiq)
• •
butalbital-acetaminophen-caffeine
cap 50-325-40 mg
1200 mcg (Actiq)
• •
butalbital-acetaminophen-caffeine
tab 50-325-40 mg
1600 mcg (Actiq)
• •
butalbital-aspirin-caffeine cap
50-325-40 mg (Fiorinal)
fentanyl td patch 72hr 12 mcg/hr
(Duragesic)
•
salsalate tab 500 mg
(Duragesic)
•
NARCOTIC DRUGS
(Duragesic)
•
acetaminophen w/ codeine soln
120-12 mg/5ml
(Duragesic)
•
acetaminophen w/ codeine tab
300-15 mg (Tylenol/codeine)
(Duragesic)
•
300-30 mg (Tylenol/codeine #3)
hydrocodone-acetaminophen soln
7.5-325 mg/15ml (Hycet)
300-60 mg (Tylenol/codeine #4)
hydrocodone-acetaminophen tab
10-325 mg (Norco)
salsalate tab 750 mg
buprenorphine hcl sl tab 2 mg (base
equiv)
• •
buprenorphine hcl sl tab 8 mg (base
equiv)
• •
butalbital-aspirin-caff w/ codeine cap
50-325-40-30 mg (Fiorinal/codeine
#3)
7.5-325 mg (Norco)
hydrocodone-ibuprofen tab
7.5-200 mg (Vicoprofen)
hydrocodone-ibuprofen tab
10-200 mg (Ibudone)
codeine sulfate tab 15 mg (Codeine
sulfate)
hydromorphone hcl liqd 1 mg/ml
(Dilaudid)
codeine sulfate tab 30 mg
codeine sulfate tab 60 mg
34
5-325 mg (Norco)
hydrocodone-ibuprofen tab 5-200 mg
(Reprexain)
CODEINE SULFATE – codeine sulfate
tab 15 mg
200 mcg (Actiq)
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Drug Name
Prior Authorization
Specialty
2015
• •
hydromorphone hcl tab 2 mg
(Dilaudid)
(Dilaudid)
(Dilaudid)
MORPHINE SULFATE – morphine
sulfate suppos 20 mg
KADIAN – morphine sulfate cap sr 24hr
10 mg
•
20 mg
•
morphine sulfate (concentrate) oral
soln 20 mg/ml
30 mg
•
morphine sulfate oral soln 10 mg/5ml
40 mg
•
50 mg
•
60 mg
•
80 mg
•
100 mg
•
200 mg
•
morphine sulfate oral soln 20 mg/5ml
morphine sulfate tab cr 15 mg (Ms
contin)
•
contin)
•
contin)
•
contin)
•
contin)
•
NUCYNTA ER – tapentadol hcl tab sr
12hr 50 mg
•
methadone hcl conc 10 mg/ml
(Methadose)
12hr 100 mg
•
methadone hcl soln 5 mg/5ml
(Methadone hcl)
12hr 150 mg
•
methadone hcl soln 10 mg/5ml
(Methadone hcl)
12hr 200 mg
•
methadone hcl tab for oral susp
40 mg
12hr 250 mg
•
methadone hcl tab 5 mg (Dolophine
hcl)
oxycodone hcl cap 5 mg
methadone hcl tab 10 mg (Dolophine)
oxycodone hcl conc 100 mg/5ml
(20 mg/ml) (Oxycodone hcl)
sulfate tab 15 mg
oxycodone hcl soln 5 mg/5ml
(Oxycodone hcl)
sulfate tab 30 mg
oxycodone hcl tab 5 mg (Roxicodone)
sulfate suppos 5 mg
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
oxycodone hcl tab 10 mg
(Roxicodone)
35
(Roxicodone)
celecoxib cap 100 mg (Celebrex)
oxycodone w/ acetaminophen tab
5-325 mg (Percocet)
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Drug Name
Prior Authorization
Specialty
2015
•
•
•
diclofenac potassium tab 50 mg
(Cataflam)
7.5-325 mg (Percocet)
diclofenac sodium tab delayed
release 25 mg
10-325 mg (Percocet)
release 50 mg
oxycodone-aspirin tab
4.8355-325 mg (Percodan)
OXYCONTIN – oxycodone hcl tab er
12hr deter 10 mg
•
release 75 mg
12hr deter 15 mg
•
diclofenac sodium tab sr 24hr
100 mg (Voltaren-xr)
12hr deter 20 mg
•
ENBREL – etanercept for
subcutaneous inj kit 25 mg
•
• •
12hr deter 30 mg
•
ENBREL – etanercept subcutaneous
soln prefilled syringe 25 mg/0.5ml
•
• •
12hr deter 40 mg
•
ENBREL – etanercept subcutaneous
soln prefilled syringe 50 mg/ml
•
• •
12hr deter 60 mg
•
•
• •
12hr deter 80 mg
•
ENBREL SURECLICK – etanercept
subcutaneous solution auto-injector
50 mg/ml
tramadol hcl tab sr 24hr 100 mg
(Ultram er)
•
etodolac cap 300 mg
(Ultram er)
•
etodolac tab sr 24hr 500 mg
(Ultram er)
•
tramadol hcl tab 50 mg (Ultram)
•
HUMIRA – adalimumab prefilled
syringe kit 10 mg/0.2ml
•
• •
•
• •
•
• •
etodolac cap 200 mg
etodolac tab 400 mg
etodolac tab 500 mg
flurbiprofen tab 50 mg
tramadol-acetaminophen tab
37.5-325 mg (Ultracet)
flurbiprofen tab 100 mg
RHEUMATOID AND OSTEOARTHRITIS
CELEBREX – celecoxib cap 50 mg
36
•
•
•
•
•
•
•
•
•
HUMIRA PEDIATRIC CROHNS D –
adalimumab prefilled syringe kit 40
mg/0.8ml
•
• •
HUMIRA PEN – adalimumab peninjector kit 40 mg/0.8ml
•
• •
HUMIRA PEN-CROHNS DISEASE
– adalimumab pen-injector kit 40
mg/0.8ml
•
• •
HUMIRA PEN-PSORIASIS STAR
– adalimumab pen-injector kit 40
mg/0.8ml
•
• •
•
• •
SIMPONI – golimumab subcutaneous
soln auto-injector 100 mg/ml
•
• •
soln prefilled syringe 50 mg/0.5ml
•
• •
soln prefilled syringe 100 mg/ml
•
• •
sulindac tab 150 mg
ibuprofen tab 400 mg
MIGRAINE HEADACHES
acetaminophen-isometheptenedichloral cap 325-65-100 mg
indomethacin cap 50 mg
ketoprofen cap 50 mg
ketoprofen cap 75 mg
leflunomide tab 10 mg (Arava)
leflunomide tab 20 mg (Arava)
meloxicam tab 7.5 mg (Mobic)
meloxicam tab 15 mg (Mobic)
nabumetone tab 500 mg
nabumetone tab 750 mg
naproxen sodium tab 275 mg
(Anaprox)
naproxen sodium tab 550 mg
(Anaprox ds)
naproxen tab ec 375 mg (Ecnaprosyn)
naproxen tab ec 500 mg (Ecnaprosyn)
naproxen tab 250 mg (Naprosyn)
Step Therapy
soln auto-injector 50 mg/0.5ml
sulindac tab 200 mg
indomethacin cap 25 mg
Dispensing Limits
piroxicam cap 20 mg (Feldene)
ibuprofen susp 100 mg/5ml
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
IMITREX – sumatriptan nasal spray 5
mg/act
•
IMITREX – sumatriptan nasal spray 20
mg/act
•
MIGRANAL – dihydroergotamine
mesylate nasal spray 4 mg/ml
•
naratriptan hcl tab 1 mg (base equiv)
(Amerge)
•
naratriptan hcl tab 2.5 mg (base
equiv) (Amerge)
•
rizatriptan benzoate orally
disintegrating tab 5 mg (Maxalt-mlt)
•
rizatriptan benzoate orally
disintegrating tab 10 mg (Maxaltmlt)
•
rizatriptan benzoate tab 5 mg
(Maxalt)
•
rizatriptan benzoate tab 10 mg
(Maxalt)
•
sumatriptan succinate inj 6 mg/0.5ml
(Imitrex)
•
sumatriptan succinate solution autoinjector 4 mg/0.5ml (Imitrex statdose
sys)
•
oxaprozin tab 600 mg (Daypro)
piroxicam cap 10 mg (Feldene)
37
sumatriptan succinate solution autoinjector 6 mg/0.5ml (Imitrex statdose
sys)
•
sumatriptan succinate solution
cartridge 4 mg/0.5ml (Imitrex
statdose ref)
•
sumatriptan succinate solution
cartridge 6 mg/0.5ml (Imitrex
statdose ref)
•
sumatriptan succinate tab 25 mg
(Imitrex)
•
(Imitrex)
•
(Imitrex)
•
CELONTIN – methsuximide cap 300
mg
clonazepam tab 0.5 mg (Klonopin)
clonazepam tab 1 mg (Klonopin)
DIASTAT ACUDIAL – diazepam rectal
gel delivery system 10 mg
DIASTAT ACUDIAL – diazepam rectal
gel delivery system 20 mg
DIASTAT PEDIATRIC – diazepam
rectal gel delivery system 2.5 mg
divalproex sodium cap sprinkle
125 mg (Depakote sprinkles)
allopurinol tab 300 mg (Zyloprim)
colchicine w/ probenecid tab
0.5-500 mg
divalproex sodium tab delayed
release 125 mg (Depakote)
COLCRYS – colchicine tab 0.6 mg
probenecid tab 500 mg
LOCAL ANESTHETICS INJECTABLE
lidocaine hcl local inj 1% (Xylocaine)
lidocaine hcl local preservative free
(pf) inj 1% (Xylocaine-mpf)
divalproex sodium tab sr 24 hr
250 mg (Depakote er)
NEUROMUSCULAR DRUGS
divalproex sodium tab sr 24 hr
500 mg (Depakote er)
carbamazepine cap sr 12hr 200 mg
(Carbatrol)
ethosuximide cap 250 mg (Zarontin)
ethosuximide soln 250 mg/5ml
(Zarontin)
gabapentin cap 100 mg (Neurontin)
(Carbatrol)
carbamazepine chew tab 100 mg
gabapentin oral soln 250 mg/5ml
(Neurontin)
carbamazepine susp 100 mg/5ml
(Tegretol)
carbamazepine tab sr 12hr 200 mg
(Tegretol-xr)
38
Step Therapy
carbamazepine tab 200 mg (Tegretol)
DILANTIN – phenytoin sodium
extended cap 30 mg
allopurinol tab 100 mg (Zyloprim)
(Carbatrol)
Dispensing Limits
carbamazepine tab sr 12hr 400 mg
(Tegretol-xr)
clonazepam tab 2 mg (Klonopin)
GOUT
SEIZURES
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Drug Name
Prior Authorization
Specialty
2015
gabapentin tab 600 mg (Neurontin)
gabapentin tab 800 mg (Neurontin)
GABITRIL – tiagabine hcl tab 12 mg
phenytoin susp 125 mg/5ml (Dilantin)
GABITRIL – tiagabine hcl tab 16 mg
primidone tab 50 mg (Mysoline)
lamotrigine tab chewable dispersible
5 mg (Lamictal chewable di)
primidone tab 250 mg (Mysoline)
lamotrigine tab chewable dispersible
25 mg (Lamictal chewable di)
SABRIL – vigabatrin powd pack 500 mg
lamotrigine tab 25 mg (Lamictal)
levetiracetam oral soln 100 mg/ml
(Keppra)
topiramate sprinkle cap 15 mg
(Topamax sprinkle)
topiramate sprinkle cap 25 mg
(Topamax sprinkle)
topiramate tab 25 mg (Topamax)
levetiracetam tab sr 24hr 750 mg
(Keppra xr)
levetiracetam tab 250 mg (Keppra)
valproate sodium syrup 250 mg/5ml
(base equiv) (Depakene)
valproic acid cap 250 mg (Depakene)
zonisamide cap 25 mg (Zonegran)
zonisamide cap 50 mg
LYRICA – pregabalin cap 25 mg
zonisamide cap 100 mg (Zonegran)
PARKINSON'S DISEASE
amantadine hcl cap 100 mg
amantadine hcl syrup 50 mg/5ml
AZILECT – rasagiline mesylate tab 0.5
mg (base equiv)
Step Therapy
TEGRETOL-XR – carbamazepine tab
sr 12hr 100 mg
Dispensing Limits
SABRIL – vigabatrin tab 500 mg
levetiracetam tab sr 24hr 500 mg
(Keppra xr)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
AZILECT – rasagiline mesylate tab 1
mg (base equiv)
oxcarbazepine susp 300 mg/5ml
(60 mg/ml) (Trileptal)
benztropine mesylate tab 0.5 mg
oxcarbazepine tab 150 mg (Trileptal)
benztropine mesylate tab 2 mg
bromocriptine mesylate cap 5 mg
(Parlodel)
phenytoin chew tab 50 mg (Dilantin
infatabs)
bromocriptine mesylate tab 2.5 mg
(Parlodel)
phenytoin sodium extended cap
100 mg (Dilantin)
carbidopa & levodopa orally
disintegrating tab 10-100 mg
benztropine mesylate tab 1 mg
39
ropinirole hydrochloride tab 5 mg
(Requip)
selegiline hcl cap 5 mg (Eldepryl)
carbidopa & levodopa tab cr
25-100 mg (Sinemet cr)
trihexyphenidyl hcl elixir 0.4 mg/ml
carbidopa & levodopa tab cr
50-200 mg (Sinemet cr)
trihexyphenidyl hcl tab 5 mg
Step Therapy
trihexyphenidyl hcl tab 2 mg
MUSCLE RELAXANTS
carbidopa & levodopa tab 25-100 mg
(Sinemet)
baclofen tab 20 mg
(Sinemet)
baclofen tab 10 mg
chlorzoxazone tab 500 mg (Parafon
forte dsc)
cyclobenzaprine hcl tab 5 mg
entacapone tab 200 mg (Comtan)
cyclobenzaprine hcl tab 10 mg
pramipexole dihydrochloride tab
0.125 mg (Mirapex)
dantrolene sodium cap 25 mg
(Dantrium)
0.25 mg (Mirapex)
dantrolene sodium cap 50 mg
(Dantrium)
0.5 mg (Mirapex)
metaxalone tab 800 mg (Skelaxin)
methocarbamol tab 500 mg (Robaxin)
0.75 mg (Mirapex)
methocarbamol tab 750 mg
(Robaxin-750)
1 mg (Mirapex)
orphenadrine citrate tab sr 12hr
100 mg
1.5 mg (Mirapex)
ropinirole hydrochloride tab 0.25 mg
(Requip)
(Requip)
Dispensing Limits
selegiline hcl tab 5 mg
(Sinemet)
ropinirole hydrochloride tab 0.5 mg
(Requip)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Drug Name
Prior Authorization
Specialty
2015
orphenadrine w/ aspirin & caffeine
tab 25-385-30 mg
tizanidine hcl tab 2 mg (base
equivalent)
•
tizanidine hcl tab 4 mg (base
equivalent) (Zanaflex)
•
OTHER NEUROMUSCULAR DRUGS
(Requip)
MESTINON – pyridostigmine bromide
syrup 60 mg/5ml
(Requip)
MESTINON TIMESPAN –
pyridostigmine bromide tab cr 180 mg
(Requip)
pyridostigmine bromide tab 60 mg
(Mestinon)
riluzole tab 50 mg (Rilutek)
40
SUPPLEMENTS
VITAMINS
SE-NATAL 19 – prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
ergocalciferol cap 50000 unit
(Drisdol)
SE-NATAL 19 – prenatal vit w/ dss-fe
fumarate-fa tab 29-1 mg
MEPHYTON – phytonadione tab 5 mg
MINERALS AND ELECTROLYTES
MULTIVITAMINS
K-PHOS – potassium phosphate
monobasic tab 500 mg
pediatric multiple vitamins w/ fl-fe
drops 0.25-10 mg/ml
pediatric multiple vitamins w/
fluoride chew tab 0.25 mg
fluoride chew tab 0.5 mg
fluoride chew tab 1 mg
fluoride soln 0.25 mg/ml
fluoride soln 0.5 mg/ml
pediatric vitamins acd w/ fluoride
soln 0.25 mg/ml
pediatric vitamins acd w/ fluoride
soln 0.5 mg/ml
PRENAPLUS – prenatal vit w/ fe
PRENATABS FA – prenatal vit w/ fe
PRENATAL LOW IRON – prenatal vit
w/ fe fumarate-fa tab 27-1 mg
PRENATAL PLUS – prenatal vit w/ fe
PRENATAL PLUS/IRON – prenatal vit
w/ fe fumarate-fa tab 27-1 mg
PRENATAL VITAMINS PLUS –
prenatal vit w/ fe fumarate-fa tab 27-1
mg
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
pot bicarbonate & chloride effer tab
25 meq
pot phos monobasic w/sod phos di
& monobas tab 155-852-130mg (Kphos neutral)
potassium chloride cap cr 8 meq
(Micro-k)
potassium chloride cap cr 10 meq
(Micro-k)
potassium chloride
microencapsulated crys cr tab 10
meq
potassium chloride
microencapsulated crys cr tab 20
meq
potassium chloride oral liq 10% (20
meq/15ml)
potassium chloride oral liq 20% (40
meq/15ml)
potassium chloride powder packet
20 meq
potassium chloride tab cr 8 meq
(600 mg)
potassium chloride tab cr 10 meq (Ktab)
sodium fluoride chew tab 0.25 mg f
(from 0.55 mg naf) (Luride)
sodium fluoride chew tab 0.5 mg f
PRENATAL 19 – prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
sodium fluoride chew tab 1 mg f
PRENATAL 19 – prenatal vit w/ dss-fe
sodium fluoride soln 0.125 mg/drop f
(0.275 mg/drop naf)
41
sodium fluoride soln 0.5 mg/ml f
(from 1.1 mg/ml naf) (Luride)
ALPROLIX – coagulation factor ix
(recomb) (rfixfc) for inj 1000 unit
•
BLOOD MODIFYING DRUGS
•
•
ADVATE – antihemophilic factor rahfpfm for inj 250 unit
•
•
•
anagrelide hcl cap 1 mg
ARANESP ALBUMIN FREE –
darbepoetin alfa-polysorbate 80 soln
inj 10 mcg/0.4ml
• •
•
•
• •
•
inj 25 mcg/ml
• •
•
inj 25 mcg/0.42ml
ALPHANATE/VON WILLEBRAND –
antihemophilic factor/vwf (human) for
inj 250 unit
•
inj 40 mcg/ml
• •
inj 500 unit
•
inj 40 mcg/0.4ml
• •
inj 1000 unit
•
inj 60 mcg/ml
• •
inj 1500 unit
•
inj 60 mcg/0.3ml
• •
inj 2000 unit
•
inj 100 mcg/ml
• •
ALPHANINE SD – coagulation factor ix
for inj 500 unit
•
• •
for inj 1000 unit
•
inj 100 mcg/0.5ml
• •
for inj 1500 unit
•
inj 150 mcg/0.3ml
•
inj 200 mcg/ml
• •
42
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Drug Name
Prior Authorization
Specialty
2015
anagrelide hcl cap 0.5 mg (Agrylin)
inj 200 mcg/0.4ml
• •
inj 300 mcg/ml
• •
inj 300 mcg/0.6ml
• •
inj 500 mcg/ml
• •
BEBULIN – factor ix complex for inj
200-1200 unit
•
•
ELIQUIS – apixaban tab 2.5 mg
ELIQUIS – apixaban tab 5 mg
ELOCTATE – antihemophilic factor
(recomb) rfviiifc for inj 250 unit
•
•
•
•
•
•
•
BEBULIN VH – factor ix complex for inj
200-1200 unit
•
•
BENEFIX – coagulation factor ix
(recombinant) for inj 250 unit
•
•
•
enoxaparin sodium inj 30 mg/0.3ml
(Lovenox)
•
•
(Lovenox)
•
•
(Lovenox)
•
•
(Lovenox)
enoxaparin sodium inj 100 mg/ml
(Lovenox)
•
(Lovenox)
•
enoxaparin sodium inj 150 mg/ml
(Lovenox)
•
enoxaparin sodium inj 300 mg/3ml
(Lovenox)
•
cilostazol tab 50 mg (Pletal)
cilostazol tab 100 mg (Pletal)
clopidogrel bisulfate tab 75 mg (base
equiv) (Plavix)
CORIFACT – factor xiii concentrate
(human) for inj kit 1000-1600 unit
cyanocobalamin inj 1000 mcg/ml
dipyridamole tab 25 mg (Persantine)
DROXIA – hydroxyurea cap 200 mg
•
EPOGEN – epoetin alfa inj 2000 unit/ml
EPOGEN – epoetin alfa inj 10000 unit/
ml
EPOGEN – epoetin alfa inj 20000 unit/
ml
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
•
•
•
•
•
•
•
•
• •
43
FEIBA – antiinhibitor coagulant
complex for inj
•
KOATE-DVI – antihemophilic factor
(human) for inj 250 unit
•
FEIBA NF – antiinhibitor coagulant
complex for inj
•
•
FIRAZYR – icatibant acetate inj 30
mg/3ml (base equivalent)
•
•
•
folic acid tab 1 mg
•
HELIXATE FS – antihemophilic factor
(recombinant) for inj kit 250 unit
•
KOGENATE FS – antihemophilic factor
•
•
•
•
•
•
•
•
•
HEMOFIL M – antihemophilic factor
(human) for inj 220-400 unit
•
KOGENATE FS BIO-SET –
antihemophilic factor (recombinant)
for inj kit 250 unit
•
•
•
•
•
•
•
•
•
•
•
•
MONOCLATE-P – antihemophilic factor
(human) for inj kit 250 unit
•
•
HUMATE-P – antihemophilic factor/vwf
•
•
•
•
MONONINE – coagulation factor ix for
inj 250 unit
•
44
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Drug Name
Prior Authorization
Specialty
2015
inj 500 unit
•
PROCRIT – epoetin alfa inj 3000 unit/
ml
• •
inj 1000 unit
•
ml
• •
NEULASTA – pegfilgrastim inj 6
mg/0.6ml
•
ml
• •
NEULASTA DELIVERY KIT –
pegfilgrastim inj 6 mg/0.6ml
•
ml
• •
NEUPOGEN – filgrastim inj 300 mcg/ml
•
•
ml
• •
•
NEUPOGEN – filgrastim inj 300
mcg/0.5ml (600 mcg/ml)
•
PROFILNINE – factor ix complex for inj
500 unit
•
•
1000 unit
•
NOVOEIGHT – antihemophilic factor
•
1500 unit
•
•
PROFILNINE SD – factor ix complex
for inj 500 unit
•
•
for inj 1000 unit
•
•
for inj 1500 unit
•
•
RECOMBINATE – antihemophilic factor
(recombinant) for inj 220-400 unit
•
•
•
NOVOSEVEN RT – coagulation factor
viia (recomb) for inj 1 mg (1000 mcg)
•
•
•
•
•
•
•
RIXUBIS – coagulation factor ix
•
OBIZUR – antihemophilic factor
(recomb porc) rpfviii for inj 500 unit
•
•
•
pentoxifylline tab cr 400 mg
ml
• •
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
45
•
TRETTEN – coagulation factor xiii asubunit for inj 2000-3125 unit
•
XYNTHA SOLOFUSE – antihemophilic
factor recombinant paf for inj kit 500
unit
•
unit
•
unit
•
•
warfarin sodium tab 5 mg (Coumadin)
unit
TOPICAL PRODUCTS
warfarin sodium tab 7.5 mg
(Coumadin)
EYE
warfarin sodium tab 10 mg
(Coumadin)
BACITRACIN – bacitracin ophth oint
500 unit/gm
warfarin sodium tab 2.5 mg
(Coumadin)
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Drug Name
Prior Authorization
Specialty
2015
Anti-infectives
WILATE – antihemophilic factor/vwf
•
bacitracin-polymyxin b ophth oint
WILATE – antihemophilic factor/vwf
•
ciprofloxacin hcl ophth soln 0.3%
(Ciloxan)
•
•
•
•
XARELTO – rivaroxaban tab 10 mg
XARELTO STARTER PACK –
rivaroxaban tab starter therapy pack
15 mg & 20 mg
XYNTHA – antihemophilic factor
recombinant paf for inj kit 250 unit
•
•
•
•
unit
•
erythromycin ophth oint 5 mg/gm
gentamicin sulfate ophth oint 0.3%
gentamicin sulfate ophth soln 0.3%
(Garamycin)
NATACYN – natamycin ophth susp 5%
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml
(Neosporin)
ofloxacin ophth soln 0.3% (Ocuflox)
polymyxin b-trimethoprim ophth
soln 10000 unit/ml-0.1% (Polytrim)
sulfacetamide sodium ophth soln
10% (Bleph-10)
tobramycin ophth soln 0.3% (Tobrex)
trifluridine ophth soln 1% (Viroptic)
VIGAMOX – moxifloxacin hcl ophth
soln 0.5% (base equiv)
46
Steroids and Combination Products
bacitracin-polymyxin-neomycin-hc
ophth oint 1%
dexamethasone sodium phosphate
ophth soln 0.1%
fluorometholone ophth susp 0.1%
(Fml liquifilm)
LOTEMAX – loteprednol etabonate
ophth susp 0.5%
ophth gel 0.5%
ophth oint 0.5%
neomycin-polymyxindexamethasone ophth oint 0.1%
(Maxitrol)
latanoprost ophth soln 0.005%
(Xalatan)
LUMIGAN – bimatoprost ophth soln
0.01%
• •
pilocarpine hcl ophth soln 1% (Isopto
carpine)
carpine)
carpine)
timolol maleate ophth gel forming
soln 0.25% (Timoptic-xe)
PREDNISOLONE SODIUM PHOSP
– prednisolone sodium phosphate
ophth soln 1%
timolol maleate ophth gel forming
soln 0.5% (Timoptic-xe)
ZYLET – loteprednol etabonatetobramycin ophth susp 0.5-0.3%
•
levobunolol hcl ophth soln 0.5%
(Betagan)
prednisolone acetate ophth susp 1%
(Pred forte)
tobramycin-dexamethasone ophth
susp 0.3-0.1% (Tobradex)
Step Therapy
dorzolamide hcl-timolol maleate
ophth soln 22.3-6.8 mg/ml (Cosopt)
SIMBRINZA – brinzolamidebrimonidine tartrate ophth susp
1-0.2%
TOBRADEX – tobramycindexamethasone ophth oint 0.3-0.1%
Dispensing Limits
dorzolamide hcl ophth soln 2%
(Trusopt)
neomycin-polymyxindexamethasone ophth susp 0.1%
(Maxitrol)
sulfacetamide sodium-prednisolone
ophth soln 10-0.23(0.25)%
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
timolol maleate ophth soln 0.25%
(Timoptic)
timolol maleate ophth soln 0.5%
(Timoptic)
TRAVATAN Z – travoprost ophth soln
0.004% (benzalkonium free) (bak
free)
• •
Other Eye Products
Glaucoma
atropine sulfate ophth soln 1%
(Isopto atropine)
ALPHAGAN P – brimonidine tartrate
ophth soln 0.1%
azelastine hcl ophth soln 0.05%
(Optivar)
AZOPT – brinzolamide ophth susp 1%
cromolyn sodium ophth soln 4%
brimonidine tartrate ophth soln
0.15% (Alphagan p)
cyclopentolate hcl ophth soln 1%
(Cyclogyl)
brimonidine tartrate ophth soln 0.2%
diclofenac sodium ophth soln 0.1%
carteolol hcl ophth soln 1%
47
flurbiprofen sodium ophth soln
0.03% (Ocufen)
sodium fluoride gel 1.1% (0.5% f)
(Prevident fluoride)
triamcinolone acetonide dental paste
0.1%
ketorolac tromethamine ophth soln
0.5% (Acular)
ANORECTAL AGENTS
PATADAY – olopatadine hcl ophth soln
0.2%
CORTIFOAM – hydrocortisone acetate
rectal foam 90 mg/dose
PAZEO – olopatadine hcl ophth soln
0.7% (base equivalent)
hydrocortisone acetate suppos
25 mg (Anusol-hc)
tropicamide ophth soln 0.5%
hydrocortisone acetate suppos
30 mg (Proctocort)
tropicamide ophth soln 1%
(Mydriacyl)
hydrocortisone enema 100 mg/60ml
(Cortenema)
EAR
acetic acid otic soln 2%
hydrocortisone rectal cream 2.5%
(Anusol-hc)
antipyrine-benzocaine otic soln
54-14 mg/ml (5.4-1.4%)
SKIN CONDITIONS/PRODUCTS
CIPRODEX – ciprofloxacindexamethasone otic susp 0.3-0.1%
Acne
hydrocortisone w/ acetic acid otic
soln 1-2% (Vosol hc)
adapalene gel 0.1% (Differin)
adapalene cream 0.1% (Differin)
neomycin-polymyxin-hc otic soln 1%
(Cortisporin)
MOUTH AND THROAT (LOCAL)
adapalene gel 0.3% (Differin)
benzoyl peroxide-erythromycin gel
5-3% (Benzamycin)
clindamycin phosph-benzoyl
peroxide (refrig) gel 1.2 (1)-5%
(Duac)
cevimeline hcl cap 30 mg (Evoxac)
clindamycin phosphate gel 1%
(Cleocin-t)
chlorhexidine gluconate soln 0.12%
(Peridex)
clindamycin phosphate lotion 1%
(Cleocin-t)
clotrimazole troche 10 mg
clindamycin phosphate soln 1%
(Cleocin-t)
lidocaine hcl laryngotracheal soln
4% (Lta 360 kit)
lidocaine hcl viscous soln 2%
nystatin susp 100000 unit/ml
pilocarpine hcl tab 5 mg (Salagen)
48
Step Therapy
sodium fluoride cream 1.1%
(Prevident 5000 plus)
ketorolac tromethamine ophth soln
0.4% (Acular ls)
ofloxacin otic soln 0.3%
Dispensing Limits
pilocarpine hcl tab 7.5 mg (Salagen)
homatropine hbr ophth soln 5%
(Isopto homatropine)
neomycin-polymyxin-hc otic susp
3.5 mg/ml-10000 unit/ml-1%
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Drug Name
Prior Authorization
Specialty
2015
clindamycin phosphate swab 1%
(Cleocin-t)
clindamycin phosphate-benzoyl
peroxide gel 1-5% (Benzaclin)
DIFFERIN – adapalene gel 0.3%
erythromycin gel 2% (Erygel)
erythromycin pads 2%
erythromycin soln 2%
FINACEA – azelaic acid gel 15%
isotretinoin cap 10 mg
ciclopirox shampoo 1% (Loprox
shampoo)
ciclopirox solution 8% (Penlac nail
lacquer)
metronidazole gel 0.75%
ketoconazole shampoo 2% (Nizoral)
metronidazole gel 1% (Metrogel)
mupirocin calcium cream 2%
(Bactroban)
ketoconazole cream 2%
mupirocin oint 2% (Bactroban)
sulfacetamide sodium lotion 10%
(acne) (Klaron)
nystatin cream 100000 unit/gm
sulfacetamide sodium w/ sulfur
cream 10-5%
nystatin topical powder
nystatin oint 100000 unit/gm
emulsion 10-5%
silver sulfadiazine cream 1%
(Silvadene)
lotion 10-5%
VOLTAREN – diclofenac sodium gel
1%
TAZORAC – tazarotene cream 0.05%
Corticosteroids
TAZORAC – tazarotene cream 0.1%
alclometasone dipropionate cream
0.05% (Aclovate)
TAZORAC – tazarotene gel 0.1%
tretinoin cream 0.025% (Retin-a)
tretinoin gel 0.01% (Retin-a)
tretinoin gel 0.025% (Retin-a)
tretinoin microsphere gel 0.04%
(Retin-a micro)
tretinoin microsphere gel 0.1%
(Retin-a micro)
Anti-infectives
ciclopirox gel 0.77% (Loprox)
Step Therapy
ciclopirox olamine susp 0.77% (base
equiv)
econazole nitrate cream 1%
TAZORAC – tazarotene gel 0.05%
Dispensing Limits
ciclopirox olamine cream 0.77%
(base equiv)
metronidazole cream 0.75%
(Metrocream)
metronidazole lotion 0.75%
(Metrolotion)
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
alclometasone dipropionate oint
0.05%
betamethasone dipropionate
augmented cream 0.05% (Diprolene
af)
augmented gel 0.05%
augmented lotion 0.05% (Diprolene)
augmented oint 0.05% (Diprolene)
betamethasone dipropionate cream
0.05%
betamethasone dipropionate lotion
0.05%
49
betamethasone dipropionate oint
0.05%
fluocinonide gel 0.05%
betamethasone valerate cream 0.1%
fluocinonide soln 0.05%
betamethasone valerate lotion 0.1%
betamethasone valerate oint 0.1%
fluticasone propionate cream 0.05%
(Cutivate)
clobetasol propionate cream 0.05%
(Temovate)
fluticasone propionate oint 0.005%
(Cutivate)
clobetasol propionate emollient base
cream 0.05% (Temovate e)
halobetasol propionate cream 0.05%
(Ultravate)
clobetasol propionate foam 0.05%
(Olux)
halobetasol propionate oint 0.05%
(Ultravate)
clobetasol propionate gel 0.05%
(Temovate)
hydrocortisone cream 2.5%
clobetasol propionate oint 0.05%
(Temovate)
hydrocortisone oint 2.5%
Step Therapy
Dispensing Limits
fluocinonide oint 0.05%
hydrocortisone lotion 2.5%
hydrocortisone valerate cream 0.2%
clobetasol propionate soln 0.05%
(Temovate)
hydrocortisone valerate oint 0.2%
(Westcort)
desonide cream 0.05% (Desowen)
mometasone furoate cream 0.1%
(Elocon)
desonide lotion 0.05% (Desowen)
desonide oint 0.05% (Desowen)
mometasone furoate oint 0.1%
(Elocon)
desoximetasone cream 0.25%
(Topicort)
desoximetasone gel 0.05% (Topicort)
desoximetasone oint 0.25% (Topicort)
mometasone furoate solution 0.1%
(lotion) (Elocon)
fluocinolone acetonide cream 0.01%
nystatin-triamcinolone cream
100000-0.1 unit/gm-%
fluocinolone acetonide cream
0.025% (Synalar)
nystatin-triamcinolone oint
100000-0.1 unit/gm-%
fluocinolone acetonide oil 0.01%
(body oil) (Derma-smoothe/fs bod)
triamcinolone acetonide cream
0.025%
fluocinolone acetonide oil 0.01%
(scalp oil) (Derma-smoothe/fs sca)
triamcinolone acetonide cream 0.1%
fluocinolone acetonide oint 0.025%
(Synalar)
triamcinolone acetonide lotion
0.025%
fluocinolone acetonide soln 0.01%
(Synalar)
triamcinolone acetonide lotion 0.1%
fluocinonide cream 0.05%
triamcinolone acetonide oint 0.1%
fluocinonide emulsified base cream
0.05%
Other Skin Products
50
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Drug Name
Prior Authorization
Specialty
2015
triamcinolone acetonide cream 0.5%
triamcinolone acetonide oint 0.025%
acitretin cap 10 mg (Soriatane)
acitretin cap 17.5 mg (Soriatane)
acitretin cap 25 mg (Soriatane)
VALCHLOR – mechlorethamine hcl gel
0.016% (base equivalent)
calcipotriene cream 0.005%
(Dovonex)
XERAC AC – aluminum chloride in
alcohol solution 6.25%
calcipotriene oint 0.005%
ZYCLARA – imiquimod cream 3.75%
calcipotriene soln 0.005% (50 mcg/
ml)
ZYCLARA PUMP – imiquimod cream
2.5%
CARAC – fluorouracil cream 0.5%
ZYCLARA PUMP – imiquimod cream
3.75%
diclofenac sodium (actinic
keratoses) gel 3% (Solaraze)
•
•
•
•
MISCELLANEOUS CATEGORIES
ELIDEL – pimecrolimus cream 1%
DIABETIC SUPPLIES
FLUOROPLEX – fluorouracil cream 1%
TEST STRIPS – BAYER ASCENSIA
AUTODISC, BREEZE 2, CONTOUR,
CONTOUR NEXT
•
TEST STRIPS – ROCHE ACCU-CHEK
ACTIVE, AVIVA, AVIVA PLUS,
COMPACT, SMARTVIEW
•
TEST STRIPS – ROCHE
ACCUTREND
•
INSULIN PEN NEEDLES – BD
ULTRAFINE, NOVOFINE,
NOVOTWIST
•
INSULIN SYRINGES – BD
•
fluorouracil cream 5% (Efudex)
fluorouracil soln 2%
fluorouracil soln 5%
•
imiquimod cream 5% (Aldara)
lidocaine hcl gel 2%
lidocaine hcl soln 4% (Xylocaine)
lidocaine oint 5%
lidocaine patch 5% (700 mg)
(Lidoderm)
lidocaine-prilocaine cream 2.5-2.5%
(Emla)
LANCETS – BAYER FINGERSTIX,
MICROLET, SINGLE-LET
lindane lotion 1%
LANCETS – BD MICROTAINER,
ULTRAFINE
lindane shampoo 1%
LANCETS – ROCHE ACCU-CHEK
FASTCLIX, MULTICLIX, SOFT
TOUCH, SOFTCLIX
malathion lotion 0.5% (Ovide)
permethrin cream 5% (Elimite)
podofilox soln 0.5% (Condylox)
RESPIRATORY INHALER-ASSIST DEVICES
PROTOPIC – tacrolimus oint 0.03%
BREATHERITE – spacer/aerosolholding chambers - device
PROTOPIC – tacrolimus oint 0.1%
selenium sulfide lotion 2.5%
STELARA – ustekinumab soln prefilled
syringe 45 mg/0.5ml
•
• •
STELARA – ustekinumab soln prefilled
syringe 90 mg/ml
•
• •
tacrolimus oint 0.03% (Protopic)
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Prior Authorization
Drug Name
Specialty
2015
MISCELLANEOUS DRUGS
azathioprine tab 50 mg (Imuran)
buprenorphine hcl-naloxone hcl sl
tab 2-0.5 mg (base equiv)
• •
buprenorphine hcl-naloxone hcl sl
tab 8-2 mg (base equiv)
• •
tacrolimus oint 0.1% (Protopic)
51
CELLCEPT – mycophenolate mofetil
for oral susp 200 mg/ml
REVLIMID – lenalidomide cap 20 mg
CHEMET – succimer cap 100 mg
Step Therapy
Dispensing Limits
• •
• •
sirolimus tab 0.5 mg (Rapamune)
•
CUPRIMINE – penicillamine cap 250
mg
Prior Authorization
Drug Name
Specialty
Step Therapy
Dispensing Limits
Drug Name
Prior Authorization
Specialty
2015
sirolimus tab 1 mg (Rapamune)
sirolimus tab 2 mg (Rapamune)
cyclosporine cap 25 mg
(Sandimmune)
sodium polystyrene sulfonate oral
susp 15 gm/60ml (Sps)
cyclosporine cap 100 mg
(Sandimmune)
sodium polystyrene sulfonate
powder (Kayexalate)
CYCLOSPORINE MODIFIED –
cyclosporine modified cap 50 mg
(Neoral)
(Neoral)
cyclosporine modified oral soln
100 mg/ml (Neoral)
mycophenolate mofetil cap 250 mg
(Cellcept)
mycophenolate mofetil for oral susp
200 mg/ml (Cellcept)
SUBOXONE – buprenorphine hclnaloxone hcl sl film 2-0.5 mg (base
equiv)
• •
SUBOXONE – buprenorphine hclnaloxone hcl sl film 4-1 mg (base
equiv)
• •
equiv)
• •
equiv)
• •
mycophenolate mofetil tab 500 mg
(Cellcept)
tacrolimus cap 0.5 mg (Prograf)
mycophenolate sodium tab dr
180 mg (mycophenolic acid equiv)
(Myfortic)
tacrolimus cap 5 mg (Prograf)
mycophenolate sodium tab dr
360 mg (mycophenolic acid equiv)
(Myfortic)
THALOMID – thalidomide cap 100 mg
naloxone hcl inj 0.4 mg/ml
ZORTRESS – everolimus tab 0.25 mg
naltrexone hcl tab 50 mg (Revia)
RAPAMUNE – sirolimus oral soln 1 mg/
ml
tacrolimus cap 1 mg (Prograf)
•
•
•
•
•
•
•
•
RAPAMUNE – sirolimus tab 1 mg
RAPAMUNE – sirolimus tab 2 mg
REVLIMID – lenalidomide caps 2.5 mg
52
•
•
•
•
•
•
•
•
2015
INDEX
A
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg (Trizivir).................................................4
abacavir sulfate tab 300 mg (base equiv) (Ziagen).........4
acamprosate calcium tab delayed release 333 mg
(Campral)........................................................................ 33
acarbose tab 100 mg (Precose)..................................... 10
acarbose tab 25 mg (Precose)....................................... 10
acarbose tab 50 mg (Precose)....................................... 10
acebutolol hcl cap 200 mg (Sectral).............................. 16
acebutolol hcl cap 400 mg (Sectral)..............................16
acetaminophen-isometheptene-dichloral cap
325-65-100 mg................................................................ 37
acetaminophen w/ codeine soln 120-12 mg/5ml...........34
acetaminophen w/ codeine tab 300-15 mg (Tylenol/
codeine).......................................................................... 34
codeine #3).....................................................................34
codeine #4).....................................................................34
acetazolamide cap sr 12hr 500 mg (Diamox)................19
acetazolamide tab 250 mg..............................................19
acetic acid otic soln 2%................................................. 48
acetylcysteine inhal soln 10%........................................22
acetylcysteine inhal soln 20%........................................22
acitretin cap 10 mg (Soriatane)......................................50
acitretin cap 17.5 mg (Soriatane)...................................51
acitretin cap 25 mg (Soriatane)......................................51
ACTONEL – risedronate sodium tab 150 mg....................12
ACTONEL – risedronate sodium tab 30 mg......................12
ACTONEL – risedronate sodium tab 35 mg......................12
ACTONEL – risedronate sodium tab 5 mg........................12
acyclovir cap 200 mg (Zovirax)........................................4
acyclovir susp 200 mg/5ml (Zovirax).............................. 4
acyclovir tab 400 mg (Zovirax)........................................ 4
acyclovir tab 800 mg (Zovirax)........................................ 4
adapalene cream 0.1% (Differin)....................................48
adapalene gel 0.1% (Differin)......................................... 48
adapalene gel 0.3% (Differin)......................................... 48
ADCIRCA – tadalafil tab 20 mg (pah)............................... 20
adefovir dipivoxil tab 10 mg (Hepsera)........................... 3
ADVAIR DISKUS – fluticasone-salmeterol aer powder ba
100-50 mcg/dose............................................................. 22
250-50 mcg/dose............................................................. 22
500-50 mcg/dose............................................................. 22
ADVAIR HFA – fluticasone-salmeterol inhal aerosol
115-21 mcg/act................................................................ 22
ADVAIR HFA – fluticasone-salmeterol inhal aerosol
230-21 mcg/act................................................................ 22
ADVAIR HFA – fluticasone-salmeterol inhal aerosol 45-21
mcg/act............................................................................ 22
ADVATE – antihemophilic factor rahf-pfm for inj 1000
unit................................................................................... 42
unit................................................................................... 42
unit................................................................................... 42
unit................................................................................... 42
unit................................................................................... 42
unit................................................................................... 42
unit................................................................................... 42
AFINITOR – everolimus tab 10 mg.....................................6
AFINITOR – everolimus tab 2.5 mg....................................6
AFINITOR – everolimus tab 5 mg.......................................6
AFINITOR – everolimus tab 7.5 mg....................................6
ALBENZA – albendazole tab 200 mg................................. 6
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)..........22
albuterol sulfate soln nebu 0.5% (5 mg/ml).................. 22
albuterol sulfate soln nebu 0.63 mg/3ml (base
equiv).............................................................................. 22
albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv).............................................................................. 22
albuterol sulfate syrup 2 mg/5ml................................... 22
albuterol sulfate tab 2 mg.............................................. 22
albuterol sulfate tab 4 mg.............................................. 22
alclometasone dipropionate cream 0.05%
(Aclovate)........................................................................49
alclometasone dipropionate oint 0.05%........................ 49
alendronate sodium tab 10 mg...................................... 12
alendronate sodium tab 35 mg...................................... 12
alendronate sodium tab 5 mg........................................ 12
alendronate sodium tab 70 mg (Fosamax)................... 12
alfuzosin hcl tab sr 24hr 10 mg (Uroxatral).................. 27
ALKERAN – melphalan tab 2 mg....................................... 6
allopurinol tab 100 mg (Zyloprim)................................. 38
allopurinol tab 300 mg (Zyloprim)................................. 38
ALPHAGAN P – brimonidine tartrate ophth soln 0.1%...... 47
ALPHANATE/VON WILLEBRAND – antihemophilic factor/
vwf (human) for inj 1000 unit...........................................42
vwf (human) for inj 250 unit............................................ 42
vwf (human) for inj 500 unit............................................ 42
ALPHANINE SD – coagulation factor ix for inj 1000
unit................................................................................... 42
ALPHANINE SD – coagulation factor ix for inj 1500
unit................................................................................... 42
53
2015
ALPHANINE SD – coagulation factor ix for inj 500 unit.....42
alprazolam tab 0.25 mg (Xanax).................................... 27
alprazolam tab 0.5 mg (Xanax)...................................... 27
alprazolam tab 1 mg (Xanax)......................................... 27
alprazolam tab 2 mg (Xanax)......................................... 27
alprazolam tab sr 24hr 0.5 mg (Xanax xr)..................... 27
alprazolam tab sr 24hr 1 mg (Xanax xr)........................ 27
ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj
1000 unit..........................................................................42
2000 unit..........................................................................42
3000 unit..........................................................................42
500 unit............................................................................42
amantadine hcl cap 100 mg........................................... 39
amantadine hcl syrup 50 mg/5ml...................................39
amiloride & hydrochlorothiazide tab 5-50 mg...............19
amiloride hcl tab 5 mg....................................................19
amiodarone hcl tab 100 mg........................................... 20
amiodarone hcl tab 200 mg (Cordarone)...................... 20
amiodarone hcl tab 400 mg........................................... 20
amitriptyline hcl tab 100 mg...........................................28
amitriptyline hcl tab 10 mg............................................ 28
amitriptyline hcl tab 150 mg...........................................28
amlodipine besylate-atorvastatin calcium tab 10-10 mg
(Caduet).......................................................................... 17
(Caduet).......................................................................... 17
(Caduet).......................................................................... 17
(Caduet).......................................................................... 17
amlodipine besylate-atorvastatin calcium tab 2.5-10
mg (Caduet)....................................................................17
mg (Caduet)....................................................................17
mg (Caduet)....................................................................17
(Caduet).......................................................................... 17
(Caduet).......................................................................... 17
(Caduet).......................................................................... 17
(Caduet).......................................................................... 17
amlodipine besylate-benazepril hcl cap 10-20 mg
(Lotrel).............................................................................17
(Lotrel).............................................................................17
54
amlodipine besylate-benazepril hcl cap 2.5-10 mg
(Lotrel).............................................................................17
(Lotrel).............................................................................17
(Lotrel).............................................................................17
(Lotrel).............................................................................17
amlodipine besylate tab 10 mg (Norvasc).....................17
amlodipine besylate tab 2.5 mg (Norvasc)....................17
amlodipine besylate tab 5 mg (Norvasc)...................... 17
amlodipine besylate-valsartan tab 10-160 mg
(Exforge)......................................................................... 17
(Exforge)......................................................................... 17
(Exforge)......................................................................... 17
(Exforge)......................................................................... 17
amlodipine-valsartan-hydrochlorothiazide tab
10-160-12.5 mg (Exforge hct)....................................... 14
10-160-25 mg (Exforge hct).......................................... 14
10-320-25 mg (Exforge hct).......................................... 14
5-160-12.5 mg (Exforge hct)......................................... 14
amlodipine-valsartan-hydrochlorothiazide tab 5-160-25
mg (Exforge hct)............................................................14
amoxicillin (trihydrate) cap 250 mg................................. 1
amoxicillin (trihydrate) cap 500 mg................................. 1
amoxicillin (trihydrate) for susp 125 mg/5ml.................. 1
amoxicillin (trihydrate) tab 500 mg..................................1
amoxicillin (trihydrate) tab 875 mg..................................1
amoxicillin & k clavulanate chew tab 200-28.5 mg.........1
amoxicillin & k clavulanate chew tab 400-57 mg............1
amoxicillin & k clavulanate for susp 200-28.5
mg/5ml.............................................................................. 1
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
(Augmentin)......................................................................1
amoxicillin & k clavulanate for susp 400-57 mg/5ml...... 1
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
(Augmentin es-600)......................................................... 1
amoxicillin & k clavulanate tab 250-125 mg................... 1
amoxicillin & k clavulanate tab 500-125 mg
(Augmentin)......................................................................1
amoxicillin & k clavulanate tab 875-125 mg
(Augmentin)......................................................................1
amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg
(Augmentin xr)................................................................. 1
amphetamine-dextroamphetamine cap sr 24hr 10 mg
(Adderall xr)................................................................... 31
2015
(Adderall xr)................................................................... 31
(Adderall xr)................................................................... 31
(Adderall xr)................................................................... 31
(Adderall xr)................................................................... 31
(Adderall xr)................................................................... 31
amphetamine-dextroamphetamine tab 10 mg
(Adderall)........................................................................ 31
amphetamine-dextroamphetamine tab 12.5 mg
(Adderall)........................................................................ 31
(Adderall)........................................................................ 31
(Adderall)........................................................................ 32
(Adderall)........................................................................ 32
(Adderall)........................................................................ 31
amphetamine-dextroamphetamine tab 7.5 mg
(Adderall)........................................................................ 31
ampicillin cap 250 mg.......................................................1
ampicillin cap 500 mg.......................................................1
anagrelide hcl cap 0.5 mg (Agrylin).............................. 42
anagrelide hcl cap 1 mg................................................. 42
anastrozole tab 1 mg (Arimidex)..................................... 6
ANDRODERM – testosterone td patch 24hr 2 mg/24hr...... 8
ANDRODERM – testosterone td patch 24hr 4 mg/24hr...... 8
ANDROGEL PUMP – testosterone td gel 12.5 mg/act
(1%)................................................................................... 8
ANDROGEL PUMP – testosterone td gel 20.25 mg/act
(1.62%).............................................................................. 8
ANDROGEL – testosterone td gel 20.25 mg/1.25gm
(1.62%).............................................................................. 8
ANDROGEL – testosterone td gel 25 mg/2.5gm (1%)........ 8
ANDROGEL – testosterone td gel 40.5 mg/2.5gm
(1.62%).............................................................................. 8
ANDROGEL – testosterone td gel 50 mg/5gm (1%)........... 8
ANORO ELLIPTA – umeclidinium-vilanterol aero powd ba
62.5-25 mcg/inh............................................................... 22
antipyrine-benzocaine otic soln 54-14 mg/ml
(5.4-1.4%)........................................................................ 48
APTIVUS – tipranavir cap 250 mg......................................4
APTIVUS – tipranavir oral soln 100 mg/ml......................... 4
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 100 mcg/0.5ml............................ 42
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 100 mcg/ml.................................42
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 10 mcg/0.4ml.............................. 42
ARANESP ALBUMIN FREE – darbepoetin alfapolysorbate 80 soln inj 25 mcg/ml...................................42
ARNUITY ELLIPTA – fluticasone furoate aerosol powder
breath activ 100 mcg/act................................................. 22
ARNUITY ELLIPTA – fluticasone furoate aerosol powder
breath activ 200 mcg/act................................................. 22
ASACOL HD – mesalamine tab delayed release 800
mg.................................................................................... 26
ASMANEX HFA – mometasone furoate inhal aerosol
suspension 100 mcg/act..................................................22
ASMANEX HFA – mometasone furoate inhal aerosol
suspension 200 mcg/act..................................................22
ASMANEX TWISTHALER 120 ME – mometasone furoate
inhal powd 220 mcg/inh (breath activated)......................22
ASMANEX TWISTHALER 14 MET – mometasone furoate
ASMANEX TWISTHALER 7 METE – mometasone furoate
ASTEPRO – azelastine hcl nasal spray 0.15% (205.5
mcg/spray)....................................................................... 22
atenolol & chlorthalidone tab 100-25 mg (Tenoretic
100)..................................................................................16
atenolol & chlorthalidone tab 50-25 mg (Tenoretic
50)....................................................................................16
atenolol tab 100 mg (Tenormin).....................................16
atenolol tab 25 mg (Tenormin).......................................16
atenolol tab 50 mg (Tenormin).......................................16
atorvastatin calcium tab 10 mg (base equivalent)
(Lipitor)........................................................................... 18
55
2015
(Lipitor)........................................................................... 18
(Lipitor)........................................................................... 18
(Lipitor)........................................................................... 18
atovaquone-proguanil hcl tab 250-100 mg
(Malarone).........................................................................5
atovaquone-proguanil hcl tab 62.5-25 mg
(Malarone).........................................................................5
ATRIPLA – efavirenz-emtricitabine-tenofovir df tab
600-200-300 mg................................................................ 4
atropine sulfate ophth soln 1% (Isopto atropine)......... 47
ATROVENT HFA – ipratropium bromide hfa inhal aerosol
17 mcg/act....................................................................... 23
AVODART – dutasteride cap 0.5 mg................................ 27
azathioprine tab 50 mg (Imuran)....................................51
azelastine hcl nasal spray 0.1% (137 mcg/spray).........22
azelastine hcl nasal spray 0.15% (205.5 mcg/spray)
(Astepro)......................................................................... 22
azelastine hcl ophth soln 0.05% (Optivar).................... 47
AZILECT – rasagiline mesylate tab 0.5 mg (base
equiv)............................................................................... 39
AZILECT – rasagiline mesylate tab 1 mg (base equiv)..... 39
AZITHROMYCIN – azithromycin powd pack for susp 1
gm...................................................................................... 2
azithromycin for susp 100 mg/5ml (Zithromax)..............2
azithromycin for susp 200 mg/5ml (Zithromax)..............2
azithromycin tab 250 mg (Zithromax)............................. 2
AZOPT – brinzolamide ophth susp 1%............................. 47
B
BACITRACIN – bacitracin ophth oint 500 unit/gm.............46
bacitracin-polymyxin b ophth oint.................................46
bacitracin-polymyxin-neomycin-hc ophth oint 1%.......47
baclofen tab 10 mg......................................................... 40
baclofen tab 20 mg......................................................... 40
balsalazide disodium cap 750 mg (Colazal)..................26
BARACLUDE – entecavir oral soln 0.05 mg/ml.................. 3
BARACLUDE – entecavir tab 0.5 mg................................. 3
BARACLUDE – entecavir tab 1 mg.................................... 3
BEBULIN – factor ix complex for inj 200-1200 unit........... 43
BEBULIN VH – factor ix complex for inj 200-1200 unit......43
benazepril & hydrochlorothiazide tab 10-12.5 mg
(Lotensin hct)................................................................. 13
benazepril & hydrochlorothiazide tab 20-12.5 mg
(Lotensin hct)................................................................. 13
benazepril & hydrochlorothiazide tab 20-25 mg
(Lotensin hct)................................................................. 13
benazepril & hydrochlorothiazide tab 5-6.25 mg..........13
benazepril hcl tab 10 mg (Lotensin).............................. 13
benazepril hcl tab 5 mg.................................................. 13
56
BENEFIX – coagulation factor ix (recombinant) for inj 1000
unit................................................................................... 43
unit................................................................................... 43
unit................................................................................... 43
unit................................................................................... 43
unit................................................................................... 43
BENICAR HCT – olmesartan medoxomilhydrochlorothiazide tab 20-12.5 mg................................ 15
BENICAR HCT – olmesartan medoxomilhydrochlorothiazide tab 40-12.5 mg................................ 15
BENICAR HCT – olmesartan medoxomilhydrochlorothiazide tab 40-25 mg................................... 15
BENICAR – olmesartan medoxomil tab 20 mg................. 15
BENICAR – olmesartan medoxomil tab 40 mg................. 15
BENICAR – olmesartan medoxomil tab 5 mg................... 15
benzoyl peroxide-erythromycin gel 5-3%
(Benzamycin)..................................................................48
benztropine mesylate tab 0.5 mg...................................39
benztropine mesylate tab 1 mg..................................... 39
benztropine mesylate tab 2 mg..................................... 39
betamethasone dipropionate augmented cream 0.05%
(Diprolene af)................................................................. 49
betamethasone dipropionate augmented gel
0.05%...............................................................................49
betamethasone dipropionate augmented lotion 0.05%
(Diprolene)...................................................................... 49
betamethasone dipropionate augmented oint 0.05%
(Diprolene)...................................................................... 49
betamethasone dipropionate cream 0.05%...................49
betamethasone dipropionate lotion 0.05%................... 49
betamethasone dipropionate oint 0.05%...................... 50
betamethasone valerate cream 0.1%.............................50
betamethasone valerate lotion 0.1%............................. 50
betamethasone valerate oint 0.1%.................................50
BETASERON – interferon beta-1b for inj kit 0.3 mg..........32
bexarotene cap 75 mg (Targretin)................................... 6
bicalutamide tab 50 mg (Casodex).................................. 6
BILTRICIDE – praziquantel tab 600 mg..............................6
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
(Ziac)............................................................................... 16
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
(Ziac)............................................................................... 16
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
(Ziac)............................................................................... 16
bisoprolol fumarate tab 10 mg (Zebeta)........................16
bisoprolol fumarate tab 5 mg (Zebeta)..........................16
BREATHERITE – spacer/aerosol-holding chambers device...............................................................................51
BREO ELLIPTA – fluticasone furoate-vilanterol aero powd
ba 100-25 mcg/inh...........................................................23
BREO ELLIPTA – fluticasone furoate-vilanterol aero powd
ba 200-25 mcg/inh...........................................................23
2015
brimonidine tartrate ophth soln 0.15% (Alphagan
p)......................................................................................47
brimonidine tartrate ophth soln 0.2%............................47
bromocriptine mesylate cap 5 mg (Parlodel)................39
bromocriptine mesylate tab 2.5 mg (Parlodel)..............39
budesonide cap sr 24hr 3 mg (Entocort ec)................... 8
budesonide inhalation susp 0.25 mg/2ml
(Pulmicort)...................................................................... 23
budesonide inhalation susp 0.5 mg/2ml
(Pulmicort)...................................................................... 23
budesonide inhalation susp 1 mg/2ml (Pulmicort).......23
bumetanide tab 0.5 mg................................................... 19
bumetanide tab 1 mg...................................................... 19
bumetanide tab 2 mg...................................................... 19
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base
equiv).............................................................................. 51
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
equiv).............................................................................. 51
buprenorphine hcl sl tab 2 mg (base equiv)................. 34
buprenorphine hcl sl tab 8 mg (base equiv)................. 34
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
(Zyban)............................................................................ 33
bupropion hcl tab 100 mg (Wellbutrin)......................... 28
bupropion hcl tab 75 mg (Wellbutrin)........................... 28
bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr)........ 28
bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl).........28
bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl).........28
buspirone hcl tab 10 mg................................................ 27
buspirone hcl tab 5 mg.................................................. 27
butalbital-acetaminophen-caffeine cap 50-325-40
mg....................................................................................34
butalbital-acetaminophen-caffeine tab 50-325-40
mg....................................................................................34
butalbital-acetaminophen tab 50-325 mg...................... 34
butalbital-aspirin-caffeine cap 50-325-40 mg
(Fiorinal)..........................................................................34
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
(Fiorinal/codeine #3)......................................................34
BYDUREON – exenatide extended release for inj susp 2
mg.................................................................................... 10
BYDUREON – exenatide extended release for susp peninjector 2 mg....................................................................10
C
cabergoline tab 0.5 mg................................................... 12
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base
equiv) (Cafcit).................................................................32
calcipotriene cream 0.005% (Dovonex).........................51
calcipotriene oint 0.005%............................................... 51
calcipotriene soln 0.005% (50 mcg/ml)..........................51
calcitonin (salmon) nasal soln 200 unit/act
(Miacalcin)...................................................................... 12
calcitriol cap 0.25 mcg (Rocaltrol).................................12
calcitriol cap 0.5 mcg (Rocaltrol)...................................13
calcitriol oral soln 1 mcg/ml (Rocaltrol)........................13
calcium acetate (phosphate binder) cap 667 mg (169
mg ca) (Phoslo)............................................................. 26
calcium acetate (phosphate binder) tab 667 mg
(Eliphos)..........................................................................26
CANASA – mesalamine suppos 1000 mg........................ 26
candesartan cilexetil-hydrochlorothiazide tab 16-12.5
mg (Atacand hct)........................................................... 15
candesartan cilexetil-hydrochlorothiazide tab 32-12.5
mg (Atacand hct)........................................................... 15
candesartan cilexetil-hydrochlorothiazide tab 32-25
mg (Atacand hct)........................................................... 15
candesartan cilexetil tab 16 mg (Atacand)....................15
candesartan cilexetil tab 32 mg (Atacand)....................15
candesartan cilexetil tab 4 mg (Atacand)......................15
candesartan cilexetil tab 8 mg (Atacand)......................15
capecitabine tab 150 mg (Xeloda)................................... 6
capecitabine tab 500 mg (Xeloda)................................... 6
captopril tab 100 mg....................................................... 13
captopril tab 12.5 mg...................................................... 13
captopril tab 25 mg......................................................... 13
captopril tab 50 mg......................................................... 13
CARAC – fluorouracil cream 0.5%....................................51
carbamazepine cap sr 12hr 100 mg (Carbatrol)............38
carbamazepine chew tab 100 mg.................................. 38
carbamazepine susp 100 mg/5ml (Tegretol)................. 38
carbamazepine tab 200 mg (Tegretol)........................... 38
carbamazepine tab sr 12hr 200 mg (Tegretol-xr)..........38
carbamazepine tab sr 12hr 400 mg (Tegretol-xr)..........38
carbidopa & levodopa orally disintegrating tab 10-100
mg....................................................................................39
mg....................................................................................40
mg....................................................................................40
carbidopa & levodopa tab 10-100 mg (Sinemet)...........40
carbidopa & levodopa tab cr 25-100 mg (Sinemet
cr).................................................................................... 40
carbidopa & levodopa tab cr 50-200 mg (Sinemet
cr).................................................................................... 40
carteolol hcl ophth soln 1%........................................... 47
carvedilol tab 12.5 mg (Coreg).......................................16
carvedilol tab 25 mg (Coreg)..........................................16
carvedilol tab 3.125 mg (Coreg).....................................16
carvedilol tab 6.25 mg (Coreg).......................................16
cefaclor cap 250 mg......................................................... 1
cefaclor cap 500 mg......................................................... 1
cefadroxil cap 500 mg...................................................... 1
cefadroxil for susp 250 mg/5ml....................................... 1
cefadroxil for susp 500 mg/5ml....................................... 1
57
2015
cefadroxil tab 1 gm........................................................... 1
cefdinir cap 300 mg.......................................................... 1
cefdinir for susp 125 mg/5ml........................................... 1
cefdinir for susp 250 mg/5ml........................................... 1
cefixime for susp 100 mg/5ml (Suprax).......................... 1
cefixime for susp 200 mg/5ml (Suprax).......................... 1
cefpodoxime proxetil for susp 100 mg/5ml.................... 1
cefpodoxime proxetil for susp 50 mg/5ml...................... 1
cefpodoxime proxetil tab 100 mg.................................... 1
cefpodoxime proxetil tab 200 mg.................................... 1
cefprozil for susp 125 mg/5ml......................................... 1
cefprozil for susp 250 mg/5ml......................................... 1
cefprozil tab 250 mg......................................................... 1
cefprozil tab 500 mg......................................................... 1
CEFTIN – cefuroxime axetil for susp 125 mg/5ml...............1
ceftriaxone sodium for inj 1 gm (Rocephin)................... 1
ceftriaxone sodium for inj 250 mg...................................1
ceftriaxone sodium for inj 2 gm...................................... 2
ceftriaxone sodium for inj 500 mg (Rocephin)............... 1
cefuroxime axetil tab 250 mg (Ceftin)............................. 2
cefuroxime axetil tab 500 mg (Ceftin)............................. 2
CELEBREX – celecoxib cap 100 mg................................ 36
CELEBREX – celecoxib cap 50 mg.................................. 36
celecoxib cap 100 mg (Celebrex).................................. 36
celecoxib cap 50 mg (Celebrex).................................... 36
CELLCEPT – mycophenolate mofetil for oral susp 200 mg/
ml..................................................................................... 52
CELONTIN – methsuximide cap 300 mg.......................... 38
cephalexin cap 250 mg (Keflex).......................................2
cephalexin cap 500 mg (Keflex).......................................2
cephalexin for susp 125 mg/5ml......................................2
cephalexin for susp 250 mg/5ml......................................2
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)...................21
cevimeline hcl cap 30 mg (Evoxac)...............................48
CHANTIX CONTINUING MONTH – varenicline tartrate tab
1 mg (base equiv)........................................................... 33
CHANTIX STARTING MONTH PA – varenicline tartrate
tab 0.5 mg x 11 & tab 1 mg x 42 pack............................ 33
CHANTIX – varenicline tartrate tab 0.5 mg (base
equiv)............................................................................... 33
CHANTIX – varenicline tartrate tab 1 mg (base equiv)......33
CHEMET – succimer cap 100 mg.................................... 52
CHENODAL – chenodiol tab 250 mg................................26
chlorhexidine gluconate soln 0.12% (Peridex)............. 48
chloroquine phosphate tab 250 mg.................................5
chloroquine phosphate tab 500 mg (Aralen).................. 5
chlorothiazide tab 500 mg.............................................. 19
chlorpromazine hcl tab 100 mg..................................... 29
chlorpromazine hcl tab 10 mg....................................... 29
chlorpromazine hcl tab 200 mg..................................... 29
58
chlorzoxazone tab 500 mg (Parafon forte dsc).............40
cholestyramine light powder 4 gm/dose (Questran
light)................................................................................ 18
cholestyramine light powder packets 4 gm..................18
cholestyramine powder 4 gm/dose (Questran)............ 18
cholestyramine powder packets 4 gm (Questran)........18
choline fenofibrate cap dr 135 mg (fenofibric acid
equiv) (Trilipix)............................................................... 18
choline fenofibrate cap dr 45 mg (fenofibric acid
equiv) (Trilipix)............................................................... 18
chorionic gonadotropin for inj 10000 unit.................... 10
CIALIS – tadalafil tab 10 mg.............................................21
CIALIS – tadalafil tab 2.5 mg............................................21
CIALIS – tadalafil tab 20 mg.............................................21
CIALIS – tadalafil tab 5 mg...............................................21
ciclopirox gel 0.77% (Loprox)........................................ 49
ciclopirox olamine cream 0.77% (base equiv).............. 49
ciclopirox olamine susp 0.77% (base equiv)................ 49
ciclopirox shampoo 1% (Loprox shampoo)..................49
ciclopirox solution 8% (Penlac nail lacquer)................ 49
cilostazol tab 100 mg (Pletal).........................................43
cilostazol tab 50 mg (Pletal)...........................................43
cimetidine hcl soln 300 mg/5ml..................................... 24
cimetidine tab 300 mg.................................................... 24
CIPRODEX – ciprofloxacin-dexamethasone otic susp
0.3-0.1%...........................................................................48
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000
mg(base eq) (Cipro xr)....................................................2
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg
(base eq) (Cipro xr)......................................................... 2
ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml) (Cipro)............................................................ 2
ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml) (Cipro)............................................................ 2
ciprofloxacin hcl ophth soln 0.3% (Ciloxan).................46
ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)......... 2
ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)......... 2
ciprofloxacin hcl tab 750 mg (base equiv)......................2
citalopram hydrobromide oral soln 10 mg/5ml.............28
citalopram hydrobromide tab 10 mg (base equiv)
(Celexa)........................................................................... 28
(Celexa)........................................................................... 28
(Celexa)........................................................................... 28
clarithromycin for susp 125 mg/5ml................................2
clarithromycin for susp 250 mg/5ml (Biaxin)..................2
clarithromycin tab 250 mg (Biaxin)................................. 2
clarithromycin tab 500 mg (Biaxin)................................. 2
clarithromycin tab sr 24hr 500 mg (Biaxin xl pac)..........2
CLEOCIN – clindamycin phosphate vaginal suppos 100
mg.................................................................................... 27
clindamycin hcl cap 150 mg (Cleocin)............................ 6
clindamycin hcl cap 300 mg (Cleocin)............................ 6
2015
clindamycin hcl cap 75 mg (Cleocin).............................. 6
clindamycin palmitate hcl for soln 75 mg/5ml (base
equiv) (Cleocin pediatric gr)...........................................6
clindamycin phosphate-benzoyl peroxide gel 1-5%
(Benzaclin)......................................................................48
clindamycin phosphate gel 1% (Cleocin-t)................... 48
clindamycin phosphate lotion 1% (Cleocin-t)...............48
clindamycin phosphate soln 1% (Cleocin-t)................. 48
clindamycin phosphate swab 1% (Cleocin-t)................48
clindamycin phosphate vaginal cream 2%
(Cleocin)..........................................................................27
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2
(1)-5% (Duac)..................................................................48
clobetasol propionate cream 0.05% (Temovate).......... 50
clobetasol propionate emollient base cream 0.05%
(Temovate e).................................................................. 50
clobetasol propionate foam 0.05% (Olux).....................50
clobetasol propionate gel 0.05% (Temovate)................50
clobetasol propionate oint 0.05% (Temovate).............. 50
clobetasol propionate soln 0.05% (Temovate)............. 50
clomiphene citrate tab 50 mg (Clomid)......................... 10
clomipramine hcl cap 25 mg (Anafranil)....................... 28
clonazepam tab 0.5 mg (Klonopin)................................38
clonazepam tab 1 mg (Klonopin)...................................38
clonazepam tab 2 mg (Klonopin)...................................38
clonidine hcl tab 0.1 mg (Catapres).............................. 20
clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1)................................................................................ 20
clopidogrel bisulfate tab 75 mg (base equiv)
(Plavix)............................................................................ 43
clotrimazole troche 10 mg..............................................48
clozapine tab 100 mg (Clozaril)..................................... 29
clozapine tab 200 mg......................................................29
clozapine tab 25 mg (Clozaril)....................................... 29
clozapine tab 50 mg........................................................29
CODEINE SULFATE – codeine sulfate tab 15 mg............34
codeine sulfate tab 15 mg (Codeine sulfate)................ 34
codeine sulfate tab 30 mg..............................................34
codeine sulfate tab 60 mg..............................................34
colchicine w/ probenecid tab 0.5-500 mg......................38
COLCRYS – colchicine tab 0.6 mg...................................38
colestipol hcl granule packets 5 gm (Colestid
flavored)..........................................................................19
colestipol hcl granules 5 gm (Colestid flavored)..........19
colestipol hcl tab 1 gm (Colestid)..................................19
COMBIPATCH – estradiol-norethindrone ace td pttw
0.05-0.14 mg/day...............................................................9
COMBIPATCH – estradiol-norethindrone ace td pttw
0.05-0.25 mg/day...............................................................9
COMBIVENT RESPIMAT – ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act........................................... 23
COPAXONE – glatiramer acetate soln prefilled syringe 20
mg/ml............................................................................... 32
COPAXONE – glatiramer acetate soln prefilled syringe 40
mg/ml............................................................................... 32
CORIFACT – factor xiii concentrate (human) for inj kit
1000-1600 unit.................................................................43
CORTIFOAM – hydrocortisone acetate rectal foam 90 mg/
dose................................................................................. 48
CORTISONE ACETATE – cortisone acetate tab 25 mg..... 8
CREON – pancrelipase (lip-prot-amyl) dr cap
12000-38000-60000 unit..................................................25
24000-76000-120000 unit................................................25
3000-9500-15000 unit......................................................25
36000-114000-180000 unit..............................................25
6000-19000-30000 unit....................................................25
CRESTOR – rosuvastatin calcium tab 10 mg................... 19
CRESTOR – rosuvastatin calcium tab 5 mg..................... 19
CRINONE – progesterone vaginal gel 4%........................ 27
CRINONE – progesterone vaginal gel 8%........................ 27
CRIXIVAN – indinavir sulfate cap 200 mg.......................... 4
CRIXIVAN – indinavir sulfate cap 400 mg.......................... 4
cromolyn sodium ophth soln 4%...................................47
CUPRIMINE – penicillamine cap 250 mg......................... 52
cyanocobalamin inj 1000 mcg/ml.................................. 43
cyclobenzaprine hcl tab 10 mg......................................40
cyclobenzaprine hcl tab 5 mg........................................40
cyclopentolate hcl ophth soln 1% (Cyclogyl)............... 47
cyclosporine cap 100 mg (Sandimmune)......................52
cyclosporine cap 25 mg (Sandimmune)........................52
cyclosporine modified cap 100 mg (Neoral)................. 52
cyclosporine modified cap 25 mg (Neoral)................... 52
CYCLOSPORINE MODIFIED – cyclosporine modified cap
50 mg...............................................................................52
cyclosporine modified oral soln 100 mg/ml
(Neoral)........................................................................... 52
cyproheptadine hcl syrup 2 mg/5ml..............................21
cyproheptadine hcl tab 4 mg......................................... 21
CYSTAGON – cysteamine bitartrate cap 150 mg............. 27
CYSTAGON – cysteamine bitartrate cap 50 mg............... 27
D
danazol cap 100 mg..........................................................8
danazol cap 200 mg.......................................................... 8
danazol cap 50 mg............................................................8
dantrolene sodium cap 25 mg (Dantrium).................... 40
dantrolene sodium cap 50 mg (Dantrium).................... 40
59
2015
DAPSONE – dapsone tab 100 mg..................................... 6
DAPSONE – dapsone tab 25 mg....................................... 6
DARAPRIM – pyrimethamine tab 25 mg.............................5
DELZICOL – mesalamine cap dr 400 mg......................... 26
demeclocycline hcl tab 150 mg....................................... 2
demeclocycline hcl tab 300 mg....................................... 2
desipramine hcl tab 100 mg (Norpramin)......................28
desipramine hcl tab 10 mg (Norpramin)....................... 28
desipramine hcl tab 150 mg (Norpramin)......................28
desloratadine tab 5 mg (Clarinex)................................. 21
desloratadine tab orally disintegrating 2.5 mg
(Clarinex reditabs)......................................................... 21
desloratadine tab orally disintegrating 5 mg (Clarinex
reditabs)..........................................................................21
desmopressin acetate inj 4 mcg/ml (Ddavp)................ 13
desmopressin acetate nasal soln 0.01% (refrigerated)
(Ddavp)............................................................................13
desmopressin acetate nasal spray soln 0.01%
(Ddavp)............................................................................13
desmopressin acetate nasal spray soln 0.01%
(refrigerated)...................................................................13
desmopressin acetate tab 0.1 mg (Ddavp)................... 13
desmopressin acetate tab 0.2 mg (Ddavp)................... 13
desonide cream 0.05% (Desowen).................................50
desonide lotion 0.05% (Desowen)................................. 50
desonide oint 0.05% (Desowen).................................... 50
desoximetasone cream 0.25% (Topicort)......................50
desoximetasone gel 0.05% (Topicort)........................... 50
desoximetasone oint 0.25% (Topicort)..........................50
DEXAMETHASONE – dexamethasone soln 0.5
mg/5ml............................................................................... 8
dexamethasone elixir 0.5 mg/5ml.................................... 8
dexamethasone sodium phosphate ophth soln
0.1%.................................................................................47
dexamethasone tab 0.5 mg.............................................. 8
dexamethasone tab 0.75 mg............................................ 8
dexamethasone tab 1.5 mg.............................................. 8
dexamethasone tab 4 mg................................................. 8
dexamethasone tab 6 mg................................................. 8
dextroamphetamine sulfate cap sr 24hr 10 mg
(Dexedrine)..................................................................... 32
(Dexedrine)..................................................................... 32
(Dexedrine)..................................................................... 32
dextroamphetamine sulfate tab 5 mg............................32
DIASTAT ACUDIAL – diazepam rectal gel delivery system
10 mg...............................................................................38
DIASTAT ACUDIAL – diazepam rectal gel delivery system
20 mg...............................................................................38
DIASTAT PEDIATRIC – diazepam rectal gel delivery
system 2.5 mg................................................................. 38
DIAZEPAM – diazepam soln 1 mg/ml...............................27
60
diazepam tab 10 mg (Valium).........................................27
diazepam tab 2 mg (Valium)...........................................27
diazepam tab 5 mg (Valium)...........................................27
DIBENZYLINE – phenoxybenzamine hcl cap 10 mg........ 20
diclofenac potassium tab 50 mg (Cataflam)................. 36
diclofenac sodium (actinic keratoses) gel 3%
(Solaraze)........................................................................51
diclofenac sodium ophth soln 0.1%.............................. 47
diclofenac sodium tab delayed release 25 mg............. 36
diclofenac sodium tab sr 24hr 100 mg (Voltarenxr).................................................................................... 36
dicloxacillin sodium cap 250 mg..................................... 1
dicloxacillin sodium cap 500 mg..................................... 1
dicyclomine hcl cap 10 mg (Bentyl).............................. 24
dicyclomine hcl tab 20 mg (Bentyl)...............................24
didanosine delayed release capsule 125 mg (Videx
ec)......................................................................................4
ec)......................................................................................4
ec)......................................................................................4
ec)......................................................................................4
DIFFERIN – adapalene gel 0.3%......................................48
digoxin tab 125 mcg (0.125 mg) (Lanoxin)....................20
digoxin tab 250 mcg (0.25 mg) (Lanoxin)......................21
DILANTIN – phenytoin sodium extended cap 30 mg........ 38
diltiazem hcl cap sr 24hr 120 mg...................................17
diltiazem hcl coated beads cap sr 24hr 120 mg
(Cardizem cd)................................................................. 17
(Cardizem cd)................................................................. 17
(Cardizem cd)................................................................. 17
(Cardizem cd)................................................................. 17
(Cardizem cd)................................................................. 17
diltiazem hcl extended release beads cap sr 24hr 120
mg (Tiazac).....................................................................17
mg (Tiazac).....................................................................17
mg (Tiazac).....................................................................17
mg (Tiazac).....................................................................17
mg (Tiazac).....................................................................17
mg (Tiazac).....................................................................17
diltiazem hcl tab 120 mg (Cardizem)............................. 17
diltiazem hcl tab 30 mg (Cardizem)............................... 17
2015
diltiazem hcl tab 60 mg (Cardizem)............................... 17
diltiazem hcl tab 90 mg.................................................. 17
diphenoxylate w/ atropine tab 2.5-0.025 mg
(Lomotil)..........................................................................24
dipyridamole tab 25 mg (Persantine)............................ 43
disopyramide phosphate cap 100 mg (Norpace)..........20
disopyramide phosphate cap 150 mg (Norpace)..........20
disulfiram tab 250 mg (Antabuse)................................. 33
disulfiram tab 500 mg (Antabuse)................................. 33
divalproex sodium cap sprinkle 125 mg (Depakote
sprinkles)........................................................................ 38
divalproex sodium tab delayed release 125 mg
(Depakote)...................................................................... 38
(Depakote)...................................................................... 38
(Depakote)...................................................................... 38
divalproex sodium tab sr 24 hr 250 mg (Depakote
er).................................................................................... 38
divalproex sodium tab sr 24 hr 500 mg (Depakote
er).................................................................................... 38
DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%)............ 9
DIVIGEL – estradiol td gel 0.5 mg/0.5gm (0.1%)................ 9
DIVIGEL – estradiol td gel 1 mg/gm (0.1%)........................9
donepezil hydrochloride orally disintegrating tab 10
mg (Aricept odt).............................................................33
donepezil hydrochloride orally disintegrating tab 5 mg
(Aricept odt)................................................................... 33
donepezil hydrochloride tab 10 mg (Aricept)............... 33
donepezil hydrochloride tab 5 mg (Aricept)................. 33
DONNATAL – pb-hyoscy-atrop-scopol tab
16.2-0.1037-0.0194-0.0065 mg....................................... 24
dorzolamide hcl ophth soln 2% (Trusopt).....................47
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8
mg/ml (Cosopt).............................................................. 47
doxazosin mesylate tab 1 mg (Cardura)....................... 21
doxepin hcl cap 100 mg................................................. 28
doxepin hcl cap 10 mg................................................... 28
doxepin hcl conc 10 mg/ml............................................ 28
doxycycline hyclate cap 100 mg (Vibramycin)............... 2
doxycycline hyclate cap 50 mg....................................... 2
doxycycline hyclate tab 100 mg...................................... 2
doxycycline hyclate tab 20 mg........................................ 2
doxycycline monohydrate cap 100 mg (Monodox)........ 2
doxycycline monohydrate cap 150 mg (Adoxa)............. 2
doxycycline monohydrate cap 50 mg............................. 2
doxycycline monohydrate cap 75 mg (Monodox).......... 2
doxycycline monohydrate tab 100 mg (Adoxa pak
1/100).................................................................................2
doxycycline monohydrate tab 150 mg (Adoxa pak
1/150).................................................................................2
doxycycline monohydrate tab 50 mg (Adoxa)................ 2
doxycycline monohydrate tab 75 mg (Adoxa)................ 2
DROXIA – hydroxyurea cap 200 mg.................................43
DULERA – mometasone furoate-formoterol fumarate
aerosol 100-5 mcg/act..................................................... 23
DULERA – mometasone furoate-formoterol fumarate
aerosol 200-5 mcg/act..................................................... 23
duloxetine hcl enteric coated pellets cap 20 mg
(Cymbalta)...................................................................... 28
(Cymbalta)...................................................................... 28
(Cymbalta)...................................................................... 28
E
econazole nitrate cream 1%........................................... 49
ELIDEL – pimecrolimus cream 1%................................... 51
ELIQUIS – apixaban tab 2.5 mg....................................... 43
ELIQUIS – apixaban tab 5 mg.......................................... 43
ELLA – ulipristal acetate tab 30 mg.................................... 9
ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj
1000 unit..........................................................................43
1500 unit..........................................................................43
2000 unit..........................................................................43
250 unit............................................................................43
3000 unit..........................................................................43
500 unit............................................................................43
750 unit............................................................................43
EMCYT – estramustine phosphate sodium cap 140 mg..... 6
EMEND – aprepitant capsule 125 mg...............................25
EMEND – aprepitant capsule 40 mg.................................25
EMEND – aprepitant capsule 80 mg.................................25
EMEND – aprepitant capsule therapy pack 80 & 125
mg.................................................................................... 25
EMTRIVA – emtricitabine caps 200 mg.............................. 4
EMTRIVA – emtricitabine soln 10 mg/ml............................ 4
enalapril maleate & hydrochlorothiazide tab 10-25 mg
(Vaseretic).......................................................................14
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg....................................................................................14
enalapril maleate tab 10 mg (Vasotec).......................... 14
enalapril maleate tab 2.5 mg (Vasotec)......................... 14
enalapril maleate tab 20 mg (Vasotec).......................... 14
enalapril maleate tab 5 mg (Vasotec)............................ 14
ENBREL – etanercept for subcutaneous inj kit 25 mg...... 36
61
2015
ENBREL – etanercept subcutaneous soln prefilled syringe
25 mg/0.5ml.....................................................................36
ENBREL – etanercept subcutaneous soln prefilled syringe
50 mg/ml..........................................................................36
ENBREL SURECLICK – etanercept subcutaneous
solution auto-injector 50 mg/ml....................................... 36
ENJUVIA – estrogens, conjugated synthetic b tab 0.3
mg...................................................................................... 9
mg...................................................................................... 9
mg...................................................................................... 9
mg...................................................................................... 9
mg...................................................................................... 9
enoxaparin sodium inj 100 mg/ml (Lovenox)............... 43
enoxaparin sodium inj 120 mg/0.8ml (Lovenox)...........43
enoxaparin sodium inj 150 mg/ml (Lovenox)............... 43
enoxaparin sodium inj 300 mg/3ml (Lovenox)..............43
enoxaparin sodium inj 30 mg/0.3ml (Lovenox).............43
entacapone tab 200 mg (Comtan)..................................40
entecavir tab 0.5 mg (Baraclude).....................................3
entecavir tab 1 mg (Baraclude)........................................3
EPIPEN 2-PAK – epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................21
EPIPEN-JR 2-PAK – epinephrine solution auto-injector
0.15 mg/0.3ml (1:2000)................................................... 21
EPIVIR – lamivudine oral soln 10 mg/ml.............................4
eplerenone tab 25 mg (Inspra).......................................21
eplerenone tab 50 mg (Inspra).......................................21
EPOGEN – epoetin alfa inj 10000 unit/ml......................... 43
EPOGEN – epoetin alfa inj 20000 unit/ml......................... 43
EPOGEN – epoetin alfa inj 2000 unit/ml...........................43
EPZICOM – abacavir sulfate-lamivudine tab 600-300
mg...................................................................................... 4
ergocalciferol cap 50000 unit (Drisdol)......................... 41
erythromycin gel 2% (Erygel).........................................49
erythromycin ophth oint 5 mg/gm................................. 46
erythromycin pads 2%....................................................49
erythromycin soln 2%.....................................................49
erythromycin w/ delayed release particles cap 250
mg......................................................................................2
escitalopram oxalate soln 5 mg/5ml (base equiv)
(Lexapro).........................................................................28
escitalopram oxalate tab 10 mg (base equiv)
(Lexapro).........................................................................28
(Lexapro).........................................................................28
(Lexapro).........................................................................28
62
esomeprazole magnesium cap delayed release 20 mg
(base eq) (Nexium)........................................................ 24
esomeprazole magnesium cap delayed release 40 mg
(base eq) (Nexium)........................................................ 24
estazolam tab 1 mg.........................................................31
estazolam tab 2 mg.........................................................31
ESTRACE – estradiol vaginal cream 0.1 mg/gm.............. 27
estradiol & norethindrone acetate tab 0.5-0.1 mg
(Activella)..........................................................................9
estradiol & norethindrone acetate tab 1-0.5 mg
(Activella)..........................................................................9
estradiol tab 0.5 mg (Estrace)..........................................9
estradiol tab 1 mg (Estrace).............................................9
estradiol tab 2 mg (Estrace).............................................9
estradiol td patch twice weekly 0.025 mg/24hr (Vivelledot).................................................................................... 9
estradiol td patch twice weekly 0.0375 mg/24hr
(Vivelle-dot)...................................................................... 9
estradiol td patch weekly 0.025 mg/24hr (Climara)........ 9
estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr) (Climara)......................................................... 9
estradiol td patch weekly 0.05 mg/24hr (Climara).......... 9
estradiol td patch weekly 0.06 mg/24hr (Climara).......... 9
estradiol td patch weekly 0.075 mg/24hr (Climara)........ 9
estradiol td patch weekly 0.1 mg/24hr (Climara)............ 9
estropipate tab 0.75 mg....................................................9
estropipate tab 1.5 mg......................................................9
eszopiclone tab 1 mg (Lunesta).................................... 31
ethambutol hcl tab 100 mg (Myambutol)........................ 3
ethambutol hcl tab 400 mg (Myambutol)........................ 3
ethosuximide cap 250 mg (Zarontin).............................38
ethosuximide soln 250 mg/5ml (Zarontin).................... 38
etodolac cap 200 mg.......................................................36
etodolac cap 300 mg.......................................................36
etodolac tab 400 mg....................................................... 36
etodolac tab 500 mg....................................................... 36
etodolac tab sr 24hr 400 mg.......................................... 36
EXELON – rivastigmine td patch 24hr 13.3 mg/24hr.........33
EXELON – rivastigmine td patch 24hr 4.6 mg/24hr...........33
EXELON – rivastigmine td patch 24hr 9.5 mg/24hr...........33
exemestane tab 25 mg (Aromasin)..................................6
F
famciclovir tab 125 mg (Famvir)...................................... 4
2015
famotidine tab 20 mg (Pepcid).......................................24
famotidine tab 40 mg (Pepcid).......................................24
FARESTON – toremifene citrate tab 60 mg (base
equivalent)......................................................................... 6
FEIBA – antiinhibitor coagulant complex for inj.................44
FEIBA NF – antiinhibitor coagulant complex for inj........... 44
felodipine tab sr 24hr 10 mg.......................................... 18
felodipine tab sr 24hr 2.5 mg......................................... 17
felodipine tab sr 24hr 5 mg............................................17
fenofibrate micronized cap 134 mg (Lofibra)................19
fenofibrate micronized cap 200 mg (Lofibra)................19
fenofibrate micronized cap 67 mg (Lofibra)..................19
fenofibrate tab 145 mg (Tricor)...................................... 19
fenofibrate tab 160 mg (Lofibra).................................... 19
fenofibrate tab 48 mg (Tricor)........................................ 19
fenofibrate tab 54 mg (Lofibra)...................................... 19
fentanyl citrate lozenge on a handle 1200 mcg
(Actiq)..............................................................................34
(Actiq)..............................................................................34
(Actiq)..............................................................................34
(Actiq)..............................................................................34
(Actiq)..............................................................................34
(Actiq)..............................................................................34
fentanyl td patch 72hr 100 mcg/hr (Duragesic)............ 34
fentanyl td patch 72hr 12 mcg/hr (Duragesic).............. 34
FINACEA – azelaic acid gel 15%..................................... 49
finasteride tab 5 mg (Proscar)....................................... 27
FIRAZYR – icatibant acetate inj 30 mg/3ml (base
equivalent)....................................................................... 44
flecainide acetate tab 100 mg........................................ 20
flecainide acetate tab 150 mg........................................ 20
flecainide acetate tab 50 mg.......................................... 20
FLOVENT DISKUS – fluticasone propionate aer pow ba
100 mcg/blister................................................................ 23
250 mcg/blister................................................................ 23
50 mcg/blister.................................................................. 23
FLOVENT HFA – fluticasone propionate hfa inhal aer 110
mcg/act (125/valve)......................................................... 23
FLOVENT HFA – fluticasone propionate hfa inhal aer 220
mcg/act (250/valve)......................................................... 23
FLOVENT HFA – fluticasone propionate hfa inhal aero 44
mcg/act (50/valve)........................................................... 23
fluconazole for susp 10 mg/ml (Diflucan)....................... 3
fluconazole for susp 40 mg/ml (Diflucan)....................... 3
fluconazole tab 100 mg (Diflucan)................................... 3
fluconazole tab 50 mg (Diflucan).....................................3
flucytosine cap 250 mg (Ancobon)..................................3
flucytosine cap 500 mg (Ancobon)..................................3
fludrocortisone acetate tab 0.1 mg..................................8
flunisolide nasal soln 25 mcg/act (0.025%)
(Flunisolide)....................................................................22
fluocinolone acetonide cream 0.01%............................ 50
fluocinolone acetonide cream 0.025% (Synalar).......... 50
fluocinolone acetonide oil 0.01% (body oil) (Dermasmoothe/fs bod).............................................................50
fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca)............................................................. 50
fluocinolone acetonide oint 0.025% (Synalar).............. 50
fluocinolone acetonide soln 0.01% (Synalar)............... 50
fluocinonide cream 0.05%.............................................. 50
fluocinonide emulsified base cream 0.05%.................. 50
fluocinonide gel 0.05%................................................... 50
fluocinonide oint 0.05%.................................................. 50
fluocinonide soln 0.05%................................................. 50
fluorometholone ophth susp 0.1% (Fml liquifilm)........ 47
FLUOROPLEX – fluorouracil cream 1%........................... 51
fluorouracil cream 5% (Efudex)..................................... 51
fluorouracil soln 2%........................................................51
fluorouracil soln 5%........................................................51
fluoxetine hcl cap 10 mg (Prozac)................................. 28
fluoxetine hcl solution 20 mg/5ml................................. 28
fluoxetine hcl tab 10 mg.................................................29
fluoxetine hcl tab 20 mg.................................................29
fluphenazine decanoate inj 25 mg/ml............................29
FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5
mg/5ml............................................................................. 29
FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/
ml..................................................................................... 29
fluphenazine hcl tab 10 mg............................................ 30
fluphenazine hcl tab 1 mg..............................................29
fluphenazine hcl tab 2.5 mg........................................... 30
fluphenazine hcl tab 5 mg..............................................30
flurbiprofen sodium ophth soln 0.03% (Ocufen).......... 48
flurbiprofen tab 100 mg.................................................. 36
flurbiprofen tab 50 mg.................................................... 36
flutamide cap 125 mg....................................................... 6
fluticasone propionate cream 0.05% (Cutivate)............50
fluticasone propionate nasal susp 50 mcg/act
(Flonase)......................................................................... 22
fluticasone propionate oint 0.005% (Cutivate)..............50
fluvoxamine maleate tab 100 mg................................... 29
fluvoxamine maleate tab 25 mg.....................................29
fluvoxamine maleate tab 50 mg.....................................29
folic acid tab 1 mg.......................................................... 44
FOLLISTIM AQ – follitropin beta inj 300 unit/0.36ml......... 10
FOLLISTIM AQ – follitropin beta inj 75 unit/0.5ml............. 10
63
2015
FORADIL AEROLIZER – formoterol fumarate inhal cap 12
mcg.................................................................................. 23
FORTEO – teriparatide (recombinant) inj 600
mcg/2.4ml........................................................................ 13
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg....................................................................................14
fosinopril sodium & hydrochlorothiazide tab 20-12.5
mg....................................................................................14
fosinopril sodium tab 10 mg.......................................... 14
furosemide oral soln 10 mg/ml...................................... 19
furosemide tab 20 mg (Lasix)........................................ 19
FUZEON – enfuvirtide for inj 90 mg....................................4
G
gabapentin cap 100 mg (Neurontin).............................. 38
gabapentin oral soln 250 mg/5ml (Neurontin).............. 38
gabapentin tab 600 mg (Neurontin)...............................38
gabapentin tab 800 mg (Neurontin)...............................38
GABITRIL – tiagabine hcl tab 12 mg................................ 39
GABITRIL – tiagabine hcl tab 16 mg................................ 39
galantamine hydrobromide cap sr 24hr 16 mg
(Razadyne er)................................................................. 33
(Razadyne er)................................................................. 33
(Razadyne er)................................................................. 33
galantamine hydrobromide tab 12 mg (Razadyne).......33
galantamine hydrobromide tab 4 mg (Razadyne)........ 33
galantamine hydrobromide tab 8 mg (Razadyne)........ 33
GANIRELIX ACETATE – ganirelix acetate inj 250
mcg/0.5ml........................................................................ 10
gemfibrozil tab 600 mg (Lopid)......................................19
gentamicin sulfate ophth oint 0.3%...............................46
gentamicin sulfate ophth soln 0.3% (Garamycin)........ 46
glatiramer acetate soln prefilled syringe 20 mg/ml
(Copaxone)..................................................................... 32
GLEEVEC – imatinib mesylate tab 100 mg (base
equivalent)......................................................................... 6
GLEEVEC – imatinib mesylate tab 400 mg (base
equivalent)......................................................................... 6
glimepiride tab 1 mg (Amaryl)....................................... 10
glipizide-metformin hcl tab 2.5-250 mg......................... 10
glipizide-metformin hcl tab 2.5-500 mg......................... 10
glipizide-metformin hcl tab 5-500 mg............................ 10
glipizide tab 10 mg (Glucotrol)...................................... 10
glipizide tab 5 mg (Glucotrol)........................................ 10
glipizide tab sr 24hr 10 mg (Glucotrol xl)......................10
glipizide tab sr 24hr 2.5 mg (Glucotrol xl).....................10
64
glipizide tab sr 24hr 5 mg (Glucotrol xl)....................... 10
GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj
kit 1 mg............................................................................10
(Glucovance).................................................................. 10
glyburide-metformin tab 2.5-500 mg (Glucovance)...... 10
glyburide-metformin tab 5-500 mg (Glucovance)......... 10
glyburide micronized tab 1.5 mg (Glynase).................. 10
glyburide micronized tab 3 mg (Glynase)..................... 10
glyburide micronized tab 6 mg (Glynase)..................... 10
glyburide tab 1.25 mg..................................................... 10
glyburide tab 2.5 mg....................................................... 10
glyburide tab 5 mg.......................................................... 10
glycopyrrolate tab 1 mg (Robinul).................................24
glycopyrrolate tab 2 mg (Robinul forte)........................24
granisetron hcl tab 1 mg................................................ 25
griseofulvin microsize susp 125 mg/5ml........................ 3
griseofulvin microsize tab 500 mg (Grifulvin v)............. 3
guanfacine hcl tab 1 mg (Tenex)................................... 21
guanfacine hcl tab 2 mg (Tenex)................................... 21
guanfacine hcl tab sr 24hr 1 mg (base equiv)
(Intuniv)...........................................................................32
(Intuniv)...........................................................................32
(Intuniv)...........................................................................32
(Intuniv)...........................................................................32
H
halobetasol propionate cream 0.05% (Ultravate)......... 50
halobetasol propionate oint 0.05% (Ultravate)............. 50
haloperidol decanoate im soln 100 mg/ml (Haldol
decanoate 100)...............................................................30
haloperidol decanoate im soln 50 mg/ml (Haldol
decanoate 50).................................................................30
haloperidol lactate oral conc 2 mg/ml...........................30
haloperidol tab 0.5 mg....................................................30
haloperidol tab 10 mg.....................................................30
haloperidol tab 1 mg.......................................................30
haloperidol tab 20 mg.....................................................30
HARVONI – ledipasvir-sofosbuvir tab 90-400 mg............... 3
HELIXATE FS – antihemophilic factor (recombinant) for inj
kit 1000 unit..................................................................... 44
kit 2000 unit..................................................................... 44
kit 250 unit.......................................................................44
kit 3000 unit..................................................................... 44
kit 500 unit.......................................................................44
HEMOFIL M – antihemophilic factor (human) for inj 1000
unit................................................................................... 44
2015
HEMOFIL M – antihemophilic factor (human) for inj
1501-2000 unit.................................................................44
unit................................................................................... 44
220-400 unit.....................................................................44
unit................................................................................... 44
401-800 unit.....................................................................44
unit................................................................................... 44
801-1500 unit...................................................................44
homatropine hbr ophth soln 5% (Isopto
homatropine).................................................................. 48
HUMATE-P – antihemophilic factor/vwf (human) for inj
1000-2400 unit.................................................................44
250-600 unit.....................................................................44
500-1200 unit...................................................................44
HUMIRA – adalimumab prefilled syringe kit 10
mg/0.2ml.......................................................................... 36
mg/0.4ml.......................................................................... 36
mg/0.8ml.......................................................................... 36
HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled
syringe kit 40 mg/0.8ml................................................... 37
HUMIRA PEN – adalimumab pen-injector kit 40
mg/0.8ml.......................................................................... 37
HUMIRA PEN-CROHNS DISEASE – adalimumab peninjector kit 40 mg/0.8ml................................................... 37
HUMIRA PEN-PSORIASIS STAR – adalimumab peninjector kit 40 mg/0.8ml................................................... 37
hydralazine hcl tab 100 mg............................................ 21
hydralazine hcl tab 10 mg.............................................. 21
hydrochlorothiazide cap 12.5 mg (Microzide)...............19
hydrochlorothiazide tab 12.5 mg................................... 19
hydrochlorothiazide tab 25 mg...................................... 19
hydrochlorothiazide tab 50 mg...................................... 19
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
(Hycet).............................................................................34
hydrocodone-acetaminophen tab 10-325 mg
(Norco)............................................................................ 34
hydrocodone-acetaminophen tab 5-325 mg
(Norco)............................................................................ 34
hydrocodone-acetaminophen tab 7.5-325 mg
(Norco)............................................................................ 34
hydrocodone-ibuprofen tab 10-200 mg (Ibudone)........34
hydrocodone-ibuprofen tab 5-200 mg (Reprexain)...... 34
hydrocodone-ibuprofen tab 7.5-200 mg
(Vicoprofen)....................................................................34
hydrocortisone acetate suppos 25 mg (Anusol-hc)..... 48
hydrocortisone acetate suppos 30 mg
(Proctocort).................................................................... 48
hydrocortisone cream 2.5%........................................... 50
hydrocortisone enema 100 mg/60ml (Cortenema)....... 48
hydrocortisone lotion 2.5%............................................ 50
hydrocortisone oint 2.5%............................................... 50
hydrocortisone rectal cream 2.5% (Anusol-hc)............ 48
hydrocortisone tab 10 mg (Cortef).................................. 8
hydrocortisone tab 20 mg (Cortef).................................. 8
hydrocortisone tab 5 mg (Cortef).................................... 8
hydrocortisone valerate cream 0.2%.............................50
hydrocortisone valerate oint 0.2% (Westcort).............. 50
hydrocortisone w/ acetic acid otic soln 1-2% (Vosol
hc)....................................................................................48
hydromorphone hcl liqd 1 mg/ml (Dilaudid)................. 34
hydromorphone hcl tab 2 mg (Dilaudid)....................... 34
hydroxychloroquine sulfate tab 200 mg (Plaquenil)...... 5
hydroxyurea cap 500 mg (Hydrea).................................. 6
hydroxyzine hcl syrup 10 mg/5ml..................................27
hydroxyzine hcl tab 10 mg.............................................27
hydroxyzine hcl tab 25 mg.............................................27
hydroxyzine hcl tab 50 mg............................................. 27
hydroxyzine pamoate cap 25 mg (Vistaril)....................28
hydroxyzine pamoate cap 50 mg (Vistaril)....................28
hyoscyamine sulfate elixir 0.125 mg/5ml...................... 24
hyoscyamine sulfate soln 0.125 mg/ml......................... 24
hyoscyamine sulfate tab 0.125 mg (Levsin)................. 24
hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)...... 24
hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl)..........24
hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid).....24
I
ibandronate sodium tab 150 mg (base equivalent)
(Boniva)...........................................................................13
IBRANCE – palbociclib cap 100 mg................................... 6
IBRANCE – palbociclib cap 125 mg................................... 6
IBRANCE – palbociclib cap 75 mg..................................... 6
ibuprofen susp 100 mg/5ml............................................37
ibuprofen tab 400 mg......................................................37
ibuprofen tab 600 mg......................................................37
ibuprofen tab 800 mg......................................................37
imipramine hcl tab 10 mg (Tofranil).............................. 29
imiquimod cream 5% (Aldara)........................................51
IMITREX – sumatriptan nasal spray 20 mg/act.................37
IMITREX – sumatriptan nasal spray 5 mg/act...................37
INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml)........ 12
INCRUSE ELLIPTA – umeclidinium br aero powd breath
act 62.5 mcg/inh (base eq)............................................. 23
indapamide tab 1.25 mg................................................. 19
indapamide tab 2.5 mg................................................... 19
indomethacin cap 25 mg................................................ 37
65
2015
indomethacin cap 50 mg................................................ 37
INNOPRAN XL – propranolol hcl sustained-release beads
cap sr 24hr 120 mg.........................................................16
INNOPRAN XL – propranolol hcl sustained-release beads
cap sr 24hr 80 mg...........................................................16
INSULIN PEN NEEDLES – BD ULTRAFINE, NOVOFINE,
NOVOTWIST................................................................... 51
INSULIN SYRINGES – BD............................................... 51
INTELENCE – etravirine tab 100 mg.................................. 4
INTELENCE – etravirine tab 200 mg.................................. 4
INTELENCE – etravirine tab 25 mg.................................... 4
INTUNIV – guanfacine hcl tab sr 24hr 1 mg (base
equiv)............................................................................... 32
equiv)............................................................................... 32
equiv)............................................................................... 32
equiv)............................................................................... 32
INVIRASE – saquinavir mesylate cap 200 mg.................... 4
INVIRASE – saquinavir mesylate tab 500 mg.....................4
INVOKAMET – canagliflozin-metformin hcl tab 150-1000
mg.................................................................................... 10
mg.................................................................................... 10
mg.................................................................................... 10
mg.................................................................................... 10
INVOKANA – canagliflozin tab 100 mg.............................10
INVOKANA – canagliflozin tab 300 mg.............................11
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml
(Duoneb)......................................................................... 23
ipratropium bromide inhal soln 0.02%.......................... 23
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
(Atrovent)........................................................................22
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
(Atrovent)........................................................................22
irbesartan-hydrochlorothiazide tab 150-12.5 mg
(Avalide)..........................................................................15
irbesartan-hydrochlorothiazide tab 300-12.5 mg
(Avalide)..........................................................................15
irbesartan tab 150 mg (Avapro)..................................... 15
irbesartan tab 300 mg (Avapro)..................................... 15
irbesartan tab 75 mg (Avapro)....................................... 15
ISENTRESS – raltegravir potassium chew tab 100 mg
(base equiv).......................................................................4
ISENTRESS – raltegravir potassium chew tab 25 mg
(base equiv).......................................................................4
ISENTRESS – raltegravir potassium packet for susp 100
mg (base equiv).................................................................4
ISENTRESS – raltegravir potassium tab 400 mg (base
equiv)................................................................................. 4
isoniazid tab 100 mg.........................................................3
isoniazid tab 300 mg.........................................................3
isosorbide dinitrate tab 10 mg.......................................18
66
isosorbide dinitrate tab 20 mg.......................................18
isosorbide dinitrate tab 5 mg (Isordil titradose)........... 18
isosorbide mononitrate tab 10 mg................................ 18
isosorbide mononitrate tab 20 mg................................ 18
isosorbide mononitrate tab sr 24hr 120 mg (Imdur).....18
isosorbide mononitrate tab sr 24hr 30 mg (Imdur).......18
isosorbide mononitrate tab sr 24hr 60 mg (Imdur).......18
isotretinoin cap 10 mg....................................................49
itraconazole cap 100 mg (Sporanox)...............................3
ivermectin tab 3 mg (Stromectol).................................... 6
J
JANUMET – sitagliptin-metformin hcl tab 50-1000 mg......11
JANUMET – sitagliptin-metformin hcl tab 50-500 mg........11
JANUMET XR – sitagliptin-metformin hcl tab sr 24hr
100-1000 mg................................................................... 11
50-1000 mg..................................................................... 11
50-500 mg....................................................................... 11
JANUVIA – sitagliptin phosphate tab 100 mg (base
equiv)............................................................................... 11
equiv)............................................................................... 11
equiv)............................................................................... 11
JARDIANCE – empagliflozin tab 10 mg............................11
JARDIANCE – empagliflozin tab 25 mg............................11
K
KADIAN – morphine sulfate cap sr 24hr 100 mg.............. 35
KADIAN – morphine sulfate cap sr 24hr 10 mg................ 35
KADIAN – morphine sulfate cap sr 24hr 200 mg.............. 35
KALETRA – lopinavir-ritonavir soln 400-100 mg/5ml
(80-20 mg/ml).................................................................... 4
KALETRA – lopinavir-ritonavir tab 100-25 mg.................... 4
KALETRA – lopinavir-ritonavir tab 200-50 mg.................... 4
KALYDECO – ivacaftor packet 50 mg.............................. 24
KALYDECO – ivacaftor packet 75 mg.............................. 24
KALYDECO – ivacaftor tab 150 mg..................................24
ketoconazole cream 2%..................................................49
ketoconazole shampoo 2% (Nizoral)............................. 49
ketoprofen cap 50 mg.....................................................37
ketoprofen cap 75 mg.....................................................37
ketorolac tromethamine ophth soln 0.4% (Acular
ls).....................................................................................48
ketorolac tromethamine ophth soln 0.5% (Acular).......48
2015
KOATE-DVI – antihemophilic factor (human) for inj 1000
unit................................................................................... 44
unit................................................................................... 44
unit................................................................................... 44
KOGENATE FS – antihemophilic factor (recombinant) for
inj kit 1000 unit................................................................ 44
inj kit 2000 unit................................................................ 44
inj kit 250 unit.................................................................. 44
inj kit 3000 unit................................................................ 44
inj kit 500 unit.................................................................. 44
KOGENATE FS BIO-SET – antihemophilic factor
(recombinant) for inj kit 1000 unit....................................44
(recombinant) for inj kit 250 unit......................................44
(recombinant) for inj kit 500 unit......................................44
KOMBIGLYZE XR – saxagliptin-metformin hcl tab sr 24hr
2.5-1000 mg.................................................................... 11
5-1000 mg....................................................................... 11
5-500 mg......................................................................... 11
K-PHOS – potassium phosphate monobasic tab 500
mg.................................................................................... 41
L
labetalol hcl tab 100 mg (Trandate)...............................16
lactulose (encephalopathy) solution 10 gm/15ml.........26
lactulose solution 10 gm/15ml....................................... 24
lamivudine oral soln 10 mg/ml (Epivir)........................... 4
lamivudine tab 100 mg (hbv) (Epivir hbv)....................... 3
lamivudine tab 150 mg (Epivir)........................................ 4
lamivudine tab 300 mg (Epivir)........................................ 4
lamivudine-zidovudine tab 150-300 mg (Combivir)........ 4
lamotrigine tab 100 mg (Lamictal)................................. 39
lamotrigine tab 25 mg (Lamictal)................................... 39
lamotrigine tab chewable dispersible 25 mg (Lamictal
chewable di)................................................................... 39
lamotrigine tab chewable dispersible 5 mg (Lamictal
chewable di)................................................................... 39
LANCETS – BAYER FINGERSTIX, MICROLET, SINGLELET.................................................................................. 51
LANCETS – BD MICROTAINER, ULTRAFINE.................51
LANCETS – ROCHE ACCU-CHEK FASTCLIX,
MULTICLIX, SOFT TOUCH, SOFTCLIX......................... 51
lansoprazole cap delayed release 15 mg
(Prevacid)........................................................................24
lansoprazole cap delayed release 30 mg
(Prevacid)........................................................................25
LANTUS – insulin glargine inj 100 unit/ml.........................12
LANTUS SOLOSTAR – insulin glargine soln pen-injector
100 unit/ml....................................................................... 12
latanoprost ophth soln 0.005% (Xalatan)...................... 47
leflunomide tab 10 mg (Arava).......................................37
leflunomide tab 20 mg (Arava).......................................37
LETAIRIS – ambrisentan tab 10 mg................................. 21
LETAIRIS – ambrisentan tab 5 mg................................... 21
letrozole tab 2.5 mg (Femara).......................................... 6
LEUCOVORIN CALCIUM – leucovorin calcium tab 10
mg...................................................................................... 6
LEUCOVORIN CALCIUM – leucovorin calcium tab 15
mg...................................................................................... 6
leucovorin calcium tab 25 mg..........................................6
leucovorin calcium tab 5 mg........................................... 6
LEUKERAN – chlorambucil tab 2 mg................................. 6
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
(Xopenex)........................................................................23
(Xopenex)........................................................................23
(Xopenex)........................................................................23
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base
equiv).............................................................................. 23
LEVEMIR FLEXPEN – insulin detemir soln pen-injector
100 unit/ml....................................................................... 12
LEVEMIR FLEXTOUCH – insulin detemir soln pen-injector
100 unit/ml....................................................................... 12
LEVEMIR – insulin detemir inj 100 unit/ml........................ 12
levetiracetam oral soln 100 mg/ml (Keppra)................. 39
levetiracetam tab 1000 mg (Keppra)..............................39
levetiracetam tab 250 mg (Keppra)................................39
levetiracetam tab sr 24hr 500 mg (Keppra xr).............. 39
levetiracetam tab sr 24hr 750 mg (Keppra xr).............. 39
levobunolol hcl ophth soln 0.5% (Betagan)..................47
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 13
levocarnitine tab 330 mg (Carnitor)...............................13
levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5
mg/ml) (Xyzal)................................................................ 21
levocetirizine dihydrochloride tab 5 mg (Xyzal)........... 21
levofloxacin oral soln 25 mg/ml (Levaquin)....................2
levofloxacin tab 250 mg (Levaquin)................................ 2
levonorgestrel tab 1.5 mg (Plan b one-step)...................9
levothyroxine sodium tab 100 mcg (Synthroid)........... 12
67
2015
levothyroxine sodium tab 25 mcg (Synthroid)............. 12
LEXIVA – fosamprenavir calcium susp 50 mg/ml (base
equiv)................................................................................. 4
LEXIVA – fosamprenavir calcium tab 700 mg (base
equiv)................................................................................. 4
LIALDA – mesalamine tab delayed release 1.2 gm.......... 26
lidocaine hcl gel 2%........................................................51
lidocaine hcl laryngotracheal soln 4% (Lta 360 kit)......48
lidocaine hcl local inj 1% (Xylocaine)............................38
lidocaine hcl local preservative free (pf) inj 1%
(Xylocaine-mpf).............................................................. 38
lidocaine hcl soln 4% (Xylocaine)..................................51
lidocaine hcl viscous soln 2%....................................... 48
lidocaine oint 5%.............................................................51
lidocaine patch 5% (700 mg) (Lidoderm)...................... 51
lidocaine-prilocaine cream 2.5-2.5% (Emla)..................51
lindane lotion 1%.............................................................51
lindane shampoo 1%...................................................... 51
linezolid tab 600 mg (Zyvox)............................................ 6
LINZESS – linaclotide cap 145 mcg................................. 26
LINZESS – linaclotide cap 290 mcg................................. 26
liothyronine sodium tab 25 mcg (Cytomel)...................12
liothyronine sodium tab 50 mcg (Cytomel)...................12
liothyronine sodium tab 5 mcg (Cytomel).....................12
lisinopril & hydrochlorothiazide tab 10-12.5 mg
(Zestoretic)..................................................................... 14
lisinopril & hydrochlorothiazide tab 20-12.5 mg
(Zestoretic)..................................................................... 14
lisinopril & hydrochlorothiazide tab 20-25 mg
(Zestoretic)..................................................................... 14
lisinopril tab 10 mg (Prinivil)..........................................14
lisinopril tab 2.5 mg (Zestril).......................................... 14
lisinopril tab 20 mg (Prinivil)..........................................14
lisinopril tab 30 mg (Zestril)........................................... 14
lisinopril tab 40 mg (Zestril)........................................... 14
lisinopril tab 5 mg (Prinivil)............................................14
lithium carbonate cap 150 mg (Lithium carbonate)......30
lithium carbonate cap 300 mg....................................... 30
lithium carbonate cap 600 mg (Lithium carbonate)......30
lithium carbonate tab 300 mg........................................ 30
lithium carbonate tab cr 300 mg (Lithobid)...................30
lithium carbonate tab cr 450 mg....................................30
loperamide hcl cap 2 mg................................................24
lorazepam conc 2 mg/ml (Lorazepam intensol)............28
lorazepam tab 0.5 mg (Ativan)....................................... 28
lorazepam tab 1 mg (Ativan).......................................... 28
lorazepam tab 2 mg (Ativan).......................................... 28
68
losartan potassium & hydrochlorothiazide tab
100-12.5 mg (Hyzaar).....................................................15
losartan potassium & hydrochlorothiazide tab 100-25
mg (Hyzaar).................................................................... 15
losartan potassium & hydrochlorothiazide tab 50-12.5
mg (Hyzaar).................................................................... 15
losartan potassium tab 100 mg (Cozaar)...................... 15
losartan potassium tab 25 mg (Cozaar)........................ 15
losartan potassium tab 50 mg (Cozaar)........................ 15
LOTEMAX – loteprednol etabonate ophth gel 0.5%..........47
LOTEMAX – loteprednol etabonate ophth oint 0.5%.........47
LOTEMAX – loteprednol etabonate ophth susp 0.5%....... 47
lovastatin tab 10 mg....................................................... 19
lovastatin tab 20 mg (Mevacor)..................................... 19
lovastatin tab 40 mg (Mevacor)..................................... 19
loxapine succinate cap 10 mg....................................... 30
loxapine succinate cap 5 mg (Loxitane)....................... 30
LUMIGAN – bimatoprost ophth soln 0.01%...................... 47
LYRICA – pregabalin cap 100 mg.................................... 39
LYRICA – pregabalin cap 25 mg...................................... 39
M
malathion lotion 0.5% (Ovide)........................................51
meclizine hcl tab 12.5 mg...............................................25
meclizine hcl tab 25 mg..................................................25
medroxyprogesterone acetate im susp 150 mg/ml
(Depo-provera contrac)................................................... 9
medroxyprogesterone acetate tab 10 mg (Provera).......9
medroxyprogesterone acetate tab 2.5 mg (Provera)......9
medroxyprogesterone acetate tab 5 mg (Provera).........9
mefloquine hcl tab 250 mg...............................................5
megestrol acetate susp 40 mg/ml (Megace oral)............6
megestrol acetate tab 20 mg........................................... 6
megestrol acetate tab 40 mg........................................... 6
MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg
(base equivalent)............................................................... 7
MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (base
equivalent)......................................................................... 7
meloxicam tab 15 mg (Mobic)........................................37
meloxicam tab 7.5 mg (Mobic).......................................37
memantine hcl tab 10 mg (Namenda)............................33
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak
(Namenda titration pa).................................................. 33
memantine hcl tab 5 mg (Namenda)............................. 33
MEPHYTON – phytonadione tab 5 mg............................. 41
mercaptopurine tab 50 mg (Purinethol).......................... 7
mesalamine enema 4 gm................................................26
MESNEX – mesna tab 400 mg...........................................7
2015
MESTINON – pyridostigmine bromide syrup 60
mg/5ml............................................................................. 40
MESTINON TIMESPAN – pyridostigmine bromide tab cr
180 mg.............................................................................40
metaxalone tab 800 mg (Skelaxin).................................40
metformin hcl tab 1000 mg (Glucophage).....................11
metformin hcl tab 500 mg (Glucophage)...................... 11
metformin hcl tab 850 mg (Glucophage)...................... 11
metformin hcl tab sr 24hr 500 mg (Glucophage xr)......11
metformin hcl tab sr 24hr 750 mg (Glucophage xr)......11
methadone hcl conc 10 mg/ml (Methadose).................35
methadone hcl soln 10 mg/5ml (Methadone hcl)..........35
methadone hcl soln 5 mg/5ml (Methadone hcl)............35
methadone hcl tab 10 mg (Dolophine).......................... 35
methadone hcl tab 5 mg (Dolophine hcl)......................35
methadone hcl tab for oral susp 40 mg........................ 35
methazolamide tab 25 mg (Neptazane)......................... 19
methazolamide tab 50 mg (Neptazane)......................... 19
methimazole tab 10 mg (Tapazole)................................12
methimazole tab 5 mg (Tapazole)..................................12
methocarbamol tab 500 mg (Robaxin).......................... 40
methocarbamol tab 750 mg (Robaxin-750)................... 40
methotrexate sodium tab 2.5 mg (base equiv)............... 7
methscopolamine bromide tab 2.5 mg (Pamine)..........25
methscopolamine bromide tab 5 mg (Pamine
forte)................................................................................25
methyldopa tab 250 mg.................................................. 21
methyldopa tab 500 mg.................................................. 21
methylergonovine maleate tab 0.2 mg.......................... 13
methylphenidate hcl tab 10 mg (Ritalin)....................... 32
methylphenidate hcl tab 20 mg (Ritalin)....................... 32
methylphenidate hcl tab 5 mg (Ritalin)......................... 32
methylphenidate hcl tab cr 20 mg (Ritalin sr)...............32
methylprednisolone tab 16 mg (Medrol)......................... 8
methylprednisolone tab 32 mg (Medrol)......................... 8
methylprednisolone tab 4 mg (Medrol)........................... 8
methylprednisolone tab 4 mg dose pack (Medrol
dosepak)........................................................................... 8
methylprednisolone tab 8 mg (Medrol)........................... 8
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml).........26
metoclopramide hcl tab 10 mg (Reglan)....................... 26
metoclopramide hcl tab 5 mg (Reglan)......................... 26
metolazone tab 10 mg.................................................... 20
metolazone tab 2.5 mg (Zaroxolyn)............................... 20
metolazone tab 5 mg (Zaroxolyn).................................. 20
metoprolol succinate tab sr 24hr 100 mg (Toprol
xl).....................................................................................16
metoprolol succinate tab sr 24hr 200 mg (Toprol
xl).....................................................................................16
metoprolol succinate tab sr 24hr 25 mg (Toprol xl)..... 16
metoprolol succinate tab sr 24hr 50 mg (Toprol xl)..... 16
metoprolol tartrate tab 100 mg (Lopressor)..................16
metoprolol tartrate tab 25 mg........................................ 16
metoprolol tartrate tab 50 mg (Lopressor)....................16
metronidazole cream 0.75% (Metrocream)....................49
metronidazole gel 0.75%................................................ 49
metronidazole gel 1% (Metrogel)................................... 49
metronidazole lotion 0.75% (Metrolotion)..................... 49
metronidazole tab 250 mg (Flagyl).................................. 6
metronidazole tab 500 mg (Flagyl).................................. 6
metronidazole vaginal gel 0.75% (Metrogelvaginal)........................................................................... 27
mexiletine hcl cap 150 mg............................................. 20
midodrine hcl tab 10 mg................................................ 21
midodrine hcl tab 2.5 mg............................................... 21
midodrine hcl tab 5 mg.................................................. 21
MIGRANAL – dihydroergotamine mesylate nasal spray 4
mg/ml............................................................................... 37
minocycline hcl cap 100 mg (Minocin)............................2
minocycline hcl cap 50 mg (Minocin)............................. 2
minocycline hcl cap 75 mg (Minocin)............................. 2
minocycline hcl tab 100 mg............................................. 2
minocycline hcl tab 50 mg............................................... 2
minocycline hcl tab 75 mg............................................... 2
minoxidil tab 10 mg........................................................ 21
minoxidil tab 2.5 mg....................................................... 21
MIRENA – levonorgestrel releasing iud 20 mcg/24hr (52
mg total)...........................................................................10
mirtazapine tab 15 mg (Remeron)................................. 29
mirtazapine tab 7.5 mg................................................... 29
misoprostol tab 100 mcg (Cytotec)............................... 25
misoprostol tab 200 mcg (Cytotec)............................... 25
modafinil tab 100 mg (Provigil)......................................32
modafinil tab 200 mg (Provigil)......................................32
moexipril hcl tab 15 mg (Univasc).................................14
moexipril hcl tab 7.5 mg (Univasc)................................14
moexipril-hydrochlorothiazide tab 15-12.5 mg
(Uniretic)......................................................................... 14
moexipril-hydrochlorothiazide tab 15-25 mg................ 14
moexipril-hydrochlorothiazide tab 7.5-12.5 mg............ 14
mometasone furoate cream 0.1% (Elocon)................... 50
mometasone furoate oint 0.1% (Elocon).......................50
mometasone furoate solution 0.1% (lotion)
(Elocon)...........................................................................50
MONOCLATE-P – antihemophilic factor (human) for inj kit
1000 unit..........................................................................44
1500 unit..........................................................................44
250 unit............................................................................44
500 unit............................................................................44
MONONINE – coagulation factor ix for inj 1000 unit......... 45
MONONINE – coagulation factor ix for inj 250 unit........... 44
MONONINE – coagulation factor ix for inj 500 unit........... 45
montelukast sodium chew tab 4 mg (base equiv)
(Singulair)....................................................................... 23
69
2015
montelukast sodium chew tab 5 mg (base equiv)
(Singulair)....................................................................... 23
montelukast sodium oral granules packet 4 mg (base
equiv) (Singulair)........................................................... 23
montelukast sodium tab 10 mg (base equiv)
(Singulair)....................................................................... 23
morphine sulfate (concentrate) oral soln 20 mg/ml..... 35
MORPHINE SULFATE – morphine sulfate suppos 10
mg.................................................................................... 35
mg.................................................................................... 35
mg.................................................................................... 35
mg.................................................................................... 35
MORPHINE SULFATE – morphine sulfate tab 15 mg.......35
MORPHINE SULFATE – morphine sulfate tab 30 mg.......35
morphine sulfate oral soln 10 mg/5ml...........................35
morphine sulfate oral soln 20 mg/5ml...........................35
morphine sulfate tab cr 100 mg (Ms contin)................. 35
morphine sulfate tab cr 15 mg (Ms contin)...................35
morphine sulfate tab cr 200 mg (Ms contin)................. 35
MULTAQ – dronedarone hcl tab 400 mg (base
equivalent)....................................................................... 20
mupirocin calcium cream 2% (Bactroban)....................49
mupirocin oint 2% (Bactroban)......................................49
mycophenolate mofetil cap 250 mg (Cellcept)............. 52
mycophenolate mofetil for oral susp 200 mg/ml
(Cellcept).........................................................................52
mycophenolate mofetil tab 500 mg (Cellcept).............. 52
mycophenolate sodium tab dr 180 mg (mycophenolic
acid equiv) (Myfortic).................................................... 52
mycophenolate sodium tab dr 360 mg (mycophenolic
acid equiv) (Myfortic).................................................... 52
MYLERAN – busulfan tab 2 mg..........................................7
N
nabumetone tab 500 mg.................................................37
nabumetone tab 750 mg.................................................37
nadolol tab 20 mg (Corgard).......................................... 16
naloxone hcl inj 0.4 mg/ml............................................. 52
naltrexone hcl tab 50 mg (Revia)...................................52
naproxen sodium tab 275 mg (Anaprox)...................... 37
naproxen sodium tab 550 mg (Anaprox ds)................. 37
naproxen tab 250 mg (Naprosyn).................................. 37
naproxen tab ec 375 mg (Ec-naprosyn)........................ 37
naproxen tab ec 500 mg (Ec-naprosyn)........................ 37
naratriptan hcl tab 1 mg (base equiv) (Amerge)........... 37
naratriptan hcl tab 2.5 mg (base equiv) (Amerge)........ 37
70
NASONEX – mometasone furoate nasal susp 50 mcg/
act.................................................................................... 22
NATACYN – natamycin ophth susp 5%............................46
nateglinide tab 120 mg (Starlix).....................................11
nateglinide tab 60 mg (Starlix).......................................11
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin.................................46
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml (Neosporin)............... 46
neomycin-polymyxin-dexamethasone ophth oint 0.1%
(Maxitrol).........................................................................47
neomycin-polymyxin-dexamethasone ophth susp
0.1% (Maxitrol)............................................................... 47
neomycin-polymyxin-hc otic soln 1% (Cortisporin).....48
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000
unit/ml-1%.......................................................................48
neomycin sulfate tab 500 mg...........................................3
NEULASTA DELIVERY KIT – pegfilgrastim inj 6
mg/0.6ml.......................................................................... 45
NEULASTA – pegfilgrastim inj 6 mg/0.6ml....................... 45
NEUPOGEN – filgrastim inj 300 mcg/0.5ml (600 mcg/
ml).................................................................................... 45
NEUPOGEN – filgrastim inj 300 mcg/ml........................... 45
ml).................................................................................... 45
ml).................................................................................... 45
nevirapine tab 200 mg (Viramune)...................................4
nevirapine tab sr 24hr 400 mg (Viramune xr)................. 4
NEXAVAR – sorafenib tosylate tab 200 mg (base
equivalent)......................................................................... 7
NEXIUM – esomeprazole magnesium cap delayed release
20 mg (base eq)..............................................................25
NEXIUM – esomeprazole magnesium cap delayed release
40 mg (base eq)..............................................................25
NEXIUM – esomeprazole magnesium for delayed release
susp pack 2.5 mg............................................................25
susp packet 10 mg.......................................................... 25
susp packet 20 mg.......................................................... 25
susp packet 40 mg.......................................................... 25
susp packet 5 mg............................................................25
niacin tab cr 1000 mg (antihyperlipidemic)
(Niaspan).........................................................................19
(Niaspan).........................................................................19
(Niaspan).........................................................................19
NICOTROL INHALER – nicotine inhaler system 10 mg (4
mg delivered)...................................................................33
NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/
spray)............................................................................... 33
nifedipine tab sr 24hr 30 mg (Adalat cc).......................18
2015
nifedipine tab sr 24hr osmotic 30 mg (Procardia
xl).....................................................................................18
xl).....................................................................................18
xl).....................................................................................18
NILANDRON – nilutamide tab 150 mg............................... 7
nitrofurantoin macrocrystalline cap 100 mg
(Macrodantin)................................................................. 26
nitrofurantoin macrocrystalline cap 50 mg
(Macrodantin)................................................................. 26
nitrofurantoin monohydrate macrocrystalline cap 100
mg (Macrobid)................................................................ 26
nitrofurantoin susp 25 mg/5ml (Furadantin)................. 26
nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)......... 18
NITROSTAT – nitroglycerin sl tab 0.3 mg.........................18
norelgestromin-ethinyl estradiol td ptwk 150-35
mcg/24hr (Ortho evra)................................................... 10
norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5
mcg (Femhrt low dose)...................................................9
norethindrone acetate-ethinyl estradiol tab 1 mg-5
mcg....................................................................................9
norethindrone acetate tab 5 mg (Aygestin).................... 9
nortriptyline hcl cap 10 mg (Pamelor)...........................29
NORVIR – ritonavir cap 100 mg......................................... 4
NORVIR – ritonavir oral soln 80 mg/ml...............................5
NORVIR – ritonavir tab 100 mg.......................................... 4
NOVOEIGHT – antihemophilic factor (recombinant) for inj
1000 unit..........................................................................45
1500 unit..........................................................................45
2000 unit..........................................................................45
250 unit............................................................................45
3000 unit..........................................................................45
500 unit............................................................................45
NOVOLIN 70/30 – insulin nph isophane & regular human
inj 100 unit/ml (70-30)..................................................... 11
NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/
ml..................................................................................... 11
NOVOLIN R – insulin regular (human) inj 100 unit/ml....... 11
NOVOLOG FLEXPEN – insulin aspart soln pen-injector
100 unit/ml....................................................................... 11
NOVOLOG – insulin aspart inj 100 unit/ml........................11
NOVOLOG MIX 70/30 – insulin aspart prot & aspart
(human) inj 100 unit/ml (70-30)....................................... 11
NOVOLOG MIX 70/30 PREFILL – insulin aspart prot &
aspart sus pen-inj 100 unit/ml (70-30).............................12
NOVOLOG PENFILL – insulin aspart inj 100 unit/ml........ 11
NOVOLOG PENFILL – insulin aspart soln cartridge 100
unit/ml.............................................................................. 11
NOVOSEVEN RT – coagulation factor viia (recomb) for inj
1 mg (1000 mcg).............................................................45
2 mg (2000 mcg).............................................................45
5 mg (5000 mcg).............................................................45
8 mg (8000 mcg).............................................................45
NOXAFIL – posaconazole susp 40 mg/ml.......................... 3
NUCYNTA ER – tapentadol hcl tab sr 12hr 100 mg..........35
NUCYNTA ER – tapentadol hcl tab sr 12hr 50 mg........... 35
NUEDEXTA – dextromethorphan hbr-quinidine sulfate cap
20-10 mg......................................................................... 33
NUVARING – etonogestrel-ethinyl estradiol va ring
0.120-0.015 mg/24hr....................................................... 10
nystatin cream 100000 unit/gm......................................49
nystatin oint 100000 unit/gm..........................................49
nystatin susp 100000 unit/ml......................................... 48
nystatin tab 500000 unit................................................... 3
nystatin topical powder.................................................. 49
nystatin-triamcinolone cream 100000-0.1 unit/gm%......................................................................................50
nystatin-triamcinolone oint 100000-0.1 unit/gm-%....... 50
O
OBIZUR – antihemophilic factor (recomb porc) rpfviii for inj
500 unit............................................................................45
octreotide acetate inj 1000 mcg/ml (1 mg/ml)
(Sandostatin).................................................................. 13
octreotide acetate inj 100 mcg/ml (0.1 mg/ml)
(Sandostatin).................................................................. 13
(Sandostatin).................................................................. 13
(Sandostatin).................................................................. 13
(Sandostatin).................................................................. 13
ofloxacin ophth soln 0.3% (Ocuflox)............................. 46
ofloxacin otic soln 0.3%................................................. 48
olanzapine orally disintegrating tab 10 mg (Zyprexa
zydis)...............................................................................30
zydis)...............................................................................30
zydis)...............................................................................30
71
2015
zydis)...............................................................................30
olanzapine tab 10 mg (Zyprexa).................................... 30
olanzapine tab 2.5 mg (Zyprexa)................................... 30
olanzapine tab 5 mg (Zyprexa)...................................... 30
olanzapine tab 7.5 mg (Zyprexa)................................... 30
OLYSIO – simeprevir sodium cap 150 mg (base
equivalent)......................................................................... 3
omeprazole cap delayed release 10 mg (Prilosec)....... 25
OMNITROPE – somatropin for inj 5.8 mg.........................12
OMNITROPE – somatropin inj 10 mg/1.5ml..................... 12
OMNITROPE – somatropin inj 5 mg/1.5ml....................... 12
ondansetron hcl inj 40 mg/20ml (2 mg/ml) (Zofran)..... 25
ondansetron hcl inj 4 mg/2ml (2 mg/ml)....................... 25
ondansetron hcl oral soln 4 mg/5ml (Zofran)............... 25
ondansetron hcl tab 24 mg............................................ 25
ondansetron hcl tab 4 mg (Zofran)................................25
ondansetron hcl tab 8 mg (Zofran)................................25
ondansetron orally disintegrating tab 4 mg (Zofran
odt).................................................................................. 25
ondansetron orally disintegrating tab 8 mg (Zofran
odt).................................................................................. 25
ONGLYZA – saxagliptin hcl tab 2.5 mg (base equiv)........ 11
ONGLYZA – saxagliptin hcl tab 5 mg (base equiv)........... 11
OPSUMIT – macitentan tab 10 mg................................... 21
oral contraceptives– all generics.......................................10
ORAP – pimozide tab 1 mg.............................................. 33
ORAP – pimozide tab 2 mg.............................................. 33
ORFADIN – nitisinone cap 10 mg.....................................13
ORFADIN – nitisinone cap 2 mg.......................................13
ORFADIN – nitisinone cap 5 mg.......................................13
orphenadrine citrate tab sr 12hr 100 mg.......................40
orphenadrine w/ aspirin & caffeine tab 25-385-30
mg....................................................................................40
oxaprozin tab 600 mg (Daypro)..................................... 37
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
(Trileptal).........................................................................39
oxcarbazepine tab 150 mg (Trileptal)............................ 39
oxybutynin chloride syrup 5 mg/5ml.............................26
oxybutynin chloride tab 5 mg........................................ 26
oxybutynin chloride tab sr 24hr 10 mg (Ditropan
xl).....................................................................................26
oxybutynin chloride tab sr 24hr 15 mg (Ditropan
xl).....................................................................................26
oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)......26
oxycodone-aspirin tab 4.8355-325 mg (Percodan)....... 36
oxycodone hcl cap 5 mg................................................ 35
oxycodone hcl conc 100 mg/5ml (20 mg/ml)
(Oxycodone hcl).............................................................35
oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)........... 35
72
oxycodone hcl tab 10 mg...............................................35
oxycodone hcl tab 15 mg (Roxicodone)....................... 35
oxycodone hcl tab 20 mg...............................................35
oxycodone hcl tab 30 mg (Roxicodone)....................... 36
oxycodone hcl tab 5 mg (Roxicodone)......................... 35
oxycodone w/ acetaminophen tab 10-325 mg
(Percocet)....................................................................... 36
oxycodone w/ acetaminophen tab 5-325 mg
(Percocet)....................................................................... 36
oxycodone w/ acetaminophen tab 7.5-325 mg
(Percocet)....................................................................... 36
OXYCONTIN – oxycodone hcl tab er 12hr deter 10
mg.................................................................................... 36
mg.................................................................................... 36
mg.................................................................................... 36
mg.................................................................................... 36
mg.................................................................................... 36
mg.................................................................................... 36
mg.................................................................................... 36
P
pantoprazole sodium ec tab 20 mg (base equiv)
(Protonix)........................................................................ 25
pantoprazole sodium ec tab 40 mg (base equiv)
(Protonix)........................................................................ 25
paricalcitol cap 1 mcg (Zemplar)................................... 13
paromomycin sulfate cap 250 mg................................... 3
paroxetine hcl tab 10 mg (Paxil).................................... 29
paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)................ 29
paroxetine hcl tab sr 24hr 25 mg (Paxil cr)...................29
paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)................ 29
PATADAY – olopatadine hcl ophth soln 0.2%...................48
PAZEO – olopatadine hcl ophth soln 0.7% (base
equivalent)....................................................................... 48
pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/
ml.....................................................................................41
pediatric multiple vitamins w/ fluoride chew tab 0.25
mg....................................................................................41
pediatric multiple vitamins w/ fluoride chew tab 0.5
mg....................................................................................41
pediatric multiple vitamins w/ fluoride chew tab 1
mg....................................................................................41
pediatric multiple vitamins w/ fluoride soln 0.25 mg/
ml.....................................................................................41
2015
pediatric multiple vitamins w/ fluoride soln 0.5 mg/
ml.....................................................................................41
pediatric vitamins acd w/ fluoride soln 0.25 mg/ml...... 41
pediatric vitamins acd w/ fluoride soln 0.5 mg/ml........ 41
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm
(Golytely)........................................................................ 24
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm
(Colyte-flavor packs)..................................................... 24
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
(Nulytely/flavor pack).................................................... 24
PEGASYS – peginterferon alfa-2a inj 180 mcg/0.5ml......... 3
PEGASYS – peginterferon alfa-2a inj 180 mcg/ml.............. 3
PEGASYS PROCLICK – peginterferon alfa-2a inj 135
mcg/0.5ml.......................................................................... 3
PEGASYS PROCLICK – peginterferon alfa-2a inj 180
mcg/0.5ml.......................................................................... 3
penicillin v potassium for soln 125 mg/5ml.................... 1
penicillin v potassium for soln 250 mg/5ml.................... 1
penicillin v potassium tab 250 mg...................................1
penicillin v potassium tab 500 mg...................................1
PENTASA – mesalamine cap cr 250 mg.......................... 26
PENTASA – mesalamine cap cr 500 mg.......................... 26
pentoxifylline tab cr 400 mg...........................................45
perindopril erbumine tab 2 mg...................................... 14
perindopril erbumine tab 4 mg (Aceon)........................ 14
perindopril erbumine tab 8 mg (Aceon)........................ 14
permethrin cream 5% (Elimite)...................................... 51
perphenazine tab 16 mg................................................. 30
perphenazine tab 2 mg................................................... 30
phenelzine sulfate tab 15 mg (Nardil)............................29
phenobarbital elixir 20 mg/5ml...................................... 31
phenobarbital tab 16.2 mg............................................. 31
phenobarbital tab 32.4 mg............................................. 31
phenytoin chew tab 50 mg (Dilantin infatabs).............. 39
phenytoin sodium extended cap 100 mg (Dilantin)......39
phenytoin susp 125 mg/5ml (Dilantin).......................... 39
pilocarpine hcl ophth soln 1% (Isopto carpine)............47
pilocarpine hcl tab 5 mg (Salagen)................................48
pilocarpine hcl tab 7.5 mg (Salagen).............................48
pindolol tab 10 mg.......................................................... 16
pindolol tab 5 mg............................................................ 16
pioglitazone hcl-metformin hcl tab 15-500 mg
(Actoplus met)............................................................... 11
pioglitazone hcl-metformin hcl tab 15-850 mg
(Actoplus met)............................................................... 11
pioglitazone hcl tab 15 mg (base equiv) (Actos).......... 11
piroxicam cap 10 mg (Feldene)..................................... 37
piroxicam cap 20 mg (Feldene)..................................... 37
PLEGRIDY – peginterferon beta-1a soln pen-injector 125
mcg/0.5ml........................................................................ 32
PLEGRIDY – peginterferon beta-1a soln prefilled syringe
125 mcg/0.5ml................................................................. 32
PLEGRIDY STARTER PACK – peginterferon beta-1a soln
pen-inj 63 & 94 mcg/0.5ml pack......................................32
PLEGRIDY STARTER PACK – peginterferon beta-1a soln
pref syr 63 & 94 mcg/0.5ml pack.................................... 32
podofilox soln 0.5% (Condylox).....................................51
polymyxin b-trimethoprim ophth soln 10000 unit/
ml-0.1% (Polytrim)......................................................... 46
pot & sod citrates w/ cit ac soln 550-500-334
mg/5ml............................................................................ 27
potassium chloride cap cr 10 meq (Micro-k)................ 41
potassium chloride cap cr 8 meq (Micro-k).................. 41
potassium chloride microencapsulated crys cr tab 10
meq..................................................................................41
potassium chloride microencapsulated crys cr tab 20
meq..................................................................................41
potassium chloride oral liq 10% (20 meq/15ml)............41
potassium chloride oral liq 20% (40 meq/15ml)............41
potassium chloride powder packet 20 meq..................41
potassium chloride tab cr 10 meq (K-tab).................... 41
potassium chloride tab cr 8 meq (600 mg)................... 41
potassium citrate & citric acid powder pack 3300-1002
mg....................................................................................27
potassium citrate & citric acid soln 1100-334
mg/5ml............................................................................ 27
potassium citrate tab cr 10 meq (1080 mg) (Urocit-k
10)....................................................................................27
15)....................................................................................27
5)......................................................................................27
pot bicarbonate & chloride effer tab 25 meq................ 41
pot phos monobasic w/sod phos di & monobas tab
155-852-130mg (K-phos neutral).................................. 41
pramipexole dihydrochloride tab 0.125 mg
(Mirapex)......................................................................... 40
(Mirapex)......................................................................... 40
pramipexole dihydrochloride tab 0.5 mg (Mirapex)......40
(Mirapex)......................................................................... 40
pramipexole dihydrochloride tab 1.5 mg (Mirapex)......40
pramipexole dihydrochloride tab 1 mg (Mirapex)........ 40
pravastatin sodium tab 10 mg....................................... 19
pravastatin sodium tab 20 mg (Pravachol)................... 19
prazosin hcl cap 1 mg (Minipress)................................ 21
prednisolone acetate ophth susp 1% (Pred forte)........47
PREDNISOLONE SODIUM PHOSP – prednisolone
sodium phosphate ophth soln 1%................................... 47
prednisolone sod phosphate oral soln 15 mg/5ml
(base equiv)......................................................................8
73
2015
prednisolone sod phosph oral soln 6.7 mg/5ml (5
mg/5ml base) (Pediapred)...............................................8
prednisolone syrup 15 mg/5ml (usp solution
equivalent) (Prelone)....................................................... 8
PREDNISONE INTENSOL – prednisone conc 5 mg/ml......8
PREDNISONE – prednisone oral soln 5 mg/5ml................ 8
PREDNISONE – prednisone tab 50 mg............................. 8
prednisone tab 10 mg.......................................................8
prednisone tab 1 mg.........................................................8
prednisone tab 2.5 mg......................................................8
prednisone tab 20 mg.......................................................8
prednisone tab 5 mg.........................................................8
PRENAPLUS – prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................... 41
PRENATABS FA – prenatal vit w/ fe fumarate-fa tab 29-1
mg.................................................................................... 41
PRENATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab
29-1 mg........................................................................... 41
PRENATAL 19 – prenatal vit w/ fe fumarate-fa chew tab
29-1 mg........................................................................... 41
PRENATAL LOW IRON – prenatal vit w/ fe fumarate-fa
tab 27-1 mg..................................................................... 41
PRENATAL PLUS/IRON – prenatal vit w/ fe fumarate-fa
tab 27-1 mg..................................................................... 41
PRENATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................... 41
PRENATAL VITAMINS PLUS – prenatal vit w/ fe
fumarate-fa tab 27-1 mg..................................................41
PREZISTA – darunavir ethanolate susp 100 mg/ml (base
equiv)................................................................................. 5
PREZISTA – darunavir ethanolate tab 150 mg (base
equiv)................................................................................. 5
equiv)................................................................................. 5
equiv)................................................................................. 5
equiv)................................................................................. 5
PRIFTIN – rifapentine tab 150 mg...................................... 3
PRIMAQUINE PHOSPHATE – primaquine phosphate tab
26.3 mg (15 mg base).......................................................6
primidone tab 250 mg (Mysoline).................................. 39
primidone tab 50 mg (Mysoline).................................... 39
PROAIR HFA – albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv).........................................................23
PROAIR RESPICLICK – albuterol sulfate aer pow ba 108
mcg/act (90 mcg base equiv).......................................... 23
probenecid tab 500 mg...................................................38
prochlorperazine maleate tab 10 mg (base equivalent)
(Compazine)................................................................... 30
prochlorperazine maleate tab 5 mg (base equivalent)
(Compazine)................................................................... 30
prochlorperazine suppos 25 mg....................................30
PROCRIT – epoetin alfa inj 10000 unit/ml........................ 45
PROCRIT – epoetin alfa inj 2000 unit/ml.......................... 45
74
PROFILNINE – factor ix complex for inj 1000 unit............ 45
PROFILNINE – factor ix complex for inj 1500 unit............ 45
PROFILNINE – factor ix complex for inj 500 unit.............. 45
PROFILNINE SD – factor ix complex for inj 1000 unit...... 45
PROFILNINE SD – factor ix complex for inj 1500 unit...... 45
PROFILNINE SD – factor ix complex for inj 500 unit........ 45
progesterone micronized cap 100 mg (Prometrium)......9
progesterone micronized cap 200 mg (Prometrium)......9
promethazine hcl suppos 12.5 mg................................ 21
promethazine hcl suppos 25 mg................................... 21
promethazine hcl suppos 50 mg................................... 21
promethazine hcl syrup 6.25 mg/5ml............................ 21
promethazine hcl tab 12.5 mg........................................21
promethazine hcl tab 25 mg...........................................21
promethazine hcl tab 50 mg...........................................21
propafenone hcl cap sr 12hr 225 mg (Rythmol sr)....... 20
propafenone hcl tab 150 mg (Rythmol).........................20
propafenone hcl tab 225 mg (Rythmol).........................20
propafenone hcl tab 300 mg.......................................... 20
propranolol hcl cap sr 24hr 120 mg (Inderal la)........... 16
propranolol hcl cap sr 24hr 160 mg (Inderal la)........... 16
propranolol hcl cap sr 24hr 60 mg (Inderal la)............. 16
propranolol hcl cap sr 24hr 80 mg (Inderal la)............. 16
PROPRANOLOL HCL – propranolol hcl oral soln 20
mg/5ml............................................................................. 16
PROPRANOLOL HCL – propranolol hcl oral soln 40
mg/5ml............................................................................. 16
propranolol hcl tab 10 mg..............................................16
propylthiouracil tab 50 mg............................................. 12
PROTOPIC – tacrolimus oint 0.03%................................. 51
PROTOPIC – tacrolimus oint 0.1%................................... 51
PULMOZYME – dornase alfa inhal soln 1 mg/ml..............24
PURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/
ml)...................................................................................... 7
pyrazinamide tab 500 mg................................................. 3
pyridostigmine bromide tab 60 mg (Mestinon).............40
Q
quetiapine fumarate tab 100 mg (Seroquel)..................30
quetiapine fumarate tab 25 mg (Seroquel)....................30
quetiapine fumarate tab 50 mg (Seroquel)....................30
quinapril hcl tab 10 mg (Accupril)................................. 14
2015
quinapril hcl tab 5 mg (Accupril)................................... 14
quinapril-hydrochlorothiazide tab 10-12.5 mg
(Accuretic)...................................................................... 14
quinapril-hydrochlorothiazide tab 20-12.5 mg
(Accuretic)...................................................................... 14
quinapril-hydrochlorothiazide tab 20-25 mg
(Accuretic)...................................................................... 14
quinidine gluconate tab cr 324 mg................................20
quinidine sulfate tab 300 mg..........................................20
QVAR – beclomethasone dipropionate inhal aero soln 40
mcg/act............................................................................ 23
QVAR – beclomethasone dipropionate inhal aero soln 80
mcg/act............................................................................ 23
R
raloxifene hcl tab 60 mg (Evista)................................... 13
ramipril cap 1.25 mg (Altace)......................................... 14
ramipril cap 10 mg (Altace)............................................ 14
ramipril cap 2.5 mg (Altace)........................................... 14
ramipril cap 5 mg (Altace)..............................................14
ranitidine hcl cap 150 mg...............................................25
ranitidine hcl cap 300 mg...............................................25
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)................... 25
ranitidine hcl tab 150 mg (Zantac).................................25
ranitidine hcl tab 300 mg (Zantac).................................25
RAPAMUNE – sirolimus oral soln 1 mg/ml....................... 52
RAPAMUNE – sirolimus tab 1 mg.................................... 52
RAPAMUNE – sirolimus tab 2 mg.................................... 52
REBIF – interferon beta-1a inj 22 mcg/0.5ml (12mu/ml)
(44 mcg/ml)......................................................................32
REBIF – interferon beta-1a inj 44 mcg/0.5ml (24mu/ml)
(88 mcg/ml)......................................................................32
REBIF REBIDOSE – interferon beta-1a inj 22 mcg/0.5ml
(12mu/ml) (44 mcg/ml).................................................... 32
REBIF REBIDOSE – interferon beta-1a inj 44 mcg/0.5ml
(24mu/ml) (88 mcg/ml).................................................... 33
REBIF REBIDOSE TITRATION – interferon beta-1a inj 6 x
8.8 mcg/0.2ml & 6 x 22 mcg/0.5ml..................................33
REBIF TITRATION PACK – interferon beta-1a inj 6 x 8.8
mcg/0.2ml & 6 x 22 mcg/0.5ml........................................33
RECOMBINATE – antihemophilic factor (recombinant) for
inj 1241-1800 unit............................................................45
inj 1801-2400 unit............................................................45
inj 220-400 unit................................................................45
inj 401-800 unit................................................................45
inj 801-1240 unit..............................................................45
repaglinide tab 0.5 mg (Prandin)................................... 11
repaglinide tab 1 mg (Prandin)...................................... 11
repaglinide tab 2 mg (Prandin)...................................... 11
REPRONEX – menotropins for inj 75 unit.........................10
RESCRIPTOR – delavirdine mesylate tab 100 mg............. 5
RESCRIPTOR – delavirdine mesylate tab 200 mg............. 5
REVLIMID – lenalidomide cap 10 mg............................... 52
REVLIMID – lenalidomide cap 5 mg................................. 52
REVLIMID – lenalidomide caps 2.5 mg............................ 52
REYATAZ – atazanavir sulfate cap 150 mg (base
equiv)................................................................................. 5
equiv)................................................................................. 5
equiv)................................................................................. 5
REYATAZ – atazanavir sulfate oral powder packet 50 mg
(base equiv).......................................................................5
ribavirin cap 200 mg (Rebetol).........................................3
ribavirin tab 200 mg (Copegus)....................................... 3
rifabutin cap 150 mg (Mycobutin)....................................3
rifampin cap 150 mg (Rifadin)..........................................3
rifampin cap 300 mg (Rifadin)..........................................3
riluzole tab 50 mg (Rilutek)............................................ 40
risedronate sodium tab 150 mg (Actonel).....................13
risedronate sodium tab 30 mg (Actonel)...................... 13
risedronate sodium tab 35 mg (Actonel)...................... 13
risedronate sodium tab 5 mg (Actonel)........................ 13
risperidone orally disintegrating tab 0.25 mg...............30
risperidone orally disintegrating tab 0.5 mg (Risperdal
m-tab).............................................................................. 30
risperidone orally disintegrating tab 1 mg (Risperdal
m-tab).............................................................................. 30
m-tab).............................................................................. 30
m-tab).............................................................................. 30
m-tab).............................................................................. 30
risperidone soln 1 mg/ml (Risperdal)............................31
risperidone tab 0.25 mg (Risperdal).............................. 31
risperidone tab 0.5 mg (Risperdal)................................ 31
risperidone tab 1 mg (Risperdal)................................... 31
rivastigmine tartrate cap 1.5 mg (Exelon)..................... 33
rivastigmine tartrate cap 3 mg (Exelon)........................33
rivastigmine tartrate cap 4.5 mg (Exelon)..................... 33
rivastigmine tartrate cap 6 mg (Exelon)........................34
RIXUBIS – coagulation factor ix (recombinant) for inj 1000
unit................................................................................... 45
unit................................................................................... 45
unit................................................................................... 45
unit................................................................................... 46
unit................................................................................... 45
75
2015
rizatriptan benzoate orally disintegrating tab 10 mg
(Maxalt-mlt).....................................................................37
rizatriptan benzoate orally disintegrating tab 5 mg
(Maxalt-mlt).....................................................................37
rizatriptan benzoate tab 10 mg (Maxalt)........................37
rizatriptan benzoate tab 5 mg (Maxalt)..........................37
ropinirole hydrochloride tab 0.25 mg (Requip).............40
ropinirole hydrochloride tab 0.5 mg (Requip)...............40
ropinirole hydrochloride tab 1 mg (Requip)................. 40
S
SABRIL – vigabatrin powd pack 500 mg.......................... 39
SABRIL – vigabatrin tab 500 mg...................................... 39
salsalate tab 500 mg....................................................... 34
salsalate tab 750 mg....................................................... 34
selegiline hcl cap 5 mg (Eldepryl)................................. 40
selegiline hcl tab 5 mg................................................... 40
selenium sulfide lotion 2.5%.......................................... 51
SELZENTRY – maraviroc tab 150 mg................................ 5
SELZENTRY – maraviroc tab 300 mg................................ 5
SE-NATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg.................................................................................... 41
SE-NATAL 19 – prenatal vit w/ fe fumarate-fa chew tab
29-1 mg........................................................................... 41
SENSIPAR – cinacalcet hcl tab 30 mg (base equiv)......... 13
SEROQUEL XR – quetiapine fumarate tab sr 24hr 150
mg.................................................................................... 31
mg.................................................................................... 31
mg.................................................................................... 31
mg.................................................................................... 31
mg.................................................................................... 31
sertraline hcl oral conc 20 mg/ml (Zoloft).....................29
sertraline hcl tab 100 mg (Zoloft).................................. 29
sertraline hcl tab 25 mg (Zoloft).................................... 29
sertraline hcl tab 50 mg (Zoloft).................................... 29
sildenafil citrate tab 20 mg (Revatio).............................21
silver sulfadiazine cream 1% (Silvadene)..................... 49
SIMBRINZA – brinzolamide-brimonidine tartrate ophth
susp 1-0.2%.....................................................................47
SIMPONI – golimumab subcutaneous soln auto-injector
100 mg/ml........................................................................37
SIMPONI – golimumab subcutaneous soln auto-injector
50 mg/0.5ml.....................................................................37
SIMPONI – golimumab subcutaneous soln prefilled
syringe 100 mg/ml........................................................... 37
76
SIMPONI – golimumab subcutaneous soln prefilled
syringe 50 mg/0.5ml........................................................ 37
simvastatin tab 10 mg (Zocor)....................................... 19
simvastatin tab 5 mg (Zocor)......................................... 19
sirolimus tab 0.5 mg (Rapamune)..................................52
sirolimus tab 1 mg (Rapamune).................................... 52
sirolimus tab 2 mg (Rapamune).................................... 52
SIVEXTRO – tedizolid phosphate tab 200 mg.................... 6
SKYLA – levonorgestrel releasing iud 13.5 mg.................10
sodium citrate & citric acid soln 500-334 mg/5ml
(Shohls solution modi)..................................................27
sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)
(Luride)............................................................................41
sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)
(Luride)............................................................................41
sodium fluoride chew tab 1 mg f (from 2.2 mg naf)
(Luride)............................................................................41
sodium fluoride cream 1.1% (Prevident 5000 plus)......48
sodium fluoride gel 1.1% (0.5% f) (Prevident
fluoride)...........................................................................48
sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop
naf).................................................................................. 41
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)
(Luride)............................................................................42
sodium polystyrene sulfonate oral susp 15 gm/60ml
(Sps)................................................................................ 52
sodium polystyrene sulfonate powder
(Kayexalate)....................................................................52
sotalol hcl (afib/afl) tab 120 mg (Betapace af).............. 20
sotalol hcl (afib/afl) tab 160 mg (Betapace af).............. 20
sotalol hcl (afib/afl) tab 80 mg (Betapace af)................ 20
sotalol hcl tab 120 mg (Betapace)................................. 20
sotalol hcl tab 160 mg (Betapace)................................. 20
sotalol hcl tab 240 mg.................................................... 20
sotalol hcl tab 80 mg (Betapace)................................... 20
SOVALDI – sofosbuvir tab 400 mg.....................................4
SPIRIVA HANDIHALER – tiotropium bromide
monohydrate inhal cap 18 mcg (base equiv)...................23
SPIRIVA RESPIMAT – tiotropium bromide monohydrate
inhal aerosol 2.5 mcg/act................................................ 24
spironolactone & hydrochlorothiazide tab 25-25 mg
(Aldactazide)...................................................................20
spironolactone tab 100 mg (Aldactone)........................ 20
spironolactone tab 25 mg (Aldactone).......................... 20
spironolactone tab 50 mg (Aldactone).......................... 20
SPRYCEL – dasatinib tab 100 mg......................................7
SPRYCEL – dasatinib tab 140 mg......................................7
SPRYCEL – dasatinib tab 20 mg........................................7
stavudine cap 15 mg (Zerit)............................................. 5
2015
stavudine for oral soln 1 mg/ml (Zerit)............................5
STELARA – ustekinumab soln prefilled syringe 45
mg/0.5ml.......................................................................... 51
STELARA – ustekinumab soln prefilled syringe 90 mg/
ml..................................................................................... 51
STIMATE – desmopressin acetate nasal soln 1.5 mg/
ml..................................................................................... 13
STRIBILD – elvitegrav-cobicis-emtricitab-tenofov tab
150-150-200-300 mg......................................................... 5
STROMECTOL – ivermectin tab 3 mg................................6
SUBOXONE – buprenorphine hcl-naloxone hcl sl film 12-3
mg (base equiv)...............................................................52
SUBOXONE – buprenorphine hcl-naloxone hcl sl film
2-0.5 mg (base equiv)..................................................... 52
mg (base equiv)...............................................................52
mg (base equiv)...............................................................52
sucralfate tab 1 gm (Carafate)....................................... 25
sulfacetamide sodium lotion 10% (acne) (Klaron)........49
sulfacetamide sodium ophth soln 10% (Bleph-10).......46
sulfacetamide sodium-prednisolone ophth soln
10-0.23(0.25)%................................................................ 47
sulfacetamide sodium w/ sulfur cream 10-5%.............. 49
sulfacetamide sodium w/ sulfur emulsion 10-5%......... 49
sulfacetamide sodium w/ sulfur lotion 10-5%...............49
sulfamethoxazole-trimethoprim susp 200-40
mg/5ml.............................................................................. 6
sulfamethoxazole-trimethoprim tab 400-80 mg
(Bactrim)........................................................................... 6
sulfamethoxazole-trimethoprim tab 800-160 mg
(Bactrim ds)......................................................................6
sulfasalazine tab 500 mg (Azulfidine)........................... 26
sulfasalazine tab delayed release 500 mg (Azulfidine
en-tabs)........................................................................... 26
sulindac tab 150 mg........................................................37
sulindac tab 200 mg........................................................37
sumatriptan succinate inj 6 mg/0.5ml (Imitrex)............ 37
sumatriptan succinate solution auto-injector 4
mg/0.5ml (Imitrex statdose sys)................................... 37
sumatriptan succinate solution auto-injector 6
mg/0.5ml (Imitrex statdose sys)................................... 38
sumatriptan succinate solution cartridge 4 mg/0.5ml
(Imitrex statdose ref)..................................................... 38
sumatriptan succinate solution cartridge 6 mg/0.5ml
(Imitrex statdose ref)..................................................... 38
sumatriptan succinate tab 100 mg (Imitrex)................. 38
sumatriptan succinate tab 25 mg (Imitrex)................... 38
sumatriptan succinate tab 50 mg (Imitrex)................... 38
SUSTIVA – efavirenz cap 200 mg...................................... 5
SUSTIVA – efavirenz cap 50 mg........................................ 5
SUSTIVA – efavirenz tab 600 mg.......................................5
SUTENT – sunitinib malate cap 12.5 mg (base
equivalent)......................................................................... 7
SUTENT – sunitinib malate cap 25 mg (base
equivalent)......................................................................... 7
SUTENT – sunitinib malate cap 37.5 mg (base
equivalent)......................................................................... 7
SUTENT – sunitinib malate cap 50 mg (base
equivalent)......................................................................... 7
SYLATRON – peginterferon alfa-2b for inj kit 200 mcg....... 7
SYLATRON – peginterferon alfa-2b for inj kit 4 x 200
mcg.................................................................................... 7
SYLATRON – peginterferon alfa-2b for inj kit 4 x 300
mcg.................................................................................... 7
SYMBICORT – budesonide-formoterol fumarate dihyd
aerosol 160-4.5 mcg/act.................................................. 24
SYMBICORT – budesonide-formoterol fumarate dihyd
aerosol 80-4.5 mcg/act.................................................... 24
SYNAREL – nafarelin acetate nasal soln 2 mg/ml............ 10
T
TABLOID – thioguanine tab 40 mg.....................................7
tacrolimus cap 0.5 mg (Prograf).................................... 52
tacrolimus cap 1 mg (Prograf)....................................... 52
tacrolimus cap 5 mg (Prograf)....................................... 52
tacrolimus oint 0.03% (Protopic)................................... 51
tacrolimus oint 0.1% (Protopic)..................................... 51
TAFINLAR – dabrafenib mesylate cap 50 mg (base
equivalent)......................................................................... 7
TAFINLAR – dabrafenib mesylate cap 75 mg (base
equivalent)......................................................................... 7
tamoxifen citrate tab 10 mg (base equivalent)............... 7
tamoxifen citrate tab 20 mg (base equivalent)............... 7
tamsulosin hcl cap 0.4 mg (Flomax)............................. 27
TARCEVA – erlotinib hcl tab 100 mg (base equivalent)...... 7
TARCEVA – erlotinib hcl tab 150 mg (base equivalent)...... 7
TARCEVA – erlotinib hcl tab 25 mg (base equivalent)........7
TASIGNA – nilotinib hcl cap 150 mg (base equivalent).......7
TASIGNA – nilotinib hcl cap 200 mg (base equivalent).......7
TAZORAC – tazarotene cream 0.05%..............................49
TAZORAC – tazarotene cream 0.1%................................49
TAZORAC – tazarotene gel 0.05%................................... 49
TAZORAC – tazarotene gel 0.1%.....................................49
TECFIDERA – dimethyl fumarate capsule delayed release
120 mg.............................................................................33
TECFIDERA – dimethyl fumarate capsule delayed release
240 mg.............................................................................33
TECFIDERA STARTER PACK – dimethyl fumarate
capsule dr starter pack 120 mg & 240 mg...................... 33
TEGRETOL-XR – carbamazepine tab sr 12hr 100 mg..... 39
telmisartan-hydrochlorothiazide tab 40-12.5 mg
(Micardis hct)................................................................. 15
telmisartan-hydrochlorothiazide tab 80-12.5 mg
(Micardis hct)................................................................. 15
telmisartan-hydrochlorothiazide tab 80-25 mg
(Micardis hct)................................................................. 15
telmisartan tab 20 mg (Micardis)................................... 15
77
2015
temazepam cap 15 mg (Restoril)................................... 31
temazepam cap 22.5 mg (Restoril)................................ 31
temazepam cap 30 mg (Restoril)................................... 31
temazepam cap 7.5 mg (Restoril).................................. 31
temozolomide cap 100 mg (Temodar).............................7
temozolomide cap 20 mg (Temodar)...............................7
temozolomide cap 5 mg (Temodar).................................7
terazosin hcl cap 10 mg................................................. 21
terazosin hcl cap 1 mg................................................... 21
terbinafine hcl tab 250 mg (Lamisil)................................3
terbutaline sulfate tab 2.5 mg........................................ 24
terbutaline sulfate tab 5 mg........................................... 24
terconazole vaginal cream 0.4% (Terazol 7)................. 27
terconazole vaginal cream 0.8% (Terazol 3)................. 27
terconazole vaginal suppos 80 mg................................27
testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone).................................................................... 8
testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone).................................................................... 8
testosterone enanthate im inj in oil 200 mg/ml.............. 8
TEST STRIPS – BAYER ASCENSIA AUTODISC,
BREEZE 2, CONTOUR, CONTOUR NEXT.................... 51
TEST STRIPS – ROCHE ACCU-CHEK ACTIVE, AVIVA,
AVIVA PLUS, COMPACT, SMARTVIEW........................ 51
TEST STRIPS – ROCHE ACCUTREND...........................51
THALOMID – thalidomide cap 100 mg............................. 52
THALOMID – thalidomide cap 50 mg............................... 52
theophylline tab sr 12hr 100 mg.................................... 24
thiothixene cap 10 mg.................................................... 31
thiothixene cap 1 mg...................................................... 31
timolol maleate ophth gel forming soln 0.25%
(Timoptic-xe).................................................................. 47
timolol maleate ophth gel forming soln 0.5%
(Timoptic-xe).................................................................. 47
timolol maleate ophth soln 0.25% (Timoptic)............... 47
timolol maleate ophth soln 0.5% (Timoptic)................. 47
TIMOLOL MALEATE – timolol maleate tab 10 mg............16
TIMOLOL MALEATE – timolol maleate tab 20 mg............16
TIMOLOL MALEATE – timolol maleate tab 5 mg..............16
TIVICAY – dolutegravir sodium tab 50 mg (base equiv)......5
78
tizanidine hcl tab 2 mg (base equivalent)..................... 40
tizanidine hcl tab 4 mg (base equivalent)
(Zanaflex)........................................................................ 40
TOBRADEX – tobramycin-dexamethasone ophth oint
0.3-0.1%...........................................................................47
tobramycin-dexamethasone ophth susp 0.3-0.1%
(Tobradex)...................................................................... 47
tobramycin nebu soln 300 mg/5ml (Tobi)....................... 3
tobramycin ophth soln 0.3% (Tobrex)........................... 46
tolterodine tartrate cap sr 24hr 2 mg (Detrol la)........... 26
tolterodine tartrate cap sr 24hr 4 mg (Detrol la)........... 26
tolterodine tartrate tab 1 mg (Detrol).............................26
tolterodine tartrate tab 2 mg (Detrol).............................26
topiramate sprinkle cap 15 mg (Topamax sprinkle)..... 39
topiramate sprinkle cap 25 mg (Topamax sprinkle)..... 39
topiramate tab 100 mg (Topamax).................................39
topiramate tab 200 mg (Topamax).................................39
topiramate tab 25 mg (Topamax)...................................39
topiramate tab 50 mg (Topamax)...................................39
torsemide tab 100 mg (Demadex)..................................20
torsemide tab 10 mg (Demadex)....................................20
torsemide tab 20 mg (Demadex)....................................20
torsemide tab 5 mg (Demadex)......................................20
TOUJEO SOLOSTAR – insulin glargine soln pen-injector
300 unit/ml....................................................................... 12
TRACLEER – bosentan tab 125 mg................................. 21
TRACLEER – bosentan tab 62.5 mg................................ 21
tramadol-acetaminophen tab 37.5-325 mg
(Ultracet)......................................................................... 36
tramadol hcl tab 50 mg (Ultram).................................... 36
tramadol hcl tab sr 24hr 100 mg (Ultram er).................36
trandolapril tab 1 mg (Mavik)......................................... 14
tranylcypromine sulfate tab 10 mg (Parnate)............... 29
TRAVATAN Z – travoprost ophth soln 0.004%
(benzalkonium free) (bak free)........................................ 47
trazodone hcl tab 100 mg...............................................29
trazodone hcl tab 50 mg.................................................29
tretinoin cap 10 mg...........................................................7
tretinoin cream 0.025% (Retin-a)................................... 49
tretinoin cream 0.05% (Retin-a)..................................... 49
tretinoin cream 0.1% (Retin-a)....................................... 49
tretinoin gel 0.01% (Retin-a)...........................................49
tretinoin gel 0.025% (Retin-a).........................................49
tretinoin microsphere gel 0.04% (Retin-a micro)..........49
tretinoin microsphere gel 0.1% (Retin-a micro)............49
TRETTEN – coagulation factor xiii a-subunit for inj
2000-3125 unit.................................................................46
TREXALL – methotrexate sodium tab 10 mg (base
equiv)................................................................................. 7
2015
equiv)................................................................................. 7
equiv)................................................................................. 7
TREXALL – methotrexate sodium tab 7.5 mg (base
equiv)................................................................................. 7
triamcinolone acetonide cream 0.025%........................ 50
triamcinolone acetonide cream 0.1%............................ 50
triamcinolone acetonide cream 0.5%............................ 50
triamcinolone acetonide dental paste 0.1%.................. 48
triamcinolone acetonide lotion 0.025%......................... 50
triamcinolone acetonide lotion 0.1%............................. 50
triamcinolone acetonide nasal aerosol suspension 55
mcg/act (Nasacort aq)................................................... 22
triamcinolone acetonide oint 0.025%............................ 50
triamcinolone acetonide oint 0.1%................................ 50
triamterene & hydrochlorothiazide cap 37.5-25 mg
(Dyazide)......................................................................... 20
triamterene & hydrochlorothiazide tab 37.5-25 mg
(Maxzide-25)................................................................... 20
triamterene & hydrochlorothiazide tab 75-50 mg
(Maxzide).........................................................................20
trifluoperazine hcl tab 10 mg......................................... 31
trifluoperazine hcl tab 1 mg........................................... 31
trifluridine ophth soln 1% (Viroptic).............................. 46
trihexyphenidyl hcl elixir 0.4 mg/ml.............................. 40
trihexyphenidyl hcl tab 2 mg......................................... 40
trihexyphenidyl hcl tab 5 mg......................................... 40
trimethobenzamide hcl cap 300 mg (Tigan)..................25
trimethoprim tab 100 mg.................................................. 6
tropicamide ophth soln 0.5%......................................... 48
tropicamide ophth soln 1% (Mydriacyl)........................ 48
TRUVADA – emtricitabine-tenofovir disoproxil fumarate
tab 200-300 mg................................................................. 5
U
ursodiol cap 300 mg (Actigall).......................................26
ursodiol tab 250 mg (Urso 250)..................................... 26
ursodiol tab 500 mg (Urso forte)................................... 26
V
VAGIFEM – estradiol vaginal tab 10 mcg......................... 27
valacyclovir hcl tab 1 gm (Valtrex).................................. 4
valacyclovir hcl tab 500 mg (Valtrex).............................. 4
VALCHLOR – mechlorethamine hcl gel 0.016% (base
equivalent)....................................................................... 51
VALCYTE – valganciclovir hcl for soln 50 mg/ml (base
equiv)................................................................................. 3
VALCYTE – valganciclovir hcl tab 450 mg (base
equivalent)......................................................................... 3
valganciclovir hcl tab 450 mg (base equivalent)
(Valcyte)............................................................................ 3
valproate sodium syrup 250 mg/5ml (base equiv)
(Depakene)......................................................................39
valproic acid cap 250 mg (Depakene)........................... 39
valsartan-hydrochlorothiazide tab 160-12.5 mg
(Diovan hct)....................................................................15
valsartan-hydrochlorothiazide tab 160-25 mg (Diovan
hct).................................................................................. 15
valsartan-hydrochlorothiazide tab 320-12.5 mg
(Diovan hct).................................................................... 15
valsartan-hydrochlorothiazide tab 320-25 mg (Diovan
hct).................................................................................. 15
valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan
hct).................................................................................. 15
valsartan tab 160 mg (Diovan)....................................... 15
valsartan tab 320 mg (Diovan)....................................... 15
valsartan tab 40 mg (Diovan)......................................... 15
valsartan tab 80 mg (Diovan)......................................... 15
vancomycin hcl cap 125 mg (Vancocin hcl)................... 6
vancomycin hcl cap 250 mg (Vancocin hcl)................... 6
venlafaxine hcl cap sr 24hr 150 mg (base equivalent)
(Effexor xr)..................................................................... 29
venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent)
(Effexor xr)..................................................................... 29
venlafaxine hcl cap sr 24hr 75 mg (base equivalent)
(Effexor xr)..................................................................... 29
venlafaxine hcl tab 100 mg............................................ 29
venlafaxine hcl tab 25 mg.............................................. 29
venlafaxine hcl tab 37.5 mg........................................... 29
venlafaxine hcl tab sr 24hr 150 mg (base equivalent)
(Venlafaxine hcl er)....................................................... 29
venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent)
venlafaxine hcl tab sr 24hr 75 mg (base equivalent)
VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv).........................................................24
verapamil hcl cap sr 24hr 120 mg (Verelan)................. 18
verapamil hcl tab 120 mg (Calan).................................. 18
verapamil hcl tab 80 mg (Calan).................................... 18
verapamil hcl tab cr 120 mg (Calan sr)......................... 18
VESICARE – solifenacin succinate tab 10 mg.................. 27
VESICARE – solifenacin succinate tab 5 mg.................... 27
VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/
ml).................................................................................... 11
VIDEX – didanosine for soln 2 gm......................................5
VIDEX – didanosine for soln 4 gm......................................5
VIGAMOX – moxifloxacin hcl ophth soln 0.5% (base
equiv)............................................................................... 46
VIRACEPT – nelfinavir mesylate tab 250 mg..................... 5
VIRACEPT – nelfinavir mesylate tab 625 mg..................... 5
VIRAMUNE – nevirapine susp 50 mg/5ml.......................... 5
79
2015
VIRAMUNE XR – nevirapine tab sr 24hr 100 mg............... 5
VIREAD – tenofovir disoproxil fumarate oral powder 40
mg/gm................................................................................ 5
VIREAD – tenofovir disoproxil fumarate tab 150 mg........... 5
VOLTAREN – diclofenac sodium gel 1%.......................... 49
voriconazole for susp 40 mg/ml (Vfend)......................... 3
voriconazole tab 200 mg (Vfend).....................................3
voriconazole tab 50 mg (Vfend).......................................3
VOTRIENT – pazopanib hcl tab 200 mg (base equiv)........ 7
VYVANSE – lisdexamfetamine dimesylate cap 10 mg......32
W
warfarin sodium tab 10 mg (Coumadin)........................46
warfarin sodium tab 1 mg (Coumadin)..........................46
warfarin sodium tab 2.5 mg (Coumadin).......................46
warfarin sodium tab 7.5 mg (Coumadin).......................46
WELCHOL – colesevelam hcl packet for susp 3.75
gm.................................................................................... 19
WELCHOL – colesevelam hcl tab 625 mg........................19
WILATE – antihemophilic factor/vwf (human) for inj
1000-1000 unit.................................................................46
WILATE – antihemophilic factor/vwf (human) for inj
500-500 unit.....................................................................46
X
XALKORI – crizotinib cap 200 mg...................................... 7
XALKORI – crizotinib cap 250 mg...................................... 8
XARELTO – rivaroxaban tab 10 mg................................. 46
XARELTO STARTER PACK – rivaroxaban tab starter
therapy pack 15 mg & 20 mg..........................................46
XERAC AC – aluminum chloride in alcohol solution
6.25%...............................................................................51
XIFAXAN – rifaximin tab 550 mg........................................ 6
XYNTHA – antihemophilic factor recombinant paf for inj kit
1000 unit..........................................................................46
2000 unit..........................................................................46
250 unit............................................................................46
80
500 unit............................................................................46
XYNTHA SOLOFUSE – antihemophilic factor recombinant
paf for inj kit 1000 unit.................................................... 46
paf for inj kit 250 unit...................................................... 46
paf for inj kit 500 unit...................................................... 46
Y
Z
zafirlukast tab 10 mg (Accolate).................................... 24
zafirlukast tab 20 mg (Accolate).................................... 24
zaleplon cap 10 mg (Sonata)..........................................31
zaleplon cap 5 mg (Sonata)........................................... 31
ZELBORAF – vemurafenib tab 240 mg.............................. 8
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
10000-34000-55000 unit..................................................26
15000-51000-82000 unit..................................................26
20000-68000-109000 unit................................................26
25000-85000-136000 unit................................................26
3000-10000-16000 unit....................................................26
40000-136000-218000 unit..............................................26
5000-17000-27000 unit....................................................26
ZIAGEN – abacavir sulfate soln 20 mg/ml (base equiv)...... 5
zidovudine cap 100 mg (Retrovir)................................... 5
zidovudine syrup 10 mg/ml (Retrovir).............................5
zidovudine tab 300 mg..................................................... 5
ziprasidone hcl cap 20 mg (Geodon)............................ 31
zolpidem tartrate tab 10 mg (Ambien)...........................31
zolpidem tartrate tab 5 mg (Ambien).............................31
zolpidem tartrate tab cr 12.5 mg (Ambien cr)............... 31
zolpidem tartrate tab cr 6.25 mg (Ambien cr)............... 31
zonisamide cap 100 mg (Zonegran).............................. 39
zonisamide cap 25 mg (Zonegran)................................ 39
zonisamide cap 50 mg....................................................39
ZORTRESS – everolimus tab 0.25 mg............................. 52
ZORTRESS – everolimus tab 0.5 mg............................... 52
ZORTRESS – everolimus tab 0.75 mg............................. 52
ZYCLARA – imiquimod cream 3.75%............................... 51
ZYCLARA PUMP – imiquimod cream 2.5%......................51
ZYCLARA PUMP – imiquimod cream 3.75%....................51
2015
ZYLET – loteprednol etabonate-tobramycin ophth susp
0.5-0.3%...........................................................................47
ZYTIGA – abiraterone acetate tab 250 mg......................... 8
ZYVOX – linezolid for susp 100 mg/5ml............................. 6
ZYVOX – linezolid tab 600 mg........................................... 6
81

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

Transcription

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