Florida Blue September 2016 Care Choices Medication Guide

Transcription

October 2016
Care Choices Medication Guide
Please consider talking to your doctor about prescribing formulary medications, which may help
reduce your out-of-pocket costs. This list may help guide you and your doctor in selecting an
appropriate medication for you.
The drug formulary is regularly updated. Please visit www.floridablue.com for the most up-to-date
information.
Contents
Medication List
Introduction ....................................................................... I
Anti-Infective Drugs ........................................................ 1
Medication List ................................................................. I
Biologicals ..................................................................... 12
Exception Process........................................................... II
Antineoplastic Agents ................................................... 15
Your Share of Expenses ................................................ III
Endocrine and Metabolic Drugs ....................................20
Pharmacy Benefits ......................................................... III
Cardiovascular Agents...................................................37
Utilization Management Programs ................................ VI
Respiratory Agents ....................................................... 56
Notice .......................................................................... VIII
Gastrointestinal Agents ................................................ 61
Using the Medication Guide ........................................ VIII
Genitourinary Agents .................................................... 66
Abbreviation/acronym key ............................................. IX
Central Nervous System Drugs .................................... 69
Analgesics and Anesthetics .......................................... 85
Neuromuscular Drugs ................................................... 95
Nutritional Products .................................................... 104
Hematological Agents ................................................. 112
Topical Products ......................................................... 120
Miscellaneous Products .............................................. 133
Index ........................................................................... 196
To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to
Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on
Search.
3022-O FL HIM © Prime Therapeutics LLC 10/16
Rev.4/2016
Introduction
Florida Blue is pleased to present the Care Choices Medication Guide. This is a general guide that includes a
comprehensive listing of medications that may be covered under your plan. Since coverage for medication varies by the
plan purchased by you or your employer, it’s important that you refer to your plan documents for complete coverage
details. When we refer to “plan documents” we are referring to one or more of the following: Benefit Booklet, Certificate
of Coverage, Contract, Member Handbook or prescription drug endorsement.
If you are a current member, we encourage you to log on to your member account for plan specific details about your
medication coverage. Go to www.floridablue.com, click on the Members tab. Once registered, you can look up a
medication by name and compare your cost at different pharmacies. You’ll see notes that indicate if a medication requires
a prior authorization or is not covered by your plan.
Si desea hablar sobre esta guía en español con uno de nuestros representantes, por favor llame al número de
atención al cliente indicado en su tarjeta de asegurado y pida ser transferido a un representante bilingüe.
NOTE: The decision concerning whether a prescription medication should be prescribed must be made by you and your
physician. Any and all decisions that require or pertain to independent professional medical judgment or training, or the
need for, and dosage of, a prescription medication, must be made solely by you and your treating physician in accordance
with the patient/physician relationship.
Key Tips and Coverage Guidelines
By following these simple guidelines, you will be assured that you are getting the maximum benefit from your plan.
•
When you have your prescriptions filled, ask your pharmacist if a generic equivalent is available. Generic
medications are usually less expensive and most generics are covered unless specifically excluded under your
plan documents.
•
Consider asking your physician to prescribe generic medications, or if necessary, one of the preferred brand name
medications whenever appropriate. Your cost for generic and preferred brand name medications is lower than nonpreferred brand name medications
•
If you are currently taking a medication, take a moment to review the medication list to determine if it is covered. If
not, check with your doctor to understand available options and review the EXCEPTION PROCESS section of
this Guide for exception procedures.
•
If you or your provider request a covered brand name medication when there is a generic available; you will be
responsible for: (1) the difference in cost between the generic medication and the brand name medication you
received; and (2) the cost share applicable to the brand name medication you received, as indicated on your
Schedule of Benefits
Medication List
What you need to know about generic medications
Florida Blue encourages the use of generic medications as a way to provide high-quality medications at reduced costs.
Generic medications are as safe and effective as their brand name counterparts, and are usually considerably less
expensive.
A Food and Drug Administration (FDA) approved generic medication may be substituted for its brand name counterpart
because it:
•
Contains the same active ingredient(s) as the Brand medication
•
Is identical in strength, dosage form, and route of administration
•
Is therapeutically equivalent and can be expected to have the same clinical effect and safety profile
Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of
Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the
Blue Cross and Blue Shield Association.
Florida Blue October 2016 Care Choices Medication Guide
I
Changes to the formulary
This guide includes the medication list which reflects the current recommendations of Florida Blue and is developed in
conjunction with Prime Therapeutics’ National Pharmacy & Therapeutics Committee. Florida Blue reserves the right to
add or remove or change the tier of any medication in this Medication Guide at any time.
The medication list is reviewed quarterly to examine new medications and new information about medications that are
already on the market concerning safety, effectiveness and current use in therapy. The most up-to-date information about
modifications to the medications listed in this medication guide can be found by:
Going to www.floridablue.com
•
Click on the Members tab
•
Click on the Login Now button and either Login or Register
•
Once Logged in, click on My Plan, then select Pharmacy from the drop down menu
•
Under Pharmacy Resources, click on Medication Guide & Specialty Pharmacy
•
Under Medication Guide/Approved Drug Lists, click Care Choices Medication Guide or Care Choices Medication
Guide Updates
Updated medication guides are posted periodically throughout the year.
There are varying reasons changes are made to the medications listed in the Care Choices Medication Guide:
•
The tier level of a brand name medication included on the medication list may increase (change to a higher tier)
when an FDA-approved bioequivalent generic medication becomes available.
•
Newly marketed prescription medications may not be covered until the Pharmacy & Therapeutics Committee has
had an opportunity to review the medication to determine whether the medication will be covered and if so, which
tier will apply based on safety, efficacy and the availability of other products within that class of medications.
Formulary addition request
Physicians may request the addition of a medication to the formulary list by submitting a written request to Florida Blue.
Please mail to:
Florida Blue
Attn: Pharmacy Programs
P.O. Box 1798
Jacksonville, FL 32231-0014
Exception Process
Pursuant to 45 C.F.R. 156.122, if a medication is not covered on our formulary, you may request an exception. We have
established processes for both standard exception requests and expedited exception requests, as described below.
Standard Exception Requests
To request a standard exception, you, your designee or the prescribing physician (or other prescriber), as appropriate
may submit an exception request by completing and submitting the Coverage Exception Request Form at the link below.
We will notify you or your designee and the prescribing physician (or other prescriber, as appropriate) of our decision
within 72 hours of our receipt of the request. If we approve the exception, we will provide coverage of the excepted
medication for the duration of the prescription, including refills.
II
Expedited Exception Requests
You may request an expedited exception based on exigent circumstances. Exigent circumstances exist when:
1. you are suffering from a medical condition that may seriously jeopardize your life, health or ability to regain
maximum function; or
2. you are undergoing a current course of treatment using a medication that is not covered on our formulary.
To request an expedited exception, you, your designee or the prescribing physician (or other prescriber) may submit an
exception request by completing and submitting the Coverage Exception Request Form at the link below.
We will notify you or your designee and the prescribing physician (or other prescriber, as appropriate) of our decision
within 24 hours of our receipt of the request. If we approve the exception, we will provide coverage of the excepted
medication for the duration of the exigency.
Coverage Exception Request Form
What if my exception request is denied?
If we deny your standard or expedited request for exception, you, your designee, or the prescribing physician (or other
prescriber) may request a review of the original request and our denial by an external independent review organization.
1. If the original exception request was a standard request, we will notify you or your designee and the prescribing
physician (or other prescriber, as appropriate) of our decision within 72 hours of our receipt of the request. If we
approve the exception, we will provide coverage of the excepted medication for the duration of the prescription.
2. If the original exception request was an expedited request, we will notify you or your designee and the prescribing
physician (or other prescriber, as appropriate) of our decision within 24 hours of our receipt of the request. If we
approve the exception, we will provide coverage of the excepted medication for the duration of the exigency.
Your Share of Expenses
Your cost share will depend on which cost share tier the medication is assigned to:
Tier 1: Preferred generic medications and supplies
Tier 2: Preferred brand name medications and supplies
Tier 3: Non-preferred medications and supplies
Tier 4: Specialty medications
Pharmacy Benefits
Condition Care Rx Program
The Condition Care Rx Program is designed to help manage the cost of medications used to treat certain chronic
conditions and encourage medication adherence. If you have the Condition Care Rx Program as part of your benefits, you
can purchase medications from the Condition Care Rx Program Value List/Health Savings Account Preventive List at a
reduced cost.
A list of medications that are part of the Condition Care Rx Value Program may be found at: Condition Care Rx Program
Value List
A list of medications that are part of the Condition Care Rx Program for Health Savings Account (HSA) compatible plans
may be found at: Condition Care Rx Program HSA Preventive List
III
NOTE: Check your Schedule of Benefits to determine if the Condition Care Rx Program applies to your plan and the
applicable cost share. Coverage details may also be available to you by logging into the member section of
www.floridablue.com.
Immunizations
Certain vaccines which are covered under your preventive benefits can be administered by pharmacists that are certified.
Not all pharmacies provide services for vaccine administration. It is important to contact the pharmacy prior to your visit to
ensure availability and administration of the vaccine.
A list of vaccines that are covered under your pharmacy benefits may be found at: Pharmacy Benefit Vaccines List
Mail Order Pharmacy
Obtaining prescription medications through the mail order pharmacy may reduce the cost you pay for your prescription
medications.
Check your plan documents to determine if your plan provides a mail order pharmacy benefit.
Members who have pharmacy benefits through Florida Blue can access and print out the Mail Order Pharmacy Form on
our website at www.floridablue.com.
NOTE: If the original prescription was filled at a pharmacy other than the mail order pharmacy, you must submit a new,
original three-month supply prescription with a quantity of up to a three-month supply and not less than a two-month
supply along with the Registration and Prescription Order Form. Prescriptions may not be transferred from a retail
pharmacy to the mail order pharmacy.
Medications that are not covered
Your pharmacy benefit may not cover select medications. Some of the reasons a medication may not be covered are:
•
The medication has been shown to have excessive adverse effects and/or safer alternatives
•
The medication has a preferred formulary alternative or over-the-counter (OTC) alternative
•
The medication is no longer marketed
•
The medication has a widely available/distributed AB rated generic equivalent formulation
•
The medication has been repackaged — a pharmaceutical product that is removed from the original manufacturer
container (Brand Originator) and repackaged by another manufacturer with a different NDC
In addition to any drug not listed in the medication guide, a list of certain medications that are not covered may be found at
Medications Not Covered List
NOTE: To determine the medication exclusions that apply to your plan, check your plan documents. Coverage details are
also available to you by logging into the member section of www.floridablue.com
Oral Chemotherapy Drugs
Oral chemotherapy drugs are drugs prescribed by a physician to kill or slow the growth of cancerous cells in a manner
consistent with the national accepted standards of practice. A list of these drugs can be found at: Oral Chemotherapy
Drug List
IV
Over-the-counter (OTC) medications
An over-the-counter medication can be an appropriate treatment for some conditions and may offer a lower cost
alternative to some commonly prescribed medications. Your pharmacy benefit may provide coverage for select OTC
medications. Some groups may customize their pharmacy plan to exclude coverage for OTC medications, so it is
important to check your plan documents to determine if OTC medications are covered under your plan. Only those OTC
medications prescribed by your physician and designated on the formulary with “OTC” in parenthesis following the
medication name are eligible for coverage.
NOTE: Check your plan documents to determine if this benefit applies to your plan. Coverage details are also available to
you logging into the member section of www.floridablue.com.
Patient Protection and Affordable Care Act (ACA) Preventive Services
•
Preventive Medications – Certain preventive care services, medications, and immunizations are covered at no
cost share when purchased at a participating pharmacy. A list of medications covered under this benefit may be
found at: Preventive Medications List
•
Women’s Preventive Services – Certain contraceptive medications or devices (e.g., oral contraceptives,
emergency contraceptive, and diaphragms) are covered at no cost share when purchased at a participating
pharmacy. A list of medications and devices covered under this benefit may be found at: Women’s Preventive
Services List
Specialty Pharmacy medications
Specialty Pharmacy medications are high-cost injectable, infused, oral or inhaled medications that generally require close
supervision and monitoring of the patient’s therapy.
NOTE: Check your plan documents for information on how Specialty Pharmacy medications are covered on your plan.
Specialty Medications are divided into two categories:
•
Self-Administered Specialty Medications – Patients administer these Specialty Pharmacy medications themselves.
Because these medications are intended to be self-administered, these medications may not be covered if
administered in a physician’s office. If these medications are not obtained from a participating specialty pharmacy,
out-of-network coverage is not available. A current listing of Self-Administered Specialty Medications can be
found here
•
Provider-Administered Specialty Medications – These medications require the administration to be performed by
a physician. The Specialty Pharmacy medications are ordered by a provider and administered in an office or
outpatient setting. Provider-administered Specialty Pharmacy medications are covered under your medical benefit.
These medications can be obtained from any in-network health care provider. A current listing of ProviderAdministered Specialty Medications can be found here
NOTE: We have noted medications that may be covered as either Self-Administered and/or Provider-Administered. These
Specialty Pharmacy products can be obtained in either setting.
V
Participating Specialty Pharmacy Providers
Your network for Specialty Pharmacies is limited to the following participating Specialty Pharmacy providers. Unless
indicated below, any other pharmacy is considered a non-participating Specialty Pharmacy even if it participates in Florida
Blue’s networks for non-Specialty Pharmacy medications.
Caremark Specialty Pharmacy Services
All Products
Phone: 866-278-5108
Fax: 800-323-2445
Caremark Specialty Pharmacy
Caremark Hemophilia Services
Hemophilia Products
Telephone: 866-792-2731
(Mon-Fri., 9:00 a.m. to 7:30 p.m. EST)
Fax: 866-811-7450
Prime Therapeutics Specialty Pharmacy
(Prime Specialty Pharmacy)
Telephone: 877-627-MEDS (6337)
Fax: 877-828-3939
TTY 711
Prime Specialty Pharmacy
Prime Therapeutics Specialty Pharmacy
(Prime Specialty Pharmacy) is a wholly owned
subsidiary of Prime Therapeutics LLC.
Caremark Hemophilia
NOTE: Specialty Pharmacy medications are not covered when purchased through the mail order pharmacy.
If you receive a written prescription directly from your provider for a provider-administered specialty medication you should
contact customer service for further assistance.
Three-month supply
In addition to being able to obtain up to a three-month supply of medication through our mail order pharmacy, you may be
able to receive up to a three-month supply of your medication through a participating retail pharmacy. Please refer to your
plan documents to determine if your plan includes this benefit.
Utilization Management Programs
Prior Authorization Program
The Prior Authorization Program encourages the appropriate, safe and cost-effective use of medications. If you are
currently taking or are prescribed a medication that is included in the Prior Authorization Program, your physician will need
to submit a request form in order for your prescription to be considered for coverage. If you do not request and/or receive
prior approval, the medication will not be covered. Medications that require prior authorization for coverage are indicated
in the prior authorization column following the product name in the medication list.
NOTE: Some groups may customize their pharmacy plan to exclude prior authorization requirements, so it is important to
check your plan documents to determine if prior authorization requirements apply to your plan. Coverage details are also
available to you by logging into the member section of www.floridablue.com.
Obtaining Prior Authorization
Information about prior authorization and forms for how to obtain a prior authorization approval can be found here: Prior
Authorization Program Information and Forms
NOTE: Your provider is required to complete and submit the Prior Authorization form in order for a coverage
determination to be made.
VI
1. Once a decision is made, you and/or your doctor will be informed of the decision.
2. If the decision is made to authorize coverage, the medication(s) and/or supplies may be obtained from a
participating pharmacy or at the appropriate location if the medication(s) will be administered by a health
professional. Prior authorization approval does not waive your cost share.
3. If a decision is made to deny authorization, you are free to purchase the prescription medication, supplies or
Over-the-Counter (OTC) medication, but you will have to pay the full cost of the medication and will not be entitled
to reimbursement under your plan.
NOTE: You have the right to request an appeal if prior authorization is denied. Please refer to the ‘How to Appeal an
Adverse Benefit Determination’ subsection of the Complaint and Grievance Process section in your current Benefit
Booklet or Contract for information on how to file an appeal.
Responsible Quantity Program
The Responsible Quantity Program encourages the appropriate, safe and cost-effective use of medication by setting a
maximum quantity per month for a medication or supply. The quantity limitations are based on the Food and Drug
Administration guidelines and the manufacturer’s dosing recommendations. Medications that are subject to this program
are indicated in the quantity limits column following the product name in the medication list.
Information about the Responsible Quantity Program and steps for how to obtain an exception can be found here:
Responsible Quantity Program Information
Responsible Steps Program
The Responsible Steps Program promotes the appropriate, safe, and effective use of medications and helps you save on
prescriptions. Responsible Steps is based on nationally recognized therapeutic guidelines, clinical evidence, and research.
Prescription medications included in the Responsible Steps Program are not covered unless you have tried one or more
covered alternative medications first.
Responsible Steps Program (Medical Pharmacy)
Physician-administered Prescription Drugs which are rendered in a physician’s office may be included in the Responsible
Steps for Medical Pharmacy Program. If you are taking a medication in the Responsible Steps Program, please contact
your physician/provider to discuss what medication options are best for you.
Information about the Responsible Steps Program and the Responsible Steps for Medical Pharmacy Program and steps
for how to obtain an exception can be found at: Responsible Steps Program Information or Responsible Steps for Medical
Pharmacy Program Information.
NOTE: Check your plan documents to determine if Responsible Steps requirements apply to your plan. Coverage details are
also available to you by logging into the member section of www.floridablue.com or by calling the customer service number
listed on your ID card.
U/M Exception requests
If, for medical reasons, you require a quantity of medication outside the Responsible Quantity Program limits or you
cannot use one of the alternative medications and require the medication listed in the Responsible Steps or Responsible
Steps for Medical Pharmacy Programs, require a tier exception for a contraceptive, your physician may submit an
exception request by completing one of the forms below
Prior Authorization Forms
Responsible Quantity Authorization Form
Contraceptives Tier Exception Request Form
VII
Notice
This Medication Guide shall not extend, vary, alter, replace, or waive any of the provisions, benefits, exclusions,
limitations, or conditions contained in the Benefit Booklet, Contract, or prescription drug endorsement. In the event of any
inconsistencies between the Medication Guide and the provisions contained in the Benefit Booklet, Contract or
prescription drug endorsement, the provisions contained in the Benefit Booklet, Contract or prescription drug endorsement
shall control to the extent necessary to effectuate the intent of Florida Blue and Florida Blue HMO.
Using the Medication Guide
The medication list is organized into broad categories (e.g., Antibacterials). Below are descriptions of the columns
included the medication list.
Column 1.
Drug Name: lists the medication name. Generic medications are listed in lowercase boldface (e.g.,
demeclocycline) Brand name medications are capitalized (e.g., ZITHROMAX packets)
Separate medication entries are shown for each dosage form and strength.
Note: Self-administered injectable medications are designated in the medication list with “inj” following the
medication name (e.g., enoxaparin inj).
Column 2.
Drug Tier: indicates the tier level and whether the medication is on the preventive list or Condition Care Rx
List:
“P”: Preventive medications
Tier 1: Preferred generic medications and supplies
Tier 2: Preferred brand name medications and supplies
Tier 3: Non-preferred medications
Tier 4: Specialty medications
Column 3.
Specialty: indicates if the medication is a Self-Administered Specialty medication.
Column 4.
Prior Authorization: indicates if the prior authorization requirement applies to the medication. If an indicator
is present in the column, then the prior authorization requirement applies.
Column 5.
Responsible Quantity: indicates if quantity limits apply to the medication. If an indicator is present in the
column, then quantity limits apply.
Column 6.
Responsible Steps: indicates if step therapy applies to the medication. If an indicator is present in the
column, then step therapy applies.
Column 7.
Limited Distribution: indicates if the medication has limited distribution. If an indicator is present in the
column, the medication may be available only at certain pharmacies. For more information, consult your
pharmacy directory.
VIII
Abbreviation/acronym key
caps ....................................................................capsules
chew tabs .............................................. chewable tablets
OTC ........................................................ over-the-counter
PA ......................................... Prior Authorization required
conc ............................................................... concentrate
QL ............................... Responsible Quantity Program —
crm .......................................................................... cream
ext-release............................................ extended-release
quantity limit applies
SI ......................................... Self-Administered Injectable
SL...................................................................... sublingual
inhal .................................................................. inhalation
inj .........................................................................injection
lotn ........................................................................... lotion
NP ............................................................... non-preferred
ODT ........................................ orally disintegrating tablets
oint ...................................................................... ointment
SP ..................................................... Specialty Pharmacy
soln ....................................................................... solution
supp ............................................................ suppositories
susp ................................................................ suspension
tabs .........................................................................tablets
OSM ........................................................ osmotic-release
To determine if your drug is covered and/or find drug pricing, please login to Your Account on the Florida Blue
website at www.floridablue.com. In Your Account choose Tools, and then Compare Drug Prices.
IX
Nondiscrimination and Accessibility Notice (ACA §1557)
Florida Blue and Florida Blue HMO comply with applicable Federal civil rights laws and do not
discriminate on the basis of race, color, national origin, age, disability or sex. Florida Blue and Florida
Blue HMO does not exclude people or treat them differently because of race, color, national origin,
age, disability or sex.
Florida Blue and Florida Blue HMO provide free aids and services to people with disabilities to
communicate effectively with us, such as:
o
o
o
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 1-800-352-2583.
If you believe that Florida Blue and Florida Blue HMO 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:
Section 1557 Coordinator
4800 Deerwood Campus Parkway, DC1-7
Jacksonville, FL 32246
Phone 800-477-3736 x29070 (TTY: 800-955-8770)
Fax 904-301-1580
Email [email protected]
You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, our
Section 1557 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, DC 20201
1-800-368-1019, 800–537–7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Health insurance is offered by Florida Blue. HMO coverage is offered by Florida Blue HMO, an affiliate of Florida Blue. Dental insurance is
offered by Florida Combined Life Insurance Company, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are
Independent Licensees of the Blue Cross and Blue Shield Association.
86763 0616
Florida Blue and Florida Blue HMO: [1-800-352-2583]
TTY: 800-955-8770
Have a disability? Speak a language other than English? Call to get help for free.
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Health insurance is offered by Florida Blue. HMO coverage is offered by Florida Blue HMO, an affiliate of Florida Blue. Dental insurance is
offered by Florida Combined Life Insurance Company, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are
Independent Licensees of the Blue Cross and Blue Shield Association.
86763 0616
ANTI-INFECTIVE AGENTS
PENICILLINS
AMOXICILLIN - amoxicillin
(trihydrate) chew tab 125 mg
3
AMOXICILLIN - amoxicillin
(trihydrate) chew tab 250 mg
2
amoxicillin (trihydrate) cap
250 mg
1
amoxicillin (trihydrate) cap
500 mg
amoxicillin (trihydrate) for susp
125 mg/5ml
1
1
AMOXICILLIN/CLAVULANATE P amoxicillin & k clavulanate chew
tab 200-28.5 mg
3
AMOXICILLIN/CLAVULANATE P amoxicillin & k clavulanate chew
tab 400-57 mg
3
ampicillin cap 500 mg
AUGMENTIN - amoxicillin & k
clavulanate for susp 250-62.5
mg/5ml
3
clavulanate tab 500-125 mg
3
1
clavulanate tab 875-125 mg
3
AUGMENTIN ES-600 - amoxicillin
& k clavulanate for susp 600-42.9
mg/5ml
3
amoxicillin & k clavulanate
for susp 250-62.5 mg/5ml
(Augmentin)
1
1
AUGMENTIN XR - amoxicillin & k
clavulanate tab sr 12hr 1000-62.5
mg
3
amoxicillin & k clavulanate for
susp 400-57 mg/5ml
amoxicillin & k clavulanate
for susp 600-42.9 mg/5ml
(Augmentin es-600)
1
dicloxacillin sodium cap 250 mg
1
amoxicillin & k clavulanate tab sr
12hr 1000-62.5 mg (Augmentin
xr)
1
amoxicillin & k clavulanate tab
250-125 mg
1
250 mg/5ml
400 mg/5ml
amoxicillin (trihydrate) tab 500 mg
amoxicillin (trihydrate) tab 875 mg
amoxicillin & k clavulanate for
susp 200-28.5 mg/5ml
500-125 mg (Augmentin)
875-125 mg (Augmentin)
AMOXICILLIN ER - amoxicillin
(trihydrate) tab sr 24hr 775 mg
1
1
1
1
dicloxacillin sodium cap 500 mg
1
1
3
Limited Distribution
Responsible Steps
Quantity Limits
1
2
1
Prior Authorization
AMPICILLIN - ampicillin for susp 125 2
mg/5ml
AMPICILLIN - ampicillin for susp 250 2
mg/5ml
1
ampicillin cap 250 mg
clavulanate for susp 125-31.25
mg/5ml
200 mg/5ml
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
MOXATAG - amoxicillin (trihydrate)
tab sr 24hr 775 mg
3
penicillin v potassium for soln
125 mg/5ml
1
penicillin v potassium for soln
250 mg/5ml
penicillin v potassium tab 250 mg
penicillin v potassium tab 500 mg
CEPHALOSPORINS
CEDAX - ceftibuten cap 400 mg
Florida Blue October 2016 Care Choices Rx Medication Drug Guide
1
1
1
3
1
CEDAX - ceftibuten for susp 180
mg/5ml
3
CEFTIBUTEN - ceftibuten cap 400
mg
3
CEFACLOR - cefaclor for susp 125
mg/5ml
3
CEFTIBUTEN - ceftibuten for susp
180 mg/5ml
3
mg/5ml
3
CEFTIN - cefuroxime axetil for susp
125 mg/5ml
3
mg/5ml
3
CEFTIN - cefuroxime axetil for susp
250 mg/5ml
3
cefaclor cap 250 mg
1
CEFTIN - cefuroxime axetil tab 500
mg
3
cefaclor cap 500 mg
1
CEFACLOR ER - cefaclor
monohydrate tab sr 12hr 500 mg
3
cefuroxime axetil tab 250 mg
(Ceftin)
1
cefadroxil cap 500 mg
1
cefuroxime axetil tab 500 mg
(Ceftin)
1
CEPHALEXIN - cephalexin tab 250
mg
3
1
CEPHALEXIN - cephalexin tab 500
mg
3
1
cephalexin cap 250 mg (Keflex)
1
1
CEFDITOREN PIVOXIL - cefditoren
pivoxil tab 200 mg (base
equivalent)
3
CEFDITOREN PIVOXIL - cefditoren
pivoxil tab 400 mg (base
equivalent)
3
cefixime for susp 100 mg/5ml
(Suprax)
cefadroxil for susp 250 mg/5ml
cefadroxil for susp 500 mg/5ml
cefadroxil tab 1 gm
cefdinir cap 300 mg
cefdinir for susp 125 mg/5ml
cefdinir for susp 250 mg/5ml
1
1
1
cephalexin for susp 125 mg/5ml
cephalexin for susp 250 mg/5ml
1
KEFLEX - cephalexin cap 750 mg
3
SPECTRACEF - cefditoren pivoxil
tab 200 mg (base equivalent)
3
cefixime for susp 200 mg/5ml
(Suprax)
1
SPECTRACEF - cefditoren pivoxil
3
cefpodoxime proxetil for susp
50 mg/5ml
1
SUPRAX - cefixime cap 400 mg
2
SUPRAX - cefixime chew tab 100
mg
2
SUPRAX - cefixime chew tab 200
mg
2
SUPRAX - cefixime for susp 100
mg/5ml
3
mg/5ml
3
cefpodoxime proxetil tab 200 mg
cefprozil for susp 125 mg/5ml
cefprozil for susp 250 mg/5ml
cefprozil tab 250 mg
cefprozil tab 500 mg
1
1
1
1
1
1
3
1
Responsible Steps
1
cefpodoxime proxetil tab 100 mg
Quantity Limits
1
3
cefpodoxime proxetil for susp
100 mg/5ml
Prior Authorization
1
1
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
2
2
ERYPED 200 - erythromycin
ethylsuccinate for susp 200
mg/5ml
3
AZITHROMYCIN - azithromycin
powd pack for susp 1 gm
3
3
azithromycin for susp 100 mg/5ml
(Zithromax)
1
ERYPED 400 - erythromycin
mg/5ml
3
azithromycin for susp 200 mg/5ml
(Zithromax)
1
ERYTHROCIN STEARATE erythromycin stearate tab 250 mg
3
azithromycin tab 250 mg
(Zithromax)
1
ERYTHROMYCIN BASE erythromycin tab 250 mg
3
(Zithromax)
1
ERYTHROMYCIN BASE erythromycin tab 500 mg
2
(Zithromax)
1
ERYTHROMYCIN
ETHYLSUCCINA - erythromycin
ethylsuccinate tab 400 mg
BIAXIN - clarithromycin for susp 250
mg/5ml
3
erythromycin w/ delayed release
particles cap 250 mg
1
BIAXIN - clarithromycin tab 250 mg
3
3
BIAXIN - clarithromycin tab 500 mg
3
PCE - erythromycin w/ enteric
coated particles tab 333 mg
PCE - erythromycin w/ enteric
coated particles tab 500 mg
3
clarithromycin for susp
125 mg/5ml
1
1
ZITHROMAX - azithromycin for susp
100 mg/5ml
3
1
ZITHROMAX - azithromycin for susp
200 mg/5ml
3
ZITHROMAX - azithromycin powd
pack for susp 1 gm
2
ZITHROMAX - azithromycin tab 250
mg
3
mg
3
mg
3
ZITHROMAX TRI-PAK azithromycin tab 500 mg
3
ZITHROMAX Z-PAK - azithromycin
tab 250 mg
3
ZMAX - azithromycin extended
release for oral susp 2 gm
3
mg/5ml
MACROLIDES
clarithromycin for susp
250 mg/5ml (Biaxin)
clarithromycin tab sr 24hr 500 mg
clarithromycin tab 250 mg (Biaxin) 1
clarithromycin tab 500 mg (Biaxin) 1
DIFICID - fidaxomicin tab 200 mg
3
E.E.S. GRANULES - erythromycin
mg/5ml
3
E.E.S. 400 - erythromycin
ethylsuccinate tab 400 mg
2
ERY-TAB - erythromycin tab delayed 2
release 250 mg
release 333 mg
release 500 mg
•
TETRACYCLINES
demeclocycline hcl tab 150 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
3
demeclocycline hcl tab 300 mg
doxycycline hyclate cap 50 mg
1
1
doxycycline hyclate cap 100 mg
(Vibramycin)
1
doxycycline hyclate tab delayed
release 50 mg (Doryx)
1
release 75 mg
release 100 mg
release 150 mg
release 200 mg (Doryx)
doxycycline hyclate tab 20 mg
doxycycline hyclate tab 100 mg
doxycycline monohydrate cap
50 mg
75 mg (Monodox)
100 mg (Monodox)
150 mg (Adoxa)
doxycycline monohydrate for
susp 25 mg/5ml (Vibramycin)
doxycycline monohydrate tab
50 mg (Adoxa)
75 mg (Adoxa)
100 mg (Adoxa pak 1/100)
150 mg (Adoxa pak 1/150)
1
minocycline hcl tab sr 24hr 45 mg
minocycline hcl tab sr 24hr 90 mg
minocycline hcl tab sr 24hr
135 mg
minocycline hcl tab 50 mg
1
1
TETRACYCLINE HCL - tetracycline
hcl cap 500 mg
3
1
tetracycline hcl cap 250 mg
(Tetracycline hcl)
1
1
tetracycline hcl cap 500 mg
(Tetracycline hcl)
1
VIBRAMYCIN - doxycycline calcium
syrup 50 mg/5ml
3
1
1
1
1
1
1
1
minocycline hcl cap 50 mg
(Minocin)
1
(Minocin)
1
(Minocin)
1
1
1
FLUOROQUINOLONES
Responsible Steps
1
3
1
Quantity Limits
1
TETRACYCLINE HCL - tetracycline
hcl cap 250 mg
1
Prior Authorization
1
1
1
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
AVELOX - moxifloxacin hcl tab 400
mg (base equiv)
3
AVELOX ABC PACK - moxifloxacin
hcl tab 400 mg (base equiv)
3
CIPRO - ciprofloxacin for oral susp
250 mg/5ml (5%) (5 gm/100ml)
3
CIPRO - ciprofloxacin for oral susp
500 mg/5ml (10%) (10 gm/100ml)
3
CIPRO - ciprofloxacin hcl tab 250 mg 3
(base equiv)
CIPRO - ciprofloxacin hcl tab 500 mg 3
(base equiv)
3
CIPRO XR - ciprofloxacinciprofloxacin hcl tab sr 24hr 500
mg (base eq)
3
CIPRO XR - ciprofloxacinciprofloxacin hcl tab sr 24hr 1000
mg(base eq)
1
ciprofloxacin for oral susp
250 mg/5ml (5%) (5 gm/100ml)
(Cipro)
4
ciprofloxacin for oral susp
500 mg/5ml (10%) (10 gm/100ml)
(Cipro)
1
CIPROFLOXACIN HCL ciprofloxacin hcl tab 100 mg (base
equiv)
3
ciprofloxacin hcl tab 250 mg
(base equiv) (Cipro)
1
(base equiv) (Cipro)
(base equiv)
ciprofloxacin-ciprofloxacin hcl
tab sr 24hr 1000 mg(base eq)
(Cipro xr)
1
FACTIVE - gemifloxacin mesylate
tab 320 mg (base equiv)
3
•
•
KITABIS PAK - tobramycin nebu soln 4
300 mg/5ml
1
neomycin sulfate tab 500 mg
•
•
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
4
•
•
tobramycin nebu soln 300 mg/5ml
(Tobi)
4
•
•
•
3
CYCLOSERINE - cycloserine cap
250 mg
3
ethambutol hcl tab 100 mg
(Myambutol)
1
ethambutol hcl tab 400 mg
(Myambutol)
1
ISONIAZID - isoniazid syrup 50
mg/5ml
2
isoniazid tab 100 mg
1
1
MYAMBUTOL - ethambutol hcl tab
100 mg
3
MYAMBUTOL - ethambutol hcl tab
400 mg
3
MYCOBUTIN - rifabutin cap 150 mg
3
PASER - aminosalicylic acid cr
granules packet 4 gm
3
PRIFTIN - rifapentine tab 150 mg
2
pyrazinamide tab 500 mg
1
rifabutin cap 150 mg (Mycobutin)
4
paromomycin sulfate cap 250 mg
TOBI PODHALER - tobramycin inhal
cap 28 mg
isoniazid tab 300 mg
LEVAQUIN - levofloxacin tab 750 mg 3
1
levofloxacin oral soln 25 mg/ml
(Levaquin)
1
levofloxacin tab 250 mg
(Levaquin)
1
(Levaquin)
1
(Levaquin)
moxifloxacin hcl tab 400 mg (base 1
equiv) (Avelox)
OFLOXACIN - ofloxacin tab 400 mg 3
BETHKIS - tobramycin nebu soln
300 mg/4ml
•
ANTIMYCOBACTERIAL AGENTS
AMINOGLYCOSIDES
4
SULFADIAZINE - sulfadiazine tab
500 mg
1
1
TOBI - tobramycin nebu soln 300
mg/5ml
SULFONAMIDES
1
ciprofloxacin-ciprofloxacin hcl
tab sr 24hr 500 mg (base eq)
(Cipro xr)
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
RIFADIN - rifampin cap 150 mg
3
RIFADIN - rifampin cap 300 mg
3
RIFAMATE - isoniazid & rifampin cap 3
150-300 mg
1
rifampin cap 150 mg (Rifadin)
rifampin cap 300 mg (Rifadin)
RIFATER - isoniazid-rifampin w/
pyrazinamide tab 50-120-300 mg
1
3
1
5
SIRTURO - bedaquiline fumarate tab 3
100 mg (base equiv)
3
TRECATOR - ethionamide tab 250
mg
ANTIFUNGALS
griseofulvin ultramicrosize tab
125 mg (Gris-peg)
griseofulvin ultramicrosize tab
250 mg (Gris-peg)
1
1
•
3
ANCOBON - flucytosine cap 500 mg
3
ketoconazole tab 200 mg
BIO-STATIN - nystatin cap 500000
unit
3
LAMISIL - terbinafine hcl tab 250 mg
3
2
BIO-STATIN - nystatin cap 1000000
unit
3
NOXAFIL - posaconazole susp 40
mg/ml
•
•
3
•
CRESEMBA - isavuconazonium
sulfate cap 186 mg
3
NOXAFIL - posaconazole tab
delayed release 100 mg
1
DIFLUCAN - fluconazole for susp 10
mg/ml
3
nystatin tab 500000 unit
DIFLUCAN - fluconazole for susp 40
mg/ml
SPORANOX - itraconazole cap 100
mg
3
•
3
SPORANOX - itraconazole oral soln
10 mg/ml
2
•
DIFLUCAN - fluconazole tab 50 mg
3
3
•
3
SPORANOX PULSEPAK itraconazole cap 100 mg
3
1
•
3
terbinafine hcl tab 250 mg
(Lamisil)
fluconazole for susp 10 mg/ml
(Diflucan)
1
VFEND - voriconazole for susp 40
mg/ml
3
•
fluconazole for susp 40 mg/ml
(Diflucan)
1
VFEND - voriconazole tab 50 mg
3
VFEND - voriconazole tab 200 mg
3
fluconazole tab 50 mg (Diflucan)
1
voriconazole for susp 40 mg/ml
(Vfend)
1
•
•
•
voriconazole tab 50 mg (Vfend)
1
flucytosine cap 250 mg (Ancobon)
flucytosine cap 500 mg (Ancobon)
1
1
1
1
1
GRIS-PEG - griseofulvin
ultramicrosize tab 125 mg
3
GRIS-PEG - griseofulvin
ultramicrosize tab 250 mg
3
griseofulvin microsize susp
125 mg/5ml
1
griseofulvin microsize tab 500 mg
(Grifulvin v)
1
voriconazole tab 200 mg (Vfend)
ANTIVIRALS
1
•
•
1
•
abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg
(Trizivir)
1
•
acyclovir cap 200 mg (Zovirax)
1
abacavir sulfate tab 300 mg (base
equiv) (Ziagen)
acyclovir susp 200 mg/5ml
(Zovirax)
1
acyclovir tab 400 mg (Zovirax)
1
acyclovir tab 800 mg (Zovirax)
1
ANCOBON - flucytosine cap 250 mg
Responsible Steps
1
itraconazole cap 100 mg
(Sporanox)
•
Quantity Limits
Prior Authorization
Specialty
•
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
6
adefovir dipivoxil tab 10 mg
(Hepsera)
1
APTIVUS - tipranavir cap 250 mg
2
APTIVUS - tipranavir oral soln 100
mg/ml
2
• •
• •
ATRIPLA - efavirenz-emtricitabinetenofovir df tab 600-200-300 mg
2
• •
BARACLUDE - entecavir oral soln
0.05 mg/ml
2
BARACLUDE - entecavir tab 0.5 mg
3
BARACLUDE - entecavir tab 1 mg
3
COMBIVIR - lamivudine-zidovudine
tab 150-300 mg
3
• •
COMPLERA - emtricitabinerilpivirine-tenofovir df tab
200-25-300 mg
2
• •
COPEGUS - ribavirin tab 200 mg
4
CRIXIVAN - indinavir sulfate cap 200 2
mg
CRIXIVAN - indinavir sulfate cap 400 2
mg
4
DAKLINZA - daclatasvir
dihydrochloride tab 30 mg (base
equivalent)
4
equivalent)
4
equivalent)
3
DESCOVY - emtricitabine-tenofovir
alafenamide fumarate tab 200-25
mg
1
didanosine delayed release
capsule 125 mg (Videx ec)
1
1
1
• • •
• • •
EMTRIVA - emtricitabine caps 200
mg
2
• •
EMTRIVA - emtricitabine soln 10 mg/ 2
ml
1
entecavir tab 0.5 mg (Baraclude)
• •
1
4
• • •
EPIVIR - lamivudine oral soln 10 mg/ 3
ml
3
EPIVIR - lamivudine tab 150 mg
• •
• •
• •
EPIVIR - lamivudine tab 300 mg
3
EPIVIR HBV - lamivudine oral soln 5
mg/ml (hbv)
2
EPIVIR HBV - lamivudine tab 100
mg (hbv)
3
EPZICOM - abacavir sulfatelamivudine tab 600-300 mg
2
• •
EVOTAZ - atazanavir sulfatecobicistat tab 300-150 mg (base
equiv)
2
• •
famciclovir tab 125 mg (Famvir)
1
1
1
FAMVIR - famciclovir tab 125 mg
3
3
3
FLUMADINE - rimantadine
hydrochloride tab 100 mg
3
FUZEON - enfuvirtide for inj 90 mg
4
3
•
GENVOYA - elvitegrav-cobicemtricitab-tenofov af tab
150-150-200-10 mg
• • •
•
•
HARVONI - ledipasvir-sofosbuvir tab
90-400 mg
4
• • •
•
HEPSERA - adefovir dipivoxil tab 10
mg
3
INTELENCE - etravirine tab 25 mg
2
• • •
• •
•
• •
Responsible Steps
Quantity Limits
2
EPCLUSA - sofosbuvir-velpatasvir
tab 400-100 mg
• •
Prior Authorization
EDURANT - rilpivirine hcl tab 25 mg
(base equivalent)
entecavir tab 1 mg (Baraclude)
• •
• •
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
• •
7
2
2
INVIRASE - saquinavir mesylate cap 2
200 mg
INVIRASE - saquinavir mesylate tab 2
500 mg
ISENTRESS - raltegravir potassium 2
chew tab 25 mg (base equiv)
chew tab 100 mg (base equiv)
packet for susp 100 mg (base
equiv)
2
KALETRA - lopinavir-ritonavir soln
400-100 mg/5ml (80-20 mg/ml)
2
KALETRA - lopinavir-ritonavir tab
100-25 mg
2
KALETRA - lopinavir-ritonavir tab
200-50 mg
1
lamivudine oral soln 10 mg/ml
(Epivir)
1
lamivudine tab 100 mg (hbv)
(Epivir hbv)
1
lamivudine tab 150 mg (Epivir)
nevirapine tab sr 24hr 100 mg
(Viramune xr)
1
•
• •
nevirapine tab sr 24hr 400 mg
(Viramune xr)
1
•
• •
nevirapine tab 200 mg (Viramune)
1
•
• •
• •
• •
• •
• •
• •
• •
• •
•
LEXIVA - fosamprenavir calcium
susp 50 mg/ml (base equiv)
2
• •
LEXIVA - fosamprenavir calcium tab
700 mg (base equiv)
2
• •
MODERIBA - ribavirin tab 200 mg &
ribavirin tab 400 mg dose pack
4
• •
MODERIBA - ribavirin tab 400 mg &
ribavirin tab 600 mg dose pack
4
• •
MODERIBA 1200 DOSE PACK ribavirin tab 600 mg
4
• •
MODERIBA 800 DOSE PACK ribavirin tab 400 mg
4
• •
1
NORVIR - ritonavir cap 100 mg
2
NORVIR - ritonavir oral soln 80 mg/
ml
2
NORVIR - ritonavir tab 100 mg
2
ODEFSEY - emtricitabine-rilpivirinetenofovir af tab 200-25-25 mg
3
OLYSIO - simeprevir sodium cap 150 4
mg (base equivalent)
4
PEG-INTRON REDIPEN peginterferon alfa-2b for inj kit 50
mcg/0.5ml
4
mcg/0.5ml
4
mcg/0.5ml
4
mcg/0.5ml
4
PEG-INTRON REDIPEN PAK 4 peginterferon alfa-2b for inj kit 120
mcg/0.5ml
PEGASYS - peginterferon alfa-2a inj 4
180 mcg/ml
PEGASYS - peginterferon alfa-2a inj 4
180 mcg/0.5ml
4
PEGASYS PROCLICK peginterferon alfa-2a inj 135
mcg/0.5ml
4
PEGASYS PROCLICK peginterferon alfa-2a inj 180
mcg/0.5ml
PEGINTRON - peginterferon alfa-2b 4
for inj kit 50 mcg/0.5ml
• •
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Tier
2
1
lamivudine-zidovudine tab
150-300 mg (Combivir)
Drug Name
NEVIRAPINE - nevirapine susp 50
mg/5ml
•
•
•
lamivudine tab 300 mg (Epivir)
• •
• •
• •
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
• •
• •
• • •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
8
• •
RIBASPHERE RIBAPAK - ribavirin
tab 600 mg
4
• •
PEGINTRON - peginterferon alfa-2b
4
• •
tab 200 mg & ribavirin tab 400 mg
dose pack
4
• •
PREZCOBIX - darunavir-cobicistat
tab 800-150 mg
2
• •
tab 400 mg & ribavirin tab 600 mg
dose pack
4
• •
PREZISTA - darunavir ethanolate
2
PREZISTA - darunavir ethanolate tab 2
75 mg (base equiv)
150 mg (base equiv)
600 mg (base equiv)
800 mg (base equiv)
4
REBETOL - ribavirin cap 200 mg
• •
ribavirin cap 200 mg (Rebetol)
4
• •
• •
• •
• •
• •
• •
• •
• •
4
RELENZA DISKHALER - zanamivir
aero powder breath activated 5
mg/blister
3
RESCRIPTOR - delavirdine
mesylate tab 100 mg
2
RESCRIPTOR - delavirdine
mesylate tab 200 mg
2
• •
RETROVIR - zidovudine cap 100 mg 3
3
RETROVIR - zidovudine syrup 10
mg/ml
2
REYATAZ - atazanavir sulfate cap
150 mg (base equiv)
2
200 mg (base equiv)
2
300 mg (base equiv)
2
REYATAZ - atazanavir sulfate oral
powder packet 50 mg (base equiv)
RIBASPHERE - ribavirin tab 400 mg 4
• •
• •
RIBASPHERE - ribavirin tab 600 mg
4
•
• •
• •
• •
• •
• •
4
rimantadine hydrochloride tab
100 mg (Flumadine)
1
SOVALDI - sofosbuvir tab 400 mg
4
stavudine cap 15 mg (Zerit)
1
stavudine for oral soln 1 mg/ml
(Zerit)
1
• •
• •
• • •
•
•
•
•
•
STRIBILD - elvitegrav-cobicemtricitab-tenofovdf tab
150-150-200-300 mg
2
• •
SUSTIVA - efavirenz cap 50 mg
2
SUSTIVA - efavirenz cap 200 mg
2
SUSTIVA - efavirenz tab 600 mg
2
TAMIFLU - oseltamivir phosphate
cap 30 mg (base equiv)
2
• •
• •
• •
•
2
•
2
•
TAMIFLU - oseltamivir phosphate for
2
•
TECHNIVIE - ombitasvir-paritaprevir- 4
ritonavir tab 12.5-75-50 mg
• • •
SELZENTRY - maraviroc tab 150 mg 2
SELZENTRY - maraviroc tab 300 mg 2
REBETOL - ribavirin soln 40 mg/ml
• •
• •
ribavirin tab 200 mg (Copegus)
1
1
1
4
Responsible Steps
tab 400 mg
Quantity Limits
• •
Prior Authorization
4
Specialty
Drug Name
Drug Tier
• •
4
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
9
TIVICAY - dolutegravir sodium tab 10 2
mg (base equiv)
mg (base equiv)
mg (base equiv)
2
TRIUMEQ - abacavir-dolutegravirlamivudine tab 600-50-300 mg
3
TRIZIVIR - abacavir sulfatelamivudine-zidovudine tab
300-150-300 mg
2
TRUVADA - emtricitabine-tenofovir
disoproxil fumarate tab 100-150
mg
2
mg
2
mg
2
mg
2
TYBOST - cobicistat tab 150 mg
TYZEKA - telbivudine tab 600 mg
3
valacyclovir hcl tab 500 mg
(Valtrex)
1
valacyclovir hcl tab 1 gm (Valtrex)
1
VALCYTE - valganciclovir hcl for soln 2
50 mg/ml (base equiv)
1
valganciclovir hcl tab 450 mg
(base equivalent) (Valcyte)
2
VIDEX - didanosine for soln 2 gm
3
• •
VIEKIRA PAK - ombitas-paritapreriton & dasab tab pak 12.5-75-50
& 250 mg
4
• • •
• •
VIEKIRA XR - dasab-ombitparitap-riton tab sr 24hr
200-8.33-50-33.33 mg
4
• • •
• •
VIRACEPT - nelfinavir mesylate tab
250 mg
2
• •
• •
VIRACEPT - nelfinavir mesylate tab
625 mg
2
• •
2
• •
• •
VIRAMUNE - nevirapine susp 50
mg/5ml
VIRAMUNE - nevirapine tab 200 mg
3
VIRAMUNE XR - nevirapine tab sr
24hr 100 mg
2
• •
• •
VIRAMUNE XR - nevirapine tab sr
24hr 400 mg
3
• •
VIRAZOLE - ribavirin for inhal soln 6
gm
3
VIREAD - tenofovir disoproxil
fumarate oral powder 40 mg/gm
2
• •
fumarate tab 150 mg
2
• •
fumarate tab 200 mg
2
• •
fumarate tab 250 mg
2
• •
fumarate tab 300 mg
2
• •
VITEKTA - elvitegravir tab 85 mg
2
VITEKTA - elvitegravir tab 150 mg
2
ZEPATIER - elbasvir-grazoprevir tab
50-100 mg
4
• •
• •
• • •
ZERIT - stavudine cap 15 mg
3
3
3
3
• •
• •
• •
• •
VIDEX - didanosine for soln 4 gm
2
VIDEX EC - didanosine delayed
release capsule 125 mg
3
• •
• •
• •
3
• •
3
• •
•
•
•
•
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
•
•
•
•
10
ZERIT - stavudine for oral soln 1 mg/ 3
ml
2
ZIAGEN - abacavir sulfate soln 20
mg/ml (base equiv)
3
ZIAGEN - abacavir sulfate tab 300
mg (base equiv)
1
zidovudine cap 100 mg (Retrovir)
zidovudine syrup 10 mg/ml
(Retrovir)
1
zidovudine tab 300 mg
1
• •
• •
•
•
QUALAQUIN - quinine sulfate cap
324 mg
3
•
quinine sulfate cap 324 mg
(Qualaquin)
1
•
ALBENZA - albendazole tab 200 mg
2
BILTRICIDE - praziquantel tab 600
mg
2
3
ZOVIRAX - acyclovir susp 200
mg/5ml
3
EMVERM - mebendazole chew tab
100 mg
3
ZOVIRAX - acyclovir tab 400 mg
3
ivermectin tab 3 mg (Stromectol)
1
ZOVIRAX - acyclovir tab 800 mg
3
STROMECTOL - ivermectin tab 3
mg
ARALEN - chloroquine phosphate
tab 500 mg
3
atovaquone-proguanil hcl tab
62.5-25 mg (Malarone)
1
ANTI-INFECTIVE AGENTS - MISC.
2
ALINIA - nitazoxanide tab 500 mg
2
1
atovaquone susp 750 mg/5ml
(Mepron)
1
1
BACTRIM - sulfamethoxazoletrimethoprim tab 400-80 mg
3
1
BACTRIM DS - sulfamethoxazoletrimethoprim tab 800-160 mg
3
COARTEM - artemetherlumefantrine tab 20-120 mg
2
CAYSTON - aztreonam lysine for
inhal soln 75 mg (base equivalent)
2
DARAPRIM - pyrimethamine tab 25
mg
4
CLEOCIN - clindamycin hcl cap 75
mg
3
hydroxychloroquine sulfate tab
200 mg (Plaquenil)
1
mg
3
MALARONE - atovaquone-proguanil
hcl tab 62.5-25 mg
3
mg
3
MALARONE - atovaquone-proguanil
hcl tab 250-100 mg
3
3
mefloquine hcl tab 250 mg
1
CLEOCIN PEDIATRIC GRANULE clindamycin palmitate hcl for soln
75 mg/5ml (base equiv)
clindamycin hcl cap 75 mg
(Cleocin)
1
(Cleocin)
1
chloroquine phosphate tab
250 mg
chloroquine phosphate tab
500 mg (Aralen)
PLAQUENIL - hydroxychloroquine
sulfate tab 200 mg
3
• • •
•
Responsible Steps
3
ALINIA - nitazoxanide for susp 100
mg/5ml
atovaquone-proguanil hcl tab
250-100 mg (Malarone)
Quantity Limits
2
ZOVIRAX - acyclovir cap 200 mg
ANTIMALARIALS
Prior Authorization
PRIMAQUINE PHOSPHATE primaquine phosphate tab 26.3
mg (15 mg base)
ANTHELMINTICS
•
Specialty
Drug Name
Drug Tier
• •
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
•
11
(Cleocin)
1
clindamycin palmitate hcl for soln
75 mg/5ml (base equiv) (Cleocin
pediatric gr)
1
colistimethate sodium for inj
150 mg (Coly-Mycin M)
sulfamethoxazole-trimethoprim
tab 800-160 mg (Bactrim ds)
3
TINDAMAX - tinidazole tab 500 mg
3
1
tinidazole tab 250 mg (Tindamax)
1
COLY-MYCIN M - colistimethate
sodium for inj 150 mg
3
trimethoprim tab 100 mg
3
dapsone tab 25 mg
1
VANCOCIN HCL - vancomycin hcl
cap 125 mg
VANCOCIN HCL - vancomycin hcl
cap 250 mg
3
vancomycin hcl cap 125 mg
(Vancocin hcl)
1
vancomycin hcl cap 250 mg
(Vancocin hcl)
1
XIFAXAN - rifaximin tab 200 mg
3
XIFAXAN - rifaximin tab 550 mg
2
ZYVOX - linezolid for susp 100
mg/5ml
3
• •
• •
•
ZYVOX - linezolid tab 600 mg
3
•
dapsone tab 100 mg
FLAGYL - metronidazole cap 375
mg
1
3
FLAGYL - metronidazole tab 250 mg 3
FLAGYL - metronidazole tab 500 mg 3
FLAGYL ER - metronidazole tab sr
24hr 750 mg
3
IMPAVIDO - miltefosine cap 50 mg
2
KETEK - telithromycin tab 300 mg
3
KETEK - telithromycin tab 400 mg
3
linezolid for susp 100 mg/5ml
(Zyvox)
1
•
linezolid tab 600 mg (Zyvox)
1
•
BIOLOGICALS
1
1
P
3
ACTHIB - haemophilus b
polysaccharide conjugate vaccine
for inj
metronidazole cap 375 mg (Flagyl) 1
metronidazole tab 250 mg (Flagyl) 1
AFLURIA PF 2015-2016 - influenza
virus vaccine split pf susp pref
syringe 0.5 ml
P
•
AFLURIA 2015-2016 - influenza
virus vaccine split im susp
P
•
virus vaccine split im susp
P
•
syringe 0.5 ml
P
•
BEXSERO - meningococcal vac b
(recomb adsorbed) inj prefilled
syringe
P
CERVARIX - human papillomavirus
(hpv) bival (type 16, 18) recmb
vac inj
P
MEPRON - atovaquone susp 750
mg/5ml
metronidazole tab 500 mg (Flagyl)
1
NEBUPENT - pentamidine
isethionate for nebulization soln
300 mg
2
PRIMSOL - trimethoprim hcl oral
soln 50 mg/5ml (base equiv)
2
SIVEXTRO - tedizolid phosphate tab
200 mg
2
susp 200-40 mg/5ml
1
tab 400-80 mg (Bactrim)
1
• •
1
TINDAMAX - tinidazole tab 250 mg
tinidazole tab 500 mg (Tindamax)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
12
ENGERIX-B - hepatitis b vaccine
(recombinant) susp 10 mcg/0.5ml
P
(recombinant) susp 20 mcg/ml
P
(recombinant) 10 mcg/0.5ml
P
(recombinant) 20 mcg/ml
P
FLUAD 2016-2017 - influenza vac
type a&b surface ant adj susp pref
syr 0.5 ml
P
FLUARIX QUADRIVALENT
2016 - influenza virus vac split
quadrivalent susp pref syr 0.5ml
P
•
FLUARIX 2014-2015 - influenza
syringe 0.5 ml
P
•
FLUBLOK 2015-2016 - influenza
virus vac recombinant
hemagglutinin (ha) inj
P
•
FLUBLOK 2016-2017 - influenza
virus vac recombinant
hemagglutinin (ha) inj
P
•
FLUCELVAX QUADRIVALENT 20 influenza vac tiss-cult subunt quad
susp pref syr 0.5 ml
P
FLUCELVAX 2015-2016 - influenza
virus vac tiss-cult subunit susp
pref syr 0.5 ml
P
•
FLULAVAL QUADRIVALENT
P
•
FLULAVAL QUADRIVALENT 201 influenza virus vaccine split
quadrivalent im inj
P
•
FLUMIST QUADRIVALENT influenza virus vaccine live
quadrivalent intranasal susp
P
•
FLUVIRIN PF 2014-2015 - influenza
virus vac types a & b pf susp
prefilled syr 0.5 ml
P
•
•
FLUVIRIN 2015-2016 - influenza vac P
type a&b surface antigen susp
pref syr 0.5 ml
P
FLUVIRIN 2015-2016 - influenza
virus vaccine types a & b surface
antigen im susp
P
FLUVIRIN 2016-2017 - influenza
virus vaccine types a & b surface
antigen im susp
P
FLUZONE HIGH-DOSE PF 2016 influenza virus vac split high-dose
pf susp pref syr 0.5ml
P
FLUZONE INTRADERMAL
QUADR - influenza virus vac split
quad intradermal pen 9 mcg/strain
P
FLUZONE QUADRIVALENT
quadrivalent susp pref syr 0.25 ml
P
FLUZONE QUADRIVALENT
FLUZONE QUADRIVALENT 2016 - P
influenza virus vaccine split
quadrivalent im inj
FLUZONE QUADRIVALENT 2016 - P
influenza virus vaccine split
quadrivalent inj 0.5 ml
P
GARDASIL - human papillomavirus
(hpv) quadrivalent recombinant
vac inj
P
GARDASIL 9 - human
papillomavirus (hpv) 9-valent
recomb vac im susp
P
GARDASIL 9 - human
papillomavirus (hpv) 9-valent
recomb vac susp pref syr
HAVRIX - hepatitis a vaccine inj susp P
720 el unit/0.5ml
HAVRIX - hepatitis a vaccine inj susp P
1440 el unit/ml
•
P
FLUVIRIN PF 2016-2017 - influenza
virus vac types a & b pf susp
prefilled syr 0.5 ml
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
•
•
•
•
•
•
•
•
13
HIBERIX - haemophilus b
polysaccharide conjugate vac for
inj 10 mcg
P
RECOMBIVAX HB - hepatitis b
vaccine (recombinant) susp 5
mcg/0.5ml
P
M-M-R II - measles, mumps &
rubella virus vaccines for inj
P
P
MEDICAL PROVIDER EZ FLU S influenza virus vac types a & b pf
pref syringe kit 0.5 ml
P
mcg/ml
P
MEDICAL PROVIDER SINGLE U influenza virus vac split quad inj
prefilled syr kit 0.25 ml
P
mcg/ml
TRUMENBA - meningococcal group
b vaccine im susp prefilled syringe
P
MEDICAL PROVIDER SINGLE U influenza virus vac types a & b pf
pref syringe kit 0.5 ml
P
TWINRIX - hepatitis a (inact)-hep b
(recomb) vac inj 720-20 elu-mcg/
ml
P
MEDICAL PROVIDER SINGLE U influenza virus vaccine split pf
susp pref syr kit 0.5 ml
P
VAQTA - hepatitis a vaccine inj susp
25 unit/0.5ml
P
P
VAQTA - hepatitis a vaccine inj susp
50 unit/ml
P
MENACTRA - meningococcal (a, c,
y, and w-135) conjugate vaccine
inj
P
MENHIBRIX - meningococcal (c &
y)-haemophilus b tet tox conj vac
for inj
P
VARIVAX - varicella virus vac live for
subcutaneous inj 1350 pfu/0.5ml
ZOSTAVAX - zoster vaccine live for
inj 19400 unit/0.65ml
P
MENOMUNE-A/C/Y/W-135 meningococcal vaccine a, c, y,
and w-135 inj
P
ADACEL - tet tox-diph-acell pertuss
ad inj 5-2-15.5 lf-lf-mcg/0.5ml
P
P
MENVEO - meningococcal (a, c, y,
and w-135) oligo conj vac for inj
P
BOOSTRIX - tet tox-diph-acell
pertuss ad inj 5-2.5-18.5 lf-lfmcg/0.5ml
PEDVAX HIB - haemophilus b
polysaccharide conj vac im susp
7.5 mcg/0.5 ml
P
DAPTACEL - diph, acellular pert &
tet tox inj 15 lf-10 mcg-5 lf/0.5ml
P
P
PNEUMOVAX 23 - pneumococcal
vaccine polyvalent inj 25
mcg/0.5ml
P
DIPHTHERIA/TETANUS TOXOID diphtheria-tetanus tox adsorbed
(dt) im inj 25-5 unit/0.5ml
P
PNEUMOVAX 23/1 DOSE pneumococcal vaccine polyvalent
inj 25 mcg/0.5ml
P
INFANRIX - diph, acellular pert & tet
tox inj 25 lf-58 mcg-10 lf/0.5ml
KINRIX - diph-tetanus tox ad-acell
pert & polio virus, ipv vac inj
P
PREVNAR 13 - pneumococcal 13valent conjugate vaccine inj
P
PEDIARIX - diph-tetanus tox-acell
pert-hepatitis b-polio ipv vac inj
P
PROQUAD - measles-mumpsrubella-varicella virus vaccines for
inj
P
PENTACEL - diph-ac per-tet tox adpoliov-haemoph b poly vac for im
susp
P
•
•
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
14
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
GAMUNEX-C - immune globulin
(human) iv or subcutaneous soln
2.5 gm/25ml
4
• •
4
• •
TETANUS/DIPHTHERIA TOXOID tetanus-diphtheria toxoids (td) inj
2-2 lf/0.5ml
P
(human) iv or subcutaneous soln 5
gm/50ml
• •
4
• •
4
GAMMAGARD LIQUID immune globulin (human) iv or
subcutaneous soln 1 gm/10ml
10 gm/100ml
• •
4
• •
4
subcutaneous soln 2.5 gm/25ml
20 gm/200ml
• •
4
• •
4
40 gm/400ml
• •
•
4
• •
4
HIZENTRA - immune globulin
(human) subcutaneous inj 1
gm/5ml
• •
•
4
• •
4
gm/10ml
• •
•
4
• •
4
gm/20ml
• •
•
GAMMAKED - immune globulin
gm/10ml
• •
4
4
gm/50ml
• •
•
4
• •
4
2.5 gm/25ml
HYQVIA - immun glob inj 2.5
gm/25ml-hyaluron inj 200 unt/1.25
ml kit
•
4
• •
• •
gm/50ml
• •
•
10 gm/100ml
4
• •
• •
•
20 gm/200ml
4
• •
• •
•
gm/10ml
4
• •
HYQVIA - immun glob inj 5 gm/50ml- 4
hyaluron inj 400 unt/2.5 ml kit
4
HYQVIA - immun glob inj 10
gm/100ml-hyaluron inj 800 unt/5
ml kit
4
gm/200ml-hyaluron inj 1600
unt/10 ml kit
4
gm/300ml-hyaluron inj 2400
unt/15 ml kit
QUADRACEL - diph-tetanus tox adacell pert & polio virus, ipv vac inj
P
TENIVAC - tetanus-diphtheria
toxoids (td) inj 5-2 lfu
P
ANTINEOPLASTIC AGENTS
ANTINEOPLASTICS
15
4
AFINITOR DISPERZ - everolimus
tab for oral susp 2 mg
COMETRIQ - cabozantinib s-mal
cap 1 x 80 mg & 1 x 20 mg (100
dose) kit
4
• • •
COMETRIQ - cabozantinib s-mal
cap 1 x 80 mg & 3 x 20 mg (140
dose) kit
4
• • •
•
COMETRIQ - cabozantinib s-malate
cap 3 x 20 mg (60 mg dose) kit
4
• • •
•
COTELLIC - cobimetinib fumarate
4
• • •
•
CYCLOPHOSPHAMIDE cyclophosphamide cap 25 mg
2
CYCLOPHOSPHAMIDE cyclophosphamide cap 50 mg
2
EMCYT - estramustine phosphate
sodium cap 140 mg
2
• • •
•
• • •
•
• • •
•
• • •
•
• • •
•
• • •
•
• • •
•
4
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
4
• • •
•
4
• • •
•
ALECENSA - alectinib hcl cap 150
4
• • •
•
ALKERAN - melphalan tab 2 mg
2
1
ERIVEDGE - vismodegib cap 150
mg
4
anastrozole tab 1 mg (Arimidex)
3
ETOPOSIDE - etoposide cap 50 mg
2
AROMASIN - exemestane tab 25 mg 3
4
bexarotene cap 75 mg (Targretin)
exemestane tab 25 mg (Aromasin)
1
ARIMIDEX - anastrozole tab 1 mg
bicalutamide tab 50 mg (Casodex)
1
• •
FARESTON - toremifene citrate tab
60 mg (base equivalent)
• • •
• • •
• • •
•
•
•
• • •
•
BOSULIF - bosutinib tab 100 mg
4
BOSULIF - bosutinib tab 500 mg
4
CABOMETYX - cabozantinib
s-malate tab 20 mg (base
equivalent)
4
equivalent)
4
equivalent)
4
• • •
capecitabine tab 150 mg (Xeloda)
4
•
•
•
•
capecitabine tab 500 mg (Xeloda)
4
CASODEX - bicalutamide tab 50 mg
3
CAPRELSA - vandetanib tab 100 mg 4
CAPRELSA - vandetanib tab 300 mg 4
•
•
•
•
•
•
•
•
•
•
•
AFINITOR - everolimus tab 10 mg
Responsible Steps
4
Quantity Limits
AFINITOR - everolimus tab 7.5 mg
Prior Authorization
AFINITOR - everolimus tab 5 mg
4
•
•
•
•
•
Specialty
4
•
Drug Name
Drug Tier
AFINITOR - everolimus tab 2.5 mg
•
Responsible Steps
4
Quantity Limits
ACTIMMUNE - interferon gamma-1b
inj 100 mcg/0.5ml (2000000
unit/0.5ml)
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
2
FARYDAK - panobinostat lactate cap 4
1
flutamide cap 125 mg
GILOTRIF - afatinib dimaleate tab 20 4
4
GLEEVEC - imatinib mesylate tab
4
GLEEVEC - imatinib mesylate tab
4
GLEOSTINE - lomustine cap 5 mg
•
4
• • •
• • •
•
•
16
4
GLEOSTINE - lomustine cap 100 mg 4
4
HEXALEN - altretamine cap 50 mg
HYCAMTIN - topotecan hcl cap 0.25
mg (base equiv)
4
HYCAMTIN - topotecan hcl cap 1 mg 4
(base equiv)
HYDREA - hydroxyurea cap 500 mg 3
hydroxyurea cap 500 mg (Hydrea)
1
• •
4
• • •
•
•
JAKAFI - ruxolitinib phosphate tab
4
• • •
•
4
• • •
•
4
• • •
•
LENVIMA 10 MG DAILY DOSE lenvatinib cap therapy pack 10 mg
(10 mg daily dose)
4
• • •
•
LENVIMA 14 MG DAILY DOSE lenvatinib cap therapy pack 10 & 4
mg (14 mg daily dose)
4
• • •
•
LENVIMA 18 MG DAILY DOSE lenvatinib cap therapy pack 10 & 4
(2) mg (18 mg daily dose)
4
• • •
•
LENVIMA 20 MG DAILY DOSE lenvatinib cap therapy pack 10 (2)
4
• • •
•
& 4 mg (24 mg daily dose)
4
• • •
•
4
• • •
•
1
• •
• • •
•
4
• • •
IMBRUVICA - ibrutinib cap 140 mg
4
INLYTA - axitinib tab 1 mg
4
INLYTA - axitinib tab 5 mg
4
INTRON A - interferon alfa-2b inj
6000000 unit/ml
4
• • •
• • •
• • •
•
•
•
•
•
INTRON A - interferon alfa-2b inj
10000000 unit/ml
4
•
•
INTRON A - interferon alfa-2b for inj
10000000 unit
4
•
•
letrozole tab 2.5 mg (Femara)
18000000 unit
4
•
•
50000000 unit
4
•
•
INTRON A W/DILUENT - interferon
alfa-2b for inj 10000000 unit
4
•
•
4
•
•
4
•
•
ICLUSIG - ponatinib hcl tab 45 mg
(base equiv)
imatinib mesylate tab 100 mg
(base equivalent) (Gleevec)
imatinib mesylate tab 400 mg
(base equivalent) (Gleevec)
• • •
4
Responsible Steps
•
4
ICLUSIG - ponatinib hcl tab 15 mg
(base equiv)
Quantity Limits
4
•
IBRANCE - palbociclib cap 125 mg
4
Prior Authorization
JAKAFI - ruxolitinib phosphate tab 5
• • •
• • •
• • •
4
Specialty
4
4
Drug Tier
IRESSA - gefitinib tab 250 mg
•
•
•
•
4
•
•
•
•
Drug Name
•
•
•
•
•
•
•
•
Responsible Steps
•
•
•
• •
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
LEUCOVORIN CALCIUM leucovorin calcium tab 10 mg
2
LEUCOVORIN CALCIUM leucovorin calcium tab 15 mg
2
leucovorin calcium tab 5 mg
1
leucovorin calcium tab 25 mg
1
LEUKERAN - chlorambucil tab 2 mg
2
leuprolide acetate inj kit 5 mg/ml
4
LONSURF - trifluridine-tipiracil tab
15-6.14 mg
•
•
4
17
MATULANE - procarbazine hcl cap
50 mg
4
MEGACE ORAL - megestrol acetate
susp 40 mg/ml
•
NILANDRON - nilutamide tab 150
mg
3
nilutamide tab 150 mg (Nilandron)
1
4
•
• • •
Responsible Steps
LYSODREN - mitotane tab 500 mg
• • •
•
•
4
Quantity Limits
4
NEXAVAR - sorafenib tosylate tab
Prior Authorization
LYNPARZA - olaparib cap 50 mg
•
Specialty
• • •
Drug Name
Drug Tier
4
LONSURF - trifluridine-tipiracil tab
20-8.19 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
•
4
• • •
•
3
NINLARO - ixazomib citrate cap 2.3
4
• • •
•
megestrol acetate susp 40 mg/ml
(Megace oral)
1
NINLARO - ixazomib citrate cap 3
4
• • •
•
megestrol acetate tab 20 mg
1
NINLARO - ixazomib citrate cap 4
ODOMZO - sonidegib phosphate
cap 200 mg (base equivalent)
4
• • •
•
POMALYST - pomalidomide cap 1
mg
4
• • •
•
mg
4
• • •
•
mg
4
• • •
•
mg
4
• • •
•
PURIXAN - mercaptopurine susp
2000 mg/100ml (20 mg/ml)
4
•
•
SOLTAMOX - tamoxifen citrate oral
soln 10 mg/5ml (base equivalent)
3
SPRYCEL - dasatinib tab 20 mg
4
4
4
4
4
4
STIVARGA - regorafenib tab 40 mg
4
SUTENT - sunitinib malate cap 12.5
megestrol acetate tab 40 mg
1
MEKINIST - trametinib dimethyl
sulfoxide tab 0.5 mg (base
equivalent)
4
• • •
•
MEKINIST - trametinib dimethyl
sulfoxide tab 2 mg (base
equivalent)
4
• • •
•
mercaptopurine tab 50 mg
1
MESNEX - mesna tab 400 mg
2
METHOTREXATE SODIUM methotrexate sodium inj 250
mg/10ml (25 mg/ml)
3
methotrexate sodium for inj 1 gm
1
methotrexate sodium inj pf
50 mg/2ml (25 mg/ml)
100 mg/4ml (25 mg/ml)
200 mg/8ml (25 mg/ml)
250 mg/10ml (25 mg/ml)
1000 mg/40ml (25 mg/ml)
methotrexate sodium inj
50 mg/2ml (25 mg/ml)
methotrexate sodium tab 2.5 mg
(base equiv)
MYLERAN - busulfan tab 2 mg
1
1
1
1
1
1
1
2
4
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
SUTENT - sunitinib malate cap 25
4
• • •
•
SUTENT - sunitinib malate cap 37.5
4
• • •
•
SUTENT - sunitinib malate cap 50
4
• • •
•
•
•
•
•
•
•
•
•
18
•
•
SYLATRON - peginterferon alfa-2b
for inj kit 600 mcg
4
•
•
SYNRIBO - omacetaxine
mepesuccinate for inj 3.5 mg
4
•
•
TABLOID - thioguanine tab 40 mg
2
TAFINLAR - dabrafenib mesylate
4
• • •
•
TAFINLAR - dabrafenib mesylate
4
• • •
•
TAGRISSO - osimertinib mesylate
4
• • •
•
TAGRISSO - osimertinib mesylate
4
• • •
•
tamoxifen citrate tab 10 mg (base
equivalent)
P
P
TARCEVA - erlotinib hcl tab 25 mg
(base equivalent)
4
• • •
•
(base equivalent)
4
• • •
•
(base equivalent)
4
• • •
•
TARGRETIN - bexarotene cap 75
mg
4
• •
TASIGNA - nilotinib hcl cap 150 mg
(base equivalent)
4
• • •
TASIGNA - nilotinib hcl cap 200 mg
(base equivalent)
4
• • •
TEMODAR - temozolomide cap 5
mg
4
• •
mg
4
• •
mg
4
mg
4
4
• •
mg
4
• •
temozolomide cap 5 mg (Temodar) 4
4
temozolomide cap 20 mg
(Temodar)
4
(Temodar)
4
(Temodar)
4
(Temodar)
4
(Temodar)
4
tretinoin cap 10 mg
• •
• •
TREXALL - methotrexate sodium tab 3
5 mg (base equiv)
7.5 mg (base equiv)
10 mg (base equiv)
15 mg (base equiv)
4
TYKERB - lapatinib ditosylate tab
250 mg (base equiv)
VENCLEXTA - venetoclax tab 10 mg 4
4
mg
Responsible Steps
for inj kit 300 mcg
tamoxifen citrate tab 20 mg (base
equivalent)
•
Quantity Limits
•
Prior Authorization
4
Specialty
for inj kit 200 mcg
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
• •
• •
• •
• •
• •
• • •
•
•
•
•
VENCLEXTA - venetoclax tab 50 mg
4
•
VENCLEXTA - venetoclax tab 100
mg
4
• • •
• • •
• • •
•
VENCLEXTA STARTING PACK venetoclax tab therapy starter
pack 10 & 50 & 100 mg
4
• • •
•
VOTRIENT - pazopanib hcl tab 200
mg (base equiv)
4
• • •
•
XALKORI - crizotinib cap 200 mg
4
• •
XALKORI - crizotinib cap 250 mg
4
•
•
XELODA - capecitabine tab 150 mg
4
• •
XELODA - capecitabine tab 500 mg
4
XTANDI - enzalutamide cap 40 mg
4
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
19
ZYDELIG - idelalisib tab 150 mg
4
ZYKADIA - ceritinib cap 150 mg
4
ZYTIGA - abiraterone acetate tab
250 mg
4
ENDOCRINE AND METABOLIC DRUGS
CORTICOSTEROIDS
budesonide delayed release
particles cap 3 mg (Entocort ec)
1
CORTEF - hydrocortisone tab 5 mg
3
3
3
CORTISONE ACETATE - cortisone
acetate tab 25 mg
3
DEXAMETHASONE dexamethasone soln 0.5 mg/5ml
2
DEXAMETHASONE dexamethasone tab 1 mg
2
DEXAMETHASONE dexamethasone tab 2 mg
2
dexamethasone elixir 0.5 mg/5ml
1
DEXAMETHASONE INTENSOL dexamethasone conc 1 mg/ml
3
dexamethasone tab 0.5 mg
1
dexamethasone tab 4 mg
dexamethasone tab 6 mg
1
1
1
1
•
•
•
•
•
•
•
•
•
•
fludrocortisone acetate tab
0.1 mg
1
hydrocortisone tab 5 mg (Cortef)
4
•
•
•
•
•
Responsible Steps
ZYDELIG - idelalisib tab 100 mg
•
•
•
•
•
3
Quantity Limits
4
ENTOCORT EC - budesonide
delayed release particles cap 3
mg
Prior Authorization
ZOLINZA - vorinostat cap 100 mg
•
Specialty
• • •
Drug Name
Drug Tier
4
ZELBORAF - vemurafenib tab 240
mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
MEDROL - methylprednisolone tab 2 3
mg
mg
mg
3
MEDROL - methylprednisolone tab
16 mg
3
MEDROL - methylprednisolone tab
32 mg
3
MEDROL DOSEPAK methylprednisolone tab therapy
pack 4 mg (21)
1
methylprednisolone tab therapy
pack 4 mg (21) (Medrol dosepak)
1
methylprednisolone tab 4 mg
(Medrol)
1
(Medrol)
1
(Medrol)
1
(Medrol)
3
MILLIPRED - prednisolone sod
phosphate oral soln 10 mg/5ml
(base equiv)
MILLIPRED - prednisolone tab 5 mg 3
DEXPAK 10 DAY - dexamethasone
tab therapy pack 1.5 mg (35)
3
3
MILLIPRED DP - prednisolone tab
therapy pack 5 mg (21)
3
3
MILLIPRED DP - prednisolone tab
3
20
ORAPRED ODT - prednisolone sod
phos orally disintegr tab 10 mg
(base eq)
3
(base eq)
3
(base eq)
3
PEDIAPRED - prednisolone sod
phosph oral soln 6.7 mg/5ml (5
mg/5ml base)
3
prednisolone sod phos orally
disintegr tab 10 mg (base eq)
(Orapred odt)
1
(Orapred odt)
1
(Orapred odt)
1
prednisolone sod phosph oral
soln 6.7 mg/5ml (5 mg/5ml base)
(Pediapred)
1
prednisolone sod phosphate oral
1
PREDNISOLONE SODIUM
PHOSP - prednisolone sodium
(base eq)
3
prednisolone syrup 15 mg/5ml
(usp solution equivalent)
1
PREDNISONE - prednisone oral
soln 5 mg/5ml
2
PREDNISONE - prednisone tab
3
3
3
3
PREDNISONE - prednisone tab 50
mg
2
PREDNISONE INTENSOL prednisone conc 5 mg/ml
3
prednisone tab 1 mg
1
prednisone tab 2.5 mg
prednisone tab 5 mg
prednisone tab 10 mg
prednisone tab 20 mg
Responsible Steps
1
1
VERIPRED 20 - prednisolone sod
(base equiv)
3
ANDROGEN-ANABOLIC
ANADROL-50 - oxymetholone tab 50 3
mg
2
ANDRODERM - testosterone td
patch 24hr 2 mg/24hr
2
ANDRODERM - testosterone td
patch 24hr 4 mg/24hr
ANDROGEL - testosterone td gel 25 3
mg/2.5gm (1%)
ANDROGEL - testosterone td gel 50 3
mg/5gm (1%)
2
ANDROGEL - testosterone td gel
20.25 mg/1.25gm (1.62%)
2
ANDROGEL - testosterone td gel
40.5 mg/2.5gm (1.62%)
ANDROGEL PUMP - testosterone td 3
gel 12.5 mg/act (1%)
ANDROGEL PUMP - testosterone td 2
gel 20.25 mg/act (1.62%)
ANDROID - methyltestosterone cap 3
10 mg
ANDROXY - fluoxymesterone tab 10 3
mg
1
danazol cap 50 mg
Quantity Limits
1
3
danazol cap 200 mg
Prior Authorization
1
UCERIS - budesonide tab sr 24hr 9
mg
danazol cap 100 mg
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
•
• •
• •
• •
• •
• •
• •
• •
• •
•
•
•
•
•
21
3
DEPO-TESTOSTERONE testosterone cypionate im inj in oil
200 mg/ml
3
METHITEST - methyltestosterone
oral tab 10 mg
3
•
methyltestosterone cap 10 mg
(Testred)
1
•
OXANDRIN - oxandrolone tab 2.5
mg
3
•
• •
testosterone cypionate im
inj in oil 100 mg/ml (Depotestosterone)
1
•
•
•
• •
testosterone cypionate im
inj in oil 200 mg/ml (Depotestosterone)
1
• •
testosterone enanthate im inj in
oil 200 mg/ml
1
• •
1
• •
1
• •
1
• •
OXANDRIN - oxandrolone tab 10 mg 3
oxandrolone tab 2.5 mg (Oxandrin) 1
oxandrolone tab 10 mg (Oxandrin)
testosterone td gel 25 mg/2.5gm
(1%) (Androgel)
testosterone td gel 50 mg/5gm
(1%) (Androgel)
testosterone td gel 12.5 mg/act
(1%) (Androgel pump)
ESTROGENS
1
ACTIVELLA - estradiol &
norethindrone acetate tab 0.5-0.1
mg
3
ACTIVELLA - estradiol &
norethindrone acetate tab 1-0.5
mg
3
ALORA - estradiol td patch twice
weekly 0.025 mg/24hr
3
•
weekly 0.05 mg/24hr
3
•
3
•
weekly 0.1 mg/24hr
3
•
ANGELIQ - drospirenone-estradiol
tab 0.25-0.5 mg
3
ANGELIQ - drospirenone-estradiol
tab 0.5-1 mg
3
CLIMARA - estradiol td patch weekly 3
0.025 mg/24hr
0.0375 mg/24hr (37.5 mcg/24hr)
0.05 mg/24hr
0.06 mg/24hr
0.075 mg/24hr
0.1 mg/24hr
2
CLIMARA PRO - estradiollevonorgestrel td patch weekly
0.045-0.015 mg/day
3
COMBIPATCH - estradiolnorethindrone ace td pttw
0.05-0.14 mg/day
3
COMBIPATCH - estradiolnorethindrone ace td pttw
0.05-0.25 mg/day
2
DIVIGEL - estradiol td gel 0.25
mg/0.25gm (0.1%)
2
DIVIGEL - estradiol td gel 0.5
mg/0.5gm (0.1%)
2
DIVIGEL - estradiol td gel 1 mg/gm
(0.1%)
3
DUAVEE - conjugated estrogensbazedoxifene tab 0.45-20 mg
3
ELESTRIN - estradiol gel 0.06%
(0.52 mg/0.87 gm metered-dose
pump)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
• •
DEPO-TESTOSTERONE testosterone cypionate im inj in oil
100 mg/ml
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
•
•
•
•
•
•
•
•
•
•
•
22
esterified estrogens &
methyltestosterone tab
0.625-1.25 mg
esterified estrogens &
methyltestosterone tab
1.25-2.5 mg
1
ESTROGEL - estradiol gel 0.06%
(0.75 mg/1.25 gm metered-dose
pump)
2
1
ESTROPIPATE - estropipate tab
0.75 mg
3
ESTROPIPATE - estropipate tab 1.5
mg
3
ESTROPIPATE - estropipate tab 3
mg
3
ESTRACE - estradiol tab 0.5 mg
3
ESTRACE - estradiol tab 1 mg
3
ESTRACE - estradiol tab 2 mg
3
estradiol & norethindrone acetate
tab 0.5-0.1 mg (Activella)
1
EVAMIST - estradiol transdermal
spray 1.53 mg/spray
3
1
FEMHRT LOW DOSE norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg
3
MENEST - esterified estrogens tab
0.3 mg
2
estradiol & norethindrone acetate
tab 1-0.5 mg (Activella)
estradiol tab 0.5 mg (Estrace)
estradiol tab 1 mg (Estrace)
estradiol tab 2 mg (Estrace)
estradiol td patch twice weekly
0.025 mg/24hr (Vivelle-dot)
1
1
1
1
•
1.25 mg
2
•
2.5 mg
2
•
MENOSTAR - estradiol td patch
weekly 14 mcg/24hr
3
•
MINIVELLE - estradiol td patch twice 3
weekly 0.05 mg/24hr
weekly 0.1 mg/24hr
1
norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg
(Femhrt low dose)
1
norethindrone acetate-ethinyl
estradiol tab 1 mg-5 mcg
3
PREFEST - estradiol tab 1
mg(15)/estrad-norgestimate tab
1-0.09mg(15)
•
1
1
estradiol td patch weekly
0.0375 mg/24hr (37.5 mcg/24hr)
(Climara)
1
•
0.05 mg/24hr (Climara)
1
•
1
•
1
•
1
•
Responsible Steps
Quantity Limits
2
•
Prior Authorization
0.625 mg
1
•
•
•
•
1
1
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
•
•
•
•
23
PREMARIN - estrogens, conjugated
tab 0.3 mg
2
tab 0.45 mg
2
tab 0.625 mg
2
tab 0.9 mg
2
tab 1.25 mg
2
PREMPHASE - conj est 0.625(14)/
conj est-medroxypro ac tab
0.625-5mg(14)
2
PREMPRO - conjugated estrogenmedroxyprogest acetate tab
0.3-1.5 mg
2
0.45-1.5 mg
2
ESTROSTEP FE - norethindrone
ac-ethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg
3
0.625-2.5 mg
2
ethynodiol diacetate & ethinyl
P
0.625-5 mg
2
3
VIVELLE-DOT - estradiol td patch
twice weekly 0.025 mg/24hr
3
•
FEMCON FE - norethindrone &
ethinyl estradiol-fe chew tab 0.4
mg-35 mcg
3
•
3
•
GENERESS FE - norethindrone &
ethinyl estradiol-fe chew tab 0.8
mg-25 mcg
3
P
3
•
levonorg-eth est tab
0.1-0.02mg(84) & eth est tab
0.01mg(7) (Loseasonique)
3
CONTRACEPTIVES
BEYAZ - drospirenone-ethinyl
estrad-levomefolate tab
3-0.02-0.451 mg
3
BREVICON-28 - norethindrone &
ethinyl estradiol tab 0.5 mg-35
mcg
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
CYCLESSA - desogest-ethin est tab 3
0.1-0.025/0.125-0.025/0.15-0.025mgmg
3
DESOGEN - desogestrel & ethinyl
estradiol tab 0.15 mg-30 mcg
P
desogest-eth estrad & eth estrad
tab 0.15-0.02/0.01 mg(21/5)
(Mircette)
P
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mgmg (Cyclessa)
P
desogestrel & ethinyl estradiol
tab 0.15 mg-30 mcg (Desogen)
drospirenone-ethinyl estradiol tab P
3-0.02 mg (Yaz)
drospirenone-ethinyl estradiol tab P
3-0.03 mg (Yasmin 28)
P
ELLA - ulipristal acetate tab 30 mg
•
levonorg-eth est tab
0.15-0.03mg(84) & eth est tab
0.01mg(7) (Seasonique)
levonorgestrel & ethinyl estradiol
(91-day) tab 0.15-0.03 mg
tab 0.1 mg-20 mcg
tab 0.15 mg-30 mcg
levonorgestrel tab 1.5 mg
P
P
P
P
P
24
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mgmcg
levonorgestrel-ethinyl estradiol
(continuous) tab 90-20 mcg
P
norethindrone & ethinyl estradiolfe chew tab 0.8 mg-25 mcg
(Generess fe)
P
P
P
LO LOESTRIN FE - norethin-eth
estradiol-fe tab 1 mg-10 mcg
(24)/10 mcg (2)
3
norethindrone ac-ethinyl estradfe tab 1-20/1-30/1-35 mg-mcg
(Estrostep fe)
P
LOESTRIN FE 1.5/30 norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg
3
norethindrone ace & ethinyl
(Loestrin 1/20-21)
P
LOESTRIN FE 1/20 - norethindrone
ace & ethinyl estradiol-fe tab 1
mg-20 mcg
3
(Loestrin 1.5/30-21)
P
LOSEASONIQUE - levonorg-eth est
tab 0.1-0.02mg(84) & eth est tab
0.01mg(7)
3
(Loestrin fe 1/20)
P
MINASTRIN 24 FE - norethindrone
ace-eth estradiol-fe chew tab 1
mg-20 mcg (24)
3
estradiol-fe tab 1.5 mg-30 mcg
(Loestrin fe 1.5/30)
P
MODICON - norethindrone & ethinyl
3
norethindrone ace-ethinyl
(24)
P
NATAZIA - estradiol valeratedienogest tab 3 mg /2-2 mg/2-3
mg/1 mg
3
norethindrone tab 0.35 mg (Norqd)
P
NECON 1/50-28 - norethindrone &
mestranol tab 1 mg-50 mcg
3
norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg
(Ortho-novum 7/7/7)
P
NECON 10/11-28 - norethindroneeth estradiol tab 0.5-35/1-35 mgmcg (10/11)
3
norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg (Trinorinyl 28)
P
NOR-QD - norethindrone tab 0.35
mg
3
norgestimate & ethinyl estradiol
tab 0.25 mg-35 mcg (Orthocyclen)
norethindrone & ethinyl estradiol
tab 0.4 mg-35 mcg (Ovcon-35)
P
norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mgmcg (Ortho tri-cyclen lo)
P
tab 0.5 mg-35 mcg (Brevicon-28)
tab 1 mg-35 mcg (Norinyl 1+35)
norethindrone & ethinyl estradiolfe chew tab 0.4 mg-35 mcg
(Femcon fe)
P
P
P
norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mgmcg (Ortho tri-cyclen)
norgestrel & ethinyl estradiol tab
0.3 mg-30 mcg
NORINYL 1+35 - norethindrone &
ethinyl estradiol tab 1 mg-35 mcg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
P
P
3
25
NUVARING - etonogestrel-ethinyl
estradiol va ring 0.120-0.015
mg/24hr
P
ZOVIA 1/50E - ethynodiol diacetate
& ethinyl estradiol tab 1 mg-50
mcg
OGESTREL - norgestrel & ethinyl
3
PROGESTINS
ORTHO MICRONOR - norethindrone 3
tab 0.35 mg
3
ORTHO TRI-CYCLEN norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg
3
ORTHO TRI-CYCLEN LO norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg
3
ORTHO-CYCLEN - norgestimate &
ethinyl estradiol tab 0.25 mg-35
mcg
3
ORTHO-NOVUM 1/35 norethindrone & ethinyl estradiol
tab 1 mg-35 mcg
3
ORTHO-NOVUM 7/7/7 norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg
PLAN B ONE-STEP - levonorgestrel 3
tab 1.5 mg
3
QUARTETTE - levonor-eth est tab
0.15-0.02/0.025/0.03 mg &eth est
0.01 mg
3
SAFYRAL - drospirenoneethinyl estrad-levomefolate tab
3-0.03-0.451 mg
3
SEASONIQUE - levonorg-eth est
tab 0.15-0.03mg(84) & eth est tab
0.01mg(7)
3
TRI-NORINYL 28 norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg
P
XULANE - norelgestromin-ethinyl
estradiol td ptwk 150-35 mcg/24hr
3
YASMIN 28 - drospirenone-ethinyl
estradiol tab 3-0.03 mg
YAZ - drospirenone-ethinyl estradiol 3
tab 3-0.02 mg
3
medroxyprogesterone acetate tab
2.5 mg (Provera)
1
10 mg (Provera)
Responsible Steps
Quantity Limits
1
1
MEGACE ES - megestrol acetate
susp 625 mg/5ml
3
megestrol acetate susp
625 mg/5ml (Megace es)
1
norethindrone acetate tab 5 mg
(Aygestin)
1
progesterone micronized cap
100 mg (Prometrium)
1
progesterone micronized cap
200 mg (Prometrium)
Prior Authorization
3
AYGESTIN - norethindrone acetate
tab 5 mg
5 mg (Provera)
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
PROMETRIUM - progesterone
micronized cap 100 mg
3
PROMETRIUM - progesterone
micronized cap 200 mg
3
PROVERA - medroxyprogesterone
acetate tab 2.5 mg
3
acetate tab 5 mg
3
acetate tab 10 mg
3
ANTIDIABETICS
Antidiabetics
acarbose tab 25 mg (Precose)
ACTOPLUS MET - pioglitazone hclmetformin hcl tab 15-500 mg
1
1
1
3
26
ACTOPLUS MET - pioglitazone hclmetformin hcl tab 15-850 mg
3
ACTOPLUS MET XR - pioglitazone
hcl-metformin hcl tab sr 24hr
15-1000 mg
3
ACTOPLUS MET XR - pioglitazone
hcl-metformin hcl tab sr 24hr
30-1000 mg
3
ACTOS - pioglitazone hcl tab 15 mg
(base equiv)
3
(base equiv)
3
(base equiv)
3
ALOGLIPTIN - alogliptin benzoate
tab 6.25 mg (base equiv)
3
• •
3
• •
3
• •
ALOGLIPTIN/METFORMIN HCL alogliptin-metformin hcl tab
12.5-500 mg
3
• •
ALOGLIPTIN/METFORMIN HCL alogliptin-metformin hcl tab
12.5-1000 mg
3
ALOGLIPTIN/PIOGLITAZONE alogliptin-pioglitazone tab 12.5-15
mg
3
mg
3
• •
mg
3
• •
ALOGLIPTIN/PIOGLITAZONE alogliptin-pioglitazone tab 25-15
mg
3
• •
mg
3
• •
mg
3
AMARYL - glimepiride tab 1 mg
3
3
3
AVANDIA - rosiglitazone maleate tab
2 mg (base equiv)
3
AVANDIA - rosiglitazone maleate tab
4 mg (base equiv)
3
BYDUREON - exenatide extended
release for susp pen-injector 2 mg
2
• •
BYDUREON - exenatide for inj
extended release susp 2 mg
2
• •
BYETTA - exenatide soln peninjector 5 mcg/0.02ml
2
• •
BYETTA - exenatide soln peninjector 10 mcg/0.04ml
2
• •
CHLORPROPAMIDE chlorpropamide tab 100 mg
3
CHLORPROPAMIDE chlorpropamide tab 250 mg
3
• •
CYCLOSET - bromocriptine
mesylate tab 0.8 mg (base
equivalent)
3
• •
DUETACT - pioglitazone hclglimepiride tab 30-2 mg
3
DUETACT - pioglitazone hclglimepiride tab 30-4 mg
3
• •
FARXIGA - dapagliflozin propanediol 3
FARXIGA - dapagliflozin propanediol 3
1
glimepiride tab 1 mg (Amaryl)
• •
• •
1
1
glipizide tab sr 24hr 2.5 mg
(Glucotrol xl)
1
glipizide tab sr 24hr 5 mg
(Glucotrol xl)
1
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
27
glipizide tab sr 24hr 10 mg
(Glucotrol xl)
1
glyburide micronized tab 3 mg
(Glynase)
1
glipizide tab 5 mg (Glucotrol)
1
1
1
glyburide micronized tab 6 mg
(Glynase)
1
glyburide tab 1.25 mg
1
glipizide tab 10 mg (Glucotrol)
glipizide-metformin hcl tab
2.5-250 mg
2.5-500 mg
1
glyburide tab 2.5 mg
glyburide tab 5 mg
1
glyburide-metformin tab
1.25-250 mg (Glucovance)
GLUCAGEN HYPOKIT - glucagon
hcl (rdna) for inj 1 mg (base equiv)
3
glyburide-metformin tab
2.5-500 mg (Glucovance)
GLUCAGON EMERGENCY KIT glucagon (rdna) for inj kit 1 mg
2
glyburide-metformin tab 5-500 mg
(Glucovance)
GLUCOPHAGE - metformin hcl tab
500 mg
3
850 mg
3
1000 mg
3
GLUCOPHAGE XR - metformin hcl
tab sr 24hr 500 mg
3
GLUCOPHAGE XR - metformin hcl
tab sr 24hr 750 mg
3
GLUCOTROL - glipizide tab 5 mg
3
GLUCOTROL - glipizide tab 10 mg
3
GLUCOTROL XL - glipizide tab sr
24hr 2.5 mg
3
24hr 5 mg
3
24hr 10 mg
3
GLUCOVANCE - glyburidemetformin tab 1.25-250 mg
3
GLUCOVANCE - glyburidemetformin tab 2.5-500 mg
3
GLUCOVANCE - glyburidemetformin tab 5-500 mg
3
glyburide micronized tab 1.5 mg
(Glynase)
1
5-500 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
1
1
GLYNASE - glyburide micronized tab 3
1.5 mg
3 mg
6 mg
3
GLYSET - miglitol tab 25 mg
3
3
GLYXAMBI - empagliflozin-linagliptin
tab 10-5 mg
3
• •
GLYXAMBI - empagliflozin-linagliptin
tab 25-5 mg
3
• •
INVOKAMET - canagliflozinmetformin hcl tab 50-500 mg
2
• •
2
• •
2
• •
2
• •
INVOKANA - canagliflozin tab 100
mg
2
• •
INVOKANA - canagliflozin tab 300
mg
2
• •
JANUMET - sitagliptin-metformin hcl
tab 50-500 mg
2
• •
28
JANUMET - sitagliptin-metformin hcl
tab 50-1000 mg
2
• •
JANUMET XR - sitagliptin-metformin
hcl tab sr 24hr 50-500 mg
2
• •
2
• •
2
• •
JANUVIA - sitagliptin phosphate tab
25 mg (base equiv)
2
• •
50 mg (base equiv)
2
• •
100 mg (base equiv)
2
• •
nateglinide tab 60 mg (Starlix)
JENTADUETO - linagliptin-metformin 3
hcl tab 2.5-500 mg
hcl tab 2.5-850 mg
hcl tab 2.5-1000 mg
3
JENTADUETO XR - linagliptinmetformin hcl tab sr 24hr 2.5-1000
mg
3
JENTADUETO XR - linagliptinmetformin hcl tab sr 24hr 5-1000
mg
3
KAZANO - alogliptin-metformin hcl
tab 12.5-500 mg
3
KAZANO - alogliptin-metformin hcl
tab 12.5-1000 mg
2
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 2.5-1000
mg
2
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 5-500
mg
2
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 5-1000
mg
4
KORLYM - mifepristone tab 300 mg
• •
NESINA - alogliptin benzoate tab
6.25 mg (base equiv)
3
• •
• •
NESINA - alogliptin benzoate tab
12.5 mg (base equiv)
3
• •
• •
NESINA - alogliptin benzoate tab 25
mg (base equiv)
3
• •
• •
ONGLYZA - saxagliptin hcl tab 2.5
mg (base equiv)
2
• •
ONGLYZA - saxagliptin hcl tab 5 mg
(base equiv)
2
• •
OSENI - alogliptin-pioglitazone tab
12.5-15 mg
3
• •
12.5-30 mg
3
• •
12.5-45 mg
3
• •
25-15 mg
3
• •
25-30 mg
3
• •
25-45 mg
3
• •
pioglitazone hcl tab 15 mg (base
equiv) (Actos)
1
metformin hcl tab sr 24hr 500 mg
(Glucophage xr)
1
1
metformin hcl tab 500 mg
(Glucophage)
1
(Glucophage)
1
(Glucophage)
1
miglitol tab 25 mg (Glyset)
1
nateglinide tab 120 mg (Starlix)
• •
• •
• •
• •
• •
• •
• • •
metformin hcl tab sr 24hr 750 mg
(Glucophage xr)
•
equiv) (Actos)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
1
1
29
• •
1
TANZEUM - albiglutide for soln peninjector 50 mg
3
1
TOLAZAMIDE - tolazamide tab 250
mg
3
1
TOLAZAMIDE - tolazamide tab 500
mg
3
1
TOLBUTAMIDE - tolbutamide tab
500 mg
3
1
TRADJENTA - linagliptin tab 5 mg
3
TRULICITY - dulaglutide soln peninjector 0.75 mg/0.5ml
3
PRANDIN - repaglinide tab 0.5 mg
3
• •
• •
PRANDIN - repaglinide tab 1 mg
3
3
• •
PRANDIN - repaglinide tab 2 mg
3
TRULICITY - dulaglutide soln peninjector 1.5 mg/0.5ml
PRECOSE - acarbose tab 25 mg
3
2
• •
3
VICTOZA - liraglutide soln peninjector 18 mg/3ml (6 mg/ml)
3
3
• •
PROGLYCEM - diazoxide susp 50
mg/ml
2
XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr 5-500
mg
mg
3
repaglinide tab 0.5 mg (Prandin)
1
• •
mg
3
• •
mg
3
• •
equiv) (Actos)
pioglitazone hcl-glimepiride tab
30-2 mg (Duetact)
pioglitazone hcl-glimepiride tab
30-4 mg (Duetact)
pioglitazone hcl-metformin hcl
tab 15-500 mg (Actoplus met)
pioglitazone hcl-metformin hcl
tab 15-850 mg (Actoplus met)
repaglinide tab 1 mg (Prandin)
repaglinide tab 2 mg (Prandin)
1
1
REPAGLINIDE/METFORMIN HYD repaglinide-metformin hcl tab
1-500 mg
3
REPAGLINIDE/METFORMIN HYD repaglinide-metformin hcl tab
2-500 mg
3
RIOMET - metformin hcl oral soln
500 mg/5ml
3
APIDRA - insulin glulisine inj 100
unit/ml
3
•
STARLIX - nateglinide tab 60 mg
3
3
•
STARLIX - nateglinide tab 120 mg
3
SYMLINPEN 120 - pramlintide
acetate pen-inj 2700 mcg/2.7ml
(1000 mcg/ml)
2
APIDRA SOLOSTAR - insulin
glulisine soln pen-injector inj 100
unit/ml
NOVOLOG - insulin aspart inj 100
unit/ml
2
SYMLINPEN 60 - pramlintide
acetate pen-inj 1500 mcg/1.5ml
(1000 mcg/ml)
2
NOVOLOG FLEXPEN - insulin
aspart soln pen-injector 100 unit/
ml
2
TANZEUM - albiglutide for soln peninjector 30 mg
3
NOVOLOG PENFILL - insulin aspart
soln cartridge 100 unit/ml
2
Rapid-Acting Insulins
• •
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
Short-Acting Insulins
30
3
• •
AFREZZA - insulin regular (human)
inhal powd 4 (60) & 8 (30) unit/cart
3
3
• •
inhalation powder 4 unit/cartridge
3
• •
HUMULIN R U-500 (CONCENTR insulin regular (human) inj 500
unit/ml
3
HUMULIN R U-500 KWIKPEN insulin regular (human) soln peninjector 500 unit/ml
3
NOVOLIN R - insulin regular
(human) inj 100 unit/ml
2
NOVOLIN R RELION - insulin
regular (human) inj 100 unit/ml
2
ARMOUR THYROID - thyroid tab 15
mg (1/4 grain)
3
RELION R - insulin regular (human)
inj 100 unit/ml
2
mg (1/2 grain)
3
mg (1 grain)
3
mg (1 1/2 grain)
3
ARMOUR THYROID - thyroid tab
120 mg (2 grain)
3
180 mg (3 grain)
3
240 mg (4 grain)
3
300 mg (5 grain)
3
CYTOMEL - liothyronine sodium tab
5 mcg
3
25 mcg
3
50 mcg
3
levothyroxine sodium tab 25 mcg
(Synthroid)
1
Intermediate-Acting Insulins
NOVOLIN N - insulin nph (human)
(isophane) inj 100 unit/ml
2
NOVOLIN N RELION - insulin nph
(human) (isophane) inj 100 unit/ml
2
NOVOLIN 70/30 - insulin nph
isophane & regular human inj 100
unit/ml (70-30)
2
NOVOLIN 70/30 RELION - insulin
nph isophane & regular human inj
100 unit/ml (70-30)
2
NOVOLOG MIX 70/30 - insulin
aspart prot & aspart (human) inj
100 unit/ml (70-30)
2
NOVOLOG MIX 70/30 PREFILL insulin aspart prot & aspart sus
pen-inj 100 unit/ml (70-30)
2
Basal Insulins
LANTUS - insulin glargine inj 100
unit/ml
2
• •
2
LEVEMIR - insulin detemir inj 100
unit/ml
2
LEVEMIR FLEXTOUCH - insulin
detemir soln pen-injector 100 unit/
ml
2
TOUJEO SOLOSTAR - insulin
glargine soln pen-injector 300 unit/
ml
2
TRESIBA FLEXTOUCH - insulin
degludec soln pen-injector 100
unit/ml
2
TRESIBA FLEXTOUCH - insulin
degludec soln pen-injector 200
unit/ml
2
THYROID AGENTS
LANTUS SOLOSTAR - insulin
glargine soln pen-injector 100 unit/
ml
Responsible Steps
• •
Quantity Limits
3
Prior Authorization
inh powd 8 (60) & 12 (30) unit/cart
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
31
(Synthroid)
1
NATURE-THROID - thyroid tab 97.5
mg
3
(Synthroid)
1
NATURE-THROID - thyroid tab
113.75 mg
3
(Synthroid)
1
NATURE-THROID - thyroid tab 130
mg
3
levothyroxine sodium tab
100 mcg (Synthroid)
1
mg
3
1
mg
3
1
mg (5 grain)
3
1
146.25 mg
3
1
NATURE-THROID NT-2.5 - thyroid
tab 162.5 mg (2 1/2 grain)
3
1
propylthiouracil tab 50 mg
1
1
SYNTHROID - levothyroxine sodium
tab 25 mcg
3
1
tab 50 mcg
3
tab 75 mcg
3
liothyronine sodium tab 5 mcg
(Cytomel)
1
1
3
(Cytomel)
tab 88 mcg
1
tab 100 mcg
3
(Cytomel)
tab 112 mcg
3
methimazole tab 5 mg (Tapazole)
1
3
112 mcg (Synthroid)
125 mcg (Synthroid)
137 mcg (Synthroid)
150 mcg (Synthroid)
175 mcg (Synthroid)
200 mcg (Synthroid)
300 mcg (Synthroid)
methimazole tab 10 mg (Tapazole)
1
16.25 mg
3
tab 125 mcg
3
NATURE-THROID - thyroid tab 32.5
mg
3
tab 137 mcg
3
48.75 mg (3/4 grain)
3
tab 150 mcg
3
mg
3
tab 175 mcg
3
81.25 mg
3
tab 200 mcg
tab 300 mcg
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
32
3
WESTHROID - thyroid tab 97.5 mg
3
TAPAZOLE - methimazole tab 10 mg 3
1
thyroid tab 30 mg (1/2 grain)
(Armour thyroid)
1
thyroid tab 60 mg (1 grain)
(Armour thyroid)
1
thyroid tab 90 mg (1 1/2 grain)
(Armour thyroid)
2
THYROLAR-1 - liotrix (t3-t4) tab 60
mg (12.5-50 mcg)
THYROLAR-1/2 - liotrix (t3-t4) tab 30 2
mg (6.25-25 mcg)
THYROLAR-1/4 - liotrix (t3-t4) tab 15 2
mg (3.1-12.5 mcg)
THYROLAR-2 - liotrix (t3-t4) tab 120 2
mg (25-100 mcg)
THYROLAR-3 - liotrix (t3-t4) tab 180 2
mg (37.5-150 mcg)
3
TIROSINT - levothyroxine sodium
cap 13 mcg
3
cap 25 mcg
3
cap 50 mcg
3
cap 75 mcg
3
cap 88 mcg
3
cap 100 mcg
3
cap 112 mcg
3
cap 125 mcg
3
cap 137 mcg
3
cap 150 mcg
3
WESTHROID - thyroid tab 32.5 mg
WESTHROID - thyroid tab 130 mg
3
3
TAPAZOLE - methimazole tab 5 mg
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
WP THYROID - thyroid tab 16.25 mg 3
(3/4 grain)
3
WP THYROID - thyroid tab 65 mg
WP THYROID - thyroid tab 113.75
mg
3
WP THYROID - thyroid tab 130 mg
3
OXYTOCICS
methylergonovine maleate tab
0.2 mg
1
ENDOCRINE and METABOLIC AGENTS - MISC.
3
•
ACTONEL - risedronate sodium tab
5 mg
3
•
30 mg
3
•
35 mg
3
•
150 mg
3
•
ALENDRONATE SODIUM alendronate sodium oral soln 70
mg/75ml
3
•
ALENDRONATE SODIUM alendronate sodium tab 40 mg
1
•
alendronate sodium tab 5 mg
•
•
•
•
•
•
(Fosamax)
1
•
•
•
ATELVIA - risedronate sodium tab
3
• •
BINOSTO - alendronate sodium
effervescent tab 70 mg
3
• •
1
1
33
BONIVA - ibandronate sodium tab
calcitriol cap 0.25 mcg (Rocaltrol)
calcitriol cap 0.5 mcg (Rocaltrol)
calcitriol oral soln 1 mcg/ml
(Rocaltrol)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
• •
Responsible Steps
Quantity Limits
Prior Authorization
3
desmopressin acetate tab 0.1 mg
(Ddavp)
1
desmopressin acetate tab 0.2 mg
(Ddavp)
1
doxercalciferol cap 0.5 mcg
(Hectorol)
1
1
1
doxercalciferol cap 1 mcg
(Hectorol)
1
1
doxercalciferol cap 2.5 mcg
(Hectorol)
EGRIFTA - tesamorelin acetate for
inj 1 mg (base equiv)
4
• •
•
EGRIFTA - tesamorelin acetate for
4
• •
•
ETIDRONATE DISODIUM etidronate disodium tab 200 mg
3
ETIDRONATE DISODIUM etidronate disodium tab 400 mg
3
EVISTA - raloxifene hcl tab 60 mg
3
BUPHENYL - sodium phenylbutyrate 4
oral powder 3 gm/teaspoonful
BUPHENYL - sodium phenylbutyrate 4
tab 500 mg
1
cabergoline tab 0.5 mg
calcitonin (salmon) nasal soln 200
unit/act (Miacalcin)
Specialty
Drug Name
Drug Tier
2016
• • •
•
• • •
•
1
1
CARBAGLU - carglumic acid tab 200 4
mg
3
CARNITOR - levocarnitine oral soln
1 gm/10ml (10%)
3
CARNITOR - levocarnitine tab 330
mg
3
CARNITOR SF - levocarnitine oral
soln 1 gm/10ml (10%)
4
CYSTADANE - betaine powder for
oral solution
DDAVP - desmopressin acetate inj 4 3
mcg/ml
3
DDAVP - desmopressin acetate
nasal soln 0.01% (refrigerated)
3
DDAVP - desmopressin acetate
nasal spray soln 0.01%
3
DDAVP - desmopressin acetate tab
0.1 mg
3
DDAVP - desmopressin acetate tab
0.2 mg
1
desmopressin acetate inj 4 mcg/
ml (Ddavp)
1
desmopressin acetate nasal soln
0.01% (refrigerated) (Ddavp)
1
desmopressin acetate nasal
spray soln 0.01% (Ddavp)
1
desmopressin acetate nasal
spray soln 0.01% (refrigerated)
•
• •
•
•
FORTEO - teriparatide (recombinant) 4
inj 600 mcg/2.4ml
3
FORTICAL - calcitonin (salmon)
nasal soln 200 unit/act
FOSAMAX - alendronate sodium tab 3
70 mg
3
FOSAMAX PLUS D - alendronate
sodium-cholecalciferol tab
70-2800 mg-unit
3
FOSAMAX PLUS D - alendronate
sodium-cholecalciferol tab
70-5600 mg-unit
4
GENOTROPIN - somatropin for inj
12 mg (13.8 mg overfill)
4
GENOTROPIN - somatropin for
subcutaneous inj 5 mg
4
GENOTROPIN MINIQUICK somatropin for inj 0.2 mg
4
4
• •
• •
• •
• •
• •
• •
• •
• •
• •
34
Responsible Steps
4
• •
GENOTROPIN MINIQUICK somatropin for inj 1 mg
4
• •
4
• •
KUVAN - sapropterin dihydrochloride 4
soluble tab 100 mg
levocarnitine oral soln 1 gm/10ml 1
(10%) (Carnitor)
levocarnitine tab 330 mg (Carnitor) 1
4
• •
MIACALCIN - calcitonin (salmon) inj
200 unit/ml
3
4
• •
MIACALCIN - calcitonin (salmon)
nasal soln 200 unit/act
3
• •
MYALEPT - metreleptin for
subcutaneous inj 11.3 mg
4
4
• • •
•
• •
• •
•
H.P. ACTHAR - corticotropin inj gel
80 unit/ml
4
• • •
NATPARA - parathyroid hormone
(recombinant) for inj cartridge 25
mcg
4
GENOTROPIN MINIQUICK somatropin for inj 2 mg
4
mcg
4
• •
•
mcg
4
• •
•
mcg
4
• •
•
NORDITROPIN CARTRIDGE somatropin inj 5 mg/1.5ml
4
• •
•
NORDITROPIN FLEXPRO somatropin inj 5 mg/1.5ml
4
• •
•
4
• •
•
4
• •
•
NORDITROPIN FLEXPRO somatropin inj 30 mg/3ml
4
• •
•
NUTROPIN AQ NUSPIN 10 somatropin inj 10 mg/2ml
4
• •
•
4
• •
•
4
• •
•
NUTROPIN AQ PEN - somatropin inj 4
10 mg/2ml
• •
•
HECTOROL - doxercalciferol cap 0.5 3
mcg
3
HECTOROL - doxercalciferol cap 1
mcg
HECTOROL - doxercalciferol cap 2.5 3
mcg
4
HUMATROPE - somatropin for inj 5
mg
4
HUMATROPE - somatropin for inj 6
mg (18 unit)
HUMATROPE - somatropin for inj 12 4
mg (36 unit)
HUMATROPE - somatropin for inj 24 4
mg
4
HUMATROPE COMBO PACK somatropin for inj 5 mg
1
ibandronate sodium tab 150 mg
(base equivalent) (Boniva)
4
INCRELEX - mecasermin inj 40
mg/4ml (10 mg/ml)
powder packet 100 mg
powder packet 500 mg
•
• •
• •
• •
• •
• •
•
• •
•
• •
•
• •
•
• •
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
•
35
octreotide acetate inj 50 mcg/ml
(0.05 mg/ml) (Sandostatin)
octreotide acetate inj 1000 mcg/
ml (1 mg/ml) (Sandostatin)
ORFADIN - nitisinone cap 5 mg
4
4
ORFADIN - nitisinone susp 4 mg/ml
2
OSPHENA - ospemifene tab 60 mg
3
paricalcitol cap 1 mcg (Zemplar)
1
paricalcitol cap 4 mcg
raloxifene hcl tab 60 mg (Evista)
• •
•
• •
•
• •
•
• •
• •
• •
•
•
•
•
•
1
1
P
RAVICTI - glycerol phenylbutyrate
liquid 1.1 gm/ml
4
• • •
risedronate sodium tab delayed
release 35 mg (Atelvia)
1
•
risedronate sodium tab 5 mg
(Actonel)
1
•
(Actonel)
1
•
(Actonel)
1
•
(Actonel)
1
•
ROCALTROL - calcitriol cap 0.25
mcg
3
ROCALTROL - calcitriol cap 0.5 mcg
3
•
•
Responsible Steps
4
Quantity Limits
•
Prior Authorization
4
Specialty
•
Drug Name
Drug Tier
4
•
Responsible Steps
4
Quantity Limits
•
Prior Authorization
4
OMNITROPE - somatropin for inj 5.8 4
mg
4
OMNITROPE - somatropin inj 5
mg/1.5ml
4
OMNITROPE - somatropin inj 10
mg/1.5ml
4
paricalcitol cap 2 mcg (Zemplar)
Specialty
Drug Name
Drug Tier
2016
ROCALTROL - calcitriol oral soln 1
mcg/ml
3
SAIZEN - somatropin (nonrefrigerated) for inj 5 mg
4
• •
SAIZEN - somatropin (nonrefrigerated) for inj 8.8 mg
4
• •
SAIZEN CLICK.EASY - somatropin
(non-refrigerated) for inj 8.8 mg
4
• •
SAMSCA - tolvaptan tab 15 mg
4
SAMSCA - tolvaptan tab 30 mg
4
SANDOSTATIN - octreotide acetate
inj 50 mcg/ml (0.05 mg/ml)
4
•
•
•
4
•
4
•
4
•
inj 1000 mcg/ml (1 mg/ml)
4
•
SENSIPAR - cinacalcet hcl tab 30
mg (base equiv)
2
•
mg (base equiv)
2
•
mg (base equiv)
2
•
SEROSTIM - somatropin (nonrefrigerated) for subcutaneous inj
4 mg
4
• •
•
5 mg
4
• •
•
6 mg
4
• •
•
SIGNIFOR - pasireotide diaspartate
inj 0.3 mg/ml (base equiv)
4
• • •
•
4
• • •
•
4
• • •
•
•
•
•
•
36
sodium phenylbutyrate oral
powder 3 gm/teaspoonful
(Buphenyl)
4
SOMAVERT - pegvisomant for inj 10
mg (as protein)
4
mg (as protein)
4
mg (as protein)
digoxin tab 125 mcg (0.125 mg)
(Lanoxin)
1
•
digoxin tab 250 mcg (0.25 mg)
(Lanoxin)
1
•
•
LANOXIN - digoxin tab 62.5 mcg
(0.0625 mg)
3
4
•
•
LANOXIN - digoxin tab 125 mcg
(0.125 mg)
3
•
•
LANOXIN - digoxin tab 187.5 mcg
(0.1875 mg)
3
mg (as protein)
4
•
•
LANOXIN - digoxin tab 250 mcg
(0.25 mg)
3
mg (as protein)
4
STIMATE - desmopressin acetate
nasal soln 1.5 mg/ml
2
STRENSIQ - asfotase alfa
subcutaneous inj 18 mg/0.45ml
4
• •
•
4
• •
•
subcutaneous inj 40 mg/ml
4
• •
•
4
• •
•
SYNAREL - nafarelin acetate nasal
soln 2 mg/ml (200 mcg/act) (base
eq)
4
•
XURIDEN - uridine triacetate oral
4
ZEMPLAR - paricalcitol cap 1 mcg
3
isosorbide mononitrate tab sr
24hr 120 mg
ZEMPLAR - paricalcitol cap 2 mcg
3
isosorbide mononitrate tab 10 mg
ZOMACTON - somatropin for inj 10
mg
4
ZOMACTON - somatropin for
ZORBTIVE - somatropin (nonrefrigerated) for subcutaneous inj
8.8 mg
• •
Responsible Steps
Quantity Limits
DILATRATE SR - isosorbide dinitrate 3
cap cr 40 mg
3
ISOSORBIDE DINITRATE ER isosorbide dinitrate tab cr 40 mg
1
isosorbide dinitrate tab 5 mg
(Isordil titradose)
1
24hr 30 mg
•
•
4
• •
•
4
• •
DIGOXIN - digoxin oral soln 0.05 mg/ 2
ml
Prior Authorization
ANTIANGINAL AGENTS
• •
CARDIOVASCULAR AGENTS
CARDIOTONICS
•
Specialty
Drug Name
Drug Tier
• • •
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
24hr 60 mg
isosorbide mononitrate tab 20 mg
1
1
1
1
1
1
1
NITRO-BID - nitroglycerin oint 2%
2
NITRO-DUR - nitroglycerin td patch
24hr 0.1 mg/hr
3
24hr 0.2 mg/hr
3
24hr 0.3 mg/hr
2
24hr 0.4 mg/hr
3
37
24hr 0.6 mg/hr
3
24hr 0.8 mg/hr
2
nitroglycerin cap cr 2.5 mg
1
nitroglycerin cap cr 6.5 mg
nitroglycerin cap cr 9 mg
1
1
NITROGLYCERIN LINGUAL nitroglycerin lingual aerosol 400
mcg/spray
3
nitroglycerin td patch 24hr
0.1 mg/hr (Nitro-dur)
1
1
atenolol tab 25 mg (Tenormin)
Responsible Steps
1
BETAPACE - sotalol hcl tab 80 mg
3
3
3
BETAPACE AF - sotalol hcl (afib/afl)
tab 80 mg
3
tab 120 mg
3
tab 160 mg
3
betaxolol hcl tab 10 mg (Kerlone)
1
1
1
1
bisoprolol fumarate tab 5 mg
(Zebeta)
1
nitroglycerin tl soln 0.4 mg/spray
(400 mcg/spray) (Nitrolingual
pumpspr)
1
bisoprolol fumarate tab 10 mg
(Zebeta)
NITROLINGUAL PUMPSPRAY nitroglycerin tl soln 0.4 mg/spray
(400 mcg/spray)
3
NITROMIST - nitroglycerin lingual
aerosol 400 mcg/spray
3
NITROSTAT - nitroglycerin sl tab 0.3
mg
2
mg
2
mg
2
carvedilol tab 12.5 mg (Coreg)
RANEXA - ranolazine tab sr 12hr
500 mg
3
COREG - carvedilol tab 3.125 mg
3
3
RANEXA - ranolazine tab sr 12hr
1000 mg
3
3
COREG - carvedilol tab 25 mg
3
COREG CR - carvedilol phosphate
cap sr 24hr 10 mg
3
acebutolol hcl cap 200 mg
(Sectral)
1
cap sr 24hr 20 mg
3
acebutolol hcl cap 400 mg
(Sectral)
1
BETA BLOCKERS
Quantity Limits
1
betaxolol hcl tab 20 mg (Kerlone)
Prior Authorization
1
1
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
BYSTOLIC - nebivolol hcl tab 2.5 mg 3
(base equivalent)
3
BYSTOLIC - nebivolol hcl tab 5 mg
(base equivalent)
BYSTOLIC - nebivolol hcl tab 10 mg 3
(base equivalent)
BYSTOLIC - nebivolol hcl tab 20 mg 3
(base equivalent)
1
carvedilol tab 25 mg (Coreg)
1
1
1
38
cap sr 24hr 40 mg
3
cap sr 24hr 80 mg
3
CORGARD - nadolol tab 20 mg
3
3
3
HEMANGEOL - propranolol hcl oral
soln 4.28 mg/ml
3
INDERAL LA - propranolol hcl cap sr 3
24hr 60 mg
24hr 80 mg
24hr 120 mg
24hr 160 mg
3
INDERAL XL - propranolol hcl
sustained-release beads cap sr
24hr 80 mg
3
INDERAL XL - propranolol hcl
24hr 120 mg
2
INNOPRAN XL - propranolol hcl
24hr 80 mg
2
INNOPRAN XL - propranolol hcl
24hr 120 mg
KERLONE - betaxolol hcl tab 10 mg 3
KERLONE - betaxolol hcl tab 20 mg
3
labetalol hcl tab 100 mg (Trandate) 1
LEVATOL - penbutolol sulfate tab 20 3
mg
3
LOPRESSOR - metoprolol tartrate
tab 50 mg
3
LOPRESSOR - metoprolol tartrate
tab 100 mg
metoprolol succinate tab sr 24hr
25 mg (tartrate equiv) (Toprol xl)
50 mg (tartrate equiv) (Toprol xl)
•
200 mg (tartrate equiv) (Toprol
xl)
1
METOPROLOL TARTRATE metoprolol tartrate tab 37.5 mg
3
METOPROLOL TARTRATE metoprolol tartrate tab 75 mg
3
metoprolol tartrate tab 25 mg
1
(Lopressor)
1
(Lopressor)
1
nadolol tab 20 mg (Corgard)
1
pindolol tab 5 mg
pindolol tab 10 mg
1
1
PROPRANOLOL HCL - propranolol
hcl oral soln 40 mg/5ml
2
propranolol hcl cap sr 24hr 60 mg
(Inderal la)
1
propranolol hcl cap sr 24hr 80 mg
(Inderal la)
1
propranolol hcl cap sr 24hr
120 mg (Inderal la)
1
propranolol hcl tab 20 mg
1
2
Responsible Steps
1
PROPRANOLOL HCL - propranolol
hcl oral soln 20 mg/5ml
propranolol hcl cap sr 24hr
160 mg (Inderal la)
Quantity Limits
1
1
Prior Authorization
1
100 mg (tartrate equiv) (Toprol
xl)
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
1
1
39
1
3
SECTRAL - acebutolol hcl cap 200
mg
3
ADALAT CC - nifedipine tab sr 24hr
90 mg
1
SECTRAL - acebutolol hcl cap 400
mg
3
amlodipine besylate tab 2.5 mg
(Norvasc)
1
sotalol hcl (afib/afl) tab 80 mg
(Betapace af)
1
amlodipine besylate tab 5 mg
(Norvasc)
1
(Betapace af)
1
amlodipine besylate tab 10 mg
(Norvasc)
CALAN - verapamil hcl tab 80 mg
3
(Betapace af)
1
CALAN - verapamil hcl tab 120 mg
3
CALAN SR - verapamil hcl tab cr
120 mg
3
sotalol hcl tab 80 mg (Betapace)
1
180 mg
3
240 mg
3
sotalol hcl tab 240 mg
1
1
1
SOTYLIZE - sotalol hcl oral solution
5 mg/ml
3
TIMOLOL MALEATE - timolol
maleate tab 5 mg
2
CARDIZEM LA - diltiazem hcl coated 3
beads tab sr 24hr 120 mg
1
diltiazem hcl cap sr 12hr 60 mg
maleate tab 10 mg
2
maleate tab 20 mg
2
TOPROL XL - metoprolol succinate
tab sr 24hr 25 mg (tartrate equiv)
3
3
diltiazem hcl coated beads cap sr
24hr 120 mg (Cardizem cd)
3
3
ZEBETA - bisoprolol fumarate tab 5
mg
3
ZEBETA - bisoprolol fumarate tab 10
mg
3
CALCIUM CHANNEL BLOCKERS
30 mg
3
60 mg
3
diltiazem hcl coated beads tab sr
24hr 180 mg (Cardizem la)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
1
1
1
1
1
1
1
1
1
1
40
diltiazem hcl extended release
beads cap sr 24hr 300 mg
(Tiazac)
1
(Tiazac)
1
(Tiazac)
1
1
diltiazem hcl tab 120 mg
(Cardizem)
1
felodipine tab sr 24hr 2.5 mg
1
nifedipine cap 10 mg (Procardia)
nifedipine cap 20 mg
nifedipine tab sr 24hr osmotic
release 60 mg (Procardia xl)
nimodipine cap 30 mg
diltiazem hcl tab 30 mg (Cardizem) 1
diltiazem hcl tab 60 mg (Cardizem) 1
nicardipine hcl cap 30 mg
1
1
1
1
1
1
1
1
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Tier
1
1
nicardipine hcl cap 20 mg
(Tiazac)
isradipine cap 5 mg
Responsible Steps
1
1
isradipine cap 2.5 mg
Quantity Limits
1
(Tiazac)
felodipine tab sr 24hr 10 mg
Prior Authorization
nifedipine tab sr 24hr 90 mg
(Adalat cc)
1
felodipine tab sr 24hr 5 mg
Drug Name
1
(Tiazac)
diltiazem hcl tab 90 mg
Specialty
Drug Name
Drug Tier
2016
1
1
1
NISOLDIPINE - nisoldipine tab sr
24hr 20 mg
2
24hr 30 mg
2
24hr 40 mg
2
NISOLDIPINE ER - nisoldipine tab sr 2
24hr 25.5 mg
1
nisoldipine tab sr 24hr 8.5 mg
(Sular)
1
nisoldipine tab sr 24hr 17 mg
(Sular)
1
nisoldipine tab sr 24hr 34 mg
(Sular)
NORVASC - amlodipine besylate tab 3
2.5 mg
5 mg
10 mg
NYMALIZE - nimodipine oral soln 60 3
mg/20ml
PROCARDIA - nifedipine cap 10 mg 3
PROCARDIA XL - nifedipine tab sr
24hr osmotic release 30 mg
3
3
(Adalat cc)
1
3
(Adalat cc)
1
SULAR - nisoldipine tab sr 24hr 8.5
mg
3
41
SULAR - nisoldipine tab sr 24hr 17
mg
3
SULAR - nisoldipine tab sr 24hr 34
mg
3
verapamil hcl cap sr 24hr 100 mg
(Verelan pm)
1
(Verelan)
1
CORDARONE - amiodarone hcl tab
200 mg
3
(Verelan)
1
disopyramide phosphate cap
100 mg (Norpace)
1
(Verelan pm)
1
disopyramide phosphate cap
150 mg (Norpace)
(Verelan)
1
dofetilide cap 125 mcg (0.125 mg)
(Tikosyn)
1
(Verelan pm)
1
(Tikosyn)
1
(Verelan)
1
(Tikosyn)
1
verapamil hcl tab cr 120 mg
(Calan sr)
1
flecainide acetate tab 50 mg
1
(Calan sr)
1
(Calan sr)
1
verapamil hcl tab 40 mg
1
verapamil hcl tab 80 mg (Calan)
verapamil hcl tab 120 mg (Calan)
1
1
ANTIARRHYTHMICS
amiodarone hcl tab 100 mg
1
1
mexiletine hcl cap 150 mg
Responsible Steps
Quantity Limits
1
1
1
1
1
1
MULTAQ - dronedarone hcl tab 400
2
3
VERELAN - verapamil hcl cap sr
24hr 120 mg
3
NORPACE - disopyramide
phosphate cap 100 mg
3
24hr 180 mg
3
NORPACE - disopyramide
phosphate cap 150 mg
3
24hr 240 mg
3
NORPACE CR - disopyramide
phosphate cap sr 12hr 100 mg
3
24hr 360 mg
3
NORPACE CR - disopyramide
phosphate cap sr 12hr 150 mg
1
VERELAN PM - verapamil hcl cap sr
24hr 100 mg
3
propafenone hcl cap sr 12hr
225 mg (Rythmol sr)
24hr 200 mg
3
325 mg (Rythmol sr)
24hr 300 mg
3
425 mg (Rythmol sr)
Prior Authorization
1
(Cordarone)
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
42
propafenone hcl tab 150 mg
(Rythmol)
1
ACEON - perindopril erbumine tab 8
mg
3
(Rythmol)
1
ALTACE - ramipril cap 1.25 mg
3
ALTACE - ramipril cap 2.5 mg
3
1
ALTACE - ramipril cap 5 mg
3
ALTACE - ramipril cap 10 mg
3
amlodipine besylate-benazepril
hcl cap 2.5-10 mg (Lotrel)
1
quinidine gluconate tab cr 324 mg
1
QUINIDINE SULFATE - quinidine
sulfate tab 200 mg
2
QUINIDINE SULFATE - quinidine
sulfate tab 300 mg
3
RYTHMOL - propafenone hcl tab
225 mg
3
RYTHMOL SR - propafenone hcl cap 3
sr 12hr 225 mg
sr 12hr 325 mg
sr 12hr 425 mg
3
TIKOSYN - dofetilide cap 125 mcg
(0.125 mg)
3
(0.25 mg)
3
(0.5 mg)
ANTIHYPERTENSIVES
ACCUPRIL - quinapril hcl tab 5 mg
3
3
3
3
ACCURETIC - quinaprilhydrochlorothiazide tab 10-12.5
mg
3
ACCURETIC - quinaprilhydrochlorothiazide tab 20-12.5
mg
3
ACCURETIC - quinaprilhydrochlorothiazide tab 20-25 mg
3
ACEON - perindopril erbumine tab 4
mg
3
hcl cap 5-10 mg (Lotrel)
amlodipine besylate-valsartan tab
5-160 mg (Exforge)
5-320 mg (Exforge)
10-160 mg (Exforge)
10-320 mg (Exforge)
amlodipine-valsartanhydrochlorothiazide tab
5-160-12.5 mg (Exforge hct)
5-160-25 mg (Exforge hct)
10-160-12.5 mg (Exforge hct)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
1
1
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
43
ATACAND - candesartan cilexetil tab
16 mg
3
• •
32 mg
3
• •
ATACAND HCT - candesartan
cilexetil-hydrochlorothiazide tab
16-12.5 mg
3
• •
32-12.5 mg
3
• •
32-25 mg
3
• •
atenolol & chlorthalidone tab
50-25 mg (Tenoretic 50)
1
atenolol & chlorthalidone tab
100-25 mg (Tenoretic 100)
1
AVALIDE - irbesartanhydrochlorothiazide tab 150-12.5
mg
3
• •
AVALIDE - irbesartanhydrochlorothiazide tab 300-12.5
mg
3
• •
AVAPRO - irbesartan tab 75 mg
3
3
3
AZOR - amlodipine besylateolmesartan medoxomil tab 5-20
mg
3
•
•
•
•
mg
3
mg
3
• •
mg
3
• •
•
•
•
•
• •
benazepril & hydrochlorothiazide
tab 10-12.5 mg (Lotensin hct)
tab 20-12.5 mg (Lotensin hct)
tab 20-25 mg (Lotensin hct)
benazepril hcl tab 5 mg
1
1
1
1
1
(Lotensin)
1
(Lotensin)
1
(Lotensin)
1
BENICAR - olmesartan medoxomil
tab 5 mg
3
• •
tab 20 mg
3
• •
tab 40 mg
3
• •
BENICAR HCT - olmesartan
medoxomil-hydrochlorothiazide
tab 20-12.5 mg
3
• •
tab 40-12.5 mg
3
• •
tab 40-25 mg
3
• •
bisoprolol & hydrochlorothiazide
tab 2.5-6.25 mg (Ziac)
1
tab 5-6.25 mg (Ziac)
tab 10-6.25 mg (Ziac)
1
1
candesartan cilexetil tab 4 mg
(Atacand)
1
•
(Atacand)
1
•
• •
Responsible Steps
3
Quantity Limits
8 mg
tab 5-6.25 mg
Prior Authorization
• •
Specialty
3
Drug Name
Drug Tier
4 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
44
1
•
1
•
candesartan cilexetilhydrochlorothiazide tab
32-12.5 mg (Atacand hct)
32-25 mg (Atacand hct)
captopril tab 12.5 mg
captopril tab 25 mg
captopril tab 50 mg
captopril tab 100 mg
1
1
1
1
1
CAPTOPRIL/
HYDROCHLOROTHIA - captopril
& hydrochlorothiazide tab 25-15
mg
2
CAPTOPRIL/
mg
3
CAPTOPRIL/
mg
2
CAPTOPRIL/
mg
3
•
3
CATAPRES - clonidine hcl tab 0.3
mg
3
CATAPRES-TTS-1 - clonidine hcl td
patch weekly 0.1 mg/24hr
3
3
3
clonidine hcl tab 0.1 mg
(Catapres)
1
(Catapres)
1
(Catapres)
1
clonidine hcl td patch weekly
0.1 mg/24hr (Catapres-tts-1)
1
CARDURA - doxazosin mesylate tab 3
1 mg
2 mg
4 mg
8 mg
1
1
CLORPRES - clonidine &
chlorthalidone tab 0.1-15 mg
3
3
3
CORZIDE - nadolol &
bendroflumethiazide tab 40-5 mg
3
CORZIDE - nadolol &
bendroflumethiazide tab 80-5 mg
3
COZAAR - losartan potassium tab
25 mg
3
• •
50 mg
3
• •
100 mg
3
• •
16-12.5 mg (Atacand hct)
mg
Responsible Steps
•
Quantity Limits
1
3
Prior Authorization
(Atacand)
mg
Specialty
•
Drug Name
Drug Tier
1
(Atacand)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
45
EDARBYCLOR - azilsartan
medoxomil-chlorthalidone tab
40-12.5 mg
3
• •
EDARBYCLOR - azilsartan
medoxomil-chlorthalidone tab
40-25 mg
3
• •
enalapril maleate &
hydrochlorothiazide tab
5-12.5 mg
1
DIBENZYLINE - phenoxybenzamine
hcl cap 10 mg
3
DIOVAN - valsartan tab 40 mg
3
3
3
3
DIOVAN HCT - valsartanhydrochlorothiazide tab 80-12.5
mg
3
•
•
•
•
•
mg
3
• •
enalapril maleate &
10-25 mg (Vaseretic)
• •
enalapril maleate tab 2.5 mg
(Vasotec)
1
DIOVAN HCT - valsartanhydrochlorothiazide tab 160-25
mg
3
1
mg
3
• •
enalapril maleate tab 5 mg
(Vasotec)
(Vasotec)
1
DIOVAN HCT - valsartanhydrochlorothiazide tab 320-25
mg
3
• •
(Vasotec)
1
3
doxazosin mesylate tab 1 mg
(Cardura)
1
EPANED - enalapril maleate for oral
soln 1 mg/ml
eplerenone tab 25 mg (Inspra)
1
(Cardura)
1
eplerenone tab 50 mg (Inspra)
3
• •
(Cardura)
1
EPROSARTAN MESYLATE eprosartan mesylate tab 600 mg
3
• •
(Cardura)
1
EXFORGE - amlodipine besylatevalsartan tab 5-160 mg
3
• •
DUTOPROL - metoprolol &
hydrochlorothiazide tab sr 24hr
25-12.5 mg
3
3
• •
50-12.5 mg
3
3
• •
3
EXFORGE HCT - amlodipinevalsartan-hydrochlorothiazide tab
5-160-12.5 mg
3
100-12.5 mg
• •
• •
• •
EDARBI - azilsartan medoxomil tab
80 mg
3
• •
5-160-25 mg
3
EDARBI - azilsartan medoxomil tab
40 mg
3
•
•
•
•
•
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
46
10-160-12.5 mg
3
10-160-25 mg
3
10-320-25 mg
3
fosinopril sodium &
10-12.5 mg
1
fosinopril sodium &
20-12.5 mg
fosinopril sodium tab 10 mg
guanfacine hcl tab 1 mg (Tenex)
guanfacine hcl tab 2 mg (Tenex)
hydralazine hcl tab 10 mg
irbesartan-hydrochlorothiazide
tab 300-12.5 mg (Avalide)
lisinopril & hydrochlorothiazide
tab 10-12.5 mg (Zestoretic)
tab 20-12.5 mg (Zestoretic)
tab 20-25 mg (Zestoretic)
lisinopril tab 2.5 mg (Zestril)
lisinopril tab 5 mg (Prinivil)
lisinopril tab 40 mg (Zestril)
1
1
1
1
1
1
1
1
3
HYZAAR - losartan potassium &
hydrochlorothiazide tab 100-25
mg
3
INSPRA - eplerenone tab 25 mg
3
INSPRA - eplerenone tab 50 mg
3
irbesartan tab 75 mg (Avapro)
1
1
1
1
• •
• •
• •
•
•
•
•
1
1
1
1
1
1
1
1
1
1
LOPRESSOR HCT - metoprolol &
hydrochlorothiazide tab 50-25 mg
3
LOPRESSOR HCT - metoprolol &
hydrochlorothiazide tab 100-25
mg
3
losartan potassium &
50-12.5 mg (Hyzaar)
1
•
1
•
1
•
losartan potassium tab 25 mg
(Cozaar)
1
•
(Cozaar)
1
•
(Cozaar)
1
•
LOTENSIN - benazepril hcl tab 10
mg
3
mg
3
mg
3
100-12.5 mg (Hyzaar)
100-25 mg (Hyzaar)
•
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Tier
Responsible Steps
Prior Authorization
Quantity Limits
• •
1
hydrochlorothiazide tab 100-12.5
mg
irbesartan-hydrochlorothiazide
tab 150-12.5 mg (Avalide)
• •
Drug Name
lisinopril tab 30 mg (Zestril)
3
• •
1
mg
Specialty
Drug Name
Drug Tier
2016
47
LOTENSIN HCT - benazepril &
mg
3
MICARDIS HCT - telmisartanhydrochlorothiazide tab 80-12.5
mg
3
• •
mg
3
MICARDIS HCT - telmisartanhydrochlorothiazide tab 80-25 mg
3
• •
3
3
MINIPRESS - prazosin hcl cap 1 mg
3
LOTREL - amlodipine besylatebenazepril hcl cap 5-10 mg
3
3
minoxidil tab 2.5 mg
1
3
3
3
moexipril-hydrochlorothiazide tab
7.5-12.5 mg
MAVIK - trandolapril tab 1 mg
3
MAVIK - trandolapril tab 2 mg
3
15-12.5 mg
methyldopa tab 250 mg
1
methyldopa tab 500 mg
minoxidil tab 10 mg
moexipril hcl tab 7.5 mg
moexipril hcl tab 15 mg
15-25 mg
nadolol & bendroflumethiazide
tab 40-5 mg (Corzide)
1
3
METHYLDOPA/
HYDROCHLOROTHI - methyldopa
mg
3
METHYLDOPA/
HYDROCHLOROTHI - methyldopa
mg
metoprolol & hydrochlorothiazide 1
tab 50-25 mg (Lopressor hct)
tab 100-25 mg (Lopressor hct)
tab 100-50 mg
3
MICARDIS - telmisartan tab 20 mg
3
3
MICARDIS HCT - telmisartanhydrochlorothiazide tab 40-12.5
mg
3
nadolol & bendroflumethiazide
tab 80-5 mg (Corzide)
perindopril erbumine tab 2 mg
•
•
•
•
•
•
•
•
1
1
1
1
1
1
1
1
1
(Aceon)
1
(Aceon)
1
phenoxybenzamine hcl cap 10 mg
(Dibenzyline)
1
prazosin hcl cap 1 mg (Minipress)
1
1
1
PROPRANOLOL/
HYDROCHLOROTH - propranolol
mg
2
PROPRANOLOL/
HYDROCHLOROTH - propranolol
mg
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
48
quinapril hcl tab 5 mg (Accupril)
quinapril-hydrochlorothiazide tab
10-12.5 mg (Accuretic)
20-12.5 mg (Accuretic)
20-25 mg (Accuretic)
ramipril cap 1.25 mg (Altace)
ramipril cap 2.5 mg (Altace)
ramipril cap 5 mg (Altace)
1
telmisartan tab 80 mg (Micardis)
1
telmisartan-amlodipine tab
40-5 mg (Twynsta)
1
40-10 mg (Twynsta)
1
1
80-5 mg (Twynsta)
1
80-10 mg (Twynsta)
1
telmisartan-hydrochlorothiazide
tab 40-12.5 mg (Micardis hct)
1
tab 80-12.5 mg (Micardis hct)
1
1
•
1
•
1
•
1
•
1
•
3
TENEX - guanfacine hcl tab 1 mg
3
TENEX - guanfacine hcl tab 2 mg
3
TARKA - trandolapril-verapamil hcl
tab cr 2-180 mg
3
3
tab cr 2-240 mg
3
TENORETIC 100 - atenolol &
chlorthalidone tab 100-25 mg
3
tab cr 4-240 mg
3
TENORETIC 50 - atenolol &
chlorthalidone tab 50-25 mg
terazosin hcl cap 1 mg
1
TEKTURNA - aliskiren fumarate tab
3
• •
TEKTURNA - aliskiren fumarate tab
3
• •
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 150-12.5
mg
3
• •
trandolapril tab 2 mg (Mavik)
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 150-25
mg
3
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 300-12.5
mg
3
• •
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 300-25
mg
3
• •
1
1
• •
•
•
trandolapril-verapamil hcl tab cr
1-240 mg (Tarka)
2-180 mg (Tarka)
2-240 mg (Tarka)
4-240 mg (Tarka)
TRIBENZOR - olmesartanamlodipine-hydrochlorothiazide
tab 20-5-12.5 mg
1
Responsible Steps
•
tab cr 1-240 mg
Quantity Limits
1
1
Prior Authorization
1
•
•
1
tab 80-25 mg (Micardis hct)
ramipril cap 10 mg (Altace)
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
1
1
1
1
1
1
1
3
• •
49
tab 40-10-12.5 mg
3
• •
tab 40-10-25 mg
3
TWYNSTA - telmisartan-amlodipine
tab 40-5 mg
DIURETICS
3
ACETAZOLAMIDE - acetazolamide
tab 125 mg
2
acetazolamide cap sr 12hr 500 mg
(Diamox)
1
• •
acetazolamide tab 250 mg
1
ALDACTAZIDE - spironolactone &
3
3
• •
ALDACTAZIDE - spironolactone &
3
tab 40-10 mg
3
• •
ALDACTONE - spironolactone tab
25 mg
3
tab 80-5 mg
3
• •
50 mg
3
tab 80-10 mg
3
• •
100 mg
3
valsartan tab 40 mg (Diovan)
1
amiloride & hydrochlorothiazide
tab 5-50 mg
1
1
•
•
•
•
•
1
•
BUMEX - bumetanide tab 0.5 mg
3
•
3
1
BUMEX - bumetanide tab 1 mg
BUMEX - bumetanide tab 2 mg
3
1
•
CHLOROTHIAZIDE - chlorothiazide
tab 250 mg
3
chlorothiazide tab 500 mg
1
DEMADEX - torsemide tab 5 mg
3
3
3
valsartan-hydrochlorothiazide tab
80-12.5 mg (Diovan hct)
160-25 mg (Diovan hct)
320-25 mg (Diovan hct)
1
1
1
1
VECAMYL - mecamylamine hcl tab
2.5 mg
3
ZIAC - bisoprolol &
hydrochlorothiazide tab 2.5-6.25
mg
3
ZIAC - bisoprolol &
hydrochlorothiazide tab 5-6.25 mg
3
amiloride hcl tab 5 mg
bumetanide tab 0.5 mg
bumetanide tab 1 mg
bumetanide tab 2 mg
•
•
• •
Responsible Steps
3
Quantity Limits
tab 40-5-25 mg
ZIAC - bisoprolol &
mg
Prior Authorization
• •
Specialty
3
Drug Name
Drug Tier
tab 40-5-12.5 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
1
CHLORTHALIDONE - chlorthalidone 2
tab 50 mg
CHLORTHALIDONE - chlorthalidone 3
tab 100 mg
1
chlorthalidone tab 25 mg
50
DIAMOX - acetazolamide cap sr
12hr 500 mg
3
methazolamide tab 50 mg
(Neptazane)
1
DIURIL - chlorothiazide susp 250
mg/5ml
3
METHYCLOTHIAZIDE methyclothiazide tab 5 mg
3
DYAZIDE - triamterene &
hydrochlorothiazide cap 37.5-25
mg
3
metolazone tab 2.5 mg
1
DYRENIUM - triamterene cap 50 mg
3
DYRENIUM - triamterene cap 100
mg
3
MICROZIDE - hydrochlorothiazide
cap 12.5 mg
3
EDECRIN - ethacrynic acid tab 25
mg
3
NEPTAZANE - methazolamide tab
25 mg
3
ethacrynic acid tab 25 mg
1
NEPTAZANE - methazolamide tab
50 mg
3
spironolactone &
25-25 mg (Aldactazide)
1
metolazone tab 5 mg
FUROSEMIDE - furosemide oral
soln 8 mg/ml
3
furosemide oral soln 10 mg/ml
1
furosemide tab 20 mg (Lasix)
1
1
1
hydrochlorothiazide cap 12.5 mg
(Microzide)
1
hydrochlorothiazide tab 12.5 mg
1
hydrochlorothiazide tab 25 mg
hydrochlorothiazide tab 50 mg
indapamide tab 1.25 mg
indapamide tab 2.5 mg
metolazone tab 10 mg
1
1
KEVEYIS - dichlorphenamide tab 50
mg
4
LASIX - furosemide tab 20 mg
3
3
3
MAXZIDE - triamterene &
3
MAXZIDE-25 - triamterene &
hydrochlorothiazide tab 37.5-25
mg
3
methazolamide tab 25 mg
(Neptazane)
1
spironolactone tab 50 mg
(Aldactone)
1
(Aldactone)
1
torsemide tab 5 mg (Demadex)
1
• • •
•
triamterene &
hydrochlorothiazide cap
37.5-25 mg (Dyazide)
triamterene &
37.5-25 mg (Maxzide-25)
triamterene &
75-50 mg (Maxzide)
TRIAMTERENE/
HYDROCHLOROTH - triamterene
& hydrochlorothiazide cap 50-25
mg
Responsible Steps
Quantity Limits
Prior Authorization
1
1
1
1
(Aldactone)
1
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
1
1
1
3
VASOPRESSORS
51
EPINEPHRINE - epinephrine
solution auto-injector 0.15
mg/0.15ml (1:1000)
3
EPINEPHRINE - epinephrine
solution auto-injector 0.3 mg/0.3ml
(1:1000)
3
EPIPEN 2-PAK - epinephrine
solution auto-injector 0.3 mg/0.3ml
(1:1000)
2
EPIPEN-JR 2-PAK - epinephrine
solution auto-injector 0.15
mg/0.3ml (1:2000)
2
midodrine hcl tab 2.5 mg
1
midodrine hcl tab 5 mg
midodrine hcl tab 10 mg
ANTIHYPERLIPIDEMICS
1
1
3
• •
ALTOPREV - lovastatin tab sr 24hr
40 mg
3
• •
60 mg
3
• •
atorvastatin calcium tab 10 mg
(base equivalent) (Lipitor)
1
•
1
•
1
•
1
•
cholestyramine light powder
packets 4 gm
cholestyramine light powder
4 gm/dose (Questran light)
cholestyramine powder packets
4 gm (Questran)
cholestyramine powder 4 gm/
dose (Questran)
choline fenofibrate cap dr 45 mg
(fenofibric acid equiv) (Trilipix)
1
COLESTID - colestipol hcl granule
packets 5 gm
3
COLESTID - colestipol hcl granules
5 gm
3
COLESTID - colestipol hcl tab 1 gm
3
COLESTID FLAVORED - colestipol
hcl granule packets 5 gm
3
COLESTID FLAVORED - colestipol
hcl granules 5 gm
3
colestipol hcl granule packets
5 gm (Colestid flavored)
1
colestipol hcl granules 5 gm
(Colestid flavored)
1
colestipol hcl tab 1 gm (Colestid)
1
CRESTOR - rosuvastatin calcium tab 3
5 mg
10 mg
20 mg
40 mg
FENOFIBRATE - fenofibrate cap 50 3
mg
FENOFIBRATE - fenofibrate cap 150 3
mg
fenofibrate micronized cap 43 mg 1
•
•
•
•
• •
• •
1
fenofibrate micronized cap 67 mg
(Lofibra)
1
•
•
1
fenofibrate micronized cap
130 mg
1
•
1
134 mg (Lofibra)
1
•
1
200 mg (Lofibra)
1
•
1
•
•
•
1
•
fenofibrate tab 40 mg (Fenoglide)
fenofibrate tab 48 mg (Tricor)
fenofibrate tab 54 mg (Lofibra)
1
1
•
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Tier
Drug Name
choline fenofibrate cap dr 135 mg
(fenofibric acid equiv) (Trilipix)
20 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
52
• •
FIBRICOR - fenofibric acid tab 35
mg
3
• •
FIBRICOR - fenofibric acid tab 105
mg
3
• •
LOFIBRA - fenofibrate tab 160 mg
3
3
fluvastatin sodium cap 20 mg
(Lescol)
1
•
LOPID - gemfibrozil tab 600 mg
lovastatin tab 10 mg
1
fluvastatin sodium cap 40 mg
(Lescol)
1
•
fluvastatin sodium tab sr 24 hr
80 mg (Lescol xl)
1
•
1
•
• • •
gemfibrozil tab 600 mg (Lopid)
JUXTAPID - lomitapide mesylate cap 4
5 mg (base equiv)
10 mg (base equiv)
20 mg (base equiv)
30 mg (base equiv)
40 mg (base equiv)
60 mg (base equiv)
4
KYNAMRO - mipomersen sodium
soln prefilled syringe 200 mg/ml
LESCOL XL - fluvastatin sodium tab 3
sr 24 hr 80 mg
3
LIPOFEN - fenofibrate cap 50 mg
LIVALO - pitavastatin calcium tab 4
mg (base equiv)
3
• •
LOFIBRA - fenofibrate micronized
cap 67 mg
3
• •
cap 134 mg
3
• •
cap 200 mg
3
• •
LOFIBRA - fenofibrate tab 54 mg
3
LOVAZA - omega-3-acid ethyl esters
cap 1 gm
3
• •
• •
• •
•
•
•
• •
MEVACOR - lovastatin tab 40 mg
3
• •
•
niacin tab cr 500 mg
(antihyperlipidemic) (Niaspan)
1
• • •
•
• • •
•
• • •
•
• • •
•
• • •
•
• • •
•
• •
LIPOFEN - fenofibrate cap 150 mg
3
mg (base equiv)
3
• •
• •
• •
mg (base equiv)
3
• •
lovastatin tab 20 mg
lovastatin tab 40 mg (Mevacor)
1
1
1
1
NIACOR - niacin (antihyperlipidemic) 3
tab 500 mg
3
NIASPAN - niacin tab cr 500 mg
(antihyperlipidemic)
3
3
1
omega-3-acid ethyl esters cap
1 gm (Lovaza)
4
PRALUENT - alirocumab
subcutaneous soln pen-injector 75
mg/ml
4
subcutaneous soln pen-injector
150 mg/ml
3
Responsible Steps
FENOFIBRIC ACID - fenofibric acid
tab 105 mg
1
Quantity Limits
3
fenofibrate tab 160 mg (Lofibra)
Prior Authorization
FENOFIBRIC ACID - fenofibric acid
tab 35 mg
•
•
•
• •
fenofibrate tab 120 mg (Fenoglide) 1
1
fenofibrate tab 145 mg (Tricor)
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
• •
• • •
• • •
53
TRIGLIDE - fenofibrate tab 160 mg
3
pravastatin sodium tab 10 mg
1
TRILIPIX - choline fenofibrate cap dr
45 mg (fenofibric acid equiv)
3
TRILIPIX - choline fenofibrate cap dr
135 mg (fenofibric acid equiv)
3
• •
VASCEPA - icosapent ethyl cap 1
gm
3
VYTORIN - ezetimibe-simvastatin
tab 10-10 mg
3
• •
tab 10-20 mg
3
• •
tab 10-40 mg
3
• •
tab 10-80 mg
3
• •
WELCHOL - colesevelam hcl packet
for susp 3.75 gm
2
WELCHOL - colesevelam hcl tab
625 mg
2
ZETIA - ezetimibe tab 10 mg
2
ZOCOR - simvastatin tab 5 mg
3
3
3
•
3
3
•
CARDIOVASCULAR AGENTS - MISC.
ADCIRCA - tadalafil tab 20 mg (pah) 4
rosuvastatin calcium tab 40 mg
(Crestor)
1
•
simvastatin tab 5 mg (Zocor)
1
(Pravachol)
1
•
•
(Pravachol)
1
•
(Pravachol)
1
•
QUESTRAN - cholestyramine
powder packets 4 gm
3
QUESTRAN - cholestyramine
powder 4 gm/dose
3
QUESTRAN LIGHT - cholestyramine 3
light powder 4 gm/dose
4
REPATHA - evolocumab
subcutaneous soln prefilled
syringe 140 mg/ml
4
REPATHA PUSHTRONEX
SYSTEM - evolocumab
subcutaneous soln cartridge/
infusor 420 mg/3.5ml
4
REPATHA SURECLICK evolocumab subcutaneous soln
auto-injector 140 mg/ml
1
(Crestor)
1
(Crestor)
1
(Crestor)
• • •
• • •
• • •
•
1
1
1
1
ADEMPAS - riociguat tab 0.5 mg
4
ADEMPAS - riociguat tab 1 mg
4
Responsible Steps
TRICOR - fenofibrate tab 145 mg
PRAVACHOL - pravastatin sodium
tab 40 mg
Prior Authorization
• •
3
tab 80 mg
3
•
•
•
•
3
• • •
Specialty
3
tab 20 mg
• • •
Drug Name
Drug Tier
Quantity Limits
TRICOR - fenofibrate tab 48 mg
syringe 150 mg/ml
4
Quantity Limits
• •
4
Prior Authorization
3
syringe 75 mg/ml
Specialty
Drug Tier
• •
•
•
•
•
•
•
•
•
•
Drug Name
Responsible Steps
2016
• •
•
•
•
•
•
•
• • •
• • •
• • •
•
•
•
•
•
•
•
•
54
4
ADEMPAS - riociguat tab 2 mg
4
4
amlodipine besylate-atorvastatin
calcium tab 2.5-10 mg (Caduet)
1
calcium tab 5-10 mg (Caduet)
1
1
1
1
1
1
1
1
CADUET - amlodipine besylateatorvastatin calcium tab 10-10 mg
3
3
3
3
CORLANOR - ivabradine hcl tab 5
mg (base equiv)
3
CORLANOR - ivabradine hcl tab 7.5
mg (base equiv)
3
ENTRESTO - sacubitril-valsartan tab 3
24-26 mg
49-51 mg
97-103 mg
3
ISOXSUPRINE HCL - isoxsuprine
hcl tab 20 mg
1
isoxsuprine hcl tab 10 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
•
•
•
Drug Name
Drug Tier
• • •
• • •
• • •
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
• •
• •
• •
LETAIRIS - ambrisentan tab 5 mg
4
LETAIRIS - ambrisentan tab 10 mg
4
1
OPSUMIT - macitentan tab 10 mg
4
3
ORENITRAM - treprostinil diolamine
tab cr 0.125 mg (base equiv)
4
BIDIL - isosorbide dinitratehydralazine hcl tab 20-37.5 mg
•
•
•
•
4
CADUET - amlodipine besylateatorvastatin calcium tab 2.5-10 mg
3
• •
•
tab cr 1 mg (base equiv)
4
3
• •
•
4
3
• •
•
3
• •
•
3
• •
•
3
• •
•
3
REMODULIN - treprostinil sodium inj 4
2.5 mg/ml (base equiv)
• •
•
1
• •
• •
• •
•
•
•
•
•
55
TRACLEER - bosentan tab 62.5 mg
4
TRACLEER - bosentan tab 125 mg
4
TYVASO - treprostinil inhalation
solution 0.6 mg/ml
4
• • •
• • •
• • •
•
•
•
TYVASO REFILL - treprostinil
inhalation solution 0.6 mg/ml
4
• • •
•
TYVASO STARTER - treprostinil
inhalation solution 0.6 mg/ml
4
• • •
•
UPTRAVI - selexipag tab therapy
pack 200 mcg (140) & 800 mcg
(60)
4
• • •
•
UPTRAVI - selexipag tab 200 mcg
4
4
4
4
4
4
4
4
VENTAVIS - iloprost inhalation
solution 10 mcg/ml
4
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
VENTAVIS - iloprost inhalation
solution 20 mcg/ml
4
• • •
•
CIALIS - tadalafil tab 2.5 mg
3
CIALIS - tadalafil tab 5 mg
3
• •
• •
RESPIRATORY AGENTS
ANTIHISTAMINES
carbinoxamine maleate soln
4 mg/5ml
carbinoxamine maleate tab 4 mg
cetirizine hcl oral soln 1 mg/ml
(5 mg/5ml)
clemastine fumarate tab 2.68 mg
cyproheptadine hcl syrup
2 mg/5ml
1
1
1
1
1
•
•
•
•
•
•
•
•
•
1
DESLORATADINE ODT desloratadine tab orally
disintegrating 2.5 mg
3
DESLORATADINE ODT desloratadine tab orally
disintegrating 5 mg
3
desloratadine tab 5 mg (Clarinex)
1
diphenhydramine hcl cap 50 mg
diphenhydramine hcl elixir
12.5 mg/5ml
1
1
levocetirizine dihydrochloride
soln 2.5 mg/5ml (0.5 mg/ml)
(Xyzal)
1
levocetirizine dihydrochloride tab
5 mg (Xyzal)
1
loratadine rapidly-disintegrating
tab 10 mg (Claritin)
loratadine syrup 5 mg/5ml
loratadine tab 10 mg
promethazine hcl suppos 12.5 mg
promethazine hcl suppos 25 mg
promethazine hcl suppos 50 mg
promethazine hcl syrup
6.25 mg/5ml
promethazine hcl tab 12.5 mg
promethazine hcl tab 25 mg
promethazine hcl tab 50 mg
1
1
1
1
1
1
1
1
1
1
NASAL AGENTS - SYSTEMIC and TOPICAL
3
ASTEPRO - azelastine hcl nasal
spray 0.15% (205.5 mcg/spray)
1
azelastine hcl nasal spray 0.1%
(137 mcg/spray)
1
azelastine hcl nasal spray 0.15%
(205.5 mcg/spray) (Astepro)
3
BACTROBAN NASAL - mupirocin
calcium nasal oint 2%
1
flunisolide nasal soln 25 mcg/act
(0.025%) (Flunisolide)
• • •
Responsible Steps
sildenafil citrate tab 20 mg
(Revatio)
4
cyproheptadine hcl tab 4 mg
Quantity Limits
• • •
Prior Authorization
4
Specialty
REVATIO - sildenafil citrate for
suspension 10 mg/ml
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
•
•
•
•
56
1
•
PATANASE - olopatadine hcl nasal
soln 0.6%
3
•
triamcinolone acetonide nasal
aerosol suspension 55 mcg/act
1
•
TYZINE - tetrahydrozoline hcl nasal
soln 0.1%
3
TYZINE PEDIATRIC NASAL DR tetrahydrozoline hcl nasal soln
0.05%
3
COUGH/COLD/ALLERGY
acetylcysteine inhal soln 10%
acetylcysteine inhal soln 20%
BENZONATATE - benzonatate cap
150 mg
1
1
3
benzonatate cap 100 mg (Tessalon 1
perles)
1
benzonatate cap 200 mg
loratadine & pseudoephedrine tab
sr 24hr 10-240 mg
1
NEBUSAL - sodium chloride soln
nebu 6%
3
phenylephrine-promethazine w/
codeine syrup 5-6.25-10 mg/5ml
1
promethazine & phenylephrine
syrup 6.25-5 mg/5ml
promethazine w/ codeine syrup
6.25-10 mg/5ml
promethazine-dm syrup
6.25-15 mg/5ml
pseudoeph-chlorphen
w/ hydrocodone soln
60-4-5 mg/5ml (Zutripro)
pseudoephed-bromphen-dm
syrup 30-2-10 mg/5ml
1
1
1
1
1
REZIRA - pseudoephedrine w/
hydrocodone soln 60-5 mg/5ml
3
sodium chloride soln nebu 0.9%
1
sodium chloride soln nebu 3%
1
CODAR AR - chlorpheniramine w/
codeine liquid 2-8 mg/5ml
3
(Hyper-sal)
1
hydrocod polst-chlorphen polst
er susp 10-8 mg/5ml (Tussionex
pennkineti)
1
1
hydrocodone w/ homatropine
syrup 5-1.5 mg/5ml
1
TESSALON PERLES - benzonatate
cap 100 mg
3
3
1
TUSSIONEX PENNKINETIC EXT hydrocod polst-chlorphen polst er
susp 10-8 mg/5ml
3
HYPER-SAL - sodium chloride soln
nebu 7%
3
VITUZ - hydrocodonechlorpheniramine soln 5-4 mg/5ml
3
HYPERSAL - sodium chloride soln
nebu 3.5%
3
ZUTRIPRO - pseudoeph-chlorphen
w/ hydrocodone soln 60-4-5
mg/5ml
HYPERSAL - sodium chloride soln
nebu 7%
3
hydrocodone w/ homatropine tab
5-1.5 mg
olopatadine hcl nasal soln 0.6%
(Patanase)
1
Responsible Steps
•
loratadine & pseudoephedrine tab
sr 12hr 5-120 mg
Quantity Limits
1
ipratropium bromide nasal soln
0.06% (42 mcg/spray) (Atrovent)
3
Prior Authorization
•
LEXUSS 210 - chlorpheniramine w/
codeine liquid 2-10 mg/5ml
Specialty
1
ipratropium bromide nasal soln
0.03% (21 mcg/spray) (Atrovent)
Drug Name
Drug Tier
•
1
fluticasone propionate nasal susp
50 mcg/act
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
ANTIASTHMATIC and BRONCHODILATOR AGENTS
3
•
ACCOLATE - zafirlukast tab 10 mg
ACCOLATE - zafirlukast tab 20 mg
3
•
57
2
•
ADVAIR HFA - fluticasone-salmeterol 2
inhal aerosol 45-21 mcg/act
3
AEROSPAN - flunisolide hfa inhal
aerosol 80 mcg/act
1
albuterol sulfate soln nebu
0.083% (2.5 mg/3ml)
1
albuterol sulfate soln nebu 0.5%
(5 mg/ml)
1
0.63 mg/3ml (base equiv)
1
1
albuterol sulfate syrup 2 mg/5ml
•
albuterol sulfate tab sr 12hr 4 mg
(Vospire er)
1
albuterol sulfate tab sr 12hr 8 mg
(Vospire er)
1
albuterol sulfate tab 2 mg
1
albuterol sulfate tab 4 mg
1
ALVESCO - ciclesonide inhal aerosol 3
80 mcg/act
ALVESCO - ciclesonide inhal aerosol 3
160 mcg/act
2
ANORO ELLIPTA - umeclidiniumvilanterol aero powd ba 62.5-25
mcg/inh
•
•
•
•
•
•
3
•
ARNUITY ELLIPTA - fluticasone
furoate aerosol powder breath
activ 100 mcg/act
2
•
ARNUITY ELLIPTA - fluticasone
furoate aerosol powder breath
activ 200 mcg/act
2
•
ASMANEX HFA - mometasone
furoate inhal aerosol suspension
100 mcg/act
2
•
ASMANEX HFA - mometasone
furoate inhal aerosol suspension
200 mcg/act
2
•
ASMANEX TWISTHALER 120 ME mometasone furoate inhal powd
220 mcg/inh (breath activated)
2
•
ASMANEX TWISTHALER 14 MET mometasone furoate inhal powd
2
•
2
•
2
•
2
•
ASMANEX TWISTHALER 7 METE mometasone furoate inhal powd
2
•
ATROVENT HFA - ipratropium
bromide hfa inhal aerosol 17 mcg/
act
2
•
BREO ELLIPTA - fluticasone furoate- 2
vilanterol aero powd ba 100-25
mcg/inh
BREO ELLIPTA - fluticasone furoate- 2
vilanterol aero powd ba 200-25
mcg/inh
•
ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 500-50
mcg/dose
ARCAPTA NEOHALER - indacaterol
maleate inhal powder cap 75 mcg
(base equiv)
Responsible Steps
•
Quantity Limits
2
Prior Authorization
mcg/dose
Specialty
•
Drug Name
Drug Tier
2
mcg/dose
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
•
58
budesonide inhalation susp
0.25 mg/2ml (Pulmicort)
0.5 mg/2ml (Pulmicort)
1 mg/2ml (Pulmicort)
1
1
1
•
COMBIVENT RESPIMAT ipratropium-albuterol inhal aerosol
soln 20-100 mcg/act
3
CROMOLYN SODIUM - cromolyn
sodium soln nebu 20 mg/2ml
3
DALIRESP - roflumilast tab 500 mcg
3
DULERA - mometasone furoateformoterol fumarate aerosol 100-5
mcg/act
2
•
DULERA - mometasone furoateformoterol fumarate aerosol 200-5
mcg/act
2
•
dyphylline-guaifenesin liqd
100-100 mg/5ml
1
2
•
INCRUSE ELLIPTA - umeclidinium
br aero powd breath act 62.5 mcg/
inh (base eq)
2
•
ipratropium bromide inhal soln
0.02%
1
ipratropium-albuterol nebu soln
0.5-2.5(3) mg/3ml
1
levalbuterol hcl soln nebu conc
1.25 mg/0.5ml (base equiv)
(Xopenex concentrate)
1
levalbuterol hcl soln nebu
(Xopenex)
1
(Xopenex)
1
(Xopenex)
1
3
1
METAPROTERENOL SULFATE metaproterenol sulfate syrup 10
mg/5ml
2
3
FLOVENT DISKUS - fluticasone
propionate aer pow ba 50 mcg/
blister
METAPROTERENOL SULFATE metaproterenol sulfate tab 10 mg
3
blister
2
•
METAPROTERENOL SULFATE metaproterenol sulfate tab 20 mg
montelukast sodium chew tab
4 mg (base equiv) (Singulair)
1
•
blister
2
•
montelukast sodium chew tab
5 mg (base equiv) (Singulair)
1
•
1
•
FLOVENT HFA - fluticasone
propionate hfa inhal aero 44 mcg/
act (50/valve)
2
•
montelukast sodium
oral granules packet 4 mg (base
equiv) (Singulair)
1
•
propionate hfa inhal aer 110 mcg/
act (125/valve)
2
ELIXOPHYLLIN - theophylline elixir
80 mg/15ml
3
epinephrine hcl inj 1 mg/ml
1
epinephrine hcl soln prefilled
syringe 0.1 mg/ml
•
•
montelukast sodium tab 10 mg
(base equiv) (Singulair)
PERFOROMIST - formoterol
fumarate soln nebu 20 mcg/2ml
propionate hfa inhal aer 220 mcg/
act (250/valve)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
3
59
PROAIR HFA - albuterol sulfate inhal 2
aero 108 mcg/act (90mcg base
equiv)
2
PROAIR RESPICLICK - albuterol
sulfate aer pow ba 108 mcg/act
(90 mcg base equiv)
PROVENTIL HFA - albuterol sulfate 3
inhal aero 108 mcg/act (90mcg
base equiv)
PULMICORT - budesonide inhalation 3
susp 0.25 mg/2ml
susp 0.5 mg/2ml
susp 1 mg/2ml
3
PULMICORT FLEXHALER budesonide inhal aero powd 90
mcg/act (breath activated)
3
PULMICORT FLEXHALER budesonide inhal aero powd 180
mcg/act (breath activated)
QVAR - beclomethasone diprop inhal 2
aero soln 40 mcg/act (50/valve)
QVAR - beclomethasone diprop inhal 2
aero soln 80 mcg/act (100/valve)
3
SEREVENT DISKUS - salmeterol
xinafoate aer pow ba 50 mcg/dose
(base equiv)
3
SINGULAIR - montelukast sodium
oral granules packet 4 mg (base
equiv)
SPIRIVA HANDIHALER - tiotropium 2
bromide monohydrate inhal cap
18 mcg (base equiv)
2
SPIRIVA RESPIMAT - tiotropium
bromide monohydrate inhal
aerosol 1.25 mcg/act
2
SPIRIVA RESPIMAT - tiotropium
bromide monohydrate inhal
aerosol 2.5 mcg/act
STRIVERDI RESPIMAT - olodaterol 2
hcl inhal aerosol soln 2.5 mcg/act
(base equiv)
•
•
•
•
•
SYMBICORT - budesonideformoterol fumarate dihyd aerosol
160-4.5 mcg/act
2
•
terbutaline sulfate tab 2.5 mg
1
1
THEO-24 - theophylline cap sr 24hr
100 mg
3
200 mg
3
300 mg
3
400 mg
3
theophylline soln 80 mg/15ml
1
theophylline tab sr 12hr 100 mg
1
1
1
1
1
•
•
TUDORZA PRESSAIR - aclidinium
bromide aerosol powd breath
activated 400 mcg/act
3
•
•
VENTOLIN HFA - albuterol sulfate
inhal aero 108 mcg/act (90mcg
base equiv)
2
•
•
VOSPIRE ER - albuterol sulfate tab
sr 12hr 4 mg
3
VOSPIRE ER - albuterol sulfate tab
sr 12hr 8 mg
3
XOPENEX - levalbuterol hcl soln
nebu 0.31 mg/3ml (base equiv)
3
3
3
•
•
•
2
Responsible Steps
Quantity Limits
Prior Authorization
SYMBICORT - budesonideformoterol fumarate dihyd aerosol
80-4.5 mcg/act
terbutaline sulfate tab 5 mg
•
Specialty
Drug Name
Drug Tier
•
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
60
XOPENEX CONCENTRATE levalbuterol hcl soln nebu conc
1.25 mg/0.5ml (base equiv)
•
•
•
1
KALYDECO - ivacaftor tab 150 mg
4
OFEV - nintedanib esylate cap 100
4
OFEV - nintedanib esylate cap 150
4
• • •
•
ORKAMBI - lumacaftor-ivacaftor tab
200-125 mg
4
• • •
•
PULMOZYME - dornase alfa inhal
soln 1 mg/ml
4
•
4
KALYDECO - ivacaftor packet 50 mg 4
KALYDECO - ivacaftor packet 75 mg 4
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
3
NULYTELY/FLAVOR PACKS - peg
3350-kcl-sod bicarb-nacl for soln
420 gm
3
OSMOPREP - sod phos monosod phos di tabs 1.102-0.398
gm(1.5gm na phos)
3
peg 3350-kcl-sod bicarb-nacl
for soln 420 gm (Nulytely/flavor
pack)
P
peg 3350-kcl-na bicarb-naclna sulfate for soln 236 gm
(Golytely)
P
peg 3350-kcl-na bicarb-nacl-na
sulfate for soln 240 gm (Colyteflavor packs)
P
polyethylene glycol 3350 oral
packet
1
3
1
SUPREP BOWEL PREP - sodium
sulfate-potassium sulfatemagnesium sulfate oral soln
3
COLYTE-FLAVOR PACKS - peg
3350-kcl-na bicarb-nacl-na sulfate
for soln 240 gm
3
ANTIDIARRHEALS
GOLYTELY - peg 3350-kcl-na
bicarb-nacl-na sulfate packet
227.1 gm
3
GOLYTELY - peg 3350-kcl-na
bicarb-nacl-na sulfate for soln 236
gm
3
KRISTALOSE - lactulose oral crystal
packet 10 gm
3
KRISTALOSE - lactulose oral crystal
packet 20 gm
3
LAXATIVES
bisacodyl tab & peg 3350-kcl-sod
bicarb-nacl for soln kit
diphenoxylate w/ atropine tab
2.5-0.025 mg (Lomotil)
3
FULYZAQ - crofelemer tab delayed
release 125 mg
3
LOMOTIL - diphenoxylate w/
atropine tab 2.5-0.025 mg
3
loperamide hcl cap 2 mg
1
Responsible Steps
1
DIPHENOXYLATE/ATROPINE diphenoxylate w/ atropine liq
2.5-0.025 mg/5ml
MOTOFEN - difenoxin w/ atropine
tab 1-0.025 mg
Quantity Limits
1
PREPOPIK - sod picosulfate-mg
oxide-citric acid pack 10 mg-3.5
gm-12 gm
GASTROINTESTINAL AGENTS
Prior Authorization
1
MOVIPREP - peg 3350-kcl-nacl-na
sulfate-na ascorbate-c for soln
100 gm
polyethylene glycol 3350 oral
powder
Specialty
Drug Tier
•
•
•
•
•
•
ESBRIET - pirfenidone cap 267 mg
Drug Name
lactulose solution 10 gm/15ml
ZYFLO CR - zileuton tab sr 12hr 600 3
mg
RESPIRATORY AGENTS - MISC.
Responsible Steps
3
XOPENEX HFA - levalbuterol tartrate 3
inhal aerosol 45 mcg/act (base
equiv)
1
zafirlukast tab 10 mg (Accolate)
zafirlukast tab 20 mg (Accolate)
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
3
61
PAREGORIC - paregoric tincture 2
mg/5ml
3
famotidine for susp 40 mg/5ml
(Pepcid)
1
RESTORA RX - lactobacillus caseifolic acid cap 60-1.25 mg
3
famotidine tab 20 mg (Pepcid)
1
ULCER DRUGS
famotidine tab 40 mg (Pepcid)
amoxicillin cap-clarithro tablansopraz cap dr therapy pack
(Prevpac)
1
ANASPAZ - hyoscyamine sulfate tab
disp 0.125 mg
3
BENTYL - dicyclomine hcl cap 10
mg
3
BENTYL - dicyclomine hcl tab 20 mg 3
2
CARAFATE - sucralfate susp 1
gm/10ml
3
CARAFATE - sucralfate tab 1 gm
chlordiazepoxide hcl-clidinium
bromide cap 5-2.5 mg (Librax)
cimetidine hcl soln 300 mg/5ml
cimetidine tab 200 mg
1
1
1
CYTOTEC - misoprostol tab 100
mcg
3
CYTOTEC - misoprostol tab 200
mcg
3
dicyclomine hcl cap 10 mg
(Bentyl)
1
dicyclomine hcl oral soln
10 mg/5ml
1
dicyclomine hcl tab 20 mg (Bentyl) 1
1
esomeprazole magnesium cap
delayed release 20 mg (base eq)
(Nexium)
1
esomeprazole magnesium cap
delayed release 40 mg (base eq)
(Nexium)
1
glycopyrrolate tab 2 mg (Robinul
forte)
1
hyoscyamine sulfate elixir
0.125 mg/5ml
1
hyoscyamine sulfate tab sr 12hr
0.375 mg (Levbid)
1
3
glycopyrrolate tab 1 mg (Robinul)
hyoscyamine sulfate tab sl
0.125 mg (Levsin/sl)
1
CUVPOSA - glycopyrrolate oral soln
1 mg/5ml
3
hyoscyamine sulfate tab disp
0.125 mg (Anaspaz)
1
•
Responsible Steps
Quantity Limits
Prior Authorization
1
1
1
1
hyoscyamine sulfate tab 0.125 mg
(Levsin)
1
lansoprazole cap delayed release
15 mg (Prevacid)
1
•
1
•
lansoprazole cap delayed release
30 mg (Prevacid)
•
1
GASTRINEX NF - hyoscyaminephenyltoloxamine cap 0.0625-15
mg
hyoscyamine sulfate soln
0.125 mg/ml
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
LEVBID - hyoscyamine sulfate tab sr 3
12hr 0.375 mg
3
LEVSIN - hyoscyamine sulfate tab
0.125 mg
3
LEVSIN/SL - hyoscyamine sulfate
tab sl 0.125 mg
1
methscopolamine bromide tab
2.5 mg (Pamine)
1
methscopolamine bromide tab
5 mg (Pamine forte)
misoprostol tab 100 mcg (Cytotec) 1
misoprostol tab 200 mcg (Cytotec) 1
2
NEXIUM - esomeprazole
magnesium for delayed release
susp packet 5 mg
•
62
susp packet 10 mg
2
susp packet 20 mg
2
susp packet 40 mg
2
susp pack 2.5 mg
2
nizatidine cap 150 mg
1
nizatidine cap 300 mg (Axid)
•
•
•
1
OMECLAMOX-PAK - amoxicillin cap- 3
clarithro tab w/ omepraz cap dr
therapy pack
1
omeprazole cap delayed release
10 mg (Prilosec)
1
20 mg (Prilosec)
1
40 mg (Prilosec)
PAMINE - methscopolamine bromide 3
tab 2.5 mg
PAMINE FORTE - methscopolamine 3
bromide tab 5 mg
1
pantoprazole sodium ec tab
20 mg (base equiv) (Protonix)
1
pantoprazole sodium ec tab
40 mg (base equiv) (Protonix)
PREVPAC - amoxicillin cap-clarithro 3
tab-lansopraz cap dr therapy pack
1
PRILOSEC OTC - omeprazole
magnesium delayed release tab
20 mg (base equiv)
2
PROPANTHELINE BROMIDE propantheline bromide tab 15 mg
3
PYLERA - bismuth subcitmetronidazole-tetracycline cap
140-125-125 mg
rabeprazole sodium ec tab 20 mg
(Aciphex)
1
ranitidine hcl cap 150 mg
1
ranitidine hcl cap 300 mg
ranitidine hcl syrup 15 mg/ml
(75 mg/5ml)
ranitidine hcl tab 150 mg (Zantac)
ranitidine hcl tab 300 mg (Zantac)
•
•
•
1
3
sucralfate tab 1 gm (Carafate)
1
2
3
•
ANZEMET - dolasetron mesylate tab 3
50 mg
ANZEMET - dolasetron mesylate tab 3
100 mg
3
CESAMET - nabilone cap 1 mg
•
DICLEGIS - doxylamine-pyridoxine
tab delayed release 10-10 mg
3
•
dronabinol cap 2.5 mg (Marinol)
1
•
dronabinol cap 10 mg (Marinol)
1
EMEND - aprepitant capsule 80 mg
2
dronabinol cap 5 mg (Marinol)
•
•
• •
1
EMEND - aprepitant capsule therapy 2
pack 80 & 125 mg
2
EMEND - aprepitant capsule 40 mg
EMEND - aprepitant capsule 125 mg 2
2
EMEND - aprepitant for oral susp
125 mg (125 mg/5ml)
1
granisetron hcl tab 1 mg
MARINOL - dronabinol cap 2.5 mg
3
MARINOL - dronabinol cap 5 mg
3
MARINOL - dronabinol cap 10 mg
3
1
ROBINUL FORTE - glycopyrrolate
tab 2 mg
AKYNZEO - netupitant-palonosetron
cap 300-0.5 mg
Responsible Steps
Quantity Limits
1
3
ANTIEMETICS
Prior Authorization
1
ROBINUL - glycopyrrolate tab 1 mg
SYMAX DUOTAB - hyoscyamine
sulfate tab cr 0.375 mg (0.125 mg
ir/0.25 mg cr)
Specialty
Drug Name
Drug Tier
•
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
•
•
•
•
•
63
meclizine hcl tab 12.5 mg
meclizine hcl tab 25 mg
ondansetron hcl tab 24 mg
1
•
•
•
•
ondansetron hcl tab 4 mg (Zofran) 1
ondansetron hcl tab 8 mg (Zofran) 1
1
1
•
SANCUSO - granisetron td patch 3.1 3
mg/24hr (contains 34.3 mg)
TIGAN - trimethobenzamide hcl cap 3
300 mg
TRANSDERM-SCOP - scopolamine 3
td patch 72hr 1 mg/3days
1
trimethobenzamide hcl cap
300 mg (Tigan)
4
VARUBI - rolapitant hcl tab 90 mg
(base equiv)
ZOFRAN - ondansetron hcl oral soln 3
4 mg/5ml
ZOFRAN - ondansetron hcl tab 4 mg 3
•
ZOFRAN - ondansetron hcl tab 8 mg 3
3
ZOFRAN ODT - ondansetron orally
disintegrating tab 4 mg
3
ZOFRAN ODT - ondansetron orally
DIGESTIVE AIDS
CREON - pancrelipase (lip-protamyl) dr cap 3000-9500-15000
unit
2
unit
2
unit
2
•
•
•
•
•
•
•
unit
2
CREON - pancrelipase
(lip-prot-amyl) dr cap
36000-114000-180000 unit
2
PANCREAZE - pancrelipase
4200-10000-17500 unit
3
10500-25000-43750 unit
3
16800-40000-70000 unit
3
21000-37000-61000 unit
3
PERTZYE - pancrelipase (lip-protamyl) dr cap 8000-28750-30250
unit
3
PERTZYE - pancrelipase (lip-protamyl) dr cap 16000-57500-60500
unit
3
SUCRAID - sacrosidase soln 8500
unit/ml
4
VIOKACE - pancrelipase (lip-protamyl) tab 10440-39150-39150 unit
3
VIOKACE - pancrelipase (lip-protamyl) tab 20880-78300-78300 unit
3
ZENPEP - pancrelipase (lip-protamyl) dr cap 3000-10000-16000
unit
2
unit
2
unit
2
unit
2
•
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
1
1
ondansetron orally disintegrating
tab 8 mg (Zofran odt)
Responsible Steps
Quantity Limits
1
ondansetron hcl oral soln
4 mg/5ml (Zofran)
ondansetron orally disintegrating
tab 4 mg (Zofran odt)
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
•
64
4
• • •
CIMZIA STARTER KIT certolizumab pegol inj kit 6 x 200
mg/ml
4
unit
2
• • •
2
3
ZENPEP - pancrelipase
40000-136000-218000 unit
COLAZAL - balsalazide disodium
cap 750 mg
cromolyn sodium oral conc
100 mg/5ml (Gastrocrom)
1
2
GASTROINTESTINAL AGENTS- MISC.
3
ACTIGALL - ursodiol cap 300 mg
alosetron hcl tab 0.5 mg (base
equiv) (Lotronex)
alosetron hcl tab 1 mg (base
equiv) (Lotronex)
DELZICOL - mesalamine cap dr 400
mg
2
1
DIPENTUM - olsalazine sodium cap
250 mg
3
1
ELIPHOS - calcium acetate
(phosphate binder) tab 667 mg
3
ENTEREG - alvimopan cap 12 mg
3
3
•
•
AMITIZA - lubiprostone cap 8 mcg
3
AMITIZA - lubiprostone cap 24 mcg
3
APRISO - mesalamine cap sr 24hr
0.375 gm
3
FOSRENOL - lanthanum carbonate
chew tab 500 mg (elemental)
3
ASACOL HD - mesalamine tab
2
3
AZULFIDINE - sulfasalazine tab 500
mg
3
3
AZULFIDINE EN-TABS sulfasalazine tab delayed release
500 mg
3
oral powder pack 750 mg
(elemental)
3
balsalazide disodium cap 750 mg
(Colazal)
1
oral powder pack 1000 mg
(elemental)
calcium acetate (phosphate
binder) cap 667 mg (169 mg ca)
(Phoslo)
1
GASTROCROM - cromolyn sodium
oral conc 100 mg/5ml
3
4
calcium acetate (phosphate
binder) tab 667 mg (Eliphos)
1
GATTEX - teduglutide (rdna) for inj
kit 5 mg
GIAZO - balsalazide disodium tab
1.1 gm
3
lactulose (encephalopathy)
solution 10 gm/15ml
1
CANASA - mesalamine suppos 1000 2
mg
CHENODAL - chenodiol tab 250 mg 2
CHOLBAM - cholic acid cap 50 mg
4
CHOLBAM - cholic acid cap 250 mg
4
CIMZIA - certolizumab pegol for inj
kit 2 x 200 mg
4
• •
• •
• • •
•
•
•
LIALDA - mesalamine tab delayed
release 1.2 gm
2
LINZESS - linaclotide cap 145 mcg
3
LINZESS - linaclotide cap 290 mcg
3
• • •
CIMZIA - certolizumab pegol inj kit 2
x 200 mg/ml
unit
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
•
•
•
65
LOTRONEX - alosetron hcl tab 0.5
mg (base equiv)
3
RENVELA - sevelamer carbonate
packet 0.8 gm
2
LOTRONEX - alosetron hcl tab 1 mg
(base equiv)
3
packet 2.4 gm
2
MESALAMINE DR - mesalamine tab
3
tab 800 mg
2
mesalamine enema 4 gm
1
3
1
SFROWASA - mesalamine sulfitefree (sf) enema 4 gm/60ml
1
metoclopramide hcl tab 5 mg
(Reglan)
1
sulfasalazine tab delayed release
500 mg (Azulfidine en-tabs)
1
metoclopramide hcl tab 10 mg
(Reglan)
1
sulfasalazine tab 500 mg
(Azulfidine)
3
MOVANTIK - naloxegol oxalate tab
12.5 mg (base equivalent)
3
•
URSO FORTE - ursodiol tab 500 mg
URSO 250 - ursodiol tab 250 mg
3
3
•
ursodiol cap 300 mg (Actigall)
1
MOVANTIK - naloxegol oxalate tab
PENTASA - mesalamine cap cr 250
mg
2
PENTASA - mesalamine cap cr 500
mg
2
PHOSLO - calcium acetate
(phosphate binder) cap 667 mg
(169 mg ca)
3
PHOSLYRA - calcium acetate
(phosphate binder) oral soln 667
mg/5ml
3
REGLAN - metoclopramide hcl tab 5
mg
metoclopramide hcl soln
5 mg/5ml (10 mg/10ml)
ursodiol tab 250 mg (Urso 250)
ursodiol tab 500 mg (Urso forte)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
VELPHORO - sucroferric
oxyhydroxide chew tab 500 mg
3
VIBERZI - eluxadoline tab 75 mg
3
VIBERZI - eluxadoline tab 100 mg
3
• •
• •
GENITOURINARY AGENTS
URINARY ANTI-INFECTIVES
FURADANTIN - nitrofurantoin susp
25 mg/5ml
3
3
HIPREX - methenamine hippurate
tab 1 gm
3
REGLAN - metoclopramide hcl tab
10 mg
3
3
RELISTOR - methylnaltrexone
bromide inj 8 mg/0.4ml (20 mg/ml)
3
•
MACROBID - nitrofurantoin
monohydrate macrocrystalline cap
100 mg
3
RELISTOR - methylnaltrexone
bromide inj 12 mg/0.6ml (20 mg/
ml)
3
•
MACRODANTIN - nitrofurantoin
macrocrystalline cap 25 mg
3
RENAGEL - sevelamer hcl tab 400
mg
3
3
RENAGEL - sevelamer hcl tab 800
mg
3
methenamine hippurate tab 1 gm
(Hiprex)
1
66
2
•
1
MYRBETRIQ - mirabegron tab sr 24
hr 50 mg
2
•
1
oxybutynin chloride syrup
5 mg/5ml
1
•
1
oxybutynin chloride tab sr 24hr
5 mg (Ditropan xl)
1
•
10 mg (Ditropan xl)
1
nitrofurantoin monohydrate
(Macrobid)
1
•
1
•
nitrofurantoin susp 25 mg/5ml
(Furadantin)
1
1
UROGESIC-BLUE - methenaminehyoscamine-meth blue-sod phos
tab 81.6 mg
3
1
•
•
1
•
3
nitrofurantoin macrocrystalline
cap 25 mg (Macrodantin)
URINARY ANTISPASMODICS
15 mg (Ditropan xl)
oxybutynin chloride tab 5 mg
tolterodine tartrate cap sr 24hr
2 mg (Detrol la)
tolterodine tartrate cap sr 24hr
4 mg (Detrol la)
bethanechol chloride tab 5 mg
(Urecholine)
1
tolterodine tartrate tab 1 mg
(Detrol)
1
•
(Urecholine)
1
tolterodine tartrate tab 2 mg
(Detrol)
1
•
(Urecholine)
1
TOVIAZ - fesoterodine fumarate tab
sr 24hr 4 mg
3
•
(Urecholine)
1
TOVIAZ - fesoterodine fumarate tab
sr 24hr 8 mg
3
•
darifenacin hydrobromide tab
sr 24hr 7.5 mg (base equiv)
(Enablex)
1
trospium chloride cap sr 24hr
60 mg
1
•
1
•
darifenacin hydrobromide tab
sr 24hr 15 mg (base equiv)
(Enablex)
1
ENABLEX - darifenacin
hydrobromide tab sr 24hr 7.5 mg
(base equiv)
3
ENABLEX - darifenacin
hydrobromide tab sr 24hr 15 mg
(base equiv)
3
flavoxate hcl tab 100 mg
1
GELNIQUE - oxybutynin chloride td
gel 10%
•
trospium chloride tab 20 mg
3
•
•
•
•
URECHOLINE - bethanechol
chloride tab 5 mg
3
chloride tab 10 mg
3
chloride tab 25 mg
3
chloride tab 50 mg
3
VESICARE - solifenacin succinate
tab 5 mg
2
•
VESICARE - solifenacin succinate
tab 10 mg
2
•
MYRBETRIQ - mirabegron tab sr 24
hr 25 mg
MONUROL - fosfomycin
tromethamine powd pack 3 gm
(base equivalent)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
VAGINAL PRODUCTS
67
AVC - sulfanilamide vaginal cream
15%
2
CLEOCIN - clindamycin phosphate
vaginal cream 2%
3
CLEOCIN - clindamycin phosphate
vaginal suppos 100 mg
clindamycin phosphate vaginal
cream 2% (Cleocin)
CLINDESSE - clindamycin
phosphate (one dose) vaginal
cream 2%
RELAGARD - acetic acidoxyquinoline vaginal gel
0.9-0.025%
3
SHUR-SEAL - nonoxynol-9 gel 2%
P
2
TERAZOL 3 - terconazole vaginal
cream 0.8%
3
1
TERAZOL 7 - terconazole vaginal
cream 0.4%
3
3
terconazole vaginal cream 0.4%
(Terazol 7)
1
terconazole vaginal cream 0.8%
(Terazol 3)
1
terconazole vaginal suppos
80 mg
1
CRINONE - progesterone vaginal gel 3
4%
P
ENCARE - nonoxynol-9 vaginal
suppos 100 mg
ESTRACE - estradiol vaginal cream 3
0.1 mg/gm
3
ESTRING - estradiol vaginal ring 2
mg (7.5 mcg/24hrs)
3
FEM PH - acetic acid-oxyquinoline
vaginal gel 0.9-0.025%
FEMRING - estradiol acetate vaginal 3
ring 0.05 mg/24hr
FEMRING - estradiol acetate vaginal 3
ring 0.1 mg/24hr
GYNAZOLE-1 - butoconazole nitrate 3
(one dose) vaginal cream 2%
3
METROGEL-VAGINAL metronidazole vaginal gel 0.75%
1
metronidazole vaginal gel 0.75%
(Metrogel-vaginal)
MICONAZOLE 3 - miconazole nitrate 3
vaginal suppos 200 mg
P
nonoxynol-9 gel 4%
OPTIONS CONCEPTROL VAGINA - P
nonoxynol-9 gel 4%
P
OPTIONS GYNOL II VAGINAL nonoxynol-9 gel 3%
PREMARIN - estrogens, conjugated 2
vaginal cream 0.625 mg/gm
•
•
•
TODAY SPONGE - nonoxynol-9
vaginal sponge 1000 mg
P
VAGIFEM - estradiol vaginal tab 10
mcg
2
VCF VAGINAL CONTRACEPTIVE nonoxynol-9 film 28%
P
VCF VAGINAL CONTRACEPTIVE nonoxynol-9 foam 12.5%
P
GENITOURINARY AGENTS - MISC.
acetic acid irrigation soln 0.25%
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
alfuzosin hcl tab sr 24hr 10 mg
(Uroxatral)
1
AVODART - dutasteride cap 0.5 mg
3
CARDURA XL - doxazosin mesylate
tab sr 24 hr 4 mg (base equiv)
3
CARDURA XL - doxazosin mesylate
tab sr 24 hr 8 mg (base equiv)
3
CYSTAGON - cysteamine bitartrate
cap 50 mg
2
•
CYSTAGON - cysteamine bitartrate
cap 150 mg
2
•
CYTRA-3 - pot & sod citrates w/ cit
ac syrup 550-500-334 mg/5ml
3
dutasteride cap 0.5 mg (Avodart)
1
dutasteride-tamsulosin hcl cap
0.5-0.4 mg (JALYN)
1
68
ELMIRON - pentosan polysulfate
sodium caps 100 mg
3
finasteride tab 5 mg (Proscar)
1
SHOHLS SOLUTION MODIFIED sodium citrate & citric acid soln
500-334 mg/5ml
3
1
FLOMAX - tamsulosin hcl cap 0.4
mg
3
sodium chloride irrigation soln
0.9%
JALYN - dutasteride-tamsulosin hcl
cap 0.5-0.4 mg
3
sodium citrate & citric acid soln
500-334 mg/5ml (Shohls solution
modi)
1
tamsulosin hcl cap 0.4 mg
(Flomax)
1
THIOLA - tiopronin tab 100 mg
4
K-PHOS NO 2 - potassium & sodium 2
acid phosphates tab 305-700 mg
LITHOSTAT - acetohydroxamic acid 3
tab 250 mg
ORACIT - sodium citrate & citric acid 3
soln 490-640 mg/5ml
1
phenazopyridine hcl tab 100 mg
(Pyridium)
1
phenazopyridine hcl tab 200 mg
(Pyridium)
1
pot & sod citrates w/ cit ac soln
550-500-334 mg/5ml
1
potassium citrate & citric acid
powder pack 3300-1002 mg
1
potassium citrate tab cr 5 meq
(540 mg) (Urocit-k 5)
1
(1080 mg) (Urocit-k 10)
1
(1620 mg) (Urocit-k 15)
4
PROCYSBI - cysteamine bitartrate
cap delayed release 25 mg (base
equiv)
4
PROCYSBI - cysteamine bitartrate
cap delayed release 75 mg (base
equiv)
3
PROSCAR - finasteride tab 5 mg
PYRIDIUM - phenazopyridine hcl tab 3
100 mg
PYRIDIUM - phenazopyridine hcl tab 3
200 mg
3
RAPAFLO - silodosin cap 4 mg
RAPAFLO - silodosin cap 8 mg
3
• • •
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
•
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
•
UROCIT-K 10 - potassium citrate tab 3
cr 10 meq (1080 mg)
cr 15 meq (1620 mg)
cr 5 meq (540 mg)
CENTRAL NERVOUS SYSTEM DRUGS
ANTIANXIETY AGENTS
ALPRAZOLAM INTENSOL alprazolam conc 1 mg/ml
3
alprazolam orally disintegrating
tab 0.25 mg (Niravam)
1
tab 0.5 mg
• •
•
• •
•
tab 1 mg
tab 2 mg
1
1
1
alprazolam tab sr 24hr 0.5 mg
(Xanax xr)
1
alprazolam tab sr 24hr 1 mg
(Xanax xr)
1
(Xanax xr)
1
(Xanax xr)
1
alprazolam tab 0.25 mg (Xanax)
1
alprazolam tab 0.5 mg (Xanax)
alprazolam tab 1 mg (Xanax)
1
1
69
alprazolam tab 2 mg (Xanax)
buspirone hcl tab 5 mg
buspirone hcl tab 7.5 mg
chlordiazepoxide hcl cap 5 mg
clorazepate dipotassium tab
3.75 mg (Tranxene t)
7.5 mg (Tranxene t)
15 mg (Tranxene t)
1
1
1
1
1
1
1
1
1
1
1
1
oxazepam cap 10 mg
oxazepam cap 15 mg
oxazepam cap 30 mg
3
amitriptyline hcl tab 50 mg
1
1
1
1
1
2
AMOXAPINE - amoxapine tab 25 mg 3
AMOXAPINE - amoxapine tab 50 mg 3
diazepam conc 5 mg/ml
1
AMOXAPINE - amoxapine tab 100
mg
3
AMOXAPINE - amoxapine tab 150
mg
3
ANAFRANIL - clomipramine hcl cap
25 mg
3
50 mg
3
75 mg
3
bupropion hcl tab sr 12hr 100 mg
(Wellbutrin sr)
1
•
(Wellbutrin sr)
1
•
(Wellbutrin sr)
1
•
(Wellbutrin xl)
1
•
(Wellbutrin xl)
1
•
bupropion hcl tab 75 mg
(Wellbutrin)
1
•
diazepam tab 5 mg (Valium)
hydroxyzine hcl syrup 10 mg/5ml
hydroxyzine hcl tab 10 mg
1
1
1
1
1
1
1
HYDROXYZINE PAMOATE hydroxyzine pamoate cap 100 mg
3
hydroxyzine pamoate cap 25 mg
(Vistaril)
1
hydroxyzine pamoate cap 50 mg
(Vistaril)
1
lorazepam conc 2 mg/ml
(Lorazepam intensol)
1
lorazepam tab 0.5 mg (Ativan)
1
lorazepam tab 1 mg (Ativan)
lorazepam tab 2 mg (Ativan)
meprobamate tab 200 mg
meprobamate tab 400 mg
1
1
1
1
DIAZEPAM - diazepam oral soln 1
mg/ml
Responsible Steps
1
VISTARIL - hydroxyzine pamoate
cap 50 mg
Quantity Limits
1
3
Prior Authorization
1
VISTARIL - hydroxyzine pamoate
cap 25 mg
ANTIDEPRESSANTS
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
70
•
1
•
doxepin hcl cap 150 mg
1
•
duloxetine hcl enteric coated
pellets cap 20 mg (Cymbalta)
1
•
citalopram hydrobromide tab
10 mg (base equiv) (Celexa)
doxepin hcl conc 10 mg/ml
1
1
1
1
1
1
•
1
•
1
•
clomipramine hcl cap 25 mg
(Anafranil)
1
(Anafranil)
1
EMSAM - selegiline td patch 24hr 6
mg/24hr
3
(Anafranil)
1
mg/24hr
3
desipramine hcl tab 10 mg
(Norpramin)
1
mg/24hr
3
(Norpramin)
1
escitalopram oxalate soln
5 mg/5ml (base equiv) (Lexapro)
1
•
(Norpramin)
1
escitalopram oxalate tab 5 mg
(base equiv) (Lexapro)
1
•
(Norpramin)
1
1
•
(Norpramin)
1
1
•
(Norpramin)
1
FETZIMA - levomilnacipran hcl cap
sr 24hr 20 mg (base equivalent)
3
• •
DESVENLAFAXINE ER desvenlafaxine fumarate tab sr
24hr 50 mg (base equiv)
3
3
• •
3
• •
DESVENLAFAXINE ER desvenlafaxine fumarate tab sr
24hr 100 mg (base equiv)
3
3
• •
DESVENLAFAXINE ER desvenlafaxine tab sr 24hr 50 mg
3
• •
3
• •
DESVENLAFAXINE ER desvenlafaxine tab sr 24hr 100 mg
3
• •
FETZIMA TITRATION PACK levomilnacipran hcl cap sr 24hr 20
& 40 mg therapy pack
3
2
• •
DOXEPIN HCL - doxepin hcl cap 75
mg
FLUOXETINE HCL - fluoxetine hcl
tab 60 mg
1
1
•
fluoxetine hcl cap delayed release
90 mg (Prozac weekly)
• •
• •
citalopram hydrobromide oral
soln 10 mg/5ml
1
Responsible Steps
•
Quantity Limits
1
Prior Authorization
bupropion hcl tab 100 mg
(Wellbutrin)
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
71
fluoxetine hcl cap 10 mg (Prozac)
fluoxetine hcl solution 20 mg/5ml
fluoxetine hcl tab 10 mg
fluoxetine hcl tab 20 mg
fluvoxamine maleate cap sr 24hr
100 mg
fluvoxamine maleate cap sr 24hr
150 mg
fluvoxamine maleate tab 25 mg
FORFIVO XL - bupropion hcl tab sr
24hr 450 mg
1
1
1
3
imipramine hcl tab 10 mg (Tofranil) 1
1
imipramine pamoate cap 75 mg
(Tofranil-pm)
1
(Tofranil-pm)
1
(Tofranil-pm)
1
(Tofranil-pm)
3
KHEDEZLA - desvenlafaxine tab sr
24hr 50 mg
3
KHEDEZLA - desvenlafaxine tab sr
24hr 100 mg
3
LEXAPRO - escitalopram oxalate
MAPROTILINE HCL - maprotiline hcl 3
tab 25 mg
tab 50 mg
tab 75 mg
MARPLAN - isocarboxazid tab 10
mg
3
mirtazapine orally disintegrating
tab 15 mg (Remeron soltab)
1
•
1
•
1
•
1
•
•
•
•
mirtazapine tab 7.5 mg
mirtazapine tab 15 mg (Remeron)
• •
• •
• •
• •
• •
1
1
NARDIL - phenelzine sulfate tab 15
mg
3
NEFAZODONE HCL - nefazodone
hcl tab 100 mg
3
hcl tab 150 mg
3
hcl tab 200 mg
3
nefazodone hcl tab 50 mg
1
nefazodone hcl tab 250 mg
• •
1
Responsible Steps
•
•
•
• •
1
Quantity Limits
1
1
Prior Authorization
•
1
Specialty
1
1
Drug Name
Drug Tier
1
•
•
•
•
•
•
•
1
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
NORPRAMIN - desipramine hcl tab
10 mg
3
NORPRAMIN - desipramine hcl tab
25 mg
3
NORTRIPTYLINE HCL - nortriptyline 3
hcl soln 10 mg/5ml
1
nortriptyline hcl cap 10 mg
(Pamelor)
1
(Pamelor)
1
(Pamelor)
1
(Pamelor)
3
PAMELOR - nortriptyline hcl cap 10
mg
3
mg
72
mg
3
sertraline hcl tab 100 mg (Zoloft)
SURMONTIL - trimipramine maleate
cap 25 mg
3
mg
3
cap 50 mg
3
PARNATE - tranylcypromine sulfate
tab 10 mg
3
1
•
cap 100 mg
3
paroxetine hcl tab sr 24hr 12.5 mg
(Paxil cr)
1
•
tranylcypromine sulfate tab 10 mg
(Parnate)
1
paroxetine hcl tab sr 24hr 25 mg
(Paxil cr)
•
trazodone hcl tab 50 mg
1
paroxetine hcl tab sr 24hr 37.5 mg
(Paxil cr)
1
paroxetine hcl tab 10 mg (Paxil)
1
PAXIL - paroxetine hcl oral susp 10
mg/5ml (base equiv)
3
•
•
•
•
• •
PEXEVA - paroxetine mesylate tab
10 mg (base equiv)
3
• •
20 mg (base equiv)
3
• •
30 mg (base equiv)
3
• •
40 mg (base equiv)
3
• •
phenelzine sulfate tab 15 mg
(Nardil)
1
PRISTIQ - desvenlafaxine succinate
tab sr 24hr 25 mg (base equiv)
2
• •
2
• •
2
• •
protriptyline hcl tab 5 mg
1
protriptyline hcl tab 10 mg
1
1
1
1
sertraline hcl oral conc 20 mg/ml
(Zoloft)
1
•
1
•
•
1
trimipramine maleate cap 25 mg
1
1
1
1
1
1
1
3
• •
TRINTELLIX - vortioxetine hbr tab 10 3
mg (base equiv)
TRINTELLIX - vortioxetine hbr tab 20 3
mg (base equiv)
1
venlafaxine hcl cap sr 24hr
(Effexor xr)
venlafaxine hcl cap sr 24hr 75 mg 1
(base equivalent) (Effexor xr)
1
venlafaxine hcl cap sr 24hr
(Effexor xr)
3
VENLAFAXINE HCL ER venlafaxine hcl tab sr 24hr 37.5
3
VENLAFAXINE HCL ER venlafaxine hcl tab sr 24hr 75 mg
(base equivalent)
3
(base equivalent)
• •
TRINTELLIX - vortioxetine hbr tab 5
mg (base equiv)
•
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
• •
•
•
•
• •
• •
• •
73
venlafaxine hcl tab sr 24hr
(Venlafaxine hcl er)
1
•
chlorpromazine hcl tab 200 mg
CLOZAPINE ODT - clozapine orally
disintegrating tab 12.5 mg
3
venlafaxine hcl tab sr 24hr 75 mg
(base equivalent) (Venlafaxine
hcl er)
1
•
3
3
venlafaxine hcl tab sr 24hr
(Venlafaxine hcl er)
1
1
venlafaxine hcl tab 25 mg
1
clozapine orally disintegrating tab
25 mg (Fazaclo)
venlafaxine hcl tab 37.5 mg
1
1
1
1
VIIBRYD - vilazodone hcl tab 10 mg
3
3
3
VIIBRYD STARTER PACK vilazodone hcl tab starter kit 10 (7)
& 20 (23) mg
3
ZOLOFT - sertraline hcl oral conc 20
mg/ml
3
ANTIPSYCHOTICS
aripiprazole oral solution 1 mg/ml
aripiprazole orally disintegrating
tab 10 mg
aripiprazole orally disintegrating
tab 15 mg
aripiprazole tab 2 mg (Abilify)
1
1
1
1
1
1
1
1
1
1
1
•
•
•
•
•
•
•
•
•
•
clozapine orally disintegrating tab
100 mg (Fazaclo)
clozapine tab 25 mg (Clozaril)
clozapine tab 50 mg
clozapine tab 100 mg (Clozaril)
•
•
•
•
• •
•
•
•
•
•
•
•
•
•
clozapine tab 200 mg
•
•
•
•
•
•
Prior Authorization
•
•
•
•
•
•
1
1
1
1
1
1
1
1
CLOZARIL - clozapine tab 25 mg
3
CLOZARIL - clozapine tab 100 mg
3
EQUETRO - carbamazepine
(antipsychotic) cap sr 12hr 100 mg
3
3
3
FANAPT - iloperidone tab 1 mg
3
3
3
3
3
FANAPT TITRATION PACK iloperidone tab 1 mg & 2 mg & 4
mg & 6 mg titration pak
3
FAZACLO - clozapine orally
disintegrating tab 12.5 mg
3
3
3
Responsible Steps
2
Quantity Limits
(base equivalent)
Specialty
Drug Name
Drug Tier
• •
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
74
3
lithium carbonate cap 150 mg
(Lithium carbonate)
1
3
1
FLUPHENAZINE HCL - fluphenazine 2
hcl elixir 2.5 mg/5ml
FLUPHENAZINE HCL - fluphenazine 2
hcl oral conc 5 mg/ml
1
fluphenazine hcl tab 1 mg
fluphenazine hcl tab 2.5 mg
haloperidol lactate oral conc
2 mg/ml
haloperidol tab 0.5 mg
haloperidol tab 1 mg
(Lithium carbonate)
1
lithium carbonate tab cr 300 mg
(Lithobid)
1
lithium carbonate tab cr 450 mg
1
lithium carbonate tab 300 mg
1
LITHOBID - lithium carbonate tab cr
300 mg
3
1
loxapine succinate cap 5 mg
1
1
1
1
1
1
1
INVEGA - paliperidone tab sr 24hr
1.5 mg
3
• •
INVEGA - paliperidone tab sr 24hr 3
mg
3
• •
mg
3
• •
mg
3
• •
LATUDA - lurasidone hcl tab 20 mg
3
3
3
3
3
•
•
•
•
•
LITHIUM - lithium oral solution 8
meq/5ml
2
LITHIUM CARBONATE - lithium
carbonate cap 150 mg
3
LITHIUM CARBONATE - lithium
carbonate cap 600 mg
3
•
•
•
•
•
1
1
3
MOLINDONE HYDROCHLORIDE molindone hcl tab 10 mg
3
3
NUPLAZID - pimavanserin tartrate
4
• • •
olanzapine orally disintegrating
tab 5 mg (Zyprexa zydis)
1
•
1
•
1
•
1
•
1
•
•
•
•
•
•
•
olanzapine tab 2.5 mg (Zyprexa)
olanzapine tab 5 mg (Zyprexa)
olanzapine tab 7.5 mg (Zyprexa)
paliperidone tab sr 24hr 1.5 mg
(Invega)
1
Responsible Steps
Quantity Limits
Prior Authorization
1
1
1
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
1
1
1
•
75
1
•
perphenazine tab 2 mg
1
1
prochlorperazine suppos 25 mg
1
1
•
1
•
risperidone soln 1 mg/ml
(Risperdal)
1
•
risperidone tab 0.25 mg
(Risperdal)
1
•
risperidone tab 0.5 mg (Risperdal)
1
•
•
•
•
•
• •
risperidone tab 1 mg (Risperdal)
quetiapine fumarate tab 25 mg
(Seroquel)
1
•
(Seroquel)
1
•
(Seroquel)
1
•
(Seroquel)
1
•
(Seroquel)
1
•
(Seroquel)
1
•
REXULTI - brexpiprazole tab 0.25
mg
3
• •
REXULTI - brexpiprazole tab 0.5 mg
3
REXULTI - brexpiprazole tab 1 mg
3
3
3
3
risperidone orally disintegrating
tab 0.25 mg
1
•
•
•
•
•
•
tab 0.5 mg (Risperdal m-tab)
•
tab 4 mg (Risperdal m-tab)
1
prochlorperazine maleate tab
(Compazine)
1
1
1
•
1
prochlorperazine maleate
(Compazine)
1
1
•
•
•
•
•
•
1
1
1
1
SAPHRIS - asenapine maleate sl tab 3
2.5 mg (base equiv)
5 mg (base equiv)
10 mg (base equiv)
2
SEROQUEL XR - quetiapine
fumarate tab sr 24hr 50 mg
2
2
2
2
1
thioridazine hcl tab 10 mg
thiothixene cap 1 mg
paliperidone tab sr 24hr 9 mg
(Invega)
Responsible Steps
•
Quantity Limits
1
Prior Authorization
(Invega)
Specialty
•
Drug Name
Drug Tier
1
(Invega)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
• •
• •
• •
• •
• •
• •
• •
1
1
1
1
1
76
trifluoperazine hcl tab 1 mg
1
HALCION - triazolam tab 0.25 mg
3
1
HETLIOZ - tasimelteon capsule 20
mg
4
PHENOBARBITAL - phenobarbital
tab 15 mg
2
tab 30 mg
2
tab 60 mg
2
tab 100 mg
2
1
1
1
1
1
VERSACLOZ - clozapine susp 50
mg/ml
3
• •
VRAYLAR - cariprazine hcl cap
therapy pack 1.5 mg (1) & 3 mg
(6)
3
• •
VRAYLAR - cariprazine hcl cap 1.5
3
• •
phenobarbital elixir 20 mg/5ml
VRAYLAR - cariprazine hcl cap 3 mg 3
(base equivalent)
3
VRAYLAR - cariprazine hcl cap 4.5
VRAYLAR - cariprazine hcl cap 6 mg 3
(base equivalent)
1
ziprasidone hcl cap 20 mg
(Geodon)
1
(Geodon)
1
(Geodon)
1
(Geodon)
• •
phenobarbital tab 32.4 mg
• •
HYPNOTICS
BUTISOL SODIUM - butabarbital
sodium tab 30 mg
3
estazolam tab 1 mg
1
estazolam tab 2 mg
eszopiclone tab 1 mg (Lunesta)
1
1
1
1
FLURAZEPAM HCL - flurazepam hcl 3
cap 15 mg
FLURAZEPAM HCL - flurazepam hcl 3
cap 30 mg
1
3
SONATA - zaleplon cap 5 mg
3
•
SONATA - zaleplon cap 10 mg
3
temazepam cap 7.5 mg (Restoril)
1
•
temazepam cap 15 mg (Restoril)
•
temazepam cap 30 mg (Restoril)
1
triazolam tab 0.25 mg (Halcion)
1
zolpidem tartrate tab cr 6.25 mg
(Ambien cr)
1
•
•
•
zolpidem tartrate tab cr 12.5 mg
(Ambien cr)
1
•
zolpidem tartrate tab 5 mg
(Ambien)
1
•
zolpidem tartrate tab 10 mg
(Ambien)
1
•
• •
• •
1
3
zaleplon cap 10 mg (Sonata)
Responsible Steps
Quantity Limits
• •
1
TRIAZOLAM - triazolam tab 0.125
mg
zaleplon cap 5 mg (Sonata)
•
•
•
Prior Authorization
1
SECONAL SODIUM - secobarbital
sodium cap 100 mg
temazepam cap 22.5 mg (Restoril)
•
1
3
•
• • •
1
ROZEREM - ramelteon tab 8 mg
• •
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
77
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/
ANOREXIANTS
3
ADDERALL - amphetaminedextroamphetamine tab 5 mg
3
ADDERALL - amphetaminedextroamphetamine tab 7.5 mg
3
3
ADDERALL - amphetaminedextroamphetamine tab 12.5 mg
3
3
3
3
ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 5
mg
3
ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr
10 mg
3
15 mg
3
20 mg
3
25 mg
3
30 mg
1
amphetaminedextroamphetamine cap sr 24hr
5 mg (Adderall xr)
1
10 mg (Adderall xr)
•
1
•
1
•
1
•
amphetaminedextroamphetamine tab 5 mg
(Adderall)
1
•
1
•
• •
amphetaminedextroamphetamine tab 7.5 mg
(Adderall)
1
•
• •
(Adderall)
1
•
• •
amphetaminedextroamphetamine tab 12.5 mg
(Adderall)
1
•
• •
(Adderall)
1
•
• •
(Adderall)
1
•
• •
(Adderall)
APTENSIO XR - methylphenidate hcl 3
cap er 24hr 10 mg (xr)
• •
• •
• •
• •
• •
• •
• •
• •
•
•
20 mg (Adderall xr)
25 mg (Adderall xr)
30 mg (Adderall xr)
1
15 mg (Adderall xr)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
• •
• •
• •
• •
78
ARMODAFINIL - armodafinil tab 200 3
mg
1
armodafinil tab 50 mg (Nuvigil)
caffeine citrate oral soln
60 mg/3ml (10 mg/ml base
equiv)
1
1
• •
• •
• •
• •
• •
1
•
1
•
1
•
1
•
1
•
1
•
dexmethylphenidate hcl tab 5 mg
(Focalin)
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
dexmethylphenidate hcl cap sr 24
hr 15 mg (Focalin xr)
dexmethylphenidate hcl tab
2.5 mg (Focalin)
clonidine hcl tab sr 12hr 0.1 mg
(Kapvay)
1
•
CONCERTA - methylphenidate hcl
tab sa osm 18 mg
2
• •
dexmethylphenidate hcl tab
10 mg (Focalin)
tab sa osm 27 mg
2
• •
dextroamphetamine sulfate cap sr
24hr 5 mg (Dexedrine)
tab sa osm 36 mg
2
• •
tab sa osm 54 mg
2
• •
DAYTRANA - methylphenidate td
patch 10 mg/9hr
3
• •
dextroamphetamine sulfate oral
solution 5 mg/5ml (Procentra)
patch 15 mg/9hr
3
• •
dextroamphetamine sulfate tab
5 mg
patch 20 mg/9hr
3
• •
dextroamphetamine sulfate tab
10 mg
patch 30 mg/9hr
3
• •
DYANAVEL XR - amphetamine
extended release susp 2.5 mg/ml
3
• •
DESOXYN - methamphetamine hcl
tab 5 mg
3
• •
EVEKEO - amphetamine sulfate tab
5 mg
3
• •
DEXEDRINE - dextroamphetamine
sulfate cap sr 24hr 5 mg
3
• •
EVEKEO - amphetamine sulfate tab
10 mg
3
• •
3
• •
FOCALIN - dexmethylphenidate hcl
tab 2.5 mg
3
• •
3
• •
tab 5 mg
3
• •
1
•
tab 10 mg
3
• •
1
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
• •
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
79
3
• •
FOCALIN XR - dexmethylphenidate
hcl cap sr 24 hr 20 mg
3
• •
3
• •
3
• •
3
• •
3
• •
guanfacine hcl tab sr 24hr 1 mg
(base equiv) (Intuniv)
1
•
1
•
1
•
1
•
KAPVAY - clonidine hcl tab sr 12hr
0.1 mg
3
• •
METADATE CD - methylphenidate
hcl cap cr 10 mg (cd)
3
• •
3
• •
3
• •
3
• •
3
• •
3
• •
methamphetamine hcl tab 5 mg
(Desoxyn)
1
•
3
• •
METHYLIN - methylphenidate hcl
chew tab 5 mg
3
• •
chew tab 10 mg
3
• •
soln 5 mg/5ml
3
• •
soln 10 mg/5ml
3
• •
methylphenidate hcl cap cr 10 mg
(cd) (Metadate cd)
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
METHYLPHENIDATE HCL ER methylphenidate hcl tab sa osm
18 mg
3
• •
27 mg
3
• •
(cd) (Metadate cd)
(cd) (Metadate cd)
(cd) (Metadate cd)
(cd) (Metadate cd)
(cd) (Metadate cd)
methylphenidate hcl cap sr 24hr
20 mg (la) (Ritalin la)
methylphenidate hcl chew tab
2.5 mg (Methylin)
5 mg (Methylin)
10 mg (Methylin)
chew tab 2.5 mg
Responsible Steps
• •
Quantity Limits
3
Prior Authorization
Specialty
• •
Drug Name
Drug Tier
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
80
3
• •
QUILLICHEW ER - methylphenidate
hcl chew tab extended release 40
mg
3
• •
METHYLPHENIDATE HCL ER methylphenidate hcl tab sr 24hr 18
mg
3
• •
QUILLIVANT XR - methylphenidate
hcl for er susp 25 mg/5ml (5 mg/
ml)
3
• •
mg
3
• •
RITALIN - methylphenidate hcl tab 5
mg
3
• •
mg
3
• •
RITALIN - methylphenidate hcl tab
10 mg
3
• •
RITALIN - methylphenidate hcl tab
20 mg
3
• •
mg
3
• •
RITALIN LA - methylphenidate hcl
cap sr 24hr 10 mg (la)
3
• •
methylphenidate hcl soln
5 mg/5ml (Methylin)
1
•
3
• •
1
•
3
• •
1
3
• •
3
methylphenidate hcl tab 5 mg
(Ritalin)
1
•
•
•
• •
1
•
STRATTERA - atomoxetine hcl cap
10 mg (base equiv)
3
(Ritalin)
• •
1
•
18 mg (base equiv)
3
(Ritalin)
• •
25 mg (base equiv)
3
modafinil tab 100 mg (Provigil)
1
• •
40 mg (base equiv)
3
• •
60 mg (base equiv)
3
• •
80 mg (base equiv)
3
• •
100 mg (base equiv)
3
• •
VYVANSE - lisdexamfetamine
dimesylate cap 10 mg
3
• •
methylphenidate hcl soln
10 mg/5ml (Methylin)
methylphenidate hcl tab cr 10 mg
methylphenidate hcl tab cr 20 mg
1
NUVIGIL - armodafinil tab 50 mg
3
3
3
3
PROCENTRA - dextroamphetamine
sulfate oral solution 5 mg/5ml
3
•
•
•
•
•
•
•
mg
3
• •
modafinil tab 200 mg (Provigil)
1
•
•
•
•
•
•
•
mg
Responsible Steps
• •
Quantity Limits
3
Prior Authorization
54 mg
Specialty
• •
Drug Name
Drug Tier
3
36 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
81
3
• •
3
• •
3
• •
3
• •
ZENZEDI - dextroamphetamine
sulfate tab 2.5 mg
3
• •
sulfate tab 7.5 mg
3
• •
sulfate tab 15 mg
3
• •
sulfate tab 20 mg
3
• •
sulfate tab 30 mg
3
• •
PSYCHOTHERAPEUTIC and NEUROLOGICAL AGENTS
- MISC.
acamprosate calcium tab delayed 1
release 333 mg
•
AMPYRA - dalfampridine tab sr 12hr 4 • • •
10 mg
3
ANTABUSE - disulfiram tab 250 mg
ANTABUSE - disulfiram tab 500 mg
3
ARICEPT - donepezil hydrochloride
tab 5 mg
3
tab 10 mg
3
tab 23 mg
3
AUBAGIO - teriflunomide tab 7 mg
4
AUBAGIO - teriflunomide tab 14 mg
4
AVONEX - interferon beta-1a for im
inj kit 30mcg (33mcg(6.6 mu)/vial)
4
4
• • •
AVONEX PEN - interferon beta-1a
im auto-injector kit 30 mcg/0.5ml
4
• • •
BETASERON - interferon beta-1b for 4
inj kit 0.3 mg
3
BRISDELLE - paroxetine mesylate
cap 7.5 mg (base equiv)
P
bupropion hcl (smoking
deterrent) tab sr 12hr 150 mg
(Zyban)
P
CHANTIX - varenicline tartrate tab
0.5 mg (base equiv)
CHANTIX - varenicline tartrate tab 1 P
mg (base equiv)
P
CHANTIX CONTINUING MONTH varenicline tartrate tab 1 mg (base
equiv)
CHANTIX STARTING MONTH PA - P
varenicline tartrate tab 0.5 mg x 11
& tab 1 mg x 42 pack
CHLORDIAZEPOXIDE/AMITRIPT - 3
chlordiazepoxide-amitriptyline tab
5-12.5 mg
CHLORDIAZEPOXIDE/AMITRIPT - 3
chlordiazepoxide-amitriptyline tab
10-25 mg
4
COPAXONE - glatiramer acetate
4
COPAXONE - glatiramer acetate
1
disulfiram tab 250 mg (Antabuse)
• • •
disulfiram tab 500 mg (Antabuse)
donepezil hydrochloride orally
• • •
• • •
• • •
•
•
donepezil hydrochloride orally
• • •
• • •
1
1
1
donepezil hydrochloride tab 5 mg
(Aricept)
1
donepezil hydrochloride tab
10 mg (Aricept)
1
AVONEX - interferon beta-1a im
prefilled syringe kit 30 mcg/0.5ml
Responsible Steps
• •
Quantity Limits
3
Prior Authorization
Specialty
• •
Drug Name
Drug Tier
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
82
donepezil hydrochloride tab
23 mg (Aricept)
1
ERGOLOID MESYLATES - ergoloid
mesylates tab 1 mg
3
EXELON - rivastigmine tartrate cap
1.5 mg
3
EXELON - rivastigmine tartrate cap 3 3
mg
3
EXELON - rivastigmine tartrate cap
4.5 mg
EXELON - rivastigmine tartrate cap 6 3
mg
EXELON - rivastigmine td patch 24hr 3
4.6 mg/24hr
9.5 mg/24hr
13.3 mg/24hr
4
EXTAVIA - interferon beta-1b for inj
kit 0.3 mg
FLUOXETINE - fluoxetine hcl (pmdd) 3
cap 10 mg
FLUOXETINE - fluoxetine hcl (pmdd) 3
cap 20 mg
GALANTAMINE HYDROBROMIDE - 3
galantamine hydrobromide oral
soln 4 mg/ml
galantamine hydrobromide cap sr 1
24hr 8 mg (Razadyne er)
1
galantamine hydrobromide tab
4 mg (Razadyne)
1
8 mg (Razadyne)
1
12 mg (Razadyne)
GILENYA - fingolimod hcl cap 0.5 mg 4
(base equiv)
glatiramer acetate soln prefilled
syringe 20 mg/ml (Copaxone)
• • •
• • •
•
4
GRALISE - gabapentin (once-daily)
tab 300 mg
3
•
GRALISE - gabapentin (once-daily)
tab 600 mg
3
•
GRALISE STARTER - gabapentin
(once-daily) tab pack 300 mg (9) &
600 mg (69)
3
•
HORIZANT - gabapentin enacarbil
tab cr 300 mg
3
•
HORIZANT - gabapentin enacarbil
tab cr 600 mg
3
•
memantine hcl oral solution 2 mg/
ml (Namenda)
1
memantine hcl tab 5 mg
(Namenda)
1
memantine hcl tab 10 mg
(Namenda)
1
memantine hcl tab 5 mg (28)
& 10 mg (21) titration pak
(Namenda titration pa)
1
NAMENDA - memantine hcl oral
solution 2 mg/ml
3
NAMENDA - memantine hcl tab 5
mg
3
NAMENDA - memantine hcl tab 10
mg
3
NAMENDA TITRATION PAK memantine hcl tab 5 mg (28) & 10
mg (21) titration pak
3
NAMENDA XR - memantine hcl cap
sr 24hr 7 mg
2
sr 24hr 14 mg
2
sr 24hr 21 mg
2
sr 24hr 28 mg
2
NAMENDA XR TITRATION PACK memantine hcl cap sr 24hr 7 mg &
14 mg & 21 mg & 28 mg pack
2
• • •
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
83
NAMZARIC - memantine hcldonepezil hcl cap sr 24hr 14-10
mg
3
NAMZARIC - memantine hcldonepezil hcl cap sr 24hr 28-10
mg
3
nicotine polacrilex gum 2 mg
P
nicotine polacrilex gum 4 mg
nicotine td patch 24hr 7 mg/24hr
P
P
P
•
•
•
•
•
1
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Tier
Drug Name
pimozide tab 2 mg (Orap)
P
NUEDEXTA - dextromethorphan hbr- 3
quinidine sulfate cap 20-10 mg
1
olanzapine-fluoxetine hcl cap
3-25 mg (Symbyax)
1
6-25 mg (Symbyax)
1
6-50 mg (Symbyax)
1
12-25 mg (Symbyax)
1
12-50 mg (Symbyax)
3
ORAP - pimozide tab 1 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
PLEGRIDY - peginterferon beta-1a
soln pen-injector 125 mcg/0.5ml
4
• • •
•
PLEGRIDY - peginterferon beta-1a
soln prefilled syringe 125
mcg/0.5ml
4
• • •
•
PLEGRIDY STARTER PACK peginterferon beta-1a soln pen-inj
63 & 94 mcg/0.5ml pack
4
• • •
•
PLEGRIDY STARTER PACK peginterferon beta-1a soln pref syr
63 & 94 mcg/0.5ml pack
4
• • •
•
RAZADYNE - galantamine
hydrobromide tab 4 mg
3
3
3
RAZADYNE ER - galantamine
hydrobromide cap sr 24hr 8 mg
3
3
3
REBIF - interferon beta-1a soln pref
syr 22 mcg/0.5ml (12mu/ml)
4
• • •
REBIF - interferon beta-1a soln pref
syr 44 mcg/0.5ml (24mu/ml)
4
• • •
ORAP - pimozide tab 2 mg
3
PERPHENAZINE/AMITRIPTYLIN perphenazine-amitriptyline tab
2-10 mg
3
REBIF REBIDOSE - interferon
beta-1a soln auto-inj 22 mcg/0.5ml
(12mu/ml)
4
2-25 mg
3
• • •
REBIF REBIDOSE - interferon
beta-1a soln auto-inj 44 mcg/0.5ml
(24mu/ml)
4
4-10 mg
3
• • •
3
4
4-25 mg
REBIF REBIDOSE TITRATION interferon beta-1a auto-inj 6x8.8
mcg/0.2ml & 6x22 mcg/0.5ml
• • •
4-50 mg
3
• • •
pimozide tab 1 mg (Orap)
1
REBIF TITRATION PACK - interferon 4
beta-1a pref syr 6x8.8 mcg/0.2ml
& 6x22 mcg/0.5ml
1
rivastigmine tartrate cap 1.5 mg
(Exelon)
84
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
4
• • •
1
TECFIDERA STARTER PACK dimethyl fumarate capsule dr
starter pack 120 mg & 240 mg
4
• • •
rivastigmine tartrate cap 6 mg
(Exelon)
1
tetrabenazine tab 12.5 mg
(Xenazine)
4
• • •
rivastigmine td patch 24hr
4.6 mg/24hr (Exelon)
1
tetrabenazine tab 25 mg
(Xenazine)
4
• • •
•
1
XENAZINE - tetrabenazine tab 12.5
mg
4
• • •
•
1
XENAZINE - tetrabenazine tab 25
mg
4
• • •
•
SARAFEM - fluoxetine hcl (pmdd)
tab 10 mg
3
XYREM - sodium oxybate oral
solution 500 mg/ml
SARAFEM - fluoxetine hcl (pmdd)
tab 20 mg
3
SAVELLA - milnacipran hcl tab 12.5
mg
3
• •
SAVELLA - milnacipran hcl tab 25
mg
3
• •
butalbital-acetaminophen tab
50-325 mg
mg
3
• •
butalbital-acetaminophen-caffeine
cap 50-300-40 mg (Fioricet)
mg
3
• •
cap 50-325-40 mg
SAVELLA TITRATION PACK milnacipran hcl tab 12.5 mg (5) &
25 mg (8) & 50 mg (42) pak
3
• •
tab 50-325-40 mg (Esgic)
SYMBYAX - olanzapine-fluoxetine
hcl cap 3-25 mg
3
• •
hcl cap 6-25 mg
3
• •
DISALCID - salsalate tab 500 mg
3
hcl cap 6-50 mg
• •
3
3
DISALCID - salsalate tab 750 mg
salsalate tab 500 mg (Disalcid)
1
hcl cap 12-25 mg
3
• •
hcl cap 12-50 mg
3
• •
TECFIDERA - dimethyl fumarate
capsule delayed release 120 mg
4
• • •
•
acetaminophen w/ codeine tab
300-15 mg (Tylenol/codeine)
TECFIDERA - dimethyl fumarate
capsule delayed release 240 mg
4
• • •
•
300-30 mg (Tylenol/codeine #3)
rivastigmine tartrate cap 3 mg
(Exelon)
1
rivastigmine tartrate cap 4.5 mg
(Exelon)
•
ANALGESICS AND ANESTHETICS
ANALGESICS - NON-NARCOTIC
aspirin chew tab 81 mg
aspirin tab delayed release 81 mg
butalbital-aspirin-caffeine cap
50-325-40 mg (Fiorinal)
diflunisal tab 500 mg
salsalate tab 750 mg (Disalcid)
ANALGESICS - NARCOTIC
acetaminophen w/ codeine soln
120-12 mg/5ml
P
P
1
•
1
•
1
•
1
•
1
•
1
1
1
•
1
•
1
•
85
300-60 mg (Tylenol/codeine #4)
acetaminophen-caffeinedihydrocodeine cap
320.5-30-16 mg (Trezix)
ACTIQ - fentanyl citrate lozenge on a 3
handle 200 mcg
handle 400 mcg
handle 600 mcg
handle 800 mcg
handle 1200 mcg
handle 1600 mcg
3
ASPIRIN-CAFFEINE-DIHYDROC aspirin-caffeine-dihydrocodeine
cap 356.4-30-16 mg
3
BUNAVAIL - buprenorphinenaloxone buccal film 2.1-0.3 mg
(base equiv)
3
BUNAVAIL - buprenorphinenaloxone buccal film 4.2-0.7 mg
(base equiv)
3
BUNAVAIL - buprenorphinenaloxone buccal film 6.3-1 mg
(base equiv)
1
buprenorphine hcl sl tab 2 mg
(base equiv)
1
buprenorphine hcl sl tab 8 mg
(base equiv)
1
buprenorphine hcl-naloxone hcl
sl tab 2-0.5 mg (base equiv)
1
buprenorphine hcl-naloxone hcl
sl tab 8-2 mg (base equiv)
1
butalbital-acetaminophen-caff w/
cod cap 50-325-40-30 mg
1
butalbital-aspirin-caff w/ codeine
cap 50-325-40-30 mg (Fiorinal/
codeine #3)
3
• •
• •
BUTRANS - buprenorphine td patch
weekly 7.5 mcg/hr
3
• •
• •
weekly 10 mcg/hr
3
• •
• •
weekly 15 mcg/hr
3
• •
• •
weekly 20 mcg/hr
3
• •
• •
CAPITAL/CODEINE acetaminophen w/ codeine susp
120-12 mg/5ml
3
•
CODEINE SULFATE - codeine
sulfate tab 15 mg
3
•
sulfate tab 30 mg
3
•
sulfate tab 60 mg
3
•
codeine sulfate tab 15 mg
(Codeine sulfate)
1
•
(Codeine sulfate)
1
•
(Codeine sulfate)
1
•
DILAUDID - hydromorphone hcl liqd
1 mg/ml
3
•
DOLOPHINE - methadone hcl tab 5
mg
3
•
DOLOPHINE - methadone hcl tab 10 3
mg
EMBEDA - morphine-naltrexone cap 3
cr 20-0.8 mg
cr 30-1.2 mg
cr 50-2 mg
cr 60-2.4 mg
•
• •
• •
• •
• •
• •
• •
• •
•
•
1
weekly 5 mcg/hr
• •
Responsible Steps
Quantity Limits
Prior Authorization
•
butorphanol tartrate nasal soln
10 mg/ml
Specialty
1
Drug Name
Drug Tier
•
1
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
• •
• •
• •
• •
86
EXALGO - hydromorphone hcl tab er 3
24hr deter 8 mg
24hr deter 12 mg
24hr deter 16 mg
24hr deter 32 mg
3
FENTANYL - fentanyl td patch 72hr
37.5 mcg/hr
3
62.5 mcg/hr
3
87.5 mcg/hr
1
fentanyl citrate lozenge on a
handle 200 mcg (Actiq)
1
1
1
1
1
1
fentanyl td patch 72hr 12 mcg/hr
(Duragesic)
1
(Duragesic)
1
(Duragesic)
1
(Duragesic)
fentanyl td patch 72hr 100 mcg/hr 1
(Duragesic)
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
3
•
hydrocodone-acetaminophen
soln 7.5-325 mg/15ml (Hycet)
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
hydrocodone-acetaminophen
soln 10-325 mg/15ml (Zamicet)
hydrocodone-acetaminophen tab
2.5-325 mg
10-325 mg (Norco)
5-300 mg (Xodol)
7.5-300 mg (Xodol)
5-325 mg (Norco)
7.5-325 mg (Norco)
10-300 mg (Xodol)
hydrocodone-ibuprofen tab
5-200 mg (Reprexain)
7.5-200 mg (Vicoprofen)
10-200 mg (Ibudone)
HYDROMORPHONE HCL hydromorphone hcl suppos 3 mg
3
• •
HYDROMORPHONE HCL ER hydromorphone hcl tab er 24hr
deter 32 mg
3
• •
• •
hydromorphone hcl liqd 1 mg/ml
(Dilaudid)
1
•
• •
hydromorphone hcl tab er 24hr
deter 8 mg (Exalgo)
1
• •
• •
deter 12 mg (Exalgo)
1
• •
• •
deter 16 mg (Exalgo)
1
• •
• •
FIORINAL/CODEINE #3 - butalbitalaspirin-caff w/ codeine cap
50-325-40-30 mg
Responsible Steps
• •
Quantity Limits
3
Prior Authorization
EMBEDA - morphine-naltrexone cap
cr 100-4 mg
Specialty
• •
Drug Name
Drug Tier
3
EMBEDA - morphine-naltrexone cap
cr 80-3.2 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
87
1
•
hydromorphone hcl tab 4 mg
(Dilaudid)
1
•
methadone hcl tab for oral susp
40 mg
1
•
(Dilaudid)
1
•
methadone hcl tab 5 mg
(Dolophine hcl)
1
•
KADIAN - morphine sulfate cap sr
24hr 10 mg
3
• •
methadone hcl tab 10 mg
(Dolophine)
1
•
24hr 20 mg
3
• •
METHADOSE - methadone hcl conc
10 mg/ml
3
•
24hr 30 mg
3
• •
METHADOSE - methadone hcl tab
disp 40 mg
3
24hr 40 mg
3
• •
METHADOSE SUGAR-FREE methadone hcl conc 10 mg/ml
3
24hr 50 mg
3
• •
MORPHINE SULFATE - morphine
sulfate suppos 5 mg
3
24hr 60 mg
3
• •
sulfate suppos 10 mg
3
24hr 80 mg
3
• •
3
24hr 100 mg
3
• •
2
24hr 200 mg
3
• •
sulfate tab 15 mg
2
•
MEPERIDINE HCL - meperidine hcl
oral soln 50 mg/5ml
3
•
sulfate tab 30 mg
2
•
meperidine hcl tab 50 mg
(Demerol)
1
•
morphine sulfate cap sr 24hr
10 mg (Kadian)
1
• •
meperidine hcl tab 100 mg
(Demerol)
1
•
1
• •
MEPERIDINE HCL/PROMETHAZI meperidine w/ promethazine cap
50-25 mg
3
1
• •
METHADONE HCL - methadone hcl
soln 5 mg/5ml
3
•
50 mg (Kadian)
1
• •
METHADONE HCL - methadone hcl
soln 10 mg/5ml
3
•
60 mg (Kadian)
1
• •
methadone hcl conc 10 mg/ml
(Methadose)
1
•
80 mg (Kadian)
1
• •
methadone hcl soln 5 mg/5ml
(Methadone hcl)
1
•
100 mg (Kadian)
1
• •
20 mg (Kadian)
30 mg (Kadian)
methadone hcl soln 10 mg/5ml
(Methadone hcl)
Responsible Steps
•
Quantity Limits
1
Prior Authorization
(Dilaudid)
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
•
88
3
MORPHINE SULFATE ER morphine sulfate beads cap sr
24hr 45 mg
3
• •
24hr 60 mg
3
• •
24hr 75 mg
3
• •
24hr 90 mg
3
24hr 120 mg
morphine sulfate oral soln
10 mg/5ml
NUCYNTA ER - tapentadol hcl tab sr 2
12hr 100 mg
12hr 150 mg
12hr 200 mg
12hr 250 mg
OPANA - oxymorphone hcl tab 5 mg 3
• •
• •
• •
OPANA - oxymorphone hcl tab 10
mg
3
•
•
• •
OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter
5 mg
3
• •
3
• •
7.5 mg
3
• •
1
•
3
• •
1
•
10 mg
3
• •
1
•
15 mg
morphine sulfate tab cr 15 mg (Ms 1
contin)
contin)
contin)
1
morphine sulfate tab cr 100 mg
(Ms contin)
1
morphine sulfate tab cr 200 mg
(Ms contin)
3
NUCYNTA - tapentadol hcl tab 50
mg
3
mg
3
mg
12hr 50 mg
• •
20 mg
3
• •
30 mg
3
• •
40 mg
3
• •
oxycodone hcl cap 5 mg
1
1
•
•
20 mg/5ml
100 mg/5ml (20 mg/ml)
• •
• •
• •
• •
•
oxycodone hcl conc 100 mg/5ml
(20 mg/ml) (Oxycodone hcl)
•
OXYCODONE HCL ER - oxycodone
hcl tab er 12hr deter 10 mg
3
• •
•
3
• •
• •
3
• •
• •
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
• •
24hr 30 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
89
3
• •
3
• •
oxycodone hcl soln 5 mg/5ml
(Oxycodone hcl)
1
•
oxycodone hcl tab 5 mg
(Roxicodone)
1
•
1
•
•
(Roxicodone)
1
1
2
• •
OXYCONTIN - oxycodone hcl tab er
12hr deter 60 mg
2
• •
12hr deter 80 mg
2
• •
oxymorphone hcl tab sr 12hr
5 mg
1
• •
1
• •
1
• •
1
• •
1
• •
1
• •
1
• •
7.5 mg
10 mg
15 mg
20 mg
(Roxicodone)
1
•
•
oxycodone w/ acetaminophen
soln 5-325 mg/5ml (Roxicet)
1
•
40 mg
1
•
oxymorphone hcl tab 5 mg
(Opana)
1
•
1
•
oxymorphone hcl tab 10 mg
(Opana)
1
•
1
•
pentazocine w/ naloxone tab
50-0.5 mg
1
1
•
2
• •
1
•
SUBOXONE - buprenorphine hclnaloxone hcl sl film 2-0.5 mg
(base equiv)
2
• •
OXYCODONE/IBUPROFEN oxycodone-ibuprofen tab 5-400
mg
3
•
SUBOXONE - buprenorphine hclnaloxone hcl sl film 4-1 mg (base
equiv)
2
• •
12hr deter 10 mg
2
• •
equiv)
12hr deter 15 mg
2
• •
2
• •
12hr deter 20 mg
2
• •
equiv)
3
12hr deter 30 mg
2
• •
SYNALGOS-DC - aspirin-caffeinedihydrocodeine cap 356.4-30-16
mg
oxycodone w/ acetaminophen tab
2.5-325 mg (Percocet)
5-325 mg (Percocet)
7.5-325 mg (Percocet)
10-325 mg (Percocet)
oxycodone-aspirin tab
4.8355-325 mg (Percodan)
30 mg
12hr deter 40 mg
Responsible Steps
• •
Quantity Limits
3
Prior Authorization
Specialty
• •
Drug Name
Drug Tier
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
90
• •
tramadol hcl tab sr 24hr biphasic
release 100 mg
1
• •
1
• •
1
• •
release 200 mg
release 300 mg
1
•
•
TREZIX - acetaminophen-caffeinedihydrocodeine cap 320.5-30-16
mg
3
•
TYLENOL/CODEINE acetaminophen w/ codeine tab
300-15 mg
3
TYLENOL/CODEINE #3 acetaminophen w/ codeine tab
300-30 mg
3
TYLENOL/CODEINE #4 acetaminophen w/ codeine tab
300-60 mg
3
ZAMICET - hydrocodoneacetaminophen soln 10-325
mg/15ml
3
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 1.4-0.36 mg
(base eq)
3
(base eq)
3
• •
(base eq)
3
• •
(base eq)
3
tramadol hcl tab 50 mg (Ultram)
tramadol-acetaminophen tab
37.5-325 mg (Ultracet)
1
•
•
•
•
• •
• •
ANALGESICS - ANTI-INFLAMMATORY
4
ACTEMRA - tocilizumab
syringe 162 mg/0.9ml
3
ANAPROX DS - naproxen sodium
tab 550 mg
3
ARAVA - leflunomide tab 10 mg
ARAVA - leflunomide tab 20 mg
3
ARCALYST - rilonacept for inj 220
mg
4
ARTHROTEC 50 - diclofenac w/
misoprostol tab delayed release
50-0.2 mg
3
ARTHROTEC 75 - diclofenac w/
misoprostol tab delayed release
75-0.2 mg
3
CELEBREX - celecoxib cap 50 mg
3
3
3
3
celecoxib cap 50 mg (Celebrex)
1
1
diclofenac sodium tab sr 24hr
100 mg (Voltaren-xr)
diclofenac w/ misoprostol tab
delayed release 50-0.2 mg
(Arthrotec 50)
• • •
•
1
diclofenac potassium tab 50 mg
diclofenac sodium tab delayed
release 75 mg
•
1
3
release 50 mg
• • •
1
DAYPRO - oxaprozin tab 600 mg
release 25 mg
tramadol hcl tab sr 24hr 300 mg
(Ultram er)
1
• •
Responsible Steps
• •
Quantity Limits
1
3
Prior Authorization
(Ultram er)
(base eq)
Specialty
• •
Drug Name
Drug Tier
1
(Ultram er)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
1
1
91
4
• • •
HUMIRA - adalimumab prefilled
syringe kit 40 mg/0.8ml
4
EC-NAPROSYN - naproxen tab ec
375 mg
3
• • •
• • •
ENBREL - etanercept for
4
• • •
HUMIRA PEDIATRIC CROHNS D adalimumab prefilled syringe kit
40 mg/0.8ml
4
EC-NAPROSYN - naproxen tab ec
500 mg
3
4
• • •
ENBREL - etanercept subcutaneous
soln prefilled syringe 25 mg/0.5ml
4
• • •
HUMIRA PEN - adalimumab peninjector kit 40 mg/0.8ml
4
• • •
ENBREL - etanercept subcutaneous
4
• • •
HUMIRA PEN-CROHNS DISEASE adalimumab pen-injector kit 40
mg/0.8ml
4
• • •
ENBREL SURECLICK - etanercept
subcutaneous solution autoinjector 50 mg/ml
4
HUMIRA PEN-PSORIASIS STAR adalimumab pen-injector kit 40
mg/0.8ml
1
etodolac cap 200 mg
1
ibuprofen susp 100 mg/5ml
1
etodolac cap 300 mg
etodolac tab sr 24hr 400 mg
etodolac tab 400 mg
etodolac tab 500 mg
• • •
ibuprofen tab 400 mg
1
1
1
1
1
1
1
1
3
INDOCIN - indomethacin susp 25
mg/5ml
3
indomethacin cap cr 75 mg
1
FELDENE - piroxicam cap 10 mg
3
FELDENE - piroxicam cap 20 mg
3
FENOPROFEN CALCIUM fenoprofen calcium cap 200 mg
3
FENOPROFEN CALCIUM fenoprofen calcium cap 400 mg
3
ketoprofen cap 75 mg
3
FENOPROFEN CALCIUM fenoprofen calcium tab 600 mg
3
KETOPROFEN ER - ketoprofen cap
sr 24hr 200 mg
1
•
FENORTHO - fenoprofen calcium
cap 200 mg
3
ketorolac tromethamine tab
10 mg
4
• • •
FENORTHO - fenoprofen calcium
cap 400 mg
3
KINERET - anakinra subcutaneous
soln prefilled syringe 100
mg/0.67ml
flurbiprofen tab 50 mg
1
leflunomide tab 10 mg (Arava)
1
1
leflunomide tab 20 mg (Arava)
flurbiprofen tab 100 mg
4
indomethacin cap 50 mg
ketoprofen cap 50 mg
• • •
MECLOFENAMATE SODIUM meclofenamate sodium cap 50 mg
•
1
INDOCIN - indomethacin suppos 50
mg
indomethacin cap 25 mg
diclofenac w/ misoprostol tab
delayed release 75-0.2 mg
(Arthrotec 75)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
1
•
1
3
92
MECLOFENAMATE SODIUM meclofenamate sodium cap 100
mg
3
OTREXUP - methotrexate soln pf
auto-injector 12.5 mg/0.4ml
3
auto-injector 15 mg/0.4ml
3
mefenamic acid cap 250 mg
(Ponstel)
1
3
meloxicam tab 7.5 mg (Mobic)
1
3
3
3
oxaprozin tab 600 mg (Daypro)
1
meloxicam tab 15 mg (Mobic)
nabumetone tab 500 mg
nabumetone tab 750 mg
1
1
1
NALFON - fenoprofen calcium cap
400 mg
3
NAPROSYN - naproxen susp 125
mg/5ml
3
NAPROSYN - naproxen tab 500 mg
3
piroxicam cap 10 mg (Feldene)
naproxen sodium tab 275 mg
(Anaprox)
1
piroxicam cap 20 mg (Feldene)
naproxen sodium tab 550 mg
(Anaprox ds)
1
naproxen susp 125 mg/5ml
1
naproxen tab ec 375 mg (Ecnaprosyn)
1
naproxen tab ec 500 mg (Ecnaprosyn)
1
naproxen tab 250 mg (Naprosyn)
1
1
1
ORENCIA - abatacept subcutaneous 4
3
ORENCIA CLICKJECT - abatacept
subcutaneous soln auto-injector
125 mg/ml
4
OTEZLA - apremilast tab starter
therapy pack 10 mg & 20 mg & 30
mg
4
OTEZLA - apremilast tab 30 mg
3
3
• • •
• •
• • •
•
• • •
•
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
PONSTEL - mefenamic acid cap 250 3
mg
3
RASUVO - methotrexate soln pf
3
3
3
3
3
3
3
3
3
3
RHEUMATREX - methotrexate
sodium tab 2.5 mg (antirheumatic)
2
RIDAURA - auranofin cap 3 mg
93
4
SIMPONI - golimumab
100 mg/ml
4
SIMPONI - golimumab
syringe 50 mg/0.5ml
4
• • •
•
SIMPONI - golimumab
syringe 100 mg/ml
4
• • •
•
sulindac tab 150 mg
1
sulindac tab 200 mg
• • •
1
TOLMETIN SODIUM - tolmetin
sodium tab 200 mg
3
TOLMETIN SODIUM - tolmetin
sodium tab 600 mg
3
tolmetin sodium cap 400 mg
1
XELJANZ - tofacitinib citrate tab 5
4
• • •
XELJANZ XR - tofacitinib citrate tab
4
• • •
almotriptan malate tab 6.25 mg
(Axert)
1
•
almotriptan malate tab 12.5 mg
(Axert)
1
•
ALSUMA - sumatriptan succinate
solution auto-injector 6 mg/0.5ml
3
•
AXERT - almotriptan malate tab 6.25 3
mg
AXERT - almotriptan malate tab 12.5 3
mg
CAFERGOT - ergotamine w/ caffeine 3
tab 1-100 mg
3
D.H.E. 45 - dihydroergotamine
mesylate inj 1 mg/ml
3
DIHYDROERGOTAMINE
MESYLAT - dihydroergotamine
mesylate nasal spray 4 mg/ml
•
MIGRAINE PRODUCTS
•
•
•
•
dihydroergotamine mesylate inj
1 mg/ml (D.h.e. 45)
1
ERGOMAR - ergotamine tartrate sl
tab 2 mg
2
FROVA - frovatriptan succinate tab
3
•
frovatriptan succinate tab 2.5 mg
(base equivalent) (Frova)
1
•
IMITREX - sumatriptan nasal spray 5 2
mg/act
2
IMITREX - sumatriptan nasal spray
20 mg/act
1
isometheptene-caffeineacetaminophen tab
65-20-325 mg (Prodrin)
1
isometheptene-dichloralacetaminophen cap
65-100-325 mg
MIGERGOT - ergotamine w/ caffeine 3
suppos 2-100 mg
2
MIGRANAL - dihydroergotamine
mesylate nasal spray 4 mg/ml
1
naratriptan hcl tab 1 mg (base
equiv) (Amerge)
1
naratriptan hcl tab 2.5 mg (base
equiv) (Amerge)
PRODRIN - isometheptene-caffeine- 3
acetaminophen tab 65-20-325 mg
3
RELPAX - eletriptan hydrobromide
3
RELPAX - eletriptan hydrobromide
1
rizatriptan benzoate oral
disintegrating tab 5 mg (base
eq) (Maxalt-mlt)
1
rizatriptan benzoate oral
disintegrating tab 10 mg (base
eq) (Maxalt-mlt)
1
rizatriptan benzoate tab 5 mg
(base equivalent) (Maxalt)
1
rizatriptan benzoate tab 10 mg
(base equivalent) (Maxalt)
•
•
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
•
SIMPONI - golimumab
50 mg/0.5ml
Drug Name
Drug Tier
• • •
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
•
•
•
•
•
•
•
•
•
•
94
1
•
SUMATRIPTAN SUCCINATE sumatriptan succinate solution
prefilled syringe 6 mg/0.5ml
3
•
sumatriptan succinate inj
6 mg/0.5ml (Imitrex)
1
•
MITIGARE - colchicine cap 0.6 mg
3
probenecid tab 500 mg
1
sumatriptan succinate solution
auto-injector 4 mg/0.5ml (Imitrex
statdose sys)
1
•
ULORIC - febuxostat tab 40 mg
3
ULORIC - febuxostat tab 80 mg
3
ZYLOPRIM - allopurinol tab 100 mg
3
auto-injector 6 mg/0.5ml (Imitrex
statdose sys)
1
ZYLOPRIM - allopurinol tab 300 mg
3
cartridge 4 mg/0.5ml (Imitrex
statdose ref)
1
cartridge 6 mg/0.5ml (Imitrex
statdose ref)
1
•
sumatriptan succinate tab 25 mg
(Imitrex)
1
•
•
3
COLCHICINE - colchicine tab 0.6 mg 3
1
colchicine w/ probenecid tab
0.5-500 mg
2
COLCRYS - colchicine tab 0.6 mg
ANTICONVULSANTS
3
APTIOM - eslicarbazepine acetate
tab 400 mg
3
•
tab 600 mg
3
•
tab 800 mg
3
(Imitrex)
1
1
•
BANZEL - rufinamide susp 40 mg/ml
3
(Imitrex)
BANZEL - rufinamide tab 200 mg
3
zolmitriptan orally disintegrating
tab 2.5 mg (Zomig zmt)
1
•
BANZEL - rufinamide tab 400 mg
3
3
1
•
BRIVIACT - brivaracetam iv soln 50
mg/5ml
3
1
•
•
•
BRIVIACT - brivaracetam oral soln
10 mg/ml
BRIVIACT - brivaracetam tab 10 mg
3
3
3
3
BRIVIACT - brivaracetam tab 100
mg
3
carbamazepine cap sr 12hr
100 mg (Carbatrol)
1
zolmitriptan tab 2.5 mg (Zomig)
zolmitriptan tab 5 mg (Zomig)
1
ZOMIG - zolmitriptan nasal spray 2.5 3
mg/spray unit
ZOMIG NASAL SPRAY - zolmitriptan 3
nasal spray 5 mg/spray unit
GOUT AGENTS
allopurinol tab 100 mg (Zyloprim)
allopurinol tab 300 mg (Zyloprim)
1
1
•
•
•
NEUROMUSCULAR DRUGS
tab 200 mg
zolmitriptan orally disintegrating
tab 5 mg (Zomig zmt)
sumatriptan nasal spray 20 mg/
act (Imitrex)
COLCHICINE - colchicine cap 0.6
mg
Responsible Steps
•
Quantity Limits
1
Prior Authorization
sumatriptan nasal spray 5 mg/act
(Imitrex)
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
200 mg (Carbatrol)
1
95
300 mg (Carbatrol)
carbamazepine chew tab 100 mg
1
DEPAKOTE - divalproex sodium tab
3
1
3
carbamazepine susp 100 mg/5ml
(Tegretol)
1
3
carbamazepine tab sr 12hr
100 mg (Tegretol-xr)
1
DEPAKOTE ER - divalproex sodium
tab sr 24 hr 250 mg
3
1
DEPAKOTE ER - divalproex sodium
tab sr 24 hr 500 mg
3
1
DEPAKOTE SPRINKLES divalproex sodium cap delayed
release sprinkle 125 mg
carbamazepine tab 200 mg
(Tegretol)
1
DIASTAT ACUDIAL - diazepam
rectal gel delivery system 10 mg
2
CARBATROL - carbamazepine cap
sr 12hr 100 mg
3
DIASTAT ACUDIAL - diazepam
rectal gel delivery system 20 mg
2
sr 12hr 200 mg
3
DIASTAT PEDIATRIC - diazepam
rectal gel delivery system 2.5 mg
2
sr 12hr 300 mg
3
DIAZEPAM - diazepam rectal gel
delivery system 2.5 mg
3
CELONTIN - methsuximide cap 300
mg
2
delivery system 10 mg
3
clonazepam orally disintegrating
tab 0.125 mg
1
delivery system 20 mg
3
1
DILANTIN - phenytoin sodium
extended cap 30 mg
2
1
DILANTIN - phenytoin sodium
extended cap 100 mg
3
1
DILANTIN INFATABS - phenytoin
chew tab 50 mg
3
1
DILANTIN-125 - phenytoin susp 125
mg/5ml
3
1
divalproex sodium cap delayed
release sprinkle 125 mg
(Depakote sprinkles)
1
1
tab 0.25 mg
tab 0.5 mg
tab 1 mg
tab 2 mg
clonazepam tab 0.5 mg (Klonopin)
clonazepam tab 1 mg (Klonopin)
clonazepam tab 2 mg (Klonopin)
1
1
DEPAKENE - valproate sodium
syrup 250 mg/5ml (base equiv)
3
divalproex sodium tab delayed
release 125 mg (Depakote)
DEPAKENE - valproic acid cap 250
mg
3
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
96
divalproex sodium tab sr 24 hr
250 mg (Depakote er)
divalproex sodium tab sr 24 hr
500 mg (Depakote er)
1
KEPPRA - levetiracetam oral soln
100 mg/ml
3
1
KEPPRA - levetiracetam tab 250 mg
3
3
3
ethosuximide cap 250 mg
(Zarontin)
1
ethosuximide soln 250 mg/5ml
(Zarontin)
1
KEPPRA - levetiracetam tab 1000
mg
3
felbamate susp 600 mg/5ml
(Felbatol)
1
KEPPRA XR - levetiracetam tab sr
24hr 500 mg
3
felbamate tab 400 mg (Felbatol)
1
KEPPRA XR - levetiracetam tab sr
24hr 750 mg
3
LAMICTAL - lamotrigine tab 25 mg
3
3
3
3
LAMICTAL CHEWABLE DISPERS lamotrigine tab chewable
dispersible 5 mg
3
LAMICTAL CHEWABLE DISPERS lamotrigine tab chewable
dispersible 25 mg
3
LAMICTAL ODT - lamotrigine orally
3
3
3
3
LAMICTAL ODT - lamotrigine tab
disp 25 mg (21) & 50 mg (7)
titration kit
3
disp 50 mg (42) & 100 mg (14)
titration kit
3
disp 25 (14) & 50 mg (14) & 100
mg (7) kit
3
LAMICTAL STARTER/NOT TAKI lamotrigine tab 25 mg (42) & 100
mg (7) starter kit
3
felbamate tab 600 mg (Felbatol)
1
FELBATOL - felbamate susp 600
mg/5ml
3
FELBATOL - felbamate tab 400 mg
3
FELBATOL - felbamate tab 600 mg
3
FYCOMPA - perampanel susp 0.5
mg/ml
3
FYCOMPA - perampanel tab 2 mg
3
3
3
3
3
3
gabapentin cap 100 mg
(Neurontin)
1
(Neurontin)
1
(Neurontin)
1
gabapentin oral soln 250 mg/5ml
(Neurontin)
1
gabapentin tab 600 mg (Neurontin) 1
gabapentin tab 800 mg (Neurontin) 1
GABITRIL - tiagabine hcl tab 2 mg
3
3
2
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
97
LAMICTAL STARTER/TAKING V lamotrigine tab 25 mg (35) starter
kit
3
LAMICTAL XR - lamotrigine tab
sr 24hr 25 mg (21) & 50 mg (7)
titration kit
3
LAMICTAL XR - lamotrigine tab sr
24hr 25 (14) & 50 mg (14) & 100
mg(7) kit
3
24hr 50 (14) & 100 mg(14) & 200
mg(7) kit
3
24hr 25 mg
3
24hr 50 mg
3
24hr 100 mg
3
24hr 200 mg
3
24hr 250 mg
3
lamotrigine tab 100 mg (Lamictal)
24hr 300 mg
3
1
lamotrigine orally disintegrating
tab 25 mg (Lamictal odt)
1
levetiracetam oral soln 100 mg/ml
(Keppra)
1
1
levetiracetam tab sr 24hr 500 mg
(Keppra xr)
1
1
levetiracetam tab sr 24hr 750 mg
(Keppra xr)
1
lamotrigine tab chewable
dispersible 5 mg (Lamictal
chewable di)
1
lamotrigine tab chewable
dispersible 25 mg (Lamictal
chewable di)
1
•
•
•
•
•
•
•
•
Prior Authorization
Responsible Steps
3
Quantity Limits
LAMICTAL STARTER/TAKING C lamotrigine tab 25 mg (84) & 100
mg (14) starter kit
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
lamotrigine tab disp 25 mg (21) &
50 mg (7) titration kit (LAMICTAL
ODT)
1
lamotrigine tab disp 50 mg (42)
& 100 mg (14) titration kit
(LAMICTAL ODT)
1
lamotrigine tab disp 25 (14) &
50 mg (14) & 100 mg (7) kit
(LAMICTAL ODT)
1
lamotrigine tab sr 24hr 25 mg
(Lamictal xr)
1
(Lamictal xr)
1
(Lamictal xr)
1
(Lamictal xr)
1
(Lamictal xr)
1
(Lamictal xr)
1
1
1
1
levetiracetam tab 250 mg (Keppra) 1
1
levetiracetam tab 1000 mg
(Keppra)
3
LYRICA - pregabalin cap 25 mg
3
3
3
98
phenytoin chew tab 50 mg
(Dilantin infatabs)
1
phenytoin sodium extended cap
100 mg (Dilantin)
1
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
•
•
•
•
•
•
•
•
•
•
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
3
3
3
3
LYRICA - pregabalin soln 20 mg/ml
3
NEURONTIN - gabapentin cap 100
mg
3
mg
3
mg
3
NEURONTIN - gabapentin oral soln
250 mg/5ml
3
NEURONTIN - gabapentin tab 600
mg
3
NEURONTIN - gabapentin tab 800
mg
3
QUDEXY XR - topiramate cap er
24hr sprinkle 25 mg
3
ONFI - clobazam suspension 2.5
mg/ml
3
24hr sprinkle 50 mg
3
ONFI - clobazam tab 10 mg
3
ONFI - clobazam tab 20 mg
3
3
oxcarbazepine susp 300 mg/5ml
(60 mg/ml) (Trileptal)
1
24hr sprinkle 100 mg
3
oxcarbazepine tab 150 mg
(Trileptal)
1
3
(Trileptal)
1
3
•
(Trileptal)
1
SABRIL - vigabatrin powd pack 500
mg
SABRIL - vigabatrin tab 500 mg
3
•
OXTELLAR XR - oxcarbazepine tab
sr 24hr 150 mg
3
TEGRETOL - carbamazepine susp
100 mg/5ml
3
sr 24hr 300 mg
3
TEGRETOL - carbamazepine tab
200 mg
3
sr 24hr 600 mg
3
PEGANONE - ethotoin tab 250 mg
2
PHENYTEK - phenytoin sodium
extended cap 200 mg
3
PHENYTEK - phenytoin sodium
extended cap 300 mg
3
TEGRETOL-XR - carbamazepine tab 3
sr 12hr 100 mg
sr 12hr 200 mg
sr 12hr 400 mg
1
tiagabine hcl tab 2 mg (Gabitril)
200 mg (Phenytek)
300 mg (Phenytek)
1
1
phenytoin susp 125 mg/5ml
(Dilantin-125)
1
POTIGA - ezogabine tab 50 mg
3
3
3
3
primidone tab 50 mg (Mysoline)
1
primidone tab 250 mg (Mysoline)
1
99
tiagabine hcl tab 4 mg (Gabitril)
1
TROKENDI XR - topiramate cap sr
24hr 100 mg
3
24hr 200 mg
3
1
TOPAMAX - topiramate tab 25 mg
3
3
3
3
TOPAMAX SPRINKLE - topiramate
sprinkle cap 15 mg
3
valproate sodium syrup
250 mg/5ml (base equiv)
(Depakene)
3
valproic acid cap 250 mg
(Depakene)
1
TOPAMAX SPRINKLE - topiramate
sprinkle cap 25 mg
VIMPAT - lacosamide oral solution
10 mg/ml
3
TOPIRAMATE ER - topiramate cap
er 24hr sprinkle 25 mg
3
VIMPAT - lacosamide tab 50 mg
3
3
3
3
3
3
3
ZARONTIN - ethosuximide cap 250
mg
3
3
ZARONTIN - ethosuximide soln 250
mg/5ml
3
topiramate sprinkle cap 15 mg
(Topamax sprinkle)
1
ZONEGRAN - zonisamide cap 25
mg
3
topiramate sprinkle cap 25 mg
(Topamax sprinkle)
1
ZONEGRAN - zonisamide cap 100
mg
3
topiramate tab 25 mg (Topamax)
1
zonisamide cap 25 mg (Zonegran)
1
1
zonisamide cap 50 mg
1
zonisamide cap 100 mg
(Zonegran)
1
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
ANTIPARKINSON AGENTS
TRILEPTAL - oxcarbazepine susp
300 mg/5ml (60 mg/ml)
3
TRILEPTAL - oxcarbazepine tab 150
mg
3
AMANTADINE HCL - amantadine hcl 2
tab 100 mg
1
amantadine hcl cap 100 mg
mg
3
amantadine hcl syrup 50 mg/5ml
4
mg
3
APOKYN - apomorphine
hydrochloride inj 10 mg/ml
2
24hr 25 mg
3
AZILECT - rasagiline mesylate tab
0.5 mg (base equiv)
2
24hr 50 mg
3
AZILECT - rasagiline mesylate tab 1
mg (base equiv)
benztropine mesylate tab 0.5 mg
1
benztropine mesylate tab 1 mg
1
•
•
1
100
1
ELDEPRYL - selegiline hcl cap 5 mg
3
bromocriptine mesylate cap 5 mg
(Parlodel)
1
entacapone tab 200 mg (Comtan)
1
bromocriptine mesylate tab
2.5 mg
1
benztropine mesylate tab 2 mg
carbidopa & levodopa orally
disintegrating tab 10-100 mg
carbidopa & levodopa tab cr
25-100 mg (Sinemet cr)
carbidopa & levodopa tab cr
50-200 mg (Sinemet cr)
carbidopa & levodopa tab
10-100 mg (Sinemet)
25-100 mg (Sinemet)
25-250 mg (Sinemet)
carbidopa tab 25 mg (Lodosyn)
1
1
1
1
1
1
1
1
1
CARBIDOPA/LEVODOPA/ENTACA - 3
carbidopa-levodopa-entacapone
tabs 12.5-50-200 mg
tabs 18.75-75-200 mg
tabs 25-100-200 mg
tabs 31.25-125-200 mg
tabs 37.5-150-200 mg
tabs 50-200-200 mg
3
COMTAN - entacapone tab 200 mg
LODOSYN - carbidopa tab 25 mg
3
MIRAPEX - pramipexole
dihydrochloride tab 0.125 mg
3
3
3
3
dihydrochloride tab 1 mg
3
3
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr 0.375
mg
3
mg
3
dihydrochloride tab sr 24hr 1.5 mg
3
mg
3
dihydrochloride tab sr 24hr 3 mg
3
mg
3
dihydrochloride tab sr 24hr 4.5 mg
3
NEUPRO - rotigotine td patch 24hr 1
mg/24hr
3
mg/24hr
3
mg/24hr
3
mg/24hr
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
101
mg/24hr
3
REQUIP - ropinirole hydrochloride
tab 3 mg
3
mg/24hr
3
tab 4 mg
3
PARLODEL - bromocriptine mesylate 3
cap 5 mg
1
pramipexole dihydrochloride tab
sr 24hr 0.375 mg (Mirapex er)
1
1
1
1
sr 24hr 3 mg (Mirapex er)
1
1
1
0.125 mg (Mirapex)
1
0.25 mg (Mirapex)
1
0.5 mg (Mirapex)
1
0.75 mg (Mirapex)
1
1 mg (Mirapex)
1
1.5 mg (Mirapex)
3
tab 0.25 mg
3
tab 0.5 mg
3
tab 1 mg
3
tab 2 mg
tab 5 mg
3
REQUIP XL - ropinirole
hydrochloride tab sr 24hr 2 mg
(base equivalent)
3
(base equivalent)
3
(base equivalent)
3
(base equivalent)
3
(base equivalent)
3
ropinirole hydrochloride tab sr
24hr 2 mg (base equivalent)
(Requip xl)
1
(Requip xl)
1
(Requip xl)
1
(Requip xl)
1
(Requip xl)
1
ropinirole hydrochloride tab
0.25 mg (Requip)
1
ropinirole hydrochloride tab
0.5 mg (Requip)
ropinirole hydrochloride tab 1 mg
(Requip)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
102
(Requip)
1
(Requip)
1
(Requip)
1
MUSCULOSKELETAL THERAPY AGENTS
1
baclofen tab 10 mg
(Requip)
1
carisoprodol tab 350 mg (Soma)
selegiline hcl cap 5 mg (Eldepryl)
1
carisoprodol w/ aspirin & codeine
tab 200-325-16 mg
selegiline hcl tab 5 mg
1
RILUTEK - riluzole tab 50 mg
3
riluzole tab 50 mg (Rilutek)
1
baclofen tab 20 mg
carisoprodol w/ aspirin tab
200-325 mg
1
3
SINEMET - carbidopa & levodopa
tab 25-250 mg
3
cyclobenzaprine hcl tab 7.5 mg
(Fexmid)
1
SINEMET CR - carbidopa &
levodopa tab cr 25-100 mg
3
cyclobenzaprine hcl tab 10 mg
1
SINEMET CR - carbidopa &
levodopa tab cr 50-200 mg
3
trihexyphenidyl hcl elixir 0.4 mg/
ml
trihexyphenidyl hcl tab 2 mg
trihexyphenidyl hcl tab 5 mg
NEUROMUSCULAR AGENTS
1
1
1
1
tab 25-100 mg
1
Responsible Steps
1
3
tolcapone tab 100 mg (Tasmar)
Quantity Limits
1
tab 10-100 mg
STALEVO 100 - carbidopa-levodopa- 3
entacapone tabs 25-100-200 mg
entacapone tabs 31.25-125-200
mg
entacapone tabs 37.5-150-200 mg
entacapone tabs 50-200-200 mg
3
TASMAR - tolcapone tab 100 mg
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
chlorzoxazone tab 500 mg
(Parafon forte dsc)
1
cyclobenzaprine hcl tab 5 mg
1
DANTRIUM - dantrolene sodium cap 3
25 mg
DANTRIUM - dantrolene sodium cap 3
50 mg
1
dantrolene sodium cap 25 mg
(Dantrium)
1
(Dantrium)
1
METAXALONE - metaxalone tab 400 3
mg
metaxalone tab 800 mg (Skelaxin) 1
methocarbamol tab 500 mg
(Robaxin)
1
methocarbamol tab 750 mg
(Robaxin-750)
1
orphenadrine citrate tab sr 12hr
100 mg
1
PARAFON FORTE DSC chlorzoxazone tab 500 mg
3
ROBAXIN - methocarbamol tab 500
mg
3
ROBAXIN-750 - methocarbamol tab
750 mg
3
103
SKELAXIN - metaxalone tab 800 mg
3
tizanidine hcl cap 2 mg (base
equivalent) (Zanaflex)
1
cholecalciferol drops 5000 unit/ml
(1000 unit/0.2ml)
1
cholecalciferol drops 400
unit/0.03ml (per drop)
1
cholecalciferol oral liquid 400
unit/ml
tizanidine hcl tab 2 mg (base
equivalent)
tizanidine hcl tab 4 mg (base
1
1
ZANAFLEX - tizanidine hcl cap 2 mg
(base equivalent)
3
(base equivalent)
3
(base equivalent)
3
ZANAFLEX - tizanidine hcl tab 4 mg
(base equivalent)
3
ANTIMYASTHENIC AGENTS
GUANIDINE HCL - guanidine hcl tab 3
125 mg
2
MESTINON - pyridostigmine
bromide syrup 60 mg/5ml
3
MESTINON TIMESPAN pyridostigmine bromide tab cr 180
mg
1
pyridostigmine bromide tab cr
180 mg (Mestinon timespan)
1
pyridostigmine bromide tab
60 mg (Mestinon)
NUTRITIONAL PRODUCTS
VITAMINS
AMINOBENZOATE POTASSIUM potassium aminobenzoate packet
2 gm
3
cholecalciferol cap 1000 unit
P
cholecalciferol chew tab 400 unit
cholecalciferol chew tab 1000 unit
P
P
cholecalciferol tab 400 unit
Responsible Steps
Quantity Limits
P
P
P
P
P
1
MEPHYTON - phytonadione tab 5
mg
2
ACTIVE OB - prenatal w/o a w/fe
cbn-fa-dha cap 20-1-320 mg
Prior Authorization
P
ergocalciferol cap 50000 unit
(Drisdol)
MULTIVITAMINS
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
•
3
ATABEX EC - prenatal vit w/ dss-iron 3
carbonyl-fa tab dr 29-1 mg
3
BAL-CARE DHA - prenat w/fe polyna fered-fa tab 27-1 & omega cap
dr 430mg
3
BP FOLINATAL PLUS B - prenatal
w/ calcium carbonate-b6-b12-fa
tab 1 mg
BP MULTINATAL PLUS - prenatal w/ 3
o a vit w/ fe fum-fa tab chew 40-1
mg
BP MULTINATAL PLUS - prenatal w/ 3
o a vit w/ fe fumarate-fa tab 30-1
mg
C-NATE DHA - prenatal vit w/ fe fum- 3
fa-omega 3 cap 28-1-200 mg
3
CALCIUM PNV - prenatal w/o vit
a w/ fe fum-fa-omega 3 cap
28-1-250 mg
3
CITRANATAL ASSURE - prenat w/
o a w/fecbn-fegl-dss-fa tab & dha
cap 300 mg pack
3
CITRANATAL B-CALM - prenat w/o
a w/fecbn-feglu-fa tab 20-1 mg &
vit b6 tab pak
104
CITRANATAL DHA - prenat w/o a w/
fecbn-fegl-dss-fa tab & dha cap
250 mg pack
3
FOCALGIN 90 DHA - prenat w/o a
w/fecbn-fegl-dss-fa tab 90 &dha
cap 300mg pak
3
CITRANATAL HARMONY - prenat
w/o a w/fe fum-fe cbn-dss-fa-dha
cap 27-1-260 mg
3
FOLCAL DHA - prenatal w/o vit
a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg
3
CITRANATAL RX - prenatal w/o a
w/ fe carbonyl-fe gluc-dss-fa tab
27-1mg
3
FOLCAPS OMEGA 3 - prenatal vit
w/ fe cbn-fe asp glyc-fa-omega 3
cap 27-1mg
3
CITRANATAL 90 DHA - prenat w/o
a w/fecbn-fegl-dss-fa tab 90 &dha
cap 300mg pak
3
FOLET DHA - prenat w/fecbn-bisgmethylf-dss tab dr & dha cap pak
3
FOLET ONE - prenat w/o a w/
fecbn-bisg-methylf-dss-dha cap
38-1-225 mg
3
CO-NATAL FA - prenatal vit w/ fe
fumarate-fa tab 29-1 mg
3
COMPLETE NATAL DHA - prenat-fe
bis-fe prot succ-fa-ca tab & omega
3 cap 250 pk
3
FOLIVANE-OB - prenatal w/o a w/fe
fum-fe poly-fa cap 130-92.4-1 mg
3
3
HEMENATAL OB - prenat vit-fe poly
cmplx-fe heme poly-fa tab 28-6-1
mg
3
COMPLETENATE - prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
CONCEPT DHA - prenatal w/fe fumfe poly -fa-omega 3 cap 53.5-38-1
mg
3
HEMENATAL OB + DHA - prenat-fe
poly cmplx-fe heme poly-fa tab &
omega 3 cap pck
3
CONCEPT OB - prenatal w/o a w/fe
fum-fe poly-fa cap 130-92.4-1 mg
3
INATAL ADVANCE - prenatal vit w/
dss-iron carbonyl-fa tab 90-1 mg
3
DOTHELLE DHA - prenatal w/fe
fum-fe poly -fa-omega 3 cap
53.5-38-1 mg
3
INATAL GT - prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg
3
3
INATAL ULTRA - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
3
DUET DHA BALANCED - prenat
w/fe poly-na fered-fa tab 25-1 &
omega cap 267 mg
3
DUET DHA 400 - prenat w/fe polyna fered-fa tab 25-1 & omega cap
400 mg
3
INFANATE BALANCE - prenatal
w/o a w/fe cbn-dss-fa-dha cap
29-1-265 mg
3
ELITE-OB - prenatal vit w/ iron
carbonyl-fa tab 50-1.25 mg
3
LEVOMEFOLATE DHA - prenat w/
fe fum-l methylfolate-fa-dha cap
27-1.13-0.4 mg
ENBRACE HR - prenatal vit w/ fe gly 3
cys-fa-omega 3 fatty acids cap
3
EXTRA-VIRT PLUS DHA - prenatal
w/o vit a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg
3
FOCALGIN CA - prenat w/o a w/
300 mg pack
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
M-VIT - prenatal vit w/ fe fumarate-fa 3
tab 27-1 mg
3
MACNATAL CN DHA - prenatal
28-1-250 mg
MARNATAL-F - prenatal w/o vit a w/ 3
fe polysac cmplx-fa cap 60-1 mg
105
MYNATAL - prenatal multivitamins &
minerals w/ iron & fa cap 1 mg
3
O-CAL FA - prenatal vit w/ fe
3
MYNATAL ADVANCE - prenatal vit
w/ dss-iron carbonyl-fa tab 90-1
mg
3
O-CAL PRENATAL - prenatal vit w/
fe fumarate-fa tab 15-1 mg
3
OB COMPLETE - prenatal vit w/ iron
carbonyl-fa tab 50-1.25 mg
3
MYNATAL PLUS - prenatal vit w/ fe
3
OB COMPLETE GOLD - prenat w/
o a w/fecbn-methfol-fa-dha cap
27.5-1-200 mg
3
OB COMPLETE ONE - prenatal w/o
a w/fecbn-fe asp glyc-fa-fish cap
50-1-476 mg
3
OB COMPLETE PETITE - prenat w/
o a w/fecbn-feaspglyc-fa-omega
cap 35-5-1-200 mg
3
OB COMPLETE PREMIER prenatal vit w/ fe cbn-fe asp glycfa tab 30-20-1 mg
3
OB COMPLETE/DHA - prenat w/
iron cbn-fe asp glyc-fa-omega cap
30-10-1-200 mg
3
OBSTETRIX DHA - prenat w/fecbnfa-dss tab 29-1 mg & omega 3 cap
387 mg pak
3
OBSTETRIX EC - prenatal vit w/
3
PNV FERROUS FUMARATE/
DOCU - prenatal vit w/ dss-fe
3
PNV FOLIC ACID + IRON MUL prenatal vit w/ fe fumarate-fa tab
27-1 mg
3
PNV OB+DHA - prenat w/o a w/
250 mg pack
3
PNV PRENATAL PLUS MULTIVI prenatal vit w/ fe fumarate-fa tab
27-1 mg
3
PNV TABS 29-1 - prenatal vit w/ iron
3
PNV-DHA - prenat w/o a w/fefummethfol-fa-dha cap 27-0.6-0.4-300
mg
3
MYNATAL ULTRACAPLET - prenatal 3
vit w/ dss-iron carbonyl-fa tab 90-1
mg
3
MYNATAL-Z - prenatal vit w/ fe
3
MYNATE 90 PLUS - prenatal vit w/
dss-fe fumarate-fa tab cr 90-1 mg
NATACHEW - prenatal vit w/ fe fum- 3
fe bisglycin-fa chew tab 28-1 mg
3
NATALVIT - prenatal vit w/ fe
3
NATELLE ONE - prenatal w/o vit
a w/ fe fum-fa-omega 3 cap
28-1-250 mg
NEEVO DHA - prenat w/o a w/fefum- 3
methylfol-omegas cap 27-1.13 mg
3
NEPHROCAPS QT - b-complex w/
c-biotin-d & folic acid tab disp 1
mg
3
NESTABS - prenatal vit w/o vit a w/
fe bisglycinate-fa tab 32-1 mg
3
NESTABS ABC - prenatal w/o vit a
w/fe polysac-fa-ca tab & omega 3
cap
3
NESTABS DHA - prenat w/o a w/ fe
bisglyc-fa tab 32-1 mg & omega
cap pack
3
NEWGEN - prenatal vit w/o vit a w/
fe bisglycinate-fa tab 32-1 mg
NEXA PLUS - prenatal w/o vit a w/ fe 3
fum-doc-fa-dha cap 29-1.25-350
mg
3
NIVA-PLUS - prenatal vit w/ fe
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
106
PNV-DHA+DOCUSATE - prenatal w/ 3
o vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg
3
PNV-OMEGA - prenat w/o a w/ fe
fumerate-methylfolate-fa-omega 3
cap
3
PNV-SELECT - prenatal vit w/ fe
fum-methylfolate-fa tab 27-0.6-0.4
mg
3
PNV-TOTAL - prenat w/ fe cbn-fe
bisglyc-fa-fish oil cap 35-5-1.2 mg
3
PNV-VP-U - prenatal w/o a vit w/ fe
fumarate-fa cap 106.5-1 mg
PR NATAL 400 - prenat-fe bis-fe prot 3
succ-fa-ca tab & omega 3 cap 400
pk
PR NATAL 400 EC - prenat-fe bis-fe 3
prot succ-fa-ca tab & omega cap
dr 400 pk
PR NATAL 430 - prenat-fe bis-fe prot 3
succ-fa-ca tab & omega 3 cap 430
pk
PR NATAL 430 EC - prenat-fe bis-fe 3
prot succ-fa-ca tab & omega cap
dr 430 pk
3
PREFERA OB - prenat vit-fe poly
cmplx-fe heme poly-fa tab 34-1
mg
3
PREFERAOB +DHA - prenat-fe
poly cmplx 28mg-fe heme poly-fa
tab&dha cap pack
3
PREFERAOB ONE - prenat-fe poly
cmplx-fe heme poly-fa-dha cap
22-6-1-200 mg
3
PRENAISSANCE - prenatal w/o
vit a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg
3
PRENAISSANCE BALANCE prenatal w/o vit a w/ fe cbn-dss-fadha cap 30-1-260 mg
PRENAISSANCE HARMONY DHA - 3
prenat w/fe poly-na fered-fa tab
27-1 & omega cap dr 380mg
PRENAISSANCE NEXT - prenatal
w/ calcium-vit b6-fa-ginger tab 1.2
mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
3
PRENAISSANCE NEXT-B - prenatal 3
w/ calcium-vit b6-fa-ginger tab
1.22 mg
3
PRENAISSANCE PLUS - prenatal
28-1-250 mg
3
PRENATA - prenatal w/o a vit w/ fe
fum-fa tab chew 29-1 mg
3
PRENATABS FA - prenatal vit w/ fe
3
PRENATABS RX - prenatal vit w/
iron carbonyl-fa tab 29-1 mg
3
PRENATAL - prenatal vit w/ fe
PRENATAL PLUS - prenatal vit w/ fe 3
3
PRENATAL PLUS IRON - prenatal
vit w/ iron carbonyl-fa tab 29-1 mg
3
PRENATAL VITAMINS PLUS LO prenatal vit w/ fe fumarate-fa tab
27-1 mg
3
PRENATAL 19 - prenatal vit w/ dssfe fumarate-fa tab 29-1 mg
3
PRENATAL 19 - prenatal vit w/ fe
PRENATAL-U - prenatal w/o a vit w/ 3
fe fumarate-fa cap 106.5-1 mg
3
PRENATE - prenat mv & min w/ lmethylfolate-fa chew tab 0.6-0.4
mg
PRENATE AM - prenatal w/ calcium- 3
vit b6-vit b12-fa-ginger tab 1 mg
3
PRENATE DHA - prenat w/o a
w/feaspg-methfol-fa-dha cap
18-0.6-0.4-300 mg
3
PRENATE DHA - prenat w/o a
w/fefum-methfol-fa-dha cap
28-0.6-0.4-300 mg
107
PRENATE ELITE - prenatal vit w/ fe
fum-methylfolate-fa tab 26-0.6-0.4
mg
3
PRENATE ELITE - prenatal w/ fe asp 3
gly-l methylfol-fa tab 20-0.6-0.4
mg
3
PRENATE ENHANCE - prenat w/
o a w/fefum-methfol-fa-dha cap
28-0.6-0.4-400 mg
3
PRENATE ESSENTIAL - prenat w/
o a w/feasp-methylf-fa-omeg cap
29-0.6-0.4-340 mg
3
PRENATE ESSENTIAL - prenat w/
o a w/feaspg-methfol-fa-dha cap
18-0.6-0.4-300 mg
3
PRENATE MINI - prenat w/o a
w/fecbn-methylf-fa-dha cap
29-0.6-0.4-350 mg
3
PRENATE MINI - prenat w/oa w/
fecb-feasp-meth-fa-dha cap
18-0.6-0.4-350 mg
3
PRENATE PIXIE - prenat w/o a
w/feaspg-methfol-fa-dha cap
10-0.6-0.4-200 mg
3
PRENATE RESTORE - prenat w/
o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-400 mg
3
PRENATE STAR - prenatal vit w/ fe
asparto glycinate-fa tab 20-1 mg
3
PRENA1 CHEW - prenat w/ b2-b6b12-d3-folic acid chew tab 1.4 mg
3
PRENA1 PEARL - prenat w/oa w/
fefum-na fered-fa-dha cap cr
30-1.4-200 mg
3
PREPLUS - prenatal vit w/ fe
3
PREQUE 10 - prenatal mv w/
fe carbonyl-dss-fa-dha tab
15-25-0.5-50 mg
3
PRETAB - prenatal vit w/ fe
PROVIDA DHA - prenat w/o a
w/fe fum-fe poly-fa-dha cap
16-16-1.25-110 mg
3
PROVIDA OB - prenatal w/o a w/fe
fum-fe poly-fa cap 20-20-1.25 mg
3
PUREFE OB PLUS - prenatal
w/o a w/fe fum-fe poly-fa cap
162.115.2-1 mg
3
R-NATAL OB - prenatal w/o a w/fe
cbn-fa-dha cap 20-1-320 mg
3
RELNATE DHA - prenatal vit w/ fe
fum-fa-omega 3 cap 28-1-200 mg
3
RULAVITE DHA - prenat w/o a
27-0.6-0.4-300 mg
3
SE-NATAL 19 - prenatal vit w/ dss-fe
3
SE-NATAL 19 - prenatal vit w/ fe
3
SE-TAN DHA - prenatal w/fe fum-fe
poly -fa-omega 3 cap 15-15-1 mg
3
SELECT-OB - prenat w/
fepolycmplx-methylfol-fa chew tab
29-0.6-0.4 mg
3
SELECT-OB - prenatal vit w/ fe
polysac cmplx-fa chew tab 29-1
mg
3
SELECT-OB+DHA - prenatal mv w/
fe poly-fa chw 29-1 mg & dha cap
250 mg pak
3
TARON-BC - prenat w/o a w/ fe
cbnyl-fa tab 20-1 mg & vit b6 tab
pak
3
TARON-C DHA - prenatal w/fe fumfe poly -fa-omega 3 cap 53.5-38-1
mg
3
TARON-PREX - prenatal w/o vit a w/
fe fum-dss-fa-dha cap 30-1.2-265
mg
3
THRIVITE RX - prenatal vit w/ iron
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
108
THRIVITE 19 - prenatal vit w/ dss-fe
3
TL FOLATE - prenatal vit w/ fe fummethylfolate-fa tab 27-0.5-0.5 mg
3
TL-CARE DHA - prenatal w/fe
fumarate-fa-dss-fish oil cap
27-1-500 mg
ULTIMATECARE ONE - prenatal vit
w/ fe cbn-fe asp glyc-fa-omega 3
cap 27-1mg
3
3
3
ULTIMATECARE ONE NF - prenatal
w/fe cbnyl-fe asp glyc-fa-dssomega cap 20-7-1 mg
3
TL-SELECT - prenatal w/o vit a w/ fe
fum-dss-fa-dha cap 29-1.25-325
mg
3
VEMAVITE-PRX 2 - prenatal w/o
vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg
3
TRI-TABS DHA - prenat w/o a w/ fe
bisglyc-fa tab 32-1 mg & omega
cap pack
3
VENA-BAL DHA - prenat w/fe polyna fered-fa tab 27-1 & omega cap
dr 430mg
3
TRIADVANCE - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
3
VINACAL B - prenat w/o a w/fecbnfeglu-fa tab 20-1 mg & vit b6 tab
pak
TRICARE - prenatal vit w/ fe
3
3
TRICARE PRENATAL - prenat w/o a
w/fepyro-mfol chw 4.5-1 mg & dha
cap 150 thpk
3
VINATE AZ EXTRA - prenatal vit w/
fe bisglycinate chelate-fa tab 29-1
mg
VINATE C - prenatal w/o a vit w/ fe
3
TRICARE PRENATAL COMPLEAT prenat w/o a fefum-fa tab 27-1 mg
& fish oil chew cap pak
3
VINATE CALCIUM - prenatal vit w/
iron carbonyl-fe gluc-fa tab 27-1
mg
3
TRICARE PRENATAL DHA ONE prenatal w/fe fumarate-fa-dss-fish
oil cap 27-1-500 mg
3
TRINATAL GT - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
3
TRINATAL RX 1 - prenatal vit w/ fe
3
TRINATE - prenatal vit w/ fe
3
TRISTART DHA - prenat w/o a
w/fecbn-methylf-fa-dha cap
31-0.6-0.4-200 mg
3
TRIVEEN-DUO DHA - prenat-fe bisfe prot succ-fa-ca tab & omega 3
cap 400 pk
3
TRIVEEN-PRX RNF - prenatal w/
o vit a w/ fe fum-dss-fa-dha cap
26-1.2-300 mg
3
VINATE CARE - prenatal w/o a vit w/ 3
fe fum-fa tab chew 40-1 mg
3
VINATE DHA RF - prenat w/o a
w/fefum-methylfol-omegas cap
27-1.13 mg
VINATE IC - prenatal w/o a w/fe fum- 3
fe poly-fa cap 162.115.2-1 mg
3
VINATE II - prenatal vit w/ fe
bisglycinate chelate-fa tab 29-1
mg
3
VINATE M - prenatal vit w/ sel-fe
3
VINATE ONE - prenatal vit w/ fe
3
VIRT NATE - prenatal vit w/ fe
3
VIRT-ADVANCE - prenatal vit w/
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
109
VIRT-C DHA - prenatal w/fe fum-fe
poly -fa-omega 3 cap 53.5-38-1
mg
3
VITAFOL-ONE - prenatal mv w/
fe polysac cmplx-fa-dha cap
29-1-200 mg
VIRT-CARE ONE - prenatal vit w/ fe
cbn-fe asp glyc-fa-omega 3 cap
27-1mg
3
VIRT-NATE DHA - prenatal vit w/ fe
fum-fa-omega 3 cap 28-1-200 mg
3
VIRT-PN - prenatal vit w/ fe fummethylfolate-fa tab 27-0.6-0.4 mg
3
VIRT-PN DHA - prenat w/o a
27-0.6-0.4-300 mg
3
VIRT-PN PLUS - prenat w/o a w/ fe
fumerate-methylfolate-fa-omega 3
cap
3
VIRT-SELECT - prenatal w/o vit
a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg
3
VIRT-VITE GT - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
3
VIRTPREX - prenatal w/o vit a w/ fe
fum-dss-fa-dha cap 26-1.2-300
mg
3
VITA-PREN - prenatal vit w/
docusate-iron-fa tab 65-1 mg
3
VITAFOL FE+ - prenat-fepolymethol-fa-dha cap 90-1-200 mg &
dss 50mg cap
3
VITAFOL GUMMIES - prenat vit
w/ fe phos-fa-omega chew tab
3.33-0.333-34.8 mg
3
VITAFOL ULTRA - prenat w/
fe poly-methylfol-fa-dha cap
29-0.6-0.4-200 mg
3
VITAFOL-NANO - prenatal w/o a w/
fefum-l methylfol-fa tab 18-0.6-0.4
mg
3
VITAFOL-OB - prenatal vit w/ fe
3
VITAFOL-OB+DHA - prenatal mv w/
fe fum-fa tab 65-1 mg & dha cap
250 mg pack
3
VITAMEDMD ONE RX/QUATREFO - 3
prenat w/o a w/fefum-methfol-fadha cap 30-0.6-0.4-200 mg
3
VITAMEDMD PLUS RX/QUATRE prenat w/o a w/ fe chelate-l
methylfol-fa tab & dha cap pk
3
VITAMEDMD REDICHEW RX prenat w/ b2-b6-b12-d3-folic acid
chew tab 1.4 mg
3
VITAPEARL - prenat w/oa w/fefumna fered-fa-dha cap cr 30-1.4-200
mg
3
VITATRUE - prenat w/o a w/fe
chel-fa tab 30-1.4 mg & dha cap
300mg pk
VIVA DHA - prenatal vit w/ fe fum-fa- 3
omega 3 cap 28-1-200 mg
3
VOL-NATE - prenatal vit w/ fe
3
VOL-PLUS - prenatal vit w/ fe
3
VOL-TAB RX - prenatal vit w/ iron
3
VP-CH PLUS - prenatal w/o a w/fe
cbn-dss-fa-dha cap 29-1-265 mg
VP-CH-PNV - prenatal w/o vit a w/ fe 3
3
VP-GGR-B6 PRENATAL - prenatal
w/ calcium-vit b6-fa-ginger tab 1.2
mg
3
VP-HEME OB - prenat vit-fe poly
cmplx-fe heme poly-fa tab 28-6-1
mg
3
VP-HEME OB + DHA - prenat-fe
poly cmplx-fe heme poly-fa tab &
omega 3 cap pck
3
VP-HEME ONE - prenat-fe poly
cmplx-fe heme poly-fa-dha cap
22-6-1-200 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
3
110
VP-PNV-DHA - prenatal vit w/ fe
fum-fa-omega 3 cap 28-1-215.8
mg
3
K-TAB - potassium chloride tab cr 10
meq
3
meq (1500 mg)
3
ZATEAN-CH - prenatal w/o a w/fe
3
KLOR-CON M15 - potassium
chloride microencapsulated crys
cr tab 15 meq
3
ZATEAN-PN DHA - prenat w/o
a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
3
3
LOZI-FLUR - sodium fluoride
lozenge 1 mg f (from 2.2 mg naf)
3
ZATEAN-PN PLUS - prenat w/o a w/
fe fumerate-methylfolate-fa-omega
3 cap
LURIDE - sodium fluoride chew tab
0.25 mg f (from 0.55 mg naf)
3
LURIDE - sodium fluoride chew tab
0.5 mg f (from 1.1 mg naf)
3
MINERALS and ELECTROLYTES
EFFER-K - potassium bicarbonatecitric acid effer tab 10 meq
3
EFFER-K - potassium bicarbonatecitric acid effer tab 20 meq
3
FLORIVA - sodium fluoride-vitamin d
liqd drops 0.25 mg/ml-400 unit/ml
3
FLUOR-A-DAY - sodium fluoridexylitol chew tab 0.55 (0.25 mg
f)-236.79 mg
3
FLUOR-A-DAY - sodium fluoridexylitol chew tab 2.2 (1 mg
f)-236.79 mg
3
FLUORABON - sodium fluoride
soln 0.25 mg/0.6ml (from 0.55
mg/0.6ml naf)
3
FLURA-DROPS - sodium fluoride
soln 0.25 mg/drop f (from 0.55 mg/
drop naf)
3
GALZIN - zinc acetate cap 25 mg
(elemental zinc)
3
GALZIN - zinc acetate cap 50 mg
(elemental zinc)
3
K-PHOS - potassium phosphate
monobasic tab 500 mg
3
K-PHOS NEUTRAL - pot phos
monobasic w/sod phos di &
monobas tab 155-852-130mg
3
meq (600 mg)
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
LURIDE - sodium fluoride chew tab 1 3
mg f (from 2.2 mg naf)
3
LURIDE - sodium fluoride soln 0.5
mg/ml f (from 1.1 mg/ml naf)
3
MICRO-K - potassium chloride cap
cr 8 meq
3
MICRO-K - potassium chloride cap
cr 10 meq
1
pot bicarbonate & chloride effer
tab 25 meq
1
pot phos monobasic w/sod
phos di & monobas tab
155-852-130mg (K-phos neutral)
1
potassium bicarbonate effer tab
25 meq
1
potassium chloride cap cr 8 meq
(Micro-k)
potassium chloride cap cr 10 meq 1
(Micro-k)
3
POTASSIUM CHLORIDE ER potassium chloride tab cr 8 meq
(600 mg)
3
POTASSIUM CHLORIDE ER potassium chloride tab cr 20 meq
(1500 mg)
1
potassium chloride
microencapsulated crys cr tab
10 meq
111
potassium chloride
microencapsulated crys cr tab
20 meq
potassium chloride oral soln 10%
(20 meq/15ml)
potassium chloride oral soln 20%
(40 meq/15ml)
potassium chloride powder
packet 20 meq
potassium chloride tab cr 8 meq
(600 mg) (K-tab)
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 200 mcg/
ml
4
• •
ml
4
• •
ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled
syringe 10 mcg/0.4ml
4
• •
4
• •
4
• •
4
• •
4
• •
3
4
• •
1
4
• •
4
• •
syringe 500 mcg/ml
4
• •
1
1
P
P
P
P
3
NUTRESTORE - glutamine powd
pack 5 gm
3
HEMATOLOGICAL AGENTS
4
• •
• •
Responsible Steps
4
Quantity Limits
ml
1
LECITHIN - lecithin granules
ml
Prior Authorization
• •
P
HEMATOPOIETIC AGENTS
Specialty
4
sodium fluoride chew tab 0.25 mg
f (from 0.55 mg naf) (Luride)
acetylcysteine cap 600 mg
Drug Tier
ml
2
NUTRIENTS
1
SODIUM FLUORIDE - sodium
fluoride tab 1 mg f (from 2.2 mg
naf)
SSKI - potassium iodide soln 1 gm/
ml
Responsible Steps
• •
2
sodium fluoride soln 0.5 mg/ml f
(from 1.1 mg/ml naf) (Luride)
Quantity Limits
4
SODIUM FLUORIDE - sodium
fluoride tab 0.5 mg f (from 1.1 mg
naf)
sodium fluoride soln 0.125 mg/
drop f (0.275 mg/drop naf)
Prior Authorization
ml
1
sodium fluoride chew tab 1 mg f
(from 2.2 mg naf) (Luride)
Drug Name
1
potassium chloride tab cr 10 meq
(K-tab)
sodium fluoride chew tab 0.5 mg f
(from 1.1 mg naf) (Luride)
Specialty
Drug Name
Drug Tier
2016
112
carbonyl iron susp 15 mg/1.25ml
(elemental iron)
4
cyanocobalamin inj 1000 mcg/ml
1
DROXIA - hydroxyurea cap 200 mg
2
2
2
EPOGEN - epoetin alfa inj 2000 unit/ 4
ml
ml
ml
4
EPOGEN - epoetin alfa inj 10000
unit/ml
4
EPOGEN - epoetin alfa inj 20000
unit/ml
3
FERROUS SULFATE - ferrous
sulfate liquid 220 mg/5ml (44
mg/5ml elemental fe)
P
ferrous sulfate elixir 220 mg/5ml
(44 mg/5ml elemental fe)
P
ferrous sulfate soln 75 mg/ml
(15 mg/ml elemental fe)
P
folic acid tab 400 mcg
folic acid tab 1 mg
FOLIVANE-F - fe fum-fe poly-fa-c-b3
cap 62.5-62.5-1-40-3mg(125 mg
fe)
• • •
• •
• •
• •
• •
• •
P
1
3
GRANIX - tbo-filgrastim soln prefilled 4
GRANIX - tbo-filgrastim soln prefilled 4
3
INTEGRA F - fe fum-fe poly-fa-c-b3
cap 62.5-62.5-1-40-3mg(125 mg
fe)
LEUKINE - sargramostim lyophilized 4
for inj 250 mcg
• •
• •
• •
•
4
•
MIRCERA - methoxy peg-epoetin
beta soln prefilled syr 75
mcg/0.3ml
4
•
mcg/0.3ml
4
•
mcg/0.3ml
4
•
NASCOBAL - cyanocobalamin nasal
spray 500 mcg/0.1ml
3
NEULASTA - pegfilgrastim soln
4
• • •
NEULASTA ONPRO KIT pegfilgrastim soln prefilled syringe
kit 6 mg/0.6ml
4
• • •
NEUPOGEN - filgrastim inj 300 mcg/ 4
ml
4
NEUPOGEN - filgrastim inj 480
mcg/1.6ml (300 mcg/ml)
NEUPOGEN - filgrastim soln prefilled 4
NEUPOGEN - filgrastim soln prefilled 4
syringe 480 mcg/0.8ml (600 mcg/
ml)
PROCRIT - epoetin alfa inj 2000 unit/ 4
ml
ml
ml
4
PROCRIT - epoetin alfa inj 10000
unit/ml
4
unit/ml
4
unit/ml
PROMACTA - eltrombopag olamine 4
mcg/0.3ml
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
P
CERDELGA - eliglustat tartrate cap
folic acid tab 800 mcg
Specialty
Drug Name
Drug Tier
2016
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• • •
•
113
PROMACTA - eltrombopag olamine
4
• • •
•
1
•
4
• • •
•
1
•
ZARXIO - filgrastim-sndz soln
prefilled syringe 300 mcg/0.5ml
4
• •
1
•
ZARXIO - filgrastim-sndz soln
prefilled syringe 480 mcg/0.8ml
4
• •
enoxaparin sodium inj 100 mg/ml
(Lovenox)
1
•
ZAVESCA - miglustat cap 100 mg
4
• • •
enoxaparin sodium inj
120 mg/0.8ml (Lovenox)
1
•
ARIXTRA - fondaparinux sodium
subcutaneous inj 2.5 mg/0.5ml
3
•
enoxaparin sodium inj 150 mg/ml
(Lovenox)
1
•
3
•
300 mg/3ml (Lovenox)
1
•
3
•
1
•
3
•
fondaparinux sodium
(Arixtra)
1
•
COUMADIN - warfarin sodium tab 1
mg
3
fondaparinux sodium
(Arixtra)
mg
3
1
•
COUMADIN - warfarin sodium tab
2.5 mg
3
fondaparinux sodium
(Arixtra)
1
•
mg
3
fondaparinux sodium
(Arixtra)
FRAGMIN - dalteparin sodium inj
10000 unit/ml
3
mg
3
•
2500 unit/0.2ml
3
mg
3
•
5000 unit/0.2ml
3
mg
3
•
3
3
COUMADIN - warfarin sodium tab
7.5 mg
7500 unit/0.3ml
•
12500 unit/0.5ml
3
•
15000 unit/0.6ml
3
•
18000 unit/0.72ml
3
•
COUMADIN - warfarin sodium tab 10 3
mg
2
ELIQUIS - apixaban tab 2.5 mg
ELIQUIS - apixaban tab 5 mg
2
•
•
•
•
Responsible Steps
1
ANTICOAGULANTS
•
Quantity Limits
• • •
Prior Authorization
4
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
114
95000 unit/3.8ml
3
heparin sodium (porcine) inj 5000
unit/ml
1
LOVENOX - enoxaparin sodium inj
30 mg/0.3ml
3
•
40 mg/0.4ml
3
•
60 mg/0.6ml
3
•
80 mg/0.8ml
3
•
100 mg/ml
3
•
120 mg/0.8ml
3
•
150 mg/ml
3
•
300 mg/3ml
3
•
PRADAXA - dabigatran etexilate
mesylate cap 75 mg (etexilate
base eq)
2
•
base eq)
2
•
base eq)
2
•
SAVAYSA - edoxaban tosylate tab
3
•
3
•
3
•
warfarin sodium tab 1 mg
(Coumadin)
1
(Coumadin)
1
warfarin sodium tab 2.5 mg
(Coumadin)
1
(Coumadin)
1
(Coumadin)
1
(Coumadin)
1
(Coumadin)
1
warfarin sodium tab 7.5 mg
(Coumadin)
1
(Coumadin)
1
XARELTO - rivaroxaban tab 10 mg
2
2
2
XARELTO STARTER PACK rivaroxaban tab starter therapy
pack 15 mg & 20 mg
2
HEMOSTATICS
AMICAR - aminocaproic acid oral
soln 0.25 gm/ml
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
•
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
•
•
•
•
3
AMICAR - aminocaproic acid tab 500 3
mg
3
AMICAR - aminocaproic acid tab
1000 mg
LYSTEDA - tranexamic acid tab 650 3
mg
1
tranexamic acid tab 650 mg
(Lysteda)
HEMATOLOGICAL AGENTS - MISC.
ADVATE - antihemophilic factor rahfpfm for inj 250 unit
4
• •
4
• •
4
• •
4
• •
4
• •
115
• •
ADYNOVATE - antihemophilic factor
recomb pegylated for inj 500 unit
4
• •
4
• •
4
• •
AFSTYLA - antihemophilic fact rcmb
single chain for inj kit 250 unit
4
•
4
•
4
•
4
•
4
•
ALPHANINE SD - coagulation factor
ix for inj 500 unit
4
• •
ix for inj 1000 unit
4
• •
ix for inj 1500 unit
4
• •
ALPROLIX - coagulation factor ix
(recomb) (rfixfc) for inj 250 unit
4
• •
•
4
• •
•
4
• •
•
4
• •
•
4
• •
•
anagrelide hcl cap 0.5 mg (Agrylin) 1
1
anagrelide hcl cap 1 mg
ASPIRIN/DIPYRIDAMOLE - aspirindipyridamole cap sr 12hr 25-200
mg
3
BEBULIN - factor ix complex for inj
200-1200 unit
4
AGGRENOX - aspirin-dipyridamole
cap sr 12hr 25-200 mg
3
• •
3
4
AGRYLIN - anagrelide hcl cap 0.5
mg
BENEFIX - coagulation factor ix
(recombinant) for inj 250 unit
• •
4
4
ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human)
for inj 250 unit
• •
4
• •
for inj 500 unit
4
• •
4
• •
for inj 1000 unit
4
• •
4
• •
4
• •
for inj 1500 unit
4
BERINERT - c1 esterase inhibitor
(human) for iv inj kit 500 unit
BRILINTA - ticagrelor tab 60 mg
2
2
for inj 2000 unit
4
BRILINTA - ticagrelor tab 90 mg
cilostazol tab 50 mg (Pletal)
1
• •
• •
• •
4
Responsible Steps
Quantity Limits
• •
Prior Authorization
4
Specialty
Drug Name
Drug Tier
• •
4
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
cilostazol tab 100 mg (Pletal)
•
1
116
CINRYZE - c1 esterase inhibitor
(human) for iv inj 500 unit
4
clopidogrel bisulfate tab 75 mg
(base equiv) (Plavix)
1
clopidogrel bisulfate tab 300 mg
(base equiv) (Plavix)
1
COAGADEX - coagulation factor x
(human) for inj 250 unit
4
• •
•
COAGADEX - coagulation factor x
4
• •
•
CORIFACT - factor xiii concentrate
(human) for inj kit 1000-1600 unit
4
• •
•
dipyridamole tab 25 mg
(Persantine)
1
(Persantine)
1
(Persantine)
1
EFFIENT - prasugrel hcl tab 5 mg
(base equiv)
3
EFFIENT - prasugrel hcl tab 10 mg
(base equiv)
3
ELOCTATE - antihemophilic factor
(recomb) rfviiifc for inj 250 unit
4
• •
•
4
• •
•
4
• •
•
4
• •
•
4
• •
•
4
• •
•
4
• •
•
FEIBA - antiinhibitor coagulant
complex for inj
4
• •
FIRAZYR - icatibant acetate inj 30
mg/3ml (base equivalent)
4
• •
•
HELIXATE FS - antihemophilic factor 4
(recombinant) for inj kit 250 unit
4
HEMOFIL M - antihemophilic factor
4
4
4
4
HUMATE-P - antihemophilic factor/
vwf (human) for inj 250-600 unit
4
4
4
IDELVION - coagulation factor ix
(recomb) (rix-fp) for inj 250 unit
4
4
4
4
IXINITY - coagulation factor ix
4
4
4
KOATE-DVI - antihemophilic factor
Responsible Steps
• •
Quantity Limits
Prior Authorization
Specialty
•
Drug Name
Drug Tier
Responsible Steps
• •
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
•
•
•
•
• •
•
• •
•
• •
•
• •
117
• •
KOGENATE FS - antihemophilic
factor (recombinant) for inj kit 500
unit
4
• •
factor (recombinant) for inj kit
1000 unit
4
• •
2000 unit
4
• •
3000 unit
4
• •
KOGENATE FS BIO-SET antihemophilic factor
4
• •
4
4
• •
4
• •
4
• •
KOVALTRY - antihemophilic factor
4
• •
4
• •
4
4
• •
• •
• •
4
Responsible Steps
factor (recombinant) for inj kit 250
unit
Quantity Limits
• •
Prior Authorization
4
Specialty
Drug Name
Drug Tier
• •
4
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
4
• •
MONOCLATE-P - antihemophilic
factor (human) for inj kit 250 unit
4
• •
4
• •
4
• •
MONONINE - coagulation factor ix
for inj 500 unit
4
• •
MONONINE - coagulation factor ix
for inj 1000 unit
4
• •
NOVOEIGHT - antihemophilic factor
4
• •
4
• •
4
• •
4
• •
4
• •
4
• •
NOVOSEVEN RT - coagulation
factor viia (recomb) for inj 1 mg
(1000 mcg)
4
• •
•
(2000 mcg)
4
• •
•
(5000 mcg)
4
• •
•
(8000 mcg)
4
• •
•
NUWIQ - antihemophilic factor
4
• •
4
• •
4
• •
118
• •
4
• •
4
• •
OBIZUR - antihemophilic factor
(recomb porc) rpfviii for inj 500
unit
4
• •
pentoxifylline tab cr 400 mg
1
PROFILNINE - factor ix complex for
inj 500 unit
4
• •
inj 1000 unit
4
• •
inj 1500 unit
4
• •
PROFILNINE SD - factor ix complex
for inj 500 unit
4
• •
for inj 1000 unit
4
• •
for inj 1500 unit
4
• •
RECOMBINATE - antihemophilic
factor (recombinant) for inj
220-400 unit
4
• •
401-800 unit
4
801-1240 unit
4
1241-1800 unit
4
1801-2400 unit
4
• •
• •
• •
• •
•
4
Responsible Steps
Quantity Limits
• •
Prior Authorization
4
Specialty
Drug Name
Drug Tier
• •
4
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
RIXUBIS - coagulation factor ix
4
• •
4
• •
4
• •
4
• •
4
• •
RUCONEST - c1 esterase inhibitor
(recombinant) for iv inj 2100 unit
4
• •
•
TRETTEN - coagulation factor xiii asubunit for inj 2000-3125 unit
4
• •
•
VONVENDI - von willebrand factor
4
•
WILATE - antihemophilic factor/vwf
(human) for inj 500-500 unit kit
4
• •
WILATE - antihemophilic factor/vwf
(human) for inj 1000-1000 unit kit
4
• •
XYNTHA - antihemophilic factor
recombinant paf for inj kit 250 unit
4
• •
recombinant paf for inj kit 500 unit
4
• •
recombinant paf for inj kit 1000
unit
4
• •
recombinant paf for inj kit 2000
unit
4
• •
XYNTHA SOLOFUSE antihemophilic factor recombinant
paf for inj kit 250 unit
4
• •
4
• •
4
• •
4
• •
119
4
ZONTIVITY - vorapaxar sulfate tab
3
TOPICAL PRODUCTS
OPHTHALMIC AGENTS
bacitracin-polymyxin-neomycinhc ophth oint 1%
BEPREVE - bepotastine besilate
ophth soln 1.5%
3
BESIVANCE - besifloxacin hcl ophth
susp 0.6% (base equiv)
3
3
ACULAR - ketorolac tromethamine
ophth soln 0.5%
3
3
ACULAR LS - ketorolac
tromethamine ophth soln 0.4%
3
BETAGAN - levobunolol hcl ophth
soln 0.5%
1
ACUVAIL - ketorolac tromethamine
ophth soln 0.45%
3
betaxolol hcl ophth soln 0.5%
AKTEN - lidocaine hcl ophth gel
3.5%
3
ALCAINE - proparacaine hcl ophth
soln 0.5%
3
BETIMOL - timolol ophth soln 0.25%
3
BETIMOL - timolol ophth soln 0.5%
3
BETOPTIC-S - betaxolol hcl ophth
susp 0.25%
3
BIMATOPROST - bimatoprost ophth
soln 0.03%
3
BLEPH-10 - sulfacetamide sodium
ophth soln 10%
3
BLEPHAMIDE - sulfacetamide
sodium-prednisolone ophth susp
10-0.2%
2
BLEPHAMIDE S.O.P. sulfacetamide sodiumprednisolone ophth oint 10-0.2%
2
brimonidine tartrate ophth soln
0.15% (Alphagan p)
1
brimonidine tartrate ophth soln
0.2%
3
bromfenac sodium ophth soln
0.09% (base equiv) (once-daily)
1
Responsible Steps
Quantity Limits
1
3
AZOPT - brinzolamide ophth susp
1%
3
CILOXAN - ciprofloxacin hcl ophth
oint 0.3%
3
BACITRACIN - bacitracin ophth oint
500 unit/gm
2
CILOXAN - ciprofloxacin hcl ophth
soln 0.3%
1
bacitracin-polymyxin b ophth oint
1
ciprofloxacin hcl ophth soln 0.3%
(Ciloxan)
•
1
BROMFENAC - bromfenac
sodium ophth soln 0.09% (base
equivalent)
carteolol hcl ophth soln 1%
Prior Authorization
1
BETADINE OPHTHALMIC PREP povidone-iodine ophth soln 5%
ALOCRIL - nedocromil sodium ophth 3
soln 2%
3
ALOMIDE - lodoxamide
tromethamine ophth soln 0.1%
ALPHAGAN P - brimonidine tartrate 2
ophth soln 0.1%
ALPHAGAN P - brimonidine tartrate 3
ophth soln 0.15%
3
ALREX - loteprednol etabonate
ophth susp 0.2%
apraclonidine hcl ophth soln 0.5% 1
(base equivalent) (Iopidine)
2
ATROPINE SULFATE - atropine
sulfate ophth oint 1%
1
ATROPINE SULFATE - atropine
sulfate ophth soln 1%
3
AZASITE - azithromycin ophth soln
1%
1
azelastine hcl ophth soln 0.05%
Specialty
Drug Name
Drug Tier
Responsible Steps
• •
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
120
COMBIGAN - brimonidine tartratetimolol maleate ophth soln
0.2-0.5%
3
COSOPT - dorzolamide hcl-timolol
maleate ophth soln 22.3-6.8 mg/
ml
3
COSOPT PF - dorzolamide hcltimolol maleate ophth sol 22.3-6.8
mg/ml pf
3
cromolyn sodium ophth soln 4%
1
CYCLOGYL - cyclopentolate hcl
ophth soln 0.5%
3
ophth soln 1%
3
ophth soln 2%
3
CYCLOMYDRIL - cyclopentolate w/
phenylephrine ophth soln 0.2-1%
3
cyclopentolate hcl ophth soln
0.5% (Cyclogyl)
1
cyclopentolate hcl ophth soln 1%
(Cyclogyl)
1
cyclopentolate hcl ophth soln 2%
(Cyclogyl)
1
CYSTARAN - cysteamine hcl ophth
soln 0.44% (base equivalent)
4
DEXAMETHASONE SODIUM
PHOS - dexamethasone sodium
phosphate ophth soln 0.1%
3
diclofenac sodium ophth soln
0.1%
1
dorzolamide hcl ophth soln 2%
(Trusopt)
1
dorzolamide hcl-timolol maleate
ophth soln 22.3-6.8 mg/ml
(Cosopt)
1
DUREZOL - difluprednate ophth
emulsion 0.05%
3
ELESTAT - epinastine hcl ophth soln
0.05%
3
EMADINE - emedastine difumarate
ophth soln 0.05% (base equiv)
3
epinastine hcl ophth soln 0.05%
(Elestat)
1
erythromycin ophth oint 5 mg/gm
1
FLAREX - fluorometholone acetate
ophth susp 0.1%
3
fluorometholone ophth susp 0.1%
(Fml liquifilm)
1
flurbiprofen sodium ophth soln
0.03% (Ocufen)
1
FML - fluorometholone ophth oint
0.1%
•
•
•
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
3
FML FORTE - fluorometholone ophth 3
susp 0.25%
3
FML LIQUIFILM - fluorometholone
ophth susp 0.1%
1
gatifloxacin ophth soln 0.5%
(Zymaxid)
1
gentamicin sulfate ophth oint
0.3%
1
gentamicin sulfate ophth soln
0.3% (Garamycin)
1
homatropine hbr ophth soln 5%
(Isopto homatropine)
3
ILEVRO - nepafenac ophth susp
0.3%
3
IOPIDINE - apraclonidine hcl ophth
3
IOPIDINE - apraclonidine hcl ophth
soln 1% (base equivalent)
3
ISOPTO CARPINE - pilocarpine hcl
ophth soln 1%
3
ophth soln 2%
3
ophth soln 4%
3
ISTALOL - timolol maleate ophth
soln 0.5% (once-daily)
1
ketorolac tromethamine ophth
soln 0.4% (Acular ls)
1
ketorolac tromethamine ophth
soln 0.5% (Acular)
121
LACRISERT - artificial tear ophth
insert
LOTEMAX - loteprednol etabonate
ophth gel 0.5%
2
ophth oint 0.5%
2
ophth susp 0.5%
2
LUMIGAN - bimatoprost ophth soln
0.01%
2
MAXIDEX - dexamethasone ophth
susp 0.1%
3
MAXITROL - neomycin-polymyxindexamethasone ophth oint 0.1%
3
MAXITROL - neomycin-polymyxindexamethasone ophth susp 0.1%
3
METIPRANOLOL - metipranolol
ophth soln 0.3%
3
MITOSOL - mitomycin for ophth soln
kit 0.2 mg
3
MOXEZA - moxifloxacin hcl ophth
soln 0.5% (base eq) (2 times
daily)
3
MYDRIACYL - tropicamide ophth
soln 1%
3
NATACYN - natamycin ophth susp
5%
2
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op
oin
1
1
•
•
neomycin-polymyxindexamethasone ophth oint 0.1%
(Maxitrol)
1
neomycin-polymyxindexamethasone ophth susp
0.1% (Maxitrol)
1
NEOMYCIN/POLYMYXIN/
HYDROC - neomycin-polymyxinhc ophth susp
3
NEOSPORIN - neomycinpolymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml
3
NEVANAC - nepafenac ophth susp
0.1%
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
3
LASTACAFT - alcaftadine ophth soln 3
0.25%
1
latanoprost ophth soln 0.005%
(Xalatan)
1
levobunolol hcl ophth soln 0.5%
(Betagan)
1
levofloxacin ophth soln 0.5%
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml
(Neosporin)
Specialty
Drug Name
Drug Tier
2016
OCUFEN - flurbiprofen sodium ophth 3
soln 0.03%
3
OCUFLOX - ofloxacin ophth soln
0.3%
1
ofloxacin ophth soln 0.3%
(Ocuflox)
1
olopatadine hcl ophth soln 0.1%
(base equivalent) (Patanol)
3
OMNIPRED - prednisolone acetate
ophth susp 1%
2
PATADAY - olopatadine hcl ophth
3
PATANOL - olopatadine hcl ophth
PAZEO - olopatadine hcl ophth soln 2
0.7% (base equivalent)
1
phenylephrine hcl ophth soln
2.5%
phenylephrine hcl ophth soln 10% 1
PHOSPHOLINE IODIDE echothiophate iodide ophth for
soln 0.125%
3
pilocarpine hcl ophth soln 1%
(Isopto carpine)
1
(Isopto carpine)
1
(Isopto carpine)
1
122
polymyxin b-trimethoprim
ophth soln 10000 unit/ml-0.1%
(Polytrim)
1
POLYTRIM - polymyxin btrimethoprim ophth soln 10000
unit/ml-0.1%
3
PRED FORTE - prednisolone
acetate ophth susp 1%
3
PRED MILD - prednisolone acetate
ophth susp 0.12%
3
PRED-G - gentamicin-prednisolone
ace ophth susp 0.3-1%
3
PRED-G S.O.P. - gentamicinprednisolone ace ophth oint
0.3-0.6%
3
prednisolone acetate ophth susp
1% (Pred forte)
1
timolol maleate ophth gel forming
soln 0.25% (Timoptic-xe)
timolol maleate ophth gel forming
soln 0.5% (Timoptic-xe)
timolol maleate ophth soln 0.25%
(Timoptic)
1
timolol maleate ophth soln 0.5%
(Timoptic)
1
TIMOPTIC - timolol maleate ophth
soln 0.25%
3
TIMOPTIC - timolol maleate ophth
soln 0.5%
3
TIMOPTIC OCUDOSE - timolol
maleate preservative free ophth
soln 0.25%
3
TIMOPTIC OCUDOSE - timolol
maleate preservative free ophth
soln 0.5%
3
TIMOPTIC-XE - timolol maleate
ophth gel forming soln 0.25%
3
TIMOPTIC-XE - timolol maleate
ophth gel forming soln 0.5%
3
TOBRADEX - tobramycindexamethasone ophth oint
0.3-0.1%
2
TOBRADEX - tobramycindexamethasone ophth susp
0.3-0.1%
3
PROLENSA - bromfenac sodium
ophth soln 0.07% (base
equivalent)
3
proparacaine hcl ophth soln 0.5%
(Alcaine)
1
RESCULA - unoprostone isopropyl
ophth soln 0.15%
3
•
RESTASIS - cyclosporine (ophth)
emulsion 0.05%
3
• •
TOBRADEX ST - tobramycindexamethasone ophth susp
0.3-0.05%
3
SIMBRINZA - brinzolamidebrimonidine tartrate ophth susp
1-0.2%
3
tobramycin ophth soln 0.3%
(Tobrex)
1
SULFACETAMIDE SODIUM sulfacetamide sodium ophth oint
10%
3
1
sulfacetamide sodium ophth soln
10% (Bleph-10)
1
tobramycin-dexamethasone
ophth susp 0.3-0.1% (Tobradex)
tetracaine hcl ophth soln 0.5%
1
TOBREX - tobramycin ophth oint
0.3%
3
TOBREX - tobramycin ophth soln
0.3%
3
TRAVATAN Z - travoprost ophth soln
0.004% (benzalkonium free) (bak
free)
2
Responsible Steps
Quantity Limits
1
3
1
Prior Authorization
1
PREDNISOLONE SODIUM
PHOSP - prednisolone sodium
phosphate ophth soln 1%
sulfacetamide sodiumprednisolone ophth soln
10-0.23(0.25)%
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
•
123
TRAVOPROST - travoprost ophth
soln 0.004%
3
trifluridine ophth soln 1%
(Viroptic)
tropicamide ophth soln 0.5%
3
1
COLY-MYCIN S - neomycincolistin-hc-thonzonium otic susp
3.3-3-10-0.5 mg/ml
3
1
DERMOTIC - fluocinolone acetonide
(otic) oil 0.01%
tropicamide ophth soln 1%
(Mydriacyl)
1
FLOXIN OTIC - ofloxacin otic soln
0.3%
3
TRUSOPT - dorzolamide hcl ophth
soln 2%
3
fluocinolone acetonide (otic) oil
0.01% (Dermotic)
1
VEXOL - rimexolone ophth susp 1%
3
VIGAMOX - moxifloxacin hcl ophth
soln 0.5% (base equiv)
2
hydrocortisone w/ acetic acid otic
soln 1-2%
VIROPTIC - trifluridine ophth soln
1%
3
XALATAN - latanoprost ophth soln
0.005%
3
•
ZIOPTAN - tafluprost ophth soln
0.0015%
3
•
ZIRGAN - ganciclovir ophth gel
0.15%
3
ZYLET - loteprednol etabonatetobramycin ophth susp 0.5-0.3%
3
ZYMAXID - gatifloxacin ophth soln
0.5%
3
OTIC AGENTS
acetic acid otic soln 2%
1
ACETIC ACID/ALUMINUM ACET acetic acid 2% in aluminum
acetate otic soln
2
antipyrine-benzocaine otic soln
54-14 mg/ml (5.4-1.4%)
1
CETRAXAL - ciprofloxacin hcl otic
3
CIPRO HC - ciprofloxacinhydrocortisone otic susp 0.2-1%
3
CIPRODEX - ciprofloxacindexamethasone otic susp
0.3-0.1%
2
CIPROFLOXACIN - ciprofloxacin hcl
otic soln 0.2% (base equivalent)
3
neomycin-polymyxin-hc otic soln
1% (Cortisporin)
neomycin-polymyxin-hc otic susp
3.5 mg/ml-10000 unit/ml-1%
ofloxacin otic soln 0.3%
MOUTH/THROAT/DENTAL AGENTS
benzocaine dental soln 20%
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
•
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
1
1
cevimeline hcl cap 30 mg (Evoxac) 1
1
chlorhexidine gluconate soln
0.12% (Peridex)
1
clotrimazole troche 10 mg
EVOXAC - cevimeline hcl cap 30 mg 3
3
LIDOCAINE HCL - lidocaine hcl
laryngotracheal soln 4%
1
lidocaine hcl viscous soln 2%
nystatin susp 100000 unit/ml
1
ORAVIG - miconazole buccal tab 50
mg (mouth-throat)
3
PERIDEX - chlorhexidine gluconate
soln 0.12%
3
pilocarpine hcl tab 5 mg (Salagen) 1
1
pilocarpine hcl tab 7.5 mg
(Salagen)
SALAGEN - pilocarpine hcl tab 5 mg 3
SALAGEN - pilocarpine hcl tab 7.5
mg
3
triamcinolone acetonide dental
paste 0.1%
1
ANORECTAL AGENTS
124
ANALPRAM HC - hydrocortisone
acetate w/ pramoxine rectal cream
2.5-1%
3
ANALPRAM HC SINGLES hydrocortisone acetate w/
pramoxine rectal cream 2.5-1%
3
ANALPRAM-HC - hydrocortisone
acetate w/ pramoxine rectal cream
1-1%
3
ANALPRAM-HC - hydrocortisone
acetate w/ pramoxine rectal lotn
2.5-1%
3
DERMATOLOGICALS
ACANYA - clindamycin phosphatebenzoyl peroxide gel 1.2-2.5%
3
ANALPRAM-HC SINGLES hydrocortisone acetate w/
pramoxine rectal cream 1-1%
3
acitretin cap 10 mg (Soriatane)
1
ANALPRAM-HC SINGLES hydrocortisone acetate w/
3
ANUSOL-HC - hydrocortisone rectal
cream 2.5%
3
CORTENEMA - hydrocortisone
enema 100 mg/60ml
PROCTOCORT - hydrocortisone
rectal cream 1%
UCERIS - budesonide rectal foam 2
mg/act
acitretin cap 25 mg (Soriatane)
ACLOVATE - alclometasone
dipropionate cream 0.05%
3
acyclovir oint 5% (Zovirax)
1
ADAPALENE - adapalene lotion
0.1%
3
CORTIFOAM - hydrocortisone
acetate rectal foam 10% (90 mg/
dose)
2
adapalene cream 0.1% (Differin)
1
hydrocortisone acetate suppos
25 mg (Anusol-hc)
1
adapalene gel 0.1% (Differin)
hydrocortisone enema
100 mg/60ml (Cortenema)
1
3
1
Responsible Steps
1
3
hydrocortisone acetate w/
(Analpram-hc)
Quantity Limits
3
ACZONE - dapsone gel 5%
1
Prior Authorization
3
PROCTOFOAM HC - hydrocortisone 2
acetate w/ pramoxine rectal foam
1-1%
3
RECTIV - nitroglycerin oint 0.4%
acitretin cap 17.5 mg (Soriatane)
hydrocortisone acetate w/
pramoxine rectal cream 1-1%
(Analpram-hc)
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
adapalene gel 0.3% (Differin)
1
1
ALA SCALP - hydrocortisone lotion
2%
3
alclometasone dipropionate
cream 0.05% (Aclovate)
1
alclometasone dipropionate oint
0.05%
1
ALTABAX - retapamulin oint 1%
3
1
AMCINONIDE - amcinonide cream
0.1%
3
hydrocortisone rectal cream 1%
(Proctocort)
1
AMCINONIDE - amcinonide lotion
0.1%
3
hydrocortisone rectal cream 2.5%
(Anusol-hc)
1
AMCINONIDE - amcinonide oint
0.1%
3
LIDOCAINE HCL-HYDROCORTIS lidocaine-hydrocortisone acetate
rectal gel 2.8-0.55%
3
APEXICON E - diflorasone diacetate
emollient base cream 0.05%
3
125
ARZOL SILVER NITRATE APP silver nitrate-potassium nitrate
applicator 75-25%
3
betamethasone dipropionate
augmented lotion 0.05%
(Diprolene)
1
AVAR - sulfacetamide sodium w/
sulfur foam 9.5-5%
3
1
AVAR LS - sulfacetamide sodium w/
sulfur foam 10-2%
3
augmented oint 0.05%
(Diprolene)
1
AZELEX - azelaic acid cream 20%
3
cream 0.05%
BACTROBAN - mupirocin calcium
cream 2%
3
lotion 0.05%
BENZAC AC WASH - benzoyl
peroxide liq 5%
3
betamethasone dipropionate oint
0.05%
BENZACLIN - clindamycin
phosphate-benzoyl peroxide gel
1-5%
3
betamethasone valerate aerosol
foam 0.12% (Luxiq)
BENZACLIN WITH PUMP clindamycin phosphate-benzoyl
peroxide gel 1-5%
3
BENZAMYCIN - benzoyl peroxideerythromycin gel 5-3%
3
BENZAMYCINPAK - benzoyl
peroxide-erythromycin gel pack
5-3%
3
BENZIQ - benzoyl peroxide gel 5.25
%
3
BENZIQ LS - benzoyl peroxide gel
2.75%
3
benzoyl peroxide gel 10%
1
betamethasone valerate cream
0.1%
betamethasone valerate lotion
0.1%
betamethasone valerate oint 0.1%
1
1
1
1
1
1
•
calcipotriene oint 0.005%
1
1
•
•
calcipotriene-betamethasone
dipropionate oint 0.005-0.064%
(Taclonex)
1
•
CALCITRIOL - calcitriol oint 3 mcg/
gm
3
•
2
1
CAPEX - fluocinolone acetonide
shampoo 0.01%
benzoyl peroxideerythromycin gel 5-3%
(Benzamycin)
1
CARAC - fluorouracil cream 0.5%
2
CENTANY - mupirocin oint 2%
3
1
ciclopirox gel 0.77%
1
augmented cream 0.05%
(Diprolene af)
augmented gel 0.05%
1
benzoyl peroxide liq 10%
benzoyl peroxide liq 5.25%
benzoyl peroxide lotion 6%
1
1
ciclopirox olamine cream 0.77%
(base equiv)
ciclopirox olamine susp 0.77%
(base equiv)
ciclopirox shampoo 1% (Loprox
shampoo)
1
calcipotriene cream 0.005%
(Dovonex)
calcipotriene soln 0.005%
(50 mcg/ml)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
126
ciclopirox solution 8% (Penlac
Nail Lacquer)
1
CLEOCIN-T - clindamycin phosphate 3
lotion 1%
soln 1%
swab 1%
1
clindamycin phosph-benzoyl
peroxide (refrig) gel 1.2 (1)-5%
(Duac)
1
clindamycin phosphate foam 1%
(Evoclin)
1
clindamycin phosphate gel 1%
(Cleocin-t)
clindamycin phosphate lotion 1% 1
(Cleocin-t)
1
clindamycin phosphate soln 1%
(Cleocin-t)
1
clindamycin phosphate swab 1%
(Cleocin-t)
1
clindamycin phosphate-benzoyl
peroxide gel 1-5% (Benzaclin)
1
clobetasol propionate cream
0.05% (Temovate)
1
clobetasol propionate emollient
base cream 0.05% (Temovate e)
1
clobetasol propionate emulsion
foam 0.05% (Olux-e)
clobetasol propionate foam 0.05% 1
(Olux)
1
clobetasol propionate gel 0.05%
(Temovate)
1
clobetasol propionate lotion
0.05% (Clobex)
1
clobetasol propionate oint 0.05%
(Temovate)
1
clobetasol propionate shampoo
0.05% (Clobex)
clobetasol propionate soln 0.05% 1
(Temovate)
clobetasol propionate spray
0.05% (Clobex)
1
CLOBEX - clobetasol propionate
lotion 0.05%
3
shampoo 0.05%
3
spray 0.05%
3
CLOCORTOLONE PIVALATE clocortolone pivalate cream 0.1%
3
•
CLOCORTOLONE PIVALATE PUM - 3
clocortolone pivalate cream 0.1%
3
CLODERM - clocortolone pivalate
cream 0.1%
3
CLODERM PUMP - clocortolone
pivalate cream 0.1%
1
clotrimazole cream 1%
•
clotrimazole soln 1%
clotrimazole w/ betamethasone
cream 1-0.05% (Lotrisone)
clotrimazole w/ betamethasone
lotion 1-0.05%
•
•
1
1
1
COLLIGINIX - dimethicone-allantoin
bandage 5-2%
3
CONDYLOX - podofilox gel 0.5%
2
CONDYLOX - podofilox soln 0.5%
3
CORDRAN TAPE - flurandrenolide
tape 4 mcg/sqcm
3
CORTANE-B - hydrocortisonepramoxine-chloroxylenol lot
10-10-1mg/ml
3
CORTISPORIN - bacitracinpolymyxin-neomycin hc oint 1%
3
CORTISPORIN - neomycinpolymyxin-hc crm 3.5 mg/
gm-10000 unt/gm-0.5%
3
COSENTYX - secukinumab
syringe 150 mg/ml
4
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
•
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
• • •
•
127
COSENTYX SENSOREADY PEN secukinumab subcutaneous soln
auto-injector 150 mg/ml
4
CUTIVATE - fluticasone propionate
cream 0.05%
3
CUTIVATE - fluticasone propionate
lotion 0.05%
3
DENAVIR - penciclovir cream 1%
3
DERMA-SMOOTHE/FS BODY fluocinolone acetonide oil 0.01%
(body oil)
3
DERMA-SMOOTHE/FS SCALP fluocinolone acetonide oil 0.01%
(scalp oil)
diclofenac sodium soln 1.5%
1
DIFFERIN - adapalene cream 0.1%
3
•
DIFFERIN - adapalene gel 0.1%
3
DIFFERIN - adapalene gel 0.3%
3
•
DIFFERIN - adapalene lotion 0.1%
3
DIFLORASONE DIACETATE diflorasone diacetate cream
0.05%
3
DIFLORASONE DIACETATE diflorasone diacetate oint 0.05%
3
3
DIPROLENE - betamethasone
dipropionate augmented lotion
0.05%
3
DERMATOP - prednicarbate cream
0.1%
3
3
DERMATOP - prednicarbate oint
0.1%
3
DIPROLENE - betamethasone
dipropionate augmented oint
0.05%
3
DESONATE - desonide gel 0.05%
3
desonide cream 0.05% (Desowen)
1
DIPROLENE AF - betamethasone
dipropionate augmented cream
0.05%
DOVONEX - calcipotriene cream
0.005%
3
DOXEPIN HYDROCHLORIDE doxepin hcl cream 5%
3
desonide lotion 0.05% (Desowen)
desonide oint 0.05% (Desowen)
•
1
1
•
•
DESOWEN - desonide cream 0.05% 3
DESOWEN - desonide lotion 0.05% 3
DESOXIMETASONE desoximetasone cream 0.05%
3
DUAC - clindamycin phosph-benzoyl 3
peroxide (refrig) gel 1.2 (1)-5%
1
econazole nitrate cream 1%
DESOXIMETASONE desoximetasone oint 0.05%
3
EFUDEX - fluorouracil cream 5%
3
ELIDEL - pimecrolimus cream 1%
3
desoximetasone cream 0.25%
(Topicort)
1
ELIMITE - permethrin cream 5%
3
ELOCON - mometasone furoate
cream 0.1%
3
desoximetasone gel 0.05%
(Topicort)
1
ELOCON - mometasone furoate oint
0.1%
3
desoximetasone oint 0.25%
(Topicort)
1
3
ELOCON - mometasone furoate
solution 0.1% (lotion)
3
DICLOFENAC SODIUM - diclofenac
sodium cream 3%
• •
EPIDUO - adapalene-benzoyl
peroxide gel 0.1-2.5%
3
diclofenac sodium (actinic
keratoses) gel 3% (Solaraze)
1
1
•
EPIDUO FORTE - adapalenebenzoyl peroxide gel 0.3-2.5%
3
diclofenac sodium gel 1%
(Voltaren)
• •
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
•
Drug Name
Drug Tier
• • •
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
•
•
128
EPIFOAM - pramoxine-hc aerosol
foam 1-1%
3
ERTACZO - sertaconazole nitrate
cream 2%
3
ERYGEL - erythromycin gel 2%
3
erythromycin gel 2% (Erygel)
erythromycin pads 2%
erythromycin soln 2%
fluocinonide oint 0.05%
fluocinonide soln 0.05%
1
3
1
fluorouracil cream 5% (Efudex)
1
3
EURAX - crotamiton cream 10%
3
EURAX - crotamiton lotion 10%
3
EVOCLIN - clindamycin phosphate
foam 1%
3
EXELDERM - sulconazole nitrate
cream 1%
3
EXELDERM - sulconazole nitrate
solution 1%
3
EXTINA - ketoconazole foam 2%
3
FINACEA - azelaic acid foam 15%
2
FINACEA - azelaic acid gel 15%
2
fluocinolone acetonide cream
0.01%
1
1
fluorouracil soln 5%
flurandrenolide cream 0.05%
fluticasone propionate cream
0.05% (Cutivate)
fluticasone propionate lotion
0.05% (Cutivate)
fluticasone propionate oint
0.005%
1
1
1
1
GENTAMICIN SULFATE gentamicin sulfate cream 0.1%
3
GENTAMICIN SULFATE gentamicin sulfate oint 0.1%
3
GORDOFILM - salicylic & lactic acids 3
soln 16.7-16.7%
1
halobetasol propionate cream
0.05% (Ultravate)
halobetasol propionate oint 0.05% 1
(Ultravate)
3
HALOTIN - haloprogin cream 1%
fluocinolone acetonide oil 0.01%
(scalp oil) (Derma-smoothe/fs
sca)
1
hydrocortisone butyrate cream
0.1% (Locoid)
fluocinolone acetonide oint
0.025% (Synalar)
1
hydrocortisone butyrate
hydrophilic lipo base cream
0.1% (Locoid lipocream)
1
1
hydrocortisone butyrate oint 0.1%
(Locoid)
1
1
hydrocortisone butyrate soln
0.1% (Locoid)
1
hydrocortisone cream 1%
1
hydrocortisone cream 2.5%
1
hydrocortisone lotion 2% (Ala
scalp)
fluocinonide cream 0.1% (Vanos)
fluocinonide emulsified base
cream 0.05%
fluocinonide gel 0.05%
1
1
fluocinonide cream 0.05%
Responsible Steps
1
fluocinolone acetonide oil 0.01%
(body oil) (Derma-smoothe/fs
bod)
fluocinolone acetonide soln
0.01% (Synalar)
Quantity Limits
1
FLUOROURACIL - fluorouracil
cream 0.5%
fluorouracil soln 2%
Prior Authorization
1
3
1
Specialty
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
FLUOROPLEX - fluorouracil cream
1%
ESSENTRA WIPES 9X9" CLEAN isopropyl alcohol wipes 70%
fluocinolone acetonide cream
0.025% (Synalar)
Specialty
Drug Name
Drug Tier
2016
1
1
1
1
1
129
hydrocortisone lotion 2.5%
1
lindane shampoo 1%
1
LOCOID - hydrocortisone butyrate
oint 0.1%
3
•
1
LOCOID - hydrocortisone butyrate
soln 0.1%
3
•
hydrocortisone valerate oint 0.2%
(Westcort)
1
LOPROX - ciclopirox olamine cream
0.77% (base equiv)
3
imiquimod cream 5% (Aldara)
1
LOTRISONE - clotrimazole w/
betamethasone cream 1-0.05%
3
LUXIQ - betamethasone valerate
aerosol foam 0.12%
3
malathion lotion 0.5% (Ovide)
1
hydrocortisone oint 1%
hydrocortisone oint 2.5%
hydrocortisone valerate cream
0.2%
iodoquinol-hc cream 1%
isotretinoin cap 10 mg
1
1
1
1
1
1
MENTAX - butenafine hcl cream 1%
3
methoxsalen rapid cap 10 mg
(Oxsoralen ultra)
1
3
1
METROCREAM - metronidazole
cream 0.75%
ketoconazole shampoo 2%
(Nizoral)
1
METROGEL - metronidazole gel 1%
3
3
KLARON - sulfacetamide sodium
lotion 10% (acne)
3
METROLOTION - metronidazole
lotion 0.75%
1
LAC-HYDRIN - lactic acid
(ammonium lactate) cream 12%
3
metronidazole cream 0.75%
(Metrocream)
metronidazole gel 0.75%
1
LAC-HYDRIN - lactic acid
(ammonium lactate) lotion 12%
3
metronidazole gel 1% (Metrogel)
metronidazole lotion 0.75%
(Metrolotion)
1
lactic acid (ammonium lactate)
cream 12% (Lac-hydrin)
1
1
mometasone furoate cream 0.1%
(Elocon)
1
mometasone furoate oint 0.1%
(Elocon)
1
LAMISIL SPRAY - terbinafine hcl
soln 1%
3
3
1
LEVULAN KERASTICK aminolevulinic acid hcl for soln
20% (stick applicator)
mometasone furoate solution
0.1% (lotion) (Elocon)
lidocaine hcl gel 2%
1
1
KERALYT - salicylic acid gel 6%
3
ketoconazole cream 2%
1
ketoconazole foam 2% (Extina)
lactic acid (ammonium lactate)
lotion 12% (Lac-hydrin)
lidocaine hcl soln 4% (Xylocaine)
lidocaine patch 5% (Lidoderm)
lidocaine-prilocaine cream
2.5-2.5% (Emla)
LIDODERM - lidocaine patch 5%
1
1
• •
1
3
• •
1
mupirocin oint 2% (Bactroban)
1
1
NATROBA - spinosad susp 0.9%
3
NIZORAL - ketoconazole shampoo
2%
3
•
1
mupirocin calcium cream 2%
(Bactroban)
naftifine hcl cream 2% (Naftin)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
130
NUCORT - hydrocortisone acetate
lotion 2%
3
prednicarbate cream 0.1%
(Dermatop)
1
NUOX - benzoyl peroxide-sulfur gel
6-3%
3
prednicarbate oint 0.1%
(Dermatop)
1
nystatin cream 100000 unit/gm
1
PROTOPIC - tacrolimus oint 0.03%
3
1
PROTOPIC - tacrolimus oint 0.1%
3
1
PRUDOXIN - doxepin hcl cream 5%
3
1
PSORCON - diflorasone diacetate
cream 0.05%
3
1
PYROGALLIC ACID - pyrogallolchlorobutanol oint 25-2%
3
REGENECARE - lidocaine hclcollagen-aloe vera gel 2%
3
REGRANEX - becaplermin gel
0.01%
3
nystatin oint 100000 unit/gm
nystatin topical powder
nystatin-triamcinolone cream
100000-0.1 unit/gm-%
nystatin-triamcinolone oint
100000-0.1 unit/gm-%
OLUX - clobetasol propionate foam
0.05%
3
•
OLUX-E - clobetasol propionate
emulsion foam 0.05%
3
•
OVIDE - malathion lotion 0.5%
3
RETIN-A - tretinoin cream 0.025%
3
oxiconazole nitrate cream 1%
(Oxistat)
1
3
3
OXSORALEN - methoxsalen lotion
1%
3
RETIN-A - tretinoin gel 0.01%
3
OXSORALEN ULTRA - methoxsalen
rapid cap 10 mg
3
RETIN-A - tretinoin gel 0.025%
3
SALEX - salicylic acid shampoo 6%
3
PANRETIN - alitretinoin gel 0.1%
3
PENLAC NAIL LACQUER ciclopirox solution 8%
3
permethrin cream 5% (Elimite)
1
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
•
•
SALICYLIC ACID - salicylic acid soln 3
26%
1
salicylic acid cream 6%
•
salicylic acid gel 6% (Keralyt)
PICATO - ingenol mebutate gel
0.015%
2
•
PICATO - ingenol mebutate gel
0.05%
2
•
podofilox soln 0.5% (Condylox)
1
1
SALICYLIC ACID IN AMMONIU salicylic acid in ammonium lactate
vehicle foam 6%
3
salicylic acid lotion 6%
1
1
PRAMOSONE - pramoxine-hc
cream 1-1%
3
PRAMOSONE - pramoxine-hc lotion
1-1%
3
salicylic acid shampoo 6% (Salex) 1
SANTYL - collagenase oint 250 unit/ 2
gm
1
selenium sulfide lotion 2.5%
PRAMOSONE - pramoxine-hc lotion
1-2.5%
3
selenium sulfide-pyrithione zinc
in urea shampoo 2.25%
3
PRAMOSONE - pramoxine-hc oint
1-2.5%
3
SILVADENE - silver sulfadiazine
cream 1%
SILVER NITRATE - silver nitrate oint
10%
3
131
SILVER NITRATE - silver nitrate soln 3
0.5%
10%
25%
50%
1
silver nitrate-potassium nitrate
applicator 75-25% (Arzol silver
nitrate)
1
silver sulfadiazine cream 1%
(Silvadene)
3
SKLICE - ivermectin lotion 0.5%
SODIUM SULFACETAMIDE WASH - 3
sulfacetamide sodium in bakuchiol
vehicle wash 10%
SODIUM SULFACETAMIDE/SULF - 3
sulfacetamide sodium-sulfur in
urea gel 10-5%
3
SOLARAZE - diclofenac sodium
(actinic keratoses) gel 3%
SOOLANTRA - ivermectin cream 1% 3
• •
SORIATANE - acitretin cap 17.5 mg
3
SORIATANE - acitretin cap 25 mg
3
SORILUX - calcipotriene foam
0.005%
3
SPINOSAD - spinosad susp 0.9%
3
STELARA - ustekinumab soln
4
• • •
STELARA - ustekinumab soln
prefilled syringe 90 mg/ml
4
• • •
sulfacetamide sodium lotion 10%
(acne) (Klaron)
1
SULFAMYLON - mafenide acetate
packet for topical soln 5% (50 gm)
3
SULFOAM - sulfur shampoo 2%
3
3
SYNALAR - fluocinolone acetonide
oint 0.025%
3
soln 0.01%
3
tacrolimus oint 0.03% (Protopic)
1
1
•
TALTZ - ixekizumab subcutaneous
soln auto-injector 80 mg/ml
4
• • •
TALTZ - ixekizumab subcutaneous
4
• • •
TARGRETIN - bexarotene gel 1%
3
TAZORAC - tazarotene gel 0.05%
2
TAZORAC - tazarotene gel 0.1%
2
•
•
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Tier
cream 0.025%
TAZORAC - tazarotene cream 0.05% 2
TAZORAC - tazarotene cream 0.1% 2
3
3
Drug Name
tacrolimus oint 0.1% (Protopic)
SORIATANE - acitretin cap 10 mg
SULFAMYLON - mafenide acetate
cream 85 mg/gm
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
•
•
•
•
•
•
TBC - trypsin w/ castor oil & peruvian 3
balsam spray
3
TEMOVATE - clobetasol propionate
cream 0.05%
3
gel 0.05%
3
oint 0.05%
3
soln 0.05%
3
TEMOVATE E - clobetasol
propionate emollient base cream
0.05%
3
TEXACORT - hydrocortisone soln
2.5%
3
TOLAK - fluorouracil cream 4%
TOPICORT - desoximetasone cream 3
0.05%
TOPICORT - desoximetasone cream 3
0.25%
3
TOPICORT - desoximetasone gel
0.05%
132
TOPICORT - desoximetasone oint
0.05%
3
VEREGEN - sinecatechins oint 15%
3
VOLTAREN - diclofenac sodium gel
1%
3
TOPICORT - desoximetasone oint
0.25%
3
WESTCORT - hydrocortisone
valerate oint 0.2%
3
TOPICORT - desoximetasone spray
0.25%
3
1
XYLOCAINE - lidocaine hcl soln 4%
3
tretinoin cream 0.025% (Retin-a)
1
ZACLIR CLEANSING - benzoyl
peroxide lotion 8%
3
1
ZONALON - doxepin hcl cream 5%
3
1
8-MOP - methoxsalen cap 10 mg
2
1
MISCELLANEOUS PRODUCTS
tretinoin gel 0.01% (Retin-a)
tretinoin gel 0.025% (Retin-a)
tretinoin gel 0.05% (Atralin)
1
triamcinolone acetonide cream
0.5%
triamcinolone acetonide lotion
0.025%
triamcinolone acetonide lotion
0.1%
triamcinolone acetonide oint
0.025%
triamcinolone acetonide oint 0.1%
Responsible Steps
Quantity Limits
Prior Authorization
4
1
EVZIO - naloxone hcl solution autoinjector 0.4 mg/0.4ml
3
• •
• •
1
EXJADE - deferasirox tab for oral
susp 125 mg
4
•
•
1
susp 250 mg
4
•
•
1
susp 500 mg
4
•
•
1
FERRIPROX - deferiprone oral soln
100 mg/ml
4
•
•
1
FERRIPROX - deferiprone tab 500
mg
4
•
•
JADENU - deferasirox tab 90 mg
4
4
4
•
•
•
•
•
•
triamcinolone acetonide aerosol
soln 0.147 mg/gm (Kenalog)
0.1%
ANTIDOTES
•
CHEMET - succimer cap 100 mg
TRIAMCINOLONE ACETONIDE triamcinolone acetonide oint 0.5%
3
0.025%
•
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
ULESFIA - benzyl alcohol lotion 5%
3
ULTRAVATE - halobetasol
propionate cream 0.05%
3
ULTRAVATE - halobetasol
propionate oint 0.05%
3
URAMAXIN - urea in ammonium
lactate vehicle foam 20%
3
VALCHLOR - mechlorethamine hcl
gel 0.016% (base equivalent)
4
VECTICAL - calcitriol oint 3 mcg/gm
3
VERDESO - desonide foam 0.05%
3
NALOXONE HCL - naloxone hcl inj 1 3
mg/ml
1
naloxone hcl inj 0.4 mg/ml
naltrexone hcl tab 50 mg (Revia)
•
•
•
•
•
1
NARCAN - naloxone hcl nasal spray
4 mg/0.1ml
2
RADIOGARDASE - prussian blue
insoluble cap 0.5 gm
3
VISTOGARD - uridine triacetate oral
4
•
•
• •
•
DIAGNOSTIC PRODUCTS
133
3
• •
ACCU-CHEK COMPACT TEST DR - 3
glucose blood test strip
ACCU-CHEK SMARTVIEW STRIP - 3
ACCUTREND GLUCOSE - glucose 3
blood test strip
ACETEST - acetone (urine) test tab 2
• •
ACURA BLOOD GLUCOSE TEST glucose blood test strip
3
ADVANCE INTUITION TEST ST glucose blood test strip
3
ADVANCE MICRO-DRAW TEST S glucose blood test strip
3
ADVOCATE REDI-CODE - glucose
blood test strip
3
ADVOCATE REDI-CODE+ TEST glucose blood test strip
3
ADVOCATE TEST STRIPS - glucose 3
blood test strip
AGAMATRIX AMP NO CODE TES - 3
3
AGAMATRIX JAZZ TEST STRIP glucose blood test strip
AGAMATRIX KEYNOTE TEST ST - 3
AGAMATRIX PRESTO TEST STR - 3
2
ASCENSIA AUTODISC TEST ST glucose blood test disk
ASSURE II - glucose blood test strip 3
ASSURE II CHECK STRIP - glucose 3
blood test strip
ASSURE II TEST STRIPS - glucose 3
blood test strip
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
•
• •
• •
• •
3
• •
ASSURE PRISM MULTI TEST S glucose blood test strip
3
• •
ASSURE PRO TEST STRIPS glucose blood test strip
3
• •
ASSURE 3 TEST STRIPS - glucose
blood test strip
3
• •
ASSURE 4 TEST STRIPS - glucose
blood test strip
3
• •
AT LAST TEST STRIPS - glucose
blood test strip
3
• •
BAYER BREEZE 2 TEST DISC glucose blood test disk
2
•
BAYER CONTOUR BLOOD
GLUCO - glucose blood test strip
2
•
BAYER CONTOUR NEXT BLOOD glucose blood test strip
2
•
BG STAR BLOOD GLUCOSE TES glucose blood test strip
3
• •
BIOSCANNER GLUCOSE TEST S glucose blood test strip
3
• •
BLOOD GLUCOSE TEST STRIPS glucose blood test strip
3
• •
CAREONE BLOOD GLUCOSE
TES - glucose blood test strip
3
• •
CARESENS N BLOOD GLUCOSE glucose blood test strip
3
• •
CHEK-STIX COMBO PAK URINA acetone (urine) test strip
2
CHEK-STIX CONTROL - acetone
(urine) test strip
2
CHEMSTRIP-K - acetone (urine) test 2
strip
CLEVER CHEK AUTO-CODE TES - 3
CLEVER CHEK AUTO-CODE VOI - 3
3
CLEVER CHEK TEST STRIPS glucose blood test strip
ACCU-CHEK COMPACT STRIPS glucose blood test strip
ASSURE PLATINUM TEST STRI glucose blood test strip
Responsible Steps
• •
Quantity Limits
3
Prior Authorization
ACCU-CHEK COMPACT PLUS glucose blood test strip
Specialty
• •
Drug Name
Drug Tier
3
ACCU-CHEK AVIVA PLUS - glucose
blood test strip
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
• •
• •
• •
134
3
• •
EASYPRO PLUS - glucose blood
test strip
3
• •
3
• •
ELEMENT COMPACT TEST STRI glucose blood test strip
3
• •
CONTROL TEST STRIPS - glucose
blood test strip
3
• •
ELEMENT TEST STRIPS - glucose
blood test strip
3
• •
COOL BLOOD GLUCOSE TEST S glucose blood test strip
3
• •
EMBRACE BLOOD GLUCOSE
3
• •
CVS ADVANCED GLUCOSE
METE - glucose blood test strip
3
• •
EMBRACE EVO BLOOD
GLUCOSE - glucose blood test
strip
3
• •
DIATRUE PLUS BLOOD GLUCOS glucose blood test strip
3
• •
• •
EMBRACE PRO BLOOD
strip
3
• •
• •
EQ BLOOD GLUCOSE TEST STR glucose blood test strip
3
• •
• •
EVENCARE + BLOOD GLUCOSE glucose blood test strip
3
• •
• •
EVENCARE BLOOD GLUCOSE
TE - glucose blood test strip
3
• •
• •
EVENCARE G2 TEST STRIPS glucose blood test strip
3
• •
• •
EVENCARE G3 TEST STRIPS glucose blood test strip
3
• •
• •
EVENCARE MINI BLOOD GLUCO glucose blood test strip
3
• •
• •
EVOLUTION AUTOCODE - glucose
blood test strip
3
• •
• •
EXACTECH R-S-G TEST STRIP glucose blood test strip
3
• •
• •
EXACTECH TEST STRIPS - glucose 3
blood test strip
EZ SMART BLOOD GLUCOSE TE - 3
EZ SMART PLUS BLOOD GLUCO - 3
3
FIFTY50 GLUCOSE TEST STRI glucose blood test strip
• •
• •
• •
• •
CONTROL AST - glucose blood test
strip
DUO-CARE TEST STRIPS - glucose 3
blood test strip
EASY PLUS BLOOD GLUCOSE T - 3
3
EASY PLUS II BLOOD GLUCOS glucose blood test strip
3
EASY STEP TEST STRIPS glucose blood test strip
EASY TALK BLOOD GLUCOSE T - 3
EASY TOUCH GLUCOSE TEST S - 3
EASY TOUCH HEALTHPRO GLUC - 3
EASY TRAK BLOOD GLUCOSE T - 3
3
EASYGLUCO - glucose blood test
strip
EASYGLUCO PLUS - glucose blood 3
test strip
EASYMAX TEST STRIPS - glucose 3
blood test strip
3
EASYMAX 15 TEST STRIPS glucose blood test strip
EASYPLUS BLOOD GLUCOSE TE - 3
EASYPRO BLOOD GLUCOSE
Responsible Steps
• •
Quantity Limits
3
Prior Authorization
CLEVER CHOICE MICRO TEST glucose blood test strip
Specialty
• •
Drug Name
Drug Tier
3
CLEVER CHOICE AUTO-CODE P glucose blood test strip
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
• •
• •
• •
135
3
• •
FORA D40/G31 BLOOD GLUCOS glucose blood test strip
3
• •
FORA GD20 TEST STRIPS glucose blood test strip
3
• •
FORA GD50 BLOOD GLUCOSE T glucose blood test strip
3
FORA G20 BLOOD GLUCOSE TE glucose blood test strip
3
FORA G30A BLOOD GLUCOSE T glucose blood test strip
3
FORA TN'G/TN'G VOICE BLOO glucose blood test strip
3
FORA V10 BLOOD GLUCOSE TE glucose blood test strip
3
3
3
FORA V30A BLOOD GLUCOSE T glucose blood test strip
3
FORACARE GD40 - glucose blood
test strip
3
FORACARE PREMIUM V10 TEST glucose blood test strip
3
FORACARE TEST N GO TEST S glucose blood test strip
3
FREESTYLE INSULINX BLOOD glucose blood test strip
3
FREESTYLE LITE TEST STRIP glucose blood test strip
3
FREESTYLE PRECISION NEO B glucose blood test strip
3
FREESTYLE TEST STRIPS glucose blood test strip
3
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
3
• •
GE100 BLOOD GLUCOSE TEST glucose blood test strip
3
• •
GHT TEST STRIPS - glucose blood
test strip
3
• •
GLUCAGEN DIAGNOSTIC glucagon hcl (rdna) diagnostic for
3
GLUCO PERFECT 3 TEST STRI glucose blood test strip
3
• •
GLUCOCARD EXPRESSION
BLOO - glucose blood test strip
3
• •
GLUCOCARD SHINE TEST STRI glucose blood test strip
3
• •
GLUCOCARD VITAL TEST STRI glucose blood test strip
3
• •
GLUCOCARD X-SENSOR - glucose
blood test strip
3
• •
GLUCOCARD 01 SENSOR PLUS glucose blood test strip
3
• •
GLUCOCOM TEST STRIPS glucose blood test strip
3
• •
GLUCONAVII BLOOD GLUCOSE glucose blood test strip
3
• •
GLUCOSE METER TEST STRIPS glucose blood test strip
3
• •
GMATE BLOOD GLUCOSE TEST glucose blood test strip
3
• •
GNP EASY TOUCH GLUCOSE TE glucose blood test strip
3
• •
IN TOUCH BLOOD GLUCOSE TE glucose blood test strip
3
• •
INFINITY BLOOD GLUCOSE TE glucose blood test strip
3
• •
KETOCARE - acetone (urine) test
strip
2
KETONE TEST STRIPS - acetone
(urine) test strip
2
KETOSTIX - acetone (urine) test
strip
2
FORA D20 BLOOD GLUCOSE TE glucose blood test strip
GENSTRIP 50 - glucose blood test
strip
Responsible Steps
• •
Quantity Limits
3
Prior Authorization
FORA D15G BLOOD GLUCOSE T glucose blood test strip
Specialty
• •
Drug Name
Drug Tier
3
FORA D10 BLOOD GLUCOSE TE glucose blood test strip
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
136
3
• •
LIBERTY NEXT GENERATION B glucose blood test strip
3
• •
LIBERTY TEST STRIPS - glucose
blood test strip
3
• •
MAXIMA BLOOD GLUCOSE TEST - 3
MEIJER BLOOD GLUCOSE TEST - 3
3
MEIJER ESSENTIAL BLOOD GL glucose blood test strip
MEIJER PREMIUM BLOOD GLUC - 3
MEIJER TRUETEST BLOOD GLU - 3
MEIJER TRUETRACK BLOOD GL - 3
MICRODOT TEST STRIPS - glucose 3
blood test strip
3
MYGLUCOHEALTH BLOOD
3
NEUTEK 2TEK TEST STRIPS glucose blood test strip
3
NEXGEN TEST STRIPS - glucose
blood test strip
NOVA MAX GLUCOSE TEST STR - 3
ON CALL EXPRESS BLOOD GLU - 3
ON CALL PLUS BLOOD GLUCOS - 3
3
ON CALL VIVID BLOOD GLUCO glucose blood test strip
ONETOUCH ULTRA BLUE - glucose 3
blood test strip
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
3
• •
ONETOUCH VERIO TEST STRIP glucose blood test strip
3
• •
OPTIUM TEST STRIPS - glucose
blood test strip
3
• •
OPTIUMEZ TEST STRIPS - glucose
blood test strip
3
• •
OPTUMRX BLOOD GLUCOSE
3
• •
PHARMACIST CHOICE
AUTOCOD - glucose blood test
strip
3
• •
PHARMACIST CHOICE NO CODI glucose blood test strip
3
• •
POCKETCHEM EZ BLOOD
3
• •
PRECISION PCX - glucose blood
test strip
3
• •
PRECISION PCX PLUS TEST S glucose blood test strip
3
• •
PRECISION POINT OF CARE T glucose blood test strip
3
• •
PRECISION QID TEST STRIPS glucose blood test strip
3
• •
PRECISION SOF-TACT TEST S glucose blood test strip
3
• •
PRECISION XTRA BLOOD GLUC glucose blood test strip
3
• •
PREMIUM BLOOD GLUCOSE TES - 3
PRESTIGE TEST STRIPS - glucose 3
blood test strip
PRODIGY NO CODING BLOOD G - 3
3
PTS PANELS GLUCOSE TEST glucose blood test strip
QUICKTEK TEST STRIPS - glucose 3
blood test strip
3
QUINTET AC BLOOD GLUCOSE glucose blood test strip
• •
KROGER TEST STRIPS - glucose
blood test strip
ONETOUCH ULTRA TEST STRIP glucose blood test strip
Responsible Steps
• •
Quantity Limits
3
Prior Authorization
KROGER PREMIUM BLOOD
GLUC - glucose blood test strip
Specialty
• •
Drug Name
Drug Tier
3
KROGER BLOOD GLUCOSE
TEST - glucose blood test strip
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
• •
• •
• •
• •
• •
137
3
• •
RELION BLOOD GLUCOSE TEST glucose blood test strip
3
• •
RELION CONFIRM/MICRO TEST glucose blood test strip
3
• •
RELION KETONE - acetone (urine)
test strip
2
RELION KETONE TEST STRIPS acetone (urine) test strip
2
RELION PRIME BLOOD GLUCOS glucose blood test strip
3
• •
RELION ULTIMA BLOOD GLUCO glucose blood test strip
3
• •
RELION ULTIMA TEST STRIPS glucose blood test strip
3
• •
REVEAL BLOOD GLUCOSE TEST - 3
REXALL BLOOD GLUCOSE TEST - 3
RIGHTEST GS100 BLOOD GLUC - 3
3
SMART SENSE PREMIUM
BLOOD - glucose blood test strip
SMART SENSE VALUE BLOOD G - 3
3
SMARTEST BLOOD GLUCOSE
3
SOLUS V2 AUDIBLE TEST glucose blood test strip
SUPREME TEST STRIPS - glucose 3
blood test strip
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
MEDICAL DEVICES
ACCU-CHEK AVIVA - blood glucose
monitoring devices
REFUAH PLUS BLOOD
strip
• •
Responsible Steps
• •
Quantity Limits
3
Prior Authorization
RA TRUETEST STRIPS - glucose
blood test strip
SURE EDGE BLOOD GLUCOSE T - 3
3
SURE-TEST EASYPLUS MINI B glucose blood test strip
3
SURECHEK BLOOD GLUCOSE
TELCARE BLOOD GLUCOSE TES - 3
TGT BLOOD GLUCOSE TEST ST - 3
TRUE METRIX BLOOD GLUCOSE - 3
3
TRUE METRIX SELF MONITORI glucose blood test strip
3
TRUETEST BLOOD GLUCOSE T glucose blood test strip
TRUETEST STRIPS - glucose blood 3
test strip
3
TRUETRACK BLOOD GLUCOSE
T - glucose blood test strip
TRUETRACK TEST - glucose blood 3
test strip
3
ULTIMA TEST STRIPS - glucose
blood test strip
3
ULTRATRAK PRO TEST STRIPS glucose blood test strip
3
ULTRATRAK ULTIMATE TEST S glucose blood test strip
3
UNISTRIP1 GENERIC - glucose
blood test strip
3
VICTORY AGM-4000 TEST STR glucose blood test strip
VOCAL POINT BLOOD GLUCOSE - 3
WAVESENSE PRESTO TEST STR - 3
Specialty
• •
Drug Name
Drug Tier
3
QUINTET BLOOD GLUCOSE TES glucose blood test strip
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
• •
3
138
ACCU-CHEK AVIVA CONNECT blood glucose monitoring kit w/
device
3
ACCU-CHEK AVIVA PLUS - blood
glucose monitoring kit w/ device
3
ACCU-CHEK COMPACT PLUS CA - 3
blood glucose monitoring kit
ACCU-CHEK FASTCLIX LANCET - 2
lancets kit
ACCU-CHEK FASTCLIX LANCET - 2
lancets
2
ACCU-CHEK MULTICLIX LANC lancets kit
2
ACCU-CHEK MULTICLIX LANCE lancets
ACCU-CHEK NANO SMARTVIEW - 3
blood glucose monitoring kit w/
device
ACCU-CHEK SAFE-T-PRO LANC - 2
lancets
ACCU-CHEK SAFE-T-PRO PLUS - 2
lancets
ACCU-CHEK SOFT TOUCH LANC - 2
lancets
ACCU-CHEK SOFTCLIX LANCET - 2
lancet devices
lancets kit
lancets
3
ACCU-CHEK VOICEMATE - blood
2
ACTI-LANCE LANCETS 28G lancets
2
ACTI-LANCE LITE SAFETY LA lancets
2
ACTI-LANCE SPECIAL SAFETY lancets
2
ACTI-LANCE UNIVERSAL SAFE lancets
ACTIVE 1ST BLOOD LANCETS lancets
2
ACURA BLOOD GLUCOSE
MONIT - blood glucose monitoring
kit w/ device
3
ACURA PLUS BLOOD GLUCOSE blood glucose monitoring kit w/
device
3
ADJUSTABLE LANCING DEVICE lancet devices
2
ADVANCE INTUITION BLOOD G blood glucose monitoring devices
3
ADVANCE INTUITION BLOOD G blood glucose monitoring kit w/
device
3
ADVANCE MICRO-DRAW METER blood glucose monitoring devices
3
ADVOCATE BLOOD GLUCOSE
MO - blood glucose monitoring
devices
3
ADVOCATE BLOOD GLUCOSE
MO - blood glucose monitoring kit
w/ device
3
ADVOCATE INSULIN PEN NEED insulin pen needle 29 g x 12.7 mm
2
ADVOCATE INSULIN PEN NEED insulin pen needle 31 g x 5 mm
(3/16")
2
ADVOCATE INSULIN PEN NEED insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
ADVOCATE INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ml 30 x 5/16"
2
ADVOCATE INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
ml 29 x 1/2"
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
139
ml 30 x 5/16"
2
AGAMATRIX JAZZ WIRELESS 2 blood glucose monitoring kit w/
device
3
ADVOCATE INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
29 x 1/2"
2
AGAMATRIX PRESTO - blood
3
30 x 5/16"
2
31 x 5/16"
2
ml 31 x 5/16"
2
ADVOCATE LANCETS - lancets
2
ADVOCATE LANCETS 30G lancets
2
ADVOCATE LANCING DEVICE lancet devices
2
ADVOCATE RAPID-SAFE LANCI lancet devices
2
ADVOCATE REDI-CODE - blood
glucose monitoring devices
3
ADVOCATE REDI-CODE+ BLOOD - 3
blood glucose monitoring devices
3
ADVOCATE REDI-CODE+/ TALK blood glucose monitoring kit w/
device
3
ADVOCATE REDI-CODE/TALKIN blood glucose monitoring devices
3
ADVOCATE REDI-CODE/TALKIN blood glucose monitoring kit w/
device
2
ADVOCATE SAFETY LANCETS lancets
ADVOCATE SAFETY LANCETS 2 - 2
lancets
2
AF LANCETS SUPER THIN lancets
AGAMATRIX AMP NO CODE ADV - 3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
AGAMATRIX PRESTO PRO METE - 3
2
AGAMATRIX ULTRA-THIN LANC lancets
2
ALLERGY SYRINGE/1ML/27G X tuberculin/allergy syringe/needle
(disp) 1 ml 27 x 1/2"
2
ALTERNATE SITE LANCING DE lancet devices
2
ANTI-STICK INSULIN SYRING insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
ANTI-STICK INSULIN SYRING insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
ANTI-STICK INSULIN SYRING insulin syringe/needle u-100 1 ml
29 x 1/2"
2
ANTI-STICK TUBERCULIN SYR tuberculin/allergy syringe/needle
(disp) 1 ml 25 x 5/8"
2
ANTI-STICK TUBERCULIN SYR tuberculin/allergy syringe/needle
(disp) 1 ml 27 x 1/2"
AQUA LANCE ADJUSTABLE LAN - 2
lancet devices
ASSURE COMFORT LANCETS UL - 2
lancets
ASSURE HAEMOLANCE PLUS HI - 2
lancets
ASSURE HAEMOLANCE PLUS LO - 2
lancets
ASSURE HAEMOLANCE PLUS MI - 2
lancets
2
ASSURE HAEMOLANCE PLUS
NO - lancets
140
ASSURE HAEMOLANCE PLUS PE - 2
lancets
2
ASSURE ID INSULIN SAFETY insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
ASSURE ID INSULIN SAFETY insulin syringe/needle u-100 1 ml
29 x 1/2"
2
ASSURE LANCE LANCETS lancets
2
ASSURE LANCE LANCETS 21G lancets
2
ASSURE LANCE PLUS SAFETY lancets
2
ASSURE LANCETS - lancets
AURORA UNIFINE PENTIPS/MI insulin pen needle 31 g x 5 mm
(3/16")
2
AURORA UNIFINE PENTIPS/32 insulin pen needle 32 g x 4 mm
(5/32")
2
AUTO-LANCET - lancet devices
2
AUTO-LANCET MINI - lancet
devices
2
AUTOLET IMPRESSION - lancet
devices
2
AUTOLET IMPRESSION LANCIN lancet devices
2
AUTOLET MINI - lancet devices
2
3
ASSURE PLATINUM BLOOD GLU blood glucose monitoring devices
3
AUTOPEN - injection device for
insulin
3
AXILLARY BLOCK NEEDLE BLO needle (disp) 22 x 1"
3
ASSURE PRISM MULTI BLOOD blood glucose monitoring devices
AXILLARY BLOCK NEEDLE BLO needle (disp) 25 x 1"
3
ASSURE PRO BLOOD GLUCOSE blood glucose monitoring devices
3
B-D INSULIN SYRINGE MICRO insulin syringe/needle u-100 1 ml
28 x 1/2"
2
ASSURE 3 METER - blood glucose
monitoring kit
3
B-D INSULIN SYRINGE ULTRA insulin syringe/needle u-100 0.3
ml 30 x 1/2"
2
B-D INSULIN SYRINGE ULTRA insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
B-D INSULIN SYRINGE ULTRA insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
B-D INSULIN SYRINGE ULTRA insulin syringe/needle u-100 1 ml
30 x 1/2"
2
B-D INSULIN SYRINGE ULTRA insulin syringe/needle u-100 1 ml
31 x 5/16"
2
B-D INSULIN SYRINGE ULTRA insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
ASSURE 4 BLOOD GLUCOSE ME - 3
AT LAST BLOOD GLUCOSE SYS - 3
blood glucose monitoring kit
2
AT LAST LANCETS - lancets
AURORA LANCET SUPER THIN lancets
2
AURORA LANCET THIN 23G lancets
2
AURORA PEN NEEDLES 29GX12 insulin pen needle 29 g x 12 mm
(1/2")
2
AURORA PEN NEEDLES 31G X insulin pen needle 31 g x 6 mm
(1/4")
2
AURORA PEN NEEDLES 31G X insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
141
2
BD AUTOSHIELD 29G X 3/16" insulin pen needle 29 g x 5 mm
(3/16")
2
2
BAYER CONTOUR BLOOD
GLUCO - blood glucose monitoring
devices
2
BAYER CONTOUR BLOOD
kit w/ device
2
BAYER CONTOUR LINK BLOOD blood glucose monitoring kit w/
device
BAYER CONTOUR NEXT BLOOD - 2
device
BAYER CONTOUR NEXT EZ BLO - 2
device
2
BAYER CONTOUR NEXT LINK B blood glucose monitoring kit w/
device
BAYER CONTOUR NEXT LINK W - 2
device
BAYER CONTOUR NEXT USB BL - 2
device
2
BAYER MICROLET LANCETS lancets
2
BAYER MICROLET 2 LANCING lancet devices
2
BD LO-DOSE INSULIN SYRIN insulin syringe/needle u-100 1/2
ml 28 x 1/2"
BD ALLERGY/SYRINGE NEEDLE - 2
tuberculin/allergy syringe/needle
(disp) 1 ml 28 x 1/2"
BD ALLERGY/SYRINGE/NEEDLE - 2
(disp) 1 ml 28 x 1/2"
2
BD AUTOSHIELD DUO 30G X 3 insulin pen needle 30 g x 5 mm
(3/16")
BD AUTOSHIELD 29G X 5/16" insulin pen needle 29 g x 8 mm
(5/16")
2
BD BLUNT FILL NEEDLE - needle
(disp) 18 x 1-1/2"
3
BD DISPOSABLE NEEDLE REGU needle (disp) 18 x 1"
3
BD DISPOSABLE NEEDLE REGU needle (disp) 22 x 3/4"
3
3
2
BD DISPOSABLE NEEDLE 23GX needle (disp) 23 x 1"
2
BD DISPOSABLE NEEDLE 23GX needle (disp) 23 x 1-1/4"
3
BD DISPOSABLE NEEDLE 27GX needle (disp) 27 x 1-1/4"
2
BD DISPOSABLE NEEDLE/30GX needle (disp) 30 x 1"
2
BD ECLIPSE NEEDLE 21G X 1 needle (disp) 21 x 1"
3
BD ECLIPSE NEEDLE 21G X 1 needle (disp) 21 x 1-1/2"
3
BD ECLIPSE NEEDLE 25G X 1 needle (disp) 25 x 1-1/2"
2
BD ECLIPSE NEEDLE 25GX1" needle (disp) 25 x 1"
2
BD ECLIPSE NEEDLE 30G X needle (disp) 30 x 1/2"
2
BD ECLIPSE NEEDLE/22G X 1 needle (disp) 22 x 1-1/2"
2
BD ECLIPSE NEEDLE/25G X needle (disp) 25 x 5/8"
2
BD ECLIPSE 18G X 1-1/2" - needle
(disp) 18 x 1-1/2"
2
BAYER BREEZE 2 BLOOD GLUC blood glucose monitoring kit w/
device
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
142
BD ECLIPSE 22G X 1" - needle
(disp) 22 x 1"
3
BD INSULIN SYRINGE LUER-L insulin syringe (disp) u-100 1 ml
2
BD ECLIPSE 23G X 1" NEEDL needle (disp) 23 x 1"
3
BD INSULIN SYRINGE MICROF insulin syringe/needle u-100 0.3
ml 28 x 1/2"
2
BD INSULIN SYRINGE MICROF insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
BD INSULIN SYRINGE MICROF insulin syringe/needle u-100 1 ml
27 x 5/8"
2
BD INSULIN SYRINGE MICROF insulin syringe/needle u-100 1 ml
28 x 1/2"
2
BD INSULIN SYRINGE SAFETY insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
BD INSULIN SYRINGE SAFETY insulin syringe/needle u-100 1 ml
29 x 1/2"
2
BD INSULIN SYRINGE SAFETY insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
BD INSULIN SYRINGE SLIP T insulin syringe (disp) u-100 1 ml
2
BD INSULIN SYRINGE U-40/1 insulin syringe/needle u-40 1 ml
25 x 5/8"
2
BD INSULIN SYRINGE ULTRAF insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ml 30 x 1/2"
2
BD INSULIN SYRINGE ULTRAF insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
ml 29 x 1/2"
2
ml 30 x 1/2"
2
BD HYPODERMIC NEEDLE REGU - 2
needle (disp) 18 x 1-1/2"
needle (disp) 21 x 1"
needle (disp) 25 x 5/8"
BD HYPODERMIC NEEDLE SHOR - 3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
143
ml 31 x 15/64"
2
BD INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 2 ml
29 x 1/2"
2
BD INSULIN SYRINGE ULTRAF insulin syringe/needle u-100 1 ml
29 x 1/2"
2
BD INTEGRA INSULIN SYRING insulin syringe/needle u-100 1 ml
29 x 1/2"
2
30 x 1/2"
2
BD INTEGRA RETRACTABLE NE needle (disp) 23 x 1"
3
2
BD INTEGRA SYRINGE/RETRAC insulin syringe/needle u-100 1 ml
25 x 1"
2
31 x 5/16"
BD KLATSKIN BIOPSY - needle
(disp) 16 x 4"
3
ml 31 x 5/16"
2
2
ml 31 x 15/64"
2
BD LANCET DEVICE - lancet
devices
BD LANCET ULTRAFINE 30G lancets
2
31 x 15/64"
2
BD LANCET ULTRAFINE 33G lancets
2
3
BD INSULIN SYRINGE/DETACH insulin syringe/needle u-100 1 ml
25 x 5/8"
2
BD LATITUDE DIABETES MANA blood glucose monitoring kit w/
device
3
25 x 1"
2
BD LOGIC BLOOD GLUCOSE MO blood glucose monitoring kit w/
device
3
26 x 1/2"
2
BD MAGNI-GUIDE MAGNIFIER blood glucose monitoring supplies
BD MICROTAINER LANCETS lancets
2
BD INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
BD NEEDLE/16G X 1-1/2" - needle
(disp) 16 x 1-1/2"
3
2
27 x 1/2"
2
BD NEEDLE/18G 1-1/2" - needle
(disp) 18 x 1-1/2"
3
28 x 1/2"
2
BD NEEDLE/19G X 1" - needle
(disp) 19 x 1"
(disp) 20 x 1-1/2"
3
2
BD NEEDLE/20G X 1" - needle
(disp) 20 x 1"
2
27.5 x 5/8"
BD NEEDLE/21G 1-1/2" - needle
(disp) 21 x 1-1/2"
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
144
(disp) 22 x 1-1/2"
2
BD NEEDLE/25G X 5/8" - needle
(disp) 25 x 5/8"
2
(disp) 25 x 7/8"
BD SAFETYGLIDE ALLERGY S tuberculin/allergy syringe/needle
(disp) 1 ml 26 x 3/8"
2
2
2
BD SAFETYGLIDE ALLERGY SY tuberculin/allergy syringe/needle
(disp) 1 ml 27 x 1/2"
(disp) 27 x 1/2"
2
BD SAFETYGLIDE HYPODERMIC needle (disp) 18 x 1-1/2"
3
(disp) 30 x 1/2"
2
BD SAFETYGLIDE HYPODERMIC needle (disp) 25 x 5/8"
2
BD OSGOOD BIOPSY - needle
(disp) 16 x 1-5/16"
3
BD SAFETYGLIDE INJECTION needle (disp) 22 x 1-1/2"
3
BD PEN - injection device for insulin
3
3
BD PEN MINI - injection device for
insulin
3
BD SAFETYGLIDE INJECTION needle (disp) 25 x 1"
2
BD PEN NEEDLE/MINI/ULTRAF insulin pen needle 31 g x 5 mm
(3/16")
2
BD SAFETYGLIDE INSULIN SY insulin syringe/needle u-100 1/2
ml 30 x 5/16"
3
BD PEN NEEDLE/NANO/ULTRA insulin pen needle 32 g x 4 mm
(5/32")
2
BD SAFETYGLIDE SHIELDED N needle (disp) 23 x 1"
BD SAFETYGLIDE 21G X 1-1/ needle (disp) 21 x 1-1/2"
3
BD PEN NEEDLE/SHORT/ULTRA insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
BD SAFETYGLIDE 21G X 1" needle (disp) 21 x 1"
2
2
BD PEN NEEDLE/ULTRAFINE/2 insulin pen needle 29 g x 12.7 mm
2
BD 1ML TUBERCULIN SYRINGE tuberculin/allergy syringe/needle
(disp) 1 ml 26 x 3/8"
BD PEN NEEDLES SHORT/ULTR insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
BD 1ML TUBERCULIN SYRINGE tuberculin/allergy syringe/needle
(disp) 1 ml 27 x 1/2"
2
BD PLASTIPAK SYRINGES ALL tuberculin/allergy syringe/needle
(disp) 1 ml 28 x 1/2"
2
BLOOD GLUCOSE MONITORING blood glucose monitoring kit w/
device
3
BD PRECISIONGLIDE NEEDLE needle (disp) 27 x 1-1/2"
3
3
BD ROSENTHAL BIOPSY - needle
(disp) 16 x 1-5/16"
3
BLOOD GLUCOSE SYSTEM PAK blood glucose monitoring kit w/
device
BD SAFETY-GLIDE INSULIN S insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
BD SAFETY-LOK INSULIN SYR insulin syringe/needle u-100 1 ml
29 x 1/2"
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
BREEZE 2 BLOOD GLUCOSE MO - 2
2
BULLSEYE MINI SAFETY LANC lancets
2
BULLSEYE SAFETY LANCETS lancets
145
CARDIOCOM LANCING DEVICE lancet devices
2
CAREFINE PEN NEEDLE 32GX4 insulin pen needle 32 g x 4 mm
(5/32")
2
CAREONE INSULIN SYRINGES/ insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
CAREONE LANCET THIN - lancets
2
CAREONE LANCET ULTRA THIN lancets
2
CAREFINE PEN NEEDLES 29GX insulin pen needle 29 g x 12 mm
(1/2")
2
2
(1/3" or 5/16")
2
CAREONE UNIFINE PENTIPS P insulin pen needle 29 g x 12 mm
(1/2")
2
(1/4")
2
(3/16")
2
(1/3" or 5/16")
2
(1/4")
2
(1/5" or 3/16")
2
(1/3" or 5/16")
2
(1/4")
2
(5/32")
2
CAREONE ADVANCED LANCING lancet devices
2
CAREONE UNIFINE PENTIPS 2 insulin pen needle 29 g x 12 mm
(1/2")
(3/16")
2
CAREONE BLOOD GLUCOSE
MON - blood glucose monitoring kit
w/ device
3
2
(1/4")
2
CAREONE INSULIN SYRINGES/ insulin syringe/needle u-100 0.3
ml 30 x 1/2"
(1/3" or 5/16")
2
CAREONE INSULIN SYRINGES/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
CARESENS N BLOOD GLUCOSE blood glucose monitoring devices
3
CAREONE INSULIN SYRINGES/ insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
3
CAREONE INSULIN SYRINGES/ insulin syringe/needle u-100 1 ml
30 x 1/2"
2
CARESENS N GLUCOSE
MONITO - blood glucose
monitoring devices
3
CAREONE INSULIN SYRINGES/ insulin syringe/needle u-100 1 ml
31 x 5/16"
2
CARESENS N VOICE BLOOD GL blood glucose monitoring devices
CAYA - diaphragm arc-spring
P
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
146
CHEMSTRIP BG LOG BOOK - blood 3
glucose monitoring misc.
3
CHOICE DM DIABETES RISK I blood glucose monitoring kit
CLEANLET LANCETS 28G - lancets 2
CLEVER CHOICE COMFORT EZ insulin pen needle 33 g x 4 mm
(5/32")
2
(1/5" or 3/16")
2
(1/4")
2
(1/3" or 5/16")
2
CLEVER CHOICE COMFORT EZ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ml 30 x 5/16"
2
CLEVER CHEK AUTO CODE VOI blood glucose monitoring devices
3
CLEVER CHEK AUTO-CODE BLO blood glucose monitoring devices
3
CLEVER CHEK AUTO-CODE VOI blood glucose monitoring devices
3
CLEVER CHEK BLOOD
GLUCOSE - blood glucose
monitoring kit w/ device
3
CLEVER CHEK LANCETS ULTRA lancets
2
CLEVER CHOICE AUTO-CODE P blood glucose monitoring devices
3
ml 30 x 1/2"
2
(1/2")
2
CLEVER CHOICE COMFORT EZ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
(3/16")
2
ml 28 x 1/2"
2
(1/4")
2
2
ml 29 x 1/2"
2
(1/3" or 5/16")
ml 30 x 5/16"
2
(5/32")
2
ml 30 x 1/2"
2
(1/5" or 3/16")
2
2
2
(1/4")
CLEVER CHOICE COMFORT EZ insulin syringe/needle u-100 1 ml
28 x 1/2"
29 x 1/2"
2
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
147
30 x 5/16"
2
COMFORT ASSIST INSULIN SY insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
30 x 1/2"
2
ml 29 x 1/2"
2
31 x 5/16"
2
ml 30 x 5/16"
2
ml 31 x 5/16"
2
COMFORT ASSIST INSULIN SY insulin syringe/needle u-100 1 ml
29 x 1/2"
2
CLEVER CHOICE MICRO BLOOD blood glucose monitoring kit w/
device
3
30 x 5/16"
2
CLEVER CHOICE MINI BLOOD blood glucose monitoring devices
3
2
CLICKFINE PEN NEEDLE UNIV insulin pen needle 31 g x 6 mm
(1/4")
2
31 x 5/16"
2
CLICKFINE PEN NEEDLE UNIV insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
COMFORT ASSIST INSULIN SY insulin syringe/needle u-100 0.3
ml 31 x 5/16"
COMFORT ASSURED LANCETS
M - lancets
2
CLICKFINE PEN NEEDLE 32GX insulin pen needle 32 g x 4 mm
(5/32")
2
COMFORT ASSURED LANCETS
S - lancets
2
COMFORT LANCETS - lancets
2
CLICKFINE PEN NEEDLES/31G insulin pen needle 31 g x 6 mm
(1/4")
2
CLICKFINE PEN NEEDLES/31G insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
CLICKFINE UNIVERSAL PEN N insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
CLOSERCARE - lancet devices
2
COAGUCHEK LANCETS - lancets
2
ml 29 x 1/2"
2
ml 30 x 5/16"
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
3
CONTROL BLOOD GLUCOSE
w/ device
3
COOL BLOOD GLUCOSE
monitoring devices
3
COOL BLOOD GLUCOSE
3
CVS ADVANCED GLUCOSE
METE - blood glucose monitoring
kit w/ device
2
CVS LANCETS MICRO THIN 33 lancets
CVS LANCETS ORIGINAL - lancets 2
CVS LANCETS THIN 26G - lancets
2
148
CVS LANCETS ULTRA THIN 30 lancets
2
DROPLET PEN NEEDLES 32GX8 insulin pen needle 32 g x 8 mm
2
CVS LANCETS 21G - lancets
2
2
CVS LANCING DEVICE - lancet
devices
2
DRUG MART ADJUSTABLE LANC lancet devices
2
CVS ULTRA THIN LANCETS lancets
2
DRUG MART LANCETS THIN lancets
2
DIASTAR EASY TEST II LANC lancets
2
DRUG MART LANCETS ULTRA T lancets
2
DIASTAR EASY TEST LANCETS lancets
2
DRUG MART ON-THE-GO LANCE lancets
2
DIATRUE PLUS BLOOD GLUCOS blood glucose monitoring devices
3
DRUG MART UNIFINE PENTIPS insulin pen needle 29 g x 12 mm
(1/2")
DIDGET - blood glucose monitoring
kit w/ device
2
2
DROPLET LANCETS ULTRA THI lancets
2
(3/16")
2
DROPLET LANCING DEVICE lancet devices
2
(1/4")
2
2
(1/2")
2
(1/3" or 5/16")
2
(3/16")
2
(5/32")
DRUG MART UNILET LANCETS lancets
2
(1/4")
2
DUANE READE LANCET ALTERN lancets
2
2
(1/3" or 5/16")
2
DUANE READE LANCET SUPER lancets
DUANE READE LANCET ULTRA lancets
2
(5/32")
2
DUANE READE UNIFINE PENTI insulin pen needle 29 g x 12 mm
(1/2")
2
(1/5" or 3/16")
2
(1/4")
2
(1/4")
2
(1/3" or 5/16")
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
149
E-Z JECT LANCETS - lancets
2
E-Z JECT LANCETS COLOR lancets
2
E-Z JECT LANCETS SUPER TH lancets
2
E-Z JECT LANCETS THIN 26G lancets
2
E-Z JECT LANCETS 21G - lancets
2
E-ZJECT LANCETS MICRO-THI lancets
EASY COMFORT PEN NEEDLES insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
(5/32")
2
EASY MINI EJECT LANCING D lancet devices
2
2
EASY MINI LANCING DEVICE lancet devices
2
EASY COMFORT INSULIN SYRI insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
EASY PLUS BLOOD GLUCOSE M blood glucose monitoring devices
3
3
EASY COMFORT INSULIN SYRI insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
EASY PLUS BLOOD GLUCOSE M blood glucose monitoring kit w/
device
3
ml 30 x 5/16"
2
EASY PLUS II BLOOD GLUCOS blood glucose monitoring devices
EASY STEP BLOOD GLUCOSE M blood glucose monitoring devices
3
ml 30 x 1/2"
2
EASY STEP BLOOD GLUCOSE M blood glucose monitoring kit w/
device
3
EASY COMFORT INSULIN SYRI insulin syringe/needle u-100 1 ml
30 x 5/16"
2
EASY TALK BLOOD GLUCOSE M blood glucose monitoring devices
3
3
30 x 1/2"
2
EASY TALK BLOOD GLUCOSE M blood glucose monitoring kit w/
device
3
31 x 5/16"
2
EASY TOUCH ALLERGY TRAY S tuberculin/allergy syringe/needle
(disp) 1 ml 26 x 3/8"
2
EASY COMFORT LANCETS lancets
2
EASY TOUCH ALLERGY TRAY S tuberculin/allergy syringe/needle
(disp) 1 ml 27 x 1/2"
EASY COMFORT LANCETS 30G/ lancets
2
EASY TOUCH FLIPLOCK NEEDL needle (disp) 28 x 1/2" (12.7 mm)
3
(3/16")
2
EASY TOUCH FLIPLOCK NEEDL needle (disp) 29 x 1/2" (12.7 mm)
3
3
(1/4")
2
EASY TOUCH FLIPLOCK NEEDL needle (disp) 18 x 1"
EASY TOUCH FLIPLOCK NEEDL needle (disp) 18 x 1-1/2"
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
150
3
EASY TOUCH FLIPLOCK NEEDL needle (disp) 31 x 5/16" (8 mm)
3
3
2
3
EASY TOUCH FLIPLOCK SAFET insulin syringe/needle u-100 1 ml
29 x 1/2"
2
3
30 x 5/16"
3
2
3
30 x 1/2"
2
EASY TOUCH FLIPLOCK NEEDL needle (disp) 22 x 3/4"
3
31 x 5/16"
3
3
3
EASY TOUCH GLUCOSE
3
3
3
3
3
3
3
3
EASY TOUCH FLIPLOCK NEEDL needle (disp) 27 x 1" (25 mm)
3
EASY TOUCH FLIPLOCK NEEDL needle (disp) 30 x 5/16" (8 mm)
3
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
EASY TOUCH HEALTHPRO GLUC - 3
device
EASY TOUCH HYPODERMIC NEE - 3
needle (disp) 32 x 5/16" (8 mm)
needle (disp) 18 x 1.25" (30 mm)
151
needle (disp) 24 x 1.25" (30 mm)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
needle (disp) 31 x 5/16" (8 mm)
2
EASY TOUCH INSULIN SYRING insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
ml 30 x 1/2"
2
EASY TOUCH INSULIN SYRING insulin syringe/needle u-100 1/2
ml 27 x 1/2"
2
ml 31 x 5/16"
2
ml 28 x 1/2"
2
ml 29 x 1/2"
2
ml 30 x 5/16"
2
ml 30 x 1/2"
2
EASY TOUCH INSULIN SYRING insulin syringe/needle u-100 1 ml
27 x 1/2"
2
28 x 1/2"
2
29 x 1/2"
2
30 x 5/16"
2
30 x 1/2"
152
31 x 5/16"
2
EASY TOUCH PEN NEEDLES 29 insulin pen needle 29 g x 12 mm
(1/2")
2
ml 31 x 5/16"
2
(1/4")
2
EASY TOUCH LANCETS 21G/PR lancets
2
2
2
(1/3" or 5/16")
2
2
(5/32")
EASY TOUCH LANCETS 26G/PU lancets
2
2
EASY TOUCH LANCETS 26G/TW lancets
2
(1/5" or 3/16")
2
2
(1/4")
2
2
2
EASY TOUCH PEN NEEDLES/31 insulin pen needle 31 g x 5 mm
(3/16")
2
EASY TOUCH LANCETS 30G/BU lancets
2
EASY TOUCH SAFETY LANCETS lancets
2
2
2
2
2
2
2
EASY TOUCH LANCING DEVICE lancet devices
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
EASY TOUCH SHEATHLOCK SAF - 2
insulin syringe/needle u-100 1 ml
29 x 1/2"
30 x 5/16"
30 x 1/2"
31 x 5/16"
3
EASY TOUCH TUBERCULIN FLI tuberculin/allergy syringe/needle
(disp) 1 ml 27 x 1/2"
3
EASY TOUCH TUBERCULIN FLI tuberculin/allergy syringe/needle
(disp) 1 ml 28 x 1/2"
153
EASY TOUCH TUBERCULIN SHE tuberculin/allergy syringe/needle
(disp) 1 ml 25 x 5/8"
3
EASYMAX NG SELF-MONITORIN blood glucose monitoring kit w/
device
(disp) 1 ml 27 x 1/2"
3
(disp) 1 ml 28 x 1/2"
3
EASY TOUCH 32GX5MM - insulin
pen needle 32 g x 5 mm (1/5" or
3/16")
2
EASY TOUCH 32GX6MM - insulin
pen needle 32 g x 6 mm (1/4")
2
EASYMAX V BLOOD GLUCOSE S - 3
3
EASYMAX V BLOOD GLUCOSE
S - blood glucose monitoring kit w/
device
3
EASYMAX V2 SELF-MONITORIN blood glucose monitoring devices
3
EASYMAX V2 SELF-MONITORIN blood glucose monitoring kit w/
device
EASYPLUS R13N SELF-MONITO - 3
device
3
EASYPLUS V SELF-MONITORIN blood glucose monitoring kit w/
device
3
EASYPRO BLOOD GLUCOSE
w/ device
3
EASYPRO PLUS - blood glucose
2
EASYTEST II LANCETS - lancets
EASY TRAK BLOOD GLUCOSE M - 3
EASY TRAK BLOOD GLUCOSE M - 3
device
2
EASY TWIST & CAP LANCETS lancets
3
EASYGLUCO - blood glucose
monitoring kit
3
EASYGLUCO PLUS BLOOD
GLUC - blood glucose monitoring
kit w/ device
EASYGLUCO STARTER KIT - blood 3
glucose monitoring kit
EASYMAX L BLOOD GLUCOSE S - 3
3
EASYMAX L BLOOD GLUCOSE
device
EASYMAX N BLOOD GLUCOSE S - 3
3
EASYMAX N BLOOD GLUCOSE
device
EASYMAX NG SELF-MONITORIN - 3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
3
EASYTEST LANCETS - lancets
2
ELEMENT AUTOCODE SYSTEM blood glucose monitoring kit w/
device
3
ELEMENT COMPACT BLOOD
GLU - blood glucose monitoring
devices
3
ELEMENT COMPACT V BLOOD blood glucose monitoring devices
3
ELEMENT PLUS BLOOD GLUCOS - 3
2
ELITE-THIN INSULIN SYRING insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
ml 28 x 5/16"
154
ml 28 x 1/2"
2
EMBRACE PRO BLOOD
monitoring devices
3
ml 29 x 5/16"
2
EQL COLOR LANCETS MICRO T lancets
2
2
2
ml 29 x 1/2"
EQL COLOR LANCETS 21G lancets
2
ml 30 x 5/16"
2
EQL INSULIN SYRINGE/0.3ML insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ELITE-THIN INSULIN SYRING insulin syringe/needle u-100 1 ml
28 x 5/16"
2
ml 30 x 5/16"
2
28 x 1/2"
2
ml 31 x 5/16"
2
29 x 1/2"
2
EQL INSULIN SYRINGE/0.5ML insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
29 x 5/16"
2
ml 29 x 1/2"
2
30 x 5/16"
2
ml 30 x 5/16"
2
31 x 5/16"
2
EQL INSULIN SYRINGE/1ML/2 insulin syringe/needle u-100 1 ml
29 x 1/2"
2
ELITE-THIN INSULIN SYRING insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
30 x 5/16"
2
EMBRACE BLOOD GLUCOSE
MON - blood glucose monitoring
devices
3
31 x 5/16"
2
EMBRACE EVO BLOOD
3
EQL SHORT PEN NEEDLES 31G insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
EMBRACE LANCETS ULTRA THI lancets
2
EQL SUPER THIN LANCETS 30 lancets
EQL THIN LANCETS 26G - lancets
2
EQL ULTRA SHORT PEN NEEDL insulin pen needle 31 g x 6 mm
(1/4")
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
155
EVENCARE BLOOD GLUCOSE
3
EVENCARE G2 BLOOD
monitoring devices
2
3
EXEL COMFORT POINT INSULI insulin syringe/needle u-100 1 ml
29 x 1/2"
2
EVENCARE G3 BLOOD
monitoring devices
3
30 x 5/16"
EZ SMART BLOOD GLUCOSE LA lancets
2
EVENCARE MINI BLOOD GLUCO blood glucose monitoring devices
3
EZ SMART DIABETES MONITOR blood glucose monitoring devices
3
EVOLUTION AUTOCODE - blood
3
EZ SMART PLUS DIABETES MO blood glucose monitoring devices
3
EXCEL COMFORT POINT INSUL insulin pen needle 31 g x 4 mm
(1/6")
2
EZ-LETS LANCETS 21G - lancets
2
2
EXEL COMFORT POINT INSULI insulin pen needle 29 g x 12 mm
(1/2")
2
EZ-LETS LANCETS 26G SUPER lancets
2
2
(1/4")
2
EZ-LETS LANCETS 28G ULTRA lancets
2
P
(1/3" or 5/16")
2
FC FEMALE CONDOM - condoms female
P
EXEL COMFORT POINT INSULI insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
FC2 FEMALE CONDOM - condoms
- female
FEMCAP - cervical cap 22 mm
P
P
EXEL COMFORT POINT INSULI insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
P
3
EXEL COMFORT POINT INSULI insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
FIFTY50 GLUCOSE METER 2.0 blood glucose monitoring kit w/
device
FIFTY50 LANCING DEVICE - lancet
devices
2
ml 29 x 1/2"
2
FIFTY50 PEN NEEDLES 31G X insulin pen needle 31 g x 5 mm
(3/16")
2
ml 30 x 5/16"
2
FIFTY50 PEN NEEDLES 31G X insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
28 x 1/2"
2
FIFTY50 PEN NEEDLES 31GX5 insulin pen needle 31 g x 5 mm
(3/16")
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
156
FIFTY50 PEN NEEDLES/31GX8 insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
FORA TN'G VOICE BLOOD GLU blood glucose monitoring kit w/
device
(5/32")
2
(1/4")
2
FIFTY50 SAFETY SEAL LANCE lancets
2
FIFTY50 SUPERIOR COMFORT insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
FIFTY50 SUPERIOR COMFORT insulin syringe/needle u-100 1 ml
31 x 5/16"
2
FIFTY50 SUPERIOR COMFORT insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
FIFTY50 UNILET LANCETS 33 lancets
2
FINE 30 - lancets
2
FINGERSTIX LANCETS - lancets
2
FLOW-EZE VENTED NEEDLE hypodermic needles (disposable)
3
FORA V10 BLOOD GLUCOSE MO - 3
3
FORA V10/V12/D10/D20 BLOO blood glucose monitoring kit
FORA V30A BLOOD GLUCOSE M - 3
FORA V30A BLOOD GLUCOSE M - 3
device
3
FORACARE GD40 BLOOD
devices
FORACARE PREMIUM V10 BLOO - 3
3
FORACARE TEST N GO BLOOD blood glucose monitoring devices
FORTISCARE SELF-MONITORIN - 3
device
FREDS PHARMACY AUTOLET LA - 2
lancet devices
FREDS PHARMACY UNIFINE PE - 2
insulin pen needle 31 g x 5 mm
(3/16")
(1/3" or 5/16")
(5/32")
FREDS PHARMACY UNILET LAN - 2
lancets
3
FREESTYLE FLASH SYSTEM blood glucose monitoring kit
FORA GD20 BLOOD GLUCOSE M - 3
FORA GD50 BLOOD GLUCOSE M - 3
FORA G20 BLOOD GLUCOSE MO - 3
device
FORA G30A BLOOD GLUCOSE M - 3
2
FORA LANCETS - lancets
FORA LANCING DEVICE - lancet
devices
2
FORA LANCING DEVICE/CLEAR lancet devices
2
FORA TEST N' GO VOICE BLO blood glucose monitoring devices
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
3
157
FREESTYLE FREEDOM - blood
3
FREESTYLE FREEDOM LITE blood glucose monitoring kit w/
device
3
3
GHT BLOOD GLUCOSE MONITO blood glucose monitoring kit w/
device
2
FREESTYLE INSULINX BLOOD blood glucose monitoring kit w/
device
3
GLOBAL EASE INJECT PEN NE insulin pen needle 29 g x 12 mm
(1/2")
2
FREESTYLE LANCETS - lancets
2
(3/16")
FREESTYLE LITE BLOOD GLUC blood glucose monitoring devices
3
2
FREESTYLE PRECISION INSUL insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
(1/3" or 5/16")
2
FREESTYLE PRECISION INSUL insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
(5/32")
2
FREESTYLE PRECISION INSUL insulin syringe/needle u-100 1 ml
30 x 5/16"
2
GLOBAL EASY GLIDE PEN NEE insulin pen needle 32 g x 4 mm
(5/32")
2
FREESTYLE PRECISION INSUL insulin syringe/needle u-100 1 ml
31 x 5/16"
2
GLOBAL INJECT EASE INSULI insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
FREESTYLE PRECISION NEO B blood glucose monitoring kit w/
device
3
ml 30 x 5/16"
2
FREESTYLE SIDEKICK II VAL blood glucose monitoring kit w/
device
3
ml 30 x 1/2"
2
FREESTYLE SYSTEM KIT - blood
3
GLOBAL INJECT EASE INSULI insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
FREESTYLE UNISTICK II LAN lancets
2
ml 28 x 1/2"
GENTLE-LET GP LANCETS lancets
2
2
GENTLE-LET LANCETS GENERA lancets
2
ml 29 x 1/2"
2
GENTLE-LET LANCETS SAFETY lancets
2
ml 30 x 5/16"
ml 30 x 1/2"
2
GE100 BLOOD GLUCOSE MONIT blood glucose monitoring kit w/
device
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
158
GLOBAL INJECT EASE INSULI insulin syringe/needle u-100 1 ml
28 x 1/2"
2
GLUCOCARD 01-MINI BLOOD G blood glucose monitoring kit w/
device
3
29 x 1/2"
2
GLUCOCOM AUTOLINK
TELEMON - blood glucose
monitoring misc.
3
30 x 5/16"
2
GLUCOCOM BLOOD GLUCOSE
devices
3
30 x 1/2"
2
GLUCOCOM BLOOD GLUCOSE
w/ device
3
31 x 5/16"
2
GLUCOCOM LANCETS 28G lancets
2
2
ml 31 x 5/16"
2
2
GLOBAL INJECT EASE LANCET lancets
2
GLUCOLET 2 AUTOMATIC LANC lancet devices
2
GLUCONAVII BLOOD GLUCOSE blood glucose monitoring kit w/
device
3
GLUCOPRO INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
ml 30 x 1/2"
2
GLUCOPRO INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
ml 30 x 5/16"
2
ml 30 x 1/2"
2
GLUCOPRO INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
30 x 5/16"
2
GLOBAL LANCING DEVICE - lancet 2
devices
GLUCO PERFECT 3 BLOOD GLU - 3
GLUCOCARD EXPRESSION AUDI - 3
device
3
GLUCOCARD SHINE - blood
3
GLUCOCARD SHINE - blood
GLUCOCARD VITAL BLOOD GLU - 3
device
3
GLUCOCARD X-METER - blood
3
GLUCOCARD 01 BLOOD
GLUCOS - blood glucose
monitoring devices
3
GLUCOCARD 01 BLOOD
GLUCOS - blood glucose
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
159
30 x 1/2"
2
GNP INSULIN SYRINGE/0.3ML insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
31 x 5/16"
2
ml 31 x 5/16"
2
ml 31 x 5/16"
2
GNP INSULIN SYRINGE/0.5ML insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
GLUCOSOURCE LANCET
DEVICE - lancet devices
2
2
GLUCOSOURCE LANCETS lancets
2
ml 28 x 1/2"
2
GMATE LANCETS 30G - lancets
2
GMATE LANCING DEVICE - lancet
devices
2
ml 29 x 1/2"
2
GMATE ORIGIN BLOOD GLUCOS blood glucose monitoring devices
3
ml 30 x 5/16"
GMATE SMART METER KIT - blood
3
2
GMATE SMART STARTER KIT blood glucose monitoring kit w/
device
3
GNP INSULIN SYRINGE/1ML/2 insulin syringe/needle u-100 1 ml
28 x 1/2"
29 x 1/2"
2
30 x 5/16"
2
31 x 5/16"
2
GNP LANCETS - lancets
2
GNP LANCETS MICRO THIN 33 lancets
2
GNP LANCETS SUPER THIN 30 lancets
2
GNP LANCETS THIN - lancets
2
GNP LANCETS THIN 26G - lancets
2
GNP LANCETS 21G - lancets
2
GNP MICRO THIN LANCETS 33 lancets
2
GNP SUPER THIN LANCETS/30 lancets
2
GMATE VOICE BLOOD GLUCOSE - 3
2
GNP CLICKFINE PEN NEEDLE insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
GNP CLICKFINE UNIVERSAL P insulin pen needle 31 g x 6 mm
(1/4")
2
GNP CLICKFINE UNIVERSAL P insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
3
GNP EASY TOUCH GLUCOSE
devices
2
ml 29 x 1/2"
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
160
GNP ULTRA COMFORT INSULIN insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
H-E-B IN CONTROL PEN NEED insulin pen needle 32 g x 4 mm
(5/32")
2
ml 30 x 5/16"
2
H-E-B IN CONTROL UNIFINE insulin pen needle 31 g x 5 mm
(3/16")
2
GNP ULTRA COMFORT INSULIN insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
H-E-B IN CONTROL UNIFINE insulin pen needle 32 g x 4 mm
(5/32")
2
ml 28 x 1/2"
2
H-E-B INCONTROL ADVANCED lancet devices
2
H-E-B INCONTROL LANCETS M lancets
2
ml 29 x 1/2"
2
2
ml 30 x 5/16"
2
H-E-B INCONTROL LANCETS S lancets
H-E-B INCONTROL LANCETS U lancets
2
GNP ULTRA COMFORT INSULIN insulin syringe/needle u-100 1 ml
28 x 1/2"
2
H-E-B INCONTROL PEN NEEDL insulin pen needle 29 g x 12 mm
(1/2")
2
29 x 1/2"
2
HAEMOLANCE - lancets
2
HAEMOLANCE LOW FLOW
LANCE - lancets
2
30 x 5/16"
2
HAEMOLANCE PLUS - lancets
2
31 x 5/16"
2
ml 31 x 5/16"
2
(3/16")
2
(1/4")
2
(1/3" or 5/16")
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
HAEMOLANCE PLUS HIGH FLOW - 2
lancets
HAEMOLANCE PLUS LOW FLOW - 2
lancets
HAEMOLANCE PLUS MAX FLOW - 2
lancets
HAEMOLANCE PLUS PEDIATRIC - 2
lancets
2
HEALTH CARE LANCING DEVIC lancet devices
2
HEALTHWISE LANCETS 30G lancets
2
HEALTHWISE LANCING PEN lancet devices
2
HEALTHWISE MINI PEN NEEDL insulin pen needle 31 g x 6 mm
(1/4")
161
HEALTHWISE PEN NEEDLES 29 insulin pen needle 29 g x 12 mm
(1/2")
2
HEALTHWISE SHORT PEN NEED insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
HEALTHWISE UNIFINE PENTIP insulin pen needle 32 g x 4 mm
(5/32")
2
HEALTHY ACCENTS AUTOLET I lancet devices
HUBER NEEDLE/STRAIGHT 19G needle (disp) 19 x 1-1/4"
3
HUBER NEEDLE/STRAIGHT 20G needle (disp) 20 x 1"
3
3
HUBER NEEDLE/STRAIGHT 22G needle (disp) 22 x 1"
3
2
3
HEALTHY ACCENTS UNIFINE P insulin pen needle 29 g x 12 mm
(1/2")
2
HUBER NEEDLE/19GX3/4"/RIG needle (disp) 19 x 3/4"
3
3
(3/16")
2
HUBER NEEDLE/20G X 1-1/4" needle (disp) 20 x 1-1/4"
HUBER NEEDLE/22GX1-1/4"/4 needle (disp) 22 x 1-1/4"
3
(1/4")
2
HY-VEE LANCETS - lancets
2
HY-VEE THIN LANCETS - lancets
2
HYPODERMIC NEEDLE 16G X 1 needle (disp) 16 x 1"
3
(1/3" or 5/16")
2
3
(5/32")
2
HYPODERMIC NEEDLE 16G X 1 needle (disp) 16 x 1-1/2"
3
HEALTHY ACCENTS UNILET LA lancets
2
3
HUBER NEEDLE 20GX3/4"/R needle (disp) 20 x 3/4"
3
3
HUBER NEEDLE/RIGHT ANGLE needle (disp) 19 x 1"
3
3
3
3
HUBER NEEDLE/RIGHT ANGLE needle (disp) 20 x 1-1/2"
3
3
HUBER NEEDLE/RIGHT ANGLE needle (disp) 22 x 3/4"
3
HYPODERMIC NEEDLE 20GX3/4 needle (disp) 20 x 3/4"
3
3
HYPODERMIC NEEDLE 21GX1-1 needle (disp) 21 x 1-1/4"
3
HUBER NEEDLE/RIGHT ANGLE needle (disp) 22 x 1-1/2"
3
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
162
HYPODERMIC NEEDLE 21GX1" needle (disp) 21 x 1"
3
IN TOUCH DIABETES MANAGEM blood glucose monitoring misc.
3
3
IN TOUCH LANCING DEVICE lancet devices
2
3
IN TOUCH STERILE LANCETS lancets
2
3
3
3
INFINITY BLOOD GLUCOSE MO blood glucose monitoring kit w/
device
3
3
INSUL-TOTE - blood glucose
monitoring supplies
3
3
INSUL-TOTE JR - blood glucose
monitoring supplies
2
3
INSULIN SYRINGE/U-100/0.3 insulin syringe/needle u-100 0.3
ml 29 x 1/2"
3
2
3
INSULIN SYRINGE/U-100/0.5 insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
3
INSULIN SYRINGE/U-100/0.5 insulin syringe/needle u-100 1/2
ml 29 x 1/2"
3
2
3
INSULIN SYRINGE/U-100/1ML insulin syringe/needle u-100 1 ml
28 x 1/2"
2
3
29 x 1/2"
30 x 5/16"
2
3
3
2
3
31 x 5/16"
2
3
INSULIN SYRINGE/0.3ML/29G insulin syringe/needle u-100 0.3
ml 29 x 1/2"
IBG STAR BLOOD GLUCOSE MO blood glucose monitoring kit w/
device
3
ml 29 x 1"
2
IN TOUCH - blood glucose
monitoring devices
3
ml 30 x 5/16"
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
163
ml 31 x 5/16"
2
INSUPEN ULTRAFIN 31GX6MM insulin pen needle 31 g x 6 mm
(1/4")
2
INSULIN SYRINGE/0.5ML/27G insulin syringe/needle u-100 1/2
ml 27 x 1/2"
2
(1/3" or 5/16")
2
ml 28 x 1/2"
2
INSUPEN 33GX4MM - insulin pen
needle 33 g x 4 mm (5/32")
2
2
KINNEY LANCETS - lancets
2
ml 30 x 5/16"
KINNEY THIN LANCETS - lancets
2
2
ml 30 x 1/2"
2
KINRAY INSULIN SYRINGE PR insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
ml 31 x 5/16"
2
KINRAY INSULIN SYRINGE PR insulin syringe/needle u-100 1 ml
31 x 5/16"
2
INSULIN SYRINGE/1ML/28G X insulin syringe/needle u-100 1 ml
28 x 1/2"
2
KINRAY INSULIN SYRINGE PR insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
29 x 1/2"
2
KINRAY INSULIN SYRINGE/0. insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
30 x 5/16"
2
KMART VALU PLUS INSULIN S insulin syringe (disp) u-100 0.3 ml
KMART VALU PLUS INSULIN S insulin syringe (disp) u-100 1/2 ml
2
INSUPEN PEN NEEDLES 32G X insulin pen needle 32 g x 4 mm
(5/32")
2
KMART VALU PLUS INSULIN S insulin syringe (disp) u-100 1 ml
2
3
INSUPEN SENSITIVE 32GX6MM insulin pen needle 32 g x 6 mm
(1/4")
2
KROGER BLOOD GLUCOSE
MONI - blood glucose monitoring
kit w/ device
2
INSUPEN SENSITIVE 32GX8MM insulin pen needle 32 g x 8 mm
2
KROGER INSULIN SYRINGE/U- insulin syringe/needle u-100 0.3
ml 30 x 1/2"
(1/2")
2
KROGER INSULIN SYRINGE/0. insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
(1/3" or 5/16")
2
ml 30 x 5/16"
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
164
KROGER INSULIN SYRINGE/0. insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
KROGER PEN NEEDLES 31GX1/ insulin pen needle 31 g x 6 mm
(1/4")
2
ml 29 x 1/2"
2
KROGER PREMIUM BLOOD
GLUC - blood glucose monitoring
kit w/ device
3
ml 30 x 5/16"
2
LANCET DEVICE ADJUSTABLE lancet devices
2
2
LANCET DEVICE WITH EJECTO lancet devices
2
ml 31 x 5/16"
LANCETS - lancets
2
KROGER INSULIN SYRINGE/1M insulin syringe/needle u-100 1 ml
29 x 1/2"
2
LANCETS MICRO THIN 33G lancets
2
2
30 x 5/16"
2
LANCETS SAFETY SEAL 21G lancets
2
31 x 5/16"
2
2
2
KROGER LANCETS - lancets
2
KROGER LANCETS MICRO THIN lancets
2
LANCETS SUPER THIN 28G lancets
2
KROGER LANCETS SUPER THIN lancets
2
LANCETS THIN - lancets
2
2
KROGER LANCETS THIN - lancets
2
LANCETS TWIST TOP - lancets
2
KROGER LANCETS THIN 26G lancets
2
LANCETS ULTRA FINE - lancets
LANCETS ULTRA THIN - lancets
2
LANCETS ULTRA THIN 30G lancets
2
KROGER LANCETS ULTRATHIN lancets
2
KROGER LANCING DEVICE lancet devices
2
LANCETS 26G TWIST TOP lancets
2
KROGER LANCETS 21G - lancets
2
LANCETS 28G - lancets
2
LANCETS 30G - lancets
2
KROGER PEN NEEDLES 29G X insulin pen needle 29 g x 12 mm
(1/2")
2
2
KROGER PEN NEEDLES 31G X insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
LANCETS 30G/TWIST TOP lancets
2
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
165
LANCETS 33G UNIVERSAL DES lancets
2
LANCING DEVICE - lancet devices
2
LANCING DEVICE ADJUSTABLE lancet devices
LANZO - lancet devices
LEADER INSULIN SYRINGE/1M insulin syringe/needle u-100 1 ml
31 x 5/16"
2
2
LEADER LANCETS COLORED lancets
2
2
LEADER SUPER THIN LANCET lancets
2
LEADER THIN LANCETS - lancets
2
LEADER UNIFINE PENTIPS PL insulin pen needle 31 g x 5 mm
(3/16")
2
LEADER UNIFINE PENTIPS PL insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
LEADER UNIFINE PENTIPS/MI insulin pen needle 31 g x 5 mm
(3/16")
2
LEADER UNIFINE PENTIPS/NA insulin pen needle 32 g x 4 mm
(5/32")
2
LEADER UNIFINE PENTIPS/PL insulin pen needle 32 g x 4 mm
(5/32")
2
LIBERTY BLOOD GLUCOSE MET blood glucose monitoring devices
3
LDR BLOOD GLUCOSE TRUETES - 3
device
LEADER ADVANCED LANCING D - 2
lancet devices
2
LEADER INSULIN SYRINGE/0. insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ml 30 x 5/16"
2
LEADER INSULIN SYRINGE/0. insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
ml 28 x 1/2"
2
ml 29 x 1/2"
2
ml 30 x 5/16"
2
ml 31 x 5/16"
2
28 x 1/2"
2
29 x 1/2"
2
30 x 5/16"
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
LIBERTY BLOOD GLUCOSE MON - 3
2
LIBERTY MEDICAL LANCETS 3 lancets
2
LIBERTY MINI LANCING DEVI lancet devices
3
LIBERTY NEXT GENERATION B blood glucose monitoring devices
2
LIFESCAN UNISTIK II LANCE lancets
2
LIFESCAN UNISTIK 2 DEEP P lancets
2
LITE TOUCH LANCETS - lancets
LITE TOUCH LANCING DEVICE lancet devices
2
LITE TOUCH LANCING PEN lancet devices
2
166
LITE TOUCH PEN NEEDLES/31 insulin pen needle 31 g x 5 mm
(3/16")
2
LITETOUCH PEN NEEDLES 31G insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
LITETOUCH INSULIN SYRINGE insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
LIVE BETTER ADVANCED LANC lancet devices
2
2
2
ml 30 x 5/16"
LIVE BETTER LANCET SUPER lancets
2
LITETOUCH INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
LIVE BETTER LANCET ULTRA lancets
2
ml 28 x 1/2"
2
LIVE BETTER PEN NEEDLES 2 insulin pen needle 29 g x 12 mm
(1/2")
2
ml 29 x 1/2"
2
(1/4")
2
ml 30 x 5/16"
2
(1/3" or 5/16")
LOCAL ANESTHESIA SECURITY needle (disp) 20 x 4"
3
LITETOUCH INSULIN SYRINGE insulin syringe/needle u-100 1 ml
28 x 1/2"
2
3
3
29 x 1/2"
2
3
30 x 5/16"
2
LONGS INSULIN SYRINGE/0.5 insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
31 x 5/16"
2
LONGS LANCETS STANDARD lancets
2
2
ml 31 x 5/16"
2
LONGS LANCETS THIN - lancets
LONGS LANCETS ULTRA THIN lancets
2
LITETOUCH PEN NEEDLES 29G insulin pen needle 29 g x 12.7 mm
2
MAGELLAN INSULIN SAFETY S insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
LITETOUCH LANCETS MICRO T lancets
2
2
LITETOUCH PEN NEEDLES 31G insulin pen needle 31 g x 6 mm
(1/4")
2
MAGELLAN INSULIN SAFETY S insulin syringe/needle u-100 0.3
ml 30 x 5/16"
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
167
MAGELLAN INSULIN SAFETY S insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
MEDICINE SHOPPE LANCETS lancets
2
MEDICINE SHOPPE LANCETS T lancets
2
MAGELLAN INSULIN SAFETY S insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
2
MAGELLAN INSULIN SAFETY S insulin syringe/needle u-100 1 ml
29 x 1/2"
2
MEDICINE SHOPPE PEN NEEDL insulin pen needle 29 g x 12 mm
(1/2")
2
MAGELLAN INSULIN SAFETY S insulin syringe/needle u-100 1 ml
30 x 5/16"
2
(1/4")
2
MAGELLAN TUBERCULIN SAFET tuberculin/allergy syringe/needle
(disp) 1 ml 27 x 1/2"
2
(1/3" or 5/16")
2
MAGELLAN TUBERCULIN SAFET tuberculin/allergy syringe/needle
(disp) 1 ml 28 x 1/2"
3
MEDISENSE THIN LANCETS lancets
MAXI-COMFORT INSULIN SYRI insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
MAXI-COMFORT INSULIN SYRI insulin syringe/needle u-100 1 ml
28 x 1/2"
2
MAXIMA BLOOD GLUCOSE MONI - 3
device
3
MAXIMA METER KIT - blood
3
MAXIMA STARTER KIT - blood
2
MD SAFETYGLIDE 27G X 5/8" needle (disp) 27 x 5/8"
2
MEDIC INSULIN SYRINGE/0.3 insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
MEDIC INSULIN SYRINGE/0.5 insulin syringe/needle u-100 1/2
ml 30 x 5/16"
MEDICHOICE PRE-SET SAFETY - 2
lancets
2
MEDICHOICE SAFETY LANCET lancets
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
MEDLANCE PLUS EXTRA LANCE - 2
lancets
2
MEDLANCE PLUS LANCETS lancets
2
MEDLANCE PLUS LANCETS LIT lancets
2
MEDLANCE PLUS LITE LANCET lancets
MEDLANCE PLUS SPECIAL LAN - 2
lancets
2
MEDLANCE PLUS SUPERLITE 3 lancets
MEDLANCE PLUS UNIVERSAL L - 2
lancets
2
MEDLANCE PLUS/LITE 25G lancets
2
MEDLANCE/EXTRA - lancets
MEDLANCE/LITE - lancets
2
MEDLANCE/UNIVERSAL - lancets
2
MEIJER BLOOD GLUCOSE MONI blood glucose monitoring kit w/
device
3
MEIJER COLOR LANCETS UNIV lancets
2
168
MEIJER ESSENTIAL BLOOD GL blood glucose monitoring kit w/
device
3
MEIJER LANCETS - lancets
2
MEIJER LANCETS THIN - lancets
2
MEIJER LANCETS UNIVERSAL lancets
MONOJECT BLUNT CANNULA/17 needle (disp) 17 x 1-1/2"
3
MONOJECT BLUNT CANNULA/18 needle (disp) 18 x 1"
3
3
2
3
MEIJER PEN NEEDLES 29G X insulin pen needle 29 g x 12 mm
(1/2")
2
3
(1/4")
2
3
3
(1/3" or 5/16")
2
MEIJER PREMIUM BLOOD GLUC blood glucose monitoring kit w/
device
3
MEIJER SUPER THIN LANCETS lancets
2
MEIJER TRUERESULT BLOOD G blood glucose monitoring kit w/
device
3
MEIJER TRUETRACK BLOOD GL blood glucose monitoring kit w/
device
3
MEIJER TRUE2GO BLOOD GLUC blood glucose monitoring kit w/
device
3
MICRODOT BLOOD GLUCOSE
w/ device
3
MICROLET LANCETS - lancets
2
MICROTAINER SAFETY FLOW L lancets
2
MINI LANCING DEVICE - lancet
devices
2
3
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
MONOJECT HYPO/ALUM HUB/LU - 3
169
MONOJECT HYPO/ALUM HUB/16 - 3
MONOJECT HYPO/ALUM HUB/18 - 2
3
MONOJECT HYPO/
POLYPROPYLE - needle (disp) 18
x 1"
3
MONOJECT HYPO/
x 1-1/2"
3
MONOJECT HYPO/
x 1"
3
MONOJECT HYPO/
x 1-1/2"
3
MONOJECT HYPO/
x 1"
3
MONOJECT HYPO/
x 1-1/2"
MONOJECT HYPO/
x 1"
3
MONOJECT HYPO/
x 1-1/2"
3
MONOJECT HYPO/
x 1"
3
MONOJECT HYPO/
x 1-1/2"
3
MONOJECT HYPO/
x 3/4"
3
MONOJECT HYPO/
x 1"
3
MONOJECT HYPO/
x 5/8"
3
MONOJECT HYPO/
x 1"
3
MONOJECT HYPO/
x 1-1/2"
3
MONOJECT HYPO/
x 1/2"
3
MONOJECT HYPO/
x 1/2"
3
MONOJECT HYPO/
x 3/4"
3
MONOJECT HYPODERMIC
NEEDL - needle (disp) 18 x 1"
3
MONOJECT HYPODERMIC
NEEDL - needle (disp) 27 x 1-1/2"
3
MONOJECT HYPODERMIC
NEEDL - needle (disp) 30 x 3/4"
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
170
MONOJECT INSULIN SYRINGE insulin syringe (disp) u-100 1 ml
2
MONOJECT MAGELLAN SAFETY needle (disp) 19 x 1-1/2"
3
MONOJECT INSULIN SYRINGE/ insulin syringe (disp) u-100 1 ml
2
MONOJECT MAGELLAN SAFETY needle (disp) 20 x 1"
2
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
2
2
MONOJECT MAGELLAN SAFETY needle (disp) 21 x 5/8"
2
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
2
ml 29 x 1/2"
2
2
2
ml 30 x 5/16"
2
2
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
25 x 5/8"
2
2
2
27 x 1/2"
2
2
28 x 1/2"
2
29 x 1/2"
2
30 x 5/16"
2
31 x 5/16"
2
2
2
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
MONOJECT MEDICATION TRANS - 3
hypodermic needles (disposable)
3
MONOJECT STANDARD
HYPODER - needle (disp) 14 x
1-1/2"
3
MONOJECT STANDARD
HYPODER - needle (disp) 18 x 1"
3
MONOJECT STANDARD
1-1/2"
3
MONOJECT STANDARD
3
MONOJECT STANDARD
1-1/2"
3
MONOJECT STANDARD
171
MONOJECT STANDARD
1-1/2"
3
MONOJECT STANDARD
3
MONOJECT STANDARD
1-1/2"
3
MONOJECT STANDARD
3
MONOJECT STANDARD
3
MONOJECT STANDARD
1-1/2"
3
MONOJECT STANDARD
1/2"
3
MONOJECT STANDARD
3
MONOJECT STANDARD
5/8"
3
MONOJECT STANDARD
3
MONOJECT STANDARD
1-1/2"
3
MONOJECT STANDARD
1-1/2"
3
MONOJECT STANDARD
1/2"
3
MONOJECT TB SYRINGE-NDL 1 tuberculin/allergy syringe/needle
(disp) 1 ml 26 x 3/8"
3
MONOJECT TB SYRINGE-NDL 1 tuberculin/allergy syringe/needle
(disp) 1 ml 27 x 1/2"
2
MONOJECT TUBERCULIN SAFET - 2
(disp) 1 ml 25 x 5/8"
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
MONOJECT TUBERCULIN SAFET - 3
(disp) 1 ml 28 x 1/2"
MONOJECT TUBERCULIN SYRIN - 2
(disp) 1 ml 25 x 5/8"
(disp) 1 ml 26 x 3/8"
(disp) 1 ml 27 x 1/2"
(disp) 1 ml 28 x 1/2"
MONOJECT ULTRA COMFORT IN - 2
insulin syringe/needle u-100 0.3
ml 29 x 1/2"
ml 30 x 5/16"
insulin syringe/needle u-100 1/2
ml 31 x 5/16"
ml 28 x 1/2"
ml 29 x 1/2"
ml 30 x 5/16"
28 x 1/2"
29 x 1/2"
30 x 5/16"
172
ml 31 x 5/16"
2
MONOLET LANCETS - lancets
MONOLET OPD LANCETS - lancets 2
2
MONOLETTOR SAFETY
LANCETS - lancets
MOORE MED MONOJECT INSULI - 2
ml 28 x 1/2"
ml 29 x 1/2"
28 x 1/2"
29 x 1/2"
2
MS INSULIN SYRINGE/0.3ML/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ml 30 x 5/16"
2
ml 31 x 5/16"
2
MS INSULIN SYRINGE/0.5ML/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
ml 29 x 1/2"
2
ml 30 x 5/16"
2
MS INSULIN SYRINGE/1ML/29 insulin syringe/needle u-100 1 ml
29 x 1/2"
2
30 x 5/16"
31 x 5/16"
2
MULTI-DRAW NEEDLE 20GX1- needle (disp) 20 x 1-1/2"
3
MULTI-DRAW NEEDLE 21GX1-1 needle (disp) 21 x 1-1/2"
3
MULTI-DRAW NEEDLE 22GX1-1 needle (disp) 22 x 1-1/2"
3
MULTI-LANCET DEVICE - lancet
devices
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
3
MYGLUCOHEALTH BLOOD
kit w/ device
2
MYGLUCOHEALTH MGH
SOFTLAN - lancets
2
NETGROUP LANCETS - lancets
NEXGEN METER KIT - blood
3
NOKOR ADMIX NEEDLE THIN W needle (disp) 16 x 1"
3
NOKOR ADMIX NEEDLE THIN W needle (disp) 18 x 1-1/2"
3
NOKOR VENTED NEEDLE THIN needle (disp) 16 x 1"
3
NOKOR VENTED NEEDLE THIN needle (disp) 18 x 1"
3
NOKOR VENTED NEEDLE THIN needle (disp) 18 x 1-1/2"
3
NOVA MAX BLOOD GLUCOSE
devices
3
NOVA MAX BLOOD GLUCOSE
w/ device
3
NOVA SAFETY LANCETS 23G lancets
2
NOVA SAFETY LANCETS 28G lancets
2
NOVA SUREFLEX LANCETS lancets
2
173
NOVA SUREFLEX LANCING DEV lancet devices
2
NOVOFINE AUTOCOVER
30GX8M - insulin pen needle 30 g
x 8 mm (1/3" or 5/16")
2
NOVOFINE PLUS 32GX4MM insulin pen needle 32 g x 4 mm
(5/32")
ON CALL VIVID BLOOD GLUCO blood glucose monitoring kit w/
device
3
ON CALL VIVID PAL BLOOD G blood glucose monitoring devices
3
2
ON CALL VIVID PAL BLOOD G blood glucose monitoring kit w/
device
3
NOVOFINE 30GX8MM - insulin pen
needle 30 g x 8 mm (1/3" or 5/16")
2
ONETOUCH CLUB LANCETS FIN lancets
2
NOVOFINE 32GX6MM - insulin pen
needle 32 g x 6 mm (1/4")
2
ONETOUCH COMBO PACK lancets
2
NOVOPEN ECHO - injection device
for insulin
3
ONETOUCH DELICA LANCETS E lancets
2
NOVOTWIST 30GX8MM - insulin
5/16")
2
ONETOUCH DELICA LANCETS F lancets
2
2
ONETOUCH DELICA LANCING D lancet devices
2
NOVOTWIST 32GX5MM - insulin
3/16")
2
OMNIFLEX DIAPHRAGM diaphragms
P
ONETOUCH FINEPOINT LANCET lancets
ONETOUCH LANCETS - lancets
2
OMNIPOD STARTER KIT - insulin
infusion disposable pump kit
3
ON CALL EXPRESS BLOOD GLU blood glucose monitoring devices
3
ON CALL EXPRESS BLOOD GLU blood glucose monitoring kit w/
device
3
ON CALL LANCETS - lancets
2
ON CALL LANCING DEVICE lancet devices
2
ON CALL PLUS BLOOD GLUCOS blood glucose monitoring devices
3
ON CALL PLUS BLOOD GLUCOS blood glucose monitoring kit w/
device
3
ON CALL PLUS LANCETS - lancets
2
ON CALL PLUS LANCING DEVI lancet devices
2
ON CALL VIVID BLOOD GLUCO blood glucose monitoring devices
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
• •
3
ONETOUCH PING METER
REMOT - blood glucose monitoring
supplies
2
ONETOUCH SURESOFT
LANCING - lancets misc.
3
ONETOUCH ULTRA MINI - blood
3
ONETOUCH ULTRA 2 - blood
ONETOUCH ULTRALINK SYSTEM - 3
device
2
ONETOUCH ULTRASOFT
LANCET - lancets
ONETOUCH VERIO - blood glucose 3
ONETOUCH VERIO FLEX BLOOD - 3
device
174
ONETOUCH VERIO IQ BLOOD G blood glucose monitoring kit w/
device
3
3
ONETOUCH VERIO SYNC
BLOOD - blood glucose monitoring
kit w/ device
OPTIUM BLOOD GLUCOSE MONI - 3
OPTIUM BLOOD GLUCOSE MONI - 3
device
3
MET - blood glucose monitoring kit
w/ device
3
w/ device
ORTHO DIAPHRAGM COIL SPRI - P
diaphragm coil spring kit 50 mm
ORTHO DIAPHRAGM FLAT SPRI - P
diaphragm flat spring kit 55 mm
PARADIGM LINK BLOOD GLUCO blood glucose monitoring kit w/
device
3
PC LANCETS SUPER THIN 30G lancets
2
PC UNIFINE PENTIPS 29G X insulin pen needle 29 g x 12 mm
(1/2")
2
(3/16")
2
(1/4")
2
(1/3" or 5/16")
2
PEN NEEDLES 29G X 12MM insulin pen needle 29 g x 12 mm
(1/2")
2
PEN NEEDLES 29GX1/2" - insulin
2
PEN NEEDLES 30GX5/16" - insulin
5/16")
2
PEN NEEDLES 31G X 1/4" SH insulin pen needle 31 g x 6 mm
(1/4")
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
PEN NEEDLES 31G X 3/16" - insulin 2
PEN NEEDLES 31G X 5MM - insulin 2
PEN NEEDLES 31GX5/16" - insulin 2
5/16")
2
PEN NEEDLES 31GX6MM (1/4" insulin pen needle 31 g x 6 mm
(1/4")
PEN NEEDLES 31GX8MM - insulin 2
5/16")
175
PEN NEEDLES 31GX8MM (5/16 insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
POLY HUB NEEDLE/22G X 1-1 needle (disp) 22 x 1-1/2"
3
POLY HUB NEEDLE/22G X 1" needle (disp) 22 x 1"
3
PEN NEEDLES 32GX4MM - insulin
2
3
PEN-TOTE - blood glucose
monitoring supplies
3
2
3
PENLET II REPLACEMENT CAP lancets misc.
3
PENTIPS 29GX12MM - insulin pen
needle 29 g x 12 mm (1/2")
2
3
needle 31 g x 5 mm (3/16")
2
POLY HUB NEEDLE/25G X 5/8 needle (disp) 25 x 5/8"
3
needle 31 g x 6 mm (1/4")
2
2
3
needle 31 g x 8 mm (1/3" or 5/16")
2
3
needle 32 g x 4 mm (5/32")
3
PERFECT LANCETS 30G - lancets
2
PERFECT PRESSURE ACTIVATE lancets
2
PRECISION LINK - blood glucose
3
PHARMACIST CHOICE
AUTOCOD - blood glucose
3
PRECISION QID MONITOR - blood
3
2
PRECISION SOF-TACT MONITO blood glucose monitoring devices
3
PHARMACIST CHOICE ULTRA T lancets
PRECISION SURE-DOSE INSUL insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
PRECISION SURE-DOSE INSUL insulin syringe/needle u-100 1/2
ml 30 x 3/8"
2
ml 28 x 1/2"
2
ml 29 x 1/2"
2
PRECISION SURE-DOSE INSUL insulin syringe/needle u-100 1 ml
28 x 1/2"
2
PHARMACY COUNTER LANCETS - 2
lancets
3
POCKETCHEM EZ BLOOD
kit w/ device
3
3
3
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
176
PRECISION SURE-DOSE PLUS insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
PRECISION SURE-DOSE PLUS insulin syringe/needle u-100 1 ml
29 x 1/2"
2
PRECISION THIN LANCETS lancets
2
PRECISION THINS GP LANCET lancets
2
PRECISION ULTRA LANCET lancets
2
PRECISION XTRA - blood glucose
monitoring devices
3
PRECISION XTRA - blood glucose
monitoring kit
3
PRECISION XTRA MONITOR blood glucose monitoring devices
3
PREFERRED PLUS INSULIN SY insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
PREFERRED PLUS INSULIN SY insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
PREFERRED PLUS INSULIN SY insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
ml 29 x 1/2"
2
ml 30 x 5/16"
2
PREFERRED PLUS INSULIN SY insulin syringe/needle u-100 1 ml
28 x 1/2"
2
29 x 1/2"
2
30 x 5/16"
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
PREFERRED PLUS LANCETS CO - 2
lancets
PREFERRED PLUS LANCETS SU - 2
lancets
PREFERRED PLUS LANCETS TH - 2
lancets
2
PREFERRED PLUS UNIFINE PE insulin pen needle 29 g x 12 mm
(1/2")
2
(3/16")
2
(1/4")
2
(1/3" or 5/16")
2
(5/32")
P
PRENTIF CAVITY-RIM CERVIC cervical cap 22 mm
P
P
P
P
PRENTIF FITTING SET - cervical
caps
PRESSURE ACTIVATED SAFETY - 2
lancets
2
PRO COMFORT LANCETS 30G lancets
3
PRODIGY AUTOCODE BLOOD
GL - blood glucose monitoring
devices
3
PRODIGY AUTOCODE BLOOD
GL - blood glucose monitoring kit
w/ device
177
PRODIGY INSULIN SYRING/U- insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
PX INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
PRODIGY INSULIN SYRINGE/1 insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
PX INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml
30 x 1/2"
2
PRODIGY INSULIN SYRINGE/1 insulin syringe/needle u-100 1 ml
28 x 1/2"
2
PX INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml
31 x 5/16"
2
PRODIGY LANCING DEVICE lancet devices
2
PX INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
PX LANCET AUTO INJECTOR lancet devices
2
PRODIGY POCKET BLOOD GLUC - 3
device
PRODIGY PRESSURE ACTIVATE - 2
lancets
2
PRODIGY SAFETY LANCETS lancets
PRODIGY TWIST TOP LANCETS - 2
lancets
PRODIGY VOICE BLOOD GLUCO - 3
device
2
PSS SELECT GP LANCETS lancets
PSS SELECT SAFETY LANCETS - 2
lancets
PUSH BUTTON SAFETY LANCET - 2
lancets
2
PX ADVANCED LANCING DEVIC lancet devices
PX EXTRA SHORT PEN NEEDLE - 2
(1/4")
2
PX INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 0.3
ml 30 x 1/2"
2
PX INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
PX LANCETS ULTRA THIN - lancets 2
2
PX MINI PEN NEEDLES 31GX5 insulin pen needle 31 g x 5 mm
(3/16")
2
PX PEN NEEDLE 29GX12MM insulin pen needle 29 g x 12 mm
(1/2")
2
PX PEN NEEDLE 31GX8MM insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
PX SHORTLENGTH PEN NEEDLE - 2
(1/3" or 5/16")
QC ADVANCED LANCING DEVIC - 2
lancet devices
2
QC INSULIN SYRINGE/0.3ML/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
QC INSULIN SYRINGE/0.5ML/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
QC INSULIN SYRINGE/0.5ML/ insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
QC INSULIN SYRINGE/1ML/29 insulin syringe/needle u-100 1 ml
29 x 1/2"
178
QC INSULIN SYRINGE/1ML/31 insulin syringe/needle u-100 1 ml
31 x 5/16"
2
RA INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
QC LANCETS SUPER THIN lancets
2
2
QC LANCETS ULTRA THIN lancets
2
RA INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml
30 x 5/16"
2
QC PEN NEEDLES 29G X 12MM insulin pen needle 29 g x 12 mm
(1/2")
2
RA INSULIN SYRINGE/0.5ML/ insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
(1/4")
2
RA INSULIN SYRINGE/1ML/29 insulin syringe/needle u-100 1 ml
29 x 1/2"
2
(1/3" or 5/16")
2
RA LANCING DEVICE - lancet
devices
2
QC UNIFINE PENTIPS 32GX4M insulin pen needle 32 g x 4 mm
(5/32")
2
RA PEN NEEDLES 31G X 5MM insulin pen needle 31 g x 5 mm
(3/16")
2
QC UNILET LANCETS 28G/ULT lancets
2
RA PEN NEEDLES 31G X 8MM insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
QC UNILET LANCETS 33G/MIC lancets
2
QUICKTEK - blood glucose
3
QUICKTEK - blood glucose
monitoring kit
3
QUINTET AC BLOOD GLUCOSE blood glucose monitoring devices
3
QUINTET BLOOD GLUCOSE
devices
3
RA BLOOD GLUCOSE MONITOR blood glucose monitoring devices
3
RA E-ZJECT COLOR LANCETS lancets
2
RA E-ZJECT LANCETS THIN 2 lancets
2
RA E-ZJECT LANCETS ULTRA lancets
2
RA E-ZJECT LANCETS 28G lancets
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
RA TRUERESULT BLOOD GLUCO - 3
device
RA TRUE2GO BLOOD GLUCOSE - 3
device
2
REALITY INSULIN SYRINGE/U insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
REALITY INSULIN SYRINGE/U insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
REALITY INSULIN SYRINGE/U insulin syringe/needle u-100 1 ml
28 x 1/2"
2
REALITY INSULIN SYRINGE/U insulin syringe/needle u-100 1 ml
29 x 1/2"
2
REALITY LANCETS - lancets
REALITY TRIGGER LANCETS lancets
2
179
REFUAH PLUS BLOOD
3
RELION INSULIN SYRINGE/U- insulin syringe/needle u-100 1 ml
30 x 5/16"
2
REGIONAL BLOCK NEEDLE SAF needle (disp) 22 x 1-1/2"
3
2
RELION CONFIRM BLOOD GLUC blood glucose monitoring kit w/
device
3
31 x 5/16"
2
RELION INSULIN SYRINGE/U insulin syringe/needle u-100 1/2
ml 29 g
2
RELION INSULIN SYRINGE/U- insulin syringe/needle u-100 0.3
ml 31 x 5/16"
RELION LANCETS - lancets
2
RELION LANCETS MICRO-THIN lancets
2
ml 29 g
2
2
ml 30 g
2
RELION LANCETS STANDARD 2 lancets
RELION LANCETS THIN 26G lancets
2
ml 29 x 1/2"
2
RELION LANCETS ULTRA-THIN lancets
2
2
ml 30 x 5/16"
2
RELION LANCING DEVICE - lancet
devices
3
RELION INSULIN SYRINGE/U- insulin syringe/needle u-100 1/2
ml 30 g
2
RELION MICRO BLOOD GLUCOS blood glucose monitoring kit w/
device
2
ml 31 x 5/16"
2
RELION MINI PEN NEEDLES 3 insulin pen needle 31 g x 6 mm
(1/4")
2
ml 29 x 1/2"
2
RELION PEN NEEDLES 29GX12 insulin pen needle 29 g x 12 mm
(1/2")
2
ml 30 x 5/16"
2
RELION PEN NEEDLES 31GX6M insulin pen needle 31 g x 6 mm
(1/4")
2
29 x 1/2"
2
(1/3" or 5/16")
2
30 g
2
(5/32")
RELION PRIME BLOOD GLUCOS blood glucose monitoring devices
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
180
RELION SHORT PEN NEEDLES insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
RELION THIN LANCETS - lancets
2
RELION ULTIMA BLOOD GLUCO blood glucose monitoring kit w/
device
SAFE-T-LANCE NORMAL FLOW lancets
2
SAFE-T-LANCE PLUS SAFETY lancets
2
3
SAFESNAP ALLERGY SYRINGE/ tuberculin/allergy syringe/needle
(disp) 1 ml 27 x 1/2"
2
RELION ULTRA THIN LANCETS lancets
2
2
RELION ULTRA THIN PLUS LA lancets
2
SAFESNAP INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
RELION 2-IN-1 LANCING DEV lancet devices
2
SAFESNAP INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 29 x 1/2"
SAFESNAP INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
SAFESNAP INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
28 x 1/2"
2
SAFESNAP INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
29 x 1/2"
2
SAFESNAP TUBERCULIN SYRIN tuberculin/allergy syringe/needle
(disp) 1 ml 25 x 5/8"
2
SAFESNAP TUBERCULIN SYRIN tuberculin/allergy syringe/needle
(disp) 1 ml 27 x 1/2"
2
SAFETY LANCET 21G/PRESSUR lancets
2
SAFETY LANCET 28G/PRESSUR lancets
2
SAFETY LANCETS - lancets
2
SAFETY LANCETS 21G - lancets
2
SAFETY LANCETS 28G - lancets
2
SAFETY LET LANCETS - lancets
2
SAFETY SEAL LANCETS 28G lancets
2
SAFETY SEAL LANCETS 30G lancets
2
SAFETY-GARD SHIELDED NEED hypodermic needles (disposable)
3
RETROBULBAR NEEDLE 25G TW - 3
REVEAL BLOOD GLUCOSE MONI - 3
device
REXALL BLOOD GLUCOSE MONI - 3
device
2
REXALL LANCETS ULTRA THIN lancets
2
RIGHTEST GD500 LANCING DE lancet devices
2
RIGHTEST GL300 LANCETS lancets
RIGHTEST GM100 BLOOD GLUC - 3
device
device
device
3
RIGHTSOURCE BLOOD
monitoring devices
2
SAFE-T-LANCE LOW FLOW 25G lancets
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
181
SAFETY-GLIDE INSULIN SYRI insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
SHOPKO UNIFINE PENTIPS PE insulin pen needle 29 g x 12 mm
(1/2")
2
SAFETY-LOK SAFETY SYRINGE tuberculin/allergy syringe/needle
(disp) 1 ml 25 x 5/8"
2
(3/16")
2
SAFETY-LOK TB SYRINGE PER tuberculin/allergy syringe/needle
(disp) 1 ml 27 x 1/2"
2
(1/3" or 5/16")
2
SAPSCARE TWIST TOP LANCET lancets
2
2
SB INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
(5/32")
2
SB INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
SHOPKO UNIFINE PENTIPS PL insulin pen needle 29 g x 12 mm
(1/2")
2
SB INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml
29 x 1/2"
2
(3/16")
2
30 x 5/16"
2
(1/3" or 5/16")
2
31 x 5/16"
2
(5/32")
SHOPKO UNILET LANCETS SUP lancets
2
SB LANCETS THIN - lancets
2
SHOPKO UNILET LANCETS ULT lancets
2
SIDE BUTTON SAFETY LANCET lancets
2
SIMPLE DIAGNOSTICS LANCIN lancet devices
2
SINGLE-LET - lancets
2
SM INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
SM INSULIN SYRINGE/1ML/31 insulin syringe/needle u-100 1 ml
31 x 5/16"
2
SM MICRO THIN LANCETS 33G lancets
2
SB LANCETS ULTRA THIN - lancets 2
2
SCHNUCKS INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
SCHNUCKS INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
SELECT-LITE LANCING DEVIC lancet devices
SHOPKO AUTOLET LANCING DE - 2
lancet devices
SHOPKO ON-THE-GO COMFORT - 2
lancets
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
182
SM ULTRA COMFORT INSULIN insulin syringe/needle u-100 1 ml
30 x 5/16"
2
SOLUS V2 AUDIBLE BLOOD GL blood glucose monitoring kit w/
device
3
SMART DIABETES VANTAGE LA lancet devices
2
SOLUS V2 LANCING DEVICE lancet devices
2
SOLUS V2 PRESSURE ACTIVAT lancets
2
SOLUS V2 TWIST LANCETS 30 lancets
2
STERILANCE TL - lancets
2
STIMEX INSULATED NEEDLE T needle (disp) 22 x 1-1/2"
3
3
3
SUPER THIN LANCETS - lancets
2
SUPREME II CONFIDENCE PAD blood glucose monitoring misc.
3
SURE COMFORT INSULIN SYRI insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ml 30 x 5/16"
2
ml 30 x 1/2"
2
SURE COMFORT INSULIN SYRI insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
ml 28 x 1/2"
2
ml 29 x 1/2"
2
ml 30 x 5/16"
2
SMART SENSE COLOR LANCETS - 2
lancets
3
SMART SENSE PREMIUM
BLOOD - blood glucose monitoring
kit w/ device
SMART SENSE STANDARD LANC - 2
lancets
2
SMART SENSE SUPER THIN LA lancets
2
SMART SENSE THIN LANCETS lancets
3
SMART SENSE VALUE BLOOD blood glucose monitoring kit w/
device
SMARTEST EJECT BLOOD GLUC - 3
3
SMARTEST EJECT STARTER KI blood glucose monitoring kit w/
device
2
SMARTEST LANCETS 28G lancets
SMARTEST PERSONA STARTER - 3
device
3
SMARTEST PRONTO STARTER blood glucose monitoring kit w/
device
3
SMARTEST PROTEGE BLOOD
GL - blood glucose monitoring
devices
SMARTEST PROTEGE STARTER - 3
device
3
SOLUS V2 AUDIBLE BLOOD GL blood glucose monitoring devices
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
183
ml 30 x 1/2"
2
SURE COMFORT PEN NEEDLES insulin pen needle 32 g x 4 mm
(5/32")
2
ml 31 x 1/4" (6 mm)
2
(1/4")
2
SURE COMFORT INSULIN SYRI insulin syringe/needle u-100 1 ml
28 x 1/2"
2
SURE EDGE BLOOD GLUCOSE
M - blood glucose monitoring
devices
3
29 x 1/2"
2
SURE-FINE PEN NEEDLES 29G insulin pen needle 29 g x 12.7 mm
2
SURE-FINE PEN NEEDLES 31G insulin pen needle 31 g x 5 mm
(3/16")
2
30 x 5/16"
2
SURE-FINE PEN NEEDLES 31G insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
30 x 1/2"
2
2
SURE-JECT INSULIN SYRINGE insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
31 x 5/16"
ml 30 x 5/16"
2
ml 31 x 5/16"
2
SURE-JECT INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
SURE COMFORT LANCETS 28G lancets
2
SURE COMFORT LANCETS 30G lancets
2
2
SURE COMFORT LANCING PEN lancet devices
2
ml 28 x 1/2"
2
SURE COMFORT PEN NEEDLES insulin pen needle 29 g x 12.7 mm
2
ml 29 x 1/2"
(1/3" or 5/16")
2
ml 30 x 5/16"
2
(3/16")
2
SURE-JECT INSULIN SYRINGE insulin syringe/needle u-100 1 ml
28 x 1/2"
2
(1/3" or 5/16")
2
29 x 1/2"
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
184
30 x 5/16"
2
TECHLITE PEN NEEDLES/31G insulin pen needle 31 g x 5 mm
(3/16")
2
31 x 5/16"
2
(1/4")
2
ml 31 x 5/16"
2
(1/3" or 5/16")
2
SURE-LANCE FLAT LANCETS lancets
2
2
SURE-LANCE LANCETS 26G lancets
2
(5/32")
2
SURE-LANCE THIN LANCETS 2 lancets
2
(1/4")
SURE-LANCE ULTRA THIN LAN lancets
2
2
SURE-PEN - lancet devices
2
SURE-TEST EASYPLUS MINI S blood glucose monitoring devices
3
SURE-TOUCH LANCETS UNIVER lancets
2
devices
3
w/ device
3
SURELITE LANCETS - lancets
2
SURESTEP PRO LINEARITY KI blood glucose monitoring misc.
3
SYMPATHETIC NERVE NEEDLE needle (disp) 18 x 6"
3
3
3
TELCARE BLOOD GLUCOSE
w/ device
2
TGT ADVANCED LANCING DEVI lancet devices
3
TGT BLOOD GLUCOSE METER
M - blood glucose monitoring kit w/
device
3
TGT BLOOD GLUCOSE
MONITOR - blood glucose
2
TGT LANCET ALTERNATE SITE lancets
2
TGT LANCET MICRO THIN 33G lancets
2
TGT LANCET SUPER THIN 30G lancets
2
TGT LANCET THIN 23G - lancets
3
TECHLITE AST LANCETS - lancets
2
TECHLITE LANCETS - lancets
2
TECHLITE LANCETS 30G - lancets
2
TGT LANCET THIN 26G - lancets
2
TGT LANCET ULTRA THIN 28G lancets
2
TGT LANCET ULTRA THIN 30G lancets
2
TGT LANCING DEVICE - lancet
devices
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
185
THINLETS GP LANCETS - lancets
2
THINLETS LANCET - lancets
2
TODAYS HEALTH ADVANCED LA lancet devices
2
TODAYS HEALTH MINI PEN NE insulin pen needle 31 g x 6 mm
(1/4")
2
TODAYS HEALTH ORIGINAL PE insulin pen needle 29 g x 12 mm
(1/2")
2
TODAYS HEALTH SHORT PEN N insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
TODAYS HEALTH SUPER THIN lancets
2
TODAYS HEALTH ULTRA THIN lancets
2
TOPCARE CLICKFINE UNIVERS insulin pen needle 31 g x 6 mm
(1/4")
2
TOPCARE CLICKFINE UNIVERS insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
TOPCARE ULTRA COMFORT INS insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ml 30 x 5/16"
2
TOPCARE ULTRA COMFORT INS insulin syringe/needle u-100 1/2
ml 31 x 5/16"
TOPCARE ULTRA COMFORT INS insulin syringe/needle u-100 1 ml
30 x 5/16"
2
31 x 5/16"
2
ml 31 x 5/16"
2
TOPCO INSULIN SYRINGE/U-1 insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
TOPCO INSULIN SYRINGE/U-1 insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
TOPCO INSULIN SYRINGE/U-1 insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
TOPCO INSULIN SYRINGE/U-1 insulin syringe/needle u-100 1 ml
28 x 1/2"
2
TOPCO INSULIN SYRINGE/U-1 insulin syringe/needle u-100 1 ml
29 x 1/2"
2
TRACER II 3 VOLT BATTERY blood glucose monitoring misc.
3
TRAVEL LANCETS 30G - lancets
2
TRUE METRIX - blood glucose
monitoring devices
3
2
TRUE METRIX AIR BLOOD GLU blood glucose monitoring devices
3
3
ml 29 x 1/2"
2
TRUE METRIX AIR BLOOD GLU blood glucose monitoring kit w/
device
3
ml 30 x 5/16"
2
TRUE METRIX AIR W/BLUETOO blood glucose monitoring kit w/
device
29 x 1/2"
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
TRUE METRIX BLOOD GLUCOSE - 3
device
2
TRUEDRAW LANCING DEVICE lancet devices
186
TRUEPLUS INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
TRUEPLUS LANCETS 33G MICR lancets
2
TRUEPLUS SAFETY LANCETS 2 lancets
2
ml 30 x 5/16"
2
3
TRUEPLUS INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
TRUERESULT BLOOD GLUCOSE blood glucose monitoring kit w/
device
3
ml 28 x 1/2"
2
M - blood glucose monitoring
devices
ml 29 x 1/2"
2
ml 30 x 5/16"
2
TRUEPLUS INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
28 x 1/2"
2
29 x 1/2"
2
30 x 5/16"
2
31 x 5/16"
2
ml 31 x 5/16"
2
TRUEPLUS LANCETS 26G - lancets 2
TRUEPLUS LANCETS 28G SUPE lancets
2
TRUEPLUS LANCETS 30G ULTR - 2
lancets
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
3
M - blood glucose monitoring kit w/
device
3
TRUETRACK SMART SYSTEM blood glucose monitoring kit w/
device
3
TRUE2GO BLOOD GLUCOSE
w/ device
2
ULTI-LANCE AUTOMATIC/ CLE lancet devices
2
ULTICARE INSULIN SAFETY S insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
ULTICARE INSULIN SAFETY S insulin syringe/needle u-100 1 ml
29 x 1/2"
2
ULTICARE INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
ULTICARE INSULIN SYRINGE insulin syringe/needle u-100 1 ml
31 x 5/16"
2
ULTICARE INSULIN SYRINGE insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
ULTICARE INSULIN SYRINGE/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ml 30 x 5/16"
187
ml 30 x 1/2"
2
ULTICARE MINI PEN NEEDLES insulin pen needle 31 g x 6 mm
(1/4")
2
ULTICARE INSULIN SYRINGE/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
ULTICARE ORIGINAL PEN NEE insulin pen needle 29 g x 12 mm
(1/2")
2
ml 28 x 1/2"
2
ULTICARE PEN NEEDLES/29G insulin pen needle 29 g x 12.7 mm
2
2
ULTICARE SHORT PEN NEEDLE insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
ml 29 x 1/2"
ULTICARE THIN LANCETS 30G lancets
2
ml 30 x 5/16"
2
2
ml 30 x 1/2"
2
ULTICARE TUBERCULIN SAFET tuberculin/allergy syringe/needle
(disp) 1 ml 25 x 5/8"
2
ULTICARE INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml
28 x 1/2"
2
ULTICARE TUBERCULIN SAFET tuberculin/allergy syringe/needle
(disp) 1 ml 25 x 1"
2
29 x 1/2"
2
ULTICARE U-100 INSULIN SY insulin syringe/needle u-100 0.3
ml 31 x 1/4" (6 mm)
2
30 x 5/16"
2
ULTICARE U-100 INSULIN SY insulin syringe/needle u-100 0.5
ml 31 x 1/4" (6 mm)
2
30 x 1/2"
2
ULTICARE U-100 INSULIN SY insulin syringe/needle u-100 1 ml
31 x 1/4" (6 mm)
2
31 x 5/16"
2
ULTIGUARD INSULIN SYRINGE insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ml 31 x 5/16"
2
ULTIGUARD INSULIN SYRINGE insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
ULTICARE MICRO PEN NEEDLE insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
ULTIGUARD INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
ULTICARE MICRO PEN NEEDLE insulin pen needle 32 g x 4 mm
(5/32")
2
ULTIGUARD INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 30 x 5/16"
ULTIGUARD INSULIN SYRINGE insulin syringe/needle u-100 1 ml
29 x 1/2"
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
188
ULTIGUARD INSULIN SYRINGE insulin syringe/needle u-100 1 ml
30 x 5/16"
2
ULTRA INSULIN SYRINGE/U-1 insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
ULTILET CLASSIC LANCETS lancets
2
ULTRA THIN LANCETS 28G lancets
2
ULTILET INSULIN SYRINGE/S insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
ULTRA TRAK PRO BLOOD GLUC blood glucose monitoring kit w/
device
3
ULTILET INSULIN SYRINGE/S insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
ULTRA-COMFORT INSULIN SYR insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ULTILET INSULIN SYRINGE/S insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
ml 30 x 5/16"
2
ULTILET INSULIN SYRINGE/S insulin syringe/needle u-100 1 ml
30 x 5/16"
2
ULTRA-COMFORT INSULIN SYR insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
ULTILET INSULIN SYRINGE/S insulin syringe/needle u-100 1 ml
31 x 5/16"
2
ml 28 x 1/2"
2
ULTILET INSULIN SYRINGE/S insulin syringe/needle u-100 0.3
ml 31 x 5/16"
2
ml 29 x 1/2"
2
ULTILET LANCETS - lancets
2
2
ULTILET LANCETS 33G - lancets
2
ULTILET PEN NEEDLE 32GX4M insulin pen needle 32 g x 4 mm
(5/32")
2
ml 30 x 5/16"
2
ULTILET SAFETY LANCETS 23 lancets
2
ULTRA-COMFORT INSULIN SYR insulin syringe/needle u-100 1 ml
28 x 1/2"
2
ULTILET SHORT PEN NEEDLES insulin pen needle 31 g x 5 mm
(3/16")
2
29 x 1/2"
2
ULTILET SHORT PEN NEEDLES insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
30 x 5/16"
2
ULTIMA - blood glucose monitoring
kit
3
31 x 5/16"
ULTRA COMFORT INSULIN SYR insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
ml 31 x 5/16"
2
ULTRA-THIN II AUTO LANCET lancets
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
189
ULTRA-THIN II INSULIN SYR insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ULTRATRAK PRO - blood glucose
monitoring devices
3
ULTRATRAK ULTIMATE MONITO blood glucose monitoring devices
3
ml 30 x 5/16"
2
2
ULTRA-THIN II INSULIN SYR insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
UNIFINE PENTIPS PLUS 29GX insulin pen needle 29 g x 12 mm
(1/2")
2
ml 29 x 1/2"
2
(3/16")
2
ml 30 x 5/16"
2
(1/4")
2
ULTRA-THIN II INSULIN SYR insulin syringe/needle u-100 1 ml
29 x 1/2"
2
(1/3" or 5/16")
2
30 x 5/16"
2
(5/32")
2
31 x 5/16"
2
UNIFINE PENTIPS 29GX12MM insulin pen needle 29 g x 12 mm
(1/2")
2
ml 31 x 5/16"
2
UNIFINE PENTIPS 31G X 3/1 insulin pen needle 31 g x 5 mm
(3/16")
2
ULTRA-THIN II LANCETS 28G lancets
2
UNIFINE PENTIPS 31G X 6MM insulin pen needle 31 g x 6 mm
(1/4")
2
UNIFINE PENTIPS 31G X 8MM insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
ULTRA-THIN II LANCETS 30G lancets
ULTRA-THIN II MINI PEN NE insulin pen needle 31 g x 5 mm
(3/16")
2
(3/16")
2
ULTRA-THIN II PEN NEEDLES insulin pen needle 29 g x 12.7 mm
2
2
ULTRA-THIN II PEN NEEDLES insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
(1/4")
2
ULTRA-THIN II SAFETY AUTO lancets
2
(1/3" or 5/16")
2
ULTRATRAK ACTIVE - blood
3
(5/32")
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
190
UNILET COMFORTOUCH
LANCET - lancets
2
UNILET EXCELITE - lancets
2
UNILET EXCELITE II - lancets
2
UNILET G.P. LANCET - lancets
2
UNILET G.P. SUPERLITE LAN lancets
2
UNILET GP 28 ULTRA THIN lancets
2
UNILET LANCET - lancets
2
UNILET LANCETS MICRO-THIN lancets
2
UNILET LANCETS SUPER-THIN lancets
V-R MONOJECT INSULIN SYRI insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
V-R MONOJECT INSULIN SYRI insulin syringe/needle u-100 1 ml
28 x 1/2"
2
V-R MONOJECT INSULIN SYRI insulin syringe/needle u-100 1 ml
29 x 1/2"
2
VALUE HEALTH INSULIN SYRI insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
2
2
VALUE HEALTH INSULIN SYRI insulin syringe/needle u-100 1 ml
29 x 1/2"
UNILET LANCETS ULTRA-THIN lancets
2
VALUE PLUS LANCETS STANDA lancets
2
UNILET SUPERLITE LANCET lancets
2
VALUE PLUS LANCETS SUPER lancets
2
UNISTIK SAFETY LANCETS 28 lancets
2
VALUE PLUS LANCETS THIN 2 lancets
2
UNISTIK SAFETY LANCETS 30 lancets
2
VALUE PLUS LANCING DEVICE lancet devices
2
UNISTIK TOUCH SAFETY LANC lancets
2
VALUMARK LANCET SUPER THI lancets
2
UNISTIK 3 GENTLE - lancets
2
2
UNIVERSAL 1 LANCETS THIN lancets
2
VALUMARK LANCET ULTRA THI lancets
2
UNIVERSAL 1 LANCETS ULTRA lancets
2
VALUMARK PEN NEEDLES 29GX insulin pen needle 29 g x 12 mm
(1/2")
VALUMARK PEN NEEDLES 31G insulin pen needle 31 g x 6 mm
(1/4")
2
VALUMARK PEN NEEDLES 31G insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
VANISHPOINT INSULIN SYRIN insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
VANISHPOINT INSULIN SYRIN insulin syringe/needle u-100 1 ml
29 x 1/2"
2
V-GO 20 - insulin infusion disposable 3
pump kit
pump kit
pump kit
2
V-R MONOJECT INSULIN SYRI insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
V-R MONOJECT INSULIN SYRI insulin syringe/needle u-100 1/2
ml 28 x 1/2"
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
191
VICTORY BLOOD GLUCOSE
devices
3
WAVESENSE AMP - blood glucose
3
WAVESENSE KEYNOTE - blood
3
VIDA MIA AUTOLET LANCING lancet devices
2
WAVESENSE KEYNOTE PRO
MET - blood glucose monitoring
devices
3
VIDA MIA UNIFINE PENTIPS insulin pen needle 29 g x 12 mm
(1/2")
2
2
WEGMANS UNIFINE PENTIPS P insulin pen needle 31 g x 5 mm
(3/16")
2
(1/4")
(1/4")
2
(5/32")
2
(1/3" or 5/16")
2
VIDA MIA UNILET LANCETS S lancets
2
VIDA MIA UNILET LANCETS U lancets
2
2
VIDA MIA UNIPFINE PENTIPS insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
(5/32")
WHITE PEDIATRIC ARTERIAL needle (disp) 19 x 1-1/2"
3
VITALET PRO LANCETS - lancets
2
3
VITALET PRO PLUS LANCETS lancets
2
WHITE PEDIATRIC ARTERIAL needle (disp) 20 x 1-1/2"
WIDE-SEAL SILICONE DIAPHR diaphragm wide seal 60 mm
P
P
P
P
P
VOCAL POINT BLOOD GLUCOSE - 3
2
VP INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
W&F LANCETS COLORED 21G lancets
2
W&F LANCETS 26G - lancets
WALGREENS ADVANCED
TRAVEL - lancets
2
P
WALGREENS COMFORT
ASSURED - lancets
2
P
WALGREENS LANCETS - lancets
2
WALGREENS THIN LANCETS lancets
2
P
WALGREENS ULTRA THIN LANC lancets
2
YALE NEEDLES - needle (disp) 18 x
1"
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
192
2"
3
1"
2
3/4"
3
YALE NEEDLES SHORT BEVEL needle (disp) 23 x 1"
3
YALE NEEDLES 16G X 1" - needle
(disp) 16 x 1"
3
YALE NEEDLES 18G X 1-1/2" needle (disp) 18 x 1-1/2"
3
3
3
(disp) 21 x 1"
2
(disp) 21 x 1"
3
2
3
(disp) 22 x 1"
3
3
YALE NEEDLES 26G X 1/2" - needle 2
(disp) 26 x 1/2"
YALE NEEDLES 26G X 3/8" - needle 2
(disp) 26 x 3/8"
YALE NEEDLES/REGULAR BEVE - 3
3
YALE NEEDLES/SHORT BEVEL/ needle (disp) 19 x 1"
3
YALE NEEDLES/SHORT BEVEL/ needle (disp) 19 x 1-1/2"
2
1ML ALLERGIST SYRINGE DET tuberculin/allergy syringe/needle
(disp) 1 ml 27 x 1/2"
1ML ALLERGY SYRINGE tuberculin/allergy syringe/needle
(disp) 1 ml 27 x 1/2"
2
1ML ALLERGY SYRINGE 28G X tuberculin/allergy syringe/needle
(disp) 1 ml 28 x 1/2"
3
1ML TB SYRINGE/25G X 5/8" tuberculin/allergy syringe/needle
(disp) 1 ml 25 x 5/8"
2
(disp) 1 ml 26 x 3/8"
3
(disp) 1 ml 27 x 1/2"
2
1ML TUBERCULIN SYRINGE DE tuberculin/allergy syringe/needle
(disp) 1 ml 25 x 5/8"
2
1ML TUBERCULIN SYRINGE DE tuberculin/allergy syringe/needle
(disp) 1 ml 26 x 3/8"
2
1ML VANISHPOINT TUBERCULI tuberculin/allergy syringe/needle
(disp) 1 ml 25 x 5/8"
2
(disp) 1 ml 25 x 1"
2
(disp) 1 ml 27 x 1/2"
2
1ST CHOICE LANCETS SUPER lancets
2
1ST CHOICE LANCETS THIN lancets
2
1ST CHOICE LANCETS ULTRA lancets
2
1ST TIER UNIFINE PENTIPS insulin pen needle 29 g x 12 mm
(1/2")
2
(3/16")
2
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
193
(1/4")
2
(1/3" or 5/16")
2
(5/32")
2
1ST TIER UNILET COMFORTOU lancets
2
ASSORTED CLASSES
DEPEN TITRATABS - penicillamine
tab 250 mg
4
ENVARSUS XR - tacrolimus tab sr
24hr 0.75 mg
3
24hr 1 mg
3
24hr 4 mg
3
IMURAN - azathioprine tab 50 mg
3
irrigation solution, physiological
1
KAYEXALATE - sodium polystyrene
sulfonate powder
3
lactated ringer's for irrigation
1
ASTAGRAF XL - tacrolimus cap sr
24hr 0.5 mg
3
24hr 1 mg
3
mycophenolate mofetil cap
250 mg (Cellcept)
24hr 5 mg
3
mycophenolate mofetil for oral
susp 200 mg/ml (Cellcept)
AZASAN - azathioprine tab 75 mg
3
AZASAN - azathioprine tab 100 mg
3
mycophenolate mofetil tab
500 mg (Cellcept)
azathioprine tab 50 mg (Imuran)
1
CELLCEPT - mycophenolate mofetil
cap 250 mg
3
for oral susp 200 mg/ml
3
tab 500 mg
3
cyclosporine cap 25 mg
(Sandimmune)
1
cyclosporine cap 100 mg
(Sandimmune)
1
CYCLOSPORINE MODIFIED cyclosporine modified cap 50 mg
3
cyclosporine modified cap 25 mg
(Neoral)
1
cyclosporine modified cap 50 mg
(Cyclosporine modifie)
1
cyclosporine modified cap
100 mg (Neoral)
1
cyclosporine modified oral soln
100 mg/ml (Neoral)
1
mycophenolate sodium tab dr
180 mg (mycophenolic acid
equiv) (Myfortic)
Responsible Steps
• •
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
1
mycophenolate sodium tab dr
360 mg (mycophenolic acid
equiv) (Myfortic)
1
PROGRAF - tacrolimus cap 1 mg
3
PROGRAF - tacrolimus cap 5 mg
3
MYFORTIC - mycophenolate sodium 3
tab dr 180 mg (mycophenolic acid
equiv)
MYFORTIC - mycophenolate sodium 3
tab dr 360 mg (mycophenolic acid
equiv)
3
NEORAL - cyclosporine modified
cap 25 mg
3
cap 100 mg
3
oral soln 100 mg/ml
3
PROGRAF - tacrolimus cap 0.5 mg
194
RAPAMUNE - sirolimus oral soln 1
mg/ml
2
RAPAMUNE - sirolimus tab 0.5 mg
3
RAPAMUNE - sirolimus tab 1 mg
3
RAPAMUNE - sirolimus tab 2 mg
3
REVLIMID - lenalidomide caps 2.5
mg
4
• • •
•
REVLIMID - lenalidomide cap 5 mg
4
4
4
4
4
•
•
•
•
•
•
•
•
•
•
ringer's solution for irrigation
1
SANDIMMUNE - cyclosporine cap
25 mg
3
SANDIMMUNE - cyclosporine cap
100 mg
3
SANDIMMUNE - cyclosporine oral
soln 100 mg/ml
3
sirolimus tab 0.5 mg (Rapamune)
1
sirolimus tab 1 mg (Rapamune)
sirolimus tab 2 mg (Rapamune)
sodium polystyrene sulfonate
oral susp 15 gm/60ml (Sps)
powder (Kayexalate)
rectal susp 30 gm/120ml
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
3
• •
VELTASSA - patiromer sorbitex
calcium for susp packet 16.8 gm
(base eq)
3
• •
(base eq)
3
• •
water for irrigation, sterile
irrigation soln
1
ZORTRESS - everolimus tab 0.25
mg
2
ZORTRESS - everolimus tab 0.5 mg
2
ZORTRESS - everolimus tab 0.75
mg
2
1
1
1
1
4
tacrolimus cap 0.5 mg (Prograf)
1
tacrolimus cap 5 mg (Prograf)
•
•
•
•
•
(base eq)
1
SYPRINE - trientine hcl cap 250 mg
tacrolimus cap 1 mg (Prograf)
•
•
•
•
•
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
• •
1
1
4
• • •
• • •
•
•
THALOMID - thalidomide cap 150
mg
4
• • •
•
mg
4
• • •
•
THALOMID - thalidomide cap 50 mg
4
mg
195
2016
INDEX
A
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg (Trizivir)................................................ 6
abacavir sulfate tab 300 mg (base equiv) (Ziagen)........ 6
acamprosate calcium tab delayed release 333 mg...... 82
ACANYA -clindamycin phosphate-benzoyl peroxide gel
1.2-2.5%........................................................................ 125
acarbose tab 25 mg (Precose)....................................... 26
acarbose tab 50 mg (Precose)....................................... 26
acarbose tab 100 mg (Precose)..................................... 26
ACCOLATE -zafirlukast tab 10 mg....................................57
ACCOLATE -zafirlukast tab 20 mg....................................57
ACCU-CHEK AVIVA -blood glucose monitoring
devices.......................................................................... 138
ACCU-CHEK AVIVA CONNECT -blood glucose
monitoring kit w/ device................................................ 139
ACCU-CHEK AVIVA PLUS -blood glucose monitoring kit
w/ device....................................................................... 139
ACCU-CHEK AVIVA PLUS -glucose blood test strip...... 134
ACCU-CHEK COMPACT PLUS CA -blood glucose
monitoring kit................................................................. 139
ACCU-CHEK COMPACT PLUS -glucose blood test
strip................................................................................ 134
ACCU-CHEK COMPACT STRIPS -glucose blood test
strip................................................................................ 134
ACCU-CHEK COMPACT TEST DR -glucose blood test
strip................................................................................ 134
ACCU-CHEK FASTCLIX LANCET -lancets.................... 139
ACCU-CHEK FASTCLIX LANCET -lancets kit............... 139
ACCU-CHEK MULTICLIX LANCE -lancets.....................139
ACCU-CHEK MULTICLIX LANC -lancets kit.................. 139
ACCU-CHEK NANO SMARTVIEW -blood glucose
ACCU-CHEK SAFE-T-PRO LANC -lancets.................... 139
ACCU-CHEK SAFE-T-PRO PLUS -lancets.................... 139
ACCU-CHEK SMARTVIEW STRIP -glucose blood test
strip................................................................................ 134
ACCU-CHEK SOFTCLIX LANCET -lancet devices........ 139
ACCU-CHEK SOFTCLIX LANCET -lancets................... 139
ACCU-CHEK SOFTCLIX LANCET -lancets kit............... 139
ACCU-CHEK SOFT TOUCH LANC -lancets.................. 139
ACCU-CHEK VOICEMATE -blood glucose monitoring kit
w/ device....................................................................... 139
ACCUPRIL -quinapril hcl tab 5 mg................................... 43
ACCUPRIL -quinapril hcl tab 10 mg................................. 43
ACCURETIC -quinapril-hydrochlorothiazide tab 10-12.5
mg.................................................................................... 43
ACCURETIC -quinapril-hydrochlorothiazide tab 20-12.5
mg.................................................................................... 43
ACCURETIC -quinapril-hydrochlorothiazide tab 20-25
mg.................................................................................... 43
ACCUTREND GLUCOSE -glucose blood test strip........ 134
acebutolol hcl cap 200 mg (Sectral).............................. 38
acebutolol hcl cap 400 mg (Sectral).............................. 38
ACEON -perindopril erbumine tab 4 mg........................... 43
ACEON -perindopril erbumine tab 8 mg........................... 43
acetaminophen-caffeine-dihydrocodeine cap
320.5-30-16 mg (Trezix)................................................ 86
acetaminophen w/ codeine soln 120-12 mg/5ml.......... 85
acetaminophen w/ codeine tab 300-15 mg (Tylenol/
codeine).......................................................................... 85
codeine #3).................................................................... 85
codeine #4).................................................................... 86
ACETAZOLAMIDE -acetazolamide tab 125 mg............... 50
acetazolamide cap sr 12hr 500 mg (Diamox)............... 50
acetazolamide tab 250 mg.............................................. 50
ACETEST -acetone (urine) test tab................................ 134
ACETIC ACID/ALUMINUM ACET -acetic acid 2% in
aluminum acetate otic soln...........................................124
acetic acid irrigation soln 0.25%................................... 68
acetic acid otic soln 2%................................................ 124
acetylcysteine cap 600 mg........................................... 112
acetylcysteine inhal soln 10%........................................ 57
acetylcysteine inhal soln 20%........................................ 57
acitretin cap 10 mg (Soriatane).................................... 125
acitretin cap 17.5 mg (Soriatane)................................. 125
acitretin cap 25 mg (Soriatane).................................... 125
ACLOVATE -alclometasone dipropionate cream
0.05%.............................................................................125
ACTEMRA -tocilizumab subcutaneous soln prefilled
syringe 162 mg/0.9ml..................................................... 91
ACTHIB -haemophilus b polysaccharide conjugate
vaccine for inj.................................................................. 12
ACTIGALL -ursodiol cap 300 mg...................................... 65
ACTI-LANCE LANCETS 28G -lancets............................ 139
ACTI-LANCE LITE SAFETY LA -lancets........................ 139
ACTI-LANCE SPECIAL SAFETY -lancets...................... 139
ACTI-LANCE UNIVERSAL SAFE -lancets..................... 139
ACTIMMUNE -interferon gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)....................................................... 16
ACTIQ -fentanyl citrate lozenge on a handle 200 mcg..... 86
ACTIQ -fentanyl citrate lozenge on a handle 1200
mcg.................................................................................. 86
ACTIQ -fentanyl citrate lozenge on a handle 1600
mcg.................................................................................. 86
ACTIVELLA -estradiol & norethindrone acetate tab
0.5-0.1 mg....................................................................... 22
ACTIVELLA -estradiol & norethindrone acetate tab 1-0.5
mg.................................................................................... 22
ACTIVE OB -prenatal w/o a w/fe cbn-fa-dha cap 20-1-320
mg.................................................................................. 104
ACTIVE 1ST BLOOD LANCETS -lancets....................... 139
ACTONEL -risedronate sodium tab 5 mg......................... 33
196
2016
ACTONEL -risedronate sodium tab 30 mg....................... 33
ACTONEL -risedronate sodium tab 35 mg....................... 33
ACTONEL -risedronate sodium tab 150 mg..................... 33
ACTOPLUS MET -pioglitazone hcl-metformin hcl tab
15-500 mg....................................................................... 26
ACTOPLUS MET -pioglitazone hcl-metformin hcl tab
15-850 mg....................................................................... 27
ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab
sr 24hr 15-1000 mg........................................................ 27
ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab
sr 24hr 30-1000 mg........................................................ 27
ACTOS -pioglitazone hcl tab 15 mg (base equiv)............. 27
ACULAR -ketorolac tromethamine ophth soln 0.5%....... 120
ACULAR LS -ketorolac tromethamine ophth soln
0.4%...............................................................................120
ACURA BLOOD GLUCOSE MONIT -blood glucose
ACURA BLOOD GLUCOSE TEST -glucose blood test
strip................................................................................ 134
ACURA PLUS BLOOD GLUCOSE -blood glucose
ACUVAIL -ketorolac tromethamine ophth soln
0.45%.............................................................................120
acyclovir cap 200 mg (Zovirax)........................................ 6
acyclovir oint 5% (Zovirax)........................................... 125
acyclovir susp 200 mg/5ml (Zovirax).............................. 6
acyclovir tab 400 mg (Zovirax)........................................ 6
acyclovir tab 800 mg (Zovirax)........................................ 6
ACZONE -dapsone gel 5%............................................. 125
ADACEL -tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lfmcg/0.5ml........................................................................ 14
ADALAT CC -nifedipine tab sr 24hr 30 mg....................... 40
ADAPALENE -adapalene lotion 0.1%............................. 125
adapalene cream 0.1% (Differin).................................. 125
adapalene gel 0.1% (Differin)....................................... 125
adapalene gel 0.3% (Differin)....................................... 125
ADCIRCA -tadalafil tab 20 mg (pah)................................. 54
ADDERALL -amphetamine-dextroamphetamine tab 5
mg.................................................................................... 78
ADDERALL -amphetamine-dextroamphetamine tab 7.5
mg.................................................................................... 78
mg.................................................................................... 78
ADDERALL -amphetamine-dextroamphetamine tab 12.5
mg.................................................................................... 78
mg.................................................................................... 78
mg.................................................................................... 78
mg.................................................................................... 78
ADDERALL XR -amphetamine-dextroamphetamine cap
sr 24hr 5 mg................................................................... 78
sr 24hr 10 mg................................................................. 78
sr 24hr 15 mg................................................................. 78
sr 24hr 20 mg................................................................. 78
sr 24hr 25 mg................................................................. 78
sr 24hr 30 mg................................................................. 78
adefovir dipivoxil tab 10 mg (Hepsera)........................... 7
ADEMPAS -riociguat tab 0.5 mg....................................... 54
ADEMPAS -riociguat tab 1 mg.......................................... 54
ADEMPAS -riociguat tab 2 mg.......................................... 55
ADJUSTABLE LANCING DEVICE -lancet devices......... 139
ADVAIR DISKUS -fluticasone-salmeterol aer powder ba
100-50 mcg/dose............................................................ 58
250-50 mcg/dose............................................................ 58
500-50 mcg/dose............................................................ 58
ADVAIR HFA -fluticasone-salmeterol inhal aerosol 45-21
mcg/act............................................................................ 58
mcg/act............................................................................ 58
mcg/act............................................................................ 58
ADVANCE INTUITION BLOOD G -blood glucose
monitoring devices........................................................ 139
ADVANCE INTUITION BLOOD G -blood glucose
ADVANCE INTUITION TEST ST -glucose blood test
strip................................................................................ 134
ADVANCE MICRO-DRAW METER -blood glucose
ADVANCE MICRO-DRAW TEST S -glucose blood test
strip................................................................................ 134
ADVATE -antihemophilic factor rahf-pfm for inj 250
unit................................................................................. 115
unit................................................................................. 115
unit................................................................................. 115
unit................................................................................. 115
unit................................................................................. 115
unit................................................................................. 116
unit................................................................................. 116
ADVOCATE BLOOD GLUCOSE MO -blood glucose
ADVOCATE BLOOD GLUCOSE MO -blood glucose
197
2016
ADVOCATE INSULIN PEN NEED -insulin pen needle 29
g x 12.7 mm..................................................................139
g x 5 mm (3/16")...........................................................139
g x 8 mm (1/3" or 5/16")...............................................139
ADVOCATE INSULIN SYRINGE/ -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 139
u-100 1/2 ml 29 x 1/2".................................................. 139
u-100 1/2 ml 30 x 5/16"................................................ 140
u-100 0.3 ml 29 x 1/2".................................................. 139
u-100 0.3 ml 30 x 5/16"................................................ 139
u-100 1 ml 29 x 1/2".....................................................140
u-100 1 ml 30 x 5/16"...................................................140
u-100 1 ml 31 x 5/16"...................................................140
u-100 0.3 ml 31 x 5/16"................................................ 140
ADVOCATE LANCETS 30G -lancets.............................. 140
ADVOCATE LANCETS -lancets...................................... 140
ADVOCATE LANCING DEVICE -lancet devices............ 140
ADVOCATE RAPID-SAFE LANCI -lancet devices......... 140
ADVOCATE REDI-CODE/TALKIN -blood glucose
ADVOCATE REDI-CODE/TALKIN -blood glucose
ADVOCATE REDI-CODE+/ TALK -blood glucose
ADVOCATE REDI-CODE+ BLOOD -blood glucose
ADVOCATE REDI-CODE+ TEST -glucose blood test
strip................................................................................ 134
ADVOCATE REDI-CODE -blood glucose monitoring
devices.......................................................................... 140
ADVOCATE REDI-CODE -glucose blood test strip........ 134
ADVOCATE SAFETY LANCETS -lancets...................... 140
ADVOCATE SAFETY LANCETS 2 -lancets................... 140
ADVOCATE TEST STRIPS -glucose blood test strip..... 134
ADYNOVATE -antihemophilic factor recomb pegylated for
inj 250 unit.................................................................... 116
inj 500 unit.................................................................... 116
inj 1000 unit.................................................................. 116
inj 2000 unit.................................................................. 116
AEROSPAN -flunisolide hfa inhal aerosol 80 mcg/act...... 58
AFINITOR DISPERZ -everolimus tab for oral susp 2
mg.................................................................................... 16
mg.................................................................................... 16
mg.................................................................................... 16
AFINITOR -everolimus tab 2.5 mg.................................... 16
AFINITOR -everolimus tab 5 mg....................................... 16
AFINITOR -everolimus tab 7.5 mg.................................... 16
AFINITOR -everolimus tab 10 mg..................................... 16
AF LANCETS SUPER THIN -lancets............................. 140
AFLURIA 2015-2016 -influenza virus vaccine split im
susp................................................................................. 12
AFLURIA 2016-2017 -influenza virus vaccine split im
susp................................................................................. 12
AFLURIA 2016-2017 -influenza virus vaccine split pf susp
pref syringe 0.5 ml.......................................................... 12
AFLURIA PF 2015-2016 -influenza virus vaccine split pf
susp pref syringe 0.5 ml................................................. 12
AFREZZA -insulin regular (human) inhalation powder 4
unit/cartridge.................................................................... 31
AFREZZA -insulin regular (human) inhal powd 4 (30) & 8
(60) unit/cart.................................................................... 31
(30) unit/cart.................................................................... 31
(90) unit/cart.................................................................... 31
AFREZZA -insulin regular (human) inh powd 8 (60) & 12
(30) unit/cart.................................................................... 31
AFSTYLA -antihemophilic fact rcmb single chain for inj kit
250 unit......................................................................... 116
500 unit......................................................................... 116
1000 unit....................................................................... 116
2000 unit....................................................................... 116
3000 unit....................................................................... 116
AGAMATRIX AMP NO CODE ADV -blood glucose
AGAMATRIX AMP NO CODE TES -glucose blood test
strip................................................................................ 134
AGAMATRIX JAZZ TEST STRIP -glucose blood test
strip................................................................................ 134
AGAMATRIX JAZZ WIRELESS 2 -blood glucose
AGAMATRIX KEYNOTE TEST ST -glucose blood test
strip................................................................................ 134
AGAMATRIX PRESTO -blood glucose monitoring kit w/
device............................................................................ 140
AGAMATRIX PRESTO PRO METE -blood glucose
AGAMATRIX PRESTO TEST STR -glucose blood test
strip................................................................................ 134
AGAMATRIX ULTRA-THIN LANC -lancets..................... 140
AGGRENOX -aspirin-dipyridamole cap sr 12hr 25-200
mg.................................................................................. 116
AGRYLIN -anagrelide hcl cap 0.5 mg............................. 116
AKTEN -lidocaine hcl ophth gel 3.5%............................. 120
AKYNZEO -netupitant-palonosetron cap 300-0.5 mg....... 63
198
2016
ALA SCALP -hydrocortisone lotion 2%........................... 125
ALBENZA -albendazole tab 200 mg................................. 11
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)......... 58
albuterol sulfate soln nebu 0.5% (5 mg/ml).................. 58
albuterol sulfate soln nebu 0.63 mg/3ml (base
equiv).............................................................................. 58
albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv).............................................................................. 58
albuterol sulfate syrup 2 mg/5ml................................... 58
albuterol sulfate tab 2 mg...............................................58
albuterol sulfate tab 4 mg...............................................58
albuterol sulfate tab sr 12hr 4 mg (Vospire er)............ 58
albuterol sulfate tab sr 12hr 8 mg (Vospire er)............ 58
ALCAINE -proparacaine hcl ophth soln 0.5%................. 120
alclometasone dipropionate cream 0.05%
(Aclovate)..................................................................... 125
alclometasone dipropionate oint 0.05%......................125
ALDACTAZIDE -spironolactone & hydrochlorothiazide tab
25-25 mg......................................................................... 50
ALDACTAZIDE -spironolactone & hydrochlorothiazide tab
50-50 mg......................................................................... 50
ALDACTONE -spironolactone tab 25 mg......................... 50
ALDACTONE -spironolactone tab 50 mg......................... 50
ALDACTONE -spironolactone tab 100 mg....................... 50
ALECENSA -alectinib hcl cap 150 mg (base
equivalent)....................................................................... 16
ALENDRONATE SODIUM -alendronate sodium oral soln
70 mg/75ml..................................................................... 33
ALENDRONATE SODIUM -alendronate sodium tab 40
mg.................................................................................... 33
alendronate sodium tab 5 mg........................................ 33
alendronate sodium tab 10 mg...................................... 33
alendronate sodium tab 35 mg...................................... 33
alendronate sodium tab 70 mg (Fosamax)................... 33
alfuzosin hcl tab sr 24hr 10 mg (Uroxatral).................. 68
ALINIA -nitazoxanide for susp 100 mg/5ml.......................11
ALINIA -nitazoxanide tab 500 mg..................................... 11
ALKERAN -melphalan tab 2 mg....................................... 16
ALLERGY SYRINGE/1ML/27G X -tuberculin/allergy
syringe/needle (disp) 1 ml 27 x 1/2"............................ 140
allopurinol tab 100 mg (Zyloprim)................................. 95
allopurinol tab 300 mg (Zyloprim)................................. 95
almotriptan malate tab 6.25 mg (Axert).........................94
almotriptan malate tab 12.5 mg (Axert).........................94
ALOCRIL -nedocromil sodium ophth soln 2%................ 120
ALOGLIPTIN/METFORMIN HCL -alogliptin-metformin hcl
tab 12.5-500 mg............................................................. 27
ALOGLIPTIN/METFORMIN HCL -alogliptin-metformin hcl
tab 12.5-1000 mg........................................................... 27
ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab
12.5-15 mg...................................................................... 27
12.5-30 mg...................................................................... 27
12.5-45 mg...................................................................... 27
25-15 mg......................................................................... 27
25-30 mg......................................................................... 27
25-45 mg......................................................................... 27
ALOGLIPTIN -alogliptin benzoate tab 6.25 mg (base
equiv)............................................................................... 27
ALOGLIPTIN -alogliptin benzoate tab 12.5 mg (base
equiv)............................................................................... 27
ALOGLIPTIN -alogliptin benzoate tab 25 mg (base
equiv)............................................................................... 27
ALOMIDE -lodoxamide tromethamine ophth soln
0.1%...............................................................................120
ALORA -estradiol td patch twice weekly 0.025
mg/24hr........................................................................... 22
ALORA -estradiol td patch twice weekly 0.05 mg/24hr..... 22
ALORA -estradiol td patch twice weekly 0.075
mg/24hr........................................................................... 22
ALORA -estradiol td patch twice weekly 0.1 mg/24hr....... 22
alosetron hcl tab 0.5 mg (base equiv) (Lotronex)........ 65
alosetron hcl tab 1 mg (base equiv) (Lotronex)........... 65
ALPHAGAN P -brimonidine tartrate ophth soln 0.1%..... 120
ALPHAGAN P -brimonidine tartrate ophth soln
0.15%.............................................................................120
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 250 unit......................................... 116
vwf (human) for inj 500 unit......................................... 116
vwf (human) for inj 1000 unit....................................... 116
ALPHANINE SD -coagulation factor ix for inj 500
unit................................................................................. 116
unit................................................................................. 116
unit................................................................................. 116
ALPRAZOLAM INTENSOL -alprazolam conc 1 mg/
ml..................................................................................... 69
alprazolam orally disintegrating tab 0.5 mg................. 69
alprazolam orally disintegrating tab 1 mg.................... 69
alprazolam orally disintegrating tab 2 mg.................... 69
alprazolam orally disintegrating tab 0.25 mg
(Niravam)........................................................................ 69
alprazolam tab 0.25 mg (Xanax).................................... 69
alprazolam tab 0.5 mg (Xanax)...................................... 69
alprazolam tab 1 mg (Xanax)..........................................69
alprazolam tab 2 mg (Xanax)..........................................70
alprazolam tab sr 24hr 0.5 mg (Xanax xr)..................... 69
alprazolam tab sr 24hr 1 mg (Xanax xr)........................ 69
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
250 unit......................................................................... 116
199
2016
500 unit......................................................................... 116
1000 unit....................................................................... 116
2000 unit....................................................................... 116
3000 unit....................................................................... 116
ALREX -loteprednol etabonate ophth susp 0.2%........... 120
ALSUMA -sumatriptan succinate solution auto-injector 6
mg/0.5ml.......................................................................... 94
ALTABAX -retapamulin oint 1%.......................................125
ALTACE -ramipril cap 1.25 mg.......................................... 43
ALTACE -ramipril cap 2.5 mg............................................ 43
ALTACE -ramipril cap 5 mg............................................... 43
ALTACE -ramipril cap 10 mg............................................. 43
ALTERNATE SITE LANCING DE -lancet devices.......... 140
ALTOPREV -lovastatin tab sr 24hr 20 mg........................ 52
ALVESCO -ciclesonide inhal aerosol 80 mcg/act............. 58
ALVESCO -ciclesonide inhal aerosol 160 mcg/act........... 58
AMANTADINE HCL -amantadine hcl tab 100 mg........... 100
amantadine hcl cap 100 mg......................................... 100
amantadine hcl syrup 50 mg/5ml................................ 100
AMARYL -glimepiride tab 1 mg......................................... 27
AMCINONIDE -amcinonide cream 0.1%........................ 125
AMCINONIDE -amcinonide lotion 0.1%.......................... 125
AMCINONIDE -amcinonide oint 0.1%.............................125
AMICAR -aminocaproic acid oral soln 0.25 gm/ml......... 115
AMICAR -aminocaproic acid tab 500 mg........................ 115
AMICAR -aminocaproic acid tab 1000 mg...................... 115
amiloride & hydrochlorothiazide tab 5-50 mg.............. 50
amiloride hcl tab 5 mg.................................................... 50
AMINOBENZOATE POTASSIUM -potassium
aminobenzoate packet 2 gm........................................ 104
amiodarone hcl tab 100 mg............................................ 42
amiodarone hcl tab 400 mg............................................ 42
amiodarone hcl tab 200 mg (Cordarone)...................... 42
AMITIZA -lubiprostone cap 8 mcg.................................... 65
AMITIZA -lubiprostone cap 24 mcg.................................. 65
amitriptyline hcl tab 10 mg............................................. 70
amitriptyline hcl tab 100 mg........................................... 70
amitriptyline hcl tab 150 mg........................................... 70
amlodipine besylate-atorvastatin calcium tab 2.5-10
mg (Caduet)................................................................... 55
mg (Caduet)................................................................... 55
mg (Caduet)................................................................... 55
amlodipine besylate-atorvastatin calcium tab 5-10 mg
(Caduet).......................................................................... 55
(Caduet).......................................................................... 55
(Caduet).......................................................................... 55
(Caduet).......................................................................... 55
amlodipine besylate-atorvastatin calcium tab 10-10
mg (Caduet)................................................................... 55
mg (Caduet)................................................................... 55
mg (Caduet)................................................................... 55
mg (Caduet)................................................................... 55
amlodipine besylate-benazepril hcl cap 2.5-10 mg
(Lotrel)............................................................................ 43
amlodipine besylate-benazepril hcl cap 5-10 mg
(Lotrel)............................................................................ 43
(Lotrel)............................................................................ 43
(Lotrel)............................................................................ 43
(Lotrel)............................................................................ 43
(Lotrel)............................................................................ 43
amlodipine besylate tab 2.5 mg (Norvasc)................... 40
amlodipine besylate tab 5 mg (Norvasc)...................... 40
amlodipine besylate tab 10 mg (Norvasc).................... 40
amlodipine besylate-valsartan tab 5-160 mg
(Exforge)......................................................................... 43
(Exforge)......................................................................... 43
(Exforge)......................................................................... 43
(Exforge)......................................................................... 43
amlodipine-valsartan-hydrochlorothiazide tab
5-160-12.5 mg (Exforge hct)........................................ 43
5-160-25 mg (Exforge hct)........................................... 43
10-160-12.5 mg (Exforge hct)...................................... 43
10-160-25 mg (Exforge hct)......................................... 43
10-320-25 mg (Exforge hct)......................................... 43
AMOXAPINE -amoxapine tab 25 mg................................ 70
AMOXAPINE -amoxapine tab 50 mg................................ 70
AMOXAPINE -amoxapine tab 100 mg.............................. 70
AMOXAPINE -amoxapine tab 150 mg.............................. 70
AMOXICILLIN/CLAVULANATE P -amoxicillin & k
clavulanate chew tab 200-28.5 mg.................................. 1
AMOXICILLIN/CLAVULANATE P -amoxicillin & k
clavulanate chew tab 400-57 mg..................................... 1
amoxicillin & k clavulanate for susp 200-28.5
mg/5ml.............................................................................. 1
200
2016
amoxicillin & k clavulanate for susp 400-57 mg/5ml..... 1
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
(Augmentin)..................................................................... 1
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
(Augmentin es-600)........................................................ 1
amoxicillin & k clavulanate tab 250-125 mg................... 1
amoxicillin & k clavulanate tab 500-125 mg
(Augmentin)..................................................................... 1
amoxicillin & k clavulanate tab 875-125 mg
(Augmentin)..................................................................... 1
amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg
(Augmentin xr)................................................................ 1
AMOXICILLIN -amoxicillin (trihydrate) chew tab 125
mg...................................................................................... 1
AMOXICILLIN -amoxicillin (trihydrate) chew tab 250
mg...................................................................................... 1
amoxicillin cap-clarithro tab-lansopraz cap dr therapy
pack (Prevpac).............................................................. 62
AMOXICILLIN ER -amoxicillin (trihydrate) tab sr 24hr 775
mg...................................................................................... 1
amoxicillin (trihydrate) cap 250 mg................................. 1
amoxicillin (trihydrate) cap 500 mg................................. 1
amoxicillin (trihydrate) for susp 125 mg/5ml..................1
amoxicillin (trihydrate) tab 500 mg.................................. 1
amoxicillin (trihydrate) tab 875 mg.................................. 1
amphetamine-dextroamphetamine cap sr 24hr 5 mg
(Adderall xr)................................................................... 78
(Adderall xr)................................................................... 78
(Adderall xr)................................................................... 78
(Adderall xr)................................................................... 78
(Adderall xr)................................................................... 78
(Adderall xr)................................................................... 78
amphetamine-dextroamphetamine tab 5 mg
(Adderall)........................................................................ 78
amphetamine-dextroamphetamine tab 7.5 mg
(Adderall)........................................................................ 78
(Adderall)........................................................................ 78
amphetamine-dextroamphetamine tab 12.5 mg
(Adderall)........................................................................ 78
(Adderall)........................................................................ 78
(Adderall)........................................................................ 78
(Adderall)........................................................................ 78
AMPICILLIN -ampicillin for susp 125 mg/5ml..................... 1
AMPICILLIN -ampicillin for susp 250 mg/5ml..................... 1
ampicillin cap 250 mg....................................................... 1
ampicillin cap 500 mg....................................................... 1
AMPYRA -dalfampridine tab sr 12hr 10 mg...................... 82
ANADROL-50 -oxymetholone tab 50 mg.......................... 21
ANAFRANIL -clomipramine hcl cap 25 mg....................... 70
anagrelide hcl cap 1 mg............................................... 116
anagrelide hcl cap 0.5 mg (Agrylin)............................ 116
ANALPRAM-HC -hydrocortisone acetate w/ pramoxine
rectal cream 1-1%........................................................ 125
ANALPRAM HC -hydrocortisone acetate w/ pramoxine
rectal cream 2.5-1%..................................................... 125
ANALPRAM-HC -hydrocortisone acetate w/ pramoxine
rectal lotn 2.5-1%..........................................................125
ANALPRAM-HC SINGLES -hydrocortisone acetate w/
pramoxine rectal cream 1-1%...................................... 125
ANALPRAM-HC SINGLES -hydrocortisone acetate w/
pramoxine rectal cream 2.5-1%................................... 125
ANALPRAM HC SINGLES -hydrocortisone acetate w/
pramoxine rectal cream 2.5-1%................................... 125
ANAPROX DS -naproxen sodium tab 550 mg................. 91
ANASPAZ -hyoscyamine sulfate tab disp 0.125 mg......... 62
anastrozole tab 1 mg (Arimidex)................................... 16
ANCOBON -flucytosine cap 250 mg................................... 6
ANCOBON -flucytosine cap 500 mg................................... 6
ANDRODERM -testosterone td patch 24hr 2 mg/24hr..... 21
ANDRODERM -testosterone td patch 24hr 4 mg/24hr..... 21
ANDROGEL PUMP -testosterone td gel 12.5 mg/act
(1%)................................................................................. 21
ANDROGEL PUMP -testosterone td gel 20.25 mg/act
(1.62%)............................................................................ 21
ANDROGEL -testosterone td gel 25 mg/2.5gm (1%)....... 21
ANDROGEL -testosterone td gel 50 mg/5gm (1%).......... 21
ANDROGEL -testosterone td gel 20.25 mg/1.25gm
(1.62%)............................................................................ 21
ANDROGEL -testosterone td gel 40.5 mg/2.5gm
(1.62%)............................................................................ 21
ANDROID -methyltestosterone cap 10 mg....................... 21
ANDROXY -fluoxymesterone tab 10 mg........................... 21
ANGELIQ -drospirenone-estradiol tab 0.25-0.5 mg.......... 22
ANGELIQ -drospirenone-estradiol tab 0.5-1 mg............... 22
ANORO ELLIPTA -umeclidinium-vilanterol aero powd ba
62.5-25 mcg/inh.............................................................. 58
ANTABUSE -disulfiram tab 250 mg.................................. 82
ANTABUSE -disulfiram tab 500 mg.................................. 82
antipyrine-benzocaine otic soln 54-14 mg/ml
(5.4-1.4%)...................................................................... 124
ANTI-STICK INSULIN SYRING -insulin syringe/needle
u-100 1/2 ml 28 x 1/2".................................................. 140
u-100 1/2 ml 29 x 1/2".................................................. 140
u-100 1 ml 29 x 1/2".....................................................140
ANTI-STICK TUBERCULIN SYR -tuberculin/allergy
ANTI-STICK TUBERCULIN SYR -tuberculin/allergy
201
2016
ANUSOL-HC -hydrocortisone rectal cream 2.5%........... 125
ANZEMET -dolasetron mesylate tab 50 mg..................... 63
ANZEMET -dolasetron mesylate tab 100 mg................... 63
APEXICON E -diflorasone diacetate emollient base
cream 0.05%................................................................. 125
APIDRA -insulin glulisine inj 100 unit/ml........................... 30
APIDRA SOLOSTAR -insulin glulisine soln pen-injector inj
100 unit/ml.......................................................................30
APOKYN -apomorphine hydrochloride inj 10 mg/ml....... 100
apraclonidine hcl ophth soln 0.5% (base equivalent)
(Iopidine)...................................................................... 120
APRISO -mesalamine cap sr 24hr 0.375 gm.................... 65
APTENSIO XR -methylphenidate hcl cap er 24hr 10 mg
(xr)................................................................................... 78
(xr)................................................................................... 78
(xr)................................................................................... 78
(xr)................................................................................... 78
(xr)................................................................................... 78
(xr)................................................................................... 79
(xr)................................................................................... 79
APTIOM -eslicarbazepine acetate tab 200 mg................. 95
APTIVUS -tipranavir cap 250 mg........................................ 7
APTIVUS -tipranavir oral soln 100 mg/ml........................... 7
AQUA LANCE ADJUSTABLE LAN -lancet devices........ 140
ARALEN -chloroquine phosphate tab 500 mg.................. 11
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 25
mcg/ml........................................................................... 112
mcg/ml........................................................................... 112
mcg/ml........................................................................... 112
mcg/ml........................................................................... 112
mcg/ml........................................................................... 112
mcg/ml........................................................................... 112
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 10 mcg/0.4ml..................................... 112
prefilled syringe 25 mcg/0.42ml................................... 112
prefilled syringe 500 mcg/ml........................................ 112
ARAVA -leflunomide tab 10 mg......................................... 91
ARAVA -leflunomide tab 20 mg......................................... 91
ARCALYST -rilonacept for inj 220 mg...............................91
ARCAPTA NEOHALER -indacaterol maleate inhal powder
cap 75 mcg (base equiv)................................................58
ARICEPT -donepezil hydrochloride tab 5 mg................... 82
ARICEPT -donepezil hydrochloride tab 10 mg................. 82
ARICEPT -donepezil hydrochloride tab 23 mg................. 82
ARIMIDEX -anastrozole tab 1 mg..................................... 16
aripiprazole orally disintegrating tab 10 mg.................74
aripiprazole orally disintegrating tab 15 mg.................74
aripiprazole oral solution 1 mg/ml................................. 74
aripiprazole tab 2 mg (Abilify)........................................ 74
aripiprazole tab 5 mg (Abilify)........................................ 74
aripiprazole tab 10 mg (Abilify)...................................... 74
ARIXTRA -fondaparinux sodium subcutaneous inj 2.5
mg/0.5ml........................................................................ 114
ARIXTRA -fondaparinux sodium subcutaneous inj 5
mg/0.4ml........................................................................ 114
ARIXTRA -fondaparinux sodium subcutaneous inj 7.5
mg/0.6ml........................................................................ 114
ARIXTRA -fondaparinux sodium subcutaneous inj 10
mg/0.8ml........................................................................ 114
ARMODAFINIL -armodafinil tab 200 mg........................... 79
armodafinil tab 50 mg (Nuvigil)......................................79
armodafinil tab 150 mg (Nuvigil)................................... 79
armodafinil tab 250 mg (Nuvigil)................................... 79
ARMOUR THYROID -thyroid tab 15 mg (1/4 grain)......... 31
ARMOUR THYROID -thyroid tab 30 mg (1/2 grain)......... 31
ARMOUR THYROID -thyroid tab 90 mg (1 1/2 grain)...... 31
ARMOUR THYROID -thyroid tab 60 mg (1 grain)............ 31
ARMOUR THYROID -thyroid tab 120 mg (2 grain).......... 31
ARNUITY ELLIPTA -fluticasone furoate aerosol powder
breath activ 100 mcg/act................................................ 58
ARNUITY ELLIPTA -fluticasone furoate aerosol powder
breath activ 200 mcg/act................................................ 58
AROMASIN -exemestane tab 25 mg................................ 16
ARTHROTEC 50 -diclofenac w/ misoprostol tab delayed
release 50-0.2 mg...........................................................91
ARTHROTEC 75 -diclofenac w/ misoprostol tab delayed
release 75-0.2 mg...........................................................91
ARZOL SILVER NITRATE APP -silver nitrate-potassium
nitrate applicator 75-25%............................................. 126
202
2016
ASACOL HD -mesalamine tab delayed release 800
mg.................................................................................... 65
ASCENSIA AUTODISC TEST ST -glucose blood test
disk................................................................................ 134
ASMANEX HFA -mometasone furoate inhal aerosol
suspension 100 mcg/act................................................. 58
ASMANEX HFA -mometasone furoate inhal aerosol
suspension 200 mcg/act................................................. 58
ASMANEX TWISTHALER 120 ME -mometasone furoate
inhal powd 220 mcg/inh (breath activated).................... 58
ASMANEX TWISTHALER 7 METE -mometasone furoate
ASMANEX TWISTHALER 14 MET -mometasone furoate
ASPIRIN/DIPYRIDAMOLE -aspirin-dipyridamole cap sr
12hr 25-200 mg............................................................ 116
ASPIRIN-CAFFEINE-DIHYDROC -aspirin-caffeinedihydrocodeine cap 356.4-30-16 mg............................. 86
aspirin chew tab 81 mg...................................................85
aspirin tab delayed release 81 mg.................................85
ASSURE 4 BLOOD GLUCOSE ME -blood glucose
ASSURE COMFORT LANCETS UL -lancets................. 140
ASSURE HAEMOLANCE PLUS HI -lancets.................. 140
ASSURE HAEMOLANCE PLUS LO -lancets................. 140
ASSURE HAEMOLANCE PLUS MI -lancets.................. 140
ASSURE HAEMOLANCE PLUS NO -lancets................. 140
ASSURE HAEMOLANCE PLUS PE -lancets................. 141
ASSURE ID INSULIN SAFETY -insulin syringe/needle
u-100 1/2 ml 29 x 1/2".................................................. 141
ASSURE ID INSULIN SAFETY -insulin syringe/needle
u-100 1 ml 29 x 1/2".....................................................141
ASSURE II CHECK STRIP -glucose blood test strip...... 134
ASSURE II -glucose blood test strip............................... 134
ASSURE II TEST STRIPS -glucose blood test strip....... 134
ASSURE LANCE LANCETS 21G -lancets..................... 141
ASSURE LANCE LANCETS -lancets............................. 141
ASSURE LANCE PLUS SAFETY -lancets..................... 141
ASSURE LANCETS -lancets...........................................141
ASSURE 3 METER -blood glucose monitoring kit.......... 141
ASSURE PLATINUM BLOOD GLU -blood glucose
ASSURE PLATINUM TEST STRI -glucose blood test
strip................................................................................ 134
ASSURE PRISM MULTI BLOOD -blood glucose
ASSURE PRISM MULTI TEST S -glucose blood test
strip................................................................................ 134
ASSURE PRO BLOOD GLUCOSE -blood glucose
ASSURE PRO TEST STRIPS -glucose blood test
strip................................................................................ 134
ASSURE 3 TEST STRIPS -glucose blood test strip....... 134
ASSURE 4 TEST STRIPS -glucose blood test strip....... 134
ASTAGRAF XL -tacrolimus cap sr 24hr 0.5 mg.............. 194
ASTAGRAF XL -tacrolimus cap sr 24hr 1 mg................. 194
ASTAGRAF XL -tacrolimus cap sr 24hr 5 mg................. 194
ASTEPRO -azelastine hcl nasal spray 0.15% (205.5 mcg/
spray)............................................................................... 56
ATABEX EC -prenatal vit w/ dss-iron carbonyl-fa tab dr
29-1 mg......................................................................... 104
ATACAND -candesartan cilexetil tab 4 mg....................... 44
ATACAND -candesartan cilexetil tab 8 mg....................... 44
ATACAND -candesartan cilexetil tab 16 mg..................... 44
ATACAND -candesartan cilexetil tab 32 mg..................... 44
ATACAND HCT -candesartan cilexetil-hydrochlorothiazide
tab 16-12.5 mg............................................................... 44
tab 32-12.5 mg............................................................... 44
tab 32-25 mg...................................................................44
ATELVIA -risedronate sodium tab delayed release 35
mg.................................................................................... 33
atenolol & chlorthalidone tab 50-25 mg (Tenoretic
50).................................................................................... 44
atenolol & chlorthalidone tab 100-25 mg (Tenoretic
100).................................................................................. 44
atenolol tab 25 mg (Tenormin)....................................... 38
atenolol tab 50 mg (Tenormin)....................................... 38
atenolol tab 100 mg (Tenormin)..................................... 38
AT LAST BLOOD GLUCOSE SYS -blood glucose
monitoring kit................................................................. 141
AT LAST LANCETS -lancets........................................... 141
AT LAST TEST STRIPS -glucose blood test strip.......... 134
atorvastatin calcium tab 10 mg (base equivalent)
(Lipitor)........................................................................... 52
(Lipitor)........................................................................... 52
(Lipitor)........................................................................... 52
(Lipitor)........................................................................... 52
atovaquone-proguanil hcl tab 62.5-25 mg
(Malarone)...................................................................... 11
atovaquone-proguanil hcl tab 250-100 mg
(Malarone)...................................................................... 11
atovaquone susp 750 mg/5ml (Mepron)....................... 11
ATRIPLA -efavirenz-emtricitabine-tenofovir df tab
600-200-300 mg................................................................7
ATROPINE SULFATE -atropine sulfate ophth oint
1%.................................................................................. 120
ATROPINE SULFATE -atropine sulfate ophth soln
1%.................................................................................. 120
ATROVENT HFA -ipratropium bromide hfa inhal aerosol
17 mcg/act.......................................................................58
AUBAGIO -teriflunomide tab 7 mg.................................... 82
AUBAGIO -teriflunomide tab 14 mg.................................. 82
203
2016
AUGMENTIN -amoxicillin & k clavulanate for susp
125-31.25 mg/5ml............................................................. 1
AUGMENTIN -amoxicillin & k clavulanate for susp
250-62.5 mg/5ml............................................................... 1
AUGMENTIN -amoxicillin & k clavulanate tab 500-125
mg...................................................................................... 1
AUGMENTIN -amoxicillin & k clavulanate tab 875-125
mg...................................................................................... 1
AUGMENTIN ES-600 -amoxicillin & k clavulanate for
susp 600-42.9 mg/5ml...................................................... 1
AUGMENTIN XR -amoxicillin & k clavulanate tab sr 12hr
1000-62.5 mg.................................................................... 1
AURORA LANCET SUPER THIN -lancets..................... 141
AURORA LANCET THIN 23G -lancets........................... 141
AURORA PEN NEEDLES 29GX12 -insulin pen needle 29
g x 12 mm (1/2")...........................................................141
AURORA PEN NEEDLES 31G X -insulin pen needle 31 g
x 6 mm (1/4")................................................................ 141
AURORA PEN NEEDLES 31G X -insulin pen needle 31 g
x 8 mm (1/3" or 5/16").................................................. 141
AURORA UNIFINE PENTIPS/32 -insulin pen needle 32 g
x 4 mm (5/32").............................................................. 141
AURORA UNIFINE PENTIPS/MI -insulin pen needle 31 g
x 5 mm (3/16").............................................................. 141
AUTO-LANCET -lancet devices...................................... 141
AUTO-LANCET MINI -lancet devices............................. 141
AUTOLET IMPRESSION -lancet devices....................... 141
AUTOLET IMPRESSION LANCIN -lancet devices......... 141
AUTOLET MINI -lancet devices...................................... 141
AUTOPEN -injection device for insulin............................141
AVALIDE -irbesartan-hydrochlorothiazide tab 150-12.5
mg.................................................................................... 44
AVALIDE -irbesartan-hydrochlorothiazide tab 300-12.5
mg.................................................................................... 44
AVANDIA -rosiglitazone maleate tab 2 mg (base
equiv)............................................................................... 27
AVANDIA -rosiglitazone maleate tab 4 mg (base
equiv)............................................................................... 27
AVAPRO -irbesartan tab 75 mg........................................ 44
AVAPRO -irbesartan tab 150 mg...................................... 44
AVAPRO -irbesartan tab 300 mg...................................... 44
AVAR LS -sulfacetamide sodium w/ sulfur foam
10-2%............................................................................ 126
AVAR -sulfacetamide sodium w/ sulfur foam 9.5-5%...... 126
AVC -sulfanilamide vaginal cream 15%............................ 68
AVELOX ABC PACK -moxifloxacin hcl tab 400 mg (base
equiv)................................................................................. 4
AVELOX -moxifloxacin hcl tab 400 mg (base equiv).......... 4
AVODART -dutasteride cap 0.5 mg.................................. 68
AVONEX -interferon beta-1a for im inj kit 30mcg
(33mcg(6.6 mu)/vial)....................................................... 82
AVONEX -interferon beta-1a im prefilled syringe kit 30
mcg/0.5ml........................................................................ 82
AVONEX PEN -interferon beta-1a im auto-injector kit 30
mcg/0.5ml........................................................................ 82
AXERT -almotriptan malate tab 6.25 mg.......................... 94
AXERT -almotriptan malate tab 12.5 mg.......................... 94
AXILLARY BLOCK NEEDLE BLO -needle (disp) 22 x
1".................................................................................... 141
AXILLARY BLOCK NEEDLE BLO -needle (disp) 25 x
1".................................................................................... 141
AYGESTIN -norethindrone acetate tab 5 mg.................... 26
AZASAN -azathioprine tab 75 mg................................... 194
AZASAN -azathioprine tab 100 mg................................. 194
AZASITE -azithromycin ophth soln 1%........................... 120
azathioprine tab 50 mg (Imuran).................................. 194
azelastine hcl nasal spray 0.1% (137 mcg/spray)........ 56
azelastine hcl nasal spray 0.15% (205.5 mcg/spray)
(Astepro).........................................................................56
azelastine hcl ophth soln 0.05%.................................. 120
AZELEX -azelaic acid cream 20%.................................. 126
AZILECT -rasagiline mesylate tab 0.5 mg (base
equiv)............................................................................. 100
AZILECT -rasagiline mesylate tab 1 mg (base
equiv)............................................................................. 100
AZITHROMYCIN -azithromycin powd pack for susp 1
gm...................................................................................... 3
azithromycin for susp 100 mg/5ml (Zithromax)............. 3
azithromycin for susp 200 mg/5ml (Zithromax)............. 3
azithromycin tab 250 mg (Zithromax)............................. 3
AZOPT -brinzolamide ophth susp 1%............................. 120
AZOR -amlodipine besylate-olmesartan medoxomil tab
5-20 mg........................................................................... 44
5-40 mg........................................................................... 44
10-20 mg......................................................................... 44
10-40 mg......................................................................... 44
AZULFIDINE EN-TABS -sulfasalazine tab delayed
release 500 mg............................................................... 65
AZULFIDINE -sulfasalazine tab 500 mg........................... 65
B
BACITRACIN -bacitracin ophth oint 500 unit/gm............ 120
bacitracin-polymyxin b ophth oint.............................. 120
bacitracin-polymyxin-neomycin-hc ophth oint
1%.................................................................................. 120
baclofen tab 10 mg........................................................ 103
baclofen tab 20 mg........................................................ 103
BACTRIM DS -sulfamethoxazole-trimethoprim tab
800-160 mg..................................................................... 11
BACTRIM -sulfamethoxazole-trimethoprim tab 400-80
mg.................................................................................... 11
BACTROBAN -mupirocin calcium cream 2%................. 126
BACTROBAN NASAL -mupirocin calcium nasal oint
2%.................................................................................... 56
BAL-CARE DHA -prenat w/fe poly-na fered-fa tab 27-1 &
omega cap dr 430mg................................................... 104
balsalazide disodium cap 750 mg (Colazal)................. 65
BANZEL -rufinamide susp 40 mg/ml................................. 95
BANZEL -rufinamide tab 200 mg...................................... 95
204
2016
BANZEL -rufinamide tab 400 mg...................................... 95
BARACLUDE -entecavir oral soln 0.05 mg/ml.................... 7
BARACLUDE -entecavir tab 0.5 mg................................... 7
BARACLUDE -entecavir tab 1 mg...................................... 7
BAYER BREEZE 2 BLOOD GLUC -blood glucose
BAYER BREEZE 2 TEST DISC -glucose blood test
disk................................................................................ 134
BAYER CONTOUR BLOOD GLUCO -blood glucose
BAYER CONTOUR BLOOD GLUCO -blood glucose
BAYER CONTOUR BLOOD GLUCO -glucose blood test
strip................................................................................ 134
BAYER CONTOUR LINK BLOOD -blood glucose
BAYER CONTOUR NEXT BLOOD -blood glucose
BAYER CONTOUR NEXT BLOOD -glucose blood test
strip................................................................................ 134
BAYER CONTOUR NEXT EZ BLO -blood glucose
BAYER CONTOUR NEXT LINK B -blood glucose
BAYER CONTOUR NEXT LINK W -blood glucose
BAYER CONTOUR NEXT USB BL -blood glucose
BAYER MICROLET LANCETS -lancets......................... 142
BAYER MICROLET 2 LANCING -lancet devices........... 142
BD ALLERGY/SYRINGE/NEEDLE -tuberculin/allergy
BD ALLERGY/SYRINGE NEEDLE -tuberculin/allergy
BD AUTOSHIELD DUO 30G X 3 -insulin pen needle 30 g
x 5 mm (3/16").............................................................. 142
BD AUTOSHIELD 29G X 3/16" -insulin pen needle 29 g x
5 mm (3/16")................................................................. 142
BD AUTOSHIELD 29G X 5/16" -insulin pen needle 29 g x
8 mm (5/16")................................................................. 142
BD BLUNT FILL NEEDLE -needle (disp) 18 x 1-1/2"..... 142
BD DISPOSABLE NEEDLE/30GX -needle (disp) 30 x
1".................................................................................... 142
BD DISPOSABLE NEEDLE 23GX -needle (disp) 23 x
1-1/4"............................................................................. 142
1-1/4"............................................................................. 142
1".................................................................................... 142
BD DISPOSABLE NEEDLE REGU -needle (disp) 22 x
3/4".................................................................................142
1".................................................................................... 142
1".................................................................................... 142
1".................................................................................... 142
BD ECLIPSE 18G X 1-1/2" -needle (disp) 18 x
1-1/2"............................................................................. 142
BD ECLIPSE 22G X 1" -needle (disp) 22 x 1"................ 143
BD ECLIPSE 23G X 1" NEEDL -needle (disp) 23 x
1".................................................................................... 143
BD ECLIPSE NEEDLE/22G X 1 -needle (disp) 22 x
1-1/2"............................................................................. 142
BD ECLIPSE NEEDLE/25G X -needle (disp) 25 x
5/8".................................................................................142
BD ECLIPSE NEEDLE 25GX1" -needle (disp) 25 x
1".................................................................................... 142
BD ECLIPSE NEEDLE 21G X 1 -needle (disp) 21 x
1-1/2"............................................................................. 142
1-1/2"............................................................................. 142
BD ECLIPSE NEEDLE 30G X -needle (disp) 30 x
1/2".................................................................................142
1".................................................................................... 142
BD HYPODERMIC NEEDLE REGU -needle (disp) 18 x
1-1/2"............................................................................. 143
1-1/2"............................................................................. 143
1-1/2"............................................................................. 143
1-1/2"............................................................................. 143
1-1/2"............................................................................. 143
1-1/2"............................................................................. 143
5/8".................................................................................143
5/8".................................................................................143
1".................................................................................... 143
1".................................................................................... 143
1".................................................................................... 143
1".................................................................................... 143
BD HYPODERMIC NEEDLE SHOR -needle (disp) 18 x
1-1/2"............................................................................. 143
1-1/2"............................................................................. 143
1-1/2"............................................................................. 143
BD INSULIN SYRINGE/DETACH -insulin syringe/needle
u-100 1 ml 25 x 5/8".....................................................144
u-100 1 ml 26 x 1/2".....................................................144
u-100 1 ml 25 x 1"........................................................144
BD INSULIN SYRINGE/U-100/ -insulin syringe/needle
u-100 1/2 ml 30 x 1/2".................................................. 144
205
2016
u-100 1 ml 27 x 1/2".....................................................144
u-100 1 ml 28 x 1/2".....................................................144
u-100 2 ml 27.5 x 5/8".................................................. 144
u-100 2 ml 29 x 1/2".....................................................144
BD INSULIN SYRINGE LUER-L -insulin syringe (disp)
u-100 1 ml..................................................................... 143
BD INSULIN SYRINGE MICROF -insulin syringe/needle
u-100 1/2 ml 28 x 1/2".................................................. 143
u-100 0.3 ml 28 x 1/2".................................................. 143
u-100 1 ml 27 x 5/8".....................................................143
u-100 1 ml 28 x 1/2".....................................................143
B-D INSULIN SYRINGE MICRO -insulin syringe/needle
u-100 1 ml 28 x 1/2".....................................................141
BD INSULIN SYRINGE SAFETY -insulin syringe/needle
u-100 1/2 ml 29 x 1/2".................................................. 143
u-100 1 ml 29 x 1/2".....................................................143
u-100 0.3 ml 31 x 5/16"................................................ 143
BD INSULIN SYRINGE SLIP T -insulin syringe (disp)
u-100 1 ml..................................................................... 143
BD INSULIN SYRINGE U-40/1 -insulin syringe/needle
u-40 1 ml 25 x 5/8".......................................................143
BD INSULIN SYRINGE ULTRAF -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 143
u-100 1/2 ml 29 x 1/2".................................................. 143
u-100 1/2 ml 30 x 1/2".................................................. 143
u-100 1/2 ml 31 x 15/64".............................................. 144
u-100 0.3 ml 29 x 1/2".................................................. 143
u-100 0.3 ml 30 x 1/2".................................................. 143
u-100 0.3 ml 31 x 15/64".............................................. 144
u-100 1 ml 29 x 1/2".....................................................144
u-100 1 ml 30 x 1/2".....................................................144
u-100 1 ml 31 x 5/16"...................................................144
u-100 0.3 ml 31 x 5/16"................................................ 144
u-100 1 ml 31 x 15/64"................................................. 144
B-D INSULIN SYRINGE ULTRA -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 141
u-100 1/2 ml 30 x 1/2".................................................. 141
u-100 0.3 ml 30 x 1/2".................................................. 141
u-100 1 ml 30 x 1/2".....................................................141
u-100 1 ml 31 x 5/16"...................................................141
u-100 0.3 ml 31 x 5/16"................................................ 141
BD INTEGRA INSULIN SYRING -insulin syringe/needle
u-100 1 ml 29 x 1/2".....................................................144
BD INTEGRA RETRACTABLE NE -needle (disp) 23 x
1".................................................................................... 144
BD INTEGRA SYRINGE/RETRAC -insulin syringe/needle
u-100 1 ml 25 x 1"........................................................144
BD KLATSKIN BIOPSY -needle (disp) 16 x 4"............... 144
BD LANCET DEVICE -lancet devices............................ 144
BD LANCET ULTRAFINE 30G -lancets.......................... 144
BD LANCET ULTRAFINE 33G -lancets.......................... 144
BD LATITUDE DIABETES MANA -blood glucose
BD LO-DOSE INSULIN SYRIN -insulin syringe/needle
u-100 1/2 ml 28 x 1/2".................................................. 142
BD LOGIC BLOOD GLUCOSE MO -blood glucose
BD MAGNI-GUIDE MAGNIFIER -blood glucose
monitoring supplies....................................................... 144
BD MICROTAINER LANCETS -lancets.......................... 144
BD 1ML TUBERCULIN SYRINGE -tuberculin/allergy
BD 1ML TUBERCULIN SYRINGE -tuberculin/allergy
BD NEEDLE/18G 1-1/2" -needle (disp) 18 x 1-1/2"........ 144
BD NEEDLE/21G 1-1/2" -needle (disp) 21 x 1-1/2"........ 144
BD NEEDLE/16G X 1-1/2" -needle (disp) 16 x
1-1/2"............................................................................. 144
1-1/2"............................................................................. 144
1-1/2"............................................................................. 145
BD NEEDLE/25G X 5/8" -needle (disp) 25 x 5/8"........... 145
BD NEEDLE/19G X 1" -needle (disp) 19 x 1"................. 144
BD NEEDLE/20G X 1" -needle (disp) 20 x 1"................. 144
BD OSGOOD BIOPSY -needle (disp) 16 x 1-5/16"........ 145
BD PEN -injection device for insulin............................... 145
BD PEN MINI -injection device for insulin....................... 145
BD PEN NEEDLE/MINI/ULTRAF -insulin pen needle 31 g
x 5 mm (3/16").............................................................. 145
BD PEN NEEDLE/NANO/ULTRA -insulin pen needle 32 g
x 4 mm (5/32").............................................................. 145
BD PEN NEEDLE/SHORT/ULTRA -insulin pen needle 31
g x 8 mm (1/3" or 5/16")...............................................145
206
2016
BD PEN NEEDLE/ULTRAFINE/2 -insulin pen needle 29 g
x 12.7 mm..................................................................... 145
BD PEN NEEDLES SHORT/ULTR -insulin pen needle 31
g x 8 mm (1/3" or 5/16")...............................................145
BD PLASTIPAK SYRINGES ALL -tuberculin/allergy
BD PRECISIONGLIDE NEEDLE -needle (disp) 27 x
1-1/2"............................................................................. 145
BD ROSENTHAL BIOPSY -needle (disp) 16 x
1-5/16"........................................................................... 145
BD SAFETYGLIDE ALLERGY S -tuberculin/allergy
BD SAFETYGLIDE ALLERGY SY -tuberculin/allergy
BD SAFETYGLIDE 21G X 1-1/ -needle (disp) 21 x
1-1/2"............................................................................. 145
BD SAFETYGLIDE 21G X 1" -needle (disp) 21 x 1".......145
BD SAFETYGLIDE HYPODERMIC -needle (disp) 18 x
1-1/2"............................................................................. 145
BD SAFETYGLIDE HYPODERMIC -needle (disp) 25 x
5/8".................................................................................145
BD SAFETYGLIDE INJECTION -needle (disp) 22 x
1-1/2"............................................................................. 145
BD SAFETYGLIDE INJECTION -needle (disp) 25 x
1".................................................................................... 145
BD SAFETY-GLIDE INSULIN S -insulin syringe/needle
u-100 1/2 ml 29 x 1/2".................................................. 145
BD SAFETYGLIDE INSULIN SY -insulin syringe/needle
u-100 1/2 ml 30 x 5/16"................................................ 145
BD SAFETYGLIDE SHIELDED N -needle (disp) 23 x
1".................................................................................... 145
BD SAFETY-LOK INSULIN SYR -insulin syringe/needle
u-100 1 ml 29 x 1/2".....................................................145
BEBULIN -factor ix complex for inj 200-1200 unit.......... 116
benazepril & hydrochlorothiazide tab 5-6.25 mg......... 44
benazepril & hydrochlorothiazide tab 10-12.5 mg
(Lotensin hct)................................................................ 44
benazepril & hydrochlorothiazide tab 20-12.5 mg
(Lotensin hct)................................................................ 44
benazepril & hydrochlorothiazide tab 20-25 mg
(Lotensin hct)................................................................ 44
benazepril hcl tab 5 mg.................................................. 44
benazepril hcl tab 10 mg (Lotensin).............................. 44
BENEFIX -coagulation factor ix (recombinant) for inj 250
unit................................................................................. 116
unit................................................................................. 116
unit................................................................................. 116
unit................................................................................. 116
unit................................................................................. 116
BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 20-12.5 mg...............................44
BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 40-12.5 mg...............................44
BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 40-25 mg.................................. 44
BENICAR -olmesartan medoxomil tab 5 mg.....................44
BENICAR -olmesartan medoxomil tab 20 mg...................44
BENICAR -olmesartan medoxomil tab 40 mg...................44
BENTYL -dicyclomine hcl cap 10 mg............................... 62
BENTYL -dicyclomine hcl tab 20 mg................................ 62
BENZAC AC WASH -benzoyl peroxide liq 5%............... 126
BENZACLIN -clindamycin phosphate-benzoyl peroxide
gel 1-5%........................................................................ 126
BENZACLIN WITH PUMP -clindamycin phosphatebenzoyl peroxide gel 1-5%........................................... 126
BENZAMYCIN -benzoyl peroxide-erythromycin gel
5-3%.............................................................................. 126
BENZAMYCINPAK -benzoyl peroxide-erythromycin gel
pack 5-3%..................................................................... 126
BENZIQ -benzoyl peroxide gel 5.25 %........................... 126
BENZIQ LS -benzoyl peroxide gel 2.75%....................... 126
benzocaine dental soln 20%.........................................124
BENZONATATE -benzonatate cap 150 mg...................... 57
benzonatate cap 200 mg................................................. 57
benzonatate cap 100 mg (Tessalon perles).................. 57
benzoyl peroxide-erythromycin gel 5-3%
(Benzamycin)............................................................... 126
benzoyl peroxide gel 10%.............................................126
benzoyl peroxide liq 5.25%...........................................126
benzoyl peroxide liq 10%..............................................126
benzoyl peroxide lotion 6%.......................................... 126
benztropine mesylate tab 0.5 mg................................ 100
benztropine mesylate tab 1 mg................................... 100
benztropine mesylate tab 2 mg................................... 101
BEPREVE -bepotastine besilate ophth soln 1.5%.......... 120
BERINERT -c1 esterase inhibitor (human) for iv inj kit 500
unit................................................................................. 116
BESIVANCE -besifloxacin hcl ophth susp 0.6% (base
equiv)............................................................................. 120
BETADINE OPHTHALMIC PREP -povidone-iodine ophth
soln 5%......................................................................... 120
BETAGAN -levobunolol hcl ophth soln 0.5%.................. 120
betamethasone dipropionate augmented cream 0.05%
(Diprolene af)............................................................... 126
betamethasone dipropionate augmented gel
0.05%.............................................................................126
betamethasone dipropionate augmented lotion 0.05%
(Diprolene)................................................................... 126
betamethasone dipropionate augmented oint 0.05%
(Diprolene)................................................................... 126
betamethasone dipropionate cream 0.05%................ 126
betamethasone dipropionate lotion 0.05%................. 126
betamethasone dipropionate oint 0.05%.................... 126
betamethasone valerate aerosol foam 0.12%
(Luxiq)........................................................................... 126
betamethasone valerate cream 0.1%.......................... 126
betamethasone valerate lotion 0.1%........................... 126
betamethasone valerate oint 0.1%.............................. 126
207
2016
BETAPACE AF -sotalol hcl (afib/afl) tab 80 mg................ 38
BETAPACE AF -sotalol hcl (afib/afl) tab 120 mg.............. 38
BETAPACE AF -sotalol hcl (afib/afl) tab 160 mg.............. 38
BETAPACE -sotalol hcl tab 80 mg.................................... 38
BETAPACE -sotalol hcl tab 120 mg.................................. 38
BETAPACE -sotalol hcl tab 160 mg.................................. 38
BETASERON -interferon beta-1b for inj kit 0.3 mg........... 82
betaxolol hcl ophth soln 0.5%......................................120
betaxolol hcl tab 10 mg (Kerlone)................................. 38
betaxolol hcl tab 20 mg (Kerlone)................................. 38
bethanechol chloride tab 5 mg (Urecholine)................ 67
bethanechol chloride tab 10 mg (Urecholine).............. 67
BETHKIS -tobramycin nebu soln 300 mg/4ml.................... 5
BETIMOL -timolol ophth soln 0.25%............................... 120
BETIMOL -timolol ophth soln 0.5%................................. 120
BETOPTIC-S -betaxolol hcl ophth susp 0.25%.............. 120
bexarotene cap 75 mg (Targretin)..................................16
BEXSERO -meningococcal vac b (recomb adsorbed) inj
prefilled syringe............................................................... 12
BEYAZ -drospirenone-ethinyl estrad-levomefolate tab
3-0.02-0.451 mg..............................................................24
BG STAR BLOOD GLUCOSE TES -glucose blood test
strip................................................................................ 134
BIAXIN -clarithromycin for susp 250 mg/5ml...................... 3
BIAXIN -clarithromycin tab 250 mg..................................... 3
BIAXIN -clarithromycin tab 500 mg..................................... 3
bicalutamide tab 50 mg (Casodex)................................ 16
BIDIL -isosorbide dinitrate-hydralazine hcl tab 20-37.5
mg.................................................................................... 55
BILTRICIDE -praziquantel tab 600 mg.............................. 11
BIMATOPROST -bimatoprost ophth soln 0.03%............ 120
BINOSTO -alendronate sodium effervescent tab 70
mg.................................................................................... 33
BIOSCANNER GLUCOSE TEST S -glucose blood test
strip................................................................................ 134
BIO-STATIN -nystatin cap 500000 unit............................... 6
BIO-STATIN -nystatin cap 1000000 unit............................. 6
bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln
kit..................................................................................... 61
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
(Ziac)............................................................................... 44
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
(Ziac)............................................................................... 44
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
(Ziac)............................................................................... 44
bisoprolol fumarate tab 5 mg (Zebeta)..........................38
bisoprolol fumarate tab 10 mg (Zebeta)........................38
BLEPHAMIDE S.O.P. -sulfacetamide sodiumprednisolone ophth oint 10-0.2%................................. 120
BLEPHAMIDE -sulfacetamide sodium-prednisolone ophth
susp 10-0.2%................................................................ 120
BLEPH-10 -sulfacetamide sodium ophth soln 10%........ 120
BLOOD GLUCOSE MONITORING -blood glucose
BLOOD GLUCOSE SYSTEM PAK -blood glucose
BLOOD GLUCOSE TEST STRIPS -glucose blood test
strip................................................................................ 134
BONIVA -ibandronate sodium tab 150 mg (base
equivalent)....................................................................... 34
BOOSTRIX -tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lflf-mcg/0.5ml..................................................................... 14
BOSULIF -bosutinib tab 100 mg....................................... 16
BOSULIF -bosutinib tab 500 mg....................................... 16
BP FOLINATAL PLUS B -prenatal w/ calcium carbonateb6-b12-fa tab 1 mg....................................................... 104
BP MULTINATAL PLUS -prenatal w/o a vit w/ fe fumaratefa tab 30-1 mg.............................................................. 104
BP MULTINATAL PLUS -prenatal w/o a vit w/ fe fum-fa
tab chew 40-1 mg......................................................... 104
BREEZE 2 BLOOD GLUCOSE MO -blood glucose
BREO ELLIPTA -fluticasone furoate-vilanterol aero powd
ba 100-25 mcg/inh.......................................................... 58
BREO ELLIPTA -fluticasone furoate-vilanterol aero powd
ba 200-25 mcg/inh.......................................................... 58
BREVICON-28 -norethindrone & ethinyl estradiol tab 0.5
mg-35 mcg...................................................................... 24
BRILINTA -ticagrelor tab 60 mg...................................... 116
BRILINTA -ticagrelor tab 90 mg...................................... 116
brimonidine tartrate ophth soln 0.2%......................... 120
brimonidine tartrate ophth soln 0.15% (Alphagan
p)................................................................................... 120
BRISDELLE -paroxetine mesylate cap 7.5 mg (base
equiv)............................................................................... 82
BRIVIACT -brivaracetam iv soln 50 mg/5ml..................... 95
BRIVIACT -brivaracetam oral soln 10 mg/ml.................... 95
BRIVIACT -brivaracetam tab 10 mg................................. 95
BRIVIACT -brivaracetam tab 100 mg............................... 95
BROMFENAC -bromfenac sodium ophth soln 0.09%
(base equivalent).......................................................... 120
bromfenac sodium ophth soln 0.09% (base equiv)
(once-daily).................................................................. 120
bromocriptine mesylate cap 5 mg (Parlodel)............. 101
bromocriptine mesylate tab 2.5 mg............................. 101
budesonide delayed release particles cap 3 mg
(Entocort ec).................................................................. 20
budesonide inhalation susp 0.25 mg/2ml
(Pulmicort)......................................................................59
budesonide inhalation susp 0.5 mg/2ml
(Pulmicort)......................................................................59
budesonide inhalation susp 1 mg/2ml (Pulmicort)...... 59
BULLSEYE MINI SAFETY LANC -lancets...................... 145
BULLSEYE SAFETY LANCETS -lancets....................... 145
bumetanide tab 0.5 mg................................................... 50
bumetanide tab 1 mg...................................................... 50
bumetanide tab 2 mg...................................................... 50
BUMEX -bumetanide tab 0.5 mg...................................... 50
208
2016
BUMEX -bumetanide tab 1 mg......................................... 50
BUMEX -bumetanide tab 2 mg......................................... 50
BUNAVAIL -buprenorphine-naloxone buccal film 2.1-0.3
mg (base equiv).............................................................. 86
BUNAVAIL -buprenorphine-naloxone buccal film 4.2-0.7
mg (base equiv).............................................................. 86
BUNAVAIL -buprenorphine-naloxone buccal film 6.3-1 mg
(base equiv).................................................................... 86
BUPHENYL -sodium phenylbutyrate oral powder 3 gm/
teaspoonful...................................................................... 34
BUPHENYL -sodium phenylbutyrate tab 500 mg............. 34
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base
equiv).............................................................................. 86
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
equiv).............................................................................. 86
buprenorphine hcl sl tab 2 mg (base equiv)................ 86
buprenorphine hcl sl tab 8 mg (base equiv)................ 86
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
(Zyban)............................................................................ 82
bupropion hcl tab 75 mg (Wellbutrin)........................... 70
bupropion hcl tab 100 mg (Wellbutrin)......................... 71
bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr)........ 70
bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl)........ 70
bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl)........ 70
buspirone hcl tab 5 mg................................................... 70
buspirone hcl tab 7.5 mg................................................ 70
buspirone hcl tab 10 mg................................................. 70
butalbital-acetaminophen-caffeine cap 50-325-40
mg................................................................................... 85
butalbital-acetaminophen-caffeine cap 50-300-40 mg
(Fioricet)......................................................................... 85
butalbital-acetaminophen-caffeine tab 50-325-40 mg
(Esgic)............................................................................. 85
butalbital-acetaminophen-caff w/ cod cap
50-325-40-30 mg............................................................ 86
butalbital-acetaminophen tab 50-325 mg......................85
butalbital-aspirin-caffeine cap 50-325-40 mg
(Fiorinal)......................................................................... 85
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
(Fiorinal/codeine #3)..................................................... 86
BUTISOL SODIUM -butabarbital sodium tab 30 mg.........77
butorphanol tartrate nasal soln 10 mg/ml.................... 86
BUTRANS -buprenorphine td patch weekly 5 mcg/hr.......86
BUTRANS -buprenorphine td patch weekly 7.5 mcg/
hr...................................................................................... 86
BUTRANS -buprenorphine td patch weekly 10 mcg/
hr...................................................................................... 86
hr...................................................................................... 86
hr...................................................................................... 86
BYDUREON -exenatide extended release for susp peninjector 2 mg................................................................... 27
BYDUREON -exenatide for inj extended release susp 2
mg.................................................................................... 27
BYETTA -exenatide soln pen-injector 5 mcg/0.02ml........ 27
BYETTA -exenatide soln pen-injector 10 mcg/0.04ml...... 27
BYSTOLIC -nebivolol hcl tab 2.5 mg (base
equivalent)....................................................................... 38
BYSTOLIC -nebivolol hcl tab 5 mg (base equivalent).......38
BYSTOLIC -nebivolol hcl tab 10 mg (base
equivalent)....................................................................... 38
BYSTOLIC -nebivolol hcl tab 20 mg (base
equivalent)....................................................................... 38
C
cabergoline tab 0.5 mg................................................... 34
CABOMETYX -cabozantinib s-malate tab 20 mg (base
equivalent)....................................................................... 16
equivalent)....................................................................... 16
equivalent)....................................................................... 16
CADUET -amlodipine besylate-atorvastatin calcium tab
2.5-10 mg........................................................................ 55
2.5-20 mg........................................................................ 55
2.5-40 mg........................................................................ 55
5-10 mg........................................................................... 55
5-20 mg........................................................................... 55
5-40 mg........................................................................... 55
5-80 mg........................................................................... 55
10-10 mg......................................................................... 55
10-20 mg......................................................................... 55
10-40 mg......................................................................... 55
10-80 mg......................................................................... 55
CAFERGOT -ergotamine w/ caffeine tab 1-100 mg......... 94
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base
equiv).............................................................................. 79
CALAN SR -verapamil hcl tab cr 120 mg......................... 40
CALAN -verapamil hcl tab 80 mg..................................... 40
CALAN -verapamil hcl tab 120 mg................................... 40
calcipotriene-betamethasone dipropionate oint
0.005-0.064% (Taclonex)............................................ 126
calcipotriene cream 0.005% (Dovonex).......................126
calcipotriene oint 0.005%..............................................126
calcipotriene soln 0.005% (50 mcg/ml)....................... 126
calcitonin (salmon) nasal soln 200 unit/act
(Miacalcin)...................................................................... 34
209
2016
CALCITRIOL -calcitriol oint 3 mcg/gm............................ 126
calcitriol cap 0.25 mcg (Rocaltrol)................................. 34
calcitriol cap 0.5 mcg (Rocaltrol)................................... 34
calcitriol oral soln 1 mcg/ml (Rocaltrol)........................34
calcium acetate (phosphate binder) cap 667 mg (169
mg ca) (Phoslo)............................................................. 65
calcium acetate (phosphate binder) tab 667 mg
(Eliphos)......................................................................... 65
CALCIUM PNV -prenatal w/o vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg.......................................................... 104
CANASA -mesalamine suppos 1000 mg.......................... 65
candesartan cilexetil-hydrochlorothiazide tab 16-12.5
mg (Atacand hct).......................................................... 45
candesartan cilexetil-hydrochlorothiazide tab 32-12.5
mg (Atacand hct).......................................................... 45
candesartan cilexetil-hydrochlorothiazide tab 32-25
mg (Atacand hct).......................................................... 45
candesartan cilexetil tab 4 mg (Atacand)..................... 44
candesartan cilexetil tab 8 mg (Atacand)..................... 44
candesartan cilexetil tab 16 mg (Atacand)................... 45
candesartan cilexetil tab 32 mg (Atacand)................... 45
capecitabine tab 150 mg (Xeloda)................................. 16
capecitabine tab 500 mg (Xeloda)................................. 16
CAPEX -fluocinolone acetonide shampoo 0.01%........... 126
CAPITAL/CODEINE -acetaminophen w/ codeine susp
120-12 mg/5ml................................................................ 86
CAPRELSA -vandetanib tab 100 mg................................ 16
CAPRELSA -vandetanib tab 300 mg................................ 16
CAPTOPRIL/HYDROCHLOROTHIA -captopril &
hydrochlorothiazide tab 25-15 mg.................................. 45
captopril tab 12.5 mg...................................................... 45
captopril tab 25 mg......................................................... 45
captopril tab 50 mg......................................................... 45
captopril tab 100 mg....................................................... 45
CARAC -fluorouracil cream 0.5%.................................... 126
CARAFATE -sucralfate susp 1 gm/10ml........................... 62
CARAFATE -sucralfate tab 1 gm.......................................62
CARBAGLU -carglumic acid tab 200 mg.......................... 34
carbamazepine cap sr 12hr 100 mg (Carbatrol)........... 95
carbamazepine chew tab 100 mg.................................. 96
carbamazepine susp 100 mg/5ml (Tegretol)................. 96
carbamazepine tab 200 mg (Tegretol)........................... 96
carbamazepine tab sr 12hr 100 mg (Tegretol-xr)......... 96
CARBATROL -carbamazepine cap sr 12hr 100 mg......... 96
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 12.5-50-200 mg................................ 101
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 18.75-75-200 mg.............................. 101
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 25-100-200 mg................................. 101
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 31.25-125-200 mg............................ 101
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 37.5-150-200 mg.............................. 101
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 50-200-200 mg................................. 101
carbidopa & levodopa orally disintegrating tab 10-100
mg................................................................................. 101
mg................................................................................. 101
mg................................................................................. 101
carbidopa & levodopa tab cr 25-100 mg (Sinemet
cr).................................................................................. 101
carbidopa & levodopa tab cr 50-200 mg (Sinemet
cr).................................................................................. 101
carbidopa & levodopa tab 10-100 mg (Sinemet)........ 101
carbidopa tab 25 mg (Lodosyn)................................... 101
carbinoxamine maleate soln 4 mg/5ml......................... 56
carbinoxamine maleate tab 4 mg.................................. 56
carbonyl iron susp 15 mg/1.25ml (elemental
iron)............................................................................... 113
CARDIOCOM LANCING DEVICE -lancet devices......... 146
CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr
120 mg............................................................................ 40
CARDURA -doxazosin mesylate tab 1 mg....................... 45
CARDURA XL -doxazosin mesylate tab sr 24 hr 4 mg
(base equiv).................................................................... 68
CARDURA XL -doxazosin mesylate tab sr 24 hr 8 mg
(base equiv).................................................................... 68
CAREFINE PEN NEEDLE 32GX4 -insulin pen needle 32
g x 4 mm (5/32")...........................................................146
CAREFINE PEN NEEDLES 29GX -insulin pen needle 29
g x 12 mm (1/2")...........................................................146
g x 6 mm (1/4").............................................................146
g x 6 mm (1/4").............................................................146
g x 8 mm (1/3" or 5/16")...............................................146
g x 8 mm (1/3" or 5/16")...............................................146
g x 5 mm (1/5" or 3/16")...............................................146
CAREONE ADVANCED LANCING -lancet devices....... 146
210
2016
CAREONE BLOOD GLUCOSE MON -blood glucose
CAREONE BLOOD GLUCOSE TES -glucose blood test
strip................................................................................ 134
CAREONE INSULIN SYRINGES/ -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 146
u-100 1/2 ml 30 x 1/2".................................................. 146
u-100 0.3 ml 30 x 1/2".................................................. 146
u-100 1 ml 30 x 1/2".....................................................146
u-100 1 ml 31 x 5/16"...................................................146
u-100 0.3 ml 31 x 5/16"................................................ 146
CAREONE LANCET THIN -lancets................................ 146
CAREONE LANCET ULTRA THIN -lancets................... 146
CAREONE UNIFINE PENTIPS 2 -insulin pen needle 29 g
x 12 mm (1/2").............................................................. 146
x 5 mm (3/16").............................................................. 146
x 6 mm (1/4")................................................................ 146
x 8 mm (1/3" or 5/16").................................................. 146
CAREONE UNIFINE PENTIPS P -insulin pen needle 29 g
x 12 mm (1/2").............................................................. 146
x 5 mm (3/16").............................................................. 146
x 6 mm (1/4")................................................................ 146
x 4 mm (5/32").............................................................. 146
x 8 mm (1/3" or 5/16").................................................. 146
CARESENS N BLOOD GLUCOSE -blood glucose
CARESENS N BLOOD GLUCOSE -glucose blood test
strip................................................................................ 134
CARESENS N GLUCOSE MONITO -blood glucose
CARESENS N VOICE BLOOD GL -blood glucose
carisoprodol tab 350 mg (Soma)................................. 103
carisoprodol w/ aspirin & codeine tab 200-325-16
mg................................................................................. 103
carisoprodol w/ aspirin tab 200-325 mg......................103
CARNITOR -levocarnitine oral soln 1 gm/10ml (10%)...... 34
CARNITOR -levocarnitine tab 330 mg.............................. 34
CARNITOR SF -levocarnitine oral soln 1 gm/10ml
(10%)............................................................................... 34
carteolol hcl ophth soln 1%......................................... 120
carvedilol tab 3.125 mg (Coreg)..................................... 38
carvedilol tab 6.25 mg (Coreg)....................................... 38
carvedilol tab 12.5 mg (Coreg)....................................... 38
carvedilol tab 25 mg (Coreg).......................................... 38
CASODEX -bicalutamide tab 50 mg................................. 16
CATAPRES -clonidine hcl tab 0.1 mg............................... 45
CATAPRES-TTS-1 -clonidine hcl td patch weekly 0.1
mg/24hr........................................................................... 45
mg/24hr........................................................................... 45
mg/24hr........................................................................... 45
CAYA -diaphragm arc-spring........................................... 146
CAYSTON -aztreonam lysine for inhal soln 75 mg (base
equivalent)....................................................................... 11
CEDAX -ceftibuten cap 400 mg.......................................... 1
CEDAX -ceftibuten for susp 180 mg/5ml............................ 2
cefaclor cap 250 mg.......................................................... 2
cefaclor cap 500 mg.......................................................... 2
CEFACLOR -cefaclor for susp 125 mg/5ml........................ 2
CEFACLOR ER -cefaclor monohydrate tab sr 12hr 500
mg...................................................................................... 2
cefadroxil cap 500 mg....................................................... 2
cefadroxil for susp 250 mg/5ml....................................... 2
cefadroxil for susp 500 mg/5ml....................................... 2
cefadroxil tab 1 gm............................................................ 2
cefdinir cap 300 mg........................................................... 2
cefdinir for susp 125 mg/5ml........................................... 2
cefdinir for susp 250 mg/5ml........................................... 2
CEFDITOREN PIVOXIL -cefditoren pivoxil tab 200 mg
(base equivalent).............................................................. 2
CEFDITOREN PIVOXIL -cefditoren pivoxil tab 400 mg
(base equivalent).............................................................. 2
cefixime for susp 100 mg/5ml (Suprax).......................... 2
cefixime for susp 200 mg/5ml (Suprax).......................... 2
cefpodoxime proxetil for susp 50 mg/5ml...................... 2
cefpodoxime proxetil for susp 100 mg/5ml.................... 2
cefpodoxime proxetil tab 100 mg.................................... 2
cefpodoxime proxetil tab 200 mg.................................... 2
cefprozil for susp 125 mg/5ml..........................................2
cefprozil for susp 250 mg/5ml..........................................2
cefprozil tab 250 mg.......................................................... 2
cefprozil tab 500 mg.......................................................... 2
CEFTIBUTEN -ceftibuten cap 400 mg................................ 2
CEFTIBUTEN -ceftibuten for susp 180 mg/5ml.................. 2
CEFTIN -cefuroxime axetil for susp 125 mg/5ml................ 2
CEFTIN -cefuroxime axetil for susp 250 mg/5ml................ 2
CEFTIN -cefuroxime axetil tab 500 mg............................... 2
cefuroxime axetil tab 250 mg (Ceftin)............................. 2
cefuroxime axetil tab 500 mg (Ceftin)............................. 2
CELEBREX -celecoxib cap 50 mg.................................... 91
CELEBREX -celecoxib cap 100 mg.................................. 91
celecoxib cap 50 mg (Celebrex).................................... 91
celecoxib cap 100 mg (Celebrex).................................. 91
211
2016
CELLCEPT -mycophenolate mofetil cap 250 mg........... 194
CELLCEPT -mycophenolate mofetil for oral susp 200 mg/
ml................................................................................... 194
CELLCEPT -mycophenolate mofetil tab 500 mg............ 194
CELONTIN -methsuximide cap 300 mg............................ 96
CENTANY -mupirocin oint 2%.........................................126
cephalexin cap 250 mg (Keflex)....................................... 2
CEPHALEXIN -cephalexin tab 250 mg............................... 2
CEPHALEXIN -cephalexin tab 500 mg............................... 2
cephalexin for susp 125 mg/5ml...................................... 2
cephalexin for susp 250 mg/5ml...................................... 2
CERDELGA -eliglustat tartrate cap 84 mg (base
equivalent)..................................................................... 113
CERVARIX -human papillomavirus (hpv) bival (type 16,
18) recmb vac inj............................................................ 12
CESAMET -nabilone cap 1 mg......................................... 63
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml).................. 56
CETRAXAL -ciprofloxacin hcl otic soln 0.2% (base
equivalent)..................................................................... 124
cevimeline hcl cap 30 mg (Evoxac)............................. 124
CHANTIX CONTINUING MONTH -varenicline tartrate tab
1 mg (base equiv).......................................................... 82
CHANTIX STARTING MONTH PA -varenicline tartrate tab
0.5 mg x 11 & tab 1 mg x 42 pack.................................82
CHANTIX -varenicline tartrate tab 0.5 mg (base
equiv)............................................................................... 82
CHANTIX -varenicline tartrate tab 1 mg (base equiv).......82
CHEK-STIX COMBO PAK URINA -acetone (urine) test
strip................................................................................ 134
CHEK-STIX CONTROL -acetone (urine) test strip......... 134
CHEMET -succimer cap 100 mg.................................... 133
CHEMSTRIP BG LOG BOOK -blood glucose monitoring
misc............................................................................... 147
CHEMSTRIP-K -acetone (urine) test strip...................... 134
CHENODAL -chenodiol tab 250 mg................................. 65
CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 5-12.5 mg............................................. 82
CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 10-25 mg.............................................. 82
chlordiazepoxide hcl cap 5 mg...................................... 70
chlordiazepoxide hcl cap 10 mg.................................... 70
chlordiazepoxide hcl cap 25 mg.................................... 70
chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg
(Librax)........................................................................... 62
chlorhexidine gluconate soln 0.12% (Peridex)...........124
chloroquine phosphate tab 250 mg.............................. 11
chloroquine phosphate tab 500 mg (Aralen)................ 11
CHLOROTHIAZIDE -chlorothiazide tab 250 mg............... 50
chlorothiazide tab 500 mg.............................................. 50
chlorpromazine hcl tab 10 mg....................................... 74
chlorpromazine hcl tab 100 mg..................................... 74
chlorpromazine hcl tab 200 mg..................................... 74
CHLORPROPAMIDE -chlorpropamide tab 100 mg.......... 27
CHLORPROPAMIDE -chlorpropamide tab 250 mg.......... 27
CHLORTHALIDONE -chlorthalidone tab 50 mg............... 50
CHLORTHALIDONE -chlorthalidone tab 100 mg............. 50
chlorthalidone tab 25 mg................................................ 50
chlorzoxazone tab 500 mg (Parafon forte dsc).......... 103
CHOICE DM DIABETES RISK I -blood glucose
monitoring kit................................................................. 147
CHOLBAM -cholic acid cap 50 mg................................... 65
CHOLBAM -cholic acid cap 250 mg................................. 65
cholecalciferol cap 1000 unit....................................... 104
cholecalciferol chew tab 400 unit................................ 104
cholecalciferol chew tab 1000 unit.............................. 104
cholecalciferol drops 400 unit/0.03ml (per drop)....... 104
cholecalciferol drops 5000 unit/ml (1000
unit/0.2ml).....................................................................104
cholecalciferol oral liquid 400 unit/ml......................... 104
cholecalciferol tab 400 unit.......................................... 104
cholecalciferol tab 1000 unit........................................ 104
cholecalciferol tab 50000 unit...................................... 104
cholestyramine light powder 4 gm/dose (Questran
light)................................................................................ 52
cholestyramine light powder packets 4 gm................. 52
cholestyramine powder 4 gm/dose (Questran)............ 52
cholestyramine powder packets 4 gm (Questran)....... 52
choline fenofibrate cap dr 45 mg (fenofibric acid
equiv) (Trilipix).............................................................. 52
choline fenofibrate cap dr 135 mg (fenofibric acid
equiv) (Trilipix).............................................................. 52
CIALIS -tadalafil tab 2.5 mg.............................................. 56
CIALIS -tadalafil tab 5 mg................................................. 56
ciclopirox gel 0.77%...................................................... 126
ciclopirox olamine cream 0.77% (base equiv)............126
ciclopirox olamine susp 0.77% (base equiv).............. 126
ciclopirox shampoo 1% (Loprox shampoo)............... 126
ciclopirox solution 8% (Penlac Nail Lacquer)............ 127
cilostazol tab 50 mg (Pletal)......................................... 116
cilostazol tab 100 mg (Pletal)....................................... 116
CILOXAN -ciprofloxacin hcl ophth oint 0.3%.................. 120
CILOXAN -ciprofloxacin hcl ophth soln 0.3%..................120
cimetidine hcl soln 300 mg/5ml..................................... 62
cimetidine tab 200 mg..................................................... 62
CIMZIA -certolizumab pegol for inj kit 2 x 200 mg............ 65
CIMZIA -certolizumab pegol inj kit 2 x 200 mg/ml............ 65
CIMZIA STARTER KIT -certolizumab pegol inj kit 6 x 200
mg/ml............................................................................... 65
CINRYZE -c1 esterase inhibitor (human) for iv inj 500
unit................................................................................. 117
CIPRO -ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml).......................................................................... 4
CIPRO -ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml).......................................................................... 4
CIPRO -ciprofloxacin hcl tab 250 mg (base equiv)............. 4
CIPRO -ciprofloxacin hcl tab 500 mg (base equiv)............. 4
212
2016
CIPRODEX -ciprofloxacin-dexamethasone otic susp
0.3-0.1%........................................................................ 124
CIPROFLOXACIN -ciprofloxacin hcl otic soln 0.2% (base
equivalent)..................................................................... 124
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000
mg(base eq) (Cipro xr)................................................... 5
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg
(base eq) (Cipro xr)........................................................ 5
ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml) (Cipro)........................................................... 4
ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml) (Cipro)........................................................... 5
CIPROFLOXACIN HCL -ciprofloxacin hcl tab 100 mg
(base equiv)...................................................................... 5
ciprofloxacin hcl ophth soln 0.3% (Ciloxan).............. 120
ciprofloxacin hcl tab 750 mg (base equiv)..................... 5
ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)......... 5
ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)......... 5
CIPRO HC -ciprofloxacin-hydrocortisone otic susp
0.2-1%........................................................................... 124
CIPRO XR -ciprofloxacin-ciprofloxacin hcl tab sr 24hr
1000 mg(base eq)............................................................ 4
CIPRO XR -ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500
mg (base eq).....................................................................4
citalopram hydrobromide oral soln 10 mg/5ml............ 71
citalopram hydrobromide tab 10 mg (base equiv)
(Celexa)........................................................................... 71
(Celexa)........................................................................... 71
(Celexa)........................................................................... 71
CITRANATAL ASSURE -prenat w/o a w/fecbn-fegl-dss-fa
tab & dha cap 300 mg pack......................................... 104
CITRANATAL B-CALM -prenat w/o a w/fecbn-feglu-fa tab
20-1 mg & vit b6 tab pak............................................. 104
CITRANATAL DHA -prenat w/o a w/fecbn-fegl-dss-fa tab
& dha cap 250 mg pack............................................... 105
CITRANATAL 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa
tab 90 &dha cap 300mg pak........................................ 105
CITRANATAL HARMONY -prenat w/o a w/fe fum-fe cbndss-fa-dha cap 27-1-260 mg........................................ 105
CITRANATAL RX -prenatal w/o a w/ fe carbonyl-fe glucdss-fa tab 27-1mg.........................................................105
clarithromycin for susp 125 mg/5ml............................... 3
clarithromycin for susp 250 mg/5ml (Biaxin)................. 3
clarithromycin tab 250 mg (Biaxin)................................. 3
clarithromycin tab 500 mg (Biaxin)................................. 3
clarithromycin tab sr 24hr 500 mg.................................. 3
CLEANLET LANCETS 28G -lancets...............................147
clemastine fumarate tab 2.68 mg.................................. 56
CLEOCIN -clindamycin hcl cap 75 mg............................. 11
CLEOCIN -clindamycin hcl cap 150 mg........................... 11
CLEOCIN -clindamycin hcl cap 300 mg........................... 11
CLEOCIN -clindamycin phosphate vaginal cream 2%......68
CLEOCIN -clindamycin phosphate vaginal suppos 100
mg.................................................................................... 68
CLEOCIN PEDIATRIC GRANULE -clindamycin palmitate
hcl for soln 75 mg/5ml (base equiv)...............................11
CLEOCIN-T -clindamycin phosphate lotion 1%.............. 127
CLEOCIN-T -clindamycin phosphate soln 1%................ 127
CLEOCIN-T -clindamycin phosphate swab 1%.............. 127
CLEVER CHEK AUTO-CODE BLO -blood glucose
CLEVER CHEK AUTO-CODE TES -glucose blood test
strip................................................................................ 134
CLEVER CHEK AUTO-CODE VOI -blood glucose
CLEVER CHEK AUTO CODE VOI -blood glucose
CLEVER CHEK AUTO-CODE VOI -glucose blood test
strip................................................................................ 134
CLEVER CHEK BLOOD GLUCOSE -blood glucose
CLEVER CHEK LANCETS ULTRA -lancets................... 147
CLEVER CHEK TEST STRIPS -glucose blood test
strip................................................................................ 134
CLEVER CHOICE AUTO-CODE P -blood glucose
CLEVER CHOICE AUTO-CODE P -glucose blood test
strip................................................................................ 135
CLEVER CHOICE COMFORT EZ -insulin pen needle 32
g x 8 mm....................................................................... 147
g x 12 mm (1/2")...........................................................147
g x 5 mm (3/16")...........................................................147
g x 6 mm (1/4").............................................................147
g x 4 mm (5/32")...........................................................147
g x 6 mm (1/4").............................................................147
g x 4 mm (5/32")...........................................................147
g x 6 mm (1/4").............................................................147
g x 8 mm (1/3" or 5/16")...............................................147
g x 5 mm (1/5" or 3/16")...............................................147
g x 5 mm (1/5" or 3/16")...............................................147
g x 8 mm (1/3" or 5/16")...............................................147
CLEVER CHOICE COMFORT EZ -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 147
u-100 1/2 ml 28 x 1/2".................................................. 147
u-100 1/2 ml 29 x 1/2".................................................. 147
u-100 1/2 ml 30 x 5/16"................................................ 147
213
2016
u-100 1/2 ml 30 x 1/2".................................................. 147
u-100 0.3 ml 29 x 1/2".................................................. 147
u-100 0.3 ml 30 x 5/16"................................................ 147
u-100 0.3 ml 30 x 1/2".................................................. 147
u-100 1 ml 28 x 1/2".....................................................147
u-100 1 ml 29 x 1/2".....................................................147
u-100 1 ml 30 x 5/16"...................................................148
u-100 1 ml 30 x 1/2".....................................................148
u-100 1 ml 31 x 5/16"...................................................148
u-100 0.3 ml 31 x 5/16"................................................ 148
CLEVER CHOICE MICRO BLOOD -blood glucose
CLEVER CHOICE MICRO TEST -glucose blood test
strip................................................................................ 135
CLEVER CHOICE MINI BLOOD -blood glucose
CLICKFINE PEN NEEDLE 32GX -insulin pen needle 32 g
x 4 mm (5/32").............................................................. 148
CLICKFINE PEN NEEDLES/31G -insulin pen needle 31 g
x 6 mm (1/4")................................................................ 148
CLICKFINE PEN NEEDLES/31G -insulin pen needle 31 g
x 8 mm (1/3" or 5/16").................................................. 148
CLICKFINE PEN NEEDLE UNIV -insulin pen needle 31 g
x 6 mm (1/4")................................................................ 148
CLICKFINE PEN NEEDLE UNIV -insulin pen needle 31 g
x 8 mm (1/3" or 5/16").................................................. 148
CLICKFINE UNIVERSAL PEN N -insulin pen needle 31 g
x 8 mm (1/3" or 5/16").................................................. 148
CLIMARA -estradiol td patch weekly 0.025 mg/24hr........ 22
CLIMARA -estradiol td patch weekly 0.05 mg/24hr.......... 22
CLIMARA -estradiol td patch weekly 0.06 mg/24hr.......... 22
CLIMARA -estradiol td patch weekly 0.075 mg/24hr........ 22
CLIMARA -estradiol td patch weekly 0.1 mg/24hr............ 22
CLIMARA -estradiol td patch weekly 0.0375 mg/24hr
(37.5 mcg/24hr)...............................................................22
CLIMARA PRO -estradiol-levonorgestrel td patch weekly
0.045-0.015 mg/day........................................................ 22
clindamycin hcl cap 75 mg (Cleocin)............................ 11
clindamycin hcl cap 150 mg (Cleocin).......................... 11
clindamycin hcl cap 300 mg (Cleocin).......................... 12
clindamycin palmitate hcl for soln 75 mg/5ml (base
equiv) (Cleocin pediatric gr)........................................12
clindamycin phosphate-benzoyl peroxide gel 1-5%
(Benzaclin)................................................................... 127
clindamycin phosphate foam 1% (Evoclin)................ 127
clindamycin phosphate gel 1% (Cleocin-t)................. 127
clindamycin phosphate lotion 1% (Cleocin-t)............ 127
clindamycin phosphate soln 1% (Cleocin-t)............... 127
clindamycin phosphate swab 1% (Cleocin-t)............. 127
clindamycin phosphate vaginal cream 2%
(Cleocin)......................................................................... 68
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2
(1)-5% (Duac)............................................................... 127
CLINDESSE -clindamycin phosphate (one dose) vaginal
cream 2%........................................................................ 68
clobetasol propionate cream 0.05% (Temovate)........ 127
clobetasol propionate emollient base cream 0.05%
(Temovate e)................................................................ 127
clobetasol propionate emulsion foam 0.05% (Oluxe).................................................................................... 127
clobetasol propionate foam 0.05% (Olux).................. 127
clobetasol propionate gel 0.05% (Temovate)............. 127
clobetasol propionate lotion 0.05% (Clobex)............. 127
clobetasol propionate oint 0.05% (Temovate)............ 127
clobetasol propionate shampoo 0.05% (Clobex)....... 127
clobetasol propionate soln 0.05% (Temovate)........... 127
clobetasol propionate spray 0.05% (Clobex)............. 127
CLOBEX -clobetasol propionate lotion 0.05%................ 127
CLOBEX -clobetasol propionate shampoo 0.05%.......... 127
CLOBEX -clobetasol propionate spray 0.05%................ 127
CLOCORTOLONE PIVALATE -clocortolone pivalate
cream 0.1%................................................................... 127
CLOCORTOLONE PIVALATE PUM -clocortolone pivalate
cream 0.1%................................................................... 127
CLODERM -clocortolone pivalate cream 0.1%............... 127
CLODERM PUMP -clocortolone pivalate cream
0.1%...............................................................................127
clomipramine hcl cap 25 mg (Anafranil)....................... 71
clonazepam orally disintegrating tab 0.125 mg........... 96
clonazepam orally disintegrating tab 0.25 mg............. 96
clonazepam orally disintegrating tab 0.5 mg............... 96
clonazepam orally disintegrating tab 1 mg.................. 96
clonazepam orally disintegrating tab 2 mg.................. 96
clonazepam tab 0.5 mg (Klonopin)................................ 96
clonazepam tab 1 mg (Klonopin)................................... 96
clonazepam tab 2 mg (Klonopin)................................... 96
clonidine hcl tab 0.1 mg (Catapres).............................. 45
clonidine hcl tab sr 12hr 0.1 mg (Kapvay).................... 79
clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1)................................................................................ 45
clopidogrel bisulfate tab 75 mg (base equiv)
(Plavix).......................................................................... 117
clopidogrel bisulfate tab 300 mg (base equiv)
(Plavix).......................................................................... 117
clorazepate dipotassium tab 3.75 mg (Tranxene t)...... 70
clorazepate dipotassium tab 7.5 mg (Tranxene t)........ 70
214
2016
clorazepate dipotassium tab 15 mg (Tranxene t)......... 70
CLORPRES -clonidine & chlorthalidone tab 0.1-15
mg.................................................................................... 45
mg.................................................................................... 45
mg.................................................................................... 45
CLOSERCARE -lancet devices....................................... 148
clotrimazole cream 1%.................................................. 127
clotrimazole soln 1%..................................................... 127
clotrimazole troche 10 mg............................................ 124
clotrimazole w/ betamethasone cream 1-0.05%
(Lotrisone).................................................................... 127
clotrimazole w/ betamethasone lotion 1-0.05%..........127
CLOZAPINE ODT -clozapine orally disintegrating tab 12.5
mg.................................................................................... 74
CLOZAPINE ODT -clozapine orally disintegrating tab 150
mg.................................................................................... 74
CLOZAPINE ODT -clozapine orally disintegrating tab 200
mg.................................................................................... 74
clozapine orally disintegrating tab 25 mg
(Fazaclo)......................................................................... 74
clozapine orally disintegrating tab 100 mg
(Fazaclo)......................................................................... 74
clozapine tab 50 mg........................................................ 74
clozapine tab 200 mg...................................................... 74
clozapine tab 25 mg (Clozaril)........................................74
clozapine tab 100 mg (Clozaril)..................................... 74
CLOZARIL -clozapine tab 25 mg...................................... 74
CLOZARIL -clozapine tab 100 mg.................................... 74
C-NATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg.................................................................. 104
COAGADEX -coagulation factor x (human) for inj 250
unit................................................................................. 117
COAGADEX -coagulation factor x (human) for inj 500
unit................................................................................. 117
COAGUCHEK LANCETS -lancets.................................. 148
COARTEM -artemether-lumefantrine tab 20-120 mg....... 11
CODAR AR -chlorpheniramine w/ codeine liquid 2-8
mg/5ml............................................................................. 57
CODEINE SULFATE -codeine sulfate tab 15 mg............. 86
codeine sulfate tab 15 mg (Codeine sulfate)................ 86
COLAZAL -balsalazide disodium cap 750 mg.................. 65
COLCHICINE -colchicine cap 0.6 mg............................... 95
COLCHICINE -colchicine tab 0.6 mg................................ 95
colchicine w/ probenecid tab 0.5-500 mg..................... 95
COLCRYS -colchicine tab 0.6 mg..................................... 95
COLESTID -colestipol hcl granule packets 5 gm.............. 52
COLESTID -colestipol hcl granules 5 gm......................... 52
COLESTID -colestipol hcl tab 1 gm.................................. 52
COLESTID FLAVORED -colestipol hcl granule packets 5
gm.................................................................................... 52
COLESTID FLAVORED -colestipol hcl granules 5 gm..... 52
colestipol hcl granule packets 5 gm (Colestid
flavored)......................................................................... 52
colestipol hcl granules 5 gm (Colestid flavored)......... 52
colestipol hcl tab 1 gm (Colestid)..................................52
colistimethate sodium for inj 150 mg (Coly-Mycin
M)..................................................................................... 12
COLLIGINIX -dimethicone-allantoin bandage 5-2%....... 127
COLY-MYCIN M -colistimethate sodium for inj 150
mg.................................................................................... 12
COLY-MYCIN S -neomycin-colistin-hc-thonzonium otic
susp 3.3-3-10-0.5 mg/ml.............................................. 124
COLYTE-FLAVOR PACKS -peg 3350-kcl-na bicarb-naclna sulfate for soln 240 gm............................................. 61
COMBIGAN -brimonidine tartrate-timolol maleate ophth
soln 0.2-0.5%................................................................ 121
COMBIPATCH -estradiol-norethindrone ace td pttw
0.05-0.14 mg/day............................................................ 22
COMBIPATCH -estradiol-norethindrone ace td pttw
0.05-0.25 mg/day............................................................ 22
COMBIVENT RESPIMAT -ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act.......................................... 59
COMBIVIR -lamivudine-zidovudine tab 150-300 mg.......... 7
COMETRIQ -cabozantinib s-malate cap 3 x 20 mg (60 mg
dose) kit........................................................................... 16
COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 1 x 20
mg (100 dose) kit............................................................16
COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 3 x 20
mg (140 dose) kit............................................................16
COMFORT ASSIST INSULIN SY -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 148
u-100 1/2 ml 29 x 1/2".................................................. 148
u-100 1/2 ml 30 x 5/16"................................................ 148
u-100 0.3 ml 29 x 1/2".................................................. 148
u-100 0.3 ml 30 x 5/16"................................................ 148
u-100 1 ml 29 x 1/2".....................................................148
u-100 1 ml 30 x 5/16"...................................................148
u-100 1 ml 31 x 5/16"...................................................148
u-100 0.3 ml 31 x 5/16"................................................ 148
COMFORT ASSURED LANCETS M -lancets................ 148
COMFORT ASSURED LANCETS S -lancets................. 148
COMFORT LANCETS -lancets....................................... 148
COMPLERA -emtricitabine-rilpivirine-tenofovir df tab
200-25-300 mg.................................................................. 7
COMPLETE NATAL DHA -prenat-fe bis-fe prot succ-fa-ca
tab & omega 3 cap 250 pk.......................................... 105
COMPLETENATE -prenatal vit w/ fe fumarate-fa chew tab
29-1 mg......................................................................... 105
COMTAN -entacapone tab 200 mg................................. 101
215
2016
CO-NATAL FA -prenatal vit w/ fe fumarate-fa tab 29-1
mg.................................................................................. 105
CONCEPT DHA -prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg......................................................... 105
CONCEPT OB -prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg...............................................................105
CONCERTA -methylphenidate hcl tab sa osm 18 mg...... 79
CONDYLOX -podofilox gel 0.5%.................................... 127
CONDYLOX -podofilox soln 0.5%................................... 127
CONTROL AST -glucose blood test strip....................... 135
CONTROL BLOOD GLUCOSE MON -blood glucose
CONTROL TEST STRIPS -glucose blood test strip....... 135
COOL BLOOD GLUCOSE MONITO -blood glucose
COOL BLOOD GLUCOSE MONITO -blood glucose
COOL BLOOD GLUCOSE TEST S -glucose blood test
strip................................................................................ 135
COPAXONE -glatiramer acetate soln prefilled syringe 20
mg/ml............................................................................... 82
COPAXONE -glatiramer acetate soln prefilled syringe 40
mg/ml............................................................................... 82
COPEGUS -ribavirin tab 200 mg........................................ 7
CORDARONE -amiodarone hcl tab 200 mg..................... 42
CORDRAN TAPE -flurandrenolide tape 4 mcg/sqcm..... 127
COREG -carvedilol tab 3.125 mg..................................... 38
COREG -carvedilol tab 6.25 mg....................................... 38
COREG -carvedilol tab 12.5 mg....................................... 38
COREG -carvedilol tab 25 mg.......................................... 38
COREG CR -carvedilol phosphate cap sr 24hr 10 mg..... 38
CORGARD -nadolol tab 20 mg......................................... 39
CORIFACT -factor xiii concentrate (human) for inj kit
1000-1600 unit.............................................................. 117
CORLANOR -ivabradine hcl tab 5 mg (base equiv)......... 55
CORLANOR -ivabradine hcl tab 7.5 mg (base equiv)...... 55
CORTANE-B -hydrocortisone-pramoxine-chloroxylenol lot
10-10-1mg/ml................................................................ 127
CORTEF -hydrocortisone tab 5 mg...................................20
CORTEF -hydrocortisone tab 10 mg.................................20
CORTEF -hydrocortisone tab 20 mg.................................20
CORTENEMA -hydrocortisone enema 100 mg/60ml..... 125
CORTIFOAM -hydrocortisone acetate rectal foam 10%
(90 mg/dose)................................................................. 125
CORTISONE ACETATE -cortisone acetate tab 25 mg..... 20
CORTISPORIN -bacitracin-polymyxin-neomycin hc oint
1%.................................................................................. 127
CORTISPORIN -neomycin-polymyxin-hc crm 3.5 mg/
gm-10000 unt/gm-0.5%................................................ 127
CORZIDE -nadolol & bendroflumethiazide tab 40-5
mg.................................................................................... 45
CORZIDE -nadolol & bendroflumethiazide tab 80-5
mg.................................................................................... 45
COSENTYX -secukinumab subcutaneous soln prefilled
syringe 150 mg/ml........................................................ 127
COSENTYX SENSOREADY PEN -secukinumab
subcutaneous soln auto-injector 150 mg/ml................ 128
COSOPT -dorzolamide hcl-timolol maleate ophth soln
22.3-6.8 mg/ml.............................................................. 121
COSOPT PF -dorzolamide hcl-timolol maleate ophth sol
22.3-6.8 mg/ml pf..........................................................121
COTELLIC -cobimetinib fumarate tab 20 mg (base
equivalent)....................................................................... 16
COUMADIN -warfarin sodium tab 1 mg.......................... 114
COUMADIN -warfarin sodium tab 2.5 mg....................... 114
COUMADIN -warfarin sodium tab 7.5 mg....................... 114
COUMADIN -warfarin sodium tab 10 mg........................ 114
COZAAR -losartan potassium tab 25 mg..........................45
COZAAR -losartan potassium tab 50 mg..........................45
COZAAR -losartan potassium tab 100 mg........................45
CREON -pancrelipase (lip-prot-amyl) dr cap
3000-9500-15000 unit.....................................................64
6000-19000-30000 unit...................................................64
12000-38000-60000 unit................................................ 64
24000-76000-120000 unit.............................................. 64
36000-114000-180000 unit............................................. 64
CRESEMBA -isavuconazonium sulfate cap 186 mg.......... 6
CRESTOR -rosuvastatin calcium tab 5 mg.......................52
CRESTOR -rosuvastatin calcium tab 10 mg.....................52
CRINONE -progesterone vaginal gel 4%.......................... 68
CRIXIVAN -indinavir sulfate cap 200 mg............................ 7
CRIXIVAN -indinavir sulfate cap 400 mg............................ 7
CROMOLYN SODIUM -cromolyn sodium soln nebu 20
mg/2ml............................................................................. 59
cromolyn sodium ophth soln 4%................................ 121
cromolyn sodium oral conc 100 mg/5ml
(Gastrocrom).................................................................. 65
CUTIVATE -fluticasone propionate cream 0.05%........... 128
CUTIVATE -fluticasone propionate lotion 0.05%.............128
CUVPOSA -glycopyrrolate oral soln 1 mg/5ml................. 62
CVS ADVANCED GLUCOSE METE -blood glucose
CVS ADVANCED GLUCOSE METE -glucose blood test
strip................................................................................ 135
CVS LANCETS 21G -lancets.......................................... 149
216
2016
CVS LANCETS MICRO THIN 33 -lancets...................... 148
CVS LANCETS ORIGINAL -lancets............................... 148
CVS LANCETS THIN 26G -lancets................................ 148
CVS LANCETS ULTRA THIN 30 -lancets...................... 149
CVS LANCING DEVICE -lancet devices........................ 149
CVS ULTRA THIN LANCETS -lancets............................149
cyanocobalamin inj 1000 mcg/ml................................ 113
CYCLESSA -desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg...................... 24
cyclobenzaprine hcl tab 5 mg...................................... 103
cyclobenzaprine hcl tab 10 mg.................................... 103
cyclobenzaprine hcl tab 7.5 mg (Fexmid)................... 103
CYCLOGYL -cyclopentolate hcl ophth soln 0.5%........... 121
CYCLOGYL -cyclopentolate hcl ophth soln 1%.............. 121
CYCLOGYL -cyclopentolate hcl ophth soln 2%.............. 121
CYCLOMYDRIL -cyclopentolate w/ phenylephrine ophth
soln 0.2-1%................................................................... 121
cyclopentolate hcl ophth soln 0.5% (Cyclogyl)..........121
cyclopentolate hcl ophth soln 1% (Cyclogyl).............121
cyclopentolate hcl ophth soln 2% (Cyclogyl).............121
CYCLOPHOSPHAMIDE -cyclophosphamide cap 25
mg.................................................................................... 16
CYCLOPHOSPHAMIDE -cyclophosphamide cap 50
mg.................................................................................... 16
CYCLOSERINE -cycloserine cap 250 mg.......................... 5
CYCLOSET -bromocriptine mesylate tab 0.8 mg (base
equivalent)....................................................................... 27
cyclosporine cap 25 mg (Sandimmune)..................... 194
cyclosporine cap 100 mg (Sandimmune)................... 194
cyclosporine modified cap 50 mg (Cyclosporine
modifie)......................................................................... 194
cyclosporine modified cap 25 mg (Neoral).................194
cyclosporine modified cap 100 mg (Neoral)...............194
CYCLOSPORINE MODIFIED -cyclosporine modified cap
50 mg............................................................................ 194
cyclosporine modified oral soln 100 mg/ml
(Neoral)......................................................................... 194
cyproheptadine hcl syrup 2 mg/5ml.............................. 56
cyproheptadine hcl tab 4 mg......................................... 56
CYSTADANE -betaine powder for oral solution................ 34
CYSTAGON -cysteamine bitartrate cap 50 mg.................68
CYSTAGON -cysteamine bitartrate cap 150 mg...............68
CYSTARAN -cysteamine hcl ophth soln 0.44% (base
equivalent)..................................................................... 121
CYTOMEL -liothyronine sodium tab 5 mcg.......................31
CYTOMEL -liothyronine sodium tab 25 mcg.....................31
CYTOMEL -liothyronine sodium tab 50 mcg.....................31
CYTOTEC -misoprostol tab 100 mcg................................62
CYTOTEC -misoprostol tab 200 mcg................................62
CYTRA-3 -pot & sod citrates w/ cit ac syrup 550-500-334
mg/5ml............................................................................. 68
D
DAKLINZA -daclatasvir dihydrochloride tab 30 mg (base
equivalent)......................................................................... 7
equivalent)......................................................................... 7
equivalent)......................................................................... 7
DALIRESP -roflumilast tab 500 mcg................................. 59
danazol cap 50 mg.......................................................... 21
danazol cap 100 mg........................................................ 21
danazol cap 200 mg........................................................ 21
DANTRIUM -dantrolene sodium cap 25 mg................... 103
DANTRIUM -dantrolene sodium cap 50 mg................... 103
dantrolene sodium cap 100 mg................................... 103
dantrolene sodium cap 25 mg (Dantrium).................. 103
dantrolene sodium cap 50 mg (Dantrium).................. 103
dapsone tab 25 mg.......................................................... 12
dapsone tab 100 mg........................................................ 12
DAPTACEL -diph, acellular pert & tet tox inj 15 lf-10
mcg-5 lf/0.5ml................................................................. 14
DARAPRIM -pyrimethamine tab 25 mg............................ 11
darifenacin hydrobromide tab sr 24hr 7.5 mg (base
equiv) (Enablex)............................................................ 67
darifenacin hydrobromide tab sr 24hr 15 mg (base
equiv) (Enablex)............................................................ 67
DAYPRO -oxaprozin tab 600 mg...................................... 91
DAYTRANA -methylphenidate td patch 10 mg/9hr........... 79
DDAVP -desmopressin acetate inj 4 mcg/ml.................... 34
DDAVP -desmopressin acetate nasal soln 0.01%
(refrigerated).................................................................... 34
DDAVP -desmopressin acetate nasal spray soln
0.01%...............................................................................34
DDAVP -desmopressin acetate tab 0.1 mg...................... 34
DDAVP -desmopressin acetate tab 0.2 mg...................... 34
DELZICOL -mesalamine cap dr 400 mg........................... 65
DEMADEX -torsemide tab 5 mg....................................... 50
DEMADEX -torsemide tab 10 mg..................................... 50
DEMADEX -torsemide tab 20 mg..................................... 50
demeclocycline hcl tab 150 mg....................................... 3
demeclocycline hcl tab 300 mg....................................... 4
DENAVIR -penciclovir cream 1%.................................... 128
DEPAKENE -valproate sodium syrup 250 mg/5ml (base
equiv)............................................................................... 96
DEPAKENE -valproic acid cap 250 mg.............................96
DEPAKOTE -divalproex sodium tab delayed release 125
mg.................................................................................... 96
mg.................................................................................... 96
mg.................................................................................... 96
DEPAKOTE ER -divalproex sodium tab sr 24 hr 250
mg.................................................................................... 96
DEPAKOTE ER -divalproex sodium tab sr 24 hr 500
mg.................................................................................... 96
DEPAKOTE SPRINKLES -divalproex sodium cap delayed
release sprinkle 125 mg................................................. 96
DEPEN TITRATABS -penicillamine tab 250 mg............. 194
DEPO-TESTOSTERONE -testosterone cypionate im inj in
oil 100 mg/ml.................................................................. 22
217
2016
DEPO-TESTOSTERONE -testosterone cypionate im inj in
oil 200 mg/ml.................................................................. 22
DERMA-SMOOTHE/FS BODY -fluocinolone acetonide oil
0.01% (body oil)............................................................ 128
DERMA-SMOOTHE/FS SCALP -fluocinolone acetonide
oil 0.01% (scalp oil)...................................................... 128
DERMATOP -prednicarbate cream 0.1%........................ 128
DERMATOP -prednicarbate oint 0.1%............................ 128
DERMOTIC -fluocinolone acetonide (otic) oil 0.01%...... 124
DESCOVY -emtricitabine-tenofovir alafenamide fumarate
tab 200-25 mg...................................................................7
desipramine hcl tab 10 mg (Norpramin)....................... 71
desipramine hcl tab 100 mg (Norpramin)..................... 71
desipramine hcl tab 150 mg (Norpramin)..................... 71
DESLORATADINE ODT -desloratadine tab orally
disintegrating 2.5 mg...................................................... 56
DESLORATADINE ODT -desloratadine tab orally
disintegrating 5 mg......................................................... 56
desloratadine tab 5 mg (Clarinex)................................. 56
desmopressin acetate inj 4 mcg/ml (Ddavp)................ 34
desmopressin acetate nasal soln 0.01% (refrigerated)
(Ddavp)........................................................................... 34
desmopressin acetate nasal spray soln 0.01%
(Ddavp)........................................................................... 34
desmopressin acetate nasal spray soln 0.01%
(refrigerated).................................................................. 34
desmopressin acetate tab 0.1 mg (Ddavp)................... 34
desmopressin acetate tab 0.2 mg (Ddavp)................... 34
DESOGEN -desogestrel & ethinyl estradiol tab 0.15
mg-30 mcg...................................................................... 24
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01
mg(21/5) (Mircette)........................................................ 24
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg
(Cyclessa).......................................................................24
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg
(Desogen)....................................................................... 24
DESONATE -desonide gel 0.05%................................... 128
desonide cream 0.05% (Desowen).............................. 128
desonide lotion 0.05% (Desowen)............................... 128
desonide oint 0.05% (Desowen).................................. 128
DESOWEN -desonide cream 0.05%...............................128
DESOWEN -desonide lotion 0.05%................................ 128
desoximetasone cream 0.25% (Topicort)....................128
DESOXIMETASONE -desoximetasone cream
0.05%.............................................................................128
DESOXIMETASONE -desoximetasone oint 0.05%........ 128
desoximetasone gel 0.05% (Topicort)......................... 128
desoximetasone oint 0.25% (Topicort)........................ 128
DESOXYN -methamphetamine hcl tab 5 mg.................... 79
DESVENLAFAXINE ER -desvenlafaxine fumarate tab sr
24hr 50 mg (base equiv)................................................ 71
DESVENLAFAXINE ER -desvenlafaxine fumarate tab sr
24hr 100 mg (base equiv).............................................. 71
DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 50
mg.................................................................................... 71
DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 100
mg.................................................................................... 71
DEXAMETHASONE -dexamethasone soln 0.5
mg/5ml............................................................................. 20
DEXAMETHASONE -dexamethasone tab 1 mg...............20
DEXAMETHASONE -dexamethasone tab 2 mg...............20
dexamethasone elixir 0.5 mg/5ml.................................. 20
DEXAMETHASONE INTENSOL -dexamethasone conc 1
mg/ml............................................................................... 20
DEXAMETHASONE SODIUM PHOS -dexamethasone
sodium phosphate ophth soln 0.1%............................. 121
dexamethasone tab 0.5 mg............................................ 20
dexamethasone tab 0.75 mg.......................................... 20
dexamethasone tab 1.5 mg............................................ 20
dexamethasone tab 4 mg............................................... 20
dexamethasone tab 6 mg............................................... 20
DEXEDRINE -dextroamphetamine sulfate cap sr 24hr 5
mg.................................................................................... 79
mg.................................................................................... 79
mg.................................................................................... 79
dexmethylphenidate hcl cap sr 24 hr 5 mg (Focalin
xr).................................................................................... 79
xr).................................................................................... 79
xr).................................................................................... 79
xr).................................................................................... 79
xr).................................................................................... 79
xr).................................................................................... 79
dexmethylphenidate hcl tab 2.5 mg (Focalin).............. 79
dexmethylphenidate hcl tab 5 mg (Focalin)................. 79
dexmethylphenidate hcl tab 10 mg (Focalin)............... 79
DEXPAK 10 DAY -dexamethasone tab therapy pack 1.5
mg (35)............................................................................ 20
mg (51)............................................................................ 20
mg (21)............................................................................ 20
dextroamphetamine sulfate cap sr 24hr 5 mg
(Dexedrine)..................................................................... 79
(Dexedrine)..................................................................... 79
(Dexedrine)..................................................................... 79
dextroamphetamine sulfate oral solution 5 mg/5ml
(Procentra)..................................................................... 79
dextroamphetamine sulfate tab 5 mg........................... 79
dextroamphetamine sulfate tab 10 mg......................... 79
D.H.E. 45 -dihydroergotamine mesylate inj 1 mg/ml.........94
DIAMOX -acetazolamide cap sr 12hr 500 mg.................. 51
218
2016
DIASTAR EASY TEST II LANC -lancets......................... 149
DIASTAR EASY TEST LANCETS -lancets..................... 149
DIASTAT ACUDIAL -diazepam rectal gel delivery system
10 mg.............................................................................. 96
DIASTAT ACUDIAL -diazepam rectal gel delivery system
20 mg.............................................................................. 96
DIASTAT PEDIATRIC -diazepam rectal gel delivery
system 2.5 mg................................................................ 96
DIATRUE PLUS BLOOD GLUCOS -blood glucose
DIATRUE PLUS BLOOD GLUCOS -glucose blood test
strip................................................................................ 135
diazepam conc 5 mg/ml.................................................. 70
DIAZEPAM -diazepam oral soln 1 mg/ml..........................70
DIAZEPAM -diazepam rectal gel delivery system 2.5
mg.................................................................................... 96
DIAZEPAM -diazepam rectal gel delivery system 10
mg.................................................................................... 96
DIAZEPAM -diazepam rectal gel delivery system 20
mg.................................................................................... 96
diazepam tab 2 mg (Valium)........................................... 70
diazepam tab 5 mg (Valium)........................................... 70
diazepam tab 10 mg (Valium)......................................... 70
DIBENZYLINE -phenoxybenzamine hcl cap 10 mg..........46
DICLEGIS -doxylamine-pyridoxine tab delayed release
10-10 mg......................................................................... 63
diclofenac potassium tab 50 mg................................... 91
diclofenac sodium (actinic keratoses) gel 3%
(Solaraze)..................................................................... 128
DICLOFENAC SODIUM -diclofenac sodium cream
3%.................................................................................. 128
diclofenac sodium gel 1% (Voltaren)...........................128
diclofenac sodium ophth soln 0.1%............................ 121
diclofenac sodium soln 1.5%....................................... 128
diclofenac sodium tab delayed release 25 mg............. 91
diclofenac sodium tab sr 24hr 100 mg (Voltarenxr).................................................................................... 91
diclofenac w/ misoprostol tab delayed release 50-0.2
mg (Arthrotec 50)..........................................................91
diclofenac w/ misoprostol tab delayed release 75-0.2
mg (Arthrotec 75)..........................................................92
dicloxacillin sodium cap 250 mg..................................... 1
dicloxacillin sodium cap 500 mg..................................... 1
dicyclomine hcl cap 10 mg (Bentyl).............................. 62
dicyclomine hcl oral soln 10 mg/5ml............................ 62
dicyclomine hcl tab 20 mg (Bentyl)............................... 62
didanosine delayed release capsule 125 mg (Videx
ec)...................................................................................... 7
ec)...................................................................................... 7
ec)...................................................................................... 7
ec)...................................................................................... 7
DIDGET -blood glucose monitoring kit w/ device........... 149
DIFFERIN -adapalene cream 0.1%................................ 128
DIFFERIN -adapalene gel 0.1%...................................... 128
DIFFERIN -adapalene gel 0.3%...................................... 128
DIFFERIN -adapalene lotion 0.1%.................................. 128
DIFICID -fidaxomicin tab 200 mg........................................ 3
DIFLORASONE DIACETATE -diflorasone diacetate
cream 0.05%................................................................. 128
DIFLORASONE DIACETATE -diflorasone diacetate oint
0.05%.............................................................................128
DIFLUCAN -fluconazole for susp 10 mg/ml........................ 6
DIFLUCAN -fluconazole for susp 40 mg/ml........................ 6
DIFLUCAN -fluconazole tab 50 mg..................................... 6
DIFLUCAN -fluconazole tab 100 mg................................... 6
diflunisal tab 500 mg....................................................... 85
DIGOXIN -digoxin oral soln 0.05 mg/ml............................ 37
digoxin tab 125 mcg (0.125 mg) (Lanoxin)................... 37
digoxin tab 250 mcg (0.25 mg) (Lanoxin)..................... 37
DIHYDROERGOTAMINE MESYLAT -dihydroergotamine
mesylate nasal spray 4 mg/ml....................................... 94
dihydroergotamine mesylate inj 1 mg/ml (D.h.e.
45).................................................................................... 94
DILANTIN INFATABS -phenytoin chew tab 50 mg........... 96
DILANTIN -phenytoin sodium extended cap 30 mg......... 96
DILANTIN -phenytoin sodium extended cap 100 mg........96
DILANTIN-125 -phenytoin susp 125 mg/5ml.................... 96
DILATRATE SR -isosorbide dinitrate cap cr 40 mg.......... 37
DILAUDID -hydromorphone hcl liqd 1 mg/ml.................... 86
diltiazem hcl cap sr 12hr 60 mg.....................................40
diltiazem hcl cap sr 12hr 90 mg.....................................40
diltiazem hcl cap sr 12hr 120 mg...................................40
diltiazem hcl coated beads cap sr 24hr 120 mg
(Cardizem cd)................................................................ 40
(Cardizem cd)................................................................ 40
(Cardizem cd)................................................................ 40
(Cardizem cd)................................................................ 40
(Cardizem cd)................................................................ 40
diltiazem hcl coated beads tab sr 24hr 180 mg
(Cardizem la)................................................................. 40
(Cardizem la)................................................................. 40
(Cardizem la)................................................................. 40
(Cardizem la)................................................................. 41
(Cardizem la)................................................................. 41
diltiazem hcl extended release beads cap sr 24hr 120
mg (Tiazac).................................................................... 41
219
2016
mg (Tiazac).................................................................... 41
mg (Tiazac).................................................................... 41
mg (Tiazac).................................................................... 41
mg (Tiazac).................................................................... 41
mg (Tiazac).................................................................... 41
diltiazem hcl tab 90 mg................................................... 41
diltiazem hcl tab 30 mg (Cardizem)............................... 41
diltiazem hcl tab 60 mg (Cardizem)............................... 41
diltiazem hcl tab 120 mg (Cardizem)............................. 41
DIOVAN HCT -valsartan-hydrochlorothiazide tab 80-12.5
mg.................................................................................... 46
mg.................................................................................... 46
DIOVAN HCT -valsartan-hydrochlorothiazide tab 160-25
mg.................................................................................... 46
mg.................................................................................... 46
DIOVAN HCT -valsartan-hydrochlorothiazide tab 320-25
mg.................................................................................... 46
DIOVAN -valsartan tab 40 mg........................................... 46
DIOVAN -valsartan tab 80 mg........................................... 46
DIOVAN -valsartan tab 160 mg......................................... 46
DIOVAN -valsartan tab 320 mg......................................... 46
DIPENTUM -olsalazine sodium cap 250 mg.....................65
diphenhydramine hcl cap 50 mg................................... 56
diphenhydramine hcl elixir 12.5 mg/5ml....................... 56
DIPHENOXYLATE/ATROPINE -diphenoxylate w/ atropine
liq 2.5-0.025 mg/5ml....................................................... 61
diphenoxylate w/ atropine tab 2.5-0.025 mg
(Lomotil)......................................................................... 61
DIPHTHERIA/TETANUS TOXOID -diphtheria-tetanus tox
adsorbed (dt) im inj 25-5 unit/0.5ml............................... 14
DIPROLENE AF -betamethasone dipropionate
augmented cream 0.05%............................................. 128
DIPROLENE -betamethasone dipropionate augmented
lotion 0.05%.................................................................. 128
DIPROLENE -betamethasone dipropionate augmented
oint 0.05%..................................................................... 128
dipyridamole tab 25 mg (Persantine).......................... 117
DISALCID -salsalate tab 500 mg...................................... 85
DISALCID -salsalate tab 750 mg...................................... 85
disopyramide phosphate cap 100 mg (Norpace)......... 42
disopyramide phosphate cap 150 mg (Norpace)......... 42
disulfiram tab 250 mg (Antabuse)................................. 82
disulfiram tab 500 mg (Antabuse)................................. 82
DIURIL -chlorothiazide susp 250 mg/5ml......................... 51
divalproex sodium cap delayed release sprinkle 125
mg (Depakote sprinkles).............................................. 96
divalproex sodium tab delayed release 125 mg
(Depakote)...................................................................... 96
(Depakote)...................................................................... 96
(Depakote)...................................................................... 96
divalproex sodium tab sr 24 hr 250 mg (Depakote
er).................................................................................... 97
divalproex sodium tab sr 24 hr 500 mg (Depakote
er).................................................................................... 97
DIVIGEL -estradiol td gel 0.25 mg/0.25gm (0.1%)........... 22
DIVIGEL -estradiol td gel 0.5 mg/0.5gm (0.1%)............... 22
DIVIGEL -estradiol td gel 1 mg/gm (0.1%)....................... 22
dofetilide cap 125 mcg (0.125 mg) (Tikosyn)................42
dofetilide cap 250 mcg (0.25 mg) (Tikosyn)..................42
dofetilide cap 500 mcg (0.5 mg) (Tikosyn)....................42
DOLOPHINE -methadone hcl tab 5 mg............................ 86
DOLOPHINE -methadone hcl tab 10 mg.......................... 86
donepezil hydrochloride orally disintegrating tab 5
mg................................................................................... 82
donepezil hydrochloride orally disintegrating tab 10
mg................................................................................... 82
donepezil hydrochloride tab 5 mg (Aricept)................. 82
donepezil hydrochloride tab 10 mg (Aricept)............... 82
donepezil hydrochloride tab 23 mg (Aricept)............... 83
dorzolamide hcl ophth soln 2% (Trusopt).................. 121
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8
mg/ml (Cosopt)............................................................121
DOTHELLE DHA -prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg......................................................... 105
DOVONEX -calcipotriene cream 0.005%........................128
doxazosin mesylate tab 1 mg (Cardura)....................... 46
doxepin hcl cap 10 mg....................................................71
doxepin hcl cap 100 mg..................................................71
doxepin hcl cap 150 mg..................................................71
doxepin hcl conc 10 mg/ml............................................ 71
DOXEPIN HCL -doxepin hcl cap 75 mg........................... 71
DOXEPIN HYDROCHLORIDE -doxepin hcl cream
5%.................................................................................. 128
doxercalciferol cap 0.5 mcg (Hectorol)......................... 34
doxercalciferol cap 1 mcg (Hectorol)............................ 34
doxercalciferol cap 2.5 mcg (Hectorol)......................... 34
doxycycline hyclate cap 50 mg....................................... 4
doxycycline hyclate cap 100 mg (Vibramycin)...............4
doxycycline hyclate tab delayed release 75 mg............ 4
doxycycline hyclate tab delayed release 100 mg.......... 4
doxycycline hyclate tab delayed release 150 mg.......... 4
doxycycline hyclate tab delayed release 50 mg
(Doryx).............................................................................. 4
doxycycline hyclate tab delayed release 200 mg
(Doryx).............................................................................. 4
doxycycline hyclate tab 20 mg........................................ 4
doxycycline hyclate tab 100 mg...................................... 4
doxycycline monohydrate cap 50 mg............................. 4
220
2016
doxycycline monohydrate cap 150 mg (Adoxa).............4
doxycycline monohydrate cap 75 mg (Monodox)..........4
doxycycline monohydrate cap 100 mg (Monodox)........4
doxycycline monohydrate for susp 25 mg/5ml
(Vibramycin)..................................................................... 4
doxycycline monohydrate tab 50 mg (Adoxa)............... 4
doxycycline monohydrate tab 75 mg (Adoxa)............... 4
doxycycline monohydrate tab 100 mg (Adoxa pak
1/100)................................................................................. 4
doxycycline monohydrate tab 150 mg (Adoxa pak
1/150)................................................................................. 4
dronabinol cap 2.5 mg (Marinol).................................... 63
dronabinol cap 5 mg (Marinol)....................................... 63
dronabinol cap 10 mg (Marinol)..................................... 63
DROPLET LANCETS ULTRA THI -lancets.................... 149
DROPLET LANCING DEVICE -lancet devices...............149
DROPLET PEN NEEDLES 29GX1 -insulin pen needle 29
g x 10 mm.....................................................................149
g x 8 mm....................................................................... 149
g x 12 mm (1/2")...........................................................149
g x 5 mm (3/16")...........................................................149
g x 6 mm (1/4").............................................................149
g x 4 mm (5/32")...........................................................149
g x 6 mm (1/4").............................................................149
g x 8 mm (1/3" or 5/16")...............................................149
g x 5 mm (1/5" or 3/16")...............................................149
drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin
28).................................................................................... 24
drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)..... 24
DROXIA -hydroxyurea cap 200 mg................................ 113
DRUG MART ADJUSTABLE LANC -lancet devices....... 149
DRUG MART LANCETS THIN -lancets.......................... 149
DRUG MART LANCETS ULTRA T -lancets................... 149
DRUG MART ON-THE-GO LANCE -lancets.................. 149
DRUG MART UNIFINE PENTIPS -insulin pen needle 29
g x 12 mm (1/2")...........................................................149
g x 5 mm (3/16")...........................................................149
g x 6 mm (1/4").............................................................149
g x 4 mm (5/32")...........................................................149
g x 8 mm (1/3" or 5/16")...............................................149
DRUG MART UNILET LANCETS -lancets..................... 149
DUAC -clindamycin phosph-benzoyl peroxide (refrig) gel
1.2 (1)-5%..................................................................... 128
DUANE READE LANCET ALTERN -lancets.................. 149
DUANE READE LANCET SUPER -lancets.................... 149
DUANE READE LANCET ULTRA -lancets..................... 149
DUANE READE UNIFINE PENTI -insulin pen needle 29 g
x 12 mm (1/2").............................................................. 149
x 6 mm (1/4")................................................................ 149
x 8 mm (1/3" or 5/16").................................................. 149
DUAVEE -conjugated estrogens-bazedoxifene tab
0.45-20 mg...................................................................... 22
DUETACT -pioglitazone hcl-glimepiride tab 30-2 mg....... 27
DUETACT -pioglitazone hcl-glimepiride tab 30-4 mg....... 27
DUET DHA BALANCED -prenat w/fe poly-na fered-fa tab
25-1 & omega cap 267 mg.......................................... 105
DUET DHA 400 -prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 400 mg...................................................... 105
DULERA -mometasone furoate-formoterol fumarate
aerosol 100-5 mcg/act.................................................... 59
DULERA -mometasone furoate-formoterol fumarate
aerosol 200-5 mcg/act.................................................... 59
duloxetine hcl enteric coated pellets cap 20 mg
(Cymbalta)...................................................................... 71
(Cymbalta)...................................................................... 71
(Cymbalta)...................................................................... 71
DUO-CARE TEST STRIPS -glucose blood test strip......135
DUREZOL -difluprednate ophth emulsion 0.05%........... 121
dutasteride cap 0.5 mg (Avodart).................................. 68
dutasteride-tamsulosin hcl cap 0.5-0.4 mg
(JALYN)........................................................................... 68
DUTOPROL -metoprolol & hydrochlorothiazide tab sr
24hr 25-12.5 mg............................................................. 46
24hr 50-12.5 mg............................................................. 46
24hr 100-12.5 mg........................................................... 46
DYANAVEL XR -amphetamine extended release susp 2.5
mg/ml............................................................................... 79
DYAZIDE -triamterene & hydrochlorothiazide cap 37.5-25
mg.................................................................................... 51
dyphylline-guaifenesin liqd 100-100 mg/5ml................ 59
DYRENIUM -triamterene cap 50 mg................................. 51
DYRENIUM -triamterene cap 100 mg............................... 51
E
EASY COMFORT INSULIN SYRI -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 150
u-100 1/2 ml 30 x 5/16"................................................ 150
u-100 1/2 ml 30 x 1/2".................................................. 150
u-100 0.3 ml 30 x 5/16"................................................ 150
u-100 1 ml 30 x 5/16"...................................................150
221
2016
u-100 1 ml 30 x 1/2".....................................................150
u-100 1 ml 31 x 5/16"...................................................150
EASY COMFORT LANCETS 30G/ -lancets................... 150
EASY COMFORT LANCETS -lancets............................ 150
EASY COMFORT PEN NEEDLES -insulin pen needle 31
g x 5 mm (3/16")...........................................................150
g x 6 mm (1/4").............................................................150
g x 4 mm (5/32")...........................................................150
g x 8 mm (1/3" or 5/16")...............................................150
EASYGLUCO -blood glucose monitoring kit................... 154
EASYGLUCO -glucose blood test strip........................... 135
EASYGLUCO PLUS BLOOD GLUC -blood glucose
EASYGLUCO PLUS -glucose blood test strip................ 135
EASYGLUCO STARTER KIT -blood glucose monitoring
kit................................................................................... 154
EASYMAX L BLOOD GLUCOSE S -blood glucose
EASYMAX L BLOOD GLUCOSE S -blood glucose
EASYMAX N BLOOD GLUCOSE S -blood glucose
EASYMAX N BLOOD GLUCOSE S -blood glucose
EASYMAX NG SELF-MONITORIN -blood glucose
EASYMAX NG SELF-MONITORIN -blood glucose
EASYMAX TEST STRIPS -glucose blood test strip....... 135
EASYMAX 15 TEST STRIPS -glucose blood test
strip................................................................................ 135
EASYMAX V BLOOD GLUCOSE S -blood glucose
EASYMAX V BLOOD GLUCOSE S -blood glucose
EASYMAX V2 SELF-MONITORIN -blood glucose
EASYMAX V2 SELF-MONITORIN -blood glucose
EASY MINI EJECT LANCING D -lancet devices............ 150
EASY MINI LANCING DEVICE -lancet devices............. 150
EASY PLUS BLOOD GLUCOSE M -blood glucose
EASY PLUS BLOOD GLUCOSE M -blood glucose
EASYPLUS BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 135
EASY PLUS BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 135
EASY PLUS II BLOOD GLUCOS -blood glucose
EASY PLUS II BLOOD GLUCOS -glucose blood test
strip................................................................................ 135
EASYPLUS R13N SELF-MONITO -blood glucose
EASYPLUS V SELF-MONITORIN -blood glucose
EASYPRO BLOOD GLUCOSE MON -blood glucose
EASYPRO BLOOD GLUCOSE TES -glucose blood test
strip................................................................................ 135
EASYPRO PLUS -blood glucose monitoring kit w/
device............................................................................ 154
EASYPRO PLUS -glucose blood test strip..................... 135
EASY STEP BLOOD GLUCOSE M -blood glucose
EASY STEP BLOOD GLUCOSE M -blood glucose
EASY STEP TEST STRIPS -glucose blood test strip..... 135
EASY TALK BLOOD GLUCOSE M -blood glucose
EASY TALK BLOOD GLUCOSE M -blood glucose
EASY TALK BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 135
EASYTEST II LANCETS -lancets................................... 154
EASYTEST LANCETS -lancets...................................... 154
EASY TOUCH ALLERGY TRAY S -tuberculin/allergy
EASY TOUCH ALLERGY TRAY S -tuberculin/allergy
EASY TOUCH FLIPLOCK NEEDL -needle (disp) 18 x
1-1/2"............................................................................. 150
1-1/2"............................................................................. 151
1-1/2"............................................................................. 151
1-1/2"............................................................................. 151
3/4".................................................................................151
1-1/2"............................................................................. 151
5/8".................................................................................151
1-1/2"............................................................................. 151
5/8".................................................................................151
1-1/2"............................................................................. 151
1/2".................................................................................151
1/2".................................................................................151
1/2".................................................................................151
222
2016
1/2" (12.7 mm).............................................................. 150
1/2" (12.7 mm).............................................................. 150
5/16" (8 mm)................................................................. 151
5/16" (8 mm)................................................................. 151
1".................................................................................... 150
1".................................................................................... 151
1".................................................................................... 151
1".................................................................................... 151
1".................................................................................... 151
1".................................................................................... 151
1".................................................................................... 151
1" (25 mm).................................................................... 151
EASY TOUCH FLIPLOCK SAFET -insulin syringe/needle
u-100 1 ml 29 x 1/2".....................................................151
u-100 1 ml 30 x 5/16"...................................................151
u-100 1 ml 30 x 1/2".....................................................151
u-100 1 ml 31 x 5/16"...................................................151
EASY TOUCH GLUCOSE MONITO -blood glucose
EASY TOUCH GLUCOSE TEST S -glucose blood test
strip................................................................................ 135
EASY TOUCH 32GX6MM -insulin pen needle 32 g x 6
mm (1/4")...................................................................... 154
EASY TOUCH 32GX5MM -insulin pen needle 32 g x 5
mm (1/5" or 3/16")........................................................ 154
EASY TOUCH HEALTHPRO GLUC -blood glucose
EASY TOUCH HEALTHPRO GLUC -glucose blood test
strip................................................................................ 135
EASY TOUCH HYPODERMIC NEE -needle (disp) 16 x
1-1/2"............................................................................. 151
1-1/2"............................................................................. 151
1-1/2"............................................................................. 151
1-1/2"............................................................................. 151
1-1/2"............................................................................. 152
1-1/2"............................................................................. 152
3/4".................................................................................152
1-1/4"............................................................................. 152
1-1/2"............................................................................. 152
5/8".................................................................................152
1-1/2"............................................................................. 152
3/8".................................................................................152
1/2".................................................................................152
5/8".................................................................................152
1/2".................................................................................152
1-1/4"............................................................................. 152
1-1/2"............................................................................. 152
1/2".................................................................................152
5/16" (8 mm)................................................................. 151
5/16" (8 mm)................................................................. 152
1".................................................................................... 151
1".................................................................................... 151
1".................................................................................... 151
1".................................................................................... 151
1".................................................................................... 151
1".................................................................................... 152
1".................................................................................... 152
1".................................................................................... 152
1".................................................................................... 152
1".................................................................................... 152
1.25" (30 mm)............................................................... 151
1.25" (30 mm)............................................................... 152
EASY TOUCH INSULIN SYRING -insulin syringe/needle
u-100 1/2 ml 27 x 1/2".................................................. 152
u-100 1/2 ml 31 x 5/16"................................................ 152
223
2016
u-100 1/2 ml 28 x 1/2".................................................. 152
u-100 1/2 ml 29 x 1/2".................................................. 152
u-100 1/2 ml 30 x 5/16"................................................ 152
u-100 1/2 ml 30 x 1/2".................................................. 152
u-100 0.3 ml 30 x 5/16"................................................ 152
u-100 0.3 ml 30 x 1/2".................................................. 152
u-100 1 ml 27 x 1/2".....................................................152
u-100 1 ml 28 x 1/2".....................................................152
u-100 1 ml 29 x 1/2".....................................................152
u-100 1 ml 30 x 5/16"...................................................152
u-100 1 ml 30 x 1/2".....................................................152
u-100 1 ml 31 x 5/16"...................................................153
u-100 0.3 ml 31 x 5/16"................................................ 153
EASY TOUCH LANCETS 30G/BU -lancets.................... 153
EASY TOUCH LANCETS 21G/PR -lancets.................... 153
EASY TOUCH LANCETS 26G/PU -lancets.................... 153
EASY TOUCH LANCETS 26G/TW -lancets................... 153
EASY TOUCH LANCING DEVICE -lancet devices........ 153
EASY TOUCH PEN NEEDLES/31 -insulin pen needle 31
g x 5 mm (3/16")...........................................................153
EASY TOUCH PEN NEEDLES 29 -insulin pen needle 29
g x 12 mm (1/2")...........................................................153
g x 6 mm (1/4").............................................................153
g x 4 mm (5/32")...........................................................153
g x 6 mm (1/4").............................................................153
g x 8 mm (1/3" or 5/16")...............................................153
g x 5 mm (1/5" or 3/16")...............................................153
EASY TOUCH SAFETY LANCETS -lancets...................153
EASY TOUCH SHEATHLOCK SAF -insulin syringe/
needle u-100 1 ml 29 x 1/2"......................................... 153
needle u-100 1 ml 30 x 5/16"....................................... 153
needle u-100 1 ml 30 x 1/2"......................................... 153
needle u-100 1 ml 31 x 5/16"....................................... 153
EASY TOUCH TUBERCULIN FLI -tuberculin/allergy
EASY TOUCH TUBERCULIN FLI -tuberculin/allergy
EASY TOUCH TUBERCULIN SHE -tuberculin/allergy
EASY TRAK BLOOD GLUCOSE M -blood glucose
EASY TRAK BLOOD GLUCOSE M -blood glucose
EASY TRAK BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 135
EASY TWIST & CAP LANCETS -lancets....................... 154
EC-NAPROSYN -naproxen tab ec 375 mg.......................92
EC-NAPROSYN -naproxen tab ec 500 mg.......................92
econazole nitrate cream 1%......................................... 128
EDARBI -azilsartan medoxomil tab 40 mg........................46
EDARBI -azilsartan medoxomil tab 80 mg........................46
EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab
40-12.5 mg...................................................................... 46
EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab
40-25 mg......................................................................... 46
EDECRIN -ethacrynic acid tab 25 mg.............................. 51
EDURANT -rilpivirine hcl tab 25 mg (base equivalent)....... 7
E.E.S. 400 -erythromycin ethylsuccinate tab 400 mg......... 3
E.E.S. GRANULES -erythromycin ethylsuccinate for susp
200 mg/5ml....................................................................... 3
EFFER-K -potassium bicarbonate-citric acid effer tab 10
meq................................................................................ 111
EFFER-K -potassium bicarbonate-citric acid effer tab 20
meq................................................................................ 111
EFFIENT -prasugrel hcl tab 5 mg (base equiv).............. 117
EFFIENT -prasugrel hcl tab 10 mg (base equiv)............ 117
EFUDEX -fluorouracil cream 5%..................................... 128
EGRIFTA -tesamorelin acetate for inj 1 mg (base
equiv)............................................................................... 34
EGRIFTA -tesamorelin acetate for inj 2 mg (base
equiv)............................................................................... 34
ELDEPRYL -selegiline hcl cap 5 mg...............................101
ELEMENT AUTOCODE SYSTEM -blood glucose
ELEMENT COMPACT BLOOD GLU -blood glucose
224
2016
ELEMENT COMPACT TEST STRI -glucose blood test
strip................................................................................ 135
ELEMENT COMPACT V BLOOD -blood glucose
ELEMENT PLUS BLOOD GLUCOS -blood glucose
ELEMENT TEST STRIPS -glucose blood test strip........ 135
ELESTAT -epinastine hcl ophth soln 0.05%................... 121
ELESTRIN -estradiol gel 0.06% (0.52 mg/0.87 gm
metered-dose pump)...................................................... 22
ELIDEL -pimecrolimus cream 1%................................... 128
ELIMITE -permethrin cream 5%...................................... 128
ELIPHOS -calcium acetate (phosphate binder) tab 667
mg.................................................................................... 65
ELIQUIS -apixaban tab 2.5 mg....................................... 114
ELIQUIS -apixaban tab 5 mg.......................................... 114
ELITE-OB -prenatal vit w/ iron carbonyl-fa tab 50-1.25
mg.................................................................................. 105
ELITE-THIN INSULIN SYRING -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 154
u-100 1/2 ml 28 x 5/16"................................................ 154
u-100 1/2 ml 28 x 1/2".................................................. 155
u-100 1/2 ml 29 x 5/16"................................................ 155
u-100 1/2 ml 29 x 1/2".................................................. 155
u-100 1/2 ml 30 x 5/16"................................................ 155
u-100 1 ml 28 x 5/16"...................................................155
u-100 1 ml 28 x 1/2".....................................................155
u-100 1 ml 29 x 1/2".....................................................155
u-100 1 ml 29 x 5/16"...................................................155
u-100 1 ml 30 x 5/16"...................................................155
u-100 1 ml 31 x 5/16"...................................................155
u-100 0.3 ml 31 x 5/16"................................................ 155
ELIXOPHYLLIN -theophylline elixir 80 mg/15ml............... 59
ELLA -ulipristal acetate tab 30 mg.................................... 24
ELMIRON -pentosan polysulfate sodium caps 100
mg.................................................................................... 69
ELOCON -mometasone furoate cream 0.1%................. 128
ELOCON -mometasone furoate oint 0.1%......................128
ELOCON -mometasone furoate solution 0.1%
(lotion)............................................................................ 128
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
250 unit......................................................................... 117
500 unit......................................................................... 117
750 unit......................................................................... 117
1000 unit....................................................................... 117
1500 unit....................................................................... 117
2000 unit....................................................................... 117
3000 unit....................................................................... 117
EMADINE -emedastine difumarate ophth soln 0.05%
(base equiv).................................................................. 121
EMBEDA -morphine-naltrexone cap cr 20-0.8 mg............86
EMBEDA -morphine-naltrexone cap cr 50-2 mg...............86
EMBEDA -morphine-naltrexone cap cr 100-4 mg.............87
EMBRACE BLOOD GLUCOSE MON -blood glucose
EMBRACE BLOOD GLUCOSE TES -glucose blood test
strip................................................................................ 135
EMBRACE EVO BLOOD GLUCOSE -blood glucose
EMBRACE EVO BLOOD GLUCOSE -glucose blood test
strip................................................................................ 135
EMBRACE LANCETS ULTRA THI -lancets.................... 155
EMBRACE PRO BLOOD GLUCOSE -blood glucose
EMBRACE PRO BLOOD GLUCOSE -glucose blood test
strip................................................................................ 135
EMCYT -estramustine phosphate sodium cap 140
mg.................................................................................... 16
EMEND -aprepitant capsule 40 mg.................................. 63
EMEND -aprepitant capsule 80 mg.................................. 63
EMEND -aprepitant capsule 125 mg................................ 63
EMEND -aprepitant capsule therapy pack 80 & 125
mg.................................................................................... 63
EMEND -aprepitant for oral susp 125 mg (125
mg/5ml)............................................................................ 63
EMSAM -selegiline td patch 24hr 6 mg/24hr.................... 71
EMSAM -selegiline td patch 24hr 9 mg/24hr.................... 71
EMSAM -selegiline td patch 24hr 12 mg/24hr.................. 71
EMTRIVA -emtricitabine caps 200 mg................................ 7
EMTRIVA -emtricitabine soln 10 mg/ml.............................. 7
EMVERM -mebendazole chew tab 100 mg...................... 11
ENABLEX -darifenacin hydrobromide tab sr 24hr 7.5 mg
(base equiv).................................................................... 67
ENABLEX -darifenacin hydrobromide tab sr 24hr 15 mg
(base equiv).................................................................... 67
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg................................................................................... 46
enalapril maleate & hydrochlorothiazide tab 10-25 mg
(Vaseretic)...................................................................... 46
enalapril maleate tab 2.5 mg (Vasotec)......................... 46
enalapril maleate tab 5 mg (Vasotec)............................ 46
enalapril maleate tab 10 mg (Vasotec).......................... 46
225
2016
enalapril maleate tab 20 mg (Vasotec).......................... 46
ENBRACE HR -prenatal vit w/ fe gly cys-fa-omega 3 fatty
acids cap....................................................................... 105
ENBREL -etanercept for subcutaneous inj 25 mg............ 92
ENBREL -etanercept subcutaneous soln prefilled syringe
25 mg/0.5ml.................................................................... 92
ENBREL -etanercept subcutaneous soln prefilled syringe
50 mg/ml......................................................................... 92
ENBREL SURECLICK -etanercept subcutaneous solution
auto-injector 50 mg/ml.................................................... 92
ENCARE -nonoxynol-9 vaginal suppos 100 mg............... 68
ENGERIX-B -hepatitis b vaccine (recombinant) 10
mcg/0.5ml........................................................................ 13
ENGERIX-B -hepatitis b vaccine (recombinant) 20 mcg/
ml..................................................................................... 13
ENGERIX-B -hepatitis b vaccine (recombinant) susp 10
mcg/0.5ml........................................................................ 13
ENGERIX-B -hepatitis b vaccine (recombinant) susp 20
mcg/ml............................................................................. 13
enoxaparin sodium inj 30 mg/0.3ml (Lovenox).......... 114
enoxaparin sodium inj 100 mg/ml (Lovenox)............. 114
enoxaparin sodium inj 120 mg/0.8ml (Lovenox)........ 114
enoxaparin sodium inj 150 mg/ml (Lovenox)............. 114
enoxaparin sodium inj 300 mg/3ml (Lovenox)........... 114
entacapone tab 200 mg (Comtan)............................... 101
entecavir tab 0.5 mg (Baraclude)..................................... 7
entecavir tab 1 mg (Baraclude)........................................ 7
ENTEREG -alvimopan cap 12 mg.................................... 65
ENTOCORT EC -budesonide delayed release particles
cap 3 mg......................................................................... 20
ENTRESTO -sacubitril-valsartan tab 24-26 mg................ 55
ENTRESTO -sacubitril-valsartan tab 49-51 mg................ 55
ENTRESTO -sacubitril-valsartan tab 97-103 mg.............. 55
ENVARSUS XR -tacrolimus tab sr 24hr 0.75 mg............194
ENVARSUS XR -tacrolimus tab sr 24hr 1 mg................ 194
ENVARSUS XR -tacrolimus tab sr 24hr 4 mg................ 194
EPANED -enalapril maleate for oral soln 1 mg/ml............ 46
EPCLUSA -sofosbuvir-velpatasvir tab 400-100 mg............ 7
EPIDUO -adapalene-benzoyl peroxide gel 0.1-2.5%......128
EPIDUO FORTE -adapalene-benzoyl peroxide gel
0.3-2.5%........................................................................ 128
EPIFOAM -pramoxine-hc aerosol foam 1-1%.................129
epinastine hcl ophth soln 0.05% (Elestat).................. 121
EPINEPHRINE -epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)......................................................... 52
EPINEPHRINE -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)........................................................... 52
epinephrine hcl inj 1 mg/ml............................................ 59
epinephrine hcl soln prefilled syringe 0.1 mg/ml.........59
EPIPEN-JR 2-PAK -epinephrine solution auto-injector
0.15 mg/0.3ml (1:2000).................................................. 52
EPIPEN 2-PAK -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)........................................................... 52
EPIVIR HBV -lamivudine oral soln 5 mg/ml (hbv)............... 7
EPIVIR HBV -lamivudine tab 100 mg (hbv)........................ 7
EPIVIR -lamivudine oral soln 10 mg/ml.............................. 7
EPIVIR -lamivudine tab 150 mg.......................................... 7
EPIVIR -lamivudine tab 300 mg.......................................... 7
eplerenone tab 25 mg (Inspra)....................................... 46
eplerenone tab 50 mg (Inspra)....................................... 46
EPOGEN -epoetin alfa inj 2000 unit/ml...........................113
EPOGEN -epoetin alfa inj 10000 unit/ml.........................113
EPOGEN -epoetin alfa inj 20000 unit/ml.........................113
EPROSARTAN MESYLATE -eprosartan mesylate tab 600
mg.................................................................................... 46
EPZICOM -abacavir sulfate-lamivudine tab 600-300
mg...................................................................................... 7
EQ BLOOD GLUCOSE TEST STR -glucose blood test
strip................................................................................ 135
EQL COLOR LANCETS 21G -lancets............................ 155
EQL COLOR LANCETS MICRO T -lancets....................155
EQL INSULIN SYRINGE/1ML/2 -insulin syringe/needle
u-100 1 ml 29 x 1/2".....................................................155
u-100 1 ml 30 x 5/16"...................................................155
u-100 1 ml 31 x 5/16"...................................................155
EQL INSULIN SYRINGE/0.5ML -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 155
u-100 1/2 ml 29 x 1/2".................................................. 155
u-100 1/2 ml 30 x 5/16"................................................ 155
u-100 0.3 ml 29 x 1/2".................................................. 155
u-100 0.3 ml 30 x 5/16"................................................ 155
u-100 0.3 ml 31 x 5/16"................................................ 155
EQL SHORT PEN NEEDLES 31G -insulin pen needle 31
g x 8 mm (1/3" or 5/16")...............................................155
EQL SUPER THIN LANCETS 30 -lancets...................... 155
EQL THIN LANCETS 26G -lancets................................ 155
EQL ULTRA SHORT PEN NEEDL -insulin pen needle 31
g x 6 mm (1/4").............................................................155
EQUETRO -carbamazepine (antipsychotic) cap sr 12hr
100 mg............................................................................ 74
200 mg............................................................................ 74
300 mg............................................................................ 74
ergocalciferol cap 50000 unit (Drisdol)....................... 104
ERGOLOID MESYLATES -ergoloid mesylates tab 1
mg.................................................................................... 83
ERGOMAR -ergotamine tartrate sl tab 2 mg.................... 94
ERIVEDGE -vismodegib cap 150 mg............................... 16
ERTACZO -sertaconazole nitrate cream 2%.................. 129
ERYGEL -erythromycin gel 2%....................................... 129
226
2016
ERYPED 200 -erythromycin ethylsuccinate for susp 200
mg/5ml............................................................................... 3
ERYPED 400 -erythromycin ethylsuccinate for susp 400
mg/5ml............................................................................... 3
ERY-TAB -erythromycin tab delayed release 250 mg........ 3
ERYTHROCIN STEARATE -erythromycin stearate tab
250 mg.............................................................................. 3
ERYTHROMYCIN BASE -erythromycin tab 250 mg.......... 3
ERYTHROMYCIN BASE -erythromycin tab 500 mg.......... 3
ERYTHROMYCIN ETHYLSUCCINA -erythromycin
ethylsuccinate tab 400 mg............................................... 3
erythromycin gel 2% (Erygel)....................................... 129
erythromycin ophth oint 5 mg/gm............................... 121
erythromycin pads 2%.................................................. 129
erythromycin soln 2%................................................... 129
erythromycin w/ delayed release particles cap 250
mg......................................................................................3
ESBRIET -pirfenidone cap 267 mg................................... 61
escitalopram oxalate soln 5 mg/5ml (base equiv)
(Lexapro)........................................................................ 71
escitalopram oxalate tab 5 mg (base equiv)
(Lexapro)........................................................................ 71
(Lexapro)........................................................................ 71
(Lexapro)........................................................................ 71
esomeprazole magnesium cap delayed release 20 mg
(base eq) (Nexium)....................................................... 62
esomeprazole magnesium cap delayed release 40 mg
(base eq) (Nexium)....................................................... 62
ESSENTRA WIPES 9X9" CLEAN -isopropyl alcohol
wipes 70%..................................................................... 129
estazolam tab 1 mg......................................................... 77
estazolam tab 2 mg......................................................... 77
esterified estrogens & methyltestosterone tab
0.625-1.25 mg................................................................ 23
esterified estrogens & methyltestosterone tab
1.25-2.5 mg.....................................................................23
ESTRACE -estradiol tab 0.5 mg....................................... 23
ESTRACE -estradiol tab 1 mg.......................................... 23
ESTRACE -estradiol tab 2 mg.......................................... 23
ESTRACE -estradiol vaginal cream 0.1 mg/gm................ 68
estradiol & norethindrone acetate tab 0.5-0.1 mg
(Activella)....................................................................... 23
estradiol & norethindrone acetate tab 1-0.5 mg
(Activella)....................................................................... 23
estradiol tab 0.5 mg (Estrace)........................................ 23
estradiol tab 1 mg (Estrace)........................................... 23
estradiol tab 2 mg (Estrace)........................................... 23
estradiol td patch twice weekly 0.025 mg/24hr (Vivelledot).................................................................................. 23
estradiol td patch twice weekly 0.0375 mg/24hr
(Vivelle-dot).................................................................... 23
estradiol td patch weekly 0.025 mg/24hr (Climara)......23
estradiol td patch weekly 0.05 mg/24hr (Climara)........23
estradiol td patch weekly 0.06 mg/24hr (Climara)........23
estradiol td patch weekly 0.075 mg/24hr (Climara)......23
estradiol td patch weekly 0.1 mg/24hr (Climara)..........23
estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr) (Climara)...................................................... 23
ESTRING -estradiol vaginal ring 2 mg (7.5
mcg/24hrs).......................................................................68
ESTROGEL -estradiol gel 0.06% (0.75 mg/1.25 gm
metered-dose pump)...................................................... 23
ESTROPIPATE -estropipate tab 0.75 mg......................... 23
ESTROPIPATE -estropipate tab 1.5 mg........................... 23
ESTROPIPATE -estropipate tab 3 mg.............................. 23
ESTROSTEP FE -norethindrone ac-ethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg.................................................. 24
eszopiclone tab 1 mg (Lunesta).................................... 77
ethacrynic acid tab 25 mg.............................................. 51
ethambutol hcl tab 100 mg (Myambutol)........................ 5
ethambutol hcl tab 400 mg (Myambutol)........................ 5
ethosuximide cap 250 mg (Zarontin)............................ 97
ethosuximide soln 250 mg/5ml (Zarontin).................... 97
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35
mcg................................................................................. 24
ETIDRONATE DISODIUM -etidronate disodium tab 200
mg.................................................................................... 34
ETIDRONATE DISODIUM -etidronate disodium tab 400
mg.................................................................................... 34
etodolac cap 200 mg....................................................... 92
etodolac cap 300 mg....................................................... 92
etodolac tab 400 mg........................................................ 92
etodolac tab 500 mg........................................................ 92
etodolac tab sr 24hr 400 mg.......................................... 92
ETOPOSIDE -etoposide cap 50 mg..................................16
EURAX -crotamiton cream 10%...................................... 129
EURAX -crotamiton lotion 10%....................................... 129
EVAMIST -estradiol transdermal spray 1.53 mg/spray..... 23
EVEKEO -amphetamine sulfate tab 5 mg.........................79
EVEKEO -amphetamine sulfate tab 10 mg.......................79
EVENCARE + BLOOD GLUCOSE -glucose blood test
strip................................................................................ 135
EVENCARE BLOOD GLUCOSE MO -blood glucose
monitoring kit................................................................. 156
EVENCARE BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 135
EVENCARE G2 BLOOD GLUCOSE -blood glucose
EVENCARE G3 BLOOD GLUCOSE -blood glucose
227
2016
EVENCARE G2 TEST STRIPS -glucose blood test
strip................................................................................ 135
EVENCARE G3 TEST STRIPS -glucose blood test
strip................................................................................ 135
EVENCARE MINI BLOOD GLUCO -blood glucose
EVENCARE MINI BLOOD GLUCO -glucose blood test
strip................................................................................ 135
EVISTA -raloxifene hcl tab 60 mg..................................... 34
EVOCLIN -clindamycin phosphate foam 1%.................. 129
EVOLUTION AUTOCODE -blood glucose monitoring
devices.......................................................................... 156
EVOLUTION AUTOCODE -glucose blood test strip....... 135
EVOTAZ -atazanavir sulfate-cobicistat tab 300-150 mg
(base equiv)...................................................................... 7
EVOXAC -cevimeline hcl cap 30 mg.............................. 124
EVZIO -naloxone hcl solution auto-injector 0.4
mg/0.4ml........................................................................ 133
EXACTECH R-S-G TEST STRIP -glucose blood test
strip................................................................................ 135
EXACTECH TEST STRIPS -glucose blood test strip..... 135
EXALGO -hydromorphone hcl tab er 24hr deter 8 mg......87
EXALGO -hydromorphone hcl tab er 24hr deter 12
mg.................................................................................... 87
mg.................................................................................... 87
mg.................................................................................... 87
EXCEL COMFORT POINT INSUL -insulin pen needle 31
g x 4 mm (1/6").............................................................156
EXEL COMFORT POINT INSULI -insulin pen needle 29 g
x 12 mm (1/2").............................................................. 156
x 6 mm (1/4")................................................................ 156
x 8 mm (1/3" or 5/16").................................................. 156
EXEL COMFORT POINT INSULI -insulin syringe/needle
u-100 1/2 ml 28 x 1/2".................................................. 156
u-100 1/2 ml 29 x 1/2".................................................. 156
u-100 1/2 ml 30 x 5/16"................................................ 156
u-100 0.3 ml 29 x 1/2".................................................. 156
u-100 0.3 ml 30 x 5/16"................................................ 156
u-100 1 ml 28 x 1/2".....................................................156
u-100 1 ml 29 x 1/2".....................................................156
u-100 1 ml 30 x 5/16"...................................................156
EXELDERM -sulconazole nitrate cream 1%................... 129
EXELDERM -sulconazole nitrate solution 1%................ 129
EXELON -rivastigmine tartrate cap 1.5 mg....................... 83
EXELON -rivastigmine tartrate cap 3 mg.......................... 83
EXELON -rivastigmine tartrate cap 4.5 mg....................... 83
EXELON -rivastigmine tartrate cap 6 mg.......................... 83
EXELON -rivastigmine td patch 24hr 4.6 mg/24hr............ 83
EXELON -rivastigmine td patch 24hr 9.5 mg/24hr............ 83
EXELON -rivastigmine td patch 24hr 13.3 mg/24hr.......... 83
exemestane tab 25 mg (Aromasin)................................ 16
EXFORGE -amlodipine besylate-valsartan tab 5-160
mg.................................................................................... 46
mg.................................................................................... 46
mg.................................................................................... 46
mg.................................................................................... 46
EXFORGE HCT -amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5 mg......................... 46
EXFORGE HCT -amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg............................ 46
EXFORGE HCT -amlodipine-valsartanhydrochlorothiazide tab 10-160-12.5 mg....................... 47
EXFORGE HCT -amlodipine-valsartanhydrochlorothiazide tab 10-160-25 mg.......................... 47
EXFORGE HCT -amlodipine-valsartanhydrochlorothiazide tab 10-320-25 mg.......................... 47
EXJADE -deferasirox tab for oral susp 125 mg.............. 133
EXTAVIA -interferon beta-1b for inj kit 0.3 mg.................. 83
EXTINA -ketoconazole foam 2%..................................... 129
EXTRA-VIRT PLUS DHA -prenatal w/o vit a w/ fe fumdoc-fa-dha cap 29-1.25-350 mg................................... 105
E-Z JECT LANCETS COLOR -lancets........................... 150
E-Z JECT LANCETS 21G -lancets................................. 150
E-Z JECT LANCETS -lancets......................................... 150
E-ZJECT LANCETS MICRO-THI -lancets...................... 150
E-Z JECT LANCETS SUPER TH -lancets...................... 150
E-Z JECT LANCETS THIN 26G -lancets........................ 150
EZ-LETS LANCETS 21G -lancets.................................. 156
EZ-LETS LANCETS 26G SUPER -lancets..................... 156
EZ-LETS LANCETS 28G ULTRA -lancets...................... 156
EZ SMART BLOOD GLUCOSE LA -lancets...................156
EZ SMART BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 135
EZ SMART DIABETES MONITOR -blood glucose
EZ SMART PLUS BLOOD GLUCO -glucose blood test
strip................................................................................ 135
EZ SMART PLUS DIABETES MO -blood glucose
F
FACTIVE -gemifloxacin mesylate tab 320 mg (base
equiv)................................................................................. 5
famciclovir tab 125 mg (Famvir)...................................... 7
228
2016
famotidine for susp 40 mg/5ml (Pepcid)....................... 62
famotidine tab 20 mg (Pepcid)....................................... 62
famotidine tab 40 mg (Pepcid)....................................... 62
FAMVIR -famciclovir tab 125 mg........................................ 7
FANAPT -iloperidone tab 1 mg......................................... 74
FANAPT -iloperidone tab 10 mg....................................... 74
FANAPT -iloperidone tab 12 mg....................................... 74
FANAPT TITRATION PACK -iloperidone tab 1 mg & 2 mg
& 4 mg & 6 mg titration pak........................................... 74
FARESTON -toremifene citrate tab 60 mg (base
equivalent)....................................................................... 16
FARXIGA -dapagliflozin propanediol tab 5 mg (base
equivalent)....................................................................... 27
FARXIGA -dapagliflozin propanediol tab 10 mg (base
equivalent)....................................................................... 27
FARYDAK -panobinostat lactate cap 10 mg (base
equivalent)....................................................................... 16
equivalent)....................................................................... 16
equivalent)....................................................................... 16
FAZACLO -clozapine orally disintegrating tab 12.5
mg.................................................................................... 74
FAZACLO -clozapine orally disintegrating tab 25 mg....... 74
FAZACLO -clozapine orally disintegrating tab 100 mg..... 74
FC FEMALE CONDOM -condoms - female....................156
FC2 FEMALE CONDOM -condoms - female..................156
FEIBA -antiinhibitor coagulant complex for inj................ 117
felbamate susp 600 mg/5ml (Felbatol).......................... 97
felbamate tab 400 mg (Felbatol).................................... 97
felbamate tab 600 mg (Felbatol).................................... 97
FELBATOL -felbamate susp 600 mg/5ml..........................97
FELBATOL -felbamate tab 400 mg................................... 97
FELBATOL -felbamate tab 600 mg................................... 97
FELDENE -piroxicam cap 10 mg...................................... 92
FELDENE -piroxicam cap 20 mg...................................... 92
felodipine tab sr 24hr 2.5 mg......................................... 41
felodipine tab sr 24hr 5 mg............................................ 41
felodipine tab sr 24hr 10 mg.......................................... 41
FEMCAP -cervical cap 22 mm........................................ 156
FEMCON FE -norethindrone & ethinyl estradiol-fe chew
tab 0.4 mg-35 mcg......................................................... 24
FEMHRT LOW DOSE -norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg......................................... 23
FEM PH -acetic acid-oxyquinoline vaginal gel
0.9-0.025%...................................................................... 68
FEMRING -estradiol acetate vaginal ring 0.05
mg/24hr........................................................................... 68
FEMRING -estradiol acetate vaginal ring 0.1 mg/24hr..... 68
FENOFIBRATE -fenofibrate cap 50 mg............................ 52
FENOFIBRATE -fenofibrate cap 150 mg.......................... 52
fenofibrate micronized cap 43 mg................................. 52
fenofibrate micronized cap 130 mg............................... 52
fenofibrate micronized cap 67 mg (Lofibra)................. 52
fenofibrate micronized cap 134 mg (Lofibra)............... 52
fenofibrate micronized cap 200 mg (Lofibra)............... 52
fenofibrate tab 40 mg (Fenoglide)................................. 52
fenofibrate tab 120 mg (Fenoglide)............................... 53
fenofibrate tab 54 mg (Lofibra)...................................... 52
fenofibrate tab 160 mg (Lofibra).................................... 53
fenofibrate tab 48 mg (Tricor)........................................ 52
fenofibrate tab 145 mg (Tricor)...................................... 53
FENOFIBRIC ACID -fenofibric acid tab 35 mg................. 53
FENOFIBRIC ACID -fenofibric acid tab 105 mg............... 53
FENOPROFEN CALCIUM -fenoprofen calcium cap 200
mg.................................................................................... 92
FENOPROFEN CALCIUM -fenoprofen calcium cap 400
mg.................................................................................... 92
FENOPROFEN CALCIUM -fenoprofen calcium tab 600
mg.................................................................................... 92
FENORTHO -fenoprofen calcium cap 200 mg................. 92
FENORTHO -fenoprofen calcium cap 400 mg................. 92
fentanyl citrate lozenge on a handle 200 mcg
(Actiq)............................................................................. 87
(Actiq)............................................................................. 87
(Actiq)............................................................................. 87
(Actiq)............................................................................. 87
(Actiq)............................................................................. 87
(Actiq)............................................................................. 87
FENTANYL -fentanyl td patch 72hr 37.5 mcg/hr...............87
fentanyl td patch 72hr 12 mcg/hr (Duragesic).............. 87
fentanyl td patch 72hr 100 mcg/hr (Duragesic)............ 87
FERRIPROX -deferiprone oral soln 100 mg/ml.............. 133
FERRIPROX -deferiprone tab 500 mg............................ 133
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental
fe).................................................................................. 113
FERROUS SULFATE -ferrous sulfate liquid 220 mg/5ml
(44 mg/5ml elemental fe)............................................. 113
ferrous sulfate soln 75 mg/ml (15 mg/ml elemental
fe).................................................................................. 113
FETZIMA -levomilnacipran hcl cap sr 24hr 20 mg (base
equivalent)....................................................................... 71
equivalent)....................................................................... 71
equivalent)....................................................................... 71
229
2016
equivalent)....................................................................... 71
FETZIMA TITRATION PACK -levomilnacipran hcl cap sr
24hr 20 & 40 mg therapy pack...................................... 71
FIBRICOR -fenofibric acid tab 35 mg............................... 53
FIBRICOR -fenofibric acid tab 105 mg............................. 53
FIFTY50 GLUCOSE METER 2.0 -blood glucose
FIFTY50 GLUCOSE TEST STRI -glucose blood test
strip................................................................................ 135
FIFTY50 LANCING DEVICE -lancet devices.................. 156
FIFTY50 PEN NEEDLES/32GX4 -insulin pen needle 32 g
x 4 mm (5/32").............................................................. 157
x 6 mm (1/4")................................................................ 157
x 8 mm (1/3" or 5/16").................................................. 157
FIFTY50 PEN NEEDLES 31GX5 -insulin pen needle 31 g
x 5 mm (3/16").............................................................. 156
FIFTY50 PEN NEEDLES 31G X -insulin pen needle 31 g
x 5 mm (3/16").............................................................. 156
FIFTY50 PEN NEEDLES 31G X -insulin pen needle 31 g
x 8 mm (1/3" or 5/16").................................................. 156
FIFTY50 SAFETY SEAL LANCE -lancets...................... 157
FIFTY50 SUPERIOR COMFORT -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 157
u-100 1 ml 31 x 5/16"...................................................157
u-100 0.3 ml 31 x 5/16"................................................ 157
FIFTY50 UNILET LANCETS 33 -lancets........................ 157
FINACEA -azelaic acid foam 15%.................................. 129
FINACEA -azelaic acid gel 15%..................................... 129
finasteride tab 5 mg (Proscar)....................................... 69
FINE 30 -lancets.............................................................. 157
FINGERSTIX LANCETS -lancets.................................... 157
FIORINAL/CODEINE #3 -butalbital-aspirin-caff w/ codeine
cap 50-325-40-30 mg..................................................... 87
FIRAZYR -icatibant acetate inj 30 mg/3ml (base
equivalent)..................................................................... 117
FLAGYL ER -metronidazole tab sr 24hr 750 mg.............. 12
FLAGYL -metronidazole cap 375 mg................................ 12
FLAGYL -metronidazole tab 250 mg................................ 12
FLAGYL -metronidazole tab 500 mg................................ 12
FLAREX -fluorometholone acetate ophth susp 0.1%..... 121
flavoxate hcl tab 100 mg.................................................67
flecainide acetate tab 50 mg.......................................... 42
flecainide acetate tab 100 mg........................................ 42
flecainide acetate tab 150 mg........................................ 42
FLOMAX -tamsulosin hcl cap 0.4 mg............................... 69
FLORIVA -sodium fluoride-vitamin d liqd drops 0.25 mg/
ml-400 unit/ml............................................................... 111
FLOVENT DISKUS -fluticasone propionate aer pow ba 50
mcg/blister....................................................................... 59
FLOVENT DISKUS -fluticasone propionate aer pow ba
100 mcg/blister................................................................ 59
FLOVENT DISKUS -fluticasone propionate aer pow ba
250 mcg/blister................................................................ 59
FLOVENT HFA -fluticasone propionate hfa inhal aer 110
mcg/act (125/valve)........................................................ 59
FLOVENT HFA -fluticasone propionate hfa inhal aer 220
mcg/act (250/valve)........................................................ 59
FLOVENT HFA -fluticasone propionate hfa inhal aero 44
mcg/act (50/valve)...........................................................59
FLOW-EZE VENTED NEEDLE -hypodermic needles
(disposable)................................................................... 157
FLOXIN OTIC -ofloxacin otic soln 0.3%..........................124
FLUAD 2016-2017 -influenza vac type a&b surface ant
adj susp pref syr 0.5 ml................................................. 13
FLUARIX 2014-2015 -influenza virus vaccine split pf susp
pref syringe 0.5 ml.......................................................... 13
FLUARIX QUADRIVALENT 2016 -influenza virus vac split
quadrivalent susp pref syr 0.5ml.................................... 13
FLUBLOK 2015-2016 -influenza virus vac recombinant
hemagglutinin (ha) inj..................................................... 13
FLUBLOK 2016-2017 -influenza virus vac recombinant
hemagglutinin (ha) inj..................................................... 13
FLUCELVAX 2015-2016 -influenza virus vac tiss-cult
subunit susp pref syr 0.5 ml........................................... 13
FLUCELVAX QUADRIVALENT 20 -influenza vac tiss-cult
subunt quad susp pref syr 0.5 ml.................................. 13
fluconazole for susp 10 mg/ml (Diflucan)....................... 6
fluconazole for susp 40 mg/ml (Diflucan)....................... 6
fluconazole tab 50 mg (Diflucan)..................................... 6
fluconazole tab 100 mg (Diflucan)................................... 6
flucytosine cap 250 mg (Ancobon)................................. 6
flucytosine cap 500 mg (Ancobon)................................. 6
fludrocortisone acetate tab 0.1 mg............................... 20
FLULAVAL QUADRIVALENT 201 -influenza virus vaccine
split quadrivalent im inj................................................... 13
FLULAVAL QUADRIVALENT 201 -influenza virus vac split
quadrivalent susp pref syr 0.5ml.................................... 13
FLUMADINE -rimantadine hydrochloride tab 100 mg.........7
FLUMIST QUADRIVALENT -influenza virus vaccine live
quadrivalent intranasal susp...........................................13
flunisolide nasal soln 25 mcg/act (0.025%)
(Flunisolide)................................................................... 56
fluocinolone acetonide cream 0.01%.......................... 129
fluocinolone acetonide cream 0.025% (Synalar)........129
fluocinolone acetonide oil 0.01% (body oil) (Dermasmoothe/fs bod).......................................................... 129
fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca)...........................................................129
fluocinolone acetonide oint 0.025% (Synalar)............ 129
fluocinolone acetonide (otic) oil 0.01%
(Dermotic).................................................................... 124
fluocinolone acetonide soln 0.01% (Synalar)............. 129
fluocinonide cream 0.05%............................................ 129
fluocinonide cream 0.1% (Vanos)................................ 129
fluocinonide emulsified base cream 0.05%................ 129
fluocinonide gel 0.05%.................................................. 129
230
2016
fluocinonide oint 0.05%................................................ 129
fluocinonide soln 0.05%................................................ 129
FLUORABON -sodium fluoride soln 0.25 mg/0.6ml (from
0.55 mg/0.6ml naf)........................................................111
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 0.55
(0.25 mg f)-236.79 mg..................................................111
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 2.2 (1 mg
f)-236.79 mg.................................................................. 111
fluorometholone ophth susp 0.1% (Fml liquifilm)..... 121
FLUOROPLEX -fluorouracil cream 1%........................... 129
fluorouracil cream 5% (Efudex)................................... 129
FLUOROURACIL -fluorouracil cream 0.5%.................... 129
fluorouracil soln 2%...................................................... 129
fluorouracil soln 5%...................................................... 129
FLUOXETINE -fluoxetine hcl (pmdd) cap 10 mg.............. 83
FLUOXETINE -fluoxetine hcl (pmdd) cap 20 mg.............. 83
fluoxetine hcl cap delayed release 90 mg (Prozac
weekly)............................................................................ 71
fluoxetine hcl cap 10 mg (Prozac)................................. 72
FLUOXETINE HCL -fluoxetine hcl tab 60 mg................... 71
fluoxetine hcl solution 20 mg/5ml................................. 72
fluoxetine hcl tab 10 mg................................................. 72
fluoxetine hcl tab 20 mg................................................. 72
FLUPHENAZINE HCL -fluphenazine hcl elixir 2.5
mg/5ml............................................................................. 75
FLUPHENAZINE HCL -fluphenazine hcl oral conc 5 mg/
ml..................................................................................... 75
fluphenazine hcl tab 1 mg.............................................. 75
fluphenazine hcl tab 2.5 mg........................................... 75
fluphenazine hcl tab 5 mg.............................................. 75
fluphenazine hcl tab 10 mg............................................ 75
FLURA-DROPS -sodium fluoride soln 0.25 mg/drop f
(from 0.55 mg/drop naf)............................................... 111
flurandrenolide cream 0.05%....................................... 129
FLURAZEPAM HCL -flurazepam hcl cap 15 mg.............. 77
FLURAZEPAM HCL -flurazepam hcl cap 30 mg.............. 77
flurbiprofen sodium ophth soln 0.03% (Ocufen)........121
flurbiprofen tab 50 mg.................................................... 92
flurbiprofen tab 100 mg.................................................. 92
flutamide cap 125 mg...................................................... 16
fluticasone propionate cream 0.05% (Cutivate)......... 129
fluticasone propionate lotion 0.05% (Cutivate).......... 129
fluticasone propionate nasal susp 50 mcg/act............ 57
fluticasone propionate oint 0.005%............................. 129
fluvastatin sodium cap 20 mg (Lescol)......................... 53
fluvastatin sodium cap 40 mg (Lescol)......................... 53
fluvastatin sodium tab sr 24 hr 80 mg (Lescol xl)........53
FLUVIRIN 2015-2016 -influenza vac type a&b surface
antigen susp pref syr 0.5 ml...........................................13
FLUVIRIN 2015-2016 -influenza virus vaccine types a & b
surface antigen im susp................................................. 13
FLUVIRIN 2016-2017 -influenza virus vaccine types a & b
surface antigen im susp................................................. 13
FLUVIRIN PF 2014-2015 -influenza virus vac types a & b
pf susp prefilled syr 0.5 ml............................................. 13
FLUVIRIN PF 2016-2017 -influenza virus vac types a & b
pf susp prefilled syr 0.5 ml............................................. 13
fluvoxamine maleate cap sr 24hr 100 mg..................... 72
fluvoxamine maleate cap sr 24hr 150 mg..................... 72
fluvoxamine maleate tab 25 mg..................................... 72
fluvoxamine maleate tab 50 mg..................................... 72
fluvoxamine maleate tab 100 mg................................... 72
FLUZONE HIGH-DOSE PF 2016 -influenza virus vac split
high-dose pf susp pref syr 0.5ml....................................13
FLUZONE INTRADERMAL QUADR -influenza virus vac
split quad intradermal pen 9 mcg/strain......................... 13
FLUZONE QUADRIVALENT 2016 -influenza virus
vaccine split quadrivalent im inj..................................... 13
FLUZONE QUADRIVALENT 2016 -influenza virus
vaccine split quadrivalent inj 0.5 ml............................... 13
FLUZONE QUADRIVALENT 2016 -influenza virus vac
split quadrivalent susp pref syr 0.25 ml......................... 13
FLUZONE QUADRIVALENT 2016 -influenza virus vac
split quadrivalent susp pref syr 0.5ml............................ 13
FML -fluorometholone ophth oint 0.1%........................... 121
FML FORTE -fluorometholone ophth susp 0.25%.......... 121
FML LIQUIFILM -fluorometholone ophth susp 0.1%...... 121
FOCALGIN CA -prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 300 mg pack...................................................105
FOCALGIN 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa tab
90 &dha cap 300mg pak.............................................. 105
FOCALIN -dexmethylphenidate hcl tab 2.5 mg................ 79
FOCALIN -dexmethylphenidate hcl tab 5 mg................... 79
FOCALIN -dexmethylphenidate hcl tab 10 mg................. 79
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 5
mg.................................................................................... 80
mg.................................................................................... 80
mg.................................................................................... 80
mg.................................................................................... 80
mg.................................................................................... 80
mg.................................................................................... 80
mg.................................................................................... 80
mg.................................................................................... 80
FOLCAL DHA -prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 27-1.25-300 mg..................................................... 105
FOLCAPS OMEGA 3 -prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg............................................... 105
FOLET DHA -prenat w/fecbn-bisg-methylf-dss tab dr &
dha cap pak.................................................................. 105
FOLET ONE -prenat w/o a w/fecbn-bisg-methylf-dss-dha
cap 38-1-225 mg.......................................................... 105
folic acid tab 400 mcg................................................... 113
folic acid tab 800 mcg................................................... 113
folic acid tab 1 mg......................................................... 113
231
2016
FOLIVANE-F -fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe)................................... 113
FOLIVANE-OB -prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg...............................................................105
fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml
(Arixtra).........................................................................114
fondaparinux sodium subcutaneous inj 5 mg/0.4ml
(Arixtra).........................................................................114
fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml
(Arixtra).........................................................................114
fondaparinux sodium subcutaneous inj 10 mg/0.8ml
(Arixtra).........................................................................114
FORACARE GD40 BLOOD GLUCO -blood glucose
FORACARE GD40 -glucose blood test strip...................136
FORACARE PREMIUM V10 BLOO -blood glucose
FORACARE PREMIUM V10 TEST -glucose blood test
strip................................................................................ 136
FORACARE TEST N GO BLOOD -blood glucose
FORACARE TEST N GO TEST S -glucose blood test
strip................................................................................ 136
FORA D40/G31 BLOOD GLUCOS -glucose blood test
strip................................................................................ 136
FORA D10 BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 136
FORA D20 BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 136
FORA D15G BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 136
FORA G30A BLOOD GLUCOSE M -blood glucose
FORA G30A BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 136
FORA G20 BLOOD GLUCOSE MO -blood glucose
FORA G20 BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 136
FORA GD20 BLOOD GLUCOSE M -blood glucose
FORA GD50 BLOOD GLUCOSE M -blood glucose
FORA GD50 BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 136
FORA GD20 TEST STRIPS -glucose blood test
strip................................................................................ 136
FORA LANCETS -lancets............................................... 157
FORA LANCING DEVICE/CLEAR -lancet devices.........157
FORA LANCING DEVICE -lancet devices...................... 157
FORA TEST N' GO VOICE BLO -blood glucose
FORA TN'G/TN'G VOICE BLOO -glucose blood test
strip................................................................................ 136
FORA TN'G VOICE BLOOD GLU -blood glucose
FORA V10/V12/D10/D20 BLOO -blood glucose
monitoring kit................................................................. 157
FORA V30A BLOOD GLUCOSE M -blood glucose
FORA V30A BLOOD GLUCOSE M -blood glucose
FORA V30A BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 136
FORA V10 BLOOD GLUCOSE MO -blood glucose
FORA V10 BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 136
strip................................................................................ 136
strip................................................................................ 136
FORFIVO XL -bupropion hcl tab sr 24hr 450 mg............. 72
FORTEO -teriparatide (recombinant) inj 600
mcg/2.4ml........................................................................ 34
FORTICAL -calcitonin (salmon) nasal soln 200 unit/
act.................................................................................... 34
FORTISCARE SELF-MONITORIN -blood glucose
FOSAMAX -alendronate sodium tab 70 mg......................34
FOSAMAX PLUS D -alendronate sodium-cholecalciferol
tab 70-2800 mg-unit....................................................... 34
FOSAMAX PLUS D -alendronate sodium-cholecalciferol
tab 70-5600 mg-unit....................................................... 34
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg................................................................................... 47
fosinopril sodium & hydrochlorothiazide tab 20-12.5
mg................................................................................... 47
fosinopril sodium tab 10 mg.......................................... 47
FOSRENOL -lanthanum carbonate chew tab 500 mg
(elemental).......................................................................65
(elemental).......................................................................65
(elemental).......................................................................65
FOSRENOL -lanthanum carbonate oral powder pack 750
mg (elemental)................................................................ 65
FOSRENOL -lanthanum carbonate oral powder pack
1000 mg (elemental).......................................................65
FRAGMIN -dalteparin sodium inj 10000 unit/ml..............114
FRAGMIN -dalteparin sodium inj 2500 unit/0.2ml...........114
FRAGMIN -dalteparin sodium inj 12500 unit/0.5ml.........114
FRAGMIN -dalteparin sodium inj 18000 unit/0.72ml.......114
232
2016
FREDS PHARMACY AUTOLET LA -lancet devices...... 157
FREDS PHARMACY UNIFINE PE -insulin pen needle 31
g x 5 mm (3/16")...........................................................157
g x 4 mm (5/32")...........................................................157
g x 8 mm (1/3" or 5/16")...............................................157
FREDS PHARMACY UNILET LAN -lancets................... 157
FREESTYLE FLASH SYSTEM -blood glucose monitoring
kit................................................................................... 157
FREESTYLE FREEDOM -blood glucose monitoring kit w/
device............................................................................ 158
FREESTYLE FREEDOM LITE -blood glucose monitoring
kit w/ device.................................................................. 158
FREESTYLE INSULINX BLOOD -blood glucose
FREESTYLE INSULINX BLOOD -glucose blood test
strip................................................................................ 136
FREESTYLE LANCETS -lancets.................................... 158
FREESTYLE LITE BLOOD GLUC -blood glucose
FREESTYLE LITE TEST STRIP -glucose blood test
strip................................................................................ 136
FREESTYLE PRECISION INSUL -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 158
u-100 1/2 ml 30 x 5/16"................................................ 158
u-100 1 ml 30 x 5/16"...................................................158
u-100 1 ml 31 x 5/16"...................................................158
FREESTYLE PRECISION NEO B -blood glucose
FREESTYLE PRECISION NEO B -glucose blood test
strip................................................................................ 136
FREESTYLE SIDEKICK II VAL -blood glucose monitoring
kit w/ device.................................................................. 158
FREESTYLE SYSTEM KIT -blood glucose monitoring
kit................................................................................... 158
FREESTYLE TEST STRIPS -glucose blood test
strip................................................................................ 136
FREESTYLE UNISTICK II LAN -lancets......................... 158
FROVA -frovatriptan succinate tab 2.5 mg (base
equivalent)....................................................................... 94
frovatriptan succinate tab 2.5 mg (base equivalent)
(Frova).............................................................................94
FULYZAQ -crofelemer tab delayed release 125 mg......... 61
FURADANTIN -nitrofurantoin susp 25 mg/5ml................. 66
FUROSEMIDE -furosemide oral soln 8 mg/ml..................51
furosemide oral soln 10 mg/ml...................................... 51
furosemide tab 20 mg (Lasix)........................................ 51
FUZEON -enfuvirtide for inj 90 mg..................................... 7
FYCOMPA -perampanel susp 0.5 mg/ml.......................... 97
FYCOMPA -perampanel tab 2 mg.................................... 97
FYCOMPA -perampanel tab 4 mg.................................... 97
FYCOMPA
FYCOMPA
FYCOMPA
FYCOMPA
-perampanel
-perampanel
-perampanel
-perampanel
tab
tab
tab
tab
6 mg.................................... 97
8 mg.................................... 97
10 mg.................................. 97
12 mg.................................. 97
G
gabapentin cap 100 mg (Neurontin).............................. 97
gabapentin oral soln 250 mg/5ml (Neurontin).............. 97
gabapentin tab 600 mg (Neurontin)............................... 97
gabapentin tab 800 mg (Neurontin)............................... 97
GABITRIL -tiagabine hcl tab 2 mg.................................... 97
GABITRIL -tiagabine hcl tab 4 mg.................................... 97
GABITRIL -tiagabine hcl tab 12 mg.................................. 97
GABITRIL -tiagabine hcl tab 16 mg.................................. 97
galantamine hydrobromide cap sr 24hr 8 mg
(Razadyne er)................................................................ 83
(Razadyne er)................................................................ 83
(Razadyne er)................................................................ 83
GALANTAMINE HYDROBROMIDE -galantamine
hydrobromide oral soln 4 mg/ml.................................... 83
galantamine hydrobromide tab 4 mg (Razadyne)........ 83
galantamine hydrobromide tab 8 mg (Razadyne)........ 83
galantamine hydrobromide tab 12 mg (Razadyne)...... 83
GALZIN -zinc acetate cap 25 mg (elemental zinc)......... 111
GALZIN -zinc acetate cap 50 mg (elemental zinc)......... 111
GAMMAGARD LIQUID -immune globulin (human) iv or
subcutaneous soln 1 gm/10ml....................................... 15
subcutaneous soln 2.5 gm/25ml.................................... 15
subcutaneous soln 10 gm/100ml................................... 15
GAMMAKED -immune globulin (human) iv or
GAMUNEX-C -immune globulin (human) iv or
233
2016
GARDASIL -human papillomavirus (hpv) quadrivalent
recombinant vac inj.........................................................13
GARDASIL 9 -human papillomavirus (hpv) 9-valent
recomb vac im susp....................................................... 13
GARDASIL 9 -human papillomavirus (hpv) 9-valent
recomb vac susp pref syr............................................... 13
GASTRINEX NF -hyoscyamine-phenyltoloxamine cap
0.0625-15 mg.................................................................. 62
GASTROCROM -cromolyn sodium oral conc 100
mg/5ml............................................................................. 65
gatifloxacin ophth soln 0.5% (Zymaxid)..................... 121
GATTEX -teduglutide (rdna) for inj kit 5 mg...................... 65
GE100 BLOOD GLUCOSE MONIT -blood glucose
GE100 BLOOD GLUCOSE TEST -glucose blood test
strip................................................................................ 136
GELNIQUE -oxybutynin chloride td gel 10%.................... 67
gemfibrozil tab 600 mg (Lopid)...................................... 53
GENERESS FE -norethindrone & ethinyl estradiol-fe
chew tab 0.8 mg-25 mcg................................................24
GENOTROPIN MINIQUICK -somatropin for inj 0.2
mg.................................................................................... 34
mg.................................................................................... 34
mg.................................................................................... 34
mg.................................................................................... 35
GENOTROPIN MINIQUICK -somatropin for inj 1 mg....... 35
mg.................................................................................... 35
mg.................................................................................... 35
mg.................................................................................... 35
mg.................................................................................... 35
GENOTROPIN MINIQUICK -somatropin for inj 2 mg....... 35
GENOTROPIN -somatropin for inj 12 mg (13.8 mg
overfill)............................................................................. 34
GENOTROPIN -somatropin for subcutaneous inj 5
mg.................................................................................... 34
GENSTRIP 50 -glucose blood test strip..........................136
GENTAMICIN SULFATE -gentamicin sulfate cream
0.1%...............................................................................129
GENTAMICIN SULFATE -gentamicin sulfate oint
0.1%...............................................................................129
gentamicin sulfate ophth oint 0.3%............................. 121
gentamicin sulfate ophth soln 0.3% (Garamycin)...... 121
GENTLE-LET GP LANCETS -lancets.............................158
GENTLE-LET LANCETS GENERA -lancets...................158
GENTLE-LET LANCETS SAFETY -lancets.................... 158
GENVOYA -elvitegrav-cobic-emtricitab-tenofov af tab
150-150-200-10 mg.......................................................... 7
GHT BLOOD GLUCOSE MONITO -blood glucose
GHT TEST STRIPS -glucose blood test strip................. 136
GIAZO -balsalazide disodium tab 1.1 gm......................... 65
GILENYA -fingolimod hcl cap 0.5 mg (base equiv)........... 83
GILOTRIF -afatinib dimaleate tab 20 mg (base
equivalent)....................................................................... 16
equivalent)....................................................................... 16
equivalent)....................................................................... 16
glatiramer acetate soln prefilled syringe 20 mg/ml
(Copaxone)..................................................................... 83
GLEEVEC -imatinib mesylate tab 100 mg (base
equivalent)....................................................................... 16
GLEEVEC -imatinib mesylate tab 400 mg (base
equivalent)....................................................................... 16
GLEOSTINE -lomustine cap 5 mg.................................... 16
GLEOSTINE -lomustine cap 10 mg.................................. 16
GLEOSTINE -lomustine cap 40 mg.................................. 17
GLEOSTINE -lomustine cap 100 mg................................ 17
glimepiride tab 1 mg (Amaryl)........................................27
glipizide-metformin hcl tab 2.5-250 mg......................... 28
glipizide-metformin hcl tab 2.5-500 mg......................... 28
glipizide-metformin hcl tab 5-500 mg............................ 28
glipizide tab 5 mg (Glucotrol).........................................28
glipizide tab 10 mg (Glucotrol).......................................28
glipizide tab sr 24hr 2.5 mg (Glucotrol xl).................... 27
glipizide tab sr 24hr 5 mg (Glucotrol xl)....................... 27
glipizide tab sr 24hr 10 mg (Glucotrol xl)..................... 28
GLOBAL EASE INJECT PEN NE -insulin pen needle 29 g
x 12 mm (1/2").............................................................. 158
x 5 mm (3/16").............................................................. 158
x 4 mm (5/32").............................................................. 158
x 8 mm (1/3" or 5/16").................................................. 158
GLOBAL EASY GLIDE PEN NEE -insulin pen needle 32
g x 4 mm (5/32")...........................................................158
GLOBAL INJECT EASE INSULI -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 158
u-100 1/2 ml 28 x 1/2".................................................. 158
u-100 1/2 ml 29 x 1/2".................................................. 158
u-100 1/2 ml 30 x 5/16"................................................ 158
u-100 1/2 ml 30 x 1/2".................................................. 158
u-100 0.3 ml 29 x 1/2".................................................. 158
234
2016
u-100 0.3 ml 30 x 5/16"................................................ 158
u-100 0.3 ml 30 x 1/2".................................................. 158
u-100 1 ml 28 x 1/2".....................................................159
u-100 1 ml 29 x 1/2".....................................................159
u-100 1 ml 30 x 5/16"...................................................159
u-100 1 ml 30 x 1/2".....................................................159
u-100 1 ml 31 x 5/16"...................................................159
u-100 0.3 ml 31 x 5/16"................................................ 159
GLOBAL INJECT EASE LANCET -lancets..................... 159
GLOBAL LANCING DEVICE -lancet devices................. 159
GLUCAGEN DIAGNOSTIC -glucagon hcl (rdna)
diagnostic for inj 1 mg (base equiv)............................. 136
GLUCAGEN HYPOKIT -glucagon hcl (rdna) for inj 1 mg
(base equiv).................................................................... 28
GLUCAGON EMERGENCY KIT -glucagon (rdna) for inj
kit 1 mg........................................................................... 28
GLUCOCARD 01 BLOOD GLUCOS -blood glucose
GLUCOCARD 01 BLOOD GLUCOS -blood glucose
GLUCOCARD EXPRESSION AUDI -blood glucose
GLUCOCARD EXPRESSION BLOO -glucose blood test
strip................................................................................ 136
GLUCOCARD 01-MINI BLOOD G -blood glucose
GLUCOCARD 01 SENSOR PLUS -glucose blood test
strip................................................................................ 136
GLUCOCARD SHINE -blood glucose monitoring
devices.......................................................................... 159
GLUCOCARD SHINE -blood glucose monitoring kit w/
device............................................................................ 159
GLUCOCARD SHINE TEST STRI -glucose blood test
strip................................................................................ 136
GLUCOCARD VITAL BLOOD GLU -blood glucose
GLUCOCARD VITAL TEST STRI -glucose blood test
strip................................................................................ 136
GLUCOCARD X-METER -blood glucose monitoring kit w/
device............................................................................ 159
GLUCOCARD X-SENSOR -glucose blood test strip...... 136
GLUCOCOM AUTOLINK TELEMON -blood glucose
monitoring misc............................................................. 159
GLUCOCOM BLOOD GLUCOSE MO -blood glucose
GLUCOCOM BLOOD GLUCOSE MO -blood glucose
GLUCOCOM LANCETS 28G -lancets............................ 159
GLUCOCOM TEST STRIPS -glucose blood test
strip................................................................................ 136
GLUCOLET 2 AUTOMATIC LANC -lancet devices........ 159
GLUCONAVII BLOOD GLUCOSE -blood glucose
GLUCONAVII BLOOD GLUCOSE -glucose blood test
strip................................................................................ 136
GLUCO PERFECT 3 BLOOD GLU -blood glucose
GLUCO PERFECT 3 TEST STRI -glucose blood test
strip................................................................................ 136
GLUCOPHAGE -metformin hcl tab 500 mg...................... 28
GLUCOPHAGE -metformin hcl tab 850 mg...................... 28
GLUCOPHAGE -metformin hcl tab 1000 mg.................... 28
GLUCOPHAGE XR -metformin hcl tab sr 24hr 500
mg.................................................................................... 28
GLUCOPHAGE XR -metformin hcl tab sr 24hr 750
mg.................................................................................... 28
GLUCOPRO INSULIN SYRINGE/ -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 159
u-100 1/2 ml 30 x 5/16"................................................ 159
u-100 1/2 ml 30 x 1/2".................................................. 159
u-100 0.3 ml 30 x 5/16"................................................ 159
u-100 0.3 ml 30 x 1/2".................................................. 159
u-100 1 ml 30 x 5/16"...................................................159
u-100 1 ml 30 x 1/2".....................................................160
u-100 1 ml 31 x 5/16"...................................................160
u-100 0.3 ml 31 x 5/16"................................................ 160
GLUCOSE METER TEST STRIPS -glucose blood test
strip................................................................................ 136
GLUCOSOURCE LANCET DEVICE -lancet devices..... 160
GLUCOSOURCE LANCETS -lancets............................. 160
GLUCOTROL -glipizide tab 5 mg..................................... 28
GLUCOTROL -glipizide tab 10 mg................................... 28
GLUCOTROL XL -glipizide tab sr 24hr 2.5 mg.................28
GLUCOTROL XL -glipizide tab sr 24hr 5 mg....................28
GLUCOTROL XL -glipizide tab sr 24hr 10 mg..................28
GLUCOVANCE -glyburide-metformin tab 1.25-250
mg.................................................................................... 28
GLUCOVANCE -glyburide-metformin tab 2.5-500 mg...... 28
GLUCOVANCE -glyburide-metformin tab 5-500 mg......... 28
glyburide-metformin tab 1.25-250 mg
(Glucovance).................................................................. 28
glyburide-metformin tab 2.5-500 mg (Glucovance)..... 28
glyburide-metformin tab 5-500 mg (Glucovance)........ 28
glyburide micronized tab 1.5 mg (Glynase)..................28
glyburide micronized tab 3 mg (Glynase).....................28
glyburide micronized tab 6 mg (Glynase).....................28
235
2016
glyburide tab 1.25 mg..................................................... 28
glyburide tab 2.5 mg....................................................... 28
glyburide tab 5 mg.......................................................... 28
glycopyrrolate tab 1 mg (Robinul)................................. 62
glycopyrrolate tab 2 mg (Robinul forte)........................62
GLYNASE -glyburide micronized tab 1.5 mg.................... 28
GLYNASE -glyburide micronized tab 3 mg....................... 28
GLYNASE -glyburide micronized tab 6 mg....................... 28
GLYSET -miglitol tab 25 mg.............................................. 28
GLYSET -miglitol tab 50 mg.............................................. 28
GLYSET -miglitol tab 100 mg............................................ 28
GLYXAMBI -empagliflozin-linagliptin tab 10-5 mg............ 28
GLYXAMBI -empagliflozin-linagliptin tab 25-5 mg............ 28
GMATE BLOOD GLUCOSE TEST -glucose blood test
strip................................................................................ 136
GMATE LANCETS 30G -lancets..................................... 160
GMATE LANCING DEVICE -lancet devices................... 160
GMATE ORIGIN BLOOD GLUCOS -blood glucose
GMATE SMART METER KIT -blood glucose monitoring
devices.......................................................................... 160
GMATE SMART STARTER KIT -blood glucose monitoring
kit w/ device.................................................................. 160
GMATE VOICE BLOOD GLUCOSE -blood glucose
GNP CLICKFINE PEN NEEDLE -insulin pen needle 31 g
x 8 mm (1/3" or 5/16").................................................. 160
GNP CLICKFINE UNIVERSAL P -insulin pen needle 31 g
x 6 mm (1/4")................................................................ 160
GNP CLICKFINE UNIVERSAL P -insulin pen needle 31 g
x 8 mm (1/3" or 5/16").................................................. 160
GNP EASY TOUCH GLUCOSE MO -blood glucose
GNP EASY TOUCH GLUCOSE TE -glucose blood test
strip................................................................................ 136
GNP INSULIN SYRINGE/1ML/2 -insulin syringe/needle
u-100 1 ml 28 x 1/2".....................................................160
u-100 1 ml 29 x 1/2".....................................................160
u-100 1 ml 30 x 5/16"...................................................160
u-100 1 ml 31 x 5/16"...................................................160
GNP INSULIN SYRINGE/0.5ML -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 160
u-100 1/2 ml 28 x 1/2".................................................. 160
u-100 1/2 ml 29 x 1/2".................................................. 160
u-100 1/2 ml 30 x 5/16"................................................ 160
u-100 0.3 ml 29 x 1/2".................................................. 160
u-100 0.3 ml 30 x 5/16"................................................ 160
u-100 0.3 ml 31 x 5/16"................................................ 160
GNP LANCETS 21G -lancets..........................................160
GNP LANCETS -lancets.................................................. 160
GNP LANCETS MICRO THIN 33 -lancets......................160
GNP LANCETS SUPER THIN 30 -lancets..................... 160
GNP LANCETS THIN 26G -lancets................................ 160
GNP LANCETS THIN -lancets........................................ 160
GNP MICRO THIN LANCETS 33 -lancets......................160
GNP SUPER THIN LANCETS/30 -lancets..................... 160
GNP ULTRA COMFORT INSULIN -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 161
u-100 1/2 ml 28 x 1/2".................................................. 161
u-100 1/2 ml 29 x 1/2".................................................. 161
u-100 1/2 ml 30 x 5/16"................................................ 161
u-100 0.3 ml 29 x 1/2".................................................. 161
u-100 0.3 ml 30 x 5/16"................................................ 161
u-100 1 ml 28 x 1/2".....................................................161
u-100 1 ml 29 x 1/2".....................................................161
u-100 1 ml 30 x 5/16"...................................................161
u-100 1 ml 31 x 5/16"...................................................161
u-100 0.3 ml 31 x 5/16"................................................ 161
GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate for
soln 236 gm.................................................................... 61
GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate
packet 227.1 gm............................................................. 61
GORDOFILM -salicylic & lactic acids soln
16.7-16.7%.................................................................... 129
GRALISE -gabapentin (once-daily) tab 300 mg................83
GRALISE -gabapentin (once-daily) tab 600 mg................83
GRALISE STARTER -gabapentin (once-daily) tab pack
300 mg (9) & 600 mg (69)............................................. 83
granisetron hcl tab 1 mg................................................ 63
GRANIX -tbo-filgrastim soln prefilled syringe 300
mcg/0.5ml...................................................................... 113
GRANIX -tbo-filgrastim soln prefilled syringe 480
mcg/0.8ml...................................................................... 113
griseofulvin microsize susp 125 mg/5ml........................ 6
griseofulvin microsize tab 500 mg (Grifulvin v)............. 6
griseofulvin ultramicrosize tab 125 mg (Gris-peg)........ 6
griseofulvin ultramicrosize tab 250 mg (Gris-peg)........ 6
GRIS-PEG -griseofulvin ultramicrosize tab 125 mg............ 6
GRIS-PEG -griseofulvin ultramicrosize tab 250 mg............ 6
guanfacine hcl tab 1 mg (Tenex)................................... 47
guanfacine hcl tab 2 mg (Tenex)................................... 47
guanfacine hcl tab sr 24hr 1 mg (base equiv)
(Intuniv).......................................................................... 80
(Intuniv).......................................................................... 80
236
2016
(Intuniv).......................................................................... 80
(Intuniv).......................................................................... 80
GUANIDINE HCL -guanidine hcl tab 125 mg................. 104
GYNAZOLE-1 -butoconazole nitrate (one dose) vaginal
cream 2%........................................................................ 68
H
HAEMOLANCE -lancets.................................................. 161
HAEMOLANCE LOW FLOW LANCE -lancets................ 161
HAEMOLANCE PLUS HIGH FLOW -lancets................. 161
HAEMOLANCE PLUS -lancets....................................... 161
HAEMOLANCE PLUS LOW FLOW -lancets.................. 161
HAEMOLANCE PLUS MAX FLOW -lancets................... 161
HAEMOLANCE PLUS PEDIATRIC -lancets................... 161
HALCION -triazolam tab 0.25 mg..................................... 77
halobetasol propionate cream 0.05% (Ultravate)....... 129
halobetasol propionate oint 0.05% (Ultravate)........... 129
haloperidol lactate oral conc 2 mg/ml...........................75
haloperidol tab 0.5 mg.................................................... 75
haloperidol tab 1 mg....................................................... 75
haloperidol tab 10 mg..................................................... 75
haloperidol tab 20 mg..................................................... 75
HALOTIN -haloprogin cream 1%.................................... 129
HARVONI -ledipasvir-sofosbuvir tab 90-400 mg................ 7
HAVRIX -hepatitis a vaccine inj susp 720 el
unit/0.5ml......................................................................... 13
HAVRIX -hepatitis a vaccine inj susp 1440 el unit/ml....... 13
HEALTH CARE LANCING DEVIC -lancet devices......... 161
HEALTHWISE LANCETS 30G -lancets.......................... 161
HEALTHWISE LANCING PEN -lancet devices.............. 161
HEALTHWISE MINI PEN NEEDL -insulin pen needle 31 g
x 6 mm (1/4")................................................................ 161
HEALTHWISE PEN NEEDLES 29 -insulin pen needle 29
g x 12 mm (1/2")...........................................................162
HEALTHWISE SHORT PEN NEED -insulin pen needle 31
g x 8 mm (1/3" or 5/16")...............................................162
HEALTHWISE UNIFINE PENTIP -insulin pen needle 32 g
x 4 mm (5/32").............................................................. 162
HEALTHY ACCENTS AUTOLET I -lancet devices......... 162
HEALTHY ACCENTS UNIFINE P -insulin pen needle 29 g
x 12 mm (1/2").............................................................. 162
x 5 mm (3/16").............................................................. 162
x 6 mm (1/4")................................................................ 162
x 4 mm (5/32").............................................................. 162
x 8 mm (1/3" or 5/16").................................................. 162
HEALTHY ACCENTS UNILET LA -lancets..................... 162
H-E-B INCONTROL ADVANCED -lancet devices.......... 161
H-E-B INCONTROL LANCETS M -lancets..................... 161
H-E-B INCONTROL LANCETS S -lancets..................... 161
H-E-B INCONTROL LANCETS U -lancets..................... 161
H-E-B IN CONTROL PEN NEED -insulin pen needle 31 g
x 5 mm (3/16").............................................................. 161
x 6 mm (1/4")................................................................ 161
x 4 mm (5/32").............................................................. 161
x 8 mm (1/3" or 5/16").................................................. 161
H-E-B INCONTROL PEN NEEDL -insulin pen needle 29
g x 12 mm (1/2")...........................................................161
H-E-B IN CONTROL UNIFINE -insulin pen needle 31 g x
5 mm (3/16")................................................................. 161
H-E-B IN CONTROL UNIFINE -insulin pen needle 32 g x
4 mm (5/32")................................................................. 161
HECTOROL -doxercalciferol cap 0.5 mcg........................ 35
HECTOROL -doxercalciferol cap 1 mcg........................... 35
HECTOROL -doxercalciferol cap 2.5 mcg........................ 35
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 250 unit.................................................................... 117
kit 500 unit.................................................................... 117
kit 1000 unit.................................................................. 117
kit 2000 unit.................................................................. 117
kit 3000 unit.................................................................. 117
HEMANGEOL -propranolol hcl oral soln 4.28 mg/ml........ 39
HEMENATAL OB + DHA -prenat-fe poly cmplx-fe heme
poly-fa tab & omega 3 cap pck.................................... 105
HEMENATAL OB -prenat vit-fe poly cmplx-fe heme polyfa tab 28-6-1 mg........................................................... 105
HEMOFIL M -antihemophilic factor (human) for inj 250
unit................................................................................. 117
unit................................................................................. 117
unit................................................................................. 117
unit................................................................................. 117
heparin sodium (porcine) inj 5000 unit/ml.................. 115
HEPSERA -adefovir dipivoxil tab 10 mg............................. 7
HETLIOZ -tasimelteon capsule 20 mg.............................. 77
HEXALEN -altretamine cap 50 mg................................... 17
HIBERIX -haemophilus b polysaccharide conjugate vac
for inj 10 mcg.................................................................. 14
HIPREX -methenamine hippurate tab 1 gm......................66
HIZENTRA -immune globulin (human) subcutaneous inj 1
gm/5ml............................................................................. 15
gm/10ml........................................................................... 15
gm/20ml........................................................................... 15
HIZENTRA -immune globulin (human) subcutaneous inj
10 gm/50ml..................................................................... 15
237
2016
homatropine hbr ophth soln 5% (Isopto
homatropine)............................................................... 121
HORIZANT -gabapentin enacarbil tab cr 300 mg............. 83
HORIZANT -gabapentin enacarbil tab cr 600 mg............. 83
H.P. ACTHAR -corticotropin inj gel 80 unit/ml................... 35
HUBER NEEDLE/22GX1-1/4"/4 -needle (disp) 22 x
1-1/4"............................................................................. 162
HUBER NEEDLE/19GX3/4"/RIG -needle (disp) 19 x
3/4".................................................................................162
HUBER NEEDLE/20G X 1-1/4" -needle (disp) 20 x
1-1/4"............................................................................. 162
HUBER NEEDLE/RIGHT ANGLE -needle (disp) 20 x
1-1/2"............................................................................. 162
3/4".................................................................................162
1-1/2"............................................................................. 162
1".................................................................................... 162
1".................................................................................... 162
1".................................................................................... 162
HUBER NEEDLE/STRAIGHT 19G -needle (disp) 19 x
1-1/4"............................................................................. 162
1-1/2"............................................................................. 162
1-1/2"............................................................................. 162
1".................................................................................... 162
1".................................................................................... 162
HUBER NEEDLE 20GX3/4"/R -needle (disp) 20 x
3/4".................................................................................162
HUMATE-P -antihemophilic factor/vwf (human) for inj
250-600 unit.................................................................. 117
500-1200 unit................................................................ 117
1000-2400 unit.............................................................. 117
HUMATROPE COMBO PACK -somatropin for inj 5
mg.................................................................................... 35
HUMATROPE -somatropin for inj 5 mg............................ 35
HUMATROPE -somatropin for inj 24 mg.......................... 35
HUMATROPE -somatropin for inj 6 mg (18 unit).............. 35
HUMATROPE -somatropin for inj 12 mg (36 unit)............ 35
HUMIRA -adalimumab prefilled syringe kit 10
mg/0.2ml.......................................................................... 92
mg/0.4ml.......................................................................... 92
mg/0.8ml.......................................................................... 92
HUMIRA PEDIATRIC CROHNS D -adalimumab prefilled
syringe kit 40 mg/0.8ml.................................................. 92
HUMIRA PEN -adalimumab pen-injector kit 40
mg/0.8ml.......................................................................... 92
HUMIRA PEN-CROHNS DISEASE -adalimumab peninjector kit 40 mg/0.8ml.................................................. 92
HUMIRA PEN-PSORIASIS STAR -adalimumab peninjector kit 40 mg/0.8ml.................................................. 92
HUMULIN R U-500 (CONCENTR -insulin regular (human)
inj 500 unit/ml..................................................................31
HUMULIN R U-500 KWIKPEN -insulin regular (human)
soln pen-injector 500 unit/ml.......................................... 31
HYCAMTIN -topotecan hcl cap 0.25 mg (base equiv)...... 17
HYCAMTIN -topotecan hcl cap 1 mg (base equiv)........... 17
hydralazine hcl tab 10 mg.............................................. 47
hydralazine hcl tab 100 mg............................................ 47
HYDREA -hydroxyurea cap 500 mg................................. 17
hydrochlorothiazide cap 12.5 mg (Microzide).............. 51
hydrochlorothiazide tab 12.5 mg................................... 51
hydrochlorothiazide tab 25 mg...................................... 51
hydrochlorothiazide tab 50 mg...................................... 51
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
(Hycet).............................................................................87
hydrocodone-acetaminophen soln 10-325 mg/15ml
(Zamicet).........................................................................87
hydrocodone-acetaminophen tab 2.5-325 mg.............. 87
hydrocodone-acetaminophen tab 7.5-325 mg
(Norco)............................................................................ 87
hydrocodone-acetaminophen tab 5-325 mg
(Norco)............................................................................ 87
(Norco)............................................................................ 87
hydrocodone-acetaminophen tab 7.5-300 mg
(Xodol)............................................................................ 87
(Xodol)............................................................................ 87
(Xodol)............................................................................ 87
hydrocodone-ibuprofen tab 10-200 mg (Ibudone)....... 87
hydrocodone-ibuprofen tab 5-200 mg (Reprexain)......87
hydrocodone-ibuprofen tab 7.5-200 mg
(Vicoprofen)................................................................... 87
hydrocodone w/ homatropine syrup 5-1.5 mg/5ml...... 57
hydrocodone w/ homatropine tab 5-1.5 mg..................57
hydrocod polst-chlorphen polst er susp 10-8 mg/5ml
(Tussionex pennkineti)................................................. 57
hydrocortisone acetate suppos 25 mg (Anusolhc)................................................................................. 125
hydrocortisone acetate w/ pramoxine rectal cream
1-1% (Analpram-hc).................................................... 125
hydrocortisone acetate w/ pramoxine rectal cream
2.5-1% (Analpram-hc)................................................. 125
hydrocortisone butyrate cream 0.1% (Locoid)...........129
hydrocortisone butyrate hydrophilic lipo base cream
0.1% (Locoid lipocream)............................................ 129
hydrocortisone butyrate oint 0.1% (Locoid)............... 129
hydrocortisone butyrate soln 0.1% (Locoid).............. 129
hydrocortisone cream 1%.............................................129
hydrocortisone cream 2.5%..........................................129
238
2016
hydrocortisone enema 100 mg/60ml
(Cortenema)................................................................. 125
hydrocortisone lotion 2.5%.......................................... 130
hydrocortisone lotion 2% (Ala scalp).......................... 129
hydrocortisone oint 1%................................................. 130
hydrocortisone oint 2.5%..............................................130
hydrocortisone rectal cream 2.5% (Anusol-hc)......... 125
hydrocortisone rectal cream 1% (Proctocort)............ 125
hydrocortisone tab 5 mg (Cortef).................................. 20
hydrocortisone tab 10 mg (Cortef)................................ 20
hydrocortisone tab 20 mg (Cortef)................................ 20
hydrocortisone valerate cream 0.2%...........................130
hydrocortisone valerate oint 0.2% (Westcort)............ 130
hydrocortisone w/ acetic acid otic soln 1-2%............ 124
HYDROMORPHONE HCL ER -hydromorphone hcl tab er
24hr deter 32 mg............................................................ 87
HYDROMORPHONE HCL -hydromorphone hcl suppos 3
mg.................................................................................... 87
hydromorphone hcl liqd 1 mg/ml (Dilaudid).................87
hydromorphone hcl tab er 24hr deter 8 mg
(Exalgo).......................................................................... 87
(Exalgo).......................................................................... 87
(Exalgo).......................................................................... 87
hydromorphone hcl tab 2 mg (Dilaudid)....................... 88
hydroxychloroquine sulfate tab 200 mg
(Plaquenil)...................................................................... 11
hydroxyurea cap 500 mg (Hydrea)................................ 17
hydroxyzine hcl syrup 10 mg/5ml................................. 70
hydroxyzine hcl tab 10 mg............................................. 70
hydroxyzine pamoate cap 25 mg (Vistaril)................... 70
hydroxyzine pamoate cap 50 mg (Vistaril)................... 70
HYDROXYZINE PAMOATE -hydroxyzine pamoate cap
100 mg............................................................................ 70
hyoscyamine sulfate elixir 0.125 mg/5ml...................... 62
hyoscyamine sulfate soln 0.125 mg/ml......................... 62
hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)..... 62
hyoscyamine sulfate tab 0.125 mg (Levsin)................. 62
hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl)......... 62
hyoscyamine sulfate tab sr 12hr 0.375 mg
(Levbid)........................................................................... 62
HYPERSAL -sodium chloride soln nebu 3.5%..................57
HYPER-SAL -sodium chloride soln nebu 7%................... 57
HYPERSAL -sodium chloride soln nebu 7%.....................57
HYPODERMIC NEEDLE 20GX3/4 -needle (disp) 20 x
3/4".................................................................................162
3/4".................................................................................163
3/4".................................................................................163
3/4".................................................................................163
5/8".................................................................................163
1/2".................................................................................163
3/8".................................................................................163
5/8".................................................................................163
1/2".................................................................................163
1/2".................................................................................163
HYPODERMIC NEEDLE 21GX1" -needle (disp) 21 x
1".................................................................................... 163
1".................................................................................... 163
1".................................................................................... 163
1".................................................................................... 163
HYPODERMIC NEEDLE 21GX1-1 -needle (disp) 21 x
1-1/4"............................................................................. 162
1-1/2"............................................................................. 162
1-1/4"............................................................................. 163
1-1/2"............................................................................. 163
1-1/2"............................................................................. 163
1-1/4"............................................................................. 163
1-1/2"............................................................................. 163
HYPODERMIC NEEDLE 16G X 1 -needle (disp) 16 x
1-1/2"............................................................................. 162
1-1/2"............................................................................. 162
1-1/2"............................................................................. 162
1-1/2"............................................................................. 162
1".................................................................................... 162
1".................................................................................... 162
1".................................................................................... 162
1".................................................................................... 162
HYQVIA -immun glob inj 2.5 gm/25ml-hyaluron inj 200
unt/1.25 ml kit................................................................. 15
HYQVIA -immun glob inj 5 gm/50ml-hyaluron inj 400
unt/2.5 ml kit................................................................... 15
unt/5 ml kit...................................................................... 15
239
2016
unt/10 ml kit.................................................................... 15
unt/15 ml kit.................................................................... 15
HY-VEE LANCETS -lancets............................................ 162
HY-VEE THIN LANCETS -lancets.................................. 162
HYZAAR -losartan potassium & hydrochlorothiazide tab
50-12.5 mg...................................................................... 47
100-12.5 mg.................................................................... 47
100-25 mg....................................................................... 47
I
ibandronate sodium tab 150 mg (base equivalent)
(Boniva).......................................................................... 35
IBG STAR BLOOD GLUCOSE MO -blood glucose
IBRANCE -palbociclib cap 75 mg..................................... 17
IBRANCE -palbociclib cap 100 mg................................... 17
IBRANCE -palbociclib cap 125 mg................................... 17
ibuprofen susp 100 mg/5ml............................................ 92
ibuprofen tab 400 mg...................................................... 92
ibuprofen tab 600 mg...................................................... 92
ibuprofen tab 800 mg...................................................... 92
ICLUSIG -ponatinib hcl tab 15 mg (base equiv)............... 17
ICLUSIG -ponatinib hcl tab 45 mg (base equiv)............... 17
IDELVION -coagulation factor ix (recomb) (rix-fp) for inj
250 unit......................................................................... 117
500 unit......................................................................... 117
1000 unit....................................................................... 117
2000 unit....................................................................... 117
ILEVRO -nepafenac ophth susp 0.3%............................ 121
imatinib mesylate tab 100 mg (base equivalent)
(Gleevec)........................................................................ 17
imatinib mesylate tab 400 mg (base equivalent)
(Gleevec)........................................................................ 17
IMBRUVICA -ibrutinib cap 140 mg................................... 17
imipramine hcl tab 10 mg (Tofranil).............................. 72
imipramine pamoate cap 75 mg (Tofranil-pm)............. 72
imipramine pamoate cap 100 mg (Tofranil-pm)........... 72
imiquimod cream 5% (Aldara)...................................... 130
IMITREX -sumatriptan nasal spray 5 mg/act.................... 94
IMITREX -sumatriptan nasal spray 20 mg/act.................. 94
IMPAVIDO -miltefosine cap 50 mg.................................... 12
IMURAN -azathioprine tab 50 mg................................... 194
INATAL ADVANCE -prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg...................................................................105
INATAL GT -prenatal vit w/ dss-iron carbonyl-fa tab 90-1
mg.................................................................................. 105
INATAL ULTRA -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg......................................................................... 105
INCRELEX -mecasermin inj 40 mg/4ml (10 mg/ml)..........35
INCRUSE ELLIPTA -umeclidinium br aero powd breath
act 62.5 mcg/inh (base eq)............................................ 59
indapamide tab 1.25 mg..................................................51
indapamide tab 2.5 mg.................................................... 51
INDERAL LA -propranolol hcl cap sr 24hr 60 mg............. 39
INDERAL LA -propranolol hcl cap sr 24hr 80 mg............. 39
INDERAL LA -propranolol hcl cap sr 24hr 120 mg........... 39
INDERAL LA -propranolol hcl cap sr 24hr 160 mg........... 39
INDERAL XL -propranolol hcl sustained-release beads
cap sr 24hr 80 mg.......................................................... 39
INDERAL XL -propranolol hcl sustained-release beads
cap sr 24hr 120 mg........................................................ 39
INDOCIN -indomethacin suppos 50 mg............................ 92
INDOCIN -indomethacin susp 25 mg/5ml......................... 92
indomethacin cap cr 75 mg............................................ 92
indomethacin cap 25 mg................................................ 92
indomethacin cap 50 mg................................................ 92
INFANATE BALANCE -prenatal w/o a w/fe cbn-dss-fa-dha
cap 29-1-265 mg.......................................................... 105
INFANRIX -diph, acellular pert & tet tox inj 25 lf-58
mcg-10 lf/0.5ml............................................................... 14
INFINITY BLOOD GLUCOSE MO -blood glucose
INFINITY BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 136
INLYTA -axitinib tab 1 mg.................................................. 17
INLYTA -axitinib tab 5 mg.................................................. 17
INNOPRAN XL -propranolol hcl sustained-release beads
cap sr 24hr 80 mg.......................................................... 39
INNOPRAN XL -propranolol hcl sustained-release beads
cap sr 24hr 120 mg........................................................ 39
INSPRA -eplerenone tab 25 mg....................................... 47
INSPRA -eplerenone tab 50 mg....................................... 47
INSULIN SYRINGE/0.5ML/27G -insulin syringe/needle
u-100 1/2 ml 27 x 1/2".................................................. 164
u-100 1/2 ml 28 x 1/2".................................................. 164
u-100 1/2 ml 30 x 5/16"................................................ 164
u-100 1/2 ml 30 x 1/2".................................................. 164
u-100 1/2 ml 31 x 5/16"................................................ 164
u-100 0.3 ml 29 x 1/2".................................................. 163
u-100 0.3 ml 30 x 5/16"................................................ 163
u-100 0.3 ml 31 x 5/16"................................................ 164
u-100 0.3 ml 29 x 1".....................................................163
INSULIN SYRINGE/1ML/28G X -insulin syringe/needle
u-100 1 ml 28 x 1/2".....................................................164
240
2016
u-100 1 ml 29 x 1/2".....................................................164
u-100 1 ml 30 x 5/16"...................................................164
INSULIN SYRINGE/U-100/0.5 -insulin syringe/needle
u-100 1/2 ml 28 x 1/2".................................................. 163
u-100 1/2 ml 29 x 1/2".................................................. 163
u-100 0.3 ml 29 x 1/2".................................................. 163
INSULIN SYRINGE/U-100/1ML -insulin syringe/needle
u-100 1 ml 28 x 1/2".....................................................163
u-100 1 ml 29 x 1/2".....................................................163
u-100 1 ml 30 x 5/16"...................................................163
u-100 1 ml 31 x 5/16"...................................................163
INSUL-TOTE -blood glucose monitoring supplies.......... 163
INSUL-TOTE JR -blood glucose monitoring supplies..... 163
INSUPEN 33GX4MM -insulin pen needle 33 g x 4 mm
(5/32")............................................................................ 164
INSUPEN PEN NEEDLES 32G X -insulin pen needle 32
g x 4 mm (5/32")...........................................................164
INSUPEN SENSITIVE 32GX8MM -insulin pen needle 32
g x 8 mm....................................................................... 164
INSUPEN SENSITIVE 32GX6MM -insulin pen needle 32
g x 6 mm (1/4").............................................................164
INSUPEN ULTRAFIN 29GX12MM -insulin pen needle 29
g x 12 mm (1/2")...........................................................164
INSUPEN ULTRAFIN 31GX6MM -insulin pen needle 31 g
x 6 mm (1/4")................................................................ 164
x 8 mm (1/3" or 5/16").................................................. 164
x 8 mm (1/3" or 5/16").................................................. 164
INTEGRA F -fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe)................................... 113
INTELENCE -etravirine tab 25 mg...................................... 7
INTELENCE -etravirine tab 100 mg.................................... 8
INTELENCE -etravirine tab 200 mg.................................... 8
IN TOUCH -blood glucose monitoring devices............... 163
IN TOUCH BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 136
IN TOUCH DIABETES MANAGEM -blood glucose
monitoring misc............................................................. 163
IN TOUCH LANCING DEVICE -lancet devices.............. 163
IN TOUCH STERILE LANCETS -lancets........................163
INTRON A -interferon alfa-2b for inj 10000000 unit.......... 17
INTRON A -interferon alfa-2b inj 6000000 unit/ml............ 17
INTRON A -interferon alfa-2b inj 10000000 unit/ml.......... 17
INTRON A W/DILUENT -interferon alfa-2b for inj
10000000 unit................................................................. 17
18000000 unit................................................................. 17
50000000 unit................................................................. 17
INVEGA -paliperidone tab sr 24hr 1.5 mg........................ 75
INVEGA -paliperidone tab sr 24hr 3 mg........................... 75
INVIRASE -saquinavir mesylate cap 200 mg..................... 8
INVIRASE -saquinavir mesylate tab 500 mg...................... 8
INVOKAMET -canagliflozin-metformin hcl tab 50-500
mg.................................................................................... 28
mg.................................................................................... 28
mg.................................................................................... 28
mg.................................................................................... 28
INVOKANA -canagliflozin tab 100 mg.............................. 28
INVOKANA -canagliflozin tab 300 mg.............................. 28
iodoquinol-hc cream 1%............................................... 130
IOPIDINE -apraclonidine hcl ophth soln 0.5% (base
equivalent)..................................................................... 121
IOPIDINE -apraclonidine hcl ophth soln 1% (base
equivalent)..................................................................... 121
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml..... 59
ipratropium bromide inhal soln 0.02%.......................... 59
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
(Atrovent)....................................................................... 57
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
(Atrovent)....................................................................... 57
irbesartan-hydrochlorothiazide tab 150-12.5 mg
(Avalide)..........................................................................47
irbesartan-hydrochlorothiazide tab 300-12.5 mg
(Avalide)..........................................................................47
irbesartan tab 75 mg (Avapro)....................................... 47
irbesartan tab 150 mg (Avapro)..................................... 47
irbesartan tab 300 mg (Avapro)..................................... 47
IRESSA -gefitinib tab 250 mg........................................... 17
irrigation solution, physiological................................. 194
ISENTRESS -raltegravir potassium chew tab 25 mg (base
equiv)................................................................................. 8
ISENTRESS -raltegravir potassium chew tab 100 mg
(base equiv)...................................................................... 8
ISENTRESS -raltegravir potassium packet for susp 100
mg (base equiv)................................................................ 8
ISENTRESS -raltegravir potassium tab 400 mg (base
equiv)................................................................................. 8
isometheptene-caffeine-acetaminophen tab 65-20-325
mg (Prodrin)...................................................................94
isometheptene-dichloral-acetaminophen cap
65-100-325 mg............................................................... 94
ISONIAZID -isoniazid syrup 50 mg/5ml.............................. 5
isoniazid tab 100 mg......................................................... 5
isoniazid tab 300 mg......................................................... 5
ISOPTO CARPINE -pilocarpine hcl ophth soln 1%........ 121
241
2016
ISOSORBIDE DINITRATE ER -isosorbide dinitrate tab cr
40 mg.............................................................................. 37
isosorbide dinitrate tab 10 mg....................................... 37
isosorbide dinitrate tab 5 mg (Isordil titradose).......... 37
isosorbide mononitrate tab 10 mg................................ 37
isosorbide mononitrate tab 20 mg................................ 37
isosorbide mononitrate tab sr 24hr 30 mg................... 37
isosorbide mononitrate tab sr 24hr 60 mg................... 37
isosorbide mononitrate tab sr 24hr 120 mg................. 37
isotretinoin cap 10 mg.................................................. 130
ISOXSUPRINE HCL -isoxsuprine hcl tab 20 mg.............. 55
isoxsuprine hcl tab 10 mg.............................................. 55
isradipine cap 2.5 mg...................................................... 41
isradipine cap 5 mg......................................................... 41
ISTALOL -timolol maleate ophth soln 0.5% (oncedaily).............................................................................. 121
itraconazole cap 100 mg (Sporanox).............................. 6
ivermectin tab 3 mg (Stromectol).................................. 11
IXINITY -coagulation factor ix (recombinant) for inj 500
unit................................................................................. 117
unit................................................................................. 117
unit................................................................................. 117
J
JADENU -deferasirox tab 90 mg..................................... 133
JADENU -deferasirox tab 180 mg................................... 133
JADENU -deferasirox tab 360 mg................................... 133
JAKAFI -ruxolitinib phosphate tab 5 mg (base
equivalent)....................................................................... 17
equivalent)....................................................................... 17
equivalent)....................................................................... 17
equivalent)....................................................................... 17
equivalent)....................................................................... 17
JALYN -dutasteride-tamsulosin hcl cap 0.5-0.4 mg.......... 69
JANUMET -sitagliptin-metformin hcl tab 50-500 mg......... 28
JANUMET -sitagliptin-metformin hcl tab 50-1000 mg....... 29
JANUMET XR -sitagliptin-metformin hcl tab sr 24hr
50-500 mg....................................................................... 29
50-1000 mg..................................................................... 29
100-1000 mg................................................................... 29
JANUVIA -sitagliptin phosphate tab 25 mg (base
equiv)............................................................................... 29
equiv)............................................................................... 29
equiv)............................................................................... 29
JENTADUETO -linagliptin-metformin hcl tab 2.5-1000
mg.................................................................................... 29
mg.................................................................................... 29
mg.................................................................................... 29
JENTADUETO XR -linagliptin-metformin hcl tab sr 24hr
2.5-1000 mg.................................................................... 29
JENTADUETO XR -linagliptin-metformin hcl tab sr 24hr
5-1000 mg....................................................................... 29
JUXTAPID -lomitapide mesylate cap 5 mg (base
equiv)............................................................................... 53
equiv)............................................................................... 53
equiv)............................................................................... 53
equiv)............................................................................... 53
equiv)............................................................................... 53
equiv)............................................................................... 53
K
KADIAN -morphine sulfate cap sr 24hr 10 mg..................88
KADIAN -morphine sulfate cap sr 24hr 100 mg................88
KADIAN -morphine sulfate cap sr 24hr 200 mg................88
KALETRA -lopinavir-ritonavir soln 400-100 mg/5ml (80-20
mg/ml)................................................................................ 8
KALETRA -lopinavir-ritonavir tab 100-25 mg...................... 8
KALETRA -lopinavir-ritonavir tab 200-50 mg...................... 8
KALYDECO -ivacaftor packet 50 mg................................ 61
KALYDECO -ivacaftor packet 75 mg................................ 61
KALYDECO -ivacaftor tab 150 mg.................................... 61
KAPVAY -clonidine hcl tab sr 12hr 0.1 mg........................ 80
KAYEXALATE -sodium polystyrene sulfonate
powder........................................................................... 194
KAZANO -alogliptin-metformin hcl tab 12.5-1000 mg....... 29
KAZANO -alogliptin-metformin hcl tab 12.5-500 mg......... 29
KEFLEX -cephalexin cap 250 mg....................................... 2
KEPPRA -levetiracetam oral soln 100 mg/ml................... 97
KEPPRA -levetiracetam tab 250 mg................................. 97
KEPPRA -levetiracetam tab 1000 mg............................... 97
KEPPRA XR -levetiracetam tab sr 24hr 500 mg.............. 97
KEPPRA XR -levetiracetam tab sr 24hr 750 mg.............. 97
242
2016
KERALYT -salicylic acid gel 6%...................................... 130
KERLONE -betaxolol hcl tab 10 mg................................. 39
KERLONE -betaxolol hcl tab 20 mg................................. 39
KETEK -telithromycin tab 300 mg..................................... 12
KETEK -telithromycin tab 400 mg..................................... 12
KETOCARE -acetone (urine) test strip........................... 136
ketoconazole cream 2%................................................ 130
ketoconazole foam 2% (Extina)................................... 130
ketoconazole shampoo 2% (Nizoral)........................... 130
ketoconazole tab 200 mg.................................................. 6
KETONE TEST STRIPS -acetone (urine) test strip........ 136
ketoprofen cap 50 mg..................................................... 92
ketoprofen cap 75 mg..................................................... 92
KETOPROFEN ER -ketoprofen cap sr 24hr 200 mg........ 92
ketorolac tromethamine ophth soln 0.5%
(Acular)......................................................................... 121
ketorolac tromethamine ophth soln 0.4% (Acular
ls)................................................................................... 121
ketorolac tromethamine tab 10 mg............................... 92
KETOSTIX -acetone (urine) test strip............................. 136
KEVEYIS -dichlorphenamide tab 50 mg........................... 51
KHEDEZLA -desvenlafaxine tab sr 24hr 50 mg............... 72
KHEDEZLA -desvenlafaxine tab sr 24hr 100 mg............. 72
KINERET -anakinra subcutaneous soln prefilled syringe
100 mg/0.67ml................................................................ 92
KINNEY LANCETS -lancets............................................ 164
KINNEY THIN LANCETS -lancets.................................. 164
KINRAY INSULIN SYRINGE/0. -insulin syringe/needle
u-100 1/2 ml 29 x 1/2".................................................. 164
KINRAY INSULIN SYRINGE PR -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 164
u-100 1 ml 31 x 5/16"...................................................164
u-100 0.3 ml 31 x 5/16"................................................ 164
KINRIX -diph-tetanus tox ad-acell pert & polio virus, ipv
vac inj.............................................................................. 14
KITABIS PAK -tobramycin nebu soln 300 mg/5ml.............. 5
KLARON -sulfacetamide sodium lotion 10% (acne)....... 130
KLOR-CON M15 -potassium chloride microencapsulated
crys cr tab 15 meq....................................................... 111
KMART VALU PLUS INSULIN S -insulin syringe (disp)
u-100 1/2 ml.................................................................. 164
u-100 0.3 ml.................................................................. 164
u-100 1 ml..................................................................... 164
KOATE-DVI -antihemophilic factor (human) for inj 250
unit................................................................................. 117
unit................................................................................. 118
unit................................................................................. 118
KOGENATE FS -antihemophilic factor (recombinant) for
inj kit 250 unit............................................................... 118
inj kit 500 unit............................................................... 118
inj kit 1000 unit............................................................. 118
inj kit 2000 unit............................................................. 118
inj kit 3000 unit............................................................. 118
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 250 unit.................................. 118
(recombinant) for inj kit 500 unit.................................. 118
(recombinant) for inj kit 1000 unit................................ 118
KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr
2.5-1000 mg.................................................................... 29
5-500 mg......................................................................... 29
5-1000 mg....................................................................... 29
KORLYM -mifepristone tab 300 mg.................................. 29
KOVALTRY -antihemophilic factor (recombinant) for inj
250 unit......................................................................... 118
500 unit......................................................................... 118
1000 unit....................................................................... 118
2000 unit....................................................................... 118
3000 unit....................................................................... 118
K-PHOS NEUTRAL -pot phos monobasic w/sod phos di &
monobas tab 155-852-130mg...................................... 111
K-PHOS NO 2 -potassium & sodium acid phosphates tab
305-700 mg..................................................................... 69
K-PHOS -potassium phosphate monobasic tab 500
mg.................................................................................. 111
KRISTALOSE -lactulose oral crystal packet 10 gm.......... 61
KRISTALOSE -lactulose oral crystal packet 20 gm.......... 61
KROGER BLOOD GLUCOSE MONI -blood glucose
KROGER BLOOD GLUCOSE TEST -glucose blood test
strip................................................................................ 137
KROGER INSULIN SYRINGE/0. -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 165
u-100 1/2 ml 29 x 1/2".................................................. 165
u-100 1/2 ml 30 x 5/16"................................................ 165
u-100 0.3 ml 29 x 1/2".................................................. 164
u-100 0.3 ml 30 x 5/16"................................................ 164
u-100 0.3 ml 31 x 5/16"................................................ 165
243
2016
KROGER INSULIN SYRINGE/1M -insulin syringe/needle
u-100 1 ml 29 x 1/2".....................................................165
u-100 1 ml 30 x 5/16"...................................................165
u-100 1 ml 31 x 5/16"...................................................165
KROGER INSULIN SYRINGE/U- -insulin syringe/needle
u-100 0.3 ml 30 x 1/2".................................................. 164
KROGER LANCETS 21G -lancets.................................. 165
KROGER LANCETS -lancets.......................................... 165
KROGER LANCETS MICRO THIN -lancets................... 165
KROGER LANCETS SUPER THIN -lancets.................. 165
KROGER LANCETS THIN 26G -lancets........................ 165
KROGER LANCETS THIN -lancets................................ 165
KROGER LANCETS ULTRATHIN -lancets..................... 165
KROGER LANCING DEVICE -lancet devices................ 165
KROGER PEN NEEDLES 31GX1/ -insulin pen needle 31
g x 6 mm (1/4").............................................................165
KROGER PEN NEEDLES 29G X -insulin pen needle 29 g
x 12 mm (1/2").............................................................. 165
KROGER PEN NEEDLES 31G X -insulin pen needle 31 g
x 8 mm (1/3" or 5/16").................................................. 165
KROGER PREMIUM BLOOD GLUC -blood glucose
KROGER PREMIUM BLOOD GLUC -glucose blood test
strip................................................................................ 137
KROGER TEST STRIPS -glucose blood test strip......... 137
K-TAB -potassium chloride tab cr 10 meq...................... 111
K-TAB -potassium chloride tab cr 8 meq (600 mg)......... 111
K-TAB -potassium chloride tab cr 20 meq (1500 mg)..... 111
KUVAN -sapropterin dihydrochloride powder packet 100
mg.................................................................................... 35
KUVAN -sapropterin dihydrochloride powder packet 500
mg.................................................................................... 35
KUVAN -sapropterin dihydrochloride soluble tab 100
mg.................................................................................... 35
KYNAMRO -mipomersen sodium soln prefilled syringe
200 mg/ml....................................................................... 53
L
labetalol hcl tab 100 mg (Trandate)............................... 39
LAC-HYDRIN -lactic acid (ammonium lactate) cream
12%................................................................................130
LAC-HYDRIN -lactic acid (ammonium lactate) lotion
12%................................................................................130
LACRISERT -artificial tear ophth insert...........................122
lactated ringer's for irrigation...................................... 194
lactic acid (ammonium lactate) cream 12% (Lachydrin).......................................................................... 130
lactic acid (ammonium lactate) lotion 12% (Lachydrin).......................................................................... 130
lactulose (encephalopathy) solution 10 gm/15ml........ 65
lactulose solution 10 gm/15ml....................................... 61
LAMICTAL CHEWABLE DISPERS -lamotrigine tab
chewable dispersible 5 mg............................................. 97
LAMICTAL CHEWABLE DISPERS -lamotrigine tab
chewable dispersible 25 mg........................................... 97
LAMICTAL -lamotrigine tab 25 mg.................................... 97
LAMICTAL -lamotrigine tab 100 mg.................................. 97
LAMICTAL ODT -lamotrigine orally disintegrating tab 25
mg.................................................................................... 97
mg.................................................................................... 97
mg.................................................................................... 97
mg.................................................................................... 97
LAMICTAL ODT -lamotrigine tab disp 25 (14) & 50 mg
(14) & 100 mg (7) kit...................................................... 97
LAMICTAL ODT -lamotrigine tab disp 25 mg (21) & 50 mg
(7) titration kit.................................................................. 97
LAMICTAL ODT -lamotrigine tab disp 50 mg (42) & 100
mg (14) titration kit......................................................... 97
LAMICTAL STARTER/NOT TAKI -lamotrigine tab 25 mg
(42) & 100 mg (7) starter kit...........................................97
LAMICTAL STARTER/TAKING C -lamotrigine tab 25 mg
(84) & 100 mg (14) starter kit.........................................98
LAMICTAL STARTER/TAKING V -lamotrigine tab 25 mg
(35) starter kit..................................................................98
LAMICTAL XR -lamotrigine tab sr 24hr 25 (14) & 50 mg
(14) & 100 mg(7) kit....................................................... 98
LAMICTAL XR -lamotrigine tab sr 24hr 50 (14) & 100
mg(14) & 200 mg(7) kit.................................................. 98
LAMICTAL XR -lamotrigine tab sr 24hr 25 mg................. 98
LAMICTAL XR -lamotrigine tab sr 24hr 50 mg................. 98
LAMICTAL XR -lamotrigine tab sr 24hr 100 mg............... 98
LAMICTAL XR -lamotrigine tab sr 24hr 25 mg (21) & 50
mg (7) titration kit............................................................98
LAMISIL SPRAY -terbinafine hcl soln 1%....................... 130
LAMISIL -terbinafine hcl tab 250 mg.................................. 6
lamivudine oral soln 10 mg/ml (Epivir)........................... 8
lamivudine tab 150 mg (Epivir)........................................ 8
lamivudine tab 300 mg (Epivir)........................................ 8
lamivudine tab 100 mg (hbv) (Epivir hbv)....................... 8
lamivudine-zidovudine tab 150-300 mg (Combivir)....... 8
lamotrigine orally disintegrating tab 25 mg (Lamictal
odt).................................................................................. 98
odt).................................................................................. 98
odt).................................................................................. 98
odt).................................................................................. 98
lamotrigine tab chewable dispersible 5 mg (Lamictal
chewable di).................................................................. 98
lamotrigine tab chewable dispersible 25 mg (Lamictal
chewable di).................................................................. 98
244
2016
lamotrigine tab disp 25 (14) & 50 mg (14) & 100 mg (7)
kit (LAMICTAL ODT)..................................................... 98
lamotrigine tab disp 25 mg (21) & 50 mg (7) titration
kit (LAMICTAL ODT)..................................................... 98
lamotrigine tab disp 50 mg (42) & 100 mg (14) titration
kit (LAMICTAL ODT)..................................................... 98
lamotrigine tab 25 mg (Lamictal)................................... 98
lamotrigine tab 100 mg (Lamictal)................................. 98
lamotrigine tab sr 24hr 25 mg (Lamictal xr)................. 98
lamotrigine tab sr 24hr 50 mg (Lamictal xr)................. 98
lamotrigine tab sr 24hr 100 mg (Lamictal xr)............... 98
LANCET DEVICE ADJUSTABLE -lancet devices.......... 165
LANCET DEVICE WITH EJECTO -lancet devices......... 165
LANCETS 30G/TWIST TOP -lancets.............................. 165
LANCETS 28G -lancets................................................... 165
LANCETS 30G -lancets................................................... 165
LANCETS 26G TWIST TOP -lancets..............................165
LANCETS 33G UNIVERSAL DES -lancets.................... 166
LANCETS -lancets........................................................... 165
LANCETS MICRO THIN 33G -lancets............................ 165
LANCETS SAFETY SEAL 21G -lancets......................... 165
LANCETS SUPER THIN 28G -lancets........................... 165
LANCETS THIN -lancets................................................. 165
LANCETS TWIST TOP -lancets......................................165
LANCETS ULTRA FINE -lancets.................................... 165
LANCETS ULTRA THIN 30G -lancets............................ 165
LANCETS ULTRA THIN -lancets.................................... 165
LANCING DEVICE ADJUSTABLE -lancet devices......... 166
LANCING DEVICE -lancet devices................................. 166
LANOXIN -digoxin tab 62.5 mcg (0.0625 mg).................. 37
LANOXIN -digoxin tab 125 mcg (0.125 mg)..................... 37
LANOXIN -digoxin tab 187.5 mcg (0.1875 mg)................ 37
LANOXIN -digoxin tab 250 mcg (0.25 mg)....................... 37
lansoprazole cap delayed release 15 mg
(Prevacid)....................................................................... 62
lansoprazole cap delayed release 30 mg
(Prevacid)....................................................................... 62
LANTUS -insulin glargine inj 100 unit/ml.......................... 31
LANTUS SOLOSTAR -insulin glargine soln pen-injector
100 unit/ml.......................................................................31
LANZO -lancet devices.................................................... 166
LASIX -furosemide tab 20 mg........................................... 51
LASTACAFT -alcaftadine ophth soln 0.25%................... 122
latanoprost ophth soln 0.005% (Xalatan).................... 122
LATUDA -lurasidone hcl tab 20 mg...................................75
LATUDA -lurasidone hcl tab 120 mg.................................75
LDR BLOOD GLUCOSE TRUETES -blood glucose
LEADER ADVANCED LANCING D -lancet devices....... 166
LEADER INSULIN SYRINGE/0. -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 166
u-100 1/2 ml 28 x 1/2".................................................. 166
u-100 1/2 ml 29 x 1/2".................................................. 166
u-100 1/2 ml 30 x 5/16"................................................ 166
u-100 0.3 ml 29 x 1/2".................................................. 166
u-100 0.3 ml 30 x 5/16"................................................ 166
u-100 0.3 ml 31 x 5/16"................................................ 166
LEADER INSULIN SYRINGE/1M -insulin syringe/needle
u-100 1 ml 28 x 1/2".....................................................166
u-100 1 ml 29 x 1/2".....................................................166
u-100 1 ml 30 x 5/16"...................................................166
u-100 1 ml 31 x 5/16"...................................................166
LEADER LANCETS COLORED -lancets........................ 166
LEADER SUPER THIN LANCET -lancets...................... 166
LEADER THIN LANCETS -lancets................................. 166
LEADER UNIFINE PENTIPS/MI -insulin pen needle 31 g
x 5 mm (3/16").............................................................. 166
LEADER UNIFINE PENTIPS/NA -insulin pen needle 32 g
x 4 mm (5/32").............................................................. 166
LEADER UNIFINE PENTIPS/PL -insulin pen needle 32 g
x 4 mm (5/32").............................................................. 166
LEADER UNIFINE PENTIPS PL -insulin pen needle 31 g
x 5 mm (3/16").............................................................. 166
LEADER UNIFINE PENTIPS PL -insulin pen needle 31 g
x 8 mm (1/3" or 5/16").................................................. 166
LECITHIN -lecithin granules............................................ 112
leflunomide tab 10 mg (Arava)....................................... 92
leflunomide tab 20 mg (Arava)....................................... 92
LENVIMA 14 MG DAILY DOSE -lenvatinib cap therapy
pack 10 & 4 mg (14 mg daily dose)............................... 17
pack 10 & 4 (2) mg (18 mg daily dose)......................... 17
pack 10 (2) & 4 mg (24 mg daily dose)......................... 17
pack 10 mg (10 mg daily dose)..................................... 17
pack 10 (2) mg (20 mg daily dose)................................ 17
pack 4 (2) mg (8 mg daily dose).................................... 17
245
2016
LESCOL XL -fluvastatin sodium tab sr 24 hr 80 mg......... 53
LETAIRIS -ambrisentan tab 5 mg..................................... 55
LETAIRIS -ambrisentan tab 10 mg................................... 55
letrozole tab 2.5 mg (Femara)........................................ 17
LEUCOVORIN CALCIUM -leucovorin calcium tab 10
mg.................................................................................... 17
LEUCOVORIN CALCIUM -leucovorin calcium tab 15
mg.................................................................................... 17
leucovorin calcium tab 5 mg.......................................... 17
leucovorin calcium tab 25 mg........................................ 17
LEUKERAN -chlorambucil tab 2 mg................................. 17
LEUKINE -sargramostim lyophilized for inj 250 mcg...... 113
leuprolide acetate inj kit 5 mg/ml.................................. 17
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base
equiv) (Xopenex concentrate)..................................... 59
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
(Xopenex)....................................................................... 59
(Xopenex)....................................................................... 59
(Xopenex)....................................................................... 59
LEVAQUIN -levofloxacin tab 250 mg.................................. 5
LEVATOL -penbutolol sulfate tab 20 mg........................... 39
LEVBID -hyoscyamine sulfate tab sr 12hr 0.375 mg........ 62
LEVEMIR FLEXTOUCH -insulin detemir soln pen-injector
100 unit/ml.......................................................................31
LEVEMIR -insulin detemir inj 100 unit/ml..........................31
levetiracetam oral soln 100 mg/ml (Keppra).................98
levetiracetam tab 250 mg (Keppra)............................... 98
levetiracetam tab 1000 mg (Keppra)............................. 98
levetiracetam tab sr 24hr 500 mg (Keppra xr).............. 98
levetiracetam tab sr 24hr 750 mg (Keppra xr).............. 98
levobunolol hcl ophth soln 0.5% (Betagan)............... 122
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)..... 35
levocarnitine tab 330 mg (Carnitor)............................... 35
levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5
mg/ml) (Xyzal)................................................................ 56
levocetirizine dihydrochloride tab 5 mg (Xyzal)...........56
levofloxacin ophth soln 0.5%....................................... 122
levofloxacin oral soln 25 mg/ml (Levaquin)................... 5
levofloxacin tab 250 mg (Levaquin)................................ 5
LEVOMEFOLATE DHA -prenat w/fe fum-l methylfolate-fadha cap 27-1.13-0.4 mg............................................... 105
levonorgestrel & ethinyl estradiol (91-day) tab
0.15-0.03 mg.................................................................. 24
levonorgestrel & ethinyl estradiol tab 0.1 mg-20
mcg................................................................................. 24
levonorgestrel & ethinyl estradiol tab 0.15 mg-30
mcg................................................................................. 24
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg............................... 25
levonorgestrel-ethinyl estradiol (continuous) tab
90-20 mcg.......................................................................25
levonorgestrel tab 1.5 mg............................................... 24
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab
0.01mg(7) (Loseasonique)........................................... 24
levonorg-eth est tab 0.15-0.03mg(84) & eth est tab
0.01mg(7) (Seasonique)............................................... 24
levothyroxine sodium tab 25 mcg (Synthroid)............. 31
levothyroxine sodium tab 100 mcg (Synthroid)........... 32
LEVSIN/SL -hyoscyamine sulfate tab sl 0.125 mg........... 62
LEVSIN -hyoscyamine sulfate tab 0.125 mg.................... 62
LEVULAN KERASTICK -aminolevulinic acid hcl for soln
20% (stick applicator)................................................... 130
LEXAPRO -escitalopram oxalate soln 5 mg/5ml (base
equiv)............................................................................... 72
LEXIVA -fosamprenavir calcium susp 50 mg/ml (base
equiv)................................................................................. 8
LEXIVA -fosamprenavir calcium tab 700 mg (base
equiv)................................................................................. 8
LEXUSS 210 -chlorpheniramine w/ codeine liquid 2-10
mg/5ml............................................................................. 57
LIALDA -mesalamine tab delayed release 1.2 gm........... 65
LIBERTY BLOOD GLUCOSE MET -blood glucose
LIBERTY BLOOD GLUCOSE MON -blood glucose
LIBERTY MEDICAL LANCETS 3 -lancets...................... 166
LIBERTY MINI LANCING DEVI -lancet devices............. 166
LIBERTY NEXT GENERATION B -blood glucose
LIBERTY NEXT GENERATION B -glucose blood test
strip................................................................................ 137
LIBERTY TEST STRIPS -glucose blood test strip.......... 137
lidocaine hcl gel 2%...................................................... 130
LIDOCAINE HCL-HYDROCORTIS -lidocainehydrocortisone acetate rectal gel 2.8-0.55%............... 125
LIDOCAINE HCL -lidocaine hcl laryngotracheal soln
4%.................................................................................. 124
lidocaine hcl soln 4% (Xylocaine)............................... 130
lidocaine hcl viscous soln 2%..................................... 124
lidocaine patch 5% (Lidoderm).................................... 130
lidocaine-prilocaine cream 2.5-2.5% (Emla)............... 130
LIDODERM -lidocaine patch 5%..................................... 130
LIFESCAN UNISTIK 2 DEEP P -lancets........................ 166
LIFESCAN UNISTIK II LANCE -lancets.......................... 166
lindane shampoo 1%..................................................... 130
linezolid for susp 100 mg/5ml (Zyvox).......................... 12
246
2016
linezolid tab 600 mg (Zyvox).......................................... 12
LINZESS -linaclotide cap 145 mcg................................... 65
LINZESS -linaclotide cap 290 mcg................................... 65
liothyronine sodium tab 5 mcg (Cytomel).................... 32
liothyronine sodium tab 25 mcg (Cytomel).................. 32
liothyronine sodium tab 50 mcg (Cytomel).................. 32
LIPOFEN -fenofibrate cap 50 mg...................................... 53
LIPOFEN -fenofibrate cap 150 mg.................................... 53
lisinopril & hydrochlorothiazide tab 10-12.5 mg
(Zestoretic)..................................................................... 47
lisinopril & hydrochlorothiazide tab 20-12.5 mg
(Zestoretic)..................................................................... 47
lisinopril & hydrochlorothiazide tab 20-25 mg
(Zestoretic)..................................................................... 47
lisinopril tab 5 mg (Prinivil)............................................ 47
lisinopril tab 10 mg (Prinivil).......................................... 47
lisinopril tab 20 mg (Prinivil).......................................... 47
lisinopril tab 2.5 mg (Zestril).......................................... 47
lisinopril tab 30 mg (Zestril)........................................... 47
lisinopril tab 40 mg (Zestril)........................................... 47
LITETOUCH INSULIN SYRINGE -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 167
u-100 1/2 ml 28 x 1/2".................................................. 167
u-100 1/2 ml 29 x 1/2".................................................. 167
u-100 1/2 ml 30 x 5/16"................................................ 167
u-100 0.3 ml 29 x 1/2".................................................. 167
u-100 0.3 ml 30 x 5/16"................................................ 167
u-100 1 ml 28 x 1/2".....................................................167
u-100 1 ml 29 x 1/2".....................................................167
u-100 1 ml 30 x 5/16"...................................................167
u-100 1 ml 31 x 5/16"...................................................167
u-100 0.3 ml 31 x 5/16"................................................ 167
LITE TOUCH LANCETS -lancets.................................... 166
LITETOUCH LANCETS MICRO T -lancets.................... 167
LITE TOUCH LANCING DEVICE -lancet devices.......... 166
LITE TOUCH LANCING PEN -lancet devices................ 166
LITE TOUCH PEN NEEDLES/31 -insulin pen needle 31 g
x 5 mm (3/16").............................................................. 167
LITETOUCH PEN NEEDLES 29G -insulin pen needle 29
g x 12.7 mm..................................................................167
g x 6 mm (1/4").............................................................167
g x 8 mm (1/3" or 5/16")...............................................167
lithium carbonate cap 300 mg....................................... 75
lithium carbonate cap 150 mg (Lithium carbonate)..... 75
lithium carbonate cap 600 mg (Lithium carbonate)..... 75
LITHIUM CARBONATE -lithium carbonate cap 150
mg.................................................................................... 75
LITHIUM CARBONATE -lithium carbonate cap 600
mg.................................................................................... 75
lithium carbonate tab cr 450 mg.................................... 75
lithium carbonate tab cr 300 mg (Lithobid).................. 75
lithium carbonate tab 300 mg........................................ 75
LITHIUM -lithium oral solution 8 meq/5ml......................... 75
LITHOBID -lithium carbonate tab cr 300 mg..................... 75
LITHOSTAT -acetohydroxamic acid tab 250 mg............... 69
LIVALO -pitavastatin calcium tab 1 mg (base equiv)........ 53
LIVE BETTER ADVANCED LANC -lancet devices......... 167
LIVE BETTER LANCET SUPER -lancets....................... 167
LIVE BETTER LANCET ULTRA -lancets........................ 167
LIVE BETTER PEN NEEDLES 2 -insulin pen needle 29 g
x 12 mm (1/2").............................................................. 167
x 6 mm (1/4")................................................................ 167
x 8 mm (1/3" or 5/16").................................................. 167
LOCAL ANESTHESIA SECURITY -needle (disp) 20 x
4".................................................................................... 167
2".................................................................................... 167
3".................................................................................... 167
4".................................................................................... 167
LOCOID -hydrocortisone butyrate oint 0.1%.................. 130
LOCOID -hydrocortisone butyrate soln 0.1%..................130
LODOSYN -carbidopa tab 25 mg................................... 101
LOESTRIN FE 1.5/30 -norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg...................................... 25
LOESTRIN FE 1/20 -norethindrone ace & ethinyl
estradiol-fe tab 1 mg-20 mcg......................................... 25
LOFIBRA -fenofibrate micronized cap 67 mg................... 53
LOFIBRA -fenofibrate micronized cap 134 mg................. 53
LOFIBRA -fenofibrate micronized cap 200 mg................. 53
LOFIBRA -fenofibrate tab 54 mg...................................... 53
LOFIBRA -fenofibrate tab 160 mg.................................... 53
LO LOESTRIN FE -norethin-eth estradiol-fe tab 1 mg-10
mcg (24)/10 mcg (2)....................................................... 25
LOMOTIL -diphenoxylate w/ atropine tab 2.5-0.025
mg.................................................................................... 61
LONGS INSULIN SYRINGE/0.5 -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 167
LONGS LANCETS STANDARD -lancets........................ 167
LONGS LANCETS THIN -lancets................................... 167
LONGS LANCETS ULTRA THIN -lancets...................... 167
LONSURF -trifluridine-tipiracil tab 15-6.14 mg................. 17
LONSURF -trifluridine-tipiracil tab 20-8.19 mg................. 18
loperamide hcl cap 2 mg................................................ 61
LOPID -gemfibrozil tab 600 mg......................................... 53
LOPRESSOR HCT -metoprolol & hydrochlorothiazide tab
50-25 mg......................................................................... 47
247
2016
LOPRESSOR HCT -metoprolol & hydrochlorothiazide tab
100-25 mg....................................................................... 47
LOPRESSOR -metoprolol tartrate tab 50 mg................... 39
LOPRESSOR -metoprolol tartrate tab 100 mg................. 39
LOPROX -ciclopirox olamine cream 0.77% (base
equiv)............................................................................. 130
loratadine & pseudoephedrine tab sr 12hr 5-120
mg................................................................................... 57
loratadine & pseudoephedrine tab sr 24hr 10-240
mg................................................................................... 57
loratadine rapidly-disintegrating tab 10 mg
(Claritin).......................................................................... 56
loratadine syrup 5 mg/5ml.............................................. 56
loratadine tab 10 mg....................................................... 56
lorazepam conc 2 mg/ml (Lorazepam intensol)........... 70
lorazepam tab 0.5 mg (Ativan)....................................... 70
lorazepam tab 1 mg (Ativan).......................................... 70
lorazepam tab 2 mg (Ativan).......................................... 70
losartan potassium & hydrochlorothiazide tab 50-12.5
mg (Hyzaar)....................................................................47
losartan potassium & hydrochlorothiazide tab
100-12.5 mg (Hyzaar).................................................... 47
losartan potassium & hydrochlorothiazide tab 100-25
mg (Hyzaar)....................................................................47
losartan potassium tab 25 mg (Cozaar)........................ 47
losartan potassium tab 50 mg (Cozaar)........................ 47
losartan potassium tab 100 mg (Cozaar)...................... 47
LOSEASONIQUE -levonorg-eth est tab 0.1-0.02mg(84) &
eth est tab 0.01mg(7)..................................................... 25
LOTEMAX -loteprednol etabonate ophth gel 0.5%......... 122
LOTEMAX -loteprednol etabonate ophth oint 0.5%........ 122
LOTEMAX -loteprednol etabonate ophth susp 0.5%...... 122
LOTENSIN -benazepril hcl tab 10 mg.............................. 47
LOTENSIN HCT -benazepril & hydrochlorothiazide tab
10-12.5 mg...................................................................... 48
20-12.5 mg...................................................................... 48
20-25 mg......................................................................... 48
LOTREL -amlodipine besylate-benazepril hcl cap 5-10
mg.................................................................................... 48
mg.................................................................................... 48
mg.................................................................................... 48
mg.................................................................................... 48
LOTRISONE -clotrimazole w/ betamethasone cream
1-0.05%......................................................................... 130
LOTRONEX -alosetron hcl tab 0.5 mg (base equiv)......... 66
LOTRONEX -alosetron hcl tab 1 mg (base equiv)............ 66
lovastatin tab 10 mg........................................................ 53
lovastatin tab 20 mg........................................................ 53
lovastatin tab 40 mg (Mevacor)..................................... 53
LOVAZA -omega-3-acid ethyl esters cap 1 gm.................53
LOVENOX -enoxaparin sodium inj 30 mg/0.3ml.............115
LOVENOX -enoxaparin sodium inj 100 mg/ml................115
LOVENOX -enoxaparin sodium inj 120 mg/0.8ml...........115
LOVENOX -enoxaparin sodium inj 150 mg/ml................115
LOVENOX -enoxaparin sodium inj 300 mg/3ml..............115
loxapine succinate cap 5 mg......................................... 75
loxapine succinate cap 10 mg....................................... 75
LOZI-FLUR -sodium fluoride lozenge 1 mg f (from 2.2 mg
naf)................................................................................. 111
LUMIGAN -bimatoprost ophth soln 0.01%...................... 122
LURIDE -sodium fluoride chew tab 0.25 mg f (from 0.55
mg naf).......................................................................... 111
LURIDE -sodium fluoride chew tab 0.5 mg f (from 1.1 mg
naf)................................................................................. 111
LURIDE -sodium fluoride chew tab 1 mg f (from 2.2 mg
naf)................................................................................. 111
LURIDE -sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml
naf)................................................................................. 111
LUXIQ -betamethasone valerate aerosol foam
0.12%.............................................................................130
LYNPARZA -olaparib cap 50 mg....................................... 18
LYRICA -pregabalin cap 25 mg.........................................98
LYRICA -pregabalin cap 100 mg.......................................98
LYRICA -pregabalin soln 20 mg/ml................................... 99
LYSODREN -mitotane tab 500 mg....................................18
LYSTEDA -tranexamic acid tab 650 mg......................... 115
M
MACNATAL CN DHA -prenatal w/o a w/fe cbn-dss-fa-dha
cap 28-1-250 mg.......................................................... 105
MACROBID -nitrofurantoin monohydrate macrocrystalline
cap 100 mg..................................................................... 66
MACRODANTIN -nitrofurantoin macrocrystalline cap 25
mg.................................................................................... 66
mg.................................................................................... 66
mg.................................................................................... 66
MAGELLAN INSULIN SAFETY S -insulin syringe/needle
u-100 1/2 ml 29 x 1/2".................................................. 168
u-100 1/2 ml 30 x 5/16"................................................ 168
u-100 0.3 ml 29 x 1/2".................................................. 167
u-100 0.3 ml 30 x 5/16"................................................ 167
248
2016
u-100 1 ml 29 x 1/2".....................................................168
u-100 1 ml 30 x 5/16"...................................................168
MAGELLAN TUBERCULIN SAFET -tuberculin/allergy
MAGELLAN TUBERCULIN SAFET -tuberculin/allergy
MALARONE -atovaquone-proguanil hcl tab 62.5-25
mg.................................................................................... 11
MALARONE -atovaquone-proguanil hcl tab 250-100
mg.................................................................................... 11
malathion lotion 0.5% (Ovide)...................................... 130
MAPROTILINE HCL -maprotiline hcl tab 25 mg............... 72
MARINOL -dronabinol cap 2.5 mg.................................... 63
MARINOL -dronabinol cap 5 mg....................................... 63
MARINOL -dronabinol cap 10 mg..................................... 63
MARNATAL-F -prenatal w/o vit a w/ fe polysac cmplx-fa
cap 60-1 mg.................................................................. 105
MARPLAN -isocarboxazid tab 10 mg............................... 72
MATULANE -procarbazine hcl cap 50 mg........................ 18
MAVIK -trandolapril tab 1 mg............................................ 48
MAVIK -trandolapril tab 2 mg............................................ 48
MAXI-COMFORT INSULIN SYRI -insulin syringe/needle
u-100 1/2 ml 28 x 1/2".................................................. 168
MAXI-COMFORT INSULIN SYRI -insulin syringe/needle
u-100 1 ml 28 x 1/2".....................................................168
MAXIDEX -dexamethasone ophth susp 0.1%................ 122
MAXIMA BLOOD GLUCOSE MONI -blood glucose
MAXIMA BLOOD GLUCOSE TEST -glucose blood test
strip................................................................................ 137
MAXIMA METER KIT -blood glucose monitoring kit w/
device............................................................................ 168
MAXIMA STARTER KIT -blood glucose monitoring kit w/
device............................................................................ 168
MAXITROL -neomycin-polymyxin-dexamethasone ophth
oint 0.1%....................................................................... 122
MAXITROL -neomycin-polymyxin-dexamethasone ophth
susp 0.1%..................................................................... 122
MAXZIDE -triamterene & hydrochlorothiazide tab 75-50
mg.................................................................................... 51
MAXZIDE-25 -triamterene & hydrochlorothiazide tab
37.5-25 mg...................................................................... 51
MD SAFETYGLIDE 27G X 5/8" -needle (disp) 27 x
5/8".................................................................................168
meclizine hcl tab 12.5 mg............................................... 64
meclizine hcl tab 25 mg.................................................. 64
MECLOFENAMATE SODIUM -meclofenamate sodium
cap 50 mg....................................................................... 92
MECLOFENAMATE SODIUM -meclofenamate sodium
cap 100 mg..................................................................... 93
MEDICAL PROVIDER EZ FLU S -influenza virus vac
types a & b pf pref syringe kit 0.5 ml............................. 14
MEDICAL PROVIDER SINGLE U -influenza virus vaccine
split pf susp pref syr kit 0.5 ml....................................... 14
MEDICAL PROVIDER SINGLE U -influenza virus vac
split quad inj prefilled syr kit 0.25 ml.............................. 14
MEDICAL PROVIDER SINGLE U -influenza virus vac
types a & b pf pref syringe kit 0.5 ml............................. 14
MEDICHOICE PRE-SET SAFETY -lancets.................... 168
MEDICHOICE SAFETY LANCET -lancets..................... 168
MEDICINE SHOPPE LANCETS -lancets....................... 168
MEDICINE SHOPPE LANCETS T -lancets.................... 168
MEDICINE SHOPPE PEN NEEDL -insulin pen needle 29
g x 12 mm (1/2")...........................................................168
g x 6 mm (1/4").............................................................168
g x 8 mm (1/3" or 5/16")...............................................168
MEDIC INSULIN SYRINGE/0.5 -insulin syringe/needle
u-100 1/2 ml 30 x 5/16"................................................ 168
MEDIC INSULIN SYRINGE/0.3 -insulin syringe/needle
u-100 0.3 ml 30 x 5/16"................................................ 168
MEDISENSE THIN LANCETS -lancets.......................... 168
MEDLANCE/EXTRA -lancets.......................................... 168
MEDLANCE/LITE -lancets............................................... 168
MEDLANCE/UNIVERSAL -lancets..................................168
MEDLANCE PLUS/LITE 25G -lancets............................ 168
MEDLANCE PLUS EXTRA LANCE -lancets.................. 168
MEDLANCE PLUS LANCETS -lancets...........................168
MEDLANCE PLUS LANCETS LIT -lancets.................... 168
MEDLANCE PLUS LITE LANCET -lancets.................... 168
MEDLANCE PLUS SPECIAL LAN -lancets.................... 168
MEDLANCE PLUS SUPERLITE 3 -lancets.................... 168
MEDLANCE PLUS UNIVERSAL L -lancets.................... 168
MEDROL DOSEPAK -methylprednisolone tab therapy
pack 4 mg (21)............................................................... 20
MEDROL -methylprednisolone tab 2 mg.......................... 20
MEDROL -methylprednisolone tab 16 mg........................ 20
MEDROL -methylprednisolone tab 32 mg........................ 20
medroxyprogesterone acetate tab 2.5 mg
(Provera)......................................................................... 26
medroxyprogesterone acetate tab 5 mg (Provera)...... 26
medroxyprogesterone acetate tab 10 mg
(Provera)......................................................................... 26
mefenamic acid cap 250 mg (Ponstel).......................... 93
mefloquine hcl tab 250 mg............................................. 11
MEGACE ES -megestrol acetate susp 625 mg/5ml......... 26
MEGACE ORAL -megestrol acetate susp 40 mg/ml........ 18
megestrol acetate susp 625 mg/5ml (Megace es)........ 26
megestrol acetate susp 40 mg/ml (Megace oral)......... 18
megestrol acetate tab 20 mg.......................................... 18
megestrol acetate tab 40 mg.......................................... 18
MEIJER BLOOD GLUCOSE MONI -blood glucose
MEIJER BLOOD GLUCOSE TEST -glucose blood test
strip................................................................................ 137
MEIJER COLOR LANCETS UNIV -lancets.................... 168
249
2016
MEIJER ESSENTIAL BLOOD GL -blood glucose
MEIJER ESSENTIAL BLOOD GL -glucose blood test
strip................................................................................ 137
MEIJER LANCETS -lancets............................................ 169
MEIJER LANCETS THIN -lancets.................................. 169
MEIJER LANCETS UNIVERSAL -lancets...................... 169
MEIJER PEN NEEDLES 29G X -insulin pen needle 29 g
x 12 mm (1/2").............................................................. 169
x 6 mm (1/4")................................................................ 169
x 8 mm (1/3" or 5/16").................................................. 169
MEIJER PREMIUM BLOOD GLUC -blood glucose
MEIJER PREMIUM BLOOD GLUC -glucose blood test
strip................................................................................ 137
MEIJER SUPER THIN LANCETS -lancets..................... 169
MEIJER TRUE2GO BLOOD GLUC -blood glucose
MEIJER TRUERESULT BLOOD G -blood glucose
MEIJER TRUETEST BLOOD GLU -glucose blood test
strip................................................................................ 137
MEIJER TRUETRACK BLOOD GL -blood glucose
MEIJER TRUETRACK BLOOD GL -glucose blood test
strip................................................................................ 137
MEKINIST -trametinib dimethyl sulfoxide tab 0.5 mg
(base equivalent)............................................................ 18
MEKINIST -trametinib dimethyl sulfoxide tab 2 mg (base
equivalent)....................................................................... 18
meloxicam tab 7.5 mg (Mobic)....................................... 93
meloxicam tab 15 mg (Mobic)........................................ 93
memantine hcl oral solution 2 mg/ml (Namenda)........ 83
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak
(Namenda titration pa)................................................. 83
memantine hcl tab 5 mg (Namenda)............................. 83
memantine hcl tab 10 mg (Namenda)........................... 83
MENACTRA -meningococcal (a, c, y, and w-135)
conjugate vaccine inj...................................................... 14
MENEST -esterified estrogens tab 0.3 mg....................... 23
MENEST -esterified estrogens tab 0.625 mg................... 23
MENEST -esterified estrogens tab 1.25 mg..................... 23
MENEST -esterified estrogens tab 2.5 mg....................... 23
MENHIBRIX -meningococcal (c & y)-haemophilus b tet
tox conj vac for inj.......................................................... 14
MENOMUNE-A/C/Y/W-135 -meningococcal vaccine a, c,
y, and w-135 inj.............................................................. 14
MENOSTAR -estradiol td patch weekly 14 mcg/24hr....... 23
MENTAX -butenafine hcl cream 1%................................130
MENVEO -meningococcal (a, c, y, and w-135) oligo conj
vac for inj........................................................................ 14
MEPERIDINE HCL/PROMETHAZI -meperidine w/
promethazine cap 50-25 mg.......................................... 88
MEPERIDINE HCL -meperidine hcl oral soln 50
mg/5ml............................................................................. 88
meperidine hcl tab 50 mg (Demerol)............................. 88
meperidine hcl tab 100 mg (Demerol)........................... 88
MEPHYTON -phytonadione tab 5 mg............................. 104
meprobamate tab 200 mg............................................... 70
meprobamate tab 400 mg............................................... 70
MEPRON -atovaquone susp 750 mg/5ml......................... 12
mercaptopurine tab 50 mg............................................. 18
MESALAMINE DR -mesalamine tab delayed release 800
mg.................................................................................... 66
mesalamine enema 4 gm................................................ 66
MESNEX -mesna tab 400 mg........................................... 18
MESTINON -pyridostigmine bromide syrup 60
mg/5ml........................................................................... 104
MESTINON TIMESPAN -pyridostigmine bromide tab cr
180 mg.......................................................................... 104
METADATE CD -methylphenidate hcl cap cr 10 mg
(cd)................................................................................... 80
(cd)................................................................................... 80
(cd)................................................................................... 80
(cd)................................................................................... 80
(cd)................................................................................... 80
(cd)................................................................................... 80
METAPROTERENOL SULFATE -metaproterenol sulfate
syrup 10 mg/5ml............................................................. 59
tab 10 mg........................................................................ 59
tab 20 mg........................................................................ 59
METAXALONE -metaxalone tab 400 mg........................ 103
metaxalone tab 800 mg (Skelaxin).............................. 103
metformin hcl tab 500 mg (Glucophage)...................... 29
metformin hcl tab 850 mg (Glucophage)...................... 29
metformin hcl tab 1000 mg (Glucophage).................... 29
metformin hcl tab sr 24hr 500 mg (Glucophage xr)..... 29
metformin hcl tab sr 24hr 750 mg (Glucophage xr)..... 29
methadone hcl conc 10 mg/ml (Methadose)................ 88
METHADONE HCL -methadone hcl soln 5 mg/5ml..........88
METHADONE HCL -methadone hcl soln 10 mg/5ml........88
methadone hcl soln 5 mg/5ml (Methadone hcl)........... 88
methadone hcl soln 10 mg/5ml (Methadone hcl)......... 88
methadone hcl tab for oral susp 40 mg........................ 88
methadone hcl tab 10 mg (Dolophine).......................... 88
methadone hcl tab 5 mg (Dolophine hcl)..................... 88
METHADOSE -methadone hcl conc 10 mg/ml................. 88
METHADOSE -methadone hcl tab disp 40 mg................. 88
METHADOSE SUGAR-FREE -methadone hcl conc 10
mg/ml............................................................................... 88
methamphetamine hcl tab 5 mg (Desoxyn).................. 80
methazolamide tab 25 mg (Neptazane)......................... 51
methazolamide tab 50 mg (Neptazane)......................... 51
methenamine hippurate tab 1 gm (Hiprex)................... 66
methimazole tab 5 mg (Tapazole).................................. 32
250
2016
methimazole tab 10 mg (Tapazole)................................ 32
METHITEST -methyltestosterone oral tab 10 mg............. 22
methocarbamol tab 750 mg (Robaxin-750).................103
methocarbamol tab 500 mg (Robaxin)........................ 103
methotrexate sodium for inj 1 gm................................. 18
methotrexate sodium inj 50 mg/2ml (25 mg/ml)........... 18
methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)...... 18
methotrexate sodium inj pf 100 mg/4ml (25 mg/
ml)................................................................................... 18
ml)................................................................................... 18
ml)................................................................................... 18
ml)................................................................................... 18
METHOTREXATE SODIUM -methotrexate sodium inj 250
mg/10ml (25 mg/ml)........................................................18
methotrexate sodium tab 2.5 mg (base equiv)............. 18
methoxsalen rapid cap 10 mg (Oxsoralen ultra)........ 130
methscopolamine bromide tab 2.5 mg (Pamine)......... 62
methscopolamine bromide tab 5 mg (Pamine
forte)................................................................................62
METHYCLOTHIAZIDE -methyclothiazide tab 5 mg..........51
METHYLDOPA/HYDROCHLOROTHI -methyldopa &
hydrochlorothiazide tab 250-15 mg................................ 48
METHYLDOPA/HYDROCHLOROTHI -methyldopa &
hydrochlorothiazide tab 250-25 mg................................ 48
methyldopa tab 250 mg.................................................. 48
methyldopa tab 500 mg.................................................. 48
methylergonovine maleate tab 0.2 mg.......................... 33
METHYLIN -methylphenidate hcl chew tab 2.5 mg.......... 80
METHYLIN -methylphenidate hcl chew tab 5 mg............. 80
METHYLIN -methylphenidate hcl chew tab 10 mg........... 80
METHYLIN -methylphenidate hcl soln 5 mg/5ml.............. 80
METHYLIN -methylphenidate hcl soln 10 mg/5ml............ 80
methylphenidate hcl cap cr 10 mg (cd) (Metadate
cd)................................................................................... 80
cd)................................................................................... 80
cd)................................................................................... 80
cd)................................................................................... 80
cd)................................................................................... 80
cd)................................................................................... 80
methylphenidate hcl cap sr 24hr 20 mg (la) (Ritalin
la)..................................................................................... 80
la)..................................................................................... 80
la)..................................................................................... 80
methylphenidate hcl chew tab 2.5 mg (Methylin)........ 80
methylphenidate hcl chew tab 5 mg (Methylin)........... 80
methylphenidate hcl chew tab 10 mg (Methylin)......... 80
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sa osm 18 mg................................................................. 80
sa osm 27 mg................................................................. 80
sa osm 36 mg................................................................. 81
sa osm 54 mg................................................................. 81
sr 24hr 18 mg................................................................. 81
sr 24hr 27 mg................................................................. 81
sr 24hr 36 mg................................................................. 81
sr 24hr 54 mg................................................................. 81
methylphenidate hcl soln 5 mg/5ml (Methylin)............ 81
methylphenidate hcl soln 10 mg/5ml (Methylin).......... 81
methylphenidate hcl tab cr 10 mg................................. 81
methylphenidate hcl tab cr 20 mg................................. 81
methylphenidate hcl tab 5 mg (Ritalin)......................... 81
methylphenidate hcl tab 10 mg (Ritalin)....................... 81
methylphenidate hcl tab 20 mg (Ritalin)....................... 81
methylprednisolone tab 4 mg (Medrol)......................... 20
methylprednisolone tab 8 mg (Medrol)......................... 20
methylprednisolone tab 16 mg (Medrol)....................... 20
methylprednisolone tab 32 mg (Medrol)....................... 20
methylprednisolone tab therapy pack 4 mg (21)
(Medrol dosepak).......................................................... 20
methyltestosterone cap 10 mg (Testred)...................... 22
METIPRANOLOL -metipranolol ophth soln 0.3%........... 122
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)........ 66
metoclopramide hcl tab 5 mg (Reglan)......................... 66
metoclopramide hcl tab 10 mg (Reglan)....................... 66
metolazone tab 2.5 mg.................................................... 51
metolazone tab 5 mg....................................................... 51
metolazone tab 10 mg..................................................... 51
metoprolol & hydrochlorothiazide tab 100-50 mg....... 48
metoprolol & hydrochlorothiazide tab 50-25 mg
(Lopressor hct)..............................................................48
metoprolol & hydrochlorothiazide tab 100-25 mg
(Lopressor hct)..............................................................48
metoprolol succinate tab sr 24hr 25 mg (tartrate
equiv) (Toprol xl)........................................................... 39
equiv) (Toprol xl)........................................................... 39
equiv) (Toprol xl)........................................................... 39
equiv) (Toprol xl)........................................................... 39
METOPROLOL TARTRATE -metoprolol tartrate tab 37.5
mg.................................................................................... 39
METOPROLOL TARTRATE -metoprolol tartrate tab 75
mg.................................................................................... 39
metoprolol tartrate tab 25 mg........................................ 39
metoprolol tartrate tab 50 mg (Lopressor)................... 39
metoprolol tartrate tab 100 mg (Lopressor)................. 39
251
2016
METROCREAM -metronidazole cream 0.75%............... 130
METROGEL -metronidazole gel 1%............................... 130
METROGEL-VAGINAL -metronidazole vaginal gel
0.75%...............................................................................68
METROLOTION -metronidazole lotion 0.75%................ 130
metronidazole cap 375 mg (Flagyl)............................... 12
metronidazole cream 0.75% (Metrocream)................. 130
metronidazole gel 0.75%............................................... 130
metronidazole gel 1% (Metrogel)................................. 130
metronidazole lotion 0.75% (Metrolotion)................... 130
metronidazole tab 250 mg (Flagyl)................................ 12
metronidazole tab 500 mg (Flagyl)................................ 12
metronidazole vaginal gel 0.75% (Metrogelvaginal)........................................................................... 68
MEVACOR -lovastatin tab 40 mg...................................... 53
mexiletine hcl cap 150 mg.............................................. 42
MIACALCIN -calcitonin (salmon) inj 200 unit/ml............... 35
MIACALCIN -calcitonin (salmon) nasal soln 200 unit/
act.................................................................................... 35
MICARDIS HCT -telmisartan-hydrochlorothiazide tab
40-12.5 mg...................................................................... 48
80-12.5 mg...................................................................... 48
80-25 mg......................................................................... 48
MICARDIS -telmisartan tab 20 mg.................................... 48
MICONAZOLE 3 -miconazole nitrate vaginal suppos 200
mg.................................................................................... 68
MICRODOT BLOOD GLUCOSE MO -blood glucose
MICRODOT TEST STRIPS -glucose blood test strip..... 137
MICRO-K -potassium chloride cap cr 8 meq.................. 111
MICRO-K -potassium chloride cap cr 10 meq................ 111
MICROLET LANCETS -lancets....................................... 169
MICROTAINER SAFETY FLOW L -lancets.................... 169
MICROZIDE -hydrochlorothiazide cap 12.5 mg................51
midodrine hcl tab 2.5 mg................................................ 52
midodrine hcl tab 5 mg................................................... 52
midodrine hcl tab 10 mg................................................. 52
MIGERGOT -ergotamine w/ caffeine suppos 2-100
mg.................................................................................... 94
miglitol tab 25 mg (Glyset)............................................. 29
miglitol tab 50 mg (Glyset)............................................. 29
miglitol tab 100 mg (Glyset)........................................... 29
MIGRANAL -dihydroergotamine mesylate nasal spray 4
mg/ml............................................................................... 94
MILLIPRED DP -prednisolone tab therapy pack 5 mg
(21).................................................................................. 20
MILLIPRED DP -prednisolone tab therapy pack 5 mg
(48).................................................................................. 20
MILLIPRED -prednisolone sod phosphate oral soln 10
mg/5ml (base equiv)....................................................... 20
MILLIPRED -prednisolone tab 5 mg................................. 20
MINASTRIN 24 FE -norethindrone ace-eth estradiol-fe
chew tab 1 mg-20 mcg (24)........................................... 25
MINI LANCING DEVICE -lancet devices........................ 169
MINIPRESS -prazosin hcl cap 1 mg................................. 48
MINIVELLE -estradiol td patch twice weekly 0.025
mg/24hr........................................................................... 23
mg/24hr........................................................................... 23
mg/24hr........................................................................... 23
mg/24hr........................................................................... 23
mg/24hr........................................................................... 23
minocycline hcl cap 50 mg (Minocin)............................. 4
minocycline hcl cap 75 mg (Minocin)............................. 4
minocycline hcl cap 100 mg (Minocin)........................... 4
minocycline hcl tab 50 mg............................................... 4
minocycline hcl tab 75 mg............................................... 4
minocycline hcl tab 100 mg............................................. 4
minocycline hcl tab sr 24hr 45 mg.................................. 4
minocycline hcl tab sr 24hr 90 mg.................................. 4
minocycline hcl tab sr 24hr 135 mg................................ 4
minoxidil tab 2.5 mg........................................................ 48
minoxidil tab 10 mg......................................................... 48
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr
0.375 mg....................................................................... 101
0.75 mg......................................................................... 101
1.5 mg........................................................................... 101
2.25 mg......................................................................... 101
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 3
mg.................................................................................. 101
3.75 mg......................................................................... 101
4.5 mg........................................................................... 101
MIRAPEX -pramipexole dihydrochloride tab 0.125
mg.................................................................................. 101
mg.................................................................................. 101
MIRAPEX -pramipexole dihydrochloride tab 0.5 mg.......101
mg.................................................................................. 101
MIRAPEX -pramipexole dihydrochloride tab 1 mg..........101
MIRAPEX -pramipexole dihydrochloride tab 1.5 mg.......101
MIRCERA -methoxy peg-epoetin beta soln prefilled syr 50
mcg/0.3ml...................................................................... 113
MIRCERA -methoxy peg-epoetin beta soln prefilled syr 75
mcg/0.3ml...................................................................... 113
MIRCERA -methoxy peg-epoetin beta soln prefilled syr
100 mcg/0.3ml.............................................................. 113
252
2016
MIRCERA -methoxy peg-epoetin beta soln prefilled syr
200 mcg/0.3ml.............................................................. 113
mirtazapine orally disintegrating tab 15 mg (Remeron
soltab)............................................................................. 72
soltab)............................................................................. 72
soltab)............................................................................. 72
mirtazapine tab 7.5 mg....................................................72
mirtazapine tab 15 mg (Remeron)................................. 72
misoprostol tab 100 mcg (Cytotec)............................... 62
misoprostol tab 200 mcg (Cytotec)............................... 62
MITIGARE -colchicine cap 0.6 mg.................................... 95
MITOSOL -mitomycin for ophth soln kit 0.2 mg.............. 122
1ML ALLERGIST SYRINGE DET -tuberculin/allergy
1ML ALLERGY SYRINGE 28G X -tuberculin/allergy
1ML ALLERGY SYRINGE -tuberculin/allergy syringe/
needle (disp) 1 ml 27 x 1/2"......................................... 193
1ML TB SYRINGE/25G X 5/8" -tuberculin/allergy syringe/
needle (disp) 1 ml 25 x 5/8"......................................... 193
needle (disp) 1 ml 26 x 3/8"......................................... 193
needle (disp) 1 ml 27 x 1/2"......................................... 193
1ML TUBERCULIN SYRINGE DE -tuberculin/allergy
1ML TUBERCULIN SYRINGE DE -tuberculin/allergy
1ML VANISHPOINT TUBERCULI -tuberculin/allergy
syringe/needle (disp) 1 ml 25 x 1"............................... 193
M-M-R II -measles, mumps & rubella virus vaccines for
inj..................................................................................... 14
modafinil tab 100 mg (Provigil)...................................... 81
modafinil tab 200 mg (Provigil)...................................... 81
MODERIBA 1200 DOSE PACK -ribavirin tab 600 mg........ 8
MODERIBA 800 DOSE PACK -ribavirin tab 400 mg.......... 8
MODERIBA -ribavirin tab 200 mg & ribavirin tab 400 mg
dose pack.......................................................................... 8
MODERIBA -ribavirin tab 400 mg & ribavirin tab 600 mg
dose pack.......................................................................... 8
MODICON -norethindrone & ethinyl estradiol tab 0.5
mg-35 mcg...................................................................... 25
moexipril hcl tab 7.5 mg................................................. 48
moexipril hcl tab 15 mg.................................................. 48
moexipril-hydrochlorothiazide tab 7.5-12.5 mg........... 48
moexipril-hydrochlorothiazide tab 15-12.5 mg............ 48
moexipril-hydrochlorothiazide tab 15-25 mg............... 48
MOLINDONE HYDROCHLORIDE -molindone hcl tab 5
mg.................................................................................... 75
mg.................................................................................... 75
mg.................................................................................... 75
mometasone furoate cream 0.1% (Elocon)................ 130
mometasone furoate oint 0.1% (Elocon).................... 130
mometasone furoate solution 0.1% (lotion)
(Elocon)........................................................................ 130
MONOCLATE-P -antihemophilic factor (human) for inj kit
250 unit......................................................................... 118
1000 unit....................................................................... 118
1500 unit....................................................................... 118
MONOJECT BLUNT CANNULA/15 -needle (disp) 15 x
1-1/2"............................................................................. 169
1-1/2"............................................................................. 169
1-1/2"............................................................................. 169
1-1/2"............................................................................. 169
1-1/2"............................................................................. 169
1-1/2"............................................................................. 169
1".................................................................................... 169
1".................................................................................... 169
1".................................................................................... 169
MONOJECT HYPO/ALUM HUB/LU -needle (disp) 15 x
1-1/2"............................................................................. 169
5/8".................................................................................169
3/4".................................................................................169
1-1/2"............................................................................. 169
1-1/2"............................................................................. 169
1-1/4"............................................................................. 169
1-1/2"............................................................................. 169
1-1/2"............................................................................. 170
1-1/2"............................................................................. 170
5/8".................................................................................170
1-1/4"............................................................................. 170
1/2".................................................................................170
253
2016
1-1/4"............................................................................. 170
1".................................................................................... 169
2".................................................................................... 169
1".................................................................................... 169
1".................................................................................... 169
1".................................................................................... 169
1".................................................................................... 170
1".................................................................................... 170
2".................................................................................... 170
MONOJECT HYPO/ALUM HUB/18 -needle (disp) 18 x
1-1/2"............................................................................. 170
MONOJECT HYPO/ALUM HUB/16 -needle (disp) 16 x
1".................................................................................... 170
MONOJECT HYPO/POLYPROPYLE -needle (disp) 18 x
1-1/2"............................................................................. 170
1-1/2"............................................................................. 170
1-1/2"............................................................................. 170
1-1/2"............................................................................. 170
1-1/2"............................................................................. 170
3/4".................................................................................170
5/8".................................................................................170
1-1/2"............................................................................. 170
1/2".................................................................................170
1/2".................................................................................170
3/4".................................................................................170
1".................................................................................... 170
1".................................................................................... 170
1".................................................................................... 170
1".................................................................................... 170
1".................................................................................... 170
1".................................................................................... 170
1".................................................................................... 170
MONOJECT HYPODERMIC NEEDL -needle (disp) 27 x
1-1/2"............................................................................. 170
3/4".................................................................................170
1".................................................................................... 170
MONOJECT INSULIN SYRINGE/ -insulin syringe/needle
u-100 1/2 ml 28 x 1/2".................................................. 171
u-100 1/2 ml 29 x 1/2".................................................. 171
u-100 1/2 ml 30 x 5/16"................................................ 171
u-100 0.3 ml 29 x 1/2".................................................. 171
u-100 0.3 ml 30 x 5/16"................................................ 171
u-100 1 ml 25 x 5/8".....................................................171
u-100 1 ml 27 x 1/2".....................................................171
u-100 1 ml 28 x 1/2".....................................................171
u-100 1 ml 29 x 1/2".....................................................171
u-100 1 ml 30 x 5/16"...................................................171
u-100 1 ml 31 x 5/16"...................................................171
MONOJECT INSULIN SYRINGE/ -insulin syringe (disp)
u-100 1 ml..................................................................... 171
MONOJECT INSULIN SYRINGE -insulin syringe (disp)
u-100 1 ml..................................................................... 171
MONOJECT MAGELLAN SAFETY -needle (disp) 18 x
1-1/2"............................................................................. 171
1-1/2"............................................................................. 171
1-1/2"............................................................................. 171
5/8".................................................................................171
1-1/2"............................................................................. 171
1-1/2"............................................................................. 171
5/8".................................................................................171
5/8".................................................................................171
1".................................................................................... 171
1".................................................................................... 171
1".................................................................................... 171
254
2016
1".................................................................................... 171
1".................................................................................... 171
1".................................................................................... 171
1".................................................................................... 171
MONOJECT MEDICATION TRANS -hypodermic needles
(disposable)................................................................... 171
MONOJECT STANDARD HYPODER -needle (disp) 14 x
1-1/2"............................................................................. 171
1-1/2"............................................................................. 171
1-1/2"............................................................................. 171
1-1/2"............................................................................. 172
1-1/2"............................................................................. 172
1-1/2"............................................................................. 172
1/2".................................................................................172
5/8".................................................................................172
1-1/2"............................................................................. 172
1-1/2"............................................................................. 172
1/2".................................................................................172
1".................................................................................... 171
1".................................................................................... 171
1".................................................................................... 171
1".................................................................................... 172
2".................................................................................... 172
1".................................................................................... 172
1".................................................................................... 172
1".................................................................................... 172
MONOJECT TB SYRINGE-NDL 1 -tuberculin/allergy
MONOJECT TB SYRINGE-NDL 1 -tuberculin/allergy
MONOJECT TUBERCULIN SAFET -tuberculin/allergy
MONOJECT TUBERCULIN SAFET -tuberculin/allergy
MONOJECT TUBERCULIN SYRIN -tuberculin/allergy
MONOJECT ULTRA COMFORT IN -insulin syringe/
needle u-100 1/2 ml 31 x 5/16".................................... 172
needle u-100 1/2 ml 28 x 1/2"...................................... 172
needle u-100 1/2 ml 29 x 1/2"...................................... 172
needle u-100 1/2 ml 30 x 5/16".................................... 172
needle u-100 0.3 ml 29 x 1/2"...................................... 172
needle u-100 0.3 ml 30 x 5/16".................................... 172
needle u-100 1 ml 28 x 1/2"......................................... 172
needle u-100 1 ml 29 x 1/2"......................................... 172
needle u-100 1 ml 30 x 5/16"....................................... 172
needle u-100 0.3 ml 31 x 5/16".................................... 173
MONOLET LANCETS -lancets....................................... 173
MONOLET OPD LANCETS -lancets.............................. 173
MONOLETTOR SAFETY LANCETS -lancets.................173
MONONINE -coagulation factor ix for inj 500 unit.......... 118
MONONINE -coagulation factor ix for inj 1000 unit........ 118
montelukast sodium chew tab 4 mg (base equiv)
(Singulair)....................................................................... 59
montelukast sodium chew tab 5 mg (base equiv)
(Singulair)....................................................................... 59
montelukast sodium oral granules packet 4 mg (base
equiv) (Singulair)...........................................................59
montelukast sodium tab 10 mg (base equiv)
(Singulair)....................................................................... 59
MONUROL -fosfomycin tromethamine powd pack 3 gm
(base equivalent)............................................................ 67
MOORE MED MONOJECT INSULI -insulin syringe/
needle u-100 1/2 ml 28 x 1/2"...................................... 173
needle u-100 1/2 ml 29 x 1/2"...................................... 173
needle u-100 1 ml 28 x 1/2"......................................... 173
needle u-100 1 ml 29 x 1/2"......................................... 173
8-MOP -methoxsalen cap 10 mg.................................... 133
morphine sulfate cap sr 24hr 10 mg (Kadian).............. 88
255
2016
morphine sulfate cap sr 24hr 100 mg (Kadian)............ 88
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 30 mg......................................................................89
24hr 45 mg......................................................................89
24hr 60 mg......................................................................89
24hr 75 mg......................................................................89
24hr 90 mg......................................................................89
24hr 120 mg....................................................................89
MORPHINE SULFATE -morphine sulfate suppos 5
mg.................................................................................... 88
mg.................................................................................... 88
mg.................................................................................... 88
mg.................................................................................... 88
MORPHINE SULFATE -morphine sulfate tab 15 mg........ 88
MORPHINE SULFATE -morphine sulfate tab 30 mg........ 88
morphine sulfate oral soln 10 mg/5ml.......................... 89
morphine sulfate oral soln 20 mg/5ml.......................... 89
morphine sulfate oral soln 100 mg/5ml (20 mg/ml)..... 89
morphine sulfate tab cr 15 mg (Ms contin).................. 89
morphine sulfate tab cr 100 mg (Ms contin)................ 89
morphine sulfate tab cr 200 mg (Ms contin)................ 89
MOTOFEN -difenoxin w/ atropine tab 1-0.025 mg............61
MOVANTIK -naloxegol oxalate tab 12.5 mg (base
equivalent)....................................................................... 66
MOVANTIK -naloxegol oxalate tab 25 mg (base
equivalent)....................................................................... 66
MOVIPREP -peg 3350-kcl-nacl-na sulfate-na ascorbate-c
for soln 100 gm...............................................................61
MOXATAG -amoxicillin (trihydrate) tab sr 24hr 775 mg...... 1
MOXEZA -moxifloxacin hcl ophth soln 0.5% (base eq) (2
times daily).................................................................... 122
moxifloxacin hcl tab 400 mg (base equiv) (Avelox)....... 5
MS INSULIN SYRINGE/0.5ML/ -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 173
u-100 1/2 ml 29 x 1/2".................................................. 173
u-100 1/2 ml 30 x 5/16"................................................ 173
u-100 0.3 ml 29 x 1/2".................................................. 173
u-100 0.3 ml 30 x 5/16"................................................ 173
u-100 0.3 ml 31 x 5/16"................................................ 173
MS INSULIN SYRINGE/1ML/29 -insulin syringe/needle
u-100 1 ml 29 x 1/2".....................................................173
u-100 1 ml 30 x 5/16"...................................................173
u-100 1 ml 31 x 5/16"...................................................173
MULTAQ -dronedarone hcl tab 400 mg (base
equivalent)....................................................................... 42
MULTI-DRAW NEEDLE 20GX1- -needle (disp) 20 x
1-1/2"............................................................................. 173
MULTI-DRAW NEEDLE 21GX1-1 -needle (disp) 21 x
1-1/2"............................................................................. 173
MULTI-DRAW NEEDLE 22GX1-1 -needle (disp) 22 x
1-1/2"............................................................................. 173
MULTI-LANCET DEVICE -lancet devices....................... 173
mupirocin calcium cream 2% (Bactroban)................. 130
mupirocin oint 2% (Bactroban).................................... 130
M-VIT -prenatal vit w/ fe fumarate-fa tab 27-1 mg.......... 105
MYALEPT -metreleptin for subcutaneous inj 11.3 mg...... 35
MYAMBUTOL -ethambutol hcl tab 100 mg......................... 5
MYAMBUTOL -ethambutol hcl tab 400 mg......................... 5
MYCOBUTIN -rifabutin cap 150 mg.................................... 5
mycophenolate mofetil cap 250 mg (Cellcept)........... 194
mycophenolate mofetil for oral susp 200 mg/ml
(Cellcept)...................................................................... 194
mycophenolate mofetil tab 500 mg (Cellcept)............194
mycophenolate sodium tab dr 180 mg (mycophenolic
acid equiv) (Myfortic)................................................. 194
mycophenolate sodium tab dr 360 mg (mycophenolic
acid equiv) (Myfortic)................................................. 194
MYDRIACYL -tropicamide ophth soln 1%...................... 122
MYFORTIC -mycophenolate sodium tab dr 180 mg
(mycophenolic acid equiv)............................................ 194
MYFORTIC -mycophenolate sodium tab dr 360 mg
(mycophenolic acid equiv)............................................ 194
MYGLUCOHEALTH BLOOD GLUCO -blood glucose
MYGLUCOHEALTH BLOOD GLUCO -glucose blood test
strip................................................................................ 137
MYGLUCOHEALTH MGH SOFTLAN -lancets............... 173
MYLERAN -busulfan tab 2 mg.......................................... 18
MYNATAL ADVANCE -prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg...................................................................106
MYNATAL PLUS -prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................. 106
MYNATAL -prenatal multivitamins & minerals w/ iron & fa
cap 1 mg....................................................................... 106
MYNATAL ULTRACAPLET -prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg............................................... 106
MYNATAL-Z -prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................. 106
MYNATE 90 PLUS -prenatal vit w/ dss-fe fumarate-fa tab
cr 90-1 mg.....................................................................106
MYRBETRIQ -mirabegron tab sr 24 hr 25 mg.................. 67
MYRBETRIQ -mirabegron tab sr 24 hr 50 mg.................. 67
N
nabumetone tab 500 mg................................................. 93
nabumetone tab 750 mg................................................. 93
256
2016
nadolol & bendroflumethiazide tab 40-5 mg
(Corzide)......................................................................... 48
nadolol & bendroflumethiazide tab 80-5 mg
(Corzide)......................................................................... 48
nadolol tab 20 mg (Corgard).......................................... 39
naftifine hcl cream 2% (Naftin).................................... 130
NALFON -fenoprofen calcium cap 400 mg....................... 93
naloxone hcl inj 0.4 mg/ml........................................... 133
NALOXONE HCL -naloxone hcl inj 1 mg/ml................... 133
naltrexone hcl tab 50 mg (Revia)................................. 133
NAMENDA -memantine hcl oral solution 2 mg/ml............ 83
NAMENDA -memantine hcl tab 5 mg............................... 83
NAMENDA -memantine hcl tab 10 mg............................. 83
NAMENDA TITRATION PAK -memantine hcl tab 5 mg
(28) & 10 mg (21) titration pak....................................... 83
NAMENDA XR -memantine hcl cap sr 24hr 7 mg............ 83
NAMENDA XR -memantine hcl cap sr 24hr 14 mg.......... 83
NAMENDA XR TITRATION PACK -memantine hcl cap sr
24hr 7 mg & 14 mg & 21 mg & 28 mg pack.................. 83
NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr
14-10 mg......................................................................... 84
NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr
28-10 mg......................................................................... 84
NAPROSYN -naproxen susp 125 mg/5ml........................ 93
NAPROSYN -naproxen tab 500 mg.................................. 93
naproxen sodium tab 275 mg (Anaprox)...................... 93
naproxen sodium tab 550 mg (Anaprox ds)................. 93
naproxen susp 125 mg/5ml............................................ 93
naproxen tab ec 375 mg (Ec-naprosyn)........................ 93
naproxen tab ec 500 mg (Ec-naprosyn)........................ 93
naproxen tab 250 mg (Naprosyn).................................. 93
naratriptan hcl tab 1 mg (base equiv) (Amerge).......... 94
naratriptan hcl tab 2.5 mg (base equiv) (Amerge)....... 94
NARCAN -naloxone hcl nasal spray 4 mg/0.1ml............ 133
NARDIL -phenelzine sulfate tab 15 mg............................ 72
NASCOBAL -cyanocobalamin nasal spray 500
mcg/0.1ml...................................................................... 113
NATACHEW -prenatal vit w/ fe fum-fe bisglycin-fa chew
tab 28-1 mg...................................................................106
NATACYN -natamycin ophth susp 5%............................ 122
NATALVIT -prenatal vit w/ fe fumarate-fa tab 75-1
mg.................................................................................. 106
NATAZIA -estradiol valerate-dienogest tab 3 mg /2-2
mg/2-3 mg/1 mg............................................................. 25
nateglinide tab 60 mg (Starlix)....................................... 29
nateglinide tab 120 mg (Starlix)..................................... 29
NATELLE ONE -prenatal w/o vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg.......................................................... 106
NATPARA -parathyroid hormone (recombinant) for inj
cartridge 25 mcg............................................................. 35
cartridge 50 mcg............................................................. 35
cartridge 75 mcg............................................................. 35
cartridge 100 mcg........................................................... 35
NATROBA -spinosad susp 0.9%..................................... 130
NATURE-THROID NT-2.5 -thyroid tab 162.5 mg (2 1/2
grain)................................................................................32
NATURE-THROID -thyroid tab 16.25 mg..........................32
NATURE-THROID -thyroid tab 32.5 mg............................32
NATURE-THROID -thyroid tab 65 mg...............................32
NATURE-THROID -thyroid tab 81.25 mg..........................32
NATURE-THROID -thyroid tab 97.5 mg............................32
NATURE-THROID -thyroid tab 113.75 mg........................ 32
NATURE-THROID -thyroid tab 130 mg.............................32
NATURE-THROID -thyroid tab 146.25 mg....................... 32
NATURE-THROID -thyroid tab 48.75 mg (3/4 grain)........ 32
NATURE-THROID -thyroid tab 325 mg (5 grain).............. 32
NEBUPENT -pentamidine isethionate for nebulization
soln 300 mg.................................................................... 12
NEBUSAL -sodium chloride soln nebu 6%....................... 57
NECON 1/50-28 -norethindrone & mestranol tab 1 mg-50
mcg.................................................................................. 25
NECON 10/11-28 -norethindrone-eth estradiol tab
0.5-35/1-35 mg-mcg (10/11)........................................... 25
NEEVO DHA -prenat w/o a w/fefum-methylfol-omegas
cap 27-1.13 mg............................................................. 106
NEFAZODONE HCL -nefazodone hcl tab 100 mg........... 72
nefazodone hcl tab 50 mg.............................................. 72
nefazodone hcl tab 250 mg............................................ 72
NEOMYCIN/POLYMYXIN/HYDROC -neomycinpolymyxin-hc ophth susp.............................................. 122
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin............................. 122
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml (Neosporin)........... 122
neomycin-polymyxin-dexamethasone ophth oint 0.1%
(Maxitrol)...................................................................... 122
neomycin-polymyxin-dexamethasone ophth susp
0.1% (Maxitrol).............................................................122
neomycin-polymyxin-hc otic soln 1%
(Cortisporin).................................................................124
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000
unit/ml-1%.................................................................... 124
neomycin sulfate tab 500 mg........................................... 5
NEORAL -cyclosporine modified cap 25 mg...................194
NEORAL -cyclosporine modified cap 100 mg.................194
NEORAL -cyclosporine modified oral soln 100 mg/
ml................................................................................... 194
NEOSPORIN -neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml................................... 122
257
2016
NEPHROCAPS QT -b-complex w/ c-biotin-d & folic acid
tab disp 1 mg................................................................ 106
NEPTAZANE -methazolamide tab 25 mg......................... 51
NEPTAZANE -methazolamide tab 50 mg......................... 51
NESINA -alogliptin benzoate tab 6.25 mg (base
equiv)............................................................................... 29
NESINA -alogliptin benzoate tab 12.5 mg (base
equiv)............................................................................... 29
NESINA -alogliptin benzoate tab 25 mg (base equiv).......29
NESTABS ABC -prenatal w/o vit a w/fe polysac-fa-ca tab
& omega 3 cap............................................................. 106
NESTABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg
& omega cap pack....................................................... 106
NESTABS -prenatal vit w/o vit a w/ fe bisglycinate-fa tab
32-1 mg......................................................................... 106
NETGROUP LANCETS -lancets..................................... 173
NEULASTA ONPRO KIT -pegfilgrastim soln prefilled
syringe kit 6 mg/0.6ml.................................................. 113
NEULASTA -pegfilgrastim soln prefilled syringe 6
mg/0.6ml........................................................................ 113
NEUPOGEN -filgrastim inj 300 mcg/ml........................... 113
NEUPOGEN -filgrastim inj 480 mcg/1.6ml (300 mcg/
ml).................................................................................. 113
NEUPOGEN -filgrastim soln prefilled syringe 300
mcg/0.5ml...................................................................... 113
NEUPOGEN -filgrastim soln prefilled syringe 480
mcg/0.8ml (600 mcg/ml)............................................... 113
NEUPRO -rotigotine td patch 24hr 1 mg/24hr................ 101
NEURONTIN -gabapentin cap 100 mg............................. 99
NEURONTIN -gabapentin oral soln 250 mg/5ml.............. 99
NEURONTIN -gabapentin tab 600 mg.............................. 99
NEURONTIN -gabapentin tab 800 mg.............................. 99
NEUTEK 2TEK TEST STRIPS -glucose blood test
strip................................................................................ 137
NEVANAC -nepafenac ophth susp 0.1%........................ 122
NEVIRAPINE -nevirapine susp 50 mg/5ml......................... 8
nevirapine tab 200 mg (Viramune)...................................8
nevirapine tab sr 24hr 100 mg (Viramune xr)................. 8
nevirapine tab sr 24hr 400 mg (Viramune xr)................. 8
NEWGEN -prenatal vit w/o vit a w/ fe bisglycinate-fa tab
32-1 mg......................................................................... 106
NEXA PLUS -prenatal w/o vit a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg.............................................................106
NEXAVAR -sorafenib tosylate tab 200 mg (base
equivalent)....................................................................... 18
NEXGEN METER KIT -blood glucose monitoring kit...... 173
NEXGEN TEST STRIPS -glucose blood test strip..........137
NEXIUM -esomeprazole magnesium for delayed release
susp packet 5 mg........................................................... 62
susp packet 10 mg......................................................... 63
susp packet 20 mg......................................................... 63
susp packet 40 mg......................................................... 63
susp pack 2.5 mg........................................................... 63
niacin tab cr 500 mg (antihyperlipidemic)
(Niaspan)........................................................................ 53
(Niaspan)........................................................................ 53
(Niaspan)........................................................................ 53
NIACOR -niacin (antihyperlipidemic) tab 500 mg............. 53
NIASPAN -niacin tab cr 500 mg (antihyperlipidemic)........53
NIASPAN -niacin tab cr 750 mg (antihyperlipidemic)........53
NIASPAN -niacin tab cr 1000 mg (antihyperlipidemic)......53
nicardipine hcl cap 20 mg.............................................. 41
nicardipine hcl cap 30 mg.............................................. 41
nicotine polacrilex gum 2 mg.........................................84
nicotine polacrilex gum 4 mg.........................................84
nicotine td patch 24hr 7 mg/24hr...................................84
nicotine td patch 24hr 14 mg/24hr.................................84
nicotine td patch 24hr 21 mg/24hr.................................84
nifedipine cap 20 mg....................................................... 41
nifedipine cap 10 mg (Procardia).................................. 41
nifedipine tab sr 24hr 30 mg (Adalat cc).......................41
nifedipine tab sr 24hr osmotic release 30 mg
(Procardia xl)................................................................. 41
(Procardia xl)................................................................. 41
(Procardia xl)................................................................. 41
NILANDRON -nilutamide tab 150 mg............................... 18
nilutamide tab 150 mg (Nilandron)................................ 18
nimodipine cap 30 mg..................................................... 41
NINLARO -ixazomib citrate cap 2.3 mg (base
equivalent)....................................................................... 18
NINLARO -ixazomib citrate cap 3 mg (base
equivalent)....................................................................... 18
NINLARO -ixazomib citrate cap 4 mg (base
equivalent)....................................................................... 18
NISOLDIPINE ER -nisoldipine tab sr 24hr 25.5 mg.......... 41
NISOLDIPINE -nisoldipine tab sr 24hr 20 mg................... 41
nisoldipine tab sr 24hr 8.5 mg (Sular)........................... 41
nisoldipine tab sr 24hr 17 mg (Sular)............................41
nisoldipine tab sr 24hr 34 mg (Sular)............................41
NITRO-BID -nitroglycerin oint 2%..................................... 37
NITRO-DUR -nitroglycerin td patch 24hr 0.1 mg/hr.......... 37
258
2016
nitrofurantoin macrocrystalline cap 25 mg
(Macrodantin).................................................................67
(Macrodantin).................................................................67
(Macrodantin).................................................................67
nitrofurantoin monohydrate macrocrystalline cap 100
mg (Macrobid)............................................................... 67
nitrofurantoin susp 25 mg/5ml (Furadantin)................ 67
nitroglycerin cap cr 2.5 mg............................................ 38
nitroglycerin cap cr 6.5 mg............................................ 38
nitroglycerin cap cr 9 mg............................................... 38
NITROGLYCERIN LINGUAL -nitroglycerin lingual aerosol
400 mcg/spray................................................................ 38
nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)......... 38
nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)
(Nitrolingual pumpspr)................................................. 38
NITROLINGUAL PUMPSPRAY -nitroglycerin tl soln 0.4
mg/spray (400 mcg/spray)..............................................38
NITROMIST -nitroglycerin lingual aerosol 400 mcg/
spray................................................................................ 38
NITROSTAT -nitroglycerin sl tab 0.3 mg........................... 38
NIVA-PLUS -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 106
nizatidine cap 150 mg..................................................... 63
nizatidine cap 300 mg (Axid).......................................... 63
NIZORAL -ketoconazole shampoo 2%........................... 130
NOKOR ADMIX NEEDLE THIN W -needle (disp) 18 x
1-1/2"............................................................................. 173
NOKOR ADMIX NEEDLE THIN W -needle (disp) 16 x
1".................................................................................... 173
NOKOR VENTED NEEDLE THIN -needle (disp) 18 x
1-1/2"............................................................................. 173
1".................................................................................... 173
1".................................................................................... 173
nonoxynol-9 gel 4%......................................................... 68
NORDITROPIN CARTRIDGE -somatropin inj 5
mg/1.5ml.......................................................................... 35
NORDITROPIN FLEXPRO -somatropin inj 5
mg/1.5ml.......................................................................... 35
mg/1.5ml.......................................................................... 35
mg/1.5ml.......................................................................... 35
mg/3ml............................................................................. 35
norethindrone & ethinyl estradiol-fe chew tab 0.4
mg-35 mcg (Femcon fe)............................................... 25
norethindrone & ethinyl estradiol-fe chew tab 0.8
mg-25 mcg (Generess fe)............................................ 25
norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg
(Brevicon-28)................................................................. 25
norethindrone & ethinyl estradiol tab 1 mg-35 mcg
(Norinyl 1+35)................................................................ 25
norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg
(Ovcon-35)...................................................................... 25
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20
mcg (Loestrin fe 1/20).................................................. 25
norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30
mcg (Loestrin fe 1.5/30)............................................... 25
norethindrone ace & ethinyl estradiol tab 1 mg-20
mcg (Loestrin 1/20-21)................................................. 25
norethindrone ace & ethinyl estradiol tab 1.5 mg-30
mcg (Loestrin 1.5/30-21).............................................. 25
norethindrone ace-ethinyl estradiol-fe tab 1 mg-20
mcg (24)......................................................................... 25
norethindrone acetate-ethinyl estradiol tab 1 mg-5
mcg................................................................................. 23
norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5
mcg (Femhrt low dose)................................................ 23
norethindrone acetate tab 5 mg (Aygestin).................. 26
norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35
mg-mcg (Estrostep fe)................................................. 25
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35
mg-mcg (Ortho-novum 7/7/7)...................................... 25
norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28)...................................................... 25
norethindrone tab 0.35 mg (Nor-qd).............................. 25
norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg
(Ortho-cyclen)................................................................ 25
norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35
mg-mcg (Ortho tri-cyclen)........................................... 25
norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25
mg-mcg (Ortho tri-cyclen lo)....................................... 25
norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg........ 25
NORINYL 1+35 -norethindrone & ethinyl estradiol tab 1
mg-35 mcg...................................................................... 25
NORPACE CR -disopyramide phosphate cap sr 12hr 100
mg.................................................................................... 42
NORPACE CR -disopyramide phosphate cap sr 12hr 150
mg.................................................................................... 42
NORPACE -disopyramide phosphate cap 100 mg........... 42
NORPACE -disopyramide phosphate cap 150 mg........... 42
NORPRAMIN -desipramine hcl tab 10 mg........................72
NORPRAMIN -desipramine hcl tab 25 mg........................72
NOR-QD -norethindrone tab 0.35 mg............................... 25
nortriptyline hcl cap 10 mg (Pamelor)...........................72
NORTRIPTYLINE HCL -nortriptyline hcl soln 10
mg/5ml............................................................................. 72
NORVASC -amlodipine besylate tab 2.5 mg.................... 41
NORVASC -amlodipine besylate tab 5 mg....................... 41
NORVASC -amlodipine besylate tab 10 mg..................... 41
259
2016
NORVIR -ritonavir cap 100 mg........................................... 8
NORVIR -ritonavir oral soln 80 mg/ml.................................8
NORVIR -ritonavir tab 100 mg............................................ 8
NOVA MAX BLOOD GLUCOSE MO -blood glucose
NOVA MAX BLOOD GLUCOSE MO -blood glucose
NOVA MAX GLUCOSE TEST STR -glucose blood test
strip................................................................................ 137
NOVA SAFETY LANCETS 23G -lancets........................ 173
NOVA SAFETY LANCETS 28G -lancets........................ 173
NOVA SUREFLEX LANCETS -lancets........................... 173
NOVA SUREFLEX LANCING DEV -lancet devices........ 174
NOVOEIGHT -antihemophilic factor (recombinant) for inj
250 unit......................................................................... 118
500 unit......................................................................... 118
1000 unit....................................................................... 118
1500 unit....................................................................... 118
2000 unit....................................................................... 118
3000 unit....................................................................... 118
NOVOFINE AUTOCOVER 30GX8M -insulin pen needle
30 g x 8 mm (1/3" or 5/16")......................................... 174
NOVOFINE 32GX6MM -insulin pen needle 32 g x 6 mm
(1/4").............................................................................. 174
NOVOFINE 30GX8MM -insulin pen needle 30 g x 8 mm
(1/3" or 5/16")................................................................174
NOVOFINE PLUS 32GX4MM -insulin pen needle 32 g x 4
mm (5/32").................................................................... 174
NOVOLIN 70/30 -insulin nph isophane & regular human
inj 100 unit/ml (70-30).................................................... 31
NOVOLIN 70/30 RELION -insulin nph isophane & regular
human inj 100 unit/ml (70-30)........................................ 31
NOVOLIN N -insulin nph (human) (isophane) inj 100 unit/
ml..................................................................................... 31
NOVOLIN N RELION -insulin nph (human) (isophane) inj
100 unit/ml.......................................................................31
NOVOLIN R -insulin regular (human) inj 100 unit/ml........ 31
NOVOLIN R RELION -insulin regular (human) inj 100
unit/ml.............................................................................. 31
NOVOLOG FLEXPEN -insulin aspart soln pen-injector
100 unit/ml.......................................................................30
NOVOLOG -insulin aspart inj 100 unit/ml......................... 30
NOVOLOG MIX 70/30 -insulin aspart prot & aspart
(human) inj 100 unit/ml (70-30)...................................... 31
NOVOLOG MIX 70/30 PREFILL -insulin aspart prot &
aspart sus pen-inj 100 unit/ml (70-30)........................... 31
NOVOLOG PENFILL -insulin aspart soln cartridge 100
unit/ml.............................................................................. 30
NOVOPEN ECHO -injection device for insulin............... 174
NOVOSEVEN RT -coagulation factor viia (recomb) for inj
1 mg (1000 mcg).......................................................... 118
2 mg (2000 mcg).......................................................... 118
5 mg (5000 mcg).......................................................... 118
8 mg (8000 mcg).......................................................... 118
NOVOTWIST 30GX8MM -insulin pen needle 30 g x 8 mm
(1/3" or 5/16")................................................................174
NOVOTWIST 32GX5MM -insulin pen needle 32 g x 5 mm
(1/5" or 3/16")................................................................174
NOXAFIL -posaconazole susp 40 mg/ml............................ 6
NOXAFIL -posaconazole tab delayed release 100 mg....... 6
NUCORT -hydrocortisone acetate lotion 2%.................. 131
NUCYNTA ER -tapentadol hcl tab sr 12hr 50 mg............. 89
NUCYNTA ER -tapentadol hcl tab sr 12hr 100 mg........... 89
NUCYNTA -tapentadol hcl tab 50 mg............................... 89
NUCYNTA -tapentadol hcl tab 75 mg............................... 89
NUCYNTA -tapentadol hcl tab 100 mg............................. 89
NUEDEXTA -dextromethorphan hbr-quinidine sulfate cap
20-10 mg......................................................................... 84
NULYTELY/FLAVOR PACKS -peg 3350-kcl-sod bicarbnacl for soln 420 gm.......................................................61
NUOX -benzoyl peroxide-sulfur gel 6-3%....................... 131
NUPLAZID -pimavanserin tartrate tab 17 mg (base
equivalent)....................................................................... 75
NUTRESTORE -glutamine powd pack 5 gm.................. 112
NUTROPIN AQ NUSPIN 10 -somatropin inj 10
mg/2ml............................................................................. 35
NUTROPIN AQ NUSPIN 20 -somatropin inj 20
mg/2ml............................................................................. 35
NUTROPIN AQ NUSPIN 5 -somatropin inj 5 mg/2ml....... 35
NUTROPIN AQ PEN -somatropin inj 10 mg/2ml.............. 35
NUVARING -etonogestrel-ethinyl estradiol va ring
0.120-0.015 mg/24hr...................................................... 26
NUVIGIL -armodafinil tab 50 mg....................................... 81
NUVIGIL -armodafinil tab 150 mg..................................... 81
NUWIQ -antihemophilic factor (recombinant) for inj kit 250
unit................................................................................. 118
NUWIQ -antihemophilic factor (recombinant) for inj kit 500
unit................................................................................. 118
NUWIQ -antihemophilic factor (recombinant) for inj kit
1000 unit....................................................................... 118
NUWIQ -antihemophilic factor (recombinant) for inj kit
2000 unit....................................................................... 119
NUWIQ -antihemophilic factor (recombinant) for inj 250
unit................................................................................. 119
unit................................................................................. 119
unit................................................................................. 119
unit................................................................................. 119
260
2016
NYMALIZE -nimodipine oral soln 60 mg/20ml.................. 41
nystatin cream 100000 unit/gm.................................... 131
nystatin oint 100000 unit/gm........................................ 131
nystatin susp 100000 unit/ml....................................... 124
nystatin tab 500000 unit....................................................6
nystatin topical powder................................................ 131
nystatin-triamcinolone cream 100000-0.1 unit/gm%.................................................................................... 131
nystatin-triamcinolone oint 100000-0.1 unit/gm%.................................................................................... 131
O
OB COMPLETE/DHA -prenat w/ iron cbn-fe asp glyc-faomega cap 30-10-1-200 mg......................................... 106
OB COMPLETE GOLD -prenat w/o a w/fecbn-methfol-fadha cap 27.5-1-200 mg................................................ 106
OB COMPLETE ONE -prenatal w/o a w/fecbn-fe asp
glyc-fa-fish cap 50-1-476 mg........................................106
OB COMPLETE PETITE -prenat w/o a w/fecbnfeaspglyc-fa-omega cap 35-5-1-200 mg...................... 106
OB COMPLETE PREMIER -prenatal vit w/ fe cbn-fe asp
glyc-fa tab 30-20-1 mg................................................. 106
OB COMPLETE -prenatal vit w/ iron carbonyl-fa tab
50-1.25 mg.................................................................... 106
OBIZUR -antihemophilic factor (recomb porc) rpfviii for inj
500 unit......................................................................... 119
OBSTETRIX DHA -prenat w/fecbn-fa-dss tab 29-1 mg &
omega 3 cap 387 mg pak............................................ 106
OBSTETRIX EC -prenatal vit w/ dss-iron carbonyl-fa tab
29-1 mg......................................................................... 106
O-CAL FA -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 106
O-CAL PRENATAL -prenatal vit w/ fe fumarate-fa tab 15-1
mg.................................................................................. 106
octreotide acetate inj 50 mcg/ml (0.05 mg/ml)
(Sandostatin)................................................................. 36
(Sandostatin)................................................................. 36
(Sandostatin)................................................................. 36
(Sandostatin)................................................................. 36
octreotide acetate inj 1000 mcg/ml (1 mg/ml)
(Sandostatin)................................................................. 36
OCUFEN -flurbiprofen sodium ophth soln 0.03%........... 122
OCUFLOX -ofloxacin ophth soln 0.3%........................... 122
ODEFSEY -emtricitabine-rilpivirine-tenofovir af tab
200-25-25 mg.................................................................... 8
ODOMZO -sonidegib phosphate cap 200 mg (base
equivalent)....................................................................... 18
OFEV -nintedanib esylate cap 100 mg (base
equivalent)....................................................................... 61
OFEV -nintedanib esylate cap 150 mg (base
equivalent)....................................................................... 61
OFLOXACIN -ofloxacin tab 400 mg.................................... 5
ofloxacin ophth soln 0.3% (Ocuflox)........................... 122
ofloxacin otic soln 0.3%................................................124
OGESTREL -norgestrel & ethinyl estradiol tab 0.5 mg-50
mcg.................................................................................. 26
olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax)...... 84
olanzapine-fluoxetine hcl cap 12-25 mg
(Symbyax)...................................................................... 84
olanzapine-fluoxetine hcl cap 12-50 mg
(Symbyax)...................................................................... 84
olanzapine orally disintegrating tab 5 mg (Zyprexa
zydis)...............................................................................75
zydis)...............................................................................75
zydis)...............................................................................75
zydis)...............................................................................75
olanzapine tab 2.5 mg (Zyprexa)................................... 75
olanzapine tab 5 mg (Zyprexa)...................................... 75
olanzapine tab 7.5 mg (Zyprexa)................................... 75
olanzapine tab 10 mg (Zyprexa).................................... 75
olopatadine hcl nasal soln 0.6% (Patanase).................57
olopatadine hcl ophth soln 0.1% (base equivalent)
(Patanol)....................................................................... 122
OLUX -clobetasol propionate foam 0.05%......................131
OLUX-E -clobetasol propionate emulsion foam
0.05%.............................................................................131
OLYSIO -simeprevir sodium cap 150 mg (base
equivalent)......................................................................... 8
OMECLAMOX-PAK -amoxicillin cap-clarithro tab w/
omepraz cap dr therapy pack........................................ 63
omega-3-acid ethyl esters cap 1 gm (Lovaza)............. 53
omeprazole cap delayed release 10 mg (Prilosec)...... 63
OMNIFLEX DIAPHRAGM -diaphragms.......................... 174
OMNIPOD STARTER KIT -insulin infusion disposable
pump kit.........................................................................174
OMNIPRED -prednisolone acetate ophth susp 1%........ 122
OMNITROPE -somatropin for inj 5.8 mg.......................... 36
OMNITROPE -somatropin inj 5 mg/1.5ml......................... 36
OMNITROPE -somatropin inj 10 mg/1.5ml....................... 36
ON CALL EXPRESS BLOOD GLU -blood glucose
ON CALL EXPRESS BLOOD GLU -blood glucose
ON CALL EXPRESS BLOOD GLU -glucose blood test
strip................................................................................ 137
ON CALL LANCETS -lancets.......................................... 174
ON CALL LANCING DEVICE -lancet devices................ 174
ON CALL PLUS BLOOD GLUCOS -blood glucose
ON CALL PLUS BLOOD GLUCOS -blood glucose
261
2016
ON CALL PLUS BLOOD GLUCOS -glucose blood test
strip................................................................................ 137
ON CALL PLUS LANCETS -lancets............................... 174
ON CALL PLUS LANCING DEVI -lancet devices........... 174
ON CALL VIVID BLOOD GLUCO -blood glucose
ON CALL VIVID BLOOD GLUCO -blood glucose
ON CALL VIVID BLOOD GLUCO -glucose blood test
strip................................................................................ 137
ON CALL VIVID PAL BLOOD G -blood glucose
ON CALL VIVID PAL BLOOD G -blood glucose
ondansetron hcl oral soln 4 mg/5ml (Zofran)............... 64
ondansetron hcl tab 24 mg............................................ 64
ondansetron hcl tab 4 mg (Zofran)................................64
ondansetron hcl tab 8 mg (Zofran)................................64
ondansetron orally disintegrating tab 4 mg (Zofran
odt).................................................................................. 64
ondansetron orally disintegrating tab 8 mg (Zofran
odt).................................................................................. 64
ONETOUCH CLUB LANCETS FIN -lancets................... 174
ONETOUCH COMBO PACK -lancets............................. 174
ONETOUCH DELICA LANCETS E -lancets................... 174
ONETOUCH DELICA LANCETS F -lancets................... 174
ONETOUCH DELICA LANCING D -lancet devices........ 174
ONETOUCH FINEPOINT LANCET -lancets...................174
ONETOUCH LANCETS -lancets..................................... 174
ONETOUCH PING METER REMOT -blood glucose
monitoring supplies....................................................... 174
ONETOUCH SURESOFT LANCING -lancets misc........ 174
ONETOUCH ULTRA 2 -blood glucose monitoring kit w/
device............................................................................ 174
ONETOUCH ULTRA BLUE -glucose blood test strip..... 137
ONETOUCH ULTRALINK SYSTEM -blood glucose
ONETOUCH ULTRA MINI -blood glucose monitoring kit
w/ device....................................................................... 174
ONETOUCH ULTRASOFT LANCET -lancets................. 174
ONETOUCH ULTRA TEST STRIP -glucose blood test
strip................................................................................ 137
ONETOUCH VERIO -blood glucose monitoring kit w/
device............................................................................ 174
ONETOUCH VERIO FLEX BLOOD -blood glucose
ONETOUCH VERIO IQ BLOOD G -blood glucose
ONETOUCH VERIO SYNC BLOOD -blood glucose
ONETOUCH VERIO TEST STRIP -glucose blood test
strip................................................................................ 137
ONFI -clobazam suspension 2.5 mg/ml............................ 99
ONFI -clobazam tab 10 mg............................................... 99
ONFI -clobazam tab 20 mg............................................... 99
ONGLYZA -saxagliptin hcl tab 2.5 mg (base equiv)......... 29
ONGLYZA -saxagliptin hcl tab 5 mg (base equiv)............ 29
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 5 mg......................................................... 89
er 12hr deter 7.5 mg...................................................... 89
er 12hr deter 10 mg....................................................... 89
er 12hr deter 15 mg....................................................... 89
er 12hr deter 20 mg....................................................... 89
er 12hr deter 30 mg....................................................... 89
er 12hr deter 40 mg....................................................... 89
OPANA -oxymorphone hcl tab 5 mg................................. 89
OPANA -oxymorphone hcl tab 10 mg............................... 89
OPSUMIT -macitentan tab 10 mg..................................... 55
OPTIONS CONCEPTROL VAGINA -nonoxynol-9 gel
4%.................................................................................... 68
OPTIONS GYNOL II VAGINAL -nonoxynol-9 gel 3%....... 68
OPTIUM BLOOD GLUCOSE MONI -blood glucose
OPTIUM BLOOD GLUCOSE MONI -blood glucose
OPTIUMEZ TEST STRIPS -glucose blood test strip...... 137
OPTIUM TEST STRIPS -glucose blood test strip........... 137
OPTUMRX BLOOD GLUCOSE MET -blood glucose
OPTUMRX BLOOD GLUCOSE MON -blood glucose
OPTUMRX BLOOD GLUCOSE TES -glucose blood test
strip................................................................................ 137
ORACIT -sodium citrate & citric acid soln 490-640
mg/5ml............................................................................. 69
ORAP -pimozide tab 1 mg................................................ 84
ORAP -pimozide tab 2 mg................................................ 84
ORAPRED ODT -prednisolone sod phos orally disintegr
tab 10 mg (base eq)....................................................... 21
tab 15 mg (base eq)....................................................... 21
tab 30 mg (base eq)....................................................... 21
ORAVIG -miconazole buccal tab 50 mg (mouththroat)............................................................................ 124
ORENCIA -abatacept subcutaneous soln prefilled syringe
125 mg/ml....................................................................... 93
ORENCIA CLICKJECT -abatacept subcutaneous soln
auto-injector 125 mg/ml.................................................. 93
ORENITRAM -treprostinil diolamine tab cr 0.125 mg
(base equiv).................................................................... 55
ORENITRAM -treprostinil diolamine tab cr 0.25 mg (base
equiv)............................................................................... 55
ORENITRAM -treprostinil diolamine tab cr 1 mg (base
equiv)............................................................................... 55
ORENITRAM -treprostinil diolamine tab cr 2.5 mg (base
equiv)............................................................................... 55
ORFADIN -nitisinone cap 2 mg......................................... 36
262
2016
ORFADIN -nitisinone cap 5 mg......................................... 36
ORFADIN -nitisinone cap 10 mg....................................... 36
ORFADIN -nitisinone susp 4 mg/ml.................................. 36
ORKAMBI -lumacaftor-ivacaftor tab 200-125 mg............. 61
orphenadrine citrate tab sr 12hr 100 mg.................... 103
ORTHO-CYCLEN -norgestimate & ethinyl estradiol tab
0.25 mg-35 mcg.............................................................. 26
ORTHO DIAPHRAGM COIL SPRI -diaphragm coil spring
kit 50 mm...................................................................... 175
kit 100 mm.................................................................... 175
kit 105 mm.................................................................... 175
ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring
kit 55 mm...................................................................... 175
kit 60 mm...................................................................... 175
kit 65 mm...................................................................... 175
kit 70 mm...................................................................... 175
kit 75 mm...................................................................... 175
kit 80 mm...................................................................... 175
kit 85 mm...................................................................... 175
kit 90 mm...................................................................... 175
kit 95 mm...................................................................... 175
ORTHO MICRONOR -norethindrone tab 0.35 mg............26
ORTHO-NOVUM 7/7/7 -norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg.......................................... 26
ORTHO-NOVUM 1/35 -norethindrone & ethinyl estradiol
tab 1 mg-35 mcg............................................................ 26
ORTHO TRI-CYCLEN LO -norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg................................. 26
ORTHO TRI-CYCLEN -norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg................................. 26
OSENI -alogliptin-pioglitazone tab 12.5-15 mg................. 29
OSENI -alogliptin-pioglitazone tab 25-15 mg.................... 29
OSMOPREP -sod phos mono-sod phos di tabs
1.102-0.398 gm(1.5gm na phos).................................... 61
OSPHENA -ospemifene tab 60 mg................................... 36
OTEZLA -apremilast tab 30 mg........................................ 93
OTEZLA -apremilast tab starter therapy pack 10 mg & 20
mg & 30 mg.................................................................... 93
OTREXUP -methotrexate soln pf auto-injector 7.5
mg/0.4ml.......................................................................... 93
OTREXUP -methotrexate soln pf auto-injector 10
mg/0.4ml.......................................................................... 93
mg/0.4ml.......................................................................... 93
mg/0.4ml.......................................................................... 93
mg/0.4ml.......................................................................... 93
mg/0.4ml.......................................................................... 93
mg/0.4ml.......................................................................... 93
mg/0.4ml.......................................................................... 93
OVIDE -malathion lotion 0.5%........................................ 131
OXANDRIN -oxandrolone tab 2.5 mg............................... 22
OXANDRIN -oxandrolone tab 10 mg................................ 22
oxandrolone tab 2.5 mg (Oxandrin).............................. 22
oxandrolone tab 10 mg (Oxandrin)............................... 22
oxaprozin tab 600 mg (Daypro)..................................... 93
oxazepam cap 10 mg...................................................... 70
oxazepam cap 15 mg...................................................... 70
oxazepam cap 30 mg...................................................... 70
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
(Trileptal)........................................................................ 99
oxcarbazepine tab 150 mg (Trileptal)............................ 99
oxiconazole nitrate cream 1% (Oxistat)...................... 131
OXSORALEN -methoxsalen lotion 1%........................... 131
OXSORALEN ULTRA -methoxsalen rapid cap 10
mg.................................................................................. 131
OXTELLAR XR -oxcarbazepine tab sr 24hr 150 mg........ 99
oxybutynin chloride syrup 5 mg/5ml............................ 67
oxybutynin chloride tab 5 mg........................................ 67
oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)..... 67
oxybutynin chloride tab sr 24hr 10 mg (Ditropan
xl)..................................................................................... 67
oxybutynin chloride tab sr 24hr 15 mg (Ditropan
xl)..................................................................................... 67
OXYCODONE/IBUPROFEN -oxycodone-ibuprofen tab
5-400 mg......................................................................... 90
oxycodone-aspirin tab 4.8355-325 mg (Percodan)...... 90
oxycodone hcl cap 5 mg................................................ 89
oxycodone hcl conc 100 mg/5ml (20 mg/ml)
(Oxycodone hcl)............................................................ 89
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
10 mg.............................................................................. 89
15 mg.............................................................................. 89
20 mg.............................................................................. 89
30 mg.............................................................................. 90
40 mg.............................................................................. 90
263
2016
60 mg.............................................................................. 90
80 mg.............................................................................. 90
oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)...........90
oxycodone hcl tab 10 mg............................................... 90
oxycodone hcl tab 20 mg............................................... 90
oxycodone hcl tab 5 mg (Roxicodone)......................... 90
oxycodone hcl tab 15 mg (Roxicodone)....................... 90
oxycodone hcl tab 30 mg (Roxicodone)....................... 90
oxycodone w/ acetaminophen soln 5-325 mg/5ml
(Roxicet)......................................................................... 90
oxycodone w/ acetaminophen tab 2.5-325 mg
(Percocet)....................................................................... 90
oxycodone w/ acetaminophen tab 5-325 mg
(Percocet)....................................................................... 90
oxycodone w/ acetaminophen tab 7.5-325 mg
(Percocet)....................................................................... 90
oxycodone w/ acetaminophen tab 10-325 mg
(Percocet)....................................................................... 90
OXYCONTIN -oxycodone hcl tab er 12hr deter 10 mg..... 90
oxymorphone hcl tab 5 mg (Opana)..............................90
oxymorphone hcl tab 10 mg (Opana)............................90
oxymorphone hcl tab sr 12hr 5 mg............................... 90
oxymorphone hcl tab sr 12hr 7.5 mg............................ 90
oxymorphone hcl tab sr 12hr 10 mg............................. 90
P
paliperidone tab sr 24hr 1.5 mg (Invega)...................... 75
paliperidone tab sr 24hr 3 mg (Invega)......................... 76
PAMELOR -nortriptyline hcl cap 10 mg............................ 72
PAMINE FORTE -methscopolamine bromide tab 5
mg.................................................................................... 63
PAMINE -methscopolamine bromide tab 2.5 mg.............. 63
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
4200-10000-17500 unit...................................................64
10500-25000-43750 unit................................................ 64
16800-40000-70000 unit................................................ 64
21000-37000-61000 unit................................................ 64
PANRETIN -alitretinoin gel 0.1%..................................... 131
pantoprazole sodium ec tab 20 mg (base equiv)
(Protonix)........................................................................63
pantoprazole sodium ec tab 40 mg (base equiv)
(Protonix)........................................................................63
PARADIGM LINK BLOOD GLUCO -blood glucose
PARAFON FORTE DSC -chlorzoxazone tab 500 mg..... 103
PAREGORIC -paregoric tincture 2 mg/5ml....................... 62
paricalcitol cap 4 mcg..................................................... 36
paricalcitol cap 1 mcg (Zemplar)................................... 36
paricalcitol cap 2 mcg (Zemplar)................................... 36
PARLODEL -bromocriptine mesylate cap 5 mg.............. 102
PARNATE -tranylcypromine sulfate tab 10 mg................. 73
paromomycin sulfate cap 250 mg................................... 5
paroxetine hcl tab 10 mg (Paxil).................................... 73
paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)............... 73
paroxetine hcl tab sr 24hr 25 mg (Paxil cr).................. 73
paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)............... 73
PASER -aminosalicylic acid cr granules packet 4 gm.........5
PATADAY -olopatadine hcl ophth soln 0.2% (base
equivalent)..................................................................... 122
PATANASE -olopatadine hcl nasal soln 0.6%................... 57
PATANOL -olopatadine hcl ophth soln 0.1% (base
equivalent)..................................................................... 122
PAXIL -paroxetine hcl oral susp 10 mg/5ml (base
equiv)............................................................................... 73
PAZEO -olopatadine hcl ophth soln 0.7% (base
equivalent)..................................................................... 122
PCE -erythromycin w/ enteric coated particles tab 333
mg...................................................................................... 3
PCE -erythromycin w/ enteric coated particles tab 500
mg...................................................................................... 3
PC LANCETS SUPER THIN 30G -lancets..................... 175
PC UNIFINE PENTIPS 29G X -insulin pen needle 29 g x
12 mm (1/2")................................................................. 175
5 mm (3/16")................................................................. 175
6 mm (1/4")................................................................... 175
8 mm (1/3" or 5/16")..................................................... 175
PEDIAPRED -prednisolone sod phosph oral soln 6.7
mg/5ml (5 mg/5ml base)................................................ 21
PEDIARIX -diph-tetanus tox-acell pert-hepatitis b-polio ipv
vac inj.............................................................................. 14
PEDVAX HIB -haemophilus b polysaccharide conj vac im
susp 7.5 mcg/0.5 ml....................................................... 14
PEGANONE -ethotoin tab 250 mg.................................... 99
PEGASYS -peginterferon alfa-2a inj 180 mcg/ml............... 8
PEGASYS -peginterferon alfa-2a inj 180 mcg/0.5ml.......... 8
PEGASYS PROCLICK -peginterferon alfa-2a inj 135
mcg/0.5ml.......................................................................... 8
264
2016
PEGASYS PROCLICK -peginterferon alfa-2a inj 180
mcg/0.5ml.......................................................................... 8
PEGINTRON -peginterferon alfa-2b for inj kit 50
mcg/0.5ml.......................................................................... 8
mcg/0.5ml.......................................................................... 9
mcg/0.5ml.......................................................................... 9
mcg/0.5ml.......................................................................... 9
PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for
inj kit 120 mcg/0.5ml........................................................ 8
PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit
50 mcg/0.5ml.....................................................................8
80 mcg/0.5ml.....................................................................8
120 mcg/0.5ml.................................................................. 8
150 mcg/0.5ml.................................................................. 8
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240
gm (Colyte-flavor packs)............................................. 61
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236
gm (Golytely)................................................................. 61
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
(Nulytely/flavor pack)................................................... 61
penicillin v potassium for soln 125 mg/5ml................... 1
penicillin v potassium for soln 250 mg/5ml................... 1
penicillin v potassium tab 250 mg...................................1
penicillin v potassium tab 500 mg...................................1
PENLAC NAIL LACQUER -ciclopirox solution 8%......... 131
PENLET II REPLACEMENT CAP -lancets misc.............176
PEN NEEDLES 29GX1/2" -insulin pen needle 29 g x 12
mm (1/2")...................................................................... 175
PEN NEEDLES 31G X 3/16" -insulin pen needle 31 g x 5
mm (3/16").................................................................... 175
mm (1/3" or 5/16")........................................................ 175
mm (1/3" or 5/16")........................................................ 175
PEN NEEDLES 31G X 1/4" SH -insulin pen needle 31 g x
6 mm (1/4")................................................................... 175
PEN NEEDLES 31GX6MM (1/4" -insulin pen needle 31 g
x 6 mm (1/4")................................................................ 175
PEN NEEDLES 31GX8MM (5/16 -insulin pen needle 31 g
x 8 mm (1/3" or 5/16").................................................. 176
PEN NEEDLES 32GX4MM -insulin pen needle 32 g x 4
mm (5/32").................................................................... 176
PEN NEEDLES 29G X 12MM -insulin pen needle 29 g x
12 mm (1/2")................................................................. 175
PEN NEEDLES 31G X 5MM -insulin pen needle 31 g x 5
mm (3/16").................................................................... 175
PEN NEEDLES 31GX8MM -insulin pen needle 31 g x 8
mm (1/3" or 5/16")........................................................ 175
PENTACEL -diph-ac per-tet tox ad-poliov-haemoph b poly
vac for im susp............................................................... 14
PENTASA -mesalamine cap cr 250 mg............................ 66
PENTASA -mesalamine cap cr 500 mg............................ 66
pentazocine w/ naloxone tab 50-0.5 mg........................90
PENTIPS 29GX12MM -insulin pen needle 29 g x 12 mm
(1/2").............................................................................. 176
(3/16")............................................................................ 176
(1/4").............................................................................. 176
(5/32")............................................................................ 176
(1/3" or 5/16")................................................................176
PEN-TOTE -blood glucose monitoring supplies............. 176
pentoxifylline tab cr 400 mg......................................... 119
PERFECT LANCETS 30G -lancets................................ 176
PERFECT PRESSURE ACTIVATE -lancets................... 176
PERFOROMIST -formoterol fumarate soln nebu 20
mcg/2ml........................................................................... 59
PERIDEX -chlorhexidine gluconate soln 0.12%............. 124
perindopril erbumine tab 2 mg...................................... 48
perindopril erbumine tab 4 mg (Aceon)........................ 48
perindopril erbumine tab 8 mg (Aceon)........................ 48
permethrin cream 5% (Elimite).................................... 131
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-10 mg................................................ 84
perphenazine tab 2 mg................................................... 76
perphenazine tab 16 mg................................................. 76
PERTZYE -pancrelipase (lip-prot-amyl) dr cap
8000-28750-30250 unit...................................................64
PERTZYE -pancrelipase (lip-prot-amyl) dr cap
16000-57500-60500 unit................................................ 64
PEXEVA -paroxetine mesylate tab 10 mg (base
equiv)............................................................................... 73
equiv)............................................................................... 73
equiv)............................................................................... 73
equiv)............................................................................... 73
PHARMACIST CHOICE AUTOCOD -blood glucose
PHARMACIST CHOICE AUTOCOD -glucose blood test
strip................................................................................ 137
PHARMACIST CHOICE NO CODI -glucose blood test
strip................................................................................ 137
PHARMACIST CHOICE ULTRA T -lancets.................... 176
PHARMACY COUNTER LANCETS -lancets.................. 176
265
2016
phenazopyridine hcl tab 100 mg (Pyridium).................69
phenazopyridine hcl tab 200 mg (Pyridium).................69
phenelzine sulfate tab 15 mg (Nardil)........................... 73
phenobarbital elixir 20 mg/5ml...................................... 77
PHENOBARBITAL -phenobarbital tab 15 mg................... 77
PHENOBARBITAL -phenobarbital tab 100 mg................. 77
phenobarbital tab 16.2 mg.............................................. 77
phenoxybenzamine hcl cap 10 mg (Dibenzyline)........ 48
phenylephrine hcl ophth soln 2.5%............................. 122
phenylephrine hcl ophth soln 10%.............................. 122
phenylephrine-promethazine w/ codeine syrup
5-6.25-10 mg/5ml........................................................... 57
PHENYTEK -phenytoin sodium extended cap 200
mg.................................................................................... 99
PHENYTEK -phenytoin sodium extended cap 300
mg.................................................................................... 99
phenytoin chew tab 50 mg (Dilantin infatabs)..............99
phenytoin sodium extended cap 100 mg (Dilantin)..... 99
phenytoin sodium extended cap 200 mg
(Phenytek)...................................................................... 99
phenytoin sodium extended cap 300 mg
(Phenytek)...................................................................... 99
phenytoin susp 125 mg/5ml (Dilantin-125)................... 99
PHOSLO -calcium acetate (phosphate binder) cap 667
mg (169 mg ca).............................................................. 66
PHOSLYRA -calcium acetate (phosphate binder) oral soln
667 mg/5ml..................................................................... 66
PHOSPHOLINE IODIDE -echothiophate iodide ophth for
soln 0.125%.................................................................. 122
PICATO -ingenol mebutate gel 0.015%.......................... 131
PICATO -ingenol mebutate gel 0.05%............................ 131
pilocarpine hcl ophth soln 1% (Isopto carpine)......... 122
pilocarpine hcl tab 5 mg (Salagen)..............................124
pilocarpine hcl tab 7.5 mg (Salagen)...........................124
pimozide tab 1 mg (Orap)............................................... 84
pimozide tab 2 mg (Orap)............................................... 84
pindolol tab 5 mg............................................................. 39
pindolol tab 10 mg........................................................... 39
pioglitazone hcl-glimepiride tab 30-2 mg (Duetact)..... 30
pioglitazone hcl-glimepiride tab 30-4 mg (Duetact)..... 30
pioglitazone hcl-metformin hcl tab 15-500 mg
(Actoplus met)............................................................... 30
pioglitazone hcl-metformin hcl tab 15-850 mg
(Actoplus met)............................................................... 30
pioglitazone hcl tab 15 mg (base equiv) (Actos)..........29
piroxicam cap 10 mg (Feldene)..................................... 93
piroxicam cap 20 mg (Feldene)..................................... 93
PLAN B ONE-STEP -levonorgestrel tab 1.5 mg............... 26
PLAQUENIL -hydroxychloroquine sulfate tab 200 mg...... 11
PLEGRIDY -peginterferon beta-1a soln pen-injector 125
mcg/0.5ml........................................................................ 84
PLEGRIDY -peginterferon beta-1a soln prefilled syringe
125 mcg/0.5ml................................................................ 84
PLEGRIDY STARTER PACK -peginterferon beta-1a soln
pen-inj 63 & 94 mcg/0.5ml pack.................................... 84
PLEGRIDY STARTER PACK -peginterferon beta-1a soln
pref syr 63 & 94 mcg/0.5ml pack................................... 84
PNEUMOVAX 23/1 DOSE -pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml............................................ 14
PNEUMOVAX 23 -pneumococcal vaccine polyvalent inj
25 mcg/0.5ml.................................................................. 14
PNV-DHA+DOCUSATE -prenatal w/o vit a w/ fe fum-dssfa-dha cap 27-1.25-300 mg.......................................... 107
PNV-DHA -prenat w/o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg........................................................ 106
PNV FERROUS FUMARATE/DOCU -prenatal vit w/ dssfe fumarate-fa tab 29-1 mg.......................................... 106
PNV FOLIC ACID + IRON MUL -prenatal vit w/ fe
fumarate-fa tab 27-1 mg...............................................106
PNV OB+DHA -prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 250 mg pack...................................................106
PNV-OMEGA -prenat w/o a w/ fe fumerate-methylfolatefa-omega 3 cap............................................................. 107
PNV PRENATAL PLUS MULTIVI -prenatal vit w/ fe
fumarate-fa tab 27-1 mg...............................................106
PNV-SELECT -prenatal vit w/ fe fum-methylfolate-fa tab
27-0.6-0.4 mg................................................................ 107
PNV TABS 29-1 -prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................. 106
PNV-TOTAL -prenat w/ fe cbn-fe bisglyc-fa-fish oil cap
35-5-1.2 mg................................................................... 107
PNV-VP-U -prenatal w/o a vit w/ fe fumarate-fa cap
106.5-1 mg.................................................................... 107
POCKETCHEM EZ BLOOD GLUCO -blood glucose
POCKETCHEM EZ BLOOD GLUCO -glucose blood test
strip................................................................................ 137
podofilox soln 0.5% (Condylox)................................... 131
polyethylene glycol 3350 oral packet............................ 61
polyethylene glycol 3350 oral powder.......................... 61
POLY HUB NEEDLE/25G X 5/8 -needle (disp) 25 x
5/8".................................................................................176
1/2".................................................................................176
1/2".................................................................................176
POLY HUB NEEDLE/18G X 1" -needle (disp) 18 x
1".................................................................................... 176
1".................................................................................... 176
1".................................................................................... 176
1".................................................................................... 176
266
2016
1".................................................................................... 176
POLY HUB NEEDLE/18G X 1-1 -needle (disp) 18 x
1-1/2"............................................................................. 176
1-1/2"............................................................................. 176
1-1/2"............................................................................. 176
1-1/2"............................................................................. 176
1-1/2"............................................................................. 176
1-1/4"............................................................................. 176
polymyxin b-trimethoprim ophth soln 10000 unit/
ml-0.1% (Polytrim)...................................................... 123
POLYTRIM -polymyxin b-trimethoprim ophth soln 10000
unit/ml-0.1%.................................................................. 123
POMALYST -pomalidomide cap 1 mg.............................. 18
PONSTEL -mefenamic acid cap 250 mg.......................... 93
pot & sod citrates w/ cit ac soln 550-500-334
mg/5ml............................................................................ 69
potassium bicarbonate effer tab 25 meq.................... 111
potassium chloride cap cr 8 meq (Micro-k)................ 111
potassium chloride cap cr 10 meq (Micro-k).............. 111
POTASSIUM CHLORIDE ER -potassium chloride tab cr 8
meq (600 mg)............................................................... 111
POTASSIUM CHLORIDE ER -potassium chloride tab cr
20 meq (1500 mg)........................................................ 111
potassium chloride microencapsulated crys cr tab 10
meq............................................................................... 111
potassium chloride microencapsulated crys cr tab 20
meq............................................................................... 112
potassium chloride oral soln 10% (20 meq/15ml)...... 112
potassium chloride oral soln 20% (40 meq/15ml)...... 112
potassium chloride powder packet 20 meq............... 112
potassium chloride tab cr 10 meq (K-tab).................. 112
potassium chloride tab cr 8 meq (600 mg) (Ktab)................................................................................ 112
potassium citrate & citric acid powder pack 3300-1002
mg................................................................................... 69
potassium citrate tab cr 5 meq (540 mg) (Urocit-k
5)...................................................................................... 69
10).................................................................................... 69
15).................................................................................... 69
pot bicarbonate & chloride effer tab 25 meq.............. 111
POTIGA -ezogabine tab 50 mg......................................... 99
POTIGA -ezogabine tab 200 mg....................................... 99
pot phos monobasic w/sod phos di & monobas tab
155-852-130mg (K-phos neutral)...............................111
PRADAXA -dabigatran etexilate mesylate cap 75 mg
(etexilate base eq)........................................................ 115
PRALUENT -alirocumab subcutaneous soln pen-injector
75 mg/ml......................................................................... 53
PRALUENT -alirocumab subcutaneous soln pen-injector
150 mg/ml....................................................................... 53
PRALUENT -alirocumab subcutaneous soln prefilled
syringe 75 mg/ml............................................................ 54
PRALUENT -alirocumab subcutaneous soln prefilled
syringe 150 mg/ml.......................................................... 54
pramipexole dihydrochloride tab 0.125 mg
(Mirapex).......................................................................102
(Mirapex).......................................................................102
(Mirapex).......................................................................102
(Mirapex).......................................................................102
pramipexole dihydrochloride tab 1 mg (Mirapex)...... 102
(Mirapex).......................................................................102
pramipexole dihydrochloride tab sr 24hr 0.375 mg
(Mirapex er).................................................................. 102
(Mirapex er).................................................................. 102
(Mirapex er).................................................................. 102
(Mirapex er).................................................................. 102
pramipexole dihydrochloride tab sr 24hr 3 mg
(Mirapex er).................................................................. 102
(Mirapex er).................................................................. 102
(Mirapex er).................................................................. 102
PRAMOSONE -pramoxine-hc cream 1-1%.................... 131
PRAMOSONE -pramoxine-hc lotion 1-1%...................... 131
PRAMOSONE -pramoxine-hc lotion 1-2.5%................... 1

Florida Blue September 2016 Care Choices Medication Guide

Transcription

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