HMSA Control Formulary · HMSA Control Formulary (Effective 01/01/2018) INTRODUCTION We are pleased to provide the 2018 HMSA Control Formulary as a useful reference and informational

HMSA Control Formulary

(Effective 01/01/2018)

INTRODUCTION We are pleased to provide the 2018 HMSA Control Formulary as a useful reference and informational tool. The HMSA Control Formulary can assist practitioners in selecting clinically appropriate and cost-effective products for their patients.

The information contained in this Formulary and its appendices is provided solely for the convenience of medical providers. We do not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This Formulary is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in his or her choice of prescription drugs. All the information in the Formulary is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable.

We assume no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information.

PREFACE The HMSA Control Formulary is organized by sections. Each section is divided by therapeutic drug class primarily defined by mechanism of action. Unless exceptions are noted, generally all applicable dosage forms and strengths of the drug cited are included in the Formulary. Generics should be considered the first line of prescribing.

Drugs represented in the HMSA Control Formulary may have varying cost to the plan member. Generic medications typically are available at the lowest cost, brand-name medications on the Formulary will generally cost more than generics, and brand-name medications not on the list will generally cost the most.

The tiered format places drugs into tiers or levels of cost sharing by the plan member in the following manner:

Tier 1 - mostly Generic Drugs Tier 2 - Preferred Drugs Tier 3 - Other Brand Name Drugs Tier 4 - Preferred Brand & Generic Specialty Drugs Tier 5* - Other Brand Name Specialty Drugs

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*If applicable to your plan coverage

Zero ($0) Copay - When obtained from a Participating Provider, HMSA pays 100% of Eligible Charge. You owe no copayment. Please refer to your Plan's Prescription Drug Benefits Rider for the specific copayment or coinsurance amount associated with each tier.

ABBREVIATIONS USED IN THIS FORMULARY AGE - Age Limit: age requirements for coverage of drug OC - Oral Chemotherapy: Refer to plan benefits PA - Prior Authorization: Requires that you or your physician receive

approval from HMSA before we will cover your prescription QL - Quantity Limit: A limit on the amount of the drug that HMSA will

cover SP - Specialty Drug with Network Requirements: Must go to a Specialty

Network Provider, limited to a 30 days supply ST - Step Therapy: Requires you to first try certain drugs to treat your

medical condition before we will cover another drug for that condition $0 - Zero ($0) Copay: When obtained from a Participating Provider, HMSA

pays 100% of Eligible Charge. You owe no copayment.

EXCEPTION REQUEST Drugs listed on this formulary are considered covered benefits. Certain medications on the list are covered if utilization management criteria are met (i.e. Prior Authorization, etc.); requests for use of such medications outside of their listed criteria will be reviewed for medical necessity. If a medication is not listed on the document, a formulary exception may be requested for coverage. Medical necessity or formulary exception requests will be reviewed based on drug-specific prior authorization criteria or standard non-formulary prescription request criteria. To request a PA or an exception, please call or fax CVS Caremark®, HMSA's Pharmacy Benefit Manager

Call

Commercial 1 (855) 240-0543 toll-free

FAX Commercial 1 (855) 762-5207 toll-free This drug list is subject to change and drugs may be added or removed without notice. Please contact HMSA to confirm your drug plan coverage. This list is effective January 1, 2018.

LEGEND lowercase Indicates generic drug OC Oral Chemotherapy: Refer to plan benefits PA Prior Authorization SP Specialty Drug with network requirement UPPERCASE Indicates brand name drug $0 Zero ($0) Copay

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NOTE The status of a drug on this list is current as of the date of this publication.

The list serves as a guide to product selection for our providers and members. The list is subject to change. Participating pharmacies have the most up-to-date formulary information at the time prescriptions are filled. New drugs, strengths, forms, and/or therapeutic categories introduced in the marketplace will be reflected in the formulary, as applicable, following the completion of HMSA’s review process. Not all generic drugs may be listed. Coverage of a drug will depend on your drug plan.

HMSA's mission is to provide the people of Hawaii access to a sustainable, quality health care system that improves the overall health and well-being of our state.

HMSA CENTERS Convenient evening and Saturday hours: HMSA Center @ Honolulu 818 Keeaumoku St. Monday through Friday, 8 a.m. - 6 p.m. | Saturday, 9 a.m. - 2 p.m. HMSA Center @ Pearl City Pearl City Gateway | 1132 Kuala St., Suite 400 Monday through Friday, 9 a.m. - 7 p.m. | Saturday, 9 a.m. - 2 p.m. HMSA Center @ Hilo Waiakea Center | 303A E. Makaala St. Monday through Friday, 9 a.m. - 7 p.m. | Saturday, 9 a.m. - 2 p.m. OFFICES Visit your local HMSA office Monday through Friday, 8 a.m. - 4 p.m. Kailua-Kona, Hawaii Island | 75-1029 Henry St., Suite 301 | Phone: 329-5291 Kahului, Maui | 33 Lono Ave., Suite 350 | Phone: 871-6295 Lihue, Kauai | 4366 Kukui Grove St., Suite 103 | Phone: 245-3393 PHONE 948-6372 on Oahu If you are calling from the U.S. Mainland, please call 1 (800) 776-4672. If you need to call a local Hawaii telephone number from the Mainland, the area code is 808. Check hmsa.com/contact for our holiday schedule.

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The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. ©2017. All rights reserved. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers.

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Drug Name Drug Tier Requirements/Limits ANALGESICS COX-II INHIBITORS celecoxib cap 50 mg 1 celecoxib cap 100 mg 1 celecoxib cap 200 mg 1 celecoxib cap 400 mg 1 GOUT allopurinol tab 100 mg 1 allopurinol tab 300 mg 1 colchicine cap 0.6 mg 1 colchicine tab 0.6 mg 1 colchicine w/ probenecid tab 0.5-500 mg 1 COLCRYS TAB 0.6MG 2 MITIGARE CAP 0.6MG 3 probenecid tab 500 mg 1 ULORIC TAB 40MG 2 ULORIC TAB 80MG 2 ZYLOPRIM TAB 100MG 3 ZYLOPRIM TAB 300MG 3 NON-OPIOID ANALGESICS BUPAP TAB 50-300MG 3 butalbital-acetaminophen tab 50-325 mg 1 butalbital-acetaminophen-caffeine tab 50-

325-40 mg 1

butalbital-aspirin-caffeine cap 50-325-40 mg

1

duraxin cap 1 ESGIC TAB 3 FIORINAL CAP 3 LEVACET TAB 3 marten-tab tab 50-325mg 1 tencon tab 50-325mg 1 VANATOL LQ SOL 3 NSAIDS ANAPROX DS TAB 550MG 3 choline & magnesium salicylates liq 500

mg/5ml 1

DAYPRO TAB 600MG 3 diclofenac potassium tab 50 mg 1 diclofenac sodium tab delayed release 25

mg 1

diclofenac sodium tab delayed release 50 mg

1

diclofenac sodium tab delayed release 75 mg

1

6

Drug Name Drug Tier Requirements/Limits diclofenac sodium tab er 24hr 100 mg 1 diflunisal tab 500 mg 1 EC-NAPROSYN TAB 375MG 3 EC-NAPROSYN TAB 500MG 3 etodolac cap 200 mg 1 etodolac cap 300 mg 1 etodolac tab 400 mg 1 etodolac tab 500 mg 1 etodolac tab er 24hr 400 mg 1 etodolac tab er 24hr 500 mg 1 etodolac tab er 24hr 600 mg 1 FELDENE CAP 10MG 3 FELDENE CAP 20MG 3 fenoprofen calcium cap 400 mg 1 fenoprofen calcium tab 600 mg 1 flurbiprofen tab 50 mg 1 flurbiprofen tab 100 mg 1 ibuprofen susp 100 mg/5ml 1 ibuprofen tab 400 mg 1 ibuprofen tab 600 mg 1 ibuprofen tab 800 mg 1 INDOCIN SUP 50MG 3 indomethacin cap 25 mg 1 indomethacin cap 50 mg 1 indomethacin cap er 75 mg 1 ketoprofen cap 50 mg 1 ketoprofen cap 75 mg 1 ketoprofen cap er 24hr 200 mg 1 ketorolac tromethamine tab 10 mg 1 meclofenamate sodium cap 50 mg 1 meclofenamate sodium cap 100 mg 1 mefenamic acid cap 250 mg 1 meloxicam tab 7.5 mg 1 meloxicam tab 15 mg 1 MOBIC TAB 7.5MG 3 MOBIC TAB 15MG 3 nabumetone tab 500 mg 1 nabumetone tab 750 mg 1 NALFON CAP 400MG 3 NAPROSYN TAB 500MG 3 naproxen dr tab 375mg 1 naproxen dr tab 500mg 1 naproxen sodium tab 275 mg 1 naproxen sodium tab 550 mg 1 naproxen sodium tab er 24hr 375 mg

(base equiv) 1

7

Drug Name Drug Tier Requirements/Limits naproxen sodium tab er 24hr 500 mg

(base equiv) 1

naproxen susp 125 mg/5ml 1 naproxen tab 250 mg 1 naproxen tab 375 mg 1 naproxen tab 500 mg 1 naproxen tab 500mg 1 oxaprozin tab 600 mg 1 piroxicam cap 10 mg 1 piroxicam cap 20 mg 1 PONSTEL CAP 250MG 3 SPRIX SPR 15.75MG 3 sulindac tab 150 mg 1 sulindac tab 200 mg 1 tolmetin sodium cap 400 mg 1 tolmetin sodium tab 200 mg 1 tolmetin sodium tab 600 mg 1 ZIPSOR CAP 25MG 3 ZORVOLEX CAP 18MG 3 ZORVOLEX CAP 35MG 3 NSAIDS, COMBINATIONS diclofenac w/ misoprostol tab delayed

release 50-0.2 mg 1

diclofenac w/ misoprostol tab delayed release 75-0.2 mg

1

DUEXIS TAB 800-26.6 3 VIMOVO TAB 375-20MG 3 VIMOVO TAB 500-20MG 3 NSAIDS, TOPICAL diclofenac sodium gel 1% 1 diclofenac sodium soln 1.5% 1 klofensaid sol ii 1 VOLTAREN GEL 1% 2 OPIOID ANALGESICS acetaminophen w/ codeine soln 120-12

mg/5ml 1

acetaminophen w/ codeine tab 300-15 mg 1 acetaminophen w/ codeine tab 300-30 mg 1 acetaminophen w/ codeine tab 300-60 mg 1 acetaminophen-caffeine-dihydrocodeine

cap 320.5-30-16 mg 1

ACTIQ LOZ 200MCG 3 ACTIQ LOZ 400MCG 3 ACTIQ LOZ 600MCG 3 ACTIQ LOZ 800MCG 3 ACTIQ LOZ 1200MCG 3

8

Drug Name Drug Tier Requirements/Limits ACTIQ LOZ 1600MCG 3 ascomp/cod cap 30mg 1 aspirin-caffeine-dihydrocodeine cap 356.4-

30-16 mg 1

BELBUCA MIS 75MCG 3 BELBUCA MIS 150MCG 3 BELBUCA MIS 300MCG 3 BELBUCA MIS 450MCG 3 BELBUCA MIS 600MCG 3 BELBUCA MIS 750MCG 3 BELBUCA MIS 900MCG 3 butalbital-acetaminophen-caff w/ cod cap

50-300-40-30 mg 1

butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg

1

butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg

1

butorphanol tartrate nasal soln 10 mg/ml 1 BUTRANS DIS 5MCG/HR 3 BUTRANS DIS 7.5/HR 3 BUTRANS DIS 10MCG/HR 3 BUTRANS DIS 15MCG/HR 3 BUTRANS DIS 20MCG/HR 3 CAPITAL/COD SUS 120-12/5 3 codeine sulfate tab 15 mg 1 codeine sulfate tab 30 mg 1 codeine sulfate tab 60 mg 1 CONZIP CAP 100MG 3 CONZIP CAP 200MG 3 CONZIP CAP 300MG 3 DILAUDID LIQ 1MG/ML 3 DILAUDID TAB 2MG 3 DILAUDID TAB 4MG 3 DILAUDID TAB 8MG 3 DOLOPHINE TAB 5MG 3 DOLOPHINE TAB 10MG 3 DURAGESIC DIS 12MCG/HR 3 DURAGESIC DIS 25MCG/HR 3 DURAGESIC DIS 50MCG/HR 3 DURAGESIC DIS 75MCG/HR 3 DURAGESIC DIS 100MCG/H 3 endocet tab 2.5-325 1 endocet tab 5-325mg 1 endocet tab 7.5-325 1 endocet tab 10-325mg 1 fentanyl citrate lozenge on a handle 200

mcg 1

9

Drug Name Drug Tier Requirements/Limits fentanyl citrate lozenge on a handle 400

mcg 1

fentanyl citrate lozenge on a handle 600 mcg

1


1


1


1

FENTANYL DIS 37.5MCG 3 FENTANYL DIS 62.5MCG 3 FENTANYL DIS 87.5MCG 3 fentanyl td patch 72hr 12 mcg/hr 1 fentanyl td patch 72hr 25 mcg/hr 1 fentanyl td patch 72hr 50 mcg/hr 1 fentanyl td patch 72hr 75 mcg/hr 1 fentanyl td patch 72hr 100 mcg/hr 1 FENTORA TAB 100MCG 2 FENTORA TAB 200MCG 2 FENTORA TAB 400MCG 2 FENTORA TAB 600MCG 2 FENTORA TAB 800MCG 2 FIORICET CAP CODEINE 3 FIORINAL/COD CAP 30MG 3 HYCET SOL 7.5-325 3 hydrocodone-acetaminophen soln 7.5-325

mg/15ml 1

hydrocodone-acetaminophen soln 10-325 mg/15ml

1

hydrocodone-acetaminophen tab 2.5-325 mg

1

hydrocodone-acetaminophen tab 5-300 mg 1 hydrocodone-acetaminophen tab 5-325 mg 1 hydrocodone-acetaminophen tab 7.5-300

mg 1

hydrocodone-acetaminophen tab 7.5-325 mg

1

hydrocodone-acetaminophen tab 10-300 mg

1

hydrocodone-acetaminophen tab 10-325 mg

1

hydrocodone-ibuprofen tab 5-200 mg 1 hydrocodone-ibuprofen tab 7.5-200 mg 1 hydrocodone-ibuprofen tab 10-200 mg 1 HYDROMORPHON SUP 3MG 3 hydromorphone hcl liqd 1 mg/ml 1 hydromorphone hcl tab 2 mg 1

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Drug Name Drug Tier Requirements/Limits hydromorphone hcl tab 4 mg 1 hydromorphone hcl tab 8 mg 1 hydromorphone hcl tab er 24hr deter 8 mg 1 hydromorphone hcl tab er 24hr deter 12

mg 1

hydromorphone hcl tab er 24hr deter 16 mg

1

hydromorphone hcl tab er 24hr deter 32 mg

1

HYSINGLA ER TAB 20 MG 2 HYSINGLA ER TAB 30 MG 2 HYSINGLA ER TAB 40 MG 2 HYSINGLA ER TAB 60 MG 2 HYSINGLA ER TAB 80 MG 2 HYSINGLA ER TAB 100 MG 2 HYSINGLA ER TAB 120 MG 2 ibudone tab 5-200mg 1 ibudone tab 10-200mg 1 lorcet hd tab 10-325mg 1 lorcet plus tab 7.5-325 1 lorcet tab 5-325mg 1 LORTAB ELX 10-300MG 3 lortab tab 5-325mg 1 lortab tab 7.5-325 1 lortab tab 10-325mg 1 methadone con 10mg/ml 1 methadone hcl conc 10 mg/ml 1 methadone hcl soln 5 mg/5ml 1 methadone hcl soln 10 mg/5ml 1 methadone hcl tab 5 mg 1 methadone hcl tab 10 mg 1 methadone hcl tab for oral susp 40 mg 1 METHADOSE CON 10MG/ML 3 METHADOSE SF CON 10MG/ML 3 methadose tab 40mg 1 MORPHINE SUL SUP 30MG 3 morphine sulfate beads cap er 24hr 30 mg 1 morphine sulfate beads cap er 24hr 45 mg 1 morphine sulfate beads cap er 24hr 60 mg 1 morphine sulfate beads cap er 24hr 75 mg 1 morphine sulfate beads cap er 24hr 90 mg 1 morphine sulfate beads cap er 24hr 120

mg 1

morphine sulfate cap er 24hr 10 mg 1 morphine sulfate cap er 24hr 20 mg 1 morphine sulfate cap er 24hr 30 mg 1 morphine sulfate cap er 24hr 50 mg 1

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Drug Name Drug Tier Requirements/Limits morphine sulfate cap er 24hr 60 mg 1 morphine sulfate cap er 24hr 80 mg 1 morphine sulfate cap er 24hr 100 mg 1 morphine sulfate oral soln 10 mg/5ml 1 morphine sulfate oral soln 20 mg/5ml 1 morphine sulfate oral soln 100 mg/5ml (20

mg/ml) 1

morphine sulfate suppos 5 mg 1 morphine sulfate suppos 10 mg 1 morphine sulfate suppos 20 mg 1 morphine sulfate tab 15 mg 1 morphine sulfate tab 30 mg 1 morphine sulfate tab er 15 mg 1 morphine sulfate tab er 30 mg 1 morphine sulfate tab er 60 mg 1 morphine sulfate tab er 100 mg 1 morphine sulfate tab er 200 mg 1 MS CONTIN TAB 15MG ER 3 MS CONTIN TAB 30MG ER 3 MS CONTIN TAB 60MG ER 3 MS CONTIN TAB 100MG ER 3 MS CONTIN TAB 200MG ER 3 NORCO TAB 5-325MG 3 NORCO TAB 7.5-325 3 NORCO TAB 10-325MG 3 NUCYNTA ER TAB 50MG 2 NUCYNTA ER TAB 100MG 2 NUCYNTA ER TAB 150MG 2 NUCYNTA ER TAB 200MG 2 NUCYNTA ER TAB 250MG 2 NUCYNTA TAB 50MG 2 NUCYNTA TAB 75MG 2 NUCYNTA TAB 100MG 2 OPANA TAB 5MG 3 OPANA TAB 10MG 3 oxycodone hcl cap 5 mg 1 oxycodone hcl conc 100 mg/5ml (20

mg/ml) 1

oxycodone hcl soln 5 mg/5ml 1 oxycodone hcl tab 5 mg 1 oxycodone hcl tab 10 mg 1 oxycodone hcl tab 15 mg 1 oxycodone hcl tab 20 mg 1 oxycodone hcl tab 30 mg 1 oxycodone hcl tab er 12hr deter 10 mg 1 oxycodone hcl tab er 12hr deter 15 mg 1

12

Drug Name Drug Tier Requirements/Limits oxycodone hcl tab er 12hr deter 20 mg 1 oxycodone hcl tab er 12hr deter 30 mg 1 oxycodone hcl tab er 12hr deter 40 mg 1 oxycodone hcl tab er 12hr deter 60 mg 1 oxycodone hcl tab er 12hr deter 80 mg 1 oxycodone w/ acetaminophen soln 5-325

mg/5ml 1

oxycodone w/ acetaminophen tab 2.5-325 mg

1

oxycodone w/ acetaminophen tab 5-325 mg

1

oxycodone w/ acetaminophen tab 7.5-325 mg

1

oxycodone w/ acetaminophen tab 10-325 mg

1

oxycodone-aspirin tab 4.8355-325 mg 1 oxycodone-ibuprofen tab 5-400 mg 1 OXYCONTIN TAB 10MG CR 2 OXYCONTIN TAB 15MG CR 2 OXYCONTIN TAB 20MG CR 2 OXYCONTIN TAB 30MG CR 2 OXYCONTIN TAB 40MG CR 2 OXYCONTIN TAB 60MG CR 2 OXYCONTIN TAB 80MG CR 2 oxymorphone hcl tab 5 mg 1 oxymorphone hcl tab 10 mg 1 oxymorphone hcl tab er 12hr 5 mg 1 oxymorphone hcl tab er 12hr 7.5 mg 1 oxymorphone hcl tab er 12hr 10 mg 1 oxymorphone hcl tab er 12hr 15 mg 1 oxymorphone hcl tab er 12hr 20 mg 1 oxymorphone hcl tab er 12hr 30 mg 1 oxymorphone hcl tab er 12hr 40 mg 1 pentazocine w/ naloxone tab 50-0.5 mg 1 PERCOCET TAB 2.5-325 3 PERCOCET TAB 5-325MG 3 PERCOCET TAB 7.5-325 3 PERCOCET TAB 10-325MG 3 PRIMLEV TAB 5-300MG 3 PRIMLEV TAB 7.5-300 3 PRIMLEV TAB 10-300MG 3 REPREXAIN TAB 5-200MG 3 reprexain tab 10-200mg 1 ROXICODONE TAB 5MG 3 ROXICODONE TAB 15MG 3 ROXICODONE TAB 30MG 3 SUBSYS SPR 100MCG 2

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Drug Name Drug Tier Requirements/Limits SUBSYS SPR 200MCG 2 SUBSYS SPR 400MCG 2 SUBSYS SPR 600MCG 2 SUBSYS SPR 800MCG 2 SUBSYS SPR 1200MCG 2 SUBSYS SPR 1600MCG 2 SYNALGOS-DC CAP 3 TRAMADOL HCL CAP 150MG ER 3 tramadol hcl cap er 24hr biphasic release

100 mg 1

tramadol hcl cap er 24hr biphasic release 200 mg

1

tramadol hcl cap er 24hr biphasic release 300 mg

1

tramadol hcl tab 50 mg 1 tramadol hcl tab er 24hr 100 mg 1 tramadol hcl tab er 24hr 200 mg 1 tramadol hcl tab er 24hr 300 mg 1 tramadol hcl tab er 24hr biphasic release

100 mg 1

tramadol hcl tab er 24hr biphasic release 200 mg

1

tramadol hcl tab er 24hr biphasic release 300 mg

1

tramadol-acetaminophen tab 37.5-325 mg 1 TYLENOL/COD TAB #3 3 TYLENOL/COD TAB #4 3 ULTRACET TAB 37.5-325 3 ULTRAM TAB 50MG 3 verdrocet tab 2.5-325 1 vicodin es tab 7.5-300 1 vicodin hp tab 10-300mg 1 vicodin tab 5-300mg 1 XARTEMIS XR TAB 7.5-325 3 XODOL TAB 5-300MG 3 XODOL TAB 7.5-300 3 XODOL TAB 10-300MG 3 xylon tab 10-200mg 1 zamicet sol 10-325mg 1 ANTI-INFECTIVES AMINOGLYCOSIDES neomycin sulfate tab 500 mg 1 paromomycin sulfate cap 250 mg 1 ANTIBACTERIALS, CEPHALOSPORINS, First Generation cefadroxil cap 500 mg 1 cefadroxil for susp 250 mg/5ml 1

14

Drug Name Drug Tier Requirements/Limits cefadroxil for susp 500 mg/5ml 1 cefadroxil tab 1 gm 1 cephalexin cap 250 mg 1 cephalexin cap 500 mg 1 cephalexin cap 750 mg 1 cephalexin for susp 125 mg/5ml 1 cephalexin for susp 250 mg/5ml 1 cephalexin tab 250 mg 1 cephalexin tab 500 mg 1 KEFLEX CAP 250MG 3 KEFLEX CAP 500MG 3 KEFLEX CAP 750MG 3 ANTIBACTERIALS, CEPHALOSPORINS, Second Generation cefaclor cap 250 mg 1 cefaclor cap 500 mg 1 CEFACLOR ER TAB 500MG 3 cefaclor for susp 125 mg/5ml 1 cefaclor for susp 250 mg/5ml 1 cefaclor for susp 375 mg/5ml 1 cefprozil for susp 125 mg/5ml 1 cefprozil for susp 250 mg/5ml 1 cefprozil tab 250 mg 1 cefprozil tab 500 mg 1 CEFTIN SUS 125/5ML 3 CEFTIN SUS 250/5ML 3 cefuroxime axetil tab 250 mg 1 cefuroxime axetil tab 500 mg 1 ANTIBACTERIALS, CEPHALOSPORINS, Third Generation CEDAX CAP 400MG 3 CEDAX SUS 180/5ML 3 cefdinir cap 300 mg 1 cefdinir for susp 125 mg/5ml 1 cefdinir for susp 250 mg/5ml 1 cefditoren pivoxil tab 200 mg (base

equivalent) 1

cefditoren pivoxil tab 400 mg (base equivalent)

1

cefixime for susp 100 mg/5ml 1 cefixime for susp 200 mg/5ml 1 cefpodoxime proxetil for susp 50 mg/5ml 1 cefpodoxime proxetil for susp 100 mg/5ml 1 cefpodoxime proxetil tab 100 mg 1 cefpodoxime proxetil tab 200 mg 1 ceftibuten cap 400 mg 1 ceftibuten for susp 180 mg/5ml 1 SPECTRACEF TAB 400MG 3

15

Drug Name Drug Tier Requirements/Limits SUPRAX CAP 400MG 2 SUPRAX CHW 100MG 2 SUPRAX CHW 200MG 2 SUPRAX SUS 100/5ML 2 SUPRAX SUS 200/5ML 2 SUPRAX SUS 500/5ML 2 ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 mg/5ml 1 azithromycin for susp 200 mg/5ml 1 azithromycin tab 250 mg 1 azithromycin tab 500 mg 1 azithromycin tab 600 mg 1 BIAXIN SUS 250/5ML 3 BIAXIN TAB 250MG 3 BIAXIN TAB 500MG 3 clarithromycin for susp 125 mg/5ml 1 clarithromycin for susp 250 mg/5ml 1 clarithromycin tab 250 mg 1 clarithromycin tab 500 mg 1 clarithromycin tab er 24hr 500 mg 1 DIFICID TAB 200MG 2 e.e.s. 400 tab 400mg 1 ery-tab tab 250mg ec 1 ery-tab tab 333mg ec 1 ery-tab tab 500mg ec 1 erythrocin tab 250mg 1 erythromycin ethylsuccinate for susp 200

mg/5ml 1

erythromycin ethylsuccinate tab 400 mg 1 erythromycin tab 250 mg 1 erythromycin tab 500 mg 1 erythromycin w/ delayed release particles

cap 250 mg 1

PCE TAB 333MG EC 3 PCE TAB 500MG EC 3 ZITHROMAX SUS 100/5ML 3 ZITHROMAX SUS 200/5ML 3 ZITHROMAX TAB 250MG 3 ZITHROMAX TAB 500MG 3 ZITHROMAX TAB 600MG 3 ZITHROMAX TAB TRI-PAK 3 ZITHROMAX TAB Z-PAK 3 ZMAX SUS 2GM 3 ANTIBACTERIALS, FLUOROQUINOLONES AVELOX ABC TAB 400MG 3 AVELOX TAB 400MG 3

16

Drug Name Drug Tier Requirements/Limits CIPRO (5%) SUS 250MG/5 3 CIPRO (10%) SUS 500MG/5 3 CIPRO TAB 250MG 3 CIPRO TAB 500MG 3 CIPRO XR TAB 500MG 3 CIPRO XR TAB 1000MG 3 ciprofloxacin for oral susp 250 mg/5ml

(5%) (5 gm/100ml) 1

ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml)

1

ciprofloxacin hcl tab 100 mg (base equiv) 1 ciprofloxacin hcl tab 250 mg (base equiv) 1 ciprofloxacin hcl tab 500 mg (base equiv) 1 ciprofloxacin hcl tab 750 mg (base equiv) 1 ciprofloxacin-ciprofloxacin hcl tab er 24hr

500 mg (base eq) 1

ciprofloxacin-ciprofloxacin hcl tab er 24hr 1000 mg(base eq)

1

FACTIVE TAB 320MG 3 LEVAQUIN TAB 250MG 3 LEVAQUIN TAB 500MG 3 LEVAQUIN TAB 750MG 3 levofloxacin oral soln 25 mg/ml 1 levofloxacin tab 250 mg 1 levofloxacin tab 500 mg 1 levofloxacin tab 750 mg 1 moxifloxacin hcl tab 400 mg (base equiv) 1 ofloxacin tab 400 mg 1 ANTIBACTERIALS, PENICILLINS amoxicillin & k clavulanate chew tab 200-

28.5 mg 1

amoxicillin & k clavulanate chew tab 400-57 mg

1

amoxicillin & k clavulanate for susp 200-28.5 mg/5ml

1


1

amoxicillin & k clavulanate for susp 400-57 mg/5ml

1


1

amoxicillin & k clavulanate tab 250-125 mg 1 amoxicillin & k clavulanate tab 500-125 mg 1 amoxicillin & k clavulanate tab 875-125 mg 1 amoxicillin & k clavulanate tab er 12hr

1000-62.5 mg 1

amoxicillin (trihydrate) cap 250 mg 1

17

Drug Name Drug Tier Requirements/Limits amoxicillin (trihydrate) cap 500 mg 1 amoxicillin (trihydrate) chew tab 125 mg 1 amoxicillin (trihydrate) chew tab 250 mg 1 amoxicillin (trihydrate) for susp 125

mg/5ml 1

amoxicillin (trihydrate) for susp 200 mg/5ml

1


1


1

amoxicillin (trihydrate) tab 500 mg 1 amoxicillin (trihydrate) tab 875 mg 1 ampicillin cap 250 mg 1 ampicillin cap 500 mg 1 ampicillin for susp 125 mg/5ml 1 ampicillin for susp 250 mg/5ml 1 AUGMENTIN SUS 125/5ML 3 AUGMENTIN SUS 250/5ML 3 AUGMENTIN SUS ES-600 3 AUGMENTIN TAB 500MG 3 AUGMENTIN TAB 875MG 3 AUGMENTIN XR TAB 12HR 3 dicloxacillin sodium cap 250 mg 1 dicloxacillin sodium cap 500 mg 1 MOXATAG TAB 775MG 3 penicillin v potassium for soln 125 mg/5ml 1 penicillin v potassium for soln 250 mg/5ml 1 penicillin v potassium tab 250 mg 1 penicillin v potassium tab 500 mg 1 ANTIBACTERIALS, SULFONAMIDES BACTRIM DS TAB 800-160 3 BACTRIM TAB 400-80MG 3 SULFADIAZINE TAB 500MG 3 sulfamethoxazole-trimethoprim susp 200-

40 mg/5ml 1

sulfamethoxazole-trimethoprim tab 400-80 mg

1

sulfamethoxazole-trimethoprim tab 800-160 mg

1

sulfatrim pd sus 200-40/5 1 ANTIBACTERIALS, TETRACYCLINES ADOXA CAP 150MG 3 ADOXA PAK 1/ TAB 100MG 3 ADOXA PAK 1/ TAB 150MG 3 ADOXA PAK 2/ TAB 100MG 3 ADOXA TAB 50MG 3

18

Drug Name Drug Tier Requirements/Limits ADOXA TAB 75MG 3 ADOXA TAB 100MG 3 avidoxy tab 100mg 1 demeclocycline hcl tab 150 mg 1 demeclocycline hcl tab 300 mg 1 DORYX TAB 200MG 3 doxycycline hyclate cap 50 mg 1 doxycycline hyclate cap 100 mg 1 doxycycline hyclate tab 20 mg 1 doxycycline hyclate tab 100 mg 1 doxycycline hyclate tab delayed release 50

mg 1

doxycycline hyclate tab delayed release 75 mg

1


1


1


1

doxycycline monohydrate cap 50 mg 1 doxycycline monohydrate cap 75 mg 1 doxycycline monohydrate cap 100 mg 1 doxycycline monohydrate cap 150 mg 1 doxycycline monohydrate for susp 25

mg/5ml 1

doxycycline monohydrate tab 50 mg 1 doxycycline monohydrate tab 75 mg 1 doxycycline monohydrate tab 100 mg 1 doxycycline monohydrate tab 150 mg 1 minocycline hcl cap 50 mg 1 minocycline hcl cap 75 mg 1 minocycline hcl cap 100 mg 1 minocycline hcl tab 50 mg 1 minocycline hcl tab 75 mg 1 minocycline hcl tab 100 mg 1 minocycline hcl tab er 24hr 45 mg 1 minocycline hcl tab er 24hr 90 mg 1 minocycline hcl tab er 24hr 135 mg 1 mondoxyne nl cap 50mg 1 mondoxyne nl cap 75mg 1 mondoxyne nl cap 100mg 1 MONODOX CAP 75MG 3 MONODOX CAP 100MG 3 morgidox cap 1x100mg 1 morgidox cap 2x100mg 1 SOLODYN TAB 55MG 3

19

Drug Name Drug Tier Requirements/Limits SOLODYN TAB 65MG 3 SOLODYN TAB 80MG 3 SOLODYN TAB 105MG 3 SOLODYN TAB 115MG 3 TARGADOX TAB 50MG 3 tetracycline hcl cap 250 mg 1 tetracycline hcl cap 500 mg 1 VIBRAMYCIN CAP 100MG 3 VIBRAMYCIN SUS 25MG/5ML 3 VIBRAMYCIN SYP 50MG/5ML 3 ANTIFUNGALS ANCOBON CAP 250MG 3 ANCOBON CAP 500MG 3 BIO-STATIN CAP 500000 3 BIO-STATIN CAP 1000000 3 clotrimazole troche 10 mg 1 CRESEMBA CAP 186 MG 3 DIFLUCAN SUS 10MG/ML 3 DIFLUCAN SUS 40MG/ML 3 DIFLUCAN TAB 50MG 3 DIFLUCAN TAB 100MG 3 DIFLUCAN TAB 150MG 3 DIFLUCAN TAB 200MG 3 fluconazole for susp 10 mg/ml 1 fluconazole for susp 40 mg/ml 1 fluconazole tab 50 mg 1 fluconazole tab 100 mg 1 fluconazole tab 150 mg 1 fluconazole tab 200 mg 1 flucytosine cap 250 mg 1 flucytosine cap 500 mg 1 GRIS-PEG TAB 125MG 3 GRIS-PEG TAB 250MG 3 griseofulvin microsize susp 125 mg/5ml 1 griseofulvin microsize tab 500 mg 1 griseofulvin ultramicrosize tab 125 mg 1 griseofulvin ultramicrosize tab 250 mg 1 itraconazole cap 100 mg 1 ketoconazole tab 200 mg 1 LAMISIL TAB 250MG 3 NOXAFIL SUS 40MG/ML 3 NOXAFIL TAB 100MG 3 nystatin susp 100000 unit/ml 1 nystatin tab 500000 unit 1 ONMEL TAB 200MG 2 ORAVIG TAB 50MG 3

20

Drug Name Drug Tier Requirements/Limits terbinafine hcl tab 250 mg 1 VFEND SUS 40MG/ML 3 VFEND TAB 50MG 3 VFEND TAB 200MG 3 voriconazole for susp 40 mg/ml 1 voriconazole tab 50 mg 1 voriconazole tab 200 mg 1 ANTIMALARIALS atovaquone-proguanil hcl tab 62.5-25 mg 1 atovaquone-proguanil hcl tab 250-100 mg 1 chloroquine phosphate tab 250 mg 1 chloroquine phosphate tab 500 mg 1 COARTEM TAB 20-120MG 3 DARAPRIM TAB 25MG 3 MALARONE TAB 62.5-25 3 MALARONE TAB 250-100 3 mefloquine hcl tab 250 mg 1 PRIMAQUINE TAB 26.3MG 3 QUALAQUIN CAP 324MG 3 quinine sulfate cap 324 mg 1 ANTIRETROVIRALS, ANTIRETROVIRAL ADJUVANTS TYBOST TAB 150MG 5 SP ANTIRETROVIRALS, ANTIRETROVIRAL COMBINATIONS abacavir sulfate-lamivudine tab 600-300

mg 4 SP

abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg

4 SP

ATRIPLA TAB 4 SP COMBIVIR TAB 150-300 5 SP COMPLERA TAB 4 SP DESCOVY TAB 200/25 4 SP EPZICOM TAB 600-300 5 SP EVOTAZ TAB 300-150 4 SP GENVOYA TAB 4 SP lamivudine-zidovudine tab 150-300 mg 4 SP ODEFSEY TAB 4 SP PREZCOBIX TAB 800-150 4 SP STRIBILD TAB 4 SP TRIUMEQ TAB 4 SP TRIZIVIR TAB 5 SP TRUVADA TAB 100-150 4 SP TRUVADA TAB 133-200 4 SP TRUVADA TAB 167-250 4 SP TRUVADA TAB 200-300 4 SP ANTIRETROVIRALS, CHEMOKINE RECEPTOR ANTAGONISTS SELZENTRY SOL 20MG/ML 5 SP

21

Drug Name Drug Tier Requirements/Limits SELZENTRY TAB 25MG 5 SP SELZENTRY TAB 75MG 5 SP SELZENTRY TAB 150MG 5 SP SELZENTRY TAB 300MG 5 SP ANTIRETROVIRALS, INTEGRASE INHIBITORS ISENTRESS CHW 25MG 4 SP ISENTRESS CHW 100MG 4 SP ISENTRESS HD TAB 600MG 4 SP ISENTRESS TAB 400MG 4 SP TIVICAY TAB 10MG 4 SP TIVICAY TAB 25MG 4 SP TIVICAY TAB 50MG 4 SP VITEKTA TAB 85MG 5 SP VITEKTA TAB 150MG 5 SP ANTIRETROVIRALS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE

INHIBITORS EDURANT TAB 25MG 4 SP INTELENCE TAB 25MG 4 SP INTELENCE TAB 100MG 4 SP INTELENCE TAB 200MG 4 SP nevirapine tab 200 mg 4 SP nevirapine tab er 24hr 100 mg 4 SP nevirapine tab er 24hr 400 mg 4 SP RESCRIPTOR TAB 100 MG 5 SP RESCRIPTOR TAB 200MG 5 SP SUSTIVA CAP 50MG 4 SP SUSTIVA CAP 200MG 4 SP SUSTIVA TAB 600MG 4 SP VIRAMUNE SUS 50MG/5ML 5 SP VIRAMUNE TAB 200MG 5 SP VIRAMUNE XR TAB 100MG 5 SP VIRAMUNE XR TAB 400MG 5 SP ANTIRETROVIRALS, NUCLEOSIDE REVERSE TRANSCRIPTASE

INHIBITORS abacavir sulfate soln 20 mg/ml (base

equiv) 4 SP

abacavir sulfate tab 300 mg (base equiv) 4 SP didanosine delayed release capsule 125 mg 4 SP didanosine delayed release capsule 200 mg 4 SP didanosine delayed release capsule 250 mg 4 SP didanosine delayed release capsule 400 mg 4 SP EMTRIVA CAP 200MG 4 SP EMTRIVA SOL 10MG/ML 4 SP EPIVIR SOL 10MG/ML 5 SP EPIVIR TAB 150MG 5 SP EPIVIR TAB 300MG 5 SP

22

Drug Name Drug Tier Requirements/Limits lamivudine oral soln 10 mg/ml 4 SP lamivudine tab 150 mg 4 SP lamivudine tab 300 mg 4 SP RETROVIR CAP 100MG 5 SP RETROVIR SYP 50MG/5ML 5 SP stavudine cap 15 mg 4 SP stavudine cap 20 mg 4 SP stavudine cap 30 mg 4 SP stavudine cap 40 mg 4 SP VIDEX EC CAP 125MG 5 SP VIDEX EC CAP 200MG 5 SP VIDEX EC CAP 250MG 5 SP VIDEX EC CAP 400MG 5 SP ZERIT CAP 15MG 5 SP ZERIT CAP 20MG 5 SP ZERIT CAP 30MG 5 SP ZERIT CAP 40MG 5 SP ZERIT SOL 1MG/ML 5 SP ZIAGEN SOL 20MG/ML 5 SP ZIAGEN TAB 300MG 5 SP zidovudine cap 100 mg 4 SP zidovudine syrup 10 mg/ml 4 SP zidovudine tab 300 mg 4 SP ANTIRETROVIRALS, PROTEASE INHIBITORS APTIVUS CAP 250MG 5 SP APTIVUS SOL 5 SP CRIXIVAN CAP 200MG 5 SP CRIXIVAN CAP 400MG 5 SP fosamprenavir calcium tab 700 mg (base

equiv) 4 SP

INVIRASE CAP 200MG 5 SP INVIRASE TAB 500MG 5 SP KALETRA SOL 5 SP KALETRA TAB 100-25MG 4 SP KALETRA TAB 200-50MG 4 SP LEXIVA SUS 50MG/ML 5 SP LEXIVA TAB 700MG 5 SP lopinavir-ritonavir soln 400-100 mg/5ml

(80-20 mg/ml) 4 SP

NORVIR CAP 100MG 4 SP NORVIR SOL 80MG/ML 4 SP NORVIR TAB 100MG 4 SP PREZISTA SUS 100MG/ML 4 SP PREZISTA TAB 75MG 4 SP PREZISTA TAB 150MG 4 SP PREZISTA TAB 600MG 4 SP

23

Drug Name Drug Tier Requirements/Limits PREZISTA TAB 800MG 4 SP REYATAZ CAP 150MG 4 SP REYATAZ CAP 200MG 4 SP REYATAZ CAP 300MG 4 SP VIRACEPT TAB 250MG 5 SP VIRACEPT TAB 625MG 5 SP ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS -

NUCLEOTIDE VIREAD TAB 150MG 4 SP VIREAD TAB 200MG 4 SP VIREAD TAB 250MG 4 SP VIREAD TAB 300MG 4 SP ANTITUBERCULAR AGENTS cycloserine cap 250 mg 1 ethambutol hcl tab 100 mg 1 ethambutol hcl tab 400 mg 1 isoniazid syrup 50 mg/5ml 1 isoniazid tab 100 mg 1 isoniazid tab 300 mg 1 MYAMBUTOL TAB 100MG 3 MYAMBUTOL TAB 400MG 3 PASER GRA 4GM 3 PRIFTIN TAB 150MG 3 pyrazinamide tab 500 mg 1 RIFADIN CAP 150MG 3 RIFADIN CAP 300MG 3 RIFAMATE CAP 3 rifampin cap 150 mg 1 rifampin cap 300 mg 1 RIFATER TAB 3 SIRTURO TAB 100MG 3 TRECATOR TAB 250MG 3 ANTIVIRALS, CYTOMEGALOVIRUS AGENTS valganciclovir hcl tab 450 mg (base

equivalent) 1

ANTIVIRALS, HEPATITIS AGENTS, Hepatitis B adefovir dipivoxil tab 10 mg 4 SP BARACLUDE SOL .05MG/ML 4 SP BARACLUDE TAB 0.5MG 5 SP BARACLUDE TAB 1MG 5 SP entecavir tab 0.5 mg 4 SP entecavir tab 1 mg 4 SP EPIVIR HBV SOL 5MG/ML 5 SP EPIVIR HBV TAB 100MG 5 SP HEPSERA TAB 10MG 5 SP lamivudine tab 100 mg (hbv) 4 SP

24

Drug Name Drug Tier Requirements/Limits VEMLIDY TAB 25MG 4 SP ANTIVIRALS, HEPATITIS AGENTS, Hepatitis C COPEGUS TAB 200MG 5 PA; SP EPCLUSA TAB 400-100 4 PA; SP; for genotypes 1,

2, 3, 4, 5, 6 HARVONI TAB 90-400MG 4 PA; SP; for genotypes 1,

4, 5, 6 MODERIBA PAK 800/DAY 5 PA; SP MODERIBA PAK 1200/DAY 5 PA; SP moderiba tab 200mg 4 PA; SP MODERIBA TAB 600/DAY 5 PA; SP MODERIBA TAB 1000/DAY 5 PA; SP REBETOL CAP 200MG 5 PA; SP REBETOL SOL 40MG/ML 5 PA; SP RIBAPAK PAK 800/DAY 5 PA; SP RIBAPAK PAK 1200/DAY 5 PA; SP RIBAPAK TAB 600/DAY 5 PA; SP RIBAPAK TAB 1000/DAY 5 PA; SP ribasphere cap 200mg 4 PA; SP ribasphere tab 200mg 4 PA; SP ribasphere tab 400mg 4 PA; SP ribasphere tab 600mg 4 PA; SP ribavirin cap 200 mg 4 PA; SP ribavirin tab 200 mg 4 PA; SP SOVALDI TAB 400MG 5 PA; SP VOSEVI TAB 4 PA; SP; for use in

patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3)

ANTIVIRALS, HERPES AGENTS acyclovir cap 200 mg 1 acyclovir susp 200 mg/5ml 1 acyclovir tab 400 mg 1 acyclovir tab 800 mg 1 famciclovir tab 125 mg 1 famciclovir tab 250 mg 1 famciclovir tab 500 mg 1 FAMVIR TAB 125MG 3 FAMVIR TAB 250MG 3 FAMVIR TAB 500MG 3 SITAVIG TAB 50MG 3 valacyclovir hcl tab 1 gm 1

25

Drug Name Drug Tier Requirements/Limits valacyclovir hcl tab 500 mg 1 ZOVIRAX CAP 200MG 3 ZOVIRAX SUS 200/5ML 3 ZOVIRAX TAB 400MG 3 ZOVIRAX TAB 800MG 3 ANTIVIRALS, INFLUENZA AGENTS FLUMADINE TAB 100MG 3 oseltamivir phosphate cap 30 mg (base

equiv) 1

oseltamivir phosphate cap 45 mg (base equiv)

1

oseltamivir phosphate cap 75 mg (base equiv)

1

RELENZA MIS DISKHALE 2 rimantadine hydrochloride tab 100 mg 1 TAMIFLU CAP 30MG 2 TAMIFLU CAP 45MG 2 TAMIFLU CAP 75MG 2 TAMIFLU SUS 6MG/ML 2 MISCELLANEOUS ALBENZA TAB 200MG 3 ALINIA SUS 100/5ML 3 ALINIA TAB 500MG 3 atovaquone susp 750 mg/5ml 1 BILTRICIDE TAB 600MG 3 CLEOCIN CAP 75MG 3 CLEOCIN CAP 150MG 3 CLEOCIN CAP 300MG 3 CLEOCIN PED SOL 75MG/5ML 3 clindamycin hcl cap 75 mg 1 clindamycin hcl cap 150 mg 1 clindamycin hcl cap 300 mg 1 clindamycin palmitate hcl for soln 75

mg/5ml (base equiv) 1

dapsone tab 25 mg 1 dapsone tab 100 mg 1 EMVERM CHW 100MG 3 FLAGYL CAP 375MG 3 FLAGYL TAB 250MG 3 FLAGYL TAB 500MG 3 FURADANTIN SUS 25MG/5ML 3 HIPREX TAB 1GM 3 IMPAVIDO CAP 50MG 3 ivermectin tab 3 mg 1 linezolid for susp 100 mg/5ml 1 linezolid tab 600 mg 1

26

Drug Name Drug Tier Requirements/Limits MACROBID CAP 100MG 3 MEPRON SUS 3 methenamine hippurate tab 1 gm 1 metronidazole cap 375 mg 1 metronidazole tab 250 mg 1 metronidazole tab 500 mg 1 MONUROL PAK GRANULES 3 MYCOBUTIN CAP 150MG 3 NEBUPENT INH 300MG 3 nitrofurantoin macrocrystalline cap 25 mg 1 nitrofurantoin macrocrystalline cap 50 mg 1 nitrofurantoin macrocrystalline cap 100 mg 1 nitrofurantoin monohydrate

macrocrystalline cap 100 mg 1

nitrofurantoin susp 25 mg/5ml 1 PRIMSOL SOL 50MG/5ML 3 rifabutin cap 150 mg 1 SIVEXTRO TAB 200MG 2 STROMECTOL TAB 3MG 3 TINDAMAX TAB 500MG 3 tinidazole tab 250 mg 1 tinidazole tab 500 mg 1 trimethoprim tab 100 mg 1 VANCOCIN HCL CAP 125MG 3 VANCOCIN HCL CAP 250MG 3 vancomycin hcl cap 125 mg 1 vancomycin hcl cap 250 mg 1 XIFAXAN TAB 550MG 2 ANTINEOPLASTIC AGENTS ALKYLATING AGENTS ALKERAN TAB 2MG OC oral chemotherapy -

refer to plan benefits CYCLOPHOSPH CAP 25MG OC oral chemotherapy -

refer to plan benefits CYCLOPHOSPH CAP 50MG OC oral chemotherapy -

refer to plan benefits EMCYT CAP 140MG OC oral chemotherapy -

refer to plan benefits GLEOSTINE CAP 5MG OC oral chemotherapy -




refer to plan benefits

27

Drug Name Drug Tier Requirements/Limits HEXALEN CAP 50MG OC oral chemotherapy -

refer to plan benefits LEUKERAN TAB 2MG OC oral chemotherapy -

refer to plan benefits melphalan tab 2 mg OC oral chemotherapy -

refer to plan benefits MYLERAN TAB 2MG OC oral chemotherapy -

refer to plan benefits TEMODAR CAP 5MG OC PA; SP; oral

chemotherapy - refer to plan benefits

TEMODAR CAP 20MG OC PA; SP; oral chemotherapy - refer to plan benefits





temozolomide cap 5 mg OC PA; SP; oral chemotherapy - refer to plan benefits






VALCHLOR GEL 0.016% 5 PA; SP ANTIMETABOLITES capecitabine tab 150 mg OC PA; SP; oral


28

Drug Name Drug Tier Requirements/Limits capecitabine tab 500 mg OC PA; SP; oral


mercaptopurine tab 50 mg OC oral chemotherapy - refer to plan benefits

methotrexate sodium tab 2.5 mg (base equiv)

OC oral chemotherapy - refer to plan benefits

PURIXAN SUS 20MG/ML OC SP; oral chemotherapy - refer to plan benefits

TABLOID TAB 40MG OC oral chemotherapy - refer to plan benefits

TREXALL TAB 5MG OC oral chemotherapy - refer to plan benefits

TREXALL TAB 7.5MG OC oral chemotherapy - refer to plan benefits



XELODA TAB 150MG OC PA; SP; oral chemotherapy - refer to plan benefits

XELODA TAB 500MG OC PA; SP; oral chemotherapy - refer to plan benefits

HORMONAL ANTINEOPLASTICS, ANTIANDROGENS bicalutamide tab 50 mg OC oral chemotherapy -

refer to plan benefits CASODEX TAB 50MG OC oral chemotherapy -

refer to plan benefits flutamide cap 125 mg OC oral chemotherapy -

refer to plan benefits nilutamide tab 150 mg OC oral chemotherapy -

refer to plan benefits ZYTIGA TAB 250MG OC PA; SP; oral


HORMONAL ANTINEOPLASTICS, ANTIESTROGENS FARESTON TAB 60MG OC oral chemotherapy -

refer to plan benefits SOLTAMOX SOL 10MG/5ML OC oral chemotherapy -

refer to plan benefits tamoxifen citrate tab 10 mg (base

equivalent) OC oral chemotherapy -

refer to plan benefits tamoxifen citrate tab 20 mg (base

equivalent) OC oral chemotherapy -

refer to plan benefits HORMONAL ANTINEOPLASTICS, AROMATASE INHIBITORS

29

Drug Name Drug Tier Requirements/Limits anastrozole tab 1 mg OC oral chemotherapy -

refer to plan benefits ARIMIDEX TAB 1MG OC oral chemotherapy -

refer to plan benefits AROMASIN TAB 25MG OC oral chemotherapy -

refer to plan benefits exemestane tab 25 mg OC oral chemotherapy -

refer to plan benefits FEMARA TAB 2.5MG OC oral chemotherapy -

refer to plan benefits letrozole tab 2.5 mg OC oral chemotherapy -

refer to plan benefits HORMONAL ANTINEOPLASTICS, PROGESTINS megestrol acetate tab 20 mg OC oral chemotherapy -

refer to plan benefits megestrol acetate tab 40 mg OC oral chemotherapy -

refer to plan benefits IMMUNOMODULATORS POMALYST CAP 1MG OC PA; SP; oral


POMALYST CAP 2MG OC PA; SP; oral chemotherapy - refer to plan benefits



REVLIMID CAP 2.5MG OC PA; SP; oral chemotherapy - refer to plan benefits

REVLIMID CAP 5MG OC PA; SP; oral chemotherapy - refer to plan benefits





30

Drug Name Drug Tier Requirements/Limits THALOMID CAP 50MG OC PA; SP; oral


THALOMID CAP 100MG OC PA; SP; oral chemotherapy - refer to plan benefits



KINASE INHIBITORS AFINITOR DIS TAB 2MG OC PA; SP; oral


AFINITOR DIS TAB 3MG OC PA; SP; oral chemotherapy - refer to plan benefits

AFINITOR DIS TAB 5MG OC PA; SP; oral chemotherapy - refer to plan benefits

AFINITOR TAB 2.5MG OC PA; SP; oral chemotherapy - refer to plan benefits

AFINITOR TAB 5MG OC PA; SP; oral chemotherapy - refer to plan benefits

AFINITOR TAB 7.5MG OC PA; SP; oral chemotherapy - refer to plan benefits

AFINITOR TAB 10MG OC PA; SP; oral chemotherapy - refer to plan benefits

BOSULIF TAB 100MG OC PA; SP; oral chemotherapy - refer to plan benefits

BOSULIF TAB 500MG OC PA; SP; oral chemotherapy - refer to plan benefits

CABOMETYX TAB 20MG OC PA; SP; oral chemotherapy - refer to plan benefits



31

Drug Name Drug Tier Requirements/Limits CAPRELSA TAB 100MG OC PA; SP; oral


CAPRELSA TAB 300MG OC PA; SP; oral chemotherapy - refer to plan benefits

COMETRIQ KIT 60MG OC PA; SP; oral chemotherapy - refer to plan benefits



COTELLIC TAB 20MG OC PA; SP; oral chemotherapy - refer to plan benefits

GILOTRIF TAB 20MG OC PA; SP; oral chemotherapy - refer to plan benefits



GLEEVEC TAB 100MG OC PA; SP; oral chemotherapy - refer to plan benefits

GLEEVEC TAB 400MG OC PA; SP; oral chemotherapy - refer to plan benefits

IBRANCE CAP 75MG OC PA; SP; oral chemotherapy - refer to plan benefits



ICLUSIG TAB 15MG OC PA; SP; oral chemotherapy - refer to plan benefits

ICLUSIG TAB 45MG OC PA; SP; oral chemotherapy - refer to plan benefits

32

Drug Name Drug Tier Requirements/Limits imatinib mesylate tab 100 mg (base

equivalent) OC PA; SP; oral


imatinib mesylate tab 400 mg (base equivalent)

OC PA; SP; oral chemotherapy - refer to plan benefits

IMBRUVICA CAP 140MG OC PA; SP; oral chemotherapy - refer to plan benefits

INLYTA TAB 1MG OC PA; SP; oral chemotherapy - refer to plan benefits

INLYTA TAB 5MG OC PA; SP; oral chemotherapy - refer to plan benefits

IRESSA TAB 250MG OC PA; SP; oral chemotherapy - refer to plan benefits

JAKAFI TAB 5MG OC PA; SP; oral chemotherapy - refer to plan benefits





KISQALI TAB 200DOSE OC PA; SP; oral chemotherapy - refer to plan benefits



LENVIMA CAP 8 MG OC PA; SP; oral chemotherapy - refer to plan benefits


33

Drug Name Drug Tier Requirements/Limits LENVIMA CAP 14 MG OC PA; SP; oral





LYNPARZA CAP 50MG OC PA; SP; oral chemotherapy - refer to plan benefits

MEKINIST TAB 0.5MG OC PA; SP; oral chemotherapy - refer to plan benefits

MEKINIST TAB 2MG OC PA; SP; oral chemotherapy - refer to plan benefits

NERLYNX TAB 40MG OC PA; SP; oral chemotherapy - refer to plan benefits

NEXAVAR TAB 200MG OC PA; SP; oral chemotherapy - refer to plan benefits

NINLARO CAP 2.3MG OC PA; SP; oral chemotherapy - refer to plan benefits

NINLARO CAP 3MG OC PA; SP; oral chemotherapy - refer to plan benefits

NINLARO CAP 4MG OC PA; SP; oral chemotherapy - refer to plan benefits

RUBRACA TAB 200MG OC PA; SP; oral chemotherapy - refer to plan benefits

RUBRACA TAB 300MG OC PA; SP; oral chemotherapy - refer to plan benefits

SPRYCEL TAB 20MG OC PA; SP; oral chemotherapy - refer to plan benefits


34

Drug Name Drug Tier Requirements/Limits SPRYCEL TAB 70MG OC PA; SP; oral





STIVARGA TAB 40MG OC PA; SP; oral chemotherapy - refer to plan benefits

SUTENT CAP 12.5MG OC PA; SP; oral chemotherapy - refer to plan benefits

SUTENT CAP 25MG OC PA; SP; oral chemotherapy - refer to plan benefits

SUTENT CAP 37.5MG OC PA; SP; oral chemotherapy - refer to plan benefits

SUTENT CAP 50MG OC PA; SP; oral chemotherapy - refer to plan benefits

TAFINLAR CAP 50MG OC PA; SP; oral chemotherapy - refer to plan benefits

TAFINLAR CAP 75MG OC PA; SP; oral chemotherapy - refer to plan benefits

TAGRISSO TAB 40MG OC PA; SP; oral chemotherapy - refer to plan benefits

TAGRISSO TAB 80MG OC PA; SP; oral chemotherapy - refer to plan benefits

TARCEVA TAB 25MG OC PA; SP; oral chemotherapy - refer to plan benefits



35

Drug Name Drug Tier Requirements/Limits TYKERB TAB 250MG OC PA; SP; oral


VOTRIENT TAB 200MG OC PA; SP; oral chemotherapy - refer to plan benefits

XALKORI CAP 200MG OC PA; SP; oral chemotherapy - refer to plan benefits

XALKORI CAP 250MG OC PA; SP; oral chemotherapy - refer to plan benefits

ZELBORAF TAB 240MG OC PA; SP; oral chemotherapy - refer to plan benefits

ZYDELIG TAB 100MG OC PA; SP; oral chemotherapy - refer to plan benefits

ZYDELIG TAB 150MG OC PA; SP; oral chemotherapy - refer to plan benefits

ZYKADIA CAP 150MG OC PA; SP; oral chemotherapy - refer to plan benefits

MISCELLANEOUS bexarotene cap 75 mg OC PA; SP; oral


DROXIA CAP 200MG 3 DROXIA CAP 300MG 3 DROXIA CAP 400MG 3 ERIVEDGE CAP 150MG OC PA; SP; oral


etoposide cap 50 mg OC SP; oral chemotherapy - refer to plan benefits

HYDREA CAP 500MG OC oral chemotherapy - refer to plan benefits

hydroxyurea cap 500 mg OC oral chemotherapy - refer to plan benefits

leucovorin calcium tab 5 mg 1 leucovorin calcium tab 10 mg 1 leucovorin calcium tab 15 mg 1 leucovorin calcium tab 25 mg 1 LONSURF TAB 15-6.14 OC PA; SP; oral


36

Drug Name Drug Tier Requirements/Limits LONSURF TAB 20-8.19 OC PA; SP; oral


LYSODREN TAB 500MG OC oral chemotherapy - refer to plan benefits

MATULANE CAP 50MG OC oral chemotherapy - refer to plan benefits

MESNEX TAB 400MG 3 TARGRETIN CAP 75MG OC PA; SP; oral


TARGRETIN GEL 1% 5 PA; SP tretinoin cap 10 mg OC oral chemotherapy -

refer to plan benefits VENCLEXTA TAB 10MG OC PA; SP; oral


VENCLEXTA TAB 50MG OC PA; SP; oral chemotherapy - refer to plan benefits

VENCLEXTA TAB 100MG OC PA; SP; oral chemotherapy - refer to plan benefits

VENCLEXTA TAB START PK OC PA; SP; oral chemotherapy - refer to plan benefits

VISTOGARD PAK 10GM 2 ZEJULA CAP 100MG OC PA; SP; oral


ZOLINZA CAP 100MG OC PA; SP; oral chemotherapy - refer to plan benefits

TOPOISOMERASE INHIBITORS HYCAMTIN CAP 0.25MG OC PA; SP; oral


HYCAMTIN CAP 1MG OC PA; SP; oral chemotherapy - refer to plan benefits

CARDIOVASCULAR ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine besylate-benazepril hcl cap 2.5-

10 mg 1

amlodipine besylate-benazepril hcl cap 5-10 mg

1


1

37

Drug Name Drug Tier Requirements/Limits amlodipine besylate-benazepril hcl cap 5-

40 mg 1


1


1

LOTREL CAP 2.5-10MG 3 LOTREL CAP 5-10MG 3 LOTREL CAP 5-20MG 3 LOTREL CAP 10-20MG 3 LOTREL CAP 10-40MG 3 TARKA TAB 1-240 CR 3 TARKA TAB 2-180 CR 3 TARKA TAB 2-240 CR 3 TARKA TAB 4-240 CR 3 trandolapril-verapamil hcl tab er 1-240 mg 1 trandolapril-verapamil hcl tab er 2-180 mg 1 trandolapril-verapamil hcl tab er 2-240 mg 1 trandolapril-verapamil hcl tab er 4-240 mg 1 ACE INHIBITOR/DIURETIC COMBINATIONS ACCURETIC TAB 10-12.5 3 ACCURETIC TAB 20-12.5 3 ACCURETIC TAB 20-25MG 3 benazepril & hydrochlorothiazide tab 5-

6.25 mg 1

benazepril & hydrochlorothiazide tab 10-12.5 mg

1

benazepril & hydrochlorothiazide tab 20-12.5 mg

1

benazepril & hydrochlorothiazide tab 20-25 mg

1

captopril & hydrochlorothiazide tab 25-15 mg

1


1


1


1

enalapril maleate & hydrochlorothiazide tab 5-12.5 mg

1

enalapril maleate & hydrochlorothiazide tab 10-25 mg

1

fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg

1

fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg

1

38

Drug Name Drug Tier Requirements/Limits lisinopril & hydrochlorothiazide tab 10-12.5

mg 1

lisinopril & hydrochlorothiazide tab 20-12.5 mg

1

lisinopril & hydrochlorothiazide tab 20-25 mg

1

LOTENSIN HCT TAB 10-12.5 3 LOTENSIN HCT TAB 20-12.5 3 LOTENSIN HCT TAB 20-25MG 3 moexipril-hydrochlorothiazide tab 7.5-12.5

mg 1

moexipril-hydrochlorothiazide tab 15-12.5 mg

1

moexipril-hydrochlorothiazide tab 15-25 mg

1

quinapril-hydrochlorothiazide tab 10-12.5 mg

1

quinapril-hydrochlorothiazide tab 20-12.5 mg

1

quinapril-hydrochlorothiazide tab 20-25 mg 1 VASERETIC TAB 10-25MG 3 ZESTORETIC TAB 10-12.5 3 ZESTORETIC TAB 20-12.5 3 ZESTORETIC TAB 20-25MG 3 ACE INHIBITORS ACCUPRIL TAB 5MG 3 ACCUPRIL TAB 10MG 3 ACCUPRIL TAB 20MG 3 ACCUPRIL TAB 40MG 3 ACEON TAB 4MG 3 ACEON TAB 8MG 3 ALTACE CAP 1.25MG 3 ALTACE CAP 2.5MG 3 ALTACE CAP 5MG 3 ALTACE CAP 10MG 3 benazepril hcl tab 5 mg 1 benazepril hcl tab 10 mg 1 benazepril hcl tab 20 mg 1 benazepril hcl tab 40 mg 1 captopril tab 12.5 mg 1 captopril tab 25 mg 1 captopril tab 50 mg 1 captopril tab 100 mg 1 enalapril maleate tab 2.5 mg 1 enalapril maleate tab 5 mg 1 enalapril maleate tab 10 mg 1 enalapril maleate tab 20 mg 1

39

Drug Name Drug Tier Requirements/Limits EPANED SOL 1MG/ML 3 fosinopril sodium tab 10 mg 1 fosinopril sodium tab 20 mg 1 fosinopril sodium tab 40 mg 1 lisinopril tab 2.5 mg 1 lisinopril tab 5 mg 1 lisinopril tab 10 mg 1 lisinopril tab 20 mg 1 lisinopril tab 30 mg 1 lisinopril tab 40 mg 1 LOTENSIN TAB 20MG 3 LOTENSIN TAB 40MG 3 MAVIK TAB 1MG 3 MAVIK TAB 2MG 3 MAVIK TAB 4MG 3 moexipril hcl tab 7.5 mg 1 moexipril hcl tab 15 mg 1 perindopril erbumine tab 2 mg 1 perindopril erbumine tab 4 mg 1 perindopril erbumine tab 8 mg 1 PRINIVIL TAB 5MG 3 PRINIVIL TAB 10MG 3 PRINIVIL TAB 20MG 3 QBRELIS SOL 1MG/ML 3 quinapril hcl tab 5 mg 1 quinapril hcl tab 10 mg 1 quinapril hcl tab 20 mg 1 quinapril hcl tab 40 mg 1 ramipril cap 1.25 mg 1 ramipril cap 2.5 mg 1 ramipril cap 5 mg 1 ramipril cap 10 mg 1 trandolapril tab 1 mg 1 trandolapril tab 2 mg 1 trandolapril tab 4 mg 1 VASOTEC TAB 2.5MG 3 VASOTEC TAB 5MG 3 VASOTEC TAB 10MG 3 VASOTEC TAB 20MG 3 ZESTRIL TAB 2.5MG 3 ZESTRIL TAB 5MG 3 ZESTRIL TAB 10MG 3 ZESTRIL TAB 20MG 3 ZESTRIL TAB 30MG 3 ZESTRIL TAB 40MG 3 ADRENOLYTICS, CENTRAL

40

Drug Name Drug Tier Requirements/Limits CATAPRES TAB 0.1MG 3 CATAPRES TAB 0.2MG 3 CATAPRES TAB 0.3MG 3 CATAPRES-TTS DIS 0.1/24HR 3 CATAPRES-TTS DIS 0.2/24HR 3 CATAPRES-TTS DIS 0.3/24HR 3 clonidine hcl tab 0.1 mg 1 clonidine hcl tab 0.2 mg 1 clonidine hcl tab 0.3 mg 1 clonidine hcl td patch weekly 0.1 mg/24hr 1 clonidine hcl td patch weekly 0.2 mg/24hr 1 clonidine hcl td patch weekly 0.3 mg/24hr 1 guanfacine hcl tab 1 mg 1 guanfacine hcl tab 2 mg 1 TENEX TAB 1MG 3 TENEX TAB 2MG 3 AGENTS FOR PHEOCHROMOCYTOMA DEMSER CAP 250MG 3 DIBENZYLINE CAP 10MG 3 phenoxybenzamine hcl cap 10 mg 1 ALDOSTERONE RECEPTOR ANTAGONISTS ALDACTONE TAB 25MG 3 ALDACTONE TAB 50MG 3 ALDACTONE TAB 100MG 3 eplerenone tab 25 mg 1 eplerenone tab 50 mg 1 INSPRA TAB 25MG 3 INSPRA TAB 50MG 3 spironolactone tab 25 mg 1 spironolactone tab 50 mg 1 spironolactone tab 100 mg 1 ALPHA BLOCKERS CARDURA TAB 1MG 3 CARDURA TAB 2MG 3 CARDURA TAB 4MG 3 CARDURA TAB 8MG 3 doxazosin mesylate tab 1 mg 1 doxazosin mesylate tab 2 mg 1 doxazosin mesylate tab 4 mg 1 doxazosin mesylate tab 8 mg 1 MINIPRESS CAP 1MG 3 MINIPRESS CAP 2MG 3 MINIPRESS CAP 5MG 3 prazosin hcl cap 1 mg 1 prazosin hcl cap 2 mg 1 prazosin hcl cap 5 mg 1

41

Drug Name Drug Tier Requirements/Limits terazosin hcl cap 1 mg 1 terazosin hcl cap 2 mg 1 terazosin hcl cap 5 mg 1 terazosin hcl cap 10 mg 1 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL

BLOCKER COMBINATIONS amlodipine besylate-olmesartan medoxomil

tab 5-20 mg 1

amlodipine besylate-olmesartan medoxomil tab 5-40 mg

1


1


1

amlodipine besylate-valsartan tab 5-160 mg

1


1


1


1

AZOR TAB 5-20MG 2 AZOR TAB 5-40MG 2 AZOR TAB 10-20MG 2 AZOR TAB 10-40MG 2 telmisartan-amlodipine tab 40-5 mg 1 telmisartan-amlodipine tab 40-10 mg 1 telmisartan-amlodipine tab 80-5 mg 1 telmisartan-amlodipine tab 80-10 mg 1 TWYNSTA TAB 40-5MG 3 TWYNSTA TAB 40-10MG 3 TWYNSTA TAB 80-5MG 3 TWYNSTA TAB 80-10MG 3 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL

BLOCKER/DIURETIC COMBINATIONS amlodipine-valsartan-hydrochlorothiazide

tab 5-160-12.5 mg 1

amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg

1

amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg

1


1


1

42

Drug Name Drug Tier Requirements/Limits olmesartan-amlodipine-hydrochlorothiazide

tab 20-5-12.5 mg 1

olmesartan-amlodipine-hydrochlorothiazide tab 40-5-12.5 mg

1

olmesartan-amlodipine-hydrochlorothiazide tab 40-5-25 mg

1

olmesartan-amlodipine-hydrochlorothiazide tab 40-10-12.5 mg

1

olmesartan-amlodipine-hydrochlorothiazide tab 40-10-25 mg

1

TRIBENZOR20- TAB 5-12.5MG 2 TRIBENZOR40- TAB 5-12.5MG 2 TRIBENZOR40- TAB 5-25MG 2 TRIBENZOR40- TAB 10-12.5 2 TRIBENZOR40- TAB 10-25MG 2 ANGIOTENSIN II RECEPTOR ANTAGONIST/DIURETIC

COMBINATIONS AVALIDE TAB 150-12.5 3 AVALIDE TAB 300-12.5 3 BENICAR HCT TAB 20-12.5 2 BENICAR HCT TAB 40-12.5 2 BENICAR HCT TAB 40-25MG 2 candesartan cilexetil-hydrochlorothiazide

tab 16-12.5 mg 1

candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg

1

candesartan cilexetil-hydrochlorothiazide tab 32-25 mg

1

HYZAAR TAB 50-12.5 3 HYZAAR TAB 100-12.5 3 HYZAAR TAB 100-25 3 irbesartan-hydrochlorothiazide tab 150-

12.5 mg 1

irbesartan-hydrochlorothiazide tab 300-12.5 mg

1

losartan potassium & hydrochlorothiazide tab 50-12.5 mg

1

losartan potassium & hydrochlorothiazide tab 100-12.5 mg

1

losartan potassium & hydrochlorothiazide tab 100-25 mg

1

MICARDIS HCT TAB 40/12.5 3 MICARDIS HCT TAB 80-25MG 3 MICARDIS HCT TAB 80/12.5 3 olmesartan medoxomil-hydrochlorothiazide

tab 20-12.5 mg 1

olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg

1

43

Drug Name Drug Tier Requirements/Limits olmesartan medoxomil-hydrochlorothiazide

tab 40-25 mg 1

telmisartan-hydrochlorothiazide tab 40-12.5 mg

1

telmisartan-hydrochlorothiazide tab 80-12.5 mg

1

telmisartan-hydrochlorothiazide tab 80-25 mg

1

valsartan-hydrochlorothiazide tab 80-12.5 mg

1


1

valsartan-hydrochlorothiazide tab 160-25 mg

1


1

valsartan-hydrochlorothiazide tab 320-25 mg

1

ANGIOTENSIN II RECEPTOR ANTAGONISTS AVAPRO TAB 75MG 3 AVAPRO TAB 150MG 3 AVAPRO TAB 300MG 3 BENICAR TAB 5MG 2 BENICAR TAB 20MG 2 BENICAR TAB 40MG 2 candesartan cilexetil tab 4 mg 1 candesartan cilexetil tab 8 mg 1 candesartan cilexetil tab 16 mg 1 candesartan cilexetil tab 32 mg 1 COZAAR TAB 25MG 3 COZAAR TAB 50MG 3 COZAAR TAB 100MG 3 eprosartan mesylate tab 600 mg 1 irbesartan tab 75 mg 1 irbesartan tab 150 mg 1 irbesartan tab 300 mg 1 losartan potassium tab 25 mg 1 losartan potassium tab 50 mg 1 losartan potassium tab 100 mg 1 MICARDIS TAB 20MG 3 MICARDIS TAB 40MG 3 MICARDIS TAB 80MG 3 olmesartan medoxomil tab 5 mg 1 olmesartan medoxomil tab 20 mg 1 olmesartan medoxomil tab 40 mg 1 telmisartan tab 20 mg 1 telmisartan tab 40 mg 1

44

Drug Name Drug Tier Requirements/Limits telmisartan tab 80 mg 1 valsartan tab 40 mg 1 valsartan tab 80 mg 1 valsartan tab 160 mg 1 valsartan tab 320 mg 1 ANTIARRHYTHMICS amiodarone hcl tab 100 mg 1 amiodarone hcl tab 200 mg 1 amiodarone hcl tab 400 mg 1 disopyramide phosphate cap 100 mg 1 disopyramide phosphate cap 150 mg 1 dofetilide cap 125 mcg (0.125 mg) 4 PA; SP dofetilide cap 250 mcg (0.25 mg) 4 PA; SP dofetilide cap 500 mcg (0.5 mg) 4 PA; SP flecainide acetate tab 50 mg 1 flecainide acetate tab 100 mg 1 flecainide acetate tab 150 mg 1 mexiletine hcl cap 150 mg 1 mexiletine hcl cap 200 mg 1 mexiletine hcl cap 250 mg 1 MULTAQ TAB 400MG 2 NORPACE CAP 100MG 3 NORPACE CAP 100MG CR 3 NORPACE CAP 150MG 3 NORPACE CAP 150MG CR 3 pacerone tab 100mg 1 pacerone tab 200mg 1 pacerone tab 400mg 1 propafenone hcl cap er 12hr 225 mg 1 propafenone hcl cap er 12hr 325 mg 1 propafenone hcl cap er 12hr 425 mg 1 propafenone hcl tab 150 mg 1 propafenone hcl tab 225 mg 1 propafenone hcl tab 300 mg 1 quinidine gluconate tab er 324 mg 1 quinidine sulfate tab 200 mg 1 quinidine sulfate tab 300 mg 1 RYTHMOL SR CAP 225MG 3 RYTHMOL SR CAP 325MG 3 RYTHMOL SR CAP 425MG 3 sorine tab 80mg 1 sorine tab 120mg 1 sorine tab 160mg 1 sorine tab 240mg 1 sotalol hcl (afib/afl) tab 80 mg 1 sotalol hcl (afib/afl) tab 120 mg 1

45

Drug Name Drug Tier Requirements/Limits sotalol hcl (afib/afl) tab 160 mg 1 sotalol hcl tab 80 mg 1 sotalol hcl tab 120 mg 1 sotalol hcl tab 160 mg 1 sotalol hcl tab 240 mg 1 SOTYLIZE SOL 5MG/ML 3 TIKOSYN CAP 125MCG 5 PA; SP TIKOSYN CAP 250MCG 5 PA; SP TIKOSYN CAP 500MCG 5 PA; SP ANTILIPEMICS, BILE ACID RESINS COLESTID FLA GRA 5/7.5GM 3 COLESTID FLA GRA 5GM 3 COLESTID GRA 5GM 3 COLESTID POW 5GM 3 COLESTID TAB 1GM 3 colestipol hcl granule packets 5 gm 1 colestipol hcl granules 5 gm 1 colestipol hcl tab 1 gm 1 WELCHOL PAK 3.75GM 2 WELCHOL TAB 625MG 2 ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITORS ezetimibe tab 10 mg 1 ZETIA TAB 10MG 3 ANTILIPEMICS, FIBRATES ANTARA CAP 30MG 3 ANTARA CAP 90MG 3 choline fenofibrate cap dr 45 mg (fenofibric

acid equiv) 1

choline fenofibrate cap dr 135 mg (fenofibric acid equiv)

1

fenofibrate cap 50 mg 1 fenofibrate cap 150 mg 1 fenofibrate micronized cap 43 mg 1 fenofibrate micronized cap 67 mg 1 fenofibrate micronized cap 130 mg 1 fenofibrate micronized cap 134 mg 1 fenofibrate micronized cap 200 mg 1 fenofibrate tab 40 mg 1 fenofibrate tab 48 mg 1 fenofibrate tab 54 mg 1 fenofibrate tab 120 mg 1 fenofibrate tab 145 mg 1 fenofibrate tab 160 mg 1 fenofibric acid tab 35 mg 1 fenofibric acid tab 105 mg 1 FENOGLIDE TAB 40MG 3

46

Drug Name Drug Tier Requirements/Limits FENOGLIDE TAB 120MG 3 FIBRICOR TAB 35MG 3 FIBRICOR TAB 105MG 3 gemfibrozil tab 600 mg 1 LIPOFEN CAP 50MG 3 LIPOFEN CAP 150MG 3 LOFIBRA CAP 67MG 3 LOFIBRA CAP 134MG 3 LOFIBRA CAP 200MG 3 LOFIBRA TAB 54MG 3 LOFIBRA TAB 160MG 3 LOPID TAB 600MG 3 TRIGLIDE TAB 160MG 3 TRILIPIX CAP 45MG 3 TRILIPIX CAP 135MG 3 ANTILIPEMICS, HMG-COA REDUCTASE

INHIBITORS/COMBINATIONS atorvastatin calcium tab 10 mg (base

equivalent) 1

atorvastatin calcium tab 20 mg (base equivalent)

1


1


1

ezetimibe-simvastatin tab 10-10 mg 1 ezetimibe-simvastatin tab 10-20 mg 1 ezetimibe-simvastatin tab 10-40 mg 1 ezetimibe-simvastatin tab 10-80 mg 1 fluvastatin sodium cap 20 mg 1 fluvastatin sodium cap 40 mg 1 fluvastatin sodium tab er 24 hr 80 mg 1 lovastatin tab 10 mg 1 lovastatin tab 20 mg 1 lovastatin tab 40 mg 1 MEVACOR TAB 40MG 3 PRAVACHOL TAB 20MG 3 PRAVACHOL TAB 40MG 3 PRAVACHOL TAB 80MG 3 pravastatin sodium tab 10 mg 1 pravastatin sodium tab 20 mg 1 pravastatin sodium tab 40 mg 1 pravastatin sodium tab 80 mg 1 rosuvastatin calcium tab 5 mg 1 rosuvastatin calcium tab 10 mg 1 rosuvastatin calcium tab 20 mg 1

47

Drug Name Drug Tier Requirements/Limits rosuvastatin calcium tab 40 mg 1 simvastatin tab 5 mg 1 simvastatin tab 10 mg 1 simvastatin tab 20 mg 1 simvastatin tab 40 mg 1 simvastatin tab 80 mg 1 VYTORIN TAB 10-10MG 2 VYTORIN TAB 10-20MG 2 VYTORIN TAB 10-40MG 2 VYTORIN TAB 10-80MG 2 ZOCOR TAB 5MG 3 ZOCOR TAB 10MG 3 ZOCOR TAB 20MG 3 ZOCOR TAB 40MG 3 ZOCOR TAB 80MG 3 ANTILIPEMICS, MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN

INHIBITORS JUXTAPID CAP 5MG 4 PA; SP JUXTAPID CAP 10MG 4 PA; SP JUXTAPID CAP 20MG 4 PA; SP JUXTAPID CAP 30MG 4 PA; SP JUXTAPID CAP 40MG 4 PA; SP JUXTAPID CAP 60MG 4 PA; SP ANTILIPEMICS, NIACINS niacin tab er 500 mg (antihyperlipidemic) 1 niacin tab er 750 mg (antihyperlipidemic) 1 niacin tab er 1000 mg (antihyperlipidemic) 1 niacor tab 500mg 1 NIASPAN TAB 500MG ER 3 NIASPAN TAB 750MG ER 3 NIASPAN TAB 1000 ER 3 ANTILIPEMICS, OMEGA-3 FATTY ACIDS LOVAZA CAP 1GM 3 omega-3-acid ethyl esters cap 1 gm 1 BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone tab 50-25 mg 1 atenolol & chlorthalidone tab 100-25 mg 1 bisoprolol & hydrochlorothiazide tab 2.5-

6.25 mg 1

bisoprolol & hydrochlorothiazide tab 5-6.25 mg

1

bisoprolol & hydrochlorothiazide tab 10-6.25 mg

1

CORZIDE TAB 40-5MG 3 CORZIDE TAB 80-5MG 3 LOPRESS HCT TAB 50-25MG 3

48

Drug Name Drug Tier Requirements/Limits metoprolol & hydrochlorothiazide tab 50-

25 mg 1

metoprolol & hydrochlorothiazide tab 100-25 mg

1

metoprolol & hydrochlorothiazide tab 100-50 mg

1

nadolol & bendroflumethiazide tab 40-5 mg 1 nadolol & bendroflumethiazide tab 80-5 mg 1 propranolol & hydrochlorothiazide tab 40-

25 mg 1

propranolol & hydrochlorothiazide tab 80-25 mg

1

TENORETIC TAB 50 3 TENORETIC TAB 100 3 ZIAC TAB 2.5/6.25 3 ZIAC TAB 5-6.25MG 3 ZIAC TAB 10/6.25 3 BETA-BLOCKERS acebutolol hcl cap 200 mg 1 acebutolol hcl cap 400 mg 1 atenolol tab 25 mg 1 atenolol tab 50 mg 1 atenolol tab 100 mg 1 betaxolol hcl tab 10 mg 1 betaxolol hcl tab 20 mg 1 bisoprolol fumarate tab 5 mg 1 bisoprolol fumarate tab 10 mg 1 BYSTOLIC TAB 2.5MG 2 BYSTOLIC TAB 5MG 2 BYSTOLIC TAB 10MG 2 BYSTOLIC TAB 20MG 2 carvedilol tab 3.125 mg 1 carvedilol tab 6.25 mg 1 carvedilol tab 12.5 mg 1 carvedilol tab 25 mg 1 COREG TAB 3.125MG 3 COREG TAB 6.25MG 3 COREG TAB 12.5MG 3 COREG TAB 25MG 3 CORGARD TAB 20MG 3 CORGARD TAB 40MG 3 CORGARD TAB 80MG 3 HEMANGEOL SOL 4.28/ML 3 INDERAL LA CAP 60MG 3 INDERAL LA CAP 80MG 3 INDERAL LA CAP 120MG 3 INDERAL LA CAP 160MG 3

49

Drug Name Drug Tier Requirements/Limits INDERAL XL CAP 80MG 3 INDERAL XL CAP 120MG 3 labetalol hcl tab 100 mg 1 labetalol hcl tab 200 mg 1 labetalol hcl tab 300 mg 1 LOPRESSOR TAB 50MG 3 LOPRESSOR TAB 100MG 3 metoprolol succinate tab er 24hr 25 mg

(tartrate equiv) 1

metoprolol succinate tab er 24hr 50 mg (tartrate equiv)

1


1


1

metoprolol tartrate tab 25 mg 1 metoprolol tartrate tab 37.5 mg 1 metoprolol tartrate tab 50 mg 1 metoprolol tartrate tab 75 mg 1 metoprolol tartrate tab 100 mg 1 nadolol tab 20 mg 1 nadolol tab 40 mg 1 nadolol tab 80 mg 1 pindolol tab 5 mg 1 pindolol tab 10 mg 1 propranolol hcl cap er 24hr 60 mg 1 propranolol hcl cap er 24hr 80 mg 1 propranolol hcl cap er 24hr 120 mg 1 propranolol hcl cap er 24hr 160 mg 1 propranolol hcl oral soln 20 mg/5ml 1 propranolol hcl oral soln 40 mg/5ml 1 propranolol hcl tab 10 mg 1 propranolol hcl tab 20 mg 1 propranolol hcl tab 40 mg 1 propranolol hcl tab 60 mg 1 propranolol hcl tab 80 mg 1 SECTRAL CAP 200MG 3 SECTRAL CAP 400MG 3 TENORMIN TAB 25MG 3 TENORMIN TAB 50MG 3 TENORMIN TAB 100MG 3 timolol maleate tab 5 mg 1 timolol maleate tab 10 mg 1 timolol maleate tab 20 mg 1 TOPROL XL TAB 25MG 3 TOPROL XL TAB 50MG 3 TOPROL XL TAB 100MG 3

50

Drug Name Drug Tier Requirements/Limits TOPROL XL TAB 200MG 3 ZEBETA TAB 5MG 3 ZEBETA TAB 10MG 3 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine besylate-atorvastatin calcium

tab 2.5-10 mg 1

amlodipine besylate-atorvastatin calcium tab 2.5-20 mg

1

amlodipine besylate-atorvastatin calcium tab 2.5-40 mg

1

amlodipine besylate-atorvastatin calcium tab 5-10 mg

1


1


1


1


1


1


1


1

CADUET TAB 2.5-10MG 3 CADUET TAB 2.5-20MG 3 CADUET TAB 2.5-40MG 3 CADUET TAB 5-10MG 3 CADUET TAB 5-20MG 3 CADUET TAB 5-40MG 3 CADUET TAB 5-80MG 3 CADUET TAB 10-10MG 3 CADUET TAB 10-20MG 3 CADUET TAB 10-40MG 3 CADUET TAB 10-80MG 3 CALCIUM CHANNEL BLOCKERS, DIHYDROPYRIDINES ADALAT CC TAB 30MG ER 3 ADALAT CC TAB 60MG ER 3 ADALAT CC TAB 90MG ER 3 afeditab tab 30mg cr 1 afeditab tab 60mg cr 1 amlodipine besylate tab 2.5 mg 1 amlodipine besylate tab 5 mg 1 amlodipine besylate tab 10 mg 1 felodipine tab er 24hr 2.5 mg 1

51

Drug Name Drug Tier Requirements/Limits felodipine tab er 24hr 5 mg 1 felodipine tab er 24hr 10 mg 1 isradipine cap 2.5 mg 1 isradipine cap 5 mg 1 nicardipine hcl cap 20 mg 1 nicardipine hcl cap 30 mg 1 nifedipine cap 10 mg 1 nifedipine cap 20 mg 1 nifedipine tab er 24hr 30 mg 1 nifedipine tab er 24hr 60 mg 1 nifedipine tab er 24hr 90 mg 1 nifedipine tab er 24hr osmotic release 30

mg 1

nifedipine tab er 24hr osmotic release 60 mg

1

nifedipine tab er 24hr osmotic release 90 mg

1

nimodipine cap 30 mg 1 nisoldipine tab er 24hr 8.5 mg 1 nisoldipine tab er 24hr 17 mg 1 nisoldipine tab er 24hr 20 mg 1 nisoldipine tab er 24hr 25.5 mg 1 nisoldipine tab er 24hr 30 mg 1 nisoldipine tab er 24hr 34 mg 1 nisoldipine tab er 24hr 40 mg 1 NYMALIZE SOL 60/20ML 3 PROCARDIA CAP 10MG 3 PROCARDIA XL TAB 30MG CR 3 PROCARDIA XL TAB 60MG CR 3 PROCARDIA XL TAB 90MG CR 3 SULAR TAB 8.5MG 3 SULAR TAB 17MG 3 SULAR TAB 34MG 3 CALCIUM CHANNEL BLOCKERS, NON DIHYDROPYRIDINES CALAN SR TAB 120MG 3 CALAN SR TAB 180MG 3 CALAN SR TAB 240MG 3 CALAN TAB 80MG 3 CALAN TAB 120MG 3 cartia xt cap 120/24hr 1 cartia xt cap 180/24hr 1 cartia xt cap 240/24hr 1 cartia xt cap 300/24hr 1 dilt-xr cap 120mg 1 dilt-xr cap 180mg 1 dilt-xr cap 240mg 1

52

Drug Name Drug Tier Requirements/Limits diltiazem cap 120mg cd 1 diltiazem cap 180mg cd 1 diltiazem cap 240mg cd 1 diltiazem hcl cap er 12hr 60 mg 1 diltiazem hcl cap er 12hr 90 mg 1 diltiazem hcl cap er 12hr 120 mg 1 diltiazem hcl cap er 24hr 120 mg 1 diltiazem hcl cap er 24hr 180 mg 1 diltiazem hcl cap er 24hr 240 mg 1 diltiazem hcl coated beads cap er 24hr 120

mg 1

diltiazem hcl coated beads cap er 24hr 180 mg

1


1


1


1

diltiazem hcl extended release beads cap er 24hr 120 mg

1


1


1


1


1


1

diltiazem hcl tab 30 mg 1 diltiazem hcl tab 60 mg 1 diltiazem hcl tab 90 mg 1 diltiazem hcl tab 120 mg 1 taztia xt cap 120mg/24 1 taztia xt cap 180mg/24 1 taztia xt cap 240mg/24 1 taztia xt cap 300mg/24 1 taztia xt cap 360mg/24 1 TIAZAC CAP 120MG/24 3 TIAZAC CAP 180MG/24 3 TIAZAC CAP 240MG/24 3 TIAZAC CAP 300MG/24 3 TIAZAC CAP 360MG/24 3 TIAZAC CAP 420MG/24 3 verapamil hcl cap er 24hr 100 mg 1

53

Drug Name Drug Tier Requirements/Limits verapamil hcl cap er 24hr 120 mg 1 verapamil hcl cap er 24hr 180 mg 1 verapamil hcl cap er 24hr 200 mg 1 verapamil hcl cap er 24hr 240 mg 1 verapamil hcl cap er 24hr 300 mg 1 verapamil hcl cap er 24hr 360 mg 1 verapamil hcl tab 40 mg 1 verapamil hcl tab 80 mg 1 verapamil hcl tab 120 mg 1 verapamil hcl tab er 120 mg 1 verapamil hcl tab er 180 mg 1 verapamil hcl tab er 240 mg 1 VERELAN CAP 120MG SR 3 VERELAN CAP 180MG SR 3 VERELAN CAP 240MG SR 3 VERELAN CAP 360MG SR 3 VERELAN PM CAP 100MG ER 3 VERELAN PM CAP 200MG ER 3 VERELAN PM CAP 300MG ER 3 DIGITALIS GLYCOSIDES digitek tab 0.25mg 1 digitek tab 0.125mg 1 digox tab 0.25mg 1 digox tab 0.125mg 1 digoxin oral soln 0.05 mg/ml 1 digoxin tab 125 mcg (0.125 mg) 1 digoxin tab 250 mcg (0.25 mg) 1 LANOXIN TAB 0.0625MG 3 LANOXIN TAB 0.1875MG 3 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS TEKTURNA HCT TAB 150-12.5 2 TEKTURNA HCT TAB 150-25MG 2 TEKTURNA HCT TAB 300-12.5 2 TEKTURNA HCT TAB 300-25MG 2 TEKTURNA TAB 150MG 2 TEKTURNA TAB 300MG 2 DIURETIC COMBINATIONS ALDACTAZIDE TAB 25/25 3 ALDACTAZIDE TAB 50/50 3 amiloride & hydrochlorothiazide tab 5-50

mg 1

DYAZIDE CAP 37.5-25 3 MAXZIDE TAB 75-50 3 MAXZIDE-25 TAB 3 spironolactone & hydrochlorothiazide tab

25-25 mg 1

54

Drug Name Drug Tier Requirements/Limits triamterene & hydrochlorothiazide cap

37.5-25 mg 1

triamterene & hydrochlorothiazide cap 50-25 mg

1

triamterene & hydrochlorothiazide tab 37.5-25 mg

1

triamterene & hydrochlorothiazide tab 75-50 mg

1

DIURETICS, CARBONIC ANHYDRASE INHIBITORS acetazolamide cap er 12hr 500 mg 1 acetazolamide tab 125 mg 1 acetazolamide tab 250 mg 1 DIAMOX SEQUE CAP 500MG CR 3 KEVEYIS TAB 50MG 5 SP methazolamide tab 25 mg 1 methazolamide tab 50 mg 1 NEPTAZANE TAB 25MG 3 NEPTAZANE TAB 50MG 3 DIURETICS, LOOP bumetanide tab 0.5 mg 1 bumetanide tab 1 mg 1 bumetanide tab 2 mg 1 DEMADEX TAB 5MG 3 DEMADEX TAB 10MG 3 DEMADEX TAB 20MG 3 EDECRIN TAB 25MG 3 ethacrynic acid tab 25 mg 1 furosemide oral soln 8 mg/ml 1 furosemide oral soln 10 mg/ml 1 furosemide tab 20 mg 1 furosemide tab 40 mg 1 furosemide tab 80 mg 1 LASIX TAB 20MG 3 LASIX TAB 40MG 3 LASIX TAB 80MG 3 torsemide tab 5 mg 1 torsemide tab 10 mg 1 torsemide tab 20 mg 1 torsemide tab 100 mg 1 DIURETICS, POTASSIUM-SPARING amiloride hcl tab 5 mg 1 DIURETICS, THIAZIDES AND THIAZIDE-LIKE chlorothiazide tab 250 mg 1 chlorothiazide tab 500 mg 1 chlorthalidone tab 25 mg 1 chlorthalidone tab 50 mg 1

55

Drug Name Drug Tier Requirements/Limits DIURIL SUS 250/5ML 3 hydrochlorothiazide cap 12.5 mg 1 hydrochlorothiazide tab 12.5 mg 1 hydrochlorothiazide tab 25 mg 1 hydrochlorothiazide tab 50 mg 1 indapamide tab 1.25 mg 1 indapamide tab 2.5 mg 1 methyclothiazide tab 5 mg 1 metolazone tab 2.5 mg 1 metolazone tab 5 mg 1 metolazone tab 10 mg 1 MICROZIDE CAP 12.5MG 3 HEART FAILURE BIDIL TAB 2 CORLANOR TAB 5MG 2 CORLANOR TAB 7.5MG 2 ENTRESTO TAB 24-26MG 2 ENTRESTO TAB 49-51MG 2 ENTRESTO TAB 97-103MG 2 MISCELLANEOUS cardioplegic soln 1 clorpres tab 0.1-15mg 1 clorpres tab 0.2-15mg 1 clorpres tab 0.3-15mg 1 hydralazine hcl tab 10 mg 1 hydralazine hcl tab 25 mg 1 hydralazine hcl tab 50 mg 1 hydralazine hcl tab 100 mg 1 isoxsuprine hcl tab 10 mg 1 isoxsuprine hcl tab 20 mg 1 methyldopa & hydrochlorothiazide tab 250-

15 mg 1

methyldopa & hydrochlorothiazide tab 250-25 mg

1

methyldopa tab 250 mg 1 methyldopa tab 500 mg 1 midodrine hcl tab 2.5 mg 1 midodrine hcl tab 5 mg 1 midodrine hcl tab 10 mg 1 minoxidil tab 2.5 mg 1 minoxidil tab 10 mg 1 PLEGISOL SOL 3 RANEXA TAB 500MG 2 RANEXA TAB 1000MG 2 VECAMYL TAB 2.5MG 3 NITRATES, ORAL

56

Drug Name Drug Tier Requirements/Limits DILATRATE SR CAP 40MG 3 ISORDIL TAB 5MG 3 ISORDIL TAB 40MG 3 isosorbide dinitrate tab 5 mg 1 isosorbide dinitrate tab 10 mg 1 isosorbide dinitrate tab 20 mg 1 isosorbide dinitrate tab 30 mg 1 isosorbide dinitrate tab er 40 mg 1 isosorbide mononitrate tab 10 mg 1 isosorbide mononitrate tab 20 mg 1 isosorbide mononitrate tab er 24hr 30 mg 1 isosorbide mononitrate tab er 24hr 60 mg 1 isosorbide mononitrate tab er 24hr 120 mg 1 nitro-time cap 2.5mg cr 1 nitro-time cap 6.5mg cr 1 nitro-time cap 9mg cr 1 nitroglycerin cap er 2.5 mg 1 nitroglycerin cap er 6.5 mg 1 nitroglycerin cap er 9 mg 1 NITRATES, SUBLINGUAL/TRANSLINGUAL nitroglycerin lingual aerosol 400 mcg/spray 1 nitroglycerin sl tab 0.3 mg 1 nitroglycerin sl tab 0.4 mg 1 nitroglycerin sl tab 0.6 mg 1 nitroglycerin tl soln 0.4 mg/spray (400

mcg/spray) 1

NITROLINGUAL SPR PUMPSPRA 2 NITROSTAT SUB 0.3MG 3 NITROSTAT SUB 0.4MG 3 NITROSTAT SUB 0.6MG 3 NITRATES, TRANSDERMAL minitran dis 0.1mg/hr 1 minitran dis 0.2mg/hr 1 minitran dis 0.4mg/hr 1 minitran dis 0.6mg/hr 1 NITRO-BID OIN 2% 3 NITRO-DUR DIS 0.1MG/HR 3 NITRO-DUR DIS 0.2MG/HR 3 NITRO-DUR DIS 0.3MG/HR 3 NITRO-DUR DIS 0.4MG/HR 3 NITRO-DUR DIS 0.6MG/HR 3 NITRO-DUR DIS 0.8MG/HR 3 nitroglycerin td patch 24hr 0.1 mg/hr 1 nitroglycerin td patch 24hr 0.2 mg/hr 1 nitroglycerin td patch 24hr 0.4 mg/hr 1 nitroglycerin td patch 24hr 0.6 mg/hr 1

57

Drug Name Drug Tier Requirements/Limits PULMONARY ARTERIAL HYPERTENSION, ENDOTHELIN RECEPTOR

ANTAGONISTS LETAIRIS TAB 5MG 4 PA; SP LETAIRIS TAB 10MG 4 PA; SP TRACLEER TAB 62.5MG 4 PA; SP TRACLEER TAB 125MG 4 PA; SP PULMONARY ARTERIAL HYPERTENSION, PHOSPHODIESTERASE

INHIBITORS sildenafil citrate tab 20 mg 4 SP PULMONARY ARTERIAL HYPERTENSION, PROSTACYCLIN RECEPTOR

AGONISTS UPTRAVI TAB 200/800 5 PA; SP UPTRAVI TAB 200MCG 5 PA; SP UPTRAVI TAB 400MCG 5 PA; SP UPTRAVI TAB 600MCG 5 PA; SP UPTRAVI TAB 800MCG 5 PA; SP UPTRAVI TAB 1000MCG 5 PA; SP UPTRAVI TAB 1200MCG 5 PA; SP UPTRAVI TAB 1400MCG 5 PA; SP UPTRAVI TAB 1600MCG 5 PA; SP PULMONARY ARTERIAL HYPERTENSION, PROSTAGLANDIN

VASODILATORS ORENITRAM TAB 0.25MG 4 PA; SP ORENITRAM TAB 0.125MG 4 PA; SP ORENITRAM TAB 1MG 4 PA; SP ORENITRAM TAB 2.5MG 4 PA; SP ORENITRAM TAB 5MG 4 PA; SP TYVASO REFIL SOL 0.6MG/ML 5 PA; SP TYVASO SOL 0.6MG/ML 5 PA; SP TYVASO START SOL 0.6MG/ML 5 PA; SP VENTAVIS SOL 10MCG/ML 5 PA; SP VENTAVIS SOL 20MCG/ML 5 PA; SP PULMONARY ARTERIAL HYPERTENSION, SOLUBLE GUANYLATE

CYCLASE STIMULATORS ADEMPAS TAB 0.5MG 5 PA; SP ADEMPAS TAB 1.5MG 5 PA; SP ADEMPAS TAB 1MG 5 PA; SP ADEMPAS TAB 2.5MG 5 PA; SP ADEMPAS TAB 2MG 5 PA; SP CENTRAL NERVOUS SYSTEM ANTIANXIETY, BENZODIAZEPINES ALPRAZOLAM CON 1 MG/ML 3 alprazolam orally disintegrating tab 0.5 mg 1 alprazolam orally disintegrating tab 0.25

mg 1

58

Drug Name Drug Tier Requirements/Limits alprazolam orally disintegrating tab 1 mg 1 alprazolam orally disintegrating tab 2 mg 1 alprazolam tab 0.5 mg 1 alprazolam tab 0.5mg xr 1 alprazolam tab 0.25 mg 1 alprazolam tab 1 mg 1 alprazolam tab 1mg xr 1 alprazolam tab 2 mg 1 alprazolam tab 2mg xr 1 alprazolam tab 3mg xr 1 alprazolam tab er 24hr 0.5 mg 1 alprazolam tab er 24hr 1 mg 1 alprazolam tab er 24hr 2 mg 1 alprazolam tab er 24hr 3 mg 1 ATIVAN TAB 0.5MG 3 ATIVAN TAB 1MG 3 ATIVAN TAB 2MG 3 chlordiazepoxide hcl cap 5 mg 1 chlordiazepoxide hcl cap 10 mg 1 chlordiazepoxide hcl cap 25 mg 1 clonazepam orally disintegrating tab 0.5

mg 1

clonazepam orally disintegrating tab 0.25 mg

1

clonazepam orally disintegrating tab 0.125 mg

1

clonazepam orally disintegrating tab 1 mg 1 clonazepam orally disintegrating tab 2 mg 1 clonazepam tab 0.5 mg 1 clonazepam tab 1 mg 1 clonazepam tab 2 mg 1 clorazepate dipotassium tab 3.75 mg 1 clorazepate dipotassium tab 7.5 mg 1 clorazepate dipotassium tab 15 mg 1 diazepam con 5mg/ml 1 diazepam conc 5 mg/ml 1 diazepam oral soln 1 mg/ml 1 diazepam tab 2 mg 1 diazepam tab 5 mg 1 diazepam tab 10 mg 1 KLONOPIN TAB 0.5MG 3 KLONOPIN TAB 1MG 3 KLONOPIN TAB 2MG 3 lorazepam con 2mg/ml 1 lorazepam conc 2 mg/ml 1 lorazepam tab 0.5 mg 1 lorazepam tab 1 mg 1

59

Drug Name Drug Tier Requirements/Limits lorazepam tab 2 mg 1 oxazepam cap 10 mg 1 oxazepam cap 15 mg 1 oxazepam cap 30 mg 1 TRANXENE T TAB 7.5MG 3 VALIUM TAB 2MG 3 VALIUM TAB 5MG 3 VALIUM TAB 10MG 3 XANAX TAB 0.5MG 3 XANAX TAB 0.25MG 3 XANAX TAB 1MG 3 XANAX TAB 2MG 3 XANAX XR TAB 0.5MG 3 XANAX XR TAB 1MG 3 XANAX XR TAB 2MG 3 XANAX XR TAB 3MG 3 ANTIANXIETY, MISCELLANEOUS ANAFRANIL CAP 25MG 3 ANAFRANIL CAP 50MG 3 ANAFRANIL CAP 75MG 3 buspirone hcl tab 5 mg 1 buspirone hcl tab 7.5 mg 1 buspirone hcl tab 10 mg 1 buspirone hcl tab 15 mg 1 buspirone hcl tab 30 mg 1 clomipramine hcl cap 25 mg 1 clomipramine hcl cap 50 mg 1 clomipramine hcl cap 75 mg 1 fluvoxamine maleate cap er 24hr 100 mg 1 fluvoxamine maleate cap er 24hr 150 mg 1 fluvoxamine maleate tab 25 mg 1 fluvoxamine maleate tab 50 mg 1 fluvoxamine maleate tab 100 mg 1 meprobamate tab 200 mg 1 meprobamate tab 400 mg 1 ANTICONVULSANTS BANZEL SUS 40MG/ML 3 BANZEL TAB 200MG 3 BANZEL TAB 400MG 3 carbamazepine cap er 12hr 100 mg 1 carbamazepine cap er 12hr 200 mg 1 carbamazepine cap er 12hr 300 mg 1 carbamazepine chew tab 100 mg 1 carbamazepine susp 100 mg/5ml 1 carbamazepine tab 200 mg 1 carbamazepine tab er 12hr 100 mg 1

60

Drug Name Drug Tier Requirements/Limits carbamazepine tab er 12hr 200 mg 1 carbamazepine tab er 12hr 400 mg 1 CARBATROL CAP 100MG 3 CARBATROL CAP 200MG 3 CARBATROL CAP 300MG 3 CELONTIN CAP 300MG 3 DEPAKENE CAP 250MG 3 DEPAKENE SOL 250/5ML 3 DEPAKOTE ER TAB 250MG 3 DEPAKOTE ER TAB 500MG 3 DEPAKOTE SPR CAP 125MG 3 DEPAKOTE TAB 125MG DR 3 DEPAKOTE TAB 250MG DR 3 DEPAKOTE TAB 500MG DR 3 DIASTAT ACDL GEL 5-10MG 3 DIASTAT ACDL GEL 12.5-20 3 DIASTAT PED GEL 2.5M GEL 3 diazepam rectal gel delivery system 2.5

mg 1

diazepam rectal gel delivery system 10 mg 1 diazepam rectal gel delivery system 20 mg 1 divalproex sodium cap delayed release

sprinkle 125 mg 1

divalproex sodium tab delayed release 125 mg

1


1


1

divalproex sodium tab er 24 hr 250 mg 1 divalproex sodium tab er 24 hr 500 mg 1 epitol tab 200mg 1 ethosuximide cap 250 mg 1 ethosuximide soln 250 mg/5ml 1 felbamate susp 600 mg/5ml 1 felbamate tab 400 mg 1 felbamate tab 600 mg 1 FELBATOL SUS 600/5ML 3 FELBATOL TAB 400MG 3 FELBATOL TAB 600MG 3 FYCOMPA SUS 0.5MG/ML 2 FYCOMPA TAB 2MG 2 FYCOMPA TAB 4MG 2 FYCOMPA TAB 6MG 2 FYCOMPA TAB 8MG 2 FYCOMPA TAB 10MG 2 FYCOMPA TAB 12MG 2

61

Drug Name Drug Tier Requirements/Limits gabapentin cap 100 mg 1 gabapentin cap 300 mg 1 gabapentin cap 400 mg 1 gabapentin oral soln 250 mg/5ml 1 gabapentin tab 600 mg 1 gabapentin tab 800 mg 1 GABITRIL TAB 2MG 3 GABITRIL TAB 4MG 3 GABITRIL TAB 12MG 3 GABITRIL TAB 16MG 3 LAMICTAL ODT KIT 3 LAMICTAL ODT TAB 25MG 3 LAMICTAL ODT TAB 50MG 3 LAMICTAL ODT TAB 100MG 3 LAMICTAL ODT TAB 200MG 3 LAMICTAL XR KIT 3 LAMICTAL XR TAB 25MG 3 LAMICTAL XR TAB 50MG 3 LAMICTAL XR TAB 100MG 3 LAMICTAL XR TAB 200MG 3 LAMICTAL XR TAB 250MG 3 LAMICTAL XR TAB 300MG 3 lamotrigine orally disintegrating tab 25 mg 1 lamotrigine orally disintegrating tab 50 mg 1 lamotrigine orally disintegrating tab 100

mg 1

lamotrigine orally disintegrating tab 200 mg

1

lamotrigine tab 25 mg 1 lamotrigine tab 100 mg 1 lamotrigine tab 150 mg 1 lamotrigine tab 200 mg 1 lamotrigine tab chewable dispersible 5 mg 1 lamotrigine tab chewable dispersible 25 mg 1 lamotrigine tab disint 25 (14) & 50 mg

(14) & 100 mg (7) kit 1

lamotrigine tab disint 25 mg (21) & 50 mg (7) titration kit

1

lamotrigine tab disint 50 mg (42)- 100 mg(14) titration kit

1

lamotrigine tab er 24hr 25 mg 1 lamotrigine tab er 24hr 50 mg 1 lamotrigine tab er 24hr 100 mg 1 lamotrigine tab er 24hr 200 mg 1 lamotrigine tab er 24hr 250 mg 1 lamotrigine tab er 24hr 300 mg 1 levetiracetam oral soln 100 mg/ml 1

62

Drug Name Drug Tier Requirements/Limits levetiracetam tab 250 mg 1 levetiracetam tab 500 mg 1 levetiracetam tab 750 mg 1 levetiracetam tab 1000 mg 1 levetiracetam tab er 24hr 500 mg 1 levetiracetam tab er 24hr 750 mg 1 MYSOLINE TAB 50MG 3 MYSOLINE TAB 250MG 3 NEURONTIN CAP 100MG 3 NEURONTIN CAP 300MG 3 NEURONTIN CAP 400MG 3 NEURONTIN SOL 250/5ML 3 NEURONTIN TAB 600MG 3 NEURONTIN TAB 800MG 3 ONFI SUS 2.5MG/ML 3 ONFI TAB 10MG 3 ONFI TAB 20MG 3 oxcarbazepine susp 300 mg/5ml (60

mg/ml) 1

oxcarbazepine tab 150 mg 1 oxcarbazepine tab 300 mg 1 oxcarbazepine tab 600 mg 1 OXTELLAR XR TAB 150MG 2 OXTELLAR XR TAB 300MG 2 OXTELLAR XR TAB 600MG 2 PEGANONE TAB 250MG 3 phenobarbital elixir 20 mg/5ml 1 phenobarbital tab 15 mg 1 phenobarbital tab 16.2 mg 1 phenobarbital tab 30 mg 1 phenobarbital tab 32.4 mg 1 phenobarbital tab 60 mg 1 phenobarbital tab 64.8 mg 1 phenobarbital tab 97.2 mg 1 phenobarbital tab 100 mg 1 PHENYTEK CAP 200MG 3 PHENYTEK CAP 300MG 3 phenytoin chew tab 50 mg 1 phenytoin chw 50mg 1 phenytoin sodium extended cap 100 mg 1 phenytoin sodium extended cap 200 mg 1 phenytoin sodium extended cap 300 mg 1 phenytoin susp 125 mg/5ml 1 POTIGA TAB 50MG 3 POTIGA TAB 200MG 3 POTIGA TAB 300MG 3

63

Drug Name Drug Tier Requirements/Limits POTIGA TAB 400MG 3 primidone tab 50 mg 1 primidone tab 250 mg 1 QUDEXY XR CAP 25/24HR 3 QUDEXY XR CAP 50/24HR 3 QUDEXY XR CAP 100/24HR 3 QUDEXY XR CAP 150/24HR 3 QUDEXY XR CAP 200/24HR 3 roweepra tab 500mg 1 SABRIL TAB 500MG 5 PA; SP TEGRETOL SUS 100/5ML 3 TEGRETOL TAB 200MG 3 TEGRETOL-XR TAB 100MG 3 TEGRETOL-XR TAB 200MG 3 TEGRETOL-XR TAB 400MG 3 tiagabine hcl tab 2 mg 1 tiagabine hcl tab 4 mg 1 TOPAMAX SPR CAP 15MG 3 TOPAMAX SPR CAP 25MG 3 TOPAMAX TAB 25MG 3 TOPAMAX TAB 50MG 3 TOPAMAX TAB 100MG 3 TOPAMAX TAB 200MG 3 topiramate cap er 24hr sprinkle 25 mg 1 topiramate cap er 24hr sprinkle 50 mg 1 topiramate cap er 24hr sprinkle 100 mg 1 topiramate cap er 24hr sprinkle 150 mg 1 topiramate cap er 24hr sprinkle 200 mg 1 topiramate sprinkle cap 15 mg 1 topiramate sprinkle cap 25 mg 1 topiramate tab 25 mg 1 topiramate tab 50 mg 1 topiramate tab 100 mg 1 topiramate tab 200 mg 1 TRILEPTAL SUS 300MG/5M 3 TRILEPTAL TAB 150MG 3 TRILEPTAL TAB 300MG 3 TRILEPTAL TAB 600MG 3 TROKENDI XR CAP 25MG 2 TROKENDI XR CAP 50MG 2 TROKENDI XR CAP 100MG 2 TROKENDI XR CAP 200MG 2 valproate sodium oral soln 250 mg/5ml

(base equiv) 1

valproic acid cap 250 mg 1 VIMPAT SOL 10MG/ML 2

64

Drug Name Drug Tier Requirements/Limits VIMPAT TAB 50MG 2 VIMPAT TAB 100MG 2 VIMPAT TAB 150MG 2 VIMPAT TAB 200MG 2 ZARONTIN CAP 250MG 3 ZARONTIN SOL 250/5ML 3 zonisamide cap 25 mg 1 zonisamide cap 50 mg 1 zonisamide cap 100 mg 1 ANTIDEMENTIA ARICEPT TAB 5MG 3 ARICEPT TAB 10MG 3 ARICEPT TAB 23MG 3 donepezil hydrochloride orally

disintegrating tab 5 mg 1

donepezil hydrochloride orally disintegrating tab 10 mg

1

donepezil hydrochloride tab 5 mg 1 donepezil hydrochloride tab 10 mg 1 donepezil hydrochloride tab 23 mg 1 EXELON DIS 4.6MG/24 3 EXELON DIS 9.5MG/24 3 EXELON DIS 13.3/24 3 galantamine hydrobromide cap er 24hr 8

mg 1

galantamine hydrobromide cap er 24hr 16 mg

1

galantamine hydrobromide cap er 24hr 24 mg

1

galantamine hydrobromide oral soln 4 mg/ml

1

galantamine hydrobromide tab 4 mg 1 galantamine hydrobromide tab 8 mg 1 galantamine hydrobromide tab 12 mg 1 memantine hcl oral solution 2 mg/ml 1 memantine hcl tab 5 mg 1 memantine hcl tab 5 mg (28) & 10 mg

(21) titration pak 1

memantine hcl tab 10 mg 1 NAMENDA SOL 10MG/5ML 3 NAMENDA TAB 5-10MG 3 NAMENDA TAB 5MG 3 NAMENDA TAB 10MG 3 NAMENDA XR CAP 7MG 2 NAMENDA XR CAP 14MG 2 NAMENDA XR CAP 21MG 2 NAMENDA XR CAP 28MG 2

65

Drug Name Drug Tier Requirements/Limits NAMENDA XR CAP TITRATIO 2 NAMZARIC CAP 2 NAMZARIC CAP 7-10MG 2 NAMZARIC CAP 14-10MG 2 NAMZARIC CAP 21-10MG 2 NAMZARIC CAP 28-10MG 2 RAZADYNE ER CAP 8MG 3 RAZADYNE ER CAP 16MG 3 RAZADYNE ER CAP 24MG 3 RAZADYNE TAB 4MG 3 RAZADYNE TAB 8MG 3 RAZADYNE TAB 12MG 3 rivastigmine tartrate cap 1.5 mg 1 rivastigmine tartrate cap 3 mg 1 rivastigmine tartrate cap 4.5 mg 1 rivastigmine tartrate cap 6 mg 1 rivastigmine td patch 24hr 4.6 mg/24hr 1 rivastigmine td patch 24hr 9.5 mg/24hr 1 rivastigmine td patch 24hr 13.3 mg/24hr 1 ANTIDEPRESSANTS, MISCELLANEOUS APLENZIN TAB 174MG 3 APLENZIN TAB 348MG 3 APLENZIN TAB 522MG 3 bupropion hcl tab 75 mg 1 bupropion hcl tab 100 mg 1 bupropion hcl tab er 12hr 100 mg 1 bupropion hcl tab er 12hr 150 mg 1 bupropion hcl tab er 12hr 200 mg 1 bupropion hcl tab er 24hr 150 mg 1 bupropion hcl tab er 24hr 300 mg 1 chlordiazepoxide-amitriptyline tab 5-12.5

mg 1

chlordiazepoxide-amitriptyline tab 10-25 mg

1

FORFIVO XL TAB 450MG 3 maprotiline hcl tab 25 mg 1 maprotiline hcl tab 50 mg 1 maprotiline hcl tab 75 mg 1 mirtazapine orally disintegrating tab 15 mg 1 mirtazapine orally disintegrating tab 30 mg 1 mirtazapine orally disintegrating tab 45 mg 1 mirtazapine tab 7.5 mg 1 mirtazapine tab 15 mg 1 mirtazapine tab 30 mg 1 mirtazapine tab 45 mg 1 nefazodone hcl tab 50 mg 1

66

Drug Name Drug Tier Requirements/Limits nefazodone hcl tab 100 mg 1 nefazodone hcl tab 150 mg 1 nefazodone hcl tab 200 mg 1 nefazodone hcl tab 250 mg 1 REMERON SLTB TAB 15MG 3 REMERON SLTB TAB 30MG 3 REMERON SLTB TAB 45MG 3 REMERON TAB 15MG 3 REMERON TAB 30MG 3 REMERON TAB 45MG 3 trazodone hcl tab 50 mg 1 trazodone hcl tab 100 mg 1 trazodone hcl tab 150 mg 1 trazodone hcl tab 300 mg 1 WELLBUTRIN TAB 100MG SR 3 WELLBUTRIN TAB 150MG SR 3 WELLBUTRIN TAB 200MG SR 3 WELLBUTRIN TAB XL 150MG 3 WELLBUTRIN TAB XL 300MG 3 ANTIDEPRESSANTS, MONOAMINE OXIDASE INHIBITORS (MAOIs) EMSAM DIS 6MG/24HR 3 EMSAM DIS 9MG/24HR 3 EMSAM DIS 12MG/24H 3 MARPLAN TAB 10MG 3 NARDIL TAB 15MG 3 PARNATE TAB 10MG 3 phenelzine sulfate tab 15 mg 1 tranylcypromine sulfate tab 10 mg 1 ANTIDEPRESSANTS, SELECTIVE SEROTONIN REUPTAKE

INHIBITORS (SSRIs) CELEXA TAB 10MG 3 CELEXA TAB 20MG 3 CELEXA TAB 40MG 3 citalopram hydrobromide oral soln 10

mg/5ml 1

citalopram hydrobromide tab 10 mg (base equiv)

1


1


1

escitalopram oxalate soln 5 mg/5ml (base equiv)

1

escitalopram oxalate tab 5 mg (base equiv)

1

escitalopram oxalate tab 10 mg (base equiv)

1

67

Drug Name Drug Tier Requirements/Limits escitalopram oxalate tab 20 mg (base

equiv) 1

fluoxetine hcl (pmdd) cap 10 mg 1 fluoxetine hcl (pmdd) cap 20 mg 1 fluoxetine hcl (pmdd) tab 10 mg 1 fluoxetine hcl (pmdd) tab 20 mg 1 fluoxetine hcl cap 10 mg 1 fluoxetine hcl cap 20 mg 1 fluoxetine hcl cap 40 mg 1 fluoxetine hcl cap delayed release 90 mg 1 fluoxetine hcl solution 20 mg/5ml 1 fluoxetine hcl tab 10 mg 1 fluoxetine hcl tab 20 mg 1 LEXAPRO SOL 5MG/5ML 3 LEXAPRO TAB 5MG 3 LEXAPRO TAB 10MG 3 LEXAPRO TAB 20MG 3 paroxetine hcl tab 10 mg 1 paroxetine hcl tab 20 mg 1 paroxetine hcl tab 30 mg 1 paroxetine hcl tab 40 mg 1 paroxetine hcl tab er 24hr 12.5 mg 1 paroxetine hcl tab er 24hr 25 mg 1 paroxetine hcl tab er 24hr 37.5 mg 1 PAXIL CR TAB 12.5MG 3 PAXIL CR TAB 25MG 3 PAXIL CR TAB 37.5MG 3 PAXIL SUS 10MG/5ML 3 PAXIL TAB 10MG 3 PAXIL TAB 20MG 3 PAXIL TAB 30MG 3 PAXIL TAB 40MG 3 PEXEVA TAB 10MG 3 PEXEVA TAB 20MG 3 PEXEVA TAB 30MG 3 PEXEVA TAB 40MG 3 PROZAC CAP 10MG 3 PROZAC CAP 20MG 3 PROZAC CAP 40MG 3 PROZAC WEEKL CAP 90MG 3 SARAFEM TAB 10MG 3 SARAFEM TAB 20MG 3 sertraline hcl oral conc 20 mg/ml 1 sertraline hcl tab 25 mg 1 sertraline hcl tab 50 mg 1 sertraline hcl tab 100 mg 1

68

Drug Name Drug Tier Requirements/Limits TRINTELLIX TAB 5MG 2 TRINTELLIX TAB 10MG 2 TRINTELLIX TAB 20MG 2 VIIBRYD KIT STARTER 2 VIIBRYD TAB 10MG 2 VIIBRYD TAB 20MG 2 VIIBRYD TAB 40MG 2 ZOLOFT CON 20MG/ML 3 ZOLOFT TAB 25MG 3 ZOLOFT TAB 50MG 3 ZOLOFT TAB 100MG 3 ANTIDEPRESSANTS, SEROTONIN NOREPINEPHRINE REUPTAKE

INHIBITORS (SNRIs) desvenlafaxine succinate tab er 24hr 25

mg (base equiv) 1

desvenlafaxine succinate tab er 24hr 50 mg (base equiv)

1

desvenlafaxine succinate tab er 24hr 100 mg (base equiv)

1

desvenlafaxine tab er 24hr 50 mg 1 desvenlafaxine tab er 24hr 100 mg 1 duloxetine hcl enteric coated pellets cap 20

mg (base eq) 1

duloxetine hcl enteric coated pellets cap 30 mg (base eq)

1


1


1

EFFEXOR XR CAP 37.5MG 3 EFFEXOR XR CAP 75MG 3 EFFEXOR XR CAP 150MG 3 KHEDEZLA TAB 50MG ER 3 KHEDEZLA TAB 100MG ER 3 PRISTIQ TAB 25MG 2 PRISTIQ TAB 50MG 2 PRISTIQ TAB 100MG 2 venlafaxine hcl cap er 24hr 37.5 mg (base

equivalent) 1

venlafaxine hcl cap er 24hr 75 mg (base equivalent)

1

venlafaxine hcl cap er 24hr 150 mg (base equivalent)

1

venlafaxine hcl tab 25 mg 1 venlafaxine hcl tab 37.5 mg 1 venlafaxine hcl tab 50 mg 1 venlafaxine hcl tab 75 mg 1

69

Drug Name Drug Tier Requirements/Limits venlafaxine hcl tab 100 mg 1 venlafaxine hcl tab er 24hr 225 mg (base

equivalent) 1

VENLAFAXINE TAB 225MG ER 3 ANTIDEPRESSANTS, TRICYCLIC ANTIDEPRESSANTS (TCAs) amitriptyline hcl tab 10 mg 1 amitriptyline hcl tab 25 mg 1 amitriptyline hcl tab 50 mg 1 amitriptyline hcl tab 75 mg 1 amitriptyline hcl tab 100 mg 1 amitriptyline hcl tab 150 mg 1 amoxapine tab 25 mg 1 amoxapine tab 50 mg 1 amoxapine tab 100 mg 1 amoxapine tab 150 mg 1 desipramine hcl tab 10 mg 1 desipramine hcl tab 25 mg 1 desipramine hcl tab 50 mg 1 desipramine hcl tab 75 mg 1 desipramine hcl tab 100 mg 1 desipramine hcl tab 150 mg 1 doxepin hcl cap 10 mg 1 doxepin hcl cap 25 mg 1 doxepin hcl cap 50 mg 1 doxepin hcl cap 75 mg 1 doxepin hcl cap 100 mg 1 doxepin hcl cap 150 mg 1 doxepin hcl conc 10 mg/ml 1 imipramine hcl tab 10 mg 1 imipramine hcl tab 25 mg 1 imipramine hcl tab 50 mg 1 imipramine pamoate cap 75 mg 1 imipramine pamoate cap 100 mg 1 imipramine pamoate cap 125 mg 1 imipramine pamoate cap 150 mg 1 NORPRAMIN TAB 10MG 3 NORPRAMIN TAB 25MG 3 NORPRAMIN TAB 50MG 3 NORPRAMIN TAB 75MG 3 NORPRAMIN TAB 100MG 3 NORPRAMIN TAB 150MG 3 nortriptyline hcl cap 10 mg 1 nortriptyline hcl cap 25 mg 1 nortriptyline hcl cap 50 mg 1 nortriptyline hcl cap 75 mg 1 nortriptyline hcl soln 10 mg/5ml 1

70

Drug Name Drug Tier Requirements/Limits PAMELOR CAP 10MG 3 PAMELOR CAP 25MG 3 PAMELOR CAP 50MG 3 PAMELOR CAP 75MG 3 protriptyline hcl tab 5 mg 1 protriptyline hcl tab 10 mg 1 SURMONTIL CAP 25MG 3 SURMONTIL CAP 50MG 3 SURMONTIL CAP 100MG 3 TOFRANIL TAB 10MG 3 TOFRANIL TAB 25MG 3 TOFRANIL TAB 50MG 3 trimipramine maleate cap 25 mg 1 trimipramine maleate cap 50 mg 1 trimipramine maleate cap 100 mg 1 ANTIPARKINSONIAN AGENTS amantadine hcl cap 100 mg 1 amantadine hcl syrup 50 mg/5ml 1 amantadine hcl tab 100 mg 1 AZILECT TAB 0.5MG 2 AZILECT TAB 1MG 2 benztropine mesylate tab 0.5 mg 1 benztropine mesylate tab 1 mg 1 benztropine mesylate tab 2 mg 1 bromocriptine mesylate cap 5 mg (base

equivalent) 1

bromocriptine mesylate tab 2.5 mg (base equivalent)

1

carbidopa & levodopa orally disintegrating tab 10-100 mg

1


1


1

carbidopa & levodopa tab 10-100 mg 1 carbidopa & levodopa tab 25-100 mg 1 carbidopa & levodopa tab 25-250 mg 1 carbidopa & levodopa tab er 25-100 mg 1 carbidopa & levodopa tab er 50-200 mg 1 carbidopa tab 25 mg 1 carbidopa-levodopa-entacapone tabs 12.5-

50-200 mg 1

carbidopa-levodopa-entacapone tabs 18.75-75-200 mg

1

carbidopa-levodopa-entacapone tabs 25-100-200 mg

1

71

Drug Name Drug Tier Requirements/Limits carbidopa-levodopa-entacapone tabs

31.25-125-200 mg 1

carbidopa-levodopa-entacapone tabs 37.5-150-200 mg

1

carbidopa-levodopa-entacapone tabs 50-200-200 mg

1

COMTAN TAB 200MG 3 DUOPA SUS 4.63-20 3 ELDEPRYL CAP 5MG 3 entacapone tab 200 mg 1 LODOSYN TAB 25MG 3 MIRAPEX ER TAB 0.75MG 2 MIRAPEX ER TAB 0.375MG 2 MIRAPEX ER TAB 1.5MG 2 MIRAPEX ER TAB 2.25MG 2 MIRAPEX ER TAB 3.75MG 2 MIRAPEX ER TAB 3MG 2 MIRAPEX ER TAB 4.5MG 2 MIRAPEX TAB 0.5MG 3 MIRAPEX TAB 0.25MG 3 MIRAPEX TAB 0.75MG 3 MIRAPEX TAB 0.125MG 3 MIRAPEX TAB 1.5MG 3 MIRAPEX TAB 1MG 3 NEUPRO DIS 1MG/24HR 2 NEUPRO DIS 2MG/24HR 2 NEUPRO DIS 3MG/24HR 2 NEUPRO DIS 4MG/24HR 2 NEUPRO DIS 6MG/24HR 2 NEUPRO DIS 8MG/24HR 2 PARLODEL CAP 5MG 3 PARLODEL TAB 2.5MG 3 pramipexole dihydrochloride tab 0.5 mg 1 pramipexole dihydrochloride tab 0.25 mg 1 pramipexole dihydrochloride tab 0.75 mg 1 pramipexole dihydrochloride tab 0.125 mg 1 pramipexole dihydrochloride tab 1 mg 1 pramipexole dihydrochloride tab 1.5 mg 1 pramipexole dihydrochloride tab er 24hr

0.75 mg 1

pramipexole dihydrochloride tab er 24hr 0.375 mg

1


1


1

72

Drug Name Drug Tier Requirements/Limits pramipexole dihydrochloride tab er 24hr 3

mg 1


1


1

rasagiline mesylate tab 0.5 mg (base equiv)

1

rasagiline mesylate tab 1 mg (base equiv) 1 REQUIP TAB 0.5MG 3 REQUIP TAB 0.25MG 3 REQUIP TAB 1MG 3 REQUIP TAB 2MG 3 REQUIP TAB 3MG 3 REQUIP TAB 4MG 3 REQUIP TAB 5MG 3 REQUIP XL TAB 2MG 3 REQUIP XL TAB 4MG 3 REQUIP XL TAB 6MG 3 REQUIP XL TAB 8MG 3 REQUIP XL TAB 12MG 3 ropinirole hydrochloride tab 0.5 mg 1 ropinirole hydrochloride tab 0.25 mg 1 ropinirole hydrochloride tab 1 mg 1 ropinirole hydrochloride tab 2 mg 1 ropinirole hydrochloride tab 3 mg 1 ropinirole hydrochloride tab 4 mg 1 ropinirole hydrochloride tab 5 mg 1 ropinirole hydrochloride tab er 24hr 2 mg

(base equivalent) 1

ropinirole hydrochloride tab er 24hr 4 mg (base equivalent)

1


1


1


1

RYTARY CAP 95MG 3 RYTARY CAP 145MG 3 RYTARY CAP 195MG 3 RYTARY CAP 245MG 3 selegiline hcl cap 5 mg 1 selegiline hcl tab 5 mg 1 SINEMET CR TAB 25-100MG 3 SINEMET CR TAB 50-200MG 3 SINEMET TAB 10-100MG 3

73

Drug Name Drug Tier Requirements/Limits SINEMET TAB 25-100MG 3 SINEMET TAB 25-250MG 3 STALEVO 50 TAB 3 STALEVO 75 TAB 3 STALEVO 100 TAB 3 STALEVO 125 TAB 3 STALEVO 150 TAB 3 STALEVO 200 TAB 3 TASMAR TAB 100MG 3 tolcapone tab 100 mg 1 trihexyphenidyl hcl elixir 0.4 mg/ml 1 trihexyphenidyl hcl tab 2 mg 1 trihexyphenidyl hcl tab 5 mg 1 ZELAPAR TAB 1.25MG 3 ANTIPSYCHOTICS, ATYPICALS aripiprazole oral solution 1 mg/ml 1 aripiprazole tab 2 mg 1 aripiprazole tab 5 mg 1 aripiprazole tab 10 mg 1 aripiprazole tab 15 mg 1 aripiprazole tab 20 mg 1 aripiprazole tab 30 mg 1 clozapine orally disintegrating tab 12.5 mg 1 clozapine orally disintegrating tab 25 mg 1 clozapine orally disintegrating tab 100 mg 1 clozapine orally disintegrating tab 150 mg 1 clozapine orally disintegrating tab 200 mg 1 clozapine tab 25 mg 1 clozapine tab 50 mg 1 clozapine tab 100 mg 1 clozapine tab 200 mg 1 CLOZARIL TAB 25MG 3 CLOZARIL TAB 100MG 3 FAZACLO TAB 12.5 ODT 3 FAZACLO TAB 25MG ODT 3 FAZACLO TAB 100 ODT 3 FAZACLO TAB 150 ODT 3 FAZACLO TAB 200 ODT 3 GEODON CAP 20MG 3 GEODON CAP 40MG 3 GEODON CAP 60MG 3 GEODON CAP 80MG 3 INVEGA TAB 1.5MG 3 INVEGA TAB 3MG 3 INVEGA TAB 6MG 3 INVEGA TAB 9MG 3

74

Drug Name Drug Tier Requirements/Limits olanzapine orally disintegrating tab 5 mg 1 olanzapine orally disintegrating tab 10 mg 1 olanzapine orally disintegrating tab 15 mg 1 olanzapine orally disintegrating tab 20 mg 1 olanzapine tab 2.5 mg 1 olanzapine tab 5 mg 1 olanzapine tab 7.5 mg 1 olanzapine tab 10 mg 1 olanzapine tab 15 mg 1 olanzapine tab 20 mg 1 olanzapine-fluoxetine hcl cap 3-25 mg 1 olanzapine-fluoxetine hcl cap 6-25 mg 1 olanzapine-fluoxetine hcl cap 6-50 mg 1 olanzapine-fluoxetine hcl cap 12-25 mg 1 olanzapine-fluoxetine hcl cap 12-50 mg 1 paliperidone tab er 24hr 1.5 mg 1 paliperidone tab er 24hr 3 mg 1 paliperidone tab er 24hr 6 mg 1 paliperidone tab er 24hr 9 mg 1 quetiapine fumarate tab 25 mg 1 quetiapine fumarate tab 50 mg 1 quetiapine fumarate tab 100 mg 1 quetiapine fumarate tab 200 mg 1 quetiapine fumarate tab 300 mg 1 quetiapine fumarate tab 400 mg 1 quetiapine fumarate tab er 24hr 50 mg 1 quetiapine fumarate tab er 24hr 150 mg 1 quetiapine fumarate tab er 24hr 200 mg 1 quetiapine fumarate tab er 24hr 300 mg 1 quetiapine fumarate tab er 24hr 400 mg 1 RISPERDAL M TAB 0.5MG 3 RISPERDAL M TAB 1MG 3 RISPERDAL M TAB 2MG 3 RISPERDAL M TAB 3MG 3 RISPERDAL M TAB 4MG 3 RISPERDAL SOL 1MG/ML 3 RISPERDAL TAB 0.5MG 3 RISPERDAL TAB 0.25MG 3 RISPERDAL TAB 1MG 3 RISPERDAL TAB 2MG 3 RISPERDAL TAB 3MG 3 RISPERDAL TAB 4MG 3 risperidone orally disintegrating tab 0.5 mg 1 risperidone orally disintegrating tab 0.25

mg 1

risperidone orally disintegrating tab 1 mg 1

75

Drug Name Drug Tier Requirements/Limits risperidone orally disintegrating tab 2 mg 1 risperidone orally disintegrating tab 3 mg 1 risperidone orally disintegrating tab 4 mg 1 risperidone soln 1 mg/ml 1 risperidone tab 0.5 mg 1 risperidone tab 0.5mg od 1 risperidone tab 0.25 mg 1 risperidone tab 1 mg 1 risperidone tab 1mg odt 1 risperidone tab 2 mg 1 risperidone tab 2mg odt 1 risperidone tab 3 mg 1 risperidone tab 3mg odt 1 risperidone tab 4 mg 1 risperidone tab 4mg odt 1 SAPHRIS SUB 2.5MG 3 SAPHRIS SUB 5MG 3 SAPHRIS SUB 10MG 3 SEROQUEL TAB 25MG 3 SEROQUEL TAB 50MG 3 SEROQUEL TAB 100MG 3 SEROQUEL TAB 200MG 3 SEROQUEL TAB 300MG 3 SEROQUEL TAB 400MG 3 SEROQUEL XR TAB 50MG 2 SEROQUEL XR TAB 150MG 2 SEROQUEL XR TAB 200MG 2 SEROQUEL XR TAB 300MG 2 SEROQUEL XR TAB 400MG 2 SYMBYAX CAP 3-25MG 3 SYMBYAX CAP 6-25MG 3 SYMBYAX CAP 6-50MG 3 SYMBYAX CAP 12-25MG 3 SYMBYAX CAP 12-50MG 3 VERSACLOZ SUS 50MG/ML 3 VRAYLAR CAP 1.5-3MG 3 VRAYLAR CAP 1.5MG 3 VRAYLAR CAP 3MG 3 VRAYLAR CAP 4.5MG 3 VRAYLAR CAP 6MG 3 ziprasidone hcl cap 20 mg 1 ziprasidone hcl cap 40 mg 1 ziprasidone hcl cap 60 mg 1 ziprasidone hcl cap 80 mg 1 ZYPREXA TAB 2.5MG 3 ZYPREXA TAB 5MG 3

76

Drug Name Drug Tier Requirements/Limits ZYPREXA TAB 7.5MG 3 ZYPREXA TAB 10MG 3 ZYPREXA TAB 15MG 3 ZYPREXA TAB 20MG 3 ZYPREXA ZYDI TAB 5MG 3 ZYPREXA ZYDI TAB 10MG 3 ZYPREXA ZYDI TAB 15MG 3 ZYPREXA ZYDI TAB 20MG 3 ANTIPSYCHOTICS, MISCELLANEOUS ADASUVE INH 10MG 3 chlorpromazine hcl tab 10 mg 1 chlorpromazine hcl tab 25 mg 1 chlorpromazine hcl tab 50 mg 1 chlorpromazine hcl tab 100 mg 1 chlorpromazine hcl tab 200 mg 1 fluphenazine hcl elixir 2.5 mg/5ml 1 fluphenazine hcl oral conc 5 mg/ml 1 fluphenazine hcl tab 1 mg 1 fluphenazine hcl tab 2.5 mg 1 fluphenazine hcl tab 5 mg 1 fluphenazine hcl tab 10 mg 1 haloperidol lactate oral conc 2 mg/ml 1 haloperidol tab 0.5 mg 1 haloperidol tab 1 mg 1 haloperidol tab 2 mg 1 haloperidol tab 5 mg 1 haloperidol tab 10 mg 1 haloperidol tab 20 mg 1 loxapine succinate cap 5 mg 1 loxapine succinate cap 10 mg 1 loxapine succinate cap 25 mg 1 loxapine succinate cap 50 mg 1 molindone hcl tab 5 mg 1 molindone hcl tab 10 mg 1 molindone hcl tab 25 mg 1 NUPLAZID TAB 17MG 5 PA; SP ORAP TAB 1MG 3 ORAP TAB 2MG 3 perphenazine tab 2 mg 1 perphenazine tab 4 mg 1 perphenazine tab 8 mg 1 perphenazine tab 16 mg 1 perphenazine-amitriptyline tab 2-10 mg 1 perphenazine-amitriptyline tab 2-25 mg 1 perphenazine-amitriptyline tab 4-10 mg 1 perphenazine-amitriptyline tab 4-25 mg 1

77

Drug Name Drug Tier Requirements/Limits perphenazine-amitriptyline tab 4-50 mg 1 pimozide tab 1 mg 1 pimozide tab 2 mg 1 thioridazine hcl tab 10 mg 1 thioridazine hcl tab 25 mg 1 thioridazine hcl tab 50 mg 1 thioridazine hcl tab 100 mg 1 thiothixene cap 1 mg 1 thiothixene cap 2 mg 1 thiothixene cap 5 mg 1 thiothixene cap 10 mg 1 trifluoperazine hcl tab 1 mg (base

equivalent) 1

trifluoperazine hcl tab 2 mg (base equivalent)

1


1


1

ATTENTION DEFICIT HYPERACTIVITY DISORDER ADDERALL TAB 5MG 3 ADDERALL TAB 7.5MG 3 ADDERALL TAB 10MG 3 ADDERALL TAB 12.5MG 3 ADDERALL TAB 15MG 3 ADDERALL TAB 20MG 3 ADDERALL TAB 30MG 3 ADZENYS XR TAB 3.1MG 3 ADZENYS XR TAB 6.3MG 3 ADZENYS XR TAB 9.4MG 3 ADZENYS XR TAB 12.5MG 3 ADZENYS XR TAB 15.7 MG 3 ADZENYS XR TAB 18.8MG 3 amphetamine-dextroamphetamine cap er

24hr 5 mg 1

amphetamine-dextroamphetamine cap er 24hr 10 mg

1


1


1


1


1

amphetamine-dextroamphetamine tab 5 mg

1

78

Drug Name Drug Tier Requirements/Limits amphetamine-dextroamphetamine tab 7.5

mg 1


1

amphetamine-dextroamphetamine tab 12.5 mg

1


1


1


1

APTENSIO XR CAP 10MG 2 APTENSIO XR CAP 15MG 2 APTENSIO XR CAP 20MG 2 APTENSIO XR CAP 30MG 2 APTENSIO XR CAP 40MG 2 APTENSIO XR CAP 50MG 2 APTENSIO XR CAP 60MG 2 atomoxetine hcl cap 10 mg (base equiv) 1 atomoxetine hcl cap 18 mg (base equiv) 1 atomoxetine hcl cap 25 mg (base equiv) 1 atomoxetine hcl cap 40 mg (base equiv) 1 atomoxetine hcl cap 60 mg (base equiv) 1 atomoxetine hcl cap 80 mg (base equiv) 1 atomoxetine hcl cap 100 mg (base equiv) 1 clonidine hcl tab er 12hr 0.1 mg 1 CONCERTA TAB 18MG 3 CONCERTA TAB 27MG 3 CONCERTA TAB 36MG 3 CONCERTA TAB 54MG 3 DAYTRANA DIS 10MG/9HR 3 DAYTRANA DIS 15MG/9HR 3 DAYTRANA DIS 20MG/9HR 3 DAYTRANA DIS 30MG/9HR 3 DESOXYN TAB 5MG 3 DEXEDRINE CAP 5MG CR 3 DEXEDRINE CAP 10MG CR 3 DEXEDRINE CAP 15MG CR 3 dexedrine tab 5mg 1 dexedrine tab 10mg 1 dexmethylphenidate hcl cap er 24 hr 5 mg 1 dexmethylphenidate hcl cap er 24 hr 10

mg 1

dexmethylphenidate hcl cap er 24 hr 15 mg

1

79

Drug Name Drug Tier Requirements/Limits dexmethylphenidate hcl cap er 24 hr 20

mg 1


1


1


1


1

dexmethylphenidate hcl tab 2.5 mg 1 dexmethylphenidate hcl tab 5 mg 1 dexmethylphenidate hcl tab 10 mg 1 dextroamphetamine sulfate cap er 24hr 5

mg 1

dextroamphetamine sulfate cap er 24hr 10 mg

1

dextroamphetamine sulfate cap er 24hr 15 mg

1

dextroamphetamine sulfate oral solution 5 mg/5ml

1

dextroamphetamine sulfate tab 5 mg 1 dextroamphetamine sulfate tab 10 mg 1 DYANAVEL XR SUS 2.5MG/ML 3 EVEKEO TAB 5MG 3 EVEKEO TAB 10MG 3 FOCALIN TAB 2.5MG 3 FOCALIN TAB 5MG 3 FOCALIN TAB 10MG 3 FOCALIN XR CAP 5MG 3 FOCALIN XR CAP 10MG 3 FOCALIN XR CAP 15MG 3 FOCALIN XR CAP 20MG 3 FOCALIN XR CAP 25MG 3 FOCALIN XR CAP 30MG 3 FOCALIN XR CAP 35MG 3 FOCALIN XR CAP 40MG 3 guanfacine hcl tab er 24hr 1 mg (base

equiv) 1

guanfacine hcl tab er 24hr 2 mg (base equiv)

1


1


1

metadate tab 20mg er 1 methamphetamine hcl tab 5 mg 1 METHYLIN CHW 2.5MG 3

80

Drug Name Drug Tier Requirements/Limits METHYLIN CHW 5MG 3 METHYLIN CHW 10MG 3 METHYLIN SOL 5MG/5ML 3 METHYLIN SOL 10MG/5ML 3 methylphenidate hcl cap er 10 mg (cd) 1 methylphenidate hcl cap er 20 mg (cd) 1 methylphenidate hcl cap er 24hr 20 mg

(la) 1

methylphenidate hcl cap er 24hr 30 mg (la)

1


1


1

methylphenidate hcl cap er 30 mg (cd) 1 methylphenidate hcl cap er 40 mg (cd) 1 methylphenidate hcl cap er 50 mg (cd) 1 methylphenidate hcl cap er 60 mg (cd) 1 methylphenidate hcl chew tab 2.5 mg 1 methylphenidate hcl chew tab 5 mg 1 methylphenidate hcl chew tab 10 mg 1 methylphenidate hcl soln 5 mg/5ml 1 methylphenidate hcl soln 10 mg/5ml 1 methylphenidate hcl tab 5 mg 1 methylphenidate hcl tab 10 mg 1 methylphenidate hcl tab 20 mg 1 methylphenidate hcl tab er 10 mg 1 methylphenidate hcl tab er 20 mg 1 methylphenidate hcl tab er 24hr 18 mg 1 methylphenidate hcl tab er 24hr 27 mg 1 methylphenidate hcl tab er 24hr 36 mg 1 methylphenidate hcl tab er 24hr 54 mg 1 methylphenidate hcl tab er osmotic release

(osm) 18 mg 1

methylphenidate hcl tab er osmotic release (osm) 27 mg

1


1


1

PROCENTRA SOL 5MG/5ML 3 QUILLICHEW CHW 20MG ER 3 QUILLICHEW CHW 30MG ER 3 QUILLICHEW CHW 40MG ER 3 QUILLIVANT SUS 25MG/5ML 2 RITALIN LA CAP 10MG 3 RITALIN LA CAP 20MG 3

81

Drug Name Drug Tier Requirements/Limits RITALIN LA CAP 30MG 3 RITALIN LA CAP 40MG 3 RITALIN TAB 5MG 3 RITALIN TAB 10MG 3 RITALIN TAB 20MG 3 STRATTERA CAP 10MG 2 STRATTERA CAP 18MG 2 STRATTERA CAP 25MG 2 STRATTERA CAP 40MG 2 STRATTERA CAP 60MG 2 STRATTERA CAP 80MG 2 STRATTERA CAP 100MG 2 VYVANSE CAP 10MG 2 VYVANSE CAP 20MG 2 VYVANSE CAP 30MG 2 VYVANSE CAP 40MG 2 VYVANSE CAP 50MG 2 VYVANSE CAP 60MG 2 VYVANSE CAP 70MG 2 zenzedi tab 2.5mg 1 zenzedi tab 5mg 1 zenzedi tab 7.5mg 1 zenzedi tab 10mg 1 zenzedi tab 15mg 1 zenzedi tab 20mg 1 zenzedi tab 30mg 1 FIBROMYALGIA LYRICA CAP 25MG 2 LYRICA CAP 50MG 2 LYRICA CAP 75MG 2 LYRICA CAP 100MG 2 LYRICA CAP 150MG 2 LYRICA CAP 200MG 2 LYRICA CAP 225MG 2 LYRICA CAP 300MG 2 LYRICA SOL 20MG/ML 2 SAVELLA MIS TITR PAK 2 SAVELLA TAB 12.5MG 2 SAVELLA TAB 25MG 2 SAVELLA TAB 50MG 2 SAVELLA TAB 100MG 2 HUNTINGTON'S DISEASE AGENTS tetrabenazine tab 12.5 mg 4 PA; SP tetrabenazine tab 25 mg 4 PA; SP HYPNOTICS, BENZODIAZEPINES DORAL TAB 15MG 3

82

Drug Name Drug Tier Requirements/Limits estazolam tab 1 mg 1 estazolam tab 2 mg 1 flurazepam hcl cap 15 mg 1 flurazepam hcl cap 30 mg 1 HALCION TAB 0.25MG 3 midazolam hcl syrup 2 mg/ml (base

equivalent) 1

quazepam tab 15 mg 1 RESTORIL CAP 7.5MG 3 RESTORIL CAP 15MG 3 RESTORIL CAP 22.5MG 3 RESTORIL CAP 30MG 3 temazepam cap 7.5 mg 1 temazepam cap 15 mg 1 temazepam cap 22.5 mg 1 temazepam cap 30 mg 1 triazolam tab 0.25 mg 1 triazolam tab 0.125 mg 1 HYPNOTICS, NON-BENZODIAZEPINES AMBIEN CR TAB 6.25MG 3 AMBIEN CR TAB 12.5MG 3 AMBIEN TAB 5MG 3 AMBIEN TAB 10MG 3 BUTISOL SOD TAB 30MG 3 eszopiclone tab 1 mg 1 eszopiclone tab 2 mg 1 eszopiclone tab 3 mg 1 HETLIOZ CAP 20MG 5 PA; SP SECONAL CAP 100MG 3 SECONAL SOD CAP 100MG 3 zaleplon cap 5 mg 1 zaleplon cap 10 mg 1 zolpidem tartrate sl tab 1.75 mg 1 zolpidem tartrate sl tab 3.5 mg 1 zolpidem tartrate tab 5 mg 1 zolpidem tartrate tab 10 mg 1 zolpidem tartrate tab er 6.25 mg 1 zolpidem tartrate tab er 12.5 mg 1 MIGRAINE, ERGOTAMINE DERIVATIVES dihydroergotamine mesylate nasal spray 4

mg/ml 1

ERGOMAR SUB 2MG 3 ergotamine w/ caffeine tab 1-100 mg 1 migergot sup 2/100 1 MIGRANAL SPR 4MG/ML 3 MIGRAINE, SELECTIVE SEROTONIN AGONISTS

83

Drug Name Drug Tier Requirements/Limits almotriptan malate tab 6.25 mg 1 almotriptan malate tab 12.5 mg 1 AMERGE TAB 1MG 3 AMERGE TAB 2.5MG 3 AXERT TAB 6.25MG 3 AXERT TAB 12.5MG 3 eletriptan hydrobromide tab 20 mg (base

equivalent) 1

eletriptan hydrobromide tab 40 mg (base equivalent)

1

FROVA TAB 2.5MG 3 frovatriptan succinate tab 2.5 mg (base

equivalent) 1

IMITREX INJ 4MG/0.5 3 IMITREX INJ 6MG/0.5 3 IMITREX SPR 5MG/ACT 3 IMITREX SPR 20MG/ACT 3 IMITREX TAB 25MG 3 IMITREX TAB 50MG 3 IMITREX TAB 100MG 3 MAXALT TAB 5MG 3 MAXALT TAB 10MG 3 MAXALT-MLT TAB 5MG 3 MAXALT-MLT TAB 10MG 3 naratriptan hcl tab 1 mg (base equiv) 1 naratriptan hcl tab 2.5 mg (base equiv) 1 ONZETRA XSAI MIS 11MG 3 RELPAX TAB 20MG 2 RELPAX TAB 40MG 2 rizatriptan benzoate oral disintegrating tab

5 mg (base eq) 1

rizatriptan benzoate oral disintegrating tab 10 mg (base eq)

1

rizatriptan benzoate tab 5 mg (base equivalent)

1

rizatriptan benzoate tab 10 mg (base equivalent)

1

sumatriptan nasal spray 5 mg/act 1 sumatriptan nasal spray 20 mg/act 1 sumatriptan succinate inj 6 mg/0.5ml 1 sumatriptan succinate solution auto-

injector 4 mg/0.5ml 1

sumatriptan succinate solution auto-injector 6 mg/0.5ml

1

sumatriptan succinate solution cartridge 4 mg/0.5ml

1

84

Drug Name Drug Tier Requirements/Limits sumatriptan succinate solution cartridge 6

mg/0.5ml 1

sumatriptan succinate solution prefilled syringe 6 mg/0.5ml

1

sumatriptan succinate tab 25 mg 1 sumatriptan succinate tab 50 mg 1 sumatriptan succinate tab 100 mg 1 ZEMBRACE SYM INJ 3/0.5ML 3 zolmitriptan orally disintegrating tab 2.5

mg 1

zolmitriptan orally disintegrating tab 5 mg 1 zolmitriptan tab 2.5 mg 1 zolmitriptan tab 5 mg 1 ZOMIG SPR 2.5MG 2 ZOMIG SPR 5MG 2 ZOMIG TAB 2.5MG 3 ZOMIG TAB 5MG 3 ZOMIG ZMT TAB 2.5 MG 3 ZOMIG ZMT TAB 5MG 3 MISCELLANEOUS ergoloid mesylates tab 1 mg 1 GUANIDINE TAB 125MG 3 RILUTEK TAB 50MG 3 riluzole tab 50 mg 1 MOOD STABILIZERS EQUETRO CAP 100MG 3 EQUETRO CAP 200MG 3 EQUETRO CAP 300MG 3 lithium carbonate cap 150 mg 1 lithium carbonate cap 300 mg 1 lithium carbonate cap 600 mg 1 lithium carbonate tab 300 mg 1 lithium carbonate tab er 300 mg 1 lithium carbonate tab er 450 mg 1 LITHIUM SOL 8MEQ/5ML 3 LITHOBID TAB 300MG CR 3 MULTIPLE SCLEROSIS AMPYRA TAB 10MG 5 PA; SP AUBAGIO TAB 7MG 4 PA; SP AUBAGIO TAB 14MG 4 PA; SP GILENYA CAP 0.5MG 4 PA; SP TECFIDERA CAP 120MG 4 PA; SP TECFIDERA CAP 240MG 4 PA; SP TECFIDERA MIS STARTER 4 PA; SP MUSCULOSKELETAL THERAPY AGENTS baclofen tab 10 mg 1

85

Drug Name Drug Tier Requirements/Limits baclofen tab 20 mg 1 carisoprodol tab 250 mg 1 carisoprodol tab 350 mg 1 carisoprodol w/ aspirin & codeine tab 200-

325-16 mg 1

carisoprodol w/ aspirin tab 200-325 mg 1 chlorzoxazone tab 500 mg 1 cyclobenzaprine hcl tab 5 mg 1 cyclobenzaprine hcl tab 7.5 mg 1 cyclobenzaprine hcl tab 10 mg 1 DANTRIUM CAP 25MG 3 DANTRIUM CAP 50MG 3 dantrolene sodium cap 25 mg 1 dantrolene sodium cap 50 mg 1 dantrolene sodium cap 100 mg 1 FEXMID TAB 7.5MG 3 LORZONE TAB 375MG 3 LORZONE TAB 750MG 3 metaxall tab 800mg 1 metaxalone tab 400 mg 1 metaxalone tab 800 mg 1 methocarbamol tab 500 mg 1 methocarbamol tab 750 mg 1 orphenadrine citrate tab er 12hr 100 mg 1 PARAFON FORT TAB 500MG 3 ROBAXIN TAB 500MG 3 ROBAXIN-750 TAB 750MG 3 SKELAXIN TAB 800MG 3 SOMA TAB 250MG 3 SOMA TAB 350MG 3 tizanidine hcl cap 2 mg (base equivalent) 1 tizanidine hcl cap 4 mg (base equivalent) 1 tizanidine hcl cap 6 mg (base equivalent) 1 tizanidine hcl tab 2 mg (base equivalent) 1 tizanidine hcl tab 4 mg (base equivalent) 1 ZANAFLEX CAP 2MG 3 ZANAFLEX CAP 4MG 3 ZANAFLEX CAP 6MG 3 ZANAFLEX TAB 4MG 3 MYASTHENIA GRAVIS MESTINON SYP 60MG/5ML 3 MESTINON TAB 60MG 3 MESTINON TAB TIMESPAN 2 pyridostigmine bromide tab 60 mg 1 pyridostigmine bromide tab er 180 mg 1 NARCOLEPSY/CATAPLEXY

86

Drug Name Drug Tier Requirements/Limits armodafinil tab 50 mg 1 armodafinil tab 150 mg 1 armodafinil tab 200 mg 1 armodafinil tab 250 mg 1 modafinil tab 100 mg 1 modafinil tab 200 mg 1 NUVIGIL TAB 50MG 3 NUVIGIL TAB 150MG 3 NUVIGIL TAB 200MG 3 NUVIGIL TAB 250MG 3 XYREM SOL 500MG/ML 3 POSTHERPETIC NEURALGIA (PHN) HORIZANT TAB 300MG 2 HORIZANT TAB 600MG 2 PSYCHOTHERAPEUTIC-MISCELLANEOUS, ALCOHOL DETERRENTS acamprosate calcium tab delayed release

333 mg 1

ANTABUSE TAB 250MG 3 ANTABUSE TAB 500MG 3 disulfiram tab 250 mg 1 disulfiram tab 500 mg 1 PSYCHOTHERAPEUTIC-MISCELLANEOUS, OPIOID ANTAGONIST naltrexone hcl tab 50 mg 1 NARCAN SPR 2 PSYCHOTHERAPEUTIC-MISCELLANEOUS, PARTIAL OPIOID

AGONIST/OPIOID ANTAGONIST COMBINATIONS 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

SUBOXONE MIS 2-0.5MG 2 SUBOXONE MIS 4-1MG 2 SUBOXONE MIS 8-2MG 2 SUBOXONE MIS 12-3MG 2 PSYCHOTHERAPEUTIC-MISCELLANEOUS, PARTIAL OPIOID

AGONISTS buprenorphine hcl sl tab 2 mg (base equiv) 1 buprenorphine hcl sl tab 8 mg (base equiv) 1 PSYCHOTHERAPEUTIC-MISCELLANEOUS, PSEUDOBULBAR AFFECT NUEDEXTA CAP 20-10MG 3 PSYCHOTHERAPEUTIC-MISCELLANEOUS, SMOKING DETERRENTS bupropion hcl (smoking deterrent) tab er

12hr 150 mg $0

CHANTIX PAK 0.5& 1MG 3 CHANTIX PAK 1MG 3

87

Drug Name Drug Tier Requirements/Limits CHANTIX TAB 0.5MG 3 CHANTIX TAB 1MG 3 NICOTROL INH 3 NICOTROL NS SPR 10MG/ML 3 ZYBAN TAB 150MG SR 3 PSYCHOTHERAPEUTIC-MISCELLANEOUS, VASOMOTOR SYMPTOM

AGENTS BRISDELLE CAP 7.5MG 2 paroxetine mesylate cap 7.5 mg (base

equiv) 1

ENDOCRINE AND METABOLIC ANDROGENS ANADROL-50 TAB 50MG 3 ANDRODERM DIS 2MG/24HR 2 ANDRODERM DIS 4MG/24HR 2 ANDROID CAP 10MG 3 ANDROXY TAB 10MG 3 AXIRON SOL 30MG/ACT 2 METHITEST TAB 10MG 3 methyltestosterone cap 10 mg 1 OXANDRIN TAB 2.5MG 3 OXANDRIN TAB 10MG 3 oxandrolone tab 2.5 mg 1 oxandrolone tab 10 mg 1 STRIANT MIS 30MG 3 testosterone td gel 10mg/act (2%) 1 testosterone td gel 25 mg/2.5gm (1%) 1 testosterone td gel 50 mg/5gm (1%) 1 testosterone td soln 30 mg/act 1 TESTRED CAP 10MG 3 ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITORS acarbose tab 25 mg 1 acarbose tab 50 mg 1 acarbose tab 100 mg 1 GLYSET TAB 25MG 3 GLYSET TAB 50MG 3 GLYSET TAB 100MG 3 miglitol tab 25 mg 1 miglitol tab 50 mg 1 miglitol tab 100 mg 1 PRECOSE TAB 25MG 3 PRECOSE TAB 50MG 3 PRECOSE TAB 100MG 3 ANTIDIABETICS, AMYLIN ANALOGS SYMLINPEN 60 INJ 1000MCG 3

88

Drug Name Drug Tier Requirements/Limits SYMLNPEN 120 INJ 1000MCG 3 ANTIDIABETICS, BIGUANIDE/SULFONYLUREA COMBINATIONS glipizide-metformin hcl tab 2.5-250 mg 1 glipizide-metformin hcl tab 2.5-500 mg 1 glipizide-metformin hcl tab 5-500 mg 1 GLUCOVANCE TAB 2.5-500 3 GLUCOVANCE TAB 5-500MG 3 glyburide-metformin tab 1.25-250 mg 1 glyburide-metformin tab 2.5-500 mg 1 glyburide-metformin tab 5-500 mg 1 ANTIDIABETICS, BIGUANIDES GLUCOPHAGE TAB 500MG 3 GLUCOPHAGE TAB 500MG XR 3 GLUCOPHAGE TAB 750MG XR 3 GLUCOPHAGE TAB 850MG 3 GLUCOPHAGE TAB 1000MG 3 metformin hcl tab 500 mg 1 metformin hcl tab 850 mg 1 metformin hcl tab 1000 mg 1 metformin hcl tab er 24hr 500 mg 1 Listing does not include

generic GLUMETZA. metformin hcl tab er 24hr 750 mg 1 Listing does not include

generic GLUMETZA. metformin hcl tab er 24hr osmotic 500 mg 1 Listing does not include

generic GLUMETZA. metformin hcl tab er 24hr osmotic 1000

mg 1 Listing does not include

generic GLUMETZA. ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4)

INHIBITOR/BIGUANIDE COMBINATIONS JANUMET TAB 50-500MG 2 JANUMET TAB 50-1000 2 JANUMET XR TAB 50-500MG 2 JANUMET XR TAB 50-1000 2 JANUMET XR TAB 100-1000 2 JENTADUETO TAB 2.5-500 2 JENTADUETO TAB 2.5-850 2 JENTADUETO TAB 2.5-1000 2 JENTADUETO TAB XR 2 ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA TAB 25MG 2 JANUVIA TAB 50MG 2 JANUVIA TAB 100MG 2 TRADJENTA TAB 5MG 2 ANTIDIABETICS, INCRETIN MIMETIC AGENT/INSULIN

COMBINATIONS SOLIQUA INJ 100/33 2

89

Drug Name Drug Tier Requirements/Limits ANTIDIABETICS, INCRETIN MIMETIC AGENTS TRULICITY INJ 0.75/0.5 2 TRULICITY INJ 1.5/0.5 2 VICTOZA INJ 18MG/3ML 2 ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE

COMBINATIONS ACTOPLUS MET TAB 15-500MG 3 ACTOPLUS MET TAB 15-850MG 3 ACTOPLUS MET TAB XR 3 pioglitazone hcl-metformin hcl tab 15-500

mg 1

pioglitazone hcl-metformin hcl tab 15-850 mg

1

ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA COMBINATIONS

DUETACT TAB 30-2MG 3 DUETACT TAB 30-4MG 3 pioglitazone hcl-glimepiride tab 30-2 mg 1 pioglitazone hcl-glimepiride tab 30-4 mg 1 ANTIDIABETICS, INSULIN SENSITIZERS AVANDIA TAB 2MG 3 AVANDIA TAB 4MG 3 pioglitazone hcl tab 15 mg (base equiv) 1 pioglitazone hcl tab 30 mg (base equiv) 1 pioglitazone hcl tab 45 mg (base equiv) 1 ANTIDIABETICS, INSULINS BASAGLAR INJ 100UNIT 2 HUMULIN R INJ U-500 2 LEVEMIR INJ 2 LEVEMIR INJ FLEXTOUC 2 NOVOLIN INJ 70/30 2 NOVOLIN N INJ U-100 2 NOVOLIN R INJ U-100 2 NOVOLOG INJ 100/ML 2 NOVOLOG INJ FLEXPEN 2 NOVOLOG INJ PENFILL 2 NOVOLOG MIX INJ 70/30 2 NOVOLOG MIX INJ FLEXPEN 2 TRESIBA FLEX INJ 100UNIT 2 TRESIBA FLEX INJ 200UNIT 2 ANTIDIABETICS, MEGLITINIDE/BIGUANIDE COMBINATIONS repaglinide-metformin hcl tab 1-500 mg 1 repaglinide-metformin hcl tab 2-500 mg 1 ANTIDIABETICS, MEGLITINIDES nateglinide tab 60 mg 1

90

Drug Name Drug Tier Requirements/Limits nateglinide tab 120 mg 1 PRANDIN TAB 0.5MG 3 PRANDIN TAB 1MG 3 PRANDIN TAB 2MG 3 repaglinide tab 0.5 mg 1 repaglinide tab 1 mg 1 repaglinide tab 2 mg 1 STARLIX TAB 60MG 3 STARLIX TAB 120MG 3 ANTIDIABETICS, MISCELLANEOUS CYCLOSET TAB 0.8MG 3 ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2)

INHIBITOR/BIGUANIDE COMBINATIONS XIGDUO XR TAB 5-500MG 2 XIGDUO XR TAB 5-1000MG 2 XIGDUO XR TAB 10-500MG 2 XIGDUO XR TAB 10-1000 2 ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2)

INHIBITORS FARXIGA TAB 5MG 2 FARXIGA TAB 10MG 2 JARDIANCE TAB 10MG 2 JARDIANCE TAB 25MG 2 ANTIDIABETICS, SULFONYLUREAS AMARYL TAB 1MG 3 AMARYL TAB 2MG 3 AMARYL TAB 4MG 3 chlorpropamide tab 100 mg 1 chlorpropamide tab 250 mg 1 glimepiride tab 1 mg 1 glimepiride tab 2 mg 1 glimepiride tab 4 mg 1 glipizide tab 5 mg 1 glipizide tab 10 mg 1 glipizide tab er 24hr 2.5 mg 1 glipizide tab er 24hr 5 mg 1 glipizide tab er 24hr 10 mg 1 glipizide xl tab 2.5mg 1 glipizide xl tab 5mg 1 glipizide xl tab 10mg 1 GLUCOTROL TAB 5MG 3 GLUCOTROL TAB 10MG 3 GLUCOTROL XL TAB 2.5MG 3 GLUCOTROL XL TAB 5MG 3 GLUCOTROL XL TAB 10MG 3

91

Drug Name Drug Tier Requirements/Limits glyburide micronized tab 1.5 mg 1 glyburide micronized tab 3 mg 1 glyburide micronized tab 6 mg 1 glyburide tab 1.25 mg 1 glyburide tab 2.5 mg 1 glyburide tab 5 mg 1 GLYNASE TAB 1.5MG 3 GLYNASE TAB 3MG 3 GLYNASE TAB 6MG 3 tolazamide tab 250 mg 1 tolazamide tab 500 mg 1 tolbutamide tab 500 mg 1 ANTIDIABETICS, SUPPLIES AUTOSHIELD MIS 29X3/16" 2 BD Brand AUTOSHIELD MIS 29X5/16" 2 BD Brand AUTOSHIELD MIS 30GX3/16 2 BD Brand BD INSULIN SYRINGES AND NEEDLES 2 BD Brand BD PEN NEEDL MIS 31GX3/16 2 BD Brand BD PEN NEEDL MIS 31GX5/16 2 BD Brand BD PEN NEEDL MIS 32GX4MM 2 BD Brand BD PEN NEEDL MIS 32GX4MM 2 BD Brand BD PEN NEEDLES 2 BD Brand BD U-500 MIS 31GX6MM 2 BD Brand HUMAPEN MIS LUXURA 3 INSULIN SYRG MIS 0.3/29G 2 BD Brand INSULIN SYRG MIS 0.3/30G 2 BD Brand INSULIN SYRG MIS 0.3/31G 2 BD Brand INSULIN SYRG MIS 0.5/28G 2 BD Brand INSULIN SYRG MIS 0.5/29G 2 BD Brand INSULIN SYRG MIS 0.5/30G 2 BD Brand INSULIN SYRG MIS 0.5/31G 2 BD Brand INSULIN SYRG MIS 1ML/28G 2 BD Brand INSULIN SYRG MIS 1ML/29G 2 BD Brand INSULIN SYRG MIS 1ML/30G 2 BD Brand INSULIN SYRG MIS 1ML/31G 2 BD Brand LANCETS 3 ONETOUCH TES ULTRA BL 2 ONETOUCH TES VERIO 2 ANTIDOTES RADIOGARDASE CAP 0.5GM 3 CALCIUM RECEPTOR ANTAGONISTS SENSIPAR TAB 30MG 5 PA; SP SENSIPAR TAB 60MG 5 PA; SP SENSIPAR TAB 90MG 5 PA; SP CALCIUM REGULATORS, BISPHOSPHONATES ACTONEL TAB 5MG 3

92

Drug Name Drug Tier Requirements/Limits ACTONEL TAB 30MG 3 ACTONEL TAB 35MG 3 ACTONEL TAB 150MG 3 alendronate sodium oral soln 70 mg/75ml 1 alendronate sodium tab 5 mg 1 alendronate sodium tab 10 mg 1 alendronate sodium tab 35 mg 1 alendronate sodium tab 40 mg 1 alendronate sodium tab 70 mg 1 ATELVIA TAB 2 BINOSTO TAB 70MG 3 BONIVA TAB 150MG 3 etidronate disodium tab 200 mg 1 etidronate disodium tab 400 mg 1 FOSAMAX + D TAB 70-2800 3 FOSAMAX + D TAB 70-5600 3 FOSAMAX TAB 70MG 3 ibandronate sodium tab 150 mg (base

equivalent) 1

risedronate sodium tab 5 mg 1 risedronate sodium tab 30 mg 1 risedronate sodium tab 35 mg 1 risedronate sodium tab 150 mg 1 risedronate sodium tab delayed release 35

mg 1

CALCIUM REGULATORS, CALCITONINS calcitonin (salmon) nasal soln 200 unit/act 1 CARNITINE DEFICIENCY AGENTS levocarnitine oral soln 1 gm/10ml (10%) 1 levocarnitine tab 330 mg 1 CONTRACEPTIVES, BIPHASIC azurette tab 28 day $0 bekyree tab $0 desogest-eth estrad & eth estrad tab 0.15-

0.02/0.01 mg(21/5) $0

kariva tab 28 day $0 kimidess tab $0 LO LOESTRIN TAB 2 MIRCETTE TAB 28 DAY 3 NECON TAB 10/11-28 3 pimtrea tab $0 viorele tab $0 CONTRACEPTIVES, CONTINUOUS amethyst tab 90-20mcg $0 levonorgestrel-ethinyl estradiol

(continuous) tab 90-20 mcg $0

93

Drug Name Drug Tier Requirements/Limits CONTRACEPTIVES, EMERGENCY CONTRACEPTION ELLA TAB 30MG 3 CONTRACEPTIVES, EXTENDED CYCLE amethia lo tab $0 amethia tab $0 ashlyna tab $0 camrese lo tab $0 camrese tab $0 daysee tab $0 introvale tab $0 jolessa tab $0 levonorg-eth est tab 0.1-0.02mg(84) & eth

est tab 0.01mg(7) $0

levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7)

$0

levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg

$0

LOSEASONIQUE TAB 3 quasense tab $0 SEASONIQUE TAB 3 setlakin tab $0 CONTRACEPTIVES, FOUR PHASE NATAZIA TAB 2 CONTRACEPTIVES, MONOPHASIC, 20 mcg Estrogen aubra tab 0.1-0.02 $0 aviane tab $0 BEYAZ TAB 2 blisovi 24 tab fe 1/20 $0 blisovi fe tab 1/20 $0 delyla tab 0.1-0.02 $0 drospirenone-ethinyl estrad-levomefolate

tab 3-0.02-0.451 mg $0

drospirenone-ethinyl estradiol tab 3-0.02 mg

$0

falmina tab $0 gianvi tab 3-0.02mg $0 junel 1/20 tab $0 junel fe 24 tab 1/20 $0 junel fe tab 1/20 $0 larin 24 tab fe 1/20 $0 larin fe tab 1/20 $0 larin tab 1/20 $0 lessina tab $0 levonorgestrel & ethinyl estradiol tab 0.1

mg-20 mcg $0

LOESTRIN FE TAB 1/20 3

94

Drug Name Drug Tier Requirements/Limits LOESTRIN TAB 1/20-21 3 lomedia 24 tab fe $0 loryna tab 3-0.02mg $0 lutera tab $0 micrgstin 24 tab fe 1/20 $0 microgestin tab 1/20 $0 microgestin tab fe 1/20 $0 MINASTRIN 24 CHW FE 2 nikki tab 3-0.02mg $0 norethindrone ace & ethinyl estradiol tab 1

mg-20 mcg $0

norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg

$0

norethindrone ace-eth estradiol-fe chew tab 1 mg-20 mcg (24)

$0

norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24)

$0

orsythia tab $0 rajani tab $0 sronyx tab $0 tarina fe tab 1/20 $0 TAYTULLA CAP $0 vestura tab 3-0.02mg $0 vienva tab 0.1-20 $0 YAZ TAB 3-0.02MG 3 CONTRACEPTIVES, MONOPHASIC, 25 mcg Estrogen GENERESS FE CHW 3 kaitlib fe chw $0 layolis fe chw $0 norethindrone & ethinyl estradiol-fe chew

tab 0.8 mg-25 mcg $0

CONTRACEPTIVES, MONOPHASIC, 30 mcg Estrogen altavera tab $0 apri tab $0 blisovi fe tab 1.5/30 $0 chateal tab 0.15/30 $0 cryselle-28 tab 28 tabs $0 cyred tab $0 DESOGEN-28 TAB 3 desogestrel & ethinyl estradiol tab 0.15

mg-30 mcg $0

drospirenone-ethinyl estradiol tab 3-0.03 mg

$0

elinest tab $0 emoquette tab $0 enskyce tab $0 juleber tab $0

95

Drug Name Drug Tier Requirements/Limits junel 1.5/30 tab $0 junel fe tab 1.5/30 $0 kurvelo tab 0.15/30 $0 larin fe tab 1.5/30 $0 larin tab 1.5/30 $0 levonorgestrel & ethinyl estradiol tab 0.15

mg-30 mcg $0

levora-28 tab 0.15/30 $0 LOESTRIN 21 TAB 1.5/30 3 LOESTRIN FE TAB 1.5/30 3 low-ogestrel tab $0 marlissa tab 0.15/30 $0 microgestin tab 1.5/30 $0 microgestin tab fe1.5/30 $0 ocella tab 3-0.03mg $0 portia-28 tab $0 reclipsen tab $0 SAFYRAL TAB 2 syeda tab 3-0.03mg $0 YASMIN 28 TAB 3-0.03MG 3 zarah tab 3-0.03mg $0 CONTRACEPTIVES, MONOPHASIC, 35 mcg Estrogen alyacen tab 1/35 $0 balziva tab $0 BREVICON TAB 0.5/35 3 briellyn tab $0 cyclafem tab 1/35 $0 dasetta tab 1/35 $0 estarylla tab 0.25-35 $0 FEMCON FE CHW 3 gildagia tab 0.4-35 $0 kelnor tab 1/35 $0 mono-linyah tab 0.25-35 $0 mononessa tab $0 necon tab 0.5/35 $0 necon tab 1/35 $0 norgestimate & ethinyl estradiol tab 0.25

mg-35 mcg $0

NORINYL TAB 1/35 3 nortrel tab 0.5/35 $0 nortrel tab 1/35 $0 ORTHO-CYCLEN TAB 0.25/35 3 ORTHO-NOVUM TAB 1/35 3 OVCON-35 TAB 3 philith tab 0.4-35 $0 pirmella tab 1/35 $0

96

Drug Name Drug Tier Requirements/Limits previfem tab $0 sprintec 28 tab 28 day $0 vyfemla tab 0.4-35 $0 wera tab 0.5/35 $0 wymzya fe chw 0.4mg-35 $0 zenchent fe chw 0.4mg-35 $0 zenchent tab $0 zovia 1/35e tab $0 CONTRACEPTIVES, MONOPHASIC, 50 mcg Estrogen necon tab 1/50-28 $0 ogestrel tab $0 zovia 1/50e tab $0 CONTRACEPTIVES, PROGESTIN ONLY deblitane tab 0.35mg $0 errin tab 0.35mg $0 heather tab 0.35mg $0 jencycla tab 0.35mg $0 jolivette tab 0.35mg $0 lyza tab 0.35mg $0 nora-be tab 0.35mg $0 norethindrone tab 0.35 mg $0 norlyroc tab 0.35mg $0 ORTHO MICRON TAB 0.35MG 3 sharobel tab 0.35mg $0 CONTRACEPTIVES, TRANSDERMAL xulane dis 150-35 $0 CONTRACEPTIVES, TRIPHASIC alyacen tab 7/7/7 $0 aranelle tab $0 caziant pak $0 cyclafem tab 7/7/7 $0 CYCLESSA PAK 3 dasetta tab 7/7/7 $0 enpresse-28 tab $0 ESTROSTEP FE TAB 3 leena tab $0 levonest tab $0 levonorgestrel-eth estra tab 0.05-

30/0.075-40/0.125-30mg-mcg $0

myzilra tab $0 necon tab 7/7/7 $0 norgestimate-eth estrad tab 0.18-

25/0.215-25/0.25-25 mg-mcg $0

norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg

$0

nortrel tab 7/7/7 $0

97

Drug Name Drug Tier Requirements/Limits ORTHO TRI- TAB CYCLEN 3 ORTHO TRI- TAB CYCLN LO 3 ORTHO-NOVUM TAB 7/7/7 3 pirmella tab 7/7/7 $0 tilia fe tab $0 tri-estaryll tab $0 tri-legest tab fe $0 tri-linyah tab $0 tri-lo tab estaryll $0 tri-lo- tab marzia $0 tri-lo- tab sprintec $0 TRI-NORINYL TAB 28 3 tri-previfem tab $0 tri-sprintec tab $0 trinessa lo tab $0 trinessa tab $0 trivora-28 tab $0 velivet pak $0 CONTRACEPTIVES, VAGINAL NUVARING MIS 2 ENDOMETRIOSIS danazol cap 50 mg 1 danazol cap 100 mg 1 danazol cap 200 mg 1 SYNAREL SOL 2MG/ML 3 ESTROGEN/PROGESTIN, ORAL ACTIVELLA TAB 0.5-0.1 3 ACTIVELLA TAB 1-0.5MG 3 ANGELIQ TAB 0.5-1MG 3 ANGELIQ TAB 0.25-0.5 3 estradiol & norethindrone acetate tab 0.5-

0.1 mg 1

estradiol & norethindrone acetate tab 1-0.5 mg

1

fyavolv tab 0.5-2.5 1 fyavolv tab 1-5 1 jevantique l tab 0.5-2.5 1 jinteli tab 1mg-5mcg 1 mimvey lo tab 0.5-0.1 1 mimvey tab 1-0.5mg 1 norethindrone acetate-ethinyl estradiol tab

0.5 mg-2.5 mcg 1

norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg

1

PREFEST TAB 3 PREMPHASE TAB 2

98

Drug Name Drug Tier Requirements/Limits PREMPRO TAB 0.3-1.5 2 PREMPRO TAB 0.45-1.5 2 PREMPRO TAB 0.625-5 2 PREMPRO TAB .625-2.5 2 ESTROGEN/PROGESTIN, TRANSDERMAL CLIMARA PRO DIS WEEKLY 2 ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR

COMBINATIONS DUAVEE TAB 0.45-20 2 ESTROGENS, ORAL ESTRACE TAB 0.5MG 3 ESTRACE TAB 1MG 3 ESTRACE TAB 2MG 3 estradiol tab 0.5 mg 1 estradiol tab 1 mg 1 estradiol tab 2 mg 1 estropipate tab 0.75 mg 1 estropipate tab 1.5 mg 1 estropipate tab 3 mg 1 PREMARIN TAB 0.3MG 2 PREMARIN TAB 0.9MG 2 PREMARIN TAB 0.45MG 2 PREMARIN TAB 0.625MG 2 PREMARIN TAB 1.25MG 2 ESTROGENS, TRANSDERMAL CLIMARA DIS 0.1MG 3 CLIMARA DIS 0.05MG 3 CLIMARA DIS 0.06MG 3 CLIMARA DIS 0.025MG 3 CLIMARA DIS 0.075MG 3 CLIMARA DIS 0.0375MG 3 DIVIGEL GEL 0.5MG 2 DIVIGEL GEL 0.25MG 2 DIVIGEL GEL 1MG/GM 2 ELESTRIN GEL 0.06% 3 estradiol td patch twice weekly 0.1

mg/24hr 1

estradiol td patch twice weekly 0.05 mg/24hr

1


1


1


1

estradiol td patch weekly 0.1 mg/24hr 1

99

Drug Name Drug Tier Requirements/Limits estradiol td patch weekly 0.05 mg/24hr 1 estradiol td patch weekly 0.06 mg/24hr 1 estradiol td patch weekly 0.025 mg/24hr 1 estradiol td patch weekly 0.075 mg/24hr 1 estradiol td patch weekly 0.0375 mg/24hr

(37.5 mcg/24hr) 1

EVAMIST SPR 1.53MG 2 MINIVELLE DIS 0.1MG 2 MINIVELLE DIS 0.05MG 2 MINIVELLE DIS 0.025MG 2 MINIVELLE DIS 0.075MG 2 MINIVELLE DIS 0.0375MG 2 VIVELLE-DOT DIS 0.1MG 3 VIVELLE-DOT DIS 0.05MG 3 VIVELLE-DOT DIS 0.025MG 3 VIVELLE-DOT DIS 0.075MG 3 VIVELLE-DOT DIS 0.0375MG 3 ESTROGENS, VAGINAL ESTRACE VAG CRE 0.1MG/GM 2 estradiol vaginal tab 10 mcg 1 ESTRING MIS 2MG 3 FEMRING MIS 0.1MG/24 3 FEMRING MIS 0.05/24H 3 PREMARIN VAG CRE 0.625MG 2 VAGIFEM TAB 10MCG 2 FERTILITY REGULATORS, OVULATION STIMULANTS, SYNTHETIC clomiphene citrate tab 50 mg 1 GLUCOCORTICOIDS CORTEF TAB 5MG 3 CORTEF TAB 10MG 3 CORTEF TAB 20MG 3 cortisone acetate tab 25 mg 1 deltasone tab 20mg 1 DEXAMETHASON CON 1MG/ML 3 dexamethasone elixir 0.5 mg/5ml 1 dexamethasone soln 0.5 mg/5ml 1 dexamethasone tab 0.5 mg 1 dexamethasone tab 0.75 mg 1 dexamethasone tab 1 mg 1 dexamethasone tab 1.5 mg 1 dexamethasone tab 2 mg 1 dexamethasone tab 4 mg 1 dexamethasone tab 6 mg 1 hydrocortisone tab 5 mg 1 hydrocortisone tab 10 mg 1 hydrocortisone tab 20 mg 1

100

Drug Name Drug Tier Requirements/Limits MEDROL TAB 2MG 3 MEDROL TAB 4MG 3 MEDROL TAB 8MG 3 MEDROL TAB 16MG 3 MEDROL TAB 32MG 3 methylprednisolone tab 4 mg 1 methylprednisolone tab 8 mg 1 methylprednisolone tab 16 mg 1 methylprednisolone tab 32 mg 1 methylprednisolone tab therapy pack 4 mg

(21) 1

ORAPRED ODT TAB 10MG 3 ORAPRED ODT TAB 15MG 3 ORAPRED ODT TAB 30MG 3 PEDIAPRED SOL 6.7/5ML 3 prednisolone sod phos orally disintegr tab

10 mg (base eq) 1

prednisolone sod phos orally disintegr tab 15 mg (base eq)

1

prednisolone sod phos orally disintegr tab 30 mg (base eq)

1

prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base)

1

prednisolone sod phosphate oral soln 15 mg/5ml (base equiv)

1

prednisolone sod phosphate oral soln 20 mg/5ml (base equiv)

1

prednisolone sodium phosphate oral soln 25 mg/5ml (base eq)

1

prednisolone syrup 15 mg/5ml (usp solution equivalent)

1

PREDNISONE CON 5MG/ML 3 prednisone oral soln 5 mg/5ml 1 prednisone tab 1 mg 1 prednisone tab 2.5 mg 1 prednisone tab 5 mg 1 prednisone tab 10 mg 1 prednisone tab 20 mg 1 prednisone tab 50 mg 1 prednisone tab therapy pack 5 mg (21) 1 prednisone tab therapy pack 5 mg (48) 1 prednisone tab therapy pack 10 mg (21) 1 prednisone tab therapy pack 10 mg (48) 1 VERIPRED 20 SOL 20MG/5ML 3 GLUCOSE ELEVATING AGENTS GLUCAGEN INJ HYPOKIT 2 GLUCAGON KIT 1MG 2

101

Drug Name Drug Tier Requirements/Limits PROGLYCEM SUS 50MG/ML 3 HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol cap 0.5 mcg 1 calcitriol cap 0.25 mcg 1 calcitriol oral soln 1 mcg/ml 1 doxercalciferol cap 0.5 mcg 1 doxercalciferol cap 1 mcg 1 doxercalciferol cap 2.5 mcg 1 HECTOROL CAP 0.5MCG 3 HECTOROL CAP 1MCG 3 HECTOROL CAP 2.5MCG 3 paricalcitol cap 1 mcg 1 paricalcitol cap 2 mcg 1 paricalcitol cap 4 mcg 1 RAYALDEE CAP 30MCG 3 ROCALTROL CAP 0.5MCG 3 ROCALTROL CAP 0.25MCG 3 ROCALTROL SOL 1MCG/ML 3 ZEMPLAR CAP 1MCG 3 ZEMPLAR CAP 2MCG 3 MINERALOCORTICOIDS fludrocortisone acetate tab 0.1 mg 1 MISCELLANEOUS cabergoline tab 0.5 mg 1 CARBAGLU TAB 200MG 5 PA; SP CERVIDIL VAG MIS 10MG INS 3 CYSTAGON CAP 50MG 5 PA; SP CYSTAGON CAP 150MG 5 PA; SP KORLYM TAB 300MG 5 PA; SP methergine tab 0.2mg 1 MIFEPREX TAB 200MG 3 ORFADIN CAP 2MG 5 PA; SP ORFADIN CAP 5MG 5 PA; SP ORFADIN CAP 10MG 5 PA; SP ORFADIN CAP 20MG 5 PA; SP ORFADIN SUS 4MG/ML 5 PA; SP PREPIDIL GEL 0.5MG/3G 3 PROCYSBI CAP 25MG 5 PA; SP PROCYSBI CAP 75MG 5 PA; SP PROSTIN E2 SUP 20MG 3 RAVICTI LIQ 1.1GM/ML 5 PA; SP XURIDEN POW 2GM 5 SP ZAVESCA CAP 100MG 5 PA; SP PHENYLKETONURIA TREATMENT AGENTS KUVAN TAB 100MG 5 PA; SP

102

Drug Name Drug Tier Requirements/Limits PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) cap

667 mg (169 mg ca) 1

calcium acetate (phosphate binder) tab 667 mg

1

ELIPHOS TAB 667MG 3 PHOSLYRA SOL 2 RENAGEL TAB 400MG 3 RENAGEL TAB 800MG 3 RENVELA PAK 0.8GM 2 RENVELA PAK 2.4GM 2 RENVELA TAB 800MG 2 sevelamer carbonate packet 0.8 gm 1 sevelamer carbonate packet 2.4 gm 1 sevelamer carbonate tab 800 mg 1 VELPHORO CHW 500MG 2 POTASSIUM-REMOVING AGENTS KAYEXALATE POW 3 kionex pow 1 kionex sus 15gm/60 1 sodium polystyrene sulfonate oral susp 15

gm/60ml 1

sodium polystyrene sulfonate powder 1 sodium polystyrene sulfonate rectal susp

30 gm/120ml 1

sps sus 15gm/60 1 VELTASSA POW 8.4GM 4 SP VELTASSA POW 16.8GM 4 SP VELTASSA POW 25.2GM 4 SP PROGESTINS, ORAL AYGESTIN TAB 5MG 3 medroxyprogesterone acetate tab 2.5 mg 1 medroxyprogesterone acetate tab 5 mg 1 medroxyprogesterone acetate tab 10 mg 1 MEGACE ES SUS 625/5ML 2 MEGACE ORAL SUS 40MG/ML OC oral chemotherapy -

refer to plan benefits megestrol acetate susp 40 mg/ml OC oral chemotherapy -

refer to plan benefits megestrol acetate susp 625 mg/5ml 1 norethindrone acetate tab 5 mg 1 progesterone micronized cap 100 mg 1 progesterone micronized cap 200 mg 1 PROMETRIUM CAP 100MG 3 PROMETRIUM CAP 200MG 3 PROVERA TAB 2.5MG 3

103

Drug Name Drug Tier Requirements/Limits PROVERA TAB 5MG 3 PROVERA TAB 10MG 3 PROGESTINS, VAGINAL ENDOMETRIN SUP 100MG 2 SELECTIVE ESTROGEN RECEPTOR MODULATORS EVISTA TAB 60MG $0 OSPHENA TAB 60MG 2 raloxifene hcl tab 60 mg $0 THYROID AGENTS, ANTITHYROID AGENTS methimazole tab 5 mg 1 methimazole tab 10 mg 1 propylthiouracil tab 50 mg 1 TAPAZOLE TAB 5MG 3 TAPAZOLE TAB 10MG 3 THYROID AGENTS, THYROID SUPPLEMENTS CYTOMEL TAB 5MCG 3 CYTOMEL TAB 25MCG 3 CYTOMEL TAB 50MCG 3 levo-t tab 25mcg 1 levo-t tab 50mcg 1 levo-t tab 75mcg 1 levo-t tab 88mcg 1 levo-t tab 100mcg 1 levo-t tab 112mcg 1 levo-t tab 125mcg 1 levo-t tab 137mcg 1 levo-t tab 150mcg 1 levo-t tab 175mcg 1 levo-t tab 200 mcg 1 levo-t tab 300 mcg 1 levothyroxine sodium tab 25 mcg 1 levothyroxine sodium tab 50 mcg 1 levothyroxine sodium tab 75 mcg 1 levothyroxine sodium tab 88 mcg 1 levothyroxine sodium tab 100 mcg 1 levothyroxine sodium tab 112 mcg 1 levothyroxine sodium tab 125 mcg 1 levothyroxine sodium tab 137 mcg 1 levothyroxine sodium tab 150 mcg 1 levothyroxine sodium tab 175 mcg 1 levothyroxine sodium tab 200 mcg 1 levothyroxine sodium tab 300 mcg 1 levoxyl tab 25mcg 1 levoxyl tab 50mcg 1 levoxyl tab 75mcg 1 levoxyl tab 88mcg 1

104

Drug Name Drug Tier Requirements/Limits levoxyl tab 100mcg 1 levoxyl tab 112mcg 1 levoxyl tab 125mcg 1 levoxyl tab 137mcg 1 levoxyl tab 150mcg 1 levoxyl tab 175mcg 1 levoxyl tab 200mcg 1 liothyronine sodium tab 5 mcg 1 liothyronine sodium tab 25 mcg 1 liothyronine sodium tab 50 mcg 1 SYNTHROID TAB 25MCG 3 SYNTHROID TAB 50MCG 3 SYNTHROID TAB 75MCG 3 SYNTHROID TAB 88MCG 3 SYNTHROID TAB 100MCG 3 SYNTHROID TAB 112MCG 3 SYNTHROID TAB 125MCG 3 SYNTHROID TAB 137MCG 3 SYNTHROID TAB 150MCG 3 SYNTHROID TAB 175MCG 3 SYNTHROID TAB 200MCG 3 SYNTHROID TAB 300MCG 3 THYROLAR-1 TAB 60MG 3 THYROLAR-1/2 TAB 30MG 3 THYROLAR-1/4 TAB 15MG 3 THYROLAR-2 TAB 120MG 3 THYROLAR-3 TAB 180MG 3 TIROSINT CAP 13MCG 3 TIROSINT CAP 25MCG 3 TIROSINT CAP 50MCG 3 TIROSINT CAP 75MCG 3 TIROSINT CAP 88MCG 3 TIROSINT CAP 100MCG 3 TIROSINT CAP 112MCG 3 TIROSINT CAP 125MCG 3 TIROSINT CAP 137MCG 3 TIROSINT CAP 150MCG 3 unith direct tab 25mcg 1 unith direct tab 50mcg 1 unith direct tab 75mcg 1 unith direct tab 88mcg 1 unith direct tab 100mcg 1 unith direct tab 112mcg 1 unith direct tab 125mcg 1 unith direct tab 150mcg 1 unith direct tab 175mcg 1

105

Drug Name Drug Tier Requirements/Limits unith direct tab 200mcg 1 unith direct tab 300mcg 1 unithroid tab 25mcg 1 unithroid tab 50mcg 1 unithroid tab 75mcg 1 unithroid tab 88mcg 1 unithroid tab 100mcg 1 unithroid tab 112mcg 1 unithroid tab 125mcg 1 unithroid tab 137mcg 1 unithroid tab 150mcg 1 unithroid tab 175mcg 1 unithroid tab 200mcg 1 unithroid tab 300mcg 1 VASOPRESSIN RECEPTOR ANTAGONISTS SAMSCA TAB 15MG 5 PA; SP SAMSCA TAB 30MG 5 PA; SP VASOPRESSINS DDAVP SOL 0.01% 3 DDAVP SPR 0.01% 3 DDAVP TAB 0.1MG 3 DDAVP TAB 0.2MG 3 desmopressin acetate nasal soln 0.01%

(refrigerated) 1

desmopressin acetate nasal spray soln 0.01%

1

desmopressin acetate nasal spray soln 0.01% (refrigerated)

1

desmopressin acetate tab 0.1 mg 1 desmopressin acetate tab 0.2 mg 1 STIMATE SOL 1.5MG/ML 5 PA; SP GASTROINTESTINAL ANTIDIARRHEALS diphenoxylate w/ atropine liq 2.5-0.025

mg/5ml 1

diphenoxylate w/ atropine tab 2.5-0.025 mg

1

LOMOTIL TAB 2.5MG 3 loperamide hcl cap 2 mg 1 ANTIEMETICS AKYNZEO CAP 300-0.5 3 ANZEMET TAB 50MG 3 ANZEMET TAB 100MG 3 aprepitant capsule 40 mg 1 aprepitant capsule 80 mg 1 aprepitant capsule 125 mg 1

106

Drug Name Drug Tier Requirements/Limits aprepitant capsule therapy pack 80 & 125

mg 1

CESAMET CAP 1MG 3 compro sup 25mg 1 DICLEGIS TAB 10-10MG 3 dronabinol cap 2.5 mg 1 dronabinol cap 5 mg 1 dronabinol cap 10 mg 1 EMEND CAP 40MG 3 EMEND CAP 80MG 3 EMEND CAP 125MG 3 EMEND SUS 125MG 3 EMEND TRIPAC PAK 80 & 125 3 granisetron hcl tab 1 mg 1 MARINOL CAP 2.5MG 3 MARINOL CAP 5MG 3 MARINOL CAP 10MG 3 meclizine hcl tab 12.5 mg 1 meclizine hcl tab 25 mg 1 metoclopramide hcl orally disintegrating

tab 5 mg (base eq) 1

metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)

1

metoclopramide hcl tab 5 mg 1 metoclopramide hcl tab 10 mg 1 ondansetron hcl oral soln 4 mg/5ml 1 ondansetron hcl tab 4 mg 1 ondansetron hcl tab 8 mg 1 ondansetron hcl tab 24 mg 1 ondansetron orally disintegrating tab 4 mg 1 ondansetron orally disintegrating tab 8 mg 1 phenadoz sup 12.5mg 1 phenadoz sup 25mg 1 phenergan sup 12.5mg 1 phenergan sup 25mg 1 phenergan sup 50mg 1 prochlorperazine maleate tab 5 mg (base

equivalent) 1

prochlorperazine maleate tab 10 mg (base equivalent)

1

prochlorperazine suppos 25 mg 1 promethazine hcl suppos 12.5 mg 1 promethazine hcl suppos 25 mg 1 promethazine hcl suppos 50 mg 1 promethazine hcl syrup 6.25 mg/5ml 1 promethazine hcl tab 12.5 mg 1 promethazine hcl tab 25 mg 1

107

Drug Name Drug Tier Requirements/Limits promethazine hcl tab 50 mg 1 promethegan sup 12.5mg 1 promethegan sup 25mg 1 promethegan sup 50mg 1 REGLAN TAB 5MG 3 REGLAN TAB 10MG 3 SANCUSO DIS 3.1MG 3 scopolamine td patch 72hr 1 mg/3days 1 TIGAN CAP 300MG 3 TRANSDERM-SC DIS 1.5MG 3 trimethobenzamide hcl cap 300 mg 1 VARUBI TAB 90MG 2 ZOFRAN SOL 4MG/5ML 3 ZOFRAN TAB 4MG 3 ZOFRAN TAB 4MG ODT 3 ZOFRAN TAB 8MG 3 ZOFRAN TAB 8MG ODT 3 ZUPLENZ MIS 4MG 3 ZUPLENZ MIS 8MG 3 ANTISPASMODICS BENTYL CAP 10MG 3 chlordiazepoxide hcl-clidinium bromide cap

5-2.5 mg 1

CUVPOSA SOL 1MG/5ML 3 dicyclomine hcl cap 10 mg 1 dicyclomine hcl oral soln 10 mg/5ml 1 dicyclomine hcl tab 20 mg 1 glycopyrrolate tab 1 mg 1 glycopyrrolate tab 2 mg 1 LIBRAX CAP 5-2.5MG 3 methscopolamine bromide tab 2.5 mg 1 methscopolamine bromide tab 5 mg 1 PAMINE FORTE TAB 5MG 3 PAMINE FQ KIT 3 PAMINE TAB 2.5MG 3 propantheline bromide tab 15 mg 1 ROBINUL FORT TAB 2MG 3 ROBINUL TAB 1MG 3 CHOLELITHOLYTICS ACTIGALL CAP 300MG 3 CHENODAL TAB 250MG 3 URSO 250 TAB 250MG 3 URSO FORTE TAB 500MG 3 ursodiol cap 300 mg 1 ursodiol tab 250 mg 1 ursodiol tab 500 mg 1

108

Drug Name Drug Tier Requirements/Limits H2-RECEPTOR ANTAGONISTS cimetidine hcl soln 300 mg/5ml 1 cimetidine tab 200 mg 1 cimetidine tab 300 mg 1 cimetidine tab 400 mg 1 cimetidine tab 800 mg 1 famotidine for susp 40 mg/5ml 1 famotidine tab 20 mg 1 famotidine tab 40 mg 1 nizatidine cap 150 mg 1 nizatidine cap 300 mg 1 nizatidine oral soln 15 mg/ml 1 PEPCID SUS 40MG/5ML 3 PEPCID TAB 20MG 3 PEPCID TAB 40MG 3 ranitidine hcl cap 150 mg 1 ranitidine hcl cap 300 mg 1 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 1 ranitidine hcl tab 150 mg 1 ranitidine hcl tab 300 mg 1 ZANTAC TAB 150MG 3 ZANTAC TAB 300MG 3 INFLAMMATORY BOWEL DISEASE, ORAL AGENTS APRISO CAP 0.375GM 2 AZULFIDINE TAB 500MG 3 AZULFIDINE TAB 500MG EN 3 balsalazide disodium cap 750 mg 1 budesonide delayed release particles cap 3

mg 1

DIPENTUM CAP 250MG 3 ENTOCORT EC CAP 3MG DR 3 GIAZO TAB 1.1GM 3 LIALDA TAB 1.2GM 2 PENTASA CAP 250MG CR 2 PENTASA CAP 500MG CR 2 sulfasalazine tab 500 mg 1 sulfasalazine tab delayed release 500 mg 1 UCERIS TAB 9MG 2 INFLAMMATORY BOWEL DISEASE, RECTAL AGENTS CANASA SUP 1000MG 2 colocort ene 100mg 1 CORTENEMA ENE 100MG 3 CORTIFOAM AER 90MG 2 hydrocortisone enema 100 mg/60ml 1 mesalamine enema 4 gm 1

109

Drug Name Drug Tier Requirements/Limits mesalamine rectal enema 4 gm & cleanser

wipe kit 1

mesalamine tab delayed release 1.2 gm 1 UCERIS AER 2MG/ACT 3 IRRITABLE BOWEL SYNDROME WITH CONSTIPATION/CHRONIC

IDIOPATHIC CONSTIPATION AMITIZA CAP 8MCG 2 AMITIZA CAP 24MCG 2 LINZESS CAP 72MCG 2 LINZESS CAP 145MCG 2 LINZESS CAP 290MCG 2 TRULANCE TAB 3MG 3 IRRITABLE BOWEL SYNDROME WITH DIARRHEA alosetron hcl tab 0.5 mg (base equiv) 1 alosetron hcl tab 1 mg (base equiv) 1 LOTRONEX TAB 0.5MG 2 LOTRONEX TAB 1MG 2 VIBERZI TAB 75MG 2 VIBERZI TAB 100MG 2 LAXATIVES/STOOL SOFTENERS CASCARA EXT SAGRADA 3 COLYTE/FLAVR SOL PACKS 3 constulose sol 10gm/15 1 gavilyte-c sol 1 gavilyte-g sol 1 gavilyte-h kit 1 gavilyte-n sol flav pk 1 GOLYTELY SOL 3 GOLYTELY SOL PINEAPPL 3 KRISTALOSE PAK 10GM 3 KRISTALOSE PAK 20GM 3 lactulose solution 10 gm/15ml 1 MINERAL OIL 3 MOVIPREP SOL 3 NULYTELY SOL FLAV PKS 3 OSMOPREP TAB 1.5GM 3 peg 3350-kcl-na bicarb-nacl-na sulfate for

soln 236 gm 1

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm

1

peg 3350-kcl-sod bicarb-nacl for soln 420 gm

1

peg-prep kit 1 pegylax pow 1 polyethylene glycol 3350 oral packet 1 polyethylene glycol 3350 oral powder 1

110

Drug Name Drug Tier Requirements/Limits PREPOPIK PAK 3 SUPREP BOWEL SOL PREP KIT 2 trilyte sol 1 MISCELLANEOUS BUPHENYL TAB 500MG 5 PA; SP CARAFATE SUS 1GM/10ML 3 CARAFATE TAB 1GM 3 CHOLBAM CAP 50MG 5 PA; SP CHOLBAM CAP 250MG 5 PA; SP cromolyn sodium oral conc 100 mg/5ml 1 ENTEREG CAP 12MG 3 enulose sol 10gm/15 1 GASTROCROM CON 100/5ML 3 generlac sol 10gm/15 1 lactulose (encephalopathy) solution 10

gm/15ml 1

NUTRESTORE PAK 5GM 3 OCALIVA TAB 5MG 5 PA; SP OCALIVA TAB 10MG 5 PA; SP RECTIV OIN 0.4% 3 sodium phenylbutyrate tab 500 mg 4 PA; SP SUCRAID SOL 8500/ML 3 sucralfate tab 1 gm 1 OPIOID-INDUCED CONSTIPATION MOVANTIK TAB 12.5MG 2 MOVANTIK TAB 25MG 2 PANCREATIC ENZYMES CREON CAP 3000UNIT 2 CREON CAP 6000UNIT 2 CREON CAP 12000UNT 2 CREON CAP 24000UNT 2 CREON CAP 36000UNT 2 PANCREAZE CAP 4200UNIT 3 PANCREAZE CAP 10500UNT 3 PANCREAZE CAP 16800UNT 3 PANCREAZE CAP 21000UNT 3 PERTZYE CAP 3 VIOKACE TAB 2 VIOKACE TAB 20880 2 ZENPEP CAP 3000UNIT 2 ZENPEP CAP 5000UNIT 2 ZENPEP CAP 10000UNT 2 ZENPEP CAP 15000UNT 2 ZENPEP CAP 20000UNT 2 ZENPEP CAP 25000UNT 2 ZENPEP CAP 40000UNT 2

111

Drug Name Drug Tier Requirements/Limits PROSTAGLANDINS CYTOTEC TAB 100MCG 3 CYTOTEC TAB 200MCG 3 misoprostol tab 100 mcg 1 misoprostol tab 200 mcg 1 PROTON PUMP INHIBITORS ACIPHEX SPR CAP 5MG 3 ACIPHEX SPR CAP 10MG 3 ACIPHEX TAB 20MG 3 DEXILANT CAP 30MG DR 2 DEXILANT CAP 60MG DR 2 ESOMEPRAZOLE CAP 49.3MG 3 esomeprazole magnesium cap delayed

release 20 mg (base eq) 1

esomeprazole magnesium cap delayed release 40 mg (base eq)

1

esomeprazole strontium cap delayed release 49.3 mg

1

lansoprazole cap delayed release 15 mg 1 lansoprazole cap delayed release 30 mg 1 omeprazole cap delayed release 10 mg 1 omeprazole cap delayed release 20 mg 1 omeprazole cap delayed release 40 mg 1 omeprazole-sodium bicarbonate cap 20-

1100 mg 1

omeprazole-sodium bicarbonate cap 40-1100 mg

1

pantoprazole sodium ec tab 20 mg (base equiv)

1

pantoprazole sodium ec tab 40 mg (base equiv)

1

rabeprazole sodium ec tab 20 mg 1 SALIVA STIMULANTS cevimeline hcl cap 30 mg 1 EVOXAC CAP 30MG 3 pilocarpine hcl tab 5 mg 1 pilocarpine hcl tab 7.5 mg 1 SALAGEN TAB 5MG 3 SALAGEN TAB 7.5MG 3 STEROIDS, RECTAL ana-lex kit 1 ANALPRAM-HC CRE 1-1% 3 ANALPRAM-HC LOT 2.5% 3 ANUSOL-HC CRE 2.5% 3 hydrocortisone acetate w/ pramoxine rectal

cream 1-1% 1

hydrocortisone rectal cream 1% 1

112

Drug Name Drug Tier Requirements/Limits hydrocortisone rectal cream 2.5% 1 LIDO-HYDRO GEL 2.8-0.55 3 lidocaine-hydrocortisone acetate rectal

cream kit 2-2% 1

lidocaine-hydrocortisone acetate rectal cream kit 3-0.5%

1

lidocaine-hydrocortisone acetate rectal gel kit 3-2.5%

1

PROCORT CRE 3 procto-med cre hc 2.5% 1 procto-pak cre 1% 1 PROCTOCORT CRE 1% 3 PROCTOFOAM AER HC 1% 2 proctosol hc cre 2.5% 1 proctozone cre -hc 2.5% 1 ULCER THERAPY COMBINATIONS amoxicillin cap-clarithro tab-lansopraz cap

dr therapy pack 1

OMECLAMOX- MIS PAK 3 PREVPAC MIS 3 PYLERA CAP 2 GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl tab er 24hr 10 mg 1 AVODART CAP 0.5MG 3 CARDURA XL TAB 4MG 2 CARDURA XL TAB 8MG 2 CIALIS TAB 5MG 2 dutasteride cap 0.5 mg 1 dutasteride-tamsulosin hcl cap 0.5-0.4 mg 1 finasteride tab 5 mg 1 FLOMAX CAP 0.4MG 3 PROSCAR TAB 5MG 3 RAPAFLO CAP 4MG 2 RAPAFLO CAP 8MG 2 tamsulosin hcl cap 0.4 mg 1 GENITOURINARY IRRIGANTS acetic acid irrigation soln 0.25% 1 argyl saline sol 0.9% 1 curity salin sol 0.9% irr 1 glycine irrigation soln 1.5% 1 neomycin-polymyxin b gu irrigation soln 1 NEOSPORIN GU SOL 40/ML IR 3 RENACIDIN SOL 3 RESECTISOL SOL 5% 3 sodium chloride irrigation soln 0.9% 1

113

Drug Name Drug Tier Requirements/Limits SORBITOL SOL 3% IRR 3 SORBITOL SOL 3.3% IRR 3 SORBITOL-MAN SOL 3 MISCELLANEOUS av-phos 250 tab neutral 1 bethanechol chloride tab 5 mg 1 bethanechol chloride tab 10 mg 1 bethanechol chloride tab 25 mg 1 bethanechol chloride tab 50 mg 1 cytra-2 sol 1 cytra-k sol 1 ELMIRON CAP 100MG 3 FEM PH GEL 3 K-PHOS TAB 3 K-PHOS TAB NEUTRAL 3 K-PHOS TAB NO 2 3 LITHOSTAT TAB 250MG 3 ORACIT SOL 3 phospha 250 tab neutral 1 pot & sod citrates w/ cit ac soln 550-500-

334 mg/5ml 1

potassium citrate & citric acid soln 1100-334 mg/5ml

1

potassium citrate tab er 5 meq (540 mg) 1 potassium citrate tab er 10 meq (1080 mg) 1 potassium citrate tab er 15 meq (1620 mg) 1 relagard gel 1 SHOHLS SOL MODIFIED 3 sodium citrate & citric acid soln 500-334

mg/5ml 1

THIOLA TAB 100MG 3 URECHOLINE TAB 5MG 3 URECHOLINE TAB 10MG 3 URECHOLINE TAB 25MG 3 URECHOLINE TAB 50MG 3 UROCIT-K 5 TAB 3 UROCIT-K 10 TAB 3 UROCIT-K 15 TAB 3 virt-phos tab 250 neut 1 virtrate-2 sol 1 virtrate-2 sol 500-334 1 virtrate-3 sol 1 virtrate-k sol 1 virtrate-k sol 1100-334 1 URINARY ANTISPASMODICS

114

Drug Name Drug Tier Requirements/Limits darifenacin hydrobromide tab er 24hr 7.5

mg (base equiv) 1

darifenacin hydrobromide tab er 24hr 15 mg (base equiv)

1

DETROL TAB 1MG 3 DETROL TAB 2MG 3 DITROPAN XL TAB 5MG 3 DITROPAN XL TAB 10MG 3 DITROPAN XL TAB 15MG 3 flavoxate hcl tab 100 mg 1 MYRBETRIQ TAB 25MG 2 MYRBETRIQ TAB 50MG 2 oxybutynin chloride syrup 5 mg/5ml 1 oxybutynin chloride tab 5 mg 1 oxybutynin chloride tab er 24hr 5 mg 1 oxybutynin chloride tab er 24hr 10 mg 1 oxybutynin chloride tab er 24hr 15 mg 1 tolterodine tartrate cap er 24hr 2 mg 1 tolterodine tartrate cap er 24hr 4 mg 1 tolterodine tartrate tab 1 mg 1 tolterodine tartrate tab 2 mg 1 TOVIAZ TAB 4MG 2 TOVIAZ TAB 8MG 2 trospium chloride cap er 24hr 60 mg 1 trospium chloride tab 20 mg 1 VESICARE TAB 5MG 2 VESICARE TAB 10MG 2 VAGINAL ANTI-INFECTIVES AVC CRE 15% 3 CLEOCIN CRE 2% VAG 3 CLEOCIN SUP 100MG 3 clindamycin phosphate vaginal cream 2% 1 CLINDESSE CRE 2% 3 GYNAZOLE-1 CRE 2% 3 METROGEL-VAG GEL 0.75% 3 metronidazole vaginal gel 0.75% 1 miconazole 3 sup 200mg 1 TERAZOL 7 CRE 0.4% 3 terconazole vaginal cream 0.4% 1 terconazole vaginal cream 0.8% 1 terconazole vaginal suppos 80 mg 1 vandazole gel 0.75% 1 zazole cre 0.8% 1 zazole sup 80mg 1 HEMATOLOGIC ANTICOAGULANTS, ORAL

115

Drug Name Drug Tier Requirements/Limits COUMADIN TAB 1MG 3 COUMADIN TAB 2.5MG 3 COUMADIN TAB 2MG 3 COUMADIN TAB 3MG 3 COUMADIN TAB 4MG 3 COUMADIN TAB 5MG 3 COUMADIN TAB 6MG 3 COUMADIN TAB 7.5MG 3 COUMADIN TAB 10MG 3 ELIQUIS TAB 2.5MG 2 ELIQUIS TAB 5MG 2 jantoven tab 1mg 1 jantoven tab 2.5mg 1 jantoven tab 2mg 1 jantoven tab 3mg 1 jantoven tab 4mg 1 jantoven tab 5mg 1 jantoven tab 6mg 1 jantoven tab 7.5mg 1 jantoven tab 10mg 1 warfarin sodium tab 1 mg 1 warfarin sodium tab 2 mg 1 warfarin sodium tab 2.5 mg 1 warfarin sodium tab 3 mg 1 warfarin sodium tab 4 mg 1 warfarin sodium tab 5 mg 1 warfarin sodium tab 6 mg 1 warfarin sodium tab 7.5 mg 1 warfarin sodium tab 10 mg 1 XARELTO STAR TAB 15/20MG 2 XARELTO TAB 10MG 2 XARELTO TAB 15MG 2 XARELTO TAB 20MG 2 HEMOSTATICS, SYSTEMIC AMICAR TAB 500MG 3 AMICAR TAB 1000MG 3 LYSTEDA TAB 650MG 3 tranexamic acid tab 650 mg 1 IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS PROMACTA TAB 12.5MG 5 PA; SP PROMACTA TAB 25MG 5 PA; SP PROMACTA TAB 50MG 5 PA; SP PROMACTA TAB 75MG 5 PA; SP MISCELLANEOUS CHEMET CAP 100MG 3 cilostazol tab 50 mg 1

116

Drug Name Drug Tier Requirements/Limits cilostazol tab 100 mg 1 EXJADE TAB 125MG 5 PA; SP EXJADE TAB 250MG 5 PA; SP EXJADE TAB 500MG 5 PA; SP FERRIPROX TAB 500MG 5 PA; SP JADENU SPRKL GRA 90MG 5 PA; SP JADENU SPRKL GRA 180MG 5 PA; SP JADENU SPRKL GRA 360MG 5 PA; SP JADENU TAB 90MG 5 PA; SP JADENU TAB 180MG 5 PA; SP JADENU TAB 360MG 5 PA; SP pentoxifylline tab er 400 mg 1 PLATELET AGGREGATION INHIBITORS AGGRENOX CAP 25-200MG 3 aspirin-dipyridamole cap er 12hr 25-200

mg 1

BRILINTA TAB 60MG 2 BRILINTA TAB 90MG 2 clopidogrel bisulfate tab 75 mg (base

equiv) 1

clopidogrel bisulfate tab 300 mg (base equiv)

1

dipyridamole tab 25 mg 1 dipyridamole tab 50 mg 1 dipyridamole tab 75 mg 1 EFFIENT TAB 5MG 2 EFFIENT TAB 10MG 2 prasugrel hcl tab 5 mg (base equiv) 1 prasugrel hcl tab 10 mg (base equiv) 1 ZONTIVITY TAB 2.08MG 3 PLATELET SYNTHESIS INHIBITOR AGRYLIN CAP 0.5MG 3 anagrelide hcl cap 0.5 mg 1 anagrelide hcl cap 1 mg 1 IMMUNOLOGIC AGENTS ALLERGENIC EXTRACTS GRASTEK SUB 2800BAU 2 ORALAIR SUB 300 IR 4 PA; SP RAGWITEK SUB 2 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDS) ARAVA TAB 10MG 3 ARAVA TAB 20MG 3 hydroxychloroquine sulfate tab 200 mg 1 leflunomide tab 10 mg 1 leflunomide tab 20 mg 1 PLAQUENIL TAB 200MG 3

117

Drug Name Drug Tier Requirements/Limits RIDAURA CAP 3MG 3 IMMUNOSUPPRESSANTS, ANTIMETABOLITES AZASAN TAB 75 MG 3 AZASAN TAB 100MG 3 azathioprine tab 50 mg 1 CELLCEPT CAP 250MG 5 SP CELLCEPT SUS 200MG/ML 5 SP CELLCEPT TAB 500MG 5 SP IMURAN TAB 50MG 3 mycophenolate mofetil cap 250 mg 4 SP mycophenolate mofetil for oral susp 200

mg/ml 4 SP

mycophenolate mofetil tab 500 mg 4 SP mycophenolate sodium tab dr 180 mg

(mycophenolic acid equiv) 4 SP

mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv)

4 SP

MYFORTIC TAB 180MG 5 SP MYFORTIC TAB 360MG 5 SP IMMUNOSUPPRESSANTS, CALCINEURIN INHIBITORS ASTAGRAF XL CAP 0.5MG 5 SP ASTAGRAF XL CAP 1MG 5 SP ASTAGRAF XL CAP 5MG 5 SP cyclosporine cap 25 mg 4 PA; SP cyclosporine cap 100 mg 4 PA; SP cyclosporine modified cap 25 mg 4 SP cyclosporine modified cap 50 mg 4 SP cyclosporine modified cap 100 mg 4 SP cyclosporine modified oral soln 100 mg/ml 4 SP gengraf cap 25mg 4 SP gengraf cap 50mg 1 gengraf cap 100mg 4 SP gengraf sol 100mg/ml 4 SP NEORAL CAP 25MG 5 SP NEORAL CAP 100MG 5 SP NEORAL SOL 100MG/ML 5 SP SANDIMMUNE CAP 25MG 5 PA; SP SANDIMMUNE CAP 100MG 5 PA; SP tacrolimus cap 0.5 mg 4 SP tacrolimus cap 1 mg 4 SP tacrolimus cap 5 mg 4 SP IMMUNOSUPPRESSANTS, RAPAMYCIN DERIVATIVE RAPAMUNE SOL 1MG/ML 4 SP RAPAMUNE TAB 0.5MG 5 SP RAPAMUNE TAB 1MG 5 SP RAPAMUNE TAB 2MG 5 SP

118

Drug Name Drug Tier Requirements/Limits sirolimus tab 0.5 mg 4 SP sirolimus tab 1 mg 4 SP sirolimus tab 2 mg 4 SP ZORTRESS TAB 0.5MG 5 SP ZORTRESS TAB 0.25MG 5 SP ZORTRESS TAB 0.75MG 5 SP NUTRITIONAL / SUPPLEMENTS ALTERNATIVE MEDICINES QUINZYME TAB 90MG 3 DIETARY MANAGEMENT PRODUCTS xyzbac tab 1 ELECTROLYTES, POTASSIUM EFFER-K TAB 10MEQ 3 EFFER-K TAB 20MEQ 3 K-TAB TAB 8MEQ CR 3 K-TAB TAB 10MEQ CR 3 K-TAB TAB 20MEQ 3 klor-con 8 tab 8meq er 1 klor-con 10 tab 10meq er 1 klor-con m10 tab 10meq er 1 KLOR-CON M15 TAB 15MEQ ER 3 klor-con m20 tab 20meq er 1 klor-con spr cap 8meq 1 klor-con spr cap 10meq 1 MICRO-K CAP 8MEQ CR 3 MICRO-K CAP 10MEQ CR 3 potassium chloride cap er 8 meq 1 potassium chloride cap er 10 meq 1 potassium chloride microencapsulated crys

er tab 10 meq 1

potassium chloride microencapsulated crys er tab 20 meq

1

potassium chloride oral soln 10% (20 meq/15ml)

1

potassium chloride oral soln 20% (40 meq/15ml)

1

potassium chloride tab er 8 meq (600 mg) 1 potassium chloride tab er 10 meq 1 potassium chloride tab er 20 meq (1500

mg) 1

MISCELLANEOUS acetylcysteine cap 600 mg 1 aminoam cap rms 1 aminorelief cap rms 1 CARDIOVID CAP PLUS 3 TRYPTOPHAN CAP 500MG 3

119

Drug Name Drug Tier Requirements/Limits VITAMINS AND MINERALS, FOLIC ACID / COMBINATIONS folic acid tab 1 mg 1 VITAMINS AND MINERALS, MISCELLANEOUS ergocalciferol cap 50000 unit 1 FLUOR-A-DAY CHW 0.25MG F 3 FLUOR-A-DAY CHW 1MG F 3 fluor-a-day dro 0.125mg $0 FLUORABON DRO 3 fluoritab chw 0.5mg f $0 fluoritab chw 0.25mg f $0 fluoritab chw 1mg f 1 fluoritab chw 2.2mg 1 fluoritab dro 0.125mg $0 flura-drops dro 0.25mg f $0 flura-drops dro 0.125mg $0 karidium dro 0.125mg $0 LOZI-FLUR LOZ 1MG F 3 ludent chw 0.5mg f $0 ludent chw 0.25mg f $0 ludent chw 1mg f 1 LURIDE DRO 0.5MG/ML $0 MEPHYTON TAB 5MG 3 nafrinse chw 1mg f 1 nafrinse dro 0.125mg $0 NASCOBAL SPR 500MCG 3 niacin oral powder 1 sodium fluoride chew tab 0.5 mg f (from

1.1 mg naf) $0

sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)

$0

sodium fluoride chew tab 1 mg f (from 2.2 mg naf)

1

sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)

$0

sodium fluoride tab 0.5 mg f (from 1.1 mg naf)

$0

sodium fluoride tab 1 mg f (from 2.2 mg naf)

1

RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS epinephrine solution auto-injector 0.3

mg/0.3ml (1:1000) 1

epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000)

1

epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000)

1

EPIPEN 2-PAK INJ 0.3MG 2

120

Drug Name Drug Tier Requirements/Limits EPIPEN-JR INJ 2-PAK 2 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, Long Acting ANORO ELLIPT AER 62.5-25 2 BEVESPI AER 9-4.8MCG 2 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, Short Acting COMBIVENT AER 20-100 2 ipratropium-albuterol nebu soln 0.5-2.5(3)

mg/3ml 1

ANTICHOLINERGICS ipratropium bromide inhal soln 0.02% 1 SPIRIVA AER 1.25MCG 2 SPIRIVA CAP HANDIHLR 2 SPIRIVA SPR 2.5MCG 2 ANTIHISTAMINE/DECONGESTANT COMBINATIONS CLARINEX-D TAB 2.5-120 3 DECON-A ELX 2-5MG/5M 3 DECON-G DRO 2-1-40MG 3 prometh vc sol plain 1 promethazine & phenylephrine syrup 6.25-

5 mg/5ml 1

RELHIST CHW 3 SEMPREX-D CAP 8-60MG 3 ANTIHISTAMINES, LOW SEDATING cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) 1 levocetirizine dihydrochloride soln 2.5

mg/5ml (0.5 mg/ml) 1

levocetirizine dihydrochloride tab 5 mg 1 XYZAL SOL 3 XYZAL SOL 2.5/5ML 3 XYZAL TAB 5MG 3 ANTIHISTAMINES, NONSEDATING CLARINEX SYP 0.5MG/ML 3 CLARINEX TAB 5MG 3 desloratadine tab 5 mg 1 desloratadine tab orally disintegrating 2.5

mg 1

desloratadine tab orally disintegrating 5 mg

1

ANTIHISTAMINES, SEDATING arbinoxa sol 4mg/5ml 1 arbinoxa tab 4mg 1 brompheniramine tannate chew tab 12 mg 1 carbinoxamine maleate soln 4 mg/5ml 1 carbinoxamine maleate tab 4 mg 1 clemastine fumarate tab 2.68 mg 1 cyproheptadine hcl syrup 2 mg/5ml 1

121

Drug Name Drug Tier Requirements/Limits cyproheptadine hcl tab 4 mg 1 diphenhydramine hcl elixir 12.5 mg/5ml 1 hydroxyzine hcl syrup 10 mg/5ml 1 hydroxyzine hcl tab 10 mg 1 hydroxyzine hcl tab 25 mg 1 hydroxyzine hcl tab 50 mg 1 hydroxyzine pamoate cap 25 mg 1 hydroxyzine pamoate cap 50 mg 1 hydroxyzine pamoate cap 100 mg 1 KARBINAL ER SUS 4MG/5ML 3 pharbedryl cap 50mg 1 VISTARIL CAP 25MG 3 VISTARIL CAP 50MG 3 ANTITUSSIVE COMBINATIONS, NON-OPIOID biotuss liq 1 biotuss liq pediatrc 1 bromfed dm syp 1 CARBAPHEN 12 LIQ 3 CARBAPHEN 12 SUS PED 3 EXACTUSS LIQ 3 GILTUSS LIQ 3 giltuss ped liq 1 GILTUSS TR TAB 3 NEOTUSS PLUS LIQ 3 nortuss-de dro 1 NORTUSS-EX LIQ 200-20/5 3 promethazine-dm syrup 6.25-15 mg/5ml 1 pseudoephed-bromphen-dm syrup 30-2-10

mg/5ml 1

TGQ 15DM/5PE SYP H/2CPM 3 TGQ 30/ SYP 150/15 3 TGQ 30/PSE/3 SYP BRM/15DM 3 TUSNEL TAB 3 ANTITUSSIVE COMBINATIONS, OPIOID hydrocod polst-chlorphen polst er susp 10-

8 mg/5ml 1

hydrocodone w/ homatropine syrup 5-1.5 mg/5ml

1

hydrocodone w/ homatropine tab 5-1.5 mg 1 hydromet syp 5-1.5/5 1 prometh vc/ syp codeine 1 promethazine w/ codeine syrup 6.25-10

mg/5ml 1

promethazine-phenylephrine-codeine syrup 6.25-5-10 mg/5ml

1

pseudoeph-chlorphen w/ hydrocodone soln 60-4-5 mg/5ml

1

122

Drug Name Drug Tier Requirements/Limits REZIRA SOL 60-5/5ML 3 TUSSICAPS CAP 5-4MG 3 TUSSICAPS CAP 10-8MG 3 tussigon tab 5-1.5mg 1 TUSSIONEX SUS 10-8/5ML 3 VITUZ SOL 5-4MG 3 ZUTRIPRO LIQ 60-4-5MG 3 ANTITUSSIVES benzonatate cap 100 mg 1 benzonatate cap 150 mg 1 benzonatate cap 200 mg 1 TESSALON PER CAP 100MG 3 BETA AGONISTS, INHALANTS, LONG ACTING, Hand-held Active

Inhalation SEREVENT DIS AER 50MCG 2 STRIVERDI AER 2.5MCG 2 BETA AGONISTS, INHALANTS, LONG ACTING, Nebulized Passive

Inhalation PERFOROMIST NEB 20MCG 2 BETA AGONISTS, INHALANTS, SHORT ACTING albuterol sulfate soln nebu 0.5% (5 mg/ml)1 albuterol sulfate soln nebu 0.63 mg/3ml

(base equiv) 1

albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)

1

albuterol sulfate soln nebu 1.25 mg/3ml (base equiv)

1

levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)

1


1


1

levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv)

1

PROAIR HFA AER 2 PROAIR RESPI AER 2 XOPENEX CONC NEB 1.25/0.5 3 XOPENEX NEB 0.31MG 3 XOPENEX NEB 0.63MG 3 XOPENEX NEB 1.25/3ML 3 BETA AGONISTS, ORAL AGENTS albuterol sulfate syrup 2 mg/5ml 1 albuterol sulfate tab 2 mg 1 albuterol sulfate tab 4 mg 1 albuterol sulfate tab er 12hr 4 mg 1

123

Drug Name Drug Tier Requirements/Limits albuterol sulfate tab er 12hr 8 mg 1 metaproterenol sulfate syrup 10 mg/5ml 1 metaproterenol sulfate tab 10 mg 1 metaproterenol sulfate tab 20 mg 1 terbutaline sulfate tab 2.5 mg 1 terbutaline sulfate tab 5 mg 1 VOSPIRE ER TAB 4MG 3 VOSPIRE ER TAB 8MG 3 CYSTIC FIBROSIS BETHKIS NEB 300/4ML 4 PA; SP CAYSTON INH 75MG 5 PA; SP KALYDECO PAK 50MG 5 PA; SP KALYDECO PAK 75MG 5 PA; SP KALYDECO TAB 150MG 5 PA; SP KITABIS PAK NEB 300/5ML 5 PA; SP ORKAMBI TAB 100-125 5 PA; SP ORKAMBI TAB 200-125 5 PA; SP PULMOZYME SOL 1MG/ML 5 PA; SP tobramycin neb 300/5ml 4 PA; SP tobramycin nebu soln 300 mg/5ml 4 PA; SP DECONGESTANT/EXPECTORANT COMBINATIONS GILPHEX TR TAB 10-388MG 3 phenylephrine-guaifenesin liqd 7.5-100

mg/5ml (1.5-20 mg/ml) 1

LEUKOTRIENE MODULATORS ACCOLATE TAB 10MG 3 ACCOLATE TAB 20MG 3 montelukast sodium chew tab 4 mg (base

equiv) 1

montelukast sodium chew tab 5 mg (base equiv)

1

montelukast sodium oral granules packet 4 mg (base equiv)

1

montelukast sodium tab 10 mg (base equiv)

1

SINGULAIR CHW 4MG 3 SINGULAIR CHW 5MG 3 SINGULAIR GRA 4MG 3 SINGULAIR TAB 10MG 3 zafirlukast tab 10 mg 1 zafirlukast tab 20 mg 1 zileuton tab er 12hr 600 mg 1 ZYFLO CR TAB 600MG 3 ZYFLO TAB 600MG 3 MAST CELL STABILIZERS cromolyn sodium soln nebu 20 mg/2ml 1

124

Drug Name Drug Tier Requirements/Limits MEDICAL SUPPLIES ADULT MASK MIS 3 AERCHMBR PLS MIS LRG MASK 3 AERCHMBR PLS MIS MED MASK 3 AERCHMBR PLS MIS SM MASK 3 AERCHMBR Z- MIS STAT PLS 3 AEROCHAMBER MIS CHAMBER 3 AEROCHAMBER MIS FLOSIGNA 3 AEROCHAMBER MIS MV 3 AEROCHAMBER MIS PLUS 3 AEROVENT MIS PLUS 3 AIRZONE PEAK MIS FLOW MTR 3 ARIAL MIS CHAMBER 3 ASSESS METER MIS FULL 3 ASSESS METER MIS FULL RNG 3 ASSESS METER MIS LOW 3 ASSESS METER MIS LOW RANG 3 ASTHMA CHECK MIS SYSTEM 3 ASTHMAMENTOR MIS 3 BREATHERITE MIS 3 BREATHERITE MIS LG MASK 3 BREATHERITE MIS MDI CHMB 3 BREATHERITE MIS MED MASK 3 BREATHERITE MIS SM MASK 3 BREATHERITE MIS SPACER 3 BREATHERITE MIS W/MASK 3 COMPACT SPAC MIS CHAMBER 3 COMPACT SPAC MIS LG MASK 3 COMPACT SPAC MIS MD MASK 3 COMPACT SPAC MIS SM MASK 3 E-Z SPACER MIS 3 E-Z SPACER MIS BODY GRD 3 INSPIRACHAMB MIS LARGE 3 LITEAIRE MIS 3 MICROCHAMBER MIS 3 MICROLIFE MIS PEAK FLO 3 MICROSPACER MIS 3 MINI WRIGHT MIS PFM 3 MINI WRIGHT MIS PFM LOW 3 OPTICHAMBER MIS ADV LRG 3 OPTICHAMBER MIS ADV MED 3 OPTICHAMBER MIS ADV SM 3 OPTICHAMBER MIS ADVANTAG 3 OPTICHAMBER MIS DIA LG 3 OPTICHAMBER MIS DIA MD 3 OPTICHAMBER MIS DIA SM 3

125

Drug Name Drug Tier Requirements/Limits OPTICHAMBER MIS DIAMOND 3 OPTICHAMBER MIS FACE MAS 3 OPTIHALER MIS 3 PEAK AIR FLO MIS ADLT/PED 3 PEAK FLOW MIS METER 3 PEAK FLW MTR MIS UNIVERSL 3 PERSONAL BES MIS FULL RNG 3 PERSONAL BES MIS LOW RANG 3 PIKO 1 MIS ELECTRON 3 POCKET CHAMB MIS 3 POCKET PEAK MIS METER 3 POCKET SPACE MIS 3 POCKETPEAK MIS MTR LOW 3 POCKETPEAK MIS UNIVERSA 3 RITEFLO MIS 3 TRUZONE PEAK MIS FLOW MTR 3 VALVD HOLDNG MIS CHAMBER 3 VORTEX VALVE MIS CHAMBER 3 VORTEX/MASK MIS CHILDS 3 VORTEX/MASK MIS TODDLER 3 MISCELLANEOUS acetylcysteine inhal soln 10% 1 acetylcysteine inhal soln 20% 1 caffeine citrate oral soln 60 mg/3ml (10

mg/ml base equiv) 1

difil-g fort liq 100-100 1 HYPERSAL NEB 3.5% 3 ipratropium bromide nasal soln 0.03% (21

mcg/spray) 1

ipratropium bromide nasal soln 0.06% (42 mcg/spray)

1

NEBUSAL NEB 6% 3 sodium chloride soln nebu 10% 1 NASAL ANTIHISTAMINES ASTEPRO SPR 0.15% 3 azelastine hcl nasal spray 0.1% (137

mcg/spray) 1

azelastine hcl nasal spray 0.15% (205.5 mcg/spray)

1

olopatadine hcl nasal soln 0.6% 1 PATANASE SPR 0.6% 3 NASAL DECONGESTANTS ADRENALIN SOL 1:1000 3 TYZINE PED DRO 0.05% 3 NASAL STEROIDS/COMBINATIONS budesonide nasal susp 32 mcg/act 1

126

Drug Name Drug Tier Requirements/Limits DYMISTA SPR 137-50 2 flunisolide nasal soln 25 mcg/act (0.025%) 1 fluticasone propionate nasal susp 50

mcg/act 1

mometasone furoate nasal susp 50 mcg/act

1

NASONEX SPR 50MCG/AC 3 triamcinolone acetonide nasal aerosol

suspension 55 mcg/act 1

PHOSPHODIESTERASE-4 INHIBITORS DALIRESP TAB 500MCG 2 PULMONARY FIBROSIS AGENTS ESBRIET CAP 267MG 4 PA; SP OFEV CAP 100MG 4 PA; SP OFEV CAP 150MG 4 PA; SP RESPIRATORY SYNCYTIAL VIRUS ribavirin for inhal soln 6 gm 1 VIRAZOLE INH 6GM 3 STEROID INHALANTS ARNUITY ELPT INH 100MCG 3 ARNUITY ELPT INH 200MCG 3 ASMANEX 7 AER 110MCG 2 ASMANEX 14 AER 220MCG 2 ASMANEX 30 AER 110MCG 2 ASMANEX 30 AER 220MCG 2 ASMANEX 60 AER 220MCG 2 ASMANEX 120 AER 220MCG 2 ASMANEX HFA AER 100 MCG 2 ASMANEX HFA AER 200 MCG 2 budesonide inhalation susp 0.5 mg/2ml 1 budesonide inhalation susp 0.25 mg/2ml 1 budesonide inhalation susp 1 mg/2ml 1 PULMICORT INH 90MCG 3 PULMICORT INH 180MCG 3 QVAR AER 40MCG 2 QVAR AER 80MCG 2 STEROID/BETA AGONIST COMBINATIONS ADVAIR DISKU AER 100/50 2 ADVAIR DISKU AER 250/50 2 ADVAIR DISKU AER 500/50 2 ADVAIR HFA AER 45/21 2 ADVAIR HFA AER 115/21 2 ADVAIR HFA AER 230/21 2 BREO ELLIPTA INH 100-25 3 BREO ELLIPTA INH 200-25 3 DULERA AER 100-5MCG 2

127

Drug Name Drug Tier Requirements/Limits DULERA AER 200-5MCG 2 XANTHINES ELIXOPHYLLIN ELX 80/15ML 3 THEO-24 CAP 100MG CR 3 THEO-24 CAP 200MG CR 3 THEO-24 CAP 300MG CR 3 THEO-24 CAP 400MG ER 3 theochron tab 100mg cr 1 theochron tab 200mg cr 1 theochron tab 300mg cr 1 theophylline soln 80 mg/15ml 1 theophylline tab er 12hr 100 mg 1 theophylline tab er 12hr 200 mg 1 theophylline tab er 12hr 300 mg 1 theophylline tab er 12hr 450 mg 1 theophylline tab er 24hr 400 mg 1 theophylline tab er 24hr 600 mg 1 TOPICAL DERMATOLOGY, ACNE, Oral ABSORICA CAP 10MG 3 ABSORICA CAP 20MG 3 ABSORICA CAP 25MG 3 ABSORICA CAP 30MG 3 ABSORICA CAP 35MG 3 ABSORICA CAP 40MG 3 claravis cap 10mg 1 claravis cap 20mg 1 claravis cap 30mg 1 claravis cap 40mg 1 myorisan cap 10mg 1 myorisan cap 20mg 1 myorisan cap 30mg 1 myorisan cap 40mg 1 zenatane cap 10mg 1 zenatane cap 20mg 1 zenatane cap 30mg 1 zenatane cap 40mg 1 DERMATOLOGY, ACNE, Topical ACANYA GEL 1.2-2.5% 2 ACZONE GEL 5% 3 ACZONE GEL 7.5% 3 adapalene cream 0.1% 1 adapalene gel 0.1% 1 adapalene gel 0.3% 1 adapalene lotion 0.1% 1 adapalene-benzoyl peroxide gel 0.1-2.5% 1

128

Drug Name Drug Tier Requirements/Limits ATRALIN GEL 0.05% 2 avita cre 0.025% 1 avita gel 0.025% 1 BENZACLIN GEL 1-5% 2 BENZACLIN GEL 1-5%PUMP 2 BENZAMYCIN GEL 5-3% 3 benzoyl peroxide-erythromycin gel 5-3% 1 CLEOCIN-T GEL 1% 3 CLEOCIN-T LOT 1% 3 CLEOCIN-T PAD 1% 3 CLEOCIN-T SOL 1% 3 CLINDACIN KIT ETZ 1% 3 CLINDACIN KIT PAC 1% 3 clindacin mis etz 1% 1 clindacin-p pad 1% 1 CLINDAGEL GEL 1% 3 clindamycin phosph-benzoyl peroxide

(refrig) gel 1.2 (1)-5% 1

clindamycin phosphate foam 1% 1 clindamycin phosphate gel 1% 1 clindamycin phosphate lotion 1% 1 clindamycin phosphate soln 1% 1 clindamycin phosphate swab 1% 1 clindamycin phosphate-benzoyl peroxide

gel 1-5% 1

clindamycin phosphate-tretinoin gel 1.2-0.025%

1

dapsone gel 5% 1 DIFFERIN CRE 0.1% 2 DIFFERIN GEL 0.1% 3 DIFFERIN GEL 0.3% 2 DIFFERIN LOT 0.1% 2 DUAC GEL 1.2-5% 3 EPIDUO FORTE GEL 0.3-2.5% 2 EPIDUO GEL 0.1-2.5% 2 ery pad 2% 1 ERYGEL GEL 2% 3 erythromycin gel 2% 1 erythromycin pads 2% 1 erythromycin soln 2% 1 EVOCLIN AER 1% 3 neuac gel 1.2-5% 1 RETIN-A CRE 0.1% 3 RETIN-A CRE 0.05% 3 RETIN-A CRE 0.025% 3 RETIN-A GEL 0.01% 3 RETIN-A GEL 0.025% 3

129

Drug Name Drug Tier Requirements/Limits RETIN-A MICR GEL 0.1% 2 RETIN-A MICR GEL 0.1%PUMP 2 RETIN-A MICR GEL 0.04% 2 RETIN-A MICR GEL 0.04%PMP 2 RETIN-A MICR GEL 0.08% 2 tazarotene cream 0.1% 1 TAZORAC CRE 0.1% 2 TAZORAC CRE 0.05% 2 TAZORAC GEL 0.1% 2 TAZORAC GEL 0.05% 2 TRETIN-X CRE 0.075% 3 TRETIN-X CRE 0.0375% 3 tretinoin cream 0.1% 1 tretinoin cream 0.05% 1 tretinoin cream 0.025% 1 tretinoin gel 0.01% 1 tretinoin gel 0.05% 1 tretinoin gel 0.025% 1 tretinoin microsphere gel 0.1% 1 tretinoin microsphere gel 0.04% 1 ZIANA GEL 3 DERMATOLOGY, ACTINIC KERATOSIS diclofenac sodium (actinic keratoses) gel

3% 1

EFUDEX CRE 5% 3 FLUOROPLEX CRE 1% 3 fluorouracil cream 5% 1 fluorouracil soln 2% 1 fluorouracil soln 5% 1 LEVULAN KERA SOL 20% 3 DERMATOLOGY, ANTI-INFECTIVE/ANTI-INFLAMMATORY

COMBINATIONS CORTISPORIN CRE 0.5% 3 CORTISPORIN OIN 1% 3 DERMATOLOGY, ANTIBIOTICS ALTABAX OIN 1% 3 BACTROBAN CRE 2% 3 BACTROBAN OIN NASAL 2% 3 CENTANY AT KIT 2% 3 CENTANY OIN 2% 3 gentamicin sulfate cream 0.1% 1 gentamicin sulfate oint 0.1% 1 mupirocin calcium cream 2% 1 mupirocin oint 2% 1 SILVADENE CRE 1% 3 silver sulfadiazine cream 1% 1

130

Drug Name Drug Tier Requirements/Limits ssd cre 1% 1 DERMATOLOGY, ANTIFUNGALS ciclodan cre 0.77% 1 ciclodan sol 8% 1 CICLODAN SOL KIT 8% 3 ciclopirox gel 0.77% 1 ciclopirox kit 8% 1 ciclopirox olamine cream 0.77% (base

equiv) 1

ciclopirox olamine susp 0.77% (base equiv)

1

ciclopirox shampoo 1% 1 ciclopirox solution 8% 1 clotrimazole cream 1% 1 clotrimazole soln 1% 1 clotrimazole w/ betamethasone cream 1-

0.05% 1

clotrimazole w/ betamethasone lotion 1-0.05%

1

econazole nitrate cream 1% 1 ERTACZO CRE 2% 3 EXELDERM CRE 1% 3 EXELDERM SOL 1% 3 EXTINA AER 2% 3 HALOTIN CRE 1% 3 ketoconazole cream 2% 1 ketoconazole foam 2% 1 ketoconazole shampoo 2% 1 ketodan aer 2% 1 LOPROX SHA 1% 3 LOTRISONE CRE 3 LUZU CRE 1% 2 MENTAX CRE 1% 3 naftifine hcl cream 1% 1 naftifine hcl cream 2% 1 NAFTIN CRE 2% 2 NAFTIN GEL 1% 2 NAFTIN GEL 2% 2 NIZORAL SHA 2% 3 nystatin cream 100000 unit/gm 1 nystatin oint 100000 unit/gm 1 nystatin-triamcinolone cream 100000-0.1

unit/gm-% 1

nystatin-triamcinolone oint 100000-0.1 unit/gm-%

1

oxiconazole nitrate cream 1% 1 PENLAC SOL 8% 3

131

Drug Name Drug Tier Requirements/Limits VUSION OIN 3 XOLEGEL DUO/ KIT HEAD&SHD 3 XOLEGEL DUO/ KIT XOLEX 3 XOLEGEL GEL 2% 3 XOLEGEL KIT COREPAK 3 DERMATOLOGY, ANTIPSORIATICS, ORAL acitretin cap 10 mg 1 acitretin cap 17.5 mg 1 acitretin cap 25 mg 1 methoxsalen rapid cap 10 mg 1 OXSORALEN-UL CAP 10MG 3 SORIATANE CAP 10MG 3 SORIATANE CAP 17.5MG 3 SORIATANE CAP 25MG 3 DERMATOLOGY, ANTIPSORIATICS, TOPICAL calcipotriene cream 0.005% 1 calcipotriene oint 0.005% 1 calcipotriene soln 0.005% (50 mcg/ml) 1 calcipotriene-betamethasone dipropionate

oint 0.005-0.064% 1

calcitrene oin 0.005% 1 calcitriol oint 3 mcg/gm 1 DOVONEX CRE 0.005% 3 ENSTILAR AER 3 SORILUX AER 0.005% 3 TACLONEX OIN 3 TACLONEX SUS 3 VECTICAL OIN 3MCG/GM 3 ZITHRANOL-RR CRE 1.2% 3 DERMATOLOGY, ANTISEBORRHEICS PROMISEB KIT COMPLETE 3 selenium sulfide lotion 2.5% 1 TERSI FOAM AER 2.25% 3 DERMATOLOGY, ANTISEPTICS/DISINFECTANTS BENZALKONIUM SOL 50% 3 BENZALKONIUM SOL NF 3 BUCALSEP SOL 3 BUCALSEP SPR 3 GLUTARALDEHY SOL 25% 3 IODINE TIN 2% 3 IODOFLEX PAD PAD 3 KERR TRIPLE MIS DYE SWAB 3 triple dye solution 1 DERMATOLOGY, ATOPIC DERMATITIS ELIDEL CRE 1% 2 EUCRISA OIN 2% 3

132

Drug Name Drug Tier Requirements/Limits PROTOPIC OIN 0.1% 3 PROTOPIC OIN 0.03% 3 tacrolimus oint 0.1% 1 tacrolimus oint 0.03% 1 DERMATOLOGY, CORTICOSTEROID COMBINATIONS CORTANE-B LOT 3 HALAC KIT 3 PRAMOSONE E CRE 1-2.5% 3 PRAMOSONE LOT 1% 3 PRAMOSONE LOT 2.5% 3 PRAMOSONE OIN 1% 3 PRAMOSONE OIN 2.5% 3 SCALACORT DK KIT 3 SYNALAR KIT 0.025% 3 SYNALAR TS KIT 0.01% 3 DERMATOLOGY, CORTICOSTEROIDS, High Potency amcinonide cream 0.1% 1 amcinonide lotion 0.1% 1 AMCINONIDE OIN 0.1% 3 betamethasone dipropionate augmented

cream 0.05% 1

betamethasone dipropionate augmented lotion 0.05%

1

betamethasone dipropionate cream 0.05% 1 betamethasone dipropionate lotion 0.05% 1 betamethasone dipropionate oint 0.05% 1 desoximetasone cream 0.25% 1 desoximetasone gel 0.05% 1 desoximetasone oint 0.25% 1 diflorasone diacetate cream 0.05% 1 DIPROLENE AF CRE 0.05% 3 DIPROLENE LOT 0.05% 3 fluocinonide cream 0.1% 1 fluocinonide cream 0.05% 1 fluocinonide emulsified base cream 0.05% 1 fluocinonide gel 0.05% 1 fluocinonide oint 0.05% 1 fluocinonide soln 0.05% 1 TOPICORT CRE 0.25% 3 TOPICORT GEL 0.05% 3 TOPICORT OIN 0.25% 3 TOPICORT SPR 0.25% 3 triamcinolone acetonide cream 0.5% 1 triamcinolone acetonide oint 0.5% 1 VANOS CRE 0.1% 3 DERMATOLOGY, CORTICOSTEROIDS, Low Potency

133

Drug Name Drug Tier Requirements/Limits ACLOVATE CRE 0.05% 3 ALA SCALP LOT 2% 3 ala-cort cre 1% 1 alclometasone dipropionate cream 0.05% 1 alclometasone dipropionate oint 0.05% 1 CAPEX SHA 0.01% 3 DERMA-SMOOTH OIL /FS BODY 3 DERMA-SMOOTH OIL /FS SCLP 3 DESONATE GEL 0.05% 3 desonide cream 0.05% 1 desonide lotion 0.05% 1 desonide oint 0.05% 1 DESOWEN CRE 0.05% 3 DESOWEN LOT 0.05% 3 EPIFOAM AER 1% 3 fluocinolone acetonide cream 0.01% 1 fluocinolone acetonide oil 0.01% (body oil) 1 fluocinolone acetonide oil 0.01% (scalp oil) 1 fluocinolone acetonide soln 0.01% 1 hydrocortisone cream 1% 1 hydrocortisone cream 2.5% 1 hydrocortisone lotion 2.5% 1 hydrocortisone oint 1% 1 hydrocortisone oint 2.5% 1 lokara lot 0.05% 1 NUCORT LOT 2% 3 scalacort lot 2% 1 SYNALAR SOL 0.01% 3 TEXACORT SOL 2.5% 3 DERMATOLOGY, CORTICOSTEROIDS, Medium Potency betamethasone valerate aerosol foam

0.12% 1

betamethasone valerate cream 0.1% (base equivalent)

1

betamethasone valerate lotion 0.1% (base equivalent)

1

betamethasone valerate oint 0.1% (base equivalent)

1

clocortolone pivalate cream 0.1% 1 CLODERM CRE 0.1% 2 CLODERM CRE 0.1% PMP 2 CORDRAN CRE 0.05% 3 CORDRAN LOT 0.05% 3 CORDRAN OIN 0.05% 3 CUTIVATE CRE 0.05% 3 CUTIVATE LOT 0.05% 3

134

Drug Name Drug Tier Requirements/Limits DERMASORB TA KIT 0.1% 3 DERMATOP CRE 0.1% 3 DERMATOP OIN 0.1% 3 desoximetasone cream 0.05% 1 desoximetasone oint 0.05% 1 ELOCON CRE 0.1% 3 ELOCON LOT 0.1% 3 ELOCON OIN 0.1% 3 fluocinolone acetonide cream 0.025% 1 fluocinolone acetonide oint 0.025% 1 flurandrenolide cream 0.05% 1 flurandrenolide lotion 0.05% 1 flurandrenolide oint 0.05% 1 fluticasone propionate cream 0.05% 1 fluticasone propionate lotion 0.05% 1 fluticasone propionate oint 0.005% 1 hydrocortisone butyrate cream 0.1% 1 hydrocortisone butyrate hydrophilic lipo

base cream 0.1% 1

hydrocortisone butyrate oint 0.1% 1 hydrocortisone butyrate soln 0.1% 1 hydrocortisone valerate cream 0.2% 1 hydrocortisone valerate oint 0.2% 1 LOCOID CRE 0.1% 3 LOCOID LIPO CRE 0.1% 3 LOCOID LOT 0.1% 2 LOCOID OIN 0.1% 3 LOCOID SOL 0.1% 3 mometasone furoate cream 0.1% 1 mometasone furoate oint 0.1% 1 mometasone furoate solution 0.1% (lotion) 1 PANDEL CRE 0.1% 3 prednicarbate cream 0.1% 1 prednicarbate oint 0.1% 1 SYNALAR CRE 0.025% 3 SYNALAR OIN 0.025% 3 TOPICORT CRE 0.05% 3 TOPICORT OIN 0.05% 3 triamcinolone acetonide aerosol soln 0.147

mg/gm 1

triamcinolone acetonide cream 0.1% 1 triamcinolone acetonide cream 0.025% 1 triamcinolone acetonide lotion 0.1% 1 triamcinolone acetonide lotion 0.025% 1 triamcinolone acetonide oint 0.1% 1 triamcinolone acetonide oint 0.025% 1

135

Drug Name Drug Tier Requirements/Limits TRIANEX OIN 0.05% 3 triderm cre 0.1% 1 WESTCORT OIN 0.2% 3 DERMATOLOGY, CORTICOSTEROIDS, Very High Potency alphatrex gel 0.05% 1 betamethasone dipropionate augmented

gel 0.05% 1

betamethasone dipropionate augmented oint 0.05%

1

clobetasol e cre 0.05% 1 clobetasol propionate cream 0.05% 1 clobetasol propionate emulsion foam

0.05% 1

clobetasol propionate foam 0.05% 1 clobetasol propionate gel 0.05% 1 clobetasol propionate lotion 0.05% 1 clobetasol propionate oint 0.05% 1 clobetasol propionate shampoo 0.05% 1 clobetasol propionate soln 0.05% 1 CLOBEX LOT 0.05% 3 CLOBEX SHA 0.05% 3 clodan sha 0.05% 1 cormax scalp sol 0.05% 1 diflorasone diacetate oint 0.05% 1 DIPROLENE OIN 0.05% 3 halobetasol propionate cream 0.05% 1 halobetasol propionate oint 0.05% 1 OLUX AER 0.05% 3 TEMOVATE CRE 0.05% 3 TEMOVATE E CRE 0.05%EML 3 TEMOVATE GEL 0.05% 3 TEMOVATE OIN 0.05% 3 TEMOVATE SOL 0.05% 3 ULTRAVATE CRE 0.05% 3 ULTRAVATE OIN 0.05% 3 DERMATOLOGY, EMOLLIENTS hyaluronate sodium (emollient) gel 0.2% 1 HYLIRA GEL 0.2% 3 HYLIRA LOT 0.1% 3 LAC-HYDRIN CRE 12% 3 LAC-HYDRIN LOT 12% 3 lactic acid (ammonium lactate) cream 12% 1 lactic acid (ammonium lactate) lotion 12% 1 lactic acid w/ vitamin e cream 10%-3500

unit/30gm 1

NEOSALUS LOT 3

136

Drug Name Drug Tier Requirements/Limits DERMATOLOGY, LOCAL ANALGESIC lidocaine patch 5% 1 LIDODERM DIS 5% 3 DERMATOLOGY, LOCAL ANESTHETICS ANACAINE OIN 3 dermacinrx kit prizopak 1 glydo gel 2% 1 LIDO-K LOT 3% 3 lidocaine hcl gel 2% 1 lidocaine hcl lotion 3% 1 lidocaine hcl soln 4% 1 lidocaine oin 5% 1 lidocaine oin pak 5% 1 lidocaine oint 5% 1 lidocaine-prilocaine cream 2.5-2.5% 1 lidocaine-prilocaine cream kit 2.5-2.5% 1 lidocaine-tetracaine cream 7-7% 1 lidopril kit 2.5-2.5% 1 livixil pak kit 2.5-2.5% 1 lp lite pak kit 2.5-2.5% 1 PLIAGLIS CRE 7-7% 3 pramox gel 1% 1 relador pak kit 2.5-2.5% 1 relador pak kit plus 1 SYNERA DIS 70-70MG 3 XYLOCAINE SOL 4% 3 DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir oint 5% 1 ALDARA CRE 5% 3 celacyn gel 1 ceramax cre 1 CONDYLOX GEL 0.5% 3 CONDYLOX SOL 0.5% 3 DENAVIR CRE 1% 3 doxepin hcl cream 5% 1 GORDOFILM SOL 3 HYLATOPIC LOT PLUS 3 imiquimod cream 5% 1 METHYL SALIC LIQ 3 PANRETIN GEL 0.1% 3 PICATO GEL 0.05% 2 PICATO GEL 0.015% 2 PODOCON SOL 25% 3 podofilox soln 0.5% 1 PRUDOXIN CRE 5% 3 REGRANEX GEL 0.01% 3

137

Drug Name Drug Tier Requirements/Limits restizan gel 1 SALEX CREAM KIT 6% 3 salicylic acid cream 6% & cleanser liqd kit 1 SALICYLIC ACID SOLN 26% 3 SANTYL OIN 250/GM 3 SILVER NITRA OIN 10% 3 SILVER NITRA SOL 10% 3 SILVER NITRA SOL 25% 3 SILVER NITRA SOL 50% 3 SULFAMYLON CRE 85MG/GM 3 SULFAMYLON PAK 5% 3 tbc aer 1 TRI-CHLOR LIQ 80% 3 ZONALON CRE 5% 3 ZOVIRAX CRE 5% 3 ZOVIRAX OIN 5% 3 DERMATOLOGY, ROSACEA doxycycline (rosacea) cap delayed release

40 mg 1

FINACEA AER 15% 2 FINACEA GEL 15% 2 METROCREAM CRE 0.75% 3 METROLOTION LOT 0.75% 3 metronidazole cream 0.75% 1 metronidazole gel 0.75% 1 metronidazole gel 1% 1 metronidazole lotion 0.75% 1 ORACEA CAP 40MG 2 rosadan cre 0.75% 1 rosadan gel 0.75% 1 ROSADAN KIT 0.75% 3 SOOLANTRA CRE 1% 3 DERMATOLOGY, SCABICIDES AND PEDICULICIDES ELIMITE CRE 5% 3 EURAX CRE 10% 3 EURAX LOT 10% 3 lindane shampoo 1% 1 malathion lotion 0.5% 1 NATROBA SUS 0.9% 3 OVIDE LOT 0.5% 3 permethrin cream 5% 1 SKLICE LOT 0.5% 3 spinosad susp 0.9% 1 SULF LIME SOL 3 ULESFIA LOT 5% 3 DERMATOLOGY, WOUND CARE PRODUCTS

138

Drug Name Drug Tier Requirements/Limits ALEVICYN SOL DERMAL 3 REGENECARE GEL 3 MOUTH/THROAT/DENTAL AGENTS, MISCELLANEOUS ARESTIN MIS 1MG 3 CAPHOSOL SOL 3 chlorhexidine gluconate soln 0.12% 1 easygel gel 0.4% 1 easygel gel 0.4%chry 1 easygel gel 0.4%citr 1 easygel gel 0.4%mint 1 FLUORIDEX GEL SENSITIV 3 GEL-KAM CON 0.63% 3 lidocaine hcl laryngotracheal soln 4% 1 lidocaine hcl viscous soln 2% 1 NAFRINSE DLY SOL /NEUTRAL 3 NAFRINSE SOL DAILY 3 NAFRINSE WK SOL 0.2% 3 NUMOISYN LIQ 3 NUMOISYN LOZ 3 ORAFATE PST 10% 3 oralone dent pst 0.1% 1 paroex sol 0.12% 1 PERIDEX SOL 0.12% 3 periogard sol 0.12% 1 periomed con 0.63% 1 PROTHELIAL PST 10% 3 topex topcal aer anesthet 1 triamcinolone acetonide dental paste 0.1% 1 MOUTH/THROAT/DENTAL AGENTS, PROTECTANTS MUCOTROL WAF 3 MUGARD LIQ 3 SP ORAMAGICRX SUS 3 SALICEPT SUS 3 OPHTHALMIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY

COMBINATIONS bacitracin-polymyxin-neomycin-hc ophth

oint 1% 1

BLEPHAMIDE OIN S.O.P. 3 BLEPHAMIDE SUS OP 3 MAXITROL OIN 0.1% OP 3 MAXITROL SUS 0.1% OP 3 neo-polycin oin hc 1%op 1 neomycin-polymyxin-dexamethasone

ophth oint 0.1% 1

neomycin-polymyxin-dexamethasone ophth susp 0.1%

1

139

Drug Name Drug Tier Requirements/Limits neomycin-polymyxin-hc ophth susp 1 PRED-G S.O.P OIN OP 3 PRED-G SUS OP 3 sulfacetamide sodium-prednisolone ophth

soln 10-0.23(0.25)% 1

TOBRADEX OIN 0.3-0.1% 2 TOBRADEX ST SUS 0.3-0.05 2 TOBRADEX SUS 0.3-0.1% 3 tobramycin-dexamethasone ophth susp

0.3-0.1% 1

ZYLET SUS 0.5-0.3% 2 OPHTHALMIC, ANTI-INFECTIVES bacitracin ophth oint 500 unit/gm 1 bacitracin-polymyxin b ophth oint 1 BESIVANCE SUS 0.6% 2 BETADINE SOL 5% OP 3 BLEPH-10 SOL 10% OP 3 CILOXAN OIN 0.3% OP 3 CILOXAN SOL 0.3% OP 3 ciprofloxacin hcl ophth soln 0.3% 1 erythromycin ophth oint 5 mg/gm 1 gatifloxacin ophth soln 0.5% 1 gentak oin 0.3% op 1 gentamicin sulfate ophth oint 0.3% 1 gentamicin sulfate ophth soln 0.3% 1 ilotycin oin op 1 levofloxacin ophth soln 0.5% 1 MITOSOL KIT 0.2MG 3 MOXEZA SOL 0.5% 2 moxifloxacin hcl ophth soln 0.5% (base

equiv) 1

neo-polycin oin op 1 neomycin-bacitrac zn-polymyx 5(3.5)mg-

400unt-10000unt op oin 1

neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml

1

NEOSPORIN SOL OP 3 OCUFLOX DRO 0.3% OP 3 ofloxacin ophth soln 0.3% 1 polycin oin op 1 polymyxin b-trimethoprim ophth soln

10000 unit/ml-0.1% 1

POLYTRIM SOL OP 3 sulfacetamide sodium ophth oint 10% 1 sulfacetamide sodium ophth soln 10% 1 tobramycin ophth soln 0.3% 1 TOBREX OIN 0.3% OP 3

140

Drug Name Drug Tier Requirements/Limits TOBREX SOL 0.3% OP 3 VIGAMOX DRO 0.5% 2 OPHTHALMIC, ANTI-INFLAMMATORY, Nonsteroidal ACULAR LS SOL 0.4% 3 ACULAR SOL 0.5% OP 3 bromfenac sodium ophth soln 0.09% (base

equiv) (once-daily) 1

bromfenac sodium ophth soln 0.09% (base equivalent)

1

diclofenac sodium ophth soln 0.1% 1 flurbiprofen sodium ophth soln 0.03% 1 ketorolac tromethamine ophth soln 0.4% 1 ketorolac tromethamine ophth soln 0.5% 1 OCUFEN SOL 0.03% OP 3 PROLENSA SOL 0.07% 2 OPHTHALMIC, ANTI-INFLAMMATORY, Steroidal ALREX SUS 0.2% 2 dexamethasone sodium phosphate ophth

soln 0.1% 1

FLAREX SUS 0.1% OP 3 fluorometholone ophth susp 0.1% 1 LOTEMAX GEL 0.5% 2 LOTEMAX OIN 0.5% 2 LOTEMAX SUS 0.5% 2 MAXIDEX SUS 0.1% OP 3 OMNIPRED SUS 1% OP 3 PRED SOD PHO SOL 1% OP 3 prednisolone acetate ophth susp 1% 1 OPHTHALMIC, ANTIALLERGICS ALOCRIL SOL 2% 3 ALOMIDE SOL 0.1% OP 3 azelastine hcl ophth soln 0.05% 1 cromolyn sodium ophth soln 4% 1 ELESTAT DRO 0.05% 3 EMADINE SOL 0.05% OP 3 epinastine hcl ophth soln 0.05% 1 olopatadine hcl ophth soln 0.1% (base

equivalent) 1

olopatadine hcl ophth soln 0.2% (base equivalent)

1

PATADAY SOL 0.2% 2 PATANOL SOL 0.1% OP 3 PAZEO DRO 0.7% 2 OPHTHALMIC, ANTIFUNGALS NATACYN SUS 5% OP 3 OPHTHALMIC, ANTIVIRALS

141

Drug Name Drug Tier Requirements/Limits trifluridine ophth soln 1% 1 VIROPTIC SOL 1% OP 3 ZIRGAN GEL 0.15% 3 OPHTHALMIC, BETA-BLOCKERS, Nonselective BETAGAN SOL 0.5% OP 3 BETIMOL SOL 0.5% 2 BETIMOL SOL 0.25% 2 carteolol hcl ophth soln 1% 1 ISTALOL SOL 0.5% OP 3 levobunolol hcl ophth soln 0.5% 1 metipranolol ophth soln 0.3% 1 timolol maleate ophth gel forming soln

0.5% 1

timolol maleate ophth gel forming soln 0.25%

1

timolol maleate ophth soln 0.5% 1 timolol maleate ophth soln 0.25% 1 TIMOPTIC OCU SOL 0.5% OP 3 TIMOPTIC OCU SOL 0.25% OP 3 TIMOPTIC SOL 0.5% OP 3 TIMOPTIC SOL 0.25% OP 3 TIMOPTIC-XE SOL 0.5% OP 3 TIMOPTIC-XE SOL 0.25% OP 3 OPHTHALMIC, BETA-BLOCKERS, Selective betaxolol hcl ophth soln 0.5% 1 BETOPTIC-S SUS 0.25% OP 2 OPHTHALMIC, CARBONIC ANHYDRASE INHIBITOR/BETA-BLOCKER

COMBINATIONS COSOPT SOL 22.3-6.8 3 dorzolamide hcl-timolol maleate ophth soln

22.3-6.8 mg/ml 1

OPHTHALMIC, CARBONIC ANHYDRASE INHIBITOR/SYMPATHOMIMETIC COMBINATIONS

SIMBRINZA SUS 1-0.2% 3 OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS AZOPT SUS 1% OP 2 dorzolamide hcl ophth soln 2% 1 TRUSOPT SOL 2% OP 3 OPHTHALMIC, DIAGNOSTIC PRODUCTS altafluor sol 0.25-0.4 1 bio glo tes 1mg op 1 flucaine sol 0.25-0.5 1 fluor-i-stri tes 1mg op 1 fluorescein w/ benoxinate ophth soln 0.25-

0.4% 1

142

Drug Name Drug Tier Requirements/Limits fluorescein w/ proparacaine ophth soln

0.25-0.5% 1

FLURA-SAFE SOL 3 flurox sol op 1 FUL-GLO TES 0.6MG OP 3 ful-glo tes 1mg op 1 PAREMYD SOL 1-0.25% 3 OPHTHALMIC, DRY EYE DISEASE XIIDRA DRO 5% 2 OPHTHALMIC, LOCAL ANESTHETIC AKTEN GEL 3.5% 3 OPHTHALMIC, MISCELLANEOUS altafrin sol 2.5% op 1 altafrin sol 10% op 1 CYSTARAN SOL 0.44% 5 PA; SP GELFILM MIS OP 3 LACRISERT MIS 5MG OP 3 MEMBRANEBLUE SOL 0.15% 3 phenylephrine hcl ophth soln 2.5% 1 phenylephrine hcl ophth soln 10% 1 proparacaine hcl ophth soln 0.5% 1 tetracaine hcl ophth soln 0.5% 1 VISIONBLUE SOL 0.06% 3 OPHTHALMIC, MYDRIATICS atropine sulfate ophth soln 1% 1 CYCLOGYL SOL 0.5% OP 3 CYCLOGYL SOL 1% OP 3 CYCLOGYL SOL 2% OP 3 CYCLOMYDRIL SOL OP 3 cyclopentolate hcl ophth soln 0.5% 1 cyclopentolate hcl ophth soln 1% 1 cyclopentolate hcl ophth soln 2% 1 MYDRIACYL SOL 1% OP 3 tropicamide ophth soln 0.5% 1 tropicamide ophth soln 1% 1 OPHTHALMIC, PARASYMPATHOMIMETICS ISOPTO CARP SOL 1% OP 3 ISOPTO CARP SOL 2% OP 3 ISOPTO CARP SOL 4% OP 3 PHOSPHOLINE SOL 0.125%OP 3 pilocarpine hcl ophth soln 1% 1 pilocarpine hcl ophth soln 2% 1 pilocarpine hcl ophth soln 4% 1 OPHTHALMIC, PROSTAGLANDINS bimatoprost ophth soln 0.03% 1

143

Drug Name Drug Tier Requirements/Limits latanoprost ophth soln 0.005% 1 RESCULA SOL 0.15% 3 TRAVATAN Z DRO 0.004% 2 XALATAN SOL 0.005% 3 ZIOPTAN DRO 0.0015% 2 OPHTHALMIC, SYMPATHOMIMETIC/BETA-BLOCKER COMBINATIONS COMBIGAN SOL 0.2/0.5% 2 OPHTHALMIC, SYMPATHOMIMETICS ALPHAGAN P SOL 0.1% 2 ALPHAGAN P SOL 0.15% 2 apraclonidine hcl ophth soln 0.5% (base

equivalent) 1

brimonidine tartrate ophth soln 0.2% 1 brimonidine tartrate ophth soln 0.15% 1 IOPIDINE SOL 0.5% OP 3 IOPIDINE SOL 1% OP 3 OTIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS acetasol hc sol otic 1 CIPRO HC SUS OTIC 3 CIPRODEX SUS 0.3-0.1% 2 COLY-MYCIN S SUS OTIC 3 hydrocortisone w/ acetic acid otic soln 1-

2% 1

neomycin-polymyxin-hc otic soln 1% 1 neomycin-polymyxin-hc otic susp 3.5

mg/ml-10000 unit/ml-1% 1

OTIC, ANTI-INFECTIVES acetic acid 2% in aluminum acetate otic

soln 1

acetic acid otic soln 2% 1 CETRAXAL SOL 0.2% 3 ciprofloxacin hcl otic soln 0.2% (base

equivalent) 1

ofloxacin otic soln 0.3% 1 OTIC, MISCELLANEOUS CORTANE-B DRO OTIC 3 cortic-nd dro 1 cyotic dro 1 DERMOTIC OIL 0.01% 3 exotic-hc dro otic 1 fluocinolone acetonide (otic) oil 0.01% 1 OTICIN HC DRO 3 otomax-hc dro 1 PRAMOTIC DRO 1-0.1% 3

144

PREFERRED OPTIONS FOR EXCLUDED MEDICATIONS 1

EXCLUDED DRUG NAME(S) PREFERRED OPTION(S)*

ABILIFY aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, SEROQUEL XR

ABSTRAL fentanyl transmucosal lozenge, FENTORA, SUBSYS

ACCU-CHEK TEST STRIPS 2 ONETOUCH ULTRA TEST STRIPS, ONETOUCH VERIO TEST STRIPS

ACTICLATE doxycycline hyclate

ACTOS pioglitazone

ACUVAIL bromfenac, diclofenac, ketorolac, PROLENSA

ADCIRCA sildenafil

ADDERALL XR amphetamine-dextroamphetamine mixed salts ext-rel, dexmethylphenidate ext-rel, dextroamphetamine ext-rel, methylphenidate ext-rel, APTENSIO XR, QUILLIVANT XR, VYVANSE

ADRENACLICK epinephrine auto-injector, EPIPEN, EPIPEN JR

AEROSPAN ASMANEX, QVAR

ALCORTIN A desonide, hydrocortisone

ALLISON MEDICAL INSULIN SYRINGES 3 BD ULTRAFINE INSULIN SYRINGES

ALOQUIN desonide, hydrocortisone

ALORA estradiol, DIVIGEL, EVAMIST, MINIVELLE

ALTOPREV atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN

ALVESCO ASMANEX, QVAR

AMRIX cyclobenzaprine

ANDROGEL testosterone gel 2%, ANDRODERM, AXIRON

APEXICON-E desoximetasone, fluocinonide

APIDRA NOVOLOG

APTIOM carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT

ARCAPTA SEREVENT, STRIVERDI RESPIMAT

ARTHROTEC celecoxib or diclofenac sodium, ibuprofen, meloxicam or naproxen WITH esomeprazole, lansoprazole, omeprazole, pantoprazole or DEXILANT

ASACOL HD balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA

ASCENSIA TEST STRIPS 2 ONETOUCH ULTRA TEST STRIPS, ONETOUCH VERIO TEST STRIPS

ATACAND, ATACAND HCT candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide, BENICAR, BENICAR HCT

145


ATROVENT HFA ipratropium inhalation solution, SPIRIVA

AUVI-Q epinephrine auto-injector, EPIPEN, EPIPEN JR

AZASITE ciprofloxacin, erythromycin, gentamicin, levofloxacin, ofloxacin, sulfacetamide, tobramycin, BESIVANCE, MOXEZA, VIGAMOX

AZELEX adapalene, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN CREAM, DIFFERIN GEL 0.3%, DIFFERIN LOTION, EPIDUO, RETIN-A MICRO, TAZORAC

BECONASE AQ flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA

BENSAL HP desonide, hydrocortisone

BEPREVE azelastine, cromolyn sodium, olopatadine, PATADAY, PAZEO

BETAPACE, BETAPACE AF sotalol

BREEZE 2 TEST STRIPS 3 ONETOUCH ULTRA TEST STRIPS, ONETOUCH VERIO TEST STRIPS

BROVANA PERFOROMIST

butalbital-acetaminophen-caffeine capsule ergotamine-caffeine, naratriptan, rizatriptan, sumatriptan, zolmitriptan, RELPAX, ZOMIG NASAL SPRAY

BYDUREON TRULICITY, VICTOZA

BYETTA TRULICITY, VICTOZA

CAFERGOT ergotamine-caffeine, naratriptan, rizatriptan, sumatriptan, zolmitriptan, RELPAX, ZOMIG NASAL SPRAY

CARAC fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO

CARDIZEM diltiazem ext-rel (except generic CARDIZEM LA)

CARDIZEM CD diltiazem ext-rel (except generic CARDIZEM LA)

CARDIZEM LA (and its generics) diltiazem ext-rel (except generic CARDIZEM LA)

CARNITOR levocarnitine

CARNITOR SF levocarnitine

CELEBREX celecoxib, diclofenac sodium, ibuprofen, meloxicam, naproxen

clobetasol spray clobetasol foam

CLOBEX SPRAY clobetasol foam

COLAZAL balsalazide

COMBIPATCH CLIMARA PRO

CONTOUR NEXT TEST STRIPS 2 ONETOUCH ULTRA TEST STRIPS, ONETOUCH VERIO TEST STRIPS

CONTOUR TEST STRIPS 2 ONETOUCH ULTRA TEST STRIPS, ONETOUCH VERIO TEST STRIPS

CORDRAN TAPE clobetasol cream, clobetasol lotion, clobetasol ointment

COREG CR atenolol, carvedilol, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, propranolol, propranolol ext-rel, BYSTOLIC

COSOPT PF dorzolamide-timolol

CRESTOR atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN

CRINONE ENDOMETRIN

146


CYMBALTA duloxetine, venlafaxine, venlafaxine ext-rel capsule, PRISTIQ

DAKLINZA EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6)

DELZICOL balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA

DESVENLAFAXINE ER duloxetine, venlafaxine, venlafaxine ext-rel capsule, PRISTIQ

DETROL LA darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ, VESICARE

DEXPAK dexamethasone, methylprednisolone, prednisone

DILANTIN carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT

DIOVAN, DIOVAN HCT candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide, BENICAR, BENICAR HCT

DUREZOL dexamethasone, prednisolone acetate 1%, LOTEMAX

DUTOPROL metoprolol succinate ext-rel WITH hydrochlorothiazide

DYRENIUM amiloride

ECOZA clotrimazole, econazole, ketoconazole, oxiconazole, LUZU, NAFTIN

EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide, BENICAR, BENICAR HCT

EDLUAR zolpidem, zolpidem ext-rel, zolpidem sublingual

E.E.S. GRANULES erythromycins

EMBEDA morphine ext-rel, HYSINGLA ER, NUCYNTA ER, OXYCONTIN

ENABLEX darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ, VESICARE

ERYPED erythromycins

ESTROGEL estradiol, DIVIGEL, EVAMIST, MINIVELLE

EVZIO NARCAN NASAL SPRAY

EXALGO morphine ext-rel, HYSINGLA ER, NUCYNTA ER, OXYCONTIN

EXFORGE amlodipine-telmisartan, amlodipine-valsartan, AZOR

EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, TRIBENZOR

FABIOR adapalene, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN CREAM, DIFFERIN GEL 0.3%, DIFFERIN LOTION, EPIDUO, RETIN-A MICRO, TAZORAC

FANAPT aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, SEROQUEL XR

FEMHRT LOW DOSE estradiol-norethindrone, PREMPHASE, PREMPRO

147


FETZIMA duloxetine, venlafaxine, venlafaxine ext-rel capsule, PRISTIQ

FIORICET CAPSULE ergotamine-caffeine, naratriptan, rizatriptan, sumatriptan, zolmitriptan, RELPAX, ZOMIG NASAL SPRAY

FLECTOR diclofenac sodium, diclofenac sodium solution, ibuprofen, meloxicam, naproxen, VOLTAREN GEL

FLOVENT ASMANEX, QVAR

fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO

FLUOXETINE 60 MG citalopram, escitalopram, fluoxetine, paroxetine, paroxetine ext-rel, sertraline, TRINTELLIX, VIIBRYD

FML dexamethasone, prednisolone acetate 1%, LOTEMAX

FORTAMET metformin, metformin ext-rel (except generic GLUMETZA)

FORTESTA testosterone gel 2%, ANDRODERM, AXIRON

FOSRENOL calcium acetate, PHOSLYRA, RENVELA, VELPHORO

FREESTYLE TEST STRIPS 2 ONETOUCH ULTRA TEST STRIPS, ONETOUCH VERIO TEST STRIPS

GELNIQUE darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ, VESICARE

GLUMETZA (and its generic) metformin, metformin ext-rel (except generic GLUMETZA)

GRALISE gabapentin, HORIZANT

HALOG desoximetasone, fluocinonide

HUMALOG NOVOLOG

HUMALOG MIX 50/50 NOVOLOG MIX 70/30

HUMALOG MIX 75/25 NOVOLOG MIX 70/30

HUMULIN NOVOLIN

ILEVRO bromfenac, diclofenac, ketorolac, PROLENSA

INCRUSE ELLIPTA SPIRIVA

INDOCIN celecoxib, diclofenac sodium, ibuprofen, meloxicam, naproxen

INNOPRAN XL atenolol, carvedilol, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, propranolol, propranolol ext-rel, BYSTOLIC

INTERMEZZO zolpidem, zolpidem ext-rel, zolpidem sublingual

INTUNIV amphetamine-dextroamphetamine mixed salts ext-rel, dexmethylphenidate ext-rel, dextroamphetamine ext-rel, guanfacine ext-rel, methylphenidate ext-rel, APTENSIO XR, QUILLIVANT XR, STRATTERA, VYVANSE

INVOKAMET XIGDUO XR

INVOKANA FARXIGA, JARDIANCE

JALYN dutasteride-tamsulosin; dutasteride or finasteride WITH alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, CARDURA XL or RAPAFLO

JUBLIA terbinafine tablet, ONMEL

KADIAN morphine ext-rel, HYSINGLA ER, NUCYNTA ER, OXYCONTIN

148


KAPVAY amphetamine-dextroamphetamine mixed salts ext-rel, dexmethylphenidate ext-rel, dextroamphetamine ext-rel, guanfacine ext-rel, methylphenidate ext-rel, APTENSIO XR, QUILLIVANT XR, STRATTERA, VYVANSE

KAZANO JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR

KENALOG hydrocortisone butyrate, mometasone, triamcinolone, CLODERM, LOCOID LOTION

KEPPRA carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT

KEPPRA XR carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT

KERYDIN terbinafine tablet, ONMEL

KLOR-CON/25 potassium chloride liquid

KOMBIGLYZE XR JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR

LAMICTAL carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT

LANOXIN TABLET (125 MCG and 250 MCG only)

digoxin

LANTUS BASAGLAR, LEVEMIR, TRESIBA

LASTACAFT azelastine, cromolyn sodium, olopatadine, PATADAY, PAZEO

LATUDA aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, SEROQUEL XR

LAZANDA fentanyl transmucosal lozenge, FENTORA, SUBSYS

LESCOL XL atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN

levorphanol morphine ext-rel, HYSINGLA ER, NUCYNTA ER, OXYCONTIN

LIPITOR atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN

LIVALO atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN

LUMIGAN latanoprost, TRAVATAN Z, ZIOPTAN

LUNESTA zolpidem, zolpidem ext-rel, zolpidem sublingual

LUXIQ hydrocortisone butyrate, mometasone, triamcinolone, CLODERM, LOCOID LOTION

MACRODANTIN nitrofurantoin

149


Matzim LA diltiazem ext-rel (except generic CARDIZEM LA)

MAVYRET EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6), VOSEVI 4

MENEST estradiol, estropipate, PREMARIN

MENOSTAR estradiol

meperidine hydromorphone, morphine, oxycodone, NUCYNTA

METADATE CD amphetamine-dextroamphetamine mixed salts ext-rel, dexmethylphenidate ext-rel, dextroamphetamine ext-rel, methylphenidate ext-rel, APTENSIO XR, QUILLIVANT XR, VYVANSE

METROGEL metronidazole, FINACEA

MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, risedronate, ATELVIA

MIACALCIN NASAL SPRAY calcitonin-salmon

MILLIPRED dexamethasone, methylprednisolone, prednisone

MINOCIN minocycline

NAPRELAN diclofenac sodium, ibuprofen, meloxicam, naproxen

NATESTO testosterone gel 2%, ANDRODERM, AXIRON

NESINA JANUVIA, TRADJENTA

NEVANAC bromfenac, diclofenac, ketorolac, PROLENSA

NEXIUM esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT

NITROMIST nitroglycerin lingual spray, nitroglycerin sublingual, NITROLINGUAL

NORITATE metronidazole, FINACEA

NORVASC amlodipine

NOVACORT desonide, hydrocortisone

NOVO NORDISK NEEDLES 3 BD ULTRAFINE NEEDLES

OLEPTRO trazodone

OLUX-E clobetasol foam

OLYSIO EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6)

OMNARIS flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA

ONGLYZA JANUVIA, TRADJENTA

OPSUMIT LETAIRIS, TRACLEER

OSENI JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR

OWEN MUMFORD NEEDLES 3 BD ULTRAFINE NEEDLES

OXISTAT clotrimazole, econazole, ketoconazole, oxiconazole, LUZU, NAFTIN

OXYTROL darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ, VESICARE

PENNSAID diclofenac sodium, diclofenac sodium solution, ibuprofen, meloxicam, naproxen, VOLTAREN GEL

PERRIGO NEEDLES 3 BD ULTRAFINE NEEDLES

PLAVIX clopidogrel, dipyridamole ext-rel-aspirin, BRILINTA, EFFIENT

150


PRADAXA warfarin, ELIQUIS, XARELTO

PRECISION XTRA TEST STRIPS 2 ONETOUCH ULTRA TEST STRIPS, ONETOUCH VERIO TEST STRIPS

PRED FORTE dexamethasone, prednisolone acetate 1%, LOTEMAX

PRED MILD dexamethasone, prednisolone acetate 1%, LOTEMAX

PREVACID esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT

PROGRAF tacrolimus

PROTONIX esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT

PROVENTIL HFA levalbuterol tartrate CFC-free aerosol, PROAIR HFA, PROAIR RESPICLICK

PROVIGIL armodafinil, modafinil

PULMICORT RESPULES budesonide inhalation suspension, ASMANEX, QVAR

QNASL flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA

QUARTETTE NATAZIA

RAYOS dexamethasone, methylprednisolone, prednisone

RELION INSULIN NOVOLIN INSULIN

RESTASIS XIIDRA

REVATIO sildenafil

RHINOCORT AQUA flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA

RIMSO-50 Consult doctor

RIOMET metformin, metformin ext-rel (except generic GLUMETZA)

RITALIN SR amphetamine-dextroamphetamine mixed salts ext-rel, dexmethylphenidate ext-rel, dextroamphetamine ext-rel, methylphenidate ext-rel, APTENSIO XR, QUILLIVANT XR, VYVANSE

ROWASA mesalamine rectal suspension

ROZEREM zolpidem, zolpidem ext-rel, zolpidem sublingual

SFROWASA mesalamine rectal suspension

SILENOR zolpidem, zolpidem ext-rel, zolpidem sublingual

SOLARAZE fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO

SONATA zolpidem, zolpidem ext-rel, zolpidem sublingual

SPORANOX CAPSULE itraconazole, terbinafine tablet, ONMEL

SPORANOX SOLUTION fluconazole

SUMAVEL DOSEPRO naratriptan, rizatriptan, sumatriptan, zolmitriptan, RELPAX, ZOMIG NASAL SPRAY

SYMBICORT ADVAIR, DULERA

TANZEUM TRULICITY, VICTOZA

TECHNIVIE EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6)

TESTIM testosterone gel 2%, ANDRODERM, AXIRON

testosterone gel 1% 5 testosterone gel 2%, ANDRODERM, AXIRON

TOBI tobramycin inhalation solution, BETHKIS

151


TOBI PODHALER tobramycin inhalation solution, BETHKIS

TOUJEO BASAGLAR, LEVEMIR, TRESIBA

TREXIMET diclofenac sodium, ibuprofen, meloxicam or naproxen WITH naratriptan, rizatriptan, sumatriptan, zolmitriptan, RELPAX or ZOMIG NASAL SPRAY

TRICOR fenofibrate, fenofibric acid

TRIVIDIA INSULIN SYRINGES 3 BD ULTRAFINE INSULIN SYRINGES

TUDORZA SPIRIVA

ULTIMED INSULIN SYRINGES 3 BD ULTRAFINE INSULIN SYRINGES

ULTIMED NEEDLES BD ULTRAFINE NEEDLES

UROXATRAL alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, CARDURA XL, RAPAFLO

VALCYTE valganciclovir

VALTREX acyclovir, valacyclovir

VANOXIDE-HC adapalene, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN CREAM, DIFFERIN GEL 0.3%, DIFFERIN LOTION, EPIDUO, RETIN-A MICRO, TAZORAC

VASCEPA omega-3 acid ethyl esters

VELTIN adapalene, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN CREAM, DIFFERIN GEL 0.3%, DIFFERIN LOTION, EPIDUO, RETIN-A MICRO, TAZORAC

venlafaxine ext-rel tablet (except 225 mg) duloxetine, venlafaxine, venlafaxine ext-rel capsule, PRISTIQ

VENLAFAXINE EXT-REL TABLET (except 225 MG)

duloxetine, venlafaxine, venlafaxine ext-rel capsule, PRISTIQ

VENTOLIN HFA levalbuterol tartrate CFC-free aerosol, PROAIR HFA, PROAIR RESPICLICK

VERDESO desonide, hydrocortisone

VEREGEN imiquimod, podofilox

VIEKIRA PAK EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6)

VIEKIRA XR EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6)

VOGELXO testosterone gel 2%, ANDRODERM, AXIRON

XENAZINE tetrabenazine

XERESE acyclovir (except ointment), valacyclovir

XIFAXAN 200 MG sulfamethoxazole-trimethoprim

XOPENEX HFA levalbuterol tartrate CFC-free aerosol, PROAIR HFA, PROAIR RESPICLICK

ZEGERID esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT

ZEPATIER EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6)

ZETONNA flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA

ZOHYDRO ER morphine ext-rel, HYSINGLA ER, NUCYNTA ER, OXYCONTIN

ZOLPIMIST zolpidem, zolpidem ext-rel, zolpidem sublingual

152


ZONEGRAN carbamazepine, carbamazepine ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR XR, TROKENDI XR, VIMPAT

ZUBSOLV buprenorphine-naloxone sublingual tablet, SUBOXONE FILM

ZYCLARA fluorouracil 5% cream, fluorouracil solution, imiquimod, PICATO

ZYMAXID ciprofloxacin, erythromycin, gentamicin, levofloxacin, ofloxacin, sulfacetamide, tobramycin, BESIVANCE, MOXEZA, VIGAMOX

ZYVOX SIVEXTRO

* The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not

necessarily represent clinical equivalency. 1 An exception process is in place for specific clinical or regulatory circumstances that may require coverage of an excluded medication. 2 ONETOUCH brand test strips are the only preferred options. 3 BD ULTRAFINE syringes and needles are the only preferred options. 4 For use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an

NS5A inhibitor (for genotypes 1a or 3). 5 Listing reflects the authorized generics for TESTIM and VOGELXO.

153

Index A abacavir sulfate soln 20 mg/ml (base equiv) ............................................. 21 abacavir sulfate tab 300 mg (base equiv) ..................................................... 21 abacavir sulfate-lamivudine tab 600-300 mg ................................................. 20 abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg ........................ 20 ABSORICA CAP 10MG ..................... 127 ABSORICA CAP 20MG ..................... 127 ABSORICA CAP 25MG ..................... 127 ABSORICA CAP 30MG ..................... 127 ABSORICA CAP 35MG ..................... 127 ABSORICA CAP 40MG ..................... 127 acamprosate calcium tab delayed release 333 mg ........................................... 86 ACANYA GEL 1.2-2.5% .................... 127 acarbose tab 100 mg ........................ 87 acarbose tab 25 mg .......................... 87 acarbose tab 50 mg .......................... 87 ACCOLATE TAB 10MG ..................... 123 ACCOLATE TAB 20MG ..................... 123 ACCUPRIL TAB 10MG ........................ 38 ACCUPRIL TAB 20MG ........................ 38 ACCUPRIL TAB 40MG ........................ 38 ACCUPRIL TAB 5MG .......................... 38 ACCURETIC TAB 10-12.5 ................... 37 ACCURETIC TAB 20-12.5 ................... 37 ACCURETIC TAB 20-25MG ................. 37 acebutolol hcl cap 200 mg ................. 48 acebutolol hcl cap 400 mg ................. 48 ACEON TAB 4MG .............................. 38 ACEON TAB 8MG .............................. 38 acetaminophen w/ codeine soln 120-12 mg/5ml ............................................ 7 acetaminophen w/ codeine tab 300-15 mg .................................................. 7 acetaminophen w/ codeine tab 300-30 mg .................................................. 7 acetaminophen w/ codeine tab 300-60 mg .................................................. 7 acetaminophen-caffeine-dihydrocodeine cap 320.5-30-16 mg .......................... 7

acetasol hc sol otic ......................... 143 acetazolamide cap er 12hr 500 mg .... 54 acetazolamide tab 125 mg ................ 54 acetazolamide tab 250 mg ................ 54 acetic acid 2% in aluminum acetate otic soln .............................................. 143 acetic acid irrigation soln 0.25% ....... 112 acetic acid otic soln 2% ................... 143 acetylcysteine cap 600 mg ............... 118 acetylcysteine inhal soln 10% ........... 125 acetylcysteine inhal soln 20% ........... 125 ACIPHEX SPR CAP 10MG .................. 111 ACIPHEX SPR CAP 5MG ................... 111 ACIPHEX TAB 20MG ........................ 111 acitretin cap 10 mg ......................... 131 acitretin cap 17.5 mg ...................... 131 acitretin cap 25 mg ......................... 131 ACLOVATE CRE 0.05% .................... 133 ACTIGALL CAP 300MG ..................... 107 ACTIQ LOZ 1200MCG ......................... 7 ACTIQ LOZ 1600MCG ......................... 8 ACTIQ LOZ 200MCG ........................... 7 ACTIQ LOZ 400MCG ........................... 7 ACTIQ LOZ 600MCG ........................... 7 ACTIQ LOZ 800MCG ........................... 7 ACTIVELLA TAB 0.5-0.1 .................... 97 ACTIVELLA TAB 1-0.5MG .................. 97 ACTONEL TAB 150MG ....................... 92 ACTONEL TAB 30MG ........................ 92 ACTONEL TAB 35MG ........................ 92 ACTONEL TAB 5MG .......................... 91 ACTOPLUS MET TAB 15-500MG ......... 89 ACTOPLUS MET TAB 15-850MG ......... 89 ACTOPLUS MET TAB XR .................... 89 ACULAR LS SOL 0.4% ..................... 140 ACULAR SOL 0.5% OP ..................... 140 acyclovir cap 200 mg ....................... 24 acyclovir oint 5% ............................ 136 acyclovir susp 200 mg/5ml ............... 24 acyclovir tab 400 mg ........................ 24 acyclovir tab 800 mg ........................ 24 ACZONE GEL 5% ............................ 127 ACZONE GEL 7.5% ......................... 127 ADALAT CC TAB 30MG ER ................. 50

154

ADALAT CC TAB 60MG ER .................. 50 ADALAT CC TAB 90MG ER .................. 50 adapalene cream 0.1% ................... 127 adapalene gel 0.1% ........................ 127 adapalene gel 0.3% ........................ 127 adapalene lotion 0.1% .................... 127 adapalene-benzoyl peroxide gel 0.1-2.5% ............................................ 127 ADASUVE INH 10MG ......................... 76 ADDERALL TAB 10MG ....................... 77 ADDERALL TAB 12.5MG ..................... 77 ADDERALL TAB 15MG ....................... 77 ADDERALL TAB 20MG ....................... 77 ADDERALL TAB 30MG ....................... 77 ADDERALL TAB 5MG ......................... 77 ADDERALL TAB 7.5MG ...................... 77 adefovir dipivoxil tab 10 mg ............... 23 ADEMPAS TAB 0.5MG ........................ 57 ADEMPAS TAB 1.5MG ........................ 57 ADEMPAS TAB 1MG .......................... 57 ADEMPAS TAB 2.5MG ........................ 57 ADEMPAS TAB 2MG .......................... 57 ADOXA CAP 150MG .......................... 17 ADOXA PAK 1/ TAB 100MG ................ 17 ADOXA PAK 1/ TAB 150MG ................ 17 ADOXA PAK 2/ TAB 100MG ................ 17 ADOXA TAB 100MG .......................... 18 ADOXA TAB 50MG ............................ 17 ADOXA TAB 75MG ............................ 18 ADRENALIN SOL 1:1000 .................. 125 ADULT MASK MIS ........................... 124 ADVAIR DISKU AER 100/50 ............. 126 ADVAIR DISKU AER 250/50 ............. 126 ADVAIR DISKU AER 500/50 ............. 126 ADVAIR HFA AER 115/21 ................. 126 ADVAIR HFA AER 230/21 ................. 126 ADVAIR HFA AER 45/21 .................. 126 ADZENYS XR TAB 12.5MG ................. 77 ADZENYS XR TAB 15.7 MG ................ 77 ADZENYS XR TAB 18.8MG ................. 77 ADZENYS XR TAB 3.1MG ................... 77 ADZENYS XR TAB 6.3MG ................... 77 ADZENYS XR TAB 9.4MG ................... 77 AERCHMBR PLS MIS LRG MASK ........ 124 AERCHMBR PLS MIS MED MASK ....... 124

AERCHMBR PLS MIS SM MASK .......... 124 AERCHMBR Z- MIS STAT PLS ........... 124 AEROCHAMBER MIS CHAMBER ......... 124 AEROCHAMBER MIS FLOSIGNA ......... 124 AEROCHAMBER MIS MV ................... 124 AEROCHAMBER MIS PLUS ................ 124 AEROVENT MIS PLUS ...................... 124 afeditab tab 30mg cr ........................ 50 afeditab tab 60mg cr ........................ 50 AFINITOR DIS TAB 2MG ................... 30 AFINITOR DIS TAB 3MG ................... 30 AFINITOR DIS TAB 5MG ................... 30 AFINITOR TAB 10MG ........................ 30 AFINITOR TAB 2.5MG ....................... 30 AFINITOR TAB 5MG ......................... 30 AFINITOR TAB 7.5MG ....................... 30 AGGRENOX CAP 25-200MG .............. 116 AGRYLIN CAP 0.5MG ....................... 116 AIRZONE PEAK MIS FLOW MTR ......... 124 AKTEN GEL 3.5% ............................ 142 AKYNZEO CAP 300-0.5 .................... 105 ALA SCALP LOT 2% ........................ 133 ala-cort cre 1% .............................. 133 ALBENZA TAB 200MG ....................... 25 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)........................................ 122 albuterol sulfate soln nebu 0.5% (5 mg/ml) ......................................... 122 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) .................................. 122 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) .................................. 122 albuterol sulfate syrup 2 mg/5ml ...... 122 albuterol sulfate tab 2 mg ................ 122 albuterol sulfate tab 4 mg ................ 122 albuterol sulfate tab er 12hr 4 mg ..... 122 albuterol sulfate tab er 12hr 8 mg ..... 123 alclometasone dipropionate cream 0.05% .................................................... 133 alclometasone dipropionate oint 0.05% .................................................... 133 ALDACTAZIDE TAB 25/25 ................. 53 ALDACTAZIDE TAB 50/50 ................. 53 ALDACTONE TAB 100MG ................... 40 ALDACTONE TAB 25MG .................... 40

155

ALDACTONE TAB 50MG ..................... 40 ALDARA CRE 5% ............................ 136 alendronate sodium oral soln 70 mg/75ml ......................................... 92 alendronate sodium tab 10 mg ........... 92 alendronate sodium tab 35 mg ........... 92 alendronate sodium tab 40 mg ........... 92 alendronate sodium tab 5 mg ............. 92 alendronate sodium tab 70 mg ........... 92 ALEVICYN SOL DERMAL ................... 138 alfuzosin hcl tab er 24hr 10 mg ........ 112 ALINIA SUS 100/5ML ........................ 25 ALINIA TAB 500MG ........................... 25 ALKERAN TAB 2MG ........................... 26 allopurinol tab 100 mg ....................... 5 allopurinol tab 300 mg ....................... 5 almotriptan malate tab 12.5 mg ......... 83 almotriptan malate tab 6.25 mg ......... 83 ALOCRIL SOL 2% ........................... 140 ALOMIDE SOL 0.1% OP ................... 140 alosetron hcl tab 0.5 mg (base equiv) 109 alosetron hcl tab 1 mg (base equiv) .. 109 ALPHAGAN P SOL 0.1% ................... 143 ALPHAGAN P SOL 0.15% ................. 143 alphatrex gel 0.05% ....................... 135 ALPRAZOLAM CON 1 MG/ML .............. 57 alprazolam orally disintegrating tab 0.25 mg ................................................. 57 alprazolam orally disintegrating tab 0.5 mg ................................................. 57 alprazolam orally disintegrating tab 1 mg ..................................................... 58 alprazolam orally disintegrating tab 2 mg ..................................................... 58 alprazolam tab 0.25 mg .................... 58 alprazolam tab 0.5 mg ...................... 58 alprazolam tab 0.5mg xr ................... 58 alprazolam tab 1 mg ......................... 58 alprazolam tab 1mg xr ...................... 58 alprazolam tab 2 mg ......................... 58 alprazolam tab 2mg xr ...................... 58 alprazolam tab 3mg xr ...................... 58 alprazolam tab er 24hr 0.5 mg ........... 58 alprazolam tab er 24hr 1 mg .............. 58 alprazolam tab er 24hr 2 mg .............. 58

alprazolam tab er 24hr 3 mg ............. 58 ALREX SUS 0.2%............................ 140 ALTABAX OIN 1% ........................... 129 ALTACE CAP 1.25MG ........................ 38 ALTACE CAP 10MG ........................... 38 ALTACE CAP 2.5MG .......................... 38 ALTACE CAP 5MG ............................ 38 altafluor sol 0.25-0.4 ...................... 141 altafrin sol 10% op ......................... 142 altafrin sol 2.5% op ........................ 142 altavera tab .................................... 94 alyacen tab 1/35 ............................. 95 alyacen tab 7/7/7 ............................ 96 amantadine hcl cap 100 mg .............. 70 amantadine hcl syrup 50 mg/5ml ....... 70 amantadine hcl tab 100 mg .............. 70 AMARYL TAB 1MG ............................ 90 AMARYL TAB 2MG ............................ 90 AMARYL TAB 4MG ............................ 90 AMBIEN CR TAB 12.5MG ................... 82 AMBIEN CR TAB 6.25MG ................... 82 AMBIEN TAB 10MG .......................... 82 AMBIEN TAB 5MG ............................ 82 amcinonide cream 0.1% .................. 132 amcinonide lotion 0.1% ................... 132 AMCINONIDE OIN 0.1% .................. 132 AMERGE TAB 1MG ........................... 83 AMERGE TAB 2.5MG ......................... 83 amethia lo tab ................................. 93 amethia tab .................................... 93 amethyst tab 90-20mcg ................... 92 AMICAR TAB 1000MG ...................... 115 AMICAR TAB 500MG ....................... 115 amiloride & hydrochlorothiazide tab 5-50 mg ................................................ 53 amiloride hcl tab 5 mg ..................... 54 aminoam cap rms ........................... 118 aminorelief cap rms ........................ 118 amiodarone hcl tab 100 mg .............. 44 amiodarone hcl tab 200 mg .............. 44 amiodarone hcl tab 400 mg .............. 44 AMITIZA CAP 24MCG ...................... 109 AMITIZA CAP 8MCG ........................ 109 amitriptyline hcl tab 10 mg ............... 69 amitriptyline hcl tab 100 mg ............. 69

156

amitriptyline hcl tab 150 mg .............. 69 amitriptyline hcl tab 25 mg ................ 69 amitriptyline hcl tab 50 mg ................ 69 amitriptyline hcl tab 75 mg ................ 69 amlodipine besylate tab 10 mg ........... 50 amlodipine besylate tab 2.5 mg .......... 50 amlodipine besylate tab 5 mg ............ 50 amlodipine besylate-atorvastatin calcium tab 10-10 mg .................................. 50 amlodipine besylate-atorvastatin calcium tab 10-20 mg .................................. 50 amlodipine besylate-atorvastatin calcium tab 10-40 mg .................................. 50 amlodipine besylate-atorvastatin calcium tab 10-80 mg .................................. 50 amlodipine besylate-atorvastatin calcium tab 2.5-10 mg ................................. 50 amlodipine besylate-atorvastatin calcium tab 2.5-20 mg ................................. 50 amlodipine besylate-atorvastatin calcium tab 2.5-40 mg ................................. 50 amlodipine besylate-atorvastatin calcium tab 5-10 mg .................................... 50 amlodipine besylate-atorvastatin calcium tab 5-20 mg .................................... 50 amlodipine besylate-atorvastatin calcium tab 5-40 mg .................................... 50 amlodipine besylate-atorvastatin calcium tab 5-80 mg .................................... 50 amlodipine besylate-benazepril hcl cap 10-20 mg ........................................ 37 amlodipine besylate-benazepril hcl cap 10-40 mg ........................................ 37 amlodipine besylate-benazepril hcl cap 2.5-10 mg ....................................... 36 amlodipine besylate-benazepril hcl cap 5-10 mg ............................................ 36 amlodipine besylate-benazepril hcl cap 5-20 mg ............................................ 36 amlodipine besylate-benazepril hcl cap 5-40 mg ............................................ 37 amlodipine besylate-olmesartan medoxomil tab 10-20 mg .................. 41 amlodipine besylate-olmesartan medoxomil tab 10-40 mg .................. 41

amlodipine besylate-olmesartan medoxomil tab 5-20 mg ................... 41 amlodipine besylate-olmesartan medoxomil tab 5-40 mg ................... 41 amlodipine besylate-valsartan tab 10-160 mg .......................................... 41 amlodipine besylate-valsartan tab 10-320 mg .......................................... 41 amlodipine besylate-valsartan tab 5-160 mg ................................................ 41 amlodipine besylate-valsartan tab 5-320 mg ................................................ 41 amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg ........................ 41 amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg ........................... 41 amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg ........................... 41 amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg .......................... 41 amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg ............................. 41 amoxapine tab 100 mg ..................... 69 amoxapine tab 150 mg ..................... 69 amoxapine tab 25 mg ...................... 69 amoxapine tab 50 mg ...................... 69 amoxicillin & k clavulanate chew tab 200-28.5 mg ......................................... 16 amoxicillin & k clavulanate chew tab 400-57 mg ............................................ 16 amoxicillin & k clavulanate for susp 200-28.5 mg/5ml ................................... 16 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml ................................... 16 amoxicillin & k clavulanate for susp 400-57 mg/5ml ..................................... 16 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml ................................... 16 amoxicillin & k clavulanate tab 250-125 mg ................................................ 16 amoxicillin & k clavulanate tab 500-125 mg ................................................ 16 amoxicillin & k clavulanate tab 875-125 mg ................................................ 16 amoxicillin & k clavulanate tab er 12hr

157

1000-62.5 mg .................................. 16 amoxicillin (trihydrate) cap 250 mg .... 16 amoxicillin (trihydrate) cap 500 mg .... 17 amoxicillin (trihydrate) chew tab 125 mg ..................................................... 17 amoxicillin (trihydrate) chew tab 250 mg ..................................................... 17 amoxicillin (trihydrate) for susp 125 mg/5ml ........................................... 17 amoxicillin (trihydrate) for susp 200 mg/5ml ........................................... 17 amoxicillin (trihydrate) for susp 250 mg/5ml ........................................... 17 amoxicillin (trihydrate) for susp 400 mg/5ml ........................................... 17 amoxicillin (trihydrate) tab 500 mg ..... 17 amoxicillin (trihydrate) tab 875 mg ..... 17 amoxicillin cap-clarithro tab-lansopraz cap dr therapy pack ........................ 112 amphetamine-dextroamphetamine cap er 24hr 10 mg ..................................... 77 amphetamine-dextroamphetamine cap er 24hr 15 mg ..................................... 77 amphetamine-dextroamphetamine cap er 24hr 20 mg ..................................... 77 amphetamine-dextroamphetamine cap er 24hr 25 mg ..................................... 77 amphetamine-dextroamphetamine cap er 24hr 30 mg ..................................... 77 amphetamine-dextroamphetamine cap er 24hr 5 mg ....................................... 77 amphetamine-dextroamphetamine tab 10 mg ............................................ 78 amphetamine-dextroamphetamine tab 12.5 mg .......................................... 78 amphetamine-dextroamphetamine tab 15 mg ............................................ 78 amphetamine-dextroamphetamine tab 20 mg ............................................ 78 amphetamine-dextroamphetamine tab 30 mg ............................................ 78 amphetamine-dextroamphetamine tab 5 mg ................................................. 77 amphetamine-dextroamphetamine tab 7.5 mg ........................................... 78

ampicillin cap 250 mg ...................... 17 ampicillin cap 500 mg ...................... 17 ampicillin for susp 125 mg/5ml .......... 17 ampicillin for susp 250 mg/5ml .......... 17 AMPYRA TAB 10MG .......................... 84 ANACAINE OIN ............................... 136 ANADROL-50 TAB 50MG ................... 87 ANAFRANIL CAP 25MG ..................... 59 ANAFRANIL CAP 50MG ..................... 59 ANAFRANIL CAP 75MG ..................... 59 anagrelide hcl cap 0.5 mg ................ 116 anagrelide hcl cap 1 mg .................. 116 ana-lex kit ..................................... 111 ANALPRAM-HC CRE 1-1% ................ 111 ANALPRAM-HC LOT 2.5%................. 111 ANAPROX DS TAB 550MG ................... 5 anastrozole tab 1 mg ....................... 29 ANCOBON CAP 250MG ..................... 19 ANCOBON CAP 500MG ..................... 19 ANDRODERM DIS 2MG/24HR ............ 87 ANDRODERM DIS 4MG/24HR ............ 87 ANDROID CAP 10MG ........................ 87 ANDROXY TAB 10MG ........................ 87 ANGELIQ TAB 0.25-0.5 ..................... 97 ANGELIQ TAB 0.5-1MG ..................... 97 ANORO ELLIPT AER 62.5-25 ............. 120 ANTABUSE TAB 250MG ..................... 86 ANTABUSE TAB 500MG ..................... 86 ANTARA CAP 30MG .......................... 45 ANTARA CAP 90MG .......................... 45 ANUSOL-HC CRE 2.5% .................... 111 ANZEMET TAB 100MG ..................... 105 ANZEMET TAB 50MG ....................... 105 APLENZIN TAB 174MG ...................... 65 APLENZIN TAB 348MG ...................... 65 APLENZIN TAB 522MG ...................... 65 apraclonidine hcl ophth soln 0.5% (base equivalent) .................................... 143 aprepitant capsule 125 mg ............... 105 aprepitant capsule 40 mg ................ 105 aprepitant capsule 80 mg ................ 105 aprepitant capsule therapy pack 80 & 125 mg ......................................... 106 apri tab .......................................... 94 APRISO CAP 0.375GM ..................... 108

158

APTENSIO XR CAP 10MG ................... 78 APTENSIO XR CAP 15MG ................... 78 APTENSIO XR CAP 20MG ................... 78 APTENSIO XR CAP 30MG ................... 78 APTENSIO XR CAP 40MG ................... 78 APTENSIO XR CAP 50MG ................... 78 APTENSIO XR CAP 60MG ................... 78 APTIVUS CAP 250MG ........................ 22 APTIVUS SOL ................................... 22 aranelle tab ..................................... 96 ARAVA TAB 10MG ........................... 116 ARAVA TAB 20MG ........................... 116 arbinoxa sol 4mg/5ml ..................... 120 arbinoxa tab 4mg ........................... 120 ARESTIN MIS 1MG .......................... 138 argyl saline sol 0.9% ...................... 112 ARIAL MIS CHAMBER ...................... 124 ARICEPT TAB 10MG .......................... 64 ARICEPT TAB 23MG .......................... 64 ARICEPT TAB 5MG ............................ 64 ARIMIDEX TAB 1MG .......................... 29 aripiprazole oral solution 1 mg/ml ....... 73 aripiprazole tab 10 mg ...................... 73 aripiprazole tab 15 mg ...................... 73 aripiprazole tab 2 mg ........................ 73 aripiprazole tab 20 mg ...................... 73 aripiprazole tab 30 mg ...................... 73 aripiprazole tab 5 mg ........................ 73 armodafinil tab 150 mg ..................... 86 armodafinil tab 200 mg ..................... 86 armodafinil tab 250 mg ..................... 86 armodafinil tab 50 mg ....................... 86 ARNUITY ELPT INH 100MCG ............. 126 ARNUITY ELPT INH 200MCG ............. 126 AROMASIN TAB 25MG ....................... 29 ascomp/cod cap 30mg ....................... 8 ashlyna tab ..................................... 93 ASMANEX 120 AER 220MCG ............ 126 ASMANEX 14 AER 220MCG .............. 126 ASMANEX 30 AER 110MCG .............. 126 ASMANEX 30 AER 220MCG .............. 126 ASMANEX 60 AER 220MCG .............. 126 ASMANEX 7 AER 110MCG ................ 126 ASMANEX HFA AER 100 MCG ........... 126 ASMANEX HFA AER 200 MCG ........... 126

aspirin-caffeine-dihydrocodeine cap 356.4-30-16 mg ................................ 8 aspirin-dipyridamole cap er 12hr 25-200 mg ............................................... 116 ASSESS METER MIS FULL ................ 124 ASSESS METER MIS FULL RNG ......... 124 ASSESS METER MIS LOW ................ 124 ASSESS METER MIS LOW RANG ........ 124 ASTAGRAF XL CAP 0.5MG ................ 117 ASTAGRAF XL CAP 1MG ................... 117 ASTAGRAF XL CAP 5MG ................... 117 ASTEPRO SPR 0.15% ...................... 125 ASTHMA CHECK MIS SYSTEM ........... 124 ASTHMAMENTOR MIS ...................... 124 ATELVIA TAB .................................. 92 atenolol & chlorthalidone tab 100-25 mg ..................................................... 47 atenolol & chlorthalidone tab 50-25 mg ..................................................... 47 atenolol tab 100 mg ......................... 48 atenolol tab 25 mg .......................... 48 atenolol tab 50 mg .......................... 48 ATIVAN TAB 0.5MG .......................... 58 ATIVAN TAB 1MG ............................ 58 ATIVAN TAB 2MG ............................ 58 atomoxetine hcl cap 10 mg (base equiv) ..................................................... 78 atomoxetine hcl cap 100 mg (base equiv) ............................................ 78 atomoxetine hcl cap 18 mg (base equiv) ..................................................... 78 atomoxetine hcl cap 25 mg (base equiv) ..................................................... 78 atomoxetine hcl cap 40 mg (base equiv) ..................................................... 78 atomoxetine hcl cap 60 mg (base equiv) ..................................................... 78 atomoxetine hcl cap 80 mg (base equiv) ..................................................... 78 atorvastatin calcium tab 10 mg (base equivalent) ..................................... 46 atorvastatin calcium tab 20 mg (base equivalent) ..................................... 46 atorvastatin calcium tab 40 mg (base equivalent) ..................................... 46

159

atorvastatin calcium tab 80 mg (base equivalent) ...................................... 46 atovaquone susp 750 mg/5ml ............ 25 atovaquone-proguanil hcl tab 250-100 mg ................................................. 20 atovaquone-proguanil hcl tab 62.5-25 mg ................................................. 20 ATRALIN GEL 0.05% ....................... 128 ATRIPLA TAB ................................... 20 atropine sulfate ophth soln 1% ......... 142 AUBAGIO TAB 14MG ......................... 84 AUBAGIO TAB 7MG ........................... 84 aubra tab 0.1-0.02 ........................... 93 AUGMENTIN SUS 125/5ML ................. 17 AUGMENTIN SUS 250/5ML ................. 17 AUGMENTIN SUS ES-600 ................... 17 AUGMENTIN TAB 500MG ................... 17 AUGMENTIN TAB 875MG ................... 17 AUGMENTIN XR TAB 12HR ................. 17 AUTOSHIELD MIS 29X3/16" ............... 91 AUTOSHIELD MIS 29X5/16" ............... 91 AUTOSHIELD MIS 30GX3/16 .............. 91 AVALIDE TAB 150-12.5 ..................... 42 AVALIDE TAB 300-12.5 ..................... 42 AVANDIA TAB 2MG ........................... 89 AVANDIA TAB 4MG ........................... 89 AVAPRO TAB 150MG ......................... 43 AVAPRO TAB 300MG ......................... 43 AVAPRO TAB 75MG ........................... 43 AVC CRE 15% ................................ 114 AVELOX ABC TAB 400MG ................... 15 AVELOX TAB 400MG ......................... 15 aviane tab ....................................... 93 avidoxy tab 100mg ........................... 18 avita cre 0.025% ........................... 128 avita gel 0.025% ............................ 128 AVODART CAP 0.5MG ...................... 112 av-phos 250 tab neutral .................. 113 AXERT TAB 12.5MG .......................... 83 AXERT TAB 6.25MG .......................... 83 AXIRON SOL 30MG/ACT .................... 87 AYGESTIN TAB 5MG ........................ 102 AZASAN TAB 100MG ....................... 117 AZASAN TAB 75 MG ........................ 117 azathioprine tab 50 mg ................... 117

azelastine hcl nasal spray 0.1% (137 mcg/spray) .................................... 125 azelastine hcl nasal spray 0.15% (205.5 mcg/spray) .................................... 125 azelastine hcl ophth soln 0.05% ....... 140 AZILECT TAB 0.5MG ........................ 70 AZILECT TAB 1MG ........................... 70 azithromycin for susp 100 mg/5ml ..... 15 azithromycin for susp 200 mg/5ml ..... 15 azithromycin tab 250 mg .................. 15 azithromycin tab 500 mg .................. 15 azithromycin tab 600 mg .................. 15 AZOPT SUS 1% OP ......................... 141 AZOR TAB 10-20MG ......................... 41 AZOR TAB 10-40MG ......................... 41 AZOR TAB 5-20MG .......................... 41 AZOR TAB 5-40MG .......................... 41 AZULFIDINE TAB 500MG ................. 108 AZULFIDINE TAB 500MG EN ............. 108 azurette tab 28 day ......................... 92 B bacitracin ophth oint 500 unit/gm ..... 139 bacitracin-polymyxin b ophth oint ..... 139 bacitracin-polymyxin-neomycin-hc ophth oint 1% ......................................... 138 baclofen tab 10 mg .......................... 84 baclofen tab 20 mg .......................... 85 BACTRIM DS TAB 800-160 ................ 17 BACTRIM TAB 400-80MG .................. 17 BACTROBAN CRE 2% ...................... 129 BACTROBAN OIN NASAL 2% ............ 129 balsalazide disodium cap 750 mg ...... 108 balziva tab ...................................... 95 BANZEL SUS 40MG/ML ..................... 59 BANZEL TAB 200MG ......................... 59 BANZEL TAB 400MG ......................... 59 BARACLUDE SOL .05MG/ML .............. 23 BARACLUDE TAB 0.5MG ................... 23 BARACLUDE TAB 1MG ...................... 23 BASAGLAR INJ 100UNIT ................... 89 BD INSULIN SYRINGES AND NEEDLES 91 BD PEN NEEDL MIS 31GX3/16 ........... 91 BD PEN NEEDL MIS 31GX5/16 ........... 91 BD PEN NEEDL MIS 32GX4MM ........... 91 BD PEN NEEDLES ............................ 91

160

BD U-500 MIS 31GX6MM ................... 91 bekyree tab ..................................... 92 BELBUCA MIS 150MCG ....................... 8 BELBUCA MIS 300MCG ....................... 8 BELBUCA MIS 450MCG ....................... 8 BELBUCA MIS 600MCG ....................... 8 BELBUCA MIS 750MCG ....................... 8 BELBUCA MIS 75MCG ........................ 8 BELBUCA MIS 900MCG ....................... 8 benazepril & hydrochlorothiazide tab 10-12.5 mg .......................................... 37 benazepril & hydrochlorothiazide tab 20-12.5 mg .......................................... 37 benazepril & hydrochlorothiazide tab 20-25 mg ............................................ 37 benazepril & hydrochlorothiazide tab 5-6.25 mg .......................................... 37 benazepril hcl tab 10 mg ................... 38 benazepril hcl tab 20 mg ................... 38 benazepril hcl tab 40 mg ................... 38 benazepril hcl tab 5 mg ..................... 38 BENICAR HCT TAB 20-12.5 ................ 42 BENICAR HCT TAB 40-12.5 ................ 42 BENICAR HCT TAB 40-25MG .............. 42 BENICAR TAB 20MG.......................... 43 BENICAR TAB 40MG.......................... 43 BENICAR TAB 5MG ........................... 43 BENTYL CAP 10MG ......................... 107 BENZACLIN GEL 1-5% .................... 128 BENZACLIN GEL 1-5%PUMP ............. 128 BENZALKONIUM SOL 50% ............... 131 BENZALKONIUM SOL NF .................. 131 BENZAMYCIN GEL 5-3% .................. 128 benzonatate cap 100 mg ................. 122 benzonatate cap 150 mg ................. 122 benzonatate cap 200 mg ................. 122 benzoyl peroxide-erythromycin gel 5-3% ................................................... 128 benztropine mesylate tab 0.5 mg ....... 70 benztropine mesylate tab 1 mg .......... 70 benztropine mesylate tab 2 mg .......... 70 BESIVANCE SUS 0.6% .................... 139 BETADINE SOL 5% OP .................... 139 BETAGAN SOL 0.5% OP .................. 141 betamethasone dipropionate augmented

cream 0.05% ................................. 132 betamethasone dipropionate augmented gel 0.05% ..................................... 135 betamethasone dipropionate augmented lotion 0.05% .................................. 132 betamethasone dipropionate augmented oint 0.05% .................................... 135 betamethasone dipropionate cream 0.05% .......................................... 132 betamethasone dipropionate lotion 0.05% .......................................... 132 betamethasone dipropionate oint 0.05% .................................................... 132 betamethasone valerate aerosol foam 0.12% .......................................... 133 betamethasone valerate cream 0.1% (base equivalent) ........................... 133 betamethasone valerate lotion 0.1% (base equivalent) ........................... 133 betamethasone valerate oint 0.1% (base equivalent) .................................... 133 betaxolol hcl ophth soln 0.5% .......... 141 betaxolol hcl tab 10 mg .................... 48 betaxolol hcl tab 20 mg .................... 48 bethanechol chloride tab 10 mg ........ 113 bethanechol chloride tab 25 mg ........ 113 bethanechol chloride tab 5 mg .......... 113 bethanechol chloride tab 50 mg ........ 113 BETHKIS NEB 300/4ML .................... 123 BETIMOL SOL 0.25% ...................... 141 BETIMOL SOL 0.5% ........................ 141 BETOPTIC-S SUS 0.25% OP ............. 141 BEVESPI AER 9-4.8MCG .................. 120 bexarotene cap 75 mg ..................... 35 BEYAZ TAB ..................................... 93 BIAXIN SUS 250/5ML ....................... 15 BIAXIN TAB 250MG .......................... 15 BIAXIN TAB 500MG .......................... 15 bicalutamide tab 50 mg .................... 28 BIDIL TAB ...................................... 55 BILTRICIDE TAB 600MG ................... 25 bimatoprost ophth soln 0.03% ......... 142 BINOSTO TAB 70MG ........................ 92 bio glo tes 1mg op .......................... 141 BIO-STATIN CAP 1000000 ................ 19

161

BIO-STATIN CAP 500000 ................... 19 biotuss liq ..................................... 121 biotuss liq pediatrc ......................... 121 bisoprolol & hydrochlorothiazide tab 10-6.25 mg .......................................... 47 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg .......................................... 47 bisoprolol & hydrochlorothiazide tab 5-6.25 mg .......................................... 47 bisoprolol fumarate tab 10 mg ........... 48 bisoprolol fumarate tab 5 mg ............. 48 BLEPH-10 SOL 10% OP ................... 139 BLEPHAMIDE OIN S.O.P. ................. 138 BLEPHAMIDE SUS OP ...................... 138 blisovi 24 tab fe 1/20 ........................ 93 blisovi fe tab 1.5/30 ......................... 94 blisovi fe tab 1/20 ............................ 93 BONIVA TAB 150MG ......................... 92 BOSULIF TAB 100MG ........................ 30 BOSULIF TAB 500MG ........................ 30 BREATHERITE MIS .......................... 124 BREATHERITE MIS LG MASK ............ 124 BREATHERITE MIS MDI CHMB .......... 124 BREATHERITE MIS MED MASK .......... 124 BREATHERITE MIS SM MASK ............ 124 BREATHERITE MIS SPACER .............. 124 BREATHERITE MIS W/MASK ............. 124 BREO ELLIPTA INH 100-25 .............. 126 BREO ELLIPTA INH 200-25 .............. 126 BREVICON TAB 0.5/35 ...................... 95 briellyn tab ...................................... 95 BRILINTA TAB 60MG ....................... 116 BRILINTA TAB 90MG ....................... 116 brimonidine tartrate ophth soln 0.15% ................................................... 143 brimonidine tartrate ophth soln 0.2% 143 BRISDELLE CAP 7.5MG ...................... 87 bromfed dm syp ............................. 121 bromfenac sodium ophth soln 0.09% (base equiv) (once-daily) ................ 140 bromfenac sodium ophth soln 0.09% (base equivalent) ........................... 140 bromocriptine mesylate cap 5 mg (base equivalent) ...................................... 70 bromocriptine mesylate tab 2.5 mg (base

equivalent) ..................................... 70 brompheniramine tannate chew tab 12 mg ............................................... 120 BUCALSEP SOL ............................... 131 BUCALSEP SPR ............................... 131 budesonide delayed release particles cap 3 mg ............................................ 108 budesonide inhalation susp 0.25 mg/2ml .................................................... 126 budesonide inhalation susp 0.5 mg/2ml .................................................... 126 budesonide inhalation susp 1 mg/2ml 126 budesonide nasal susp 32 mcg/act .... 125 bumetanide tab 0.5 mg .................... 54 bumetanide tab 1 mg ....................... 54 bumetanide tab 2 mg ....................... 54 BUPAP TAB 50-300MG ........................ 5 BUPHENYL TAB 500MG .................... 110 buprenorphine hcl sl tab 2 mg (base equiv) ............................................ 86 buprenorphine hcl sl tab 8 mg (base equiv) ............................................ 86 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 bupropion hcl (smoking deterrent) tab er 12hr 150 mg ................................... 86 bupropion hcl tab 100 mg ................. 65 bupropion hcl tab 75 mg ................... 65 bupropion hcl tab er 12hr 100 mg ...... 65 bupropion hcl tab er 12hr 150 mg ...... 65 bupropion hcl tab er 12hr 200 mg ...... 65 bupropion hcl tab er 24hr 150 mg ...... 65 bupropion hcl tab er 24hr 300 mg ...... 65 buspirone hcl tab 10 mg ................... 59 buspirone hcl tab 15 mg ................... 59 buspirone hcl tab 30 mg ................... 59 buspirone hcl tab 5 mg ..................... 59 buspirone hcl tab 7.5 mg .................. 59 butalbital-acetaminophen tab 50-325 mg ....................................................... 5 butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg .............................. 8 butalbital-acetaminophen-caff w/ cod cap

162

50-325-40-30 mg .............................. 8 butalbital-acetaminophen-caffeine tab 50-325-40 mg .................................. 5 butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg .................................. 8 butalbital-aspirin-caffeine cap 50-325-40 mg .................................................. 5 BUTISOL SOD TAB 30MG ................... 82 butorphanol tartrate nasal soln 10 mg/ml ...................................................... 8 BUTRANS DIS 10MCG/HR ................... 8 BUTRANS DIS 15MCG/HR ................... 8 BUTRANS DIS 20MCG/HR ................... 8 BUTRANS DIS 5MCG/HR ..................... 8 BUTRANS DIS 7.5/HR ........................ 8 BYSTOLIC TAB 10MG ........................ 48 BYSTOLIC TAB 2.5MG ....................... 48 BYSTOLIC TAB 20MG ........................ 48 BYSTOLIC TAB 5MG .......................... 48 C cabergoline tab 0.5 mg ................... 101 CABOMETYX TAB 20MG ..................... 30 CABOMETYX TAB 40MG ..................... 30 CABOMETYX TAB 60MG ..................... 30 CADUET TAB 10-10MG ...................... 50 CADUET TAB 10-20MG ...................... 50 CADUET TAB 10-40MG ...................... 50 CADUET TAB 10-80MG ...................... 50 CADUET TAB 2.5-10MG ..................... 50 CADUET TAB 2.5-20MG ..................... 50 CADUET TAB 2.5-40MG ..................... 50 CADUET TAB 5-10MG ........................ 50 CADUET TAB 5-20MG ........................ 50 CADUET TAB 5-40MG ........................ 50 CADUET TAB 5-80MG ........................ 50 caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) ......................... 125 CALAN SR TAB 120MG ...................... 51 CALAN SR TAB 180MG ...................... 51 CALAN SR TAB 240MG ...................... 51 CALAN TAB 120MG ........................... 51 CALAN TAB 80MG ............................. 51 calcipotriene cream 0.005% ............. 131 calcipotriene oint 0.005% ................ 131 calcipotriene soln 0.005% (50 mcg/ml)

.................................................... 131 calcipotriene-betamethasone dipropionate oint 0.005-0.064% ....... 131 calcitonin (salmon) nasal soln 200 unit/act .......................................... 92 calcitrene oin 0.005% ..................... 131 calcitriol cap 0.25 mcg .................... 101 calcitriol cap 0.5 mcg ...................... 101 calcitriol oint 3 mcg/gm ................... 131 calcitriol oral soln 1 mcg/ml ............. 101 calcium acetate (phosphate binder) cap 667 mg (169 mg ca) ....................... 102 calcium acetate (phosphate binder) tab 667 mg ......................................... 102 camrese lo tab ................................ 93 camrese tab .................................... 93 CANASA SUP 1000MG ..................... 108 candesartan cilexetil tab 16 mg ......... 43 candesartan cilexetil tab 32 mg ......... 43 candesartan cilexetil tab 4 mg ........... 43 candesartan cilexetil tab 8 mg ........... 43 candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg ............................... 42 candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg ............................... 42 candesartan cilexetil-hydrochlorothiazide tab 32-25 mg .................................. 42 capecitabine tab 150 mg .................. 27 capecitabine tab 500 mg .................. 28 CAPEX SHA 0.01% .......................... 133 CAPHOSOL SOL .............................. 138 CAPITAL/COD SUS 120-12/5 ............... 8 CAPRELSA TAB 100MG ..................... 31 CAPRELSA TAB 300MG ..................... 31 captopril & hydrochlorothiazide tab 25-15 mg ................................................ 37 captopril & hydrochlorothiazide tab 25-25 mg ................................................ 37 captopril & hydrochlorothiazide tab 50-15 mg ................................................ 37 captopril & hydrochlorothiazide tab 50-25 mg ................................................ 37 captopril tab 100 mg ........................ 38 captopril tab 12.5 mg ....................... 38 captopril tab 25 mg ......................... 38

163

captopril tab 50 mg .......................... 38 CARAFATE SUS 1GM/10ML .............. 110 CARAFATE TAB 1GM ....................... 110 CARBAGLU TAB 200MG ................... 101 carbamazepine cap er 12hr 100 mg .... 59 carbamazepine cap er 12hr 200 mg .... 59 carbamazepine cap er 12hr 300 mg .... 59 carbamazepine chew tab 100 mg ........ 59 carbamazepine susp 100 mg/5ml ....... 59 carbamazepine tab 200 mg ................ 59 carbamazepine tab er 12hr 100 mg .... 59 carbamazepine tab er 12hr 200 mg .... 60 carbamazepine tab er 12hr 400 mg .... 60 CARBAPHEN 12 LIQ ........................ 121 CARBAPHEN 12 SUS PED ................. 121 CARBATROL CAP 100MG .................... 60 CARBATROL CAP 200MG .................... 60 CARBATROL CAP 300MG .................... 60 carbidopa & levodopa orally disintegrating tab 10-100 mg ............. 70 carbidopa & levodopa orally disintegrating tab 25-100 mg ............. 70 carbidopa & levodopa orally disintegrating tab 25-250 mg ............. 70 carbidopa & levodopa tab 10-100 mg .. 70 carbidopa & levodopa tab 25-100 mg .. 70 carbidopa & levodopa tab 25-250 mg .. 70 carbidopa & levodopa tab er 25-100 mg ..................................................... 70 carbidopa & levodopa tab er 50-200 mg ..................................................... 70 carbidopa tab 25 mg ......................... 70 carbidopa-levodopa-entacapone tabs 12.5-50-200 mg ............................... 70 carbidopa-levodopa-entacapone tabs 18.75-75-200 mg ............................. 70 carbidopa-levodopa-entacapone tabs 25-100-200 mg .................................... 70 carbidopa-levodopa-entacapone tabs 31.25-125-200 mg ........................... 71 carbidopa-levodopa-entacapone tabs 37.5-150-200 mg ............................. 71 carbidopa-levodopa-entacapone tabs 50-200-200 mg .................................... 71 carbinoxamine maleate soln 4 mg/5ml

.................................................... 120 carbinoxamine maleate tab 4 mg ...... 120 cardioplegic soln .............................. 55 CARDIOVID CAP PLUS ..................... 118 CARDURA TAB 1MG ......................... 40 CARDURA TAB 2MG ......................... 40 CARDURA TAB 4MG ......................... 40 CARDURA TAB 8MG ......................... 40 CARDURA XL TAB 4MG .................... 112 CARDURA XL TAB 8MG .................... 112 carisoprodol tab 250 mg ................... 85 carisoprodol tab 350 mg ................... 85 carisoprodol w/ aspirin & codeine tab 200-325-16 mg ............................... 85 carisoprodol w/ aspirin tab 200-325 mg ..................................................... 85 carteolol hcl ophth soln 1% .............. 141 cartia xt cap 120/24hr ...................... 51 cartia xt cap 180/24hr ...................... 51 cartia xt cap 240/24hr ...................... 51 cartia xt cap 300/24hr ...................... 51 carvedilol tab 12.5 mg ..................... 48 carvedilol tab 25 mg ........................ 48 carvedilol tab 3.125 mg .................... 48 carvedilol tab 6.25 mg ..................... 48 CASCARA EXT SAGRADA ................. 109 CASODEX TAB 50MG ........................ 28 CATAPRES TAB 0.1MG ...................... 40 CATAPRES TAB 0.2MG ...................... 40 CATAPRES TAB 0.3MG ...................... 40 CATAPRES-TTS DIS 0.1/24HR ........... 40 CATAPRES-TTS DIS 0.2/24HR ........... 40 CATAPRES-TTS DIS 0.3/24HR ........... 40 CAYSTON INH 75MG ....................... 123 caziant pak ..................................... 96 CEDAX CAP 400MG .......................... 14 CEDAX SUS 180/5ML ....................... 14 cefaclor cap 250 mg ......................... 14 cefaclor cap 500 mg ......................... 14 CEFACLOR ER TAB 500MG ................ 14 cefaclor for susp 125 mg/5ml ............ 14 cefaclor for susp 250 mg/5ml ............ 14 cefaclor for susp 375 mg/5ml ............ 14 cefadroxil cap 500 mg ...................... 13 cefadroxil for susp 250 mg/5ml ......... 13

164

cefadroxil for susp 500 mg/5ml .......... 14 cefadroxil tab 1 gm ........................... 14 cefdinir cap 300 mg .......................... 14 cefdinir for susp 125 mg/5ml ............. 14 cefdinir for susp 250 mg/5ml ............. 14 cefditoren pivoxil tab 200 mg (base equivalent) ...................................... 14 cefditoren pivoxil tab 400 mg (base equivalent) ...................................... 14 cefixime for susp 100 mg/5ml ............ 14 cefixime for susp 200 mg/5ml ............ 14 cefpodoxime proxetil for susp 100 mg/5ml ........................................... 14 cefpodoxime proxetil for susp 50 mg/5ml ..................................................... 14 cefpodoxime proxetil tab 100 mg ........ 14 cefpodoxime proxetil tab 200 mg ........ 14 cefprozil for susp 125 mg/5ml ............ 14 cefprozil for susp 250 mg/5ml ............ 14 cefprozil tab 250 mg ......................... 14 cefprozil tab 500 mg ......................... 14 ceftibuten cap 400 mg ...................... 14 ceftibuten for susp 180 mg/5ml .......... 14 CEFTIN SUS 125/5ML ....................... 14 CEFTIN SUS 250/5ML ....................... 14 cefuroxime axetil tab 250 mg ............. 14 cefuroxime axetil tab 500 mg ............. 14 celacyn gel .................................... 136 celecoxib cap 100 mg ........................ 5 celecoxib cap 200 mg ........................ 5 celecoxib cap 400 mg ........................ 5 celecoxib cap 50 mg .......................... 5 CELEXA TAB 10MG ........................... 66 CELEXA TAB 20MG ........................... 66 CELEXA TAB 40MG ........................... 66 CELLCEPT CAP 250MG ..................... 117 CELLCEPT SUS 200MG/ML ............... 117 CELLCEPT TAB 500MG ..................... 117 CELONTIN CAP 300MG ...................... 60 CENTANY AT KIT 2% ...................... 129 CENTANY OIN 2% .......................... 129 cephalexin cap 250 mg ..................... 14 cephalexin cap 500 mg ..................... 14 cephalexin cap 750 mg ..................... 14 cephalexin for susp 125 mg/5ml ......... 14

cephalexin for susp 250 mg/5ml ........ 14 cephalexin tab 250 mg ..................... 14 cephalexin tab 500 mg ..................... 14 ceramax cre ................................... 136 CERVIDIL VAG MIS 10MG INS .......... 101 CESAMET CAP 1MG ......................... 106 cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)........................................ 120 CETRAXAL SOL 0.2% ...................... 143 cevimeline hcl cap 30 mg ................. 111 CHANTIX PAK 0.5& 1MG ................... 86 CHANTIX PAK 1MG .......................... 86 CHANTIX TAB 0.5MG ........................ 87 CHANTIX TAB 1MG .......................... 87 chateal tab 0.15/30 ......................... 94 CHEMET CAP 100MG ....................... 115 CHENODAL TAB 250MG ................... 107 chlordiazepoxide hcl cap 10 mg ......... 58 chlordiazepoxide hcl cap 25 mg ......... 58 chlordiazepoxide hcl cap 5 mg ........... 58 chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg ................................. 107 chlordiazepoxide-amitriptyline tab 10-25 mg ................................................ 65 chlordiazepoxide-amitriptyline tab 5-12.5 mg ................................................ 65 chlorhexidine gluconate soln 0.12% .. 138 chloroquine phosphate tab 250 mg .... 20 chloroquine phosphate tab 500 mg .... 20 chlorothiazide tab 250 mg ................ 54 chlorothiazide tab 500 mg ................ 54 chlorpromazine hcl tab 10 mg ........... 76 chlorpromazine hcl tab 100 mg .......... 76 chlorpromazine hcl tab 200 mg .......... 76 chlorpromazine hcl tab 25 mg ........... 76 chlorpromazine hcl tab 50 mg ........... 76 chlorpropamide tab 100 mg .............. 90 chlorpropamide tab 250 mg .............. 90 chlorthalidone tab 25 mg .................. 54 chlorthalidone tab 50 mg .................. 54 chlorzoxazone tab 500 mg ................ 85 CHOLBAM CAP 250MG ..................... 110 CHOLBAM CAP 50MG ....................... 110 choline & magnesium salicylates liq 500 mg/5ml ............................................ 5

165

choline fenofibrate cap dr 135 mg (fenofibric acid equiv) ....................... 45 choline fenofibrate cap dr 45 mg (fenofibric acid equiv) ....................... 45 CIALIS TAB 5MG ............................ 112 ciclodan cre 0.77% ......................... 130 ciclodan sol 8% .............................. 130 CICLODAN SOL KIT 8% ................... 130 ciclopirox gel 0.77% ....................... 130 ciclopirox kit 8% ............................ 130 ciclopirox olamine cream 0.77% (base equiv) ........................................... 130 ciclopirox olamine susp 0.77% (base equiv) ........................................... 130 ciclopirox shampoo 1% ................... 130 ciclopirox solution 8% ..................... 130 cilostazol tab 100 mg ...................... 116 cilostazol tab 50 mg ........................ 115 CILOXAN OIN 0.3% OP ................... 139 CILOXAN SOL 0.3% OP ................... 139 cimetidine hcl soln 300 mg/5ml ........ 108 cimetidine tab 200 mg .................... 108 cimetidine tab 300 mg .................... 108 cimetidine tab 400 mg .................... 108 cimetidine tab 800 mg .................... 108 CIPRO (10%) SUS 500MG/5 .............. 16 CIPRO (5%) SUS 250MG/5 ................ 16 CIPRO HC SUS OTIC ....................... 143 CIPRO TAB 250MG ........................... 16 CIPRO TAB 500MG ........................... 16 CIPRO XR TAB 1000MG ..................... 16 CIPRO XR TAB 500MG ....................... 16 CIPRODEX SUS 0.3-0.1% ................ 143 ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) .......................... 16 ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) ...................... 16 ciprofloxacin hcl ophth soln 0.3% ..... 139 ciprofloxacin hcl otic soln 0.2% (base equivalent) .................................... 143 ciprofloxacin hcl tab 100 mg (base equiv) ..................................................... 16 ciprofloxacin hcl tab 250 mg (base equiv) ..................................................... 16 ciprofloxacin hcl tab 500 mg (base equiv)

..................................................... 16 ciprofloxacin hcl tab 750 mg (base equiv) ..................................................... 16 ciprofloxacin-ciprofloxacin hcl tab er 24hr 1000 mg(base eq) ........................... 16 ciprofloxacin-ciprofloxacin hcl tab er 24hr 500 mg (base eq) ............................ 16 citalopram hydrobromide oral soln 10 mg/5ml .......................................... 66 citalopram hydrobromide tab 10 mg (base equiv) ................................... 66 citalopram hydrobromide tab 20 mg (base equiv) ................................... 66 citalopram hydrobromide tab 40 mg (base equiv) ................................... 66 claravis cap 10mg ........................... 127 claravis cap 20mg ........................... 127 claravis cap 30mg ........................... 127 claravis cap 40mg ........................... 127 CLARINEX SYP 0.5MG/ML ................ 120 CLARINEX TAB 5MG ........................ 120 CLARINEX-D TAB 2.5-120 ................ 120 clarithromycin for susp 125 mg/5ml ... 15 clarithromycin for susp 250 mg/5ml ... 15 clarithromycin tab 250 mg ................ 15 clarithromycin tab 500 mg ................ 15 clarithromycin tab er 24hr 500 mg ..... 15 clemastine fumarate tab 2.68 mg ..... 120 CLEOCIN CAP 150MG ....................... 25 CLEOCIN CAP 300MG ....................... 25 CLEOCIN CAP 75MG ......................... 25 CLEOCIN CRE 2% VAG .................... 114 CLEOCIN PED SOL 75MG/5ML ........... 25 CLEOCIN SUP 100MG ...................... 114 CLEOCIN-T GEL 1% ........................ 128 CLEOCIN-T LOT 1% ........................ 128 CLEOCIN-T PAD 1% ........................ 128 CLEOCIN-T SOL 1% ........................ 128 CLIMARA DIS 0.025MG ..................... 98 CLIMARA DIS 0.0375MG ................... 98 CLIMARA DIS 0.05MG ...................... 98 CLIMARA DIS 0.06MG ...................... 98 CLIMARA DIS 0.075MG ..................... 98 CLIMARA DIS 0.1MG ........................ 98 CLIMARA PRO DIS WEEKLY ............... 98

166

CLINDACIN KIT ETZ 1% .................. 128 CLINDACIN KIT PAC 1% .................. 128 clindacin mis etz 1% ....................... 128 clindacin-p pad 1% ......................... 128 CLINDAGEL GEL 1% ....................... 128 clindamycin hcl cap 150 mg ............... 25 clindamycin hcl cap 300 mg ............... 25 clindamycin hcl cap 75 mg ................. 25 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) ........................ 25 clindamycin phosphate foam 1% ...... 128 clindamycin phosphate gel 1% ......... 128 clindamycin phosphate lotion 1% ...... 128 clindamycin phosphate soln 1% ........ 128 clindamycin phosphate swab 1% ...... 128 clindamycin phosphate vaginal cream 2% ................................................... 114 clindamycin phosphate-benzoyl peroxide gel 1-5% ....................................... 128 clindamycin phosphate-tretinoin gel 1.2-0.025% ........................................ 128 clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% .................... 128 CLINDESSE CRE 2% ....................... 114 clobetasol e cre 0.05% .................... 135 clobetasol propionate cream 0.05% .. 135 clobetasol propionate emulsion foam 0.05% .......................................... 135 clobetasol propionate foam 0.05% .... 135 clobetasol propionate gel 0.05% ....... 135 clobetasol propionate lotion 0.05% ... 135 clobetasol propionate oint 0.05% ..... 135 clobetasol propionate shampoo 0.05% ................................................... 135 clobetasol propionate soln 0.05% ..... 135 CLOBEX LOT 0.05% ........................ 135 CLOBEX SHA 0.05% ....................... 135 clocortolone pivalate cream 0.1% ..... 133 clodan sha 0.05% .......................... 135 CLODERM CRE 0.1% ....................... 133 CLODERM CRE 0.1% PMP ................ 133 clomiphene citrate tab 50 mg ............. 99 clomipramine hcl cap 25 mg .............. 59 clomipramine hcl cap 50 mg .............. 59 clomipramine hcl cap 75 mg .............. 59

clonazepam orally disintegrating tab 0.125 mg ....................................... 58 clonazepam orally disintegrating tab 0.25 mg ................................................ 58 clonazepam orally disintegrating tab 0.5 mg ................................................ 58 clonazepam orally disintegrating tab 1 mg ................................................ 58 clonazepam orally disintegrating tab 2 mg ................................................ 58 clonazepam tab 0.5 mg .................... 58 clonazepam tab 1 mg ....................... 58 clonazepam tab 2 mg ....................... 58 clonidine hcl tab 0.1 mg ................... 40 clonidine hcl tab 0.2 mg ................... 40 clonidine hcl tab 0.3 mg ................... 40 clonidine hcl tab er 12hr 0.1 mg ........ 78 clonidine hcl td patch weekly 0.1 mg/24hr ......................................... 40 clonidine hcl td patch weekly 0.2 mg/24hr ......................................... 40 clonidine hcl td patch weekly 0.3 mg/24hr ......................................... 40 clopidogrel bisulfate tab 300 mg (base equiv) ........................................... 116 clopidogrel bisulfate tab 75 mg (base equiv) ........................................... 116 clorazepate dipotassium tab 15 mg .... 58 clorazepate dipotassium tab 3.75 mg . 58 clorazepate dipotassium tab 7.5 mg ... 58 clorpres tab 0.1-15mg ...................... 55 clorpres tab 0.2-15mg ...................... 55 clorpres tab 0.3-15mg ...................... 55 clotrimazole cream 1% .................... 130 clotrimazole soln 1% ....................... 130 clotrimazole troche 10 mg ................ 19 clotrimazole w/ betamethasone cream 1-0.05% .......................................... 130 clotrimazole w/ betamethasone lotion 1-0.05% .......................................... 130 clozapine orally disintegrating tab 100 mg ................................................ 73 clozapine orally disintegrating tab 12.5 mg ................................................ 73 clozapine orally disintegrating tab 150

167

mg ................................................. 73 clozapine orally disintegrating tab 200 mg ................................................. 73 clozapine orally disintegrating tab 25 mg ..................................................... 73 clozapine tab 100 mg ........................ 73 clozapine tab 200 mg ........................ 73 clozapine tab 25 mg ......................... 73 clozapine tab 50 mg ......................... 73 CLOZARIL TAB 100MG ...................... 73 CLOZARIL TAB 25MG ........................ 73 COARTEM TAB 20-120MG .................. 20 codeine sulfate tab 15 mg .................. 8 codeine sulfate tab 30 mg .................. 8 codeine sulfate tab 60 mg .................. 8 colchicine cap 0.6 mg ........................ 5 colchicine tab 0.6 mg ......................... 5 colchicine w/ probenecid tab 0.5-500 mg ...................................................... 5 COLCRYS TAB 0.6MG ......................... 5 COLESTID FLA GRA 5/7.5GM ............. 45 COLESTID FLA GRA 5GM ................... 45 COLESTID GRA 5GM ......................... 45 COLESTID POW 5GM......................... 45 COLESTID TAB 1GM .......................... 45 colestipol hcl granule packets 5 gm ..... 45 colestipol hcl granules 5 gm ............... 45 colestipol hcl tab 1 gm ...................... 45 colocort ene 100mg ........................ 108 COLY-MYCIN S SUS OTIC ................ 143 COLYTE/FLAVR SOL PACKS .............. 109 COMBIGAN SOL 0.2/0.5% ............... 143 COMBIVENT AER 20-100 ................. 120 COMBIVIR TAB 150-300 .................... 20 COMETRIQ KIT 100MG ...................... 31 COMETRIQ KIT 140MG ...................... 31 COMETRIQ KIT 60MG ........................ 31 COMPACT SPAC MIS CHAMBER ......... 124 COMPACT SPAC MIS LG MASK .......... 124 COMPACT SPAC MIS MD MASK ......... 124 COMPACT SPAC MIS SM MASK ......... 124 COMPLERA TAB ................................ 20 compro sup 25mg .......................... 106 COMTAN TAB 200MG ........................ 71 CONCERTA TAB 18MG ....................... 78

CONCERTA TAB 27MG ...................... 78 CONCERTA TAB 36MG ...................... 78 CONCERTA TAB 54MG ...................... 78 CONDYLOX GEL 0.5% ..................... 136 CONDYLOX SOL 0.5% ..................... 136 constulose sol 10gm/15 ................... 109 CONZIP CAP 100MG ........................... 8 CONZIP CAP 200MG ........................... 8 CONZIP CAP 300MG ........................... 8 COPEGUS TAB 200MG ...................... 24 CORDRAN CRE 0.05% ..................... 133 CORDRAN LOT 0.05% ..................... 133 CORDRAN OIN 0.05% ..................... 133 COREG TAB 12.5MG ......................... 48 COREG TAB 25MG ........................... 48 COREG TAB 3.125MG ....................... 48 COREG TAB 6.25MG ......................... 48 CORGARD TAB 20MG ....................... 48 CORGARD TAB 40MG ....................... 48 CORGARD TAB 80MG ....................... 48 CORLANOR TAB 5MG........................ 55 CORLANOR TAB 7.5MG ..................... 55 cormax scalp sol 0.05% .................. 135 CORTANE-B DRO OTIC .................... 143 CORTANE-B LOT ............................. 132 CORTEF TAB 10MG .......................... 99 CORTEF TAB 20MG .......................... 99 CORTEF TAB 5MG ............................ 99 CORTENEMA ENE 100MG ................. 108 cortic-nd dro .................................. 143 CORTIFOAM AER 90MG ................... 108 cortisone acetate tab 25 mg .............. 99 CORTISPORIN CRE 0.5% ................. 129 CORTISPORIN OIN 1% .................... 129 CORZIDE TAB 40-5MG ..................... 47 CORZIDE TAB 80-5MG ..................... 47 COSOPT SOL 22.3-6.8 ..................... 141 COTELLIC TAB 20MG ........................ 31 COUMADIN TAB 10MG ..................... 115 COUMADIN TAB 1MG ...................... 115 COUMADIN TAB 2.5MG .................... 115 COUMADIN TAB 2MG ...................... 115 COUMADIN TAB 3MG ...................... 115 COUMADIN TAB 4MG ...................... 115 COUMADIN TAB 5MG ...................... 115

168

COUMADIN TAB 6MG ...................... 115 COUMADIN TAB 7.5MG ................... 115 COZAAR TAB 100MG ......................... 43 COZAAR TAB 25MG .......................... 43 COZAAR TAB 50MG .......................... 43 CREON CAP 12000UNT .................... 110 CREON CAP 24000UNT .................... 110 CREON CAP 3000UNIT .................... 110 CREON CAP 36000UNT .................... 110 CREON CAP 6000UNIT .................... 110 CRESEMBA CAP 186 MG .................... 19 CRIXIVAN CAP 200MG ...................... 22 CRIXIVAN CAP 400MG ...................... 22 cromolyn sodium ophth soln 4% ....... 140 cromolyn sodium oral conc 100 mg/5ml ................................................... 110 cromolyn sodium soln nebu 20 mg/2ml ................................................... 123 cryselle-28 tab 28 tabs ..................... 94 curity salin sol 0.9% irr ................... 112 CUTIVATE CRE 0.05% ..................... 133 CUTIVATE LOT 0.05% ..................... 133 CUVPOSA SOL 1MG/5ML ................. 107 cyclafem tab 1/35 ............................ 95 cyclafem tab 7/7/7 ........................... 96 CYCLESSA PAK................................. 96 cyclobenzaprine hcl tab 10 mg ........... 85 cyclobenzaprine hcl tab 5 mg ............. 85 cyclobenzaprine hcl tab 7.5 mg .......... 85 CYCLOGYL SOL 0.5% OP ................. 142 CYCLOGYL SOL 1% OP .................... 142 CYCLOGYL SOL 2% OP .................... 142 CYCLOMYDRIL SOL OP .................... 142 cyclopentolate hcl ophth soln 0.5% ... 142 cyclopentolate hcl ophth soln 1% ...... 142 cyclopentolate hcl ophth soln 2% ...... 142 CYCLOPHOSPH CAP 25MG ................. 26 CYCLOPHOSPH CAP 50MG ................. 26 cycloserine cap 250 mg ..................... 23 CYCLOSET TAB 0.8MG ....................... 90 cyclosporine cap 100 mg ................. 117 cyclosporine cap 25 mg ................... 117 cyclosporine modified cap 100 mg .... 117 cyclosporine modified cap 25 mg ...... 117 cyclosporine modified cap 50 mg ...... 117

cyclosporine modified oral soln 100 mg/ml .......................................... 117 cyotic dro ...................................... 143 cyproheptadine hcl syrup 2 mg/5ml .. 120 cyproheptadine hcl tab 4 mg ............ 121 cyred tab ........................................ 94 CYSTAGON CAP 150MG ................... 101 CYSTAGON CAP 50MG ..................... 101 CYSTARAN SOL 0.44% .................... 142 CYTOMEL TAB 25MCG ..................... 103 CYTOMEL TAB 50MCG ..................... 103 CYTOMEL TAB 5MCG ....................... 103 CYTOTEC TAB 100MCG .................... 111 CYTOTEC TAB 200MCG .................... 111 cytra-2 sol ..................................... 113 cytra-k sol ..................................... 113 D DALIRESP TAB 500MCG ................... 126 danazol cap 100 mg ......................... 97 danazol cap 200 mg ......................... 97 danazol cap 50 mg .......................... 97 DANTRIUM CAP 25MG ...................... 85 DANTRIUM CAP 50MG ...................... 85 dantrolene sodium cap 100 mg .......... 85 dantrolene sodium cap 25 mg ........... 85 dantrolene sodium cap 50 mg ........... 85 dapsone gel 5% ............................. 128 dapsone tab 100 mg ........................ 25 dapsone tab 25 mg .......................... 25 DARAPRIM TAB 25MG ...................... 20 darifenacin hydrobromide tab er 24hr 15 mg (base equiv) ............................. 114 darifenacin hydrobromide tab er 24hr 7.5 mg (base equiv) ............................. 114 dasetta tab 1/35 ............................. 95 dasetta tab 7/7/7 ............................ 96 DAYPRO TAB 600MG .......................... 5 daysee tab ..................................... 93 DAYTRANA DIS 10MG/9HR ................ 78 DAYTRANA DIS 15MG/9HR ................ 78 DAYTRANA DIS 20MG/9HR ................ 78 DAYTRANA DIS 30MG/9HR ................ 78 DDAVP SOL 0.01% ......................... 105 DDAVP SPR 0.01% ......................... 105 DDAVP TAB 0.1MG .......................... 105

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DDAVP TAB 0.2MG ......................... 105 deblitane tab 0.35mg ........................ 96 DECON-A ELX 2-5MG/5M ................. 120 DECON-G DRO 2-1-40MG ................ 120 deltasone tab 20mg .......................... 99 delyla tab 0.1-0.02 ........................... 93 DEMADEX TAB 10MG ........................ 54 DEMADEX TAB 20MG ........................ 54 DEMADEX TAB 5MG .......................... 54 demeclocycline hcl tab 150 mg ........... 18 demeclocycline hcl tab 300 mg ........... 18 DEMSER CAP 250MG ......................... 40 DENAVIR CRE 1% .......................... 136 DEPAKENE CAP 250MG ..................... 60 DEPAKENE SOL 250/5ML ................... 60 DEPAKOTE ER TAB 250MG ................. 60 DEPAKOTE ER TAB 500MG ................. 60 DEPAKOTE SPR CAP 125MG ............... 60 DEPAKOTE TAB 125MG DR ................ 60 DEPAKOTE TAB 250MG DR ................ 60 DEPAKOTE TAB 500MG DR ................ 60 dermacinrx kit prizopak ................... 136 DERMA-SMOOTH OIL /FS BODY ........ 133 DERMA-SMOOTH OIL /FS SCLP ........ 133 DERMASORB TA KIT 0.1% ............... 134 DERMATOP CRE 0.1% ..................... 134 DERMATOP OIN 0.1% ..................... 134 DERMOTIC OIL 0.01% .................... 143 DESCOVY TAB 200/25 ....................... 20 desipramine hcl tab 10 mg ................ 69 desipramine hcl tab 100 mg ............... 69 desipramine hcl tab 150 mg ............... 69 desipramine hcl tab 25 mg ................ 69 desipramine hcl tab 50 mg ................ 69 desipramine hcl tab 75 mg ................ 69 desloratadine tab 5 mg ................... 120 desloratadine tab orally disintegrating 2.5 mg ......................................... 120 desloratadine tab orally disintegrating 5 mg ............................................... 120 desmopressin acetate nasal soln 0.01% (refrigerated) ................................. 105 desmopressin acetate nasal spray soln 0.01% .......................................... 105 desmopressin acetate nasal spray soln

0.01% (refrigerated) ....................... 105 desmopressin acetate tab 0.1 mg ..... 105 desmopressin acetate tab 0.2 mg ..... 105 DESOGEN-28 TAB ............................ 94 desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) ................. 92 desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg ..................................... 94 DESONATE GEL 0.05% .................... 133 desonide cream 0.05% .................... 133 desonide lotion 0.05% ..................... 133 desonide oint 0.05% ....................... 133 DESOWEN CRE 0.05% ..................... 133 DESOWEN LOT 0.05% ..................... 133 desoximetasone cream 0.05% .......... 134 desoximetasone cream 0.25% .......... 132 desoximetasone gel 0.05% .............. 132 desoximetasone oint 0.05% ............. 134 desoximetasone oint 0.25% ............. 132 DESOXYN TAB 5MG.......................... 78 desvenlafaxine succinate tab er 24hr 100 mg (base equiv) .............................. 68 desvenlafaxine succinate tab er 24hr 25 mg (base equiv) .............................. 68 desvenlafaxine succinate tab er 24hr 50 mg (base equiv) .............................. 68 desvenlafaxine tab er 24hr 100 mg .... 68 desvenlafaxine tab er 24hr 50 mg ...... 68 DETROL TAB 1MG ........................... 114 DETROL TAB 2MG ........................... 114 DEXAMETHASON CON 1MG/ML .......... 99 dexamethasone elixir 0.5 mg/5ml ...... 99 dexamethasone sodium phosphate ophth soln 0.1% ...................................... 140 dexamethasone soln 0.5 mg/5ml ....... 99 dexamethasone tab 0.5 mg ............... 99 dexamethasone tab 0.75 mg ............. 99 dexamethasone tab 1 mg ................. 99 dexamethasone tab 1.5 mg ............... 99 dexamethasone tab 2 mg ................. 99 dexamethasone tab 4 mg ................. 99 dexamethasone tab 6 mg ................. 99 DEXEDRINE CAP 10MG CR ................ 78 DEXEDRINE CAP 15MG CR ................ 78 DEXEDRINE CAP 5MG CR .................. 78

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dexedrine tab 10mg ......................... 78 dexedrine tab 5mg ........................... 78 DEXILANT CAP 30MG DR ................. 111 DEXILANT CAP 60MG DR ................. 111 dexmethylphenidate hcl cap er 24 hr 10 mg ................................................. 78 dexmethylphenidate hcl cap er 24 hr 15 mg ................................................. 78 dexmethylphenidate hcl cap er 24 hr 20 mg ................................................. 79 dexmethylphenidate hcl cap er 24 hr 25 mg ................................................. 79 dexmethylphenidate hcl cap er 24 hr 30 mg ................................................. 79 dexmethylphenidate hcl cap er 24 hr 35 mg ................................................. 79 dexmethylphenidate hcl cap er 24 hr 40 mg ................................................. 79 dexmethylphenidate hcl cap er 24 hr 5 mg ................................................. 78 dexmethylphenidate hcl tab 10 mg ..... 79 dexmethylphenidate hcl tab 2.5 mg .... 79 dexmethylphenidate hcl tab 5 mg ....... 79 dextroamphetamine sulfate cap er 24hr 10 mg ............................................ 79 dextroamphetamine sulfate cap er 24hr 15 mg ............................................ 79 dextroamphetamine sulfate cap er 24hr 5 mg ................................................. 79 dextroamphetamine sulfate oral solution 5 mg/5ml ........................................ 79 dextroamphetamine sulfate tab 10 mg 79 dextroamphetamine sulfate tab 5 mg .. 79 DIAMOX SEQUE CAP 500MG CR .......... 54 DIASTAT ACDL GEL 12.5-20 .............. 60 DIASTAT ACDL GEL 5-10MG .............. 60 DIASTAT PED GEL 2.5M GEL .............. 60 diazepam con 5mg/ml ....................... 58 diazepam conc 5 mg/ml .................... 58 diazepam oral soln 1 mg/ml ............... 58 diazepam rectal gel delivery system 10 mg ................................................. 60 diazepam rectal gel delivery system 2.5 mg ................................................. 60 diazepam rectal gel delivery system 20

mg ................................................ 60 diazepam tab 10 mg ........................ 58 diazepam tab 2 mg .......................... 58 diazepam tab 5 mg .......................... 58 DIBENZYLINE CAP 10MG .................. 40 DICLEGIS TAB 10-10MG .................. 106 diclofenac potassium tab 50 mg ........... 5 diclofenac sodium (actinic keratoses) gel 3% ............................................... 129 diclofenac sodium gel 1% ................... 7 diclofenac sodium ophth soln 0.1% ... 140 diclofenac sodium soln 1.5% ............... 7 diclofenac sodium tab delayed release 25 mg .................................................. 5 diclofenac sodium tab delayed release 50 mg .................................................. 5 diclofenac sodium tab delayed release 75 mg .................................................. 5 diclofenac sodium tab er 24hr 100 mg .. 6 diclofenac w/ misoprostol tab delayed release 50-0.2 mg ............................. 7 diclofenac w/ misoprostol tab delayed release 75-0.2 mg ............................. 7 dicloxacillin sodium cap 250 mg ......... 17 dicloxacillin sodium cap 500 mg ......... 17 dicyclomine hcl cap 10 mg ............... 107 dicyclomine hcl oral soln 10 mg/5ml .. 107 dicyclomine hcl tab 20 mg ............... 107 didanosine delayed release capsule 125 mg ................................................ 21 didanosine delayed release capsule 200 mg ................................................ 21 didanosine delayed release capsule 250 mg ................................................ 21 didanosine delayed release capsule 400 mg ................................................ 21 DIFFERIN CRE 0.1% ....................... 128 DIFFERIN GEL 0.1% ........................ 128 DIFFERIN GEL 0.3% ........................ 128 DIFFERIN LOT 0.1% ........................ 128 DIFICID TAB 200MG ........................ 15 difil-g fort liq 100-100 ..................... 125 diflorasone diacetate cream 0.05% ... 132 diflorasone diacetate oint 0.05% ....... 135 DIFLUCAN SUS 10MG/ML .................. 19

171

DIFLUCAN SUS 40MG/ML .................. 19 DIFLUCAN TAB 100MG ...................... 19 DIFLUCAN TAB 150MG ...................... 19 DIFLUCAN TAB 200MG ...................... 19 DIFLUCAN TAB 50MG ........................ 19 diflunisal tab 500 mg ......................... 6 digitek tab 0.125mg ......................... 53 digitek tab 0.25mg ........................... 53 digox tab 0.125mg ........................... 53 digox tab 0.25mg ............................. 53 digoxin oral soln 0.05 mg/ml ............. 53 digoxin tab 125 mcg (0.125 mg) ........ 53 digoxin tab 250 mcg (0.25 mg) .......... 53 dihydroergotamine mesylate nasal spray 4 mg/ml .......................................... 82 DILATRATE SR CAP 40MG .................. 56 DILAUDID LIQ 1MG/ML ...................... 8 DILAUDID TAB 2MG ........................... 8 DILAUDID TAB 4MG ........................... 8 DILAUDID TAB 8MG ........................... 8 diltiazem cap 120mg cd .................... 52 diltiazem cap 180mg cd .................... 52 diltiazem cap 240mg cd .................... 52 diltiazem hcl cap er 12hr 120 mg ........ 52 diltiazem hcl cap er 12hr 60 mg ......... 52 diltiazem hcl cap er 12hr 90 mg ......... 52 diltiazem hcl cap er 24hr 120 mg ........ 52 diltiazem hcl cap er 24hr 180 mg ........ 52 diltiazem hcl cap er 24hr 240 mg ........ 52 diltiazem hcl coated beads cap er 24hr 120 mg ........................................... 52 diltiazem hcl coated beads cap er 24hr 180 mg ........................................... 52 diltiazem hcl coated beads cap er 24hr 240 mg ........................................... 52 diltiazem hcl coated beads cap er 24hr 300 mg ........................................... 52 diltiazem hcl coated beads cap er 24hr 360 mg ........................................... 52 diltiazem hcl extended release beads cap er 24hr 120 mg ................................ 52 diltiazem hcl extended release beads cap er 24hr 180 mg ................................ 52 diltiazem hcl extended release beads cap er 24hr 240 mg ................................ 52

diltiazem hcl extended release beads cap er 24hr 300 mg ............................... 52 diltiazem hcl extended release beads cap er 24hr 360 mg ............................... 52 diltiazem hcl extended release beads cap er 24hr 420 mg ............................... 52 diltiazem hcl tab 120 mg .................. 52 diltiazem hcl tab 30 mg .................... 52 diltiazem hcl tab 60 mg .................... 52 diltiazem hcl tab 90 mg .................... 52 dilt-xr cap 120mg ............................ 51 dilt-xr cap 180mg ............................ 51 dilt-xr cap 240mg ............................ 51 DIPENTUM CAP 250MG .................... 108 diphenhydramine hcl elixir 12.5 mg/5ml .................................................... 121 diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml ......................................... 105 diphenoxylate w/ atropine tab 2.5-0.025 mg ............................................... 105 DIPROLENE AF CRE 0.05% .............. 132 DIPROLENE LOT 0.05% ................... 132 DIPROLENE OIN 0.05% ................... 135 dipyridamole tab 25 mg ................... 116 dipyridamole tab 50 mg ................... 116 dipyridamole tab 75 mg ................... 116 disopyramide phosphate cap 100 mg .. 44 disopyramide phosphate cap 150 mg .. 44 disulfiram tab 250 mg ...................... 86 disulfiram tab 500 mg ...................... 86 DITROPAN XL TAB 10MG ................. 114 DITROPAN XL TAB 15MG ................. 114 DITROPAN XL TAB 5MG ................... 114 DIURIL SUS 250/5ML ....................... 55 divalproex sodium cap delayed release sprinkle 125 mg .............................. 60 divalproex sodium tab delayed release 125 mg .......................................... 60 divalproex sodium tab delayed release 250 mg .......................................... 60 divalproex sodium tab delayed release 500 mg .......................................... 60 divalproex sodium tab er 24 hr 250 mg ..................................................... 60 divalproex sodium tab er 24 hr 500 mg

172

..................................................... 60 DIVIGEL GEL 0.25MG ........................ 98 DIVIGEL GEL 0.5MG ......................... 98 DIVIGEL GEL 1MG/GM ...................... 98 dofetilide cap 125 mcg (0.125 mg) ..... 44 dofetilide cap 250 mcg (0.25 mg) ....... 44 dofetilide cap 500 mcg (0.5 mg) ......... 44 DOLOPHINE TAB 10MG ...................... 8 DOLOPHINE TAB 5MG ........................ 8 donepezil hydrochloride orally disintegrating tab 10 mg ................... 64 donepezil hydrochloride orally disintegrating tab 5 mg ..................... 64 donepezil hydrochloride tab 10 mg ..... 64 donepezil hydrochloride tab 23 mg ..... 64 donepezil hydrochloride tab 5 mg ....... 64 DORAL TAB 15MG ............................ 81 DORYX TAB 200MG ........................... 18 dorzolamide hcl ophth soln 2% ......... 141 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml ....................... 141 DOVONEX CRE 0.005% ................... 131 doxazosin mesylate tab 1 mg ............. 40 doxazosin mesylate tab 2 mg ............. 40 doxazosin mesylate tab 4 mg ............. 40 doxazosin mesylate tab 8 mg ............. 40 doxepin hcl cap 10 mg ...................... 69 doxepin hcl cap 100 mg .................... 69 doxepin hcl cap 150 mg .................... 69 doxepin hcl cap 25 mg ...................... 69 doxepin hcl cap 50 mg ...................... 69 doxepin hcl cap 75 mg ...................... 69 doxepin hcl conc 10 mg/ml ................ 69 doxepin hcl cream 5% .................... 136 doxercalciferol cap 0.5 mcg ............. 101 doxercalciferol cap 1 mcg ................ 101 doxercalciferol cap 2.5 mcg ............. 101 doxycycline (rosacea) cap delayed release 40 mg ................................ 137 doxycycline hyclate cap 100 mg ......... 18 doxycycline hyclate cap 50 mg ........... 18 doxycycline hyclate tab 100 mg .......... 18 doxycycline hyclate tab 20 mg ........... 18 doxycycline hyclate tab delayed release 100 mg ........................................... 18

doxycycline hyclate tab delayed release 150 mg .......................................... 18 doxycycline hyclate tab delayed release 200 mg .......................................... 18 doxycycline hyclate tab delayed release 50 mg ............................................ 18 doxycycline hyclate tab delayed release 75 mg ............................................ 18 doxycycline monohydrate cap 100 mg 18 doxycycline monohydrate cap 150 mg 18 doxycycline monohydrate cap 50 mg .. 18 doxycycline monohydrate cap 75 mg .. 18 doxycycline monohydrate for susp 25 mg/5ml .......................................... 18 doxycycline monohydrate tab 100 mg 18 doxycycline monohydrate tab 150 mg 18 doxycycline monohydrate tab 50 mg .. 18 doxycycline monohydrate tab 75 mg .. 18 dronabinol cap 10 mg ..................... 106 dronabinol cap 2.5 mg .................... 106 dronabinol cap 5 mg ....................... 106 drospirenone-ethinyl estradiol tab 3-0.02 mg ................................................ 93 drospirenone-ethinyl estradiol tab 3-0.03 mg ................................................ 94 drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg ....................... 93 DROXIA CAP 200MG ........................ 35 DROXIA CAP 300MG ........................ 35 DROXIA CAP 400MG ........................ 35 DUAC GEL 1.2-5% .......................... 128 DUAVEE TAB 0.45-20 ....................... 98 DUETACT TAB 30-2MG ..................... 89 DUETACT TAB 30-4MG ..................... 89 DUEXIS TAB 800-26.6 ........................ 7 DULERA AER 100-5MCG .................. 126 DULERA AER 200-5MCG .................. 127 duloxetine hcl enteric coated pellets cap 20 mg (base eq) .............................. 68 duloxetine hcl enteric coated pellets cap 30 mg (base eq) .............................. 68 duloxetine hcl enteric coated pellets cap 40 mg (base eq) .............................. 68 duloxetine hcl enteric coated pellets cap 60 mg (base eq) .............................. 68

173

DUOPA SUS 4.63-20 ......................... 71 DURAGESIC DIS 100MCG/H ................ 8 DURAGESIC DIS 12MCG/HR................ 8 DURAGESIC DIS 25MCG/HR................ 8 DURAGESIC DIS 50MCG/HR................ 8 DURAGESIC DIS 75MCG/HR................ 8 duraxin cap ...................................... 5 dutasteride cap 0.5 mg ................... 112 dutasteride-tamsulosin hcl cap 0.5-0.4 mg ............................................... 112 DYANAVEL XR SUS 2.5MG/ML ............ 79 DYAZIDE CAP 37.5-25 ...................... 53 DYMISTA SPR 137-50 ..................... 126 E e.e.s. 400 tab 400mg ....................... 15 easygel gel 0.4% ........................... 138 easygel gel 0.4%chry ..................... 138 easygel gel 0.4%citr ....................... 138 easygel gel 0.4%mint ..................... 138 EC-NAPROSYN TAB 375MG ................. 6 EC-NAPROSYN TAB 500MG ................. 6 econazole nitrate cream 1% ............ 130 EDECRIN TAB 25MG ......................... 54 EDURANT TAB 25MG ......................... 21 EFFER-K TAB 10MEQ ....................... 118 EFFER-K TAB 20MEQ ....................... 118 EFFEXOR XR CAP 150MG ................... 68 EFFEXOR XR CAP 37.5MG .................. 68 EFFEXOR XR CAP 75MG ..................... 68 EFFIENT TAB 10MG......................... 116 EFFIENT TAB 5MG .......................... 116 EFUDEX CRE 5% ............................ 129 ELDEPRYL CAP 5MG .......................... 71 ELESTAT DRO 0.05% ...................... 140 ELESTRIN GEL 0.06% ....................... 98 eletriptan hydrobromide tab 20 mg (base equivalent) ...................................... 83 eletriptan hydrobromide tab 40 mg (base equivalent) ...................................... 83 ELIDEL CRE 1% ............................. 131 ELIMITE CRE 5% ............................ 137 elinest tab ....................................... 94 ELIPHOS TAB 667MG ...................... 102 ELIQUIS TAB 2.5MG ....................... 115 ELIQUIS TAB 5MG .......................... 115

ELIXOPHYLLIN ELX 80/15ML ............ 127 ELLA TAB 30MG ............................... 93 ELMIRON CAP 100MG ...................... 113 ELOCON CRE 0.1% ......................... 134 ELOCON LOT 0.1% ......................... 134 ELOCON OIN 0.1% ......................... 134 EMADINE SOL 0.05% OP ................. 140 EMCYT CAP 140MG .......................... 26 EMEND CAP 125MG ......................... 106 EMEND CAP 40MG .......................... 106 EMEND CAP 80MG .......................... 106 EMEND SUS 125MG ........................ 106 EMEND TRIPAC PAK 80 & 125 .......... 106 emoquette tab ................................ 94 EMSAM DIS 12MG/24H ..................... 66 EMSAM DIS 6MG/24HR..................... 66 EMSAM DIS 9MG/24HR..................... 66 EMTRIVA CAP 200MG ....................... 21 EMTRIVA SOL 10MG/ML.................... 21 EMVERM CHW 100MG ...................... 25 enalapril maleate & hydrochlorothiazide tab 10-25 mg .................................. 37 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg ................................. 37 enalapril maleate tab 10 mg .............. 38 enalapril maleate tab 2.5 mg ............. 38 enalapril maleate tab 20 mg .............. 38 enalapril maleate tab 5 mg ............... 38 endocet tab 10-325mg ....................... 8 endocet tab 2.5-325 .......................... 8 endocet tab 5-325mg ......................... 8 endocet tab 7.5-325 .......................... 8 ENDOMETRIN SUP 100MG ................ 103 enpresse-28 tab .............................. 96 enskyce tab .................................... 94 ENSTILAR AER ............................... 131 entacapone tab 200 mg .................... 71 entecavir tab 0.5 mg ........................ 23 entecavir tab 1 mg .......................... 23 ENTEREG CAP 12MG ....................... 110 ENTOCORT EC CAP 3MG DR ............. 108 ENTRESTO TAB 24-26MG .................. 55 ENTRESTO TAB 49-51MG .................. 55 ENTRESTO TAB 97-103MG ................ 55 enulose sol 10gm/15 ....................... 110

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EPANED SOL 1MG/ML ....................... 39 EPCLUSA TAB 400-100 ...................... 24 EPIDUO FORTE GEL 0.3-2.5% .......... 128 EPIDUO GEL 0.1-2.5% .................... 128 EPIFOAM AER 1% ........................... 133 epinastine hcl ophth soln 0.05% ....... 140 epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000) ....................... 119 epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000) ........................ 119 epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) ........................ 119 EPIPEN 2-PAK INJ 0.3MG ................. 119 EPIPEN-JR INJ 2-PAK ...................... 120 epitol tab 200mg .............................. 60 EPIVIR HBV SOL 5MG/ML .................. 23 EPIVIR HBV TAB 100MG .................... 23 EPIVIR SOL 10MG/ML ....................... 21 EPIVIR TAB 150MG ........................... 21 EPIVIR TAB 300MG ........................... 21 eplerenone tab 25 mg ....................... 40 eplerenone tab 50 mg ....................... 40 eprosartan mesylate tab 600 mg ........ 43 EPZICOM TAB 600-300 ..................... 20 EQUETRO CAP 100MG ....................... 84 EQUETRO CAP 200MG ....................... 84 EQUETRO CAP 300MG ....................... 84 ergocalciferol cap 50000 unit ........... 119 ergoloid mesylates tab 1 mg .............. 84 ERGOMAR SUB 2MG ......................... 82 ergotamine w/ caffeine tab 1-100 mg .. 82 ERIVEDGE CAP 150MG ...................... 35 errin tab 0.35mg .............................. 96 ERTACZO CRE 2% .......................... 130 ery pad 2% ................................... 128 ERYGEL GEL 2% ............................. 128 ery-tab tab 250mg ec ....................... 15 ery-tab tab 333mg ec ....................... 15 ery-tab tab 500mg ec ....................... 15 erythrocin tab 250mg ....................... 15 erythromycin ethylsuccinate for susp 200 mg/5ml ........................................... 15 erythromycin ethylsuccinate tab 400 mg ..................................................... 15 erythromycin gel 2% ...................... 128

erythromycin ophth oint 5 mg/gm ..... 139 erythromycin pads 2% .................... 128 erythromycin soln 2% ..................... 128 erythromycin tab 250 mg ................. 15 erythromycin tab 500 mg ................. 15 erythromycin w/ delayed release particles cap 250 mg ........................ 15 ESBRIET CAP 267MG ....................... 126 escitalopram oxalate soln 5 mg/5ml (base equiv) ................................... 66 escitalopram oxalate tab 10 mg (base equiv) ............................................ 66 escitalopram oxalate tab 20 mg (base equiv) ............................................ 67 escitalopram oxalate tab 5 mg (base equiv) ............................................ 66 ESGIC TAB ....................................... 5 ESOMEPRAZOLE CAP 49.3MG ........... 111 esomeprazole magnesium cap delayed release 20 mg (base eq) .................. 111 esomeprazole magnesium cap delayed release 40 mg (base eq) .................. 111 esomeprazole strontium cap delayed release 49.3 mg ............................. 111 estarylla tab 0.25-35 ....................... 95 estazolam tab 1 mg ......................... 82 estazolam tab 2 mg ......................... 82 ESTRACE TAB 0.5MG ........................ 98 ESTRACE TAB 1MG .......................... 98 ESTRACE TAB 2MG .......................... 98 ESTRACE VAG CRE 0.1MG/GM ........... 99 estradiol & norethindrone acetate tab 0.5-0.1 mg ..................................... 97 estradiol & norethindrone acetate tab 1-0.5 mg ........................................... 97 estradiol tab 0.5 mg ......................... 98 estradiol tab 1 mg ........................... 98 estradiol tab 2 mg ........................... 98 estradiol td patch twice weekly 0.025 mg/24hr ......................................... 98 estradiol td patch twice weekly 0.0375 mg/24hr ......................................... 98 estradiol td patch twice weekly 0.05 mg/24hr ......................................... 98 estradiol td patch twice weekly 0.075

175

mg/24hr ......................................... 98 estradiol td patch twice weekly 0.1 mg/24hr ......................................... 98 estradiol td patch weekly 0.025 mg/24hr ..................................................... 99 estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) ................. 99 estradiol td patch weekly 0.05 mg/24hr ..................................................... 99 estradiol td patch weekly 0.06 mg/24hr ..................................................... 99 estradiol td patch weekly 0.075 mg/24hr ..................................................... 99 estradiol td patch weekly 0.1 mg/24hr 98 estradiol vaginal tab 10 mcg .............. 99 ESTRING MIS 2MG ........................... 99 estropipate tab 0.75 mg .................... 98 estropipate tab 1.5 mg ...................... 98 estropipate tab 3 mg ........................ 98 ESTROSTEP FE TAB .......................... 96 eszopiclone tab 1 mg ........................ 82 eszopiclone tab 2 mg ........................ 82 eszopiclone tab 3 mg ........................ 82 ethacrynic acid tab 25 mg ................. 54 ethambutol hcl tab 100 mg ................ 23 ethambutol hcl tab 400 mg ................ 23 ethosuximide cap 250 mg .................. 60 ethosuximide soln 250 mg/5ml .......... 60 etidronate disodium tab 200 mg ......... 92 etidronate disodium tab 400 mg ......... 92 etodolac cap 200 mg ......................... 6 etodolac cap 300 mg ......................... 6 etodolac tab 400 mg .......................... 6 etodolac tab 500 mg .......................... 6 etodolac tab er 24hr 400 mg ............... 6 etodolac tab er 24hr 500 mg ............... 6 etodolac tab er 24hr 600 mg ............... 6 etoposide cap 50 mg......................... 35 EUCRISA OIN 2% ........................... 131 EURAX CRE 10% ............................ 137 EURAX LOT 10% ............................ 137 EVAMIST SPR 1.53MG ....................... 99 EVEKEO TAB 10MG ........................... 79 EVEKEO TAB 5MG ............................. 79 EVISTA TAB 60MG .......................... 103

EVOCLIN AER 1% ........................... 128 EVOTAZ TAB 300-150 ...................... 20 EVOXAC CAP 30MG ......................... 111 EXACTUSS LIQ ............................... 121 EXELDERM CRE 1% ........................ 130 EXELDERM SOL 1% ........................ 130 EXELON DIS 13.3/24 ....................... 64 EXELON DIS 4.6MG/24 ..................... 64 EXELON DIS 9.5MG/24 ..................... 64 exemestane tab 25 mg ..................... 29 EXJADE TAB 125MG ........................ 116 EXJADE TAB 250MG ........................ 116 EXJADE TAB 500MG ........................ 116 exotic-hc dro otic ............................ 143 EXTINA AER 2% ............................. 130 E-Z SPACER MIS ............................ 124 E-Z SPACER MIS BODY GRD ............. 124 ezetimibe tab 10 mg ........................ 45 ezetimibe-simvastatin tab 10-10 mg .. 46 ezetimibe-simvastatin tab 10-20 mg .. 46 ezetimibe-simvastatin tab 10-40 mg .. 46 ezetimibe-simvastatin tab 10-80 mg .. 46 F FACTIVE TAB 320MG ........................ 16 falmina tab ..................................... 93 famciclovir tab 125 mg ..................... 24 famciclovir tab 250 mg ..................... 24 famciclovir tab 500 mg ..................... 24 famotidine for susp 40 mg/5ml ......... 108 famotidine tab 20 mg ...................... 108 famotidine tab 40 mg ...................... 108 FAMVIR TAB 125MG ......................... 24 FAMVIR TAB 250MG ......................... 24 FAMVIR TAB 500MG ......................... 24 FARESTON TAB 60MG ...................... 28 FARXIGA TAB 10MG ......................... 90 FARXIGA TAB 5MG ........................... 90 FAZACLO TAB 100 ODT .................... 73 FAZACLO TAB 12.5 ODT ................... 73 FAZACLO TAB 150 ODT .................... 73 FAZACLO TAB 200 ODT .................... 73 FAZACLO TAB 25MG ODT .................. 73 felbamate susp 600 mg/5ml .............. 60 felbamate tab 400 mg ...................... 60 felbamate tab 600 mg ...................... 60

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FELBATOL SUS 600/5ML .................... 60 FELBATOL TAB 400MG ...................... 60 FELBATOL TAB 600MG ...................... 60 FELDENE CAP 10MG ........................... 6 FELDENE CAP 20MG ........................... 6 felodipine tab er 24hr 10 mg .............. 51 felodipine tab er 24hr 2.5 mg ............. 50 felodipine tab er 24hr 5 mg ............... 51 FEM PH GEL ................................... 113 FEMARA TAB 2.5MG .......................... 29 FEMCON FE CHW .............................. 95 FEMRING MIS 0.05/24H .................... 99 FEMRING MIS 0.1MG/24 .................... 99 fenofibrate cap 150 mg ..................... 45 fenofibrate cap 50 mg ....................... 45 fenofibrate micronized cap 130 mg ..... 45 fenofibrate micronized cap 134 mg ..... 45 fenofibrate micronized cap 200 mg ..... 45 fenofibrate micronized cap 43 mg ....... 45 fenofibrate micronized cap 67 mg ....... 45 fenofibrate tab 120 mg ..................... 45 fenofibrate tab 145 mg ..................... 45 fenofibrate tab 160 mg ..................... 45 fenofibrate tab 40 mg ....................... 45 fenofibrate tab 48 mg ....................... 45 fenofibrate tab 54 mg ....................... 45 fenofibric acid tab 105 mg ................. 45 fenofibric acid tab 35 mg ................... 45 FENOGLIDE TAB 120MG .................... 46 FENOGLIDE TAB 40MG ...................... 45 fenoprofen calcium cap 400 mg ........... 6 fenoprofen calcium tab 600 mg ........... 6 fentanyl citrate lozenge on a handle 1200 mcg ................................................ 9 fentanyl citrate lozenge on a handle 1600 mcg ................................................ 9 fentanyl citrate lozenge on a handle 200 mcg ................................................ 8 fentanyl citrate lozenge on a handle 400 mcg ................................................ 9 fentanyl citrate lozenge on a handle 600 mcg ................................................ 9 fentanyl citrate lozenge on a handle 800 mcg ................................................ 9 FENTANYL DIS 37.5MCG .................... 9

FENTANYL DIS 62.5MCG ..................... 9 FENTANYL DIS 87.5MCG ..................... 9 fentanyl td patch 72hr 100 mcg/hr ....... 9 fentanyl td patch 72hr 12 mcg/hr ........ 9 fentanyl td patch 72hr 25 mcg/hr ........ 9 fentanyl td patch 72hr 50 mcg/hr ........ 9 fentanyl td patch 72hr 75 mcg/hr ........ 9 FENTORA TAB 100MCG ....................... 9 FENTORA TAB 200MCG ....................... 9 FENTORA TAB 400MCG ....................... 9 FENTORA TAB 600MCG ....................... 9 FENTORA TAB 800MCG ....................... 9 FERRIPROX TAB 500MG ................... 116 FEXMID TAB 7.5MG ......................... 85 FIBRICOR TAB 105MG ...................... 46 FIBRICOR TAB 35MG ........................ 46 FINACEA AER 15% ......................... 137 FINACEA GEL 15% .......................... 137 finasteride tab 5 mg ........................ 112 FIORICET CAP CODEINE ..................... 9 FIORINAL CAP ................................... 5 FIORINAL/COD CAP 30MG .................. 9 FLAGYL CAP 375MG ......................... 25 FLAGYL TAB 250MG ......................... 25 FLAGYL TAB 500MG ......................... 25 FLAREX SUS 0.1% OP ..................... 140 flavoxate hcl tab 100 mg ................. 114 flecainide acetate tab 100 mg ........... 44 flecainide acetate tab 150 mg ........... 44 flecainide acetate tab 50 mg ............. 44 FLOMAX CAP 0.4MG ........................ 112 flucaine sol 0.25-0.5 ....................... 141 fluconazole for susp 10 mg/ml ........... 19 fluconazole for susp 40 mg/ml ........... 19 fluconazole tab 100 mg .................... 19 fluconazole tab 150 mg .................... 19 fluconazole tab 200 mg .................... 19 fluconazole tab 50 mg ...................... 19 flucytosine cap 250 mg .................... 19 flucytosine cap 500 mg .................... 19 fludrocortisone acetate tab 0.1 mg .... 101 FLUMADINE TAB 100MG ................... 25 flunisolide nasal soln 25 mcg/act (0.025%) ...................................... 126 fluocinolone acetonide (otic) oil 0.01%

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................................................... 143 fluocinolone acetonide cream 0.01% . 133 fluocinolone acetonide cream 0.025% 134 fluocinolone acetonide oil 0.01% (body oil) ............................................... 133 fluocinolone acetonide oil 0.01% (scalp oil) ............................................... 133 fluocinolone acetonide oint 0.025% ... 134 fluocinolone acetonide soln 0.01% .... 133 fluocinonide cream 0.05% ............... 132 fluocinonide cream 0.1% ................. 132 fluocinonide emulsified base cream 0.05% .......................................... 132 fluocinonide gel 0.05% .................... 132 fluocinonide oint 0.05% .................. 132 fluocinonide soln 0.05% .................. 132 FLUORABON DRO ........................... 119 FLUOR-A-DAY CHW 0.25MG F .......... 119 FLUOR-A-DAY CHW 1MG F ............... 119 fluor-a-day dro 0.125mg ................. 119 fluorescein w/ benoxinate ophth soln 0.25-0.4% .................................... 141 fluorescein w/ proparacaine ophth soln 0.25-0.5% .................................... 142 FLUORIDEX GEL SENSITIV ............... 138 fluor-i-stri tes 1mg op ..................... 141 fluoritab chw 0.25mg f .................... 119 fluoritab chw 0.5mg f ...................... 119 fluoritab chw 1mg f ........................ 119 fluoritab chw 2.2mg ........................ 119 fluoritab dro 0.125mg ..................... 119 fluorometholone ophth susp 0.1% .... 140 FLUOROPLEX CRE 1% ..................... 129 fluorouracil cream 5% ..................... 129 fluorouracil soln 2% ........................ 129 fluorouracil soln 5% ........................ 129 fluoxetine hcl (pmdd) cap 10 mg ........ 67 fluoxetine hcl (pmdd) cap 20 mg ........ 67 fluoxetine hcl (pmdd) tab 10 mg ........ 67 fluoxetine hcl (pmdd) tab 20 mg ........ 67 fluoxetine hcl cap 10 mg ................... 67 fluoxetine hcl cap 20 mg ................... 67 fluoxetine hcl cap 40 mg ................... 67 fluoxetine hcl cap delayed release 90 mg ..................................................... 67

fluoxetine hcl solution 20 mg/5ml ...... 67 fluoxetine hcl tab 10 mg ................... 67 fluoxetine hcl tab 20 mg ................... 67 fluphenazine hcl elixir 2.5 mg/5ml ..... 76 fluphenazine hcl oral conc 5 mg/ml .... 76 fluphenazine hcl tab 1 mg ................. 76 fluphenazine hcl tab 10 mg ............... 76 fluphenazine hcl tab 2.5 mg .............. 76 fluphenazine hcl tab 5 mg ................. 76 flura-drops dro 0.125mg .................. 119 flura-drops dro 0.25mg f ................. 119 flurandrenolide cream 0.05% ........... 134 flurandrenolide lotion 0.05% ............ 134 flurandrenolide oint 0.05% .............. 134 FLURA-SAFE SOL ............................ 142 flurazepam hcl cap 15 mg ................. 82 flurazepam hcl cap 30 mg ................. 82 flurbiprofen sodium ophth soln 0.03% .................................................... 140 flurbiprofen tab 100 mg ...................... 6 flurbiprofen tab 50 mg ....................... 6 flurox sol op .................................. 142 flutamide cap 125 mg ...................... 28 fluticasone propionate cream 0.05% . 134 fluticasone propionate lotion 0.05% .. 134 fluticasone propionate nasal susp 50 mcg/act ........................................ 126 fluticasone propionate oint 0.005% ... 134 fluvastatin sodium cap 20 mg ............ 46 fluvastatin sodium cap 40 mg ............ 46 fluvastatin sodium tab er 24 hr 80 mg 46 fluvoxamine maleate cap er 24hr 100 mg ..................................................... 59 fluvoxamine maleate cap er 24hr 150 mg ..................................................... 59 fluvoxamine maleate tab 100 mg ....... 59 fluvoxamine maleate tab 25 mg ......... 59 fluvoxamine maleate tab 50 mg ......... 59 FOCALIN TAB 10MG ......................... 79 FOCALIN TAB 2.5MG ........................ 79 FOCALIN TAB 5MG ........................... 79 FOCALIN XR CAP 10MG .................... 79 FOCALIN XR CAP 15MG .................... 79 FOCALIN XR CAP 20MG .................... 79 FOCALIN XR CAP 25MG .................... 79

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FOCALIN XR CAP 30MG ..................... 79 FOCALIN XR CAP 35MG ..................... 79 FOCALIN XR CAP 40MG ..................... 79 FOCALIN XR CAP 5MG ....................... 79 folic acid tab 1 mg .......................... 119 FORFIVO XL TAB 450MG.................... 65 FOSAMAX + D TAB 70-2800 .............. 92 FOSAMAX + D TAB 70-5600 .............. 92 FOSAMAX TAB 70MG ........................ 92 fosamprenavir calcium tab 700 mg (base equiv) ............................................. 22 fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg ................................ 37 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg ................................ 37 fosinopril sodium tab 10 mg ............... 39 fosinopril sodium tab 20 mg ............... 39 fosinopril sodium tab 40 mg ............... 39 FROVA TAB 2.5MG ............................ 83 frovatriptan succinate tab 2.5 mg (base equivalent) ...................................... 83 FUL-GLO TES 0.6MG OP .................. 142 ful-glo tes 1mg op .......................... 142 FURADANTIN SUS 25MG/5ML ............. 25 furosemide oral soln 10 mg/ml ........... 54 furosemide oral soln 8 mg/ml............. 54 furosemide tab 20 mg ....................... 54 furosemide tab 40 mg ....................... 54 furosemide tab 80 mg ....................... 54 fyavolv tab 0.5-2.5 ........................... 97 fyavolv tab 1-5 ................................ 97 FYCOMPA SUS 0.5MG/ML .................. 60 FYCOMPA TAB 10MG ......................... 60 FYCOMPA TAB 12MG ......................... 60 FYCOMPA TAB 2MG ........................... 60 FYCOMPA TAB 4MG ........................... 60 FYCOMPA TAB 6MG ........................... 60 FYCOMPA TAB 8MG ........................... 60 G gabapentin cap 100 mg ..................... 61 gabapentin cap 300 mg ..................... 61 gabapentin cap 400 mg ..................... 61 gabapentin oral soln 250 mg/5ml ....... 61 gabapentin tab 600 mg ..................... 61 gabapentin tab 800 mg ..................... 61

GABITRIL TAB 12MG ........................ 61 GABITRIL TAB 16MG ........................ 61 GABITRIL TAB 2MG .......................... 61 GABITRIL TAB 4MG .......................... 61 galantamine hydrobromide cap er 24hr 16 mg ............................................ 64 galantamine hydrobromide cap er 24hr 24 mg ............................................ 64 galantamine hydrobromide cap er 24hr 8 mg ................................................ 64 galantamine hydrobromide oral soln 4 mg/ml ........................................... 64 galantamine hydrobromide tab 12 mg 64 galantamine hydrobromide tab 4 mg .. 64 galantamine hydrobromide tab 8 mg .. 64 GASTROCROM CON 100/5ML ............ 110 gatifloxacin ophth soln 0.5% ............ 139 gavilyte-c sol ................................. 109 gavilyte-g sol ................................. 109 gavilyte-h kit ................................. 109 gavilyte-n sol flav pk ....................... 109 GELFILM MIS OP............................. 142 GEL-KAM CON 0.63% ...................... 138 gemfibrozil tab 600 mg .................... 46 GENERESS FE CHW .......................... 94 generlac sol 10gm/15 ..................... 110 gengraf cap 100mg ......................... 117 gengraf cap 25mg .......................... 117 gengraf cap 50mg .......................... 117 gengraf sol 100mg/ml ..................... 117 gentak oin 0.3% op ........................ 139 gentamicin sulfate cream 0.1% ........ 129 gentamicin sulfate oint 0.1% ............ 129 gentamicin sulfate ophth oint 0.3% ... 139 gentamicin sulfate ophth soln 0.3% .. 139 GENVOYA TAB ................................. 20 GEODON CAP 20MG ......................... 73 GEODON CAP 40MG ......................... 73 GEODON CAP 60MG ......................... 73 GEODON CAP 80MG ......................... 73 gianvi tab 3-0.02mg ........................ 93 GIAZO TAB 1.1GM .......................... 108 gildagia tab 0.4-35 .......................... 95 GILENYA CAP 0.5MG ........................ 84 GILOTRIF TAB 20MG ........................ 31

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GILOTRIF TAB 30MG ......................... 31 GILOTRIF TAB 40MG ......................... 31 GILPHEX TR TAB 10-388MG ............. 123 GILTUSS LIQ ................................. 121 giltuss ped liq ................................ 121 GILTUSS TR TAB ............................ 121 GLEEVEC TAB 100MG ........................ 31 GLEEVEC TAB 400MG ........................ 31 GLEOSTINE CAP 100MG .................... 26 GLEOSTINE CAP 10MG ...................... 26 GLEOSTINE CAP 40MG ...................... 26 GLEOSTINE CAP 5MG ........................ 26 glimepiride tab 1 mg ......................... 90 glimepiride tab 2 mg ......................... 90 glimepiride tab 4 mg ......................... 90 glipizide tab 10 mg ........................... 90 glipizide tab 5 mg ............................. 90 glipizide tab er 24hr 10 mg ................ 90 glipizide tab er 24hr 2.5 mg ............... 90 glipizide tab er 24hr 5 mg .................. 90 glipizide xl tab 10mg ......................... 90 glipizide xl tab 2.5mg ........................ 90 glipizide xl tab 5mg .......................... 90 glipizide-metformin hcl tab 2.5-250 mg ..................................................... 88 glipizide-metformin hcl tab 2.5-500 mg ..................................................... 88 glipizide-metformin hcl tab 5-500 mg .. 88 GLUCAGEN INJ HYPOKIT ................. 100 GLUCAGON KIT 1MG ....................... 100 GLUCOPHAGE TAB 1000MG ............... 88 GLUCOPHAGE TAB 500MG ................. 88 GLUCOPHAGE TAB 500MG XR ............ 88 GLUCOPHAGE TAB 750MG XR ............ 88 GLUCOPHAGE TAB 850MG ................. 88 GLUCOTROL TAB 10MG ..................... 90 GLUCOTROL TAB 5MG ....................... 90 GLUCOTROL XL TAB 10MG ................. 90 GLUCOTROL XL TAB 2.5MG ................ 90 GLUCOTROL XL TAB 5MG .................. 90 GLUCOVANCE TAB 2.5-500 ................ 88 GLUCOVANCE TAB 5-500MG .............. 88 GLUTARALDEHY SOL 25% ............... 131 glyburide micronized tab 1.5 mg ........ 91 glyburide micronized tab 3 mg ........... 91

glyburide micronized tab 6 mg .......... 91 glyburide tab 1.25 mg ...................... 91 glyburide tab 2.5 mg ........................ 91 glyburide tab 5 mg .......................... 91 glyburide-metformin tab 1.25-250 mg 88 glyburide-metformin tab 2.5-500 mg .. 88 glyburide-metformin tab 5-500 mg .... 88 glycine irrigation soln 1.5% .............. 112 glycopyrrolate tab 1 mg................... 107 glycopyrrolate tab 2 mg................... 107 glydo gel 2% ................................. 136 GLYNASE TAB 1.5MG ....................... 91 GLYNASE TAB 3MG .......................... 91 GLYNASE TAB 6MG .......................... 91 GLYSET TAB 100MG ......................... 87 GLYSET TAB 25MG ........................... 87 GLYSET TAB 50MG ........................... 87 GOLYTELY SOL ............................... 109 GOLYTELY SOL PINEAPPL ................. 109 GORDOFILM SOL ............................ 136 granisetron hcl tab 1 mg.................. 106 GRASTEK SUB 2800BAU .................. 116 griseofulvin microsize susp 125 mg/5ml ..................................................... 19 griseofulvin microsize tab 500 mg ...... 19 griseofulvin ultramicrosize tab 125 mg 19 griseofulvin ultramicrosize tab 250 mg 19 GRIS-PEG TAB 125MG ...................... 19 GRIS-PEG TAB 250MG ...................... 19 guanfacine hcl tab 1 mg ................... 40 guanfacine hcl tab 2 mg ................... 40 guanfacine hcl tab er 24hr 1 mg (base equiv) ............................................ 79 guanfacine hcl tab er 24hr 2 mg (base equiv) ............................................ 79 guanfacine hcl tab er 24hr 3 mg (base equiv) ............................................ 79 guanfacine hcl tab er 24hr 4 mg (base equiv) ............................................ 79 GUANIDINE TAB 125MG ................... 84 GYNAZOLE-1 CRE 2% ..................... 114 H HALAC KIT ..................................... 132 HALCION TAB 0.25MG ...................... 82 halobetasol propionate cream 0.05% 135

180

halobetasol propionate oint 0.05% .... 135 haloperidol lactate oral conc 2 mg/ml .. 76 haloperidol tab 0.5 mg ...................... 76 haloperidol tab 1 mg ......................... 76 haloperidol tab 10 mg ....................... 76 haloperidol tab 2 mg ......................... 76 haloperidol tab 20 mg ....................... 76 haloperidol tab 5 mg ......................... 76 HALOTIN CRE 1% ........................... 130 HARVONI TAB 90-400MG .................. 24 heather tab 0.35mg .......................... 96 HECTOROL CAP 0.5MCG .................. 101 HECTOROL CAP 1MCG ..................... 101 HECTOROL CAP 2.5MCG .................. 101 HEMANGEOL SOL 4.28/ML ................. 48 HEPSERA TAB 10MG ......................... 23 HETLIOZ CAP 20MG .......................... 82 HEXALEN CAP 50MG ......................... 27 HIPREX TAB 1GM ............................. 25 HORIZANT TAB 300MG...................... 86 HORIZANT TAB 600MG...................... 86 HUMAPEN MIS LUXURA ..................... 91 HUMULIN R INJ U-500 ...................... 89 hyaluronate sodium (emollient) gel 0.2% ................................................... 135 HYCAMTIN CAP 0.25MG ..................... 36 HYCAMTIN CAP 1MG ......................... 36 HYCET SOL 7.5-325 ........................... 9 hydralazine hcl tab 10 mg ................. 55 hydralazine hcl tab 100 mg ................ 55 hydralazine hcl tab 25 mg ................. 55 hydralazine hcl tab 50 mg ................. 55 HYDREA CAP 500MG ......................... 35 hydrochlorothiazide cap 12.5 mg ........ 55 hydrochlorothiazide tab 12.5 mg ........ 55 hydrochlorothiazide tab 25 mg ........... 55 hydrochlorothiazide tab 50 mg ........... 55 hydrocod polst-chlorphen polst er susp 10-8 mg/5ml ................................. 121 hydrocodone w/ homatropine syrup 5-1.5 mg/5ml ................................... 121 hydrocodone w/ homatropine tab 5-1.5 mg ............................................... 121 hydrocodone-acetaminophen soln 10-325 mg/15ml .......................................... 9

hydrocodone-acetaminophen soln 7.5-325 mg/15ml .................................... 9 hydrocodone-acetaminophen tab 10-300 mg .................................................. 9 hydrocodone-acetaminophen tab 10-325 mg .................................................. 9 hydrocodone-acetaminophen tab 2.5-325 mg .................................................. 9 hydrocodone-acetaminophen tab 5-300 mg .................................................. 9 hydrocodone-acetaminophen tab 5-325 mg .................................................. 9 hydrocodone-acetaminophen tab 7.5-300 mg .................................................. 9 hydrocodone-acetaminophen tab 7.5-325 mg .................................................. 9 hydrocodone-ibuprofen tab 10-200 mg . 9 hydrocodone-ibuprofen tab 5-200 mg ... 9 hydrocodone-ibuprofen tab 7.5-200 mg 9 hydrocortisone acetate w/ pramoxine rectal cream 1-1% .......................... 111 hydrocortisone butyrate cream 0.1% . 134 hydrocortisone butyrate hydrophilic lipo base cream 0.1% ........................... 134 hydrocortisone butyrate oint 0.1% .... 134 hydrocortisone butyrate soln 0.1% .... 134 hydrocortisone cream 1% ................ 133 hydrocortisone cream 2.5% ............. 133 hydrocortisone enema 100 mg/60ml . 108 hydrocortisone lotion 2.5% .............. 133 hydrocortisone oint 1% ................... 133 hydrocortisone oint 2.5% ................ 133 hydrocortisone rectal cream 1% ....... 111 hydrocortisone rectal cream 2.5% ..... 112 hydrocortisone tab 10 mg ................. 99 hydrocortisone tab 20 mg ................. 99 hydrocortisone tab 5 mg ................... 99 hydrocortisone valerate cream 0.2% . 134 hydrocortisone valerate oint 0.2% .... 134 hydrocortisone w/ acetic acid otic soln 1-2% ............................................... 143 hydromet syp 5-1.5/5 ..................... 121 HYDROMORPHON SUP 3MG ................. 9 hydromorphone hcl liqd 1 mg/ml ......... 9 hydromorphone hcl tab 2 mg .............. 9

181

hydromorphone hcl tab 4 mg ............. 10 hydromorphone hcl tab 8 mg ............. 10 hydromorphone hcl tab er 24hr deter 12 mg ................................................. 10 hydromorphone hcl tab er 24hr deter 16 mg ................................................. 10 hydromorphone hcl tab er 24hr deter 32 mg ................................................. 10 hydromorphone hcl tab er 24hr deter 8 mg ................................................. 10 hydroxychloroquine sulfate tab 200 mg ................................................... 116 hydroxyurea cap 500 mg ................... 35 hydroxyzine hcl syrup 10 mg/5ml ..... 121 hydroxyzine hcl tab 10 mg ............... 121 hydroxyzine hcl tab 25 mg ............... 121 hydroxyzine hcl tab 50 mg ............... 121 hydroxyzine pamoate cap 100 mg .... 121 hydroxyzine pamoate cap 25 mg ...... 121 hydroxyzine pamoate cap 50 mg ...... 121 HYLATOPIC LOT PLUS ..................... 136 HYLIRA GEL 0.2% .......................... 135 HYLIRA LOT 0.1% .......................... 135 HYPERSAL NEB 3.5% ...................... 125 HYSINGLA ER TAB 100 MG ................ 10 HYSINGLA ER TAB 120 MG ................ 10 HYSINGLA ER TAB 20 MG .................. 10 HYSINGLA ER TAB 30 MG .................. 10 HYSINGLA ER TAB 40 MG .................. 10 HYSINGLA ER TAB 60 MG .................. 10 HYSINGLA ER TAB 80 MG .................. 10 HYZAAR TAB 100-12.5 ...................... 42 HYZAAR TAB 100-25 ......................... 42 HYZAAR TAB 50-12.5 ........................ 42 I ibandronate sodium tab 150 mg (base equivalent) ...................................... 92 IBRANCE CAP 100MG ........................ 31 IBRANCE CAP 125MG ........................ 31 IBRANCE CAP 75MG.......................... 31 ibudone tab 10-200mg ...................... 10 ibudone tab 5-200mg ....................... 10 ibuprofen susp 100 mg/5ml ................ 6 ibuprofen tab 400 mg ........................ 6 ibuprofen tab 600 mg ........................ 6

ibuprofen tab 800 mg ......................... 6 ICLUSIG TAB 15MG ......................... 31 ICLUSIG TAB 45MG ......................... 31 ilotycin oin op ................................ 139 imatinib mesylate tab 100 mg (base equivalent) ..................................... 32 imatinib mesylate tab 400 mg (base equivalent) ..................................... 32 IMBRUVICA CAP 140MG ................... 32 imipramine hcl tab 10 mg ................. 69 imipramine hcl tab 25 mg ................. 69 imipramine hcl tab 50 mg ................. 69 imipramine pamoate cap 100 mg ....... 69 imipramine pamoate cap 125 mg ....... 69 imipramine pamoate cap 150 mg ....... 69 imipramine pamoate cap 75 mg ......... 69 imiquimod cream 5% ...................... 136 IMITREX INJ 4MG/0.5 ...................... 83 IMITREX INJ 6MG/0.5 ...................... 83 IMITREX SPR 20MG/ACT ................... 83 IMITREX SPR 5MG/ACT .................... 83 IMITREX TAB 100MG ........................ 83 IMITREX TAB 25MG ......................... 83 IMITREX TAB 50MG ......................... 83 IMPAVIDO CAP 50MG ....................... 25 IMURAN TAB 50MG ......................... 117 indapamide tab 1.25 mg ................... 55 indapamide tab 2.5 mg .................... 55 INDERAL LA CAP 120MG ................... 48 INDERAL LA CAP 160MG ................... 48 INDERAL LA CAP 60MG ..................... 48 INDERAL LA CAP 80MG ..................... 48 INDERAL XL CAP 120MG ................... 49 INDERAL XL CAP 80MG ..................... 49 INDOCIN SUP 50MG ........................... 6 indomethacin cap 25 mg .................... 6 indomethacin cap 50 mg .................... 6 indomethacin cap er 75 mg ................. 6 INLYTA TAB 1MG ............................. 32 INLYTA TAB 5MG ............................. 32 INSPIRACHAMB MIS LARGE ............. 124 INSPRA TAB 25MG ........................... 40 INSPRA TAB 50MG ........................... 40 INSULIN SYRG MIS 0.3/29G .............. 91 INSULIN SYRG MIS 0.3/30G .............. 91

182

INSULIN SYRG MIS 0.3/31G .............. 91 INSULIN SYRG MIS 0.5/28G .............. 91 INSULIN SYRG MIS 0.5/29G .............. 91 INSULIN SYRG MIS 0.5/30G .............. 91 INSULIN SYRG MIS 0.5/31G .............. 91 INSULIN SYRG MIS 1ML/28G ............. 91 INSULIN SYRG MIS 1ML/29G ............. 91 INSULIN SYRG MIS 1ML/30G ............. 91 INSULIN SYRG MIS 1ML/31G ............. 91 INTELENCE TAB 100MG ..................... 21 INTELENCE TAB 200MG ..................... 21 INTELENCE TAB 25MG ...................... 21 introvale tab .................................... 93 INVEGA TAB 1.5MG .......................... 73 INVEGA TAB 3MG ............................. 73 INVEGA TAB 6MG ............................. 73 INVEGA TAB 9MG ............................. 73 INVIRASE CAP 200MG ....................... 22 INVIRASE TAB 500MG ....................... 22 IODINE TIN 2% ............................. 131 IODOFLEX PAD PAD ........................ 131 IOPIDINE SOL 0.5% OP .................. 143 IOPIDINE SOL 1% OP ..................... 143 ipratropium bromide inhal soln 0.02% ................................................... 120 ipratropium bromide nasal soln 0.03% (21 mcg/spray) .............................. 125 ipratropium bromide nasal soln 0.06% (42 mcg/spray) .............................. 125 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml ............................... 120 irbesartan tab 150 mg ...................... 43 irbesartan tab 300 mg ...................... 43 irbesartan tab 75 mg ........................ 43 irbesartan-hydrochlorothiazide tab 150-12.5 mg .......................................... 42 irbesartan-hydrochlorothiazide tab 300-12.5 mg .......................................... 42 IRESSA TAB 250MG .......................... 32 ISENTRESS CHW 100MG ................... 21 ISENTRESS CHW 25MG ..................... 21 ISENTRESS HD TAB 600MG ............... 21 ISENTRESS TAB 400MG .................... 21 isoniazid syrup 50 mg/5ml ................. 23 isoniazid tab 100 mg......................... 23

isoniazid tab 300 mg ........................ 23 ISOPTO CARP SOL 1% OP ................ 142 ISOPTO CARP SOL 2% OP ................ 142 ISOPTO CARP SOL 4% OP ................ 142 ISORDIL TAB 40MG ......................... 56 ISORDIL TAB 5MG ........................... 56 isosorbide dinitrate tab 10 mg ........... 56 isosorbide dinitrate tab 20 mg ........... 56 isosorbide dinitrate tab 30 mg ........... 56 isosorbide dinitrate tab 5 mg ............. 56 isosorbide dinitrate tab er 40 mg ....... 56 isosorbide mononitrate tab 10 mg ...... 56 isosorbide mononitrate tab 20 mg ...... 56 isosorbide mononitrate tab er 24hr 120 mg ................................................ 56 isosorbide mononitrate tab er 24hr 30 mg ................................................ 56 isosorbide mononitrate tab er 24hr 60 mg ................................................ 56 isoxsuprine hcl tab 10 mg ................. 55 isoxsuprine hcl tab 20 mg ................. 55 isradipine cap 2.5 mg ....................... 51 isradipine cap 5 mg ......................... 51 ISTALOL SOL 0.5% OP .................... 141 itraconazole cap 100 mg ................... 19 ivermectin tab 3 mg ......................... 25 J JADENU SPRKL GRA 180MG ............. 116 JADENU SPRKL GRA 360MG ............. 116 JADENU SPRKL GRA 90MG ............... 116 JADENU TAB 180MG ....................... 116 JADENU TAB 360MG ....................... 116 JADENU TAB 90MG ......................... 116 JAKAFI TAB 10MG ............................ 32 JAKAFI TAB 15MG ............................ 32 JAKAFI TAB 20MG ............................ 32 JAKAFI TAB 25MG ............................ 32 JAKAFI TAB 5MG ............................. 32 jantoven tab 10mg ......................... 115 jantoven tab 1mg ........................... 115 jantoven tab 2.5mg ........................ 115 jantoven tab 2mg ........................... 115 jantoven tab 3mg ........................... 115 jantoven tab 4mg ........................... 115 jantoven tab 5mg ........................... 115

183

jantoven tab 6mg ........................... 115 jantoven tab 7.5mg ........................ 115 JANUMET TAB 50-1000 ..................... 88 JANUMET TAB 50-500MG ................... 88 JANUMET XR TAB 100-1000 ............... 88 JANUMET XR TAB 50-1000 ................. 88 JANUMET XR TAB 50-500MG .............. 88 JANUVIA TAB 100MG ........................ 88 JANUVIA TAB 25MG .......................... 88 JANUVIA TAB 50MG .......................... 88 JARDIANCE TAB 10MG ...................... 90 JARDIANCE TAB 25MG ...................... 90 jencycla tab 0.35mg ......................... 96 JENTADUETO TAB 2.5-1000 ............... 88 JENTADUETO TAB 2.5-500 ................. 88 JENTADUETO TAB 2.5-850 ................. 88 JENTADUETO TAB XR ........................ 88 jevantique l tab 0.5-2.5 ..................... 97 jinteli tab 1mg-5mcg ........................ 97 jolessa tab ...................................... 93 jolivette tab 0.35mg ......................... 96 juleber tab ...................................... 94 junel 1.5/30 tab ............................... 95 junel 1/20 tab .................................. 93 junel fe 24 tab 1/20 .......................... 93 junel fe tab 1.5/30 ........................... 95 junel fe tab 1/20 .............................. 93 JUXTAPID CAP 10MG ........................ 47 JUXTAPID CAP 20MG ........................ 47 JUXTAPID CAP 30MG ........................ 47 JUXTAPID CAP 40MG ........................ 47 JUXTAPID CAP 5MG .......................... 47 JUXTAPID CAP 60MG ........................ 47 K kaitlib fe chw ................................... 94 KALETRA SOL .................................. 22 KALETRA TAB 100-25MG ................... 22 KALETRA TAB 200-50MG ................... 22 KALYDECO PAK 50MG ..................... 123 KALYDECO PAK 75MG ..................... 123 KALYDECO TAB 150MG ................... 123 KARBINAL ER SUS 4MG/5ML ............ 121 karidium dro 0.125mg .................... 119 kariva tab 28 day ............................. 92 KAYEXALATE POW .......................... 102

KEFLEX CAP 250MG ......................... 14 KEFLEX CAP 500MG ......................... 14 KEFLEX CAP 750MG ......................... 14 kelnor tab 1/35 ............................... 95 KERR TRIPLE MIS DYE SWAB ........... 131 ketoconazole cream 2% .................. 130 ketoconazole foam 2% .................... 130 ketoconazole shampoo 2% .............. 130 ketoconazole tab 200 mg .................. 19 ketodan aer 2% ............................. 130 ketoprofen cap 50 mg ........................ 6 ketoprofen cap 75 mg ........................ 6 ketoprofen cap er 24hr 200 mg ........... 6 ketorolac tromethamine ophth soln 0.4% .................................................... 140 ketorolac tromethamine ophth soln 0.5% .................................................... 140 ketorolac tromethamine tab 10 mg ...... 6 KEVEYIS TAB 50MG ......................... 54 KHEDEZLA TAB 100MG ER ................ 68 KHEDEZLA TAB 50MG ER .................. 68 kimidess tab ................................... 92 kionex pow .................................... 102 kionex sus 15gm/60 ....................... 102 KISQALI TAB 200DOSE .................... 32 KISQALI TAB 400DOSE .................... 32 KISQALI TAB 600DOSE .................... 32 KITABIS PAK NEB 300/5ML .............. 123 klofensaid sol ii ................................. 7 KLONOPIN TAB 0.5MG ...................... 58 KLONOPIN TAB 1MG ........................ 58 KLONOPIN TAB 2MG ........................ 58 klor-con 10 tab 10meq er ................ 118 klor-con 8 tab 8meq er .................... 118 klor-con m10 tab 10meq er .............. 118 KLOR-CON M15 TAB 15MEQ ER ........ 118 klor-con m20 tab 20meq er .............. 118 klor-con spr cap 10meq ................... 118 klor-con spr cap 8meq ..................... 118 KORLYM TAB 300MG ....................... 101 K-PHOS TAB .................................. 113 K-PHOS TAB NEUTRAL .................... 113 K-PHOS TAB NO 2 .......................... 113 KRISTALOSE PAK 10GM ................... 109 KRISTALOSE PAK 20GM ................... 109

184

K-TAB TAB 10MEQ CR ..................... 118 K-TAB TAB 20MEQ .......................... 118 K-TAB TAB 8MEQ CR ....................... 118 kurvelo tab 0.15/30 .......................... 95 KUVAN TAB 100MG ......................... 101 L labetalol hcl tab 100 mg .................... 49 labetalol hcl tab 200 mg .................... 49 labetalol hcl tab 300 mg .................... 49 LAC-HYDRIN CRE 12% .................... 135 LAC-HYDRIN LOT 12% .................... 135 LACRISERT MIS 5MG OP .................. 142 lactic acid (ammonium lactate) cream 12% ............................................. 135 lactic acid (ammonium lactate) lotion 12% ............................................. 135 lactic acid w/ vitamin e cream 10%-3500 unit/30gm ..................................... 135 lactulose (encephalopathy) solution 10 gm/15ml ....................................... 110 lactulose solution 10 gm/15ml ......... 109 LAMICTAL ODT KIT ........................... 61 LAMICTAL ODT TAB 100MG ............... 61 LAMICTAL ODT TAB 200MG ............... 61 LAMICTAL ODT TAB 25MG ................. 61 LAMICTAL ODT TAB 50MG ................. 61 LAMICTAL XR KIT ............................. 61 LAMICTAL XR TAB 100MG .................. 61 LAMICTAL XR TAB 200MG .................. 61 LAMICTAL XR TAB 250MG .................. 61 LAMICTAL XR TAB 25MG ................... 61 LAMICTAL XR TAB 300MG .................. 61 LAMICTAL XR TAB 50MG ................... 61 LAMISIL TAB 250MG ......................... 19 lamivudine oral soln 10 mg/ml ........... 22 lamivudine tab 100 mg (hbv) ............. 23 lamivudine tab 150 mg ..................... 22 lamivudine tab 300 mg ..................... 22 lamivudine-zidovudine tab 150-300 mg ..................................................... 20 lamotrigine orally disintegrating tab 100 mg ................................................. 61 lamotrigine orally disintegrating tab 200 mg ................................................. 61 lamotrigine orally disintegrating tab 25

mg ................................................ 61 lamotrigine orally disintegrating tab 50 mg ................................................ 61 lamotrigine tab 100 mg .................... 61 lamotrigine tab 150 mg .................... 61 lamotrigine tab 200 mg .................... 61 lamotrigine tab 25 mg ...................... 61 lamotrigine tab chewable dispersible 25 mg ................................................ 61 lamotrigine tab chewable dispersible 5 mg ................................................ 61 lamotrigine tab disint 25 (14) & 50 mg (14) & 100 mg (7) kit ...................... 61 lamotrigine tab disint 25 mg (21) & 50 mg (7) titration kit ........................... 61 lamotrigine tab disint 50 mg (42)- 100 mg(14) titration kit .......................... 61 lamotrigine tab er 24hr 100 mg ......... 61 lamotrigine tab er 24hr 200 mg ......... 61 lamotrigine tab er 24hr 25 mg ........... 61 lamotrigine tab er 24hr 250 mg ......... 61 lamotrigine tab er 24hr 300 mg ......... 61 lamotrigine tab er 24hr 50 mg ........... 61 LANCETS ........................................ 91 LANOXIN TAB 0.0625MG .................. 53 LANOXIN TAB 0.1875MG .................. 53 lansoprazole cap delayed release 15 mg .................................................... 111 lansoprazole cap delayed release 30 mg .................................................... 111 larin 24 tab fe 1/20 .......................... 93 larin fe tab 1.5/30 ........................... 95 larin fe tab 1/20 .............................. 93 larin tab 1.5/30 ............................... 95 larin tab 1/20 .................................. 93 LASIX TAB 20MG ............................. 54 LASIX TAB 40MG ............................. 54 LASIX TAB 80MG ............................. 54 latanoprost ophth soln 0.005% ......... 143 layolis fe chw .................................. 94 leena tab ........................................ 96 leflunomide tab 10 mg .................... 116 leflunomide tab 20 mg .................... 116 LENVIMA CAP 10 MG ........................ 32 LENVIMA CAP 14 MG ........................ 33

185

LENVIMA CAP 18 MG ......................... 33 LENVIMA CAP 20 MG ......................... 33 LENVIMA CAP 24 MG ......................... 33 LENVIMA CAP 8 MG .......................... 32 lessina tab ....................................... 93 LETAIRIS TAB 10MG ......................... 57 LETAIRIS TAB 5MG ........................... 57 letrozole tab 2.5 mg ......................... 29 leucovorin calcium tab 10 mg ............. 35 leucovorin calcium tab 15 mg ............. 35 leucovorin calcium tab 25 mg ............. 35 leucovorin calcium tab 5 mg .............. 35 LEUKERAN TAB 2MG ......................... 27 LEVACET TAB .................................... 5 levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) .................................. 122 levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) .................................. 122 levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) .................................. 122 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) .................... 122 LEVAQUIN TAB 250MG ...................... 16 LEVAQUIN TAB 500MG ...................... 16 LEVAQUIN TAB 750MG ...................... 16 LEVEMIR INJ .................................... 89 LEVEMIR INJ FLEXTOUC .................... 89 levetiracetam oral soln 100 mg/ml ...... 61 levetiracetam tab 1000 mg ................ 62 levetiracetam tab 250 mg .................. 62 levetiracetam tab 500 mg .................. 62 levetiracetam tab 750 mg .................. 62 levetiracetam tab er 24hr 500 mg ....... 62 levetiracetam tab er 24hr 750 mg ....... 62 levobunolol hcl ophth soln 0.5% ....... 141 levocarnitine oral soln 1 gm/10ml (10%) ..................................................... 92 levocarnitine tab 330 mg ................... 92 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) ....................... 120 levocetirizine dihydrochloride tab 5 mg ................................................... 120 levofloxacin ophth soln 0.5% ........... 139 levofloxacin oral soln 25 mg/ml .......... 16 levofloxacin tab 250 mg .................... 16

levofloxacin tab 500 mg ................... 16 levofloxacin tab 750 mg ................... 16 levonest tab .................................... 96 levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg ..................... 93 levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg ..................................... 93 levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg ............................. 95 levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg .......... 96 levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg .............. 92 levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) ...................... 93 levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) ...................... 93 levora-28 tab 0.15/30 ...................... 95 levo-t tab 100mcg .......................... 103 levo-t tab 112mcg .......................... 103 levo-t tab 125mcg .......................... 103 levo-t tab 137mcg .......................... 103 levo-t tab 150mcg .......................... 103 levo-t tab 175mcg .......................... 103 levo-t tab 200 mcg ......................... 103 levo-t tab 25mcg ............................ 103 levo-t tab 300 mcg ......................... 103 levo-t tab 50mcg ............................ 103 levo-t tab 75mcg ............................ 103 levo-t tab 88mcg ............................ 103 levothyroxine sodium tab 100 mcg .... 103 levothyroxine sodium tab 112 mcg .... 103 levothyroxine sodium tab 125 mcg .... 103 levothyroxine sodium tab 137 mcg .... 103 levothyroxine sodium tab 150 mcg .... 103 levothyroxine sodium tab 175 mcg .... 103 levothyroxine sodium tab 200 mcg .... 103 levothyroxine sodium tab 25 mcg ..... 103 levothyroxine sodium tab 300 mcg .... 103 levothyroxine sodium tab 50 mcg ..... 103 levothyroxine sodium tab 75 mcg ..... 103 levothyroxine sodium tab 88 mcg ..... 103 levoxyl tab 100mcg ........................ 104 levoxyl tab 112mcg ........................ 104 levoxyl tab 125mcg ........................ 104

186

levoxyl tab 137mcg ........................ 104 levoxyl tab 150mcg ........................ 104 levoxyl tab 175mcg ........................ 104 levoxyl tab 200mcg ........................ 104 levoxyl tab 25mcg .......................... 103 levoxyl tab 50mcg .......................... 103 levoxyl tab 75mcg .......................... 103 levoxyl tab 88mcg .......................... 103 LEVULAN KERA SOL 20% ................ 129 LEXAPRO SOL 5MG/5ML .................... 67 LEXAPRO TAB 10MG ......................... 67 LEXAPRO TAB 20MG ......................... 67 LEXAPRO TAB 5MG ........................... 67 LEXIVA SUS 50MG/ML ....................... 22 LEXIVA TAB 700MG .......................... 22 LIALDA TAB 1.2GM ......................... 108 LIBRAX CAP 5-2.5MG ...................... 107 lidocaine hcl gel 2% ........................ 136 lidocaine hcl laryngotracheal soln 4% 138 lidocaine hcl lotion 3% .................... 136 lidocaine hcl soln 4% ...................... 136 lidocaine hcl viscous soln 2% ........... 138 lidocaine oin 5% ............................ 136 lidocaine oin pak 5% ....................... 136 lidocaine oint 5% ........................... 136 lidocaine patch 5% ......................... 136 lidocaine-hydrocortisone acetate rectal cream kit 2-2% .............................. 112 lidocaine-hydrocortisone acetate rectal cream kit 3-0.5% ........................... 112 lidocaine-hydrocortisone acetate rectal gel kit 3-2.5% ............................... 112 lidocaine-prilocaine cream 2.5-2.5% . 136 lidocaine-prilocaine cream kit 2.5-2.5% ................................................... 136 lidocaine-tetracaine cream 7-7% ...... 136 LIDODERM DIS 5% ......................... 136 LIDO-HYDRO GEL 2.8-0.55 .............. 112 LIDO-K LOT 3% ............................. 136 lidopril kit 2.5-2.5% ........................ 136 lindane shampoo 1% ...................... 137 linezolid for susp 100 mg/5ml ............ 25 linezolid tab 600 mg ......................... 25 LINZESS CAP 145MCG .................... 109 LINZESS CAP 290MCG .................... 109

LINZESS CAP 72MCG ...................... 109 liothyronine sodium tab 25 mcg ........ 104 liothyronine sodium tab 5 mcg ......... 104 liothyronine sodium tab 50 mcg ........ 104 LIPOFEN CAP 150MG ........................ 46 LIPOFEN CAP 50MG ......................... 46 lisinopril & hydrochlorothiazide tab 10-12.5 mg ......................................... 38 lisinopril & hydrochlorothiazide tab 20-12.5 mg ......................................... 38 lisinopril & hydrochlorothiazide tab 20-25 mg ................................................ 38 lisinopril tab 10 mg .......................... 39 lisinopril tab 2.5 mg ......................... 39 lisinopril tab 20 mg .......................... 39 lisinopril tab 30 mg .......................... 39 lisinopril tab 40 mg .......................... 39 lisinopril tab 5 mg ............................ 39 LITEAIRE MIS ................................ 124 lithium carbonate cap 150 mg ........... 84 lithium carbonate cap 300 mg ........... 84 lithium carbonate cap 600 mg ........... 84 lithium carbonate tab 300 mg ........... 84 lithium carbonate tab er 300 mg ........ 84 lithium carbonate tab er 450 mg ........ 84 LITHIUM SOL 8MEQ/5ML .................. 84 LITHOBID TAB 300MG CR ................. 84 LITHOSTAT TAB 250MG ................... 113 livixil pak kit 2.5-2.5% .................... 136 LO LOESTRIN TAB ........................... 92 LOCOID CRE 0.1% .......................... 134 LOCOID LIPO CRE 0.1% .................. 134 LOCOID LOT 0.1% .......................... 134 LOCOID OIN 0.1% .......................... 134 LOCOID SOL 0.1% .......................... 134 LODOSYN TAB 25MG ........................ 71 LOESTRIN 21 TAB 1.5/30 ................. 95 LOESTRIN FE TAB 1.5/30 .................. 95 LOESTRIN FE TAB 1/20 .................... 93 LOESTRIN TAB 1/20-21 .................... 94 LOFIBRA CAP 134MG ....................... 46 LOFIBRA CAP 200MG ....................... 46 LOFIBRA CAP 67MG ......................... 46 LOFIBRA TAB 160MG ....................... 46 LOFIBRA TAB 54MG ......................... 46

187

lokara lot 0.05% ............................ 133 lomedia 24 tab fe ............................. 94 LOMOTIL TAB 2.5MG ...................... 105 LONSURF TAB 15-6.14 ...................... 35 LONSURF TAB 20-8.19 ...................... 36 loperamide hcl cap 2 mg ................. 105 LOPID TAB 600MG ............................ 46 lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) ................................. 22 LOPRESS HCT TAB 50-25MG .............. 47 LOPRESSOR TAB 100MG ................... 49 LOPRESSOR TAB 50MG ..................... 49 LOPROX SHA 1% ............................ 130 lorazepam con 2mg/ml ..................... 58 lorazepam conc 2 mg/ml ................... 58 lorazepam tab 0.5 mg ....................... 58 lorazepam tab 1 mg .......................... 58 lorazepam tab 2 mg .......................... 59 lorcet hd tab 10-325mg .................... 10 lorcet plus tab 7.5-325 ...................... 10 lorcet tab 5-325mg ........................... 10 LORTAB ELX 10-300MG ..................... 10 lortab tab 10-325mg ......................... 10 lortab tab 5-325mg .......................... 10 lortab tab 7.5-325 ............................ 10 loryna tab 3-0.02mg ......................... 94 LORZONE TAB 375MG ....................... 85 LORZONE TAB 750MG ....................... 85 losartan potassium & hydrochlorothiazide tab 100-12.5 mg .............................. 42 losartan potassium & hydrochlorothiazide tab 100-25 mg ................................. 42 losartan potassium & hydrochlorothiazide tab 50-12.5 mg ................................ 42 losartan potassium tab 100 mg .......... 43 losartan potassium tab 25 mg ............ 43 losartan potassium tab 50 mg ............ 43 LOSEASONIQUE TAB ......................... 93 LOTEMAX GEL 0.5% ....................... 140 LOTEMAX OIN 0.5% ....................... 140 LOTEMAX SUS 0.5% ....................... 140 LOTENSIN HCT TAB 10-12.5 .............. 38 LOTENSIN HCT TAB 20-12.5 .............. 38 LOTENSIN HCT TAB 20-25MG ............ 38 LOTENSIN TAB 20MG ........................ 39

LOTENSIN TAB 40MG ....................... 39 LOTREL CAP 10-20MG ...................... 37 LOTREL CAP 10-40MG ...................... 37 LOTREL CAP 2.5-10MG ..................... 37 LOTREL CAP 5-10MG ........................ 37 LOTREL CAP 5-20MG ........................ 37 LOTRISONE CRE ............................. 130 LOTRONEX TAB 0.5MG .................... 109 LOTRONEX TAB 1MG ....................... 109 lovastatin tab 10 mg ........................ 46 lovastatin tab 20 mg ........................ 46 lovastatin tab 40 mg ........................ 46 LOVAZA CAP 1GM ............................ 47 low-ogestrel tab .............................. 95 loxapine succinate cap 10 mg ............ 76 loxapine succinate cap 25 mg ............ 76 loxapine succinate cap 5 mg ............. 76 loxapine succinate cap 50 mg ............ 76 LOZI-FLUR LOZ 1MG F .................... 119 lp lite pak kit 2.5-2.5% ................... 136 ludent chw 0.25mg f ....................... 119 ludent chw 0.5mg f ......................... 119 ludent chw 1mg f............................ 119 LURIDE DRO 0.5MG/ML ................... 119 lutera tab ....................................... 94 LUZU CRE 1% ................................ 130 LYNPARZA CAP 50MG ....................... 33 LYRICA CAP 100MG ......................... 81 LYRICA CAP 150MG ......................... 81 LYRICA CAP 200MG ......................... 81 LYRICA CAP 225MG ......................... 81 LYRICA CAP 25MG ........................... 81 LYRICA CAP 300MG ......................... 81 LYRICA CAP 50MG ........................... 81 LYRICA CAP 75MG ........................... 81 LYRICA SOL 20MG/ML ...................... 81 LYSODREN TAB 500MG .................... 36 LYSTEDA TAB 650MG ...................... 115 lyza tab 0.35mg .............................. 96 M MACROBID CAP 100MG .................... 26 MALARONE TAB 250-100 .................. 20 MALARONE TAB 62.5-25 ................... 20 malathion lotion 0.5% ..................... 137 maprotiline hcl tab 25 mg ................. 65

188

maprotiline hcl tab 50 mg .................. 65 maprotiline hcl tab 75 mg .................. 65 MARINOL CAP 10MG ....................... 106 MARINOL CAP 2.5MG ...................... 106 MARINOL CAP 5MG ......................... 106 marlissa tab 0.15/30......................... 95 MARPLAN TAB 10MG ......................... 66 marten-tab tab 50-325mg .................. 5 MATULANE CAP 50MG ....................... 36 MAVIK TAB 1MG ............................... 39 MAVIK TAB 2MG ............................... 39 MAVIK TAB 4MG ............................... 39 MAXALT TAB 10MG ........................... 83 MAXALT TAB 5MG ............................. 83 MAXALT-MLT TAB 10MG .................... 83 MAXALT-MLT TAB 5MG ...................... 83 MAXIDEX SUS 0.1% OP .................. 140 MAXITROL OIN 0.1% OP ................. 138 MAXITROL SUS 0.1% OP ................. 138 MAXZIDE TAB 75-50 ......................... 53 MAXZIDE-25 TAB ............................. 53 meclizine hcl tab 12.5 mg ................ 106 meclizine hcl tab 25 mg .................. 106 meclofenamate sodium cap 100 mg ..... 6 meclofenamate sodium cap 50 mg ....... 6 MEDROL TAB 16MG ........................ 100 MEDROL TAB 2MG .......................... 100 MEDROL TAB 32MG ........................ 100 MEDROL TAB 4MG .......................... 100 MEDROL TAB 8MG .......................... 100 medroxyprogesterone acetate tab 10 mg ................................................... 102 medroxyprogesterone acetate tab 2.5 mg ............................................... 102 medroxyprogesterone acetate tab 5 mg ................................................... 102 mefenamic acid cap 250 mg ............... 6 mefloquine hcl tab 250 mg ................ 20 MEGACE ES SUS 625/5ML ............... 102 MEGACE ORAL SUS 40MG/ML........... 102 megestrol acetate susp 40 mg/ml ..... 102 megestrol acetate susp 625 mg/5ml . 102 megestrol acetate tab 20 mg ............. 29 megestrol acetate tab 40 mg ............. 29 MEKINIST TAB 0.5MG ....................... 33

MEKINIST TAB 2MG ......................... 33 meloxicam tab 15 mg ......................... 6 meloxicam tab 7.5 mg ........................ 6 melphalan tab 2 mg ......................... 27 memantine hcl oral solution 2 mg/ml . 64 memantine hcl tab 10 mg ................. 64 memantine hcl tab 5 mg ................... 64 memantine hcl tab 5 mg (28) & 10 mg (21) titration pak ............................. 64 MEMBRANEBLUE SOL 0.15% ............ 142 MENTAX CRE 1% ............................ 130 MEPHYTON TAB 5MG ....................... 119 meprobamate tab 200 mg ................ 59 meprobamate tab 400 mg ................ 59 MEPRON SUS .................................. 26 mercaptopurine tab 50 mg ................ 28 mesalamine enema 4 gm ................. 108 mesalamine rectal enema 4 gm & cleanser wipe kit ............................ 109 mesalamine tab delayed release 1.2 gm .................................................... 109 MESNEX TAB 400MG ........................ 36 MESTINON SYP 60MG/5ML ................ 85 MESTINON TAB 60MG ...................... 85 MESTINON TAB TIMESPAN ................ 85 metadate tab 20mg er ..................... 79 metaproterenol sulfate syrup 10 mg/5ml .................................................... 123 metaproterenol sulfate tab 10 mg ..... 123 metaproterenol sulfate tab 20 mg ..... 123 metaxall tab 800mg ......................... 85 metaxalone tab 400 mg .................... 85 metaxalone tab 800 mg .................... 85 metformin hcl tab 1000 mg ............... 88 metformin hcl tab 500 mg ................ 88 metformin hcl tab 850 mg ................ 88 metformin hcl tab er 24hr 500 mg ..... 88 metformin hcl tab er 24hr 750 mg ..... 88 metformin hcl tab er 24hr osmotic 1000 mg ................................................ 88 metformin hcl tab er 24hr osmotic 500 mg ................................................ 88 methadone con 10mg/ml .................. 10 methadone hcl conc 10 mg/ml .......... 10 methadone hcl soln 10 mg/5ml ......... 10

189

methadone hcl soln 5 mg/5ml ............ 10 methadone hcl tab 10 mg .................. 10 methadone hcl tab 5 mg ................... 10 methadone hcl tab for oral susp 40 mg 10 METHADOSE CON 10MG/ML ............... 10 METHADOSE SF CON 10MG/ML .......... 10 methadose tab 40mg ........................ 10 methamphetamine hcl tab 5 mg ......... 79 methazolamide tab 25 mg ................. 54 methazolamide tab 50 mg ................. 54 methenamine hippurate tab 1 gm ....... 26 methergine tab 0.2mg .................... 101 methimazole tab 10 mg .................. 103 methimazole tab 5 mg .................... 103 METHITEST TAB 10MG ...................... 87 methocarbamol tab 500 mg ............... 85 methocarbamol tab 750 mg ............... 85 methotrexate sodium tab 2.5 mg (base equiv) ............................................. 28 methoxsalen rapid cap 10 mg .......... 131 methscopolamine bromide tab 2.5 mg ................................................... 107 methscopolamine bromide tab 5 mg . 107 methyclothiazide tab 5 mg ................. 55 METHYL SALIC LIQ ......................... 136 methyldopa & hydrochlorothiazide tab 250-15 mg ...................................... 55 methyldopa & hydrochlorothiazide tab 250-25 mg ...................................... 55 methyldopa tab 250 mg .................... 55 methyldopa tab 500 mg .................... 55 METHYLIN CHW 10MG ....................... 80 METHYLIN CHW 2.5MG ...................... 79 METHYLIN CHW 5MG ........................ 80 METHYLIN SOL 10MG/5ML ................. 80 METHYLIN SOL 5MG/5ML ................... 80 methylphenidate hcl cap er 10 mg (cd) 80 methylphenidate hcl cap er 20 mg (cd) 80 methylphenidate hcl cap er 24hr 20 mg (la) ................................................ 80 methylphenidate hcl cap er 24hr 30 mg (la) ................................................ 80 methylphenidate hcl cap er 24hr 40 mg (la) ................................................ 80 methylphenidate hcl cap er 24hr 60 mg

(la) ................................................ 80 methylphenidate hcl cap er 30 mg (cd) 80 methylphenidate hcl cap er 40 mg (cd) 80 methylphenidate hcl cap er 50 mg (cd) 80 methylphenidate hcl cap er 60 mg (cd) 80 methylphenidate hcl chew tab 10 mg . 80 methylphenidate hcl chew tab 2.5 mg 80 methylphenidate hcl chew tab 5 mg ... 80 methylphenidate hcl soln 10 mg/5ml .. 80 methylphenidate hcl soln 5 mg/5ml .... 80 methylphenidate hcl tab 10 mg ......... 80 methylphenidate hcl tab 20 mg ......... 80 methylphenidate hcl tab 5 mg ........... 80 methylphenidate hcl tab er 10 mg ...... 80 methylphenidate hcl tab er 20 mg ...... 80 methylphenidate hcl tab er 24hr 18 mg ..................................................... 80 methylphenidate hcl tab er 24hr 27 mg ..................................................... 80 methylphenidate hcl tab er 24hr 36 mg ..................................................... 80 methylphenidate hcl tab er 24hr 54 mg ..................................................... 80 methylphenidate hcl tab er osmotic release (osm) 18 mg ........................ 80 methylphenidate hcl tab er osmotic release (osm) 27 mg ........................ 80 methylphenidate hcl tab er osmotic release (osm) 36 mg ........................ 80 methylphenidate hcl tab er osmotic release (osm) 54 mg ........................ 80 methylprednisolone tab 16 mg ......... 100 methylprednisolone tab 32 mg ......... 100 methylprednisolone tab 4 mg ........... 100 methylprednisolone tab 8 mg ........... 100 methylprednisolone tab therapy pack 4 mg (21) ........................................ 100 methyltestosterone cap 10 mg .......... 87 metipranolol ophth soln 0.3% .......... 141 metoclopramide hcl orally disintegrating tab 5 mg (base eq) ......................... 106 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) ...................................... 106 metoclopramide hcl tab 10 mg ......... 106 metoclopramide hcl tab 5 mg ........... 106

190

metolazone tab 10 mg ...................... 55 metolazone tab 2.5 mg ..................... 55 metolazone tab 5 mg ........................ 55 metoprolol & hydrochlorothiazide tab 100-25 mg ...................................... 48 metoprolol & hydrochlorothiazide tab 100-50 mg ...................................... 48 metoprolol & hydrochlorothiazide tab 50-25 mg ............................................ 48 metoprolol succinate tab er 24hr 100 mg (tartrate equiv) ................................ 49 metoprolol succinate tab er 24hr 200 mg (tartrate equiv) ................................ 49 metoprolol succinate tab er 24hr 25 mg (tartrate equiv) ................................ 49 metoprolol succinate tab er 24hr 50 mg (tartrate equiv) ................................ 49 metoprolol tartrate tab 100 mg .......... 49 metoprolol tartrate tab 25 mg ............ 49 metoprolol tartrate tab 37.5 mg ......... 49 metoprolol tartrate tab 50 mg ............ 49 metoprolol tartrate tab 75 mg ............ 49 METROCREAM CRE 0.75% ............... 137 METROGEL-VAG GEL 0.75% ............. 114 METROLOTION LOT 0.75% .............. 137 metronidazole cap 375 mg ................ 26 metronidazole cream 0.75% ............ 137 metronidazole gel 0.75% ................. 137 metronidazole gel 1% ..................... 137 metronidazole lotion 0.75% ............. 137 metronidazole tab 250 mg ................. 26 metronidazole tab 500 mg ................. 26 metronidazole vaginal gel 0.75% ...... 114 MEVACOR TAB 40MG ........................ 46 mexiletine hcl cap 150 mg ................. 44 mexiletine hcl cap 200 mg ................. 44 mexiletine hcl cap 250 mg ................. 44 MICARDIS HCT TAB 40/12.5 .............. 42 MICARDIS HCT TAB 80/12.5 .............. 42 MICARDIS HCT TAB 80-25MG ............ 42 MICARDIS TAB 20MG ........................ 43 MICARDIS TAB 40MG ........................ 43 MICARDIS TAB 80MG ........................ 43 miconazole 3 sup 200mg ................. 114 micrgstin 24 tab fe 1/20 .................... 94

MICROCHAMBER MIS ...................... 124 microgestin tab 1.5/30 ..................... 95 microgestin tab 1/20 ........................ 94 microgestin tab fe 1/20 .................... 94 microgestin tab fe1.5/30 .................. 95 MICRO-K CAP 10MEQ CR ................. 118 MICRO-K CAP 8MEQ CR ................... 118 MICROLIFE MIS PEAK FLO ............... 124 MICROSPACER MIS ......................... 124 MICROZIDE CAP 12.5MG .................. 55 midazolam hcl syrup 2 mg/ml (base equivalent) ..................................... 82 midodrine hcl tab 10 mg ................... 55 midodrine hcl tab 2.5 mg .................. 55 midodrine hcl tab 5 mg .................... 55 MIFEPREX TAB 200MG ..................... 101 migergot sup 2/100 ......................... 82 miglitol tab 100 mg ......................... 87 miglitol tab 25 mg ........................... 87 miglitol tab 50 mg ........................... 87 MIGRANAL SPR 4MG/ML ................... 82 mimvey lo tab 0.5-0.1 ...................... 97 mimvey tab 1-0.5mg ....................... 97 MINASTRIN 24 CHW FE .................... 94 MINERAL OIL ................................. 109 MINI WRIGHT MIS PFM ................... 124 MINI WRIGHT MIS PFM LOW ............ 124 MINIPRESS CAP 1MG ....................... 40 MINIPRESS CAP 2MG ....................... 40 MINIPRESS CAP 5MG ....................... 40 minitran dis 0.1mg/hr ...................... 56 minitran dis 0.2mg/hr ...................... 56 minitran dis 0.4mg/hr ...................... 56 minitran dis 0.6mg/hr ...................... 56 MINIVELLE DIS 0.025MG .................. 99 MINIVELLE DIS 0.0375MG ................ 99 MINIVELLE DIS 0.05MG .................... 99 MINIVELLE DIS 0.075MG .................. 99 MINIVELLE DIS 0.1MG ..................... 99 minocycline hcl cap 100 mg .............. 18 minocycline hcl cap 50 mg ................ 18 minocycline hcl cap 75 mg ................ 18 minocycline hcl tab 100 mg ............... 18 minocycline hcl tab 50 mg ................ 18 minocycline hcl tab 75 mg ................ 18

191

minocycline hcl tab er 24hr 135 mg .... 18 minocycline hcl tab er 24hr 45 mg ...... 18 minocycline hcl tab er 24hr 90 mg ...... 18 minoxidil tab 10 mg .......................... 55 minoxidil tab 2.5 mg ......................... 55 MIRAPEX ER TAB 0.375MG ................ 71 MIRAPEX ER TAB 0.75MG .................. 71 MIRAPEX ER TAB 1.5MG .................... 71 MIRAPEX ER TAB 2.25MG .................. 71 MIRAPEX ER TAB 3.75MG .................. 71 MIRAPEX ER TAB 3MG ....................... 71 MIRAPEX ER TAB 4.5MG .................... 71 MIRAPEX TAB 0.125MG ..................... 71 MIRAPEX TAB 0.25MG ....................... 71 MIRAPEX TAB 0.5MG......................... 71 MIRAPEX TAB 0.75MG ....................... 71 MIRAPEX TAB 1.5MG......................... 71 MIRAPEX TAB 1MG ........................... 71 MIRCETTE TAB 28 DAY ...................... 92 mirtazapine orally disintegrating tab 15 mg ................................................. 65 mirtazapine orally disintegrating tab 30 mg ................................................. 65 mirtazapine orally disintegrating tab 45 mg ................................................. 65 mirtazapine tab 15 mg ...................... 65 mirtazapine tab 30 mg ...................... 65 mirtazapine tab 45 mg ...................... 65 mirtazapine tab 7.5 mg ..................... 65 misoprostol tab 100 mcg ................. 111 misoprostol tab 200 mcg ................. 111 MITIGARE CAP 0.6MG ........................ 5 MITOSOL KIT 0.2MG ....................... 139 MOBIC TAB 15MG .............................. 6 MOBIC TAB 7.5MG ............................. 6 modafinil tab 100 mg ........................ 86 modafinil tab 200 mg ........................ 86 MODERIBA PAK 1200/DAY ................. 24 MODERIBA PAK 800/DAY ................... 24 MODERIBA TAB 1000/DAY ................. 24 moderiba tab 200mg ........................ 24 MODERIBA TAB 600/DAY ................... 24 moexipril hcl tab 15 mg ..................... 39 moexipril hcl tab 7.5 mg .................... 39 moexipril-hydrochlorothiazide tab 15-

12.5 mg ......................................... 38 moexipril-hydrochlorothiazide tab 15-25 mg ................................................ 38 moexipril-hydrochlorothiazide tab 7.5-12.5 mg ......................................... 38 molindone hcl tab 10 mg .................. 76 molindone hcl tab 25 mg .................. 76 molindone hcl tab 5 mg .................... 76 mometasone furoate cream 0.1% ..... 134 mometasone furoate nasal susp 50 mcg/act ........................................ 126 mometasone furoate oint 0.1% ........ 134 mometasone furoate solution 0.1% (lotion) ......................................... 134 mondoxyne nl cap 100mg ................. 18 mondoxyne nl cap 50mg .................. 18 mondoxyne nl cap 75mg .................. 18 MONODOX CAP 100MG ..................... 18 MONODOX CAP 75MG ...................... 18 mono-linyah tab 0.25-35 .................. 95 mononessa tab ................................ 95 montelukast sodium chew tab 4 mg (base equiv) .................................. 123 montelukast sodium chew tab 5 mg (base equiv) .................................. 123 montelukast sodium oral granules packet 4 mg (base equiv) .......................... 123 montelukast sodium tab 10 mg (base equiv) ........................................... 123 MONUROL PAK GRANULES ................ 26 morgidox cap 1x100mg .................... 18 morgidox cap 2x100mg .................... 18 MORPHINE SUL SUP 30MG ................ 10 morphine sulfate beads cap er 24hr 120 mg ................................................ 10 morphine sulfate beads cap er 24hr 30 mg ................................................ 10 morphine sulfate beads cap er 24hr 45 mg ................................................ 10 morphine sulfate beads cap er 24hr 60 mg ................................................ 10 morphine sulfate beads cap er 24hr 75 mg ................................................ 10 morphine sulfate beads cap er 24hr 90 mg ................................................ 10

192

morphine sulfate cap er 24hr 10 mg ... 10 morphine sulfate cap er 24hr 100 mg .. 11 morphine sulfate cap er 24hr 20 mg ... 10 morphine sulfate cap er 24hr 30 mg ... 10 morphine sulfate cap er 24hr 50 mg ... 10 morphine sulfate cap er 24hr 60 mg ... 11 morphine sulfate cap er 24hr 80 mg ... 11 morphine sulfate oral soln 10 mg/5ml . 11 morphine sulfate oral soln 100 mg/5ml (20 mg/ml) ..................................... 11 morphine sulfate oral soln 20 mg/5ml . 11 morphine sulfate suppos 10 mg .......... 11 morphine sulfate suppos 20 mg .......... 11 morphine sulfate suppos 5 mg ........... 11 morphine sulfate tab 15 mg ............... 11 morphine sulfate tab 30 mg ............... 11 morphine sulfate tab er 100 mg ......... 11 morphine sulfate tab er 15 mg ........... 11 morphine sulfate tab er 200 mg ......... 11 morphine sulfate tab er 30 mg ........... 11 morphine sulfate tab er 60 mg ........... 11 MOVANTIK TAB 12.5MG .................. 110 MOVANTIK TAB 25MG ..................... 110 MOVIPREP SOL .............................. 109 MOXATAG TAB 775MG ...................... 17 MOXEZA SOL 0.5% ......................... 139 moxifloxacin hcl ophth soln 0.5% (base equiv) ........................................... 139 moxifloxacin hcl tab 400 mg (base equiv) ..................................................... 16 MS CONTIN TAB 100MG ER................ 11 MS CONTIN TAB 15MG ER ................. 11 MS CONTIN TAB 200MG ER................ 11 MS CONTIN TAB 30MG ER ................. 11 MS CONTIN TAB 60MG ER ................. 11 MUCOTROL WAF ............................. 138 MUGARD LIQ ................................. 138 MULTAQ TAB 400MG ......................... 44 mupirocin calcium cream 2% ........... 129 mupirocin oint 2% .......................... 129 MYAMBUTOL TAB 100MG ................... 23 MYAMBUTOL TAB 400MG ................... 23 MYCOBUTIN CAP 150MG ................... 26 mycophenolate mofetil cap 250 mg ... 117 mycophenolate mofetil for oral susp 200

mg/ml .......................................... 117 mycophenolate mofetil tab 500 mg ... 117 mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) ............... 117 mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) ............... 117 MYDRIACYL SOL 1% OP .................. 142 MYFORTIC TAB 180MG .................... 117 MYFORTIC TAB 360MG .................... 117 MYLERAN TAB 2MG .......................... 27 myorisan cap 10mg ........................ 127 myorisan cap 20mg ........................ 127 myorisan cap 30mg ........................ 127 myorisan cap 40mg ........................ 127 MYRBETRIQ TAB 25MG .................... 114 MYRBETRIQ TAB 50MG .................... 114 MYSOLINE TAB 250MG ..................... 62 MYSOLINE TAB 50MG ....................... 62 myzilra tab ..................................... 96 N nabumetone tab 500 mg .................... 6 nabumetone tab 750 mg .................... 6 nadolol & bendroflumethiazide tab 40-5 mg ................................................ 48 nadolol & bendroflumethiazide tab 80-5 mg ................................................ 48 nadolol tab 20 mg ........................... 49 nadolol tab 40 mg ........................... 49 nadolol tab 80 mg ........................... 49 nafrinse chw 1mg f ......................... 119 NAFRINSE DLY SOL /NEUTRAL .......... 138 nafrinse dro 0.125mg ...................... 119 NAFRINSE SOL DAILY ..................... 138 NAFRINSE WK SOL 0.2% ................. 138 naftifine hcl cream 1% .................... 130 naftifine hcl cream 2% .................... 130 NAFTIN CRE 2% ............................. 130 NAFTIN GEL 1% ............................. 130 NAFTIN GEL 2% ............................. 130 NALFON CAP 400MG .......................... 6 naltrexone hcl tab 50 mg .................. 86 NAMENDA SOL 10MG/5ML ................ 64 NAMENDA TAB 10MG ....................... 64 NAMENDA TAB 5-10MG .................... 64 NAMENDA TAB 5MG ......................... 64

193

NAMENDA XR CAP 14MG ................... 64 NAMENDA XR CAP 21MG ................... 64 NAMENDA XR CAP 28MG ................... 64 NAMENDA XR CAP 7MG ..................... 64 NAMENDA XR CAP TITRATIO .............. 65 NAMZARIC CAP ................................ 65 NAMZARIC CAP 14-10MG .................. 65 NAMZARIC CAP 21-10MG .................. 65 NAMZARIC CAP 28-10MG .................. 65 NAMZARIC CAP 7-10MG .................... 65 NAPROSYN TAB 500MG ...................... 6 naproxen dr tab 375mg ...................... 6 naproxen dr tab 500mg ...................... 6 naproxen sodium tab 275 mg .............. 6 naproxen sodium tab 550 mg .............. 6 naproxen sodium tab er 24hr 375 mg (base equiv) ..................................... 6 naproxen sodium tab er 24hr 500 mg (base equiv) ..................................... 7 naproxen susp 125 mg/5ml ................ 7 naproxen tab 250 mg ........................ 7 naproxen tab 375 mg ........................ 7 naproxen tab 500 mg ........................ 7 naproxen tab 500mg ......................... 7 naratriptan hcl tab 1 mg (base equiv) . 83 naratriptan hcl tab 2.5 mg (base equiv) ..................................................... 83 NARCAN SPR ................................... 86 NARDIL TAB 15MG ........................... 66 NASCOBAL SPR 500MCG ................. 119 NASONEX SPR 50MCG/AC ............... 126 NATACYN SUS 5% OP ..................... 140 NATAZIA TAB................................... 93 nateglinide tab 120 mg ..................... 90 nateglinide tab 60 mg ....................... 89 NATROBA SUS 0.9% ....................... 137 NEBUPENT INH 300MG ...................... 26 NEBUSAL NEB 6% .......................... 125 necon tab 0.5/35 .............................. 95 necon tab 1/35 ................................ 95 necon tab 1/50-28 ............................ 96 NECON TAB 10/11-28 ....................... 92 necon tab 7/7/7 ............................... 96 nefazodone hcl tab 100 mg ................ 66 nefazodone hcl tab 150 mg ................ 66

nefazodone hcl tab 200 mg ............... 66 nefazodone hcl tab 250 mg ............... 66 nefazodone hcl tab 50 mg ................. 65 neomycin sulfate tab 500 mg ............ 13 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin ... 139 neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml ............. 139 neomycin-polymyxin b gu irrigation soln .................................................... 112 neomycin-polymyxin-dexamethasone ophth oint 0.1% ............................. 138 neomycin-polymyxin-dexamethasone ophth susp 0.1% ............................ 138 neomycin-polymyxin-hc ophth susp .. 139 neomycin-polymyxin-hc otic soln 1% 143 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% ................ 143 neo-polycin oin hc 1%op ................. 138 neo-polycin oin op .......................... 139 NEORAL CAP 100MG ....................... 117 NEORAL CAP 25MG ......................... 117 NEORAL SOL 100MG/ML .................. 117 NEOSALUS LOT .............................. 135 NEOSPORIN GU SOL 40/ML IR .......... 112 NEOSPORIN SOL OP........................ 139 NEOTUSS PLUS LIQ ........................ 121 NEPTAZANE TAB 25MG ..................... 54 NEPTAZANE TAB 50MG ..................... 54 NERLYNX TAB 40MG ........................ 33 neuac gel 1.2-5% ........................... 128 NEUPRO DIS 1MG/24HR ................... 71 NEUPRO DIS 2MG/24HR ................... 71 NEUPRO DIS 3MG/24HR ................... 71 NEUPRO DIS 4MG/24HR ................... 71 NEUPRO DIS 6MG/24HR ................... 71 NEUPRO DIS 8MG/24HR ................... 71 NEURONTIN CAP 100MG ................... 62 NEURONTIN CAP 300MG ................... 62 NEURONTIN CAP 400MG ................... 62 NEURONTIN SOL 250/5ML ................ 62 NEURONTIN TAB 600MG ................... 62 NEURONTIN TAB 800MG ................... 62 nevirapine tab 200 mg ..................... 21 nevirapine tab er 24hr 100 mg .......... 21

194

nevirapine tab er 24hr 400 mg ........... 21 NEXAVAR TAB 200MG ....................... 33 niacin oral powder .......................... 119 niacin tab er 1000 mg (antihyperlipidemic) .......................... 47 niacin tab er 500 mg (antihyperlipidemic) ..................................................... 47 niacin tab er 750 mg (antihyperlipidemic) ..................................................... 47 niacor tab 500mg ............................. 47 NIASPAN TAB 1000 ER ...................... 47 NIASPAN TAB 500MG ER ................... 47 NIASPAN TAB 750MG ER ................... 47 nicardipine hcl cap 20 mg .................. 51 nicardipine hcl cap 30 mg .................. 51 NICOTROL INH................................. 87 NICOTROL NS SPR 10MG/ML ............. 87 nifedipine cap 10 mg ........................ 51 nifedipine cap 20 mg ........................ 51 nifedipine tab er 24hr 30 mg .............. 51 nifedipine tab er 24hr 60 mg .............. 51 nifedipine tab er 24hr 90 mg .............. 51 nifedipine tab er 24hr osmotic release 30 mg ................................................. 51 nifedipine tab er 24hr osmotic release 60 mg ................................................. 51 nifedipine tab er 24hr osmotic release 90 mg ................................................. 51 nikki tab 3-0.02mg ........................... 94 nilutamide tab 150 mg ...................... 28 nimodipine cap 30 mg ....................... 51 NINLARO CAP 2.3MG ........................ 33 NINLARO CAP 3MG ........................... 33 NINLARO CAP 4MG ........................... 33 nisoldipine tab er 24hr 17 mg ............ 51 nisoldipine tab er 24hr 20 mg ............ 51 nisoldipine tab er 24hr 25.5 mg .......... 51 nisoldipine tab er 24hr 30 mg ............ 51 nisoldipine tab er 24hr 34 mg ............ 51 nisoldipine tab er 24hr 40 mg ............ 51 nisoldipine tab er 24hr 8.5 mg ........... 51 NITRO-BID OIN 2% .......................... 56 NITRO-DUR DIS 0.1MG/HR ................ 56 NITRO-DUR DIS 0.2MG/HR ................ 56 NITRO-DUR DIS 0.3MG/HR ................ 56

NITRO-DUR DIS 0.4MG/HR ............... 56 NITRO-DUR DIS 0.6MG/HR ............... 56 NITRO-DUR DIS 0.8MG/HR ............... 56 nitrofurantoin macrocrystalline cap 100 mg ................................................ 26 nitrofurantoin macrocrystalline cap 25 mg ................................................ 26 nitrofurantoin macrocrystalline cap 50 mg ................................................ 26 nitrofurantoin monohydrate macrocrystalline cap 100 mg ............. 26 nitrofurantoin susp 25 mg/5ml .......... 26 nitroglycerin cap er 2.5 mg ............... 56 nitroglycerin cap er 6.5 mg ............... 56 nitroglycerin cap er 9 mg .................. 56 nitroglycerin lingual aerosol 400 mcg/spray ...................................... 56 nitroglycerin sl tab 0.3 mg ................ 56 nitroglycerin sl tab 0.4 mg ................ 56 nitroglycerin sl tab 0.6 mg ................ 56 nitroglycerin td patch 24hr 0.1 mg/hr . 56 nitroglycerin td patch 24hr 0.2 mg/hr . 56 nitroglycerin td patch 24hr 0.4 mg/hr . 56 nitroglycerin td patch 24hr 0.6 mg/hr . 56 nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) ..................................... 56 NITROLINGUAL SPR PUMPSPRA ......... 56 NITROSTAT SUB 0.3MG .................... 56 NITROSTAT SUB 0.4MG .................... 56 NITROSTAT SUB 0.6MG .................... 56 nitro-time cap 2.5mg cr .................... 56 nitro-time cap 6.5mg cr .................... 56 nitro-time cap 9mg cr ...................... 56 nizatidine cap 150 mg ..................... 108 nizatidine cap 300 mg ..................... 108 nizatidine oral soln 15 mg/ml ........... 108 NIZORAL SHA 2% ........................... 130 nora-be tab 0.35mg ......................... 96 NORCO TAB 10-325MG ..................... 11 NORCO TAB 5-325MG ...................... 11 NORCO TAB 7.5-325 ........................ 11 norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg .......................... 94 norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg .................................. 94

195

norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg ............................. 94 norethindrone ace-eth estradiol-fe chew tab 1 mg-20 mcg (24) ...................... 94 norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24) ...................... 94 norethindrone acetate tab 5 mg ....... 102 norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg .......................... 97 norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg ............................... 97 norethindrone tab 0.35 mg ................ 96 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg ..................................... 95 norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg ........... 96 norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg ........... 96 NORINYL TAB 1/35 ........................... 95 norlyroc tab 0.35mg ......................... 96 NORPACE CAP 100MG ....................... 44 NORPACE CAP 100MG CR .................. 44 NORPACE CAP 150MG ....................... 44 NORPACE CAP 150MG CR .................. 44 NORPRAMIN TAB 100MG ................... 69 NORPRAMIN TAB 10MG ..................... 69 NORPRAMIN TAB 150MG ................... 69 NORPRAMIN TAB 25MG ..................... 69 NORPRAMIN TAB 50MG ..................... 69 NORPRAMIN TAB 75MG ..................... 69 nortrel tab 0.5/35 ............................. 95 nortrel tab 1/35 ............................... 95 nortrel tab 7/7/7 .............................. 96 nortriptyline hcl cap 10 mg ................ 69 nortriptyline hcl cap 25 mg ................ 69 nortriptyline hcl cap 50 mg ................ 69 nortriptyline hcl cap 75 mg ................ 69 nortriptyline hcl soln 10 mg/5ml ......... 69 nortuss-de dro ............................... 121 NORTUSS-EX LIQ 200-20/5 ............. 121 NORVIR CAP 100MG ......................... 22 NORVIR SOL 80MG/ML ...................... 22 NORVIR TAB 100MG ......................... 22 NOVOLIN INJ 70/30 .......................... 89 NOVOLIN N INJ U-100 ...................... 89

NOVOLIN R INJ U-100 ...................... 89 NOVOLOG INJ 100/ML ...................... 89 NOVOLOG INJ FLEXPEN .................... 89 NOVOLOG INJ PENFILL ..................... 89 NOVOLOG MIX INJ 70/30 .................. 89 NOVOLOG MIX INJ FLEXPEN .............. 89 NOXAFIL SUS 40MG/ML .................... 19 NOXAFIL TAB 100MG ....................... 19 NUCORT LOT 2% ............................ 133 NUCYNTA ER TAB 100MG .................. 11 NUCYNTA ER TAB 150MG .................. 11 NUCYNTA ER TAB 200MG .................. 11 NUCYNTA ER TAB 250MG .................. 11 NUCYNTA ER TAB 50MG ................... 11 NUCYNTA TAB 100MG ...................... 11 NUCYNTA TAB 50MG ........................ 11 NUCYNTA TAB 75MG ........................ 11 NUEDEXTA CAP 20-10MG ................. 86 NULYTELY SOL FLAV PKS ................. 109 NUMOISYN LIQ .............................. 138 NUMOISYN LOZ .............................. 138 NUPLAZID TAB 17MG ....................... 76 NUTRESTORE PAK 5GM ................... 110 NUVARING MIS ............................... 97 NUVIGIL TAB 150MG ........................ 86 NUVIGIL TAB 200MG ........................ 86 NUVIGIL TAB 250MG ........................ 86 NUVIGIL TAB 50MG ......................... 86 NYMALIZE SOL 60/20ML ................... 51 nystatin cream 100000 unit/gm ........ 130 nystatin oint 100000 unit/gm ........... 130 nystatin susp 100000 unit/ml ............ 19 nystatin tab 500000 unit .................. 19 nystatin-triamcinolone cream 100000-0.1 unit/gm-% ............................... 130 nystatin-triamcinolone oint 100000-0.1 unit/gm-% .................................... 130 O OCALIVA TAB 10MG ........................ 110 OCALIVA TAB 5MG .......................... 110 ocella tab 3-0.03mg ......................... 95 OCUFEN SOL 0.03% OP ................... 140 OCUFLOX DRO 0.3% OP .................. 139 ODEFSEY TAB ................................. 20 OFEV CAP 100MG ........................... 126

196

OFEV CAP 150MG ........................... 126 ofloxacin ophth soln 0.3% ............... 139 ofloxacin otic soln 0.3% .................. 143 ofloxacin tab 400 mg ........................ 16 ogestrel tab ..................................... 96 olanzapine orally disintegrating tab 10 mg ................................................. 74 olanzapine orally disintegrating tab 15 mg ................................................. 74 olanzapine orally disintegrating tab 20 mg ................................................. 74 olanzapine orally disintegrating tab 5 mg ..................................................... 74 olanzapine tab 10 mg ....................... 74 olanzapine tab 15 mg ....................... 74 olanzapine tab 2.5 mg ...................... 74 olanzapine tab 20 mg ....................... 74 olanzapine tab 5 mg ......................... 74 olanzapine tab 7.5 mg ...................... 74 olanzapine-fluoxetine hcl cap 12-25 mg ..................................................... 74 olanzapine-fluoxetine hcl cap 12-50 mg ..................................................... 74 olanzapine-fluoxetine hcl cap 3-25 mg 74 olanzapine-fluoxetine hcl cap 6-25 mg 74 olanzapine-fluoxetine hcl cap 6-50 mg 74 olmesartan medoxomil tab 20 mg ....... 43 olmesartan medoxomil tab 40 mg ....... 43 olmesartan medoxomil tab 5 mg ........ 43 olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg .... 42 olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg .... 42 olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg ...... 43 olmesartan-amlodipine-hydrochlorothiazide tab 20-5-12.5 mg . 42 olmesartan-amlodipine-hydrochlorothiazide tab 40-10-12.5 mg ..................................................... 42 olmesartan-amlodipine-hydrochlorothiazide tab 40-10-25 mg .. 42 olmesartan-amlodipine-hydrochlorothiazide tab 40-5-12.5 mg . 42 olmesartan-amlodipine-

hydrochlorothiazide tab 40-5-25 mg ... 42 olopatadine hcl nasal soln 0.6% ........ 125 olopatadine hcl ophth soln 0.1% (base equivalent) .................................... 140 olopatadine hcl ophth soln 0.2% (base equivalent) .................................... 140 OLUX AER 0.05% ........................... 135 OMECLAMOX- MIS PAK .................... 112 omega-3-acid ethyl esters cap 1 gm ... 47 omeprazole cap delayed release 10 mg .................................................... 111 omeprazole cap delayed release 20 mg .................................................... 111 omeprazole cap delayed release 40 mg .................................................... 111 omeprazole-sodium bicarbonate cap 20-1100 mg ....................................... 111 omeprazole-sodium bicarbonate cap 40-1100 mg ....................................... 111 OMNIPRED SUS 1% OP ................... 140 ondansetron hcl oral soln 4 mg/5ml .. 106 ondansetron hcl tab 24 mg .............. 106 ondansetron hcl tab 4 mg ................ 106 ondansetron hcl tab 8 mg ................ 106 ondansetron orally disintegrating tab 4 mg ............................................... 106 ondansetron orally disintegrating tab 8 mg ............................................... 106 ONETOUCH TES ULTRA BL ................ 91 ONETOUCH TES VERIO ..................... 91 ONFI SUS 2.5MG/ML ........................ 62 ONFI TAB 10MG .............................. 62 ONFI TAB 20MG .............................. 62 ONMEL TAB 200MG .......................... 19 ONZETRA XSAI MIS 11MG ................ 83 OPANA TAB 10MG ............................ 11 OPANA TAB 5MG ............................. 11 OPTICHAMBER MIS ADV LRG ............ 124 OPTICHAMBER MIS ADV MED ........... 124 OPTICHAMBER MIS ADV SM ............. 124 OPTICHAMBER MIS ADVANTAG ........ 124 OPTICHAMBER MIS DIA LG .............. 124 OPTICHAMBER MIS DIA MD ............. 124 OPTICHAMBER MIS DIA SM .............. 124 OPTICHAMBER MIS DIAMOND .......... 125

197

OPTICHAMBER MIS FACE MAS .......... 125 OPTIHALER MIS ............................. 125 ORACEA CAP 40MG ......................... 137 ORACIT SOL .................................. 113 ORAFATE PST 10% ......................... 138 ORALAIR SUB 300 IR ...................... 116 oralone dent pst 0.1% .................... 138 ORAMAGICRX SUS ......................... 138 ORAP TAB 1MG ................................ 76 ORAP TAB 2MG ................................ 76 ORAPRED ODT TAB 10MG ................ 100 ORAPRED ODT TAB 15MG ................ 100 ORAPRED ODT TAB 30MG ................ 100 ORAVIG TAB 50MG ........................... 19 ORENITRAM TAB 0.125MG ................. 57 ORENITRAM TAB 0.25MG .................. 57 ORENITRAM TAB 1MG ....................... 57 ORENITRAM TAB 2.5MG .................... 57 ORENITRAM TAB 5MG ....................... 57 ORFADIN CAP 10MG ....................... 101 ORFADIN CAP 20MG ....................... 101 ORFADIN CAP 2MG ......................... 101 ORFADIN CAP 5MG ......................... 101 ORFADIN SUS 4MG/ML .................... 101 ORKAMBI TAB 100-125 ................... 123 ORKAMBI TAB 200-125 ................... 123 orphenadrine citrate tab er 12hr 100 mg ..................................................... 85 orsythia tab ..................................... 94 ORTHO MICRON TAB 0.35MG ............. 96 ORTHO TRI- TAB CYCLEN .................. 97 ORTHO TRI- TAB CYCLN LO ............... 97 ORTHO-CYCLEN TAB 0.25/35 ............. 95 ORTHO-NOVUM TAB 1/35 .................. 95 ORTHO-NOVUM TAB 7/7/7 ................. 97 oseltamivir phosphate cap 30 mg (base equiv) ............................................. 25 oseltamivir phosphate cap 45 mg (base equiv) ............................................. 25 oseltamivir phosphate cap 75 mg (base equiv) ............................................. 25 OSMOPREP TAB 1.5GM .................... 109 OSPHENA TAB 60MG ....................... 103 OTICIN HC DRO ............................. 143 otomax-hc dro ............................... 143

OVCON-35 TAB ............................... 95 OVIDE LOT 0.5% ............................ 137 OXANDRIN TAB 10MG ...................... 87 OXANDRIN TAB 2.5MG ..................... 87 oxandrolone tab 10 mg .................... 87 oxandrolone tab 2.5 mg ................... 87 oxaprozin tab 600 mg ........................ 7 oxazepam cap 10 mg ....................... 59 oxazepam cap 15 mg ....................... 59 oxazepam cap 30 mg ....................... 59 oxcarbazepine susp 300 mg/5ml (60 mg/ml) .......................................... 62 oxcarbazepine tab 150 mg ................ 62 oxcarbazepine tab 300 mg ................ 62 oxcarbazepine tab 600 mg ................ 62 oxiconazole nitrate cream 1% .......... 130 OXSORALEN-UL CAP 10MG .............. 131 OXTELLAR XR TAB 150MG ................ 62 OXTELLAR XR TAB 300MG ................ 62 OXTELLAR XR TAB 600MG ................ 62 oxybutynin chloride syrup 5 mg/5ml . 114 oxybutynin chloride tab 5 mg ........... 114 oxybutynin chloride tab er 24hr 10 mg .................................................... 114 oxybutynin chloride tab er 24hr 15 mg .................................................... 114 oxybutynin chloride tab er 24hr 5 mg 114 oxycodone hcl cap 5 mg ................... 11 oxycodone hcl conc 100 mg/5ml (20 mg/ml) .......................................... 11 oxycodone hcl soln 5 mg/5ml ............ 11 oxycodone hcl tab 10 mg .................. 11 oxycodone hcl tab 15 mg .................. 11 oxycodone hcl tab 20 mg .................. 11 oxycodone hcl tab 30 mg .................. 11 oxycodone hcl tab 5 mg ................... 11 oxycodone hcl tab er 12hr deter 10 mg ..................................................... 11 oxycodone hcl tab er 12hr deter 15 mg ..................................................... 11 oxycodone hcl tab er 12hr deter 20 mg ..................................................... 12 oxycodone hcl tab er 12hr deter 30 mg ..................................................... 12 oxycodone hcl tab er 12hr deter 40 mg

198

..................................................... 12 oxycodone hcl tab er 12hr deter 60 mg ..................................................... 12 oxycodone hcl tab er 12hr deter 80 mg ..................................................... 12 oxycodone w/ acetaminophen soln 5-325 mg/5ml ........................................... 12 oxycodone w/ acetaminophen tab 10-325 mg ................................................. 12 oxycodone w/ acetaminophen tab 2.5-325 mg ........................................... 12 oxycodone w/ acetaminophen tab 5-325 mg ................................................. 12 oxycodone w/ acetaminophen tab 7.5-325 mg ........................................... 12 oxycodone-aspirin tab 4.8355-325 mg 12 oxycodone-ibuprofen tab 5-400 mg .... 12 OXYCONTIN TAB 10MG CR ................ 12 OXYCONTIN TAB 15MG CR ................ 12 OXYCONTIN TAB 20MG CR ................ 12 OXYCONTIN TAB 30MG CR ................ 12 OXYCONTIN TAB 40MG CR ................ 12 OXYCONTIN TAB 60MG CR ................ 12 OXYCONTIN TAB 80MG CR ................ 12 oxymorphone hcl tab 10 mg .............. 12 oxymorphone hcl tab 5 mg ................ 12 oxymorphone hcl tab er 12hr 10 mg ... 12 oxymorphone hcl tab er 12hr 15 mg ... 12 oxymorphone hcl tab er 12hr 20 mg ... 12 oxymorphone hcl tab er 12hr 30 mg ... 12 oxymorphone hcl tab er 12hr 40 mg ... 12 oxymorphone hcl tab er 12hr 5 mg ..... 12 oxymorphone hcl tab er 12hr 7.5 mg .. 12 P pacerone tab 100mg ......................... 44 pacerone tab 200mg ......................... 44 pacerone tab 400mg ......................... 44 paliperidone tab er 24hr 1.5 mg ......... 74 paliperidone tab er 24hr 3 mg ............ 74 paliperidone tab er 24hr 6 mg ............ 74 paliperidone tab er 24hr 9 mg ............ 74 PAMELOR CAP 10MG ......................... 70 PAMELOR CAP 25MG ......................... 70 PAMELOR CAP 50MG ......................... 70 PAMELOR CAP 75MG ......................... 70

PAMINE FORTE TAB 5MG ................. 107 PAMINE FQ KIT .............................. 107 PAMINE TAB 2.5MG ........................ 107 PANCREAZE CAP 10500UNT ............. 110 PANCREAZE CAP 16800UNT ............. 110 PANCREAZE CAP 21000UNT ............. 110 PANCREAZE CAP 4200UNIT .............. 110 PANDEL CRE 0.1% .......................... 134 PANRETIN GEL 0.1% ....................... 136 pantoprazole sodium ec tab 20 mg (base equiv) ........................................... 111 pantoprazole sodium ec tab 40 mg (base equiv) ........................................... 111 PARAFON FORT TAB 500MG .............. 85 PAREMYD SOL 1-0.25% ................... 142 paricalcitol cap 1 mcg ...................... 101 paricalcitol cap 2 mcg ...................... 101 paricalcitol cap 4 mcg ...................... 101 PARLODEL CAP 5MG ........................ 71 PARLODEL TAB 2.5MG ...................... 71 PARNATE TAB 10MG ........................ 66 paroex sol 0.12% ........................... 138 paromomycin sulfate cap 250 mg ...... 13 paroxetine hcl tab 10 mg .................. 67 paroxetine hcl tab 20 mg .................. 67 paroxetine hcl tab 30 mg .................. 67 paroxetine hcl tab 40 mg .................. 67 paroxetine hcl tab er 24hr 12.5 mg .... 67 paroxetine hcl tab er 24hr 25 mg ....... 67 paroxetine hcl tab er 24hr 37.5 mg .... 67 paroxetine mesylate cap 7.5 mg (base equiv) ............................................ 87 PASER GRA 4GM ............................. 23 PATADAY SOL 0.2% ........................ 140 PATANASE SPR 0.6% ...................... 125 PATANOL SOL 0.1% OP ................... 140 PAXIL CR TAB 12.5MG ...................... 67 PAXIL CR TAB 25MG ........................ 67 PAXIL CR TAB 37.5MG ...................... 67 PAXIL SUS 10MG/5ML ...................... 67 PAXIL TAB 10MG ............................. 67 PAXIL TAB 20MG ............................. 67 PAXIL TAB 30MG ............................. 67 PAXIL TAB 40MG ............................. 67 PAZEO DRO 0.7% ........................... 140

199

PCE TAB 333MG EC .......................... 15 PCE TAB 500MG EC .......................... 15 PEAK AIR FLO MIS ADLT/PED ........... 125 PEAK FLOW MIS METER ................... 125 PEAK FLW MTR MIS UNIVERSL ......... 125 PEDIAPRED SOL 6.7/5ML ................. 100 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm ............................. 109 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm ............................. 109 peg 3350-kcl-sod bicarb-nacl for soln 420 gm ......................................... 109 PEGANONE TAB 250MG ..................... 62 peg-prep kit .................................. 109 pegylax pow .................................. 109 penicillin v potassium for soln 125 mg/5ml ........................................... 17 penicillin v potassium for soln 250 mg/5ml ........................................... 17 penicillin v potassium tab 250 mg ....... 17 penicillin v potassium tab 500 mg ....... 17 PENLAC SOL 8% ............................ 130 PENTASA CAP 250MG CR ................. 108 PENTASA CAP 500MG CR ................. 108 pentazocine w/ naloxone tab 50-0.5 mg ..................................................... 12 pentoxifylline tab er 400 mg ............ 116 PEPCID SUS 40MG/5ML ................... 108 PEPCID TAB 20MG .......................... 108 PEPCID TAB 40MG .......................... 108 PERCOCET TAB 10-325MG ................. 12 PERCOCET TAB 2.5-325 .................... 12 PERCOCET TAB 5-325MG ................... 12 PERCOCET TAB 7.5-325 .................... 12 PERFOROMIST NEB 20MCG .............. 122 PERIDEX SOL 0.12% ...................... 138 perindopril erbumine tab 2 mg ........... 39 perindopril erbumine tab 4 mg ........... 39 perindopril erbumine tab 8 mg ........... 39 periogard sol 0.12% ....................... 138 periomed con 0.63% ...................... 138 permethrin cream 5% ..................... 137 perphenazine tab 16 mg .................... 76 perphenazine tab 2 mg ..................... 76 perphenazine tab 4 mg ..................... 76

perphenazine tab 8 mg ..................... 76 perphenazine-amitriptyline tab 2-10 mg ..................................................... 76 perphenazine-amitriptyline tab 2-25 mg ..................................................... 76 perphenazine-amitriptyline tab 4-10 mg ..................................................... 76 perphenazine-amitriptyline tab 4-25 mg ..................................................... 76 perphenazine-amitriptyline tab 4-50 mg ..................................................... 77 PERSONAL BES MIS FULL RNG ......... 125 PERSONAL BES MIS LOW RANG ........ 125 PERTZYE CAP ................................. 110 PEXEVA TAB 10MG .......................... 67 PEXEVA TAB 20MG .......................... 67 PEXEVA TAB 30MG .......................... 67 PEXEVA TAB 40MG .......................... 67 pharbedryl cap 50mg ...................... 121 phenadoz sup 12.5mg ..................... 106 phenadoz sup 25mg ........................ 106 phenelzine sulfate tab 15 mg ............ 66 phenergan sup 12.5mg ................... 106 phenergan sup 25mg ...................... 106 phenergan sup 50mg ...................... 106 phenobarbital elixir 20 mg/5ml .......... 62 phenobarbital tab 100 mg ................. 62 phenobarbital tab 15 mg .................. 62 phenobarbital tab 16.2 mg ................ 62 phenobarbital tab 30 mg .................. 62 phenobarbital tab 32.4 mg ................ 62 phenobarbital tab 60 mg .................. 62 phenobarbital tab 64.8 mg ................ 62 phenobarbital tab 97.2 mg ................ 62 phenoxybenzamine hcl cap 10 mg ..... 40 phenylephrine hcl ophth soln 10% .... 142 phenylephrine hcl ophth soln 2.5% ... 142 phenylephrine-guaifenesin liqd 7.5-100 mg/5ml (1.5-20 mg/ml) .................. 123 PHENYTEK CAP 200MG ..................... 62 PHENYTEK CAP 300MG ..................... 62 phenytoin chew tab 50 mg ................ 62 phenytoin chw 50mg ........................ 62 phenytoin sodium extended cap 100 mg ..................................................... 62

200

phenytoin sodium extended cap 200 mg ..................................................... 62 phenytoin sodium extended cap 300 mg ..................................................... 62 phenytoin susp 125 mg/5ml .............. 62 philith tab 0.4-35 ............................. 95 PHOSLYRA SOL .............................. 102 phospha 250 tab neutral ................. 113 PHOSPHOLINE SOL 0.125%OP ......... 142 PICATO GEL 0.015% ....................... 136 PICATO GEL 0.05% ........................ 136 PIKO 1 MIS ELECTRON .................... 125 pilocarpine hcl ophth soln 1% .......... 142 pilocarpine hcl ophth soln 2% .......... 142 pilocarpine hcl ophth soln 4% .......... 142 pilocarpine hcl tab 5 mg .................. 111 pilocarpine hcl tab 7.5 mg ............... 111 pimozide tab 1 mg ............................ 77 pimozide tab 2 mg ............................ 77 pimtrea tab ..................................... 92 pindolol tab 10 mg ........................... 49 pindolol tab 5 mg ............................. 49 pioglitazone hcl tab 15 mg (base equiv) ..................................................... 89 pioglitazone hcl tab 30 mg (base equiv) ..................................................... 89 pioglitazone hcl tab 45 mg (base equiv) ..................................................... 89 pioglitazone hcl-glimepiride tab 30-2 mg ..................................................... 89 pioglitazone hcl-glimepiride tab 30-4 mg ..................................................... 89 pioglitazone hcl-metformin hcl tab 15-500 mg ........................................... 89 pioglitazone hcl-metformin hcl tab 15-850 mg ........................................... 89 pirmella tab 1/35 ............................. 95 pirmella tab 7/7/7 ............................ 97 piroxicam cap 10 mg ......................... 7 piroxicam cap 20 mg ......................... 7 PLAQUENIL TAB 200MG ................... 116 PLEGISOL SOL ................................. 55 PLIAGLIS CRE 7-7% ....................... 136 POCKET CHAMB MIS ....................... 125 POCKET PEAK MIS METER ............... 125

POCKET SPACE MIS ........................ 125 POCKETPEAK MIS MTR LOW ............. 125 POCKETPEAK MIS UNIVERSA ............ 125 PODOCON SOL 25% ....................... 136 podofilox soln 0.5% ........................ 136 polycin oin op ................................ 139 polyethylene glycol 3350 oral packet . 109 polyethylene glycol 3350 oral powder 109 polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% ....................... 139 POLYTRIM SOL OP .......................... 139 POMALYST CAP 1MG ........................ 29 POMALYST CAP 2MG ........................ 29 POMALYST CAP 3MG ........................ 29 POMALYST CAP 4MG ........................ 29 PONSTEL CAP 250MG ......................... 7 portia-28 tab .................................. 95 pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml ................................... 113 potassium chloride cap er 10 meq ..... 118 potassium chloride cap er 8 meq ...... 118 potassium chloride microencapsulated crys er tab 10 meq ......................... 118 potassium chloride microencapsulated crys er tab 20 meq ......................... 118 potassium chloride oral soln 10% (20 meq/15ml) .................................... 118 potassium chloride oral soln 20% (40 meq/15ml) .................................... 118 potassium chloride tab er 10 meq ..... 118 potassium chloride tab er 20 meq (1500 mg) .............................................. 118 potassium chloride tab er 8 meq (600 mg) .............................................. 118 potassium citrate & citric acid soln 1100-334 mg/5ml ................................... 113 potassium citrate tab er 10 meq (1080 mg) .............................................. 113 potassium citrate tab er 15 meq (1620 mg) .............................................. 113 potassium citrate tab er 5 meq (540 mg) .................................................... 113 POTIGA TAB 200MG ......................... 62 POTIGA TAB 300MG ......................... 62 POTIGA TAB 400MG ......................... 63

201

POTIGA TAB 50MG ........................... 62 pramipexole dihydrochloride tab 0.125 mg ................................................. 71 pramipexole dihydrochloride tab 0.25 mg ..................................................... 71 pramipexole dihydrochloride tab 0.5 mg ..................................................... 71 pramipexole dihydrochloride tab 0.75 mg ..................................................... 71 pramipexole dihydrochloride tab 1 mg . 71 pramipexole dihydrochloride tab 1.5 mg ..................................................... 71 pramipexole dihydrochloride tab er 24hr 0.375 mg ........................................ 71 pramipexole dihydrochloride tab er 24hr 0.75 mg .......................................... 71 pramipexole dihydrochloride tab er 24hr 1.5 mg ........................................... 71 pramipexole dihydrochloride tab er 24hr 2.25 mg .......................................... 71 pramipexole dihydrochloride tab er 24hr 3 mg .............................................. 72 pramipexole dihydrochloride tab er 24hr 3.75 mg .......................................... 72 pramipexole dihydrochloride tab er 24hr 4.5 mg ........................................... 72 PRAMOSONE E CRE 1-2.5% ............. 132 PRAMOSONE LOT 1% ...................... 132 PRAMOSONE LOT 2.5% ................... 132 PRAMOSONE OIN 1% ...................... 132 PRAMOSONE OIN 2.5% ................... 132 PRAMOTIC DRO 1-0.1% .................. 143 pramox gel 1% .............................. 136 PRANDIN TAB 0.5MG ........................ 90 PRANDIN TAB 1MG ........................... 90 PRANDIN TAB 2MG ........................... 90 prasugrel hcl tab 10 mg (base equiv) 116 prasugrel hcl tab 5 mg (base equiv) .. 116 PRAVACHOL TAB 20MG ..................... 46 PRAVACHOL TAB 40MG ..................... 46 PRAVACHOL TAB 80MG ..................... 46 pravastatin sodium tab 10 mg ............ 46 pravastatin sodium tab 20 mg ............ 46 pravastatin sodium tab 40 mg ............ 46 pravastatin sodium tab 80 mg ............ 46

prazosin hcl cap 1 mg ...................... 40 prazosin hcl cap 2 mg ...................... 40 prazosin hcl cap 5 mg ...................... 40 PRECOSE TAB 100MG ....................... 87 PRECOSE TAB 25MG ........................ 87 PRECOSE TAB 50MG ........................ 87 PRED SOD PHO SOL 1% OP ............. 140 PRED-G S.O.P OIN OP ..................... 139 PRED-G SUS OP ............................. 139 prednicarbate cream 0.1% ............... 134 prednicarbate oint 0.1% .................. 134 prednisolone acetate ophth susp 1% . 140 prednisolone sod phos orally disintegr tab 10 mg (base eq) ....................... 100 prednisolone sod phos orally disintegr tab 15 mg (base eq) ....................... 100 prednisolone sod phos orally disintegr tab 30 mg (base eq) ....................... 100 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) ................ 100 prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) ...................... 100 prednisolone sod phosphate oral soln 20 mg/5ml (base equiv) ...................... 100 prednisolone sodium phosphate oral soln 25 mg/5ml (base eq) ...................... 100 prednisolone syrup 15 mg/5ml (usp solution equivalent) ........................ 100 PREDNISONE CON 5MG/ML .............. 100 prednisone oral soln 5 mg/5ml ......... 100 prednisone tab 1 mg ....................... 100 prednisone tab 10 mg ..................... 100 prednisone tab 2.5 mg .................... 100 prednisone tab 20 mg ..................... 100 prednisone tab 5 mg ....................... 100 prednisone tab 50 mg ..................... 100 prednisone tab therapy pack 10 mg (21) .................................................... 100 prednisone tab therapy pack 10 mg (48) .................................................... 100 prednisone tab therapy pack 5 mg (21) .................................................... 100 prednisone tab therapy pack 5 mg (48) .................................................... 100 PREFEST TAB .................................. 97

202

PREMARIN TAB 0.3MG ...................... 98 PREMARIN TAB 0.45MG ..................... 98 PREMARIN TAB 0.625MG ................... 98 PREMARIN TAB 0.9MG ...................... 98 PREMARIN TAB 1.25MG ..................... 98 PREMARIN VAG CRE 0.625MG ............ 99 PREMPHASE TAB .............................. 97 PREMPRO TAB .625-2.5 ..................... 98 PREMPRO TAB 0.3-1.5 ...................... 98 PREMPRO TAB 0.45-1.5 ..................... 98 PREMPRO TAB 0.625-5 ...................... 98 PREPIDIL GEL 0.5MG/3G ................. 101 PREPOPIK PAK ............................... 110 previfem tab .................................... 96 PREVPAC MIS ................................ 112 PREZCOBIX TAB 800-150 .................. 20 PREZISTA SUS 100MG/ML ................. 22 PREZISTA TAB 150MG....................... 22 PREZISTA TAB 600MG....................... 22 PREZISTA TAB 75MG ........................ 22 PREZISTA TAB 800MG....................... 23 PRIFTIN TAB 150MG ......................... 23 PRIMAQUINE TAB 26.3MG ................. 20 primidone tab 250 mg ....................... 63 primidone tab 50 mg ........................ 63 PRIMLEV TAB 10-300MG ................... 12 PRIMLEV TAB 5-300MG ..................... 12 PRIMLEV TAB 7.5-300 ....................... 12 PRIMSOL SOL 50MG/5ML .................. 26 PRINIVIL TAB 10MG .......................... 39 PRINIVIL TAB 20MG .......................... 39 PRINIVIL TAB 5MG ........................... 39 PRISTIQ TAB 100MG ......................... 68 PRISTIQ TAB 25MG .......................... 68 PRISTIQ TAB 50MG .......................... 68 PROAIR HFA AER ............................ 122 PROAIR RESPI AER ......................... 122 probenecid tab 500 mg ...................... 5 PROCARDIA CAP 10MG ..................... 51 PROCARDIA XL TAB 30MG CR ............ 51 PROCARDIA XL TAB 60MG CR ............ 51 PROCARDIA XL TAB 90MG CR ............ 51 PROCENTRA SOL 5MG/5ML ................ 80 prochlorperazine maleate tab 10 mg (base equivalent) ........................... 106

prochlorperazine maleate tab 5 mg (base equivalent) .................................... 106 prochlorperazine suppos 25 mg ........ 106 PROCORT CRE ................................ 112 PROCTOCORT CRE 1% .................... 112 PROCTOFOAM AER HC 1% ............... 112 procto-med cre hc 2.5% .................. 112 procto-pak cre 1% .......................... 112 proctosol hc cre 2.5% ..................... 112 proctozone cre -hc 2.5% ................. 112 PROCYSBI CAP 25MG ...................... 101 PROCYSBI CAP 75MG ...................... 101 progesterone micronized cap 100 mg 102 progesterone micronized cap 200 mg 102 PROGLYCEM SUS 50MG/ML .............. 101 PROLENSA SOL 0.07% .................... 140 PROMACTA TAB 12.5MG .................. 115 PROMACTA TAB 25MG ..................... 115 PROMACTA TAB 50MG ..................... 115 PROMACTA TAB 75MG ..................... 115 prometh vc sol plain ....................... 120 prometh vc/ syp codeine ................. 121 promethazine & phenylephrine syrup 6.25-5 mg/5ml ............................... 120 promethazine hcl suppos 12.5 mg ..... 106 promethazine hcl suppos 25 mg ....... 106 promethazine hcl suppos 50 mg ....... 106 promethazine hcl syrup 6.25 mg/5ml 106 promethazine hcl tab 12.5 mg .......... 106 promethazine hcl tab 25 mg ............. 106 promethazine hcl tab 50 mg ............. 107 promethazine w/ codeine syrup 6.25-10 mg/5ml ......................................... 121 promethazine-dm syrup 6.25-15 mg/5ml .................................................... 121 promethazine-phenylephrine-codeine syrup 6.25-5-10 mg/5ml ................. 121 promethegan sup 12.5mg ................ 107 promethegan sup 25mg................... 107 promethegan sup 50mg................... 107 PROMETRIUM CAP 100MG ................ 102 PROMETRIUM CAP 200MG ................ 102 PROMISEB KIT COMPLETE ............... 131 propafenone hcl cap er 12hr 225 mg .. 44 propafenone hcl cap er 12hr 325 mg .. 44

203

propafenone hcl cap er 12hr 425 mg ... 44 propafenone hcl tab 150 mg .............. 44 propafenone hcl tab 225 mg .............. 44 propafenone hcl tab 300 mg .............. 44 propantheline bromide tab 15 mg ..... 107 proparacaine hcl ophth soln 0.5% ..... 142 propranolol & hydrochlorothiazide tab 40-25 mg ........................................ 48 propranolol & hydrochlorothiazide tab 80-25 mg ........................................ 48 propranolol hcl cap er 24hr 120 mg .... 49 propranolol hcl cap er 24hr 160 mg .... 49 propranolol hcl cap er 24hr 60 mg ...... 49 propranolol hcl cap er 24hr 80 mg ...... 49 propranolol hcl oral soln 20 mg/5ml .... 49 propranolol hcl oral soln 40 mg/5ml .... 49 propranolol hcl tab 10 mg .................. 49 propranolol hcl tab 20 mg .................. 49 propranolol hcl tab 40 mg .................. 49 propranolol hcl tab 60 mg .................. 49 propranolol hcl tab 80 mg .................. 49 propylthiouracil tab 50 mg ............... 103 PROSCAR TAB 5MG ........................ 112 PROSTIN E2 SUP 20MG ................... 101 PROTHELIAL PST 10% .................... 138 PROTOPIC OIN 0.03% ..................... 132 PROTOPIC OIN 0.1% ...................... 132 protriptyline hcl tab 10 mg ................ 70 protriptyline hcl tab 5 mg .................. 70 PROVERA TAB 10MG ....................... 103 PROVERA TAB 2.5MG ...................... 102 PROVERA TAB 5MG ......................... 103 PROZAC CAP 10MG ........................... 67 PROZAC CAP 20MG ........................... 67 PROZAC CAP 40MG ........................... 67 PROZAC WEEKL CAP 90MG ................ 67 PRUDOXIN CRE 5% ........................ 136 pseudoeph-chlorphen w/ hydrocodone soln 60-4-5 mg/5ml ........................ 121 pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml .................................... 121 PULMICORT INH 180MCG ................ 126 PULMICORT INH 90MCG .................. 126 PULMOZYME SOL 1MG/ML ............... 123 PURIXAN SUS 20MG/ML .................... 28

PYLERA CAP ................................... 112 pyrazinamide tab 500 mg ................. 23 pyridostigmine bromide tab 60 mg ..... 85 pyridostigmine bromide tab er 180 mg 85 Q QBRELIS SOL 1MG/ML ...................... 39 QUALAQUIN CAP 324MG ................... 20 quasense tab .................................. 93 quazepam tab 15 mg ....................... 82 QUDEXY XR CAP 100/24HR ............... 63 QUDEXY XR CAP 150/24HR ............... 63 QUDEXY XR CAP 200/24HR ............... 63 QUDEXY XR CAP 25/24HR ................. 63 QUDEXY XR CAP 50/24HR ................. 63 quetiapine fumarate tab 100 mg ........ 74 quetiapine fumarate tab 200 mg ........ 74 quetiapine fumarate tab 25 mg ......... 74 quetiapine fumarate tab 300 mg ........ 74 quetiapine fumarate tab 400 mg ........ 74 quetiapine fumarate tab 50 mg ......... 74 quetiapine fumarate tab er 24hr 150 mg ..................................................... 74 quetiapine fumarate tab er 24hr 200 mg ..................................................... 74 quetiapine fumarate tab er 24hr 300 mg ..................................................... 74 quetiapine fumarate tab er 24hr 400 mg ..................................................... 74 quetiapine fumarate tab er 24hr 50 mg ..................................................... 74 QUILLICHEW CHW 20MG ER ............. 80 QUILLICHEW CHW 30MG ER ............. 80 QUILLICHEW CHW 40MG ER ............. 80 QUILLIVANT SUS 25MG/5ML ............. 80 quinapril hcl tab 10 mg ..................... 39 quinapril hcl tab 20 mg ..................... 39 quinapril hcl tab 40 mg ..................... 39 quinapril hcl tab 5 mg ...................... 39 quinapril-hydrochlorothiazide tab 10-12.5 mg ................................................ 38 quinapril-hydrochlorothiazide tab 20-12.5 mg ................................................ 38 quinapril-hydrochlorothiazide tab 20-25 mg ................................................ 38 quinidine gluconate tab er 324 mg ..... 44

204

quinidine sulfate tab 200 mg .............. 44 quinidine sulfate tab 300 mg .............. 44 quinine sulfate cap 324 mg ................ 20 QUINZYME TAB 90MG ..................... 118 QVAR AER 40MCG .......................... 126 QVAR AER 80MCG .......................... 126 R rabeprazole sodium ec tab 20 mg ..... 111 RADIOGARDASE CAP 0.5GM .............. 91 RAGWITEK SUB ............................. 116 rajani tab ........................................ 94 raloxifene hcl tab 60 mg .................. 103 ramipril cap 1.25 mg ........................ 39 ramipril cap 10 mg ........................... 39 ramipril cap 2.5 mg .......................... 39 ramipril cap 5 mg ............................. 39 RANEXA TAB 1000MG ....................... 55 RANEXA TAB 500MG ......................... 55 ranitidine hcl cap 150 mg ................ 108 ranitidine hcl cap 300 mg ................ 108 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) ....................................... 108 ranitidine hcl tab 150 mg ................. 108 ranitidine hcl tab 300 mg ................. 108 RAPAFLO CAP 4MG ......................... 112 RAPAFLO CAP 8MG ......................... 112 RAPAMUNE SOL 1MG/ML ................. 117 RAPAMUNE TAB 0.5MG .................... 117 RAPAMUNE TAB 1MG ...................... 117 RAPAMUNE TAB 2MG ...................... 117 rasagiline mesylate tab 0.5 mg (base equiv) ............................................. 72 rasagiline mesylate tab 1 mg (base equiv) ............................................. 72 RAVICTI LIQ 1.1GM/ML ................... 101 RAYALDEE CAP 30MCG .................... 101 RAZADYNE ER CAP 16MG .................. 65 RAZADYNE ER CAP 24MG .................. 65 RAZADYNE ER CAP 8MG .................... 65 RAZADYNE TAB 12MG ....................... 65 RAZADYNE TAB 4MG ......................... 65 RAZADYNE TAB 8MG ......................... 65 REBETOL CAP 200MG ........................ 24 REBETOL SOL 40MG/ML .................... 24 reclipsen tab .................................... 95

RECTIV OIN 0.4% ........................... 110 REGENECARE GEL .......................... 138 REGLAN TAB 10MG ......................... 107 REGLAN TAB 5MG ........................... 107 REGRANEX GEL 0.01% .................... 136 relador pak kit 2.5-2.5% ................. 136 relador pak kit plus ......................... 136 relagard gel ................................... 113 RELENZA MIS DISKHALE .................. 25 RELHIST CHW ................................ 120 RELPAX TAB 20MG ........................... 83 RELPAX TAB 40MG ........................... 83 REMERON SLTB TAB 15MG ................ 66 REMERON SLTB TAB 30MG ................ 66 REMERON SLTB TAB 45MG ................ 66 REMERON TAB 15MG ....................... 66 REMERON TAB 30MG ....................... 66 REMERON TAB 45MG ....................... 66 RENACIDIN SOL ............................. 112 RENAGEL TAB 400MG ...................... 102 RENAGEL TAB 800MG ...................... 102 RENVELA PAK 0.8GM ....................... 102 RENVELA PAK 2.4GM ....................... 102 RENVELA TAB 800MG ...................... 102 repaglinide tab 0.5 mg ..................... 90 repaglinide tab 1 mg ........................ 90 repaglinide tab 2 mg ........................ 90 repaglinide-metformin hcl tab 1-500 mg ..................................................... 89 repaglinide-metformin hcl tab 2-500 mg ..................................................... 89 reprexain tab 10-200mg ................... 12 REPREXAIN TAB 5-200MG ................. 12 REQUIP TAB 0.25MG ........................ 72 REQUIP TAB 0.5MG .......................... 72 REQUIP TAB 1MG ............................ 72 REQUIP TAB 2MG ............................ 72 REQUIP TAB 3MG ............................ 72 REQUIP TAB 4MG ............................ 72 REQUIP TAB 5MG ............................ 72 REQUIP XL TAB 12MG ...................... 72 REQUIP XL TAB 2MG ........................ 72 REQUIP XL TAB 4MG ........................ 72 REQUIP XL TAB 6MG ........................ 72 REQUIP XL TAB 8MG ........................ 72

205

RESCRIPTOR TAB 100 MG ................. 21 RESCRIPTOR TAB 200MG .................. 21 RESCULA SOL 0.15% ...................... 143 RESECTISOL SOL 5% ...................... 112 restizan gel ................................... 137 RESTORIL CAP 15MG ........................ 82 RESTORIL CAP 22.5MG ..................... 82 RESTORIL CAP 30MG ........................ 82 RESTORIL CAP 7.5MG ....................... 82 RETIN-A CRE 0.025% ..................... 128 RETIN-A CRE 0.05% ....................... 128 RETIN-A CRE 0.1% ......................... 128 RETIN-A GEL 0.01% ....................... 128 RETIN-A GEL 0.025% ..................... 128 RETIN-A MICR GEL 0.04% ............... 129 RETIN-A MICR GEL 0.04%PMP ......... 129 RETIN-A MICR GEL 0.08% ............... 129 RETIN-A MICR GEL 0.1% ................. 129 RETIN-A MICR GEL 0.1%PUMP ......... 129 RETROVIR CAP 100MG ...................... 22 RETROVIR SYP 50MG/5ML ................. 22 REVLIMID CAP 10MG ........................ 29 REVLIMID CAP 15MG ........................ 29 REVLIMID CAP 2.5MG ....................... 29 REVLIMID CAP 20MG ........................ 29 REVLIMID CAP 25MG ........................ 29 REVLIMID CAP 5MG .......................... 29 REYATAZ CAP 150MG ........................ 23 REYATAZ CAP 200MG ........................ 23 REYATAZ CAP 300MG ........................ 23 REZIRA SOL 60-5/5ML .................... 122 RIBAPAK PAK 1200/DAY .................... 24 RIBAPAK PAK 800/DAY ...................... 24 RIBAPAK TAB 1000/DAY .................... 24 RIBAPAK TAB 600/DAY ...................... 24 ribasphere cap 200mg ...................... 24 ribasphere tab 200mg ....................... 24 ribasphere tab 400mg ....................... 24 ribasphere tab 600mg ....................... 24 ribavirin cap 200 mg ......................... 24 ribavirin for inhal soln 6 gm ............. 126 ribavirin tab 200 mg ......................... 24 RIDAURA CAP 3MG ......................... 117 rifabutin cap 150 mg ........................ 26 RIFADIN CAP 150MG ........................ 23

RIFADIN CAP 300MG ........................ 23 RIFAMATE CAP ................................ 23 rifampin cap 150 mg ........................ 23 rifampin cap 300 mg ........................ 23 RIFATER TAB .................................. 23 RILUTEK TAB 50MG ......................... 84 riluzole tab 50 mg ........................... 84 rimantadine hydrochloride tab 100 mg 25 risedronate sodium tab 150 mg ......... 92 risedronate sodium tab 30 mg ........... 92 risedronate sodium tab 35 mg ........... 92 risedronate sodium tab 5 mg ............. 92 risedronate sodium tab delayed release 35 mg ............................................ 92 RISPERDAL M TAB 0.5MG ................. 74 RISPERDAL M TAB 1MG .................... 74 RISPERDAL M TAB 2MG .................... 74 RISPERDAL M TAB 3MG .................... 74 RISPERDAL M TAB 4MG .................... 74 RISPERDAL SOL 1MG/ML .................. 74 RISPERDAL TAB 0.25MG ................... 74 RISPERDAL TAB 0.5MG..................... 74 RISPERDAL TAB 1MG ....................... 74 RISPERDAL TAB 2MG ....................... 74 RISPERDAL TAB 3MG ....................... 74 RISPERDAL TAB 4MG ....................... 74 risperidone orally disintegrating tab 0.25 mg ................................................ 74 risperidone orally disintegrating tab 0.5 mg ................................................ 74 risperidone orally disintegrating tab 1 mg ..................................................... 74 risperidone orally disintegrating tab 2 mg ..................................................... 75 risperidone orally disintegrating tab 3 mg ..................................................... 75 risperidone orally disintegrating tab 4 mg ..................................................... 75 risperidone soln 1 mg/ml .................. 75 risperidone tab 0.25 mg ................... 75 risperidone tab 0.5 mg ..................... 75 risperidone tab 0.5mg od .................. 75 risperidone tab 1 mg ........................ 75 risperidone tab 1mg odt ................... 75 risperidone tab 2 mg ........................ 75

206

risperidone tab 2mg odt .................... 75 risperidone tab 3 mg ......................... 75 risperidone tab 3mg odt .................... 75 risperidone tab 4 mg ......................... 75 risperidone tab 4mg odt .................... 75 RITALIN LA CAP 10MG ...................... 80 RITALIN LA CAP 20MG ...................... 80 RITALIN LA CAP 30MG ...................... 81 RITALIN LA CAP 40MG ...................... 81 RITALIN TAB 10MG ........................... 81 RITALIN TAB 20MG ........................... 81 RITALIN TAB 5MG ............................ 81 RITEFLO MIS ................................. 125 rivastigmine tartrate cap 1.5 mg ........ 65 rivastigmine tartrate cap 3 mg ........... 65 rivastigmine tartrate cap 4.5 mg ........ 65 rivastigmine tartrate cap 6 mg ........... 65 rivastigmine td patch 24hr 13.3 mg/24hr ..................................................... 65 rivastigmine td patch 24hr 4.6 mg/24hr ..................................................... 65 rivastigmine td patch 24hr 9.5 mg/24hr ..................................................... 65 rizatriptan benzoate oral disintegrating tab 10 mg (base eq) ......................... 83 rizatriptan benzoate oral disintegrating tab 5 mg (base eq) ........................... 83 rizatriptan benzoate tab 10 mg (base equivalent) ...................................... 83 rizatriptan benzoate tab 5 mg (base equivalent) ...................................... 83 ROBAXIN TAB 500MG ....................... 85 ROBAXIN-750 TAB 750MG ................. 85 ROBINUL FORT TAB 2MG ................. 107 ROBINUL TAB 1MG ......................... 107 ROCALTROL CAP 0.25MCG ............... 101 ROCALTROL CAP 0.5MCG ................ 101 ROCALTROL SOL 1MCG/ML .............. 101 ropinirole hydrochloride tab 0.25 mg ... 72 ropinirole hydrochloride tab 0.5 mg .... 72 ropinirole hydrochloride tab 1 mg ....... 72 ropinirole hydrochloride tab 2 mg ....... 72 ropinirole hydrochloride tab 3 mg ....... 72 ropinirole hydrochloride tab 4 mg ....... 72 ropinirole hydrochloride tab 5 mg ....... 72

ropinirole hydrochloride tab er 24hr 12 mg (base equivalent) ....................... 72 ropinirole hydrochloride tab er 24hr 2 mg (base equivalent) ............................ 72 ropinirole hydrochloride tab er 24hr 4 mg (base equivalent) ............................ 72 ropinirole hydrochloride tab er 24hr 6 mg (base equivalent) ............................ 72 ropinirole hydrochloride tab er 24hr 8 mg (base equivalent) ............................ 72 rosadan cre 0.75% ......................... 137 rosadan gel 0.75% ......................... 137 ROSADAN KIT 0.75% ...................... 137 rosuvastatin calcium tab 10 mg ......... 46 rosuvastatin calcium tab 20 mg ......... 46 rosuvastatin calcium tab 40 mg ......... 47 rosuvastatin calcium tab 5 mg ........... 46 roweepra tab 500mg ........................ 63 ROXICODONE TAB 15MG .................. 12 ROXICODONE TAB 30MG .................. 12 ROXICODONE TAB 5MG .................... 12 RUBRACA TAB 200MG ...................... 33 RUBRACA TAB 300MG ...................... 33 RYTARY CAP 145MG ......................... 72 RYTARY CAP 195MG ......................... 72 RYTARY CAP 245MG ......................... 72 RYTARY CAP 95MG .......................... 72 RYTHMOL SR CAP 225MG ................. 44 RYTHMOL SR CAP 325MG ................. 44 RYTHMOL SR CAP 425MG ................. 44 S SABRIL TAB 500MG ......................... 63 SAFYRAL TAB .................................. 95 SALAGEN TAB 5MG ......................... 111 SALAGEN TAB 7.5MG ...................... 111 SALEX CREAM KIT 6% ..................... 137 SALICEPT SUS ............................... 138 salicylic acid cream 6% & cleanser liqd kit ................................................ 137 SALICYLIC ACID SOLN 26% ............. 137 SAMSCA TAB 15MG ......................... 105 SAMSCA TAB 30MG ......................... 105 SANCUSO DIS 3.1MG ...................... 107 SANDIMMUNE CAP 100MG ............... 117 SANDIMMUNE CAP 25MG ................. 117

207

SANTYL OIN 250/GM ...................... 137 SAPHRIS SUB 10MG ......................... 75 SAPHRIS SUB 2.5MG ........................ 75 SAPHRIS SUB 5MG ........................... 75 SARAFEM TAB 10MG ......................... 67 SARAFEM TAB 20MG ......................... 67 SAVELLA MIS TITR PAK ..................... 81 SAVELLA TAB 100MG ........................ 81 SAVELLA TAB 12.5MG ....................... 81 SAVELLA TAB 25MG .......................... 81 SAVELLA TAB 50MG .......................... 81 SCALACORT DK KIT ........................ 132 scalacort lot 2% ............................. 133 scopolamine td patch 72hr 1 mg/3days ................................................... 107 SEASONIQUE TAB ............................ 93 SECONAL CAP 100MG ....................... 82 SECONAL SOD CAP 100MG ................ 82 SECTRAL CAP 200MG ........................ 49 SECTRAL CAP 400MG ........................ 49 selegiline hcl cap 5 mg ...................... 72 selegiline hcl tab 5 mg ...................... 72 selenium sulfide lotion 2.5% ............ 131 SELZENTRY SOL 20MG/ML ................. 20 SELZENTRY TAB 150MG .................... 21 SELZENTRY TAB 25MG ...................... 21 SELZENTRY TAB 300MG .................... 21 SELZENTRY TAB 75MG ...................... 21 SEMPREX-D CAP 8-60MG ................. 120 SENSIPAR TAB 30MG ........................ 91 SENSIPAR TAB 60MG ........................ 91 SENSIPAR TAB 90MG ........................ 91 SEREVENT DIS AER 50MCG ............. 122 SEROQUEL TAB 100MG ..................... 75 SEROQUEL TAB 200MG ..................... 75 SEROQUEL TAB 25MG ....................... 75 SEROQUEL TAB 300MG ..................... 75 SEROQUEL TAB 400MG ..................... 75 SEROQUEL TAB 50MG ....................... 75 SEROQUEL XR TAB 150MG ................ 75 SEROQUEL XR TAB 200MG ................ 75 SEROQUEL XR TAB 300MG ................ 75 SEROQUEL XR TAB 400MG ................ 75 SEROQUEL XR TAB 50MG .................. 75 sertraline hcl oral conc 20 mg/ml ........ 67

sertraline hcl tab 100 mg .................. 67 sertraline hcl tab 25 mg ................... 67 sertraline hcl tab 50 mg ................... 67 setlakin tab .................................... 93 sevelamer carbonate packet 0.8 gm .. 102 sevelamer carbonate packet 2.4 gm .. 102 sevelamer carbonate tab 800 mg ...... 102 sharobel tab 0.35mg ........................ 96 SHOHLS SOL MODIFIED .................. 113 sildenafil citrate tab 20 mg ............... 57 SILVADENE CRE 1% ....................... 129 SILVER NITRA OIN 10% .................. 137 SILVER NITRA SOL 10% .................. 137 SILVER NITRA SOL 25% .................. 137 SILVER NITRA SOL 50% .................. 137 silver sulfadiazine cream 1% ............ 129 SIMBRINZA SUS 1-0.2% ................. 141 simvastatin tab 10 mg ...................... 47 simvastatin tab 20 mg ...................... 47 simvastatin tab 40 mg ...................... 47 simvastatin tab 5 mg ....................... 47 simvastatin tab 80 mg ...................... 47 SINEMET CR TAB 25-100MG ............. 72 SINEMET CR TAB 50-200MG ............. 72 SINEMET TAB 10-100MG .................. 72 SINEMET TAB 25-100MG .................. 73 SINEMET TAB 25-250MG .................. 73 SINGULAIR CHW 4MG ..................... 123 SINGULAIR CHW 5MG ..................... 123 SINGULAIR GRA 4MG ...................... 123 SINGULAIR TAB 10MG ..................... 123 sirolimus tab 0.5 mg ....................... 118 sirolimus tab 1 mg .......................... 118 sirolimus tab 2 mg .......................... 118 SIRTURO TAB 100MG ....................... 23 SITAVIG TAB 50MG.......................... 24 SIVEXTRO TAB 200MG ..................... 26 SKELAXIN TAB 800MG...................... 85 SKLICE LOT 0.5% ........................... 137 sodium chloride irrigation soln 0.9% . 112 sodium chloride soln nebu 10% ........ 125 sodium citrate & citric acid soln 500-334 mg/5ml ......................................... 113 sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) ......................... 119

208

sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) ................................... 119 sodium fluoride chew tab 1 mg f (from 2.2 mg naf) ................................... 119 sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) .............................. 119 sodium fluoride tab 0.5 mg f (from 1.1 mg naf) ........................................ 119 sodium fluoride tab 1 mg f (from 2.2 mg naf) .............................................. 119 sodium phenylbutyrate tab 500 mg ... 110 sodium polystyrene sulfonate oral susp 15 gm/60ml .................................. 102 sodium polystyrene sulfonate powder 102 sodium polystyrene sulfonate rectal susp 30 gm/120ml ................................. 102 SOLIQUA INJ 100/33 ........................ 88 SOLODYN TAB 105MG ....................... 19 SOLODYN TAB 115MG ....................... 19 SOLODYN TAB 55MG ........................ 18 SOLODYN TAB 65MG ........................ 19 SOLODYN TAB 80MG ........................ 19 SOLTAMOX SOL 10MG/5ML ................ 28 SOMA TAB 250MG ............................ 85 SOMA TAB 350MG ............................ 85 SOOLANTRA CRE 1% ...................... 137 SORBITOL SOL 3% IRR ................... 113 SORBITOL SOL 3.3% IRR ................ 113 SORBITOL-MAN SOL ....................... 113 SORIATANE CAP 10MG .................... 131 SORIATANE CAP 17.5MG ................. 131 SORIATANE CAP 25MG .................... 131 SORILUX AER 0.005% .................... 131 sorine tab 120mg ............................. 44 sorine tab 160mg ............................. 44 sorine tab 240mg ............................. 44 sorine tab 80mg ............................... 44 sotalol hcl (afib/afl) tab 120 mg ......... 44 sotalol hcl (afib/afl) tab 160 mg ......... 45 sotalol hcl (afib/afl) tab 80 mg ........... 44 sotalol hcl tab 120 mg....................... 45 sotalol hcl tab 160 mg....................... 45 sotalol hcl tab 240 mg....................... 45 sotalol hcl tab 80 mg ........................ 45 SOTYLIZE SOL 5MG/ML ..................... 45

SOVALDI TAB 400MG ....................... 24 SPECTRACEF TAB 400MG .................. 14 spinosad susp 0.9% ........................ 137 SPIRIVA AER 1.25MCG .................... 120 SPIRIVA CAP HANDIHLR .................. 120 SPIRIVA SPR 2.5MCG ...................... 120 spironolactone & hydrochlorothiazide tab 25-25 mg ....................................... 53 spironolactone tab 100 mg ................ 40 spironolactone tab 25 mg ................. 40 spironolactone tab 50 mg ................. 40 sprintec 28 tab 28 day ..................... 96 SPRIX SPR 15.75MG .......................... 7 SPRYCEL TAB 100MG ....................... 34 SPRYCEL TAB 140MG ....................... 34 SPRYCEL TAB 20MG ......................... 33 SPRYCEL TAB 50MG ......................... 33 SPRYCEL TAB 70MG ......................... 34 SPRYCEL TAB 80MG ......................... 34 sps sus 15gm/60 ............................ 102 sronyx tab ...................................... 94 ssd cre 1% .................................... 130 STALEVO 100 TAB ........................... 73 STALEVO 125 TAB ........................... 73 STALEVO 150 TAB ........................... 73 STALEVO 200 TAB ........................... 73 STALEVO 50 TAB ............................. 73 STALEVO 75 TAB ............................. 73 STARLIX TAB 120MG ........................ 90 STARLIX TAB 60MG ......................... 90 stavudine cap 15 mg ........................ 22 stavudine cap 20 mg ........................ 22 stavudine cap 30 mg ........................ 22 stavudine cap 40 mg ........................ 22 STIMATE SOL 1.5MG/ML .................. 105 STIVARGA TAB 40MG ....................... 34 STRATTERA CAP 100MG ................... 81 STRATTERA CAP 10MG ..................... 81 STRATTERA CAP 18MG ..................... 81 STRATTERA CAP 25MG ..................... 81 STRATTERA CAP 40MG ..................... 81 STRATTERA CAP 60MG ..................... 81 STRATTERA CAP 80MG ..................... 81 STRIANT MIS 30MG ......................... 87 STRIBILD TAB ................................. 20

209

STRIVERDI AER 2.5MCG .................. 122 STROMECTOL TAB 3MG ..................... 26 SUBOXONE MIS 12-3MG ................... 86 SUBOXONE MIS 2-0.5MG .................. 86 SUBOXONE MIS 4-1MG ..................... 86 SUBOXONE MIS 8-2MG ..................... 86 SUBSYS SPR 100MCG ....................... 12 SUBSYS SPR 1200MCG ..................... 13 SUBSYS SPR 1600MCG ..................... 13 SUBSYS SPR 200MCG ....................... 13 SUBSYS SPR 400MCG ....................... 13 SUBSYS SPR 600MCG ....................... 13 SUBSYS SPR 800MCG ....................... 13 SUCRAID SOL 8500/ML ................... 110 sucralfate tab 1 gm ........................ 110 SULAR TAB 17MG ............................. 51 SULAR TAB 34MG ............................. 51 SULAR TAB 8.5MG ............................ 51 SULF LIME SOL .............................. 137 sulfacetamide sodium ophth oint 10% ................................................... 139 sulfacetamide sodium ophth soln 10% ................................................... 139 sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% ............. 139 SULFADIAZINE TAB 500MG ............... 17 sulfamethoxazole-trimethoprim susp 200-40 mg/5ml ................................ 17 sulfamethoxazole-trimethoprim tab 400-80 mg ............................................ 17 sulfamethoxazole-trimethoprim tab 800-160 mg ........................................... 17 SULFAMYLON CRE 85MG/GM ............ 137 SULFAMYLON PAK 5% ..................... 137 sulfasalazine tab 500 mg ................. 108 sulfasalazine tab delayed release 500 mg ................................................... 108 sulfatrim pd sus 200-40/5 ................. 17 sulindac tab 150 mg .......................... 7 sulindac tab 200 mg .......................... 7 sumatriptan nasal spray 20 mg/act ..... 83 sumatriptan nasal spray 5 mg/act ....... 83 sumatriptan succinate inj 6 mg/0.5ml . 83 sumatriptan succinate solution auto-injector 4 mg/0.5ml .......................... 83

sumatriptan succinate solution auto-injector 6 mg/0.5ml ......................... 83 sumatriptan succinate solution cartridge 4 mg/0.5ml .................................... 83 sumatriptan succinate solution cartridge 6 mg/0.5ml .................................... 84 sumatriptan succinate solution prefilled syringe 6 mg/0.5ml ......................... 84 sumatriptan succinate tab 100 mg ..... 84 sumatriptan succinate tab 25 mg ....... 84 sumatriptan succinate tab 50 mg ....... 84 SUPRAX CAP 400MG ........................ 15 SUPRAX CHW 100MG ....................... 15 SUPRAX CHW 200MG ....................... 15 SUPRAX SUS 100/5ML ...................... 15 SUPRAX SUS 200/5ML ...................... 15 SUPRAX SUS 500/5ML ...................... 15 SUPREP BOWEL SOL PREP KIT .......... 110 SURMONTIL CAP 100MG ................... 70 SURMONTIL CAP 25MG ..................... 70 SURMONTIL CAP 50MG ..................... 70 SUSTIVA CAP 200MG ....................... 21 SUSTIVA CAP 50MG ......................... 21 SUSTIVA TAB 600MG ....................... 21 SUTENT CAP 12.5MG ....................... 34 SUTENT CAP 25MG .......................... 34 SUTENT CAP 37.5MG ....................... 34 SUTENT CAP 50MG .......................... 34 syeda tab 3-0.03mg ......................... 95 SYMBYAX CAP 12-25MG ................... 75 SYMBYAX CAP 12-50MG ................... 75 SYMBYAX CAP 3-25MG ..................... 75 SYMBYAX CAP 6-25MG ..................... 75 SYMBYAX CAP 6-50MG ..................... 75 SYMLINPEN 60 INJ 1000MCG ............ 87 SYMLNPEN 120 INJ 1000MCG ............ 88 SYNALAR CRE 0.025% .................... 134 SYNALAR KIT 0.025% ..................... 132 SYNALAR OIN 0.025% ..................... 134 SYNALAR SOL 0.01% ...................... 133 SYNALAR TS KIT 0.01% .................. 132 SYNALGOS-DC CAP .......................... 13 SYNAREL SOL 2MG/ML ..................... 97 SYNERA DIS 70-70MG ..................... 136 SYNTHROID TAB 100MCG ................ 104

210

SYNTHROID TAB 112MCG ................ 104 SYNTHROID TAB 125MCG ................ 104 SYNTHROID TAB 137MCG ................ 104 SYNTHROID TAB 150MCG ................ 104 SYNTHROID TAB 175MCG ................ 104 SYNTHROID TAB 200MCG ................ 104 SYNTHROID TAB 25MCG ................. 104 SYNTHROID TAB 300MCG ................ 104 SYNTHROID TAB 50MCG ................. 104 SYNTHROID TAB 75MCG ................. 104 SYNTHROID TAB 88MCG ................. 104 T TABLOID TAB 40MG .......................... 28 TACLONEX OIN .............................. 131 TACLONEX SUS .............................. 131 tacrolimus cap 0.5 mg .................... 117 tacrolimus cap 1 mg ....................... 117 tacrolimus cap 5 mg ....................... 117 tacrolimus oint 0.03% ..................... 132 tacrolimus oint 0.1% ...................... 132 TAFINLAR CAP 50MG ........................ 34 TAFINLAR CAP 75MG ........................ 34 TAGRISSO TAB 40MG ....................... 34 TAGRISSO TAB 80MG ....................... 34 TAMIFLU CAP 30MG .......................... 25 TAMIFLU CAP 45MG .......................... 25 TAMIFLU CAP 75MG .......................... 25 TAMIFLU SUS 6MG/ML ...................... 25 tamoxifen citrate tab 10 mg (base equivalent) ...................................... 28 tamoxifen citrate tab 20 mg (base equivalent) ...................................... 28 tamsulosin hcl cap 0.4 mg ............... 112 TAPAZOLE TAB 10MG ...................... 103 TAPAZOLE TAB 5MG ....................... 103 TARCEVA TAB 100MG ....................... 34 TARCEVA TAB 150MG ....................... 34 TARCEVA TAB 25MG ......................... 34 TARGADOX TAB 50MG ...................... 19 TARGRETIN CAP 75MG ...................... 36 TARGRETIN GEL 1% ......................... 36 tarina fe tab 1/20 ............................. 94 TARKA TAB 1-240 CR ........................ 37 TARKA TAB 2-180 CR ........................ 37 TARKA TAB 2-240 CR ........................ 37

TARKA TAB 4-240 CR ....................... 37 TASMAR TAB 100MG ........................ 73 TAYTULLA CAP ................................ 94 tazarotene cream 0.1% ................... 129 TAZORAC CRE 0.05% ...................... 129 TAZORAC CRE 0.1% ....................... 129 TAZORAC GEL 0.05% ...................... 129 TAZORAC GEL 0.1% ....................... 129 taztia xt cap 120mg/24 .................... 52 taztia xt cap 180mg/24 .................... 52 taztia xt cap 240mg/24 .................... 52 taztia xt cap 300mg/24 .................... 52 taztia xt cap 360mg/24 .................... 52 tbc aer .......................................... 137 TECFIDERA CAP 120MG .................... 84 TECFIDERA CAP 240MG .................... 84 TECFIDERA MIS STARTER ................. 84 TEGRETOL SUS 100/5ML .................. 63 TEGRETOL TAB 200MG ..................... 63 TEGRETOL-XR TAB 100MG ................ 63 TEGRETOL-XR TAB 200MG ................ 63 TEGRETOL-XR TAB 400MG ................ 63 TEKTURNA HCT TAB 150-12.5 ........... 53 TEKTURNA HCT TAB 150-25MG ......... 53 TEKTURNA HCT TAB 300-12.5 ........... 53 TEKTURNA HCT TAB 300-25MG ......... 53 TEKTURNA TAB 150MG ..................... 53 TEKTURNA TAB 300MG ..................... 53 telmisartan tab 20 mg ...................... 43 telmisartan tab 40 mg ...................... 43 telmisartan tab 80 mg ...................... 44 telmisartan-amlodipine tab 40-10 mg . 41 telmisartan-amlodipine tab 40-5 mg ... 41 telmisartan-amlodipine tab 80-10 mg . 41 telmisartan-amlodipine tab 80-5 mg ... 41 telmisartan-hydrochlorothiazide tab 40-12.5 mg ......................................... 43 telmisartan-hydrochlorothiazide tab 80-12.5 mg ......................................... 43 telmisartan-hydrochlorothiazide tab 80-25 mg ............................................ 43 temazepam cap 15 mg ..................... 82 temazepam cap 22.5 mg .................. 82 temazepam cap 30 mg ..................... 82 temazepam cap 7.5 mg .................... 82

211

TEMODAR CAP 100MG ...................... 27 TEMODAR CAP 140MG ...................... 27 TEMODAR CAP 180MG ...................... 27 TEMODAR CAP 20MG ........................ 27 TEMODAR CAP 250MG ...................... 27 TEMODAR CAP 5MG .......................... 27 TEMOVATE CRE 0.05% .................... 135 TEMOVATE E CRE 0.05%EML ........... 135 TEMOVATE GEL 0.05% .................... 135 TEMOVATE OIN 0.05% .................... 135 TEMOVATE SOL 0.05% .................... 135 temozolomide cap 100 mg ................. 27 temozolomide cap 140 mg ................. 27 temozolomide cap 180 mg ................. 27 temozolomide cap 20 mg .................. 27 temozolomide cap 250 mg ................. 27 temozolomide cap 5 mg .................... 27 tencon tab 50-325mg ........................ 5 TENEX TAB 1MG ............................... 40 TENEX TAB 2MG ............................... 40 TENORETIC TAB 100 ......................... 48 TENORETIC TAB 50 .......................... 48 TENORMIN TAB 100MG ..................... 49 TENORMIN TAB 25MG ....................... 49 TENORMIN TAB 50MG ....................... 49 TERAZOL 7 CRE 0.4% ..................... 114 terazosin hcl cap 1 mg ...................... 41 terazosin hcl cap 10 mg .................... 41 terazosin hcl cap 2 mg ...................... 41 terazosin hcl cap 5 mg ...................... 41 terbinafine hcl tab 250 mg ................. 20 terbutaline sulfate tab 2.5 mg .......... 123 terbutaline sulfate tab 5 mg ............. 123 terconazole vaginal cream 0.4% ....... 114 terconazole vaginal cream 0.8% ....... 114 terconazole vaginal suppos 80 mg .... 114 TERSI FOAM AER 2.25% ................. 131 TESSALON PER CAP 100MG ............. 122 testosterone td gel 10mg/act (2%) ..... 87 testosterone td gel 25 mg/2.5gm (1%)87 testosterone td gel 50 mg/5gm (1%) .. 87 testosterone td soln 30 mg/act ........... 87 TESTRED CAP 10MG ......................... 87 tetrabenazine tab 12.5 mg ................ 81 tetrabenazine tab 25 mg ................... 81

tetracaine hcl ophth soln 0.5% ......... 142 tetracycline hcl cap 250 mg .............. 19 tetracycline hcl cap 500 mg .............. 19 TEXACORT SOL 2.5% ...................... 133 TGQ 15DM/5PE SYP H/2CPM ............ 121 TGQ 30/ SYP 150/15 ....................... 121 TGQ 30/PSE/3 SYP BRM/15DM ......... 121 THALOMID CAP 100MG ..................... 30 THALOMID CAP 150MG ..................... 30 THALOMID CAP 200MG ..................... 30 THALOMID CAP 50MG ...................... 30 THEO-24 CAP 100MG CR ................. 127 THEO-24 CAP 200MG CR ................. 127 THEO-24 CAP 300MG CR ................. 127 THEO-24 CAP 400MG ER .................. 127 theochron tab 100mg cr .................. 127 theochron tab 200mg cr .................. 127 theochron tab 300mg cr .................. 127 theophylline soln 80 mg/15ml .......... 127 theophylline tab er 12hr 100 mg ....... 127 theophylline tab er 12hr 200 mg ....... 127 theophylline tab er 12hr 300 mg ....... 127 theophylline tab er 12hr 450 mg ....... 127 theophylline tab er 24hr 400 mg ....... 127 theophylline tab er 24hr 600 mg ....... 127 THIOLA TAB 100MG ........................ 113 thioridazine hcl tab 10 mg ................ 77 thioridazine hcl tab 100 mg ............... 77 thioridazine hcl tab 25 mg ................ 77 thioridazine hcl tab 50 mg ................ 77 thiothixene cap 1 mg ....................... 77 thiothixene cap 10 mg ...................... 77 thiothixene cap 2 mg ....................... 77 thiothixene cap 5 mg ....................... 77 THYROLAR-1 TAB 60MG .................. 104 THYROLAR-1/2 TAB 30MG ............... 104 THYROLAR-1/4 TAB 15MG ............... 104 THYROLAR-2 TAB 120MG ................. 104 THYROLAR-3 TAB 180MG ................. 104 tiagabine hcl tab 2 mg ...................... 63 tiagabine hcl tab 4 mg ...................... 63 TIAZAC CAP 120MG/24 .................... 52 TIAZAC CAP 180MG/24 .................... 52 TIAZAC CAP 240MG/24 .................... 52 TIAZAC CAP 300MG/24 .................... 52

212

TIAZAC CAP 360MG/24 ..................... 52 TIAZAC CAP 420MG/24 ..................... 52 TIGAN CAP 300MG ......................... 107 TIKOSYN CAP 125MCG ...................... 45 TIKOSYN CAP 250MCG ...................... 45 TIKOSYN CAP 500MCG ...................... 45 tilia fe tab ....................................... 97 timolol maleate ophth gel forming soln 0.25% .......................................... 141 timolol maleate ophth gel forming soln 0.5% ............................................ 141 timolol maleate ophth soln 0.25% .... 141 timolol maleate ophth soln 0.5% ...... 141 timolol maleate tab 10 mg ................. 49 timolol maleate tab 20 mg ................. 49 timolol maleate tab 5 mg................... 49 TIMOPTIC OCU SOL 0.25% OP ......... 141 TIMOPTIC OCU SOL 0.5% OP ........... 141 TIMOPTIC SOL 0.25% OP ................ 141 TIMOPTIC SOL 0.5% OP .................. 141 TIMOPTIC-XE SOL 0.25% OP ........... 141 TIMOPTIC-XE SOL 0.5% OP ............. 141 TINDAMAX TAB 500MG ..................... 26 tinidazole tab 250 mg ....................... 26 tinidazole tab 500 mg ....................... 26 TIROSINT CAP 100MCG ................... 104 TIROSINT CAP 112MCG ................... 104 TIROSINT CAP 125MCG ................... 104 TIROSINT CAP 137MCG ................... 104 TIROSINT CAP 13MCG .................... 104 TIROSINT CAP 150MCG ................... 104 TIROSINT CAP 25MCG .................... 104 TIROSINT CAP 50MCG .................... 104 TIROSINT CAP 75MCG .................... 104 TIROSINT CAP 88MCG .................... 104 TIVICAY TAB 10MG ........................... 21 TIVICAY TAB 25MG ........................... 21 TIVICAY TAB 50MG ........................... 21 tizanidine hcl cap 2 mg (base equivalent) ..................................................... 85 tizanidine hcl cap 4 mg (base equivalent) ..................................................... 85 tizanidine hcl cap 6 mg (base equivalent) ..................................................... 85 tizanidine hcl tab 2 mg (base equivalent)

..................................................... 85 tizanidine hcl tab 4 mg (base equivalent) ..................................................... 85 TOBRADEX OIN 0.3-0.1% ................ 139 TOBRADEX ST SUS 0.3-0.05 ............ 139 TOBRADEX SUS 0.3-0.1% ............... 139 tobramycin neb 300/5ml ................. 123 tobramycin nebu soln 300 mg/5ml .... 123 tobramycin ophth soln 0.3% ............ 139 tobramycin-dexamethasone ophth susp 0.3-0.1% ...................................... 139 TOBREX OIN 0.3% OP ..................... 139 TOBREX SOL 0.3% OP ..................... 140 TOFRANIL TAB 10MG ....................... 70 TOFRANIL TAB 25MG ....................... 70 TOFRANIL TAB 50MG ....................... 70 tolazamide tab 250 mg ..................... 91 tolazamide tab 500 mg ..................... 91 tolbutamide tab 500 mg ................... 91 tolcapone tab 100 mg ...................... 73 tolmetin sodium cap 400 mg ............... 7 tolmetin sodium tab 200 mg ............... 7 tolmetin sodium tab 600 mg ............... 7 tolterodine tartrate cap er 24hr 2 mg 114 tolterodine tartrate cap er 24hr 4 mg 114 tolterodine tartrate tab 1 mg ............ 114 tolterodine tartrate tab 2 mg ............ 114 TOPAMAX SPR CAP 15MG ................. 63 TOPAMAX SPR CAP 25MG ................. 63 TOPAMAX TAB 100MG ...................... 63 TOPAMAX TAB 200MG ...................... 63 TOPAMAX TAB 25MG ........................ 63 TOPAMAX TAB 50MG ........................ 63 topex topcal aer anesthet ................ 138 TOPICORT CRE 0.05% ..................... 134 TOPICORT CRE 0.25% ..................... 132 TOPICORT GEL 0.05% ..................... 132 TOPICORT OIN 0.05% ..................... 134 TOPICORT OIN 0.25% ..................... 132 TOPICORT SPR 0.25% ..................... 132 topiramate cap er 24hr sprinkle 100 mg ..................................................... 63 topiramate cap er 24hr sprinkle 150 mg ..................................................... 63 topiramate cap er 24hr sprinkle 200 mg

213

..................................................... 63 topiramate cap er 24hr sprinkle 25 mg 63 topiramate cap er 24hr sprinkle 50 mg 63 topiramate sprinkle cap 15 mg ........... 63 topiramate sprinkle cap 25 mg ........... 63 topiramate tab 100 mg ..................... 63 topiramate tab 200 mg ..................... 63 topiramate tab 25 mg ....................... 63 topiramate tab 50 mg ....................... 63 TOPROL XL TAB 100MG ..................... 49 TOPROL XL TAB 200MG ..................... 50 TOPROL XL TAB 25MG ....................... 49 TOPROL XL TAB 50MG ....................... 49 torsemide tab 10 mg ........................ 54 torsemide tab 100 mg ....................... 54 torsemide tab 20 mg ........................ 54 torsemide tab 5 mg .......................... 54 TOVIAZ TAB 4MG ........................... 114 TOVIAZ TAB 8MG ........................... 114 TRACLEER TAB 125MG ...................... 57 TRACLEER TAB 62.5MG ..................... 57 TRADJENTA TAB 5MG ........................ 88 TRAMADOL HCL CAP 150MG ER .......... 13 tramadol hcl cap er 24hr biphasic release 100 mg ........................................... 13 tramadol hcl cap er 24hr biphasic release 200 mg ........................................... 13 tramadol hcl cap er 24hr biphasic release 300 mg ........................................... 13 tramadol hcl tab 50 mg ..................... 13 tramadol hcl tab er 24hr 100 mg ........ 13 tramadol hcl tab er 24hr 200 mg ........ 13 tramadol hcl tab er 24hr 300 mg ........ 13 tramadol hcl tab er 24hr biphasic release 100 mg ........................................... 13 tramadol hcl tab er 24hr biphasic release 200 mg ........................................... 13 tramadol hcl tab er 24hr biphasic release 300 mg ........................................... 13 tramadol-acetaminophen tab 37.5-325 mg ................................................. 13 trandolapril tab 1 mg ........................ 39 trandolapril tab 2 mg ........................ 39 trandolapril tab 4 mg ........................ 39 trandolapril-verapamil hcl tab er 1-240

mg ................................................ 37 trandolapril-verapamil hcl tab er 2-180 mg ................................................ 37 trandolapril-verapamil hcl tab er 2-240 mg ................................................ 37 trandolapril-verapamil hcl tab er 4-240 mg ................................................ 37 tranexamic acid tab 650 mg ............. 115 TRANSDERM-SC DIS 1.5MG ............. 107 TRANXENE T TAB 7.5MG ................... 59 tranylcypromine sulfate tab 10 mg ..... 66 TRAVATAN Z DRO 0.004% ............... 143 trazodone hcl tab 100 mg ................. 66 trazodone hcl tab 150 mg ................. 66 trazodone hcl tab 300 mg ................. 66 trazodone hcl tab 50 mg ................... 66 TRECATOR TAB 250MG ..................... 23 TRESIBA FLEX INJ 100UNIT .............. 89 TRESIBA FLEX INJ 200UNIT .............. 89 tretinoin cap 10 mg ......................... 36 tretinoin cream 0.025% ................... 129 tretinoin cream 0.05% .................... 129 tretinoin cream 0.1% ...................... 129 tretinoin gel 0.01% ......................... 129 tretinoin gel 0.025% ....................... 129 tretinoin gel 0.05% ......................... 129 tretinoin microsphere gel 0.04% ....... 129 tretinoin microsphere gel 0.1% ......... 129 TRETIN-X CRE 0.0375% .................. 129 TRETIN-X CRE 0.075% .................... 129 TREXALL TAB 10MG ......................... 28 TREXALL TAB 15MG ......................... 28 TREXALL TAB 5MG ........................... 28 TREXALL TAB 7.5MG ........................ 28 triamcinolone acetonide aerosol soln 0.147 mg/gm ................................. 134 triamcinolone acetonide cream 0.025% .................................................... 134 triamcinolone acetonide cream 0.1% . 134 triamcinolone acetonide cream 0.5% . 132 triamcinolone acetonide dental paste 0.1% ............................................ 138 triamcinolone acetonide lotion 0.025% .................................................... 134 triamcinolone acetonide lotion 0.1% .. 134

214

triamcinolone acetonide nasal aerosol suspension 55 mcg/act ................... 126 triamcinolone acetonide oint 0.025% 134 triamcinolone acetonide oint 0.1% .... 134 triamcinolone acetonide oint 0.5% .... 132 triamterene & hydrochlorothiazide cap 37.5-25 mg ..................................... 54 triamterene & hydrochlorothiazide cap 50-25 mg ........................................ 54 triamterene & hydrochlorothiazide tab 37.5-25 mg ..................................... 54 triamterene & hydrochlorothiazide tab 75-50 mg ........................................ 54 TRIANEX OIN 0.05% ....................... 135 triazolam tab 0.125 mg ..................... 82 triazolam tab 0.25 mg ....................... 82 TRIBENZOR20- TAB 5-12.5MG ........... 42 TRIBENZOR40- TAB 10-12.5 .............. 42 TRIBENZOR40- TAB 10-25MG ............ 42 TRIBENZOR40- TAB 5-12.5MG ........... 42 TRIBENZOR40- TAB 5-25MG .............. 42 TRI-CHLOR LIQ 80% ....................... 137 triderm cre 0.1% ............................ 135 tri-estaryll tab .................................. 97 trifluoperazine hcl tab 1 mg (base equivalent) ...................................... 77 trifluoperazine hcl tab 10 mg (base equivalent) ...................................... 77 trifluoperazine hcl tab 2 mg (base equivalent) ...................................... 77 trifluoperazine hcl tab 5 mg (base equivalent) ...................................... 77 trifluridine ophth soln 1% ................ 141 TRIGLIDE TAB 160MG ....................... 46 trihexyphenidyl hcl elixir 0.4 mg/ml .... 73 trihexyphenidyl hcl tab 2 mg .............. 73 trihexyphenidyl hcl tab 5 mg .............. 73 tri-legest tab fe ................................ 97 TRILEPTAL SUS 300MG/5M ................ 63 TRILEPTAL TAB 150MG ...................... 63 TRILEPTAL TAB 300MG ...................... 63 TRILEPTAL TAB 600MG ...................... 63 tri-linyah tab ................................... 97 TRILIPIX CAP 135MG ........................ 46 TRILIPIX CAP 45MG .......................... 46

tri-lo tab estaryll ............................. 97 tri-lo- tab marzia ............................. 97 tri-lo- tab sprintec ........................... 97 trilyte sol ....................................... 110 trimethobenzamide hcl cap 300 mg ... 107 trimethoprim tab 100 mg .................. 26 trimipramine maleate cap 100 mg ...... 70 trimipramine maleate cap 25 mg ....... 70 trimipramine maleate cap 50 mg ....... 70 trinessa lo tab ................................. 97 trinessa tab .................................... 97 TRI-NORINYL TAB 28 ....................... 97 TRINTELLIX TAB 10MG ..................... 68 TRINTELLIX TAB 20MG ..................... 68 TRINTELLIX TAB 5MG ....................... 68 triple dye solution ........................... 131 tri-previfem tab ............................... 97 tri-sprintec tab ................................ 97 TRIUMEQ TAB ................................. 20 trivora-28 tab ................................. 97 TRIZIVIR TAB ................................. 20 TROKENDI XR CAP 100MG ................ 63 TROKENDI XR CAP 200MG ................ 63 TROKENDI XR CAP 25MG .................. 63 TROKENDI XR CAP 50MG .................. 63 tropicamide ophth soln 0.5%............ 142 tropicamide ophth soln 1% .............. 142 trospium chloride cap er 24hr 60 mg . 114 trospium chloride tab 20 mg ............ 114 TRULANCE TAB 3MG ....................... 109 TRULICITY INJ 0.75/0.5 ................... 89 TRULICITY INJ 1.5/0.5 ..................... 89 TRUSOPT SOL 2% OP ...................... 141 TRUVADA TAB 100-150 .................... 20 TRUVADA TAB 133-200 .................... 20 TRUVADA TAB 167-250 .................... 20 TRUVADA TAB 200-300 .................... 20 TRUZONE PEAK MIS FLOW MTR ........ 125 TRYPTOPHAN CAP 500MG ................ 118 TUSNEL TAB .................................. 121 TUSSICAPS CAP 10-8MG ................. 122 TUSSICAPS CAP 5-4MG ................... 122 tussigon tab 5-1.5mg ...................... 122 TUSSIONEX SUS 10-8/5ML .............. 122 TWYNSTA TAB 40-10MG ................... 41

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TWYNSTA TAB 40-5MG ..................... 41 TWYNSTA TAB 80-10MG .................... 41 TWYNSTA TAB 80-5MG ..................... 41 TYBOST TAB 150MG ......................... 20 TYKERB TAB 250MG ......................... 35 TYLENOL/COD TAB #3 ...................... 13 TYLENOL/COD TAB #4 ...................... 13 TYVASO REFIL SOL 0.6MG/ML ............ 57 TYVASO SOL 0.6MG/ML ..................... 57 TYVASO START SOL 0.6MG/ML ........... 57 TYZINE PED DRO 0.05% ................. 125 U UCERIS AER 2MG/ACT .................... 109 UCERIS TAB 9MG ........................... 108 ULESFIA LOT 5% ............................ 137 ULORIC TAB 40MG ............................ 5 ULORIC TAB 80MG ............................ 5 ULTRACET TAB 37.5-325 ................... 13 ULTRAM TAB 50MG ........................... 13 ULTRAVATE CRE 0.05% .................. 135 ULTRAVATE OIN 0.05% ................... 135 unith direct tab 100mcg .................. 104 unith direct tab 112mcg .................. 104 unith direct tab 125mcg .................. 104 unith direct tab 150mcg .................. 104 unith direct tab 175mcg .................. 104 unith direct tab 200mcg .................. 105 unith direct tab 25mcg .................... 104 unith direct tab 300mcg .................. 105 unith direct tab 50mcg .................... 104 unith direct tab 75mcg .................... 104 unith direct tab 88mcg .................... 104 unithroid tab 100mcg ...................... 105 unithroid tab 112mcg ...................... 105 unithroid tab 125mcg ...................... 105 unithroid tab 137mcg ...................... 105 unithroid tab 150mcg ...................... 105 unithroid tab 175mcg ...................... 105 unithroid tab 200mcg ...................... 105 unithroid tab 25mcg ....................... 105 unithroid tab 300mcg ...................... 105 unithroid tab 50mcg ....................... 105 unithroid tab 75mcg ....................... 105 unithroid tab 88mcg ....................... 105 UPTRAVI TAB 1000MCG .................... 57

UPTRAVI TAB 1200MCG .................... 57 UPTRAVI TAB 1400MCG .................... 57 UPTRAVI TAB 1600MCG .................... 57 UPTRAVI TAB 200/800 ..................... 57 UPTRAVI TAB 200MCG ..................... 57 UPTRAVI TAB 400MCG ..................... 57 UPTRAVI TAB 600MCG ..................... 57 UPTRAVI TAB 800MCG ..................... 57 URECHOLINE TAB 10MG .................. 113 URECHOLINE TAB 25MG .................. 113 URECHOLINE TAB 50MG .................. 113 URECHOLINE TAB 5MG .................... 113 UROCIT-K 10 TAB ........................... 113 UROCIT-K 15 TAB ........................... 113 UROCIT-K 5 TAB ............................ 113 URSO 250 TAB 250MG .................... 107 URSO FORTE TAB 500MG ................. 107 ursodiol cap 300 mg ....................... 107 ursodiol tab 250 mg ........................ 107 ursodiol tab 500 mg ........................ 107 V VAGIFEM TAB 10MCG ....................... 99 valacyclovir hcl tab 1 gm .................. 24 valacyclovir hcl tab 500 mg ............... 25 VALCHLOR GEL 0.016% ................... 27 valganciclovir hcl tab 450 mg (base equivalent) ..................................... 23 VALIUM TAB 10MG........................... 59 VALIUM TAB 2MG ............................ 59 VALIUM TAB 5MG ............................ 59 valproate sodium oral soln 250 mg/5ml (base equiv) ................................... 63 valproic acid cap 250 mg .................. 63 valsartan tab 160 mg ....................... 44 valsartan tab 320 mg ....................... 44 valsartan tab 40 mg ......................... 44 valsartan tab 80 mg ......................... 44 valsartan-hydrochlorothiazide tab 160-12.5 mg ......................................... 43 valsartan-hydrochlorothiazide tab 160-25 mg ................................................ 43 valsartan-hydrochlorothiazide tab 320-12.5 mg ......................................... 43 valsartan-hydrochlorothiazide tab 320-25 mg ................................................ 43

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valsartan-hydrochlorothiazide tab 80-12.5 mg .......................................... 43 VALVD HOLDNG MIS CHAMBER ........ 125 VANATOL LQ SOL .............................. 5 VANCOCIN HCL CAP 125MG ............... 26 VANCOCIN HCL CAP 250MG ............... 26 vancomycin hcl cap 125 mg ............... 26 vancomycin hcl cap 250 mg ............... 26 vandazole gel 0.75% ...................... 114 VANOS CRE 0.1% ........................... 132 VARUBI TAB 90MG ......................... 107 VASERETIC TAB 10-25MG .................. 38 VASOTEC TAB 10MG ......................... 39 VASOTEC TAB 2.5MG ........................ 39 VASOTEC TAB 20MG ......................... 39 VASOTEC TAB 5MG ........................... 39 VECAMYL TAB 2.5MG ........................ 55 VECTICAL OIN 3MCG/GM ................. 131 velivet pak ...................................... 97 VELPHORO CHW 500MG .................. 102 VELTASSA POW 16.8GM .................. 102 VELTASSA POW 25.2GM .................. 102 VELTASSA POW 8.4GM .................... 102 VEMLIDY TAB 25MG .......................... 24 VENCLEXTA TAB 100MG .................... 36 VENCLEXTA TAB 10MG ...................... 36 VENCLEXTA TAB 50MG ...................... 36 VENCLEXTA TAB START PK ................ 36 venlafaxine hcl cap er 24hr 150 mg (base equivalent) ............................. 68 venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) ............................. 68 venlafaxine hcl cap er 24hr 75 mg (base equivalent) ...................................... 68 venlafaxine hcl tab 100 mg ................ 69 venlafaxine hcl tab 25 mg.................. 68 venlafaxine hcl tab 37.5 mg ............... 68 venlafaxine hcl tab 50 mg.................. 68 venlafaxine hcl tab 75 mg.................. 68 venlafaxine hcl tab er 24hr 225 mg (base equivalent) ...................................... 69 VENLAFAXINE TAB 225MG ER ............ 69 VENTAVIS SOL 10MCG/ML ................. 57 VENTAVIS SOL 20MCG/ML ................. 57 verapamil hcl cap er 24hr 100 mg ...... 52

verapamil hcl cap er 24hr 120 mg ...... 53 verapamil hcl cap er 24hr 180 mg ...... 53 verapamil hcl cap er 24hr 200 mg ...... 53 verapamil hcl cap er 24hr 240 mg ...... 53 verapamil hcl cap er 24hr 300 mg ...... 53 verapamil hcl cap er 24hr 360 mg ...... 53 verapamil hcl tab 120 mg ................. 53 verapamil hcl tab 40 mg ................... 53 verapamil hcl tab 80 mg ................... 53 verapamil hcl tab er 120 mg ............. 53 verapamil hcl tab er 180 mg ............. 53 verapamil hcl tab er 240 mg ............. 53 verdrocet tab 2.5-325 ...................... 13 VERELAN CAP 120MG SR .................. 53 VERELAN CAP 180MG SR .................. 53 VERELAN CAP 240MG SR .................. 53 VERELAN CAP 360MG SR .................. 53 VERELAN PM CAP 100MG ER ............. 53 VERELAN PM CAP 200MG ER ............. 53 VERELAN PM CAP 300MG ER ............. 53 VERIPRED 20 SOL 20MG/5ML ........... 100 VERSACLOZ SUS 50MG/ML ............... 75 VESICARE TAB 10MG ...................... 114 VESICARE TAB 5MG ........................ 114 vestura tab 3-0.02mg ...................... 94 VFEND SUS 40MG/ML....................... 20 VFEND TAB 200MG .......................... 20 VFEND TAB 50MG ............................ 20 VIBERZI TAB 100MG ....................... 109 VIBERZI TAB 75MG ......................... 109 VIBRAMYCIN CAP 100MG .................. 19 VIBRAMYCIN SUS 25MG/5ML ............ 19 VIBRAMYCIN SYP 50MG/5ML ............. 19 vicodin es tab 7.5-300 ...................... 13 vicodin hp tab 10-300mg .................. 13 vicodin tab 5-300mg ........................ 13 VICTOZA INJ 18MG/3ML ................... 89 VIDEX EC CAP 125MG ...................... 22 VIDEX EC CAP 200MG ...................... 22 VIDEX EC CAP 250MG ...................... 22 VIDEX EC CAP 400MG ...................... 22 vienva tab 0.1-20 ............................ 94 VIGAMOX DRO 0.5% ....................... 140 VIIBRYD KIT STARTER ..................... 68 VIIBRYD TAB 10MG ......................... 68

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VIIBRYD TAB 20MG .......................... 68 VIIBRYD TAB 40MG .......................... 68 VIMOVO TAB 375-20MG ..................... 7 VIMOVO TAB 500-20MG ..................... 7 VIMPAT SOL 10MG/ML ...................... 63 VIMPAT TAB 100MG .......................... 64 VIMPAT TAB 150MG .......................... 64 VIMPAT TAB 200MG .......................... 64 VIMPAT TAB 50MG ........................... 64 VIOKACE TAB ................................ 110 VIOKACE TAB 20880 ....................... 110 viorele tab ....................................... 92 VIRACEPT TAB 250MG ...................... 23 VIRACEPT TAB 625MG ...................... 23 VIRAMUNE SUS 50MG/5ML ................ 21 VIRAMUNE TAB 200MG ..................... 21 VIRAMUNE XR TAB 100MG ................. 21 VIRAMUNE XR TAB 400MG ................. 21 VIRAZOLE INH 6GM ........................ 126 VIREAD TAB 150MG .......................... 23 VIREAD TAB 200MG .......................... 23 VIREAD TAB 250MG .......................... 23 VIREAD TAB 300MG .......................... 23 VIROPTIC SOL 1% OP ..................... 141 virt-phos tab 250 neut .................... 113 virtrate-2 sol ................................. 113 virtrate-2 sol 500-334 ..................... 113 virtrate-3 sol ................................. 113 virtrate-k sol ................................. 113 virtrate-k sol 1100-334 ................... 113 VISIONBLUE SOL 0.06% ................. 142 VISTARIL CAP 25MG ....................... 121 VISTARIL CAP 50MG ....................... 121 VISTOGARD PAK 10GM ..................... 36 VITEKTA TAB 150MG ........................ 21 VITEKTA TAB 85MG .......................... 21 VITUZ SOL 5-4MG .......................... 122 VIVELLE-DOT DIS 0.025MG ............... 99 VIVELLE-DOT DIS 0.0375MG ............. 99 VIVELLE-DOT DIS 0.05MG ................. 99 VIVELLE-DOT DIS 0.075MG ............... 99 VIVELLE-DOT DIS 0.1MG ................... 99 VOLTAREN GEL 1% ........................... 7 voriconazole for susp 40 mg/ml .......... 20 voriconazole tab 200 mg ................... 20

voriconazole tab 50 mg .................... 20 VORTEX VALVE MIS CHAMBER .......... 125 VORTEX/MASK MIS CHILDS ............. 125 VORTEX/MASK MIS TODDLER ........... 125 VOSEVI TAB ................................... 24 VOSPIRE ER TAB 4MG ..................... 123 VOSPIRE ER TAB 8MG ..................... 123 VOTRIENT TAB 200MG ..................... 35 VRAYLAR CAP 1.5-3MG ..................... 75 VRAYLAR CAP 1.5MG ........................ 75 VRAYLAR CAP 3MG .......................... 75 VRAYLAR CAP 4.5MG ........................ 75 VRAYLAR CAP 6MG .......................... 75 VUSION OIN .................................. 131 vyfemla tab 0.4-35 .......................... 96 VYTORIN TAB 10-10MG .................... 47 VYTORIN TAB 10-20MG .................... 47 VYTORIN TAB 10-40MG .................... 47 VYTORIN TAB 10-80MG .................... 47 VYVANSE CAP 10MG ........................ 81 VYVANSE CAP 20MG ........................ 81 VYVANSE CAP 30MG ........................ 81 VYVANSE CAP 40MG ........................ 81 VYVANSE CAP 50MG ........................ 81 VYVANSE CAP 60MG ........................ 81 VYVANSE CAP 70MG ........................ 81 W warfarin sodium tab 1 mg ................ 115 warfarin sodium tab 10 mg .............. 115 warfarin sodium tab 2 mg ................ 115 warfarin sodium tab 2.5 mg ............. 115 warfarin sodium tab 3 mg ................ 115 warfarin sodium tab 4 mg ................ 115 warfarin sodium tab 5 mg ................ 115 warfarin sodium tab 6 mg ................ 115 warfarin sodium tab 7.5 mg ............. 115 WELCHOL PAK 3.75GM ..................... 45 WELCHOL TAB 625MG ...................... 45 WELLBUTRIN TAB 100MG SR ............. 66 WELLBUTRIN TAB 150MG SR ............. 66 WELLBUTRIN TAB 200MG SR ............. 66 WELLBUTRIN TAB XL 150MG ............. 66 WELLBUTRIN TAB XL 300MG ............. 66 wera tab 0.5/35 .............................. 96 WESTCORT OIN 0.2% ..................... 135

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wymzya fe chw 0.4mg-35 .................. 96 X XALATAN SOL 0.005% .................... 143 XALKORI CAP 200MG ........................ 35 XALKORI CAP 250MG ........................ 35 XANAX TAB 0.25MG .......................... 59 XANAX TAB 0.5MG ........................... 59 XANAX TAB 1MG .............................. 59 XANAX TAB 2MG .............................. 59 XANAX XR TAB 0.5MG ....................... 59 XANAX XR TAB 1MG ......................... 59 XANAX XR TAB 2MG ......................... 59 XANAX XR TAB 3MG ......................... 59 XARELTO STAR TAB 15/20MG .......... 115 XARELTO TAB 10MG ....................... 115 XARELTO TAB 15MG ....................... 115 XARELTO TAB 20MG ....................... 115 XARTEMIS XR TAB 7.5-325 ................ 13 XELODA TAB 150MG ......................... 28 XELODA TAB 500MG ......................... 28 XIFAXAN TAB 550MG ........................ 26 XIGDUO XR TAB 10-1000 .................. 90 XIGDUO XR TAB 10-500MG ............... 90 XIGDUO XR TAB 5-1000MG ............... 90 XIGDUO XR TAB 5-500MG ................. 90 XIIDRA DRO 5% ............................ 142 XODOL TAB 10-300MG ...................... 13 XODOL TAB 5-300MG ....................... 13 XODOL TAB 7.5-300 ......................... 13 XOLEGEL DUO/ KIT HEAD&SHD ........ 131 XOLEGEL DUO/ KIT XOLEX .............. 131 XOLEGEL GEL 2% ........................... 131 XOLEGEL KIT COREPAK ................... 131 XOPENEX CONC NEB 1.25/0.5 .......... 122 XOPENEX NEB 0.31MG .................... 122 XOPENEX NEB 0.63MG .................... 122 XOPENEX NEB 1.25/3ML .................. 122 xulane dis 150-35 ............................ 96 XURIDEN POW 2GM ........................ 101 XYLOCAINE SOL 4% ....................... 136 xylon tab 10-200mg ......................... 13 XYREM SOL 500MG/ML ...................... 86 XYZAL SOL .................................... 120 XYZAL SOL 2.5/5ML ........................ 120 XYZAL TAB 5MG ............................. 120

xyzbac tab ..................................... 118 Y YASMIN 28 TAB 3-0.03MG ................ 95 YAZ TAB 3-0.02MG .......................... 94 Z zafirlukast tab 10 mg ...................... 123 zafirlukast tab 20 mg ...................... 123 zaleplon cap 10 mg .......................... 82 zaleplon cap 5 mg ........................... 82 zamicet sol 10-325mg ...................... 13 ZANAFLEX CAP 2MG ......................... 85 ZANAFLEX CAP 4MG ......................... 85 ZANAFLEX CAP 6MG ......................... 85 ZANAFLEX TAB 4MG ......................... 85 ZANTAC TAB 150MG ....................... 108 ZANTAC TAB 300MG ....................... 108 zarah tab 3-0.03mg ......................... 95 ZARONTIN CAP 250MG ..................... 64 ZARONTIN SOL 250/5ML .................. 64 ZAVESCA CAP 100MG ..................... 101 zazole cre 0.8% ............................. 114 zazole sup 80mg ............................ 114 ZEBETA TAB 10MG .......................... 50 ZEBETA TAB 5MG ............................ 50 ZEJULA CAP 100MG ......................... 36 ZELAPAR TAB 1.25MG ...................... 73 ZELBORAF TAB 240MG ..................... 35 ZEMBRACE SYM INJ 3/0.5ML ............. 84 ZEMPLAR CAP 1MCG ....................... 101 ZEMPLAR CAP 2MCG ....................... 101 zenatane cap 10mg ........................ 127 zenatane cap 20mg ........................ 127 zenatane cap 30mg ........................ 127 zenatane cap 40mg ........................ 127 zenchent fe chw 0.4mg-35 ................ 96 zenchent tab ................................... 96 ZENPEP CAP 10000UNT ................... 110 ZENPEP CAP 15000UNT ................... 110 ZENPEP CAP 20000UNT ................... 110 ZENPEP CAP 25000UNT ................... 110 ZENPEP CAP 3000UNIT .................... 110 ZENPEP CAP 40000UNT ................... 110 ZENPEP CAP 5000UNIT .................... 110 zenzedi tab 10mg ............................ 81 zenzedi tab 15mg ............................ 81

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zenzedi tab 2.5mg ............................ 81 zenzedi tab 20mg ............................. 81 zenzedi tab 30mg ............................. 81 zenzedi tab 5mg .............................. 81 zenzedi tab 7.5mg ............................ 81 ZERIT CAP 15MG .............................. 22 ZERIT CAP 20MG .............................. 22 ZERIT CAP 30MG .............................. 22 ZERIT CAP 40MG .............................. 22 ZERIT SOL 1MG/ML .......................... 22 ZESTORETIC TAB 10-12.5 ................. 38 ZESTORETIC TAB 20-12.5 ................. 38 ZESTORETIC TAB 20-25MG ................ 38 ZESTRIL TAB 10MG .......................... 39 ZESTRIL TAB 2.5MG ......................... 39 ZESTRIL TAB 20MG .......................... 39 ZESTRIL TAB 30MG .......................... 39 ZESTRIL TAB 40MG .......................... 39 ZESTRIL TAB 5MG ............................ 39 ZETIA TAB 10MG .............................. 45 ZIAC TAB 10/6.25 ............................ 48 ZIAC TAB 2.5/6.25 ........................... 48 ZIAC TAB 5-6.25MG ......................... 48 ZIAGEN SOL 20MG/ML ...................... 22 ZIAGEN TAB 300MG ......................... 22 ZIANA GEL .................................... 129 zidovudine cap 100 mg ..................... 22 zidovudine syrup 10 mg/ml ............... 22 zidovudine tab 300 mg ...................... 22 zileuton tab er 12hr 600 mg ............ 123 ZIOPTAN DRO 0.0015% .................. 143 ziprasidone hcl cap 20 mg ................. 75 ziprasidone hcl cap 40 mg ................. 75 ziprasidone hcl cap 60 mg ................. 75 ziprasidone hcl cap 80 mg ................. 75 ZIPSOR CAP 25MG ............................ 7 ZIRGAN GEL 0.15% ........................ 141 ZITHRANOL-RR CRE 1.2% ............... 131 ZITHROMAX SUS 100/5ML ................. 15 ZITHROMAX SUS 200/5ML ................. 15 ZITHROMAX TAB 250MG ................... 15 ZITHROMAX TAB 500MG ................... 15 ZITHROMAX TAB 600MG ................... 15 ZITHROMAX TAB TRI-PAK .................. 15 ZITHROMAX TAB Z-PAK .................... 15

ZMAX SUS 2GM ............................... 15 ZOCOR TAB 10MG ........................... 47 ZOCOR TAB 20MG ........................... 47 ZOCOR TAB 40MG ........................... 47 ZOCOR TAB 5MG ............................. 47 ZOCOR TAB 80MG ........................... 47 ZOFRAN SOL 4MG/5ML .................... 107 ZOFRAN TAB 4MG ........................... 107 ZOFRAN TAB 4MG ODT .................... 107 ZOFRAN TAB 8MG ........................... 107 ZOFRAN TAB 8MG ODT .................... 107 ZOLINZA CAP 100MG ....................... 36 zolmitriptan orally disintegrating tab 2.5 mg ................................................ 84 zolmitriptan orally disintegrating tab 5 mg ................................................ 84 zolmitriptan tab 2.5 mg .................... 84 zolmitriptan tab 5 mg ....................... 84 ZOLOFT CON 20MG/ML..................... 68 ZOLOFT TAB 100MG ......................... 68 ZOLOFT TAB 25MG .......................... 68 ZOLOFT TAB 50MG .......................... 68 zolpidem tartrate sl tab 1.75 mg ........ 82 zolpidem tartrate sl tab 3.5 mg ......... 82 zolpidem tartrate tab 10 mg .............. 82 zolpidem tartrate tab 5 mg ............... 82 zolpidem tartrate tab er 12.5 mg ....... 82 zolpidem tartrate tab er 6.25 mg ....... 82 ZOMIG SPR 2.5MG ........................... 84 ZOMIG SPR 5MG ............................. 84 ZOMIG TAB 2.5MG ........................... 84 ZOMIG TAB 5MG ............................. 84 ZOMIG ZMT TAB 2.5 MG ................... 84 ZOMIG ZMT TAB 5MG....................... 84 ZONALON CRE 5% .......................... 137 zonisamide cap 100 mg .................... 64 zonisamide cap 25 mg ...................... 64 zonisamide cap 50 mg ...................... 64 ZONTIVITY TAB 2.08MG .................. 116 ZORTRESS TAB 0.25MG .................. 118 ZORTRESS TAB 0.5MG .................... 118 ZORTRESS TAB 0.75MG .................. 118 ZORVOLEX CAP 18MG ........................ 7 ZORVOLEX CAP 35MG ........................ 7 zovia 1/35e tab ............................... 96

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zovia 1/50e tab ................................ 96 ZOVIRAX CAP 200MG ........................ 25 ZOVIRAX CRE 5% .......................... 137 ZOVIRAX OIN 5% ........................... 137 ZOVIRAX SUS 200/5ML ..................... 25 ZOVIRAX TAB 400MG ........................ 25 ZOVIRAX TAB 800MG ........................ 25 ZUPLENZ MIS 4MG ......................... 107 ZUPLENZ MIS 8MG ......................... 107 ZUTRIPRO LIQ 60-4-5MG ................ 122 ZYBAN TAB 150MG SR ...................... 87 ZYDELIG TAB 100MG ........................ 35 ZYDELIG TAB 150MG ........................ 35 ZYFLO CR TAB 600MG ..................... 123 ZYFLO TAB 600MG ......................... 123

ZYKADIA CAP 150MG ....................... 35 ZYLET SUS 0.5-0.3% ...................... 139 ZYLOPRIM TAB 100MG ....................... 5 ZYLOPRIM TAB 300MG ....................... 5 ZYPREXA TAB 10MG ......................... 76 ZYPREXA TAB 15MG ......................... 76 ZYPREXA TAB 2.5MG ........................ 75 ZYPREXA TAB 20MG ......................... 76 ZYPREXA TAB 5MG .......................... 75 ZYPREXA TAB 7.5MG ........................ 76 ZYPREXA ZYDI TAB 10MG ................. 76 ZYPREXA ZYDI TAB 15MG ................. 76 ZYPREXA ZYDI TAB 20MG ................. 76 ZYPREXA ZYDI TAB 5MG ................... 76 ZYTIGA TAB 250MG ......................... 28

Documents

HMSA Control Formulary · HMSA Control Formulary (Effective 01/01/2018) INTRODUCTION We are pleased to provide the 2018 HMSA Control Formulary as a useful reference and informational