2016 Formulary (List of Covered Drugs)

Transcription

2016 Formulary
(List of Covered Drugs)
Blue Cross Community MMAI (Medicare-Medicaid Plan)SM
PLEASE READ:
THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
If you have questions, please call Blue Cross Community MMAI at 1-877-723-7702. TTY/TDD: 711. We are
open 8:00 a.m. until 8:00 p.m. Central time, seven (7) days a week. On weekends and Federal holidays, voice
messaging is available. If you leave a voice message, a Member Services representative will return your call
no later than the next business day. The call is free.
For questions about enrolling call: Illinois Client Enrollment Services 1-877-912-8880 (TTY: 1-866-565-8576)
Website: enrollhfs.illinois.gov
HPMS Approved Formulary File ID: 16055, Version 18
This formulary was updated on 9/2/2016.
H0927_BEN_IL_RX16 Accepted 09052015
230005.0916
Blue Cross Community MMAI
2016 List of Covered Drugs (Formulary)
Blue Cross Community MMAI is a health plan that contracts with both Medicare and Illinois Medicaid to
provide benefits of both programs to enrollees.
The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will
send you a notice before we make a change that affects you.
Benefits may change on January 1 of each year. You can always check Blue Cross Community MMAI’s
up‑to‑date List of Covered Drugs online at www.bcbsilcommunitymmai.com.
You can get this information for free in other formats, such as large print, Braille, or audio. Call 1-877-723-7702
TTY/TDD: 711. The call is free.
Limitations and restrictions may apply. For more information, call Blue Cross Community MMAI Member
Services or read the Blue Cross Community MMAI Member Handbook.
You can get this document in Spanish, or speak with someone about this information in other languages for
free. Call 1-877-723-7702 TTY/TDD: 711. The call is free.
Usted puede obtener este documento en español o hablar con alguien, de forma gratuita, acerca de esta
información en otros idiomas. Llame al 1-877-723-7702 TTY/TDD: 711. La llamada es gratuita.
If you have questions, please call Blue Cross Community MMAI at 1-877-723-7702. TTY/TDD: 711. We are open
8:00 a.m. until 8:00 p.m. Central time, seven (7) days a week. On weekends and Federal holidays, voice
messaging is available. If you leave a voice message, a Member Services representative will return your call no
later than the next business day. The call is free. For more information, visit www.bcbsilcommunitymmai.com.
i
Frequently Asked Questions (FAQ)
Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn
more, or look for a question and answer.
1. W
hat prescription drugs are on the List of Covered Drugs?
(We call the List of Covered Drugs the “Drug List” for short.)
The drugs on the List of Covered Drugs that starts on page 1 are the drugs covered by Blue Cross Community
MMAI. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have
an agreement with them to work with us and provide you services. We refer to these pharmacies as “network
pharmacies.”
Blue Cross Community MMAI will cover all medically necessary drugs on the Drug List if:
• your doctor or other prescriber says you need them to get better or stay healthy, and
• you fill the prescription at a Blue Cross Community MMAI network pharmacy.
Blue Cross Community MMAI may have additional steps to access certain drugs (see question #5 below).
You can also see an up-to-date list of drugs that we cover on our website at
www.bcbsilcommunitymmai.com or call Member Services at 1-877-723-7702 TTY/TDD: 711. We are open
later than the next business day. The call is free.
2. Does the Drug List ever change?
Yes. Blue Cross Community MMAI may add or remove drugs on the Drug List during the year. Generally, the
Drug List will only change if:
• a cheaper drug comes along that works as well as a drug on the Drug List now, or
• we learn that a drug is not safe.
We may also change our rules about drugs. For example, we could:
• Decide to require or not require prior approval for a drug. (Prior approval is permission from Blue Cross
Community MMAI before you can get a drug.)
• Add or change the amount of a drug you can get (called “quantity limits”).
• Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before
we will cover another drug.)
(For more information on these drug rules, see pages 1-117.)
We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we
change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens
when the Drug List changes.
ii
You can always check Blue Cross Community MMAI’s up to date Drug List online at
www.bcbsilcommunitymmai.com.
You can also call Member Services to check the current Drug List at 1-877-723-7702 TTY/TDD: 711.
3. What happens when a cheaper drug comes along that works as well as a drug
on the Drug List now?
If you are taking a drug that is removed because a cheaper drug that works just as well comes along, we will tell
you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then
you can get a 60-day supply of the drug before the change to the Drug List is made. We will send you a letter
telling you a change has occurred.
4. What happens when we find out a drug is not safe?
If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List
right away. We will also send you a letter telling you that. Contact your doctor for further instructions. Do not stop
taking your medications until you have spoken to your doctor.
5. A
re there any restrictions or limits on drug coverage? Or are there any required
actions to take in order to get certain drugs?
Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor
or other prescriber must do something before you can get the drug. For example:
• Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get
approval from Blue Cross Community MMAI before you fill your prescription. If you don’t get approval, Blue
Cross Community MMAI may not cover the drug.
• Quantity limits: Sometimes Blue Cross Community MMAI limits the amount of a drug you can get.
• Step therapy: Sometimes Blue Cross Community MMAI requires you to do step therapy. This means you will
have to try drugs in a certain order for your medical condition. You might have to try one drug before we will
cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second.
You can find out if your drug has any additional requirements or limits by looking in the tables on page vi. You can
also get more information by visiting our website at www.bcbsilcommunitymmai.com.
We have posted online documents that explain our prior authorization and step therapy restrictions. You may
also ask us to send you a copy.
You can ask for an “exception” from these limits. Please see question 11 for more information on exceptions.
• If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if
you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug
you need (unless you have a prescription for fewer days), whether or not you are a new Blue Cross Community
MMAI member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide
if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see
question 11 for more information about exceptions.
iii
6. How will you know if the drug you want has limitations or if there are
required actions to take to get the drug?
The List of Covered Drugs on pages 1-117 has a column labeled “Necessary actions, restrictions, or limits
on use.”
7. W
hat happens if we change our rules on how we cover some drugs? For
example, if we add prior authorization (approval), quantity limits, and/or step
therapy restrictions on a drug.
We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell
you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day
supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or
other prescriber about what to do next.
8. How can you find a drug on the Drug List?
There are two ways to find a drug:
• You can search alphabetically (if you know how to spell the drug), or
• You can search by medical condition.
To search alphabetically, go to the Alphabetical Listing section. You can find it in the index that begins on
page 118.
To search by medical condition, find the section labeled “List of drugs by medical condition” on pages 1-117.
The drugs in this section are grouped into categories depending on the type of medical conditions they are
used to treat. For example, if you have a heart condition, you should look in the category, benazepril. That is
where you will find drugs that treat heart conditions.
9. What if the drug you want to take is not on the Drug List?
If you don’t see your drug on the Drug List, call Member Services at 1-877-723-7702 TTY/TDD: 711 and ask
about it. If you learn that Blue Cross Community MMAI will not cover the drug, you can do one of these things:
• Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or
other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take.
Or
• You can ask the health plan to make an exception to cover your drug. Please see question 11 for more
information about exceptions.
iv
10. W
hat if you are a new Blue Cross Community MMAI member and can’t find
your drug on the Drug List or have a problem getting your drug?
We can help. We may cover a temporary 30-day supply of your drug during the first 90 days for Medicare Part
D drugs and 180 days for Medicaid drugs as a member of Blue Cross Community MMAI. This will give you
time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the
Drug List you can take instead or whether to request an exception.
We will cover a 30-day supply of your drug if:
• you are taking a drug that is not on our Drug List, or
• health plan rules do not let you get the amount ordered by your prescriber, or
• the drug requires prior approval by Blue Cross Community MMAI, or
• you are taking a drug that is part of a step therapy restriction.
If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 91
days. You may refill the drug multiple times during your first 90 days in the plan. This gives your prescriber time
to change your drugs to ones on the Drug List or ask for an exception.
Circumstances exist in which unplanned transitions for current members could arise and in which prescribed
drug regimens may not be on the formulary. These circumstances usually involve level of care changes in
which a member is changing from one treatment setting to another. For these unplanned transitions, you must
use our exceptions and appeals process. Coverage determinations and redeterminations will be processed as
expeditiously as your health condition requires.
In order to prevent a temporary gap in care when a member is discharged to home, members are permitted to
have a full outpatient supply available to continue therapy once their limited supply provided at discharge is
exhausted. This outpatient supply is available in advance of discharge from a Part A stay.
When a member is admitted to or discharged from a long-term care facility, he or she does not have access to
the remainder of the previously dispensed prescription. We will ensure you have a refill upon admission or
discharge. A one-time override of the “refill too soon” edits are provided for each medication which would be
impacted due to a member being admitted to or discharged from a long-term care facility. Early refill edits are
not used to limit appropriate and necessary access to a member’s Part D benefit, and such members are
allowed to access a refill upon admission or discharge.
To ask for a temporary supply, call Member Services (phone numbers are printed on the back cover of this
booklet).
During the time when you are getting a temporary supply of a drug, you should talk with your provider to
decide what to do when your temporary supply runs out. You can either switch to a different drug covered by
the plan or ask the plan to make an exception for you and cover your current drug. The sections below tell you
more about these options.
v
11. Can you ask for an exception to cover your drug?
Yes. You can ask Blue Cross Community MMAI to make an exception to cover a drug that is not on the Drug List.
You can also ask us to change the rules on your drug.
• For example, Blue Cross Community MMAI may limit the amount of a drug we will cover. If your drug has a
limit, you can ask us to change the limit and cover more.
• Other examples: You can ask us to drop step therapy restrictions or prior approval requirements.
12. How long does it take to get an exception?
First, we must receive a statement from your prescriber supporting your request for an exception. After we
receive the statement, we will give you a decision on your exception request within 72 hours.
If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can
ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give
you a decision within 24 hours of receiving your prescriber’s supporting statement.
13. How can you ask for an exception?
To ask for an exception, call Member Services at 1-877-723-7702 TTY/TDD: 711. A Member Services
representative will work with you and your provider to help you ask for an exception.
14. What are generic drugs?
Generic drugs are made up of the same ingredients as brand name drugs. They usually cost less than the
brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug
Administration (FDA).
Blue Cross Community MMAI covers both brand name drugs and generic drugs.
15. What are OTC drugs?
OTC stands for “over-the-counter”. Blue Cross Community MMAI covers some OTC drugs when they are
written as prescriptions by your provider. You can read the Blue Cross Community MMAI Drug List to see
what OTC drugs are covered.
16. Does Blue Cross Community MMAI cover OTC non-drug products?
Blue Cross Community MMAI covers some OTC non-drug products when they are written as prescriptions by
your provider.
You can read the Blue Cross Community MMAI Drug List to see what OTC non-drug products are covered.
17. What is your copay?
Copay for Blue Cross Community MMAI members is $0.
Blue Cross Community MMAI members living in nursing homes or other long-term care facilities will have no
copays. Some members getting long-term care in the community will also have no copays.
vi
List of Covered Drugs
The list of covered drugs that begins on page 1 gives you information about the drugs covered by Blue Cross
Community MMAI. If you have trouble finding your drug in the list, turn to the Index that begins on page 118.
The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., CELEBREX)
and generic drugs are listed in lower-case italics (e.g., butorphanol).
The information in the necessary actions, restrictions, or limits on use column tells you if Blue Cross
Community MMAI has any rules for covering your drug.
KEY
Uppercase = BRAND NAME
Lower case italics = generics
Tier 1 = Generic Drugs
Tier 2 = Brand Drugs
Tier 3 = Over the Counter Drugs
BD = Drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance.
PA = Prior Authorization
ST = Step Therapy
QL = Quantity limit restrictions apply.
MC = Medicaid Covered Drug; different appeal rules may apply
* = Limited distribution drug. This prescription may be available only at certain pharmacies.
For more information consult your Pharmacy Directory or call your Care Coordinator.
# = High Risk Medication (HRM). Medicine that may be unsafe in patients greater than 65 years of age.
2016 DOSAGE FORM ABBREVIATIONS KEY
caps
chew tabs
conc
crm
DR
ER
g
hr
IM
inhal
inj
IR
IV
liq
lotn
mcg
mEq
mg
mL
NF
ODT
oint
SL
soln
supp
susp
tabs
capsules
chewable tablets
concentrate
cream
delayed-release
extended-release
gram
hour
intramuscular
inhalation
injection
immediate-release
intravenous
liquid
lotion
microgram
milliequivalent
milligram
milliliter
non-formulary
orally disintegrating tablets
ointment
sublingual
solution
suppositories
suspension
tablets
vii
2016
Name of Drug
Analgesics
ABSTRAL - fentanyl citrate sl tab 100 mcg
Necessary actions,
What the drug will restrictions, or limits on
cost you (tier level) use
$0(2)
PA, QL (120 tablets/30 days)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
acetaminophen cap 500 mg
$0(3)
MC
acetaminophen chew tab 80 mg
$0(3)
MC
acetaminophen chew tab 160 mg
$0(3)
MC
acetaminophen elixir 160 mg/5ml
$0(3)
MC
acetaminophen liquid 160 mg/5ml
$0(3)
MC
acetaminophen soln 100 mg/ml
$0(3)
MC
acetaminophen soln 160 mg/5ml
$0(3)
MC
acetaminophen susp 80 mg/0.8ml
$0(3)
MC
acetaminophen susp 160 mg/5ml
$0(3)
MC
acetaminophen w/ codeine soln 120-12 mg/5ml
$0(1)
QL (2700 mls/30 days)
acetaminophen w/ codeine tab 300-15 mg
$0(1)
QL (360 tablets/30 days)
$0(1)
$0(1)
butorphanol tartrate inj 1 mg/ml
$0(2)
butorphanol tartrate inj 2 mg/ml
$0(2)
butorphanol tartrate nasal soln 10 mg/ml
$0(2)
celecoxib cap 50 mg
$0(1)
QL (60 capsules/30 days)
celecoxib cap 100 mg
$0(1)
$0(1)
$0(1)
codeine sulfate tab 15 mg
$0(1)
$0(1)
$0(1)
diclofenac potassium tab 50 mg
$0(1)
diclofenac sodium gel 1%
$0(1)
diclofenac sodium tab delayed release 25 mg
$0(1)
$0(1)
$0(1)
diclofenac sodium tab sr 24hr 100 mg
$0(1)
diclofenac w/ misoprostol tab delayed release 50-0.2 mg
$0(1)
$0(1)
ST
You can find information on what the symbols and abbreviations in this table mean by going to the List of Covered
Drugs section.
1
2016
Name of Drug
etodolac cap 200 mg
Necessary actions,
$0(1)
etodolac cap 300 mg
$0(1)
etodolac tab sr 24hr 400 mg
$0(1)
$0(1)
$0(1)
etodolac tab 400 mg
$0(1)
etodolac tab 500 mg
$0(1)
fentanyl citrate lozenge on a handle 200 mcg
$0(1)
PA, QL (120
lozenges/30 days)
$0(1)
PA, QL (120
lozenges/30 days)
$0(1)
PA, QL (120
lozenges/30 days)
$0(1)
PA, QL (120
lozenges/30 days)
$0(1)
PA, QL (120
lozenges/30 days)
$0(1)
PA, QL (120
lozenges/30 days)
fentanyl td patch 72hr 12 mcg/hr
$0(2)
QL (15 patches/30 days)
$0(2)
$0(2)
$0(2)
$0(2)
flurbiprofen tab 50 mg
$0(1)
$0(1)
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
$0(2)
hydrocodone-acetaminophen tab 10-325 mg
$0(2)
$0(2)
hydrocodone-acetaminophen tab 7.5-300 mg
$0(2)
$0(2)
hydrocodone-acetaminophen tab 7.5-325 mg
$0(2)
$0(2)
hydrocodone-ibuprofen tab 5-200 mg
$0(2)
hydrocodone-ibuprofen tab 7.5-200 mg
$0(2)
hydrocodone-ibuprofen tab 10-200 mg
$0(2)
hydromorphone hcl liqd 1 mg/ml
$0(1)
hydromorphone hcl preservative free inj 10 mg/ml
$0(2)
BD
hydromorphone hcl tab 2 mg
$0(2)
Drugs section.
2
2016
Name of Drug
Necessary actions,
$0(2)
$0(2)
ibuprofen cap 200 mg
$0(3)
MC
ibuprofen susp 100 mg/5ml
$0(1)
ibuprofen tab 200 mg
$0(3)
$0(1)
$0(1)
$0(1)
ketoprofen cap 50 mg
$0(1)
$0(1)
LAZANDA - fentanyl citrate nasal spray 100 mcg/act
$0(2)
PA, QL (30 bottles/30 days)
$0(2)
$0(2)
LEVORPHANOL TARTRATE - levorphanol tartrate tab
2 mg
meloxicam tab 7.5 mg
$0(2)
meloxicam tab 15 mg
$0(1)
methadone hcl tab 5 mg
$0(1)
methadone hcl tab 10 mg
$0(1)
MORPHINE SULFATE - morphine sulfate tab 15 mg
$0(2)
MORPHINE SULFATE - morphine sulfate tab 30 mg
$0(2)
morphine sulfate beads cap sr 24hr 120 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
morphine sulfate inj pf 0.5 mg/ml
$0(2)
BD
morphine sulfate inj pf 1 mg/ml
$0(2)
BD
morphine sulfate oral soln 10 mg/5ml
$0(2)
morphine sulfate oral soln 20 mg/5ml
$0(2)
morphine sulfate oral soln 100 mg/5ml (20 mg/ml)
$0(2)
morphine sulfate tab cr 15 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
nabumetone tab 500 mg
$0(1)
MC
$0(1)
Drugs section.
3
2016
Name of Drug
Necessary actions,
$0(1)
naproxen sodium tab 220 mg
$0(3)
MC
$0(1)
$0(1)
naproxen susp 125 mg/5ml
$0(1)
naproxen tab ec 375 mg
$0(1)
$0(1)
naproxen tab 250 mg
$0(1)
naproxen tab 375 mg
$0(1)
naproxen tab 500 mg
$0(1)
NUCYNTA ER - tapentadol hcl tab sr 12hr 50 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
oxaprozin tab 600 mg
$0(1)
oxycodone hcl tab 5 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
oxycodone w/ acetaminophen tab 2.5-325 mg
$0(2)
oxycodone w/ acetaminophen tab 5-325 mg
$0(2)
oxycodone w/ acetaminophen tab 7.5-325 mg
$0(2)
oxycodone w/ acetaminophen tab 10-325 mg
$0(2)
oxycodone-aspirin tab 4.8355-325 mg
$0(2)
piroxicam cap 10 mg
$0(1)
piroxicam cap 20 mg
$0(1)
sulindac tab 150 mg
$0(1)
sulindac tab 200 mg
$0(1)
tolmetin sodium cap 400 mg
$0(1)
tramadol hcl tab sr 24hr 100 mg
$0(1)
$0(1)
$0(1)
tramadol hcl tab 50 mg
$0(1)
tramadol-acetaminophen tab 37.5-325 mg
$0(1)
TYLENOL - acetaminophen tab 325 mg
$0(3)
MC
Drugs section.
4
2016
Name of Drug
TYLENOL EXTRA STRENGTH - acetaminophen tab
500 mg
VOLTAREN - diclofenac sodium gel 1%
Necessary actions,
$0(3)
MC
$0(2)
ST
ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr abusedeterrent 10 mg
ZOHYDRO ER - hydrocodone bitartrate cap sr 12hr 10 mg
$0(2)
PA, QL (60 capsules/30 days)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
Anesthetics
lidocaine hcl gel 2%
$0(2)
lidocaine hcl local inj 1%
$0(1)
lidocaine hcl local preservative free inj 1%
$0(1)
lidocaine hcl soln 4%
$0(1)
lidocaine hcl viscous soln 2%
$0(1)
lidocaine oint 5%
$0(1)
lidocaine patch 5%
$0(1)
lidocaine-prilocaine cream 2.5-2.5%
$0(1)
LMX 4 - lidocaine cream 4%
Anti-Addiction/Substance Abuse Treatment Agents
acamprosate calcium tab delayed release 333 mg
$0(3)
buprenorphine hcl sl tab 2 mg
$0(1)
PA
buprenorphine hcl sl tab 8 mg
$0(1)
PA
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg
$0(1)
PA
buprenorphine hcl-naloxone hcl sl tab 8-2 mg
$0(1)
PA
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
$0(1)
BUTRANS - buprenorphine td patch weekly 5 mcg/hr
$0(1)
BUTRANS - buprenorphine td patch weekly 7.5 mcg/hr
$0(1)
$0(1)
PA, QL (90 patches/30 days)
MC
$0(1)
Drugs section.
5
2016
Name of Drug
Necessary actions,
$0(1)
$0(1)
$0(1)
CHANTIX - varenicline tartrate tab 0.5 mg
$0(1)
CHANTIX - varenicline tartrate tab 1 mg
$0(1)
CHANTIX CONTINUING MONTH - varenicline tartrate tab
1 mg
CHANTIX STARTING MONTH PACK - varenicline tartrate
tab 0.5 mg x 11 & tab 1 mg x 42 pack
disulfiram tab 250 mg
$0(1)
disulfiram tab 500 mg
$0(1)
NALOXONE HCL - naloxone hcl inj 1 mg/ml
$0(2)
naloxone hcl inj 0.4 mg/ml
$0(1)
naltrexone hcl tab 50 mg
$0(1)
NARCAN - naloxone hcl nasal spray 4 mg/0.1ml
$0(2)
NICODERM CQ - nicotine td patch 24hr 7 mg/24hr
$0(3)
MC
NICODERM CQ - nicotine td patch 24hr 14 mg/24hr
$0(3)
MC
NICORETTE - nicotine polacrilex lozenge 4 mg
$0(3)
MC
nicotine polacrilex gum 2 mg
$0(3)
MC
nicotine polacrilex gum 4 mg
$0(3)
MC
nicotine polacrilex lozenge 2 mg
$0(3)
MC
nicotine td patch 24hr 21 mg/24hr
$0(3)
MC
NICOTINE TRANSDERMAL SYSTEM - nicotine td patch
24 hr kit 21-14-7 mg/24hr
NICOTROL INHALER - nicotine inhaler system 10 mg
(4 mg delivered)
NICOTROL NS - nicotine nasal spray 10 mg/ml (0.5 mg/
spray)
SUBOXONE - buprenorphine hcl-naloxone hcl sl film
2-0.5 mg
4-1 mg
8-2 mg
12-3 mg
VIVITROL - naltrexone for im extended release susp
380 mg
Antibacterials
amikacin sulfate inj 500 mg/2ml (250 mg/ml)
$0(3)
MC
amikacin sulfate inj 1 gm/4ml (250 mg/ml)
$0(1)
$0(1)
$0(1)
$0(2)
$0(2)
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
$0(1)
Drugs section.
6
2016
Name of Drug
amoxicillin (trihydrate) cap 250 mg
Necessary actions,
$0(1)
amoxicillin (trihydrate) cap 500 mg
$0(1)
amoxicillin (trihydrate) for susp 125 mg/5ml
$0(1)
$0(1)
$0(1)
$0(1)
amoxicillin (trihydrate) tab 500 mg
$0(1)
amoxicillin (trihydrate) tab 875 mg
$0(1)
amoxicillin & k clavulanate chew tab 200-28.5 mg
$0(1)
amoxicillin & k clavulanate chew tab 400-57 mg
$0(1)
amoxicillin & k clavulanate for susp 200-28.5 mg/5ml
$0(1)
amoxicillin & k clavulanate for susp 400-57 mg/5ml
$0(1)
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
$0(1)
amoxicillin & k clavulanate tab 250-125 mg
$0(1)
$0(1)
$0(1)
AMPICILLIN - ampicillin for susp 125 mg/5ml
$0(2)
AMPICILLIN - ampicillin for susp 250 mg/5ml
$0(2)
ampicillin & sulbactam sodium for inj 2-1 gm
$0(1)
ampicillin cap 250 mg
$0(1)
ampicillin cap 500 mg
$0(1)
AMPICILLIN SODIUM - ampicillin sodium for iv soln 1 gm
$0(2)
AMPICILLIN SODIUM - ampicillin sodium for iv soln 2 gm
$0(2)
ampicillin sodium for inj 250 mg
$0(1)
ampicillin sodium for inj 500 mg
$0(1)
ampicillin sodium for inj 1 gm
$0(1)
ampicillin sodium for inj 2 gm
$0(1)
ampicillin sodium for iv soln 10 gm
$0(1)
AVELOX - moxifloxacin hcl 400 mg/250ml in sodium
chloride 0.8% inj
AZACTAM - aztreonam in dextrose inj 1 gm/50 ml
$0(1)
AZACTAM - aztreonam in dextrose inj 2 gm/50 ml
$0(2)
AZITHROMYCIN - azithromycin powd pack for susp 1 gm
$0(2)
azithromycin for susp 100 mg/5ml
$0(1)
azithromycin for susp 200 mg/5ml
$0(1)
azithromycin iv for soln 500 mg
$0(1)
azithromycin tab 250 mg
$0(1)
$0(1)
$0(2)
Drugs section.
7
2016
Name of Drug
Necessary actions,
$0(1)
aztreonam for inj 1 gm
$0(1)
aztreonam for inj 2 gm
$0(1)
BICILLIN L-A - penicillin g benzathine intramuscular susp
600000 unit/ml
1200000 unit/2ml
2400000 unit/4ml
cefaclor cap 250 mg
$0(2)
cefaclor cap 500 mg
$0(1)
cefadroxil cap 500 mg
$0(1)
cefadroxil for susp 250 mg/5ml
$0(1)
cefadroxil for susp 500 mg/5ml
$0(1)
cefadroxil tab 1 gm
$0(1)
cefazolin sodium for inj 500 mg
$0(1)
cefazolin sodium for inj 1 gm
$0(1)
$0(1)
$0(1)
cefdinir cap 300 mg
$0(1)
cefdinir for susp 125 mg/5ml
$0(1)
cefdinir for susp 250 mg/5ml
$0(1)
cefepime hcl for inj 1 gm
$0(1)
cefepime hcl for inj 2 gm
$0(1)
cefotaxime sodium for inj 500 mg
$0(1)
cefotaxime sodium for inj 1 gm
$0(1)
$0(1)
$0(1)
cefoxitin sodium for inj 10 gm
$0(1)
cefoxitin sodium for iv soln 1 gm
$0(1)
cefoxitin sodium for iv soln 2 gm
$0(1)
cefpodoxime proxetil for susp 50 mg/5ml
$0(1)
cefpodoxime proxetil for susp 100 mg/5ml
$0(1)
cefpodoxime proxetil tab 100 mg
$0(1)
cefpodoxime proxetil tab 200 mg
$0(1)
cefprozil for susp 125 mg/5ml
$0(1)
cefprozil for susp 250 mg/5ml
$0(1)
cefprozil tab 250 mg
$0(1)
cefprozil tab 500 mg
$0(1)
$0(2)
$0(2)
$0(1)
Drugs section.
8
2016
Name of Drug
ceftazidime for inj 1 gm
Necessary actions,
$0(1)
$0(1)
$0(1)
ceftazidime for iv soln 1 gm
$0(1)
ceftazidime for iv soln 2 gm
$0(1)
CEFTRIAXONE IN ISO-OSMOTIC - ceftriaxone sodium in
dextrose inj 20 mg/ml
CEFTRIAXONE IN ISO-OSMOTIC - ceftriaxone sodium in
dextrose inj 40 mg/ml
ceftriaxone sodium for inj 250 mg
$0(2)
ceftriaxone sodium for inj 500 mg
$0(1)
ceftriaxone sodium for inj 1 gm
$0(1)
$0(1)
$0(1)
ceftriaxone sodium for iv soln 1 gm
$0(1)
ceftriaxone sodium for iv soln 2 gm
$0(1)
CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv
soln 1 gm and dextrose 3.74%
CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv
soln 2 gm and dextrose 2.22%
cefuroxime axetil tab 250 mg
$0(2)
cefuroxime axetil tab 500 mg
$0(1)
cefuroxime sodium for inj 750 mg
$0(1)
cefuroxime sodium for inj 1.5 gm
$0(1)
cefuroxime sodium for inj 7.5 gm
$0(1)
cefuroxime sodium for iv soln 1.5 gm
$0(1)
cephalexin cap 250 mg
$0(1)
$0(1)
$0(1)
cephalexin for susp 125 mg/5ml
$0(1)
cephalexin for susp 250 mg/5ml
$0(1)
CHLORAMPHENICOL SODIUM SUCCINATE chloramphenicol sodium succinate for iv inj 1 gm
ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml)
$0(2)
ciprofloxacin for oral susp 500 mg/5ml (10%)
(10 gm/100ml)
CIPROFLOXACIN HCL - ciprofloxacin hcl tab 100 mg
$0(1)
ciprofloxacin hcl tab sr 24hr 500 mg
$0(1)
ciprofloxacin hcl tab sr 24hr 1000 mg
$0(1)
$0(2)
$0(1)
$0(2)
$0(1)
$0(1)
$0(2)
Drugs section.
9
2016
Name of Drug
ciprofloxacin hcl tab 250 mg
Necessary actions,
$0(1)
$0(1)
$0(1)
ciprofloxacin iv soln 200 mg/20ml (1%)
$0(1)
ciprofloxacin iv soln 400 mg/40ml (1%)
$0(1)
ciprofloxacin 200 mg/100ml in d5w
$0(1)
ciprofloxacin 400 mg/200ml in d5w
$0(1)
CLAFORAN/D5W - cefotaxime sodium in d5w iv soln
1 gm/50ml
CLAFORAN/D5W - cefotaxime sodium in d5w iv soln
2 gm/50ml
clarithromycin for susp 125 mg/5ml
$0(2)
clarithromycin for susp 250 mg/5ml
$0(1)
clarithromycin tab sr 24hr 500 mg
$0(1)
clarithromycin tab 250 mg
$0(1)
clarithromycin tab 500 mg
$0(1)
clindamycin hcl cap 75 mg
$0(1)
$0(1)
$0(1)
clindamycin phosphate in d5w iv soln 300 mg/50ml
$0(1)
$0(1)
$0(1)
clindamycin phosphate inj 300 mg/2ml
$0(1)
$0(1)
$0(1)
clindamycin phosphate inj 9 gm/60ml
$0(1)
clindamycin phosphate iv soln 300 mg/2ml
$0(1)
$0(1)
$0(1)
clindamycin phosphate vaginal cream 2%
$0(1)
colistimethate sodium for inj 150 mg
$0(1)
CUBICIN - daptomycin for iv soln 500 mg
$0(2)
CUBICIN RF - daptomycin for iv soln 500 mg
$0(2)
DALVANCE - dalbavancin hcl for iv soln 500 mg
$0(2)
demeclocycline hcl tab 150 mg
$0(1)
demeclocycline hcl tab 300 mg
$0(1)
dicloxacillin sodium cap 250 mg
$0(1)
dicloxacillin sodium cap 500 mg
$0(1)
$0(2)
$0(1)
Drugs section.
10
2016
Name of Drug
DIFICID - fidaxomicin tab 200 mg
Necessary actions,
$0(2)
doxycycline hyclate cap 50 mg
$0(1)
$0(1)
doxycycline hyclate for inj 100 mg
$0(1)
doxycycline hyclate tab 20 mg
$0(1)
$0(1)
doxycycline monohydrate cap 50 mg
$0(1)
$0(1)
$0(1)
$0(1)
doxycycline monohydrate tab 50 mg
$0(1)
$0(1)
$0(1)
$0(1)
E.E.S. GRANULES - erythromycin ethylsuccinate for susp
200 mg/5ml
ERY-TAB - erythromycin tab delayed release 250 mg
$0(2)
$0(2)
$0(2)
ERYPED 200 - erythromycin ethylsuccinate for susp
200 mg/5ml
ERYPED 400 - erythromycin ethylsuccinate for susp
400 mg/5ml
ERYTHROCIN LACTOBIONATE - erythromycin
lactobionate for inj 500 mg
ERYTHROCIN STEARATE - erythromycin stearate tab
250 mg
ERYTHROMYCIN BASE - erythromycin tab 250 mg
$0(2)
ERYTHROMYCIN BASE - erythromycin tab 500 mg
$0(2)
FORTAZ - ceftazidime for inj 500 mg
$0(2)
FORTAZ - ceftazidime sodium in d5w inj 1 gm/50ml
$0(2)
FORTAZ - ceftazidime sodium in d5w inj 2 gm/50ml
$0(2)
gentamicin in saline inj 0.8 mg/ml
$0(1)
gentamicin in saline inj 1 mg/ml
$0(1)
$0(1)
$0(1)
gentamicin sulfate inj 10 mg/ml
$0(1)
gentamicin sulfate inj 40 mg/ml
$0(1)
gentamicin sulfate iv soln 10 mg/ml
$0(1)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
Drugs section.
11
2016
Name of Drug
GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE
- gentamicin in saline inj 0.9 mg/ml
GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE
- gentamicin in saline inj 1.4 mg/ml
imipenem-cilastatin intravenous for soln 250 mg
Necessary actions,
$0(2)
$0(2)
$0(1)
imipenem-cilastatin intravenous for soln 500 mg
$0(1)
INVANZ - ertapenem sodium for inj 1 gm
$0(2)
INVANZ - ertapenem sodium for iv inj 1 gm
$0(2)
levofloxacin in d5w iv soln 250 mg/50ml
$0(1)
$0(1)
$0(1)
levofloxacin iv soln 25 mg/ml
$0(1)
levofloxacin oral soln 25 mg/ml
$0(1)
levofloxacin tab 250 mg
$0(1)
$0(1)
$0(1)
linezolid for susp 100 mg/5ml
$0(1)
linezolid in sodium chloride iv soln 600 mg/300ml-0.9%
$0(1)
linezolid iv soln 600 mg/300ml (2 mg/ml)
$0(1)
linezolid tab 600 mg
$0(1)
meropenem iv for soln 500 mg
$0(1)
meropenem iv for soln 1 gm
$0(1)
methenamine hippurate tab 1 gm
$0(1)
METRO IV - metronidazole in nacl 0.74% iv soln
500 mg/100ml
metronidazole cap 375 mg
$0(2)
metronidazole in nacl 0.79% iv soln 500 mg/100ml
$0(1)
metronidazole tab 250 mg
$0(1)
metronidazole tab 500 mg
$0(1)
metronidazole vaginal gel 0.75%
$0(1)
minocycline hcl cap 50 mg
$0(1)
$0(1)
$0(1)
minocycline hcl tab 50 mg
$0(1)
$0(1)
$0(1)
moxifloxacin hcl tab 400 mg
$0(1)
NAFCILLIN SODIUM - nafcillin sodium for iv soln 1 gm
$0(2)
NAFCILLIN SODIUM - nafcillin sodium for iv soln 2 gm
$0(2)
PA
PA
$0(1)
Drugs section.
12
2016
Name of Drug
nafcillin sodium for inj 1 gm
Necessary actions,
$0(1)
$0(1)
$0(1)
neomycin sulfate tab 500 mg
$0(1)
neomycin-polymyxin b gu irrigation soln
$0(1)
nitrofurantoin macrocrystalline cap 50 mg#
$0(2)
PA
nitrofurantoin macrocrystalline cap 100 mg#
$0(2)
PA
nitrofurantoin monohydrate macrocrystalline cap 100 mg#
$0(2)
PA
nitrofurantoin susp 25 mg/5ml#
$0(2)
PA
OFLOXACIN - ofloxacin tab 400 mg
$0(2)
paromomycin sulfate cap 250 mg
$0(1)
penicillin g potassium for inj 5000000 unit
$0(1)
penicillin g potassium for inj 20000000 unit
$0(1)
PENICILLIN G POTASSIUM IN DEXTROSE - penicillin g
potassium inj 20000 unit/ml in dextrose
PENICILLIN G SODIUM - penicillin g sodium for inj
5000000 unit
penicillin v potassium for soln 125 mg/5ml
$0(2)
penicillin v potassium for soln 250 mg/5ml
$0(1)
penicillin v potassium tab 250 mg
$0(1)
penicillin v potassium tab 500 mg
$0(1)
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)
$0(1)
piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm)
$0(1)
SIVEXTRO - tedizolid phosphate tab 200 mg
$0(2)
SIVEXTRO - tedizolid phosphate for iv soln 200 mg
$0(2)
STREPTOMYCIN SULFATE - streptomycin sulfate for inj
1 gm
SULFADIAZINE - sulfadiazine tab 500 mg
$0(2)
sulfamethoxazole-trimethoprim susp 200-40 mg/5ml
$0(1)
sulfamethoxazole-trimethoprim tab 400-80 mg
$0(1)
sulfamethoxazole-trimethoprim tab 800-160 mg
$0(1)
SULFAMETHOXAZOLE/TRIMETHOPRIM sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml
SUPRAX - cefixime cap 400 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(1)
$0(1)
PA
$0(2)
$0(2)
Drugs section.
13
2016
Name of Drug
SUPRAX - cefixime chew tab 100 mg
Necessary actions,
$0(2)
SUPRAX - cefixime chew tab 200 mg
$0(2)
SYNERCID - quinupristin-dalfopristin for inj 500 mg
(150-350 mg)
TEFLARO - ceftaroline fosamil for iv soln 400 mg
$0(2)
TEFLARO - ceftaroline fosamil for iv soln 600 mg
$0(2)
tetracycline hcl cap 250 mg
$0(1)
tetracycline hcl cap 500 mg
$0(1)
tobramycin sulfate for inj 1.2 gm
$0(1)
tobramycin sulfate inj 10 mg/ml
$0(1)
tobramycin sulfate inj 80 mg/2ml (40 mg/ml)
$0(1)
tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml)
$0(1)
tobramycin sulfate inj 2 gm/50ml (40 mg/ml)
$0(1)
trimethoprim tab 100 mg
$0(1)
TYGACIL - tigecycline for iv soln 50 mg
$0(2)
vancomycin hcl cap 125 mg
$0(1)
vancomycin hcl cap 250 mg
$0(1)
vancomycin hcl for inj 500 mg
$0(1)
$0(1)
$0(1)
vancomycin hcl for inj 10 gm
$0(1)
VANCOMYCIN HCL IN DEXTROSE - vancomycin hcl in
dextrose inj 500 mg/100ml
dextrose inj 750 mg/150ml
dextrose inj 1 gm/200ml
XIFAXAN - rifaximin tab 550 mg
$0(2)
ZINACEF - cefuroxime in sterile water inj 1.5 gm/50ml
$0(2)
ZOSYN - piperacillin sod-tazobactam sod in dex iv soln
2-0.25gm/50ml
ZOSYN - piperacillin sod-tazobactam sod in dex iv soln
4-0.5gm/100ml
ZOSYN - piperacillin sod-tazobactam sod in dex iv sol
3-0.375gm/50ml
ZYVOX - linezolid for susp 100 mg/5ml
Anticonvulsants
APTIOM - eslicarbazepine acetate tab 200 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
PA
$0(2)
Drugs section.
14
2016
Name of Drug
Necessary actions,
$0(2)
BANZEL - rufinamide susp 40 mg/ml
$0(2)
BANZEL - rufinamide tab 200 mg
$0(2)
BANZEL - rufinamide tab 400 mg
$0(2)
BRIVIACT - brivaracetam tab 10 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
BRIVIACT - brivaracetam oral soln 10 mg/ml
$0(2)
BRIVIACT - brivaracetam iv soln 50 mg/5ml
$0(2)
carbamazepine cap sr 12hr 100 mg
$0(1)
$0(1)
$0(1)
carbamazepine chew tab 100 mg
$0(1)
carbamazepine susp 100 mg/5ml
$0(1)
carbamazepine tab sr 12hr 100 mg
$0(1)
$0(1)
$0(1)
carbamazepine tab 200 mg
$0(1)
CELONTIN - methsuximide cap 300 mg
$0(2)
clonazepam orally disintegrating tab 0.125 mg
$0(1)
$0(1)
$0(1)
clonazepam orally disintegrating tab 1 mg
$0(1)
$0(1)
clonazepam tab 0.5 mg
$0(1)
clonazepam tab 1 mg
$0(1)
clonazepam tab 2 mg
$0(1)
clorazepate dipotassium tab 3.75 mg
$0(1)
$0(1)
clorazepate dipotassium tab 15 mg
$0(1)
DIASTAT ACUDIAL - diazepam rectal gel delivery system
10 mg
DIASTAT ACUDIAL - diazepam rectal gel delivery system
20 mg
DIASTAT PEDIATRIC - diazepam rectal gel delivery system
2.5 mg
DIAZEPAM - diazepam oral soln 1 mg/ml
$0(2)
QL (5 twin pack(s)/30 days)
$0(2)
$0(2)
$0(2)
PA, QL (1200 mls/30 days)
Drugs section.
15
2016
Name of Drug
DIAZEPAM - diazepam rectal gel delivery system 2.5 mg
Necessary actions,
$0(2)
DIAZEPAM - diazepam rectal gel delivery system 10 mg
$0(2)
DIAZEPAM - diazepam rectal gel delivery system 20 mg
$0(2)
diazepam conc 5 mg/ml
$0(1)
diazepam tab 2 mg
$0(1)
diazepam tab 5 mg
$0(1)
diazepam tab 10 mg
$0(1)
DILANTIN - phenytoin sodium extended cap 30 mg
$0(2)
divalproex sodium cap delayed release sprinkle 125 mg
$0(1)
divalproex sodium tab delayed release 125 mg
$0(1)
$0(1)
$0(1)
divalproex sodium tab sr 24 hr 250 mg
$0(1)
$0(1)
ethosuximide cap 250 mg
$0(1)
ethosuximide soln 250 mg/5ml
$0(1)
felbamate susp 600 mg/5ml
$0(1)
felbamate tab 400 mg
$0(1)
felbamate tab 600 mg
$0(1)
fosphenytoin sodium inj 100 mg/2ml
$0(1)
fosphenytoin sodium inj 500 mg/10ml
$0(1)
FYCOMPA - perampanel susp 0.5 mg/ml
$0(2)
FYCOMPA - perampanel tab 2 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
gabapentin cap 100 mg
$0(1)
$0(1)
$0(1)
gabapentin oral soln 250 mg/5ml
$0(1)
gabapentin tab 600 mg
$0(1)
gabapentin tab 800 mg
$0(1)
GABITRIL - tiagabine hcl tab 12 mg
$0(2)
GABITRIL - tiagabine hcl tab 16 mg
$0(2)
lamotrigine orally disintegrating tab 25 mg
$0(1)
$0(1)
Drugs section.
16
2016
Name of Drug
Necessary actions,
$0(1)
$0(1)
lamotrigine tab chewable dispersible 5 mg
$0(1)
$0(1)
lamotrigine tab 25 mg
$0(1)
$0(1)
$0(1)
$0(1)
LEVETIRACETAM - levetiracetam in sodium chloride iv
soln 500 mg/100ml
soln 1000 mg/100ml
soln 1500 mg/100ml
levetiracetam inj 500 mg/5ml (100 mg/ml)
$0(2)
levetiracetam oral soln 100 mg/ml
$0(1)
levetiracetam tab 250 mg
$0(1)
$0(1)
$0(1)
$0(1)
LYRICA - pregabalin soln 20 mg/ml
$0(1)
LYRICA - pregabalin cap 25 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
ONFI - clobazam suspension 2.5 mg/ml
$0(2)
ONFI - clobazam tab 5 mg
$0(2)
$0(2)
$0(2)
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
$0(1)
oxcarbazepine tab 150 mg
$0(1)
$0(1)
$0(1)
PEGANONE - ethotoin tab 250 mg
$0(2)
PHENOBARBITAL - phenobarbital tab 15 mg#
$0(2)
$0(2)
$0(2)
$0(1)
PA
Drugs section.
17
2016
Name of Drug
Necessary actions,
$0(2)
PA
$0(2)
PA
$0(2)
PA
phenobarbital elixir 20 mg/5ml#
$0(2)
PA
PHENOBARBITAL SODIUM - phenobarbital sodium inj
65 mg/ml#
PHENOBARBITAL SODIUM - phenobarbital sodium inj
130 mg/ml#
phenobarbital tab 16.2 mg#
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
phenytoin chew tab 50 mg
$0(1)
phenytoin sodium extended cap 100 mg
$0(1)
$0(1)
$0(1)
phenytoin susp 125 mg/5ml
$0(1)
POTIGA - ezogabine tab 50 mg
$0(2)
$0(2)
$0(2)
$0(2)
primidone tab 50 mg
$0(1)
primidone tab 250 mg
$0(1)
SABRIL - vigabatrin tab 500 mg*
$0(2)
SABRIL - vigabatrin powd pack 500 mg*
$0(2)
SPRITAM - levetiracetam tab disintegrating soluble 250 mg
$0(2)
$0(2)
$0(2)
SPRITAM - levetiracetam tab disintegrating soluble
1000 mg
TEGRETOL-XR - carbamazepine tab sr 12hr 100 mg
$0(2)
tiagabine hcl tab 2 mg
$0(1)
tiagabine hcl tab 4 mg
$0(1)
topiramate sprinkle cap 15 mg
$0(1)
$0(1)
topiramate tab 25 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(2)
Drugs section.
18
2016
Name of Drug
valproate sodium inj 100 mg/ml
Necessary actions,
$0(1)
valproate sodium syrup 250 mg/5ml
$0(1)
valproic acid cap 250 mg
$0(1)
VIMPAT - lacosamide tab 50 mg
$0(1)
$0(1)
$0(1)
$0(1)
VIMPAT - lacosamide iv inj 200 mg/20ml (10 mg/ml)
$0(1)
VIMPAT - lacosamide oral solution 10 mg/ml
$0(1)
zonisamide cap 25 mg
$0(1)
$0(1)
Antidementia Agents
donepezil hydrochloride orally disintegrating tab 5 mg
$0(1)
donepezil hydrochloride orally disintegrating tab 10 mg
$0(1)
donepezil hydrochloride tab 5 mg
$0(1)
$0(1)
$0(1)
ergoloid mesylates tab 1 mg#
$0(1)
EXELON - rivastigmine td patch 24hr 4.6 mg/24hr
$0(1)
$0(1)
$0(1)
GALANTAMINE HYDROBROMIDE - galantamine
hydrobromide oral soln 4 mg/ml
galantamine hydrobromide cap sr 24hr 8 mg
$0(2)
$0(1)
$0(1)
galantamine hydrobromide tab 4 mg
$0(1)
$0(1)
$0(1)
memantine hcl oral solution 2 mg/ml
$0(1)
PA
memantine hcl tab 5 mg
$0(1)
PA
memantine hcl tab 10 mg
$0(1)
PA
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak
$0(1)
PA
NAMENDA - memantine hcl oral solution 2 mg/ml
$0(1)
PA
NAMENDA - memantine hcl tab 5 mg
$0(1)
PA
NAMENDA - memantine hcl tab 10 mg
$0(1)
PA
$0(1)
PA
$0(1)
Drugs section.
19
2016
Necessary actions,
Name of Drug
NAMENDA TITRATION PAK - memantine hcl tab 5 mg (28)
$0(1)
PA
& 10 mg (21) titration pak
NAMENDA XR - memantine hcl cap sr 24hr 7 mg
$0(1)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
NAMENDA XR TITRATION PACK - memantine hcl cap sr
24hr 7 mg & 14 mg & 21 mg & 28 mg pack
rivastigmine tartrate cap 1.5 mg
$0(1)
PA
rivastigmine tartrate cap 3 mg
$0(1)
rivastigmine tartrate cap 4.5 mg
$0(1)
rivastigmine tartrate cap 6 mg
$0(1)
rivastigmine td patch 24hr 4.6 mg/24hr
$0(1)
$0(1)
Antidepressants
ABILIFY MAINTENA - aripiprazole im for extended release
susp 300 mg
$0(1)
$0(2)
PA, QL (1 syringe
or vial/30 days)
susp 400 mg
$0(2)
PA, QL (1 syringe
or vial/30 days)
amitriptyline hcl tab 10 mg#
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
AMOXAPINE - amoxapine tab 25 mg
$0(2)
$0(2)
$0(2)
$0(2)
aripiprazole oral solution 1 mg/ml
$0(1)
aripiprazole orally disintegrating tab 10 mg
$0(1)
$0(1)
aripiprazole tab 2 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
Drugs section.
20
2016
Name of Drug
bupropion hcl tab sr 12hr 100 mg
Necessary actions,
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
bupropion hcl tab 75 mg
$0(1)
bupropion hcl tab 100 mg
$0(1)
citalopram hydrobromide oral soln 10 mg/5ml
$0(1)
citalopram hydrobromide tab 10 mg
$0(1)
$0(1)
$0(1)
clomipramine hcl cap 25 mg#
$0(2)
PA
$0(2)
PA
$0(2)
PA
desipramine hcl tab 10 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
DOXEPIN HCL - doxepin hcl cap 75 mg#
$0(2)
PA
doxepin hcl cap 10 mg#
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
doxepin hcl conc 10 mg/ml#
$0(2)
PA
duloxetine hcl enteric coated pellets cap 20 mg
$0(1)
$0(1)
$0(1)
EMSAM - selegiline td patch 24hr 6 mg/24hr
$0(2)
$0(2)
$0(2)
escitalopram oxalate soln 5 mg/5ml
$0(1)
escitalopram oxalate tab 5 mg
$0(1)
$0(1)
$0(1)
FETZIMA - levomilnacipran hcl cap sr 24hr 20 mg
$0(2)
Drugs section.
21
2016
Name of Drug
Necessary actions,
$0(2)
$0(2)
$0(2)
FETZIMA TITRATION PACK - levomilnacipran hcl cap sr
24hr 20 & 40 mg therapy pack
fluoxetine hcl cap delayed release 90 mg
$0(2)
$0(1)
fluoxetine hcl cap 10 mg
$0(1)
$0(1)
$0(1)
fluoxetine hcl solution 20 mg/5ml
$0(1)
fluoxetine hcl tab 10 mg
$0(1)
fluoxetine hcl tab 20 mg
$0(1)
fluvoxamine maleate tab 25 mg
$0(1)
$0(1)
$0(1)
imipramine hcl tab 10 mg#
$0(2)
PA
$0(2)
PA
$0(2)
PA
MAPROTILINE HCL - maprotiline hcl tab 25 mg
$0(2)
$0(2)
$0(2)
MARPLAN - isocarboxazid tab 10 mg
$0(2)
mirtazapine orally disintegrating tab 15 mg
$0(1)
$0(1)
$0(1)
mirtazapine tab 7.5 mg
$0(1)
mirtazapine tab 15 mg
$0(1)
$0(1)
$0(1)
NEFAZODONE HCL - nefazodone hcl tab 100 mg
$0(2)
$0(2)
$0(2)
nefazodone hcl tab 50 mg
$0(1)
nefazodone hcl tab 250 mg
$0(1)
NORTRIPTYLINE HCL - nortriptyline hcl soln 10 mg/5ml
$0(2)
nortriptyline hcl cap 10 mg
$0(1)
$0(1)
$0(1)
Drugs section.
22
2016
Name of Drug
Necessary actions,
$0(1)
paroxetine hcl tab sr 24hr 12.5 mg
$0(1)
paroxetine hcl tab sr 24hr 25 mg
$0(1)
$0(1)
paroxetine hcl tab 10 mg
$0(1)
$0(1)
$0(1)
$0(1)
PAXIL - paroxetine hcl oral susp 10 mg/5ml
$0(2)
phenelzine sulfate tab 15 mg
$0(1)
PRISTIQ - desvenlafaxine succinate tab sr 24hr 25 mg
$0(2)
$0(2)
$0(2)
protriptyline hcl tab 5 mg
$0(1)
protriptyline hcl tab 10 mg
$0(1)
quetiapine fumarate tab 25 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
REXULTI - brexpiprazole tab 0.25 mg
$0(2)
$0(2)
REXULTI - brexpiprazole tab 1 mg
$0(2)
$0(2)
$0(2)
$0(2)
SEROQUEL XR - quetiapine fumarate tab sr 24hr 50 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
sertraline hcl oral conc 20 mg/ml
$0(1)
sertraline hcl tab 25 mg
$0(1)
$0(1)
$0(1)
SURMONTIL - trimipramine maleate cap 25 mg#
$0(2)
PA
$0(2)
PA
Drugs section.
23
2016
Name of Drug
Necessary actions,
$0(2)
PA
tranylcypromine sulfate tab 10 mg
$0(1)
trazodone hcl tab 50 mg
$0(1)
$0(1)
$0(1)
$0(1)
trimipramine maleate cap 25 mg#
$0(2)
PA
$0(2)
PA
$0(2)
PA
TRINTELLIX - vortioxetine hbr tab 5 mg
$0(2)
$0(2)
$0(2)
venlafaxine hcl cap sr 24hr 37.5 mg
$0(1)
venlafaxine hcl cap sr 24hr 75 mg
$0(1)
$0(1)
venlafaxine hcl tab sr 24hr 37.5 mg
$0(1)
venlafaxine hcl tab sr 24hr 75 mg
$0(1)
$0(1)
venlafaxine hcl tab 25 mg
$0(1)
venlafaxine hcl tab 37.5 mg
$0(1)
$0(1)
$0(1)
$0(1)
VIIBRYD - vilazodone hcl tab 10 mg
$0(2)
$0(2)
$0(2)
VIIBRYD STARTER PACK - vilazodone hcl tab starter kit 10
(7) & 20 (23) mg
Antiemetics
ALER-DRYL - diphenhydramine hcl tab 50 mg
$0(2)
QL (1 kit/30 days)
$0(3)
MC
ALOXI - palonosetron hcl iv soln 0.25 mg/5ml
$0(2)
BENADRYL ALLERGY CHILDRENS - diphenhydramine hcl
chew tab 12.5 mg
liquid 12.5 mg/5ml
CHLORPROMAZINE HCL - chlorpromazine hcl inj 25 mg/
ml
CHLORPROMAZINE HCL - chlorpromazine hcl inj
50 mg/2ml
$0(3)
MC
$0(3)
MC
$0(2)
PA
$0(2)
PA
Drugs section.
24
2016
Name of Drug
chlorpromazine hcl tab 10 mg
Necessary actions,
$0(1)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
diphenhydramine hcl cap 25 mg#
$0(3)
MC
diphenhydramine hcl inj 50 mg/ml
$0(1)
diphenhydramine hcl tab 25 mg
$0(3)
MC
DRAMAMINE - dimenhydrinate tab 50 mg
$0(3)
MC
dronabinol cap 2.5 mg
$0(1)
BD
dronabinol cap 5 mg
$0(1)
BD
dronabinol cap 10 mg
$0(1)
BD
EMEND - aprepitant capsule therapy pack 80 & 125 mg
$0(2)
BD
EMEND - fosaprepitant dimeglumine for iv infusion 150 mg
$0(2)
EMEND - aprepitant capsule 40 mg
$0(2)
BD
$0(2)
BD
$0(2)
BD
EMETROL - fructose-dextrose-phosphoric acid oral soln
$0(3)
MC
granisetron hcl tab 1 mg
$0(1)
BD
hydroxyzine hcl syrup 10 mg/5ml#
$0(2)
PA
hydroxyzine hcl tab 10 mg#
$0(2)
PA
$0(2)
PA
$0(2)
PA
meclizine hcl chew tab 25 mg
$0(3)
MC
meclizine hcl tab 12.5 mg
$0(1)
meclizine hcl tab 25 mg
$0(1)
metoclopramide hcl inj 5 mg/ml
$0(1)
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)
$0(1)
metoclopramide hcl tab 5 mg
$0(1)
$0(1)
ondansetron hcl inj 4 mg/2ml (2 mg/ml)
$0(1)
ondansetron hcl inj 40 mg/20ml (2 mg/ml)
$0(1)
ondansetron hcl oral soln 4 mg/5ml
$0(1)
BD
ondansetron hcl tab 4 mg
$0(1)
BD
$0(1)
BD
$0(1)
BD
ondansetron orally disintegrating tab 4 mg
$0(1)
BD
ondansetron orally disintegrating tab 8 mg
$0(1)
BD
Drugs section.
25
2016
Name of Drug
perphenazine tab 2 mg
Necessary actions,
$0(1)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
prochlorperazine edisylate inj 5 mg/ml
$0(1)
prochlorperazine maleate tab 5 mg
$0(1)
$0(1)
prochlorperazine suppos 25 mg
$0(1)
promethazine hcl suppos 12.5 mg#
$0(2)
PA
promethazine hcl suppos 25 mg#
$0(2)
PA
promethazine hcl syrup 6.25 mg/5ml#
$0(2)
PA
promethazine hcl tab 12.5 mg#
$0(2)
PA
promethazine hcl tab 25 mg#
$0(2)
PA
Antifungals
AMBISOME - amphotericin b liposome iv for susp 50 mg
$0(2)
PA
$0(2)
BD
AMPHOTERICIN B - amphotericin b for inj 50 mg
$0(2)
BD
CANCIDAS - caspofungin acetate for iv soln 50 mg
$0(2)
CANCIDAS - caspofungin acetate for iv soln 70 mg
$0(2)
clotrimazole troche 10 mg
$0(1)
CRESEMBA - isavuconazonium sulfate cap 186 mg
$0(2)
PA
CRESEMBA - isavuconazonium sulfate for iv soln 372 mg
$0(2)
PA
fluconazole for susp 10 mg/ml
$0(1)
fluconazole for susp 40 mg/ml
$0(1)
fluconazole in dextrose inj 200 mg/100ml
$0(1)
fluconazole in dextrose inj 400 mg/200ml
$0(1)
fluconazole in nacl 0.9% inj 200 mg/100ml
$0(1)
fluconazole in nacl 0.9% inj 400 mg/200ml
$0(1)
fluconazole tab 50 mg
$0(1)
$0(1)
$0(1)
$0(1)
flucytosine cap 250 mg
$0(1)
flucytosine cap 500 mg
$0(1)
griseofulvin microsize susp 125 mg/5ml
$0(1)
griseofulvin ultramicrosize tab 125 mg
$0(1)
griseofulvin ultramicrosize tab 250 mg
$0(1)
GYNE-LOTRIMIN - clotrimazole vaginal cream 1%
$0(3)
MC
Drugs section.
26
2016
Name of Drug
GYNE-LOTRIMIN 3 - clotrimazole vaginal cream 2%
Necessary actions,
$0(3)
MC
itraconazole cap 100 mg
$0(1)
ketoconazole tab 200 mg
$0(1)
LAMISIL AT - terbinafine hcl cream 1%
$0(3)
MC
miconazole nitrate vaginal app 200 mg & 2% cream 9 gm
kit
miconazole nitrate vaginal cream 2%
$0(3)
MC
$0(3)
MC
miconazole nitrate vaginal cream 4% (200 mg/5gm)
$0(3)
MC
miconazole nitrate vaginal suppos 100 mg
$0(3)
MC
miconazole nitrate vaginal supp 200 mg & 2% cream 9 gm
kit
MYCAMINE - micafungin sodium for iv soln 50 mg
$0(3)
MC
MYCAMINE - micafungin sodium for iv soln 100 mg
$0(2)
NOXAFIL - posaconazole tab delayed release 100 mg
$0(2)
PA
NOXAFIL - posaconazole susp 40 mg/ml
$0(2)
PA
NOXAFIL - posaconazole iv soln 300 mg/16.7ml (18 mg/ml)
$0(2)
PA
nystatin susp 100000 unit/ml
$0(1)
nystatin tab 500000 unit
$0(1)
terbinafine hcl tab 250 mg
$0(1)
terconazole vaginal cream 0.4%
$0(1)
terconazole vaginal cream 0.8%
$0(1)
terconazole vaginal suppos 80 mg
$0(1)
tolnaftate aerosol 1%
$0(3)
MC
VAGISTAT-1 - tioconazole vaginal oint 6.5%
$0(3)
MC
voriconazole for inj 200 mg
$0(1)
PA
voriconazole for susp 40 mg/ml
$0(1)
PA
voriconazole tab 50 mg
$0(1)
PA
voriconazole tab 200 mg
Antigout Agents
allopurinol tab 100 mg
$0(1)
PA
allopurinol tab 300 mg
$0(1)
ALOPRIM - allopurinol sodium for inj 500 mg
$0(2)
colchicine w/ probenecid tab 0.5-500 mg
$0(1)
COLCRYS - colchicine tab 0.6 mg
$0(1)
probenecid tab 500 mg
$0(1)
ULORIC - febuxostat tab 40 mg
$0(1)
ULORIC - febuxostat tab 80 mg
Anti-Inflammatory Agents
aspirin chew tab 81 mg
$0(1)
$0(2)
$0(1)
$0(3)
MC
Drugs section.
27
2016
Name of Drug
aspirin tab delayed release 81 mg
Necessary actions,
$0(3)
MC
aspirin tab delayed release 325 mg
$0(3)
MC
aspirin tab 325 mg
$0(3)
MC
aspirin tab 81 mg
$0(3)
MC
celecoxib cap 50 mg
$0(1)
$0(1)
$0(1)
$0(1)
diclofenac potassium tab 50 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
diclofenac sodium tab sr 24hr 100 mg
$0(1)
$0(1)
$0(1)
etodolac cap 200 mg
$0(1)
etodolac cap 300 mg
$0(1)
$0(1)
$0(1)
$0(1)
etodolac tab 400 mg
$0(1)
etodolac tab 500 mg
$0(1)
$0(1)
$0(1)
ibuprofen cap 200 mg
$0(3)
ibuprofen susp 100 mg/5ml
$0(1)
$0(3)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
meloxicam tab 7.5 mg
$0(1)
meloxicam tab 15 mg
$0(1)
$0(1)
$0(1)
$0(3)
ST
MC
MC
MC
Drugs section.
28
2016
Name of Drug
Necessary actions,
$0(1)
$0(1)
naproxen susp 125 mg/5ml
$0(1)
$0(1)
$0(1)
naproxen tab 250 mg
$0(1)
naproxen tab 375 mg
$0(1)
naproxen tab 500 mg
$0(1)
oxaprozin tab 600 mg
$0(1)
piroxicam cap 10 mg
$0(1)
piroxicam cap 20 mg
$0(1)
sulindac tab 150 mg
$0(1)
sulindac tab 200 mg
$0(1)
tolmetin sodium cap 400 mg
$0(1)
Antimigraine Agents
butalbital-acetaminophen-caff w/ cod cap
50-300-40-30 mg#
$0(2)
$0(2)
PA, QL (180
capsules/30 days)
50-325-40-30 mg#
$0(2)
PA, QL (180
capsules/30 days)
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg#
$0(2)
PA, QL (180
capsules/30 days)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
MIGERGOT - ergotamine w/ caffeine suppos 2-100 mg
$0(2)
MIGRANAL - dihydroergotamine mesylate nasal spray
4 mg/ml
naratriptan hcl tab 1 mg
$0(1)
$0(1)
naratriptan hcl tab 2.5 mg
$0(1)
propranolol hcl cap sr 24hr 60 mg
$0(1)
$0(1)
$0(1)
$0(1)
propranolol hcl inj 1 mg/ml
$0(1)
propranolol hcl tab 10 mg
$0(1)
ST
Drugs section.
29
2016
Name of Drug
Necessary actions,
$0(1)
$0(1)
$0(1)
$0(1)
rizatriptan benzoate orally disintegrating tab 5 mg
$0(1)
rizatriptan benzoate orally disintegrating tab 10 mg
$0(1)
rizatriptan benzoate tab 5 mg
$0(1)
rizatriptan benzoate tab 10 mg
$0(1)
sumatriptan nasal spray 5 mg/act
$0(1)
QL (12 units (2
packages)/30 days)
sumatriptan nasal spray 20 mg/act
$0(1)
QL (12 units (2
packages)/30 days)
SUMATRIPTAN SUCCINATE - sumatriptan succinate
solution prefilled syringe 6 mg/0.5ml
sumatriptan succinate inj 6 mg/0.5ml
$0(1)
sumatriptan succinate solution auto-injector 4 mg/0.5ml
$0(1)
sumatriptan succinate solution auto-injector 6 mg/0.5ml
$0(1)
sumatriptan succinate solution cartridge 4 mg/0.5ml
$0(1)
sumatriptan succinate solution cartridge 6 mg/0.5ml
$0(1)
sumatriptan succinate tab 25 mg
$0(1)
$0(1)
$0(1)
TIMOLOL MALEATE - timolol maleate tab 5 mg
$0(2)
$0(2)
$0(2)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
Antimyasthenic Agents
GUANIDINE HCL - guanidine hcl tab 125 mg
$0(1)
MESTINON - pyridostigmine bromide syrup 60 mg/5ml
$0(2)
MESTINON TIMESPAN - pyridostigmine bromide tab cr
180 mg
pyridostigmine bromide tab cr 180 mg
$0(1)
pyridostigmine bromide tab 60 mg
$0(1)
$0(1)
$0(2)
$0(1)
Drugs section.
30
2016
Name of Drug
Antimycobacterials
CAPASTAT SULFATE - capreomycin sulfate for inj 1 gm
Necessary actions,
$0(2)
CYCLOSERINE - cycloserine cap 250 mg
$0(2)
dapsone tab 25 mg
$0(1)
dapsone tab 100 mg
$0(1)
ethambutol hcl tab 100 mg
$0(1)
ethambutol hcl tab 400 mg
$0(1)
ISONIAZID - isoniazid inj 100 mg/ml
$0(2)
isoniazid tab 100 mg
$0(1)
isoniazid tab 300 mg
$0(1)
PASER - aminosalicylic acid cr granules packet 4 gm
$0(2)
PRIFTIN - rifapentine tab 150 mg
$0(2)
pyrazinamide tab 500 mg
$0(1)
rifabutin cap 150 mg
$0(1)
rifampin cap 150 mg
$0(1)
rifampin cap 300 mg
$0(1)
rifampin for inj 600 mg
$0(1)
SIRTURO - bedaquiline fumarate tab 100 mg
$0(2)
TRECATOR - ethionamide tab 250 mg
Antineoplastics
ABRAXANE - paclitaxel protein-bound particles for iv susp
100 mg
AFINITOR - everolimus tab 2.5 mg
$0(2)
$0(2)
AFINITOR - everolimus tab 5 mg
$0(2)
AFINITOR - everolimus tab 7.5 mg
$0(2)
AFINITOR - everolimus tab 10 mg
$0(2)
AFINITOR DISPERZ - everolimus tab for oral susp 2 mg
$0(2)
$0(2)
$0(2)
ALECENSA - alectinib hcl cap 150 mg
$0(2)
ALIMTA - pemetrexed disodium for iv soln 100 mg
$0(2)
ALIMTA - pemetrexed disodium for iv soln 500 mg
$0(2)
amifostine crystalline for inj 500 mg
$0(1)
anastrozole tab 1 mg
$0(1)
ARRANON - nelarabine iv soln 5 mg/ml
$0(2)
ARZERRA - ofatumumab conc for iv infusion 100 mg/5ml*
$0(2)
ARZERRA - ofatumumab conc for iv infusion
1000 mg/50ml*
$0(2)
$0(2)
PA, QL (240
capsules/30 days)
Drugs section.
31
2016
Name of Drug
AVASTIN - bevacizumab iv soln 100 mg/4ml (for infusion)*
Necessary actions,
$0(2)
AVASTIN - bevacizumab iv soln 400 mg/16ml (for infusion)*
$0(2)
azacitidine for inj 100 mg
$0(1)
BELEODAQ - belinostat for iv inj 500 mg*
$0(2)
BENDEKA - bendamustine hcl iv soln 100 mg/4ml (25 mg/
ml)
bexarotene cap 75 mg
$0(2)
bicalutamide tab 50 mg
$0(1)
BICNU - carmustine for inj 100 mg
$0(2)
BLEO 15K - bleomycin sulf for inj 15 usp unit(15000
international unit)
bleomycin sulfate for inj 15 unit
$0(2)
BD
$0(1)
BD
bleomycin sulfate for inj 30 unit
$0(1)
BD
BLINCYTO - blinatumomab for iv infusion 35 mcg*
$0(2)
BOSULIF - bosutinib tab 100 mg
$0(2)
BOSULIF - bosutinib tab 500 mg
$0(2)
BUSULFEX - busulfan inj 6 mg/ml
$0(2)
CABOMETYX - cabozantinib s-malate tab 20 mg
$0(2)
$0(2)
$0(2)
CAPRELSA - vandetanib tab 100 mg*
$0(2)
CAPRELSA - vandetanib tab 300 mg*
$0(2)
carboplatin iv soln 50 mg/5ml
$0(1)
$0(1)
$0(1)
$0(1)
CISPLATIN - cisplatin inj 200 mg/200ml (1 mg/ml)
$0(1)
cisplatin inj 50 mg/50ml (1 mg/ml)
$0(1)
cisplatin inj 100 mg/100ml (1 mg/ml)
$0(1)
cladribine iv soln 10 mg/10ml (1 mg/ml)
$0(1)
CLOLAR - clofarabine iv soln 1 mg/ml
$0(2)
COMETRIQ - cabozantinib s-malate cap 3 x 20 mg (60 mg
dose) kit*
COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 1 x
20 mg (100 dose) kit*
COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 3 x
20 mg (140 dose) kit*
$0(2)
$0(2)
COSMEGEN - dactinomycin for inj 0.5 mg
$0(2)
COTELLIC - cobimetinib fumarate tab 20 mg*
$0(2)
$0(1)
$0(2)
PA
BD
PA, QL (112
capsules/28 days)
Drugs section.
32
2016
Name of Drug
CYCLOPHOSPHAMIDE - cyclophosphamide cap 25 mg
Necessary actions,
$0(2)
BD
CYCLOPHOSPHAMIDE - cyclophosphamide cap 50 mg
$0(2)
BD
cyclophosphamide for inj 500 mg
$0(1)
cyclophosphamide for inj 1 gm
$0(1)
cyclophosphamide for inj 2 gm
$0(1)
CYRAMZA - ramucirumab iv soln 100 mg/10ml (for
infusion)*
CYRAMZA - ramucirumab iv soln 500 mg/50ml (for
infusion)*
cytarabine inj pf 20 mg/ml
$0(2)
$0(1)
BD
cytarabine inj pf 100 mg/ml
$0(1)
BD
cytarabine inj 20 mg/ml
$0(1)
BD
DACARBAZINE - dacarbazine for inj 100 mg
$0(2)
dacarbazine for inj 200 mg
$0(1)
DARZALEX - daratumumab iv soln 100 mg/5ml*
$0(2)
DARZALEX - daratumumab iv soln 400 mg/20ml*
$0(2)
daunorubicin hcl inj 5 mg/ml
$0(1)
DAUNOXOME - daunorubicin citrate liposome inj 2 mg/ml
$0(2)
decitabine for inj 50 mg
$0(1)
dexrazoxane for inj 250 mg
$0(1)
dexrazoxane for inj 500 mg
$0(1)
DOCEFREZ - docetaxel for inj 20 mg
$0(2)
DOCETAXEL - docetaxel for inj conc 20 mg/ml
$0(2)
DOCETAXEL - docetaxel for inj conc 80 mg/4ml (20 mg/ml)
$0(2)
DOCETAXEL - docetaxel for inj conc 140 mg/7ml (20 mg/
ml)
DOCETAXEL - docetaxel for inj conc 160 mg/8ml (20 mg/
ml)
DOCETAXEL - docetaxel soln for iv infusion 20 mg/2ml
$0(2)
$0(2)
$0(2)
$0(2)
docetaxel for inj conc 20 mg/ml
$0(1)
docetaxel for inj conc 80 mg/4ml (20 mg/ml)
$0(1)
doxorubicin hcl for inj 10 mg
$0(1)
BD
doxorubicin hcl for inj 50 mg
$0(1)
BD
doxorubicin hcl inj 2 mg/ml
$0(1)
BD
doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml
$0(1)
BD
ELITEK - rasburicase for iv soln 1.5 mg
$0(2)
$0(2)
$0(2)
$0(2)
Drugs section.
33
2016
Name of Drug
ELITEK - rasburicase for iv soln 7.5 mg
Necessary actions,
$0(2)
EMCYT - estramustine phosphate sodium cap 140 mg
$0(2)
EMPLICITI - elotuzumab for iv soln 300 mg
$0(2)
EMPLICITI - elotuzumab for iv soln 400 mg
$0(2)
epirubicin hcl iv soln 50 mg/25ml (2 mg/ml)
$0(1)
epirubicin hcl iv soln 200 mg/100ml (2 mg/ml)
$0(1)
ERBITUX - cetuximab iv soln 100 mg/50ml (2 mg/ml)
$0(2)
ERBITUX - cetuximab iv soln 200 mg/100ml (2 mg/ml)
$0(2)
ERIVEDGE - vismodegib cap 150 mg*
$0(2)
ERWINAZE - asparaginase erwinia chrysanthemi for inj
10000 unit
ETOPOPHOS - etoposide phosphate iv for inj 100 mg
$0(2)
etoposide inj 100 mg/5ml (20 mg/ml)
$0(1)
etoposide inj 500 mg/25ml (20 mg/ml)
$0(1)
etoposide inj 1 gm/50ml (20 mg/ml)
$0(1)
EVOMELA - melphalan hcl for inj 50 mg
$0(2)
exemestane tab 25 mg
$0(1)
FARESTON - toremifene citrate tab 60 mg
$0(2)
FARYDAK - panobinostat lactate cap 10 mg
$0(2)
$0(2)
$0(2)
FASLODEX - fulvestrant inj 250 mg/5ml
$0(2)
fludarabine phosphate for inj 50 mg
$0(1)
fludarabine phosphate inj 25 mg/ml
$0(1)
fluorouracil inj 500 mg/10ml (50 mg/ml)
$0(1)
BD
fluorouracil inj 1 gm/20ml (50 mg/ml)
$0(1)
BD
fluorouracil inj 2.5 gm/50ml (50 mg/ml)
$0(1)
BD
fluorouracil inj 5 gm/100ml (50 mg/ml)
$0(1)
BD
flutamide cap 125 mg
$0(1)
FOLOTYN - pralatrexate iv inj 20 mg/ml
$0(2)
FOLOTYN - pralatrexate iv inj 40 mg/2ml
$0(2)
GAZYVA - obinutuzumab soln for iv infusion 1000 mg/40ml
(25 mg/ml)
gemcitabine hcl for inj 200 mg
$0(2)
gemcitabine hcl for inj 1 gm
$0(1)
gemcitabine hcl for inj 2 gm
$0(1)
gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml)
$0(1)
gemcitabine hcl inj 1 gm/26.3ml (38 mg/ml)
$0(1)
$0(2)
$0(1)
Drugs section.
34
2016
Name of Drug
gemcitabine hcl inj 2 gm/52.6ml (38 mg/ml)
Necessary actions,
$0(1)
GILOTRIF - afatinib dimaleate tab 20 mg
$0(2)
$0(2)
$0(2)
GLEEVEC - imatinib mesylate tab 100 mg
$0(2)
GLEEVEC - imatinib mesylate tab 400 mg
$0(2)
GLEOSTINE - lomustine cap 5 mg
$0(2)
$0(2)
$0(2)
$0(2)
HALAVEN - eribulin mesylate inj 1 mg/2ml (0.5 mg/ml)
$0(2)
HERCEPTIN - trastuzumab for iv soln 440 mg*
$0(2)
HEXALEN - altretamine cap 50 mg
$0(2)
HYDROXYPROGESTERONE CAPROATE hydroxyprogesterone caproate im in oil 1.25 gm/5ml
hydroxyurea cap 500 mg
$0(2)
IBRANCE - palbociclib cap 75 mg
$0(2)
$0(2)
$0(2)
ICLUSIG - ponatinib hcl tab 15 mg
$0(2)
ICLUSIG - ponatinib hcl tab 45 mg
$0(2)
idarubicin hcl iv inj 5 mg/5ml (1 mg/ml)
$0(1)
$0(1)
$0(1)
IFEX - ifosfamide for inj 3 gm
$0(2)
IFOSFAMIDE - ifosfamide for inj 3 gm
$0(2)
ifosfamide for inj 1 gm
$0(1)
ifosfamide iv inj 1 gm/20ml (50 mg/ml)
$0(1)
ifosfamide iv inj 3 gm/60ml (50 mg/ml)
$0(1)
imatinib mesylate tab 100 mg
$0(1)
imatinib mesylate tab 400 mg
$0(1)
IMBRUVICA - ibrutinib cap 140 mg
$0(2)
IMLYGIC - talimogene laherparepvec intralesional inj
1000000 unit/ml
IMLYGIC - talimogene laherparepvec intralesional inj
100000000 unit/ml
INLYTA - axitinib tab 1 mg*
$0(2)
$0(2)
INLYTA - axitinib tab 5 mg*
$0(2)
PA
$0(1)
PA, QL (120
capsules/30 days)
$0(2)
Drugs section.
35
2016
Name of Drug
IRESSA - gefitinib tab 250 mg
Necessary actions,
$0(2)
IRINOTECAN - irinotecan hcl inj 500 mg/25ml (20 mg/ml)
$0(1)
irinotecan hcl inj 40 mg/2ml (20 mg/ml)
$0(1)
irinotecan hcl inj 100 mg/5ml (20 mg/ml)
$0(1)
ISTODAX - romidepsin for iv inj 10 mg
$0(2)
IXEMPRA KIT - ixabepilone for iv infusion 15 mg
$0(2)
IXEMPRA KIT - ixabepilone for iv infusion 45 mg
$0(2)
JAKAFI - ruxolitinib phosphate tab 5 mg*
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
JEVTANA - cabazitaxel inj 60 mg/1.5ml (for iv infusion)
$0(2)
KADCYLA - ado-trastuzumab emtansine for iv soln 100 mg
$0(2)
KADCYLA - ado-trastuzumab emtansine for iv soln 160 mg
$0(2)
KEYTRUDA - pembrolizumab iv soln 100 mg/4ml (25 mg/
ml)*
KEYTRUDA - pembrolizumab for iv soln 50 mg*
$0(2)
LENVIMA 10 MG DAILY DOSE - lenvatinib cap therapy
pack 10 mg
pack 10 & 4 mg
pack 10 & 4 (2) mg
pack 10 (2) mg
pack 10 (2) & 4 mg
LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack
4 (2) mg
letrozole tab 2.5 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
LEUCOVORIN CALCIUM - leucovorin calcium tab 10 mg
$0(2)
LEUCOVORIN CALCIUM - leucovorin calcium tab 15 mg
$0(2)
LEUCOVORIN CALCIUM - leucovorin calcium for inj 50 mg
$0(2)
LEUCOVORIN CALCIUM - leucovorin calcium for inj
500 mg
leucovorin calcium for inj 100 mg
$0(2)
$0(1)
$0(1)
leucovorin calcium tab 5 mg
$0(1)
$0(2)
$0(1)
$0(1)
Drugs section.
36
2016
Name of Drug
leucovorin calcium tab 25 mg
Necessary actions,
$0(1)
LEUKERAN - chlorambucil tab 2 mg
$0(1)
LONSURF - trifluridine-tipiracil tab 15-6.14 mg
$0(2)
LONSURF - trifluridine-tipiracil tab 20-8.19 mg
$0(2)
LYNPARZA - olaparib cap 50 mg
$0(2)
MARQIBO - vincristine sulfate liposome iv susp 5 mg/31ml
(0.16 mg/ml)
MATULANE - procarbazine hcl cap 50 mg*
$0(2)
$0(2)
PA
MEKINIST - trametinib dimethyl sulfoxide tab 0.5 mg
$0(2)
MEKINIST - trametinib dimethyl sulfoxide tab 2 mg
$0(2)
melphalan hcl for inj 50 mg
$0(1)
mercaptopurine tab 50 mg
$0(1)
mesna inj 100 mg/ml
$0(1)
MESNEX - mesna tab 400 mg
$0(2)
methotrexate sodium for inj 1 gm
$0(1)
methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
methotrexate sodium inj 250 mg/10ml (25 mg/ml)
$0(1)
$0(1)
methotrexate sodium tab 2.5 mg
$0(1)
MITOMYCIN - mitomycin for iv soln 5 mg
$0(2)
mitomycin for iv soln 20 mg
$0(1)
mitomycin for iv soln 40 mg
$0(1)
mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml)
$0(1)
mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml)
$0(1)
$0(1)
MUSTARGEN - mechlorethamine hcl for inj 10 mg
$0(2)
NEXAVAR - sorafenib tosylate tab 200 mg*
$0(2)
NILANDRON - nilutamide tab 150 mg
$0(2)
nilutamide tab 150 mg
$0(1)
NINLARO - ixazomib citrate cap 2.3 mg
$0(2)
NINLARO - ixazomib citrate cap 3 mg
$0(2)
NINLARO - ixazomib citrate cap 4 mg
$0(2)
NIPENT - pentostatin for inj 10 mg
$0(2)
PA, QL (480
capsules/30 days)
Drugs section.
37
2016
Name of Drug
ODOMZO - sonidegib phosphate cap 200 mg*
Necessary actions,
$0(2)
ONCASPAR - pegaspargase inj 750 unit/ml
$0(2)
OPDIVO - nivolumab iv soln 40 mg/4ml
$0(2)
OPDIVO - nivolumab iv soln 100 mg/10ml
$0(2)
oxaliplatin for iv inj 50 mg
$0(1)
oxaliplatin for iv inj 100 mg
$0(1)
oxaliplatin iv soln 50 mg/10ml
$0(1)
oxaliplatin iv soln 100 mg/20ml
$0(1)
paclitaxel iv conc 30 mg/5ml (6 mg/ml)
$0(1)
paclitaxel iv conc 100 mg/16.7ml (6 mg/ml)
$0(1)
paclitaxel iv conc 300 mg/50ml (6 mg/ml)
$0(1)
PANRETIN - alitretinoin gel 0.1%
$0(2)
PERJETA - pertuzumab soln for iv infusion 420 mg/14ml
(30 mg/ml)*
POMALYST - pomalidomide cap 1 mg*
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
PORTRAZZA - necitumumab iv soln 800 mg/50ml (16 mg/
ml)
PROLEUKIN - aldesleukin for iv soln 22000000 unit
$0(2)
PURIXAN - mercaptopurine susp 2000 mg/100ml (20 mg/
ml)*
REVLIMID - lenalidomide caps 2.5 mg*
$0(2)
$0(2)
REVLIMID - lenalidomide cap 5 mg*
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
RITUXAN - rituximab iv soln 100 mg/10ml*
$0(2)
PA
RITUXAN - rituximab iv soln 500 mg/50ml*
$0(2)
PA
SOLTAMOX - tamoxifen citrate oral soln 10 mg/5ml
$0(2)
SPRYCEL - dasatinib tab 20 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
STIVARGA - regorafenib tab 40 mg*
$0(2)
$0(2)
Drugs section.
38
2016
Name of Drug
SUTENT - sunitinib malate cap 12.5 mg
Necessary actions,
$0(2)
SUTENT - sunitinib malate cap 25 mg
$0(2)
SUTENT - sunitinib malate cap 37.5 mg
$0(2)
SUTENT - sunitinib malate cap 50 mg
$0(2)
SYLATRON - peginterferon alfa-2b for inj kit 200 mcg
$0(2)
PA
$0(2)
PA
$0(2)
PA
SYLATRON - peginterferon alfa-2b for inj kit 4 x 200 mcg
$0(2)
PA
$0(2)
PA
SYLVANT - siltuximab for iv infusion 100 mg
$0(2)
SYLVANT - siltuximab for iv infusion 400 mg
$0(2)
SYNRIBO - omacetaxine mepesuccinate for inj 3.5 mg
$0(2)
TABLOID - thioguanine tab 40 mg
$0(2)
TAFINLAR - dabrafenib mesylate cap 50 mg
$0(2)
PA, QL (120
capsules/30 days)
TAFINLAR - dabrafenib mesylate cap 75 mg
$0(2)
PA, QL (120
capsules/30 days)
TAGRISSO - osimertinib mesylate tab 40 mg*
$0(2)
TAGRISSO - osimertinib mesylate tab 80 mg*
$0(2)
tamoxifen citrate tab 10 mg
$0(1)
tamoxifen citrate tab 20 mg
$0(1)
TARCEVA - erlotinib hcl tab 25 mg
$0(2)
$0(2)
$0(2)
TARGRETIN - bexarotene cap 75 mg
$0(2)
PA
TARGRETIN - bexarotene gel 1%
$0(2)
TASIGNA - nilotinib hcl cap 150 mg
$0(2)
PA, QL (120
capsules/30 days)
TASIGNA - nilotinib hcl cap 200 mg
$0(2)
PA, QL (120
capsules/30 days)
TAXOTERE - docetaxel for inj conc 20 mg/ml
$0(2)
TAXOTERE - docetaxel for inj conc 80 mg/4ml (20 mg/ml)
$0(2)
TECENTRIQ - atezolizumab iv soln 1200 mg/20ml
$0(2)
TEMODAR - temozolomide for iv soln 100 mg
$0(2)
THALOMID - thalidomide cap 50 mg
$0(2)
$0(2)
$0(2)
$0(2)
Drugs section.
39
2016
Name of Drug
THIOTEPA - thiotepa for inj 15 mg
Necessary actions,
$0(2)
TOPOTECAN HCL - topotecan hcl inj 4 mg/4ml (for
infusion)
topotecan hcl for inj 4 mg
$0(2)
TORISEL - temsirolimus soln for iv infusion 25 mg/ml
$0(2)
TREANDA - bendamustine hcl iv soln 180 mg/2ml (90 mg/
ml)
TREANDA - bendamustine hcl for iv soln 25 mg
$0(2)
TREANDA - bendamustine hcl for iv soln 100 mg
$0(2)
tretinoin cap 10 mg
$0(1)
TRISENOX - arsenic trioxide inj 10 mg/10ml (1 mg/ml)
$0(2)
TYKERB - lapatinib ditosylate tab 250 mg*
$0(2)
UNITUXIN - dinutuximab iv soln 17.5 mg/5ml (3.5 mg/ml)
$0(2)
UVADEX - methoxsalen soln 20 mcg/ml
$0(2)
VECTIBIX - panitumumab iv soln 100 mg/5ml
$0(2)
VECTIBIX - panitumumab iv soln 400 mg/20ml
$0(2)
VELCADE - bortezomib for inj 3.5 mg
$0(2)
VENCLEXTA - venetoclax tab 10 mg
$0(2)
$0(2)
$0(2)
VENCLEXTA STARTING PACK - venetoclax tab therapy
starter pack 10 & 50 & 100 mg
$0(2)
PA, QL (1 pack (42
tablets)/28 days)
VINBLASTINE SULFATE - vinblastine sulfate inj 1 mg/ml
$0(2)
BD
vincristine sulfate iv soln 1 mg/ml
$0(1)
vinorelbine tartrate inj 10 mg/ml
$0(1)
vinorelbine tartrate inj 50 mg/5ml (10 mg/ml)
$0(1)
VOTRIENT - pazopanib hcl tab 200 mg*
$0(2)
XALKORI - crizotinib cap 200 mg*
$0(2)
XALKORI - crizotinib cap 250 mg*
$0(2)
XTANDI - enzalutamide cap 40 mg*
$0(2)
YERVOY - ipilimumab soln for iv infusion 50 mg/10ml
(5 mg/ml)*
YERVOY - ipilimumab soln for iv infusion 200 mg/40ml
(5 mg/ml)*
YONDELIS - trabectedin for inj 1 mg
$0(2)
ZALTRAP - ziv-aflibercept iv soln 100 mg/4ml (for infusion)
$0(2)
ZALTRAP - ziv-aflibercept iv soln 200 mg/8ml (for infusion)
$0(2)
ZANOSAR - streptozocin for inj 1 gm
$0(2)
$0(1)
$0(2)
PA
PA, QL (120
capsules/30 days)
$0(2)
$0(2)
Drugs section.
40
2016
Name of Drug
ZELBORAF - vemurafenib tab 240 mg*
Necessary actions,
$0(2)
ZOLINZA - vorinostat cap 100 mg
$0(2)
PA, QL (120
capsules/30 days)
ZYDELIG - idelalisib tab 100 mg*
$0(2)
ZYDELIG - idelalisib tab 150 mg*
$0(2)
ZYKADIA - ceritinib cap 150 mg*
$0(2)
ZYTIGA - abiraterone acetate tab 250 mg*
Antiparasitics
ALBENZA - albendazole tab 200 mg
$0(2)
ALINIA - nitazoxanide tab 500 mg
$0(2)
ALINIA - nitazoxanide for susp 100 mg/5ml
$0(2)
atovaquone susp 750 mg/5ml
$0(1)
atovaquone-proguanil hcl tab 62.5-25 mg
$0(1)
atovaquone-proguanil hcl tab 250-100 mg
$0(1)
BILTRICIDE - praziquantel tab 600 mg
$0(2)
chloroquine phosphate tab 250 mg
$0(1)
chloroquine phosphate tab 500 mg
$0(1)
COARTEM - artemether-lumefantrine tab 20-120 mg
$0(2)
DARAPRIM - pyrimethamine tab 25 mg
$0(2)
hydroxychloroquine sulfate tab 200 mg
$0(1)
ivermectin tab 3 mg
$0(1)
lindane shampoo 1%
$0(1)
malathion lotion 0.5%
$0(1)
mefloquine hcl tab 250 mg
$0(1)
NEBUPENT - pentamidine isethionate for nebulization soln
300 mg
PENTAM 300 - pentamidine isethionate for soln 300 mg
$0(2)
BD
$0(2)
BD
permethrin cream 5%
$0(1)
permethrin creme rinse 1%
$0(3)
MC
permethrin lotion 1%
$0(3)
MC
PRIMAQUINE PHOSPHATE - primaquine phosphate tab
26.3 mg
Antiparkinson Agents
ALER-DRYL - diphenhydramine hcl tab 50 mg
$0(2)
AMANTADINE HCL - amantadine hcl tab 100 mg
$0(2)
amantadine hcl cap 100 mg
$0(1)
amantadine hcl syrup 50 mg/5ml
$0(1)
APOKYN - apomorphine hydrochloride inj 10 mg/ml*
$0(2)
PA, QL (150
capsules/30 days)
$0(2)
$0(3)
MC
Drugs section.
41
2016
Name of Drug
AZILECT - rasagiline mesylate tab 0.5 mg
Necessary actions,
$0(1)
AZILECT - rasagiline mesylate tab 1 mg
$0(1)
chew tab 12.5 mg
liquid 12.5 mg/5ml
benztropine mesylate tab 0.5 mg#
$0(3)
MC
$0(3)
MC
$0(2)
PA
benztropine mesylate tab 1 mg#
$0(2)
PA
benztropine mesylate tab 2 mg#
$0(2)
PA
bromocriptine mesylate cap 5 mg
$0(1)
bromocriptine mesylate tab 2.5 mg
$0(1)
carbidopa & levodopa orally disintegrating tab 10-100 mg
$0(1)
$0(1)
$0(1)
carbidopa & levodopa tab cr 25-100 mg
$0(1)
carbidopa & levodopa tab cr 50-200 mg
$0(1)
carbidopa & levodopa tab 10-100 mg
$0(1)
$0(1)
$0(1)
carbidopa tab 25 mg
$0(1)
CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopalevodopa-entacapone tabs 12.5-50-200 mg
CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopalevodopa-entacapone tabs 25-100-200 mg
CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopalevodopa-entacapone tabs 50-200-200 mg
diphenhydramine hcl cap 25 mg#
$0(1)
diphenhydramine hcl inj 50 mg/ml
$0(1)
diphenhydramine hcl tab 25 mg
$0(3)
entacapone tab 200 mg
$0(1)
NEUPRO - rotigotine td patch 24hr 1 mg/24hr
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(3)
MC
MC
Drugs section.
42
2016
Name of Drug
Necessary actions,
$0(1)
$0(1)
NUPLAZID - pimavanserin tartrate tab 17 mg
$0(2)
pramipexole dihydrochloride tab 0.125 mg
$0(1)
$0(1)
$0(1)
$0(1)
pramipexole dihydrochloride tab 1 mg
$0(1)
$0(1)
ropinirole hydrochloride tab 0.25 mg
$0(1)
ropinirole hydrochloride tab 0.5 mg
$0(1)
ropinirole hydrochloride tab 1 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
selegiline hcl cap 5 mg
$0(1)
selegiline hcl tab 5 mg
$0(1)
tolcapone tab 100 mg
Antipsychotics
susp 300 mg
$0(1)
$0(2)
PA, QL (1 syringe
or vial/30 days)
susp 400 mg
$0(2)
PA, QL (1 syringe
or vial/30 days)
ADASUVE - loxapine aerosol powder breath activated
10 mg
$0(2)
PA
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
CHLORPROMAZINE HCL - chlorpromazine hcl inj 25 mg/
ml
CHLORPROMAZINE HCL - chlorpromazine hcl inj
50 mg/2ml
$0(2)
PA
$0(2)
PA
Drugs section.
43
2016
Name of Drug
Necessary actions,
$0(1)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
clozapine orally disintegrating tab 25 mg
$0(1)
clozapine orally disintegrating tab 100 mg
$0(1)
clozapine tab 25 mg
$0(1)
clozapine tab 50 mg
$0(1)
clozapine tab 100 mg
$0(1)
clozapine tab 200 mg
$0(1)
FANAPT - iloperidone tab 1 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
FANAPT TITRATION PACK - iloperidone tab 1 mg & 2 mg
& 4 mg & 6 mg titration pak
$0(2)
PA, QL (7 packs (56
tablets)/28 days)
FAZACLO - clozapine orally disintegrating tab 12.5 mg
$0(2)
FAZACLO - clozapine orally disintegrating tab 25 mg
$0(2)
$0(2)
$0(2)
$0(2)
fluphenazine decanoate inj 25 mg/ml
$0(1)
PA
FLUPHENAZINE HCL - fluphenazine hcl elixir 2.5 mg/5ml
$0(2)
PA
FLUPHENAZINE HCL - fluphenazine hcl oral conc 5 mg/ml
$0(2)
PA
FLUPHENAZINE HCL - fluphenazine hcl inj 2.5 mg/ml
$0(2)
PA
fluphenazine hcl tab 1 mg
$0(1)
PA
fluphenazine hcl tab 2.5 mg
$0(1)
PA
$0(1)
PA
$0(1)
PA
GEODON - ziprasidone mesylate for inj 20 mg
$0(2)
PA, QL (60 vials/30 days)
haloperidol decanoate im soln 50 mg/ml
$0(1)
PA
haloperidol decanoate im soln 100 mg/ml
$0(1)
PA
haloperidol lactate inj 5 mg/ml
$0(1)
PA
haloperidol lactate oral conc 2 mg/ml
$0(1)
PA
Drugs section.
44
2016
Name of Drug
haloperidol tab 0.5 mg
Necessary actions,
$0(1)
PA
haloperidol tab 1 mg
$0(1)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
INVEGA - paliperidone tab sr 24hr 1.5 mg
$0(2)
INVEGA - paliperidone tab sr 24hr 3 mg
$0(2)
$0(2)
$0(2)
INVEGA SUSTENNA - paliperidone palmitate im extendedrelease susp 39 mg/0.25ml
INVEGA SUSTENNA - paliperidone palmitate im extendrelease susp 117 mg/0.75ml
INVEGA SUSTENNA - paliperidone palmitate im extendedrelease susp 156 mg/ml
INVEGA TRINZA - paliperidone palmitate im extendrelease susp 273 mg/0.875ml
LATUDA - lurasidone hcl tab 20 mg
$0(2)
PA, QL (1 kit/30 days)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
loxapine succinate cap 5 mg
$0(1)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
MOLINDONE HYDROCHLORIDE - molindone hcl tab 5 mg
$0(2)
PA
MOLINDONE HYDROCHLORIDE - molindone hcl tab
10 mg
$0(2)
PA
Drugs section.
45
2016
Name of Drug
MOLINDONE HYDROCHLORIDE - molindone hcl tab
25 mg
NUPLAZID - pimavanserin tartrate tab 17 mg
Necessary actions,
$0(2)
PA
$0(2)
olanzapine for im inj 10 mg
$0(1)
olanzapine orally disintegrating tab 5 mg
$0(1)
$0(1)
$0(1)
$0(1)
olanzapine tab 2.5 mg
$0(1)
olanzapine tab 5 mg
$0(1)
$0(1)
olanzapine tab 10 mg
$0(1)
$0(1)
$0(1)
ORAP - pimozide tab 1 mg
$0(2)
ORAP - pimozide tab 2 mg
$0(2)
paliperidone tab sr 24hr 1.5 mg
$0(1)
paliperidone tab sr 24hr 3 mg
$0(1)
$0(1)
$0(1)
$0(1)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
pimozide tab 1 mg
$0(1)
pimozide tab 2 mg
$0(1)
prochlorperazine edisylate inj 5 mg/ml
$0(1)
$0(1)
$0(1)
prochlorperazine suppos 25 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(2)
$0(2)
Drugs section.
46
2016
Name of Drug
Necessary actions,
$0(2)
$0(2)
$0(2)
$0(2)
RISPERDAL CONSTA - risperidone microspheres for inj
12.5 mg
25 mg
37.5 mg
50 mg
risperidone orally disintegrating tab 0.25 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(1)
$0(1)
risperidone orally disintegrating tab 1 mg
$0(1)
$0(1)
$0(1)
$0(1)
risperidone soln 1 mg/ml
$0(1)
risperidone tab 0.25 mg
$0(1)
$0(1)
risperidone tab 1 mg
$0(1)
$0(1)
$0(1)
$0(1)
SAPHRIS - asenapine maleate sl tab 2.5 mg
$0(2)
SAPHRIS - asenapine maleate sl tab 5 mg
$0(2)
SAPHRIS - asenapine maleate sl tab 10 mg
$0(2)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
thioridazine hcl tab 10 mg#
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
thiothixene cap 1 mg
$0(1)
PA
$0(1)
PA
Drugs section.
47
2016
Name of Drug
Necessary actions,
$0(1)
PA
$0(1)
PA
trifluoperazine hcl tab 1 mg
$0(1)
PA
$0(1)
PA
$0(1)
PA
$0(1)
PA
VERSACLOZ - clozapine susp 50 mg/ml
$0(2)
VRAYLAR - cariprazine hcl cap therapy pack 1.5 mg (1) &
3 mg (6)
VRAYLAR - cariprazine hcl cap 1.5 mg
$0(2)
$0(2)
VRAYLAR - cariprazine hcl cap 3 mg
$0(2)
$0(2)
$0(2)
ziprasidone hcl cap 20 mg
$0(1)
$0(1)
$0(1)
$0(1)
ZYPREXA RELPREVV - olanzapine pamoate for extended
rel im susp 210 mg
rel im susp 300 mg
rel im susp 405 mg
Antispasticity Agents
baclofen tab 10 mg
$0(2)
$0(2)
$0(2)
PA, QL (1 vial/28 days)
baclofen tab 20 mg
$0(1)
dantrolene sodium cap 25 mg
$0(1)
$0(1)
$0(1)
tizanidine hcl cap 2 mg
$0(1)
$0(1)
$0(1)
tizanidine hcl tab 2 mg
$0(1)
tizanidine hcl tab 4 mg
Antivirals
abacavir sulfate tab 300 mg
$0(1)
$0(1)
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg
acyclovir cap 200 mg
$0(1)
$0(1)
$0(1)
Drugs section.
48
2016
Name of Drug
acyclovir sodium for inj 500 mg
Necessary actions,
$0(1)
BD
acyclovir sodium iv soln 50 mg/ml
$0(1)
BD
acyclovir susp 200 mg/5ml
$0(1)
acyclovir tab 400 mg
$0(1)
acyclovir tab 800 mg
$0(1)
adefovir dipivoxil tab 10 mg
$0(1)
AMANTADINE HCL - amantadine hcl tab 100 mg
$0(2)
amantadine hcl cap 100 mg
$0(1)
amantadine hcl syrup 50 mg/5ml
$0(1)
APTIVUS - tipranavir cap 250 mg
$0(2)
APTIVUS - tipranavir oral soln 100 mg/ml
$0(2)
ATRIPLA - efavirenz-emtricitabine-tenofovir df tab
600-200-300 mg
BARACLUDE - entecavir oral soln 0.05 mg/ml
$0(2)
cidofovir iv inj 75 mg/ml
$0(1)
COMPLERA - emtricitabine-rilpivirine-tenofovir df tab
200-25-300 mg
CRIXIVAN - indinavir sulfate cap 200 mg
$0(2)
$0(1)
CRIXIVAN - indinavir sulfate cap 400 mg
$0(1)
DAKLINZA - daclatasvir dihydrochloride tab 30 mg
$0(2)
PA
$0(2)
PA
$0(2)
PA
didanosine delayed release capsule 125 mg
$0(1)
$0(1)
$0(1)
$0(1)
EDURANT - rilpivirine hcl tab 25 mg
$0(2)
EMTRIVA - emtricitabine caps 200 mg
$0(2)
EMTRIVA - emtricitabine soln 10 mg/ml
$0(2)
entecavir tab 0.5 mg
$0(1)
entecavir tab 1 mg
$0(1)
EPIVIR HBV - lamivudine oral soln 5 mg/ml (hbv)
$0(1)
EPZICOM - abacavir sulfate-lamivudine tab 600-300 mg
$0(2)
EVOTAZ - atazanavir sulfate-cobicistat tab 300-150 mg
$0(2)
famciclovir tab 125 mg
$0(1)
$0(1)
$0(1)
FUZEON - enfuvirtide for inj 90 mg
$0(2)
$0(2)
QL (60 vials/30 days)
Drugs section.
49
2016
Name of Drug
ganciclovir sodium for inj 500 mg
Necessary actions,
$0(1)
BD
GENVOYA - elvitegrav-cobic-emtricitab-tenofov af tab
150-150-200-10 mg
HARVONI - ledipasvir-sofosbuvir tab 90-400 mg
$0(2)
$0(2)
PA
INTELENCE - etravirine tab 25 mg
$0(2)
$0(2)
$0(2)
INTRON A - interferon alfa-2b inj 6000000 unit/ml
$0(2)
INTRON A - interferon alfa-2b inj 10000000 unit/ml
$0(2)
INTRON A - interferon alfa-2b for inj 10000000 unit
$0(2)
$0(2)
$0(2)
INTRON A W/DILUENT - interferon alfa-2b for inj
10000000 unit
18000000 unit
50000000 unit
INVIRASE - saquinavir mesylate cap 200 mg
$0(2)
$0(2)
INVIRASE - saquinavir mesylate tab 500 mg
$0(2)
ISENTRESS - raltegravir potassium tab 400 mg
$0(2)
ISENTRESS - raltegravir potassium packet for susp
100 mg
ISENTRESS - raltegravir potassium chew tab 25 mg
$0(2)
QL (60 packets/30 days)
$0(1)
ISENTRESS - raltegravir potassium chew tab 100 mg
$0(1)
KALETRA - lopinavir-ritonavir soln 400-100 mg/5ml
(80-20 mg/ml)
KALETRA - lopinavir-ritonavir tab 100-25 mg
$0(2)
$0(2)
KALETRA - lopinavir-ritonavir tab 200-50 mg
$0(2)
lamivudine oral soln 10 mg/ml
$0(1)
lamivudine tab 100 mg (hbv)
$0(1)
lamivudine tab 150 mg
$0(1)
lamivudine tab 300 mg
$0(1)
lamivudine-zidovudine tab 150-300 mg
$0(1)
LEXIVA - fosamprenavir calcium tab 700 mg
$0(2)
LEXIVA - fosamprenavir calcium susp 50 mg/ml
$0(2)
NEVIRAPINE - nevirapine susp 50 mg/5ml
$0(2)
nevirapine tab sr 24hr 100 mg
$0(1)
nevirapine tab sr 24hr 400 mg
$0(1)
$0(2)
$0(2)
Drugs section.
50
2016
Name of Drug
nevirapine tab 200 mg
Necessary actions,
$0(1)
NORVIR - ritonavir cap 100 mg
$0(2)
NORVIR - ritonavir tab 100 mg
$0(2)
NORVIR - ritonavir oral soln 80 mg/ml
$0(2)
OLYSIO - simeprevir sodium cap 150 mg
$0(2)
PA
PEG-INTRON - peginterferon alfa-2b for inj kit
50 mcg/0.5ml
80 mcg/0.5ml
120 mcg/0.5ml
150 mcg/0.5ml
PEG-INTRON REDIPEN - peginterferon alfa-2b for inj kit
50 mcg/0.5ml
80 mcg/0.5ml
120 mcg/0.5ml
150 mcg/0.5ml
PEG-INTRON REDIPEN PAK 4 - peginterferon alfa-2b for
inj kit 50 mcg/0.5ml
PEGASYS - peginterferon alfa-2a inj 180 mcg/ml
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
PEGASYS - peginterferon alfa-2a inj 180 mcg/0.5ml
$0(2)
PA
PEGASYS PROCLICK - peginterferon alfa-2a inj
135 mcg/0.5ml
PEGASYS PROCLICK - peginterferon alfa-2a inj
180 mcg/0.5ml
PREZCOBIX - darunavir-cobicistat tab 800-150 mg
$0(2)
PA
$0(2)
PA
$0(2)
PREZISTA - darunavir ethanolate susp 100 mg/ml
$0(2)
PREZISTA - darunavir ethanolate tab 75 mg
$0(2)
$0(2)
$0(2)
$0(2)
REBETOL - ribavirin soln 40 mg/ml
$0(2)
Drugs section.
51
2016
Name of Drug
RESCRIPTOR - delavirdine mesylate tab 100 mg
Necessary actions,
$0(2)
RESCRIPTOR - delavirdine mesylate tab 200 mg
$0(2)
RETROVIR IV INFUSION - zidovudine iv soln 10 mg/ml
$0(2)
REYATAZ - atazanavir sulfate oral powder packet 50 mg
$0(2)
REYATAZ - atazanavir sulfate cap 150 mg
$0(2)
$0(2)
$0(2)
RIBASPHERE - ribavirin tab 400 mg
$0(2)
RIBASPHERE - ribavirin tab 600 mg
$0(2)
RIBASPHERE RIBAPAK - ribavirin tab 400 mg
$0(2)
RIBASPHERE RIBAPAK - ribavirin tab 600 mg
$0(2)
ribavirin cap 200 mg
$0(1)
ribavirin tab 200 mg
$0(1)
rimantadine hydrochloride tab 100 mg
$0(1)
SELZENTRY - maraviroc tab 150 mg
$0(2)
SELZENTRY - maraviroc tab 300 mg
$0(2)
SOVALDI - sofosbuvir tab 400 mg
$0(2)
PA
stavudine cap 15 mg
$0(1)
stavudine cap 20 mg
$0(1)
stavudine cap 30 mg
$0(1)
stavudine cap 40 mg
$0(1)
stavudine for oral soln 1 mg/ml
$0(1)
STRIBILD - elvitegrav-cobic-emtricitab-tenofovdf tab
150-150-200-300 mg
SUSTIVA - efavirenz tab 600 mg
$0(2)
$0(2)
SUSTIVA - efavirenz cap 50 mg
$0(2)
SUSTIVA - efavirenz cap 200 mg
$0(2)
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
TAMIFLU - oseltamivir phosphate for susp 6 mg/ml
$0(2)
TAMIFLU - oseltamivir phosphate cap 30 mg
$0(2)
$0(2)
$0(2)
TECHNIVIE - ombitasvir-paritaprevir-ritonavir tab
12.5-75-50 mg
$0(2)
PA
Drugs section.
52
2016
Name of Drug
TIVICAY - dolutegravir sodium tab 10 mg
Necessary actions,
$0(2)
$0(2)
$0(2)
TRIUMEQ - abacavir-dolutegravir-lamivudine tab
600-50-300 mg
TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab
100-150 mg
133-200 mg
167-250 mg
200-300 mg
TYBOST - cobicistat tab 150 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
TYZEKA - telbivudine tab 600 mg
$0(2)
valacyclovir hcl tab 500 mg
$0(1)
valacyclovir hcl tab 1 gm
$0(1)
VALCYTE - valganciclovir hcl for soln 50 mg/ml
$0(2)
valganciclovir hcl tab 450 mg
$0(1)
VIDEX - didanosine for soln 2 gm
$0(2)
VIDEX - didanosine for soln 4 gm
$0(2)
VIEKIRA PAK - ombitas-paritapre-riton & dasab tab pak
12.5-75-50 & 250 mg
VIRACEPT - nelfinavir mesylate tab 250 mg
$0(2)
PA
$0(2)
VIRACEPT - nelfinavir mesylate tab 625 mg
$0(2)
VIRAMUNE - nevirapine susp 50 mg/5ml
$0(2)
VIRAMUNE XR - nevirapine tab sr 24hr 100 mg
$0(2)
VIRAZOLE - ribavirin for inhal soln 6 gm
$0(2)
VIREAD - tenofovir disoproxil fumarate oral powder 40 mg/
gm
VIREAD - tenofovir disoproxil fumarate tab 150 mg
$0(2)
QL (240 grams/30 days)
$0(2)
$0(2)
$0(2)
$0(2)
VITEKTA - elvitegravir tab 85 mg
$0(2)
VITEKTA - elvitegravir tab 150 mg
$0(2)
ZEPATIER - elbasvir-grazoprevir tab 50-100 mg
$0(2)
PA
ZIAGEN - abacavir sulfate soln 20 mg/ml
$0(2)
zidovudine cap 100 mg
$0(1)
zidovudine syrup 10 mg/ml
$0(1)
Drugs section.
53
2016
Name of Drug
zidovudine tab 300 mg
Anxiolytics
buspirone hcl tab 5 mg
Necessary actions,
$0(1)
$0(1)
buspirone hcl tab 7.5 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
clonazepam tab 0.5 mg
$0(1)
clonazepam tab 1 mg
$0(1)
clonazepam tab 2 mg
$0(1)
$0(1)
$0(1)
clorazepate dipotassium tab 15 mg
$0(1)
DIAZEPAM - diazepam oral soln 1 mg/ml
$0(2)
diazepam conc 5 mg/ml
$0(1)
diazepam tab 2 mg
$0(1)
diazepam tab 5 mg
$0(1)
diazepam tab 10 mg
$0(1)
DOXEPIN HCL - doxepin hcl cap 75 mg#
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
doxepin hcl conc 10 mg/ml#
$0(2)
PA
$0(1)
$0(1)
$0(1)
escitalopram oxalate soln 5 mg/5ml
$0(1)
$0(1)
$0(1)
$0(1)
$0(2)
PA
Drugs section.
54
2016
Name of Drug
Necessary actions,
$0(2)
PA
$0(2)
PA
$0(2)
PA
lorazepam tab 0.5 mg
$0(1)
lorazepam tab 1 mg
$0(1)
lorazepam tab 2 mg
$0(1)
$0(1)
paroxetine hcl tab sr 24hr 25 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
PAXIL - paroxetine hcl oral susp 10 mg/5ml
$0(2)
sertraline hcl oral conc 20 mg/ml
$0(1)
$0(1)
$0(1)
$0(1)
venlafaxine hcl cap sr 24hr 37.5 mg
$0(1)
$0(1)
$0(1)
venlafaxine hcl tab sr 24hr 37.5 mg
$0(1)
$0(1)
$0(1)
$0(1)
venlafaxine hcl tab 37.5 mg
$0(1)
$0(1)
$0(1)
Bipolar Agents
susp 300 mg
$0(1)
$0(2)
PA, QL (1 syringe
or vial/30 days)
susp 400 mg
$0(2)
PA, QL (1 syringe
or vial/30 days)
$0(1)
$0(1)
$0(1)
$0(1)
Drugs section.
55
2016
Name of Drug
Necessary actions,
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
EQUETRO - carbamazepine cap sr 12hr 100 mg
$0(2)
$0(2)
$0(2)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
LITHIUM - lithium oral solution 8 meq/5ml
$0(2)
lithium carbonate cap 150 mg
$0(1)
$0(1)
$0(1)
lithium carbonate tab cr 300 mg
$0(1)
lithium carbonate tab cr 450 mg
$0(1)
lithium carbonate tab 300 mg
$0(1)
olanzapine for im inj 10 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
olanzapine tab 5 mg
$0(1)
Drugs section.
56
2016
Name of Drug
Necessary actions,
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
12.5 mg
25 mg
37.5 mg
50 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
risperidone soln 1 mg/ml
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
valproic acid cap 250 mg
$0(1)
VRAYLAR - cariprazine hcl cap therapy pack 1.5 mg (1) &
3 mg (6)
$0(2)
Drugs section.
57
2016
Name of Drug
Necessary actions,
$0(2)
$0(2)
$0(2)
$0(2)
$0(1)
$0(1)
$0(1)
Blood Glucose Regulators
acarbose tab 25 mg
$0(1)
$0(1)
acarbose tab 50 mg
$0(1)
acarbose tab 100 mg
$0(1)
ALCOHOL SWABS
$0(1)
BYDUREON - exenatide extended release for susp peninjector 2 mg
BYDUREON - exenatide for inj extended release susp
2 mg
CYCLOSET - bromocriptine mesylate tab 0.8 mg
$0(1)
$0(1)
$0(2)
GAUZE PADS 2" X 2"
$0(1)
glimepiride tab 1 mg
$0(1)
$0(1)
$0(1)
glipizide tab sr 24hr 2.5 mg
$0(1)
glipizide tab sr 24hr 5 mg
$0(1)
glipizide tab sr 24hr 10 mg
$0(1)
glipizide tab 5 mg
$0(1)
glipizide tab 10 mg
$0(1)
glipizide-metformin hcl tab 2.5-250 mg
$0(1)
glipizide-metformin hcl tab 2.5-500 mg
$0(1)
glipizide-metformin hcl tab 5-500 mg
$0(1)
GLUCAGEN HYPOKIT - glucagon hcl (rdna) for inj 1 mg
$0(1)
GLUCAGON EMERGENCY KIT - glucagon (rdna) for inj kit
1 mg
GLUCOSE - glucose chew tab 4 gm
$0(1)
HUMALOG - insulin lispro (human) soln cartridge 100 unit/
ml
HUMALOG - insulin lispro (human) inj 100 unit/ml
$0(1)
HUMALOG KWIKPEN - insulin lispro (human) soln peninjector 100 unit/ml
$0(1)
$0(3)
MC
$0(1)
Drugs section.
58
2016
Name of Drug
HUMALOG KWIKPEN - insulin lispro (human) soln peninjector 200 unit/ml
HUMALOG MIX 50/50 - insulin lispro prot & lispro (human)
inj 100 unit/ml (50-50)
HUMALOG MIX 50/50 KWIKPEN - insulin lispro prot &
lispro sus pen-inj 100 unit/ml (50-50)
HUMALOG MIX 75/25 - insulin lispro prot & lispro (human)
inj 100 unit/ml (75-25)
HUMALOG MIX 75/25 KWIKPEN - insulin lispro prot &
lispro sus pen-inj 100 unit/ml (75-25)
HUMULIN N - insulin nph (human) (isophane) inj 100 unit/
ml
HUMULIN N KWIKPEN - insulin nph (human) (isophane)
susp pen-injector 100 unit/ml
HUMULIN R - insulin regular (human) inj 100 unit/ml
Necessary actions,
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
HUMULIN R U-500 (CONCENTRATE) - insulin regular
(human) inj 500 unit/ml
HUMULIN R U-500 KWIKPEN - insulin regular (human)
soln pen-injector 500 unit/ml
HUMULIN 70/30 - insulin nph isophane & regular human inj
100 unit/ml (70-30)
HUMULIN 70/30 KWIKPEN - insulin nph & regular susp
pen-inj 100 unit/ml (70-30)
INSTA-GLUCOSE - glucose gel 77.4%
$0(1)
INSULIN INJECTION DEVICE
$0(1)
INSULIN SYRINGE/NEEDLE
$0(1)
INVOKAMET - canagliflozin-metformin hcl tab 50-500 mg
$0(1)
$0(1)
$0(1)
INVOKAMET - canagliflozin-metformin hcl tab
150-1000 mg
INVOKANA - canagliflozin tab 100 mg
$0(1)
$0(1)
INVOKANA - canagliflozin tab 300 mg
$0(1)
JANUMET - sitagliptin-metformin hcl tab 50-500 mg
$0(1)
JANUMET - sitagliptin-metformin hcl tab 50-1000 mg
$0(1)
JANUMET XR - sitagliptin-metformin hcl tab sr 24hr
50-500 mg
50-1000 mg
100-1000 mg
JANUVIA - sitagliptin phosphate tab 25 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(3)
MC
Drugs section.
59
2016
Name of Drug
Necessary actions,
$0(1)
$0(1)
JARDIANCE - empagliflozin tab 10 mg
$0(2)
JARDIANCE - empagliflozin tab 25 mg
$0(2)
JENTADUETO - linagliptin-metformin hcl tab 2.5-500 mg
$0(2)
$0(2)
$0(2)
KOMBIGLYZE XR - saxagliptin-metformin hcl tab sr 24hr
2.5-1000 mg
5-500 mg
5-1000 mg
LANTUS - insulin glargine inj 100 unit/ml
$0(1)
$0(1)
$0(1)
LANTUS SOLOSTAR - insulin glargine soln pen-injector
100 unit/ml
LEVEMIR - insulin detemir inj 100 unit/ml
$0(1)
LEVEMIR FLEXPEN - insulin detemir soln pen-injector 100
unit/ml
LEVEMIR FLEXTOUCH - insulin detemir soln pen-injector
100 unit/ml
metformin hcl tab sr 24hr 500 mg
$0(1)
$0(1)
metformin hcl tab sr 24hr 750 mg
$0(1)
metformin hcl tab 500 mg
$0(1)
$0(1)
$0(1)
nateglinide tab 60 mg
$0(1)
nateglinide tab 120 mg
$0(1)
ONGLYZA - saxagliptin hcl tab 2.5 mg
$0(1)
ONGLYZA - saxagliptin hcl tab 5 mg
$0(1)
pioglitazone hcl tab 15 mg
$0(1)
$0(1)
$0(1)
pioglitazone hcl-glimepiride tab 30-2 mg
$0(1)
pioglitazone hcl-glimepiride tab 30-4 mg
$0(1)
pioglitazone hcl-metformin hcl tab 15-500 mg
$0(1)
pioglitazone hcl-metformin hcl tab 15-850 mg
$0(1)
PROGLYCEM - diazoxide susp 50 mg/ml
$0(2)
repaglinide tab 0.5 mg
$0(1)
$0(1)
$0(1)
$0(1)
Drugs section.
60
2016
Name of Drug
repaglinide tab 1 mg
Necessary actions,
$0(1)
repaglinide tab 2 mg
$0(1)
SM GLUCOSE - glucose-vitamin c chew tab 4-0.006 gm
$0(3)
MC
SYMLINPEN 120 - pramlintide acetate pen-inj
2700 mcg/2.7ml (1000 mcg/ml)
SYMLINPEN 60 - pramlintide acetate pen-inj
1500 mcg/1.5ml (1000 mcg/ml)
SYNJARDY - empagliflozin-metformin hcl tab 5-500 mg
$0(1)
$0(2)
SYNJARDY - empagliflozin-metformin hcl tab 5-1000 mg
$0(2)
SYNJARDY - empagliflozin-metformin hcl tab 12.5-500 mg
$0(2)
SYNJARDY - empagliflozin-metformin hcl tab
12.5-1000 mg
TOUJEO SOLOSTAR - insulin glargine soln pen-injector
300 unit/ml
TRADJENTA - linagliptin tab 5 mg
$0(2)
$0(2)
VICTOZA - liraglutide soln pen-injector 18 mg/3ml (6 mg/
ml)
WELCHOL - colesevelam hcl tab 625 mg
$0(1)
QL (1 package/30 days)
WELCHOL - colesevelam hcl packet for susp 3.75 gm
Blood Products/Modifiers/Volume Expanders
AGGRENOX - aspirin-dipyridamole cap sr 12hr 25-200 mg
$0(2)
anagrelide hcl cap 0.5 mg
$0(1)
anagrelide hcl cap 1 mg
$0(1)
ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled
syringe 10 mcg/0.4ml
syringe 500 mcg/ml
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(1)
$0(1)
$0(2)
$0(2)
Drugs section.
61
2016
Name of Drug
ARANESP ALBUMIN FREE - darbepoetin alfa soln inj
25 mcg/ml
40 mcg/ml
60 mcg/ml
100 mcg/ml
200 mcg/ml
300 mcg/ml
BRILINTA - ticagrelor tab 60 mg
Necessary actions,
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(1)
BRILINTA - ticagrelor tab 90 mg
$0(1)
cilostazol tab 50 mg
$0(1)
cilostazol tab 100 mg
$0(1)
clopidogrel bisulfate tab 75 mg
$0(1)
COUMADIN - warfarin sodium tab 1 mg
$0(2)
$0(2)
COUMADIN - warfarin sodium tab 2.5 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
COUMADIN - warfarin sodium tab 7.5 mg
$0(2)
$0(2)
dipyridamole tab 25 mg#
$0(2)
$0(2)
$0(2)
EFFIENT - prasugrel hcl tab 5 mg
$0(1)
EFFIENT - prasugrel hcl tab 10 mg
$0(1)
ELIQUIS - apixaban tab 2.5 mg
$0(1)
ELIQUIS - apixaban tab 5 mg
$0(1)
enoxaparin sodium inj 30 mg/0.3ml
$0(1)
QL (30 syringes/90 days)
$0(1)
$0(1)
$0(1)
enoxaparin sodium inj 100 mg/ml
$0(1)
$0(1)
Drugs section.
62
2016
Name of Drug
enoxaparin sodium inj 150 mg/ml
Necessary actions,
$0(1)
enoxaparin sodium inj 300 mg/3ml
$0(1)
EPOGEN - epoetin alfa inj 2000 unit/ml
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml
$0(1)
fondaparinux sodium subcutaneous inj 5 mg/0.4ml
$0(1)
fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml
$0(1)
fondaparinux sodium subcutaneous inj 10 mg/0.8ml
$0(1)
GRANIX - tbo-filgrastim soln prefilled syringe
300 mcg/0.5ml
GRANIX - tbo-filgrastim soln prefilled syringe
480 mcg/0.8ml
heparin sodium (porcine) inj 1000 unit/ml
$0(2)
$0(1)
$0(1)
$0(1)
heparin sodium (porcine) pf inj 5000 unit/0.5ml
$0(1)
heparin sodium (porcine) 40 unit/ml in d5w
$0(1)
LEUKINE - sargramostim lyophilized for inj 250 mcg
$0(2)
MOZOBIL - plerixafor subcutaneous inj 24 mg/1.2ml
(20 mg/ml)
NEULASTA - pegfilgrastim soln prefilled syringe 6 mg/0.6ml
$0(2)
NEULASTA ONPRO KIT - pegfilgrastim soln prefilled
syringe kit 6 mg/0.6ml
PRADAXA - dabigatran etexilate mesylate cap 75 mg
$0(2)
$0(2)
$0(2)
$0(2)
PROCRIT - epoetin alfa inj 2000 unit/ml
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
PROMACTA - eltrombopag olamine tab 12.5 mg*
$0(2)
PA
PROMACTA - eltrombopag olamine tab 25 mg*
$0(2)
PA
$0(2)
PA
$0(2)
$0(1)
$0(2)
Drugs section.
63
2016
Name of Drug
Necessary actions,
$0(2)
PA
tranexamic acid iv soln 1000 mg/10ml (100 mg/ml)
$0(1)
tranexamic acid tab 650 mg
$0(1)
warfarin sodium tab 1 mg
$0(1)
$0(1)
warfarin sodium tab 2.5 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
warfarin sodium tab 7.5 mg
$0(1)
$0(1)
XARELTO - rivaroxaban tab 10 mg
$0(1)
$0(1)
$0(1)
XARELTO STARTER PACK - rivaroxaban tab starter
therapy pack 15 mg & 20 mg
ZONTIVITY - vorapaxar sulfate tab 2.08 mg
Cardiovascular Agents
acebutolol hcl cap 200 mg
$0(1)
acebutolol hcl cap 400 mg
$0(1)
ACETAZOLAMIDE - acetazolamide tab 125 mg
$0(2)
acetazolamide cap sr 12hr 500 mg
$0(1)
acetazolamide tab 250 mg
$0(1)
amiloride & hydrochlorothiazide tab 5-50 mg
$0(1)
amiloride hcl tab 5 mg
$0(1)
amiodarone hcl tab 200 mg
$0(1)
amiodarone hcl tab 400 mg
$0(1)
amlodipine besylate tab 2.5 mg
$0(1)
amlodipine besylate tab 5 mg
$0(1)
amlodipine besylate tab 10 mg
$0(1)
amlodipine besylate-atorvastatin calcium tab 2.5-10 mg
$0(1)
$0(1)
$0(1)
amlodipine besylate-atorvastatin calcium tab 5-10 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(2)
$0(1)
Drugs section.
64
2016
Name of Drug
Necessary actions,
$0(1)
$0(1)
$0(1)
$0(1)
amlodipine besylate-benazepril hcl cap 2.5-10 mg
$0(1)
amlodipine besylate-benazepril hcl cap 5-10 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
amlodipine besylate-valsartan tab 5-160 mg
$0(1)
$0(1)
$0(1)
$0(1)
amlodipine-valsartan-hydrochlorothiazide tab
5-160-12.5 mg
amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg
$0(1)
$0(1)
10-160-12.5 mg
$0(1)
$0(1)
$0(1)
atenolol & chlorthalidone tab 50-25 mg
$0(1)
atenolol & chlorthalidone tab 100-25 mg
$0(1)
atenolol tab 25 mg
$0(1)
atenolol tab 50 mg
$0(1)
atenolol tab 100 mg
$0(1)
atorvastatin calcium tab 10 mg
$0(1)
$0(1)
$0(1)
$0(1)
benazepril & hydrochlorothiazide tab 5-6.25 mg
$0(1)
$0(1)
$0(1)
benazepril & hydrochlorothiazide tab 20-25 mg
$0(1)
benazepril hcl tab 5 mg
$0(1)
$0(1)
$0(1)
$0(1)
Drugs section.
65
2016
Name of Drug
betaxolol hcl tab 10 mg
Necessary actions,
$0(1)
betaxolol hcl tab 20 mg
$0(1)
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
$0(1)
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
$0(1)
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
$0(1)
bisoprolol fumarate tab 5 mg
$0(1)
bisoprolol fumarate tab 10 mg
$0(1)
bumetanide inj 0.25 mg/ml
$0(1)
bumetanide tab 0.5 mg
$0(1)
bumetanide tab 1 mg
$0(1)
bumetanide tab 2 mg
$0(1)
candesartan cilexetil tab 4 mg
$0(1)
$0(1)
$0(1)
$0(1)
candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg
$0(1)
candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg
$0(1)
candesartan cilexetil-hydrochlorothiazide tab 32-25 mg
$0(1)
captopril tab 12.5 mg
$0(1)
captopril tab 25 mg
$0(1)
captopril tab 50 mg
$0(1)
captopril tab 100 mg
$0(1)
carvedilol tab 3.125 mg
$0(1)
$0(1)
$0(1)
carvedilol tab 25 mg
$0(1)
CHLOROTHIAZIDE - chlorothiazide tab 250 mg
$0(2)
chlorothiazide tab 500 mg
$0(1)
CHLORTHALIDONE - chlorthalidone tab 50 mg
$0(2)
chlorthalidone tab 25 mg
$0(1)
cholestyramine light powder packets 4 gm
$0(1)
cholestyramine light powder 4 gm/dose
$0(1)
cholestyramine powder packets 4 gm
$0(1)
cholestyramine powder 4 gm/dose
$0(1)
choline fenofibrate cap dr 45 mg
$0(1)
choline fenofibrate cap dr 135 mg
$0(1)
clonidine hcl tab 0.1 mg
$0(1)
$0(1)
Drugs section.
66
2016
Name of Drug
Necessary actions,
$0(1)
clonidine hcl td patch weekly 0.1 mg/24hr
$0(1)
$0(1)
$0(1)
colestipol hcl granule packets 5 gm
$0(1)
colestipol hcl granules 5 gm
$0(1)
colestipol hcl tab 1 gm
$0(1)
CORLANOR - ivabradine hcl tab 5 mg
$0(1)
CORLANOR - ivabradine hcl tab 7.5 mg
$0(1)
CRESTOR - rosuvastatin calcium tab 5 mg
$0(1)
$0(1)
$0(1)
$0(1)
DEMSER - metyrosine cap 250 mg
$0(2)
DIGOXIN - digoxin oral soln 0.05 mg/ml#
$0(2)
digoxin tab 125 mcg (0.125 mg)#
$0(1)
digoxin tab 250 mcg (0.25 mg)#
$0(2)
diltiazem hcl cap sr 12hr 60 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
diltiazem hcl coated beads cap sr 24hr 120 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
diltiazem hcl coated beads tab sr 24hr 180 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
diltiazem hcl extended release beads cap sr 24hr 120 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
Drugs section.
67
2016
Name of Drug
Necessary actions,
$0(1)
diltiazem hcl tab 30 mg
$0(1)
$0(1)
$0(1)
$0(1)
dofetilide cap 125 mcg (0.125 mg)
$0(1)
$0(1)
$0(1)
doxazosin mesylate tab 1 mg
$0(1)
$0(1)
$0(1)
$0(1)
enalapril maleate & hydrochlorothiazide tab 5-12.5 mg
$0(1)
enalapril maleate & hydrochlorothiazide tab 10-25 mg
$0(1)
enalapril maleate tab 2.5 mg
$0(1)
enalapril maleate tab 5 mg
$0(1)
$0(1)
$0(1)
eplerenone tab 25 mg
$0(1)
eplerenone tab 50 mg
$0(1)
eprosartan mesylate tab 600 mg
$0(1)
felodipine tab sr 24hr 2.5 mg
$0(1)
felodipine tab sr 24hr 5 mg
$0(1)
felodipine tab sr 24hr 10 mg
$0(1)
fenofibrate micronized cap 67 mg
$0(1)
$0(1)
$0(1)
fenofibrate tab 48 mg
$0(1)
$0(1)
$0(1)
$0(1)
flecainide acetate tab 50 mg
$0(1)
$0(1)
$0(1)
fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg
$0(1)
fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg
$0(1)
fosinopril sodium tab 10 mg
$0(1)
$0(1)
Drugs section.
68
2016
Name of Drug
Necessary actions,
$0(1)
furosemide inj 10 mg/ml
$0(1)
furosemide oral soln 10 mg/ml
$0(1)
furosemide tab 20 mg
$0(1)
$0(1)
$0(1)
gemfibrozil tab 600 mg
$0(1)
hydralazine hcl tab 10 mg
$0(1)
$0(1)
$0(1)
$0(1)
hydrochlorothiazide cap 12.5 mg
$0(1)
hydrochlorothiazide tab 12.5 mg
$0(1)
hydrochlorothiazide tab 25 mg
$0(1)
hydrochlorothiazide tab 50 mg
$0(1)
indapamide tab 1.25 mg
$0(1)
indapamide tab 2.5 mg
$0(1)
irbesartan tab 75 mg
$0(1)
$0(1)
$0(1)
irbesartan-hydrochlorothiazide tab 150-12.5 mg
$0(1)
irbesartan-hydrochlorothiazide tab 300-12.5 mg
$0(1)
isosorbide dinitrate tab cr 40 mg
$0(1)
isosorbide dinitrate tab 5 mg
$0(1)
$0(1)
$0(1)
$0(1)
isosorbide mononitrate tab sr 24hr 30 mg
$0(1)
$0(1)
$0(1)
isosorbide mononitrate tab 10 mg
$0(1)
isosorbide mononitrate tab 20 mg
$0(1)
isradipine cap 2.5 mg
$0(1)
isradipine cap 5 mg
$0(1)
JUXTAPID - lomitapide mesylate cap 5 mg*
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
Drugs section.
69
2016
Name of Drug
Necessary actions,
$0(2)
PA
$0(2)
PA
KYNAMRO - mipomersen sodium soln prefilled syringe
200 mg/ml*
labetalol hcl tab 100 mg
$0(2)
PA
$0(1)
$0(1)
LIDOCAINE HCL - lidocaine hcl iv inj 10 mg/ml
$0(2)
lisinopril & hydrochlorothiazide tab 10-12.5 mg
$0(1)
lisinopril & hydrochlorothiazide tab 20-12.5 mg
$0(1)
lisinopril & hydrochlorothiazide tab 20-25 mg
$0(1)
lisinopril tab 2.5 mg
$0(1)
lisinopril tab 5 mg
$0(1)
lisinopril tab 10 mg
$0(1)
$0(1)
$0(1)
$0(1)
LIVALO - pitavastatin calcium tab 1 mg
$0(2)
$0(2)
$0(2)
losartan potassium & hydrochlorothiazide tab 50-12.5 mg
$0(1)
losartan potassium & hydrochlorothiazide tab 100-12.5 mg
$0(1)
losartan potassium & hydrochlorothiazide tab 100-25 mg
$0(1)
losartan potassium tab 25 mg
$0(1)
$0(1)
$0(1)
lovastatin tab 10 mg
$0(1)
$0(1)
$0(1)
methazolamide tab 25 mg
$0(1)
methazolamide tab 50 mg
$0(1)
metolazone tab 2.5 mg
$0(1)
metolazone tab 5 mg
$0(1)
metolazone tab 10 mg
$0(1)
metoprolol & hydrochlorothiazide tab 50-25 mg
$0(1)
metoprolol & hydrochlorothiazide tab 100-25 mg
$0(1)
metoprolol succinate tab sr 24hr 25 mg
$0(1)
$0(1)
$0(1)
Drugs section.
70
2016
Name of Drug
Necessary actions,
$0(1)
$0(1)
metoprolol tartrate tab 25 mg
$0(1)
$0(1)
$0(1)
mexiletine hcl cap 150 mg
$0(1)
$0(1)
$0(1)
midodrine hcl tab 2.5 mg
$0(1)
midodrine hcl tab 5 mg
$0(1)
midodrine hcl tab 10 mg
$0(1)
minoxidil tab 2.5 mg
$0(1)
minoxidil tab 10 mg
$0(1)
moexipril hcl tab 7.5 mg
$0(1)
moexipril hcl tab 15 mg
$0(1)
moexipril-hydrochlorothiazide tab 7.5-12.5 mg
$0(1)
moexipril-hydrochlorothiazide tab 15-12.5 mg
$0(1)
moexipril-hydrochlorothiazide tab 15-25 mg
$0(1)
MULTAQ - dronedarone hcl tab 400 mg
$0(1)
nadolol tab 20 mg
$0(1)
nadolol tab 40 mg
$0(1)
nadolol tab 80 mg
$0(1)
niacin cap cr 250 mg
$0(3)
MC
niacin cap cr 500 mg
$0(3)
MC
niacin tab cr 500 mg
$0(1)
$0(1)
$0(1)
$0(3)
MC
$0(3)
MC
niacin tab 50 mg
$0(3)
MC
niacin tab 100 mg
$0(3)
MC
niacin tab 250 mg
$0(3)
MC
niacin tab 500 mg
$0(3)
MC
NIACIN TR - niacin tab cr 1000 mg
$0(3)
MC
nicardipine hcl cap 20 mg
$0(1)
nicardipine hcl cap 30 mg
$0(1)
nifedipine tab sr 24hr 30 mg
$0(1)
$0(1)
Drugs section.
71
2016
Name of Drug
Necessary actions,
$0(1)
nifedipine tab sr 24hr osmotic release 30 mg
$0(1)
$0(1)
$0(1)
NISOLDIPINE ER - nisoldipine tab sr 24hr 25.5 mg
$0(2)
nisoldipine tab sr 24hr 8.5 mg
$0(1)
nisoldipine tab sr 24hr 17 mg
$0(1)
nisoldipine tab sr 24hr 34 mg
$0(1)
NITRO-BID - nitroglycerin oint 2%
$0(2)
nitroglycerin td patch 24hr 0.1 mg/hr
$0(1)
$0(1)
$0(1)
$0(1)
nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)
$0(1)
NITROSTAT - nitroglycerin sl tab 0.3 mg
$0(1)
$0(1)
$0(1)
NORTHERA - droxidopa cap 100 mg
$0(2)
PA
$0(2)
PA
$0(2)
PA
omega-3-acid ethyl esters cap 1 gm
$0(1)
pentoxifylline tab cr 400 mg
$0(1)
perindopril erbumine tab 2 mg
$0(1)
$0(1)
$0(1)
phenoxybenzamine hcl cap 10 mg
$0(1)
pindolol tab 5 mg
$0(1)
pindolol tab 10 mg
$0(1)
PRALUENT - alirocumab subcutaneous soln pen-injector
75 mg/ml
PRALUENT - alirocumab subcutaneous soln pen-injector
150 mg/ml
PRALUENT - alirocumab subcutaneous soln prefilled
syringe 75 mg/ml
PRALUENT - alirocumab subcutaneous soln prefilled
syringe 150 mg/ml
pravastatin sodium tab 10 mg
$0(2)
PA, QL (2 pens/28 days)
$0(2)
$0(2)
PA, QL (2 syringes/28 days)
$0(2)
$0(1)
$0(1)
$0(1)
Drugs section.
72
2016
Name of Drug
Necessary actions,
$0(1)
prazosin hcl cap 1 mg
$0(1)
$0(1)
$0(1)
propafenone hcl cap sr 12hr 225 mg
$0(1)
$0(1)
$0(1)
propafenone hcl tab 150 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
propranolol hcl inj 1 mg/ml
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
quinapril hcl tab 5 mg
$0(1)
$0(1)
$0(1)
$0(1)
quinapril-hydrochlorothiazide tab 10-12.5 mg
$0(1)
quinapril-hydrochlorothiazide tab 20-12.5 mg
$0(1)
quinapril-hydrochlorothiazide tab 20-25 mg
$0(1)
quinidine gluconate tab cr 324 mg
$0(1)
QUINIDINE SULFATE - quinidine sulfate tab 200 mg
$0(2)
quinidine sulfate tab 300 mg
$0(1)
ramipril cap 1.25 mg
$0(1)
ramipril cap 2.5 mg
$0(1)
ramipril cap 5 mg
$0(1)
ramipril cap 10 mg
$0(1)
RANEXA - ranolazine tab sr 12hr 500 mg
$0(1)
RANEXA - ranolazine tab sr 12hr 1000 mg
$0(1)
REPATHA - evolocumab subcutaneous soln prefilled
syringe 140 mg/ml
$0(2)
Drugs section.
73
2016
Name of Drug
REPATHA PUSHTRONEX SYSTEM - evolocumab
subcutaneous soln cartridge/infusor 420 mg/3.5ml
REPATHA SURECLICK - evolocumab subcutaneous soln
auto-injector 140 mg/ml
rosuvastatin calcium tab 5 mg
Necessary actions,
$0(2)
PA, QL (1 system/30 days)
$0(2)
$0(1)
$0(1)
$0(1)
$0(1)
simvastatin tab 5 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
SLO-NIACIN - niacin tab cr 500 mg
$0(3)
MC
sotalol hcl (afib/afl) tab 80 mg
$0(1)
$0(1)
$0(1)
sotalol hcl tab 80 mg
$0(1)
$0(1)
$0(1)
$0(1)
spironolactone & hydrochlorothiazide tab 25-25 mg
$0(1)
spironolactone tab 25 mg
$0(1)
$0(1)
$0(1)
TEKTURNA - aliskiren fumarate tab 150 mg
$0(1)
TEKTURNA - aliskiren fumarate tab 300 mg
$0(1)
TEKTURNA HCT - aliskiren-hydrochlorothiazide tab
150-12.5 mg
150-25 mg
300-12.5 mg
300-25 mg
telmisartan tab 20 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
telmisartan-hydrochlorothiazide tab 40-12.5 mg
$0(1)
Drugs section.
74
2016
Name of Drug
telmisartan-hydrochlorothiazide tab 80-12.5 mg
Necessary actions,
$0(1)
telmisartan-hydrochlorothiazide tab 80-25 mg
$0(1)
terazosin hcl cap 1 mg
$0(1)
$0(1)
$0(1)
$0(1)
TIKOSYN - dofetilide cap 125 mcg (0.125 mg)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
torsemide tab 5 mg
$0(1)
torsemide tab 10 mg
$0(1)
torsemide tab 20 mg
$0(1)
torsemide tab 100 mg
$0(1)
trandolapril tab 1 mg
$0(1)
$0(1)
$0(1)
triamterene & hydrochlorothiazide cap 37.5-25 mg
$0(1)
triamterene & hydrochlorothiazide tab 37.5-25 mg
$0(1)
triamterene & hydrochlorothiazide tab 75-50 mg
$0(1)
valsartan tab 40 mg
$0(1)
valsartan tab 80 mg
$0(1)
valsartan tab 160 mg
$0(1)
valsartan tab 320 mg
$0(1)
valsartan-hydrochlorothiazide tab 80-12.5 mg
$0(1)
$0(1)
valsartan-hydrochlorothiazide tab 160-25 mg
$0(1)
$0(1)
valsartan-hydrochlorothiazide tab 320-25 mg
$0(1)
VASCEPA - icosapent ethyl cap 1 gm
$0(1)
verapamil hcl cap sr 24hr 100 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
Drugs section.
75
2016
Name of Drug
Necessary actions,
$0(1)
verapamil hcl tab cr 120 mg
$0(1)
$0(1)
$0(1)
verapamil hcl tab 40 mg
$0(1)
$0(1)
$0(1)
VYTORIN - ezetimibe-simvastatin tab 10-10 mg
$0(1)
$0(1)
$0(1)
$0(1)
WELCHOL - colesevelam hcl tab 625 mg
$0(2)
WELCHOL - colesevelam hcl packet for susp 3.75 gm
$0(2)
ZETIA - ezetimibe tab 10 mg
Central Nervous System Agents
amphetamine-dextroamphetamine cap sr 24hr 5 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
AMPYRA - dalfampridine tab sr 12hr 10 mg*
$0(2)
PA
AVONEX - interferon beta-1a im prefilled syringe kit
30 mcg/0.5ml
AVONEX - interferon beta-1a for im inj kit 30mcg
(33mcg(6.6 mu)/vial)
AVONEX PEN - interferon beta-1a im auto-injector kit
30 mcg/0.5ml
BETASERON - interferon beta-1b for inj kit 0.3 mg
$0(2)
$0(2)
$0(2)
$0(2)
PA, QL (15 vials/
syringes/30 days)
clonidine hcl tab sr 12hr 0.1 mg
$0(1)
COPAXONE - glatiramer acetate soln prefilled syringe
20 mg/ml
COPAXONE - glatiramer acetate soln prefilled syringe
40 mg/ml
dexmethylphenidate hcl tab 2.5 mg
$0(2)
$0(2)
$0(1)
dexmethylphenidate hcl tab 5 mg
$0(1)
dexmethylphenidate hcl tab 10 mg
$0(1)
dextroamphetamine sulfate cap sr 24hr 5 mg
$0(1)
Drugs section.
76
2016
Name of Drug
Necessary actions,
$0(1)
$0(1)
dextroamphetamine sulfate tab 5 mg
$0(1)
dextroamphetamine sulfate tab 10 mg
$0(1)
$0(1)
$0(1)
$0(1)
Glatopa - glatiramer acetate soln prefilled syringe 20 mg/ml
$0(2)
LYRICA - pregabalin soln 20 mg/ml
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
methylphenidate hcl tab cr 20 mg
$0(1)
methylphenidate hcl tab 5 mg
$0(1)
$0(1)
$0(1)
$0(1)
mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml)
$0(1)
$0(1)
NUEDEXTA - dextromethorphan hbr-quinidine sulfate cap
20-10 mg
PLEGRIDY - peginterferon beta-1a soln pen-injector
125 mcg/0.5ml
PLEGRIDY - peginterferon beta-1a soln prefilled syringe
125 mcg/0.5ml
PLEGRIDY STARTER PACK - peginterferon beta-1a soln
pen-inj 63 & 94 mcg/0.5ml pack
PLEGRIDY STARTER PACK - peginterferon beta-1a soln
pref syr 63 & 94 mcg/0.5ml pack
riluzole tab 50 mg
$0(1)
STRATTERA - atomoxetine hcl cap 10 mg
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(1)
Drugs section.
77
2016
Name of Drug
Necessary actions,
$0(2)
$0(2)
$0(2)
TECFIDERA - dimethyl fumarate capsule delayed release
120 mg
TECFIDERA - dimethyl fumarate capsule delayed release
240 mg
TECFIDERA STARTER PACK - dimethyl fumarate capsule
dr starter pack 120 mg & 240 mg
tetrabenazine tab 12.5 mg
$0(2)
$0(2)
$0(2)
$0(1)
tetrabenazine tab 25 mg
$0(1)
TYSABRI - natalizumab for iv inj conc 300 mg/15ml*
$0(2)
PA
XENAZINE - tetrabenazine tab 12.5 mg*
$0(2)
XENAZINE - tetrabenazine tab 25 mg*
Dental and Oral Agents
benzocaine dental gel 7.5%
$0(2)
$0(3)
MC
chlorhexidine gluconate soln 0.12%
$0(1)
$0(1)
$0(1)
doxycycline hyclate for inj 100 mg
$0(1)
$0(1)
$0(1)
KEPIVANCE - palifermin for iv inj 6.25 mg
$0(2)
pilocarpine hcl tab 5 mg
$0(1)
pilocarpine hcl tab 7.5 mg
$0(1)
triamcinolone acetonide dental paste 0.1%
Dermatological Agents
acitretin cap 10 mg
$0(1)
acitretin cap 17.5 mg
$0(1)
acitretin cap 25 mg
$0(1)
acyclovir oint 5%
$0(1)
alclometasone dipropionate cream 0.05%
$0(1)
alclometasone dipropionate oint 0.05%
$0(1)
ALOE VESTA ANTIFUNGAL - miconazole nitrate ointment
2%
ALOE VESTA SKIN CONDITIONER - dimethicone lotion
3%
aluminum sulfate & calcium acetate powd pack
$0(3)
MC
$0(3)
MC
$0(3)
MC
AZELEX - azelaic acid cream 20%
$0(2)
$0(1)
Drugs section.
78
2016
Name of Drug
bacitracin oint 500 unit/gm
Necessary actions,
$0(3)
MC
bacitracin zinc oint 500 unit/gm
$0(3)
MC
benzoyl peroxide-erythromycin gel 5-3%
$0(1)
betamethasone dipropionate augmented cream 0.05%
$0(1)
betamethasone dipropionate augmented gel 0.05%
$0(1)
betamethasone dipropionate augmented lotion 0.05%
$0(1)
betamethasone dipropionate augmented oint 0.05%
$0(1)
betamethasone dipropionate cream 0.05%
$0(1)
betamethasone dipropionate lotion 0.05%
$0(1)
betamethasone dipropionate oint 0.05%
$0(1)
betamethasone valerate cream 0.1%
$0(1)
betamethasone valerate lotion 0.1%
$0(1)
betamethasone valerate oint 0.1%
$0(1)
BOUDREAUXS BUTT PASTE - zinc oxide oint 16%
$0(3)
MC
CALAMINE - calamine lotion
$0(3)
MC
calcipotriene cream 0.005%
$0(1)
calcipotriene oint 0.005%
$0(1)
calcipotriene soln 0.005% (50 mcg/ml)
$0(1)
capsaicin cream 0.025%
$0(3)
MC
capsaicin cream 0.075%
$0(3)
MC
CAPZASIN-P - capsaicin cream 0.035%
$0(3)
MC
CARAC - fluorouracil cream 0.5%
$0(2)
chlorhexidine gluconate liquid 4%
$0(3)
ciclopirox gel 0.77%
$0(1)
ciclopirox olamine cream 0.77%
$0(1)
ciclopirox olamine susp 0.77%
$0(1)
ciclopirox shampoo 1%
$0(1)
ciclopirox solution 8%
$0(1)
clindamycin phosphate gel 1%
$0(1)
clindamycin phosphate lotion 1%
$0(1)
clindamycin phosphate soln 1%
$0(1)
clindamycin phosphate swab 1%
$0(1)
clindamycin phosphate-benzoyl peroxide gel 1-5%
$0(1)
clobetasol propionate cream 0.05%
$0(1)
clobetasol propionate emollient base cream 0.05%
$0(1)
clobetasol propionate gel 0.05%
$0(1)
clobetasol propionate oint 0.05%
$0(1)
clobetasol propionate soln 0.05%
$0(1)
MC
Drugs section.
79
2016
Name of Drug
clotrimazole cream 1%
Necessary actions,
$0(1)
clotrimazole w/ betamethasone cream 1-0.05%
$0(1)
clotrimazole w/ betamethasone lotion 1-0.05%
$0(1)
DENAVIR - penciclovir cream 1%
$0(2)
desonide cream 0.05%
$0(1)
desonide lotion 0.05%
$0(1)
desonide oint 0.05%
$0(1)
DESOXIMETASONE - desoximetasone cream 0.05%
$0(2)
desoximetasone cream 0.25%
$0(1)
desoximetasone gel 0.05%
$0(1)
desoximetasone oint 0.25%
$0(1)
diaper rash products - ointment
$0(3)
MC
dibucaine oint 1%
$0(3)
MC
$0(1)
ST
$0(1)
DIFLORASONE DIACETATE - diflorasone diacetate oint
0.05%
dimethicone lotion 1%
$0(2)
econazole nitrate cream 1%
$0(1)
ELIDEL - pimecrolimus cream 1%
$0(2)
ST
ENCARE - nonoxynol-9 vaginal suppos 100 mg
$0(3)
MC
erythromycin pads 2%
$0(1)
erythromycin soln 2%
$0(1)
FINACEA - azelaic acid foam 15%
$0(2)
FINACEA - azelaic acid gel 15%
$0(2)
fluocinolone acetonide cream 0.01%
$0(1)
fluocinonide cream 0.05%
$0(1)
fluocinonide emulsified base cream 0.05%
$0(1)
fluocinonide gel 0.05%
$0(1)
fluocinonide oint 0.05%
$0(1)
fluocinonide soln 0.05%
$0(1)
fluorouracil cream 5%
$0(1)
fluorouracil soln 2%
$0(1)
fluorouracil soln 5%
$0(1)
fluticasone propionate cream 0.05%
$0(1)
fluticasone propionate oint 0.005%
$0(1)
FUNGOID TINCTURE - miconazole nitrate soln 2%
$0(3)
GENTAMICIN SULFATE - gentamicin sulfate cream 0.1%
$0(2)
$0(3)
MC
MC
Drugs section.
80
2016
Name of Drug
GENTAMICIN SULFATE - gentamicin sulfate oint 0.1%
Necessary actions,
$0(2)
halobetasol propionate cream 0.05%
$0(1)
halobetasol propionate oint 0.05%
$0(1)
HEMORRHOIDAL - rectal protectant-emollient ointments
$0(3)
MC
hydrocortisone acetate cream 1%
$0(3)
MC
hydrocortisone butyrate cream 0.1%
$0(1)
hydrocortisone butyrate oint 0.1%
$0(1)
hydrocortisone butyrate soln 0.1%
$0(1)
hydrocortisone cream 0.5%
$0(3)
hydrocortisone cream 1%
$0(1)
hydrocortisone cream 1%
$0(3)
hydrocortisone cream 2.5%
$0(1)
hydrocortisone lotion 1%
$0(3)
hydrocortisone lotion 2.5%
$0(1)
hydrocortisone oint 0.5%
$0(3)
hydrocortisone oint 1%
$0(1)
hydrocortisone oint 2.5%
$0(1)
hydrocortisone valerate cream 0.2%
$0(1)
hydrocortisone valerate oint 0.2%
$0(1)
hydrocortisone-aloe vera cream 1%
$0(3)
MC
imiquimod cream 5%
$0(1)
PA
isotretinoin cap 10 mg
$0(1)
$0(1)
$0(1)
$0(1)
ketoconazole cream 2%
$0(1)
ketoconazole shampoo 2%
$0(1)
lactic acid (ammonium lactate) cream 12%
$0(1)
lactic acid (ammonium lactate) lotion 12%
$0(1)
LAMISIL AT - terbinafine hcl cream 1%
$0(3)
MC
lubricant gels - gel
$0(3)
MC
methoxsalen rapid cap 10 mg
$0(1)
metronidazole cream 0.75%
$0(1)
metronidazole gel 0.75%
$0(1)
metronidazole gel 1%
$0(1)
metronidazole lotion 0.75%
$0(1)
miconazole nitrate aerosol pow 2%
$0(3)
MC
miconazole nitrate cream 2%
$0(3)
MC
MC
MC
MC
MC
Drugs section.
81
2016
Name of Drug
miconazole nitrate powder 2%
Necessary actions,
$0(3)
MC
mometasone furoate cream 0.1%
$0(1)
mometasone furoate oint 0.1%
$0(1)
mometasone furoate solution 0.1% (lotion)
$0(1)
mupirocin oint 2%
$0(1)
neomycin-bacitracin-polymyxin-pramoxine oint 1%
$0(3)
MC
NEOSPORIN ORIGINAL - neomycin-bacitracin-polymyxin
oint
NEOSPORIN PLUS PAIN RELIEF MAXIMUM STRENGTH
- neomycin-polymyxin w/ pramoxine cream 1%
NUPERCAINAL - dibucaine rectal ointment 1%
$0(3)
MC
$0(3)
MC
$0(3)
MC
nystatin cream 100000 unit/gm
$0(1)
nystatin oint 100000 unit/gm
$0(1)
nystatin topical powder
$0(1)
nystatin-triamcinolone cream 100000-0.1 unit/gm-%
$0(1)
nystatin-triamcinolone oint 100000-0.1 unit/gm-%
$0(1)
OPTIONS CONCEPTROL VAGINAL CONTRACEPTIVE nonoxynol-9 gel 4%
OPTIONS GYNOL II VAGINAL CONTRACEPTIVE nonoxynol-9 gel 3%
ORACEA - doxycycline cap delayed release 40 mg
$0(3)
MC
$0(3)
MC
phenylephrine in hard fat rectal suppos 0.25%
$0(3)
MC
PICATO - ingenol mebutate gel 0.015%
$0(1)
QL (3 tubes/30 days)
PICATO - ingenol mebutate gel 0.05%
$0(1)
QL (2 tubes/30 days)
podofilox soln 0.5%
$0(1)
POLYSPORIN - bacitracin-polymyxin b oint
$0(3)
MC
povidone-iodine oint 10%
$0(3)
MC
povidone-iodine soln 7.5%
$0(3)
MC
povidone-iodine soln 10%
$0(3)
MC
povidone-iodine swabs 10%
$0(3)
MC
prednicarbate cream 0.1%
$0(1)
prednicarbate oint 0.1%
$0(1)
PREMIUM CONDOMS LUBRICATED - condoms latex
lubricated
PROSHIELD PLUS SKIN PROTECTANT - dimethicone
cream 1%
PROSHIELD PROTECTIVE HAND CREAM - skin
protectants misc - cream
pyreth-piperonyl butox sham-permeth aero-nit remover gel
kit
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(2)
Drugs section.
82
2016
Name of Drug
pyrethrins-piperonyl butoxide liq 0.33-4%
Necessary actions,
$0(3)
MC
pyrethrins-piperonyl butoxide shampoo 0.33-4%
$0(3)
MC
SANTYL - collagenase oint 250 unit/gm
$0(1)
SEA-CLENS WOUND CLEANSER - wound cleansers liquid
selenium sulfide lotion 2.5%
$0(3)
SHUR-SEAL - nonoxynol-9 gel 2%
$0(3)
silver sulfadiazine cream 1%
$0(1)
skin protectants misc - ointment
$0(3)
MC
STELARA - ustekinumab soln prefilled syringe 45 mg/0.5ml
$0(2)
PA
STELARA - ustekinumab soln prefilled syringe 90 mg/ml
$0(2)
PA
sulfacetamide sodium lotion 10%
$0(1)
SWEEN CREAM - vitamins a & d cream
$0(3)
MC
tacrolimus oint 0.03%
$0(1)
ST
tacrolimus oint 0.1%
$0(1)
ST
TAZORAC - tazarotene cream 0.05%
$0(2)
TAZORAC - tazarotene cream 0.1%
$0(2)
TAZORAC - tazarotene gel 0.05%
$0(2)
TAZORAC - tazarotene gel 0.1%
$0(2)
tretinoin cream 0.025%
$0(1)
$0(1)
$0(1)
tretinoin gel 0.01%
$0(1)
tretinoin gel 0.025%
$0(1)
TRIAMCINOLONE ACETONIDE - triamcinolone acetonide
oint 0.5%
triamcinolone acetonide cream 0.025%
$0(2)
$0(1)
$0(1)
triamcinolone acetonide lotion 0.025%
$0(1)
triamcinolone acetonide lotion 0.1%
$0(1)
triamcinolone acetonide oint 0.025%
$0(1)
triamcinolone acetonide oint 0.1%
$0(1)
TRIPLE PASTE - zinc oxide oint 12.8%
$0(3)
MC
TRIXAICIN - capsicum oleoresin cream 0.025%
$0(3)
MC
TROJAN - condoms latex non-lubricated
$0(3)
MC
UVADEX - methoxsalen soln 20 mcg/ml
$0(2)
VALCHLOR - mechlorethamine hcl gel 0.016%*
$0(2)
MC
$0(1)
MC
$0(1)
Drugs section.
83
2016
Necessary actions,
Name of Drug
VCF VAGINAL CONTRACEPTIVE FILM - nonoxynol-9 film
$0(3)
MC
28%
VCF VAGINAL CONTRACEPTIVE FOAM - nonoxynol-9
$0(3)
MC
foam 12.5%
$0(3)
MC
vitamins a & d oint
$0(2)
ST
zinc oxide oint 20%
$0(3)
MC
zinc oxide oint 40%
$0(3)
MC
zinc oxide oint 10%
Enzyme Replacements/Modifiers
ADAGEN - pegademase bovine inj 250 unit/ml*
$0(3)
MC
ALDURAZYME - laronidase soln for iv infusion 2.9 mg/5ml
(500 unit/5ml)*
BUPHENYL - sodium phenylbutyrate tab 500 mg
$0(2)
CEREZYME - imiglucerase for inj 400 unit*
$0(2)
CREON - pancrelipase (lip-prot-amyl) dr cap
3000-9500-15000 unit
6000-19000-30000 unit
12000-38000-60000 unit
24000-76000-120000 unit
36000-114000-180000 unit
CYSTADANE - betaine powder for oral solution
$0(1)
CYSTAGON - cysteamine bitartrate cap 50 mg*
$0(2)
CYSTAGON - cysteamine bitartrate cap 150 mg*
$0(2)
ELAPRASE - idursulfase soln for iv infusion 6 mg/3ml
(2 mg/ml)*
ELELYSO - taliglucerase alfa for inj 200 unit*
$0(2)
FABRAZYME - agalsidase beta for iv soln 5 mg*
$0(2)
FABRAZYME - agalsidase beta for iv soln 35 mg*
$0(2)
KUVAN - sapropterin dihydrochloride soluble tab 100 mg*
$0(2)
PA
KUVAN - sapropterin dihydrochloride powder packet
100 mg*
KUVAN - sapropterin dihydrochloride powder packet
500 mg*
NAGLAZYME - galsulfase soln for iv infusion 1 mg/ml*
$0(2)
PA
$0(2)
PA
ORFADIN - nitisinone susp 4 mg/ml*
$0(2)
ORFADIN - nitisinone cap 2 mg*
$0(2)
$0(2)
$0(2)
$0(1)
$0(1)
$0(1)
$0(1)
$0(2)
$0(2)
$0(2)
Drugs section.
84
2016
Name of Drug
Necessary actions,
$0(2)
$0(2)
$0(2)
sodium phenylbutyrate oral powder 3 gm/teaspoonful
$0(1)
STRENSIQ - asfotase alfa subcutaneous inj 18 mg/0.45ml*
$0(2)
$0(2)
STRENSIQ - asfotase alfa subcutaneous inj 40 mg/ml*
$0(2)
$0(2)
VIOKACE - pancrelipase (lip-prot-amyl) tab
10440-39150-39150 unit
VIOKACE - pancrelipase (lip-prot-amyl) tab
20880-78300-78300 unit
VPRIV - velaglucerase alfa for inj 400 unit
$0(2)
ZAVESCA - miglustat cap 100 mg*
$0(2)
ZENPEP - pancrelipase (lip-prot-amyl) dr cap
3000-10000-16000 unit
5000-17000-27000 unit
10000-34000-55000 unit
15000-51000-82000 unit
20000-68000-109000 unit
25000-85000-136000 unit
40000-136000-218000 unit
Gastrointestinal Agents
alosetron hcl tab 0.5 mg
$0(1)
alosetron hcl tab 1 mg
$0(1)
alum & mag hydroxide-simethicone susp
200-200-20 mg/5ml
ALUMINUM HYDROXIDE - aluminum hydroxide gel susp
320 mg/5ml
AMITIZA - lubiprostone cap 8 mcg
$0(3)
MC
$0(3)
MC
$0(1)
PA
AMITIZA - lubiprostone cap 24 mcg
$0(1)
PA
BENEFIBER - wheat dextrin oral powder
$0(3)
MC
bisacodyl suppos 10 mg
$0(3)
MC
bisacodyl tab delayed release 5 mg
$0(3)
MC
bismuth subsalicylate chew tab 262 mg
$0(3)
MC
$0(2)
$0(2)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
Drugs section.
85
2016
Name of Drug
bismuth subsalicylate susp 262 mg/15ml
Necessary actions,
$0(3)
MC
bismuth subsalicylate susp 525 mg/15ml
$0(3)
MC
calcium carbonate (antacid) chew tab 500 mg
$0(3)
MC
calcium carbonate (antacid) chew tab 750 mg
$0(3)
MC
calcium carbonate tab 600 mg
$0(3)
MC
calcium carbonate tab 1250 mg (500 mg elemental ca)
$0(3)
MC
calcium carbonate-cholecalciferol tab 600 mg-400 unit
$0(3)
MC
calcium carbonate-mag hydroxide chew tab 700-300 mg
$0(3)
MC
CHENODAL - chenodiol tab 250 mg*
$0(2)
cimetidine hcl soln 300 mg/5ml
$0(1)
cimetidine tab 200 mg
$0(1)
$0(1)
$0(1)
$0(1)
CITRUCEL FIBER LAXATIVE - methylcellulose powder
laxative
COLACE - docusate sodium cap 50 mg
$0(3)
MC
$0(3)
MC
cromolyn sodium oral conc 100 mg/5ml
$0(1)
DEXILANT - dexlansoprazole cap delayed release 30 mg
$0(2)
DEXILANT - dexlansoprazole cap delayed release 60 mg
$0(2)
dicyclomine hcl tab 20 mg
$0(1)
docusate calcium cap 240 mg
$0(3)
MC
docusate sodium cap 100 mg
$0(3)
MC
docusate sodium cap 250 mg
$0(3)
MC
docusate sodium liquid 150 mg/15ml
$0(3)
MC
docusate sodium syrup 60 mg/15ml
$0(3)
MC
docusate sodium tab 100 mg
$0(3)
MC
EQL NATURAL FIBER - psyllium powder 92%
$0(3)
MC
esomeprazole magnesium cap delayed release 20 mg
$0(1)
esomeprazole magnesium cap delayed release 40 mg
$0(1)
ESOMEPRAZOLE SODIUM - esomeprazole sodium for
intravenous soln 20 mg
esomeprazole sodium for intravenous soln 40 mg
$0(2)
EX-LAX - sennosides tab 15 mg
$0(3)
famotidine for susp 40 mg/5ml
$0(1)
famotidine inj 20 mg/2ml
$0(1)
$0(1)
$0(1)
$0(1)
MC
Drugs section.
86
2016
Name of Drug
famotidine tab 10 mg
Necessary actions,
$0(3)
MC
$0(1)
$0(1)
FIBERCON - calcium polycarbophil tab 625 mg
$0(3)
MC
FLEET LIQUID GLYCERIN SUPPOSITORIES - glycerin
enema adult 5.4 gm/average delivered dose
GATTEX - teduglutide (rdna) for inj kit 5 mg*
$0(3)
MC
$0(2)
PA
GAVISCON - aluminum hydroxide-magnesium trisilicate
chew tab 80-14.2 mg
GAVISCON - aluminum hydroxide-magnesium carbonate
susp 95-358 mg/15ml
GAVISCON EXTRA STRENGTH RELIEF FORMULA
- aluminum hydroxide-magnesium carbonate susp
508-475 mg/10ml
GELUSIL - alum & mag hydroxide-simethicone chew tab
200-200-25 mg
GLYCERIN - glycerin liquid
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
glycerin suppos 1 gm
$0(3)
MC
glycerin suppos 1.2 gm
$0(3)
MC
glycerin suppos 2 gm
$0(3)
MC
glycerin suppos 80.7%
$0(3)
MC
glycerin topical liquid
$0(3)
MC
glycopyrrolate tab 1 mg
$0(1)
glycopyrrolate tab 2 mg
$0(1)
KONSYL - psyllium powder 60.3%
$0(3)
MC
KONSYL - psyllium powder 71.67%
$0(3)
MC
KONSYL - psyllium powder 100%
$0(3)
MC
KONSYL-D - psyllium powder 52.3%
$0(3)
MC
lactulose (encephalopathy) solution 10 gm/15ml
$0(1)
lactulose solution 10 gm/15ml
$0(1)
lansoprazole cap delayed release 15 mg
$0(1)
lansoprazole cap delayed release 30 mg
$0(1)
LINZESS - linaclotide cap 145 mcg
$0(1)
PA
LINZESS - linaclotide cap 290 mcg
$0(1)
PA
loperamide hcl cap 2 mg
$0(1)
loperamide hcl liq 1 mg/7.5ml
$0(3)
MC
loperamide hcl liq 1 mg/5ml (0.2 mg/ml)
$0(3)
MC
loperamide hcl tab 2 mg
$0(3)
MC
magnesium citrate soln
$0(3)
MC
Drugs section.
87
2016
Name of Drug
magnesium hydroxide susp 400 mg/5ml
Necessary actions,
$0(3)
MC
magnesium oxide tab 400 mg
$0(3)
MC
METAMUCIL MULTIHEALTH FIBER - psyllium powder
55.46%
METAMUCIL MULTIHEALTH FIBER - psyllium powder
63%
methscopolamine bromide tab 2.5 mg
$0(3)
MC
$0(3)
MC
methscopolamine bromide tab 5 mg
$0(1)
methylcellulose tab 500 mg
$0(3)
metoclopramide hcl inj 5 mg/ml
$0(1)
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)
$0(1)
$0(1)
$0(1)
misoprostol tab 100 mcg
$0(1)
misoprostol tab 200 mcg
$0(1)
MOVIPREP - peg 3350-kcl-nacl-na sulfate-na ascorbate-c
for soln 100 gm
MYLANTA DOUBLE-STRENGTH - alum & mag hydroxidesimethicone susp 400-400-40 mg/5ml
NEXIUM - esomeprazole magnesium for delayed release
susp packet 2.5 mg
susp packet 5 mg
susp packet 10 mg
susp packet 20 mg
susp packet 40 mg
nizatidine cap 150 mg
$0(2)
nizatidine cap 300 mg
$0(1)
NUTRISOURCE FIBER - guar gum oral powder
$0(3)
MC
OMEPRAZOLE - omeprazole delayed release tab 20 mg
$0(3)
MC
omeprazole cap delayed release 10 mg
$0(1)
$0(1)
$0(1)
pantoprazole sodium ec tab 20 mg
$0(1)
pantoprazole sodium ec tab 40 mg
$0(1)
pantoprazole sodium for iv soln 40 mg
$0(1)
PEDIA-LAX - glycerin liquid suppos 2.8 gm (2.7 ml)
$0(3)
$0(1)
MC
$0(3)
MC
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(1)
MC
Drugs section.
88
2016
Name of Drug
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
Necessary actions,
$0(1)
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm
$0(1)
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm
$0(1)
polyethylene glycol 3350 oral packet
$0(1)
polyethylene glycol 3350 oral powder
$0(1)
psyllium cap 0.52 gm
$0(3)
MC
psyllium powder 28.3%
$0(3)
MC
psyllium powder 30%
$0(3)
MC
$0(3)
MC
psyllium powder 33%
$0(3)
MC
$0(3)
MC
psyllium powder 49%
$0(3)
MC
$0(3)
MC
psyllium powder 68%
$0(3)
MC
psyllium powder 95%
$0(3)
MC
PYLERA - bismuth subcit-metronidazole-tetracycline cap
140-125-125 mg
rabeprazole sodium ec tab 20 mg
$0(1)
ranitidine hcl cap 150 mg
$0(1)
ranitidine hcl cap 300 mg
$0(1)
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)
$0(1)
ranitidine hcl tab 75 mg
$0(3)
$0(1)
$0(1)
RELISTOR - methylnaltrexone bromide inj kit 12 mg/0.6ml
$0(2)
PA
RELISTOR - methylnaltrexone bromide inj 8 mg/0.4ml
(20 mg/ml)
RELISTOR - methylnaltrexone bromide inj 12 mg/0.6ml
(20 mg/ml)
SENNA - senna syrup 176 mg/5ml
$0(2)
PA
$0(2)
PA
$0(3)
MC
sennosides syrup 8.8 mg/5ml
$0(3)
MC
sennosides tab 8.6 mg
$0(3)
MC
sennosides-docusate sodium tab 8.6-50 mg
$0(3)
MC
sodium bicarbonate tab 325 mg
$0(3)
MC
sodium bicarbonate tab 650 mg
$0(3)
MC
sodium phosphates - soln
$0(3)
MC
sucralfate tab 1 gm
$0(1)
SUPREP BOWEL PREP - sodium sulfate-potassium
sulfate-magnesium sulfate oral soln
$0(2)
$0(1)
MC
Drugs section.
89
2016
Necessary actions,
Name of Drug
TUMS ULTRA 1000 - calcium carbonate (antacid) chew tab
$0(3)
MC
1000 mg
$0(1)
ursodiol cap 300 mg
XIFAXAN - rifaximin tab 550 mg
Genitourinary Agents
alfuzosin hcl tab sr 24hr 10 mg
$0(2)
bethanechol chloride tab 5 mg
$0(1)
$0(1)
$0(1)
$0(1)
calcium acetate cap 667 mg
$0(1)
calcium acetate tab 667 mg
$0(1)
CUPRIMINE - penicillamine cap 250 mg
$0(2)
DEPEN TITRATABS - penicillamine tab 250 mg
$0(2)
$0(1)
$0(1)
$0(1)
$0(1)
dutasteride cap 0.5 mg
$0(1)
dutasteride-tamsulosin hcl cap 0.5-0.4 mg
$0(1)
finasteride tab 5 mg
$0(1)
FOSRENOL - lanthanum carbonate chew tab 500 mg
$0(1)
$0(1)
$0(1)
FOSRENOL - lanthanum carbonate oral powder pack
750 mg
FOSRENOL - lanthanum carbonate oral powder pack
1000 mg
methylergonovine maleate tab 0.2 mg
$0(1)
MYRBETRIQ - mirabegron tab sr 24 hr 25 mg
$0(1)
MYRBETRIQ - mirabegron tab sr 24 hr 50 mg
$0(1)
neomycin-polymyxin b gu irrigation soln
$0(1)
oxybutynin chloride syrup 5 mg/5ml
$0(1)
oxybutynin chloride tab sr 24hr 5 mg
$0(1)
$0(1)
$0(1)
oxybutynin chloride tab 5 mg
$0(1)
PHOSLYRA - calcium acetate oral soln 667 mg/5ml
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
Drugs section.
90
2016
Name of Drug
Necessary actions,
$0(1)
$0(1)
RAPAFLO - silodosin cap 4 mg
$0(1)
RAPAFLO - silodosin cap 8 mg
$0(1)
RENVELA - sevelamer carbonate tab 800 mg
$0(2)
RENVELA - sevelamer carbonate packet 0.8 gm
$0(2)
RENVELA - sevelamer carbonate packet 2.4 gm
$0(2)
tamsulosin hcl cap 0.4 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
tolterodine tartrate cap sr 24hr 2 mg
$0(1)
tolterodine tartrate cap sr 24hr 4 mg
$0(1)
tolterodine tartrate tab 1 mg
$0(1)
tolterodine tartrate tab 2 mg
$0(1)
TOVIAZ - fesoterodine fumarate tab sr 24hr 4 mg
$0(1)
TOVIAZ - fesoterodine fumarate tab sr 24hr 8 mg
$0(1)
trospium chloride cap sr 24hr 60 mg
$0(1)
trospium chloride tab 20 mg
$0(1)
VESICARE - solifenacin succinate tab 5 mg
$0(1)
VESICARE - solifenacin succinate tab 10 mg
$0(1)
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
CORTISONE ACETATE - cortisone acetate tab 25 mg
$0(2)
DEXAMETHASONE - dexamethasone tab 1 mg
$0(2)
DEXAMETHASONE - dexamethasone tab 2 mg
$0(2)
dexamethasone elixir 0.5 mg/5ml
$0(1)
dexamethasone sodium phosphate inj 4 mg/ml
$0(1)
dexamethasone sodium phosphate inj 20 mg/5ml
$0(1)
dexamethasone sodium phosphate inj 120 mg/30ml
$0(1)
dexamethasone tab 0.5 mg
$0(1)
$0(1)
$0(1)
dexamethasone tab 4 mg
$0(1)
dexamethasone tab 6 mg
$0(1)
fludrocortisone acetate tab 0.1 mg
$0(1)
H.P. ACTHAR - corticotropin inj gel 80 unit/ml*
$0(2)
hydrocortisone tab 5 mg
$0(1)
PA
Drugs section.
91
2016
Name of Drug
Necessary actions,
$0(1)
$0(1)
methylprednisolone sodium succinate for inj 40 mg
$0(1)
$0(1)
$0(1)
methylprednisolone tab therapy pack 4 mg (21)
$0(1)
methylprednisolone tab 4 mg
$0(1)
BD
$0(1)
BD
$0(1)
BD
$0(1)
BD
MYALEPT - metreleptin for subcutaneous inj 11.3 mg*
$0(2)
PA
prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml
base)
prednisolone sod phosphate oral soln 15 mg/5ml
$0(1)
BD
$0(1)
BD
prednisolone syrup 15 mg/5ml
$0(1)
BD
PREDNISONE - prednisone tab 50 mg
$0(2)
BD
PREDNISONE - prednisone oral soln 5 mg/5ml
$0(2)
BD
PREDNISONE - prednisone tab therapy pack 5 mg (21)
$0(1)
$0(1)
$0(1)
$0(1)
prednisone tab 1 mg
$0(1)
BD
prednisone tab 2.5 mg
$0(1)
BD
prednisone tab 5 mg
$0(1)
BD
prednisone tab 10 mg
$0(1)
BD
$0(1)
prednisone tab 20 mg
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
$0(1)
chorionic gonadotropin for inj 10000 unit
BD
desmopressin acetate inj 4 mcg/ml
$0(1)
desmopressin acetate nasal soln 0.01% (refrigerated)
$0(1)
desmopressin acetate nasal spray soln 0.01%
$0(1)
(refrigerated)
desmopressin acetate tab 0.1 mg
$0(1)
desmopressin acetate tab 0.2 mg
$0(1)
EGRIFTA - tesamorelin acetate for inj 1 mg*
$0(2)
PA
EGRIFTA - tesamorelin acetate for inj 2 mg*
$0(2)
PA
INCRELEX - mecasermin inj 40 mg/4ml (10 mg/ml)*
$0(2)
$0(1)
Drugs section.
92
2016
Name of Drug
OMNITROPE - somatropin for inj 5.8 mg*
Necessary actions,
$0(1)
PA
OMNITROPE - somatropin inj 5 mg/1.5ml*
$0(2)
PA
OMNITROPE - somatropin inj 10 mg/1.5ml*
$0(2)
PA
STIMATE - desmopressin acetate nasal soln 1.5 mg/ml
$0(2)
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
ANADROL-50 - oxymetholone tab 50 mg
$0(2)
PA
ANDRODERM - testosterone td patch 24hr 2 mg/24hr
$0(1)
ANDRODERM - testosterone td patch 24hr 4 mg/24hr
$0(1)
ANDROGEL - testosterone td gel 25 mg/2.5gm (1%)
$0(1)
PA, QL (90 packets/30 days)
ANDROGEL - testosterone td gel 50 mg/5gm (1%)
$0(1)
ANDROGEL - testosterone td gel 20.25 mg/1.25gm
(1.62%)
ANDROGEL - testosterone td gel 40.5 mg/2.5gm (1.62%)
$0(1)
$0(1)
ANDROGEL PUMP - testosterone td gel 20.25 mg/act
(1.62%)
$0(1)
PA, QL (2 pump
bottles/30 days)
ANDROID - methyltestosterone cap 10 mg
$0(2)
PA
ANDROXY - fluoxymesterone tab 10 mg
$0(2)
PA
AXIRON - testosterone td soln 30 mg/act
$0(2)
PA, QL (2 pump
bottles/30 days)
danazol cap 50 mg
$0(1)
PA
danazol cap 100 mg
$0(1)
PA
danazol cap 200 mg
$0(1)
PA
DEPO-PROVERA - medroxyprogesterone acetate im susp
400 mg/ml
desogest-eth estrad & eth estrad tab
0.15-0.02/0.01 mg(21/5)
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg
$0(2)
DIVIGEL - estradiol td gel 0.25 mg/0.25gm (0.1%)#
$0(2)
PA
DIVIGEL - estradiol td gel 0.5 mg/0.5gm (0.1%)#
$0(2)
PA
DIVIGEL - estradiol td gel 1 mg/gm (0.1%)#
$0(2)
PA
drospirenone-ethinyl estradiol tab 3-0.02 mg
$0(1)
drospirenone-ethinyl estradiol tab 3-0.03 mg
$0(1)
ELLA - ulipristal acetate tab 30 mg
$0(1)
ESTRACE - estradiol vaginal cream 0.1 mg/gm
$0(2)
estradiol & norethindrone acetate tab 0.5-0.1 mg#
$0(2)
PA
estradiol & norethindrone acetate tab 1-0.5 mg#
$0(2)
PA
estradiol tab 0.5 mg#
$0(2)
PA
$0(1)
$0(1)
$0(1)
Drugs section.
93
2016
Name of Drug
estradiol tab 1 mg#
Necessary actions,
$0(2)
PA
estradiol tab 2 mg#
$0(2)
PA
estradiol td patch weekly 0.025 mg/24hr#
$0(2)
PA
estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)#
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
ESTROPIPATE - estropipate tab 3 mg#
$0(2)
PA
estropipate tab 0.75 mg#
$0(2)
PA
estropipate tab 1.5 mg#
$0(2)
PA
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg
$0(1)
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab
0.01mg(7)
0.01mg(7)
levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg
$0(1)
levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg
$0(1)
levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg
$0(1)
levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mgmcg
levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg
$0(1)
medroxyprogesterone acetate im susp 150 mg/ml
$0(1)
medroxyprogesterone acetate tab 2.5 mg
$0(1)
medroxyprogesterone acetate tab 5 mg
$0(1)
medroxyprogesterone acetate tab 10 mg
$0(1)
megestrol acetate susp 40 mg/ml#
$0(2)
PA
megestrol acetate tab 20 mg#
$0(2)
PA
megestrol acetate tab 40 mg#
$0(2)
PA
MENEST - esterified estrogens tab 0.3 mg#
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
methyltestosterone cap 10 mg
$0(1)
PA
norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg
$0(1)
norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg
$0(1)
norethindrone & ethinyl estradiol tab 1 mg-35 mcg
$0(1)
norethindrone & ethinyl estradiol-fe chew tab
0.4 mg-35 mcg
$0(1)
$0(1)
$0(1)
$0(1)
Drugs section.
94
2016
Name of Drug
norethindrone & ethinyl estradiol-fe chew tab
0.8 mg-25 mcg
norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mgmcg
norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg
Necessary actions,
$0(1)
$0(1)
$0(1)
norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg
$0(1)
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg
$0(1)
norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg
$0(1)
norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24)
$0(1)
norethindrone acetate tab 5 mg
$0(1)
norethindrone tab 0.35 mg
$0(1)
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mgmcg
norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg
$0(1)
norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg
$0(1)
norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mgmcg
norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mgmcg
norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg
$0(1)
oxandrolone tab 2.5 mg
$0(1)
PA
oxandrolone tab 10 mg
$0(1)
PA
PREMARIN - estrogens, conjugated vaginal cream
0.625 mg/gm
PREMARIN - estrogens, conjugated tab 0.3 mg#
$0(1)
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
PREMPHASE - conj est 0.625(14)/conj est-medroxypro ac
tab 0.625-5mg(14)#
PREMPRO - conjugated estrogen-medroxyprogest acetate
tab 0.3-1.5 mg#
tab 0.45-1.5 mg#
tab 0.625-2.5 mg#
tab 0.625-5 mg#
raloxifene hcl tab 60 mg
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
testosterone cypionate im inj in oil 100 mg/ml
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
PA
Drugs section.
95
2016
Name of Drug
testosterone cypionate im inj in oil 200 mg/ml
Necessary actions,
$0(1)
PA
testosterone enanthate im inj in oil 200 mg/ml
$0(1)
PA
testosterone td gel 25 mg/2.5gm (1%) (generic for
AndroGel 1%)
testosterone td gel 50 mg/5gm (1%) (generic for AndroGel
1%)
testosterone td gel 12.5 mg/act (1%) (generic for AndroGel
Pump 1%)
$0(1)
$0(1)
$0(1)
PA, QL (4 pump
bottles/30 days)
VAGIFEM - estradiol vaginal tab 10 mcg
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
levothyroxine sodium tab 25 mcg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
liothyronine sodium tab 5 mcg
$0(1)
$0(1)
$0(1)
NATPARA - parathyroid hormone (recombinant) for inj
cartridge 25 mcg*
cartridge 50 mcg*
cartridge 75 mcg*
cartridge 100 mcg*
SYNTHROID - levothyroxine sodium tab 25 mcg
$0(2)
PA, QL (2 cartridges/28 days)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(1)
$0(2)
Drugs section.
96
2016
Name of Drug
Necessary actions,
$0(2)
$0(2)
$0(2)
$0(2)
Hormonal Agents, Suppressant (Adrenal)
KORLYM - mifepristone tab 300 mg
$0(2)
LYSODREN - mitotane tab 500 mg
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR - cinacalcet hcl tab 30 mg
$0(1)
$0(1)
PA
$0(1)
PA
Hormonal Agents, Suppressant (Pituitary)
bromocriptine mesylate cap 5 mg
$0(1)
PA
bromocriptine mesylate tab 2.5 mg
$0(1)
cabergoline tab 0.5 mg
$0(1)
ELIGARD - leuprolide acetate for subcutaneous inj kit
7.5 mg
ELIGARD - leuprolide acetate (3 month) for subcutaneous
inj kit 22.5mg
inj kit 30 mg
inj kit 45 mg
FIRMAGON - degarelix acetate for inj 80 mg
$0(2)
FIRMAGON - degarelix acetate for inj 120 mg
$0(2)
leuprolide acetate inj kit 5 mg/ml
$0(1)
LUPRON DEPOT - leuprolide acetate for inj kit 3.75 mg
$0(2)
LUPRON DEPOT - leuprolide acetate for inj kit 7.5 mg
$0(2)
LUPRON DEPOT - leuprolide acetate (3 month) for inj kit
11.25 mg
22.5 mg
30 mg
45 mg
LUPRON DEPOT-PED - leuprolide acetate for inj pediatric
kit 7.5 mg
kit 11.25 mg
$0(2)
$0(2)
$0(1)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
Drugs section.
97
2016
Necessary actions,
Name of Drug
$0(2)
kit 15 mg
LUPRON DEPOT-PED - leuprolide acetate (3 month) for inj
$0(2)
pediatric kit 11.25 mg
LUPRON DEPOT-PED - leuprolide acetate (3 month) for inj
$0(2)
pediatric kit 30 mg
$0(1)
PA
octreotide acetate inj 50 mcg/ml (0.05 mg/ml)
$0(1)
PA
$0(1)
PA
$0(1)
PA
octreotide acetate inj 1000 mcg/ml (1 mg/ml)
$0(1)
PA
SIGNIFOR - pasireotide diaspartate inj 0.3 mg/ml*
$0(2)
PA
$0(2)
PA
$0(2)
PA
SIGNIFOR LAR - pasireotide pamoate for im er susp
20 mg*
40 mg*
60 mg*
SOMATULINE DEPOT - lanreotide acetate extended
release inj 60 mg/0.2ml
SOMAVERT - pegvisomant for inj 10 mg*
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
SYNAREL - nafarelin acetate nasal soln 2 mg/ml (200 mcg/
act)
TRELSTAR - triptorelin pamoate for im susp 3.75 mg
$0(2)
TRELSTAR - triptorelin pamoate for im susp 11.25 mg
$0(2)
TRELSTAR MIXJECT - triptorelin pamoate for im susp
3.75 mg
11.25 mg
22.5 mg
$0(2)
$0(2)
$0(2)
$0(2)
Drugs section.
98
2016
Name of Drug
Hormonal Agents, Suppressant (Thyroid)
methimazole tab 5 mg
Necessary actions,
$0(1)
methimazole tab 10 mg
$0(1)
propylthiouracil tab 50 mg
Immunological Agents
ACTHIB - haemophilus b polysaccharide conjugate vaccine
for inj
ACTIMMUNE - interferon gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)*
ADACEL - tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lfmcg/0.5ml
ARCALYST - rilonacept for inj 220 mg*
$0(1)
$0(2)
PA
ATGAM - lymphocyte immune globulin anti-thymocyte g inj
50 mg/ml(eq)
AZASAN - azathioprine tab 75 mg
$0(2)
BD
$0(2)
BD
AZASAN - azathioprine tab 100 mg
$0(2)
BD
AZATHIOPRINE - azathioprine sodium for inj 100 mg
$0(2)
BD
azathioprine tab 50 mg
$0(1)
BD
BCG VACCINE - bcg vaccine inj
$0(2)
BENLYSTA - belimumab for iv soln 120 mg
$0(2)
PA
BENLYSTA - belimumab for iv soln 400 mg
$0(2)
PA
BEXSERO - meningococcal vac b (recomb adsorbed) inj
prefilled syringe
BOOSTRIX - tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lfmcg/0.5ml
CELLCEPT INTRAVENOUS - mycophenolate mofetil hcl
for iv soln 500 mg
CERVARIX - human papillomavirus (hpv) bival (type 16, 18)
recmb vac inj
CINRYZE - c1 esterase inhibitor (human) for iv inj 500 unit*
$0(2)
$0(2)
cyclosporine cap 25 mg
$0(1)
BD
cyclosporine cap 100 mg
$0(1)
BD
cyclosporine iv soln 50 mg/ml
$0(1)
BD
cyclosporine modified cap 25 mg
$0(1)
BD
$0(1)
BD
$0(1)
BD
cyclosporine modified oral soln 100 mg/ml
$0(1)
BD
DAPTACEL - diph, acellular pert & tet tox inj 15 lf-10 mcg-5
lf/0.5ml
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
BD
$0(2)
$0(2)
$0(2)
Drugs section.
99
2016
Name of Drug
DIPHTHERIA/TETANUS TOXOID - diphtheria-tetanus tox
adsorbed (dt) im inj 25-5 unit/0.5ml
ELIDEL - pimecrolimus cream 1%
Necessary actions,
$0(2)
$0(2)
ST
ENBREL - etanercept for subcutaneous inj 25 mg
$0(2)
PA
ENBREL - etanercept subcutaneous soln prefilled syringe
25 mg/0.5ml
ENBREL - etanercept subcutaneous soln prefilled syringe
50 mg/ml
ENBREL SURECLICK - etanercept subcutaneous solution
auto-injector 50 mg/ml
ENGERIX-B - hepatitis b vaccine (recombinant) susp
10 mcg/0.5ml
ENGERIX-B - hepatitis b vaccine (recombinant) susp
20 mcg/ml
FIRAZYR - icatibant acetate inj 30 mg/3ml*
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
BD
$0(2)
BD
$0(2)
GAMMAPLEX - immune globulin (human) iv soln
2.5 gm/50ml
5 gm/100ml
10 gm/200ml
20 gm/400ml
GAMUNEX-C - immune globulin (human) iv or
subcutaneous soln 1 gm/10ml
subcutaneous soln 2.5 gm/25ml
GARDASIL - human papillomavirus (hpv) quadrivalent
recombinant vac inj
GARDASIL 9 - human papillomavirus (hpv) 9-valent
recomb vac susp pref syr
GARDASIL 9 - human papillomavirus (hpv) 9-valent
recomb vac im susp
HAVRIX - hepatitis a vaccine inj susp 720 el unit/0.5ml
$0(2)
BD, PA
$0(2)
BD, PA
$0(2)
BD, PA
$0(2)
BD, PA
$0(1)
BD, PA
$0(1)
BD, PA
$0(1)
BD, PA
$0(1)
BD, PA
$0(1)
BD, PA
$0(1)
BD, PA
HAVRIX - hepatitis a vaccine inj susp 1440 el unit/ml
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
Drugs section.
100
2016
Necessary actions,
Name of Drug
HIBERIX - haemophilus b polysaccharide conjugate vac for
$0(2)
inj 10 mcg
HUMIRA - adalimumab prefilled syringe kit 10 mg/0.2ml
$0(2)
PA
$0(2)
PA
$0(2)
PA
HUMIRA PEDIATRIC CROHNS DISEASE STARTER
PACK - adalimumab prefilled syringe kit 40 mg/0.8ml
HUMIRA PEN - adalimumab pen-injector kit 40 mg/0.8ml
$0(2)
PA
$0(2)
PA
HUMIRA PEN-CROHNS DISEASE STARTER adalimumab pen-injector kit 40 mg/0.8ml
HUMIRA PEN-PSORIASIS STARTER - adalimumab peninjector kit 40 mg/0.8ml
ILARIS - canakinumab for inj 180 mg*
$0(2)
PA
$0(2)
PA
$0(2)
PA
IMOVAX RABIES (H.D.C.V.) - rabies virus vaccine, hdc inj
$0(1)
BD
INFANRIX - diph, acellular pert & tet tox inj 25 lf-58 mcg-10
lf/0.5ml
IPOL INACTIVATED IPV - poliovirus vaccine, ipv injection
$0(2)
IXIARO - japanese encephalitis vaccine inactivated
adsorbed inj
KINERET - anakinra subcutaneous soln prefilled syringe
100 mg/0.67ml
KINRIX - diph-tetanus tox ad-acell pert & polio virus, ipv
vac inj
leflunomide tab 10 mg
$0(2)
leflunomide tab 20 mg
$0(1)
M-M-R II - measles, mumps & rubella virus vaccines for inj
$0(2)
MENACTRA - meningococcal (a, c, y, and w-135)
conjugate vaccine inj
MENHIBRIX - meningococcal (c & y)-haemophilus b tet tox
conj vac for inj
MENOMUNE-A/C/Y/W-135 - meningococcal vaccine a, c,
y, and w-135 inj
MENVEO - meningococcal (a, c, y, and w-135) oligo conj
vac for inj
methotrexate sodium for inj 1 gm
$0(2)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(2)
$0(2)
PA
$0(2)
$0(1)
$0(2)
$0(2)
$0(2)
$0(1)
Drugs section.
101
2016
Name of Drug
Necessary actions,
$0(1)
methotrexate sodium tab 2.5 mg
$0(1)
mycophenolate mofetil cap 250 mg
$0(1)
BD
mycophenolate mofetil for oral susp 200 mg/ml
$0(1)
BD
mycophenolate mofetil tab 500 mg
$0(1)
BD
mycophenolate sodium tab dr 180 mg
$0(1)
BD
mycophenolate sodium tab dr 360 mg
$0(1)
BD
NULOJIX - belatacept for iv infusion 250 mg
$0(2)
BD
PEDVAX HIB - haemophilus b polysaccharide conj vac im
susp 7.5 mcg/0.5 ml
PENTACEL - diph-ac per-tet tox ad-poliov-haemoph b poly
vac for im susp
PROGRAF - tacrolimus inj 5 mg/ml
$0(2)
PROQUAD - measles-mumps-rubella-varicella virus
vaccines for inj
QUADRACEL - diph-tetanus tox ad-acell pert & polio virus,
ipv vac inj
RABAVERT - rabies vaccine, pcec for inj
$0(2)
$0(2)
BD
RAPAMUNE - sirolimus oral soln 1 mg/ml
$0(2)
BD
RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp
5 mcg/0.5ml
10 mcg/ml
40 mcg/ml
REMICADE - infliximab for iv inj 100 mg
$0(2)
BD
$0(2)
BD
$0(2)
BD
$0(2)
PA
RIDAURA - auranofin cap 3 mg
$0(2)
ROTARIX - rotavirus vaccine, live for oral susp
$0(2)
ROTATEQ - rotavirus vaccine, live oral pentavalent soln
$0(2)
SANDIMMUNE - cyclosporine oral soln 100 mg/ml
$0(2)
BD
SIMULECT - basiliximab for iv soln 10 mg
$0(2)
BD
SIMULECT - basiliximab for iv soln 20 mg
$0(2)
BD
sirolimus tab 0.5 mg
$0(1)
BD
sirolimus tab 1 mg
$0(1)
BD
sirolimus tab 2 mg
$0(1)
BD
STELARA - ustekinumab soln prefilled syringe 45 mg/0.5ml
$0(2)
PA
STELARA - ustekinumab soln prefilled syringe 90 mg/ml
$0(2)
PA
SYNAGIS - palivizumab im soln 50 mg/0.5ml*
$0(2)
SYNAGIS - palivizumab im soln 100 mg/ml*
$0(2)
tacrolimus cap 0.5 mg
$0(1)
$0(2)
$0(2)
BD
$0(2)
BD
Drugs section.
102
2016
Name of Drug
tacrolimus cap 1 mg
Necessary actions,
$0(1)
BD
tacrolimus cap 5 mg
$0(1)
BD
TENIVAC - tetanus-diphtheria toxoids (td) inj 5-2 lfu
$0(1)
TETANUS/DIPHTHERIA TOXOID - tetanus-diphtheria
toxoids (td) inj 2-2 lf/0.5ml
$0(1)
$0(2)
$0(2)
$0(2)
$0(2)
THYMOGLOBULIN - anti-thymocyte globulin for iv soln
25 mg (lymphocyte ig)
TRUMENBA - meningococcal group b vaccine im susp
prefilled syringe
TWINRIX - hepatitis a (inact)-hep b (recomb) vac inj 720-20
elu-mcg/ml
TYPHIM VI - typhoid vi polysaccharide intramuscular vac
inj 25 mcg/0.5ml
TYSABRI - natalizumab for iv inj conc 300 mg/15ml*
$0(2)
BD
VAQTA - hepatitis a vaccine inj susp 25 unit/0.5ml
$0(2)
VAQTA - hepatitis a vaccine inj susp 50 unit/ml
$0(2)
VARIVAX - varicella virus vac live for subcutaneous inj
1350 pfu/0.5ml
YF-VAX - yellow fever vaccine subcutaneous inj
$0(2)
ZORTRESS - everolimus tab 0.25 mg
$0(2)
BD
$0(2)
BD
$0(2)
BD
ZOSTAVAX - zoster vaccine live for inj 19400 unit/0.65ml
Inflammatory Bowel Disease Agents
APRISO - mesalamine cap sr 24hr 0.375 gm
$0(2)
QL (1 vaccine/lifetime)
ASACOL HD - mesalamine tab delayed release 800 mg
$0(1)
balsalazide disodium cap 750 mg
$0(1)
budesonide delayed release particles cap 3 mg
$0(1)
CANASA - mesalamine suppos 1000 mg
$0(1)
DELZICOL - mesalamine cap dr 400 mg
$0(1)
DIPENTUM - olsalazine sodium cap 250 mg
$0(2)
hydrocortisone enema 100 mg/60ml
$0(1)
hydrocortisone rectal cream 1%
$0(1)
hydrocortisone rectal cream 2.5%
$0(1)
LIALDA - mesalamine tab delayed release 1.2 gm
$0(2)
mesalamine enema 4 gm
$0(1)
$0(2)
$0(2)
$0(2)
$0(2)
PA
$0(2)
$0(2)
Drugs section.
103
2016
Name of Drug
PENTASA - mesalamine cap cr 250 mg
Necessary actions,
$0(2)
PENTASA - mesalamine cap cr 500 mg
$0(2)
sulfasalazine tab delayed release 500 mg
$0(1)
sulfasalazine tab 500 mg
Metabolic Bone Disease Agents
alendronate sodium tab 5 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
calcitonin (salmon) nasal soln 200 unit/act
$0(1)
calcitriol cap 0.25 mcg
$0(1)
calcitriol cap 0.5 mcg
$0(1)
calcitriol inj 1 mcg/ml
$0(1)
calcitriol oral soln 1 mcg/ml
$0(1)
ETIDRONATE DISODIUM - etidronate disodium tab
200 mg
ETIDRONATE DISODIUM - etidronate disodium tab
400 mg
FORTEO - teriparatide (recombinant) inj 600 mcg/2.4ml
$0(2)
FORTICAL - calcitonin (salmon) nasal soln 200 unit/act
$0(2)
ibandronate sodium iv soln 3 mg/3ml
$0(1)
ibandronate sodium tab 150 mg
$0(1)
MIACALCIN - calcitonin (salmon) inj 200 unit/ml
$0(2)
paricalcitol cap 1 mcg
$0(1)
$0(1)
$0(1)
paricalcitol iv soln 2 mcg/ml
$0(1)
paricalcitol iv soln 5 mcg/ml
$0(1)
PROLIA - denosumab inj 60 mg/ml
$0(2)
PA
risedronate sodium tab delayed release 35 mg
$0(1)
risedronate sodium tab 5 mg
$0(1)
$0(1)
$0(1)
$0(1)
QL (1 tablet/28 days)
XGEVA - denosumab inj 120 mg/1.7ml
$0(2)
ZEMPLAR - paricalcitol iv soln 2 mcg/ml
$0(1)
ZEMPLAR - paricalcitol iv soln 5 mcg/ml
$0(1)
zoledronic acid inj conc for iv infusion 4 mg/5ml
$0(1)
$0(2)
$0(2)
PA
QL (1 tablet/28 days)
Drugs section.
104
2016
Name of Drug
zoledronic acid iv soln 5 mg/100ml
Necessary actions,
$0(1)
ZOMETA - zoledronic acid iv soln 4 mg/100ml
Ophthalmic Agents
ALPHAGAN P - brimonidine tartrate ophth soln 0.1%
$0(2)
artificial tear ophth ointment
$0(3)
MC
artificial tear ophth solution
$0(3)
MC
azelastine hcl ophth soln 0.05%
$0(1)
AZOPT - brinzolamide ophth susp 1%
$0(2)
BACITRACIN - bacitracin ophth oint 500 unit/gm
$0(2)
bacitracin-polymyxin b ophth oint
$0(1)
bacitracin-polymyxin-neomycin-hc ophth oint 1%
$0(1)
BESIVANCE - besifloxacin hcl ophth susp 0.6%
$0(2)
betaxolol hcl ophth soln 0.5%
$0(1)
BETOPTIC-S - betaxolol hcl ophth susp 0.25%
$0(2)
brimonidine tartrate ophth soln 0.15%
$0(1)
brimonidine tartrate ophth soln 0.2%
$0(1)
bromfenac sodium ophth soln 0.09% (once-daily)
$0(1)
carteolol hcl ophth soln 1%
$0(1)
ciprofloxacin hcl ophth soln 0.3%
$0(1)
COMBIGAN - brimonidine tartrate-timolol maleate ophth
soln 0.2-0.5%
cromolyn sodium ophth soln 4%
$0(1)
dexamethasone sodium phosphate ophth soln 0.1%
$0(1)
diclofenac sodium ophth soln 0.1%
$0(1)
dorzolamide hcl ophth soln 2%
$0(1)
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml
$0(1)
DUREZOL - difluprednate ophth emulsion 0.05%
$0(1)
epinastine hcl ophth soln 0.05%
$0(1)
erythromycin ophth oint 5 mg/gm
$0(1)
fluorometholone ophth susp 0.1%
$0(1)
flurbiprofen sodium ophth soln 0.03%
$0(1)
gentamicin sulfate ophth oint 0.3%
$0(1)
gentamicin sulfate ophth soln 0.3%
$0(1)
GENTEAL SEVERE - hypromellose ophth gel 0.3%
$0(3)
MC
hypromellose ophth soln 0.3%
$0(3)
MC
hypromellose ophth soln 0.4%
$0(3)
MC
ILEVRO - nepafenac ophth susp 0.3%
$0(1)
ISOPTO TEARS - hypromellose ophth soln 0.5%
$0(3)
$0(2)
$0(1)
MC
Drugs section.
105
2016
Name of Drug
ISTALOL - timolol maleate ophth soln 0.5% (once-daily)
Necessary actions,
$0(2)
ketorolac tromethamine ophth soln 0.4%
$0(1)
ketorolac tromethamine ophth soln 0.5%
$0(1)
ketotifen fumarate ophth soln 0.025%
$0(3)
LACRISERT - artificial tear ophth insert
$0(2)
latanoprost ophth soln 0.005%
$0(1)
levobunolol hcl ophth soln 0.5%
$0(1)
LOTEMAX - loteprednol etabonate ophth susp 0.5%
$0(1)
LOTEMAX - loteprednol etabonate ophth gel 0.5%
$0(1)
LOTEMAX - loteprednol etabonate ophth oint 0.5%
$0(1)
LUMIGAN - bimatoprost ophth soln 0.01%
$0(1)
MOXEZA - moxifloxacin hcl ophth soln 0.5% (2 times daily)
$0(2)
MURO 128 - sodium chloride hypertonic ophth soln 2%
$0(3)
NATACYN - natamycin ophth susp 5%
$0(2)
neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt
op oin
neomycin-polymy-gramicid op sol 1.75-10000-0.025mgunt-mg/ml
neomycin-polymyxin-dexamethasone ophth oint 0.1%
$0(1)
neomycin-polymyxin-dexamethasone ophth susp 0.1%
$0(1)
NEVANAC - nepafenac ophth susp 0.1%
$0(1)
ofloxacin ophth soln 0.3%
$0(1)
olopatadine hcl ophth soln 0.1%
$0(1)
PATADAY - olopatadine hcl ophth soln 0.2%
$0(1)
PATANOL - olopatadine hcl ophth soln 0.1%
$0(2)
PAZEO - olopatadine hcl ophth soln 0.7%
$0(1)
PHOSPHOLINE IODIDE - echothiophate iodide ophth for
soln 0.125%
pilocarpine hcl ophth soln 1%
$0(2)
$0(1)
$0(1)
polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%
$0(1)
polyvinyl alcohol ophth soln 1.4%
$0(3)
MC
polyvinyl alcohol-povidone ophth soln 5-6 mg/ml (0.5-0.6%)
$0(3)
MC
prednisolone acetate ophth susp 1%
$0(1)
PROLENSA - bromfenac sodium ophth soln 0.07%
$0(2)
REFRESH - polyvinyl alcohol-povidone ophth soln
1.4-0.6%
$0(3)
MC
MC
$0(1)
$0(1)
$0(1)
MC
Drugs section.
106
2016
Name of Drug
REFRESH CELLUVISC - carboxymethylcellulose sodium
ophth soln 1%
REFRESH PLUS - carboxymethylcellulose sodium ophth
soln 0.5%
RESTASIS - cyclosporine (ophth) emulsion 0.05%
Necessary actions,
$0(3)
MC
$0(3)
MC
$0(1)
PA
SIMBRINZA - brinzolamide-brimonidine tartrate ophth susp
1-0.2%
sodium chloride hypertonic ophth oint 5%
$0(1)
$0(3)
MC
sodium chloride hypertonic ophth soln 5%
$0(3)
MC
sulfacetamide sodium ophth soln 10%
$0(1)
sulfacetamide sodium-prednisolone ophth soln
10-0.23(0.25)%
SYSTANE - polyethylene glycol-propylene glycol ophth soln
0.4-0.3%
TEARS NATURALE PM - white petrolatum-mineral oil
ophth ointment
timolol maleate ophth gel forming soln 0.25%
$0(1)
timolol maleate ophth gel forming soln 0.5%
$0(1)
timolol maleate ophth soln 0.25%
$0(1)
timolol maleate ophth soln 0.5%
$0(1)
TOBRADEX - tobramycin-dexamethasone ophth oint
0.3-0.1%
tobramycin ophth soln 0.3%
$0(2)
tobramycin-dexamethasone ophth susp 0.3-0.1%
$0(1)
TRAVATAN Z - travoprost ophth soln 0.004%
$0(1)
trifluridine ophth soln 1%
$0(1)
VIGAMOX - moxifloxacin hcl ophth soln 0.5%
Otic Agents
acetic acid otic soln 2%
$0(1)
ACETIC ACID/ALUMINUM ACETATE - acetic acid 2% in
aluminum acetate otic soln
carbamide peroxide 6.5% otic soln
$0(2)
CIPRODEX - ciprofloxacin-dexamethasone otic susp
0.3-0.1%
fluocinolone acetonide (otic) oil 0.01%
$0(2)
hydrocortisone w/ acetic acid otic soln 1-2%
$0(1)
neomycin-polymyxin-hc otic soln 1%
$0(1)
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/
ml-1%
ofloxacin otic soln 0.3%
$0(1)
$0(3)
MC
$0(3)
MC
$0(1)
$0(1)
$0(1)
$0(3)
MC
$0(1)
$0(1)
Drugs section.
107
2016
Name of Drug
Respiratory Tract/Pulmonary Agents
acetylcysteine inhal soln 10%
Necessary actions,
$0(1)
BD
acetylcysteine inhal soln 20%
$0(1)
BD
ADCIRCA - tadalafil tab 20 mg
$0(2)
ADEMPAS - riociguat tab 0.5 mg
$0(2)
ADEMPAS - riociguat tab 1 mg
$0(2)
$0(2)
ADEMPAS - riociguat tab 2 mg
$0(2)
$0(2)
ADVAIR DISKUS - fluticasone-salmeterol aer powder ba
100-50 mcg/dose
250-50 mcg/dose
500-50 mcg/dose
ADVAIR HFA - fluticasone-salmeterol inhal aerosol
45-21 mcg/act
115-21 mcg/act
230-21 mcg/act
AEROCHAMBER PLUS FLOW-VU - spacer/aerosolholding chambers - device
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)
$0(1)
QL (1 inhaler/30 days)
$0(1)
$0(1)
$0(1)
QL (1 canister/30 days)
$0(1)
$0(1)
$0(3)
MC
$0(1)
BD
albuterol sulfate soln nebu 0.5% (5 mg/ml)
$0(1)
BD
albuterol sulfate soln nebu 0.63 mg/3ml
$0(1)
BD
albuterol sulfate soln nebu 1.25 mg/3ml
$0(1)
BD
albuterol sulfate syrup 2 mg/5ml
$0(1)
albuterol sulfate tab sr 12hr 4 mg
$0(1)
albuterol sulfate tab sr 12hr 8 mg
$0(1)
albuterol sulfate tab 2 mg
$0(1)
albuterol sulfate tab 4 mg
$0(1)
ANORO ELLIPTA - umeclidinium-vilanterol aero powd ba
62.5-25 mcg/inh
ARNUITY ELLIPTA - fluticasone furoate aerosol powder
breath activ 100 mcg/act
ARNUITY ELLIPTA - fluticasone furoate aerosol powder
breath activ 200 mcg/act
ASMANEX HFA - mometasone furoate inhal aerosol
suspension 100 mcg/act
$0(1)
$0(1)
QL (30 blisters/30 days)
$0(1)
$0(1)
Drugs section.
108
2016
Name of Drug
ASMANEX HFA - mometasone furoate inhal aerosol
suspension 200 mcg/act
ASMANEX TWISTHALER 120 METERED DOSES mometasone furoate inhal powd 220 mcg/inh
ATROVENT HFA - ipratropium bromide hfa inhal aerosol
17 mcg/act
AYR NASAL DROPS - saline nasal soln 0.65%
Necessary actions,
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(2)
QL (2 canisters/30 days)
$0(3)
MC
azelastine hcl nasal spray 0.1% (137 mcg/spray)
$0(1)
QL (2 bottles/30 days)
azelastine hcl nasal spray 0.15% (205.5 mcg/spray)
$0(1)
BREO ELLIPTA - fluticasone furoate-vilanterol aero powd
ba 100-25 mcg/inh
BREO ELLIPTA - fluticasone furoate-vilanterol aero powd
ba 200-25 mcg/inh
BROHIST D - brompheniramine & phenylephrine tab
4-10 mg
brompheniramine & phenylephrine elixir 1-2.5 mg/5ml
$0(1)
$0(1)
$0(3)
MC
$0(3)
MC
brompheniramine & phenylephrine susp 6-10 mg/5ml#
$0(3)
MC
caffeine citrate oral soln 60 mg/3ml
$0(1)
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)
$0(3)
MC
cetirizine hcl tab 5 mg
$0(3)
MC
cetirizine hcl tab 10 mg
$0(3)
MC
CHLOR-TRIMETON - chlorpheniramine maleate tab 4 mg
$0(3)
MC
chlorpheniramine & phenylephrine liquid 4-10 mg/5ml
$0(3)
MC
chlorpheniramine & phenylephrine tab 4-10 mg
$0(3)
MC
clemastine fumarate tab 2.68 mg#
$0(2)
PA
COMBIVENT RESPIMAT - ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act
CROMOLYN SODIUM - cromolyn sodium soln nebu
20 mg/2ml
DALIRESP - roflumilast tab 500 mcg
$0(2)
$0(2)
BD
DECON-A - brompheniramine & phenylephrine liqd 2-5 mg/
ml
$0(3)
$0(2)
MC
Drugs section.
109
2016
Name of Drug
dextromethorphan-guaifenesin liquid 10-100 mg/5ml
Necessary actions,
$0(3)
MC
diphenhydramine-phenylephrine liq 6.25-2.5 mg/5ml
$0(3)
MC
diphenhydramine-phenylephrine soln 12.5-5 mg/5ml
$0(3)
MC
diphenhydramine-phenylephrine tab 25-10 mg
$0(3)
MC
DOMETUSS-DA/CHILDREN - chlorpheniramine &
phenylephrine liquid 1-2.5 mg/5ml
DULERA - mometasone furoate-formoterol fumarate
aerosol 100-5 mcg/act
DULERA - mometasone furoate-formoterol fumarate
aerosol 200-5 mcg/act
ED CHLORPED D - chlorpheniramine & phenylephrine
liquid 2-5 mg/ml
EPIPEN 2-PAK - epinephrine solution auto-injector
0.3 mg/0.3ml (1:1000)
EPIPEN-JR 2-PAK - epinephrine solution auto-injector
0.15 mg/0.3ml (1:2000)
ESBRIET - pirfenidone cap 267 mg
$0(3)
MC
$0(2)
$0(2)
$0(3)
MC
FLOVENT DISKUS - fluticasone propionate aer pow ba
50 mcg/blister
100 mcg/blister
250 mcg/blister
FLOVENT HFA - fluticasone propionate hfa inhal aero
44 mcg/act (50/valve)
FLOVENT HFA - fluticasone propionate hfa inhal aer
FLOVENT HFA - fluticasone propionate hfa inhal aer
fluticasone propionate nasal susp 50 mcg/act
$0(1)
$0(1)
$0(1)
QL (4 inhalers/30 days)
$0(1)
$0(1)
$0(1)
$0(1)
QL (1 bottle/30 days)
FORADIL AEROLIZER - formoterol fumarate inhal cap
12 mcg
GRASTEK - timothy grass pollen allergen ext tab sl 2800
bau
guaifenesin liquid 100 mg/5ml
$0(1)
$0(2)
$0(3)
MC
guaifenesin-codeine soln 100-10 mg/5ml
$0(3)
MC
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(2)
PA
$0(1)
$0(1)
$0(2)
PA, QL (270
capsules/30 days)
Drugs section.
110
2016
Necessary actions,
Name of Drug
INCRUSE ELLIPTA - umeclidinium br aero powd breath act
$0(1)
62.5 mcg/inh
$0(1)
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
$0(1)
KALYDECO - ivacaftor tab 150 mg
$0(2)
KALYDECO - ivacaftor packet 50 mg
$0(2)
KALYDECO - ivacaftor packet 75 mg
$0(2)
LETAIRIS - ambrisentan tab 5 mg*
$0(2)
LETAIRIS - ambrisentan tab 10 mg*
$0(2)
levocetirizine dihydrochloride tab 5 mg
$0(1)
loratadine syrup 5 mg/5ml
$0(3)
MC
loratadine tab 10 mg
$0(3)
MC
montelukast sodium chew tab 4 mg
$0(1)
montelukast sodium chew tab 5 mg
$0(1)
montelukast sodium oral granules packet 4 mg
$0(1)
montelukast sodium tab 10 mg
$0(1)
NASONEX - mometasone furoate nasal susp 50 mcg/act
$0(1)
OFEV - nintedanib esylate cap 100 mg
$0(2)
OFEV - nintedanib esylate cap 150 mg
$0(2)
olopatadine hcl nasal soln 0.6%
$0(1)
OPSUMIT - macitentan tab 10 mg*
$0(2)
ORALAIR - grass mixed pollen ext tab sl 300 ir
$0(2)
ORKAMBI - lumacaftor-ivacaftor tab 200-125 mg
$0(2)
PHENAGIL - chlorpheniramine & phenylephrine tab
3.5-10 mg
phenylephrine hcl tab 10 mg
$0(3)
MC
$0(3)
MC
phenylephrine w/ dm-gg liqd 5-10-200 mg/5ml
$0(3)
MC
phenylephrine-brompheniramine-dm elixir 2.5-1-5 mg/5ml
$0(3)
MC
phenylephrine-guaifenesin tab 10-400 mg
$0(3)
MC
PROAIR HFA - albuterol sulfate inhal aero 108 mcg/act
$0(1)
PROAIR RESPICLICK - albuterol sulfate aer pow ba
108 mcg/act
PROLASTIN-C - alpha1-proteinase inhibitor (human) for iv
soln 1000 mg*
promethazine hcl suppos 12.5 mg#
$0(1)
$0(2)
PA
promethazine hcl suppos 25 mg#
$0(2)
PA
promethazine hcl syrup 6.25 mg/5ml#
$0(2)
PA
promethazine hcl tab 12.5 mg#
$0(2)
PA
$0(2)
PA
$0(2)
Drugs section.
111
2016
Name of Drug
Necessary actions,
$0(2)
PA
PULMOZYME - dornase alfa inhal soln 1 mg/ml
$0(2)
BD
QVAR - beclomethasone diprop inhal aero soln 40 mcg/act
(50/valve)
QVAR - beclomethasone diprop inhal aero soln 80 mcg/act
(100/valve)
RAGWITEK - short ragweed pollen allergen extract tab sl
12 amb a 1-u
REMODULIN - treprostinil sodium inj 1 mg/ml*
$0(1)
$0(1)
$0(2)
$0(2)
BD
REMODULIN - treprostinil sodium inj 2.5 mg/ml*
$0(2)
BD
$0(2)
BD
$0(2)
BD
saline nasal spray 0.65%
$0(3)
MC
SEREVENT DISKUS - salmeterol xinafoate aer pow ba
50 mcg/dose
sildenafil citrate tab 20 mg
$0(1)
$0(1)
SPIRIVA HANDIHALER - tiotropium bromide monohydrate
inhal cap 18 mcg
SPIRIVA RESPIMAT - tiotropium bromide monohydrate
inhal aerosol 1.25 mcg/act
SPIRIVA RESPIMAT - tiotropium bromide monohydrate
inhal aerosol 2.5 mcg/act
STIOLTO RESPIMAT - tiotropium br-olodaterol inhal aero
soln 2.5-2.5 mcg/act
SYMBICORT - budesonide-formoterol fumarate dihyd
aerosol 80-4.5 mcg/act
SYMBICORT - budesonide-formoterol fumarate dihyd
aerosol 160-4.5 mcg/act
terbutaline sulfate tab 2.5 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
terbutaline sulfate tab 5 mg
$0(1)
theophylline tab sr 12hr 100 mg
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
tobramycin nebu soln 300 mg/5ml
$0(1)
BD
TRACLEER - bosentan tab 62.5 mg*
$0(2)
TRACLEER - bosentan tab 125 mg*
$0(2)
triamcinolone acetonide nasal aerosol suspension 55 mcg/
act
$0(1)
$0(1)
Drugs section.
112
2016
Name of Drug
TRIAMINIC COLD & ALLERGY CHILDRENS chlorpheniramine & phenylephrine syrup 1-2.5 mg/5ml
TRIAMINIC NIGHT TIME COLD & COUGH diphenhydramine-phenylephrine syrup 6.25-2.5 mg/5ml
TYZINE PEDIATRIC NASAL DROPS - tetrahydrozoline hcl
nasal soln 0.05%
UPTRAVI - selexipag tab therapy pack 200 mcg (140) &
800 mcg (60)*
Necessary actions,
$0(3)
MC
$0(3)
MC
$0(2)
$0(2)
PA, QL (1 pack (200
tablets)/28 days)
UPTRAVI - selexipag tab 200 mcg*
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
$0(2)
VENTAVIS - iloprost inhalation solution 10 mcg/ml
$0(2)
BD, PA, QL (270 mls/30 days)
VENTAVIS - iloprost inhalation solution 20 mcg/ml
$0(2)
BD, PA, QL (270 mls/30 days)
VENTOLIN HFA - albuterol sulfate inhal aero 108 mcg/act
$0(1)
XOLAIR - omalizumab for inj 150 mg*
$0(2)
PA
XOPENEX HFA - levalbuterol tartrate inhal aerosol 45 mcg/
act
zafirlukast tab 10 mg
$0(2)
zafirlukast tab 20 mg
Skeletal Muscle Relaxants
cyclobenzaprine hcl tab 5 mg#
$0(1)
$0(2)
PA
cyclobenzaprine hcl tab 7.5 mg#
$0(2)
PA
cyclobenzaprine hcl tab 10 mg#
$0(2)
PA
methocarbamol tab 500 mg#
$0(2)
methocarbamol tab 750 mg#
Sleep Disorder Agents
armodafinil tab 50 mg
$0(2)
$0(1)
$0(1)
$0(1)
HETLIOZ - tasimelteon capsule 20 mg*
$0(2)
modafinil tab 100 mg
$0(1)
modafinil tab 200 mg
$0(1)
NUVIGIL - armodafinil tab 50 mg
$0(2)
$0(2)
$0(1)
Drugs section.
113
2016
Name of Drug
Necessary actions,
$0(2)
$0(2)
SILENOR - doxepin hcl tab 3 mg
$0(1)
SILENOR - doxepin hcl tab 6 mg
$0(1)
XYREM - sodium oxybate oral solution 500 mg/ml*
$0(2)
zaleplon cap 5 mg#
$0(1)
PA
zaleplon cap 10 mg#
$0(1)
PA
zolpidem tartrate tab 5 mg#
$0(2)
PA
zolpidem tartrate tab 10 mg#
Therapeutic Nutrients/Minerals/Electrolytes
amino acid infusion 6%
$0(2)
PA
$0(1)
BD
$0(1)
BD
$0(1)
BD
ascorbic acid tab 500 mg
$0(3)
MC
B-1 - thiamine hcl tab 500 mg
$0(3)
MC
B-12 - cyanocobalamin tab 2500 mcg
$0(3)
MC
B-12 SUPER STRENGTH - cyanocobalamin sublingual
liquid 5000 mcg/ml
calcium carbonate-vitamin d tab 250 mg-125 unit
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
calcium citrate tab 950 mg (200 mg elemental ca)
$0(3)
MC
calcium citrate-vitamin d tab 315 mg-200 unit (elemental
ca)
calcium tab 500 mg
$0(3)
MC
$0(3)
MC
calcium tab 600 mg
$0(3)
MC
calcium w/ vitamin d tab 600 mg-200 unit
$0(3)
MC
CARBAGLU - carglumic acid tab 200 mg
$0(2)
CENTRUM SPECIALIST PRENATAL - prenatal w/fe fum-fa
tab 27-0.8 mg & dha cap 200 mg pack
CHEMET - succimer cap 100 mg
$0(3)
cholecalciferol cap 400 unit
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
cholecalciferol chew tab 400 unit
$0(3)
MC
MC
$0(2)
Drugs section.
114
2016
Name of Drug
cholecalciferol chew tab 1000 unit
Necessary actions,
$0(3)
MC
cholecalciferol drops 5000 unit/ml (1000 unit/0.2ml)
$0(3)
MC
cholecalciferol drops 400 unit/0.03ml (per drop)
$0(3)
MC
cholecalciferol drops 2000 unit/0.03ml (per drop)
$0(3)
MC
cholecalciferol oral liquid 400 unit/ml
$0(3)
MC
cholecalciferol tab 400 unit
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(2)
cyanocobalamin inj 1000 mcg/ml
$0(3)
MC
cyanocobalamin liquid 1000 mcg/15ml
$0(3)
MC
cyanocobalamin lozenge 500 mcg
$0(3)
MC
cyanocobalamin tab cr 1000 mcg
$0(3)
MC
cyanocobalamin tab cr 2000 mcg
$0(3)
MC
cyanocobalamin tab sl 500 mcg
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
cyanocobalamin tab 50 mcg
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(2)
dextrose inj 5%
$0(1)
dextrose inj 10%
$0(1)
dextrose 5% in lactated ringers
$0(1)
dextrose 2.5% w/ sodium chloride 0.45%
$0(1)
dextrose 5% w/ sodium chloride 0.2%
$0(1)
$0(1)
$0(1)
$0(1)
electrolyte-m in d5w soln
$0(1)
EXJADE - deferasirox tab for oral susp 125 mg*
$0(2)
$0(2)
Drugs section.
115
2016
Name of Drug
Necessary actions,
$0(2)
fat emulsion iv soln 20%
$0(1)
BD
ferrous gluconate tab 325 mg (36 mg elemental fe)
$0(3)
MC
FERROUS SULFATE - ferrous sulfate tab ec 324 mg
(65 mg fe equivalent)
FERROUS SULFATE - ferrous sulfate liquid 220 mg/5ml
(44 mg/5ml elemental fe)
ferrous sulfate dried tab 200 mg (65 mg elemental fe)
$0(3)
MC
$0(3)
MC
$0(3)
MC
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe)
$0(3)
MC
ferrous sulfate tab ec 325 mg (65 mg fe equivalent)
$0(3)
MC
ferrous sulfate tab 325 mg (65 mg elemental fe)
$0(3)
MC
folic acid tab 400 mcg
$0(3)
MC
folic acid tab 800 mcg
$0(3)
MC
fomepizole inj 1 gm/ml (for iv infusion)
$0(1)
HM VITAMIN D3 - cholecalciferol cap 4000 unit
$0(3)
JADENU - deferasirox tab 90 mg
$0(2)
$0(2)
$0(2)
KCL 0.15%/D5W/LR - potassium chloride 20 meq/l (0.15%)
in d5w lactated ringers
KCL 0.3%/D5W/LR IV LACTATED RINGERS - potassium
chloride 40 meq/l (0.3%) in d5w lactated ringers
kcl 20 meq/l (0.15%) in nacl 0.45% inj
$0(2)
kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
$0(1)
KP PRENATAL MULTIVITAMINS - prenatal vit w/ fe
fumarate-fa tab 28-0.8 mg
KPN PRENATAL - prenatal multivitamins & minerals w/iron
& fa tab 0.1 mg
lactated ringer's solution
$0(3)
MC
$0(3)
MC
levocarnitine oral soln 1 gm/10ml (10%)
$0(1)
levocarnitine tab 330 mg
$0(1)
magnesium sulfate inj 50%
$0(1)
MISSION PRENATAL - prenatal vit w/ fe gluconate-fa tab
30-0.4 mg
$0(3)
MC
$0(2)
$0(1)
$0(1)
MC
Drugs section.
116
2016
Name of Drug
MISSION PRENATAL HP - prenatal vit w/ fe gluconate-fa
tab 30-0.8 mg
multiple vitamin tab
Necessary actions,
$0(3)
MC
$0(3)
MC
multiple vitamins w/ iron tab
$0(3)
MC
multiple vitamins w/ minerals tab
$0(3)
MC
NASCOBAL - cyanocobalamin nasal spray 500 mcg/0.1ml
$0(3)
MC
NUTRICION PORVIDA - prenatal multivitamins & minerals
w/ fe & fa tab 0.25 mg
omega-3 fatty acids cap 300 mg
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(3)
MC
omega-3 fatty acids cap delayed release 1000 mg
$0(3)
MC
omega-3 fatty acids cap delayed release 1200 mg
$0(3)
MC
ONE-A-DAY WOMENS PRENATAL - prenat w/ fe fum-fa
tab 28-0.8 mg & omega 3 cap 440 mg pak
oral electrolyte solution
$0(3)
MC
$0(3)
MC
PERRY PRENATAL - prenatal vit w/ fe fumarate-fa cap
13.5-0.4 mg
PHYSICIANS EZ USE B-12 COMPLIANCE KIT cyanocobalamin inj kit 1000 mcg/ml
potassium chloride cap cr 8 meq
$0(3)
MC
$0(3)
MC
potassium chloride cap cr 10 meq
$0(1)
potassium chloride inj 2 meq/ml
$0(1)
potassium chloride microencapsulated crys cr tab 10 meq
$0(1)
potassium chloride microencapsulated crys cr tab 20 meq
$0(1)
potassium chloride tab cr 8 meq (600 mg)
$0(1)
potassium chloride tab cr 10 meq
$0(1)
potassium chloride 20 meq/l (0.15%) in dextrose 5% inj
$0(1)
potassium chloride 40 meq/l (0.3%) in dextrose 5% inj
$0(1)
potassium citrate tab cr 5 meq (540 mg)
$0(1)
$0(1)
$0(1)
PRENATAL - prenatal vit w/ fe fumarate-fa tab 27-0.8 mg
$0(3)
MC
PRENATAL AND IRON - prenatal multivitamins & minerals
w/iron & fa tab 0.8 mg
PRENATAL MULTIVITAMIN + D - prenatal w/fe fum-fa tab
28-0.8 mg & dha cap 200 mg pack
PROFE FORTE - prenatal w/o vit a w/ fe polysac cmplx-fa
cap 155-1 mg
$0(3)
MC
$0(3)
MC
$0(3)
MC
$0(1)
Drugs section.
117
2016
Name of Drug
RA VITAMIN B-12 - cyanocobalamin liquid 1000 mcg/ml
Necessary actions,
$0(3)
MC
SAMSCA - tolvaptan tab 15 mg
$0(2)
PA
SAMSCA - tolvaptan tab 30 mg
$0(2)
PA
sodium chloride inj 0.45%
$0(1)
sodium chloride irrigation soln 0.9%
$0(1)
sodium chloride iv soln 0.9%
$0(1)
sodium polystyrene sulfonate oral susp 15 gm/60ml
$0(1)
sodium polystyrene sulfonate powder
$0(1)
sodium polystyrene sulfonate rectal susp 30 gm/120ml
$0(1)
STUART ONE - prenatal mv & min w/fe carbonyl-fa-dha
cap 27-0.8-200 mg
SUPER TWIN EPA/DHA - omega-3 fatty acids cap
1250 mg
SYPRINE - trientine hcl cap 250 mg
$0(3)
MC
$0(3)
MC
THERA-D 4000 - cholecalciferol tab 4000 unit
$0(3)
MC
THERANATAL COMPLETE - prenatal w/fe fum-fa tab
27-1 mg & vit-dha cap 300 mg pak
THERANATAL OVAVITE - prenat mv fe fum-fa tab 18-1 mg
& coenzyme q10 cap 125 mg
thiamine hcl inj 100 mg/ml
$0(3)
MC
$0(3)
MC
$0(3)
MC
thiamine hcl tab 50 mg
$0(3)
MC
thiamine hcl tab 100 mg
$0(3)
MC
VITAMIN D2 - ergocalciferol tab 400 unit
$0(3)
MC
VITAMIN D2 - ergocalciferol tab 2000 unit
$0(3)
MC
VITAMIN D3 - cholecalciferol oral liquid 1200 unit/15ml
$0(3)
MC
VITAMIN D3 - cholecalciferol tab 3000 unit
$0(3)
MC
water for irrigation, sterile irrigation soln
$0(1)
$0(2)
Drugs section.
118
2016
INDEX
A
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg........................................................48
abacavir sulfate tab 300 mg....................................... 48
ABILIFY MAINTENA.................................................... 20
ABRAXANE................................................................... 31
ABSTRAL........................................................................ 1
ABSTRAL........................................................................ 1
ABSTRAL........................................................................ 1
ABSTRAL........................................................................ 1
ABSTRAL........................................................................ 1
ABSTRAL........................................................................ 1
acamprosate calcium tab delayed release 333
mg.................................................................................. 5
acarbose tab 100 mg.................................................. 58
acarbose tab 25 mg.................................................... 58
acarbose tab 50 mg.................................................... 58
acebutolol hcl cap 200 mg......................................... 64
acebutolol hcl cap 400 mg......................................... 64
acetaminophen cap 500 mg......................................... 1
acetaminophen chew tab 160 mg............................... 1
acetaminophen chew tab 80 mg................................. 1
acetaminophen elixir 160 mg/5ml................................ 1
acetaminophen liquid 160 mg/5ml............................... 1
acetaminophen soln 100 mg/ml................................... 1
acetaminophen soln 160 mg/5ml.................................1
acetaminophen susp 160 mg/5ml................................1
acetaminophen susp 80 mg/0.8ml.............................. 1
acetaminophen w/ codeine soln 120-12 mg/5ml....... 1
acetaminophen w/ codeine tab 300-15 mg................ 1
ACETAZOLAMIDE....................................................... 64
acetazolamide cap sr 12hr 500 mg........................... 64
acetazolamide tab 250 mg......................................... 64
ACETIC ACID/ALUMINUM ACETATE.................... 107
acetic acid otic soln 2%............................................ 107
acetylcysteine inhal soln 10%.................................. 108
acetylcysteine inhal soln 20%.................................. 108
acitretin cap 10 mg...................................................... 78
acitretin cap 17.5 mg...................................................78
acitretin cap 25 mg...................................................... 78
ACTHIB.......................................................................... 99
ACTIMMUNE................................................................ 99
acyclovir cap 200 mg.................................................. 48
acyclovir oint 5%.......................................................... 78
acyclovir sodium for inj 500 mg................................. 49
acyclovir sodium iv soln 50 mg/ml............................ 49
acyclovir susp 200 mg/5ml......................................... 49
acyclovir tab 400 mg................................................... 49
acyclovir tab 800 mg................................................... 49
ADACEL........................................................................ 99
ADAGEN........................................................................84
ADASUVE..................................................................... 43
ADCIRCA.................................................................... 108
adefovir dipivoxil tab 10 mg....................................... 49
ADEMPAS................................................................... 108
ADEMPAS................................................................... 108
ADEMPAS................................................................... 108
ADEMPAS................................................................... 108
ADEMPAS................................................................... 108
ADVAIR DISKUS....................................................... 108
ADVAIR DISKUS....................................................... 108
ADVAIR DISKUS....................................................... 108
ADVAIR HFA.............................................................. 108
ADVAIR HFA.............................................................. 108
ADVAIR HFA.............................................................. 108
AEROCHAMBER PLUS FLOW-VU........................ 108
AFINITOR...................................................................... 31
AFINITOR...................................................................... 31
AFINITOR...................................................................... 31
AFINITOR...................................................................... 31
AFINITOR DISPERZ................................................... 31
AGGRENOX................................................................. 61
ALBENZA...................................................................... 41
albuterol sulfate soln nebu 0.083% (2.5
mg/3ml).....................................................................108
albuterol sulfate soln nebu 0.5% (5 mg/ml)........... 108
albuterol sulfate soln nebu 0.63 mg/3ml................ 108
albuterol sulfate soln nebu 1.25 mg/3ml................ 108
albuterol sulfate syrup 2 mg/5ml............................. 108
albuterol sulfate tab 2 mg.........................................108
albuterol sulfate tab 4 mg.........................................108
albuterol sulfate tab sr 12hr 4 mg........................... 108
albuterol sulfate tab sr 12hr 8 mg........................... 108
alclometasone dipropionate cream 0.05%............... 78
alclometasone dipropionate oint 0.05%....................78
ALCOHOL SWABS...................................................... 58
ALDURAZYME............................................................. 84
ALECENSA................................................................... 31
alendronate sodium tab 10 mg................................ 104
alendronate sodium tab 5 mg.................................. 104
119
2016
ALER-DRYL.................................................................. 24
ALER-DRYL.................................................................. 41
alfuzosin hcl tab sr 24hr 10 mg................................. 90
ALIMTA.......................................................................... 31
ALIMTA.......................................................................... 31
ALINIA............................................................................ 41
ALINIA............................................................................ 41
allopurinol tab 100 mg................................................ 27
allopurinol tab 300 mg................................................ 27
ALOE VESTA ANTIFUNGAL..................................... 78
ALOE VESTA SKIN CONDITIONER........................ 78
ALOPRIM...................................................................... 27
alosetron hcl tab 0.5 mg............................................. 85
alosetron hcl tab 1 mg................................................ 85
ALOXI.............................................................................24
ALPHAGAN P............................................................ 105
alum & mag hydroxide-simethicone susp 200-200-20
mg/5ml........................................................................ 85
ALUMINUM HYDROXIDE.......................................... 85
aluminum sulfate & calcium acetate powd pack...... 78
AMANTADINE HCL..................................................... 41
AMANTADINE HCL..................................................... 49
amantadine hcl cap 100 mg....................................... 41
amantadine hcl cap 100 mg....................................... 49
amantadine hcl syrup 50 mg/5ml.............................. 41
amantadine hcl syrup 50 mg/5ml.............................. 49
AMBISOME................................................................... 26
amifostine crystalline for inj 500 mg.......................... 31
amikacin sulfate inj 1 gm/4ml (250 mg/ml)................. 6
amikacin sulfate inj 500 mg/2ml (250 mg/ml).............6
amiloride & hydrochlorothiazide tab 5-50 mg.......... 64
amiloride hcl tab 5 mg................................................ 64
amino acid infusion 15%.......................................... 114
amino acid infusion 6%............................................ 114
amino acid infusion 8%............................................ 114
amiodarone hcl tab 200 mg....................................... 64
amiodarone hcl tab 400 mg....................................... 64
AMITIZA......................................................................... 85
AMITIZA......................................................................... 85
amitriptyline hcl tab 100 mg....................................... 20
amitriptyline hcl tab 10 mg......................................... 20
amitriptyline hcl tab 150 mg....................................... 20
amlodipine besylate-atorvastatin calcium tab 10-10
mg................................................................................65
mg................................................................................65
mg................................................................................65
120
mg................................................................................65
amlodipine besylate-atorvastatin calcium tab 2.5-10
mg................................................................................64
mg................................................................................64
mg................................................................................64
mg................................................................................64
mg................................................................................64
mg................................................................................64
mg................................................................................64
amlodipine besylate-benazepril hcl cap 10-20
mg................................................................................65
mg................................................................................65
amlodipine besylate-benazepril hcl cap 2.5-10
mg................................................................................65
mg................................................................................65
mg................................................................................65
mg................................................................................65
amlodipine besylate tab 10 mg.................................. 64
amlodipine besylate tab 2.5 mg................................. 64
amlodipine besylate tab 5 mg.................................... 64
amlodipine besylate-valsartan tab 10-160 mg......... 65
amlodipine besylate-valsartan tab 10-320 mg......... 65
amlodipine besylate-valsartan tab 5-160 mg........... 65
amlodipine besylate-valsartan tab 5-320 mg........... 65
10-160-12.5 mg......................................................... 65
10-160-25 mg............................................................ 65
10-320-25 mg............................................................ 65
5-160-12.5 mg........................................................... 65
5-160-25 mg.............................................................. 65
AMOXAPINE................................................................. 20
AMOXAPINE................................................................. 20
AMOXAPINE................................................................. 20
AMOXAPINE................................................................. 20
amoxicillin (trihydrate) cap 250 mg............................. 7
amoxicillin (trihydrate) cap 500 mg............................. 7
amoxicillin (trihydrate) for susp 125 mg/5ml...............7
2016
amoxicillin (trihydrate) tab 500 mg.............................. 7
amoxicillin (trihydrate) tab 875 mg.............................. 7
amoxicillin & k clavulanate chew tab 200-28.5
mg.................................................................................. 7
amoxicillin & k clavulanate chew tab 400-57 mg....... 7
amoxicillin & k clavulanate for susp 200-28.5
mg/5ml.......................................................................... 7
amoxicillin & k clavulanate for susp 400-57
mg/5ml.......................................................................... 7
amoxicillin & k clavulanate for susp 600-42.9
mg/5ml.......................................................................... 7
amoxicillin & k clavulanate tab 250-125 mg............... 7
amphetamine-dextroamphetamine cap sr 24hr 10
mg................................................................................76
mg................................................................................76
mg................................................................................76
mg................................................................................76
mg................................................................................76
mg................................................................................76
AMPHOTERICIN B...................................................... 26
AMPICILLIN.................................................................... 7
AMPICILLIN.................................................................... 7
ampicillin & sulbactam sodium for inj 2-1 gm............. 7
ampicillin cap 250 mg................................................... 7
ampicillin cap 500 mg................................................... 7
AMPICILLIN SODIUM................................................... 7
AMPICILLIN SODIUM................................................... 7
ampicillin sodium for inj 1 gm...................................... 7
ampicillin sodium for inj 250 mg.................................. 7
ampicillin sodium for inj 2 gm...................................... 7
ampicillin sodium for inj 500 mg.................................. 7
ampicillin sodium for iv soln 10 gm............................. 7
AMPYRA........................................................................76
ANADROL-50............................................................... 93
anagrelide hcl cap 0.5 mg.......................................... 61
anagrelide hcl cap 1 mg............................................. 61
anastrozole tab 1 mg.................................................. 31
ANDRODERM.............................................................. 93
ANDRODERM.............................................................. 93
ANDROGEL.................................................................. 93
ANDROGEL.................................................................. 93
ANDROGEL.................................................................. 93
ANDROGEL.................................................................. 93
ANDROGEL PUMP..................................................... 93
ANDROID...................................................................... 93
ANDROXY..................................................................... 93
ANORO ELLIPTA.......................................................108
APOKYN........................................................................ 41
APRISO....................................................................... 103
APTIOM......................................................................... 14
APTIOM......................................................................... 14
APTIOM......................................................................... 14
APTIOM......................................................................... 15
APTIVUS....................................................................... 49
APTIVUS....................................................................... 49
ARANESP ALBUMIN FREE...................................... 61
ARCALYST.................................................................... 99
aripiprazole orally disintegrating tab 10 mg............. 20
aripiprazole oral solution 1 mg/ml............................. 20
aripiprazole tab 10 mg................................................ 20
aripiprazole tab 2 mg.................................................. 20
121
2016
armodafinil tab 150 mg............................................. 113
armodafinil tab 250 mg............................................. 113
armodafinil tab 50 mg............................................... 113
ARNUITY ELLIPTA.................................................... 108
ARNUITY ELLIPTA.................................................... 108
ARRANON.................................................................... 31
artificial tear ophth ointment..................................... 105
artificial tear ophth solution...................................... 105
ARZERRA..................................................................... 31
ARZERRA..................................................................... 31
ASACOL HD............................................................... 103
ascorbic acid tab 500 mg......................................... 114
ASMANEX HFA..........................................................108
ASMANEX HFA..........................................................109
ASMANEX TWISTHALER 120 METERED
DOSES..................................................................... 109
DOSES..................................................................... 109
DOSES..................................................................... 109
DOSES..................................................................... 109
DOSES..................................................................... 109
DOSES..................................................................... 109
aspirin chew tab 81 mg.............................................. 27
aspirin tab 325 mg....................................................... 28
aspirin tab 81 mg......................................................... 28
aspirin tab delayed release 325 mg.......................... 28
aspirin tab delayed release 81 mg............................ 28
atenolol & chlorthalidone tab 100-25 mg.................. 65
atenolol & chlorthalidone tab 50-25 mg.................... 65
atenolol tab 100 mg.....................................................65
atenolol tab 25 mg....................................................... 65
atenolol tab 50 mg....................................................... 65
ATGAM.......................................................................... 99
atorvastatin calcium tab 10 mg.................................. 65
atovaquone-proguanil hcl tab 250-100 mg...............41
atovaquone-proguanil hcl tab 62.5-25 mg................ 41
atovaquone susp 750 mg/5ml.................................... 41
ATRIPLA........................................................................ 49
ATROVENT HFA........................................................ 109
AVASTIN........................................................................ 32
AVASTIN........................................................................ 32
122
AVELOX........................................................................... 7
AVONEX........................................................................ 76
AVONEX........................................................................ 76
AVONEX PEN.............................................................. 76
AXIRON......................................................................... 93
AYR NASAL DROPS................................................ 109
azacitidine for inj 100 mg........................................... 32
AZACTAM........................................................................ 7
AZACTAM........................................................................ 7
AZASAN........................................................................ 99
AZASAN........................................................................ 99
AZATHIOPRINE........................................................... 99
azathioprine tab 50 mg............................................... 99
azelastine hcl nasal spray 0.1% (137 mcg/
spray)........................................................................ 109
azelastine hcl nasal spray 0.15% (205.5 mcg/
spray)........................................................................ 109
azelastine hcl ophth soln 0.05%.............................. 105
AZELEX......................................................................... 78
AZILECT........................................................................ 42
AZILECT........................................................................ 42
AZITHROMYCIN............................................................ 7
azithromycin for susp 100 mg/5ml.............................. 7
azithromycin for susp 200 mg/5ml.............................. 7
azithromycin iv for soln 500 mg................................... 7
azithromycin tab 250 mg.............................................. 7
AZOPT......................................................................... 105
aztreonam for inj 1 gm.................................................. 8
aztreonam for inj 2 gm.................................................. 8
B
B-1................................................................................ 114
B-12.............................................................................. 114
B-12 SUPER STRENGTH........................................114
BACITRACIN.............................................................. 105
bacitracin oint 500 unit/gm......................................... 79
bacitracin-polymyxin b ophth oint............................ 105
bacitracin-polymyxin-neomycin-hc ophth oint
1%............................................................................. 105
bacitracin zinc oint 500 unit/gm................................. 79
baclofen tab 10 mg......................................................48
baclofen tab 20 mg......................................................48
balsalazide disodium cap 750 mg........................... 103
BANZEL......................................................................... 15
BANZEL......................................................................... 15
BANZEL......................................................................... 15
BARACLUDE................................................................ 49
BCG VACCINE............................................................. 99
BELEODAQ.................................................................. 32
BENADRYL ALLERGY CHILDRENS....................... 24
2016
benazepril & hydrochlorothiazide tab 10-12.5
mg................................................................................65
benazepril & hydrochlorothiazide tab 20-12.5
mg................................................................................65
benazepril & hydrochlorothiazide tab 20-25 mg...... 65
benazepril & hydrochlorothiazide tab 5-6.25 mg..... 65
benazepril hcl tab 10 mg............................................ 65
benazepril hcl tab 5 mg.............................................. 65
BENDEKA..................................................................... 32
BENEFIBER.................................................................. 85
BENLYSTA.................................................................... 99
BENLYSTA.................................................................... 99
benzocaine dental gel 7.5%....................................... 78
benzoyl peroxide-erythromycin gel 5-3%................. 79
benztropine mesylate tab 0.5 mg.............................. 42
benztropine mesylate tab 1 mg................................. 42
benztropine mesylate tab 2 mg................................. 42
BESIVANCE................................................................ 105
betamethasone dipropionate augmented cream
0.05%.......................................................................... 79
betamethasone dipropionate augmented gel
0.05%.......................................................................... 79
betamethasone dipropionate augmented lotion
0.05%.......................................................................... 79
betamethasone dipropionate augmented oint
0.05%.......................................................................... 79
betamethasone dipropionate cream 0.05%............. 79
betamethasone dipropionate lotion 0.05%............... 79
betamethasone dipropionate oint 0.05%.................. 79
betamethasone valerate cream 0.1%....................... 79
betamethasone valerate lotion 0.1%.........................79
betamethasone valerate oint 0.1%............................ 79
BETASERON................................................................ 76
betaxolol hcl ophth soln 0.5%.................................. 105
betaxolol hcl tab 10 mg.............................................. 66
betaxolol hcl tab 20 mg.............................................. 66
bethanechol chloride tab 10 mg................................ 90
bethanechol chloride tab 5 mg.................................. 90
BETOPTIC-S.............................................................. 105
bexarotene cap 75 mg................................................ 32
BEXSERO..................................................................... 99
bicalutamide tab 50 mg.............................................. 32
BICILLIN L-A................................................................... 8
BICILLIN L-A................................................................... 8
BICILLIN L-A................................................................... 8
BICNU............................................................................ 32
BILTRICIDE................................................................... 41
bisacodyl suppos 10 mg............................................. 85
bisacodyl tab delayed release 5 mg......................... 85
bismuth subsalicylate chew tab 262 mg................... 85
bismuth subsalicylate susp 262 mg/15ml................. 86
bismuth subsalicylate susp 525 mg/15ml................. 86
bisoprolol & hydrochlorothiazide tab 10-6.25
mg................................................................................66
bisoprolol & hydrochlorothiazide tab 2.5-6.25
mg................................................................................66
bisoprolol & hydrochlorothiazide tab 5-6.25 mg...... 66
bisoprolol fumarate tab 10 mg................................... 66
bisoprolol fumarate tab 5 mg..................................... 66
BLEO 15K..................................................................... 32
bleomycin sulfate for inj 15 unit................................. 32
bleomycin sulfate for inj 30 unit................................. 32
BLINCYTO.....................................................................32
BOOSTRIX.................................................................... 99
BOSULIF....................................................................... 32
BOSULIF....................................................................... 32
BOUDREAUXS BUTT PASTE................................... 79
BREO ELLIPTA.......................................................... 109
BREO ELLIPTA.......................................................... 109
BRILINTA....................................................................... 62
BRILINTA....................................................................... 62
brimonidine tartrate ophth soln 0.15%.................... 105
brimonidine tartrate ophth soln 0.2%...................... 105
BRIVIACT...................................................................... 15
BRIVIACT...................................................................... 15
BRIVIACT...................................................................... 15
BRIVIACT...................................................................... 15
BRIVIACT...................................................................... 15
BRIVIACT...................................................................... 15
BRIVIACT...................................................................... 15
BROHIST D................................................................ 109
bromfenac sodium ophth soln 0.09% (oncedaily)......................................................................... 105
bromocriptine mesylate cap 5 mg............................. 42
bromocriptine mesylate cap 5 mg............................. 97
bromocriptine mesylate tab 2.5 mg........................... 42
bromocriptine mesylate tab 2.5 mg........................... 97
brompheniramine & phenylephrine elixir 1-2.5
mg/5ml...................................................................... 109
brompheniramine & phenylephrine susp 6-10
mg/5ml...................................................................... 109
budesonide delayed release particles cap 3
mg............................................................................. 103
bumetanide inj 0.25 mg/ml......................................... 66
bumetanide tab 0.5 mg............................................... 66
bumetanide tab 1 mg.................................................. 66
bumetanide tab 2 mg.................................................. 66
123
2016
BUPHENYL................................................................... 84
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg........ 5
buprenorphine hcl-naloxone hcl sl tab 8-2 mg........... 5
buprenorphine hcl sl tab 2 mg..................................... 5
buprenorphine hcl sl tab 8 mg..................................... 5
bupropion hcl (smoking deterrent) tab sr 12hr 150
mg.................................................................................. 5
bupropion hcl tab 100 mg...........................................21
bupropion hcl tab 75 mg............................................. 21
bupropion hcl tab sr 12hr 100 mg............................. 21
buspirone hcl tab 10 mg............................................. 54
buspirone hcl tab 5 mg............................................... 54
buspirone hcl tab 7.5 mg............................................ 54
BUSULFEX................................................................... 32
50-300-40-30 mg...................................................... 29
50-325-40-30 mg...................................................... 29
butalbital-aspirin-caff w/ codeine cap 50-325-40-30
mg................................................................................29
butorphanol tartrate inj 1 mg/ml................................... 1
butorphanol tartrate inj 2 mg/ml................................... 1
butorphanol tartrate nasal soln 10 mg/ml................... 1
BUTRANS........................................................................5
BUTRANS........................................................................5
BUTRANS........................................................................6
BUTRANS........................................................................6
BUTRANS........................................................................6
BYDUREON.................................................................. 58
BYDUREON.................................................................. 58
C
cabergoline tab 0.5 mg............................................... 97
CABOMETYX............................................................... 32
CABOMETYX............................................................... 32
CABOMETYX............................................................... 32
caffeine citrate oral soln 60 mg/3ml........................ 109
CALAMINE.................................................................... 79
calcipotriene cream 0.005%....................................... 79
calcipotriene oint 0.005%........................................... 79
calcipotriene soln 0.005% (50 mcg/ml).....................79
calcitonin (salmon) nasal soln 200 unit/act............ 104
calcitriol cap 0.25 mcg.............................................. 104
calcitriol cap 0.5 mcg................................................ 104
calcitriol inj 1 mcg/ml................................................. 104
calcitriol oral soln 1 mcg/ml......................................104
124
calcium acetate cap 667 mg...................................... 90
calcium acetate tab 667 mg....................................... 90
calcium carbonate (antacid) chew tab 500 mg........ 86
calcium carbonate (antacid) chew tab 750 mg........ 86
calcium carbonate-cholecalciferol tab 600 mg-400
unit............................................................................... 86
calcium carbonate-mag hydroxide chew tab 700-300
mg................................................................................86
calcium carbonate tab 1250 mg (500 mg elemental
ca)................................................................................86
calcium carbonate tab 600 mg.................................. 86
calcium carbonate-vitamin d tab 250 mg-125
unit............................................................................ 114
unit............................................................................ 114
unit............................................................................ 114
unit............................................................................ 114
calcium citrate tab 950 mg (200 mg elemental
ca)............................................................................. 114
calcium citrate-vitamin d tab 315 mg-200 unit
(elemental ca)......................................................... 114
calcium tab 500 mg................................................... 114
calcium tab 600 mg................................................... 114
calcium w/ vitamin d tab 600 mg-200 unit.............. 114
CANASA...................................................................... 103
CANCIDAS.................................................................... 26
CANCIDAS.................................................................... 26
candesartan cilexetil-hydrochlorothiazide tab 16-12.5
mg................................................................................66
candesartan cilexetil-hydrochlorothiazide tab 32-12.5
mg................................................................................66
candesartan cilexetil-hydrochlorothiazide tab 32-25
mg................................................................................66
candesartan cilexetil tab 16 mg................................. 66
candesartan cilexetil tab 32 mg................................. 66
candesartan cilexetil tab 4 mg................................... 66
candesartan cilexetil tab 8 mg................................... 66
CAPASTAT SULFATE..................................................31
CAPRELSA................................................................... 32
CAPRELSA................................................................... 32
capsaicin cream 0.025%.............................................79
capsaicin cream 0.075%.............................................79
captopril tab 100 mg................................................... 66
captopril tab 12.5 mg.................................................. 66
captopril tab 25 mg......................................................66
captopril tab 50 mg......................................................66
CAPZASIN-P................................................................ 79
CARAC.......................................................................... 79
CARBAGLU................................................................ 114
carbamazepine cap sr 12hr 100 mg......................... 15
2016
carbamazepine chew tab 100 mg............................. 15
carbamazepine susp 100 mg/5ml............................. 15
carbamazepine tab 200 mg........................................15
carbamazepine tab sr 12hr 100 mg.......................... 15
carbamide peroxide 6.5% otic soln......................... 107
CARBIDOPA/LEVODOPA/ENTACAPONE.............. 42
carbidopa & levodopa orally disintegrating tab
10-100 mg.................................................................. 42
25-100 mg.................................................................. 42
25-250 mg.................................................................. 42
carbidopa & levodopa tab 10-100 mg....................... 42
carbidopa & levodopa tab cr 25-100 mg.................. 42
carbidopa & levodopa tab cr 50-200 mg.................. 42
carbidopa tab 25 mg................................................... 42
carboplatin iv soln 150 mg/15ml................................ 32
carboplatin iv soln 50 mg/5ml.................................... 32
carteolol hcl ophth soln 1%...................................... 105
carvedilol tab 12.5 mg.................................................66
carvedilol tab 25 mg.................................................... 66
carvedilol tab 3.125 mg.............................................. 66
carvedilol tab 6.25 mg.................................................66
cefaclor cap 250 mg...................................................... 8
cefaclor cap 500 mg...................................................... 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 sodium for inj 10 gm..................................... 8
cefazolin sodium for inj 1 gm....................................... 8
cefazolin sodium for inj 20 gm..................................... 8
cefazolin sodium for inj 500 mg................................... 8
cefdinir cap 300 mg....................................................... 8
cefdinir for susp 125 mg/5ml........................................ 8
cefdinir for susp 250 mg/5ml........................................ 8
cefepime hcl for inj 1 gm.............................................. 8
cefepime hcl for inj 2 gm.............................................. 8
cefotaxime sodium for inj 10 gm..................................8
cefotaxime sodium for inj 1 gm.................................... 8
cefotaxime sodium for inj 2 gm.................................... 8
cefotaxime sodium for inj 500 mg............................... 8
cefoxitin sodium for inj 10 gm...................................... 8
cefoxitin sodium for iv soln 1 gm................................. 8
cefoxitin sodium for iv soln 2 gm................................. 8
cefpodoxime proxetil for susp 100 mg/5ml................. 8
cefpodoxime proxetil for susp 50 mg/5ml................... 8
cefpodoxime proxetil tab 100 mg................................ 8
cefpodoxime proxetil tab 200 mg................................ 8
cefprozil for susp 125 mg/5ml...................................... 8
cefprozil for susp 250 mg/5ml...................................... 8
cefprozil tab 250 mg...................................................... 8
cefprozil tab 500 mg...................................................... 8
ceftazidime for inj 1 gm.................................................9
ceftazidime for iv soln 1 gm......................................... 9
ceftazidime for iv soln 2 gm......................................... 9
CEFTRIAXONE/DEXTROSE....................................... 9
CEFTRIAXONE/DEXTROSE....................................... 9
CEFTRIAXONE IN ISO-OSMOTIC............................. 9
CEFTRIAXONE IN ISO-OSMOTIC............................. 9
ceftriaxone sodium for inj 10 gm................................. 9
ceftriaxone sodium for inj 1 gm................................... 9
ceftriaxone sodium for inj 250 mg............................... 9
ceftriaxone sodium for inj 2 gm................................... 9
ceftriaxone sodium for inj 500 mg............................... 9
ceftriaxone sodium for iv soln 1 gm............................ 9
ceftriaxone sodium for iv soln 2 gm............................ 9
cefuroxime axetil tab 250 mg....................................... 9
cefuroxime axetil tab 500 mg....................................... 9
cefuroxime sodium for inj 1.5 gm................................ 9
cefuroxime sodium for inj 7.5 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 100 mg................................................. 28
celecoxib cap 200 mg................................................... 1
celecoxib cap 200 mg................................................. 28
celecoxib cap 400 mg................................................... 1
celecoxib cap 400 mg................................................. 28
celecoxib cap 50 mg..................................................... 1
celecoxib cap 50 mg................................................... 28
CELLCEPT INTRAVENOUS...................................... 99
CELONTIN.................................................................... 15
CENTRUM SPECIALIST PRENATAL.....................114
cephalexin cap 250 mg................................................. 9
cephalexin for susp 125 mg/5ml.................................. 9
cephalexin for susp 250 mg/5ml.................................. 9
125
2016
CEREZYME.................................................................. 84
CERVARIX.................................................................... 99
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml).............109
cetirizine hcl tab 10 mg............................................ 109
cetirizine hcl tab 5 mg............................................... 109
CHANTIX......................................................................... 6
CHANTIX......................................................................... 6
CHANTIX CONTINUING MONTH............................... 6
CHANTIX STARTING MONTH PACK......................... 6
CHEMET..................................................................... 114
CHENODAL.................................................................. 86
CHLORAMPHENICOL SODIUM SUCCINATE..........9
chlorhexidine gluconate liquid 4%............................. 79
chlorhexidine gluconate soln 0.12%......................... 78
chloroquine phosphate tab 250 mg...........................41
chloroquine phosphate tab 500 mg...........................41
CHLOROTHIAZIDE..................................................... 66
chlorothiazide tab 500 mg.......................................... 66
chlorpheniramine & phenylephrine liquid 4-10
mg/5ml...................................................................... 109
chlorpheniramine & phenylephrine tab 4-10
mg............................................................................. 109
CHLORPROMAZINE HCL..........................................24
chlorpromazine hcl tab 100 mg................................. 25
chlorpromazine hcl tab 10 mg................................... 25
CHLORTHALIDONE.................................................... 66
chlorthalidone tab 25 mg............................................ 66
CHLOR-TRIMETON.................................................. 109
cholecalciferol cap 10000 unit................................. 114
cholecalciferol cap 1000 unit................................... 114
cholecalciferol cap 400 unit......................................114
cholecalciferol cap 50000 unit................................. 114
cholecalciferol chew tab 1000 unit.......................... 115
cholecalciferol chew tab 400 unit............................ 114
cholecalciferol drops 2000 unit/0.03ml (per
drop)..........................................................................115
cholecalciferol drops 400 unit/0.03ml (per
drop)..........................................................................115
126
cholecalciferol drops 5000 unit/ml (1000
unit/0.2ml)................................................................ 115
cholecalciferol oral liquid 400 unit/ml...................... 115
cholecalciferol tab 1000 unit.................................... 115
cholecalciferol tab 400 unit...................................... 115
cholecalciferol tab 50000 unit.................................. 115
cholestyramine light powder 4 gm/dose................... 66
cholestyramine light powder packets 4 gm.............. 66
cholestyramine powder 4 gm/dose........................... 66
cholestyramine powder packets 4 gm...................... 66
choline fenofibrate cap dr 135 mg.............................66
choline fenofibrate cap dr 45 mg............................... 66
chorionic gonadotropin for inj 10000 unit................. 92
ciclopirox gel 0.77%.................................................... 79
ciclopirox olamine cream 0.77%................................ 79
ciclopirox olamine susp 0.77%.................................. 79
ciclopirox shampoo 1%............................................... 79
ciclopirox solution 8%..................................................79
cidofovir iv inj 75 mg/ml.............................................. 49
cilostazol tab 100 mg.................................................. 62
cilostazol tab 50 mg.................................................... 62
cimetidine hcl soln 300 mg/5ml................................. 86
cimetidine tab 200 mg.................................................86
CINRYZE....................................................................... 99
CIPRODEX................................................................. 107
ciprofloxacin 200 mg/100ml in d5w........................... 10
ciprofloxacin 400 mg/200ml in d5w........................... 10
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................................................. 9
ciprofloxacin hcl ophth soln 0.3%............................ 105
ciprofloxacin hcl tab 250 mg...................................... 10
ciprofloxacin hcl tab sr 24hr 1000 mg......................... 9
ciprofloxacin hcl tab sr 24hr 500 mg........................... 9
ciprofloxacin iv soln 200 mg/20ml (1%).................... 10
ciprofloxacin iv soln 400 mg/40ml (1%).................... 10
CISPLATIN.................................................................... 32
cisplatin inj 100 mg/100ml (1 mg/ml)........................ 32
cisplatin inj 50 mg/50ml (1 mg/ml)............................ 32
citalopram hydrobromide oral soln 10 mg/5ml......... 21
citalopram hydrobromide tab 10 mg......................... 21
2016
CITRUCEL FIBER LAXATIVE....................................86
cladribine iv soln 10 mg/10ml (1 mg/ml)................... 32
CLAFORAN/D5W......................................................... 10
CLAFORAN/D5W......................................................... 10
clarithromycin for susp 125 mg/5ml.......................... 10
clarithromycin for susp 250 mg/5ml.......................... 10
clarithromycin tab 250 mg.......................................... 10
clarithromycin tab 500 mg.......................................... 10
clarithromycin tab sr 24hr 500 mg............................. 10
clemastine fumarate tab 2.68 mg............................ 109
clindamycin hcl cap 150 mg....................................... 10
clindamycin hcl cap 300 mg....................................... 10
clindamycin hcl cap 75 mg......................................... 10
clindamycin phosphate-benzoyl peroxide gel
1-5%............................................................................ 79
clindamycin phosphate gel 1%.................................. 79
clindamycin phosphate in d5w iv soln 300
mg/50ml...................................................................... 10
mg/50ml...................................................................... 10
mg/50ml...................................................................... 10
clindamycin phosphate inj 300 mg/2ml.....................10
clindamycin phosphate inj 9 gm/60ml....................... 10
clindamycin phosphate iv soln 300 mg/2ml............. 10
clindamycin phosphate lotion 1%.............................. 79
clindamycin phosphate soln 1%................................ 79
clindamycin phosphate swab 1%.............................. 79
clindamycin phosphate vaginal cream 2%............... 10
clobetasol propionate cream 0.05%.......................... 79
clobetasol propionate emollient base cream
0.05%.......................................................................... 79
clobetasol propionate gel 0.05%............................... 79
clobetasol propionate oint 0.05%.............................. 79
clobetasol propionate soln 0.05%............................. 79
CLOLAR........................................................................ 32
clomipramine hcl cap 25 mg...................................... 21
clonazepam orally disintegrating tab 0.125 mg....... 15
clonazepam orally disintegrating tab 0.125 mg....... 54
clonazepam orally disintegrating tab 0.25 mg......... 15
clonazepam orally disintegrating tab 0.25 mg......... 54
clonazepam orally disintegrating tab 0.5 mg............15
clonazepam orally disintegrating tab 0.5 mg............54
clonazepam orally disintegrating tab 1 mg............... 15
clonazepam tab 0.5 mg.............................................. 15
clonazepam tab 0.5 mg.............................................. 54
clonazepam tab 1 mg................................................. 15
clonidine hcl tab 0.1 mg..............................................66
clonidine hcl tab sr 12hr 0.1 mg................................ 76
clonidine hcl td patch weekly 0.1 mg/24hr............... 67
clopidogrel bisulfate tab 75 mg.................................. 62
clorazepate dipotassium tab 15 mg.......................... 15
clorazepate dipotassium tab 15 mg.......................... 54
clorazepate dipotassium tab 3.75 mg....................... 15
clorazepate dipotassium tab 3.75 mg....................... 54
clorazepate dipotassium tab 7.5 mg......................... 15
clorazepate dipotassium tab 7.5 mg......................... 54
clotrimazole cream 1%................................................80
clotrimazole troche 10 mg.......................................... 26
clotrimazole w/ betamethasone cream 1-0.05%......80
clotrimazole w/ betamethasone lotion 1-0.05%....... 80
clozapine orally disintegrating tab 100 mg............... 44
clozapine orally disintegrating tab 25 mg................. 44
clozapine tab 100 mg.................................................. 44
clozapine tab 200 mg.................................................. 44
clozapine tab 25 mg.................................................... 44
clozapine tab 50 mg.................................................... 44
COARTEM.....................................................................41
codeine sulfate tab 15 mg............................................ 1
COLACE........................................................................ 86
colchicine w/ probenecid tab 0.5-500 mg................. 27
COLCRYS..................................................................... 27
colestipol hcl granule packets 5 gm.......................... 67
colestipol hcl granules 5 gm...................................... 67
colestipol hcl tab 1 gm................................................ 67
colistimethate sodium for inj 150 mg........................ 10
COMBIGAN................................................................ 105
COMBIVENT RESPIMAT......................................... 109
COMETRIQ................................................................... 32
COMETRIQ................................................................... 32
COMETRIQ................................................................... 32
COMPLERA.................................................................. 49
COPAXONE.................................................................. 76
COPAXONE.................................................................. 76
CORLANOR.................................................................. 67
CORLANOR.................................................................. 67
127
2016
CORTISONE ACETATE.............................................. 91
COSMEGEN................................................................. 32
COTELLIC..................................................................... 32
COUMADIN................................................................... 62
COUMADIN................................................................... 62
COUMADIN................................................................... 62
COUMADIN................................................................... 62
COUMADIN................................................................... 62
COUMADIN................................................................... 62
COUMADIN................................................................... 62
COUMADIN................................................................... 62
COUMADIN................................................................... 62
CREON.......................................................................... 84
CREON.......................................................................... 84
CREON.......................................................................... 84
CREON.......................................................................... 84
CREON.......................................................................... 84
CRESEMBA.................................................................. 26
CRESEMBA.................................................................. 26
CRESTOR..................................................................... 67
CRESTOR..................................................................... 67
CRESTOR..................................................................... 67
CRESTOR..................................................................... 67
CRIXIVAN...................................................................... 49
CRIXIVAN...................................................................... 49
CROMOLYN SODIUM.............................................. 109
cromolyn sodium ophth soln 4%............................. 105
cromolyn sodium oral conc 100 mg/5ml................... 86
CUBICIN........................................................................ 10
CUBICIN RF................................................................. 10
CUPRIMINE.................................................................. 90
CUPRIMINE.................................................................. 99
CUPRIMINE................................................................ 115
cyanocobalamin inj 1000 mcg/ml............................ 115
cyanocobalamin liquid 1000 mcg/15ml...................115
cyanocobalamin lozenge 500 mcg.......................... 115
cyanocobalamin tab 1000 mcg................................ 115
cyanocobalamin tab 100 mcg.................................. 115
cyanocobalamin tab 2000 mcg................................ 115
cyanocobalamin tab 50 mcg.................................... 115
cyanocobalamin tab cr 1000 mcg........................... 115
cyanocobalamin tab cr 2000 mcg........................... 115
cyanocobalamin tab sl 2500 mcg............................ 115
cyanocobalamin tab sl 500 mcg.............................. 115
cyclobenzaprine hcl tab 10 mg................................ 113
cyclobenzaprine hcl tab 5 mg.................................. 113
cyclobenzaprine hcl tab 7.5 mg............................... 113
CYCLOPHOSPHAMIDE............................................. 33
128
CYCLOPHOSPHAMIDE............................................. 33
cyclophosphamide for inj 1 gm.................................. 33
cyclophosphamide for inj 2 gm.................................. 33
cyclophosphamide for inj 500 mg.............................. 33
CYCLOSERINE............................................................ 31
CYCLOSET................................................................... 58
cyclosporine cap 100 mg............................................ 99
cyclosporine cap 25 mg.............................................. 99
cyclosporine iv soln 50 mg/ml.................................... 99
cyclosporine modified cap 100 mg............................ 99
cyclosporine modified cap 25 mg.............................. 99
cyclosporine modified cap 50 mg.............................. 99
cyclosporine modified oral soln 100 mg/ml.............. 99
CYRAMZA..................................................................... 33
CYRAMZA..................................................................... 33
CYSTADANE................................................................ 84
CYSTAGON.................................................................. 84
CYSTAGON.................................................................. 84
cytarabine inj 20 mg/ml............................................... 33
cytarabine inj pf 100 mg/ml........................................ 33
cytarabine inj pf 20 mg/ml.......................................... 33
D
DACARBAZINE............................................................ 33
dacarbazine for inj 200 mg.........................................33
DAKLINZA..................................................................... 49
DAKLINZA..................................................................... 49
DAKLINZA..................................................................... 49
DALIRESP.................................................................. 109
DALVANCE................................................................... 10
danazol cap 100 mg.................................................... 93
danazol cap 200 mg.................................................... 93
danazol cap 50 mg...................................................... 93
dantrolene sodium cap 100 mg................................. 48
dantrolene sodium cap 25 mg................................... 48
dantrolene sodium cap 50 mg................................... 48
dapsone tab 100 mg................................................... 31
dapsone tab 25 mg..................................................... 31
DAPTACEL.................................................................... 99
DARAPRIM................................................................... 41
DARZALEX................................................................... 33
DARZALEX................................................................... 33
daunorubicin hcl inj 5 mg/ml...................................... 33
DAUNOXOME.............................................................. 33
decitabine for inj 50 mg.............................................. 33
DECON-A.................................................................... 109
DELZICOL................................................................... 103
demeclocycline hcl tab 150 mg................................. 10
demeclocycline hcl tab 300 mg................................. 10
DEMSER....................................................................... 67
DENAVIR....................................................................... 80
DEPEN TITRATABS.................................................... 90
2016
DEPEN TITRATABS.................................................... 99
DEPEN TITRATABS.................................................. 115
DEPO-PROVERA........................................................ 93
desipramine hcl tab 100 mg....................................... 21
desipramine hcl tab 10 mg......................................... 21
desipramine hcl tab 150 mg....................................... 21
desmopressin acetate inj 4 mcg/ml........................... 92
desmopressin acetate nasal soln 0.01%
(refrigerated).............................................................. 92
desmopressin acetate nasal spray soln 0.01%....... 92
(refrigerated).............................................................. 92
desmopressin acetate tab 0.1 mg............................. 92
desmopressin acetate tab 0.2 mg............................. 92
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01
mg(21/5)..................................................................... 93
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg..............93
desogestrel & ethinyl estradiol tab 0.15 mg-30
mcg..............................................................................93
desonide cream 0.05%............................................... 80
desonide lotion 0.05%................................................. 80
desonide oint 0.05%.................................................... 80
DESOXIMETASONE................................................... 80
desoximetasone cream 0.25%...................................80
desoximetasone gel 0.05%........................................ 80
desoximetasone oint 0.25%....................................... 80
DEXAMETHASONE.................................................... 91
DEXAMETHASONE.................................................... 91
dexamethasone elixir 0.5 mg/5ml..............................91
dexamethasone sodium phosphate inj 120
mg/30ml...................................................................... 91
dexamethasone sodium phosphate inj 20
mg/5ml........................................................................ 91
dexamethasone sodium phosphate inj 4 mg/ml...... 91
dexamethasone sodium phosphate ophth soln
0.1%.......................................................................... 105
dexamethasone tab 0.5 mg........................................91
dexamethasone tab 0.75 mg..................................... 91
dexamethasone tab 1.5 mg........................................91
dexamethasone tab 4 mg........................................... 91
dexamethasone tab 6 mg........................................... 91
DEXILANT..................................................................... 86
DEXILANT..................................................................... 86
dexmethylphenidate hcl tab 10 mg........................... 76
dexmethylphenidate hcl tab 2.5 mg.......................... 76
dexmethylphenidate hcl tab 5 mg............................. 76
dexrazoxane for inj 250 mg........................................33
dexrazoxane for inj 500 mg........................................33
dextroamphetamine sulfate cap sr 24hr 10 mg....... 77
dextroamphetamine sulfate cap sr 24hr 15 mg....... 77
dextroamphetamine sulfate cap sr 24hr 5 mg......... 76
dextroamphetamine sulfate tab 10 mg..................... 77
dextroamphetamine sulfate tab 5 mg....................... 77
dextromethorphan-guaifenesin liquid 10-100
mg/5ml...................................................................... 110
dextrose 2.5% w/ sodium chloride 0.45%.............. 115
dextrose 5% in lactated ringers............................... 115
dextrose 5% w/ sodium chloride 0.2%................... 115
dextrose 5% w/ sodium chloride 0.33%................. 115
dextrose 5% w/ sodium chloride 0.45%................. 115
dextrose 5% w/ sodium chloride 0.9%................... 115
dextrose inj 10%........................................................ 115
dextrose inj 5%.......................................................... 115
diaper rash products - ointment................................. 80
DIASTAT ACUDIAL......................................................15
DIASTAT ACUDIAL......................................................15
DIASTAT PEDIATRIC.................................................. 15
DIAZEPAM.................................................................... 15
DIAZEPAM.................................................................... 16
DIAZEPAM.................................................................... 16
DIAZEPAM.................................................................... 16
DIAZEPAM.................................................................... 54
diazepam conc 5 mg/ml..............................................16
diazepam conc 5 mg/ml..............................................54
diazepam tab 10 mg................................................... 16
diazepam tab 10 mg................................................... 54
diazepam tab 2 mg......................................................16
diazepam tab 2 mg......................................................54
diazepam tab 5 mg......................................................16
diazepam tab 5 mg......................................................54
dibucaine oint 1%........................................................ 80
diclofenac potassium tab 50 mg.................................. 1
diclofenac potassium tab 50 mg................................ 28
diclofenac sodium gel 1%............................................. 1
diclofenac sodium gel 1%...........................................28
diclofenac sodium ophth soln 0.1%........................ 105
diclofenac sodium tab delayed release 25 mg........... 1
diclofenac sodium tab delayed release 25 mg........ 28
diclofenac sodium tab sr 24hr 100 mg........................1
diclofenac sodium tab sr 24hr 100 mg..................... 28
diclofenac w/ misoprostol tab delayed release 50-0.2
mg.................................................................................. 1
mg................................................................................28
129
2016
mg.................................................................................. 1
mg................................................................................28
dicloxacillin sodium cap 250 mg................................ 10
dicloxacillin sodium cap 500 mg................................ 10
dicyclomine hcl tab 20 mg.......................................... 86
didanosine delayed release capsule 125 mg........... 49
DIFICID.......................................................................... 11
DIFLORASONE DIACETATE..................................... 80
DIGOXIN........................................................................67
digoxin tab 125 mcg (0.125 mg)................................67
digoxin tab 250 mcg (0.25 mg).................................. 67
DILANTIN...................................................................... 16
diltiazem hcl cap sr 12hr 120 mg.............................. 67
diltiazem hcl cap sr 12hr 60 mg................................ 67
diltiazem hcl cap sr 12hr 90 mg................................ 67
diltiazem hcl coated beads cap sr 24hr 120 mg...... 67
diltiazem hcl coated beads tab sr 24hr 180 mg....... 67
diltiazem hcl extended release beads cap sr 24hr
120 mg....................................................................... 67
180 mg....................................................................... 67
240 mg....................................................................... 67
300 mg....................................................................... 67
360 mg....................................................................... 67
420 mg....................................................................... 68
diltiazem hcl tab 120 mg............................................ 68
diltiazem hcl tab 30 mg............................................... 68
dimethicone lotion 1%................................................. 80
DIPENTUM................................................................. 103
diphenhydramine hcl cap 25 mg............................... 25
130
diphenhydramine hcl cap 25 mg............................... 42
diphenhydramine hcl inj 50 mg/ml.............................25
diphenhydramine hcl inj 50 mg/ml.............................42
diphenhydramine hcl tab 25 mg................................ 25
diphenhydramine hcl tab 25 mg................................ 42
diphenhydramine-phenylephrine liq 6.25-2.5
mg/5ml...................................................................... 110
diphenhydramine-phenylephrine soln 12.5-5
mg/5ml...................................................................... 110
diphenhydramine-phenylephrine tab 25-10 mg..... 110
DIPHTHERIA/TETANUS TOXOID.......................... 100
dipyridamole tab 25 mg.............................................. 62
disulfiram tab 250 mg.................................................... 6
disulfiram tab 500 mg.................................................... 6
divalproex sodium cap delayed release sprinkle 125
mg................................................................................16
mg................................................................................29
mg................................................................................56
divalproex sodium tab delayed release 125 mg...... 16
divalproex sodium tab sr 24 hr 250 mg.................... 16
DIVIGEL......................................................................... 93
DIVIGEL......................................................................... 93
DIVIGEL......................................................................... 93
DOCEFREZ.................................................................. 33
DOCETAXEL.................................................................33
DOCETAXEL.................................................................33
DOCETAXEL.................................................................33
DOCETAXEL.................................................................33
DOCETAXEL.................................................................33
DOCETAXEL.................................................................33
DOCETAXEL.................................................................33
DOCETAXEL.................................................................33
docetaxel for inj conc 20 mg/ml................................. 33
docetaxel for inj conc 80 mg/4ml (20 mg/ml)........... 33
docusate calcium cap 240 mg................................... 86
2016
docusate sodium cap 100 mg.................................... 86
docusate sodium cap 250 mg.................................... 86
docusate sodium liquid 150 mg/15ml....................... 86
docusate sodium syrup 60 mg/15ml......................... 86
docusate sodium tab 100 mg.....................................86
dofetilide cap 125 mcg (0.125 mg)............................68
dofetilide cap 250 mcg (0.25 mg).............................. 68
dofetilide cap 500 mcg (0.5 mg)................................ 68
DOMETUSS-DA/CHILDREN................................... 110
donepezil hydrochloride orally disintegrating tab 10
mg................................................................................19
donepezil hydrochloride orally disintegrating tab 5
mg................................................................................19
donepezil hydrochloride tab 10 mg........................... 19
donepezil hydrochloride tab 23 mg........................... 19
donepezil hydrochloride tab 5 mg............................. 19
dorzolamide hcl ophth soln 2%............................... 105
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8
mg/ml........................................................................ 105
doxazosin mesylate tab 1 mg.................................... 68
DOXEPIN HCL............................................................. 21
DOXEPIN HCL............................................................. 54
doxepin hcl cap 100 mg............................................. 21
doxepin hcl cap 10 mg............................................... 21
doxepin hcl conc 10 mg/ml........................................ 21
doxepin hcl conc 10 mg/ml........................................ 54
doxorubicin hcl for inj 10 mg...................................... 33
doxorubicin hcl for inj 50 mg...................................... 33
doxorubicin hcl inj 2 mg/ml.........................................33
doxorubicin hcl liposomal inj (for iv infusion) 2 mg/
ml................................................................................. 33
doxycycline hyclate cap 100 mg................................11
doxycycline hyclate cap 100 mg................................78
doxycycline hyclate cap 50 mg.................................. 11
doxycycline hyclate cap 50 mg.................................. 78
doxycycline hyclate for inj 100 mg............................ 11
doxycycline hyclate for inj 100 mg............................ 78
doxycycline hyclate tab 100 mg................................ 11
doxycycline hyclate tab 100 mg................................ 78
doxycycline hyclate tab 20 mg...................................11
doxycycline hyclate tab 20 mg...................................78
doxycycline monohydrate cap 100 mg..................... 11
doxycycline monohydrate cap 150 mg..................... 11
doxycycline monohydrate cap 50 mg....................... 11
doxycycline monohydrate cap 75 mg....................... 11
doxycycline monohydrate tab 100 mg...................... 11
doxycycline monohydrate tab 150 mg...................... 11
doxycycline monohydrate tab 50 mg........................ 11
doxycycline monohydrate tab 75 mg........................ 11
DRAMAMINE................................................................ 25
dronabinol cap 10 mg................................................. 25
dronabinol cap 2.5 mg................................................ 25
dronabinol cap 5 mg................................................... 25
drospirenone-ethinyl estradiol tab 3-0.02 mg.......... 93
drospirenone-ethinyl estradiol tab 3-0.03 mg.......... 93
DULERA...................................................................... 110
DULERA...................................................................... 110
duloxetine hcl enteric coated pellets cap 20 mg...... 21
DUREZOL................................................................... 105
dutasteride cap 0.5 mg............................................... 90
dutasteride-tamsulosin hcl cap 0.5-0.4 mg.............. 90
E
E.E.S. GRANULES...................................................... 11
econazole nitrate cream 1%...................................... 80
ED CHLORPED D..................................................... 110
EDURANT..................................................................... 49
EFFIENT........................................................................ 62
EFFIENT........................................................................ 62
EGRIFTA....................................................................... 92
EGRIFTA....................................................................... 92
ELAPRASE................................................................... 84
electrolyte-m in d5w soln.......................................... 115
ELELYSO.......................................................................84
ELIDEL........................................................................... 80
ELIDEL........................................................................ 100
ELIGARD....................................................................... 97
ELIGARD....................................................................... 97
ELIGARD....................................................................... 97
ELIGARD....................................................................... 97
ELIQUIS......................................................................... 62
131
2016
ELIQUIS......................................................................... 62
ELITEK........................................................................... 33
ELITEK........................................................................... 34
ELLA...............................................................................93
EMCYT.......................................................................... 34
EMEND.......................................................................... 25
EMEND.......................................................................... 25
EMEND.......................................................................... 25
EMEND.......................................................................... 25
EMEND.......................................................................... 25
EMETROL..................................................................... 25
EMPLICITI..................................................................... 34
EMPLICITI..................................................................... 34
EMSAM.......................................................................... 21
EMSAM.......................................................................... 21
EMSAM.......................................................................... 21
EMTRIVA....................................................................... 49
EMTRIVA....................................................................... 49
enalapril maleate & hydrochlorothiazide tab 10-25
mg................................................................................68
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg................................................................................68
enalapril maleate tab 10 mg...................................... 68
enalapril maleate tab 2.5 mg..................................... 68
enalapril maleate tab 20 mg...................................... 68
enalapril maleate tab 5 mg.........................................68
ENBREL...................................................................... 100
ENBREL...................................................................... 100
ENBREL...................................................................... 100
ENBREL SURECLICK.............................................. 100
ENCARE........................................................................ 80
ENGERIX-B................................................................ 100
ENGERIX-B................................................................ 100
enoxaparin sodium inj 100 mg/ml............................. 62
enoxaparin sodium inj 120 mg/0.8ml........................ 62
enoxaparin sodium inj 150 mg/ml............................. 63
enoxaparin sodium inj 300 mg/3ml........................... 63
enoxaparin sodium inj 30 mg/0.3ml.......................... 62
entacapone tab 200 mg.............................................. 42
entecavir tab 0.5 mg................................................... 49
entecavir tab 1 mg....................................................... 49
epinastine hcl ophth soln 0.05%............................. 105
EPIPEN 2-PAK........................................................... 110
EPIPEN-JR 2-PAK..................................................... 110
epirubicin hcl iv soln 200 mg/100ml (2 mg/ml)........ 34
epirubicin hcl iv soln 50 mg/25ml (2 mg/ml)............. 34
EPIVIR HBV.................................................................. 49
eplerenone tab 25 mg................................................. 68
eplerenone tab 50 mg................................................. 68
132
EPOGEN....................................................................... 63
EPOGEN....................................................................... 63
EPOGEN....................................................................... 63
EPOGEN....................................................................... 63
EPOGEN....................................................................... 63
eprosartan mesylate tab 600 mg............................... 68
EPZICOM...................................................................... 49
EQL NATURAL FIBER................................................ 86
EQUETRO..................................................................... 56
EQUETRO..................................................................... 56
EQUETRO..................................................................... 56
ERBITUX....................................................................... 34
ERBITUX....................................................................... 34
ergoloid mesylates tab 1 mg...................................... 19
ERIVEDGE.................................................................... 34
ERWINAZE................................................................... 34
ERYPED 200................................................................ 11
ERYPED 400................................................................ 11
ERY-TAB....................................................................... 11
ERY-TAB....................................................................... 11
ERY-TAB....................................................................... 11
ERYTHROCIN LACTOBIONATE...............................11
ERYTHROCIN STEARATE........................................ 11
ERYTHROMYCIN BASE............................................ 11
ERYTHROMYCIN BASE............................................ 11
erythromycin ophth oint 5 mg/gm............................ 105
erythromycin pads 2%................................................ 80
erythromycin soln 2%.................................................. 80
ESBRIET..................................................................... 110
escitalopram oxalate soln 5 mg/5ml..........................21
escitalopram oxalate soln 5 mg/5ml..........................54
escitalopram oxalate tab 10 mg................................ 21
escitalopram oxalate tab 5 mg...................................21
escitalopram oxalate tab 5 mg...................................54
esomeprazole magnesium cap delayed release 20
mg................................................................................86
esomeprazole magnesium cap delayed release 40
mg................................................................................86
ESOMEPRAZOLE SODIUM...................................... 86
esomeprazole sodium for intravenous soln 40
mg................................................................................86
ESTRACE......................................................................93
estradiol & norethindrone acetate tab 0.5-0.1
mg................................................................................93
estradiol & norethindrone acetate tab 1-0.5 mg...... 93
estradiol tab 0.5 mg.....................................................93
estradiol tab 1 mg........................................................ 94
estradiol tab 2 mg........................................................ 94
estradiol td patch weekly 0.025 mg/24hr.................. 94
2016
estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr)................................................................... 94
estradiol td patch weekly 0.05 mg/24hr.................... 94
estradiol td patch weekly 0.06 mg/24hr.................... 94
estradiol td patch weekly 0.075 mg/24hr.................. 94
estradiol td patch weekly 0.1 mg/24hr...................... 94
ESTROPIPATE............................................................. 94
estropipate tab 0.75 mg.............................................. 94
estropipate tab 1.5 mg................................................ 94
ethambutol hcl tab 100 mg.........................................31
ethambutol hcl tab 400 mg.........................................31
ethosuximide cap 250 mg.......................................... 16
ethosuximide soln 250 mg/5ml.................................. 16
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35
mcg..............................................................................94
ETIDRONATE DISODIUM........................................ 104
ETIDRONATE DISODIUM........................................ 104
etodolac cap 200 mg..................................................... 2
etodolac cap 200 mg...................................................28
etodolac cap 300 mg..................................................... 2
etodolac cap 300 mg...................................................28
etodolac tab 400 mg......................................................2
etodolac tab 400 mg................................................... 28
etodolac tab 500 mg......................................................2
etodolac tab 500 mg................................................... 28
etodolac tab sr 24hr 400 mg........................................ 2
etodolac tab sr 24hr 400 mg...................................... 28
ETOPOPHOS............................................................... 34
etoposide inj 100 mg/5ml (20 mg/ml)....................... 34
etoposide inj 1 gm/50ml (20 mg/ml).......................... 34
etoposide inj 500 mg/25ml (20 mg/ml)..................... 34
EVOMELA..................................................................... 34
EVOTAZ......................................................................... 49
EXELON........................................................................ 19
EXELON........................................................................ 19
EXELON........................................................................ 19
exemestane tab 25 mg............................................... 34
EXJADE....................................................................... 115
EXJADE....................................................................... 115
EXJADE....................................................................... 116
EX-LAX.......................................................................... 86
F
FABRAZYME................................................................ 84
FABRAZYME................................................................ 84
famciclovir tab 125 mg................................................ 49
famotidine for susp 40 mg/5ml.................................. 86
famotidine inj 200 mg/20ml........................................ 86
famotidine inj 20 mg/2ml.............................................86
famotidine inj 40 mg/4ml.............................................86
famotidine tab 10 mg.................................................. 87
FANAPT......................................................................... 44
FANAPT......................................................................... 44
FANAPT......................................................................... 44
FANAPT......................................................................... 44
FANAPT......................................................................... 44
FANAPT......................................................................... 44
FANAPT......................................................................... 44
FANAPT TITRATION PACK....................................... 44
FARESTON................................................................... 34
FARYDAK...................................................................... 34
FARYDAK...................................................................... 34
FARYDAK...................................................................... 34
FASLODEX................................................................... 34
fat emulsion iv soln 20%.......................................... 116
FAZACLO...................................................................... 44
FAZACLO...................................................................... 44
FAZACLO...................................................................... 44
FAZACLO...................................................................... 44
FAZACLO...................................................................... 44
felbamate susp 600 mg/5ml....................................... 16
felbamate tab 400 mg................................................. 16
felbamate tab 600 mg................................................. 16
felodipine tab sr 24hr 10 mg...................................... 68
felodipine tab sr 24hr 2.5 mg..................................... 68
felodipine tab sr 24hr 5 mg........................................ 68
fenofibrate micronized cap 134 mg........................... 68
fenofibrate micronized cap 200 mg........................... 68
fenofibrate micronized cap 67 mg............................. 68
fenofibrate tab 145 mg................................................ 68
fenofibrate tab 160 mg................................................ 68
fenofibrate tab 48 mg.................................................. 68
fenofibrate tab 54 mg.................................................. 68
fentanyl citrate lozenge on a handle 1200 mcg......... 2
fentanyl citrate lozenge on a handle 1600 mcg......... 2
fentanyl citrate lozenge on a handle 200 mcg........... 2
fentanyl td patch 72hr 100 mcg/hr...............................2
fentanyl td patch 72hr 12 mcg/hr................................. 2
ferrous gluconate tab 325 mg (36 mg elemental
fe).............................................................................. 116
133
2016
FERROUS SULFATE................................................ 116
FERROUS SULFATE................................................ 116
ferrous sulfate dried tab 200 mg (65 mg elemental
fe).............................................................................. 116
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml
elemental fe)............................................................116
ferrous sulfate tab 325 mg (65 mg elemental
fe).............................................................................. 116
ferrous sulfate tab ec 325 mg (65 mg fe
equivalent)............................................................... 116
FETZIMA....................................................................... 21
FETZIMA....................................................................... 22
FETZIMA....................................................................... 22
FETZIMA....................................................................... 22
FETZIMA TITRATION PACK......................................22
FIBERCON.................................................................... 87
FINACEA....................................................................... 80
FINACEA....................................................................... 80
finasteride tab 5 mg.....................................................90
FIRAZYR..................................................................... 100
FIRMAGON................................................................... 97
FIRMAGON................................................................... 97
flecainide acetate tab 100 mg.................................... 68
flecainide acetate tab 150 mg.................................... 68
flecainide acetate tab 50 mg...................................... 68
FLEET LIQUID GLYCERIN SUPPOSITORIES....... 87
FLOVENT DISKUS.................................................... 110
FLOVENT DISKUS.................................................... 110
FLOVENT DISKUS.................................................... 110
FLOVENT HFA........................................................... 110
FLOVENT HFA........................................................... 110
FLOVENT HFA........................................................... 110
fluconazole for susp 10 mg/ml................................... 26
fluconazole for susp 40 mg/ml................................... 26
fluconazole in dextrose inj 200 mg/100ml................ 26
fluconazole in dextrose inj 400 mg/200ml................ 26
fluconazole in nacl 0.9% inj 200 mg/100ml.............. 26
fluconazole in nacl 0.9% inj 400 mg/200ml.............. 26
fluconazole tab 100 mg.............................................. 26
fluconazole tab 50 mg.................................................26
flucytosine cap 250 mg............................................... 26
flucytosine cap 500 mg............................................... 26
fludarabine phosphate for inj 50 mg......................... 34
fludarabine phosphate inj 25 mg/ml.......................... 34
fludrocortisone acetate tab 0.1 mg............................ 91
fluocinolone acetonide (otic) oil 0.01%................... 107
fluocinolone acetonide cream 0.01%........................ 80
fluocinonide cream 0.05%.......................................... 80
fluocinonide emulsified base cream 0.05%.............. 80
fluocinonide gel 0.05%................................................ 80
134
fluocinonide oint 0.05%............................................... 80
fluocinonide soln 0.05%.............................................. 80
fluorometholone ophth susp 0.1%...........................105
fluorouracil cream 5%................................................. 80
fluorouracil inj 1 gm/20ml (50 mg/ml)........................34
fluorouracil inj 2.5 gm/50ml (50 mg/ml).................... 34
fluorouracil inj 500 mg/10ml (50 mg/ml)................... 34
fluorouracil inj 5 gm/100ml (50 mg/ml)..................... 34
fluorouracil soln 2%..................................................... 80
fluorouracil soln 5%..................................................... 80
fluoxetine hcl cap 10 mg............................................ 22
fluoxetine hcl cap delayed release 90 mg................ 22
fluoxetine hcl solution 20 mg/5ml.............................. 22
fluoxetine hcl tab 10 mg............................................. 22
fluoxetine hcl tab 20 mg............................................. 22
fluphenazine decanoate inj 25 mg/ml....................... 44
FLUPHENAZINE HCL................................................. 44
fluphenazine hcl tab 10 mg........................................ 44
fluphenazine hcl tab 1 mg.......................................... 44
fluphenazine hcl tab 2.5 mg....................................... 44
fluphenazine hcl tab 5 mg.......................................... 44
flurbiprofen sodium ophth soln 0.03%.................... 105
flurbiprofen tab 100 mg................................................. 2
flurbiprofen tab 100 mg............................................... 28
flurbiprofen tab 50 mg................................................... 2
flurbiprofen tab 50 mg................................................. 28
flutamide cap 125 mg................................................. 34
fluticasone propionate cream 0.05%.........................80
fluticasone propionate nasal susp 50 mcg/act.......110
fluticasone propionate oint 0.005%........................... 80
fluvoxamine maleate tab 100 mg.............................. 22
fluvoxamine maleate tab 25 mg................................ 22
fluvoxamine maleate tab 50 mg................................ 22
folic acid tab 400 mcg............................................... 116
folic acid tab 800 mcg............................................... 116
FOLOTYN......................................................................34
FOLOTYN......................................................................34
fomepizole inj 1 gm/ml (for iv infusion)................... 116
fondaparinux sodium subcutaneous inj 10
mg/0.8ml..................................................................... 63
fondaparinux sodium subcutaneous inj 2.5
mg/0.5ml..................................................................... 63
fondaparinux sodium subcutaneous inj 5
mg/0.4ml..................................................................... 63
fondaparinux sodium subcutaneous inj 7.5
mg/0.6ml..................................................................... 63
FORADIL AEROLIZER............................................. 110
FORTAZ......................................................................... 11
2016
FORTAZ......................................................................... 11
FORTAZ......................................................................... 11
FORTEO...................................................................... 104
FORTICAL...................................................................104
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg................................................................................68
fosinopril sodium & hydrochlorothiazide tab 20-12.5
mg................................................................................68
fosinopril sodium tab 10 mg....................................... 68
fosphenytoin sodium inj 100 mg/2ml........................ 16
fosphenytoin sodium inj 500 mg/10ml...................... 16
FOSRENOL.................................................................. 90
FOSRENOL.................................................................. 90
FOSRENOL.................................................................. 90
FOSRENOL.................................................................. 90
FOSRENOL.................................................................. 90
FUNGOID TINCTURE.................................................80
furosemide inj 10 mg/ml............................................. 69
furosemide oral soln 10 mg/ml.................................. 69
furosemide tab 20 mg................................................. 69
FUZEON........................................................................ 49
FYCOMPA..................................................................... 16
FYCOMPA..................................................................... 16
FYCOMPA..................................................................... 16
FYCOMPA..................................................................... 16
FYCOMPA..................................................................... 16
FYCOMPA..................................................................... 16
FYCOMPA..................................................................... 16
G
gabapentin cap 100 mg.............................................. 16
gabapentin oral soln 250 mg/5ml.............................. 16
gabapentin tab 600 mg............................................... 16
gabapentin tab 800 mg............................................... 16
GABITRIL...................................................................... 16
GABITRIL...................................................................... 16
GALANTAMINE HYDROBROMIDE.......................... 19
galantamine hydrobromide cap sr 24hr 16 mg........ 19
galantamine hydrobromide cap sr 24hr 24 mg........ 19
galantamine hydrobromide cap sr 24hr 8 mg.......... 19
galantamine hydrobromide tab 12 mg...................... 19
galantamine hydrobromide tab 4 mg........................ 19
galantamine hydrobromide tab 8 mg........................ 19
GAMMAPLEX............................................................. 100
GAMMAPLEX............................................................. 100
GAMMAPLEX............................................................. 100
GAMMAPLEX............................................................. 100
GAMUNEX-C.............................................................. 100
GAMUNEX-C.............................................................. 100
GAMUNEX-C.............................................................. 100
GAMUNEX-C.............................................................. 100
GAMUNEX-C.............................................................. 100
GAMUNEX-C.............................................................. 100
ganciclovir sodium for inj 500 mg.............................. 50
GARDASIL.................................................................. 100
GARDASIL 9.............................................................. 100
GARDASIL 9.............................................................. 100
GATTEX......................................................................... 87
GAUZE PADS 2" X 2"................................................. 58
GAVISCON.................................................................... 87
GAVISCON.................................................................... 87
GAVISCON EXTRA STRENGTH RELIEF
FORMULA.................................................................. 87
GAZYVA.........................................................................34
GELUSIL........................................................................87
gemcitabine hcl for inj 1 gm....................................... 34
gemcitabine hcl for inj 200 mg...................................34
gemcitabine hcl for inj 2 gm....................................... 34
gemcitabine hcl inj 1 gm/26.3ml (38 mg/ml)............ 34
gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml)........ 34
gemcitabine hcl inj 2 gm/52.6ml (38 mg/ml)............ 35
gemfibrozil tab 600 mg............................................... 69
gentamicin in saline inj 0.8 mg/ml............................. 11
gentamicin in saline inj 1 mg/ml................................ 11
GENTAMICIN SULFATE............................................. 80
GENTAMICIN SULFATE............................................. 81
GENTAMICIN SULFATE/0.9% SODIUM
CHLORIDE.................................................................12
GENTAMICIN SULFATE/0.9% SODIUM
CHLORIDE.................................................................12
gentamicin sulfate inj 10 mg/ml................................. 11
gentamicin sulfate inj 40 mg/ml................................. 11
gentamicin sulfate iv soln 10 mg/ml.......................... 11
gentamicin sulfate ophth oint 0.3%......................... 105
gentamicin sulfate ophth soln 0.3%........................ 105
GENTEAL SEVERE.................................................. 105
GENVOYA..................................................................... 50
GEODON....................................................................... 44
GILOTRIF...................................................................... 35
GILOTRIF...................................................................... 35
GILOTRIF...................................................................... 35
Glatopa - glatiramer acetate soln prefilled syringe 20
mg/ml.......................................................................... 77
GLEEVEC......................................................................35
GLEEVEC......................................................................35
GLEOSTINE..................................................................35
135
2016
GLEOSTINE..................................................................35
GLEOSTINE..................................................................35
GLEOSTINE..................................................................35
glimepiride tab 1 mg.................................................... 58
glipizide-metformin hcl tab 2.5-250 mg.....................58
glipizide-metformin hcl tab 2.5-500 mg.....................58
glipizide-metformin hcl tab 5-500 mg........................ 58
glipizide tab 10 mg...................................................... 58
glipizide tab 5 mg........................................................ 58
glipizide tab sr 24hr 10 mg.........................................58
glipizide tab sr 24hr 2.5 mg........................................58
glipizide tab sr 24hr 5 mg........................................... 58
GLUCAGEN HYPOKIT............................................... 58
GLUCAGON EMERGENCY KIT............................... 58
GLUCOSE..................................................................... 58
GLYCERIN.................................................................... 87
glycerin suppos 1.2 gm............................................... 87
glycerin suppos 1 gm.................................................. 87
glycerin suppos 2 gm.................................................. 87
glycerin suppos 80.7%................................................ 87
glycerin topical liquid................................................... 87
glycopyrrolate tab 1 mg.............................................. 87
glycopyrrolate tab 2 mg.............................................. 87
granisetron hcl tab 1 mg............................................. 25
GRANIX......................................................................... 63
GRANIX......................................................................... 63
GRASTEK................................................................... 110
griseofulvin microsize susp 125 mg/5ml................... 26
griseofulvin ultramicrosize tab 125 mg..................... 26
griseofulvin ultramicrosize tab 250 mg..................... 26
guaifenesin-codeine soln 100-10 mg/5ml.............. 110
guaifenesin liquid 100 mg/5ml................................. 110
GUANIDINE HCL......................................................... 30
GYNE-LOTRIMIN......................................................... 26
GYNE-LOTRIMIN 3..................................................... 27
H
H.P. ACTHAR............................................................... 91
HALAVEN...................................................................... 35
halobetasol propionate cream 0.05%....................... 81
halobetasol propionate oint 0.05%............................ 81
haloperidol decanoate im soln 100 mg/ml................44
haloperidol decanoate im soln 50 mg/ml.................. 44
haloperidol lactate inj 5 mg/ml................................... 44
haloperidol lactate oral conc 2 mg/ml....................... 44
haloperidol tab 0.5 mg................................................ 45
haloperidol tab 10 mg................................................. 45
haloperidol tab 1 mg................................................... 45
haloperidol tab 20 mg................................................. 45
136
HARVONI...................................................................... 50
HAVRIX........................................................................100
HAVRIX........................................................................100
HEMORRHOIDAL........................................................ 81
heparin sodium (porcine) 40 unit/ml in d5w............. 63
heparin sodium (porcine) inj 10000 unit/ml.............. 63
heparin sodium (porcine) inj 1000 unit/ml................ 63
heparin sodium (porcine) inj 20000 unit/ml.............. 63
heparin sodium (porcine) inj 5000 unit/ml................ 63
heparin sodium (porcine) pf inj 5000 unit/0.5ml.......63
HERCEPTIN................................................................. 35
HETLIOZ..................................................................... 113
HEXALEN...................................................................... 35
HIBERIX...................................................................... 101
HM VITAMIN D3........................................................ 116
HUMALOG.................................................................... 58
HUMALOG.................................................................... 58
HUMALOG KWIKPEN.................................................58
HUMALOG KWIKPEN.................................................59
HUMALOG MIX 50/50................................................ 59
HUMALOG MIX 50/50 KWIKPEN............................. 59
HUMALOG MIX 75/25................................................ 59
HUMALOG MIX 75/25 KWIKPEN............................. 59
HUMIRA...................................................................... 101
HUMIRA...................................................................... 101
HUMIRA...................................................................... 101
HUMIRA PEDIATRIC CROHNS DISEASE
STARTER PACK..................................................... 101
HUMIRA PEN............................................................. 101
HUMIRA PEN-CROHNS DISEASE STARTER..... 101
HUMIRA PEN-PSORIASIS STARTER................... 101
HUMULIN 70/30........................................................... 59
HUMULIN 70/30 KWIKPEN....................................... 59
HUMULIN N.................................................................. 59
HUMULIN N KWIKPEN.............................................. 59
HUMULIN R.................................................................. 59
HUMULIN R U-500 (CONCENTRATE).................... 59
HUMULIN R U-500 KWIKPEN.................................. 59
hydralazine hcl tab 100 mg........................................ 69
hydralazine hcl tab 10 mg.......................................... 69
hydrochlorothiazide cap 12.5 mg.............................. 69
hydrochlorothiazide tab 12.5 mg............................... 69
hydrochlorothiazide tab 25 mg...................................69
hydrochlorothiazide tab 50 mg...................................69
hydrocodone-acetaminophen soln 7.5-325
mg/15ml........................................................................ 2
hydrocodone-acetaminophen tab 10-300 mg............ 2
hydrocodone-acetaminophen tab 10-325 mg............ 2
hydrocodone-acetaminophen tab 5-300 mg.............. 2
2016
hydrocodone-acetaminophen tab 5-325 mg.............. 2
hydrocodone-acetaminophen tab 7.5-300 mg........... 2
hydrocodone-acetaminophen tab 7.5-325 mg........... 2
hydrocodone-ibuprofen tab 10-200 mg....................... 2
hydrocodone-ibuprofen tab 5-200 mg......................... 2
hydrocodone-ibuprofen tab 7.5-200 mg......................2
hydrocortisone acetate cream 1%............................. 81
hydrocortisone-aloe vera cream 1%......................... 81
hydrocortisone butyrate cream 0.1%........................ 81
hydrocortisone butyrate oint 0.1%............................. 81
hydrocortisone butyrate soln 0.1%............................ 81
hydrocortisone cream 0.5%........................................81
hydrocortisone cream 1%........................................... 81
hydrocortisone cream 1%........................................... 81
hydrocortisone cream 2.5%........................................81
hydrocortisone enema 100 mg/60ml...................... 103
hydrocortisone lotion 1%............................................ 81
hydrocortisone lotion 2.5%......................................... 81
hydrocortisone oint 0.5%............................................ 81
hydrocortisone oint 1%............................................... 81
hydrocortisone oint 2.5%............................................ 81
hydrocortisone rectal cream 1%.............................. 103
hydrocortisone rectal cream 2.5%...........................103
hydrocortisone tab 10 mg........................................... 92
hydrocortisone tab 20 mg........................................... 92
hydrocortisone tab 5 mg............................................. 91
hydrocortisone valerate cream 0.2%........................ 81
hydrocortisone valerate oint 0.2%............................. 81
hydrocortisone w/ acetic acid otic soln 1-2%......... 107
hydromorphone hcl liqd 1 mg/ml................................. 2
hydromorphone hcl preservative free inj 10 mg/
ml................................................................................... 2
hydromorphone hcl tab 2 mg....................................... 2
hydroxychloroquine sulfate tab 200 mg.................... 41
HYDROXYPROGESTERONE CAPROATE............ 35
hydroxyurea cap 500 mg............................................ 35
hydroxyzine hcl syrup 10 mg/5ml.............................. 25
hydroxyzine hcl syrup 10 mg/5ml.............................. 54
hydroxyzine hcl syrup 10 mg/5ml............................ 110
hydroxyzine hcl tab 10 mg......................................... 25
hydroxyzine hcl tab 10 mg....................................... 110
hypromellose ophth soln 0.3%................................ 105
hypromellose ophth soln 0.4%................................ 105
I
ibandronate sodium iv soln 3 mg/3ml..................... 104
ibandronate sodium tab 150 mg..............................104
IBRANCE....................................................................... 35
IBRANCE....................................................................... 35
IBRANCE....................................................................... 35
ibuprofen cap 200 mg................................................... 3
ibuprofen cap 200 mg................................................. 28
ibuprofen susp 100 mg/5ml.......................................... 3
ibuprofen susp 100 mg/5ml........................................ 28
ibuprofen tab 200 mg.................................................... 3
ibuprofen tab 200 mg.................................................. 28
ibuprofen tab 400 mg.................................................... 3
ibuprofen tab 400 mg.................................................. 28
ibuprofen tab 600 mg.................................................... 3
ibuprofen tab 600 mg.................................................. 28
ibuprofen tab 800 mg.................................................... 3
ibuprofen tab 800 mg.................................................. 28
ICLUSIG........................................................................ 35
ICLUSIG........................................................................ 35
idarubicin hcl iv inj 10 mg/10ml (1 mg/ml)................ 35
idarubicin hcl iv inj 20 mg/20ml (1 mg/ml)................ 35
idarubicin hcl iv inj 5 mg/5ml (1 mg/ml).................... 35
IFEX............................................................................... 35
IFOSFAMIDE................................................................ 35
ifosfamide for inj 1 gm................................................ 35
ifosfamide iv inj 1 gm/20ml (50 mg/ml)..................... 35
ifosfamide iv inj 3 gm/60ml (50 mg/ml)..................... 35
ILARIS..........................................................................101
ILEVRO........................................................................105
imatinib mesylate tab 100 mg.................................... 35
imatinib mesylate tab 400 mg.................................... 35
IMBRUVICA.................................................................. 35
imipenem-cilastatin intravenous for soln 250
mg................................................................................12
imipenem-cilastatin intravenous for soln 500
mg................................................................................12
imipramine hcl tab 10 mg........................................... 22
imiquimod cream 5%................................................... 81
IMLYGIC........................................................................ 35
IMLYGIC........................................................................ 35
IMOVAX RABIES (H.D.C.V.).................................... 101
INCRELEX.................................................................... 92
INCRUSE ELLIPTA................................................... 111
indapamide tab 1.25 mg............................................. 69
indapamide tab 2.5 mg............................................... 69
INFANRIX.................................................................... 101
INLYTA........................................................................... 35
INLYTA........................................................................... 35
137
2016
INSTA-GLUCOSE........................................................ 59
INSULIN INJECTION DEVICE.................................. 59
INSULIN SYRINGE/NEEDLE.....................................59
INTELENCE.................................................................. 50
INTELENCE.................................................................. 50
INTELENCE.................................................................. 50
INTRON A..................................................................... 50
INTRON A..................................................................... 50
INTRON A..................................................................... 50
INTRON A..................................................................... 50
INTRON A..................................................................... 50
INTRON A W/DILUENT.............................................. 50
INVANZ.......................................................................... 12
INVANZ.......................................................................... 12
INVEGA......................................................................... 45
INVEGA......................................................................... 45
INVEGA......................................................................... 45
INVEGA......................................................................... 45
INVEGA SUSTENNA.................................................. 45
INVEGA SUSTENNA.................................................. 45
INVEGA SUSTENNA.................................................. 45
INVEGA SUSTENNA.................................................. 45
INVEGA SUSTENNA.................................................. 45
INVEGA TRINZA..........................................................45
INVEGA TRINZA..........................................................45
INVEGA TRINZA..........................................................45
INVEGA TRINZA..........................................................45
INVIRASE...................................................................... 50
INVIRASE...................................................................... 50
INVOKAMET................................................................. 59
INVOKAMET................................................................. 59
INVOKAMET................................................................. 59
INVOKAMET................................................................. 59
INVOKANA.................................................................... 59
INVOKANA.................................................................... 59
IPOL INACTIVATED IPV.......................................... 101
ipratropium bromide nasal soln 0.03% (21 mcg/
spray)........................................................................ 111
ipratropium bromide nasal soln 0.06% (42 mcg/
spray)........................................................................ 111
irbesartan-hydrochlorothiazide tab 150-12.5 mg..... 69
irbesartan-hydrochlorothiazide tab 300-12.5 mg..... 69
irbesartan tab 150 mg................................................. 69
irbesartan tab 300 mg................................................. 69
irbesartan tab 75 mg................................................... 69
IRESSA.......................................................................... 36
IRINOTECAN................................................................ 36
irinotecan hcl inj 100 mg/5ml (20 mg/ml)................. 36
irinotecan hcl inj 40 mg/2ml (20 mg/ml)....................36
ISENTRESS.................................................................. 50
138
ISENTRESS.................................................................. 50
ISENTRESS.................................................................. 50
ISENTRESS.................................................................. 50
ISONIAZID.................................................................... 31
isoniazid tab 100 mg................................................... 31
isoniazid tab 300 mg................................................... 31
ISOPTO TEARS.........................................................105
isosorbide dinitrate tab 10 mg................................... 69
isosorbide dinitrate tab 5 mg......................................69
isosorbide dinitrate tab cr 40 mg............................... 69
isosorbide mononitrate tab 10 mg............................. 69
isosorbide mononitrate tab 20 mg............................. 69
isosorbide mononitrate tab sr 24hr 120 mg............. 69
isosorbide mononitrate tab sr 24hr 30 mg................69
isosorbide mononitrate tab sr 24hr 60 mg................69
isotretinoin cap 10 mg.................................................81
isradipine cap 2.5 mg.................................................. 69
isradipine cap 5 mg..................................................... 69
ISTALOL...................................................................... 106
ISTODAX....................................................................... 36
itraconazole cap 100 mg............................................ 27
ivermectin tab 3 mg..................................................... 41
IXEMPRA KIT............................................................... 36
IXEMPRA KIT............................................................... 36
IXIARO......................................................................... 101
J
JADENU...................................................................... 116
JADENU...................................................................... 116
JADENU...................................................................... 116
JAKAFI........................................................................... 36
JAKAFI........................................................................... 36
JAKAFI........................................................................... 36
JAKAFI........................................................................... 36
JAKAFI........................................................................... 36
JANUMET......................................................................59
JANUMET......................................................................59
JANUMET XR...............................................................59
JANUMET XR...............................................................59
JANUMET XR...............................................................59
JANUVIA........................................................................59
JANUVIA........................................................................60
JANUVIA........................................................................60
JARDIANCE.................................................................. 60
JARDIANCE.................................................................. 60
JENTADUETO.............................................................. 60
JENTADUETO.............................................................. 60
2016
JENTADUETO.............................................................. 60
JEVTANA....................................................................... 36
JUXTAPID..................................................................... 69
JUXTAPID..................................................................... 69
JUXTAPID..................................................................... 69
JUXTAPID..................................................................... 69
JUXTAPID..................................................................... 70
JUXTAPID..................................................................... 70
K
KADCYLA...................................................................... 36
KADCYLA...................................................................... 36
KALETRA...................................................................... 50
KALETRA...................................................................... 50
KALETRA...................................................................... 50
KALYDECO................................................................. 111
KALYDECO................................................................. 111
KALYDECO................................................................. 111
KCL 0.15%/D5W/LR.................................................. 116
KCL 0.3%/D5W/LR IV LACTATED RINGERS....... 116
kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45%
inj............................................................................... 116
inj............................................................................... 116
inj............................................................................... 116
inj............................................................................... 116
kcl 20 meq/l (0.15%) in nacl 0.45% inj................... 116
inj............................................................................... 116
inj............................................................................... 116
KEPIVANCE.................................................................. 78
ketoconazole cream 2%............................................. 81
ketoconazole shampoo 2%........................................ 81
ketoconazole tab 200 mg........................................... 27
ketoprofen cap 50 mg................................................... 3
ketoprofen cap 50 mg................................................. 28
ketoprofen cap 75 mg................................................... 3
ketoprofen cap 75 mg................................................. 28
ketorolac tromethamine ophth soln 0.4%............... 106
ketorolac tromethamine ophth soln 0.5%............... 106
ketotifen fumarate ophth soln 0.025%.................... 106
KEYTRUDA................................................................... 36
KEYTRUDA................................................................... 36
KINERET..................................................................... 101
KINRIX......................................................................... 101
KOMBIGLYZE XR........................................................ 60
KOMBIGLYZE XR........................................................ 60
KOMBIGLYZE XR........................................................ 60
KONSYL........................................................................ 87
KONSYL........................................................................ 87
KONSYL........................................................................ 87
KONSYL-D.................................................................... 87
KORLYM........................................................................ 97
KPN PRENATAL........................................................ 116
KP PRENATAL MULTIVITAMINS............................ 116
KUVAN........................................................................... 84
KUVAN........................................................................... 84
KUVAN........................................................................... 84
KYNAMRO.................................................................... 70
L
labetalol hcl tab 100 mg............................................. 70
LACRISERT................................................................ 106
lactated ringer's solution........................................... 116
lactic acid (ammonium lactate) cream 12%............. 81
lactic acid (ammonium lactate) lotion 12%............... 81
lactulose (encephalopathy) solution 10
gm/15ml...................................................................... 87
lactulose solution 10 gm/15ml................................... 87
LAMISIL AT................................................................... 27
LAMISIL AT................................................................... 81
lamivudine oral soln 10 mg/ml................................... 50
lamivudine tab 100 mg (hbv)..................................... 50
lamivudine tab 150 mg................................................50
lamivudine tab 300 mg................................................50
lamivudine-zidovudine tab 150-300 mg.................... 50
lamotrigine orally disintegrating tab 100 mg............ 17
lamotrigine orally disintegrating tab 25 mg...............16
lamotrigine tab 100 mg............................................... 17
lamotrigine tab 25 mg................................................. 17
lamotrigine tab 25 mg................................................. 56
lamotrigine tab chewable dispersible 25 mg............ 17
lamotrigine tab chewable dispersible 25 mg............ 56
lamotrigine tab chewable dispersible 5 mg.............. 17
lamotrigine tab chewable dispersible 5 mg.............. 56
lansoprazole cap delayed release 15 mg................. 87
lansoprazole cap delayed release 30 mg................. 87
LANTUS......................................................................... 60
139
2016
LANTUS SOLOSTAR.................................................. 60
latanoprost ophth soln 0.005%................................ 106
LATUDA......................................................................... 45
LATUDA......................................................................... 45
LATUDA......................................................................... 45
LATUDA......................................................................... 45
LATUDA......................................................................... 45
LAZANDA........................................................................ 3
LAZANDA........................................................................ 3
LAZANDA........................................................................ 3
leflunomide tab 10 mg.............................................. 101
leflunomide tab 20 mg.............................................. 101
LENVIMA 10 MG DAILY DOSE.................................36
LENVIMA 8 MG DAILY DOSE................................... 36
LETAIRIS..................................................................... 111
LETAIRIS..................................................................... 111
letrozole tab 2.5 mg.....................................................36
LEUCOVORIN CALCIUM........................................... 36
leucovorin calcium for inj 100 mg.............................. 36
leucovorin calcium tab 25 mg.................................... 37
leucovorin calcium tab 5 mg...................................... 36
LEUKERAN................................................................... 37
LEUKINE....................................................................... 63
leuprolide acetate inj kit 5 mg/ml............................... 97
LEVEMIR....................................................................... 60
LEVEMIR FLEXPEN................................................... 60
LEVEMIR FLEXTOUCH..............................................60
LEVETIRACETAM........................................................17
LEVETIRACETAM........................................................17
LEVETIRACETAM........................................................17
levetiracetam inj 500 mg/5ml (100 mg/ml)............... 17
levetiracetam oral soln 100 mg/ml............................ 17
levetiracetam tab 1000 mg......................................... 17
levetiracetam tab 250 mg........................................... 17
levobunolol hcl ophth soln 0.5%..............................106
levocarnitine oral soln 1 gm/10ml (10%)................ 116
levocarnitine tab 330 mg.......................................... 116
levocetirizine dihydrochloride tab 5 mg.................. 111
levofloxacin in d5w iv soln 250 mg/50ml.................. 12
levofloxacin in d5w iv soln 500 mg/100ml................ 12
levofloxacin in d5w iv soln 750 mg/150ml................ 12
140
levofloxacin iv soln 25 mg/ml..................................... 12
levofloxacin oral soln 25 mg/ml................................. 12
levofloxacin tab 250 mg.............................................. 12
levonorgestrel & ethinyl estradiol (91-day) tab
0.15-0.03 mg............................................................. 94
levonorgestrel & ethinyl estradiol tab 0.15 mg-30
mcg..............................................................................94
levonorgestrel & ethinyl estradiol tab 0.1 mg-20
mcg..............................................................................94
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg........................ 94
levonorgestrel-ethinyl estradiol (continuous) tab
90-20 mcg.................................................................. 94
0.01mg(7)................................................................... 94
0.01mg(7)................................................................... 94
LEVORPHANOL TARTRATE....................................... 3
levothyroxine sodium tab 100 mcg........................... 96
levothyroxine sodium tab 112 mcg............................ 96
levothyroxine sodium tab 25 mcg.............................. 96
LEXIVA........................................................................... 50
LEXIVA........................................................................... 50
LIALDA........................................................................ 103
LIDOCAINE HCL..........................................................70
lidocaine hcl gel 2%...................................................... 5
lidocaine hcl local inj 1%.............................................. 5
lidocaine hcl local preservative free inj 1%................ 5
lidocaine hcl soln 4%.....................................................5
lidocaine hcl viscous soln 2%...................................... 5
lidocaine oint 5%............................................................ 5
lidocaine patch 5%.........................................................5
lidocaine-prilocaine cream 2.5-2.5%........................... 5
lindane shampoo 1%................................................... 41
linezolid for susp 100 mg/5ml.................................... 12
linezolid in sodium chloride iv soln 600
mg/300ml-0.9%......................................................... 12
linezolid iv soln 600 mg/300ml (2 mg/ml)................. 12
linezolid tab 600 mg.................................................... 12
LINZESS........................................................................ 87
LINZESS........................................................................ 87
2016
liothyronine sodium tab 25 mcg................................. 96
liothyronine sodium tab 50 mcg................................. 96
liothyronine sodium tab 5 mcg................................... 96
lisinopril & hydrochlorothiazide tab 10-12.5 mg....... 70
lisinopril & hydrochlorothiazide tab 20-12.5 mg....... 70
lisinopril & hydrochlorothiazide tab 20-25 mg.......... 70
lisinopril tab 10 mg...................................................... 70
lisinopril tab 2.5 mg..................................................... 70
lisinopril tab 5 mg........................................................ 70
LITHIUM........................................................................ 56
lithium carbonate cap 150 mg................................... 56
lithium carbonate tab 300 mg.................................... 56
lithium carbonate tab cr 300 mg................................ 56
lithium carbonate tab cr 450 mg................................ 56
LIVALO........................................................................... 70
LIVALO........................................................................... 70
LIVALO........................................................................... 70
LMX 4...............................................................................5
LONSURF..................................................................... 37
LONSURF..................................................................... 37
loperamide hcl cap 2 mg............................................ 87
loperamide hcl liq 1 mg/5ml (0.2 mg/ml).................. 87
loperamide hcl liq 1 mg/7.5ml.................................... 87
loperamide hcl tab 2 mg............................................. 87
loratadine syrup 5 mg/5ml........................................ 111
loratadine tab 10 mg................................................. 111
lorazepam tab 0.5 mg................................................. 55
lorazepam tab 1 mg.................................................... 55
lorazepam tab 2 mg.................................................... 55
losartan potassium & hydrochlorothiazide tab
100-12.5 mg.............................................................. 70
losartan potassium & hydrochlorothiazide tab 100-25
mg................................................................................70
losartan potassium & hydrochlorothiazide tab
50-12.5 mg.................................................................70
losartan potassium tab 100 mg................................. 70
losartan potassium tab 25 mg................................... 70
losartan potassium tab 50 mg................................... 70
LOTEMAX................................................................... 106
LOTEMAX................................................................... 106
LOTEMAX................................................................... 106
lovastatin tab 10 mg.................................................... 70
loxapine succinate cap 10 mg................................... 45
loxapine succinate cap 5 mg..................................... 45
lubricant gels - gel....................................................... 81
LUMIGAN.................................................................... 106
LUPRON DEPOT......................................................... 97
LUPRON DEPOT......................................................... 97
LUPRON DEPOT......................................................... 97
LUPRON DEPOT......................................................... 97
LUPRON DEPOT......................................................... 97
LUPRON DEPOT......................................................... 97
LUPRON DEPOT-PED............................................... 97
LUPRON DEPOT-PED............................................... 97
LUPRON DEPOT-PED............................................... 98
LUPRON DEPOT-PED............................................... 98
LUPRON DEPOT-PED............................................... 98
LYNPARZA.................................................................... 37
LYRICA.......................................................................... 17
LYRICA.......................................................................... 17
LYRICA.......................................................................... 17
LYRICA.......................................................................... 17
LYRICA.......................................................................... 17
LYRICA.......................................................................... 17
LYRICA.......................................................................... 17
LYRICA.......................................................................... 17
LYRICA.......................................................................... 17
LYRICA.......................................................................... 77
LYRICA.......................................................................... 77
LYRICA.......................................................................... 77
LYRICA.......................................................................... 77
LYRICA.......................................................................... 77
LYRICA.......................................................................... 77
LYRICA.......................................................................... 77
LYRICA.......................................................................... 77
LYRICA.......................................................................... 77
LYSODREN................................................................... 97
M
magnesium citrate soln............................................... 87
magnesium hydroxide susp 400 mg/5ml.................. 88
magnesium oxide tab 400 mg................................... 88
magnesium sulfate inj 50%...................................... 116
malathion lotion 0.5%.................................................. 41
MAPROTILINE HCL.................................................... 22
MAPROTILINE HCL.................................................... 22
MAPROTILINE HCL.................................................... 22
MARPLAN..................................................................... 22
MARQIBO......................................................................37
MATULANE................................................................... 37
meclizine hcl chew tab 25 mg................................... 25
meclizine hcl tab 12.5 mg...........................................25
meclizine hcl tab 25 mg.............................................. 25
medroxyprogesterone acetate im susp 150 mg/
ml................................................................................. 94
medroxyprogesterone acetate tab 10 mg.................94
141
2016
medroxyprogesterone acetate tab 2.5 mg............... 94
medroxyprogesterone acetate tab 5 mg................... 94
mefloquine hcl tab 250 mg......................................... 41
megestrol acetate susp 40 mg/ml............................. 94
megestrol acetate tab 20 mg..................................... 94
megestrol acetate tab 40 mg..................................... 94
MEKINIST......................................................................37
MEKINIST......................................................................37
meloxicam tab 15 mg.................................................... 3
meloxicam tab 15 mg.................................................. 28
meloxicam tab 7.5 mg................................................... 3
meloxicam tab 7.5 mg................................................. 28
melphalan hcl for inj 50 mg........................................ 37
memantine hcl oral solution 2 mg/ml........................ 19
memantine hcl tab 10 mg........................................... 19
memantine hcl tab 5 mg............................................. 19
memantine hcl tab 5 mg (28) & 10 mg (21) titration
pak............................................................................... 19
MENACTRA................................................................ 101
MENEST........................................................................ 94
MENEST........................................................................ 94
MENEST........................................................................ 94
MENEST........................................................................ 94
MENHIBRIX................................................................ 101
MENOMUNE-A/C/Y/W-135...................................... 101
MENVEO..................................................................... 101
mercaptopurine tab 50 mg......................................... 37
meropenem iv for soln 1 gm...................................... 12
meropenem iv for soln 500 mg.................................. 12
mesalamine enema 4 gm......................................... 103
mesna inj 100 mg/ml................................................... 37
MESNEX........................................................................37
MESTINON................................................................... 30
MESTINON TIMESPAN.............................................. 30
METAMUCIL MULTIHEALTH FIBER........................ 88
METAMUCIL MULTIHEALTH FIBER........................ 88
metformin hcl tab 1000 mg........................................ 60
metformin hcl tab 500 mg...........................................60
metformin hcl tab 850 mg...........................................60
metformin hcl tab sr 24hr 500 mg............................. 60
metformin hcl tab sr 24hr 750 mg............................. 60
methadone hcl tab 10 mg............................................. 3
methadone hcl tab 5 mg............................................... 3
methazolamide tab 25 mg.......................................... 70
methazolamide tab 50 mg.......................................... 70
methenamine hippurate tab 1 gm............................. 12
methimazole tab 10 mg.............................................. 99
methimazole tab 5 mg................................................ 99
methocarbamol tab 500 mg..................................... 113
methocarbamol tab 750 mg..................................... 113
methotrexate sodium for inj 1 gm.............................. 37
methotrexate sodium for inj 1 gm............................101
142
methotrexate sodium inj 250 mg/10ml (25 mg/
ml)................................................................................37
ml)............................................................................. 101
methotrexate sodium inj 50 mg/2ml (25 mg/ml)...... 37
ml)............................................................................. 102
methotrexate sodium inj pf 1000 mg/40ml (25 mg/
ml)................................................................................37
ml)............................................................................. 101
ml)................................................................................37
ml)............................................................................. 101
ml)................................................................................37
ml)............................................................................. 101
ml)................................................................................37
ml)............................................................................. 101
ml)................................................................................37
ml)............................................................................. 101
methotrexate sodium tab 2.5 mg............................... 37
methotrexate sodium tab 2.5 mg.............................102
methoxsalen rapid cap 10 mg................................... 81
methscopolamine bromide tab 2.5 mg..................... 88
methscopolamine bromide tab 5 mg......................... 88
methylcellulose tab 500 mg........................................88
methylergonovine maleate tab 0.2 mg..................... 90
methylphenidate hcl tab 10 mg................................. 77
methylphenidate hcl tab 20 mg................................. 77
methylphenidate hcl tab 5 mg.................................... 77
methylphenidate hcl tab cr 20 mg............................. 77
methylprednisolone sodium succinate for inj 1000
mg................................................................................92
mg................................................................................92
mg................................................................................92
methylprednisolone tab 16 mg...................................92
methylprednisolone tab 32 mg...................................92
methylprednisolone tab 4 mg..................................... 92
methylprednisolone tab 8 mg..................................... 92
methylprednisolone tab therapy pack 4 mg (21)..... 92
methyltestosterone cap 10 mg...................................94
metoclopramide hcl inj 5 mg/ml................................. 25
metoclopramide hcl inj 5 mg/ml................................. 88
2016
metoclopramide hcl soln 5 mg/5ml (10
mg/10ml).....................................................................25
metoclopramide hcl soln 5 mg/5ml (10
mg/10ml).....................................................................88
metoclopramide hcl tab 10 mg.................................. 25
metoclopramide hcl tab 10 mg.................................. 88
metoclopramide hcl tab 5 mg.....................................25
metoclopramide hcl tab 5 mg.....................................88
metolazone tab 10 mg................................................ 70
metolazone tab 2.5 mg............................................... 70
metolazone tab 5 mg.................................................. 70
metoprolol & hydrochlorothiazide tab 100-25
mg................................................................................70
metoprolol & hydrochlorothiazide tab 50-25 mg...... 70
metoprolol succinate tab sr 24hr 100 mg................. 71
metoprolol succinate tab sr 24hr 200 mg................. 71
metoprolol succinate tab sr 24hr 25 mg................... 70
metoprolol succinate tab sr 24hr 50 mg................... 70
metoprolol tartrate tab 100 mg.................................. 71
metoprolol tartrate tab 25 mg.....................................71
metoprolol tartrate tab 50 mg.....................................71
METRO IV..................................................................... 12
metronidazole cap 375 mg......................................... 12
metronidazole cream 0.75%...................................... 81
metronidazole gel 0.75%............................................ 81
metronidazole gel 1%..................................................81
metronidazole in nacl 0.79% iv soln 500
mg/100ml....................................................................12
metronidazole lotion 0.75%........................................ 81
metronidazole tab 250 mg.......................................... 12
metronidazole tab 500 mg.......................................... 12
metronidazole vaginal gel 0.75%.............................. 12
mexiletine hcl cap 150 mg......................................... 71
MIACALCIN................................................................ 104
miconazole nitrate aerosol pow 2%.......................... 81
miconazole nitrate cream 2%.................................... 81
miconazole nitrate powder 2%...................................82
miconazole nitrate vaginal app 200 mg & 2% cream
9 gm kit...................................................................... 27
miconazole nitrate vaginal cream 2%....................... 27
miconazole nitrate vaginal cream 4% (200
mg/5gm)..................................................................... 27
miconazole nitrate vaginal supp 200 mg & 2% cream
9 gm kit...................................................................... 27
miconazole nitrate vaginal suppos 100 mg.............. 27
midodrine hcl tab 10 mg............................................. 71
midodrine hcl tab 2.5 mg............................................ 71
midodrine hcl tab 5 mg............................................... 71
MIGERGOT................................................................... 29
MIGRANAL....................................................................29
minocycline hcl cap 100 mg....................................... 12
minocycline hcl cap 50 mg......................................... 12
minocycline hcl cap 75 mg......................................... 12
minocycline hcl tab 100 mg........................................12
minocycline hcl tab 50 mg.......................................... 12
minocycline hcl tab 75 mg.......................................... 12
minoxidil tab 10 mg..................................................... 71
minoxidil tab 2.5 mg.................................................... 71
mirtazapine orally disintegrating tab 15 mg............. 22
mirtazapine tab 15 mg................................................ 22
mirtazapine tab 7.5 mg............................................... 22
misoprostol tab 100 mcg............................................ 88
misoprostol tab 200 mcg............................................ 88
MISSION PRENATAL................................................116
MISSION PRENATAL HP......................................... 117
MITOMYCIN.................................................................. 37
mitomycin for iv soln 20 mg....................................... 37
mitomycin for iv soln 40 mg....................................... 37
mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml)..... 37
mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/
ml)................................................................................37
mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/
ml)................................................................................77
M-M-R II...................................................................... 101
modafinil tab 100 mg................................................ 113
modafinil tab 200 mg................................................ 113
moexipril hcl tab 15 mg.............................................. 71
moexipril hcl tab 7.5 mg............................................. 71
moexipril-hydrochlorothiazide tab 15-12.5 mg......... 71
moexipril-hydrochlorothiazide tab 15-25 mg............ 71
moexipril-hydrochlorothiazide tab 7.5-12.5 mg........ 71
MOLINDONE HYDROCHLORIDE............................ 45
mometasone furoate cream 0.1%............................. 82
mometasone furoate oint 0.1%.................................. 82
mometasone furoate solution 0.1% (lotion)..............82
montelukast sodium chew tab 4 mg....................... 111
montelukast sodium chew tab 5 mg....................... 111
montelukast sodium oral granules packet 4
mg............................................................................. 111
montelukast sodium tab 10 mg............................... 111
MORPHINE SULFATE.................................................. 3
MORPHINE SULFATE.................................................. 3
morphine sulfate beads cap sr 24hr 120 mg..............3
143
2016
morphine sulfate beads cap sr 24hr 30 mg................ 3
morphine sulfate inj pf 0.5 mg/ml................................ 3
morphine sulfate inj pf 1 mg/ml................................... 3
morphine sulfate oral soln 100 mg/5ml (20 mg/
ml).................................................................................. 3
morphine sulfate oral soln 10 mg/5ml......................... 3
morphine sulfate oral soln 20 mg/5ml......................... 3
morphine sulfate tab cr 100 mg................................... 3
morphine sulfate tab cr 15 mg..................................... 3
morphine sulfate tab cr 200 mg................................... 3
MOVIPREP................................................................... 88
MOXEZA..................................................................... 106
moxifloxacin hcl tab 400 mg...................................... 12
MOZOBIL...................................................................... 63
MULTAQ........................................................................ 71
multiple vitamins w/ iron tab.....................................117
multiple vitamins w/ minerals tab............................ 117
multiple vitamin tab....................................................117
mupirocin oint 2%........................................................ 82
MURO 128.................................................................. 106
MUSTARGEN............................................................... 37
MYALEPT...................................................................... 92
MYCAMINE................................................................... 27
MYCAMINE................................................................... 27
mycophenolate mofetil cap 250 mg........................ 102
mycophenolate mofetil for oral susp 200 mg/
ml............................................................................... 102
mycophenolate mofetil tab 500 mg......................... 102
mycophenolate sodium tab dr 180 mg................... 102
mycophenolate sodium tab dr 360 mg................... 102
MYLANTA DOUBLE-STRENGTH............................. 88
MYRBETRIQ................................................................. 90
MYRBETRIQ................................................................. 90
N
nabumetone tab 500 mg............................................... 3
nabumetone tab 500 mg............................................ 28
nabumetone tab 750 mg............................................... 4
nabumetone tab 750 mg............................................ 28
nadolol tab 20 mg........................................................ 71
nadolol tab 40 mg........................................................ 71
nadolol tab 80 mg........................................................ 71
NAFCILLIN SODIUM................................................... 12
NAFCILLIN SODIUM................................................... 12
nafcillin sodium for inj 10 gm..................................... 13
nafcillin sodium for inj 1 gm....................................... 13
144
nafcillin sodium for inj 2 gm....................................... 13
NAGLAZYME................................................................ 84
NALOXONE HCL........................................................... 6
naloxone hcl inj 0.4 mg/ml............................................6
naltrexone hcl tab 50 mg.............................................. 6
NAMENDA.................................................................... 19
NAMENDA.................................................................... 19
NAMENDA.................................................................... 19
NAMENDA TITRATION PAK......................................20
NAMENDA XR............................................................. 20
NAMENDA XR............................................................. 20
NAMENDA XR............................................................. 20
NAMENDA XR............................................................. 20
NAMENDA XR TITRATION PACK............................ 20
naproxen sodium tab 220 mg...................................... 4
naproxen sodium tab 220 mg.................................... 28
naproxen susp 125 mg/5ml.......................................... 4
naproxen susp 125 mg/5ml........................................ 29
naproxen tab 250 mg.................................................... 4
naproxen tab 250 mg.................................................. 29
naproxen tab 375 mg.................................................... 4
naproxen tab 375 mg.................................................. 29
naproxen tab 500 mg.................................................... 4
naproxen tab 500 mg.................................................. 29
naproxen tab ec 375 mg...............................................4
naproxen tab ec 375 mg............................................ 29
naproxen tab ec 500 mg...............................................4
naproxen tab ec 500 mg............................................ 29
naratriptan hcl tab 1 mg..............................................29
naratriptan hcl tab 2.5 mg.......................................... 29
NARCAN.......................................................................... 6
NASCOBAL................................................................ 117
NASONEX................................................................... 111
NATACYN.................................................................... 106
nateglinide tab 120 mg............................................... 60
nateglinide tab 60 mg................................................. 60
NATPARA...................................................................... 96
NATPARA...................................................................... 96
NATPARA...................................................................... 96
NATPARA...................................................................... 96
NEBUPENT................................................................... 41
NEFAZODONE HCL....................................................22
NEFAZODONE HCL....................................................22
NEFAZODONE HCL....................................................22
nefazodone hcl tab 250 mg........................................22
nefazodone hcl tab 50 mg.......................................... 22
neomycin-bacitracin-polymyxin-pramoxine oint
1%............................................................................... 82
2016
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin....................... 106
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml........................... 106
neomycin-polymyxin b gu irrigation soln.................. 13
neomycin-polymyxin b gu irrigation soln.................. 90
neomycin-polymyxin-dexamethasone ophth oint
0.1%.......................................................................... 106
neomycin-polymyxin-dexamethasone ophth susp
0.1%.......................................................................... 106
neomycin-polymyxin-hc otic soln 1%...................... 107
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000
unit/ml-1%................................................................ 107
neomycin sulfate tab 500 mg..................................... 13
NEOSPORIN ORIGINAL............................................ 82
NEOSPORIN PLUS PAIN RELIEF MAXIMUM
STRENGTH............................................................... 82
NEULASTA.................................................................... 63
NEULASTA ONPRO KIT............................................ 63
NEUPRO....................................................................... 42
NEUPRO....................................................................... 42
NEUPRO....................................................................... 42
NEUPRO....................................................................... 42
NEUPRO....................................................................... 43
NEUPRO....................................................................... 43
NEVANAC................................................................... 106
NEVIRAPINE................................................................ 50
nevirapine tab 200 mg................................................ 51
nevirapine tab sr 24hr 100 mg...................................50
nevirapine tab sr 24hr 400 mg...................................50
NEXAVAR...................................................................... 37
NEXIUM......................................................................... 88
NEXIUM......................................................................... 88
NEXIUM......................................................................... 88
NEXIUM......................................................................... 88
NEXIUM......................................................................... 88
niacin cap cr 250 mg.................................................. 71
niacin cap cr 500 mg.................................................. 71
niacin tab 100 mg........................................................ 71
niacin tab 250 mg........................................................ 71
niacin tab 500 mg........................................................ 71
niacin tab 50 mg.......................................................... 71
niacin tab cr 1000 mg................................................. 71
niacin tab cr 250 mg................................................... 71
niacin tab cr 500 mg................................................... 71
niacin tab cr 750 mg................................................... 71
niacin tab cr 750 mg................................................... 71
NIACIN TR.................................................................... 71
nicardipine hcl cap 20 mg.......................................... 71
nicardipine hcl cap 30 mg.......................................... 71
NICODERM CQ............................................................. 6
NICODERM CQ............................................................. 6
NICORETTE....................................................................6
nicotine polacrilex gum 2 mg....................................... 6
nicotine polacrilex gum 4 mg....................................... 6
nicotine polacrilex lozenge 2 mg................................. 6
nicotine td patch 24hr 21 mg/24hr...............................6
NICOTINE TRANSDERMAL SYSTEM....................... 6
NICOTROL INHALER................................................... 6
NICOTROL NS............................................................... 6
nifedipine tab sr 24hr 30 mg...................................... 71
nifedipine tab sr 24hr osmotic release 30 mg.......... 72
NILANDRON................................................................. 37
nilutamide tab 150 mg................................................ 37
NINLARO....................................................................... 37
NINLARO....................................................................... 37
NINLARO....................................................................... 37
NIPENT.......................................................................... 37
NISOLDIPINE ER........................................................ 72
nisoldipine tab sr 24hr 17 mg.................................... 72
nisoldipine tab sr 24hr 34 mg.................................... 72
nisoldipine tab sr 24hr 8.5 mg................................... 72
NITRO-BID.................................................................... 72
nitrofurantoin macrocrystalline cap 100 mg............. 13
nitrofurantoin macrocrystalline cap 50 mg............... 13
nitrofurantoin monohydrate macrocrystalline cap 100
mg................................................................................13
nitrofurantoin susp 25 mg/5ml................................... 13
nitroglycerin td patch 24hr 0.1 mg/hr........................ 72
nitroglycerin tl soln 0.4 mg/spray (400 mcg/
spray).......................................................................... 72
NITROSTAT.................................................................. 72
NITROSTAT.................................................................. 72
NITROSTAT.................................................................. 72
nizatidine cap 150 mg................................................. 88
nizatidine cap 300 mg................................................. 88
norethindrone & ethinyl estradiol-fe chew tab 0.4
mg-35 mcg................................................................. 94
norethindrone & ethinyl estradiol-fe chew tab 0.8
mg-25 mcg................................................................. 95
norethindrone & ethinyl estradiol tab 0.4 mg-35
mcg..............................................................................94
norethindrone & ethinyl estradiol tab 0.5 mg-35
mcg..............................................................................94
norethindrone & ethinyl estradiol tab 1 mg-35
mcg..............................................................................94
145
2016
norethindrone ace & ethinyl estradiol-fe tab 1.5
mg-30 mcg................................................................. 95
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20
mcg..............................................................................95
norethindrone ace & ethinyl estradiol tab 1.5 mg-30
mcg..............................................................................95
norethindrone ace & ethinyl estradiol tab 1 mg-20
mcg..............................................................................95
norethindrone ace-ethinyl estradiol-fe tab 1 mg-20
mcg (24)..................................................................... 95
norethindrone acetate tab 5 mg................................ 95
norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35
mg-mcg....................................................................... 95
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35
mg-mcg....................................................................... 95
norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35
mg-mcg....................................................................... 95
norethindrone tab 0.35 mg......................................... 95
norgestimate & ethinyl estradiol tab 0.25 mg-35
mcg..............................................................................95
norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg......................... 95
norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg......................... 95
norgestrel & ethinyl estradiol tab 0.3 mg-30
mcg..............................................................................95
NORTHERA.................................................................. 72
NORTHERA.................................................................. 72
NORTHERA.................................................................. 72
NORTRIPTYLINE HCL............................................... 22
nortriptyline hcl cap 10 mg......................................... 22
NORVIR......................................................................... 51
NORVIR......................................................................... 51
NORVIR......................................................................... 51
NOXAFIL....................................................................... 27
NOXAFIL....................................................................... 27
NOXAFIL....................................................................... 27
NUCYNTA ER.................................................................4
NUCYNTA ER.................................................................4
NUCYNTA ER.................................................................4
NUCYNTA ER.................................................................4
NUCYNTA ER.................................................................4
NUEDEXTA................................................................... 77
NULOJIX..................................................................... 102
NUPERCAINAL............................................................ 82
NUPLAZID..................................................................... 43
NUPLAZID..................................................................... 46
NUTRICION PORVIDA............................................. 117
NUTRISOURCE FIBER.............................................. 88
146
NUVIGIL...................................................................... 113
NUVIGIL...................................................................... 113
NUVIGIL...................................................................... 114
NUVIGIL...................................................................... 114
nystatin cream 100000 unit/gm................................. 82
nystatin oint 100000 unit/gm...................................... 82
nystatin susp 100000 unit/ml..................................... 27
nystatin tab 500000 unit............................................. 27
nystatin topical powder............................................... 82
nystatin-triamcinolone cream 100000-0.1 unit/gm%..................................................................................82
nystatin-triamcinolone oint 100000-0.1 unit/gm%..................................................................................82
O
octreotide acetate inj 1000 mcg/ml (1 mg/ml).......... 98
octreotide acetate inj 100 mcg/ml (0.1 mg/ml)......... 98
ODOMZO...................................................................... 38
OFEV........................................................................... 111
OFEV........................................................................... 111
OFLOXACIN................................................................. 13
ofloxacin ophth soln 0.3%........................................ 106
ofloxacin otic soln 0.3%............................................ 107
olanzapine for im inj 10 mg........................................ 46
olanzapine for im inj 10 mg........................................ 56
olanzapine orally disintegrating tab 10 mg............... 46
olanzapine orally disintegrating tab 5 mg................. 46
olanzapine orally disintegrating tab 5 mg................. 56
olanzapine tab 10 mg................................................. 46
olanzapine tab 2.5 mg................................................ 46
olanzapine tab 5 mg.................................................... 46
olanzapine tab 5 mg.................................................... 56
olopatadine hcl nasal soln 0.6%..............................111
olopatadine hcl ophth soln 0.1%............................. 106
OLYSIO.......................................................................... 51
omega-3-acid ethyl esters cap 1 gm.........................72
2016
omega-3 fatty acids cap 1000 mg........................... 117
omega-3 fatty acids cap 1200 mg........................... 117
omega-3 fatty acids cap 300 mg............................. 117
omega-3 fatty acids cap 435 mg............................. 117
omega-3 fatty acids cap delayed release 1000
mg............................................................................. 117
omega-3 fatty acids cap delayed release 1200
mg............................................................................. 117
OMEPRAZOLE............................................................. 88
omeprazole cap delayed release 10 mg.................. 88
OMNITROPE................................................................ 93
OMNITROPE................................................................ 93
OMNITROPE................................................................ 93
ONCASPAR.................................................................. 38
ondansetron hcl inj 40 mg/20ml (2 mg/ml)............... 25
ondansetron hcl inj 4 mg/2ml (2 mg/ml)................... 25
ondansetron hcl oral soln 4 mg/5ml.......................... 25
ondansetron hcl tab 24 mg........................................ 25
ondansetron hcl tab 4 mg...........................................25
ondansetron hcl tab 8 mg...........................................25
ondansetron orally disintegrating tab 4 mg.............. 25
ondansetron orally disintegrating tab 8 mg.............. 25
ONE-A-DAY WOMENS PRENATAL....................... 117
ONFI............................................................................... 17
ONFI............................................................................... 17
ONFI............................................................................... 17
ONFI............................................................................... 17
ONGLYZA...................................................................... 60
ONGLYZA...................................................................... 60
OPDIVO......................................................................... 38
OPDIVO......................................................................... 38
OPSUMIT.................................................................... 111
OPTIONS CONCEPTROL VAGINAL
CONTRACEPTIVE................................................... 82
OPTIONS GYNOL II VAGINAL
CONTRACEPTIVE................................................... 82
ORACEA........................................................................82
ORALAIR..................................................................... 111
oral electrolyte solution............................................. 117
ORAP............................................................................. 46
ORAP............................................................................. 46
ORFADIN....................................................................... 84
ORFADIN....................................................................... 84
ORFADIN....................................................................... 85
ORFADIN....................................................................... 85
ORFADIN....................................................................... 85
ORKAMBI.................................................................... 111
oxaliplatin for iv inj 100 mg........................................ 38
oxaliplatin for iv inj 50 mg...........................................38
oxaliplatin iv soln 100 mg/20ml..................................38
oxaliplatin iv soln 50 mg/10ml.................................... 38
oxandrolone tab 10 mg............................................... 95
oxandrolone tab 2.5 mg.............................................. 95
oxaprozin tab 600 mg................................................... 4
oxaprozin tab 600 mg................................................. 29
oxcarbazepine susp 300 mg/5ml (60 mg/ml)........... 17
oxcarbazepine tab 150 mg......................................... 17
oxybutynin chloride syrup 5 mg/5ml..........................90
oxybutynin chloride tab 5 mg..................................... 90
oxybutynin chloride tab sr 24hr 10 mg..................... 90
oxybutynin chloride tab sr 24hr 15 mg..................... 90
oxybutynin chloride tab sr 24hr 5 mg........................90
oxycodone-aspirin tab 4.8355-325 mg....................... 4
oxycodone hcl tab 10 mg............................................. 4
oxycodone hcl tab 5 mg............................................... 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
paclitaxel iv conc 100 mg/16.7ml (6 mg/ml)............. 38
paclitaxel iv conc 300 mg/50ml (6 mg/ml)................ 38
paclitaxel iv conc 30 mg/5ml (6 mg/ml).................... 38
paliperidone tab sr 24hr 1.5 mg................................ 46
paliperidone tab sr 24hr 3 mg.................................... 46
PANRETIN.....................................................................38
pantoprazole sodium ec tab 20 mg........................... 88
pantoprazole sodium ec tab 40 mg........................... 88
pantoprazole sodium for iv soln 40 mg.....................88
paricalcitol cap 1 mcg............................................... 104
paricalcitol iv soln 2 mcg/ml..................................... 104
paricalcitol iv soln 5 mcg/ml..................................... 104
paromomycin sulfate cap 250 mg............................. 13
paroxetine hcl tab 10 mg............................................ 23
paroxetine hcl tab sr 24hr 12.5 mg........................... 23
147
2016
paroxetine hcl tab sr 24hr 25 mg.............................. 23
paroxetine hcl tab sr 24hr 25 mg.............................. 55
PASER........................................................................... 31
PATADAY..................................................................... 106
PATANOL.................................................................... 106
PAXIL............................................................................. 23
PAXIL............................................................................. 55
PAZEO......................................................................... 106
PEDIA-LAX....................................................................88
PEDVAX HIB.............................................................. 102
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236
gm................................................................................89
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240
gm................................................................................89
peg 3350-kcl-sod bicarb-nacl for soln 420 gm......... 89
PEGANONE.................................................................. 17
PEGASYS..................................................................... 51
PEGASYS..................................................................... 51
PEGASYS PROCLICK................................................ 51
PEGASYS PROCLICK................................................ 51
PEG-INTRON............................................................... 51
PEG-INTRON............................................................... 51
PEG-INTRON............................................................... 51
PEG-INTRON............................................................... 51
PEG-INTRON REDIPEN............................................ 51
PEG-INTRON REDIPEN PAK 4................................ 51
penicillin g potassium for inj 20000000 unit............. 13
penicillin g potassium for inj 5000000 unit............... 13
PENICILLIN G POTASSIUM IN DEXTROSE.......... 13
PENICILLIN G SODIUM............................................. 13
penicillin v potassium for soln 125 mg/5ml.............. 13
penicillin v potassium for soln 250 mg/5ml.............. 13
penicillin v potassium tab 250 mg............................. 13
penicillin v potassium tab 500 mg............................. 13
PENTACEL................................................................. 102
PENTAM 300................................................................ 41
PENTASA.................................................................... 104
PENTASA.................................................................... 104
pentoxifylline tab cr 400 mg....................................... 72
perindopril erbumine tab 2 mg................................... 72
148
PERJETA....................................................................... 38
permethrin cream 5%.................................................. 41
permethrin creme rinse 1%........................................ 41
permethrin lotion 1%................................................... 41
perphenazine tab 16 mg............................................. 26
perphenazine tab 16 mg............................................. 46
perphenazine tab 2 mg............................................... 26
PERRY PRENATAL................................................... 117
PHENAGIL.................................................................. 111
phenelzine sulfate tab 15 mg..................................... 23
PHENOBARBITAL....................................................... 17
PHENOBARBITAL....................................................... 18
PHENOBARBITAL....................................................... 18
PHENOBARBITAL....................................................... 18
phenobarbital elixir 20 mg/5ml................................... 18
PHENOBARBITAL SODIUM...................................... 18
PHENOBARBITAL SODIUM...................................... 18
phenobarbital tab 16.2 mg......................................... 18
phenoxybenzamine hcl cap 10 mg........................... 72
phenylephrine-brompheniramine-dm elixir 2.5-1-5
mg/5ml...................................................................... 111
phenylephrine-guaifenesin tab 10-400 mg............. 111
phenylephrine hcl tab 10 mg................................... 111
phenylephrine in hard fat rectal suppos 0.25%....... 82
phenylephrine w/ dm-gg liqd 5-10-200 mg/5ml..... 111
phenytoin chew tab 50 mg......................................... 18
phenytoin sodium extended cap 100 mg................. 18
phenytoin susp 125 mg/5ml....................................... 18
PHOSLYRA................................................................... 90
PHOSPHOLINE IODIDE.......................................... 106
PHYSICIANS EZ USE B-12 COMPLIANCE
KIT............................................................................. 117
PICATO.......................................................................... 82
PICATO.......................................................................... 82
pilocarpine hcl ophth soln 1%.................................. 106
pilocarpine hcl tab 5 mg............................................. 78
pilocarpine hcl tab 7.5 mg.......................................... 78
pimozide tab 1 mg....................................................... 46
pimozide tab 2 mg....................................................... 46
2016
pindolol tab 10 mg....................................................... 72
pindolol tab 5 mg......................................................... 72
pioglitazone hcl-glimepiride tab 30-2 mg.................. 60
pioglitazone hcl-glimepiride tab 30-4 mg.................. 60
pioglitazone hcl-metformin hcl tab 15-500 mg......... 60
pioglitazone hcl-metformin hcl tab 15-850 mg......... 60
pioglitazone hcl tab 15 mg......................................... 60
piperacillin sod-tazobactam na for inj 3.375 gm
(3-0.375 gm).............................................................. 13
piperacillin sod-tazobactam sod for inj 2.25 gm
(2-0.25 gm)................................................................ 13
piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5
gm).............................................................................. 13
piroxicam cap 10 mg..................................................... 4
piroxicam cap 10 mg................................................... 29
piroxicam cap 20 mg..................................................... 4
piroxicam cap 20 mg................................................... 29
PLEGRIDY.................................................................... 77
PLEGRIDY.................................................................... 77
PLEGRIDY STARTER PACK..................................... 77
PLEGRIDY STARTER PACK..................................... 77
podofilox soln 0.5%..................................................... 82
polyethylene glycol 3350 oral packet........................ 89
polyethylene glycol 3350 oral powder.......................89
polymyxin b-trimethoprim ophth soln 10000 unit/
ml-0.1%.................................................................... 106
POLYSPORIN............................................................... 82
polyvinyl alcohol ophth soln 1.4%........................... 106
polyvinyl alcohol-povidone ophth soln 5-6 mg/ml
(0.5-0.6%)................................................................ 106
POMALYST................................................................... 38
POMALYST................................................................... 38
POMALYST................................................................... 38
POMALYST................................................................... 38
PORTRAZZA................................................................ 38
potassium chloride 20 meq/l (0.15%) in dextrose 5%
inj............................................................................... 117
potassium chloride 40 meq/l (0.3%) in dextrose 5%
inj............................................................................... 117
potassium chloride cap cr 10 meq.......................... 117
potassium chloride cap cr 8 meq............................ 117
potassium chloride inj 2 meq/ml.............................. 117
potassium chloride microencapsulated crys cr tab 10
meq........................................................................... 117
potassium chloride microencapsulated crys cr tab 20
meq........................................................................... 117
potassium chloride tab cr 10 meq........................... 117
potassium chloride tab cr 8 meq (600 mg)............ 117
potassium citrate tab cr 10 meq (1080 mg)........... 117
potassium citrate tab cr 15 meq (1620 mg)........... 117
potassium citrate tab cr 5 meq (540 mg)............... 117
POTIGA......................................................................... 18
POTIGA......................................................................... 18
POTIGA......................................................................... 18
POTIGA......................................................................... 18
povidone-iodine oint 10%........................................... 82
povidone-iodine soln 10%.......................................... 82
povidone-iodine soln 7.5%......................................... 82
povidone-iodine swabs 10%...................................... 82
PRADAXA..................................................................... 63
PRADAXA..................................................................... 63
PRADAXA..................................................................... 63
PRALUENT................................................................... 72
PRALUENT................................................................... 72
PRALUENT................................................................... 72
PRALUENT................................................................... 72
pramipexole dihydrochloride tab 0.125 mg.............. 43
pramipexole dihydrochloride tab 0.25 mg................ 43
pramipexole dihydrochloride tab 0.5 mg.................. 43
pramipexole dihydrochloride tab 0.75 mg................ 43
pramipexole dihydrochloride tab 1.5 mg.................. 43
pramipexole dihydrochloride tab 1 mg...................... 43
pravastatin sodium tab 10 mg................................... 72
prazosin hcl cap 1 mg.................................................73
prednicarbate cream 0.1%......................................... 82
prednicarbate oint 0.1%.............................................. 82
prednisolone acetate ophth susp 1%..................... 106
prednisolone sod phosphate oral soln 15
mg/5ml........................................................................ 92
prednisolone sod phosph oral soln 6.7 mg/5ml (5
mg/5ml base)............................................................. 92
prednisolone syrup 15 mg/5ml...................................92
PREDNISONE.............................................................. 92
PREDNISONE.............................................................. 92
PREDNISONE.............................................................. 92
PREDNISONE.............................................................. 92
PREDNISONE.............................................................. 92
PREDNISONE.............................................................. 92
prednisone tab 10 mg................................................. 92
prednisone tab 1 mg................................................... 92
prednisone tab 2.5 mg................................................ 92
prednisone tab 20 mg................................................. 92
prednisone tab 5 mg................................................... 92
PREMARIN................................................................... 95
149
2016
PREMARIN................................................................... 95
PREMARIN................................................................... 95
PREMARIN................................................................... 95
PREMARIN................................................................... 95
PREMARIN................................................................... 95
PREMIUM CONDOMS LUBRICATED......................82
PREMPHASE............................................................... 95
PREMPRO.................................................................... 95
PREMPRO.................................................................... 95
PREMPRO.................................................................... 95
PREMPRO.................................................................... 95
PRENATAL.................................................................. 117
PRENATAL AND IRON............................................. 117
PRENATAL MULTIVITAMIN + D............................. 117
PREZCOBIX................................................................. 51
PREZISTA..................................................................... 51
PREZISTA..................................................................... 51
PREZISTA..................................................................... 51
PREZISTA..................................................................... 51
PREZISTA..................................................................... 51
PRIFTIN......................................................................... 31
PRIMAQUINE PHOSPHATE...................................... 41
primidone tab 250 mg................................................. 18
primidone tab 50 mg................................................... 18
PRISTIQ........................................................................ 23
PRISTIQ........................................................................ 23
PRISTIQ........................................................................ 23
PROAIR HFA.............................................................. 111
PROAIR RESPICLICK.............................................. 111
probenecid tab 500 mg............................................... 27
prochlorperazine edisylate inj 5 mg/ml..................... 26
prochlorperazine edisylate inj 5 mg/ml..................... 46
prochlorperazine maleate tab 10 mg........................ 26
prochlorperazine maleate tab 10 mg........................ 46
prochlorperazine maleate tab 5 mg.......................... 26
prochlorperazine maleate tab 5 mg.......................... 46
prochlorperazine suppos 25 mg................................ 26
prochlorperazine suppos 25 mg................................ 46
PROCRIT...................................................................... 63
PROCRIT...................................................................... 63
PROCRIT...................................................................... 63
PROCRIT...................................................................... 63
PROCRIT...................................................................... 63
PROCRIT...................................................................... 63
PROFE FORTE..........................................................117
PROGLYCEM............................................................... 60
PROGRAF.................................................................. 102
PROLASTIN-C........................................................... 111
PROLENSA................................................................ 106
PROLEUKIN................................................................. 38
PROLIA........................................................................104
PROMACTA.................................................................. 63
150
PROMACTA.................................................................. 63
PROMACTA.................................................................. 63
PROMACTA.................................................................. 64
promethazine hcl suppos 12.5 mg............................ 26
promethazine hcl suppos 12.5 mg.......................... 111
promethazine hcl suppos 25 mg............................... 26
promethazine hcl suppos 25 mg............................. 111
promethazine hcl syrup 6.25 mg/5ml........................ 26
promethazine hcl syrup 6.25 mg/5ml...................... 111
promethazine hcl tab 12.5 mg................................... 26
promethazine hcl tab 12.5 mg................................. 111
promethazine hcl tab 25 mg...................................... 26
promethazine hcl tab 25 mg.................................... 111
promethazine hcl tab 50 mg...................................... 26
promethazine hcl tab 50 mg.................................... 112
propafenone hcl cap sr 12hr 225 mg........................ 73
propafenone hcl tab 150 mg...................................... 73
propranolol hcl cap sr 24hr 120 mg.......................... 29
propranolol hcl cap sr 24hr 60 mg............................ 29
propranolol hcl inj 1 mg/ml......................................... 29
propranolol hcl inj 1 mg/ml......................................... 73
propranolol hcl tab 10 mg...........................................29
propylthiouracil tab 50 mg.......................................... 99
PROQUAD.................................................................. 102
PROSHIELD PLUS SKIN PROTECTANT................ 82
PROSHIELD PROTECTIVE HAND CREAM........... 82
protriptyline hcl tab 10 mg.......................................... 23
protriptyline hcl tab 5 mg............................................ 23
psyllium cap 0.52 gm.................................................. 89
psyllium powder 28.3%............................................... 89
psyllium powder 30.9%............................................... 89
psyllium powder 30%.................................................. 89
psyllium powder 33%.................................................. 89
2016
psyllium powder 48.57%............................................. 89
psyllium powder 49%.................................................. 89
psyllium powder 58.6%............................................... 89
psyllium powder 68%.................................................. 89
psyllium powder 95%.................................................. 89
PULMOZYME............................................................. 112
PURIXAN....................................................................... 38
PYLERA......................................................................... 89
pyrazinamide tab 500 mg........................................... 31
pyreth-piperonyl butox sham-permeth aero-nit
remover gel kit.......................................................... 82
pyrethrins-piperonyl butoxide liq 0.33-4%................ 83
pyrethrins-piperonyl butoxide shampoo
0.33-4%...................................................................... 83
pyridostigmine bromide tab 60 mg............................ 30
pyridostigmine bromide tab cr 180 mg..................... 30
Q
QUADRACEL............................................................. 102
quetiapine fumarate tab 100 mg................................23
quetiapine fumarate tab 25 mg.................................. 23
quinapril hcl tab 10 mg............................................... 73
quinapril hcl tab 5 mg................................................. 73
quinapril-hydrochlorothiazide tab 10-12.5 mg.......... 73
quinapril-hydrochlorothiazide tab 20-12.5 mg.......... 73
quinapril-hydrochlorothiazide tab 20-25 mg............. 73
quinidine gluconate tab cr 324 mg............................ 73
QUINIDINE SULFATE................................................. 73
quinidine sulfate tab 300 mg...................................... 73
QVAR........................................................................... 112
QVAR........................................................................... 112
R
RABAVERT................................................................. 102
rabeprazole sodium ec tab 20 mg.............................89
RAGWITEK................................................................. 112
raloxifene hcl tab 60 mg............................................. 95
ramipril cap 1.25 mg................................................... 73
ramipril cap 10 mg....................................................... 73
ramipril cap 2.5 mg......................................................73
ramipril cap 5 mg......................................................... 73
RANEXA........................................................................ 73
RANEXA........................................................................ 73
ranitidine hcl cap 150 mg........................................... 89
ranitidine hcl cap 300 mg........................................... 89
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)............... 89
ranitidine hcl tab 150 mg............................................ 89
ranitidine hcl tab 300 mg............................................ 89
ranitidine hcl tab 75 mg.............................................. 89
RAPAFLO...................................................................... 91
RAPAFLO...................................................................... 91
RAPAMUNE................................................................ 102
RA VITAMIN B-12......................................................118
REBETOL...................................................................... 51
RECOMBIVAX HB..................................................... 102
RECOMBIVAX HB..................................................... 102
RECOMBIVAX HB..................................................... 102
REFRESH................................................................... 106
REFRESH CELLUVISC............................................ 107
REFRESH PLUS....................................................... 107
RELISTOR.....................................................................89
RELISTOR.....................................................................89
RELISTOR.....................................................................89
REMICADE................................................................. 102
REMODULIN.............................................................. 112
REMODULIN.............................................................. 112
REMODULIN.............................................................. 112
REMODULIN.............................................................. 112
RENVELA...................................................................... 91
RENVELA...................................................................... 91
RENVELA...................................................................... 91
repaglinide tab 0.5 mg................................................ 60
repaglinide tab 1 mg................................................... 61
repaglinide tab 2 mg................................................... 61
REPATHA...................................................................... 73
REPATHA PUSHTRONEX SYSTEM........................ 74
REPATHA SURECLICK.............................................. 74
RESCRIPTOR.............................................................. 52
RESCRIPTOR.............................................................. 52
RESTASIS................................................................... 107
RETROVIR IV INFUSION.......................................... 52
REVLIMID......................................................................38
REVLIMID......................................................................38
REVLIMID......................................................................38
REVLIMID......................................................................38
REVLIMID......................................................................38
REVLIMID......................................................................38
151
2016
REXULTI........................................................................ 23
REXULTI........................................................................ 23
REXULTI........................................................................ 23
REXULTI........................................................................ 23
REXULTI........................................................................ 23
REXULTI........................................................................ 23
REXULTI........................................................................ 46
REXULTI........................................................................ 46
REXULTI........................................................................ 47
REXULTI........................................................................ 47
REXULTI........................................................................ 47
REXULTI........................................................................ 47
REYATAZ....................................................................... 52
REYATAZ....................................................................... 52
REYATAZ....................................................................... 52
REYATAZ....................................................................... 52
RIBASPHERE............................................................... 52
RIBASPHERE............................................................... 52
RIBASPHERE RIBAPAK............................................ 52
RIBASPHERE RIBAPAK............................................ 52
ribavirin cap 200 mg.................................................... 52
ribavirin tab 200 mg.....................................................52
RIDAURA.................................................................... 102
rifabutin cap 150 mg................................................... 31
rifampin cap 150 mg................................................... 31
rifampin cap 300 mg................................................... 31
rifampin for inj 600 mg................................................ 31
riluzole tab 50 mg........................................................ 77
rimantadine hydrochloride tab 100 mg..................... 52
risedronate sodium tab 150 mg............................... 104
risedronate sodium tab 30 mg................................. 104
risedronate sodium tab 35 mg................................. 104
risedronate sodium tab 5 mg................................... 104
risedronate sodium tab delayed release 35
mg............................................................................. 104
RISPERDAL CONSTA................................................ 47
risperidone orally disintegrating tab 0.25 mg........... 47
risperidone orally disintegrating tab 0.25 mg........... 57
risperidone orally disintegrating tab 0.5 mg............. 47
risperidone orally disintegrating tab 0.5 mg............. 57
risperidone orally disintegrating tab 1 mg................ 47
152
risperidone soln 1 mg/ml............................................ 47
risperidone soln 1 mg/ml............................................ 57
risperidone tab 0.25 mg.............................................. 47
risperidone tab 0.25 mg.............................................. 57
risperidone tab 0.5 mg................................................ 47
risperidone tab 0.5 mg................................................ 57
risperidone tab 1 mg................................................... 47
RITUXAN....................................................................... 38
RITUXAN....................................................................... 38
rivastigmine tartrate cap 1.5 mg................................ 20
rivastigmine tartrate cap 3 mg................................... 20
rivastigmine tartrate cap 4.5 mg................................ 20
rivastigmine tartrate cap 6 mg................................... 20
rivastigmine td patch 24hr 13.3 mg/24hr.................. 20
rivastigmine td patch 24hr 4.6 mg/24hr.................... 20
rivastigmine td patch 24hr 9.5 mg/24hr.................... 20
rizatriptan benzoate orally disintegrating tab 10
mg................................................................................30
rizatriptan benzoate orally disintegrating tab 5
mg................................................................................30
rizatriptan benzoate tab 10 mg.................................. 30
rizatriptan benzoate tab 5 mg.................................... 30
ropinirole hydrochloride tab 0.25 mg........................ 43
ropinirole hydrochloride tab 0.5 mg...........................43
ropinirole hydrochloride tab 1 mg.............................. 43
rosuvastatin calcium tab 10 mg................................. 74
rosuvastatin calcium tab 5 mg................................... 74
ROTARIX..................................................................... 102
ROTATEQ....................................................................102
S
SABRIL.......................................................................... 18
SABRIL.......................................................................... 18
saline nasal spray 0.65%......................................... 112
SAMSCA..................................................................... 118
SAMSCA..................................................................... 118
2016
SANDIMMUNE........................................................... 102
SANTYL......................................................................... 83
SAPHRIS....................................................................... 47
SAPHRIS....................................................................... 47
SAPHRIS....................................................................... 47
SEA-CLENS WOUND CLEANSER...........................83
selegiline hcl cap 5 mg............................................... 43
selegiline hcl tab 5 mg................................................ 43
selenium sulfide lotion 2.5%...................................... 83
SELZENTRY................................................................. 52
SELZENTRY................................................................. 52
SENNA........................................................................... 89
sennosides-docusate sodium tab 8.6-50 mg........... 89
sennosides syrup 8.8 mg/5ml.................................... 89
sennosides tab 8.6 mg................................................89
SENSIPAR.....................................................................97
SENSIPAR.....................................................................97
SENSIPAR.....................................................................97
SEREVENT DISKUS.................................................112
SEROQUEL XR........................................................... 23
SEROQUEL XR........................................................... 23
SEROQUEL XR........................................................... 23
SEROQUEL XR........................................................... 23
SEROQUEL XR........................................................... 23
SEROQUEL XR........................................................... 47
SEROQUEL XR........................................................... 47
SEROQUEL XR........................................................... 47
SEROQUEL XR........................................................... 47
SEROQUEL XR........................................................... 47
SEROQUEL XR........................................................... 57
SEROQUEL XR........................................................... 57
SEROQUEL XR........................................................... 57
SEROQUEL XR........................................................... 57
SEROQUEL XR........................................................... 57
sertraline hcl oral conc 20 mg/ml.............................. 23
sertraline hcl oral conc 20 mg/ml.............................. 55
sertraline hcl tab 100 mg............................................ 23
sertraline hcl tab 100 mg............................................ 55
sertraline hcl tab 25 mg.............................................. 23
SHUR-SEAL..................................................................83
SIGNIFOR..................................................................... 98
SIGNIFOR..................................................................... 98
SIGNIFOR..................................................................... 98
SIGNIFOR LAR............................................................ 98
SIGNIFOR LAR............................................................ 98
SIGNIFOR LAR............................................................ 98
sildenafil citrate tab 20 mg....................................... 112
SILENOR..................................................................... 114
SILENOR..................................................................... 114
silver sulfadiazine cream 1%..................................... 83
SIMBRINZA................................................................ 107
SIMULECT.................................................................. 102
SIMULECT.................................................................. 102
simvastatin tab 10 mg................................................. 74
simvastatin tab 5 mg................................................... 74
sirolimus tab 0.5 mg.................................................. 102
sirolimus tab 1 mg..................................................... 102
sirolimus tab 2 mg..................................................... 102
SIRTURO.......................................................................31
SIVEXTRO.................................................................... 13
SIVEXTRO.................................................................... 13
skin protectants misc - ointment................................ 83
SLO-NIACIN..................................................................74
SM GLUCOSE............................................................. 61
sodium bicarbonate tab 325 mg................................ 89
sodium bicarbonate tab 650 mg................................ 89
sodium chloride hypertonic ophth oint 5%............. 107
sodium chloride hypertonic ophth soln 5%............ 107
sodium chloride inj 0.45%........................................ 118
sodium chloride irrigation soln 0.9%....................... 118
sodium chloride iv soln 0.9%................................... 118
sodium phenylbutyrate oral powder 3 gm/
teaspoonful.................................................................85
sodium phosphates - soln.......................................... 89
sodium polystyrene sulfonate oral susp 15
gm/60ml....................................................................118
sodium polystyrene sulfonate powder.................... 118
sodium polystyrene sulfonate rectal susp 30
gm/120ml................................................................. 118
SOLTAMOX................................................................... 38
SOMATULINE DEPOT................................................ 98
SOMAVERT.................................................................. 98
SOMAVERT.................................................................. 98
SOMAVERT.................................................................. 98
SOMAVERT.................................................................. 98
SOMAVERT.................................................................. 98
sotalol hcl (afib/afl) tab 120 mg................................. 74
sotalol hcl (afib/afl) tab 160 mg................................. 74
sotalol hcl (afib/afl) tab 80 mg................................... 74
sotalol hcl tab 120 mg.................................................74
sotalol hcl tab 80 mg................................................... 74
SOVALDI....................................................................... 52
SPIRIVA HANDIHALER............................................ 112
SPIRIVA RESPIMAT................................................. 112
153
2016
SPIRIVA RESPIMAT................................................. 112
spironolactone & hydrochlorothiazide tab 25-25
mg................................................................................74
spironolactone tab 100 mg......................................... 74
spironolactone tab 25 mg........................................... 74
spironolactone tab 50 mg........................................... 74
SPRITAM....................................................................... 18
SPRITAM....................................................................... 18
SPRITAM....................................................................... 18
SPRITAM....................................................................... 18
SPRYCEL...................................................................... 38
SPRYCEL...................................................................... 38
SPRYCEL...................................................................... 38
SPRYCEL...................................................................... 38
SPRYCEL...................................................................... 38
SPRYCEL...................................................................... 38
stavudine cap 15 mg................................................... 52
stavudine cap 20 mg................................................... 52
stavudine cap 30 mg................................................... 52
stavudine cap 40 mg................................................... 52
stavudine for oral soln 1 mg/ml................................. 52
STELARA...................................................................... 83
STELARA...................................................................... 83
STELARA.................................................................... 102
STELARA.................................................................... 102
STIMATE....................................................................... 93
STIOLTO RESPIMAT................................................ 112
STIVARGA.....................................................................38
STRATTERA................................................................. 77
STRATTERA................................................................. 77
STRATTERA................................................................. 77
STRATTERA................................................................. 77
STRATTERA................................................................. 78
STRATTERA................................................................. 78
STRATTERA................................................................. 78
STRENSIQ.................................................................... 85
STRENSIQ.................................................................... 85
STRENSIQ.................................................................... 85
STRENSIQ.................................................................... 85
STREPTOMYCIN SULFATE...................................... 13
STRIBILD...................................................................... 52
STUART ONE............................................................ 118
SUBOXONE.................................................................... 6
SUBOXONE.................................................................... 6
SUBOXONE.................................................................... 6
SUBOXONE.................................................................... 6
sucralfate tab 1 gm......................................................89
sulfacetamide sodium lotion 10%.............................. 83
sulfacetamide sodium ophth soln 10%................... 107
sulfacetamide sodium-prednisolone ophth soln
10-0.23(0.25)%....................................................... 107
SULFADIAZINE............................................................ 13
154
SULFAMETHOXAZOLE/TRIMETHOPRIM.............. 13
sulfamethoxazole-trimethoprim susp 200-40
mg/5ml........................................................................ 13
sulfamethoxazole-trimethoprim tab 400-80 mg....... 13
sulfamethoxazole-trimethoprim tab 800-160 mg..... 13
sulfasalazine tab 500 mg......................................... 104
sulfasalazine tab delayed release 500 mg............. 104
sulindac tab 150 mg...................................................... 4
sulindac tab 150 mg.................................................... 29
sulindac tab 200 mg...................................................... 4
sulindac tab 200 mg.................................................... 29
sumatriptan nasal spray 20 mg/act........................... 30
sumatriptan nasal spray 5 mg/act............................. 30
SUMATRIPTAN SUCCINATE.....................................30
sumatriptan succinate inj 6 mg/0.5ml....................... 30
sumatriptan succinate solution auto-injector 4
mg/0.5ml..................................................................... 30
sumatriptan succinate solution auto-injector 6
mg/0.5ml..................................................................... 30
sumatriptan succinate solution cartridge 4
mg/0.5ml..................................................................... 30
sumatriptan succinate solution cartridge 6
mg/0.5ml..................................................................... 30
sumatriptan succinate tab 100 mg............................ 30
sumatriptan succinate tab 25 mg.............................. 30
sumatriptan succinate tab 50 mg.............................. 30
SUPER TWIN EPA/DHA.......................................... 118
SUPRAX........................................................................ 13
SUPRAX........................................................................ 14
SUPRAX........................................................................ 14
SUPREP BOWEL PREP............................................ 89
SURMONTIL................................................................. 23
SURMONTIL................................................................. 23
SURMONTIL................................................................. 24
SUSTIVA........................................................................ 52
SUSTIVA........................................................................ 52
SUSTIVA........................................................................ 52
SUTENT........................................................................ 39
SUTENT........................................................................ 39
SUTENT........................................................................ 39
SUTENT........................................................................ 39
SWEEN CREAM.......................................................... 83
SYLATRON................................................................... 39
SYLATRON................................................................... 39
SYLATRON................................................................... 39
SYLATRON................................................................... 39
SYLATRON................................................................... 39
SYLATRON................................................................... 52
SYLATRON................................................................... 52
SYLATRON................................................................... 52
SYLATRON................................................................... 52
SYLATRON................................................................... 52
2016
SYLVANT....................................................................... 39
SYLVANT....................................................................... 39
SYMBICORT...............................................................112
SYMBICORT...............................................................112
SYMLINPEN 120......................................................... 61
SYMLINPEN 60........................................................... 61
SYNAGIS.................................................................... 102
SYNAGIS.................................................................... 102
SYNAREL...................................................................... 98
SYNERCID.................................................................... 14
SYNJARDY................................................................... 61
SYNJARDY................................................................... 61
SYNJARDY................................................................... 61
SYNJARDY................................................................... 61
SYNRIBO...................................................................... 39
SYNTHROID................................................................. 96
SYNTHROID................................................................. 96
SYNTHROID................................................................. 96
SYNTHROID................................................................. 96
SYNTHROID................................................................. 96
SYNTHROID................................................................. 96
SYNTHROID................................................................. 96
SYNTHROID................................................................. 97
SYNTHROID................................................................. 97
SYNTHROID................................................................. 97
SYNTHROID................................................................. 97
SYNTHROID................................................................. 97
SYPRINE..................................................................... 118
SYSTANE.................................................................... 107
T
TABLOID........................................................................39
tacrolimus cap 0.5 mg.............................................. 102
tacrolimus cap 1 mg.................................................. 103
tacrolimus cap 5 mg.................................................. 103
tacrolimus oint 0.03%.................................................. 83
tacrolimus oint 0.1%.................................................... 83
TAFINLAR..................................................................... 39
TAFINLAR..................................................................... 39
TAGRISSO.................................................................... 39
TAGRISSO.................................................................... 39
TAMIFLU........................................................................52
TAMIFLU........................................................................52
TAMIFLU........................................................................52
TAMIFLU........................................................................52
tamoxifen citrate tab 10 mg........................................39
tamoxifen citrate tab 20 mg........................................39
tamsulosin hcl cap 0.4 mg......................................... 91
TARCEVA...................................................................... 39
TARCEVA...................................................................... 39
TARCEVA...................................................................... 39
TARGRETIN.................................................................. 39
TARGRETIN.................................................................. 39
TASIGNA....................................................................... 39
TASIGNA....................................................................... 39
TAXOTERE................................................................... 39
TAXOTERE................................................................... 39
TAZORAC...................................................................... 83
TAZORAC...................................................................... 83
TAZORAC...................................................................... 83
TAZORAC...................................................................... 83
TEARS NATURALE PM........................................... 107
TECENTRIQ................................................................. 39
TECFIDERA.................................................................. 78
TECFIDERA.................................................................. 78
TECFIDERA STARTER PACK...................................78
TECHNIVIE................................................................... 52
TEFLARO...................................................................... 14
TEFLARO...................................................................... 14
TEGRETOL-XR............................................................ 18
TEKTURNA................................................................... 74
TEKTURNA................................................................... 74
TEKTURNA HCT......................................................... 74
TEKTURNA HCT......................................................... 74
TEKTURNA HCT......................................................... 74
TEKTURNA HCT......................................................... 74
telmisartan-hydrochlorothiazide tab 40-12.5 mg..... 74
telmisartan-hydrochlorothiazide tab 80-12.5 mg..... 75
telmisartan-hydrochlorothiazide tab 80-25 mg.........75
telmisartan tab 20 mg................................................. 74
TEMODAR.................................................................... 39
TENIVAC..................................................................... 103
terazosin hcl cap 10 mg............................................. 75
terazosin hcl cap 10 mg............................................. 91
terazosin hcl cap 1 mg............................................... 75
terbinafine hcl tab 250 mg.......................................... 27
terbutaline sulfate tab 2.5 mg.................................. 112
terbutaline sulfate tab 5 mg..................................... 112
terconazole vaginal cream 0.4%............................... 27
terconazole vaginal cream 0.8%............................... 27
terconazole vaginal suppos 80 mg........................... 27
testosterone cypionate im inj in oil 100 mg/ml......... 95
testosterone cypionate im inj in oil 200 mg/ml......... 96
testosterone enanthate im inj in oil 200 mg/ml........ 96
testosterone td gel 12.5 mg/act (1%) (generic for
AndroGel Pump 1%)................................................ 96
testosterone td gel 25 mg/2.5gm (1%) (generic for
AndroGel 1%)............................................................ 96
155
2016
testosterone td gel 50 mg/5gm (1%) (generic for
AndroGel 1%)............................................................ 96
TETANUS/DIPHTHERIA TOXOID.......................... 103
tetrabenazine tab 12.5 mg......................................... 78
tetrabenazine tab 25 mg............................................. 78
tetracycline hcl cap 250 mg....................................... 14
tetracycline hcl cap 500 mg....................................... 14
THALOMID.................................................................... 39
THALOMID.................................................................... 39
THALOMID.................................................................... 39
THALOMID.................................................................... 39
THALOMID..................................................................103
THALOMID..................................................................103
THALOMID..................................................................103
THALOMID..................................................................103
theophylline tab sr 12hr 100 mg.............................. 112
THERA-D 4000.......................................................... 118
THERANATAL COMPLETE..................................... 118
THERANATAL OVAVITE.......................................... 118
thiamine hcl inj 100 mg/ml....................................... 118
thiamine hcl tab 100 mg........................................... 118
thiamine hcl tab 50 mg............................................. 118
thioridazine hcl tab 100 mg........................................ 47
thioridazine hcl tab 10 mg.......................................... 47
THIOTEPA..................................................................... 40
thiothixene cap 10 mg.................................................48
thiothixene cap 1 mg................................................... 47
THYMOGLOBULIN.................................................... 103
tiagabine hcl tab 2 mg................................................ 18
tiagabine hcl tab 4 mg................................................ 18
TIKOSYN....................................................................... 75
TIKOSYN....................................................................... 75
TIKOSYN....................................................................... 75
TIMOLOL MALEATE................................................... 30
TIMOLOL MALEATE................................................... 30
TIMOLOL MALEATE................................................... 30
TIMOLOL MALEATE................................................... 75
TIMOLOL MALEATE................................................... 75
TIMOLOL MALEATE................................................... 75
timolol maleate ophth gel forming soln 0.25%....... 107
timolol maleate ophth gel forming soln 0.5%......... 107
timolol maleate ophth soln 0.25%........................... 107
timolol maleate ophth soln 0.5%............................. 107
156
TIVICAY......................................................................... 53
TIVICAY......................................................................... 53
TIVICAY......................................................................... 53
tizanidine hcl cap 2 mg............................................... 48
tizanidine hcl tab 2 mg................................................ 48
tizanidine hcl tab 4 mg................................................ 48
TOBRADEX................................................................ 107
tobramycin-dexamethasone ophth susp
0.3-0.1%................................................................... 107
tobramycin nebu soln 300 mg/5ml.......................... 112
tobramycin ophth soln 0.3%.................................... 107
tobramycin sulfate for inj 1.2 gm............................... 14
tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml)........ 14
tobramycin sulfate inj 10 mg/ml................................. 14
tobramycin sulfate inj 2 gm/50ml (40 mg/ml)........... 14
tobramycin sulfate inj 80 mg/2ml (40 mg/ml)........... 14
tolcapone tab 100 mg................................................. 43
tolmetin sodium cap 400 mg........................................ 4
tolmetin sodium cap 400 mg...................................... 29
tolnaftate aerosol 1%.................................................. 27
tolterodine tartrate cap sr 24hr 2 mg........................ 91
tolterodine tartrate cap sr 24hr 4 mg........................ 91
tolterodine tartrate tab 1 mg....................................... 91
tolterodine tartrate tab 2 mg....................................... 91
topiramate sprinkle cap 15 mg.................................. 18
topiramate tab 100 mg................................................ 18
topiramate tab 25 mg.................................................. 18
TOPOTECAN HCL...................................................... 40
topotecan hcl for inj 4 mg........................................... 40
TORISEL....................................................................... 40
torsemide tab 100 mg................................................. 75
torsemide tab 10 mg................................................... 75
torsemide tab 20 mg................................................... 75
torsemide tab 5 mg..................................................... 75
TOUJEO SOLOSTAR..................................................61
TOVIAZ.......................................................................... 91
TOVIAZ.......................................................................... 91
TRACLEER................................................................. 112
TRACLEER................................................................. 112
TRADJENTA................................................................. 61
tramadol-acetaminophen tab 37.5-325 mg................ 4
2016
tramadol hcl tab 50 mg................................................. 4
tramadol hcl tab sr 24hr 100 mg................................. 4
trandolapril tab 1 mg................................................... 75
tranexamic acid iv soln 1000 mg/10ml (100 mg/
ml)................................................................................64
tranexamic acid tab 650 mg....................................... 64
tranylcypromine sulfate tab 10 mg............................ 24
TRAVATAN Z.............................................................. 107
trazodone hcl tab 100 mg...........................................24
trazodone hcl tab 50 mg............................................. 24
TREANDA..................................................................... 40
TREANDA..................................................................... 40
TREANDA..................................................................... 40
TRECATOR................................................................... 31
TRELSTAR.................................................................... 98
TRELSTAR.................................................................... 98
TRELSTAR MIXJECT..................................................98
tretinoin cap 10 mg......................................................40
tretinoin cream 0.025%............................................... 83
tretinoin cream 0.05%................................................. 83
tretinoin cream 0.1%................................................... 83
tretinoin gel 0.01%....................................................... 83
tretinoin gel 0.025%.....................................................83
TRIAMCINOLONE ACETONIDE............................... 83
triamcinolone acetonide cream 0.025%................... 83
triamcinolone acetonide cream 0.1%........................ 83
triamcinolone acetonide cream 0.5%........................ 83
triamcinolone acetonide dental paste 0.1%............. 78
triamcinolone acetonide lotion 0.025%..................... 83
triamcinolone acetonide lotion 0.1%......................... 83
triamcinolone acetonide nasal aerosol suspension
55 mcg/act............................................................... 112
triamcinolone acetonide oint 0.025%........................ 83
triamcinolone acetonide oint 0.1%............................ 83
TRIAMINIC COLD & ALLERGY CHILDRENS...... 113
TRIAMINIC NIGHT TIME COLD & COUGH.......... 113
triamterene & hydrochlorothiazide cap 37.5-25
mg................................................................................75
triamterene & hydrochlorothiazide tab 37.5-25
mg................................................................................75
triamterene & hydrochlorothiazide tab 75-50
mg................................................................................75
trifluoperazine hcl tab 10 mg......................................48
trifluoperazine hcl tab 1 mg........................................ 48
trifluridine ophth soln 1%.......................................... 107
trimethoprim tab 100 mg.............................................14
trimipramine maleate cap 100 mg............................. 24
trimipramine maleate cap 25 mg............................... 24
trimipramine maleate cap 50 mg............................... 24
TRINTELLIX.................................................................. 24
TRINTELLIX.................................................................. 24
TRINTELLIX.................................................................. 24
TRIPLE PASTE............................................................ 83
TRISENOX.................................................................... 40
TRIUMEQ...................................................................... 53
TRIXAICIN..................................................................... 83
TROJAN........................................................................ 83
trospium chloride cap sr 24hr 60 mg........................ 91
trospium chloride tab 20 mg...................................... 91
TRUMENBA................................................................ 103
TRUVADA...................................................................... 53
TRUVADA...................................................................... 53
TRUVADA...................................................................... 53
TRUVADA...................................................................... 53
TUMS ULTRA 1000..................................................... 90
TWINRIX..................................................................... 103
TYBOST........................................................................ 53
TYGACIL....................................................................... 14
TYKERB........................................................................ 40
TYLENOL........................................................................ 4
TYLENOL EXTRA STRENGTH................................... 5
TYPHIM VI.................................................................. 103
TYSABRI....................................................................... 78
TYSABRI..................................................................... 103
TYZEKA......................................................................... 53
TYZINE PEDIATRIC NASAL DROPS.................... 113
U
ULORIC......................................................................... 27
ULORIC......................................................................... 27
UNITUXIN......................................................................40
UPTRAVI..................................................................... 113
UPTRAVI..................................................................... 113
UPTRAVI..................................................................... 113
UPTRAVI..................................................................... 113
UPTRAVI..................................................................... 113
UPTRAVI..................................................................... 113
UPTRAVI..................................................................... 113
UPTRAVI..................................................................... 113
UPTRAVI..................................................................... 113
ursodiol cap 300 mg.................................................... 90
UVADEX........................................................................ 40
UVADEX........................................................................ 83
157
2016
V
VAGIFEM....................................................................... 96
VAGISTAT-1.................................................................. 27
valacyclovir hcl tab 1 gm............................................ 53
valacyclovir hcl tab 500 mg........................................ 53
VALCHLOR................................................................... 83
VALCYTE.......................................................................53
valganciclovir hcl tab 450 mg.....................................53
valproate sodium inj 100 mg/ml................................. 19
valproate sodium syrup 250 mg/5ml......................... 19
valproic acid cap 250 mg........................................... 19
valproic acid cap 250 mg........................................... 57
valsartan-hydrochlorothiazide tab 160-12.5 mg...... 75
valsartan-hydrochlorothiazide tab 160-25 mg.......... 75
valsartan-hydrochlorothiazide tab 320-12.5 mg...... 75
valsartan-hydrochlorothiazide tab 320-25 mg.......... 75
valsartan-hydrochlorothiazide tab 80-12.5 mg.........75
valsartan tab 160 mg.................................................. 75
valsartan tab 320 mg.................................................. 75
valsartan tab 40 mg.....................................................75
valsartan tab 80 mg.....................................................75
vancomycin hcl cap 125 mg...................................... 14
vancomycin hcl cap 250 mg...................................... 14
vancomycin hcl for inj 1000 mg................................. 14
vancomycin hcl for inj 10 gm..................................... 14
vancomycin hcl for inj 5000 mg................................. 14
vancomycin hcl for inj 500 mg................................... 14
VANCOMYCIN HCL IN DEXTROSE........................ 14
VAQTA......................................................................... 103
VAQTA......................................................................... 103
VARIVAX..................................................................... 103
VASCEPA...................................................................... 75
VCF VAGINAL CONTRACEPTIVE FILM................. 84
VCF VAGINAL CONTRACEPTIVE FOAM............... 84
VECTIBIX...................................................................... 40
VECTIBIX...................................................................... 40
VELCADE...................................................................... 40
VENCLEXTA................................................................. 40
VENCLEXTA................................................................. 40
VENCLEXTA................................................................. 40
VENCLEXTA STARTING PACK................................ 40
venlafaxine hcl cap sr 24hr 150 mg.......................... 24
venlafaxine hcl cap sr 24hr 150 mg.......................... 55
venlafaxine hcl cap sr 24hr 37.5 mg......................... 24
venlafaxine hcl cap sr 24hr 37.5 mg......................... 55
venlafaxine hcl cap sr 24hr 75 mg............................ 24
venlafaxine hcl cap sr 24hr 75 mg............................ 55
venlafaxine hcl tab 100 mg........................................ 24
venlafaxine hcl tab 100 mg........................................ 55
158
venlafaxine hcl tab 25 mg.......................................... 24
venlafaxine hcl tab 37.5 mg....................................... 24
venlafaxine hcl tab 37.5 mg....................................... 55
venlafaxine hcl tab sr 24hr 150 mg........................... 24
venlafaxine hcl tab sr 24hr 150 mg........................... 55
venlafaxine hcl tab sr 24hr 37.5 mg.......................... 24
venlafaxine hcl tab sr 24hr 37.5 mg.......................... 55
venlafaxine hcl tab sr 24hr 75 mg............................. 24
venlafaxine hcl tab sr 24hr 75 mg............................. 55
VENTAVIS................................................................... 113
VENTAVIS................................................................... 113
VENTOLIN HFA......................................................... 113
verapamil hcl cap sr 24hr 100 mg............................. 75
verapamil hcl tab 120 mg........................................... 76
verapamil hcl tab 40 mg............................................. 76
verapamil hcl tab 80 mg............................................. 76
verapamil hcl tab cr 120 mg...................................... 76
VERSACLOZ................................................................ 48
VESICARE.................................................................... 91
VESICARE.................................................................... 91
VICTOZA....................................................................... 61
VIDEX............................................................................ 53
VIDEX............................................................................ 53
VIEKIRA PAK................................................................53
VIGAMOX....................................................................107
VIIBRYD.........................................................................24
VIIBRYD.........................................................................24
VIIBRYD.........................................................................24
VIIBRYD STARTER PACK......................................... 24
VIMPAT.......................................................................... 19
VIMPAT.......................................................................... 19
VIMPAT.......................................................................... 19
VIMPAT.......................................................................... 19
VIMPAT.......................................................................... 19
VIMPAT.......................................................................... 19
VINBLASTINE SULFATE............................................ 40
vincristine sulfate iv soln 1 mg/ml............................. 40
vinorelbine tartrate inj 10 mg/ml................................ 40
vinorelbine tartrate inj 50 mg/5ml (10 mg/ml).......... 40
2016
VIOKACE....................................................................... 85
VIOKACE....................................................................... 85
VIRACEPT.................................................................... 53
VIRACEPT.................................................................... 53
VIRAMUNE................................................................... 53
VIRAMUNE XR............................................................ 53
VIRAZOLE..................................................................... 53
VIREAD..........................................................................53
VIREAD..........................................................................53
VIREAD..........................................................................53
VIREAD..........................................................................53
VIREAD..........................................................................53
VITAMIN D2................................................................ 118
VITAMIN D2................................................................ 118
VITAMIN D3................................................................ 118
VITAMIN D3................................................................ 118
vitamins a & d oint.......................................................84
VITEKTA........................................................................ 53
VITEKTA........................................................................ 53
VIVITROL........................................................................ 6
VOLTAREN...................................................................... 5
VOLTAREN....................................................................29
VOLTAREN....................................................................84
voriconazole for inj 200 mg........................................ 27
voriconazole for susp 40 mg/ml................................. 27
voriconazole tab 200 mg............................................ 27
voriconazole tab 50 mg.............................................. 27
VOTRIENT.................................................................... 40
VPRIV............................................................................ 85
VRAYLAR...................................................................... 48
VRAYLAR...................................................................... 48
VRAYLAR...................................................................... 48
VRAYLAR...................................................................... 48
VRAYLAR...................................................................... 48
VRAYLAR...................................................................... 57
VRAYLAR...................................................................... 58
VRAYLAR...................................................................... 58
VRAYLAR...................................................................... 58
VRAYLAR...................................................................... 58
VYTORIN....................................................................... 76
VYTORIN....................................................................... 76
VYTORIN....................................................................... 76
VYTORIN....................................................................... 76
W
warfarin
warfarin
warfarin
warfarin
warfarin
warfarin
warfarin
warfarin
sodium
sodium
sodium
sodium
sodium
sodium
sodium
sodium
tab
tab
tab
tab
tab
tab
tab
tab
10 mg.........................................64
1 mg........................................... 64
2.5 mg........................................64
2 mg........................................... 64
3 mg........................................... 64
4 mg........................................... 64
5 mg........................................... 64
6 mg........................................... 64
warfarin sodium tab 7.5 mg........................................64
water for irrigation, sterile irrigation soln................ 118
WELCHOL..................................................................... 61
WELCHOL..................................................................... 61
WELCHOL..................................................................... 76
WELCHOL..................................................................... 76
X
XALKORI....................................................................... 40
XALKORI....................................................................... 40
XARELTO...................................................................... 64
XARELTO...................................................................... 64
XARELTO...................................................................... 64
XARELTO STARTER PACK....................................... 64
XENAZINE.................................................................... 78
XENAZINE.................................................................... 78
XGEVA......................................................................... 104
XIFAXAN........................................................................14
XIFAXAN........................................................................90
XOLAIR........................................................................113
XOPENEX HFA.......................................................... 113
XTANDI.......................................................................... 40
XYREM........................................................................ 114
Y
YERVOY........................................................................ 40
YERVOY........................................................................ 40
YF-VAX........................................................................ 103
YONDELIS.................................................................... 40
Z
zafirlukast tab 10 mg................................................. 113
zafirlukast tab 20 mg................................................. 113
zaleplon cap 10 mg................................................... 114
zaleplon cap 5 mg..................................................... 114
ZALTRAP....................................................................... 40
ZALTRAP....................................................................... 40
ZANOSAR..................................................................... 40
ZAVESCA...................................................................... 85
ZELBORAF................................................................... 41
ZEMPLAR................................................................... 104
ZEMPLAR................................................................... 104
ZENPEP........................................................................ 85
ZENPEP........................................................................ 85
ZENPEP........................................................................ 85
ZENPEP........................................................................ 85
ZENPEP........................................................................ 85
ZENPEP........................................................................ 85
ZENPEP........................................................................ 85
ZEPATIER..................................................................... 53
ZETIA............................................................................. 76
ZIAGEN..........................................................................53
zidovudine cap 100 mg............................................... 53
159
2016
zidovudine syrup 10 mg/ml........................................ 53
zidovudine tab 300 mg................................................54
ZINACEF....................................................................... 14
zinc oxide oint 10%..................................................... 84
zinc oxide oint 20%..................................................... 84
zinc oxide oint 40%..................................................... 84
ziprasidone hcl cap 20 mg......................................... 48
ZOHYDRO ER................................................................ 5
ZOHYDRO ER................................................................ 5
ZOHYDRO ER................................................................ 5
ZOHYDRO ER................................................................ 5
ZOHYDRO ER................................................................ 5
ZOHYDRO ER................................................................ 5
ZOHYDRO ER................................................................ 5
ZOHYDRO ER................................................................ 5
ZOHYDRO ER................................................................ 5
ZOHYDRO ER................................................................ 5
ZOHYDRO ER................................................................ 5
ZOHYDRO ER................................................................ 5
zoledronic acid inj conc for iv infusion 4
mg/5ml...................................................................... 104
zoledronic acid iv soln 5 mg/100ml......................... 105
ZOLINZA........................................................................41
zolpidem tartrate tab 10 mg..................................... 114
zolpidem tartrate tab 5 mg....................................... 114
ZOMETA...................................................................... 105
zonisamide cap 100 mg..............................................19
zonisamide cap 25 mg................................................ 19
zonisamide cap 50 mg................................................ 19
ZONTIVITY....................................................................64
ZORTRESS.................................................................103
ZORTRESS.................................................................103
ZORTRESS.................................................................103
ZOSTAVAX.................................................................. 103
ZOSYN........................................................................... 14
ZOSYN........................................................................... 14
ZOSYN........................................................................... 14
ZYDELIG....................................................................... 41
ZYDELIG....................................................................... 41
ZYKADIA....................................................................... 41
ZYPREXA RELPREVV............................................... 48
ZYTIGA.......................................................................... 41
ZYVOX........................................................................... 14
160
Blue Cross and Blue Shield of Illinois complies with applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross and Blue Shield
of Illinois does not exclude people or treat them differently because of race, color, national origin, age,
disability, or sex.
Blue Cross and Blue Shield of Illinois:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
○ Qualified sign language interpreters
○ Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English, such as:
○ Qualified interpreters
○ Information written in other languages
If you need these services, contact <Civil Rights Coordinator>
If you believe that Blue Cross and Blue Shield of Illinois has failed to provide these services or discriminated
in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
<Civil Rights Coordinator>, <Office of Civil Rights Coordinator, 300 E. Randolph St., 35th floor, Chicago,
Illinois 60601>, <1-855-664-7270>, <TTY/TDD: 1-855-661-6965>, <Fax: 1-855-661-6960>,
<[email protected]>. You can file a grievance in person or by mail, fax, or email. If you need
help filing a grievance, <Civil Rights Coordinator> is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for
Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
English: ATTENTION: If you speak <a non-English language>, language assistance services, free of charge,
are available to you. Call <1-877-723-7702 (TTY/TDD: 711)>.
Español (Spanish): ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia
lingüística. Llame al <1-877-723-7702 (TTY/TDD: 711)>.
繁體中文 (Chinese): 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 <1-877723-7702 (TTY/TDD: 711)>.
Tagalog (Tagalog – Filipino): PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng
mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa <1-877-723-7702 (TTY/TDD:
711)>.
Français (French): ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont
proposés gratuitement. Appelez le <1-877-723-7702 (ATS : 711)>.
Tiếng Việt (Vietnamese): CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí
dành cho bạn. Gọi số <1-877-723-7702 (TTY/TDD: 711)>.
Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche
Hilfsdienstleistungen zur Verfügung. Rufnummer: <1-877-723-7702 (TTY/TDD: 711)>.
한국어 (Korean): 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.
<1-877-723-7702 (TTY/TDD: 711)>번으로 전화해 주십시오.
Русский (Russian): ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны
бесплатные услуги перевода. Звоните <1-877-723-7702 (телетайп: 711)>.
‫( العربية‬Arabic):
‫ (رقم هاتف الصم‬2077-327-778-1 <‫ اتصل برقم‬.‫ فإن خدمات المساعدة اللغوية تتوافر لك بالمجان‬،‫ إذا كنت تتحدث اذكر اللغة‬:‫ملحوظة‬
.>)117 :‫والبكم‬
ह द
िं ी (Hindi): ध्यान दें : यदद आप द द
िं ी बोलते ैं तो आपके ललए मफ्
ु त में भाषा स ायता सेवाएिं उपलब्ध ैं।
<1-877-723-7702 (TTY/TDD: 711)> पर कॉल करें ।
Italiano (Italian): ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di
assistenza linguistica gratuiti. Chiamare il numero <1-877-723-7702 (TTY/TDD: 711)>.
ુ રાતી (Gujarati): સુચના: જો તમે ગુજરાતી બોલતા હો, તો નન:શુલ્ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ
ગજ
છે . ફોન કરો <1-877-723-7702 (TTY/TDD: 711)>.
‫( اُردُو‬Urdu): -723-877-1< ‫ تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں ۔ کال کریں‬،‫اگر آپ اردو بولتے ہیں‬: ‫خبردار‬
7702 (TTY/TDD: 711)>.
Polski (Polish): UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej.
Zadzwoń pod numer <1-877-723-7702 (TTY/TDD: 711)>.
λληνικά (Greek): ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθε
σή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι
οποίες παρέχονται δωρεάν. Καλέστε <1-877-723-7702 (TTY/TDD: 711)>.
The formulary may change at any time. You will receive notice when necessary.
If you have questions, please call Blue Cross Community MMAI at 1-877-723-7702. TTY/TDD: 711. We are
open 8:00 a.m. until 8:00 p.m. Central time, seven (7) days a week. On weekends and Federal holidays, voice
later than the next business day. The call is free.
For questions about enrolling call: Illinois Client Enrollment Services 1-877-912-8880 (TTY: 1-866-565-8576)
Website: enrollhfs.illinois.gov
HPMS Approved Formulary File ID: 16055, Version 18
This formulary was updated on 9/2/2016.
Medicare-Medicaid Plan provided by Blue Cross and Blue Shield of Illinois, a Division of Health Care Service
Corporation, a Mutual Legal Reserve Company (HCSC), an Independent Licensee of the Blue Cross and Blue
Shield Association. HCSC is a health plan that contracts with both Medicare and Illinois Medicaid to provide
benefits of both programs to enrollees. Enrollment in HCSC’s plan depends on contract renewal.

2016 Formulary (List of Covered Drugs)

Transcription

Similar documents

BOUGAINVILLEA (Bougainvillea Comm. ex Juss.)

List of Covered Drugs - Inland Empire Health Plan

(PDP) 2016 Formulary - Blue Cross and Blue Shield of Illinois

Florida Blue July 2016 Medication Guide

OTC Catalog - Cigna

Medi-Pak Rx Basic (PDP) 2015 Comprehensive

Español - Santa Clara Family Health Plan

Blue Medicare Rx Standard

Horizon BCBSNJ Health Insurance Marketplace

2016 LIST OF COVERED DRUGS - WellCare Advocate Complete

Rx Formulary - Millenium Medical Solutions Corp

English - UHCCommunityPlan.com

HealthPartners EnhancedRx

Lista de Medicamentos - Blue Cross and Blue Shield of Illinois

Comprehensive Formulary

Kaiser Permanente comprehensive formulary