Comprehensive Formulary

Transcription

HMSA Akamai Advantage
®
2016 Formulary
PLEASE READ: THIS DOCUMENT
CONTAINS INFORMATION
ABOUT THE DRUGS
WE COVER IN THIS PLAN.
List of Covered Drugs
Formulary ID 00016094, version 15
An Independent Licensee of Blue Cross and Blue Shield Association
This formulary was updated on 10/01/2016. For more recent information
or other questions, please contact HMSA at 948-6000 on Oahu, or
1 (800) 660-4672 toll-free. TTY users, call 711. Telephone hours are 8 a.m.
to 8 p.m., seven days a week or visit http://www.hmsa.com/advantage.
H3832_1085_8740_3125_V3_Final_7
Note to existing members: This formulary has
changed since last year. Please review this document to make sure that it still contains the drugs
you take.
continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in
which you can save additional money or we can
ensure your safety.
When this drug list (formulary) refers to “we,” “us,”
or “our,” it means HMSA. When it refers to “plan”
or “our plan,” it means Akamai Advantage.
If we remove drugs from our formulary, add prior
authorization, quantity limits, and/or step therapy
restrictions on a drug or move a drug to a higher
cost-sharing tier, we must notify affected members
of the change at least 60 days before the change
becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the
Food and Drug Administration deems a drug on
our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will
immediately remove the drug from our formulary
and provide notice to members who take the drug.
The enclosed formulary is current as of October 1,
2016. To get updated information about the drugs
covered by Akamai Advantage, please contact us.
Our contact information appears on the front and
back cover pages. We will inform members of any
formulary changes to this comprehensive formulary through our website.
This document includes a list of the drugs
(formulary) for our plan which is current as of
October 1, 2016. For an updated formulary, please
contact us. Our contact information, along with the
date we last updated the formulary, appears on the
front and back cover pages.
You must generally use network pharmacies to use
your prescription drug benefit. Benefits, formulary,
pharmacy network, premium and/or copayments/
coinsurance may change on January 1, 2017 and
from time to time during the year.
What is the Akamai Advantage
Formulary?
A formulary is a list of covered drugs selected by
Akamai Advantage in consultation with a team of
health care providers, which represents the prescription therapies believed to be a necessary part
of a quality treatment program. Akamai Advantage
will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the
prescription is filled at an Akamai Advantage network pharmacy, and other plan rules are followed.
For more information on how to fill your prescriptions, please review your Evidence of Coverage.
How do I use the Formulary?
There are two ways to find your drug within the
formulary:
Medical Condition
The formulary begins on page 1. The drugs in this
formulary are grouped into categories depending
on the type of medical conditions that they are
used to treat. For example, drugs used to treat
a heart condition are listed under the category,
“Cardiovascular.” If you know what your drug is
used for, look for the category name in the list that
begins on page 1. Then look under the category
name for your drug.
Can the Formulary (drug list)
change?
Generally, if you are taking a drug on our 2016
formulary that was covered at the beginning of
the year, we will not discontinue or reduce coverage of the drug during the 2016 coverage year
except when a new, less expensive generic drug
becomes available or when new adverse information about the safety or effectiveness of a drug is
released. Other types of formulary changes, such
as removing a drug from our formulary, will not
affect members who are currently taking the drug.
It will remain available at the same cost-sharing for
those members taking it for the remainder of the
coverage year. We feel it is important that you have
Alphabetical Listing
If you are not sure what category to look under,
you should look for your drug in the Index that
begins on page 61. The Index provides an alphabetical list of all of the drugs included in this
document. Both brand name drugs and generic
drugs are listed in the Index. Look in the Index
and find your drug. Next to your drug, you will
see the page number where you can find coverage
information. Turn to the page listed in the Index
i
and find the name of your drug in the first column
of the list.
You can ask Akamai Advantage to make an exception to these restrictions or limits or for a list
of other similar drugs that may treat your health
condition. See the section, “How do I request an
exception to the Akamai Advantage formulary?” on
this page for information about how to request an
exception.
What are generic drugs?
Akamai Advantage covers both brand name drugs
and generic drugs. A generic drug is approved by
the FDA as having the same active ingredient as
the brand name drug. Generally, generic drugs
cost less than brand name drugs.
What if my drug is not on the
Formulary?
Are there any restrictions on my
coverage?
If your drug is not included in this formulary (list
of covered drugs), you should first contact our Customer Relations and ask if your drug is covered. If
you learn that Akamai Advantage does not cover
your drug, you have two options:
Some covered drugs may have additional requirements or limits on coverage. These requirements
and limits may include:
•You can ask Customer Relations for a list of similar drugs that are covered by Akamai Advantage.
When you receive the list, show it to your doctor
and ask him or her to prescribe a similar drug
that is covered by Akamai Advantage.
•Prior Authorization: Akamai Advantage requires you or your physician to get prior authorization for certain drugs. This means that you will
need to get approval from Akamai Advantage
before you fill your prescriptions. If you don’t get
approval, Akamai Advantage may not cover
the drug.
•You can ask Akamai Advantage to make an
exception and cover your drug. See below for
information about how to request an exception.
•Quantity Limits: For certain drugs, Akamai Advantage limits the amount of the drug that Akamai Advantage will cover. For example, Akamai
Advantage provides 12 tablets per prescription
for REPLAX. This may be in addition to a standard one-month or three-month supply.
How do I request an exception to the
Akamai Advantage Formulary?
You can ask Akamai Advantage to make an exception to our coverage rules. There are several types
of exceptions that you can ask us to make.
•Step Therapy: In some cases, Akamai Advantage requires you to first try certain drugs to
treat your medical condition before we will cover
another drug for that condition. For example, if
Drug A and Drug B both treat your medical condition, Akamai Advantage may not cover Drug B
unless you try Drug A first. If Drug A does not
work for you, Akamai Advantage will then cover
Drug B.
•You can ask us to cover a drug even if it is not
on our formulary. If approved, this drug will be
covered at a pre-determined cost-sharing level,
and you would not be able to ask us to provide
the drug at a lower cost-sharing level.
•You can ask us to cover a formulary drug at a
lower cost-sharing level if this drug is not on the
specialty tier. If approved this would lower the
amount you must pay for your drug.
You can find out if your drug has any additional
requirements or limits by looking in the formulary
that begins on page 1. You can also get more
information about the restrictions applied to
specific covered drugs by visiting our website. We
have posted online documents that explain our
prior authorization and step therapy restrictions.
You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back
cover pages.
•You can ask us to waive coverage restrictions
or limits on your drug. For example, for certain
drugs, Akamai Advantage limits the amount of
the drug that we will cover. If your drug has a
quantity limit, you can ask us to waive the limit
and cover a greater amount.
Generally, Akamai Advantage will only approve
your request for an exception if the alternative
drugs included on the plan’s formulary, the lower
cost-sharing drug, or additional utilization restricii
tions would not be as effective in treating your
condition and/or would cause you to have adverse
medical effects.
refill of these drugs for the first 90 days you are
a member of our plan. If you need a drug that is
not on our formulary or if your ability to get your
drugs is limited, but you are past the first 90 days
of membership in our plan, we will cover a 31-day
emergency supply of that drug (unless you have
a prescription for fewer days) while you pursue a
formulary exception.
You should contact us to ask us for an initial
coverage decision for a formulary, tiering, or utilization restriction exception. When you request
a formulary, tiering, or utilization restriction
exception, you should submit a statement from
your prescriber or physician supporting your
request. Generally, we must make our decision
within 72 hours of getting your prescriber’s supporting statement. You can request an expedited
(fast) exception if you or your doctor believe that
your health could be seriously harmed by waiting
up to 72 hours for a decision. If your request to
expedite is granted, we must give you a decision
no later than 24 hours after we get a supporting
statement from your doctor or other prescriber.
Transition policy
New members in our Plan may be taking drugs
that aren’t on our formulary or that are subject to
certain restrictions, such as prior authorization.
Current members may also be affected by changes in our formulary from one year to the next.
Members should talk to their doctors to decide
if they should switch to a different drug that we
cover or request a formulary exception in order to
get coverage for the drug. See the section above,
“How do I request an exception to HMSA’s Akamai
Advantage formulary?” to learn more about how
to request an exception. Please contact Customer
Relations if your drug is not on our formulary, is
subject to certain restrictions such as prior authorization, and you need to switch to a different drug
that we cover or request a formulary exception.
During the period of time members are talking to
their doctors to determine a course of action, we
may provide a temporary supply of a non-formulary drug if those members need a refill for the
drug during the first 90 days of new membership
in our Plan. If you are a current member affected by a formulary change from one year to the
next, we will provide you with the opportunity to
request a formulary exception in advance for the
following year.
What do I do before I can talk to my
doctor about changing my drugs or
requesting an exception?
As a new or continuing member in our plan you
may be taking drugs that are not on our formulary.
Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us
before you can fill your prescription. You should
talk to your doctor to decide if you should switch
to an appropriate drug that we cover or request a
formulary exception so that we will cover the drug
you take. While you talk to your doctor to determine the right course of action for you, we may
cover your drug in certain cases during the first 90
days you are a member of our plan.
For each of your drugs that is not on our formulary
or if your ability to get your drugs is limited, we
will cover a temporary 30-day supply (unless you
have a prescription written for fewer days) when
you go to a network pharmacy. After your first 30day supply, we will not pay for these drugs, even
if you have been a member of the plan less than
90 days.
When a member goes to a network pharmacy and
we provide a temporary supply of a drug that isn’t
on our formulary, or that has coverage restrictions
or limits (but is otherwise considered a Part D
drug), we will cover a 30-day supply (unless the
prescription is written for fewer days). After we
cover the temporary 30-day supply, we generally
will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply.
This notice will explain the steps you can take to
request an exception and how to work with your
doctor to decide if you should switch to an appropriate drug that we cover.
If you are a resident of a long-term care (LTC)
facility, we will allow you to refill your prescription until we have provided you with a 93-day
transition supply consistent with the dispensing
increment (unless you have a prescription written for fewer days). We will cover more than one
iii
Akamai Advantage Formulary
If a new member is a resident of a long-term care
facility (like a nursing home), we will also cover
a temporary 31-day transition supply (unless the
prescription is written for fewer days). If necessary,
we will cover more than one refill of these drugs
during the first 90 days a new member is enrolled
in our Plan. If the resident has been enrolled in
our Plan for more than 90 days and needs a drug
that isn’t on our formulary or is subject to other
restrictions, such as dosage limits, we will cover a
temporary 31-day emergency supply of that drug
(unless the prescription is for fewer days) while the
new member pursues a formulary exception.
The formulary that begins on page 1 provides
coverage information about the drugs covered by
Akamai Advantage. If you have trouble finding
your drug in the list, turn to the Index that begins
on page 61.
The first column of the chart lists the drug name.
Brand name drugs are capitalized (e.g., REPLAX)
and generic drugs are listed in lower-case italics
(e.g., ibuprofen).
The information in the requirements/limits column
tells you if Akamai Advantage has any special
requirements for coverage of your drug.
Current members are also eligible to receive a
transition fill under certain conditions. If a current
member enters a long-term care (LTC) facility, or is
in an LTC facility and requires an emergency supply of non-formulary drugs, we will cover a temporary 31-day transition supply (unless the prescription is written for fewer days). We will cover more
than one refill of these drugs for these members
for the first 90 days. A member may experience a
change in their level of care at an inpatient hospital
facility or skilled nursing facility which results in
non-coverage of drugs previously covered by Medicare Part D. For current members experiencing a
level of care change, we will also cover a temporary 31-day transition supply as outlined above.
Drug tier index:
Tier 1 - Preferred Generic
Tier 2 - Generic
Tier 3 - Preferred Brand
Tier 4 - Non-Preferred Brand
Tier 5 - Specialty Tier
Please refer to the Summary of Benefits or Evidence of Coverage for the specific copayment or
coinsurance amount associated with each tier.
Abbreviations used in this
Formulary
Please note that our transition policy applies only
to those drugs that are Part D drugs and bought
at a network pharmacy. The transition policy can’t
be used to buy a non-Part D drug or a drug outof-network, unless you qualify for out-of-network
access.
PA – Prior Authorization: Requires that you or your
physician receive approval from Akamai Advantage
before we will cover your prescription.
QL – Quantity Limits: A limit on the amount of the
drug that Akamai Advantage will cover.
ST – Step Therapy: Requires you to first try certain
drugs to treat your medical condition before we
will cover another drug for that condition.
For more information
For more detailed information about your Akamai Advantage prescription drug coverage, please
review your Evidence of Coverage and other plan
materials.
M – Mail Order: These drugs are available through
HMSA’s mail order pharmacy, CVS Caremark.
B/D – B or D: This drug may be covered under
Medicare Part B or D depending upon the circumstances. Information may need to be submitted
describing the use and setting of the drug to make
the determination. For more information, please
call Customer Relations.
If you have questions about Akamai Advantage,
please contact us. Our contact information, along
with the date we last updated the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at
1 (800) MEDICARE [1 (800) 633-4227] 24 hours
a day/seven days a week. TTY users should call
1 (877) 486-2048. Or visit http://www.medicare.gov.
LA – Limited Availability: This prescription may
be available only at certain pharmacies. For more
information, please call Customer Relations.
iv
Prescription drugs can be shipped to your home
from the Akamai Advantage Mail Order pharmacy.
Usually a mail-order pharmacy order will get to
you in no more than 14 days after the pharmacy
receives the order. If your drugs do not arrive
within this timeframe, please call 1 (855) 479-3659
toll-free, 24 hours a day, seven days a week; TTY
users, call 711. You can also choose to sign up for
our optional automatic delivery program by calling
these numbers.
Drug Name
Drug Requirements/
Tier
Limits
ANALGESICS
GOUT
allopurinol tab 100 mg
allopurinol tab 300 mg
colchicine w/ probenecid tab
0.5-500 mg
COLCRYS TAB 0.6MG
QL (120 tabs / 30 days)
probenecid tab 500 mg
ULORIC TAB 40MG
ULORIC TAB 80MG
1
1
2
M
M
M
3
QL M
2
3
3
M
M ST
M ST
2
QL M
2
QL M
2
QL M
2
QL M
2
M
2
M
2
M
2
M
2
M
2
2
2
2
2
2
2
2
2
2
2
1
1
1
2
2
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
NSAIDS
celecoxib cap 50 mg
QL (60 caps / 30 days)
celecoxib cap 100 mg
diclofenac potassium tab 50
mg
diclofenac sodium tab delayed
release 25 mg
release 50 mg
release 75 mg
diclofenac sodium tab sr 24hr
100 mg
diflunisal tab 500 mg
etodolac cap 200 mg
etodolac cap 300 mg
etodolac tab 400 mg
etodolac tab 500 mg
etodolac tab sr 24hr 400 mg
flurbiprofen tab 50 mg
flurbiprofen tab 100 mg
ibuprofen susp 100 mg/5ml
ibuprofen tab 400 mg
ketoprofen cap 50 mg
ketoprofen cap 75 mg
Drug Name
Drug Requirements/
Tier
Limits
MELOXICAM SUSP 7.5
MG/5ML
meloxicam tab 7.5 mg
meloxicam tab 15 mg
nabumetone tab 500 mg
nabumetone tab 750 mg
naproxen dr tab 375mg
naproxen dr tab 500mg
naproxen sodium tab 275 mg
naproxen susp 125 mg/5ml
naproxen tab 250 mg
naproxen tab 375 mg
naproxen tab 500 mg
piroxicam cap 10 mg
piroxicam cap 20 mg
sulindac tab 150 mg
sulindac tab 200 mg
2
M
1
1
2
2
1
1
1
1
2
1
1
1
2
2
1
1
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
2
QL M
2
QL M
2
QL M
2
QL M
2
M
2
M
2
2
2
M
M
QL M
2
QL M
2
2
2
B/D M
B/D M
QL M
OPIOID ANALGESICS
acetaminophen w/ codeine
soln 120-12 mg/5ml
QL (5000 mL / 30 days)
acetaminophen w/ codeine tab
300-15 mg
300-30 mg
300-60 mg
butorphanol tartrate inj 1
mg/ml
mg/ml
nalbuphine hcl inj 10 mg/ml
nalbuphine hcl inj 20 mg/ml
tramadol hcl tab 50 mg
tramadol-acetaminophen tab
37.5-325 mg
OPIOID ANALGESICS, CII
DURAMORPH INJ 0.5MG/ML
DURAMORPH INJ 1MG/ML
endocet tab 5-325mg
PA - Prior Authorization
QL - Quantity Limits
ST - Step Therapy
B/D - Covered under Medicare B or D
LA - Limited Access
M - Available at mail-order
1
Drug Name
Drug Requirements/
Tier
Limits
endocet tab 7.5-325
endocet tab 10-325mg
fentanyl citrate lozenge on a
handle 200 mcg
QL (120 lozenges / 30
days)
handle 400 mcg
days)
handle 600 mcg
days)
handle 800 mcg
days)
handle 1200 mcg
days)
handle 1600 mcg
days)
fentanyl td patch 72hr 12
mcg/hr
QL (10 patches / 30
days)
mcg/hr
QL (10 patches / 30
days)
mcg/hr
QL (10 patches / 30
days)
mcg/hr
QL (10 patches / 30
days)
mcg/hr
QL (10 patches / 30
days)
2
QL M
2
QL M
5
QL M PA
5
5
QL M PA
QL M PA
5
QL M PA
5
QL M PA
5
2
2
2
2
2
QL M PA
QL M
QL M
QL M PA
QL M PA
QL M PA
Drug Name
Drug Requirements/
Tier
Limits
FENTORA TAB 100MCG
FENTORA TAB 200MCG
FENTORA TAB 400MCG
FENTORA TAB 600MCG
FENTORA TAB 800MCG
hydrocodone-acetaminophen
soln 7.5-325 mg/15ml
QL (5400 mL / 30 days)
tab 5-325 mg
tab 7.5-325 mg
tab 10-325 mg
hydrocodone-ibuprofen tab
7.5-200 mg
hydromorphone hcl liqd 1
mg/ml
hydromorphone hcl
preservative free (pf) inj 10
mg/ml
hydromorphone hcl tab 2 mg
methadone con 10mg/ml
QL (120 mL / 30 days)
methadone hcl soln 5 mg/5ml
QL (600 mL / 30 days)
QL (600 mL / 30 days)
methadone hcl tab 5 mg
methadone hcl tab 10 mg
MORPHINE SUL INJ 2MG/ML
ST - Step Therapy
LA - Limited Access
5
QL M PA
5
QL M PA
5
QL M PA
5
QL M PA
5
QL M PA
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
M
2
B/D M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
2
B/D M
B/D M
2
Drug Name
Drug Requirements/
Tier
Limits
morphine sulfate beads cap sr
24hr 30 mg
24hr 45 mg
24hr 60 mg
24hr 75 mg
24hr 90 mg
24hr 120 mg
morphine sulfate cap sr 24hr
10 mg
20 mg
30 mg
50 mg
60 mg
80 mg
100 mg
morphine sulfate inj pf 0.5
mg/ml
morphine sulfate inj pf 1 mg/ml
MORPHINE SULFATE IV
SOLN 1 MG/ML
morphine sulfate iv soln pf 4
mg/ml
2
2
B/D M
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
5
QL M
5
QL M
2
B/D M
2
2
B/D M
B/D M
2
B/D M
Drug Name
Drug Requirements/
Tier
Limits
mg/ml
MORPHINE SULFATE IV
SOLN PF 10 MG/ML
MORPHINE SULFATE IV
SOLN PF 15 MG/ML
MORPHINE SULFATE ORAL
SOLN 10 MG/5ML
SOLN 20 MG/5ML
SOLN 100 MG/5ML (20
MG/ML)
MORPHINE SULFATE TAB
15 MG
30 MG
morphine sulfate tab cr 15 mg
morphine sulfate tab cr 100
mg
mg
oxycodone hcl cap 5 mg
oxycodone hcl conc 100
mg/5ml (20 mg/ml)
OXYCODONE HCL SOLN 5
MG/5ML
oxycodone hcl tab 5 mg
ST - Step Therapy
LA - Limited Access
2
B/D M
2
B/D M
2
B/D M
2
M
2
M
2
M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
M
2
M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
3
Drug Name
Drug Requirements/
Tier
Limits
oxycodone w/ acetaminophen
soln 5-325 mg/5ml
QL (1800 mL / 30 days)
tab 2.5-325 mg
tab 5-325 mg
tab 7.5-325 mg
tab 10-325 mg
2
QL M
2
QL M
2
QL M
2
2
QL M
QL M
ANESTHETICS
LOCAL ANESTHETICS
lidocaine hcl local inj 0.5%
lidocaine hcl local inj 1%
lidocaine hcl local inj 1.5%
lidocaine hcl local inj 2%
lidocaine hcl local preservative
free (pf) inj 0.5%
lidocaine hcl local preservative
free (pf) inj 1%
2
2
2
2
2
B/D M
B/D M
B/D M
B/D M
B/D M
2
B/D M
ANTI-INFECTIVES
ANTI-BACTERIALS - MISCELLANEOUS
amikacin sulfate inj 1 gm/4ml
(250 mg/ml)
amikacin sulfate inj 500
mg/2ml (250 mg/ml)
gentam/nacl inj 0.9mg/ml
gentam/nacl inj 1.4mg/ml
gentamicin in saline inj 0.8
mg/ml
gentamicin in saline inj 1
mg/ml
mg/ml
mg/ml
mg/ml
gentamicin sulfate inj 10
mg/ml
mg/ml
2
M
2
M
2
2
2
M
M
M
2
M
2
M
2
M
2
M
2
M
2
M
Drug Name
Drug Requirements/
Tier
Limits
gentamicin sulfate iv soln 10
mg/ml
neomycin sulfate tab 500 mg
paromomycin sulfate cap 250
mg
streptomycin sulfate for inj 1
gm
sulfadiazine tab 500mg
tobramycin nebu soln 300
mg/5ml
tobramycin sulfate for inj 1.2
gm
tobramycin sulfate inj 1.2
gm/30ml (40 mg/ml) (base
equiv)
tobramycin sulfate inj 2
equiv)
mg/ml (base equivalent)
mg/2ml (40 mg/ml) (base
equiv)
2
M
2
2
M
M
2
M
4
5
M
B/D
2
M
2
M
2
M
2
M
2
M
ANTI-INFECTIVES - MISCELLANEOUS
ALBENZA TAB 200MG
ALINIA SUS 100/5ML
ALINIA TAB 500MG
atovaquone susp 750 mg/5ml
AZACTAM/DEX INJ 1GM
AZACTAM/DEX INJ 2GM
aztreonam for inj 1 gm
aztreonam for inj 2 gm
BILTRICIDE TAB 600MG
CAYSTON INH 75MG
clindamycin hcl cap 75 mg
clindamycin palmitate hcl for
soln 75 mg/5ml (base equiv)
clindamycin phosphate in d5w
iv soln 300 mg/50ml
iv soln 600 mg/50ml
iv soln 900 mg/50ml
clindamycin phosphate inj 9
gm/60ml
ST - Step Therapy
LA - Limited Access
4
4
4
5
4
5
2
2
3
5
1
1
1
2
M
M
M
M
M
M
M
M
M
LA PA
M
M
M
M
2
M
2
M
2
M
2
M
4
Drug Name
Drug Requirements/
Tier
Limits
mg/2ml
mg/4ml
mg/6ml
clindamycin phosphate iv soln
300 mg/2ml
600 mg/4ml
900 mg/6ml
colistimethate sodium for inj
150 mg
CUBICIN SOL 500MG
dapsone tab 25 mg
dapsone tab 100 mg
DARAPRIM TAB 25MG
emverm chw 100mg
imipenem-cilastatin
intravenous for soln 250 mg
imipenem-cilastatin
intravenous for soln 500 mg
INVANZ INJ 1GM
ivermectin tab 3 mg
LINEZOLID FOR SUSP 100
MG/5ML
LINEZOLID IN SODIUM
CHLORIDE IV SOLN 600
MG/300ML-0.9%
linezolid iv soln 600 mg/300ml
(2 mg/ml)
LINEZOLID TAB 600 MG
meropenem iv for soln 1 gm
meropenem iv for soln 500 mg
methenamine hippurate tab 1
gm
metronidazole in nacl 0.79% iv
soln 500 mg/100ml
metronidazole tab 250 mg
metronidazole tab 500 mg
NEBUPENT INH 300MG
nitrofurantoin macrocrystalline
cap 50 mg
PA applies if 65 years and
older after a 90 day supply
in a calendar year
2
M
2
M
2
M
2
M
2
M
2
M
2
M
5
2
2
4
4
2
M
M
M
M
M
M
2
M
4
2
5
M
M
M
5
M
5
M
5
2
2
2
M
M
M
M
2
M
1
1
4
4
M
M
B/D M
M PA
Drug Name
Drug Requirements/
Tier
Limits
nitrofurantoin macrocrystalline
cap 100 mg
in a calendar year
nitrofurantoin monohydrate
macrocrystalline cap 100 mg
in a calendar year
PENTAM 300 INJ 300MG
SIVEXTRO INJ 200MG
SIVEXTRO TAB 200MG
sulfamethoxazole-trimethopri
m iv soln 400-80 mg/5ml
m susp 200-40 mg/5ml
m tab 400-80 mg
m tab 800-160 mg
SYNERCID INJ 500MG
trimethoprim tab 100 mg
TYGACIL INJ 50MG
vancomycin hcl cap 125 mg
vancomycin hcl cap 250 mg
vancomycin hcl for inj 10 gm
vancomycin hcl for inj 500 mg
VANCOMYCIN INJ 1 GM
VANCOMYCIN INJ 500MG
vancomycin inj 750mg
VANCOMYCIN INJ 750MG
ZYVOX TAB 600MG
4
M PA
4
M PA
4
5
5
2
M
M
M
M
2
M
1
M
1
M
5
1
5
5
5
2
2
2
2
4
4
2
4
5
M
M
M
M
M
M
M
M
M
M
M
M
M
M
5
5
2
5
5
2
2
2
B/D M
B/D M
B/D M
M
M
M
M
M
2
M
ANTIFUNGALS
ABELCET INJ 5MG/ML
AMBISOME INJ 50MG
amphotericin b for inj 50 mg
CANCIDAS INJ 50MG
CANCIDAS INJ 70MG
fluconazole for susp 10 mg/ml
fluconazole for susp 40 mg/ml
fluconazole in dextrose inj 200
mg/100ml
fluconazole in dextrose inj 400
mg/200ml
ST - Step Therapy
LA - Limited Access
5
Drug Name
Drug Requirements/
Tier
Limits
fluconazole in nacl 0.9% inj
200 mg/100ml
400 mg/200ml
fluconazole tab 50 mg
fluconazole/ inj nacl 100
flucytosine cap 250 mg
flucytosine cap 500 mg
griseofulvin microsize susp
125 mg/5ml
griseofulvin microsize tab 500
mg
griseofulvin ultramicrosize tab
125 mg
griseofulvin ultramicrosize tab
250 mg
itraconazole cap 100 mg
ketoconazole tab 200 mg
MYCAMINE INJ 50MG
MYCAMINE INJ 100MG
NOXAFIL SUS 40MG/ML
NOXAFIL TAB 100MG
nystatin tab 500000 unit
terbinafine hcl tab 250 mg
voriconazole for inj 200 mg
voriconazole for susp 40
mg/ml
voriconazole tab 50 mg
voriconazole tab 200 mg
2
M
2
M
2
2
2
2
2
5
5
2
M
M
M
M
M
M
M
M
2
M
2
M
2
M
2
2
5
5
5
5
2
1
M PA
M PA
M
M
M
M
M
QL M
2
5
M
M
5
5
M
M
2
M
2
M
2
M
2
M
4
2
3
2
M
M
M
M PA
ANTIMALARIALS
atovaquone-proguanil hcl tab
62.5-25 mg
250-100 mg
chloroquine phosphate tab
250 mg
500 mg
COARTEM TAB 20-120MG
mefloquine hcl tab 250 mg
PRIMAQUINE TAB 26.3MG
quinine sulfate cap 324 mg
ANTIRETROVIRAL AGENTS
Drug Name
Drug Requirements/
Tier
Limits
abacavir sulfate tab 300 mg
(base equiv)
APTIVUS CAP 250MG
APTIVUS SOL
CRIXIVAN CAP 200MG
CRIXIVAN CAP 400MG
didanosine delayed release
capsule 125 mg
capsule 200 mg
capsule 250 mg
capsule 400 mg
EDURANT TAB 25MG
EMTRIVA CAP 200MG
EMTRIVA SOL 10MG/ML
FUZEON INJ 90MG
INTELENCE TAB 25MG
INTELENCE TAB 100MG
INTELENCE TAB 200MG
INVIRASE CAP 200MG
INVIRASE TAB 500MG
ISENTRESS CHW 25MG
ISENTRESS CHW 100MG
ISENTRESS POW 100MG
ISENTRESS TAB 400MG
lamivudine oral soln 10 mg/ml
lamivudine tab 150 mg
lamivudine tab 300 mg
LEXIVA SUS 50MG/ML
LEXIVA TAB 700MG
NEVIRAPINE SUSP 50
MG/5ML
nevirapine tab 200 mg
nevirapine tab sr 24hr 100 mg
NORVIR CAP 100MG
NORVIR SOL 80MG/ML
NORVIR TAB 100MG
PREZISTA SUS 100MG/ML
PREZISTA TAB 75MG
PREZISTA TAB 150MG
PREZISTA TAB 600MG
PREZISTA TAB 800MG
RESCRIPTOR TAB 100 MG
RESCRIPTOR TAB 200MG
ST - Step Therapy
LA - Limited Access
2
M
5
5
4
4
2
M
M
M
M
M
2
M
2
M
2
M
5
3
3
5
4
5
5
5
5
3
5
3
5
2
2
2
4
5
2
M
M
M
2
2
2
3
3
3
5
3
3
5
5
4
4
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
6
Drug Name
Drug Requirements/
Tier
Limits
RETROVIR INJ 10MG/ML
REYATAZ CAP 150MG
REYATAZ CAP 200MG
REYATAZ CAP 300MG
REYATAZ POW 50MG
SELZENTRY TAB 150MG
SELZENTRY TAB 300MG
stavudine cap 15 mg
stavudine cap 20 mg
stavudine cap 30 mg
stavudine cap 40 mg
stavudine for oral soln 1 mg/ml
SUSTIVA CAP 50MG
SUSTIVA CAP 200MG
SUSTIVA TAB 600MG
TIVICAY TAB 10MG
TIVICAY TAB 25MG
TIVICAY TAB 50MG
TYBOST TAB 150MG
VIDEX SOL 2GM
VIDEX SOL 4GM
VIRACEPT TAB 250MG
VIRACEPT TAB 625MG
VIRAMUNE XR TAB 100MG
VIREAD POW 40MG/GM
VIREAD TAB 150MG
VIREAD TAB 200MG
VIREAD TAB 250MG
VIREAD TAB 300MG
VITEKTA TAB 85MG
VITEKTA TAB 150MG
ZIAGEN SOL 20MG/ML
zidovudine cap 100 mg
zidovudine syrup 10 mg/ml
zidovudine tab 300 mg
3
5
5
5
5
5
5
2
2
2
2
2
3
3
5
3
5
5
3
4
4
5
5
4
5
5
5
5
5
5
5
3
2
2
2
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
Drug Requirements/
Tier
Limits
KALETRA TAB 100-25MG
KALETRA TAB 200-50MG
lamivudine-zidovudine tab
150-300 mg
ODEFSEY TAB
PREZCOBIX TAB 800-150
STRIBILD TAB
TRIUMEQ TAB
TRUVADA TAB 100-150
TRUVADA TAB 133-200
TRUVADA TAB 167-250
TRUVADA TAB 200-300
3
5
5
M
M
M
5
5
5
5
5
M
M
M
M
QL M
5
QL M
5
QL M
5
QL M
ANTITUBERCULAR AGENTS
CAPASTAT SUL INJ 1GM
cycloserine cap 250 mg
ethambutol hcl tab 100 mg
ethambutol hcl tab 400 mg
isoniazid inj 100 mg/ml
isoniazid syrup 50 mg/5ml
isoniazid tab 100 mg
isoniazid tab 300 mg
paser gra 4gm
PRIFTIN TAB 150MG
pyrazinamide tab 500 mg
rifabutin cap 150 mg
rifampin cap 150 mg
rifampin cap 300 mg
rifampin for inj 600 mg
RIFATER TAB
SIRTURO TAB 100MG
TRECATOR TAB 250MG
4
5
2
2
2
2
1
1
3
4
2
2
2
2
2
4
5
4
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M LA PA
M
1
2
2
M
B/D M
B/D M
2
1
1
5
3
5
5
M
M
M
M
M
PA
PA
ANTIVIRALS
ANTIRETROVIRAL COMBINATION
AGENTS
abacavir
sulfate-lamivudine-zidovudine
tab 300-150-300 mg
ATRIPLA TAB
COMPLERA TAB
DESCOVY TAB 200/25
EPZICOM TAB 600-300
EVOTAZ TAB 300-150
GENVOYA TAB
KALETRA SOL
Drug Name
5
M
5
5
5
5
5
5
5
M
M
M
M
M
M
M
acyclovir cap 200 mg
acyclovir sodium for inj 500 mg
acyclovir sodium iv soln 50
mg/ml
acyclovir susp 200 mg/5ml
acyclovir tab 400 mg
acyclovir tab 800 mg
adefovir dipivoxil tab 10 mg
BARACLUDE SOL .05MG/ML
DAKLINZA TAB 30MG
DAKLINZA TAB 60MG
ST - Step Therapy
LA - Limited Access
7
Drug Name
Drug Requirements/
Tier
Limits
DAKLINZA TAB 90MG
entecavir tab 0.5 mg
entecavir tab 1 mg
EPIVIR HBV SOL 5MG/ML
famciclovir tab 125 mg
ganciclovir sodium for inj 500
mg
HARVONI TAB 90-400MG
lamivudine tab 100 mg (hbv)
moderiba pak 600/day
MODERIBA PAK 1200/DAY
PEG-INTRON KIT 50MCG RP
PEG-INTRON KIT 80MCG RP
PEG-INTRON KIT 120 RP
PEG-INTRON KIT 150 RP
PEGASYS INJ
PEGASYS INJ 180MCG/M
PEGASYS INJ PROCLICK
PEGINTRON KIT 50MCG
PEGINTRON KIT 80MCG
PEGINTRON KIT 120MCG
PEGINTRON KIT 150MCG
REBETOL SOL 40MG/ML
RELENZA MIS DISKHALE
ribapak pak 600/day
ribapak pak 800/day
ribapak pak 1000/day
ribapak pak 1200/day
ribasphere cap 200mg
ribasphere tab 200mg
ribavirin cap 200 mg
ribavirin tab 200 mg
rimantadine hydrochloride tab
100 mg
SOVALDI TAB 400MG
TAMIFLU CAP 30MG
TAMIFLU CAP 45MG
TAMIFLU CAP 75MG
TAMIFLU SUS 6MG/ML
TYZEKA TAB 600MG
5
5
5
4
2
2
2
2
PA
M
M
M
M
M
M
B/D M
5
2
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
3
5
5
5
5
2
2
2
5
2
2
2
PA
M
5
3
3
3
3
5
PA
M
M
M
M
M
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
M
M
Drug Name
Drug Requirements/
Tier
Limits
valacyclovir hcl tab 1 gm
valacyclovir hcl tab 500 mg
VALCYTE SOL 50MG/ML
valganciclovir hcl tab 450 mg
(base equivalent)
2
2
5
5
M
M
M
M
2
2
3
2
2
2
1
2
2
2
3
2
2
2
2
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
2
M
3
2
2
2
2
2
2
2
2
2
2
M
M
M
M
M
M
M
M
M
M
M
2
2
M
M
2
M
2
M
2
M
2
M
CEPHALOSPORINS
cefaclor cap 250 mg
cefaclor cap 500 mg
cefaclor er tab 500mg
cefaclor for susp 125 mg/5ml
cefadroxil cap 500 mg
cefadroxil for susp 250 mg/5ml
cefadroxil for susp 500 mg/5ml
cefadroxil tab 1 gm
cefazolin inj 1gm/50ml
cefazolin sodium for inj 1 gm
cefazolin sodium for inj 500
mg
cefazolin sodium for iv soln 1
gm
CEFAZOLIN SOL
cefdinir cap 300 mg
cefdinir for susp 125 mg/5ml
cefepime hcl for inj 1 gm
cefepime hcl for inj 2 gm
cefixime for susp 100 mg/5ml
cefotaxime sodium for inj 1 gm
cefotaxime sodium for inj 2 gm
cefotaxime sodium for inj 500
mg
cefoxitin sodium for inj 10 gm
cefoxitin sodium for iv soln 1
gm
gm
cefpodoxime proxetil for susp
50 mg/5ml
100 mg/5ml
cefpodoxime proxetil tab 100
mg
ST - Step Therapy
LA - Limited Access
8
Drug Name
Drug Requirements/
Tier
Limits
mg
cefprozil for susp 125 mg/5ml
cefprozil tab 250 mg
cefprozil tab 500 mg
ceftazidime for inj 1 gm
CEFTAZIDIME/ SOL D5W
1GM
2GM
ceftriaxone sodium for inj 1 gm
ceftriaxone sodium for inj 2 gm
ceftriaxone sodium for inj 10
gm
mg
mg
ceftriaxone sodium for iv soln
1 gm
2 gm
cefuroxime axetil tab 250 mg
cefuroxime sodium for inj 1.5
gm
gm
cefuroxime sodium for inj 750
mg
cefuroxime sodium for iv soln
1.5 gm
cephalexin cap 250 mg
cephalexin cap 500 mg
cephalexin for susp 125
mg/5ml
mg/5ml
SUPRAX CAP 400MG
suprax chw 100mg
suprax chw 200mg
SUPRAX SUS 500/5ML
tazicef inj 1gm
tazicef inj 2gm
2
M
2
2
2
2
2
2
2
4
M
M
M
M
M
M
M
M
4
M
2
2
2
M
M
M
2
M
2
M
2
M
2
M
2
2
2
M
M
M
2
M
2
M
2
M
1
1
2
M
M
M
2
M
3
4
4
3
2
2
M
M
M
M
M
M
Drug Name
Drug Requirements/
Tier
Limits
tazicef inj 6gm
TEFLARO INJ 400MG
TEFLARO INJ 600MG
2
4
4
M
M
M
ERYTHROMYCINS/MACROLIDES
azithromycin for susp 100
mg/5ml
mg/5ml
azithromycin iv for soln 500
mg
AZITHROMYCIN POWD
PACK FOR SUSP 1 GM
azithromycin tab 250 mg
clarithromycin for susp 125
mg/5ml
mg/5ml
clarithromycin tab 250 mg
clarithromycin tab 500 mg
clarithromycin tab sr 24hr 500
mg
DIFICID TAB 200MG
e.e.s. 400 tab 400mg
ery-tab tab 250mg ec
erythrocin inj 500mg
erythrocin tab 250mg
erythromycin ethylsuccinate
tab 400 mg
erythromycin tab 250 mg
erythromycin tab 500 mg
erythromycin w/ delayed
release particles cap 250 mg
2
M
2
M
2
M
2
M
1
1
1
2
M
M
M
M
2
M
2
2
2
M
M
M
5
2
2
2
2
4
2
2
M
M
M
M
M
M
M
M
2
2
2
M
M
M
2
M
2
M
2
M
2
M
1
M
FLUOROQUINOLONES
ciprofloxacin 200 mg/100ml in
d5w
ciprofloxacin 400 mg/200ml in
d5w
ciprofloxacin for oral susp 250
mg/5ml (5%) (5 gm/100ml)
ciprofloxacin for oral susp 500
mg/5ml (10%) (10 gm/100ml)
ciprofloxacin hcl tab 100 mg
(base equiv)
ST - Step Therapy
LA - Limited Access
9
Drug Name
Drug Requirements/
Tier
Limits
(base equiv)
(base equiv)
(base equiv)
ciprofloxacin iv soln 200
mg/20ml (1%)
mg/40ml (1%)
ciprofloxacin-ciprofloxacin hcl
tab sr 24hr 500 mg (base eq)
tab sr 24hr 1000 mg(base eq)
levofloxacin in d5w iv soln 250
mg/50ml
mg/100ml
mg/150ml
levofloxacin iv soln 25 mg/ml
levofloxacin oral soln 25 mg/ml
levofloxacin tab 250 mg
1
M
1
M
1
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
2
1
1
1
M
M
M
M
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
1
M
PENICILLINS
amoxicillin & k clavulanate
chew tab 200-28.5 mg
chew tab 400-57 mg
amoxicillin & k clavulanate for
susp 200-28.5 mg/5ml
susp 400-57 mg/5ml
amoxicillin & k clavulanate tab
250-125 mg
500-125 mg
875-125 mg
sr 12hr 1000-62.5 mg
amoxicillin (trihydrate) cap 250
mg
Drug Name
Drug Requirements/
Tier
Limits
amoxicillin (trihydrate) cap 500
mg
amoxicillin (trihydrate) chew
tab 125 mg
tab 250 mg
amoxicillin (trihydrate) for susp
125 mg/5ml
200 mg/5ml
250 mg/5ml
400 mg/5ml
amoxicillin (trihydrate) tab 500
mg
amoxicillin (trihydrate) tab 875
mg
ampicillin & sulbactam sodium
for inj 1-0.5 gm
for inj 2-1 gm
for inj 10-5 gm
for iv soln 2-1 gm
for iv soln 10-5 gm
ampicillin cap 250 mg
ampicillin cap 500 mg
ampicillin for susp 125 mg/5ml
ampicillin for susp 250 mg/5ml
ampicillin sodium for inj 1 gm
ampicillin sodium for inj 125
mg
mg
mg
ampicillin sodium for iv soln 1
gm
gm
gm
BICILLIN L-A INJ 600000
ST - Step Therapy
LA - Limited Access
1
M
1
M
1
M
1
M
1
M
1
M
1
M
1
M
1
M
2
M
2
M
2
M
2
M
2
M
1
1
2
2
2
2
2
M
M
M
M
M
M
M
2
M
2
M
2
M
2
M
2
M
4
4
M
M
10
Drug Name
Drug Requirements/
Tier
Limits
dicloxacillin sodium cap 250
mg
mg
nafcillin sodium for inj 1 gm
nafcillin sodium for iv soln 1
gm
gm
oxacillin sodium for inj 1 gm
pen g proc inj 600000
PENICILL GK/ INJ DEX 2MU
penicillin g potassium for inj
5000000 unit
20000000 unit
penicillin g sodium for inj
5000000 unit
penicillin v potassium for soln
125 mg/5ml
250 mg/5ml
penicillin v potassium tab 250
mg
mg
piperacillin sod-tazobactam na
for inj 3.375 gm (3-0.375 gm)
piperacillin sod-tazobactam
sod for inj 2.25 gm (2-0.25 gm)
4
2
M
M
2
M
2
5
5
2
M
M
M
M
5
M
2
2
5
3
4
4
2
M
M
M
M
M
M
M
2
M
2
M
1
M
1
M
1
M
1
M
2
M
2
M
2
M
2
M
2
2
2
M
M
M
2
M
2
M
TETRACYCLINES
doxy 100 inj 100mg
doxycycline hyclate cap 50 mg
doxycycline hyclate cap 100
mg
doxycycline hyclate for inj 100
mg
doxycycline hyclate tab 20 mg
Drug Name
Drug Requirements/
Tier
Limits
doxycycline hyclate tab 100
mg
doxycycline monohydrate cap
50 mg
doxycycline monohydrate cap
100 mg
doxycycline monohydrate tab
50 mg
75 mg
100 mg
150 mg
minocycline hcl cap 50 mg
morgidox cap 1x50mg
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
2
2
2
M
M
M
M
ANTINEOPLASTIC AGENTS
ALKYLATING AGENTS
BENDEKA INJ 100/4ML
BICNU INJ 100MG
BUSULFEX INJ 6MG/ML
CYCLOPHOSPH CAP 25MG
cyclophosphamide for inj 1 gm
cyclophosphamide for inj 2 gm
cyclophosphamide for inj 500
mg
dacarbazine for inj 100 mg
dacarbazine for inj 200 mg
EMCYT CAP 140MG
GLEOSTINE CAP 5MG
GLEOSTINE CAP 10MG
GLEOSTINE CAP 40MG
GLEOSTINE CAP 100MG
HEXALEN CAP 50MG
IFEX INJ 3GM
ifosfamide for inj 1 gm
IFOSFAMIDE INJ 3GM
ifosfamide iv inj 1 gm/20ml (50
mg/ml)
ifosfamide iv inj 3 gm/60ml (50
mg/ml)
LEUKERAN TAB 2MG
melphalan hcl for inj 50 mg
(base equiv)
ST - Step Therapy
LA - Limited Access
5
4
5
4
4
5
2
5
B/D
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
2
2
4
4
4
4
4
5
4
2
4
2
B/D M
B/D M
M
M
M
M
M
M
B/D M
B/D M
B/D M
B/D M
2
B/D M
4
5
M
B/D M
11
Drug Name
Drug Requirements/
Tier
Limits
MUSTARGEN INJ 10MG
TREANDA INJ 25MG
TREANDA INJ 45/0.5ML
TREANDA INJ 100MG
TREANDA INJ 180/2ML
4
5
5
5
5
B/D M
B/D
B/D
B/D
B/D
2
B/D M
2
2
5
B/D M
B/D M
B/D M
2
B/D M
2
B/D M
5
B/D M
5
B/D M
5
B/D M
2
2
2
2
2
B/D M
B/D M
B/D M
B/D M
B/D M
2
2
2
5
5
5
5
B/D M
B/D M
B/D M
B/D M
B/D M
B/D
B/D M
2
2
B/D M
B/D M
2
B/D M
2
B/D M
2
B/D M
ANTHRACYCLINES
daunorubicin hcl inj 5 mg/ml
(base equiv)
doxorubicin hcl for inj 50 mg
doxorubicin hcl inj 2 mg/ml
doxorubicin hcl liposomal inj
(for iv infusion) 2 mg/ml
epirubicin hcl iv soln 50
mg/25ml (2 mg/ml)
mg/100ml (2 mg/ml)
idarubicin hcl iv inj 5 mg/5ml (1
mg/ml)
idarubicin hcl iv inj 10 mg/10ml
(1 mg/ml)
(1 mg/ml)
ANTIBIOTICS
bleomycin sulfate for inj 15 unit
bleomycin sulfate for inj 30 unit
mitomycin for iv soln 5 mg
ANTIMETABOLITES
adrucil inj 2.5g/50m
adrucil inj 5gm/100m
adrucil inj 500/10ml
ALIMTA INJ 100MG
ALIMTA INJ 500MG
azacitidine for inj 100 mg
cladribine iv soln 10 mg/10ml
(1 mg/ml)
cytarabine inj 20 mg/ml
fludarabine phosphate for inj
50 mg
fludarabine phosphate inj 25
mg/ml
fluorouracil inj 1 gm/20ml (50
mg/ml)
fluorouracil inj 2.5 gm/50ml (50
mg/ml)
Drug Name
Drug Requirements/
Tier
Limits
mg/ml)
fluorouracil inj 500 mg/10ml
(50 mg/ml)
gemcitabine hcl for inj 1 gm
gemcitabine hcl for inj 200 mg
GEMCITABINE HCL INJ 1
GM/26.3ML (38 MG/ML)
(BASE EQUIV)
(BASE EQUIV)
MG/5.26ML (38 MG/ML)
(BASE EQUIV)
mercaptopurine tab 50 mg
methotrexate sodium for inj 1
gm
METHOTREXATE SODIUM
INJ 50 MG/2ML (25 MG/ML)
methotrexate sodium inj 250
mg/10ml (25 mg/ml)
methotrexate sodium inj pf 50
mg/2ml (25 mg/ml)
mg/4ml (25 mg/ml)
mg/8ml (25 mg/ml)
mg/10ml (25 mg/ml)
methotrexate sodium inj pf
1000 mg/40ml (25 mg/ml)
NIPENT INJ 10MG
PURIXAN SUS 20MG/ML
TABLOID TAB 40MG
2
B/D M
2
B/D M
5
5
5
5
B/D M
B/D M
B/D M
B/D M
5
B/D M
5
B/D M
2
2
M
B/D M
2
B/D M
2
B/D M
2
B/D M
2
B/D M
2
B/D M
2
B/D M
2
B/D M
5
5
4
B/D M
5
5
B/D M
B/D M
5
B/D M
2
5
5
5
5
B/D M
B/D M
B/D M
B/D M
B/D M
M
ANTIMITOTIC, TAXOIDS
ABRAXANE INJ 100MG
DOCETAXEL FOR INJ CONC
20 MG/ML
DOCETAXEL FOR INJ CONC
80 MG/4ML (20 MG/ML)
DOCETAXEL INJ 20MG/2ML
docetaxel inj 140/7ml
DOCETAXEL INJ 160/16ML
DOCETAXEL INJ 200MG/20
ST - Step Therapy
LA - Limited Access
12
Drug Name
Drug Requirements/
Tier
Limits
paclitaxel iv conc 30 mg/5ml (6
mg/ml)
paclitaxel iv conc 100
mg/16.7ml (6 mg/ml)
paclitaxel iv conc 150 mg/25ml
(6 mg/ml)
(6 mg/ml)
2
B/D M
2
B/D M
2
B/D M
2
B/D M
ANTIMITOTIC, VINCA ALKALOIDS
vinblastine sulfate inj 1 mg/ml
vincasar pfs inj 1mg/ml
vincristine sulfate iv soln 1
mg/ml
vinorelbine tartrate inj 10
mg/ml (base equiv)
equiv)
3
2
2
B/D M
B/D M
B/D M
2
B/D M
2
B/D M
BIOLOGIC RESPONSE MODIFIERS
AVASTIN INJ
AVASTIN INJ 400/16ML
BELEODAQ INJ 500MG
ERIVEDGE CAP 150MG
FARYDAK CAP 10MG
FARYDAK CAP 15MG
FARYDAK CAP 20MG
HERCEPTIN INJ 440MG
IBRANCE CAP 75MG
IBRANCE CAP 100MG
IBRANCE CAP 125MG
ISTODAX INJ 10MG
KADCYLA INJ 100MG
KADCYLA INJ 160MG
KEYTRUDA INJ 100MG/4M
KEYTRUDA SOL 50MG
LYNPARZA CAP 50MG
NINLARO CAP 2.3MG
NINLARO CAP 3MG
NINLARO CAP 4MG
PROLEUKIN INJ 22MU
RITUXAN INJ 100MG
RITUXAN INJ 500MG
TECENTRIQ INJ 1200/20
VELCADE INJ 3.5MG
VENCLEXTA TAB 10MG
VENCLEXTA TAB 50MG
VENCLEXTA TAB 100MG
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
4
4
5
B/D LA
B/D LA
PA
LA PA
LA PA
LA PA
LA PA
B/D
LA PA
LA PA
LA PA
B/D
B/D
B/D
PA
PA
LA PA
PA
PA
PA
B/D
LA PA
LA PA
LA PA
B/D
LA PA
LA PA
LA PA
Drug Name
Drug Requirements/
Tier
Limits
VENCLEXTA TAB START PK
YERVOY INJ 50MG
YERVOY INJ 200MG
ZOLINZA CAP 100MG
5
5
5
5
LA PA
PA
PA
PA
HORMONAL ANTINEOPLASTIC AGENTS
anastrozole tab 1 mg
bicalutamide tab 50 mg
DEPO-PROVERA INJ 400/ML
exemestane tab 25 mg
FARESTON TAB 60MG
FASLODEX INJ 250MG
flutamide cap 125 mg
hydroxyprogesterone
caproate im in oil 1.25 gm/5ml
letrozole tab 2.5 mg
leuprolide acetate inj kit 5
mg/ml
LUPR DEP-PED INJ 7.5MG
LUPR DEP-PED INJ 15MG
LUPRON DEPOT INJ 3.75MG
LUPRON DEPOT INJ
11.25MG
LYSODREN TAB 500MG
megestrol acetate susp 40
mg/ml
PA if 65 years and older
MEGESTROL ACETATE
SUSP 625 MG/5ML
megestrol acetate tab 20 mg
NILANDRON TAB 150MG
nilutamide tab 150 mg
SOLTAMOX SOL 10MG/5ML
tamoxifen citrate tab 10 mg
(base equivalent)
(base equivalent)
TRELSTAR MIX INJ 3.75MG
XTANDI CAP 40MG
ZYTIGA TAB 250MG
2
2
4
2
5
5
2
4
M
M
B/D M
M
M
B/D M
M
B/D M
2
2
M
PA
5
5
5
5
5
5
PA
PA
PA
PA
PA
PA
3
4
M
M PA
5
M PA
4
M PA
4
M PA
5
5
4
1
M
M
M
M
1
M
5
5
5
5
PA
PA
LA PA
LA PA
5
PA
KINASE INHIBITORS
AFINITOR DIS TAB 2MG
ST - Step Therapy
LA - Limited Access
13
Drug Name
Drug Requirements/
Tier
Limits
AFINITOR TAB 2.5MG
AFINITOR TAB 5MG
AFINITOR TAB 7.5MG
AFINITOR TAB 10MG
ALECENSA CAP 150MG
BOSULIF TAB 100MG
BOSULIF TAB 500MG
CABOMETYX TAB 20MG
CABOMETYX TAB 40MG
CABOMETYX TAB 60MG
CAPRELSA TAB 100MG
CAPRELSA TAB 300MG
COMETRIQ KIT 60MG
COMETRIQ KIT 100MG
COMETRIQ KIT 140MG
COTELLIC TAB 20MG
GILOTRIF TAB 20MG
GILOTRIF TAB 30MG
GILOTRIF TAB 40MG
ICLUSIG TAB 15MG
ICLUSIG TAB 45MG
imatinib mesylate tab 100 mg
(base equivalent)
(base equivalent)
IMBRUVICA CAP 140MG
INLYTA TAB 1MG
INLYTA TAB 5MG
IRESSA TAB 250MG
JAKAFI TAB 5MG
JAKAFI TAB 10MG
JAKAFI TAB 15MG
JAKAFI TAB 20MG
JAKAFI TAB 25MG
LENVIMA CAP 8 MG
LENVIMA CAP 10 MG
LENVIMA CAP 14 MG
LENVIMA CAP 18 MG
LENVIMA CAP 20 MG
LENVIMA CAP 24 MG
MEKINIST TAB 0.5MG
MEKINIST TAB 2MG
NEXAVAR TAB 200MG
SPRYCEL TAB 20MG
SPRYCEL TAB 50MG
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
PA
PA
PA
PA
PA
PA
LA PA
PA
PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
PA
5
PA
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
PA
PA
Drug Name
Drug Requirements/
Tier
Limits
SPRYCEL TAB 70MG
SPRYCEL TAB 80MG
SPRYCEL TAB 100MG
SPRYCEL TAB 140MG
STIVARGA TAB 40MG
SUTENT CAP 12.5MG
SUTENT CAP 25MG
SUTENT CAP 37.5MG
SUTENT CAP 50MG
TAFINLAR CAP 50MG
TAFINLAR CAP 75MG
TAGRISSO TAB 40MG
TAGRISSO TAB 80MG
TARCEVA TAB 25MG
TARCEVA TAB 100MG
TARCEVA TAB 150MG
TASIGNA CAP 150MG
TASIGNA CAP 200MG
TYKERB TAB 250MG
VOTRIENT TAB 200MG
XALKORI CAP 200MG
XALKORI CAP 250MG
ZELBORAF TAB 240MG
ZYDELIG TAB 100MG
ZYDELIG TAB 150MG
ZYKADIA CAP 150MG
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
PA
PA
PA
PA
LA PA
PA
PA
PA
PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
PA
PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
5
3
3
3
2
5
5
5
2
PA
M
M
M
M
PA
PA
M LA
B/D
2
B/D
2
B/D
5
5
5
5
5
5
LA PA
LA PA
LA PA
LA PA
LA PA
PA
MISCELLANEOUS
bexarotene cap 75 mg
DROXIA CAP 200MG
DROXIA CAP 300MG
DROXIA CAP 400MG
hydroxyurea cap 500 mg
LONSURF TAB 15-6.14
LONSURF TAB 20-8.19
MATULANE CAP 50MG
mitoxantrone hcl inj conc 20
mg/10ml (2 mg/ml)
mg/12.5ml (2 mg/ml)
mg/15ml (2 mg/ml)
ODOMZO CAP 200MG
POMALYST CAP 1MG
POMALYST CAP 2MG
POMALYST CAP 3MG
POMALYST CAP 4MG
SYLATRON KIT 200MCG
ST - Step Therapy
LA - Limited Access
14
Drug Name
Drug Requirements/
Tier
Limits
SYLATRON KIT 300MCG
SYLATRON KIT 600MCG
SYNRIBO INJ 3.5MG
tretinoin cap 10 mg
TRISENOX SOL 10MG/10M
5
5
5
5
5
PA
PA
PA
M
B/D M
PLATINUM-BASED AGENTS
carboplatin iv soln 50 mg/5ml
carboplatin iv soln 150
mg/15ml
mg/45ml
mg/60ml
cisplatin inj 50 mg/50ml (1
mg/ml)
mg/ml)
mg/ml)
oxaliplatin for iv inj 50 mg
oxaliplatin for iv inj 100 mg
oxaliplatin iv soln 50 mg/10ml
Drug Requirements/
Tier
Limits
levoleucovorin calcium inj 175
mg/17.5ml (base equiv)
mesna inj 100 mg/ml
MESNEX TAB 400MG
5
B/D
2
5
B/D M
M
TOPOISOMERASE INHIBITORS
etoposide inj 500 mg/25ml (20
mg/ml)
irinotecan hcl inj 40 mg/2ml
(20 mg/ml)
(20 mg/ml)
(20 mg/ml)
toposar inj 1gm/50ml
topotecan hcl for inj 4 mg
2
B/D M
2
B/D M
2
B/D M
2
B/D M
2
5
B/D M
B/D M
2
2
B/D M
B/D M
2
B/D M
2
B/D M
2
B/D M
2
B/D M
CARDIOVASCULAR
ACE INHIBITOR COMBINATIONS
2
B/D M
5
5
5
5
B/D M
B/D M
B/D M
B/D M
5
B/D M
5
5
5
5
2
B/D M
B/D M
B/D M
B/D
B/D M
2
B/D M
2
B/D M
2
B/D M
2
B/D M
2
2
2
2
5
5
M
M
M
M
B/D
B/D
amlodipine
besylate-benazepril hcl cap
2.5-10 mg
amlodipine
5-10 mg
amlodipine
5-20 mg
amlodipine
5-40 mg
amlodipine
10-20 mg
amlodipine
10-40 mg
benazepril &
hydrochlorothiazide tab 5-6.25
mg
benazepril &
hydrochlorothiazide tab
10-12.5 mg
PROTECTIVE AGENTS
amifostine crystalline for inj
500 mg
dexrazoxane for inj 250 mg
ELITEK INJ 1.5MG
ELITEK INJ 7.5MG
FUSILEV INJ 50MG
leucovorin calcium for inj 50
mg
mg
mg
mg
mg
leucovorin calcium tab 5 mg
levoleucovor sol 250mg/25
levoleucovorin calcium for iv
inj 50 mg (base equiv)
Drug Name
ST - Step Therapy
LA - Limited Access
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
M
1
M
1
M
15
Drug Name
Drug Requirements/
Tier
Limits
benazepril &
20-12.5 mg
benazepril &
hydrochlorothiazide tab 20-25
mg
captopril &
mg
captopril &
mg
captopril &
mg
captopril &
mg
enalapril maleate &
mg
enalapril maleate &
mg
fosinopril sodium &
10-12.5 mg
fosinopril sodium &
20-12.5 mg
lisinopril & hydrochlorothiazide
tab 10-12.5 mg
tab 20-12.5 mg
tab 20-25 mg
moexipril-hydrochlorothiazide
tab 7.5-12.5 mg
tab 15-12.5 mg
tab 15-25 mg
quinapril-hydrochlorothiazide
tab 10-12.5 mg
tab 20-12.5 mg
tab 20-25 mg
1
M
1
M
1
M
1
M
1
M
1
M
1
M
1
M
1
M
1
M
1
M
1
M
1
M
1
M
1
M
1
M
1
M
1
M
1
M
Drug Name
Drug Requirements/
Tier
Limits
ACE INHIBITORS
benazepril hcl tab 5 mg
captopril tab 12.5 mg
captopril tab 25 mg
captopril tab 50 mg
captopril tab 100 mg
enalapril maleate tab 2.5 mg
enalapril maleate tab 5 mg
fosinopril sodium tab 10 mg
lisinopril tab 2.5 mg
lisinopril tab 5 mg
lisinopril tab 10 mg
moexipril hcl tab 7.5 mg
moexipril hcl tab 15 mg
perindopril erbumine tab 2 mg
quinapril hcl tab 5 mg
ramipril cap 1.25 mg
ramipril cap 2.5 mg
ramipril cap 5 mg
ramipril cap 10 mg
trandolapril tab 1 mg
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
ALDOSTERONE RECEPTOR
ANTAGONISTS
eplerenone tab 25 mg
eplerenone tab 50 mg
spironolactone tab 25 mg
2
2
1
1
1
M
M
M
M
M
ALPHA BLOCKERS
ST - Step Therapy
LA - Limited Access
16
Drug Name
Drug Requirements/
Tier
Limits
doxazosin mesylate tab 1 mg
prazosin hcl cap 1 mg
terazosin hcl cap 1 mg
2
QL M
2
QL M
2
QL M
2
2
2
2
1
1
1
1
M
M
M
M
M
M
M
M
ANGIOTENSIN II RECEPTOR
ANTAGONIST COMBINATIONS
amlodipine besylate-valsartan
tab 5-160 mg
tab 5-320 mg
tab 10-160 mg
tab 10-320 mg
amlodipine-valsartan-hydrochl
orothiazide tab 5-160-12.5 mg
orothiazide tab 5-160-25 mg
orothiazide tab 10-160-12.5
mg
AZOR TAB 5-20MG
AZOR TAB 5-40MG
AZOR TAB 10-20MG
1
QL M
1
QL M
1
QL M
1
M
1
QL M
1
QL M
1
1
QL M
QL M
Drug Name
Drug Requirements/
Tier
Limits
AZOR TAB 10-40MG
BENICAR HCT TAB 20-12.5
BENICAR HCT TAB 40-25MG
ENTRESTO TAB 24-26MG
irbesartan-hydrochlorothiazide
tab 150-12.5 mg
irbesartan-hydrochlorothiazide
tab 300-12.5 mg
losartan potassium &
50-12.5 mg
100-12.5 mg
100-25 mg
TRIBENZOR20- TAB
5-12.5MG
TRIBENZOR40- TAB
5-12.5MG
TRIBENZOR40- TAB 5-25MG
TRIBENZOR40- TAB 10-12.5
TRIBENZOR40- TAB
10-25MG
valsartan-hydrochlorothiazide
tab 80-12.5 mg
tab 160-12.5 mg
tab 160-25 mg
tab 320-12.5 mg
tab 320-25 mg
3
3
3
3
4
4
4
1
M
M
M
M
M PA
M PA
M PA
M
1
M
1
M
1
M
1
M
3
QL M
3
QL M
3
QL M
3
QL M
3
M
1
M
1
M
1
M
1
M
1
M
1
M
3
QL M
ANGIOTENSIN II RECEPTOR
ANTAGONISTS
3
QL M
3
QL M
BENICAR TAB 5MG
BENICAR TAB 20MG
BENICAR TAB 40MG
irbesartan tab 75 mg
ST - Step Therapy
LA - Limited Access
3
3
3
1
M
M
M
M
17
Drug Name
Drug Requirements/
Tier
Limits
losartan potassium tab 25 mg
valsartan tab 40 mg
valsartan tab 80 mg
valsartan tab 160 mg
valsartan tab 320 mg
1
1
1
1
1
1
1
1
1
M
M
M
M
M
M
M
M
M
ANTIARRHYTHMICS
amiodarone hcl inj 150 mg/3ml
(50 mg/ml)
amiodarone hcl inj 450 mg/9ml
(50 mg/ml)
amiodarone hcl inj 900
mg/18ml (50 mg/ml)
amiodarone hcl tab 100 mg
disopyramide phosphate cap
100 mg
150 mg
dofetilide cap 125 mcg (0.125
mg)
mg)
mg)
flecainide acetate tab 50 mg
mexiletine hcl cap 150 mg
MULTAQ TAB 400MG
NORPACE CAP 100MG CR
pacerone tab 100mg
pacerone tab 200mg
pacerone tab 400mg
propafenone hcl cap sr 12hr
225 mg
2
M
2
M
2
M
2
1
2
4
M
M
M
M PA
4
M PA
2
Drug Name
Drug Requirements/
Tier
Limits
325 mg
425 mg
propafenone hcl tab 150 mg
quinidine gluconate tab cr 324
mg
quinidine sulfate tab 200 mg
sorine tab 80mg
sorine tab 120mg
sorine tab 160mg
sorine tab 240mg
sotalol hcl (afib/afl) tab 80 mg
sotalol hcl tab 80 mg
TIKOSYN CAP 125MCG
TIKOSYN CAP 250MCG
TIKOSYN CAP 500MCG
2
M
2
M
2
2
2
2
M
M
M
M
2
2
2
2
2
2
2
2
2
1
1
1
1
4
4
4
M
M
M
M
M
M
M
M
M
M
M
M
M
ANTILIPEMICS, HMG-CoA REDUCTASE
INHIBITORS
2
2
2
2
2
2
2
2
4
4
M
M
M
M
M
M
M
M PA
4
M PA
2
1
2
2
M
M
M
M
atorvastatin calcium tab 10 mg
(base equivalent)
(base equivalent)
(base equivalent)
(base equivalent)
CRESTOR TAB 5MG
CRESTOR TAB 10MG
CRESTOR TAB 20MG
CRESTOR TAB 40MG
ST - Step Therapy
LA - Limited Access
1
QL M
1
QL M
1
QL M
1
QL M
3
QL M
3
QL M
3
QL M
3
QL M
18
Drug Name
Drug Requirements/
Tier
Limits
lovastatin tab 10 mg
pravastatin sodium tab 10 mg
rosuvastatin calcium tab 5 mg
rosuvastatin calcium tab 10
mg
mg
mg
simvastatin tab 5 mg
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
ANTILIPEMICS, MISCELLANEOUS
cholestyramine light powder 4
gm/dose
cholestyramine light powder
packets 4 gm
cholestyramine powder 4
gm/dose
cholestyramine powder
packets 4 gm
choline fenofibrate cap dr 45
mg (fenofibric acid equiv)
mg (fenofibric acid equiv)
2
M
2
M
2
M
2
M
2
M
2
M
Drug Name
Drug Requirements/
Tier
Limits
colestipol hcl granule packets
5 gm
colestipol hcl granules 5 gm
colestipol hcl tab 1 gm
fenofibrate micronized cap 67
mg
fenofibrate micronized cap
134 mg
200 mg
fenofibrate tab 48 mg
gemfibrozil tab 600 mg
JUXTAPID CAP 5MG
JUXTAPID CAP 10MG
JUXTAPID CAP 20MG
JUXTAPID CAP 30MG
JUXTAPID CAP 40MG
JUXTAPID CAP 60MG
KYNAMRO INJ 200MG/ML
niacin tab cr 500 mg
(antihyperlipidemic)
niacor tab 500mg
omega-3-acid ethyl esters cap
1 gm
PRALUENT INJ 75MG/ML
prevalite pow 4gm
prevalite pow 4gm pk
VASCEPA CAP 1GM
WELCHOL PAK 3.75GM
WELCHOL TAB 625MG
ZETIA TAB 10MG
2
M
2
2
2
M
M
M
2
M
2
M
2
2
2
2
1
5
5
5
5
5
5
5
2
M
M
M
M
M
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
PA
QL M
2
M
2
M
2
2
M
M
5
5
2
2
4
3
3
3
PA
PA
M
M
M
M
M
M
2
M
2
M
BETA-BLOCKER/DIURETIC
COMBINATIONS
atenolol & chlorthalidone tab
50-25 mg
100-25 mg
ST - Step Therapy
LA - Limited Access
19
Drug Name
Drug Requirements/
Tier
Limits
bisoprolol &
2.5-6.25 mg
bisoprolol &
mg
bisoprolol &
10-6.25 mg
metoprolol &
mg
metoprolol &
100-25 mg
metoprolol &
100-50 mg
propranolol &
mg
propranolol &
mg
1
M
1
M
1
M
2
M
2
M
2
M
2
M
2
M
BETA-BLOCKERS
acebutolol hcl cap 200 mg
acebutolol hcl cap 400 mg
atenolol tab 25 mg
atenolol tab 50 mg
atenolol tab 100 mg
bisoprolol fumarate tab 5 mg
BYSTOLIC TAB 2.5MG
BYSTOLIC TAB 5MG
BYSTOLIC TAB 10MG
BYSTOLIC TAB 20MG
carvedilol tab 3.125 mg
carvedilol tab 25 mg
labetalol hcl tab 100 mg
metoprolol succinate tab sr
24hr 25 mg (tartrate equiv)
1
1
1
1
1
2
2
4
4
4
4
1
1
1
1
2
2
2
2
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
QL M
Drug Name
Drug Requirements/
Tier
Limits
metoprolol tartrate inj 1 mg/ml
metoprolol tartrate tab 25 mg
nadolol tab 20 mg
nadolol tab 40 mg
nadolol tab 80 mg
pindolol tab 5 mg
pindolol tab 10 mg
propranolol hcl cap sr 24hr 60
mg
mg
propranolol hcl cap sr 24hr
120 mg
160 mg
propranolol hcl inj 1 mg/ml
propranolol hcl oral soln 20
mg/5ml
mg/5ml
propranolol hcl tab 10 mg
timolol maleate tab 5 mg
2
QL M
2
QL M
2
M
2
1
1
1
2
2
2
2
2
2
M
M
M
M
M
M
M
M
M
M
2
M
2
M
2
M
2
2
M
M
2
M
1
1
1
1
1
2
2
2
M
M
M
M
M
M
M
M
CALCIUM CHANNEL BLOCKERS
afeditab tab 30mg cr
afeditab tab 60mg cr
amlodipine besylate tab 2.5
mg
amlodipine besylate tab 5 mg
ST - Step Therapy
LA - Limited Access
2
QL M
2
1
M
QL M
1
QL M
20
Drug Name
Drug Requirements/
Tier
Limits
diltiazem hcl cap sr 12hr 60
mg
mg
mg
mg
mg
mg
diltiazem hcl coated beads cap
sr 24hr 120 mg
sr 24hr 180 mg
sr 24hr 240 mg
sr 24hr 300 mg
sr 24hr 360 mg
diltiazem hcl extended release
beads cap sr 24hr 120 mg
diltiazem hcl iv soln 25 mg/5ml
(5 mg/ml)
diltiazem hcl iv soln 50
mg/10ml (5 mg/ml)
mg/25ml (5 mg/ml)
diltiazem hcl tab 30 mg
felodipine tab sr 24hr 2.5 mg
1
2
M
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
1
1
1
1
2
M
M
M
M
QL M
Drug Name
Drug Requirements/
Tier
Limits
felodipine tab sr 24hr 5 mg
isradipine cap 2.5 mg
isradipine cap 5 mg
nicardipine hcl cap 20 mg
nicardipine hcl cap 30 mg
nifedical xl tab 30mg
nifedical xl tab 60mg
nifedipine tab sr 24hr 30 mg
nifedipine tab sr 24hr osmotic
release 30 mg
release 60 mg
release 90 mg
nimodipine cap 30 mg
NYMALIZE SOL 60/20ML
taztia xt cap 120mg/24
verapamil hcl cap sr 24hr 100
mg
mg
mg
mg
mg
mg
VERAPAMIL HCL CAP SR
24HR 360 MG
verapamil hcl iv soln 2.5 mg/ml
verapamil hcl tab 40 mg
verapamil hcl tab cr 120 mg
ST - Step Therapy
LA - Limited Access
2
QL M
2
2
2
2
2
2
M
M
M
M
M
QL M
2
2
M
QL M
2
2
2
M
M
QL M
2
M
2
M
5
5
2
2
2
2
2
2
M
M
M
M
M
M
M
M
2
M
2
M
2
M
2
M
2
M
2
M
2
1
1
1
1
M
M
M
M
M
21
Drug Name
Drug Requirements/
Tier
Limits
1
1
M
M
2
M PA
2
QL M
2
2
M
M PA
2
QL M
2
M PA
DIGITALIS GLYCOSIDES
digitek tab 0.25mg
digitek tab 0.125mg
digoxin inj 0.25 mg/ml
DIGOXIN ORAL SOLN 0.05
MG/ML
digoxin tab 125 mcg (0.125
mg)
digoxin tab 250 mcg (0.25 mg)
DIRECT RENIN
INHIBITORS/COMBINATIONS
TEKTURNA HCT TAB
150-12.5
TEKTURNA HCT TAB
150-25MG
TEKTURNA HCT TAB
300-12.5
TEKTURNA HCT TAB
300-25MG
TEKTURNA TAB 150MG
TEKTURNA TAB 300MG
3
QL M
3
QL M
3
QL M
3
M
3
QL M
3
M
2
M
2
2
1
M
M
M
2
2
2
2
2
2
2
M
M
M
M
M
M
M
DIURETICS
acetazolamide cap sr 12hr 500
mg
acetazolamide tab 125 mg
acetazolamide tab 250 mg
amiloride &
mg
amiloride hcl tab 5 mg
bumetanide inj 0.25 mg/ml
bumetanide tab 0.5 mg
bumetanide tab 1 mg
bumetanide tab 2 mg
chlorothiazide tab 250 mg
chlorothiazide tab 500 mg
Drug Name
Drug Requirements/
Tier
Limits
chlorthalidone tab 25 mg
chlorthalidone tab 50 mg
furosemide inj 10 mg/ml
FUROSEMIDE INJ 10 MG/ML
furosemide oral soln 8 mg/ml
furosemide tab 20 mg
hydrochlorothiazide cap 12.5
mg
hydrochlorothiazide tab 12.5
mg
hydrochlorothiazide tab 25 mg
hydrochlorothiazide tab 50 mg
indapamide tab 1.25 mg
indapamide tab 2.5 mg
methazolamide tab 25 mg
methazolamide tab 50 mg
methyclothiazide tab 5 mg
metolazone tab 2.5 mg
metolazone tab 5 mg
metolazone tab 10 mg
spironolactone &
mg
torsemide inj 50mg/5ml
torsemide tab 5 mg
torsemide tab 10 mg
torsemide tab 20 mg
torsemide tab 100 mg
triamterene &
hydrochlorothiazide cap
37.5-25 mg
triamterene &
37.5-25 mg
triamterene &
mg
2
2
2
2
1
1
1
1
1
1
M
M
M
M
M
M
M
M
M
M
1
M
1
1
1
1
2
2
2
2
2
2
2
M
M
M
M
M
M
M
M
M
M
M
2
1
1
1
1
1
M
M
M
M
M
M
1
M
1
M
1
1
1
2
M
M
M
M
MISCELLANEOUS
clonidine hcl tab 0.1 mg
clonidine hcl td patch weekly
0.1 mg/24hr
ST - Step Therapy
LA - Limited Access
22
Drug Name
Drug Requirements/
Tier
Limits
0.2 mg/24hr
0.3 mg/24hr
DEMSER CAP 250MG
hydralazine hcl inj 20 mg/ml
hydralazine hcl tab 10 mg
midodrine hcl tab 2.5 mg
midodrine hcl tab 5 mg
midodrine hcl tab 10 mg
minoxidil tab 2.5 mg
minoxidil tab 10 mg
RANEXA TAB 500MG
RANEXA TAB 1000MG
2
M
2
M
5
2
2
2
2
2
2
2
2
2
2
3
3
M
M
M
M
M
M
M
M
M
M
M
M
M
2
2
2
2
2
M
M
M
M
M
1
M
1
M
1
M
1
M
1
M
2
2
2
2
3
4
4
2
M
M
M
M
M
M
M
M
2
M
2
M
NITRATES
isosorbide dinitrate tab 5 mg
isosorbide dinitrate tab cr 40
mg
isosorbide mononitrate tab 10
mg
isosorbide mononitrate tab 20
mg
isosorbide mononitrate tab sr
24hr 30 mg
24hr 60 mg
24hr 120 mg
minitran dis 0.1mg/hr
nitro-bid oin 2%
NITRO-DUR DIS 0.3MG/HR
nitroglycerin td patch 24hr 0.1
mg/hr
mg/hr
mg/hr
Drug Name
Drug Requirements/
Tier
Limits
mg/hr
NITROSTAT SUB 0.3MG
NITROSTAT SUB 0.4MG
NITROSTAT SUB 0.6MG
2
M
3
3
3
M
M
M
PULMONARY ARTERIAL HYPERTENSION
ADEMPAS TAB 0.5MG
ADEMPAS TAB 1.5MG
ADEMPAS TAB 1MG
ADEMPAS TAB 2.5MG
ADEMPAS TAB 2MG
LETAIRIS TAB 5MG
LETAIRIS TAB 10MG
OPSUMIT TAB 10MG
REMODULIN INJ 1MG/ML
REMODULIN INJ 2.5MG/ML
REVATIO SUS 10MG/ML
QL (224 mL / 30 days)
sildenafil citrate tab 20 mg
TRACLEER TAB 62.5MG
TRACLEER TAB 125MG
UPTRAVI TAB 200/800
UPTRAVI TAB 200MCG
UPTRAVI TAB 400MCG
UPTRAVI TAB 600MCG
UPTRAVI TAB 800MCG
UPTRAVI TAB 1000MCG
UPTRAVI TAB 1200MCG
ST - Step Therapy
LA - Limited Access
5
QL LA PA
5
QL LA PA
5
QL LA PA
5
QL LA PA
5
QL LA PA
5
QL LA PA
5
QL LA PA
5
QL LA PA
5
5
5
5
5
B/D LA
B/D LA
B/D LA
B/D LA
QL PA
2
QL PA
5
QL LA PA
5
QL LA PA
5
5
LA PA
QL LA PA
5
QL LA PA
5
QL LA PA
5
QL LA PA
5
QL LA PA
5
QL LA PA
23
Drug Name
Drug Requirements/
Tier
Limits
UPTRAVI TAB 1400MCG
UPTRAVI TAB 1600MCG
5
QL LA PA
5
QL LA PA
CENTRAL NERVOUS SYSTEM
ANTIANXIETY
alprazolam tab 0.5 mg
alprazolam tab 0.25 mg
alprazolam tab 1 mg
alprazolam tab 2 mg
buspirone hcl tab 5 mg
buspirone hcl tab 7.5 mg
fluvoxamine maleate tab 25
mg
mg
mg
lorazepam con 2mg/ml
QL (150 mL / 30 days)
lorazepam inj 2 mg/ml
lorazepam inj 4 mg/ml
lorazepam tab 0.5 mg
lorazepam tab 1 mg
lorazepam tab 2 mg
1
QL M
1
QL M
1
QL M
1
QL M
2
2
2
2
2
2
M
M
M
M
M
QL M
2
QL M
2
M
2
QL M
2
2
1
M
M
QL M
1
QL M
1
QL M
4
QL M
5
QL M
5
QL M
5
QL M
5
4
M PA
M PA
ANTICONVULSANTS
APTIOM TAB 200MG
APTIOM TAB 400MG
APTIOM TAB 600MG
APTIOM TAB 800MG
BANZEL SUS 40MG/ML
BANZEL TAB 200MG
Drug Name
Drug Requirements/
Tier
Limits
BANZEL TAB 400MG
BRIVIACT INJ 50MG/5ML
BRIVIACT SOL 10MG/ML
BRIVIACT TAB 10MG
BRIVIACT TAB 25MG
BRIVIACT TAB 50MG
BRIVIACT TAB 75MG
BRIVIACT TAB 100MG
carbamazepine cap sr 12hr
100 mg
200 mg
300 mg
carbamazepine chew tab 100
mg
carbamazepine susp 100
mg/5ml
carbamazepine tab 200 mg
carbamazepine tab sr 12hr
100 mg
200 mg
400 mg
CELONTIN CAP 300MG
clonazepam orally
disintegrating tab 0.5 mg
clonazepam orally
clonazepam orally
clonazepam orally
disintegrating tab 1 mg
clonazepam orally
clonazepam tab 0.5 mg
clonazepam tab 1 mg
clonazepam tab 2 mg
ST - Step Therapy
LA - Limited Access
5
4
5
5
5
5
5
5
2
M PA
M PA
M PA
M PA
M PA
M PA
M PA
M PA
M
2
M
2
M
2
M
2
M
2
2
M
M
2
M
2
M
4
2
M
QL M
2
QL M
2
QL M
2
QL M
2
QL M
1
QL M
1
QL M
1
QL M
24
Drug Name
Drug Requirements/
Tier
Limits
clorazepate dipotassium tab
3.75 mg
7.5 mg
15 mg
diazepam con 5mg/ml
QL (240 mL / 30 days)
diazepam inj 5 mg/ml
diazepam oral soln 1 mg/ml
QL (1200 mL / 30 days)
DIAZEPAM RECTAL GEL
DELIVERY SYSTEM 2.5 MG
DIAZEPAM RECTAL GEL
DELIVERY SYSTEM 10 MG
DIAZEPAM RECTAL GEL
diazepam tab 2 mg
diazepam tab 5 mg
diazepam tab 10 mg
dilantin cap 30mg
dilantin cap 100mg
dilantin chw 50mg
DILANTIN-125 SUS 125/5ML
divalproex sodium cap
delayed release sprinkle 125
mg
divalproex sodium tab delayed
release 125 mg
release 250 mg
release 500 mg
divalproex sodium tab sr 24 hr
250 mg
divalproex sodium tab sr 24 hr
500 mg
epitol tab 200mg
ethosuximide cap 250 mg
ethosuximide soln 250 mg/5ml
felbamate susp 600 mg/5ml
felbamate tab 400 mg
2
QL M PA
2
QL M PA
2
QL M PA
2
QL M PA
2
2
M
QL M PA
2
M
2
M
2
M
1
QL M PA
1
QL M PA
1
QL M PA
3
3
3
3
2
M
M
M
M
M
2
M
2
M
2
M
2
M
2
M
2
2
2
5
2
M
M
M
M
M
Drug Name
Drug Requirements/
Tier
Limits
felbamate tab 600 mg
FYCOMPA SUS 0.5MG/ML
QL (720 mL / 30 days)
FYCOMPA TAB 2MG
FYCOMPA TAB 4MG
FYCOMPA TAB 6MG
FYCOMPA TAB 8MG
FYCOMPA TAB 10MG
FYCOMPA TAB 12MG
gabapentin cap 100 mg
gabapentin oral soln 250
mg/5ml
QL (2160 mL / 30 days)
gabapentin tab 600 mg
gabapentin tab 800 mg
GABITRIL TAB 12MG
GABITRIL TAB 16MG
lamotrigine tab 25 mg
lamotrigine tab chewable
dispersible 5 mg
dispersible 25 mg
lamotrigine tab sr 24hr 25 mg
LEVETIRACETA INJ 5MG/ML
LEVETIRACETA INJ
10MG/ML
ST - Step Therapy
LA - Limited Access
2
4
M
QL M PA
4
QL M PA
4
QL M PA
4
QL M PA
4
QL M PA
4
QL M PA
4
QL M PA
1
QL M
1
QL M
1
QL M
2
QL M
2
QL M
2
QL M
4
4
1
1
1
1
2
M
M
M
M
M
M
M
2
M
2
2
2
2
2
2
4
4
M
M
M
M
M
M
M
M
25
Drug Name
Drug Requirements/
Tier
Limits
LEVETIRACETA INJ
15MG/ML
levetiracetam inj 500 mg/5ml
(100 mg/ml)
levetiracetam oral soln 100
mg/ml
levetiracetam tab 250 mg
levetiracetam tab sr 24hr 500
mg
mg
LYRICA CAP 25MG
LYRICA CAP 50MG
LYRICA CAP 75MG
LYRICA CAP 100MG
LYRICA CAP 150MG
LYRICA CAP 200MG
LYRICA CAP 225MG
LYRICA CAP 300MG
LYRICA SOL 20MG/ML
QL (946 mL / 30 days)
ONFI SUS 2.5MG/ML
ONFI TAB 10MG
ONFI TAB 20MG
oxcarbazepine susp 300
mg/5ml (60 mg/ml)
oxcarbazepine tab 150 mg
PEGANONE TAB 250MG
PHENOBARB INJ 65MG/ML
phenobarbital elixir 20 mg/5ml
phenobarbital sodium inj 130
mg/ml
4
M
2
M
2
M
2
2
2
2
2
M
M
M
M
M
2
M
3
QL M
3
QL M
3
QL M
3
QL M
3
QL M
3
QL M
3
QL M
3
QL M
3
QL M
5
4
5
2
M PA
M PA
M PA
M
2
2
2
4
4
M
M
M
M
M PA
4
M PA
4
M PA
Drug Name
Drug Requirements/
Tier
Limits
phenobarbital tab 15 mg
phenobarbital tab 16.2 mg
phenytek cap 200mg
phenytek cap 300mg
phenytoin chew tab 50 mg
phenytoin sodium extended
cap 100 mg
cap 200 mg
cap 300 mg
phenytoin sodium inj 50 mg/ml
phenytoin susp 125 mg/5ml
POTIGA TAB 50MG
POTIGA TAB 200MG
POTIGA TAB 300MG
POTIGA TAB 400MG
primidone tab 50 mg
primidone tab 250 mg
roweepra tab 500mg
SABRIL POW 500MG
QL (180 packets / 30
days)
SABRIL TAB 500MG
SPRITAM TAB 250MG
SPRITAM TAB 500MG
SPRITAM TAB 750MG
SPRITAM TAB 1000MG
TEGRETOL SUS 100/5ML
TEGRETOL TAB 200MG
ST - Step Therapy
LA - Limited Access
4
M PA
4
M PA
4
M PA
4
M PA
4
M PA
4
M PA
4
M PA
4
M PA
3
3
2
2
M
M
M
M
2
M
2
M
2
2
4
5
M
M
M
QL M
5
QL M
5
QL M
2
2
2
5
M
M
M
QL LA PA
5
QL LA PA
4
4
4
4
4
4
M
M
M
M
M
M
26
Drug Name
Drug Requirements/
Tier
Limits
TEGRETOL-XR TAB 100MG
tiagabine hcl tab 2 mg
tiagabine hcl tab 4 mg
topiramate sprinkle cap 15 mg
topiramate sprinkle cap 25 mg
topiramate tab 25 mg
valproate sodium inj 100
mg/ml
valproate sodium syrup 250
mg/5ml (base equiv)
valproic acid cap 250 mg
VIMPAT INJ 200MG/20
VIMPAT SOL 10MG/ML
QL (1200 mL / 30 days)
VIMPAT TAB 50MG
VIMPAT TAB 100MG
VIMPAT TAB 150MG
VIMPAT TAB 200MG
zonisamide cap 25 mg
4
4
4
2
2
2
2
1
1
1
1
2
M
M
M
M
M
M
M
M
M
M
M
M
2
M
2
4
4
M
M
QL M
4
QL M
5
QL M
5
QL M
5
QL M
2
2
2
M
M
M
2
QL M
ANTIDEMENTIA
donepezil hydrochloride orally
donepezil hydrochloride orally
donepezil hydrochloride tab 5
mg
mg
mg
EXELON DIS 4.6MG/24
QL (30 patches / 30
days)
2
M
2
QL M
2
M
2
M
4
QL M
Drug Name
Drug Requirements/
Tier
Limits
EXELON DIS 9.5MG/24
QL (30 patches / 30
days)
EXELON DIS 13.3/24
QL (30 patches / 30
days)
galantamine hydrobromide
cap sr 24hr 8 mg
cap sr 24hr 16 mg
cap sr 24hr 24 mg
oral soln 4 mg/ml
galantamine hydrobromide tab
4 mg
8 mg
12 mg
memantine hcl oral solution 2
mg/ml
PA if < 30 yrs
memantine hcl tab 5 mg
PA if < 30 yrs
memantine hcl tab 10 mg
PA if < 30 yrs
NAMENDA XR CAP 7MG
PA if < 30 yrs
NAMENDA XR CAP 14MG
PA if < 30 yrs
NAMENDA XR CAP 21MG
PA if < 30 yrs
NAMENDA XR CAP 28MG
PA if < 30 yrs
NAMENDA XR CAP
TITRATIO
PA if < 30 yrs
NAMZARIC CAP 14-10MG
rivastigmine tartrate cap 1.5
mg
rivastigmine tartrate cap 3 mg
ST - Step Therapy
LA - Limited Access
4
QL M
4
QL M
2
QL M
2
QL M
2
M
2
M
2
QL M
2
QL M
2
M
2
M PA
2
M PA
2
M PA
4
M PA
4
M PA
4
M PA
4
M PA
4
M PA
4
4
2
M
M
M
2
M
27
Drug Name
Drug Requirements/
Tier
Limits
mg
rivastigmine td patch 24hr 4.6
mg/24hr
QL (30 patches / 30
days)
mg/24hr
QL (30 patches / 30
days)
mg/24hr
QL (30 patches / 30
days)
2
M
2
2
M
QL M
2
2
QL M
QL M
ANTIDEPRESSANTS
amitriptyline hcl tab 10 mg
amoxapine tab 25 mg
amoxapine tab 50 mg
amoxapine tab 100 mg
amoxapine tab 150 mg
BRINTELLIX TAB 5MG
BRINTELLIX TAB 10MG
BRINTELLIX TAB 20MG
bupropion hcl tab 75 mg
bupropion hcl tab 100 mg
bupropion hcl tab sr 12hr 100
mg
mg
mg
4
4
4
4
M PA
M PA
M PA
M PA
4
M PA
4
M PA
2
2
2
2
4
M
M
M
M
QL M
4
QL M
4
QL M
2
2
2
M
M
M
2
M
2
M
Drug Name
Drug Requirements/
Tier
Limits
mg
mg
citalopram hydrobromide oral
soln 10 mg/5ml
citalopram hydrobromide tab
10 mg (base equiv)
20 mg (base equiv)
40 mg (base equiv)
clomipramine hcl cap 25 mg
desipramine hcl tab 10 mg
doxepin hcl cap 10 mg
doxepin hcl conc 10 mg/ml
duloxetine hcl enteric coated
pellets cap 20 mg
ST - Step Therapy
LA - Limited Access
2
QL M
2
QL M
2
M
1
QL M
1
QL M
1
QL M
4
M PA
4
M PA
4
M PA
2
2
2
2
2
2
4
M
M
M
M
M
M
M PA
4
M PA
4
M PA
4
M PA
4
M PA
4
M PA
4
M PA
2
QL M
28
Drug Name
Drug Requirements/
Tier
Limits
pellets cap 30 mg
pellets cap 60 mg
EMSAM DIS 6MG/24HR
QL (30 patches / 30
days)
EMSAM DIS 9MG/24HR
QL (30 patches / 30
days)
EMSAM DIS 12MG/24H
QL (30 patches / 30
days)
escitalopram oxalate soln 5
mg/5ml (base equiv)
QL (600 mL / 30 days)
escitalopram oxalate tab 5 mg
(base equiv)
escitalopram oxalate tab 10
mg (base equiv)
mg (base equiv)
FETZIMA CAP 20MG
FETZIMA CAP 40MG
FETZIMA CAP 80MG
FETZIMA CAP 120MG
FETZIMA CAP TITRATIO
fluoxetine hcl cap 10 mg
fluoxetine hcl solution 20
mg/5ml
fluoxetine hcl tab 10 mg
fluoxetine hcl tab 20 mg
imipramine hcl tab 10 mg
2
QL M
2
QL M
5
QL M PA
5
QL M PA
5
QL M PA
2
QL M
2
QL M
2
QL M
2
QL M
4
QL M
4
QL M
4
QL M
4
QL M
4
1
M
QL M
1
QL M
1
2
M
M
2
QL M
2
4
M
M PA
Drug Name
Drug Requirements/
Tier
Limits
maprotiline hcl tab 25 mg
MARPLAN TAB 10MG
mirtazapine orally
mirtazapine orally
mirtazapine orally
mirtazapine tab 7.5 mg
mirtazapine tab 15 mg
nefazodone hcl tab 50 mg
nortriptyline hcl cap 10 mg
nortriptyline hcl soln 10
mg/5ml
paroxetine hcl tab 10 mg
PAXIL SUS 10MG/5ML
QL (900 mL / 30 days)
phenelzine sulfate tab 15 mg
PRISTIQ TAB 25MG
PRISTIQ TAB 50MG
ST - Step Therapy
LA - Limited Access
4
M PA
4
M PA
2
2
2
4
M
M
M
QL M
2
QL M
2
M
2
M
1
QL M
1
QL M
1
1
2
2
2
2
2
1
1
1
1
2
M
M
M
M
M
M
M
M
M
M
M
M
1
QL M
1
QL M
1
QL M
1
QL M
4
QL M
2
3
M
QL M
3
QL M
29
Drug Name
Drug Requirements/
Tier
Limits
PRISTIQ TAB 100MG
protriptyline hcl tab 5 mg
protriptyline hcl tab 10 mg
sertraline hcl oral conc 20
mg/ml
sertraline hcl tab 25 mg
SURMONTIL CAP 25MG
SURMONTIL CAP 50MG
SURMONTIL CAP 100MG
tranylcypromine sulfate tab 10
mg
trazodone hcl tab 50 mg
trimipramine maleate cap 25
mg
mg
mg
TRINTELLIX TAB 5MG
TRINTELLIX TAB 10MG
TRINTELLIX TAB 20MG
venlafaxine hcl cap sr 24hr
37.5 mg (base equivalent)
3
QL M
2
2
2
M
M
M
1
QL M
1
QL M
1
4
M
QL M PA
4
QL M PA
4
QL M PA
2
M
1
1
1
4
M
M
M
QL M PA
4
QL M PA
4
QL M PA
4
QL M
4
QL M
4
QL M
2
QL M
Drug Name
Drug Requirements/
Tier
Limits
venlafaxine hcl cap sr 24hr 75
mg (base equivalent)
150 mg (base equivalent)
venlafaxine hcl tab 25 mg
venlafaxine hcl tab 37.5 mg
VIIBRYD KIT
VIIBRYD KIT STARTER
VIIBRYD TAB 10MG
VIIBRYD TAB 20MG
VIIBRYD TAB 40MG
2
QL M
2
QL M
2
2
2
2
2
4
4
4
M
M
M
M
M
M
M
QL M
4
QL M
4
QL M
ANTIPARKINSONIAN AGENTS
amantadine hcl cap 100 mg
amantadine hcl syrup 50
mg/5ml
amantadine hcl tab 100 mg
APOKYN INJ 10MG/ML
AZILECT TAB 0.5MG
AZILECT TAB 1MG
BENZTROPINE MESYLATE
INJ 1 MG/ML
benztropine mesylate tab 0.5
mg
benztropine mesylate tab 1 mg
benztropine mesylate tab 2 mg
bromocriptine mesylate cap 5
mg
bromocriptine mesylate tab
2.5 mg
carbidopa & levodopa orally
disintegrating tab 10-100 mg
carbidopa & levodopa tab
10-100 mg
ST - Step Therapy
LA - Limited Access
2
2
M
M
2
5
3
3
2
M
LA PA
M
M
M
4
M PA
4
M PA
4
M PA
2
M
2
M
2
M
2
M
2
M
2
M
30
Drug Name
Drug Requirements/
Tier
Limits
25-100 mg
25-250 mg
carbidopa & levodopa tab cr
25-100 mg
50-200 mg
CARBIDOPA-LEVODOPA-EN
TACAPONE TABS
12.5-50-200 MG
TACAPONE TABS
18.75-75-200 MG
TACAPONE TABS
25-100-200 MG
TACAPONE TABS
31.25-125-200 MG
TACAPONE TABS
37.5-150-200 MG
TACAPONE TABS
50-200-200 MG
ENTACAPONE TAB 200 MG
NEUPRO DIS 1MG/24HR
NEUPRO DIS 2MG/24HR
NEUPRO DIS 3MG/24HR
NEUPRO DIS 4MG/24HR
NEUPRO DIS 6MG/24HR
NEUPRO DIS 8MG/24HR
pramipexole dihydrochloride
tab 0.5 mg
tab 0.25 mg
tab 0.75 mg
tab 0.125 mg
tab 1 mg
tab 1.5 mg
ropinirole hydrochloride tab
0.5 mg
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
4
4
4
4
4
4
2
M
M
M
M
M
M
M
M
2
M
2
M
2
M
2
M
2
M
2
M
Drug Name
Drug Requirements/
Tier
Limits
0.25 mg
ropinirole hydrochloride tab 1
mg
mg
mg
mg
mg
selegiline hcl cap 5 mg
selegiline hcl tab 5 mg
2
M
2
M
2
M
2
M
2
M
2
M
2
2
M
M
5
QL M
5
QL M
5
QL M
5
QL M
5
QL M
5
QL M
5
QL M
5
QL M
5
QL M
5
QL M
5
QL M
5
QL M
4
4
2
2
2
2
M
M
M
M
M
M
ANTIPSYCHOTICS
ABILIFY DISC TAB 10MG
ABILIFY MAIN INJ 300MG
QL (1 injection / 28 days)
ABILIFY MAIN INJ 400MG
aripiprazole oral solution 1
mg/ml
QL (900ml / 30 days)
aripiprazole orally
aripiprazole orally
aripiprazole tab 2 mg
chlorpromaz inj 25mg/ml
chlorpromaz inj 50mg/2ml
chlorpromazine hcl tab 10 mg
ST - Step Therapy
LA - Limited Access
31
Drug Name
Drug Requirements/
Tier
Limits
CLOZAPINE ORALLY
DISINTEGRATING TAB 12.5
MG
CLOZAPINE ORALLY
DISINTEGRATING TAB 25
MG
CLOZAPINE ORALLY
MG
CLOZAPINE ORALLY
MG
CLOZAPINE ORALLY
MG
clozapine tab 25 mg
clozapine tab 50 mg
clozapine tab 100 mg
clozapine tab 200 mg
FANAPT PAK
FANAPT TAB 1MG
FANAPT TAB 2MG
FANAPT TAB 4MG
FANAPT TAB 6MG
FANAPT TAB 8MG
FANAPT TAB 10MG
FANAPT TAB 12MG
FAZACLO TAB 150 ODT
FAZACLO TAB 200 ODT
fluphenazine decanoate inj 25
mg/ml
fluphenazine hcl elixir 2.5
mg/5ml
2
2
M
M PA
2
M PA
2
QL M PA
5
5
QL M PA
QL M PA
2
2
2
M
M
QL M
2
QL M
4
4
M ST
QL M ST
4
QL M ST
4
QL M ST
4
QL M ST
4
QL M ST
4
QL M ST
4
QL M ST
5
QL M PA
5
QL M PA
2
M
2
M
Drug Name
Drug Requirements/
Tier
Limits
fluphenazine hcl inj 2.5 mg/ml
fluphenazine hcl oral conc 5
mg/ml
fluphenazine hcl tab 1 mg
fluphenazine hcl tab 2.5 mg
GEODON INJ 20MG
QL (6 mL / 3 days)
haloperidol decanoate im soln
50 mg/ml
haloperidol decanoate im soln
100 mg/ml
haloperidol lactate inj 5 mg/ml
haloperidol lactate oral conc 2
mg/ml
haloperidol tab 0.5 mg
haloperidol tab 1 mg
INVEGA SUST INJ 39/0.25
INVEGA SUST INJ 78/0.5ML
INVEGA SUST INJ
156MG/ML
INVEGA TAB 1.5MG
INVEGA TAB 3MG
INVEGA TAB 6MG
INVEGA TAB 9MG
INVEGA TRINZ INJ 273MG
QL (1 syringe / 90 days)
ST - Step Therapy
LA - Limited Access
2
2
M
M
2
2
2
2
4
M
M
M
M
QL M
2
M
2
M
2
2
M
M
2
2
2
2
2
2
4
M
M
M
M
M
M
QL M
5
QL M
5
QL M
5
QL M
5
QL M
4
QL M
4
QL M
4
QL M
4
QL M
5
QL M
5
QL M
5
QL M
32
Drug Name
Drug Requirements/
Tier
Limits
LATUDA TAB 20MG
LATUDA TAB 40MG
LATUDA TAB 60MG
LATUDA TAB 80MG
LATUDA TAB 120MG
loxapine succinate cap 5 mg
molindone hcl tab 5 mg
NUPLAZID TAB 17MG
olanzapine for im inj 10 mg
QL (3 vials / 1 day)
olanzapine orally
olanzapine orally
olanzapine orally
olanzapine orally
olanzapine tab 2.5 mg
olanzapine tab 5 mg
olanzapine tab 7.5 mg
olanzapine tab 10 mg
5
QL M
4
QL M
4
QL M
4
QL M
4
QL M
4
QL M
2
2
2
2
2
2
2
5
M
M
M
M
M
M
M
QL LA PA
2
QL M
2
QL M
2
QL M
2
2
QL M
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
Drug Name
Drug Requirements/
Tier
Limits
paliperidone tab sr 24hr 1.5
mg
paliperidone tab sr 24hr 3 mg
perphenazine tab 2 mg
pimozide tab 1 mg
pimozide tab 2 mg
quetiapine fumarate tab 25 mg
quetiapine fumarate tab 50 mg
quetiapine fumarate tab 100
mg
mg
mg
mg
REXULTI TAB 0.5MG
REXULTI TAB 0.25MG
REXULTI TAB 1MG
REXULTI TAB 2MG
REXULTI TAB 3MG
REXULTI TAB 4MG
RISPERDAL INJ 12.5MG
QL (2 injections / 28
days)
ST - Step Therapy
LA - Limited Access
2
QL M
2
QL M
2
QL M
2
QL M
2
2
2
2
2
2
2
M
M
M
M
M
M
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
5
QL M ST
5
QL M ST
5
QL M ST
5
QL M ST
5
QL M ST
5
QL M ST
4
QL M
33
Drug Name
Drug Requirements/
Tier
Limits
RISPERDAL INJ 25MG
days)
RISPERDAL INJ 37.5MG
days)
RISPERDAL INJ 50MG
days)
risperidone orally
risperidone orally
risperidone orally
risperidone orally
risperidone orally
risperidone orally
risperidone soln 1 mg/ml
QL (240 mL / 30 days)
risperidone tab 0.5 mg
risperidone tab 0.25 mg
risperidone tab 1 mg
SAPHRIS SUB 2.5MG
SAPHRIS SUB 5MG
SAPHRIS SUB 10MG
4
QL M
5
QL M
5
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
4
QL M
4
QL M
4
QL M
Drug Name
Drug Requirements/
Tier
Limits
SEROQUEL XR TAB 50MG
thioridazine hcl tab 10 mg
thiothixene cap 1 mg
trifluoperazine hcl tab 1 mg
VERSACLOZ SUS 50MG/ML
QL (600 mL / 30 days)
VRAYLAR CAP 1.5-3MG
VRAYLAR CAP 1.5MG
VRAYLAR CAP 3MG
VRAYLAR CAP 4.5MG
VRAYLAR CAP 6MG
ziprasidone hcl cap 20 mg
ZYPREXA RELP INJ 210MG
QL (2 vials / 28 days)
ST - Step Therapy
LA - Limited Access
4
QL M
4
QL M
4
QL M
4
QL M
4
QL M
4
M PA
4
M PA
4
M PA
4
M PA
2
2
2
2
2
2
2
2
5
M
M
M
M
M
M
M
M
QL M PA
4
5
M ST
QL M ST
5
QL M ST
5
QL M ST
5
QL M ST
2
QL M
2
QL M
2
QL M
2
QL M
5
QL M PA
34
Drug Name
Drug Requirements/
Tier
Limits
QL (1 vial / 28 days)
5
QL M PA
5
QL M PA
ATTENTION DEFICIT HYPERACTIVITY
DISORDER
amphetamine-dextroampheta
mine cap sr 24hr 5 mg
mine tab 5 mg
mine tab 7.5 mg
mine tab 10 mg
mine tab 12.5 mg
mine tab 15 mg
mine tab 20 mg
mine tab 30 mg
guanfacine hcl tab sr 24hr 1
mg (base equiv)
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
2
2
QL M
QL M
QL M
2
QL M
2
QL M
4
M PA
Drug Name
Drug Requirements/
Tier
Limits
mg (base equiv)
mg (base equiv)
mg (base equiv)
methylphenidate hcl soln 5
mg/5ml
QL (1800 mL / 30 days)
mg/5ml
QL (900 mL / 30 days)
methylphenidate hcl tab 5 mg
methylphenidate hcl tab cr 10
mg
mg
STRATTERA CAP 10MG
STRATTERA CAP 18MG
STRATTERA CAP 25MG
STRATTERA CAP 40MG
STRATTERA CAP 60MG
STRATTERA CAP 80MG
STRATTERA CAP 100MG
4
M PA
4
M PA
4
M PA
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
4
QL M
4
QL M
4
QL M
4
QL M
4
QL M
4
QL M
4
QL M
5
4
LA PA
QL M
3
QL M
HYPNOTICS
HETLIOZ CAP 20MG
ROZEREM TAB 8MG
SILENOR TAB 3MG
ST - Step Therapy
LA - Limited Access
35
Drug Name
Drug Requirements/
Tier
Limits
SILENOR TAB 6MG
temazepam cap 7.5 mg
in a calendar year
temazepam cap 15 mg
in a calendar year
zolpidem tartrate tab 5 mg
in a calendar year
in a calendar year
3
QL M
2
QL M PA
2
QL M PA
4
QL M PA
4
QL M PA
MIGRAINE
dihydroergotamine mesylate
inj 1 mg/ml
naratriptan hcl tab 1 mg (base
equiv)
naratriptan hcl tab 2.5 mg
(base equiv)
RELPAX TAB 20MG
RELPAX TAB 40MG
rizatriptan benzoate oral
disintegrating tab 5 mg (base
eq)
eq)
rizatriptan benzoate tab 5 mg
(base equivalent)
(base equivalent)
2
M
2
QL M
2
QL M
3
QL M
3
QL M
2
QL M
2
QL M
2
QL M
2
QL M
Drug Name
Drug Requirements/
Tier
Limits
SUMATRIPTAN NASAL
SPRAY 5 MG/ACT
QL (24 inhalers / 30
days)
SUMATRIPTAN NASAL
SPRAY 20 MG/ACT
QL (12 inhalers / 30
days)
sumatriptan succinate inj 6
mg/0.5ml
days)
sumatriptan succinate solution
auto-injector 4 mg/0.5ml
days)
auto-injector 6 mg/0.5ml
days)
SUMATRIPTAN SUCCINATE
SOLUTION CARTRIDGE 4
MG/0.5ML
days)
SUMATRIPTAN SUCCINATE
SOLUTION CARTRIDGE 6
MG/0.5ML
days)
prefilled syringe 6 mg/0.5ml
days)
sumatriptan succinate tab 25
mg
mg
mg
zolmitriptan orally
zolmitriptan orally
ST - Step Therapy
LA - Limited Access
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
2
QL M
36
Drug Name
Drug Requirements/
Tier
Limits
zolmitriptan tab 2.5 mg
zolmitriptan tab 5 mg
2
QL M
2
QL M
MISCELLANEOUS
lithium carbonate cap 150 mg
lithium carbonate tab 300 mg
lithium carbonate tab cr 300
mg
mg
LITHIUM SOL 8MEQ/5ML
NUEDEXTA CAP 20-10MG
pyridostigmine bromide tab 60
mg
riluzole tab 50 mg
tetrabenazine tab 12.5 mg
tetrabenazine tab 25 mg
1
1
1
1
2
M
M
M
M
M
2
M
3
3
2
M
M PA
M
2
5
M
QL PA
5
QL PA
MULTIPLE SCLEROSIS AGENTS
AMPYRA TAB 10MG
BETASERON INJ 0.3MG
QL (14 syringes / 28
days)
COPAXONE INJ 40MG/ML
days)
GILENYA CAP 0.5MG
glatopa inj 20mg/ml
days)
TYSABRI INJ 300/15ML
5
5
LA PA
QL PA
5
QL PA
5
QL PA
5
QL PA
5
LA PA
MUSCULOSKELETAL THERAPY AGENTS
baclofen tab 10 mg
baclofen tab 20 mg
dantrolene sodium cap 25 mg
dantrolene sodium cap 100
mg
tizanidine hcl tab 2 mg (base
equivalent)
equivalent)
2
2
2
2
2
M
M
M
M
M
2
M
2
M
Drug Name
Drug Requirements/
Tier
Limits
NARCOLEPSY/CATAPLEXY
armodafinil tab 50 mg
ARMODAFINIL TAB 200 MG
NUVIGIL TAB 50MG
NUVIGIL TAB 150MG
NUVIGIL TAB 200MG
NUVIGIL TAB 250MG
XYREM SOL 500MG/ML
QL (540 mL / 30 days)
2
QL M PA
2
QL M PA
2
QL M PA
2
QL M PA
4
QL M PA
4
QL M PA
4
QL M PA
4
QL M PA
5 QL M LA PA
PSYCHOTHERAPEUTIC-MISC
acamprosate calcium tab
delayed release 333 mg
buprenorphine hcl sl tab 2 mg
(base equiv)
(base equiv)
buprenorphine hcl-naloxone
hcl sl tab 2-0.5 mg (base
equiv)
hcl sl tab 8-2 mg (base equiv)
bupropion hcl (smoking
deterrent) tab sr 12hr 150 mg
CHANTIX PAK 0.5& 1MG
CHANTIX PAK 1MG
CHANTIX TAB 0.5MG
CHANTIX TAB 1MG
disulfiram tab 250 mg
disulfiram tab 500 mg
naloxone hcl inj 0.4 mg/ml
naloxone hcl inj 1 mg/ml
naltrexone hcl tab 50 mg
NICOTROL INH
NICOTROL NS SPR
10MG/ML
ST - Step Therapy
LA - Limited Access
2
M
2
M PA
2
M PA
2
QL M PA
2
QL M PA
2
M
4
4
4
4
2
2
2
2
2
4
4
M PA
M PA
M PA
M PA
M
M
M
M
M
M
M
37
Drug Name
Drug Requirements/
Tier
Limits
SUBOXONE MIS 2-0.5MG
QL (120 SL films / 30
days)
SUBOXONE MIS 4-1MG
days)
SUBOXONE MIS 8-2MG
days)
SUBOXONE MIS 12-3MG
days)
4
QL M PA
4
QL M PA
4
QL M PA
4
QL M PA
ENDOCRINE AND METABOLIC
ANDROGENS
ANDRODERM DIS
2MG/24HR
QL (30 patches / 30
days)
ANDRODERM DIS
4MG/24HR
QL (30 patches / 30
days)
AXIRON SOL 30MG/ACT
QL (440 mL / 30 days)
oxandrolone tab 2.5 mg
oxandrolone tab 10 mg
testosterone cypionate im inj
in oil 100 mg/ml
in oil 200 mg/ml
testosterone enanthate im inj
in oil 200 mg/ml
4
QL M PA
4
QL M PA
3
QL M PA
2
5
2
M PA
M PA
M PA
2
M PA
2
M PA
ANTIDIABETICS, INJECTABLE
ALCOHOL SWABS
BYDUREON INJ 2MG
BYDUREON PEN INJ 2MG
QL (4 pens / 28 days)
BYETTA INJ 5MCG
QL (1 pen / 30 days)
BYETTA INJ 10MCG
GAUZE PADS 2" X 2"
HUMULIN R INJ U-500
HUMULIN R INJ U-500
INSULIN PEN NEEDLE
INSULIN SAFETY NEEDLES
INSULIN SYRINGE
3
3
M
QL M
3
QL M
4
QL M
4
QL M
3
5
5
3
3
3
M
M
B/D M
M
M
M
Drug Name
Drug Requirements/
Tier
Limits
LANTUS INJ 100/ML
LANTUS INJ SOLOSTAR
LEVEMIR INJ
LEVEMIR INJ FLEXTOUC
NOVOLIN INJ 70/30
(brand RELION not
covered)
NOVOLIN N INJ U-100
(brand RELION not
covered)
NOVOLIN R INJ U-100
(brand RELION not
covered)
NOVOLOG INJ 100/ML
NOVOLOG INJ FLEXPEN
NOVOLOG INJ PENFILL
NOVOLOG MIX INJ 70/30
NOVOLOG MIX INJ
FLEXPEN
SYMLINPEN 60 INJ
1000MCG
SYMLNPEN 120 INJ
1000MCG
TOUJEO SOLO INJ 300IU/ML
TRESIBA FLEX INJ 100UNIT
TRULICITY INJ 0.75/0.5
TRULICITY INJ 1.5/0.5
VICTOZA INJ 18MG/3ML
3
3
3
3
3
M
M
M
M
M
3
M
3
M
3
3
3
3
3
M
M
M
M
M
4
QL M PA
5
QL M PA
3
3
3
4
M
M
M
QL M
4
QL M
3
QL M
2
2
2
3
M
M
M
QL M
3
QL M
1
QL M
1
QL M
1
QL M
ANTIDIABETICS, ORAL
acarbose tab 25 mg
acarbose tab 50 mg
acarbose tab 100 mg
FARXIGA TAB 5MG
FARXIGA TAB 10MG
glimepiride tab 1 mg
ST - Step Therapy
LA - Limited Access
38
Drug Name
Drug Requirements/
Tier
Limits
glipizide tab 5 mg
glipizide tab 10 mg
glipizide tab sr 24hr 2.5 mg
GLIPIZIDE TAB SR 24HR 2.5
MG
glipizide tab sr 24hr 5 mg
glipizide tab sr 24hr 10 mg
GLIPIZIDE XL TAB 5MG
glipizide-metformin hcl tab
2.5-250 mg
2.5-500 mg
5-500 mg
INVOKAMET TAB 50-500MG
INVOKAMET TAB 50-1000
INVOKANA TAB 100MG
INVOKANA TAB 300MG
JANUMET TAB 50-500MG
JANUMET TAB 50-1000
JANUMET XR TAB 50-500MG
JANUMET XR TAB 50-1000
JANUVIA TAB 25MG
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
3
QL M
3
QL M
3
QL M
3
QL M
3
QL M
3
QL M
3
QL M
3
QL M
3
QL M
3
QL M
3
QL M
3
QL M
Drug Name
Drug Requirements/
Tier
Limits
JANUVIA TAB 50MG
JANUVIA TAB 100MG
JENTADUETO TAB 2.5-500
JENTADUETO TAB XR
JENTADUETO TAB XR
metformin hcl tab 500 mg
metformin hcl tab sr 24hr 500
mg
mg
nateglinide tab 60 mg
nateglinide tab 120 mg
pioglitazone hcl tab 15 mg
(base equiv)
(base equiv)
(base equiv)
repaglinide tab 0.5 mg
repaglinide tab 1 mg
repaglinide tab 2 mg
TRADJENTA TAB 5MG
ST - Step Therapy
LA - Limited Access
3
QL M
3
QL M
3
QL M
3
QL M
3
QL M
3
QL M
3
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
1
QL M
3
QL M
39
Drug Name
Drug Requirements/
Tier
Limits
XIGDUO XR TAB 5-500MG
XIGDUO XR TAB 10-1000
3
QL M
3
QL M
3
QL M
3
QL M
1
1
1
M
M
QL M
1
1
M
QL M
2
B/D QL M
2
B/D M
2
B/D M
2
2
B/D M
B/D
2
B/D
BISPHOSPHONATES
alendronate sodium tab 5 mg
ibandronate sodium tab 150
mg (base equivalent)
QL (1 tab / 30 days)
pamidronate disodium iv soln
3 mg/ml
9 mg/ml
pamidronate inj 6mg/ml
zoledronic acid inj conc for iv
infusion 4 mg/5ml
zoledronic acid iv soln 5
mg/100ml
CALCIUM RECEPTOR AGONISTS
SENSIPAR TAB 30MG
SENSIPAR TAB 60MG
SENSIPAR TAB 90MG
3
QL
5
QL
5
QL
CHELATING AGENTS
CHEMET CAP 100MG
DEPEN TITRA TAB 250MG
EXJADE TAB 125MG
EXJADE TAB 250MG
EXJADE TAB 500MG
FERRIPROX SOL 100MG/ML
FERRIPROX TAB 500MG
kionex pow
kionex sus 15gm/60
sodium polystyrene sulfonate
oral susp 15 gm/60ml
4
5
5
5
5
5
5
2
2
2
M
M
LA PA
LA PA
LA PA
LA PA
LA PA
M
M
M
Drug Name
Drug Requirements/
Tier
Limits
powder
sps sus 15gm/60
SYPRINE CAP 250MG
2
M
2
5
M
M
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
2
M
2
M
2
M
2
M
2
M
4
2
2
2
2
2
2
2
2
2
2
2
2
M
M
M
M
M
M
M
M
M
M
M
M
M
CONTRACEPTIVES
altavera tab
apri tab
aranelle tab
aubra tab 0.1-0.02
aviane tab
balziva tab
bekyree tab
blisovi fe tab 1.5/30
blisovi fe tab 1/20
briellyn tab
camila tab 0.35mg
cryselle-28 tab 28 tabs
cyclafem tab 1/35
cyclafem tab 7/7/7
deblitane tab 0.35mg
delyla tab 0.1-0.02
desogest-eth estrad & eth
estrad tab 0.15-0.02/0.01
mg(21/5)
desogestrel & ethinyl estradiol
tab 0.15 mg-30 mcg
drospirenone-ethinyl estradiol
tab 3-0.02 mg
DROSPIRENONE-ETHINYL
ESTRADIOL TAB 3-0.02 MG
drospirenone-ethinyl estradiol
tab 3-0.03 mg
ELLA TAB 30MG
emoquette tab
enpresse-28 tab
errin tab 0.35mg
falmina tab
gildagia tab 0.4-35
gildess tab 1.5/30
heather tab 0.35mg
introvale tab
JOLIVETTE TAB 0.35MG
juleber tab
junel 1.5/30 tab
junel 1/20 tab
ST - Step Therapy
LA - Limited Access
40
Drug Name
Drug Requirements/
Tier
Limits
junel fe tab 1.5/30
junel fe tab 1/20
kariva tab 28 day
kelnor tab 1/35
kimidess tab
larin fe tab 1.5/30
larin fe tab 1/20
larin tab 1.5/30
larin tab 1/20
lessina tab
levonest tab
levonorgestrel & ethinyl
estradiol (91-day) tab
0.15-0.03 mg
LEVONORGESTREL &
ETHINYL ESTRADIOL
(91-DAY) TAB 0.15-0.03 MG
estradiol tab 0.1 mg-20 mcg
levonorgestrel tab 0.75 mg
levonorgestrel tab 1.5 mg
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg
-mcg
levora-28 tab 0.15/30
loryna tab 3-0.02mg
lutera tab
lyza tab 0.35mg
marlissa tab 0.15/30
medroxyprogesterone acetate
im susp 150 mg/ml
MEDROXYPROGESTERON
E ACETATE IM SUSP 150
MG/ML
MONONESSA TAB
myzilra tab
necon tab 0.5/35
necon tab 1/35
NECON TAB 1/50-28
NECON TAB 7/7/7
necon tab 10/11-28
nikki tab 3-0.02mg
norelgestromin-ethinyl
estradiol td ptwk 150-35
mcg/24hr
2
2
2
2
2
2
2
2
2
2
2
2
M
M
M
M
M
M
M
M
M
M
M
M
2
M
2
M
2
2
2
M
M
M
2
2
2
2
2
2
M
M
M
M
M
M
2
M
2
2
2
2
2
2
3
2
2
M
M
M
M
M
M
M
M
M
Drug Name
Drug Requirements/
Tier
Limits
NORETHINDRONE ACE &
ETHINYL ESTRADIOL TAB 1
MG-20 MCG
NORETHINDRONE ACE &
ETHINYL ESTRADIOL TAB
1.5 MG-30 MCG
NORETHINDRONE ACE &
ETHINYL ESTRADIOL-FE
TAB 1 MG-20 MCG
NORETHINDRONE ACE &
TAB 1.5 MG-30 MCG
norethindrone tab 0.35 mg
NORETHINDRONE TAB 0.35
MG
NORETHINDRONE-ETH
ESTRADIOL TAB
0.5-35/1-35/0.5-35 MG-MCG
norgestimate & ethinyl
norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35
mg-mcg
norgestrel & ethinyl estradiol
tab 0.3 mg-30 mcg
norlyroc tab 0.35mg
nortrel tab 0.5/35
nortrel tab 1/35
nortrel tab 7/7/7
NUVARING MIS
orsythia tab
philith tab 0.4-35
pimtrea tab
pirmella tab 1/35
portia-28 tab
previfem tab
quasense tab
reclipsen tab
sharobel tab 0.35mg
sprintec 28 tab 28 day
tarina fe tab 1/20
tri-legest tab fe
tri-previfem tab
tri-sprintec tab
TRINESSA TAB
trivora-28 tab
velivet pak
vienva tab 0.1-20
ST - Step Therapy
LA - Limited Access
2
M
2
M
2
M
2
M
2
2
M
M
2
M
2
M
2
M
2
M
2
2
2
2
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
41
Drug Name
Drug Requirements/
Tier
Limits
viorele tab
vyfemla tab 0.4-35
zarah tab 3-0.03mg
zenchent tab
zovia 1/35e tab
zovia 1/50e tab
2
2
2
2
2
2
M
M
M
M
M
M
ENDOMETRIOSIS
danazol cap 50 mg
danazol cap 100 mg
danazol cap 200 mg
SYNAREL SOL 2MG/ML
2
2
2
5
M
M
M
M
5
5
5
5
5
5
5
5
4
4
5
5
5
5
5
2
2
LA PA
LA PA
LA PA
LA PA
PA
LA PA
LA PA
LA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
B/D M
B/D M
2
5
5
5
5
5
5
5
5
5
5
B/D M
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
PA
5
LA PA
4
M
4
M
ENZYME REPLACEMENTS
ADAGEN INJ 250/ML
ALDURAZYME INJ 2.9MG/5M
BUPHENYL TAB 500MG
CARBAGLU TAB 200MG
CERDELGA CAP 84MG
CEREZYME INJ 200UNIT
CEREZYME INJ 400UNIT
CYSTADANE POW
CYSTAGON CAP 50MG
CYSTAGON CAP 150MG
FABRAZYME INJ 5MG
FABRAZYME INJ 35MG
KUVAN POW 100MG
KUVAN POW 500MG
KUVAN TAB 100MG
levocarnitine inj 200 mg/ml
levocarnitine oral soln 1
gm/10ml (10%)
levocarnitine tab 330 mg
LUMIZYME INJ 50MG
MYOZYME INJ 50MG
NAGLAZYME INJ 1MG/ML
ORFADIN CAP 2MG
ORFADIN CAP 5MG
ORFADIN CAP 10MG
ORFADIN CAP 20MG
ORFADIN SUS 4MG/ML
RAVICTI LIQ 1.1GM/ML
sodium phenylbutyrate oral
powder 3 gm/teaspoonful
ZAVESCA CAP 100MG
ESTROGENS
DELESTROGEN INJ
10MG/ML
estrace vag cre 0.1mg/gm
Drug Name
Drug Requirements/
Tier
Limits
estradiol tab 0.5 mg
estradiol tab 1 mg
estradiol tab 2 mg
estradiol td patch weekly 0.1
mg/24hr
mg/24hr
mg/24hr
estradiol td patch weekly
0.025 mg/24hr
0.075 mg/24hr
0.0375 mg/24hr (37.5
mcg/24hr)
estradiol valerate im in oil 20
mg/ml
mg/ml
jinteli tab 1mg-5mcg
norethindrone acetate-ethinyl
estradiol tab 1 mg-5 mcg
VAGIFEM TAB 10MCG
4
M PA
4
M PA
4
M PA
4
M PA
4
M PA
4
M PA
4
M PA
4
M PA
4
M PA
2
M
2
M
4
M PA
4
M PA
4
M
2
2
2
2
M
M
M
M
2
M
2
M
2
M
GLUCOCORTICOIDS
a-hydrocort inj 100mg
cortisone acetate tab 25 mg
dexamethason con 1mg/ml
dexamethasone elixir 0.5
mg/5ml
dexamethasone sod
phosphate preservative free
inj 10 mg/ml
dexamethasone sodium
phosphate inj 4 mg/ml
phosphate inj 10 mg/ml
ST - Step Therapy
LA - Limited Access
42
Drug Name
Drug Requirements/
Tier
Limits
phosphate inj 20 mg/5ml
dexamethasone soln 0.5
mg/5ml
dexamethasone tab 0.5 mg
dexamethasone tab 1 mg
fludrocortisone acetate tab 0.1
mg
hydrocortisone tab 5 mg
methylprednisolone acetate inj
susp 40 mg/ml
methylprednisolone acetate inj
susp 80 mg/ml
methylprednisolone sodium
succinate for inj 40 mg
methylprednisolone tab 4 mg
methylprednisolone tab
therapy pack 4 mg (21)
prednisolone sod phosph oral
soln 6.7 mg/5ml (5 mg/5ml
base)
prednisolone sod phosphate
oral soln 15 mg/5ml (base
equiv)
prednisolone sodium
phosphate oral soln 25 mg/5ml
(base eq)
prednisolone syrup 15 mg/5ml
(usp solution equivalent)
prednisone con 5mg/ml
2
M
2
M
2
M
2
M
1
1
1
1
1
1
1
2
M
M
M
M
M
M
M
M
2
2
2
2
M
M
M
B/D M
2
B/D M
2
B/D M
2
B/D M
2
B/D M
2
2
2
2
2
B/D M
B/D M
B/D M
B/D M
M
2
B/D M
Drug Name
Drug Requirements/
Tier
Limits
prednisone oral soln 5 mg/5ml
prednisone tab 1 mg
prednisone tab 2.5 mg
prednisone tab 5 mg
prednisone tab 10 mg
prednisone tab therapy pack 5
mg (21)
prednisone tab therapy pack 5
mg (48)
prednisone tab therapy pack
10 mg (21)
10 mg (48)
SOLU-CORTEF INJ 250MG
2
1
1
1
1
1
1
2
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
M
2
M
2
M
2
M
4
M
GLUCOSE ELEVATING AGENTS
2
B/D M
2
B/D M
1
B/D M
3
B/D M
GLUCAGEN INJ HYPOKIT
GLUCAGON KIT 1MG
KORLYM TAB 300MG
PROGLYCEM SUS 50MG/ML
3
3
5
4
M
M
LA PA
M
HUMAN GROWTH HORMONES
NORDITROPIN INJ 5/1.5ML
NORDITROPIN INJ 30/3ML
5
5
5
5
PA
PA
PA
PA
2
2
M
M
3
5
2
M
LA PA
M
5
2
B/D M
PA
2
PA
5
PA
5
PA
5
PA
4
QL
MISCELLANEOUS
cabergoline tab 0.5 mg
calcitonin (salmon) nasal soln
200 unit/act
FORTICAL SPR 200/ACT
INCRELEX INJ 40MG/4ML
methylergonovine maleate tab
0.2 mg
MIACALCIN INJ 200/ML
octreotide acetate inj 50
mcg/ml (0.05 mg/ml)
mcg/ml (0.1 mg/ml)
mcg/ml (0.2 mg/ml)
mcg/ml (0.5 mg/ml)
mcg/ml (1 mg/ml)
PROLIA SOL 60MG/ML
ST - Step Therapy
LA - Limited Access
43
Drug Name
Drug Requirements/
Tier
Limits
raloxifene hcl tab 60 mg
SANDOSTATIN KIT LAR
10MG
SANDOSTATIN KIT LAR
20MG
SANDOSTATIN KIT LAR
30MG
SIGNIFOR INJ 0.3MG/ML
SOMATULINE INJ 60/0.2ML
SOMATULINE INJ 120/.5ML
SOMAVERT INJ 10MG
SOMAVERT INJ 15MG
SOMAVERT INJ 20MG
SOMAVERT INJ 25MG
SOMAVERT INJ 30MG
XGEVA INJ
2
5
M
PA
5
PA
5
PA
5
5
5
5
5
5
5
5
5
5
5
5
LA PA
LA PA
LA PA
PA
PA
PA
LA PA
LA PA
LA PA
LA PA
LA PA
PA
PARATHYROID HORMONES
FORTEO SOL 600/2.4
NATPARA INJ 25MCG
NATPARA INJ 50MCG
NATPARA INJ 75MCG
NATPARA INJ 100MCG
5
QL PA
5
5
5
5
PA
PA
PA
PA
PHOSPHATE BINDER AGENTS
calcium acetate (phosphate
binder) cap 667 mg (169 mg
ca)
binder) tab 667 mg
RENVELA PAK 0.8GM
RENVELA PAK 2.4GM
RENVELA TAB 800MG
2
M
2
M
5
5
5
M
M
M
1
M
1
M
1
M
2
M
1
M
PROGESTINS
tab 2.5 mg
tab 5 mg
tab 10 mg
norethindrone acetate tab 5
mg
THYROID AGENTS
levothyroxine sodium tab 25
mcg
Drug Name
Drug Requirements/
Tier
Limits
mcg
mcg
mcg
mcg
mcg
mcg
mcg
mcg
mcg
mcg
mcg
LEVOXYL TAB 25MCG
LEVOXYL TAB 50MCG
LEVOXYL TAB 75MCG
LEVOXYL TAB 88MCG
LEVOXYL TAB 100MCG
LEVOXYL TAB 112MCG
LEVOXYL TAB 125MCG
LEVOXYL TAB 137MCG
LEVOXYL TAB 150MCG
LEVOXYL TAB 175MCG
LEVOXYL TAB 200MCG
liothyronine sodium tab 5 mcg
liothyronine sodium tab 25
mcg
mcg
methimazole tab 5 mg
methimazole tab 10 mg
propylthiouracil tab 50 mg
SYNTHROID TAB 25MCG
SYNTHROID TAB 50MCG
SYNTHROID TAB 75MCG
SYNTHROID TAB 88MCG
SYNTHROID TAB 100MCG
ST - Step Therapy
LA - Limited Access
1
M
1
M
1
M
1
M
1
M
1
M
1
M
1
M
1
M
1
M
1
M
1
1
1
1
1
1
1
1
1
1
1
2
2
M
M
M
M
M
M
M
M
M
M
M
M
M
2
M
1
1
2
3
3
3
3
3
3
M
M
M
M
M
M
M
M
M
44
Drug Name
Drug Requirements/
Tier
Limits
UNITHROID TAB 25MCG
UNITHROID TAB 50MCG
UNITHROID TAB 75MCG
UNITHROID TAB 88MCG
UNITHROID TAB 100MCG
3
3
3
3
3
3
1
1
1
1
1
1
1
1
1
1
1
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
2
M
2
M
2
M
2
M
VASOPRESSINS
desmopressin acetate inj 4
mcg/ml
DESMOPRESSIN ACETATE
NASAL SOLN 0.01%
(REFRIGERATED)
desmopressin acetate nasal
spray soln 0.01%
spray soln 0.01%
(refrigerated)
desmopressin acetate tab 0.1
mg
mg
2
M
2
M
GASTROINTESTINAL
ANTIEMETICS
compro sup 25mg
dronabinol cap 2.5 mg
dronabinol cap 5 mg
dronabinol cap 10 mg
EMEND CAP 40MG
EMEND CAP 80MG
EMEND CAP 125MG
EMEND PAK 80 & 125
EMEND SUS 125MG
granisetron hcl inj 0.1 mg/ml
2
2
M
B/D QL M
2
B/D QL M
5
B/D QL M
4
4
4
4
4
2
B/D M
B/D M
B/D M
B/D M
B/D M
M
Drug Name
Drug Requirements/
Tier
Limits
granisetron hcl inj 1 mg/ml
granisetron hcl inj 4 mg/4ml (1
mg/ml)
granisetron hcl tab 1 mg
meclizine hcl tab 12.5 mg
meclizine hcl tab 25 mg
metoclopramide hcl inj 5
mg/ml
metoclopramide hcl soln 5
mg/5ml (10 mg/10ml)
metoclopramide hcl tab 5 mg
ondansetron hcl inj 4 mg/2ml
(2 mg/ml)
ondansetron hcl inj 40
mg/20ml (2 mg/ml)
ondansetron hcl oral soln 4
mg/5ml
ondansetron hcl tab 4 mg
ondansetron orally
ondansetron orally
phenadoz sup 12.5mg
phenergan sup 12.5mg
phenergan sup 25mg
phenergan sup 50mg
prochlorperazine edisylate inj
5 mg/ml
prochlorperazine maleate tab
prochlorperazine suppos 25
mg
promethazine hcl inj 25 mg/ml
promethazine hcl inj 50 mg/ml
promethazine hcl suppos 12.5
mg
ST - Step Therapy
LA - Limited Access
2
2
M
M
2
2
2
2
B/D M
M
M
M
1
M
1
1
2
M
M
M
2
M
2
B/D M
2
2
2
2
B/D M
B/D M
B/D M
B/D M
2
B/D M
4
M PA
4
M PA
4
M PA
4
M PA
2
M
1
M
1
M
2
M
4
M PA
4
M PA
4
M PA
45
Drug Name
Drug Requirements/
Tier
Limits
promethazine hcl suppos 25
mg
mg
promethazine hcl syrup 6.25
mg/5ml
promethazine hcl tab 12.5 mg
promethazine hcl tab 25 mg
promethegan sup 25mg
promethegan sup 50mg
TRANSDERM-SC DIS 1MG
QL (10 patches / 30
days)
4
M PA
4
M PA
4
M PA
4
M PA
4
M PA
4
M PA
4
M PA
4
M PA
4
QL M PA
ranitidine hcl tab 150 mg
ranitidine hcl tab 300 mg
1
1
M
M
APRISO CAP 0.375GM
ASACOL HD TAB 800MG
balsalazide disodium cap 750
mg
budesonide delayed release
particles cap 3 mg
CANASA SUP 1000MG
DELZICOL CAP 400MG
DIPENTUM CAP 250MG
hydrocortisone enema 100
mg/60ml
HYDROCORTISONE ENEMA
100 MG/60ML
mesalamine enema 4 gm
mesalamine rectal enema 4
gm & cleanser wipe kit
sulfasalazin tab 500mg dr
sulfasalazine tab 500 mg
UCERIS TAB 9MG
3
4
2
M
M
M
5
M
5
4
5
2
M
M
M
M
2
M
2
2
M
M
2
2
5
M
M
M
2
M
2
2
1
1
2
2
3
2
M
M
M
M
M
M
M
M
2
4
3
1
M
M
M
M
1
M
2
M
LAXATIVES
4
1
2
M
M
M
1
2
M
M
2
2
M
M
H2-RECEPTOR ANTAGONISTS
famotidine for susp 40 mg/5ml
famotidine in nacl 0.9% iv soln
20 mg/50ml
famotidine inj 20 mg/2ml
famotidine tab 20 mg
famotidine tab 40 mg
ranitidine hcl inj 50 mg/2ml (25
mg/ml)
ranitidine hcl inj 150 mg/6ml
(25 mg/ml)
ranitidine hcl syrup 15 mg/ml
(75 mg/5ml)
Drug Requirements/
Tier
Limits
INFLAMMATORY BOWEL DISEASE
ANTISPASMODICS
CUVPOSA SOL 1MG/5ML
dicyclomine hcl cap 10 mg
dicyclomine hcl oral soln 10
mg/5ml
dicyclomine hcl tab 20 mg
glycopyrrolate inj 4 mg/20ml
(0.2 mg/ml)
glycopyrrolate tab 1 mg
glycopyrrolate tab 2 mg
Drug Name
2
2
M
M
2
2
2
1
1
2
M
M
M
M
M
M
2
M
2
M
bisacodyl tab & peg
3350-kcl-sod bicarb-nacl for
soln kit
constulose sol 10gm/15
enulose sol 10gm/15
gavilyte-c sol
gavilyte-g sol
gavilyte-n sol flav pk
generlac sol 10gm/15
GOLYTELY SOL
lactulose (encephalopathy)
solution 10 gm/15ml
lactulose solution 10 gm/15ml
MOVIPREP SOL
NULYTELY SOL FLAV PKS
PEG 3350-KCL-NA
BICARB-NACL-NA SULFATE
FOR SOLN 236 GM
PEG 3350-KCL-NA
BICARB-NACL-NA SULFATE
FOR SOLN 240 GM
peg 3350-kcl-sod bicarb-nacl
for soln 420 gm
ST - Step Therapy
LA - Limited Access
46
Drug Name
Drug Requirements/
Tier
Limits
polyethylene glycol 3350 oral
packet
powder
RELISTOR INJ 8/0.4ML
RELISTOR INJ 12/0.6ML
SUPREP BOWEL SOL PREP
trilyte sol
2
M
2
M
5
5
4
2
M PA
M PA
M
M
5
M PA
5
M PA
3
QL M
3
QL M
5
M
2
M
2
M
5
3
LA PA
QL M
3
QL M
1
2
2
3
M
M
M
QL M
3
QL M
5
2
2
2
2
5
M LA
M
M
M
M
M PA
3
3
3
3
3
M
M
M
M
M
MISCELLANEOUS
alosetron hcl tab 0.5 mg (base
equiv)
alosetron hcl tab 1 mg (base
equiv)
AMITIZA CAP 8MCG
AMITIZA CAP 24MCG
cromolyn sodium oral conc
100 mg/5ml
diphenoxylate w/ atropine liq
2.5-0.025 mg/5ml
diphenoxylate w/ atropine tab
2.5-0.025 mg
GATTEX KIT 5MG
LINZESS CAP 145MCG
LINZESS CAP 290MCG
loperamide hcl cap 2 mg
misoprostol tab 100 mcg
misoprostol tab 200 mcg
MOVANTIK TAB 12.5MG
MOVANTIK TAB 25MG
SUCRAID SOL 8500/ML
sucralfate tab 1 gm
ursodiol cap 300 mg
ursodiol tab 250 mg
ursodiol tab 500 mg
XIFAXAN TAB 550MG
PANCREATIC ENZYMES
CREON CAP 3000UNIT
CREON CAP 6000UNIT
CREON CAP 12000UNT
CREON CAP 24000UNT
CREON CAP 36000UNT
Drug Name
Drug Requirements/
Tier
Limits
ZENPEP CAP 3000UNIT
ZENPEP CAP 5000UNIT
ZENPEP CAP 10000UNT
ZENPEP CAP 15000UNT
ZENPEP CAP 20000UNT
ZENPEP CAP 25000UNT
ZENPEP CAP 40000UNT
4
4
4
4
4
4
4
M
M
M
M
M
M
M
PROTON PUMP INHIBITORS
DEXILANT CAP 30MG DR
esomeprazole magnesium
cap delayed release 20 mg
(base eq)
(base eq)
esomeprazole sodium for
intravenous soln 20 mg (base
equiv)
equiv)
NEXIUM CAP 20MG
NEXIUM CAP 40MG
NEXIUM GRA 2.5MG DR
NEXIUM GRA 5MG DR
NEXIUM GRA 10MG DR
QL (30 packets / 30
days)
NEXIUM GRA 20MG DR
QL (30 packets / 30
days)
NEXIUM GRA 40MG DR
QL (30 packets / 30
days)
omeprazole cap delayed
release 10 mg
release 20 mg
ST - Step Therapy
LA - Limited Access
3
QL M
3
QL M
2
QL M
2
QL M
2
M
2
M
3
QL M
3
QL M
3
3
3
M
M
QL M
3
QL M
3
QL M
1
QL M
1
QL M
47
Drug Name
Drug Requirements/
Tier
Limits
1
release 40 mg
pantoprazole sodium ec tab 20 1
mg (base equiv)
pantoprazole sodium ec tab 40 1
mg (base equiv)
QL M
QL M
QL M
GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA
alfuzosin hcl tab sr 24hr 10 mg
dutasteride cap 0.5 mg
dutasteride-tamsulosin hcl cap
0.5-0.4 mg
finasteride tab 5 mg
tamsulosin hcl cap 0.4 mg
2
QL M
2
QL M
2
QL M
1
2
M
M
2
2
M
M
2
M
2
M
4
2
M
M
MISCELLANEOUS
bethanechol chloride tab 5 mg
bethanechol chloride tab 10
mg
mg
mg
ELMIRON CAP 100MG
POTASSIUM CITRATE TAB
CR 5 MEQ (540 MG)
CR 10 MEQ (1080 MG)
2
M
URINARY ANTISPASMODICS
MYRBETRIQ TAB 25MG
MYRBETRIQ TAB 50MG
oxybutynin chloride syrup 5
mg/5ml
oxybutynin chloride tab 5 mg
oxybutynin chloride tab sr 24hr
5 mg
10 mg
4
QL M
4
QL M
1
M
2
2
M
QL M
2
QL M
Drug Name
Drug Requirements/
Tier
Limits
15 mg
tolterodine tartrate cap sr 24hr
2 mg
tolterodine tartrate cap sr 24hr
4 mg
tolterodine tartrate tab 1 mg
TOVIAZ TAB 4MG
TOVIAZ TAB 8MG
trospium chloride tab 20 mg
VESICARE TAB 5MG
VESICARE TAB 10MG
2
QL M
2
QL M
2
QL M
2
2
3
M
M
QL M
3
QL M
2
QL M
4
QL M
4
QL M
VAGINAL ANTI-INFECTIVES
clindamycin phosphate
vaginal cream 2%
metronidazole vaginal gel
0.75%
terconazole vaginal cream
0.4%
0.8%
TERCONAZOLE VAGINAL
CREAM 0.8%
terconazole vaginal suppos 80
mg
VANDAZOLE GEL 0.75%
2
M
2
M
2
M
2
M
2
M
2
M
2
M
4
4
4
4
4
4
4
4
4
3
M
M
M
M
M
M
M
M
M
M
HEMATOLOGIC
ANTICOAGULANTS
COUMADIN TAB 1MG
COUMADIN TAB 2.5MG
COUMADIN TAB 2MG
COUMADIN TAB 3MG
COUMADIN TAB 4MG
COUMADIN TAB 5MG
COUMADIN TAB 6MG
COUMADIN TAB 7.5MG
COUMADIN TAB 10MG
ELIQUIS TAB 2.5MG
ST - Step Therapy
LA - Limited Access
48
Drug Name
Drug Requirements/
Tier
Limits
ELIQUIS TAB 5MG
enoxaparin sodium inj 30
mg/0.3ml
mg/0.4ml
mg/0.6ml
mg/0.8ml
mg/ml
mg/0.8ml
mg/ml
mg/3ml
fondaparinux sodium
subcutaneous inj 2.5 mg/0.5ml
fondaparinux sodium
subcutaneous inj 5 mg/0.4ml
fondaparinux sodium
subcutaneous inj 7.5 mg/0.6ml
fondaparinux sodium
HEP SOD/NACL INJ
25000UNT
HEPARIN SOD INJ 2000/ML
HEPARIN SODIUM
(PORCINE) 40 UNIT/ML IN
D5W
HEPARIN SODIUM
D5W
HEPARIN SODIUM
D5W
heparin sodium (porcine) inj
1000 unit/ml
5000 unit/ml
10000 unit/ml
20000 unit/ml
jantoven tab 1mg
jantoven tab 2.5mg
3
2
M
M
2
M
2
M
2
M
5
M
5
M
5
M
2
M
2
M
5
M
5
M
5
M
3
M
3
3
3
B/D M
B/D M
M
3
M
3
M
2
B/D M
2
B/D M
2
B/D M
2
B/D M
1
1
M
M
Drug Name
Drug Requirements/
Tier
Limits
jantoven tab 2mg
jantoven tab 3mg
jantoven tab 4mg
jantoven tab 5mg
jantoven tab 6mg
jantoven tab 7.5mg
jantoven tab 10mg
PRADAXA CAP 75MG
PRADAXA CAP 110MG
PRADAXA CAP 150MG
warfarin sodium tab 1 mg
warfarin sodium tab 2.5 mg
XARELTO STAR TAB
15/20MG
XARELTO TAB 10MG
XARELTO TAB 15MG
XARELTO TAB 20MG
1
1
1
1
1
1
1
3
3
3
1
1
1
1
1
1
1
1
1
3
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
3
3
3
M
M
M
HEMATOPOIETIC GROWTH FACTORS
GRANIX INJ 300/0.5
GRANIX INJ 480/0.8
LEUKINE INJ 250MCG
MOZOBIL INJ
NEUMEGA INJ 5MG
NEUPOGEN INJ 300/0.5
NEUPOGEN INJ 300MCG
NEUPOGEN INJ 480/0.8
NEUPOGEN INJ 480MCG
PROCRIT INJ 2000/ML
PROCRIT INJ 3000/ML
PROCRIT INJ 4000/ML
PROCRIT INJ 10000/ML
5
5
5
5
5
5
5
5
5
3
3
3
3
5
5
PA
PA
PA
PA
2
2
2
2
5
5
M
M
M
M
LA PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
MISCELLANEOUS
anagrelide hcl cap 0.5 mg
anagrelide hcl cap 1 mg
cilostazol tab 50 mg
cilostazol tab 100 mg
CINRYZE SOL 500 UNIT
FIRAZYR INJ 30MG/3ML
ST - Step Therapy
LA - Limited Access
49
Drug Name
Drug Requirements/
Tier
Limits
pentoxifylline tab cr 400 mg
PROMACTA TAB 12.5MG
PROMACTA TAB 25MG
PROMACTA TAB 50MG
PROMACTA TAB 75MG
tranexamic acid iv soln 1000
mg/10ml (100 mg/ml)
tranexamic acid tab 650 mg
2
5
M
QL LA PA
5
QL LA PA
5
QL LA PA
5
QL LA PA
2
M
2
M
PLATELET AGGREGATION INHIBITORS
AGGRENOX CAP 25-200MG
ASPIRIN-DIPYRIDAMOLE
CAP SR 12HR 25-200 MG
BRILINTA TAB 60MG
BRILINTA TAB 90MG
clopidogrel bisulfate tab 75 mg
(base equiv)
EFFIENT TAB 5MG
EFFIENT TAB 10MG
ZONTIVITY TAB 2.08MG
4
2
M
M
3
3
1
M
M
M
4
4
4
M
M
M
IMMUNOLOGIC AGENTS
DISEASE-MODIFYING ANTI-RHEUMATIC
DRUGS (DMARDS)
CIMZIA KIT
CIMZIA KIT STARTER
CIMZIA PREFL KIT
200MG/ML
HUMIRA INJ 10MG/0.2
HUMIRA KIT 20MG/0.4
HUMIRA KIT 40MG/0.8
HUMIRA PEDIA INJ CROHNS
HUMIRA PEN INJ 40MG/0.8
HUMIRA PEN INJ CROHNS
HUMIRA PEN INJ PSORIASI
hydroxychloroquine sulfate tab
200 mg
leflunomide tab 10 mg
leflunomide tab 20 mg
methotrexate sodium tab 2.5
mg (base equiv)
REMICADE INJ 100MG
5
5
5
PA
PA
PA
5
5
5
5
5
5
5
2
PA
PA
PA
PA
PA
PA
PA
M
2
2
2
M
M
M
5
PA
5
5
PA
PA
IMMUNOGLOBULINS
BIVIGAM INJ 10%
CARIMUNE NF INJ 6GM
Drug Name
Drug Requirements/
Tier
Limits
CARIMUNE NF INJ 12GM
FLEBOGAMMA INJ 5%
FLEBOGAMMA INJ 10/200ML
FLEBOGAMMA INJ 20/400ML
FLEBOGAMMA INJ DIF 5%
GAMASTAN S/D INJ
GAMMAGARD INJ
1GM/10ML
GAMMAGARD INJ 2.5GM/25
GAMMAGARD INJ
5GM/50ML
GAMMAGARD INJ 10GM/100
GAMMAGARD SD INJ 2.5GM
HU
GAMMAGARD SD INJ 5GM
HU
HU
GAMMAKED INJ 1GM/10ML
GAMMAKED INJ 2.5GM/25
GAMMAKED INJ 10GM/100
GAMMAPLEX INJ 2.5GM
GAMMAPLEX INJ 5GM
GAMMAPLEX INJ 10GM
GAMUNEX-C INJ 1GM/10ML
GAMUNEX-C INJ 2.5GM/25
GAMUNEX-C INJ 10GM/100
GAMUNEX-C INJ 40/400ML
OCTAGAM INJ 1GM
OCTAGAM INJ 2.5GM
OCTAGAM INJ 2GM/20ML
OCTAGAM INJ 5GM
OCTAGAM INJ 10GM
OCTAGAM INJ 25GM
PRIVIGEN INJ 5 GRAMS
PRIVIGEN INJ 10GRAMS
5
5
5
5
5
5
3
5
PA
PA
PA
PA
PA
PA
B/D
PA
5
5
PA
PA
5
5
5
5
PA
PA
PA
PA
5
PA
5
PA
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
5
LA PA
IMMUNOMODULATORS
ACTIMMUNE INJ 2MU/0.5
ST - Step Therapy
LA - Limited Access
50
Drug Name
Drug Requirements/
Tier
Limits
ARCALYST INJ 220MG
INTRON A INJ 10MU
INTRON A INJ 18MU
INTRON A INJ 25MU
INTRON A INJ 50MU
REVLIMID CAP 2.5MG
REVLIMID CAP 5MG
REVLIMID CAP 10MG
REVLIMID CAP 15MG
REVLIMID CAP 20MG
REVLIMID CAP 25MG
THALOMID CAP 50MG
THALOMID CAP 100MG
THALOMID CAP 150MG
THALOMID CAP 200MG
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
PA
B/D
B/D
B/D
B/D
LA PA
LA PA
LA PA
LA PA
LA PA
LA PA
PA
PA
PA
PA
2
2
5
5
2
2
2
2
B/D M
B/D M
PA
PA
B/D M
B/D M
B/D M
B/D M
2
B/D M
2
B/D M
2
B/D M
2
2
2
2
2
B/D M
B/D M
B/D M
B/D M
B/D M
5
B/D M
2
B/D M
2
B/D M
5
B/D M
IMMUNOSUPPRESSANTS
azathioprine inj 100mg
azathioprine tab 50 mg
BENLYSTA INJ 120MG
BENLYSTA INJ 400MG
cyclosporine cap 25 mg
cyclosporine cap 100 mg
cyclosporine iv soln 50 mg/ml
cyclosporine modified cap 25
mg
mg
mg
cyclosporine modified oral
soln 100 mg/ml
gengraf cap 25mg
gengraf cap 50mg
gengraf cap 100mg
gengraf sol 100mg/ml
mycophenolate mofetil cap
250 mg
mycophenolate mofetil for oral
susp 200 mg/ml
mycophenolate mofetil tab 500
mg
mycophenolate sodium tab dr
180 mg (mycophenolic acid
equiv)
equiv)
Drug Name
Drug Requirements/
Tier
Limits
NEORAL CAP 25MG
NEORAL CAP 100MG
NEORAL SOL 100MG/ML
NULOJIX INJ 250MG
PROGRAF CAP 0.5MG
PROGRAF CAP 1MG
PROGRAF CAP 5MG
RAPAMUNE SOL 1MG/ML
SANDIMMUNE SOL
100MG/ML
sirolimus tab 0.5 mg
sirolimus tab 1 mg
SIROLIMUS TAB 2 MG
tacrolimus cap 0.5 mg
tacrolimus cap 1 mg
tacrolimus cap 5 mg
ZORTRESS TAB 0.5MG
ZORTRESS TAB 0.25MG
ZORTRESS TAB 0.75MG
3
3
3
5
4
4
5
5
3
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
2
2
5
2
2
5
5
4
5
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
M
M
M
M
M
M
M
M
B/D M
B/D M
B/D M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
VACCINES
ACTHIB INJ
ADACEL INJ
BCG VACCINE INJ
BEXSERO INJ
BOOSTRIX INJ
CERVARIX INJ
COMVAX INJ
DAPTACEL INJ
DIP/TET PED INJ 25-5LFU
ENGERIX-B INJ 10/0.5ML
ENGERIX-B INJ 20MCG/ML
GARDASIL 9 INJ
GARDASIL INJ
HAVRIX INJ 720UNIT
HAVRIX INJ 1440UNIT
HIBERIX SOL 10MCG
IMOVAX RABIE INJ 2.5/ML
INFANRIX INJ
IPOL INJ INACTIVE
IXIARO INJ
KINRIX INJ
M-M-R II INJ
MENACTRA INJ
MENHIBRIX INJ
MENOMUNE INJ A/C/Y/W
MENVEO INJ
PEDIARIX INJ 0.5ML
ST - Step Therapy
LA - Limited Access
51
Drug Name
Drug Requirements/
Tier
Limits
PEDVAX HIB INJ
PENTACEL INJ
PROQUAD INJ
QUADRACEL INJ
RABAVERT INJ
RECOMBIVA HB INJ
5MCG/0.5
RECOMBIVA HB INJ
10MCG/ML
RECOMBIVA-HB INJ
40MCG/ML
ROTARIX SUS
ROTATEQ SOL
SYNAGIS INJ 50MG
SYNAGIS INJ 100MG/ML
TENIVAC INJ 5-2LF
TET/DIP TOX INJ 2-2 LF
TRUMENBA INJ
TWINRIX INJ
TYPHIM VI INJ
VAQTA INJ 25/0.5ML
VAQTA INJ 50UNT/ML
VARIVAX INJ
YF-VAX INJ
ZOSTAVAX INJ
QL (1 vial per lifetime)
3
3
3
3
3
3
M
M
M
M
M
B/D M
3
B/D M
3
B/D M
3
3
5
5
3
3
3
3
3
3
3
3
3
3
M
M
B/D M
B/D M
M
M
M
M
M
M
M
QL M
NUTRITIONAL/SUPPLEMENTS
ELECTROLYTES
KLOR-CON 8 TAB 8MEQ ER
KLOR-CON 10 TAB 10MEQ
ER
klor-con m15 tab 15meq er
klor-con pow 20meq
MAGNESIUM SU INJ
2GM/50ML
MAGNESIUM SU INJ
4G/100ML
MAGNESIUM SU INJ
20/500ML
MAGNESIUM SU INJ
40G/1000
MAGNESIUM SU INJ
80MG/ML
magnesium sulfate inj 50%
MAGNESIUM SULFATE INJ
50%
2
2
M
M
2
2
3
M
M
M
3
M
3
M
3
M
3
M
2
2
M
M
Drug Name
Drug Requirements/
Tier
Limits
magnesium sulfate iv soln 2
gm/50ml (40 mg/ml)
MG SO4/D5W INJ 10MG/ML
potassium chloride cap cr 8
meq
meq
potassium chloride
microencapsulated crys cr tab
10 meq
potassium chloride
microencapsulated crys cr tab
20 meq
POTASSIUM CHLORIDE
ORAL SOLN 10% (20
MEQ/15ML)
POTASSIUM CHLORIDE
ORAL SOLN 20% (40
MEQ/15ML)
potassium chloride tab cr 8
meq (600 mg)
POTASSIUM CHLORIDE TAB
CR 10 MEQ
POTASSIUM CHLORIDE TAB
CR 20 MEQ (1500 MG)
SODIUM CHLORIDE INJ 2.5
MEQ/ML (14.6%)
SODIUM FLUORIDE CHEW;
TAB; 1.1 (0.5 F) MG/ML SOLN
TPN ELECTROL INJ
2
M
3
3
2
M
M
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
4
B/D M
2
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
IV NUTRITION
amino acid infusion 6%
AMINOSYN 7% INJ /LYTES
AMINOSYN II INJ 7%
AMINOSYN II INJ 8.5%
AMINOSYN II INJ 8.5/LYTE
AMINOSYN II INJ 10%
AMINOSYN INJ 8.5%
AMINOSYN INJ 8.5/LYTE
AMINOSYN INJ 10%
AMINOSYN M INJ 3.5%
AMINOSYN-HBC INJ 7%
AMINOSYN-PF INJ 7%
AMINOSYN-PF INJ 10%
AMINOSYN-RF INJ 5.2%
CLINIMIX INJ 2.75/D5W
CLINIMIX INJ 4.25/D5W
ST - Step Therapy
LA - Limited Access
52
Drug Name
Drug Requirements/
Tier
Limits
CLINIMIX INJ 4.25/D10
CLINIMIX INJ 5%/D15W
FAT EMULSION IV SOLN
20%
FREAMINE HBC INJ 6.9%
FREAMINE III INJ 10%
HEPATAMINE SOL 8%
INTRALIPID INJ 20%
INTRALIPID INJ 30%
NEPHRAMINE INJ 5.4%
premasol sol 10%
PROCALAMINE INJ 3%
PROSOL INJ 20%
TRAVASOL INJ 10%
TROPHAMINE INJ 10%
4
4
4
4
4
4
4
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
4
4
4
4
4
4
4
4
4
4
4
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
IV REPLACEMENT SOLUTIONS
D5W/LYTES INJ #48
D5W/NACL INJ 0.3%
D10W/NACL INJ 0.2%
DEXTROSE 2.5% W/
SODIUM CHLORIDE 0.45%
DEXTROSE 5% IN
LACTATED RINGERS
DEXTROSE 5% W/ SODIUM
CHLORIDE 0.2%
CHLORIDE 0.9%
CHLORIDE 0.33%
CHLORIDE 0.45%
CHLORIDE 0.225%
CHLORIDE 0.45%
DEXTROSE INJ 5%
DEXTROSE INJ 10%
DEXTROSE INJ 50%
DEXTROSE INJ 70%
IONOSOL-B/ INJ D5W
IONOSOL-MB INJ /D5W
ISOLYTE-P INJ /D5W
ISOLYTE-S INJ
3
2
3
2
M
M
M
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
2
2
2
4
4
4
4
M
M
M
M
M
M
M
M
Drug Name
Drug Requirements/
Tier
Limits
KCL 10 MEQ/L (0.075%) IN
DEXTROSE 5% & NACL
0.45% INJ
KCL 20 MEQ/L (0.15%) IN
DEXTROSE 5% & NACL 0.2%
INJ
KCL 20 MEQ/L (0.15%) IN
DEXTROSE 5% & NACL 0.9%
INJ
KCL 20 MEQ/L (0.15%) IN
DEXTROSE 5% & NACL
0.33% INJ
KCL 20 MEQ/L (0.15%) IN
DEXTROSE 5% & NACL
0.45% INJ
KCL 20 MEQ/L (0.15%) IN
NACL 0.9% INJ
kcl 20 meq/l (0.15%) in nacl
0.45% inj
KCL 20 MEQ/L (0.15%) IN
NACL 0.45% INJ
KCL 30 MEQ/L (0.224%) IN
DEXTROSE 5% & NACL
0.45% INJ
KCL 40 MEQ/L (0.3%) IN
DEXTROSE 5% & NACL
0.45% INJ
NACL 0.9% INJ
KCL/D5W/NACL INJ 0.3/0.9%
KCL/D5W/NACL INJ 0.15/0.2
LACTATED RINGER'S
SOLUTION
NORMOSOL -M INJ /D5W
NORMOSOL -R INJ /D5W
NORMOSOL-R INJ PH 7.4
PLASMA-LYTE INJ 56/D5W
PLASMA-LYTE INJ -148
PLASMA-LYTE INJ -A
POTASSIUM CHLORIDE 20
MEQ/L (0.15%) IN
DEXTROSE 5% INJ
MEQ/L (0.3%) IN DEXTROSE
5% INJ
potassium chloride inj 2
meq/ml
ST - Step Therapy
LA - Limited Access
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
3
2
M
M
M
2
4
4
4
4
4
2
M
M
M
M
M
M
M
2
M
2
M
53
Drug Name
Drug Requirements/
Tier
Limits
POTASSIUM CHLORIDE INJ
10 MEQ/50ML
10 MEQ/100ML
20 MEQ/50ML
20 MEQ/100ML
40 MEQ/100ML
RINGER'S SOLUTION
SODIUM CHLORIDE INJ
0.45%
SODIUM CHLORIDE INJ 3%
SODIUM CHLORIDE IV
SOLN 0.9%
2
M
2
M
2
M
2
M
2
M
2
2
M
M
2
2
2
M
M
M
VITAMINS
calcitriol cap 0.5 mcg
calcitriol cap 0.25 mcg
calcitriol inj 1 mcg/ml
calcitriol oral soln 1 mcg/ml
paricalcitol cap 1 mcg
PRENATAL VITAMIN/FOLIC
ACID > 0.8 MG (GENERIC)
2
2
2
2
2
2
2
2
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
B/D M
M
OPHTHALMIC
ANTI-INFECTIVE/ANTI-INFLAMMATORY
bacitracin-polymyxin-neomyci
n-hc ophth oint 1%
blephamide oin s.o.p.
neomycin-polymyxin-dexamet
hasone ophth oint 0.1%
neomycin-polymyxin-dexamet
hasone ophth susp 0.1%
neomycin-polymyxin-hc ophth
susp
sulfacetamide
sodium-prednisolone ophth
soln 10-0.23(0.25)%
TOBRADEX OIN 0.3-0.1%
TOBRADEX ST SUS 0.3-0.05
tobramycin-dexamethasone
ophth susp 0.3-0.1%
ZYLET SUS 0.5-0.3%
ANTI-INFECTIVES
Drug Name
Drug Requirements/
Tier
Limits
bacitracin ophth oint 500
unit/gm
bacitracin-polymyxin b ophth
oint
BESIVANCE SUS 0.6%
CILOXAN OIN 0.3% OP
ciprofloxacin hcl ophth soln
0.3%
erythromycin ophth oint 5
mg/gm
gatifloxacin ophth soln 0.5%
gentak oin 0.3% op
gentamicin sulfate ophth oint
0.3%
gentamicin sulfate ophth soln
0.3%
ilotycin oin op
MOXEZA SOL 0.5%
NATACYN SUS 5% OP
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op
oin
neomycin-polymy-gramicid op
sol
1.75-10000-0.025mg-unt-mg/
ml
ofloxacin ophth soln 0.3%
polymyxin b-trimethoprim
ophth soln 10000 unit/ml-0.1%
sulfacetamide sodium ophth
oint 10%
soln 10%
tobramycin ophth soln 0.3%
TOBREX OIN 0.3% OP
trifluridine ophth soln 1%
VIGAMOX DRO 0.5%
ZIRGAN GEL 0.15%
2
M
4
2
M
M
2
M
2
M
2
M
ANTI-INFLAMMATORIES
3
3
2
M
M
M
3
M
ALREX SUS 0.2%
BROMFENAC SODIUM
OPHTH SOLN 0.09% (BASE
EQUIV) (ONCE-DAILY)
bromfenac sodium ophth soln
0.09% (base equivalent)
phosphate ophth soln 0.1%
ST - Step Therapy
LA - Limited Access
2
M
2
M
3
3
2
M
M
M
1
M
2
2
2
M
M
M
1
M
1
3
4
2
M
M
M
M
2
M
2
1
M
M
2
M
2
M
1
4
2
3
4
M
M
M
M
M
3
2
M
M
2
M
2
M
54
Drug Name
Drug Requirements/
Tier
Limits
diclofenac sodium ophth soln
0.1%
DUREZOL EMU 0.05%
FLUOROMETHOLONE
OPHTH SUSP 0.1%
flurbiprofen sodium ophth soln
0.03%
ILEVRO DRO 0.3% OP
ketorolac tromethamine ophth
soln 0.4%
ketorolac tromethamine ophth
soln 0.5%
LOTEMAX GEL 0.5%
LOTEMAX OIN 0.5%
LOTEMAX SUS 0.5%
MAXIDEX SUS 0.1% OP
pred sod pho sol 1% op
PREDNISOLONE ACETATE
OPHTH SUSP 1%
2
M
3
2
M
M
1
M
3
2
M
M
2
M
3
3
3
3
3
2
M
M
M
M
M
M
ANTIALLERGICS
azelastine hcl ophth soln
0.05%
BEPREVE DRO 1.5%
cromolyn sodium ophth soln
4%
LASTACAFT SOL 0.25%
PATADAY SOL 0.2%
PAZEO DRO 0.7%
2
M
3
1
M
M
4
3
3
M
M
M
ANTIGLAUCOMA
ALPHAGAN P SOL 0.1%
AZOPT SUS 1% OP
betaxolol hcl ophth soln 0.5%
BETOPTIC-S SUS 0.25% OP
brimonidine tartrate ophth soln
0.2%
BRIMONIDINE TARTRATE
OPHTH SOLN 0.15%
carteolol hcl ophth soln 1%
COMBIGAN SOL 0.2/0.5%
dorzolamide hcl ophth soln 2%
dorzolamide hcl-timolol
maleate ophth soln 22.3-6.8
mg/ml
ISTALOL SOL 0.5% OP
latanoprost ophth soln 0.005%
levobunolol hcl ophth soln
0.5%
3
3
2
3
1
2
M
M
M
M
M
M
1
3
2
2
M
M
M
M
3
1
2
M
M
M
Drug Name
Drug Requirements/
Tier
Limits
LUMIGAN SOL 0.01%
metipranolol ophth soln 0.3%
PHOSPHOLINE SOL
0.125%OP
PILOCARPINE HCL OPHTH
SOLN 1%
SOLN 2%
SOLN 4%
SIMBRINZA SUS 1-0.2%
TIMOLOL MALEATE OPHTH
GEL FORMING SOLN 0.5%
timolol maleate ophth soln
0.5%
0.25%
TRAVATAN Z DRO 0.004%
3
2
4
M
M
M
2
M
2
M
2
M
3
2
M
M
2
M
1
M
1
M
3
M
1
M
3
1
M
M
3
QL M
MISCELLANEOUS
naphazoline hcl ophth soln
0.1%
PROLENSA SOL 0.07%
proparacaine hcl ophth soln
0.5%
RESTASIS EMU 0.05%
RESPIRATORY
ANTICHOLINERGIC/BETA AGONIST
COMBINATIONS
ANORO ELLIPT AER 62.5-25 3
QL (60 inhalations / 30
days)
COMBIVENT AER 20-100
4
QL (2 inhalers / 30 days)
ipratropium-albuterol nebu
2
soln 0.5-2.5(3) mg/3ml
QL M
QL M
B/D M
ANTICHOLINERGICS
ATROVENT HFA AER
4
17MCG
INCRUSE ELPT INH
3
62.5MCG
QL (1 inhaler / 30 days)
ipratropium bromide inhal soln 2
0.02%
ST - Step Therapy
LA - Limited Access
QL M
QL M
B/D M
55
Drug Name
Drug Requirements/
Tier
Limits
ipratropium bromide nasal
soln 0.03% (21 mcg/spray)
2
M
2
M
ANTIHISTAMINES
ASTEPRO SPR 0.15%
azelastine hcl nasal spray
0.1% (137 mcg/spray)
0.15% (205.5 mcg/spray)
cetirizine hcl oral soln 1 mg/ml
(5 mg/5ml)
diphenhydramine hcl inj 50
mg/ml
hydroxyzine hcl im soln 25
mg/ml
mg/ml
levocetirizine dihydrochloride
soln 2.5 mg/5ml (0.5 mg/ml)
tab 5 mg
olopatadine hcl nasal soln
0.6%
Drug Requirements/
Tier
Limits
SEREVENT DIS AER 50MCG
days)
terbutaline sulfate inj 1 mg/ml
terbutaline sulfate tab 2.5 mg
terbutaline sulfate tab 5 mg
VENTOLIN HFA AER
XOPENEX HFA AER
3
2
M
M
2
M
2
M
LEUKOTRIENE RECEPTOR
ANTAGONISTS
2
M
4
M PA
4
M PA
2
M
2
M
montelukast sodium chew tab
4 mg (base equiv)
montelukast sodium chew tab
5 mg (base equiv)
montelukast sodium oral
granules packet 4 mg (base
equiv)
montelukast sodium tab 10 mg
(base equiv)
zafirlukast tab 10 mg
zafirlukast tab 20 mg
2
M
2
B/D M
2
B/D M
2
B/D M
2
B/D M
1
M
2
2
2
M
M
M
2
M
2
B/D M
4
B/D M
BETA AGONISTS
albuterol sulfate soln nebu
0.5% (5 mg/ml)
0.63 mg/3ml (base equiv)
0.083% (2.5 mg/3ml)
1.25 mg/3ml (base equiv)
albuterol sulfate syrup 2
mg/5ml
albuterol sulfate tab 2 mg
albuterol sulfate tab 4 mg
albuterol sulfate tab sr 12hr 4
mg
mg
levalbuterol hcl soln nebu conc
1.25 mg/0.5ml (base equiv)
PERFOROMIST NEB 20MCG
Drug Name
3
QL M
5
2
2
3
M
M
M
QL M
3
QL M
2
M
2
M
2
M
2
M
2
2
M
M
MAST CELL STABILIZERS
cromolyn sodium soln nebu 20 2
mg/2ml
B/D M
MISCELLANEOUS
acetylcysteine inhal soln 10%
ARALAST NP INJ 500MG
DALIRESP TAB 500MCG
EPIPEN 2-PAK INJ 0.3MG
EPIPEN-JR INJ 2-PAK
ESBRIET CAP 267MG
KALYDECO PAK 50MG
KALYDECO PAK 75MG
KALYDECO TAB 150MG
OFEV CAP 100MG
OFEV CAP 150MG
ORKAMBI TAB 200-125
PROLASTIN-C INJ 1000MG
PULMOZYME SOL 1MG/ML
XOLAIR SOL 150MG
ZEMAIRA INJ 1000MG
2
2
5
5
4
3
3
5
5
5
5
5
5
5
5
5
5
5
B/D M
B/D M
LA PA
LA PA
M
M
M
PA
PA
PA
PA
PA
PA
PA
LA PA
B/D
LA PA
LA PA
NASAL STEROIDS
ST - Step Therapy
LA - Limited Access
56
Drug Name
Drug Requirements/
Tier
Limits
flunisolide nasal soln 25
mcg/act (0.025%)
QL (2 bottles / 30 days)
fluticasone propionate nasal
susp 50 mcg/act
QL (1 bottle / 30 days)
mometasone furoate nasal
susp 50 mcg/act
QL (2 bottles / 30 days)
NASONEX SPR 50MCG/AC
2
QL M
2
QL M
2
QL M
3
QL M
STEROID INHALANTS
ARNUITY ELPT INH 100MCG
days)
ARNUITY ELPT INH 200MCG
days)
budesonide inhalation susp
0.5 mg/2ml
0.25 mg/2ml
FLOVENT DISK AER 50MCG
days)
FLOVENT DISK AER
100MCG
days)
FLOVENT DISK AER
250MCG
days)
FLOVENT HFA AER 44MCG
PULMICORT INH 90MCG
PULMICORT INH 180MCG
3
3
QL M
QL M
2
B/D M
2
B/D M
3
QL M
3
QL M
3
QL M
3
QL M
3
QL M
3
QL M
3
QL M
3
QL M
STEROID/BETA-AGONIST
COMBINATIONS
ADVAIR DISKU AER 100/50
days)
3
QL M
Drug Name
Drug Requirements/
Tier
Limits
days)
days)
ADVAIR HFA AER 45/21
BREO ELLIPTA INH 100-25
QL (60 blisters / 30 days)
QL (60 blisters / 30 days)
SYMBICORT AER 80-4.5
3
QL M
3
QL M
3
QL M
3
QL M
3
QL M
3
QL M
3
QL M
3
QL M
3
QL M
2
4
4
4
4
4
2
2
M
M
M
M
M
M
M
M
2
M
2
M
2
M
2
M
2
M
2
2
2
2
M
M
M
M
XANTHINES
aminophylline inj 25 mg/ml
elixophyllin elx 80/15ml
theo-24 cap 100mg cr
theo-24 cap 400mg er
theophylline soln 80 mg/15ml
theophylline tab sr 12hr 100
mg
mg
mg
mg
mg
mg
TOPICAL
DERMATOLOGY, ACNE
adapalene cream 0.1%
adapalene gel 0.1%
AVITA CRE 0.025%
AVITA GEL 0.025%
ST - Step Therapy
LA - Limited Access
57
Drug Name
Drug Requirements/
Tier
Limits
benzoyl
peroxide-erythromycin gel
5-3%
claravis cap 10mg
claravis cap 20mg
claravis cap 30mg
claravis cap 40mg
clindamax gel 1%
clindamycin phosphate gel 1%
clindamycin phosphate lotion
1%
clindamycin phosphate soln
1%
clindamycin phosphate swab
1%
erythromycin gel 2%
erythromycin pads 2%
erythromycin soln 2%
isotretinoin cap 10 mg
myorisan cap 10mg
myorisan cap 20mg
myorisan cap 30mg
myorisan cap 40mg
sulfacetamide sodium lotion
10% (acne)
tretinoin cream 0.1%
TRETINOIN GEL 0.01%
tretinoin gel 0.025%
zenatane cap 10mg
zenatane cap 20mg
zenatane cap 30mg
zenatane cap 40mg
2
M
Drug Requirements/
Tier
Limits
DERMATOLOGY, ANTIFUNGALS
ciclopirox gel 0.77%
ciclopirox olamine cream
0.77% (base equiv)
ciclopirox olamine susp 0.77%
(base equiv)
ciclopirox shampoo 1%
clotrimazole cream 1%
clotrimazole soln 1%
econazole nitrate cream 1%
ketoconazole cream 2%
nyamyc pow 100000
nystatin cream 100000
unit/gm
nystatin oint 100000 unit/gm
nystatin topical powder
nystop pow 100000
2
2
M
M
2
M
2
2
2
2
2
2
2
M
M
M
M
M
M
M
2
2
2
M
M
M
2
2
2
2
2
2
2
M
M
M
M
M
M
M
2
M
2
M
2
2
2
2
2
2
2
2
2
2
2
M
M
M
M
M
M
M
M
M
M
M
2
2
2
2
2
2
2
2
2
M
M
M
M
M
M
M
M
M
acitretin cap 10 mg
acitretin cap 17.5 mg
acitretin cap 25 mg
calcipotriene cream 0.005%
calcipotriene oint 0.005%
calcipotriene soln 0.005% (50
mcg/ml)
calcitrene oin 0.005%
8-MOP CAP 10MG
TAZORAC CRE 0.1%
TAZORAC CRE 0.05%
2
M
DERMATOLOGY, ANTISEBORRHEICS
2
1
2
M
M
M
2
4
M
M
5
M
DERMATOLOGY, ANTIBIOTICS
gentamicin sulfate cream
0.1%
gentamicin sulfate oint 0.1%
mupirocin oint 2%
SILVER SULFADIAZINE
CREAM 1%
SSD CRE 1%
SULFAMYLON CRE
85MG/GM
SULFAMYLON PAK 5%
Drug Name
DERMATOLOGY, ANTIPRURITIC
DOXEPIN HCL CREAM 5%
hydrocortisone rectal cream
2.5%
procto-med cre hc 2.5%
procto-pak cre 1%
proctozone cre -hc 2.5%
PRUDOXIN CRE 5%
2
2
M
M
2
2
2
2
M
M
M
M
DERMATOLOGY, ANTIPSORIATICS
ketoconazole shampoo 2%
selenium sulfide lotion 2.5%
5
5
5
2
2
2
M PA
M PA
M PA
M
M
M
2
4
4
4
M
M
M PA
M PA
1
1
M
M
DERMATOLOGY, CORTICOSTEROIDS
ala cort cre 1%
alclometasone dipropionate
cream 0.05%
oint 0.05%
ST - Step Therapy
LA - Limited Access
1
2
M
M
2
M
58
Drug Name
Drug Requirements/
Tier
Limits
betamethasone dipropionate
augmented cream 0.05%
augmented gel 0.05%
augmented lotion 0.05%
augmented oint 0.05%
cream 0.05%
lotion 0.05%
oint 0.05%
betamethasone valerate
cream 0.1%
betamethasone valerate lotion
0.1%
betamethasone valerate oint
0.1%
clobetasol propionate cream
0.05%
clobetasol propionate
emollient base cream 0.05%
clobetasol propionate gel
0.05%
clobetasol propionate oint
0.05%
clobetasol propionate soln
0.05%
cormax scalp sol 0.05%
DESONIDE CREAM 0.05%
desonide lotion 0.05%
desonide oint 0.05%
desoximetasone cream 0.05%
desoximetasone cream 0.25%
desoximetasone gel 0.05%
DESOXIMETASONE OINT
0.05%
desoximetasone oint 0.25%
diflorasone diacetate cream
0.05%
diflorasone diacetate oint
0.05%
fluocin acet oil body
fluocin acet oil scalp
fluocinolone acetonide cream
0.01%
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
M
2
2
2
2
2
2
2
2
M
M
M
M
M
M
M
M
2
2
M
M
2
M
2
2
2
M
M
M
Drug Name
Drug Requirements/
Tier
Limits
0.025%
fluocinolone acetonide oint
0.025%
fluocinolone acetonide soln
0.01%
fluocinonide cream 0.05%
fluocinonide emulsified base
cream 0.05%
fluocinonide gel 0.05%
fluocinonide oint 0.05%
fluocinonide soln 0.05%
fluticasone propionate cream
0.05%
fluticasone propionate oint
0.005%
halobetasol propionate cream
0.05%
halobetasol propionate oint
0.05%
hydrocortisone butyrate cream
0.1%
hydrocortisone butyrate oint
0.1%
hydrocortisone butyrate soln
0.1%
hydrocortisone cream 1%
hydrocortisone cream 2.5%
hydrocortisone lotion 2.5%
hydrocortisone oint 1%
hydrocortisone oint 2.5%
hydrocortisone valerate cream
0.2%
hydrocortisone valerate oint
0.2%
lokara lot 0.05%
mometasone furoate cream
0.1%
mometasone furoate oint 0.1%
mometasone furoate solution
0.1% (lotion)
texacort sol 2.5%
triamcinolone acetonide
cream 0.1%
cream 0.5%
cream 0.025%
ST - Step Therapy
LA - Limited Access
2
M
2
M
2
M
2
2
M
M
2
2
2
2
M
M
M
M
2
M
2
M
2
M
2
M
2
M
2
M
1
1
2
1
1
2
M
M
M
M
M
M
2
M
2
2
M
M
2
2
M
M
4
1
M
M
1
M
1
M
59
Drug Name
Drug Requirements/
Tier
Limits
triamcinolone acetonide lotion
0.1%
triamcinolone acetonide lotion
0.025%
triamcinolone acetonide oint
0.1%
0.5%
0.025%
triderm cre 0.1%
Drug Name
Drug Requirements/
Tier
Limits
2
M
malathion lotion 0.5%
permethrin cream 5%
2
M
DERMATOLOGY, WOUND CARE AGENTS
1
M
1
M
1
M
1
M
acetic acid irrigation soln
0.25%
REGRANEX GEL 0.01%
SANTYL OIN 250/GM
SODIUM CHLORIDE
IRRIGATION SOLN 0.9%
WATER FOR IRRIGATION,
STERILE IRRIGATION SOLN
2
2
M
M
1
M
5
4
1
M PA
M
M
2
M
DERMATOLOGY, LOCAL ANESTHETICS
MOUTH/THROAT/DENTAL AGENTS
lidocaine hcl gel 2%
lidocaine hcl soln 4%
lidocaine oint 5%
lidocaine patch 5%
QL (3 patches / 1 day)
lidocaine-prilocaine cream
2.5-2.5%
cevimeline hcl cap 30 mg
chlorhexidine gluconate soln
0.12%
clotrimazole troche 10 mg
lidocaine hcl viscous soln 2%
nystatin susp 100000 unit/ml
periogard sol 0.12%
PILOCARPINE HCL TAB 5
MG
pilocarpine hcl tab 7.5 mg
triamcinolone acetonide dental
paste 0.1%
2
1
2
2
M
M
M
QL M PA
2
B/D M
DERMATOLOGY, MISCELLANEOUS SKIN
AND MUCOUS MEMBRANE
acyclovir oint 5%
diclofenac sodium gel 1%
ELIDEL CRE 1%
fluorouracil cream 5%
fluorouracil soln 2%
fluorouracil soln 5%
imiquimod cream 5%
lactic acid (ammonium lactate)
cream 12%
lactic acid (ammonium lactate)
lotion 12%
metronidazole cream 0.75%
metronidazole gel 0.75%
metronidazole lotion 0.75%
PANRETIN GEL 0.1%
podofilox soln 0.5%
rosadan cre 0.75%
tacrolimus oint 0.1%
tacrolimus oint 0.03%
TARGRETIN GEL 1%
VALCHLOR GEL 0.016%
VOLTAREN GEL 1%
2
2
4
2
2
2
2
2
M
M
M PA
M
M
M
M
M
2
M
2
2
2
5
2
2
2
2
5
5
3
M
M
M
M
M
M
M PA
M PA
PA
LA PA
M
2
1
M
M
2
1
2
1
2
M
M
M
M
M
2
2
M
M
2
M
2
3
2
M
M
M
2
M
2
M
2
M
OTIC
acetic acid 2% in aluminum
acetate otic soln
acetic acid otic soln 2%
CIPRODEX SUS 0.3-0.1%
fluocinolone acetonide (otic)
oil 0.01%
neomycin-polymyxin-hc otic
soln 1%
susp 3.5 mg/ml-10000
unit/ml-1%
ofloxacin otic soln 0.3%
DERMATOLOGY, SCABICIDES AND
PEDICULIDES
EURAX CRE 10%
EURAX LOT 10%
4
4
M
M
ST - Step Therapy
LA - Limited Access
60
Index
8
8-MOP CAP 10MG ...........58
A
abacavir sulfate tab 300 mg
(base equiv) ........................6
abacavir
sulfate-lamivudine-zidovudin
e tab 300-150-300 mg .........7
ABELCET INJ 5MG/ML ......5
ABILIFY DISC TAB 10MG 31
ABILIFY MAIN INJ 300MG31
ABILIFY MAIN INJ 400MG31
ABRAXANE INJ 100MG ...12
acamprosate calcium tab
delayed release 333 mg ....37
acarbose tab 100 mg ........38
acarbose tab 25 mg ..........38
acarbose tab 50 mg ..........38
acebutolol hcl cap 200 mg 20
acebutolol hcl cap 400 mg 20
soln 120-12 mg/5ml ............1
tab 300-15 mg .....................1
tab 300-30 mg .....................1
tab 300-60 mg .....................1
acetazolamide cap sr 12hr
500 mg ..............................22
acetazolamide tab 125 mg 22
acetazolamide tab 250 mg 22
acetic acid 2% in aluminum
acetate otic soln ................60
acetic acid irrigation soln
0.25% ................................60
acetic acid otic soln 2% .....60
..........................................56
..........................................56
acitretin cap 10 mg ............58
acitretin cap 17.5 mg .........58
acitretin cap 25 mg ............58
ACTHIB INJ ......................51
ACTIMMUNE INJ 2MU/0.5
..........................................50
acyclovir cap 200 mg .......... 7
acyclovir oint 5% ............... 60
acyclovir sodium for inj 500
mg ....................................... 7
acyclovir sodium iv soln 50
mg/ml .................................. 7
acyclovir susp 200 mg/5ml.. 7
acyclovir tab 400 mg ........... 7
acyclovir tab 800 mg ........... 7
ADACEL INJ ..................... 51
ADAGEN INJ 250/ML ....... 42
adapalene cream 0.1% ..... 57
adapalene gel 0.1% .......... 57
adefovir dipivoxil tab 10 mg 7
ADEMPAS TAB 0.5MG..... 23
ADEMPAS TAB 1MG........ 23
ADEMPAS TAB 2MG........ 23
adrucil inj 2.5g/50m ........... 12
adrucil inj 500/10ml ........... 12
adrucil inj 5gm/100m ......... 12
.......................................... 57
.......................................... 57
.......................................... 57
ADVAIR HFA AER 115/21 57
ADVAIR HFA AER 230/21 57
ADVAIR HFA AER 45/21 .. 57
afeditab tab 30mg cr ......... 20
afeditab tab 60mg cr ......... 20
AFINITOR DIS TAB 2MG . 13
AFINITOR TAB 10MG ...... 14
AFINITOR TAB 2.5MG ..... 14
AFINITOR TAB 5MG ........ 14
AFINITOR TAB 7.5MG ..... 14
AGGRENOX CAP
25-200MG ......................... 50
a-hydrocort inj 100mg ....... 42
ala cort cre 1% .................. 58
ALBENZA TAB 200MG ....... 4
0.083% (2.5 mg/3ml)......... 56
0.5% (5 mg/ml) ................. 56
0.63 mg/3ml (base equiv) . 56
1.25 mg/3ml (base equiv) . 56
albuterol sulfate syrup 2
mg/5ml .............................. 56
albuterol sulfate tab 2 mg . 56
albuterol sulfate tab 4 mg . 56
mg..................................... 56
mg..................................... 56
cream 0.05% .................... 58
oint 0.05%......................... 58
ALCOHOL SWABS........... 38
ALDURAZYME INJ
2.9MG/5M ......................... 42
ALECENSA CAP 150MG . 14
alendronate sodium tab 10
mg..................................... 40
mg..................................... 40
mg..................................... 40
.......................................... 40
mg..................................... 40
alfuzosin hcl tab sr 24hr 10
mg..................................... 48
ALIMTA INJ 100MG.......... 12
ALIMTA INJ 500MG.......... 12
ALINIA SUS 100/5ML ......... 4
ALINIA TAB 500MG............ 4
allopurinol tab 100 mg ........ 1
allopurinol tab 300 mg ........ 1
alosetron hcl tab 0.5 mg
(base equiv) ...................... 47
alosetron hcl tab 1 mg (base
equiv) ................................ 47
ALPHAGAN P SOL 0.1% . 55
alprazolam tab 0.25 mg .... 24
alprazolam tab 0.5 mg ...... 24
61
alprazolam tab 1 mg .........24
alprazolam tab 2 mg .........24
ALREX SUS 0.2%.............54
altavera tab .......................40
amantadine hcl cap 100 mg
..........................................30
amantadine hcl syrup 50
mg/5ml ..............................30
amantadine hcl tab 100 mg
..........................................30
AMBISOME INJ 50MG .......5
amifostine crystalline for inj
500 mg ..............................15
amikacin sulfate inj 1 gm/4ml
(250 mg/ml) .........................4
amikacin sulfate inj 500
mg/2ml (250 mg/ml) ............4
amiloride &
mg .....................................22
amiloride hcl tab 5 mg .......22
amino acid infusion 6% .....52
aminophylline inj 25 mg/ml 57
AMINOSYN 7% INJ /LYTES
..........................................52
AMINOSYN II INJ 10% .....52
AMINOSYN II INJ 7% .......52
AMINOSYN II INJ 8.5% ....52
AMINOSYN II INJ 8.5/LYTE
..........................................52
AMINOSYN INJ 10% ........52
AMINOSYN INJ 8.5% .......52
AMINOSYN INJ 8.5/LYTE.52
AMINOSYN M INJ 3.5% ...52
AMINOSYN-HBC INJ 7%..52
AMINOSYN-PF INJ 10%...52
AMINOSYN-PF INJ 7% ....52
AMINOSYN-RF INJ 5.2% .52
mg/3ml (50 mg/ml) ............18
mg/9ml (50 mg/ml) ............18
mg/18ml (50 mg/ml) ..........18
..........................................18
..........................................18
.......................................... 18
AMITIZA CAP 24MCG ...... 47
AMITIZA CAP 8MCG ........ 47
amitriptyline hcl tab 10 mg 28
.......................................... 28
.......................................... 28
amlodipine besylate tab 10
mg ..................................... 21
amlodipine besylate tab 2.5
mg ..................................... 20
.......................................... 20
amlodipine
10-20 mg........................... 15
amlodipine
10-40 mg........................... 15
amlodipine
2.5-10 mg.......................... 15
amlodipine
5-10 mg............................. 15
amlodipine
5-20 mg............................. 15
amlodipine
5-40 mg............................. 15
amlodipine
besylate-valsartan tab
10-160 mg......................... 17
amlodipine
besylate-valsartan tab
10-320 mg......................... 17
amlodipine
besylate-valsartan tab 5-160
mg ..................................... 17
amlodipine
besylate-valsartan tab 5-320
mg ..................................... 17
amlodipine-valsartan-hydroc
hlorothiazide tab 10-160-12.5
mg..................................... 17
hlorothiazide tab 10-160-25
mg..................................... 17
mg..................................... 17
hlorothiazide tab 5-160-12.5
mg..................................... 17
mg..................................... 17
amoxapine tab 100 mg ..... 28
amoxapine tab 150 mg ..... 28
amoxapine tab 25 mg ....... 28
amoxapine tab 50 mg ....... 28
chew tab 200-28.5 mg ...... 10
chew tab 400-57 mg ......... 10
susp 200-28.5 mg/5ml ...... 10
susp 250-62.5 mg/5ml ...... 10
susp 400-57 mg/5ml ......... 10
susp 600-42.9 mg/5ml ...... 10
tab 250-125 mg ................ 10
tab 500-125 mg ................ 10
tab 875-125 mg ................ 10
tab sr 12hr 1000-62.5 mg . 10
amoxicillin (trihydrate) cap
250 mg.............................. 10
amoxicillin (trihydrate) cap
500 mg.............................. 10
tab 125 mg ........................ 10
tab 250 mg ........................ 10
amoxicillin (trihydrate) for
62
susp 125 mg/5ml...............10
susp 200 mg/5ml...............10
susp 250 mg/5ml...............10
susp 400 mg/5ml...............10
amoxicillin (trihydrate) tab
500 mg ..............................10
amoxicillin (trihydrate) tab
875 mg ..............................10
amphetamine-dextroamphet
amine cap sr 24hr 10 mg ..35
amine cap sr 24hr 5 mg ....35
amine tab 10 mg ...............35
amine tab 12.5 mg ............35
amine tab 15 mg ...............35
amine tab 20 mg ...............35
amine tab 30 mg ...............35
amine tab 5 mg .................35
amine tab 7.5 mg ..............35
amphotericin b for inj 50 mg 5
ampicillin & sulbactam
sodium for inj 1-0.5 gm .....10
sodium for inj 10-5 gm ......10
sodium for inj 2-1 gm ........10
sodium for iv soln 10-5 gm 10
sodium for iv soln 2-1 gm ..10
ampicillin cap 250 mg ....... 10
ampicillin cap 500 mg ....... 10
ampicillin for susp 125
mg/5ml .............................. 10
ampicillin for susp 250
mg/5ml .............................. 10
.......................................... 10
mg ..................................... 10
.......................................... 10
mg ..................................... 10
mg ..................................... 10
gm ..................................... 10
ampicillin sodium for iv soln
10 gm ................................ 10
gm ..................................... 10
AMPYRA TAB 10MG ........ 37
anagrelide hcl cap 0.5 mg . 49
anagrelide hcl cap 1 mg .... 49
anastrozole tab 1 mg ........ 13
ANDRODERM DIS
2MG/24HR ........................ 38
ANDRODERM DIS
4MG/24HR ........................ 38
ANORO ELLIPT AER
62.5-25.............................. 55
APOKYN INJ 10MG/ML .... 30
apri tab .............................. 40
APRISO CAP 0.375GM .... 46
APTIOM TAB 200MG ....... 24
APTIVUS CAP 250MG ....... 6
APTIVUS SOL .................... 6
.......................................... 56
ARALAST NP INJ 500MG 56
aranelle tab ....................... 40
ARCALYST INJ 220MG .... 51
aripiprazole oral solution 1
mg/ml ................................ 31
aripiprazole orally
disintegrating tab 10 mg ... 31
aripiprazole orally
disintegrating tab 15 mg ... 31
aripiprazole tab 10 mg ...... 31
aripiprazole tab 2 mg ........ 31
aripiprazole tab 5 mg ........ 31
armodafinil tab 150 mg ..... 37
ARMODAFINIL TAB 200 MG
.......................................... 37
armodafinil tab 250 mg ..... 37
armodafinil tab 50 mg ....... 37
ARNUITY ELPT INH
100MCG ........................... 57
ARNUITY ELPT INH
200MCG ........................... 57
ASACOL HD TAB 800MG 46
ASPIRIN-DIPYRIDAMOLE
CAP SR 12HR 25-200 MG50
ASTEPRO SPR 0.15% ..... 56
100-25 mg ........................ 19
50-25 mg .......................... 19
atenolol tab 100 mg .......... 20
atenolol tab 25 mg ............ 20
atenolol tab 50 mg ............ 20
atorvastatin calcium tab 10
mg (base equivalent) ........ 18
atovaquone susp 750 mg/5ml
............................................ 4
250-100 mg ........................ 6
62.5-25 mg ......................... 6
ATRIPLA TAB ..................... 7
ATROVENT HFA AER
17MCG ............................. 55
aubra tab 0.1-0.02 ............ 40
63
AVASTIN INJ ....................13
AVASTIN INJ 400/16ML ...13
aviane tab .........................40
AVITA CRE 0.025% ..........57
AVITA GEL 0.025% ..........57
AXIRON SOL 30MG/ACT .38
azacitidine for inj 100 mg ..12
AZACTAM/DEX INJ 1GM ...4
AZACTAM/DEX INJ 2GM ...4
azathioprine inj 100mg ......51
azathioprine tab 50 mg .....51
0.1% (137 mcg/spray) .......56
0.15% (205.5 mcg/spray) ..56
azelastine hcl ophth soln
0.05% ................................55
AZILECT TAB 0.5MG .......30
AZILECT TAB 1MG ..........30
mg/5ml ................................9
mg/5ml ................................9
azithromycin iv for soln 500
mg .......................................9
AZITHROMYCIN POWD
PACK FOR SUSP 1 GM .....9
azithromycin tab 250 mg .....9
AZOPT SUS 1% OP .........55
AZOR TAB 10-20MG ........17
AZOR TAB 10-40MG ........17
AZOR TAB 5-20MG ..........17
AZOR TAB 5-40MG ..........17
aztreonam for inj 1 gm ........4
aztreonam for inj 2 gm ........4
B
bacitracin ophth oint 500
unit/gm ..............................54
bacitracin-polymyxin b ophth
oint ....................................54
bacitracin-polymyxin-neomyc
in-hc ophth oint 1% ...........54
baclofen tab 10 mg ...........37
baclofen tab 20 mg ...........37
balsalazide disodium cap 750
mg .....................................46
balziva tab......................... 40
BANZEL SUS 40MG/ML ... 24
BANZEL TAB 200MG ....... 24
BANZEL TAB 400MG ....... 24
BARACLUDE SOL
.05MG/ML ........................... 7
BCG VACCINE INJ ........... 51
bekyree tab ....................... 40
BELEODAQ INJ 500MG ... 13
benazepril &
10-12.5 mg........................ 15
benazepril &
20-12.5 mg........................ 16
benazepril &
20-25 mg........................... 16
benazepril &
5-6.25 mg.......................... 15
benazepril hcl tab 10 mg ... 16
benazepril hcl tab 5 mg ..... 16
BENDEKA INJ 100/4ML ... 11
.......................................... 17
.......................................... 17
BENICAR HCT TAB
40-25MG ........................... 17
BENICAR TAB 20MG ....... 17
BENICAR TAB 40MG ....... 17
BENICAR TAB 5MG ......... 17
BENLYSTA INJ 120MG .... 51
BENLYSTA INJ 400MG .... 51
benzoyl
peroxide-erythromycin gel
5-3% ................................. 58
BENZTROPINE MESYLATE
INJ 1 MG/ML..................... 30
benztropine mesylate tab 0.5
mg ..................................... 30
benztropine mesylate tab 1
mg ..................................... 30
benztropine mesylate tab 2
mg ..................................... 30
BEPREVE DRO 1.5%....... 55
BESIVANCE SUS 0.6%.... 54
augmented cream 0.05%.. 59
augmented gel 0.05% ....... 59
augmented lotion 0.05% ... 59
augmented oint 0.05% ...... 59
cream 0.05% .................... 59
lotion 0.05% ...................... 59
oint 0.05%......................... 59
cream 0.1% ...................... 59
lotion 0.1% ........................ 59
betamethasone valerate oint
0.1% ................................. 59
BETASERON INJ 0.3MG . 37
betaxolol hcl ophth soln 0.5%
.......................................... 55
mg..................................... 48
mg..................................... 48
mg..................................... 48
mg..................................... 48
BETOPTIC-S SUS 0.25% OP
.......................................... 55
bexarotene cap 75 mg ...... 14
BEXSERO INJ .................. 51
bicalutamide tab 50 mg..... 13
BICILLIN L-A INJ 600000 . 10
BICNU INJ 100MG ........... 11
BILTRICIDE TAB 600MG ... 4
bisacodyl tab & peg
3350-kcl-sod bicarb-nacl for
soln kit .............................. 46
bisoprolol &
64
10-6.25 mg ........................20
bisoprolol &
2.5-6.25 mg .......................20
bisoprolol &
5-6.25 mg ..........................20
bisoprolol fumarate tab 10
mg .....................................20
..........................................20
BIVIGAM INJ 10% ............50
bleomycin sulfate for inj 15
unit ....................................12
bleomycin sulfate for inj 30
unit ....................................12
blephamide oin s.o.p. ........54
blisovi fe tab 1.5/30 ...........40
blisovi fe tab 1/20 ..............40
BOOSTRIX INJ .................51
BOSULIF TAB 100MG ......14
BOSULIF TAB 500MG ......14
..........................................57
..........................................57
briellyn tab.........................40
BRILINTA TAB 60MG .......50
BRILINTA TAB 90MG .......50
BRIMONIDINE TARTRATE
OPHTH SOLN 0.15% .......55
brimonidine tartrate ophth
soln 0.2% ..........................55
BRINTELLIX TAB 10MG ...28
BRINTELLIX TAB 20MG ...28
BRINTELLIX TAB 5MG .....28
BRIVIACT INJ 50MG/5ML 24
BRIVIACT SOL 10MG/ML.24
BRIVIACT TAB 100MG .....24
BRIVIACT TAB 10MG .......24
BROMFENAC SODIUM
OPHTH SOLN 0.09% (BASE
EQUIV) (ONCE-DAILY) ....54
bromfenac sodium ophth soln
0.09% (base equivalent) ...54
bromocriptine mesylate cap 5
mg ..................................... 30
bromocriptine mesylate tab
2.5 mg ............................... 30
budesonide delayed release
particles cap 3 mg ............. 46
0.25 mg/2ml ...................... 57
0.5 mg/2ml ........................ 57
bumetanide inj 0.25 mg/ml 22
bumetanide tab 0.5 mg ..... 22
bumetanide tab 1 mg ........ 22
bumetanide tab 2 mg ........ 22
BUPHENYL TAB 500MG .. 42
(base equiv) ...................... 37
(base equiv) ...................... 37
hcl sl tab 2-0.5 mg (base
equiv) ................................ 37
hcl sl tab 8-2 mg (base equiv)
.......................................... 37
bupropion hcl (smoking
deterrent) tab sr 12hr 150 mg
.......................................... 37
bupropion hcl tab 100 mg . 28
bupropion hcl tab 75 mg ... 28
mg ..................................... 28
mg ..................................... 28
mg ..................................... 28
mg ..................................... 28
mg ..................................... 28
buspirone hcl tab 10 mg.... 24
buspirone hcl tab 5 mg...... 24
buspirone hcl tab 7.5 mg... 24
BUSULFEX INJ 6MG/ML .. 11
mg/ml .................................. 1
mg/ml .................................. 1
BYDUREON INJ 2MG ...... 38
BYDUREON PEN INJ 2MG
.......................................... 38
BYETTA INJ 10MCG ........ 38
BYETTA INJ 5MCG .......... 38
BYSTOLIC TAB 10MG ..... 20
BYSTOLIC TAB 2.5MG .... 20
BYSTOLIC TAB 20MG ..... 20
BYSTOLIC TAB 5MG ....... 20
C
cabergoline tab 0.5 mg ..... 43
CABOMETYX TAB 20MG 14
calcipotriene cream 0.005%
.......................................... 58
calcipotriene oint 0.005%.. 58
calcipotriene soln 0.005% (50
mcg/ml) ............................. 58
calcitonin (salmon) nasal soln
200 unit/act ....................... 43
calcitrene oin 0.005% ....... 58
calcitriol cap 0.25 mcg ...... 54
calcitriol cap 0.5 mcg ........ 54
calcitriol inj 1 mcg/ml......... 54
calcitriol oral soln 1 mcg/ml
.......................................... 54
binder) cap 667 mg (169 mg
ca)..................................... 44
binder) tab 667 mg............ 44
camila tab 0.35mg ............ 40
CANASA SUP 1000MG .... 46
CANCIDAS INJ 50MG ........ 5
CANCIDAS INJ 70MG ........ 5
CAPASTAT SUL INJ 1GM .. 7
CAPRELSA TAB 100MG .. 14
CAPRELSA TAB 300MG .. 14
captopril &
25-15 mg .......................... 16
captopril &
25-25 mg .......................... 16
captopril &
65
50-15 mg ...........................16
captopril &
50-25 mg ...........................16
captopril tab 100 mg .........16
captopril tab 12.5 mg ........16
captopril tab 25 mg ...........16
captopril tab 50 mg ...........16
CARBAGLU TAB 200MG..42
100 mg ..............................24
200 mg ..............................24
300 mg ..............................24
carbamazepine chew tab 100
mg .....................................24
carbamazepine susp 100
mg/5ml ..............................24
carbamazepine tab 200 mg
..........................................24
100 mg ..............................24
200 mg ..............................24
400 mg ..............................24
..........................................30
..........................................30
..........................................30
10-100 mg .........................30
25-100 mg .........................31
25-250 mg .........................31
25-100 mg .........................31
50-200 mg .........................31
CARBIDOPA-LEVODOPA-E
NTACAPONE TABS
12.5-50-200 MG ................ 31
NTACAPONE TABS
18.75-75-200 MG .............. 31
NTACAPONE TABS
25-100-200 MG ................. 31
NTACAPONE TABS
31.25-125-200 MG ............ 31
NTACAPONE TABS
37.5-150-200 MG .............. 31
NTACAPONE TABS
50-200-200 MG ................. 31
mg/15ml ............................ 15
mg/45ml ............................ 15
carboplatin iv soln 50 mg/5ml
.......................................... 15
mg/60ml ............................ 15
CARIMUNE NF INJ 12GM 50
CARIMUNE NF INJ 6GM .. 50
carteolol hcl ophth soln 1%
.......................................... 55
carvedilol tab 12.5 mg ....... 20
carvedilol tab 25 mg .......... 20
carvedilol tab 3.125 mg ..... 20
carvedilol tab 6.25 mg ....... 20
CAYSTON INH 75MG......... 4
cefaclor cap 250 mg ........... 8
cefaclor cap 500 mg ........... 8
cefaclor er tab 500mg ......... 8
............................................ 8
............................................ 8
............................................ 8
cefadroxil cap 500 mg ......... 8
cefadroxil for susp 250
mg/5ml ................................ 8
cefadroxil for susp 500
mg/5ml ................................ 8
cefadroxil tab 1 gm ............. 8
cefazolin inj 1gm/50ml ........ 8
............................................ 8
............................................ 8
............................................ 8
cefazolin sodium for inj 500
mg....................................... 8
cefazolin sodium for iv soln 1
gm....................................... 8
CEFAZOLIN SOL ............... 8
cefdinir cap 300 mg ............ 8
............................................ 8
............................................ 8
cefepime hcl for inj 1 gm ..... 8
cefepime hcl for inj 2 gm ..... 8
............................................ 8
............................................ 8
gm....................................... 8
gm....................................... 8
mg....................................... 8
cefoxitin sodium for inj 10 gm
............................................ 8
gm....................................... 8
gm....................................... 8
100 mg/5ml ......................... 8
50 mg/5ml ........................... 8
mg....................................... 8
mg....................................... 9
............................................ 9
............................................ 9
66
cefprozil tab 250 mg ............9
cefprozil tab 500 mg ............9
ceftazidime for inj 1 gm .......9
1GM ....................................9
2GM ....................................9
gm .......................................9
gm .......................................9
gm .......................................9
mg .......................................9
mg .......................................9
1 gm ....................................9
2 gm ....................................9
............................................9
............................................9
gm .......................................9
gm .......................................9
cefuroxime sodium for inj 750
mg .......................................9
cefuroxime sodium for iv soln
1.5 gm .................................9
celecoxib cap 100 mg .........1
celecoxib cap 50 mg ...........1
CELONTIN CAP 300MG ...24
cephalexin cap 250 mg .......9
cephalexin cap 500 mg .......9
mg/5ml ................................9
mg/5ml ................................9
CERDELGA CAP 84MG ...42
CEREZYME INJ 200UNIT 42
CEREZYME INJ 400UNIT 42
CERVARIX INJ ................. 51
cetirizine hcl oral soln 1
mg/ml (5 mg/5ml) .............. 56
cevimeline hcl cap 30 mg.. 60
CHANTIX PAK 0.5& 1MG . 37
CHANTIX PAK 1MG ......... 37
CHANTIX TAB 0.5MG ...... 37
CHANTIX TAB 1MG ......... 37
CHEMET CAP 100MG...... 40
chlorhexidine gluconate soln
0.12%................................ 60
250 mg ................................ 6
500 mg ................................ 6
chlorothiazide tab 250 mg . 22
chlorothiazide tab 500 mg . 22
chlorpromaz inj 25mg/ml ... 31
chlorpromaz inj 50mg/2ml . 31
.......................................... 31
chlorpromazine hcl tab 100
mg ..................................... 31
chlorpromazine hcl tab 200
mg ..................................... 32
.......................................... 31
.......................................... 31
chlorthalidone tab 25 mg... 22
chlorthalidone tab 50 mg... 22
4 gm/dose ......................... 19
packets 4 gm .................... 19
cholestyramine powder 4
gm/dose ............................ 19
cholestyramine powder
packets 4 gm .................... 19
mg (fenofibric acid equiv) .. 19
mg (fenofibric acid equiv) .. 19
ciclopirox gel 0.77% .......... 58
ciclopirox olamine cream
0.77% (base equiv) ........... 58
ciclopirox olamine susp
0.77% (base equiv) ........... 58
ciclopirox shampoo 1% ..... 58
cilostazol tab 100 mg ........ 49
cilostazol tab 50 mg .......... 49
CILOXAN OIN 0.3% OP ... 54
CIMZIA KIT ....................... 50
CIMZIA KIT STARTER ..... 50
CIMZIA PREFL KIT
200MG/ML ........................ 50
CINRYZE SOL 500 UNIT . 49
CIPRODEX SUS 0.3-0.1%60
ciprofloxacin 200 mg/100ml
in d5w ................................. 9
ciprofloxacin 400 mg/200ml
in d5w ................................. 9
ciprofloxacin for oral susp
250 mg/5ml (5%) (5
gm/100ml) ........................... 9
ciprofloxacin for oral susp
500 mg/5ml (10%) (10
gm/100ml) ........................... 9
ciprofloxacin hcl ophth soln
0.3% ................................. 54
(base equiv) ........................ 9
(base equiv) ...................... 10
(base equiv) ...................... 10
(base equiv) ...................... 10
mg/20ml (1%) ................... 10
mg/40ml (1%) ................... 10
tab sr 24hr 1000 mg(base eq)
.......................................... 10
tab sr 24hr 500 mg (base eq)
.......................................... 10
mg/ml)............................... 15
mg/ml)............................... 15
mg/ml)............................... 15
citalopram hydrobromide oral
67
soln 10 mg/5ml..................28
10 mg (base equiv) ...........28
20 mg (base equiv) ...........28
40 mg (base equiv) ...........28
cladribine iv soln 10 mg/10ml
(1 mg/ml) ...........................12
claravis cap 10mg .............58
claravis cap 20mg .............58
claravis cap 30mg .............58
claravis cap 40mg .............58
mg/5ml ................................9
mg/5ml ................................9
clarithromycin tab 250 mg ...9
clarithromycin tab 500 mg ...9
clarithromycin tab sr 24hr 500
mg .......................................9
clindamax gel 1% ..............58
clindamycin hcl cap 150 mg 4
clindamycin hcl cap 300 mg 4
clindamycin hcl cap 75 mg ..4
clindamycin palmitate hcl for
soln 75 mg/5ml (base equiv)
............................................4
clindamycin phosphate gel
1% .....................................58
clindamycin phosphate in
d5w iv soln 300 mg/50ml ....4
clindamycin phosphate inj
300 mg/2ml .........................5
600 mg/4ml .........................5
gm/60ml ..............................4
900 mg/6ml .........................5
clindamycin phosphate iv
soln 300 mg/2ml..................5
soln 600 mg/4ml..................5
soln 900 mg/6ml ................. 5
clindamycin phosphate lotion
1% .................................... 58
clindamycin phosphate soln
1% .................................... 58
clindamycin phosphate swab
1% .................................... 58
clindamycin phosphate
vaginal cream 2% ............. 48
CLINIMIX INJ 2.75/D5W ... 52
CLINIMIX INJ 4.25/D10 .... 53
CLINIMIX INJ 4.25/D5W ... 52
CLINIMIX INJ 5%/D15W ... 53
clobetasol propionate cream
0.05%................................ 59
clobetasol propionate
emollient base cream 0.05%
.......................................... 59
clobetasol propionate gel
0.05%................................ 59
clobetasol propionate oint
0.05%................................ 59
clobetasol propionate soln
0.05%................................ 59
.......................................... 28
.......................................... 28
.......................................... 28
clonazepam orally
.......................................... 24
clonazepam orally
disintegrating tab 0.25 mg. 24
clonazepam orally
disintegrating tab 0.5 mg... 24
clonazepam orally
disintegrating tab 1 mg...... 24
clonazepam orally
clonazepam tab 0.5 mg..... 24
clonazepam tab 1 mg........ 24
clonazepam tab 2 mg ....... 24
clonidine hcl tab 0.1 mg .... 22
0.1 mg/24hr ...................... 22
0.2 mg/24hr ...................... 23
0.3 mg/24hr ...................... 23
clopidogrel bisulfate tab 75
mg (base equiv) ................ 50
15 mg................................ 25
3.75 mg ............................. 25
7.5 mg............................... 25
clotrimazole cream 1% ..... 58
clotrimazole soln 1% ......... 58
clotrimazole troche 10 mg . 60
CLOZAPINE ORALLY
MG .................................... 32
CLOZAPINE ORALLY
DISINTEGRATING TAB 12.5
MG .................................... 32
CLOZAPINE ORALLY
MG .................................... 32
CLOZAPINE ORALLY
MG .................................... 32
CLOZAPINE ORALLY
MG .................................... 32
clozapine tab 100 mg........ 32
clozapine tab 200 mg........ 32
clozapine tab 25 mg.......... 32
clozapine tab 50 mg.......... 32
COARTEM TAB 20-120MG 6
colchicine w/ probenecid tab
0.5-500 mg ......................... 1
COLCRYS TAB 0.6MG....... 1
colestipol hcl granule packets
5 gm.................................. 19
colestipol hcl granules 5 gm
.......................................... 19
68
colestipol hcl tab 1 gm ......19
colistimethate sodium for inj
150 mg ................................5
COMBIGAN SOL 0.2/0.5%
..........................................55
COMBIVENT AER 20-100 55
COMETRIQ KIT 100MG ...14
COMETRIQ KIT 140MG ...14
COMETRIQ KIT 60MG .....14
COMPLERA TAB ................7
compro sup 25mg .............45
COMVAX INJ ....................51
constulose sol 10gm/15 ....46
COPAXONE INJ 40MG/ML
..........................................37
cormax scalp sol 0.05% ....59
cortisone acetate tab 25 mg
..........................................42
COTELLIC TAB 20MG ......14
COUMADIN TAB 10MG ....48
COUMADIN TAB 1MG ......48
COUMADIN TAB 2.5MG ...48
COUMADIN TAB 7.5MG ...48
CREON CAP 12000UNT ..47
CREON CAP 3000UNIT ...47
CREON CAP 6000UNIT ...47
CRESTOR TAB 10MG ......18
CRESTOR TAB 5MG ........18
CRIXIVAN CAP 200MG ......6
CRIXIVAN CAP 400MG ......6
cromolyn sodium ophth soln
4% .....................................55
cromolyn sodium oral conc
100 mg/5ml .......................47
cromolyn sodium soln nebu
20 mg/2ml .........................56
cryselle-28 tab 28 tabs ......40
CUBICIN SOL 500MG ........5
CUVPOSA SOL 1MG/5ML46
cyclafem tab 1/35 .............. 40
cyclafem tab 7/7/7 ............. 40
.......................................... 11
.......................................... 11
gm ..................................... 11
gm ..................................... 11
mg ..................................... 11
cycloserine cap 250 mg ...... 7
cyclosporine cap 100 mg .. 51
cyclosporine cap 25 mg .... 51
cyclosporine iv soln 50 mg/ml
.......................................... 51
cyclosporine modified cap
100 mg .............................. 51
mg ..................................... 51
mg ..................................... 51
cyclosporine modified oral
soln 100 mg/ml ................. 51
CYSTADANE POW .......... 42
CYSTAGON CAP 150MG. 42
CYSTAGON CAP 50MG... 42
cytarabine inj 20 mg/ml ..... 12
D
D10W/NACL INJ 0.2% ...... 53
D5W/LYTES INJ #48 ........ 53
D5W/NACL INJ 0.3% ........ 53
dacarbazine for inj 100 mg 11
dacarbazine for inj 200 mg 11
DAKLINZA TAB 30MG........ 7
DALIRESP TAB 500MCG . 56
danazol cap 100 mg ......... 42
danazol cap 200 mg ......... 42
danazol cap 50 mg ........... 42
dantrolene sodium cap 100
mg ..................................... 37
.......................................... 37
.......................................... 37
dapsone tab 100 mg ........... 5
dapsone tab 25 mg ............. 5
DAPTACEL INJ ................ 51
DARAPRIM TAB 25MG ...... 5
daunorubicin hcl inj 5 mg/ml
(base equiv) ...................... 12
deblitane tab 0.35mg ........ 40
DELESTROGEN INJ
10MG/ML .......................... 42
delyla tab 0.1-0.02 ............ 40
DELZICOL CAP 400MG ... 46
DEMSER CAP 250MG ..... 23
DEPEN TITRA TAB 250MG
.......................................... 40
DEPO-PROVERA INJ
400/ML.............................. 13
DESCOVY TAB 200/25 ...... 7
desipramine hcl tab 10 mg 28
.......................................... 28
.......................................... 28
desmopressin acetate inj 4
mcg/ml .............................. 45
DESMOPRESSIN ACETATE
NASAL SOLN 0.01%
(REFRIGERATED) ........... 45
spray soln 0.01% .............. 45
spray soln 0.01%
(refrigerated) ..................... 45
mg..................................... 45
mg..................................... 45
desogest-eth estrad & eth
estrad tab 0.15-0.02/0.01
mg(21/5) ........................... 40
desogestrel & ethinyl
.......................................... 40
DESONIDE CREAM 0.05%
.......................................... 59
desonide lotion 0.05% ...... 59
69
desonide oint 0.05% .........59
desoximetasone cream
0.05% ................................59
desoximetasone cream
0.25% ................................59
desoximetasone gel 0.05%
..........................................59
DESOXIMETASONE OINT
0.05% ................................59
desoximetasone oint 0.25%
..........................................59
dexamethason con 1mg/ml
..........................................42
dexamethasone elixir 0.5
mg/5ml ..............................42
dexamethasone sod
phosphate preservative free
inj 10 mg/ml.......................42
phosphate inj 10 mg/ml .....42
..........................................43
..........................................43
phosphate inj 20 mg/5ml ...43
phosphate inj 4 mg/ml .......42
phosphate ophth soln 0.1%
..........................................54
dexamethasone soln 0.5
mg/5ml ..............................43
..........................................43
..........................................43
dexamethasone tab 1 mg .43
..........................................43
..........................................47
.......................................... 47
dexrazoxane for inj 250 mg
.......................................... 15
DEXTROSE 10% W/
.......................................... 53
DEXTROSE 2.5% W/
.......................................... 53
DEXTROSE 5% IN
LACTATED RINGERS ...... 53
CHLORIDE 0.2% .............. 53
CHLORIDE 0.225% .......... 53
CHLORIDE 0.33% ............ 53
CHLORIDE 0.45% ............ 53
CHLORIDE 0.9% .............. 53
DEXTROSE INJ 10%........ 53
DEXTROSE INJ 5%.......... 53
diazepam con 5mg/ml ....... 25
diazepam inj 5 mg/ml ........ 25
diazepam oral soln 1 mg/ml
.......................................... 25
DIAZEPAM RECTAL GEL
.......................................... 25
DIAZEPAM RECTAL GEL
DELIVERY SYSTEM 2.5 MG
.......................................... 25
DIAZEPAM RECTAL GEL
.......................................... 25
diazepam tab 10 mg ......... 25
diazepam tab 2 mg ........... 25
diazepam tab 5 mg ........... 25
diclofenac potassium tab 50
mg ....................................... 1
diclofenac sodium gel 1% . 60
diclofenac sodium ophth soln
0.1%.................................. 55
diclofenac sodium tab
delayed release 25 mg........ 1
delayed release 50 mg ....... 1
delayed release 75 mg ....... 1
diclofenac sodium tab sr 24hr
100 mg................................ 1
mg..................................... 11
mg..................................... 11
dicyclomine hcl cap 10 mg 46
dicyclomine hcl oral soln 10
mg/5ml .............................. 46
dicyclomine hcl tab 20 mg 46
capsule 125 mg .................. 6
capsule 200 mg .................. 6
capsule 250 mg .................. 6
capsule 400 mg .................. 6
DIFICID TAB 200MG .......... 9
diflorasone diacetate cream
0.05% ............................... 59
diflorasone diacetate oint
0.05% ............................... 59
diflunisal tab 500 mg ........... 1
digitek tab 0.125mg .......... 22
digitek tab 0.25mg ............ 22
digoxin inj 0.25 mg/ml ....... 22
DIGOXIN ORAL SOLN 0.05
MG/ML .............................. 22
mg) ................................... 22
mg) ................................... 22
dihydroergotamine mesylate
inj 1 mg/ml ........................ 36
dilantin cap 100mg............ 25
dilantin cap 30mg.............. 25
dilantin chw 50mg ............. 25
DILANTIN-125 SUS 125/5ML
.......................................... 25
mg..................................... 21
mg..................................... 21
70
mg .....................................21
mg .....................................21
mg .....................................21
mg .....................................21
diltiazem hcl coated beads
cap sr 24hr 120 mg ...........21
cap sr 24hr 180 mg ...........21
cap sr 24hr 240 mg ...........21
cap sr 24hr 300 mg ...........21
cap sr 24hr 360 mg ...........21
diltiazem hcl extended
release beads cap sr 24hr
120 mg ..............................21
180 mg ..............................21
240 mg ..............................21
300 mg ..............................21
360 mg ..............................21
420 mg ..............................21
mg/25ml (5 mg/ml) ............21
mg/5ml (5 mg/ml) ..............21
mg/10ml (5 mg/ml) ............21
diltiazem hcl tab 120 mg ...21
diltiazem hcl tab 30 mg .....21
DIP/TET PED INJ 25-5LFU
..........................................51
DIPENTUM CAP 250MG .. 46
diphenhydramine hcl inj 50
mg/ml ................................ 56
diphenoxylate w/ atropine liq
2.5-0.025 mg/5ml .............. 47
diphenoxylate w/ atropine tab
2.5-0.025 mg ..................... 47
100 mg .............................. 18
150 mg .............................. 18
disulfiram tab 250 mg........ 37
disulfiram tab 500 mg........ 37
divalproex sodium cap
delayed release sprinkle 125
mg ..................................... 25
divalproex sodium tab
delayed release 125 mg.... 25
divalproex sodium tab sr 24
hr 250 mg.......................... 25
divalproex sodium tab sr 24
hr 500 mg.......................... 25
DOCETAXEL FOR INJ
CONC 20 MG/ML ............. 12
DOCETAXEL FOR INJ
CONC 80 MG/4ML (20
MG/ML) ............................. 12
docetaxel inj 140/7ml ........ 12
DOCETAXEL INJ 160/16ML
.......................................... 12
DOCETAXEL INJ 200MG/20
.......................................... 12
.......................................... 12
.......................................... 12
mg).................................... 18
mg).................................... 18
mg).................................... 18
donepezil hydrochloride
orally disintegrating tab 10
mg..................................... 27
donepezil hydrochloride
orally disintegrating tab 5 mg
.......................................... 27
donepezil hydrochloride tab
10 mg................................ 27
donepezil hydrochloride tab
23 mg................................ 27
mg..................................... 27
dorzolamide hcl ophth soln
2% .................................... 55
dorzolamide hcl-timolol
maleate ophth soln 22.3-6.8
mg/ml ................................ 55
.......................................... 17
.......................................... 17
.......................................... 17
.......................................... 17
doxepin hcl cap 10 mg ...... 28
doxepin hcl cap 100 mg .... 28
doxepin hcl cap 150 mg .... 28
doxepin hcl conc 10 mg/ml28
DOXEPIN HCL CREAM 5%
.......................................... 58
doxorubicin hcl for inj 50 mg
.......................................... 12
doxorubicin hcl inj 2 mg/ml 12
doxorubicin hcl liposomal inj
(for iv infusion) 2 mg/ml .... 12
doxy 100 inj 100mg........... 11
mg..................................... 11
mg..................................... 11
doxycycline hyclate for inj
100 mg.............................. 11
mg..................................... 11
mg..................................... 11
71
doxycycline monohydrate
cap 100 mg .......................11
doxycycline monohydrate
cap 50 mg .........................11
100 mg ..............................11
150 mg ..............................11
50 mg ................................11
75 mg ................................11
dronabinol cap 10 mg .......45
dronabinol cap 2.5 mg ......45
dronabinol cap 5 mg .........45
drospirenone-ethinyl
estradiol tab 3-0.02 mg .....40
..........................................40
drospirenone-ethinyl
estradiol tab 3-0.03 mg .....40
..........................................40
DROXIA CAP 200MG .......14
pellets cap 20 mg ..............28
pellets cap 30 mg ..............29
pellets cap 60 mg ..............29
DURAMORPH INJ
0.5MG/ML ...........................1
DURAMORPH INJ 1MG/ML
............................................1
DUREZOL EMU 0.05% .....55
dutasteride cap 0.5 mg .....48
dutasteride-tamsulosin hcl
cap 0.5-0.4 mg ..................48
E
e.e.s. 400 tab 400mg ..........9
econazole nitrate cream 1%
..........................................58
EDURANT TAB 25MG ........6
EFFIENT TAB 10MG ........50
EFFIENT TAB 5MG .......... 50
ELIDEL CRE 1% ............... 60
ELIQUIS TAB 2.5MG ........ 48
ELIQUIS TAB 5MG ........... 49
ELITEK INJ 1.5MG ........... 15
ELITEK INJ 7.5MG ........... 15
elixophyllin elx 80/15ml ..... 57
ELLA TAB 30MG .............. 40
ELMIRON CAP 100MG .... 48
EMCYT CAP 140MG ........ 11
EMEND CAP 125MG ........ 45
EMEND CAP 40MG .......... 45
EMEND CAP 80MG .......... 45
EMEND PAK 80 & 125 ..... 45
EMEND SUS 125MG ........ 45
emoquette tab ................... 40
EMSAM DIS 12MG/24H ... 29
EMSAM DIS 6MG/24HR ... 29
EMSAM DIS 9MG/24HR ... 29
EMTRIVA CAP 200MG ....... 6
EMTRIVA SOL 10MG/ML ... 6
emverm chw 100mg............ 5
enalapril maleate &
10-25 mg........................... 16
enalapril maleate &
5-12.5 mg.......................... 16
.......................................... 16
enalapril maleate tab 2.5 mg
.......................................... 16
.......................................... 16
enalapril maleate tab 5 mg 16
endocet tab 10-325mg ........ 2
endocet tab 5-325mg .......... 1
endocet tab 7.5-325 ............ 2
ENGERIX-B INJ 10/0.5ML 51
ENGERIX-B INJ 20MCG/ML
.......................................... 51
mg/ml ................................ 49
mg/0.8ml ........................... 49
mg/ml ................................ 49
mg/0.3ml ........................... 49
mg/3ml .............................. 49
mg/0.4ml ........................... 49
mg/0.6ml ........................... 49
mg/0.8ml ........................... 49
enpresse-28 tab ................ 40
ENTACAPONE TAB 200 MG
.......................................... 31
entecavir tab 0.5 mg ........... 8
entecavir tab 1 mg .............. 8
.......................................... 17
.......................................... 17
.......................................... 17
enulose sol 10gm/15......... 46
EPIPEN 2-PAK INJ 0.3MG
.......................................... 56
EPIPEN-JR INJ 2-PAK ..... 56
mg/100ml (2 mg/ml) .......... 12
mg/25ml (2 mg/ml) ............ 12
epitol tab 200mg ............... 25
EPIVIR HBV SOL 5MG/ML . 8
eplerenone tab 25 mg ....... 16
eplerenone tab 50 mg ....... 16
EPZICOM TAB 600-300 ..... 7
ERIVEDGE CAP 150MG .. 13
errin tab 0.35mg................ 40
ery-tab tab 250mg ec .......... 9
ery-tab tab 333mg ec .......... 9
ery-tab tab 500mg ec .......... 9
erythrocin inj 500mg ........... 9
erythrocin tab 250mg .......... 9
erythromycin ethylsuccinate
tab 400 mg .......................... 9
erythromycin gel 2% ......... 58
erythromycin ophth oint 5
mg/gm............................... 54
erythromycin pads 2% ...... 58
erythromycin soln 2% ....... 58
erythromycin tab 250 mg .... 9
72
erythromycin tab 500 mg ....9
erythromycin w/ delayed
release particles cap 250 mg
............................................9
ESBRIET CAP 267MG .....56
escitalopram oxalate soln 5
mg/5ml (base equiv) .........29
mg (base equiv) ................29
mg (base equiv) ................29
mg (base equiv) ................29
(base eq) ...........................47
(base eq) ...........................47
equiv) ................................47
equiv) ................................47
estrace vag cre 0.1mg/gm.42
estradiol tab 0.5 mg ..........42
estradiol tab 1 mg .............42
estradiol tab 2 mg .............42
0.025 mg/24hr ...................42
0.0375 mg/24hr (37.5
mcg/24hr) ..........................42
mg/24hr .............................42
mg/24hr .............................42
0.075 mg/24hr ...................42
mg/24hr .............................42
mg/ml ................................42
mg/ml ................................42
ethambutol hcl tab 100 mg ..7
ethambutol hcl tab 400 mg ..7
ethosuximide cap 250 mg . 25
ethosuximide soln 250
mg/5ml .............................. 25
etodolac cap 200 mg........... 1
etodolac cap 300 mg........... 1
etodolac tab 400 mg ........... 1
etodolac tab 500 mg ........... 1
............................................ 1
............................................ 1
............................................ 1
etoposide inj 500 mg/25ml
(20 mg/ml)......................... 15
EURAX CRE 10% ............. 60
EURAX LOT 10% ............. 60
EVOTAZ TAB 300-150 ....... 7
EXELON DIS 13.3/24 ....... 27
EXELON DIS 4.6MG/24.... 27
EXELON DIS 9.5MG/24.... 27
exemestane tab 25 mg ..... 13
EXJADE TAB 125MG ....... 40
F
FABRAZYME INJ 35MG ... 42
FABRAZYME INJ 5MG ..... 42
falmina tab ........................ 40
famciclovir tab 125 mg ........ 8
famotidine for susp 40
mg/5ml .............................. 46
famotidine in nacl 0.9% iv
soln 20 mg/50ml ............... 46
famotidine inj 20 mg/2ml ... 46
.......................................... 46
famotidine inj 40 mg/4ml ... 46
famotidine tab 20 mg ........ 46
famotidine tab 40 mg ........ 46
FANAPT PAK ................... 32
FANAPT TAB 10MG ......... 32
FANAPT TAB 12MG ......... 32
FANAPT TAB 1MG ........... 32
FANAPT TAB 2MG ........... 32
FANAPT TAB 4MG ........... 32
FANAPT TAB 6MG ........... 32
FANAPT TAB 8MG ........... 32
FARESTON TAB 60MG ... 13
FARXIGA TAB 10MG ....... 38
FARXIGA TAB 5MG ......... 38
FARYDAK CAP 10MG...... 13
FASLODEX INJ 250MG ... 13
FAT EMULSION IV SOLN
20% .................................. 53
FAZACLO TAB 150 ODT.. 32
FAZACLO TAB 200 ODT.. 32
felbamate susp 600 mg/5ml
.......................................... 25
felbamate tab 400 mg ....... 25
felbamate tab 600 mg ....... 25
.......................................... 21
felodipine tab sr 24hr 2.5 mg
.......................................... 21
felodipine tab sr 24hr 5 mg21
134 mg.............................. 19
200 mg.............................. 19
fenofibrate micronized cap 67
mg..................................... 19
fenofibrate tab 145 mg ...... 19
fenofibrate tab 160 mg ...... 19
fenofibrate tab 48 mg ........ 19
fenofibrate tab 54 mg ........ 19
handle 1200 mcg ................ 2
handle 1600 mcg ................ 2
handle 200 mcg .................. 2
handle 400 mcg .................. 2
handle 600 mcg .................. 2
handle 800 mcg .................. 2
mcg/hr................................. 2
mcg/hr................................. 2
73
mcg/hr .................................2
mcg/hr .................................2
mcg/hr .................................2
FENTORA TAB 100MCG....2
FERRIPROX SOL
100MG/ML ........................40
FERRIPROX TAB 500MG 40
FETZIMA CAP 120MG .....29
FETZIMA CAP 20MG .......29
FETZIMA CAP TITRATIO .29
finasteride tab 5 mg ..........48
FIRAZYR INJ 30MG/3ML..49
FLEBOGAMMA INJ
10/200ML ..........................50
FLEBOGAMMA INJ
20/400ML ..........................50
FLEBOGAMMA INJ 5% ....50
..........................................50
..........................................50
..........................................18
..........................................18
..........................................18
FLOVENT DISK AER
100MCG............................57
FLOVENT DISK AER
250MCG............................57
FLOVENT DISK AER
50MCG .............................57
FLOVENT HFA AER
110MCG............................57
FLOVENT HFA AER
220MCG............................57
..........................................57
fluconazole for susp 10
mg/ml .................................. 5
fluconazole for susp 40
mg/ml .................................. 5
fluconazole in dextrose inj
200 mg/100ml ..................... 5
fluconazole in dextrose inj
400 mg/200ml ..................... 5
200 mg/100ml ..................... 6
400 mg/200ml ..................... 6
fluconazole tab 100 mg ....... 6
fluconazole tab 50 mg ......... 6
fluconazole/ inj nacl 100...... 6
flucytosine cap 250 mg ....... 6
flucytosine cap 500 mg ....... 6
fludarabine phosphate for inj
50 mg ................................ 12
fludarabine phosphate inj 25
mg/ml ................................ 12
fludrocortisone acetate tab
0.1 mg ............................... 43
flunisolide nasal soln 25
mcg/act (0.025%) .............. 57
fluocin acet oil body .......... 59
fluocin acet oil scalp .......... 59
fluocinolone acetonide (otic)
oil 0.01% ........................... 60
0.01%................................ 59
0.025%.............................. 59
fluocinolone acetonide oint
0.025%.............................. 59
fluocinolone acetonide soln
0.01%................................ 59
fluocinonide cream 0.05%. 59
fluocinonide emulsified base
cream 0.05%..................... 59
fluocinonide gel 0.05% ...... 59
fluocinonide oint 0.05% ..... 59
fluocinonide soln 0.05% .... 59
FLUOROMETHOLONE
OPHTH SUSP 0.1% ......... 55
fluorouracil cream 5% ....... 60
mg/ml)............................... 12
fluorouracil inj 2.5 gm/50ml
(50 mg/ml) ........................ 12
fluorouracil inj 5 gm/100ml
(50 mg/ml) ........................ 12
fluorouracil inj 500 mg/10ml
(50 mg/ml) ........................ 12
fluorouracil soln 2% .......... 60
fluorouracil soln 5% .......... 60
fluoxetine hcl cap 10 mg ... 29
fluoxetine hcl solution 20
mg/5ml .............................. 29
fluoxetine hcl tab 10 mg .... 29
fluoxetine hcl tab 20 mg .... 29
fluphenazine decanoate inj
25 mg/ml ........................... 32
fluphenazine hcl elixir 2.5
mg/5ml .............................. 32
fluphenazine hcl inj 2.5 mg/ml
.......................................... 32
fluphenazine hcl oral conc 5
mg/ml ................................ 32
fluphenazine hcl tab 1 mg . 32
.......................................... 32
fluphenazine hcl tab 2.5 mg
.......................................... 32
fluphenazine hcl tab 5 mg . 32
flurbiprofen sodium ophth
soln 0.03% ........................ 55
flurbiprofen tab 100 mg ....... 1
flurbiprofen tab 50 mg ......... 1
flutamide cap 125 mg ....... 13
fluticasone propionate cream
0.05% ............................... 59
fluticasone propionate nasal
susp 50 mcg/act................ 57
fluticasone propionate oint
0.005% ............................. 59
mg..................................... 24
mg..................................... 24
mg..................................... 24
74
fondaparinux sodium
subcutaneous inj 10
mg/0.8ml ...........................49
fondaparinux sodium
subcutaneous inj 2.5
mg/0.5ml ...........................49
fondaparinux sodium
..........................................49
fondaparinux sodium
subcutaneous inj 7.5
mg/0.6ml ...........................49
FORTEO SOL 600/2.4 ......44
FORTICAL SPR 200/ACT .43
fosinopril sodium &
10-12.5 mg ........................16
fosinopril sodium &
20-12.5 mg ........................16
..........................................16
..........................................16
..........................................16
FREAMINE HBC INJ 6.9%
..........................................53
FREAMINE III INJ 10% .....53
furosemide inj 10 mg/ml ....22
FUROSEMIDE INJ 10
MG/ML ..............................22
furosemide oral soln 10
mg/ml ................................22
..........................................22
furosemide tab 20 mg .......22
FUSILEV INJ 50MG ..........15
FUZEON INJ 90MG ............6
FYCOMPA SUS 0.5MG/ML
..........................................25
FYCOMPA TAB 10MG .....25
FYCOMPA TAB 12MG .....25
FYCOMPA TAB 2MG .......25
FYCOMPA TAB 8MG ....... 25
G
gabapentin cap 100 mg .... 25
gabapentin oral soln 250
mg/5ml .............................. 25
gabapentin tab 600 mg ..... 25
gabapentin tab 800 mg ..... 25
GABITRIL TAB 12MG ....... 25
GABITRIL TAB 16MG ....... 25
cap sr 24hr 16 mg ............. 27
cap sr 24hr 24 mg ............. 27
cap sr 24hr 8 mg ............... 27
oral soln 4 mg/ml .............. 27
tab 12 mg .......................... 27
tab 4 mg ............................ 27
tab 8 mg ............................ 27
GAMASTAN S/D INJ ........ 50
GAMMAGARD INJ
10GM/100 ......................... 50
GAMMAGARD INJ
1GM/10ML ........................ 50
GAMMAGARD INJ 2.5GM/25
.......................................... 50
GAMMAGARD INJ
20GM/200 ......................... 50
GAMMAGARD INJ
30GM/300 ......................... 50
GAMMAGARD INJ
5GM/50ML ........................ 50
HU..................................... 50
GAMMAGARD SD INJ
2.5GM HU ......................... 50
HU..................................... 50
.......................................... 50
.......................................... 50
GAMMAKED INJ 2.5GM/25
.......................................... 50
.......................................... 50
.......................................... 50
GAMMAPLEX INJ 10GM .. 50
GAMMAPLEX INJ 2.5GM . 50
GAMMAPLEX INJ 5GM .... 50
.......................................... 50
.......................................... 50
GAMUNEX-C INJ 2.5GM/25
.......................................... 50
.......................................... 50
GAMUNEX-C INJ 40/400ML
.......................................... 50
.......................................... 50
ganciclovir sodium for inj 500
mg....................................... 8
GARDASIL 9 INJ .............. 51
GARDASIL INJ ................. 51
gatifloxacin ophth soln 0.5%
.......................................... 54
GATTEX KIT 5MG ............ 47
GAUZE PADS 2" X 2"....... 38
gavilyte-c sol ..................... 46
gavilyte-g sol ..................... 46
gavilyte-n sol flav pk ......... 46
.......................................... 12
.......................................... 12
gemcitabine hcl for inj 200 mg
.......................................... 12
(BASE EQUIV).................. 12
(BASE EQUIV).................. 12
MG/5.26ML (38 MG/ML)
(BASE EQUIV).................. 12
gemfibrozil tab 600 mg ..... 19
75
generlac sol 10gm/15 ........46
gengraf cap 100mg ...........51
gengraf cap 25mg .............51
gengraf cap 50mg .............51
gengraf sol 100mg/ml .......51
gentak oin 0.3% op ...........54
gentam/nacl inj 0.9mg/ml ....4
gentam/nacl inj 1.4mg/ml ....4
mg/ml ..................................4
mg/ml ..................................4
mg/ml ..................................4
mg/ml ..................................4
mg/ml ..................................4
gentamicin sulfate cream
0.1% ..................................58
mg/ml ..................................4
mg/ml ..................................4
gentamicin sulfate iv soln 10
mg/ml ..................................4
gentamicin sulfate oint 0.1%
..........................................58
gentamicin sulfate ophth oint
0.3% ..................................54
gentamicin sulfate ophth soln
0.3% ..................................54
GENVOYA TAB ..................7
GEODON INJ 20MG .........32
gildagia tab 0.4-35 ............40
gildess tab 1.5/30 ..............40
GILENYA CAP 0.5MG ......37
GILOTRIF TAB 20MG .......14
glatopa inj 20mg/ml ...........37
GLEOSTINE CAP 100MG 11
GLEOSTINE CAP 10MG ..11
GLEOSTINE CAP 40MG ..11
GLEOSTINE CAP 5MG ....11
glimepiride tab 1 mg ..........38
glipizide tab 10 mg ............ 39
glipizide tab 5 mg .............. 39
glipizide tab sr 24hr 10 mg 39
glipizide tab sr 24hr 2.5 mg
.......................................... 39
GLIPIZIDE TAB SR 24HR 2.5
MG .................................... 39
glipizide tab sr 24hr 5 mg .. 39
GLIPIZIDE XL TAB 5MG .. 39
2.5-250 mg........................ 39
2.5-500 mg........................ 39
5-500 mg........................... 39
GLUCAGEN INJ HYPOKIT
.......................................... 43
GLUCAGON KIT 1MG ...... 43
glycopyrrolate inj 4 mg/20ml
(0.2 mg/ml)........................ 46
glycopyrrolate tab 1 mg..... 46
glycopyrrolate tab 2 mg..... 46
GOLYTELY SOL ............... 46
granisetron hcl inj 0.1 mg/ml
.......................................... 45
granisetron hcl inj 1 mg/ml 45
granisetron hcl inj 4 mg/4ml
(1 mg/ml)........................... 45
granisetron hcl tab 1 mg ... 45
GRANIX INJ 300/0.5 ......... 49
GRANIX INJ 480/0.8 ......... 49
griseofulvin microsize susp
125 mg/5ml ......................... 6
griseofulvin microsize tab
500 mg ................................ 6
griseofulvin ultramicrosize
tab 125 mg .......................... 6
griseofulvin ultramicrosize
tab 250 mg .......................... 6
mg (base equiv) ................ 35
mg (base equiv) ................ 35
mg (base equiv) ................ 35
mg (base equiv) ................ 35
H
halobetasol propionate
cream 0.05% .................... 59
halobetasol propionate oint
0.05% ............................... 59
haloperidol decanoate im
soln 100 mg/ml ................. 32
haloperidol decanoate im
soln 50 mg/ml ................... 32
haloperidol lactate inj 5
mg/ml ................................ 32
haloperidol lactate oral conc
2 mg/ml ............................. 32
haloperidol tab 0.5 mg ...... 32
haloperidol tab 1 mg ......... 32
haloperidol tab 10 mg ....... 32
haloperidol tab 20 mg ....... 32
HARVONI TAB 90-400MG . 8
HAVRIX INJ 1440UNIT..... 51
HAVRIX INJ 720UNIT....... 51
heather tab 0.35mg........... 40
HEP SOD/NACL INJ
25000UNT ........................ 49
.......................................... 49
.......................................... 49
HEPARIN SODIUM
D5W .................................. 49
HEPARIN SODIUM
D5W .................................. 49
HEPARIN SODIUM
D5W .................................. 49
1000 unit/ml ...................... 49
10000 unit/ml .................... 49
20000 unit/ml .................... 49
5000 unit/ml ...................... 49
HEPATAMINE SOL 8% .... 53
HERCEPTIN INJ 440MG .. 13
76
HETLIOZ CAP 20MG ........35
HEXALEN CAP 50MG ......11
HIBERIX SOL 10MCG ......51
HUMIRA INJ 10MG/0.2 .....50
HUMIRA KIT 20MG/0.4 ....50
HUMIRA KIT 40MG/0.8 ....50
HUMIRA PEDIA INJ
CROHNS ..........................50
HUMIRA PEN INJ 40MG/0.8
..........................................50
HUMIRA PEN INJ CROHNS
..........................................50
HUMIRA PEN INJ PSORIASI
..........................................50
HUMULIN R INJ U-500 .....38
hydralazine hcl inj 20 mg/ml
..........................................23
hydralazine hcl tab 10 mg .23
..........................................23
hydrochlorothiazide cap 12.5
mg .....................................22
hydrochlorothiazide tab 12.5
mg .....................................22
hydrochlorothiazide tab 25
mg .....................................22
hydrochlorothiazide tab 50
mg .....................................22
soln 7.5-325 mg/15ml .........2
tab 10-325 mg .....................2
tab 5-325 mg .......................2
tab 7.5-325 mg ....................2
hydrocodone-ibuprofen tab
7.5-200 mg ..........................2
hydrocortisone butyrate
cream 0.1% .......................59
hydrocortisone butyrate oint
0.1% ..................................59
hydrocortisone butyrate soln
0.1% ..................................59
hydrocortisone cream 1% .59
hydrocortisone cream 2.5%
.......................................... 59
hydrocortisone enema 100
mg/60ml ............................ 46
HYDROCORTISONE
ENEMA 100 MG/60ML ..... 46
hydrocortisone lotion 2.5% 59
hydrocortisone oint 1% ..... 59
hydrocortisone oint 2.5% .. 59
hydrocortisone rectal cream
2.5%.................................. 58
hydrocortisone tab 10 mg . 43
hydrocortisone tab 20 mg . 43
hydrocortisone tab 5 mg ... 43
hydrocortisone valerate
cream 0.2%....................... 59
hydrocortisone valerate oint
0.2%.................................. 59
hydromorphone hcl liqd 1
mg/ml .................................. 2
hydromorphone hcl
preservative free (pf) inj 10
mg/ml .................................. 2
............................................ 2
............................................ 2
............................................ 2
hydroxychloroquine sulfate
tab 200 mg ........................ 50
hydroxyprogesterone
caproate im in oil 1.25
gm/5ml .............................. 13
hydroxyurea cap 500 mg .. 14
mg/ml ................................ 56
mg/ml ................................ 56
I
ibandronate sodium tab 150
IBRANCE CAP 100MG ..... 13
IBRANCE CAP 125MG ..... 13
IBRANCE CAP 75MG ....... 13
ibuprofen susp 100 mg/5ml. 1
ibuprofen tab 400 mg .......... 1
ICLUSIG TAB 15MG......... 14
ICLUSIG TAB 45MG......... 14
idarubicin hcl iv inj 10
mg/10ml (1 mg/ml) ............ 12
idarubicin hcl iv inj 20
mg/20ml (1 mg/ml) ............ 12
(1 mg/ml) .......................... 12
IFEX INJ 3GM .................. 11
ifosfamide for inj 1 gm....... 11
IFOSFAMIDE INJ 3GM..... 11
ifosfamide iv inj 1 gm/20ml
(50 mg/ml) ........................ 11
ifosfamide iv inj 3 gm/60ml
(50 mg/ml) ........................ 11
ILEVRO DRO 0.3% OP .... 55
ilotycin oin op .................... 54
(base equivalent) .............. 14
IMBRUVICA CAP 140MG . 14
imipenem-cilastatin
intravenous for soln 250 mg 5
imipenem-cilastatin
intravenous for soln 500 mg 5
imipramine hcl tab 10 mg .. 29
imiquimod cream 5% ........ 60
IMOVAX RABIE INJ 2.5/ML
.......................................... 51
INCRELEX INJ 40MG/4ML
.......................................... 43
INCRUSE ELPT INH
62.5MCG .......................... 55
indapamide tab 1.25 mg ... 22
indapamide tab 2.5 mg ..... 22
INFANRIX INJ .................. 51
INLYTA TAB 1MG ............ 14
INLYTA TAB 5MG ............ 14
INSULIN PEN NEEDLE .... 38
INSULIN SAFETY NEEDLES
.......................................... 38
INSULIN SYRINGE .......... 38
INTELENCE TAB 100MG ... 6
INTELENCE TAB 200MG ... 6
INTELENCE TAB 25MG ..... 6
77
INTRALIPID INJ 20% ........53
INTRALIPID INJ 30% ........53
INTRON A INJ 10MU ........51
introvale tab ......................40
INVANZ INJ 1GM................5
..........................................32
INVEGA SUST INJ
156MG/ML ........................32
..........................................32
..........................................32
INVEGA SUST INJ 78/0.5ML
..........................................32
INVEGA TAB 1.5MG .........32
INVEGA TAB 3MG............32
INVEGA TAB 6MG............32
INVEGA TAB 9MG............32
..........................................32
..........................................32
..........................................32
..........................................33
INVIRASE CAP 200MG ......6
INVIRASE TAB 500MG ......6
..........................................39
..........................................39
..........................................39
INVOKAMET TAB
50-500MG .........................39
INVOKANA TAB 100MG ...39
INVOKANA TAB 300MG ...39
IONOSOL-B/ INJ D5W ......53
IONOSOL-MB INJ /D5W ...53
IPOL INJ INACTIVE ..........51
ipratropium bromide inhal
soln 0.02% ........................55
.......................................... 56
.......................................... 56
ipratropium-albuterol nebu
soln 0.5-2.5(3) mg/3ml ...... 55
irbesartan tab 150 mg ....... 18
irbesartan tab 300 mg ....... 18
irbesartan tab 75 mg ......... 17
irbesartan-hydrochlorothiazid
e tab 150-12.5 mg ............. 17
irbesartan-hydrochlorothiazid
e tab 300-12.5 mg ............. 17
IRESSA TAB 250MG ........ 14
(20 mg/ml)......................... 15
(20 mg/ml)......................... 15
irinotecan hcl inj 500
mg/25ml (20 mg/ml) .......... 15
ISENTRESS CHW 100MG . 6
ISENTRESS CHW 25MG ... 6
ISENTRESS POW 100MG . 6
ISENTRESS TAB 400MG ... 6
ISOLYTE-P INJ /D5W ....... 53
ISOLYTE-S INJ................. 53
isoniazid inj 100 mg/ml........ 7
isoniazid syrup 50 mg/5ml .. 7
isoniazid tab 100 mg ........... 7
isoniazid tab 300 mg ........... 7
.......................................... 23
.......................................... 23
.......................................... 23
.......................................... 23
isosorbide dinitrate tab cr 40
mg ..................................... 23
isosorbide mononitrate tab
10 mg ................................ 23
isosorbide mononitrate tab
20 mg ................................ 23
24hr 120 mg...................... 23
24hr 30 mg ....................... 23
24hr 60 mg ....................... 23
isotretinoin cap 10 mg....... 58
isradipine cap 2.5 mg........ 21
isradipine cap 5 mg........... 21
ISTALOL SOL 0.5% OP ... 55
ISTODAX INJ 10MG ......... 13
itraconazole cap 100 mg ..... 6
ivermectin tab 3 mg ............ 5
IXIARO INJ ....................... 51
J
JAKAFI TAB 10MG ........... 14
JAKAFI TAB 15MG ........... 14
JAKAFI TAB 20MG ........... 14
JAKAFI TAB 25MG ........... 14
JAKAFI TAB 5MG ............. 14
jantoven tab 10mg ............ 49
jantoven tab 1mg .............. 49
jantoven tab 2.5mg ........... 49
jantoven tab 2mg .............. 49
jantoven tab 3mg .............. 49
jantoven tab 4mg .............. 49
jantoven tab 5mg .............. 49
jantoven tab 6mg .............. 49
jantoven tab 7.5mg ........... 49
JANUMET TAB 50-1000... 39
JANUMET TAB 50-500MG
.......................................... 39
.......................................... 39
.......................................... 39
JANUMET XR TAB
50-500MG ......................... 39
JANUVIA TAB 100MG ...... 39
JANUVIA TAB 25MG ........ 39
JANUVIA TAB 50MG ........ 39
JENTADUETO TAB
2.5-1000 ........................... 39
.......................................... 39
.......................................... 39
JENTADUETO TAB XR .... 39
jinteli tab 1mg-5mcg.......... 42
78
JOLIVETTE TAB 0.35MG .40
juleber tab .........................40
junel 1.5/30 tab .................40
junel 1/20 tab ....................40
junel fe tab 1.5/30 .............41
junel fe tab 1/20 ................41
JUXTAPID CAP 10MG .....19
JUXTAPID CAP 5MG .......19
K
KADCYLA INJ 100MG ......13
KADCYLA INJ 160MG ......13
KALETRA SOL ...................7
KALETRA TAB 100-25MG ..7
KALETRA TAB 200-50MG ..7
KALYDECO PAK 50MG ...56
KALYDECO PAK 75MG ...56
KALYDECO TAB 150MG ..56
kariva tab 28 day...............41
KCL 10 MEQ/L (0.075%) IN
DEXTROSE 5% & NACL
0.45% INJ .........................53
KCL 20 MEQ/L (0.15%) IN
DEXTROSE 5% & NACL
0.2% INJ ...........................53
KCL 20 MEQ/L (0.15%) IN
DEXTROSE 5% & NACL
0.33% INJ .........................53
KCL 20 MEQ/L (0.15%) IN
DEXTROSE 5% & NACL
0.45% INJ .........................53
KCL 20 MEQ/L (0.15%) IN
DEXTROSE 5% & NACL
0.9% INJ ...........................53
kcl 20 meq/l (0.15%) in nacl
0.45% inj ...........................53
KCL 20 MEQ/L (0.15%) IN
NACL 0.45% INJ ...............53
KCL 20 MEQ/L (0.15%) IN
NACL 0.9% INJ .................53
KCL 30 MEQ/L (0.224%) IN
DEXTROSE 5% & NACL
0.45% INJ .........................53
DEXTROSE 5% & NACL
0.45% INJ ......................... 53
NACL 0.9% INJ................. 53
KCL/D5W/NACL INJ 0.15/0.2
.......................................... 53
KCL/D5W/NACL INJ
0.3/0.9%............................ 53
kelnor tab 1/35 .................. 41
ketoconazole cream 2%.... 58
ketoconazole shampoo 2%
.......................................... 58
ketoconazole tab 200 mg .... 6
ketoprofen cap 50 mg ......... 1
ketoprofen cap 75 mg ......... 1
ketorolac tromethamine
ophth soln 0.4% ................ 55
ketorolac tromethamine
ophth soln 0.5% ................ 55
KEYTRUDA INJ 100MG/4M
.......................................... 13
KEYTRUDA SOL 50MG ... 13
kimidess tab ...................... 41
KINRIX INJ ....................... 51
kionex pow ........................ 40
kionex sus 15gm/60 .......... 40
KLOR-CON 10 TAB 10MEQ
ER ..................................... 52
KLOR-CON 8 TAB 8MEQ ER
.......................................... 52
klor-con m15 tab 15meq er
.......................................... 52
klor-con pow 20meq ......... 52
KORLYM TAB 300MG ...... 43
KUVAN POW 100MG ....... 42
KUVAN POW 500MG ....... 42
KUVAN TAB 100MG ......... 42
KYNAMRO INJ 200MG/ML
.......................................... 19
L
labetalol hcl tab 100 mg .... 20
LACTATED RINGER'S
SOLUTION ....................... 53
lactic acid (ammonium
lactate) cream 12% ........... 60
lactic acid (ammonium
lactate) lotion 12% ............ 60
lactulose (encephalopathy)
solution 10 gm/15ml.......... 46
lactulose solution 10
gm/15ml ............................ 46
lamivudine oral soln 10 mg/ml
............................................ 6
lamivudine tab 100 mg (hbv)
............................................ 8
lamivudine tab 150 mg........ 6
lamivudine tab 300 mg........ 6
lamivudine-zidovudine tab
150-300 mg ........................ 7
lamotrigine tab 100 mg ..... 25
lamotrigine tab 25 mg ....... 25
dispersible 25 mg.............. 25
dispersible 5 mg................ 25
lamotrigine tab sr 24hr 100
mg..................................... 25
mg..................................... 25
.......................................... 25
mg..................................... 25
mg..................................... 25
.......................................... 25
LANTUS INJ 100/ML ........ 38
LANTUS INJ SOLOSTAR. 38
larin fe tab 1.5/30 .............. 41
larin fe tab 1/20 ................. 41
larin tab 1.5/30 .................. 41
larin tab 1/20 ..................... 41
LASTACAFT SOL 0.25%.. 55
latanoprost ophth soln
0.005% ............................. 55
LATUDA TAB 120MG ....... 33
LATUDA TAB 20MG ......... 33
LATUDA TAB 40MG ......... 33
LATUDA TAB 60MG ......... 33
LATUDA TAB 80MG ......... 33
leflunomide tab 10 mg ...... 50
leflunomide tab 20 mg ...... 50
79
LENVIMA CAP 10 MG ......14
LENVIMA CAP 8 MG ........14
lessina tab .........................41
LETAIRIS TAB 10MG .......23
LETAIRIS TAB 5MG .........23
letrozole tab 2.5 mg ..........13
mg .....................................15
mg .....................................15
mg .....................................15
mg .....................................15
mg .....................................15
..........................................15
..........................................15
..........................................15
..........................................15
LEUKERAN TAB 2MG ......11
LEUKINE INJ 250MCG .....49
leuprolide acetate inj kit 5
mg/ml ................................13
levalbuterol hcl soln nebu
conc 1.25 mg/0.5ml (base
equiv) ................................56
LEVEMIR INJ ....................38
LEVEMIR INJ FLEXTOUC 38
LEVETIRACETA INJ
10MG/ML ..........................25
LEVETIRACETA INJ
15MG/ML ..........................26
LEVETIRACETA INJ
5MG/ML ............................25
levetiracetam inj 500 mg/5ml
(100 mg/ml) .......................26
levetiracetam oral soln 100
mg/ml ................................26
levetiracetam tab 1000 mg 26
levetiracetam tab 250 mg.. 26
mg ..................................... 26
mg ..................................... 26
levobunolol hcl ophth soln
0.5%.................................. 55
levocarnitine inj 200 mg/ml42
levocarnitine oral soln 1
gm/10ml (10%) ................. 42
levocarnitine tab 330 mg ... 42
soln 2.5 mg/5ml (0.5 mg/ml)
.......................................... 56
tab 5 mg ............................ 56
levofloxacin in d5w iv soln
250 mg/50ml ..................... 10
500 mg/100ml ................... 10
750 mg/150ml ................... 10
levofloxacin iv soln 25 mg/ml
.......................................... 10
levofloxacin oral soln 25
mg/ml ................................ 10
levofloxacin tab 250 mg .... 10
levoleucovor sol 250mg/25
.......................................... 15
levoleucovorin calcium for iv
inj 50 mg (base equiv)....... 15
levoleucovorin calcium inj
175 mg/17.5ml (base equiv)
.......................................... 15
levonest tab ...................... 41
estradiol (91-day) tab
0.15-0.03 mg ..................... 41
LEVONORGESTREL &
ETHINYL ESTRADIOL
(91-DAY) TAB 0.15-0.03 MG
.......................................... 41
.......................................... 41
levonorgestrel tab 0.75 mg41
levonorgestrel tab 1.5 mg . 41
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30m
g-mcg ................................ 41
levora-28 tab 0.15/30 ........ 41
mcg ................................... 44
mcg ................................... 44
mcg ................................... 44
mcg ................................... 44
mcg ................................... 44
mcg ................................... 44
mcg ................................... 44
mcg ................................... 44
mcg ................................... 44
mcg ................................... 44
mcg ................................... 44
mcg ................................... 44
LEVOXYL TAB 100MCG .. 44
LEVOXYL TAB 25MCG .... 44
LEXIVA SUS 50MG/ML ...... 6
LEXIVA TAB 700MG .......... 6
lidocaine hcl gel 2% .......... 60
lidocaine hcl local inj 0.5% .. 4
lidocaine hcl local inj 1% ..... 4
lidocaine hcl local inj 1.5% .. 4
80
lidocaine hcl local inj 2% .....4
lidocaine hcl local
preservative free (pf) inj 0.5%
............................................4
lidocaine hcl local
preservative free (pf) inj 1% 4
lidocaine hcl soln 4% ........60
lidocaine hcl viscous soln 2%
..........................................60
lidocaine oint 5% ...............60
lidocaine patch 5% ............60
lidocaine-prilocaine cream
2.5-2.5%............................60
LINEZOLID FOR SUSP 100
MG/5ML ..............................5
LINEZOLID IN SODIUM
CHLORIDE IV SOLN 600
MG/300ML-0.9% .................5
linezolid iv soln 600
mg/300ml (2 mg/ml) ............5
LINEZOLID TAB 600 MG ....5
LINZESS CAP 145MCG ...47
LINZESS CAP 290MCG ...47
mcg ...................................44
mcg ...................................44
mcg ...................................44
lisinopril &
10-12.5 mg ........................16
lisinopril &
20-12.5 mg ........................16
lisinopril &
20-25 mg ...........................16
lisinopril tab 10 mg ............16
lisinopril tab 2.5 mg ...........16
lisinopril tab 5 mg ..............16
..........................................37
..........................................37
.......................................... 37
lithium carbonate tab 300 mg
.......................................... 37
mg ..................................... 37
mg ..................................... 37
LITHIUM SOL 8MEQ/5ML 37
lokara lot 0.05% ................ 59
LONSURF TAB 15-6.14.... 14
LONSURF TAB 20-8.19.... 14
loperamide hcl cap 2 mg ... 47
lorazepam con 2mg/ml...... 24
lorazepam inj 2 mg/ml ....... 24
lorazepam inj 4 mg/ml ....... 24
lorazepam tab 0.5 mg ....... 24
lorazepam tab 1 mg .......... 24
lorazepam tab 2 mg .......... 24
loryna tab 3-0.02mg .......... 41
100-12.5 mg...................... 17
100-25 mg......................... 17
50-12.5 mg........................ 17
losartan potassium tab 100
mg ..................................... 18
.......................................... 18
.......................................... 18
LOTEMAX GEL 0.5% ....... 55
LOTEMAX OIN 0.5% ........ 55
LOTEMAX SUS 0.5% ....... 55
lovastatin tab 10 mg .......... 19
.......................................... 33
.......................................... 33
.......................................... 33
.......................................... 33
LUMIGAN SOL 0.01% ...... 55
LUMIZYME INJ 50MG ...... 42
LUPR DEP-PED INJ
11.25MG ........................... 13
.......................................... 13
.......................................... 13
.......................................... 13
LUPRON DEPOT INJ
11.25MG ........................... 13
LUPRON DEPOT INJ
3.75MG ............................. 13
lutera tab........................... 41
LYNPARZA CAP 50MG.... 13
LYRICA CAP 100MG........ 26
LYRICA CAP 25MG.......... 26
LYRICA CAP 50MG.......... 26
LYRICA CAP 75MG.......... 26
LYRICA SOL 20MG/ML .... 26
LYSODREN TAB 500MG . 13
lyza tab 0.35mg ................ 41
M
MAGNESIUM SU INJ
20/500ML.......................... 52
MAGNESIUM SU INJ
2GM/50ML ........................ 52
MAGNESIUM SU INJ
40G/1000 .......................... 52
MAGNESIUM SU INJ
4G/100ML ......................... 52
MAGNESIUM SU INJ
80MG/ML .......................... 52
magnesium sulfate inj 50%
.......................................... 52
MAGNESIUM SULFATE INJ
50% .................................. 52
magnesium sulfate iv soln 2
gm/50ml (40 mg/ml) .......... 52
malathion lotion 0.5% ....... 60
maprotiline hcl tab 25 mg .. 29
maprotiline hcl tab 50 mg .. 29
81
maprotiline hcl tab 75 mg ..29
marlissa tab 0.15/30..........41
MARPLAN TAB 10MG ......29
MATULANE CAP 50MG ...14
MAXIDEX SUS 0.1% OP ..55
meclizine hcl tab 12.5 mg..45
meclizine hcl tab 25 mg ....45
medroxyprogesterone
acetate im susp 150 mg/ml
..........................................41
MEDROXYPROGESTERON
E ACETATE IM SUSP 150
MG/ML ..............................41
medroxyprogesterone
acetate tab 10 mg .............44
medroxyprogesterone
acetate tab 2.5 mg ............44
medroxyprogesterone
acetate tab 5 mg ...............44
mefloquine hcl tab 250 mg ..6
megestrol acetate susp 40
mg/ml ................................13
MEGESTROL ACETATE
SUSP 625 MG/5ML ..........13
..........................................13
..........................................13
MEKINIST TAB 0.5MG .....14
MEKINIST TAB 2MG ........14
MELOXICAM SUSP 7.5
MG/5ML ..............................1
meloxicam tab 15 mg ..........1
meloxicam tab 7.5 mg .........1
melphalan hcl for inj 50 mg
(base equiv) ......................11
memantine hcl oral solution 2
mg/ml ................................27
memantine hcl tab 10 mg ..27
memantine hcl tab 5 mg ....27
MENACTRA INJ ...............51
MENHIBRIX INJ................51
MENOMUNE INJ A/C/Y/W 51
MENVEO INJ ....................51
mercaptopurine tab 50 mg 12
meropenem iv for soln 1 gm5
meropenem iv for soln 500
mg .......................................5
mesalamine enema 4 gm.. 46
mesalamine rectal enema 4
gm & cleanser wipe kit ...... 46
mesna inj 100 mg/ml ......... 15
MESNEX TAB 400MG ...... 15
metformin hcl tab 1000 mg39
metformin hcl tab 500 mg . 39
metformin hcl tab 850 mg . 39
mg ..................................... 39
mg ..................................... 39
methadone con 10mg/ml .... 2
methadone hcl soln 10
mg/5ml ................................ 2
............................................ 2
methadone hcl tab 10 mg ... 2
methadone hcl tab 5 mg ..... 2
methazolamide tab 25 mg. 22
methazolamide tab 50 mg. 22
methenamine hippurate tab 1
gm ....................................... 5
methimazole tab 10 mg..... 44
methimazole tab 5 mg....... 44
methotrexate sodium for inj 1
gm ..................................... 12
methotrexate sodium inj 250
mg/10ml (25 mg/ml) .......... 12
METHOTREXATE SODIUM
INJ 50 MG/2ML (25 MG/ML)
.......................................... 12
100 mg/4ml (25 mg/ml) ..... 12
1000 mg/40ml (25 mg/ml) . 12
200 mg/8ml (25 mg/ml) ..... 12
250 mg/10ml (25 mg/ml) ... 12
mg/2ml (25 mg/ml) ............ 12
methotrexate sodium tab 2.5
mg (base equiv) ................ 50
methyclothiazide tab 5 mg 22
methylergonovine maleate
tab 0.2 mg ......................... 43
mg/5ml .............................. 35
mg/5ml .............................. 35
methylphenidate hcl tab 10
mg..................................... 35
methylphenidate hcl tab 20
mg..................................... 35
.......................................... 35
mg..................................... 35
mg..................................... 35
methylprednisolone acetate
inj susp 40 mg/ml .............. 43
methylprednisolone acetate
inj susp 80 mg/ml .............. 43
succinate for inj 1000 mg .. 43
succinate for inj 125 mg .... 43
succinate for inj 40 mg ...... 43
methylprednisolone tab 16
mg..................................... 43
methylprednisolone tab 32
mg..................................... 43
.......................................... 43
.......................................... 43
methylprednisolone tab
therapy pack 4 mg (21) ..... 43
metipranolol ophth soln 0.3%
.......................................... 55
metoclopramide hcl inj 5
mg/ml ................................ 45
metoclopramide hcl soln 5
mg/5ml (10 mg/10ml) ........ 45
metoclopramide hcl tab 10
mg..................................... 45
.......................................... 45
metolazone tab 10 mg ...... 22
metolazone tab 2.5 mg ..... 22
metolazone tab 5 mg ........ 22
metoprolol &
82
100-25 mg .........................20
metoprolol &
100-50 mg .........................20
metoprolol &
50-25 mg ...........................20
..........................................20
..........................................20
24hr 25 mg (tartrate equiv)20
24hr 50 mg (tartrate equiv)20
metoprolol tartrate inj 1 mg/ml
..........................................20
metoprolol tartrate tab 100
mg .....................................20
..........................................20
..........................................20
metronidazole cream 0.75%
..........................................60
metronidazole gel 0.75% ..60
metronidazole in nacl 0.79%
iv soln 500 mg/100ml ..........5
metronidazole lotion 0.75%
..........................................60
metronidazole tab 250 mg...5
metronidazole tab 500 mg...5
metronidazole vaginal gel
0.75% ................................48
mexiletine hcl cap 150 mg.18
..........................................52
..........................................52
MIACALCIN INJ 200/ML ...43
midodrine hcl tab 10 mg ....23
midodrine hcl tab 2.5 mg ...23
midodrine hcl tab 5 mg ......23
minitran dis 0.1mg/hr ........23
minitran dis 0.2mg/hr ........ 23
.......................................... 11
minocycline hcl cap 50 mg 11
minocycline hcl cap 75 mg 11
minoxidil tab 10 mg ........... 23
minoxidil tab 2.5 mg .......... 23
mirtazapine orally
disintegrating tab 15 mg.... 29
mirtazapine orally
mirtazapine orally
mirtazapine tab 15 mg ...... 29
mirtazapine tab 7.5 mg ..... 29
misoprostol tab 100 mcg ... 47
misoprostol tab 200 mcg ... 47
.......................................... 12
.......................................... 12
mitomycin for iv soln 5 mg 12
mg/10ml (2 mg/ml) ............ 14
mg/12.5ml (2 mg/ml) ......... 14
mg/15ml (2 mg/ml) ............ 14
M-M-R II INJ ..................... 51
moderiba pak 1000/day ...... 8
MODERIBA PAK 1200/DAY
............................................ 8
moderiba pak 600/day ........ 8
moderiba pak 800/day ........ 8
moexipril hcl tab 15 mg ..... 16
moexipril hcl tab 7.5 mg .... 16
moexipril-hydrochlorothiazid
e tab 15-12.5 mg ............... 16
e tab 15-25 mg .................. 16
e tab 7.5-12.5 mg .............. 16
molindone hcl tab 10 mg ... 33
molindone hcl tab 25 mg ... 33
molindone hcl tab 5 mg..... 33
mometasone furoate cream
0.1% ................................. 59
mometasone furoate nasal
susp 50 mcg/act................ 57
mometasone furoate oint
0.1% ................................. 59
mometasone furoate solution
0.1% (lotion) ..................... 59
MONONESSA TAB .......... 41
montelukast sodium chew
tab 4 mg (base equiv) ....... 56
montelukast sodium chew
tab 5 mg (base equiv) ....... 56
montelukast sodium oral
granules packet 4 mg (base
equiv) ................................ 56
montelukast sodium tab 10
mg (base equiv) ................ 56
morgidox cap 1x50mg ...... 11
MORPHINE SUL INJ
2MG/ML .............................. 2
MORPHINE SUL INJ
4MG/ML .............................. 2
MORPHINE SUL INJ
8MG/ML .............................. 3
morphine sulfate beads cap
sr 24hr 120 mg ................... 3
sr 24hr 30 mg ..................... 3
sr 24hr 45 mg ..................... 3
sr 24hr 60 mg ..................... 3
sr 24hr 75 mg ..................... 3
sr 24hr 90 mg ..................... 3
10 mg.................................. 3
100 mg................................ 3
20 mg.................................. 3
30 mg.................................. 3
50 mg.................................. 3
83
60 mg ..................................3
80 mg ..................................3
morphine sulfate inj pf 0.5
mg/ml ..................................3
morphine sulfate inj pf 1
mg/ml ..................................3
MORPHINE SULFATE IV
SOLN 1 MG/ML ..................3
MORPHINE SULFATE IV
SOLN PF 10 MG/ML ...........3
MORPHINE SULFATE IV
SOLN PF 15 MG/ML ...........3
mg/ml ..................................3
mg/ml ..................................3
MORPHINE SULFATE
ORAL SOLN 10 MG/5ML ....3
MORPHINE SULFATE
ORAL SOLN 100 MG/5ML
(20 MG/ML) .........................3
MORPHINE SULFATE
ORAL SOLN 20 MG/5ML ....3
15 MG .................................3
30 MG .................................3
mg .......................................3
............................................3
mg .......................................3
............................................3
............................................3
MOVANTIK TAB 12.5MG..47
MOVANTIK TAB 25MG ....47
MOVIPREP SOL ...............46
MOXEZA SOL 0.5% .........54
MOZOBIL INJ ...................49
MULTAQ TAB 400MG ......18
mupirocin oint 2% .............58
MUSTARGEN INJ 10MG ..12
MYCAMINE INJ 100MG .....6
MYCAMINE INJ 50MG ....... 6
mycophenolate mofetil cap
250 mg .............................. 51
mycophenolate mofetil for
oral susp 200 mg/ml.......... 51
mycophenolate mofetil tab
500 mg .............................. 51
equiv) ................................ 51
equiv) ................................ 51
myorisan cap 10mg .......... 58
MYOZYME INJ 50MG....... 42
MYRBETRIQ TAB 25MG .. 48
MYRBETRIQ TAB 50MG .. 48
myzilra tab ........................ 41
N
nabumetone tab 500 mg ..... 1
nabumetone tab 750 mg ..... 1
nadolol tab 20 mg ............. 20
nadolol tab 40 mg ............. 20
nadolol tab 80 mg ............. 20
.......................................... 11
.......................................... 11
.......................................... 11
gm ..................................... 11
gm ..................................... 11
NAGLAZYME INJ 1MG/ML
.......................................... 42
nalbuphine hcl inj 10 mg/ml 1
nalbuphine hcl inj 20 mg/ml 1
naloxone hcl inj 0.4 mg/ml 37
naloxone hcl inj 1 mg/ml ... 37
naltrexone hcl tab 50 mg... 37
NAMENDA XR CAP 14MG
.......................................... 27
NAMENDA XR CAP 21MG
.......................................... 27
NAMENDA XR CAP 28MG
.......................................... 27
NAMENDA XR CAP 7MG . 27
NAMENDA XR CAP
TITRATIO ......................... 27
.......................................... 27
.......................................... 27
naphazoline hcl ophth soln
0.1% ................................. 55
naproxen dr tab 375mg....... 1
naproxen dr tab 500mg....... 1
............................................ 1
............................................ 1
naproxen susp 125 mg/5ml 1
naproxen tab 250 mg .......... 1
naratriptan hcl tab 1 mg (base
equiv) ................................ 36
naratriptan hcl tab 2.5 mg
(base equiv) ...................... 36
NASONEX SPR 50MCG/AC
.......................................... 57
NATACYN SUS 5% OP .... 54
nateglinide tab 120 mg ..... 39
nateglinide tab 60 mg ....... 39
NATPARA INJ 100MCG ... 44
NATPARA INJ 25MCG ..... 44
NEBUPENT INH 300MG .... 5
necon tab 0.5/35 ............... 41
necon tab 1/35 .................. 41
NECON TAB 1/50-28........ 41
necon tab 10/11-28 ........... 41
NECON TAB 7/7/7 ............ 41
.......................................... 29
.......................................... 29
.......................................... 29
.......................................... 29
84
nefazodone hcl tab 50 mg .29
neomycin sulfate tab 500 mg
............................................4
neomycin-bacitrac
zn-polymyx
5(3.5)mg-400unt-10000unt
op oin ................................54
neomycin-polymy-gramicid
op sol
1.75-10000-0.025mg-unt-mg
/ml .....................................54
neomycin-polymyxin-dexame
thasone ophth oint 0.1% ...54
neomycin-polymyxin-dexame
thasone ophth susp 0.1% .54
neomycin-polymyxin-hc
ophth susp ........................54
soln 1% .............................60
susp 3.5 mg/ml-10000
unit/ml-1% .........................60
NEORAL CAP 100MG ......51
NEORAL CAP 25MG ........51
NEORAL SOL 100MG/ML 51
NEPHRAMINE INJ 5.4%...53
NEUMEGA INJ 5MG .........49
NEUPOGEN INJ 300/0.5 ..49
NEUPOGEN INJ 300MCG 49
NEUPOGEN INJ 480/0.8 ..49
NEUPOGEN INJ 480MCG 49
NEUPRO DIS 1MG/24HR .31
NEVIRAPINE SUSP 50
MG/5ML ..............................6
nevirapine tab 200 mg ........6
............................................6
............................................6
NEXAVAR TAB 200MG ....14
NEXIUM CAP 20MG .........47
NEXIUM CAP 40MG .........47
NEXIUM GRA 10MG DR ..47
NEXIUM GRA 2.5MG DR . 47
NEXIUM GRA 20MG DR .. 47
NEXIUM GRA 40MG DR .. 47
NEXIUM GRA 5MG DR .... 47
(antihyperlipidemic) ........... 19
niacor tab 500mg .............. 19
nicardipine hcl cap 20 mg . 21
nicardipine hcl cap 30 mg . 21
NICOTROL INH ................ 37
NICOTROL NS SPR
10MG/ML .......................... 37
nifedical xl tab 30mg ......... 21
nifedical xl tab 60mg ......... 21
.......................................... 21
.......................................... 21
.......................................... 21
release 30 mg ................... 21
release 60 mg ................... 21
release 90 mg ................... 21
nikki tab 3-0.02mg ............ 41
NILANDRON TAB 150MG 13
nilutamide tab 150 mg....... 13
nimodipine cap 30 mg ....... 21
NINLARO CAP 2.3MG ...... 13
NINLARO CAP 3MG ......... 13
NINLARO CAP 4MG ......... 13
NIPENT INJ 10MG ........... 12
nitro-bid oin 2% ................. 23
.......................................... 23
.......................................... 23
nitrofurantoin
............................................ 5
nitrofurantoin
macrocrystalline cap 50 mg 5
nitrofurantoin monohydrate
............................................ 5
mg/hr ................................ 23
mg/hr ................................ 23
mg/hr ................................ 23
mg/hr ................................ 23
NITROSTAT SUB 0.3MG . 23
NORDITROPIN INJ
10/1.5ML........................... 43
NORDITROPIN INJ
15/1.5ML........................... 43
NORDITROPIN INJ 30/3ML
.......................................... 43
.......................................... 43
norelgestromin-ethinyl
estradiol td ptwk 150-35
mcg/24hr........................... 41
NORETHINDRONE ACE &
1 MG-20 MCG .................. 41
NORETHINDRONE ACE &
1.5 MG-30 MCG ............... 41
NORETHINDRONE ACE &
TAB 1 MG-20 MCG .......... 41
NORETHINDRONE ACE &
TAB 1.5 MG-30 MCG ....... 41
norethindrone acetate tab 5
mg..................................... 44
norethindrone acetate-ethinyl
estradiol tab 1 mg-5 mcg .. 42
norethindrone tab 0.35 mg 41
NORETHINDRONE TAB
0.35 MG ............................ 41
NORETHINDRONE-ETH
ESTRADIOL TAB
0.5-35/1-35/0.5-35 MG-MCG
.......................................... 41
85
norgestimate & ethinyl
..........................................41
norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35
mg-mcg .............................41
norgestrel & ethinyl estradiol
tab 0.3 mg-30 mcg ............41
norlyroc tab 0.35mg ..........41
NORMOSOL -M INJ /D5W 53
NORMOSOL -R INJ /D5W 53
NORMOSOL-R INJ PH 7.4
..........................................53
..........................................18
..........................................18
nortrel tab 0.5/35 ...............41
nortrel tab 1/35 ..................41
nortrel tab 7/7/7 .................41
nortriptyline hcl cap 10 mg 29
nortriptyline hcl soln 10
mg/5ml ..............................29
NORVIR CAP 100MG .........6
NORVIR SOL 80MG/ML .....6
NORVIR TAB 100MG .........6
NOVOLIN INJ 70/30 .........38
NOVOLIN N INJ U-100 .....38
NOVOLIN R INJ U-100 .....38
NOVOLOG INJ 100/ML ....38
NOVOLOG INJ FLEXPEN 38
NOVOLOG INJ PENFILL ..38
NOVOLOG MIX INJ 70/30 38
NOVOLOG MIX INJ
FLEXPEN..........................38
NOXAFIL SUS 40MG/ML....6
NOXAFIL TAB 100MG ........6
NUEDEXTA CAP 20-10MG
..........................................37
NULOJIX INJ 250MG ........51
NULYTELY SOL FLAV PKS
..........................................46
NUPLAZID TAB 17MG .....33
NUVARING MIS................41
NUVIGIL TAB 150MG .......37
NUVIGIL TAB 200MG ....... 37
NUVIGIL TAB 250MG ....... 37
NUVIGIL TAB 50MG ......... 37
nyamyc pow 100000 ......... 58
NYMALIZE SOL 60/20ML . 21
nystatin cream 100000
unit/gm .............................. 58
nystatin oint 100000 unit/gm
.......................................... 58
nystatin susp 100000 unit/ml
.......................................... 60
nystatin tab 500000 unit ...... 6
nystatin topical powder ..... 58
nystop pow 100000 ........... 58
O
OCTAGAM INJ 10GM....... 50
OCTAGAM INJ 1GM......... 50
OCTAGAM INJ 2.5GM...... 50
OCTAGAM INJ 25GM....... 50
OCTAGAM INJ 2GM/20ML
.......................................... 50
OCTAGAM INJ 5GM......... 50
mcg/ml (0.1 mg/ml) ........... 43
mcg/ml (1 mg/ml) .............. 43
mcg/ml (0.2 mg/ml) ........... 43
mcg/ml (0.05 mg/ml) ......... 43
mcg/ml (0.5 mg/ml) ........... 43
ODEFSEY TAB ................... 7
ODOMZO CAP 200MG..... 14
OFEV CAP 100MG ........... 56
OFEV CAP 150MG ........... 56
ofloxacin ophth soln 0.3% . 54
ofloxacin otic soln 0.3% .... 60
olanzapine for im inj 10 mg
.......................................... 33
olanzapine orally
olanzapine orally
olanzapine orally
olanzapine orally
olanzapine tab 10 mg ....... 33
olanzapine tab 2.5 mg ...... 33
olanzapine tab 5 mg ......... 33
olanzapine tab 7.5 mg ...... 33
olopatadine hcl nasal soln
0.6% ................................. 56
omega-3-acid ethyl esters
cap 1 gm ........................... 19
release 10 mg ................... 47
release 20 mg ................... 47
release 40 mg ................... 48
ondansetron hcl inj 4 mg/2ml
(2 mg/ml) .......................... 45
ondansetron hcl inj 40
mg/20ml (2 mg/ml) ............ 45
ondansetron hcl oral soln 4
mg/5ml .............................. 45
ondansetron hcl tab 24 mg45
ondansetron hcl tab 4 mg . 45
ondansetron hcl tab 8 mg . 45
ondansetron orally
disintegrating tab 4 mg ..... 45
ondansetron orally
ONFI SUS 2.5MG/ML ....... 26
ONFI TAB 10MG .............. 26
ONFI TAB 20MG .............. 26
OPSUMIT TAB 10MG....... 23
ORFADIN CAP 10MG ...... 42
ORFADIN CAP 20MG ...... 42
ORFADIN CAP 2MG ........ 42
ORFADIN CAP 5MG ........ 42
ORFADIN SUS 4MG/ML .. 42
ORKAMBI TAB 200-125 ... 56
orsythia tab ....................... 41
.......................................... 11
.......................................... 11
.......................................... 11
oxaliplatin for iv inj 100 mg 15
oxaliplatin for iv inj 50 mg . 15
86
oxaliplatin iv soln 100
mg/20ml ............................15
..........................................15
oxandrolone tab 10 mg .....38
oxandrolone tab 2.5 mg ....38
oxcarbazepine susp 300
mg/5ml (60 mg/ml) ............26
oxcarbazepine tab 150 mg 26
oxybutynin chloride syrup 5
mg/5ml ..............................48
oxybutynin chloride tab 5 mg
..........................................48
oxybutynin chloride tab sr
24hr 10 mg ........................48
24hr 15 mg ........................48
24hr 5 mg ..........................48
oxycodone hcl cap 5 mg .....3
oxycodone hcl conc 100
mg/5ml (20 mg/ml) ..............3
OXYCODONE HCL SOLN 5
MG/5ML ..............................3
oxycodone hcl tab 10 mg ....3
oxycodone hcl tab 5 mg ......3
oxycodone w/
acetaminophen soln 5-325
mg/5ml ................................4
oxycodone w/
acetaminophen tab 10-325
mg .......................................4
oxycodone w/
acetaminophen tab 2.5-325
mg .......................................4
oxycodone w/
acetaminophen tab 5-325 mg
............................................4
oxycodone w/
acetaminophen tab 7.5-325
mg .......................................4
P
pacerone tab 100mg .........18
pacerone tab 200mg ......... 18
pacerone tab 400mg ......... 18
mg/16.7ml (6 mg/ml) ......... 13
mg/25ml (6 mg/ml) ............ 13
(6 mg/ml)........................... 13
mg/50ml (6 mg/ml) ............ 13
paliperidone tab sr 24hr 1.5
mg ..................................... 33
.......................................... 33
.......................................... 33
.......................................... 33
3 mg/ml ............................. 40
9 mg/ml ............................. 40
pamidronate inj 6mg/ml..... 40
PANRETIN GEL 0.1% ...... 60
pantoprazole sodium ec tab
20 mg (base equiv) ........... 48
pantoprazole sodium ec tab
40 mg (base equiv) ........... 48
paricalcitol cap 1 mcg ....... 54
paromomycin sulfate cap 250
mg ....................................... 4
paroxetine hcl tab 10 mg... 29
paser gra 4gm..................... 7
PATADAY SOL 0.2% ........ 55
PAXIL SUS 10MG/5ML..... 29
PAZEO DRO 0.7% ........... 55
PEDIARIX INJ 0.5ML ........ 51
PEDVAX HIB INJ .............. 52
PEG 3350-KCL-NA
BICARB-NACL-NA
SULFATE FOR SOLN 236
GM .................................... 46
PEG 3350-KCL-NA
BICARB-NACL-NA
SULFATE FOR SOLN 240
GM .................................... 46
peg 3350-kcl-sod bicarb-nacl
for soln 420 gm ................. 46
PEGANONE TAB 250MG . 26
PEGASYS INJ .................... 8
PEGASYS INJ 180MCG/M . 8
PEGASYS INJ PROCLICK . 8
PEG-INTRON KIT 120 RP .. 8
PEGINTRON KIT 120MCG 8
PEG-INTRON KIT 150 RP .. 8
PEGINTRON KIT 150MCG 8
PEGINTRON KIT 50MCG .. 8
PEG-INTRON KIT 50MCG
RP....................................... 8
PEGINTRON KIT 80MCG .. 8
PEG-INTRON KIT 80MCG
RP....................................... 8
pen g proc inj 600000 ....... 11
.......................................... 11
.......................................... 11
20000000 unit ................... 11
5000000 unit ..................... 11
penicillin g sodium for inj
5000000 unit ..................... 11
125 mg/5ml ....................... 11
250 mg/5ml ....................... 11
mg..................................... 11
mg..................................... 11
PENTACEL INJ ................ 52
PENTAM 300 INJ 300MG ... 5
pentoxifylline tab cr 400 mg
.......................................... 50
PERFOROMIST NEB
20MCG ............................. 56
perindopril erbumine tab 2
mg..................................... 16
mg..................................... 16
87
mg .....................................16
periogard sol 0.12% ..........60
permethrin cream 5% ........60
perphenazine tab 16 mg ...33
perphenazine tab 2 mg .....33
phenadoz sup 12.5mg ......45
phenelzine sulfate tab 15 mg
..........................................29
phenergan sup 12.5mg .....45
phenergan sup 25mg ........45
phenergan sup 50mg ........45
PHENOBARB INJ 65MG/ML
..........................................26
phenobarbital elixir 20
mg/5ml ..............................26
phenobarbital sodium inj 130
mg/ml ................................26
phenobarbital tab 100 mg .26
phenobarbital tab 15 mg ...26
phenobarbital tab 16.2 mg 26
phenytek cap 200mg .........26
phenytek cap 300mg .........26
phenytoin chew tab 50 mg 26
cap 100 mg .......................26
cap 200 mg .......................26
cap 300 mg .......................26
phenytoin sodium inj 50
mg/ml ................................26
phenytoin susp 125 mg/5ml
..........................................26
philith tab 0.4-35 ...............41
PHOSPHOLINE SOL
0.125%OP.........................55
SOLN 1% ..........................55
SOLN 2% ..........................55
SOLN 4% .......................... 55
PILOCARPINE HCL TAB 5
MG .................................... 60
pilocarpine hcl tab 7.5 mg . 60
pimozide tab 1 mg ............ 33
pimozide tab 2 mg ............ 33
pimtrea tab ........................ 41
pindolol tab 10 mg ............ 20
pindolol tab 5 mg .............. 20
(base equiv) ...................... 39
(base equiv) ...................... 39
(base equiv) ...................... 39
na for inj 3.375 gm (3-0.375
gm).................................... 11
sod for inj 2.25 gm (2-0.25
gm).................................... 11
.......................................... 11
sod for inj 40.5 gm (36-4.5
gm).................................... 11
pirmella tab 1/35 ............... 41
piroxicam cap 10 mg ........... 1
piroxicam cap 20 mg ........... 1
PLASMA-LYTE INJ -148... 53
PLASMA-LYTE INJ 56/D5W
.......................................... 53
PLASMA-LYTE INJ -A ...... 53
podofilox soln 0.5% ........... 60
packet ............................... 47
powder .............................. 47
polymyxin b-trimethoprim
ophth soln 10000
unit/ml-0.1% ...................... 54
POMALYST CAP 1MG ..... 14
portia-28 tab...................... 41
MEQ/L (0.15%) IN
DEXTROSE 5% INJ ......... 53
MEQ/L (0.3%) IN
DEXTROSE 5% INJ ......... 53
meq................................... 52
meq................................... 52
10 MEQ/100ML................. 54
10 MEQ/50ML .................. 54
potassium chloride inj 2
meq/ml .............................. 53
20 MEQ/100ML................. 54
20 MEQ/50ML .................. 54
40 MEQ/100ML................. 54
potassium chloride
microencapsulated crys cr
tab 10 meq ........................ 52
potassium chloride
microencapsulated crys cr
tab 20 meq ........................ 52
POTASSIUM CHLORIDE
ORAL SOLN 10% (20
MEQ/15ML) ...................... 52
POTASSIUM CHLORIDE
ORAL SOLN 20% (40
MEQ/15ML) ...................... 52
POTASSIUM CHLORIDE
TAB CR 10 MEQ .............. 52
POTASSIUM CHLORIDE
TAB CR 20 MEQ (1500 MG)
.......................................... 52
potassium chloride tab cr 8
meq (600 mg) ................... 52
CR 10 MEQ (1080 MG) .... 48
CR 5 MEQ (540 MG) ........ 48
POTIGA TAB 200MG ....... 26
88
POTIGA TAB 50MG ..........26
PRADAXA CAP 110MG ....49
PRADAXA CAP 150MG ....49
PRADAXA CAP 75MG ......49
..........................................19
PRALUENT INJ 75MG/ML 19
tab 0.125 mg .....................31
tab 0.25 mg .......................31
tab 0.5 mg .........................31
tab 0.75 mg .......................31
tab 1 mg ............................31
tab 1.5 mg .........................31
..........................................19
..........................................19
..........................................19
..........................................19
prazosin hcl cap 1 mg .......17
pred sod pho sol 1% op ....55
PREDNISOLONE ACETATE
OPHTH SUSP 1% ............55
prednisolone sod phosph oral
soln 6.7 mg/5ml (5 mg/5ml
base) .................................43
prednisolone sod phosphate
oral soln 15 mg/5ml (base
equiv) ................................43
prednisolone sodium
phosphate oral soln 25
mg/5ml (base eq) ..............43
prednisolone syrup 15
mg/5ml (usp solution
equivalent) ........................43
prednisone con 5mg/ml .....43
prednisone oral soln 5
mg/5ml ..............................43
prednisone tab 1 mg ......... 43
prednisone tab 10 mg ....... 43
prednisone tab 2.5 mg ...... 43
prednisone tab 5 mg ......... 43
10 mg (21) ........................ 43
10 mg (48) ........................ 43
5 mg (21) .......................... 43
5 mg (48) .......................... 43
premasol sol 10% ............. 53
PRENATAL VITAMIN/FOLIC
ACID > 0.8 MG (GENERIC)
.......................................... 54
prevalite pow 4gm ............. 19
prevalite pow 4gm pk ........ 19
previfem tab ...................... 41
PREZCOBIX TAB 800-150 . 7
PREZISTA SUS 100MG/ML
............................................ 6
PREZISTA TAB 150MG...... 6
PREZISTA TAB 75MG........ 6
PRIFTIN TAB 150MG ......... 7
PRIMAQUINE TAB 26.3MG6
primidone tab 250 mg ....... 26
primidone tab 50 mg ......... 26
PRISTIQ TAB 100MG ....... 30
PRISTIQ TAB 25MG ......... 29
PRISTIQ TAB 50MG ......... 29
PRIVIGEN INJ 10GRAMS 50
PRIVIGEN INJ 5 GRAMS . 50
probenecid tab 500 mg ....... 1
PROCALAMINE INJ 3% ... 53
prochlorperazine edisylate inj
5 mg/ml ............................. 45
10 mg (base equivalent) ... 45
5 mg (base equivalent) ..... 45
prochlorperazine suppos 25
mg..................................... 45
PROCRIT INJ 10000/ML .. 49
PROCRIT INJ 2000/ML .... 49
procto-med cre hc 2.5%.... 58
procto-pak cre 1%............. 58
proctozone cre -hc 2.5% ... 58
PROGLYCEM SUS
50MG/ML .......................... 43
PROGRAF CAP 0.5MG .... 51
PROGRAF CAP 1MG ....... 51
PROGRAF CAP 5MG ....... 51
PROLASTIN-C INJ 1000MG
.......................................... 56
PROLENSA SOL 0.07% ... 55
PROLEUKIN INJ 22MU .... 13
PROLIA SOL 60MG/ML.... 43
PROMACTA TAB 12.5MG 50
PROMACTA TAB 25MG ... 50
promethazine hcl inj 25
mg/ml ................................ 45
promethazine hcl inj 50
mg/ml ................................ 45
promethazine hcl suppos
12.5 mg ............................. 45
mg..................................... 46
mg..................................... 46
promethazine hcl syrup 6.25
mg/5ml .............................. 46
promethazine hcl tab 12.5 mg
.......................................... 46
.......................................... 46
.......................................... 46
promethegan sup 25mg .... 46
promethegan sup 50mg .... 46
225 mg.............................. 18
325 mg.............................. 18
89
425 mg ..............................18
..........................................18
..........................................18
..........................................18
proparacaine hcl ophth soln
0.5% ..................................55
propranolol &
40-25 mg ...........................20
propranolol &
80-25 mg ...........................20
120 mg ..............................20
160 mg ..............................20
mg .....................................20
mg .....................................20
propranolol hcl inj 1 mg/ml 20
mg/5ml ..............................20
mg/5ml ..............................20
propranolol hcl tab 10 mg .20
propylthiouracil tab 50 mg .44
PROQUAD INJ .................52
PROSOL INJ 20% ............53
protriptyline hcl tab 10 mg .30
protriptyline hcl tab 5 mg ...30
PRUDOXIN CRE 5% ........58
PULMICORT INH 180MCG
..........................................57
PULMICORT INH 90MCG 57
PULMOZYME SOL 1MG/ML
..........................................56
PURIXAN SUS 20MG/ML .12
pyrazinamide tab 500 mg ....7
pyridostigmine bromide tab
60 mg ................................ 37
Q
QUADRACEL INJ ............. 52
quasense tab .................... 41
mg ..................................... 33
mg ..................................... 33
mg ..................................... 33
mg ..................................... 33
mg ..................................... 33
mg ..................................... 33
quinapril hcl tab 10 mg ...... 16
quinapril hcl tab 5 mg ........ 16
tab 10-12.5 mg .................. 16
tab 20-12.5 mg .................. 16
tab 20-25 mg ..................... 16
quinidine gluconate tab cr
324 mg .............................. 18
.......................................... 18
.......................................... 18
quinine sulfate cap 324 mg . 6
R
RABAVERT INJ ................ 52
raloxifene hcl tab 60 mg .... 44
ramipril cap 1.25 mg ......... 16
ramipril cap 10 mg ............ 16
ramipril cap 2.5 mg ........... 16
ramipril cap 5 mg .............. 16
RANEXA TAB 1000MG .... 23
RANEXA TAB 500MG ...... 23
(25 mg/ml)......................... 46
(25 mg/ml)......................... 46
ranitidine hcl syrup 15 mg/ml
(75 mg/5ml) ....................... 46
ranitidine hcl tab 150 mg ... 46
ranitidine hcl tab 300 mg ... 46
RAPAMUNE SOL 1MG/ML
.......................................... 51
RAVICTI LIQ 1.1GM/ML ... 42
REBETOL SOL 40MG/ML .. 8
reclipsen tab ..................... 41
RECOMBIVA HB INJ
10MCG/ML ....................... 52
RECOMBIVA HB INJ
5MCG/0.5 ......................... 52
RECOMBIVA-HB INJ
40MCG/ML ....................... 52
REGRANEX GEL 0.01% .. 60
RELENZA MIS DISKHALE . 8
RELISTOR INJ 12/0.6ML . 47
RELISTOR INJ 8/0.4ML ... 47
RELPAX TAB 20MG ......... 36
RELPAX TAB 40MG ......... 36
REMICADE INJ 100MG.... 50
.......................................... 23
.......................................... 23
REMODULIN INJ 2.5MG/ML
.......................................... 23
.......................................... 23
RENVELA PAK 0.8GM ..... 44
RENVELA PAK 2.4GM ..... 44
RENVELA TAB 800MG .... 44
repaglinide tab 0.5 mg ...... 39
repaglinide tab 1 mg ......... 39
repaglinide tab 2 mg ......... 39
RESCRIPTOR TAB 100 MG
............................................ 6
RESCRIPTOR TAB 200MG 6
RESTASIS EMU 0.05% .... 55
RETROVIR INJ 10MG/ML .. 7
REVATIO SUS 10MG/ML . 23
REVLIMID CAP 10MG...... 51
REVLIMID CAP 2.5MG..... 51
REVLIMID CAP 5MG........ 51
REXULTI TAB 0.25MG ..... 33
REXULTI TAB 0.5MG ....... 33
90
REXULTI TAB 1MG ..........33
REYATAZ CAP 150MG ......7
REYATAZ POW 50MG .......7
ribapak pak 1000/day ..........8
ribapak pak 1200/day ..........8
ribapak pak 600/day............8
ribapak pak 800/day............8
ribasphere cap 200mg ........8
ribasphere tab 200mg .........8
ribavirin cap 200 mg ............8
ribavirin tab 200 mg ............8
rifabutin cap 150 mg ...........7
rifampin cap 150 mg ...........7
rifampin cap 300 mg ...........7
rifampin for inj 600 mg ........7
RIFATER TAB.....................7
riluzole tab 50 mg ..............37
rimantadine hydrochloride
tab 100 mg ..........................8
RINGER'S SOLUTION......54
RISPERDAL INJ 12.5MG..33
RISPERDAL INJ 25MG ....34
RISPERDAL INJ 37.5MG..34
RISPERDAL INJ 50MG ....34
risperidone orally
disintegrating tab 0.25 mg .34
risperidone orally
disintegrating tab 0.5 mg ...34
risperidone orally
disintegrating tab 1 mg ......34
risperidone orally
risperidone orally
risperidone orally
risperidone soln 1 mg/ml ...34
risperidone tab 0.25 mg ....34
risperidone tab 0.5 mg ......34
risperidone tab 1 mg .........34
risperidone tab 2 mg .........34
risperidone tab 3 mg ......... 34
risperidone tab 4 mg ......... 34
RITUXAN INJ 100MG ....... 13
RITUXAN INJ 500MG ....... 13
mg ..................................... 27
.......................................... 27
mg ..................................... 28
.......................................... 28
rivastigmine td patch 24hr
13.3 mg/24hr..................... 28
mg/24hr............................. 28
mg/24hr............................. 28
(base eq)........................... 36
eq) .................................... 36
rizatriptan benzoate tab 10
0.25 mg ............................. 31
0.5 mg ............................... 31
mg ..................................... 31
mg ..................................... 31
mg ..................................... 31
mg ..................................... 31
mg ..................................... 31
rosadan cre 0.75% ............ 60
mg ..................................... 19
mg ..................................... 19
mg..................................... 19
rosuvastatin calcium tab 5 mg
.......................................... 19
ROTARIX SUS ................. 52
ROTATEQ SOL ................ 52
roweepra tab 500mg ......... 26
ROZEREM TAB 8MG ....... 35
S
SABRIL POW 500MG....... 26
SABRIL TAB 500MG ........ 26
SANDIMMUNE SOL
100MG/ML ........................ 51
SANDOSTATIN KIT LAR
10MG ................................ 44
SANDOSTATIN KIT LAR
20MG ................................ 44
SANDOSTATIN KIT LAR
30MG ................................ 44
SANTYL OIN 250/GM....... 60
SAPHRIS SUB 10MG ....... 34
SAPHRIS SUB 2.5MG ...... 34
SAPHRIS SUB 5MG ......... 34
selegiline hcl cap 5 mg ..... 31
selegiline hcl tab 5 mg ...... 31
selenium sulfide lotion 2.5%
.......................................... 58
SELZENTRY TAB 150MG .. 7
SELZENTRY TAB 300MG .. 7
SENSIPAR TAB 30MG ..... 40
SEREVENT DIS AER
50MCG ............................. 56
.......................................... 34
.......................................... 34
.......................................... 34
.......................................... 34
.......................................... 34
sertraline hcl oral conc 20
mg/ml ................................ 30
sertraline hcl tab 100 mg .. 30
sertraline hcl tab 25 mg .... 30
sertraline hcl tab 50 mg .... 30
91
sharobel tab 0.35mg .........41
SIGNIFOR INJ 0.3MG/ML.44
sildenafil citrate tab 20 mg 23
SILENOR TAB 3MG .........35
SILENOR TAB 6MG .........36
SILVER SULFADIAZINE
CREAM 1% .......................58
SIMBRINZA SUS 1-0.2% ..55
simvastatin tab 10 mg .......19
simvastatin tab 5 mg .........19
sirolimus tab 0.5 mg ..........51
sirolimus tab 1 mg .............51
SIROLIMUS TAB 2 MG ....51
SIRTURO TAB 100MG .......7
SIVEXTRO INJ 200MG .......5
SIVEXTRO TAB 200MG .....5
SODIUM CHLORIDE INJ
0.45% ................................54
SODIUM CHLORIDE INJ 2.5
MEQ/ML (14.6%) ..............52
..........................................54
..........................................54
SODIUM CHLORIDE
IRRIGATION SOLN 0.9% .60
SODIUM CHLORIDE IV
SOLN 0.9% .......................54
SODIUM FLUORIDE CHEW;
TAB; 1.1 (0.5 F) MG/ML
SOLN ................................52
sodium phenylbutyrate oral
powder 3 gm/teaspoonful ..42
oral susp 15 gm/60ml ........40
powder ..............................40
SOLTAMOX SOL 10MG/5ML
..........................................13
SOLU-CORTEF INJ 250MG
..........................................43
SOMATULINE INJ 120/.5ML
..........................................44
.......................................... 44
.......................................... 44
SOMAVERT INJ 10MG..... 44
sorine tab 120mg .............. 18
sorine tab 160mg .............. 18
sorine tab 240mg .............. 18
sorine tab 80mg ................ 18
sotalol hcl (afib/afl) tab 120
mg ..................................... 18
sotalol hcl (afib/afl) tab 160
mg ..................................... 18
.......................................... 18
sotalol hcl tab 120 mg ....... 18
sotalol hcl tab 80 mg ......... 18
SOVALDI TAB 400MG........ 8
spironolactone &
25-25 mg........................... 22
spironolactone tab 100 mg 16
spironolactone tab 25 mg.. 16
spironolactone tab 50 mg.. 16
sprintec 28 tab 28 day....... 41
SPRITAM TAB 1000MG ... 26
SPRITAM TAB 250MG ..... 26
SPRYCEL TAB 100MG .... 14
SPRYCEL TAB 140MG .... 14
SPRYCEL TAB 20MG ...... 14
sps sus 15gm/60 ............... 40
SSD CRE 1%.................... 58
stavudine cap 15 mg ........... 7
stavudine for oral soln 1
mg/ml .................................. 7
STIVARGA TAB 40MG ..... 14
STRATTERA CAP 100MG35
STRATTERA CAP 10MG . 35
streptomycin sulfate for inj 1
gm....................................... 4
STRIBILD TAB.................... 7
SUBOXONE MIS 12-3MG 38
SUBOXONE MIS 2-0.5MG
.......................................... 38
SUBOXONE MIS 4-1MG .. 38
SUBOXONE MIS 8-2MG .. 38
SUCRAID SOL 8500/ML .. 47
sucralfate tab 1 gm ........... 47
sulfacetamide sodium lotion
10% (acne) ....................... 58
oint 10%............................ 54
soln 10% ........................... 54
sulfacetamide
sodium-prednisolone ophth
soln 10-0.23(0.25)% ......... 54
sulfadiazine tab 500mg ....... 4
m iv soln 400-80 mg/5ml..... 5
m susp 200-40 mg/5ml ....... 5
m tab 400-80 mg................. 5
m tab 800-160 mg............... 5
SULFAMYLON CRE
85MG/GM ......................... 58
SULFAMYLON PAK 5% ... 58
sulfasalazin tab 500mg dr . 46
sulfasalazine tab 500 mg .. 46
sulindac tab 150 mg............ 1
sulindac tab 200 mg............ 1
SUMATRIPTAN NASAL
SPRAY 20 MG/ACT.......... 36
SUMATRIPTAN NASAL
SPRAY 5 MG/ACT............ 36
92
sumatriptan succinate inj 6
mg/0.5ml ...........................36
sumatriptan succinate
solution auto-injector 4
mg/0.5ml ...........................36
solution auto-injector 6
mg/0.5ml ...........................36
SUMATRIPTAN
SUCCINATE SOLUTION
CARTRIDGE 4 MG/0.5ML 36
SUMATRIPTAN
SUCCINATE SOLUTION
CARTRIDGE 6 MG/0.5ML 36
solution prefilled syringe 6
mg/0.5ml ...........................36
sumatriptan succinate tab
100 mg ..............................36
mg .....................................36
mg .....................................36
SUPRAX CAP 400MG ........9
suprax chw 100mg ..............9
suprax chw 200mg ..............9
SUPRAX SUS 500/5ML ......9
SUPREP BOWEL SOL
PREP ................................47
SURMONTIL CAP 100MG 30
SURMONTIL CAP 25MG ..30
SURMONTIL CAP 50MG ..30
SUSTIVA CAP 200MG .......7
SUSTIVA CAP 50MG .........7
SUSTIVA TAB 600MG ........7
SUTENT CAP 12.5MG .....14
SUTENT CAP 25MG ........14
SUTENT CAP 37.5MG .....14
SUTENT CAP 50MG ........14
SYLATRON KIT 200MCG .14
..........................................57
SYMBICORT AER 80-4.5 .57
SYMLINPEN 60 INJ
1000MCG..........................38
SYMLNPEN 120 INJ
1000MCG ......................... 38
SYNAGIS INJ 100MG/ML . 52
SYNAGIS INJ 50MG ......... 52
SYNAREL SOL 2MG/ML .. 42
SYNERCID INJ 500MG ...... 5
SYNRIBO INJ 3.5MG........ 15
.......................................... 44
.......................................... 44
.......................................... 45
.......................................... 45
.......................................... 45
.......................................... 45
.......................................... 45
SYNTHROID TAB 25MCG44
.......................................... 45
SYPRINE CAP 250MG ..... 40
T
TABLOID TAB 40MG ........ 12
tacrolimus cap 0.5 mg ....... 51
tacrolimus cap 1 mg .......... 51
tacrolimus cap 5 mg .......... 51
tacrolimus oint 0.03%........ 60
tacrolimus oint 0.1%.......... 60
TAFINLAR CAP 50MG ..... 14
TAFINLAR CAP 75MG ..... 14
TAGRISSO TAB 40MG..... 14
TAGRISSO TAB 80MG..... 14
TAMIFLU CAP 30MG ......... 8
TAMIFLU SUS 6MG/ML ..... 8
tamsulosin hcl cap 0.4 mg 48
TARCEVA TAB 100MG .... 14
TARCEVA TAB 150MG .... 14
TARCEVA TAB 25MG ...... 14
TARGRETIN GEL 1%....... 60
tarina fe tab 1/20 ............... 41
TASIGNA CAP 150MG ..... 14
TASIGNA CAP 200MG ..... 14
tazicef inj 1gm ..................... 9
tazicef inj 2gm ..................... 9
tazicef inj 6gm ..................... 9
TAZORAC CRE 0.05% ..... 58
TAZORAC CRE 0.1% ....... 58
taztia xt cap 120mg/24...... 21
TECENTRIQ INJ 1200/20. 13
TEFLARO INJ 400MG ........ 9
TEFLARO INJ 600MG ........ 9
TEGRETOL SUS 100/5ML
.......................................... 26
TEGRETOL TAB 200MG .. 26
.......................................... 27
.......................................... 27
.......................................... 27
TEKTURNA HCT TAB
150-12.5 ........................... 22
TEKTURNA HCT TAB
150-25MG ......................... 22
TEKTURNA HCT TAB
300-12.5 ........................... 22
TEKTURNA HCT TAB
300-25MG ......................... 22
TEKTURNA TAB 150MG .. 22
TEKTURNA TAB 300MG .. 22
temazepam cap 15 mg ..... 36
temazepam cap 7.5 mg .... 36
TENIVAC INJ 5-2LF ......... 52
terazosin hcl cap 1 mg ...... 17
terazosin hcl cap 10 mg .... 17
terbinafine hcl tab 250 mg .. 6
terbutaline sulfate inj 1 mg/ml
.......................................... 56
93
terbutaline sulfate tab 2.5 mg
..........................................56
terbutaline sulfate tab 5 mg
..........................................56
0.4% ..................................48
0.8% ..................................48
TERCONAZOLE VAGINAL
CREAM 0.8% ....................48
terconazole vaginal suppos
80 mg ................................48
in oil 100 mg/ml .................38
in oil 200 mg/ml .................38
testosterone enanthate im inj
in oil 200 mg/ml .................38
TET/DIP TOX INJ 2-2 LF ..52
tetrabenazine tab 12.5 mg 37
tetrabenazine tab 25 mg ...37
texacort sol 2.5% ..............59
THALOMID CAP 100MG ..51
THALOMID CAP 50MG ....51
theo-24 cap 100mg cr .......57
theo-24 cap 200mg cr .......57
theo-24 cap 300mg cr .......57
theo-24 cap 400mg er .......57
theophylline soln 80 mg/15ml
..........................................57
mg .....................................57
mg .....................................57
mg .....................................57
mg .....................................57
mg .....................................57
mg .....................................57
thioridazine hcl tab 10 mg .34
..........................................34
thioridazine hcl tab 25 mg .34
thioridazine hcl tab 50 mg . 34
thiothixene cap 1 mg ......... 34
thiothixene cap 10 mg ....... 34
tiagabine hcl tab 2 mg ....... 27
tiagabine hcl tab 4 mg ....... 27
TIKOSYN CAP 125MCG .. 18
.......................................... 55
.......................................... 55
0.25%................................ 55
0.5%.................................. 55
timolol maleate tab 10 mg . 20
timolol maleate tab 20 mg . 20
timolol maleate tab 5 mg ... 20
TIVICAY TAB 10MG ........... 7
equivalent) ........................ 37
equivalent) ........................ 37
TOBRADEX OIN 0.3-0.1%54
TOBRADEX ST SUS
0.3-0.05............................. 54
tobramycin nebu soln 300
mg/5ml ................................ 4
tobramycin ophth soln 0.3%
.......................................... 54
tobramycin sulfate for inj 1.2
gm ....................................... 4
tobramycin sulfate inj 1.2
equiv) .................................. 4
mg/ml (base equivalent)...... 4
equiv) .................................. 4
equiv) .................................. 4
tobramycin-dexamethasone
ophth susp 0.3-0.1% ......... 54
TOBREX OIN 0.3% OP .... 54
tolterodine tartrate cap sr
24hr 2 mg ......................... 48
tolterodine tartrate cap sr
24hr 4 mg ......................... 48
.......................................... 48
.......................................... 48
topiramate sprinkle cap 15
mg..................................... 27
topiramate sprinkle cap 25
mg..................................... 27
topiramate tab 100 mg ...... 27
topiramate tab 200 mg ...... 27
topiramate tab 25 mg ........ 27
topiramate tab 50 mg ........ 27
toposar inj 1gm/50ml ........ 15
topotecan hcl for inj 4 mg .. 15
torsemide inj 50mg/5ml..... 22
torsemide tab 10 mg ......... 22
torsemide tab 100 mg ....... 22
torsemide tab 20 mg ......... 22
torsemide tab 5 mg ........... 22
TOUJEO SOLO INJ
300IU/ML .......................... 38
TOVIAZ TAB 4MG ............ 48
TOVIAZ TAB 8MG ............ 48
TPN ELECTROL INJ ........ 52
TRACLEER TAB 125MG .. 23
TRACLEER TAB 62.5MG . 23
TRADJENTA TAB 5MG .... 39
tramadol hcl tab 50 mg ....... 1
tramadol-acetaminophen tab
37.5-325 mg ....................... 1
trandolapril tab 1 mg ......... 16
tranexamic acid iv soln 1000
mg/10ml (100 mg/ml) ........ 50
tranexamic acid tab 650 mg
.......................................... 50
TRANSDERM-SC DIS 1MG
.......................................... 46
94
tranylcypromine sulfate tab
10 mg ................................30
TRAVASOL INJ 10% ........53
TRAVATAN Z DRO 0.004%
..........................................55
trazodone hcl tab 100 mg .30
trazodone hcl tab 150 mg .30
trazodone hcl tab 50 mg ...30
TREANDA INJ 100MG ......12
TREANDA INJ 180/2ML ...12
TREANDA INJ 25MG ........12
TREANDA INJ 45/0.5ML ..12
TRECATOR TAB 250MG....7
TRELSTAR MIX INJ
11.25MG ...........................13
..........................................13
..........................................38
..........................................38
tretinoin cap 10 mg ...........15
tretinoin cream 0.025% .....58
tretinoin cream 0.05% .......58
tretinoin cream 0.1% .........58
TRETINOIN GEL 0.01% ...58
tretinoin gel 0.025% ..........58
cream 0.025% ...................59
cream 0.1% .......................59
cream 0.5% .......................59
dental paste 0.1% .............60
lotion 0.025% ....................60
lotion 0.1% ........................60
0.025% ..............................60
0.1% ..................................60
0.5% ..................................60
triamterene &
hydrochlorothiazide cap
37.5-25 mg ........................22
triamterene &
37.5-25 mg........................ 22
triamterene &
75-50 mg........................... 22
TRIBENZOR20- TAB
5-12.5MG .......................... 17
TRIBENZOR40- TAB
10-12.5.............................. 17
TRIBENZOR40- TAB
10-25MG ........................... 17
TRIBENZOR40- TAB
5-12.5MG .......................... 17
TRIBENZOR40- TAB
5-25MG ............................. 17
triderm cre 0.1% ............... 60
.......................................... 34
.......................................... 34
.......................................... 34
.......................................... 34
trifluridine ophth soln 1%... 54
tri-legest tab fe .................. 41
trilyte sol............................ 47
trimethoprim tab 100 mg ..... 5
trimipramine maleate cap
100 mg .............................. 30
mg ..................................... 30
mg ..................................... 30
TRINESSA TAB ................ 41
TRINTELLIX TAB 10MG ... 30
TRINTELLIX TAB 20MG ... 30
TRINTELLIX TAB 5MG ..... 30
tri-previfem tab .................. 41
TRISENOX SOL 10MG/10M
.......................................... 15
tri-sprintec tab ................... 41
TRIUMEQ TAB ................... 7
trivora-28 tab..................... 41
TROPHAMINE INJ 10% ... 53
trospium chloride tab 20 mg
.......................................... 48
TRULICITY INJ 0.75/0.5 ... 38
TRULICITY INJ 1.5/0.5 ..... 38
TRUMENBA INJ ............... 52
TRUVADA TAB 100-150 .... 7
TRUVADA TAB 133-200 .... 7
TRUVADA TAB 167-250 .... 7
TRUVADA TAB 200-300 .... 7
TWINRIX INJ .................... 52
TYBOST TAB 150MG......... 7
TYGACIL INJ 50MG ........... 5
TYKERB TAB 250MG....... 14
TYPHIM VI INJ ................. 52
TYSABRI INJ 300/15ML ... 37
TYZEKA TAB 600MG ......... 8
U
UCERIS TAB 9MG ........... 46
ULORIC TAB 40MG ........... 1
ULORIC TAB 80MG ........... 1
.......................................... 45
.......................................... 45
.......................................... 45
.......................................... 45
.......................................... 45
.......................................... 45
UNITHROID TAB 25MCG 45
.......................................... 45
UPTRAVI TAB 1000MCG . 23
UPTRAVI TAB 200/800 .... 23
UPTRAVI TAB 200MCG ... 23
ursodiol cap 300 mg ......... 47
ursodiol tab 250 mg .......... 47
ursodiol tab 500 mg .......... 47
95
V
VAGIFEM TAB 10MCG ....42
valacyclovir hcl tab 1 gm .....8
valacyclovir hcl tab 500 mg .8
VALCHLOR GEL 0.016% .60
VALCYTE SOL 50MG/ML ...8
valganciclovir hcl tab 450 mg
(base equivalent) ................8
valproate sodium inj 100
mg/ml ................................27
valproate sodium syrup 250
mg/5ml (base equiv) .........27
valproic acid cap 250 mg ..27
valsartan tab 160 mg ........18
valsartan tab 320 mg ........18
valsartan tab 40 mg ..........18
valsartan tab 80 mg ..........18
valsartan-hydrochlorothiazid
e tab 160-12.5 mg .............17
e tab 160-25 mg ................17
e tab 320-12.5 mg .............17
e tab 320-25 mg ................17
e tab 80-12.5 mg ...............17
vancomycin hcl cap 125 mg 5
vancomycin hcl cap 250 mg 5
vancomycin hcl for inj 10 gm
............................................5
vancomycin hcl for inj 1000
mg .......................................5
............................................5
vancomycin hcl for inj 5000
mg .......................................5
VANCOMYCIN INJ 1 GM....5
VANCOMYCIN INJ 500MG.5
vancomycin inj 750mg ........5
VANCOMYCIN INJ 750MG.5
VANDAZOLE GEL 0.75% .48
VAQTA INJ 25/0.5ML .......52
VAQTA INJ 50UNT/ML .....52
VARIVAX INJ ....................52
VASCEPA CAP 1GM ........19
VELCADE INJ 3.5MG .......13
velivet pak .........................41
VENCLEXTA TAB 100MG 13
VENCLEXTA TAB 10MG .. 13
VENCLEXTA TAB 50MG .. 13
VENCLEXTA TAB START
PK ..................................... 13
150 mg (base equivalent) . 30
37.5 mg (base equivalent) 30
venlafaxine hcl cap sr 24hr 75
.......................................... 30
venlafaxine hcl tab 25 mg . 30
venlafaxine hcl tab 37.5 mg
.......................................... 30
VENTOLIN HFA AER ....... 56
mg ..................................... 21
mg ..................................... 21
mg ..................................... 21
mg ..................................... 21
mg ..................................... 21
mg ..................................... 21
VERAPAMIL HCL CAP SR
24HR 360 MG ................... 21
verapamil hcl iv soln 2.5
mg/ml ................................ 21
verapamil hcl tab 120 mg .. 21
verapamil hcl tab 40 mg .... 21
verapamil hcl tab 80 mg .... 21
.......................................... 21
.......................................... 22
.......................................... 22
VERSACLOZ SUS 50MG/ML
.......................................... 34
VESICARE TAB 10MG ..... 48
VESICARE TAB 5MG ....... 48
VICTOZA INJ 18MG/3ML . 38
VIDEX SOL 2GM ................ 7
VIDEX SOL 4GM ................ 7
vienva tab 0.1-20 .............. 41
VIGAMOX DRO 0.5% ....... 54
VIIBRYD KIT ..................... 30
VIIBRYD KIT STARTER ... 30
VIIBRYD TAB 10MG......... 30
VIMPAT INJ 200MG/20 .... 27
VIMPAT SOL 10MG/ML ... 27
VIMPAT TAB 100MG........ 27
VIMPAT TAB 50MG.......... 27
vinblastine sulfate inj 1 mg/ml
.......................................... 13
vincasar pfs inj 1mg/ml ..... 13
vincristine sulfate iv soln 1
mg/ml ................................ 13
mg/ml (base equiv) ........... 13
equiv) ................................ 13
viorele tab ......................... 42
VIRACEPT TAB 250MG ..... 7
VIRACEPT TAB 625MG ..... 7
VIRAMUNE XR TAB 100MG
............................................ 7
VIREAD POW 40MG/GM ... 7
VIREAD TAB 150MG.......... 7
VIREAD TAB 200MG.......... 7
VIREAD TAB 250MG.......... 7
VIREAD TAB 300MG.......... 7
VITEKTA TAB 150MG ........ 7
VITEKTA TAB 85MG .......... 7
VOLTAREN GEL 1% ........ 60
voriconazole for inj 200 mg . 6
voriconazole for susp 40
mg/ml .................................. 6
voriconazole tab 200 mg ..... 6
voriconazole tab 50 mg....... 6
VOTRIENT TAB 200MG ... 14
VRAYLAR CAP 1.5-3MG .. 34
VRAYLAR CAP 1.5MG ..... 34
VRAYLAR CAP 3MG ........ 34
96
VRAYLAR CAP 4.5MG .....34
VRAYLAR CAP 6MG ........34
vyfemla tab 0.4-35 ............42
W
warfarin sodium tab 1 mg ..49
warfarin sodium tab 10 mg 49
..........................................49
..........................................49
WATER FOR IRRIGATION,
STERILE IRRIGATION
SOLN ................................60
WELCHOL PAK 3.75GM ..19
WELCHOL TAB 625MG ...19
X
XALKORI CAP 200MG .....14
XALKORI CAP 250MG .....14
XARELTO STAR TAB
15/20MG ...........................49
XARELTO TAB 10MG ......49
XGEVA INJ .......................44
XIFAXAN TAB 550MG ......47
XIGDUO XR TAB 10-1000 40
..........................................40
..........................................40
..........................................40
XOLAIR SOL 150MG ........ 56
XOPENEX HFA AER ........ 56
XTANDI CAP 40MG.......... 13
XYREM SOL 500MG/ML .. 37
Y
YERVOY INJ 200MG ........ 13
YERVOY INJ 50MG .......... 13
YF-VAX INJ ...................... 52
Z
zafirlukast tab 10 mg ......... 56
zafirlukast tab 20 mg ......... 56
zarah tab 3-0.03mg ........... 42
ZAVESCA CAP 100MG .... 42
ZELBORAF TAB 240MG .. 14
ZEMAIRA INJ 1000MG ..... 56
zenatane cap 10mg .......... 58
zenchent tab ..................... 42
ZENPEP CAP 10000UNT . 47
ZENPEP CAP 3000UNIT .. 47
ZENPEP CAP 5000UNIT .. 47
ZETIA TAB 10MG ............. 19
ZIAGEN SOL 20MG/ML...... 7
zidovudine cap 100 mg ....... 7
zidovudine syrup 10 mg/ml . 7
zidovudine tab 300 mg ........ 7
ziprasidone hcl cap 20 mg 34
ZIRGAN GEL 0.15% ......... 54
zoledronic acid inj conc for iv
infusion 4 mg/5ml.............. 40
zoledronic acid iv soln 5
mg/100ml .......................... 40
ZOLINZA CAP 100MG ..... 13
zolmitriptan orally
disintegrating tab 2.5 mg .. 36
zolmitriptan orally
zolmitriptan tab 2.5 mg ..... 37
zolmitriptan tab 5 mg ........ 37
.......................................... 36
zolpidem tartrate tab 5 mg 36
zonisamide cap 100 mg .... 27
zonisamide cap 25 mg ...... 27
zonisamide cap 50 mg ...... 27
ZONTIVITY TAB 2.08MG . 50
ZORTRESS TAB 0.25MG 51
ZORTRESS TAB 0.5MG .. 51
ZORTRESS TAB 0.75MG 51
ZOSTAVAX INJ ................ 52
zovia 1/35e tab ................. 42
zovia 1/50e tab ................. 42
ZYDELIG TAB 100MG...... 14
ZYDELIG TAB 150MG...... 14
ZYKADIA CAP 150MG ..... 14
ZYLET SUS 0.5-0.3% ....... 54
.......................................... 34
.......................................... 35
.......................................... 35
ZYTIGA TAB 250MG ........ 13
ZYVOX TAB 600MG ........... 5
97
HMSA Akamai Advantage is a PPO plan with a Medicare contract. Enrollment in HMSA Akamai
Advantage depends on contract renewal.
This formulary was updated on 10/01/2016. For more recent information or other questions,
please contact HMSA at:
PHONE
Call 8 a.m. to 8 p.m., seven days a week
948-6000 on Oahu
1 (800) 660-4672 toll-free
TTY users, call 711
Online
http://www.hmsa.com/advantage
HMSA CENTERS
Convenient evening and Saturday hours:
HMSA Center @ Honolulu
818 Keeaumoku St.
Monday - Friday, 8 a.m. - 6 p.m. | Saturday, 9 a.m. - 2 p.m.
HMSA Center @ Pearl City
Pearl City Gateway | 1132 Kuala St., Suite 400
HMSA Center @ Hilo
Waiakea Center | 303A E. Makaala St.
OFFICES
Visit your local HMSA office Monday through Friday, 8 a.m. - 4 p.m.:
Kailua-Kona, Hawaii Island | 75-1029 Henry St., Suite 301 | Phone: 329-5291
Kahului, Maui | 33 Lono Ave., Suite 350 | Phone: 871-6295
Lihue, Kauai | 4366 Kukui Grove St., Suite 103 | Phone: 245-3393
HMSA’s mission is to provide the people of Hawaii access
to a sustainable, quality health care system that improves
the overall health and well-being of our state.
http://www.hmsa.com/advantage
(00) 8740-3125OCT 9:16 LE

Comprehensive Formulary

Transcription

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