BCBSAL Individual Market Standard Drug List for October

Transcription

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October 2014
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List
Contents
Therapeutic Class Drug List
Introduction .................................................................... I
Anti-Infective Drugs...................................................... 1
How drugs are selected ................................................... I
Biologicals .................................................................. 17
Coverage considerations ................................................. I
Antineoplastic Agents ................................................ 20
Member Prescription Benefit .......................................... II
Endocrine and Metabolic Drugs................................. 24
Brand Drugs and Generic Drugs .................................... II
Cardiovascular Agents ............................................... 45
Affordable Care Act ........................................................ II
Respiratory Agents .................................................... 65
Compounds ................................................................... III
Gastrointestinal Agents .............................................. 75
Contraceptives ............................................................... III
Genitourinary Agents ................................................. 83
Specialty ........................................................................ III
Central Nervous System Drugs ................................. 86
Utilization Management ................................................. III
Analgesics and Anesthetics ..................................... 105
Step Therapy ................................................................. III
Neuromuscular Drugs .............................................. 120
Prior Authorization ......................................................... III
Nutritional Products.................................................. 129
Dispensing Limits........................................................... IV
Hematological Agents .............................................. 144
Notice ............................................................................. IV
Topical Products ...................................................... 153
Key ................................................................................. IV
Miscellaneous Products ........................................... 177
Index ........................................................................ 191
The Prescription Drug List is regularly updated. Please visit AlabamaBlue.com/pharmacy 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.
4157-F AL IVL © Prime Therapeutics LLC 10/14
Introduction
The attached Blue Cross and Blue Shield of Alabama Standard Prescription Drug List shows covered drugs for
a broad range of diseases.
Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand
drug in (parentheses). Some generic products have no reference brand.
Brand prescription drugs are shown in capital letters followed by the generic name.
The Blue Cross and Blue Shield of Alabama Standard Prescription Drug List is organized into broad categories
(e.g. Anti-Infective drugs). Within most categories, drugs are sub-grouped by drug class (e.g. Penicillins) or by
use for a specific medical condition (e.g. Diabetes).
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.
The current version of this Prescription Drug List is available at AlabamaBlue.com/pharmacy or by calling the
customer service number listed on back of your identification card. Online pharmacy tools are available at
AlabamaBlue.com/pharmacy. Blue Cross members can find drug cost estimates or check if a particular drug
is on the Standard Prescription Drug List.
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 the
health insurer or claims administrator of your health plan, 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.
Coverage Considerations
Most prescription drug benefit plans provide coverage for up to a 30- to 34-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 (example: Viagra) or infertility (example: Follistim AQ). You should refer to your
benefit plan booklet for details about your particular benefits.
I
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List, October 2014
Member Prescription Benefit
The Blue Cross prescription benefit is multi-tiered, placing prescription drugs into one of four tier levels;
Generic drugs (Tier 1), Preferred Brand drugs (Tier 2), Other Brand drugs (Tier 3) and Specialty drugs
(Tier 4). Coverage and copayment/co-insurance levels vary depending on the plan. Drugs that require
Prior Authorization, Step Therapy, or that have Dispensing Limits are noted in the Prescription Drug List.
• Generic drugs (Tier 1)
• Preferred Brand drugs (Tier 2)
• Other Brand drugs (Tier 3)
• Specialty drugs (Tier 4)
Brand Drugs and Generic Drugs
Classification
Prescription drugs are classified as either: (1) Brand drug or (2) Generic drug. The Brand/Generic
classification is linked to the copayment/co-insurance level or Tier. Blue Cross uses the Brand or Generic
status provided by a nationally recognized company providing drug product information. The
Brand/Generic status for a specific drug/specific marketer can sometimes change over the life of a
product in the marketplace and change from Brand to Generic or from Generic to Brand. Such changes
might change your copayment/co-insurance share. Brand drug or Generic drug status is never based
upon a product having a trade name. Generic drugs often have trade names.
Generic Substitution
Blue Cross encourages generic utilization as a way to provide high quality drugs at a reduced cost. Generic drugs
are as safe and effective as their brand counterparts, but are usually less expensive. Generic drugs are
manufactured under the same strict requirements of FDA’s current Good Manufacturing Practice regulations
required for Brand drugs and cover the manufacturing, and identity, strength, purity and quality.
An FDA-approved Generic drug may be substituted for the Brand counterpart when it:
• Contains the same active ingredient(s) as the brand drug;
• Is identical in strength, dosage form and route of administration; and
• Is therapeutically equivalent and can be expected to have the same clinical effect and safety profile.
Affordable Care Act
Please note, some drugs may have limited or $0 cost-sharing under the Affordable Care Act. Examples of
categories of drugs that may be subject to limited or $0 cost share include aspirin, breast cancer preventive,
fluoride supplements, folic acid supplements, gonorrhea prophylaxis (newborn), iron supplements, tobacco
cessation, vaccines, vitamin D supplements, and some contraceptive drugs and devices. If you do not find the
drug you are searching for, consult or contact Blue Cross to find out if the drug is available over the counter or is
covered under your medical benefit.
II
Compounds
Compounded prescriptions contain two or more drugs mixed together. These prescriptions are processed
according to member benefits. To be eligible for coverage, compounded medications must contain at least
one FDA-approved prescription ingredient and must not be a copy of a commercially available product. All
compounded medications are subject to review and may require prior authorization.
Contraceptives
If you have health coverage through your employer, some or all of the contraceptive methods or prescription
drugs listed in this Prescription Drug Guide may not be covered under your plan because of your employer’s
religious beliefs. To find out if contraceptive methods and prescription drugs are excluded, you may find this
information in the exclusions section of your benefit booklet or you may contact your group administrator.
Specialty
Specialty drugs are used in the treatment of medical conditions such as hepatitis, multiple sclerosis and
rheumatoid arthritis. Specialty drugs may be oral or injectable medications that can either be selfadministered or administered by a health care professional.
Some Blue Cross members must obtain their specialty drugs from Prime Therapeutics Specialty Pharmacy.
If the preferred provider is not utilized you may be responsible for up to 100 percent of the drug cost.
Utilization Management
Blue Cross is committed to supporting proper selection and use of drugs for its members. To help assure
these goals are met, several programs have been developed to promote drug selection that encourages both
effectiveness and safety. Detailed coverage criteria can be found at AlabamaBlue.com/pharmacy. Drugs
requiring Prior Authorization or Step Therapy, or drugs with Dispensing Limits will be noted in the
Therapeutic Class Drug List portion of the Prescription Drug List.
Step Therapy
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. If step
therapy is required for a medication listed in this document, it will be noted next to the medication with a dot
under the step therapy column.
Prior Authorization
Your benefit plan may require prior authorization for certain drugs that are high-cost or have the potential for
misuse. 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. If prior authorization is required for a medication listed in this document, it will be noted next to the
medication with a dot under the prior authorization column.
III
Dispensing Limits
Drug dispensing limits help encourage medication use as intended by the FDA. Dispensing limits are placed on
medications in certain drug categories. For the medications listed in this document, if a dispensing limit applies,
it will be noted next to the medication with a dot under the dispensing limits column.
Limits may include: quantity of covered medication per prescription and/or quantity of covered medication in a
given time period. 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
AlabamaBlue.com/pharmacy.
There may also be limits for members within a certain age range, and coverage only for members of a
specific gender.
Notice
The purpose of the Blue Cross and Blue Shield of Alabama Standard Prescription Drug List is to provide a
guide to coverage. This Standard Prescription Drug List is not intended to dictate to physicians how to
practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most
appropriate for their patients.
Drug List, nor the successful adjudication of a pharmacy claim, is guarantee of payment
Key
cap ................................................................. capsules
odt. ....................................... orally disintegrating tabs
chew ............................................................. chewable
oint ................................................................ ointment
conc ..........................................................concentrate
ophth ............................................................ opthalmic
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
IV
ANTI-INFECTIVE AGENTS
PENICILLINS
AMOXICILLIN ER - amoxicillin
(trihydrate) tab sr 24hr 775 mg
3
AMOXICILLIN - amoxicillin (trihydrate)
chew tab 125 mg
3
AMPICILLIN - ampicillin for susp 125
mg/5ml
3
AMOXICILLIN - amoxicillin (trihydrate)
chew tab 250 mg
3
AMPICILLIN - ampicillin for susp 250
mg/5ml
3
amoxicillin (trihydrate) cap 250 mg
1
1
amoxicillin (trihydrate) cap 500 mg
1
ampicillin & sulbactam sodium for
inj 1-0.5 gm (Unasyn)
1
inj 10-5 gm (Unasyn bulk pack)
1
amoxicillin (trihydrate) for susp
125 mg/5ml
1
inj 2-1 gm (Unasyn)
1
200 mg/5ml
1
ampicillin & sulbactam sodium for iv
soln 1-0.5 gm
1
250 mg/5ml
1
ampicillin & sulbactam sodium for iv
soln 10-5 gm
1
400 mg/5ml
1
ampicillin cap 250 mg
1
amoxicillin (trihydrate) tab 500 mg
1
ampicillin cap 500 mg
1
amoxicillin (trihydrate) tab 875 mg
1
AMPICILLIN SODIUM - ampicillin
sodium for inj 125 mg
3
amoxicillin & k clavulanate chew tab
200-28.5 mg
1
sodium for iv soln 1 gm
3
amoxicillin & k clavulanate chew tab
400-57 mg
1
3
amoxicillin & k clavulanate for susp
200-28.5 mg/5ml
1
sodium for inj 10 gm
1
250-62.5 mg/5ml (Augmentin)
1
ampicillin sodium for inj 1 gm
1
400-57 mg/5ml
ampicillin sodium for inj 125 mg
1
ampicillin sodium for inj 2 gm
1
1
1
ampicillin sodium for iv soln 10 gm
1
1
600-42.9 mg/5ml (Augmentin es-600)
1
amoxicillin & k clavulanate tab sr
12hr 1000-62.5 mg (Augmentin xr)
1
amoxicillin & k clavulanate tab
250-125 mg
1
500-125 mg (Augmentin)
1
875-125 mg (Augmentin)
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
AMPICILLIN-SULBACTAM - ampicillin & 3
sulbactam sodium for iv soln 2-1 gm
3
AUGMENTIN - amoxicillin & k
clavulanate tab 500-125 mg
3
clavulanate tab 875-125 mg
Blue Cross and Blue Shield of Alabama Standard Prescription Drug List October 2014
1
clavulanate for susp 125-31.25
mg/5ml
3
PENICILLIN G PROCAINE - penicillin g
procaine intramuscular susp 600000
unit/ml
3
clavulanate for susp 250-62.5 mg/5ml
3
PENICILLIN G SODIUM - penicillin g
sodium for inj 5000000 unit
3
AUGMENTIN ES-600 - amoxicillin & k
clavulanate for susp 600-42.9 mg/5ml
3
penicillin v potassium for soln
125 mg/5ml
1
AUGMENTIN XR - amoxicillin & k
clavulanate tab sr 12hr 1000-62.5 mg
3
penicillin v potassium for soln
250 mg/5ml
1
BICILLIN C-R - penicillin g benzathine &
procaine inj susp 1200000 unit/2ml
3
penicillin v potassium tab 250 mg
1
penicillin v potassium tab 500 mg
1
BICILLIN C-R - penicillin g benzathine &
procaine inj 900000-300000 unt/2ml
3
PFIZERPEN-G - penicillin g potassium
for inj 5000000 unit
3
BICILLIN L-A - penicillin g benzathine
intramuscular susp 600000 unit/ml
3
PFIZERPEN-G - penicillin g potassium
for inj 20000000 unit
3
intramuscular susp 1200000 unit/2ml
3
piperacillin sodium-tazobactam
sodium for inj 2-0.25 gm (Zosyn)
1
intramuscular susp 2400000 unit/4ml
3
1
dicloxacillin sodium cap 250 mg
1
dicloxacillin sodium cap 500 mg
1
1
MOXATAG - amoxicillin (trihydrate) tab
sr 24hr 775 mg
3
1
NAFCILLIN SODIUM - nafcillin sodium
for iv soln 1 gm
3
NAFCILLIN SODIUM - nafcillin sodium
for iv soln 2 gm
3
nafcillin sodium for inj 1 gm
1
1
1
oxacillin sodium for inj 1 gm
1
1
1
penicillin g potassium for inj
20000000 unit (Pfizerpen-g)
1
penicillin g potassium for inj
5000000 unit (Pfizerpen-g)
1
TIMENTIN - ticarcillin & k clavulanate for 3
inj 3.1 gm
TIMENTIN - ticarcillin & k clavulanate for 3
inj 31 gm
3
UNASYN - ampicillin & sulbactam
sodium for inj 1-0.5 gm
3
sodium for iv soln 1-0.5 gm
3
sodium for inj 2-1 gm
3
UNASYN ADD-VANTAGE - ampicillin
& sulbactam sodium for iv soln 1-0.5
gm
UNASYN ADD-VANTAGE - ampicillin & 3
sulbactam sodium for iv soln 2-1 gm
3
UNASYN BULK PACK - ampicillin &
sulbactam sodium for inj 10-5 gm
2
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
3
ZOSYN - piperacillin sodiumtazobactam sodium for inj 3-0.375 gm
3
3
3
CEPHALOSPORINS
cefdinir for susp 250 mg/5ml
1
CEFDITOREN PIVOXIL - cefditoren
pivoxil tab 200 mg (base equivalent)
3
CEFDITOREN PIVOXIL - cefditoren
pivoxil tab 400 mg (base equivalent)
3
cefepime hcl for inj 1 gm (Maxipime)
1
cefepime hcl for inj 2 gm (Maxipime)
1
cefotaxime sodium for inj 1 gm
(Claforan)
1
CEDAX - ceftibuten cap 400 mg
3
CEDAX - ceftibuten for susp 90 mg/5ml
3
CEDAX - ceftibuten for susp 180
mg/5ml
(Claforan)
1
3
CEFACLOR - cefaclor for susp 125
mg/5ml
(Claforan)
1
3
3
cefotaxime sodium for inj 500 mg
(Claforan)
1
mg/5ml
3
CEFOTETAN - cefotetan disodium for
inj 1 gm
3
mg/5ml
cefaclor cap 250 mg
inj 2 gm
3
1
cefaclor cap 500 mg
1
3
CEFACLOR ER - cefaclor monohydrate
tab sr 12hr 500 mg
3
inj 10 gm
cefoxitin sodium for inj 1 gm
1
cefadroxil cap 500 mg
1
1
cefadroxil for susp 250 mg/5ml
1
1
cefadroxil for susp 500 mg/5ml
1
1
cefadroxil tab 1 gm
1
cefpodoxime proxetil for susp
100 mg/5ml
CEFAZOLIN SODIUM - cefazolin
3
cefpodoxime proxetil for susp
50 mg/5ml
1
sodium (bulk) for inj 100 gm
3
cefpodoxime proxetil tab 100 mg
1
cefpodoxime proxetil tab 200 mg
1
3
cefprozil for susp 125 mg/5ml
1
cefprozil for susp 250 mg/5ml
1
cefazolin sodium for inj 1 gm
1
cefprozil tab 250 mg
1
1
cefprozil tab 500 mg
1
1
cefazolin sodium for inj 500 mg
CEFTAZIDIME - ceftazidime (bulk) for
inj 100 gm
3
1
cefdinir cap 300 mg
1
ceftazidime for inj 1 gm (Fortaz)
1
Dispensing Limits
1
Step Therapy
cefdinir for susp 125 mg/5ml
Prior Authorization
Dispensing Limits
Step Therapy
Drug Name
Drug Tier
Prior Authorization
Drug Name
Drug Tier
2014
3
1
1
cefuroxime sodium for iv soln 1.5 gm
(Zinacef)
ceftazidime for iv soln 1 gm (Fortaz)
1
CEPHALEXIN - cephalexin tab 250 mg
3
ceftazidime for iv soln 2 gm (Fortaz)
1
CEPHALEXIN - cephalexin tab 500 mg
3
CEFTIBUTEN - ceftibuten cap 400 mg
3
cephalexin cap 250 mg (Keflex)
1
CEFTIBUTEN - ceftibuten for susp 180
mg/5ml
3
1
1
CEFTIN - cefuroxime axetil tab 250 mg
3
cephalexin for susp 125 mg/5ml
1
CEFTIN - cefuroxime axetil tab 500 mg
3
cephalexin for susp 250 mg/5ml
1
CEFTIN - cefuroxime axetil for susp 125
mg/5ml
3
CLAFORAN - cefotaxime sodium for inj
500 mg
3
CEFTIN - cefuroxime axetil for susp 250
mg/5ml
3
1 gm
3
ceftriaxone sodium for inj 1 gm
(Rocephin)
1
CLAFORAN - cefotaxime sodium for iv
soln 1 gm
3
1
3
1
2 gm
ceftriaxone sodium for inj 250 mg
1
3
ceftriaxone sodium for inj 500 mg
(Rocephin)
1
CLAFORAN - cefotaxime sodium for iv
soln 2 gm
3
ceftriaxone sodium for iv soln 1 gm
1
10 gm
1
FORTAZ - ceftazidime for inj 500 mg
3
ceftriaxone sodium for iv soln 2 gm
1
FORTAZ - ceftazidime for inj 1 gm
3
cefuroxime axetil for susp
125 mg/5ml (Ceftin)
FORTAZ - ceftazidime for iv soln 1 gm
3
cefuroxime axetil tab 250 mg (Ceftin)
1
3
cefuroxime axetil tab 500 mg (Ceftin)
1
FORTAZ - ceftazidime for iv soln 2 gm
3
CEFUROXIME SODIUM - cefuroxime
sodium for iv soln 7.5 gm
3
3
KEFLEX - cephalexin cap 250 mg
3
3
3
3
3
MAXIPIME - cefepime hcl for inj 1 gm
3
1
MAXIPIME - cefepime hcl for iv soln 1
gm
3
cefuroxime sodium for inj 1.5 gm
(Zinacef)
1
MAXIPIME - cefepime hcl for inj 2 gm
3
cefuroxime sodium for inj 7.5 gm
(Zinacef)
3
cefuroxime sodium for inj 750 mg
(Zinacef)
1
MAXIPIME - cefepime hcl for iv soln 2
gm
ROCEPHIN - ceftriaxone sodium for inj
500 mg
3
4
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
1
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
ROCEPHIN - ceftriaxone sodium for inj
1 gm
3
BIAXIN - clarithromycin for susp 250
mg/5ml
3
SPECTRACEF - cefditoren pivoxil tab
200 mg (base equivalent)
3
BIAXIN XL - clarithromycin tab sr 24hr
500 mg
3
SPECTRACEF - cefditoren pivoxil tab
3
BIAXIN XL PAC - clarithromycin tab sr
24hr 500 mg
3
SUPRAX - cefixime cap 400 mg
2
clarithromycin for susp 125 mg/5ml
1
SUPRAX - cefixime tab 400 mg
2
1
SUPRAX - cefixime chew tab 100 mg
2
clarithromycin for susp 250 mg/5ml
(Biaxin)
SUPRAX - cefixime chew tab 200 mg
2
1
SUPRAX - cefixime for susp 100
mg/5ml
2
clarithromycin tab sr 24hr 500 mg
(Biaxin xl pac)
clarithromycin tab 250 mg (Biaxin)
1
mg/5ml
2
clarithromycin tab 500 mg (Biaxin)
1
DIFICID - fidaxomicin tab 200 mg
3
mg/5ml
2
E.E.S. GRANULES - erythromycin
ethylsuccinate for susp 200 mg/5ml
3
ZINACEF - cefuroxime sodium for inj
750 mg
3
E.E.S. 400 - erythromycin
ethylsuccinate tab 400 mg
3
ZINACEF - cefuroxime sodium for iv
soln 750 mg
3
ERY-TAB - erythromycin tab delayed
release 250 mg
3
ZINACEF - cefuroxime sodium for inj 1.5 3
gm
3
ZINACEF - cefuroxime sodium for iv
soln 1.5 gm
ZINACEF - cefuroxime sodium for inj 7.5 3
gm
release 333 mg
3
release 500 mg
3
ERYPED 200 - erythromycin
3
MACROLIDES
3
AZITHROMYCIN - azithromycin powd
pack for susp 1 gm
3
ERYPED 400 - erythromycin
3
azithromycin for susp 100 mg/5ml
(Zithromax)
1
ERYTHROCIN STEARATE erythromycin stearate tab 250 mg
3
azithromycin for susp 200 mg/5ml
(Zithromax)
1
ERYTHROMYCIN - erythromycin w/
delayed release particles cap 250 mg
3
azithromycin tab 250 mg (Zithromax)
1
ERYTHROMYCIN BASE - erythromycin
tab 250 mg
1
3
1
ERYTHROMYCIN BASE - erythromycin
tab 500 mg
3
BIAXIN - clarithromycin tab 500 mg
3
ERYTHROMYCIN ETHYLSUCCINA erythromycin ethylsuccinate tab 400
mg
3
BIAXIN - clarithromycin tab 250 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
5
3
•
3
ALODOX CONVENIENCE KIT doxycycline hyclate tab 20 mg w/
eyelid cleansers kit
3
•
PCE - erythromycin w/ enteric coated
particles tab 500 mg
3
AVIDOXY DK - doxycycline tab 100 mg
& suncreen & sal acid wash 2% kit
demeclocycline hcl tab 150 mg
1
ZITHROMAX - azithromycin tab 250 mg
3
demeclocycline hcl tab 300 mg
1
3
3
•
3
DORYX - doxycycline hyclate tab
delayed release 150 mg
ZITHROMAX - azithromycin for susp
100 mg/5ml
3
DORYX - doxycycline hyclate tab
3
•
ZITHROMAX - azithromycin for susp
200 mg/5ml
3
3
•
ZITHROMAX - azithromycin powd pack
for susp 1 gm
3
DOXYCYCLINE HYCLATE doxycycline hyclate cap dr particles
100 mg
1
ZITHROMAX TRI-PAK - azithromycin
tab 500 mg
3
doxycycline hyclate cap 100 mg
(Vibramycin)
doxycycline hyclate cap 50 mg
1
ZITHROMAX Z-PAK - azithromycin tab
250 mg
3
doxycycline hyclate tab delayed
release 100 mg
1
•
ZMAX - azithromycin extended release
for oral susp 2 gm
3
release 150 mg (Doryx)
1
•
release 75 mg
1
•
doxycycline hyclate tab 100 mg
1
•
doxycycline hyclate tab 20 mg
1
1
•
doxycycline monohydrate cap
100 mg (Monodox)
1
•
doxycycline monohydrate cap
150 mg (Adoxa)
doxycycline monohydrate cap 50 mg
1
erythromycin w/ delayed release
particles cap 250 mg
1
PCE - erythromycin w/ enteric coated
particles tab 333 mg
TETRACYCLINES
•
ACTICLATE - doxycycline hyclate tab
75 mg
3
ACTICLATE - doxycycline hyclate tab
150 mg
3
ADOXA - doxycycline monohydrate cap
150 mg
3
ADOXA - doxycycline monohydrate tab
50 mg
3
75 mg
3
•
doxycycline monohydrate cap 75 mg
(Monodox)
1
100 mg
3
•
doxycycline monohydrate for susp
25 mg/5ml (Vibramycin)
1
ADOXA PAK 1/100 - doxycycline
monohydrate tab 100 mg
3
•
doxycycline monohydrate tab
100 mg (Adoxa pak 1/100)
1
3
•
doxycycline monohydrate tab
150 mg (Adoxa pak 1/150)
1
3
•
doxycycline monohydrate tab 50 mg
(Adoxa)
1
6
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
doxycycline monohydrate tab 75 mg
(Adoxa)
1
DYNACIN - minocycline hcl tab 50 mg
3
3
3
MINOCIN - minocycline hcl cap 50 mg
3
3
3
MINOCIN KIT - minocycline hcl cap 50
mg w/ acne care products kit
3
MINOCIN KIT - minocycline hcl cap 100
mg w/ acne care products kit
3
NUTRIDOX - doxycycline monohyd cap
75 mg w/ omega 3-vit e cap kit
3
•
OCUDOX - doxycycline hyclate cap 50
mg & eyelid cleans & spray kit
3
•
ORAXYL - doxycycline hyclate cap 20
mg
3
•
SOLODYN - minocycline hcl tab sr 24hr
45 mg
3
•
55 mg
3
•
65 mg
3
•
80 mg
3
•
90 mg
3
•
105 mg
3
•
115 mg
3
•
135 mg
3
•
3
•
TETRACYCLINE HCL - tetracycline hcl
cap 250 mg
3
•
TETRACYCLINE HCL - tetracycline hcl
cap 500 mg
3
•
•
VIBRAMYCIN - doxycycline
monohydrate for susp 25 mg/5ml
3
•
•
VIBRAMYCIN - doxycycline hyclate cap
100 mg
VIBRAMYCIN - doxycycline calcium
syrup 50 mg/5ml
3
•
•
•
•
•
•
•
•
•
minocycline hcl cap 100 mg (Minocin) 1
minocycline hcl cap 50 mg (Minocin) 1
minocycline hcl cap 75 mg (Minocin)
1
minocycline hcl tab sr 24hr 135 mg
1
1
1
minocycline hcl tab 100 mg
1
1
1
MONODOX - doxycycline monohydrate
cap 50 mg
3
cap 75 mg
3
cap 100 mg
3
MORGIDOX 1X100MG - doxycycline
hyclate cap 1 x 100 mg w/ cleanser
kit
3
MORGIDOX 2X100MG - doxycycline
hyclate cap 2 x 100 mg w/ cleanser
kit
3
NICAZELDOXY 30 KIT - doxycycline
monohyd tab 100 mg &multivit/
minerals tab kit
3
•
NICAZELDOXY 60 KIT - doxycycline
monohyd tab 100 mg &multivit/
minerals tab kit
3
•
•
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
FLUOROQUINOLONES
AVELOX - moxifloxacin hcl tab 400 mg
(base equiv)
3
AVELOX ABC PACK - moxifloxacin hcl
tab 400 mg (base equiv)
3
CIPRO - ciprofloxacin for oral susp 250
mg/5ml (5%) (5 gm/100ml)
3
7
CIPRO - ciprofloxacin for oral susp 500
mg/5ml (10%) (10 gm/100ml)
3
LEVAQUIN - levofloxacin in d5w iv soln
500 mg/100ml
3
CIPRO - ciprofloxacin hcl tab 250 mg
(base equiv)
3
750 mg/150ml
3
CIPRO - ciprofloxacin hcl tab 500 mg
(base equiv)
3
levofloxacin in d5w iv soln
250 mg/50ml (Levaquin)
1
CIPRO XR - ciprofloxacin-ciprofloxacin
hcl tab sr 24hr 500 mg (base eq)
3
1
CIPRO XR - ciprofloxacin-ciprofloxacin
hcl tab sr 24hr 1000 mg(base eq)
3
1
ciprofloxacin for oral susp
250 mg/5ml (5%) (5 gm/100ml)
(Cipro)
1
levofloxacin iv soln 25 mg/ml
1
levofloxacin oral soln 25 mg/ml
(Levaquin)
1
ciprofloxacin for oral susp
500 mg/5ml (10%) (10 gm/100ml)
(Cipro)
1
levofloxacin tab 250 mg (Levaquin)
1
1
ciprofloxacin hcl tab 100 mg (base
equiv)
1
1
1
equiv) (Cipro)
1
moxifloxacin hcl tab 400 mg (base
equiv) (Avelox)
NOROXIN - norfloxacin tab 400 mg
3
equiv) (Cipro)
1
OFLOXACIN - ofloxacin tab 400 mg
1
ofloxacin tab 200 mg
1
equiv)
1
1
1
1
ciprofloxacin-ciprofloxacin hcl tab sr
24hr 1000 mg(base eq) (Cipro xr)
ciprofloxacin-ciprofloxacin hcl tab sr
24hr 500 mg (base eq) (Cipro xr)
1
AMIKACIN SULFATE - amikacin sulfate
inj 100 mg/2ml (50 mg/ml)
3
FACTIVE - gemifloxacin mesylate tab
320 mg (base equiv)
3
amikacin sulfate inj 1 gm/4ml
(250 mg/ml)
1
LEVAQUIN - levofloxacin tab 250 mg
3
1
3
amikacin sulfate inj 500 mg/2ml
(250 mg/ml)
3
LEVAQUIN - levofloxacin iv soln 25 mg/
ml
3
BETHKIS - tobramycin nebu soln 300
mg/4ml
4
gentamicin sulfate inj 10 mg/ml
1
3
gentamicin sulfate inj 40 mg/ml
1
LEVAQUIN - levofloxacin oral soln 25
mg/ml
gentamicin sulfate iv soln 10 mg/ml
1
250 mg/50ml
3
KANAMYCIN SULFATE - kanamycin
sulfate inj 333 mg/ml
3
8
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
AMINOGLYCOSIDES
•
NEO-FRADIN - neomycin sulfate soln
25 mg/ml
3
MYAMBUTOL - ethambutol hcl tab 400
mg
3
neomycin sulfate tab 500 mg
1
MYCOBUTIN - rifabutin cap 150 mg
3
paromomycin sulfate cap 250 mg
1
3
STREPTOMYCIN SULFATE streptomycin sulfate for inj 1 gm
3
PASER - aminosalicylic acid cr granules
packet 4 gm
PRIFTIN - rifapentine tab 150 mg
2
TOBI - tobramycin nebu soln 300
mg/5ml
4
•
pyrazinamide tab 500 mg
1
1
4
•
rifabutin cap 150 mg (Mycobutin)
TOBI PODHALER - tobramycin inhal
cap 28 mg
RIFADIN - rifampin cap 150 mg
3
4
•
RIFADIN - rifampin cap 300 mg
3
tobramycin nebu soln 300 mg/5ml
(Tobi)
3
tobramycin sulfate for inj 1.2 gm
1
RIFAMATE - isoniazid & rifampin cap
150-300 mg
1
rifampin cap 150 mg (Rifadin)
1
tobramycin sulfate inj 1.2 gm/30ml
(40 mg/ml)
rifampin cap 300 mg (Rifadin)
1
tobramycin sulfate inj 10 mg/ml
1
3
tobramycin sulfate inj 2 gm/50ml
(40 mg/ml)
1
RIFATER - isoniazid-rifampin w/
pyrazinamide tab 50-120-300 mg
SEROMYCIN - cycloserine cap 250 mg
3
tobramycin sulfate inj 80 mg/2ml
(40 mg/ml)
1
SIRTURO - bedaquiline fumarate tab
100 mg (base equiv)
3
TRECATOR - ethionamide tab 250 mg
3
SULFONAMIDES
SULFADIAZINE - sulfadiazine tab 500
mg
3
ANTIMYCOBACTERIAL AGENTS
CAPASTAT SULFATE - capreomycin
sulfate for inj 1 gm
3
CYCLOSERINE - cycloserine cap 250
mg
3
ethambutol hcl tab 100 mg
(Myambutol)
1
ethambutol hcl tab 400 mg
(Myambutol)
1
ISONIAZID - isoniazid syrup 50 mg/5ml
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
ANTIFUNGALS
nystatin oral powder
1
AMPHOTERICIN B - amphotericin b for
inj 50 mg
3
ANCOBON - flucytosine cap 250 mg
3
ANCOBON - flucytosine cap 500 mg
3
BIO-STATIN - nystatin cap 500000 unit
3
BIO-STATIN - nystatin cap 1000000 unit 3
3
DIFLUCAN - fluconazole tab 50 mg
3
3
3
ISONIAZID - isoniazid inj 100 mg/ml
3
3
isoniazid & rifampin cap 150-300 mg
1
3
isoniazid tab 100 mg
1
DIFLUCAN - fluconazole for susp 10
mg/ml
1
MYAMBUTOL - ethambutol hcl tab 100
mg
3
DIFLUCAN - fluconazole for susp 40
mg/ml
3
isoniazid tab 300 mg
9
fluconazole for susp 10 mg/ml
(Diflucan)
1
LAMISIL - terbinafine hcl oral granules
packet 187.5 mg
3
fluconazole for susp 40 mg/ml
(Diflucan)
1
NOXAFIL - posaconazole tab delayed
release 100 mg
3
fluconazole in dextrose inj
200 mg/100ml
1
NOXAFIL - posaconazole susp 40 mg/
ml
2
fluconazole in dextrose inj
400 mg/200ml
1
nystatin tab 500000 unit
1
ONMEL - itraconazole tab 200 mg
3
FLUCONAZOLE IN NACL - fluconazole
in nacl 0.9% inj 100 mg/50ml
3
SPORANOX - itraconazole cap 100 mg
3
1
SPORANOX - itraconazole oral soln 10
mg/ml
3
fluconazole in nacl 0.9% inj
200 mg/100ml
1
SPORANOX PULSEPAK - itraconazole
cap 100 mg
3
fluconazole in nacl 0.9% inj
400 mg/200ml
1
terbinafine hcl tab 250 mg (Lamisil)
1
fluconazole tab 100 mg (Diflucan)
1
VFEND - voriconazole tab 50 mg
3
1
VFEND - voriconazole tab 200 mg
3
1
VFEND - voriconazole for susp 40 mg/
ml
3
flucytosine cap 250 mg (Ancobon)
1
flucytosine cap 500 mg (Ancobon)
voriconazole for susp 40 mg/ml
(Vfend)
1
1
GRIFULVIN V - griseofulvin microsize
tab 500 mg
3
voriconazole tab 200 mg (Vfend)
1
voriconazole tab 50 mg (Vfend)
1
GRIS-PEG - griseofulvin ultramicrosize
tab 125 mg
3
GRIS-PEG - griseofulvin ultramicrosize
tab 250 mg
3
griseofulvin microsize susp
125 mg/5ml
1
griseofulvin microsize tab 500 mg
(Grifulvin v)
1
griseofulvin ultramicrosize tab
125 mg (Gris-peg)
1
griseofulvin ultramicrosize tab
250 mg (Gris-peg)
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
ANTIVIRALS
abacavir sulfate tab 300 mg (base
equiv) (Ziagen)
1
•
abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg
(Trizivir)
1
•
acyclovir cap 200 mg (Zovirax)
1
acyclovir susp 200 mg/5ml (Zovirax)
1
acyclovir tab 400 mg (Zovirax)
1
1
acyclovir tab 800 mg (Zovirax)
1
1
itraconazole cap 100 mg (Sporanox)
1
adefovir dipivoxil tab 10 mg
(Hepsera)
ketoconazole tab 200 mg
1
APTIVUS - tipranavir cap 250 mg
2
LAMISIL - terbinafine hcl tab 250 mg
3
2
LAMISIL - terbinafine hcl oral granules
packet 125 mg
3
APTIVUS - tipranavir oral soln 100 mg/
ml
10
•
•
FAMVIR - famciclovir tab 125 mg
3
3
3
FLUMADINE - rimantadine
hydrochloride tab 100 mg
3
FUZEON - enfuvirtide for inj 90 mg
4
HEPSERA - adefovir dipivoxil tab 10 mg
3
Dispensing Limits
Drug Tier
•
Step Therapy
Drug Name
Prior Authorization
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
ATRIPLA - efavirenz-emtricitabinetenofovir df tab 600-200-300 mg
2
BARACLUDE - entecavir tab 0.5 mg
2
BARACLUDE - entecavir tab 1 mg
2
BARACLUDE - entecavir oral soln 0.05
mg/ml
2
COMBIVIR - lamivudine-zidovudine tab
150-300 mg
3
•
2
•
INCIVEK - telaprevir tab 375 mg
4
COMPLERA - emtricitabine-rilpivirinetenofovir df tab 200-25-300 mg
4
COPEGUS - ribavirin tab 200 mg
4
INFERGEN - interferon alfacon-1 inj 9
mcg/0.3ml
2
•
INFERGEN - interferon alfacon-1 inj 15
mcg/0.5ml
4
CRIXIVAN - indinavir sulfate cap 200
mg
2
•
INTELENCE - etravirine tab 25 mg
2
CRIXIVAN - indinavir sulfate cap 400
mg
2
didanosine delayed release capsule
125 mg (Videx ec)
1
•
2
2
200 mg (Videx ec)
1
•
INVIRASE - saquinavir mesylate cap
200 mg
•
•
•
•
2
•
250 mg (Videx ec)
1
•
INVIRASE - saquinavir mesylate tab
500 mg
2
•
400 mg (Videx ec)
1
•
ISENTRESS - raltegravir potassium tab
400 mg (base equiv)
2
•
EDURANT - rilpivirine hcl tab 25 mg
(base equivalent)
2
•
ISENTRESS - raltegravir potassium
chew tab 25 mg (base equiv)
2
•
EMTRIVA - emtricitabine caps 200 mg
2
chew tab 100 mg (base equiv)
EMTRIVA - emtricitabine soln 10 mg/ml
2
2
•
EPIVIR - lamivudine tab 150 mg
3
packet for susp 100 mg (base equiv)
3
KALETRA - lopinavir-ritonavir tab
100-25 mg
2
EPIVIR - lamivudine tab 300 mg
•
EPIVIR - lamivudine oral soln 10 mg/ml
2
•
EPIVIR HBV - lamivudine tab 100 mg
KALETRA - lopinavir-ritonavir tab
200-50 mg
2
3
EPIVIR HBV - lamivudine oral soln 5
mg/ml
3
KALETRA - lopinavir-ritonavir soln
400-100 mg/5ml (80-20 mg/ml)
2
•
EPZICOM - abacavir sulfate-lamivudine
tab 600-300 mg
2
lamivudine tab 100 mg (Epivir hbv)
1
lamivudine tab 150 mg (Epivir)
1
famciclovir tab 125 mg (Famvir)
1
lamivudine tab 300 mg (Epivir)
1
1
lamivudine-zidovudine tab
150-300 mg (Combivir)
1
1
•
•
•
•
•
•
•
•
•
•
•
11
•
PEG-INTRON REDIPEN PAK 4 peginterferon alfa-2b for inj kit 120
mcg/0.5ml
4
•
mcg/0.5ml
4
•
•
PEGASYS - peginterferon alfa-2a inj
180 mcg/ml
4
•
1
•
PEGASYS - peginterferon alfa-2a inj
180 mcg/0.5ml
4
•
1
PEGASYS - peginterferon alfa-2a inj kit
180 mcg/0.5ml
•
NORVIR - ritonavir cap 100 mg
2
•
NORVIR - ritonavir tab 100 mg
PEGASYS PROCLICK - peginterferon
alfa-2a inj 135 mcg/0.5ml
4
2
NORVIR - ritonavir oral soln 80 mg/ml
2
•
•
•
•
4
nevirapine tab 200 mg (Viramune)
4
•
OLYSIO - simeprevir sodium cap 150
mg (base equivalent)
4
PEGASYS PROCLICK - peginterferon
alfa-2a inj 180 mcg/0.5ml
2
•
LEXIVA - fosamprenavir calcium susp
50 mg/ml (base equiv)
2
•
MODERIBA - ribavirin tab 200 mg &
ribavirin tab 400 mg dose pack
4
MODERIBA - ribavirin tab 400 mg &
4
MODERIBA 1200 DOSE PACK ribavirin tab 600 mg
4
MODERIBA 800 DOSE PACK - ribavirin
tab 400 mg
4
NEVIRAPINE - nevirapine susp 50
mg/5ml
3
nevirapine tab sr 24hr 400 mg
(Viramune xr)
PEG-INTRON - peginterferon alfa-2b for 4
inj kit 50 mcg/0.5ml
PEG-INTRON REDIPEN - peginterferon 4
alfa-2b for inj kit 50 mcg/0.5ml
12
•
•
•
•
•
•
•
Dispensing Limits
Prior Authorization
4
LEXIVA - fosamprenavir calcium tab
700 mg (base equiv)
Drug Name
Step Therapy
Drug Tier
mcg/0.5ml
Dispensing Limits
•
Step Therapy
4
Drug Tier
mcg/0.5ml
Drug Name
Prior Authorization
2014
PREZISTA - darunavir ethanolate tab 75 2
mg (base equiv)
2
PREZISTA - darunavir ethanolate tab
150 mg (base equiv)
2
400 mg (base equiv)
2
600 mg (base equiv)
2
800 mg (base equiv)
2
PREZISTA - darunavir ethanolate susp
100 mg/ml (base equiv)
4
REBETOL - ribavirin cap 200 mg
•
•
•
•
•
•
REBETOL - ribavirin soln 40 mg/ml
4
RELENZA DISKHALER - zanamivir
aero powder breath activated 5 mg/
blister
3
•
•
RESCRIPTOR - delavirdine mesylate
tab 100 mg
2
•
RETROVIR - zidovudine cap 100 mg
3
RETROVIR - zidovudine tab 300 mg
3
•
•
•
RETROVIR - zidovudine syrup 10 mg/ml 3
2
REYATAZ - atazanavir sulfate cap 100
mg (base equiv)
2
mg (base equiv)
2
mg (base equiv)
2
mg (base equiv)
4
RIBASPHERE - ribavirin tab 400 mg
Dispensing Limits
stavudine cap 15 mg (Zerit)
Step Therapy
•
Prior Authorization
2
Drug Tier
RESCRIPTOR - delavirdine mesylate
tab 200 mg
Step Therapy
Drug Name
Drug Name
Drug Tier
Dispensing Limits
Prior Authorization
2014
1
1
1
1
stavudine for oral soln 1 mg/ml
(Zerit)
1
•
•
•
•
•
STRIBILD - elvitegrav-cobicisemtricitab-tenofov tab
150-150-200-300 mg
2
•
•
•
SUSTIVA - efavirenz cap 50 mg
2
SUSTIVA - efavirenz cap 200 mg
2
SUSTIVA - efavirenz tab 600 mg
2
TAMIFLU - oseltamivir phosphate cap
30 mg (base equiv)
2
•
•
•
•
•
RIBASPHERE - ribavirin tab 600 mg
4
•
4
45 mg (base equiv)
2
RIBASPHERE RIBAPAK - ribavirin tab
400 mg
•
600 mg
75 mg (base equiv)
2
4
•
200 mg & ribavirin tab 400 mg dose
pack
TAMIFLU - oseltamivir phosphate for
susp 6 mg/ml (base equiv)
2
4
TAMIFLU - oseltamivir phosphate for
susp 12 mg/ml (base equiv)
3
400 mg & ribavirin tab 600 mg dose
pack
4
TIVICAY - dolutegravir sodium tab 50
mg (base equiv)
2
•
4
TRIZIVIR - abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg
3
RIBATAB - ribavirin tab 400 mg
•
RIBATAB - ribavirin tab 600 mg
4
•
RIBATAB - ribavirin tab 400 mg &
TRUVADA - emtricitabine-tenofovir
disoproxil fumarate tab 200-300 mg
2
4
TYZEKA - telbivudine tab 600 mg
3
ribavirin cap 200 mg (Rebetol)
4
valacyclovir hcl tab 1 gm (Valtrex)
1
ribavirin tab 200 mg (Copegus)
4
valacyclovir hcl tab 500 mg (Valtrex)
1
rimantadine hydrochloride tab
100 mg (Flumadine)
1
VALCYTE - valganciclovir hcl tab 450
mg
2
RIMANTALIST - rimantadine tab 100
mg & dietary management cap pack
3
SELZENTRY - maraviroc tab 150 mg
2
SELZENTRY - maraviroc tab 300 mg
2
SITAVIG - acyclovir buccal tab 50 mg
3
SOVALDI - sofosbuvir tab 400 mg
4
•
•
•
VALCYTE - valganciclovir hcl for soln 50 2
mg/ml (base equiv)
VALTREX - valacyclovir hcl tab 500 mg 3
VALTREX - valacyclovir hcl tab 1 gm
3
VICTRELIS - boceprevir cap 200 mg
4
•
13
2
VIDEX EC - didanosine delayed release
capsule 125 mg
3
capsule 200 mg
3
•
capsule 250 mg
3
•
capsule 400 mg
3
VIRACEPT - nelfinavir mesylate tab 250
mg
2
VIRACEPT - nelfinavir mesylate tab 625
mg
2
VIRAMUNE - nevirapine tab 200 mg
3
VIRAMUNE - nevirapine susp 50
mg/5ml
2
•
•
VIRAMUNE XR - nevirapine tab sr 24hr
100 mg
2
VIRAMUNE XR - nevirapine tab sr 24hr
400 mg
2
VIRAZOLE - ribavirin for inhal soln 6 gm
3
VIREAD - tenofovir disoproxil fumarate
tab 150 mg
2
tab 200 mg
2
tab 250 mg
2
tab 300 mg
2
oral powder 40 mg/gm
2
•
ZERIT - stavudine cap 15 mg
3
3
3
3
ZERIT - stavudine for oral soln 1 mg/ml
3
ZIAGEN - abacavir sulfate tab 300 mg
(base equiv)
3
•
•
•
•
•
•
14
Dispensing Limits
VIDEX - didanosine for soln 4 gm
•
•
•
Step Therapy
2
Prior Authorization
VIDEX - didanosine for soln 2 gm
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Drug Tier
Prior Authorization
2014
ZIAGEN - abacavir sulfate soln 20 mg/
ml (base equiv)
2
•
zidovudine cap 100 mg (Retrovir)
1
zidovudine syrup 10 mg/ml (Retrovir)
1
zidovudine tab 300 mg
1
•
•
•
ZOVIRAX - acyclovir cap 200 mg
3
ZOVIRAX - acyclovir tab 400 mg
3
•
ZOVIRAX - acyclovir tab 800 mg
3
ZOVIRAX - acyclovir susp 200 mg/5ml
3
•
ANTIMALARIALS
3
•
ARALEN - chloroquine phosphate tab
500 mg
atovaquone-proguanil hcl tab
250-100 mg (Malarone)
1
atovaquone-proguanil hcl tab
62.5-25 mg (Malarone)
1
•
chloroquine phosphate tab 250 mg
1
1
•
chloroquine phosphate tab 500 mg
(Aralen)
COARTEM - artemether-lumefantrine
tab 20-120 mg
3
•
DARAPRIM - pyrimethamine tab 25 mg
2
1
•
hydroxychloroquine sulfate tab
200 mg (Plaquenil)
3
•
MALARONE - atovaquone-proguanil hcl
tab 62.5-25 mg
3
•
MALARONE - atovaquone-proguanil hcl
tab 250-100 mg
mefloquine hcl tab 250 mg
1
PLAQUENIL - hydroxychloroquine
sulfate tab 200 mg
3
PRIMAQUINE PHOSPHATE primaquine phosphate tab 26.3 mg
2
QUALAQUIN - quinine sulfate cap 324
mg
3
•
quinine sulfate cap 324 mg
(Qualaquin)
1
•
AMEBICIDES
ANTHELMINTICS
ALBENZA - albendazole tab 200 mg
2
BILTRICIDE - praziquantel tab 600 mg
2
STROMECTOL - ivermectin tab 3 mg
2
ANTI-INFECTIVE AGENTS - MISC.
CLEOCIN PHOSPHATE - clindamycin
phosphate inj 9 gm/60ml
3
phosphate iv soln 600 mg/4ml
3
phosphate iv soln 900 mg/6ml
3
clindamycin hcl cap 150 mg (Cleocin)
1
1
1
clindamycin palmitate hcl for soln
75 mg/5ml (base equiv) (Cleocin
pediatric gr)
1
CLINDAMYCIN PHOSPHATE clindamycin phosphate iv soln 300
mg/2ml
3
clindamycin phosphate inj
300 mg/2ml (Cleocin phosphate)
1
ALINIA - nitazoxanide tab 500 mg
3
ALINIA - nitazoxanide for susp 100
mg/5ml
3
atovaquone susp 750 mg/5ml
(Mepron)
1
AZACTAM - aztreonam for inj 1 gm
3
AZACTAM - aztreonam for inj 2 gm
3
aztreonam for inj 1 gm (Azactam)
1
aztreonam for inj 2 gm (Azactam)
1
3
1
BACITRACIN - bacitracin intramuscular
for soln 50000 unit
1
9 gm/60ml (Cleocin phosphate)
1
bacitracin intramuscular for soln
50000 unit (Bacitracin)
3
1
BACTRIM - sulfamethoxazoletrimethoprim tab 400-80 mg
3
clindamycin phosphate iv soln
1
BACTRIM DS - sulfamethoxazoletrimethoprim tab 800-160 mg
3
clindamycin phosphate iv soln
1
CAYSTON - aztreonam lysine for inhal
soln 75 mg (base equivalent)
3
colistimethate sodium for inj 150 mg
(Coly-mycin m)
1
CLEOCIN - clindamycin hcl cap 75 mg
3
3
CLEOCIN PEDIATRIC GRANULE clindamycin palmitate hcl for soln 75
mg/5ml (base equiv)
3
phosphate inj 300 mg/2ml
•
Dispensing Limits
Step Therapy
Prior Authorization
3
Drug Name
Drug Tier
YODOXIN - iodoquinol tab 650 mg
Dispensing Limits
3
Step Therapy
YODOXIN - iodoquinol tab 210 mg
Prior Authorization
Drug Name
Drug Tier
2014
COLY-MYCIN M - colistimethate sodium 3
for inj 150 mg
2
DAPSONE - dapsone tab 25 mg
DAPSONE - dapsone tab 100 mg
2
3
DORIBAX - doripenem for iv infusion
250 mg
3
3
DORIBAX - doripenem for iv infusion
500 mg
3
3
erythromycin-sulfisoxazole for susp
200-600 mg/5ml
1
15
FIRST-VANCOMYCIN 25 - vancomycin
hcl oral soln 25 mg/ml (compound kit)
3
PRIMAXIN I.M. - imipenem-cilastatin
intramuscular for soln 500 mg
3
FIRST-VANCOMYCIN 50 - vancomycin
hcl oral soln 50 mg/ml (compound kit)
3
PRIMAXIN IV - imipenem-cilastatin
intravenous for soln 250 mg
3
FLAGYL - metronidazole cap 375 mg
3
3
FLAGYL - metronidazole tab 250 mg
3
PRIMAXIN IV - imipenem-cilastatin
intravenous for soln 500 mg
FLAGYL - metronidazole tab 500 mg
3
3
FLAGYL ER - metronidazole tab sr 24hr
750 mg
3
PRIMAXIN IV ADD-VANTAGE imipenem-cilastatin intravenous for
soln 250 mg
1
PRIMAXIN IV ADD-VANTAGE imipenem-cilastatin intravenous for
soln 500 mg
3
imipenem-cilastatin intravenous for
soln 250 mg (Primaxin iv)
imipenem-cilastatin intravenous for
soln 500 mg (Primaxin iv)
1
INVANZ - ertapenem sodium for inj 1
gm (base equivalent)
3
INVANZ - ertapenem sodium for iv inj 1
gm (base equivalent)
3
KETEK - telithromycin tab 300 mg
3
KETEK - telithromycin tab 400 mg
3
LINCOCIN - lincomycin hcl inj 300 mg/
ml
3
MEPRON - atovaquone susp 750
mg/5ml
3
meropenem iv for soln 1 gm
(Merrem)
1
meropenem iv for soln 500 mg
(Merrem)
1
MERREM - meropenem iv for soln 500
mg
3
MERREM - meropenem iv for soln 1 gm
3
metronidazole cap 375 mg (Flagyl)
1
metronidazole tab 250 mg (Flagyl)
1
metronidazole tab 500 mg (Flagyl)
1
NEBUPENT - pentamidine isethionate
for nebulization soln 300 mg
Dispensing Limits
Step Therapy
PRIMSOL - trimethoprim hcl oral soln 50 3
mg/5ml (base equiv)
3
SEPTRA DS - sulfamethoxazoletrimethoprim tab 800-160 mg
3
SIVEXTRO - tedizolid phosphate tab
200 mg
sulfamethoxazole-trimethoprim susp 1
200-40 mg/5ml
1
sulfamethoxazole-trimethoprim tab
400-80 mg (Bactrim)
1
sulfamethoxazole-trimethoprim tab
800-160 mg (Bactrim ds)
3
TINDAMAX - tinidazole tab 250 mg
TINDAMAX - tinidazole tab 500 mg
3
tinidazole tab 250 mg (Tindamax)
1
tinidazole tab 500 mg (Tindamax)
1
trimethoprim tab 100 mg
1
VANCOCIN HCL - vancomycin hcl cap
125 mg
3
VANCOCIN HCL - vancomycin hcl cap
250 mg
3
VANCOMYCIN HCL - vancomycin hcl
for inj 750 mg
3
3
PENTAM 300 - pentamidine isethionate
for soln 300 mg
vancomycin hcl cap 125 mg
(Vancocin hcl)
1
3
polymyxin b sulfate for inj 500000
unit
vancomycin hcl cap 250 mg
(Vancocin hcl)
1
1
vancomycin hcl for inj 10 gm
1
16
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
VANCOMYCIN HCL IN DEXTROS vancomycin hcl in dextrose inj 500
mg/100ml
3
mg/150ml
3
gm/200ml
3
XIFAXAN - rifaximin tab 200 mg
3
XIFAXAN - rifaximin tab 550 mg
2
ZYVOX - linezolid tab 600 mg
2
ZYVOX - linezolid for susp 100 mg/5ml
2
BIOLOGICALS
VACCINES
FLUARIX QUADRIVALENT 2014 influenza virus vaccine split
quadrivalent inj 0.5 ml
3
FLUARIX 2011-2012 - influenza virus
vaccine split preservative free inj
3
3
3
FLUCELVAX 2012-2013 - influenza
virus vaccine tissue-cultured subunit
inj
3
inj
3
inj
3
FLULAVAL QUADRIVALENT
201 - influenza virus vaccine split
quadrivalent im inj
3
FLULAVAL QUADRIVALENT
201 - influenza virus vaccine split
3
FLULAVAL 2011-2012 - influenza virus
vaccine split inj
3
vaccine split inj
3
AFLURIA PF 2011-2012 - influenza
virus vaccine split preservative free
inj
3
inj
3
inj
3
inj
3
AFLURIA 2011-2012 - influenza virus
vaccine split inj
3
vaccine split inj
3
vaccine split inj
3
vaccine split inj
3
vaccine split inj
3
3
vaccine split inj
3
FLUMIST NASAL VACCINE 201 influenza virus vaccine live intranasal
liquid
FLUMIST QUADRIVALENT - influenza
virus vaccine live quadrivalent
intranasal susp
3
Dispensing Limits
1
3
Step Therapy
vancomycin hcl for inj 5000 mg
FLUARIX QUADRIVALENT 2013 influenza virus vaccine split
Prior Authorization
1
Drug Name
Drug Tier
Dispensing Limits
1
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
17
FLUVIRIN PF 2011-2012 - influenza
virus vaccine types a & b preservative
free inj
3
FLUZONE PEDIATRIC PF 2014 influenza virus vaccine split
preservative free inj
3
free inj
3
FLUZONE PF 2012-2013 - influenza
inj
3
free inj
3
FLUZONE PF 2013-2014 - influenza
inj
3
free inj
3
FLUZONE QUADRIVALENT 2013 influenza virus vaccine split
3
FLUVIRIN 2011-2012 - influenza virus
vaccine types a & b surface antigen
inj
3
3
inj
3
3
inj
3
3
inj
3
FLUZONE SPLIT 2012-2013 - influenza
virus vaccine split inj
3
FLUZONE HIGH-DOSE PF 2012 influenza virus vac split high-dose
3
3
3
3
INFLUENZA A (H1N1) MONOVA influenza a (h1n1) monovalent
vaccine live intranasal liquid
3
3
PNEUMOVAX 23 - pneumococcal
vaccine polyvalent inj 25 mcg/0.5ml
3
3
PNEUMOVAX 23/1 DOSE pneumococcal vaccine polyvalent inj
25 mcg/0.5ml
3
FLUZONE INTRADERMAL - influenza
virus vaccine split intradermal inj 9
mcg/strain
3
PNEUMOVAX 23/5 DOSE pneumococcal vaccine polyvalent inj
25 mcg/0.5ml
3
3
18
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
PREVNAR 13 - pneumococcal 13-valent 3
conjugate vaccine inj
3
ZOSTAVAX - zoster vaccine live for inj
19400 unit/0.65ml
3
•
GAMMAGARD LIQUID - immune
globulin (human) iv or subcutaneous
soln 20 gm/200ml
3
•
soln 30 gm/300ml
3
•
BIVIGAM - immune globulin (human) iv
soln 5 gm/50ml
3
BIVIGAM - immune globulin (human) iv
soln 10 gm/100ml
3
CARIMUNE NANOFILTERED - immune
globulin (human) iv for soln 3 gm
3
3
3
GAMMAGARD S/D - immune globulin
(human) iv for soln 2.5 gm
3
•
3
(human) iv for soln 5 gm
3
FLEBOGAMMA - immune globulin
(human) iv soln 0.5 gm/10ml
•
3
(human) iv for soln 10 gm
3
FLEBOGAMMA DIF - immune globulin
•
3
GAMMAGARD S/D IGA LESS TH immune globulin (human) iv for soln 5
gm
3
•
(human) iv soln 5 gm/100ml
3
3
•
3
GAMMAGARD S/D IGA LESS TH immune globulin (human) iv for soln
10 gm
•
GAMMAKED - immune globulin
(human) iv or subcutaneous soln 1
gm/10ml
3
3
3
3
•
3
(human) iv or subcutaneous soln 2.5
gm/25ml
3
•
3
gm/50ml
GAMASTAN S/D - immune globulin
(human) inj
3
3
•
soln 1 gm/10ml
3
gm/100ml
3
•
soln 2.5 gm/25ml
3
gm/200ml
GAMMAPLEX - immune globulin
3
soln 5 gm/50ml
3
3
3
•
•
•
Dispensing Limits
soln 10 gm/100ml
Drug Name
Step Therapy
Prior Authorization
Dispensing Limits
Drug Tier
PASSIVE IMMUNIZING AGENTS
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
19
3
GAMUNEX - immune globulin (human)
iv soln 10 gm/100ml
3
GAMUNEX-C - immune globulin
gm/10ml
4
•
(human) iv or subcutaneous soln 2.5
gm/25ml
4
•
gm/50ml
4
•
gm/100ml
4
•
gm/200ml
4
HIZENTRA - immune globulin (human)
subcutaneous inj 1 gm/5ml
4
•
4
•
4
•
4
OCTAGAM - immune globulin (human)
iv soln 1 gm/20ml
Dispensing Limits
PRIVIGEN - immune globulin (human) iv 3
soln 20 gm/200ml
soln 40 gm/400ml
3
SYNAGIS - palivizumab im soln 50
mg/0.5ml
SYNAGIS - palivizumab im soln 100 mg/ 3
ml
3
GRASTEK - timothy grass pollen
allergen ext tab sl 2800 bau
ORALAIR - grass mixed pollen ext tab sl 3
300 ir (index of reactivity)
3
RAGWITEK - short ragweed pollen
allergen extract tab sl 12 amb a 1-u
•
•
ANTINEOPLASTIC AGENTS
•
ANTINEOPLASTICS
ACTIMMUNE - interferon gamma-1b inj
100 mcg/0.5ml (2000000 unit/0.5ml)
4
AFINITOR - everolimus tab 2.5 mg
4
AFINITOR - everolimus tab 5 mg
4
AFINITOR - everolimus tab 7.5 mg
4
AFINITOR - everolimus tab 10 mg
4
AFINITOR DISPERZ - everolimus tab
for oral susp 2 mg
4
•
•
•
•
•
4
•
3
for oral susp 3 mg
4
•
iv soln 2.5 gm/50ml
3
for oral susp 5 mg
4
iv soln 5 gm/100ml
3
ALFERON N - interferon alfa-n3 inj
5000000 unit/ml
ALKERAN - melphalan tab 2 mg
2
iv soln 10 gm/200ml
3
anastrozole tab 1 mg (Arimidex)
1
ARIMIDEX - anastrozole tab 1 mg
3
iv soln 25 gm/500ml
3
AROMASIN - exemestane tab 25 mg
3
bicalutamide tab 50 mg (Casodex)
1
BOSULIF - bosutinib tab 100 mg
4
BOSULIF - bosutinib tab 500 mg
4
capecitabine tab 150 mg (Xeloda)
4
soln 5 gm/50ml
soln 10 gm/100ml
20
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
•
•
•
CASODEX - bicalutamide tab 50 mg
3
CEENU - lomustine cap 10 mg
2
2
2
COMETRIQ - cabozantinib s-malate cap 4
3 x 20 mg (60 mg dose) kit
COMETRIQ - cabozantinib s-mal cap 1 4
x 80 mg & 1 x 20 mg (100 dose) kit
COMETRIQ - cabozantinib s-mal cap 1 4
x 80 mg & 3 x 20 mg (140 dose) kit
2
CYCLOPHOSPHAMIDE cyclophosphamide cap 25 mg
2
CYCLOPHOSPHAMIDE cyclophosphamide cap 50 mg
2
CYCLOPHOSPHAMIDE cyclophosphamide tab 25 mg
2
CYCLOPHOSPHAMIDE cyclophosphamide tab 50 mg
3
DEPO-PROVERA medroxyprogesterone acetate im
susp 400 mg/ml
4
ELIGARD - leuprolide acetate for
subcutaneous inj kit 7.5 mg
ELIGARD - leuprolide acetate (3 month) 4
for subcutaneous inj kit 22.5mg
for subcutaneous inj kit 30 mg
for subcutaneous inj kit 45 mg
2
EMCYT - estramustine phosphate
sodium cap 140 mg
4
ERIVEDGE - vismodegib cap 150 mg
•
•
•
FIRMAGON - degarelix acetate for inj
80 mg (base equiv)
4
FIRMAGON - degarelix acetate for inj
120 mg (base equiv)
4
flutamide cap 125 mg
1
GEMCITABINE - gemcitabine hcl inj 200 3
mg/5.26ml (38 mg/ml) (base equiv)
3
GEMCITABINE - gemcitabine hcl inj 1
gm/26.3ml (38 mg/ml) (base equiv)
3
GEMCITABINE - gemcitabine hcl inj 2
gm/52.6ml (38 mg/ml) (base equiv)
1
gemcitabine hcl for inj 1 gm
(Gemzar)
1
gemcitabine hcl for inj 2 gm
gemcitabine hcl for inj 200 mg
(Gemzar)
1
GEMZAR - gemcitabine hcl for inj 200
mg
3
GEMZAR - gemcitabine hcl for inj 1 gm
3
GILOTRIF - afatinib dimaleate tab 20
4
•
4
•
4
•
GLEEVEC - imatinib mesylate tab 100
4
•
GLEEVEC - imatinib mesylate tab 400
4
•
HEXALEN - altretamine cap 50 mg
4
•
•
ETOPOSIDE - etoposide cap 50 mg
2
HYCAMTIN - topotecan hcl cap 0.25 mg 4
(base equiv)
4
HYCAMTIN - topotecan hcl cap 1 mg
(base equiv)
3
HYDREA - hydroxyurea cap 500 mg
exemestane tab 25 mg (Aromasin)
1
hydroxyurea cap 500 mg (Hydrea)
1
FARESTON - toremifene citrate tab 60
2
ICLUSIG - ponatinib hcl tab 15 mg
(base equiv)
4
•
Dispensing Limits
4
3
Step Therapy
CAPRELSA - vandetanib tab 300 mg
•
•
FEMARA - letrozole tab 2.5 mg
Prior Authorization
4
Drug Name
Drug Tier
CAPRELSA - vandetanib tab 100 mg
Dispensing Limits
4
Step Therapy
capecitabine tab 500 mg (Xeloda)
Prior Authorization
Drug Name
Drug Tier
2014
•
•
21
4
INLYTA - axitinib tab 1 mg
4
INLYTA - axitinib tab 5 mg
4
•
•
•
INTRON-A - interferon alfa-2b inj
6000000 unit/ml
4
INTRON-A - interferon alfa-2b inj
10000000 unit/ml
4
INTRON-A W/DILUENT - interferon
alfa-2b for inj 10000000 unit
4
LUPRON DEPOT - leuprolide acetate (3 2
month) for inj kit 11.25 mg
month) for inj kit 22.5 mg
month) for inj kit 30 mg
month) for inj kit 45 mg
4
LYSODREN - mitotane tab 500 mg
4
MATULANE - procarbazine hcl cap 50
mg
4
4
MEGACE ORAL - megestrol acetate
susp 40 mg/ml
3
JAKAFI - ruxolitinib phosphate tab 5 mg
(base equivalent)
4
•
megestrol acetate susp 40 mg/ml
(Megace oral)
1
JAKAFI - ruxolitinib phosphate tab 10
4
•
megestrol acetate tab 20 mg
1
megestrol acetate tab 40 mg
1
4
•
4
•
4
•
MEKINIST - trametinib dimethyl
sulfoxide tab 0.5 mg (base
equivalent)
4
•
4
•
MEKINIST - trametinib dimethyl
sulfoxide tab 2 mg (base equivalent)
1
letrozole tab 2.5 mg (Femara)
1
mercaptopurine tab 50 mg
(Purinethol)
LEUCOVORIN CALCIUM - leucovorin
calcium tab 10 mg
2
MESNEX - mesna tab 400 mg
3
methotrexate sodium for inj 1 gm
1
LEUCOVORIN CALCIUM - leucovorin
calcium tab 15 mg
2
methotrexate sodium inj pf 25 mg/ml
1
methotrexate sodium inj 25 mg/ml
1
leucovorin calcium tab 25 mg
1
leucovorin calcium tab 5 mg
methotrexate sodium tab 2.5 mg
(base equiv)
1
1
LEUKERAN - chlorambucil tab 2 mg
2
MYLERAN - busulfan tab 2 mg
2
leuprolide acetate inj kit 5 mg/ml
4
4
LOMUSTINE - lomustine cap 10 mg
2
NEXAVAR - sorafenib tosylate tab 200
2
NILANDRON - nilutamide tab 150 mg
2
2
POMALYST - pomalidomide cap 1 mg
4
LUPRON DEPOT - leuprolide acetate
for inj kit 3.75 mg
2
4
4
Dispensing Limits
IMBRUVICA - ibrutinib cap 140 mg
Step Therapy
LUPRON DEPOT - leuprolide acetate
for inj kit 7.5 mg
22
Prior Authorization
•
Drug Name
Drug Tier
4
Dispensing Limits
Prior Authorization
ICLUSIG - ponatinib hcl tab 45 mg
(base equiv)
Drug Name
Step Therapy
Drug Tier
2014
2
•
•
•
•
•
•
3
1
4
tamoxifen citrate tab 20 mg (base
equivalent)
TARCEVA - erlotinib tab 25 mg
4
4
4
TARGRETIN - bexarotene cap 75 mg
4
TASIGNA - nilotinib cap 150 mg
4
TASIGNA - nilotinib cap 200 mg
4
TEMODAR - temozolomide cap 5 mg
4
4
4
4
4
4
TEMODAR - temozolomide for iv soln
100 mg
3
temozolomide cap 100 mg (Temodar)
4
4
4
4
4
4
tretinoin cap 10 mg
4
TREXALL - methotrexate sodium tab 5
mg (base equiv)
3
TREXALL - methotrexate sodium tab
7.5 mg (base equiv)
3
mg (base equiv)
3
mg (base equiv)
3
SOLTAMOX - tamoxifen citrate oral soln 3
10 mg/5ml (base equivalent)
4
SPRYCEL - dasatinib tab 20 mg
•
4
4
4
4
4
STIVARGA - regorafenib tab 40 mg
4
SUTENT - sunitinib malate cap 12.5 mg
(base equivalent)
4
•
•
•
•
•
•
•
•
SUTENT - sunitinib malate cap 25 mg
(base equivalent)
4
•
SUTENT - sunitinib malate cap 37.5 mg
(base equivalent)
4
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
SUTENT - sunitinib malate cap 50 mg
(base equivalent)
4
SYLATRON - peginterferon alfa-2b for
inj kit 296 mcg
4
•
inj kit 444 mcg
4
•
inj kit 888 mcg
4
•
inj kit 4 x 296 mcg
4
inj kit 4 x 444 mcg
4
inj kit 4 x 888 mcg
4
TABLOID - thioguanine tab 40 mg
2
4
•
TYKERB - lapatinib ditosylate tab 250
mg (base equiv)
4
TAFINLAR - dabrafenib mesylate cap
•
4
•
VANDETANIB - vandetanib tab 100 mg
4
TAFINLAR - dabrafenib mesylate cap
VANDETANIB - vandetanib tab 300 mg
4
•
•
•
•
•
Dispensing Limits
PURIXAN - mercaptopurine susp 2000
mg/100ml (20 mg/ml)
1
Step Therapy
PURINETHOL - mercaptopurine tab 50
mg
tamoxifen citrate tab 10 mg (base
equivalent)
Prior Authorization
•
Drug Name
Drug Tier
4
Dispensing Limits
Prior Authorization
Step Therapy
Drug Name
Drug Tier
2014
23
XALKORI - crizotinib cap 200 mg
4
4
DEXAMETHASONE - dexamethasone
tab 1 mg
3
XALKORI - crizotinib cap 250 mg
XELODA - capecitabine tab 150 mg
4
4
tab 2 mg
3
XELODA - capecitabine tab 500 mg
4
soln 0.5 mg/5ml
3
XTANDI - enzalutamide cap 40 mg
ZELBORAF - vemurafenib tab 240 mg
(base equivalent)
4
•
•
•
•
•
•
dexamethasone elixir 0.5 mg/5ml
1
4
DEXAMETHASONE INTENSOL dexamethasone conc 1 mg/ml
ZYDELIG - idelalisib tab 100 mg
2
ZYDELIG - idelalisib tab 150 mg
ZYKADIA - ceritinib cap 150 mg
4
DEXAMETHASONE SODIUM PHOS dexamethasone sodium phosphate
inj 10 mg/ml
1
2
ZYTIGA - abiraterone acetate tab 250
mg
4
•
•
•
•
•
3
ZOLINZA - vorinostat cap 100 mg
DEXAMETHASONE SODIUM PHOS dexamethasone sod phosphate
preservative free inj 10 mg/ml
3
dexamethasone sodium phosphate
inj 100 mg/10ml
1
inj 120 mg/30ml
1
inj 20 mg/5ml
1
inj 4 mg/ml
1
dexamethasone tab 0.5 mg
1
1
1
dexamethasone tab 4 mg
1
dexamethasone tab 6 mg
1
DEXPAK 10 DAY - dexamethasone tab
1.5 mg taper pack
3
3
ENDOCRINE AND METABOLIC DRUGS
CORTICOSTEROIDS
A-HYDROCORT - hydrocortisone
sodium succinate for inj 100 mg
1
betamethasone sod phosphate &
acetate inj susp 6 (3-3) mg/ml
(Celestone-soluspan)
1
budesonide cap sr 24hr 3 mg
(Entocort ec)
1
CELESTONE - betamethasone soln 0.6
mg/5ml
3
CELESTONE-SOLUSPAN betamethasone sod phosphate &
acetate inj susp 6 (3-3) mg/ml
3
CORTEF - hydrocortisone tab 5 mg
3
3
3
CORTISONE ACETATE - cortisone
acetate tab 25 mg
2
1.5 mg taper pack
3
DEPO-MEDROL - methylprednisolone
acetate inj susp 20 mg/ml
3
1.5 mg taper pack
3
3
ENTOCORT EC - budesonide cap sr
24hr 3 mg
FLO-PRED - prednisolone acetate oral
susp 16.7 mg/5ml (15 mg/5ml base)
3
24
Dispensing Limits
3
Step Therapy
Prior Authorization
•
Drug Name
Drug Tier
4
Dispensing Limits
Prior Authorization
VOTRIENT - pazopanib hcl tab 200 mg
(base equiv)
Drug Name
Step Therapy
Drug Tier
2014
hydrocortisone tab 5 mg (Cortef)
1
KENALOG-10 - triamcinolone acetonide
inj susp 10 mg/ml
methylprednisolone tab 4 mg
(Medrol)
1
3
methylprednisolone tab 4 mg dose
pack (Medrol dosepak)
1
3
(Medrol)
1
KENALOG-40 - triamcinolone acetonide
inj susp 40 mg/ml
3
MILLIPRED - prednisolone tab 5 mg
3
MEDROL - methylprednisolone tab 2
mg
3
mg
3
MILLIPRED - prednisolone sod
phosphate oral soln 10 mg/5ml (base
equiv)
3
MILLIPRED DP - prednisolone tab 5 mg
dose pack
3
mg
3
ORAPRED - prednisolone sod
equiv)
3
mg
mg
3
3
MEDROL DOSEPAK methylprednisolone tab 4 mg dose
pack
3
ORAPRED ODT - prednisolone sod
phos orally disintegr tab 10 mg (base
eq)
3
methylprednisolone acetate inj susp
40 mg/ml (Depo-medrol)
1
eq)
methylprednisolone acetate inj susp
80 mg/ml (Depo-medrol)
eq)
3
1
methylprednisolone sodium
succinate for inj 1000 mg (Solumedrol)
1
1
1
1
(Medrol)
1
Dispensing Limits
1
1
Step Therapy
(Medrol)
Prior Authorization
1
Drug Name
Drug Tier
Dispensing Limits
1
Step Therapy
fludrocortisone acetate tab 0.1 mg
Prior Authorization
Drug Name
Drug Tier
2014
PEDIAPRED - prednisolone sod phosph 3
oral soln 6.7 mg/5ml (5 mg/5ml base)
1
prednisolone sod phosph oral
soln 6.7 mg/5ml (5 mg/5ml base)
(Pediapred)
1
prednisolone sod phosphate oral
soln 15 mg/5ml (base equiv)
3
PREDNISOLONE SODIUM PHOSP prednisolone sodium phosphate oral
soln 25 mg/5ml (base eq)
1
prednisolone syrup 15 mg/5ml (usp
solution equivalent) (Prelone)
3
PREDNISONE - prednisone tab 50 mg
PREDNISONE - prednisone oral soln 5
mg/5ml
3
25
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
dose pack
3
UCERIS - budesonide tab sr 24hr 9 mg
3
dose pack
VERIPRED 20 - prednisolone sod
equiv)
3
3
PREDNISONE INTENSOL - prednisone
conc 5 mg/ml
3
ANDROGEN-ANABOLIC
1
ANADROL-50 - oxymetholone tab 50
mg
3
prednisone tab 1 mg
prednisone tab 10 mg
1
2
•
prednisone tab 10 mg dose pack
1
ANDRODERM - testosterone td patch
24hr 2 mg/24hr
prednisone tab 2.5 mg
1
2
•
prednisone tab 20 mg
1
ANDRODERM - testosterone td patch
24hr 4 mg/24hr
1
ANDROGEL - testosterone td gel 25
mg/2.5gm (1%)
2
prednisone tab 5 mg
•
prednisone tab 5 mg dose pack
1
2
•
PRELONE - prednisolone syrup 15
mg/5ml (usp solution equivalent)
3
ANDROGEL - testosterone td gel 50
mg/5gm (1%)
•
3
ANDROGEL - testosterone td gel 20.25
mg/1.25gm (1.62%)
2
RAYOS - prednisone tab delayed
release 1 mg
•
release 2 mg
ANDROGEL - testosterone td gel 40.5
mg/2.5gm (1.62%)
2
3
release 5 mg
SOLU-CORTEF - hydrocortisone
sodium succinate pf for inj 100 mg
3
3
ANDROGEL PUMP - testosterone td gel 2
12.5 mg/act (1%)
ANDROGEL PUMP - testosterone td gel 2
20.25 mg/act (1.62%)
3
ANDROID - methyltestosterone cap 10
mg
ANDROXY - fluoxymesterone tab 10 mg 3
•
3
3
3
SOLU-MEDROL - methylprednisolone
3
AXIRON - testosterone td soln 30 mg/
act
3
danazol cap 100 mg
1
danazol cap 200 mg
1
danazol cap 50 mg
1
3
DELATESTRYL - testosterone
enanthate im in oil 200 mg/ml
3
3
DEPO-TESTOSTERONE - testosterone
cypionate im in oil 100 mg/ml
3
3
DEPO-TESTOSTERONE - testosterone
3
3
FIRST-TESTOSTERONE - testosterone
propionate td ointment 2%
3
26
•
•
•
•
• •
•
•
•
• •
FIRST-TESTOSTERONE MC COM testosterone propionate td cream 2%
3
• •
ALORA - estradiol td patch biweekly
0.075 mg/24hr
3
FORTESTA - testosterone td gel 10mg/
act (2%)
3
• •
ALORA - estradiol td patch biweekly 0.1
mg/24hr
3
METHITEST - methyltestosterone oral
tab 10 mg
3
•
ANGELIQ - drospirenone-estradiol tab
0.25-0.5 mg
3
OXANDRIN - oxandrolone tab 2.5 mg
3
3
ANGELIQ - drospirenone-estradiol tab
0.5-1 mg
3
OXANDRIN - oxandrolone tab 10 mg
oxandrolone tab 10 mg (Oxandrin)
1
1
CENESTIN - estrogens, conjugated
synthetic a tab 0.3 mg
3
oxandrolone tab 2.5 mg (Oxandrin)
•
•
•
•
3
• •
3
STRIANT - testosterone buccal
mucoadhesive system 30 mg
3
• •
3
TESTIM - testosterone td gel 50
mg/5gm (1%)
3
• •
3
TESTOSTERONE - testosterone td gel
50 mg/5gm (1%)
1
3
testosterone cypionate im in oil
100 mg/ml (Depo-testosterone)
1
CLIMARA - estradiol td patch weekly
0.025 mg/24hr
3
testosterone cypionate im in oil
200 mg/ml (Depo-testosterone)
1
0.0375 mg/24hr (37.5 mcg/24hr)
3
testosterone enanthate im in oil
200 mg/ml
3
0.05 mg/24hr
3
TESTOSTERONE PUMP - testosterone
td gel 12.5 mg/act (1%)
3
0.06 mg/24hr
3
TESTRED - methyltestosterone cap 10
mg
3
• •
0.075 mg/24hr
3
VOGELXO - testosterone td gel 50
mg/5gm (1%)
VOGELXO PUMP - testosterone td gel
12.5 mg/act (1%)
3
• •
ESTROGENS
ACTIVELLA - estradiol & norethindrone
acetate tab 0.5-0.1 mg
3
ACTIVELLA - estradiol & norethindrone
acetate tab 1-0.5 mg
3
0.025 mg/24hr
3
0.05 mg/24hr
3
• •
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
CLIMARA - estradiol td patch weekly 0.1 3
mg/24hr
3
CLIMARA PRO - estradiollevonorgestrel td patch weekly
0.045-0.015 mg/day
COMBIPATCH - estradiol-norethindrone 2
ace td pttw 0.05-0.14 mg/day
COMBIPATCH - estradiol-norethindrone 2
ace td pttw 0.05-0.25 mg/day
DELESTROGEN - estradiol valerate im 3
in oil 10 mg/ml
27
DELESTROGEN - estradiol valerate im
in oil 20 mg/ml
3
estradiol tab 2 mg (Estrace)
1
DELESTROGEN - estradiol valerate im
in oil 40 mg/ml
estradiol td patch weekly
0.025 mg/24hr (Climara)
1
3
DEPO-ESTRADIOL - estradiol
0.0375 mg/24hr (37.5 mcg/24hr)
(Climara)
1
3
DIVIGEL - estradiol td gel 0.25
mg/0.25gm (0.1%)
2
1
DIVIGEL - estradiol td gel 0.5 mg/0.5gm
(0.1%)
2
1
DIVIGEL - estradiol td gel 1 mg/gm
(0.1%)
2
1
DUAVEE - conjugated estrogensbazedoxifene tab 0.45-20 mg
3
1
ELESTRIN - estradiol gel 0.06% (0.52
mg/0.87 gm metered-dose pump)
3
estradiol valerate im in oil 10 mg/ml
(Delestrogen)
1
ENJUVIA - estrogens, conjugated
synthetic b tab 0.3 mg
3
(Delestrogen)
1
3
(Delestrogen)
1
3
ESTRASORB - estradiol transdermal
emulsion 4.35 mg/1.74gm
3
3
ESTROGEL - estradiol gel 0.06% (0.75
mg/1.25 gm metered-dose pump)
3
3
ESTROPIPATE - estropipate tab 3 mg
3
estropipate tab 0.75 mg
1
esterified estrogens &
methyltestosterone tab
0.625-1.25 mg
1
estropipate tab 1.5 mg
1
3
esterified estrogens &
methyltestosterone tab 1.25-2.5 mg
1
EVAMIST - estradiol transdermal spray
1.53 mg/spray
3
ESTRACE - estradiol tab 0.5 mg
3
FEMHRT LOW DOSE - norethindrone
acetate-ethinyl estradiol tab 0.5
mg-2.5 mcg
ESTRACE - estradiol tab 1 mg
3
ESTRACE - estradiol tab 2 mg
FEMHRT 1/5 - norethindrone acetateethinyl estradiol tab 1 mg-5 mcg
3
3
estradiol & norethindrone acetate
tab 0.5-0.1 mg (Activella)
1
FEMTRACE - estradiol acetate tab 0.45
mg
3
estradiol & norethindrone acetate
tab 1-0.5 mg (Activella)
1
FEMTRACE - estradiol acetate tab 0.9
mg
3
estradiol tab 0.5 mg (Estrace)
1
3
estradiol tab 1 mg (Estrace)
1
JINTELI - norethindrone acetate-ethinyl
estradiol tab 1 mg-5 mcg
28
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
MENEST - esterified estrogens tab 0.3
mg
3
MENEST - esterified estrogens tab
0.625 mg
3
mg
PREMPRO - conjugated estrogenmedroxyprogest acetate tab
0.625-2.5 mg
2
2
3
PREMPRO - conjugated estrogenmedroxyprogest acetate tab 0.625-5
mg
mg
3
VIVELLE-DOT - estradiol td patch
biweekly 0.025 mg/24hr
2
MENOSTAR - estradiol td patch weekly
14 mcg/24hr
3
2
MINIVELLE - estradiol td patch biweekly 3
0.0375 mg/24hr
0.05 mg/24hr
0.075 mg/24hr
0.1 mg/24hr
1
norethindrone acetate-ethinyl
3
PREFEST - estradiol tab 1
mg(15)/estrad-norgestimate tab
1-0.09mg(15)
PREMARIN - estrogens, conjugated tab 2
0.3 mg
0.45 mg
0.625 mg
0.9 mg
1.25 mg
2
PREMPHASE - conj est 0.625(14)/conj
est-medroxypro ac tab 0.625-5mg(14)
2
PREMPRO - conjugated estrogenmedroxyprogest acetate tab 0.3-1.5
mg
2
PREMPRO - conjugated estrogenmedroxyprogest acetate tab 0.45-1.5
mg
2
2
2
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
CONTRACEPTIVES
AMETHYST - levonorgestrel-ethinyl
estradiol (continuous) tab 90-20 mcg
3
BEYAZ - drospirenone-ethinyl estradlevomefolate tab 3-0.02-0.451 mg
3
BREVICON-28 - norethindrone & ethinyl 3
estradiol tab 0.5 mg-35 mcg
3
CYCLESSA - desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mgmg
3
DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im
susp 150 mg/ml
3
DEPO-SUBQ PROVERA 104 medroxyprogesterone acetate
subcutaneous susp 104 mg/0.65ml
3
DESOGEN - desogestrel & ethinyl
desogest-eth estrad & eth estrad tab 1
0.15-0.02/0.01 mg(21/5) (Mircette)
1
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mgmg (Cyclessa)
1
desogestrel & ethinyl estradiol tab
0.15 mg-30 mcg (Desogen)
29
drospirenone-ethinyl estradiol tab
3-0.02 mg (Yaz)
1
LO/OVRAL-28 - norgestrel & ethinyl
3
drospirenone-ethinyl estradiol tab
3-0.03 mg (Yasmin 28)
1
3
ELLA - ulipristal acetate tab 30 mg
2
LOESTRIN FE 1.5/30 - norethindrone
ace & ethinyl estradiol-fe tab 1.5
mg-30 mcg
ESTROSTEP FE - norethindrone acethinyl estrad-fe tab 1-20/1-30/1-35
mg-mcg
3
LOESTRIN FE 1/20 - norethindrone
ace & ethinyl estradiol-fe tab 1 mg-20
mcg
3
ethynodiol diacetate & ethinyl
1
3
FALESSA - levonorgest-eth estrad tab
0.1 mg-20 mcg & fa tab 1 mg kit
3
LOESTRIN 1.5/30-21 - norethindrone
ace & ethinyl estradiol tab 1.5 mg-30
mcg
3
FEMCON FE - norethindrone & ethinyl
estradiol-fe chew tab 0.4 mg-35 mcg
3
LOESTRIN 1/20-21 - norethindrone ace
& ethinyl estradiol tab 1 mg-20 mcg
3
GENERESS FE - norethindrone &
ethinyl estradiol-fe chew tab 0.8
mg-25 mcg
3
LOESTRIN 24 FE - norethindrone aceethinyl estradiol-fe tab 1 mg-20 mcg
(24)
3
levonorg-eth est tab 0.1-0.02mg(84)
& eth est tab 0.01mg(7)
(Loseasonique)
1
LOMEDIA 24 FE - norethindrone aceethinyl estradiol-fe tab 1 mg-20 mcg
(24)
3
levonorg-eth est tab 0.15-0.03mg(84)
& eth est tab 0.01mg(7)
(Seasonique)
1
LOSEASONIQUE - levonorg-eth est
tab 0.1-0.02mg(84) & eth est tab
0.01mg(7)
1
levonorgestrel & ethinyl estradiol
(91-day) tab 0.15-0.03 mg
1
medroxyprogesterone acetate im
susp 150 mg/ml (Depo-provera
contrac)
1
MINASTRIN 24 FE - norethindrone aceeth estradiol-fe chew tab 1 mg-20
mcg (24)
3
levonorgestrel & ethinyl estradiol tab
0.1 mg-20 mcg
levonorgestrel & ethinyl estradiol tab
0.15 mg-30 mcg
1
MIRCETTE - desogest-eth estrad & eth
estrad tab 0.15-0.02/0.01 mg(21/5)
3
levonorgestrel tab 0.75 mg (Plan b)
1
levonorgestrel tab 1.5 mg (Plan b
one-step)
MODICON - norethindrone & ethinyl
3
1
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg
NATAZIA - estradiol valerate-dienogest
tab 3 mg /2-2 mg/2-3 mg/1 mg
3
1
3
LO LOESTRIN FE - norethin-eth
estradiol-fe tab 1 mg-10 mcg (24)/10
mcg (2)
3
NECON 1/50-28 - norethindrone &
mestranol tab 1 mg-50 mcg
3
LO MINASTRIN FE - norethin-eth
estrad-fe chew/tab 1 mg-10 mcg/10
mcg ther pack
3
NECON 10/11-28 - norethindrone-eth
estradiol tab 0.5-35/1-35 mg-mcg
(10/11)
NOR-QD - norethindrone tab 0.35 mg
3
30
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
NORDETTE-28 - levonorgestrel &
ethinyl estradiol tab 0.15 mg-30 mcg
3
NORINYL 1+35 - norethindrone &
ethinyl estradiol tab 1 mg-35 mcg
3
norelgestromin-ethinyl estradiol td
ptwk 150-35 mcg/24hr (Ortho evra)
1
NORINYL 1+50 - norethindrone &
mestranol tab 1 mg-50 mcg
3
norethindrone & ethinyl estradiol tab
0.4 mg-35 mcg (Ovcon-35)
1
NUVARING - etonogestrel-ethinyl
estradiol va ring 0.120-0.015 mg/24hr
2
0.5 mg-35 mcg (Brevicon-28)
1
OGESTREL - norgestrel & ethinyl
3
1 mg-35 mcg (Norinyl 1+35)
1
ORTHO EVRA - norelgestromin-ethinyl
estradiol td ptwk 150-35 mcg/24hr
3
norethindrone & ethinyl estradiol-fe
chew tab 0.4 mg-35 mcg (Femcon
fe)
1
ORTHO MICRONOR - norethindrone
tab 0.35 mg
3
norethindrone ac-ethinyl estradfe tab 1-20/1-30/1-35 mg-mcg
(Estrostep fe)
ORTHO TRI-CYCLEN norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg
3
1
1
ORTHO TRI-CYCLEN LO norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg
3
norethindrone ace & ethinyl estradiol
tab 1 mg-20 mcg (Loestrin 1/20-21)
norethindrone ace & ethinyl estradiol
tab 1.5 mg-30 mcg (Loestrin
1.5/30-21)
1
ORTHO-CEPT - desogestrel & ethinyl
3
norethindrone ace & ethinyl
estradiol-fe tab 1 mg-20 mcg
(Loestrin fe 1/20)
ORTHO-CYCLEN - norgestimate &
ethinyl estradiol tab 0.25 mg-35 mcg
3
1
norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg
(Loestrin fe 1.5/30)
1
norethindrone tab 0.35 mg (Nor-qd)
1
norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg (Orthonovum 7/7/7)
1
norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg (Trinorinyl 28)
1
norgestimate & ethinyl estradiol tab
0.25 mg-35 mcg (Ortho-cyclen)
1
norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg
(Ortho tri-cyclen)
1
norgestrel & ethinyl estradiol tab
0.3 mg-30 mcg
1
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
ORTHO-NOVUM 1/35 - norethindrone & 3
ORTHO-NOVUM 7/7/7 - norethindrone- 3
eth estradiol tab 0.5-35/0.75-35/1-35
mg-mcg
3
OVCON-35 - norethindrone & ethinyl
OVCON-50 28 - norethindrone & ethinyl 3
3
PLAN B - levonorgestrel tab 0.75 mg
PLAN B ONE-STEP - levonorgestrel tab
1.5 mg
3
QUARTETTE - levonor-eth est tab
0.15-0.02/0.025/0.03 mg &eth est
0.01 mg
3
SAFYRAL - drospirenone-ethinyl estrad- 3
levomefolate tab 3-0.03-0.451 mg
SEASONALE - levonorgestrel & ethinyl 3
estradiol (91-day) tab 0.15-0.03 mg
31
SEASONIQUE - levonorg-eth est
tab 0.15-0.03mg(84) & eth est tab
0.01mg(7)
3
TRI-NORINYL 28 - norethindrone-eth
estradiol tab 0.5-35/1-35/0.5-35 mgmcg
3
YASMIN 28 - drospirenone-ethinyl
estradiol tab 3-0.03 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
ANTIDIABETICS
acarbose tab 100 mg (Precose)
1
1
1
3
•
3
ACTOPLUS MET - pioglitazone hclmetformin hcl tab 15-500 mg
3
•
YAZ - drospirenone-ethinyl estradiol tab
3-0.02 mg
3
ACTOPLUS MET - pioglitazone hclmetformin hcl tab 15-850 mg
3
•
ZOVIA 1/50E - ethynodiol diacetate &
3
ACTOPLUS MET XR - pioglitazone hclmetformin hcl tab sr 24hr 15-1000 mg
ACTOPLUS MET XR - pioglitazone hclmetformin hcl tab sr 24hr 30-1000 mg
3
•
PROGESTINS
AYGESTIN - norethindrone acetate tab
5 mg
3
ACTOS - pioglitazone hcl tab 15 mg
(base equiv)
3
•
medroxyprogesterone acetate tab
10 mg (Provera)
1
(base equiv)
3
•
2.5 mg (Provera)
1
(base equiv)
3
•
5 mg (Provera)
1
AMARYL - glimepiride tab 1 mg
3
3
MEGACE ES - megestrol acetate susp
625 mg/5ml
3
3
•
norethindrone acetate tab 5 mg
(Aygestin)
AVANDAMET - rosiglitazone maleatemetformin hcl tab 2-500 mg
3
1
•
1
3
progesterone im in oil 50 mg/ml
progesterone micronized cap 100 mg
(Prometrium)
1
3
•
progesterone micronized cap 200 mg
(Prometrium)
1
3
•
PROMETRIUM - progesterone
micronized cap 100 mg
3
AVANDARYL - rosiglitazone maleateglimepiride tab 4-1 mg
3
•
PROMETRIUM - progesterone
micronized cap 200 mg
3
3
•
PROVERA - medroxyprogesterone
acetate tab 2.5 mg
3
3
•
acetate tab 5 mg
3
3
•
acetate tab 10 mg
3
3
•
32
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
AVANDIA - rosiglitazone maleate tab 2
mg (base equiv)
3
•
DUETACT - pioglitazone hcl-glimepiride
tab 30-4 mg
3
•
mg (base equiv)
3
•
FARXIGA - dapagliflozin propanediol
tab 5 mg (base equivalent)
3
•
mg (base equiv)
3
•
FARXIGA - dapagliflozin propanediol
tab 10 mg (base equivalent)
3
•
BD GLUCOSE - glucose chew tab 5 gm
3
3
BYDUREON - exenatide extended
release for susp pen-injector 2 mg
2
• •
FORTAMET - metformin hcl tab sr 24hr
osmotic 500 mg
3
BYDUREON - exenatide extended
release for inj susp 2 mg
2
• •
FORTAMET - metformin hcl tab sr 24hr
osmotic 1000 mg
glimepiride tab 1 mg (Amaryl)
1
BYETTA - exenatide soln pen-injector 5
mcg/0.02ml
2
1
1
BYETTA - exenatide soln pen-injector
10 mcg/0.04ml
2
glipizide tab sr 24hr 10 mg (Glucotrol
xl)
1
CHLORPROPAMIDE - chlorpropamide
tab 100 mg
3
glipizide tab sr 24hr 2.5 mg (Glucotrol
xl)
1
CHLORPROPAMIDE - chlorpropamide
tab 250 mg
3
glipizide tab sr 24hr 5 mg (Glucotrol
xl)
1
CVS GLUCOSE - glucose chew tab 4
gm
3
glipizide tab 10 mg (Glucotrol)
1
3
glipizide tab 5 mg (Glucotrol)
1
CVS GLUCOSE BITS - glucose chew
tab 1 gm
1
CYCLOSET - bromocriptine mesylate
tab 0.8 mg (base equivalent)
3
glipizide-metformin hcl tab
2.5-250 mg
1
DEX4 - glucose chew tab 1 gm
3
glipizide-metformin hcl tab
2.5-500 mg
3
glipizide-metformin hcl tab 5-500 mg
1
DEX4 GLUCOSE - glucose chew tab 4
gm
3
DEX4 GLUCOSE - glucose oral liquid
15 gm/59ml
3
GLUCAGEN - glucagon hcl (rdna) for inj
1 mg (base equiv)
3
DEX4 QUICK DISSOLVE GLUCO glucose chew tab 4 gm
3
GLUCAGEN HYPOKIT - glucagon hcl
(rdna) for inj 1 mg (base equiv)
2
DIABETA - glyburide tab 1.25 mg
3
GLUCAGON EMERGENCY KIT glucagon (rdna) for inj kit 1 mg
3
GLUCOPHAGE - metformin hcl tab 500
mg
3
DIABETA - glyburide tab 2.5 mg
DIABETA - glyburide tab 5 mg
3
3
GLUCOPHAGE - metformin hcl tab 850
mg
3
DRUG MART GLUCOSE - glucose
chew tab 4 gm
DUETACT - pioglitazone hcl-glimepiride
tab 30-2 mg
GLUCOPHAGE - metformin hcl tab
1000 mg
3
3
• •
• •
•
33
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
GLUCOPHAGE XR - metformin hcl tab
sr 24hr 500 mg
3
glyburide-metformin tab 2.5-500 mg
(Glucovance)
1
GLUCOPHAGE XR - metformin hcl tab
sr 24hr 750 mg
3
glyburide-metformin tab 5-500 mg
(Glucovance)
1
GLUCOSE - glucose chew tab 4 gm
3
3
glucose gel 40%
1
GLYCRON - glyburide micronized tab
4.5 mg
glucose oral liquid 15 gm/59ml
1
3
GLUCOTROL - glipizide tab 5 mg
3
GLYNASE - glyburide micronized tab
1.5 mg
3
GLYNASE - glyburide micronized tab 3
mg
3
GLUCOTROL - glipizide tab 10 mg
GLUCOTROL XL - glipizide tab sr 24hr
2.5 mg
3
GLYNASE - glyburide micronized tab 6
mg
3
5 mg
3
GLYSET - miglitol tab 25 mg
3
3
3
10 mg
3
GLUCOVANCE - glyburide-metformin
tab 1.25-250 mg
3
GNP GLUCOSE - glucose chew tab 4
gm
3
tab 2.5-500 mg
3
GNP QUICK DISSOLVE GLUCOS glucose chew tab 4 gm
3
tab 5-500 mg
3
INSTA-GLUCOSE - glucose gel 77.4%
1
3
•
GLUMETZA - metformin hcl tab sr 24hr
modified release 500 mg
3
INVOKAMET - canagliflozin-metformin
hcl tab 50-500 mg
3
•
GLUMETZA - metformin hcl tab sr 24hr
modified release 1000 mg
3
hcl tab 50-1000 mg
3
•
GLYBURIDE - glyburide tab 1.25 mg
3
hcl tab 150-500 mg
GLYBURIDE - glyburide tab 2.5 mg
3
3
•
GLYBURIDE - glyburide tab 5 mg
3
hcl tab 150-1000 mg
1
INVOKANA - canagliflozin tab 100 mg
2
glyburide micronized tab 1.5 mg
(Glynase)
INVOKANA - canagliflozin tab 300 mg
2
glyburide micronized tab 3 mg
(Glynase)
1
JANUMET - sitagliptin-metformin hcl tab
50-500 mg
2
•
•
•
glyburide micronized tab 6 mg
(Glynase)
1
JANUMET - sitagliptin-metformin hcl tab
50-1000 mg
2
•
glyburide tab 1.25 mg
1
2
•
glyburide tab 2.5 mg
1
JANUMET XR - sitagliptin-metformin hcl
tab sr 24hr 50-500 mg
1
tab sr 24hr 50-1000 mg
2
glyburide tab 5 mg
•
(Glucovance)
1
34
•
tab sr 24hr 100-1000 mg
2
•
KROGER GLUCOSE - glucose chew
tab 4 gm
3
JANUVIA - sitagliptin phosphate tab 25
mg (base equiv)
2
•
LEADER GLUCOSE - glucose chew tab
4 gm
3
JANUVIA - sitagliptin phosphate tab 50
mg (base equiv)
2
•
LEADER QUICK DISSOLVE GLU glucose chew tab 4 gm
3
JANUVIA - sitagliptin phosphate tab 100 2
mg (base equiv)
3
JARDIANCE - empagliflozin tab 10 mg
•
LONGS GLUCOSE - glucose chew tab
4 gm
3
MEDICINE SHOPPE GLUCOSE glucose chew tab 4 gm
3
METAGLIP - glipizide-metformin hcl tab
2.5-250 mg
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
JARDIANCE - empagliflozin tab 25 mg
3
JENTADUETO - linagliptin-metformin
hcl tab 2.5-500 mg
3
•
•
•
hcl tab 2.5-850 mg
3
•
metformin hcl tab sr 24hr osmotic
1000 mg (Fortamet)
1
hcl tab 2.5-1000 mg
3
•
metformin hcl tab sr 24hr osmotic
500 mg (Fortamet)
1
JUVISYNC - sitagliptin-simvastatin tab
50-10 mg
2
•
metformin hcl tab sr 24hr 500 mg
(Glucophage xr)
1
50-20 mg
2
•
metformin hcl tab sr 24hr 750 mg
(Glucophage xr)
1
50-40 mg
2
•
metformin hcl tab 1000 mg
(Glucophage)
1
100-10 mg
2
•
(Glucophage)
1
100-20 mg
2
•
(Glucophage)
1
100-40 mg
2
•
MS QUICK DISSOLVE GLUCOSE glucose chew tab 4 gm
3
KAZANO - alogliptin-metformin hcl tab
12.5-500 mg
3
•
nateglinide tab 120 mg (Starlix)
1
nateglinide tab 60 mg (Starlix)
1
KAZANO - alogliptin-metformin hcl tab
12.5-1000 mg
3
•
NESINA - alogliptin benzoate tab 6.25
mg (base equiv)
3
•
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 2.5-1000
mg
2
•
NESINA - alogliptin benzoate tab 12.5
mg (base equiv)
3
•
•
•
2
NESINA - alogliptin benzoate tab 25 mg
(base equiv)
3
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 5-500 mg
•
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 5-1000 mg
•
ONGLYZA - saxagliptin hcl tab 2.5 mg
(base equiv)
2
2
•
KORLYM - mifepristone tab 300 mg
ONGLYZA - saxagliptin hcl tab 5 mg
(base equiv)
2
4
•
35
OSENI - alogliptin-pioglitazone tab
12.5-15 mg
3
•
PROGLYCEM - diazoxide susp 50 mg/
ml
3
12.5-30 mg
3
•
repaglinide tab 0.5 mg (Prandin)
1
1
12.5-45 mg
•
repaglinide tab 1 mg (Prandin)
3
repaglinide tab 2 mg (Prandin)
1
3
•
RIOMET - metformin hcl oral soln 500
mg/5ml
3
25-15 mg
3
•
SM GLUCOSE - glucose chew tab 4 gm
3
25-30 mg
STARLIX - nateglinide tab 60 mg
3
25-45 mg
3
•
STARLIX - nateglinide tab 120 mg
3
3
pioglitazone hcl tab 15 mg (base
equiv) (Actos)
1
•
SYMLIN - pramlintide acetate inj 600
mcg/ml (base equiv)
2
equiv) (Actos)
1
•
SYMLINPEN 120 - pramlintide acetate
pen-inj 2700 mcg/2.7ml (1000 mcg/
ml)
equiv) (Actos)
1
•
2
pioglitazone hcl-glimepiride tab
30-2 mg (Duetact)
1
•
SYMLINPEN 60 - pramlintide acetate
pen-inj 1500 mcg/1.5ml (1000 mcg/
ml)
3
pioglitazone hcl-glimepiride tab
30-4 mg (Duetact)
1
TANZEUM - albiglutide for soln peninjector 30 mg
3
pioglitazone hcl-metformin hcl tab
15-500 mg (Actoplus met)
1
TANZEUM - albiglutide for soln peninjector 50 mg
TOLAZAMIDE - tolazamide tab 500 mg
3
pioglitazone hcl-metformin hcl tab
15-850 mg (Actoplus met)
1
tolazamide tab 250 mg
1
3
PRANDIMET - repaglinide-metformin
hcl tab 1-500 mg
3
TOLBUTAMIDE - tolbutamide tab 500
mg
TRADJENTA - linagliptin tab 5 mg
3
PRANDIMET - repaglinide-metformin
hcl tab 2-500 mg
3
ULTILET GLUCOSE - glucose chew tab
4 gm
3
PRANDIN - repaglinide tab 0.5 mg
3
3
PRANDIN - repaglinide tab 1 mg
3
VALUE PLUS GLUCOSE - glucose
chew tab 4 gm
PRANDIN - repaglinide tab 2 mg
3
2
PRECOSE - acarbose tab 25 mg
3
VICTOZA - liraglutide soln pen-injector
18 mg/3ml (6 mg/ml)
3
WALGREENS GLUCOSE - glucose
chew tab 4 gm
3
3
PREFERRED PLUS GLUCOSE glucose chew tab 4 gm
3
36
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
• •
•
• •
Rapid-Acting Insulins
APIDRA - insulin glulisine inj 100 unit/ml
3
APIDRA SOLOSTAR - insulin glulisine
soln pen-injector inj 100 unit/ml
3
HUMALOG - insulin lispro (human) soln
cartridge 100 unit/ml
2
HUMALOG - insulin lispro (human) inj
100 unit/ml
2
HUMALOG KWIKPEN - insulin lispro
(human) soln pen-injector 100 unit/ml
2
NOVOLOG - insulin aspart inj 100 unit/
ml
2
NOVOLOG FLEXPEN - insulin aspart
soln pen-injector 100 unit/ml
2
NOVOLOG PENFILL - insulin aspart
soln cartridge 100 unit/ml
2
NOVOLOG PENFILL - insulin aspart inj
100 unit/ml
2
Short-Acting Insulins
HUMULIN R - insulin regular (human) inj 2
100 unit/ml
2
HUMULIN R U-500 (CONCENTR insulin regular (human) inj 500 unit/ml
NOVOLIN R - insulin regular (human) inj 2
100 unit/ml
2
NOVOLIN R RELION - insulin regular
(human) inj 100 unit/ml
3
RELION R - insulin regular (human) inj
100 unit/ml
Intermediate-Acting Insulins
HUMALOG MIX 50/50 - insulin lispro
prot & lispro (human) inj 100 unit/ml
(50-50)
2
HUMALOG MIX 50/50 KWIKPEN insulin lispro prot & lispro sus pen-inj
100 unit/ml (50-50)
2
HUMALOG MIX 75/25 - insulin lispro
prot & lispro (human) inj 100 unit/ml
(75-25)
2
HUMALOG MIX 75/25 KWIKPEN insulin lispro prot & lispro sus pen-inj
100 unit/ml (75-25)
2
HUMULIN N - insulin isophane (human)
inj 100 unit/ml
2
HUMULIN N KWIKPEN - insulin
isophane (human) susp pen-injector
100 unit/ml
2
HUMULIN N U-100 PEN - insulin
isophane (human) susp pen-injector
100 unit/ml
2
HUMULIN 70/30 - insulin isophane
& regular (human) inj 100 unit/ml
(70-30)
2
HUMULIN 70/30 KWIKPEN - insulin
isophane & regular susp pen-inj 100
unit/ml (70-30)
2
HUMULIN 70/30 PEN - insulin isophane
& regular susp pen-inj 100 unit/ml
(70-30)
2
NOVOLIN N - insulin isophane (human)
inj 100 unit/ml
2
NOVOLIN N RELION - insulin isophane
(human) inj 100 unit/ml
2
NOVOLIN 70/30 - insulin isophane
& regular (human) inj 100 unit/ml
(70-30)
2
NOVOLIN 70/30 RELION - insulin
isophane & regular (human) inj 100
unit/ml (70-30)
2
NOVOLOG MIX 70/30 - insulin aspart
prot & aspart (human) inj 100 unit/ml
(70-30)
2
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
NOVOLOG MIX 70/30 PREFILL - insulin 2
aspart prot & aspart sus pen-inj 100
unit/ml (70-30)
Basal Insulins
LANTUS - insulin glargine inj 100 unit/ml 2
2
LANTUS SOLOSTAR - insulin glargine
2
LEVEMIR - insulin detemir inj 100 unit/
ml
2
LEVEMIR FLEXPEN - insulin detemir
2
LEVEMIR FLEXTOUCH - insulin
detemir soln pen-injector 100 unit/ml
37
THYROID AGENTS
ARMOUR THYROID - thyroid tab 15 mg 3
(1/4 grain)
(1/2 grain)
(1 grain)
(1 1/2 grain)
3
ARMOUR THYROID - thyroid tab 120
mg (2 grain)
3
mg (3 grain)
3
mg (4 grain)
3
mg (5 grain)
3
CYTOMEL - liothyronine sodium tab 5
mcg
CYTOMEL - liothyronine sodium tab 25 3
mcg
CYTOMEL - liothyronine sodium tab 50 3
mcg
1
levothyroxine sodium tab 100 mcg
(Synthroid)
1
(Synthroid)
1
(Synthroid)
1
(Synthroid)
1
(Synthroid)
1
(Synthroid)
1
(Synthroid)
1
(Synthroid)
38
(Synthroid)
1
(Synthroid)
1
(Synthroid)
1
(Synthroid)
1
liothyronine sodium tab 25 mcg
(Cytomel)
1
(Cytomel)
1
(Cytomel)
1
methimazole tab 10 mg (Tapazole)
1
methimazole tab 5 mg (Tapazole)
1
NATURE-THROID - thyroid tab 16.25
mg
3
NATURE-THROID - thyroid tab 32.5 mg
3
mg (3/4 grain)
3
NATURE-THROID - thyroid tab 65 mg
3
mg
3
NATURE-THROID - thyroid tab 97.5 mg
3
mg
3
3
3
3
(5 grain)
3
mg
3
NATURE-THROID NT-2.5 - thyroid tab
162.5 mg (2 1/2 grain)
3
propylthiouracil tab 50 mg
1
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
SYNTHROID - levothyroxine sodium tab 2
25 mcg
50 mcg
75 mcg
88 mcg
100 mcg
112 mcg
125 mcg
137 mcg
150 mcg
175 mcg
200 mcg
300 mcg
3
TAPAZOLE - methimazole tab 5 mg
TIROSINT - levothyroxine sodium cap
13 mcg
3
25 mcg
3
50 mcg
3
75 mcg
3
88 mcg
3
100 mcg
3
112 mcg
3
125 mcg
3
137 mcg
3
150 mcg
3
WESTHROID - thyroid tab 16.25 mg
3
3
TAPAZOLE - methimazole tab 10 mg
(3/4 grain)
3
3
thyroid tab 30 mg (1/2 grain) (Armour
thyroid)
1
WESTHROID - thyroid tab 65 mg
3
3
thyroid tab 60 mg (1 grain) (Armour
thyroid)
1
3
1
3
thyroid tab 90 mg (1 1/2 grain)
(Armour thyroid)
3
THYROLAR-1 - liotrix (t3-t4) tab 60 mg
(12.5-50 mcg)
3
WESTHROID - thyroid tab 162.5 mg (2
1/2 grain)
3
THYROLAR-1/2 - liotrix (t3-t4) tab 30
mg (6.25-25 mcg)
3
3
3
THYROLAR-1/4 - liotrix (t3-t4) tab 15
mg (3.1-12.5 mcg)
3
WESTHROID - thyroid tab 325 mg (5
grain)
3
(25-100 mcg)
3
3
WESTHROID-P - thyroid tab 16.25 mg
3
(37.5-150 mcg)
3
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
39
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
•
(3/4 grain)
3
WESTHROID-P - thyroid tab 65 mg
3
ALENDRONATE SODIUM - alendronate 3
sodium oral soln 70 mg/75ml
1
alendronate sodium tab 10 mg
3
1
WESTHROID-P - thyroid tab 130 mg
3
1
WP THYROID - thyroid tab 16.25 mg
3
1
3
(Fosamax)
(3/4 grain)
3
AREDIA - pamidronate disodium for inj
30 mg
3
WP THYROID - thyroid tab 65 mg
3
2
•
3
ATELVIA - risedronate sodium tab
3
BINOSTO - alendronate sodium
effervescent tab 70 mg
3
•
3
3
•
WP THYROID - thyroid tab 130 mg
3
BONIVA - ibandronate sodium tab 150
BONIVA - ibandronate sodium iv soln 3
mg/3ml (base equivalent)
3
BRAVELLE - urofollitropin purified for inj
75 unit
4
BUPHENYL - sodium phenylbutyrate
tab 500 mg
4
•
BUPHENYL - sodium phenylbutyrate
oral powder 3 gm/teaspoonful
4
•
cabergoline tab 0.5 mg
1
calcitonin (salmon) nasal soln 200
unit/act (Miacalcin)
1
calcitriol cap 0.25 mcg (Rocaltrol)
1
calcitriol cap 0.5 mcg (Rocaltrol)
1
1
•
calcitriol oral soln 1 mcg/ml
(Rocaltrol)
4
•
CARBAGLU - carglumic acid tab 200
mg
CARNITOR - levocarnitine tab 330 mg
3
CARNITOR - levocarnitine oral soln 1
gm/10ml (10%)
3
CARNITOR SF - levocarnitine oral soln
1 gm/10ml (10%)
3
CETROTIDE - cetrorelix acetate for inj
kit 0.25 mg
4
OXYTOCICS
CERVIDIL - dinoprostone vaginal inserts 3
10 mg
HEMABATE - carboprost tromethamine 3
im soln 250 mcg/ml
3
METHERGINE - methylergonovine
maleate tab 0.2 mg
1
methylergonovine maleate tab
0.2 mg
3
PREPIDIL - dinoprostone cervical gel
0.5 mg/3gm
3
PROSTIN E2 - dinoprostone vaginal
suppos 20 mg
ENDOCRINE and METABOLIC AGENTS - MISC.
2
ACTONEL - risedronate sodium tab 5
mg
2
mg
2
mg
ACTONEL - risedronate sodium tab 150 3
mg
ALENDRONATE SODIUM - alendronate 3
sodium tab 40 mg
40
•
•
•
•
•
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
CETROTIDE - cetrorelix acetate for inj
kit 3 mg
4
ETIDRONATE DISODIUM - etidronate
disodium tab 400 mg
3
chorionic gonadotropin for inj 10000
unit
4
EVISTA - raloxifene hcl tab 60 mg
3
CLOMID - clomiphene citrate tab 50 mg
FOLLISTIM AQ - follitropin beta inj 75
unit/0.5ml
4
3
clomiphene citrate tab 50 mg
(Clomid)
1
unit/0.5ml
4
CYSTADANE - betaine powder for oral
solution
3
unit/0.36ml
4
DDAVP - desmopressin acetate tab 0.1
mg
3
unit/0.72ml
4
DDAVP - desmopressin acetate tab 0.2
mg
3
unit/1.08ml
4
DDAVP - desmopressin acetate inj 4
mcg/ml
3
FORTEO - teriparatide (recombinant) inj
600 mcg/2.4ml
4
DDAVP - desmopressin acetate nasal
soln 0.01% (refrigerated)
3
FORTICAL - calcitonin (salmon) nasal
soln 200 unit/act
3
DDAVP - desmopressin acetate nasal
spray soln 0.01%
3
FOSAMAX - alendronate sodium tab 5
mg
3
•
desmopressin acetate inj 4 mcg/ml
(Ddavp)
1
mg
3
•
desmopressin acetate nasal soln
0.01% (refrigerated) (Ddavp)
1
mg
3
•
desmopressin acetate nasal spray
soln 0.01% (Ddavp)
1
mg
3
•
desmopressin acetate nasal spray
soln 0.01% (refrigerated)
1
mg
3
•
desmopressin acetate tab 0.1 mg
(Ddavp)
1
FOSAMAX - alendronate sodium oral
soln 70 mg/75ml
3
•
desmopressin acetate tab 0.2 mg
(Ddavp)
1
3
•
DIDRONEL - etidronate disodium tab
400 mg
3
FOSAMAX PLUS D - alendronate
sodium-cholecalciferol tab 70-2800
mg-unit
3
•
doxercalciferol cap 0.5 mcg
(Hectorol)
1
FOSAMAX PLUS D - alendronate
sodium-cholecalciferol tab 70-5600
mg-unit
doxercalciferol cap 1 mcg (Hectorol)
1
4
doxercalciferol cap 2.5 mcg
(Hectorol)
1
GANIRELIX ACETATE - ganirelix
acetate inj 250 mcg/0.5ml
4
ETIDRONATE DISODIUM - etidronate
disodium tab 200 mg
3
GENOTROPIN - somatropin for
subcutaneous inj 5 mg
•
•
•
41
GENOTROPIN MINIQUICK somatropin for inj 0.2 mg
4
•
HECTOROL - doxercalciferol cap 1 mcg
3
•
HECTOROL - doxercalciferol cap 2.5
mcg
3
4
4
4
•
HUMATROPE - somatropin for inj 5 mg
4
4
•
HUMATROPE - somatropin for inj 6 mg
(18 unit)
•
•
4
•
GENOTROPIN MINIQUICK somatropin for inj 1 mg
4
•
HUMATROPE - somatropin for inj 12
mg (36 unit)
4
•
4
•
HUMATROPE - somatropin for inj 24
mg
4
•
4
•
HUMATROPE COMBO PACK somatropin for inj 5 mg
1
4
•
ibandronate sodium iv soln 3 mg/3ml
(base equivalent) (Boniva)
1
4
•
ibandronate sodium tab 150 mg
(base equivalent) (Boniva)
4
GENOTROPIN MINIQUICK somatropin for inj 2 mg
4
•
INCRELEX - mecasermin inj 40 mg/4ml
(10 mg/ml)
KUVAN - sapropterin dihydrochloride
powder packet 100 mg
4
GONAL-F - follitropin alfa for inj 450 unit
4
GONAL-F - follitropin alfa for inj 1050
unit
KUVAN - sapropterin dihydrochloride
soluble tab 100 mg
4
4
4
levocarnitine oral soln 1 gm/10ml
(10%) (Carnitor)
1
GONAL-F RFF - follitropin alfa for inj 75
unit
levocarnitine tab 330 mg (Carnitor)
1
GONAL-F RFF PEN - follitropin alfa inj
300 unit/0.5ml
4
LUPRON DEPOT-PED - leuprolide
acetate for inj pediatric kit 7.5 mg
2
450 unit/0.75ml
4
acetate for inj pediatric kit 11.25 mg
2
900 unit/1.5ml
4
acetate for inj pediatric kit 15 mg
2
GONAL-F RFF REDIJECT - follitropin
alfa inj 300 unit/0.5ml
4
2
4
acetate (3 month) for inj pediatric kit
11.25 mg
acetate (3 month) for inj pediatric kit
30 mg
2
4
Dispensing Limits
3
Step Therapy
HECTOROL - doxercalciferol cap 0.5
mcg
42
Prior Authorization
•
Drug Name
Drug Tier
4
Dispensing Limits
Prior Authorization
GENOTROPIN - somatropin for inj 12
mg (13.8 mg overfill)
Drug Name
Step Therapy
Drug Tier
2014
•
MENOPUR - menotropins for
subcutaneous inj 75 unit
4
MIACALCIN - calcitonin (salmon) inj 200 3
unit/ml
MIACALCIN - calcitonin (salmon) nasal 3
soln 200 unit/act
3
MIFEPREX - mifepristone tab 200 mg
MYALEPT - metreleptin for
subcutaneous inj 11.3 mg
4
•
NORDITROPIN CARTRIDGE somatropin inj 5 mg/1.5ml
4
•
NORDITROPIN FLEXPRO - somatropin
inj 5 mg/1.5ml
4
•
inj 10 mg/1.5ml
4
inj 15 mg/1.5ml
4
NORDITROPIN NORDIFLEX PEN somatropin inj 30 mg/3ml
4
NUTROPIN - somatropin for inj 10 mg
4
NUTROPIN AQ - somatropin inj 10
mg/2ml
4
•
•
NUTROPIN AQ NUSPIN 10 somatropin inj 10 mg/2ml
4
•
NUTROPIN AQ NUSPIN 20 somatropin inj 20 mg/2ml
4
•
NUTROPIN AQ NUSPIN 5 - somatropin
inj 5 mg/2ml
4
•
NUTROPIN AQ PEN - somatropin inj 10
mg/2ml
4
•
NUTROPIN AQ PEN - somatropin inj 20
mg/2ml
4
•
octreotide acetate inj 100 mcg/ml
(0.1 mg/ml) (Sandostatin)
4
(1 mg/ml) (Sandostatin)
4
4
4
•
•
•
4
OMNITROPE - somatropin inj 5
mg/1.5ml
4
•
OMNITROPE - somatropin inj 10
mg/1.5ml
4
•
OMNITROPE - somatropin for inj 5.8 mg 4
4
ORFADIN - nitisinone cap 2 mg
•
4
4
OSPHENA - ospemifene tab 60 mg
3
OVIDREL - choriogonadotropin alfa inj
250 mcg/0.5ml
4
PAMIDRONATE DISODIUM pamidronate disodium iv soln 6 mg/ml
3
pamidronate disodium for inj 30 mg
1
pamidronate disodium for inj 90 mg
1
pamidronate disodium iv soln 3 mg/
ml
1
pamidronate disodium iv soln 9 mg/
ml
1
paricalcitol cap 1 mcg (Zemplar)
1
1
1
raloxifene hcl tab 60 mg (Evista)
1
RAVICTI - glycerol phenylbutyrate liquid
1.1 gm/ml
4
RECLAST - zoledronic acid iv soln 5
mg/100ml
3
REPRONEX - menotropins for inj 75
unit
4
risedronate sodium tab 150 mg
(Actonel)
1
ROCALTROL - calcitriol cap 0.25 mcg
3
ROCALTROL - calcitriol cap 0.5 mcg
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
•
•
ROCALTROL - calcitriol oral soln 1 mcg/ 3
ml
43
SIGNIFOR - pasireotide diaspartate inj
0.3 mg/ml (base equiv)
4
•
SAIZEN - somatropin (non-refrigerated)
for inj 8.8 mg
4
•
4
•
SAIZEN CLICK.EASY - somatropin
(non-refrigerated) for inj 8.8 mg
4
•
4
•
SAMSCA - tolvaptan tab 15 mg
4
3
SAMSCA - tolvaptan tab 30 mg
4
SKELID - tiludronate disodium tab 200
mg (tiludronic acid equivalent)
SANDOSTATIN - octreotide acetate inj
50 mcg/ml (0.05 mg/ml)
4
sodium phenylbutyrate oral powder
3 gm/teaspoonful (Buphenyl)
4
4
4
4
1000 mcg/ml (1 mg/ml)
4
SANDOSTATIN LAR DEPOT octreotide acetate for im inj kit 10 mg
4
4
4
SOMAVERT - pegvisomant for inj 10 mg 4
(as protein)
(as protein)
(as protein)
STIMATE - desmopressin acetate nasal 2
soln 1.5 mg/ml
SYNAREL - nafarelin acetate nasal soln 2
2 mg/ml
4
TEV-TROPIN - somatropin for
subcutaneous inj 5 mg
3
ZEMPLAR - paricalcitol cap 1 mcg
SENSIPAR - cinacalcet hcl tab 30 mg
(base equiv)
3
2
3
2
ZOLEDRONIC ACID - zoledronic acid iv
soln 4 mg/100ml
3
(base equiv)
(base equiv)
ZOLEDRONIC ACID - zoledronic acid
for iv soln 4 mg
3
2
SEROSTIM - somatropin (nonrefrigerated) for subcutaneous inj 4
mg
zoledronic acid inj conc for iv
infusion 4 mg/5ml (Zometa)
1
4
1
mg
4
•
zoledronic acid iv soln 5 mg/100ml
(Reclast)
mg
4
•
44
•
ZOMETA - zoledronic acid inj conc for iv 3
infusion 4 mg/5ml
3
ZOMETA - zoledronic acid iv soln 4
mg/100ml
4
ZORBTIVE - somatropin (nonrefrigerated) for subcutaneous inj 8.8
mg
Dispensing Limits
Prior Authorization
•
Drug Name
Step Therapy
Drug Tier
4
Dispensing Limits
Prior Authorization
SAIZEN - somatropin (non-refrigerated)
for inj 5 mg
Drug Name
Step Therapy
Drug Tier
2014
•
•
•
CARDIOVASCULAR AGENTS
CARDIOTONICS
isosorbide dinitrate tab 5 mg (Isordil
titradose)
1
isosorbide mononitrate tab sr 24hr
120 mg (Imdur)
1
30 mg (Imdur)
1
60 mg (Imdur)
1
isosorbide mononitrate tab 10 mg
1
DIGOXIN - digoxin oral soln 0.05 mg/ml
3
digoxin tab 125 mcg (0.125 mg)
(Lanoxin)
1
digoxin tab 250 mcg (0.25 mg)
(Lanoxin)
1
LANOXIN - digoxin tab 62.5 mcg
(0.0625 mg)
3
LANOXIN - digoxin tab 125 mcg (0.125
mg)
3
isosorbide mononitrate tab 20 mg
1
3
LANOXIN - digoxin tab 187.5 mcg
(0.1875 mg)
3
MONOKET - isosorbide mononitrate tab
10 mg
3
LANOXIN - digoxin tab 250 mcg (0.25
mg)
3
MONOKET - isosorbide mononitrate tab
20 mg
NITRO-BID - nitroglycerin oint 2%
3
3
ANTIANGINAL AGENTS
DILATRATE SR - isosorbide dinitrate
cap cr 40 mg
3
NITRO-DUR - nitroglycerin td patch
24hr 0.1 mg/hr
3
IMDUR - isosorbide mononitrate tab sr
24hr 30 mg
3
24hr 0.2 mg/hr
3
24hr 60 mg
3
24hr 0.3 mg/hr
3
24hr 120 mg
3
24hr 0.4 mg/hr
3
ISORDIL TITRADOSE - isosorbide
dinitrate tab 5 mg
3
24hr 0.6 mg/hr
3
ISORDIL TITRADOSE - isosorbide
dinitrate tab 40 mg
3
24hr 0.8 mg/hr
nitroglycerin cap cr 2.5 mg
1
ISOSORBIDE DINITRATE - isosorbide
dinitrate tab 30 mg
3
nitroglycerin cap cr 6.5 mg
1
nitroglycerin cap cr 9 mg
1
dinitrate sl tab 2.5 mg
3
3
dinitrate sl tab 5 mg
3
NITROGLYCERIN LINGUAL nitroglycerin lingual aerosol 400 mcg/
spray
1
nitroglycerin td patch 24hr 0.1 mg/hr
(Nitro-dur)
1
isosorbide dinitrate tab cr 40 mg
isosorbide dinitrate tab 10 mg
1
1
1
(Nitro-dur)
1
(Nitro-dur)
1
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
45
(Nitro-dur)
1
BYSTOLIC - nebivolol hcl tab 2.5 mg
(base equivalent)
3
nitroglycerin tl soln 0.4 mg/spray
(400 mcg/spray) (Nitrolingual
pumpspr)
1
BYSTOLIC - nebivolol hcl tab 5 mg
(base equivalent)
3
NITROLINGUAL PUMPSPRAY nitroglycerin tl soln 0.4 mg/spray (400
mcg/spray)
(base equivalent)
3
3
(base equivalent)
3
NITROMIST - nitroglycerin lingual
aerosol 400 mcg/spray
3
carvedilol tab 12.5 mg (Coreg)
1
carvedilol tab 25 mg (Coreg)
1
1
1
COREG - carvedilol tab 3.125 mg
3
3
3
COREG - carvedilol tab 25 mg
3
COREG CR - carvedilol phosphate cap
sr 24hr 10 mg
3
sr 24hr 20 mg
3
sr 24hr 40 mg
3
NITROSTAT - nitroglycerin sl tab 0.3 mg 2
3
RANEXA - ranolazine tab sr 12hr 500
mg
3
RANEXA - ranolazine tab sr 12hr 1000
mg
BETA BLOCKERS
acebutolol hcl cap 200 mg (Sectral)
1
acebutolol hcl cap 400 mg (Sectral)
1
atenolol tab 100 mg (Tenormin)
1
1
1
3
sr 24hr 80 mg
3
BETAPACE - sotalol hcl tab 80 mg
3
CORGARD - nadolol tab 20 mg
3
3
3
BETAPACE AF - sotalol hcl (afib/afl) tab
80 mg
3
3
120 mg
3
160 mg
3
betaxolol hcl tab 10 mg (Kerlone)
1
betaxolol hcl tab 20 mg (Kerlone)
1
bisoprolol fumarate tab 10 mg
(Zebeta)
1
bisoprolol fumarate tab 5 mg
(Zebeta)
1
46
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
HEMANGEOL - propranolol hcl oral soln 3
4.28 mg/ml
3
INDERAL LA - propranolol hcl cap sr
24hr 60 mg
3
24hr 80 mg
3
24hr 120 mg
3
24hr 160 mg
3
INDERAL XL - propranolol hcl
sustained-release beads cap sr 24hr
120 mg
3
INNOPRAN XL - propranolol hcl
80 mg
3
INNOPRAN XL - propranolol hcl
120 mg
3
KERLONE - betaxolol hcl tab 10 mg
3
KERLONE - betaxolol hcl tab 20 mg
3
labetalol hcl tab 100 mg (Trandate)
1
1
1
LEVATOL - penbutolol sulfate tab 20 mg 3
3
LOPRESSOR - metoprolol tartrate tab
50 mg
3
LOPRESSOR - metoprolol tartrate tab
100 mg
1
metoprolol succinate tab sr 24hr
100 mg (Toprol xl)
1
200 mg (Toprol xl)
1
25 mg (Toprol xl)
1
50 mg (Toprol xl)
1
metoprolol tartrate tab 100 mg
(Lopressor)
1
(Lopressor)
1
nadolol tab 20 mg (Corgard)
1
1
1
pindolol tab 10 mg
1
PROPRANOLOL HCL - propranolol hcl
oral soln 20 mg/5ml
3
PROPRANOLOL HCL - propranolol hcl
oral soln 40 mg/5ml
3
propranolol hcl cap sr 24hr 120 mg
(Inderal la)
1
(Inderal la)
1
(Inderal la)
1
(Inderal la)
1
propranolol hcl tab 10 mg
1
1
1
1
1
SECTRAL - acebutolol hcl cap 200 mg
3
SECTRAL - acebutolol hcl cap 400 mg
3
sotalol hcl (afib/afl) tab 120 mg
(Betapace af)
1
(Betapace af)
1
(Betapace af)
1
sotalol hcl tab 120 mg (Betapace)
1
1
sotalol hcl tab 240 mg
1
1
TENORMIN - atenolol tab 25 mg
3
3
3
TIMOLOL MALEATE - timolol maleate
tab 5 mg
3
tab 10 mg
3
Dispensing Limits
1
Step Therapy
pindolol tab 5 mg
Prior Authorization
Dispensing Limits
Step Therapy
Drug Name
Drug Tier
INDERAL XL - propranolol hcl
80 mg
Prior Authorization
Drug Name
Drug Tier
2014
47
tab 20 mg
3
CARDENE SR - nicardipine hcl cap sr
12hr 45 mg
3
TOPROL XL - metoprolol succinate tab
sr 24hr 25 mg
3
12hr 60 mg
3
sr 24hr 50 mg
3
CARDIZEM - diltiazem hcl tab 30 mg
3
3
sr 24hr 100 mg
3
3
3
3
sr 24hr 200 mg
3
TRANDATE - labetalol hcl tab 100 mg
3
CARDIZEM CD - diltiazem hcl coated
beads cap sr 24hr 120 mg
3
3
3
ZEBETA - bisoprolol fumarate tab 5 mg
3
3
ZEBETA - bisoprolol fumarate tab 10
mg
3
3
3
CALCIUM CHANNEL BLOCKERS
ADALAT CC - nifedipine tab sr 24hr 30
mg
3
3
mg
3
CARDIZEM LA - diltiazem hcl coated
beads tab sr 24hr 120 mg
3
mg
3
3
amlodipine besylate tab 10 mg
(Norvasc)
1
3
amlodipine besylate tab 2.5 mg
(Norvasc)
1
3
amlodipine besylate tab 5 mg
(Norvasc)
1
3
CALAN - verapamil hcl tab 80 mg
3
CALAN - verapamil hcl tab 120 mg
3
3
CALAN SR - verapamil hcl tab cr 120
mg
3
COVERA-HS - verapamil hcl tab sr 24hr
(controlled onset) 180 mg
3
mg
3
COVERA-HS - verapamil hcl tab sr 24hr
(controlled onset) 240 mg
3
mg
3
DILACOR XR - diltiazem hcl cap sr 24hr
240 mg
diltiazem hcl cap sr 12hr 120 mg
1
12hr 30 mg
3
1
1
48
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
diltiazem hcl coated beads cap sr
24hr 120 mg (Cardizem cd)
1
1
DYNACIRC CR - isradipine tab sr 24hr
10 mg
3
felodipine tab sr 24hr 10 mg
1
felodipine tab sr 24hr 2.5 mg
1
felodipine tab sr 24hr 5 mg
1
1
ISOPTIN SR - verapamil hcl tab cr 120
mg
3
1
mg
3
1
mg
3
diltiazem hcl coated beads tab sr
24hr 180 mg (Cardizem la)
1
ISRADIPINE - isradipine cap 2.5 mg
3
ISRADIPINE - isradipine cap 5 mg
3
1
nicardipine hcl cap 20 mg
1
1
nicardipine hcl cap 30 mg
1
nifedipine cap 10 mg (Procardia)
1
1
nifedipine cap 20 mg
1
1
1
nifedipine tab sr 24hr osmotic 30 mg
(Procardia xl)
1
diltiazem hcl extended release beads
cap sr 24hr 120 mg (Tiazac)
1
(Procardia xl)
1
1
(Procardia xl)
1
1
nifedipine tab sr 24hr 30 mg (Adalat
cc)
1
1
cc)
1
1
cc)
nimodipine cap 30 mg
1
1
NIMOTOP - nimodipine cap 30 mg
3
1
NISOLDIPINE - nisoldipine tab sr 24hr
20 mg
3
diltiazem hcl tab 120 mg (Cardizem)
1
3
1
30 mg
diltiazem hcl tab 90 mg
1
40 mg
3
Dispensing Limits
1
3
Step Therapy
DYNACIRC CR - isradipine tab sr 24hr
5 mg
Prior Authorization
1
Drug Name
Drug Tier
Dispensing Limits
1
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
49
NISOLDIPINE ER - nisoldipine tab sr
24hr 25.5 mg
3
verapamil hcl cap sr 24hr 100 mg
(Verelan pm)
1
nisoldipine tab sr 24hr 17 mg (Sular)
1
1
nisoldipine tab sr 24hr 25.5 mg
1
(Verelan)
nisoldipine tab sr 24hr 34 mg (Sular)
1
1
nisoldipine tab sr 24hr 8.5 mg (Sular)
1
(Verelan)
3
(Verelan pm)
1
NORVASC - amlodipine besylate tab
2.5 mg
3
(Verelan)
1
NORVASC - amlodipine besylate tab 5
mg
3
(Verelan pm)
1
NORVASC - amlodipine besylate tab 10
mg
3
(Verelan)
1
NYMALIZE - nimodipine oral soln 60
mg/20ml
3
verapamil hcl tab cr 120 mg (Calan
sr)
1
PROCARDIA - nifedipine cap 10 mg
PROCARDIA XL - nifedipine tab sr 24hr
osmotic 30 mg
3
sr)
1
osmotic 60 mg
3
sr)
1
osmotic 90 mg
3
verapamil hcl tab 120 mg (Calan)
1
3
verapamil hcl tab 80 mg (Calan)
1
SULAR - nisoldipine tab sr 24hr 8.5 mg
3
VERELAN - verapamil hcl cap sr 24hr
120 mg
3
SULAR - nisoldipine tab sr 24hr 17 mg
SULAR - nisoldipine tab sr 24hr 25.5 mg 3
3
SULAR - nisoldipine tab sr 24hr 34 mg
180 mg
3
240 mg
3
360 mg
3
VERELAN PM - verapamil hcl cap sr
24hr 100 mg
3
24hr 200 mg
3
24hr 300 mg
3
TIAZAC - diltiazem hcl extended release 3
VERAPAMIL HCL - verapamil hcl tab 40 3
mg
50
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
ANTIARRHYTHMICS
amiodarone hcl tab 100 mg
1
(Cordarone)
1
CORDARONE - amiodarone hcl tab 200 3
mg
disopyramide phosphate cap 100 mg 1
(Norpace)
disopyramide phosphate cap 150 mg 1
(Norpace)
1
flecainide acetate tab 100 mg
propafenone hcl tab 225 mg
(Rythmol)
1
1
QUINIDINE GLUCONATE - quinidine
gluconate inj 80 mg/ml
3
quinidine gluconate tab cr 324 mg
1
QUINIDINE SULFATE - quinidine
sulfate tab 200 mg
1
3
1
1
QUINIDINE SULFATE ER - quinidine
sulfate tab cr 300 mg
mexiletine hcl cap 150 mg
1
quinidine sulfate tab 200 mg
1
1
quinidine sulfate tab 300 mg
1
1
2
MULTAQ - dronedarone hcl tab 400 mg
(base equivalent)
2
RYTHMOL - propafenone hcl tab 150
mg
2
NORPACE - disopyramide phosphate
cap 100 mg
3
RYTHMOL - propafenone hcl tab 225
mg
3
NORPACE - disopyramide phosphate
cap 150 mg
3
RYTHMOL SR - propafenone hcl cap sr
12hr 225 mg
3
NORPACE CR - disopyramide
phosphate cap sr 12hr 100 mg
3
12hr 325 mg
3
NORPACE CR - disopyramide
phosphate cap sr 12hr 150 mg
3
12hr 425 mg
3
PACERONE - amiodarone hcl tab 400
mg
3
TAMBOCOR - flecainide acetate tab 50
mg
3
PROCAINAMIDE HCL - procainamide
hcl inj 100 mg/ml
3
TAMBOCOR - flecainide acetate tab
100 mg
3
PROCAINAMIDE HCL - procainamide
hcl inj 500 mg/ml
3
TAMBOCOR - flecainide acetate tab
150 mg
3
procainamide hcl inj 100 mg/ml
1
TIKOSYN - dofetilide cap 125 mcg
(0.125 mg)
propafenone hcl cap sr 12hr 225 mg
(Rythmol sr)
1
(Rythmol sr)
1
(Rythmol sr)
1
(Rythmol)
1
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
1
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
TIKOSYN - dofetilide cap 250 mcg (0.25 3
mg)
3
TIKOSYN - dofetilide cap 500 mcg (0.5
mg)
ANTIHYPERTENSIVES
ACCUPRIL - quinapril hcl tab 5 mg
3
3
3
3
51
ACCURETIC - quinaprilhydrochlorothiazide tab 10-12.5 mg
3
ATACAND - candesartan cilexetil tab 4
mg
3
•
ACCURETIC - quinaprilhydrochlorothiazide tab 20-12.5 mg
3
mg
3
•
ACCURETIC - quinaprilhydrochlorothiazide tab 20-25 mg
3
mg
3
•
ACEON - perindopril erbumine tab 2 mg
3
3
•
3
mg
3
3
•
ALTACE - ramipril cap 1.25 mg
3
ATACAND HCT - candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg
3
ATACAND HCT - candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg
3
ALTACE - ramipril cap 2.5 mg
•
ALTACE - ramipril cap 5 mg
3
•
ALTACE - ramipril cap 10 mg
ATACAND HCT - candesartan cilexetilhydrochlorothiazide tab 32-25 mg
3
3
amlodipine besylate-benazepril hcl
cap 10-20 mg (Lotrel)
1
atenolol & chlorthalidone tab
100-25 mg (Tenoretic 100)
1
1
atenolol & chlorthalidone tab
50-25 mg (Tenoretic 50)
1
cap 2.5-10 mg (Lotrel)
1
AVALIDE - irbesartanhydrochlorothiazide tab 150-12.5 mg
3
•
1
AVALIDE - irbesartanhydrochlorothiazide tab 300-12.5 mg
3
•
1
AVAPRO - irbesartan tab 75 mg
3
3
1
3
3
AZOR - amlodipine besylate-olmesartan
medoxomil tab 5-20 mg
3
AMTURNIDE - aliskiren-amlodipinehydrochlorothiazide tab 150-5-12.5
mg
•
•
•
•
3
•
mg
3
3
•
AMTURNIDE - aliskiren-amlodipinehydrochlorothiazide tab 300-5-25 mg
3
•
3
•
mg
3
•
benazepril & hydrochlorothiazide tab
10-12.5 mg (Lotensin hct)
1
1
AMTURNIDE - aliskiren-amlodipinehydrochlorothiazide tab 300-10-25
mg
3
20-12.5 mg (Lotensin hct)
20-25 mg (Lotensin hct)
1
52
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
5-6.25 mg
1
benazepril hcl tab 10 mg (Lotensin)
1
1
1
benazepril hcl tab 5 mg
1
BENICAR - olmesartan medoxomil tab 5 3
mg
3
BENICAR - olmesartan medoxomil tab
20 mg
3
BENICAR - olmesartan medoxomil tab
40 mg
3
BENICAR HCT - olmesartan
medoxomil-hydrochlorothiazide tab
20-12.5 mg
3
40-12.5 mg
3
40-25 mg
bisoprolol & hydrochlorothiazide tab 1
10-6.25 mg (Ziac)
2.5-6.25 mg (Ziac)
5-6.25 mg (Ziac)
1
candesartan cilexetil tab 16 mg
(Atacand)
1
(Atacand)
1
(Atacand)
1
(Atacand)
1
candesartan cilexetilhydrochlorothiazide tab 16-12.5 mg
(Atacand hct)
candesartan cilexetilhydrochlorothiazide tab 32-12.5 mg
(Atacand hct)
1
candesartan cilexetilhydrochlorothiazide tab 32-25 mg
(Atacand hct)
1
captopril tab 100 mg
1
captopril tab 12.5 mg
1
•
captopril tab 25 mg
1
captopril tab 50 mg
1
•
CAPTOPRIL/HYDROCHLOROTHIA captopril & hydrochlorothiazide tab
25-15 mg
3
25-25 mg
3
50-15 mg
3
50-25 mg
3
CARDURA - doxazosin mesylate tab 1
mg
3
mg
3
mg
3
mg
3
CATAPRES - clonidine hcl tab 0.1 mg
3
3
3
CATAPRES-TTS-1 - clonidine hcl td
patch weekly 0.1 mg/24hr
3
3
3
clonidine hcl tab 0.1 mg (Catapres)
1
•
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
53
•
DIOVAN HCT - valsartanhydrochlorothiazide tab 320-25 mg
3
1
doxazosin mesylate tab 1 mg
(Cardura)
1
clonidine hcl td patch weekly
0.2 mg/24hr (Catapres-tts-2)
1
(Cardura)
1
1
(Cardura)
1
CLORPRES - clonidine & chlorthalidone
tab 0.1-15 mg
3
(Cardura)
1
tab 0.2-15 mg
3
2
tab 0.3-15 mg
3
DUTOPROL - metoprolol &
hydrochlorothiazide tab sr 24hr
25-12.5 mg
2
CORZIDE - nadolol &
bendroflumethiazide tab 40-5 mg
3
50-12.5 mg
3
COZAAR - losartan potassium tab 25
mg
3
•
100-12.5 mg
2
CORZIDE - nadolol &
bendroflumethiazide tab 80-5 mg
3
•
mg
3
•
EDARBI - azilsartan medoxomil tab 40
mg
3
•
mg
3
•
EDARBI - azilsartan medoxomil tab 80
mg
EDARBYCLOR - azilsartan medoxomilchlorthalidone tab 40-12.5 mg
3
•
DEMSER - metyrosine cap 250 mg
3
•
2
EDARBYCLOR - azilsartan medoxomilchlorthalidone tab 40-25 mg
3
DIBENZYLINE - phenoxybenzamine hcl
cap 10 mg
DIOVAN - valsartan tab 40 mg
2
2
2
enalapril maleate &
hydrochlorothiazide tab 5-12.5 mg
1
DIOVAN HCT - valsartanhydrochlorothiazide tab 80-12.5 mg
3
•
•
•
•
•
enalapril maleate &
hydrochlorothiazide tab 10-25 mg
(Vaseretic)
1
2
3
•
DIOVAN HCT - valsartanhydrochlorothiazide tab 160-25 mg
3
•
enalapril maleate tab 5 mg (Vasotec)
1
3
3
•
EPANED - enalapril maleate for oral
soln 1 mg/ml
eplerenone tab 25 mg (Inspra)
1
54
Dispensing Limits
Step Therapy
Prior Authorization
1
Drug Name
Drug Tier
Dispensing Limits
1
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
enalapril maleate tab 10 mg (Vasotec) 1
1
enalapril maleate tab 2.5 mg
(Vasotec)
enalapril maleate tab 20 mg (Vasotec) 1
3
•
1
HYZAAR - losartan potassium &
3
•
EXFORGE - amlodipine besylatevalsartan tab 5-160 mg
2
•
3
•
2
•
INSPRA - eplerenone tab 25 mg
3
2
•
INSPRA - eplerenone tab 50 mg
3
1
•
irbesartan tab 150 mg (Avapro)
2
1
2
•
1
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5
mg
irbesartan-hydrochlorothiazide tab
150-12.5 mg (Avalide)
1
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg
2
•
irbesartan-hydrochlorothiazide tab
300-12.5 mg (Avalide)
1
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 10-160-12.5
mg
2
•
lisinopril & hydrochlorothiazide tab
10-12.5 mg (Zestoretic)
1
1
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 10-160-25
mg
2
20-12.5 mg (Zestoretic)
20-25 mg (Zestoretic)
1
EXFORGE HCT - amlodipine-valsartanhydrochlorothiazide tab 10-320-25
mg
2
lisinopril tab 10 mg (Prinivil)
1
lisinopril tab 2.5 mg (Zestril)
1
1
1
fosinopril sodium &
lisinopril tab 30 mg (Zestril)
1
fosinopril sodium &
1
lisinopril tab 40 mg (Zestril)
1
1
fosinopril sodium tab 10 mg
1
3
1
LOPRESSOR HCT - metoprolol &
1
3
guanfacine hcl tab 1 mg (Tenex)
1
LOPRESSOR HCT - metoprolol &
1
hydralazine hcl inj 20 mg/ml
1
losartan potassium &
hydrochlorothiazide tab
100-12.5 mg (Hyzaar)
1
guanfacine hcl tab 2 mg (Tenex)
hydralazine hcl tab 10 mg
1
1
1
1
(Hyzaar)
1
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
eprosartan mesylate tab 600 mg
(Teveten)
Dispensing Limits
1
Step Therapy
eplerenone tab 50 mg (Inspra)
Prior Authorization
Drug Name
Drug Tier
2014
55
methyldopa tab 500 mg
1
METHYLDOPA/HYDROCHLOROTHI methyldopa & hydrochlorothiazide tab
250-15 mg
3
3
(Hyzaar)
1
losartan potassium tab 100 mg
(Cozaar)
1
(Cozaar)
1
(Cozaar)
1
METHYLDOPA/HYDROCHLOROTHI methyldopa & hydrochlorothiazide tab
250-25 mg
LOTENSIN - benazepril hcl tab 10 mg
metoprolol & hydrochlorothiazide
tab 100-25 mg (Lopressor hct)
1
3
3
1
3
tab 100-50 mg
LOTENSIN HCT - benazepril &
3
tab 50-25 mg (Lopressor hct)
1
3
MICARDIS - telmisartan tab 20 mg
2
2
3
2
•
LOTREL - amlodipine besylatebenazepril hcl cap 2.5-10 mg
MICARDIS HCT - telmisartanhydrochlorothiazide tab 40-12.5 mg
2
3
•
LOTREL - amlodipine besylatebenazepril hcl cap 5-10 mg
MICARDIS HCT - telmisartanhydrochlorothiazide tab 80-12.5 mg
2
3
•
MICARDIS HCT - telmisartanhydrochlorothiazide tab 80-25 mg
2
3
MINIPRESS - prazosin hcl cap 1 mg
3
3
3
3
3
minoxidil tab 10 mg
1
3
minoxidil tab 2.5 mg
1
moexipril hcl tab 15 mg (Univasc)
1
LYTENSOPRIL KIT - lisinopril tab 20 mg 3
& dietary management cap pack
LYTENSOPRIL-90 - lisinopril tab 20 mg 3
& dietary management cap pack
LYTENSOPRIL-90 KIT - lisinopril tab 20 3
3
MAVIK - trandolapril tab 1 mg
moexipril hcl tab 7.5 mg (Univasc)
1
moexipril-hydrochlorothiazide tab
15-12.5 mg (Uniretic)
1
15-25 mg
1
7.5-12.5 mg
1
3
1
3
nadolol & bendroflumethiazide tab
40-5 mg (Corzide)
56
Dispensing Limits
1
Step Therapy
methyldopa tab 250 mg
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
nadolol & bendroflumethiazide tab
80-5 mg (Corzide)
1
quinapril-hydrochlorothiazide tab
20-25 mg (Accuretic)
1
NEXICLON XR - clonidine hcl extended
release susp 0.09 mg/ml (base equiv)
3
ramipril cap 1.25 mg (Altace)
1
ramipril cap 10 mg (Altace)
1
NEXICLON XR - clonidine hcl tab sr
24hr 0.17 mg (base equivalent)
3
ramipril cap 2.5 mg (Altace)
1
1
ramipril cap 5 mg (Altace)
1
perindopril erbumine tab 2 mg
1
RESERPINE - reserpine tab 0.1 mg
3
(Aceon)
RESERPINE - reserpine tab 0.25 mg
3
(Aceon)
1
TARKA - trandolapril-verapamil hcl tab
cr 1-240 mg
3
PHENTOLAMINE MESYLATE phentolamine mesylate inj 5 mg/ml
3
cr 2-180 mg
3
PHENTOLAMINE MESYLATE phentolamine mesylate for inj 5 mg
3
cr 2-240 mg
3
prazosin hcl cap 1 mg (Minipress)
1
3
1
cr 4-240 mg
1
TEKAMLO - aliskiren-amlodipine tab
150-5 mg
3
•
PRINIVIL - lisinopril tab 5 mg
3
•
150-10 mg
3
3
3
3
•
PRINZIDE - lisinopril &
3
300-5 mg
3
•
PRINZIDE - lisinopril &
3
300-10 mg
3
•
PROPRANOLOL/HYDROCHLOROTH propranolol & hydrochlorothiazide tab
40-25 mg
3
TEKTURNA - aliskiren fumarate tab 150
TEKTURNA - aliskiren fumarate tab 300
3
•
PROPRANOLOL/HYDROCHLOROTH propranolol & hydrochlorothiazide tab
80-25 mg
3
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 150-12.5 mg
3
•
•
quinapril hcl tab 10 mg (Accupril)
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 150-25 mg
3
1
1
3
•
1
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 300-12.5 mg
1
3
•
10-12.5 mg (Accuretic)
1
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 300-25 mg
telmisartan tab 20 mg (Micardis)
1
20-12.5 mg (Accuretic)
1
1
1
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
57
telmisartan-amlodipine tab 40-10 mg
(Twynsta)
1
TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 40-5-25 mg
3
•
(Twynsta)
1
3
•
(Twynsta)
1
TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 40-10-12.5
mg
3
•
(Twynsta)
1
TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 40-10-25 mg
3
•
telmisartan-hydrochlorothiazide tab
40-12.5 mg (Micardis hct)
1
TWYNSTA - telmisartan-amlodipine tab
40-5 mg
3
•
80-12.5 mg (Micardis hct)
1
40-10 mg
3
•
80-25 mg (Micardis hct)
1
80-5 mg
3
•
TENEX - guanfacine hcl tab 1 mg
3
80-10 mg
TENEX - guanfacine hcl tab 2 mg
3
3
TENORETIC 100 - atenolol &
chlorthalidone tab 100-25 mg
3
UNIRETIC - moexiprilhydrochlorothiazide tab 7.5-12.5 mg
3
TENORETIC 50 - atenolol &
chlorthalidone tab 50-25 mg
3
UNIRETIC - moexiprilhydrochlorothiazide tab 15-12.5 mg
3
terazosin hcl cap 1 mg
1
UNIRETIC - moexiprilhydrochlorothiazide tab 15-25 mg
1
UNIVASC - moexipril hcl tab 7.5 mg
3
1
UNIVASC - moexipril hcl tab 15 mg
3
1
valsartan tab 160 mg (Diovan)
1
3
•
1
TEVETEN - eprosartan mesylate tab
400 mg
1
TEVETEN - eprosartan mesylate tab
600 mg
3
•
1
1
TEVETEN HCT - eprosartan mesylatehydrochlorothiazide tab 600-12.5 mg
3
•
valsartan-hydrochlorothiazide tab
160-12.5 mg (Diovan hct)
1
TEVETEN HCT - eprosartan mesylatehydrochlorothiazide tab 600-25 mg
3
•
160-25 mg (Diovan hct)
1
trandolapril tab 1 mg (Mavik)
1
1
1
1
320-25 mg (Diovan hct)
3
•
1
TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 20-5-12.5 mg
3
•
VALTURNA - aliskiren-valsartan tab
150-160 mg
3
TRIBENZOR - olmesartan-amlodipinehydrochlorothiazide tab 40-5-12.5 mg
58
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
VALTURNA - aliskiren-valsartan tab
300-320 mg
3
ALDACTAZIDE - spironolactone &
3
VASERETIC - enalapril maleate &
3
ALDACTAZIDE - spironolactone &
3
VASOTEC - enalapril maleate tab 2.5
mg
3
ALDACTONE - spironolactone tab 25
mg
3
VASOTEC - enalapril maleate tab 5 mg
3
3
VASOTEC - enalapril maleate tab 10
mg
3
mg
3
VASOTEC - enalapril maleate tab 20
mg
3
mg
1
VECAMYL - mecamylamine hcl tab 2.5
mg
3
amiloride & hydrochlorothiazide tab
5-50 mg
amiloride hcl tab 5 mg
1
ZESTORETIC - lisinopril &
3
bumetanide inj 0.25 mg/ml
1
bumetanide tab 0.5 mg
1
3
bumetanide tab 1 mg
1
3
bumetanide tab 2 mg
1
3
ZESTRIL - lisinopril tab 2.5 mg
3
CHLOROTHIAZIDE - chlorothiazide tab
250 mg
3
chlorothiazide tab 250 mg
1
ZESTRIL - lisinopril tab 5 mg
3
chlorothiazide tab 500 mg
1
3
CHLORTHALIDONE - chlorthalidone
tab 25 mg
3
3
3
tab 50 mg
3
ZIAC - bisoprolol & hydrochlorothiazide
tab 2.5-6.25 mg
3
tab 100 mg
3
tab 5-6.25 mg
3
chlorthalidone tab 25 mg
1
DEMADEX - torsemide tab 5 mg
3
tab 10-6.25 mg
3
3
3
3
DIAMOX - acetazolamide cap sr 12hr
500 mg
3
DIURIL - chlorothiazide susp 250
mg/5ml
3
DYAZIDE - triamterene &
hydrochlorothiazide cap 37.5-25 mg
3
DIURETICS
ACETAZOLAMIDE - acetazolamide tab
125 mg
3
acetazolamide cap sr 12hr 500 mg
(Diamox)
1
acetazolamide sodium for inj 500 mg
1
acetazolamide tab 250 mg
1
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
59
FUROSEMIDE - furosemide oral soln 8
mg/ml
3
furosemide inj 10 mg/ml
1
furosemide oral soln 10 mg/ml
1
furosemide tab 20 mg (Lasix)
NEPTAZANE - methazolamide tab 50
mg
3
spironolactone &
(Aldactazide)
1
spironolactone tab 100 mg
(Aldactone)
1
1
1
spironolactone tab 25 mg (Aldactone)
1
1
spironolactone tab 50 mg (Aldactone)
1
hydrochlorothiazide cap 12.5 mg
(Microzide)
1
THALITONE - chlorthalidone tab 15 mg
3
torsemide tab 10 mg (Demadex)
1
hydrochlorothiazide tab 12.5 mg
1
1
hydrochlorothiazide tab 25 mg
1
1
hydrochlorothiazide tab 50 mg
1
1
indapamide tab 1.25 mg
1
indapamide tab 2.5 mg
triamterene & hydrochlorothiazide
cap 37.5-25 mg (Dyazide)
1
1
INTROL - glycerin soln 75%
3
1
LASIX - furosemide tab 20 mg
3
tab 37.5-25 mg (Maxzide-25)
3
1
3
tab 75-50 mg (Maxzide)
3
TRIAMTERENE/HYDROCHLOROTH triamterene & hydrochlorothiazide
cap 50-25 mg
3
MAXZIDE - triamterene &
MAXZIDE-25 - triamterene &
hydrochlorothiazide tab 37.5-25 mg
3
ZAROXOLYN - metolazone tab 2.5 mg
3
1
ZAROXOLYN - metolazone tab 5 mg
3
methazolamide tab 25 mg
(Neptazane)
methazolamide tab 50 mg
(Neptazane)
1
ADRENACLICK - epinephrine solution
auto-injector 0.15 mg/0.15ml (1:1000)
3
METHYCLOTHIAZIDE methyclothiazide tab 5 mg
3
ADRENACLICK - epinephrine solution
3
metolazone tab 10 mg
1
3
metolazone tab 2.5 mg (Zaroxolyn)
1
AUVI-Q - epinephrine solution autoinjector 0.15 mg/0.15ml (1:1000)
1
AUVI-Q - epinephrine solution autoinjector 0.3 mg/0.3ml (1:1000)
3
metolazone tab 5 mg (Zaroxolyn)
MICROZIDE - hydrochlorothiazide cap
12.5 mg
3
EPINEPHRINE - epinephrine solution
3
60
Dispensing Limits
3
3
Step Therapy
EDECRIN - ethacrynic acid tab 25 mg
NEPTAZANE - methazolamide tab 25
mg
Prior Authorization
3
Drug Name
Drug Tier
DYRENIUM - triamterene cap 100 mg
Dispensing Limits
3
Step Therapy
DYRENIUM - triamterene cap 50 mg
Prior Authorization
Drug Name
Drug Tier
2014
VASOPRESSORS
EPINEPHRINE - epinephrine solution
3
ANTARA - fenofibrate micronized cap
130 mg
3
EPIPEN 2-PAK - epinephrine solution
2
atorvastatin calcium tab 10 mg (base
equivalent) (Lipitor)
1
EPIPEN-JR 2-PAK - epinephrine
solution auto-injector 0.15 mg/0.3ml
(1:2000)
2
1
1
1
midodrine hcl tab 10 mg
midodrine hcl tab 2.5 mg
1
1
midodrine hcl tab 5 mg
1
NORTHERA - droxidopa cap 100 mg
3
1
3
cholestyramine light powder packets
4 gm
3
cholestyramine light powder 4 gm/
dose (Questran light)
1
TWINJECT - epinephrine solution autoinjector 0.15 mg/0.15ml (1:1000)
3
cholestyramine powder packets
4 gm (Questran)
1
TWINJECT - epinephrine solution autoinjector 0.3 mg/0.3ml (1:1000)
3
cholestyramine powder 4 gm/dose
(Questran)
1
choline fenofibrate cap dr 135 mg
(fenofibric acid equiv) (Trilipix)
1
•
1
•
choline fenofibrate cap dr 45 mg
(fenofibric acid equiv) (Trilipix)
COLESTID - colestipol hcl tab 1 gm
3
COLESTID - colestipol hcl granules 5
gm
3
COLESTID - colestipol hcl granule
packets 5 gm
3
COLESTID FLAVORED - colestipol hcl
granules 5 gm
3
COLESTID FLAVORED - colestipol hcl
granule packets 5 gm
3
colestipol hcl granule packets 5 gm
(Colestid flavored)
1
ANTIHYPERLIPIDEMICS
ADVICOR - niacin-lovastatin tab sr 24hr
500-20 mg
3
750-20 mg
3
1000-20 mg
3
•
1000-40 mg
3
•
ALTOPREV - lovastatin tab sr 24hr 20
mg
3
•
mg
3
•
mg
3
•
30 mg
3
43 mg
3
90 mg
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
colestipol hcl granules 5 gm (Colestid 1
flavored)
1
colestipol hcl tab 1 gm (Colestid)
2
•
CRESTOR - rosuvastatin calcium tab 10 2
mg
•
CRESTOR - rosuvastatin calcium tab 5
mg
61
4
•
•
LESCOL - fluvastatin sodium cap 20 mg
3
LESCOL - fluvastatin sodium cap 40 mg
3
3
•
•
•
FENOFIBRATE - fenofibrate cap 150
mg
3
LESCOL XL - fluvastatin sodium tab sr
24 hr 80 mg
•
1
LIPITOR - atorvastatin calcium tab 10
3
fenofibrate micronized cap 130 mg
(Lofibra)
1
3
•
(Lofibra)
1
3
•
1
3
•
(Lofibra)
1
LIPOFEN - fenofibrate cap 50 mg
2
fenofibrate tab 145 mg (Tricor)
1
LIPOFEN - fenofibrate cap 150 mg
2
fenofibrate tab 160 mg (Lofibra)
1
3
•
fenofibrate tab 48 mg (Tricor)
1
LIPTRUZET - ezetimibe-atorvastatin tab
10-10 mg
fenofibrate tab 54 mg (Lofibra)
1
3
•
FENOFIBRIC ACID - fenofibric acid tab
35 mg
3
10-20 mg
3
•
FENOFIBRIC ACID - fenofibric acid tab
105 mg
3
10-40 mg
3
•
FENOGLIDE - fenofibrate tab 40 mg
3
10-80 mg
3
LIVALO - pitavastatin calcium tab 1 mg
(base equiv)
3
FENOGLIDE - fenofibrate tab 120 mg
•
FIBRICOR - fenofibric acid tab 35 mg
3
•
FIBRICOR - fenofibric acid tab 105 mg
(base equiv)
3
3
fluvastatin sodium cap 20 mg
(Lescol)
1
(base equiv)
3
•
fluvastatin sodium cap 40 mg
(Lescol)
1
LOFIBRA - fenofibrate tab 54 mg
3
LOFIBRA - fenofibrate tab 160 mg
3
gemfibrozil tab 600 mg (Lopid)
1
4
•
LOFIBRA - fenofibrate micronized cap
67 mg
3
JUXTAPID - lomitapide mesylate cap 5
mg (base equiv)
•
134 mg
3
JUXTAPID - lomitapide mesylate cap 10 4
mg (base equiv)
JUXTAPID - lomitapide mesylate cap 20 4
mg (base equiv)
200 mg
3
•
LOPID - gemfibrozil tab 600 mg
3
62
Dispensing Limits
KYNAMRO - mipomersen sodium inj
200 mg/ml
Drug Name
Step Therapy
Prior Authorization
•
Dispensing Limits
Drug Tier
mg
mg
FENOFIBRATE - fenofibrate cap 50 mg 3
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
lovastatin tab 40 mg (Mevacor)
1
LOVAZA - omega-3-acid ethyl esters
cap 1 gm
3
MEVACOR - lovastatin tab 20 mg
3
MEVACOR - lovastatin tab 40 mg
3
niacin tab cr 1000 mg
(antihyperlipidemic) (Niaspan)
1
1
1
NIACOR - niacin (antihyperlipidemic)
tab 500 mg
3
NIASPAN - niacin tab cr 500 mg
(antihyperlipidemic)
3
3
3
omega-3-acid ethyl esters cap 1 gm
(Lovaza)
1
PRAVACHOL - pravastatin sodium tab
20 mg
3
•
40 mg
3
•
80 mg
3
pravastatin sodium tab 10 mg
1
(Pravachol)
1
(Pravachol)
1
(Pravachol)
1
QUESTRAN - cholestyramine powder 4
gm/dose
3
•
•
•
QUESTRAN LIGHT - cholestyramine
light powder 4 gm/dose
3
QUESTRAN LIGHT - cholestyramine
light powder packets 4 gm
3
SIMCOR - niacin-simvastatin tab sr 24hr 3
500-20 mg
500-40 mg
750-20 mg
1000-20 mg
1000-40 mg
1
simvastatin tab 10 mg (Zocor)
•
•
•
•
•
1
1
1
1
TRICOR - fenofibrate tab 48 mg
3
TRICOR - fenofibrate tab 145 mg
3
TRIGLIDE - fenofibrate tab 50 mg
3
TRIGLIDE - fenofibrate tab 160 mg
3
TRILIPIX - choline fenofibrate cap dr 45
mg (fenofibric acid equiv)
3
TRILIPIX - choline fenofibrate cap dr
135 mg (fenofibric acid equiv)
3
VASCEPA - icosapent ethyl cap 1 gm
3
VYTORIN - ezetimibe-simvastatin tab
10-10 mg
3
•
10-20 mg
3
•
10-40 mg
3
•
10-80 mg
3
•
Dispensing Limits
1
3
Step Therapy
lovastatin tab 20 mg (Mevacor)
QUESTRAN - cholestyramine powder
packets 4 gm
Prior Authorization
1
Drug Name
Drug Tier
lovastatin tab 10 mg
Dispensing Limits
Step Therapy
Drug Name
Drug Tier
Prior Authorization
2014
63
WELCHOL - colesevelam hcl tab 625
mg
2
amlodipine besylate-atorvastatin
calcium tab 5-80 mg (Caduet)
1
WELCHOL - colesevelam hcl packet for
susp 3.75 gm
2
BIDIL - isosorbide dinitrate-hydralazine
hcl tab 20-37.5 mg
3
ZETIA - ezetimibe tab 10 mg
2
3
ZOCOR - simvastatin tab 5 mg
3
CADUET - amlodipine besylateatorvastatin calcium tab 2.5-10 mg
3
3
3
3
3
3
CADUET - amlodipine besylateatorvastatin calcium tab 5-10 mg
3
3
3
3
CARDIOVASCULAR AGENTS - MISC.
•
•
•
•
•
ADCIRCA - tadalafil tab 20 mg (pah)
4
ADEMPAS - riociguat tab 0.5 mg
4
ADEMPAS - riociguat tab 1 mg
4
4
ADEMPAS - riociguat tab 2 mg
4
4
3
1
3
1
3
1
1
3
CAVERJECT - alprostadil for inj 20 mcg
3
calcium tab 2.5-10 mg (Caduet)
1
CAVERJECT - alprostadil for inj 40 mcg
3
1
CAVERJECT IMPULSE - alprostadil for
inj kit 10 mcg
3
•
•
•
1
CAVERJECT IMPULSE - alprostadil for
inj kit 20 mcg
3
•
1
CIALIS - tadalafil tab 2.5 mg
2
CIALIS - tadalafil tab 5 mg
2
1
2
2
1
EDEX - alprostadil for inj kit 10 mcg
3
3
3
•
•
•
•
•
•
•
64
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
•
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
epoprostenol sodium for inj 0.5 mg
(Flolan)
4
REMODULIN - treprostinil sodium inj 5
mg/ml (base equiv)
4
epoprostenol sodium for inj 1.5 mg
(Flolan)
4
mg/ml (base equiv)
4
FLOLAN - epoprostenol sodium for inj
0.5 mg
4
REVATIO - sildenafil citrate tab 20 mg
4
4
REVATIO - sildenafil citrate iv soln 10
mg/12.5ml (base equivalent)
4
FLOLAN - epoprostenol sodium for inj
1.5 mg
sildenafil citrate tab 20 mg (Revatio)
4
ISOXSUPRINE HCL - isoxsuprine hcl
tab 20 mg
3
STAXYN - vardenafil hcl orally
disintegrating tab 10 mg
3
•
•
isoxsuprine hcl tab 10 mg
1
STENDRA - avanafil tab 50 mg
3
LETAIRIS - ambrisentan tab 5 mg
4
3
LETAIRIS - ambrisentan tab 10 mg
4
3
•
•
•
LEVITRA - vardenafil hcl tab 2.5 mg
3
TRACLEER - bosentan tab 62.5 mg
4
LEVITRA - vardenafil hcl tab 5 mg
3
TRACLEER - bosentan tab 125 mg
4
3
3
MUSE - alprostadil urethral pellet 125
mcg
3
•
•
•
•
•
•
•
•
mcg
3
•
mcg
3
•
mcg
3
•
OPSUMIT - macitentan tab 10 mg
4
ORENITRAM - treprostinil diolamine tab
cr 0.125 mg (base equiv)
4
4
cr 1 mg (base equiv)
4
•
•
•
•
•
•
4
mg/ml (base equiv)
4
REMODULIN - treprostinil sodium inj 2.5 4
mg/ml (base equiv)
•
•
•
•
TYVASO - treprostinil inhalation solution 4
0.6 mg/ml
TYVASO REFILL - treprostinil inhalation 4
solution 0.6 mg/ml
4
TYVASO STARTER - treprostinil
inhalation solution 0.6 mg/ml
4
VELETRI - epoprostenol sodium for inj
0.5 mg
4
VELETRI - epoprostenol sodium for inj
1.5 mg
VENTAVIS - iloprost inhalation solution 4
10 mcg/ml
VENTAVIS - iloprost inhalation solution 4
20 mcg/ml
3
VIAGRA - sildenafil citrate tab 25 mg
3
3
RESPIRATORY AGENTS
ANTIHISTAMINES
AEROHIST - chlorpheniraminemethscopolamine tab sr 12hr 8-2.5
mg
3
brompheniramine maleate tab sr
12hr 6 mg
1
65
BROMPHENIRAMINE TANNATE brompheniramine tannate chew tab
12 mg
3
carbinoxamine maleate soln
4 mg/5ml (Palgic)
1
carbinoxamine maleate tab 4 mg
(Palgic)
1
cetirizine hcl oral soln 1 mg/ml
(5 mg/5ml)
1
CLARINEX - desloratadine tab 5 mg
3
CLARINEX - desloratadine syrup 0.5
mg/ml
3
CLARINEX REDITABS - desloratadine
tab orally disintegrating 2.5 mg
3
CLARINEX REDITABS - desloratadine
tab orally disintegrating 5 mg
3
CLEMASTINE FUMARATE - clemastine 3
fumarate syrup 0.67 mg/5ml (0.5
mg/5ml base eq)
1
clemastine fumarate syrup
0.67 mg/5ml (0.5 mg/5ml base eq)
1
clemastine fumarate tab 2.68 mg
Dispensing Limits
Step Therapy
DOXYTEX - doxylamine succinate liquid 3
2.5 mg/2.5ml
3
ED CHLORPED - chlorpheniramine
tannate susp 2 mg/ml
3
ED-CHLOR-TAN - chlorpheniramine
tannate tab 8 mg
3
FEXOFENADINE HCL - fexofenadine
hcl tab 60 mg
KARBINAL ER - carbinoxamine maleate 3
er susp 4 mg/5ml
1
levocetirizine dihydrochloride soln
2.5 mg/5ml (0.5 mg/ml) (Xyzal)
1
levocetirizine dihydrochloride tab
5 mg (Xyzal)
PALGIC - carbinoxamine maleate tab 4 3
mg
PALGIC - carbinoxamine maleate soln 4 3
mg/5ml
3
PBZ - tripelennamine hcl tab 50 mg
PHENERGAN - promethazine hcl inj 25
mg/ml
3
PHENERGAN - promethazine hcl inj 50
mg/ml
3
promethazine hcl inj 25 mg/ml
(Phenergan)
1
promethazine hcl inj 50 mg/ml
(Phenergan)
1
promethazine hcl suppos 12.5 mg
1
promethazine hcl suppos 25 mg
1
promethazine hcl suppos 50 mg
1
promethazine hcl syrup 6.25 mg/5ml
1
promethazine hcl tab 12.5 mg
1
promethazine hcl tab 25 mg
1
cyproheptadine hcl syrup 2 mg/5ml
1
cyproheptadine hcl tab 4 mg
1
desloratadine tab orally
disintegrating 2.5 mg (Clarinex
reditabs)
1
desloratadine tab orally
disintegrating 5 mg (Clarinex
reditabs)
1
desloratadine tab 5 mg (Clarinex)
1
DEXCHLORPHENIRAMINE MALEA dexchlorpheniramine maleate syrup 2
mg/5ml
3
diphenhydramine hcl cap 50 mg
1
promethazine hcl tab 50 mg
1
diphenhydramine hcl elixir
12.5 mg/5ml
1
RESPA-BR - brompheniramine maleate
tab sr 12hr 11 mg
3
diphenhydramine hcl inj 50 mg/ml
1
3
diphenhydramine hcl syrup
12.5 mg/5ml
1
XYZAL - levocetirizine dihydrochloride
tab 5 mg
66
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
XYZAL - levocetirizine dihydrochloride
soln 2.5 mg/5ml (0.5 mg/ml)
Dispensing Limits
Step Therapy
Prior Authorization
NASACORT AQ - triamcinolone
acetonide nasal inhal 55 mcg/act
3
•
NASONEX - mometasone furoate nasal
susp 50 mcg/act
2
•
3
•
•
OMNARIS - ciclesonide nasal susp 50
mcg/act
3
•
•
PATANASE - olopatadine hcl nasal soln
0.6%
3
•
•
QNASL - beclomethasone dipropionate
nasal aerosol 80 mcg/act
RHINOCORT AQUA - budesonide nasal 3
susp 32 mcg/act
1
triamcinolone acetonide nasal inhal
55 mcg/act (Nasacort aq)
TYZINE - tetrahydrozoline hcl nasal soln 3
0.1%
3
TYZINE PEDIATRIC NASAL DR tetrahydrozoline hcl nasal soln 0.05%
3
VERAMYST - fluticasone furoate nasal
susp 27.5 mcg/spray
3
ZETONNA - ciclesonide nasal aerosol
soln 37 mcg/act (50 mcg/valve)
•
3
NASAL AGENTS - SYSTEMIC and TOPICAL
3
ADRENALIN - epinephrine hcl nasal
soln 0.1%
3
ASTELIN - azelastine hcl nasal spray
137 mcg/spray (1 mg/ml)
3
ASTEPRO - azelastine hcl nasal spray
0.15% (205.5 mcg/spray)
ATROVENT - ipratropium bromide nasal 3
soln 0.03% (21 mcg/spray)
ATROVENT - ipratropium bromide nasal 3
soln 0.06% (42 mcg/spray)
1
azelastine hcl nasal spray 0.15%
(205.5 mcg/spray) (Astepro)
1
azelastine hcl nasal spray 137 mcg/
spray (1 mg/ml)
3
BACTROBAN NASAL - mupirocin
calcium nasal oint 2%
3
BECONASE AQ - beclomethasone
dipropionate monohyd nasal susp 42
mcg/spray
1
budesonide nasal susp 32 mcg/act
(Rhinocort aqua)
3
DYMISTA - azelastine hcl-fluticasone
prop nasal spray 137-50 mcg/act
3
FLONASE - fluticasone propionate
nasal susp 50 mcg/act
3
FLUNISOLIDE - flunisolide nasal soln
25 mcg/act (0.025%)
3
FLUNISOLIDE - flunisolide nasal soln
29 mcg/act (0.025%)
1
flunisolide nasal soln 25 mcg/act
(0.025%) (Flunisolide)
1
fluticasone propionate nasal susp
50 mcg/act (Flonase)
1
ipratropium bromide nasal soln
0.03% (21 mcg/spray) (Atrovent)
1
ipratropium bromide nasal soln
0.06% (42 mcg/spray) (Atrovent)
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
•
•
•
•
•
•
•
COUGH/COLD/ALLERGY
acetylcysteine inhal soln 10%
1
acetylcysteine inhal soln 20%
1
•
ALAHIST AC - phenylephrine w/
codeine liqd 7.5-10 mg/5ml
3
•
ALAHIST DHC - phenylephrinedihydrocodeine liqd 7.5-3 mg/5ml
3
•
ALBATUSSIN - phenylephrinecarbetapentane-gg cap 10-25-400 mg
3
•
ALBATUSSIN NN - phenyleph-dm-pyrilpot guai-sod cit-cit acid liquid
3
•
ALLFEN CD - guaifenesin-codeine tab
400-10 mg
3
•
ALLFEN CDX - guaifenesin-codeine tab
400-20 mg
3
•
ALLFEN CDX - guaifenesin-codeine
liquid 200-20 mg/5ml
3
•
•
67
AMBIFED CD - pseudoephedrine w/
cod-gg tab 30-10-400 mg
3
COTAB A - chlorpheniramine w/
codeine tab 4-10 mg
3
AMBIFED CDX - pseudoephedrine w/
3
COTAB AX - chlorpheniramine w/
codeine tab 4-20 mg
3
AMBIFED-G CD - pseudoephedrine w/
3
COTABFLU - codeinechlorpheniramine-acetaminophen tab
20-4-500 mg
3
CPB WC - pseudoephedrine-bromphencodeine liq 10-1.3-6.3 mg/5ml
3
DECON-A - brompheniramine &
phenylephrine elixir 2-5 mg/5ml
3
DECON-G - phenylephrinebrompheniramine-guaifenesin liqd
2-1-40 mg/ml
3
DESPEC-EXP - pseudoephedrinedihydrocodeine-gg syrup 15-7.5-100
mg/5ml
3
DESPEC-PDC - phenylephrinechlorphen-dihydrocodeine liqd
7.5-2.5-3 mg/5ml
3
DEX-TUSS - guaifenesin-codeine liquid
300-10 mg/5ml
3
DEXTROMETHORPHAN HBR/CHLO phenylephrine-chlorphen-dm liquid
1.75-0.75-2.75 mg/ml
3
DONATUSS DC - phenylephrinedihydrocodeine-gg syrup 7.5-7.5-50
mg/5ml
3
ENDACOF-DC - pseudoephedrine w/
codeine liquid 30-10 mg/5ml
3
EXACTUSS - phenylephrine w/ dm-gg
liqd 10-28-388 mg/5ml
3
GILPHEX TR - phenylephrineguaifenesin tab 10-388 mg
3
3
AMBIFED-G CDX - pseudoephedrine w/ 3
1
benzonatate cap 100 mg (Tessalon
perles)
1
benzonatate cap 200 mg
brompheniramine & phenylephrine
susp 6-10 mg/5ml
1
brompheniramine &
pseudoephedrine tab sr 12hr
6-45 mg
1
BRONCOPECTOL - phenylephchlorphen w/ dm-gg syrup 5-2-5-75
mg/5ml
3
CAPCOF - phenylephrine-chlorphen w/
codeine syrup 5-2-10 mg/5ml
3
CARBAPHEN 12 - phenylephchlorphen-carbetapentane liqd
10-4-27.5 mg/5ml
3
CARBAPHEN 12 PED - phenylephchlorphen-carbetapentane susp
2.5-1.25-7.5 mg/ml
3
chlorpheniramine w/ codeine liquid
2-10 mg/5ml
1
CLARINEX-D 12 HOUR - desloratadine
& pseudoephedrine tab sr 12hr
2.5-120 mg
3
CLARINEX-D 24 HOUR - desloratadine
& pseudoephedrine tab sr 24hr 5-240
mg
3
CODAR AR - chlorpheniramine w/
3
GILTUSS - phenylephrine w/ dm-gg liqd
10-28-388 mg/5ml
3
CODAR D - pseudoephedrine w/
3
GILTUSS PED-C - phenylephrine w/
codeine-gg liquid 2.5-3-50 mg/ml
3
CODAR GF - guaifenesin-codeine liquid
200-8 mg/5ml
3
GILTUSS TR - phenylephrine w/ dm-gg
cap 7-14-288 mg
68
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
tab 10-28-388 mg
3
tab sr 12hr 20-30-600 mg
3
guaifenesin-codeine liquid
225-7.5 mg/5ml
MAR-COF BP - pseudoephedrinebromphen-codeine liqd 30-2-7.5
mg/5ml
3
3
1
MAR-COF CG EXPECTORANT guaifenesin-codeine liquid 225-7.5
mg/5ml
guaifenesin-codeine soln
100-10 mg/5ml
1
MAXIFED CD - pseudoephedrine w/
3
guaifenesin-codeine soln
100-6.3 mg/5ml
1
MAXIFED CDX - pseudoephedrine w/
3
hydrocod polst-chlorphen polst
cr susp 10-8 mg/5ml (Tussionex
pennkineti)
1
MAXIFED-G CD - pseudoephedrine w/
3
hydrocodone w/ homatropine syrup
5-1.5 mg/5ml
1
hydrocodone w/ homatropine tab
5-1.5 mg
1
HYPER-SAL - sodium chloride soln
nebu 7%
3
HYPERSAL - sodium chloride soln nebu 3
3.5%
HYPERSAL - sodium chloride soln nebu 3
7%
J-COF DHC - pseudoephed-bromphen- 3
dihydrocodeine liqd 15-3-7.5 mg/5ml
3
J-MAX DHC - dihydrocodeineguaifenesin liquid 7.5-100 mg/5ml
LARTUS - phenyleph-chlorphen w/ dm- 3
gg liquid 5-2-15-150 mg/5ml
3
LORTUSS EX - pseudoephedrine w/
cod-gg liqd 22.5-10-100 mg/5ml
3
M-CLEAR - guaifenesin-codeine cap
200-9 mg
3
M-END MAX D - pseudoephedrinedexbromphen-codeine liqd
20-0.667-6 mg/5ml
3
M-END PE - phenylephrine-bromphen
w/ codeine liqd 3.33-1.33-6.33
mg/5ml
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
MAXIFED-G CDX - pseudoephedrine w/ 3
3
MAXIFLU CD - pseudoephed-codeineguaifenesin-apap tab 40-10-400-500
mg
MAXIFLU CDX - pseudoephed-codeine- 3
guaifenesin-apap tab 60-20-400-500
mg
3
MAXIPHEN CD - phenylephrine w/
codeine-gg tab 10-10-400 mg
3
MAXIPHEN CDX - phenylephrine w/
codeine-gg tab 10-20-400 mg
3
NEBUSAL - sodium chloride soln nebu
6%
NEO AC - pseudoephedrine-pyrilamine- 3
codeine syrup 30-15-10 mg/5ml
3
NEOTUSS PLUS - phenylephrinechlorphen-dm liquid 7.5-4-30 mg/5ml
NEOTUSS-D - pseudoephed-chlorphen 3
w/ dm-gg liqd 30-2-30-200 mg/5ml
3
NORTUSS-EX - dextromethorphanguaifenesin liquid 20-200 mg/5ml
3
NOTUSS-NX - codeine-chlorcyclizine
liquid 10-9.375 mg/5ml
3
NOTUSS-NXD - codeinepseudoephedrine-chlorcyclizine liq
10-30-9.375mg/5ml
69
PANATUSS DXP - phenylephrinedexbromphen-dm-gg liquid
5-1-15-100 mg/5ml
3
POLY-TUSSIN - codeine-chlorcyclizine
liquid 10-9.375 mg/5ml
3
PEDIATEX TD - triprolidine &
pseudoephedrine liquid 0.938-10 mg/
ml
POLY-TUSSIN AC - phenylephrinebromphen w/ codeine liqd 7.5-4-10
mg/5ml
3
3
3
PEDIATEX TDM - pseudoephedtriprolidine-dm susp 10-0.938-4 mg/
ml
3
POLY-TUSSIN AC - phenylephrinebromphen w/ codeine liquid 10-4-10
mg/5ml
3
POLY-TUSSIN D - codeinepseudoephedrine-chlorcyclizine liq
10-30-9.375mg/5ml
3
PHENFLU CD - phenylephrine-codeineguaifenesin-apap tab 10-10-400-500
mg
PHENFLU CDX - phenylephrinecodeine-guaifenesin-apap tab
10-20-400-500 mg
POLY-TUSSIN DHC - phenylephrinebromphen-dihydrocodeine liqd
7.5-4-3 mg/5ml
3
3
phenylephrine w/ dm-gg liqd
10-15-300 mg/5ml
POLY-TUSSIN EX - phenylephrinedihydrocodeine-gg syrup 5-7.5-50
mg/5ml
3
1
10-30-200 mg/5ml
1
PRO-CLEAR AC - codeine-pyrilamine
syrup 9-8.33 mg/5ml
3
2.5-5-50 mg/ml
1
3
2.5-7.5-88 mg/ml
1
PRO-RED AC - phenylephrinepyrilamine w/ codeine syrup 5-8.33-9
mg/5ml
3
phenylephrine-brompheniramine-dm
liquid 7.5-4-15 mg/5ml
1
PRO-RED AC - phenylephrinedexchlorphenir-codeine syrup 5-1-9
mg/5ml
phenylephrine-chlorphen-dm liquid
1.5-1-3 mg/ml
1
promethazine & phenylephrine syrup
6.25-5 mg/5ml
1
phenylephrine-guaifenesin liqd
7.5-100 mg/5ml (1.5-20 mg/ml)
1
3
phenylephrine-promethazine w/
codeine syrup 5-6.25-10 mg/5ml
1
PROMETHAZINE VC PLAIN promethazine & phenylephrine syrup
6.25-5 mg/5ml
3
PHENYLHISTINE DH pseudoephedrine-chlorphen w/
codeine liq 30-2-10 mg/5ml
3
PROMETHAZINE VC/CODEINE phenylephrine-promethazine w/
codeine syrup 5-6.25-10 mg/5ml
1
POLY HIST DHC - phenylephrinepyrilamine-dihydrocod liqd 5-7.5-7.5
mg/5ml
3
promethazine w/ codeine syrup
6.25-10 mg/5ml
promethazine-dm syrup
6.25-15 mg/5ml
1
POLY HIST NC - pseudoephedrinetriprolidine w/ cod liquid 15-1.25-10
mg/5ml
3
PROTID - chlorphen-phenylephrine w/
apap tab cr 8-40-500 mg
3
pseudoeph-chlorphen w/
hydrocodone soln 60-4-5 mg/5ml
(Zutripro)
1
70
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
pseudoephed-bromphen-dm syrup
30-2-10 mg/5ml
1
pseudoephedrine w/ cod-gg soln
30-10-100 mg/5ml
1
pseudoephedrine w/ cod-gg syrup
30-10-100 mg/5ml (Suttar-sf)
1
pseudoephedrine-bromphen-codeine
liq 10-1.33-6.33 mg/5ml
1
RELHIST - bromphen tan-phenyleph tan 3
chew tab 6-15 mg
3
RESCON-JR - chlorpheniramine &
phenylephrine tab sr 12hr 4-20 mg
3
RESCON-JR - dexchlorpheniraminephenylephrine tab sr 12hr 3-20 mg
3
RESCON-MX - dexchlorpheniraminephenylephrine tab sr 12hr 6-40 mg
3
REZIRA - pseudoephedrine w/
hydrocodone soln 60-5 mg/5ml
3
RYDEX - pseudoephedrine-bromphencodeine liq 10-1.33-6.33 mg/5ml
3
SEMPREX-D - acrivastine &
pseudoephedrine cap 8-60 mg
1
sodium chloride soln nebu 0.9%
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
TGQ 15DM/5PEH/2CPM phenylephrine-chlorphen-dm syrup
5-2-15 mg/5ml
3
TGQ 30PSE/150GFN/15DM pseudoephedrine w/ dm-gg syrup
30-15-150 mg/5ml
3
TGQ 30PSE/3BRM/15DM pseudoephed-bromphen-dm syrup
30-3-15 mg/5ml
3
TGQ 50PSE/3BRM/30DM pseudoephed-bromphen-dm syrup
50-3-30 mg/5ml
1
TRICODE AR - pseudoephedrinechlorphen w/ codeine liq 30-2-8
mg/5ml
3
TRICODE GF - pseudoephedrine w/
cod-gg liquid 30-8-200 mg/5ml
3
TUSNEL - brompheniramine w/ dm-gg
cap 2-15-200 mg
3
TUSSICAPS - hydrocod polst-chlorphen
polst cap sr 12hr 5-4 mg
3
•
TUSSICAPS - hydrocod polst-chlorphen
polst cap sr 12hr 10-8 mg
3
•
TUSSIONEX PENNKINETIC EXT hydrocod polst-chlorphen polst cr
susp 10-8 mg/5ml
3
•
VANACOF CD - phenylephrinedexchlorphenir-codeine liquid 5-1-10
mg/5ml
3
VITUZ - hydrocodone-chlorpheniramine
soln 5-4 mg/5ml
3
sodium chloride soln nebu 10%
1
1
(Hyper-sal)
1
STATUSS GREEN - codeinepseudoephedrine-chlorcyclizine liq
9-30-12.5 mg/5ml
3
SUTTAR-SF - pseudoephedrine w/ codgg syrup 30-10-100 mg/5ml
3
Z-TUSS AC - chlorpheniramine w/
3
SUTTAR-2 - pseudoephedrine w/ codgg syrup 30-10-100 mg/5ml
3
Z-TUSS E - pseudoephedrine w/ cod-gg
liquid 30-9-200 mg/5ml
3
TEKRAL - diphenhydramine &
pseudoephedrine tab sr 12hr 100-120
mg
3
ZODRYL AC 25 - chlorpheniramine w/
codeine susp 0.333-1 mg/ml
3
3
TESSALON - benzonatate cap 200 mg
3
TESSALON PERLES - benzonatate cap 3
100 mg
3
71
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 500-50
mcg/dose
2
•
ADVAIR HFA - fluticasone-salmeterol
inhal aerosol 45-21 mcg/act
2
•
2
•
2
•
AEROSPAN - flunisolide hfa inhal
aerosol 80 mcg/act
3
•
albuterol sulfate soln nebu 0.083%
(2.5 mg/3ml)
1
3
albuterol sulfate soln nebu 0.5%
(5 mg/ml)
1
3
albuterol sulfate soln nebu
0.63 mg/3ml (base equiv)
1
ZODRYL DEC 30 - pseudoephedrine w/
cod-gg susp 4.286-1-20 mg/ml
3
albuterol sulfate soln nebu
1
3
albuterol sulfate syrup 2 mg/5ml
1
1
ZONATUSS - benzonatate cap 150 mg
3
albuterol sulfate tab sr 12hr 4 mg
(Vospire er)
3
albuterol sulfate tab sr 12hr 8 mg
(Vospire er)
1
ZUTRIPRO - pseudoeph-chlorphen w/
hydrocodone soln 60-4-5 mg/5ml
albuterol sulfate tab 2 mg
1
albuterol sulfate tab 4 mg
1
3
ZODRYL DAC 25 - pseudoephedrinechlorphen w/codeine susp 5-0.333-1
mg/ml
3
ZODRYL DAC 30 - pseudoephedrinechlorphen w/codeine susp
4.286-0.286-1 mg/ml
3
3.75-0.25-1 mg/ml
3
3.333-0.222-1 mg/ml
3
cod-gg susp 5-1-20 mg/ml
ANTIASTHMATIC and BRONCHODILATOR AGENTS
3
•
ACCOLATE - zafirlukast tab 10 mg
•
ACCOLATE - zafirlukast tab 20 mg
3
ACCUNEB - albuterol sulfate soln nebu
3
ACCUNEB - albuterol sulfate soln nebu
3
ADRENALIN - epinephrine hcl inj 1 mg/
ml
3
mcg/dose
2
•
mcg/dose
2
•
72
ALVESCO - ciclesonide inhal aerosol 80 3
mcg/act
3
ALVESCO - ciclesonide inhal aerosol
160 mcg/act
3
AMINOPHYLLINE - aminophylline tab
100 mg
3
AMINOPHYLLINE - aminophylline tab
200 mg
2
ANORO ELLIPTA - umeclidiniumvilanterol aero powd ba 62.5-25 mcg/
inh
3
ARCAPTA NEOHALER - indacaterol
maleate inhal powder cap 75 mcg
(base equiv)
•
•
•
•
Dispensing Limits
•
DALIRESP - roflumilast tab 500 mcg
3
2
•
•
DULERA - mometasone furoateformoterol fumarate aerosol 100-5
mcg/act
2
•
•
DULERA - mometasone furoateformoterol fumarate aerosol 200-5
mcg/act
DUONEB - ipratropium-albuterol nebu
soln 0.5-2.5(3) mg/3ml
3
dyphylline-guaifenesin liqd
100-100 mg/5ml
1
dyphylline-guaifenesin tab
200-200 mg
1
dyphylline-guaifenesin tab
200-400 mg
1
ELIXOPHYLLIN - theophylline elixir 80
mg/15ml
3
•
epinephrine hcl inj 1 mg/ml
1
1
•
epinephrine hcl soln prefilled
syringe 0.1 mg/ml
FLOVENT DISKUS - fluticasone
propionate aer pow ba 50 mcg/blister
2
•
propionate aer pow ba 100 mcg/
blister
2
•
2
•
Step Therapy
Drug Name
Drug Tier
Prior Authorization
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
ASMANEX TWISTHALER 120 ME mometasone furoate inhal powd 220
mcg/inh (breath activated)
2
ASMANEX TWISTHALER 14 MET mometasone furoate inhal powd 220
2
ASMANEX TWISTHALER 30 ME mometasone furoate inhal powd 220
2
2
•
2
•
ASMANEX TWISTHALER 7 METE mometasone furoate inhal powd 110
2
ATROVENT HFA - ipratropium bromide
hfa inhal aerosol 17 mcg/act
2
BREO ELLIPTA - fluticasone furoatevilanterol aero powd ba 100-25 mcg/
inh
2
BRONCOMAR-1 - theophylline-pse-gg
elixir 150-30-150 mg/15ml
3
BRONDIL - dyphylline-guaifenesin liqd
100-100 mg/15ml
3
BROVANA - arformoterol tartrate soln
nebu 15 mcg/2ml (base equiv)
3
propionate aer pow ba 250 mcg/
blister
budesonide inhalation susp
0.25 mg/2ml (Pulmicort)
1
FLOVENT HFA - fluticasone propionate
hfa inhal aero 44 mcg/act (50/valve)
2
•
budesonide inhalation susp
0.5 mg/2ml (Pulmicort)
1
hfa inhal aer 110 mcg/act (125/valve)
2
•
COMBIVENT - ipratropium-albuterol
aerosol 18-103 mcg/act (20-120mcg/
act)
2
hfa inhal aer 220 mcg/act (250/valve)
2
•
2
•
COMBIVENT RESPIMAT - ipratropiumalbuterol inhal aerosol soln 20-100
mcg/act
2
FORADIL AEROLIZER - formoterol
fumarate inhal cap 12 mcg
ipratropium bromide inhal soln
0.02%
1
cromolyn sodium soln nebu
20 mg/2ml
1
ipratropium-albuterol nebu soln
0.5-2.5(3) mg/3ml (Duoneb)
1
•
•
•
73
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
ISUPREL - isoproterenol hcl inj 0.2 mg/
ml
3
PULMICORT - budesonide inhalation
susp 0.25 mg/2ml
3
levalbuterol hcl soln nebu conc
1.25 mg/0.5ml (base equiv)
(Xopenex concentrate)
1
susp 0.5 mg/2ml
3
levalbuterol hcl soln nebu
0.31 mg/3ml (base equiv) (Xopenex)
susp 1 mg/2ml
2
1
PULMICORT FLEXHALER budesonide inhal aero powd 90 mcg/
act (breath activated)
3
•
PULMICORT FLEXHALER budesonide inhal aero powd 180
mcg/act (breath activated)
3
•
QVAR - beclomethasone dipropionate
inhal aero soln 40 mcg/act
2
•
QVAR - beclomethasone dipropionate
inhal aero soln 80 mcg/act
2
•
SEREVENT DISKUS - salmeterol
xinafoate aer pow ba 50 mcg/dose
(base equiv)
3
•
SINGULAIR - montelukast sodium tab
10 mg (base equiv)
3
•
SINGULAIR - montelukast sodium chew
3
•
SINGULAIR - montelukast sodium chew
3
•
1
1
3
LUFYLLIN - dyphylline tab 200 mg
LUFYLLIN - dyphylline tab 400 mg
3
MAXAIR AUTOHALER - pirbuterol
acetate breath activated inhal aerosol
200mcg/inh
3
METAPROTERENOL SULFATE metaproterenol sulfate tab 10 mg
3
METAPROTERENOL SULFATE metaproterenol sulfate tab 20 mg
3
METAPROTERENOL SULFATE metaproterenol sulfate syrup 10
mg/5ml
3
metaproterenol sulfate syrup
10 mg/5ml
1
montelukast sodium chew tab 4 mg
(base equiv) (Singulair)
1
•
SINGULAIR - montelukast sodium oral
granules packet 4 mg (base equiv)
3
•
montelukast sodium chew tab 5 mg
(base equiv) (Singulair)
1
•
2
•
1
montelukast sodium oral granules
packet 4 mg (base equiv) (Singulair)
montelukast sodium tab 10 mg (base 1
equiv) (Singulair)
3
PERFOROMIST - formoterol fumarate
soln nebu 20 mcg/2ml
2
PROAIR HFA - albuterol sulfate inhal
aero 108 mcg/act (90mcg base equiv)
3
PROVENTIL HFA - albuterol sulfate
inhal aero 108 mcg/act (90mcg base
equiv)
•
SPIRIVA HANDIHALER - tiotropium
bromide monohydrate inhal cap 18
mcg (base equiv)
STRIVERDI RESPIMAT - olodaterol hcl
inhal aerosol soln 2.5 mcg/act (base
equiv)
3
•
SYMBICORT - budesonide-formoterol
fumarate dihyd aerosol 80-4.5 mcg/
act
2
•
SYMBICORT - budesonide-formoterol
fumarate dihyd aerosol 160-4.5 mcg/
act
2
•
terbutaline sulfate inj 1 mg/ml
1
terbutaline sulfate tab 2.5 mg
1
74
•
•
•
•
THEO-24 - theophylline cap sr 24hr 100
mg
3
RESPIRATORY AGENTS - MISC.
mg
CUROSURF - poractant alfa
intratracheal susp 80 mg/ml
3
3
3
mg
3
INFASURF - calfactant in nacl 0.9%
intratracheal susp 35 mg/ml
KALYDECO - ivacaftor tab 150 mg
4
mg
3
PULMOZYME - dornase alfa inhal soln
1 mg/ml
4
theophylline soln 80 mg/15ml
1
theophylline tab sr 12hr 100 mg
SURFAXIN - lucinactant intratracheal
susp 30 mg/ml
3
1
1
3
1
1
SURVANTA INTRATRACHEAL beractant in nacl 0.9% intratracheal
susp 25 mg/ml
1
1
TUDORZA PRESSAIR - aclidinium
bromide aerosol powd breath
activated 400 mcg/act
3
VENTOLIN HFA - albuterol sulfate inhal
aero 108 mcg/act (90mcg base equiv)
2
VOSPIRE ER - albuterol sulfate tab sr
12hr 4 mg
3
VOSPIRE ER - albuterol sulfate tab sr
12hr 8 mg
3
XOPENEX - levalbuterol hcl soln nebu
3
3
Dispensing Limits
ZYFLO CR - zileuton tab sr 12hr 600 mg 3
Step Therapy
1
Prior Authorization
terbutaline sulfate tab 5 mg
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Drug Tier
Prior Authorization
2014
•
•
GASTROINTESTINAL AGENTS
LAXATIVES
•
CASCARA SAGRADA - cascara
sagrada fl ext 1 gm/ml
3
3
•
COLYTE-FLAVOR PACKS - peg 3350kcl-na bicarb-nacl-na sulfate for soln
227.1 gm
COLYTE-FLAVOR PACKS - peg 3350kcl-na bicarb-nacl-na sulfate for soln
240 gm
3
GOLYTELY - peg 3350-kcl-na bicarbnacl-na sulfate for soln 236 gm
3
GOLYTELY - peg 3350-kcl-na bicarbnacl-na sulfate packet 227.1 gm
3
3
3
HALFLYTELY BOWEL PREP/FLA bisacodyl tab & peg 3350-kcl-sod
bicarb-nacl for soln kit
XOPENEX CONCENTRATE levalbuterol hcl soln nebu conc 1.25
mg/0.5ml (base equiv)
KRISTALOSE - lactulose oral crystal
packet 10 gm
3
3
3
XOPENEX HFA - levalbuterol tartrate
inhal aerosol 45 mcg/act (base equiv)
3
•
KRISTALOSE - lactulose oral crystal
packet 20 gm
lactulose solution 10 gm/15ml
1
1
MINERAL OIL HEAVY - mineral oil
1
MOVIPREP - peg 3350-kcl-nacl-na
sulfate-na acorbate-c for soln 100 gm
3
zafirlukast tab 20 mg (Accolate)
•
•
3
zafirlukast tab 10 mg (Accolate)
ZYFLO - zileuton tab 600 mg
3
75
NULYTELY/FLAVOR PACKS - peg
3350-kcl-sod bicarb-nacl for soln 420
gm
3
OSMOPREP - sod phos mono-sod phos 3
di tabs 1.102-0.398 gm(1.5gm na
phos)
1
peg 3350-kcl-na bicarb-nacl-na
sulfate for soln 236 gm (Golytely)
1
peg 3350-kcl-na bicarb-nacl-na
sulfate for soln 240 gm (Colyteflavor packs)
peg 3350-kcl-sod bicarb-nacl for soln 1
420 gm (Nulytely/flavor pack)
polyethylene glycol 3350 oral packet 1
polyethylene glycol 3350 oral
powder
1
PREPOPIK - sod picosulfate-mg oxidecitric acid pack 10 mg-3.5 gm-12 gm
3
SENNA - senna powder
3
SENNA LEAVES - senna leaves
3
SUCLEAR - na sulf-k sulf-mg sulf & peg
3350-nacl-na bicarb-kcl kit
MOTOFEN - difenoxin w/ atropine tab
1-0.025 mg
3
OPIUM TINCTURE (PAREGORIC paregoric 2 mg/5ml
3
opium tincture 1% (10 mg/ml)
(morphine equiv)
1
RESTORA RX - lactobacillus casei-folic
acid cap 60-1.25 mg
3
REZYST IM - probiotic product - chew
tab
3
REZYST SB - saccharomyces boulardii
chew tab 250 mg
3
VSL#3 DS - probiotic product - packet
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
ANTACIDS
SODIUM BICARBONATE - sodium
bicarbonate powder
3
ULCER DRUGS
ACIPHEX - rabeprazole sodium ec tab
20 mg
3
• •
3
ACIPHEX SPRINKLE - rabeprazole
sodium capsule sprinkle dr 5 mg
3
• •
3
ACIPHEX SPRINKLE - rabeprazole
sodium capsule sprinkle dr 10 mg
3
SUPREP BOWEL PREP - sodium
sulfate-potassium sulfate-magnesium
sulfate oral soln
• •
1
VISICOL - sod phos monobasic-sod
phos dibasic-mcc tabs 1.102-0.398
gm
3
amoxicillin cap-clarithro tablansopraz cap dr therapy pack
(Prevpac)
ANASPAZ - hyoscyamine sulfate tab
disp 0.125 mg
3
ANTIDIARRHEALS
1
ATROPEN - atropine sulfate im inj
device 0.25 mg/0.3ml
3
diphenoxylate w/ atropine tab
2.5-0.025 mg (Lomotil)
3
device 0.5 mg/0.7ml
3
DIPHENOXYLATE/ATROPINE diphenoxylate w/ atropine liq
2.5-0.025 mg/5ml
3
FULYZAQ - crofelemer tab delayed
release 125 mg
3
device 1 mg/0.7ml
3
LOMOTIL - diphenoxylate w/ atropine
tab 2.5-0.025 mg
3
device 2 mg/0.7ml
3
loperamide hcl cap 2 mg
1
ATROPINE SULFATE - atropine sulfate
inj 0.05 mg/ml
inj 0.8 mg/ml
3
76
AXID - nizatidine cap 150 mg
3
AXID - nizatidine cap 300 mg
3
AXID - nizatidine oral soln 15 mg/ml
3
BELLADONNA & OPIUM - belladonna
alkaloids & opium suppos 16.2-30 mg
Dispensing Limits
1
Step Therapy
atropine sulfate inj 1 mg/ml
Prior Authorization
1
Drug Name
Drug Tier
atropine sulfate inj 0.4 mg/ml
Dispensing Limits
1
Step Therapy
atropine sulfate inj 0.1 mg/ml
Prior Authorization
Drug Name
Drug Tier
2014
• •
DEXILANT - dexlansoprazole cap
3
DICYCLOMINE HCL - dicyclomine hcl
oral soln 10 mg/5ml
3
dicyclomine hcl cap 10 mg (Bentyl)
1
dicyclomine hcl tab 20 mg (Bentyl)
1
3
DIGEX NF - hyoscyaminephenyltoloxamine cap 0.0625-15 mg
3
3
DONNATAL - belladonna alkaloidsphenobarbital tab 16.2 mg
3
BELLADONNA ALKALOIDS & OP belladonna alkaloids & opium suppos
16.2-60 mg
3
belladonna alkaloids-phenobarbital
elixir 16.2 mg/5ml (Donnatal)
1
DONNATAL - belladonna alkaloidsphenobarbital elixir 16.2 mg/5ml
3
belladonna alkaloids-phenobarbital
tab 16.2 mg (Donnatal)
1
DONNATAL EXTENTABS - belladonna
alkaloids-phenobarbital tab cr 48 mg
3
• •
BENTYL - dicyclomine hcl cap 10 mg
3
ESOMEPRAZOLE STRONTIUM esomeprazole strontium cap delayed
release 24.65 mg
BENTYL - dicyclomine hcl tab 20 mg
3
• •
BENTYL - dicyclomine hcl inj 10 mg/ml
BENTYL - dicyclomine hcl oral soln 10
mg/5ml
3
ESOMEPRAZOLE STRONTIUM esomeprazole strontium cap delayed
release 49.3 mg
3
3
1
CANTIL - mepenzolate bromide tab 25
mg
3
famotidine for susp 40 mg/5ml
(Pepcid)
famotidine tab 20 mg (Pepcid)
1
CARAFATE - sucralfate tab 1 gm
3
famotidine tab 40 mg (Pepcid)
1
FIRST-LANSOPRAZOLE - lansoprazole 3
susp 3 mg/ml (compound kit)
3
FIRST-OMEPRAZOLE - omeprazole
susp 2 mg/ml (compound kit)
3
GASTRINEX NF - hyoscyaminephenyltoloxamine cap 0.0625-15 mg
3
GLYCATE - glycopyrrolate tab 1.5 mg
CARAFATE - sucralfate susp 1 gm/10ml 3
1
cimetidine hcl inj 150 mg/ml
cimetidine hcl soln 300 mg/5ml
1
cimetidine tab 200 mg
1
1
1
1
clidinium & chlordiazepoxide cap
2.5-5 mg (Librax)
1
CUVPOSA - glycopyrrolate oral soln 1
mg/5ml
3
CYTOTEC - misoprostol tab 100 mcg
3
CYTOTEC - misoprostol tab 200 mcg
3
DEXILANT - dexlansoprazole cap
3
• •
• •
• •
glycopyrrolate inj 0.2 mg/ml (Robinul) 1
1
glycopyrrolate inj 0.4 mg/2ml
(0.2 mg/ml) (Robinul)
1
glycopyrrolate inj 1 mg/5ml (0.2 mg/
ml) (Robinul)
glycopyrrolate inj 4 mg/20ml (0.2 mg/ 1
ml) (Robinul)
1
glycopyrrolate tab 1 mg (Robinul)
77
glycopyrrolate tab 2 mg (Robinul
forte)
78
NEXIUM - esomeprazole magnesium for 2
delayed release susp pack 2.5 mg
delayed release susp packet 5 mg
2
NEXIUM - esomeprazole magnesium
cap delayed release 20 mg
2
NEXIUM - esomeprazole magnesium
cap delayed release 40 mg
1
nizatidine cap 150 mg
•
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
1
HELIDAC - metronidaz tab-tetracyc cap- 3
bis subsal chew tab therapy pack
1
hyoscyamine sulfate elixir
0.125 mg/5ml
1
hyoscyamine sulfate soln 0.125 mg/
ml
1
hyoscyamine sulfate tab disp
0.125 mg (Anaspaz)
1
hyoscyamine sulfate tab sl 0.125 mg
(Levsin/sl)
1
hyoscyamine sulfate tab sr 12hr
0.375 mg (Levbid)
1
hyoscyamine sulfate tab 0.125 mg
(Levsin)
1
lansoprazole cap delayed release
15 mg (Prevacid)
1
lansoprazole cap delayed release
30 mg (Prevacid)
1
lansoprazole tab delayed release
orally disintegrating 15 mg
1
lansoprazole tab delayed release
orally disintegrating 30 mg
3
LEVBID - hyoscyamine sulfate tab sr
12hr 0.375 mg
LEVSIN - hyoscyamine sulfate tab 0.125 3
mg
3
LEVSIN - hyoscyamine sulfate inj 0.5
mg/ml
LEVSIN/SL - hyoscyamine sulfate tab sl 3
0.125 mg
3
LIBRAX - clidinium & chlordiazepoxide
cap 2.5-5 mg
1
methscopolamine bromide tab
2.5 mg (Pamine)
1
methscopolamine bromide tab 5 mg
(Pamine forte)
1
misoprostol tab 100 mcg (Cytotec)
misoprostol tab 200 mcg (Cytotec)
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
• •
• •
• •
• •
• •
• •
• •
nizatidine cap 300 mg (Axid)
1
nizatidine oral soln 15 mg/ml (Axid)
1
OMECLAMOX-PAK - amoxicillin capclarithro tab w/ omepraz cap dr
therapy pack
3
OMEPRAZOLE + SYRSPEND SF omeprazole susp 2 mg/ml (compound
kit)
3
• •
omeprazole cap delayed release
10 mg (Prilosec)
1
•
20 mg (Prilosec)
1
•
40 mg (Prilosec)
1
•
omeprazole-sodium bicarbonate cap
20-1100 mg (Zegerid)
1
• •
omeprazole-sodium bicarbonate cap
40-1100 mg (Zegerid)
1
• •
PAMINE - methscopolamine bromide
tab 2.5 mg
3
PAMINE FORTE - methscopolamine
bromide tab 5 mg
3
PAMINE FQ - methscopolamine tab 5
mg & misc intestinal flora reg cap
3
1
pantoprazole sodium ec tab 20 mg
(base equiv) (Protonix)
1
•
pantoprazole sodium ec tab 40 mg
(base equiv) (Protonix)
1
•
PYLERA - bismuth subcitmetronidazole-tetracycline cap
140-125-125 mg
3
1
PEPCID - famotidine tab 20 mg
3
rabeprazole sodium ec tab 20 mg
(Aciphex)
PEPCID - famotidine tab 40 mg
3
ranitidine hcl cap 150 mg
1
PEPCID - famotidine for susp 40
mg/5ml
3
ranitidine hcl cap 300 mg
1
1
PREVACID - lansoprazole cap delayed
release 15 mg
3
• •
ranitidine hcl inj 1000 mg/40ml
(25 mg/ml) (Zantac)
1
PREVACID - lansoprazole cap delayed
release 30 mg
3
• •
ranitidine hcl inj 150 mg/6ml (25 mg/
ml) (Zantac)
1
PREVACID SOLUTAB - lansoprazole
tab delayed release orally
disintegrating 15 mg
3
• •
ranitidine hcl inj 50 mg/2ml (25 mg/
ml) (Zantac)
ranitidine hcl syrup 15 mg/ml
(75 mg/5ml)
1
PREVACID SOLUTAB - lansoprazole
tab delayed release orally
disintegrating 30 mg
3
ranitidine hcl tab 150 mg (Zantac)
1
ranitidine hcl tab 300 mg (Zantac)
1
3
ROBINUL - glycopyrrolate tab 1 mg
3
PREVPAC - amoxicillin cap-clarithro
tab-lansopraz cap dr therapy pack
ROBINUL - glycopyrrolate inj 0.2 mg/ml
3
PRILOSEC - omeprazole cap delayed
release 10 mg
3
• •
ROBINUL - glycopyrrolate inj 0.4
mg/2ml (0.2 mg/ml)
3
release 20 mg
3
• •
ROBINUL - glycopyrrolate inj 1 mg/5ml
(0.2 mg/ml)
3
release 40 mg
3
• •
ROBINUL - glycopyrrolate inj 4 mg/20ml
(0.2 mg/ml)
3
PRILOSEC - omeprazole magnesium
for delayed release susp packet 2.5
mg
3
• •
ROBINUL FORTE - glycopyrrolate tab 2
mg
3
3
PRILOSEC - omeprazole magnesium
for delayed release susp packet 10
mg
3
SCOPOLAMINE HYDROBROMIDE scopolamine hbr inj 0.4 mg/ml
sucralfate tab 1 gm (Carafate)
1
PROPANTHELINE BROMIDE propantheline bromide tab 15 mg
3
PROTONIX - pantoprazole sodium ec
3
• •
PROTONIX - pantoprazole sodium ec
3
• •
PROTONIX - pantoprazole sodium for
3
• •
• •
• •
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
•
SYMAX DUOTAB - hyoscyamine sulfate 3
tab cr 0.375 mg (0.125 mg ir/0.25 mg
cr)
3
ZANTAC - ranitidine hcl tab 150 mg
ZANTAC - ranitidine hcl tab 300 mg
3
ZANTAC - ranitidine hcl effer tab 25 mg
3
ZANTAC - ranitidine hcl syrup 15 mg/ml
(75 mg/5ml)
3
79
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
•
•
ZANTAC - ranitidine hcl inj 50 mg/2ml
(25 mg/ml)
3
granisetron hcl tab 1 mg
1
ZANTAC - ranitidine hcl inj 150 mg/6ml
(25 mg/ml)
GRANISOL - granisetron hcl oral soln 2
3
3
MARINOL - dronabinol cap 2.5 mg
3
ZANTAC - ranitidine hcl inj 1000
mg/40ml (25 mg/ml)
3
MARINOL - dronabinol cap 5 mg
3
3
• •
MARINOL - dronabinol cap 10 mg
3
ZEGERID - omeprazole-sodium
bicarbonate cap 20-1100 mg
meclizine hcl tab 12.5 mg
1
bicarbonate cap 40-1100 mg
3
• •
meclizine hcl tab 25 mg
1
meclizine hcl tab 32 mg
1
bicarbonate powd pack for susp
20-1680 mg
3
ondansetron hcl inj 4 mg/2ml (2 mg/
ml)
1
bicarbonate powd pack for susp
40-1680 mg
ondansetron hcl inj 40 mg/20ml
(2 mg/ml) (Zofran)
1
3
ondansetron hcl oral soln 4 mg/5ml
(Zofran)
1
•
ondansetron hcl tab 24 mg
1
ondansetron hcl tab 4 mg (Zofran)
1
ondansetron hcl tab 8 mg
1
ondansetron hcl tab 8 mg (Zofran)
1
ondansetron orally disintegrating tab
4 mg (Zofran odt)
1
•
•
•
•
•
ondansetron orally disintegrating tab
8 mg (Zofran odt)
1
•
SANCUSO - granisetron td patch 3.1
mg/24hr (contains 34.3 mg)
3
• •
• •
• •
ANTIEMETICS
ANTIVERT - meclizine hcl tab 12.5 mg
3
ANTIVERT - meclizine hcl tab 25 mg
3
ANTIVERT - meclizine hcl tab 50 mg
3
ANZEMET - dolasetron mesylate tab 50
mg
3
•
ANZEMET - dolasetron mesylate tab
100 mg
3
•
CESAMET - nabilone cap 1 mg
3
•
COCA COLA SYURP - phosphorated
carbohydrate w/ caffeine syrup
3
DICLEGIS - doxylamine-pyridoxine tab
delayed release 10-10 mg
3
DIMENHYDRINATE - dimenhydrinate
inj 50 mg/ml
3
dronabinol cap 10 mg (Marinol)
1
dronabinol cap 2.5 mg (Marinol)
1
dronabinol cap 5 mg (Marinol)
1
EMEND - aprepitant capsule 40 mg
2
2
2
EMEND - aprepitant capsule therapy
pack 80 & 125 mg
2
80
•
•
•
TIGAN - trimethobenzamide hcl cap 300 3
mg
3
TIGAN - trimethobenzamide hcl inj 100
mg/ml
2
TRANSDERM-SCOP - scopolamine td
patch 72hr 1.5 mg
1
trimethobenzamide hcl cap 300 mg
(Tigan)
trimethobenzamide hcl inj 100 mg/ml 1
(Tigan)
3
ZOFRAN - ondansetron hcl tab 4 mg
ZOFRAN - ondansetron hcl tab 8 mg
3
•
•
ZOFRAN - ondansetron hcl inj 40
mg/20ml (2 mg/ml)
3
ZOFRAN - ondansetron hcl oral soln 4
mg/5ml
3
ZOFRAN ODT - ondansetron orally
ULTRESA - pancrelipase (lip-prot-amyl)
dr cap 13800-27600-27600 unit
3
•
dr cap 20700-41400-41400 unit
3
3
•
dr cap 23000-46000-46000 unit
3
ZOFRAN ODT - ondansetron orally
3
•
VIOKACE - pancrelipase (lip-prot-amyl)
tab 10440-39150-39150 unit
3
ZUPLENZ - ondansetron oral soluble
film 4 mg
3
•
VIOKACE - pancrelipase (lip-prot-amyl)
tab 20880-78300-78300 unit
3
ZUPLENZ - ondansetron oral soluble
film 8 mg
3
•
ZENPEP - pancrelipase (lip-prot-amyl)
dr cap 3000-10000-16000 unit
2
2
DIGESTIVE AIDS
CREON - pancrelipase (lip-prot-amyl) dr
cap 3000-9500-15000 unit
2
dr cap 5000-17000-27000 unit
2
cap 6000-19000-30000 unit
2
dr cap 10000-34000-55000 unit
2
cap 12000-38000-60000 unit
2
dr cap 15000-51000-82000 unit
2
cap 24000-76000-120000 unit
2
dr cap 20000-68000-109000 unit
2
cap 36000-114000-180000 unit
2
dr cap 25000-85000-136000 unit
PANCREAZE - pancrelipase (lip-protamyl) dr cap 4200-10000-17500 unit
3
mesalamine rectal enema 4 gm &
cleanser wipe kit (Rowasa)
1
3
ACTIGALL - ursodiol cap 300 mg
3
AMITIZA - lubiprostone cap 8 mcg
3
3
AMITIZA - lubiprostone cap 24 mcg
3
3
APRISO - mesalamine cap sr 24hr
0.375 gm
3
3
ASACOL - mesalamine tab delayed
release 400 mg
2
PANCRELIPASE - pancrelipase (lipprot-amyl) dr cap 5000-17000-27000
unit
2
PERTZYE - pancrelipase (lip-prot-amyl)
dr cap 8000-28750-30250 unit
3
ASACOL HD - mesalamine tab delayed
release 800 mg
AZULFIDINE - sulfasalazine tab 500 mg
3
PERTZYE - pancrelipase (lip-prot-amyl)
dr cap 16000-57500-60500 unit
3
AZULFIDINE EN-TABS - sulfasalazine
tab delayed release 500 mg
3
SUCRAID - sacrosidase soln 8500 unit/
ml
4
balsalazide disodium cap 750 mg
(Colazal)
1
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
GASTROINTESTINAL AGENTS- MISC.
•
•
81
calcium acetate (phosphate binder)
tab 667 mg (Eliphos)
LOTRONEX - alosetron hcl tab 0.5 mg
(base equiv)
3
1
CANASA - mesalamine suppos 1000
mg
LOTRONEX - alosetron hcl tab 1 mg
(base equiv)
3
2
mesalamine enema 4 gm
1
CHENODAL - chenodiol tab 250 mg
4
1
4
• •
metoclopramide hcl inj 5 mg/ml
CIMZIA - certolizumab pegol inj kit 2 x
200 mg/ml
1
CIMZIA STARTER KIT - certolizumab
pegol inj kit 6 x 200 mg/ml
4
• •
metoclopramide hcl soln 5 mg/5ml
(10 mg/10ml)
metoclopramide hcl tab 10 mg
(Reglan)
1
COLAZAL - balsalazide disodium cap
750 mg
3
metoclopramide hcl tab 5 mg
(Reglan)
1
cromolyn sodium oral conc
100 mg/5ml (Gastrocrom)
1
METOZOLV ODT - metoclopramide hcl
orally disintegrating tab 5 mg
3
METOZOLV ODT - metoclopramide hcl
3
PENTASA - mesalamine cap cr 250 mg
2
PENTASA - mesalamine cap cr 500 mg
2
PHOSLO - calcium acetate (phosphate
binder) cap 667 mg (169 mg ca)
3
PHOSLYRA - calcium acetate
(phosphate binder) oral soln 667
mg/5ml
3
DELZICOL - mesalamine cap dr 400 mg 2
3
DEXPANTHENOL - dexpanthenol inj
250 mg/ml
DIPENTUM - olsalazine sodium cap 250 3
mg
ELIPHOS - calcium acetate (phosphate 3
binder) tab 667 mg
3
ENTEREG - alvimopan cap 12 mg
FOSRENOL - lanthanum carbonate
chew tab 500 mg
3
chew tab 750 mg
3
chew tab 1000 mg
3
GASTROCROM - cromolyn sodium oral
conc 100 mg/5ml
3
GATTEX - teduglutide (rdna) for inj kit 5
mg
4
GIAZO - balsalazide disodium tab 1.1
gm
3
lactulose (encephalopathy) solution
10 gm/15ml
1
LIALDA - mesalamine tab delayed
release 1.2 gm
2
LINZESS - linaclotide cap 145 mcg
3
82
•
•
REGLAN - metoclopramide hcl tab 5 mg 3
3
REGLAN - metoclopramide hcl tab 10
mg
REGLAN - metoclopramide hcl inj 5 mg/ 3
ml
RELISTOR - methylnaltrexone bromide 3
inj 8 mg/0.4ml (20 mg/ml)
inj 12 mg/0.6ml (20 mg/ml)
inj kit 12 mg/0.6ml
3
RENAGEL - sevelamer hcl tab 400 mg
RENAGEL - sevelamer hcl tab 800 mg
3
RENVELA - sevelamer carbonate tab
800 mg
3
Dispensing Limits
Prior Authorization
•
Drug Name
Step Therapy
Drug Tier
3
Dispensing Limits
LINZESS - linaclotide cap 290 mcg
Step Therapy
1
Drug Tier
calcium acetate (phosphate binder)
cap 667 mg (169 mg ca) (Phoslo)
Drug Name
Prior Authorization
2014
•
•
•
RENVELA - sevelamer carbonate
packet 0.8 gm
3
MACRODANTIN - nitrofurantoin
macrocrystalline cap 50 mg
3
RENVELA - sevelamer carbonate
packet 2.4 gm
3
3
ROWASA - mesalamine rectal enema 4
gm & cleanser wipe kit
3
methenamine hippurate tab 1 gm
(Hiprex)
1
SEVELAMER CARBONATE sevelamer carbonate tab 800 mg
3
METHENAMINE MANDELATE methenamine mandelate tab 0.5 gm
3
SFROWASA - mesalamine sulfite-free
(sf) enema 4 gm/60ml
3
methenamine mandelate tab 1 gm
1
sulfasalazine tab delayed release
500 mg (Azulfidine en-tabs)
1
sulfasalazine tab 500 mg (Azulfidine)
1
URSO FORTE - ursodiol tab 500 mg
3
URSO 250 - ursodiol tab 250 mg
3
ursodiol cap 300 mg (Actigall)
1
ursodiol tab 250 mg (Urso 250)
1
ursodiol tab 500 mg (Urso forte)
1
VELPHORO - sucroferric oxyhydroxide
chew tab 500 mg
3
GENITOURINARY AGENTS
URINARY ANTI-INFECTIVES
methenamine-hyos-meth blue-sod
phos-phen sal tab 81.6 mg
1
methenamine-hyosamine-meth bluesod phos tab 81.6 mg (Urogesicblue)
1
methenamine-hyosc-meth blue-sod
phos-phen sal cap 120 mg
1
FURADANTIN - nitrofurantoin susp 25
mg/5ml
3
HIPREX - methenamine hippurate tab 1
gm
3
MACROBID - nitrofurantoin
monohydrate macrocrystalline cap
100 mg
3
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
methenamine-hyosc-meth blue-benz 1
acid-phenyl sal tab 81.6mg (Prosed/
ds)
3
MONUROL - fosfomycin tromethamine
powd pack 3 gm (base equivalent)
1
nitrofurantoin macrocrystalline cap
100 mg (Macrodantin)
1
nitrofurantoin macrocrystalline cap
50 mg (Macrodantin)
1
nitrofurantoin monohydrate
(Macrobid)
1
nitrofurantoin susp 25 mg/5ml
(Furadantin)
3
PROSED/DS - methenamine-hyoscmeth blue-benz acid-phenyl sal tab
81.6mg
3
URELLE - methenamine-hyosc-meth
blue-sod phos-phen sal tab 81 mg
3
URETRON D/S - methenamine-hyoscmeth blue-sod phos-phen sal tab 120
mg
3
UREX - methenamine hippurate tab 1
gm
3
URIBEL - methenamine-hyosc-meth
blue-sod phos-phen sal cap 118 mg
URIMAR-T - methenamine-hyosc-meth 3
blue-sod phos-phen sal tab 120 mg
3
UROGESIC-BLUE - methenaminehyosamine-meth blue-sod phos tab
81.6 mg
83
UROQID #2 - methenamine mandelatesod phosphate monobasic tab
500-500 mg
3
URINARY ANTISPASMODICS
oxybutynin chloride tab sr 24hr
15 mg (Ditropan xl)
1
oxybutynin chloride tab sr 24hr 5 mg
(Ditropan xl)
1
bethanechol chloride tab 10 mg
(Urecholine)
1
oxybutynin chloride tab 5 mg
1
1
OXYTROL - oxybutynin td patch
3
(Urecholine)
1
phenazopyridine-butabarbitalhyoscyamine tab 150-15-0.3 mg
1
(Urecholine)
(Urecholine)
SANCTURA - trospium chloride tab 20
mg
3
1
DETROL - tolterodine tartrate tab 1 mg
SANCTURA XR - trospium chloride cap
sr 24hr 60 mg
3
3
DETROL - tolterodine tartrate tab 2 mg
3
1
DETROL LA - tolterodine tartrate cap sr
24hr 2 mg
3
tolterodine tartrate cap sr 24hr 2 mg
(Detrol la)
1
DETROL LA - tolterodine tartrate cap sr
24hr 4 mg
3
tolterodine tartrate cap sr 24hr 4 mg
(Detrol la)
tolterodine tartrate tab 1 mg (Detrol)
1
DITROPAN XL - oxybutynin chloride tab
sr 24hr 5 mg
3
tolterodine tartrate tab 2 mg (Detrol)
1
sr 24hr 10 mg
TOVIAZ - fesoterodine fumarate tab sr
24hr 4 mg
3
3
sr 24hr 15 mg
TOVIAZ - fesoterodine fumarate tab sr
24hr 8 mg
3
3
trospium chloride cap sr 24hr 60 mg
1
ENABLEX - darifenacin hydrobromide
tab sr 24hr 7.5 mg (base equiv)
3
trospium chloride tab 20 mg
(Sanctura)
1
ENABLEX - darifenacin hydrobromide
tab sr 24hr 15 mg (base equiv)
3
URECHOLINE - bethanechol chloride
tab 5 mg
3
flavoxate hcl tab 100 mg
1
GELNIQUE - oxybutynin td gel 3% (28
mg/act metered-dose pump)
tab 10 mg
3
3
GELNIQUE - oxybutynin chloride td gel
10%
tab 25 mg
3
3
3
MYRBETRIQ - mirabegron tab sr 24 hr
25 mg
2
tab 50 mg
2
VESICARE - solifenacin succinate tab 5
mg
2
MYRBETRIQ - mirabegron tab sr 24 hr
50 mg
oxybutynin chloride syrup 5 mg/5ml
VESICARE - solifenacin succinate tab
10 mg
2
1
oxybutynin chloride tab sr 24hr
10 mg (Ditropan xl)
1
VAGINAL PRODUCTS
84
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
3
3
FIRST-PROGESTERONE VGS 50 progesterone vaginal suppository 50
mg
CLEOCIN - clindamycin phosphate
vaginal suppos 100 mg
3
GYNAZOLE-1 - butoconazole nitrate
(one dose) vaginal cream 2%
3
clindamycin phosphate vaginal
cream 2% (Cleocin)
1
METROGEL-VAGINAL - metronidazole
vaginal gel 0.75%
3
CLINDESSE - clindamycin phosphate
(one dose) vaginal cream 2%
3
metronidazole vaginal gel 0.75%
(Metrogel-vaginal)
1
CRINONE - progesterone vaginal gel
4%
3
miconazole nitrate vaginal supp
200 mg & 2% cream 9 gm kit
1
CRINONE - progesterone vaginal gel
8%
3
MICONAZOLE 3 - miconazole nitrate
vaginal suppos 200 mg
3
ENCARE - nonoxynol-9 vaginal suppos
100 mg
3
NYSTATIN VAGINAL - nystatin vaginal
tab 100000 unit
3
ENDOMETRIN - progesterone vaginal
insert 100 mg
3
OPTIONS CONCEPTROL VAGINA nonoxynol-9 gel 4%
3
ESTRACE - estradiol vaginal cream 0.1
mg/gm
2
OPTIONS GYNOL II VAGINAL nonoxynol-9 gel 3%
3
ESTRING - estradiol vaginal ring 2 mg
(7.5 mcg/24hrs)
3
PREMARIN - estrogens, conjugated
vaginal cream 0.625 mg/gm
3
FEM PH - acetic acid-oxyquinoline
vaginal gel 0.9-0.025%
3
RELAGARD - acetic acid-oxyquinoline
vaginal gel 0.9-0.025%
3
FEMRING - estradiol acetate vaginal
ring 0.05 mg/24hr
3
SHUR-SEAL - nonoxynol-9 gel 2%
3
3
FEMRING - estradiol acetate vaginal
ring 0.1 mg/24hr
3
TERAZOL 3 - terconazole vaginal
cream 0.8%
3
mg
3
suppos 80 mg
cream 0.4%
3
mg
3
terconazole vaginal cream 0.4%
(Terazol 7)
1
mg
terconazole vaginal cream 0.8%
(Terazol 3)
1
3
terconazole vaginal suppos 80 mg
1
mg
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
CLEOCIN - clindamycin phosphate
vaginal cream 2%
Dispensing Limits
3
Step Therapy
AVC - sulfanilamide vaginal cream 15%
Prior Authorization
Drug Name
Drug Tier
2014
VAGIFEM - estradiol vaginal tab 10 mcg 2
3
VCF VAGINAL CONTRACEPTIVE nonoxynol-9 foam 12.5%
3
VCF VAGINAL CONTRACEPTIVE nonoxynol-9 film 28%
85
GENITOURINARY AGENTS - MISC.
1
alfuzosin hcl tab sr 24hr 10 mg
(Uroxatral)
1
potassium citrate tab cr 5 meq
(540 mg) (Urocit-k 5)
4
AVODART - dutasteride cap 0.5 mg
2
PROCYSBI - cysteamine bitartrate cap
delayed release 25 mg (base equiv)
CARDURA XL - doxazosin mesylate tab
sr 24 hr 4 mg (base equiv)
3
PROCYSBI - cysteamine bitartrate cap
delayed release 75 mg (base equiv)
4
CARDURA XL - doxazosin mesylate tab
sr 24 hr 8 mg (base equiv)
3
PROSCAR - finasteride tab 5 mg
3
3
CITROLITH - potassium & sodium
citrates tab 50-950 mg
3
PYRIDIUM - phenazopyridine hcl tab
100 mg
3
CYSTAGON - cysteamine bitartrate cap
50 mg
4
PYRIDIUM - phenazopyridine hcl tab
200 mg
RAPAFLO - silodosin cap 4 mg
3
CYSTAGON - cysteamine bitartrate cap
150 mg
4
RAPAFLO - silodosin cap 8 mg
3
3
CYTRA-K - potassium citrate & citric
acid soln 1100-334 mg/5ml
3
SHOHLS SOLUTION MODIFIED sodium citrate & citric acid soln
500-334 mg/5ml
CYTRA-3 - pot & sod citrates w/ cit ac
syrup 550-500-334 mg/5ml
3
SODIUM CITRATE - sodium citrate
granules
3
ELMIRON - pentosan polysulfate
sodium caps 100 mg
3
1
finasteride tab 5 mg (Proscar)
1
sodium citrate & citric acid soln
500-334 mg/5ml (Shohls solution
modi)
FLOMAX - tamsulosin hcl cap 0.4 mg
3
tamsulosin hcl cap 0.4 mg (Flomax)
1
JALYN - dutasteride-tamsulosin hcl cap
0.5-0.4 mg
3
THIOLA - tiopronin tab 100 mg
3
3
K-PHOS NO 2 - potassium & sodium
acid phosphates tab 305-700 mg
3
TRICITRATES - pot & sod citrates w/ cit
ac soln 550-500-334 mg/5ml
3
LITHOSTAT - acetohydroxamic acid tab
250 mg
3
UROCIT-K 10 - potassium citrate tab cr
10 meq (1080 mg)
3
ORACIT - sodium citrate & citric acid
soln 490-640 mg/5ml
3
UROCIT-K 15 - potassium citrate tab cr
15 meq (1620 mg)
3
phenazopyridine hcl tab 100 mg
(Pyridium)
1
UROCIT-K 5 - potassium citrate tab cr 5
meq (540 mg)
3
phenazopyridine hcl tab 200 mg
(Pyridium)
1
UROXATRAL - alfuzosin hcl tab sr 24hr
10 mg
potassium citrate & citric acid
powder pack 3300-1002 mg
1
ANTIANXIETY AGENTS
(1080 mg) (Urocit-k 10)
ALPRAZOLAM INTENSOL - alprazolam
conc 1 mg/ml
3
1
(1620 mg) (Urocit-k 15)
alprazolam orally disintegrating tab
0.25 mg (Niravam)
1
1
86
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
CENTRAL NERVOUS SYSTEM DRUGS
0.5 mg
1
DIAZEPAM INTENSOL - diazepam
conc 5 mg/ml
3
1 mg
1
diazepam tab 10 mg (Valium)
1
1
2 mg
1
1
1
GABAVALE-5 - diazepam tab 5 mg &
dietary management cap pack
3
alprazolam tab sr 24hr 0.5 mg (Xanax
xr)
1
GABAZOLAMINE - alprazolam tab 0.25
3
alprazolam tab sr 24hr 1 mg (Xanax
xr)
1
GABAZOLAMINE-0.5 - alprazolam tab
0.5 mg & dietary management cap
pack
3
xr)
xr)
1
HYDROXYZINE HCL - hydroxyzine hcl
im soln 25 mg/ml
3
alprazolam tab 0.25 mg (Xanax)
1
hydroxyzine hcl im soln 50 mg/ml
1
alprazolam tab 0.5 mg (Xanax)
1
hydroxyzine hcl syrup 10 mg/5ml
1
alprazolam tab 1 mg (Xanax)
1
hydroxyzine hcl tab 10 mg
1
alprazolam tab 2 mg (Xanax)
1
1
ATIVAN - lorazepam tab 0.5 mg
3
1
ATIVAN - lorazepam tab 1 mg
3
ATIVAN - lorazepam tab 2 mg
HYDROXYZINE PAMOATE hydroxyzine pamoate cap 100 mg
3
3
buspirone hcl tab 10 mg
1
1
1
hydroxyzine pamoate cap 25 mg
(Vistaril)
1
1
1
hydroxyzine pamoate cap 50 mg
(Vistaril)
1
lorazepam conc 2 mg/ml (Lorazepam
intensol)
1
buspirone hcl tab 7.5 mg
chlordiazepoxide hcl cap 10 mg
1
LORAZEPAM INTENSOL - lorazepam
conc 2 mg/ml
3
1
1
lorazepam tab 0.5 mg (Ativan)
1
clorazepate dipotassium tab 15 mg
(Tranxene t)
1
lorazepam tab 1 mg (Ativan)
1
lorazepam tab 2 mg (Ativan)
1
clorazepate dipotassium tab 3.75 mg
(Tranxene t)
1
meprobamate tab 200 mg
1
1
meprobamate tab 400 mg
1
clorazepate dipotassium tab 7.5 mg
(Tranxene t)
3
DIAZEPAM - diazepam soln 1 mg/ml
3
NIRAVAM - alprazolam orally
disintegrating tab 0.25 mg
3
3
DIAZEPAM - diazepam im inj device 10
mg/2ml
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
87
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
amitriptyline hcl tab 75 mg
1
AMOXAPINE - amoxapine tab 25 mg
3
3
3
3
ANAFRANIL - clomipramine hcl cap 25
mg
3
mg
3
mg
3
APLENZIN - bupropion hbr tab sr 24hr
174 mg
3
•
348 mg
3
•
3
•
3
3
oxazepam cap 10 mg
1
oxazepam cap 15 mg
1
oxazepam cap 30 mg
1
TRANXENE T - clorazepate
dipotassium tab 3.75 mg
3
dipotassium tab 7.5 mg
3
dipotassium tab 15 mg
3
VALIUM - diazepam tab 2 mg
3
3
3
VISTARIL - hydroxyzine pamoate cap
25 mg
3
522 mg
3
VISTARIL - hydroxyzine pamoate cap
50 mg
3
APPBUTAMONE - bupropion hcl tab 75
3
XANAX - alprazolam tab 0.25 mg
3
XANAX - alprazolam tab 0.5 mg
3
APPBUTAMONE-D - bupropion hcl tab
75 mg & dietary management cap
pack
3
BRINTELLIX - vortioxetine hbr tab 5 mg
(base equiv)
3
XANAX - alprazolam tab 1 mg
•
XANAX - alprazolam tab 2 mg
3
•
3
BRINTELLIX - vortioxetine hbr tab 10
mg (base equiv)
3
XANAX XR - alprazolam tab sr 24hr 0.5
mg
•
XANAX XR - alprazolam tab sr 24hr 1
mg
BRINTELLIX - vortioxetine hbr tab 20
mg (base equiv)
3
3
•
mg
bupropion hcl tab sr 12hr 100 mg
(Wellbutrin sr)
1
3
•
mg
(Wellbutrin sr)
1
3
(Wellbutrin sr)
1
•
(Wellbutrin xl)
1
•
(Wellbutrin xl)
1
•
bupropion hcl tab 100 mg (Wellbutrin) 1
•
ANTIDEPRESSANTS
1
1
1
1
1
88
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
CELEXA - citalopram hydrobromide tab
10 mg (base equiv)
Dispensing Limits
1
Step Therapy
bupropion hcl tab 75 mg (Wellbutrin)
Prior Authorization
Drug Name
Drug Tier
2014
3
•
3
DESVENLAFAXINE ER desvenlafaxine tab sr 24hr 50 mg
3
•
20 mg (base equiv)
3
DESVENLAFAXINE ER desvenlafaxine tab sr 24hr 100 mg
3
•
40 mg (base equiv)
3
DESVENLAFAXINE ER desvenlafaxine fumarate tab sr 24hr
50 mg (base equiv)
citalopram hydrobromide oral soln
10 mg/5ml
1
3
•
citalopram hydrobromide tab 10 mg
(base equiv) (Celexa)
1
DESVENLAFAXINE ER desvenlafaxine fumarate tab sr 24hr
100 mg (base equiv)
DOXEPIN HCL - doxepin hcl cap 75 mg
3
1
doxepin hcl cap 10 mg
1
1
1
1
1
clomipramine hcl cap 25 mg
(Anafranil)
1
1
1
doxepin hcl conc 10 mg/ml
1
(Anafranil)
1
•
(Anafranil)
1
duloxetine hcl enteric coated pellets
cap 20 mg (Cymbalta)
1
•
CYMBALTA - duloxetine hcl enteric
coated pellets cap 20 mg
3
1
•
3
3
•
3
EFFEXOR XR - venlafaxine hcl cap sr
24hr 37.5 mg (base equivalent)
3
•
desipramine hcl tab 10 mg
(Norpramin)
1
24hr 75 mg (base equivalent)
3
•
(Norpramin)
1
3
(Norpramin)
1
EMSAM - selegiline td patch 24hr 6
mg/24hr
3
(Norpramin)
1
mg/24hr
3
(Norpramin)
1
mg/24hr
1
(Norpramin)
1
escitalopram oxalate soln 5 mg/5ml
(base equiv) (Lexapro)
escitalopram oxalate tab 10 mg
1
•
•
•
89
escitalopram oxalate tab 20 mg
1
imipramine pamoate cap 125 mg
(Tofranil-pm)
1
escitalopram oxalate tab 5 mg (base
equiv) (Lexapro)
1
(Tofranil-pm)
1
FETZIMA - levomilnacipran hcl cap sr
3
•
(Tofranil-pm)
1
3
•
3
•
3
•
FETZIMA TITRATION PACK levomilnacipran hcl cap sr 24hr 20 &
40 mg therapy pack
3
•
FLUOXETINE HCL - fluoxetine hcl tab
60 mg
3
fluoxetine hcl cap delayed release
90 mg (Prozac weekly)
1
fluoxetine hcl cap 10 mg (Prozac)
1
1
1
fluoxetine hcl solution 20 mg/5ml
1
fluoxetine hcl tab 10 mg
1
fluoxetine hcl tab 20 mg
1
fluvoxamine maleate cap sr 24hr
100 mg (Luvox cr)
1
fluvoxamine maleate cap sr 24hr
150 mg (Luvox cr)
1
KHEDEZLA - desvenlafaxine tab sr 24hr 3
50 mg
KHEDEZLA - desvenlafaxine tab sr 24hr 3
100 mg
3
LEXAPRO - escitalopram oxalate tab 5
mg (base equiv)
LEXAPRO - escitalopram oxalate tab 10 3
mg (base equiv)
LEXAPRO - escitalopram oxalate tab 20 3
mg (base equiv)
LEXAPRO - escitalopram oxalate soln 5 3
mg/5ml (base equiv)
3
LUVOX CR - fluvoxamine maleate cap
sr 24hr 100 mg
3
LUVOX CR - fluvoxamine maleate cap
sr 24hr 150 mg
3
MAPROTILINE HCL - maprotiline hcl
tab 25 mg
3
tab 50 mg
3
tab 75 mg
3
MARPLAN - isocarboxazid tab 10 mg
fluvoxamine maleate tab 100 mg
1
1
1
FORFIVO XL - bupropion hcl tab sr 24hr 3
450 mg
1
imipramine hcl tab 10 mg (Tofranil)
•
mirtazapine orally disintegrating tab
15 mg (Remeron soltab)
1
1
1
mirtazapine tab 15 mg (Remeron)
1
1
1
1
1
(Tofranil-pm)
1
mirtazapine tab 7.5 mg
1
90
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
NEFAZODONE HCL - nefazodone hcl
tab 50 mg
Dispensing Limits
3
Step Therapy
NARDIL - phenelzine sulfate tab 15 mg
Prior Authorization
Drug Name
Drug Tier
2014
1
3
paroxetine hcl tab sr 24hr 12.5 mg
(Paxil cr)
1
tab 100 mg
3
paroxetine hcl tab sr 24hr 25 mg
(Paxil cr)
1
tab 150 mg
3
paroxetine hcl tab sr 24hr 37.5 mg
(Paxil cr)
paroxetine hcl tab 10 mg (Paxil)
1
tab 200 mg
3
1
1
nefazodone hcl tab 250 mg
1
1
NORPRAMIN - desipramine hcl tab 10
mg
3
PAXIL - paroxetine hcl tab 10 mg
3
3
3
mg
3
mg
3
3
3
mg
3
PAXIL - paroxetine hcl oral susp 10
mg/5ml (base equiv)
3
mg
3
PAXIL CR - paroxetine hcl tab sr 24hr
12.5 mg
3
mg
3
25 mg
37.5 mg
3
PEXEVA - paroxetine mesylate tab 10
mg (base equiv)
3
mg (base equiv)
3
mg (base equiv)
3
mg (base equiv)
3
phenelzine sulfate tab 15 mg (Nardil)
1
PRISTIQ - desvenlafaxine succinate tab
sr 24hr 50 mg (base equiv)
3
•
•
NORTRIPTYLINE HCL - nortriptyline hcl 3
soln 10 mg/5ml
nortriptyline hcl cap 10 mg (Pamelor) 1
nortriptyline hcl cap 25 mg (Pamelor)
1
1
1
nortriptyline hcl soln 10 mg/5ml
1
OLEPTRO - trazodone hcl tab sr 24hr
150 mg
3
OLEPTRO - trazodone hcl tab sr 24hr
300 mg
3
PAMELOR - nortriptyline hcl cap 10 mg
3
3
PRISTIQ - desvenlafaxine succinate tab
sr 24hr 100 mg (base equiv)
3
3
protriptyline hcl tab 10 mg (Vivactil)
1
3
protriptyline hcl tab 5 mg (Vivactil)
1
PARNATE - tranylcypromine sulfate tab
10 mg
3
PROZAC - fluoxetine hcl cap 10 mg
3
91
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
3
trazodone hcl tab 150 mg
1
3
1
PROZAC WEEKLY - fluoxetine hcl cap
3
1
trimipramine maleate cap 100 mg
1
REMERON - mirtazapine tab 15 mg
3
1
3
1
3
•
3
venlafaxine hcl cap sr 24hr 150 mg
(base equivalent) (Effexor xr)
1
REMERON SOLTAB - mirtazapine
•
venlafaxine hcl cap sr 24hr 37.5 mg
1
3
•
venlafaxine hcl cap sr 24hr 75 mg
1
3
•
sertraline hcl oral conc 20 mg/ml
(Zoloft)
VENLAFAXINE HCL ER - venlafaxine
hcl tab sr 24hr 37.5 mg (base
equivalent)
3
1
sertraline hcl tab 100 mg (Zoloft)
1
3
•
1
1
hcl tab sr 24hr 75 mg (base
equivalent)
3
equivalent)
3
SURMONTIL - trimipramine maleate
cap 25 mg
•
cap 50 mg
3
3
•
cap 100 mg
3
equivalent)
•
3
TOFRANIL - imipramine hcl tab 25 mg
3
venlafaxine hcl tab sr 24hr 150 mg
(base equivalent) (Venlafaxine hcl
er)
1
3
1
•
TOFRANIL-PM - imipramine pamoate
cap 75 mg
3
venlafaxine hcl tab sr 24hr 37.5 mg
er)
3
venlafaxine hcl tab sr 24hr 75 mg
er)
1
cap 100 mg
•
cap 125 mg
3
venlafaxine hcl tab 100 mg
1
3
1
cap 150 mg
venlafaxine hcl tab 37.5 mg
1
tranylcypromine sulfate tab 10 mg
(Parnate)
1
1
1
1
VIIBRYD - vilazodone hcl tab 10 mg
3
92
3
3
ABILIFY MAINTENA - aripiprazole im
for extended release susp 300 mg
3
VIVACTIL - protriptyline hcl tab 5 mg
3
3
VIVACTIL - protriptyline hcl tab 10 mg
3
ABILIFY MAINTENA - aripiprazole im
for extended release susp 400 mg
3
•
ADASUVE - loxapine aerosol powder
breath activated 10 mg
3
WELLBUTRIN - bupropion hcl tab 75
mg
3
•
CHLORPROMAZINE HCL chlorpromazine hcl inj 25 mg/ml
3
WELLBUTRIN - bupropion hcl tab 100
mg
3
•
chlorpromazine hcl tab 10 mg
1
WELLBUTRIN SR - bupropion hcl tab sr
12hr 100 mg
1
12hr 150 mg
3
•
1
1
12hr 200 mg
3
•
1
3
•
CLOZAPINE ODT - clozapine orally
3
WELLBUTRIN XL - bupropion hcl tab sr
24hr 150 mg
WELLBUTRIN XL - bupropion hcl tab sr
24hr 300 mg
•
3
3
ZOLOFT - sertraline hcl tab 25 mg
3
3
3
clozapine tab 100 mg (Clozaril)
1
3
clozapine tab 200 mg
1
ZOLOFT - sertraline hcl oral conc 20
mg/ml
3
clozapine tab 25 mg (Clozaril)
1
clozapine tab 50 mg
1
CLOZARIL - clozapine tab 25 mg
3
CLOZARIL - clozapine tab 100 mg
3
COMPAZINE - prochlorperazine
maleate tab 5 mg
3
COMPAZINE - prochlorperazine
maleate tab 10 mg
3
EQUETRO - carbamazepine
(antipsychotic) cap sr 12hr 100 mg
3
3
3
FANAPT - iloperidone tab 1 mg
3
ANTIPSYCHOTICS
ABILIFY - aripiprazole tab 2 mg
3
3
3
3
3
3
ABILIFY - aripiprazole oral solution 1
mg/ml
3
ABILIFY - aripiprazole im inj 9.75
mg/1.3ml (7.5 mg/ml)
3
ABILIFY DISCMELT - aripiprazole orally
3
Dispensing Limits
Step Therapy
VIIBRYD - vilazodone hcl tab starter kit
10 (7) & 20 (7) & 40 (16) mg
ABILIFY DISCMELT - aripiprazole orally
Prior Authorization
3
Drug Name
Drug Tier
Dispensing Limits
3
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
93
3
3
3
FANAPT TITRATION PACK iloperidone tab 1 mg & 2 mg & 4 mg
& 6 mg titration pak
3
FAZACLO - clozapine orally
3
3
3
3
HALDOL DECANOATE 50 - haloperidol
decanoate im soln 50 mg/ml
3
haloperidol decanoate im soln
100 mg/ml (Haldol decanoate 100)
1
haloperidol decanoate im soln
50 mg/ml (Haldol decanoate 50)
1
haloperidol lactate inj 5 mg/ml
(Haldol)
1
haloperidol lactate oral conc 2 mg/ml
1
haloperidol tab 0.5 mg
1
haloperidol tab 1 mg
1
1
1
1
3
1
fluphenazine decanoate inj 25 mg/ml
INVEGA - paliperidone tab sr 24hr 1.5
mg
3
1
FLUPHENAZINE HCL - fluphenazine
hcl elixir 2.5 mg/5ml
3
INVEGA - paliperidone tab sr 24hr 3 mg
3
3
hcl oral conc 5 mg/ml
3
3
3
INVEGA SUSTENNA - paliperidone
palmitate im extended-release susp
39 mg/0.25ml
3
hcl inj 2.5 mg/ml
fluphenazine hcl tab 1 mg
1
fluphenazine hcl tab 2.5 mg
1
78 mg/0.5ml
3
1
1
3
GEODON - ziprasidone hcl cap 20 mg
3
palmitate im extend-release susp 117
mg/0.75ml
3
3
3
156 mg/ml
3
GEODON - ziprasidone mesylate for inj
3
3
HALDOL - haloperidol lactate inj 5 mg/
ml
3
234 mg/1.5ml
LATUDA - lurasidone hcl tab 20 mg
3
94
Dispensing Limits
3
3
Step Therapy
HALDOL DECANOATE 100 haloperidol decanoate im soln 100
mg/ml
Prior Authorization
3
Drug Name
Drug Tier
Dispensing Limits
3
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
1
3
1
3
olanzapine orally disintegrating tab
10 mg (Zyprexa zydis)
3
1
LITHIUM CARBONATE - lithium
carbonate cap 150 mg
3
1
LITHIUM CARBONATE - lithium
carbonate cap 600 mg
3
1
lithium carbonate cap 150 mg
(Lithium carbonate)
1
olanzapine tab 10 mg (Zyprexa)
1
1
1
(Lithium carbonate)
1
olanzapine tab 2.5 mg (Zyprexa)
1
1
lithium carbonate tab cr 300 mg
(Lithobid)
1
1
olanzapine tab 7.5 mg (Zyprexa)
1
lithium carbonate tab cr 450 mg
1
perphenazine tab 16 mg
1
lithium carbonate tab 300 mg
1
1
LITHIUM CITRATE - lithium citrate oral
soln 8 meq/5ml
3
1
1
prochlorperazine edisylate inj 5 mg/
ml
1
prochlorperazine maleate tab 10 mg
(Compazine)
1
prochlorperazine maleate tab 5 mg
(Compazine)
1
prochlorperazine suppos 25 mg
1
quetiapine fumarate tab 100 mg
(Seroquel)
1
(Seroquel)
1
(Seroquel)
1
(Seroquel)
1
(Seroquel)
1
(Seroquel)
1
LITHOBID - lithium carbonate tab cr 300 3
mg
1
loxapine succinate cap 10 mg
1
(Loxitane)
1
1
LOXITANE - loxapine succinate cap 5
mg
3
mg
3
mg
3
mg
3
NAVANE - thiothixene cap 2 mg
3
3
3
3
Dispensing Limits
olanzapine for im inj 10 mg (Zyprexa)
Step Therapy
3
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
95
1
RISPERDAL - risperidone tab 0.5 mg
3
risperidone tab 1 mg (Risperdal)
1
RISPERDAL - risperidone tab 1 mg
3
1
3
1
3
1
3
3
RISPERDAL - risperidone soln 1 mg/ml
3
SAPHRIS - asenapine maleate sl tab 5
mg (base equiv)
RISPERDAL CONSTA - risperidone
microspheres for inj 12.5 mg
3
SAPHRIS - asenapine maleate sl tab 10
mg (base equiv)
3
microspheres for inj 25 mg
3
SEROQUEL - quetiapine fumarate tab
25 mg
3
microspheres for inj 37.5 mg
3
50 mg
3
microspheres for inj 50 mg
3
100 mg
3
RISPERDAL M-TAB - risperidone orally
3
200 mg
3
3
300 mg
3
3
400 mg
3
3
SEROQUEL XR - quetiapine fumarate
tab sr 24hr 50 mg
2
3
tab sr 24hr 150 mg
2
risperidone orally disintegrating tab
0.25 mg
1
tab sr 24hr 200 mg
2
0.5 mg (Risperdal m-tab)
1
tab sr 24hr 300 mg
2
1 mg (Risperdal m-tab)
1
tab sr 24hr 400 mg
2
1
thioridazine hcl tab 10 mg
1
1
1
1
1
1
thiothixene cap 1 mg
1
1
1
risperidone soln 1 mg/ml (Risperdal)
1
1
risperidone tab 0.25 mg (Risperdal)
96
Dispensing Limits
risperidone tab 0.5 mg (Risperdal)
Step Therapy
3
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
RISPERDAL - risperidone tab 0.25 mg
Prior Authorization
Drug Name
Drug Tier
2014
trifluoperazine hcl tab 2 mg
1
Dispensing Limits
1
Step Therapy
Prior Authorization
1
Drug Name
Drug Tier
Dispensing Limits
1
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
AMBIEN CR - zolpidem tartrate tab cr
6.25 mg
3
•
AMBIEN CR - zolpidem tartrate tab cr
12.5 mg
3
•
1
BUTISOL SODIUM - butabarbital
sodium tab 30 mg
3
VERSACLOZ - clozapine susp 50 mg/ml 3
1
ziprasidone hcl cap 20 mg (Geodon)
sodium tab 50 mg
3
3
1
1
sodium elixir 30 mg/5ml
1
DORAL - quazepam tab 15 mg
3
ZYPREXA - olanzapine tab 2.5 mg
3
EDLUAR - zolpidem tartrate sl tab 5 mg
3
ZYPREXA - olanzapine tab 5 mg
3
3
ZYPREXA - olanzapine tab 7.5 mg
3
EDLUAR - zolpidem tartrate sl tab 10
mg
3
estazolam tab 1 mg
1
3
estazolam tab 2 mg
1
3
eszopiclone tab 1 mg (Lunesta)
1
3
1
ZYPREXA - olanzapine for im inj 10 mg
3
1
ZYPREXA RELPREVV - olanzapine
pamoate for extended rel im susp 210
mg (base eq)
flurazepam hcl cap 15 mg
1
flurazepam hcl cap 30 mg
1
mg (base eq)
3
HALCION - triazolam tab 0.25 mg
3
HETLIOZ - tasimelteon capsule 20 mg
3
3
INTERMEZZO - zolpidem tartrate sl tab
1.75 mg
3
mg (base eq)
•
3
•
ZYPREXA ZYDIS - olanzapine orally
3
INTERMEZZO - zolpidem tartrate sl tab
3.5 mg
LUNESTA - eszopiclone tab 1 mg
3
3
3
3
•
•
•
3
midazolam hcl syrup 2 mg/ml (base
equivalent)
1
3
PHENOBARBITAL - phenobarbital tab
15 mg
3
30 mg
3
60 mg
3
HYPNOTICS
AMBIEN - zolpidem tartrate tab 5 mg
3
AMBIEN - zolpidem tartrate tab 10 mg
3
•
•
•
•
•
•
•
•
97
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
64.8 mg
3
zolpidem tartrate tab cr 12.5 mg
(Ambien cr)
1
•
97.2 mg
3
zolpidem tartrate tab cr 6.25 mg
(Ambien cr)
1
•
100 mg
3
zolpidem tartrate tab 10 mg (Ambien)
1
zolpidem tartrate tab 5 mg (Ambien)
1
phenobarbital elixir 20 mg/5ml
1
3
phenobarbital tab 100 mg
1
ZOLPIMIST - zolpidem tartrate oral
spray 5 mg/act
•
•
•
1
phenobarbital tab 16.2 mg
1
1
phenobarbital tab 32.4 mg
1
1
QUAZEPAM - quazepam tab 15 mg
3
RESTORIL - temazepam cap 7.5 mg
3
RESTORIL - temazepam cap 15 mg
3
RESTORIL - temazepam cap 22.5 mg
3
RESTORIL - temazepam cap 30 mg
3
ROZEREM - ramelteon tab 8 mg
3
SECONAL - secobarbital sodium cap
100 mg
3
SILENOR - doxepin hcl (sleep) tab 3 mg 3
(base equiv)
SILENOR - doxepin hcl (sleep) tab 6 mg 3
(base equiv)
3
SOMNOTE - chloral hydrate cap 500
mg
3
SONATA - zaleplon cap 5 mg
SONATA - zaleplon cap 10 mg
3
temazepam cap 15 mg (Restoril)
1
temazepam cap 22.5 mg (Restoril)
1
temazepam cap 30 mg (Restoril)
1
temazepam cap 7.5 mg (Restoril)
1
triazolam tab 0.125 mg
1
triazolam tab 0.25 mg (Halcion)
1
zaleplon cap 10 mg (Sonata)
1
zaleplon cap 5 mg (Sonata)
1
98
•
•
•
•
•
•
•
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/
ANOREXIANTS
3
ADDERALL - amphetaminedextroamphetamine tab 5 mg
3
ADDERALL - amphetaminedextroamphetamine tab 7.5 mg
3
3
ADDERALL - amphetaminedextroamphetamine tab 12.5 mg
3
3
3
3
ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 5 mg
3
ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 10
mg
3
mg
3
mg
3
mg
3
mg
•
•
•
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
amphetamine-dextroamphetamine
cap sr 24hr 10 mg (Adderall xr)
1
•
DAYTRANA - methylphenidate td patch
10 mg/9hr
3
•
1
•
15 mg/9hr
3
•
1
•
20 mg/9hr
3
•
1
•
30 mg/9hr
3
•
1
•
DESOXYN - methamphetamine hcl tab
5 mg
3
1
•
DEXEDRINE - dextroamphetamine
sulfate cap sr 24hr 5 mg
3
tab 10 mg (Adderall)
1
3
tab 12.5 mg (Adderall)
1
3
1
dexmethylphenidate hcl cap sr 24 hr
15 mg (Focalin xr)
1
•
1
30 mg (Focalin xr)
1
•
1
40 mg (Focalin xr)
1
•
tab 5 mg (Adderall)
1
dexmethylphenidate hcl tab 10 mg
(Focalin)
1
tab 7.5 mg (Adderall)
1
dexmethylphenidate hcl tab 2.5 mg
(Focalin)
1
CAFCIT - caffeine citrate oral soln 60
mg/3ml (10 mg/ml base equiv)
3
dexmethylphenidate hcl tab 5 mg
(Focalin)
1
caffeine citrate oral soln 60 mg/3ml
(10 mg/ml base equiv) (Cafcit)
1
dextroamphetamine sulfate cap sr
24hr 10 mg (Dexedrine)
1
clonidine hcl tab sr 12hr 0.1 mg
(Kapvay)
1
1
CONCERTA - methylphenidate hcl tab
sa osm 18 mg
3
•
1
sa osm 27 mg
3
•
dextroamphetamine sulfate oral
solution 5 mg/5ml (Procentra)
1
sa osm 36 mg
3
•
dextroamphetamine sulfate tab
10 mg
1
sa osm 54 mg
3
•
dextroamphetamine sulfate tab 5 mg
1
99
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
FOCALIN - dexmethylphenidate hcl tab
2.5 mg
3
METADATE CD - methylphenidate hcl
cap cr 40 mg
3
•
5 mg
3
cap cr 50 mg
3
•
10 mg
3
cap cr 60 mg
3
•
FOCALIN XR - dexmethylphenidate hcl
cap sr 24 hr 5 mg
2
•
methamphetamine hcl tab 5 mg
(Desoxyn)
1
cap sr 24 hr 10 mg
2
•
METHYLIN - methylphenidate hcl chew
tab 2.5 mg
3
cap sr 24 hr 15 mg
3
•
tab 5 mg
3
cap sr 24 hr 20 mg
2
•
tab 10 mg
3
cap sr 24 hr 25 mg
2
•
METHYLIN - methylphenidate hcl soln 5
mg/5ml
3
cap sr 24 hr 30 mg
3
•
METHYLIN - methylphenidate hcl soln
10 mg/5ml
3
cap sr 24 hr 35 mg
2
•
methylphenidate hcl cap cr 10 mg
(Metadate cd)
1
•
cap sr 24 hr 40 mg
3
•
(Metadate cd)
1
•
INTUNIV - guanfacine hcl tab sr 24hr 1
mg (base equiv)
2
(Metadate cd)
1
•
mg (base equiv)
2
(Metadate cd)
1
•
mg (base equiv)
2
(Metadate cd)
1
•
mg (base equiv)
2
(Metadate cd)
1
•
KAPVAY - clonidine hcl tab sr 12hr 0.1
mg
3
methylphenidate hcl cap sr 24hr
20 mg (Ritalin la)
1
•
KAPVAY DOSE PACK - clonidine hcl
tab sr 12hr therapy pack 0.1 & 0.2 mg
3
30 mg (Ritalin la)
1
•
cap cr 10 mg
3
•
40 mg (Ritalin la)
1
•
cap cr 20 mg
3
•
METHYLPHENIDATE HCL ER methylphenidate hcl tab cr 10 mg
2
cap cr 30 mg
3
•
methylphenidate hcl soln 10 mg/5ml
(Methylin)
1
100
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
methylphenidate hcl soln 5 mg/5ml
(Methylin)
1
RITALIN LA - methylphenidate hcl cap
sr 24hr 30 mg
3
•
methylphenidate hcl tab cr 20 mg
(Ritalin sr)
1
sr 24hr 40 mg
3
•
methylphenidate hcl tab sa osm
18 mg (Concerta)
1
•
RITALIN SR - methylphenidate hcl tab
cr 20 mg
3
27 mg (Concerta)
1
•
STRATTERA - atomoxetine hcl cap 10
mg (base equiv)
3
•
36 mg (Concerta)
1
•
mg (base equiv)
3
•
54 mg (Concerta)
1
•
mg (base equiv)
3
•
methylphenidate hcl tab 10 mg
(Ritalin)
1
mg (base equiv)
3
•
(Ritalin)
1
mg (base equiv)
3
•
(Ritalin)
1
mg (base equiv)
3
•
modafinil tab 100 mg (Provigil)
1
3
•
modafinil tab 200 mg (Provigil)
1
mg (base equiv)
NUVIGIL - armodafinil tab 50 mg
3
2
•
3
VYVANSE - lisdexamfetamine
dimesylate cap 20 mg
3
2
•
3
•
3
2
PROCENTRA - dextroamphetamine
sulfate oral solution 5 mg/5ml
•
PROVIGIL - modafinil tab 100 mg
2
3
PROVIGIL - modafinil tab 200 mg
3
2
•
QUILLIVANT XR - methylphenidate hcl
for er susp 25 mg/5ml (5 mg/ml)
3
2
•
RITALIN - methylphenidate hcl tab 5 mg
3
RITALIN - methylphenidate hcl tab 10
mg
3
ZENZEDI - dextroamphetamine sulfate
tab 2.5 mg
3
RITALIN - methylphenidate hcl tab 20
mg
3
tab 7.5 mg
3
sr 24hr 10 mg
3
•
tab 15 mg
3
sr 24hr 20 mg
3
•
tab 20 mg
3
•
•
•
•
•
•
•
•
•
101
tab 30 mg
3
PSYCHOTHERAPEUTIC and NEUROLOGICAL
AGENTS - MISC.
1
acamprosate calcium tab delayed
release 333 mg (Campral)
AMPYRA - dalfampridine tab sr 12hr 10 4 •
mg
3
ANTABUSE - disulfiram tab 250 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
CHANTIX - varenicline tartrate tab 1 mg
(base equiv)
2
•
CHANTIX CONTINUING MONTH varenicline tartrate tab 1 mg (base
equiv)
2
•
CHANTIX STARTING MONTH PA varenicline tartrate tab 0.5 mg x 11 &
tab 1 mg x 42 pack
2
•
CHLORDIAZEPOXIDE/AMITRIPT chlordiazepoxide-amitriptyline tab
5-12.5 mg
3
3
ANTABUSE - disulfiram tab 500 mg
3
ARICEPT - donepezil hydrochloride tab
5 mg
3
10 mg
3
CHLORDIAZEPOXIDE/AMITRIPT chlordiazepoxide-amitriptyline tab
10-25 mg
3
23 mg
3
COMMIT - nicotine polacrilex lozenge 2
mg
3
COMMIT - nicotine polacrilex lozenge 4
mg
3
ARICEPT ODT - donepezil
hydrochloride orally disintegrating tab
5 mg
COPAXONE - glatiramer acetate soln
prefilled syringe 40 mg/ml
4
•
ARICEPT ODT - donepezil
hydrochloride orally disintegrating tab
10 mg
3
COPAXONE - glatiramer acetate inj kit
20 mg/ml
4
•
4
disulfiram tab 250 mg (Antabuse)
4
disulfiram tab 500 mg (Antabuse)
1
AUBAGIO - teriflunomide tab 14 mg
4
AVONEX - interferon beta-1a im inj kit
30 mcg/0.5ml
4
• •
donepezil hydrochloride orally
disintegrating tab 10 mg (Aricept
odt)
1
AVONEX - interferon beta-1a for im inj
kit 30mcg (33mcg(6.6 mu)/vial)
• •
• •
• •
1
AUBAGIO - teriflunomide tab 7 mg
AVONEX PEN - interferon beta-1a im inj 4
kit 30 mcg/0.5ml
BETASERON - interferon beta-1b for inj 4
kit 0.3 mg
3
BRISDELLE - paroxetine mesylate cap
7.5 mg (base equiv)
1
bupropion hcl (smoking deterrent)
tab sr 12hr 150 mg (Zyban)
3
CAMPRAL - acamprosate calcium tab
2
CHANTIX - varenicline tartrate tab 0.5
mg (base equiv)
• •
102
•
•
•
1
donepezil hydrochloride orally
disintegrating tab 5 mg (Aricept odt)
1
donepezil hydrochloride tab 10 mg
(Aricept)
1
(Aricept)
1
(Aricept)
3
ERGOLOID MESYLATES - ergoloid
mesylates tab 1 mg
2
EXELON - rivastigmine td patch 24hr
4.6 mg/24hr
2
9.5 mg/24hr
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
13.3 mg/24hr
2
HORIZANT - gabapentin enacarbil tab
sr 24hr 300 mg
3
•
EXELON - rivastigmine tartrate cap 1.5
mg
3
HORIZANT - gabapentin enacarbil tab
sr 24hr 600 mg
3
•
EXELON - rivastigmine tartrate cap 3
mg
3
NAMENDA - memantine hcl tab 5 mg
3
NAMENDA - memantine hcl tab 10 mg
3
EXELON - rivastigmine tartrate cap 4.5
mg
3
NAMENDA - memantine hcl oral
solution 2 mg/ml
3
EXELON - rivastigmine tartrate cap 6
mg
3
3
EXELON - rivastigmine tartrate soln 2
mg/ml
3
NAMENDA TITRATION PAK memantine hcl tab 5 mg (28) & 10 mg
(21) titration pak
EXTAVIA - interferon beta-1b for inj kit
0.3 mg
NAMENDA XR - memantine hcl cap sr
24hr 7 mg
3
4
fluoxetine hcl (pmdd) cap 10 mg
24hr 14 mg
3
1
fluoxetine hcl (pmdd) cap 20 mg
1
3
galantamine hydrobromide cap sr
24hr 16 mg (Razadyne er)
1
24hr 21 mg
3
1
24hr 28 mg
3
1
NAMENDA XR TITRATION PACK memantine hcl cap sr 24hr 7 mg & 14
mg & 21 mg & 28 mg pack
galantamine hydrobromide oral soln
4 mg/ml (Razadyne)
1
NICODERM CQ - nicotine td patch 24hr
7 mg/24hr
3
galantamine hydrobromide tab
12 mg (Razadyne)
1
14 mg/24hr
3
galantamine hydrobromide tab 4 mg
(Razadyne)
1
21 mg/24hr
3
galantamine hydrobromide tab 8 mg
(Razadyne)
1
NICORETTE - nicotine polacrilex gum 2
mg
3
GILENYA - fingolimod hcl cap 0.5 mg
(base equiv)
4
• •
NICORETTE - nicotine polacrilex gum 4
mg
3
GRALISE - gabapentin (phn) tab 300
mg
3
•
NICORETTE - nicotine polacrilex
lozenge 2 mg
3
GRALISE - gabapentin (phn) tab 600
mg
3
•
NICORETTE - nicotine polacrilex
lozenge 4 mg
3
GRALISE STARTER - gabapentin (phn)
tab starter pack 300 mg (9) & 600 mg
(69)
3
•
NICORETTE MINI - nicotine polacrilex
lozenge 2 mg
3
NICORETTE MINI - nicotine polacrilex
lozenge 4 mg
3
• •
103
NICORETTE STARTER KIT - nicotine
polacrilex gum 2 mg
3
NICORETTE STARTER KIT - nicotine
polacrilex gum 4 mg
3
nicotine polacrilex gum 2 mg
1
nicotine polacrilex gum 4 mg
1
nicotine polacrilex lozenge 2 mg
1
nicotine polacrilex lozenge 4 mg
1
nicotine td patch 24hr 14 mg/24hr
1
1
1
NICOTINE TRANSDERMAL SYST nicotine td patch 24 hr kit 21-14-7
mg/24hr
3
NICOTROL INHALER - nicotine inhaler
system 10 mg (4 mg delivered)
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
PERPHENAZINE/AMITRIPTYLIN perphenazine-amitriptyline tab 4-10
mg
3
mg
3
mg
3
RAZADYNE - galantamine
hydrobromide tab 4 mg
3
3
3
2
hydrobromide oral soln 4 mg/ml
3
NICOTROL NS - nicotine nasal spray 10 2
mg/ml (0.5 mg/spray)
3
NUEDEXTA - dextromethorphan hbrquinidine sulfate cap 20-10 mg
1
olanzapine-fluoxetine hcl cap
12-25 mg (Symbyax)
1
12-50 mg (Symbyax)
1
3-25 mg (Symbyax)
1
6-25 mg (Symbyax)
1
6-50 mg (Symbyax)
3
ORAP - pimozide tab 1 mg
RAZADYNE ER - galantamine
hydrobromide cap sr 24hr 8 mg
3
3
3
REBIF - interferon beta-1a inj 22
mcg/0.5ml (12mu/ml) (44 mcg/ml)
4
•
REBIF - interferon beta-1a inj 44
mcg/0.5ml (24mu/ml) (88 mcg/ml)
4
•
REBIF REBIDOSE - interferon beta-1a
inj 22 mcg/0.5ml (12mu/ml) (44 mcg/
ml)
4
•
REBIF REBIDOSE - interferon beta-1a
inj 44 mcg/0.5ml (24mu/ml) (88 mcg/
ml)
4
•
4
•
•
ORAP - pimozide tab 2 mg
3
mg
3
REBIF REBIDOSE TITRATION interferon beta-1a inj 6 x 8.8
mcg/0.2ml & 6 x 22 mcg/0.5ml
mg
REBIF TITRATION PACK - interferon
beta-1a inj 6 x 8.8 mcg/0.2ml & 6 x 22
mcg/0.5ml
4
3
rivastigmine tartrate cap 1.5 mg
(Exelon)
1
104
rivastigmine tartrate cap 3 mg
(Exelon)
1
rivastigmine tartrate cap 4.5 mg
(Exelon)
1
rivastigmine tartrate cap 6 mg
(Exelon)
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
ANALGESICS AND ANESTHETICS
ANALGESICS - NON-NARCOTIC
1
1
acetaminophen-salicylamidephenyltoloxamine cap
300-200-20mg
3
ADULT ASPIRIN LOW STRENGT aspirin dispersible tab 81 mg
3
SARAFEM - fluoxetine hcl (pmdd) tab
10 mg
3
ALAGESIC LQ - butalbitalacetaminophen-caffeine soln
50-325-40 mg/15ml
3
SARAFEM - fluoxetine hcl (pmdd) tab
20 mg
SAVELLA - milnacipran hcl tab 12.5 mg
3
3
SAVELLA - milnacipran hcl tab 25 mg
3
ALPAIN - phenyltoloxamineacetaminophen tab 60-500 mg
3
aspirin chew tab 81 mg
1
3
1
SAVELLA TITRATION PACK milnacipran hcl tab 12.5 mg (5) & 25
mg (8) & 50 mg (42) pak
3
ASPIRIN LOW DOSE - aspirin tab 81
mg
aspirin tab delayed release 81 mg
1
aspirin tab 81 mg
1
SYMBYAX - olanzapine-fluoxetine hcl
cap 3-25 mg
3
BIOREGESIC - phenyltoloxamineacetaminophen tab 50-650 mg
3
cap 6-25 mg
3
BUPAP - butalbital-acetaminophen tab
50-300 mg
3
•
cap 6-50 mg
3
BUPAP - butalbital-acetaminophen tab
50-650 mg
3
•
cap 12-25 mg
3
butalbital-acetaminophen tab
50-325 mg
1
•
cap 12-50 mg
3
butalbital-acetaminophen tab
50-650 mg
1
•
TECFIDERA - dimethyl fumarate
capsule delayed release 120 mg
4
•
butalbital-acetaminophen-caffeine
cap 50-300-40 mg (Fioricet)
1
•
TECFIDERA - dimethyl fumarate
capsule delayed release 240 mg
4
•
cap 50-325-40 mg
1
•
TECFIDERA STARTER PACK dimethyl fumarate capsule dr starter
pack 120 mg & 240 mg
4
•
cap 50-500-40 mg
1
•
•
4
tab 50-325-40 mg (Esgic)
1
XENAZINE - tetrabenazine tab 12.5 mg
XENAZINE - tetrabenazine tab 25 mg
4
1
•
XYREM - sodium oxybate oral solution
500 mg/ml
4
tab 50-500-40 mg
1
•
ZYBAN - bupropion hcl (smoking
deterrent) tab sr 12hr 150 mg
3
butalbital-aspirin-caffeine cap
50-325-40 mg (Fiorinal)
•
•
•
105
butalbital-aspirin-caffeine tab
50-325-40 mg
1
•
ORBIVAN CF - butalbitalacetaminophen tab 50-300 mg
3
BUTALBITAL/ASPIRIN/CAFFEI butalbital-aspirin-caffeine tab
50-325-40 mg
3
•
phenyltoloxamine-acetaminophen
tab 30-500 mg
1
choline & magnesium salicylates liq
500 mg/5ml
tab 50-500 mg
1
1
1
tab 55-500 mg
1
choline & magnesium salicylates tab
1000 mg
diflunisal tab 500 mg
PHRENILIN FORTE - butalbitalacetaminophen cap 50-650 mg
3
1
DOLGIC PLUS - butalbitalacetaminophen-caffeine tab
50-750-40 mg
3
RELAGESIC - phenyltoloxamineacetaminophen tab 50-650 mg
3
DOLOGESIC - phenyltoloxamineacetaminophen liquid 30-500
mg/15ml
RHINOFLEX-650 - phenyltoloxamineacetaminophen tab 50-650 mg
3
3
salsalate tab 500 mg
1
salsalate tab 750 mg
1
STAFLEX - phenyltoloxamineacetaminophen tab 55-500 mg
3
EQUAGESIC - meprobamate-aspirin tab 3
200-325 mg
3
ESGIC - butalbital-acetaminophencaffeine cap 50-325-40 mg
3
ESGIC - butalbital-acetaminophencaffeine tab 50-325-40 mg
3
ESGIC-PLUS - butalbitalacetaminophen-caffeine cap
50-500-40 mg
3
ESGIC-PLUS - butalbitalacetaminophen-caffeine tab
50-500-40 mg
3
FIORICET - butalbital-acetaminophencaffeine cap 50-300-40 mg
3
FIORICET - butalbital-acetaminophencaffeine tab 50-325-40 mg
3
FIORINAL - butalbital-aspirin-caffeine
cap 50-325-40 mg
3
LEVACET - aspirin-apap-salicylamidecaffeine tab 500-250-150-32.5 mg
3
MST 600 - magnesium salicylate tab
600 mg
3
ORBIVAN - butalbital-acetaminophencaffeine cap 50-300-40 mg
106
•
•
•
•
•
•
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
•
•
•
TENCON - butalbital-acetaminophen tab 3
50-650 mg
3
ZGESIC - phenyltoloxamineacetaminophen tab cr 66-600 mg
ANALGESICS - NARCOTIC
ABSTRAL - fentanyl citrate sl tab 100
mcg (base equiv)
3
•
mcg (base equiv)
3
•
mcg (base equiv)
3
•
mcg (base equiv)
3
•
mcg (base equiv)
3
•
mcg (base equiv)
3
•
acetaminophen w/ codeine soln
120-12 mg/5ml
1
•
acetaminophen w/ codeine tab
300-15 mg (Tylenol/codeine)
1
•
300-30 mg (Tylenol/codeine #3)
1
•
300-60 mg (Tylenol/codeine #4)
1
ACETAMINOPHEN/CAFFEINE/
DI - acetaminophen-caffeinedihydrocodeine tab 712.8-60-32 mg
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
1
•
•
butalbital-acetaminophen-caff w/
cod cap 50-300-40-30 mg (Fioricet/
codeine)
1
•
•
butalbital-acetaminophen-caff w/ cod
cap 50-325-40-30 mg
butalbital-aspirin-caff w/ codeine cap
50-325-40-30 mg (Fiorinal/codeine
#3)
1
•
butorphanol tartrate nasal soln
10 mg/ml
1
BUTRANS - buprenorphine td patch
weekly 5 mcg/hr
3
•
weekly 10 mcg/hr
3
•
weekly 15 mcg/hr
3
•
weekly 20 mcg/hr
3
•
ACTIQ - fentanyl citrate lollipop 1200
mcg
3
•
•
•
•
•
ACTIQ - fentanyl citrate lollipop 1600
mcg
3
•
ASPIRIN-CAFFEINE-DIHYDROC aspirin-caffeine-dihydrocodeine cap
356.4-30-16 mg
3
•
AVINZA - morphine sulfate beads cap sr 3
24hr 30 mg
24hr 45 mg
24hr 60 mg
24hr 75 mg
24hr 90 mg
24hr 120 mg
1
buprenorphine hcl sl tab 2 mg (base
equiv)
1
buprenorphine hcl sl tab 8 mg (base
equiv)
1
buprenorphine hcl-naloxone hcl sl
tab 2-0.5 mg (base equiv)
1
buprenorphine hcl-naloxone hcl sl
tab 8-2 mg (base equiv)
•
CAPITAL/CODEINE - acetaminophen
w/ codeine susp 120-12 mg/5ml
3
•
•
CODEINE SULFATE - codeine sulfate
tab 15 mg
3
•
•
tab 30 mg
3
•
•
tab 60 mg
3
•
•
oral soln 30 mg/5ml
3
•
CONZIP - tramadol hcl cap sr 24hr
biphasic release 100 mg
3
•
•
3
•
•
3
•
•
DEMEROL - meperidine hcl tab 50 mg
3
DEMEROL - meperidine hcl tab 100 mg
3
•
DILAUDID - hydromorphone hcl tab 2
mg
3
•
•
•
mg
3
•
ACTIQ - fentanyl citrate lollipop 200 mcg 3
107
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
mg
3
•
fentanyl td patch 72hr 12 mcg/hr
(Duragesic)
1
•
DILAUDID - hydromorphone hcl liqd 1
mg/ml
3
•
(Duragesic)
1
•
DOLOPHINE - methadone hcl tab 10
mg
3
•
(Duragesic)
1
•
DOLOPHINE HCL - methadone hcl tab
5 mg
3
•
(Duragesic)
1
•
DURAGESIC - fentanyl td patch 72hr 12 3
mcg/hr
mcg/hr
mcg/hr
mcg/hr
3
DURAGESIC - fentanyl td patch 72hr
100 mcg/hr
3
EXALGO - hydromorphone hcl tab er
24hr deter 8 mg
3
24hr deter 12 mg
3
24hr deter 16 mg
3
24hr deter 32 mg
1
fentanyl citrate lollipop 1200 mcg
(Actiq)
1
(Actiq)
1
(Actiq)
1
(Actiq)
1
(Actiq)
1
(Actiq)
1
(Duragesic)
•
FENTORA - fentanyl citrate buccal tab
100 mcg (base equiv)
3
•
•
3
•
•
3
•
•
3
•
•
3
•
•
FIORICET/CODEINE - butalbitalacetaminophen-caff w/ cod cap
50-300-40-30 mg
3
•
FIORICET/CODEINE - butalbitalacetaminophen-caff w/ cod cap
50-325-40-30 mg
3
•
FIORINAL/CODEINE #3 - butalbitalaspirin-caff w/ codeine cap
50-325-40-30 mg
3
•
HYCET - hydrocodone-acetaminophen
soln 7.5-325 mg/15ml
3
•
1
•
•
HYDROCODONE BITARTRATE/AC hydrocodone-acetaminophen tab
10-750 mg
•
hydrocodone-acetaminophen cap
5-500 mg
1
•
•
hydrocodone-acetaminophen soln
10-325 mg/15ml
1
•
•
7.5-325 mg/15ml (Hycet)
1
•
7.5-500 mg/15ml
1
•
108
•
•
•
•
•
•
hydrocodone-acetaminophen tab
10-300 mg (Xodol)
1
•
10-325 mg (Norco)
1
•
10-500 mg
1
•
10-650 mg
1
•
10-660 mg
1
•
10-750 mg
1
2.5-325 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
HYDROCODONE/ACETAMINOPHEN hydrocodone-acetaminophen tab
7.5-500 mg
3
•
7.5-650 mg
3
•
7.5-750 mg
1
•
1
•
•
HYDROCODONE/ACETAMINOPHEN hydrocodone-acetaminophen soln
10-325 mg/15ml
1
•
HYDROMORPHONE HCL hydromorphone hcl suppos 3 mg
3
1
•
•
5-300 mg (Xodol)
1
•
HYDROMORPHONE HCL ER hydromorphone hcl tab er 24hr deter
32 mg
3
2.5-500 mg
1
•
5-325 mg (Norco)
1
•
hydromorphone hcl liqd 1 mg/ml
(Dilaudid)
1
•
5-500 mg
1
•
hydromorphone hcl tab er 24hr deter
12 mg (Exalgo)
1
•
7.5-300 mg (Xodol)
1
•
16 mg (Exalgo)
1
•
7.5-325 mg (Norco)
1
•
8 mg (Exalgo)
1
•
7.5-500 mg
1
•
hydromorphone hcl tab 2 mg
(Dilaudid)
1
•
7.5-650 mg
1
•
(Dilaudid)
1
•
7.5-750 mg
1
•
(Dilaudid)
3
•
hydrocodone-ibuprofen tab
10-200 mg (Ibudone)
1
•
IBUDONE - hydrocodone-ibuprofen tab
10-200 mg
3
•
2.5-200 mg (Reprexain)
1
•
KADIAN - morphine sulfate cap sr 24hr
10 mg
3
•
hydrocodone-ibuprofen tab 5-200 mg
(Reprexain)
1
•
20 mg
3
•
7.5-200 mg (Vicoprofen)
1
•
30 mg
40 mg
3
•
109
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
50 mg
3
•
MAGNACET - oxycodone w/
acetaminophen tab 7.5-400 mg
3
•
60 mg
3
•
acetaminophen tab 10-400 mg
3
•
70 mg
3
•
MAXIDONE - hydrocodoneacetaminophen tab 10-750 mg
3
•
80 mg
3
•
•
100 mg
3
•
MEPERIDINE HCL - meperidine hcl oral 3
soln 50 mg/5ml
meperidine hcl tab 100 mg (Demerol) 1
130 mg
3
•
150 mg
3
200 mg
3
LAZANDA - fentanyl citrate nasal spray
100 mcg/act (base equiv)
3
LAZANDA - fentanyl citrate nasal spray
400 mcg/act (base equiv)
3
LEVORPHANOL TARTRATE levorphanol tartrate tab 2 mg
3
•
•
meperidine hcl tab 50 mg (Demerol)
1
3
•
MEPERIDINE HCL/PROMETHAZI meperidine w/ promethazine cap
50-25 mg
3
•
METHADONE HCL - methadone hcl
soln 5 mg/5ml
•
METHADONE HCL - methadone hcl
soln 10 mg/5ml
3
•
•
methadone hcl conc 10 mg/ml
(Methadose)
1
•
•
methadone hcl soln 10 mg/5ml
(Methadone hcl)
1
•
•
LIQUICET - hydrocodoneacetaminophen soln 10-500 mg/15ml
methadone hcl soln 5 mg/5ml
(Methadone hcl)
1
3
1
3
•
•
LORCET PLUS - hydrocodoneacetaminophen tab 7.5-650 mg
methadone hcl tab for oral susp
40 mg
1
3
•
methadone hcl tab 10 mg (Dolophine)
LORCET 10/650 - hydrocodoneacetaminophen tab 10-650 mg
1
LORTAB - hydrocodone-acetaminophen 3
tab 5-500 mg
tab 7.5-500 mg
tab 10-500 mg
soln 7.5-500 mg/15ml
soln 10-300 mg/15ml
3
•
methadone hcl tab 5 mg (Dolophine
hcl)
•
•
METHADOSE - methadone hcl conc 10
mg/ml
3
•
METHADOSE SUGAR-FREE methadone hcl conc 10 mg/ml
3
•
MORPHINE SULFATE - morphine
sulfate tab 15 mg
2
•
sulfate tab 30 mg
2
•
sulfate suppos 5 mg
2
sulfate suppos 10 mg
2
110
•
•
•
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
2
morphine sulfate tab cr 200 mg (Ms
contin)
1
•
2
contin)
1
•
sulfate im inj device 10 mg/0.7ml
3
contin)
1
•
morphine sulfate (concentrate) oral
soln 20 mg/ml
1
•
MS CONTIN - morphine sulfate tab cr
15 mg
3
•
morphine sulfate beads cap sr 24hr
120 mg (Avinza)
1
•
30 mg
3
•
30 mg (Avinza)
1
•
60 mg
3
•
45 mg (Avinza)
1
•
100 mg
3
•
60 mg (Avinza)
1
•
200 mg
3
•
75 mg (Avinza)
1
•
nalbuphine hcl inj 10 mg/ml
1
1
1
•
nalbuphine hcl inj 20 mg/ml
90 mg (Avinza)
3
•
morphine sulfate cap sr 24hr 10 mg
(Kadian)
1
•
NORCO - hydrocodone-acetaminophen
tab 10-325 mg
3
•
(Kadian)
1
•
tab 5-325 mg
3
•
(Kadian)
1
•
tab 7.5-325 mg
NUCYNTA - tapentadol hcl tab 50 mg
3
1
•
3
(Kadian)
3
(Kadian)
1
•
NUCYNTA ER - tapentadol hcl tab sr
12hr 50 mg
2
•
•
•
•
(Kadian)
1
•
12hr 100 mg
2
•
(Kadian)
1
•
12hr 150 mg
2
•
morphine sulfate oral soln 10 mg/5ml
1
•
1
12hr 200 mg
2
morphine sulfate oral soln 20 mg/5ml
1
12hr 250 mg
2
contin)
•
•
•
•
1
•
ONSOLIS - fentanyl citrate buccal
soluble film 200 mcg
3
contin)
•
111
•
3
•
ORAMORPH SR - morphine sulfate tab
cr 30 mg
3
•
3
•
cr 60 mg
3
•
3
•
cr 100 mg
3
•
OPANA - oxymorphone hcl tab 5 mg
3
•
3
OXECTA - oxycodone hcl tab abuse
deter 5 mg
3
OPANA - oxymorphone hcl tab 10 mg
OPANA ER - oxymorphone hcl tab sr
12hr 5 mg
3
•
•
•
OXECTA - oxycodone hcl tab abuse
deter 7.5 mg
3
•
12hr 10 mg
3
•
OXYCODONE HCL - oxycodone hcl
conc 100 mg/5ml (20 mg/ml)
3
•
12hr 20 mg
3
•
OXYCODONE HCL - oxycodone hcl
soln 5 mg/5ml
3
•
12hr 30 mg
3
•
oxycodone hcl cap 5 mg
1
1
12hr 40 mg
3
•
oxycodone hcl conc 100 mg/5ml
(20 mg/ml) (Oxycodone hcl)
•
•
1
•
OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter 5
mg
3
•
oxycodone hcl soln 5 mg/5ml
(Oxycodone hcl)
oxycodone hcl tab 10 mg
1
•
•
OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter
7.5 mg
3
(Roxicodone)
1
1
3
(Roxicodone)
1
mg
mg
3
mg
3
mg
3
•
mg
3
•
112
•
•
•
Dispensing Limits
3
Step Therapy
cr 15 mg
•
Prior Authorization
•
Drug Name
Drug Tier
3
Dispensing Limits
Prior Authorization
Drug Name
Step Therapy
Drug Tier
2014
oxycodone hcl tab 5 mg (Roxicodone) 1
1
oxycodone w/ acetaminophen cap
5-500 mg
1
oxycodone w/ acetaminophen tab
10-325 mg (Percocet)
1
10-650 mg
1
2.5-325 mg (Percocet)
1
5-325 mg (Percocet)
1
7.5-325 mg (Percocet)
•
•
•
•
•
•
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
7.5-500 mg
1
•
PERCOCET - oxycodone w/
3
•
oxycodone-aspirin tab
4.8355-325 mg (Percodan)
1
•
3
•
oxycodone-ibuprofen tab 5-400 mg
1
•
2
3
OXYCONTIN - oxycodone hcl tab er
12hr deter 10 mg
•
•
3
•
12hr deter 15 mg
2
•
PERCODAN - oxycodone-aspirin tab
4.8355-325 mg
3
•
12hr deter 20 mg
2
•
PRIMLEV - oxycodone w/
3
•
12hr deter 30 mg
2
•
3
•
12hr deter 40 mg
2
•
3
•
12hr deter 60 mg
2
•
REPREXAIN - hydrocodone-ibuprofen
tab 2.5-200 mg
3
•
12hr deter 80 mg
2
•
REPREXAIN - hydrocodone-ibuprofen
tab 5-200 mg
3
•
oxymorphone hcl tab sr 12hr 10 mg
1
ROXICET - oxycodone w/
acetaminophen soln 5-325 mg/5ml
1
3
•
1
ROXICODONE - oxycodone hcl tab 5
mg
1
mg
3
•
1
•
1
mg
3
oxymorphone hcl tab sr 12hr 7.5 mg
1
3
•
oxymorphone hcl tab 10 mg (Opana)
1
RYBIX ODT - tramadol hcl orally
oxymorphone hcl tab 5 mg (Opana)
1
3
•
pentazocine w/ naloxone tab
50-0.5 mg
1
RYZOLT - tramadol hcl tab sr 24hr
3
•
pentazocine-acetaminophen tab
25-650 mg
1
3
•
3
3
•
3
•
SUBOXONE - buprenorphine hclnaloxone hcl sl tab 2-0.5 mg (base
equiv)
3
•
SUBOXONE - buprenorphine hclnaloxone hcl sl tab 8-2 mg (base
equiv)
3
•
•
•
•
•
•
•
•
•
•
•
•
113
2
•
SUBOXONE - buprenorphine hclnaloxone hcl sl film 12-3 mg (base
equiv)
2
SUBSYS - fentanyl sublingual spray 100 3
mcg
mcg
mcg
mcg
mcg
3
SUBSYS - fentanyl sublingual spray
1200 mcg (600 mcg x 2)
3
SUBSYS - fentanyl sublingual spray
1600 mcg (800 mcg x 2)
3
SUBUTEX - buprenorphine hcl sl tab 2
mg (base equiv)
3
SUBUTEX - buprenorphine hcl sl tab 8
mg (base equiv)
3
SYNALGOS-DC - aspirin-caffeinedihydrocodeine cap 356.4-30-16 mg
TALWIN - pentazocine lactate inj 30 mg/ 3
ml
TRAMADOL HCL ER - tramadol hcl cap 3
sr 24hr biphasic release 150 mg
1
tramadol hcl tab sr 24hr biphasic
release 100 mg
1
release 200 mg
114
Dispensing Limits
equiv)
Step Therapy
equiv)
2
Prior Authorization
•
Drug Name
Drug Tier
2
Dispensing Limits
Prior Authorization
SUBOXONE - buprenorphine hclnaloxone hcl sl film 2-0.5 mg (base
equiv)
Drug Name
Step Therapy
Drug Tier
2014
release 300 mg
1
•
tramadol hcl tab sr 24hr 100 mg
(Ultram er)
1
•
(Ultram er)
1
•
(Ultram er)
1
•
•
tramadol hcl tab 50 mg (Ultram)
1
tramadol-acetaminophen tab
37.5-325 mg (Ultracet)
1
•
•
•
TREZIX - acetaminophen-caffeinedihydrocodeine cap 356.4-30-16 mg
3
•
•
TYLENOL/CODEINE - acetaminophen
w/ codeine tab 300-15 mg
3
•
•
TYLENOL/CODEINE #3 acetaminophen w/ codeine tab
300-30 mg
3
•
3
•
•
TYLENOL/CODEINE #4 acetaminophen w/ codeine tab
300-60 mg
•
TYLOX - oxycodone w/ acetaminophen
cap 5-500 mg
3
•
•
ULTRACET - tramadol-acetaminophen
tab 37.5-325 mg
3
•
•
ULTRAM - tramadol hcl tab 50 mg
3
ULTRAM ER - tramadol hcl tab sr 24hr
100 mg
3
•
•
200 mg
3
•
300 mg
3
•
VICODIN - hydrocodoneacetaminophen tab 5-500 mg
3
•
VICODIN ES - hydrocodoneacetaminophen tab 7.5-750 mg
3
•
VICOPROFEN - hydrocodone-ibuprofen
tab 7.5-200 mg
3
•
XARTEMIS XR - oxycodone w/
acetaminophen tab cr 7.5-325 mg
3
•
•
•
•
•
•
•
•
XODOL - hydrocodone-acetaminophen
tab 7.5-300 mg
3
•
tab 10-300 mg
3
•
XOLOX - oxycodone w/ acetaminophen
tab 10-500 mg
3
•
ZOHYDRO ER - hydrocodone bitartrate
cap sr 12hr 10 mg
3
•
CATAFLAM - diclofenac potassium tab
50 mg
3
cap sr 12hr 15 mg
3
•
CELEBREX - celecoxib cap 50 mg
3
3
cap sr 12hr 20 mg
•
3
3
3
•
3
cap sr 12hr 30 mg
CLINORIL - sulindac tab 200 mg
3
cap sr 12hr 40 mg
3
•
DAYPRO - oxaprozin tab 600 mg
3
1
cap sr 12hr 50 mg
3
•
diclofenac potassium tab 50 mg
(Cataflam)
1
ZOLVIT - hydrocodone-acetaminophen
soln 10-300 mg/15ml
3
•
diclofenac sodium tab delayed
release 25 mg
1
•
release 50 mg
1
•
release 75 mg
diclofenac sodium tab sr 24hr
100 mg (Voltaren-xr)
1
diclofenac w/ misoprostol tab
delayed release 50-0.2 mg
(Arthrotec 50)
1
diclofenac w/ misoprostol tab
delayed release 75-0.2 mg
(Arthrotec 75)
1
DUEXIS - ibuprofen-famotidine tab
800-26.6 mg
3
ZUBSOLV - buprenorphine hcl-naloxone 3
hcl sl tab 1.4-0.36 mg (base eq)
ZUBSOLV - buprenorphine hcl-naloxone 3
hcl sl tab 5.7-1.4 mg (base eq)
3
ZYDONE - hydrocodoneacetaminophen tab 5-400 mg
3
ZYDONE - hydrocodoneacetaminophen tab 7.5-400 mg
3
ZYDONE - hydrocodoneacetaminophen tab 10-400 mg
•
•
•
ANALGESICS - ANTI-INFLAMMATORY
• •
3
ARCALYST - rilonacept for inj 220 mg
4
ARTHROTEC 50 - diclofenac w/
misoprostol tab delayed release
50-0.2 mg
3
ARTHROTEC 75 - diclofenac w/
misoprostol tab delayed release
75-0.2 mg
3
ACTEMRA - tocilizumab subcutaneous
soln prefilled syringe 162 mg/0.9ml
4
3
EC-NAPROSYN - naproxen tab ec 375
mg
3
ANAPROX - naproxen sodium tab 275
mg
3
EC-NAPROSYN - naproxen tab ec 500
mg
3
ANAPROX DS - naproxen sodium tab
550 mg
3
ENBREL - etanercept subcutaneous inj
50 mg/ml
4
ARAVA - leflunomide tab 10 mg
Dispensing Limits
ARAVA - leflunomide tab 20 mg
Step Therapy
•
Prior Authorization
3
Drug Tier
tab 5-300 mg
Step Therapy
Drug Name
Drug Name
Drug Tier
Dispensing Limits
Prior Authorization
2014
•
•
•
•
•
• •
115
ENBREL - etanercept subcutaneous inj
25 mg/0.5ml
4
• •
IC 800 - ibuprofen tab 800 mg &
caffeine-vitamins cap kit
3
ENBREL - etanercept for subcutaneous
inj kit 25 mg
4
• •
ILARIS - canakinumab for inj 180 mg
4
ENBREL SURECLICK - etanercept
subcutaneous inj 50 mg/ml
• •
INDOCIN - indomethacin susp 25
mg/5ml
3
4
INDOCIN - indomethacin suppos 50 mg
3
etodolac cap 200 mg
1
indomethacin cap cr 75 mg
1
etodolac cap 300 mg
1
indomethacin cap 25 mg
1
etodolac tab sr 24hr 400 mg
1
indomethacin cap 50 mg
1
1
ketoprofen cap 50 mg
1
1
ketoprofen cap 75 mg
1
etodolac tab 400 mg
1
etodolac tab 500 mg
KETOPROFEN ER - ketoprofen cap sr
24hr 200 mg
3
1
FELDENE - piroxicam cap 10 mg
3
3
FELDENE - piroxicam cap 20 mg
3
FENOPROFEN CALCIUM - fenoprofen
calcium tab 600 mg
3
KETOROLAC TROMETHAMINE ketorolac tromethamine inj 300
mg/10ml (30 mg/ml)
3
flurbiprofen tab 100 mg
1
KETOROLAC TROMETHAMINE ketorolac tromethamine im inj 30 mg/
ml
flurbiprofen tab 50 mg
1
HUMIRA - adalimumab inj kit 20
mg/0.4ml
ketorolac tromethamine im inj
60 mg/2ml (30 mg/ml)
1
4
1
HUMIRA - adalimumab inj kit 40
mg/0.8ml (50 mg/ml)
4
• •
ketorolac tromethamine inj 15 mg/ml
ketorolac tromethamine inj 30 mg/ml
1
4
• •
ketorolac tromethamine inj
60 mg/2ml (30 mg/ml)
1
HUMIRA PEN - adalimumab inj kit 40
mg/0.8ml (50 mg/ml)
4
• •
ketorolac tromethamine tab 10 mg
1
HUMIRA PEN-CROHNS DISEASE adalimumab inj kit 40 mg/0.8ml (50
mg/ml)
KINERET - anakinra subcutaneous inj
100 mg/0.67ml
4
HUMIRA PEN-PSORIASIS STAR adalimumab inj kit 40 mg/0.8ml (50
mg/ml)
4
• •
leflunomide tab 10 mg (Arava)
1
leflunomide tab 20 mg (Arava)
1
3
ibuprofen susp 100 mg/5ml
1
MECLOFENAMATE SODIUM meclofenamate sodium cap 50 mg
ibuprofen tab 400 mg
1
3
1
MECLOFENAMATE SODIUM meclofenamate sodium cap 100 mg
1
mefenamic acid cap 250 mg (Ponstel)
1
IC 400 - ibuprofen tab 400 mg &
caffeine-vitamins cap kit
3
MELOXICAM - meloxicam susp 7.5
mg/5ml
3
meloxicam tab 15 mg (Mobic)
1
116
• •
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
•
• •
4
3
OTEZLA - apremilast tab starter therapy
pack 10 mg & 20 mg & 30 mg
MOBIC - meloxicam tab 15 mg
3
OTEZLA - apremilast tab 30 mg
4
MOBIC - meloxicam susp 7.5 mg/5ml
3
3
nabumetone tab 500 mg
1
OTREXUP - methotrexate soln pf autoinjector 10mg/0.4ml
1
3
nabumetone tab 750 mg
NALFON - fenoprofen calcium cap 200
mg
3
3
NALFON - fenoprofen calcium cap 400
mg
3
3
NAPRELAN - naproxen sodium tab sr
24hr 375 mg (base equiv)
3
oxaprozin tab 600 mg (Daypro)
1
3
piroxicam cap 10 mg (Feldene)
1
piroxicam cap 20 mg (Feldene)
1
3
PONSTEL - mefenamic acid cap 250
mg
3
24hr 500 mg (14) & 750 mg (6) pack
3
RASUVO - methotrexate soln pf autoinjector 7.5 mg/0.15ml
3
NAPROSYN - naproxen tab 250 mg
3
3
3
RASUVO - methotrexate soln pf autoinjector 10 mg/0.2ml
3
3
NAPROSYN - naproxen susp 125
mg/5ml
3
3
naproxen sodium tab 275 mg
(Anaprox)
1
3
naproxen sodium tab 550 mg
(Anaprox ds)
1
3
naproxen susp 125 mg/5ml
(Naprosyn)
1
3
naproxen tab ec 375 mg (Ecnaprosyn)
1
3
naproxen tab ec 500 mg (Ecnaprosyn)
1
3
naproxen tab 250 mg (Naprosyn)
1
3
1
1
3
ORENCIA - abatacept subcutaneous inj
125 mg/ml
4
RHEUMATREX - methotrexate sodium
tab 2.5 mg (antirheumatic)
RIDAURA - auranofin cap 3 mg
3
• •
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
MOBIC - meloxicam tab 7.5 mg
Dispensing Limits
1
Step Therapy
meloxicam tab 7.5 mg (Mobic)
Prior Authorization
Drug Name
Drug Tier
2014
117
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
SIMPONI - golimumab subcutaneous inj
50 mg/0.5ml
4
• •
AXERT - almotriptan malate tab 12.5
mg
3
SIMPONI - golimumab subcutaneous inj
100 mg/ml
4
• •
CAFERGOT - ergotamine w/ caffeine
tab 1-100 mg
3
SPRIX - ketorolac tromethamine nasal
spray 15.75 mg/spray
3
•
CAMBIA - diclofenac potassium packet
50 mg
3
sulindac tab 150 mg
1
3
sulindac tab 200 mg
1
D.H.E. 45 - dihydroergotamine mesylate
inj 1 mg/ml
TOLMETIN SODIUM - tolmetin sodium
tab 200 mg
3
3
TOLMETIN SODIUM - tolmetin sodium
tab 600 mg
3
DIHYDROERGOTAMINE MESYLAT dihydroergotamine mesylate nasal
spray 4 mg/ml
1
tolmetin sodium cap 400 mg
1
dihydroergotamine mesylate inj
1 mg/ml (D.h.e. 45)
3
ERGOMAR - ergotamine tartrate sl tab
2 mg
3
VIMOVO - naproxen-esomeprazole
magnesium tab dr 375-20 mg
3
FROVA - frovatriptan succinate tab 2.5
3
VIMOVO - naproxen-esomeprazole
magnesium tab dr 500-20 mg
•
3
IMITREX - sumatriptan nasal spray 5
mg/act
3
VOLTAREN-XR - diclofenac sodium tab
sr 24hr 100 mg
•
4
IMITREX - sumatriptan nasal spray 20
mg/act
3
XELJANZ - tofacitinib citrate tab 5 mg
(base equivalent)
•
3
IMITREX - sumatriptan succinate tab 25
mg
3
ZIPSOR - diclofenac potassium cap 25
mg
•
3
IMITREX - sumatriptan succinate tab 50
mg
3
ZORVOLEX - diclofenac cap 18 mg
•
ZORVOLEX - diclofenac cap 35 mg
3
IMITREX - sumatriptan succinate tab
100 mg
3
•
• •
MIGRAINE PRODUCTS
•
acetaminophen-isometheptenecaffeine tab 325-65-20 mg (Prodrin)
1
IMITREX - sumatriptan succinate inj 6
mg/0.5ml
3
•
acetaminophen-isometheptenedichloral cap 325-65-100 mg
1
3
•
ALSUMA - sumatriptan succinate
solution auto-injector 6 mg/0.5ml
3
IMITREX STATDOSE REFILL sumatriptan succinate solution
cartridge 4 mg/0.5ml
3
•
AMERGE - naratriptan hcl tab 1 mg
(base equiv)
3
•
IMITREX STATDOSE REFILL sumatriptan succinate solution
cartridge 6 mg/0.5ml
AMERGE - naratriptan hcl tab 2.5 mg
(base equiv)
3
•
3
•
AXERT - almotriptan malate tab 6.25
mg
3
•
IMITREX STATDOSE SYSTEM sumatriptan succinate solution autoinjector 4 mg/0.5ml
IMITREX STATDOSE SYSTEM sumatriptan succinate solution autoinjector 6 mg/0.5ml
3
•
118
•
ISOMETHEPTENE/CAFFEINE/AC acetaminophen-isometheptenecaffeine tab 500-130-20 mg
1
MAXALT - rizatriptan benzoate tab 5 mg 3
3
MAXALT - rizatriptan benzoate tab 10
mg
3
MAXALT-MLT - rizatriptan benzoate
3
MAXALT-MLT - rizatriptan benzoate
3
MIGERGOT - ergotamine w/ caffeine
suppos 2-100 mg
3
MIGRAL - isometheptene mucate tab
130 mg
3
MIGRALAM - acetaminophenisometheptene-caffeine cap
325-65-100 mg
3
MIGRANAL - dihydroergotamine
mesylate nasal spray 4 mg/ml
naratriptan hcl tab 1 mg (base equiv) 1
(Amerge)
1
naratriptan hcl tab 2.5 mg (base
equiv) (Amerge)
3
PRODRIN - acetaminophenisometheptene-caffeine tab
325-65-20 mg
3
PRODRIN - acetaminophenisometheptene-caffeine tab
500-130-20 mg
3
RELPAX - eletriptan hydrobromide tab
3
RELPAX - eletriptan hydrobromide tab
1
rizatriptan benzoate orally
disintegrating tab 10 mg (Maxaltmlt)
1
rizatriptan benzoate orally
disintegrating tab 5 mg (Maxalt-mlt)
1
rizatriptan benzoate tab 10 mg
(Maxalt)
•
•
•
•
•
•
•
•
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
rizatriptan benzoate tab 5 mg
(Maxalt)
1
•
SUMATRIPTAN - sumatriptan nasal
spray 5 mg/act
2
•
SUMATRIPTAN - sumatriptan nasal
spray 20 mg/act
2
•
SUMATRIPTAN SUCCINATE sumatriptan succinate solution
prefilled syringe 6 mg/0.5ml
1
•
SUMATRIPTAN SUCCINATE sumatriptan succinate inj 4 mg/0.5ml
1
•
sumatriptan succinate inj 4 mg/0.5ml
1
sumatriptan succinate inj 6 mg/0.5ml
(Imitrex)
1
•
sumatriptan succinate solution auto- 1
injector 4 mg/0.5ml (Imitrex statdose
sys)
sumatriptan succinate solution auto- 1
injector 6 mg/0.5ml (Imitrex statdose
sys)
1
sumatriptan succinate solution
cartridge 4 mg/0.5ml (Imitrex
statdose ref)
1
cartridge 6 mg/0.5ml (Imitrex
statdose ref)
1
prefilled syringe 6 mg/0.5ml
1
sumatriptan succinate tab 100 mg
(Imitrex)
1
(Imitrex)
1
(Imitrex)
3
SUMAVEL DOSEPRO - sumatriptan
succinate solution jet-injector 6
mg/0.5ml
3
TREXIMET - sumatriptan-naproxen
sodium tab 85-500 mg
1
zolmitriptan orally disintegrating tab
2.5 mg (Zomig zmt)
•
•
•
•
•
•
•
•
•
•
•
119
zolmitriptan tab 2.5 mg (Zomig)
1
zolmitriptan tab 5 mg (Zomig)
1
ZOMIG - zolmitriptan tab 2.5 mg
3
ZOMIG - zolmitriptan tab 5 mg
3
ZOMIG - zolmitriptan nasal spray 2.5
mg/spray unit
3
•
•
•
•
•
ZOMIG - zolmitriptan nasal spray 5 mg/
spray unit
3
•
carbamazepine chew tab 100 mg
1
1
ZOMIG NASAL SPRAY - zolmitriptan
nasal spray 5 mg/spray unit
3
•
carbamazepine susp 100 mg/5ml
(Tegretol)
1
ZOMIG ZMT - zolmitriptan orally
3
•
carbamazepine tab sr 12hr 200 mg
(Tegretol-xr)
1
ZOMIG ZMT - zolmitriptan orally
3
•
carbamazepine tab sr 12hr 400 mg
(Tegretol-xr)
carbamazepine tab 200 mg (Tegretol)
1
CARBATROL - carbamazepine cap sr
12hr 100 mg
3
12hr 200 mg
3
12hr 300 mg
3
CELONTIN - methsuximide cap 300 mg
3
CEREBYX - fosphenytoin sodium inj
100 mg/2ml (phenytoin equiv)
3
CEREBYX - fosphenytoin sodium inj
3
clonazepam orally disintegrating tab
0.125 mg
1
0.25 mg
1
0.5 mg
1
1 mg
1
2 mg
1
clonazepam tab 0.5 mg (Klonopin)
1
clonazepam tab 1 mg (Klonopin)
1
GOUT AGENTS
allopurinol tab 100 mg (Zyloprim)
1
allopurinol tab 300 mg (Zyloprim)
1
colchicine w/ probenecid tab
0.5-500 mg
1
COLCRYS - colchicine tab 0.6 mg
2
probenecid tab 500 mg
1
ULORIC - febuxostat tab 40 mg
3
ULORIC - febuxostat tab 80 mg
3
ZYLOPRIM - allopurinol tab 100 mg
3
ZYLOPRIM - allopurinol tab 300 mg
3
NEUROMUSCULAR DRUGS
ANTICONVULSANTS
APTIOM - eslicarbazepine acetate tab
200 mg
3
400 mg
3
600 mg
3
800 mg
3
BANZEL - rufinamide tab 200 mg
3
120
•
•
3
BANZEL - rufinamide susp 40 mg/ml
3
carbamazepine cap sr 12hr 100 mg
(Carbatrol)
1
(Carbatrol)
1
(Carbatrol)
1
Dispensing Limits
BANZEL - rufinamide tab 400 mg
Step Therapy
•
Prior Authorization
1
Drug Tier
zolmitriptan orally disintegrating tab
5 mg (Zomig zmt)
Drug Name
Step Therapy
Drug Name
Drug Tier
Dispensing Limits
Prior Authorization
2014
1
3
divalproex sodium tab delayed
release 250 mg (Depakote)
1
DEPAKENE - valproic acid cap 250 mg
3
DEPAKOTE - divalproex sodium tab
3
divalproex sodium tab sr 24 hr
250 mg (Depakote er)
1
3
divalproex sodium tab sr 24 hr
500 mg (Depakote er)
1
3
ethosuximide cap 250 mg (Zarontin)
1
1
DEPAKOTE ER - divalproex sodium tab
sr 24 hr 250 mg
3
ethosuximide soln 250 mg/5ml
(Zarontin)
felbamate susp 600 mg/5ml (Felbatol)
1
DEPAKOTE ER - divalproex sodium tab
sr 24 hr 500 mg
3
felbamate tab 400 mg (Felbatol)
1
felbamate tab 600 mg (Felbatol)
1
DEPAKOTE SPRINKLES - divalproex
sodium cap sprinkle 125 mg
3
FELBATOL - felbamate tab 400 mg
3
2
FELBATOL - felbamate tab 600 mg
3
DIASTAT ACUDIAL - diazepam rectal
gel delivery system 10 mg
3
DIASTAT ACUDIAL - diazepam rectal
gel delivery system 20 mg
2
FELBATOL - felbamate susp 600
mg/5ml
1
DIASTAT PEDIATRIC - diazepam rectal
gel delivery system 2.5 mg
2
fosphenytoin sodium inj 100 mg/2ml
(phenytoin equiv) (Cerebyx)
1
DIAZEPAM - diazepam rectal gel
delivery system 2.5 mg
3
fosphenytoin sodium inj
(Cerebyx)
3
FYCOMPA - perampanel tab 2 mg
3
delivery system 10 mg
3
delivery system 20 mg
3
3
3
DILANTIN - phenytoin susp 125 mg/5ml
3
3
DILANTIN - phenytoin sodium extended
cap 30 mg
2
3
gabapentin cap 100 mg (Neurontin)
1
DILANTIN - phenytoin sodium extended
cap 100 mg
2
1
3
1
DILANTIN INFATABS - phenytoin chew
tab 50 mg
1
divalproex sodium cap sprinkle
125 mg (Depakote sprinkles)
1
gabapentin oral soln 250 mg/5ml
(Neurontin)
gabapentin tab 600 mg (Neurontin)
1
1
gabapentin tab 800 mg (Neurontin)
1
GABITRIL - tiagabine hcl tab 2 mg
3
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
DEPAKENE - valproate sodium syrup
250 mg/5ml (base equiv)
Dispensing Limits
1
Step Therapy
clonazepam tab 2 mg (Klonopin)
Prior Authorization
Drug Name
Drug Tier
2014
121
KEPPRA - levetiracetam tab 500 mg
3
3
3
KEPPRA - levetiracetam oral soln 100
mg/ml
LAMICTAL STARTER/NOT TAKI lamotrigine tab 25 mg (42) & 100 mg
(7) starter kit
3
3
3
LAMICTAL STARTER/TAKING C lamotrigine tab 25 mg (84) & 100 mg
(14) starter kit
3
KEPPRA XR - levetiracetam tab sr 24hr
500 mg
3
LAMICTAL STARTER/TAKING V lamotrigine tab 25 mg (35) starter kit
3
KEPPRA XR - levetiracetam tab sr 24hr
750 mg
3
LAMICTAL XR - lamotrigine tab sr 24hr
25 mg (21) & 50 mg (7) titration kit
3
KLONOPIN - clonazepam tab 0.5 mg
3
25 (14) & 50 mg (14) & 100 mg(7) kit
KLONOPIN - clonazepam tab 1 mg
3
3
KLONOPIN - clonazepam tab 2 mg
3
50 (14) & 100 mg(14) & 200 mg(7) kit
3
25 mg
3
LAMICTAL - lamotrigine tab 25 mg
3
50 mg
3
3
3
3
LAMICTAL - lamotrigine tab chewable
dispersible 2 mg
2
100 mg
3
LAMICTAL CHEWABLE DISPERS lamotrigine tab chewable dispersible
5 mg
3
200 mg
250 mg
3
LAMICTAL CHEWABLE DISPERS lamotrigine tab chewable dispersible
25 mg
3
300 mg
3
LAMICTAL ODT - lamotrigine tab disp
lamotrigine tab chewable dispersible
25 mg (Lamictal chewable di)
1
3
lamotrigine tab chewable dispersible
5 mg (Lamictal chewable di)
1
3
1
25 (14) & 50 mg (14) & 100 mg (7) kit
3
lamotrigine tab sr 24hr 100 mg
(Lamictal xr)
3
(Lamictal xr)
1
LAMICTAL ODT - lamotrigine orally
(Lamictal xr)
1
3
(Lamictal xr)
1
3
122
Dispensing Limits
3
3
Step Therapy
Prior Authorization
3
Drug Name
Drug Tier
Dispensing Limits
3
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
ONFI - clobazam tab 20 mg
3
ONFI - clobazam suspension 2.5 mg/ml
3
oxcarbazepine susp 300 mg/5ml
(60 mg/ml) (Trileptal)
1
oxcarbazepine tab 150 mg (Trileptal)
1
1
1
OXTELLAR XR - oxcarbazepine tab sr
24hr 150 mg
3
24hr 300 mg
3
24hr 600 mg
3
PEGANONE - ethotoin tab 250 mg
3
PHENYTEK - phenytoin sodium
extended cap 200 mg
3
PHENYTEK - phenytoin sodium
extended cap 300 mg
3
phenytoin chew tab 50 mg (Dilantin
infatabs)
1
phenytoin sodium extended cap
100 mg (Dilantin)
1
200 mg (Phenytek)
1
300 mg (Phenytek)
1
phenytoin sodium inj 50 mg/ml
1
(Lamictal xr)
1
lamotrigine tab 100 mg (Lamictal)
1
1
1
1
levetiracetam oral soln 100 mg/ml
(Keppra)
1
levetiracetam tab sr 24hr 500 mg
(Keppra xr)
1
levetiracetam tab sr 24hr 750 mg
(Keppra xr)
1
levetiracetam tab 1000 mg (Keppra)
1
1
1
1
LYRICA - pregabalin cap 25 mg
2
2
2
2
2
2
2
2
LYRICA - pregabalin soln 20 mg/ml
3
MYSOLINE - primidone tab 50 mg
3
phenytoin susp 125 mg/5ml (Dilantin)
1
MYSOLINE - primidone tab 250 mg
3
POTIGA - ezogabine tab 50 mg
3
NEURONTIN - gabapentin cap 100 mg
3
3
3
3
3
3
NEURONTIN - gabapentin tab 600 mg
3
primidone tab 250 mg (Mysoline)
1
NEURONTIN - gabapentin tab 800 mg
3
primidone tab 50 mg (Mysoline)
1
NEURONTIN - gabapentin oral soln 250
mg/5ml
3
QUDEXY XR - topiramate cap er 24hr
sprinkle 25 mg
3
3
•
•
•
•
•
•
•
•
•
Dispensing Limits
3
1
Step Therapy
(Lamictal xr)
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
123
sprinkle 50 mg
3
TOPIRAMATE ER - topiramate cap er
24hr sprinkle 25 mg
3
sprinkle 100 mg
3
24hr sprinkle 50 mg
3
sprinkle 150 mg
3
24hr sprinkle 100 mg
3
sprinkle 200 mg
3
3
SABRIL - vigabatrin tab 500 mg
2
3
SABRIL - vigabatrin powd pack 500 mg
2
STAVZOR - valproic acid cap delayed
release 125 mg
3
topiramate sprinkle cap 15 mg
(Topamax sprinkle)
1
release 250 mg
3
topiramate sprinkle cap 25 mg
(Topamax sprinkle)
1
release 500 mg
3
topiramate tab 100 mg (Topamax)
1
1
TEGRETOL - carbamazepine tab 200
mg
3
1
1
TEGRETOL - carbamazepine chew tab
100 mg
3
TRILEPTAL - oxcarbazepine tab 150
mg
3
TEGRETOL - carbamazepine susp 100
mg/5ml
3
mg
3
TEGRETOL-XR - carbamazepine tab sr
12hr 100 mg
2
mg
3
12hr 200 mg
3
TRILEPTAL - oxcarbazepine susp 300
mg/5ml (60 mg/ml)
3
12hr 400 mg
3
TROKENDI XR - topiramate cap sr 24hr
25 mg
3
tiagabine hcl tab 2 mg (Gabitril)
1
tiagabine hcl tab 4 mg (Gabitril)
50 mg
3
1
TOPAMAX - topiramate tab 25 mg
3
3
3
100 mg
3
3
3
200 mg
3
valproate sodium syrup 250 mg/5ml
(base equiv) (Depakene)
1
TOPAMAX SPRINKLE - topiramate
sprinkle cap 15 mg
3
valproic acid cap 250 mg (Depakene)
1
TOPAMAX SPRINKLE - topiramate
sprinkle cap 25 mg
VIMPAT - lacosamide tab 50 mg
3
3
124
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
1
3
carbidopa & levodopa tab cr
50-200 mg (Sinemet cr)
1
ZARONTIN - ethosuximide cap 250 mg
3
1
ZARONTIN - ethosuximide soln 250
mg/5ml
3
carbidopa & levodopa tab 10-100 mg
(Sinemet)
1
ZONEGRAN - zonisamide cap 25 mg
3
(Sinemet)
3
(Sinemet)
1
ZONEGRAN - zonisamide cap 100 mg
zonisamide cap 100 mg (Zonegran)
1
carbidopa tab 25 mg (Lodosyn)
1
zonisamide cap 25 mg (Zonegran)
1
zonisamide cap 50 mg
CARBIDOPA/LEVODOPA/ENTACA carbidopa-levodopa-entacapone tabs
12.5-50-200 mg
3
1
18.75-75-200 mg
3
25-100-200 mg
3
31.25-125-200 mg
3
37.5-150-200 mg
3
50-200-200 mg
3
COGENTIN - benztropine mesylate inj 1
mg/ml
3
COMTAN - entacapone tab 200 mg
3
ELDEPRYL - selegiline hcl cap 5 mg
3
entacapone tab 200 mg (Comtan)
1
3
ANTIPARKINSON AGENTS
AMANTADINE HCL - amantadine hcl
tab 100 mg
3
amantadine hcl cap 100 mg
1
amantadine hcl syrup 50 mg/5ml
1
APOKYN - apomorphine hydrochloride
inj 10 mg/ml
4
AZILECT - rasagiline mesylate tab 0.5
mg (base equiv)
3
AZILECT - rasagiline mesylate tab 1 mg
(base equiv)
3
benztropine mesylate inj 1 mg/ml
(Cogentin)
1
benztropine mesylate tab 0.5 mg
1
benztropine mesylate tab 1 mg
1
benztropine mesylate tab 2 mg
1
bromocriptine mesylate cap 5 mg
(Parlodel)
1
bromocriptine mesylate tab 2.5 mg
(Parlodel)
1
carbidopa & levodopa orally
disintegrating tab 10-100 mg
1
LODOSYN - carbidopa tab 25 mg
1
1
MIRAPEX - pramipexole dihydrochloride 3
tab 0.125 mg
tab 0.25 mg
Dispensing Limits
Step Therapy
VIMPAT - lacosamide oral solution 10
mg/ml
carbidopa & levodopa tab cr
25-100 mg (Sinemet cr)
Prior Authorization
3
Drug Name
Drug Tier
Dispensing Limits
3
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
125
tab 0.5 mg
tab 0.75 mg
tab 1 mg
tab 1.5 mg
3
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr 0.375 mg
3
3
3
3
dihydrochloride tab sr 24hr 3 mg
3
3
3
NEUPRO - rotigotine td patch 24hr 1
mg/24hr
3
mg/24hr
3
mg/24hr
3
mg/24hr
3
mg/24hr
3
mg/24hr
3
PARCOPA - carbidopa & levodopa
orally disintegrating tab 10-100 mg
3
3
126
PARLODEL - bromocriptine mesylate
cap 5 mg
3
PARLODEL - bromocriptine mesylate
tab 2.5 mg
3
pramipexole dihydrochloride tab
0.125 mg (Mirapex)
1
0.25 mg (Mirapex)
1
0.5 mg (Mirapex)
1
0.75 mg (Mirapex)
1
1 mg (Mirapex)
1
1.5 mg (Mirapex)
1
REQUIP - ropinirole hydrochloride tab
0.25 mg
3
REQUIP - ropinirole hydrochloride tab
0.5 mg
3
REQUIP - ropinirole hydrochloride tab 1
mg
3
mg
3
mg
3
mg
3
mg
3
REQUIP XL - ropinirole hydrochloride
tab sr 24hr 2 mg (base equivalent)
3
3
3
3
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
ropinirole hydrochloride tab sr 24hr
12 mg (base equivalent) (Requip xl)
1
STALEVO 150 - carbidopa-levodopaentacapone tabs 37.5-150-200 mg
3
1
STALEVO 200 - carbidopa-levodopaentacapone tabs 50-200-200 mg
3
1
3
1
3
1
TASMAR - tolcapone tab 100 mg
3
trihexyphenidyl hcl elixir 0.4 mg/ml
1
ropinirole hydrochloride tab 0.25 mg
(Requip)
1
trihexyphenidyl hcl tab 2 mg
1
1
trihexyphenidyl hcl tab 5 mg
1
ropinirole hydrochloride tab 0.5 mg
(Requip)
3
ropinirole hydrochloride tab 1 mg
(Requip)
1
ZELAPAR - selegiline hcl orally
(Requip)
1
(Requip)
1
(Requip)
1
(Requip)
1
selegiline hcl cap 5 mg (Eldepryl)
1
selegiline hcl tab 5 mg
1
SINEMET - carbidopa & levodopa tab
10-100 mg
3
25-100 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
NEUROMUSCULAR AGENTS
RILUTEK - riluzole tab 50 mg
2
riluzole tab 50 mg (Rilutek)
1
MUSCULOSKELETAL THERAPY AGENTS
3
ACTIVE-CYCLOBENZAPRINE KI cyclobenzaprine hcl td cream 5%
(compound kit)
3
AMRIX - cyclobenzaprine hcl cap sr
24hr 15 mg
3
AMRIX - cyclobenzaprine hcl cap sr
24hr 30 mg
1
baclofen tab 10 mg
baclofen tab 20 mg
1
3
CARISOPRODOL - carisoprodol tab
250 mg
3
25-250 mg
3
carisoprodol tab 350 mg (Soma)
1
SINEMET CR - carbidopa & levodopa
tab cr 25-100 mg
carisoprodol w/ aspirin & codeine
tab 200-325-16 mg
1
3
3
carisoprodol w/ aspirin tab
200-325 mg
1
SINEMET CR - carbidopa & levodopa
tab cr 50-200 mg
3
chlorzoxazone tab 500 mg (Parafon
forte dsc)
1
STALEVO 100 - carbidopa-levodopaentacapone tabs 25-100-200 mg
cyclobenzaprine hcl tab 10 mg
1
3
cyclobenzaprine hcl tab 5 mg
1
127
cyclobenzaprine hcl tab 7.5 mg
(Fexmid)
1
PARAFON FORTE DSC chlorzoxazone tab 500 mg
3
DANTRIUM - dantrolene sodium cap 25
mg
3
ROBAXIN - methocarbamol tab 500 mg
3
DANTRIUM - dantrolene sodium cap 50
mg
ROBAXIN - methocarbamol inj 100 mg/
ml
3
3
DANTRIUM - dantrolene sodium cap
100 mg
3
ROBAXIN-750 - methocarbamol tab 750 3
mg
3
SKELAXIN - metaxalone tab 800 mg
DANTROLENE SODIUM - dantrolene
sodium cap 100 mg
1
dantrolene sodium cap 25 mg
(Dantrium)
1
dantrolene sodium cap 50 mg
(Dantrium)
1
ENOVARX-CYCLOBENZAPRINE H cyclobenzaprine hcl td cream 20 mg/
gm (compound kit)
3
FEXMID - cyclobenzaprine hcl tab 7.5
mg
3
FLEXERIL - cyclobenzaprine hcl tab 5
mg
3
FLEXERIL - cyclobenzaprine hcl tab 10
mg
3
ANTIMYASTHENIC AGENTS
3
ENLON - edrophonium chloride inj 10
mg/ml
3
LORZONE - chlorzoxazone tab 375 mg
LORZONE - chlorzoxazone tab 750 mg
3
3
metaxalone tab 800 mg (Skelaxin)
1
GUANIDINE HCL - guanidine hcl tab
125 mg
MESTINON - pyridostigmine bromide
tab 60 mg
3
MESTINON - pyridostigmine bromide
syrup 60 mg/5ml
3
MESTINON TIMESPAN pyridostigmine bromide tab cr 180 mg
3
MYTELASE - ambenonium chloride tab
10 mg
3
PROSTIGMIN - neostigmine bromide
tab 15 mg
3
pyridostigmine bromide tab 60 mg
(Mestinon)
1
REGONOL - pyridostigmine bromide inj
5 mg/ml
3
methocarbamol tab 500 mg (Robaxin) 1
1
methocarbamol tab 750 mg
(Robaxin-750)
3
NORFLEX - orphenadrine citrate inj 30
mg/ml
1
orphenadrine citrate inj 30 mg/ml
(Norflex)
1
orphenadrine citrate tab sr 12hr
100 mg
3
ORPHENADRINE COMPOUND DS orphenadrine w/ aspirin & caffeine tab
50-770-60 mg
1
orphenadrine w/ aspirin & caffeine
tab 25-385-30 mg
128
SOMA - carisoprodol tab 250 mg
3
SOMA - carisoprodol tab 350 mg
3
tizanidine hcl cap 2 mg (Zanaflex)
1
1
1
tizanidine hcl tab 2 mg
1
tizanidine hcl tab 4 mg (Zanaflex)
1
ZANAFLEX - tizanidine hcl cap 2 mg
3
3
3
ZANAFLEX - tizanidine hcl tab 4 mg
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
NUTRITIONAL PRODUCTS
VITAMINS
POTABA - potassium aminobenzoate
cap 500 mg
3
POTABA - potassium aminobenzoate
tab 500 mg
3
PYRIDOXINE HCL - pyridoxine hcl inj
100 mg/ml
3
sodium ascorbate inj 250 mg/ml
1
AMINOBENZOATE POTASSIUM potassium aminobenzoate packet 2
gm
3
AQUASOL A PARENTERAL - vitamin a
inj 50000 unit/ml
3
ASCORBIC ACID - ascorbic acid oral
granules
3
SUPER DAILY D3 - cholecalciferol
drops 1000 unit/0.03ml (per drop)
3
ascorbic acid inj 500 mg/ml
1
thiamine hcl inj 100 mg/ml
1
BABY DDROPS - cholecalciferol drops
400 unit/0.03ml (per drop)
3
VITAMIN D - cholecalciferol cap 400
unit
3
cholecalciferol cap 1000 unit
1
cholecalciferol chew tab 1000 unit
1
cholecalciferol chew tab 400 unit
1
cholecalciferol drops 400 unit/0.03ml
(per drop)
1
cholecalciferol drops 5000 unit/ml
(1000 unit/0.2ml)
1
cholecalciferol oral liquid 400 unit/ml
1
cholecalciferol tab 1000 unit
1
cholecalciferol tab 400 unit
1
CVS VITAMIN D3 - cholecalciferol cap
400 unit
3
VITAMIN D2 - ergocalciferol tab 400 unit 3
3
VITAMIN D3 - cholecalciferol cap 400
unit
3
VITAMIN D3 - cholecalciferol spray
1000 unit/spray
3
VITAMIN D3 400 - cholecalciferol cap
400 unit
3
VITAMIN K1 - phytonadione inj 10 mg/
ml
3
WELLESSE VITAMIN D3 cholecalciferol oral liquid 1000
unit/10ml
3
WHEAT GERM - wheat germ - oil
D-VI-SOL - cholecalciferol oral liquid
400 unit/ml
3
DDROPS - cholecalciferol drops 1000
unit/0.03ml (per drop)
3
DECARA - cholecalciferol cap 25000
unit
3
DRISDOL - ergocalciferol cap 50000
unit
3
D3 - cholecalciferol cap 400 unit
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
MULTIVITAMINS
b-complex vitamin inj
1
b-complex w/ c & folic acid cap 1 mg
(Nephrocaps)
1
b-complex w/ c & folic acid tab 1 mg
(Nephro-vite rx)
1
b-complex w/ c & folic acid tab 5 mg
1
3
b-complex w/ c & folic acid tab
1
ergocalciferol cap 50000 unit
(Drisdol)
1
b-complex w/ c-biotin-minerals &
folic acid tab 5 mg (Diatx zn)
1
MEPHYTON - phytonadione tab 5 mg
2
b-complex w/ minerals liq
1
phytonadione inj 1 mg/0.5ml (2 mg/
ml)
1
multiple vitamins w/ minerals & fa
tab 1.25 mg (Corvite)
1
multiple vitamins w/ minerals cap
1
129
multiple vitamins w/ minerals tab
(Strovite forte)
1
pediatric multiple vitamin w/
minerals & c drops 45 mg/ml
1
pediatric multiple vitamins w/ fl-fe
drops 0.25-10 mg/ml
1
pediatric multiple vitamins w/
fluoride chew tab 0.25 mg
1
fluoride chew tab 0.5 mg
1
fluoride chew tab 1 mg
1
fluoride soln 0.25 mg/ml
1
fluoride soln 0.5 mg/ml
1
pediatric vitamins acd w/ fluoride
soln 0.25 mg/ml
1
pediatric vitamins acd w/ fluoride
soln 0.5 mg/ml
1
speciality vitamin product tab
1
ACTIVE OB - prenatal w/o a w/fe cbnfa-dha cap 20-1-320 mg
3
ADRENAL C FORMULA - bioflavonoid
products tab
3
ADVANCED AM/PM - multiple vitamins
w/ calcium therapy pack
3
ALBAFORT - b-complex w/ iron inj
3
AP-ZEL - multiple vitamins w/ minerals
tab
3
ATABEX EC - prenatal vit w/ dss-iron
carbonyl-fa tab dr 29-1 mg
3
ATABEX PRENATAL - prenatal vit w/
iron carbonyl-fa tab 65-1 mg
3
B-NEXA - prenatal w/ calcium-vit b6-faginger tab 1.2 mg
3
B-NEXA - prenatal w/ calcium-vit b6-faginger tab 1.22 mg
3
BACMIN - multiple vitamins w/ minerals
tab
3
130
BAL-CARE DHA - prenat w/fe poly-na
fered-fa tab 27-1 & omega cap dr
430mg
3
BAL-CARE DHA ESSENTIAL - prenat
w/fe poly-na fered-fa tab 27-1 &
omega cap dr 374mg
3
BP FOLINATAL PLUS B - prenatal w/
calcium carbonate-b6-b12-fa tab 1
mg
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
BP MULTINATAL PLUS - prenatal w/o a 3
vit w/ fe fumarate-fa tab 30-1 mg
BP MULTINATAL PLUS - prenatal w/o a 3
vit w/ fe fum-fa tab chew 40-1 mg
C-NATE DHA - prenatal vit w/ fe fum-fa- 3
omega 3 cap 28-1-200 mg
CALCIUM PNV - prenatal w/o vit a w/ fe 3
fum-fa-omega 3 cap 28-1-250 mg
3
CAVAN-ALPHA KIT - prenat w/fe polyna fered-fa tab 27-1 & omega cap dr
300mg
CAVAN-EC SOD DHA - prenatal w/ sod 3
feredetate-fa tab 30-1 & omega 3 cap
dr
3
CHOICE-OB+DHA - prenatal mv w/fe
poly-fa chw 29-1 mg & dha cap 250
mg pak
2
CITRANATAL ASSURE - prenat w/o
a w/fecbn-fegl-dss-fa tab & dha cap
300 mg pack
2
CITRANATAL B-CALM - prenat w/o a
w/fecbn-feglu-fa tab 20-1 mg & vit b6
tab pak
2
CITRANATAL DHA - prenat w/o a w/
fecbn-fegl-dss-fa tab & dha cap 250
mg pack
CITRANATAL HARMONY - prenatal w/ 2
o a w/fe cbn-dss-fa-dha cap 29-1-265
mg
2
CITRANATAL HARMONY - prenatal
w/o vit a w/ fe cbn-dss-fa-dha cap
30-1-260 mg
CITRANATAL HARMONY - prenat w/
o a w/fe fum-fe cbn-dss-fa-dha cap
27-1-260 mg
3
DUET DHA BALANCED - prenat w/fe
poly-na fered-fa tab 24-1 & omega
cap 272 mg
3
CITRANATAL RX - prenatal w/o a w/ fe
carbonyl-fe gluc-dss-fa tab 27-1mg
2
3
CITRANATAL 90 DHA - prenat w/o a
w/fecbn-fegl-dss-fa tab 90 &dha cap
300mg pak
2
cap 267 mg
3
CO-NATAL FA - prenatal vit w/ fe
fumarate-fa tab 29-1 mg
3
cap 278 mg
3
COD LIVER OIL - cod liver oil
3
COMPLETE NATAL DHA - prenat-fe
bis-fe prot succ-fa-ca tab & omega 3
cap 250 pk
3
cap dr 380mg
3
COMPLETE-RF PRENATAL - prenatal
without a w/ fe carbonyl-docusate-fa
tab 90-1mg
3
DUET DHA EC - prenat w/fe poly-na
400mg
3
COMPLETENATE - prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
3
DUET DHA EC - prenat w/fe poly-na
430mg
3
CONCEPT DHA - prenatal w/fe fum-fe
poly -fa-omega 3 cap 53.5-38-1 mg
3
DUET DHA 400 - prenat w/fe poly-na
fered-fa tab 25-1 & omega cap 400
mg
3
DUET DHA 400EC - prenat w/fe polyna fered-fa tab 25-1 & omega cap dr
400mg
3
CONCEPT OB - prenatal w/o a w/fe
fum-fe poly-fa cap 130-92.4-1 mg
CORVITE - multiple vitamins w/
minerals & fa tab 1.25 mg
3
3
CRNATAL - prenatal mv w/fecbn-fegldss-fa tab & dha cap 275 mg pack
3
DUET DHA 430 - prenat w/fe poly-na
fered-fa tab 25-1 & omega cap 430
mg
3
DUET DHA 430EC - prenat w/fe polyna fered-fa tab 25-1 & omega cap dr
430mg
3
DIALYVITE SUPREME D - multiple
vitamins w/ minerals & fa tab 3 mg
DIALYVITE 3000 - b-complex w/ cbiotin-e-minerals & folic acid tab 3 mg
3
DIALYVITE 5000 - b-complex w/ cbiotin-e-minerals & folic acid tab 5 mg
3
DIALYVITE/ZINC - b-complex w/ c-zn &
folic acid tab 1 mg
3
DIATX ZN - b-complex w/ c-biotinminerals & folic acid tab 5 mg
3
DUET DHA - prenat w/fe poly-na feredfa tab 25-1 & omega cap 400 mg
3
DUET DHA - prenat w/fe poly-na feredfa tab 25-1 & omega cap 430 mg
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
ELITE OB WITH DHA - prenatal vit w/ fe 3
fum-fa-omega 3 cap 28-1.25-200 mg
ELITE-OB - prenatal vit w/ iron carbonyl- 3
fa tab 50-1.25 mg
3
ESCAVITE - pediatric multiple vitamins
w/ fl-fe chew tab 0.25-7.5 mg
3
ESCAVITE D - pediatric multiple
vitamins w/ fl-fe chew tab 0.25-6 mg
3
EXTRA-VIRT PLUS DHA - prenatal
w/o vit a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg
131
FOCALGIN-B - prenatal w/ calcium-vit
b6-fa-ginger tab 1.22 mg
3
FOLBECAL - prenatal w/ calcium
carbonate-b6-b12-fa tab 1 mg
3
3
L-METHYLFOLATE PNV DHA - prenat
w/fe fum-l methylfolate-fa-dha cap
27-1.13-0.4 mg
3
FOLCAL DHA - prenatal w/o vit a w/ fe
fum-dss-fa-dha cap 27-1.25-300 mg
3
LACTOCAL-F - prenatal vit w/ fe
3
FOLCAPS OMEGA 3 - prenatal vit w/
fe cbn-fe asp glyc-fa-omega 3 cap
27-1mg
3
LEVOMEFOLATE DHA - prenat w/
fe fum-l methylfolate-fa-dha cap
27-1.13-0.4 mg
3
FOLET DHA - prenat w/fecbn-bisgmethylf-dss tab dr & dha cap pak
3
LEVOMEFOLATE PNV - prenatal w/ fe
polycmplx-methylfol-fa pak 29-1.4-0.5
mg
FOLET ONE - prenat w/o a w/fecbnbisg-methylf-dss-dha cap 38-1-225
mg
3
FOLGARD OS - multiple vit w/ min &
calcium-folic acid tab 500-1.1 mg
3
FOLIVANE-OB - prenatal w/o a w/fe
fum-fe poly-fa cap 130-92.4-1 mg
3
FOLIVANE-PRX DHA NF - prenatal
w/o vit a w/fe fum-dss-fa-dha cap
30-1.24-265 mg
3
FORTAVIT - multiple vitamins w/
minerals cap
3
GESTICARE DHA - prenatal w/fe fumfa tab dr 27-1 mg & dha cap 250 mg
pack
3
HEMENATAL OB - prenat vit-fe poly
cmplx-fe heme poly-fa tab 28-6-1 mg
3
HEMENATAL OB + DHA - prenat-fe
poly cmplx-fe heme poly-fa tab &
omega 3 cap pck
3
INATAL ADVANCE - prenatal vit w/ dss- 3
3
INATAL GT - prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg
INATAL ULTRA - prenatal vit w/ dss-iron 3
3
INFANATE BALANCE - prenatal w/o a
w/fe cbn-dss-fa-dha cap 29-1-265 mg
132
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
M-VIT - prenatal vit w/ fe fumarate-fa tab 3
27-1 mg
3
MACNATAL CN DHA - prenatal w/o a
3
MARNATAL-F - prenatal w/o vit a w/ fe
polysac cmplx-fa cap 60-1 mg
3
MAXINATE - prenatal vit w/ fe gluc-fe
fum-fa tab 20-0.8 mg
3
MOMS CHOICE RX - prenat w/fe polyna fered-fa tab 26-1 & omega cap
278 mg
3
MULTICHEW - multiple vitamins w/
minerals & fa chew tab 1 mg
3
MYKIDZ IRON FL - pediatric vitamins
acd fluoride & fe susp 0.25-10
mg/2ml
3
MYNATAL - prenatal multivitamins &
minerals w/ iron & fa cap 1 mg
3
MYNATAL ADVANCE - prenatal vit w/
dss-iron carbonyl-fa tab 90-1 mg
3
MYNATAL PLUS - prenatal vit w/ fe
MYNATAL ULTRACAPLET - prenatal vit 3
w/ dss-iron carbonyl-fa tab 90-1 mg
3
MYNATAL-Z - prenatal vit w/ fe
MYNATE 90 PLUS - prenatal vit w/ dss- 3
fe fumarate-fa tab cr 90-1 mg
3
NATA KOMPLETE - prenatal vit w/ fe
fum-fe bisglycinate-fa tab 25-1 mg
NATACHEW - prenatal vit w/ fe fum-fe
bisglycin-fa chew tab 28-1 mg
3
NEXA PLUS - prenatal w/o vit a w/ fe
fum-doc-fa-dha cap 29-1.25-350 mg
3
NATAFORT - prenatal w/o a vit w/ fe
cbn-fe fum-fa tab 60-1 mg
3
NEXA SELECT - prenatal w/o vit a w/ fe
3
NATAL-V RX - prenatal vit w/ iron
3
NEXA SELECT - prenat w/o vit a w/ fe
fum-dss-fa-dha cap 29-1.25-337.5 mg
3
NATALVIRT CA - prenat w/o a w/fecbnfegl-dss-fa tab & dha cap 300 mg
pack
3
niacinamide w/ zinc-copper &folic
acid tab 750-25-1.5-0.5 mg
1
NATALVIRT 90 DHA - prenat w/o a w/
fecbn-fegl-dss-fa tab 90 &dha cap
300mg pak
NICADAN - multiple vitamins w/
minerals tab
3
3
NATALVIT - prenatal vit w/ fe fumaratefa tab 75-1 mg
3
NATELLE ONE - prenatal w/o vit a w/ fe
3
NEEVO - prenatal w/ fe polycmplxmethylfol-fa pak 29-1.4-0.5 mg
3
NEEVO DHA - prenat w/o a w/fefummethylfol-omegas cap 27-1.13 mg
3
NEEVO DHA - prenat w/o a w/fefummethylfol-fa-omegas cap 27-1.53 mg
3
NEPHPLEX RX - b-complex w/ c-zn &
folic acid tab 1 mg
3
NEPHRO-VITE RX - b-complex w/ c &
folic acid tab 1 mg
3
NEPHROCAPS - b-complex w/ c & folic
acid cap 1 mg
3
NEPHROCAPS QT - b-complex w/ cbiotin-d & folic acid tab disp 1 mg
3
NESTABS - prenatal vit w/o vit a w/ fe
bisglycinate-fa tab 32-1 mg
3
NESTABS ABC - prenatal w/o vit a w/fe
polysac-fa-ca tab & omega 3 cap
3
NESTABS DHA - prenat w/o a w/ fe
bisglyc-fa tab 32-1 mg & omega cap
pack
3
NEURODEP - b-complex w/ c inj
3
NEWGEN - prenatal vit w/o vit a w/ fe
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
NICAZEL - multiple vitamins w/ minerals 3
tab
NICAZEL FORTE - multiple vitamins w/ 3
minerals tab
3
NICOMIDE - niacinamide w/ zn-cumethylfolate tab 750-25-1.5-0.5 mg
3
NUTRI-TAB OB - prenatal vit w/o vit a
w/ fe bisglycinate-fa tab 32-1 mg
3
NUTRI-TAB OB + DHA - prenat w/o a
w/ fe bisglyc-fa tab 32-1 mg & omega
cap pack
3
NUTRICAP - multiple vitamins w/
minerals tab
NUTRIVIT - b-complex w/ lysine-min-fe 3
& fa liqd 800-15-1 mg/15ml
O-CAL FA - prenatal vit w/ fe fumarate- 3
fa tab 27-1 mg
3
O-CAL PRENATAL - prenatal vit w/ fe
3
OB COMPLETE - prenatal vit w/ iron
carbonyl-fa tab 50-1.25 mg
3
OB COMPLETE - prenatal w/o a
w/fecbn-feaspglyc-fa-dha chew
15-5-1-100 mg
3
OB COMPLETE ONE - prenatal w/
o a w/fecbn-fe asp glyc-fa-fish cap
50-1-476 mg
3
OB COMPLETE PETITE - prenat w/o
a w/fecbn-feaspglyc-fa-omega cap
35-5-1-200 mg
133
OB COMPLETE PREMIER - prenatal vit 3
w/ fe cbn-fe asp glyc-fa tab 30-20-1
mg
OB COMPLETE 400 - prenatal w/o a w/ 3
fecbn-fe asp glyc-fa-fish cap 40-10-1
mg
3
OB COMPLETE/DHA - prenat w/
iron cbn-fe asp glyc-fa-omega cap
30-10-1-200 mg
OB-NATAL ONE - prenatal vit w/ fe cbn- 3
fe asp glyc-fa-omega 3 cap 27-1mg
3
OBSTETRIX DHA - prenat w/fecbn-fadss tab 29-1 mg & omega 3 cap 387
mg pak
3
OBSTETRIX EC - prenatal vit w/ dssiron carbonyl-fa tab 29-1 mg
3
PAIRE OB - prenat w/ fe poly cmplx-fe
asp-fe gly-fa tab & dha cap pak
3
PNV FERROUS FUMARATE/DOCU prenatal vit w/ dss-fe fumarate-fa tab
29-1 mg
3
PNV FOLIC ACID + IRON MUL prenatal vit w/ fe fumarate-fa tab 27-1
mg
3
PNV OB+DHA - prenat w/o a w/fecbnfegl-dss-fa tab & dha cap 250 mg
pack
3
PNV PRENATAL PLUS MULTIVI prenatal vit w/ fe fumarate-fa tab 27-1
mg
3
PNV TABS 29-1 - prenatal vit w/ iron
3
PNV-DHA - prenat w/o a w/fefummethfol-fa-dha cap 27-0.6-0.4-300
mg
3
PNV-DHA+DOCUSATE - prenatal
w/o vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg
PNV-FIRST - prenatal mv w/ fe polysac 3
cmplx-fa-dha cap 29-1-200 mg
PNV-OB/DHA - prenatal mv w/fe fum-fa 3
tab 65-1 mg & dha cap 250 mg pack
134
PNV-OMEGA - prenat w/o a w/ fe
fumerate-methylfolate-fa-omega 3
cap
3
PNV-SELECT - prenatal vit w/ fe fummethylfolate-fa tab 27-0.6-0.4 mg
3
PNV-TOTAL - prenat w/ fe cbn-fe
bisglyc-fa-fish oil cap 35-5-1.2 mg
3
POLY-VI-FLOR - ped multiple vit w/
fluoride biphasic chew tab 0.25 mg
3
fluoride biphasic chew tab 0.5 mg
3
fluoride biphasic chew tab 1 mg
3
fluoride biphasic susp 0.25 mg/ml
3
POLY-VI-FLOR/IRON - ped multiple vit
w/ fl-fe biphasic chew tab 0.5-10 mg
3
POLY-VI-FLOR/IRON - ped multiple
vitamin w/ fl-fe biphasic susp 0.25-7
mg/ml
3
PR NATAL 400 - prenat-fe bis-fe prot
succ-fa-ca tab & omega 3 cap 400 pk
3
PR NATAL 400 EC - prenat-fe bis-fe
prot succ-fa-ca tab & omega cap dr
400 pk
3
PR NATAL 430 - prenat-fe bis-fe prot
succ-fa-ca tab & omega 3 cap 430 pk
3
PR NATAL 430 EC - prenat-fe bis-fe
prot succ-fa-ca tab & omega cap dr
430 pk
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
PREFERA OB - prenat vit-fe poly cmplx- 3
fe heme poly-fa tab 28-6-1 mg
3
PREFERA OB + DHA - prenat-fe poly
cmplx-fe heme poly-fa tab & omega 3
cap pck
3
PREFERAOB ONE - prenat-fe poly
cmplx-fe heme poly-fa-dha cap
22-6-1-200 mg
3
PREFOL-DHA - prenatal w/o vit a w/ fe
PRENAISSANCE - prenatal w/o vit a w/
fe fum-dss-fa-dha cap 29-1.25-325
mg
3
PRENATAL MV & MIN/FE-FA-D prenat-fe poly cmplx-fe hem poly-fadha cap 11-3-0.5-100mg
3
PRENAISSANCE BALANCE - prenatal
w/o vit a w/ fe cbn-dss-fa-dha cap
30-1-260 mg
3
PRENATAL PLUS - prenatal vit w/ fe
2
PRENATAL PLUS IRON - prenatal vit
w/ iron carbonyl-fa tab 29-1 mg
3
PRENATAL VITAMINS PLUS - prenatal
vit w/ fe fumarate-fa tab 27-1 mg
2
PRENATAL 19 - prenatal vit w/ fe
2
PRENATAL 19 - prenatal vit w/ dss-fe
2
PRENATAL-U - prenatal w/o a vit w/ fe
fumarate-fa cap 106.5-1 mg
2
PRENATE - prenat mv & min w/ lmethylfolate-fa chew tab 0.6-0.4 mg
3
PRENATE AM - prenatal w/ calcium-vit
b6-vit b12-fa-ginger tab 1 mg
3
PRENATE DHA - prenat w/o a w/fefummethfol-fa-dha cap 28-0.6-0.4-300
mg
3
PRENATE DHA - prenat w/o a
w/feaspg-methfol-fa-dha cap
18-0.6-0.4-300 mg
3
PRENATE ELITE - prenatal w/ fe asp
gly-l methylfol-fa tab 20-0.6-0.4 mg
3
PRENATE ELITE - prenatal vit w/ fe
fum-methylfolate-fa tab 26-0.6-0.4 mg
3
PRENATE ENHANCE - prenat w/
o a w/fefum-methfol-fa-dha cap
28-0.6-0.4-400 mg
3
PRENATE ESSENTIAL - prenat w/
o a w/feasp-methylf-fa-omeg cap
29-0.6-0.4-340 mg
3
PRENATE ESSENTIAL - prenat w/
o a w/feaspg-methfol-fa-dha cap
18-0.6-0.4-300 mg
3
PRENATE MINI - prenat w/o a w/fecbnmethylf-fa-dha cap 29-0.6-0.4-350 mg
3
PRENAISSANCE DHA - prenat w/o a w/ 3
fecbn-fegl-dss-fa tab & dha cap 250
mg pack
3
PRENAISSANCE HARMONY DHA prenat w/fe poly-na fered-fa tab 27-1
& omega cap dr 380mg
3
PRENAISSANCE NEXT - prenatal w/
calcium-vit b6-fa-ginger tab 1.2 mg
PRENAISSANCE NEXT-B - prenatal w/ 3
PRENAISSANCE PLUS - prenatal w/o a 3
PRENAISSANCE PROMISE - prenat w/ 3
o a w/fecbn-fegl-dss-fa tab & dha cap
300 mg pack
3
PRENAISSANCE 90 DHA - prenat w/
o a w/fecbn-fegl-dss-fa tab 90 &dha
cap 300mg pak
3
PRENAPLUS - prenatal vit w/ fe
PRENATA - prenatal w/o a vit w/ fe fum- 3
fa tab chew 29-1 mg
3
PRENATABS FA - prenatal vit w/ fe
3
PRENATABS OBN - prenatal w/o a vit
w/ fe carbonyl-fa tab 29-1 mg
3
PRENATABS RX - prenatal vit w/ iron
3
PRENATAL - prenatal vit w/ fe
PRENATAL AD - prenatal vit w/ dss-iron 2
PRENATAL LOW IRON - prenatal vit w/ 2
fe fumarate-fa tab 27-1 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
135
PRENATE PIXIE - prenat w/o a
w/feaspg-methfol-fa-dha cap
10-0.6-0.4-200 mg
3
PRENATE RESTORE - prenat w/
o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-400 mg
3
PRENATE STAR - prenatal vit w/ fe
asparto glycinate-fa tab 20-1 mg
3
PRENA1 CHEW - prenat w/ b2-b6-b12d3-folic acid chew tab 1.4 mg
3
PRENA1 CHEW/QUATREFOLIC prenat w/ b2-b6-b12-d3-methylfol-fa
chew tab 0.6-0.4 mg
3
PRENA1 PEARL - prenat w/oa w/fefumna fered-fa-dha cap cr 30-1.4-200 mg
3
PRENA1 PLUS/QUATREFOLIC prenat w/o a w/ fe chelate-l methylfolfa tab & dha cap pk
3
PRENA1/QUATREFOLIC - prenat
w/o a w/fefum-methfol-fa-dha cap
30-0.6-0.4-200 mg
3
PRENEXA - prenatal w/o vit a w/ fe fum- 3
dss-fa-dha cap 27-1.25-300 mg
PREPLUS - prenatal vit w/ fe fumarate- 3
fa tab 27-1 mg
3
PREQUE 10 - prenatal mv w/fe
carbonyl-dss-fa-dha tab 15-25-0.5-50
mg
PRETAB - prenatal vit w/ fe fumarate-fa 3
tab 29-1 mg
3
PROMAR - iron & b12 w/ vitamin cap
PROTECT CARDIO - speciality vitamin
product cap
3
PROTECT PLUS - multiple vitamins w/
minerals cap
3
PROTECT PLUS - multiple vitamins w/
minerals liquid
3
PROTECT PLUS NR - multiple vitamins
w/ minerals cap
3
PROTECTBONE - multiple vit w/ min &
calcium-folic acid wafer 500-1 mg
3
136
PROTECTNATAL - prenatal vit w/poly
fe-fa-fish oil tab dr 13.5-0.5-700 mg
3
PROVIDA OB - prenatal w/o a w/fe fumfe poly-fa cap 20-20-1.25 mg
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
PUREFE OB PLUS - prenatal w/o a w/fe 3
fum-fe poly-fa cap 162.115.2-1 mg
1
QUFLORA PEDIATRIC - pediatric
multiple vitamins w/ fluoride chew tab
0.25 mg
1
0.5 mg
1
1 mg
1
multiple vitamins w/ fluoride soln 0.25
mg/ml
1
multiple vitamins w/ fluoride soln 0.5
mg/ml
R-NATAL OB - prenatal w/o a w/fe cbn- 3
fa-dha cap 20-1-320 mg
REAPHIRM - prenatal mv w/ fe polysac 3
cmplx-fa-dha cap 29-1-200 mg
RELNATE DHA - prenatal vit w/ fe fum- 3
fa-omega 3 cap 28-1-200 mg
RENATABS - b-complex w/ c-biotin-vit e 3
& folic acid tab 1 mg
RENATABS WITH IRON - b complex-c- 3
biotin-e-fa tab 1mg & fe cbn tab 100
mg pack
3
RENAX - multiple vitamins w/ minerals
& fa tab 2.5 mg
REQ 49+ - multiple vitamins w/ minerals 3
tab
3
SE-NATAL 19 - prenatal vit w/ fe
3
SE-NATAL 19 - prenatal vit w/ dss-fe
SE-TAN DHA - prenatal w/fe fum-fe poly 3
-fa-omega 3 cap 15-15-1 mg
SELECT-OB - prenatal vit w/ fe polysac 3
cmplx-fa chew tab 29-1 mg
3
SELECT-OB - prenat w/ fepolycmplxmethylfol-fa chew tab 29-0.6-0.4 mg
3
SELECT-OB+DHA - prenatal mv w/fe
mg pak
3
SETON ET-EC - prenat-fe bis-fe prot
succ-fa-ca tab & omega cap dr 430
pk
3
SETONET - prenat-fe bis-fe prot succfa-ca tab & omega 3 cap 430 pk
3
SIDEROL - multiple vitamins w/
minerals tab
3
SM B-COMPLEX/VITAMIN C - bcomplex w/ c & folic acid tab
STROVITE - b-complex w/ c & folic acid 3
tab
3
STROVITE FORTE - multiple vitamins
w/ minerals tab
3
STROVITE FORTE - multiple vitamins
w/ minerals & fa syrup 1 mg/15ml
3
STROVITE ONE - multiple vitamins w/
minerals tab
SUPERVITE - b-complex w/ lysine-zn & 3
folic acid liquid
3
SUPERVITE EC - multiple vitamins w/
minerals & fa tab dr 1 mg
3
SUPPORT - multiple vitamins w/
minerals liquid
3
SUPPORT-500 - speciality vitamin
product cap
3
SYNAGEX - multiple vitamins w/
minerals & fa cap 1.25 mg
3
SYNATEK - multiple vitamins w/
minerals & fa cap 1.25 mg
TANDEM OB - prenatal w/o a w/fe fum- 3
fe poly-fa cap 162.115.2-1 mg
TARON-BC - prenat w/o a w/ fe cbnyl-fa
tab 20-1 mg & vit b6 tab pak
3
TARON-C DHA - prenatal w/fe fum-fe
poly -fa-omega 3 cap 53.5-38-1 mg
3
TARON-DUO EC - prenat-fe bis-fe prot
succ-fa-ca tab & omega cap dr 400
pk
3
TARON-PREX - prenatal w/o vit a w/ fe
3
TL G-FOL OS - multiple vit w/ min &
calcium-folic acid tab 500-1.1 mg
3
TL-ASSURE ONE - prenatal mv w/ fe
polysac cmplx-fa-dha cap 29-1-200
mg
3
TL-ASSURE+DHA - prenatal mv w/fe
mg pak
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
TL-CARE DHA - prenatal w/fe fumarate- 3
fa-dss-fish oil cap 27-1-500 mg
3
TL-FLUORIVITE - pediatric multiple
vitamins w/ fl-fe chew tab 0.25-7.5 mg
3
TL-SELECT - prenatal w/o vit a w/ fe
TL-SELECT DHA - prenatal w/o vit a w/ 3
fe fum-doc-fa-dha cap 29-1.25-350
mg
3
TRI RX - prenatal w/o a w/ fe carbonylfe gluc-dss-fa tab 27-1mg
3
TRI-TABS DHA - prenat w/o a w/ fe
pack
TRI-VI-FLOR - ped vit acd & l-methylfol 3
w/ fl biphasic susp 0.25 mg/ml
TRI-VI-FLOR - ped vit acd & l-methylfol 3
w/ fl biphasic susp 0.5 mg/ml
3
TRI-VI-FLORO - ped vit acd & lmethylfol w/ fl biphasic susp 0.25 mg/
ml
3
TRI-VI-FLORO - ped vit acd & lmethylfol w/ fl biphasic susp 0.5 mg/
ml
137
TRI-VIT/FLUORIDE/IRON - pediatric
vitamins acd fluoride & fe drops
0.25-10 mg/ml
3
UDAMIN - multiple vitamins w/ minerals
& fa tab 2 mg
3
TRI-ZEL - multiple vitamins w/ minerals
tab
UDAMIN SP - multiple vitamins w/
minerals & fa tab 1 mg
3
3
TRIADVANCE - prenatal vit w/ dss-iron
ULTIMATE OB DHA - prenat w/ fe poly
cmplx-fe asp-fe gly-fa tab & dha cap
pak
3
3
ULTIMATECARE ONE - prenatal vit w/
fe cbn-fe asp glyc-fa-omega 3 cap
27-1mg
3
ULTIMATECARE ONE NF - prenatal
w/fe cbnyl-fe asp glyc-fa-dss-omega
cap 20-7-1 mg
3
ULTRA TABS - prenatal vit w/ dss-iron
3
V-NATAL - prenatal vit w/o vit a w/ fe
3
V-NATAL DHA - prenat w/o a w/ fe
pack
3
VEMAVITE-PRX 2 - prenatal w/o vit a
w/ fe fum-dss-fa-dha cap 27-1.25-300
mg
3
VENA-BAL DHA - prenat w/fe poly-na
430mg
3
VENATAL-FA - prenatal vit w/ fe
3
VINACAL - prenatal w/o a w/ fe
carbonyl-fe gluc-dss-fa tab 27-1mg
3
VINACAL B - prenat w/o a w/fecbnfeglu-fa tab 20-1 mg & vit b6 tab pak
3
VINATE AZ - prenatal vit w/ fe
bisglycinate chelate-fa tab 27-1 mg
3
VINATE AZ EXTRA - prenatal vit w/ fe
3
VINATE C - prenatal w/o a vit w/ fe
3
VINATE CALCIUM - prenatal vit w/ iron
carbonyl-fe gluc-fa tab 27-1 mg
3
TRICARE - prenatal vit w/ fe fumarate-fa 3
tab 27-1 mg
3
TRICARE PRENATAL COMPLEAT prenat w/o a fefum-fa tab 27-1 mg &
fish oil chew cap pak
3
TRICARE PRENATAL DHA ONE prenatal w/fe fumarate-fa-dss-fish oil
cap 27-1-500 mg
3
TRIMESIS RX - prenatal w/ calcium
carbonate-b6-b12-fa tab 1 mg
TRINATAL GT - prenatal vit w/ dss-iron 3
3
TRINATAL RX 1 - prenatal vit w/ fe
TRINATAL ULTRA - prenatal vit w/ dss- 3
TRINATE - prenatal vit w/ fe fumarate-fa 3
tab 28-1 mg
3
TRIVEEN-DUO DHA - prenat-fe bis-fe
prot succ-fa-ca tab & omega 3 cap
400 pk
TRIVEEN-ONE - prenatal w/o vit a w/ fe 3
TRIVEEN-PRX RNF - prenatal w/o vit a 3
w/ fe fum-dss-fa-dha cap 26-1.2-300
mg
TRIVEEN-TEN - prenatal mv & min w/fe 3
carbonyl-fa-dha tab 15-0.5-50 mg
3
TRIVEEN-U - prenatal w/o a vit w/ fe
fumarate-fa cap 106.5-1 mg
3
TRUST NATAL DHA - prenat-fe bis-fe
prot succ-fa-ca tab & omega 3 cap
250 pk
138
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
VINATE CARE - prenatal w/o a vit w/ fe
fum-fa tab chew 40-1 mg
3
VIRT-VITE GT - prenatal vit w/ dss-iron
3
VINATE DHA - prenat w/o a w/fefummethylfol-fa-omegas cap 27-1.53 mg
3
VIRTPREX - prenatal w/o vit a w/ fe
3
VINATE DHA RF - prenat w/o a w/
fefum-methylfol-omegas cap 27-1.13
mg
3
VITA-PREN - prenatal vit w/ docusateiron-fa tab 65-1 mg
3
VITAFOL - iron w/ vitamin tab
3
VINATE GT - prenatal vit w/ dss-iron
3
3
VINATE IC - prenatal w/o a w/fe fum-fe
poly-fa cap 162.115.2-1 mg
3
VITAFOL ULTRA - prenat w/fe polymethylfol-fa-dha cap 29-0.6-0.4-200
mg
VINATE II - prenatal vit w/ fe
VITAFOL-NANO - prenatal w/o a w/
fefum-l methylfol-fa tab 18-0.6-0.4 mg
3
3
VINATE M - prenatal vit w/ sel-fe
VITAFOL-OB - prenatal vit w/ fe
3
3
3
VINATE ONE - prenatal vit w/ fe
3
VITAFOL-OB+DHA - prenatal mv w/fe
fum-fa tab 65-1 mg & dha cap 250
mg pack
VINATE PN CARE - prenatal without a
w/ fe asparto gly-doc-fa tab 30-1mg
3
3
VINATE ULTRA - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
3
VITAFOL-ONE - prenatal mv w/ fe
mg
VITAFOL-PLUS - prenatal mv w/ fe
mg
3
VITAFOL-PN - prenatal vit w/ fe
3
VITAJECT - b-complex w/ c inj
3
VITAL-D RX - b-complex w/ c-biotin-dzinc & folic acid tab 1 mg
3
VITAMEDMD ONE RX/QUATREFO prenat w/o a w/fefum-methfol-fa-dha
cap 30-0.6-0.4-200 mg
3
VITAMEDMD PLUS RX/QUATRE prenat w/o a w/ fe chelate-l methylfolfa tab & dha cap pk
3
VITAMEDMD REDICHEW RX - prenat
w/ b2-b6-b12-d3-folic acid chew tab
1.4 mg
3
VITAMEDMD REDICHEW RX/QUA prenat w/ b2-b6-b12-d3-methylfol-fa
chew tab 0.6-0.4 mg
3
VIRT NATE - prenatal vit w/ fe fumarate- 3
fa tab 28-1 mg
3
VIRT-ADVANCE - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
VIRT-BAL DHA - prenat-fepoly-nafered- 3
fa tab 13-13-1 & omega cap dr 374
mg
3
VIRT-BAL DHA PLUS - prenat w/fe
cap dr 380mg
3
VIRT-PN - prenatal vit w/ fe fummethylfolate-fa tab 27-0.6-0.4 mg
3
VIRT-PN DHA - prenat w/o a w/fefummethfol-fa-dha cap 27-0.6-0.4-300
mg
3
VIRT-PN PLUS - prenat w/o a w/ fe
fumerate-methylfolate-fa-omega 3
cap
VIRT-SELECT - prenatal w/o vit a w/ fe 3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
139
VITAPEARL - prenat w/oa w/fefum-na
fered-fa-dha cap cr 30-1.4-200 mg
3
ZATEAN-PN - prenatal vit w/ fe fummethylfolate-fa tab 27-0.6-0.4 mg
3
VITAROCA PLUS - multiple vitamins w/
minerals tab
3
3
VITASPIRE - prenatal w/o a vit w/ fe
3
ZATEAN-PN DHA - prenat w/o
a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
ZATEAN-PN PLUS - prenat w/o a w/
fe fumerate-methylfolate-fa-omega 3
cap
3
ZINGIBER - prenatal w/ calcium-vit b6fa-ginger tab 1.2 mg
3
VIVA CT PRENATAL - prenatal w/o a vit 3
w/ fe fum-fa tab chew 28-1 mg
3
VIVA DHA - prenatal vit w/ fe fum-faomega 3 cap 28-1-200 mg
VOL-NATE - prenatal vit w/ fe fumarate- 3
fa tab 28-1 mg
VOL-PLUS - prenatal vit w/ fe fumarate- 3
fa tab 27-1 mg
3
VOL-TAB RX - prenatal vit w/ iron
VP CH ULTRA - prenat w/o a w/fe fum- 3
fe cbn-dss-fa-dha cap 27-1-260 mg
VP-CH PLUS - prenatal w/o a w/fe cbn- 3
dss-fa-dha cap 29-1-265 mg
3
VP-CH-PNV - prenatal w/o vit a w/ fe
cbn-dss-fa-dha cap 30-1-260 mg
3
VP-ERA OB PLUS - prenat vit-fe poly
cmplx-fe heme poly-fa tab 22-6-1 mg
3
VP-GGR-B6 PRENATAL - prenatal w/
VP-HEME OB - prenat vit-fe poly cmplx- 3
fe heme poly-fa tab 28-6-1 mg
3
VP-HEME OB + DHA - prenat-fe poly
cmplx-fe heme poly-fa tab & omega 3
cap pck
3
VP-HEME ONE - prenat-fe poly cmplxfe heme poly-fa-dha cap 22-6-1-200
mg
VP-PNV-DHA - prenatal vit w/ fe fum-fa- 3
omega 3 cap 28-1-215.8 mg
3
VP-ZEL - multiple vitamins w/ minerals
tab
3
ZATEAN-CH - prenatal w/o a w/fe cbndss-fa-dha cap 27-1-250 mg
140
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
MINERALS and ELECTROLYTES
CALCIFOL - ca carb-folic acid-vit d-b6b12-boron-mag wafer 1342-1.6 mg
3
CALCIUM-FOLIC ACID PLUS D - ca
carb-folic acid-vit d-b6-b12-boronmag wafer 1342-1 mg
3
EFFER-K - potassium bicarbonate-citric
acid effer tab 10 meq
3
EFFER-K - potassium bicarbonate-citric
acid effer tab 20 meq
3
FLORICAL - sodium fluoride w/ calcium
carb cap 8.3-364 mg
3
FLORICAL - sodium fluoride w/ calcium
carb tab 8.3-364 mg
3
FLUOR-A-DAY - sodium fluoride-xylitol
chew tab 0.55 (0.25 mg f)-236.79 mg
3
chew tab 1.1 (0.5 mg f)-236.79 mg
3
chew tab 2.2 (1 mg f)-236.79 mg
3
FLUORABON - sodium fluoride soln
0.25 mg/0.6ml (from 0.55 mg/0.6ml
naf)
3
FLURA-DROPS - sodium fluoride soln
0.25 mg/drop f (from 0.55 mg/drop
naf)
3
GALZIN - zinc acetate cap 25 mg
(elemental zinc)
3
GALZIN - zinc acetate cap 50 mg
(elemental zinc)
3
IODINE STRONG - iodine solution
strong 5% (lugol's)
3
IODOPEN - sodium iodide inj 100 mcg/
ml
3
3
MONOCAL - sodium
monofluorophosphate-calcium carb
tab 22.75-625 mg
1
K-PHOS - potassium phosphate
monobasic tab 500 mg
2
pot bicarbonate & chloride effer tab
25 meq
1
K-PHOS NEUTRAL - pot phos
monobasic w/sod phos di & monobas
tab 155-852-130mg
3
pot phos monobasic w/sod phos di
& monobas tab 155-852-130mg (Kphos neutral)
1
K-TAB - potassium chloride tab cr 10
meq
3
potassium bicarbonate effer tab 25
meq
1
K-TAB - potassium chloride tab cr 20
meq (1500 mg)
3
potassium chloride cap cr 10 meq
(Micro-k)
1
KLOR-CON M15 - potassium chloride
microencapsulated crys cr tab 15
meq
3
potassium chloride cap cr 8 meq
(Micro-k)
3
KLOR-CON 25 - potassium chloride
powder packet 25 meq
3
POTASSIUM CHLORIDE ER potassium chloride tab cr 20 meq
(1500 mg)
1
LOZI-FLUR - sodium fluoride lozenge 1
mg f (from 2.2 mg naf)
3
potassium chloride
meq
potassium chloride
meq
1
potassium chloride oral liq 10% (20
meq/15ml)
1
potassium chloride oral liq 20% (40
meq/15ml)
1
potassium chloride powder packet
20 meq
1
potassium chloride tab cr 10 meq (Ktab)
1
potassium chloride tab cr 8 meq
(600 mg)
1
sodium chloride flush iv soln 0.9%
1
sodium chloride tab 1 gm
1
SODIUM FLUORIDE - sodium fluoride
tab 0.5 mg f (from 1.1 mg naf)
3
SODIUM FLUORIDE - sodium fluoride
tab 1 mg f (from 2.2 mg naf)
3
sodium fluoride chew tab 0.25 mg f
(from 0.55 mg naf) (Luride)
1
LURIDE - sodium fluoride chew tab 0.25 3
3
LURIDE - sodium fluoride chew tab 0.5
3
LURIDE - sodium fluoride chew tab 1
3
LURIDE - sodium fluoride soln 0.5 mg/
ml f (from 1.1 mg/ml naf)
3
MAGNEBIND 400 - magnesiumcalcium-folic acid tab 400-200-1 mg
1
magnesium chloride inj 200 mg/ml
MAGNESIUM SULFATE - magnesium
sulfate inj 4%
3
MAGNESIUM SULFATE - magnesium
sulfate inj 8%
3
magnesium sulfate inj 50%
1
MICRO-K - potassium chloride cap cr 8
meq
3
MICRO-K - potassium chloride cap cr 10 3
meq
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
141
sodium fluoride chew tab 0.5 mg f
1
CEREFOLIN - l-methylfolate w/ vit b12vit b6-vit b2 tab 6-1-50-5 mg
3
sodium fluoride chew tab 1 mg f
1
3
sodium fluoride soln 0.125 mg/drop f
(0.275 mg/drop naf)
1
CEREFOLIN NAC - l-methylfolatemethylcobalamin-acetylcyst tab
6-2-600 mg
3
sodium fluoride soln 0.5 mg/ml f
(from 1.1 mg/ml naf) (Luride)
1
CEREFOLIN NAC - l-methylfolatealgae-b12-acetylcyst tab
6-90.314-2-600mg
SSKI - potassium iodide soln 1 gm/ml
3
3
zinc sulfate cap 220 mg (50 mg
elemental zn)
1
CYANOCOBALAMIN/LEVOMEFOLA l-methylfolate w/ vit b6-vit b12 tab
1.13-25-2 mg
DEPLIN - l-methylfolate tab 7.5 mg
3
DEPLIN - l-methylfolate tab 15 mg
3
DEPLIN 15 - l-methylfolate-algae cap
15-90.314 mg
3
DEPLIN 7.5 - l-methylfolate-algae cap
7.5-90.314 mg
3
ENTERAGAM - serum-derived bovine
immunoglob/protein isolate 5 gm
packet
3
1
NUTRIENTS
glucose oral liquid
1
acetylcysteine cap 600 mg
1
CARDIOVID PLUS - dha-epa-vit b6b12-folic acid cap 240-360-20-0.5-0.8
mg
3
GLUCOSE NURSETTE - glucose oral
soln 5%
3
glucose oral soln 5%
1
LECITHIN - lecithin granules
3
NUTRESTORE - glutamine powd pack
5 gm
3
flaxseed oil-evening primrosebilberry cap 1000-500-40 mg (Tears
again hydrate)
3
ROCK CANDY - dextrose oral crystals
3
FOLBEE AR - folic acid-b12-b6arginine-black pepper tab
FOLBIC RF - l-methylfolate w/ vit b6-vit
b12 tab 1.13-25-2 mg
3
folic acid-pyridoxinecyanocobalamin tab 2.5-25-2 mg
1
FOLTANX - l-methylfolate w/ vit b6-vit
b12 tab 3-35-2 mg
3
FOLTANX RF - l-methylfolate-algae-vit
b12-b6 cap 3-90.314-2-35 mg
3
FOLTX - folic acid-pyridoxinecyanocobalamin tab 2.5-25-2 mg
3
FOLTX - l-methylfolate w/ vit b6-vit b12
tab 1.13-25-2 mg
3
FOSTEUM - genistein-zinc amino acid
chelate-vitamin d cap
3
GLYTACTIN BETTERMILK 10 nutritional supplement pack
3
TRYPTOPHAN - tryptophan cap 500 mg 3
3
WHEY PROTEIN DRINK MIX - protein
oral powder
DIETARY PRODUCTS
ALZ-NAC - l-methylfolatemethylcobalamin-acetylcyst tab
6-2-600 mg
3
AVAILNEX - carbocysteine chew tab
750 mg
3
CALAFOL RX - fa-hydroxocobalaminpolicosanol-vit b6-vit d-ca tab
3
CAMINO PRO 15PE - nutritional
supplement liquid
3
CARDIOTEK-RX - folic acid-b12-b6arginine-black pepper tab
3
142
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
GLYTACTIN BETTERMILK 15 nutritional supplement pack
3
LEVOMEFOLATE CALCIUM/ALGA - lmethylfolate-algae cap 7.5-90.314 mg
3
L-METHYL-B6-B12 - l-methylfolate w/
vit b6-vit b12 tab 3-35-2 mg
3
LEVOMEFOLATE CALCIUM/ALGA - lmethylfolate-algae cap 15-90.314 mg
3
L-METHYL-MC - l-methylfolate w/ vit
b12-vit b6-vit b2 tab 6-1-50-5 mg
3
3
L-METHYL-MC NAC - l-methylfolatemethylcobalamin-acetylcyst tab
6-2-600 mg
3
LEVOMEFOLATE CALCIUM/PYRI l-methylfolate-algae-vit b12-b6 cap
3-90.314-2-35 mg
LIMBREL - flavocoxid cap 250 mg
3
LIMBREL - flavocoxid cap 500 mg
3
L-METHYLFOLATE - l-methylfolate tab
7.5 mg
3
LIMBREL250 - flavocoxid-citrated zinc
bisglycinate cap 250-50 mg
3
L-METHYLFOLATE - l-methylfolate tab
15 mg
3
LIMBREL500 - flavocoxid-citrated zinc
bisglycinate cap 500-50 mg
3
L-METHYLFOLATE CA ME-CBL - lmethylfolate-algae-b12-acetylcyst tab
6-90.314-2-600mg
3
LMTHF/PYRIDOXINE HCL/CYAN l-methylfolate w/ vit b6-vit b12 tab
1.13-25-2 mg
3
L-METHYLFOLATE CA/ME-CBL/ l-methylfolate-methylcobalaminacetylcyst tab 6-2-600 mg
3
METAFOLBIC - l-methylfolate w/ vit
b12-vit b6-vit b2 tab 6-1-50-5 mg
3
3
METAFOLBIC PLUS - l-methylfolatemethylcobalamin-acetylcyst tab
6-2-600 mg
3
L-METHYLFOLATE CA/P-5-P/M - lmethylfolate w/ vit b6-vit b12 tab
3-35-2 mg
3
METAFOLBIC PLUS RF - lmethylfolate-algae-b12-acetylcyst tab
6-90.314-2-600mg
3
L-METHYLFOLATE CA/P-5-P/M - lmethylfolate-algae-vit b12-b6 cap
3-90.314-2-35 mg
3
METANX - l-methylfolate w/ vit b6-vit
b12 tab 3-35-2 mg
3
L-METHYLFOLATE CALCIUM - lmethylfolate tab 7.5 mg
3
METANX - l-methylfolate-algae-vit b12b6 cap 3-90.314-2-35 mg
3
L-METHYLFOLATE CALCIUM - lmethylfolate tab 15 mg
3
METHYLFOL-ALGAE-B12-ACETY - lmethylfolate-algae-b12-acetylcyst tab
6-90.314-2-600mg
3
L-METHYLFOLATE FORMULA 15 - lmethylfolate-algae cap 15-90.314 mg
L-METHYLFOLATE FORMULA 7. - lmethylfolate-algae cap 7.5-90.314 mg
3
PKU EASY MICROTABS - nutritional
supplement tabs delayed release
3
L-METHYLFOLATE FORTE - lmethylfolate-algae cap 7.5-90.314 mg
3
PODIAPN - l-methylfolate-b12-b6-alpha
lipoic ac cap 5-2-35-300 mg
3
L-METHYLFOLATE FORTE - lmethylfolate-algae cap 15-90.314 mg
3
LEVOMEFOLATE CALCIUM/ACET - lmethylfolate-algae-b12-acetylcyst tab
6-90.314-2-600mg
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
Q-TABS - levomefolate glucosamine tab 3
1 mg (folate equivalent)
3
RENASTART - nutritional supplement
pack
143
TEARS AGAIN HYDRATE - flaxseed
oil-evening primrose-bilberry cap
1000-500-40 mg
3
VASCAZEN - omega-3-acid ethyl esters
(dietary management) cap 1 gm
3
VAYACOG - phosphatidylserine-dhaepa cap 100-19.5-6.5 mg
3
VAYARIN - phosphatidylserine-dha-epa
cap 75-21.5-8.5 mg
3
VAYAROL - phytosterol esters-dha-epa
cap 630-232.5-92.5 mg
3
VITA-RESPA - folic acid-pyridoxinecyanocobalamin tab 2.2-25-1.3 mg
3
VITACIRC-B - l-methylfolate w/ vit b6-vit
b12 tab 3-35-2 mg
3
VP-GSTN - genistein-zinc amino acid
chelate-vitamin d cap
3
ZYTAZE - zinc citrate-phytase cap
25-500 mg
3
HEMATOLOGICAL AGENTS
ANIMI-3/VITAMIN D - folic acid-b6-b12d-omega 3-phytosterols cap 1 mg
3
ARANESP ALBUMIN FREE darbepoetin alfa-polysorbate 80 soln
inj 25 mcg/ml
4
inj 25 mcg/0.42ml
4
inj 40 mcg/ml
4
inj 40 mcg/0.4ml
4
inj 60 mcg/ml
4
inj 60 mcg/0.3ml
4
4
fe fum-iron polysacch complex-fab cmplx-c-zn-mn-cu cap (Tandem
plus)
1
inj 100 mcg/ml
4
ferrous fumarate-fa-b complex-c-znmg-mn-cu tab 106-1 mg
1
inj 100 mcg/0.5ml
4
folic acid-vit b6-vit b12-omega 3phytosterols cap 1 mg
1
inj 150 mcg/0.75ml
iron combination cap
1
4
iron-docusate-b12-folic acid-c-e-cubiotin tab 150-1 mg (Hematron-af)
1
inj 150 mcg/0.3ml
3
inj 200 mcg/ml
4
ACTIVE FE - fe carbonyl-fa-b complexa-c-d-e-min tab 75-1.25 mg
ALBAFORT - ferric ammon cit-vit b12liver inj 67-50 mg-mcg/ml
3
inj 200 mcg/0.4ml
4
inj 300 mcg/ml
4
HEMATOPOIETIC AGENTS
ANIMI-3 - folic acid-vit b6-vit b12-omega 3
3-phytosterols cap 1 mg
ANIMI-3 - folic acid-b6-b12-d-omega 3- 3
phytosterols cap 1 mg
144
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
inj 300 mcg/0.6ml
4
inj 500 mcg/ml
4
B-6 FOLIC ACID - cobalamine
combination cap
3
BIFERARX - polysacch fe cmplx-fe
heme poly-fa-b12 tab 22-6-1-0.025
mg
3
BP VIT 3 - folic acid-vit b6-vit b12omega 3-phytosterols cap 1 mg
Dispensing Limits
Step Therapy
EPOGEN - epoetin alfa inj 20000 unit/ml 4
3
FA-8 - folic acid cap 0.8 mg
fe fumarate w/ b12-vit c-fa-ifc cap
110-0.015-75-0.5-240 mg
1
fe fumarate-vit c-vit b12-fa cap 460
(151 fe)-60-0.01-1 mg
1
FE 90 PLUS - fe carbonyl-fe gluconatefa-vit b12-vit c-dss tab 90-1 mg
3
FER-IN-SOL - ferrous sulfate soln 75
mg/ml (15 mg/ml elemental fe)
3
3
FERIVA - fe bisglycin-fe carbonyl-c-fab12-biotin-dss cap 75-1 mg
3
carbonyl iron chew tab 15 mg
(elemental iron)
1
carbonyl iron susp 15 mg/1.25ml
(elemental iron)
1
CENFOL - folic acid-vitamin b6-vitamin
b12 tab 2.3-24.5-2 mg
3
CENTRATEX - ferrous fumarate-fa-b
complex-c-zn-mg-mn-cu cap 106-1
mg
3
CORVITE FE - iron combination tab
3
CORVITE 150 - iron combination tab
3
CORVITE 150 - iron-folic acid-vit c-vit
b6-vit b12-zinc tab 150-1.25 mg
3
cyanocobalamin inj 1000 mcg/ml
1
DIVISTA - folic acid-vit b6-vit b12omega 3-biotin-cr cap 1 mg
3
DROXIA - hydroxyurea cap 200 mg
3
3
3
ED CYTE F - ferrous fumarate-folic
acid-docusate sodium tab 324-1-50
mg
3
EPOGEN - epoetin alfa inj 2000 unit/ml
4
4
4
FERIVAFA - iron-c-fa-b12-biotin-copper- 3
docusate cap 110-1 mg
3
FERRALET 90 - fe carbonyl-fe
gluconate-fa-vit b12-vit c-dss tab 90-1
mg
FERRAPLUS 90 - iron-folic acid-vit b12- 3
vit c-docusate sod tab 90-1 mg
3
FERRETTS CHEWABLE IRON carbonyl iron chew tab 18 mg
(elemental iron)
3
FERREX 150 FORTE PLUS - fe asp
gly-fe polysacch-succ ac-c-threon acb12-fa cap
FERREX 28 - fe asparto gly-fe fum-b12- 3
fa-c-succinic ac tab ther pack
3
FERRO-PLEX HEMATINIC - fe fumdss-vit c-vit e-vit b12-if-fa tab 115-1
mg
3
FERROTRIN - iron w/ b12-vit c-fa-ifc
cap 36-0.015-75-0.5-240 mg
1
ferrous fumarate-folic acid tab
324-1 mg
3
FERROUS SULFATE - ferrous sulfate
liquid 220 mg/5ml (44 mg/5ml
elemental fe)
3
FERROUS SULFATE - ferrous sulfate
syrup 300 mg/5ml (60 mg/5ml
elemental fe)
EPOGEN - epoetin alfa inj 10000 unit/ml 4
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
145
ferrous sulfate elixir 220 mg/5ml
(44 mg/5ml elemental fe)
1
ferrous sulfate soln 75 mg/ml (15 mg/
ml elemental fe)
1
ferrous sulfate-vit c-folic acid tab cr
105-500-0.8 mg
HEMETAB - polysacch fe cmplx-fe
heme poly-fa-b12 tab 22-6-1-0.025
mg
3
3
1
HEMOCYTE PLUS - ferrous fumaratefa-b complex-c-zn-mg-mn-cu cap
106-1 mg
FOLGARD RX - folic acid-vitamin b6vitamin b12 tab 2.2-25-1 mg
3
HEMOCYTE-F - iron combination elixir
3
3
FOLIC ACID - folic acid inj 5 mg/ml
3
HYDROXOCOBALAMIN hydroxocobalamin inj 1000 mcg/ml
folic acid tab 1 mg
1
3
folic acid tab 400 mcg
1
ICAR - carbonyl iron chew tab 15 mg
(elemental iron)
1
ICAR PEDIATRIC - carbonyl iron susp
15 mg/1.25ml (elemental iron)
3
folic acid tab 800 mcg
folic acid-vitamin b6-vitamin b12 tab
2.2-25-0.5 mg
1
ICAR-C PLUS - iron-vit c-vit b12-folic
acid tab 100-250-0.025-1 mg
3
2.2-25-1 mg (Folgard rx)
1
INTEGRA F - fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe)
3
2.5-25-1 mg
1
INTEGRA PLUS - fe fum-iron polysacch
complex-fa-b complex-c-biotin cap
3
FOLIVANE-F - fe fum-fe poly-fa-c-b3
cap 62.5-62.5-1-40-3mg(125 mg fe)
3
IRON - iron combination tab
3
3
IRON ASP GLY/ POLYSACCH C - fe
asp gly-fe polysacch-succ ac-c-threon
ac-b12-fa cap
1
FOLIVANE-PLUS - fe fum-iron
polysacch complex-fa-b complex-cbiotin cap
3
iron dextran inj 50 mg/ml (elemental
iron)
1
FOLPACE RX - folic acid-hydroxocobalvit b6-vit e-mag tab 2.05 mg-425 mcg
3
iron polysacch complex-vit b12-fa
cap 150-0.025-1 mg
1
FOLTRATE - cobalamine combination
tab
3
iron-folic acid-vit c-vit b6-vit b12-zinc
tab 150-1.25 mg (Corvite 150)
1
FUMATINIC - iron combination cap cr
FUSION PLUS - fe fum-iron poly cmplxfa-b cmplx-c-biotin-probiotic cap
3
iron-vit c-vit b12-folic acid tab
100-250-0.025-1 mg (Icar-c plus)
1
GRANIX - tbo-filgrastim soln prefilled
syringe 300 mcg/0.5ml
4
IROSPAN 24/6 - fe asp gly-fe polyssucc acd-b cmplx-c-ca-fa tab ther pk
3
GRANIX - tbo-filgrastim soln prefilled
syringe 480 mcg/0.8ml
4
IS 24/6 - fe asp gly-fe polys-succ acd-b
cmplx-c-ca-fa tab ther pk
3
HEMATOGEN FA - fe fumarate-vit c-vit
b12-fa cap 200-250-0.01-1 mg
3
HEMATRON-AF - iron-docusate-b12folic acid-c-e-cu-biotin tab 150-1 mg
3
146
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
LEUKINE - sargramostim inj 500 mcg/ml 4
LEUKINE - sargramostim lyophilized for 4
inj 250 mcg
MAXARON FORTE - fe gly-fe fum-vit c- 3
vit b12-methylfolate tab
MAXFE - iron-fa-vit b12-biotin-vit cdocusate-mg-zn tab 160-1 mg
3
MOZOBIL - plerixafor subcutaneous inj
24 mg/1.2ml (20 mg/ml)
4
MULTIGEN - fe asparto gly-succ acd-cthreonic acd-b12-des stom tab
3
MULTIGEN FOLIC - fe asparto glysuccinic acd-vit c-threonic acd-b12-fa
tab
3
MULTIGEN PLUS - fe aspart gly-fe fum- 3
succ acd-c-threonic acd-b12-fa tab
3
MV FE ASPARTO GLY/FE FUM/ - fe
aspart gly-fe fum-succ acd-c-threonic
acd-b12-fa tab
3
MV FE ASPARTO GLY/VIT C/V - fe
asparto gly-succ acd-c-threonic acdb12-des stom tab
3
MYKIDZ IRON 10 - iron susp 15
mg/1.5ml
3
NASCOBAL - cyanocobalamin nasal
spray 500 mcg/0.1ml
3
NATALVIRT FLT - fe carbonyl-fe
gluconate-fa-vit b12-vit c-dss tab 90-1
mg
NEPHRON FA - ferrous fumarate w/ fa- 3
dss-b complex-vit c tab
4
NEULASTA - pegfilgrastim inj 6
mg/0.6ml
4
NEUMEGA - oprelvekin for inj 5 mg
•
NOVAFERRUM - polysacch iron
complex-vit c-fa for soln 100-60-1
mg/5ml
3
PRE-FOLIC - folic acid-vitamin c tab
1-100 mg
3
PROCRIT - epoetin alfa inj 2000 unit/ml
4
4
4
PROCRIT - epoetin alfa inj 10000 unit/
ml
4
ml
4
ml
4
PROFERRIN-FORTE - iron heme
polypeptide-folic acid tab 12-1 mg (fe
equiv)
3
PROMACTA - eltrombopag olamine tab
12.5 mg (base equiv)
4
•
25 mg (base equiv)
4
•
50 mg (base equiv)
4
•
75 mg (base equiv)
4
•
PROTECTIRON - iron polysacch-fa-b
complex-vit c-e & minerals tab 60-1
mg
3
PUREFE PLUS - ferrous fumarate-fab complex-c-zn-mg-mn-cu cap 106-1
mg
3
SPATONE PUR-ABSORB IRON ferrous sulfate liquid 5 mg/20ml
(elemental iron)
3
3
NEUPOGEN - filgrastim inj 300 mcg/ml
4
NEUPOGEN - filgrastim inj 480
mcg/1.6ml (300 mcg/ml)
4
4
4
NEURIN-SL - cyanocobalaminmethylcobalamin tab sl 600-600 mcg
3
TANDEM F - ferrous fum-iron
polysacch-fa cap 162-115.2-1 mg
(106 mg fe)
3
NIRON KOMPLETE - fe bisglycinate-fe
fum-vit c-vit b12-vit e-fa tab 30-1 mg
3
TANDEM PLUS - fe fum-iron polysacch
complex-fa-b cmplx-c-zn-mn-cu cap
TARON FORTE - fe bisglycinate-fe
polysacch-vit c-vit b12-fa cap
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
147
ANTICOAGULANTS
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
4
Step Therapy
ZAVESCA - miglustat cap 100 mg
Prior Authorization
Drug Name
Drug Tier
2014
enoxaparin sodium inj 80 mg/0.8ml
(Lovenox)
1
•
ARIXTRA - fondaparinux sodium inj 2.5
mg/0.5ml
3
•
fondaparinux sodium inj 10 mg/0.8ml
(Arixtra)
1
•
ARIXTRA - fondaparinux sodium inj 5
mg/0.4ml
3
•
fondaparinux sodium inj
2.5 mg/0.5ml (Arixtra)
1
•
ARIXTRA - fondaparinux sodium inj 7.5
mg/0.6ml
3
•
fondaparinux sodium inj 5 mg/0.4ml
(Arixtra)
1
•
ARIXTRA - fondaparinux sodium inj 10
mg/0.8ml
3
•
fondaparinux sodium inj
7.5 mg/0.6ml (Arixtra)
1
•
COUMADIN - warfarin sodium tab 1 mg
3
3
•
3
FRAGMIN - dalteparin sodium inj 10000
unit/ml
3
unit/0.2ml
3
COUMADIN - warfarin sodium tab 2.5
mg
•
3
unit/0.2ml
3
•
3
•
3
unit/0.3ml
3
3
3
•
COUMADIN - warfarin sodium tab 7.5
mg
3
unit/0.5ml
3
•
COUMADIN - warfarin sodium tab 10
mg
3
unit/0.6ml
3
•
ELIQUIS - apixaban tab 2.5 mg
3
unit/0.72ml
ELIQUIS - apixaban tab 5 mg
3
3
•
enoxaparin sodium inj 100 mg/ml
(Lovenox)
1
unit/ml
3
(Lovenox)
1
•
HEPARIN LOCK FLUSH - heparin
sodium (porcine) lock flush iv soln 1
unit/ml
1
•
(Lovenox)
1
•
HEPARIN LOCK FLUSH - heparin
sodium (porcine) lock flush iv soln 2
unit/ml
3
enoxaparin sodium inj 150 mg/ml
(Lovenox)
1
enoxaparin sodium inj 300 mg/3ml
(Lovenox)
1
•
heparin sodium (porcine) inj 10000
unit/ml
1
(Lovenox)
1
•
heparin sodium (porcine) inj 5000
unit/ml
1
(Lovenox)
1
•
heparin sodium (porcine) lock flush
iv soln 1 unit/ml (Heparin lock flush)
iv soln 10 unit/ml
1
148
•
•
•
XARELTO - rivaroxaban tab 15 mg
3
3
heparin sodium (porcine) pf inj 5000
unit/0.5ml
1
IPRIVASK - desirudin for inj 15 mg
3
3
•
AMICAR - aminocaproic acid tab 500
mg
3
LOVENOX - enoxaparin sodium inj 30
mg/0.3ml
3
•
AMICAR - aminocaproic acid tab 1000
mg
3
mg/0.4ml
mg/0.6ml
3
•
mg/0.8ml
3
•
mg/ml
3
•
mg/0.8ml
3
•
mg/ml
3
•
mg/3ml
3
•
PRADAXA - dabigatran etexilate
mesylate cap 75 mg (etexilate base
eq)
3
•
PRADAXA - dabigatran etexilate
mesylate cap 150 mg (etexilate base
eq)
3
•
warfarin sodium tab 1 mg (Coumadin) 1
1
warfarin sodium tab 10 mg
(Coumadin)
warfarin sodium tab 2.5 mg
(Coumadin)
1
warfarin sodium tab 7.5 mg
(Coumadin)
1
Dispensing Limits
3
1
Step Therapy
iv soln 100 unit/ml
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
•
•
•
HEMOSTATICS
AMICAR - aminocaproic acid syrup 25% 3
AMINOCAPROIC ACID - aminocaproic 3
acid tab 1000 mg
1
aminocaproic acid syrup 25%
(Amicar)
1
aminocaproic acid tab 500 mg
(Amicar)
3
ARTISS - fibrin sealant component
solution
ASTRINGYN - ferric subsulfate soln 259 3
mg/gm
EVICEL - fibrin sealant component kit 2 3
ml
EVICEL - fibrin sealant component kit 5 3
ml
3
EVITHROM - thrombin (human) topical
soln 800-1200 unit/ml
LYSTEDA - tranexamic acid tab 650 mg 3
MONSELS FERRIC SUBSULFATE ferric subsulfate soln
3
RECOTHROM - thrombin (recombinant)
for soln 5000 unit
3
RECOTHROM - thrombin (recombinant)
for soln 20000 unit
3
RECOTHROM SPRAY KIT - thrombin
(recombinant) for soln 20000 unit
3
THROMBIN-JMI DILUENT - thrombin
for soln 5000 unit
3
THROMBIN-JMI DILUENT - thrombin
for soln 20000 unit
3
149
THROMBIN-JMI EPISTAXIS - thrombin
for soln kit 5000 unit
3
AGRYLIN - anagrelide hcl cap 0.5 mg
3
THROMBIN-JMI SYRINGE SPRA thrombin for soln kit 5000 unit
ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human) for
inj 250 unit
4
3
THROMBIN-JMI SYRINGE SPRA thrombin for soln kit 20000 unit
3
4
THROMBIN-JMI W/DIL SPRAY thrombin for soln kit 20000 unit
3
inj 500 unit
4
THROMBOGEN - thrombin for soln
1000 unit
3
inj 1000 unit
THROMBOGEN - thrombin for soln
10000 unit
3
4
THROMBOGEN - thrombin for soln kit
10000 unit
3
inj 1500 unit
4
TISSEEL - fibrin sealant component
solution
3
ALPHANINE SD - coagulation factor ix
for inj 500 unit
4
TISSEEL - fibrin sealant component kit
2 ml
3
for inj 1000 unit
4
4 ml
3
for inj 1500 unit
4
10 ml
3
ALPROLIX - coagulation factor ix
(recomb) (rfixfc) for inj 500 unit
4
tranexamic acid tab 650 mg (Lysteda)
1
4
4
anagrelide hcl cap 0.5 mg (Agrylin)
1
anagrelide hcl cap 1 mg
1
BEBULIN - factor ix complex for inj
200-1200 unit
4
BEBULIN VH - factor ix complex for inj
200-1200 unit
4
BENEFIX - coagulation factor ix
(recombinant) for inj 250 unit
4
4
4
HEMATOLOGICAL AGENTS - MISC.
ADVATE - antihemophilic factor rahfpfm for inj 250 unit
4
4
4
4
4
4
4
AGGRENOX - aspirin-dipyridamole cap
sr 12hr 25-200 mg
2
150
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
4
HELIXATE FS - antihemophilic factor
(recombinant) for inj kit 250 unit
4
BERINERT - c1 esterase inhibitor
(human) for iv inj kit 500 unit
4
4
BRILINTA - ticagrelor tab 90 mg
3
4
cilostazol tab 100 mg (Pletal)
1
cilostazol tab 50 mg (Pletal)
1
4
clopidogrel bisulfate tab 300 mg
(base equiv) (Plavix)
1
4
clopidogrel bisulfate tab 75 mg (base
equiv) (Plavix)
1
4
CORIFACT - factor xiii concentrate
(human) for inj kit 1000-1600 unit
4
HEMOFIL M - antihemophilic factor
(human) for inj 220-400 unit
4
dipyridamole tab 25 mg (Persantine)
1
(human) for inj 250 unit
1
4
1
EFFIENT - prasugrel hcl tab 5 mg (base
equiv)
4
3
EFFIENT - prasugrel hcl tab 10 mg
(base equiv)
4
3
ELOCTATE - antihemophilic factor
(recomb) rfviiifc for inj 250 unit
4
4
4
4
4
4
HUMATE-P - antihemophilic factor/vwf
4
4
4
4
4
4
KALBITOR - ecallantide inj 10 mg/ml
4
4
KCENTRA - prothrombin complex conc
human for inj kit 500 unit
3
FEIBA NF - antiinhibitor coagulant
complex for inj
4
KCENTRA - prothrombin complex conc
human for inj kit 1000 unit
3
•
Dispensing Limits
Prior Authorization
•
Drug Name
Step Therapy
Drug Tier
4
Dispensing Limits
FIRAZYR - icatibant acetate inj 30
Step Therapy
4
Drug Tier
Drug Name
Prior Authorization
2014
•
151
KOATE-DVI - antihemophilic factor
4
MONONINE - coagulation factor ix for
inj 500 unit
4
4
inj 1000 unit
4
4
NOVOSEVEN - coagulation factor viia
(recomb) for inj 2.4 mg (2400 mcg)
4
KOGENATE FS - antihemophilic factor
4
NOVOSEVEN RT - coagulation factor
viia (recomb) for inj 1 mg (1000 mcg)
4
4
4
4
4
4
4
4
pentoxifylline tab cr 400 mg
1
PERSANTINE - dipyridamole tab 25 mg
3
KOGENATE FS BIO-SET antihemophilic factor (recombinant)
for inj kit 250 unit
4
3
3
4
4
4
4
MONOCLATE-P - antihemophilic factor
(human) for inj kit 250 unit
Dispensing Limits
Step Therapy
PLAVIX - clopidogrel bisulfate tab 75 mg 3
(base equiv)
3
PLAVIX - clopidogrel bisulfate tab 300
mg (base equiv)
3
PLETAL - cilostazol tab 50 mg
PLETAL - cilostazol tab 100 mg
3
PROFILNINE SD - factor ix complex for
inj 500 unit
4
inj 1000 unit
4
4
4
inj 1500 unit
4
4
RECOMBINATE - antihemophilic factor
(recombinant) for inj 220-400 unit
4
4
4
4
4
inj 250 unit
4
152
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
4
RIASTAP - fibrinogen conc (human) inj
approximately 1 gm (900-1300 mg)
3
RIXUBIS - coagulation factor ix
4
4
4
4
4
THROMBATE III W/10 ML STE antithrombin iii (human) for inj 500
unit
4
THROMBATE III W/20 ML STE antithrombin iii (human) for inj 1000
unit
4
ticlopidine hcl tab 250 mg
1
TRENTAL - pentoxifylline tab cr 400 mg
3
TRETTEN - coagulation factor xiii asubunit for inj 2000-3125 unit
XYNTHA SOLOFUSE - antihemophilic
factor recombinant paf for inj kit 500
unit
4
unit
4
unit
4
unit
4
ZONTIVITY - vorapaxar sulfate tab 2.08
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
TOPICAL PRODUCTS
OPHTHALMIC AGENTS
ophthalmic irrigation solution intraocular (Bss plus)
1
ACULAR - ketorolac tromethamine
ophth soln 0.5%
3
ACULAR LS - ketorolac tromethamine
ophth soln 0.4%
3
4
ACUVAIL - ketorolac tromethamine
ophth soln 0.45%
3
WILATE - antihemophilic factor/vwf
4
AKTEN - lidocaine hcl ophth gel 3.5%
3
3
WILATE - antihemophilic factor/vwf
4
ALAMAST - pemirolast potassium ophth
soln 0.1%
3
XYNTHA - antihemophilic factor
recombinant paf for inj kit 250 unit
4
ALCAINE - proparacaine hcl ophth soln
0.5%
3
4
ALOCRIL - nedocromil sodium ophth
soln 2%
3
4
ALOMIDE - lodoxamide tromethamine
ophth soln 0.1%
3
4
ALPHAGAN P - brimonidine tartrate
ophth soln 0.1%
3
unit
4
ALPHAGAN P - brimonidine tartrate
ophth soln 0.15%
ALREX - loteprednol etabonate ophth
susp 0.2%
3
153
apraclonidine hcl ophth soln 0.5%
(base equivalent) (Iopidine)
1
BROMDAY - bromfenac sodium ophth
soln 0.09% (base equiv) (once-daily)
3
ophth oint 1%
3
BROMFENAC - bromfenac sodium
ophth soln 0.09% (base equivalent)
3
atropine sulfate ophth soln 1%
(Isopto atropine)
1
bromfenac sodium ophth soln 0.09%
(base equiv) (once-daily)
1
AZASITE - azithromycin ophth soln 1%
3
carteolol hcl ophth soln 1%
1
azelastine hcl ophth soln 0.05%
(Optivar)
1
CILOXAN - ciprofloxacin hcl ophth soln
0.3%
3
AZOPT - brinzolamide ophth susp 1%
3
CILOXAN - ciprofloxacin hcl ophth oint
0.3%
3
ciprofloxacin hcl ophth soln 0.3%
(Ciloxan)
1
BACITRACIN - bacitracin ophth oint 500 2
unit/gm
1
bacitracin-polymyxin b ophth oint
bacitracin-polymyxin-neomycin-hc
ophth oint 1%
1
COMBIGAN - brimonidine tartratetimolol maleate ophth soln 0.2-0.5%
3
BEPREVE - bepotastine besilate ophth
soln 1.5%
3
COSOPT - dorzolamide hcl-timolol
maleate ophth soln 22.3-6.8 mg/ml
3
BESIVANCE - besifloxacin hcl ophth
susp 0.6% (base equiv)
3
COSOPT PF - dorzolamide hcl-timolol
maleate ophth sol 22.3-6.8 mg/ml pf
3
BETADINE OPHTHALMIC PREP povidone-iodine ophth soln 5%
3
cromolyn sodium ophth soln 4%
1
3
BETAGAN - levobunolol hcl ophth soln
0.5%
3
CYCLOGYL - cyclopentolate hcl ophth
soln 0.5%
3
betaxolol hcl ophth soln 0.5%
1
soln 1%
BETIMOL - timolol ophth soln 0.25%
3
3
BETIMOL - timolol ophth soln 0.5%
3
soln 2%
3
CYCLOMYDRIL - cyclopentolate w/
phenylephrine ophth soln 0.2-1%
3
BETOPTIC-S - betaxolol hcl ophth susp
0.25%
3
cyclopentolate hcl ophth soln 1%
(Cyclogyl)
1
BLEPH-10 - sulfacetamide sodium
ophth soln 10%
3
cyclopentolate hcl ophth soln 2%
(Cyclogyl)
1
BLEPHAMIDE - sulfacetamide sodiumprednisolone ophth susp 10-0.2%
BLEPHAMIDE S.O.P. - sulfacetamide
sodium-prednisolone ophth oint
10-0.2%
3
brimonidine tartrate ophth soln
0.15% (Alphagan p)
1
brimonidine tartrate ophth soln 0.2%
1
154
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
CYSTARAN - cysteamine hcl ophth soln 4
0.44% (base equivalent)
1
ophth soln 0.1%
1
diclofenac sodium ophth soln 0.1%
dorzolamide hcl ophth soln 2%
(Trusopt)
1
dorzolamide hcl-timolol maleate
ophth soln 22.3-6.8 mg/ml (Cosopt)
1
ISOPTO ATROPINE - atropine sulfate
ophth soln 1%
3
DUREZOL - difluprednate ophth
emulsion 0.05%
3
ISOPTO CARBACHOL - carbachol
ophth soln 1.5%
3
ELESTAT - epinastine hcl ophth soln
0.05%
3
ISOPTO CARBACHOL - carbachol
ophth soln 3%
3
EMADINE - emedastine difumarate
ophth soln 0.05% (base equiv)
3
ISOPTO CARPINE - pilocarpine hcl
ophth soln 1%
3
epinastine hcl ophth soln 0.05%
(Elestat)
1
ophth soln 2%
3
erythromycin ophth oint 5 mg/gm
1
3
FLAREX - fluorometholone acetate
ophth susp 0.1%
3
ophth soln 4%
fluorometholone ophth susp 0.1%
(Fml liquifilm)
1
flurbiprofen sodium ophth soln
0.03% (Ocufen)
1
FML - fluorometholone ophth oint 0.1%
3
FML FORTE - fluorometholone ophth
susp 0.25%
3
FML LIQUIFILM - fluorometholone
ophth susp 0.1%
3
GARAMYCIN - gentamicin sulfate ophth
soln 0.3%
3
gatifloxacin ophth soln 0.5%
(Zymaxid)
1
GELFILM OP - gelatin adsorbable ophth 3
film
1
gentamicin sulfate ophth oint 0.3%
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
ISOPTO HOMATROPINE - homatropine 3
hbr ophth soln 2%
ISOPTO HOMATROPINE - homatropine 3
hbr ophth soln 5%
ISOPTO HYOSCINE - scopolamine hbr 3
ophth soln 0.25%
3
ISTALOL - timolol maleate ophth soln
0.5% (once-daily)
1
ketorolac tromethamine ophth soln
0.4% (Acular ls)
1
ketorolac tromethamine ophth soln
0.5% (Acular)
LACRISERT - artificial tear ophth insert 3
LASTACAFT - alcaftadine ophth soln
0.25%
3
latanoprost ophth soln 0.005%
(Xalatan)
1
gentamicin sulfate ophth soln 0.3%
(Garamycin)
1
LEVOBUNOLOL HCL - levobunolol hcl
ophth soln 0.25%
3
homatropine hbr ophth soln 5%
(Isopto homatropine)
1
levobunolol hcl ophth soln 0.5%
(Betagan)
1
ILEVRO - nepafenac ophth susp 0.3%
3
levofloxacin ophth soln 0.5%
1
IOPIDINE - apraclonidine hcl ophth soln
3
LOTEMAX - loteprednol etabonate
ophth susp 0.5%
2
IOPIDINE - apraclonidine hcl ophth soln
1% (base equivalent)
3
ophth gel 0.5%
2
IQUIX - levofloxacin ophth soln 1.5%
3
ophth oint 0.5%
2
•
155
LUMIGAN - bimatoprost ophth soln
0.01%
2
•
OCUFEN - flurbiprofen sodium ophth
soln 0.03%
3
LUMIGAN - bimatoprost ophth soln
0.03%
2
•
OCUFLOX - ofloxacin ophth soln 0.3%
3
ofloxacin ophth soln 0.3% (Ocuflox)
1
MAXIDEX - dexamethasone ophth susp
0.1%
3
OMNIPRED - prednisolone acetate
ophth susp 1%
3
MAXITROL - neomycin-polymyxindexamethasone ophth susp 0.1%
3
OPTIPRANOLOL - metipranolol ophth
soln 0.3%
3
MAXITROL - neomycin-polymyxindexamethasone ophth oint 0.1%
3
OPTIVAR - azelastine hcl ophth soln
0.05%
3
METIPRANOLOL - metipranolol ophth
soln 0.3%
1
PATADAY - olopatadine hcl ophth soln
0.2%
2
MITOSOL - mitomycin for ophth soln kit
0.2 mg
3
PATANOL - olopatadine hcl ophth soln
0.1%
3
MOXEZA - moxifloxacin hcl ophth soln
0.5% (base eq) (2 times daily)
3
phenylephrine hcl ophth soln 10%
1
3
phenylephrine hcl ophth soln 2.5%
(Mydfrin)
1
MYDFRIN - phenylephrine hcl ophth
soln 2.5%
3
PHOSPHOLINE IODIDE echothiophate iodide ophth for soln
0.125%
3
MYDRIACYL - tropicamide ophth soln
1%
NAPHAZOLINE HCL - naphazoline hcl
ophth soln 0.1%
3
pilocarpine hcl ophth soln 1% (Isopto
carpine)
1
NATACYN - natamycin ophth susp 5%
2
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin
carpine)
1
1
1
carpine)
1
neomycin-polymyx-gramicid op
sol 1.75-10000-0.25mg-unt-mg/ml
(Neosporin)
neomycin-polymyxindexamethasone ophth oint 0.1%
(Maxitrol)
1
neomycin-polymyxindexamethasone ophth susp 0.1%
(Maxitrol)
1
NEOMYCIN/POLYMYXIN/HYDROC neomycin-polymyxin-hc ophth susp
3
NEOSPORIN - neomycin-polymyxgramicid op sol 1.75-10000-0.25mgunt-mg/ml
3
NEVANAC - nepafenac ophth susp
0.1%
3
156
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
PILOPINE HS - pilocarpine hcl ophth gel 3
4%
1
polymyxin b-trimethoprim ophth
soln 10000 unit/ml-0.1% (Polytrim)
3
POLYTRIM - polymyxin b-trimethoprim
ophth soln 10000 unit/ml-0.1%
3
PRED FORTE - prednisolone acetate
ophth susp 1%
3
PRED MILD - prednisolone acetate
ophth susp 0.12%
PRED-G - gentamicin-prednisolone ace 3
ophth susp 0.3-1%
3
PRED-G S.O.P. - gentamicinprednisolone ace ophth oint 0.3-0.6%
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
prednisolone acetate ophth susp 1%
(Pred forte)
1
TIMOPTIC OCUDOSE - timolol maleate
preservative free ophth soln 0.5%
3
PREDNISOLONE SODIUM PHOSP prednisolone sodium phosphate
ophth soln 1%
3
TIMOPTIC-XE - timolol maleate ophth
gel forming soln 0.25%
3
PROLENSA - bromfenac sodium ophth
soln 0.07% (base equivalent)
TIMOPTIC-XE - timolol maleate ophth
gel forming soln 0.5%
3
3
1
TOBRADEX - tobramycindexamethasone ophth susp 0.3-0.1%
3
proparacaine hcl ophth soln 0.5%
(Alcaine)
PROPINE - dipivefrin hcl ophth soln
0.1%
TOBRADEX - tobramycindexamethasone ophth oint 0.3-0.1%
3
3
QUIXIN - levofloxacin ophth soln 0.5%
RESCULA - unoprostone isopropyl
ophth soln 0.15%
3
TOBRADEX ST - tobramycindexamethasone ophth susp
0.3-0.05%
3
3
tobramycin ophth soln 0.3% (Tobrex)
1
RESTASIS - cyclosporine (ophth)
emulsion 0.05%
3
tobramycin-dexamethasone ophth
susp 0.3-0.1% (Tobradex)
1
SIMBRINZA - brinzolamide-brimonidine
tartrate ophth susp 1-0.2%
3
TOBREX - tobramycin sulfate ophth
soln 0.3%
3
SULFACETAMIDE SODIUM sulfacetamide sodium ophth oint 10%
3
TOBREX - tobramycin sulfate ophth oint
0.3%
3
sulfacetamide sodium ophth soln
10% (Bleph-10)
1
2
•
sulfacetamide sodium-prednisolone
ophth soln 10-0.23(0.25)%
1
TRAVATAN Z - travoprost ophth soln
0.004% (benzalkonium free) (bak
free)
3
•
tetracaine hcl ophth soln 0.5%
1
TRAVOPROST - travoprost ophth soln
0.004%
timolol maleate ophth gel forming
soln 0.25% (Timoptic-xe)
1
trifluridine ophth soln 1% (Viroptic)
1
tropicamide ophth soln 0.5%
1
timolol maleate ophth gel forming
soln 0.5% (Timoptic-xe)
1
tropicamide ophth soln 1%
(Mydriacyl)
1
timolol maleate ophth soln 0.25%
(Timoptic)
1
TRUSOPT - dorzolamide hcl ophth soln
2%
3
timolol maleate ophth soln 0.5%
(Timoptic)
1
VEXOL - rimexolone ophth susp 1%
3
TIMOPTIC - timolol maleate ophth soln
0.25%
VIGAMOX - moxifloxacin hcl ophth soln
0.5% (base equiv)
2
3
VIROPTIC - trifluridine ophth soln 1%
3
TIMOPTIC - timolol maleate ophth soln
0.5%
3
VOLTAREN - diclofenac sodium ophth
soln 0.1%
3
TIMOPTIC OCUDOSE - timolol maleate
preservative free ophth soln 0.25%
3
XALATAN - latanoprost ophth soln
0.005%
3
•
157
ZIOPTAN - tafluprost ophth soln
0.0015%
3
ZIRGAN - ganciclovir ophth gel 0.15%
3
ZYLET - loteprednol etabonatetobramycin ophth susp 0.5-0.3%
ZYMAXID - gatifloxacin ophth soln 0.5%
•
CORTISPORIN - neomycin-polymyxinhc otic soln 1%
3
3
3
CORTISPORIN-TC - neomycin-colistinhc-thonzonium otic susp 3.3-3-10-0.5
mg/ml
3
CRESYLATE - cresyl acetate otic soln
25%
3
1
DERMOTIC - fluocinolone acetonide
(otic) oil 0.01%
3
antipyrine-benzocaine-polycosanol
otic sol 5.4-1.4-0.0097% (Treagan
otic)
1
acetic acid otic soln 2%
1
fluocinolone acetonide (otic) oil
0.01% (Dermotic)
3
hydrocortisone w/ acetic acid otic
soln 1-2% (Vosol hc)
1
ACETIC ACID/ALUMINUM ACET acetic acid 2% in aluminum acetate
otic soln
3
antipyrine-benzocaine otic soln
54-14 mg/ml (5.4-1.4%)
1
MYOXIN - benzocaine-chloroxylenol-hc
otic soln 15-1-10 mg/ml
1
antipyrine-benzocaine otic soln
55-14 mg/ml (5.5-1.4%) (Auralgan)
1
neomycin-polymyxin-hc otic soln 1%
(Cortisporin)
1
ANTIPYRINE/BENZOCAINE antipyrine-benzocaine otic soln 55-14
mg/ml (5.5-1.4%)
1
neomycin-polymyxin-hc otic susp
3.5 mg/ml-10000 unit/ml-1%
ofloxacin otic soln 0.3%
1
3
AURALGAN - antipyrine-benzocaine
otic soln 55-14 mg/ml (5.5-1.4%)
3
OTICIN HC NR - pramoxine-hcchloroxylenol otic soln 10-10-1 mg/ml
3
CETRAXAL - ciprofloxacin hcl otic soln
3
OTOZIN - antipyrine-benzocaineglycerin-zinc ace otic liqd 5.4-1-2-1%
3
CIPRO HC - ciprofloxacinhydrocortisone otic susp 0.2-1%
3
PINNACAINE OTIC - benzocaine otic
soln 20%
3
CIPRODEX - ciprofloxacindexamethasone otic susp 0.3-0.1%
2
PRAMOTIC - pramoxine-chloroxylenol
otic liquid 1-0.1%
1
CIPROFLOXACIN - ciprofloxacin hcl
otic soln 0.2% (base equivalent)
3
pramoxine-chloroxylenol otic liquid
1-0.1% (Pramotic)
1
COLY-MYCIN S - neomycin-colistin-hcthonzonium otic susp 3.3-3-10-0.5
mg/ml
3
pramoxine-hc-chloroxylenol
aqueous otic soln 10-10-1 mg/ml
(Cortane-b aqueous)
1
CORTANE-B AQUEOUS - pramoxinehc-chloroxylenol aqueous otic soln
10-10-1 mg/ml
3
pramoxine-hc-chloroxylenol otic
soln 10-10-1 mg/ml (Cortane-b-otic)
3
CORTANE-B-OTIC - pramoxine-hcchloroxylenol otic soln 10-10-1 mg/ml
3
TREAGAN OTIC - antipyrinebenzocaine-polycosanol otic sol
5.4-1.4-0.0097%
TRIOXIN - benzocaine-chloroxylenol-hc
otic soln 15-1-10 mg/ml
3
OTIC AGENTS
158
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
VOSOL HC - hydrocortisone w/ acetic
acid otic soln 1-2%
3
MOUTH/THROAT/DENTAL AGENTS
GELCLAIR - povidone-sodium
hyaluronate-glycyrrhetinic acid gel
3
GELX - oral wound care products - gel
3
lidocaine hcl laryngotracheal soln
4% (Lta 360 kit)
1
lidocaine hcl viscous soln 2%
1
LISTERINE ESSENTIAL CARE - sod
monofluorophosph-eucal-men-methyl
sal-thymol gel 0.76%
3
LISTERINE ESSENTIAL CARE - sod
monofluorophos-eucal-men-methyl
sal-thymol paste 0.76%
3
mouthwashes - liquid
1
ACT TOTAL CARE DRY MOUTH sodium fluoride rinse 0.02%
3
APHTHASOL - amlexanox oral paste
5%
3
AQUORAL - artificial saliva - aero soln
3
benzocaine dental soln 20%
1
CAPHOSOL - artificial saliva - solution
3
cevimeline hcl cap 30 mg (Evoxac)
1
chlorhexidine gluconate soln 0.12%
(Peridex)
LISTERINE RESTORING - sodium
fluoride rinse 0.0221% (0.01% f)
3
1
3
clotrimazole troche 10 mg
1
LISTERINE SMART RINSE - sodium
COLGATE DRY MOUTH RELIEF sodium fluoride mouthwash 2.1
mg/10ml
3
LISTERINE SMART RINSE ANT sodium fluoride rinse 0.02%
3
LISTERINE TOOTH DEFENSE sodium fluoride rinse 0.0221%
(0.01% f)
3
3
DEBACTEROL - sulfuric acid-sulfonated 3
phenolics soln 30-50%
3
EVOXAC - cevimeline hcl cap 30 mg
FIRST-BXN MOUTHWASH diphenhydramine-lidocaine-nystatin
susp
3
LISTERINE TOTAL CARE - sodium
3
FIRST-DUKES MOUTHWASH diphenhydramine-hydrocortisonenystatin susp
3
LISTERINE TOTAL CARE PLUS sodium fluoride rinse 0.0221%
(0.01% f)
LISTERINE TOTAL CARE ZERO sodium fluoride rinse 0.02%
3
FIRST-MARYS MOUTHWASH diphenhydramine-hydrocortisonenystatin-tetracycline susp
3
LISTERINE WHITENING/RESTO sodium fluoride rinse 0.0221%
(0.01% f)
3
FIRST-MOUTHWASH BLM diphenhyd-lidocaine-al hydroxide-mg
hydroxide-simeth susp
3
LTA 360 KIT - lidocaine hcl
laryngotracheal soln 4%
3
FLUORIDEX DAILY DEFENSE S sodium fluoride-potassium nitrate gel
1.1-5%
3
GEL-KAM - stannous fluoride gel 0.4%
3
GEL-KAM ORAL CARE RINSE stannous fluoride conc 0.63%
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
MUCOTROL - oral wound care products 3
- wafer
3
NAFRINSE DAILY/ACIDULATED sodium fluoride-phosphoric acid for
soln 1 mg/5ml (f equiv)
3
NAFRINSE DAILY/NEUTRAL - sodium
fluoride for soln rinse 0.05%
159
NAFRINSE WEEKLY - sodium fluoride
for soln rinse 0.2%
3
PROTHELIAL - sucralfate-malate paste
10%
3
NEUTRASAL - artificial saliva - packet
3
3
NUMOISYN - artificial saliva - solution
3
REACH KIDS - sodium fluoride paste
0.15%
NUMOISYN - artificial saliva - lozenge
3
3
nystatin susp 100000 unit/ml
1
REMBRANDT CANKER SORE sodium fluoride paste 0.243%
3
ORAFATE - sucralfate-malate paste
10%
3
REMBRANDT DEEPLY WHITE+PE sodium monofluorophosphate paste
0.884%
3
OMNI GEL - stannous fluoride gel 0.4%
ORAMAGICRX - oral wound care
products - for susp rinse
REMBRANDT INTENSE STAIN sodium fluoride paste 0.243%
3
3
ORAVIG - miconazole buccal tab 50 mg
(mouth-throat)
REMBRANDT WHITENING - sodium
fluoride rinse 0.02%
3
3
SALAGEN - pilocarpine hcl tab 5 mg
3
SALAGEN - pilocarpine hcl tab 7.5 mg
3
SALICEPT - oral wound care products for susp rinse
3
sodium fluoride cream 1.1%
(Prevident 5000 plus)
1
sodium fluoride gel 1.1% (0.5% f)
(Prevident fluoride)
1
PERIDEX - chlorhexidine gluconate soln 3
0.12%
3
PHOS FLUR - sodium fluoride rinse
0.044%
3
PHOS-FLUR ORTHO DEFENSE sodium fluoride rinse 0.044%
1
pilocarpine hcl tab 5 mg (Salagen)
pilocarpine hcl tab 7.5 mg (Salagen)
1
PREVIDENT - sodium fluoride rinse
0.2%
sodium fluoride paste 1.1%
(Prevident 5000 boost)
1
3
1
PREVIDENT FLUORIDE - sodium
fluoride gel 1.1% (0.5% f)
3
sodium fluoride rinse 0.0221%
(0.01% f)
1
PREVIDENT 5000 BOOSTER - sodium
fluoride paste 1.1%
3
(Prevident)
1
PREVIDENT 5000 BOOSTER PL sodium fluoride paste 1.1%
3
sodium fluoride-potassium nitrate
paste 1.1-5% (Prevident 5000 sensi)
1
PREVIDENT 5000 DRY MOUTH sodium fluoride gel 1.1% (0.5% f)
3
stannous fluoride conc 0.63% (Gelkam oral care ri)
1
PREVIDENT 5000 ENAMEL PRO sodium fluoride-potassium nitrate
paste 1.1-5%
3
stannous fluoride gel 0.4%
1
3
PREVIDENT 5000 PLUS - sodium
fluoride cream 1.1%
3
THERA-FLUR-N - sodium fluoride gel
1.1% (0.5% f)
triamcinolone acetonide dental paste
0.1%
1
PREVIDENT 5000 SENSITIVE - sodium 3
fluoride-potassium nitrate paste
1.1-5%
160
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
ANORECTAL AGENTS
1
hc-pramoxine emol cream 2.5-1% &
pramoxine wipe 1% kit (Analpram e)
ANALPRAM ADVANCED - hcpramoxine cr & diet manage prod tab
& cleans wipe kit
3
hydrocortisone rectal cream 2.5%
(Anusol-hc)
1
ANALPRAM E - hc-pramoxine emol
cream 2.5-1% & pramoxine wipe 1%
kit
LIDOCAINE HCL-HYDROCORTIS lidocaine-hydrocortisone acetate
rectal gel 2.8-0.55%
3
3
1
ANALPRAM-HC - hydrocortisone
acetate w/ pramoxine rectal cream
1-1%
3
lidocaine-hydrocortisone acetate
rectal cream kit 2-2%
rectal cream kit 3-0.5%
1
acetate w/ pramoxine rectal cream
2.5-1%
3
rectal cream kit 3-1%
1
3
rectal cream 3-0.5%
1
acetate w/ pramoxine rectal lotn
2.5-1%
1
ANALPRAM-HC SINGLES hydrocortisone acetate w/ pramoxine
rectal cream 1-1%
3
rectal gel kit 3-2.5%
PROCORT - hydrocortisone acetate w/
pramoxine rectal cream 1.85-1.15%
3
ANALPRAM-HC SINGLES hydrocortisone acetate w/ pramoxine
rectal cream 2.5-1%
3
PROCTOCORT - hydrocortisone rectal
cream 1%
3
3
ANUSOL-HC - hydrocortisone rectal
cream 2.5%
3
PROCTOCORT - hydrocortisone
acetate suppos 30 mg
3
ANUSOL-HC - hydrocortisone acetate
suppos 25 mg
3
PROCTOFOAM HC - hydrocortisone
acetate w/ pramoxine rectal foam
1-1%
CORTENEMA - hydrocortisone enema
100 mg/60ml
3
RECTIV - nitroglycerin oint 0.4%
3
3
CORTIFOAM - hydrocortisone acetate
rectal foam 90 mg/dose
2
Z-PRAM - hydrocortisone acetate w/
pramoxine rectal cream kit 2.35-1%
3
hydrocortisone acetate suppos
25 mg (Anusol-hc)
1
ZYPRAM - hydrocortisone acetate w/
pramoxine rectal cream 2.35-1%
hydrocortisone acetate suppos
30 mg (Proctocort)
1
nystatin topical powder
1
hydrocortisone acetate w/ pramoxine
rectal cream 1-1% (Analpram-hc)
salicylic acid cream 6% & cleanser
liqd kit (Salex cream)
1
1
hydrocortisone acetate w/ pramoxine
rectal cream 2.5-1% (Analpram-hc)
salicylic acid lotion 6% & cleanser
liqd kit (Salex lotion)
1
1
1
sulfacetamide sod-sulfur wash
9-4.5% & skin cleanser kit
(Sumadan kit)
1
hydrocortisone enema 100 mg/60ml
(Cortenema)
hydrocortisone rectal cream 1%
(Proctocort)
1
sulfacetamide sodium-sulfur w/
sunscreens cream 10-5%
1
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
DERMATOLOGICALS
161
3
ABSORICA - isotretinoin cap 20 mg
3
3
3
ALUMINUM ACETATE - aluminum
acetate soln
3
aluminum chloride soln 20% (Drysol)
1
ACANYA - clindamycin phosphatebenzoyl peroxide gel 1.2-2.5%
3
ALUVEA - urea cream 39%
3
AMCINONIDE - amcinonide lotion 0.1%
3
acitretin cap 10 mg (Soriatane)
1
AMCINONIDE - amcinonide oint 0.1%
3
acitretin cap 17.5 mg (Soriatane)
1
amcinonide cream 0.1%
1
acitretin cap 25 mg (Soriatane)
1
ANACAINE - benzocaine oint 10%
3
ACLOVATE - alclometasone
dipropionate cream 0.05%
3
APEXICON E - diflorasone diacetate
emollient base cream 0.05%
3
ACTIVE-KETOPROFEN KIT ketoprofen cream 5% (compound kit)
3
3
ACTIVE-TRAMADOL KIT - tramadol hcl
cream 8% (compound kit)
3
ARZOL SILVER NITRATE APP - silver
nitrate-potassium nitrate applicator
75-25%
ATOPICLAIR - emollient - cream
3
acyclovir oint 5% (Zovirax)
1
ATRALIN - tretinoin gel 0.05%
3
ACZONE - dapsone gel 5%
3
3
adapalene cream 0.1% (Differin)
1
AURSTAT - emollient cream & wound
dressing gel kit
adapalene gel 0.1% (Differin)
1
3
adapalene gel 0.3% (Differin)
1
AVAR - sulfacetamide sodium w/ sulfur
cleansing pad 9.5-5%
3
AVAR LS - sulfacetamide sodium w/
sulfur cleansing pad 10-2%
3
AIF #2 DRUG PREPARATION flurbiprofen-gabapent-cycloben-lidodexameth cr (cmp kit)
3
AKNE-MYCIN - erythromycin oint 2%
2
AVAR LS CLEANSER - sulfacetamide
sodium w/ sulfur cleanser 10-2%
3
AVAR-E LS - sulfacetamide sodium w/
sulfur cream 10-2%
3
ALA QUIN - clioquinol-hc cream 3-0.5%
ALA SCALP - hydrocortisone lotion 2%
3
AZELEX - azelaic acid cream 20%
3
alclometasone dipropionate cream
0.05% (Aclovate)
1
BACTROBAN - mupirocin oint 2%
3
1
BACTROBAN - mupirocin calcium
cream 2%
3
alclometasone dipropionate oint
0.05%
3
BENSAL HP - salicylic acid & benzoic
acid oint 3-6%
3
ALCORTIN A - iodoquinolhydrocortisone-aloe polysaccharide
gel 1-2-1%
3
ALDARA - imiquimod cream 5%
3
BENZAC AC WASH - benzoyl peroxide
liq 5%
3
BENZAC W WASH - benzoyl peroxide
liq 5%
3
ALEVEER - capsaicin-menthol topical
patch 0.0375-5%
3
BENZACLIN - clindamycin phosphatebenzoyl peroxide gel 1-5%
3
ALOQUIN - iodoquinol-aloe
polysaccharides gel 1.25-1%
162
•
•
•
Dispensing Limits
ALTABAX - retapamulin oint 1%
Step Therapy
3
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
•
3
BENZAMYCIN - benzoyl peroxideerythromycin gel 5-3%
3
BENZAMYCINPAK - benzoyl peroxideerythromycin gel pack 5-3%
3
BENZEFOAM - benzoyl peroxide foam
5.3%
3
BENZEFOAMULTRA - benzoyl peroxide 3
foam 9.8%
3
BENZIQ - benzoyl peroxide gel 5.25 %
BENZIQ LS - benzoyl peroxide gel
2.75%
3
BENZOIN COMPOUND TINCTURE benzoin compound tincture
3
BENZOIN TINCTURE - benzoin tincture
3
benzoyl peroxide cleanser 4.25%
1
benzoyl peroxide cloth 3%
1
1
1
benzoyl peroxide creamy wash 4% &
cleanser lotion kit
1
benzoyl peroxide creamy wash 8% &
cleanser lotion kit
1
benzoyl peroxide creamy wash 8%
&benzoyl peroxide bar 5% kit (Bpo
creamy wash comp)
1
benzoyl peroxide foam 5.3%
(Benzefoam)
1
benzoyl peroxide foam 9.8%
(Benzefoamultra)
benzoyl peroxide pad 6%
1
benzoyl peroxide-erythromycin gel
5-3% (Benzamycin)
1
betamethasone dipropionate
augmented cream 0.05% (Diprolene
af)
1
augmented gel 0.05%
1
Dispensing Limits
1
Step Therapy
benzoyl peroxide pad 3%
Prior Authorization
Dispensing Limits
Step Therapy
Drug Name
Drug Tier
BENZACLIN WITH PUMP - clindamycin
phosphate-benzoyl peroxide gel 1-5%
Prior Authorization
Drug Name
Drug Tier
2014
1
augmented lotion 0.05% (Diprolene)
1
augmented oint 0.05% (Diprolene)
1
betamethasone dipropionate cream
0.05%
1
betamethasone dipropionate lotion
0.05%
1
betamethasone dipropionate oint
0.05%
1
betamethasone valerate aerosol
foam 0.12% (Luxiq)
1
betamethasone valerate cream 0.1%
betamethasone valerate lotion 0.1%
1
betamethasone valerate oint 0.1%
1
BORIC ACID - boric acid granules
3
BPO - benzoyl peroxide gel 4%
3
BPO - benzoyl peroxide gel 8%
3
3
1
BPO CREAMY WASH COMPLETE benzoyl peroxide creamy wash 8%
&benzoyl peroxide bar 5% kit
benzoyl peroxide gel 10%
BPO 3% FOAMING CLOTHS - benzoyl
peroxide cloth 3%
3
1
benzoyl peroxide gel 5%
1
3
benzoyl peroxide liq 2.5%
1
peroxide cloth 6%
benzoyl peroxide liq 5.25%
1
3
benzoyl peroxide liq 7%
1
peroxide cloth 9%
1
butamben-tetracaine-benzocaine
aerosol spray 2-2-14%
1
benzoyl peroxide lotion 6%
benzoyl peroxide lotion 9%
1
163
calcipotriene cream 0.005%
(Dovonex)
1
calcipotriene oint 0.005%
1
calcipotriene soln 0.005% (50 mcg/
ml)
1
calcipotriene-betamethasone
dipropionate oint 0.005-0.064%
(Taclonex)
1
CALCITRIOL - calcitriol oint 3 mcg/gm
3
CAPEX - fluocinolone acetonide
shampoo 0.01%
3
CARAC - fluorouracil cream 0.5%
3
CARMOL-HC - urea-hc acetate cream
1%
3
CEM-UREA - urea soln 45%
3
CENTANY - mupirocin oint 2%
3
CENTANY AT - mupirocin oint kit 2%
3
CETACAINE - butamben-tetracainebenzocaine aerosol spray 2-2-14%
3
CICLODAN CREAM KIT - ciclopirox
olamine cream 0.77% (base equiv) &
cleanser kit
3
CICLODAN SOLUTION KIT - ciclopirox
solution kit 8%
3
ciclopirox gel 0.77% (Loprox)
1
ciclopirox olamine cream 0.77%
(base equiv)
1
ciclopirox olamine susp 0.77% (base
equiv)
1
ciclopirox shampoo 1% (Loprox
shampoo)
1
ciclopirox solution kit 8% (Ciclodan
solution ki)
1
ciclopirox solution 8% (Penlac nail
lacquer)
1
CICLOPIROX TOPICAL SOLUTI ciclopirox solution 8% & vitamin e 5%
topical kit
3
CLARAVIS - isotretinoin cap 30 mg
3
164
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
CLARIFOAM EF - sulfacetamide sodium 3
w/ sulfur foam 10-5%
3
CLEOCIN-T - clindamycin phosphate
soln 1%
3
gel 1%
3
lotion 1%
3
swab 1%
3
CLINDACIN ETZ - clindamycin
phosphate swab 1% & cleanser kit
3
CLINDACIN PAC - clindamycin
phosphate swab 1% & cleanser kit
3
CLINDAGEL - clindamycin phosphate
gel 1%
1
clindamycin phosph-benzoyl
peroxide (refrig) gel 1.2 (1)-5%
(Duac)
1
clindamycin phosphate foam 1%
(Evoclin)
1
clindamycin phosphate gel 1%
(Cleocin-t)
1
clindamycin phosphate lotion 1%
(Cleocin-t)
1
clindamycin phosphate soln 1%
(Cleocin-t)
1
clindamycin phosphate swab 1%
(Cleocin-t)
1
clindamycin phosphate-benzoyl
peroxide gel 1-5% (Benzaclin)
1
clobetasol propionate cream 0.05%
(Temovate)
clobetasol propionate emollient base 1
cream 0.05% (Temovate e)
1
clobetasol propionate emulsion
foam 0.05% (Olux-e)
1
clobetasol propionate foam 0.05%
(Olux)
clobetasol propionate gel 0.05%
(Temovate)
1
CORDRAN - flurandrenolide cream
0.05%
3
clobetasol propionate lotion 0.05%
(Clobex)
1
CORDRAN - flurandrenolide lotion
0.05%
3
clobetasol propionate oint 0.05%
(Temovate)
1
CORDRAN - flurandrenolide oint 0.05%
3
1
CORDRAN TAPE - flurandrenolide tape
4 mcg/sqcm
3
clobetasol propionate shampoo
0.05% (Clobex)
1
CORTANE-B - hydrocortisonepramoxine-chloroxylenol lot
10-10-1mg/ml
3
clobetasol propionate soln 0.05%
(Temovate)
CLOBEX - clobetasol propionate spray
0.05%
3
CORTISPORIN - neomycin-polymyxinhc cream 0.5%
2
CLOBEX - clobetasol propionate lotion
0.05%
3
CORTISPORIN - bacitracin-polymyxinneomycin hc oint 1%
2
CLOBEX - clobetasol propionate
shampoo 0.05%
3
CUTIVATE - fluticasone propionate
cream 0.05%
3
CLOCORTOLONE PIVALATE clocortolone pivalate cream 0.1%
3
CUTIVATE - fluticasone propionate
lotion 0.05%
3
CLOCORTOLONE PIVALATE PUM clocortolone pivalate cream 0.1%
3
CUTIVATE - fluticasone propionate oint
0.005%
3
CLODAN KIT - clobetasol propionate
shampoo 0.05% & cleanser kit
3
DELOS - benzoyl peroxide lotion 3.5%
3
DENAVIR - penciclovir cream 1%
3
CLODERM - clocortolone pivalate
cream 0.1%
3
DERMA-SMOOTHE/FS BODY fluocinolone acetonide oil 0.01%
3
CLODERM PUMP - clocortolone
pivalate cream 0.1%
3
DERMA-SMOOTHE/FS BODY OIL fluocinolone acetonide oil 0.01%
3
clotrimazole cream 1%
1
1
DERMA-SMOOTHE/FS SCALP fluocinolone acetonide oil 0.01%
3
clotrimazole soln 1%
clotrimazole w/ betamethasone
cream 1-0.05% (Lotrisone)
1
DERMA-SMOOTHE/FS SCALP OI fluocinolone acetonide oil 0.01%
3
clotrimazole w/ betamethasone
lotion 1-0.05%
1
DERMASORB AF - clioquinol-hc cream
3-0.5% & emollient liqd kit
3
CNL8 NAIL KIT - ciclopirox soln 8% &
lacquer removal pads kit
3
DERMASORB HC - hydrocortisone lot
2% & cleanser liq kit
3
COAL TAR - coal tar soln 20%
3
COCAINE HCL - cocaine hcl soln 4%
3
COCAINE HCL - cocaine hcl soln 10%
3
CONDYLOX - podofilox soln 0.5%
3
CONDYLOX - podofilox gel 0.5%
3
DERMASORB TA - triamcinolone cream 3
0.1% & emollient cream kit
DERMASORB XM - urea cream 39% & 3
emollient cream kit
3
DERMATOP - prednicarbate cream
0.1%
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
165
desonide lotion 0.05% (Desowen)
1
desonide oint 0.05% (Desowen)
1
DESOWEN - desonide cream 0.05%
3
DESOWEN - desonide lotion 0.05%
3
DESOWEN - desonide oint 0.05%
3
DESOWEN CREAM/CETAPHIL
LO - desonide cream 0.05% w/
moisturizing lotion kit
3
DESOWEN LOTION/CETAPHIL C desonide lotion 0.05% w/ moisturizing
cream kit
3
DESOWEN OINTMENT/CETAPHIL desonide ointment 0.05% w/
moisturizing lotion kit
3
DESOXIMETASONE - desoximetasone
cream 0.05%
DIPROLENE AF - betamethasone
dipropionate augmented cream
0.05%
3
DOVONEX - calcipotriene cream
0.005%
3
DOVONEX SCALP - calcipotriene soln
0.005% (50 mcg/ml)
3
DRITHO-CREME HP - anthralin cream
1%
3
DRITHO-SCALP - anthralin cream 0.5%
2
DRYSOL - aluminum chloride soln 20%
3
DUAC - clindamycin phosph-benzoyl
peroxide (refrig) gel 1.2 (1)-5%
3
econazole nitrate cream 1%
1
ECOZA - econazole nitrate foam 1%
3
3
EFUDEX - fluorouracil cream 5%
3
3
DESOXIMETASONE - desoximetasone
oint 0.05%
3
ELENZAPATCH - lidocaine-menthol
patch 4-1%
ELETONE - emollient - cream
3
desoximetasone cream 0.25%
(Topicort)
1
ELETONE TWINPACK - emollient cream
3
desoximetasone gel 0.05% (Topicort)
1
ELIDEL - pimecrolimus cream 1%
2
ELIMITE - permethrin cream 5%
3
ELOCON - mometasone furoate
solution 0.1% (lotion)
3
ELOCON - mometasone furoate cream
0.1%
3
ELOCON - mometasone furoate oint
0.1%
3
EMLA - lidocaine-prilocaine cream
2.5-2.5%
3
desoximetasone oint 0.25% (Topicort) 1
1
diclofenac sodium (actinic
keratoses) gel 3% (Solaraze)
1
diclofenac sodium soln 1.5%
(Pennsaid)
3
DIFFERIN - adapalene cream 0.1%
•
•
•
•
DIFFERIN - adapalene gel 0.1%
3
DIFFERIN - adapalene gel 0.3%
3
DIFFERIN - adapalene lotion 0.1%
2
3
EMULSION SB - dermatological
products misc - emulsion
3
DIFLORASONE DIACETATE diflorasone diacetate cream 0.05%
1
ENOVARX-BACLOFEN - baclofen
3
diflorasone diacetate oint 0.05%
DIPROLENE - betamethasone
dipropionate augmented lotion 0.05%
3
ENOVARX-IBUPROFEN - ibuprofen
cream 10% (compounding kit)
3
166
Dispensing Limits
1
3
Step Therapy
desonide cream 0.05% (Desowen)
DIPROLENE - betamethasone
dipropionate augmented oint 0.05%
Prior Authorization
3
Drug Name
Drug Tier
DESONATE - desonide gel 0.05%
Dispensing Limits
3
Step Therapy
DERMATOP - prednicarbate oint 0.1%
Prior Authorization
Drug Name
Drug Tier
2014
ENOVARX-LIDOCAINE HCL - lidocaine
hcl cream 5% (compound kit)
3
EXELDERM - sulconazole nitrate
solution 1%
3
ENOVARX-LIDOCAINE HCL - lidocaine
hcl cream 10% (compound kit)
3
EXELDERM - sulconazole nitrate cream
1%
3
ENOVARX-NAPROXEN - naproxen
3
EXTINA - ketoconazole foam 2%
3
FABIOR - tazarotene (acne) foam 0.1%
3
ENOVARX-TRAMADOL - tramadol hcl
3
EPICERAM - dermatological products
misc - emulsion
3
EPIDUO - adapalene-benzoyl peroxide
gel 0.1-2.5%
3
EPIFOAM - pramoxine-hc aerosol foam
1-1%
3
3
FIRST-HYDROCORTISONE hydrocortisone gel 10%
3
3
FLECTOR - diclofenac epolamine patch
1.3%
3
ERTACZO - sertaconazole nitrate
cream 2%
3
fluocinolone acetonide cream 0.01%
1
ERYGEL - erythromycin gel 2%
1
fluocinolone acetonide cream
0.025% (Synalar)
1
erythromycin gel 2% (Erygel)
erythromycin pads 2%
1
erythromycin soln 2%
fluocinolone acetonide oil 0.01%
(Derma-smoothe/fs bod)
1
1
ETHYL CHLORIDE - ethyl chloride
aerosol spray
3
fluocinolone acetonide oint 0.025%
(Synalar)
1
ETHYL CHLORIDE/FINE PINPO - ethyl
chloride aerosol spray
3
fluocinolone acetonide soln 0.01%
(Synalar)
1
fluocinonide cream 0.05%
1
fluocinonide cream 0.1% (Vanos)
1
fluocinonide emulsified base cream
0.05%
1
fluocinonide gel 0.05%
1
fluocinonide oint 0.05%
1
fluocinonide soln 0.05%
1
FLUOROPLEX - fluorouracil cream 1%
3
fluorouracil cream 5% (Efudex)
1
fluorouracil soln 2%
1
fluorouracil soln 5%
1
fluticasone propionate cream 0.05%
(Cutivate)
1
EURAX - crotamiton lotion 10%
3
EVOCLIN - clindamycin phosphate foam 3
1%
Dispensing Limits
Step Therapy
•
FBL KIT - flurbiprofen-baclofen-lidocaine 3
cream 15-4-5% (cmpd kit)
2
FINACEA - azelaic acid gel 15%
FINACEA PLUS - azelaic acid gel 15%
w/cleanser & moisturizing lotion kit
ETHYL CHLORIDE/FINE STREA - ethyl 3
3
ETHYL CHLORIDE/MEDIUM JET ethyl chloride aerosol spray
3
ETHYL CHLORIDE/MEDIUM STR ethyl chloride aerosol spray
3
ETHYL CHLORIDE/MIST - ethyl
3
EUCALYPTUS OIL - eucalyptus
(topical) oil
3
EURAX - crotamiton cream 10%
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
•
•
167
fluticasone propionate lotion 0.05%
(Cutivate)
1
HPR PLUS/MB HYDROGEL - emollient
foam & wound dressing gel kit
3
fluticasone propionate oint 0.005%
(Cutivate)
1
hyaluronate sodium (emollient) gel
0.2% (Hylira)
1
GEBAUERS PAIN EASE pentafluoropropane-tetrafluoroethane
aero spray
3
HYDRO 35 - urea in lactic acid vehicle
foam 35%
3
HYDRO 40 FOAM - urea foam 40%
3
GEBAUERS SPRAY AND STRETC pentafluoropropane-tetrafluoroethane
aero spray
3
hydrocortisone acetate-aloe vera gel
2% (Nuzon)
1
3
hydrocortisone butyrate cream 0.1%
(Locoid)
1
GENADUR - dermatological products
misc - liquid
3
hydrocortisone butyrate hydrophilic
lipo base cream 0.1% (Locoid
lipocream)
1
GENTAMICIN SULFATE - gentamicin
sulfate cream 0.1%
GENTAMICIN SULFATE - gentamicin
sulfate oint 0.1%
3
hydrocortisone butyrate oint 0.1%
(Locoid)
1
gentamicin sulfate cream 0.1%
1
1
hydrocortisone butyrate soln 0.1%
(Locoid)
1
gentamicin sulfate oint 0.1%
GORDOFILM - salicylic & lactic acids
soln 16.7-16.7%
3
hydrocortisone cream 1%
1
hydrocortisone cream 2.5%
1
GORDONS UREA - urea ointment 40%
3
hydrocortisone lotion 2.5%
1
GRANULEX - trypsin w/ castor oil &
peruvian balsam spray
3
hydrocortisone lotion 2% (Ala scalp)
1
1
hydrocortisone oint 1%
1
halobetasol prop oint 0.05% &
ammonium lactate lot 12% kit
(Ultravate pac)
hydrocortisone oint 2.5%
1
hydrocortisone valerate cream 0.2%
1
halobetasol propionate cream 0.05%
(Ultravate)
1
hydrocortisone valerate oint 0.2%
(Westcort)
1
halobetasol propionate oint 0.05%
(Ultravate)
1
HYLATOPIC - emollient - aerosol foam
3
HYLATOPIC PLUS - emollient - cream
3
HALOG - halcinonide cream 0.1%
3
HALOG - halcinonide oint 0.1%
HYLATOPIC PLUS - emollient - aerosol
foam
3
3
HALONATE - halobetasol prop oint
0.05% & ammonium lactate foam
12% kit
3
HYLATOPIC PLUS/AURSTAT emollient foam & wound dressing gel
kit
3
HALOTIN - haloprogin cream 1%
3
3
HPR - emollient - aerosol foam
3
HYLIRA - hyaluronate sodium
(emollient) gel 0.2%
HPR PLUS - emollient - cream
3
3
HPR PLUS - emollient - aerosol foam
3
HYLIRA - hyaluronate sodium
(emollient) lotion 0.1%
imiquimod cream 5% (Aldara)
1
168
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
INOVA - benzoyl peroxide pad 4% &
vitamin e topical 5% kit
3
lactic acid (ammonium lactate) lotion
12% (Lac-hydrin)
1
INOVA - benzoyl peroxide pad 8% &
vitamin e topical 5% kit
3
lactic acid w/ vitamin e cream
10%-3500 unit/30gm
1
INOVA 4/1 ACNE CONTROL TH benzoyl perox pad 4% & salicylic ac
pad 1% & vit e 5% kit
3
LAMISIL SPRAY - terbinafine hcl soln
1%
3
INOVA 8/2 ACNE CONTROL TH benzoyl perox pad 8% & salicylic ac
pad 2% & vit e 5% kit
3
iodoquinol-hc cream 1%
1
isotretinoin cap 10 mg
1
1
1
JUBLIA - efinaconazole soln 10%
3
KENALOG - triamcinolone acetonide
aerosol soln
3
KERAFOAM - urea foam 30%
3
KERAFOAM 42 - urea foam 42%
3
KERALAC - urea cream 47%
3
KERALYT - salicylic acid gel 6%
3
KERALYT SCALP - salicylic acid
shampoo 6% & salicylic acid gel 6%
kit
3
ketoconazole cream 2%
1
ketoconazole foam 2% (Extina)
1
ketoconazole shampoo 2% (Nizoral)
1
KETODAN KIT - ketoconazole foam 2%
& cleanser kit
3
KLARON - sulfacetamide sodium lotion
10% (acne)
3
LAC-HYDRIN - lactic acid (ammonium
lactate) cream 12%
3
LAC-HYDRIN - lactic acid (ammonium
lactate) lotion 12%
3
lactic acid (ammonium lactate)
cream 12% (Lac-hydrin)
lactic acid (ammonium lactate) lotion
10%
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
LATRIX XM - urea in zinc undecylenate- 3
lactic acid vehicle emulsion 45%
3
LAVARE WOUND WASH - wound
cleansers - gel
3
LAVOCLEN-4 CREAMY WASH benzoyl peroxide liq 4%
3
LAVOCLEN-8 CREAMY WASH benzoyl peroxide liq 8%
LEVULAN KERASTICK - aminolevulinic 3
acid hcl for soln 20% (stick applicator)
3
LIDOCAINE HCL - lidocaine hcl lotion
3%
1
lidocaine hcl cream 3%
lidocaine hcl gel 2%
1
lidocaine hcl soln 4% (Xylocaine)
1
lidocaine oint 5%
1
lidocaine patch 5% (Lidoderm)
1
lidocaine-prilocaine cream 2.5-2.5%
(Emla)
1
LIDOCAINE/PRILOCAINE - lidocaineprilocaine kit 2.5-2.5%
3
LIDODERM - lidocaine patch 5%
3
LIDOPROFEN - ketoprofen-ketaminelidocaine cream 5-5-2% (compound
kit)
3
LIDORX - lidocaine hcl gel 3%
3
LIDOVIR - acyclovir-lidocaine hcl oint
4-4% (compounding kit)
3
lindane lotion 1%
1
1
lindane shampoo 1%
1
3
1
LOCOID - hydrocortisone butyrate soln
0.1%
169
3
LOCOID - hydrocortisone butyrate lotion 3
0.1%
3
LOCOID - hydrocortisone butyrate oint
0.1%
LOCOID LIPOCREAM - hydrocortisone 3
butyrate hydrophilic lipo base cream
0.1%
3
LOPROX - ciclopirox gel 0.77%
metronidazole gel 1% (Metrogel)
1
metronidazole lotion 0.75%
(Metrolotion)
1
METVIXIA - methyl aminolevulinate hcl
cream 16.8% (base equiv)
3
MIMYX - emollient - cream
3
mometasone furoate cream 0.1%
(Elocon)
1
3
mometasone furoate oint 0.1%
(Elocon)
1
LOPROX SHAMPOO - ciclopirox
shampoo 1%
3
mometasone furoate solution 0.1%
(lotion) (Elocon)
1
LOTRISONE - clotrimazole w/
betamethasone cream 1-0.05%
LOUTREX - antiseborrheic products
misc - cream
3
LUXIQ - betamethasone valerate
aerosol foam 0.12%
3
LUZU - luliconazole cream 1%
3
LYCELLE - nit remover - gel
3
mafenide acetate packet for topical
soln 5% (50 gm) (Sulfamylon)
1
malathion lotion 0.5% (Ovide)
MOMEXIN - mometasone furoate cream 3
0.1% & ammon lactate foam 12% kit
1
mupirocin calcium cream 2%
(Bactroban)
1
mupirocin oint 2% (Bactroban)
NAFTIN - naftifine hcl cream 1%
3
NAFTIN - naftifine hcl cream 2%
3
NAFTIN - naftifine hcl gel 1%
3
1
NAFTIN - naftifine hcl gel 2%
3
MB HYDROGEL - emollient cream &
wound dressing gel kit
3
NAPRO 15% COMPOUNDING KIT naproxen cream 15%
3
MEDROX-RX - capsaicin-mentholmethyl salicylate oint 0.05-7-20%
3
NAPRODERM COMPOUNDING KIT naproxen cream 15%
3
MENTAX - butenafine hcl cream 1%
2
NATROBA - spinosad susp 0.9%
3
methoxsalen rapid cap 10 mg
(Oxsoralen ultra)
1
NEO-SYNALAR - neomycinfluocinolone cream 0.35-0.025%
3
METHYL SALICYLATE - methyl
salicylate liquid
3
3
METROCREAM - metronidazole cream
0.75%
3
NEO-SYNALAR KIT - neomycinfluocinolone cream 0.35-0.025% &
emollient cr kit
NEOSALUS - emollient - cream
3
METROGEL - metronidazole gel 1%
3
NEOSALUS - emollient - aerosol foam
3
METROLOTION - metronidazole lotion
0.75%
3
NEOSALUS - emollient - lotion
3
NEOSALUS CP - emollient - cream
3
metronidazole cream 0.75%
(Metrocream)
1
NEUAC KIT - clindamycin-benzoyl
perox gel 1.2-5% & moisturizer cr kit
3
170
Dispensing Limits
1
Step Therapy
metronidazole gel 0.75%
Prior Authorization
Dispensing Limits
Drug Name
Drug Tier
LOCOID - hydrocortisone butyrate
cream 0.1%
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
NIVATOPIC PLUS - dermatological
products misc - cream
3
OVIDE - malathion lotion 0.5%
3
NIZORAL - ketoconazole shampoo 2%
OXISTAT - oxiconazole nitrate cream
1%
3
3
NORITATE - metronidazole cream 1%
3
NOVACORT - hydrocortisone acepramoxine-aloe polysacch gel 2-1-1%
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
OXISTAT - oxiconazole nitrate lotion 1% 3
3
OXSORALEN - methoxsalen lotion 1%
NUCORT - hydrocortisone acetate lotion 3
2%
3
NUOX - benzoyl peroxide-sulfur gel
6-3%
NUVAIL - dermatological products misc 3
- solution
3
NUZON - hydrocortisone acetate-aloe
vera gel 2%
1
nystatin cream 100000 unit/gm
OXSORALEN ULTRA - methoxsalen
rapid cap 10 mg
3
PANDEL - hydrocortisone probutate
cream 0.1%
3
PANRETIN - alitretinoin gel 0.1%
3
PEDIADERM AF COMPLETE KIT nystatin cream 100000 unit/gm &
diaper rash cream kit
3
PEDIADERM HC - hydrocortisone lot
2% & emollient cream kit
3
PEDIADERM TA - triamcinolone cream
0.1% & emollient cream kit
3
3
nystatin oint 100000 unit/gm
1
nystatin-triamcinolone cream
100000-0.1 unit/gm-%
1
nystatin-triamcinolone oint
100000-0.1 unit/gm-%
1
PEDIPIROX-4 NAIL - ciclopirox soln 8%
& lacquer removal pads & foot powd
kit
OLUX - clobetasol propionate foam
0.05%
3
PENLAC NAIL LACQUER - ciclopirox
solution 8%
3
OLUX-E - clobetasol propionate
emulsion foam 0.05%
3
PENNSAID - diclofenac sodium soln
1.5%
3
OPTASE - trypsin w/ castor oil &
peruvian balsam gel
3
PENNSAID - diclofenac sodium soln 2% 3
1
permethrin cream 5% (Elimite)
ORACEA - doxycycline (rosacea) cap
3
OVACE PLUS - sulfacetamide sodium
cream 10%
3
lotion 9.8%
3
shampoo 10%
3
OVACE PLUS WASH - sulfacetamide
sodium liquid 10%
3
OVACE PLUS WASH - sulfacetamide
sodium cleansing gel 10%
OVACE WASH - sulfacetamide sodium
liquid 10%
•
PICATO - ingenol mebutate gel 0.015%
2
PICATO - ingenol mebutate gel 0.05%
2
PLEXION - sulfacetamide sodium w/
sulfur cream 9.8-4.8%
3
PLEXION - sulfacetamide sodium w/
sulfur lotion 9.8-4.8%
3
PLEXION CLEANSER - sulfacetamide
sodium w/ sulfur cleanser 9.8-4.8%
3
3
3
PLEXION CLEANSING CLOTHS sulfacetamide sodium w/ sulfur
cleansing cloth 9.8-4.8%
PLIAGLIS - lidocaine-tetracaine cream
7-7%
3
3
•
•
171
PODOCON 25 IN BENZOIN TIN podophyllum resin soln 25%
3
REGENECARE - lidocaine hcl-collagenaloe vera gel 2%
3
podofilox soln 0.5% (Condylox)
1
REGRANEX - becaplermin gel 0.01%
3
PONTOCAINE - tetracaine hcl soln 2%
3
RETIN-A - tretinoin cream 0.025%
3
PR CREAM - dermatological products
misc - kit
3
3
3
PRAMOSONE - pramoxine-hc cream
1-1%
3
RETIN-A - tretinoin gel 0.01%
3
3
RETIN-A - tretinoin gel 0.025%
3
PRAMOSONE - pramoxine-hc cream
1-2.5%
PRAMOSONE - pramoxine-hc lotion
1-1%
3
PRAMOSONE - pramoxine-hc lotion
1-2.5%
3
PRAMOSONE - pramoxine-hc oint 1-1% 3
3
PRAMOSONE - pramoxine-hc oint
1-2.5%
3
PRAMOSONE E - pramoxine-hc
emollient base cream 1-2.5%
1
pramoxine hcl gel 1%
RETIN-A MICRO - tretinoin microsphere 3
gel 0.04%
RETIN-A MICRO - tretinoin microsphere 3
gel 0.1%
3
RETIN-A MICRO PUMP - tretinoin
microsphere gel 0.04%
3
3
3
RIAX - benzoyl peroxide foam 5.5%
RIAX - benzoyl peroxide foam 9.5%
3
ROSADAN KIT - metronidazole gel
0.75% w/ cleanser kit
3
ROSADAN KIT - metronidazole cream
0.75% w/ cleanser kit
3
ROSANIL - sulfacetamide sod-sulfur
emul 10-5% & skin cleanser kit
3
SALEX - salicylic acid shampoo 6%
3
3
SALEX CREAM - salicylic acid cream
6% & cleanser liqd kit
3
2
SALEX LOTION - salicylic acid lotion
6% & cleanser liqd kit
3
PROTOPIC - tacrolimus oint 0.03%
PROTOPIC - tacrolimus oint 0.1%
2
3
SALICYLIC ACID - salicylic acid soln
26%
3
PRUCLAIR - emollient - cream
PRUDOXIN - doxepin hcl cream 5%
3
salicylic acid cream 6%
1
PRUMYX - emollient - cream
3
1
PYROGALLIC ACID - pyrogallolchlorobutanol oint 25-2%
3
salicylic acid film forming liquid
27.5% (Virasal)
salicylic acid foam 6% (Salvax)
1
QUTENZA - capsaicin patch 8% &
cleansing gel kit
3
salicylic acid gel 6% (Keralyt)
1
pramoxine-hc cream 1-2.5%
(Pramosone)
1
prednicarbate cream 0.1%
(Dermatop)
1
prednicarbate oint 0.1% (Dermatop)
1
PRESERA - emollient - aerosol foam
3
PROMISEB - antiseborrheic products
misc - cream
3
PROMISEB COMPLETE antiseborrheic products misc - kit
172
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
•
•
•
•
•
•
•
•
•
•
SALICYLIC ACID IN AMMONIU salicylic acid in ammonium lactate
vehicle foam 6%
3
salicylic acid lotion 6%
1
salicylic acid shampoo 6% (Salex)
1
SALKERA - salicylic acid in ammonium
lactate vehicle foam 6%
SILVER NITRATE - silver nitrate soln
50%
3
SILVER NITRATE - silver nitrate oint
10%
3
1
3
silver nitrate-potassium nitrate
applicator 75-25% (Arzol silver
nitrate)
SALVAX - salicylic acid foam 6%
3
1
SALVAX DUO PLUS - salicylic acid
foam 6% & urea in lactic acid foam
35% kit
3
silver sulfadiazine cream 1%
(Silvadene)
SKLICE - ivermectin lotion 0.5%
3
3
SANARE SCAR THERAPY - scar
treatment products - cream
3
SODIUM SULFACETAMIDE WASH sulfacetamide sodium in bakuchiol
vehicle wash 10%
SANTYL - collagenase oint 250 unit/gm
3
3
SCALACORT DK - hc lot 2% & sal acidsulfur shampoo 2-2% & shampoo kit
3
SODIUM SULFACETAMIDE/SULF sulfacetamide sodium w/ sulfur susp
10-5%
3
SODIUM SULFACETAMIDE/SULF sulfacetamide sodium-sulfur in urea
emulsion 10-5%
3
SE BPO 7-5.5 WASH KIT - benzoyl
peroxide wash 7% & benzoyl
peroxide cream 5.5% kit
3
SODIUM SULFACETAMIDE/SULF sulfacetamide sodium-sulfur in urea
gel 10-5%
3
SEB-PREV - sulfacetamide sodium
lotion 10%
SELENIUM SULFIDE - selenium
sulfide-pyrithione zinc in urea
shampoo 2.25%
3
SODIUM SULFACETAMIDE/UREA sulfacetamide sodium-urea pad 10%
3
1
sodium thiosulfate-salicylic acid
lotion 25-1%
1
selenium sulfide lotion 2.5%
selenium sulfide-pyrithione zinc in
urea shampoo 2.25%
1
SOLARAZE - diclofenac sodium (actinic
keratoses) gel 3%
3
SELRX - selenium sulfide-pyrithione
zinc in urea shampoo 2.3%
3
SORIATANE - acitretin cap 10 mg
3
3
SORIATANE - acitretin cap 17.5 mg
3
SELSUN SHAMPOO - selenium sulfide
lotion 2.5%
SORIATANE - acitretin cap 25 mg
3
SILVADENE - silver sulfadiazine cream
1%
3
SORILUX - calcipotriene foam 0.005%
3
SPINOSAD - spinosad susp 0.9%
3
0.5%
3
SSS 10-4 - sulfacetamide sodium w/
sulfur foam 10-4%
3
10%
3
sulfacetamide sodium cleansing gel
10% (Ovace plus wash)
1
25%
3
sulfacetamide sodium liquid 10%
(Ovace wash)
1
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
173
sulfacetamide sodium lotion 10%
(acne) (Klaron)
1
SUMADAN WASH - sulfacetamide
sodium w/ sulfur wash 9-4.5%
3
sulfacetamide sodium shampoo 10%
(Ovace plus)
1
SUMADAN XLT - sulfacetamide sodsulfur wash 9-4.5% & sunscreen kit
3
sulfacetamide sodium w/ sulfur
cleanser 10-2% (Avar ls cleanser)
1
SUMAXIN - sulfacetamide sodium w/
sulfur cleansing pad 10-4%
3
cleansing cloth 10-5%
1
SUMAXIN CP KIT - sulfacetamide sodsulfur pad 10-4% & skin cleanser kit
3
cleansing pad 10-4% (Sumaxin)
1
cream 10-2% (Avar-e ls)
1
cream 10-5%
1
emulsion 10-1%
1
emulsion 10-5%
1
sulfacetamide sodium w/ sulfur foam
10-5% (Clarifoam ef)
1
lotion 10-5%
1
sulfacetamide sodium w/ sulfur susp
8-4% (Sumaxin ts)
1
sulfacetamide sodium w/ sulfur wash
9-4.5% (Sumadan wash)
1
sulfacetamide sodium w/ sulfur wash
9-4% (Sumaxin wash)
1
sulfacetamide sodium-sulfur in urea
emulsion 10-4%
1
SULFAMYLON - mafenide acetate
packet for topical soln 5% (50 gm)
3
SULFAMYLON - mafenide acetate
cream 85 mg/gm
3
SUMAXIN TS - sulfacetamide sodium w/ 3
sulfur susp 8-4%
3
SUMAXIN WASH - sulfacetamide
sodium w/ sulfur wash 9-4%
SYNALAR - fluocinolone acetonide soln 3
0.01%
3
SYNALAR - fluocinolone acetonide
cream 0.025%
SYNALAR - fluocinolone acetonide oint 3
0.025%
3
SYNALAR CREAM KIT - fluocinolone
cream 0.025%-emollient cream kit
3
SYNALAR OINTMENT KIT fluocinolone oint 0.025%-emollient
cream kit
3
SYNALAR TS - fluocinolone acetonide
soln 0.01% & cleanser kit
3
SYNERA - lidocaine-tetracaine topical
patch 70-70 mg
3
TACLONEX - calcipotrienebetamethasone dipropionate susp
0.005-0.064%
3
TACLONEX - calcipotrienebetamethasone dipropionate oint
0.005-0.064%
4
TARGRETIN - bexarotene gel 1%
SULFOAM - sulfur shampoo 2%
3
TAZORAC - tazarotene cream 0.05%
2
SULFURATED LIME - sulfurated lime
solution
3
TAZORAC - tazarotene cream 0.1%
2
TAZORAC - tazarotene gel 0.05%
2
SUMADAN KIT - sulfacetamide sodsulfur wash 9-4.5% & skin cleanser
kit
3
TAZORAC - tazarotene gel 0.1%
2
TEMOVATE - clobetasol propionate
soln 0.05%
3
174
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
•
•
•
•
TEMOVATE - clobetasol propionate gel
0.05%
3
tretinoin cream 0.025% (Retin-a)
1
1
TEMOVATE - clobetasol propionate oint
0.05%
3
1
3
tretinoin gel 0.01% (Retin-a)
1
TEMOVATE E - clobetasol propionate
emollient base cream 0.05%
tretinoin gel 0.025% (Retin-a)
1
TERSI FOAM - selenium sulfide foam
2.25%
3
tretinoin microsphere gel 0.04%
(Retin-a micro)
1
•
•
•
•
•
•
TETRIX - dermatological products misc
- kit
3
tretinoin microsphere gel 0.1%
(Retin-a micro)
1
•
TEXACORT - hydrocortisone soln 2.5%
3
3
TL TRISEB - antiseborrheic products
misc - cream
3
TRI-CHLOR - trichloroacetic acid liqd
80%
3
TL-CERMIDE - dermatological products
misc - emulsion
3
TRIAMCINOLONE ACETONIDE triamcinolone acetonide oint 0.5%
1
TOPICORT - desoximetasone spray
0.25%
3
triamcinolone acetonide cream
0.025%
triamcinolone acetonide cream 0.1%
1
TOPICORT - desoximetasone cream
0.05%
3
triamcinolone acetonide cream 0.5%
1
3
TOPICORT - desoximetasone cream
0.25%
3
TRIAMCINOLONE ACETONIDE I triamcinolone acetonide oint 0.05%
1
TOPICORT - desoximetasone gel
0.05%
3
triamcinolone acetonide lotion
0.025%
triamcinolone acetonide lotion 0.1%
1
TOPICORT - desoximetasone oint
0.05%
3
triamcinolone acetonide oint 0.025%
1
1
3
triamcinolone acetonide oint 0.1%
TOPICORT - desoximetasone oint
0.25%
3
TRETIN-X - tretinoin cream 0.0375%
3
TROPAZONE - emollient - lotion
3
TRETIN-X - tretinoin cream 0.075%
3
TRETIN-X - tretinoin gel 0.01% w/
cleanser & moisturizer kit
trypsin w/ castor oil & peruvian
balsam oint (Xenaderm)
1
3
•
•
•
TRIANEX - triamcinolone acetonide oint
0.05%
3
•
trypsin w/ castor oil & peruvian
balsam spray (Granulex)
1
TRETIN-X - tretinoin gel 0.025% w/
3
•
TURPENTINE SPIRITS - turpentine
spirit
3
TRETIN-X - tretinoin cream 0.025% w/
•
U-CORT - urea-hc acetate cream 1%
1
3
ULESFIA - benzyl alcohol lotion 5%
3
Dispensing Limits
Prior Authorization
•
Drug Name
Step Therapy
Drug Tier
3
Dispensing Limits
Step Therapy
3
Drug Tier
TEMOVATE - clobetasol propionate
cream 0.05%
Drug Name
Prior Authorization
2014
175
ULTRASAL-ER - salicylic acid filmforming soln 28.5%
3
urea gel 45% (Uramaxin)
1
ULTRAVATE - halobetasol propionate
cream 0.05%
urea in lactic acid vehicle foam 35%
(Hydro 35)
1
3
ULTRAVATE - halobetasol propionate
oint 0.05%
urea in lactic acid-salicylic acid
vehicle susp 50%
1
3
3
urea in zinc undecylenate-lactic acid
vehicle emulsion 50%
1
ULTRAVATE PAC - halobetasol prop
cream 0.05% & ammonium lactate lot
12% kit
urea lotion 40%
1
3
urea lotion 45% (Uramaxin)
1
ULTRAVATE PAC - halobetasol prop
oint 0.05% & ammonium lactate lot
12% kit
ULTRAVATE X - halobetasol prop
cream 0.05% & lactic acid cream
10% kit
3
UREA NAIL - urea in zinc undecylenate- 3
lactic acid vehicle stick 50%
3
UREA NAIL KIT - urea susp 40% &
hyaluronate sodium gel 0.2% kit
1
urea suspension 40% (Umecta)
ULTRAVATE X - halobetasol prop oint
0.05% & lactic acid cream 10% kit
3
UTOPIC - urea cream 41%
3
3
VALCHLOR - mechlorethamine hcl gel
4
UMECTA - urea emulsion 40%
UMECTA - urea suspension 40%
3
VANOS - fluocinonide cream 0.1%
3
UMECTA NAIL FILM - urea suspension
40%
3
VANOXIDE-HC - benzoyl peroxide-hc
lotion 5-0.5%
3
VECTICAL - calcitriol oint 3 mcg/gm
3
VELTIN - clindamycin phosphatetretinoin gel 1.2-0.025%
3
VENELEX - balsam peru-castor oil oint
3
VERDESO - desonide foam 0.05%
3
VEREGEN - sinecatechins oint 15%
3
UMECTA PD - urea-hyaluronate sodium 3
emulsion 40-0.3%
UMECTA PD - urea-hyaluronate sodium 3
susp 40-0.3%
3
URAMAXIN - urea cream 45%
URAMAXIN - urea gel 45%
3
URAMAXIN - urea lotion 45%
3
URAMAXIN - urea in ammonium lactate
vehicle foam 20%
VEXA - allantoin-lidocaine-petrolatum
patch 2-4-30%
3
3
URAMAXIN GT - urea gel 45%
VIRASAL - salicylic acid film forming
liquid 27.5%
3
3
URAMAXIN GT KIT - urea gel 45% &
emollient cream kit
3
VOLTAREN - diclofenac sodium gel 1%
2
1
VOPAC - ketoprofen-lidocaine hcl
cream 10-2% (compound kit)
3
urea cream 39% (Aluvea)
urea cream 40%
1
3
urea cream 45% (Uramaxin)
1
VOPAC GB - ketoprofen-lidocainegabapentin cream 5-2-5% (cmpd kit)
urea cream 50%
1
3
urea foam 40% (Hydro 40 foam)
1
VOPAC KT - ketoprofen-ketaminelidocaine cream 5-5-2% (compound
kit)
urea gel 40%
1
176
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
•
3
VYTONE - iodoquinol-hydrocortisone in
aloe vehicle cream 1-1.9%
3
WESTCORT - hydrocortisone valerate
oint 0.2%
3
WITCH HAZEL - witch hazel
(hamamelis virginiana) liqd
(hamamelis water)
3
XCLAIR - dermatological products misc
- cream
3
XENADERM - trypsin w/ castor oil &
peruvian balsam oint
3
XERAC AC - aluminum chloride in
alcohol solution 6.25%
3
XERESE - acyclovir-hydrocortisone
cream 5-1%
3
XOLEGEL - ketoconazole gel 2%
3
XOLEGEL COREPAK - ketoconazole
gel 2% & hydrocortisone gel 1% kit
ZONALON - doxepin hcl cream 5%
3
ZOVIRAX - acyclovir cream 5%
3
ZOVIRAX - acyclovir oint 5%
3
ZYCLARA - imiquimod cream 3.75%
3
ZYCLARA PUMP - imiquimod cream
2.5%
3
ZYCLARA PUMP - imiquimod cream
3.75%
3
8-MOP - methoxsalen cap 10 mg
3
MISCELLANEOUS PRODUCTS
ANTISEPTICS & DISINFECTANTS
BENZALKONIUM CHLORIDE benzalkonium chloride soln
3
BENZALKONIUM CHLORIDE benzalkonium chloride soln 17%
3
BENZALKONIUM CHLORIDE benzalkonium chloride soln 50%
3
3
XOLEGEL DUO/HEAD & SHOULD ketoconazole gel 2% & pyrithione
zinc shampoo 1% kit
BUCALSEP - antiseptic products misc liquid
3
3
3
XOLEGEL DUO/XOLEX - ketoconazole
gel 2% & pyrithione zinc shampoo 1%
kit
3
BUCALSEP - antiseptic products misc solution
FORMA-RAY - formaldehyde solution
20%
3
3
XYLOCAINE JELLY - lidocaine hcl gel
2%
3
FORMALDEHYDE - formaldehyde
solution 37%
3
XYLOCAINE - lidocaine hcl soln 4%
formaldehyde solution 10%
1
3
GLUTARALDEHYDE - glutaral soln
25%
3
ZACARE 4% KIT - benzoyl peroxide
lotion 4% & hyaluronate sodium gel
0.2% kit
IODINE TINCTURE - iodine tincture
3
ZACARE 8% KIT - benzoyl peroxide
lotion 8% & hyaluronate sodium gel
0.2% kit
3
IODINE TINCTURE MILD - iodine
tincture
3
3
ZACLIR CLEANSING - benzoyl
peroxide lotion 8%
3
IODINE TINCTURE STRONG - iodine
tincture strong
IODINE TINCTURE STRONG DE iodine tincture strong
3
KERR TRIPLE DYE - triple dye swabs
3
LUGOLS STRONG IODINE - iodine
solution
3
ZIANA - clindamycin phosphate-tretinoin 3
gel 1.2-0.025%
3
ZITHRANOL - anthralin shampoo 1%
Dispensing Limits
3
Step Therapy
ZITHRANOL-RR - anthralin cream 1.2%
Prior Authorization
Dispensing Limits
Step Therapy
Drug Name
Drug Tier
VUSION - miconazole-zinc oxide-white
petrolatum oint 0.25-15-81.35%
Prior Authorization
Drug Name
Drug Tier
2014
•
177
ANTIDOTES
BAL IN OIL - dimercaprol inj 100 mg/ml
3
CHEMET - succimer cap 100 mg
2
deferoxamine mesylate for inj 2 gm
(Desferal)
1
deferoxamine mesylate for inj
500 mg (Desferal)
1
DESFERAL - deferoxamine mesylate for 3
inj 500 mg
DESFERAL - deferoxamine mesylate for 3
inj 2 gm
3
DUODOTE - atropine 2.1 mg/0.7mlpralidoxime cl 600 mg/2ml inj device
4
EXJADE - deferasirox tab for oral susp
125 mg
4
250 mg
4
500 mg
4
FERRIPROX - deferiprone tab 500 mg
Dispensing Limits
Step Therapy
ACCU-CHEK AVIVA PLUS - glucose
blood test strip
2
•
ACCU-CHEK COMFORT CURVE T glucose blood test strip
2
•
ACCU-CHEK COMPACT PLUS glucose blood test strip
2
•
ACCU-CHEK COMPACT STRIPS glucose blood test strip
2
•
ACCU-CHEK COMPACT TEST DR glucose blood test strip
2
•
ACCU-CHEK SMARTVIEW STRIP glucose blood test strip
2
•
ACCUTREND GLUCOSE - glucose
blood test strip
2
•
ASCENSIA AUTODISC TEST ST glucose blood test disk
2
•
BAYER BREEZE 2 TEST DISC glucose blood test disk
2
•
BAYER CONTOUR BLOOD GLUCO glucose blood test strip
2
•
BAYER CONTOUR NEXT BLOOD glucose blood test strip
2
•
GLUCOSE BLOOD TEST STRIPS
VARIOUS
3
• •
NALOXONE HCL - naloxone hcl inj 0.4
mg/ml
3
naloxone hcl inj 0.4 mg/ml
1
naloxone hcl inj 1 mg/ml
1
naltrexone hcl tab 50 mg (Revia)
1
PRALIDOXIME CHLORIDE pralidoxime chloride im inj device 600
mg/2ml
3
QUINZYME - coenzyme q10 tab disp 90 3
mg
3
RELAMINE - glucosamine-chondroitinpaba-vit e-alpha lipoic acid tab
RADIOGARDASE - prussian blue
insoluble cap 0.5 gm
3
CHEMICALS
3
REVIA - naltrexone hcl tab 50 mg
3
DENATURED ALCOHOL - alcohol,
rubbing 95%
3
ACCU-CHEK ACTIVE STRIPS glucose blood test strip
2
•
ENOVARX-AMITRIPTYLINE amitriptyline hcl cream 2% kit
(compounding kit)
ACCU-CHEK AVIVA - glucose blood
test strip
2
•
POTASSIUM HYDROXIDE - potassium
hydroxide solution 5%
3
ALTERNATIVE MEDICINES
ISCAR MALI - european mistletoe
(viscum album) inj 5 mg/ml
DIAGNOSTIC PRODUCTS
178
Prior Authorization
3
Drug Name
Drug Tier
TRIPLE DYE - triple dye solution
Dispensing Limits
3
Step Therapy
PHISOHEX - hexachlorophene liq 3%
Prior Authorization
Drug Name
Drug Tier
2014
3
SODIUM HYDROXIDE - sodium
hydroxide solution 10%
3
MEDICAL DEVICES
ACCUTREND GLUCOSE CONTROL blood glucose calibration - liquid
2
ACURA BLOOD GLUCOSE MONIT blood glucose monitoring kit w/
device
3
ACURA PLUS BLOOD GLUCOSE blood glucose monitoring kit w/
device
3
ADVANCE INTUITION BLOOD G blood glucose monitoring devices
3
ADVANCE INTUITION BLOOD G blood glucose monitoring kit w/
device
3
ACCU-CHEK ACTIVE GLUCOSE blood glucose calibration - liquid
2
ACCU-CHEK AVIVA - blood glucose
calibration - liquid
2
ACCU-CHEK AVIVA PLUS - blood
glucose monitoring kit w/ device
2
ACCU-CHEK COMFORT CURVE C blood glucose calibration - liquid
2
ACCU-CHEK COMFORT CURVE L blood glucose calibration - liquid
2
2
ADVANCE MICRO-DRAW METER blood glucose monitoring devices
3
ACCU-CHEK COMPACT BLUE CO blood glucose calibration - liquid
2
ADVOCATE BLOOD GLUCOSE MO blood glucose monitoring devices
3
ACCU-CHEK COMPACT PLUS CA blood glucose monitoring kit
2
ADVOCATE BLOOD GLUCOSE MO blood glucose monitoring kit w/
device
3
ACCU-CHEK COMPACT PLUS CL blood glucose calibration - liquid
ACCU-CHEK FASTCLIX LANCET lancets
2
ADVOCATE REDI-CODE - blood
glucose monitoring devices
3
ACCU-CHEK INSTANT GLUCOSE blood glucose calibration - liquid
2
ADVOCATE REDI-CODE+ BLOOD blood glucose monitoring devices
3
ACCU-CHEK MULTICLIX LANCE lancets
2
ADVOCATE REDI-CODE/TALKIN blood glucose monitoring devices
3
ACCU-CHEK NANO SMARTVIEW blood glucose monitoring kit w/
device
2
ADVOCATE REDI-CODE/TALKIN blood glucose monitoring kit w/
device
3
ACCU-CHEK SAFE-T-PRO LANC lancets
2
AGAMATRIX AMP NO CODE ADV blood glucose monitoring devices
3
ACCU-CHEK SAFE-T-PRO PLUS lancets
2
AGAMATRIX JAZZ - blood glucose
monitoring kit w/ device
3
ACCU-CHEK SMARTVIEW CONTR blood glucose calibration - liquid
2
AGAMATRIX PRESTO - blood glucose
3
ACCU-CHEK SOFT TOUCH LANC lancets
2
AGAMATRIX PRESTO PRO METE blood glucose monitoring devices
3
ACCU-CHEK SOFTCLIX LANCET lancets
2
ASCENSIA AUTODISC LOW AND blood glucose calibration - liquid
2
ACCU-CHEK VOICEMATE - blood
2
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
179
ASCENSIA AUTODISC NORMAL blood glucose calibration - liquid normal
2
BAYER CONTOUR NEXT BLOOD blood glucose monitoring kit w/
device
2
ASSURE PLATINUM BLOOD GLU blood glucose monitoring devices
3
2
ASSURE PRO BLOOD GLUCOSE blood glucose monitoring devices
3
BAYER CONTOUR NEXT CONTRO blood glucose calibration - liquid normal
2
ASSURE 3 METER - blood glucose
monitoring kit
3
BAYER CONTOUR NEXT CONTRO blood glucose calibration - liquid - low
2
ASSURE 4 BLOOD GLUCOSE ME blood glucose monitoring devices
3
BAYER CONTOUR NEXT EZ BLO blood glucose monitoring kit w/
device
AT LAST BLOOD GLUCOSE SYS blood glucose monitoring kit
3
BAYER CONTOUR NEXT LINK B blood glucose monitoring kit w/
device
2
BAYER CONTOUR NEXT USB BL blood glucose monitoring kit w/
device
2
BAYER CONTOUR NORMAL CONT blood glucose calibration - liquid normal
2
BAYER CONTOUR USB BLOOD
G - blood glucose monitoring kit w/
device
2
BAYER MICROLET LANCETS - lancets
2
BD LATITUDE DIABETES MANA blood glucose monitoring kit w/
device
3
BD LOGIC BLOOD GLUCOSE MO blood glucose monitoring kit w/
device
3
BD MAGNI-GUIDE MAGNIFIER - blood
glucose monitoring supplies
3
BLOOD GLUCOSE CALIBRATION
LIQUID VARIOUS
3
BLOOD GLUCOSE MONITORING blood glucose monitoring kit w/
device
3
BLOOD GLUCOSE SYSTEM PAK blood glucose monitoring kit w/
device
3
BREEZE 2 BLOOD GLUCOSE MO blood glucose monitoring devices
2
A1C NOW - blood glucose monitoring kit 3
w/ device
2
BAYER BREEZE 2 BLOOD GLUC blood glucose monitoring kit w/
device
2
BAYER BREEZE 2 HIGH CONTR blood glucose calibration - liquid high
2
BAYER BREEZE 2 LOW CONTRO blood glucose calibration - liquid - low
2
BAYER BREEZE 2 NORMAL CON blood glucose calibration - liquid normal
2
BAYER CONTOUR BLOOD GLUCO blood glucose monitoring devices
2
BAYER CONTOUR BLOOD GLUCO blood glucose monitoring kit w/
device
2
BAYER CONTOUR HIGH CONTRO blood glucose calibration - liquid high
2
BAYER CONTOUR LINK BLOOD blood glucose monitoring kit w/
device
2
BAYER CONTOUR LOW CONTROL blood glucose calibration - liquid - low
180
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
CAREONE BLOOD GLUCOSE MON blood glucose monitoring kit w/
device
3
CARESENS N BLOOD GLUCOSE blood glucose monitoring devices
3
CARESENS N GLUCOSE MONITO blood glucose monitoring devices
EASY PLUS BLOOD GLUCOSE M blood glucose monitoring devices
3
EASY PLUS BLOOD GLUCOSE M blood glucose monitoring kit w/
device
3
3
EASY PLUS II BLOOD GLUCOS blood glucose monitoring devices
3
CARESENS N VOICE BLOOD GL blood glucose monitoring devices
3
EASY STEP BLOOD GLUCOSE M blood glucose monitoring devices
3
CHEMSTRIP BG LOG BOOK - blood
glucose monitoring misc.
3
3
CHOICE DM DIABETES RISK I - blood
glucose monitoring kit
3
EASY STEP BLOOD GLUCOSE M blood glucose monitoring kit w/
device
3
CHOICE DM FORA G20 BLOOD blood glucose monitoring devices
3
EASY TALK BLOOD GLUCOSE M blood glucose monitoring devices
3
CLEVER CHEK AUTO CODE VOI blood glucose monitoring devices
3
EASY TALK BLOOD GLUCOSE M blood glucose monitoring kit w/
device
CLEVER CHEK AUTO-CODE BLO blood glucose monitoring devices
3
3
CLEVER CHEK AUTO-CODE VOI blood glucose monitoring devices
3
EASY TOUCH GLUCOSE MONITO blood glucose monitoring kit w/
device
3
CLEVER CHEK BLOOD GLUCOSE blood glucose monitoring kit w/
device
3
EASY TOUCH HEALTHPRO GLUC blood glucose monitoring kit w/
device
3
CLEVER CHOICE AUTO-CODE P blood glucose monitoring devices
3
EASY TRAK BLOOD GLUCOSE M blood glucose monitoring devices
3
CLEVER CHOICE MICRO BLOOD blood glucose monitoring kit w/
device
3
EASY TRAK BLOOD GLUCOSE
M - blood glucose monitoring kit w/
device
3
CLEVER CHOICE MINI BLOOD - blood
3
EASYGLUCO - blood glucose
monitoring kit
3
COAGUCHEK LANCETS - lancets
2
EASYGLUCO VALUE PACK - blood
3
EASYMAX L BLOOD GLUCOSE S blood glucose monitoring devices
3
CONTROL BLOOD GLUCOSE MON blood glucose monitoring kit w/
device
3
CVS ADVANCED GLUCOSE METE blood glucose monitoring kit w/
device
3
EASYMAX L BLOOD GLUCOSE
S - blood glucose monitoring kit w/
device
3
DIDGET - blood glucose monitoring kit
w/ device
2
EASYMAX N BLOOD GLUCOSE S blood glucose monitoring devices
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
181
EASYMAX N BLOOD GLUCOSE
device
3
EMBRACE EVO BLOOD GLUCOSE blood glucose monitoring kit w/
device
3
EASYMAX NG SELF-MONITORIN blood glucose monitoring devices
3
EMBRACE PRO BLOOD GLUCOSE blood glucose monitoring devices
3
EASYMAX NG SELF-MONITORIN blood glucose monitoring kit w/
device
3
ENVISION AUTOCODE - blood glucose
3
3
EQL TRUE2GO BLOOD GLUCOSE blood glucose monitoring kit w/
device
3
EASYMAX V BLOOD GLUCOSE S blood glucose monitoring devices
EASYMAX V BLOOD GLUCOSE
device
3
EVENCARE BLOOD GLUCOSE MO blood glucose monitoring kit
3
EASYMAX V2 SELF-MONITORIN blood glucose monitoring devices
EVENCARE G2 BLOOD GLUCOSE blood glucose monitoring devices
3
3
EASYMAX V2 SELF-MONITORIN blood glucose monitoring kit w/
device
EVENCARE G3 BLOOD GLUCOSE blood glucose monitoring devices
3
3
EVOLUTION AUTOCODE - blood
3
EASYPLUS R13N SELF-MONITO blood glucose monitoring kit w/
device
3
EZ SMART DIABETES MONITOR blood glucose monitoring devices
3
3
EZ SMART PLUS DIABETES MO blood glucose monitoring devices
3
EASYPLUS V SELF-MONITORIN blood glucose monitoring kit w/
device
3
EASYPRO BLOOD GLUCOSE MON blood glucose monitoring kit w/
device
3
FASTTAKE COMPACT MONITORI blood glucose monitoring kit w/
device
3
EASYPRO PLUS - blood glucose
3
FC FEMALE CONDOM - condoms female
3
ECLIPSE BLOOD GLUCOSE MON blood glucose monitoring kit w/
device
3
FC2 FEMALE CONDOM - condoms female
ELEMENT AUTOCODE SYSTEM blood glucose monitoring kit w/
device
3
ELEMENT COMPACT BLOOD GLU blood glucose monitoring devices
3
ELEMENT PLUS BLOOD GLUCOS blood glucose monitoring devices
EMBRACE BLOOD GLUCOSE MON blood glucose monitoring devices
182
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
FIFTY50 GLUCOSE METER 2.0 - blood 3
2
FINGERSTIX LANCETS - lancets
FORA GD20 BLOOD GLUCOSE M blood glucose monitoring devices
3
3
3
FORA G20 BLOOD GLUCOSE MO blood glucose monitoring kit w/
device
3
3
FORA G30A BLOOD GLUCOSE M blood glucose monitoring devices
FORA G71A BLOOD GLUCOSE
device
3
FORA G90 BLOOD GLUCOSE MO blood glucose monitoring devices
3
FORA V10 BLOOD GLUCOSE MO blood glucose monitoring devices
3
FREESTYLE SYSTEM KIT - blood
3
GE100 BLOOD GLUCOSE MONIT blood glucose monitoring kit w/
device
3
3
3
GHT BLOOD GLUCOSE MONITO blood glucose monitoring kit w/
device
3
3
GLUCO PERFECT 3 BLOOD GLU blood glucose monitoring devices
3
FORA V22 BLOOD GLUCOSE MO blood glucose monitoring kit w/
device
3
GLUCOCARD EXPRESSION AUDI blood glucose monitoring kit w/
device
3
FORA V30A BLOOD GLUCOSE M blood glucose monitoring devices
3
GLUCOCARD VITAL BLOOD GLU blood glucose monitoring kit w/
device
FORA V30A BLOOD GLUCOSE M blood glucose monitoring kit w/
device
3
GLUCOCARD X-METER - blood
3
3
FORACARE GD40 BLOOD GLUCO blood glucose monitoring devices
3
GLUCOCARD 01 BLOOD GLUCOS blood glucose monitoring devices
3
FORACARE PREMIUM V10 BLOO blood glucose monitoring devices
3
GLUCOCARD 01 BLOOD GLUCOS blood glucose monitoring kit w/
device
FORACARE TEST N GO BLOOD blood glucose monitoring devices
3
3
FREESTYLE FLASH SYSTEM - blood
3
GLUCOCARD 01-MINI BLOOD G blood glucose monitoring kit w/
device
3
FREESTYLE FREEDOM - blood
3
GLUCOCOM AUTOLINK TELEMON blood glucose monitoring misc.
3
FREESTYLE FREEDOM - blood
3
GLUCOCOM BLOOD GLUCOSE MO blood glucose monitoring devices
3
FREESTYLE FREEDOM LITE - blood
3
GLUCOCOM BLOOD GLUCOSE
MO - blood glucose monitoring kit w/
device
GLUCOLAB BLOOD GLUCOSE MO blood glucose monitoring kit
3
GLUCONAVII BLOOD GLUCOSE blood glucose monitoring kit w/
device
3
GMATE SMART METER KIT - blood
3
FREESTYLE INSULINX BLOOD - blood 3
3
FREESTYLE LITE BLOOD GLUC blood glucose monitoring devices
3
FREESTYLE SIDEKICK II VAL - blood
3
FREESTYLE SIDEKICK II VAL - blood
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
183
GMATE SMART STARTER KIT - blood
3
GMATE VOICE BLOOD GLUCOSE blood glucose monitoring devices
3
IBG STAR BLOOD GLUCOSE MO blood glucose monitoring kit w/
device
MEIJER TRUERESULT BLOOD G blood glucose monitoring kit w/
device
3
3
3
MEIJER TRUETRACK BLOOD GL blood glucose monitoring kit w/
device
3
IN TOUCH DIABETES MANAGEM blood glucose monitoring misc.
3
MEIJER TRUE2GO BLOOD GLUC blood glucose monitoring kit w/
device
INFINITY BLOOD GLUCOSE MO blood glucose monitoring kit w/
device
3
MICRODOT BLOOD GLUCOSE MO blood glucose monitoring kit w/
device
3
MICROLET LANCETS - lancets
2
MONOJECT INSULIN SYRINGE insulin syringe (disp) u-100 1 ml
2
MONOJECT INSULIN SYRINGE/ insulin syringe (disp) u-100 1 ml
2
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 0.3 ml
29 x 1/2"
2
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 0.3 ml
30 x 5/16"
2
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 1/2 ml
28 x 1/2"
2
29 x 1/2"
2
30 x 5/16"
2
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml 25 x
5/8"
2
1/2"
2
1/2"
2
INSUL-TOTE - blood glucose monitoring 3
supplies
3
INSUL-TOTE JR - blood glucose
monitoring supplies
3
KROGER BLOOD GLUCOSE MONI blood glucose monitoring kit w/
device
3
KROGER PREMIUM BLOOD GLUC blood glucose monitoring kit w/
device
3
LIBERTY BLOOD GLUCOSE MET blood glucose monitoring devices
3
LIBERTY BLOOD GLUCOSE MON blood glucose monitoring devices
3
LIBERTY NEXT GENERATION B blood glucose monitoring devices
3
MAXIMA BLOOD GLUCOSE MONI blood glucose monitoring kit w/
device
3
MAXIMA METER KIT - blood glucose
MAXIMA STARTER KIT - blood glucose 3
3
MEIJER BLOOD GLUCOSE MONI blood glucose monitoring kit w/
device
3
MEIJER PREMIUM BLOOD GLUC blood glucose monitoring kit w/
device
184
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
1/2"
2
NEXGEN METER KIT - blood glucose
monitoring kit
3
5/16"
NOVA MAX BLOOD GLUCOSE MO blood glucose monitoring devices
3
2
3
5/16"
2
NOVA MAX BLOOD GLUCOSE MO blood glucose monitoring kit w/
device
OMNIFLEX DIAPHRAGM - diaphragms
3
2
ON CALL EXPRESS BLOOD GLU blood glucose monitoring devices
3
MONOJECT ULTRA COMFORT IN insulin syringe/needle u-100 0.3 ml
29 x 1/2"
3
30 x 5/16"
2
ON CALL EXPRESS BLOOD GLU blood glucose monitoring kit w/
device
3
MONOJECT ULTRA COMFORT IN insulin syringe/needle u-100 1/2 ml
31 x 5/16"
2
ON CALL PLUS BLOOD GLUCOS blood glucose monitoring devices
3
28 x 1/2"
2
ON CALL PLUS BLOOD GLUCOS blood glucose monitoring kit w/
device
ON CALL VIVID BLOOD GLUCO blood glucose monitoring devices
3
29 x 1/2"
2
ON CALL VIVID BLOOD GLUCO blood glucose monitoring kit w/
device
3
30 x 5/16"
2
ON CALL VIVID PAL BLOOD G - blood
3
3
MONOJECT ULTRA COMFORT IN insulin syringe/needle u-100 1 ml 28 x
1/2"
2
ON CALL VIVID PAL BLOOD G - blood
ONETOUCH BASIC SYSTEM - blood
3
1/2"
2
ONETOUCH PING METER REMOT blood glucose monitoring supplies
3
5/16"
ONETOUCH PROFILE SYSTEM blood glucose monitoring kit w/
device
3
2
31 x 5/16"
ONETOUCH ULTRA MINI - blood
3
2
3
MYGLUCOHEALTH BLOOD GLUCO blood glucose monitoring kit w/
device
3
ONETOUCH ULTRA SYSTEM KIT blood glucose monitoring kit w/
device
ONETOUCH ULTRA 2 - blood glucose
3
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
185
ONETOUCH ULTRALINK SYSTEM blood glucose monitoring kit w/
device
3
ORTHO DIAPHRAGM FLAT SPRI diaphragm flat spring kit 65 mm
3
ONETOUCH ULTRASMART - blood
3
3
ONETOUCH VERIO IQ BLOOD G blood glucose monitoring kit w/
device
3
3
3
ONETOUCH VERIO SYNC BLOOD blood glucose monitoring kit w/
device
3
3
3
3
OPTIUM BLOOD GLUCOSE MONI blood glucose monitoring devices
3
3
OPTIUM BLOOD GLUCOSE MONI blood glucose monitoring kit w/
device
3
OPTUMRX BLOOD GLUCOSE MET blood glucose monitoring kit w/
device
3
PARADIGM LINK BLOOD GLUCO blood glucose monitoring kit w/
device
3
OPTUMRX BLOOD GLUCOSE MON blood glucose monitoring kit w/
device
3
PEN-TOTE - blood glucose monitoring
supplies
3
ORTHO DIAPHRAGM ALL-FLEX/ diaphragm arc-spring 65 mm
3
PHARMACIST CHOICE AUTOCOD blood glucose monitoring kit w/
device
3
3
POCKETCHEM EZ BLOOD GLUCO blood glucose monitoring kit w/
device
3
PRECISION LINK - blood glucose
3
3
PRECISION QID MONITOR - blood
3
3
PRECISION SOF-TACT MONITO blood glucose monitoring devices
3
ORTHO DIAPHRAGM COIL SPRI diaphragm coil spring kit 50 mm
3
PRECISION XTRA - blood glucose
monitoring devices
3
3
PRECISION XTRA - blood glucose
monitoring kit
3
3
PRECISION XTRA MONITOR - blood
3
3
PRODIGY AUTOCODE BLOOD GL blood glucose monitoring devices
3
186
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
PRODIGY AUTOCODE BLOOD GL blood glucose monitoring kit w/
device
3
REFUAH PLUS BLOOD GLUCOSE blood glucose monitoring kit w/
device
3
PRODIGY AUTOCODE PRO BLOO blood glucose monitoring kit w/
device
3
RELION CONFIRM BLOOD GLUC blood glucose monitoring kit w/
device
3
PRODIGY POCKET BLOOD GLUC blood glucose monitoring kit w/
device
3
RELION MICRO BLOOD GLUCOS blood glucose monitoring kit w/
device
3
PRODIGY POCKET PRO BLOOD blood glucose monitoring kit w/
device
3
RELION PRIME BLOOD GLUCOS blood glucose monitoring devices
3
PRODIGY VOICE BLOOD GLUCO blood glucose monitoring kit w/
device
RELION ULTIMA BLOOD GLUCO blood glucose monitoring kit w/
device
3
3
PRODIGY VOICEPRO BLOOD GL blood glucose monitoring kit
REVEAL BLOOD GLUCOSE MONI blood glucose monitoring kit w/
device
3
3
QUICKTEK - blood glucose monitoring
kit
3
3
QUICKTEK - blood glucose monitoring
kit w/ device
3
REXALL BLOOD GLUCOSE MONI blood glucose monitoring kit w/
device
3
QUINTET AC BLOOD GLUCOSE blood glucose monitoring devices
3
RIGHTEST GM100 BLOOD GLUC blood glucose monitoring kit w/
device
QUINTET BLOOD GLUCOSE MON blood glucose monitoring devices
3
3
RA BLOOD GLUCOSE MONITOR blood glucose monitoring devices
3
device
3
RA TRUERESULT BLOOD GLUCO blood glucose monitoring kit w/
device
3
device
3
RA TRUE2GO BLOOD GLUCOSE blood glucose monitoring kit w/
device
3
RIGHTSOURCE BLOOD GLUCOSE blood glucose monitoring devices
SINGLE-LET - lancets
2
SMART DIABETES XPRES BLOO blood glucose monitoring kit w/
device
3
SMART SENSE PREMIUM BLOOD blood glucose monitoring kit w/
device
3
REALITY INSULIN SYRINGE/U - insulin 2
syringe/needle u-100 1/2 ml 28 x 1/2"
syringe/needle u-100 1/2 ml 29 x 1/2"
syringe/needle u-100 1 ml 28 x 1/2"
syringe/needle u-100 1 ml 29 x 1/2"
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
SMART SENSE VALUE BLOOD - blood 3
3
SMARTEST EJECT BLOOD GLUC blood glucose monitoring devices
187
SMARTEST EJECT STARTER KI blood glucose monitoring kit w/
device
3
TRACER II 3 VOLT BATTERY - blood
3
SMARTEST PERSONA STARTER blood glucose monitoring kit w/
device
TRUE METRIX BLOOD GLUCOSE blood glucose monitoring kit w/
device
3
3
3
SMARTEST PRONTO STARTER blood glucose monitoring kit w/
device
3
TRUERESULT BLOOD GLUCOSE blood glucose monitoring kit w/
device
3
TRUETRACK BLOOD GLUCOSE M blood glucose monitoring devices
3
SMARTEST PROTEGE BLOOD GL blood glucose monitoring devices
SMARTEST PROTEGE STARTER blood glucose monitoring kit w/
device
TRUETRACK BLOOD GLUCOSE
device
3
3
SOLUS V2 AUDIBLE BLOOD GL blood glucose monitoring devices
TRUETRACK SMART SYSTEM - blood
3
3
3
SOLUS V2 AUDIBLE BLOOD GL blood glucose monitoring kit w/
device
3
TRUE2GO BLOOD GLUCOSE MON blood glucose monitoring kit w/
device
ULTIMA - blood glucose monitoring kit
3
SUPREME II CONFIDENCE PAD blood glucose monitoring misc.
3
3
SURE EDGE BLOOD GLUCOSE M blood glucose monitoring devices
3
ULTRA TRAK PRO BLOOD GLUC blood glucose monitoring kit w/
device
ULTRATRAK ACTIVE - blood glucose
monitoring devices
3
ULTRATRAK PRO - blood glucose
monitoring devices
3
ULTRATRAK ULTIMATE MONITO blood glucose monitoring devices
3
VICTORY BLOOD GLUCOSE MON blood glucose monitoring devices
3
VOCAL POINT BLOOD GLUCOSE blood glucose monitoring devices
3
WAVESENSE AMP - blood glucose
3
WAVESENSE KEYNOTE - blood
3
WAVESENSE KEYNOTE PRO MET blood glucose monitoring devices
3
WIDE-SEAL SILICONE DIAPHR diaphragm wide seal 60 mm
3
SURE-TEST EASYPLUS MINI S - blood 3
3
SURECHEK BLOOD GLUCOSE MO blood glucose monitoring devices
3
SURECHEK BLOOD GLUCOSE MO blood glucose monitoring kit w/
device
SURESTEP PRO LINEARITY KI - blood 3
3
TELCARE BLOOD GLUCOSE MON blood glucose monitoring kit w/
device
3
TGT BLOOD GLUCOSE MONITOR blood glucose monitoring kit w/
device
3
TODAY SPONGE - contraceptive
sponge
188
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
3
3
CELLCEPT INTRAVENOUS mycophenolate mofetil hcl for iv soln
500 mg (base equiv)
3
CUPRIMINE - penicillamine cap 250 mg
4
3
cyclosporine cap 100 mg
(Sandimmune)
1
3
cyclosporine cap 25 mg
(Sandimmune)
1
3
CYCLOSPORINE MODIFIED cyclosporine modified cap 50 mg
2
3
cyclosporine modified cap 100 mg
(Neoral)
1
3
cyclosporine modified cap 25 mg
(Neoral)
1
1
ASSORTED CLASSES
sodium polystyrene sulfonate
powder (Kayexalate)
1
cyclosporine modified oral soln
100 mg/ml (Neoral)
4
alprostadil inj 500 mcg/ml (Prostin vr
pediatric)
1
DEPEN TITRATABS - penicillamine tab
250 mg
IMURAN - azathioprine tab 50 mg
3
AMMONIA AROMATIC INHALANT ammonia aromatic spirit
3
KAYEXALATE - sodium polystyrene
sulfonate powder
3
ASTAGRAF XL - tacrolimus cap sr 24hr
0.5 mg
3
mycophenolate mofetil cap 250 mg
(Cellcept)
1
1 mg
3
mycophenolate mofetil tab 500 mg
(Cellcept)
1
5 mg
3
1
AZASAN - azathioprine tab 75 mg
3
mycophenolate sodium tab dr
180 mg (mycophenolic acid equiv)
(Myfortic)
AZASAN - azathioprine tab 100 mg
3
1
AZATHIOPRINE SODIUM azathioprine sodium for inj 100 mg
3
mycophenolate sodium tab dr
360 mg (mycophenolic acid equiv)
(Myfortic)
1
MYFORTIC - mycophenolate sodium
tab dr 180 mg (mycophenolic acid
equiv)
3
azathioprine tab 50 mg (Imuran)
MYFORTIC - mycophenolate sodium
tab dr 360 mg (mycophenolic acid
equiv)
3
CELLCEPT - mycophenolate mofetil cap 3
250 mg
CELLCEPT - mycophenolate mofetil tab 3
500 mg
CELLCEPT - mycophenolate mofetil for 2
oral susp 200 mg/ml
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2014
NEORAL - cyclosporine modified cap 25 3
mg
3
NEORAL - cyclosporine modified cap
100 mg
189
3
NEXAVIR - liver derivative complex inj
25.5 mg/ml
3
PROGRAF - tacrolimus cap 0.5 mg
3
PROGRAF - tacrolimus cap 1 mg
3
PROGRAF - tacrolimus cap 5 mg
3
PROGRAF - tacrolimus inj 5 mg/ml
2
PROSTIN VR PEDIATRIC - alprostadil
inj 500 mcg/ml
3
RAPAMUNE - sirolimus tab 0.5 mg
3
RAPAMUNE - sirolimus tab 1 mg
2
RAPAMUNE - sirolimus tab 2 mg
2
RAPAMUNE - sirolimus oral soln 1 mg/
ml
2
REVLIMID - lenalidomide caps 2.5 mg
4
REVLIMID - lenalidomide cap 5 mg
4
4
4
4
4
SANDIMMUNE - cyclosporine cap 25
mg
3
SANDIMMUNE - cyclosporine cap 100
mg
3
SANDIMMUNE - cyclosporine oral soln
100 mg/ml
2
sirolimus tab 0.5 mg (Rapamune)
1
sodium polystyrene sulfonate oral
susp 15 gm/60ml (Sps)
1
sodium polystyrene sulfonate rectal
susp 30 gm/120ml
1
SPS - sodium polystyrene sulfonate oral
susp 15 gm/60ml
3
SYPRINE - trientine hcl cap 250 mg
4
tacrolimus cap 0.5 mg (Prograf)
1
tacrolimus cap 1 mg (Prograf)
1
tacrolimus cap 5 mg (Prograf)
1
190
THALOMID - thalidomide cap 100 mg
4
4
4
ZORTRESS - everolimus tab 0.25 mg
2
2
2
Dispensing Limits
4
Step Therapy
Prior Authorization
Dispensing Limits
Drug Name
Drug Tier
NEORAL - cyclosporine modified oral
soln 100 mg/ml
Step Therapy
Drug Name
Prior Authorization
Drug Tier
2014
•
•
•
•
•
•
•
•
•
•
2014
INDEX
8-MOP -methoxsalen cap 10 mg.....................................177
A
A1C NOW - blood glucose monitoring kit w/ device ....... 180
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg (Trizivir)............................................... 10
abacavir sulfate tab 300 mg (base equiv) (Ziagen)....... 10
ABILIFY -aripiprazole im inj 9.75 mg/1.3ml (7.5 mg/ml).....93
ABILIFY -aripiprazole oral solution 1 mg/ml...................... 93
ABILIFY -aripiprazole tab 10 mg....................................... 93
ABILIFY -aripiprazole tab 2 mg......................................... 93
ABILIFY -aripiprazole tab 5 mg......................................... 93
ABILIFY DISCMELT -aripiprazole orally disintegrating tab
10 mg............................................................................... 93
ABILIFY DISCMELT -aripiprazole orally disintegrating tab
15 mg............................................................................... 93
ABILIFY MAINTENA -aripiprazole im for extended release
susp 300 mg.................................................................... 93
ABILIFY MAINTENA -aripiprazole im for extended release
susp 400 mg.................................................................... 93
ABSORICA -isotretinoin cap 10 mg.................................162
ABSTRAL -fentanyl citrate sl tab 100 mcg (base
equiv)..............................................................................106
equiv)..............................................................................106
equiv)..............................................................................106
equiv)..............................................................................106
equiv)..............................................................................106
equiv)..............................................................................106
acamprosate calcium tab delayed release 333 mg
(Campral).......................................................................102
ACANYA -clindamycin phosphate-benzoyl peroxide gel
1.2-2.5%......................................................................... 162
acarbose tab 100 mg (Precose)..................................... 32
acarbose tab 25 mg (Precose)....................................... 32
acarbose tab 50 mg (Precose)....................................... 32
ACCOLATE -zafirlukast tab 10 mg....................................72
ACCOLATE -zafirlukast tab 20 mg....................................72
ACCU-CHEK ACTIVE GLUCOSE - blood glucose
calibration - liquid ......................................................... 179
ACCU-CHEK ACTIVE STRIPS -glucose blood test
strip.................................................................................178
ACCU-CHEK AVIVA - blood glucose calibration - liquid
....................................................................................... 179
ACCU-CHEK AVIVA -glucose blood test strip.................178
ACCU-CHEK AVIVA PLUS - blood glucose monitoring kit
w/ device .......................................................................179
ACCU-CHEK AVIVA PLUS -glucose blood test strip.......178
ACCU-CHEK COMFORT CURVE C - blood glucose
ACCU-CHEK COMFORT CURVE L - blood glucose
ACCU-CHEK COMFORT CURVE T -glucose blood test
strip.................................................................................178
ACCU-CHEK COMPACT BLUE CO - blood glucose
ACCU-CHEK COMPACT PLUS CA - blood glucose
monitoring kit ................................................................ 179
ACCU-CHEK COMPACT PLUS CL - blood glucose
ACCU-CHEK COMPACT PLUS -glucose blood test
strip.................................................................................178
ACCU-CHEK COMPACT STRIPS -glucose blood test
strip.................................................................................178
ACCU-CHEK COMPACT TEST DR -glucose blood test
strip.................................................................................178
ACCU-CHEK FASTCLIX LANCET - lancets .................. 179
ACCU-CHEK INSTANT GLUCOSE - blood glucose
ACCU-CHEK MULTICLIX LANCE - lancets ................... 179
ACCU-CHEK NANO SMARTVIEW - blood glucose
monitoring kit w/ device ................................................ 179
ACCU-CHEK SAFE-T-PRO LANC - lancets .................. 179
ACCU-CHEK SAFE-T-PRO PLUS - lancets ...................179
ACCU-CHEK SMARTVIEW CONTR - blood glucose
ACCU-CHEK SMARTVIEW STRIP -glucose blood test
strip.................................................................................178
ACCU-CHEK SOFTCLIX LANCET - lancets .................. 179
ACCU-CHEK SOFT TOUCH LANC - lancets .................179
ACCU-CHEK VOICEMATE - blood glucose monitoring kit
w/ device .......................................................................179
ACCUNEB -albuterol sulfate soln nebu 0.63 mg/3ml (base
equiv)................................................................................72
ACCUNEB -albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv)................................................................................72
ACCUPRIL -quinapril hcl tab 10 mg..................................51
ACCUPRIL -quinapril hcl tab 5 mg....................................51
ACCURETIC -quinapril-hydrochlorothiazide tab 10-12.5
mg.................................................................................... 52
ACCURETIC -quinapril-hydrochlorothiazide tab 20-12.5
mg.................................................................................... 52
ACCURETIC -quinapril-hydrochlorothiazide tab 20-25
mg.................................................................................... 52
191
2014
ACCUTREND GLUCOSE CONTROL - blood glucose
ACCUTREND GLUCOSE -glucose blood test strip.........178
acebutolol hcl cap 200 mg (Sectral).............................. 46
acebutolol hcl cap 400 mg (Sectral).............................. 46
ACEON -perindopril erbumine tab 2 mg............................52
ACETAMINOPHEN/CAFFEINE/DI -acetaminophencaffeine-dihydrocodeine tab 712.8-60-32 mg.................107
acetaminophen-isometheptene-caffeine tab 325-65-20
mg (Prodrin)................................................................. 118
acetaminophen-isometheptene-dichloral cap
325-65-100 mg.............................................................. 118
acetaminophen-salicylamide-phenyltoloxamine cap
300-200-20mg................................................................105
acetaminophen w/ codeine soln 120-12 mg/5ml......... 106
acetaminophen w/ codeine tab 300-15 mg (Tylenol/
codeine).........................................................................106
codeine #3)................................................................... 107
codeine #4)................................................................... 107
ACETAZOLAMIDE -acetazolamide tab 125 mg................ 59
acetazolamide cap sr 12hr 500 mg (Diamox)................ 59
acetazolamide sodium for inj 500 mg............................59
acetazolamide tab 250 mg.............................................. 59
ACETIC ACID/ALUMINUM ACET -acetic acid 2% in
aluminum acetate otic soln............................................ 158
acetic acid otic soln 2%................................................158
acetylcysteine cap 600 mg........................................... 142
acetylcysteine inhal soln 10%........................................ 67
acetylcysteine inhal soln 20%........................................ 67
ACIPHEX -rabeprazole sodium ec tab 20 mg................... 76
ACIPHEX SPRINKLE -rabeprazole sodium capsule
sprinkle dr 10 mg.............................................................76
ACIPHEX SPRINKLE -rabeprazole sodium capsule
sprinkle dr 5 mg...............................................................76
acitretin cap 10 mg (Soriatane).................................... 162
acitretin cap 17.5 mg (Soriatane)................................. 162
acitretin cap 25 mg (Soriatane).................................... 162
ACLOVATE -alclometasone dipropionate cream
0.05%............................................................................. 162
ACTEMRA -tocilizumab subcutaneous soln prefilled
syringe 162 mg/0.9ml.................................................... 115
ACTICLATE -doxycycline hyclate tab 150 mg.....................6
ACTICLATE -doxycycline hyclate tab 75 mg.......................6
ACTIGALL -ursodiol cap 300 mg...................................... 81
ACTIMMUNE -interferon gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)........................................................ 20
ACTIQ -fentanyl citrate lollipop 1200 mcg....................... 107
ACTIQ -fentanyl citrate lollipop 1600 mcg....................... 107
ACTIQ -fentanyl citrate lollipop 200 mcg......................... 107
192
ACTIVE-CYCLOBENZAPRINE KI - cyclobenzaprine hcl td
cream 5% (compound kit) ............................................ 127
ACTIVE FE - fe carbonyl-fa-b complex-a-c-d-e-min tab
75-1.25 mg ................................................................... 144
ACTIVE-KETOPROFEN KIT - ketoprofen cream 5%
(compound kit) .............................................................. 162
ACTIVELLA -estradiol & norethindrone acetate tab 0.5-0.1
mg.................................................................................... 27
ACTIVELLA -estradiol & norethindrone acetate tab 1-0.5
mg.................................................................................... 27
ACTIVE OB - prenatal w/o a w/fe cbn-fa-dha cap 20-1-320
mg ................................................................................. 130
ACTIVE-TRAMADOL KIT - tramadol hcl cream 8%
(compound kit) .............................................................. 162
ACTONEL -risedronate sodium tab 150 mg......................40
ACTONEL -risedronate sodium tab 30 mg........................40
ACTONEL -risedronate sodium tab 35 mg........................40
ACTONEL -risedronate sodium tab 5 mg..........................40
ACTOPLUS MET -pioglitazone hcl-metformin hcl tab
15-500 mg........................................................................32
ACTOPLUS MET -pioglitazone hcl-metformin hcl tab
15-850 mg........................................................................32
ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab sr
24hr 15-1000 mg............................................................. 32
ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab sr
24hr 30-1000 mg............................................................. 32
ACTOS -pioglitazone hcl tab 15 mg (base equiv)..............32
ACT TOTAL CARE DRY MOUTH -sodium fluoride rinse
0.02%............................................................................. 159
ACULAR -ketorolac tromethamine ophth soln 0.5%........153
ACULAR LS -ketorolac tromethamine ophth soln
0.4%............................................................................... 153
ACURA BLOOD GLUCOSE MONIT - blood glucose
ACURA PLUS BLOOD GLUCOSE - blood glucose
ACUVAIL -ketorolac tromethamine ophth soln 0.45%..... 153
acyclovir cap 200 mg (Zovirax)...................................... 10
acyclovir oint 5% (Zovirax)........................................... 162
acyclovir susp 200 mg/5ml (Zovirax).............................10
acyclovir tab 400 mg (Zovirax).......................................10
acyclovir tab 800 mg (Zovirax).......................................10
ACZONE -dapsone gel 5%............................................. 162
ADALAT CC -nifedipine tab sr 24hr 30 mg....................... 48
adapalene cream 0.1% (Differin).................................. 162
adapalene gel 0.1% (Differin)........................................162
adapalene gel 0.3% (Differin)........................................162
ADASUVE -loxapine aerosol powder breath activated 10
mg.................................................................................... 93
ADCIRCA -tadalafil tab 20 mg (pah)................................. 64
2014
ADDERALL -amphetamine-dextroamphetamine tab 10
mg.................................................................................... 98
ADDERALL -amphetamine-dextroamphetamine tab 12.5
mg.................................................................................... 98
mg.................................................................................... 98
mg.................................................................................... 98
mg.................................................................................... 98
mg.................................................................................... 98
ADDERALL -amphetamine-dextroamphetamine tab 7.5
mg.................................................................................... 98
ADDERALL XR -amphetamine-dextroamphetamine cap sr
24hr 10 mg...................................................................... 98
24hr 15 mg...................................................................... 98
24hr 20 mg...................................................................... 98
24hr 25 mg...................................................................... 98
24hr 30 mg...................................................................... 98
24hr 5 mg........................................................................ 98
adefovir dipivoxil tab 10 mg (Hepsera)..........................10
ADEMPAS -riociguat tab 0.5 mg....................................... 64
ADEMPAS -riociguat tab 1 mg.......................................... 64
ADEMPAS -riociguat tab 2 mg.......................................... 64
ADOXA -doxycycline monohydrate cap 150 mg..................6
ADOXA -doxycycline monohydrate tab 100 mg.................. 6
ADOXA -doxycycline monohydrate tab 50 mg.................... 6
ADOXA -doxycycline monohydrate tab 75 mg.................... 6
ADOXA PAK 1/100 -doxycycline monohydrate tab 100
mg...................................................................................... 6
mg...................................................................................... 6
mg...................................................................................... 6
ADRENACLICK -epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000).......................................................... 60
ADRENACLICK -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................60
ADRENAL C FORMULA - bioflavonoid products tab ......130
ADRENALIN -epinephrine hcl inj 1 mg/ml......................... 72
ADRENALIN -epinephrine hcl nasal soln 0.1%................. 67
ADULT ASPIRIN LOW STRENGT -aspirin dispersible tab
81 mg............................................................................. 105
ADVAIR DISKUS -fluticasone-salmeterol aer powder ba
100-50 mcg/dose............................................................. 72
250-50 mcg/dose............................................................. 72
500-50 mcg/dose............................................................. 72
ADVAIR HFA -fluticasone-salmeterol inhal aerosol 115-21
mcg/act.............................................................................72
mcg/act.............................................................................72
mcg/act.............................................................................72
ADVANCED AM/PM - multiple vitamins w/ calcium therapy
pack .............................................................................. 130
ADVANCE INTUITION BLOOD G - blood glucose
monitoring devices ........................................................179
ADVANCE INTUITION BLOOD G - blood glucose
ADVANCE MICRO-DRAW METER - blood glucose
ADVATE -antihemophilic factor rahf-pfm for inj 1000
unit..................................................................................150
unit..................................................................................150
unit..................................................................................150
unit..................................................................................150
unit..................................................................................150
unit..................................................................................150
unit..................................................................................150
ADVICOR -niacin-lovastatin tab sr 24hr 1000-20 mg........ 61
ADVICOR -niacin-lovastatin tab sr 24hr 1000-40 mg........ 61
ADVICOR -niacin-lovastatin tab sr 24hr 500-20 mg.......... 61
ADVICOR -niacin-lovastatin tab sr 24hr 750-20 mg.......... 61
ADVOCATE BLOOD GLUCOSE MO - blood glucose
ADVOCATE BLOOD GLUCOSE MO - blood glucose
ADVOCATE REDI-CODE/TALKIN - blood glucose
ADVOCATE REDI-CODE/TALKIN - blood glucose
ADVOCATE REDI-CODE+ BLOOD - blood glucose
ADVOCATE REDI-CODE - blood glucose monitoring
devices ..........................................................................179
AEROHIST -chlorpheniramine-methscopolamine tab sr
12hr 8-2.5 mg.................................................................. 65
AEROSPAN -flunisolide hfa inhal aerosol 80 mcg/act....... 72
AFINITOR DISPERZ -everolimus tab for oral susp 2
mg.................................................................................... 20
mg.................................................................................... 20
mg.................................................................................... 20
193
2014
AFINITOR -everolimus tab 10 mg..................................... 20
AFINITOR -everolimus tab 2.5 mg.................................... 20
AFINITOR -everolimus tab 5 mg....................................... 20
AFINITOR -everolimus tab 7.5 mg.................................... 20
AFLURIA 2011-2012 -influenza virus vaccine split inj....... 17
AFLURIA PF 2011-2012 -influenza virus vaccine split
preservative free inj......................................................... 17
AGAMATRIX AMP NO CODE ADV - blood glucose
AGAMATRIX JAZZ - blood glucose monitoring kit w/
device ............................................................................179
AGAMATRIX PRESTO - blood glucose monitoring kit w/
device ............................................................................179
AGAMATRIX PRESTO PRO METE - blood glucose
AGGRENOX -aspirin-dipyridamole cap sr 12hr 25-200
mg.................................................................................. 150
AGRYLIN -anagrelide hcl cap 0.5 mg............................. 150
A-HYDROCORT -hydrocortisone sodium succinate for inj
100 mg............................................................................. 24
AIF #2 DRUG PREPARATION - flurbiprofen-gabapentcycloben-lido-dexameth cr (cmp kit) ............................. 162
AKNE-MYCIN -erythromycin oint 2%.............................. 162
AKTEN -lidocaine hcl ophth gel 3.5%............................. 153
ALAGESIC LQ -butalbital-acetaminophen-caffeine soln
50-325-40 mg/15ml........................................................ 105
ALAHIST AC -phenylephrine w/ codeine liqd 7.5-10
mg/5ml..............................................................................67
ALAHIST DHC -phenylephrine-dihydrocodeine liqd 7.5-3
mg/5ml..............................................................................67
ALAMAST -pemirolast potassium ophth soln 0.1%......... 153
ALA QUIN -clioquinol-hc cream 3-0.5%.......................... 162
ALA SCALP -hydrocortisone lotion 2%........................... 162
ALBAFORT - b-complex w/ iron inj ................................ 130
ALBAFORT -ferric ammon cit-vit b12-liver inj 67-50 mgmcg/ml............................................................................144
ALBATUSSIN NN - phenyleph-dm-pyril-pot guai-sod cit-cit
acid liquid ........................................................................67
ALBATUSSIN -phenylephrine-carbetapentane-gg cap
10-25-400 mg...................................................................67
ALBENZA -albendazole tab 200 mg................................. 15
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml).......... 72
albuterol sulfate soln nebu 0.5% (5 mg/ml)...................72
albuterol sulfate soln nebu 0.63 mg/3ml (base
equiv)...............................................................................72
194
albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv)...............................................................................72
albuterol sulfate syrup 2 mg/5ml................................... 72
albuterol sulfate tab 2 mg...............................................72
albuterol sulfate tab 4 mg...............................................72
albuterol sulfate tab sr 12hr 4 mg (Vospire er)............. 72
albuterol sulfate tab sr 12hr 8 mg (Vospire er)............. 72
ALCAINE -proparacaine hcl ophth soln 0.5%..................153
alclometasone dipropionate cream 0.05%
(Aclovate)...................................................................... 162
alclometasone dipropionate oint 0.05%...................... 162
ALCORTIN A - iodoquinol-hydrocortisone-aloe
polysaccharide gel 1-2-1% ........................................... 162
ALDACTAZIDE -spironolactone & hydrochlorothiazide tab
25-25 mg..........................................................................59
ALDACTAZIDE -spironolactone & hydrochlorothiazide tab
50-50 mg..........................................................................59
ALDACTONE -spironolactone tab 100 mg........................ 59
ALDACTONE -spironolactone tab 25 mg.......................... 59
ALDACTONE -spironolactone tab 50 mg.......................... 59
ALDARA -imiquimod cream 5%...................................... 162
ALENDRONATE SODIUM -alendronate sodium oral soln
70 mg/75ml...................................................................... 40
ALENDRONATE SODIUM -alendronate sodium tab 40
mg.................................................................................... 40
alendronate sodium tab 10 mg...................................... 40
alendronate sodium tab 35 mg...................................... 40
alendronate sodium tab 5 mg........................................ 40
alendronate sodium tab 70 mg (Fosamax)....................40
ALEVEER -capsaicin-menthol topical patch
0.0375-5%...................................................................... 162
ALFERON N -interferon alfa-n3 inj 5000000 unit/ml..........20
alfuzosin hcl tab sr 24hr 10 mg (Uroxatral)...................86
ALINIA -nitazoxanide for susp 100 mg/5ml....................... 15
ALINIA -nitazoxanide tab 500 mg......................................15
ALKERAN -melphalan tab 2 mg........................................20
ALLFEN CD -guaifenesin-codeine tab 400-10 mg.............67
ALLFEN CDX -guaifenesin-codeine liquid 200-20
mg/5ml..............................................................................67
ALLFEN CDX -guaifenesin-codeine tab 400-20 mg.......... 67
allopurinol tab 100 mg (Zyloprim)................................120
allopurinol tab 300 mg (Zyloprim)................................120
ALOCRIL -nedocromil sodium ophth soln 2%................. 153
ALODOX CONVENIENCE KIT - doxycycline hyclate tab
20 mg w/ eyelid cleansers kit ........................................... 6
ALOMIDE -lodoxamide tromethamine ophth soln
0.1%............................................................................... 153
ALOQUIN - iodoquinol-aloe polysaccharides gel 1.25-1%
....................................................................................... 162
ALORA -estradiol td patch biweekly 0.025 mg/24hr.......... 27
ALORA -estradiol td patch biweekly 0.05 mg/24hr............ 27
ALORA -estradiol td patch biweekly 0.075 mg/24hr.......... 27
ALORA -estradiol td patch biweekly 0.1 mg/24hr.............. 27
ALPAIN -phenyltoloxamine-acetaminophen tab 60-500
mg.................................................................................. 105
2014
ALPHAGAN P -brimonidine tartrate ophth soln 0.1%...... 153
ALPHAGAN P -brimonidine tartrate ophth soln
0.15%............................................................................. 153
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 1000 unit......................................... 150
vwf (human) for inj 1500 unit......................................... 150
vwf (human) for inj 250 unit........................................... 150
vwf (human) for inj 500 unit........................................... 150
ALPHANINE SD -coagulation factor ix for inj 1000
unit..................................................................................150
ALPHANINE SD -coagulation factor ix for inj 1500
unit..................................................................................150
ALPHANINE SD -coagulation factor ix for inj 500 unit..... 150
ALPRAZOLAM INTENSOL -alprazolam conc 1 mg/ml......86
alprazolam orally disintegrating tab 0.25 mg
(Niravam).........................................................................86
alprazolam orally disintegrating tab 0.5 mg..................87
alprazolam orally disintegrating tab 1 mg.....................87
alprazolam orally disintegrating tab 2 mg.....................87
alprazolam tab 0.25 mg (Xanax).....................................87
alprazolam tab 0.5 mg (Xanax).......................................87
alprazolam tab 1 mg (Xanax)..........................................87
alprazolam tab 2 mg (Xanax)..........................................87
alprazolam tab sr 24hr 0.5 mg (Xanax xr)..................... 87
alprazolam tab sr 24hr 1 mg (Xanax xr)........................ 87
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
1000 unit........................................................................ 150
2000 unit........................................................................ 150
3000 unit........................................................................ 150
500 unit.......................................................................... 150
alprostadil inj 500 mcg/ml (Prostin vr pediatric).........189
ALREX -loteprednol etabonate ophth susp 0.2%............ 153
ALSUMA -sumatriptan succinate solution auto-injector 6
mg/0.5ml.........................................................................118
ALTABAX -retapamulin oint 1%...................................... 162
ALTACE -ramipril cap 1.25 mg......................................... 52
ALTACE -ramipril cap 10 mg............................................ 52
ALTACE -ramipril cap 2.5 mg........................................... 52
ALTACE -ramipril cap 5 mg.............................................. 52
ALTOPREV -lovastatin tab sr 24hr 20 mg.........................61
ALUMINUM ACETATE -aluminum acetate soln.............. 162
aluminum chloride soln 20% (Drysol)......................... 162
ALUVEA -urea cream 39%..............................................162
ALVESCO -ciclesonide inhal aerosol 160 mcg/act............ 72
ALVESCO -ciclesonide inhal aerosol 80 mcg/act.............. 72
ALZ-NAC - l-methylfolate-methylcobalamin-acetylcyst tab
6-2-600 mg ................................................................... 142
AMANTADINE HCL -amantadine hcl tab 100 mg............125
amantadine hcl cap 100 mg......................................... 125
amantadine hcl syrup 50 mg/5ml................................. 125
AMARYL -glimepiride tab 1 mg......................................... 32
AMBIEN CR -zolpidem tartrate tab cr 12.5 mg..................97
AMBIEN CR -zolpidem tartrate tab cr 6.25 mg..................97
AMBIEN -zolpidem tartrate tab 10 mg...............................97
AMBIEN -zolpidem tartrate tab 5 mg.................................97
AMBIFED CD -pseudoephedrine w/ cod-gg tab 30-10-400
mg.................................................................................... 68
AMBIFED CDX -pseudoephedrine w/ cod-gg tab
30-20-400 mg...................................................................68
AMBIFED-G CD -pseudoephedrine w/ cod-gg tab
20-10-400 mg...................................................................68
AMBIFED-G CDX -pseudoephedrine w/ cod-gg tab
20-20-400 mg...................................................................68
AMCINONIDE -amcinonide lotion 0.1%.......................... 162
AMCINONIDE -amcinonide oint 0.1%............................. 162
amcinonide cream 0.1%................................................162
AMERGE -naratriptan hcl tab 1 mg (base equiv)............ 118
AMERGE -naratriptan hcl tab 2.5 mg (base equiv)..........118
AMETHYST -levonorgestrel-ethinyl estradiol (continuous)
tab 90-20 mcg..................................................................29
AMICAR -aminocaproic acid syrup 25%......................... 149
AMICAR -aminocaproic acid tab 1000 mg...................... 149
AMICAR -aminocaproic acid tab 500 mg........................ 149
AMIKACIN SULFATE -amikacin sulfate inj 100 mg/2ml (50
mg/ml)................................................................................ 8
amikacin sulfate inj 1 gm/4ml (250 mg/ml)......................8
amikacin sulfate inj 500 mg/2ml (250 mg/ml).................. 8
amiloride & hydrochlorothiazide tab 5-50 mg............... 59
amiloride hcl tab 5 mg.................................................... 59
AMINOBENZOATE POTASSIUM -potassium
aminobenzoate packet 2 gm..........................................129
AMINOCAPROIC ACID -aminocaproic acid tab 1000
mg.................................................................................. 149
aminocaproic acid syrup 25% (Amicar).......................149
aminocaproic acid tab 500 mg (Amicar)......................149
AMINOPHYLLINE -aminophylline tab 100 mg.................. 72
AMINOPHYLLINE -aminophylline tab 200 mg.................. 72
amiodarone hcl tab 100 mg............................................50
amiodarone hcl tab 200 mg (Cordarone).......................50
amiodarone hcl tab 400 mg............................................51
AMITIZA -lubiprostone cap 24 mcg...................................81
AMITIZA -lubiprostone cap 8 mcg.....................................81
amitriptyline hcl tab 100 mg...........................................88
amitriptyline hcl tab 10 mg.............................................88
amitriptyline hcl tab 150 mg...........................................88
195
2014
amlodipine besylate-atorvastatin calcium tab 10-10 mg
(Caduet)...........................................................................64
(Caduet)...........................................................................64
(Caduet)...........................................................................64
(Caduet)...........................................................................64
amlodipine besylate-atorvastatin calcium tab 2.5-10
mg (Caduet).................................................................... 64
mg (Caduet).................................................................... 64
mg (Caduet).................................................................... 64
(Caduet)...........................................................................64
(Caduet)...........................................................................64
(Caduet)...........................................................................64
(Caduet)...........................................................................64
amlodipine besylate-benazepril hcl cap 10-20 mg
(Lotrel)............................................................................. 52
(Lotrel)............................................................................. 52
amlodipine besylate-benazepril hcl cap 2.5-10 mg
(Lotrel)............................................................................. 52
(Lotrel)............................................................................. 52
(Lotrel)............................................................................. 52
(Lotrel)............................................................................. 52
amlodipine besylate tab 10 mg (Norvasc)..................... 48
amlodipine besylate tab 2.5 mg (Norvasc).................... 48
amlodipine besylate tab 5 mg (Norvasc).......................48
AMMONIA AROMATIC INHALANT -ammonia aromatic
spirit................................................................................189
AMOXAPINE -amoxapine tab 100 mg.............................. 88
AMOXAPINE -amoxapine tab 150 mg.............................. 88
AMOXAPINE -amoxapine tab 25 mg................................ 88
AMOXAPINE -amoxapine tab 50 mg................................ 88
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
196
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
(Augmentin)...................................................................... 1
amoxicillin & k clavulanate for susp 400-57 mg/5ml...... 1
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
(Augmentin es-600)..........................................................1
amoxicillin & k clavulanate tab 250-125 mg....................1
amoxicillin & k clavulanate tab 500-125 mg
(Augmentin)...................................................................... 1
amoxicillin & k clavulanate tab 875-125 mg
(Augmentin)...................................................................... 1
amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg
(Augmentin xr)................................................................. 1
AMOXICILLIN -amoxicillin (trihydrate) chew tab 125 mg.....1
AMOXICILLIN -amoxicillin (trihydrate) chew tab 250 mg.....1
amoxicillin cap-clarithro tab-lansopraz cap dr therapy
pack (Prevpac)............................................................... 76
AMOXICILLIN ER -amoxicillin (trihydrate) tab sr 24hr 775
mg...................................................................................... 1
amphetamine-dextroamphetamine cap sr 24hr 10 mg
(Adderall xr)....................................................................99
(Adderall xr)....................................................................99
(Adderall xr)....................................................................99
(Adderall xr)....................................................................99
(Adderall xr)....................................................................99
(Adderall xr)....................................................................99
amphetamine-dextroamphetamine tab 10 mg
(Adderall).........................................................................99
amphetamine-dextroamphetamine tab 12.5 mg
(Adderall).........................................................................99
(Adderall).........................................................................99
(Adderall).........................................................................99
(Adderall).........................................................................99
(Adderall).........................................................................99
amphetamine-dextroamphetamine tab 7.5 mg
(Adderall).........................................................................99
AMPHOTERICIN B -amphotericin b for inj 50 mg............... 9
ampicillin & sulbactam sodium for inj 1-0.5 gm
(Unasyn)............................................................................ 1
ampicillin & sulbactam sodium for inj 10-5 gm (Unasyn
bulk pack)......................................................................... 1
ampicillin & sulbactam sodium for inj 2-1 gm
(Unasyn)............................................................................ 1
ampicillin & sulbactam sodium for iv soln 1-0.5 gm...... 1
ampicillin & sulbactam sodium for iv soln 10-5 gm....... 1
AMPICILLIN -ampicillin for susp 125 mg/5ml...................... 1
AMPICILLIN -ampicillin for susp 250 mg/5ml...................... 1
2014
ampicillin cap 250 mg....................................................... 1
ampicillin cap 500 mg....................................................... 1
AMPICILLIN SODIUM -ampicillin sodium for inj 10 gm....... 1
AMPICILLIN SODIUM -ampicillin sodium for inj 125 mg..... 1
AMPICILLIN SODIUM -ampicillin sodium for iv soln 1
gm...................................................................................... 1
AMPICILLIN SODIUM -ampicillin sodium for iv soln 2
gm...................................................................................... 1
ampicillin sodium for inj 125 mg..................................... 1
ampicillin sodium for inj 1 gm......................................... 1
ampicillin sodium for inj 2 gm......................................... 1
ampicillin sodium for iv soln 10 gm................................ 1
AMPICILLIN-SULBACTAM -ampicillin & sulbactam sodium
for iv soln 2-1 gm.............................................................. 1
AMPYRA -dalfampridine tab sr 12hr 10 mg.................... 102
AMRIX -cyclobenzaprine hcl cap sr 24hr 15 mg..............127
AMRIX -cyclobenzaprine hcl cap sr 24hr 30 mg..............127
AMTURNIDE -aliskiren-amlodipine-hydrochlorothiazide tab
150-5-12.5 mg..................................................................52
300-10-12.5 mg................................................................52
300-10-25 mg...................................................................52
300-5-12.5 mg..................................................................52
300-5-25 mg.....................................................................52
ANACAINE -benzocaine oint 10%...................................162
ANADROL-50 -oxymetholone tab 50 mg.......................... 26
ANAFRANIL -clomipramine hcl cap 25 mg....................... 88
anagrelide hcl cap 0.5 mg (Agrylin).............................150
anagrelide hcl cap 1 mg............................................... 150
ANALPRAM ADVANCED -hc-pramoxine cr & diet manage
prod tab & cleans wipe kit............................................. 161
ANALPRAM E -hc-pramoxine emol cream 2.5-1% &
pramoxine wipe 1% kit...................................................161
ANALPRAM-HC -hydrocortisone acetate w/ pramoxine
rectal cream 1-1%..........................................................161
rectal cream 2.5-1%.......................................................161
rectal lotn 2.5-1%...........................................................161
ANALPRAM-HC SINGLES -hydrocortisone acetate w/
pramoxine rectal cream 1-1%........................................161
ANALPRAM-HC SINGLES -hydrocortisone acetate w/
pramoxine rectal cream 2.5-1%.....................................161
ANAPROX DS -naproxen sodium tab 550 mg................ 115
ANAPROX -naproxen sodium tab 275 mg...................... 115
ANASPAZ -hyoscyamine sulfate tab disp 0.125 mg..........76
anastrozole tab 1 mg (Arimidex)....................................20
ANCOBON -flucytosine cap 250 mg................................... 9
ANCOBON -flucytosine cap 500 mg................................... 9
ANDRODERM -testosterone td patch 24hr 2 mg/24hr...... 26
ANDRODERM -testosterone td patch 24hr 4 mg/24hr...... 26
ANDROGEL PUMP -testosterone td gel 12.5 mg/act
(1%)..................................................................................26
ANDROGEL PUMP -testosterone td gel 20.25 mg/act
(1.62%).............................................................................26
ANDROGEL -testosterone td gel 20.25 mg/1.25gm
(1.62%).............................................................................26
ANDROGEL -testosterone td gel 25 mg/2.5gm (1%)........ 26
ANDROGEL -testosterone td gel 40.5 mg/2.5gm
(1.62%).............................................................................26
ANDROGEL -testosterone td gel 50 mg/5gm (1%)........... 26
ANDROID -methyltestosterone cap 10 mg........................26
ANDROXY -fluoxymesterone tab 10 mg........................... 26
ANGELIQ -drospirenone-estradiol tab 0.25-0.5 mg...........27
ANGELIQ -drospirenone-estradiol tab 0.5-1 mg................27
ANIMI-3/VITAMIN D - folic acid-b6-b12-d-omega 3phytosterols cap 1 mg .................................................. 144
ANIMI-3 - folic acid-b6-b12-d-omega 3-phytosterols cap 1
mg ................................................................................. 144
ANIMI-3 - folic acid-vit b6-vit b12-omega 3-phytosterols
cap 1 mg ...................................................................... 144
ANORO ELLIPTA -umeclidinium-vilanterol aero powd ba
62.5-25 mcg/inh............................................................... 72
ANTABUSE -disulfiram tab 250 mg.................................102
ANTABUSE -disulfiram tab 500 mg.................................102
ANTARA -fenofibrate micronized cap 130 mg...................61
ANTARA -fenofibrate micronized cap 30 mg.....................61
ANTIPYRINE/BENZOCAINE -antipyrine-benzocaine otic
soln 55-14 mg/ml (5.5-1.4%)......................................... 158
antipyrine-benzocaine otic soln 54-14 mg/ml
(5.4-1.4%).......................................................................158
antipyrine-benzocaine otic soln 55-14 mg/ml (5.5-1.4%)
(Auralgan)..................................................................... 158
antipyrine-benzocaine-polycosanol otic sol
5.4-1.4-0.0097% (Treagan otic)....................................158
ANTIVERT -meclizine hcl tab 12.5 mg..............................80
ANTIVERT -meclizine hcl tab 25 mg.................................80
ANTIVERT -meclizine hcl tab 50 mg.................................80
ANUSOL-HC -hydrocortisone acetate suppos 25 mg......161
ANUSOL-HC -hydrocortisone rectal cream 2.5%............ 161
ANZEMET -dolasetron mesylate tab 100 mg.................... 80
ANZEMET -dolasetron mesylate tab 50 mg...................... 80
APEXICON E -diflorasone diacetate emollient base cream
0.05%............................................................................. 162
APHTHASOL -amlexanox oral paste 5%........................ 159
APIDRA -insulin glulisine inj 100 unit/ml........................... 36
APIDRA SOLOSTAR -insulin glulisine soln pen-injector inj
100 unit/ml....................................................................... 36
APLENZIN -bupropion hbr tab sr 24hr 174 mg................. 88
197
2014
APOKYN -apomorphine hydrochloride inj 10 mg/ml........125
APPBUTAMONE -bupropion hcl tab 75 mg & dietary
management cap pack.................................................... 88
APPBUTAMONE-D -bupropion hcl tab 75 mg & dietary
apraclonidine hcl ophth soln 0.5% (base equivalent)
(Iopidine)....................................................................... 154
APRISO -mesalamine cap sr 24hr 0.375 gm.................... 81
APTIOM -eslicarbazepine acetate tab 200 mg................ 120
APTIVUS -tipranavir cap 250 mg...................................... 10
APTIVUS -tipranavir oral soln 100 mg/ml..........................10
AP-ZEL - multiple vitamins w/ minerals tab .................... 130
AQUASOL A PARENTERAL -vitamin a inj 50000 unit/
ml....................................................................................129
AQUORAL - artificial saliva - aero soln .......................... 159
ARALEN -chloroquine phosphate tab 500 mg...................14
ARANESP ALBUMIN FREE -darbepoetin alfa-polysorbate
80 soln inj 100 mcg/0.5ml..............................................144
80 soln inj 100 mcg/ml...................................................144
80 soln inj 150 mcg/0.3ml..............................................144
80 soln inj 150 mcg/0.75ml............................................144
80 soln inj 200 mcg/0.4ml..............................................144
80 soln inj 200 mcg/ml...................................................144
80 soln inj 25 mcg/0.42ml..............................................144
80 soln inj 25 mcg/ml.................................................... 144
80 soln inj 300 mcg/0.6ml..............................................145
80 soln inj 300 mcg/ml...................................................144
80 soln inj 40 mcg/0.4ml................................................144
80 soln inj 40 mcg/ml.................................................... 144
80 soln inj 500 mcg/ml...................................................145
80 soln inj 60 mcg/0.3ml................................................144
80 soln inj 60 mcg/ml.................................................... 144
ARAVA -leflunomide tab 10 mg.......................................115
ARAVA -leflunomide tab 20 mg.......................................115
ARCALYST -rilonacept for inj 220 mg.............................115
ARCAPTA NEOHALER -indacaterol maleate inhal powder
cap 75 mcg (base equiv)................................................. 72
AREDIA -pamidronate disodium for inj 30 mg...................40
198
ARICEPT -donepezil hydrochloride tab 10 mg................ 102
ARICEPT -donepezil hydrochloride tab 23 mg................ 102
ARICEPT -donepezil hydrochloride tab 5 mg.................. 102
ARICEPT ODT -donepezil hydrochloride orally
disintegrating tab 10 mg................................................ 102
ARICEPT ODT -donepezil hydrochloride orally
disintegrating tab 5 mg.................................................. 102
ARIMIDEX -anastrozole tab 1 mg..................................... 20
ARIXTRA -fondaparinux sodium inj 10 mg/0.8ml............ 148
ARIXTRA -fondaparinux sodium inj 2.5 mg/0.5ml........... 148
ARIXTRA -fondaparinux sodium inj 5 mg/0.4ml.............. 148
ARIXTRA -fondaparinux sodium inj 7.5 mg/0.6ml........... 148
ARMOUR THYROID -thyroid tab 120 mg (2 grain)........... 38
ARMOUR THYROID -thyroid tab 15 mg (1/4 grain).......... 38
ARMOUR THYROID -thyroid tab 30 mg (1/2 grain).......... 38
ARMOUR THYROID -thyroid tab 60 mg (1 grain)............. 38
ARMOUR THYROID -thyroid tab 90 mg (1 1/2 grain)....... 38
AROMASIN -exemestane tab 25 mg.................................20
ARTHROTEC 50 -diclofenac w/ misoprostol tab delayed
release 50-0.2 mg..........................................................115
ARTHROTEC 75 -diclofenac w/ misoprostol tab delayed
release 75-0.2 mg..........................................................115
ARTISS - fibrin sealant component solution ...................149
ARZOL SILVER NITRATE APP -silver nitrate-potassium
nitrate applicator 75-25%............................................... 162
ASACOL HD -mesalamine tab delayed release 800
mg.................................................................................... 81
ASACOL -mesalamine tab delayed release 400 mg......... 81
ASCENSIA AUTODISC LOW AND - blood glucose
ASCENSIA AUTODISC NORMAL - blood glucose
calibration - liquid - normal ........................................... 180
ASCENSIA AUTODISC TEST ST -glucose blood test
disk................................................................................. 178
ASCORBIC ACID -ascorbic acid oral granules............... 129
ascorbic acid inj 500 mg/ml......................................... 129
ASMANEX TWISTHALER 120 ME -mometasone furoate
inhal powd 220 mcg/inh (breath activated)...................... 73
ASMANEX TWISTHALER 14 MET -mometasone furoate
ASMANEX TWISTHALER 30 ME -mometasone furoate
ASMANEX TWISTHALER 7 METE -mometasone furoate
ASPIRIN-CAFFEINE-DIHYDROC -aspirin-caffeinedihydrocodeine cap 356.4-30-16 mg............................. 107
aspirin chew tab 81 mg.................................................105
ASPIRIN LOW DOSE -aspirin tab 81 mg........................ 105
2014
aspirin tab 81 mg...........................................................105
aspirin tab delayed release 81 mg............................... 105
ASSURE 3 METER - blood glucose monitoring kit .........180
ASSURE 4 BLOOD GLUCOSE ME - blood glucose
ASSURE PLATINUM BLOOD GLU - blood glucose
ASSURE PRO BLOOD GLUCOSE - blood glucose
ASTAGRAF XL -tacrolimus cap sr 24hr 0.5 mg.............. 189
ASTAGRAF XL -tacrolimus cap sr 24hr 1 mg................. 189
ASTAGRAF XL -tacrolimus cap sr 24hr 5 mg................. 189
ASTELIN -azelastine hcl nasal spray 137 mcg/spray (1
mg/ml).............................................................................. 67
ASTEPRO -azelastine hcl nasal spray 0.15% (205.5 mcg/
spray)............................................................................... 67
ASTRINGYN -ferric subsulfate soln 259 mg/gm..............149
ATABEX EC - prenatal vit w/ dss-iron carbonyl-fa tab dr
29-1 mg ........................................................................ 130
ATABEX PRENATAL - prenatal vit w/ iron carbonyl-fa tab
65-1 mg ........................................................................ 130
ATACAND -candesartan cilexetil tab 16 mg......................52
ATACAND -candesartan cilexetil tab 32 mg......................52
ATACAND -candesartan cilexetil tab 4 mg........................52
ATACAND -candesartan cilexetil tab 8 mg........................52
ATACAND HCT -candesartan cilexetil-hydrochlorothiazide
tab 16-12.5 mg................................................................ 52
tab 32-12.5 mg................................................................ 52
tab 32-25 mg................................................................... 52
ATELVIA -risedronate sodium tab delayed release 35
mg.................................................................................... 40
atenolol & chlorthalidone tab 100-25 mg (Tenoretic
100).................................................................................. 52
atenolol & chlorthalidone tab 50-25 mg (Tenoretic
50).................................................................................... 52
atenolol tab 100 mg (Tenormin)..................................... 46
atenolol tab 25 mg (Tenormin)....................................... 46
atenolol tab 50 mg (Tenormin)....................................... 46
ATIVAN -lorazepam tab 0.5 mg........................................ 87
ATIVAN -lorazepam tab 1 mg........................................... 87
ATIVAN -lorazepam tab 2 mg........................................... 87
AT LAST BLOOD GLUCOSE SYS - blood glucose
monitoring kit ................................................................ 180
ATOPICLAIR - emollient - cream ................................... 162
atorvastatin calcium tab 10 mg (base equivalent)
(Lipitor)............................................................................61
(Lipitor)............................................................................61
(Lipitor)............................................................................61
(Lipitor)............................................................................61
atovaquone-proguanil hcl tab 250-100 mg
(Malarone)....................................................................... 14
atovaquone-proguanil hcl tab 62.5-25 mg
(Malarone)....................................................................... 14
atovaquone susp 750 mg/5ml (Mepron)........................ 15
ATRALIN -tretinoin gel 0.05%......................................... 162
ATRIPLA -efavirenz-emtricitabine-tenofovir df tab
600-200-300 mg...............................................................11
ATROPEN -atropine sulfate im inj device 0.25
mg/0.3ml...........................................................................76
ATROPEN -atropine sulfate im inj device 0.5
mg/0.7ml...........................................................................76
ATROPEN -atropine sulfate im inj device 1 mg/0.7ml....... 76
ATROPEN -atropine sulfate im inj device 2 mg/0.7ml....... 76
ATROPINE SULFATE -atropine sulfate inj 0.05 mg/ml..... 76
ATROPINE SULFATE -atropine sulfate inj 0.8 mg/ml....... 76
ATROPINE SULFATE -atropine sulfate ophth oint
1%.................................................................................. 154
atropine sulfate inj 0.1 mg/ml.........................................77
atropine sulfate inj 0.4 mg/ml.........................................77
atropine sulfate inj 1 mg/ml............................................77
atropine sulfate ophth soln 1% (Isopto atropine)....... 154
ATROVENT HFA -ipratropium bromide hfa inhal aerosol
17 mcg/act....................................................................... 73
ATROVENT -ipratropium bromide nasal soln 0.03% (21
mcg/spray)........................................................................67
ATROVENT -ipratropium bromide nasal soln 0.06% (42
mcg/spray)........................................................................67
AUBAGIO -teriflunomide tab 14 mg................................ 102
AUBAGIO -teriflunomide tab 7 mg.................................. 102
AUGMENTIN -amoxicillin & k clavulanate for susp
125-31.25 mg/5ml.............................................................. 2
AUGMENTIN -amoxicillin & k clavulanate for susp
250-62.5 mg/5ml................................................................ 2
AUGMENTIN -amoxicillin & k clavulanate tab 500-125
mg...................................................................................... 1
AUGMENTIN -amoxicillin & k clavulanate tab 875-125
mg...................................................................................... 1
AUGMENTIN ES-600 -amoxicillin & k clavulanate for susp
600-42.9 mg/5ml................................................................ 2
AUGMENTIN XR -amoxicillin & k clavulanate tab sr 12hr
1000-62.5 mg.....................................................................2
AURALGAN -antipyrine-benzocaine otic soln 55-14 mg/ml
(5.5-1.4%).......................................................................158
AURSTAT -emollient cream & wound dressing gel kit.....162
AUVI-Q -epinephrine solution auto-injector 0.15 mg/0.15ml
(1:1000)............................................................................ 60
AUVI-Q -epinephrine solution auto-injector 0.3 mg/0.3ml
(1:1000)............................................................................ 60
AVAILNEX -carbocysteine chew tab 750 mg.................. 142
AVALIDE -irbesartan-hydrochlorothiazide tab 150-12.5
mg.................................................................................... 52
AVALIDE -irbesartan-hydrochlorothiazide tab 300-12.5
mg.................................................................................... 52
199
2014
AVANDAMET -rosiglitazone maleate-metformin hcl tab
2-1000 mg........................................................................32
2-500 mg..........................................................................32
4-1000 mg........................................................................32
4-500 mg..........................................................................32
AVANDARYL -rosiglitazone maleate-glimepiride tab 4-1
mg.................................................................................... 32
mg.................................................................................... 32
mg.................................................................................... 32
mg.................................................................................... 32
mg.................................................................................... 32
AVANDIA -rosiglitazone maleate tab 2 mg (base
equiv)................................................................................33
equiv)................................................................................33
equiv)................................................................................33
AVAPRO -irbesartan tab 150 mg...................................... 52
AVAPRO -irbesartan tab 300 mg...................................... 52
AVAPRO -irbesartan tab 75 mg........................................ 52
AVAR-E LS -sulfacetamide sodium w/ sulfur cream
10-2%............................................................................. 162
AVAR LS CLEANSER -sulfacetamide sodium w/ sulfur
cleanser 10-2%.............................................................. 162
AVAR LS -sulfacetamide sodium w/ sulfur cleansing pad
10-2%............................................................................. 162
AVAR -sulfacetamide sodium w/ sulfur cleansing pad
9.5-5%............................................................................ 162
AVC -sulfanilamide vaginal cream 15%............................ 85
AVELOX ABC PACK -moxifloxacin hcl tab 400 mg (base
equiv)..................................................................................7
AVELOX -moxifloxacin hcl tab 400 mg (base equiv)........... 7
AVIDOXY DK -doxycycline tab 100 mg & suncreen & sal
acid wash 2% kit................................................................6
AVINZA -morphine sulfate beads cap sr 24hr 120 mg.....107
AVINZA -morphine sulfate beads cap sr 24hr 30 mg...... 107
AVODART -dutasteride cap 0.5 mg.................................. 86
AVONEX -interferon beta-1a for im inj kit 30mcg
(33mcg(6.6 mu)/vial)...................................................... 102
AVONEX -interferon beta-1a im inj kit 30 mcg/0.5ml.......102
AVONEX PEN -interferon beta-1a im inj kit 30
mcg/0.5ml.......................................................................102
AXERT -almotriptan malate tab 12.5 mg.........................118
AXERT -almotriptan malate tab 6.25 mg.........................118
200
AXID -nizatidine cap 150 mg.............................................77
AXID -nizatidine cap 300 mg.............................................77
AXID -nizatidine oral soln 15 mg/ml.................................. 77
AXIRON -testosterone td soln 30 mg/act.......................... 26
AYGESTIN -norethindrone acetate tab 5 mg.................... 32
AZACTAM -aztreonam for inj 1 gm................................... 15
AZACTAM -aztreonam for inj 2 gm................................... 15
AZASAN -azathioprine tab 100 mg................................. 189
AZASAN -azathioprine tab 75 mg................................... 189
AZASITE -azithromycin ophth soln 1%........................... 154
AZATHIOPRINE SODIUM -azathioprine sodium for inj 100
mg.................................................................................. 189
azathioprine tab 50 mg (Imuran).................................. 189
azelastine hcl nasal spray 0.15% (205.5 mcg/spray)
(Astepro)......................................................................... 67
azelastine hcl nasal spray 137 mcg/spray (1 mg/
ml).................................................................................... 67
azelastine hcl ophth soln 0.05% (Optivar)...................154
AZELEX -azelaic acid cream 20%.................................. 162
AZILECT -rasagiline mesylate tab 0.5 mg (base
equiv)..............................................................................125
AZILECT -rasagiline mesylate tab 1 mg (base equiv)......125
AZITHROMYCIN -azithromycin powd pack for susp 1
gm...................................................................................... 5
azithromycin for susp 100 mg/5ml (Zithromax).............. 5
azithromycin for susp 200 mg/5ml (Zithromax).............. 5
azithromycin tab 250 mg (Zithromax)..............................5
AZOPT -brinzolamide ophth susp 1%............................. 154
AZOR -amlodipine besylate-olmesartan medoxomil tab
10-20 mg..........................................................................52
10-40 mg..........................................................................52
5-20 mg............................................................................52
5-40 mg............................................................................52
aztreonam for inj 1 gm (Azactam)..................................15
aztreonam for inj 2 gm (Azactam)..................................15
AZULFIDINE EN-TABS -sulfasalazine tab delayed release
500 mg............................................................................. 81
AZULFIDINE -sulfasalazine tab 500 mg............................81
B
B-6 FOLIC ACID - cobalamine combination cap ............ 145
BABY DDROPS -cholecalciferol drops 400 unit/0.03ml
(per drop)....................................................................... 129
BACITRACIN -bacitracin intramuscular for soln 50000
unit....................................................................................15
BACITRACIN -bacitracin ophth oint 500 unit/gm............. 154
bacitracin intramuscular for soln 50000 unit
(Bacitracin)......................................................................15
bacitracin-polymyxin b ophth oint............................... 154
bacitracin-polymyxin-neomycin-hc ophth oint 1%..... 154
baclofen tab 10 mg........................................................127
2014
baclofen tab 20 mg........................................................127
BACMIN - multiple vitamins w/ minerals tab ...................130
BACTRIM DS -sulfamethoxazole-trimethoprim tab 800-160
mg.................................................................................... 15
BACTRIM -sulfamethoxazole-trimethoprim tab 400-80
mg.................................................................................... 15
BACTROBAN -mupirocin calcium cream 2%.................. 162
BACTROBAN -mupirocin oint 2%................................... 162
BACTROBAN NASAL -mupirocin calcium nasal oint
2%.................................................................................... 67
BAL-CARE DHA ESSENTIAL -prenat w/fe poly-na fered-fa
tab 27-1 & omega cap dr 374mg...................................130
BAL-CARE DHA -prenat w/fe poly-na fered-fa tab 27-1 &
omega cap dr 430mg.....................................................130
BAL IN OIL -dimercaprol inj 100 mg/ml...........................178
balsalazide disodium cap 750 mg (Colazal).................. 81
BANZEL -rufinamide susp 40 mg/ml............................... 120
BANZEL -rufinamide tab 200 mg.................................... 120
BANZEL -rufinamide tab 400 mg.................................... 120
BARACLUDE -entecavir oral soln 0.05 mg/ml...................11
BARACLUDE -entecavir tab 0.5 mg..................................11
BARACLUDE -entecavir tab 1 mg.....................................11
BAYER BREEZE 2 BLOOD GLUC - blood glucose
BAYER BREEZE 2 HIGH CONTR - blood glucose
calibration - liquid - high ............................................... 180
BAYER BREEZE 2 LOW CONTRO - blood glucose
calibration - liquid - low .................................................180
BAYER BREEZE 2 NORMAL CON - blood glucose
BAYER BREEZE 2 TEST DISC -glucose blood test
disk................................................................................. 178
BAYER CONTOUR BLOOD GLUCO - blood glucose
BAYER CONTOUR BLOOD GLUCO - blood glucose
BAYER CONTOUR BLOOD GLUCO -glucose blood test
strip.................................................................................178
BAYER CONTOUR HIGH CONTRO - blood glucose
calibration - liquid - high ............................................... 180
BAYER CONTOUR LINK BLOOD - blood glucose
BAYER CONTOUR LOW CONTROL - blood glucose
BAYER CONTOUR NEXT BLOOD - blood glucose
BAYER CONTOUR NEXT BLOOD -glucose blood test
strip.................................................................................178
BAYER CONTOUR NEXT CONTRO - blood glucose
BAYER CONTOUR NEXT CONTRO - blood glucose
BAYER CONTOUR NEXT EZ BLO - blood glucose
BAYER CONTOUR NEXT LINK B - blood glucose
BAYER CONTOUR NEXT USB BL - blood glucose
BAYER CONTOUR NORMAL CONT - blood glucose
BAYER CONTOUR USB BLOOD G - blood glucose
BAYER MICROLET LANCETS - lancets ........................180
b-complex vitamin inj ...................................................129
b-complex w/ c & folic acid cap 1 mg
(Nephrocaps)................................................................ 129
b-complex w/ c & folic acid tab....................................129
b-complex w/ c & folic acid tab 1 mg (Nephro-vite
rx)...................................................................................129
b-complex w/ c & folic acid tab 5 mg.......................... 129
b-complex w/ c-biotin-minerals & folic acid tab 5 mg
(Diatx zn).......................................................................129
b-complex w/ minerals liq ........................................... 129
BD GLUCOSE -glucose chew tab 5 gm............................33
BD LATITUDE DIABETES MANA - blood glucose
BD LOGIC BLOOD GLUCOSE MO - blood glucose
BD MAGNI-GUIDE MAGNIFIER - blood glucose
monitoring supplies .......................................................180
BEBULIN -factor ix complex for inj 200-1200 unit........... 150
BEBULIN VH -factor ix complex for inj 200-1200 unit......150
BECONASE AQ -beclomethasone dipropionate monohyd
nasal susp 42 mcg/spray.................................................67
BELLADONNA & OPIUM -belladonna alkaloids & opium
suppos 16.2-30 mg.......................................................... 77
BELLADONNA ALKALOIDS & OP -belladonna alkaloids &
opium suppos 16.2-60 mg............................................... 77
belladonna alkaloids-phenobarbital elixir 16.2 mg/5ml
(Donnatal)........................................................................77
belladonna alkaloids-phenobarbital tab 16.2 mg
(Donnatal)........................................................................77
benazepril & hydrochlorothiazide tab 10-12.5 mg
(Lotensin hct)................................................................. 52
benazepril & hydrochlorothiazide tab 20-12.5 mg
(Lotensin hct)................................................................. 52
benazepril & hydrochlorothiazide tab 20-25 mg
(Lotensin hct)................................................................. 52
benazepril & hydrochlorothiazide tab 5-6.25 mg.......... 53
benazepril hcl tab 10 mg (Lotensin).............................. 53
benazepril hcl tab 5 mg.................................................. 53
BENEFIX -coagulation factor ix (recombinant) for inj 1000
unit..................................................................................150
unit..................................................................................151
unit..................................................................................150
201
2014
unit..................................................................................151
unit..................................................................................150
BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 20-12.5 mg................................ 53
BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 40-12.5 mg................................ 53
BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 40-25 mg................................... 53
BENICAR -olmesartan medoxomil tab 20 mg................... 53
BENICAR -olmesartan medoxomil tab 40 mg................... 53
BENICAR -olmesartan medoxomil tab 5 mg..................... 53
BENSAL HP -salicylic acid & benzoic acid oint 3-6%...... 162
BENTYL -dicyclomine hcl cap 10 mg................................ 77
BENTYL -dicyclomine hcl inj 10 mg/ml............................. 77
BENTYL -dicyclomine hcl oral soln 10 mg/5ml..................77
BENTYL -dicyclomine hcl tab 20 mg.................................77
BENZAC AC WASH -benzoyl peroxide liq 5%................ 162
BENZACLIN -clindamycin phosphate-benzoyl peroxide gel
1-5%............................................................................... 162
BENZACLIN WITH PUMP -clindamycin phosphatebenzoyl peroxide gel 1-5%............................................ 163
BENZAC W WASH -benzoyl peroxide liq 5%..................162
BENZALKONIUM CHLORIDE -benzalkonium chloride
soln.................................................................................177
BENZALKONIUM CHLORIDE -benzalkonium chloride soln
17%................................................................................ 177
BENZALKONIUM CHLORIDE -benzalkonium chloride soln
50%................................................................................ 177
BENZAMYCIN -benzoyl peroxide-erythromycin gel
5-3%............................................................................... 163
BENZAMYCINPAK -benzoyl peroxide-erythromycin gel
pack 5-3%...................................................................... 163
BENZEFOAM -benzoyl peroxide foam 5.3%...................163
BENZEFOAMULTRA -benzoyl peroxide foam 9.8%....... 163
BENZIQ -benzoyl peroxide gel 5.25 %............................163
BENZIQ LS -benzoyl peroxide gel 2.75%....................... 163
benzocaine dental soln 20%.........................................159
BENZOIN COMPOUND TINCTURE -benzoin compound
tincture............................................................................163
BENZOIN TINCTURE -benzoin tincture.......................... 163
benzonatate cap 100 mg (Tessalon perles)...................68
benzonatate cap 200 mg.................................................68
benzoyl peroxide cleanser 4.25%................................ 163
benzoyl peroxide cloth 3%........................................... 163
benzoyl peroxide creamy wash 4% & cleanser lotion
kit................................................................................... 163
benzoyl peroxide creamy wash 8% &benzoyl peroxide
bar 5% kit (Bpo creamy wash comp)......................... 163
benzoyl peroxide creamy wash 8% & cleanser lotion
kit................................................................................... 163
202
benzoyl peroxide-erythromycin gel 5-3%
(Benzamycin)................................................................ 163
benzoyl peroxide foam 5.3% (Benzefoam).................. 163
benzoyl peroxide foam 9.8% (Benzefoamultra).......... 163
benzoyl peroxide gel 10%.............................................163
benzoyl peroxide gel 5%...............................................163
benzoyl peroxide liq 2.5%.............................................163
benzoyl peroxide liq 5.25%...........................................163
benzoyl peroxide liq 7%................................................163
benzoyl peroxide lotion 6%.......................................... 163
benzoyl peroxide lotion 9%.......................................... 163
benzoyl peroxide pad 3%............................................. 163
benzoyl peroxide pad 6%............................................. 163
benztropine mesylate inj 1 mg/ml (Cogentin)............. 125
benztropine mesylate tab 0.5 mg................................. 125
benztropine mesylate tab 1 mg....................................125
benztropine mesylate tab 2 mg....................................125
BEPREVE -bepotastine besilate ophth soln 1.5%........... 154
BERINERT -c1 esterase inhibitor (human) for iv inj kit 500
unit..................................................................................151
BESIVANCE -besifloxacin hcl ophth susp 0.6% (base
equiv)..............................................................................154
BETADINE OPHTHALMIC PREP -povidone-iodine ophth
soln 5%.......................................................................... 154
BETAGAN -levobunolol hcl ophth soln 0.5%...................154
betamethasone dipropionate augmented cream 0.05%
(Diprolene af)................................................................163
betamethasone dipropionate augmented gel
0.05%............................................................................. 163
betamethasone dipropionate augmented lotion 0.05%
(Diprolene).................................................................... 163
betamethasone dipropionate augmented oint 0.05%
(Diprolene).................................................................... 163
betamethasone dipropionate cream 0.05%................. 163
betamethasone dipropionate lotion 0.05%..................163
betamethasone dipropionate oint 0.05%..................... 163
betamethasone sod phosphate & acetate inj susp 6
(3-3) mg/ml (Celestone-soluspan)................................ 24
betamethasone valerate aerosol foam 0.12%
(Luxiq)........................................................................... 163
betamethasone valerate cream 0.1%........................... 163
betamethasone valerate lotion 0.1%............................163
betamethasone valerate oint 0.1%............................... 163
BETAPACE AF -sotalol hcl (afib/afl) tab 120 mg...............46
BETAPACE AF -sotalol hcl (afib/afl) tab 160 mg...............46
BETAPACE AF -sotalol hcl (afib/afl) tab 80 mg.................46
BETAPACE -sotalol hcl tab 120 mg.................................. 46
BETAPACE -sotalol hcl tab 160 mg.................................. 46
BETAPACE -sotalol hcl tab 80 mg....................................46
BETASERON -interferon beta-1b for inj kit 0.3 mg..........102
betaxolol hcl ophth soln 0.5%......................................154
betaxolol hcl tab 10 mg (Kerlone)..................................46
betaxolol hcl tab 20 mg (Kerlone)..................................46
bethanechol chloride tab 10 mg (Urecholine)............... 84
2014
bethanechol chloride tab 5 mg (Urecholine).................84
BETHKIS -tobramycin nebu soln 300 mg/4ml..................... 8
BETIMOL -timolol ophth soln 0.25%............................... 154
BETIMOL -timolol ophth soln 0.5%................................. 154
BETOPTIC-S -betaxolol hcl ophth susp 0.25%............... 154
BEYAZ -drospirenone-ethinyl estrad-levomefolate tab
3-0.02-0.451 mg...............................................................29
BIAXIN -clarithromycin for susp 250 mg/5ml.......................5
BIAXIN -clarithromycin tab 250 mg..................................... 5
BIAXIN -clarithromycin tab 500 mg..................................... 5
BIAXIN XL -clarithromycin tab sr 24hr 500 mg....................5
BIAXIN XL PAC -clarithromycin tab sr 24hr 500 mg............5
bicalutamide tab 50 mg (Casodex)................................ 20
BICILLIN C-R -penicillin g benzathine & procaine inj
900000-300000 unt/2ml..................................................... 2
BICILLIN C-R -penicillin g benzathine & procaine inj susp
1200000 unit/2ml............................................................... 2
BICILLIN L-A -penicillin g benzathine intramuscular susp
1200000 unit/2ml............................................................... 2
2400000 unit/4ml............................................................... 2
600000 unit/ml................................................................... 2
BIDIL -isosorbide dinitrate-hydralazine hcl tab 20-37.5
mg.................................................................................... 64
BIFERARX -polysacch fe cmplx-fe heme poly-fa-b12 tab
22-6-1-0.025 mg............................................................ 145
BILTRICIDE -praziquantel tab 600 mg.............................. 15
BINOSTO -alendronate sodium effervescent tab 70
mg.................................................................................... 40
BIOREGESIC -phenyltoloxamine-acetaminophen tab
50-650 mg......................................................................105
BIO-STATIN -nystatin cap 1000000 unit............................. 9
BIO-STATIN -nystatin cap 500000 unit............................... 9
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
(Ziac)................................................................................53
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
(Ziac)................................................................................53
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
(Ziac)................................................................................53
bisoprolol fumarate tab 10 mg (Zebeta)........................ 46
bisoprolol fumarate tab 5 mg (Zebeta).......................... 46
BIVIGAM -immune globulin (human) iv soln 10
gm/100ml..........................................................................19
BIVIGAM -immune globulin (human) iv soln 5
gm/50ml............................................................................19
BLEPH-10 -sulfacetamide sodium ophth soln 10%......... 154
BLEPHAMIDE S.O.P. -sulfacetamide sodium-prednisolone
ophth oint 10-0.2%.........................................................154
BLEPHAMIDE -sulfacetamide sodium-prednisolone ophth
susp 10-0.2%................................................................. 154
BLOOD GLUCOSE CALIBRATION LIQUID
VARIOUS....................................................................... 180
BLOOD GLUCOSE MONITORING - blood glucose
BLOOD GLUCOSE SYSTEM PAK - blood glucose
B-NEXA - prenatal w/ calcium-vit b6-fa-ginger tab 1.22 mg
....................................................................................... 130
B-NEXA - prenatal w/ calcium-vit b6-fa-ginger tab 1.2 mg
....................................................................................... 130
BONIVA -ibandronate sodium iv soln 3 mg/3ml (base
equivalent)........................................................................40
BONIVA -ibandronate sodium tab 150 mg (base
equivalent)........................................................................40
BORIC ACID -boric acid granules................................... 163
BOSULIF -bosutinib tab 100 mg....................................... 20
BOSULIF -bosutinib tab 500 mg....................................... 20
BP FOLINATAL PLUS B - prenatal w/ calcium carbonateb6-b12-fa tab 1 mg .......................................................130
BP MULTINATAL PLUS - prenatal w/o a vit w/ fe
fumarate-fa tab 30-1 mg ...............................................130
BP MULTINATAL PLUS - prenatal w/o a vit w/ fe fum-fa
tab chew 40-1 mg .........................................................130
BPO 3% FOAMING CLOTHS -benzoyl peroxide cloth
3%.................................................................................. 163
6%.................................................................................. 163
9%.................................................................................. 163
BPO -benzoyl peroxide gel 4%....................................... 163
BPO -benzoyl peroxide gel 8%....................................... 163
BPO CREAMY WASH COMPLETE -benzoyl peroxide
creamy wash 8% &benzoyl peroxide bar 5% kit............ 163
BP VIT 3 - folic acid-vit b6-vit b12-omega 3-phytosterols
cap 1 mg ...................................................................... 145
BRAVELLE -urofollitropin purified for inj 75 unit................ 40
BREEZE 2 BLOOD GLUCOSE MO - blood glucose
BREO ELLIPTA -fluticasone furoate-vilanterol aero powd
ba 100-25 mcg/inh........................................................... 73
BREVICON-28 -norethindrone & ethinyl estradiol tab 0.5
mg-35 mcg....................................................................... 29
BRILINTA -ticagrelor tab 90 mg...................................... 151
brimonidine tartrate ophth soln 0.15% (Alphagan
p).................................................................................... 154
brimonidine tartrate ophth soln 0.2%.......................... 154
BRINTELLIX -vortioxetine hbr tab 10 mg (base equiv)...... 88
BRINTELLIX -vortioxetine hbr tab 20 mg (base equiv)...... 88
BRINTELLIX -vortioxetine hbr tab 5 mg (base equiv)........88
BRISDELLE -paroxetine mesylate cap 7.5 mg (base
equiv)..............................................................................102
BROMDAY -bromfenac sodium ophth soln 0.09% (base
equiv) (once-daily)......................................................... 154
BROMFENAC -bromfenac sodium ophth soln 0.09% (base
equivalent)......................................................................154
bromfenac sodium ophth soln 0.09% (base equiv)
(once-daily)................................................................... 154
203
2014
bromocriptine mesylate cap 5 mg (Parlodel).............. 125
bromocriptine mesylate tab 2.5 mg (Parlodel)............ 125
brompheniramine & phenylephrine susp 6-10
mg/5ml.............................................................................68
brompheniramine & pseudoephedrine tab sr 12hr 6-45
mg.................................................................................... 68
brompheniramine maleate tab sr 12hr 6 mg................. 65
BROMPHENIRAMINE TANNATE -brompheniramine
tannate chew tab 12 mg.................................................. 66
BRONCOMAR-1 -theophylline-pse-gg elixir 150-30-150
mg/15ml............................................................................73
BRONCOPECTOL -phenyleph-chlorphen w/ dm-gg syrup
5-2-5-75 mg/5ml...............................................................68
BRONDIL -dyphylline-guaifenesin liqd 100-100
mg/15ml............................................................................73
BROVANA -arformoterol tartrate soln nebu 15 mcg/2ml
(base equiv)..................................................................... 73
BUCALSEP - antiseptic products misc - liquid ............... 177
BUCALSEP - antiseptic products misc - solution ........... 177
budesonide cap sr 24hr 3 mg (Entocort ec)..................24
budesonide inhalation susp 0.25 mg/2ml
(Pulmicort)...................................................................... 73
budesonide inhalation susp 0.5 mg/2ml
(Pulmicort)...................................................................... 73
budesonide nasal susp 32 mcg/act (Rhinocort
aqua)................................................................................67
bumetanide inj 0.25 mg/ml............................................. 59
bumetanide tab 0.5 mg................................................... 59
bumetanide tab 1 mg...................................................... 59
bumetanide tab 2 mg...................................................... 59
BUPAP -butalbital-acetaminophen tab 50-300 mg.......... 105
BUPAP -butalbital-acetaminophen tab 50-650 mg.......... 105
BUPHENYL -sodium phenylbutyrate oral powder 3 gm/
teaspoonful.......................................................................40
BUPHENYL -sodium phenylbutyrate tab 500 mg.............. 40
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base
equiv).............................................................................107
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
equiv).............................................................................107
buprenorphine hcl sl tab 2 mg (base equiv)............... 107
buprenorphine hcl sl tab 8 mg (base equiv)............... 107
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
(Zyban).......................................................................... 102
bupropion hcl tab 100 mg (Wellbutrin)..........................88
bupropion hcl tab 75 mg (Wellbutrin)............................89
bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr).........88
bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl)......... 88
bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl)......... 88
buspirone hcl tab 10 mg.................................................87
buspirone hcl tab 5 mg...................................................87
buspirone hcl tab 7.5 mg................................................87
204
BUTALBITAL/ASPIRIN/CAFFEI -butalbital-aspirin-caffeine
tab 50-325-40 mg.......................................................... 106
butalbital-acetaminophen-caffeine cap 50-300-40 mg
(Fioricet)........................................................................ 105
butalbital-acetaminophen-caffeine cap 50-325-40
mg.................................................................................. 105
butalbital-acetaminophen-caffeine cap 50-500-40
mg.................................................................................. 105
butalbital-acetaminophen-caffeine tab 50-325-40 mg
(Esgic)........................................................................... 105
butalbital-acetaminophen-caffeine tab 50-500-40
mg.................................................................................. 105
butalbital-acetaminophen-caff w/ cod cap 50-300-40-30
mg (Fioricet/codeine)...................................................107
butalbital-acetaminophen-caff w/ cod cap 50-325-40-30
mg.................................................................................. 107
butalbital-acetaminophen tab 50-325 mg.................... 105
butalbital-acetaminophen tab 50-650 mg.................... 105
butalbital-aspirin-caffeine cap 50-325-40 mg
(Fiorinal)........................................................................ 105
butalbital-aspirin-caffeine tab 50-325-40 mg............... 106
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
(Fiorinal/codeine #3).................................................... 107
butamben-tetracaine-benzocaine aerosol spray
2-2-14%..........................................................................163
BUTISOL SODIUM -butabarbital sodium elixir 30
mg/5ml..............................................................................97
BUTISOL SODIUM -butabarbital sodium tab 30 mg..........97
BUTISOL SODIUM -butabarbital sodium tab 50 mg..........97
butorphanol tartrate nasal soln 10 mg/ml................... 107
BUTRANS -buprenorphine td patch weekly 10 mcg/
hr.................................................................................... 107
hr.................................................................................... 107
hr.................................................................................... 107
BUTRANS -buprenorphine td patch weekly 5 mcg/hr......107
BYDUREON -exenatide extended release for inj susp 2
mg.................................................................................... 33
BYDUREON -exenatide extended release for susp peninjector 2 mg.................................................................... 33
BYETTA -exenatide soln pen-injector 10 mcg/0.04ml....... 33
BYETTA -exenatide soln pen-injector 5 mcg/0.02ml......... 33
BYSTOLIC -nebivolol hcl tab 10 mg (base equivalent)......46
BYSTOLIC -nebivolol hcl tab 2.5 mg (base equivalent).....46
BYSTOLIC -nebivolol hcl tab 20 mg (base equivalent)......46
BYSTOLIC -nebivolol hcl tab 5 mg (base equivalent)........46
C
cabergoline tab 0.5 mg................................................... 40
CADUET -amlodipine besylate-atorvastatin calcium tab
10-10 mg..........................................................................64
10-20 mg..........................................................................64
10-40 mg..........................................................................64
2014
10-80 mg..........................................................................64
2.5-10 mg.........................................................................64
2.5-20 mg.........................................................................64
2.5-40 mg.........................................................................64
5-10 mg............................................................................64
5-20 mg............................................................................64
5-40 mg............................................................................64
5-80 mg............................................................................64
CAFCIT -caffeine citrate oral soln 60 mg/3ml (10 mg/ml
base equiv)...................................................................... 99
CAFERGOT -ergotamine w/ caffeine tab 1-100 mg........ 118
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base
equiv) (Cafcit)................................................................. 99
CALAFOL RX - fa-hydroxocobalamin-policosanol-vit b6-vit
d-ca tab .........................................................................142
CALAN SR -verapamil hcl tab cr 120 mg.......................... 48
CALAN -verapamil hcl tab 120 mg....................................48
CALAN -verapamil hcl tab 80 mg......................................48
CALCIFOL -ca carb-folic acid-vit d-b6-b12-boron-mag
wafer 1342-1.6 mg.........................................................140
calcipotriene-betamethasone dipropionate oint
0.005-0.064% (Taclonex)..............................................164
calcipotriene cream 0.005% (Dovonex)....................... 164
calcipotriene oint 0.005%..............................................164
calcipotriene soln 0.005% (50 mcg/ml)........................ 164
calcitonin (salmon) nasal soln 200 unit/act
(Miacalcin).......................................................................40
CALCITRIOL -calcitriol oint 3 mcg/gm.............................164
calcitriol cap 0.25 mcg (Rocaltrol)................................. 40
calcitriol cap 0.5 mcg (Rocaltrol)................................... 40
calcitriol oral soln 1 mcg/ml (Rocaltrol)........................ 40
calcium acetate (phosphate binder) cap 667 mg (169
mg ca) (Phoslo)..............................................................82
calcium acetate (phosphate binder) tab 667 mg
(Eliphos).......................................................................... 82
CALCIUM-FOLIC ACID PLUS D -ca carb-folic acid-vit db6-b12-boron-mag wafer 1342-1 mg............................. 140
CALCIUM PNV - prenatal w/o vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg .......................................................... 130
CAMBIA -diclofenac potassium packet 50 mg.................118
CAMINO PRO 15PE - nutritional supplement liquid ....... 142
CAMPRAL -acamprosate calcium tab delayed release 333
mg.................................................................................. 102
CANASA -mesalamine suppos 1000 mg...........................82
candesartan cilexetil-hydrochlorothiazide tab 16-12.5
mg (Atacand hct)........................................................... 53
candesartan cilexetil-hydrochlorothiazide tab 32-12.5
mg (Atacand hct)........................................................... 53
candesartan cilexetil-hydrochlorothiazide tab 32-25
mg (Atacand hct)........................................................... 53
candesartan cilexetil tab 16 mg (Atacand).................... 53
candesartan cilexetil tab 32 mg (Atacand).................... 53
candesartan cilexetil tab 4 mg (Atacand)......................53
candesartan cilexetil tab 8 mg (Atacand)......................53
CANTIL -mepenzolate bromide tab 25 mg........................ 77
CAPASTAT SULFATE -capreomycin sulfate for inj 1
gm...................................................................................... 9
CAPCOF -phenylephrine-chlorphen w/ codeine syrup
5-2-10 mg/5ml..................................................................68
capecitabine tab 150 mg (Xeloda)..................................20
capecitabine tab 500 mg (Xeloda)..................................21
CAPEX -fluocinolone acetonide shampoo 0.01%............164
CAPHOSOL - artificial saliva - solution .......................... 159
CAPITAL/CODEINE -acetaminophen w/ codeine susp
120-12 mg/5ml............................................................... 107
CAPRELSA -vandetanib tab 100 mg................................ 21
CAPRELSA -vandetanib tab 300 mg................................ 21
CAPTOPRIL/HYDROCHLOROTHIA -captopril &
hydrochlorothiazide tab 25-15 mg................................... 53
captopril tab 100 mg....................................................... 53
captopril tab 12.5 mg...................................................... 53
captopril tab 25 mg......................................................... 53
captopril tab 50 mg......................................................... 53
CARAC -fluorouracil cream 0.5%.................................... 164
CARAFATE -sucralfate susp 1 gm/10ml........................... 77
CARAFATE -sucralfate tab 1 gm...................................... 77
CARBAGLU -carglumic acid tab 200 mg...........................40
carbamazepine cap sr 12hr 100 mg (Carbatrol).......... 120
carbamazepine chew tab 100 mg.................................120
carbamazepine susp 100 mg/5ml (Tegretol)............... 120
carbamazepine tab 200 mg (Tegretol)......................... 120
carbamazepine tab sr 12hr 200 mg (Tegretol-xr)........ 120
carbamazepine tab sr 12hr 400 mg (Tegretol-xr)........ 120
CARBAPHEN 12 PED -phenyleph-chlorphencarbetapentane susp 2.5-1.25-7.5 mg/ml........................ 68
CARBAPHEN 12 -phenyleph-chlorphen-carbetapentane
liqd 10-4-27.5 mg/5ml...................................................... 68
CARBATROL -carbamazepine cap sr 12hr 100 mg........ 120
205
2014
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 12.5-50-200 mg.................................. 125
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 18.75-75-200 mg................................ 125
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 25-100-200 mg...................................125
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 31.25-125-200 mg.............................. 125
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 37.5-150-200 mg................................ 125
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 50-200-200 mg...................................125
carbidopa & levodopa orally disintegrating tab 10-100
mg.................................................................................. 125
mg.................................................................................. 125
mg.................................................................................. 125
carbidopa & levodopa tab 10-100 mg (Sinemet)......... 125
carbidopa & levodopa tab cr 25-100 mg (Sinemet
cr)...................................................................................125
carbidopa & levodopa tab cr 50-200 mg (Sinemet
cr)...................................................................................125
carbidopa tab 25 mg (Lodosyn)................................... 125
carbinoxamine maleate soln 4 mg/5ml (Palgic)............ 66
carbinoxamine maleate tab 4 mg (Palgic)..................... 66
carbonyl iron chew tab 15 mg (elemental iron)...........145
carbonyl iron susp 15 mg/1.25ml (elemental iron)......145
CARDENE SR -nicardipine hcl cap sr 12hr 30 mg............ 48
CARDIOTEK-RX - folic acid-b12-b6-arginine-black pepper
tab ................................................................................. 142
CARDIOVID PLUS -dha-epa-vit b6-b12-folic acid cap
240-360-20-0.5-0.8 mg.................................................. 142
CARDIZEM CD -diltiazem hcl coated beads cap sr 24hr
120 mg............................................................................. 48
180 mg............................................................................. 48
240 mg............................................................................. 48
300 mg............................................................................. 48
360 mg............................................................................. 48
CARDIZEM -diltiazem hcl tab 120 mg...............................48
CARDIZEM -diltiazem hcl tab 30 mg.................................48
CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr
120 mg............................................................................. 48
180 mg............................................................................. 48
206
240 mg............................................................................. 48
300 mg............................................................................. 48
360 mg............................................................................. 48
420 mg............................................................................. 48
CARDURA -doxazosin mesylate tab 1 mg........................ 53
CARDURA XL -doxazosin mesylate tab sr 24 hr 4 mg
(base equiv)..................................................................... 86
CARDURA XL -doxazosin mesylate tab sr 24 hr 8 mg
(base equiv)..................................................................... 86
CAREONE BLOOD GLUCOSE MON - blood glucose
CARESENS N BLOOD GLUCOSE - blood glucose
CARESENS N GLUCOSE MONITO - blood glucose
CARESENS N VOICE BLOOD GL - blood glucose
CARIMUNE NANOFILTERED -immune globulin (human)
iv for soln 12 gm..............................................................19
iv for soln 3 gm................................................................19
iv for soln 6 gm................................................................19
CARISOPRODOL -carisoprodol tab 250 mg................... 127
carisoprodol tab 350 mg (Soma)..................................127
carisoprodol w/ aspirin & codeine tab 200-325-16
mg.................................................................................. 127
carisoprodol w/ aspirin tab 200-325 mg...................... 127
CARMOL-HC -urea-hc acetate cream 1%.......................164
CARNITOR -levocarnitine oral soln 1 gm/10ml (10%)....... 40
CARNITOR -levocarnitine tab 330 mg.............................. 40
CARNITOR SF -levocarnitine oral soln 1 gm/10ml
(10%)................................................................................40
carteolol hcl ophth soln 1%......................................... 154
carvedilol tab 12.5 mg (Coreg)....................................... 46
carvedilol tab 25 mg (Coreg).......................................... 46
carvedilol tab 3.125 mg (Coreg)..................................... 46
carvedilol tab 6.25 mg (Coreg)....................................... 46
CASCARA SAGRADA -cascara sagrada fl ext 1 gm/
ml......................................................................................75
CASODEX -bicalutamide tab 50 mg................................. 21
CATAFLAM -diclofenac potassium tab 50 mg.................115
CATAPRES -clonidine hcl tab 0.1 mg............................... 53
CATAPRES-TTS-1 -clonidine hcl td patch weekly 0.1
mg/24hr............................................................................ 53
2014
mg/24hr............................................................................ 53
mg/24hr............................................................................ 53
CAVAN-ALPHA KIT -prenat w/fe poly-na fered-fa tab 27-1
& omega cap dr 300mg................................................. 130
CAVAN-EC SOD DHA -prenatal w/ sod feredetate-fa tab
30-1 & omega 3 cap dr................................................. 130
CAVERJECT -alprostadil for inj 20 mcg............................ 64
CAVERJECT -alprostadil for inj 40 mcg............................ 64
CAVERJECT IMPULSE -alprostadil for inj kit 10 mcg....... 64
CAVERJECT IMPULSE -alprostadil for inj kit 20 mcg....... 64
CAYSTON -aztreonam lysine for inhal soln 75 mg (base
equivalent)........................................................................15
CEDAX -ceftibuten cap 400 mg.......................................... 3
CEDAX -ceftibuten for susp 180 mg/5ml.............................3
CEDAX -ceftibuten for susp 90 mg/5ml...............................3
CEENU -lomustine cap 100 mg........................................ 21
CEENU -lomustine cap 10 mg.......................................... 21
CEENU -lomustine cap 40 mg.......................................... 21
cefaclor cap 250 mg..........................................................3
cefaclor cap 500 mg..........................................................3
CEFACLOR -cefaclor for susp 125 mg/5ml.........................3
CEFACLOR ER -cefaclor monohydrate tab sr 12hr 500
mg...................................................................................... 3
cefadroxil cap 500 mg.......................................................3
cefadroxil for susp 250 mg/5ml........................................3
cefadroxil for susp 500 mg/5ml........................................3
cefadroxil tab 1 gm........................................................... 3
CEFAZOLIN SODIUM -cefazolin sodium (bulk) for inj 100
gm...................................................................................... 3
CEFAZOLIN SODIUM -cefazolin sodium (bulk) for inj 300
gm...................................................................................... 3
CEFAZOLIN SODIUM -cefazolin sodium for iv soln 1
gm...................................................................................... 3
cefazolin sodium for inj 10 gm.........................................3
cefazolin sodium for inj 1 gm.......................................... 3
cefazolin sodium for inj 20 gm.........................................3
cefazolin sodium for inj 500 mg.......................................3
cefdinir cap 300 mg...........................................................3
cefdinir for susp 125 mg/5ml........................................... 3
cefdinir for susp 250 mg/5ml........................................... 3
CEFDITOREN PIVOXIL -cefditoren pivoxil tab 200 mg
(base equivalent)............................................................... 3
CEFDITOREN PIVOXIL -cefditoren pivoxil tab 400 mg
(base equivalent)............................................................... 3
cefepime hcl for inj 1 gm (Maxipime).............................. 3
cefepime hcl for inj 2 gm (Maxipime).............................. 3
cefotaxime sodium for inj 10 gm (Claforan)....................3
cefotaxime sodium for inj 1 gm (Claforan)......................3
cefotaxime sodium for inj 2 gm (Claforan)......................3
cefotaxime sodium for inj 500 mg (Claforan)..................3
CEFOTETAN -cefotetan disodium for inj 10 gm..................3
CEFOTETAN -cefotetan disodium for inj 1 gm....................3
CEFOTETAN -cefotetan disodium for inj 2 gm....................3
cefoxitin sodium for inj 10 gm......................................... 3
cefoxitin sodium for inj 1 gm........................................... 3
cefoxitin sodium for inj 2 gm........................................... 3
cefpodoxime proxetil for susp 100 mg/5ml.....................3
cefpodoxime proxetil for susp 50 mg/5ml.......................3
cefpodoxime proxetil tab 100 mg.................................... 3
cefpodoxime proxetil tab 200 mg.................................... 3
cefprozil for susp 125 mg/5ml..........................................3
cefprozil for susp 250 mg/5ml..........................................3
cefprozil tab 250 mg..........................................................3
cefprozil tab 500 mg..........................................................3
CEFTAZIDIME -ceftazidime (bulk) for inj 100 gm................3
ceftazidime for inj 1 gm (Fortaz)...................................... 3
ceftazidime for iv soln 1 gm (Fortaz)...............................4
ceftazidime for iv soln 2 gm (Fortaz)...............................4
CEFTIBUTEN -ceftibuten cap 400 mg................................ 4
CEFTIBUTEN -ceftibuten for susp 180 mg/5ml...................4
CEFTIN -cefuroxime axetil for susp 125 mg/5ml................. 4
CEFTIN -cefuroxime axetil for susp 250 mg/5ml................. 4
CEFTIN -cefuroxime axetil tab 250 mg............................... 4
CEFTIN -cefuroxime axetil tab 500 mg............................... 4
ceftriaxone sodium for inj 10 gm.....................................4
ceftriaxone sodium for inj 1 gm (Rocephin)................... 4
ceftriaxone sodium for inj 250 mg................................... 4
ceftriaxone sodium for inj 2 gm.......................................4
ceftriaxone sodium for inj 500 mg (Rocephin)................4
ceftriaxone sodium for iv soln 1 gm................................4
ceftriaxone sodium for iv soln 2 gm................................4
cefuroxime axetil for susp 125 mg/5ml (Ceftin).............. 4
cefuroxime axetil tab 250 mg (Ceftin)..............................4
cefuroxime axetil tab 500 mg (Ceftin)..............................4
CEFUROXIME SODIUM -cefuroxime sodium (bulk) for inj
225 gm............................................................................... 4
CEFUROXIME SODIUM -cefuroxime sodium (bulk) for inj
75 gm................................................................................. 4
CEFUROXIME SODIUM -cefuroxime sodium for iv soln
7.5 gm................................................................................ 4
cefuroxime sodium for inj 1.5 gm (Zinacef).................... 4
cefuroxime sodium for inj 7.5 gm (Zinacef).................... 4
cefuroxime sodium for inj 750 mg (Zinacef)................... 4
cefuroxime sodium for iv soln 1.5 gm (Zinacef)............. 4
CELEBREX -celecoxib cap 100 mg................................ 115
CELEBREX -celecoxib cap 50 mg.................................. 115
CELESTONE -betamethasone soln 0.6 mg/5ml................24
CELESTONE-SOLUSPAN -betamethasone sod
phosphate & acetate inj susp 6 (3-3) mg/ml.................... 24
CELEXA -citalopram hydrobromide tab 10 mg (base
equiv)................................................................................89
207
2014
equiv)................................................................................89
equiv)................................................................................89
CELLCEPT INTRAVENOUS -mycophenolate mofetil hcl
for iv soln 500 mg (base equiv)..................................... 189
CELLCEPT -mycophenolate mofetil cap 250 mg............ 189
CELLCEPT -mycophenolate mofetil for oral susp 200 mg/
ml....................................................................................189
CELLCEPT -mycophenolate mofetil tab 500 mg............. 189
CELONTIN -methsuximide cap 300 mg.......................... 120
CEM-UREA -urea soln 45%............................................ 164
CENESTIN -estrogens, conjugated synthetic a tab 0.3
mg.................................................................................... 27
mg.................................................................................... 27
mg.................................................................................... 27
mg.................................................................................... 27
mg.................................................................................... 27
CENFOL -folic acid-vitamin b6-vitamin b12 tab 2.3-24.5-2
mg.................................................................................. 145
CENTANY AT -mupirocin oint kit 2%.............................. 164
CENTANY -mupirocin oint 2%.........................................164
CENTRATEX - ferrous fumarate-fa-b complex-c-zn-mgmn-cu cap 106-1 mg .................................................... 145
cephalexin cap 250 mg (Keflex)....................................... 4
CEPHALEXIN -cephalexin tab 250 mg............................... 4
CEPHALEXIN -cephalexin tab 500 mg............................... 4
cephalexin for susp 125 mg/5ml...................................... 4
cephalexin for susp 250 mg/5ml...................................... 4
CEREBYX -fosphenytoin sodium inj 100 mg/2ml
(phenytoin equiv)........................................................... 120
CEREBYX -fosphenytoin sodium inj 500 mg/10ml
(phenytoin equiv)........................................................... 120
CEREFOLIN - l-methylfolate w/ vit b12-vit b6-vit b2 tab
6-1-50-5 mg .................................................................. 142
CEREFOLIN NAC - l-methylfolate-algae-b12-acetylcyst
tab 6-90.314-2-600mg .................................................. 142
CEREFOLIN NAC - l-methylfolate-methylcobalaminacetylcyst tab 6-2-600 mg ............................................ 142
CERVIDIL -dinoprostone vaginal inserts 10 mg................ 40
CESAMET -nabilone cap 1 mg......................................... 80
CETACAINE -butamben-tetracaine-benzocaine aerosol
spray 2-2-14%................................................................164
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)................... 66
CETRAXAL -ciprofloxacin hcl otic soln 0.2% (base
equivalent)......................................................................158
CETROTIDE -cetrorelix acetate for inj kit 0.25 mg............ 40
CETROTIDE -cetrorelix acetate for inj kit 3 mg.................41
cevimeline hcl cap 30 mg (Evoxac)............................. 159
208
CHANTIX CONTINUING MONTH -varenicline tartrate tab
1 mg (base equiv)..........................................................102
CHANTIX STARTING MONTH PA -varenicline tartrate tab
0.5 mg x 11 & tab 1 mg x 42 pack................................ 102
CHANTIX -varenicline tartrate tab 0.5 mg (base
equiv)..............................................................................102
CHANTIX -varenicline tartrate tab 1 mg (base equiv)......102
CHEMET -succimer cap 100 mg.....................................178
CHEMSTRIP BG LOG BOOK - blood glucose monitoring
misc. ..............................................................................181
CHENODAL -chenodiol tab 250 mg.................................. 82
CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 10-25 mg............................................. 102
CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 5-12.5 mg............................................ 102
chlordiazepoxide hcl cap 10 mg.................................... 87
chlordiazepoxide hcl cap 25 mg.................................... 87
chlordiazepoxide hcl cap 5 mg...................................... 87
chlorhexidine gluconate soln 0.12% (Peridex)............159
chloroquine phosphate tab 250 mg............................... 14
chloroquine phosphate tab 500 mg (Aralen).................14
CHLOROTHIAZIDE -chlorothiazide tab 250 mg................59
chlorothiazide tab 250 mg.............................................. 59
chlorothiazide tab 500 mg.............................................. 59
chlorpheniramine w/ codeine liquid 2-10 mg/5ml......... 68
CHLORPROMAZINE HCL -chlorpromazine hcl inj 25 mg/
ml......................................................................................93
chlorpromazine hcl tab 100 mg......................................93
chlorpromazine hcl tab 10 mg........................................93
chlorpromazine hcl tab 200 mg......................................93
CHLORPROPAMIDE -chlorpropamide tab 100 mg...........33
CHLORPROPAMIDE -chlorpropamide tab 250 mg...........33
CHLORTHALIDONE -chlorthalidone tab 100 mg.............. 59
CHLORTHALIDONE -chlorthalidone tab 25 mg................ 59
CHLORTHALIDONE -chlorthalidone tab 50 mg................ 59
chlorthalidone tab 25 mg................................................59
chlorzoxazone tab 500 mg (Parafon forte dsc)........... 127
CHOICE DM DIABETES RISK I - blood glucose
monitoring kit ................................................................ 181
CHOICE DM FORA G20 BLOOD - blood glucose
CHOICE-OB+DHA -prenatal mv w/fe poly-fa chw 29-1 mg
& dha cap 250 mg pak .................................................130
cholecalciferol cap 1000 unit........................................129
cholecalciferol chew tab 1000 unit.............................. 129
cholecalciferol chew tab 400 unit................................ 129
cholecalciferol drops 400 unit/0.03ml (per drop)........ 129
cholecalciferol drops 5000 unit/ml (1000
unit/0.2ml)..................................................................... 129
cholecalciferol oral liquid 400 unit/ml......................... 129
cholecalciferol tab 1000 unit........................................ 129
cholecalciferol tab 400 unit.......................................... 129
2014
cholestyramine light powder 4 gm/dose (Questran
light).................................................................................61
cholestyramine light powder packets 4 gm.................. 61
cholestyramine powder 4 gm/dose (Questran).............61
cholestyramine powder packets 4 gm (Questran)........61
choline & magnesium salicylates liq 500 mg/5ml....... 106
choline & magnesium salicylates tab 1000 mg...........106
choline fenofibrate cap dr 135 mg (fenofibric acid
equiv) (Trilipix)............................................................... 61
choline fenofibrate cap dr 45 mg (fenofibric acid equiv)
(Trilipix)........................................................................... 61
chorionic gonadotropin for inj 10000 unit.....................41
CIALIS -tadalafil tab 10 mg............................................... 64
CIALIS -tadalafil tab 2.5 mg.............................................. 64
CIALIS -tadalafil tab 20 mg............................................... 64
CIALIS -tadalafil tab 5 mg................................................. 64
CICLODAN CREAM KIT -ciclopirox olamine cream 0.77%
(base equiv) & cleanser kit............................................ 164
CICLODAN SOLUTION KIT -ciclopirox solution kit
8%.................................................................................. 164
ciclopirox gel 0.77% (Loprox).......................................164
ciclopirox olamine cream 0.77% (base equiv).............164
ciclopirox olamine susp 0.77% (base equiv)...............164
ciclopirox shampoo 1% (Loprox shampoo)................ 164
ciclopirox solution 8% (Penlac nail lacquer)...............164
ciclopirox solution kit 8% (Ciclodan solution ki)........ 164
CICLOPIROX TOPICAL SOLUTI -ciclopirox solution 8% &
vitamin e 5% topical kit..................................................164
cilostazol tab 100 mg (Pletal)....................................... 151
cilostazol tab 50 mg (Pletal)......................................... 151
CILOXAN -ciprofloxacin hcl ophth oint 0.3%................... 154
CILOXAN -ciprofloxacin hcl ophth soln 0.3%.................. 154
cimetidine hcl inj 150 mg/ml.......................................... 77
cimetidine hcl soln 300 mg/5ml..................................... 77
cimetidine tab 200 mg.....................................................77
CIMZIA -certolizumab pegol inj kit 2 x 200 mg/ml............. 82
CIMZIA STARTER KIT -certolizumab pegol inj kit 6 x 200
mg/ml................................................................................82
CIPRO -ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml).......................................................................... 7
CIPRO -ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml).......................................................................... 8
CIPRO -ciprofloxacin hcl tab 250 mg (base equiv)..............8
CIPRO -ciprofloxacin hcl tab 500 mg (base equiv)..............8
CIPRODEX -ciprofloxacin-dexamethasone otic susp
0.3-0.1%......................................................................... 158
CIPROFLOXACIN -ciprofloxacin hcl otic soln 0.2% (base
equivalent)......................................................................158
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000
mg(base eq) (Cipro xr).................................................... 8
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg
(base eq) (Cipro xr)......................................................... 8
ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml) (Cipro)............................................................ 8
ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml) (Cipro)............................................................ 8
ciprofloxacin hcl ophth soln 0.3% (Ciloxan)............... 154
ciprofloxacin hcl tab 100 mg (base equiv)...................... 8
ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)..........8
ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)..........8
ciprofloxacin hcl tab 750 mg (base equiv)...................... 8
CIPRO HC -ciprofloxacin-hydrocortisone otic susp
0.2-1%............................................................................ 158
CIPRO XR -ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000
mg(base eq).......................................................................8
CIPRO XR -ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500
mg (base eq)..................................................................... 8
citalopram hydrobromide oral soln 10 mg/5ml............. 89
citalopram hydrobromide tab 10 mg (base equiv)
(Celexa)........................................................................... 89
(Celexa)........................................................................... 89
(Celexa)........................................................................... 89
CITRANATAL 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa
tab 90 &dha cap 300mg pak......................................... 131
CITRANATAL ASSURE -prenat w/o a w/fecbn-fegl-dss-fa
tab & dha cap 300 mg pack.......................................... 130
CITRANATAL B-CALM -prenat w/o a w/fecbn-feglu-fa tab
20-1 mg & vit b6 tab pak............................................... 130
CITRANATAL DHA -prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 250 mg pack.................................................... 130
CITRANATAL HARMONY - prenatal w/o a w/fe cbn-dssfa-dha cap 29-1-265 mg ............................................... 130
CITRANATAL HARMONY - prenatal w/o vit a w/ fe cbndss-fa-dha cap 30-1-260 mg ........................................ 130
CITRANATAL HARMONY - prenat w/o a w/fe fum-fe cbndss-fa-dha cap 27-1-260 mg ........................................ 131
CITRANATAL RX - prenatal w/o a w/ fe carbonyl-fe glucdss-fa tab 27-1mg ........................................................ 131
CITROLITH -potassium & sodium citrates tab 50-950
mg.................................................................................... 86
CLAFORAN -cefotaxime sodium for inj 10 gm.................... 4
CLAFORAN -cefotaxime sodium for inj 1 gm...................... 4
CLAFORAN -cefotaxime sodium for inj 2 gm...................... 4
CLAFORAN -cefotaxime sodium for inj 500 mg.................. 4
CLAFORAN -cefotaxime sodium for iv soln 1 gm................4
CLAFORAN -cefotaxime sodium for iv soln 2 gm................4
CLARAVIS -isotretinoin cap 30 mg................................. 164
CLARIFOAM EF -sulfacetamide sodium w/ sulfur foam
10-5%............................................................................. 164
CLARINEX-D 12 HOUR -desloratadine &
pseudoephedrine tab sr 12hr 2.5-120 mg........................68
CLARINEX-D 24 HOUR -desloratadine &
pseudoephedrine tab sr 24hr 5-240 mg...........................68
CLARINEX -desloratadine syrup 0.5 mg/ml...................... 66
CLARINEX -desloratadine tab 5 mg..................................66
209
2014
CLARINEX REDITABS -desloratadine tab orally
disintegrating 2.5 mg....................................................... 66
CLARINEX REDITABS -desloratadine tab orally
disintegrating 5 mg.......................................................... 66
clarithromycin for susp 125 mg/5ml................................ 5
clarithromycin for susp 250 mg/5ml (Biaxin).................. 5
clarithromycin tab 250 mg (Biaxin)..................................5
clarithromycin tab 500 mg (Biaxin)..................................5
clarithromycin tab sr 24hr 500 mg (Biaxin xl pac).......... 5
CLEMASTINE FUMARATE -clemastine fumarate syrup
0.67 mg/5ml (0.5 mg/5ml base eq)..................................66
clemastine fumarate syrup 0.67 mg/5ml (0.5 mg/5ml
base eq).......................................................................... 66
clemastine fumarate tab 2.68 mg...................................66
CLEOCIN -clindamycin hcl cap 150 mg............................ 15
CLEOCIN -clindamycin hcl cap 300 mg............................ 15
CLEOCIN -clindamycin hcl cap 75 mg.............................. 15
CLEOCIN -clindamycin phosphate vaginal cream 2%.......85
CLEOCIN -clindamycin phosphate vaginal suppos 100
mg.................................................................................... 85
CLEOCIN PEDIATRIC GRANULE -clindamycin palmitate
hcl for soln 75 mg/5ml (base equiv)................................ 15
CLEOCIN PHOSPHATE -clindamycin phosphate inj 300
mg/2ml..............................................................................15
mg/4ml..............................................................................15
mg/6ml..............................................................................15
gm/60ml............................................................................15
CLEOCIN PHOSPHATE -clindamycin phosphate iv soln
600 mg/4ml...................................................................... 15
CLEOCIN PHOSPHATE -clindamycin phosphate iv soln
900 mg/6ml...................................................................... 15
CLEOCIN-T -clindamycin phosphate gel 1%...................164
CLEOCIN-T -clindamycin phosphate lotion 1%............... 164
CLEOCIN-T -clindamycin phosphate soln 1%................. 164
CLEOCIN-T -clindamycin phosphate swab 1%............... 164
CLEVER CHEK AUTO-CODE BLO - blood glucose
CLEVER CHEK AUTO CODE VOI - blood glucose
CLEVER CHEK AUTO-CODE VOI - blood glucose
CLEVER CHEK BLOOD GLUCOSE - blood glucose
CLEVER CHOICE AUTO-CODE P - blood glucose
CLEVER CHOICE MICRO BLOOD - blood glucose
CLEVER CHOICE MINI BLOOD - blood glucose
clidinium & chlordiazepoxide cap 2.5-5 mg
(Librax)............................................................................ 77
CLIMARA -estradiol td patch weekly 0.025 mg/24hr......... 27
210
CLIMARA -estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr)......................................................................... 27
CLIMARA -estradiol td patch weekly 0.05 mg/24hr........... 27
CLIMARA -estradiol td patch weekly 0.06 mg/24hr........... 27
CLIMARA -estradiol td patch weekly 0.075 mg/24hr......... 27
CLIMARA -estradiol td patch weekly 0.1 mg/24hr............. 27
CLIMARA PRO -estradiol-levonorgestrel td patch weekly
0.045-0.015 mg/day......................................................... 27
CLINDACIN ETZ -clindamycin phosphate swab 1% &
cleanser kit.....................................................................164
CLINDACIN PAC -clindamycin phosphate swab 1% &
cleanser kit.....................................................................164
CLINDAGEL -clindamycin phosphate gel 1%..................164
clindamycin hcl cap 150 mg (Cleocin)...........................15
clindamycin hcl cap 300 mg (Cleocin)...........................15
clindamycin hcl cap 75 mg (Cleocin)............................ 15
clindamycin palmitate hcl for soln 75 mg/5ml (base
equiv) (Cleocin pediatric gr)......................................... 15
clindamycin phosphate-benzoyl peroxide gel 1-5%
(Benzaclin).................................................................... 164
CLINDAMYCIN PHOSPHATE -clindamycin phosphate iv
soln 300 mg/2ml.............................................................. 15
clindamycin phosphate foam 1% (Evoclin)................. 164
clindamycin phosphate gel 1% (Cleocin-t)..................164
clindamycin phosphate inj 300 mg/2ml (Cleocin
phosphate)...................................................................... 15
phosphate)...................................................................... 15
phosphate)...................................................................... 15
clindamycin phosphate inj 9 gm/60ml (Cleocin
phosphate)...................................................................... 15
clindamycin phosphate iv soln 600 mg/4ml (Cleocin
phosphate)...................................................................... 15
clindamycin phosphate iv soln 900 mg/6ml (Cleocin
phosphate)...................................................................... 15
clindamycin phosphate lotion 1% (Cleocin-t)............. 164
clindamycin phosphate soln 1% (Cleocin-t)................164
clindamycin phosphate swab 1% (Cleocin-t).............. 164
clindamycin phosphate vaginal cream 2%
(Cleocin).......................................................................... 85
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2
(1)-5% (Duac)................................................................ 164
CLINDESSE -clindamycin phosphate (one dose) vaginal
cream 2%.........................................................................85
CLINORIL -sulindac tab 200 mg..................................... 115
clobetasol propionate cream 0.05% (Temovate).........164
clobetasol propionate emollient base cream 0.05%
(Temovate e).................................................................164
clobetasol propionate emulsion foam 0.05% (Oluxe).................................................................................... 164
clobetasol propionate foam 0.05% (Olux)................... 164
clobetasol propionate gel 0.05% (Temovate).............. 165
clobetasol propionate lotion 0.05% (Clobex).............. 165
clobetasol propionate oint 0.05% (Temovate).............165
2014
clobetasol propionate shampoo 0.05% (Clobex)........ 165
clobetasol propionate soln 0.05% (Temovate)............165
CLOBEX -clobetasol propionate lotion 0.05%................. 165
CLOBEX -clobetasol propionate shampoo 0.05%........... 165
CLOBEX -clobetasol propionate spray 0.05%.................165
CLOCORTOLONE PIVALATE -clocortolone pivalate
cream 0.1%....................................................................165
CLOCORTOLONE PIVALATE PUM -clocortolone pivalate
cream 0.1%....................................................................165
CLODAN KIT -clobetasol propionate shampoo 0.05% &
cleanser kit.....................................................................165
CLODERM -clocortolone pivalate cream 0.1%................165
CLODERM PUMP -clocortolone pivalate cream 0.1%.....165
CLOMID -clomiphene citrate tab 50 mg............................ 41
clomiphene citrate tab 50 mg (Clomid)......................... 41
clomipramine hcl cap 25 mg (Anafranil)....................... 89
clonazepam orally disintegrating tab 0.125 mg.......... 120
clonazepam orally disintegrating tab 0.25 mg............ 120
clonazepam orally disintegrating tab 0.5 mg.............. 120
clonazepam orally disintegrating tab 1 mg................. 120
clonazepam orally disintegrating tab 2 mg................. 120
clonazepam tab 0.5 mg (Klonopin).............................. 120
clonazepam tab 1 mg (Klonopin)................................. 120
clonazepam tab 2 mg (Klonopin)................................. 121
clonidine hcl tab 0.1 mg (Catapres)...............................53
clonidine hcl tab sr 12hr 0.1 mg (Kapvay).....................99
clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1).................................................................................54
clopidogrel bisulfate tab 300 mg (base equiv)
(Plavix)...........................................................................151
clopidogrel bisulfate tab 75 mg (base equiv)
(Plavix)...........................................................................151
clorazepate dipotassium tab 15 mg (Tranxene t)..........87
clorazepate dipotassium tab 3.75 mg (Tranxene t).......87
clorazepate dipotassium tab 7.5 mg (Tranxene t).........87
CLORPRES -clonidine & chlorthalidone tab 0.1-15 mg..... 54
clotrimazole cream 1%..................................................165
clotrimazole soln 1%..................................................... 165
clotrimazole troche 10 mg............................................ 159
clotrimazole w/ betamethasone cream 1-0.05%
(Lotrisone).....................................................................165
clotrimazole w/ betamethasone lotion 1-0.05%...........165
CLOZAPINE ODT -clozapine orally disintegrating tab 100
mg.................................................................................... 93
CLOZAPINE ODT -clozapine orally disintegrating tab 12.5
mg.................................................................................... 93
CLOZAPINE ODT -clozapine orally disintegrating tab 25
mg.................................................................................... 93
clozapine tab 100 mg (Clozaril)......................................93
clozapine tab 200 mg...................................................... 93
clozapine tab 25 mg (Clozaril)........................................93
clozapine tab 50 mg........................................................ 93
CLOZARIL -clozapine tab 100 mg.................................... 93
CLOZARIL -clozapine tab 25 mg...................................... 93
C-NATE DHA - prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg ................................................................. 130
CNL8 NAIL KIT -ciclopirox soln 8% & lacquer removal
pads kit...........................................................................165
COAGUCHEK LANCETS - lancets ................................ 181
COAL TAR -coal tar soln 20%........................................ 165
COARTEM -artemether-lumefantrine tab 20-120 mg........ 14
COCA COLA SYURP -phosphorated carbohydrate w/
caffeine syrup...................................................................80
COCAINE HCL -cocaine hcl soln 10%............................ 165
COCAINE HCL -cocaine hcl soln 4%..............................165
CODAR AR -chlorpheniramine w/ codeine liquid 2-8
mg/5ml..............................................................................68
CODAR D -pseudoephedrine w/ codeine liquid 30-8
mg/5ml..............................................................................68
CODAR GF -guaifenesin-codeine liquid 200-8 mg/5ml..... 68
CODEINE SULFATE -codeine sulfate oral soln 30
mg/5ml............................................................................107
CODEINE SULFATE -codeine sulfate tab 15 mg............ 107
COD LIVER OIL - cod liver oil ....................................... 131
COGENTIN -benztropine mesylate inj 1 mg/ml............... 125
COLAZAL -balsalazide disodium cap 750 mg................... 82
colchicine w/ probenecid tab 0.5-500 mg.................... 120
COLCRYS -colchicine tab 0.6 mg................................... 120
COLESTID -colestipol hcl granule packets 5 gm...............61
COLESTID -colestipol hcl granules 5 gm.......................... 61
COLESTID -colestipol hcl tab 1 gm.................................. 61
COLESTID FLAVORED -colestipol hcl granule packets 5
gm.................................................................................... 61
COLESTID FLAVORED -colestipol hcl granules 5 gm...... 61
colestipol hcl granule packets 5 gm (Colestid
flavored).......................................................................... 61
colestipol hcl granules 5 gm (Colestid flavored).......... 61
colestipol hcl tab 1 gm (Colestid).................................. 61
COLGATE DRY MOUTH RELIEF -sodium fluoride
mouthwash 2.1 mg/10ml................................................159
colistimethate sodium for inj 150 mg (Coly-mycin
m)..................................................................................... 15
COLY-MYCIN M -colistimethate sodium for inj 150 mg..... 15
COLY-MYCIN S -neomycin-colistin-hc-thonzonium otic
susp 3.3-3-10-0.5 mg/ml................................................ 158
COLYTE-FLAVOR PACKS -peg 3350-kcl-na bicarb-naclna sulfate for soln 227.1 gm............................................75
211
2014
COLYTE-FLAVOR PACKS -peg 3350-kcl-na bicarb-naclna sulfate for soln 240 gm...............................................75
COMBIGAN -brimonidine tartrate-timolol maleate ophth
soln 0.2-0.5%................................................................. 154
COMBIPATCH -estradiol-norethindrone ace td pttw
0.05-0.14 mg/day............................................................. 27
COMBIPATCH -estradiol-norethindrone ace td pttw
0.05-0.25 mg/day............................................................. 27
COMBIVENT -ipratropium-albuterol aerosol 18-103 mcg/
act (20-120mcg/act)......................................................... 73
COMBIVENT RESPIMAT -ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act............................................73
COMBIVIR -lamivudine-zidovudine tab 150-300 mg......... 11
COMETRIQ -cabozantinib s-malate cap 3 x 20 mg (60 mg
dose) kit........................................................................... 21
COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 1 x 20
mg (100 dose) kit.............................................................21
COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 3 x 20
mg (140 dose) kit.............................................................21
COMMIT -nicotine polacrilex lozenge 2 mg.....................102
COMMIT -nicotine polacrilex lozenge 4 mg.....................102
COMPAZINE -prochlorperazine maleate tab 10 mg..........93
COMPAZINE -prochlorperazine maleate tab 5 mg............93
COMPLERA -emtricitabine-rilpivirine-tenofovir df tab
200-25-300 mg.................................................................11
COMPLETE NATAL DHA -prenat-fe bis-fe prot succ-fa-ca
tab & omega 3 cap 250 pk............................................ 131
COMPLETENATE - prenatal vit w/ fe fumarate-fa chew tab
29-1 mg ........................................................................ 131
COMPLETE-RF PRENATAL - prenatal without a w/ fe
carbonyl-docusate-fa tab 90-1mg ................................. 131
COMTAN -entacapone tab 200 mg................................. 125
CO-NATAL FA - prenatal vit w/ fe fumarate-fa tab 29-1 mg
....................................................................................... 131
CONCEPT DHA - prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg ......................................................... 131
CONCEPT OB - prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg .............................................................. 131
CONCERTA -methylphenidate hcl tab sa osm 18 mg....... 99
CONDYLOX -podofilox gel 0.5%.....................................165
CONDYLOX -podofilox soln 0.5%................................... 165
CONTROL BLOOD GLUCOSE MON - blood glucose
CONZIP -tramadol hcl cap sr 24hr biphasic release 100
mg.................................................................................. 107
mg.................................................................................. 107
mg.................................................................................. 107
COPAXONE -glatiramer acetate inj kit 20 mg/ml............ 102
COPAXONE -glatiramer acetate soln prefilled syringe 40
mg/ml..............................................................................102
212
COPEGUS -ribavirin tab 200 mg.......................................11
CORDARONE -amiodarone hcl tab 200 mg..................... 51
CORDRAN -flurandrenolide cream 0.05%...................... 165
CORDRAN -flurandrenolide lotion 0.05%........................165
CORDRAN -flurandrenolide oint 0.05%...........................165
CORDRAN TAPE -flurandrenolide tape 4 mcg/sqcm...... 165
COREG -carvedilol tab 12.5 mg........................................46
COREG -carvedilol tab 25 mg...........................................46
COREG -carvedilol tab 3.125 mg......................................46
COREG -carvedilol tab 6.25 mg........................................46
COREG CR -carvedilol phosphate cap sr 24hr 10 mg...... 46
CORGARD -nadolol tab 20 mg......................................... 46
CORIFACT -factor xiii concentrate (human) for inj kit
1000-1600 unit............................................................... 151
CORTANE-B AQUEOUS -pramoxine-hc-chloroxylenol
aqueous otic soln 10-10-1 mg/ml.................................. 158
CORTANE-B -hydrocortisone-pramoxine-chloroxylenol lot
10-10-1mg/ml................................................................. 165
CORTANE-B-OTIC -pramoxine-hc-chloroxylenol otic soln
10-10-1 mg/ml................................................................158
CORTEF -hydrocortisone tab 10 mg................................. 24
CORTEF -hydrocortisone tab 20 mg................................. 24
CORTEF -hydrocortisone tab 5 mg...................................24
CORTENEMA -hydrocortisone enema 100 mg/60ml.......161
CORTIFOAM -hydrocortisone acetate rectal foam 90 mg/
dose................................................................................161
CORTISONE ACETATE -cortisone acetate tab 25 mg......24
CORTISPORIN -bacitracin-polymyxin-neomycin hc oint
1%.................................................................................. 165
CORTISPORIN -neomycin-polymyxin-hc cream
0.5%............................................................................... 165
CORTISPORIN -neomycin-polymyxin-hc otic soln
1%.................................................................................. 158
CORTISPORIN-TC -neomycin-colistin-hc-thonzonium otic
susp 3.3-3-10-0.5 mg/ml................................................ 158
CORVITE 150 - iron combination tab .............................145
CORVITE 150 -iron-folic acid-vit c-vit b6-vit b12-zinc tab
150-1.25 mg...................................................................145
CORVITE FE - iron combination tab .............................. 145
CORVITE -multiple vitamins w/ minerals & fa tab 1.25
mg.................................................................................. 131
CORZIDE -nadolol & bendroflumethiazide tab 40-5
mg.................................................................................... 54
CORZIDE -nadolol & bendroflumethiazide tab 80-5
mg.................................................................................... 54
COSOPT -dorzolamide hcl-timolol maleate ophth soln
22.3-6.8 mg/ml............................................................... 154
COSOPT PF -dorzolamide hcl-timolol maleate ophth sol
22.3-6.8 mg/ml pf...........................................................154
COTAB A -chlorpheniramine w/ codeine tab 4-10 mg....... 68
2014
COTAB AX -chlorpheniramine w/ codeine tab 4-20 mg.....68
COTABFLU -codeine-chlorpheniramine-acetaminophen
tab 20-4-500 mg.............................................................. 68
COUMADIN -warfarin sodium tab 10 mg........................ 148
COUMADIN -warfarin sodium tab 1 mg.......................... 148
COUMADIN -warfarin sodium tab 2.5 mg....................... 148
COUMADIN -warfarin sodium tab 7.5 mg....................... 148
COVERA-HS -verapamil hcl tab sr 24hr (controlled onset)
180 mg............................................................................. 48
COVERA-HS -verapamil hcl tab sr 24hr (controlled onset)
240 mg............................................................................. 48
COZAAR -losartan potassium tab 100 mg........................ 54
COZAAR -losartan potassium tab 25 mg.......................... 54
COZAAR -losartan potassium tab 50 mg.......................... 54
CPB WC -pseudoephedrine-bromphen-codeine liq
10-1.3-6.3 mg/5ml............................................................68
CREON -pancrelipase (lip-prot-amyl) dr cap
12000-38000-60000 unit.................................................. 81
24000-76000-120000 unit................................................ 81
3000-9500-15000 unit...................................................... 81
36000-114000-180000 unit.............................................. 81
6000-19000-30000 unit.................................................... 81
CRESTOR -rosuvastatin calcium tab 10 mg..................... 61
CRESTOR -rosuvastatin calcium tab 5 mg....................... 61
CRESYLATE -cresyl acetate otic soln 25%.................... 158
CRINONE -progesterone vaginal gel 4%.......................... 85
CRINONE -progesterone vaginal gel 8%.......................... 85
CRIXIVAN -indinavir sulfate cap 200 mg...........................11
CRIXIVAN -indinavir sulfate cap 400 mg...........................11
CRNATAL -prenatal mv w/fecbn-fegl-dss-fa tab & dha cap
275 mg pack.................................................................. 131
cromolyn sodium ophth soln 4%................................. 154
cromolyn sodium oral conc 100 mg/5ml
(Gastrocrom)...................................................................82
cromolyn sodium soln nebu 20 mg/2ml........................ 73
CUPRIMINE -penicillamine cap 250 mg..........................189
CUROSURF -poractant alfa intratracheal susp 80 mg/
ml......................................................................................75
CUTIVATE -fluticasone propionate cream 0.05%............165
CUTIVATE -fluticasone propionate lotion 0.05%............. 165
CUTIVATE -fluticasone propionate oint 0.005%..............165
CUVPOSA -glycopyrrolate oral soln 1 mg/5ml.................. 77
CVS ADVANCED GLUCOSE METE - blood glucose
CVS GLUCOSE BITS -glucose chew tab 1 gm.................33
CVS GLUCOSE -glucose chew tab 4 gm......................... 33
CVS VITAMIN D3 -cholecalciferol cap 400 unit...............129
CYANOCOBALAMIN/LEVOMEFOLA - l-methylfolate w/ vit
b6-vit b12 tab 1.13-25-2 mg ......................................... 142
cyanocobalamin inj 1000 mcg/ml.................................145
CYCLESSA -desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg.........................29
cyclobenzaprine hcl tab 10 mg.................................... 127
cyclobenzaprine hcl tab 5 mg...................................... 127
cyclobenzaprine hcl tab 7.5 mg (Fexmid)....................128
CYCLOGYL -cyclopentolate hcl ophth soln 0.5%............154
CYCLOGYL -cyclopentolate hcl ophth soln 1%...............154
CYCLOGYL -cyclopentolate hcl ophth soln 2%...............154
CYCLOMYDRIL -cyclopentolate w/ phenylephrine ophth
soln 0.2-1%.................................................................... 154
cyclopentolate hcl ophth soln 1% (Cyclogyl)..............154
cyclopentolate hcl ophth soln 2% (Cyclogyl)..............154
CYCLOPHOSPHAMIDE -cyclophosphamide cap 25
mg.................................................................................... 21
CYCLOPHOSPHAMIDE -cyclophosphamide cap 50
mg.................................................................................... 21
CYCLOPHOSPHAMIDE -cyclophosphamide tab 25
mg.................................................................................... 21
CYCLOPHOSPHAMIDE -cyclophosphamide tab 50
mg.................................................................................... 21
CYCLOSERINE -cycloserine cap 250 mg...........................9
CYCLOSET -bromocriptine mesylate tab 0.8 mg (base
equivalent)........................................................................33
cyclosporine cap 100 mg (Sandimmune).................... 189
cyclosporine cap 25 mg (Sandimmune)...................... 189
cyclosporine modified cap 100 mg (Neoral)............... 189
cyclosporine modified cap 25 mg (Neoral)................. 189
CYCLOSPORINE MODIFIED -cyclosporine modified cap
50 mg............................................................................. 189
cyclosporine modified oral soln 100 mg/ml
(Neoral)..........................................................................189
CYMBALTA -duloxetine hcl enteric coated pellets cap 20
mg.................................................................................... 89
mg.................................................................................... 89
mg.................................................................................... 89
cyproheptadine hcl syrup 2 mg/5ml.............................. 66
cyproheptadine hcl tab 4 mg......................................... 66
CYSTADANE - betaine powder for oral solution .............. 41
CYSTAGON -cysteamine bitartrate cap 150 mg............... 86
CYSTAGON -cysteamine bitartrate cap 50 mg................. 86
CYSTARAN -cysteamine hcl ophth soln 0.44% (base
equivalent)......................................................................154
CYTOMEL -liothyronine sodium tab 25 mcg..................... 38
CYTOMEL -liothyronine sodium tab 50 mcg..................... 38
CYTOMEL -liothyronine sodium tab 5 mcg....................... 38
CYTOTEC -misoprostol tab 100 mcg................................ 77
CYTOTEC -misoprostol tab 200 mcg................................ 77
213
2014
CYTRA-3 -pot & sod citrates w/ cit ac syrup 550-500-334
mg/5ml..............................................................................86
CYTRA-K -potassium citrate & citric acid soln 1100-334
mg/5ml..............................................................................86
D
D.H.E. 45 -dihydroergotamine mesylate inj 1 mg/ml........118
D3 -cholecalciferol cap 400 unit...................................... 129
DALIRESP -roflumilast tab 500 mcg................................. 73
danazol cap 100 mg........................................................ 26
danazol cap 200 mg........................................................ 26
danazol cap 50 mg.......................................................... 26
DANTRIUM -dantrolene sodium cap 100 mg.................. 128
DANTRIUM -dantrolene sodium cap 25 mg.................... 128
DANTRIUM -dantrolene sodium cap 50 mg.................... 128
dantrolene sodium cap 25 mg (Dantrium)...................128
dantrolene sodium cap 50 mg (Dantrium)...................128
DANTROLENE SODIUM -dantrolene sodium cap 100
mg.................................................................................. 128
DAPSONE -dapsone tab 100 mg......................................15
DAPSONE -dapsone tab 25 mg........................................15
DARAPRIM -pyrimethamine tab 25 mg.............................14
DAYPRO -oxaprozin tab 600 mg.................................... 115
DAYTRANA -methylphenidate td patch 10 mg/9hr............99
DDAVP -desmopressin acetate inj 4 mcg/ml.....................41
DDAVP -desmopressin acetate nasal soln 0.01%
(refrigerated).....................................................................41
DDAVP -desmopressin acetate nasal spray soln
0.01%............................................................................... 41
DDAVP -desmopressin acetate tab 0.1 mg.......................41
DDAVP -desmopressin acetate tab 0.2 mg.......................41
DDROPS -cholecalciferol drops 1000 unit/0.03ml (per
drop)............................................................................... 129
DEBACTEROL -sulfuric acid-sulfonated phenolics soln
30-50%........................................................................... 159
DECARA -cholecalciferol cap 25000 unit........................ 129
DECON-A -brompheniramine & phenylephrine elixir 2-5
mg/5ml..............................................................................68
DECON-G -phenylephrine-brompheniramine-guaifenesin
liqd 2-1-40 mg/ml............................................................. 68
deferoxamine mesylate for inj 2 gm (Desferal)........... 178
deferoxamine mesylate for inj 500 mg (Desferal)....... 178
DELATESTRYL -testosterone enanthate im in oil 200 mg/
ml......................................................................................26
DELESTROGEN -estradiol valerate im in oil 10 mg/ml..... 27
DELOS -benzoyl peroxide lotion 3.5%............................ 165
DELZICOL -mesalamine cap dr 400 mg........................... 82
DEMADEX -torsemide tab 100 mg....................................59
DEMADEX -torsemide tab 10 mg......................................59
DEMADEX -torsemide tab 20 mg......................................59
DEMADEX -torsemide tab 5 mg........................................59
214
demeclocycline hcl tab 150 mg........................................6
demeclocycline hcl tab 300 mg........................................6
DEMEROL -meperidine hcl tab 100 mg.......................... 107
DEMEROL -meperidine hcl tab 50 mg............................ 107
DEMSER -metyrosine cap 250 mg................................... 54
DENATURED ALCOHOL -alcohol, rubbing 95%.............178
DENAVIR -penciclovir cream 1%.................................... 165
DEPAKENE -valproate sodium syrup 250 mg/5ml (base
equiv)..............................................................................121
DEPAKENE -valproic acid cap 250 mg........................... 121
DEPAKOTE -divalproex sodium tab delayed release 125
mg.................................................................................. 121
mg.................................................................................. 121
mg.................................................................................. 121
DEPAKOTE ER -divalproex sodium tab sr 24 hr 250
mg.................................................................................. 121
DEPAKOTE ER -divalproex sodium tab sr 24 hr 500
mg.................................................................................. 121
DEPAKOTE SPRINKLES -divalproex sodium cap sprinkle
125 mg........................................................................... 121
DEPEN TITRATABS -penicillamine tab 250 mg..............189
DEPLIN 15 - l-methylfolate-algae cap 15-90.314 mg ......142
DEPLIN 7.5 - l-methylfolate-algae cap 7.5-90.314 mg
....................................................................................... 142
DEPLIN - l-methylfolate tab 15 mg .................................142
DEPLIN - l-methylfolate tab 7.5 mg ................................142
DEPO-ESTRADIOL -estradiol cypionate im in oil 5 mg/
ml......................................................................................28
DEPO-MEDROL -methylprednisolone acetate inj susp 20
mg/ml................................................................................24
mg/ml................................................................................24
mg/ml................................................................................24
DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp 150 mg/ml.......... 29
DEPO-PROVERA -medroxyprogesterone acetate im susp
400 mg/ml........................................................................ 21
DEPO-SUBQ PROVERA 104 -medroxyprogesterone
acetate subcutaneous susp 104 mg/0.65ml.................... 29
DEPO-TESTOSTERONE -testosterone cypionate im in oil
100 mg/ml........................................................................ 26
DEPO-TESTOSTERONE -testosterone cypionate im in oil
200 mg/ml........................................................................ 26
DERMA-SMOOTHE/FS BODY -fluocinolone acetonide oil
0.01%............................................................................. 165
DERMA-SMOOTHE/FS BODY OIL -fluocinolone
acetonide oil 0.01%....................................................... 165
DERMA-SMOOTHE/FS SCALP -fluocinolone acetonide oil
0.01%............................................................................. 165
DERMA-SMOOTHE/FS SCALP OI -fluocinolone acetonide
oil 0.01%........................................................................ 165
2014
DERMASORB AF -clioquinol-hc cream 3-0.5% & emollient
liqd kit.............................................................................165
DERMASORB HC -hydrocortisone lot 2% & cleanser liq
kit....................................................................................165
DERMASORB TA -triamcinolone cream 0.1% & emollient
cream kit........................................................................ 165
DERMASORB XM -urea cream 39% & emollient cream
kit....................................................................................165
DERMATOP -prednicarbate cream 0.1%........................ 165
DERMATOP -prednicarbate oint 0.1%............................ 166
DERMOTIC -fluocinolone acetonide (otic) oil 0.01%....... 158
DESFERAL -deferoxamine mesylate for inj 2 gm............178
DESFERAL -deferoxamine mesylate for inj 500 mg........178
desipramine hcl tab 100 mg (Norpramin)......................89
desipramine hcl tab 10 mg (Norpramin)........................89
desipramine hcl tab 150 mg (Norpramin)......................89
desloratadine tab 5 mg (Clarinex)..................................66
desloratadine tab orally disintegrating 2.5 mg
(Clarinex reditabs)......................................................... 66
desloratadine tab orally disintegrating 5 mg (Clarinex
reditabs).......................................................................... 66
desmopressin acetate inj 4 mcg/ml (Ddavp).................41
desmopressin acetate nasal soln 0.01% (refrigerated)
(Ddavp)............................................................................ 41
desmopressin acetate nasal spray soln 0.01%
(Ddavp)............................................................................ 41
desmopressin acetate nasal spray soln 0.01%
(refrigerated)................................................................... 41
desmopressin acetate tab 0.1 mg (Ddavp)....................41
desmopressin acetate tab 0.2 mg (Ddavp)....................41
DESOGEN -desogestrel & ethinyl estradiol tab 0.15 mg-30
mcg...................................................................................29
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01
mg(21/5) (Mircette)......................................................... 29
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg (Cyclessa).....29
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg
(Desogen)........................................................................29
DESONATE -desonide gel 0.05%................................... 166
desonide cream 0.05% (Desowen)............................... 166
desonide lotion 0.05% (Desowen)................................166
desonide oint 0.05% (Desowen)...................................166
DESOWEN CREAM/CETAPHIL LO -desonide cream
0.05% w/ moisturizing lotion kit..................................... 166
DESOWEN -desonide cream 0.05%............................... 166
DESOWEN -desonide lotion 0.05%................................ 166
DESOWEN -desonide oint 0.05%................................... 166
DESOWEN LOTION/CETAPHIL C -desonide lotion 0.05%
w/ moisturizing cream kit............................................... 166
DESOWEN OINTMENT/CETAPHIL -desonide ointment
0.05% w/ moisturizing lotion kit..................................... 166
desoximetasone cream 0.25% (Topicort).................... 166
DESOXIMETASONE -desoximetasone cream 0.05%.....166
DESOXIMETASONE -desoximetasone oint 0.05%......... 166
desoximetasone gel 0.05% (Topicort)......................... 166
desoximetasone oint 0.25% (Topicort)........................ 166
DESOXYN -methamphetamine hcl tab 5 mg.................... 99
DESPEC-EXP -pseudoephedrine-dihydrocodeine-gg syrup
15-7.5-100 mg/5ml...........................................................68
DESPEC-PDC -phenylephrine-chlorphen-dihydrocodeine
liqd 7.5-2.5-3 mg/5ml....................................................... 68
DESVENLAFAXINE ER -desvenlafaxine fumarate tab sr
24hr 100 mg (base equiv)............................................... 89
DESVENLAFAXINE ER -desvenlafaxine fumarate tab sr
24hr 50 mg (base equiv)................................................. 89
DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 100
mg.................................................................................... 89
DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 50
mg.................................................................................... 89
DETROL LA -tolterodine tartrate cap sr 24hr 2 mg........... 84
DETROL LA -tolterodine tartrate cap sr 24hr 4 mg........... 84
DETROL -tolterodine tartrate tab 1 mg............................. 84
DETROL -tolterodine tartrate tab 2 mg............................. 84
DEX4 -glucose chew tab 1 gm..........................................33
DEX4 GLUCOSE -glucose chew tab 4 gm....................... 33
DEX4 GLUCOSE -glucose oral liquid 15 gm/59ml............ 33
DEX4 QUICK DISSOLVE GLUCO -glucose chew tab 4
gm.................................................................................... 33
DEXAMETHASONE -dexamethasone soln 0.5
mg/5ml..............................................................................24
DEXAMETHASONE -dexamethasone tab 1 mg............... 24
DEXAMETHASONE -dexamethasone tab 2 mg............... 24
dexamethasone elixir 0.5 mg/5ml.................................. 24
DEXAMETHASONE INTENSOL -dexamethasone conc 1
mg/ml................................................................................24
DEXAMETHASONE SODIUM PHOS -dexamethasone
sodium phosphate inj 10 mg/ml.......................................24
DEXAMETHASONE SODIUM PHOS -dexamethasone sod
phosphate preservative free inj 10 mg/ml........................24
dexamethasone sodium phosphate inj 100
mg/10ml...........................................................................24
dexamethasone sodium phosphate inj 120
mg/30ml...........................................................................24
dexamethasone sodium phosphate inj 20 mg/5ml....... 24
dexamethasone sodium phosphate inj 4 mg/ml........... 24
dexamethasone sodium phosphate ophth soln
0.1%............................................................................... 154
dexamethasone tab 0.5 mg............................................ 24
dexamethasone tab 0.75 mg.......................................... 24
dexamethasone tab 1.5 mg............................................ 24
dexamethasone tab 4 mg............................................... 24
dexamethasone tab 6 mg............................................... 24
DEXCHLORPHENIRAMINE MALEA -dexchlorpheniramine
maleate syrup 2 mg/5ml.................................................. 66
DEXEDRINE -dextroamphetamine sulfate cap sr 24hr 10
mg.................................................................................... 99
215
2014
mg.................................................................................... 99
mg.................................................................................... 99
DEXILANT -dexlansoprazole cap delayed release 30
mg.................................................................................... 77
DEXILANT -dexlansoprazole cap delayed release 60
mg.................................................................................... 77
dexmethylphenidate hcl cap sr 24 hr 15 mg (Focalin
xr).....................................................................................99
xr).....................................................................................99
xr).....................................................................................99
dexmethylphenidate hcl tab 10 mg (Focalin)................ 99
dexmethylphenidate hcl tab 2.5 mg (Focalin)............... 99
dexmethylphenidate hcl tab 5 mg (Focalin).................. 99
DEXPAK 10 DAY -dexamethasone tab 1.5 mg taper
pack..................................................................................24
pack..................................................................................24
pack..................................................................................24
DEXPANTHENOL -dexpanthenol inj 250 mg/ml............... 82
dextroamphetamine sulfate cap sr 24hr 10 mg
(Dexedrine)......................................................................99
(Dexedrine)......................................................................99
(Dexedrine)......................................................................99
dextroamphetamine sulfate oral solution 5 mg/5ml
(Procentra)...................................................................... 99
dextroamphetamine sulfate tab 10 mg.......................... 99
dextroamphetamine sulfate tab 5 mg............................ 99
DEXTROMETHORPHAN HBR/CHLO -phenylephrinechlorphen-dm liquid 1.75-0.75-2.75 mg/ml...................... 68
DEX-TUSS -guaifenesin-codeine liquid 300-10
mg/5ml..............................................................................68
DIABETA -glyburide tab 1.25 mg...................................... 33
DIABETA -glyburide tab 2.5 mg........................................ 33
DIABETA -glyburide tab 5 mg........................................... 33
DIALYVITE/ZINC -b-complex w/ c-zn & folic acid tab 1
mg.................................................................................. 131
DIALYVITE 3000 -b-complex w/ c-biotin-e-minerals & folic
acid tab 3 mg.................................................................131
DIALYVITE 5000 -b-complex w/ c-biotin-e-minerals & folic
acid tab 5 mg.................................................................131
DIALYVITE SUPREME D -multiple vitamins w/ minerals &
fa tab 3 mg.................................................................... 131
DIAMOX -acetazolamide cap sr 12hr 500 mg................... 59
DIASTAT ACUDIAL -diazepam rectal gel delivery system
10 mg............................................................................. 121
DIASTAT ACUDIAL -diazepam rectal gel delivery system
20 mg............................................................................. 121
216
DIASTAT PEDIATRIC -diazepam rectal gel delivery
system 2.5 mg............................................................... 121
DIATX ZN -b-complex w/ c-biotin-minerals & folic acid tab
5 mg............................................................................... 131
DIAZEPAM -diazepam im inj device 10 mg/2ml................ 87
DIAZEPAM -diazepam rectal gel delivery system 10
mg.................................................................................. 121
DIAZEPAM -diazepam rectal gel delivery system 2.5
mg.................................................................................. 121
DIAZEPAM -diazepam rectal gel delivery system 20
mg.................................................................................. 121
DIAZEPAM -diazepam soln 1 mg/ml................................. 87
DIAZEPAM INTENSOL -diazepam conc 5 mg/ml............. 87
diazepam tab 10 mg (Valium)......................................... 87
diazepam tab 2 mg (Valium)........................................... 87
diazepam tab 5 mg (Valium)...........................................87
DIBENZYLINE -phenoxybenzamine hcl cap 10 mg...........54
DICLEGIS -doxylamine-pyridoxine tab delayed release
10-10 mg..........................................................................80
diclofenac potassium tab 50 mg (Cataflam)................115
diclofenac sodium (actinic keratoses) gel 3%
(Solaraze)...................................................................... 166
diclofenac sodium ophth soln 0.1%............................ 154
diclofenac sodium soln 1.5% (Pennsaid).................... 166
diclofenac sodium tab delayed release 25 mg............115
diclofenac sodium tab sr 24hr 100 mg (Voltarenxr)...................................................................................115
diclofenac w/ misoprostol tab delayed release 50-0.2
mg (Arthrotec 50).........................................................115
diclofenac w/ misoprostol tab delayed release 75-0.2
mg (Arthrotec 75).........................................................115
dicloxacillin sodium cap 250 mg..................................... 2
dicloxacillin sodium cap 500 mg..................................... 2
dicyclomine hcl cap 10 mg (Bentyl).............................. 77
DICYCLOMINE HCL -dicyclomine hcl oral soln 10
mg/5ml..............................................................................77
dicyclomine hcl tab 20 mg (Bentyl)............................... 77
didanosine delayed release capsule 125 mg (Videx
ec).................................................................................... 11
ec).................................................................................... 11
ec).................................................................................... 11
ec).................................................................................... 11
DIDGET - blood glucose monitoring kit w/ device .......... 181
DIDRONEL -etidronate disodium tab 400 mg....................41
DIFFERIN -adapalene cream 0.1%.................................166
DIFFERIN -adapalene gel 0.1%...................................... 166
DIFFERIN -adapalene gel 0.3%...................................... 166
DIFFERIN -adapalene lotion 0.1%.................................. 166
DIFICID -fidaxomicin tab 200 mg........................................ 5
2014
DIFLORASONE DIACETATE -diflorasone diacetate cream
0.05%............................................................................. 166
diflorasone diacetate oint 0.05%..................................166
DIFLUCAN -fluconazole for susp 10 mg/ml.........................9
DIFLUCAN -fluconazole for susp 40 mg/ml.........................9
DIFLUCAN -fluconazole tab 100 mg................................... 9
DIFLUCAN -fluconazole tab 50 mg..................................... 9
diflunisal tab 500 mg.....................................................106
DIGEX NF -hyoscyamine-phenyltoloxamine cap 0.0625-15
mg.................................................................................... 77
DIGOXIN -digoxin oral soln 0.05 mg/ml............................ 45
digoxin tab 125 mcg (0.125 mg) (Lanoxin).................... 45
digoxin tab 250 mcg (0.25 mg) (Lanoxin)...................... 45
DIHYDROERGOTAMINE MESYLAT -dihydroergotamine
mesylate nasal spray 4 mg/ml....................................... 118
dihydroergotamine mesylate inj 1 mg/ml (D.h.e.
45).................................................................................. 118
DILACOR XR -diltiazem hcl cap sr 24hr 240 mg...............48
DILANTIN INFATABS -phenytoin chew tab 50 mg..........121
DILANTIN -phenytoin sodium extended cap 100 mg.......121
DILANTIN -phenytoin sodium extended cap 30 mg.........121
DILANTIN -phenytoin susp 125 mg/5ml.......................... 121
DILATRATE SR -isosorbide dinitrate cap cr 40 mg........... 45
DILAUDID -hydromorphone hcl liqd 1 mg/ml...................108
DILAUDID -hydromorphone hcl tab 2 mg........................107
diltiazem hcl cap sr 12hr 120 mg................................... 48
diltiazem hcl cap sr 12hr 60 mg.....................................48
diltiazem hcl cap sr 12hr 90 mg.....................................48
diltiazem hcl coated beads cap sr 24hr 120 mg
(Cardizem cd)................................................................. 49
(Cardizem cd)................................................................. 49
(Cardizem cd)................................................................. 49
(Cardizem cd)................................................................. 49
(Cardizem cd)................................................................. 49
diltiazem hcl coated beads tab sr 24hr 180 mg
(Cardizem la).................................................................. 49
(Cardizem la).................................................................. 49
(Cardizem la).................................................................. 49
(Cardizem la).................................................................. 49
(Cardizem la).................................................................. 49
diltiazem hcl extended release beads cap sr 24hr 120
mg (Tiazac)..................................................................... 49
mg (Tiazac)..................................................................... 49
mg (Tiazac)..................................................................... 49
mg (Tiazac)..................................................................... 49
mg (Tiazac)..................................................................... 49
mg (Tiazac)..................................................................... 49
diltiazem hcl tab 120 mg (Cardizem)............................. 49
diltiazem hcl tab 30 mg (Cardizem)............................... 49
diltiazem hcl tab 60 mg (Cardizem)............................... 49
diltiazem hcl tab 90 mg...................................................49
DIMENHYDRINATE -dimenhydrinate inj 50 mg/ml........... 80
DIOVAN HCT -valsartan-hydrochlorothiazide tab 160-12.5
mg.................................................................................... 54
DIOVAN HCT -valsartan-hydrochlorothiazide tab 160-25
mg.................................................................................... 54
mg.................................................................................... 54
DIOVAN HCT -valsartan-hydrochlorothiazide tab 320-25
mg.................................................................................... 54
mg.................................................................................... 54
DIOVAN -valsartan tab 160 mg.........................................54
DIOVAN -valsartan tab 320 mg.........................................54
DIOVAN -valsartan tab 40 mg...........................................54
DIOVAN -valsartan tab 80 mg...........................................54
DIPENTUM -olsalazine sodium cap 250 mg..................... 82
diphenhydramine hcl cap 50 mg....................................66
diphenhydramine hcl elixir 12.5 mg/5ml........................66
diphenhydramine hcl inj 50 mg/ml.................................66
diphenhydramine hcl syrup 12.5 mg/5ml...................... 66
DIPHENOXYLATE/ATROPINE -diphenoxylate w/ atropine
liq 2.5-0.025 mg/5ml........................................................ 76
diphenoxylate w/ atropine tab 2.5-0.025 mg
(Lomotil).......................................................................... 76
DIPROLENE AF -betamethasone dipropionate augmented
cream 0.05%..................................................................166
DIPROLENE -betamethasone dipropionate augmented
lotion 0.05%................................................................... 166
DIPROLENE -betamethasone dipropionate augmented
oint 0.05%...................................................................... 166
dipyridamole tab 25 mg (Persantine)...........................151
disopyramide phosphate cap 100 mg (Norpace).......... 51
disopyramide phosphate cap 150 mg (Norpace).......... 51
disulfiram tab 250 mg (Antabuse)................................102
disulfiram tab 500 mg (Antabuse)................................102
DITROPAN XL -oxybutynin chloride tab sr 24hr 10 mg..... 84
DITROPAN XL -oxybutynin chloride tab sr 24hr 15 mg..... 84
217
2014
DITROPAN XL -oxybutynin chloride tab sr 24hr 5 mg.......84
DIURIL -chlorothiazide susp 250 mg/5ml.......................... 59
divalproex sodium cap sprinkle 125 mg (Depakote
sprinkles)...................................................................... 121
divalproex sodium tab delayed release 125 mg
(Depakote).....................................................................121
(Depakote).....................................................................121
(Depakote).....................................................................121
divalproex sodium tab sr 24 hr 250 mg (Depakote
er)...................................................................................121
divalproex sodium tab sr 24 hr 500 mg (Depakote
er)...................................................................................121
DIVIGEL -estradiol td gel 0.25 mg/0.25gm (0.1%)............ 28
DIVIGEL -estradiol td gel 0.5 mg/0.5gm (0.1%)................ 28
DIVIGEL -estradiol td gel 1 mg/gm (0.1%)........................ 28
DIVISTA - folic acid-vit b6-vit b12-omega 3-biotin-cr cap 1
mg ................................................................................. 145
DOLGIC PLUS -butalbital-acetaminophen-caffeine tab
50-750-40 mg.................................................................106
DOLOGESIC -phenyltoloxamine-acetaminophen liquid
30-500 mg/15ml............................................................. 106
DOLOPHINE HCL -methadone hcl tab 5 mg.................. 108
DOLOPHINE -methadone hcl tab 10 mg.........................108
DONATUSS DC -phenylephrine-dihydrocodeine-gg syrup
7.5-7.5-50 mg/5ml............................................................68
donepezil hydrochloride orally disintegrating tab 10
mg (Aricept odt)........................................................... 102
donepezil hydrochloride orally disintegrating tab 5 mg
(Aricept odt)..................................................................102
donepezil hydrochloride tab 10 mg (Aricept)..............102
donepezil hydrochloride tab 23 mg (Aricept)..............102
donepezil hydrochloride tab 5 mg (Aricept)................102
DONNATAL -belladonna alkaloids-phenobarbital elixir 16.2
mg/5ml..............................................................................77
DONNATAL -belladonna alkaloids-phenobarbital tab 16.2
mg.................................................................................... 77
DONNATAL EXTENTABS -belladonna alkaloidsphenobarbital tab cr 48 mg..............................................77
DORAL -quazepam tab 15 mg.......................................... 97
DORIBAX -doripenem for iv infusion 250 mg.................... 15
DORIBAX -doripenem for iv infusion 500 mg.................... 15
DORYX -doxycycline hyclate tab delayed release 150
mg...................................................................................... 6
DORYX -doxycycline hyclate tab delayed release 200
mg...................................................................................... 6
dorzolamide hcl ophth soln 2% (Trusopt)................... 154
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8
mg/ml (Cosopt).............................................................155
DOVONEX -calcipotriene cream 0.005%........................ 166
DOVONEX SCALP -calcipotriene soln 0.005% (50 mcg/
ml).................................................................................. 166
doxazosin mesylate tab 1 mg (Cardura)........................54
218
doxepin hcl cap 100 mg..................................................89
doxepin hcl cap 10 mg................................................... 89
doxepin hcl cap 150 mg..................................................89
doxepin hcl conc 10 mg/ml............................................ 89
DOXEPIN HCL -doxepin hcl cap 75 mg............................89
doxercalciferol cap 0.5 mcg (Hectorol)......................... 41
doxercalciferol cap 1 mcg (Hectorol)............................ 41
doxercalciferol cap 2.5 mcg (Hectorol)......................... 41
doxycycline hyclate cap 100 mg (Vibramycin)............... 6
doxycycline hyclate cap 50 mg........................................6
DOXYCYCLINE HYCLATE -doxycycline hyclate cap dr
particles 100 mg................................................................ 6
doxycycline hyclate tab 100 mg.......................................6
doxycycline hyclate tab 20 mg.........................................6
doxycycline hyclate tab delayed release 100 mg........... 6
doxycycline hyclate tab delayed release 150 mg
(Doryx)...............................................................................6
doxycycline hyclate tab delayed release 75 mg............. 6
doxycycline monohydrate cap 100 mg (Monodox).........6
doxycycline monohydrate cap 150 mg (Adoxa)............. 6
doxycycline monohydrate cap 50 mg..............................6
doxycycline monohydrate cap 75 mg (Monodox)...........6
doxycycline monohydrate for susp 25 mg/5ml
(Vibramycin)......................................................................6
doxycycline monohydrate tab 100 mg (Adoxa pak
1/100)................................................................................. 6
doxycycline monohydrate tab 150 mg (Adoxa pak
1/150)................................................................................. 6
doxycycline monohydrate tab 50 mg (Adoxa)................ 6
doxycycline monohydrate tab 75 mg (Adoxa)................ 7
DOXYTEX -doxylamine succinate liquid 2.5 mg/2.5ml...... 66
DRISDOL -ergocalciferol cap 50000 unit........................ 129
DRITHO-CREME HP -anthralin cream 1%......................166
DRITHO-SCALP -anthralin cream 0.5%..........................166
dronabinol cap 10 mg (Marinol)..................................... 80
dronabinol cap 2.5 mg (Marinol).................................... 80
dronabinol cap 5 mg (Marinol)....................................... 80
drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)......30
drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin
28).................................................................................... 30
DROXIA -hydroxyurea cap 200 mg................................. 145
DRUG MART GLUCOSE -glucose chew tab 4 gm........... 33
DRYSOL -aluminum chloride soln 20%...........................166
DUAC -clindamycin phosph-benzoyl peroxide (refrig) gel
1.2 (1)-5%...................................................................... 166
DUAVEE -conjugated estrogens-bazedoxifene tab 0.45-20
mg.................................................................................... 28
DUETACT -pioglitazone hcl-glimepiride tab 30-2 mg........ 33
DUETACT -pioglitazone hcl-glimepiride tab 30-4 mg........ 33
2014
DUET DHA 400EC -prenat w/fe poly-na fered-fa tab 25-1
& omega cap dr 400mg................................................. 131
DUET DHA 400 -prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 400 mg........................................................131
DUET DHA 430EC -prenat w/fe poly-na fered-fa tab 25-1
& omega cap dr 430mg................................................. 131
DUET DHA 430 -prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 430 mg........................................................131
DUET DHA BALANCED -prenat w/fe poly-na fered-fa tab
24-1 & omega cap 272 mg............................................131
25-1 & omega cap 267 mg............................................131
26-1 & omega cap 278 mg............................................131
27-1 & omega cap dr 380mg.........................................131
DUET DHA EC -prenat w/fe poly-na fered-fa tab 25-1 &
omega cap dr 400mg.....................................................131
DUET DHA EC -prenat w/fe poly-na fered-fa tab 25-1 &
omega cap dr 430mg.....................................................131
DUET DHA -prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 400 mg........................................................131
DUET DHA -prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 430 mg........................................................131
DUEXIS -ibuprofen-famotidine tab 800-26.6 mg............. 115
DULERA -mometasone furoate-formoterol fumarate
aerosol 100-5 mcg/act..................................................... 73
DULERA -mometasone furoate-formoterol fumarate
aerosol 200-5 mcg/act..................................................... 73
duloxetine hcl enteric coated pellets cap 20 mg
(Cymbalta).......................................................................89
(Cymbalta).......................................................................89
(Cymbalta).......................................................................89
DUODOTE -atropine 2.1 mg/0.7ml-pralidoxime cl 600
mg/2ml inj device........................................................... 178
DUONEB -ipratropium-albuterol nebu soln 0.5-2.5(3)
mg/3ml..............................................................................73
DURAGESIC -fentanyl td patch 72hr 100 mcg/hr............108
DURAGESIC -fentanyl td patch 72hr 12 mcg/hr..............108
DUREZOL -difluprednate ophth emulsion 0.05%............ 155
DUTOPROL -metoprolol & hydrochlorothiazide tab sr 24hr
100-12.5 mg.....................................................................54
25-12.5 mg.......................................................................54
50-12.5 mg.......................................................................54
D-VI-SOL -cholecalciferol oral liquid 400 unit/ml............. 129
DYAZIDE -triamterene & hydrochlorothiazide cap 37.5-25
mg.................................................................................... 59
DYMISTA -azelastine hcl-fluticasone prop nasal spray
137-50 mcg/act................................................................ 67
DYNACIN -minocycline hcl tab 100 mg...............................7
DYNACIN -minocycline hcl tab 50 mg.................................7
DYNACIN -minocycline hcl tab 75 mg.................................7
DYNACIRC CR -isradipine tab sr 24hr 10 mg...................49
DYNACIRC CR -isradipine tab sr 24hr 5 mg.....................49
dyphylline-guaifenesin liqd 100-100 mg/5ml.................73
dyphylline-guaifenesin tab 200-200 mg.........................73
dyphylline-guaifenesin tab 200-400 mg.........................73
DYRENIUM -triamterene cap 100 mg............................... 60
DYRENIUM -triamterene cap 50 mg................................. 60
E
E.E.S. 400 -erythromycin ethylsuccinate tab 400 mg.......... 5
E.E.S. GRANULES -erythromycin ethylsuccinate for susp
200 mg/5ml........................................................................ 5
EASYGLUCO - blood glucose monitoring kit ................. 181
EASYGLUCO VALUE PACK - blood glucose monitoring kit
....................................................................................... 181
EASYMAX L BLOOD GLUCOSE S - blood glucose
EASYMAX L BLOOD GLUCOSE S - blood glucose
EASYMAX N BLOOD GLUCOSE S - blood glucose
EASYMAX N BLOOD GLUCOSE S - blood glucose
EASYMAX NG SELF-MONITORIN - blood glucose
EASYMAX NG SELF-MONITORIN - blood glucose
EASYMAX V2 SELF-MONITORIN - blood glucose
EASYMAX V2 SELF-MONITORIN - blood glucose
EASYMAX V BLOOD GLUCOSE S - blood glucose
EASYMAX V BLOOD GLUCOSE S - blood glucose
EASY PLUS BLOOD GLUCOSE M - blood glucose
EASY PLUS BLOOD GLUCOSE M - blood glucose
EASY PLUS II BLOOD GLUCOS - blood glucose
EASYPLUS R13N SELF-MONITO - blood glucose
EASYPLUS V SELF-MONITORIN - blood glucose
EASYPRO BLOOD GLUCOSE MON - blood glucose
EASYPRO PLUS - blood glucose monitoring kit w/ device
....................................................................................... 182
EASY STEP BLOOD GLUCOSE M - blood glucose
219
2014
EASY STEP BLOOD GLUCOSE M - blood glucose
EASY TALK BLOOD GLUCOSE M - blood glucose
EASY TALK BLOOD GLUCOSE M - blood glucose
EASY TOUCH GLUCOSE MONITO - blood glucose
EASY TOUCH HEALTHPRO GLUC - blood glucose
EASY TRAK BLOOD GLUCOSE M - blood glucose
EASY TRAK BLOOD GLUCOSE M - blood glucose
ECLIPSE BLOOD GLUCOSE MON - blood glucose
EC-NAPROSYN -naproxen tab ec 375 mg..................... 115
EC-NAPROSYN -naproxen tab ec 500 mg..................... 115
econazole nitrate cream 1%......................................... 166
ECOZA -econazole nitrate foam 1%............................... 166
EDARBI -azilsartan medoxomil tab 40 mg........................ 54
EDARBI -azilsartan medoxomil tab 80 mg........................ 54
EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab
40-12.5 mg.......................................................................54
EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab
40-25 mg..........................................................................54
ED CHLORPED -chlorpheniramine tannate susp 2 mg/
ml......................................................................................66
ED-CHLOR-TAN -chlorpheniramine tannate tab 8 mg...... 66
ED CYTE F -ferrous fumarate-folic acid-docusate sodium
tab 324-1-50 mg............................................................ 145
EDECRIN -ethacrynic acid tab 25 mg............................... 60
EDEX -alprostadil for inj kit 10 mcg...................................64
EDLUAR -zolpidem tartrate sl tab 10 mg.......................... 97
EDLUAR -zolpidem tartrate sl tab 5 mg............................ 97
EDURANT -rilpivirine hcl tab 25 mg (base equivalent)...... 11
EFFER-K -potassium bicarbonate-citric acid effer tab 10
meq................................................................................ 140
EFFER-K -potassium bicarbonate-citric acid effer tab 20
meq................................................................................ 140
EFFEXOR XR -venlafaxine hcl cap sr 24hr 150 mg (base
equivalent)........................................................................89
EFFEXOR XR -venlafaxine hcl cap sr 24hr 37.5 mg (base
equivalent)........................................................................89
EFFEXOR XR -venlafaxine hcl cap sr 24hr 75 mg (base
equivalent)........................................................................89
EFFIENT -prasugrel hcl tab 10 mg (base equiv)............. 151
EFFIENT -prasugrel hcl tab 5 mg (base equiv)............... 151
EFUDEX -fluorouracil cream 5%..................................... 166
ELDEPRYL -selegiline hcl cap 5 mg............................... 125
ELEMENT AUTOCODE SYSTEM - blood glucose
220
ELEMENT COMPACT BLOOD GLU - blood glucose
ELEMENT PLUS BLOOD GLUCOS - blood glucose
ELENZAPATCH -lidocaine-menthol patch 4-1%............. 166
ELESTAT -epinastine hcl ophth soln 0.05%....................155
ELESTRIN -estradiol gel 0.06% (0.52 mg/0.87 gm
metered-dose pump)........................................................28
ELETONE - emollient - cream ........................................166
ELETONE TWINPACK - emollient - cream .................... 166
ELIDEL -pimecrolimus cream 1%....................................166
ELIGARD -leuprolide acetate (3 month) for subcutaneous
inj kit 22.5mg................................................................... 21
inj kit 30 mg..................................................................... 21
inj kit 45 mg..................................................................... 21
ELIGARD -leuprolide acetate for subcutaneous inj kit 7.5
mg.................................................................................... 21
ELIMITE -permethrin cream 5%...................................... 166
ELIPHOS -calcium acetate (phosphate binder) tab 667
mg.................................................................................... 82
ELIQUIS -apixaban tab 2.5 mg....................................... 148
ELIQUIS -apixaban tab 5 mg.......................................... 148
ELITE-OB - prenatal vit w/ iron carbonyl-fa tab 50-1.25 mg
....................................................................................... 131
ELITE OB WITH DHA - prenatal vit w/ fe fum-fa-omega 3
cap 28-1.25-200 mg ..................................................... 131
ELIXOPHYLLIN -theophylline elixir 80 mg/15ml................73
ELLA -ulipristal acetate tab 30 mg.................................... 30
ELMIRON -pentosan polysulfate sodium caps 100 mg..... 86
ELOCON -mometasone furoate cream 0.1%.................. 166
ELOCON -mometasone furoate oint 0.1%...................... 166
ELOCON -mometasone furoate solution 0.1%
(lotion)............................................................................ 166
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
1000 unit........................................................................ 151
1500 unit........................................................................ 151
2000 unit........................................................................ 151
250 unit.......................................................................... 151
3000 unit........................................................................ 151
500 unit.......................................................................... 151
750 unit.......................................................................... 151
EMADINE -emedastine difumarate ophth soln 0.05%
(base equiv)................................................................... 155
EMBRACE BLOOD GLUCOSE MON - blood glucose
EMBRACE EVO BLOOD GLUCOSE - blood glucose
2014
EMBRACE PRO BLOOD GLUCOSE - blood glucose
EMCYT -estramustine phosphate sodium cap 140 mg......21
EMEND -aprepitant capsule 125 mg................................. 80
EMEND -aprepitant capsule 40 mg...................................80
EMEND -aprepitant capsule 80 mg...................................80
EMEND -aprepitant capsule therapy pack 80 & 125
mg.................................................................................... 80
EMLA -lidocaine-prilocaine cream 2.5-2.5%....................166
EMSAM -selegiline td patch 24hr 12 mg/24hr................... 89
EMSAM -selegiline td patch 24hr 6 mg/24hr..................... 89
EMSAM -selegiline td patch 24hr 9 mg/24hr..................... 89
EMTRIVA -emtricitabine caps 200 mg.............................. 11
EMTRIVA -emtricitabine soln 10 mg/ml.............................11
EMULSION SB - dermatological products misc - emulsion
....................................................................................... 166
ENABLEX -darifenacin hydrobromide tab sr 24hr 15 mg
(base equiv)..................................................................... 84
ENABLEX -darifenacin hydrobromide tab sr 24hr 7.5 mg
(base equiv)..................................................................... 84
enalapril maleate & hydrochlorothiazide tab 10-25 mg
(Vaseretic)....................................................................... 54
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg.................................................................................... 54
enalapril maleate tab 10 mg (Vasotec).......................... 54
enalapril maleate tab 2.5 mg (Vasotec)......................... 54
enalapril maleate tab 20 mg (Vasotec).......................... 54
enalapril maleate tab 5 mg (Vasotec)............................ 54
ENBREL -etanercept for subcutaneous inj kit 25 mg.......116
ENBREL -etanercept subcutaneous inj 25 mg/0.5ml.......116
ENBREL -etanercept subcutaneous inj 50 mg/ml............115
ENBREL SURECLICK -etanercept subcutaneous inj 50
mg/ml..............................................................................116
ENCARE -nonoxynol-9 vaginal suppos 100 mg................ 85
ENDACOF-DC -pseudoephedrine w/ codeine liquid 30-10
mg/5ml..............................................................................68
ENDOMETRIN -progesterone vaginal insert 100 mg........ 85
ENJUVIA -estrogens, conjugated synthetic b tab 0.3
mg.................................................................................... 28
mg.................................................................................... 28
mg.................................................................................... 28
mg.................................................................................... 28
mg.................................................................................... 28
ENLON -edrophonium chloride inj 10 mg/ml................... 128
ENOVARX-AMITRIPTYLINE -amitriptyline hcl cream 2%
kit (compounding kit)......................................................178
ENOVARX-BACLOFEN - baclofen cream 1% (compound
kit) ................................................................................. 166
ENOVARX-CYCLOBENZAPRINE H - cyclobenzaprine hcl
td cream 20 mg/gm (compound kit) ..............................128
ENOVARX-IBUPROFEN - ibuprofen cream 10%
(compounding kit) ......................................................... 166
ENOVARX-LIDOCAINE HCL - lidocaine hcl cream 10%
(compound kit) .............................................................. 167
ENOVARX-LIDOCAINE HCL - lidocaine hcl cream 5%
(compound kit) .............................................................. 167
ENOVARX-NAPROXEN - naproxen cream 10%
(compound kit) .............................................................. 167
ENOVARX-TRAMADOL - tramadol hcl cream 5%
(compound kit) .............................................................. 167
enoxaparin sodium inj 100 mg/ml (Lovenox).............. 148
enoxaparin sodium inj 120 mg/0.8ml (Lovenox)......... 148
enoxaparin sodium inj 150 mg/ml (Lovenox).............. 148
enoxaparin sodium inj 300 mg/3ml (Lovenox)............ 148
enoxaparin sodium inj 30 mg/0.3ml (Lovenox)........... 148
entacapone tab 200 mg (Comtan)................................ 125
ENTERAGAM -serum-derived bovine immunoglob/protein
isolate 5 gm packet....................................................... 142
ENTEREG -alvimopan cap 12 mg.....................................82
ENTOCORT EC -budesonide cap sr 24hr 3 mg................24
ENVISION AUTOCODE - blood glucose monitoring kit w/
device ............................................................................182
EPANED -enalapril maleate for oral soln 1 mg/ml.............54
EPICERAM - dermatological products misc - emulsion
....................................................................................... 167
EPIDUO -adapalene-benzoyl peroxide gel 0.1-2.5%.......167
EPIFOAM -pramoxine-hc aerosol foam 1-1%................. 167
epinastine hcl ophth soln 0.05% (Elestat)................... 155
EPINEPHRINE -epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000).......................................................... 60
EPINEPHRINE -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................61
epinephrine hcl inj 1 mg/ml............................................73
epinephrine hcl soln prefilled syringe 0.1 mg/ml..........73
EPIPEN 2-PAK -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)............................................................61
EPIPEN-JR 2-PAK -epinephrine solution auto-injector 0.15
mg/0.3ml (1:2000)............................................................61
EPIVIR HBV -lamivudine oral soln 5 mg/ml.......................11
EPIVIR HBV -lamivudine tab 100 mg................................11
EPIVIR -lamivudine oral soln 10 mg/ml.............................11
EPIVIR -lamivudine tab 150 mg........................................ 11
EPIVIR -lamivudine tab 300 mg........................................ 11
eplerenone tab 25 mg (Inspra)....................................... 54
eplerenone tab 50 mg (Inspra)....................................... 55
EPOGEN -epoetin alfa inj 10000 unit/ml......................... 145
EPOGEN -epoetin alfa inj 20000 unit/ml......................... 145
EPOGEN -epoetin alfa inj 2000 unit/ml........................... 145
epoprostenol sodium for inj 0.5 mg (Flolan).................65
epoprostenol sodium for inj 1.5 mg (Flolan).................65
221
2014
eprosartan mesylate tab 600 mg (Teveten)................... 55
EPZICOM -abacavir sulfate-lamivudine tab 600-300
mg.................................................................................... 11
EQL TRUE2GO BLOOD GLUCOSE - blood glucose
EQUAGESIC -meprobamate-aspirin tab 200-325 mg..... 106
EQUETRO -carbamazepine (antipsychotic) cap sr 12hr
100 mg............................................................................. 93
200 mg............................................................................. 93
300 mg............................................................................. 93
ergocalciferol cap 50000 unit (Drisdol)........................129
ERGOLOID MESYLATES -ergoloid mesylates tab 1
mg.................................................................................. 102
ERGOMAR -ergotamine tartrate sl tab 2 mg...................118
ERIVEDGE -vismodegib cap 150 mg................................21
ERTACZO -sertaconazole nitrate cream 2%...................167
ERYGEL -erythromycin gel 2%....................................... 167
ERYPED 200 -erythromycin ethylsuccinate for susp 200
mg/5ml................................................................................5
ERYPED 400 -erythromycin ethylsuccinate for susp 400
mg/5ml................................................................................5
ERY-TAB -erythromycin tab delayed release 250 mg......... 5
ERYTHROCIN STEARATE -erythromycin stearate tab 250
mg...................................................................................... 5
ERYTHROMYCIN BASE -erythromycin tab 250 mg........... 5
ERYTHROMYCIN BASE -erythromycin tab 500 mg........... 5
ERYTHROMYCIN -erythromycin w/ delayed release
particles cap 250 mg......................................................... 5
ERYTHROMYCIN ETHYLSUCCINA -erythromycin
ethylsuccinate tab 400 mg.................................................5
erythromycin gel 2% (Erygel)....................................... 167
erythromycin ophth oint 5 mg/gm............................... 155
erythromycin pads 2%.................................................. 167
erythromycin soln 2%................................................... 167
erythromycin-sulfisoxazole for susp 200-600
mg/5ml.............................................................................15
erythromycin w/ delayed release particles cap 250
mg...................................................................................... 6
ESCAVITE D - pediatric multiple vitamins w/ fl-fe chew tab
0.25-6 mg ..................................................................... 131
ESCAVITE - pediatric multiple vitamins w/ fl-fe chew tab
0.25-7.5 mg .................................................................. 131
escitalopram oxalate soln 5 mg/5ml (base equiv)
(Lexapro)......................................................................... 89
escitalopram oxalate tab 10 mg (base equiv)
(Lexapro)......................................................................... 89
(Lexapro)......................................................................... 90
(Lexapro)......................................................................... 90
222
ESGIC -butalbital-acetaminophen-caffeine cap 50-325-40
mg.................................................................................. 106
ESGIC -butalbital-acetaminophen-caffeine tab 50-325-40
mg.................................................................................. 106
ESGIC-PLUS -butalbital-acetaminophen-caffeine cap
50-500-40 mg.................................................................106
ESGIC-PLUS -butalbital-acetaminophen-caffeine tab
50-500-40 mg.................................................................106
ESOMEPRAZOLE STRONTIUM -esomeprazole strontium
cap delayed release 24.65 mg........................................ 77
ESOMEPRAZOLE STRONTIUM -esomeprazole strontium
cap delayed release 49.3 mg.......................................... 77
estazolam tab 1 mg......................................................... 97
estazolam tab 2 mg......................................................... 97
esterified estrogens & methyltestosterone tab
0.625-1.25 mg................................................................. 28
esterified estrogens & methyltestosterone tab 1.25-2.5
mg.................................................................................... 28
ESTRACE -estradiol tab 0.5 mg........................................28
ESTRACE -estradiol tab 1 mg.......................................... 28
ESTRACE -estradiol tab 2 mg.......................................... 28
ESTRACE -estradiol vaginal cream 0.1 mg/gm.................85
estradiol & norethindrone acetate tab 0.5-0.1 mg
(Activella)........................................................................ 28
estradiol & norethindrone acetate tab 1-0.5 mg
(Activella)........................................................................ 28
estradiol tab 0.5 mg (Estrace)........................................ 28
estradiol tab 1 mg (Estrace)........................................... 28
estradiol tab 2 mg (Estrace)........................................... 28
estradiol td patch weekly 0.025 mg/24hr (Climara).......28
estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr) (Climara)....................................................... 28
estradiol td patch weekly 0.05 mg/24hr (Climara).........28
estradiol td patch weekly 0.06 mg/24hr (Climara).........28
estradiol td patch weekly 0.075 mg/24hr (Climara).......28
estradiol td patch weekly 0.1 mg/24hr (Climara)...........28
estradiol valerate im in oil 10 mg/ml (Delestrogen)...... 28
ESTRASORB -estradiol transdermal emulsion 4.35
mg/1.74gm....................................................................... 28
ESTRING -estradiol vaginal ring 2 mg (7.5 mcg/24hrs).....85
ESTROGEL -estradiol gel 0.06% (0.75 mg/1.25 gm
metered-dose pump)........................................................28
ESTROPIPATE -estropipate tab 3 mg.............................. 28
estropipate tab 0.75 mg.................................................. 28
estropipate tab 1.5 mg.................................................... 28
ESTROSTEP FE -norethindrone ac-ethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg....................................................30
eszopiclone tab 1 mg (Lunesta).....................................97
ethambutol hcl tab 100 mg (Myambutol).........................9
ethambutol hcl tab 400 mg (Myambutol).........................9
ethosuximide cap 250 mg (Zarontin)........................... 121
2014
ethosuximide soln 250 mg/5ml (Zarontin)...................121
ETHYL CHLORIDE/FINE PINPO -ethyl chloride aerosol
spray...............................................................................167
ETHYL CHLORIDE/FINE STREA -ethyl chloride aerosol
spray...............................................................................167
ETHYL CHLORIDE/MEDIUM JET -ethyl chloride aerosol
spray...............................................................................167
ETHYL CHLORIDE/MEDIUM STR -ethyl chloride aerosol
spray...............................................................................167
ETHYL CHLORIDE/MIST -ethyl chloride aerosol
spray...............................................................................167
ETHYL CHLORIDE -ethyl chloride aerosol spray............167
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35
mcg.................................................................................. 30
ETIDRONATE DISODIUM -etidronate disodium tab 200
mg.................................................................................... 41
ETIDRONATE DISODIUM -etidronate disodium tab 400
mg.................................................................................... 41
etodolac cap 200 mg..................................................... 116
etodolac cap 300 mg..................................................... 116
etodolac tab 400 mg......................................................116
etodolac tab 500 mg......................................................116
etodolac tab sr 24hr 400 mg.........................................116
ETOPOSIDE -etoposide cap 50 mg.................................. 21
EUCALYPTUS OIL -eucalyptus (topical) oil.................... 167
EURAX -crotamiton cream 10%...................................... 167
EURAX -crotamiton lotion 10%....................................... 167
EVAMIST -estradiol transdermal spray 1.53 mg/spray...... 28
EVENCARE BLOOD GLUCOSE MO - blood glucose
monitoring kit ................................................................ 182
EVENCARE G2 BLOOD GLUCOSE - blood glucose
EVENCARE G3 BLOOD GLUCOSE - blood glucose
EVICEL - fibrin sealant component kit 2 ml ....................149
EVICEL - fibrin sealant component kit 5 ml ....................149
EVISTA -raloxifene hcl tab 60 mg..................................... 41
EVITHROM -thrombin (human) topical soln 800-1200 unit/
ml....................................................................................149
EVOCLIN -clindamycin phosphate foam 1%................... 167
EVOLUTION AUTOCODE - blood glucose monitoring
devices ..........................................................................182
EVOXAC -cevimeline hcl cap 30 mg...............................159
EXACTUSS -phenylephrine w/ dm-gg liqd 10-28-388
mg/5ml..............................................................................68
EXALGO -hydromorphone hcl tab er 24hr deter 12
mg.................................................................................. 108
mg.................................................................................. 108
mg.................................................................................. 108
EXALGO -hydromorphone hcl tab er 24hr deter 8 mg.....108
EXELDERM -sulconazole nitrate cream 1%....................167
EXELDERM -sulconazole nitrate solution 1%................. 167
EXELON -rivastigmine tartrate cap 1.5 mg..................... 103
EXELON -rivastigmine tartrate cap 3 mg........................ 103
EXELON -rivastigmine tartrate cap 4.5 mg..................... 103
EXELON -rivastigmine tartrate cap 6 mg........................ 103
EXELON -rivastigmine tartrate soln 2 mg/ml................... 103
EXELON -rivastigmine td patch 24hr 13.3 mg/24hr.........103
EXELON -rivastigmine td patch 24hr 4.6 mg/24hr...........102
EXELON -rivastigmine td patch 24hr 9.5 mg/24hr...........102
exemestane tab 25 mg (Aromasin)................................ 21
EXFORGE -amlodipine besylate-valsartan tab 10-160
mg.................................................................................... 55
mg.................................................................................... 55
mg.................................................................................... 55
mg.................................................................................... 55
EXFORGE HCT -amlodipine-valsartan-hydrochlorothiazide
tab 10-160-12.5 mg......................................................... 55
tab 10-160-25 mg............................................................ 55
tab 10-320-25 mg............................................................ 55
tab 5-160-12.5 mg........................................................... 55
tab 5-160-25 mg.............................................................. 55
EXJADE -deferasirox tab for oral susp 125 mg............... 178
EXTAVIA -interferon beta-1b for inj kit 0.3 mg................ 103
EXTINA -ketoconazole foam 2%..................................... 167
EXTRA-VIRT PLUS DHA - prenatal w/o vit a w/ fe fumdoc-fa-dha cap 29-1.25-350 mg ................................... 131
EZ SMART DIABETES MONITOR - blood glucose
EZ SMART PLUS DIABETES MO - blood glucose
F
FA-8 -folic acid cap 0.8 mg............................................. 145
FABIOR -tazarotene (acne) foam 0.1%...........................167
FACTIVE -gemifloxacin mesylate tab 320 mg (base
equiv)..................................................................................8
FALESSA -levonorgest-eth estrad tab 0.1 mg-20 mcg & fa
tab 1 mg kit......................................................................30
famciclovir tab 125 mg (Famvir).................................... 11
famotidine for susp 40 mg/5ml (Pepcid)....................... 77
famotidine tab 20 mg (Pepcid)....................................... 77
famotidine tab 40 mg (Pepcid)....................................... 77
FAMVIR -famciclovir tab 125 mg.......................................11
223
2014
FANAPT -iloperidone tab 10 mg....................................... 94
FANAPT -iloperidone tab 12 mg....................................... 94
FANAPT -iloperidone tab 1 mg......................................... 93
FANAPT TITRATION PACK -iloperidone tab 1 mg & 2 mg
& 4 mg & 6 mg titration pak............................................ 94
FARESTON -toremifene citrate tab 60 mg (base
equivalent)........................................................................21
FARXIGA -dapagliflozin propanediol tab 10 mg (base
equivalent)........................................................................33
FARXIGA -dapagliflozin propanediol tab 5 mg (base
equivalent)........................................................................33
FASTTAKE COMPACT MONITORI - blood glucose
FAZACLO -clozapine orally disintegrating tab 100 mg...... 94
FAZACLO -clozapine orally disintegrating tab 12.5 mg..... 94
FAZACLO -clozapine orally disintegrating tab 25 mg........ 94
FBL KIT - flurbiprofen-baclofen-lidocaine cream 15-4-5%
(cmpd kit) ......................................................................167
FC2 FEMALE CONDOM - condoms - female ................ 182
FC FEMALE CONDOM - condoms - female .................. 182
FE 90 PLUS - fe carbonyl-fe gluconate-fa-vit b12-vit c-dss
tab 90-1 mg .................................................................. 145
fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1
mg.................................................................................. 145
fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240
mg.................................................................................. 145
fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu
cap (Tandem plus)....................................................... 144
FEIBA NF - antiinhibitor coagulant complex for inj ......... 151
felbamate susp 600 mg/5ml (Felbatol).........................121
felbamate tab 400 mg (Felbatol)...................................121
felbamate tab 600 mg (Felbatol)...................................121
FELBATOL -felbamate susp 600 mg/5ml........................ 121
FELBATOL -felbamate tab 400 mg................................. 121
FELBATOL -felbamate tab 600 mg................................. 121
FELDENE -piroxicam cap 10 mg.................................... 116
FELDENE -piroxicam cap 20 mg.................................... 116
felodipine tab sr 24hr 10 mg.......................................... 49
felodipine tab sr 24hr 2.5 mg......................................... 49
felodipine tab sr 24hr 5 mg............................................ 49
FEMARA -letrozole tab 2.5 mg......................................... 21
FEMCON FE -norethindrone & ethinyl estradiol-fe chew
tab 0.4 mg-35 mcg.......................................................... 30
FEMHRT 1/5 -norethindrone acetate-ethinyl estradiol tab 1
mg-5 mcg......................................................................... 28
FEMHRT LOW DOSE -norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg........................................... 28
FEM PH -acetic acid-oxyquinoline vaginal gel
0.9-0.025%....................................................................... 85
224
FEMRING -estradiol acetate vaginal ring 0.05
mg/24hr............................................................................ 85
FEMRING -estradiol acetate vaginal ring 0.1 mg/24hr...... 85
FEMTRACE -estradiol acetate tab 0.45 mg...................... 28
FEMTRACE -estradiol acetate tab 0.9 mg........................ 28
FENOFIBRATE -fenofibrate cap 150 mg.......................... 62
FENOFIBRATE -fenofibrate cap 50 mg............................ 62
fenofibrate micronized cap 130 mg............................... 62
fenofibrate micronized cap 134 mg (Lofibra)................ 62
fenofibrate micronized cap 200 mg (Lofibra)................ 62
fenofibrate micronized cap 43 mg................................. 62
fenofibrate micronized cap 67 mg (Lofibra).................. 62
fenofibrate tab 145 mg (Tricor)...................................... 62
fenofibrate tab 160 mg (Lofibra).................................... 62
fenofibrate tab 48 mg (Tricor)........................................ 62
fenofibrate tab 54 mg (Lofibra)...................................... 62
FENOFIBRIC ACID -fenofibric acid tab 105 mg................ 62
FENOFIBRIC ACID -fenofibric acid tab 35 mg.................. 62
FENOGLIDE -fenofibrate tab 120 mg................................62
FENOGLIDE -fenofibrate tab 40 mg................................. 62
FENOPROFEN CALCIUM -fenoprofen calcium tab 600
mg.................................................................................. 116
fentanyl citrate lollipop 1200 mcg (Actiq)....................108
fentanyl citrate lollipop 1600 mcg (Actiq)....................108
fentanyl citrate lollipop 200 mcg (Actiq)..................... 108
fentanyl td patch 72hr 100 mcg/hr (Duragesic)...........108
fentanyl td patch 72hr 12 mcg/hr (Duragesic).............108
FENTORA -fentanyl citrate buccal tab 100 mcg (base
equiv)..............................................................................108
equiv)..............................................................................108
equiv)..............................................................................108
equiv)..............................................................................108
equiv)..............................................................................108
FER-IN-SOL -ferrous sulfate soln 75 mg/ml (15 mg/ml
elemental fe).................................................................. 145
FERIVAFA - iron-c-fa-b12-biotin-copper-docusate cap
110-1 mg ...................................................................... 145
FERIVA - fe bisglycin-fe carbonyl-c-fa-b12-biotin-dss cap
75-1 mg ........................................................................ 145
FERRALET 90 - fe carbonyl-fe gluconate-fa-vit b12-vit cdss tab 90-1 mg ........................................................... 145
FERRAPLUS 90 - iron-folic acid-vit b12-vit c-docusate sod
tab 90-1 mg .................................................................. 145
FERRETTS CHEWABLE IRON -carbonyl iron chew tab 18
mg (elemental iron)........................................................145
2014
FERREX 150 FORTE PLUS - fe asp gly-fe polysacch-succ
ac-c-threon ac-b12-fa cap ............................................ 145
FERREX 28 - fe asparto gly-fe fum-b12-fa-c-succinic ac
tab ther pack .................................................................145
FERRIPROX -deferiprone tab 500 mg............................ 178
FERRO-PLEX HEMATINIC - fe fum-dss-vit c-vit e-vit b12if-fa tab 115-1 mg ......................................................... 145
FERROTRIN -iron w/ b12-vit c-fa-ifc cap
36-0.015-75-0.5-240 mg................................................ 145
ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab
106-1 mg ...................................................................... 144
ferrous fumarate-folic acid tab 324-1 mg.................... 145
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental
fe)................................................................................... 146
FERROUS SULFATE -ferrous sulfate liquid 220 mg/5ml
(44 mg/5ml elemental fe)...............................................145
FERROUS SULFATE -ferrous sulfate syrup 300 mg/5ml
(60 mg/5ml elemental fe)...............................................145
ferrous sulfate soln 75 mg/ml (15 mg/ml elemental
fe)................................................................................... 146
ferrous sulfate-vit c-folic acid tab cr 105-500-0.8
mg.................................................................................. 146
FETZIMA -levomilnacipran hcl cap sr 24hr 120 mg (base
equivalent)........................................................................90
equivalent)........................................................................90
equivalent)........................................................................90
equivalent)........................................................................90
FETZIMA TITRATION PACK -levomilnacipran hcl cap sr
24hr 20 & 40 mg therapy pack........................................ 90
FEXMID -cyclobenzaprine hcl tab 7.5 mg....................... 128
FEXOFENADINE HCL -fexofenadine hcl tab 60 mg......... 66
FIBRICOR -fenofibric acid tab 105 mg..............................62
FIBRICOR -fenofibric acid tab 35 mg................................62
FIFTY50 GLUCOSE METER 2.0 - blood glucose
FINACEA -azelaic acid gel 15%......................................167
FINACEA PLUS -azelaic acid gel 15% w/cleanser &
moisturizing lotion kit..................................................... 167
finasteride tab 5 mg (Proscar)........................................86
FINGERSTIX LANCETS - lancets ..................................182
FIORICET/CODEINE -butalbital-acetaminophen-caff w/
cod cap 50-300-40-30 mg............................................. 108
FIORICET/CODEINE -butalbital-acetaminophen-caff w/
cod cap 50-325-40-30 mg............................................. 108
FIORICET -butalbital-acetaminophen-caffeine cap
50-300-40 mg.................................................................106
FIORICET -butalbital-acetaminophen-caffeine tab
50-325-40 mg.................................................................106
FIORINAL/CODEINE #3 -butalbital-aspirin-caff w/ codeine
cap 50-325-40-30 mg.................................................... 108
FIORINAL -butalbital-aspirin-caffeine cap 50-325-40
mg.................................................................................. 106
FIRAZYR -icatibant acetate inj 30 mg/3ml (base
equivalent)......................................................................151
FIRMAGON -degarelix acetate for inj 120 mg (base
equiv)................................................................................21
FIRMAGON -degarelix acetate for inj 80 mg (base
equiv)................................................................................21
FIRST-BXN MOUTHWASH - diphenhydramine-lidocainenystatin susp .................................................................159
FIRST-DUKES MOUTHWASH - diphenhydraminehydrocortisone-nystatin susp ........................................ 159
FIRST-HYDROCORTISONE -hydrocortisone gel
10%................................................................................ 167
FIRST-LANSOPRAZOLE - lansoprazole susp 3 mg/ml
(compound kit) ................................................................ 77
FIRST-MARYS MOUTHWASH - diphenhydraminehydrocortisone-nystatin-tetracycline susp ..................... 159
FIRST-MOUTHWASH BLM - diphenhyd-lidocaine-al
hydroxide-mg hydroxide-simeth susp ........................... 159
FIRST-OMEPRAZOLE - omeprazole susp 2 mg/ml
(compound kit) ................................................................ 77
FIRST-PROGESTERONE VGS 10 -progesterone vaginal
suppository 100 mg......................................................... 85
suppository 200 mg......................................................... 85
suppository 25 mg........................................................... 85
suppository 400 mg......................................................... 85
suppository 50 mg........................................................... 85
FIRST-TESTOSTERONE MC COM -testosterone
propionate td cream 2%.................................................. 27
FIRST-TESTOSTERONE -testosterone propionate td
ointment 2%..................................................................... 26
FIRST-VANCOMYCIN 25 - vancomycin hcl oral soln 25
mg/ml (compound kit) ..................................................... 16
FIRST-VANCOMYCIN 50 - vancomycin hcl oral soln 50
FLAGYL ER -metronidazole tab sr 24hr 750 mg............... 16
FLAGYL -metronidazole cap 375 mg................................ 16
FLAGYL -metronidazole tab 250 mg................................. 16
FLAGYL -metronidazole tab 500 mg................................. 16
FLAREX -fluorometholone acetate ophth susp 0.1%...... 155
flavoxate hcl tab 100 mg.................................................84
flaxseed oil-evening primrose-bilberry cap 1000-500-40
mg (Tears again hydrate)............................................ 142
FLEBOGAMMA DIF -immune globulin (human) iv soln 0.5
gm/10ml............................................................................19
FLEBOGAMMA DIF -immune globulin (human) iv soln 10
gm/100ml..........................................................................19
gm/200ml..........................................................................19
FLEBOGAMMA DIF -immune globulin (human) iv soln 2.5
gm/50ml............................................................................19
225
2014
gm/200ml..........................................................................19
gm/400ml..........................................................................19
gm/100ml..........................................................................19
gm/50ml............................................................................19
FLEBOGAMMA -immune globulin (human) iv soln 0.5
gm/10ml............................................................................19
flecainide acetate tab 100 mg.........................................51
flecainide acetate tab 150 mg.........................................51
flecainide acetate tab 50 mg.......................................... 51
FLECTOR -diclofenac epolamine patch 1.3%................. 167
FLEXERIL -cyclobenzaprine hcl tab 10 mg..................... 128
FLEXERIL -cyclobenzaprine hcl tab 5 mg.......................128
FLOLAN -epoprostenol sodium for inj 0.5 mg................... 65
FLOLAN -epoprostenol sodium for inj 1.5 mg................... 65
FLOMAX -tamsulosin hcl cap 0.4 mg................................86
FLONASE -fluticasone propionate nasal susp 50 mcg/
act.....................................................................................67
FLO-PRED -prednisolone acetate oral susp 16.7 mg/5ml
(15 mg/5ml base).............................................................24
FLORICAL -sodium fluoride w/ calcium carb cap 8.3-364
mg.................................................................................. 140
FLORICAL -sodium fluoride w/ calcium carb tab 8.3-364
mg.................................................................................. 140
FLOVENT DISKUS -fluticasone propionate aer pow ba
100 mcg/blister.................................................................73
FLOVENT DISKUS -fluticasone propionate aer pow ba
250 mcg/blister.................................................................73
FLOVENT DISKUS -fluticasone propionate aer pow ba 50
mcg/blister........................................................................ 73
FLOVENT HFA -fluticasone propionate hfa inhal aer 110
mcg/act (125/valve)..........................................................73
FLOVENT HFA -fluticasone propionate hfa inhal aer 220
mcg/act (250/valve)..........................................................73
FLOVENT HFA -fluticasone propionate hfa inhal aero 44
mcg/act (50/valve)............................................................73
FLUARIX 2011-2012 -influenza virus vaccine split
FLUARIX QUADRIVALENT 2013 -influenza virus vaccine
split quadrivalent inj 0.5 ml.............................................. 17
FLUARIX QUADRIVALENT 2014 -influenza virus vaccine
FLUCELVAX 2012-2013 -influenza virus vaccine tissuecultured subunit inj...........................................................17
226
fluconazole for susp 10 mg/ml (Diflucan)..................... 10
fluconazole for susp 40 mg/ml (Diflucan)..................... 10
fluconazole in dextrose inj 200 mg/100ml..................... 10
fluconazole in dextrose inj 400 mg/200ml..................... 10
fluconazole in nacl 0.9% inj 200 mg/100ml................... 10
fluconazole in nacl 0.9% inj 400 mg/200ml................... 10
FLUCONAZOLE IN NACL -fluconazole in nacl 0.9% inj
100 mg/50ml.................................................................... 10
fluconazole tab 100 mg (Diflucan)................................. 10
fluconazole tab 50 mg (Diflucan)................................... 10
flucytosine cap 250 mg (Ancobon)................................ 10
flucytosine cap 500 mg (Ancobon)................................ 10
fludrocortisone acetate tab 0.1 mg................................ 25
FLULAVAL 2011-2012 -influenza virus vaccine split inj.....17
FLULAVAL QUADRIVALENT 201 -influenza virus vaccine
split quadrivalent im inj.................................................... 17
FLULAVAL QUADRIVALENT 201 -influenza virus vaccine
FLUMADINE -rimantadine hydrochloride tab 100 mg........11
FLUMIST NASAL VACCINE 201 -influenza virus vaccine
live intranasal liquid......................................................... 17
FLUMIST QUADRIVALENT -influenza virus vaccine live
quadrivalent intranasal susp............................................ 17
FLUNISOLIDE -flunisolide nasal soln 25 mcg/act
(0.025%)...........................................................................67
FLUNISOLIDE -flunisolide nasal soln 29 mcg/act
(0.025%)...........................................................................67
flunisolide nasal soln 25 mcg/act (0.025%)
(Flunisolide).................................................................... 67
fluocinolone acetonide (otic) oil 0.01% (Dermotic).....158
fluocinolone acetonide cream 0.01%...........................167
fluocinolone acetonide cream 0.025% (Synalar).........167
fluocinolone acetonide oil 0.01% (Derma-smoothe/fs
bod)................................................................................167
fluocinolone acetonide oint 0.025% (Synalar).............167
fluocinolone acetonide soln 0.01% (Synalar)..............167
fluocinonide cream 0.05%............................................ 167
fluocinonide cream 0.1% (Vanos)................................ 167
fluocinonide emulsified base cream 0.05%.................167
fluocinonide gel 0.05%..................................................167
fluocinonide oint 0.05%................................................ 167
fluocinonide soln 0.05%................................................167
FLUORABON -sodium fluoride soln 0.25 mg/0.6ml (from
0.55 mg/0.6ml naf).........................................................140
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 0.55 (0.25
mg f)-236.79 mg............................................................ 140
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 1.1 (0.5
mg f)-236.79 mg............................................................ 140
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 2.2 (1 mg
f)-236.79 mg...................................................................140
2014
FLUORIDEX DAILY DEFENSE S -sodium fluoridepotassium nitrate gel 1.1-5%......................................... 159
fluorometholone ophth susp 0.1% (Fml liquifilm).......155
FLUOROPLEX -fluorouracil cream 1%............................167
fluorouracil cream 5% (Efudex)....................................167
fluorouracil soln 2%...................................................... 167
fluorouracil soln 5%...................................................... 167
fluoxetine hcl (pmdd) cap 10 mg................................. 103
fluoxetine hcl (pmdd) cap 20 mg................................. 103
fluoxetine hcl cap 10 mg (Prozac)................................. 90
fluoxetine hcl cap delayed release 90 mg (Prozac
weekly)............................................................................ 90
FLUOXETINE HCL -fluoxetine hcl tab 60 mg....................90
fluoxetine hcl solution 20 mg/5ml..................................90
fluoxetine hcl tab 10 mg................................................. 90
fluoxetine hcl tab 20 mg................................................. 90
fluphenazine decanoate inj 25 mg/ml............................ 94
FLUPHENAZINE HCL -fluphenazine hcl elixir 2.5
mg/5ml..............................................................................94
FLUPHENAZINE HCL -fluphenazine hcl inj 2.5 mg/ml...... 94
FLUPHENAZINE HCL -fluphenazine hcl oral conc 5 mg/
ml......................................................................................94
fluphenazine hcl tab 10 mg............................................ 94
fluphenazine hcl tab 1 mg.............................................. 94
fluphenazine hcl tab 2.5 mg........................................... 94
fluphenazine hcl tab 5 mg.............................................. 94
FLURA-DROPS -sodium fluoride soln 0.25 mg/drop f (from
0.55 mg/drop naf).......................................................... 140
flurazepam hcl cap 15 mg.............................................. 97
flurazepam hcl cap 30 mg.............................................. 97
flurbiprofen sodium ophth soln 0.03% (Ocufen).........155
flurbiprofen tab 100 mg................................................ 116
flurbiprofen tab 50 mg.................................................. 116
flutamide cap 125 mg......................................................21
fluticasone propionate cream 0.05% (Cutivate).......... 167
fluticasone propionate lotion 0.05% (Cutivate)...........168
fluticasone propionate nasal susp 50 mcg/act
(Flonase)......................................................................... 67
fluticasone propionate oint 0.005% (Cutivate)............ 168
fluvastatin sodium cap 20 mg (Lescol)......................... 62
fluvastatin sodium cap 40 mg (Lescol)......................... 62
FLUVIRIN 2011-2012 -influenza virus vaccine types a & b
surface antigen inj............................................................18
FLUVIRIN PF 2011-2012 -influenza virus vaccine types a
& b preservative free inj...................................................18
fluvoxamine maleate cap sr 24hr 100 mg (Luvox
cr).....................................................................................90
fluvoxamine maleate cap sr 24hr 150 mg (Luvox
cr).....................................................................................90
fluvoxamine maleate tab 100 mg................................... 90
fluvoxamine maleate tab 25 mg..................................... 90
fluvoxamine maleate tab 50 mg..................................... 90
FLUZONE HIGH-DOSE PF 2012 -influenza virus vac split
high-dose preservative free inj.........................................18
FLUZONE INTRADERMAL -influenza virus vaccine split
intradermal inj 9 mcg/strain............................................. 18
FLUZONE PEDIATRIC PF 2012 -influenza virus vaccine
split preservative free inj..................................................18
FLUZONE PF 2012-2013 -influenza virus vaccine split
FLUZONE PF 2013-2014 -influenza virus vaccine split
FLUZONE QUADRIVALENT 2013 -influenza virus vaccine
split quadrivalent inj 0.25 ml............................................ 18
split quadrivalent inj 0.25 ml............................................ 18
FLUZONE SPLIT 2012-2013 -influenza virus vaccine split
inj......................................................................................18
inj......................................................................................18
inj......................................................................................18
FML -fluorometholone ophth oint 0.1%........................... 155
FML FORTE -fluorometholone ophth susp 0.25%...........155
FML LIQUIFILM -fluorometholone ophth susp 0.1%....... 155
FOCALGIN-B - prenatal w/ calcium-vit b6-fa-ginger tab
1.22 mg .........................................................................132
FOCALIN -dexmethylphenidate hcl tab 10 mg................ 100
FOCALIN -dexmethylphenidate hcl tab 2.5 mg............... 100
FOCALIN -dexmethylphenidate hcl tab 5 mg.................. 100
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 10
mg.................................................................................. 100
mg.................................................................................. 100
227
2014
mg.................................................................................. 100
mg.................................................................................. 100
mg.................................................................................. 100
mg.................................................................................. 100
mg.................................................................................. 100
mg.................................................................................. 100
FOLBECAL - prenatal w/ calcium carbonate-b6-b12-fa tab
1 mg ..............................................................................132
FOLBEE AR - folic acid-b12-b6-arginine-black pepper tab
....................................................................................... 142
FOLBIC RF - l-methylfolate w/ vit b6-vit b12 tab 1.13-25-2
mg ................................................................................. 142
FOLCAL DHA - prenatal w/o vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg ............................................................ 132
FOLCAPS OMEGA 3 - prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg ............................................... 132
FOLET DHA -prenat w/fecbn-bisg-methylf-dss tab dr &
dha cap pak................................................................... 132
FOLET ONE - prenat w/o a w/fecbn-bisg-methylf-dss-dha
cap 38-1-225 mg .......................................................... 132
FOLGARD OS -multiple vit w/ min & calcium-folic acid tab
500-1.1 mg.....................................................................132
FOLGARD RX -folic acid-vitamin b6-vitamin b12 tab
2.2-25-1 mg....................................................................146
FOLIC ACID -folic acid inj 5 mg/ml................................. 146
folic acid-pyridoxine-cyanocobalamin tab 2.5-25-2
mg.................................................................................. 142
folic acid tab 1 mg.........................................................146
folic acid tab 400 mcg...................................................146
folic acid tab 800 mcg...................................................146
folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5
mg.................................................................................. 146
folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg
(Folgard rx)................................................................... 146
folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg...... 146
folic acid-vit b6-vit b12-omega 3-phytosterols cap 1
mg .................................................................................144
FOLIVANE-F - fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe) ....................................146
FOLIVANE-OB - prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg .............................................................. 132
FOLIVANE-PLUS - fe fum-iron polysacch complex-fa-b
complex-c-biotin cap .....................................................146
FOLIVANE-PRX DHA NF - prenatal w/o vit a w/fe fum-dssfa-dha cap 30-1.24-265 mg .......................................... 132
FOLLISTIM AQ -follitropin beta inj 150 unit/0.5ml............. 41
FOLLISTIM AQ -follitropin beta inj 300 unit/0.36ml........... 41
FOLLISTIM AQ -follitropin beta inj 75 unit/0.5ml............... 41
228
FOLPACE RX -folic acid-hydroxocobal-vit b6-vit e-mag tab
2.05 mg-425 mcg...........................................................146
FOLTANX - l-methylfolate w/ vit b6-vit b12 tab 3-35-2 mg
....................................................................................... 142
FOLTANX RF - l-methylfolate-algae-vit b12-b6 cap
3-90.314-2-35 mg ......................................................... 142
FOLTRATE - cobalamine combination tab ..................... 146
FOLTX -folic acid-pyridoxine-cyanocobalamin tab 2.5-25-2
mg.................................................................................. 142
FOLTX - l-methylfolate w/ vit b6-vit b12 tab 1.13-25-2 mg
....................................................................................... 142
fondaparinux sodium inj 10 mg/0.8ml (Arixtra)...........148
fondaparinux sodium inj 2.5 mg/0.5ml (Arixtra)..........148
fondaparinux sodium inj 5 mg/0.4ml (Arixtra).............148
fondaparinux sodium inj 7.5 mg/0.6ml (Arixtra)..........148
FORACARE GD40 BLOOD GLUCO - blood glucose
FORACARE PREMIUM V10 BLOO - blood glucose
FORACARE TEST N GO BLOOD - blood glucose
FORADIL AEROLIZER -formoterol fumarate inhal cap 12
mcg...................................................................................73
FORA G20 BLOOD GLUCOSE MO - blood glucose
FORA G30A BLOOD GLUCOSE M - blood glucose
FORA G71A BLOOD GLUCOSE M - blood glucose
FORA G90 BLOOD GLUCOSE MO - blood glucose
FORA GD20 BLOOD GLUCOSE M - blood glucose
FORA V10 BLOOD GLUCOSE MO - blood glucose
FORA V30A BLOOD GLUCOSE M - blood glucose
FORA V30A BLOOD GLUCOSE M - blood glucose
FORFIVO XL -bupropion hcl tab sr 24hr 450 mg.............. 90
FORMALDEHYDE -formaldehyde solution 37%............. 177
formaldehyde solution 10%.......................................... 177
FORMA-RAY -formaldehyde solution 20%......................177
FORTAMET -metformin hcl tab sr 24hr osmotic 1000
mg.................................................................................... 33
FORTAMET -metformin hcl tab sr 24hr osmotic 500
mg.................................................................................... 33
FORTAVIT - multiple vitamins w/ minerals cap .............. 132
2014
FORTAZ -ceftazidime for inj 1 gm.......................................4
FORTAZ -ceftazidime for inj 500 mg...................................4
FORTAZ -ceftazidime for iv soln 1 gm................................ 4
FORTAZ -ceftazidime for iv soln 2 gm................................ 4
FORTEO -teriparatide (recombinant) inj 600
mcg/2.4ml.........................................................................41
FORTESTA -testosterone td gel 10mg/act (2%)............... 27
FORTICAL -calcitonin (salmon) nasal soln 200 unit/
act.....................................................................................41
FOSAMAX -alendronate sodium oral soln 70 mg/75ml..... 41
FOSAMAX -alendronate sodium tab 10 mg...................... 41
FOSAMAX -alendronate sodium tab 5 mg........................ 41
FOSAMAX PLUS D -alendronate sodium-cholecalciferol
tab 70-2800 mg-unit.........................................................41
FOSAMAX PLUS D -alendronate sodium-cholecalciferol
tab 70-5600 mg-unit.........................................................41
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg.................................................................................... 55
fosinopril sodium & hydrochlorothiazide tab 20-12.5
mg.................................................................................... 55
fosinopril sodium tab 10 mg.......................................... 55
fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv)
(Cerebyx).......................................................................121
fosphenytoin sodium inj 500 mg/10ml (phenytoin
equiv) (Cerebyx)........................................................... 121
FOSRENOL -lanthanum carbonate chew tab 1000 mg..... 82
FOSRENOL -lanthanum carbonate chew tab 500 mg....... 82
FOSRENOL -lanthanum carbonate chew tab 750 mg....... 82
FOSTEUM - genistein-zinc amino acid chelate-vitamin d
cap ................................................................................ 142
FRAGMIN -dalteparin sodium inj 10000 unit/ml.............. 148
FRAGMIN -dalteparin sodium inj 12500 unit/0.5ml..........148
FRAGMIN -dalteparin sodium inj 15000 unit/0.6ml..........148
FRAGMIN -dalteparin sodium inj 18000 unit/0.72ml........148
FRAGMIN -dalteparin sodium inj 25000 unit/ml.............. 148
FRAGMIN -dalteparin sodium inj 2500 unit/0.2ml............148
FREESTYLE FLASH SYSTEM - blood glucose monitoring
kit .................................................................................. 183
FREESTYLE FREEDOM - blood glucose monitoring kit
....................................................................................... 183
FREESTYLE FREEDOM - blood glucose monitoring kit w/
device ............................................................................183
FREESTYLE FREEDOM LITE - blood glucose monitoring
kit w/ device ..................................................................183
FREESTYLE INSULINX BLOOD - blood glucose
FREESTYLE LITE BLOOD GLUC - blood glucose
FREESTYLE SIDEKICK II VAL - blood glucose monitoring
kit .................................................................................. 183
FREESTYLE SIDEKICK II VAL - blood glucose monitoring
kit w/ device ..................................................................183
FREESTYLE SYSTEM KIT - blood glucose monitoring kit
....................................................................................... 183
FROVA -frovatriptan succinate tab 2.5 mg (base
equivalent)......................................................................118
FULYZAQ -crofelemer tab delayed release 125 mg..........76
FUMATINIC - iron combination cap cr ........................... 146
FURADANTIN -nitrofurantoin susp 25 mg/5ml.................. 83
FUROSEMIDE -furosemide oral soln 8 mg/ml.................. 60
furosemide inj 10 mg/ml................................................. 60
furosemide oral soln 10 mg/ml...................................... 60
furosemide tab 20 mg (Lasix).........................................60
FUSION PLUS - fe fum-iron poly cmplx-fa-b cmplx-cbiotin-probiotic cap ........................................................146
FUZEON -enfuvirtide for inj 90 mg....................................11
FYCOMPA -perampanel tab 10 mg.................................121
FYCOMPA -perampanel tab 12 mg.................................121
FYCOMPA -perampanel tab 2 mg.................................. 121
G
gabapentin cap 100 mg (Neurontin)............................ 121
gabapentin oral soln 250 mg/5ml (Neurontin).............121
gabapentin tab 600 mg (Neurontin)............................. 121
gabapentin tab 800 mg (Neurontin)............................. 121
GABAVALE-5 -diazepam tab 5 mg & dietary management
cap pack...........................................................................87
GABAZOLAMINE-0.5 -alprazolam tab 0.5 mg & dietary
GABAZOLAMINE -alprazolam tab 0.25 mg & dietary
GABITRIL -tiagabine hcl tab 12 mg.................................122
GABITRIL -tiagabine hcl tab 16 mg.................................122
GABITRIL -tiagabine hcl tab 2 mg.................................. 121
GABITRIL -tiagabine hcl tab 4 mg.................................. 121
galantamine hydrobromide cap sr 24hr 16 mg
(Razadyne er)............................................................... 103
(Razadyne er)............................................................... 103
(Razadyne er)............................................................... 103
galantamine hydrobromide oral soln 4 mg/ml
(Razadyne).................................................................... 103
galantamine hydrobromide tab 12 mg (Razadyne)..... 103
galantamine hydrobromide tab 4 mg (Razadyne)....... 103
229
2014
galantamine hydrobromide tab 8 mg (Razadyne)....... 103
GALZIN -zinc acetate cap 25 mg (elemental zinc).......... 140
GALZIN -zinc acetate cap 50 mg (elemental zinc).......... 140
GAMASTAN S/D -immune globulin (human) inj................ 19
GAMMAGARD LIQUID -immune globulin (human) iv or
subcutaneous soln 10 gm/100ml..................................... 19
subcutaneous soln 1 gm/10ml......................................... 19
subcutaneous soln 2.5 gm/25ml...................................... 19
GAMMAGARD S/D IGA LESS TH -immune globulin
(human) iv for soln 10 gm............................................... 19
GAMMAGARD S/D IGA LESS TH -immune globulin
(human) iv for soln 5 gm................................................. 19
GAMMAGARD S/D -immune globulin (human) iv for soln
10 gm............................................................................... 19
GAMMAGARD S/D -immune globulin (human) iv for soln
2.5 gm.............................................................................. 19
GAMMAGARD S/D -immune globulin (human) iv for soln 5
gm.................................................................................... 19
GAMMAKED -immune globulin (human) iv or
GAMMAPLEX -immune globulin (human) iv soln 10
gm/200ml..........................................................................19
GAMMAPLEX -immune globulin (human) iv soln 2.5
gm/50ml............................................................................19
gm/400ml..........................................................................20
gm/100ml..........................................................................19
GAMUNEX-C -immune globulin (human) iv or
230
GAMUNEX -immune globulin (human) iv soln 10
gm/100ml..........................................................................20
GANIRELIX ACETATE -ganirelix acetate inj 250
mcg/0.5ml.........................................................................41
GARAMYCIN -gentamicin sulfate ophth soln 0.3%......... 155
GASTRINEX NF -hyoscyamine-phenyltoloxamine cap
0.0625-15 mg...................................................................77
GASTROCROM -cromolyn sodium oral conc 100
mg/5ml..............................................................................82
gatifloxacin ophth soln 0.5% (Zymaxid)...................... 155
GATTEX -teduglutide (rdna) for inj kit 5 mg...................... 82
GE100 BLOOD GLUCOSE MONIT - blood glucose
GEBAUERS PAIN EASE -pentafluoropropanetetrafluoroethane aero spray..........................................168
GEBAUERS SPRAY AND STRETC -pentafluoropropanetetrafluoroethane aero spray..........................................168
GELCLAIR - povidone-sodium hyaluronate-glycyrrhetinic
acid gel ......................................................................... 159
GELFILM OP -gelatin adsorbable ophth film................... 155
GEL-KAM ORAL CARE RINSE -stannous fluoride conc
0.63%............................................................................. 159
GEL-KAM -stannous fluoride gel 0.4%............................159
GELNIQUE -oxybutynin chloride td gel 10%..................... 84
GELNIQUE -oxybutynin td gel 3% (28 mg/act metereddose pump)...................................................................... 84
GELX - oral wound care products - gel .......................... 159
GEMCITABINE -gemcitabine hcl inj 1 gm/26.3ml (38 mg/
ml) (base equiv)............................................................... 21
GEMCITABINE -gemcitabine hcl inj 200 mg/5.26ml (38
mg/ml) (base equiv)......................................................... 21
GEMCITABINE -gemcitabine hcl inj 2 gm/52.6ml (38 mg/
ml) (base equiv)............................................................... 21
gemcitabine hcl for inj 1 gm (Gemzar).......................... 21
gemcitabine hcl for inj 200 mg (Gemzar)...................... 21
gemcitabine hcl for inj 2 gm.......................................... 21
gemfibrozil tab 600 mg (Lopid)...................................... 62
GEMZAR -gemcitabine hcl for inj 1 gm............................. 21
GEMZAR -gemcitabine hcl for inj 200 mg......................... 21
GENADUR - dermatological products misc - liquid .........168
GENERESS FE -norethindrone & ethinyl estradiol-fe chew
tab 0.8 mg-25 mcg.......................................................... 30
GENOTROPIN MINIQUICK -somatropin for inj 0.2 mg..... 42
GENOTROPIN MINIQUICK -somatropin for inj 1 mg........ 42
GENOTROPIN MINIQUICK -somatropin for inj 2 mg........ 42
GENOTROPIN -somatropin for inj 12 mg (13.8 mg
overfill)..............................................................................42
GENOTROPIN -somatropin for subcutaneous inj 5 mg.....41
2014
gentamicin sulfate cream 0.1%.................................... 168
GENTAMICIN SULFATE -gentamicin sulfate cream
0.1%............................................................................... 168
GENTAMICIN SULFATE -gentamicin sulfate oint
0.1%............................................................................... 168
gentamicin sulfate inj 10 mg/ml....................................... 8
gentamicin sulfate inj 40 mg/ml....................................... 8
gentamicin sulfate iv soln 10 mg/ml................................8
gentamicin sulfate oint 0.1%........................................ 168
gentamicin sulfate ophth oint 0.3%............................. 155
gentamicin sulfate ophth soln 0.3% (Garamycin)....... 155
GEODON -ziprasidone hcl cap 20 mg.............................. 94
GEODON -ziprasidone mesylate for inj 20 mg (base
equivalent)........................................................................94
GESTICARE DHA -prenatal w/fe fum-fa tab dr 27-1 mg &
dha cap 250 mg pack ...................................................132
GHT BLOOD GLUCOSE MONITO - blood glucose
GIAZO -balsalazide disodium tab 1.1 gm..........................82
GILENYA -fingolimod hcl cap 0.5 mg (base equiv)..........103
GILOTRIF -afatinib dimaleate tab 20 mg (base
equivalent)........................................................................21
equivalent)........................................................................21
equivalent)........................................................................21
GILPHEX TR -phenylephrine-guaifenesin tab 10-388
mg.................................................................................... 68
GILTUSS PED-C -phenylephrine w/ codeine-gg liquid
2.5-3-50 mg/ml.................................................................68
GILTUSS -phenylephrine w/ dm-gg liqd 10-28-388
mg/5ml..............................................................................68
GILTUSS TR -phenylephrine w/ dm-gg cap 7-14-288
mg.................................................................................... 68
GILTUSS TR -phenylephrine w/ dm-gg tab 10-28-388
mg.................................................................................... 69
GILTUSS TR -phenylephrine w/ dm-gg tab sr 12hr
20-30-600 mg...................................................................69
GLEEVEC -imatinib mesylate tab 100 mg (base
equivalent)........................................................................21
GLEEVEC -imatinib mesylate tab 400 mg (base
equivalent)........................................................................21
glimepiride tab 1 mg (Amaryl)........................................33
glipizide-metformin hcl tab 2.5-250 mg......................... 33
glipizide-metformin hcl tab 2.5-500 mg......................... 33
glipizide-metformin hcl tab 5-500 mg............................ 33
glipizide tab 10 mg (Glucotrol).......................................33
glipizide tab 5 mg (Glucotrol).........................................33
glipizide tab sr 24hr 10 mg (Glucotrol xl)......................33
glipizide tab sr 24hr 2.5 mg (Glucotrol xl)..................... 33
glipizide tab sr 24hr 5 mg (Glucotrol xl)........................33
GLUCAGEN -glucagon hcl (rdna) for inj 1 mg (base
equiv)................................................................................33
GLUCAGEN HYPOKIT -glucagon hcl (rdna) for inj 1 mg
(base equiv)..................................................................... 33
GLUCAGON EMERGENCY KIT -glucagon (rdna) for inj kit
1 mg................................................................................. 33
GLUCOCARD 01 BLOOD GLUCOS - blood glucose
GLUCOCARD 01 BLOOD GLUCOS - blood glucose
GLUCOCARD 01-MINI BLOOD G - blood glucose
GLUCOCARD EXPRESSION AUDI - blood glucose
GLUCOCARD VITAL BLOOD GLU - blood glucose
GLUCOCARD X-METER - blood glucose monitoring kit w/
device ............................................................................183
GLUCOCOM AUTOLINK TELEMON - blood glucose
monitoring misc. ............................................................183
GLUCOCOM BLOOD GLUCOSE MO - blood glucose
GLUCOCOM BLOOD GLUCOSE MO - blood glucose
GLUCOLAB BLOOD GLUCOSE MO - blood glucose
monitoring kit ................................................................ 183
GLUCONAVII BLOOD GLUCOSE - blood glucose
GLUCO PERFECT 3 BLOOD GLU - blood glucose
GLUCOPHAGE -metformin hcl tab 1000 mg.................... 33
GLUCOPHAGE -metformin hcl tab 500 mg...................... 33
GLUCOPHAGE -metformin hcl tab 850 mg...................... 33
GLUCOPHAGE XR -metformin hcl tab sr 24hr 500 mg.....34
GLUCOPHAGE XR -metformin hcl tab sr 24hr 750 mg.....34
GLUCOSE BLOOD TEST STRIPS VARIOUS................ 178
glucose gel 40%.............................................................. 34
GLUCOSE -glucose chew tab 4 gm..................................34
GLUCOSE NURSETTE -glucose oral soln 5%............... 142
glucose oral liquid ....................................................... 142
glucose oral liquid 15 gm/59ml...................................... 34
glucose oral soln 5%.....................................................142
GLUCOTROL -glipizide tab 10 mg....................................34
GLUCOTROL -glipizide tab 5 mg......................................34
GLUCOTROL XL -glipizide tab sr 24hr 10 mg.................. 34
GLUCOTROL XL -glipizide tab sr 24hr 2.5 mg................. 34
GLUCOTROL XL -glipizide tab sr 24hr 5 mg.................... 34
GLUCOVANCE -glyburide-metformin tab 1.25-250 mg.....34
GLUCOVANCE -glyburide-metformin tab 2.5-500 mg.......34
GLUCOVANCE -glyburide-metformin tab 5-500 mg..........34
GLUMETZA -metformin hcl tab sr 24hr modified release
1000 mg........................................................................... 34
GLUMETZA -metformin hcl tab sr 24hr modified release
500 mg............................................................................. 34
231
2014
GLUTARALDEHYDE -glutaral soln 25%......................... 177
GLYBURIDE -glyburide tab 1.25 mg................................. 34
GLYBURIDE -glyburide tab 2.5 mg...................................34
GLYBURIDE -glyburide tab 5 mg......................................34
(Glucovance)...................................................................34
glyburide-metformin tab 2.5-500 mg (Glucovance)...... 34
glyburide-metformin tab 5-500 mg (Glucovance)......... 34
glyburide micronized tab 1.5 mg (Glynase).................. 34
glyburide micronized tab 3 mg (Glynase)..................... 34
glyburide micronized tab 6 mg (Glynase)..................... 34
glyburide tab 1.25 mg..................................................... 34
glyburide tab 2.5 mg....................................................... 34
glyburide tab 5 mg.......................................................... 34
GLYCATE -glycopyrrolate tab 1.5 mg............................... 77
glycopyrrolate inj 0.2 mg/ml (Robinul).......................... 77
glycopyrrolate inj 0.4 mg/2ml (0.2 mg/ml) (Robinul).....77
glycopyrrolate inj 1 mg/5ml (0.2 mg/ml) (Robinul)........77
glycopyrrolate inj 4 mg/20ml (0.2 mg/ml) (Robinul)......77
glycopyrrolate tab 1 mg (Robinul)................................. 77
glycopyrrolate tab 2 mg (Robinul forte)........................ 78
GLYCRON -glyburide micronized tab 4.5 mg....................34
GLYNASE -glyburide micronized tab 1.5 mg.................... 34
GLYNASE -glyburide micronized tab 3 mg....................... 34
GLYNASE -glyburide micronized tab 6 mg....................... 34
GLYSET -miglitol tab 100 mg............................................34
GLYSET -miglitol tab 25 mg..............................................34
GLYSET -miglitol tab 50 mg..............................................34
GLYTACTIN BETTERMILK 10 - nutritional supplement
pack .............................................................................. 142
GLYTACTIN BETTERMILK 15 - nutritional supplement
pack .............................................................................. 143
GMATE SMART METER KIT - blood glucose monitoring
devices ..........................................................................183
GMATE SMART STARTER KIT - blood glucose
GMATE VOICE BLOOD GLUCOSE - blood glucose
GNP GLUCOSE -glucose chew tab 4 gm......................... 34
GNP QUICK DISSOLVE GLUCOS -glucose chew tab 4
gm.................................................................................... 34
GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate for
soln 236 gm..................................................................... 75
GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate
packet 227.1 gm.............................................................. 75
GONAL-F -follitropin alfa for inj 1050 unit......................... 42
GONAL-F -follitropin alfa for inj 450 unit........................... 42
GONAL-F RFF -follitropin alfa for inj 75 unit..................... 42
GONAL-F RFF PEN -follitropin alfa inj 300 unit/0.5ml....... 42
GONAL-F RFF PEN -follitropin alfa inj 450 unit/0.75ml..... 42
GONAL-F RFF PEN -follitropin alfa inj 900 unit/1.5ml....... 42
GONAL-F RFF REDIJECT -follitropin alfa inj 300
unit/0.5ml..........................................................................42
unit/0.75ml........................................................................42
232
unit/1.5ml..........................................................................42
GORDOFILM -salicylic & lactic acids soln
16.7-16.7%..................................................................... 168
GORDONS UREA -urea ointment 40%...........................168
GRALISE -gabapentin (phn) tab 300 mg.........................103
GRALISE -gabapentin (phn) tab 600 mg.........................103
GRALISE STARTER -gabapentin (phn) tab starter pack
300 mg (9) & 600 mg (69).............................................103
granisetron hcl tab 1 mg................................................ 80
GRANISOL -granisetron hcl oral soln 2 mg/10ml (base
equivalent)........................................................................80
GRANIX -tbo-filgrastim soln prefilled syringe 300
mcg/0.5ml.......................................................................146
GRANIX -tbo-filgrastim soln prefilled syringe 480
mcg/0.8ml.......................................................................146
GRANULEX -trypsin w/ castor oil & peruvian balsam
spray...............................................................................168
GRASTEK -timothy grass pollen allergen ext tab sl 2800
bau................................................................................... 20
GRIFULVIN V -griseofulvin microsize tab 500 mg.............10
griseofulvin microsize susp 125 mg/5ml.......................10
griseofulvin microsize tab 500 mg (Grifulvin v)............ 10
griseofulvin ultramicrosize tab 125 mg (Gris-peg)....... 10
griseofulvin ultramicrosize tab 250 mg (Gris-peg)....... 10
GRIS-PEG -griseofulvin ultramicrosize tab 125 mg...........10
GRIS-PEG -griseofulvin ultramicrosize tab 250 mg...........10
guaifenesin-codeine liquid 225-7.5 mg/5ml...................69
guaifenesin-codeine soln 100-10 mg/5ml......................69
guaifenesin-codeine soln 100-6.3 mg/5ml..................... 69
guanfacine hcl tab 1 mg (Tenex)................................... 55
guanfacine hcl tab 2 mg (Tenex)................................... 55
GUANIDINE HCL -guanidine hcl tab 125 mg.................. 128
GYNAZOLE-1 -butoconazole nitrate (one dose) vaginal
cream 2%.........................................................................85
H
HALCION -triazolam tab 0.25 mg......................................97
HALDOL DECANOATE 100 -haloperidol decanoate im
soln 100 mg/ml................................................................ 94
HALDOL DECANOATE 50 -haloperidol decanoate im soln
50 mg/ml.......................................................................... 94
HALDOL -haloperidol lactate inj 5 mg/ml.......................... 94
HALFLYTELY BOWEL PREP/FLA -bisacodyl tab & peg
3350-kcl-sod bicarb-nacl for soln kit................................ 75
halobetasol propionate cream 0.05% (Ultravate)........ 168
halobetasol propionate oint 0.05% (Ultravate)............168
halobetasol prop oint 0.05% & ammonium lactate lot
12% kit (Ultravate pac)................................................ 168
HALOG -halcinonide cream 0.1%................................... 168
HALOG -halcinonide oint 0.1%........................................168
HALONATE -halobetasol prop oint 0.05% & ammonium
lactate foam 12% kit...................................................... 168
haloperidol decanoate im soln 100 mg/ml (Haldol
decanoate 100)............................................................... 94
2014
haloperidol decanoate im soln 50 mg/ml (Haldol
decanoate 50)................................................................. 94
haloperidol lactate inj 5 mg/ml (Haldol).........................94
haloperidol lactate oral conc 2 mg/ml........................... 94
haloperidol tab 0.5 mg.................................................... 94
haloperidol tab 10 mg..................................................... 94
haloperidol tab 1 mg....................................................... 94
haloperidol tab 20 mg..................................................... 94
HALOTIN -haloprogin cream 1%.....................................168
hc-pramoxine emol cream 2.5-1% & pramoxine wipe
1% kit (Analpram e)..................................................... 160
HECTOROL -doxercalciferol cap 0.5 mcg.........................42
HECTOROL -doxercalciferol cap 1 mcg............................42
HECTOROL -doxercalciferol cap 2.5 mcg.........................42
HELIDAC -metronidaz tab-tetracyc cap-bis subsal chew
tab therapy pack.............................................................. 78
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 1000 unit................................................................... 151
kit 2000 unit................................................................... 151
kit 250 unit..................................................................... 151
kit 3000 unit................................................................... 151
kit 500 unit..................................................................... 151
HEMABATE -carboprost tromethamine im soln 250 mcg/
ml......................................................................................40
HEMANGEOL -propranolol hcl oral soln 4.28 mg/ml.........46
HEMATOGEN FA -fe fumarate-vit c-vit b12-fa cap
200-250-0.01-1 mg........................................................ 146
HEMATRON-AF - iron-docusate-b12-folic acid-c-e-cubiotin tab 150-1 mg ...................................................... 146
HEMENATAL OB + DHA -prenat-fe poly cmplx-fe heme
poly-fa tab & omega 3 cap pck......................................132
HEMENATAL OB - prenat vit-fe poly cmplx-fe heme polyfa tab 28-6-1 mg ...........................................................132
HEMETAB -polysacch fe cmplx-fe heme poly-fa-b12 tab
22-6-1-0.025 mg............................................................ 146
HEMOCYTE-F - iron combination elixir ..........................146
HEMOCYTE PLUS - ferrous fumarate-fa-b complex-c-znmg-mn-cu cap 106-1 mg .............................................. 146
HEMOFIL M -antihemophilic factor (human) for inj 1000
unit..................................................................................151
HEMOFIL M -antihemophilic factor (human) for inj
1501-2000 unit............................................................... 151
unit..................................................................................151
HEMOFIL M -antihemophilic factor (human) for inj 220-400
unit..................................................................................151
unit..................................................................................151
HEMOFIL M -antihemophilic factor (human) for inj 401-800
unit..................................................................................151
unit..................................................................................151
HEMOFIL M -antihemophilic factor (human) for inj
801-1500 unit................................................................. 151
HEPARIN LOCK FLUSH -heparin sodium (porcine) lock
flush iv soln 1 unit/ml..................................................... 148
HEPARIN LOCK FLUSH -heparin sodium (porcine) lock
flush iv soln 2 unit/ml..................................................... 148
heparin sodium (porcine) inj 10000 unit/ml.................148
heparin sodium (porcine) inj 5000 unit/ml...................148
heparin sodium (porcine) lock flush iv soln 100 unit/
ml................................................................................... 149
heparin sodium (porcine) lock flush iv soln 10 unit/
ml................................................................................... 148
heparin sodium (porcine) lock flush iv soln 1 unit/ml
(Heparin lock flush)..................................................... 148
heparin sodium (porcine) pf inj 5000 unit/0.5ml......... 149
HEPSERA -adefovir dipivoxil tab 10 mg........................... 11
HETLIOZ -tasimelteon capsule 20 mg.............................. 97
HEXALEN -altretamine cap 50 mg....................................21
HIPREX -methenamine hippurate tab 1 gm...................... 83
HIZENTRA -immune globulin (human) subcutaneous inj 10
gm/50ml............................................................................20
gm/5ml..............................................................................20
gm/10ml............................................................................20
gm/20ml............................................................................20
homatropine hbr ophth soln 5% (Isopto
homatropine)................................................................ 155
HORIZANT -gabapentin enacarbil tab sr 24hr 300
mg.................................................................................. 103
HORIZANT -gabapentin enacarbil tab sr 24hr 600
mg.................................................................................. 103
HPR - emollient - aerosol foam ......................................168
HPR PLUS/MB HYDROGEL -emollient foam & wound
dressing gel kit...............................................................168
HPR PLUS - emollient - aerosol foam ............................168
HPR PLUS - emollient - cream ...................................... 168
HUMALOG -insulin lispro (human) inj 100 unit/ml............. 37
HUMALOG -insulin lispro (human) soln cartridge 100 unit/
ml......................................................................................37
HUMALOG KWIKPEN -insulin lispro (human) soln peninjector 100 unit/ml...........................................................37
HUMALOG MIX 50/50 -insulin lispro prot & lispro (human)
inj 100 unit/ml (50-50)......................................................37
HUMALOG MIX 50/50 KWIKPEN -insulin lispro prot &
lispro sus pen-inj 100 unit/ml (50-50).............................. 37
HUMALOG MIX 75/25 -insulin lispro prot & lispro (human)
inj 100 unit/ml (75-25)......................................................37
HUMALOG MIX 75/25 KWIKPEN -insulin lispro prot &
lispro sus pen-inj 100 unit/ml (75-25).............................. 37
233
2014
HUMATE-P -antihemophilic factor/vwf (human) for inj
1000-2400 unit............................................................... 151
250-600 unit................................................................... 151
500-1200 unit................................................................. 151
HUMATROPE COMBO PACK -somatropin for inj 5
mg.................................................................................... 42
HUMATROPE -somatropin for inj 12 mg (36 unit).............42
HUMATROPE -somatropin for inj 24 mg...........................42
HUMATROPE -somatropin for inj 5 mg.............................42
HUMATROPE -somatropin for inj 6 mg (18 unit)...............42
HUMIRA -adalimumab inj kit 20 mg/0.4ml.......................116
HUMIRA -adalimumab inj kit 40 mg/0.8ml (50 mg/ml)..... 116
HUMIRA PEN -adalimumab inj kit 40 mg/0.8ml (50 mg/
ml).................................................................................. 116
HUMIRA PEN-CROHNS DISEASE -adalimumab inj kit 40
mg/0.8ml (50 mg/ml)......................................................116
HUMIRA PEN-PSORIASIS STAR -adalimumab inj kit 40
mg/0.8ml (50 mg/ml)......................................................116
HUMULIN 70/30 -insulin isophane & regular (human) inj
100 unit/ml (70-30)...........................................................37
HUMULIN 70/30 KWIKPEN -insulin isophane & regular
susp pen-inj 100 unit/ml (70-30)...................................... 37
HUMULIN 70/30 PEN -insulin isophane & regular susp
pen-inj 100 unit/ml (70-30)...............................................37
HUMULIN N -insulin isophane (human) inj 100 unit/ml......37
HUMULIN N KWIKPEN -insulin isophane (human) susp
pen-injector 100 unit/ml................................................... 37
HUMULIN N U-100 PEN -insulin isophane (human) susp
pen-injector 100 unit/ml................................................... 37
HUMULIN R -insulin regular (human) inj 100 unit/ml.........37
HUMULIN R U-500 (CONCENTR -insulin regular (human)
inj 500 unit/ml.................................................................. 37
hyaluronate sodium (emollient) gel 0.2% (Hylira)....... 168
HYCAMTIN -topotecan hcl cap 0.25 mg (base equiv)....... 21
HYCAMTIN -topotecan hcl cap 1 mg (base equiv)............21
HYCET -hydrocodone-acetaminophen soln 7.5-325
mg/15ml..........................................................................108
hydralazine hcl inj 20 mg/ml.......................................... 55
hydralazine hcl tab 100 mg............................................ 55
hydralazine hcl tab 10 mg.............................................. 55
HYDREA -hydroxyurea cap 500 mg..................................21
HYDRO 35 -urea in lactic acid vehicle foam 35%........... 168
HYDRO 40 FOAM -urea foam 40%................................ 168
hydrochlorothiazide cap 12.5 mg (Microzide)............... 60
hydrochlorothiazide tab 12.5 mg................................... 60
hydrochlorothiazide tab 25 mg...................................... 60
hydrochlorothiazide tab 50 mg...................................... 60
HYDROCODONE/ACETAMINOPHEN -hydrocodoneacetaminophen soln 10-325 mg/15ml............................109
HYDROCODONE/ACETAMINOPHEN -hydrocodoneacetaminophen tab 7.5-500 mg..................................... 109
234
hydrocodone-acetaminophen cap 5-500 mg...............108
hydrocodone-acetaminophen soln 10-325
mg/15ml.........................................................................108
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
(Hycet)........................................................................... 108
hydrocodone-acetaminophen soln 7.5-500
mg/15ml.........................................................................108
hydrocodone-acetaminophen tab 10-300 mg
(Xodol)........................................................................... 109
(Norco)...........................................................................109
hydrocodone-acetaminophen tab 10-500 mg..............109
hydrocodone-acetaminophen tab 2.5-325 mg.............109
(Xodol)........................................................................... 109
(Norco)...........................................................................109
hydrocodone-acetaminophen tab 5-500 mg................109
hydrocodone-acetaminophen tab 7.5-300 mg
(Xodol)........................................................................... 109
hydrocodone-acetaminophen tab 7.5-325 mg
(Norco)...........................................................................109
HYDROCODONE BITARTRATE/AC -hydrocodoneacetaminophen tab 10-750 mg...................................... 108
hydrocodone-ibuprofen tab 10-200 mg (Ibudone)...... 109
hydrocodone-ibuprofen tab 2.5-200 mg
(Reprexain)....................................................................109
hydrocodone-ibuprofen tab 5-200 mg (Reprexain).....109
hydrocodone-ibuprofen tab 7.5-200 mg
(Vicoprofen).................................................................. 109
hydrocodone w/ homatropine syrup 5-1.5 mg/5ml....... 69
hydrocodone w/ homatropine tab 5-1.5 mg.................. 69
hydrocod polst-chlorphen polst cr susp 10-8 mg/5ml
(Tussionex pennkineti).................................................. 69
hydrocortisone acetate-aloe vera gel 2% (Nuzon)...... 168
hydrocortisone acetate suppos 25 mg (Anusolhc).................................................................................. 161
hydrocortisone acetate suppos 30 mg
(Proctocort)...................................................................161
hydrocortisone acetate w/ pramoxine rectal cream
1-1% (Analpram-hc)..................................................... 161
hydrocortisone acetate w/ pramoxine rectal cream
2.5-1% (Analpram-hc).................................................. 161
hydrocortisone butyrate cream 0.1% (Locoid)............168
2014
hydrocortisone butyrate hydrophilic lipo base cream
0.1% (Locoid lipocream)..............................................168
hydrocortisone butyrate oint 0.1% (Locoid)................168
hydrocortisone butyrate soln 0.1% (Locoid)...............168
hydrocortisone cream 1%.............................................168
hydrocortisone cream 2.5%..........................................168
hydrocortisone enema 100 mg/60ml (Cortenema)......161
hydrocortisone lotion 2.5%...........................................168
hydrocortisone lotion 2% (Ala scalp).......................... 168
hydrocortisone oint 1%.................................................168
hydrocortisone oint 2.5%..............................................168
hydrocortisone rectal cream 1% (Proctocort).............161
hydrocortisone rectal cream 2.5% (Anusol-hc).......... 161
hydrocortisone tab 10 mg (Cortef).................................25
hydrocortisone tab 20 mg (Cortef).................................25
hydrocortisone tab 5 mg (Cortef).................................. 25
hydrocortisone valerate cream 0.2%........................... 168
hydrocortisone valerate oint 0.2% (Westcort).............168
hydrocortisone w/ acetic acid otic soln 1-2% (Vosol
hc).................................................................................. 158
HYDROMORPHONE HCL ER -hydromorphone hcl tab er
24hr deter 32 mg........................................................... 109
HYDROMORPHONE HCL -hydromorphone hcl suppos 3
mg.................................................................................. 109
hydromorphone hcl liqd 1 mg/ml (Dilaudid)............... 109
hydromorphone hcl tab 2 mg (Dilaudid)..................... 109
hydromorphone hcl tab er 24hr deter 12 mg
(Exalgo)......................................................................... 109
(Exalgo)......................................................................... 109
(Exalgo)......................................................................... 109
HYDROXOCOBALAMIN -hydroxocobalamin inj 1000 mcg/
ml....................................................................................146
hydroxychloroquine sulfate tab 200 mg (Plaquenil).....14
hydroxyurea cap 500 mg (Hydrea).................................21
HYDROXYZINE HCL -hydroxyzine hcl im soln 25 mg/
ml......................................................................................87
hydroxyzine hcl im soln 50 mg/ml................................. 87
hydroxyzine hcl syrup 10 mg/5ml.................................. 87
hydroxyzine hcl tab 10 mg............................................. 87
hydroxyzine pamoate cap 25 mg (Vistaril).................... 87
hydroxyzine pamoate cap 50 mg (Vistaril).................... 87
HYDROXYZINE PAMOATE -hydroxyzine pamoate cap
100 mg............................................................................. 87
HYLATOPIC - emollient - aerosol foam ......................... 168
HYLATOPIC PLUS/AURSTAT -emollient foam & wound
dressing gel kit...............................................................168
HYLATOPIC PLUS - emollient - aerosol foam ............... 168
HYLATOPIC PLUS - emollient - cream ..........................168
HYLIRA -hyaluronate sodium (emollient) gel 0.2%..........168
HYLIRA -hyaluronate sodium (emollient) lotion 0.1%...... 168
hyoscyamine sulfate elixir 0.125 mg/5ml...................... 78
hyoscyamine sulfate soln 0.125 mg/ml......................... 78
hyoscyamine sulfate tab 0.125 mg (Levsin)..................78
hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)...... 78
hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl).......... 78
hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid)..... 78
HYPERSAL -sodium chloride soln nebu 3.5%.................. 69
HYPERSAL -sodium chloride soln nebu 7%..................... 69
HYPER-SAL -sodium chloride soln nebu 7%.................... 69
HYZAAR -losartan potassium & hydrochlorothiazide tab
100-12.5 mg.....................................................................55
100-25 mg........................................................................55
50-12.5 mg.......................................................................55
I
ibandronate sodium iv soln 3 mg/3ml (base equivalent)
(Boniva)........................................................................... 42
ibandronate sodium tab 150 mg (base equivalent)
(Boniva)........................................................................... 42
IBG STAR BLOOD GLUCOSE MO - blood glucose
IBUDONE -hydrocodone-ibuprofen tab 10-200 mg......... 109
ibuprofen susp 100 mg/5ml.......................................... 116
ibuprofen tab 400 mg.................................................... 116
ibuprofen tab 600 mg.................................................... 116
ibuprofen tab 800 mg.................................................... 116
IC 400 -ibuprofen tab 400 mg & caffeine-vitamins cap
kit....................................................................................116
IC 800 -ibuprofen tab 800 mg & caffeine-vitamins cap
kit....................................................................................116
ICAR -carbonyl iron chew tab 15 mg (elemental iron)..... 146
ICAR-C PLUS -iron-vit c-vit b12-folic acid tab
100-250-0.025-1 mg...................................................... 146
ICAR PEDIATRIC -carbonyl iron susp 15 mg/1.25ml
(elemental iron).............................................................. 146
ICLUSIG -ponatinib hcl tab 15 mg (base equiv)................ 21
ICLUSIG -ponatinib hcl tab 45 mg (base equiv)................ 22
ILARIS -canakinumab for inj 180 mg...............................116
ILEVRO -nepafenac ophth susp 0.3%.............................155
IMBRUVICA -ibrutinib cap 140 mg....................................22
IMDUR -isosorbide mononitrate tab sr 24hr 120 mg......... 45
IMDUR -isosorbide mononitrate tab sr 24hr 30 mg........... 45
IMDUR -isosorbide mononitrate tab sr 24hr 60 mg........... 45
imipenem-cilastatin intravenous for soln 250 mg
(Primaxin iv)................................................................... 16
imipenem-cilastatin intravenous for soln 500 mg
(Primaxin iv)................................................................... 16
imipramine hcl tab 10 mg (Tofranil)...............................90
imipramine pamoate cap 100 mg (Tofranil-pm)............ 90
235
2014
imipramine pamoate cap 75 mg (Tofranil-pm).............. 90
imiquimod cream 5% (Aldara)...................................... 168
IMITREX STATDOSE REFILL -sumatriptan succinate
solution cartridge 4 mg/0.5ml.........................................118
IMITREX STATDOSE REFILL -sumatriptan succinate
solution cartridge 6 mg/0.5ml.........................................118
IMITREX STATDOSE SYSTEM -sumatriptan succinate
solution auto-injector 4 mg/0.5ml...................................118
IMITREX STATDOSE SYSTEM -sumatriptan succinate
solution auto-injector 6 mg/0.5ml...................................118
IMITREX -sumatriptan nasal spray 20 mg/act................. 118
IMITREX -sumatriptan nasal spray 5 mg/act................... 118
IMITREX -sumatriptan succinate inj 6 mg/0.5ml..............118
IMITREX -sumatriptan succinate tab 100 mg.................. 118
IMITREX -sumatriptan succinate tab 25 mg.................... 118
IMITREX -sumatriptan succinate tab 50 mg.................... 118
IMURAN -azathioprine tab 50 mg................................... 189
INATAL ADVANCE - prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg .................................................................. 132
INATAL GT - prenatal vit w/ dss-iron carbonyl-fa tab 90-1
mg ................................................................................. 132
INATAL ULTRA - prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg ........................................................................ 132
INCIVEK -telaprevir tab 375 mg........................................ 11
INCRELEX -mecasermin inj 40 mg/4ml (10 mg/ml)...........42
indapamide tab 1.25 mg..................................................60
indapamide tab 2.5 mg....................................................60
INDERAL LA -propranolol hcl cap sr 24hr 120 mg............ 46
INDERAL LA -propranolol hcl cap sr 24hr 160 mg............ 46
INDERAL LA -propranolol hcl cap sr 24hr 60 mg.............. 46
INDERAL LA -propranolol hcl cap sr 24hr 80 mg.............. 46
INDERAL XL -propranolol hcl sustained-release beads cap
sr 24hr 120 mg................................................................ 47
INDERAL XL -propranolol hcl sustained-release beads cap
sr 24hr 80 mg.................................................................. 47
INDOCIN -indomethacin suppos 50 mg.......................... 116
INDOCIN -indomethacin susp 25 mg/5ml........................116
indomethacin cap 25 mg.............................................. 116
indomethacin cap 50 mg.............................................. 116
indomethacin cap cr 75 mg.......................................... 116
INFANATE BALANCE - prenatal w/o a w/fe cbn-dss-fadha cap 29-1-265 mg ................................................... 132
INFASURF -calfactant in nacl 0.9% intratracheal susp 35
mg/ml................................................................................75
INFERGEN -interferon alfacon-1 inj 15 mcg/0.5ml............ 11
INFERGEN -interferon alfacon-1 inj 9 mcg/0.3ml.............. 11
INFINITY BLOOD GLUCOSE MO - blood glucose
INFLUENZA A (H1N1) MONOVA -influenza a (h1n1)
monovalent vaccine live intranasal liquid.........................18
INLYTA -axitinib tab 1 mg................................................. 22
INLYTA -axitinib tab 5 mg................................................. 22
INNOPRAN XL -propranolol hcl sustained-release beads
cap sr 24hr 120 mg......................................................... 47
236
INNOPRAN XL -propranolol hcl sustained-release beads
cap sr 24hr 80 mg........................................................... 47
INOVA 4/1 ACNE CONTROL TH -benzoyl perox pad 4% &
salicylic ac pad 1% & vit e 5% kit..................................169
INOVA 8/2 ACNE CONTROL TH -benzoyl perox pad 8% &
salicylic ac pad 2% & vit e 5% kit..................................169
INOVA -benzoyl peroxide pad 4% & vitamin e topical 5%
kit....................................................................................169
INOVA -benzoyl peroxide pad 8% & vitamin e topical 5%
kit....................................................................................169
INSPRA -eplerenone tab 25 mg........................................55
INSPRA -eplerenone tab 50 mg........................................55
INSTA-GLUCOSE -glucose gel 77.4%..............................34
INSUL-TOTE - blood glucose monitoring supplies ......... 184
INSUL-TOTE JR - blood glucose monitoring supplies
....................................................................................... 184
INTEGRA F - fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe) ....................................146
INTEGRA PLUS - fe fum-iron polysacch complex-fa-b
complex-c-biotin cap .....................................................146
INTELENCE -etravirine tab 100 mg.................................. 11
INTELENCE -etravirine tab 200 mg.................................. 11
INTELENCE -etravirine tab 25 mg.................................... 11
INTERMEZZO -zolpidem tartrate sl tab 1.75 mg...............97
INTERMEZZO -zolpidem tartrate sl tab 3.5 mg.................97
IN TOUCH DIABETES MANAGEM - blood glucose
monitoring misc. ............................................................184
INTROL -glycerin soln 75%...............................................60
INTRON-A -interferon alfa-2b inj 10000000 unit/ml........... 22
INTRON-A -interferon alfa-2b inj 6000000 unit/ml............. 22
INTRON-A W/DILUENT -interferon alfa-2b for inj
10000000 unit.................................................................. 22
18000000 unit.................................................................. 22
50000000 unit.................................................................. 22
INTUNIV -guanfacine hcl tab sr 24hr 1 mg (base
equiv)..............................................................................100
equiv)..............................................................................100
equiv)..............................................................................100
equiv)..............................................................................100
INVANZ -ertapenem sodium for inj 1 gm (base
equivalent)........................................................................16
INVANZ -ertapenem sodium for iv inj 1 gm (base
equivalent)........................................................................16
INVEGA -paliperidone tab sr 24hr 1.5 mg.........................94
INVEGA -paliperidone tab sr 24hr 3 mg............................94
INVEGA SUSTENNA -paliperidone palmitate im extendedrelease susp 156 mg/ml.................................................. 94
2014
INVEGA SUSTENNA -paliperidone palmitate im extendedrelease susp 234 mg/1.5ml............................................. 94
INVEGA SUSTENNA -paliperidone palmitate im extendedrelease susp 39 mg/0.25ml............................................. 94
INVEGA SUSTENNA -paliperidone palmitate im extendedrelease susp 78 mg/0.5ml............................................... 94
INVEGA SUSTENNA -paliperidone palmitate im extendrelease susp 117 mg/0.75ml............................................94
INVIRASE -saquinavir mesylate cap 200 mg.................... 11
INVIRASE -saquinavir mesylate tab 500 mg..................... 11
INVOKAMET -canagliflozin-metformin hcl tab 150-1000
mg.................................................................................... 34
mg.................................................................................... 34
mg.................................................................................... 34
mg.................................................................................... 34
INVOKANA -canagliflozin tab 100 mg............................... 34
INVOKANA -canagliflozin tab 300 mg............................... 34
IODINE STRONG -iodine solution strong 5%
(lugol's)........................................................................... 141
IODINE TINCTURE - iodine tincture .............................. 177
IODINE TINCTURE MILD - iodine tincture .....................177
IODINE TINCTURE STRONG DE - iodine tincture strong
....................................................................................... 177
IODINE TINCTURE STRONG - iodine tincture strong
....................................................................................... 177
IODOPEN -sodium iodide inj 100 mcg/ml....................... 141
iodoquinol-hc cream 1%............................................... 169
IOPIDINE -apraclonidine hcl ophth soln 0.5% (base
equivalent)......................................................................155
IOPIDINE -apraclonidine hcl ophth soln 1% (base
equivalent)......................................................................155
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml
(Duoneb)..........................................................................73
ipratropium bromide inhal soln 0.02%.......................... 73
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
(Atrovent)........................................................................ 67
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
(Atrovent)........................................................................ 67
IPRIVASK -desirudin for inj 15 mg.................................. 149
IQUIX -levofloxacin ophth soln 1.5%............................... 155
irbesartan-hydrochlorothiazide tab 150-12.5 mg
(Avalide).......................................................................... 55
irbesartan-hydrochlorothiazide tab 300-12.5 mg
(Avalide).......................................................................... 55
irbesartan tab 150 mg (Avapro)..................................... 55
irbesartan tab 300 mg (Avapro)..................................... 55
irbesartan tab 75 mg (Avapro)....................................... 55
IRON ASP GLY/ POLYSACCH C - fe asp gly-fe
polysacch-succ ac-c-threon ac-b12-fa cap ................... 146
iron combination cap ................................................... 144
iron dextran inj 50 mg/ml (elemental iron).................. 146
iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg
(Hematron-af)................................................................144
iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg
(Corvite 150)................................................................. 146
IRON - iron combination tab .......................................... 146
iron polysacch complex-vit b12-fa cap 150-0.025-1
mg.................................................................................. 146
iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg
(Icar-c plus)...................................................................146
IROSPAN 24/6 - fe asp gly-fe polys-succ acd-b cmplx-cca-fa tab ther pk ........................................................... 146
IS 24/6 - fe asp gly-fe polys-succ acd-b cmplx-c-ca-fa tab
ther pk ...........................................................................146
ISCAR MALI -european mistletoe (viscum album) inj 5 mg/
ml....................................................................................178
ISENTRESS -raltegravir potassium chew tab 100 mg
(base equiv)..................................................................... 11
ISENTRESS -raltegravir potassium chew tab 25 mg (base
equiv)................................................................................11
ISENTRESS -raltegravir potassium packet for susp 100
mg (base equiv)............................................................... 11
ISENTRESS -raltegravir potassium tab 400 mg (base
equiv)................................................................................11
ISOMETHEPTENE/CAFFEINE/AC -acetaminophenisometheptene-caffeine tab 500-130-20 mg.................. 119
isoniazid & rifampin cap 150-300 mg.............................. 9
ISONIAZID -isoniazid inj 100 mg/ml....................................9
ISONIAZID -isoniazid syrup 50 mg/5ml...............................9
isoniazid tab 100 mg......................................................... 9
isoniazid tab 300 mg......................................................... 9
ISOPTIN SR -verapamil hcl tab cr 120 mg........................49
ISOPTO ATROPINE -atropine sulfate ophth soln 1%......155
ISOPTO CARBACHOL -carbachol ophth soln 1.5%....... 155
ISOPTO CARBACHOL -carbachol ophth soln 3%.......... 155
ISOPTO CARPINE -pilocarpine hcl ophth soln 1%......... 155
ISOPTO HOMATROPINE -homatropine hbr ophth soln
2%.................................................................................. 155
ISOPTO HOMATROPINE -homatropine hbr ophth soln
5%.................................................................................. 155
ISOPTO HYOSCINE -scopolamine hbr ophth soln
0.25%............................................................................. 155
ISORDIL TITRADOSE -isosorbide dinitrate tab 40 mg......45
ISORDIL TITRADOSE -isosorbide dinitrate tab 5 mg........45
ISOSORBIDE DINITRATE -isosorbide dinitrate sl tab 2.5
mg.................................................................................... 45
ISOSORBIDE DINITRATE -isosorbide dinitrate sl tab 5
mg.................................................................................... 45
ISOSORBIDE DINITRATE -isosorbide dinitrate tab 30
mg.................................................................................... 45
isosorbide dinitrate tab 10 mg....................................... 45
237
2014
isosorbide dinitrate tab 5 mg (Isordil titradose)........... 45
isosorbide dinitrate tab cr 40 mg...................................45
isosorbide mononitrate tab 10 mg.................................45
isosorbide mononitrate tab 20 mg.................................45
isosorbide mononitrate tab sr 24hr 120 mg (Imdur)..... 45
isosorbide mononitrate tab sr 24hr 30 mg (Imdur)....... 45
isosorbide mononitrate tab sr 24hr 60 mg (Imdur)....... 45
isotretinoin cap 10 mg.................................................. 169
ISOXSUPRINE HCL -isoxsuprine hcl tab 20 mg............... 65
isoxsuprine hcl tab 10 mg.............................................. 65
ISRADIPINE -isradipine cap 2.5 mg..................................49
ISRADIPINE -isradipine cap 5 mg.....................................49
ISTALOL -timolol maleate ophth soln 0.5% (oncedaily)...............................................................................155
ISUPREL -isoproterenol hcl inj 0.2 mg/ml......................... 74
itraconazole cap 100 mg (Sporanox)............................. 10
J
JAKAFI -ruxolitinib phosphate tab 10 mg (base
equivalent)........................................................................22
equivalent)........................................................................22
equivalent)........................................................................22
equivalent)........................................................................22
equivalent)........................................................................22
JALYN -dutasteride-tamsulosin hcl cap 0.5-0.4 mg...........86
JANUMET -sitagliptin-metformin hcl tab 50-1000 mg........ 34
JANUMET -sitagliptin-metformin hcl tab 50-500 mg..........34
JANUMET XR -sitagliptin-metformin hcl tab sr 24hr
100-1000 mg....................................................................35
JANUMET XR -sitagliptin-metformin hcl tab sr 24hr
50-1000 mg......................................................................34
JANUMET XR -sitagliptin-metformin hcl tab sr 24hr 50-500
mg.................................................................................... 34
JANUVIA -sitagliptin phosphate tab 100 mg (base
equiv)................................................................................35
equiv)................................................................................35
equiv)................................................................................35
JARDIANCE -empagliflozin tab 10 mg.............................. 35
JARDIANCE -empagliflozin tab 25 mg.............................. 35
J-COF DHC -pseudoephed-bromphen-dihydrocodeine liqd
15-3-7.5 mg/5ml...............................................................69
JENTADUETO -linagliptin-metformin hcl tab 2.5-1000
mg.................................................................................... 35
mg.................................................................................... 35
mg.................................................................................... 35
238
JINTELI -norethindrone acetate-ethinyl estradiol tab 1
mg-5 mcg......................................................................... 28
J-MAX DHC -dihydrocodeine-guaifenesin liquid 7.5-100
mg/5ml..............................................................................69
JUBLIA -efinaconazole soln 10%.................................... 169
JUVISYNC -sitagliptin-simvastatin tab 100-10 mg.............35
JUVISYNC -sitagliptin-simvastatin tab 50-10 mg...............35
JUXTAPID -lomitapide mesylate cap 10 mg (base
equiv)................................................................................62
equiv)................................................................................62
equiv)................................................................................62
K
KADIAN -morphine sulfate cap sr 24hr 100 mg...............110
KADIAN -morphine sulfate cap sr 24hr 10 mg................ 109
KALBITOR -ecallantide inj 10 mg/ml............................... 151
KALETRA -lopinavir-ritonavir soln 400-100 mg/5ml (80-20
mg/ml).............................................................................. 11
KALETRA -lopinavir-ritonavir tab 100-25 mg.....................11
KALETRA -lopinavir-ritonavir tab 200-50 mg.....................11
KALYDECO -ivacaftor tab 150 mg.................................... 75
KANAMYCIN SULFATE -kanamycin sulfate inj 333 mg/
ml........................................................................................8
KAPVAY -clonidine hcl tab sr 12hr 0.1 mg......................100
KAPVAY DOSE PACK -clonidine hcl tab sr 12hr therapy
pack 0.1 & 0.2 mg......................................................... 100
KARBINAL ER -carbinoxamine maleate er susp 4
mg/5ml..............................................................................66
KAYEXALATE - sodium polystyrene sulfonate powder
....................................................................................... 189
KAZANO -alogliptin-metformin hcl tab 12.5-1000 mg........35
KAZANO -alogliptin-metformin hcl tab 12.5-500 mg..........35
KCENTRA -prothrombin complex conc human for inj kit
1000 unit........................................................................ 151
KCENTRA -prothrombin complex conc human for inj kit
500 unit.......................................................................... 151
KEFLEX -cephalexin cap 250 mg....................................... 4
2014
KENALOG-10 -triamcinolone acetonide inj susp 10 mg/
ml......................................................................................25
KENALOG-40 -triamcinolone acetonide inj susp 40 mg/
ml......................................................................................25
KENALOG -triamcinolone acetonide aerosol soln........... 169
KEPPRA -levetiracetam oral soln 100 mg/ml.................. 122
KEPPRA -levetiracetam tab 1000 mg............................. 122
KEPPRA -levetiracetam tab 250 mg............................... 122
KEPPRA XR -levetiracetam tab sr 24hr 500 mg............. 122
KEPPRA XR -levetiracetam tab sr 24hr 750 mg............. 122
KERAFOAM 42 -urea foam 42%.....................................169
KERAFOAM -urea foam 30%..........................................169
KERALAC -urea cream 47%........................................... 169
KERALYT -salicylic acid gel 6%......................................169
KERALYT SCALP -salicylic acid shampoo 6% & salicylic
acid gel 6% kit............................................................... 169
KERLONE -betaxolol hcl tab 10 mg.................................. 47
KERLONE -betaxolol hcl tab 20 mg.................................. 47
KERR TRIPLE DYE -triple dye swabs............................ 177
KETEK -telithromycin tab 300 mg..................................... 16
KETEK -telithromycin tab 400 mg..................................... 16
ketoconazole cream 2%................................................ 169
ketoconazole foam 2% (Extina)....................................169
ketoconazole shampoo 2% (Nizoral)........................... 169
ketoconazole tab 200 mg................................................10
KETODAN KIT -ketoconazole foam 2% & cleanser
kit....................................................................................169
ketoprofen cap 50 mg................................................... 116
ketoprofen cap 75 mg................................................... 116
KETOPROFEN ER -ketoprofen cap sr 24hr 200 mg....... 116
ketorolac tromethamine im inj 60 mg/2ml (30 mg/
ml).................................................................................. 116
ketorolac tromethamine inj 15 mg/ml.......................... 116
ketorolac tromethamine inj 30 mg/ml.......................... 116
ketorolac tromethamine inj 60 mg/2ml (30 mg/ml)......116
KETOROLAC TROMETHAMINE -ketorolac tromethamine
im inj 30 mg/ml.............................................................. 116
KETOROLAC TROMETHAMINE -ketorolac tromethamine
inj 300 mg/10ml (30 mg/ml)........................................... 116
ketorolac tromethamine ophth soln 0.4% (Acular
ls)................................................................................... 155
ketorolac tromethamine ophth soln 0.5% (Acular)..... 155
ketorolac tromethamine tab 10 mg.............................. 116
KHEDEZLA -desvenlafaxine tab sr 24hr 100 mg.............. 90
KHEDEZLA -desvenlafaxine tab sr 24hr 50 mg................ 90
KINERET -anakinra subcutaneous inj 100 mg/0.67ml.....116
KLARON -sulfacetamide sodium lotion 10% (acne)........ 169
KLONOPIN -clonazepam tab 0.5 mg.............................. 122
KLONOPIN -clonazepam tab 1 mg................................. 122
KLONOPIN -clonazepam tab 2 mg................................. 122
KLOR-CON 25 -potassium chloride powder packet 25
meq................................................................................ 141
KLOR-CON M15 -potassium chloride microencapsulated
crys cr tab 15 meq.........................................................141
KOATE-DVI -antihemophilic factor (human) for inj 1000
unit..................................................................................152
unit..................................................................................152
unit..................................................................................152
KOGENATE FS -antihemophilic factor (recombinant) for inj
kit 1000 unit................................................................... 152
kit 2000 unit................................................................... 152
kit 250 unit..................................................................... 152
kit 3000 unit................................................................... 152
kit 500 unit..................................................................... 152
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 1000 unit.................................. 152
(recombinant) for inj kit 250 unit.................................... 152
(recombinant) for inj kit 500 unit.................................... 152
KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr
2.5-1000 mg.....................................................................35
5-1000 mg........................................................................35
5-500 mg..........................................................................35
KORLYM -mifepristone tab 300 mg.................................. 35
K-PHOS NEUTRAL -pot phos monobasic w/sod phos di &
monobas tab 155-852-130mg........................................141
K-PHOS NO 2 -potassium & sodium acid phosphates tab
305-700 mg......................................................................86
K-PHOS -potassium phosphate monobasic tab 500
mg.................................................................................. 141
KRISTALOSE -lactulose oral crystal packet 10 gm........... 75
KRISTALOSE -lactulose oral crystal packet 20 gm........... 75
KROGER BLOOD GLUCOSE MONI - blood glucose
KROGER GLUCOSE -glucose chew tab 4 gm..................35
KROGER PREMIUM BLOOD GLUC - blood glucose
K-TAB -potassium chloride tab cr 10 meq.......................141
K-TAB -potassium chloride tab cr 20 meq (1500 mg)...... 141
KUVAN -sapropterin dihydrochloride powder packet 100
mg.................................................................................... 42
KUVAN -sapropterin dihydrochloride soluble tab 100
mg.................................................................................... 42
KYNAMRO -mipomersen sodium inj 200 mg/ml................62
239
2014
L
labetalol hcl tab 100 mg (Trandate)............................... 47
LAC-HYDRIN -lactic acid (ammonium lactate) cream
12%................................................................................ 169
LAC-HYDRIN -lactic acid (ammonium lactate) lotion
12%................................................................................ 169
LACRISERT - artificial tear ophth insert .........................155
lactic acid (ammonium lactate) cream 12% (Lachydrin)........................................................................... 169
lactic acid (ammonium lactate) lotion 10%................. 169
lactic acid (ammonium lactate) lotion 12% (Lachydrin)........................................................................... 169
lactic acid w/ vitamin e cream 10%-3500
unit/30gm...................................................................... 169
LACTOCAL-F - prenatal vit w/ fe fumarate-fa tab 65-1 mg
....................................................................................... 132
lactulose (encephalopathy) solution 10 gm/15ml......... 82
lactulose solution 10 gm/15ml....................................... 75
LAMICTAL CHEWABLE DISPERS -lamotrigine tab
chewable dispersible 25 mg.......................................... 122
LAMICTAL CHEWABLE DISPERS -lamotrigine tab
chewable dispersible 5 mg............................................ 122
LAMICTAL -lamotrigine tab 100 mg................................ 122
LAMICTAL -lamotrigine tab 25 mg.................................. 122
LAMICTAL -lamotrigine tab chewable dispersible 2
mg.................................................................................. 122
LAMICTAL ODT -lamotrigine orally disintegrating tab 100
mg.................................................................................. 122
mg.................................................................................. 122
mg.................................................................................. 122
mg.................................................................................. 122
LAMICTAL ODT -lamotrigine tab disp 25 (14) & 50 mg (14)
& 100 mg (7) kit.............................................................122
LAMICTAL ODT -lamotrigine tab disp 25 mg (21) & 50 mg
(7) titration kit................................................................. 122
LAMICTAL ODT -lamotrigine tab disp 50 mg (42) & 100
mg (14) titration kit.........................................................122
LAMICTAL STARTER/NOT TAKI -lamotrigine tab 25 mg
(42) & 100 mg (7) starter kit.......................................... 122
LAMICTAL STARTER/TAKING C -lamotrigine tab 25 mg
(84) & 100 mg (14) starter kit........................................ 122
LAMICTAL STARTER/TAKING V -lamotrigine tab 25 mg
(35) starter kit................................................................ 122
LAMICTAL XR -lamotrigine tab sr 24hr 100 mg.............. 122
LAMICTAL XR -lamotrigine tab sr 24hr 25 (14) & 50 mg
(14) & 100 mg(7) kit...................................................... 122
240
LAMICTAL XR -lamotrigine tab sr 24hr 25 mg................ 122
LAMICTAL XR -lamotrigine tab sr 24hr 25 mg (21) & 50
mg (7) titration kit...........................................................122
LAMICTAL XR -lamotrigine tab sr 24hr 50 (14) & 100
mg(14) & 200 mg(7) kit..................................................122
LAMICTAL XR -lamotrigine tab sr 24hr 50 mg................ 122
LAMISIL SPRAY -terbinafine hcl soln 1%....................... 169
LAMISIL -terbinafine hcl oral granules packet 125 mg...... 10
LAMISIL -terbinafine hcl oral granules packet 187.5
mg.................................................................................... 10
LAMISIL -terbinafine hcl tab 250 mg................................. 10
lamivudine tab 100 mg (Epivir hbv)............................... 11
lamivudine tab 150 mg (Epivir)...................................... 11
lamivudine tab 300 mg (Epivir)...................................... 11
lamivudine-zidovudine tab 150-300 mg (Combivir)...... 11
lamotrigine tab 100 mg (Lamictal)............................... 123
lamotrigine tab 25 mg (Lamictal)................................. 123
lamotrigine tab chewable dispersible 25 mg (Lamictal
chewable di)................................................................. 122
lamotrigine tab chewable dispersible 5 mg (Lamictal
chewable di)................................................................. 122
lamotrigine tab sr 24hr 100 mg (Lamictal xr).............. 122
lamotrigine tab sr 24hr 25 mg (Lamictal xr)................ 122
lamotrigine tab sr 24hr 50 mg (Lamictal xr)................ 123
LANOXIN -digoxin tab 125 mcg (0.125 mg)...................... 45
LANOXIN -digoxin tab 187.5 mcg (0.1875 mg)................. 45
LANOXIN -digoxin tab 250 mcg (0.25 mg)........................ 45
LANOXIN -digoxin tab 62.5 mcg (0.0625 mg)................... 45
lansoprazole cap delayed release 15 mg
(Prevacid)........................................................................ 78
lansoprazole cap delayed release 30 mg
(Prevacid)........................................................................ 78
lansoprazole tab delayed release orally disintegrating
15 mg...............................................................................78
lansoprazole tab delayed release orally disintegrating
30 mg...............................................................................78
LANTUS -insulin glargine inj 100 unit/ml........................... 37
LANTUS SOLOSTAR -insulin glargine soln pen-injector
100 unit/ml....................................................................... 37
LARTUS -phenyleph-chlorphen w/ dm-gg liquid 5-2-15-150
mg/5ml..............................................................................69
LASIX -furosemide tab 20 mg........................................... 60
LASTACAFT -alcaftadine ophth soln 0.25%....................155
latanoprost ophth soln 0.005% (Xalatan).................... 155
LATRIX XM -urea in zinc undecylenate-lactic acid vehicle
emulsion 45%................................................................ 169
LATUDA -lurasidone hcl tab 120 mg.................................95
2014
LATUDA -lurasidone hcl tab 20 mg...................................94
LAVARE WOUND WASH - wound cleansers - gel .........169
LAVOCLEN-4 CREAMY WASH -benzoyl peroxide liq
4%.................................................................................. 169
LAVOCLEN-8 CREAMY WASH -benzoyl peroxide liq
8%.................................................................................. 169
LAZANDA -fentanyl citrate nasal spray 100 mcg/act (base
equiv)..............................................................................110
LAZANDA -fentanyl citrate nasal spray 400 mcg/act (base
equiv)..............................................................................110
LEADER GLUCOSE -glucose chew tab 4 gm...................35
LEADER QUICK DISSOLVE GLU -glucose chew tab 4
gm.................................................................................... 35
LECITHIN -lecithin granules............................................ 142
leflunomide tab 10 mg (Arava)..................................... 116
leflunomide tab 20 mg (Arava)..................................... 116
LESCOL -fluvastatin sodium cap 20 mg........................... 62
LESCOL -fluvastatin sodium cap 40 mg........................... 62
LESCOL XL -fluvastatin sodium tab sr 24 hr 80 mg.......... 62
LETAIRIS -ambrisentan tab 10 mg................................... 65
LETAIRIS -ambrisentan tab 5 mg..................................... 65
letrozole tab 2.5 mg (Femara).........................................22
LEUCOVORIN CALCIUM -leucovorin calcium tab 10
mg.................................................................................... 22
LEUCOVORIN CALCIUM -leucovorin calcium tab 15
mg.................................................................................... 22
leucovorin calcium tab 25 mg........................................ 22
leucovorin calcium tab 5 mg.......................................... 22
LEUKERAN -chlorambucil tab 2 mg..................................22
LEUKINE -sargramostim inj 500 mcg/ml......................... 146
LEUKINE -sargramostim lyophilized for inj 250 mcg....... 146
leuprolide acetate inj kit 5 mg/ml...................................22
LEVACET -aspirin-apap-salicylamide-caffeine tab
500-250-150-32.5 mg.................................................... 106
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
(Xopenex)........................................................................ 74
(Xopenex)........................................................................ 74
(Xopenex)........................................................................ 74
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base
equiv) (Xopenex concentrate).......................................74
LEVAQUIN -levofloxacin in d5w iv soln 250 mg/50ml......... 8
LEVAQUIN -levofloxacin in d5w iv soln 500 mg/100ml....... 8
LEVAQUIN -levofloxacin in d5w iv soln 750 mg/150ml....... 8
LEVAQUIN -levofloxacin iv soln 25 mg/ml.......................... 8
LEVAQUIN -levofloxacin oral soln 25 mg/ml....................... 8
LEVAQUIN -levofloxacin tab 250 mg.................................. 8
LEVATOL -penbutolol sulfate tab 20 mg........................... 47
LEVBID -hyoscyamine sulfate tab sr 12hr 0.375 mg......... 78
LEVEMIR FLEXPEN -insulin detemir soln pen-injector 100
unit/ml...............................................................................37
LEVEMIR FLEXTOUCH -insulin detemir soln pen-injector
100 unit/ml....................................................................... 37
LEVEMIR -insulin detemir inj 100 unit/ml.......................... 37
levetiracetam oral soln 100 mg/ml (Keppra)............... 123
levetiracetam tab 1000 mg (Keppra)............................ 123
levetiracetam tab 250 mg (Keppra).............................. 123
levetiracetam tab sr 24hr 500 mg (Keppra xr).............123
levetiracetam tab sr 24hr 750 mg (Keppra xr).............123
LEVITRA -vardenafil hcl tab 10 mg................................... 65
LEVITRA -vardenafil hcl tab 2.5 mg.................................. 65
LEVITRA -vardenafil hcl tab 20 mg................................... 65
LEVITRA -vardenafil hcl tab 5 mg.....................................65
LEVOBUNOLOL HCL -levobunolol hcl ophth soln
0.25%............................................................................. 155
levobunolol hcl ophth soln 0.5% (Betagan)................ 155
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 42
levocarnitine tab 330 mg (Carnitor)............................... 42
levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/
ml) (Xyzal)....................................................................... 66
levocetirizine dihydrochloride tab 5 mg (Xyzal)............66
levofloxacin in d5w iv soln 250 mg/50ml (Levaquin)...... 8
levofloxacin in d5w iv soln 500 mg/100ml
(Levaquin)......................................................................... 8
levofloxacin in d5w iv soln 750 mg/150ml
(Levaquin)......................................................................... 8
levofloxacin iv soln 25 mg/ml.......................................... 8
levofloxacin ophth soln 0.5%....................................... 155
levofloxacin oral soln 25 mg/ml (Levaquin).................... 8
levofloxacin tab 250 mg (Levaquin).................................8
LEVOMEFOLATE CALCIUM/ACET - l-methylfolate-algaeb12-acetylcyst tab 6-90.314-2-600mg .......................... 143
LEVOMEFOLATE CALCIUM/ALGA - l-methylfolate-algae
cap 15-90.314 mg ........................................................ 143
LEVOMEFOLATE CALCIUM/ALGA - l-methylfolate-algae
cap 7.5-90.314 mg ....................................................... 143
LEVOMEFOLATE CALCIUM/PYRI - l-methylfolate-algaevit b12-b6 cap 3-90.314-2-35 mg ................................. 143
LEVOMEFOLATE DHA - prenat w/fe fum-l methylfolate-fadha cap 27-1.13-0.4 mg ............................................... 132
LEVOMEFOLATE PNV - prenatal w/ fe polycmplxmethylfol-fa pak 29-1.4-0.5 mg .....................................132
levonorgestrel & ethinyl estradiol (91-day) tab
0.15-0.03 mg................................................................... 30
levonorgestrel & ethinyl estradiol tab 0.15 mg-30
mcg.................................................................................. 30
levonorgestrel & ethinyl estradiol tab 0.1 mg-20
mcg.................................................................................. 30
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg.................................30
241
2014
levonorgestrel tab 0.75 mg (Plan b)...............................30
levonorgestrel tab 1.5 mg (Plan b one-step)................. 30
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab
0.01mg(7) (Loseasonique).............................................30
levonorg-eth est tab 0.15-0.03mg(84) & eth est tab
0.01mg(7) (Seasonique).................................................30
LEVORPHANOL TARTRATE -levorphanol tartrate tab 2
mg.................................................................................. 110
levothyroxine sodium tab 100 mcg (Synthroid)............38
levothyroxine sodium tab 25 mcg (Synthroid)..............38
LEVSIN/SL -hyoscyamine sulfate tab sl 0.125 mg............ 78
LEVSIN -hyoscyamine sulfate inj 0.5 mg/ml......................78
LEVSIN -hyoscyamine sulfate tab 0.125 mg..................... 78
LEVULAN KERASTICK -aminolevulinic acid hcl for soln
20% (stick applicator).................................................... 169
LEXAPRO -escitalopram oxalate soln 5 mg/5ml (base
equiv)................................................................................90
LEXAPRO -escitalopram oxalate tab 10 mg (base
equiv)................................................................................90
equiv)................................................................................90
equiv)................................................................................90
LEXIVA -fosamprenavir calcium susp 50 mg/ml (base
equiv)................................................................................12
LEXIVA -fosamprenavir calcium tab 700 mg (base
equiv)................................................................................12
LIALDA -mesalamine tab delayed release 1.2 gm............ 82
LIBERTY BLOOD GLUCOSE MET - blood glucose
LIBERTY BLOOD GLUCOSE MON - blood glucose
LIBERTY NEXT GENERATION B - blood glucose
LIBRAX -clidinium & chlordiazepoxide cap 2.5-5 mg.........78
LIDOCAINE/PRILOCAINE -lidocaine-prilocaine kit
2.5-2.5%......................................................................... 169
lidocaine hcl cream 3%.................................................169
lidocaine hcl gel 2%...................................................... 169
LIDOCAINE HCL-HYDROCORTIS -lidocainehydrocortisone acetate rectal gel 2.8-0.55%..................161
lidocaine hcl laryngotracheal soln 4% (Lta 360
kit).................................................................................. 159
LIDOCAINE HCL -lidocaine hcl lotion 3%....................... 169
lidocaine hcl soln 4% (Xylocaine)................................ 169
242
lidocaine hcl viscous soln 2%......................................159
lidocaine-hydrocortisone acetate rectal cream
3-0.5%............................................................................ 161
lidocaine-hydrocortisone acetate rectal cream kit
2-2%............................................................................... 161
3-0.5%............................................................................ 161
3-1%............................................................................... 161
lidocaine-hydrocortisone acetate rectal gel kit
3-2.5%............................................................................ 161
lidocaine oint 5%........................................................... 169
lidocaine patch 5% (Lidoderm).................................... 169
lidocaine-prilocaine cream 2.5-2.5% (Emla)................ 169
LIDODERM -lidocaine patch 5%..................................... 169
LIDOPROFEN - ketoprofen-ketamine-lidocaine cream
5-5-2% (compound kit) ................................................. 169
LIDORX -lidocaine hcl gel 3%......................................... 169
LIDOVIR - acyclovir-lidocaine hcl oint 4-4% (compounding
kit) ................................................................................. 169
LIMBREL250 -flavocoxid-citrated zinc bisglycinate cap
250-50 mg......................................................................143
LIMBREL500 -flavocoxid-citrated zinc bisglycinate cap
500-50 mg......................................................................143
LIMBREL -flavocoxid cap 250 mg................................... 143
LIMBREL -flavocoxid cap 500 mg................................... 143
LINCOCIN -lincomycin hcl inj 300 mg/ml.......................... 16
lindane lotion 1%........................................................... 169
lindane shampoo 1%.....................................................169
LINZESS -linaclotide cap 145 mcg....................................82
LINZESS -linaclotide cap 290 mcg....................................82
liothyronine sodium tab 25 mcg (Cytomel)................... 38
liothyronine sodium tab 50 mcg (Cytomel)................... 38
liothyronine sodium tab 5 mcg (Cytomel)..................... 38
LIPITOR -atorvastatin calcium tab 10 mg (base
equivalent)........................................................................62
equivalent)........................................................................62
equivalent)........................................................................62
equivalent)........................................................................62
LIPOFEN -fenofibrate cap 150 mg.................................... 62
LIPOFEN -fenofibrate cap 50 mg...................................... 62
LIPTRUZET -ezetimibe-atorvastatin tab 10-10 mg............62
LIQUICET -hydrocodone-acetaminophen soln 10-500
mg/15ml..........................................................................110
lisinopril & hydrochlorothiazide tab 10-12.5 mg
(Zestoretic)......................................................................55
lisinopril & hydrochlorothiazide tab 20-12.5 mg
(Zestoretic)......................................................................55
2014
lisinopril & hydrochlorothiazide tab 20-25 mg
(Zestoretic)......................................................................55
lisinopril tab 10 mg (Prinivil).......................................... 55
lisinopril tab 2.5 mg (Zestril).......................................... 55
lisinopril tab 20 mg (Prinivil).......................................... 55
lisinopril tab 30 mg (Zestril)........................................... 55
lisinopril tab 40 mg (Zestril)........................................... 55
lisinopril tab 5 mg (Prinivil)............................................ 55
LISTERINE ESSENTIAL CARE - sod monofluorophoseucal-men-methyl sal-thymol paste 0.76% ................... 159
LISTERINE ESSENTIAL CARE - sod monofluorophospheucal-men-methyl sal-thymol gel 0.76% ....................... 159
LISTERINE RESTORING -sodium fluoride rinse 0.0221%
(0.01% f)........................................................................ 159
LISTERINE SMART RINSE ANT -sodium fluoride rinse
0.02%............................................................................. 159
LISTERINE SMART RINSE -sodium fluoride rinse
0.0221% (0.01% f)......................................................... 159
LISTERINE TOOTH DEFENSE -sodium fluoride rinse
0.0221% (0.01% f)......................................................... 159
LISTERINE TOTAL CARE PLUS -sodium fluoride rinse
0.0221% (0.01% f)......................................................... 159
LISTERINE TOTAL CARE -sodium fluoride rinse 0.0221%
(0.01% f)........................................................................ 159
LISTERINE TOTAL CARE ZERO -sodium fluoride rinse
0.02%............................................................................. 159
LISTERINE WHITENING/RESTO -sodium fluoride rinse
0.0221% (0.01% f)......................................................... 159
lithium carbonate cap 150 mg (Lithium carbonate)...... 95
lithium carbonate cap 300 mg........................................95
lithium carbonate cap 600 mg (Lithium carbonate)...... 95
LITHIUM CARBONATE -lithium carbonate cap 150
mg.................................................................................... 95
LITHIUM CARBONATE -lithium carbonate cap 600
mg.................................................................................... 95
lithium carbonate tab 300 mg.........................................95
lithium carbonate tab cr 300 mg (Lithobid)................... 95
lithium carbonate tab cr 450 mg.................................... 95
LITHIUM CITRATE -lithium citrate oral soln 8 meq/5ml.....95
LITHOBID -lithium carbonate tab cr 300 mg..................... 95
LITHOSTAT -acetohydroxamic acid tab 250 mg............... 86
LIVALO -pitavastatin calcium tab 1 mg (base equiv)......... 62
L-METHYL-B6-B12 - l-methylfolate w/ vit b6-vit b12 tab
3-35-2 mg ..................................................................... 143
L-METHYLFOLATE CA/ME-CBL/ - l-methylfolatemethylcobalamin-acetylcyst tab 6-2-600 mg .................143
L-METHYLFOLATE CA/P-5-P/M - l-methylfolate-algae-vit
b12-b6 cap 3-90.314-2-35 mg ...................................... 143
L-METHYLFOLATE CA/P-5-P/M - l-methylfolate w/ vit b6vit b12 tab 3-35-2 mg ................................................... 143
L-METHYLFOLATE CALCIUM - l-methylfolate tab 15 mg
....................................................................................... 143
L-METHYLFOLATE CALCIUM - l-methylfolate tab 7.5 mg
....................................................................................... 143
L-METHYLFOLATE CA ME-CBL - l-methylfolate-algaeb12-acetylcyst tab 6-90.314-2-600mg .......................... 143
L-METHYLFOLATE FORMULA 15 - l-methylfolate-algae
cap 15-90.314 mg ........................................................ 143
L-METHYLFOLATE FORMULA 7. - l-methylfolate-algae
cap 7.5-90.314 mg ....................................................... 143
L-METHYLFOLATE FORTE - l-methylfolate-algae cap
15-90.314 mg ............................................................... 143
L-METHYLFOLATE FORTE - l-methylfolate-algae cap
7.5-90.314 mg ...............................................................143
L-METHYLFOLATE - l-methylfolate tab 15 mg .............. 143
L-METHYLFOLATE - l-methylfolate tab 7.5 mg ............. 143
L-METHYLFOLATE PNV DHA - prenat w/fe fum-l
methylfolate-fa-dha cap 27-1.13-0.4 mg ....................... 132
L-METHYL-MC - l-methylfolate w/ vit b12-vit b6-vit b2 tab
6-1-50-5 mg .................................................................. 143
L-METHYL-MC NAC - l-methylfolate-methylcobalaminacetylcyst tab 6-2-600 mg ............................................ 143
LMTHF/PYRIDOXINE HCL/CYAN - l-methylfolate w/ vit
b6-vit b12 tab 1.13-25-2 mg ......................................... 143
LO/OVRAL-28 -norgestrel & ethinyl estradiol tab 0.3
mg-30 mcg....................................................................... 30
LOCOID -hydrocortisone butyrate cream 0.1%............... 170
LOCOID -hydrocortisone butyrate lotion 0.1%................ 170
LOCOID -hydrocortisone butyrate oint 0.1%................... 170
LOCOID -hydrocortisone butyrate soln 0.1%.................. 169
LOCOID LIPOCREAM -hydrocortisone butyrate
hydrophilic lipo base cream 0.1%.................................. 170
LODOSYN -carbidopa tab 25 mg....................................125
LOESTRIN 1/20-21 -norethindrone ace & ethinyl estradiol
tab 1 mg-20 mcg............................................................. 30
LOESTRIN 1.5/30-21 -norethindrone ace & ethinyl
estradiol tab 1.5 mg-30 mcg............................................ 30
LOESTRIN 24 FE -norethindrone ace-ethinyl estradiol-fe
tab 1 mg-20 mcg (24)......................................................30
LOESTRIN FE 1/20 -norethindrone ace & ethinyl estradiolfe tab 1 mg-20 mcg......................................................... 30
LOESTRIN FE 1.5/30 -norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg........................................30
LOFIBRA -fenofibrate micronized cap 134 mg.................. 62
LOFIBRA -fenofibrate micronized cap 200 mg.................. 62
LOFIBRA -fenofibrate micronized cap 67 mg.................... 62
LOFIBRA -fenofibrate tab 160 mg.....................................62
LOFIBRA -fenofibrate tab 54 mg.......................................62
LO LOESTRIN FE -norethin-eth estradiol-fe tab 1 mg-10
mcg (24)/10 mcg (2)........................................................ 30
LOMEDIA 24 FE -norethindrone ace-ethinyl estradiol-fe
tab 1 mg-20 mcg (24)......................................................30
LO MINASTRIN FE -norethin-eth estrad-fe chew/tab 1
mg-10 mcg/10 mcg ther pack.......................................... 30
LOMOTIL -diphenoxylate w/ atropine tab 2.5-0.025
mg.................................................................................... 76
LOMUSTINE -lomustine cap 100 mg................................ 22
243
2014
LOMUSTINE -lomustine cap 10 mg.................................. 22
LOMUSTINE -lomustine cap 40 mg.................................. 22
LONGS GLUCOSE -glucose chew tab 4 gm.................... 35
loperamide hcl cap 2 mg................................................ 76
LOPID -gemfibrozil tab 600 mg......................................... 62
LOPRESSOR HCT -metoprolol & hydrochlorothiazide tab
100-25 mg........................................................................55
LOPRESSOR HCT -metoprolol & hydrochlorothiazide tab
50-25 mg..........................................................................55
LOPRESSOR -metoprolol tartrate tab 100 mg.................. 47
LOPRESSOR -metoprolol tartrate tab 50 mg.................... 47
LOPROX -ciclopirox gel 0.77%....................................... 170
LOPROX SHAMPOO -ciclopirox shampoo 1%............... 170
lorazepam conc 2 mg/ml (Lorazepam intensol)............ 87
LORAZEPAM INTENSOL -lorazepam conc 2 mg/ml........ 87
lorazepam tab 0.5 mg (Ativan)....................................... 87
lorazepam tab 1 mg (Ativan).......................................... 87
lorazepam tab 2 mg (Ativan).......................................... 87
LORCET 10/650 -hydrocodone-acetaminophen tab 10-650
mg.................................................................................. 110
LORCET PLUS -hydrocodone-acetaminophen tab 7.5-650
mg.................................................................................. 110
LORTAB -hydrocodone-acetaminophen soln 10-300
mg/15ml..........................................................................110
LORTAB -hydrocodone-acetaminophen soln 7.5-500
mg/15ml..........................................................................110
LORTAB -hydrocodone-acetaminophen tab 10-500
mg.................................................................................. 110
LORTAB -hydrocodone-acetaminophen tab 5-500
mg.................................................................................. 110
LORTAB -hydrocodone-acetaminophen tab 7.5-500
mg.................................................................................. 110
LORTUSS EX -pseudoephedrine w/ cod-gg liqd
22.5-10-100 mg/5ml......................................................... 69
LORZONE -chlorzoxazone tab 375 mg...........................128
LORZONE -chlorzoxazone tab 750 mg...........................128
losartan potassium & hydrochlorothiazide tab 100-12.5
mg (Hyzaar).................................................................... 55
losartan potassium & hydrochlorothiazide tab 100-25
mg (Hyzaar).................................................................... 55
losartan potassium & hydrochlorothiazide tab 50-12.5
mg (Hyzaar).................................................................... 56
losartan potassium tab 100 mg (Cozaar)...................... 56
losartan potassium tab 25 mg (Cozaar)........................ 56
losartan potassium tab 50 mg (Cozaar)........................ 56
LOSEASONIQUE -levonorg-eth est tab 0.1-0.02mg(84) &
eth est tab 0.01mg(7)...................................................... 30
LOTEMAX -loteprednol etabonate ophth gel 0.5%..........155
LOTEMAX -loteprednol etabonate ophth oint 0.5%.........155
LOTEMAX -loteprednol etabonate ophth susp 0.5%....... 155
LOTENSIN -benazepril hcl tab 10 mg............................... 56
LOTENSIN HCT -benazepril & hydrochlorothiazide tab
10-12.5 mg.......................................................................56
244
20-12.5 mg.......................................................................56
20-25 mg..........................................................................56
LOTREL -amlodipine besylate-benazepril hcl cap 10-20
mg.................................................................................... 56
mg.................................................................................... 56
LOTREL -amlodipine besylate-benazepril hcl cap 2.5-10
mg.................................................................................... 56
mg.................................................................................... 56
mg.................................................................................... 56
mg.................................................................................... 56
LOTRISONE -clotrimazole w/ betamethasone cream
1-0.05%.......................................................................... 170
LOTRONEX -alosetron hcl tab 0.5 mg (base equiv)..........82
LOTRONEX -alosetron hcl tab 1 mg (base equiv).............82
LOUTREX - antiseborrheic products misc - cream .........170
lovastatin tab 10 mg........................................................63
lovastatin tab 20 mg (Mevacor)......................................63
lovastatin tab 40 mg (Mevacor)......................................63
LOVAZA -omega-3-acid ethyl esters cap 1 gm................. 63
LOVENOX -enoxaparin sodium inj 100 mg/ml................ 149
LOVENOX -enoxaparin sodium inj 120 mg/0.8ml............149
LOVENOX -enoxaparin sodium inj 150 mg/ml................ 149
LOVENOX -enoxaparin sodium inj 300 mg/3ml.............. 149
LOVENOX -enoxaparin sodium inj 30 mg/0.3ml............. 149
loxapine succinate cap 10 mg........................................95
loxapine succinate cap 5 mg (Loxitane)........................95
LOXITANE -loxapine succinate cap 10 mg....................... 95
LOXITANE -loxapine succinate cap 5 mg......................... 95
LOZI-FLUR -sodium fluoride lozenge 1 mg f (from 2.2 mg
naf)................................................................................. 141
LTA 360 KIT -lidocaine hcl laryngotracheal soln 4%....... 159
LUFYLLIN -dyphylline tab 200 mg.................................... 74
LUFYLLIN -dyphylline tab 400 mg.................................... 74
LUGOLS STRONG IODINE - iodine solution ................. 177
LUMIGAN -bimatoprost ophth soln 0.01%.......................156
LUMIGAN -bimatoprost ophth soln 0.03%.......................156
LUNESTA -eszopiclone tab 1 mg......................................97
LUPRON DEPOT -leuprolide acetate (3 month) for inj kit
11.25 mg.......................................................................... 22
2014
22.5 mg............................................................................ 22
30 mg............................................................................... 22
45 mg............................................................................... 22
LUPRON DEPOT -leuprolide acetate for inj kit 3.75
mg.................................................................................... 22
LUPRON DEPOT -leuprolide acetate for inj kit 7.5 mg......22
LUPRON DEPOT-PED -leuprolide acetate (3 month) for inj
pediatric kit 11.25 mg...................................................... 42
LUPRON DEPOT-PED -leuprolide acetate (3 month) for inj
pediatric kit 30 mg........................................................... 42
LUPRON DEPOT-PED -leuprolide acetate for inj pediatric
kit 11.25 mg..................................................................... 42
kit 15 mg.......................................................................... 42
kit 7.5 mg......................................................................... 42
LURIDE -sodium fluoride chew tab 0.25 mg f (from 0.55
mg naf)...........................................................................141
LURIDE -sodium fluoride chew tab 0.5 mg f (from 1.1 mg
naf)................................................................................. 141
LURIDE -sodium fluoride chew tab 1 mg f (from 2.2 mg
naf)................................................................................. 141
LURIDE -sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml
naf)................................................................................. 141
LUVOX CR -fluvoxamine maleate cap sr 24hr 100 mg......90
LUVOX CR -fluvoxamine maleate cap sr 24hr 150 mg......90
LUXIQ -betamethasone valerate aerosol foam 0.12%.....170
LUZU -luliconazole cream 1%......................................... 170
LYCELLE - nit remover - gel ..........................................170
LYRICA -pregabalin cap 100 mg.....................................123
LYRICA -pregabalin cap 25 mg.......................................123
LYRICA -pregabalin soln 20 mg/ml................................. 123
LYSODREN -mitotane tab 500 mg....................................22
LYSTEDA -tranexamic acid tab 650 mg..........................149
LYTENSOPRIL-90 KIT -lisinopril tab 20 mg & dietary
LYTENSOPRIL-90 -lisinopril tab 20 mg & dietary
LYTENSOPRIL KIT -lisinopril tab 20 mg & dietary
M
MACNATAL CN DHA - prenatal w/o a w/fe cbn-dss-fa-dha
cap 28-1-250 mg .......................................................... 132
MACROBID -nitrofurantoin monohydrate macrocrystalline
cap 100 mg......................................................................83
MACRODANTIN -nitrofurantoin macrocrystalline cap 100
mg.................................................................................... 83
mg.................................................................................... 83
mg.................................................................................... 83
mafenide acetate packet for topical soln 5% (50 gm)
(Sulfamylon)..................................................................170
MAGNACET -oxycodone w/ acetaminophen tab 10-400
mg.................................................................................. 110
MAGNACET -oxycodone w/ acetaminophen tab 5-400
mg.................................................................................. 110
MAGNACET -oxycodone w/ acetaminophen tab 7.5-400
mg.................................................................................. 110
MAGNEBIND 400 -magnesium-calcium-folic acid tab
400-200-1 mg.................................................................141
magnesium chloride inj 200 mg/ml..............................141
magnesium sulfate inj 50%.......................................... 141
MAGNESIUM SULFATE -magnesium sulfate inj 4%.......141
MAGNESIUM SULFATE -magnesium sulfate inj 8%.......141
MALARONE -atovaquone-proguanil hcl tab 250-100
mg.................................................................................... 14
MALARONE -atovaquone-proguanil hcl tab 62.5-25
mg.................................................................................... 14
malathion lotion 0.5% (Ovide)...................................... 170
MAPROTILINE HCL -maprotiline hcl tab 25 mg................90
MAR-COF BP -pseudoephedrine-bromphen-codeine liqd
30-2-7.5 mg/5ml...............................................................69
MAR-COF CG EXPECTORANT -guaifenesin-codeine
liquid 225-7.5 mg/5ml...................................................... 69
MARINOL -dronabinol cap 10 mg..................................... 80
MARINOL -dronabinol cap 2.5 mg.................................... 80
MARINOL -dronabinol cap 5 mg....................................... 80
MARNATAL-F - prenatal w/o vit a w/ fe polysac cmplx-fa
cap 60-1 mg ................................................................. 132
MARPLAN -isocarboxazid tab 10 mg................................ 90
MATULANE -procarbazine hcl cap 50 mg.........................22
MAVIK -trandolapril tab 1 mg............................................ 56
MAXAIR AUTOHALER -pirbuterol acetate breath activated
inhal aerosol 200mcg/inh................................................. 74
MAXALT-MLT -rizatriptan benzoate orally disintegrating
tab 10 mg.......................................................................119
MAXALT-MLT -rizatriptan benzoate orally disintegrating
tab 5 mg.........................................................................119
MAXALT -rizatriptan benzoate tab 10 mg....................... 119
MAXALT -rizatriptan benzoate tab 5 mg......................... 119
MAXARON FORTE - fe gly-fe fum-vit c-vit b12methylfolate tab ............................................................ 146
MAXFE - iron-fa-vit b12-biotin-vit c-docusate-mg-zn tab
160-1 mg ...................................................................... 147
MAXIDEX -dexamethasone ophth susp 0.1%................. 156
245
2014
MAXIDONE -hydrocodone-acetaminophen tab 10-750
mg.................................................................................. 110
MAXIFED CD -pseudoephedrine w/ cod-gg tab 60-10-400
mg.................................................................................... 69
MAXIFED CDX -pseudoephedrine w/ cod-gg tab
60-20-400 mg...................................................................69
MAXIFED-G CD -pseudoephedrine w/ cod-gg tab
40-10-400 mg...................................................................69
MAXIFED-G CDX -pseudoephedrine w/ cod-gg tab
40-20-400 mg...................................................................69
MAXIFLU CD -pseudoephed-codeine-guaifenesin-apap
tab 40-10-400-500 mg..................................................... 69
MAXIFLU CDX -pseudoephed-codeine-guaifenesin-apap
tab 60-20-400-500 mg..................................................... 69
MAXIMA BLOOD GLUCOSE MONI - blood glucose
MAXIMA METER KIT - blood glucose monitoring kit w/
device ............................................................................184
MAXIMA STARTER KIT - blood glucose monitoring kit w/
device ............................................................................184
MAXINATE - prenatal vit w/ fe gluc-fe fum-fa tab 20-0.8
mg ................................................................................. 132
MAXIPHEN CD -phenylephrine w/ codeine-gg tab
10-10-400 mg...................................................................69
MAXIPHEN CDX -phenylephrine w/ codeine-gg tab
10-20-400 mg...................................................................69
MAXIPIME -cefepime hcl for inj 1 gm................................. 4
MAXIPIME -cefepime hcl for inj 2 gm................................. 4
MAXIPIME -cefepime hcl for iv soln 1 gm...........................4
MAXIPIME -cefepime hcl for iv soln 2 gm...........................4
MAXITROL -neomycin-polymyxin-dexamethasone ophth
oint 0.1%........................................................................ 156
MAXITROL -neomycin-polymyxin-dexamethasone ophth
susp 0.1%...................................................................... 156
MAXZIDE-25 -triamterene & hydrochlorothiazide tab
37.5-25 mg.......................................................................60
MAXZIDE -triamterene & hydrochlorothiazide tab 75-50
mg.................................................................................... 60
MB HYDROGEL -emollient cream & wound dressing gel
kit....................................................................................170
M-CLEAR -guaifenesin-codeine cap 200-9 mg................. 69
meclizine hcl tab 12.5 mg............................................... 80
meclizine hcl tab 25 mg.................................................. 80
meclizine hcl tab 32 mg.................................................. 80
MECLOFENAMATE SODIUM -meclofenamate sodium
cap 100 mg....................................................................116
MECLOFENAMATE SODIUM -meclofenamate sodium
cap 50 mg......................................................................116
MEDICINE SHOPPE GLUCOSE -glucose chew tab 4
gm.................................................................................... 35
MEDROL DOSEPAK -methylprednisolone tab 4 mg dose
pack..................................................................................25
MEDROL -methylprednisolone tab 16 mg......................... 25
MEDROL -methylprednisolone tab 2 mg...........................25
MEDROL -methylprednisolone tab 32 mg......................... 25
246
MEDROX-RX -capsaicin-menthol-methyl salicylate oint
0.05-7-20%.....................................................................170
medroxyprogesterone acetate im susp 150 mg/ml
(Depo-provera contrac)................................................. 30
medroxyprogesterone acetate tab 10 mg (Provera)..... 32
medroxyprogesterone acetate tab 2.5 mg
(Provera)..........................................................................32
medroxyprogesterone acetate tab 5 mg (Provera)....... 32
mefenamic acid cap 250 mg (Ponstel).........................116
mefloquine hcl tab 250 mg............................................. 14
MEGACE ES -megestrol acetate susp 625 mg/5ml.......... 32
MEGACE ORAL -megestrol acetate susp 40 mg/ml......... 22
megestrol acetate susp 40 mg/ml (Megace oral).......... 22
megestrol acetate tab 20 mg.......................................... 22
megestrol acetate tab 40 mg.......................................... 22
MEIJER BLOOD GLUCOSE MONI - blood glucose
MEIJER PREMIUM BLOOD GLUC - blood glucose
MEIJER TRUE2GO BLOOD GLUC - blood glucose
MEIJER TRUERESULT BLOOD G - blood glucose
MEIJER TRUETRACK BLOOD GL - blood glucose
MEKINIST -trametinib dimethyl sulfoxide tab 0.5 mg (base
equivalent)........................................................................22
MEKINIST -trametinib dimethyl sulfoxide tab 2 mg (base
equivalent)........................................................................22
MELOXICAM -meloxicam susp 7.5 mg/5ml.................... 116
meloxicam tab 15 mg (Mobic)...................................... 116
meloxicam tab 7.5 mg (Mobic)..................................... 117
M-END MAX D -pseudoephedrine-dexbromphen-codeine
liqd 20-0.667-6 mg/5ml.................................................... 69
M-END PE -phenylephrine-bromphen w/ codeine liqd
3.33-1.33-6.33 mg/5ml..................................................... 69
MENEST -esterified estrogens tab 0.3 mg........................ 29
MENEST -esterified estrogens tab 0.625 mg.................... 29
MENEST -esterified estrogens tab 1.25 mg...................... 29
MENEST -esterified estrogens tab 2.5 mg........................ 29
MENOPUR -menotropins for subcutaneous inj 75 unit......43
MENOSTAR -estradiol td patch weekly 14 mcg/24hr........ 29
MENTAX -butenafine hcl cream 1%................................170
MEPERIDINE HCL/PROMETHAZI -meperidine w/
promethazine cap 50-25 mg.......................................... 110
MEPERIDINE HCL -meperidine hcl oral soln 50
mg/5ml............................................................................110
meperidine hcl tab 100 mg (Demerol)..........................110
meperidine hcl tab 50 mg (Demerol)........................... 110
MEPHYTON -phytonadione tab 5 mg............................. 129
meprobamate tab 200 mg............................................... 87
meprobamate tab 400 mg............................................... 87
MEPRON -atovaquone susp 750 mg/5ml......................... 16
2014
mercaptopurine tab 50 mg (Purinethol).........................22
meropenem iv for soln 1 gm (Merrem).......................... 16
meropenem iv for soln 500 mg (Merrem)...................... 16
MERREM -meropenem iv for soln 1 gm............................16
MERREM -meropenem iv for soln 500 mg........................16
mesalamine enema 4 gm................................................ 82
mesalamine rectal enema 4 gm & cleanser wipe kit
(Rowasa)......................................................................... 81
MESNEX -mesna tab 400 mg........................................... 22
MESTINON -pyridostigmine bromide syrup 60
mg/5ml............................................................................128
MESTINON -pyridostigmine bromide tab 60 mg............. 128
MESTINON TIMESPAN -pyridostigmine bromide tab cr
180 mg........................................................................... 128
METADATE CD -methylphenidate hcl cap cr 10 mg....... 100
METAFOLBIC - l-methylfolate w/ vit b12-vit b6-vit b2 tab
6-1-50-5 mg .................................................................. 143
METAFOLBIC PLUS - l-methylfolate-methylcobalaminacetylcyst tab 6-2-600 mg ............................................ 143
METAFOLBIC PLUS RF - l-methylfolate-algae-b12acetylcyst tab 6-90.314-2-600mg ................................. 143
METAGLIP -glipizide-metformin hcl tab 2.5-250 mg..........35
METANX - l-methylfolate-algae-vit b12-b6 cap
3-90.314-2-35 mg ......................................................... 143
METANX - l-methylfolate w/ vit b6-vit b12 tab 3-35-2 mg
....................................................................................... 143
METAPROTERENOL SULFATE -metaproterenol sulfate
syrup 10 mg/5ml.............................................................. 74
tab 10 mg.........................................................................74
tab 20 mg.........................................................................74
metaproterenol sulfate syrup 10 mg/5ml.......................74
metaxalone tab 800 mg (Skelaxin)............................... 128
metformin hcl tab 1000 mg (Glucophage)..................... 35
metformin hcl tab 500 mg (Glucophage).......................35
metformin hcl tab 850 mg (Glucophage).......................35
metformin hcl tab sr 24hr 500 mg (Glucophage xr)...... 35
metformin hcl tab sr 24hr 750 mg (Glucophage xr)...... 35
metformin hcl tab sr 24hr osmotic 1000 mg
(Fortamet)........................................................................35
metformin hcl tab sr 24hr osmotic 500 mg
(Fortamet)........................................................................35
methadone hcl conc 10 mg/ml (Methadose)............... 110
METHADONE HCL -methadone hcl soln 10 mg/5ml.......110
METHADONE HCL -methadone hcl soln 5 mg/5ml.........110
methadone hcl soln 10 mg/5ml (Methadone hcl)........ 110
methadone hcl soln 5 mg/5ml (Methadone hcl).......... 110
methadone hcl tab 10 mg (Dolophine)........................ 110
methadone hcl tab 5 mg (Dolophine hcl).................... 110
methadone hcl tab for oral susp 40 mg...................... 110
METHADOSE -methadone hcl conc 10 mg/ml................110
METHADOSE SUGAR-FREE -methadone hcl conc 10 mg/
ml....................................................................................110
methamphetamine hcl tab 5 mg (Desoxyn).................100
methazolamide tab 25 mg (Neptazane)......................... 60
methazolamide tab 50 mg (Neptazane)......................... 60
methenamine hippurate tab 1 gm (Hiprex)....................83
methenamine-hyosamine-meth blue-sod phos tab 81.6
mg (Urogesic-blue)........................................................ 83
methenamine-hyosc-meth blue-benz acid-phenyl sal
tab 81.6mg (Prosed/ds)................................................. 83
methenamine-hyosc-meth blue-sod phos-phen sal cap
120 mg ........................................................................... 83
methenamine-hyos-meth blue-sod phos-phen sal tab
81.6 mg .......................................................................... 83
METHENAMINE MANDELATE -methenamine mandelate
tab 0.5 gm........................................................................83
methenamine mandelate tab 1 gm.................................83
METHERGINE -methylergonovine maleate tab 0.2 mg.....40
methimazole tab 10 mg (Tapazole)................................ 38
methimazole tab 5 mg (Tapazole).................................. 38
METHITEST -methyltestosterone oral tab 10 mg.............. 27
methocarbamol tab 500 mg (Robaxin)........................ 128
methocarbamol tab 750 mg (Robaxin-750)................. 128
methotrexate sodium for inj 1 gm..................................22
methotrexate sodium inj 25 mg/ml................................ 22
methotrexate sodium inj pf 25 mg/ml............................ 22
methotrexate sodium tab 2.5 mg (base equiv)..............22
methoxsalen rapid cap 10 mg (Oxsoralen ultra).........170
methscopolamine bromide tab 2.5 mg (Pamine).......... 78
methscopolamine bromide tab 5 mg (Pamine
forte)................................................................................ 78
METHYCLOTHIAZIDE -methyclothiazide tab 5 mg...........60
METHYLDOPA/HYDROCHLOROTHI -methyldopa &
hydrochlorothiazide tab 250-15 mg................................. 56
METHYLDOPA/HYDROCHLOROTHI -methyldopa &
hydrochlorothiazide tab 250-25 mg................................. 56
methyldopa tab 250 mg.................................................. 56
methyldopa tab 500 mg.................................................. 56
methylergonovine maleate tab 0.2 mg.......................... 40
METHYLFOL-ALGAE-B12-ACETY - l-methylfolate-algaeb12-acetylcyst tab 6-90.314-2-600mg .......................... 143
METHYLIN -methylphenidate hcl chew tab 10 mg.......... 100
METHYLIN -methylphenidate hcl chew tab 2.5 mg......... 100
METHYLIN -methylphenidate hcl chew tab 5 mg............ 100
METHYLIN -methylphenidate hcl soln 10 mg/5ml........... 100
METHYLIN -methylphenidate hcl soln 5 mg/5ml............. 100
methylphenidate hcl cap cr 10 mg (Metadate cd)....... 100
247
2014
methylphenidate hcl cap sr 24hr 20 mg (Ritalin
la)................................................................................... 100
la)................................................................................... 100
la)................................................................................... 100
METHYLPHENIDATE HCL ER -methylphenidate hcl tab cr
10 mg............................................................................. 100
methylphenidate hcl soln 10 mg/5ml (Methylin)......... 100
methylphenidate hcl soln 5 mg/5ml (Methylin)........... 101
methylphenidate hcl tab 10 mg (Ritalin)......................101
methylphenidate hcl tab 20 mg (Ritalin)......................101
methylphenidate hcl tab 5 mg (Ritalin)........................101
methylphenidate hcl tab cr 20 mg (Ritalin sr)............. 101
methylphenidate hcl tab sa osm 18 mg
(Concerta)..................................................................... 101
(Concerta)..................................................................... 101
(Concerta)..................................................................... 101
(Concerta)..................................................................... 101
methylprednisolone acetate inj susp 40 mg/ml (Depomedrol)............................................................................ 25
methylprednisolone acetate inj susp 80 mg/ml (Depomedrol)............................................................................ 25
methylprednisolone sodium succinate for inj 1000 mg
(Solu-medrol).................................................................. 25
(Solu-medrol).................................................................. 25
(Solu-medrol).................................................................. 25
(Solu-medrol).................................................................. 25
methylprednisolone tab 16 mg (Medrol)........................25
methylprednisolone tab 32 mg (Medrol)........................25
methylprednisolone tab 4 mg (Medrol)......................... 25
methylprednisolone tab 4 mg dose pack (Medrol
dosepak)..........................................................................25
methylprednisolone tab 8 mg (Medrol)......................... 25
METHYL SALICYLATE - methyl salicylate liquid ............170
METIPRANOLOL -metipranolol ophth soln 0.3%............ 156
metoclopramide hcl inj 5 mg/ml.....................................82
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)......... 82
metoclopramide hcl tab 10 mg (Reglan)....................... 82
metoclopramide hcl tab 5 mg (Reglan)......................... 82
metolazone tab 10 mg.....................................................60
metolazone tab 2.5 mg (Zaroxolyn)............................... 60
metolazone tab 5 mg (Zaroxolyn).................................. 60
metoprolol & hydrochlorothiazide tab 100-25 mg
(Lopressor hct)...............................................................56
metoprolol & hydrochlorothiazide tab 100-50 mg........ 56
metoprolol & hydrochlorothiazide tab 50-25 mg
(Lopressor hct)...............................................................56
248
metoprolol succinate tab sr 24hr 100 mg (Toprol
xl)..................................................................................... 47
metoprolol succinate tab sr 24hr 200 mg (Toprol
xl)..................................................................................... 47
metoprolol succinate tab sr 24hr 25 mg (Toprol xl)......47
metoprolol succinate tab sr 24hr 50 mg (Toprol xl)......47
metoprolol tartrate tab 100 mg (Lopressor).................. 47
metoprolol tartrate tab 25 mg.........................................47
metoprolol tartrate tab 50 mg (Lopressor).................... 47
METOZOLV ODT -metoclopramide hcl orally disintegrating
tab 10 mg.........................................................................82
METOZOLV ODT -metoclopramide hcl orally disintegrating
tab 5 mg...........................................................................82
METROCREAM -metronidazole cream 0.75%................ 170
METROGEL -metronidazole gel 1%................................170
METROGEL-VAGINAL -metronidazole vaginal gel
0.75%............................................................................... 85
METROLOTION -metronidazole lotion 0.75%................. 170
metronidazole cap 375 mg (Flagyl)................................16
metronidazole cream 0.75% (Metrocream).................. 170
metronidazole gel 0.75%...............................................170
metronidazole gel 1% (Metrogel)................................. 170
metronidazole lotion 0.75% (Metrolotion)....................170
metronidazole tab 250 mg (Flagyl).................................16
metronidazole tab 500 mg (Flagyl).................................16
metronidazole vaginal gel 0.75% (Metrogelvaginal)............................................................................85
METVIXIA -methyl aminolevulinate hcl cream 16.8% (base
equiv)..............................................................................170
MEVACOR -lovastatin tab 20 mg......................................63
MEVACOR -lovastatin tab 40 mg......................................63
mexiletine hcl cap 150 mg..............................................51
MIACALCIN -calcitonin (salmon) inj 200 unit/ml................43
MIACALCIN -calcitonin (salmon) nasal soln 200 unit/
act.....................................................................................43
MICARDIS HCT -telmisartan-hydrochlorothiazide tab
40-12.5 mg.......................................................................56
80-12.5 mg.......................................................................56
80-25 mg..........................................................................56
MICARDIS -telmisartan tab 20 mg.................................... 56
MICONAZOLE 3 -miconazole nitrate vaginal suppos 200
mg.................................................................................... 85
miconazole nitrate vaginal supp 200 mg & 2% cream 9
gm kit.............................................................................. 85
MICRODOT BLOOD GLUCOSE MO - blood glucose
MICRO-K -potassium chloride cap cr 10 meq................. 141
MICRO-K -potassium chloride cap cr 8 meq................... 141
MICROLET LANCETS - lancets .....................................184
2014
MICROZIDE -hydrochlorothiazide cap 12.5 mg................ 60
midazolam hcl syrup 2 mg/ml (base equivalent).......... 97
midodrine hcl tab 10 mg.................................................61
midodrine hcl tab 2.5 mg................................................61
midodrine hcl tab 5 mg...................................................61
MIFEPREX -mifepristone tab 200 mg............................... 43
MIGERGOT -ergotamine w/ caffeine suppos 2-100
mg.................................................................................. 119
MIGRALAM -acetaminophen-isometheptene-caffeine cap
325-65-100 mg...............................................................119
MIGRAL -isometheptene mucate tab 130 mg................. 119
MIGRANAL -dihydroergotamine mesylate nasal spray 4
mg/ml..............................................................................119
MILLIPRED DP -prednisolone tab 5 mg dose pack...........25
MILLIPRED -prednisolone sod phosphate oral soln 10
mg/5ml (base equiv)........................................................ 25
MILLIPRED -prednisolone tab 5 mg..................................25
MIMYX - emollient - cream ............................................ 170
MINASTRIN 24 FE -norethindrone ace-eth estradiol-fe
chew tab 1 mg-20 mcg (24)............................................ 30
MINERAL OIL HEAVY -mineral oil....................................75
MINIPRESS -prazosin hcl cap 1 mg................................. 56
MINIVELLE -estradiol td patch biweekly 0.0375
mg/24hr............................................................................ 29
MINIVELLE -estradiol td patch biweekly 0.05 mg/24hr......29
MINIVELLE -estradiol td patch biweekly 0.075
mg/24hr............................................................................ 29
MINIVELLE -estradiol td patch biweekly 0.1 mg/24hr........29
MINOCIN KIT - minocycline hcl cap 100 mg w/ acne care
products kit ....................................................................... 7
MINOCIN KIT - minocycline hcl cap 50 mg w/ acne care
products kit ....................................................................... 7
MINOCIN -minocycline hcl cap 100 mg.............................. 7
MINOCIN -minocycline hcl cap 50 mg................................ 7
MINOCIN -minocycline hcl cap 75 mg................................ 7
minocycline hcl cap 100 mg (Minocin)............................ 7
minocycline hcl cap 50 mg (Minocin)..............................7
minocycline hcl cap 75 mg (Minocin)..............................7
minocycline hcl tab 100 mg............................................. 7
minocycline hcl tab 50 mg............................................... 7
minocycline hcl tab 75 mg............................................... 7
minocycline hcl tab sr 24hr 135 mg................................ 7
minocycline hcl tab sr 24hr 45 mg.................................. 7
minocycline hcl tab sr 24hr 90 mg.................................. 7
minoxidil tab 10 mg.........................................................56
minoxidil tab 2.5 mg........................................................56
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr
0.375 mg........................................................................ 126
0.75 mg.......................................................................... 126
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 1.5
mg.................................................................................. 126
2.25 mg.......................................................................... 126
3.75 mg.......................................................................... 126
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 3
mg.................................................................................. 126
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 4.5
mg.................................................................................. 126
MIRAPEX -pramipexole dihydrochloride tab 0.125
mg.................................................................................. 125
MIRAPEX -pramipexole dihydrochloride tab 0.25 mg......125
MIRAPEX -pramipexole dihydrochloride tab 0.5 mg........126
MIRAPEX -pramipexole dihydrochloride tab 0.75 mg......126
MIRAPEX -pramipexole dihydrochloride tab 1.5 mg........126
MIRAPEX -pramipexole dihydrochloride tab 1 mg...........126
MIRCETTE -desogest-eth estrad & eth estrad tab
0.15-0.02/0.01 mg(21/5)...................................................30
mirtazapine orally disintegrating tab 15 mg (Remeron
soltab)..............................................................................90
soltab)..............................................................................90
soltab)..............................................................................90
mirtazapine tab 15 mg (Remeron)..................................90
mirtazapine tab 7.5 mg....................................................90
misoprostol tab 100 mcg (Cytotec)................................78
misoprostol tab 200 mcg (Cytotec)................................78
MITOSOL -mitomycin for ophth soln kit 0.2 mg...............156
MOBIC -meloxicam susp 7.5 mg/5ml.............................. 117
MOBIC -meloxicam tab 15 mg........................................ 117
MOBIC -meloxicam tab 7.5 mg....................................... 117
modafinil tab 100 mg (Provigil).................................... 101
modafinil tab 200 mg (Provigil).................................... 101
MODERIBA 1200 DOSE PACK -ribavirin tab 600 mg....... 12
MODERIBA 800 DOSE PACK -ribavirin tab 400 mg......... 12
MODERIBA -ribavirin tab 200 mg & ribavirin tab 400 mg
dose pack.........................................................................12
MODERIBA -ribavirin tab 400 mg & ribavirin tab 600 mg
dose pack.........................................................................12
MODICON -norethindrone & ethinyl estradiol tab 0.5
mg-35 mcg....................................................................... 30
moexipril hcl tab 15 mg (Univasc)................................. 56
moexipril hcl tab 7.5 mg (Univasc)................................ 56
moexipril-hydrochlorothiazide tab 15-12.5 mg
(Uniretic)..........................................................................56
moexipril-hydrochlorothiazide tab 15-25 mg................ 56
moexipril-hydrochlorothiazide tab 7.5-12.5 mg............ 56
mometasone furoate cream 0.1% (Elocon)................. 170
mometasone furoate oint 0.1% (Elocon)..................... 170
mometasone furoate solution 0.1% (lotion)
(Elocon)......................................................................... 170
MOMEXIN -mometasone furoate cream 0.1% & ammon
lactate foam 12% kit...................................................... 170
249
2014
MOMS CHOICE RX -prenat w/fe poly-na fered-fa tab 26-1
& omega cap 278 mg.................................................... 132
MONOCAL -sodium monofluorophosphate-calcium carb
tab 22.75-625 mg...........................................................141
MONOCLATE-P -antihemophilic factor (human) for inj kit
1000 unit........................................................................ 152
1500 unit........................................................................ 152
250 unit.......................................................................... 152
500 unit.......................................................................... 152
MONODOX -doxycycline monohydrate cap 100 mg........... 7
MONODOX -doxycycline monohydrate cap 50 mg............. 7
MONODOX -doxycycline monohydrate cap 75 mg............. 7
MONOJECT INSULIN SYRINGE/ -insulin syringe/needle
u-100 0.3 ml 29 x 1/2"................................................... 184
u-100 0.3 ml 30 x 5/16"................................................. 184
u-100 1/2 ml 28 x 1/2"................................................... 184
u-100 1/2 ml 29 x 1/2"................................................... 184
u-100 1/2 ml 30 x 5/16"................................................. 184
u-100 1 ml 25 x 5/8"...................................................... 184
u-100 1 ml 27 x 1/2"...................................................... 184
u-100 1 ml 28 x 1/2"...................................................... 184
u-100 1 ml 29 x 1/2"...................................................... 185
u-100 1 ml 30 x 5/16".................................................... 185
u-100 1 ml 31 x 5/16".................................................... 185
MONOJECT INSULIN SYRINGE/ -insulin syringe (disp)
u-100 1 ml......................................................................184
MONOJECT INSULIN SYRINGE -insulin syringe (disp)
u-100 1 ml......................................................................184
MONOJECT ULTRA COMFORT IN -insulin syringe/needle
u-100 0.3 ml 29 x 1/2"................................................... 185
u-100 0.3 ml 30 x 5/16"................................................. 185
u-100 0.3 ml 31 x 5/16"................................................. 185
u-100 1/2 ml 28 x 1/2"................................................... 185
u-100 1/2 ml 29 x 1/2"................................................... 185
u-100 1/2 ml 30 x 5/16"................................................. 185
u-100 1/2 ml 31 x 5/16"................................................. 185
250
u-100 1 ml 28 x 1/2"...................................................... 185
u-100 1 ml 29 x 1/2"...................................................... 185
u-100 1 ml 30 x 5/16".................................................... 185
MONOKET -isosorbide mononitrate tab 10 mg................. 45
MONOKET -isosorbide mononitrate tab 20 mg................. 45
MONONINE -coagulation factor ix for inj 1000 unit......... 152
MONONINE -coagulation factor ix for inj 250 unit........... 152
MONONINE -coagulation factor ix for inj 500 unit........... 152
MONSELS FERRIC SUBSULFATE - ferric subsulfate soln
....................................................................................... 149
montelukast sodium chew tab 4 mg (base equiv)
(Singulair)........................................................................74
montelukast sodium chew tab 5 mg (base equiv)
(Singulair)........................................................................74
montelukast sodium oral granules packet 4 mg (base
equiv) (Singulair)............................................................74
montelukast sodium tab 10 mg (base equiv)
(Singulair)........................................................................74
MONUROL -fosfomycin tromethamine powd pack 3 gm
(base equivalent)............................................................. 83
MORGIDOX 1X100MG - doxycycline hyclate cap 1 x 100
mg w/ cleanser kit ............................................................ 7
MORGIDOX 2X100MG - doxycycline hyclate cap 2 x 100
mg w/ cleanser kit ............................................................ 7
morphine sulfate (concentrate) oral soln 20 mg/
ml................................................................................... 111
morphine sulfate beads cap sr 24hr 120 mg
(Avinza)......................................................................... 111
(Avinza)......................................................................... 111
(Avinza)......................................................................... 111
(Avinza)......................................................................... 111
(Avinza)......................................................................... 111
(Avinza)......................................................................... 111
morphine sulfate cap sr 24hr 100 mg (Kadian)........... 111
morphine sulfate cap sr 24hr 10 mg (Kadian).............111
MORPHINE SULFATE -morphine sulfate im inj device 10
mg/0.7ml.........................................................................111
MORPHINE SULFATE -morphine sulfate suppos 10
mg.................................................................................. 110
mg.................................................................................. 111
2014
mg.................................................................................. 111
mg.................................................................................. 110
MORPHINE SULFATE -morphine sulfate tab 15 mg.......110
MORPHINE SULFATE -morphine sulfate tab 30 mg.......110
morphine sulfate oral soln 10 mg/5ml......................... 111
morphine sulfate oral soln 20 mg/5ml......................... 111
morphine sulfate tab cr 100 mg (Ms contin)............... 111
morphine sulfate tab cr 15 mg (Ms contin)................. 111
morphine sulfate tab cr 200 mg (Ms contin)............... 111
MOTOFEN -difenoxin w/ atropine tab 1-0.025 mg............ 76
mouthwashes - liquid ...................................................159
MOVIPREP -peg 3350-kcl-nacl-na sulfate-na acorbate-c
for soln 100 gm................................................................75
MOXATAG -amoxicillin (trihydrate) tab sr 24hr 775 mg.......2
MOXEZA -moxifloxacin hcl ophth soln 0.5% (base eq) (2
times daily).....................................................................156
moxifloxacin hcl tab 400 mg (base equiv) (Avelox)........8
MOZOBIL -plerixafor subcutaneous inj 24 mg/1.2ml (20
mg/ml)............................................................................ 147
MS CONTIN -morphine sulfate tab cr 100 mg.................111
MS CONTIN -morphine sulfate tab cr 15 mg...................111
MS CONTIN -morphine sulfate tab cr 200 mg.................111
MS QUICK DISSOLVE GLUCOSE -glucose chew tab 4
gm.................................................................................... 35
MST 600 -magnesium salicylate tab 600 mg.................. 106
MUCOTROL - oral wound care products - wafer ............159
MULTAQ -dronedarone hcl tab 400 mg (base
equivalent)........................................................................51
MULTICHEW -multiple vitamins w/ minerals & fa chew tab
1 mg............................................................................... 132
MULTIGEN - fe asparto gly-succ acd-c-threonic acd-b12des stom tab .................................................................147
MULTIGEN FOLIC - fe asparto gly-succinic acd-vit cthreonic acd-b12-fa tab .................................................147
MULTIGEN PLUS - fe aspart gly-fe fum-succ acd-cthreonic acd-b12-fa tab .................................................147
multiple vitamins w/ minerals & fa tab 1.25 mg
(Corvite).........................................................................129
multiple vitamins w/ minerals cap .............................. 129
multiple vitamins w/ minerals tab (Strovite forte)....... 130
mupirocin calcium cream 2% (Bactroban).................. 170
mupirocin oint 2% (Bactroban).................................... 170
MUSE -alprostadil urethral pellet 1000 mcg...................... 65
MUSE -alprostadil urethral pellet 125 mcg........................ 65
MV FE ASPARTO GLY/FE FUM/ - fe aspart gly-fe fumsucc acd-c-threonic acd-b12-fa tab .............................. 147
MV FE ASPARTO GLY/VIT C/V - fe asparto gly-succ acdc-threonic acd-b12-des stom tab .................................. 147
M-VIT - prenatal vit w/ fe fumarate-fa tab 27-1 mg ......... 132
MYALEPT -metreleptin for subcutaneous inj 11.3 mg....... 43
MYAMBUTOL -ethambutol hcl tab 100 mg......................... 9
MYAMBUTOL -ethambutol hcl tab 400 mg......................... 9
MYCOBUTIN -rifabutin cap 150 mg.................................... 9
mycophenolate mofetil cap 250 mg (Cellcept)............189
mycophenolate mofetil tab 500 mg (Cellcept).............189
mycophenolate sodium tab dr 180 mg (mycophenolic
acid equiv) (Myfortic)...................................................189
mycophenolate sodium tab dr 360 mg (mycophenolic
acid equiv) (Myfortic)...................................................189
MYDFRIN -phenylephrine hcl ophth soln 2.5%............... 156
MYDRIACYL -tropicamide ophth soln 1%....................... 156
MYFORTIC -mycophenolate sodium tab dr 180 mg
(mycophenolic acid equiv)............................................. 189
MYFORTIC -mycophenolate sodium tab dr 360 mg
(mycophenolic acid equiv)............................................. 189
MYGLUCOHEALTH BLOOD GLUCO - blood glucose
MYKIDZ IRON 10 -iron susp 15 mg/1.5ml...................... 147
MYKIDZ IRON FL -pediatric vitamins acd fluoride & fe
susp 0.25-10 mg/2ml..................................................... 132
MYLERAN -busulfan tab 2 mg.......................................... 22
MYNATAL ADVANCE - prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg .................................................................. 132
MYNATAL PLUS - prenatal vit w/ fe fumarate-fa tab 65-1
mg ................................................................................. 132
MYNATAL -prenatal multivitamins & minerals w/ iron & fa
cap 1 mg........................................................................132
MYNATAL ULTRACAPLET - prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg ............................................... 132
MYNATAL-Z - prenatal vit w/ fe fumarate-fa tab 65-1 mg
....................................................................................... 132
MYNATE 90 PLUS - prenatal vit w/ dss-fe fumarate-fa tab
cr 90-1 mg .................................................................... 132
MYOXIN -benzocaine-chloroxylenol-hc otic soln 15-1-10
mg/ml..............................................................................158
MYRBETRIQ -mirabegron tab sr 24 hr 25 mg...................84
MYRBETRIQ -mirabegron tab sr 24 hr 50 mg...................84
MYSOLINE -primidone tab 250 mg................................. 123
MYSOLINE -primidone tab 50 mg...................................123
MYTELASE -ambenonium chloride tab 10 mg................ 128
N
nabumetone tab 500 mg............................................... 117
nabumetone tab 750 mg............................................... 117
nadolol & bendroflumethiazide tab 40-5 mg
(Corzide)..........................................................................56
nadolol & bendroflumethiazide tab 80-5 mg
(Corzide)..........................................................................57
nadolol tab 20 mg (Corgard).......................................... 47
nafcillin sodium for inj 10 gm.......................................... 2
251
2014
nafcillin sodium for inj 1 gm............................................ 2
nafcillin sodium for inj 2 gm............................................ 2
NAFCILLIN SODIUM -nafcillin sodium for iv soln 1 gm....... 2
NAFCILLIN SODIUM -nafcillin sodium for iv soln 2 gm....... 2
NAFRINSE DAILY/ACIDULATED -sodium fluoridephosphoric acid for soln 1 mg/5ml (f equiv)................... 159
NAFRINSE DAILY/NEUTRAL -sodium fluoride for soln
rinse 0.05%.................................................................... 159
NAFRINSE WEEKLY -sodium fluoride for soln rinse
0.2%............................................................................... 160
NAFTIN -naftifine hcl cream 1%......................................170
NAFTIN -naftifine hcl cream 2%......................................170
NAFTIN -naftifine hcl gel 1%........................................... 170
NAFTIN -naftifine hcl gel 2%...........................................170
nalbuphine hcl inj 10 mg/ml......................................... 111
nalbuphine hcl inj 20 mg/ml......................................... 111
NALFON -fenoprofen calcium cap 200 mg......................117
NALFON -fenoprofen calcium cap 400 mg......................117
naloxone hcl inj 0.4 mg/ml........................................... 178
naloxone hcl inj 1 mg/ml.............................................. 178
NALOXONE HCL -naloxone hcl inj 0.4 mg/ml.................178
naltrexone hcl tab 50 mg (Revia)................................. 178
NAMENDA -memantine hcl oral solution 2 mg/ml........... 103
NAMENDA -memantine hcl tab 10 mg............................ 103
NAMENDA -memantine hcl tab 5 mg..............................103
NAMENDA TITRATION PAK -memantine hcl tab 5 mg
(28) & 10 mg (21) titration pak...................................... 103
NAMENDA XR -memantine hcl cap sr 24hr 14 mg......... 103
NAMENDA XR -memantine hcl cap sr 24hr 7 mg........... 103
NAMENDA XR TITRATION PACK -memantine hcl cap sr
24hr 7 mg & 14 mg & 21 mg & 28 mg pack.................. 103
NAPHAZOLINE HCL -naphazoline hcl ophth soln
0.1%............................................................................... 156
NAPRELAN -naproxen sodium tab sr 24hr 375 mg (base
equiv)..............................................................................117
NAPRELAN -naproxen sodium tab sr 24hr 500 mg (14) &
750 mg (6) pack............................................................ 117
equiv)..............................................................................117
equiv)..............................................................................117
NAPRO 15% COMPOUNDING KIT -naproxen cream
15%................................................................................ 170
NAPRODERM COMPOUNDING KIT -naproxen cream
15%................................................................................ 170
NAPROSYN -naproxen susp 125 mg/5ml....................... 117
NAPROSYN -naproxen tab 250 mg................................ 117
naproxen sodium tab 275 mg (Anaprox)..................... 117
naproxen sodium tab 550 mg (Anaprox ds)................117
naproxen susp 125 mg/5ml (Naprosyn).......................117
naproxen tab 250 mg (Naprosyn).................................117
252
naproxen tab ec 375 mg (Ec-naprosyn)...................... 117
naproxen tab ec 500 mg (Ec-naprosyn)...................... 117
naratriptan hcl tab 1 mg (base equiv) (Amerge)......... 119
naratriptan hcl tab 2.5 mg (base equiv) (Amerge)...... 119
NARDIL -phenelzine sulfate tab 15 mg............................. 91
NASACORT AQ -triamcinolone acetonide nasal inhal 55
mcg/act.............................................................................67
NASCOBAL -cyanocobalamin nasal spray 500
mcg/0.1ml.......................................................................147
NASONEX -mometasone furoate nasal susp 50 mcg/
act.....................................................................................67
NATACHEW - prenatal vit w/ fe fum-fe bisglycin-fa chew
tab 28-1 mg .................................................................. 133
NATACYN -natamycin ophth susp 5%............................ 156
NATAFORT - prenatal w/o a vit w/ fe cbn-fe fum-fa tab
60-1 mg ........................................................................ 133
NATA KOMPLETE - prenatal vit w/ fe fum-fe bisglycinatefa tab 25-1 mg ..............................................................132
NATALVIRT 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa tab
90 &dha cap 300mg pak............................................... 133
NATALVIRT CA -prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 300 mg pack.................................................... 133
NATALVIRT FLT - fe carbonyl-fe gluconate-fa-vit b12-vit cdss tab 90-1 mg ........................................................... 147
NATALVIT - prenatal vit w/ fe fumarate-fa tab 75-1 mg
....................................................................................... 133
NATAL-V RX - prenatal vit w/ iron carbonyl-fa tab 29-1 mg
....................................................................................... 133
NATAZIA -estradiol valerate-dienogest tab 3 mg /2-2
mg/2-3 mg/1 mg...............................................................30
nateglinide tab 120 mg (Starlix)..................................... 35
nateglinide tab 60 mg (Starlix)....................................... 35
NATELLE ONE - prenatal w/o vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg .......................................................... 133
NATROBA -spinosad susp 0.9%.....................................170
NATURE-THROID NT-2.5 -thyroid tab 162.5 mg (2 1/2
grain)................................................................................ 38
NATURE-THROID -thyroid tab 113.75 mg........................ 38
NATURE-THROID -thyroid tab 130 mg.............................38
NATURE-THROID -thyroid tab 146.25 mg........................ 38
NATURE-THROID -thyroid tab 16.25 mg.......................... 38
NATURE-THROID -thyroid tab 32.5 mg............................38
NATURE-THROID -thyroid tab 325 mg (5 grain)...............38
NATURE-THROID -thyroid tab 48.75 mg (3/4 grain).........38
NATURE-THROID -thyroid tab 65 mg...............................38
NATURE-THROID -thyroid tab 81.25 mg.......................... 38
NATURE-THROID -thyroid tab 97.5 mg............................38
NAVANE -thiothixene cap 10 mg...................................... 95
NAVANE -thiothixene cap 20 mg...................................... 95
NAVANE -thiothixene cap 2 mg........................................ 95
NAVANE -thiothixene cap 5 mg........................................ 95
2014
NEBUPENT -pentamidine isethionate for nebulization soln
300 mg............................................................................. 16
NEBUSAL -sodium chloride soln nebu 6%........................69
NECON 1/50-28 -norethindrone & mestranol tab 1 mg-50
mcg...................................................................................30
NECON 10/11-28 -norethindrone-eth estradiol tab
0.5-35/1-35 mg-mcg (10/11)............................................ 30
NEEVO DHA - prenat w/o a w/fefum-methylfol-fa-omegas
cap 27-1.53 mg ............................................................ 133
NEEVO DHA - prenat w/o a w/fefum-methylfol-omegas
cap 27-1.13 mg ............................................................ 133
NEEVO - prenatal w/ fe polycmplx-methylfol-fa pak
29-1.4-0.5 mg ............................................................... 133
NEFAZODONE HCL -nefazodone hcl tab 100 mg............ 91
NEFAZODONE HCL -nefazodone hcl tab 50 mg.............. 91
nefazodone hcl tab 250 mg............................................ 91
NEO AC -pseudoephedrine-pyrilamine-codeine syrup
30-15-10 mg/5ml..............................................................69
NEO-FRADIN -neomycin sulfate soln 25 mg/ml..................9
NEOMYCIN/POLYMYXIN/HYDROC -neomycinpolymyxin-hc ophth susp............................................... 156
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin............................... 156
neomycin-polymyx-gramicid op sol
1.75-10000-0.25mg-unt-mg/ml (Neosporin)................156
neomycin-polymyxin-dexamethasone ophth oint 0.1%
(Maxitrol)....................................................................... 156
neomycin-polymyxin-dexamethasone ophth susp 0.1%
(Maxitrol)....................................................................... 156
neomycin-polymyxin-hc otic soln 1%
(Cortisporin)..................................................................158
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000
unit/ml-1%..................................................................... 158
neomycin sulfate tab 500 mg........................................... 9
NEORAL -cyclosporine modified cap 100 mg................. 189
NEORAL -cyclosporine modified cap 25 mg................... 189
NEORAL -cyclosporine modified oral soln 100 mg/ml..... 190
NEOSALUS CP - emollient - cream ...............................170
NEOSALUS - emollient - aerosol foam .......................... 170
NEOSALUS - emollient - cream .....................................170
NEOSALUS - emollient - lotion ...................................... 170
NEOSPORIN -neomycin-polymyx-gramicid op sol
1.75-10000-0.25mg-unt-mg/ml.......................................156
NEO-SYNALAR KIT -neomycin-fluocinolone cream
0.35-0.025% & emollient cr kit.......................................170
NEO-SYNALAR -neomycin-fluocinolone cream
0.35-0.025%................................................................... 170
NEOTUSS-D -pseudoephed-chlorphen w/ dm-gg liqd
30-2-30-200 mg/5ml.........................................................69
NEOTUSS PLUS -phenylephrine-chlorphen-dm liquid
7.5-4-30 mg/5ml...............................................................69
NEPHPLEX RX -b-complex w/ c-zn & folic acid tab 1
mg.................................................................................. 133
NEPHROCAPS -b-complex w/ c & folic acid cap 1
mg.................................................................................. 133
NEPHROCAPS QT -b-complex w/ c-biotin-d & folic acid
tab disp 1 mg.................................................................133
NEPHRON FA - ferrous fumarate w/ fa-dss-b complex-vit c
tab ................................................................................. 147
NEPHRO-VITE RX -b-complex w/ c & folic acid tab 1
mg.................................................................................. 133
NEPTAZANE -methazolamide tab 25 mg......................... 60
NEPTAZANE -methazolamide tab 50 mg......................... 60
NESINA -alogliptin benzoate tab 12.5 mg (base equiv).....35
NESINA -alogliptin benzoate tab 25 mg (base equiv)........35
NESINA -alogliptin benzoate tab 6.25 mg (base equiv).....35
NESTABS ABC -prenatal w/o vit a w/fe polysac-fa-ca tab
& omega 3 cap.............................................................. 133
NESTABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg
& omega cap pack.........................................................133
NESTABS - prenatal vit w/o vit a w/ fe bisglycinate-fa tab
32-1 mg ........................................................................ 133
NEUAC KIT -clindamycin-benzoyl perox gel 1.2-5% &
moisturizer cr kit.............................................................170
NEULASTA -pegfilgrastim inj 6 mg/0.6ml........................147
NEUMEGA -oprelvekin for inj 5 mg.................................147
NEUPOGEN -filgrastim inj 300 mcg/0.5ml (600 mcg/
ml).................................................................................. 147
NEUPOGEN -filgrastim inj 300 mcg/ml........................... 147
ml).................................................................................. 147
ml).................................................................................. 147
NEUPRO -rotigotine td patch 24hr 1 mg/24hr................. 126
NEURIN-SL -cyanocobalamin-methylcobalamin tab sl
600-600 mcg.................................................................. 147
NEURODEP - b-complex w/ c inj ................................... 133
NEURONTIN -gabapentin cap 100 mg........................... 123
NEURONTIN -gabapentin oral soln 250 mg/5ml............. 123
NEURONTIN -gabapentin tab 600 mg............................ 123
NEURONTIN -gabapentin tab 800 mg............................ 123
NEUTRASAL - artificial saliva - packet .......................... 160
NEVANAC -nepafenac ophth susp 0.1%........................ 156
NEVIRAPINE -nevirapine susp 50 mg/5ml........................12
nevirapine tab 200 mg (Viramune)................................. 12
nevirapine tab sr 24hr 400 mg (Viramune xr)................12
NEWGEN - prenatal vit w/o vit a w/ fe bisglycinate-fa tab
32-1 mg ........................................................................ 133
NEXA PLUS - prenatal w/o vit a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg ............................................................ 133
253
2014
NEXA SELECT - prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg ..................................................... 133
NEXA SELECT - prenat w/o vit a w/ fe fum-dss-fa-dha cap
29-1.25-337.5 mg ......................................................... 133
NEXAVAR -sorafenib tosylate tab 200 mg (base
equivalent)........................................................................22
NEXAVIR -liver derivative complex inj 25.5 mg/ml.......... 190
NEXGEN METER KIT - blood glucose monitoring kit ..... 185
NEXICLON XR -clonidine hcl extended release susp 0.09
mg/ml (base equiv).......................................................... 57
NEXICLON XR -clonidine hcl tab sr 24hr 0.17 mg (base
equivalent)........................................................................57
NEXIUM -esomeprazole magnesium cap delayed release
20 mg............................................................................... 78
NEXIUM -esomeprazole magnesium cap delayed release
40 mg............................................................................... 78
NEXIUM -esomeprazole magnesium for delayed release
susp pack 2.5 mg............................................................ 78
susp packet 10 mg.......................................................... 78
susp packet 20 mg.......................................................... 78
susp packet 40 mg.......................................................... 78
susp packet 5 mg............................................................ 78
niacinamide w/ zinc-copper &folic acid tab
750-25-1.5-0.5 mg......................................................... 133
niacin tab cr 1000 mg (antihyperlipidemic)
(Niaspan)......................................................................... 63
(Niaspan)......................................................................... 63
(Niaspan)......................................................................... 63
NIACOR -niacin (antihyperlipidemic) tab 500 mg.............. 63
NIASPAN -niacin tab cr 1000 mg (antihyperlipidemic)...... 63
NIASPAN -niacin tab cr 500 mg (antihyperlipidemic)........ 63
NIASPAN -niacin tab cr 750 mg (antihyperlipidemic)........ 63
NICADAN - multiple vitamins w/ minerals tab ................ 133
nicardipine hcl cap 20 mg.............................................. 49
nicardipine hcl cap 30 mg.............................................. 49
NICAZELDOXY 30 KIT -doxycycline monohyd tab 100 mg
&multivit/minerals tab kit.................................................... 7
NICAZELDOXY 60 KIT -doxycycline monohyd tab 100 mg
&multivit/minerals tab kit.................................................... 7
NICAZEL FORTE - multiple vitamins w/ minerals tab .....133
NICAZEL - multiple vitamins w/ minerals tab ................. 133
NICODERM CQ -nicotine td patch 24hr 14 mg/24hr....... 103
NICODERM CQ -nicotine td patch 24hr 21 mg/24hr....... 103
NICODERM CQ -nicotine td patch 24hr 7 mg/24hr......... 103
NICOMIDE - niacinamide w/ zn-cu-methylfolate tab
750-25-1.5-0.5 mg ........................................................ 133
NICORETTE MINI -nicotine polacrilex lozenge 2 mg...... 103
NICORETTE MINI -nicotine polacrilex lozenge 4 mg...... 103
NICORETTE -nicotine polacrilex gum 2 mg.................... 103
254
NICORETTE -nicotine polacrilex gum 4 mg.................... 103
NICORETTE -nicotine polacrilex lozenge 2 mg...............103
NICORETTE -nicotine polacrilex lozenge 4 mg...............103
NICORETTE STARTER KIT -nicotine polacrilex gum 2
mg.................................................................................. 104
NICORETTE STARTER KIT -nicotine polacrilex gum 4
mg.................................................................................. 104
nicotine polacrilex gum 2 mg.......................................104
nicotine polacrilex gum 4 mg.......................................104
nicotine polacrilex lozenge 2 mg................................. 104
nicotine polacrilex lozenge 4 mg................................. 104
nicotine td patch 24hr 14 mg/24hr............................... 104
nicotine td patch 24hr 21 mg/24hr............................... 104
nicotine td patch 24hr 7 mg/24hr................................. 104
NICOTINE TRANSDERMAL SYST -nicotine td patch 24 hr
kit 21-14-7 mg/24hr........................................................104
NICOTROL INHALER -nicotine inhaler system 10 mg (4
mg delivered)................................................................. 104
NICOTROL NS -nicotine nasal spray 10 mg/ml (0.5 mg/
spray)............................................................................. 104
nifedipine cap 10 mg (Procardia)...................................49
nifedipine cap 20 mg.......................................................49
nifedipine tab sr 24hr 30 mg (Adalat cc)....................... 49
nifedipine tab sr 24hr osmotic 30 mg (Procardia xl).....49
NILANDRON -nilutamide tab 150 mg................................22
nimodipine cap 30 mg.....................................................49
NIMOTOP -nimodipine cap 30 mg.................................... 49
NIRAVAM -alprazolam orally disintegrating tab 0.25
mg.................................................................................... 87
NIRAVAM -alprazolam orally disintegrating tab 0.5 mg..... 87
NIRAVAM -alprazolam orally disintegrating tab 1 mg........88
NIRAVAM -alprazolam orally disintegrating tab 2 mg........88
NIRON KOMPLETE - fe bisglycinate-fe fum-vit c-vit b12-vit
e-fa tab 30-1 mg ...........................................................147
NISOLDIPINE ER -nisoldipine tab sr 24hr 25.5 mg...........50
NISOLDIPINE -nisoldipine tab sr 24hr 20 mg................... 49
nisoldipine tab sr 24hr 17 mg (Sular)............................ 50
nisoldipine tab sr 24hr 25.5 mg..................................... 50
nisoldipine tab sr 24hr 34 mg (Sular)............................ 50
nisoldipine tab sr 24hr 8.5 mg (Sular)........................... 50
NITRO-BID -nitroglycerin oint 2%......................................45
NITRO-DUR -nitroglycerin td patch 24hr 0.1 mg/hr........... 45
nitrofurantoin macrocrystalline cap 100 mg
(Macrodantin)..................................................................83
2014
nitrofurantoin macrocrystalline cap 50 mg
(Macrodantin)..................................................................83
nitrofurantoin monohydrate macrocrystalline cap 100
mg (Macrobid)................................................................ 83
nitrofurantoin susp 25 mg/5ml (Furadantin)................. 83
nitroglycerin cap cr 2.5 mg............................................ 45
nitroglycerin cap cr 6.5 mg............................................ 45
nitroglycerin cap cr 9 mg............................................... 45
NITROGLYCERIN LINGUAL -nitroglycerin lingual aerosol
400 mcg/spray................................................................. 45
nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)..........45
nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)
(Nitrolingual pumpspr).................................................. 46
NITROLINGUAL PUMPSPRAY -nitroglycerin tl soln 0.4
mg/spray (400 mcg/spray)............................................... 46
NITROMIST -nitroglycerin lingual aerosol 400 mcg/
spray.................................................................................46
NITROSTAT -nitroglycerin sl tab 0.3 mg........................... 46
NIVATOPIC PLUS - dermatological products misc - cream
....................................................................................... 171
nizatidine cap 150 mg..................................................... 78
nizatidine cap 300 mg (Axid).......................................... 78
nizatidine oral soln 15 mg/ml (Axid).............................. 78
NIZORAL -ketoconazole shampoo 2%............................171
NORCO -hydrocodone-acetaminophen tab 10-325
mg.................................................................................. 111
NORCO -hydrocodone-acetaminophen tab 5-325 mg.....111
NORCO -hydrocodone-acetaminophen tab 7.5-325
mg.................................................................................. 111
NORDETTE-28 -levonorgestrel & ethinyl estradiol tab 0.15
mg-30 mcg....................................................................... 31
NORDITROPIN CARTRIDGE -somatropin inj 5
mg/1.5ml...........................................................................43
NORDITROPIN FLEXPRO -somatropin inj 10
mg/1.5ml...........................................................................43
NORDITROPIN FLEXPRO -somatropin inj 15
mg/1.5ml...........................................................................43
NORDITROPIN FLEXPRO -somatropin inj 5 mg/1.5ml.....43
NORDITROPIN NORDIFLEX PEN -somatropin inj 30
mg/3ml..............................................................................43
norelgestromin-ethinyl estradiol td ptwk 150-35
mcg/24hr (Ortho evra)................................................... 31
norethindrone & ethinyl estradiol-fe chew tab 0.4
mg-35 mcg (Femcon fe)................................................ 31
norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg
(Ovcon-35).......................................................................31
norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg
(Brevicon-28).................................................................. 31
norethindrone & ethinyl estradiol tab 1 mg-35 mcg
(Norinyl 1+35)................................................................. 31
norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30
mcg (Loestrin fe 1.5/30)................................................ 31
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20
mcg (Loestrin fe 1/20)................................................... 31
norethindrone ace & ethinyl estradiol tab 1.5 mg-30
mcg (Loestrin 1.5/30-21)................................................31
norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg
(Loestrin 1/20-21)........................................................... 31
norethindrone acetate-ethinyl estradiol tab 1 mg-5
mcg.................................................................................. 29
norethindrone acetate tab 5 mg (Aygestin)...................32
norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35
mg-mcg (Estrostep fe)...................................................31
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mgmcg (Ortho-novum 7/7/7).............................................. 31
norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28)....................................................... 31
norethindrone tab 0.35 mg (Nor-qd).............................. 31
NORFLEX -orphenadrine citrate inj 30 mg/ml................. 128
norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg
(Ortho-cyclen).................................................................31
norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35
mg-mcg (Ortho tri-cyclen).............................................31
norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg.........31
NORINYL 1+35 -norethindrone & ethinyl estradiol tab 1
mg-35 mcg....................................................................... 31
NORINYL 1+50 -norethindrone & mestranol tab 1 mg-50
mcg...................................................................................31
NORITATE -metronidazole cream 1%.............................171
NOROXIN -norfloxacin tab 400 mg..................................... 8
NORPACE CR -disopyramide phosphate cap sr 12hr 100
mg.................................................................................... 51
NORPACE CR -disopyramide phosphate cap sr 12hr 150
mg.................................................................................... 51
NORPACE -disopyramide phosphate cap 100 mg............ 51
NORPACE -disopyramide phosphate cap 150 mg............ 51
NORPRAMIN -desipramine hcl tab 100 mg...................... 91
NORPRAMIN -desipramine hcl tab 10 mg........................ 91
NORPRAMIN -desipramine hcl tab 150 mg...................... 91
NOR-QD -norethindrone tab 0.35 mg................................30
NORTHERA -droxidopa cap 100 mg.................................61
nortriptyline hcl cap 10 mg (Pamelor)........................... 91
NORTRIPTYLINE HCL -nortriptyline hcl soln 10
mg/5ml..............................................................................91
nortriptyline hcl soln 10 mg/5ml.................................... 91
NORTUSS-EX -dextromethorphan-guaifenesin liquid
20-200 mg/5ml................................................................. 69
255
2014
NORVASC -amlodipine besylate tab 10 mg......................50
NORVASC -amlodipine besylate tab 2.5 mg..................... 50
NORVASC -amlodipine besylate tab 5 mg........................50
NORVIR -ritonavir cap 100 mg......................................... 12
NORVIR -ritonavir oral soln 80 mg/ml............................... 12
NORVIR -ritonavir tab 100 mg.......................................... 12
NOTUSS-NX -codeine-chlorcyclizine liquid 10-9.375
mg/5ml..............................................................................69
NOTUSS-NXD -codeine-pseudoephedrine-chlorcyclizine
liq 10-30-9.375mg/5ml..................................................... 69
NOVACORT - hydrocortisone ace-pramoxine-aloe
polysacch gel 2-1-1% ................................................... 171
NOVAFERRUM -polysacch iron complex-vit c-fa for soln
100-60-1 mg/5ml............................................................147
NOVA MAX BLOOD GLUCOSE MO - blood glucose
NOVA MAX BLOOD GLUCOSE MO - blood glucose
NOVOLIN 70/30 -insulin isophane & regular (human) inj
100 unit/ml (70-30)...........................................................37
NOVOLIN 70/30 RELION -insulin isophane & regular
(human) inj 100 unit/ml (70-30)....................................... 37
NOVOLIN N -insulin isophane (human) inj 100 unit/ml......37
NOVOLIN N RELION -insulin isophane (human) inj 100
unit/ml...............................................................................37
NOVOLIN R -insulin regular (human) inj 100 unit/ml......... 37
NOVOLIN R RELION -insulin regular (human) inj 100 unit/
ml......................................................................................37
NOVOLOG FLEXPEN -insulin aspart soln pen-injector 100
unit/ml...............................................................................37
NOVOLOG -insulin aspart inj 100 unit/ml..........................37
NOVOLOG MIX 70/30 -insulin aspart prot & aspart
(human) inj 100 unit/ml (70-30)....................................... 37
NOVOLOG MIX 70/30 PREFILL -insulin aspart prot &
aspart sus pen-inj 100 unit/ml (70-30)............................. 37
NOVOLOG PENFILL -insulin aspart inj 100 unit/ml...........37
NOVOLOG PENFILL -insulin aspart soln cartridge 100
unit/ml...............................................................................37
NOVOSEVEN -coagulation factor viia (recomb) for inj 2.4
mg (2400 mcg)...............................................................152
NOVOSEVEN RT -coagulation factor viia (recomb) for inj 1
mg (1000 mcg)...............................................................152
mg (2000 mcg)...............................................................152
mg (5000 mcg)...............................................................152
mg (8000 mcg)...............................................................152
NOXAFIL -posaconazole susp 40 mg/ml.......................... 10
NOXAFIL -posaconazole tab delayed release 100 mg...... 10
NUCORT -hydrocortisone acetate lotion 2%................... 171
NUCYNTA ER -tapentadol hcl tab sr 12hr 100 mg..........111
256
NUCYNTA ER -tapentadol hcl tab sr 12hr 50 mg............111
NUCYNTA -tapentadol hcl tab 100 mg........................... 111
NUCYNTA -tapentadol hcl tab 50 mg............................. 111
NUCYNTA -tapentadol hcl tab 75 mg............................. 111
NUEDEXTA -dextromethorphan hbr-quinidine sulfate cap
20-10 mg........................................................................104
NULYTELY/FLAVOR PACKS -peg 3350-kcl-sod bicarbnacl for soln 420 gm........................................................76
NUMOISYN - artificial saliva - lozenge ...........................160
NUMOISYN - artificial saliva - solution ...........................160
NUOX -benzoyl peroxide-sulfur gel 6-3%........................171
NUTRESTORE -glutamine powd pack 5 gm................... 142
NUTRICAP - multiple vitamins w/ minerals tab .............. 133
NUTRIDOX - doxycycline monohyd cap 75 mg w/ omega
3-vit e cap kit ....................................................................7
NUTRI-TAB OB + DHA -prenat w/o a w/ fe bisglyc-fa tab
32-1 mg & omega cap pack.......................................... 133
NUTRI-TAB OB - prenatal vit w/o vit a w/ fe bisglycinate-fa
tab 32-1 mg .................................................................. 133
NUTRIVIT -b-complex w/ lysine-min-fe & fa liqd 800-15-1
mg/15ml..........................................................................133
NUTROPIN AQ NUSPIN 10 -somatropin inj 10
mg/2ml..............................................................................43
NUTROPIN AQ NUSPIN 20 -somatropin inj 20
mg/2ml..............................................................................43
NUTROPIN AQ NUSPIN 5 -somatropin inj 5 mg/2ml........ 43
NUTROPIN AQ PEN -somatropin inj 10 mg/2ml............... 43
NUTROPIN AQ PEN -somatropin inj 20 mg/2ml............... 43
NUTROPIN AQ -somatropin inj 10 mg/2ml....................... 43
NUTROPIN -somatropin for inj 10 mg...............................43
NUVAIL - dermatological products misc - solution ..........171
NUVARING -etonogestrel-ethinyl estradiol va ring
0.120-0.015 mg/24hr........................................................31
NUVIGIL -armodafinil tab 150 mg................................... 101
NUVIGIL -armodafinil tab 50 mg..................................... 101
NUZON -hydrocortisone acetate-aloe vera gel 2%..........171
NYMALIZE -nimodipine oral soln 60 mg/20ml...................50
nystatin cream 100000 unit/gm.................................... 171
nystatin oint 100000 unit/gm........................................ 171
nystatin oral powder ........................................................ 9
nystatin susp 100000 unit/ml........................................160
nystatin tab 500000 unit..................................................10
nystatin topical powder ............................................... 161
nystatin-triamcinolone cream 100000-0.1 unit/gm%.................................................................................... 171
nystatin-triamcinolone oint 100000-0.1 unit/gm-%..... 171
NYSTATIN VAGINAL -nystatin vaginal tab 100000
unit....................................................................................85
O
OB COMPLETE/DHA - prenat w/ iron cbn-fe asp glyc-faomega cap 30-10-1-200 mg ......................................... 134
OB COMPLETE 400 - prenatal w/o a w/fecbn-fe asp glycfa-fish cap 40-10-1 mg ................................................. 134
2014
OB COMPLETE ONE - prenatal w/o a w/fecbn-fe asp glycfa-fish cap 50-1-476 mg ............................................... 133
OB COMPLETE PETITE - prenat w/o a w/fecbn-feaspglycfa-omega cap 35-5-1-200 mg ....................................... 133
OB COMPLETE PREMIER - prenatal vit w/ fe cbn-fe asp
glyc-fa tab 30-20-1 mg ................................................. 134
OB COMPLETE - prenatal vit w/ iron carbonyl-fa tab
50-1.25 mg ................................................................... 133
OB COMPLETE - prenatal w/o a w/fecbn-feaspglyc-fa-dha
chew 15-5-1-100 mg .....................................................133
OB-NATAL ONE - prenatal vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg ................................................... 134
OBSTETRIX DHA -prenat w/fecbn-fa-dss tab 29-1 mg &
omega 3 cap 387 mg pak..............................................134
OBSTETRIX EC - prenatal vit w/ dss-iron carbonyl-fa tab
29-1 mg ........................................................................ 134
O-CAL FA - prenatal vit w/ fe fumarate-fa tab 27-1 mg
....................................................................................... 133
O-CAL PRENATAL - prenatal vit w/ fe fumarate-fa tab
15-1 mg ........................................................................ 133
OCTAGAM -immune globulin (human) iv soln 10
gm/200ml..........................................................................20
gm/20ml............................................................................20
OCTAGAM -immune globulin (human) iv soln 2.5
gm/50ml............................................................................20
gm/500ml..........................................................................20
gm/100ml..........................................................................20
octreotide acetate inj 1000 mcg/ml (1 mg/ml)
(Sandostatin).................................................................. 43
octreotide acetate inj 100 mcg/ml (0.1 mg/ml)
(Sandostatin).................................................................. 43
(Sandostatin).................................................................. 43
(Sandostatin).................................................................. 43
(Sandostatin).................................................................. 43
OCUDOX -doxycycline hyclate cap 50 mg & eyelid cleans
& spray kit..........................................................................7
OCUFEN -flurbiprofen sodium ophth soln 0.03%............ 156
OCUFLOX -ofloxacin ophth soln 0.3%............................ 156
OFLOXACIN -ofloxacin tab 400 mg.................................... 8
ofloxacin ophth soln 0.3% (Ocuflox)........................... 156
ofloxacin otic soln 0.3%................................................158
ofloxacin tab 200 mg.........................................................8
ofloxacin tab 300 mg.........................................................8
ofloxacin tab 400 mg.........................................................8
OGESTREL -norgestrel & ethinyl estradiol tab 0.5 mg-50
mcg...................................................................................31
olanzapine-fluoxetine hcl cap 12-25 mg
(Symbyax)..................................................................... 104
olanzapine-fluoxetine hcl cap 12-50 mg
(Symbyax)..................................................................... 104
olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax)..... 104
olanzapine for im inj 10 mg (Zyprexa)........................... 95
olanzapine orally disintegrating tab 10 mg (Zyprexa
zydis)............................................................................... 95
zydis)............................................................................... 95
zydis)............................................................................... 95
zydis)............................................................................... 95
olanzapine tab 10 mg (Zyprexa).....................................95
olanzapine tab 2.5 mg (Zyprexa)....................................95
olanzapine tab 5 mg (Zyprexa).......................................95
olanzapine tab 7.5 mg (Zyprexa)....................................95
OLEPTRO -trazodone hcl tab sr 24hr 150 mg.................. 91
OLEPTRO -trazodone hcl tab sr 24hr 300 mg.................. 91
OLUX -clobetasol propionate foam 0.05%...................... 171
OLUX-E -clobetasol propionate emulsion foam
0.05%............................................................................. 171
OLYSIO -simeprevir sodium cap 150 mg (base
equivalent)........................................................................12
OMECLAMOX-PAK -amoxicillin cap-clarithro tab w/
omepraz cap dr therapy pack.......................................... 78
omega-3-acid ethyl esters cap 1 gm (Lovaza).............. 63
OMEPRAZOLE + SYRSPEND SF - omeprazole susp 2
omeprazole cap delayed release 10 mg (Prilosec)....... 78
omeprazole-sodium bicarbonate cap 20-1100 mg
(Zegerid).......................................................................... 78
omeprazole-sodium bicarbonate cap 40-1100 mg
(Zegerid).......................................................................... 78
OMNARIS -ciclesonide nasal susp 50 mcg/act................. 67
OMNIFLEX DIAPHRAGM - diaphragms ........................ 185
OMNI GEL -stannous fluoride gel 0.4%.......................... 160
OMNIPRED -prednisolone acetate ophth susp 1%......... 156
OMNITROPE -somatropin for inj 5.8 mg........................... 43
OMNITROPE -somatropin inj 10 mg/1.5ml........................43
OMNITROPE -somatropin inj 5 mg/1.5ml......................... 43
ON CALL EXPRESS BLOOD GLU - blood glucose
ON CALL EXPRESS BLOOD GLU - blood glucose
ON CALL PLUS BLOOD GLUCOS - blood glucose
ON CALL PLUS BLOOD GLUCOS - blood glucose
257
2014
ON CALL VIVID BLOOD GLUCO - blood glucose
ON CALL VIVID BLOOD GLUCO - blood glucose
ON CALL VIVID PAL BLOOD G - blood glucose
ON CALL VIVID PAL BLOOD G - blood glucose
ondansetron hcl inj 40 mg/20ml (2 mg/ml) (Zofran)......80
ondansetron hcl inj 4 mg/2ml (2 mg/ml)........................80
ondansetron hcl oral soln 4 mg/5ml (Zofran)................80
ondansetron hcl tab 24 mg............................................ 80
ondansetron hcl tab 4 mg (Zofran)................................ 80
ondansetron hcl tab 8 mg.............................................. 80
ondansetron hcl tab 8 mg (Zofran)................................ 80
ondansetron orally disintegrating tab 4 mg (Zofran
odt)...................................................................................80
ondansetron orally disintegrating tab 8 mg (Zofran
odt)...................................................................................80
ONETOUCH BASIC SYSTEM - blood glucose monitoring
kit w/ device ..................................................................185
ONETOUCH PING METER REMOT - blood glucose
monitoring supplies .......................................................185
ONETOUCH PROFILE SYSTEM - blood glucose
ONETOUCH ULTRA 2 - blood glucose monitoring kit w/
device ............................................................................185
ONETOUCH ULTRALINK SYSTEM - blood glucose
ONETOUCH ULTRA MINI - blood glucose monitoring kit
w/ device .......................................................................185
ONETOUCH ULTRASMART - blood glucose monitoring kit
w/ device .......................................................................186
ONETOUCH ULTRA SYSTEM KIT - blood glucose
ONETOUCH VERIO IQ BLOOD G - blood glucose
ONETOUCH VERIO SYNC BLOOD - blood glucose
ONFI -clobazam suspension 2.5 mg/ml.......................... 123
ONFI -clobazam tab 10 mg............................................. 123
ONFI -clobazam tab 20 mg............................................. 123
ONFI -clobazam tab 5 mg............................................... 123
ONGLYZA -saxagliptin hcl tab 2.5 mg (base equiv).......... 35
ONGLYZA -saxagliptin hcl tab 5 mg (base equiv)............. 35
ONMEL -itraconazole tab 200 mg..................................... 10
ONSOLIS -fentanyl citrate buccal soluble film 1200
mcg.................................................................................112
mcg.................................................................................111
mcg.................................................................................112
mcg.................................................................................112
258
mcg.................................................................................112
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 10 mg.......................................................112
er 12hr deter 15 mg.......................................................112
er 12hr deter 20 mg.......................................................112
er 12hr deter 30 mg.......................................................112
er 12hr deter 40 mg.......................................................112
er 12hr deter 5 mg.........................................................112
er 12hr deter 7.5 mg......................................................112
OPANA ER -oxymorphone hcl tab sr 12hr 10 mg........... 112
OPANA ER -oxymorphone hcl tab sr 12hr 5 mg............. 112
OPANA -oxymorphone hcl tab 10 mg............................. 112
OPANA -oxymorphone hcl tab 5 mg............................... 112
ophthalmic irrigation solution - intraocular (Bss
plus)...............................................................................153
OPIUM TINCTURE (PAREGORIC -paregoric 2
mg/5ml..............................................................................76
opium tincture 1% (10 mg/ml) (morphine equiv)...........76
OPSUMIT -macitentan tab 10 mg..................................... 65
OPTASE -trypsin w/ castor oil & peruvian balsam gel..... 171
OPTIONS CONCEPTROL VAGINA -nonoxynol-9 gel
4%.................................................................................... 85
OPTIONS GYNOL II VAGINAL -nonoxynol-9 gel 3%........85
OPTIPRANOLOL -metipranolol ophth soln 0.3%............ 156
OPTIUM BLOOD GLUCOSE MONI - blood glucose
OPTIUM BLOOD GLUCOSE MONI - blood glucose
OPTIVAR -azelastine hcl ophth soln 0.05%.................... 156
OPTUMRX BLOOD GLUCOSE MET - blood glucose
OPTUMRX BLOOD GLUCOSE MON - blood glucose
ORACEA -doxycycline (rosacea) cap delayed release 40
mg.................................................................................. 171
ORACIT -sodium citrate & citric acid soln 490-640
mg/5ml..............................................................................86
ORAFATE - sucralfate-malate paste 10% ......................160
ORALAIR - grass mixed pollen ext tab sl 300 ir (index of
reactivity) .........................................................................20
ORAMAGICRX - oral wound care products - for susp rinse
....................................................................................... 160
ORAMORPH SR -morphine sulfate tab cr 100 mg.......... 112
ORAMORPH SR -morphine sulfate tab cr 15 mg............112
2014
ORAP -pimozide tab 1 mg.............................................. 104
ORAP -pimozide tab 2 mg.............................................. 104
ORAPRED ODT -prednisolone sod phos orally disintegr
tab 10 mg (base eq)........................................................ 25
tab 15 mg (base eq)........................................................ 25
tab 30 mg (base eq)........................................................ 25
ORAPRED -prednisolone sod phosphate oral soln 15
mg/5ml (base equiv)........................................................ 25
ORAVIG -miconazole buccal tab 50 mg (mouththroat)............................................................................. 160
ORAXYL -doxycycline hyclate cap 20 mg........................... 7
ORBIVAN -butalbital-acetaminophen-caffeine cap
50-300-40 mg.................................................................106
ORBIVAN CF -butalbital-acetaminophen tab 50-300
mg.................................................................................. 106
ORENCIA -abatacept subcutaneous inj 125 mg/ml.........117
ORENITRAM -treprostinil diolamine tab cr 0.125 mg (base
equiv)................................................................................65
equiv)................................................................................65
ORENITRAM -treprostinil diolamine tab cr 1 mg (base
equiv)................................................................................65
equiv)................................................................................65
ORFADIN -nitisinone cap 10 mg....................................... 43
ORFADIN -nitisinone cap 2 mg......................................... 43
ORFADIN -nitisinone cap 5 mg......................................... 43
orphenadrine citrate inj 30 mg/ml (Norflex)................ 128
orphenadrine citrate tab sr 12hr 100 mg..................... 128
ORPHENADRINE COMPOUND DS -orphenadrine w/
aspirin & caffeine tab 50-770-60 mg..............................128
orphenadrine w/ aspirin & caffeine tab 25-385-30
mg.................................................................................. 128
ORTHO-CEPT -desogestrel & ethinyl estradiol tab 0.15
mg-30 mcg....................................................................... 31
ORTHO-CYCLEN -norgestimate & ethinyl estradiol tab
0.25 mg-35 mcg...............................................................31
ORTHO DIAPHRAGM ALL-FLEX/ -diaphragm arc-spring
65 mm............................................................................ 186
70 mm............................................................................ 186
75 mm............................................................................ 186
80 mm............................................................................ 186
ORTHO DIAPHRAGM COIL SPRI -diaphragm coil spring
kit 100 mm..................................................................... 186
kit 105 mm..................................................................... 186
kit 50 mm....................................................................... 186
ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring
kit 55 mm....................................................................... 186
kit 60 mm....................................................................... 186
kit 65 mm....................................................................... 186
kit 70 mm....................................................................... 186
kit 75 mm....................................................................... 186
kit 80 mm....................................................................... 186
kit 85 mm....................................................................... 186
kit 90 mm....................................................................... 186
kit 95 mm....................................................................... 186
ORTHO EVRA -norelgestromin-ethinyl estradiol td ptwk
150-35 mcg/24hr..............................................................31
ORTHO MICRONOR -norethindrone tab 0.35 mg.............31
ORTHO-NOVUM 1/35 -norethindrone & ethinyl estradiol
tab 1 mg-35 mcg............................................................. 31
ORTHO-NOVUM 7/7/7 -norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg............................................31
ORTHO TRI-CYCLEN LO -norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg...................................31
ORTHO TRI-CYCLEN -norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg...................................31
OSENI -alogliptin-pioglitazone tab 12.5-15 mg..................36
OSENI -alogliptin-pioglitazone tab 25-15 mg.....................36
OSMOPREP -sod phos mono-sod phos di tabs
1.102-0.398 gm(1.5gm na phos)..................................... 76
OSPHENA -ospemifene tab 60 mg................................... 43
OTEZLA -apremilast tab 30 mg.......................................117
OTEZLA -apremilast tab starter therapy pack 10 mg & 20
mg & 30 mg................................................................... 117
OTICIN HC NR -pramoxine-hc-chloroxylenol otic soln
10-10-1 mg/ml................................................................158
OTOZIN -antipyrine-benzocaine-glycerin-zinc ace otic liqd
5.4-1-2-1%......................................................................158
OTREXUP -methotrexate soln pf auto-injector
10mg/0.4ml.....................................................................117
15mg/0.4ml.....................................................................117
20mg/0.4ml.....................................................................117
25mg/0.4ml.....................................................................117
OVACE PLUS -sulfacetamide sodium cream 10%..........171
OVACE PLUS -sulfacetamide sodium lotion 9.8%.......... 171
259
2014
OVACE PLUS -sulfacetamide sodium shampoo 10%..... 171
OVACE PLUS WASH -sulfacetamide sodium cleansing gel
10%................................................................................ 171
OVACE PLUS WASH -sulfacetamide sodium liquid
10%................................................................................ 171
OVACE WASH -sulfacetamide sodium liquid 10%.......... 171
OVCON-35 -norethindrone & ethinyl estradiol tab 0.4
mg-35 mcg....................................................................... 31
OVCON-50 28 -norethindrone & ethinyl estradiol tab 1
mg-50 mcg....................................................................... 31
OVIDE -malathion lotion 0.5%.........................................171
OVIDREL -choriogonadotropin alfa inj 250 mcg/0.5ml...... 43
oxacillin sodium for inj 10 gm......................................... 2
oxacillin sodium for inj 1 gm........................................... 2
oxacillin sodium for inj 2 gm........................................... 2
OXANDRIN -oxandrolone tab 10 mg.................................27
OXANDRIN -oxandrolone tab 2.5 mg................................27
oxandrolone tab 10 mg (Oxandrin)................................ 27
oxandrolone tab 2.5 mg (Oxandrin)............................... 27
oxaprozin tab 600 mg (Daypro)....................................117
oxazepam cap 10 mg...................................................... 88
oxazepam cap 15 mg...................................................... 88
oxazepam cap 30 mg...................................................... 88
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
(Trileptal)....................................................................... 123
oxcarbazepine tab 150 mg (Trileptal).......................... 123
OXECTA -oxycodone hcl tab abuse deter 5 mg..............112
OXECTA -oxycodone hcl tab abuse deter 7.5 mg........... 112
OXISTAT -oxiconazole nitrate cream 1%........................ 171
OXISTAT -oxiconazole nitrate lotion 1%......................... 171
OXSORALEN -methoxsalen lotion 1%............................ 171
OXSORALEN ULTRA -methoxsalen rapid cap 10 mg.....171
OXTELLAR XR -oxcarbazepine tab sr 24hr 150 mg....... 123
oxybutynin chloride syrup 5 mg/5ml............................. 84
oxybutynin chloride tab 5 mg........................................ 84
oxybutynin chloride tab sr 24hr 10 mg (Ditropan
xl)..................................................................................... 84
oxybutynin chloride tab sr 24hr 15 mg (Ditropan
xl)..................................................................................... 84
oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)...... 84
oxycodone-aspirin tab 4.8355-325 mg (Percodan)..... 113
oxycodone hcl cap 5 mg.............................................. 112
oxycodone hcl conc 100 mg/5ml (20 mg/ml)
(Oxycodone hcl)........................................................... 112
OXYCODONE HCL -oxycodone hcl conc 100 mg/5ml (20
mg/ml)............................................................................ 112
OXYCODONE HCL -oxycodone hcl soln 5 mg/5ml.........112
oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)..........112
oxycodone hcl tab 10 mg............................................. 112
oxycodone hcl tab 15 mg (Roxicodone)......................112
oxycodone hcl tab 20 mg............................................. 112
260
oxycodone hcl tab 30 mg (Roxicodone)......................112
oxycodone hcl tab 5 mg (Roxicodone)........................112
oxycodone-ibuprofen tab 5-400 mg............................. 113
oxycodone w/ acetaminophen cap 5-500 mg.............. 112
oxycodone w/ acetaminophen tab 10-325 mg
(Percocet)......................................................................112
oxycodone w/ acetaminophen tab 10-650 mg.............112
oxycodone w/ acetaminophen tab 2.5-325 mg
(Percocet)......................................................................112
oxycodone w/ acetaminophen tab 5-325 mg
(Percocet)......................................................................112
oxycodone w/ acetaminophen tab 7.5-325 mg
(Percocet)......................................................................112
oxycodone w/ acetaminophen tab 7.5-500 mg............113
OXYCONTIN -oxycodone hcl tab er 12hr deter 10
mg.................................................................................. 113
mg.................................................................................. 113
mg.................................................................................. 113
mg.................................................................................. 113
mg.................................................................................. 113
mg.................................................................................. 113
mg.................................................................................. 113
oxymorphone hcl tab 10 mg (Opana).......................... 113
oxymorphone hcl tab 5 mg (Opana)............................ 113
oxymorphone hcl tab sr 12hr 10 mg............................113
oxymorphone hcl tab sr 12hr 5 mg............................. 113
oxymorphone hcl tab sr 12hr 7.5 mg...........................113
OXYTROL -oxybutynin td patch biweekly 3.9 mg/24hr......84
P
PACERONE -amiodarone hcl tab 400 mg.........................51
PAIRE OB -prenat w/ fe poly cmplx-fe asp-fe gly-fa tab &
dha cap pak................................................................... 134
PALGIC -carbinoxamine maleate soln 4 mg/5ml...............66
PALGIC -carbinoxamine maleate tab 4 mg....................... 66
PAMELOR -nortriptyline hcl cap 10 mg.............................91
pamidronate disodium for inj 30 mg............................. 43
pamidronate disodium for inj 90 mg............................. 43
pamidronate disodium iv soln 3 mg/ml......................... 43
pamidronate disodium iv soln 9 mg/ml......................... 43
PAMIDRONATE DISODIUM -pamidronate disodium iv
soln 6 mg/ml.................................................................... 43
PAMINE FORTE -methscopolamine bromide tab 5 mg.....78
2014
PAMINE FQ -methscopolamine tab 5 mg & misc intestinal
flora reg cap.....................................................................78
PAMINE -methscopolamine bromide tab 2.5 mg...............78
PANATUSS DXP -phenylephrine-dexbromphen-dm-gg
liquid 5-1-15-100 mg/5ml................................................. 70
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
10500-25000-43750 unit.................................................. 81
16800-40000-70000 unit.................................................. 81
21000-37000-61000 unit.................................................. 81
4200-10000-17500 unit.................................................... 81
PANCRELIPASE -pancrelipase (lip-prot-amyl) dr cap
5000-17000-27000 unit.................................................... 81
PANDEL -hydrocortisone probutate cream 0.1%............ 171
PANRETIN -alitretinoin gel 0.1%.....................................171
pantoprazole sodium ec tab 20 mg (base equiv)
(Protonix)........................................................................ 79
pantoprazole sodium ec tab 40 mg (base equiv)
(Protonix)........................................................................ 79
PARADIGM LINK BLOOD GLUCO - blood glucose
PARAFON FORTE DSC -chlorzoxazone tab 500 mg......128
PARCOPA -carbidopa & levodopa orally disintegrating tab
10-100 mg......................................................................126
25-100 mg......................................................................126
25-250 mg......................................................................126
paricalcitol cap 1 mcg (Zemplar)................................... 43
PARLODEL -bromocriptine mesylate cap 5 mg.............. 126
PARLODEL -bromocriptine mesylate tab 2.5 mg............ 126
PARNATE -tranylcypromine sulfate tab 10 mg..................91
paromomycin sulfate cap 250 mg....................................9
paroxetine hcl tab 10 mg (Paxil).................................... 91
paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)................ 91
paroxetine hcl tab sr 24hr 25 mg (Paxil cr)................... 91
paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)................ 91
PASER -aminosalicylic acid cr granules packet 4 gm......... 9
PATADAY -olopatadine hcl ophth soln 0.2%...................156
PATANASE -olopatadine hcl nasal soln 0.6%...................67
PATANOL -olopatadine hcl ophth soln 0.1%...................156
PAXIL CR -paroxetine hcl tab sr 24hr 12.5 mg................. 91
PAXIL CR -paroxetine hcl tab sr 24hr 25 mg.................... 91
PAXIL CR -paroxetine hcl tab sr 24hr 37.5 mg................. 91
PAXIL -paroxetine hcl oral susp 10 mg/5ml (base
equiv)................................................................................91
PAXIL -paroxetine hcl tab 10 mg...................................... 91
PBZ -tripelennamine hcl tab 50 mg................................... 66
PCE -erythromycin w/ enteric coated particles tab 333
mg...................................................................................... 6
PCE -erythromycin w/ enteric coated particles tab 500
mg...................................................................................... 6
PEDIADERM AF COMPLETE KIT -nystatin cream 100000
unit/gm & diaper rash cream kit.....................................171
PEDIADERM HC -hydrocortisone lot 2% & emollient
cream kit........................................................................ 171
PEDIADERM TA -triamcinolone cream 0.1% & emollient
cream kit........................................................................ 171
PEDIAPRED -prednisolone sod phosph oral soln 6.7
mg/5ml (5 mg/5ml base)..................................................25
PEDIATEX TDM -pseudoephed-triprolidine-dm susp
10-0.938-4 mg/ml.............................................................70
PEDIATEX TD -triprolidine & pseudoephedrine liquid
0.938-10 mg/ml................................................................ 70
pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ml
....................................................................................... 130
pediatric multiple vitamins w/ fluoride chew tab 0.25
mg .................................................................................130
pediatric multiple vitamins w/ fluoride chew tab 0.5 mg
....................................................................................... 130
pediatric multiple vitamins w/ fluoride chew tab 1 mg
....................................................................................... 130
pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml
....................................................................................... 130
pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml
....................................................................................... 130
pediatric multiple vitamin w/ minerals & c drops 45
mg/ml.............................................................................130
pediatric vitamins acd w/ fluoride soln 0.25 mg/ml
....................................................................................... 130
pediatric vitamins acd w/ fluoride soln 0.5 mg/ml ..... 130
PEDIPIROX-4 NAIL -ciclopirox soln 8% & lacquer removal
pads & foot powd kit......................................................171
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm
(Golytely).........................................................................76
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm
(Colyte-flavor packs)......................................................76
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
(Nulytely/flavor pack).....................................................76
PEGANONE -ethotoin tab 250 mg.................................. 123
PEGASYS -peginterferon alfa-2a inj 180 mcg/0.5ml......... 12
PEGASYS -peginterferon alfa-2a inj 180 mcg/ml.............. 12
PEGASYS -peginterferon alfa-2a inj kit 180 mcg/0.5ml.....12
PEGASYS PROCLICK -peginterferon alfa-2a inj 135
mcg/0.5ml.........................................................................12
PEGASYS PROCLICK -peginterferon alfa-2a inj 180
mcg/0.5ml.........................................................................12
PEG-INTRON -peginterferon alfa-2b for inj kit 120
mcg/0.5ml.........................................................................12
261
2014
mcg/0.5ml.........................................................................12
mcg/0.5ml.........................................................................12
mcg/0.5ml.........................................................................12
PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for
inj kit 120 mcg/0.5ml........................................................12
inj kit 150 mcg/0.5ml........................................................12
inj kit 50 mcg/0.5ml..........................................................12
inj kit 80 mcg/0.5ml..........................................................12
PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit
120 mcg/0.5ml................................................................. 12
150 mcg/0.5ml................................................................. 12
50 mcg/0.5ml................................................................... 12
80 mcg/0.5ml................................................................... 12
penicillin g potassium for inj 20000000 unit (Pfizerpeng)........................................................................................ 2
penicillin g potassium for inj 5000000 unit (Pfizerpeng)........................................................................................ 2
PENICILLIN G PROCAINE -penicillin g procaine
intramuscular susp 600000 unit/ml.................................... 2
PENICILLIN G SODIUM -penicillin g sodium for inj
5000000 unit...................................................................... 2
penicillin v potassium for soln 125 mg/5ml.................... 2
penicillin v potassium for soln 250 mg/5ml.................... 2
penicillin v potassium tab 250 mg................................... 2
penicillin v potassium tab 500 mg................................... 2
PENLAC NAIL LACQUER -ciclopirox solution 8%.......... 171
PENNSAID -diclofenac sodium soln 1.5%.......................171
PENNSAID -diclofenac sodium soln 2%......................... 171
PENTAM 300 -pentamidine isethionate for soln 300
mg.................................................................................... 16
PENTASA -mesalamine cap cr 250 mg............................ 82
PENTASA -mesalamine cap cr 500 mg............................ 82
pentazocine-acetaminophen tab 25-650 mg................113
pentazocine w/ naloxone tab 50-0.5 mg...................... 113
PEN-TOTE - blood glucose monitoring supplies ............ 186
pentoxifylline tab cr 400 mg......................................... 152
PEPCID -famotidine for susp 40 mg/5ml...........................79
PEPCID -famotidine tab 20 mg......................................... 79
PEPCID -famotidine tab 40 mg......................................... 79
PERCOCET -oxycodone w/ acetaminophen tab 10-325
mg.................................................................................. 113
mg.................................................................................. 113
PERCOCET -oxycodone w/ acetaminophen tab 2.5-325
mg.................................................................................. 113
262
mg.................................................................................. 113
mg.................................................................................. 113
mg.................................................................................. 113
PERCODAN -oxycodone-aspirin tab 4.8355-325 mg...... 113
PERFOROMIST -formoterol fumarate soln nebu 20
mcg/2ml............................................................................74
PERIDEX -chlorhexidine gluconate soln 0.12%.............. 160
perindopril erbumine tab 2 mg.......................................57
perindopril erbumine tab 4 mg (Aceon)........................ 57
perindopril erbumine tab 8 mg (Aceon)........................ 57
permethrin cream 5% (Elimite).....................................171
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-10 mg............................................... 104
perphenazine tab 16 mg................................................. 95
perphenazine tab 2 mg................................................... 95
PERSANTINE -dipyridamole tab 25 mg.......................... 152
PERTZYE -pancrelipase (lip-prot-amyl) dr cap
16000-57500-60500 unit.................................................. 81
PERTZYE -pancrelipase (lip-prot-amyl) dr cap
8000-28750-30250 unit.................................................... 81
PEXEVA -paroxetine mesylate tab 10 mg (base equiv).....91
PFIZERPEN-G -penicillin g potassium for inj 20000000
unit......................................................................................2
PFIZERPEN-G -penicillin g potassium for inj 5000000
unit......................................................................................2
PHARMACIST CHOICE AUTOCOD - blood glucose
phenazopyridine-butabarbital-hyoscyamine tab
150-15-0.3 mg................................................................. 84
phenazopyridine hcl tab 100 mg (Pyridium)................. 86
phenazopyridine hcl tab 200 mg (Pyridium)................. 86
phenelzine sulfate tab 15 mg (Nardil)............................ 91
PHENERGAN -promethazine hcl inj 25 mg/ml.................. 66
PHENERGAN -promethazine hcl inj 50 mg/ml.................. 66
PHENFLU CD -phenylephrine-codeine-guaifenesin-apap
tab 10-10-400-500 mg..................................................... 70
2014
PHENFLU CDX -phenylephrine-codeine-guaifenesin-apap
tab 10-20-400-500 mg..................................................... 70
phenobarbital elixir 20 mg/5ml.......................................98
PHENOBARBITAL -phenobarbital tab 100 mg..................98
PHENOBARBITAL -phenobarbital tab 15 mg....................97
PHENOBARBITAL -phenobarbital tab 64.8 mg.................98
PHENOBARBITAL -phenobarbital tab 97.2 mg.................98
phenobarbital tab 100 mg...............................................98
phenobarbital tab 15 mg.................................................98
phenobarbital tab 16.2 mg..............................................98
phenobarbital tab 32.4 mg..............................................98
PHENTOLAMINE MESYLATE -phentolamine mesylate for
inj 5 mg............................................................................ 57
PHENTOLAMINE MESYLATE -phentolamine mesylate inj
5 mg/ml............................................................................ 57
phenylephrine-brompheniramine-dm liquid 7.5-4-15
mg/5ml.............................................................................70
phenylephrine-chlorphen-dm liquid 1.5-1-3 mg/ml.......70
phenylephrine-guaifenesin liqd 7.5-100 mg/5ml (1.5-20
mg/ml)..............................................................................70
phenylephrine hcl ophth soln 10%.............................. 156
phenylephrine hcl ophth soln 2.5% (Mydfrin)............. 156
phenylephrine-promethazine w/ codeine syrup
5-6.25-10 mg/5ml............................................................ 70
phenylephrine w/ dm-gg liqd 10-15-300 mg/5ml........... 70
phenylephrine w/ dm-gg liqd 10-30-200 mg/5ml........... 70
phenylephrine w/ dm-gg liqd 2.5-5-50 mg/ml................ 70
phenylephrine w/ dm-gg liqd 2.5-7.5-88 mg/ml............. 70
PHENYLHISTINE DH -pseudoephedrine-chlorphen w/
codeine liq 30-2-10 mg/5ml............................................. 70
phenyltoloxamine-acetaminophen tab 30-500 mg...... 106
PHENYTEK -phenytoin sodium extended cap 200
mg.................................................................................. 123
PHENYTEK -phenytoin sodium extended cap 300
mg.................................................................................. 123
phenytoin chew tab 50 mg (Dilantin infatabs)............ 123
phenytoin sodium extended cap 100 mg
(Dilantin)........................................................................123
(Phenytek)..................................................................... 123
(Phenytek)..................................................................... 123
phenytoin sodium inj 50 mg/ml....................................123
phenytoin susp 125 mg/5ml (Dilantin)......................... 123
PHISOHEX -hexachlorophene liq 3%..............................178
PHOS-FLUR ORTHO DEFENSE -sodium fluoride rinse
0.044%........................................................................... 160
PHOS FLUR -sodium fluoride rinse 0.044%....................160
PHOSLO -calcium acetate (phosphate binder) cap 667 mg
(169 mg ca)..................................................................... 82
PHOSLYRA -calcium acetate (phosphate binder) oral soln
667 mg/5ml...................................................................... 82
PHOSPHOLINE IODIDE -echothiophate iodide ophth for
soln 0.125%................................................................... 156
PHRENILIN FORTE -butalbital-acetaminophen cap 50-650
mg.................................................................................. 106
phytonadione inj 1 mg/0.5ml (2 mg/ml)....................... 129
PICATO -ingenol mebutate gel 0.015%.......................... 171
PICATO -ingenol mebutate gel 0.05%............................ 171
pilocarpine hcl ophth soln 1% (Isopto carpine).......... 156
pilocarpine hcl tab 5 mg (Salagen).............................. 160
pilocarpine hcl tab 7.5 mg (Salagen)........................... 160
PILOPINE HS -pilocarpine hcl ophth gel 4%...................156
pindolol tab 10 mg.......................................................... 47
pindolol tab 5 mg............................................................ 47
PINNACAINE OTIC -benzocaine otic soln 20%.............. 158
pioglitazone hcl-glimepiride tab 30-2 mg (Duetact)...... 36
pioglitazone hcl-glimepiride tab 30-4 mg (Duetact)...... 36
pioglitazone hcl-metformin hcl tab 15-500 mg
(Actoplus met)................................................................36
pioglitazone hcl-metformin hcl tab 15-850 mg
(Actoplus met)................................................................36
pioglitazone hcl tab 15 mg (base equiv) (Actos)...........36
piperacillin sodium-tazobactam sodium for inj 2-0.25
gm (Zosyn)........................................................................2
gm (Zosyn)........................................................................2
gm (Zosyn)........................................................................2
gm (Zosyn)........................................................................2
piroxicam cap 10 mg (Feldene)....................................117
piroxicam cap 20 mg (Feldene)....................................117
PKU EASY MICROTABS - nutritional supplement tabs
delayed release ............................................................ 143
PLAN B -levonorgestrel tab 0.75 mg.................................31
PLAN B ONE-STEP -levonorgestrel tab 1.5 mg................31
PLAQUENIL -hydroxychloroquine sulfate tab 200 mg....... 14
PLAVIX -clopidogrel bisulfate tab 300 mg (base
equiv)..............................................................................152
PLAVIX -clopidogrel bisulfate tab 75 mg (base equiv).....152
PLETAL -cilostazol tab 100 mg....................................... 152
PLETAL -cilostazol tab 50 mg......................................... 152
PLEXION CLEANSER -sulfacetamide sodium w/ sulfur
cleanser 9.8-4.8%.......................................................... 171
PLEXION CLEANSING CLOTHS -sulfacetamide sodium
w/ sulfur cleansing cloth 9.8-4.8%................................. 171
PLEXION -sulfacetamide sodium w/ sulfur cream
9.8-4.8%......................................................................... 171
263
2014
PLEXION -sulfacetamide sodium w/ sulfur lotion
9.8-4.8%......................................................................... 171
PLIAGLIS -lidocaine-tetracaine cream 7-7%................... 171
PNEUMOVAX 23/1 DOSE -pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml............................................. 18
PNEUMOVAX 23/5 DOSE -pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml............................................. 18
PNEUMOVAX 23 -pneumococcal vaccine polyvalent inj 25
mcg/0.5ml.........................................................................18
PNV-DHA+DOCUSATE - prenatal w/o vit a w/ fe fum-dssfa-dha cap 27-1.25-300 mg .......................................... 134
PNV-DHA - prenat w/o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg ........................................................ 134
PNV FERROUS FUMARATE/DOCU - prenatal vit w/ dssfe fumarate-fa tab 29-1 mg ...........................................134
PNV-FIRST - prenatal mv w/ fe polysac cmplx-fa-dha cap
29-1-200 mg ................................................................. 134
PNV FOLIC ACID + IRON MUL - prenatal vit w/ fe
PNV-OB/DHA -prenatal mv w/fe fum-fa tab 65-1 mg & dha
cap 250 mg pack ..........................................................134
PNV OB+DHA -prenat w/o a w/fecbn-fegl-dss-fa tab & dha
cap 250 mg pack........................................................... 134
PNV-OMEGA - prenat w/o a w/ fe fumerate-methylfolatefa-omega 3 cap ............................................................ 134
PNV PRENATAL PLUS MULTIVI - prenatal vit w/ fe
PNV-SELECT - prenatal vit w/ fe fum-methylfolate-fa tab
27-0.6-0.4 mg ............................................................... 134
PNV TABS 29-1 - prenatal vit w/ iron carbonyl-fa tab 29-1
mg ................................................................................. 134
PNV-TOTAL - prenat w/ fe cbn-fe bisglyc-fa-fish oil cap
35-5-1.2 mg .................................................................. 134
POCKETCHEM EZ BLOOD GLUCO - blood glucose
PODIAPN - l-methylfolate-b12-b6-alpha lipoic ac cap
5-2-35-300 mg .............................................................. 143
PODOCON 25 IN BENZOIN TIN -podophyllum resin soln
25%................................................................................ 172
podofilox soln 0.5% (Condylox)................................... 172
polyethylene glycol 3350 oral packet............................ 76
polyethylene glycol 3350 oral powder...........................76
POLY HIST DHC -phenylephrine-pyrilamine-dihydrocod
liqd 5-7.5-7.5 mg/5ml....................................................... 70
POLY HIST NC -pseudoephedrine-triprolidine w/ cod liquid
15-1.25-10 mg/5ml...........................................................70
polymyxin b sulfate for inj 500000 unit......................... 16
polymyxin b-trimethoprim ophth soln 10000 unit/
ml-0.1% (Polytrim)........................................................156
POLYTRIM -polymyxin b-trimethoprim ophth soln 10000
unit/ml-0.1%................................................................... 156
POLY-TUSSIN AC -phenylephrine-bromphen w/ codeine
liqd 7.5-4-10 mg/5ml........................................................ 70
POLY-TUSSIN AC -phenylephrine-bromphen w/ codeine
liquid 10-4-10 mg/5ml...................................................... 70
264
POLY-TUSSIN -codeine-chlorcyclizine liquid 10-9.375
mg/5ml..............................................................................70
POLY-TUSSIN D -codeine-pseudoephedrinechlorcyclizine liq 10-30-9.375mg/5ml............................... 70
POLY-TUSSIN DHC -phenylephrine-bromphendihydrocodeine liqd 7.5-4-3 mg/5ml.................................70
POLY-TUSSIN EX -phenylephrine-dihydrocodeine-gg
syrup 5-7.5-50 mg/5ml.....................................................70
POLY-VI-FLOR/IRON - ped multiple vitamin w/ fl-fe
biphasic susp 0.25-7 mg/ml ..........................................134
POLY-VI-FLOR/IRON - ped multiple vit w/ fl-fe biphasic
chew tab 0.5-10 mg ......................................................134
POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic chew
tab 0.25 mg .................................................................. 134
tab 0.5 mg .................................................................... 134
tab 1 mg ....................................................................... 134
POLY-VI-FLOR - ped multiple vit w/ fluoride biphasic susp
0.25 mg/ml ....................................................................134
POMALYST -pomalidomide cap 1 mg...............................22
PONSTEL -mefenamic acid cap 250 mg.........................117
PONTOCAINE -tetracaine hcl soln 2%........................... 172
POTABA -potassium aminobenzoate cap 500 mg.......... 129
POTABA -potassium aminobenzoate tab 500 mg........... 129
potassium bicarbonate effer tab 25 meq.....................141
potassium chloride cap cr 10 meq (Micro-k)...............141
potassium chloride cap cr 8 meq (Micro-k).................141
POTASSIUM CHLORIDE ER -potassium chloride tab cr
20 meq (1500 mg)......................................................... 141
potassium chloride microencapsulated crys cr tab 10
meq................................................................................ 141
potassium chloride microencapsulated crys cr tab 20
meq................................................................................ 141
potassium chloride oral liq 10% (20 meq/15ml).......... 141
potassium chloride oral liq 20% (40 meq/15ml).......... 141
potassium chloride powder packet 20 meq................ 141
potassium chloride tab cr 10 meq (K-tab)................... 141
potassium chloride tab cr 8 meq (600 mg)..................141
potassium citrate & citric acid powder pack 3300-1002
mg.................................................................................... 86
potassium citrate tab cr 10 meq (1080 mg) (Urocit-k
10).................................................................................... 86
15).................................................................................... 86
5)...................................................................................... 86
POTASSIUM HYDROXIDE -potassium hydroxide solution
5%.................................................................................. 178
pot bicarbonate & chloride effer tab 25 meq...............141
POTIGA -ezogabine tab 200 mg..................................... 123
2014
POTIGA -ezogabine tab 50 mg....................................... 123
pot phos monobasic w/sod phos di & monobas tab
155-852-130mg (K-phos neutral)................................ 141
PRADAXA -dabigatran etexilate mesylate cap 150 mg
(etexilate base eq)......................................................... 149
PRADAXA -dabigatran etexilate mesylate cap 75 mg
(etexilate base eq)......................................................... 149
PRALIDOXIME CHLORIDE -pralidoxime chloride im inj
device 600 mg/2ml.........................................................178
pramipexole dihydrochloride tab 0.125 mg
(Mirapex)....................................................................... 126
(Mirapex)....................................................................... 126
(Mirapex)....................................................................... 126
(Mirapex)....................................................................... 126
(Mirapex)....................................................................... 126
pramipexole dihydrochloride tab 1 mg (Mirapex)....... 126
PRAMOSONE E -pramoxine-hc emollient base cream
1-2.5%............................................................................ 172
PRAMOSONE -pramoxine-hc cream 1-1%..................... 172
PRAMOSONE -pramoxine-hc cream 1-2.5%.................. 172
PRAMOSONE -pramoxine-hc lotion 1-1%...................... 172
PRAMOSONE -pramoxine-hc lotion 1-2.5%................... 172
PRAMOSONE -pramoxine-hc oint 1-1%......................... 172
PRAMOSONE -pramoxine-hc oint 1-2.5%...................... 172
PRAMOTIC -pramoxine-chloroxylenol otic liquid
1-0.1%............................................................................ 158
pramoxine-chloroxylenol otic liquid 1-0.1%
(Pramotic)......................................................................158
pramoxine-hc-chloroxylenol aqueous otic soln 10-10-1
mg/ml (Cortane-b aqueous)........................................ 158
pramoxine-hc-chloroxylenol otic soln 10-10-1 mg/ml
(Cortane-b-otic)............................................................ 158
pramoxine-hc cream 1-2.5% (Pramosone).................. 172
pramoxine hcl gel 1%....................................................172
PRANDIMET -repaglinide-metformin hcl tab 1-500 mg..... 36
PRANDIMET -repaglinide-metformin hcl tab 2-500 mg..... 36
PRANDIN -repaglinide tab 0.5 mg.................................... 36
PRANDIN -repaglinide tab 1 mg....................................... 36
PRANDIN -repaglinide tab 2 mg....................................... 36
PRAVACHOL -pravastatin sodium tab 20 mg................... 63
pravastatin sodium tab 10 mg........................................63
pravastatin sodium tab 20 mg (Pravachol)................... 63
prazosin hcl cap 1 mg (Minipress).................................57
PR CREAM - dermatological products misc - kit ............ 172
PRECISION LINK - blood glucose monitoring kit w/ device
....................................................................................... 186
PRECISION QID MONITOR - blood glucose monitoring
devices ..........................................................................186
PRECISION SOF-TACT MONITO - blood glucose
PRECISION XTRA - blood glucose monitoring devices
....................................................................................... 186
PRECISION XTRA - blood glucose monitoring kit ..........186
PRECISION XTRA MONITOR - blood glucose monitoring
devices ..........................................................................186
PRECOSE -acarbose tab 100 mg.....................................36
PRECOSE -acarbose tab 25 mg.......................................36
PRECOSE -acarbose tab 50 mg.......................................36
PRED FORTE -prednisolone acetate ophth susp 1%......156
PRED-G -gentamicin-prednisolone ace ophth susp
0.3-1%............................................................................ 156
PRED-G S.O.P. -gentamicin-prednisolone ace ophth oint
0.3-0.6%......................................................................... 156
PRED MILD -prednisolone acetate ophth susp
0.12%............................................................................. 156
prednicarbate cream 0.1% (Dermatop)........................ 172
prednicarbate oint 0.1% (Dermatop)............................ 172
prednisolone acetate ophth susp 1% (Pred forte)...... 157
PREDNISOLONE SODIUM PHOSP -prednisolone sodium
phosphate ophth soln 1%.............................................. 157
PREDNISOLONE SODIUM PHOSP -prednisolone sodium
phosphate oral soln 25 mg/5ml (base eq)....................... 25
prednisolone sod phosphate oral soln 15 mg/5ml
(base equiv).................................................................... 25
prednisolone sod phosph oral soln 6.7 mg/5ml (5
mg/5ml base) (Pediapred)............................................. 25
prednisolone syrup 15 mg/5ml (usp solution
equivalent) (Prelone)......................................................25
PREDNISONE INTENSOL -prednisone conc 5 mg/ml...... 26
PREDNISONE -prednisone oral soln 5 mg/5ml.................25
PREDNISONE -prednisone tab 10 mg dose pack.............26
PREDNISONE -prednisone tab 50 mg..............................25
PREDNISONE -prednisone tab 5 mg dose pack...............26
prednisone tab 10 mg..................................................... 26
prednisone tab 10 mg dose pack.................................. 26
prednisone tab 1 mg....................................................... 26
prednisone tab 2.5 mg.................................................... 26
prednisone tab 20 mg..................................................... 26
prednisone tab 5 mg....................................................... 26
prednisone tab 5 mg dose pack.................................... 26
PREFERA OB + DHA -prenat-fe poly cmplx-fe heme polyfa tab & omega 3 cap pck............................................. 134
PREFERAOB ONE - prenat-fe poly cmplx-fe heme poly-fadha cap 22-6-1-200 mg ................................................ 134
PREFERA OB - prenat vit-fe poly cmplx-fe heme poly-fa
tab 28-6-1 mg ............................................................... 134
PREFERRED PLUS GLUCOSE -glucose chew tab 4
gm.................................................................................... 36
265
2014
PREFEST -estradiol tab 1 mg(15)/estrad-norgestimate tab
1-0.09mg(15)....................................................................29
PREFOL-DHA - prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 26-1.2-300 mg ....................................................... 134
PRE-FOLIC -folic acid-vitamin c tab 1-100 mg................147
PRELONE -prednisolone syrup 15 mg/5ml (usp solution
equivalent)........................................................................26
PREMARIN -estrogens, conjugated tab 0.3 mg................ 29
PREMARIN -estrogens, conjugated tab 0.45 mg.............. 29
PREMARIN -estrogens, conjugated tab 0.625 mg............ 29
PREMARIN -estrogens, conjugated tab 0.9 mg................ 29
PREMARIN -estrogens, conjugated tab 1.25 mg.............. 29
PREMARIN -estrogens, conjugated vaginal cream 0.625
mg/gm.............................................................................. 85
PREMPHASE -conj est 0.625(14)/conj est-medroxypro ac
tab 0.625-5mg(14)........................................................... 29
PREMPRO -conjugated estrogen-medroxyprogest acetate
tab 0.3-1.5 mg................................................................. 29
tab 0.45-1.5 mg............................................................... 29
tab 0.625-2.5 mg..............................................................29
tab 0.625-5 mg................................................................ 29
PRENA1/QUATREFOLIC - prenat w/o a w/fefum-methfolfa-dha cap 30-0.6-0.4-200 mg ...................................... 136
PRENA1 CHEW/QUATREFOLIC - prenat w/ b2-b6-b12d3-methylfol-fa chew tab 0.6-0.4 mg ............................ 136
PRENA1 CHEW - prenat w/ b2-b6-b12-d3-folic acid chew
tab 1.4 mg .................................................................... 136
PRENA1 PEARL - prenat w/oa w/fefum-na fered-fa-dha
cap cr 30-1.4-200 mg ................................................... 136
PRENA1 PLUS/QUATREFOLIC -prenat w/o a w/ fe
chelate-l methylfol-fa tab & dha cap pk......................... 136
PRENAISSANCE 90 DHA -prenat w/o a w/fecbn-fegl-dssfa tab 90 &dha cap 300mg pak..................................... 135
PRENAISSANCE BALANCE - prenatal w/o vit a w/ fe cbndss-fa-dha cap 30-1-260 mg ........................................ 135
PRENAISSANCE DHA -prenat w/o a w/fecbn-fegl-dss-fa
tab & dha cap 250 mg pack.......................................... 135
PRENAISSANCE HARMONY DHA -prenat w/fe poly-na
fered-fa tab 27-1 & omega cap dr 380mg......................135
PRENAISSANCE NEXT-B - prenatal w/ calcium-vit b6-faginger tab 1.22 mg ....................................................... 135
PRENAISSANCE NEXT - prenatal w/ calcium-vit b6-faginger tab 1.2 mg ......................................................... 135
PRENAISSANCE PLUS - prenatal w/o a w/fe cbn-dss-fadha cap 28-1-250 mg ................................................... 135
PRENAISSANCE - prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg ..................................................... 135
PRENAISSANCE PROMISE -prenat w/o a w/fecbn-fegldss-fa tab & dha cap 300 mg pack................................135
PRENAPLUS - prenatal vit w/ fe fumarate-fa tab 27-1 mg
....................................................................................... 135
266
PRENATABS FA - prenatal vit w/ fe fumarate-fa tab 29-1
mg ................................................................................. 135
PRENATABS OBN - prenatal w/o a vit w/ fe carbonyl-fa
tab 29-1 mg .................................................................. 135
PRENATABS RX - prenatal vit w/ iron carbonyl-fa tab 29-1
mg ................................................................................. 135
PRENATAL 19 - prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg ................................................................................. 135
PRENATAL 19 - prenatal vit w/ fe fumarate-fa chew tab
29-1 mg ........................................................................ 135
PRENATAL AD - prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg ........................................................................ 135
PRENATAL LOW IRON - prenatal vit w/ fe fumarate-fa tab
27-1 mg ........................................................................ 135
PRENATAL MV & MIN/FE-FA-D -prenat-fe poly cmplx-fe
hem poly-fa-dha cap 11-3-0.5-100mg............................135
PRENATAL PLUS IRON - prenatal vit w/ iron carbonyl-fa
tab 29-1 mg .................................................................. 135
PRENATAL PLUS - prenatal vit w/ fe fumarate-fa tab 27-1
mg ................................................................................. 135
PRENATAL - prenatal vit w/ fe fumarate-fa tab 27-1 mg
....................................................................................... 135
PRENATAL-U - prenatal w/o a vit w/ fe fumarate-fa cap
106.5-1 mg ................................................................... 135
PRENATAL VITAMINS PLUS - prenatal vit w/ fe fumaratefa tab 27-1 mg ..............................................................135
PRENATA - prenatal w/o a vit w/ fe fum-fa tab chew 29-1
mg ................................................................................. 135
PRENATE AM - prenatal w/ calcium-vit b6-vit b12-faginger tab 1 mg ............................................................ 135
PRENATE DHA - prenat w/o a w/feaspg-methfol-fa-dha
cap 18-0.6-0.4-300 mg ................................................. 135
PRENATE DHA - prenat w/o a w/fefum-methfol-fa-dha cap
28-0.6-0.4-300 mg ........................................................ 135
PRENATE ELITE - prenatal vit w/ fe fum-methylfolate-fa
tab 26-0.6-0.4 mg ......................................................... 135
PRENATE ELITE - prenatal w/ fe asp gly-l methylfol-fa tab
20-0.6-0.4 mg ............................................................... 135
PRENATE ENHANCE - prenat w/o a w/fefum-methfol-fadha cap 28-0.6-0.4-400 mg .......................................... 135
PRENATE ESSENTIAL - prenat w/o a w/feaspg-methfolfa-dha cap 18-0.6-0.4-300 mg ...................................... 135
PRENATE ESSENTIAL - prenat w/o a w/feasp-methylf-faomeg cap 29-0.6-0.4-340 mg ....................................... 135
PRENATE MINI - prenat w/o a w/fecbn-methylf-fa-dha cap
29-0.6-0.4-350 mg ........................................................ 135
PRENATE PIXIE - prenat w/o a w/feaspg-methfol-fa-dha
cap 10-0.6-0.4-200 mg ................................................. 136
PRENATE -prenat mv & min w/ l-methylfolate-fa chew tab
0.6-0.4 mg......................................................................135
PRENATE RESTORE - prenat w/o a w/fefum-methfol-fadha cap 27-0.6-0.4-400 mg .......................................... 136
PRENATE STAR - prenatal vit w/ fe asparto glycinate-fa
tab 20-1 mg .................................................................. 136
2014
PRENEXA - prenatal w/o vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg ............................................................ 136
PREPIDIL -dinoprostone cervical gel 0.5 mg/3gm.............40
PREPLUS - prenatal vit w/ fe fumarate-fa tab 27-1 mg
....................................................................................... 136
PREPOPIK -sod picosulfate-mg oxide-citric acid pack 10
mg-3.5 gm-12 gm............................................................ 76
PREQUE 10 - prenatal mv w/fe carbonyl-dss-fa-dha tab
15-25-0.5-50 mg ........................................................... 136
PRESERA - emollient - aerosol foam .............................172
PRETAB - prenatal vit w/ fe fumarate-fa tab 29-1 mg .....136
PREVACID -lansoprazole cap delayed release 15 mg...... 79
PREVACID -lansoprazole cap delayed release 30 mg...... 79
PREVACID SOLUTAB -lansoprazole tab delayed release
orally disintegrating 15 mg...............................................79
PREVACID SOLUTAB -lansoprazole tab delayed release
orally disintegrating 30 mg...............................................79
PREVIDENT 5000 BOOSTER PL -sodium fluoride paste
1.1%............................................................................... 160
PREVIDENT 5000 BOOSTER -sodium fluoride paste
1.1%............................................................................... 160
PREVIDENT 5000 DRY MOUTH -sodium fluoride gel
1.1% (0.5% f)................................................................. 160
PREVIDENT 5000 ENAMEL PRO -sodium fluoridepotassium nitrate paste 1.1-5%..................................... 160
PREVIDENT 5000 PLUS -sodium fluoride cream
1.1%............................................................................... 160
PREVIDENT 5000 SENSITIVE -sodium fluoride-potassium
nitrate paste 1.1-5%.......................................................160
PREVIDENT FLUORIDE -sodium fluoride gel 1.1% (0.5%
f)..................................................................................... 160
PREVIDENT -sodium fluoride rinse 0.2%........................160
PREVNAR 13 -pneumococcal 13-valent conjugate vaccine
inj......................................................................................18
PREVPAC -amoxicillin cap-clarithro tab-lansopraz cap dr
therapy pack.................................................................... 79
PREZISTA -darunavir ethanolate susp 100 mg/ml (base
equiv)................................................................................12
PREZISTA -darunavir ethanolate tab 150 mg (base
equiv)................................................................................12
equiv)................................................................................12
equiv)................................................................................12
equiv)................................................................................12
equiv)................................................................................12
PRIFTIN -rifapentine tab 150 mg........................................ 9
PRILOSEC -omeprazole cap delayed release 10 mg........79
PRILOSEC -omeprazole magnesium for delayed release
susp packet 10 mg.......................................................... 79
PRILOSEC -omeprazole magnesium for delayed release
susp packet 2.5 mg......................................................... 79
PRIMAQUINE PHOSPHATE -primaquine phosphate tab
26.3 mg............................................................................ 14
PRIMAXIN I.M. -imipenem-cilastatin intramuscular for soln
500 mg............................................................................. 16
PRIMAXIN IV ADD-VANTAGE -imipenem-cilastatin
intravenous for soln 250 mg............................................ 16
PRIMAXIN IV ADD-VANTAGE -imipenem-cilastatin
intravenous for soln 500 mg............................................ 16
PRIMAXIN IV -imipenem-cilastatin intravenous for soln
250 mg............................................................................. 16
PRIMAXIN IV -imipenem-cilastatin intravenous for soln
500 mg............................................................................. 16
primidon

BCBSAL Individual Market Standard Drug List for October

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