Navitus MedicareRx (PDP) 2020 Formulary List of …...1 When this formulary refers to “we,” “us”, “our,” “plan,” or “our plan,” it means Navitus MedicareRx (PDP)

S9701_2020_CCN_FORM_Comp_V01.17_C

Navitus MedicareRx (PDP)

2020 Formulary

List of Covered Drugs

Clark County, Nevada & Participating Entities

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

HPMS Approved Formulary File Submission ID 00020268, Version Number 17

This formulary was updated on 08/01/2020. For more recent information or other questions, please contact Navitus MedicareRx Customer Care at 1-866-270-3877 (for TTY users, please call

711), available 24 hours a day, 7 days a week (except Thanksgiving and Christmas Day) or visit

the member portal at https://medicarerx.navitus.com.

Note to existing members: This formulary has changed since last year. Please review this

document to make sure that it still contains the drugs you take.

https://medicarerx.navitus.com/

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When this formulary refers to “we,” “us”, “our,” “plan,” or “our plan,” it means Navitus MedicareRx

(PDP).

This document includes a list of the drugs for our plan which is current as of 08/01/2020. For an updated formulary, please contact us. Our contact information, along with the date we last

updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits,

formulary, pharmacy network, and/or copayments/coinsurance may change on January 1,

2021, and from time to time during the year.

What is the Navitus MedicareRx (PDP) Formulary?

A formulary is a list of covered drugs selected by Navitus MedicareRx in consultation with a

team of health care providers, which represents the prescription therapies believed to be a

necessary part of a quality treatment program. Navitus MedicareRx will generally cover the

drugs listed in our formulary as long as the drug is medically necessary, the prescription is

filled at a Navitus MedicareRx network pharmacy, and other plan rules are followed. For more

information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change?

Most changes in drug coverage happen on January 1, but we may add or remove drugs on

the Formulary during the year, move them to different cost-sharing tiers, or add new

restrictions. We must follow Medicare rules in making these changes.

Changes that can affect you this year: In the below cases, you will be affected by coverage

changes during the year:

New generic drugs. We may immediately remove a brand name drug on our Formulary

if we are replacing it with a new generic drug that will appear on the same or lower cost-

sharing tier and with the same or fewer restrictions. Also, when adding the new generic

drug, we may decide to keep the brand name drug on our Formulary, but immediately

move it to a different cost-sharing tier or add new restrictions. If you are currently taking

that brand name drug, we may not tell you in advance before we make that change, but

we will later provide you with information about the specific change(s) we have made.

o If we make such a change, you or your prescriber can ask us to make an

exception and continue to cover the brand name drug for you. The notice we

provide you will also include information on how to request an exception, and

you can also find information in the section below entitled “How do I request an

exception to the Navitus MedicareRx (PDP) Formulary?”

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Drugs removed from the market. If the Food and Drug Administration deems a drug

on our formulary to be unsafe or the drug’s manufacturer removes the drug from the

market, we will immediately remove the drug from our formulary and provide notice to

members who take the drug.

Other changes. We may make other changes that affect members currently taking a

drug. For instance, we may add a generic drug that is not new to market to replace a

brand name drug currently on the formulary or add new restrictions to the brand name

drug or move it to a different cost-sharing tier. Or we may make changes based on new

clinical guidelines. If we remove drugs from our formulary, add prior authorization,

quantity limits and/or step therapy restrictions on a drug or move a drug to a higher

cost-sharing tier, we must notify affected members of the change at least 30 days

before the change becomes effective, or at the time the member requests a refill of the

drug, at which time the member will receive a 30-day supply of the drug.

o If we make these other changes, you or your prescriber can ask us to make an

exception and continue to cover the brand name drug for you. The notice we

provide you will also include information on how to request an exception, and

you can also find information in the section below entitled “How do I request an

exception to the Navitus MedicareRx (PDP) Formulary?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are

taking a drug on our 2020 formulary that was covered at the beginning of the year, we will not

discontinue or reduce coverage of the drug during the 2020 coverage year except as described

above. This means these drugs will remain available at the same cost-sharing and with no new

restrictions for those members taking them for the remainder of the coverage year.

We will update our online Formulary on a regularly scheduled basis to include any changes that

have occurred after the last update. When changes to the Formulary occur during the year, we

post the Formulary on our website incorporating those changes. In the event of CMS-approved

non-maintenance changes to the Formulary throughout the Plan Year, Navitus MedicareRx will

notify you. The enclosed formulary is current as of 08/01/2020. To get updated information about the drugs covered by Navitus MedicareRx (PDP), please contact us. Our contact

information appears on the front and back cover pages.

How do I use the Formulary?

There are two ways to find your drug within the formulary:

Medical Condition

The formulary begins on page 11. The drugs in this formulary are grouped into categories

depending on the type of medical conditions that they are used to treat. For example, drugs

used to treat a heart condition are listed under the category, “Cardiovascular Agents”. If you

know what your drug is used for, look for the category name in the list that begins on page

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11. Then look under the category name for your drug.

Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the Index that

begins on page 159. The Index provides an alphabetical list of all of the drugs included in this

document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index

and find your drug. Next to your drug, you will see the page number where you can find

coverage information. Turn to the page listed in the Index and find the name of your drug in the

first column of the list.

What are generic drugs?

Navitus MedicareRx covers both brand name drugs and generic drugs. A generic drug is

approved by the FDA as having the same active ingredient as the brand name drug. Generally,

generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage?

Some covered drugs may have additional requirements or limits on coverage. These

requirements and limits may include:

Prior Authorization: Navitus MedicareRx requires you or your physician to get prior

authorization for certain drugs. This means that you will need to get approval from

Navitus MedicareRx before you fill your prescriptions. If you don’t get approval, Navitus

MedicareRx may not cover the drug.

Quantity Limits: For certain drugs, Navitus MedicareRx limits the amount of the drug

that Navitus MedicareRx will cover. For example, Navitus MedicareRx provides 18 tablets

per prescription for Imitrex tablets.

Step Therapy: In some cases, Navitus MedicareRx requires you to first try certain drugs

to treat your medical condition before we will cover another drug for that condition. For

example, if Drug A and Drug B both treat your medical condition, Navitus MedicareRx

may not cover Drug B unless you try Drug A first. If Drug A does not work for you,

Navitus MedicareRx will then cover Drug B.

Prior Authorization Restriction for New Starts Only (PA NSO): If you are a new

member, or if this drug is new to you, you (or your physician) may be required to get

prior authorization from Navitus MedicareRx before you fill your prescription for this

drug. Without prior approval, Navitus MedicareRx may not cover this drug.

Prior Authorization Restriction for Part B vs Part D Determination (PA BvD): This

drug may be eligible for payment under Medicare Part B or Part D. You (or your

physician) are required to get prior authorization from Navitus MedicareRx to determine

that this drug is covered under Medicare Part D before you fill your prescription for this

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drug. Without prior approval, Navitus MedicareRx may not cover this drug.

You can find out if your drug has any additional requirements or limits by looking in the

formulary that begins on page 11. You can also get more information about the restrictions

applied to specific covered drugs by visiting our Web site. We have posted on line documents

that explain our prior authorization and step therapy restrictions. You may also ask us to send

you a copy. Our contact information, along with the date we last updated the formulary,

appears on the front and back cover pages.

You can ask Navitus MedicareRx to make an exception to these restrictions or limits or for a

list of other, similar drugs that may treat your health condition. See the section, “How do I

request an exception to the Navitus MedicareRx formulary?” on page below for information

about how to request an exception.

What are over-the counter (OTC) drugs?

OTC drugs are non-prescription drugs that are not normally covered by a Medicare

Prescription Drug Plan. Navitus MedicareRx pays for certain OTC drugs. Navitus MedicareRx

will provide these OTC drugs at no cost to you. The cost to Navitus MedicareRx of these OTC

drugs will not count toward your total Part D drug costs (that is, the cost of the OTC drugs

does not count for the coverage gap).

What if my drug is not on the Formulary?

If your drug is not included in this formulary (list of covered drugs), you should first contact

Customer Care and ask if your drug is covered.

If you learn that Navitus MedicareRx does not cover your drug, you have two options:

You can ask Customer Care for a list of similar drugs that are covered by Navitus

MedicareRx. When you receive the list, show it to your doctor and ask him or her to

prescribe a similar drug that is covered by Navitus MedicareRx.

You can ask Navitus MedicareRx to make an exception and cover your drug. See below

for information about how to request an exception.

How do I request an exception to the Navitus MedicareRx (PDP) Formulary?

You can ask Navitus MedicareRx to make an exception to our coverage rules. There are

several types of exceptions that you can ask us to make.

You can ask us to cover a drug even if it is not on our formulary. If approved, this drug

will be covered at a pre-determined cost-sharing tier, and you would not be able to ask

us to provide the drug at a lower cost-sharing tier.

You can ask us to cover certain Formulary drugs at a lower cost-sharing tier. If approved

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this would lower the amount you must pay for your drug.

You can ask us to waive coverage restrictions or limits on your drug. For example, for

certain drugs, Navitus MedicareRx limits the amount of the drug that we will cover. If

your drug has a quantity limit, you can ask us to waive the limit and cover a greater

amount.

Generally, Navitus MedicareRx will only approve your request for an exception if the

alternative drugs included on the plan’s formulary, or additional utilization restrictions would

not be as effective in treating your condition and/or would cause you to have adverse

medical effects.

You should contact us to ask us for an initial coverage decision for a formulary or utilization

restriction exception. When you request a formulary or utilization restriction exception

you should submit a statement from your prescriber or physician supporting your

request. Generally, we must make our decision within 72 hours of getting your prescriber’s

supporting statement. You can request an expedited (fast) exception if you or your doctor

believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If

your request to expedite is granted, we must give you a decision no later than 24 hours after

we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or

requesting an exception?

As a new or continuing member in our plan you may be taking drugs that are not on our

formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is

limited. For example, you may need a prior authorization from us before you can fill your

prescription. You should talk to your doctor to decide if you should switch to an appropriate

drug that we cover or request a formulary exception so that we will cover the drug you take.

While you talk to your doctor to determine the right course of action for you, we may cover

your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is

limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days,

we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first

30-day supply, we will not pay for these drugs, even if you have been a member of the plan

less than 90 days.

If you are a resident of a long-term care facility and you need a drug that is not on our

formulary or if your ability to get your drugs is limited, but you are past the first 90 days of

membership in our plan, we will cover a 31-day emergency supply of that drug while you

pursue a formulary exception.

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Level of Care Changes

Navitus MedicareRx’s level of care transition process accounts for unplanned changes for

members. In some instances, these changes may result in the prescribed drug regimen(s) not

being available on our formulary. These instances usually occur when a member moves from

one treatment setting to another. This could include members who:

Enter long-term care (LTC) facilities with a discharge list of medications from the

hospital with very short-term planning taken into account (e.g., less than 8 hours).

Are discharged from a hospital to a home with very short-term planning taken into

account.

End their skilled nursing facility Medicare Part A stay (where payments include all

pharmacy charges) and who need to go back to their Part D plan formulary.

Give up hospice status to revert to standard Medicare Part A and Part B benefits.

End an LTC facility stay and return to their home.

Are discharged from psychiatric hospitals with drug regimens that are highly tailored

to them.

These changes often result in members and/or prescribers using Navitus’ exceptions and/or

appeals processes. For these types of changes, we will make coverage determinations and re-

determinations as quickly as the member’s health requires.

Navitus MedicareRx ensures proper medication continuance for members upon discharge

from an LTC facility or other facilities to ensure an effective transition of care. This may

include:

A refill upon entrance to, or discharge from, an LTC facility. The current standard of

care promotes caregivers receiving outpatient Part D prescriptions before discharge

from a Part A stay. Members, through no fault of their own, may not have access to

the balance of their prescription.

Navitus MedicareRx allows the member to access a refill upon entrance to, or

discharge from, an LTC facility.

To process these transition refills, the pharmacy may need to call Navitus MedicareRx

Customer Care (phone numbers are on the back cover of this booklet). Navitus MedicareRx

Customer Care can help the pharmacy process an override.

For more information

For more detailed information about your Navitus MedicareRx prescription drug coverage,

please review your Evidence of Coverage and other plan materials.

If you have questions about Navitus MedicareRx, please contact us. Our contact information,

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along with the date we last updated the formulary, appears on the front and back cover

pages.

If you have general questions about Medicare prescription drug coverage, please call

Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users

should call 1-877-486-2048. Or, visit http://www.medicare.gov.

Navitus MedicareRx’s (PDP) Formulary

The formulary that begins on page 11 provides coverage information about the drugs

covered by Navitus MedicareRx. If you have trouble finding your drug in the list, turn to the

Index that begins on page 159.

The first column of the chart lists the drug name.

Brand name drugs are capitalized (e.g., PROZAC)

Generic drugs are listed in lower-case italics (e.g., fluoxetine).

The second column of the chart lists the Drug Tier. You can reference the Summary of

Benefits booklet or Chapter 4 (Section 5.2) in the Evidence of Coverage booklet to learn what

your copay or coinsurance will be.

Tier 1 includes preferred generics and certain low-cost brand name drugs

Tier 2 includes preferred brand drugs and certain high-cost generic drugs

Tier 3 includes non-preferred drugs (may include both brand and generics)

Tier $0 includes certain preventative medications (specific guidelines apply)

The third column of the chart lists information in the Requirements/Limits column which tells

you if Navitus MedicareRx has any special requirements for coverage of your drug.

The symbol PA in the Notes column indicates that prior authorization may apply.

The symbol PA BvD in the Notes column indicates that prior authorization may apply

for medications that could be eligible for payment under either Medicare Part B or Part

D.

The symbol PA NSO in the Notes column indicates that prior authorization may apply

on certain medications for new members or members starting a new drug for the first

time.

The symbol QL in the Notes column indicates that quantities dispensed may be limited.

The symbol ST in the Notes column indicates that step therapy may apply.

The symbol NDS in the Notes column indicates that the drug is not available for an

extended supply (greater than 1-month) at retail or mail order.

The symbol RXC in the Notes column indicates this medication is offered at half the

stated tier copay when your prescriber writes a prescription for half-tab daily. For

example, if you take one 20mg tablet that’s listed on the Formulary at Tier 1 per day,

http://www.medicare.gov/

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the prescriber might write the prescription for half of a 40mg tab per day. Then you

would pay $2.50 per month instead of $5 per month. For more information or to

acquire a tab-splitter, contact Navitus Customer Care.

The * symbol after the Tier indicates these prescription drugs are not normally covered in a

Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this

drug does not count towards your total drug costs (that is, the amount you pay does not help

you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for

your prescriptions, you will not get any extra help to pay for these drugs

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Non-Discrimination Statement: Clark County and Participating Entities comply with applicable Federal civil

rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Clark

County does not exclude people or treat them differently because of race, color, national origin, age, disability or

sex. Clark County provides free aids and services to people with disabilities to communicate effectively with us,

such as: qualified sign language interpreters and written information in other formats (large print, audio,

accessible electronic formats, other formats). Clark County provides free language services to people whose

primary language is not English such as: qualified interpreters and information written in other languages. If you

need these services, contact the Customer Care Center at 1-866-270-3877.

Filing a Grievance or Complaint: If you believe that Clark County has failed to provide these services or

discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a

grievance. If you need help filing a grievance, Geree Gonzales at The Office of Risk Management is available to

help you. You can file a grievance in person or by mail, fax, or email:

Geree Gonzales, Health Benefit Manager

500 S. Grand Central Parkway

Las Vegas, Nevada 89155

(702) 455-4544

[email protected]

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for

Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

1-800-368-1019, 1-800-537-7697 (TDD)

mailto:[email protected]

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

You can find information on what the symbols and abbreviations on this table mean by going to the

beginning of this table.

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ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS

AMPHETAMINES

ADDERALL TAB 20MG 3

ADDERALL TAB 5MG 3

ADDERALL TAB 7.5MG 3

ADDERALL XR CAP 10MG 3






amphetamine/dextroamphetamine ER cap 10mg 2






amphetamine/dextroamphetamine tab 10mg 1

amphetamine/dextroamphetamine tab 12.5mg 1





amphetamine/dextroamphetamine tab 7.5mg 1

DEXEDRINE CAP 10MG 3


DEXEDRINE CAP 5MG 3

dextroamphetamine ER cap 10mg 2



dextroamphetamine soln 5mg/5ml 2

dextroamphetamine tab 10mg 1


METAPROTERENOL SYRUP 10MG/5ML 1

ANOREXIANTS NON-AMPHETAMINE

ADIPEX CAP 3* PA QL=30 Quantity/30 Days

ADIPEX TAB 3* PA QL=30 Quantity/30 Days

phentermine cap 1* PA QL=30 Quantity/30 Days

phentermine tab 1* PA QL=30 Quantity/30 Days

QSYMIA CAP 3* PA QL=30 Quantity/30 Days

ANTI-OBESITY AGENTS

BELVIQ TAB 2* PA QL=60 Quantity/30 Days




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BELVIQ XR TAB 2* PA QL=30 Quantity/30 Days

CONTRAVE TAB 2* PA QL=120 Quantity/30 Days

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS

atomoxetine cap 100mg 2







guanfacine ER tab 1mg 1




INTUNIV TAB 1MG 3

INTUNIV TAB 2MG 3

INTUNIV TAB 3MG 3

INTUNIV TAB 4MG 3

STRATTERA CAP 100MG 3







DOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITORS (DNRIS)

SUNOSI TAB 150MG 2 PA QL=30 Quantity/30 Days

SUNOSI TAB 75MG 2 PA QL=30 Quantity/30 Days

HISTAMINE H3-RECEPTOR ANTAGONIST/INVERSE AGONISTS

WAKIX TAB 17.8MG 2 NDS PA QL=60 Quantity/30 Days

WAKIX TAB 4.45MG 2 NDS PA QL=60 Quantity/30 Days

STIMULANTS - MISC.

armodafinil tab 150mg 2 PA QL=30 Quantity/30 Days




CONCERTA ER TAB 18MG 3




dexmethylphenidate ER cap 10mg 2





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dexmethylphenidate tab 10mg 1

dexmethylphenidate tab 2.5mg 1


FOCALIN TAB 10MG 3

FOCALIN TAB 2.5MG 3

FOCALIN TAB 5MG 3

FOCALIN XR CAP 10MG 3








METADATE CD CAP 10MG 3






METHYLIN SOLN 10MG/5ML 2

METHYLIN SOLN 5MG/5ML 2

methylphenidate 18mg sr tab 2




methylphenidate CD cap 10mg 2






methylphenidate chew tab 10mg 2

methylphenidate chew tab 2.5mg 2

methylphenidate chew tab 5mg 2

methylphenidate ER osmotic tab 18mg 2




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methylphenidate ER tab 10mg 2

METHYLPHENIDATE ER TAB 18MG 2


methylphenidate er tab 27mg 2



methylphenidate LA cap 10mg 2





methylphenidate soln 10mg/5ml 2

methylphenidate soln 5mg/5ml 2

methylphenidate tab 10mg 1



modafinil tab 100mg 2 PA QL=60 Quantity/30 Days

modafinil tab 200mg 2 PA QL=60 Quantity/30 Days

NUVIGIL TAB 150MG 3 PA

NUVIGIL TAB 200MG 3 PA QL=30 Quantity/30 Days



PROVIGIL TAB 100MG 3 PA QL=60 Quantity/30 Days

PROVIGIL TAB 200MG 3 PA QL=60 Quantity/30 Days

RITALIN LA CAP 10MG 3




RITALIN TAB 10MG 3

RITALIN TAB 20MG 3

RITALIN TAB 5MG 3

AMEBICIDES

AMEBICIDES

SOLOSEC GRANULE PACKET 2GM 3 PA

AMINOGLYCOSIDES

AMINOGLYCOSIDES

amikacin sulfate inj 1gm/4ml 2

amikacin sulfate inj 500mg/2ml 2

ARIKAYCE INHALATION SUSP 70.3MG/ML 2 NDS PA QL=252 Quantity/30 Days




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gentamicin inj 40mg/ml 2

GENTAMICIN SULFATE INJ 0.8MG/ML 2

gentamicin sulfate inj 1.2mg/ml 2

GENTAMICIN SULFATE INJ 1.6MG/ML 2

GENTAMICIN SULFATE INJ 1MG/ML 2

KITABIS NEB SOLN 300MG/5ML 3 NDS PA

neomycin tab 500mg 1

PAROMOMYCIN CAP 250MG 2

paromomycin cap 250mg 2

STREPTOMYCIN INJ 1GM 3

TOBI PODHALER 28MG 2 NDS PA

tobramycin inj 1.2gm 2

tobramycin inj 1.2gm/30ml 2

TOBRAMYCIN INJ 10MG/ML 2

TOBRAMYCIN INJ 2GM/50ML 2

tobramycin inj 80mg/2ml 2

tobramycin neb soln 300mg/5ml 2 NDS PA

ANALGESICS - ANTI-INFLAMMATORY

ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES

HUMIRA AUTO-INJECTOR 40MG/0.8ML 2 NDS PA

HUMIRA INJ 10MG/0.1ML 2 NDS PA





HUMIRA PEDIATRIC CROHN'S STARTER PACK

SYRINGE (2) 40MG/0.4ML, 80MG/0.8ML

2 NDS PA


SYRINGE 40MG/0.8ML

2 NDS PA


SYRINGE 80MG/0.8ML

2 NDS PA

HUMIRA PEN INJ CROHN'S KIT 80MG/0.8ML 2 NDS PA

HUMIRA PEN INJ PSORIASIS KIT 80MG/0.8ML,

40MG/0.4ML

2 NDS PA

HUMIRA PEN INJECTOR 40MG/0.4ML 2 NDS PA

SIMPONI AUTO-INJECTOR 100MG/ML 3 NDS PA

SIMPONI AUTO-INJECTOR 50MG/0.5ML 3 NDS PA

SIMPONI INJ 100MG/ML 3 NDS PA

SIMPONI INJ 50MG/0.5ML 3 NDS PA

ANTIRHEUMATIC - ENZYME INHIBITORS

OLUMIANT TAB 1MG 2 PA

OLUMIANT TAB 2MG 2 PA




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RINVOQ ER TAB 15MG 2 NDS PA

XELJANZ TAB 10MG 3 NDS PA

XELJANZ TAB 5MG 3 NDS PA

GOLD COMPOUNDS

RIDAURA CAP 3MG 2

INTERLEUKIN-1 BLOCKERS

ARCALYST INJ 220MG 3 NDS PA

INTERLEUKIN-6 RECEPTOR INHIBITORS

ACTEMRA ACTPEN INJ 162MG/0.9ML 2 NDS PA

ACTEMRA SYRINGE 162MG/0.9ML 2 NDS PA

KEVZARA INJ 150MG/1.14ML 2 NDS PA

KEVZARA INJ 200MG/1.14ML 2 NDS PA

NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)

ANAPROX DS TAB 550MG 3

ARTHROTEC TAB 50-0.2MG 3

ARTHROTEC TAB 75-0.2MG 3

CELEBREX CAP 100MG 3



CELEBREX CAP 50MG 3

celecoxib cap 100mg 1




DAYPRO TAB 600MG 3

diclofenac DR tab 25mg 1



diclofenac potassium tab 50mg 1

diclofenac SR tab 100mg 1

diclofenac/misoprostol tab 50-0.2mg 2

diclofenac/misoprostol tab 75-0.2mg 2

EC-NAPROSYN TAB 375MG 1

EC-NAPROSYN TAB 500MG 1

etodolac cap 200mg 1


etodolac ER tab 400mg 2



etodolac tab 400mg 1


FELDENE CAP 10MG 3




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FELDENE CAP 20MG 3

flurbiprofen tab 100mg 1


ibuprofen susp (rx only) 100mg/5ml 1

ibuprofen tab (rx only) 400mg 1



INDOCIN SUPP 50MG 2

KETOPROFEN CAP 25MG 1

ketoprofen cap 75mg 1

KETOPROFEN ER CAP 200MG 3

ketorolac tromethamine tab 10mg 1 QL=20 Quantity/5 Days

LODINE TAB 400MG 3

meloxicam tab 15mg 1

meloxicam tab 7.5mg 1

MOBIC TAB 15MG 3

MOBIC TAB 7.5MG 3

MOTRIN SUSP (OTC) 3*

nabumetone tab 500mg 1


naproxen EC tab 375mg 1


naproxen sodium tab 275mg 2


naproxen tab 250mg 1



oxaprozin tab 600mg 2

piroxicam cap 10mg 2


sulindac tab 150mg 1


TOLMETIN SODIUM CAP 400MG 3

TOLMETIN SODIUM TAB 200MG 3

TOLMETIN SODIUM TAB 600MG 3

PHOSPHODIESTERASE 4 (PDE4) INHIBITORS

OTEZLA TAB 28-DAY STARTER PACK 2 NDS PA

OTEZLA TAB 30MG 2 NDS PA

PYRIMIDINE SYNTHESIS INHIBITORS

ARAVA TAB 10MG 3

ARAVA TAB 20MG 3

leflunomide tab 10mg 1




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SELECTIVE COSTIMULATION MODULATORS

ORENCIA AUTO-INJECTOR 125MG/ML 2 NDS PA

ORENCIA SYRINGE 125MG/ML 2 NDS PA

ORENCIA SYRINGE 50MG/0.4ML 2 NDS PA

ORENCIA SYRINGE 87.5MG/0.7ML 2 NDS PA

SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS

ENBREL INJ 25MG 2 NDS PA

ENBREL INJ 25MG/0.5ML 2 NDS PA

ENBREL INJ 50MG/ML 2 NDS PA

ENBREL MINI INJ 50MG/ML 2 NDS PA

ENBREL SURECLICK INJ 50MG/ML 2 NDS PA

ANALGESICS - NONNARCOTIC

SALICYLATES

aspirin chew tab 81mg $0*

ASPIRIN EC TAB 325MG $0*

aspirin EC tab 81mg, 325mg $0*

ASPIRIN TAB 81MG $0*

aspirin tab 81mg, 325mg $0*

CHOLINE MAGNESIUM TRISALICYLATE TAB

1000MG

1*

choline magnesium trisalicylate tab 500mg, 750mg 1*

diflunisal tab 500mg 1

salsalate tab 2*

ANALGESICS - OPIOID

OPIOID AGONISTS

ABSTRAL SL TAB 100MCG 3 PA QL=120 Quantity/30 Days






ACTIQ LOZENGE 1200MCG 3 PA QL=120 Quantity/30 Days






CODEINE SULFATE TAB 15MG 1 QL=240 Quantity/30 Days

codeine sulfate tab 15mg 1 QL=240 Quantity/30 Days






19



DILAUDID ORAL SOLN 1MG/ML 3 QL=2400 Quantity/30 Days

DILAUDID PF INJ 2MG/ML 3


DILAUDID TAB 2MG 3 QL=450 Quantity/30 Days



DOLOPHINE TAB 10MG 3 QL=360 Quantity/30 Days

DOLOPHINE TAB 5MG 3 QL=360 Quantity/30 Days

DURAGESIC PATCH 100MCG 3 QL=10 Quantity/30 Days





duramorph inj 0.5mg/ml 2 PA_BvD

duramorph inj 1mg/ml 2 PA_BvD

FENTANYL BUCCAL TAB 100MCG 3 PA QL=120 Quantity/30 Days





fentanyl lozenge 1200mcg 2 PA QL=120 Quantity/30 Days






fentanyl patch 100mcg 2 QL=10 Quantity/30 Days





hydromorphone inj 2mg/ml 2

HYDROMORPHONE INJ 4MG/ML 2

hydromorphone oral soln 1mg/ml 2 QL=2400 Quantity/30 Days

HYDROMORPHONE PF INJ 10MG/ML 2

hydromorphone PF inj 10mg/ml 2

hydromorphone PF inj 2mg/ml 2

HYDROMORPHONE SUPP 1*

hydromorphone tab 2mg 1 QL=450 Quantity/30 Days





20


HYSINGLA ER TAB 100MG 2 QL=30 Quantity/30 Days







LAZANDA NASAL SPRAY 100MCG 3 PA QL=30 Quantity/30 Days



methadone conc 10mg/ml 1

methadone oral soln 10mg/5ml 1 QL=1800 Quantity/30 Days

METHADONE ORAL SOLN 10MG/5ML 1 QL=1800 Quantity/30 Days

methadone oral soln 5mg/5ml 1 QL=3600 Quantity/30 Days

METHADONE ORAL SOLN 5MG/5ML 1 QL=3600 Quantity/30 Days

methadone tab 10mg 1 QL=360 Quantity/30 Days

methadone tab 5mg 1 QL=360 Quantity/30 Days

morphine sulfate ER tab 100mg 1 QL=120 Quantity/30 Days





MORPHINE SULFATE INJ 10MG/ML 3


morphine sulfate inj 1mg/ml 2



MORPHINE SULFATE IV SOLN 25MG/ML 3



morphine sulfate oral soln 100mg/5ml 1 QL=180 Quantity/30 Days



morphine sulfate PF inj 10mg/ml 3

MORPHINE SULFATE PF INJ 10MG/ML 3






MORPHINE SULFATE SUPP 2*




21

MORPHINE SULFATE TAB 15MG 1 QL=180 Quantity/30 Days

morphine sulfate tab 15mg 1 QL=180 Quantity/30 Days

MORPHINE SULFATE TAB 30MG 1 QL=180 Quantity/30 Days

morphine sulfate tab 30mg 1 QL=180 Quantity/30 Days

MS CONTIN TAB 100MG 3 QL=120 Quantity/30 Days





NUCYNTA ER TAB 100MG 2 QL=60 Quantity/30 Days





OPANA TAB 10MG 3 QL=360 Quantity/30 Days

OPANA TAB 5MG 3 QL=360 Quantity/30 Days

oxycodone cap 5mg 1 QL=360 Quantity/30 Days

oxycodone oral soln 20mg/ml 2 QL=270 Quantity/30 Days

oxycodone oral soln 5mg/5ml 2 QL=5400 Quantity/30 Days

oxycodone tab 10mg 1 QL=180 Quantity/30 Days





oxycodone/acetaminophen tab 5-325mg 1 QL=360 Quantity/30 Days

oxymorphone tab 10mg 2 QL=360 Quantity/30 Days

oxymorphone tab 5mg 2 QL=360 Quantity/30 Days

ROXICODONE TAB 15MG 3 QL=180 Quantity/30 Days



tramadol ER tab 100mg 2 QL=60 Quantity/30 Days

tramadol ER tab 100mg (matrix delivery) 2 QL=60 Quantity/30 Days





tramadol tab 50mg 1 QL=240 Quantity/30 Days

ULTRAM TAB 50MG 3 QL=240 Quantity/30 Days

XTAMPZA ER CAP 13.5MG 2 QL=120 Quantity/30 Days

XTAMPZA ER CAP 18MG 2 QL=120 Quantity/30 Days






22


OPIOID COMBINATIONS

acetaminophen/codeine soln 120-12mg/5ml 1 QL=4980 Quantity/30 Days

acetaminophen/codeine tab 300-15mg 1 QL=390 Quantity/30 Days



HYCET SOLN 7.5-325MG/15ML 3 QL=5400 Quantity/30 Days

hydrocodone/acetaminophen soln 10-325mg/15ml 1 QL=5400 Quantity/30 Days

hydrocodone/acetaminophen soln 7.5-325mg/15ml 1 QL=5400 Quantity/30 Days

hydrocodone/acetaminophen tab 10-300mg 2 QL=390 Quantity/30 Days




hydrocodone/acetaminophen tab 7.5-300mg 2 QL=390 Quantity/30 Days

hydrocodone/acetaminophen tab 7.5-325mg 1 QL=360 Quantity/30 Days

hydrocodone/ibuprofen tab 10-200mg 2 QL=480 Quantity/30 Days

hydrocodone/ibuprofen tab 5-200mg 2 QL=480 Quantity/30 Days

hydrocodone/ibuprofen tab 7.5-200mg 2 QL=480 Quantity/30 Days

IBUDONE TAB 10-200MG 3 QL=480 Quantity/30 Days

NORCO TAB 10-325MG 3 QL=360 Quantity/30 Days

NORCO TAB 5-325MG 3 QL=360 Quantity/30 Days

NORCO TAB 7.5-325MG 3 QL=360 Quantity/30 Days

oxycodone/acetaminophen tab 10-325mg 1 QL=360 Quantity/30 Days

oxycodone/acetaminophen tab 2.5-325mg 1 QL=360 Quantity/30 Days

oxycodone/acetaminophen tab 7.5-325mg 1 QL=360 Quantity/30 Days

oxycodone/aspirin tab 4.84-325mg 1 QL=360 Quantity/30 Days

OXYCODONE/ASPIRIN TAB 4.84-325MG 1 QL=360 Quantity/30 Days

OXYCODONE/IBUPROFEN TAB 5-400MG 2 QL=240 Quantity/30 Days

PERCOCET TAB 10-325MG 3 QL=360 Quantity/30 Days

PERCOCET TAB 2.5-325MG 3 QL=360 Quantity/30 Days

PERCOCET TAB 5-325MG 3 QL=360 Quantity/30 Days

PERCOCET TAB 7.5-325MG 3 QL=360 Quantity/30 Days

tramadol/acetaminophen tab 37.5-325mg 2 QL=360 Quantity/30 Days

TYLENOL/CODEINE TAB 300-30MG 3 QL=390 Quantity/30 Days

TYLENOL/CODEINE TAB 300-60MG 3 QL=390 Quantity/30 Days

ULTRACET TAB 37.5-325MG 3 QL=360 Quantity/30 Days

XODOL TAB 5-300MG 3 QL=390 Quantity/30 Days

XODOL TAB 7.5-300MG 3 QL=390 Quantity/30 Days

ZAMICET SOLN 10-325MG/15ML 3 QL=5400 Quantity/30 Days

OPIOID PARTIAL AGONISTS

buprenorphine SL tab 2mg 1





23

buprenorphine weekly patch 10mcg 2 QL=4 Quantity/28 Days




buprenorphine weekly patch 7.5mcg 2 QL=4 Quantity/28 Days

buprenorphine/naloxone SL film 12-3mg 1

buprenorphine/naloxone SL film 2-0.5mg 1



buprenorphine/naloxone SL tab 2-0.5mg 1

buprenorphine/naloxone SL tab 8-2mg 1

butorphanol nasal spray 10mg/ml 2 QL=4 Quantity/30 Days

ZUBSOLV SL TAB 1.4-0.36MG 2 QL=90 Quantity/30 Days





ANDROGENS-ANABOLIC

ANABOLIC STEROIDS

ANADROL TAB 50MG 3

oxandrolone tab 10mg 1

oxandrolone tab 2.5mg 1

ANDROGENS

ANDRODERM PATCH 2MG 2 PA QL=60 Quantity/30 Days

ANDRODERM PATCH 4MG 2 PA QL=30 Quantity/30 Days

ANDROGEL 1.62% (1.25GM) POUCH 3 PA QL=60 Quantity/30 Days

ANDROGEL 1.62% (2.5GM) POUCH 3 PA QL=60 Quantity/30 Days

ANDROGEL GEL 1% (25MG) 3 PA QL=120 Quantity/30 Days

ANDROGEL GEL, TESTIM GEL 1% (50MG) POUCH 3 PA QL=60 Quantity/30 Days

ANDROGEL PUMP 1.62% BOTTLE 3 PA QL=2 Quantity/30 Days

danazol cap 100mg 2

danazol cap 200mg 2

danazol cap 50mg 2

DEPO-TESTOSTERONE INJ 100MG/ML 3

DEPO-TESTOSTERONE INJ 200MG/ML 3

METHITEST TAB 10MG 3 PA

METHYLTESTOSTERONE CAP 10MG 2 PA

TESTOSTERONE CYPIONATE INJ (1ML) 200MG/

ML

2

testosterone cypionate inj 100mg/ml 1

testosterone cypionate inj 200mg/ml 1

testosterone enanthate inj 200mg/ml 2




24

TESTOSTERONE ENANTHATE INJ 200MG/ML 2

testosterone gel 1% (25mg) pouch 2 PA QL=120 Quantity/30 Days

TESTOSTERONE GEL 1% (25MG) POUCH 2 PA QL=120 Quantity/30 Days

TESTOSTERONE GEL 1% (50MG) POUCH 2 PA QL=60 Quantity/30 Days

testosterone gel 1% (50mg) pouch 2 PA QL=60 Quantity/30 Days

testosterone gel 1.62% (1.25gm) pouch 2 PA QL=60 Quantity/30 Days

testosterone gel 1.62% (2.5gm) pouch 2 PA QL=60 Quantity/30 Days

testosterone gel pump 1% (12.5mg) bottle 2 PA QL=4 Quantity/30 Days

TESTOSTERONE GEL PUMP 1% (12.5MG) BOTTLE 2 PA QL=4 Quantity/30 Days

TESTOSTERONE GEL PUMP 1% BOTTLE 2 PA QL=4 Quantity/30 Days

testosterone gel pump 1.62% bottle 2 PA QL=2 Quantity/30 Days

VOGELXO GEL 1% (50GM) POUCH 3 PA QL=60 Quantity/30 Days

VOGELXO GEL PUMP 1% 3 PA QL=4 Quantity/30 Days

ANORECTAL AGENTS

INTRARECTAL STEROIDS

hydrocortisone enema 100mg/60ml 2

UCERIS RECTAL FOAM 2MG 3 PA

RECTAL COMBINATIONS

ANALPRAM-HC CREAM 3*

hydrocortisone/pramoxine rectal cream 1-1% 1

hydrocortisone/pramoxine rectal cream 2.5-1% 1*

lidocaine/hydrocortisone cream 2*

RECTAL STEROIDS

ANUSOL-HC CREAM 2.5% 3

ANUSOL-HC SUPP 3*

hydrocortisone supp 2*

procto-pak cream 1% 1

proctozone-HC cream 2.5% 1

VASODILATING AGENTS

RECTIV RECTAL OINTMENT 0.4% 3 QL=30 Quantity/30 Days

ANTHELMINTICS

ANTHELMINTICS

albendazole tab 200mg 3 NDS

ALBENZA TAB 200MG 3 NDS

BENZNIDAZOLE TAB 100MG 2 PA

BENZNIDAZOLE TAB 12.5MG 2 PA

BILTRICIDE TAB 600MG 3

ivermectin tab 3mg 2

praziquantel tab 600mg 2

STROMECTOL TAB 3MG 3

ANTI-INFECTIVE AGENTS - MISC.

ANTI-INFECTIVE AGENTS - MISC.




25

FLAGYL CAP 375MG 3

FLAGYL TAB 250MG 3

FLAGYL TAB 500MG 3

metronidazole cap 375mg 1

metronidazole tab 250mg 1


METRONIDAZOLE/NACL INJ 0.74%/500MG/100ML 2

metronidazole/nacl inj 0.74%/500mg/100ml 2

metronidazole/nacl inj 0.79%/500mg/100ml 2

NEBUPENT NEB SOLN 300MG 2 PA_BvD

PENTAM INJ 300MG 2

pentamidine inj 300mg 2

pentamidine neb soln 300mg 2 PA_BvD

TINDAMAX TAB 500MG 3

tinidazole tab 250mg 2


trimethoprim tab 100mg 1

XIFAXAN TAB 200MG 3 QL=9 Quantity/3 Days

XIFAXAN TAB 550MG 3 PA QL=60 Quantity/30 Days

ANTI-INFECTIVE MISC. - COMBINATIONS

BACTRIM DS TAB 800-160MG 3

BACTRIM TAB 400-80MG 3

sulfamethoxazole/trimethoprim DS tab 800-160mg 1

sulfamethoxazole/trimethoprim susp 200-40mg/5ml 1

sulfamethoxazole/trimethoprim tab 400-80mg 1

ANTIPROTOZOAL AGENTS

ALINIA SUSP 100MG/5ML 2 PA QL=150 Quantity/3 Days

ALINIA TAB 500MG 2 PA QL=6 Quantity/3 Days

atovaquone susp 750mg/5ml 2

MEPRON SUSP 750MG/5ML 3

CARBAPENEMS

CILASTATIN/IMIPENEM INJ 250MG 2

cilastatin/imipenem inj 250mg 2

cilastatin/imipenem inj 500mg 2

ertapenem inj 1gm 2

INVANZ INJ 1GM 3

MEROPENEM INJ 0.9%/1GM/50ML 2

meropenem inj 1gm 2

meropenem inj 500mg 2

MEROPENEM INJ 500MG/50ML 2

MERREM INJ 500MG 3

PRIMAXIN INJ 500MG 3




26

CYCLIC LIPOPEPTIDES

CUBICIN INJ 500MG 3 NDS

DAPTOMYCIN INJ 350MG 3 NDS

daptomycin inj 350mg 3 NDS

daptomycin inj 500mg 3 NDS

GLYCOPEPTIDES

DALVANCE INJ 500MG 3 NDS

FIRST-VANCOMYCIN ORAL SOLN 25MG/ML 1*

FIRST-VANCOMYCIN ORAL SOLN 50MG/ML 1*

FIRVANQ ORAL SOLN 25MG/ML 1

FIRVANQ ORAL SOLN 50MG/ML 1

VANCOCIN CAP 125MG 3


vancomycin cap 125mg 2


VANCOMYCIN INJ 0.9%/1GM/200ML 2

VANCOMYCIN INJ 0.9%/500MG/100ML 2

VANCOMYCIN INJ 0.9%/750MG/150ML 2

vancomycin inj 1000mg 2

VANCOMYCIN INJ 100GM 2

vancomycin inj 10gm 2

VANCOMYCIN INJ 250MG 2





VANCOMYCIN IV SOLN 1.25GM 2

VANCOMYCIN/DEXTROSE INJ 5%/1GM/200ML 2

VANCOMYCIN/DEXTROSE INJ 5%/500MG/100ML 2

VANCOMYCIN/DEXTROSE INJ 5%/750MG/150ML 2

LEPROSTATICS

dapsone tab 100mg 1

dapsone tab 25mg 1

LINCOSAMIDES

CLEOCIN CAP 150MG 3

CLEOCIN CAP 300MG 3

CLEOCIN CAP 75MG 3

CLEOCIN INJ 300MG/2ML 3

CLEOCIN INJ 300MG/50ML/D5W 3







27


CLEOCIN PED ORAL SOLN 75MG/5ML 3

clindamycin cap 150mg 1



clindamycin inj 300mg/2ml 2

clindamycin inj 300mg/50ml/D5W 2





clindamycin inj 9gm/60ml 2

clindamycin IV soln 300mg/2ml 2



clindamycin oral soln 75MG/5ML 2

CLINDAMYCIN/NACL 9% IV SOLN 300MG/50ML 2



MONOBACTAMS

aztreonam inj 1gm 2

CAYSTON INHALATION SOLN 75MG 2 NDS PA

OXAZOLIDINONES

LINEZOLID INJ 2MG/ML 3 NDS

linezolid inj 600mg/300ml 3 NDS

linezolid susp 100mg/5ml 2

linezolid tab 600mg 2

SIVEXTRO INJ 200MG 3 NDS PA QL=6 Quantity/6 Days

SIVEXTRO TAB 200MG 2 NDS PA QL=6 Quantity/6 Days

ZYVOX IV SOLN 200MG/100ML 3 NDS

ZYVOX IV SOLN 600MG/300ML 3 NDS

ZYVOX SUSP 100MG/5ML 3 NDS

ZYVOX TAB 600MG 3 NDS

PLEUROMUTILINS

XENLETA TAB 600MG 2 PA QL=14 Quantity/7 Days

POLYMYXINS

colistimeth inj 150mg 2

polymyxin B inj 500000unit 2

ANTIANGINAL AGENTS

ANTIANGINALS-OTHER

RANEXA TAB 1000MG 3

RANEXA TAB 500MG 3




28

ranolazine tab 1000mg 2


NITRATES

DILATRATE SR CAP 40MG 3

ISORDIL TAB 40MG 3

ISORDIL TAB 5MG 3

ISOSORBIDE DINITRATE ER TAB 40MG 1

isosorbide dinitrate tab 10mg 1





isosorbide mononitrate ER tab 120mg 1



isosorbide mononitrate tab 10mg 1

isosorbide mononitrate tab 20mg 1

NITRO-BID OINTMENT 2% 2

NITRO-DUR PATCH 0.1MG 3






NITROGLYCERIN AEROSOL 400MCG 2

NITROGLYCERIN CAP 1*

nitroglycerin lingual pump spray 400mcg 2

nitroglycerin patch 0.1mg 1




nitroglycerin SL tab 0.3mg 1



NITROLINGUAL PUMP SPRAY 400MCG 3

NITROMIST AEROSOL 400MCG 3

NITROSTAT SL TAB 0.3MG 3



ANTIANXIETY AGENTS

ANTIANXIETY AGENTS - MISC.

buspirone tab 10mg 1




29



buspirone tab 5mg 1

buspirone tab 7.5mg 1

HYDROXYZINE PAMOATE CAP 100MG 1

hydroxyzine pamoate cap 25mg 1

hydroxyzine pamoate cap 50mg 1

hydroxyzine syrup 10mg/5ml 1

hydroxyzine tab 10mg 1



VISTARIL CAP 25MG 3

VISTARIL CAP 50MG 3

BENZODIAZEPINES

alprazolam ER tab 0.5mg 2

alprazolam ER tab 1mg 2



ALPRAZOLAM INTENSOL CONC 1MG/ML 3

alprazolam ODT 0.25mg 2


alprazolam ODT 1mg 2


alprazolam tab 0.25mg 1


alprazolam tab 1mg 1


ATIVAN TAB 0.5MG 3

ATIVAN TAB 1MG 3

ATIVAN TAB 2MG 3

chlordiazepoxide cap 10mg 1



clorazepate dipotassium tab 15mg 2

clorazepate dipotassium tab 3.75mg 2

clorazepate dipotassium tab 7.5mg 2

diazepam intensol conc 5mg/ml 1

DIAZEPAM ORAL SOLN 1MG/ML 1

diazepam tab 10mg 1

diazepam tab 2mg 1

diazepam tab 5mg 1

lorazepam intensol conc 2mg/ml 1




30

lorazepam tab 0.5mg 1

lorazepam tab 1mg 1

lorazepam tab 2mg 1

OXAZEPAM CAP 10MG 1

OXAZEPAM CAP 15MG 1

OXAZEPAM CAP 30MG 1

TRANXENE T TAB 7.5MG 3

VALIUM TAB 10MG 3

VALIUM TAB 2MG 3

VALIUM TAB 5MG 3

XANAX TAB 0.25MG 3

XANAX TAB 0.5MG 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

ANTIARRHYTHMICS

ANTIARRHYTHMICS TYPE I-A

disopyramide cap 100mg 1 PA

disopyramide cap 150mg 1 PA

NORPACE CAP 100MG 3 PA

NORPACE CAP 150MG 3 PA

NORPACE CR CAP 100MG 2 PA

NORPACE CR CAP 150MG 2 PA

quinidine gluconate CR tab 324mg 2

QUINIDINE SULFATE TAB 200MG 1

QUINIDINE SULFATE TAB 300MG 1

ANTIARRHYTHMICS TYPE I-B

mexiletine cap 150mg 2



ANTIARRHYTHMICS TYPE I-C

flecainide tab 100mg 1



propafenone ER cap 225mg 2



propafenone tab 150mg 1





31


RYTHMOL SR CAP 225MG 3



ANTIARRHYTHMICS TYPE III

amiodarone tab 100mg 1



dofetilide cap 125mcg 2



MULTAQ TAB 400MG 2

TIKOSYN CAP 125MCG 3



ANTIASTHMATIC AND BRONCHODILATOR AGENTS

ANTI-INFLAMMATORY AGENTS

cromolyn neb soln 20mg/2ml 1 PA_BvD

ANTIASTHMATIC - MONOCLONAL ANTIBODIES

FASENRA PEN INJ 30MG/ML 3 PA

FASENRA SYRINGE 30MG/ML 3 PA

NUCALA AUTO-INJECTOR 100MG/ML 2 NDS PA

NUCALA INJ 100MG 3 NDS PA

NUCALA SYRINGE 100MG/ML 2 NDS PA

XOLAIR INJ 150MG 3 NDS PA

XOLAIR SYRINGE 150MG/ML 3 NDS PA

XOLAIR SYRINGE 75MG/0.5ML 3 NDS PA

BRONCHODILATORS - ANTICHOLINERGICS

ATROVENT HFA INHALER 17MCG/ACT 2

INCRUSE ELLIPTA INHALER 62.5MCG 2

ipratropium neb soln 0.02% 1 PA_BvD

LONHALA NEB SOLN 0.0025% 2 ST

SPIRIVA RESPIMAT INHALER 1.25MCG 2 ST QL=1 Quantity/30 Days

LEUKOTRIENE MODULATORS

ACCOLATE TAB 10MG 3

ACCOLATE TAB 20MG 3

montelukast chew tab 4mg 1


montelukast granules 4mg 2

montelukast tab 10mg 1

SINGULAIR CHEW TAB 4MG 3

SINGULAIR CHEW TAB 5MG 3




32

SINGULAIR GRANULES 4MG 3

SINGULAIR TAB 10MG 3

zafirlukast tab 10mg 2


SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS

DALIRESP TAB 250MCG 3


STEROID INHALANTS

ARNUITY ELLIPTA INHALER 100MCG 1 QL=1 Quantity/30 Days



ASMANEX HFA INHALER 100MCG 1 QL=1 Quantity/30 Days



ASMANEX INHALER 110MCG 1 QL=1 Quantity/30 Days

ASMANEX INHALER 220MCG 1 QL=1 Quantity/30 Days

budesonide neb susp 0.25mg/2ml 1 PA_BvD QL=60 Quantity/30 Days

budesonide neb susp 0.5mg/2ml 1 PA_BvD QL=60 Quantity/30 Days

budesonide neb susp 1mg/2ml 1 PA_BvD QL=60 Quantity/30 Days

FLOVENT DISKUS 100MCG 1 QL=1 Quantity/30 Days



FLOVENT HFA INHALER 100MCG 1 QL=2 Quantity/30 Days



PULMICORT NEB SUSP 0.25MG/2ML 3 PA_BvD QL=60 Quantity/30 Days

PULMICORT NEB SUSP 0.5MG/2ML 3 PA_BvD QL=60 Quantity/30 Days

PULMICORT NEB SUSP 1MG/2ML 3 PA_BvD QL=60 Quantity/30 Days

SYMPATHOMIMETICS

ADVAIR HFA INHALER 115-21MCG 2 QL=1 Quantity/30 Days



ALBUTEROL ER TAB 4MG 2


albuterol neb soln 0.083% 1 PA_BvD

albuterol neb soln 0.5% 1 PA_BvD

albuterol neb soln 0.63mg/3ml 1 PA_BvD

albuterol neb soln 1.25mg/3ml 1 PA_BvD

albuterol syrup 2mg/5ml 1

albuterol tab 2mg 1

albuterol tab 4mg 1

ANORO ELLIPTA INHALER 62.5-25MCG 2 QL=1 Quantity/30 Days




33

BREO ELLIPTA INHALER 100-25MCG 2 QL=1 Quantity/30 Days

BREO ELLIPTA INHALER 200-25MCG 2 QL=1 Quantity/30 Days

BROVANA NEB SOLN 15MCG/2ML 3 PA_BvD

COMBIVENT RESPIMAT INHALER 20-100MCG/

ACT

2

DULERA INHALER 100-5MCG 2 QL=1 Quantity/30 Days



FLUTICASONE PROPIONATE/SALMETEROL

XINAFOATE INH 232-14MCG/ACT

1 QL=1 Quantity/30 Days


XINAFOATE INHALER 113-14MCG



XINAFOATE INHALER 55-14MCG


fluticasone/salmeterol diskus 100-50mcg 2 QL=1 Quantity/30 Days



ipratropium/albuterol neb soln 0.5-2.5(3)mg/3ml 1 PA_BvD

LEVALBUTEROL HFA INHALER, XOPENEX HFA

INHALER 45MCG

3 ST QL=2 Quantity/30 Days

levalbuterol neb soln 0.31mg/3ml 2 PA_BvD


levalbuterol neb soln 1.25mg/0.5ml 2 PA_BvD


PERFOROMIST NEB SOLN 20MCG/2ML 3 PA_BvD

SEREVENT DISK 50MCG/DOSE 2

STIOLTO INHALER 2.5-2.5MCG 2 QL=1 Quantity/30 Days

terbutaline tab 2.5mg 1

terbutaline tab 5mg 1

TRELEGY ELLIPTA INHALER 100- 62.5-25MCG 2 QL=1 Quantity/30 Days

VENTOLIN HFA INHALER 18GM 1 QL=2 Quantity/30 Days

VENTOLIN HFA INHALER 8GM 1 QL=5 Quantity/30 Days

XOPENEX NEB SOLN 0.31MG/3ML 3 PA_BvD



XOPENEX NEB SOLN CONC 1.25MG/0.5ML 3 PA_BvD

XANTHINES

ELIXOPHYLLINE ELIXIR 80MG/15ML 2

THEO-24 CR CAP 100MG 3







34

THEOCHRON TAB 100MG 1



THEOPHYLLINE CR TAB 300MG 1

theophylline ER tab 400mg 1


theophylline soln 80mg/15ml 1

theophylline SR tab 300mg 1

ANTICOAGULANTS

COUMARIN ANTICOAGULANTS

COUMADIN TAB 10MG 3

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


warfarin tab 10mg 1

warfarin tab 1mg 1

warfarin tab 2.5mg 1

warfarin tab 2mg 1

warfarin tab 3mg 1

warfarin tab 4mg 1

warfarin tab 5mg 1

warfarin tab 6mg 1


DIRECT FACTOR XA INHIBITORS

ELIQUIS TAB 2.5MG 2

ELIQUIS TAB 5MG 2

XARELTO TAB 10MG 2

XARELTO TAB 15MG 2

XARELTO TAB 2.5MG 2

XARELTO TAB 20MG 2

XARELTO TAB STARTER PACK 15MG/20MG 2

HEPARINS AND HEPARINOID-LIKE AGENTS

ARIXTRA INJ 10MG/0.8ML 3

ARIXTRA INJ 2.5MG/0.5ML 3


ARIXTRA INJ 7.5MG/0.6ML 3

enoxaparin inj 100mg/ml 2 QL=60 Quantity/30 Days




35

enoxaparin inj 120mg/0.8ml 2 QL=60 Quantity/30 Days

enoxaparin inj 150mg/ml 2 QL=60 Quantity/30 Days

enoxaparin inj 300mg/3ml 2 QL=30 Quantity/30 Days





fondaparinux inj 10mg/0.8ml 2

fondaparinux inj 2.5mg/0.5ml 2



FRAGMIN INJ 10000UNIT/ML 3

FRAGMIN INJ 12500UNIT/0.5ML 3







heparin sodium inj (PF) 5000unit/0.5ml 2 PA_BvD

heparin sodium inj 10000unit/ml 2 PA_BvD




LOVENOX INJ 100MG/ML 3 QL=60 Quantity/30 Days

LOVENOX INJ 120MG/0.8ML 3 QL=60 Quantity/30 Days

LOVENOX INJ 150MG/ML 3 QL=60 Quantity/30 Days

LOVENOX INJ 300MG/3ML 3 QL=30 Quantity/30 Days





THROMBIN INHIBITORS

PRADAXA CAP 110MG 2

PRADAXA CAP 150MG 2

PRADAXA CAP 75MG 2

ANTICONVULSANTS

AMPA GLUTAMATE RECEPTOR ANTAGONISTS

FYCOMPA SUSP 0.5MG/ML 3 PA_NSO

FYCOMPA TAB 10MG 3 PA_NSO






36




ANTICONVULSANTS - BENZODIAZEPINES

clobazam susp 2.5mg/ml 2

clobazam tab 10mg 1

clobazam tab 20mg 1

clonazepam ODT 0.125mg 2



clonazepam ODT 1mg 2


clonazepam tab 0.5mg 1

clonazepam tab 1mg 1


DIASTAT RECTAL GEL, DIAZEPAM RECTAL GEL

10MG

3


2.5MG

3


20MG

3

KLONOPIN TAB 0.5MG 3

KLONOPIN TAB 1MG 3

KLONOPIN TAB 2MG 3

NAYZILAM NASAL SPRAY 5MG/0.1ML 3

ONFI SUSP 2.5MG/ML 3

ONFI TAB 10MG 3

ONFI TAB 20MG 3

SYMPAZAN STRIP 10MG 3 ST_NSO



VALTOCO DOSE KIT PACK 10MG/0.1ML 3

VALTOCO DOSE KIT PACK 5MG/0.1ML 3

VALTOCO DOSE KIT PACK 7.5MG/0.1ML 3

ANTICONVULSANTS - MISC.

APTIOM TAB 200MG 3 PA_NSO




BANZEL SUSP 40MG/ML 2

BANZEL TAB 200MG 2

BANZEL TAB 400MG 2




37

BRIVIACT ORAL SOLN 10MG/ML 3 PA_NSO

BRIVIACT TAB 100MG 3 PA_NSO





carbamazepine chew tab 100mg 1

carbamazepine ER tab 100mg 2



carbamazepine SR cap 100mg 2



carbamazepine susp 100mg/5ml 1

carbamazepine tab 200mg 1

CARBATROL SR CAP 100MG 3



EPIDIOLEX ORAL SOLN 100MG/ML 2 PA_NSO

gabapentin cap 100mg 1



gabapentin oral soln 250mg/5ml 2

gabapentin tab 600mg 1


KEPPRA ORAL SOLN 100MG/ML 3

KEPPRA TAB 1000MG 3

KEPPRA TAB 250MG 3

KEPPRA TAB 500MG 3

KEPPRA TAB 750MG 3

KEPPRA XR TAB 500MG 3


LAMICTAL CHEW TAB 25MG 3

LAMICTAL CHEW TAB 5MG 3

LAMICTAL ODT 100MG 3


LAMICTAL ODT 25MG 3

LAMICTAL ODT 50MG 3

LAMICTAL ODT KIT 3

LAMICTAL TAB 100MG 3






38

LAMICTAL TAB 25MG 3

LAMICTAL TAB STARTER KIT 3

LAMICTAL XR KIT 3

LAMICTAL XR TAB 100MG 3






lamotrigine chew tab 25mg 1


lamotrigine ER tab 100mg 2






lamotrigine ODT 100mg 2




lamotrigine tab 100mg 1




lamotrigine tab starter kit 25mg (35) 2

lamotrigine tab starter kit 25mg (42)/100mg (7) 2

lamotrigine tab starter kit 25mg (84)/100mg (14) 2

levetiracetam ER tab 500mg 1


levetiracetam oral soln 100mg/ml 1

levetiracetam tab 1000mg 1




MYSOLINE TAB 250MG 3

MYSOLINE TAB 50MG 3

NEURONTIN CAP 100MG 3



NEURONTIN ORAL SOLN 250MG/5ML 3

NEURONTIN TAB 600MG 3




39


oxcarbazepine susp 300mg/5ml 1

oxcarbazepine tab 150mg 1



OXTELLAR XR TAB 150MG 3



pregabalin cap 100mg 1








pregabalin soln 20mg/ml 2

primidone tab 250mg 1


roweepra tab 1000mg 1

SPRITAM ODT 1000MG 3 PA_NSO




TEGRETOL SUSP 100MG/5ML 3

TEGRETOL TAB 200MG 3

TEGRETOL XR TAB 100MG 3



TOPAMAX SPRINKLE CAP 15MG 3

TOPAMAX SPRINKLE CAP 25MG 3

TOPAMAX TAB 100MG 3

TOPAMAX TAB 200MG 3

TOPAMAX TAB 25MG 3

TOPAMAX TAB 50MG 3

TOPIRAMATE ER CAP 100MG 3 PA_NSO





topiramate sprinkle cap 15mg 1





40

topiramate tab 100mg 1




TRILEPTAL SUSP 300MG/5ML 3

TRILEPTAL TAB 150MG 3



TROKENDI XR CAP 100MG 3 PA_NSO




VIMPAT INJ 200MG/20ML 2

VIMPAT SOLN 10MG/ML 2

VIMPAT TAB 100MG 2

VIMPAT TAB 150MG 2

VIMPAT TAB 200MG 2

VIMPAT TAB 50MG 2

ZONEGRAN CAP 100MG 3

ZONEGRAN CAP 25MG 3

zonisamide cap 100mg 1



CARBAMATES

felbamate susp 600mg/5ml 2

felbamate tab 400mg 2


FELBATOL SUSP 600MG/5ML 3

FELBATOL TAB 400MG 3


XCOPRI PACK TAB 150/200MG 3 PA_NSO

XCOPRI PACK TAB 50/200MG 3 PA_NSO

XCOPRI TAB 100MG 3 PA_NSO




XCOPRI TITRATION PACK 12.5/25MG 3 PA_NSO

XCOPRI TITRATION PACK 150/200MG 3 PA_NSO

XCOPRI TITRATION PACK 50/100MG 3 PA_NSO

GABA MODULATORS

GABITRIL TAB 12MG 3

GABITRIL TAB 16MG 3




41

GABITRIL TAB 2MG 3

GABITRIL TAB 4MG 3

tiagabine tab 12mg 2


tiagabine tab 2mg 2

tiagabine tab 4mg 2

vigabatrin powder 500mg 2 NDS PA_NSO

vigabatrin tab 500mg 2 NDS PA_NSO

HYDANTOINS

DILANTIN CAP 100MG 3

DILANTIN CAP 30MG 2

DILANTIN INFATABS 50MG 3

DILANTIN SUSP 125MG/5ML 3

PEGANONE TAB 250MG 2

PHENYTEK CAP 200MG 3


phenytoin chew tab 50mg 2

phenytoin EX cap 100mg 1



phenytoin susp 125mg/5ml 1

SUCCINIMIDES

CELONTIN CAP 300MG 2

ethosuximide cap 250mg 2

ethosuximide soln 250mg/5ml 1

ZARONTIN CAP 250MG 3

ZARONTIN SOLN 250MG/5ML 3

VALPROIC ACID

DEPAKOTE DR TAB 125MG 3



DEPAKOTE ER TAB 250MG 3


DEPAKOTE SPRINKLE CAP 125MG 3

divalproex DR tab 125mg 1



divalproex ER tab 250mg 1


divalproex sprinkle cap 125mg 1

valproic acid cap 250mg 1

valproic acid oral soln 250mg/5ml 1




42

ANTIDEPRESSANTS

ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)

mirtazapine ODT 15mg 1



mirtazapine tab 15mg 1



mirtazapine tab 7.5mg 1

REMERON SOLUTAB 15MG 3



REMERON TAB 15MG 3

REMERON TAB 30MG 3

ANTIDEPRESSANTS - MISC.

APLENZIN ER TAB 174MG 3 ST_NSO



bupropion SR tab 100mg 1



bupropion tab 100mg 1


bupropion XL tab 150mg 1


MAPROTILINE TAB 25MG 1



WELLBUTRIN XL TAB 100MG 3




MODIFIED CYCLICS

NEFAZODONE TAB 100MG 1



trazodone tab 100mg 1




TRINTELLIX TAB 10MG 2 ST_NSO





43


VIIBRYD TAB 10MG 3 ST_NSO



MONOAMINE OXIDASE INHIBITORS (MAOIS)

EMSAM PATCH 12MG 3

EMSAM PATCH 6MG 3

EMSAM PATCH 9MG 3

MARPLAN TAB 10MG 2

NARDIL TAB 15MG 2

PARNATE TAB 10MG 3

phenelzine tab 15mg 1

tranylcypromine tab 10mg 2

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)

CELEXA TAB 10MG 3

CELEXA TAB 20MG 3

CELEXA TAB 40MG 3

citalopram oral soln 10mg/5ml 1

citalopram tab 10mg 1



escitalopram soln 5mg/5ml 2

escitalopram tab 10mg 1



fluoxetine cap 10mg 1



fluoxetine soln 20mg/5ml 1

fluoxetine tab 10mg 1


fluvoxamine ER cap 100mg 2 ST_NSO

fluvoxamine ER cap 150mg 2 ST_NSO

fluvoxamine tab 100mg 1



LEXAPRO TAB 10MG 3

LEXAPRO TAB 20MG 3

LEXAPRO TAB 5MG 3

paroxetine ER tab 12.5mg 2 PA_NSO

paroxetine ER tab 25mg 2 PA_NSO

paroxetine ER tab 37.5mg 2 PA_NSO




44

paroxetine tab 10mg 1 PA_NSO




PAXIL CR TAB 12.5MG 3 PA_NSO

PAXIL CR TAB 25MG 3 PA_NSO

PAXIL CR TAB 37.5MG 3 PA_NSO

PAXIL ORAL SUSP 10MG/5ML 3 PA_NSO

PAXIL TAB 10MG 3 PA_NSO




PEXEVA TAB 10MG 3 PA_NSO




PROZAC CAP 10MG 3

PROZAC CAP 20MG 3

PROZAC CAP 40MG 3

sertraline soln 20mg/ml 1

sertraline tab 100mg 1



ZOLOFT ORAL SOLN 20MG/ML 3

ZOLOFT TAB 100MG 3

ZOLOFT TAB 25MG 3

ZOLOFT TAB 50MG 3

SEROTONIN MODULATORS



VIIBRYD TAB STARTER KIT 10/20MG 3 ST_NSO

SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)

CYMBALTA CAP 20MG 3

CYMBALTA CAP 30MG 3

CYMBALTA CAP 60MG 3

desvenlafaxine succinate ER tab 100mg 2



DRIZALMA DR CAP 20MG 3 ST_NSO







45

duloxetine cap 20mg 1


duloxetine cap 40mg 2 ST_NSO


EFFEXOR XR CAP 150MG 3

EFFEXOR XR CAP 37.5MG 3


FETZIMA CAP TITRATION PACK 3 ST_NSO

FETZIMA ER CAP 120MG 3 ST_NSO




PRISTIQ TAB 100MG 3 ST_NSO



venlafaxine ER cap 150mg 1

venlafaxine ER cap 37.5mg 1


venlafaxine tab 100mg 1


venlafaxine tab 37.5mg 1



TRICYCLIC AGENTS

amitriptyline tab 100mg 1 PA_NSO






AMOXAPINE TAB 100MG 1 PA_NSO




ANAFRANIL CAP 25MG 3 PA_NSO



clomipramine cap 25mg 2 PA_NSO



desipramine tab 100mg 2 PA_NSO





46





doxepin cap 100mg 1 PA_NSO


DOXEPIN CAP 150MG 1 PA_NSO




doxepin oral soln 10mg/ml 1 PA_NSO

ELAVIL TAB 25MG 3 PA_NSO

imipramine pamoate cap 100mg 2 PA_NSO




imipramine tab 10mg 1 PA_NSO



NORPRAMIN TAB 10MG 3 PA_NSO



nortriptyline cap 10mg 1




NORTRIPTYLINE ORAL SOLN 10MG/5ML 1

PAMELOR CAP 10MG 3

PAMELOR CAP 25MG 3

PAMELOR CAP 50MG 3

PAMELOR CAP 75MG 3

protriptyline tab 10mg 2 PA_NSO

protriptyline tab 5mg 2 PA_NSO

SURMONTIL CAP 100MG 3 PA_NSO



TOFRANIL TAB 10MG 3 PA_NSO



trimipramine cap 100mg 2 PA_NSO






47

ANTIDIABETICS

ALPHA-GLUCOSIDASE INHIBITORS

acarbose tab 100mg 1

acarbose tab 25mg 1

acarbose tab 50mg 1

GLYSET TAB 100MG 3

GLYSET TAB 25MG 3

GLYSET TAB 50MG 3

miglitol tab 100mg 2

miglitol tab 25mg 2

miglitol tab 50mg 2

PRECOSE TAB 100MG 3

PRECOSE TAB 25MG 3

PRECOSE TAB 50MG 3

ANTIDIABETIC COMBINATIONS

glipizide/metformin tab 2.5-250mg 1

glipizide/metformin tab 2.5-500mg 1

glipizide/metformin tab 5-500mg 1

GLUCOVANCE TAB 2.5-500MG 3

GLUCOVANCE TAB 5-500MG 3

glyburide/metformin tab 1.25-250mg 1

glyburide/metformin tab 2.5-500mg 1

glyburide/metformin tab 5-500mg 1

GLYXAMBI TAB 10-5MG 2 QL=30 Quantity/30 Days

GLYXAMBI TAB 25-5MG 2 QL=30 Quantity/30 Days

JANUMET TAB 50-1000MG 2 QL=60 Quantity/30 Days

JANUMET TAB 50-500MG 2 QL=60 Quantity/30 Days

JANUMET XR TAB 100-1000MG 2 QL=30 Quantity/30 Days



JENTADUETO TAB 2.5-1000MG 2 QL=60 Quantity/30 Days



JENTADUETO XR TAB 2.5-1000MG 2

JENTADUETO XR TAB 5-1000MG 2 QL=30 Quantity/30 Days

REPAGLINIDE/METFORMIN TAB 1-500MG 3

REPAGLINIDE/METFORMIN TAB 2-500MG 3

SYNJARDY TAB 12.5-1000MG 2 QL=60 Quantity/30 Days

SYNJARDY TAB 12.5-500MG 2 QL=60 Quantity/30 Days

SYNJARDY TAB 5-1000MG 2 QL=60 Quantity/30 Days

SYNJARDY TAB 5-500MG 2

SYNJARDY XR TAB 10-1000MG 2 QL=30 Quantity/30 Days




48

SYNJARDY XR TAB 12.5-1000MG 2 QL=60 Quantity/30 Days



TRIJARDY ER TAB 10-5-1000MG 2 QL=30 Quantity/30 Days

TRIJARDY ER TAB 12.5-2.5-1000MG 2 QL=60 Quantity/30 Days

TRIJARDY ER TAB 25-5-1000MG 2 QL=30 Quantity/30 Days

TRIJARDY ER TAB 5-2.5-1000MG 2 QL=60 Quantity/30 Days

XIGDUO XR TAB 10-1000MG 2 QL=30 Quantity/30 Days


XIGDUO XR TAB 2.5-1000MG 2


XIGDUO XR TAB 5-500MG 2

XULTOPHY INJ 100-3.6UNIT-MG/ML 2 PA

BIGUANIDES

GLUCOPHAGE TAB 1000MG 3



GLUCOPHAGE XR TAB 500MG 3

GLUCOPHAGE XR TAB 750MG 3

metformin ER tab 500mg 1


metformin hcl soln 500mg/5ml 2

metformin tab 1000mg 1



RIOMET ER SUSP 500MG/5ML 3

RIOMET ORAL SOLN 500MG/5ML 3

DIABETIC OTHER

BAQSIMI NASAL POWDER 3MG/DOSE 2

diazoxide susp 50mg/ml 2

GLUCAGEN HYPOKIT INJ 1MG 2

GLUCAGON KIT 1MG 2

GVOKE INJ 0.5MG/0.1ML 2 QL=2 Quantity/7 Days

GVOKE INJ 1MG/0.2ML 2 QL=2 Quantity/7 Days

GVOKE SYRINGE 0.5MG/0.1ML 2

GVOKE SYRINGE 1MG/0.2ML 2

KORLYM TAB 300MG 2 NDS PA

PROGLYCEM SUSP 50MG/ML 3

DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS

JANUVIA TAB 100MG 2 RXC QL=30 Quantity/30 Days

JANUVIA TAB 25MG 2 RXC

JANUVIA TAB 50MG 2 RXC




49

TRADJENTA TAB 5MG 2 QL=30 Quantity/30 Days

DOPAMINE RECEPTOR AGONISTS - ANTIDIABETIC

CYCLOSET TAB 0.8MG 3

INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)

BYDUREON BCISE AUTO INJ 2MG/0.85ML 2 QL=4 Quantity/28 Days

BYDUREON INJ 2MG 2 QL=4 Quantity/28 Days

BYDUREON PEN INJ 2MG 2 QL=4 Quantity/28 Days

BYETTA INJ 10MCG/0.04ML 3 QL=1 Quantity/30 Days

BYETTA INJ 5MCG/0.02ML 3 QL=1 Quantity/30 Days

OZEMPIC INJ 1MG/DOSE 2 QL=3 Quantity/28 Days

OZEMPIC INJ 2MG/1.5ML 2 QL=1 Quantity/28 Days

RYBELSUS TAB 14MG 2 QL=30 Quantity/30 Days



TRULICITY INJ 0.75MG/0.5ML 2 QL=4 Quantity/28 Days

TRULICITY INJ 1.5MG/0.5ML 2 QL=4 Quantity/28 Days

VICTOZA INJ 18MG/3ML 2 QL=9 Quantity/30 Days

INSULIN

FIASP FLEXTOUCH INJ 100UNIT/ML 2

FIASP INJ 100UNIT/ML 2 PA_BvD

FIASP PENFILL INJ 100UNIT/ML 2

HUMULIN R U-500 INJ 500UNIT/ML 2 PA_BvD

HUMULIN R U-500 KWIKPEN 500UNIT/ML 2

LANTUS INJ 100UNIT/ML 2

LANTUS SOLOSTAR INJ 100UNIT/ML 2

LEVEMIR FLEXTOUCH 100UNIT/ML 2

LEVEMIR INJ 100UNIT/ML 2

NOVOLIN MIX (70/30) FLEXPEN 100UNIT/ML 2

NOVOLIN MIX (70/30) VIAL 100UNIT/ML 2

NOVOLIN N FLEXPEN INJ 100UNIT/ML 2

NOVOLIN N INJ 100UNIT/ML 2

NOVOLIN R FLEXPEN INJ 100UNIT/ML 2

NOVOLIN R INJ 100UNIT/ML 2

NOVOLOG CARTRIDGE 100UNIT/ML, INSULIN

ASPART CARTRIDGE 100UNIT/ML

2

NOVOLOG INJ 100UNIT/ML, INSULIN ASPART INJ

100UNIT/ML

2 PA_BvD

NOVOLOG MIX (70/30) INJ 100UNIT/ML, INSULIN

ASPART MIX (70/30) INJ 100UNIT/ML

2

NOVOLOG MIX (70/30) PEN INJ 100UNIT/ML,

INSULIN ASPART MIX (70/30) PEN INJ 100UNIT/

ML

2




50

NOVOLOG PEN INJ 100UNIT/ML , INSULIN

ASPART PEN INJ 100UNIT/ML

2

TOUJEO MAX SOLOSTAR INJ 300UNIT/ML 2

TOUJEO SOLOSTAR INJ 300UNIT/ML 2

TRESIBA FLEXTOUCH PEN INJ 100UNIT/ML 2

TRESIBA FLEXTOUCH PEN INJ 200UNIT/ML 2

TRESIBA INJ (VIAL) 100UNIT/ML 2

INSULIN SENSITIZING AGENTS

ACTOS TAB 15MG 3

ACTOS TAB 30MG 3

ACTOS TAB 45MG 3

AVANDIA TAB 2MG 2

AVANDIA TAB 4MG 2

pioglitazone tab 15mg 1



MEGLITINIDE ANALOGUES

nateglinide tab 120mg 2


PRANDIN TAB 0.5MG 3

PRANDIN TAB 1MG 3

PRANDIN TAB 2MG 3

repaglinide tab 0.5mg 1

repaglinide tab 1mg 1


STARLIX TAB 120MG 3

STARLIX TAB 60MG 3

SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS

FARXIGA TAB 10MG 2 QL=30 Quantity/30 Days

FARXIGA TAB 5MG 2

JARDIANCE TAB 10MG 2

JARDIANCE TAB 25MG 2 QL=30 Quantity/30 Days

SULFONYLUREAS

AMARYL TAB 1MG 3

AMARYL TAB 2MG 3

AMARYL TAB 4MG 3

glimepiride tab 1mg 1



glipizide ER tab 10mg 1

glipizide ER tab 2.5mg 1





51

glipizide tab 10mg 1

glipizide tab 5mg 1

GLUCOTROL TAB 10MG 3

GLUCOTROL TAB 5MG 3

GLUCOTROL XL TAB 10MG 3

GLUCOTROL XL TAB 2.5MG 3


TOLBUTAMIDE TAB 500MG 2

ANTIDIARRHEAL/PROBIOTIC AGENTS

ANTIPERISTALTIC AGENTS

DIPHENOXYLATE/ATROPINE LIQUID

2.5-0.025MG/5ML

1

ANTIDIARRHEALS

ANTIPERISTALTIC AGENTS

diphenoxylate/atropine tab 2.5-0.025mg 1

LOMOTIL TAB 2.5-0.025MG 3

loperamide cap 2mg 1

opium tincture 3*

ANTIDOTES

ANTIDOTES - CHELATING AGENTS

CHEMET CAP 100MG 2

FERRIPROX ORAL SOLN 100MG/ML 2 NDS PA

FERRIPROX TAB 500MG 2 NDS PA

OPIOID ANTAGONISTS

naloxone inj 0.4mg/ml 1

VIVITROL INJ 380MG 3 NDS

ANTIDOTES AND SPECIFIC ANTAGONISTS

ANTIDOTES - CHELATING AGENTS

deferasirox tab (for suspension) 125mg 2 NDS



deferasirox tab 180mg 2 NDS



EXJADE TAB (FOR SUSPENSION) 125MG 3 NDS



FERRIPROX 2-DAY TAB 1000MG 2 NDS PA

FERRIPROX TAB 1000MG 2 NDS PA

JADENU GRANULE PACKET 180MG 2 NDS






52

JADENU TAB 180MG 2 NDS



OPIOID ANTAGONISTS

naloxone prefilled inj 2mg/2ml 1

NALOXONE SOLN CARTRIDGE 0.4MG/ML 1

naltrexone tab 50mg 1

NARCAN NASAL SPRAY 4MG/0.1ML 1

ANTIEMETICS

5-HT3 RECEPTOR ANTAGONISTS

ANZEMET TAB 100MG 3 PA_BvD

ANZEMET TAB 50MG 3 PA_BvD

granisetron tab 1mg 1 PA_BvD

ondansetron ODT 4mg 1 PA_BvD

ondansetron ODT 8mg 1 PA_BvD

ondansetron oral soln 4mg/5ml 1 PA_BvD

ondansetron tab 24mg 1 PA_BvD

ONDANSETRON TAB 24MG 1 PA_BvD



SANCUSO PATCH 3.1MG 3

ZOFRAN ODT 4MG 3 PA_BvD

ZOFRAN ODT 8MG 3 PA_BvD

ZOFRAN ORAL SOLN 4MG/5ML 3 PA_BvD

ZOFRAN TAB 4MG 3 PA_BvD

ZOFRAN TAB 8MG 3 PA_BvD

ANTIEMETICS - ANTICHOLINERGIC

meclizine chew tab 1*

meclizine tab 12.5mg 1

meclizine tab 25mg 1

scopolamine patch 1mg/3 days 2

TIGAN CAP 300MG 3

TRANSDERM-SCOP PATCH 1MG/3 DAYS 3

trimethobenzamide cap 300mg 1

ANTIEMETICS - MISCELLANEOUS

AKYNZEO CAP 300-0.5MG 2 PA_BvD

CESAMET CAP 1MG 3 PA

dronabinol cap 10mg 2 PA

dronabinol cap 2.5mg 2 PA

dronabinol cap 5mg 2 PA

MARINOL CAP 10MG 3 PA

MARINOL CAP 2.5MG 3 PA




53

MARINOL CAP 5MG 3 PA

SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS

aprepitant cap 125mg 2 PA_BvD



aprepitant cap therapy pack 80/125mg 2 PA_BvD

EMEND CAP 125MG 3 PA_BvD



EMEND CAP THERAPY PACK 80-125MG 3 PA_BvD

VARUBI TAB 90MG 2 PA_BvD

ANTIFUNGALS

ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS)

CANCIDAS INJ 50MG 3 NDS

CANCIDAS INJ 70MG 3 NDS

CASPOFUNGIN ACETATE INJ 50MG 3 NDS

caspofungin acetate inj 50mg 3 NDS

CASPOFUNGIN ACETATE INJ 70MG 3 NDS

caspofungin acetate inj 70mg 3 NDS

ERAXIS INJ 100MG 2

ERAXIS INJ 50MG 2

micafungin inj 100mg 2


MYCAMINE INJ 100MG 3

MYCAMINE INJ 50MG 3

ANTIFUNGALS

ABELCET INJ 5MG/ML 3 PA_BvD

AMBISOME INJ 50MG 3 PA_BvD

AMPHOTERICIN INJ 50MG 3 PA_BvD

ANCOBON CAP 250MG 3

ANCOBON CAP 500MG 3

flucytosine cap 250mg 2


GRIS-PEG TAB 125MG 3


griseofulvin micro tab 500mg 2

griseofulvin susp 125mg/5ml 2

griseofulvin tab 125mg 2


nystatin tab 500000unit 1

terbinafine tab 250mg 1

IMIDAZOLE-RELATED ANTIFUNGALS




54

DIFLUCAN SUSP 10MG/ML 3

DIFLUCAN SUSP 40MG/ML 3

DIFLUCAN TAB 100MG 3



DIFLUCAN TAB 50MG 3

fluconazole inj 200mg/100ml 2


fluconazole susp 10mg/ml 1


fluconazole tab 100mg 1




fluconazole/dextrose inj 200mg/100ml 2

fluconazole/dextrose inj 400mg/200ml 2

itraconazole cap 100mg 2 PA

itraconazole oral soln 10mg/ml 2 PA

ketoconazole tab 200mg 1

NOXAFIL DR TAB 100MG 2 NDS PA

NOXAFIL SUSP 40MG/ML 2 PA

posaconazole DR tab 100mg 2 NDS PA

SPORANOX CAP 100MG 3 PA

SPORANOX SOLN 10MG/ML 3 PA

VFEND INJ 200MG 3 PA

VFEND SUSP 40MG/ML 3 NDS PA

VFEND TAB 200MG 3 NDS PA

VFEND TAB 50MG 3 NDS PA

voriconazole inj 200mg 2 PA

voriconazole susp 40mg/ml 2 PA

voriconazole tab 200mg 2 PA

voriconazole tab 50mg 2 PA

ANTIHISTAMINES

ANTIHISTAMINES - ETHANOLAMINES

diphenhydramine elixir 12.5mg/5ml (rx only) 2

ANTIHISTAMINES - NON-SEDATING

ALLEGRA SYRUP 3*

ALLEGRA TAB 3*

cetirizine cap 1*

cetirizine oral soln 5mg/5ml (rx only) 1

cetirizine tab 1*

CLARINEX SYRUP 0.5MG/ML 3




55

CLARINEX TAB 5MG 3

CLARITIN CAP 3*

CLARITIN CHEW TAB 3*

CLARITIN REDITAB 3*

CLARITIN SYRUP 3*

CLARITIN TAB 3*

desloratadine tab 5mg 2

fexofenadine syrup 1*

fexofenadine tab 1*

levocetirizine oral soln 2.5mg/5ml 2

levocetirizine tab 5mg 1

loratadine cap 1*

loratadine chew tab 1*

loratadine ODT 1*

loratadine syrup 1*

loratadine tab 1*

XYZAL ORAL SOLN 2.5MG/5ML 3

ZYRTEC CAP 3*

ZYRTEC SYRUP 3*

ZYRTEC TAB 3*

ANTIHISTAMINES - PHENOTHIAZINES

promethazine supp 12.5mg 2

promethazine supp 25mg 2


promethazine syrup 6.25mg/5ml 1

promethazine tab 12.5mg 1

promethazine tab 25mg 1


PROMETHEGAN SUPP 50MG 2

ANTIHYPERLIPIDEMICS

ANTIHYPERLIPIDEMICS - COMBINATIONS

ezetimibe/simvastatin tab 10-10mg 2 QL=30 Quantity/30 Days




VYTORIN TAB 10-10MG 3 QL=30 Quantity/30 Days




ANTIHYPERLIPIDEMICS - MISC.

LOVAZA CAP 1GM 3

omega-3-acid ethyl esters cap 1gm 2




56

VASCEPA CAP 1GM 2

VASCEPA CAP 500MG 2

BILE ACID SEQUESTRANTS

cholestyramine bulk powder 4gm 1

cholestyramine light bulk powder 4gm 1

cholestyramine light powder packet 4gm 1

cholestyramine powder packet 4gm 1

colesevelam packet 3.75gm 2

colesevelam tab 625mg 2

COLESTID GRANULE 5GM 3

COLESTID POWDER PACK 5GM 3

COLESTID TAB 1GM 3

colestipol granule 5gm 2

colestipol granule packet 5gm 2

colestipol tab 1gm 1

QUESTRAN BULK POWDER 4GM 3

QUESTRAN LIGHT BULK POWDER 4GM 3

QUESTRAN POWDER PACKET 4GM 3

WELCHOL PACKET 3.75GM 3

WELCHOL TAB 625MG 3

FIBRIC ACID DERIVATIVES

ANTARA CAP 30MG 3

ANTARA CAP 90MG 3

fenofibrate cap 134mg 1



fenofibrate tab 145mg 1




fenofibric acid DR cap 135mg 1


FIBRICOR TAB 105MG 3

FIBRICOR TAB 35MG 3

gemfibrozil tab 600mg 1

LIPOFEN CAP 150MG 3

LIPOFEN CAP 50MG 3

LOPID TAB 600MG 3

TRICOR TAB 145MG 3

TRICOR TAB 48MG 3

TRIGLIDE TAB 160MG 3

TRILIPIX CAP 135MG 3




57

TRILIPIX CAP 45MG 3

HMG COA REDUCTASE INHIBITORS

atorvastatin tab 10mg $0

atorvastatin tab 20mg $0

atorvastatin tab 40mg 1


CRESTOR TAB 10MG 3 ST




fluvastatin cap 20mg 2


fluvastatin ER tab 80mg 2

LESCOL XL TAB 80MG 3 ST

LIPITOR TAB 10MG 3 ST




LIVALO TAB 1MG 3 ST

LIVALO TAB 2MG 3 ST

LIVALO TAB 4MG 3 ST

lovastatin tab 10mg $0



PRAVACHOL TAB 20MG 3 ST



pravastatin tab 10mg $0




rosuvastatin tab 10mg $0

rosuvastatin tab 20mg 1


rosuvastatin tab 5mg $0

simvastatin tab 10mg $0




simvastatin tab 80mg 1

ZOCOR TAB 10MG 3 ST

ZOCOR TAB 20MG 3 ST




58

ZOCOR TAB 40MG 3 ST

ZOCOR TAB 5MG 3 ST

ZOCOR TAB 80MG 3 ST

INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS

ezetimibe tab 10mg 1 QL=30 Quantity/30 Days

ZETIA TAB 10MG 3 QL=30 Quantity/30 Days

MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN (MTP) INHIBITORS

JUXTAPID CAP 10MG 3 NDS PA






NICOTINIC ACID DERIVATIVES

niacin ER tab 1000mg 1



NIASPAN ER TAB 1000MG 3



PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS

PRALUENT INJ 150MG/ML 2 PA QL=2 Quantity/28 Days

PRALUENT INJ 75MG/ML 2 PA QL=2 Quantity/28 Days

REPATHA INJ 120MG/ML 2 PA QL=3.50 Quantity/28 Days

REPATHA INJ 140MG/ML 2 PA QL=2 Quantity/28 Days

ANTIHYPERTENSIVES

ACE INHIBITORS

ACCUPRIL TAB 10MG 3

ACCUPRIL TAB 20MG 3

ACCUPRIL TAB 40MG 3

ACCUPRIL TAB 5MG 3

ALTACE CAP 1.25MG 3

ALTACE CAP 10MG 3

ALTACE CAP 2.5MG 3

ALTACE CAP 5MG 3

benazepril tab 10mg 1




captopril tab 100mg 2

captopril tab 12.5mg 2





59


enalapril tab 10mg 1

enalapril tab 2.5mg 1


enalapril tab 5mg 1

fosinopril tab 10mg 1



lisinopril tab 10mg 1

lisinopril tab 2.5mg 1





LOTENSIN TAB 10MG 3

LOTENSIN TAB 20MG 3

LOTENSIN TAB 40MG 3

moexipril tab 15mg 1

moexipril tab 7.5mg 1

perindopril tab 2mg 1



PRINIVIL TAB 10MG 3

PRINIVIL TAB 2.5MG 3

PRINIVIL TAB 20MG 3

PRINIVIL TAB 30MG 3

PRINIVIL TAB 40MG 3

PRINIVIL TAB 5MG 3

QBRELIS ORAL SOLN 1MG/ML 3 PA

quinapril tab 10mg 1



quinapril tab 5mg 1

ramipril cap 1.25mg 1

ramipril cap 10mg 1


ramipril cap 5mg 1

trandolapril tab 1mg 1



VASOTEC TAB 10MG 3

VASOTEC TAB 2.5MG 3




60

VASOTEC TAB 20MG 3

VASOTEC TAB 5MG 3

AGENTS FOR PHEOCHROMOCYTOMA

DIBENZYLINE CAP 10MG 3

phenoxybenzamine cap 10mg 2

ANGIOTENSIN II RECEPTOR ANTAGONISTS

AVAPRO TAB 150MG 3

AVAPRO TAB 300MG 3

AVAPRO TAB 75MG 3

BENICAR TAB 20MG 3

BENICAR TAB 40MG 3

BENICAR TAB 5MG 3

COZAAR TAB 100MG 3

COZAAR TAB 25MG 3

COZAAR TAB 50MG 3

DIOVAN TAB 160MG 3

DIOVAN TAB 320MG 3

DIOVAN TAB 40MG 3

DIOVAN TAB 80MG 3

irbesartan tab 150mg 1



losartan tab 100mg 1

losartan tab 25mg 1

losartan tab 50mg 1

MICARDIS TAB 20MG 3

MICARDIS TAB 40MG 3

MICARDIS TAB 80MG 3

olmesartan tab 20mg 1



telmisartan tab 20mg 2



valsartan tab 160mg 1




ANTIADRENERGIC ANTIHYPERTENSIVES

CARDURA TAB 1MG 3

CARDURA TAB 2MG 3

CARDURA TAB 4MG 3




61

CARDURA TAB 8MG 3

CATAPRES TAB 0.1MG 3



CATAPRES-TTS PATCH 0.1MG 3



clonidine patch 0.1mg 2



clonidine tab 0.1mg 1



doxazosin tab 1mg 1

doxazosin tab 2mg 1

doxazosin tab 4mg 1

doxazosin tab 8mg 1

MINIPRESS CAP 1MG 3

MINIPRESS CAP 2MG 3

MINIPRESS CAP 5MG 3

prazosin cap 1mg 1

prazosin cap 2mg 1

prazosin cap 5mg 1

terazosin cap 10mg 1

terazosin cap 1mg 1

terazosin cap 2mg 1

terazosin cap 5mg 1

ANTIHYPERTENSIVE COMBINATIONS

ACCURETIC TAB 10-12.5MG 3

ACCURETIC TAB 20-12.5MG 3

ACCURETIC TAB 20-25MG 3

amlodipine/benazepril cap 10-20mg 1


amlodipine/benazepril cap 2.5-10mg 1




amlodipine/olmesartan tab 10-20mg 2




amlodipine/valsartan tab 10-160mg 2




62




amlodipine/valsartan/hydrochlorothiazide tab5-160-12.5mg

2

amlodipine/valsartan/hydrochlorothiazide tab5-160-25mg

2

amlodipine/valsartan/hydrochlorothiazidetab10-160-12.5mg

2

amlodipine/valsartan/hydrochlorothiazidetab10-160-25mg

2

amlodipine/valsartan/hydrochlorothiazidetab10-320-25mg

2

atenolol/chlorthalidone tab 100-25mg 1

atenolol/chlorthalidone tab 50-25mg 1

AVALIDE TAB 150-12.5MG 3


AZOR TAB 10-20MG 3

AZOR TAB 10-40MG 3

AZOR TAB 5-20MG 3

AZOR TAB 5-40MG 3

benazepril/hydrochlorothiazide tab 10-12.5mg 1


benazepril/hydrochlorothiazide tab 20-25mg 1


BENICAR HCT TAB 20-12.5MG 3

BENICAR HCT TAB 40-12.5MG 3

BENICAR HCT TAB 40-25MG 3

bisoprolol/hydrochlorothiazide tab 10-6.25mg 1

bisoprolol/hydrochlorothiazide tab 2.5-6.25mg 1

bisoprolol/hydrochlorothiazide tab 5-6.25mg 1

CAPTOPRIL/HYDROCHLOROTHIAZIDE TAB

25-15MG

2


25-25MG

2


50-15MG

2


50-25MG

2

DIOVAN HCT TAB 160-12.5MG 3

DIOVAN HCT TAB 160-25MG 3


DIOVAN HCT TAB 320-25MG 3




63


enalapril/hydrochlorothiazide tab 10-25mg 1

enalapril/hydrochlorothiazide tab 5-12.5mg 1

EXFORGE HCT TAB 10-160-12.5MG 3

EXFORGE HCT TAB 10-160-25MG 3


EXFORGE HCT TAB 5-160-12.5MG 3


EXFORGE TAB 10-160MG 3




fosinopril/hydrochlorothiazide tab 10-12.5mg 1

fosinopril/hydrochlorothiazide tab 20-12.5mg 1

HYZAAR TAB 100-12.5MG 3

HYZAAR TAB 100-25MG 3


irbesartan/hydrochlorothiazide tab 150-12.5mg 1

irbesartan/hydrochlorothiazide tab 300-12.5mg 1

lisinopril/hydrochlorothiazide tab 10-12.5mg 1

lisinopril/hydrochlorothiazide tab 20-12.5mg 1

lisinopril/hydrochlorothiazide tab 20-25mg 1

LOPRESSOR HCT TAB 50-25MG 3

losartan/hydrochlorothiazide tab 100-12.5mg 1

losartan/hydrochlorothiazide tab 100-25mg 1

losartan/hydrochlorothiazide tab 50-12.5mg 1

LOTREL CAP 10-20MG 3


LOTREL CAP 5-10MG 3

LOTREL CAP 5-20MG 3

metoprolol/hydrochlorothiazide tab 100-25mg 2


METOPROLOL/HYDROCHLOROTHIAZIDE TAB

100-50MG

2


MICARDIS HCT TAB 40-12.5MG 3

MICARDIS HCT TAB 80-12.5MG 3

MICARDIS HCT TAB 80-25MG 3

moexipril/hydrochlorothiazide tab 15-12.5mg 1

moexipril/hydrochlorothiazide tab 15-25mg 1

moexipril/hydrochlorothiazide tab 7.5-12.5mg 1

olmesartan/hydrochlorothiazide tab 20-12.5mg 1




64

olmesartan/hydrochlorothiazide tab 40-12.5mg 1

olmesartan/hydrochlorothiazide tab 40-25mg 1

PRINIVIL TAB 20-25MG 3

PRINZIDE TAB 10-12.5MG 3


PROPRANOLOL/HYDROCHLOROTHIAZIDE TAB

40-25MG

1

PROPRANOLOL/HYDROCHLOROTHIAZIDE TAB

80-25MG

1

quinapril/hydrochlorothiazide tab 10-12.5mg 1

quinapril/hydrochlorothiazide tab 20-12.5mg 1

quinapril/hydrochlorothiazide tab 20-25mg 1

TARKA TAB 2-180MG 3

TARKA TAB 2-240MG 3

TARKA TAB 4-240MG 3

TEKTURNA HCT TAB 150-12.5MG 3

TEKTURNA HCT TAB 150-25MG 3

TEKTURNA HCT TAB 300-12.5MG 3

TEKTURNA HCT TAB 300-25MG 3

telmisartan/amlodipine tab 40-10mg 2




telmisartan/hydrochlorothiazide tab 40-12.5mg 2

telmisartan/hydrochlorothiazide tab 80-12.5mg 2

telmisartan/hydrochlorothiazide tab 80-25mg 2

TENORETIC TAB 100-25MG 3


TRANDOLAPRIL/VERAPAMIL ER TAB 1-240MG 2

trandolapril/verapamil ER tab 2-180mg 2



TWYNSTA TAB 40-10MG 3




valsartan/hydrochlorothiazide tab 160-12.5mg 1

valsartan/hydrochlorothiazide tab 160-25mg 1


valsartan/hydrochlorothiazide tab 320-25mg 1


VASERETIC TAB 10-25MG 3




65

ZIAC TAB 10-6.25MG 3

ZIAC TAB 2.5-6.25MG 3

ZIAC TAB 5-6.25MG 3

DIRECT RENIN INHIBITORS

aliskiren tab 150mg 2 RXC

aliskiren tab 300mg 2 RXC

TEKTURNA TAB 150MG 3


SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS)

eplerenone tab 25mg 2 RXC

eplerenone tab 50mg 2 RXC

INSPRA TAB 25MG 3

INSPRA TAB 50MG 3

VASODILATORS

hydralazine tab 100mg 1




minoxidil tab 10mg 1

minoxidil tab 2.5mg 1

ANTIMALARIALS

ANTIMALARIAL COMBINATIONS

atovaquone/proguanil tab 250-100mg 1

atovaquone/proguanil tab 62.5-25mg 1

COARTEM TAB 20-120MG 2

MALARONE TAB 250-100MG 3

MALARONE TAB 62.5-25MG 3

ANTIMALARIALS

chloroquine tab 250mg 1


CHLOROQUINE TAB 500MG 1

DARAPRIM TAB 25MG 2 NDS QL=90 Quantity/30 Days

hydroxychloroquine tab 200mg 1

KRINTAFEL TAB 150MG 2

MEFLOQUINE TAB 250MG 2

PLAQUENIL TAB 200MG 3

primaquine tab 26.3mg 1

PRIMAQUINE TAB 26.3MG 1

pyrimethamine tab 25mg 2 NDS QL=90 Quantity/30 Days

QUALAQUIN CAP 324MG 3

quinine sulfate cap 324mg 2

ANTIMYASTHENIC AGENTS




66

ANTIMYASTHENIC AGENTS

GUANIDINE TAB 125MG 2

MESTINON TAB 60MG 3

pyridostigmine tab 60mg 1

ANTIMYASTHENIC/CHOLINERGIC AGENTS

ANTIMYASTHENIC/CHOLINERGIC AGENTS

MESTINON TIMESPAN TAB 180MG 3

pyridostigmine CR tab 180mg 2

pyridostigmine oral soln 60mg/5ml 2

RUZURGI TAB 10MG 2 NDS PA

ANTIMYCOBACTERIAL AGENTS

ANTI TB COMBINATIONS

RIFAMATE CAP 150-300MG 2

RIFATER TAB 50-120-300MG 3

ANTIMYCOBACTERIAL AGENTS

ethambutol tab 100mg 2


ISONIAZID SYRUP 50MG/5ML 1

ISONIAZID TAB 100MG 1

isoniazid tab 100mg 1


MYAMBUTOL TAB 400MG 3

MYCOBUTIN CAP 150MG 3

PASER GRANULE 4GM 2

PRIFTIN TAB 150MG 2

pyrazinamide tab 500mg 1

rifabutin cap 150mg 2

RIFADIN CAP 150MG 3

RIFADIN CAP 300MG 3

RIFADIN INJ 600MG 3

rifampin cap 150mg 2


rifampin inj 600mg 2

SIRTURO TAB 100MG 3 NDS PA

SIRTURO TAB 20MG 3 NDS PA

TRECATOR TAB 250MG 3

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

ALKYLATING AGENTS

ALKERAN TAB 3*

CYCLOPHOSPHAMIDE CAP 25MG 2 PA_BvD

cyclophosphamide cap 25mg 2 PA_BvD

CYCLOPHOSPHAMIDE CAP 50MG 2 PA_BvD




67

cyclophosphamide cap 50mg 2 PA_BvD

HEXALEN CAP 50MG 2 NDS

LEUKERAN TAB 2MG 2

LOMUSTINE CAP 100MG 2



melphalan tab 2*

MYLERAN TAB 2*

TEMODAR CAP 3*

temozolomide cap 2*

ANTIMETABOLITES

capecitabine tab 2*

mercaptopurine tab 50mg 2

METHOTREXATE INJ 250MG/10ML 1

methotrexate inj 50mg/2ml 1

methotrexate PF inj 50mg/2ml 1

methotrexate tab 2.5mg 1

PURIXAN SUSP 20MG/ML 3

TABLOID TAB 40MG 2

TREXALL TAB 10MG 2

TREXALL TAB 15MG 2

TREXALL TAB 5MG 2

TREXALL TAB 7.5MG 2

XATMEP ORAL SOLN 2.5MG/ML 3 PA

XELODA TAB 3*

ANTINEOPLASTIC - BCL-2 INHIBITORS

VENCLEXTA TAB 100MG 2 NDS PA_NSO

VENCLEXTA TAB 10MG 2 PA_NSO

VENCLEXTA TAB 50MG 2 PA_NSO

VENCLEXTA TAB STARTING PACK 2 NDS PA_NSO

ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS

DAURISMO TAB 100MG 3 NDS PA_NSO

DAURISMO TAB 25MG 3 NDS PA_NSO

ERIVEDGE CAP 150MG 2 NDS PA_NSO

ODOMZO CAP 200MG 2 NDS PA_NSO

ANTINEOPLASTIC - HORMONAL AGENTS

anastrozole tab 1mg 1

ARIMIDEX TAB 1MG 3

AROMASIN TAB 25MG 3

bicalutamide tab 50mg 1

CASODEX TAB 50MG 3

ELIGARD INJ 22.5MG 3




68

ELIGARD INJ 30MG 3

ELIGARD INJ 45MG 3

ELIGARD INJ 7.5MG 3

EMCYT CAP 140MG 2

exemestane tab 25mg 2

FEMARA TAB 2.5MG 3

flutamide cap 125mg 2

letrozole tab 2.5mg 1

leuprolide inj 5mg/ml 2

LUPRON DEPOT INJ 11.25MG 3



LUPRON DEPOT INJ 30MG 3



LYSODREN TAB 500MG 2

megestrol acetate susp 40mg/ml 1 PA

megestrol acetate tab 20mg 1 PA_NSO

megestrol acetate tab 40mg 1 PA_NSO

tamoxifen tab 10mg $0

tamoxifen tab 20mg $0

TRELSTAR DEPOT INJ 3.75MG 3

TRELSTAR LA INJ 11.25MG 3

TRELSTAR MIX INJ 22.5MG 3

ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS

abiraterone tab 250mg 2 NDS QL=120 Quantity/30 Days

DEPO-PROVERA INJ 400MG/ML 3

ERLEADA TAB 60MG 2 NDS PA_NSO QL=120

Quantity/30 Days

FARESTON TAB 60MG 3

FIRMAGON INJ 120MG 2 PA_NSO

FIRMAGON INJ 80MG 2 PA_NSO

NILANDRON TAB 150MG 3

nilutamide tab 150mg 2

NUBEQA TAB 300MG 3 NDS PA_NSO QL=120

Quantity/30 Days

SOLTAMOX ORAL SOLN 10MG/5ML 3 PA_NSO

toremifene tab 60mg 2

XTANDI CAP 40MG 2 NDS PA_NSO QL=120

Quantity/30 Days

ANTINEOPLASTIC - IMMUNOMODULATORS

POMALYST CAP 1MG 3 NDS PA_NSO




69




ANTINEOPLASTIC - XPO1 INHIBITORS

XPOVIO 40MG ONCE WEEKLY PACK 3 NDS PA_NSO

XPOVIO 40MG TWICE WEEKLY PACK 3 NDS PA_NSO

XPOVIO 60MG TWICE WEEKLY PACK 3 NDS PA_NSO

XPOVIO ONCE WEEKLY PACK 100MG 3 NDS PA_NSO



XPOVIO TWICE WEEKLY PACK 80MG 3 NDS PA_NSO

ANTINEOPLASTIC COMBINATIONS

KISQALI/FEMARA TAB CO-PACK 200MG 2 NDS PA_NSO QL=49

Quantity/28 Days


Quantity/28 Days


Quantity/28 Days

LONSURF TAB 15-6.14MG 2 NDS PA_NSO

LONSURF TAB 20-8.19MG 2 NDS PA_NSO

ANTINEOPLASTIC ENZYME INHIBITORS

AFINITOR DISPERZ TAB 2MG 2 NDS PA_NSO



AFINITOR TAB 10MG 2 NDS PA_NSO QL=30

Quantity/30 Days

AFINITOR TAB 2.5MG 2 NDS PA_NSO

AFINITOR TAB 5MG 2 NDS PA_NSO

AFINITOR TAB 7.5MG 2 NDS PA_NSO

ALECENSA CAP 150MG 2 NDS PA_NSO QL=240

Quantity/30 Days

ALUNBRIG TAB 180MG 2 NDS PA_NSO QL=30

Quantity/30 Days

ALUNBRIG TAB 30MG 2 NDS PA_NSO

ALUNBRIG TAB 90MG 2 NDS PA_NSO

ALUNBRIG TAB STARTER PACK 3 NDS PA_NSO

AYVAKIT TAB 100MG 3 NDS PA_NSO

AYVAKIT TAB 200MG 3 NDS PA_NSO QL=30

Quantity/30 Days

AYVAKIT TAB 300MG 3 NDS PA_NSO QL=30

Quantity/30 Days

BALVERSA TAB 3MG 3 NDS PA_NSO




70

BALVERSA TAB 4MG 3 NDS PA_NSO QL=60

Quantity/30 Days

BALVERSA TAB 5MG 3 NDS PA_NSO QL=30

Quantity/30 Days

BOSULIF TAB 100MG 2 NDS PA_NSO



BRAFTOVI CAP 75MG 2 NDS PA_NSO QL=180

Quantity/30 Days

BRUKINSA CAP 80MG 3 NDS PA_NSO QL=120

Quantity/30 Days

CABOMETYX TAB 20MG 2 NDS PA_NSO



CALQUENCE CAP 100MG 2 NDS PA_NSO QL=60

Quantity/30 Days

CAPRELSA TAB 100MG 2 NDS PA_NSO

CAPRELSA TAB 300MG 2 NDS PA_NSO QL=30

Quantity/30 Days

COMETRIQ CAP DOSE PACK (100MG) 2 NDS PA_NSO



COPIKTRA CAP 15MG 2 NDS PA_NSO QL=60

Quantity/30 Days

COPIKTRA CAP 25MG 2 NDS PA_NSO QL=60

Quantity/30 Days

COTELLIC TAB 20MG 2 NDS PA_NSO QL=63

Quantity/28 Days

erlotinib tab 100mg 2 NDS PA_NSO



everolimus tab 2.5mg 2 NDS PA_NSO

everolimus tab 5mg 2 NDS PA_NSO

everolimus tab 7.5mg 2 NDS PA_NSO

FARYDAK CAP 10MG 2 NDS PA_NSO



GILOTRIF TAB 20MG 2 NDS PA_NSO

GILOTRIF TAB 30MG 2 NDS PA_NSO QL=30

Quantity/30 Days

GILOTRIF TAB 40MG 2 NDS PA_NSO QL=30

Quantity/30 Days




71

IBRANCE CAP 100MG 2 NDS PA_NSO QL=21

Quantity/28 Days


Quantity/28 Days


Quantity/28 Days

IBRANCE TAB 100MG 2 NDS PA_NSO QL=30

Quantity/30 Days


Quantity/30 Days


Quantity/30 Days

ICLUSIG TAB 15MG 2 NDS PA_NSO

ICLUSIG TAB 45MG 2 NDS PA_NSO QL=30

Quantity/30 Days

IDHIFA TAB 100MG 2 NDS PA_NSO QL=30

Quantity/30 Days

IDHIFA TAB 50MG 2 NDS PA_NSO

imatinib tab 100mg 1


IMBRUVICA CAP 140MG 2 NDS PA_NSO

IMBRUVICA CAP 70MG 2 NDS PA_NSO

IMBRUVICA TAB 140MG 2 NDS PA_NSO



IMBRUVICA TAB 560MG 2 NDS PA_NSO QL=30

Quantity/30 Days

INLYTA TAB 1MG 2 NDS PA_NSO

INLYTA TAB 5MG 2 NDS PA_NSO

INREBIC CAP 100MG 3 NDS PA_NSO QL=120

Quantity/30 Days

IRESSA TAB 250MG 2 NDS PA_NSO

JAKAFI TAB 10MG 2 NDS PA_NSO

JAKAFI TAB 15MG 2 NDS PA_NSO QL=60

Quantity/30 Days


Quantity/30 Days


Quantity/30 Days

JAKAFI TAB 5MG 2 NDS PA_NSO

KISQALI DAILY DOSE PACK 200MG 2 NDS PA_NSO

KISQALI DAILY DOSE PACK 400MG 2 NDS PA_NSO




72

KISQALI DAILY DOSE PACK 600MG 2 NDS PA_NSO QL=63

Quantity/28 Days

KOSELUGO CAP 10MG 3 NDS PA_NSO

KOSELUGO CAP 25MG 3 NDS PA_NSO

LENVIMA CAP THERAPY PACK (10MG) 2 NDS PA_NSO








LORBRENA TAB 100MG 3 NDS PA_NSO QL=30

Quantity/30 Days

LORBRENA TAB 25MG 3 NDS PA_NSO

LYNPARZA CAP 50MG 2 NDS PA_NSO

LYNPARZA TAB 100MG 2 NDS PA_NSO

LYNPARZA TAB 150MG 2 NDS PA_NSO QL=120

Quantity/30 Days

MEKINIST TAB 0.5MG 2 NDS PA_NSO

MEKINIST TAB 2MG 2 NDS PA_NSO QL=30

Quantity/30 Days

MEKTOVI TAB 15MG 2 NDS PA_NSO QL=180

Quantity/30 Days

NERLYNX TAB 40MG 2 NDS PA_NSO

NEXAVAR TAB 200MG 2 NDS PA_NSO

NINLARO CAP 2.3MG 2 NDS PA_NSO

NINLARO CAP 3MG 2 NDS PA_NSO

NINLARO CAP 4MG 2 NDS PA_NSO

PEMAZYRE TAB 13.5MG 3 NDS PA_NSO QL=14

Quantity/21 Days

PEMAZYRE TAB 4.5MG 3 NDS PA_NSO

PEMAZYRE TAB 9MG 3 NDS PA_NSO

PIQRAY DAILY DOSE PACK 200MG 3 NDS PA_NSO QL=30

Quantity/30 Days


Quantity/30 Days


Quantity/30 Days

QINLOCK TAB 50MG 3 NDS PA_NSO QL=90

Quantity/30 Days

RETEVMO CAP 40MG 3 NDS PA_NSO




73

RETEVMO CAP 80MG 3 NDS PA_NSO QL=120

Quantity/30 Days

ROZLYTREK CAP 100MG 3 NDS PA_NSO

ROZLYTREK CAP 200MG 3 NDS PA_NSO QL=90

Quantity/30 Days

RUBRACA TAB 200MG 2 NDS PA_NSO

RUBRACA TAB 250MG 2 NDS PA_NSO QL=120

Quantity/30 Days

RUBRACA TAB 300MG 2 NDS PA_NSO QL=120

Quantity/30 Days

RYDAPT CAP 25MG 2 NDS PA_NSO

SPRYCEL TAB 100MG 2 NDS PA_NSO






STIVARGA TAB 40MG 2 NDS PA_NSO QL=120

Quantity/30 Days

SUTENT CAP 12.5MG 2 NDS PA_NSO

SUTENT CAP 25MG 2 NDS PA_NSO

SUTENT CAP 37.5MG 2 NDS PA_NSO

SUTENT CAP 50MG 2 NDS PA_NSO

TAFINLAR CAP 50MG 2 NDS PA_NSO

TAFINLAR CAP 75MG 2 NDS PA_NSO QL=120

Quantity/30 Days

TAGRISSO TAB 40MG 2 NDS PA_NSO

TAGRISSO TAB 80MG 2 NDS PA_NSO

TALZENNA CAP 0.25MG 2 NDS PA_NSO

TALZENNA CAP 1MG 2 NDS PA_NSO QL=30

Quantity/30 Days

TARCEVA TAB 100MG 3 NDS PA_NSO



TASIGNA CAP 150MG 2 NDS PA_NSO



TAZVERIK TAB 200MG 3 NDS PA_NSO QL=240

Quantity/30 Days

TIBSOVO TAB 250MG 2 NDS PA_NSO QL=60

Quantity/30 Days

TUKYSA TAB 150MG 3 NDS PA_NSO QL=120

Quantity/30 Days




74

TUKYSA TAB 50MG 3 NDS PA_NSO

TURALIO CAP 200MG 3 NDS PA_NSO QL=120

Quantity/30 Days

TYKERB TAB 250MG 2 NDS PA_NSO

VERZENIO TAB 100MG 2 NDS PA_NSO

VERZENIO TAB 150MG 2 NDS PA_NSO QL=56

Quantity/28 Days

VERZENIO TAB 200MG 2 NDS PA_NSO QL=56

Quantity/28 Days

VERZENIO TAB 50MG 2 NDS PA_NSO

VITRAKVI CAP 100MG 3 NDS PA_NSO

VITRAKVI CAP 25MG 3 NDS PA_NSO

VITRAKVI ORAL SOLN 20MG/ML 3 NDS PA_NSO

VIZIMPRO TAB 15MG 2 NDS PA_NSO

VIZIMPRO TAB 30MG 2 NDS PA_NSO

VIZIMPRO TAB 45MG 2 NDS PA_NSO QL=30

Quantity/30 Days

VOTRIENT TAB 200MG 2 NDS PA_NSO

XALKORI CAP 200MG 2 NDS PA_NSO QL=60

Quantity/30 Days

XALKORI CAP 250MG 2 NDS PA_NSO QL=60

Quantity/30 Days

XOSPATA TAB 40MG 3 NDS PA_NSO

ZEJULA CAP 100MG 2 NDS PA_NSO QL=90

Quantity/30 Days

ZELBORAF TAB 240MG 2 NDS PA_NSO QL=240

Quantity/30 Days

ZOLINZA CAP 100MG 2 NDS PA_NSO

ZYDELIG TAB 100MG 2 NDS PA_NSO QL=60

Quantity/30 Days

ZYDELIG TAB 150MG 2 NDS PA_NSO QL=60

Quantity/30 Days

ZYKADIA CAP 150MG 2 NDS PA_NSO QL=90

Quantity/30 Days

ZYKADIA TAB 150MG 2 NDS PA_NSO QL=150

Quantity/30 Days

ANTINEOPLASTICS MISC.

ACTIMMUNE INJ 100MCG/0.5ML 2 NDS PA_NSO

bexarotene cap 75mg 2 NDS PA_NSO

HYDREA CAP 500MG 3

hydroxyurea cap 500mg 1

INTRON-A INJ 10000000UNIT 2

INTRON-A INJ 18000000UNIT 2 NDS




75

INTRON-A INJ 50000000UNIT 2 NDS

INTRON-A INJ 6000000UNIT 2

MATULANE CAP 50MG 2 NDS

SYLATRON INJ KIT 200MCG 3 NDS PA_NSO



SYNRIBO INJ 3.5MG 3 NDS

TARGRETIN CAP 75MG 3 NDS PA_NSO

tretinoin cap 10mg 1

CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS

LEUCOVORIN TAB 10MG 1


leucovorin tab 25mg 1


MESNEX TAB 400MG 2

MITOTIC INHIBITORS

docetaxel inj conc 160mg/8ml 3 NDS

DOCETAXEL INJ CONC 160MG/8ML 3 NDS

DOCETAXEL INJ CONC 200MG/10ML 3 NDS

DOCETAXEL INJ CONC 20MG/ML 3 NDS

docetaxel inj conc 20mg/ml 3 NDS

docetaxel inj conc 80mg/4ml 3 NDS

docetaxel IV soln 20mg/2ml 2

DOCETAXEL IV SOLN 20MG/2ML 2

ETOPOSIDE CAP 2*

TOPOISOMERASE I INHIBITORS

HYCAMTIN CAP 2* PA

ANTIPARKINSON AGENTS

ANTIPARKINSON ADJUVANTS

carbidopa tab 25mg 2

LODOSYN TAB 25MG 3

ANTIPARKINSON ANTICHOLINERGICS

benztropine tab 0.5mg 1

benztropine tab 1mg 1


trihexyphenidyl tab 2mg 1


ANTIPARKINSON COMT INHIBITORS

COMTAN TAB 200MG 3

entacapone tab 200mg 2

TASMAR TAB 100MG 3

tolcapone tab 100mg 2




76

ANTIPARKINSON DOPAMINERGICS

amantadine cap 100mg 1

amantadine soln 50mg/5ml 1

amantadine tab 100mg 2

APOKYN INJ 30MG/3ML 2 NDS

bromocriptine cap 5mg 2

bromocriptine tab 2.5mg 2

carbidopa/levodopa ER tab 25-100mg 1

carbidopa/levodopa ER tab 50-200mg 1

carbidopa/levodopa ODT 10-100mg 1



carbidopa/levodopa tab 10-100mg 1



CARBIDOPA/LEVODOPA/ENTACAPONE TAB

12.5-50-200MG

2


18.75-75-200MG

2


25-100-200MG

2


31.25-125-200MG

2


37.5-150-200MG

2


50-200-200MG

2

MIRAPEX ER TAB 0.375MG 3





MIRAPEX ER TAB 3MG 3


MIRAPEX TAB 0.125MG 3


MIRAPEX TAB 0.5MG 3


MIRAPEX TAB 1.5MG 3

MIRAPEX TAB 1MG 3

NEUPRO PATCH 1MG 3

NEUPRO PATCH 2MG 3




77

NEUPRO PATCH 3MG 3

NEUPRO PATCH 4MG 3

NEUPRO PATCH 6MG 3

NEUPRO PATCH 8MG 3

PARLODEL CAP 5MG 3

PARLODEL TAB 2.5MG 3

pramipexole ER tab 0.375mg 2





pramipexole ER tab 3mg 2


pramipexole tab 0.125mg 1





pramipexole tab 1mg 1

REQUIP XL TAB 12MG 3

REQUIP XL TAB 2MG 3

REQUIP XL TAB 4MG 3

REQUIP XL TAB 6MG 3

REQUIP XL TAB 8MG 3

ropinirole ER tab 12mg 2





ropinirole tab 0.25mg 1


ropinirole tab 1mg 1





SINEMET CR TAB 25-100MG 3

SINEMET CR TAB 50-200MG 3

SINEMET TAB 10-100MG 3



STALEVO TAB 12.5-50-200MG 3




78


STALEVO TAB 25-100-200MG 3



STALEVO TAB 50-200-200MG 3

ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS

AZILECT TAB 0.5MG 3

AZILECT TAB 1MG 3

ELDEPRYL CAP 5MG 3

rasagiline tab 0.5mg 2 RXC

rasagiline tab 1mg 2 RXC

selegiline cap 5mg 1

selegiline tab 5mg 1

ZELAPAR ODT 1.25MG 3

ANTIPARKINSON AND RELATED THERAPY AGENTS

ANTIPARKINSON ANTICHOLINERGICS

trihexyphenidyl elixir 0.4mg/ml 1

ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS

SELEGILINE TAB 5MG 1

ANTIPSYCHOTICS/ANTIMANIC AGENTS

ANTIMANIC AGENTS

LITHIUM CARBONATE CAP 150MG 1

lithium carbonate cap 150mg 1


LITHIUM CARBONATE CAP 600MG 1


lithium carbonate ER tab 300mg 1

lithium carbonate ER tab 450mg 1

lithium carbonate tab 300mg 1

lithium citrate soln 8meq/5ml 1

LITHIUM CITRATE SOLN 8MEQ/5ML 1

LITHOBID CR TAB 300MG 3

ANTIPSYCHOTICS - MISC.

CAPLYTA CAP 42MG 3 PA_NSO QL=30 Quantity/30 Days

EQUETRO CAP 100MG 2

EQUETRO CAP 200MG 2

EQUETRO CAP 300MG 2

GEODON CAP 20MG 3

GEODON CAP 40MG 3

GEODON CAP 60MG 3

GEODON CAP 80MG 3

GEODON INJ 20MG 3




79

LATUDA TAB 120MG 2 ST_NSO RXC QL=30

Quantity/30 Days


Quantity/30 Days


Quantity/30 Days


Quantity/30 Days


Quantity/30 Days

NUPLAZID CAP 34MG 3 PA_NSO QL=30 Quantity/30 Days

NUPLAZID TAB 10MG 3 PA_NSO QL=30 Quantity/30 Days

NUPLAZID TAB 17MG 3 PA_NSO

VRAYLAR CAP 1.5MG 3 PA_NSO QL=30 Quantity/30 Days

VRAYLAR CAP 3MG 3 PA_NSO QL=30 Quantity/30 Days

VRAYLAR CAP 4.5MG 3 PA_NSO QL=30 Quantity/30 Days

VRAYLAR CAP 6MG 3 PA_NSO QL=30 Quantity/30 Days

VRAYLAR CAP THERAPY PACK 3 PA_NSO QL=30 Quantity/30 Days

ziprasidone cap 20mg 1




ziprasidone mesylate inj 20mg 2

BENZISOXAZOLES

FANAPT TAB 10MG 3 PA_NSO QL=60 Quantity/30 Days







FANAPT TAB TITRATION PACK 3 PA_NSO QL=60 Quantity/30 Days

INVEGA SUSTENNA INJ 117MG/0.75ML 3

INVEGA SUSTENNA INJ 156MG/ML 3




INVEGA TAB 1.5MG 3 PA_NSO QL=30 Quantity/30 Days

INVEGA TAB 3MG 3 PA_NSO QL=30 Quantity/30 Days



INVEGA TRINZA INJ 273MG/0.875ML 3




80




paliperidone SR tab 1.5mg 2 PA_NSO QL=30 Quantity/30 Days

paliperidone SR tab 3mg 2 PA_NSO QL=30 Quantity/30 Days



PERSERIS SYRINGE 120MG 3 NDS

PERSERIS SYRINGE 90MG 3 NDS

RISPERDAL 12.5MG INJ 3

RISPERDAL INJ 25MG 3

RISPERDAL INJ 37.5MG 3


RISPERDAL SOLN 1MG/ML 3

RISPERDAL TAB 0.5MG 3

RISPERDAL TAB 1MG 3

RISPERDAL TAB 2MG 3

RISPERDAL TAB 3MG 3

RISPERDAL TAB 4MG 3

risperidone ODT 0.25mg 2

RISPERIDONE ODT 0.25MG 2


risperidone ODT 1mg 2




risperidone soln 1mg/ml 1

risperidone tab 0.25mg 1


risperidone tab 1mg 1




BUTYROPHENONES

HALDOL DECANOATE INJ 100MG/ML 3

HALDOL DECANOATE INJ 50MG/ML 3

HALDOL LACTATE INJ 5MG/ML 3

haloperidol decanoate inj 100mg/ml 2

haloperidol decanoate inj 50mg/ml 2

haloperidol lactate inj 5mg/ml 2

haloperidol lactate soln 2mg/ml 1

haloperidol tab 0.5mg 1




81

haloperidol tab 10mg 1





DIBENZAPINES

clozapine ODT 100mg 2

CLOZAPINE ODT 12.5MG 2

CLOZAPINE ODT 150MG 2



clozapine tab 100mg 2




CLOZARIL TAB 100MG 3


CLOZARIL TAB 25MG 3

CLOZARIL TAB 50MG 3

FAZACLO ODT 100MG 3

FAZACLO ODT 12.5MG 3

FAZACLO ODT 150MG 2

FAZACLO ODT 200MG 2

FAZACLO ODT 25MG 3

loxapine cap 10mg 1

loxapine cap 25mg 1

loxapine cap 50mg 1

loxapine cap 5mg 1

olanzapine inj 10mg 2

olanzapine ODT 10mg 2




olanzapine tab 10mg 1


olanzapine tab 2.5mg 1




quetiapine tab 100mg 1






82




quetiapine XR tab 150mg 1





SAPHRIS SL TAB 10MG 3 PA_NSO QL=60 Quantity/30 Days

SAPHRIS SL TAB 2.5MG 3 PA_NSO QL=60 Quantity/30 Days

SAPHRIS SL TAB 5MG 3 PA_NSO QL=60 Quantity/30 Days

SECUADO PATCH 3.8MG/24HR 3 PA_NSO QL=30 Quantity/30 Days



SEROQUEL TAB 100MG 3


SEROQUEL TAB 25MG 3



SEROQUEL TAB 50MG 3

SEROQUEL XR TAB 150MG 3





VERSACLOZ SUSP 50MG/ML 3

ZYPREXA INJ 10MG 3

ZYPREXA INJ 210MG 3

ZYPREXA ODT 10MG 3

ZYPREXA ODT 15MG 3

ZYPREXA ODT 20MG 3

ZYPREXA ODT 5MG 3

ZYPREXA TAB 10MG 3

ZYPREXA TAB 15MG 3

ZYPREXA TAB 2.5MG 3

ZYPREXA TAB 20MG 3

ZYPREXA TAB 5MG 3

ZYPREXA TAB 7.5MG 3

DIHYDROINDOLONES

MOLINDONE TAB 10MG 2


MOLINDONE TAB 5MG 2




83

PHENOTHIAZINES

chlorpromazine tab 100mg 1





fluphenazine decanoate inj 25mg/ml 2

FLUPHENAZINE ELIXIR 2.5MG/5ML 2

FLUPHENAZINE INJ 2.5MG/ML 2

FLUPHENAZINE ORAL CONC 5MG/ML 2

fluphenazine tab 10mg 1


fluphenazine tab 2.5mg 1


perphenazine tab 16mg 1




prochlorperazine supp 25mg 1

prochlorperazine tab 10mg 1


thioridazine tab 100mg 1




trifluoperazine tab 10mg 1




QUINOLINONE DERIVATIVES

ABILIFY MAINTENA INJ 300MG 3 NDS

ABILIFY MAINTENA INJ 400MG 3 NDS

ABILIFY MAINTENA SYRINGE 300MG 3 NDS

ABILIFY MAINTENA SYRINGE 400MG 3 NDS

ABILIFY TAB 10MG 3

ABILIFY TAB 15MG 3

ABILIFY TAB 20MG 3

ABILIFY TAB 2MG 3

ABILIFY TAB 30MG 3

ABILIFY TAB 5MG 3

aripiprazole ODT 10mg 2 PA_NSO QL=60 Quantity/30 Days

aripiprazole ODT 15mg 2 PA_NSO QL=60 Quantity/30 Days




84

aripiprazole soln 1mg/ml 2 PA_NSO

aripiprazole tab 10mg 1






ARISTADA (2-MONTH) INJ 1064MG/3.9ML 3

ARISTADA INJ 441MG/1.6ML 3 NDS



ARISTADA INJ 882MG/3.2ML 3

REXULTI TAB 0.25MG 3 PA_NSO QL=30 Quantity/30 Days

REXULTI TAB 0.5MG 3 PA_NSO QL=30 Quantity/30 Days

REXULTI TAB 1MG 3 PA_NSO QL=30 Quantity/30 Days




THIOXANTHENES

thiothixene cap 10mg 1




ANTIVIRALS

ANTIRETROVIRALS

abacavir oral soln 20mg/ml 2

abacavir tab 300mg 2

abacavir/lamivudine tab 600-300mg 2

abacavir/lamivudine/zidovudine tab 300-150-300mg 2

APTIVUS CAP 250MG 2

APTIVUS ORAL SOLN 100MG/ML 2

atazanavir cap 150mg 2



ATRIPLA TAB 600-200-300MG 2

BIKTARVY TAB 50-200-25MG 2

CIMDUO TAB 300-300MG 2

COMBIVIR TAB 150-300MG 3

COMPLERA TAB 200-25-300MG 2

CRIXIVAN CAP 200MG 2


DELSTRIGO TAB 100-300-300MG 2




85

DESCOVY TAB 200-25MG 2

didanosine DR cap 200mg 2

DIDANOSINE DR CAP 200MG 2




DOVATO TAB 50-300MG 2

EDURANT TAB 25MG 2

efavirenz cap 200mg 2


efavirenz tab 600mg 2

EMTRIVA CAP 200MG 2

EMTRIVA SOLN 10MG/ML 2

EPIVIR ORAL SOLN 10MG/ML 3

EPIVIR TAB 150MG 3

EPIVIR TAB 300MG 3

EPZICOM TAB 600-300MG 3

EVOTAZ TAB 300-150MG 2

fosamprenavir tab 700mg 2

FUZEON INJ 90MG 2

GENVOYA TAB 150-150-200-10MG 2

INTELENCE TAB 100MG 2



INVIRASE CAP 200MG 2

INVIRASE TAB 500MG 2

ISENTRESS CHEW TAB 100MG 2

ISENTRESS CHEW TAB 25MG 2

ISENTRESS HD TAB 600MG 2

ISENTRESS POWDER PACK 100MG 2

ISENTRESS TAB 400MG 2

JULUCA TAB 50-25MG 2

KALETRA ORAL SOLN 400-100MG/5ML 3

KALETRA TAB 100-25MG 2


lamivudine oral soln 10mg/ml 2

lamivudine tab 150mg 2


lamivudine/zidovudine tab 150-300mg 2

LEXIVA SUSP 50MG/ML 2

LEXIVA TAB 700MG 3

lopinavir/ritonavir oral soln 400-100mg/5ml 2




86

nevirapine ER tab 100mg 2

NEVIRAPINE ER TAB 100MG 2


nevirapine susp 50mg/5ml 2

nevirapine tab 200mg 1

NORVIR ORAL SOLN 80MG/ML 2

NORVIR POWDER PACKET 100MG 2

NORVIR TAB 100MG 3

ODEFSEY TAB 200-25-25MG 2

PIFELTRO TAB 100MG 2

PREZCOBIX TAB 800-150MG 2

PREZISTA SUSP 100MG/ML 2

PREZISTA TAB 150MG 2


PREZISTA TAB 75MG 2


RESCRIPTOR TAB 200MG 2

RETROVIR CAP 100MG 3

RETROVIR SYRUP 10MG/ML 3

REYATAZ CAP 150MG 3

REYATAZ CAP 200MG 3

REYATAZ CAP 300MG 3

REYATAZ POWDER PACKET 50MG 2

ritonavir tab 100mg 2

SELZENTRY ORAL SOLN 20MG/ML 2

SELZENTRY TAB 150MG 2




stavudine cap 15mg 2




STRIBILD TAB 150-150-200-300MG 2

SUSTIVA CAP 200MG 3

SUSTIVA CAP 50MG 3

SUSTIVA TAB 600MG 3

SYMFI LO TAB 400-300-300MG 2

SYMFI TAB 600-300-300MG 2

SYMTUZA TAB 800-150-200-10MG 2

tenofovir disoproxil fumarate tab 300mg 2

TIVICAY TAB 10MG 2




87

TIVICAY TAB 25MG 2

TIVICAY TAB 50MG 2

TRIUMEQ TAB 600-50-300MG 2

TRIZIVIR TAB 300-150-300MG 3

TRUVADA TAB 100-150MG 2




TYBOST TAB 150MG 2

VIDEX EC CAP 125MG 2




VIDEX ORAL SOLN 2GM 2


VIRACEPT TAB 250MG 2


VIRAMUNE SUSP 50MG/5ML 3

VIRAMUNE TAB 200MG 3

VIRAMUNE XR TAB 400MG 3

VIREAD POWDER 40MG/GM 2

VIREAD TAB 150MG 2

VIREAD TAB 200MG 2

VIREAD TAB 250MG 2

VIREAD TAB 300MG 3

ZERIT CAP 15MG 3

ZERIT CAP 20MG 3

ZERIT CAP 30MG 3

ZERIT CAP 40MG 3

ZIAGEN ORAL SOLN 20MG/ML 3

ZIAGEN TAB 300MG 3

zidovudine cap 100mg 2

zidovudine syrup 10mg/ml 2

zidovudine tab 300mg 2

CMV AGENTS

PREVYMIS TAB 240MG 3 NDS PA

PREVYMIS TAB 480MG 3 NDS PA

VALCYTE ORAL SOLN 50MG/ML 3 NDS

VALCYTE TAB 450MG 3 NDS

valganciclovir oral soln 50mg/ml 2 NDS

valganciclovir tab 450mg 2 NDS

HEPATITIS AGENTS




88

adefovir dipivoxil tab 10mg 2

BARACLUDE TAB 0.5MG 3

BARACLUDE TAB 1MG 3

entecavir tab 0.5mg 2

entecavir tab 1mg 2

EPIVIR HBV ORAL SOLN 5MG/ML 2

EPIVIR HBV TAB 100MG 3

HEPSERA TAB 10MG 3


MAVYRET TAB 100-40MG 2 NDS PA QL=90 Quantity/30 Days

PEGASYS PROCLICK INJ 135MCG/0.5ML 2 NDS

PEGASYS PROCLICK INJ 180MCG/0.5ML 2 NDS

PEGASYS PROCLICK INJ 180MCG/ML 2 NDS

REBETOL ORAL SOLN 40MG/ML 2 NDS

RIBAPAK TAB 400MG 3

RIBAPAK TAB 600MG 3 NDS

RIBAPAK TAB DOSE PACK 1000MG/DAY 3 NDS

RIBAPAK TAB DOSE PACK 600MG/DAY 3 NDS

ribavirin cap 200mg 1

ribavirin tab 200mg 1

RIBAVIRIN TAB 600MG 2 NDS

ribavirin tab 600mg 2 NDS

SOFOSBUVIR/VELPATASVIR TAB 400-100MG 3 NDS PA QL=30 Quantity/30 Days

VEMLIDY TAB 25MG 2 NDS

VOSEVI TAB 400-100-100MG 2 NDS PA QL=30 Quantity/30 Days

HERPES AGENTS

acyclovir cap 200mg 1

acyclovir inj 50mg/ml 2 PA_BvD

acyclovir susp 200mg/5ml 1

acyclovir tab 400mg 1


famciclovir tab 125mg 2



valacyclovir tab 1gm 1

valacyclovir tab 500mg 1

VALTREX TAB 1GM 3

VALTREX TAB 500MG 3

ZOVIRAX CAP 200MG 3

ZOVIRAX SUSP 200MG/5ML 3

ZOVIRAX TAB 800MG 3

INFLUENZA AGENTS




89

FLUMADINE TAB 100MG 3

oseltamivir cap 30mg 1 QL=84 Quantity/180 Days



oseltamivir susp 6mg/ml 2 QL=540 Quantity/180 Days

RELENZA DISKHALER 5MG/BLISTER 2 QL=120 Quantity/30 Days

RIMANTADINE TAB 100MG 1

TAMIFLU CAP 30MG 3 QL=84 Quantity/180 Days



TAMIFLU SUSP 6MG/ML 3 QL=540 Quantity/180 Days

XOFLUZA THERAPY PACK 20MG 3 QL=1 Quantity/30 Days

XOFLUZA THERAPY PACK 40MG 3 QL=1 Quantity/30 Days

RESPIRATORY SYNCYTIAL VIRUS (RSV) AGENTS

ribavirin inhalation soln 6gm 3 NDS

VIRAZOLE INHALATION SOLN 6GM 3 NDS

ASSORTED CLASSES

IMMUNOMODULATORS

REVLIMID CAP 10MG 2 NDS PA_NSO

REVLIMID CAP 15MG 2 NDS PA_NSO QL=30

Quantity/30 Days

REVLIMID CAP 2.5MG 2 NDS PA_NSO


Quantity/30 Days


Quantity/30 Days

REVLIMID CAP 5MG 2 NDS PA_NSO

THALOMID CAP 100MG 2 NDS PA_NSO




IMMUNOSUPPRESSIVE AGENTS

ASTAGRAF XL CAP 0.5MG 3 PA_BvD

ASTAGRAF XL CAP 1MG 3 PA_BvD

ASTAGRAF XL CAP 5MG 3 PA_BvD

AZASAN TAB 100MG 3 PA_BvD

AZASAN TAB 75MG 3 PA_BvD

azathioprine tab 50mg 1 PA_BvD

CELLCEPT CAP 250MG 3 PA_BvD

CELLCEPT SUSP 200MG/ML 3 PA_BvD

CELLCEPT TAB 500MG 3 PA_BvD

cyclosporine cap 100mg 2 PA_BvD




90

cyclosporine cap 25mg 2 PA_BvD

cyclosporine modified cap 100mg 2 PA_BvD


cyclosporine modified oral soln 100mg/ml 2 PA_BvD

ENVARSUS XR TAB 0.75MG 3 PA_BvD

ENVARSUS XR TAB 1MG 3 PA_BvD

ENVARSUS XR TAB 4MG 3 PA_BvD

IMURAN TAB 50MG 3 PA_BvD

mycophenolate cap 250mg 1 PA_BvD

mycophenolate DR tab 180mg 2 PA_BvD

mycophenolate DR tab 360mg 2 PA_BvD

mycophenolate mofetil susp 200mg/ml 2 PA_BvD

mycophenolate tab 500mg 1 PA_BvD

MYFORTIC TAB 180MG 3 PA_BvD

MYFORTIC TAB 360MG 3 PA_BvD

NEORAL CAP 100MG 3 PA_BvD

NEORAL CAP 25MG 3 PA_BvD

NEORAL SOLN 100MG/ML 3 PA_BvD

PROGRAF CAP 0.5MG 3 PA_BvD

PROGRAF CAP 1MG 3 PA_BvD

PROGRAF CAP 5MG 3 PA_BvD

RAPAMUNE TAB 0.5MG 3 PA_BvD

RAPAMUNE TAB 1MG 3 PA_BvD

RAPAMUNE TAB 2MG 3 PA_BvD

SANDIMMUNE CAP 100MG 3 PA_BvD

SANDIMMUNE CAP 25MG 3 PA_BvD

SANDIMMUNE ORAL SOLN 100MG/ML 2 PA_BvD

sirolimus tab 0.5mg 2 PA_BvD

sirolimus tab 1mg 2 PA_BvD

sirolimus tab 2mg 2 PA_BvD

tacrolimus cap 0.5mg 1 PA_BvD

tacrolimus cap 1mg 1 PA_BvD

tacrolimus cap 5mg 1 PA_BvD

POTASSIUM REMOVING AGENTS

sodium polystyrene rectal susp 30gm/120ml 1

POTASSIUM REMOVING RESINS

sodium polystyrene oral susp 15gm/60ml 1

sodium polystyrene powder 250mg/ml 2

VELTASSA POWDER PACK 16.8GM 2 PA



BETA BLOCKERS




91

ALPHA-BETA BLOCKERS

carvedilol ER cap 10mg 2




carvedilol tab 12.5mg 1

carvedilol tab 25mg 1



COREG CR CAP 10MG 3

COREG CR CAP 20MG 3

COREG CR CAP 40MG 3

COREG CR CAP 80MG 3

COREG TAB 12.5MG 3

COREG TAB 25MG 3

COREG TAB 3.125MG 3

COREG TAB 6.25MG 3

labetalol tab 100mg 1



BETA BLOCKERS CARDIO-SELECTIVE

acebutolol cap 200mg 1


atenolol tab 100mg 1

atenolol tab 25mg 1

atenolol tab 50mg 1

betaxolol tab 10mg 1


bisoprolol fumarate tab 10mg 1


BYSTOLIC TAB 10MG 2 RXC

BYSTOLIC TAB 2.5MG 2 RXC



FIRST ATENOLOL ORAL SOLN 3*

FIRST METOPROLOL ORAL SOLN 3*

LOPRESSOR TAB 100MG 3

metoprolol ER tab 100mg 1




metoprolol tab 100mg 1




92



SECTRAL CAP 200MG 3

SECTRAL CAP 400MG 3

TENORMIN TAB 100MG 3

TENORMIN TAB 25MG 3

TENORMIN TAB 50MG 3

TOPROL XL TAB 100MG 3




BETA BLOCKERS NON-SELECTIVE

BETAPACE AF TAB 120MG 3



BETAPACE TAB 120MG 3


BETAPACE TAB 80MG 3

CORGARD TAB 20MG 3

CORGARD TAB 40MG 3

CORGARD TAB 80MG 3

INDERAL LA CAP 120MG 3




INNOPRAN XL CAP 120MG 3


nadolol tab 20mg 2

nadolol tab 40mg 2

nadolol tab 80mg 2

pindolol tab 10mg 1

pindolol tab 5mg 1

propranolol ER cap 120mg 1




PROPRANOLOL ORAL SOLN 20MG/5ML 1

PROPRANOLOL ORAL SOLN 40MG/5ML 1

propranolol tab 10mg 1







93


sotalol AF tab 120mg 1



sotalol tab 120mg 1

sotalol tab 160mg 1

sotalol tab 240mg 1

sotalol tab 80mg 1

timolol maleate tab 10mg 1



CALCIUM CHANNEL BLOCKERS

CALCIUM CHANNEL BLOCKERS

ADALAT CC ER TAB 30MG 3



amlodipine tab 10mg 1

amlodipine tab 2.5mg 1


CALAN SR TAB 120MG 3



CALAN TAB 120MG 3

CALAN TAB 80MG 3

CARDIZEM CD CAP 120MG 3





CARDIZEM LA TAB 120MG 3






CARDIZEM TAB 120MG 3

CARDIZEM TAB 30MG 3

CARDIZEM TAB 60MG 3

diltiazem CD cap 120mg 1







94


DILTIAZEM ER CAP 120MG 1

diltiazem ER cap 120mg 1






diltiazem LA tab 180mg 2





diltiazem SR cap 120mg 1



diltiazem tab 120mg 1




DILTIAZEM XR CAP 180MG 1

diltiazem XR cap 180mg 1


DILTIAZEM XR CAP 240MG 1

felodipine ER tab 10mg 1

felodipine ER tab 2.5mg 1


isradipine cap 2.5mg 1

isradipine cap 5mg 1

nicardipine cap 20mg 1


nifedipine ER tab 30mg 1



nimodipine cap 30mg 2

nisoldipine ER tab 17mg 2

NISOLDIPINE ER TAB 20MG 2




nisoldipine ER tab 8.5mg 2

NISOLDIPINE SR TAB 25.5MG 2




95

NORVASC TAB 10MG 3

NORVASC TAB 2.5MG 3

NORVASC TAB 5MG 3

PROCARDIA XL TAB 30MG 3



SULAR TAB 17MG 3

SULAR TAB 34MG 3

SULAR TAB 8.5MG 3

TIAZAC CAP 120MG 3

TIAZAC CAP 180MG 3

TIAZAC CAP 240MG 3

TIAZAC CAP 300MG 3

TIAZAC CAP 360MG 3

TIAZAC CAP 420MG 3

verapamil CR tab 120mg 1



VERAPAMIL ER CAP 100MG 1

verapamil ER cap 120mg 1







verapamil tab 120mg 1



VERELAN CAP 120MG 3

VERELAN CAP 180MG 3

VERELAN CAP 240MG 3

VERELAN SR CAP 360MG 3

CARDIOTONICS

CARDIAC GLYCOSIDES

DIGOXIN 0.05MG/ML ORAL SOLN 1

digoxin oral soln 0.05mg/ml 1

DIGOXIN ORAL SOLN 0.05MG/ML 1

digoxin tab 125mcg 1


LANOXIN TAB 125MCG 3





96

CARDIOVASCULAR AGENTS - MISC.

CARDIOVASCULAR AGENTS MISC. - COMBINATIONS

amlodipine/atorvastatin tab 10-10mg 2




amlodipine/atorvastatin tab 2.5-10mg 2







BIDIL TAB 20-37.5mg 2

CADUET TAB 10-10MG 3




CADUET TAB 2.5-10MG 3



CADUET TAB 5-10MG 3

CADUET TAB 5-20MG 3

CADUET TAB 5-40MG 3

CADUET TAB 5-80MG 3

ENTRESTO TAB 24-26MG 2



IMPOTENCE AGENTS

MUSE SUPP 2* QL=6 Quantity/30 Days

sildenafil tab 25mg, 50mg, 100mg 2* QL=6 Quantity/30 Days

STENDRA TAB 2* QL=6 Quantity/30 Days

tadalafil tab 10mg 2* QL=6 Quantity/30 Days

tadalafil tab 2.5mg 2* QL=6 Quantity/30 Days



vardenafil ODT 2* QL=6 Quantity/30 Days

vardenafil tab 2* QL=6 Quantity/30 Days

PERIPHERAL VASODILATORS

isoxsuprine tab 3*

PROSTAGLANDIN VASODILATORS

ORENITRAM ER TAB 0.125MG 3 PA




97

ORENITRAM ER TAB 0.25MG 3 NDS PA

ORENITRAM ER TAB 1MG 3 NDS PA

ORENITRAM ER TAB 2.5MG 3 NDS PA

ORENITRAM ER TAB 5MG 3 NDS PA

VENTAVIS INHALATION SOLN 10MCG/ML 2 NDS PA

VENTAVIS INHALATION SOLN 20MCG/ML 2 NDS PA

PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS

ambrisentan tab 10mg 2 NDS PA

ambrisentan tab 5mg 2 NDS PA

bosentan tab 125mg 3 NDS PA QL=60 Quantity/30 Days

bosentan tab 62.5mg 3 NDS PA

OPSUMIT TAB 10MG 2 NDS PA QL=30 Quantity/30 Days

TRACLEER TAB 125MG 2 NDS PA QL=60 Quantity/30 Days

TRACLEER TAB 62.5MG 2 NDS PA

TRACLEER TAB FOR ORAL SUSP 32MG 2 NDS PA QL=120 Quantity/30 Days

PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS

ADCIRCA TAB 20MG 3 NDS PA

REVATIO TAB 20MG 3 NDS PA

sildenafil tab 20mg 1 PA

tadalafil tab (PAH) 20mg 1 PA

PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST

UPTRAVI TAB 1000MCG 2 NDS PA








UPTRAVI TAB TITRATION PACK 2 NDS PA QL=200 Quantity/28 Days

PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR

ADEMPAS TAB 0.5MG 2 NDS PA


ADEMPAS TAB 1MG 2 NDS PA


ADEMPAS TAB 2MG 2 NDS PA

SINUS NODE INHIBITORS

CORLANOR ORAL SOLN 5MG/ML 3 PA

CORLANOR TAB 5MG 3 PA

CORLANOR TAB 7.5MG 3 PA

TRANSTHYRETIN STABILIZERS

VYNDAMAX CAP 61MG 2 NDS PA QL=30 Quantity/30 Days




98

CEPHALOSPORINS

CEPHALOSPORIN COMBINATIONS

AVYCAZ INJ 2-0.5GM 3 NDS

ZERBAXA INJ 1.5GM 3 NDS

CEPHALOSPORINS - 1ST GENERATION

cefadroxil cap 500mg 1

cefadroxil susp 250mg/5ml 1


cefadroxil tab 1gm 1

CEFAZOLIN INJ 1 GM 2

CEFAZOLIN INJ 100GM 2

cefazolin inj 10gm 2

cefazolin inj 1gm 2



cefazolin inj 500mg 2

CEFAZOLIN/DEXTROSE IV SOLN 1GM/4% 2

CEFAZOLIN/DEXTROSE IV SOLN 1GM/50ML-4% 2

cephalexin cap 250mg 1


cephalexin susp 125mg/5ml 1


CEPHALOSPORINS - 2ND GENERATION

cefaclor cap 250mg 2


CEFACLOR ER TAB 500MG 3

CEFACLOR SUSP 125MG/5ML 2

cefaclor susp 250mg/5ml 2



cefotetan inj 1gm 2

cefotetan inj 2gm 2

CEFOTETAN/DEXTROSE INJ 1GM/3.58% 2

CEFOTETAN/DEXTROSE INJ 2GM/2.08% 2

cefoxitin inj 10mg 2

cefoxitin inj 1gm 2

cefoxitin inj 2gm 2

CEFOXITIN/DEXTROSE INJ 1GM/4% 2

CEFOXITIN/DEXTROSE INJ 2GM/2.2% 2

cefprozil susp 125mg/5ml 1


cefprozil tab 250mg 1




99


cefuroxime inj 1.5gm 2


cefuroxime inj 750mg 2

cefuroxime tab 250mg 1


CEPHALOSPORINS - 3RD GENERATION

cefdinir cap 300mg 1

cefdinir susp 125mg/5ml 1


cefixime cap 400mg 2

cefixime susp 100mg/5ml 2


CEFOTAXIME INJ 10GM 2


cefpodoxime proxetil susp 100mg/5ml 2

cefpodoxime proxetil susp 50mg/5ml 2

cefpodoxime proxetil tab 100mg 2

cefpodoxime proxetil tab 200mg 2

ceftazidime inj 1gm 2



CEFTAZIDIME/DEXTROSE INJ 1GM/50ML/5% 2

CEFTAZIDIME/DEXTROSE INJ 2GM/50ML/5% 2

CEFTRIAXONE SODIUM INJ 100GM 2

ceftriaxone sodium inj 10gm 2


ceftriaxone sodium inj 250mg 2



CEFTRIAXONE/DEXTROSE INJ 20MG/ML 2

CEFTRIAXONE/DEXTROSE INJ 40MG/ML 2

CEFTRIAXONE/DEXTROSE IV SOLN 1GM-3.74% 2

CEFTRIAXONE/DEXTROSE IV SOLN 2GM-2.22% 2

SUPRAX CAP 400MG 3

SUPRAX CHEW TAB 100MG 3

SUPRAX CHEW TAB 200MG 3

SUPRAX SUSP 100MG/5ML 3



TAZICEF INJ 1GM 2

TAZICEF INJ 2GM 2




100

CEPHALOSPORINS - 4TH GENERATION

cefepime inj 1gm 2

cefepime inj 2gm 2

CEFEPIME IV SOLN 1GM/50ML 2

CEFEPIME IV SOLN 2GM/100ML 2

CEFEPIME/DEXTROSE INJ 1GM/50ML 2

CEFEPIME/DEXTROSE INJ 2GM/50ML 2

MAXIPIME INJ 1GM 3

MAXIPIME INJ 2GM 3

CEPHALOSPORINS - 5TH GENERATION

TEFLARO INJ 400MG 3 NDS

TEFLARO INJ 600MG 3 NDS

CONTRACEPTIVES

COMBINATION CONTRACEPTIVES - ORAL

amethia tab $0

amethyst tab $0

apri tab $0

aranelle tab $0

aviane tab $0

balziva tab $0

camrese LO tab $0

cesia tab $0

cryselle tab $0

cyclafem tab $0

DESOGEN TAB 3

enpresse tab $0

GENERESS FE CHEW TAB 3

junel FE tab $0

junel tab $0

kariva tab $0

kelnor tab $0

levora-28 tab $0

LO LOESTRIN FE TAB 3

LOESTRIN FE TAB 3

LOESTRIN TAB 3

LOSEASONIQUE TAB 3

mibelas chew tab 2

MINASTRIN CHEW TAB 3

NATAZIA TAB 3

necon tab $0

nikki 28 day tab $0

norethindrone/ethinyl estradiol FE chew tab $0




101

norethindrone/ethinyl estradiol FE tab $0

NORINYL TAB 3

ocella tab, zarah tab $0

OGESTREL TAB 3

ORTHO TRI-CYCLEN LO TAB 3

ORTHO TRI-CYCLEN TAB 3

ORTHO-CYCLEN TAB 3

ORTHO-NOVUM TAB 3

previfem tab $0

QUARTETTE TAB 3

quasense tab $0

rivelsa tab $0

SAFYRAL TAB 3

SEASONIQUE TAB 3

tri-legest FE tab $0

tri-nessa lo tab $0

TRI-NORINYL TAB 3

trinessa tab $0

tydemy tab 2

YASMIN TAB 3

YAZ TAB 3

zeosa tab $0

zovia tab $0

COMBINATION CONTRACEPTIVES - TRANSDERMAL

XULANE PATCH 150-35MCG $0

COMBINATION CONTRACEPTIVES - VAGINAL

eluryng 0.120-0.015mg $0

NUVARING 0.120-0.015MG $0

COPPER CONTRACEPTIVES - IUD

PARAGARD IUD $0*

EMERGENCY CONTRACEPTIVES

levonorgestrel tab $0*

PROGESTIN CONTRACEPTIVES - IMPLANTS

IMPLANON IMPLANT, NEXPLANON IMPLANT $0*

PROGESTIN CONTRACEPTIVES - INJECTABLE

DEPO-PROVERA INJ 150MG/ML 3

DEPO-PROVERA SC INJ 104MG $0* QL=1 Quantity/90 Days

DEPO-PROVERA SYRINGE 150MG/ML 3

medroxyprogesterone inj 150mg/ml $0

PROGESTIN CONTRACEPTIVES - IUD

MIRENA IUD $0*

PROGESTIN CONTRACEPTIVES - ORAL




102

NOR-QD TAB 0.35MG 3

norethindrone tab 0.35mg $0

SLYND PACK 4MG 3

CORTICOSTEROIDS

GLUCOCORTICOSTEROIDS

budesonide EC cap 3mg 2

budesonide ER tab 9mg 2 PA QL=30 Quantity/30 Days

CORTEF TAB 10MG 3

CORTEF TAB 20MG 3

CORTEF TAB 5MG 3

CORTISONE AC TAB 25MG 2

DEXAMETHASONE CONC 1MG/ML 1

dexamethasone elixir 0.5mg/5ml 1

DEXAMETHASONE ORAL SOLN 0.5MG/5ML 1

dexamethasone tab 0.5mg 1



DEXAMETHASONE TAB 1MG 1

DEXAMETHASONE TAB 2MG 1

dexamethasone tab 4mg 1


ENTOCORT EC CAP 3MG 3

hydrocortisone tab 10mg 1



MEDROL TAB 16MG 3 PA_BvD





MEDROL TAB DOSE PACK 4MG (21) 3

methylprednisolone tab 16mg 1 PA_BvD




methylprednisolone tab dose pack 4mg 1

MILLIPRED DP PAK 5MG (21) 3

MILLIPRED DP PAK 5MG (48) 3

MILLIPRED TAB 5MG 3 PA_BvD

ORAPRED ODT 10MG 3 PA_BvD






103

prednisolone ODT 10mg 2 PA_BvD



PREDNISOLONE ORAL SOLN 25MG/5ML 3 PA_BvD

PREDNISOLONE ORAL SYRUP 15MG/5ML 1 PA_BvD

prednisolone sodium phosphate oral soln 10mg/5ml 1 PA_BvD



prednisolone sodium phosphate oral soln 6.7mg/5ml 1 PA_BvD

PREDNISONE CONC 5MG/ML 2 PA_BvD

PREDNISONE ORAL SOLN 5MG/5ML 1 PA_BvD

prednisone tab 10mg 1 PA_BvD


prednisone tab 2.5mg 1 PA_BvD




UCERIS ER TAB 9MG 3 PA QL=30 Quantity/30 Days

MINERALOCORTICOIDS

fludrocortisone tab 0.1mg 1

COUGH/COLD/ALLERGY

ANTITUSSIVES

benzonatate cap 100mg, 200mg 1*

hydrocodone/homatropine syrup 1*

TESSALON CAP 100MG 3*

tussigon tab 1*

COUGH/COLD/ALLERGY COMBINATIONS

ALBATUSSIN LIQUID 3*

ALLEGRA-D 12-HOUR TAB 3*

ALLEGRA-D 24-HOUR TAB 3*

cetirizine/pseudoephedrine tab 1*

CLARINEX-D ER TAB 2.5-120MG 3

CLARITIN-D TAB 3*

DECON-A ELIXIR 3*

DECONEX DM TAB 3*

fexofenadine/pseudoephedrine 12-hour tab 1*

fexofenadine/pseudoephedrine 24 hour tab 1*

GILTUSS LIQUID 3*

guaifenesin/codeine syrup 1* QL=240 Quantity/ Per Dispensing

GUAIFENESIN/CODEINE SYRUP 1* QL=240 Quantity/ Per Dispensing

hydrocodone/chlorpheniramine susp 3* QL=120 Quantity/ Per Dispensing




104

HYDROCODONE/CHLORPHENIRAMINE/PSE

LIQUID

3* QL=120 Quantity/ Per Dispensing

hydrocodone/chlorpheniramine/pseudoephedrine liquid 3* QL=120 Quantity/ Per Dispensing

loratadine/pseudoephedrine tab 1*

NEOTUSS LIQUID 3*

PEDIATEX TDM SUSP 3*

promethazine DM syrup 1*

PROMETHAZINE VC SYRUP 6.25-5MG/5ML 1

promethazine VC w/codeine syrup 1*

PROMETHAZINE VC W/CODEINE SYRUP 1*

promethazine/codeine syrup 1*

RESCON TAB 3*

REZIRA SOLN 3*

SUTTAR-SF SYRUP 3*

TUSNEL C SYRUP 3*

TUSSI-ORGANI SYRUP 3* QL=240 Quantity/ Per Dispensing

TUSSIONEX SUSP 3* QL=120 Quantity/ Per Dispensing

ZUTRIPRO LIQUID 3* QL=120 Quantity/ Per Dispensing

ZYRTEC-D TAB 3*

MISC. RESPIRATORY INHALANTS

HYPER SAL NEB SOLN 3*

NEBUSAL NEB SOLN 2*

sodium chloride neb soln 1*

MUCOLYTICS

acetylcysteine soln 10% 1 PA_BvD

acetylcysteine soln 20% 1 PA_BvD

DERMATOLOGICALS

ACNE PRODUCTS

ACANYA GEL 1.2-2.5% 3

adapalene cream 0.1% 2 PA

adapalene gel 0.1% 2 PA

adapalene gel 0.3% 2 PA

ADAPALENE LOTION, DIFFERIN LOTION 0.1% 3 PA

adapalene/benzoyl peroxide gel 0.1-2.5% 2 PA

ATRALIN GEL 0.05% 3 PA

AZELEX CREAM 20% 3 PA

BENZACLIN GEL 1-5% 3

BENZAMYCIN GEL 5-3% 3

CLEOCIN-T GEL 1% 3

CLEOCIN-T LOTION 1% 3

CLEOCIN-T PAD 1% 3

clindamycin foam 1% 2




105

CLINDAMYCIN GEL 1% 1

clindamycin gel 1% 1

clindamycin lotion 1% 1

clindamycin pad 1% 1

clindamycin topical soln 1% 1 QL=300 Quantity/30 Days

clindamycin/benzoyl peroxide gel 1-5% 2

clindamycin/benzoyl peroxide gel 1.2-2.5% 2

clindamycin/benzoyl peroxide gel 1.2-5% 2

clindamycin/tretinoin gel 1.2-0.025% 2

DIFFERIN CREAM 0.1% 3 PA

DIFFERIN GEL 0.1% 3 PA

DIFFERIN GEL 0.1% (OTC) 1* PA

DIFFERIN GEL 0.3% 3 PA

DIFFERIN LOTION 0.1% 3 PA

DUAC GEL 1.2-5% 3

EPIDUO (FORTE) GEL 0.3-2.5% 2 PA

EPIDUO GEL 0.1-2.5% 3 PA

ERYGEL 2% 3

erythromycin gel 2% 1

erythromycin pad 2% 1

ERYTHROMYCIN PAD 2% 1

erythromycin soln 2% 1

erythromycin/benzoyl peroxide gel 5-3% 2

EVOCLIN FOAM 1% 3

isotretinoin cap 10mg 2




KLARON LOTION 10% 3

ONEXTON GEL 1.2-3.75% 3

PLEXION SCT CREAM 3*

RETIN-A CREAM 0.025% 3 PA



RETIN-A GEL 0.01% 3 PA

RETIN-A GEL 0.025% 3 PA

RETIN-A MICRO GEL 0.04% 2 PA

RETIN-A MICRO GEL 0.1% 2 PA

sulfacetamide sodium lotion 10% 2

sulfacetamide sodium/sulfur cream 2*

sulfacetamide sodium/sulfur emulsion 2*

sulfacetamide sodium/sulfur wash 2*




106

sulfacleanse susp 2*

SUMAXIN TS SUSP 3*

SUMAXIN WASH 3*

tretinoin cream 0.025% 2 PA



tretinoin gel 0.01% 2 PA



tretinoin micro gel 0.04% 2 PA

tretinoin micro gel 0.1% 2 PA

VELTIN GEL 1.2-0.025% 3

ZIANA GEL 1.2-0.025% 3

ANTI-INFLAMMATORY AGENTS - TOPICAL

diclofenac gel 1% 2 QL=10 Quantity/30 Days

diclofenac sodium topical soln 1.5% 2 QL=450 Quantity/30 Days

FLECTOR PATCH, DICLOFENAC PATCH 1.3%, 3 PA QL=60 Quantity/30 Days

VOLTAREN GEL 1% 3 QL=10 Quantity/30 Days

ANTIBIOTICS - TOPICAL

CORTISPORIN CREAM 3.5MG/GM-10000 UNT/

GM-0.5%

3

CORTISPORIN OINTMENT 1% 3

gentamicin cream 0.1% 1

gentamicin ointment 0.1% 1

mupirocin ointment 2% 1 QL=220 Quantity/30 Days

ANTIFUNGALS - TOPICAL

ciclopirox cream 0.77% 1

ciclopirox gel 0.77% 1

ciclopirox shampoo 1% 2

ciclopirox soln 8% 1

ciclopirox susp 0.77% 1

clotrimazole cream 1% 2

clotrimazole soln 1% 2

clotrimazole/betamethasone cream 1-0.05% 1

clotrimazole/betamethasone lotion 1-0.05% 2

econazole cream 1% 1

ERTACZO CREAM 2% 3

EXELDERM CREAM 1% 3

EXELDERM SOLN 1% 3

EXTINA FOAM 2% 3

iodoquinol/hydrocortisone cream 3*

ketoconazole cream 2% 1




107

ketoconazole foam 2% 2

ketoconazole shampoo 2% 1

LOPROX CREAM 0.77% 3

LOPROX SHAMPOO 1% 3

LOTRISONE CREAM 1-0.05% 3

MENTAX CREAM 1% 3

NAFTIFINE CREAM 1% 2

naftifine cream 1% 2


NAFTIN CREAM 2% 3

NAFTIN GEL 1% 3

NAFTIN GEL 2% 3

NIZORAL SHAMPOO 2% 3

nystatin cream 100000unit/gm 1

nystatin ointment 100000unit/gm 1

nystatin powder 100000unit/gm 1

oxiconazole nitrate cream 1% 2 QL=270 Quantity/30 Days

OXISTAT CREAM 1% 3 QL=270 Quantity/30 Days

OXISTAT LOTION 1% 3

SULCONAZOLE NITRATE SOLN 1% 3

ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL

CARAC CREAM 0.5% 3

diclofenac gel 3% 2 PA QL=3 Quantity/30 Days

EFUDEX CREAM 5% 3

FLUOROPLEX CREAM 1% 2

FLUOROURACIL CREAM 0.5% 2

fluorouracil cream 5% 1

FLUOROURACIL SOLN 2% 2

FLUOROURACIL SOLN 5% 2

PANRETIN GEL 0.1% 3 NDS

PICATO GEL 0.015% 3 NDS QL=3 Quantity/10 Days

PICATO GEL 0.05% 3 NDS QL=2 Quantity/10 Days

TARGRETIN GEL 1% 2 NDS PA_NSO

TOLAK CREAM 4% 2

VALCHLOR GEL 0.016% 2 NDS PA_NSO

ANTIPSORIATICS

acitretin cap 10mg 2

acitretin cap 17.5mg 2


calcipotriene cream 0.005% 2 QL=240 Quantity/30 Days

CALCIPOTRIENE FOAM 0.005%, SORILUX FOAM

0.005%

3




108

calcipotriene ointment 0.005% 2 QL=240 Quantity/30 Days

calcipotriene soln 0.005% 2

CALCITRIOL OINTMENT 3MCG/GM 3

COSENTYX AUTO-INJECTOR 150MG/ML 2 NDS PA

COSENTYX INJ 150MG/ML 2 NDS PA

DOVONEX CREAM 0.005% 3 QL=240 Quantity/30 Days

methoxsalen cap 10mg 2

OXSORALEN ULTRA CAP 10MG 3

SKYRIZI SYRINGE DOSE PACK 150MG 2 PA

SORIATANE CAP 10MG 3

SORIATANE CAP 17.5MG 3


STELARA INJ 45MG/0.5ML 3 PA

STELARA SYRINGE 45MG/0.5ML 3 PA

STELARA SYRINGE 90MG/ML 3 PA

tazarotene cream 0.1% 2

TAZORAC CREAM 0.05% 3


TAZORAC GEL 0.05% 3

TAZORAC GEL 0.1% 3

ANTISEBORRHEIC PRODUCTS

OVACE CREAM 3*

OVACE PLUS SHAMPOO 3*

OVACE PLUS WASH 3*

OVACE WASH 3*

seb-prev cream 3*

selenium sulfide lotion/shampoo 2.5% 1

selenium sulfide shampoo 2.25% 2*

sulfacetamide sodium gel 3*

sulfacetamide sodium shampoo 3*

sulfacetamide sodium wash 2*

ANTIVIRALS - TOPICAL

acyclovir cream 5% 2

acyclovir ointment 5% 2

DENAVIR CREAM 1% 2

XERESE CREAM 5-1% 3

ZOVIRAX CREAM 5% 3

ZOVIRAX OINTMENT 5% 3

BURN PRODUCTS

mafenide topical soln 5% 2

SILVADENE CREAM 1% 3

silver sulfadiazine cream 1% 1




109

SULFAMYLON CREAM 85MG/GM 2

SULFAMYLON PAK 5% 3

CORTICOSTEROIDS - TOPICAL

alclometasone cream 0.05% 2

alclometasone ointment 0.05% 2

AMCINONIDE CREAM 0.1% 3 PA

AMCINONIDE LOTION 0.1% 3

AMCINONIDE OINTMENT 0.1% 3 PA

APEXICON E CREAM 0.05% 3 PA

augmented betamethasone cream 0.05% 1

augmented betamethasone lotion 0.05% 1

augmented betamethasone ointment 0.05% 1

BETAMETHASONE AUGMENTED GEL 0.05% 1

betamethasone dipropionate cream 0.05% 1

betamethasone dipropionate lotion 0.05% 1

betamethasone dipropionate ointment 0.05% 1

betamethasone valerate cream 0.1% 1

betamethasone valerate foam 0.12% 2 PA

betamethasone valerate lotion 0.1% 1

betamethasone valerate ointment 0.1% 1

calcipotriene-betamethasone dipropionate susp0.005-0.064%


calcipotriene/betamethasone ointment 0.005-0.064% 2 QL=420 Quantity/30 Days

CAPEX SHAMPOO 0.01% 3

clobetasol propionate cream 0.05% 1

clobetasol propionate emollient cream 0.05% 2

clobetasol propionate emulsion foam 0.05% 2 PA

clobetasol propionate foam 0.05% 2

clobetasol propionate gel 0.05% 2

clobetasol propionate lotion 0.05% 2

clobetasol propionate ointment 0.05% 1

clobetasol propionate shampoo 0.05% 2

clobetasol propionate soln 0.05% 1 QL=450 Quantity/30 Days

clobetasol propionate spray 0.05% 2

CLOBEX LOTION 0.05% 3 PA

CLOBEX SHAMPOO 0.05% 3 PA

CLOBEX SPRAY 0.05% 3 PA

CLOCORTOLONE CREAM 0.1% 3 PA

CORDRAN TAPE 4MCG/SQCM 3

CUTIVATE LOTION 0.05% 3 PA

DERMA-SMOOTHE FS 0.01% OIL 2

DERMA-SMOOTHE FS OIL 0.01% 2




110

DESONATE GEL 0.05% 3 PA

desonide cream 0.05% 2 PA

desonide gel 0.05% 3 PA

desonide lotion 0.05% 2 PA

desonide ointment 0.05% 2

DESOWEN LOTION 0.05% 3 PA

DESOWEN/TRIDESILON CREAM 0.05% 3 PA

desoximetasone cream 0.05% 2

desoximetasone cream 0.25% 2

desoximetasone gel 0.05% 2

desoximetasone ointment 0.05% 2

desoximetasone ointment 0.25% 2

DIPROLENE AF CREAM 0.05% 3

DIPROLENE OINTMENT 0.05% 3

ELOCON CREAM 0.1% 3

ELOCON OINTMENT 0.1% 3

fluocinolone acetonide body oil 0.01% 2

fluocinolone acetonide cream 0.01% 1

fluocinolone acetonide cream 0.025% 1

fluocinolone acetonide ointment 0.025% 1

fluocinolone acetonide scalp oil 0.01% 2

fluocinolone acetonide topical soln 0.01% 1

fluocinonide cream 0.05% 1

fluocinonide e cream 0.05% 1

fluocinonide gel 0.05% 1

fluocinonide ointment 0.05% 1

fluocinonide soln 0.05% 1

flurandrenolide cream 0.05% 2

flurandrenolide lotion 0.05% 2

fluticasone cream 0.05% 1

fluticasone ointment 0.005% 1

fluticasone propionate lotion 0.05% 2 PA

halobetasol cream 0.05% 2

halobetasol ointment 0.05% 2

hydrocortisone cream 1% 1

hydrocortisone cream 2.5% 1

hydrocortisone lotion 2.5% 1

hydrocortisone ointment 2.5% 1

hydrocortisone valerate cream 0.2% 2

hydrocortisone valerate ointment 0.2% 2

KENALOG SPRAY 0.147MG/GM 3

mometasone cream 0.1% 1




111

mometasone furoate ointment 0.1% 1

mometasone lotion 0.1% 1

NUCORT LOTION 3*

OLUX FOAM 0.05% 3 PA

OLUX-E FOAM 0.05% 3 PA

PANDEL CREAM 0.1% 3 PA

PREDNICARBATE CREAM 0.1% 2

PREDNICARBATE OINTMENT 0.1% 2

TACLONEX OINTMENT 0.005-0.064% 3 QL=420 Quantity/30 Days

TACLONEX SUSP 0.005-0.064% 3 QL=420 Quantity/30 Days

TEMOVATE OINTMENT 0.05% 3 PA

TOPICORT CREAM 0.05% 3


TOPICORT GEL 0.05% 3 PA

TOPICORT OINTMENT 0.05% 3 PA

TOPICORT OINTMENT 0.25% 3 PA

triamcinolone cream 0.025% 1



triamcinolone lotion 0.025% 1


triamcinolone ointment 0.025% 1



triamcinolone topical spray 0.147mg/gm 2

ULTRAVATE OINTMENT 0.05% 3

ECZEMA AGENTS

DUPIXENT PEN INJ 300MG/2ML 2 NDS PA

DUPIXENT SYRINGE 200MG/1.14ML 2 NDS PA

DUPIXENT SYRINGE 300MG/2ML 2 NDS PA

EMOLLIENTS

ammonium lactate cream 12% 1

ammonium lactate lotion 12% 1

LAC-HYDRIN LOTION 3*

ENZYMES - TOPICAL

SANTYL OINTMENT 250UNIT/GM 2 QL=1 Quantity/30 Days

IMMUNOMODULATING AGENTS - TOPICAL

ALDARA CREAM 5% 3

imiquimod cream 5% 2

ZYCLARA CREAM 2.5% 3


ZYCLARA PUMP CREAM 3.75% 3




112

IMMUNOSUPPRESSIVE AGENTS - TOPICAL

ELIDEL CREAM 1% 3

pimecrolimus cream 1% 2

PROTOPIC OINTMENT 0.03% 3 QL=100 Quantity/30 Days

PROTOPIC OINTMENT 0.1% 3 QL=100 Quantity/30 Days

tacrolimus ointment 0.03% 2 QL=100 Quantity/30 Days

tacrolimus ointment 0.1% 2 QL=100 Quantity/30 Days

KERATOLYTIC/ANTIMITOTIC AGENTS

CONDYLOX GEL 0.5% 3

PODOCON SOLN 2*

podofilox soln 0.5% 2

SALEX SHAMPOO 3*

salicylic acid shampoo 2*

LOCAL ANESTHETICS - TOPICAL

lidocaine cream (rx only) 3% 1*

lidocaine gel 2% 1

LIDOCAINE GEL 2% 1

lidocaine ointment 5% 2 PA QL=107 Quantity/30 Days

lidocaine patch 5% 2 PA QL=90 Quantity/30 Days

lidocaine topical soln 4% 1

lidocaine/prilocaine cream 2.5-2.5% 1 QL=60 Quantity/30 Days

LIDODERM PATCH 5% 3 PA QL=90 Quantity/30 Days

MISC. TOPICAL

ALCOHOL SWAB 1"x1" (DIABETIC) $0

aluminum chloride soln 1*

DRYSOL SOLN 1*

ROSACEA AGENTS

azelaic acid gel 15% 2

FINACEA FOAM 15% 2

FINACEA GEL 15% 3

METROCREAM 0.75% 3

METROGEL 1% 3

METROLOTION 0.75% 3

metronidazole cream 0.75% 2

metronidazole gel 0.75% 2

metronidazole gel 1% 2

metronidazole lotion 0.75% 1

SCABICIDES & PEDICULICIDES

CROTAN LOTION 10% 3

ELIMITE CREAM 5% 3

EURAX CREAM 10% 2

EURAX LOTION 10% 3




113

LINDANE SHAMPOO 1% 2

lindane shampoo 1% 2

malathion lotion 0.5% 2

OVIDE LOTION 0.5% 3

permethrin cream 5% 1

SKLICE LOTION 0.5% 3 QL=1 Quantity/15 Days

WOUND CARE PRODUCTS

REGRANEX GEL 0.01% 2 NDS QL=2 Quantity/15 Days

DIAGNOSTIC PRODUCTS

DIAGNOSTIC TESTS

CLINISTIX 1*

GLUCOSE BLOOD TEST STRIP 1*

KETO-DIASTIX 1*

KETONE BLOOD TEST STRIP 1*

KETOSTIX 1*

DIGESTIVE AIDS

DIGESTIVE ENZYMES

CREON DR CAP 12000-38000-60000UNIT 2

CREON DR CAP 24000-76000-120000UNIT 2

CREON DR CAP 3000-9500-15000UNIT 2

CREON DR CAP 36000-114000-180000UNIT 2

CREON DR CAP 6000-19000-30000UNIT 2

PERTZYE DR CAP 24000-86250-90750UNIT 3 ST

SUCRAID ORAL SOLN 8500UNIT/ML 3 NDS PA

ZENPEP DR CAP 10000-32000-42000UNIT 3 ST








DIURETICS

CARBONIC ANHYDRASE INHIBITORS

acetazolamide ER cap 500mg 2

acetazolamide tab 125mg 2


DIAMOX SEQUELS CAP 500MG 3

methazolamide tab 25mg 2


DIURETIC COMBINATIONS

ALDACTAZIDE TAB 25-25MG 3




114

ALDACTAZIDE TAB 50-50MG 3

amiloride/hydrochlorothiazide tab 5-50mg 1

DYAZIDE CAP 37.5-25MG 3

MAXZIDE TAB 37.5-25MG 3

MAXZIDE TAB 75-50MG 3

spironolactone/hydrochlorothiazide tab 25-25mg 1

triamterene/hydrochlorothiazide cap 37.5-25mg 1

triamterene/hydrochlorothiazide tab 37.5-25mg 1

triamterene/hydrochlorothiazide tab 75-50mg 1

LOOP DIURETICS

bumetanide inj 0.25mg/ml 2

bumetanide tab 0.5mg 1

bumetanide tab 1mg 1


DEMADEX TAB 10MG 3

EDECRIN TAB 25MG 3

ethacrynic acid tab 25mg 2

furosemide inj 10mg/ml 2

furosemide oral soln 10mg/ml 1

FUROSEMIDE ORAL SOLN 8MG/ML 1

furosemide tab 20mg 1



LASIX TAB 20MG 3

LASIX TAB 40MG 3

LASIX TAB 80MG 3

torsemide tab 100mg 1



torsemide tab 5mg 1

POTASSIUM SPARING DIURETICS

ALDACTONE TAB 100MG 3



amiloride tab 5mg 1

DYRENIUM CAP 100MG 2

DYRENIUM CAP 50MG 2

spironolactone tab 100mg 1



triamterene cap 100mg 2





115

THIAZIDES AND THIAZIDE-LIKE DIURETICS

CHLOROTHIAZIDE TAB 250MG 1

CHLOROTHIAZIDE TAB 500MG 1

chlorthalidone tab 25mg 1


DIURIL SUSP 250MG/5ML 2

hydrochlorothiazide cap 12.5mg 1

hydrochlorothiazide tab 12.5mg 1

hydrochlorothiazide tab 25mg 1

hydrochlorothiazide tab 50mg 1

indapamide tab 1.25mg 1


METHYCLOTHIAZIDE TAB 5MG 1

metolazone tab 10mg 1

metolazone tab 2.5mg 1


MICROZIDE CAP 12.5MG 3

ENDOCRINE AND METABOLIC AGENTS - MISC.

BONE DENSITY REGULATORS

ACTONEL TAB 150MG 3

ACTONEL TAB 30MG 3

ACTONEL TAB 35MG 3

ACTONEL TAB 5MG 3

ALENDRONATE ORAL SOLN 70MG/75ML 3

alendronate tab 10mg 1


ALENDRONATE TAB 40MG 2



BONIVA TAB 150MG 3 QL=1 Quantity/30 Days

calcitonin nasal spray 200unit 2

FORTEO INJ 600MCG/2.4ML 2 NDS

FORTICAL SPRAY 200UNIT 2

FOSAMAX TAB 70MG 3

ibandronate tab 150mg 1 QL=1 Quantity/30 Days

NATPARA INJ 100MCG 2 NDS PA




PROLIA INJ 60MG/ML 3 PA

risedronate tab 150mg 2





116



TYMLOS PEN INJECTOR 3120MCG/1.56ML 2 NDS

XGEVA INJ 120MG/1.7ML 3 NDS PA

GNRH/LHRH ANTAGONISTS

ORILISSA TAB 150MG 2 PA QL=30 Quantity/30 Days

ORILISSA TAB 200MG 2 PA QL=60 Quantity/30 Days

GROWTH HORMONE RECEPTOR ANTAGONISTS

SOMAVERT INJ 10MG 2 NDS PA





GROWTH HORMONES

GENOTROPIN INJ 0.2MG 2 NDS PA








GENOTROPIN INJ 12MG 2 NDS PA




HORMONE RECEPTOR MODULATORS

EVISTA TAB 60MG 3

OSPHENA TAB 60MG 3 PA

raloxifene tab 60mg $0

INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS)

INCRELEX INJ 40MG/4ML 2 NDS PA

LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS

LUPANETA PACK 1-MONTH PACK 3 NDS

LUPANETA PACK 3-MONTH PACK 3

LUPRON INJ PED KIT 11.25MG (3 MONTH) 3

LUPRON INJ PED KIT 7.5MG (1 MONTH) 3

SYNAREL NASAL SOLN 2MG/ML 2 NDS

METABOLIC MODIFIERS

BUPHENYL ORAL POWDER 0.94MG/MG 3 NDS

calcitriol cap 0.25mcg 1 PA_BvD

calcitriol cap 0.5mcg 1 PA_BvD




117

calcitriol oral soln 1mcg/ml 1 PA_BvD

CARBAGLU TAB 200MG 3 PA

CARNITOR ORAL SOLN 1GM/10ML 3 PA_BvD

CARNITOR TAB 330MG 3 PA_BvD

cinacalcet tab 30mg 2 PA_BvD



doxercalciferol cap 0.2mcg 2 PA_BvD

doxercalciferol cap 1mcg 2 PA_BvD

doxercalciferol cap 2.5mcg 2 PA_BvD

GALAFOLD CAP 123MG 2 NDS PA QL=15 Quantity/30 Days

KUVAN POWDER PACKET 100MG 2 NDS PA

KUVAN POWDER PACKET 500MG 2 NDS PA

KUVAN TAB 100MG 2 NDS PA

levocarnitine oral soln 1gm/10ml 1 PA_BvD

levocarnitine tab 330mg 1 PA_BvD

nitisinone cap 10mg 3 NDS PA



ORFADIN CAP 10MG 3 NDS PA




ORFADIN ORAL SUSP 4MG/ML 3 NDS PA

PALYNZIQ SYRINGE 10MG/0.5ML 2 NDS PA

PALYNZIQ SYRINGE 2.5MG/0.5ML 2 NDS PA

PALYNZIQ SYRINGE 20MG/ML 2 NDS PA

paricalcitol cap 1mcg 2 PA_BvD



RAVICTI LIQUID 1.1GM/ML 3 NDS PA

ROCALTROL CAP 0.25MCG 3 PA_BvD

ROCALTROL CAP 0.5MCG 3 PA_BvD

ROCALTROL ORAL SOLN 1MCG/ML 3 PA_BvD

SENSIPAR TAB 30MG 2 PA_BvD



sodium phenylbutyrate oral powder 0.94mg/mg 2

ZEMPLAR CAP 1MCG 3 PA_BvD

ZEMPLAR CAP 2MCG 3 PA_BvD

POSTERIOR PITUITARY HORMONES

DDAVP NASAL SOLN 0.01% 3




118

DDAVP NASAL SPRAY 0.01% 3

DDAVP TAB 0.1MG 3

DDAVP TAB 0.2MG 3

desmopressin nasal spray 0.01% 2

desmopressin nasal spray 0.01%(refrigerated) 2

desmopressin tab 0.1mg 2


STIMATE NASAL SPRAY 1.5MG/ML 2

PROLACTIN INHIBITORS

cabergoline tab 0.5mg 1

SOMATOSTATIC AGENTS

octreotide inj 1000mcg/ml 1





SANDOSTATIN INJ 100MCG/ML 3 NDS

SANDOSTATIN INJ 500MCG/ML 3 NDS

SANDOSTATIN INJ 50MCG/ML 3

SIGNIFOR INJ 0.3MG/ML 2 NDS PA

SIGNIFOR INJ 0.6MG/ML 2 NDS PA

SIGNIFOR INJ 0.9MG/ML 2 NDS PA QL=60 Quantity/30 Days

SOMATULINE INJ 120MG/0.5ML 3 NDS



VASOPRESSIN RECEPTOR ANTAGONISTS

JYNARQUE TAB 15MG 2 NDS PA

JYNARQUE TAB 30MG 2 NDS PA

JYNARQUE TAB THERAPY PACK 30/15MG 2 NDS PA QL=60 Quantity/30 Days

JYNARQUE TAB THERAPY PACK 45/15MG 2 NDS PA



ESTROGENS

ESTROGEN COMBINATIONS

ACTIVELLA TAB 0.5-0.1MG 3

ACTIVELLA TAB 1-0.5MG 3

ANGELIQ TAB 3

CLIMARA PRO PATCH 0.045-0.015MG 3

COMBIPATCH 0.05-0.14MG 3

COMBIPATCH 0.05-0.25MG 3

esterified estrogens/methyltestosterone tab 1*

FEMHRT LOW DOSE TAB 3




119

jinteli tab 1mg/5mcg 2

mimvey LO tab 0.5-0.1mg 2

mimvey tab 1-0.5mg 2

norethindrone acetate/ethinyl estradiol tab0.5mg/2.5mcg

2

PREFEST TAB 3

PREMPHASE TAB 0.625-5MG 2

PREMPRO TAB 0.3-1.5MG 2



PREMPRO TAB 0.625-5MG 2

ESTROGENS

ALORA PATCH, MINIVELLE PATCH 0.025MG 3




CLIMARA PATCH 0.025MG 3






DELESTROGEN INJ 10MG/ML 3



DEPO ESTRADIOL INJ 5MG/ML 3

ESTRACE TAB 0.5MG 3

ESTRACE TAB 1MG 3

ESTRACE TAB 2MG 3

estradiol patch 0.025mg 1






estradiol tab 0.5mg 1

estradiol tab 1mg 1

estradiol tab 2mg 1

estradiol twice weekly patch 0.025mg 1







120


estradiol valerate inj 20mg/ml 2

estradiol valerate inj 40mg/ml 2

EVAMIST SPRAY 1.53MG 3

MENEST TAB 0.3MG 3

MENEST TAB 0.625MG 3

MENEST TAB 1.25MG 3

MENOSTAR PATCH 14MCG 3

MINIVELLE PATCH 0.0375MG 3

PREMARIN TAB 0.3MG 2





VIVELLE-DOT PATCH 0.025MG 3





FLUOROQUINOLONES

FLUOROQUINOLONES

AVELOX INJ 400MG/250ML 3

BAXDELA TAB 450MG 2 PA QL=60 Quantity/30 Days

CIPRO INJ 400MG/200ML/D5W 3

CIPRO SUSP 250MG/5ML 3


CIPRO TAB 250MG 3

CIPRO TAB 500MG 3

ciprofloxacin inj 200mg/100ml/D5W 2

ciprofloxacin inj 400mg/200ml/D5W 2

ciprofloxacin susp 250mg/5ml 2

ciprofloxacin susp 500mg/5ml 2

ciprofloxacin tab 250mg 1



levofloxacin inj 250mg/50ml/D5W 2

levofloxacin inj 25mg/ml 2



levofloxacin oral soln 25mg/ml 1

levofloxacin tab 250mg 1





121


MOXIFLOXACIN IN SODIUM CHLORIDE INJ

400MG/250ML

2

MOXIFLOXACIN IV SOLN 400MG/250ML 2

moxifloxacin tab 400mg 2

ofloxacin tab 400mg 1

GASTROINTESTINAL AGENTS - MISC.

BILE ACID SYNTHESIS DISORDER AGENTS

CHOLBAM CAP 250MG 2 NDS PA

CHOLBAM CAP 50MG 2 NDS PA

FARNESOID X RECEPTOR (FXR) AGONISTS

OCALIVA TAB 10MG 2 NDS PA RXC QL=30

Quantity/30 Days

OCALIVA TAB 5MG 2 NDS PA RXC QL=30

Quantity/30 Days

GALLSTONE SOLUBILIZING AGENTS

ACTIGALL CAP 300MG 3

CHENODAL TAB 250MG 3 NDS

URSO FORTE TAB 500MG 3

URSO TAB 250MG 3

ursodiol cap 300mg 1

ursodiol tab 250mg 1


GASTROINTESTINAL ANTIALLERGY AGENTS

cromolyn oral soln 100mg/5ml 2

GASTROCROM SOLN 100MG/5ML 3

GASTROINTESTINAL STIMULANTS

metoclopramide soln 5mg/5ml 1

metoclopramide tab 10mg 1


REGLAN TAB 10MG 3

REGLAN TAB 5MG 3

INFLAMMATORY BOWEL AGENTS

APRISO CAP 0.375GM 2

AZULFIDINE DR TAB 500MG 3

AZULFIDINE TAB 500MG 3

balsalazide cap 750mg 1

CANASA RECTAL SUPP 1000MG 3

CIMZIA INJ 200MG 2 NDS PA

CIMZIA INJ STARTER KIT 200MG/ML 2 NDS PA

CIMZIA PF SYRINGE 200MG/ML 2 NDS PA

COLAZAL CAP 750MG 3




122

DIPENTUM CAP 250MG 3

mesalamine DR cap 400mg 2

mesalamine DR tab 1.2gm 2

mesalamine DR tab 800mg 2

mesalamine enema 4gm 2

mesalamine enema kit 4gm 2

mesalamine er cap 0.375gm 2

mesalamine rectal supp 1000mg 2

SFROWASA ENEMA 4GM/60ML 3

sulfasalazine EC tab 500mg 1

sulfasalazine tab 500mg 1

INTESTINAL ACIDIFIERS

lactulose soln 10gm/15ml 1

IRRITABLE BOWEL SYNDROME (IBS) AGENTS

alosetron tab 0.5mg 2

alosetron tab 1mg 2

LINZESS CAP 145MCG 2 PA



LOTRONEX TAB 0.5MG 3

LOTRONEX TAB 1MG 3

PERIPHERAL OPIOID RECEPTOR ANTAGONISTS

MOVANTIK TAB 12.5MG 2 PA

MOVANTIK TAB 25MG 2 PA

RELISTOR INJ 12MG/0.6ML 3 PA

RELISTOR INJ 8MG/0.4ML 3 PA

SYMPROIC TAB 0.2MG 2 PA

PHOSPHATE BINDER AGENTS

AURYXIA TAB 1GM 3 PA

calcium acetate cap 667mg 1

calcium acetate tab 667mg 1

FOSRENOL POWDER PACK 1000MG 2

FOSRENOL POWDER PACK 750MG 2

lanthanum carbonate chew tab 1000mg 2



PHOSLO CAP 667MG 3

PHOSLYRA ORAL SOLN 667MG/5ML 2

RENAGEL TAB 800MG 3

RENVELA PACKET 0.8GM 3

RENVELA PACKET 2.4GM 3

RENVELA TAB 800MG 3




123

sevelamer carbonate packet 0.8gm 2

sevelamer carbonate packet 2.4gm 2

sevelamer carbonate tab 800mg 2

SEVELAMER TAB 400MG 2

sevelamer tab 800mg 2

VELPHORO CHEW TAB 500MG 3

SHORT BOWEL SYNDROME (SBS) AGENTS

GATTEX INJ 5MG 3 NDS PA

GENITOURINARY AGENTS - MISCELLANEOUS

ALKALINIZERS

CYTRA-3 SYRUP 1*

ORACIT SOLN 1*

potassium citrate CR tab 10meq 2



potassium citrate/citric acid granule 1*

potassium citrate/citric acid soln 1*

sodium citrate/citric acid soln 1*

tricitrates soln 1*

UROCIT-K TAB 10MEQ 3


UROCIT-K TAB 5MEQ 3

CYSTINOSIS AGENTS

CYSTAGON CAP 150MG 2

CYSTAGON CAP 50MG 2

GENITOURINARY IRRIGANTS

sodium chloride irrigation soln 0.9% 2

INTERSTITIAL CYSTITIS AGENTS

ELMIRON CAP 100MG 2

PROSTATIC HYPERTROPHY AGENTS

alfuzosin tab 10mg 1

AVODART CAP 0.5MG 3

CARDURA XL TAB 4MG 3


dutasteride cap 0.5mg 1

dutasteride/tamsulosin cap 0.5-0.4mg 2

finasteride tab 5mg 1

FLOMAX CAP 0.4MG 3

JALYN CAP 0.5-0.4MG 3

PROSCAR TAB 5MG 3

RAPAFLO CAP 4MG 3

RAPAFLO CAP 8MG 3




124

silodosin cap 4mg 2

silodosin cap 8mg 2

tamsulosin cap 0.4mg 1

UROXATRAL TAB 10MG 3

URINARY ANALGESICS

phenazopyridine tab 1*

PYRIDIUM TAB 3*

URINARY STONE AGENTS

LITHOSTAT TAB 250MG 3

THIOLA DR TAB 100MG 3


THIOLA TAB 100MG 3

GOUT AGENTS

GOUT AGENT COMBINATIONS

DUZALLO TAB 200-300MG 3 PA QL=30 Quantity/30 Days

probenecid/colchicine tab 0.5-500mg 1

GOUT AGENTS

allopurinol tab 100mg 1


colchicine tab 0.6mg 3 PA

COLCRYS TAB 0.6MG NC

febuxostat tab 40mg 2 ST RXC

febuxostat tab 80mg 2 ST RXC

MITIGARE CAP 0.6MG 2

ULORIC TAB 40MG 2 ST

ULORIC TAB 80MG 2 ST

ZYLOPRIM TAB 100MG 3


URICOSURICS

probenecid tab 500mg 1

HEMATOLOGICAL AGENTS - MISC.

BRADYKININ B2 RECEPTOR ANTAGONISTS

icatibant inj 30mg/3ml 2 NDS PA

COMPLEMENT INHIBITORS

BERINERT INJ KIT 500UNIT 2 NDS PA

CINRYZE INJ 500UNIT 2 NDS PA

HAEGARDA INJ 2000UNIT 2 NDS PA

HAEGARDA INJ 3000UNIT 2 NDS PA

RUCONEST INJ 2100UNIT 2 NDS PA

HEMATAOLOGIC - TYROSINE KINASE INHIBITORS

TAVALISSE TAB 100MG 2 NDS PA QL=60 Quantity/30 Days

TAVALISSE TAB 150MG 2 NDS PA QL=60 Quantity/30 Days




125

HEMATORHEOLOGIC AGENTS

pentoxifylline ER tab 400mg 1

PLASMA KALLIKREIN INHIBITORS

TAKHZYRO INJ 300MG/2ML 2 NDS PA QL=2 Quantity/28 Days

PLATELET AGGREGATION INHIBITORS

AGGRENOX CAP 25-200MG 3

AGRYLIN CAP 0.5MG 3

anagrelide cap 0.5mg 1

anagrelide cap 1mg 1

aspirin/dipyridamole cap 25-200mg 2

BRILINTA TAB 60MG 3

BRILINTA TAB 90MG 3

cilostazol tab 100mg 1


clopidogrel tab 75mg 1

EFFIENT TAB 10MG 3

EFFIENT TAB 5MG 3

PLAVIX TAB 75MG 3

prasugrel tab 10mg 1

prasugrel tab 5mg 1

ZONTIVITY TAB 2.08MG 3 PA

HEMATOPOIETIC AGENTS

AGENTS FOR GAUCHER DISEASE

CERDELGA CAP 84MG 3 NDS PA QL=60 Quantity/30 Days

miglustat cap 100mg 2 NDS PA

AGENTS FOR SICKLE CELL ANEMIA

DROXIA CAP 200MG 2

DROXIA CAP 300MG 2

DROXIA CAP 400MG 2

ENDARI POWDER FOR ORAL SOLN 5GM 3 NDS PA QL=180 Quantity/30 Days

AGENTS FOR SICKLE CELL DISEASE

OXBRYTA TAB 500MG 2 NDS PA QL=90 Quantity/30 Days

COBALAMINS

cyanocobalamin inj 1*

NASCOBAL SPRAY 3*

FOLIC ACID/FOLATES

folic acid tab (OTC) $0*

folic acid tab 1mg $0*

HEMATOPOIETIC GROWTH FACTORS

ARANESP INJ 100MCG/ML 3 PA_BvD ST






126




ARANESP SYRINGE 100MCG/0.5ML 3 PA_BvD ST







ARANESP SYRINGE 500MCG/ML 3 PA_BvD ST


DOPTELET DAILY DOSE PACK 40MG 2 NDS PA QL=1 Quantity/5 Days

DOPTELET DAILY DOSE PACK 60MG 2 NDS PA QL=1 Quantity/5 Days

DOPTELET TAB 20MG 2 NDS PA QL=60 Quantity/30 Days

FULPHILA INJ 6MG/0.6ML 2 NDS

LEUKINE INJ 250MCG 2 NDS PA

MULPLETA TAB 3MG 2 NDS PA QL=7 Quantity/7 Days

NIVESTYM INJ 300MCG/1ML 2 NDS

NIVESTYM INJ 480MCG/1.6ML 2 NDS

NIVESTYM PF INJ 300MCG/0.5ML 2 NDS

NIVESTYM PF INJ 480MCG/0.8ML 2 NDS

PROMACTA POWDER FOR ORAL SUSP 12.5MG 2 NDS PA

PROMACTA POWDER FOR ORAL SUSP 25MG 2 NDS PA

PROMACTA TAB 12.5MG 2 NDS PA

PROMACTA TAB 25MG 2 NDS PA



RETACRIT INJ 10000UNIT/ML 2 PA_BvD





UDENYCA SYRINGE 6MG/0.6ML 2 NDS

ZARXIO INJ 300MCG/0.5ML 2 NDS

ZARXIO INJ 480MCG/0.8ML 2 NDS

ZIEXTENZO SYRINGE 6MG/0.6M 3 NDS

HEMATOPOIETIC MIXTURES

ferrex forte cap 1*

folbee tab 1*

IRON POLYSACCH/THREONIC ACID/B12/FA CAP 1*

IRON/VITAMIN C/VITAMIN B12/FOLIC ACID TAB 3*




127

iron/vitamin C/vitamin B12/folic acid tab 3*

MULTIGEN FOLIC TAB 1*

MULTIGEN PLUS TAB 1*

MULTIGEN TAB 1*

REPLIVA TAB 3*

tricon cap 1*

IRON

ferrous sulfate elixir $0*

FERROUS SULFATE LIQUID $0*

ferrous sulfate soln $0*

FERROUS SULFATE SYRUP $0*

IRON SUSP $0*

HEMOSTATICS

HEMOSTATICS - SYSTEMIC

LYSTEDA TAB 650MG 3

tranex acid tab 650mg 2

HYPNOTICS

BARBITURATE HYPNOTICS

phenobarbital elixir 20mg/5ml 1

phenobarbital tab 16.2mg 1




NON-BARBITURATE HYPNOTICS

AMBIEN TAB 10MG 3 QL=30 Quantity/30 Days

AMBIEN TAB 5MG 3 QL=60 Quantity/30 Days

estazolam tab 1mg 1

estazolam tab 2mg 1

eszopiclone tab 1mg 1 QL=30 Quantity/30 Days



FLURAZEPAM CAP 15MG 1


HALCION TAB 0.25MG 3

LUNESTA TAB 1MG 3 QL=30 Quantity/30 Days



RESTORIL CAP 15MG 3

RESTORIL CAP 22.5MG 3

RESTORIL CAP 30MG 3


temazepam cap 15mg 1




128

temazepam cap 22.5mg 2



triazolam tab 0.25mg 1

zaleplon cap 10mg 1 QL=30 Quantity/30 Days

zaleplon cap 5mg 1 QL=30 Quantity/30 Days

zolpidem tab 10mg 1 QL=30 Quantity/30 Days

zolpidem tab 5mg 1 QL=60 Quantity/30 Days

SELECTIVE MELATONIN RECEPTOR AGONISTS

HETLIOZ CAP 20MG 3 NDS PA QL=30 Quantity/30 Days

HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS

BARBITURATE HYPNOTICS

phenobarbital tab 100mg 1




NON-BARBITURATE HYPNOTICS


SELECTIVE MELATONIN RECEPTOR AGONISTS

ramelteon tab 8 mg 2 QL=30 Quantity/30 Days

LAXATIVES

LAXATIVE COMBINATIONS

CLENPIQ POWDER 10 MG-3.5GM-12GM/160ML 2

COLYTE FLAVOR PACK 240GM 3

GAVILYTE-C SOLN $0

gavilyte-G soln 236gm $0

GOLYTELY SOLN 236GM 3

peg 3350/electrolytes soln 240 gm $0

trilyte soln/gavilyte soln 420gm $0

LAXATIVES - MISCELLANEOUS

KRISTALOSE PACK 10GM 3

KRISTALOSE PACKET 20GM 3

lactulose soln 10mg/15ml 1

MACROLIDES

AZITHROMYCIN

azithromycin inj 500mg 2

azithromycin susp 100mg/5ml 1

azithromycin susp 200mg/5ml 1

azithromycin tab 250mg 1



ZITHROMAX INJ 500MG 3




129

ZITHROMAX POWDER PACK 1GM 3

ZITHROMAX SUSP 100MG/5ML 3

ZITHROMAX SUSP 200MG/5ML 3

ZITHROMAX TAB 250MG 3



CLARITHROMYCIN

clarithromycin ER tab 500mg 2

CLARITHROMYCIN SUSP 125MG/5ML 2

CLARITHROMYCIN SUSP 250MG/5ML 2

clarithromycin tab 250mg 1


ERYTHROMYCINS

ery-tab DR tab 250mg 3



ERYPED SUSP 200MG/5ML 3

ERYPED SUSP 400MG/5ML 3

ERYTHROCIN INJ 500MG 3

erythromycin DR cap 250mg 2

ERYTHROMYCIN DR CAP 250MG 2

erythromycin susp 200mg/5ml 2

erythromycin susp 400mg/5ml 2

erythromycin tab 250mg 2



FIDAXOMICIN

DIFICID TAB 200MG 2 NDS ST QL=20 Quantity/10 Days

MEDICAL DEVICES

BANDAGES-DRESSINGS-TAPE

GAUZE PAD 2X2 2

CONTRACEPTIVES

CERVICAL CAP $0*

DIAPHRAGM $0*

FEMALE CONDOMS $0*

DIABETIC SUPPLIES

ACCU-CHEK NANO METER $0*

CALIBRATION LIQUID $0*

FREESTYLE FREEDOM METER $0*

FREESTYLE INSULINX METER $0*

FREESTYLE LITE METER $0*

LANCET DEVICE $0*




130

LANCET KIT $0*

LANCETS $0*

PRECISION XTRA METER $0*

V-GO KIT 20 2

V-GO KIT 30 2

V-GO KIT 40 2

MISC. DEVICES

ALCOHOL SWAB 1”x1” (DIABETIC) $0

PARENTERAL THERAPY SUPPLIES

INSULIN SYRINGE $0

PEN NEEDLE $0

MEDICAL DEVICES AND SUPPLIES

DIABETIC SUPPLIES

ACCU-CHECK GUIDE CARE METER $0*

ACCU-CHEK AVIVA PLUS METER $0*

FREESTYLE PRECISION NEO METER $0*

PARENTERAL THERAPY SUPPLIES

INSULIN SYRINGE $0

INSULIN SYRINGE U-500 $0

PEN NEEDLE $0

MIGRAINE PRODUCTS

MIGRAINE COMBINATIONS

ISOMETHEPTENE/CAFFEINE/ACETAMINOPHEN

TAB

2*

isometheptene/caffeine/acetaminophen tab 2*

MIGRAINE PRODUCTS

dihydroergotamine nasal spray 4mg/ml 3 QL=16 Quantity/30 Days

ERGOMAR SL TAB 2MG 2

MIGRAINE PRODUCTS - MONOCLONAL ANTIBODIES

AIMOVIG AUTO-INJECTOR 140MG/ML 2 PA

AIMOVIG AUTO-INJECTOR 70MG/ML 2 PA

EMGALITY AUTO-INJECTOR 120MG/ML 2 PA

EMGALITY SYRINGE 100MG/ML 2 PA

EMGALITY SYRINGE 120MG/ML 2 PA

SEROTONIN AGONISTS

AMERGE TAB 1MG 3 QL=18 Quantity/30 Days

AMERGE TAB 2.5MG 3 QL=18 Quantity/30 Days

eletriptan tab 20mg 1 QL=18 Quantity/30 Days

eletriptan tab 40mg 1 QL=18 Quantity/30 Days

IMITREX INJ 6MG/0.5ML 3 QL=10 Quantity/30 Days

IMITREX NASAL SPRAY 20MG 3 QL=12 Quantity/30 Days

IMITREX NASAL SPRAY 5MG 3 QL=12 Quantity/30 Days




131

IMITREX STATDOSE INJ 6MG/0.5ML 3 QL=10 Quantity/30 Days

IMITREX STATDOSE REFILL INJ 6MG/0.5ML 3 QL=10 Quantity/30 Days

IMITREX TAB 100MG 3 QL=18 Quantity/30 Days



MAXALT MLT TAB 10MG 3 QL=36 Quantity/60 Days

MAXALT MLT TAB 5MG 3 QL=36 Quantity/60 Days

MAXALT TAB 10MG 3 QL=36 Quantity/60 Days

naratriptan tab 1mg 2 QL=18 Quantity/30 Days

naratriptan tab 2.5mg 2 QL=18 Quantity/30 Days

rizatriptan ODT 10mg 1 QL=36 Quantity/60 Days

rizatriptan ODT 5mg 1 QL=36 Quantity/60 Days

rizatriptan tab 10mg 1 QL=36 Quantity/60 Days

rizatriptan tab 5mg 1 QL=36 Quantity/60 Days

sumatriptan auto-injector 4mg/0.5ml 2 QL=10 Quantity/30 Days

sumatriptan auto-injector 6mg/0.5ml 2 QL=10 Quantity/30 Days

sumatriptan inj 6mg/0.5ml 2 QL=10 Quantity/30 Days

SUMATRIPTAN INJ 6MG/0.5ML 2 QL=10 Quantity/30 Days

sumatriptan nasal spray 20mg/act 2 QL=12 Quantity/30 Days

sumatriptan nasal spray 5mg/act 2 QL=12 Quantity/30 Days

sumatriptan refill inj 4mg/0.5ml 2 QL=10 Quantity/30 Days

sumatriptan refill inj 6mg/0.5ml 2 QL=10 Quantity/30 Days

sumatriptan tab 100mg 1 QL=18 Quantity/30 Days



zolmitriptan ODT 2.5mg 2 QL=18 Quantity/30 Days

zolmitriptan ODT 5mg 2 QL=18 Quantity/30 Days

zolmitriptan tab 2.5mg 2 QL=18 Quantity/30 Days

zolmitriptan tab 5mg 2 QL=18 Quantity/30 Days

ZOMIG NASAL SPRAY 2.5MG 3 QL=16 Quantity/30 Days

ZOMIG NASAL SPRAY 5MG 3 QL=12 Quantity/30 Days

ZOMIG TAB 2.5MG 3 QL=18 Quantity/30 Days

ZOMIG TAB 5MG 3 QL=18 Quantity/30 Days

ZOMIG ZMT TAB 2.5MG 3 QL=18 Quantity/30 Days

ZOMIG ZMT TAB 5MG 3 QL=18 Quantity/30 Days

MINERALS & ELECTROLYTES

BICARBONATES

SODIUM LACTATE INJ 5MEQ/ML 2

ELECTROLYTE MIXTURES

D10W/NACL INJ 10%/0.2% 2 PA_BvD

D10W/NACL INJ 10%/0.45% 2 PA_BvD

D2.5W/NACL INJ 0.45% 2




132

d5w/nacl inj 5%/0.2% 2

D5W/NACL INJ 5%/0.225% 2

d5w/nacl inj 5%/0.33% 2

d5w/nacl inj 5%/0.45% 2

d5w/nacl inj 5%/0.9% 2

ELECTROLYTE-48 INJ/D5W 2

IONOSOL-MB INJ D5W 2

IONOSOL-MB INJ/D5W 2

ISOLYTE-P INJ/D5W 2

ISOLYTE-S INJ 2

ISOLYTE-S INJ (PH 7.4) 2

KCL/ NACL INJ 40MEQ/0.9% 2

kcl/d5w inj 20meq/5% 2

kcl/d5w/nacl inj 10meq/5%/0.45% 2


KCL/D5W/NACL INJ 20MEQ/5%/0.225% 2








kcl/nacl inj 20meq/0.45% 2

KCL/NACL INJ 20MEQ/0.45% 2



NORMOSOL-M INJ/D5W 2

NORMOSOL-R INJ 2

NORMOSOL-R INJ (PH 7.4) 2

NORMOSOL-R INJ/D5W 2

PLASMA-LYTE INJ 148 soln 2

PLASMA-LYTE-A INJ 2

POTASSIUM CHLORIDE INJ 0.15%/D5W LR 2

POTASSIUM CHLORIDE INJ 0.3%/D5W LR 2

POTASSIUM CHLORIDE INJ 40MEQ/L 5% 2

TPN ELECTROL INJ 2 PA_BvD

FLUORIDE

FLUORABON SOLN $0*

LURIDE CHEW TAB $0*

LURIDE SOLN $0*

sodium fluoride chew tab $0*




133

SODIUM FLUORIDE LOZENGE $0*

sodium fluoride soln $0*

SODIUM FLUORIDE TAB $0*

MAGNESIUM

MAGNESIUM SULFATE 1%/D5W INJ 3

magnesium sulfate inj 20gm/500ml 2





magnesium sulfate inj 50% 2

MAGNESIUM SULFATE/D5W 5% IV SOLN 2

magnesium sulfate/d5w inj 2

PHOSPHATE

K-PHOS NEUTRAL TAB 3*

K-PHOS TAB 2*

phospha 250 neutral tab 1*

POTASSIUM

K-TAB 20MEQ 1

K-TAB ER TAB 8MEQ 1

K-TABS CR TAB 10MEQ 3

klor-con M10 ER tab 10meq 1

KLOR-CON M15 ER TAB 15MEQ 2


KLOR-CON POWDER PACKET 3*

potassium bicarbonate effer tab 1*

potassium chloride effer tab 1*

POTASSIUM CHLORIDE EFFER TAB 1*

potassium chloride ER cap 10meq 1

potassium chloride ER cap 8meq 1

potassium chloride ER tab 10meq 1

potassium chloride er tab 20meq 1

POTASSIUM CHLORIDE ER TAB 20MEQ 1

potassium chloride ER tab 8meq 1

POTASSIUM CHLORIDE INJ 10MEQ 2

potassium chloride inj 10meq/100ml 2

POTASSIUM CHLORIDE INJ 10MEQ/50ML 2


POTASSIUM CHLORIDE INJ 20MEQ/100ML 2

potassium chloride inj 20meq/100ml 2

potassium chloride inj 2meq/ml 2





134

potassium chloride oral soln 10% 2

potassium chloride oral soln 20% 2

potassium chloride powder 20meq 2

SODIUM

sodium chloride inj 0.45% 2


sodium chloride inj 2.5meq/ml 2


sodium chloride inj 3% 2


ZINC

GALZIN CAP 2*

zinc sulfate cap 1*

MISCELLANEOUS THERAPEUTIC CLASSES

CHELATING AGENTS

D-PENAMINE TAB 125MG 2

DEPEN TITRA TAB 250MG 2

penicillamine tab 250mg 2

SYPRINE CAP 250MG 3 PA

trientine cap 250mg 2 PA

IMMUNOSUPPRESSIVE AGENTS


everolimus tab 0.25mg 2 PA_BvD



PROGRAF GRANULES PACKET 0.2MG 3 PA_BvD

PROGRAF GRANULES PACKET 1MG 3 PA_BvD

RAPAMUNE ORAL SOLN 1MG/ML 3 PA_BvD

sirolimus oral soln 1mg/ml 2 PA_BvD

ZORTRESS 1MG TAB 2 PA_BvD

ZORTRESS TAB 0.25MG 2 PA_BvD



POTASSIUM REMOVING AGENTS

LOKELMA PACKET 10GM 2 PA

LOKELMA PACKET 5GM 2 PA

SYSTEMIC LUPUS ERYTHEMATOSUS AGENTS

BENLYSTA AUTO-INJECTOR 200MG/ML 2 NDS PA QL=4 Quantity/28 Days

BENLYSTA INJ 200MG/ML 2 NDS PA QL=4 Quantity/28 Days

MOUTH/THROAT/DENTAL AGENTS

ANESTHETICS TOPICAL ORAL

FIRST MOUTHWASH BLM SUSP 3*




135

LIDOCAINE ORAL SOLN 4% 1

lidocaine viscous soln 2% 1

ANTI-INFECTIVES - THROAT

clotrimazole troche 10mg 1

nystatin susp 100000unit/ml 1

ORAVIG TAB 50MG 3

ANTISEPTICS - MOUTH/THROAT

PERIDEX SOLN 3*

periogard soln 0.12% 1

DENTAL PRODUCTS

PREVIDENT 5000 BOOSTER PASTE 2*

PREVIDENT 5000 DRY MOUTH GEL 2*

PREVIDENT 5000 PASTE 2*

PREVIDENT 5000 PLUS CREAM $0*

PREVIDENT RINSE 2*

sodium fluoride cream $0*

sodium fluoride gel 1*

sodium fluoride paste 1*

sodium fluoride rinse 1*

sodium fluoride/potassium nitrate paste 1*

STEROIDS - MOUTH/THROAT

triamcinolone/oragel paste 0.1% 1

THROAT PRODUCTS - MISC.

cevimeline cap 30mg 2

EVOXAC CAP 30MG 3

pilocarpine tab 5mg 1

pilocarpine tab 7.5mg 1

SALAGEN TAB 5MG 3

SALAGEN TAB 7.5MG 3

MULTIVITAMINS

B-COMPLEX W/ FOLIC ACID

DIALYVITE TAB 1*

dialyvite tab 1*

DIALYVITE/ZINC TAB 1*

FOLBEE PLUS CZ TAB 1*

NEPHRO CAP 3*

NEPHRO-VITE TAB 3*

renaphro cap 1*

MULTIPLE VITAMINS W/ MINERALS

multivitamin/minerals tab 1*

STROVITE TAB 3*

V-C FORTE CAP 3*




136

PED MULTI VITAMINS W/FL & FE

ESCAVITE CHEW TAB 3*

pediatric multiple vitamins/fluoride/iron soln 1*

PED MV W/ FLUORIDE

FLORIVA PLUS DROPS 2*

pediatric multiple vitamins/fluoride chew tab 1*

pediatric multiple vitamins/fluoride soln 1*

QUFLORA PEDIATRIC CHEW TAB 3*

MUSCULOSKELETAL THERAPY AGENTS

CENTRAL MUSCLE RELAXANTS

baclofen tab 10mg 1

baclofen tab 20mg 1

carisoprodol tab 350mg 1

chlorzoxazone tab 500mg 1

cyclobenzaprine tab 10mg 1


cyclobenzaprine tab 7.5mg 2

FEXMID TAB 7.5MG 3

metaxalone tab 400mg 3

METAXALONE TAB 400MG 3


methocarbamol tab 500mg 1


orphenadrine ER tab 100mg 1

SKELAXIN TAB 800MG 3

SOMA TAB 350MG 3

tizanidine cap 2mg 2



tizanidine tab 2mg 1


ZANAFLEX CAP 2MG 3

ZANAFLEX CAP 4MG 3

ZANAFLEX CAP 6MG 3

ZANAFLEX TAB 4MG 3

DIRECT MUSCLE RELAXANTS

DANTRIUM CAP 100MG 3

DANTRIUM CAP 25MG 3

DANTRIUM CAP 50MG 3

dantrolene cap 100mg 2






137

NASAL AGENTS - SYSTEMIC AND TOPICAL

NASAL ANTI-INFECTIVES

BACTROBAN NASAL OINTMENT 2% 3

NASAL ANTIALLERGY

ASTEPRO NASAL SPRAY 0.15% 3

azelastine nasal spray 0.1% (137mcg) 1

azelastine nasal spray 0.15% (205.5mcg) 2

olopatadine nasal spray 0.6% 2

PATANASE NASAL SPRAY 0.6% 3

NASAL ANTICHOLINERGICS

ipratropium nasal spray 0.03% 1

ipratropium nasal spray 0.06% 1

NASAL STEROIDS

FLUNISOLIDE NASAL SPRAY 0.025% 2

fluticasone nasal spray 50mcg 1

NASACORT NASAL SPRAY (OTC) 1* QL=2 Quantity/15 Days

triamcinolone nasal spray (OTC) 1* QL=2 Quantity/15 Days

NEUROMUSCULAR AGENTS

ALS AGENTS

RILUTEK TAB 50MG 3 NDS

riluzole tab 50mg 2

NUTRIENTS

CARBOHYDRATES

dextrose inj 10% 2 PA_BvD

dextrose inj 5% 2

LIPIDS

INTRALIPID INJ 20% 2 PA_BvD

INTRALIPID INJ 30% 3 PA_BvD

PROTEINS

AMINOSYN II INJ 10% 3 PA_BvD



CLINIMIX E INJ 2.75%/D10W 2 PA_BvD




CLINIMIX E INJ 5%/D15W 2 PA_BvD

CLINIMIX E INJ 5%/D20W 2 PA_BvD

CLINIMIX INJ 4.25%/D10W 2 PA_BvD



CLINIMIX INJ 5%/D15W 2 PA_BvD




138

CLINIMIX INJ 5%/D20W 2 PA_BvD

FREAMINE HBC INJ 6.9% 3 PA_BvD

HEPATAMINE SOLN 8% 2 PA_BvD

NEPHRAMINE INJ 5.4% 3 PA_BvD

novamine inj 15% 2 PA_BvD

premasol inj 6% 2 PA_BvD

PROCALAMINE INJ 3% 3 PA_BvD

PROSOL INJ 20% 3 PA_BvD

TROPHAMINE INJ 6% 3 PA_BvD

OPHTHALMIC AGENTS

ARTIFICIAL TEARS AND LUBRICANTS

LACRISERT OPHTH INSERT 2

BETA-BLOCKERS - OPHTHALMIC

BETAGAN OPHTH SOLN 0.5% 3

betaxolol ophth soln 0.5% 1

BETIMOL OPHTH SOLN 0.25% 2

BETIMOL OPHTH SOLN 0.5% 2

BETOPTIC-S OPHTH SUSP 0.25% 2

CARTEOLOL OPHTH SOLN 1% 1

COMBIGAN OPHTH SOLN 0.2-0.5% 2

COSOPT OPHTH SOLN 22.3-6.8MG/ML 3

COSOPT PF OPHTH SOLN 22.3-6.8MG/ML 3

dorzolamide/timolol ophth soln 22.3-6.8mg/ml 1

dorzolamide/timolol PF ophth soln 22.3-6.8mg.ml 1

ISTALOL OPHTH SOLN 0.5% 3

levobunolol ophth soln 0.5% 1

LEVOBUNOLOL OPHTH SOLN 0.5% 1

TIMOLOL MALEATE OPHTH GEL 0.5% 2

timolol maleate ophth soln 0.25% 1

timolol maleate ophth soln 0.5% 1

timolol maleate ophth soln 0.5% (24hr) 2

TIMOPTIC OCUDOSE OPHTH SOLN 0.25% 3

TIMOPTIC OCUDOSE OPHTH SOLN 0.5% 3

TIMOPTIC OPHTH SOLN 0.25% 3

TIMOPTIC OPHTH SOLN 0.5% 3

TIMOPTIC-XE OPHTH SOLN 0.25% 2

CYCLOPLEGIC MYDRIATICS

ATROPINE SULFATE OPHTH SOLN 1% 1

HOMATROPINE OPHTH SOLN 1*

homatropine ophth soln 1*

MIOTICS

ISOPTO CARBACHOL OPHTH SOLN 2*




139

ISOPTO CARPINE OPHTH SOLN 1% 3



PHOSPHOLINE OPHTH SOLN 0.125% 2

pilocarpine ophth soln 1% 1



OPHTHALMIC ADRENERGIC AGENTS

ALPHAGAN P OPHTH SOLN 0.1% 2

ALPHAGAN P OPHTH SOLN 0.15% 3

apraclonidine ophth soln 0.5% 2

brimonidine ophth soln 0.15% 2

brimonidine ophth soln 0.2% 1

IOPIDINE OPHTH SOLN 1% 2

SIMBRINZA OPHTH SUSP 1-0.2% 2

OPHTHALMIC ANTI-INFECTIVES

AZASITE OPHTH SOLN 1% 2

BACITRACIN OPHTH OINTMENT 500UNIT/GM 2

bacitracin/neomycin/polymyxin B ophth ointment 1

bacitracin/polymyxin B ophth ointment 1

BLEPH-10 OPHTH SOLN 10% 3

CILOXAN OPHTH OINTMENT 0.3% 3

CILOXAN OPHTH SOLN 0.3% 3

ciprofloxacin ophth soln 0.3% 1

erythromycin ophth ointment 5mg/gm 1

gatifloxacin ophth soln 0.5% 2

GENTAK OPHTH OINTMENT 0.3% 1

gentamicin ophth soln 0.3% 1

levofloxacin ophth soln 0.5% 1

moxifloxacin 0.5% ophth soln 1

moxifloxacin ophth soln 0.5% 1

NATACYN OPHTH SUSP 5% 2

NEOMYCIN/GRAMICIDIN/POLYMYXIN B OPHTH

SOLN 1.75-10000UNIT-0.025MG/ML

1

NEOSPORIN OPHTH SOLN

1.75-10000UNIT-0.025MG/ML

3

OCUFLOX OPHTH SOLN 0.3% 3

ofloxacin ophth soln 0.3% 1

polymyxin B/trimethoprim ophth soln 10000unit/ml-0.1% 1

POLYTRIM OPHTH SOLN 10000UNIT/ML-0.1% 3

SULFACETAMIDE SODIUM OPHTH OINTMENT

10%

2




140

sulfacetamide sodium ophth soln 10% 1

tobramycin ophth soln 0.3% 1

TOBREX OPHTH OINTMENT 0.3% 3

TOBREX OPHTH SOLN 0.3% 3

TRIFLURIDINE OPHTH SOLN 1% 2

VIGAMOX OPHTH SOLN 0.5% 3

ZIRGAN OPHTH GEL 0.15% 2

ZYMAXID OPHTH SOLN 0.5% 3

OPHTHALMIC IMMUNOMODULATORS

RESTASIS OPHTH EMULSION 0.05% 2

OPHTHALMIC LOCAL ANESTHETICS

ALCAINE OPHTH SOLN 0.5% 3

proparacaine ophth soln 0.5% 1

OPHTHALMIC NERVE GROWTH FACTORS

OXERVATE OPHTH SOLN 0.002% 2 NDS PA QL=112 Quantity/365 Days

OPHTHALMIC STEROIDS

ALREX OPHTH SUSP 0.2% 2

bacitracin/polymyxin/neomcyin/hydrocortisone ophthointment 1%

1

BLEPHAMIDE OPHTH SUSP 10-0.2% 2

BLEPHAMIDE S.O.P OPHTH OINTMENT 10-0.2% 3

DEXAMETHASONE SODIUM PHOSPHATE OPHTH

SOLN 0.1%

1

DUREZOL OPHTH EMULSION 0.05% 2

FLAREX OPHTH SUSP 0.1% 3

fluorometholone ophth susp 0.1% 1

FML FORTE OPHTH SUSP 0.25% 3

FML LIQUIFLM OPHTH SUSP 0.1% 3

FML OPHTH OINTMENT 0.1% 3

LOTEMAX OPHTH GEL 0.5% 2

LOTEMAX OPHTH OINTMENT 0.5% 2

LOTEMAX OPHTH SUSP 0.5% 2

loteprednol ophth susp 0.5% 2

MAXIDEX OPHTH SUSP 0.1% 2

MAXITROL OPHTH OINTMENT 0.1% 3

MAXITROL OPHTH SUSP 0.1% 3

neomycin/polymyxin/dexamethasone ophth ointment0.1%

1

neomycin/polymyxin/dexamethasone ophth susp 0.1% 1

NEOMYCIN/POLYMYXIN/HYDROCORTISONE

OPHTH SUSP 3.5-10000UNIT-10MG/ML

1

PRED FORTE OPHTH SUSP 1% 3




141

PRED MILD OPHTH SUSP 0.12% 2

PRED-G OPHTH SUSP 0.3-1% 2

PRED-G S.O.P OPHTH OINTMENT 0.3-0.6% 3

PREDNISOLONE OPHTH SUSP 1% 2

PREDNISOLONE SODIUM PHOSPHATE OPHTH

SOLN 1%

2

SULFACETAMIDE/PREDNISOLONE OPHTH SOLN

10-0.25%

1

TOBRADEX OPHTH OINTMENT 0.3-0.1% 2

TOBRADEX OPHTH SUSP 0.3-0.1% 3

TOBRADEX ST OPHTH SUSP 0.3-0.05% 3

tobramycin/dexamethasone ophth susp 0.3-0.1% 1

ZYLET OPHTH SUSP 0.5-0.3% 2

OPHTHALMICS - MISC.

ACULAR LS OPHTH SOLN 0.4% 3

ACULAR OPHTH SOLN 0.5% 3

ACUVAIL OPHTH SOLN 0.45% 3

ALOCRIL OPHTH SOLN 2% 2

ALOMIDE OPHTH SOLN 0.1% 2

azelastine ophth soln 0.05% 1

AZOPT OPHTH SUSP 1% 2

BEPREVE OPHTH SOLN 1.5% 3

bromfenac ophth soln (once daily) 0.09% 2

cromolyn sodium ophth soln 4% 1

CYSTARAN OPHTH SOLN 0.44% 2 NDS PA

diclofenac ophth soln 0.1% 1

dorzolamide ophth soln 2% 1

epinastine ophth soln 0.05% 2

flurbiprofen ophth soln 0.03% 1

FLURBIPROFEN OPHTH SOLN 0.03% 1

ILEVRO OPHTH SUSP 0.3% 2

ketorolac ophth soln 0.4% 1


ketotifen ophth soln 1*

LASTACAFT OPHTH SOLN 0.25% 3

NEVANAC OPHTH SUSP 0.1% 2

olopatadine ophth soln 0.1% 1


PATADAY OPHTH SOLN 0.2% 3

PATANOL OPHTH SOLN 0.1% 3

PROLENSA OPHTH SOLN 0.07% 2

TRUSOPT OPHTH SOLN 2% 3




142

PROSTAGLANDINS - OPHTHALMIC

bimatoprost ophth soln 0.03% 2

latanoprost ophth soln 0.005% 1

LUMIGAN OPHTH SOLN 0.01% 2

TRAVATAN Z OPHTH SOLN 0.004% 2

travoprost ophth soln 0.004% 2

XALATAN OPHTH SOLN 0.005% 3

ZIOPTAN OPHTH SOLN 0.0015% 3 ST

OTIC AGENTS

OTIC AGENTS - MISCELLANEOUS

acetic acid otic soln 2% 1

OTIC ANTI-INFECTIVES

CIPROFLOXACIN OTIC SOLN 0.2% 2

ofloxacin otic soln 0.3% 2

OTIC COMBINATIONS

CIPRO HC OTIC SUSP 0.2-1% 3

CIPRODEX OTIC SUSP 0.3-0.1% 2

neomycin/polymyxin/hydrocortisone otic soln 1% 1

neomycin/polymyxin/hydrocortisone otic susp3.5-10000unit-1%

1

OTIC STEROIDS

acetic acid/hydrocortisone otic soln 1-2% 1

fluocinolone otic oil 0.01% 2

OXYTOCICS

OXYTOCICS

methylergonovine tab 0.2mg 2

PASSIVE IMMUNIZING AGENTS

IMMUNE SERUMS

CARIMUNE INJ 6GM 3 NDS PA

FLEBOGAMMA INJ 0.5GM/10ML 3 NDS PA

FLEBOGAMMA INJ 20GM/200ML 3 NDS PA

GAMMAGARD INJ 10GM 3 NDS PA

GAMMAGARD INJ 10GM/100ML 3 NDS PA


GAMMAGARD INJ 2.5GM/25ML 3 NDS PA



GAMMAGARD INJ 5GM 3 NDS PA


GAMMAPLEX INJ 10GM/100ML 3 NDS PA






143


GAMUNEX-C INJ 40GM/400ML 3 NDS PA

HIZENTRA INJ 10GM/50ML 2 NDS PA_BvD




OCTAGAM INJ 1GM/20ML 3 NDS PA

OCTAGAM INJ 2.5GM/50ML 3 NDS PA




PRIVIGEN INJ 40GM/400ML 3 NDS PA

PASSIVE IMMUNIZING AND TREATMENT AGENTS

IMMUNE SERUMS

CUVITRU INJ 8GM/40ML 2 NDS PA_BvD

HYPERRAB INJ 1500UNIT/10ML 3 PA_BvD



HYPERRAB INJ 300UNIT/ML 3 PA_BvD



PANZYGA IV SOLN 10GM/100ML 3 NDS PA


PANZYGA IV SOLN 2.5GM/25ML 3 NDS PA




VARIZIG 124.8/1.2ML INJ 3 NDS

PENICILLINS

AMINOPENICILLINS

amoxicillin cap 250mg 1


AMOXICILLIN CHEW TAB 125MG 1

AMOXICILLIN CHEW TAB 250MG 1

amoxicillin susp 125mg/5ml 1




amoxicillin tab 500mg 1


AMPICILLIN CAP 500MG 1

ampicillin inj 10gm 2




144


ampicillin inj 250mg 2



AMPICILLIN SODIUM INJ 125MG 2

AMPICILLIN SODIUM INJ 1GM 2

NATURAL PENICILLINS

BICILLIN L-A INJ 600000 UNIT/ML 2

BICILLIN L-A INJ 1200000 UNIT/2ML 2

BICILLIN L-A INJ 2400000 UNIT/4ML 2

PENICILLIN G PROCAINE INJ 600000 UNIT/ML 2

PENICILLIN G SODIUM INJ 5000000UNIT 2

penicillin gk inj 20000000unit 2


PENICILLIN GK/DEXTROSE INJ 40000UNIT/ML 2

PENICILLIN GK/DEXTROSE INJ 60000UNIT/ML 2

PENICILLIN VK SOLN 125MG/5ML 1

PENICILLIN VK SOLN 250MG/5ML 1

penicillin vk tab 250mg 1


PENICILLIN COMBINATIONS

AMOXICILLIN/K CLAVULANATE ER TAB

1000-62.5 MG

3

amoxicillin/k clavulanate ER tab 1000-62.5mg 3

amoxicillin/k clavulanate susp 200-28.5mg/5ml 1


amoxicillin/k clavulanate susp 400-57mg/5ml 1


amoxicillin/k clavulanate tab 250-125mg 1



AMPICILLIN/SULBACTAM INJ 1.5GM 2

ampicillin/sulbactam inj 1.5gm 2

ampicillin/sulbactam inj 15gm 2

ampicillin/sulbactam inj 3gm 2

AMPICILLIN/SULBACTAM INJ 3GM 2

AUGMENTIN CHEW TAB 200-28.5MG 1

AUGMENTIN CHEW TAB 400-57MG 1

AUGMENTIN SUSP 125-31.25MG/5ML 3

BICILLIN C-R INJ 1200000UNIT/2ML 2

BICILLIN C-R INJ 900000-300000UNIT/2ML 2

piperacillin/tazobactam inj 12-1.5gm 2




145





UNASYN INJ 15GM 3

UNASYN INJ 3GM 3

ZOSYN INJ 2-0.25GM 3



ZOSYN INJ 4-0.5GM 3

ZOSYN/DEXTROSE INJ 2-0.25GM/50ML 3



PENICILLINASE-RESISTANT PENICILLINS

BACTOCILL/DEXTROSE INJ 1GM/50ML 2

BACTOCILL/DEXTROSE INJ 2GM/50ML 2

dicloxacillin cap 250mg 1


nafcillin inj 10gm 2

nafcillin inj 1gm 2

NAFCILLIN INJ 1GM 2

NAFCILLIN INJ 2GM 2

nafcillin inj 2gm 2

NAFCILLIN INJ 10GM 2

oxacillin inj 10gm 2

oxacillin inj 1gm 2

oxacillin inj 2gm 2

PHARMACEUTICAL ADJUVANTS

SEMI SOLID VEHICLES

POLYETHYLENE GLYCOL 8000 GRANULES 2*

PROGESTINS

PROGESTINS

AYGESTIN TAB 5MG 3

medroxyprogesterone acetate tab 10mg 1

medroxyprogesterone acetate tab 2.5mg 1

medroxyprogesterone acetate tab 5mg 1

MEGACE ES SUSP 625MG/5ML 3 PA

megestrol ES susp 325mg/5ml 2 PA

norethindrone acetate tab 5mg 1

progesterone cap 100mg 2


PROMETRIUM CAP 100MG 3




146

PROMETRIUM CAP 200MG 3

PROVERA TAB 10MG 3

PROVERA TAB 2.5MG 3

PROVERA TAB 5MG 3

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.

AGENTS FOR CHEMICAL DEPENDENCY

acamprosate calcium tab 333mg 2

ANTABUSE TAB 250MG 3


disulfiram tab 250mg 1


LUCEMYRA TAB 0.18MG 3 PA

ANTI-CATAPLECTIC AGENTS

XYREM SOLN 500MG/ML 2 NDS PA QL=540 Quantity/30 Days

ANTIDEMENTIA AGENTS

ARICEPT TAB 10MG 3

ARICEPT TAB 23MG 3 QL=30 Quantity/30 Days

ARICEPT TAB 5MG 3

donepezil ODT 10mg 1 QL=30 Quantity/30 Days

donepezil ODT 5mg 1

donepezil tab 10mg 1

donepezil tab 23mg 2 QL=30 Quantity/30 Days

donepezil tab 5mg 1

EXELON PATCH 13.3MG 3



galantamine ER cap 16mg 2



GALANTAMINE ORAL SOLN 4MG/ML 2

galantamine tab 12mg 1 RXC



memantine ER cap 14mg 2




memantine oral soln 2mg/ml 2

memantine tab 10mg 1

memantine tab 5mg 1

memantine tab titration pack 5mg/10mg 1

NAMENDA TAB 10MG 3




147

NAMENDA TAB 5MG 3

NAMENDA TAB TITRATION PACK 3

NAMENDA XR CAP 14MG 3




NAMENDA XR CAP TITRATION PACK 2

RAZADYNE ER CAP 16MG 3



RAZADYNE TAB 12MG 3

RAZADYNE TAB 4MG 3

RAZADYNE TAB 8MG 3

rivastigmine cap 1.5mg 1

rivastigmine cap 3mg 1



rivastigmine patch 13.3mg 2



COMBINATION PSYCHOTHERAPEUTICS

CHLORDIAZEPOXIDE/AMITRIPTYLINE TAB

10-25MG

1

CHLORDIAZEPOXIDE/AMITRIPTYLINE TAB

5-12.5MG

1

olanzapine/fluoxetine cap 12-25mg 2





PERPHENAZINE/AMITRIPTYLINE TAB 2-10MG 1





SYMBYAX CAP 12-25MG 3





FIBROMYALGIA AGENTS

SAVELLA TAB 100MG 2 QL=60 Quantity/30 Days




148

SAVELLA TAB 12.5MG 2

SAVELLA TAB 25MG 2

SAVELLA TAB 50MG 2

SAVELLA TAB TITRATION PACK 2

MOVEMENT DISORDER DRUG THERAPY

AUSTEDO TAB 12MG 2 NDS PA



INGREZZA CAP 40MG 2 NDS PA

INGREZZA CAP 80MG 2 NDS PA

tetrabenazine tab 12.5mg 2 NDS PA

tetrabenazine tab 25mg 2 NDS PA

MULTIPLE SCLEROSIS AGENTS

AUBAGIO TAB 14MG 2 NDS

AUBAGIO TAB 7MG 2 NDS

AVONEX AUTO-INJECTOR KIT 30MCG/0.5ML 2 NDS

AVONEX PREFILLED INJ KIT 30MCG/0.5ML 2 NDS

COPAXONE INJ 20MG/ML 3 NDS

COPAXONE INJ 40MG/ML 3 NDS

dalfampridine ER tab 10mg 1 PA QL=60 Quantity/30 Days

EXTAVIA INJ 0.3MG 3 NDS

GILENYA CAP 0.25MG 2 NDS

GILENYA CAP 0.5MG 2 NDS

glatiramer inj, glatopa inj 20mg/ml 2 NDS

glatiramer inj, glatopa inj 40mg/ml 2 NDS

MAYZENT TAB 0.25MG 2 NDS

MAYZENT TAB 2MG 2 NDS

PLEGRIDY INJ 125MCG/0.5ML 2 NDS

PLEGRIDY INJ STARTER PACK 2 NDS

PLEGRIDY PEN INJECTOR 125MCG/0.5ML 2 NDS

PLEGRIDY PEN STARTER PACK 2 NDS

REBIF AUTO-INJECTOR 22MCG/0.5ML 2 NDS

REBIF AUTO-INJECTOR 44MCG/0.5ML 2 NDS

REBIF INJ 22MCG/0.5ML 2 NDS

REBIF INJ 44MCG/0.5ML 2 NDS

REBIF INJ TITRATION PACK 2 NDS

REBIF REBIDOSE PACK 2 NDS

TECFIDERA CAP 120MG 2 NDS

TECFIDERA CAP 240MG 2 NDS

TECFIDERA CAP STARTER PACK 2 NDS

PREMENSTRUAL DYSPHORIC DISORDER (PMDD) AGENTS

fluoxetine tab (PMDD) 10mg 1




149

fluoxetine tab (PMDD) 20mg 1

PSEUDOBULBAR AFFECT (PBA) AGENTS

NUEDEXTA CAP 20-10MG 2 PA QL=60 Quantity/30 Days

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.

ERGOLOID MESYLATES TAB 1MG 3

PIMOZIDE TAB 1MG 2

PIMOZIDE TAB 2MG 2

SMOKING DETERRENTS

buproban tab 150mg $0

CHANTIX PAK 0.5MG/1MG $0

CHANTIX TAB 0.5MG $0

CHANTIX TAB 1MG $0

COMMIT LOZENGE $0*

NICORETTE CQ PATCH $0*

NICORETTE GUM $0*

nicotine gum $0*

nicotine lozenge $0*

nicotine patch $0*

NICOTINE PATCH KIT $0*

NICOTROL INHALER 10MG $0

NICOTROL NASAL SPRAY 10MG/ML $0

TRANSTHYRETIN AMYLOIDOSIS AGENTS

TEGSEDI SYRINGE 189MG/ML 2 NDS PA QL=4 Quantity/28 Days

RESPIRATORY AGENTS - MISC.

ALPHA-PROTEINASE INHIBITOR (HUMAN)

ARALAST NP INJ 500MG 3 NDS

GLASSIA INJ 1000MG 3 NDS

PROLASTIN-C INJ 1000MG 3 NDS

CYSTIC FIBROSIS AGENTS

KALYDECO PACKET 25MG 2 NDS PA



KALYDECO TAB 150MG 2 NDS PA

ORKAMBI PACKET 100-125MG 2 NDS PA

ORKAMBI PACKET 150-188MG 2 NDS PA

ORKAMBI TAB 100-125MG 2 NDS PA

ORKAMBI TAB 200-125MG 2 NDS PA

PULMOZYME INHALATION SOLN 1MG/ML 2 NDS PA_BvD

SYMDEKO TAB 4-WEEK PACK 2 NDS PA

TRIKAFTA PACK 100-50-75MG/150MG 2 NDS PA QL=90 Quantity/30 Days

PULMONARY FIBROSIS AGENTS

ESBRIET CAP 267MG 2 NDS PA




150

ESBRIET TAB 267MG 2 NDS PA

ESBRIET TAB 801MG 2 NDS PA

OFEV CAP 100MG 2 NDS PA

OFEV CAP 150MG 2 NDS PA

SULFONAMIDES

SULFONAMIDES

SULFADIAZINE TAB 500MG 1

TETRACYCLINES

AMINOMETHYLCYCLINES

NUZYRA TAB 150MG 3 NDS PA QL=30 Quantity/14 Days

GLYCYLCYCLINES

TIGECYCLINE INJ 50MG 3 NDS

tigecycline inj 50mg 3 NDS

TYGACIL INJ 50MG 3 NDS

TETRACYCLINES

demeclocycline tab 150mg 2


doxycycline hyclate cap 100mg 1

doxycycline hyclate cap 50mg 1

doxycycline hyclate inj 100mg 2

doxycycline hyclate tab 100mg 1

doxycycline hyclate tab 20mg 1

doxycycline monohydrate cap 100mg 1

doxycycline monohydrate cap 50mg 1

doxycycline monohydrate susp 25mg/5ml 2

doxycycline monohydrate tab 100mg 1



MINOCIN CAP 100MG 3

MINOCIN CAP 50MG 3

MINOCIN INJ 100MG 3

minocycline cap 100mg 1



minocycline tab 100mg 2



tetracycline cap 250mg 3


VIBRAMYCIN CAP 100MG 3

VIBRAMYCIN SUSP 25MG/5ML 3

VIBRAMYCIN SYRUP 50MG/5ML 3




151

THYROID AGENTS

ANTITHYROID AGENTS

methimazole tab 10mg 1


propylthiouracil tab 50mg 1

TAPAZOLE TAB 10MG 3

TAPAZOLE TAB 5MG 3

THYROID HORMONES

ARMOUR THYROID TAB 1*

CYTOMEL TAB 25MCG 3

CYTOMEL TAB 50MCG 3

CYTOMEL TAB 5MCG 3

levothyroxine tab 100mcg 1












liothyronine tab 25mcg 1



SYNTHROID TAB 100MCG 3












thyroid tab 1*

THYROLAR TAB 120MG 2

THYROLAR TAB 15MG 2




152


THYROLAR TAB 30MG 2

THYROLAR TAB 60MG 2

TOXOIDS

TOXOID COMBINATIONS

ADACEL INJ $0

BOOSTRIX INJ $0

DAPTACEL INJ $0

DIPHTHERIA/TETANUS PED VACCINE INJ $0 PA_BvD

INFANRIX INJ $0

PEDIARIX INJ $0

PENTACEL INJ $0

QUADRACEL INJ $0

TENIVAC INJ $0 PA_BvD

TETANUS/DIPHTHERIA TOXOID INJ $0 PA_BvD

ULCER DRUGS

ANTISPASMODICS

ANASPAZ TAB 3*

BELLADONNA ALKALOID/OPIUM SUPP 2*

BENTYL INJ 10MG/ML 3

BENTYL TAB 20MG 3

chlordiazepoxide/clidinium cap 2*

CUVPOSA ORAL SOLN 1MG/5ML 3

dicyclomine cap 10mg 1

dicyclomine inj 10mg/ml 2

dicyclomine oral soln 10mg/5ml 2

dicyclomine tab 20mg 1

DONNATAL ELIXIR 3*

glycopyrrolate tab 1mg 2


hyoscyamine sulfate CR tab 1*

hyoscyamine sulfate elixir 1*

hyoscyamine sulfate ODT 1*

hyoscyamine sulfate SL tab 1*

hyoscyamine sulfate soln 1*

hyoscyamine sulfate tab 1*

LEVBID TAB 3*

LEVSIN SL TAB 3*

LEVSIN TAB 3*

LIBRAX CAP 3*

methscopolamine tab 2.5mg 2

methscopolamine tab 5mg 2




153

pb-belladonna elixir 3*

ROBINUL FORTE TAB 2MG 3

ROBINUL TAB 1MG 3

SYMAX DUOTAB 3*

H-2 ANTAGONISTS

CIMETIDINE ORAL SOLN 300MG/5ML 1

cimetidine tab 200mg 1




famotidine susp 40mg/5ml 2

famotidine tab 20mg 1


nizatidine cap 150mg 1


NIZATIDINE ORAL SOLN 15MG/ML 3

PEPCID SUSP 40MG/5ML 3

PEPCID TAB 20MG 3

PEPCID TAB 40MG 3

ranitidine cap 150mg 1


ranitidine syrup 15mg/ml 1

ranitidine tab 150mg 1


ZANTAC TAB 300MG 3

MISC. ANTI-ULCER

CARAFATE TAB 1GM 3

sucralfate tab 1gm 1

PROTON PUMP INHIBITORS

ACIPHEX TAB 20MG 3

esomeprazole DR cap (rx only) 20mg 2

esomeprazole DR cap (rx only) 40mg 2

FIRST OMEPRAZOLE SUSP 3*

lansoprazole DR cap 15mg 2


LANSOPRAZOLE SUSP 3*

NEXIUM DR CAP 20MG (RX ONLY) 3

NEXIUM DR CAP 40MG (RX ONLY) 3

omeprazole cap 10mg 1



pantoprazole tab 20mg 1




154


PREVACID DR CAP 15MG 3


PROTONIX TAB 20MG 3

PROTONIX TAB 40MG 3

rabeprazole tab 20mg 2

ULCER DRUGS - PROSTAGLANDINS

CYTOTEC TAB 100MCG 3


misoprostol tab 100mcg 1


ULCER THERAPY COMBINATIONS

lansoprazole/amoxicillin/clarithromycin pack500-500-30mg

2

PREVPAC CAP THERAPY PACK 500-500-30MG 3

PYLERA CAP 140-125-125MG 3

ZEGERID CAP (OTC) 1*

ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS

ANTISPASMODICS

hyoscyamine inj 3*

LEVSIN INJ 3*

H-2 ANTAGONISTS

NIZATIDINE CAP 150MG 1

MISC. ANTI-ULCER

CARAFATE SUSP 1GM/10ML 2

sucralfate susp 1gm/10ml 2

PROTON PUMP INHIBITORS

lansoprazole ODT 15mg 2


URINARY ANTI-INFECTIVES

URINARY ANTI-INFECTIVE COMBINATIONS

UROQID #2 TAB 3*

URINARY ANTI-INFECTIVES

FURADANTIN SUSP 25MG/5ML 2

HIPREX TAB 1GM 3

MACROBID CAP 100MG 3

MACRODANTIN CAP 100MG 3



methenamine hippurate tab 1gm 2

methenamine mandelate tab 1*

MONUROL PACKET 3GM 3




155

nitrofurantoin cap 100mg 1

nitrofurantoin macro cap 100mg 1



nitrofurantoin susp 25mg/5ml 2

URINARY ANTISPASMODICS

BETA-3 ADRENERGIC AGONISTS

MYRBETRIQ TAB 25MG 2


URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLIN) (NEW)

DETROL TAB 1MG 3

DETROL TAB 2MG 3

DITROPAN XL TAB 10MG 3



oxybutynin ER tab 10mg 1



oxybutynin syrup 5mg/5ml 1

oxybutynin tab 5mg 1

tolterodine tab 1mg 2 RXC

tolterodine tab 2mg 2 RXC

trospium chloride SR cap 60mg 2

trospium tab 20mg 2

URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)

darifenacin SR tab 15mg 2

darifenacin SR tab 7.5mg 2

DETROL LA CAP 2MG 3

DETROL LA CAP 4MG 3

ENABLEX ER TAB 15MG 3

ENABLEX ER TAB 7.5MG 3

solifenacin succinate tab 10mg 1

solifenacin succinate tab 5mg 1

tolterodine ER cap 2mg 2


URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS (NEW)

bethanechol tab 10mg 1




URECHOLINE TAB 10MG 3





156



URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS

flavoxate tab 100mg 2

VACCINES

BACTERIAL VACCINES

ACTHIB INJ $0

BCG VACCINE INJ $0

BEXSERO INJ $0

HIBERIX INJ $0

MENACTRA INJ $0

MENVEO INJ $0

PEDVAX HIB INJ $0

TRUMENBA INJ $0

TYPHIM VI INJ $0

VIVOTIF BERNA CAP $0* QL=4 Quantity/ Per Dispensing

VIRAL VACCINES

ENGERIX-B INJ $0 PA_BvD

GARDASIL INJ $0

HAVRIX INJ 1440 EL UNIT/ML $0

HAVRIX INJ 720 EL UNIT/0.5ML $0

IMOVAX RABIES INJ $0 PA_BvD

IPOL INJ $0

IXIARO INJ $0

M-M-R II INJ $0

PROQUAD INJ $0

RABAVERT INJ $0 PA_BvD

RECOMBIVAX-HB INJ $0 PA_BvD

ROTARIX SUSP $0

ROTATEQ SOLN $0

SHINGRIX INJ $0

TWINRIX INJ $0

VAQTA INJ 25UNIT/0.5ML $0

VAQTA INJ 50 UNIT/ML $0

VARIVAX INJ $0

YF-VAX INJ $0

ZOSTAVAX INJ $0

VAGINAL PRODUCTS

MISCELLANEOUS VAGINAL PRODUCTS

FEM PH GEL 3*

SPERMICIDES

CONTRACEPTIVE FILM $0*




157

CONTRACEPTIVE FOAM $0*

CONTRACEPTIVE GEL $0*

contraceptive gel $0*

CONTRACEPTIVE SPONGE $0*

CONTRACEPTIVE SUPP $0*

VAGINAL ANTI-INFECTIVES

AVC VAGINAL CREAM 15% 2

CLEOCIN SUPP 100MG 3

CLEOCIN VAGINAL CREAM 2% 3

clindamycin vaginal cream 2% 1

CLINDESSE VAGINAL CREAM 2% 3

METROGEL VAGINAL GEL 0.75% 3

metronidazole vaginal gel 0.75% 1

MICONAZOLE 3 SUPP 200MG 3

terconazole cream 0.4% 1

terconazole supp 80mg 1

TERCONAZOLE VAGINAL CREAM 0.8% 1

VAGINAL ESTROGENS

ESTRACE VAGINAL CREAM 0.1MG 3

estradiol vaginal cream 0.1mg/gm 1

ESTRING VAGINAL RING 2MG 2 ST

FEMRING VAGINAL RING 0.05MG 3 ST

FEMRING VAGINAL RING 0.1MG 3 ST

PREMARIN VAGINAL CREAM 0.625MG/GM 2

VAGIFEM TAB 10MCG 3

yuvafem tab 10mcg 2

VAGINAL PROGESTINS

CRINONE GEL 8% 2 PA

CRINONE VAGINAL GEL 4% 2 PA

VASOPRESSORS

ANAPHYLAXIS THERAPY AGENTS

epinephrine auto-injector 0.3mg/0.3ml 2 QL=2 Quantity/15 Days

epinephrine inj 0.15mg (2 pack) 2 QL=2 Quantity/15 Days

SYMJEPI INJ 0.15MG/0.3ML 2 QL=2 Quantity/15 Days

SYMJEPI INJ 0.3MG/0.3ML 2 QL=2 Quantity/15 Days

NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS

NORTHERA CAP 100MG 3 NDS PA



VASOPRESSORS

midodrine tab 10mg 1

midodrine tab 2.5mg 1




158

midodrine tab 5mg 1

VITAMINS

OIL SOLUBLE VITAMINS

DRISDOL CAP 3*

vitamin D cap 50000unit 1*

VITAMIN D TAB 400UNIT $0*

vitamin D3 cap 400unit, 1000unit $0*

WATER SOLUBLE VITAMINS

niacin cap (OTC) 1*

niacin CR tab 1*

niacin tab (OTC) 1*

NIACIN TR TAB (OTC) 1*

niacinamide tab 1*

POTABA CAP 3*

SLO-NIACIN TAB 3*IDX_159

ALPHABETICAL LISTING OF DRUGS


beginning of this table. 159

A

abacavir/lamivudine/zidovudine tab300-150-300mg 84

abacavir/lamivudine tab600-300mg 84

abacavir oral soln 20mg/ml 84

abacavir tab 300mg 84

ABELCET INJ 5MG/ML 53

ABILIFY MAINTENA INJ

300MG 83

ABILIFY MAINTENA INJ

400MG 83

ABILIFY MAINTENA

SYRINGE 300MG 83

ABILIFY MAINTENA

SYRINGE 400MG 83

ABILIFY TAB 10MG 83

ABILIFY TAB 15MG 83

ABILIFY TAB 20MG 83

ABILIFY TAB 2MG 83

ABILIFY TAB 30MG 83

ABILIFY TAB 5MG 83

abiraterone tab 250mg 68

ABSTRAL SL TAB 100MCG18






acamprosate calcium tab333mg 146

ACANYA GEL 1.2-2.5% 104




ACCOLATE TAB 10MG 31

ACCOLATE TAB 20MG 31

ACCU-CHECK GUIDE

CARE METER 130

ACCU-CHEK AVIVA PLUS

METER 130

ACCU-CHEK NANO

METER 129

ACCUPRIL TAB 10MG 58



ACCUPRIL TAB 5MG 58

ACCURETIC TAB

10-12.5MG 61

ACCURETIC TAB

20-12.5MG 61

ACCURETIC TAB 20-25MG 61



acetaminophen/codeine soln120-12mg/5ml 22

acetaminophen/codeine tab300-15mg 22



acetazolamide ER cap500mg 113



acetic acid/hydrocortisoneotic soln 1-2% 142

acetic acid otic soln 2% 142

acetylcysteine soln 10% 104

acetylcysteine soln 20% 104

ACIPHEX TAB 20MG 153


acitretin cap 17.5mg 107


ACTEMRA ACTPEN INJ

162MG/0.9ML 16

ACTEMRA SYRINGE

162MG/0.9ML 16

ACTHIB INJ 156

ACTIGALL CAP 300MG 121

ACTIMMUNE INJ

100MCG/0.5ML 74

ACTIQ LOZENGE

1200MCG 18

ACTIQ LOZENGE

1600MCG 18

ACTIQ LOZENGE 200MCG 18




ACTIVELLA TAB

0.5-0.1MG 118

ACTIVELLA TAB 1-0.5MG118

ACTONEL TAB 150MG 115



ACTONEL TAB 5MG 115

ACTOS TAB 15MG 50

ACTOS TAB 30MG 50

ACTOS TAB 45MG 50

ACULAR LS OPHTH SOLN

0.4% 141

ACULAR OPHTH SOLN

0.5% 141

ACUVAIL OPHTH SOLN

0.45% 141

acyclovir cap 200mg 88

acyclovir cream 5% 108

acyclovir inj 50mg/ml 88

acyclovir ointment 5% 108

acyclovir susp 200mg/5ml 88



ADACEL INJ 152




adapalene/benzoyl peroxidegel 0.1-2.5% 104

adapalene cream 0.1% 104

adapalene gel 0.1% 104

adapalene gel 0.3% 104

ADAPALENE LOTION,

DIFFERIN LOTION

0.1% 104

ADCIRCA TAB 20MG 97

ADDERALL TAB 20MG 11

ADDERALL TAB 5MG 11




ADDERALL TAB 7.5MG 11







adefovir dipivoxil tab 10mg 88

ADEMPAS TAB 0.5MG 97


ADEMPAS TAB 1MG 97


ADEMPAS TAB 2MG 97

ADIPEX CAP 11

ADIPEX TAB 11

ADVAIR HFA INHALER

115-21MCG 32

ADVAIR HFA INHALER

230-21MCG 32

ADVAIR HFA INHALER

45-21MCG 32

AFINITOR DISPERZ TAB

2MG 69


3MG 69


5MG 69

AFINITOR TAB 10MG 69

AFINITOR TAB 2.5MG 69

AFINITOR TAB 5MG 69

AFINITOR TAB 7.5MG 69

AGGRENOX CAP

25-200MG 125

AGRYLIN CAP 0.5MG 125

AIMOVIG

AUTO-INJECTOR

140MG/ML 130

AIMOVIG

AUTO-INJECTOR

70MG/ML 130

AKYNZEO CAP 300-0.5MG 52

ALBATUSSIN LIQUID 103

albendazole tab 200mg 24

ALBENZA TAB 200MG 24



albuterol neb soln 0.083% 32

albuterol neb soln 0.5% 32

albuterol neb soln 0.63mg/3ml32

albuterol neb soln 1.25mg/3ml32

albuterol syrup 2mg/5ml 32

albuterol tab 2mg 32

albuterol tab 4mg 32

ALCAINE OPHTH SOLN

0.5% 140

alclometasone cream 0.05% 109

alclometasone ointment0.05% 109

ALCOHOL SWAB

1"x1" (DIABETIC) 112

ALCOHOL SWAB

1”x1” (DIABETIC) 130

ALDACTAZIDE TAB

25-25MG 113

ALDACTAZIDE TAB

50-50MG 114




ALDARA CREAM 5% 111

ALECENSA CAP 150MG 69

ALENDRONATE ORAL

SOLN 70MG/75ML 115



ALENDRONATE TAB

40MG 115



alfuzosin tab 10mg 123

ALINIA SUSP 100MG/5ML 25

ALINIA TAB 500MG 25

aliskiren tab 150mg 65

aliskiren tab 300mg 65

ALKERAN TAB 66

ALLEGRA-D 12-HOUR

TAB 103

ALLEGRA-D 24-HOUR

TAB 103

ALLEGRA SYRUP 54

ALLEGRA TAB 54



ALOCRIL OPHTH SOLN

2% 141

ALOMIDE OPHTH SOLN

0.1% 141

ALORA PATCH,

MINIVELLE PATCH

0.025MG 119

ALORA PATCH,

MINIVELLE PATCH

0.05MG 119

ALORA PATCH,

MINIVELLE PATCH

0.075MG 119

ALORA PATCH,

MINIVELLE PATCH

0.1MG 119

alosetron tab 0.5mg 122

alosetron tab 1mg 122

ALPHAGAN P OPHTH

SOLN 0.1% 139

ALPHAGAN P OPHTH

SOLN 0.15% 139

alprazolam ER tab 0.5mg 29




ALPRAZOLAM INTENSOL

CONC 1MG/ML 29









ALREX OPHTH SUSP

0.2% 140




ALTACE CAP 1.25MG 58

ALTACE CAP 10MG 58

ALTACE CAP 2.5MG 58

ALTACE CAP 5MG 58

aluminum chloride soln 112

ALUNBRIG TAB 180MG 69



ALUNBRIG TAB STARTER

PACK 69

amantadine cap 100mg 76

amantadine soln 50mg/5ml 76

amantadine tab 100mg 76

AMARYL TAB 1MG 50

AMARYL TAB 2MG 50

AMARYL TAB 4MG 50

AMBIEN TAB 10MG 127

AMBIEN TAB 5MG 127

AMBISOME INJ 50MG 53

ambrisentan tab 10mg 97

ambrisentan tab 5mg 97

AMCINONIDE CREAM

0.1% 109

AMCINONIDE LOTION

0.1% 109

AMCINONIDE OINTMENT

0.1% 109

AMERGE TAB 1MG 130

AMERGE TAB 2.5MG 130

amethia tab 100

amethyst tab 100

amikacin sulfate inj 1gm/4ml 14

amikacin sulfate inj500mg/2ml 14

amiloride/hydrochlorothiazide tab5-50mg 114

amiloride tab 5mg 114

AMINOSYN II INJ 10% 137






amitriptyline tab 100mg 45






amlodipine/atorvastatin tab10-10mg 96




amlodipine/atorvastatin tab2.5-10mg 96







amlodipine/benazepril cap10-20mg 61


amlodipine/benazepril cap2.5-10mg 61




amlodipine/olmesartan tab10-20mg 61




amlodipine/valsartan/hydrochlorothiazidetab10-160-12.5mg 62

amlodipine/valsartan/hydrochlorothiazidetab10-160-25mg 62

amlodipine/valsartan/hydrochlorothiazidetab10-320-25mg 62

amlodipine/valsartan/hydrochlorothiazide tab5-160-12.5mg 62

amlodipine/valsartan/hydrochlorothiazide tab5-160-25mg 62

amlodipine/valsartan tab10-160mg 61





amlodipine tab 2.5mg 93


ammonium lactate cream12% 111

ammonium lactate lotion12% 111

AMOXAPINE TAB 100MG 45




amoxicillin/k clavulanate ERtab 1000-62.5mg 144

AMOXICILLIN/K

CLAVULANATE ER TAB

1000-62.5 MG 144




amoxicillin/k clavulanatesusp 200-28.5mg/5ml 144


amoxicillin/k clavulanatesusp 400-57mg/5ml 144


amoxicillin/k clavulanate tab250-125mg 144





AMOXICILLIN CHEW TAB

125MG 143

AMOXICILLIN CHEW TAB

250MG 143







amphetamine/dextroamphetamine ERcap 10mg 11






amphetamine/dextroamphetamine tab10mg 11

amphetamine/dextroamphetamine tab12.5mg 11





amphetamine/dextroamphetamine tab7.5mg 11

AMPHOTERICIN INJ 50MG 53

ampicillin/sulbactam inj1.5gm 144

AMPICILLIN/SULBACTAM

INJ 1.5GM 144

ampicillin/sulbactam inj15gm 144

ampicillin/sulbactam inj 3gm144

AMPICILLIN/SULBACTAM

INJ 3GM 144

AMPICILLIN CAP 500MG 143






AMPICILLIN SODIUM INJ

125MG 144

AMPICILLIN SODIUM INJ

1GM 144

ANADROL TAB 50MG 23

ANAFRANIL CAP 25MG 45



anagrelide cap 0.5mg 125

anagrelide cap 1mg 125

ANALPRAM-HC CREAM 24

ANAPROX DS TAB 550MG 16

ANASPAZ TAB 152

anastrozole tab 1mg 67

ANCOBON CAP 250MG 53

ANCOBON CAP 500MG 53

ANDRODERM PATCH 2MG 23

ANDRODERM PATCH 4MG 23

ANDROGEL 1.62%

(1.25GM) POUCH 23

ANDROGEL 1.62% (2.5GM)

POUCH 23

ANDROGEL GEL, TESTIM

GEL 1% (50MG) POUCH 23

ANDROGEL GEL 1%

(25MG) 23

ANDROGEL PUMP 1.62%

BOTTLE 23

ANGELIQ TAB 118

ANORO ELLIPTA

INHALER 62.5-25MCG 32



ANTARA CAP 30MG 56

ANTARA CAP 90MG 56

ANUSOL-HC CREAM 2.5% 24

ANUSOL-HC SUPP 24

ANZEMET TAB 100MG 52

ANZEMET TAB 50MG 52

APEXICON E CREAM

0.05% 109

APLENZIN ER TAB 174MG 42



APOKYN INJ 30MG/3ML 76

apraclonidine ophth soln0.5% 139

aprepitant cap 125mg 53






aprepitant cap therapy pack80/125mg 53

APRISO CAP 0.375GM 121

apri tab 100

APTIOM TAB 200MG 36

APTIOM TAB 400MG 36

APTIOM TAB 600MG 36

APTIOM TAB 800MG 36

APTIVUS CAP 250MG 84

APTIVUS ORAL SOLN

100MG/ML 84

ARALAST NP INJ 500MG 149

aranelle tab 100

ARANESP INJ

100MCG/ML 125

ARANESP INJ

200MCG/ML 125

ARANESP INJ 25MCG/ML 125

ARANESP INJ

300MCG/ML 126



ARANESP SYRINGE

100MCG/0.5ML 126

ARANESP SYRINGE

10MCG/0.4ML 126

ARANESP SYRINGE

150MCG/0.3ML 126

ARANESP SYRINGE

200MCG/0.4ML 126

ARANESP SYRINGE

25MCG/0.42ML 126

ARANESP SYRINGE

300MCG/0.6ML 126

ARANESP SYRINGE

40MCG/0.4ML 126

ARANESP SYRINGE

500MCG/ML 126

ARANESP SYRINGE

60MCG/0.3ML 126

ARAVA TAB 10MG 17

ARAVA TAB 20MG 17

ARCALYST INJ 220MG 16

ARICEPT TAB 10MG 146

ARICEPT TAB 23MG 146

ARICEPT TAB 5MG 146

ARIKAYCE INHALATION

SUSP 70.3MG/ML 14

ARIMIDEX TAB 1MG 67

aripiprazole ODT 10mg 83

aripiprazole ODT 15mg 83

aripiprazole soln 1mg/ml 84







ARISTADA (2-MONTH) INJ

1064MG/3.9ML 84

ARISTADA INJ

441MG/1.6ML 84

ARISTADA INJ

662MG/2.4ML 84

ARISTADA INJ

675MG/2.4ML 84

ARISTADA INJ

882MG/3.2ML 84


ARIXTRA INJ 2.5MG/0.5ML34


ARIXTRA INJ 7.5MG/0.6ML34

armodafinil tab 150mg 12




ARMOUR THYROID TAB 151

ARNUITY ELLIPTA

INHALER 100MCG 32

ARNUITY ELLIPTA

INHALER 200MCG 32

ARNUITY ELLIPTA

INHALER 50MCG 32

AROMASIN TAB 25MG 67

ARTHROTEC TAB

50-0.2MG 16

ARTHROTEC TAB

75-0.2MG 16

ASMANEX HFA INHALER

100MCG 32

ASMANEX HFA INHALER

200MCG 32

ASMANEX HFA INHALER

50MCG 32

ASMANEX INHALER

110MCG 32

ASMANEX INHALER

220MCG 32

aspirin/dipyridamole cap25-200mg 125

aspirin chew tab 81mg 18

ASPIRIN EC TAB 325MG 18

aspirin EC tab 81mg, 325mg 18

ASPIRIN TAB 81MG 18

aspirin tab 81mg, 325mg 18

ASTAGRAF XL CAP 0.5MG 89

ASTAGRAF XL CAP 1MG 89

ASTAGRAF XL CAP 5MG 89

ASTEPRO NASAL SPRAY

0.15% 137




atenolol/chlorthalidone tab100-25mg 62

atenolol/chlorthalidone tab50-25mg 62




ATIVAN TAB 0.5MG 29

ATIVAN TAB 1MG 29

ATIVAN TAB 2MG 29















atovaquone/proguanil tab250-100mg 65

atovaquone/proguanil tab62.5-25mg 65

atovaquone susp 750mg/5ml 25

ATRALIN GEL 0.05% 104

ATRIPLA TAB

600-200-300MG 84

ATROPINE SULFATE

OPHTH SOLN 1% 138

ATROVENT HFA INHALER

17MCG/ACT 31

AUBAGIO TAB 14MG 148

AUBAGIO TAB 7MG 148

augmented betamethasonecream 0.05% 109

augmented betamethasonelotion 0.05% 109

augmented betamethasoneointment 0.05% 109

AUGMENTIN CHEW TAB

200-28.5MG 144

AUGMENTIN CHEW TAB

400-57MG 144

AUGMENTIN SUSP

125-31.25MG/5ML 144

AURYXIA TAB 1GM 122

AUSTEDO TAB 12MG 148

AUSTEDO TAB 6MG 148

AUSTEDO TAB 9MG 148



AVANDIA TAB 2MG 50

AVANDIA TAB 4MG 50

AVAPRO TAB 150MG 60

AVAPRO TAB 300MG 60

AVAPRO TAB 75MG 60

AVC VAGINAL CREAM

15% 157

AVELOX INJ

400MG/250ML 120

aviane tab 100

AVODART CAP 0.5MG 123

AVONEX AUTO-INJECTOR

KIT 30MCG/0.5ML 148

AVONEX PREFILLED INJ

KIT 30MCG/0.5ML 148

AVYCAZ INJ 2-0.5GM 98

AYGESTIN TAB 5MG 145

AYVAKIT TAB 100MG 69



AZASAN TAB 100MG 89

AZASAN TAB 75MG 89

AZASITE OPHTH SOLN

1% 139

azathioprine tab 50mg 89

azelaic acid gel 15% 112

azelastine nasal spray 0.1%(137mcg) 137

azelastine nasal spray 0.15%(205.5mcg) 137

azelastine ophth soln 0.05% 141

AZELEX CREAM 20% 104

AZILECT TAB 0.5MG 78

AZILECT TAB 1MG 78

azithromycin inj 500mg 128

azithromycin susp100mg/5ml 128

azithromycin susp200mg/5ml 128




AZOPT OPHTH SUSP 1% 141

AZOR TAB 10-20MG 62

AZOR TAB 10-40MG 62

AZOR TAB 5-20MG 62

AZOR TAB 5-40MG 62

aztreonam inj 1gm 27

AZULFIDINE DR TAB

500MG 121

AZULFIDINE TAB 500MG 121

B

bacitracin/neomycin/polymyxin B ophthointment 139

bacitracin/polymyxin/neomcyin/hydrocortisoneophth ointment 1% 140

bacitracin/polymyxin B ophthointment 139

BACITRACIN OPHTH

OINTMENT

500UNIT/GM 139

baclofen tab 10mg 136

baclofen tab 20mg 136

BACTOCILL/DEXTROSE

INJ 1GM/50ML 145

BACTOCILL/DEXTROSE

INJ 2GM/50ML 145

BACTRIM DS TAB

800-160MG 25

BACTRIM TAB 400-80MG 25

BACTROBAN NASAL

OINTMENT 2% 137

balsalazide cap 750mg 121

BALVERSA TAB 3MG 69

BALVERSA TAB 4MG 70

BALVERSA TAB 5MG 70

balziva tab 100

BANZEL SUSP 40MG/ML 36

BANZEL TAB 200MG 36

BANZEL TAB 400MG 36

BAQSIMI NASAL POWDER

3MG/DOSE 48

BARACLUDE TAB 0.5MG 88

BARACLUDE TAB 1MG 88

BAXDELA TAB 450MG 120

BCG VACCINE INJ 156

BELLADONNA

ALKALOID/OPIUM

SUPP 152

BELVIQ TAB 11

BELVIQ XR TAB 12




benazepril/hydrochlorothiazide tab10-12.5mg 62


benazepril/hydrochlorothiazide tab20-25mg 62






BENICAR HCT TAB

20-12.5MG 62

BENICAR HCT TAB

40-12.5MG 62

BENICAR HCT TAB

40-25MG 62

BENICAR TAB 20MG 60

BENICAR TAB 40MG 60

BENICAR TAB 5MG 60

BENLYSTA

AUTO-INJECTOR

200MG/ML 134

BENLYSTA INJ

200MG/ML 134

BENTYL INJ 10MG/ML 152

BENTYL TAB 20MG 152

BENZACLIN GEL 1-5% 104

BENZAMYCIN GEL 5-3% 104

BENZNIDAZOLE TAB

100MG 24

BENZNIDAZOLE TAB

12.5MG 24

benzonatate cap 100mg,200mg 103

benztropine tab 0.5mg 75



BEPREVE OPHTH SOLN

1.5% 141

BERINERT INJ KIT

500UNIT 124

BETAGAN OPHTH SOLN

0.5% 138

BETAMETHASONE

AUGMENTED GEL

0.05% 109

betamethasone dipropionatecream 0.05% 109

betamethasone dipropionatelotion 0.05% 109

betamethasone dipropionateointment 0.05% 109

betamethasone valeratecream 0.1% 109

betamethasone valerate foam0.12% 109

betamethasone valerate lotion0.1% 109

betamethasone valerateointment 0.1% 109







betaxolol ophth soln 0.5% 138







BETIMOL OPHTH SOLN

0.25% 138

BETIMOL OPHTH SOLN

0.5% 138

BETOPTIC-S OPHTH SUSP

0.25% 138

bexarotene cap 75mg 74

BEXSERO INJ 156

bicalutamide tab 50mg 67

BICILLIN C-R INJ

1200000UNIT/2ML 144

BICILLIN C-R INJ

900000-300000UNIT/2ML144

BICILLIN L-A INJ 1200000

UNIT/2ML 144


UNIT/4ML 144


UNIT/ML 144

BIDIL TAB 20-37.5mg 96

BIKTARVY TAB

50-200-25MG 84

BILTRICIDE TAB 600MG 24

bimatoprost ophth soln0.03% 142

bisoprolol/hydrochlorothiazide tab10-6.25mg 62

bisoprolol/hydrochlorothiazide tab2.5-6.25mg 62

bisoprolol/hydrochlorothiazide tab5-6.25mg 62



BLEPH-10 OPHTH SOLN

10% 139

BLEPHAMIDE OPHTH

SUSP 10-0.2% 140

BLEPHAMIDE S.O.P

OPHTH OINTMENT

10-0.2% 140

BONIVA TAB 150MG 115

BOOSTRIX INJ 152

bosentan tab 125mg 97

bosentan tab 62.5mg 97

BOSULIF TAB 100MG 70



BRAFTOVI CAP 75MG 70




BREO ELLIPTA INHALER

100-25MCG 33

BREO ELLIPTA INHALER

200-25MCG 33

BRILINTA TAB 60MG 125

BRILINTA TAB 90MG 125

brimonidine ophth soln0.15% 139

brimonidine ophth soln 0.2%139

BRIVIACT ORAL SOLN

10MG/ML 37

BRIVIACT TAB 100MG 37





bromfenac ophth soln (oncedaily) 0.09% 141

bromocriptine cap 5mg 76

bromocriptine tab 2.5mg 76

BROVANA NEB SOLN

15MCG/2ML 33

BRUKINSA CAP 80MG 70

budesonide EC cap 3mg 102

budesonide ER tab 9mg 102

budesonide neb susp0.25mg/2ml 32

budesonide neb susp0.5mg/2ml 32

budesonide neb susp 1mg/2ml 32

bumetanide inj 0.25mg/ml 114

bumetanide tab 0.5mg 114



BUPHENYL ORAL

POWDER 0.94MG/MG 116

buprenorphine/naloxone SLfilm 12-3mg 23

buprenorphine/naloxone SLfilm 2-0.5mg 23



buprenorphine/naloxone SLtab 2-0.5mg 23

buprenorphine/naloxone SLtab 8-2mg 23



buprenorphine weekly patch10mcg 23




buprenorphine weekly patch7.5mcg 23

buproban tab 150mg 149












buspirone tab 7.5mg 29

butorphanol nasal spray10mg/ml 23

BYDUREON BCISE AUTO

INJ 2MG/0.85ML 49

BYDUREON INJ 2MG 49

BYDUREON PEN INJ 2MG 49

BYETTA INJ

10MCG/0.04ML 49

BYETTA INJ 5MCG/0.02ML 49

BYSTOLIC TAB 10MG 91

BYSTOLIC TAB 2.5MG 91

BYSTOLIC TAB 20MG 91

BYSTOLIC TAB 5MG 91

C

cabergoline tab 0.5mg 118

CABOMETYX TAB 20MG 70

















CALAN TAB 120MG 93

CALAN TAB 80MG 93

calcipotriene/betamethasoneointment 0.005-0.064% 109

calcipotriene-betamethasonedipropionate susp0.005-0.064% 109

calcipotriene cream 0.005% 107

CALCIPOTRIENE FOAM

0.005%, SORILUX FOAM

0.005% 107

calcipotriene ointment0.005% 108

calcipotriene soln 0.005% 108

calcitonin nasal spray200unit 115

calcitriol cap 0.25mcg 116

calcitriol cap 0.5mcg 116

CALCITRIOL OINTMENT

3MCG/GM 108

calcitriol oral soln 1mcg/ml 117

calcium acetate cap 667mg 122

calcium acetate tab 667mg 122

CALIBRATION LIQUID 129




CALQUENCE CAP 100MG 70

camrese LO tab 100

CANASA RECTAL SUPP

1000MG 121

CANCIDAS INJ 50MG 53

CANCIDAS INJ 70MG 53

capecitabine tab 67

CAPEX SHAMPOO 0.01% 109

CAPLYTA CAP 42MG 78

CAPRELSA TAB 100MG 70

CAPRELSA TAB 300MG 70

CAPTOPRIL/

HYDROCHLOROTHIAZIDE

TAB 25-15MG 62

CAPTOPRIL/

HYDROCHLOROTHIAZIDE

TAB 25-25MG 62

CAPTOPRIL/

HYDROCHLOROTHIAZIDE

TAB 50-15MG 62

CAPTOPRIL/

HYDROCHLOROTHIAZIDE

TAB 50-25MG 62


captopril tab 12.5mg 58



CARAC CREAM 0.5% 107

CARAFATE SUSP

1GM/10ML 154

CARAFATE TAB 1GM 153

CARBAGLU TAB 200MG 117

carbamazepine chew tab100mg 37




carbamazepine SR cap 100mg37



carbamazepine susp100mg/5ml 37

carbamazepine tab 200mg 37

CARBATROL SR CAP

100MG 37

CARBATROL SR CAP

200MG 37

CARBATROL SR CAP

300MG 37

CARBIDOPA/LEVODOPA/

ENTACAPONE TAB

12.5-50-200MG 76

CARBIDOPA/LEVODOPA/

ENTACAPONE TAB

18.75-75-200MG 76

CARBIDOPA/LEVODOPA/

ENTACAPONE TAB

25-100-200MG 76

CARBIDOPA/LEVODOPA/

ENTACAPONE TAB

31.25-125-200MG 76

CARBIDOPA/LEVODOPA/

ENTACAPONE TAB

37.5-150-200MG 76

CARBIDOPA/LEVODOPA/

ENTACAPONE TAB

50-200-200MG 76

carbidopa/levodopa ER tab25-100mg 76

carbidopa/levodopa ER tab50-200mg 76

carbidopa/levodopa ODT10-100mg 76



carbidopa/levodopa tab10-100mg 76



carbidopa tab 25mg 75

CARDIZEM CD CAP

120MG 93

CARDIZEM CD CAP

180MG 93

CARDIZEM CD CAP

240MG 93

CARDIZEM CD CAP

300MG 93

CARDIZEM CD CAP

360MG 93

CARDIZEM LA TAB

120MG 93

CARDIZEM LA TAB

180MG 93

CARDIZEM LA TAB

240MG 93

CARDIZEM LA TAB

300MG 93

CARDIZEM LA TAB

360MG 93

CARDIZEM LA TAB

420MG 93




CARDURA TAB 1MG 60

CARDURA TAB 2MG 60

CARDURA TAB 4MG 60

CARDURA TAB 8MG 61



CARIMUNE INJ 6GM 142

carisoprodol tab 350mg 136

CARNITOR ORAL SOLN

1GM/10ML 117

CARNITOR TAB 330MG 117

CARTEOLOL OPHTH

SOLN 1% 138






carvedilol tab 25mg 91






CASODEX TAB 50MG 67

caspofungin acetate inj 50mg 53

CASPOFUNGIN ACETATE

INJ 50MG 53

caspofungin acetate inj 70mg 53

CASPOFUNGIN ACETATE

INJ 70MG 53




CATAPRES-TTS PATCH

0.1MG 61

CATAPRES-TTS PATCH

0.2MG 61

CATAPRES-TTS PATCH

0.3MG 61

CAYSTON INHALATION

SOLN 75MG 27



CEFACLOR ER TAB 500MG 98

CEFACLOR SUSP

125MG/5ML 98

cefaclor susp 250mg/5ml 98

CEFACLOR SUSP

250MG/5ML 98

CEFACLOR SUSP

375MG/5ML 98

cefadroxil cap 500mg 98



cefadroxil tab 1gm 98

CEFAZOLIN/DEXTROSE

IV SOLN 1GM/4% 98

CEFAZOLIN/DEXTROSE

IV SOLN 1GM/50ML-4% 98




CEFAZOLIN INJ 1 GM 98



cefazolin inj 500mg 98

cefdinir cap 300mg 99



CEFEPIME/DEXTROSE INJ

1GM/50ML 100

CEFEPIME/DEXTROSE INJ

2GM/50ML 100

cefepime inj 1gm 100

cefepime inj 2gm 100

CEFEPIME IV SOLN

1GM/50ML 100

CEFEPIME IV SOLN

2GM/100ML 100

cefixime cap 400mg 99





CEFOTETAN/DEXTROSE

INJ 1GM/3.58% 98

CEFOTETAN/DEXTROSE

INJ 2GM/2.08% 98

cefotetan inj 1gm 98

cefotetan inj 2gm 98

CEFOXITIN/DEXTROSE

INJ 1GM/4% 98

CEFOXITIN/DEXTROSE

INJ 2GM/2.2% 98

cefoxitin inj 10mg 98

cefoxitin inj 1gm 98

cefoxitin inj 2gm 98

cefpodoxime proxetil susp100mg/5ml 99

cefpodoxime proxetil susp50mg/5ml 99

cefpodoxime proxetil tab100mg 99

cefpodoxime proxetil tab200mg 99





CEFTAZIDIME/DEXTROSE

INJ 1GM/50ML/5% 99

CEFTAZIDIME/DEXTROSE

INJ 2GM/50ML/5% 99




CEFTRIAXONE/

DEXTROSE INJ

20MG/ML 99

CEFTRIAXONE/

DEXTROSE INJ

40MG/ML 99

CEFTRIAXONE/

DEXTROSE IV SOLN

1GM-3.74% 99

CEFTRIAXONE/

DEXTROSE IV SOLN

2GM-2.22% 99

CEFTRIAXONE SODIUM

INJ 100GM 99








cefuroxime inj 750mg 99











CELEXA TAB 10MG 43

CELEXA TAB 20MG 43

CELEXA TAB 40MG 43

CELLCEPT CAP 250MG 89

CELLCEPT SUSP

200MG/ML 89

CELLCEPT TAB 500MG 89




CELONTIN CAP 300MG 41





CERDELGA CAP 84MG 125

CERVICAL CAP 129

CESAMET CAP 1MG 52

cesia tab 100

cetirizine/pseudoephedrinetab 103

cetirizine cap 54

cetirizine oral soln 5mg/5ml(rx only) 54

cetirizine tab 54

cevimeline cap 30mg 135

CHANTIX PAK

0.5MG/1MG 149

CHANTIX TAB 0.5MG 149

CHANTIX TAB 1MG 149

CHEMET CAP 100MG 51

CHENODAL TAB 250MG 121

CHLORDIAZEPOXIDE/

AMITRIPTYLINE TAB

10-25MG 147

CHLORDIAZEPOXIDE/

AMITRIPTYLINE TAB

5-12.5MG 147

chlordiazepoxide/clidiniumcap 152






CHLOROQUINE TAB

500MG 65

CHLOROTHIAZIDE TAB

250MG 115

CHLOROTHIAZIDE TAB

500MG 115








chlorzoxazone tab 500mg 136

CHOLBAM CAP 250MG 121

CHOLBAM CAP 50MG 121

cholestyramine bulk powder4gm 56

cholestyramine light bulkpowder 4gm 56

cholestyramine light powderpacket 4gm 56

cholestyramine powderpacket 4gm 56

CHOLINE MAGNESIUM

TRISALICYLATE TAB

1000MG 18

choline magnesiumtrisalicylate tab 500mg,750mg 18

ciclopirox cream 0.77% 106

ciclopirox gel 0.77% 106

ciclopirox shampoo 1% 106

ciclopirox soln 8% 106

ciclopirox susp 0.77% 106

cilastatin/imipenem inj 250mg25

CILASTATIN/IMIPENEM

INJ 250MG 25

cilastatin/imipenem inj 500mg25



CILOXAN OPHTH

OINTMENT 0.3% 139

CILOXAN OPHTH SOLN

0.3% 139

CIMDUO TAB 300-300MG 84

CIMETIDINE ORAL SOLN

300MG/5ML 153





CIMZIA INJ 200MG 121

CIMZIA INJ STARTER KIT

200MG/ML 121

CIMZIA PF SYRINGE

200MG/ML 121

cinacalcet tab 30mg 117



CINRYZE INJ 500UNIT 124

CIPRODEX OTIC SUSP

0.3-0.1% 142

ciprofloxacin inj200mg/100ml/D5W 120

ciprofloxacin inj400mg/200ml/D5W 120

ciprofloxacin ophth soln0.3% 139

CIPROFLOXACIN OTIC

SOLN 0.2% 142

ciprofloxacin susp250mg/5ml 120

ciprofloxacin susp500mg/5ml 120




CIPRO HC OTIC SUSP

0.2-1% 142

CIPRO INJ

400MG/200ML/D5W 120



CIPRO TAB 250MG 120

CIPRO TAB 500MG 120

citalopram oral soln10mg/5ml 43




CLARINEX-D ER TAB

2.5-120MG 103

CLARINEX SYRUP

0.5MG/ML 54

CLARINEX TAB 5MG 55




clarithromycin ER tab500mg 129

CLARITHROMYCIN SUSP

125MG/5ML 129

CLARITHROMYCIN SUSP

250MG/5ML 129



CLARITIN CAP 55

CLARITIN CHEW TAB 55

CLARITIN-D TAB 103

CLARITIN REDITAB 55

CLARITIN SYRUP 55

CLARITIN TAB 55

CLENPIQ POWDER 10

MG-3.5GM-12GM/160ML128

CLEOCIN CAP 150MG 26

CLEOCIN CAP 300MG 26

CLEOCIN CAP 75MG 26


CLEOCIN INJ

300MG/50ML/D5W 26


CLEOCIN INJ

600MG/50ML/D5W 26

CLEOCIN INJ

900MG/50ML/D5W 26


CLEOCIN PED ORAL

SOLN 75MG/5ML 27

CLEOCIN SUPP 100MG 157

CLEOCIN-T GEL 1% 104

CLEOCIN-T LOTION 1% 104

CLEOCIN-T PAD 1% 104

CLEOCIN VAGINAL

CREAM 2% 157

CLIMARA PATCH

0.025MG 119

CLIMARA PATCH

0.0375MG 119



CLIMARA PATCH

0.075MG 119


CLIMARA PRO PATCH

0.045-0.015MG 118

clindamycin/benzoyl peroxidegel 1.2-2.5% 105

clindamycin/benzoyl peroxidegel 1.2-5% 105

clindamycin/benzoyl peroxidegel 1-5% 105

CLINDAMYCIN/NACL 9%

IV SOLN 300MG/50ML 27

CLINDAMYCIN/NACL 9%


CLINDAMYCIN/NACL 9%


clindamycin/tretinoin gel1.2-0.025% 105




clindamycin foam 1% 104

clindamycin gel 1% 105

CLINDAMYCIN GEL 1% 105


clindamycin inj300mg/50ml/D5W 27





clindamycin inj 9gm/60ml 27

clindamycin IV soln300mg/2ml 27



clindamycin lotion 1% 105

clindamycin oral soln75MG/5ML 27

clindamycin pad 1% 105

clindamycin topical soln 1% 105

clindamycin vaginal cream2% 157

CLINDESSE VAGINAL

CREAM 2% 157

CLINIMIX E INJ

2.75%/D10W 137

CLINIMIX E INJ

2.75%/D5W 137

CLINIMIX E INJ

4.25%/D10W 137

CLINIMIX E INJ

4.25%/D5W 137

CLINIMIX E INJ 5%/D15W137

CLINIMIX E INJ 5%/D20W137

CLINIMIX INJ

4.25%/D10W 137

CLINIMIX INJ

4.25%/D20W 137

CLINIMIX INJ 4.25%/D5W 137

CLINIMIX INJ 5%/D15W 137

CLINIMIX INJ 5%/D20W 138

CLINISTIX 113

clobazam susp 2.5mg/ml 36

clobazam tab 10mg 36

clobazam tab 20mg 36

clobetasol propionate cream0.05% 109

clobetasol propionateemollient cream 0.05% 109

clobetasol propionateemulsion foam 0.05% 109

clobetasol propionate foam0.05% 109

clobetasol propionate gel0.05% 109

clobetasol propionate lotion0.05% 109

clobetasol propionateointment 0.05% 109

clobetasol propionateshampoo 0.05% 109

clobetasol propionate soln0.05% 109




clobetasol propionate spray0.05% 109

CLOBEX LOTION 0.05% 109

CLOBEX SHAMPOO

0.05% 109

CLOBEX SPRAY 0.05% 109

CLOCORTOLONE CREAM

0.1% 109

clomipramine cap 25mg 45








clonazepam tab 0.5mg 36









clopidogrel tab 75mg 125

clorazepate dipotassium tab15mg 29

clorazepate dipotassium tab3.75mg 29

clorazepate dipotassium tab7.5mg 29

clotrimazole/betamethasonecream 1-0.05% 106

clotrimazole/betamethasonelotion 1-0.05% 106

clotrimazole cream 1% 106

clotrimazole soln 1% 106

clotrimazole troche 10mg 135


CLOZAPINE ODT 12.5MG 81












COARTEM TAB 20-120MG 65

codeine sulfate tab 15mg 18

CODEINE SULFATE TAB

15MG 18


CODEINE SULFATE TAB

30MG 18


CODEINE SULFATE TAB

60MG 19

COLAZAL CAP 750MG 121

colchicine tab 0.6mg 124

COLCRYS TAB 0.6MG 124

colesevelam packet 3.75gm 56

colesevelam tab 625mg 56

COLESTID GRANULE 5GM56

COLESTID POWDER PACK

5GM 56

COLESTID TAB 1GM 56

colestipol granule 5gm 56

colestipol granule packet 5gm 56

colestipol tab 1gm 56

colistimeth inj 150mg 27

COLYTE FLAVOR PACK

240GM 128

COMBIGAN OPHTH SOLN

0.2-0.5% 138

COMBIPATCH

0.05-0.14MG 118

COMBIPATCH

0.05-0.25MG 118

COMBIVENT RESPIMAT

INHALER

20-100MCG/ACT 33

COMBIVIR TAB

150-300MG 84

COMETRIQ CAP DOSE

PACK (100MG) 70

COMETRIQ CAP DOSE

PACK (140MG) 70

COMETRIQ CAP DOSE

PACK (60MG) 70

COMMIT LOZENGE 149

COMPLERA TAB

200-25-300MG 84

COMTAN TAB 200MG 75





CONDYLOX GEL 0.5% 112

CONTRACEPTIVE FILM 156

CONTRACEPTIVE FOAM 157

contraceptive gel 157

CONTRACEPTIVE GEL 157

CONTRACEPTIVE

SPONGE 157

CONTRACEPTIVE SUPP 157

CONTRAVE TAB 12

COPAXONE INJ 20MG/ML 148

COPAXONE INJ 40MG/ML 148

COPIKTRA CAP 15MG 70

COPIKTRA CAP 25MG 70

CORDRAN TAPE

4MCG/SQCM 109

COREG CR CAP 10MG 91




COREG TAB 12.5MG 91

COREG TAB 25MG 91

COREG TAB 3.125MG 91

COREG TAB 6.25MG 91

CORGARD TAB 20MG 92

CORGARD TAB 40MG 92

CORGARD TAB 80MG 92

CORLANOR ORAL SOLN

5MG/ML 97

CORLANOR TAB 5MG 97

CORLANOR TAB 7.5MG 97




CORTEF TAB 10MG 102

CORTEF TAB 20MG 102

CORTEF TAB 5MG 102

CORTISONE AC TAB

25MG 102

CORTISPORIN CREAM

3.5MG/GM-10000

UNT/GM-0.5% 106

CORTISPORIN OINTMENT

1% 106

COSENTYX

AUTO-INJECTOR

150MG/ML 108

COSENTYX INJ

150MG/ML 108

COSOPT OPHTH SOLN

22.3-6.8MG/ML 138

COSOPT PF OPHTH SOLN

22.3-6.8MG/ML 138

COTELLIC TAB 20MG 70

COUMADIN TAB 10MG 34

COUMADIN TAB 1MG 34


COUMADIN TAB 2MG 34

COUMADIN TAB 3MG 34

COUMADIN TAB 4MG 34

COUMADIN TAB 5MG 34

COUMADIN TAB 6MG 34


COZAAR TAB 100MG 60

COZAAR TAB 25MG 60

COZAAR TAB 50MG 60

CREON DR CAP

12000-38000-60000UNIT 113

CREON DR CAP

24000-76000-120000UNIT113

CREON DR CAP

3000-9500-15000UNIT 113

CREON DR CAP

36000-114000-180000UNIT113

CREON DR CAP

6000-19000-30000UNIT 113

CRESTOR TAB 10MG 57

CRESTOR TAB 20MG 57

CRESTOR TAB 40MG 57

CRESTOR TAB 5MG 57

CRINONE GEL 8% 157

CRINONE VAGINAL GEL

4% 157



cromolyn neb soln 20mg/2ml 31

cromolyn oral soln100mg/5ml 121

cromolyn sodium ophth soln4% 141

CROTAN LOTION 10% 112

cryselle tab 100

CUBICIN INJ 500MG 26

CUTIVATE LOTION 0.05% 109

CUVITRU INJ 8GM/40ML 143

CUVPOSA ORAL SOLN

1MG/5ML 152

cyanocobalamin inj 125

cyclafem tab 100



cyclobenzaprine tab 7.5mg 136

cyclophosphamide cap 25mg 66

CYCLOPHOSPHAMIDE

CAP 25MG 66

cyclophosphamide cap 50mg 67

CYCLOPHOSPHAMIDE

CAP 50MG 66

CYCLOSET TAB 0.8MG 49

cyclosporine cap 100mg 89

cyclosporine cap 25mg 90

cyclosporine modified cap100mg 90



cyclosporine modified oralsoln 100mg/ml 90

CYMBALTA CAP 20MG 44





CYSTARAN OPHTH SOLN

0.44% 141

CYTOMEL TAB 25MCG 151





CYTRA-3 SYRUP 123

D

D10W/NACL INJ 10%/0.2%131

D10W/NACL INJ

10%/0.45% 131

D2.5W/NACL INJ 0.45% 131

d5w/nacl inj 5%/0.2% 132

D5W/NACL INJ 5%/0.225%132

d5w/nacl inj 5%/0.33% 132

d5w/nacl inj 5%/0.45% 132

d5w/nacl inj 5%/0.9% 132

dalfampridine ER tab 10mg 148



DALVANCE INJ 500MG 26

danazol cap 100mg 23

danazol cap 200mg 23

danazol cap 50mg 23







dapsone tab 100mg 26

dapsone tab 25mg 26

DAPTACEL INJ 152

daptomycin inj 350mg 26

DAPTOMYCIN INJ 350MG 26

daptomycin inj 500mg 26

DARAPRIM TAB 25MG 65

darifenacin SR tab 15mg 155

darifenacin SR tab 7.5mg 155

DAURISMO TAB 100MG 67




DAURISMO TAB 25MG 67

DAYPRO TAB 600MG 16

DDAVP NASAL SOLN

0.01% 117

DDAVP NASAL SPRAY

0.01% 118

DDAVP TAB 0.1MG 118

DDAVP TAB 0.2MG 118

DECON-A ELIXIR 103

DECONEX DM TAB 103

deferasirox tab (forsuspension) 125mg 51



deferasirox tab 180mg 51



DELESTROGEN INJ

10MG/ML 119

DELESTROGEN INJ

20MG/ML 119

DELESTROGEN INJ

40MG/ML 119

DELSTRIGO TAB

100-300-300MG 84

DEMADEX TAB 10MG 114



DENAVIR CREAM 1% 108

DEPAKOTE DR TAB 125MG41





DEPAKOTE SPRINKLE

CAP 125MG 41

DEPEN TITRA TAB

250MG 134

DEPO ESTRADIOL INJ

5MG/ML 119

DEPO-PROVERA INJ

150MG/ML 101

DEPO-PROVERA INJ

400MG/ML 68

DEPO-PROVERA SC INJ

104MG 101

DEPO-PROVERA SYRINGE

150MG/ML 101

DEPO-TESTOSTERONE INJ

100MG/ML 23

DEPO-TESTOSTERONE INJ

200MG/ML 23

DERMA-SMOOTHE FS

0.01% OIL 109

DERMA-SMOOTHE FS OIL

0.01% 109

DESCOVY TAB 200-25MG 85

desipramine tab 100mg 45






desloratadine tab 5mg 55

desmopressin nasal spray0.01% 118

desmopressin nasal spray0.01%(refrigerated) 118



DESOGEN TAB 100

DESONATE GEL 0.05% 110

desonide cream 0.05% 110

desonide gel 0.05% 110

desonide lotion 0.05% 110

desonide ointment 0.05% 110

DESOWEN/TRIDESILON

CREAM 0.05% 110

DESOWEN LOTION 0.05% 110

desoximetasone cream0.05% 110

desoximetasone cream0.25% 110

desoximetasone gel 0.05% 110

desoximetasone ointment0.05% 110

desoximetasone ointment0.25% 110

desvenlafaxine succinate ERtab 100mg 44



DETROL LA CAP 2MG 155

DETROL LA CAP 4MG 155

DETROL TAB 1MG 155

DETROL TAB 2MG 155

DEXAMETHASONE CONC

1MG/ML 102

dexamethasone elixir0.5mg/5ml 102

DEXAMETHASONE ORAL

SOLN 0.5MG/5ML 102

DEXAMETHASONE

SODIUM PHOSPHATE

OPHTH SOLN 0.1% 140




DEXAMETHASONE TAB

1MG 102

DEXAMETHASONE TAB

2MG 102






dexmethylphenidate ER cap10mg 12












dexmethylphenidate tab 2.5mg13


dextroamphetamine ER cap10mg 11



dextroamphetamine soln5mg/5ml 11



dextrose inj 10% 137

dextrose inj 5% 137

DIALYVITE/ZINC TAB 135

dialyvite tab 135

DIALYVITE TAB 135

DIAMOX SEQUELS CAP

500MG 113

DIAPHRAGM 129

DIASTAT RECTAL GEL,

DIAZEPAM RECTAL

GEL 10MG 36

DIASTAT RECTAL GEL,

DIAZEPAM RECTAL

GEL 2.5MG 36

DIASTAT RECTAL GEL,

DIAZEPAM RECTAL

GEL 20MG 36

diazepam intensol conc5mg/ml 29

DIAZEPAM ORAL SOLN

1MG/ML 29

diazepam tab 10mg 29

diazepam tab 2mg 29

diazepam tab 5mg 29

diazoxide susp 50mg/ml 48

DIBENZYLINE CAP 10MG 60

diclofenac/misoprostol tab50-0.2mg 16

diclofenac/misoprostol tab75-0.2mg 16




diclofenac gel 1% 106

diclofenac gel 3% 107

diclofenac ophth soln 0.1% 141

diclofenac potassium tab50mg 16

diclofenac sodium topicalsoln 1.5% 106

diclofenac SR tab 100mg 16



dicyclomine cap 10mg 152

dicyclomine inj 10mg/ml 152

dicyclomine oral soln10mg/5ml 152

dicyclomine tab 20mg 152


DIDANOSINE DR CAP

200MG 85


DIDANOSINE DR CAP

250MG 85

DIDANOSINE DR CAP

400MG 85

DIFFERIN CREAM 0.1% 105

DIFFERIN GEL 0.1% 105

DIFFERIN GEL 0.1%

(OTC) 105

DIFFERIN GEL 0.3% 105

DIFFERIN LOTION 0.1% 105

DIFICID TAB 200MG 129

DIFLUCAN SUSP

10MG/ML 54

DIFLUCAN SUSP

40MG/ML 54





diflunisal tab 500mg 18

DIGOXIN 0.05MG/ML

ORAL SOLN 95

digoxin oral soln 0.05mg/ml 95

DIGOXIN ORAL SOLN

0.05MG/ML 95



dihydroergotamine nasalspray 4mg/ml 130



DILANTIN INFATABS

50MG 41

DILANTIN SUSP

125MG/5ML 41

DILATRATE SR CAP 40MG 28

DILAUDID ORAL SOLN

1MG/ML 19



DILAUDID TAB 2MG 19

DILAUDID TAB 4MG 19

DILAUDID TAB 8MG 19







DILTIAZEM ER CAP

120MG 94






















DILTIAZEM XR CAP

180MG 94


DILTIAZEM XR CAP

240MG 94

DIOVAN HCT TAB

160-12.5MG 62

DIOVAN HCT TAB

160-25MG 62

DIOVAN HCT TAB

320-12.5MG 62

DIOVAN HCT TAB

320-25MG 62

DIOVAN HCT TAB

80-12.5MG 63

DIOVAN TAB 160MG 60

DIOVAN TAB 320MG 60

DIOVAN TAB 40MG 60

DIOVAN TAB 80MG 60

DIPENTUM CAP 250MG 122

diphenhydramine elixir12.5mg/5ml (rx only) 54

DIPHENOXYLATE/

ATROPINE LIQUID

2.5-0.025MG/5ML 51

diphenoxylate/atropine tab2.5-0.025mg 51

DIPHTHERIA/TETANUS

PED VACCINE INJ 152

DIPROLENE AF CREAM

0.05% 110

DIPROLENE OINTMENT

0.05% 110

disopyramide cap 100mg 30

disopyramide cap 150mg 30






DIURIL SUSP 250MG/5ML 115






divalproex sprinkle cap125mg 41

docetaxel inj conc 160mg/8ml 75

DOCETAXEL INJ CONC

160MG/8ML 75

DOCETAXEL INJ CONC

200MG/10ML 75

docetaxel inj conc 20mg/ml 75

DOCETAXEL INJ CONC

20MG/ML 75

docetaxel inj conc 80mg/4ml 75

docetaxel IV soln 20mg/2ml 75

DOCETAXEL IV SOLN

20MG/2ML 75




DOLOPHINE TAB 10MG 19

DOLOPHINE TAB 5MG 19

donepezil ODT 10mg 146

donepezil ODT 5mg 146




DONNATAL ELIXIR 152

DOPTELET DAILY DOSE

PACK 40MG 126

DOPTELET DAILY DOSE

PACK 60MG 126

DOPTELET TAB 20MG 126

dorzolamide/timolol ophthsoln 22.3-6.8mg/ml 138

dorzolamide/timolol PF ophthsoln 22.3-6.8mg.ml 138

dorzolamide ophth soln 2% 141

DOVATO TAB 50-300MG 85

DOVONEX CREAM

0.005% 108

doxazosin tab 1mg 61




doxepin cap 100mg 46

doxepin cap 10mg 46

DOXEPIN CAP 150MG 46

doxepin cap 25mg 46

doxepin cap 50mg 46

doxepin cap 75mg 46

doxepin oral soln 10mg/ml 46

doxercalciferol cap 0.2mcg 117

doxercalciferol cap 1mcg 117

doxercalciferol cap 2.5mcg 117

doxycycline hyclate cap100mg 150

doxycycline hyclate cap50mg 150

doxycycline hyclate inj100mg 150

doxycycline hyclate tab100mg 150

doxycycline hyclate tab20mg 150

doxycycline monohydrate cap100mg 150

doxycycline monohydrate cap50mg 150

doxycycline monohydratesusp 25mg/5ml 150

doxycycline monohydrate tab100mg 150



D-PENAMINE TAB 125MG134

DRISDOL CAP 158

DRIZALMA DR CAP 20MG 44







dronabinol cap 10mg 52

dronabinol cap 2.5mg 52

dronabinol cap 5mg 52

DROXIA CAP 200MG 125



DRYSOL SOLN 112

DUAC GEL 1.2-5% 105

DULERA INHALER

100-5MCG 33

DULERA INHALER

200-5MCG 33

DULERA INHALER

50-5MCG 33





DUPIXENT PEN INJ

300MG/2ML 111

DUPIXENT SYRINGE

200MG/1.14ML 111

DUPIXENT SYRINGE

300MG/2ML 111

DURAGESIC PATCH

100MCG 19

DURAGESIC PATCH

12MCG 19

DURAGESIC PATCH

25MCG 19

DURAGESIC PATCH

50MCG 19

DURAGESIC PATCH

75MCG 19

duramorph inj 0.5mg/ml 19

duramorph inj 1mg/ml 19

DUREZOL OPHTH

EMULSION 0.05% 140

dutasteride/tamsulosin cap0.5-0.4mg 123

dutasteride cap 0.5mg 123

DUZALLO TAB

200-300MG 124

DYAZIDE CAP 37.5-25MG 114



E

EC-NAPROSYN TAB

375MG 16

EC-NAPROSYN TAB

500MG 16

econazole cream 1% 106

EDECRIN TAB 25MG 114

EDURANT TAB 25MG 85



efavirenz tab 600mg 85


EFFEXOR XR CAP 37.5MG 45


EFFIENT TAB 10MG 125

EFFIENT TAB 5MG 125

EFUDEX CREAM 5% 107

ELAVIL TAB 25MG 46

ELDEPRYL CAP 5MG 78

ELECTROLYTE-48

INJ/D5W 132

eletriptan tab 20mg 130

eletriptan tab 40mg 130

ELIDEL CREAM 1% 112


ELIGARD INJ 30MG 68

ELIGARD INJ 45MG 68


ELIMITE CREAM 5% 112

ELIQUIS TAB 2.5MG 34

ELIQUIS TAB 5MG 34

ELIXOPHYLLINE ELIXIR

80MG/15ML 33

ELMIRON CAP 100MG 123

ELOCON CREAM 0.1% 110

ELOCON OINTMENT

0.1% 110

eluryng 0.120-0.015mg 101

EMCYT CAP 140MG 68

EMEND CAP 125MG 53

EMEND CAP 40MG 53

EMEND CAP 80MG 53

EMEND CAP THERAPY

PACK 80-125MG 53

EMGALITY

AUTO-INJECTOR

120MG/ML 130

EMGALITY SYRINGE

100MG/ML 130

EMGALITY SYRINGE

120MG/ML 130

EMSAM PATCH 12MG 43

EMSAM PATCH 6MG 43

EMSAM PATCH 9MG 43

EMTRIVA CAP 200MG 85

EMTRIVA SOLN 10MG/ML 85

ENABLEX ER TAB 15MG 155

ENABLEX ER TAB 7.5MG 155

enalapril/hydrochlorothiazidetab 10-25mg 63

enalapril/hydrochlorothiazidetab 5-12.5mg 63


enalapril tab 2.5mg 59



ENBREL INJ 25MG 18

ENBREL INJ 25MG/0.5ML 18

ENBREL INJ 50MG/ML 18

ENBREL MINI INJ

50MG/ML 18

ENBREL SURECLICK INJ

50MG/ML 18

ENDARI POWDER FOR

ORAL SOLN 5GM 125

ENGERIX-B INJ 156

enoxaparin inj 100mg/ml 34

enoxaparin inj 120mg/0.8ml 35

enoxaparin inj 150mg/ml 35

enoxaparin inj 300mg/3ml 35








enpresse tab 100

entacapone tab 200mg 75

entecavir tab 0.5mg 88

entecavir tab 1mg 88

ENTOCORT EC CAP 3MG 102




ENVARSUS XR TAB

0.75MG 90

ENVARSUS XR TAB 1MG 90

ENVARSUS XR TAB 4MG 90

EPIDIOLEX ORAL SOLN

100MG/ML 37

EPIDUO (FORTE) GEL

0.3-2.5% 105

EPIDUO GEL 0.1-2.5% 105

epinastine ophth soln 0.05% 141

epinephrine auto-injector0.3mg/0.3ml 157

epinephrine inj 0.15mg (2pack) 157

EPIVIR HBV ORAL SOLN

5MG/ML 88

EPIVIR HBV TAB 100MG 88

EPIVIR ORAL SOLN

10MG/ML 85

EPIVIR TAB 150MG 85

EPIVIR TAB 300MG 85

eplerenone tab 25mg 65

eplerenone tab 50mg 65

EPZICOM TAB 600-300MG 85

EQUETRO CAP 100MG 78



ERAXIS INJ 100MG 53

ERAXIS INJ 50MG 53

ERGOLOID MESYLATES

TAB 1MG 149

ERGOMAR SL TAB 2MG 130

ERIVEDGE CAP 150MG 67

ERLEADA TAB 60MG 68

erlotinib tab 100mg 70



ERTACZO CREAM 2% 106

ertapenem inj 1gm 25

ERYGEL 2% 105

ERYPED SUSP

200MG/5ML 129

ERYPED SUSP

400MG/5ML 129




ERYTHROCIN INJ 500MG 129

erythromycin/benzoylperoxide gel 5-3% 105

erythromycin DR cap 250mg 129

ERYTHROMYCIN DR CAP

250MG 129

erythromycin gel 2% 105

erythromycin ophth ointment5mg/gm 139

erythromycin pad 2% 105

ERYTHROMYCIN PAD 2% 105

erythromycin soln 2% 105

erythromycin susp200mg/5ml 129

erythromycin susp400mg/5ml 129




ESBRIET CAP 267MG 149

ESBRIET TAB 267MG 150

ESBRIET TAB 801MG 150

ESCAVITE CHEW TAB 136

escitalopram soln 5mg/5ml 43




esomeprazole DR cap (rxonly) 20mg 153

esomeprazole DR cap (rxonly) 40mg 153

estazolam tab 1mg 127

estazolam tab 2mg 127

esterifiedestrogens/methyltestosterone tab 118

ESTRACE TAB 0.5MG 119

ESTRACE TAB 1MG 119

ESTRACE TAB 2MG 119

ESTRACE VAGINAL

CREAM 0.1MG 157







estradiol tab 0.5mg 119

estradiol tab 1mg 119

estradiol tab 2mg 119

estradiol twice weekly patch0.025mg 119





estradiol vaginal cream0.1mg/gm 157

estradiol valerate inj20mg/ml 120

estradiol valerate inj40mg/ml 120

ESTRING VAGINAL RING

2MG 157

eszopiclone tab 1mg 127



ethacrynic acid tab 25mg 114



ethosuximide cap 250mg 41




ethosuximide soln 250mg/5ml 41








ETOPOSIDE CAP 75

EURAX CREAM 10% 112

EURAX LOTION 10% 112

EVAMIST SPRAY 1.53MG 120

everolimus tab 0.25mg 134




everolimus tab 5mg 70


EVISTA TAB 60MG 116

EVOCLIN FOAM 1% 105

EVOTAZ TAB 300-150MG 85

EVOXAC CAP 30MG 135

EXELDERM CREAM 1% 106

EXELDERM SOLN 1% 106




exemestane tab 25mg 68

EXFORGE HCT TAB

10-160-12.5MG 63

EXFORGE HCT TAB

10-160-25MG 63

EXFORGE HCT TAB

10-320-25MG 63

EXFORGE HCT TAB

5-160-12.5MG 63

EXFORGE HCT TAB

5-160-25MG 63





EXJADE TAB (FOR

SUSPENSION) 125MG 51

EXJADE TAB (FOR


EXJADE TAB (FOR


EXTAVIA INJ 0.3MG 148

EXTINA FOAM 2% 106

ezetimibe/simvastatin tab10-10mg 55




ezetimibe tab 10mg 58

F




famotidine susp 40mg/5ml 153



FANAPT TAB 10MG 79

FANAPT TAB 12MG 79

FANAPT TAB 1MG 79

FANAPT TAB 2MG 79

FANAPT TAB 4MG 79

FANAPT TAB 6MG 79

FANAPT TAB 8MG 79

FANAPT TAB TITRATION

PACK 79

FARESTON TAB 60MG 68

FARXIGA TAB 10MG 50

FARXIGA TAB 5MG 50

FARYDAK CAP 10MG 70

FARYDAK CAP 15MG 70

FARYDAK CAP 20MG 70

FASENRA PEN INJ

30MG/ML 31

FASENRA SYRINGE

30MG/ML 31

FAZACLO ODT 100MG 81

FAZACLO ODT 12.5MG 81



FAZACLO ODT 25MG 81

febuxostat tab 40mg 124

febuxostat tab 80mg 124

felbamate susp 600mg/5ml 40



FELBATOL SUSP

600MG/5ML 40



FELDENE CAP 10MG 16

FELDENE CAP 20MG 17


felodipine ER tab 2.5mg 94


FEMALE CONDOMS 129

FEMARA TAB 2.5MG 68

FEMHRT LOW DOSE TAB 118

FEM PH GEL 156

FEMRING VAGINAL RING

0.05MG 157

FEMRING VAGINAL RING

0.1MG 157








fenofibric acid DR cap 135mg56


FENTANYL BUCCAL TAB

100MCG 19

FENTANYL BUCCAL TAB

200MCG 19

FENTANYL BUCCAL TAB

400MCG 19

FENTANYL BUCCAL TAB

600MCG 19

FENTANYL BUCCAL TAB

800MCG 19




fentanyl lozenge 1200mcg 19






fentanyl patch 100mcg 19





ferrex forte cap 126

FERRIPROX 2-DAY TAB

1000MG 51

FERRIPROX ORAL SOLN

100MG/ML 51

FERRIPROX TAB 1000MG 51

FERRIPROX TAB 500MG 51

ferrous sulfate elixir 127

FERROUS SULFATE

LIQUID 127

ferrous sulfate soln 127

FERROUS SULFATE

SYRUP 127

FETZIMA CAP TITRATION

PACK 45

FETZIMA ER CAP 120MG 45




FEXMID TAB 7.5MG 136

fexofenadine/pseudoephedrine 12-hourtab 103

fexofenadine/pseudoephedrine 24 hourtab 103

fexofenadine syrup 55

fexofenadine tab 55

FIASP FLEXTOUCH INJ

100UNIT/ML 49

FIASP INJ 100UNIT/ML 49

FIASP PENFILL INJ

100UNIT/ML 49



FINACEA FOAM 15% 112

FINACEA GEL 15% 112

finasteride tab 5mg 123

FIRMAGON INJ 120MG 68

FIRMAGON INJ 80MG 68

FIRST ATENOLOL ORAL

SOLN 91

FIRST METOPROLOL

ORAL SOLN 91

FIRST MOUTHWASH BLM

SUSP 134

FIRST OMEPRAZOLE

SUSP 153

FIRST-VANCOMYCIN

ORAL SOLN 25MG/ML 26

FIRST-VANCOMYCIN

ORAL SOLN 50MG/ML 26

FIRVANQ ORAL SOLN

25MG/ML 26

FIRVANQ ORAL SOLN

50MG/ML 26

FLAGYL CAP 375MG 25

FLAGYL TAB 250MG 25

FLAGYL TAB 500MG 25

FLAREX OPHTH SUSP

0.1% 140

flavoxate tab 100mg 156

FLEBOGAMMA INJ

0.5GM/10ML 142

FLEBOGAMMA INJ

20GM/200ML 142




FLECTOR PATCH,

DICLOFENAC PATCH

1.3%, 106

FLOMAX CAP 0.4MG 123

FLORIVA PLUS DROPS 136

FLOVENT DISKUS

100MCG 32

FLOVENT DISKUS

250MCG 32

FLOVENT DISKUS 50MCG 32

FLOVENT HFA INHALER

100MCG 32

FLOVENT HFA INHALER

220MCG 32

FLOVENT HFA INHALER

44MCG 32

fluconazole/dextrose inj200mg/100ml 54

fluconazole/dextrose inj400mg/200ml 54











fludrocortisone tab 0.1mg 103

FLUMADINE TAB 100MG 89

FLUNISOLIDE NASAL

SPRAY 0.025% 137

fluocinolone acetonide bodyoil 0.01% 110

fluocinolone acetonide cream0.01% 110

fluocinolone acetonide cream0.025% 110

fluocinolone acetonideointment 0.025% 110

fluocinolone acetonide scalpoil 0.01% 110

fluocinolone acetonidetopical soln 0.01% 110

fluocinolone otic oil 0.01% 142

fluocinonide cream 0.05% 110

fluocinonide e cream 0.05% 110

fluocinonide gel 0.05% 110

fluocinonide ointment 0.05% 110




fluocinonide soln 0.05% 110

FLUORABON SOLN 132

fluorometholone ophth susp0.1% 140

FLUOROPLEX CREAM

1% 107

FLUOROURACIL CREAM

0.5% 107

fluorouracil cream 5% 107

FLUOROURACIL SOLN

2% 107

FLUOROURACIL SOLN

5% 107




fluoxetine soln 20mg/5ml 43

fluoxetine tab (PMDD) 10mg148

fluoxetine tab (PMDD) 20mg149



fluphenazine decanoate inj25mg/ml 83

FLUPHENAZINE ELIXIR

2.5MG/5ML 83

FLUPHENAZINE INJ

2.5MG/ML 83

FLUPHENAZINE ORAL

CONC 5MG/ML 83



fluphenazine tab 2.5mg 83


flurandrenolide cream0.05% 110

flurandrenolide lotion 0.05%110



flurbiprofen ophth soln0.03% 141

FLURBIPROFEN OPHTH

SOLN 0.03% 141



flutamide cap 125mg 68

fluticasone/salmeterol diskus100-50mcg 33



fluticasone cream 0.05% 110

fluticasone nasal spray50mcg 137

fluticasone ointment 0.005% 110

FLUTICASONE

PROPIONATE/

SALMETEROL

XINAFOATE INH

232-14MCG/ACT 33

FLUTICASONE

PROPIONATE/

SALMETEROL

XINAFOATE INHALER

113-14MCG 33

FLUTICASONE

PROPIONATE/

SALMETEROL

XINAFOATE INHALER

55-14MCG 33

fluticasone propionate lotion0.05% 110



fluvastatin ER tab 80mg 57

fluvoxamine ER cap 100mg 43

fluvoxamine ER cap 150mg 43




FML FORTE OPHTH SUSP

0.25% 140

FML LIQUIFLM OPHTH

SUSP 0.1% 140

FML OPHTH OINTMENT

0.1% 140

FOCALIN TAB 10MG 13

FOCALIN TAB 2.5MG 13

FOCALIN TAB 5MG 13









FOLBEE PLUS CZ TAB 135

folbee tab 126

folic acid tab (OTC) 125

folic acid tab 1mg 125





FORTEO INJ

600MCG/2.4ML 115

FORTICAL SPRAY

200UNIT 115

FOSAMAX TAB 70MG 115

fosamprenavir tab 700mg 85

fosinopril/hydrochlorothiazide tab10-12.5mg 63

fosinopril/hydrochlorothiazide tab20-12.5mg 63




FOSRENOL POWDER

PACK 1000MG 122

FOSRENOL POWDER

PACK 750MG 122

FRAGMIN INJ

10000UNIT/ML 35

FRAGMIN INJ

12500UNIT/0.5ML 35

FRAGMIN INJ

15000UNIT/0.6ML 35

FRAGMIN INJ

18000UNIT/0.72ML 35




FRAGMIN INJ

2500UNIT/0.2ML 35

FRAGMIN INJ

5000UNIT/0.2ML 35

FRAGMIN INJ

7500UNIT/0.3ML 35

FRAGMIN INJ

95000UNIT/3.8ML 35

FREAMINE HBC INJ 6.9% 138

FREESTYLE FREEDOM

METER 129

FREESTYLE INSULINX

METER 129

FREESTYLE LITE METER 129

FREESTYLE PRECISION

NEO METER 130

FULPHILA INJ

6MG/0.6ML 126

FURADANTIN SUSP

25MG/5ML 154

furosemide inj 10mg/ml 114

furosemide oral soln10mg/ml 114

FUROSEMIDE ORAL

SOLN 8MG/ML 114




FUZEON INJ 90MG 85

FYCOMPA SUSP 0.5MG/ML35

FYCOMPA TAB 10MG 35

FYCOMPA TAB 12MG 35

FYCOMPA TAB 2MG 35

FYCOMPA TAB 4MG 36

FYCOMPA TAB 6MG 36

FYCOMPA TAB 8MG 36

G




gabapentin oral soln250mg/5ml 37



GABITRIL TAB 12MG 40

GABITRIL TAB 16MG 40

GABITRIL TAB 2MG 41

GABITRIL TAB 4MG 41

GALAFOLD CAP 123MG 117




GALANTAMINE ORAL

SOLN 4MG/ML 146

galantamine tab 12mg 146



GALZIN CAP 134

GAMMAGARD INJ 10GM 142

GAMMAGARD INJ

10GM/100ML 142

GAMMAGARD INJ

1GM/10ML 142

GAMMAGARD INJ

2.5GM/25ML 142

GAMMAGARD INJ

20GM/200ML 142

GAMMAGARD INJ

30GM/300ML 142

GAMMAGARD INJ 5GM 142

GAMMAGARD INJ

5GM/50ML 142

GAMMAPLEX INJ

10GM/100ML 142

GAMMAPLEX INJ

10GM/200ML 142

GAMMAPLEX INJ

20GM/400ML 142

GAMMAPLEX INJ

5GM/50ML 143

GAMUNEX-C INJ

40GM/400ML 143

GARDASIL INJ 156

GASTROCROM SOLN

100MG/5ML 121

gatifloxacin ophth soln 0.5% 139

GATTEX INJ 5MG 123

GAUZE PAD 2X2 129

GAVILYTE-C SOLN 128

gavilyte-G soln 236gm 128

gemfibrozil tab 600mg 56

GENERESS FE CHEW

TAB 100

GENOTROPIN INJ 0.2MG 116








GENOTROPIN INJ 12MG 116




GENTAK OPHTH

OINTMENT 0.3% 139

gentamicin cream 0.1% 106

gentamicin inj 40mg/ml 15

gentamicin ointment 0.1% 106

gentamicin ophth soln 0.3% 139

GENTAMICIN SULFATE

INJ 0.8MG/ML 15

gentamicin sulfate inj1.2mg/ml 15

GENTAMICIN SULFATE

INJ 1.6MG/ML 15

GENTAMICIN SULFATE

INJ 1MG/ML 15

GENVOYA TAB

150-150-200-10MG 85

GEODON CAP 20MG 78

GEODON CAP 40MG 78

GEODON CAP 60MG 78

GEODON CAP 80MG 78

GEODON INJ 20MG 78

GILENYA CAP 0.25MG 148

GILENYA CAP 0.5MG 148

GILOTRIF TAB 20MG 70






GILTUSS LIQUID 103

GLASSIA INJ 1000MG 149

glatiramer inj, glatopa inj20mg/ml 148

glatiramer inj, glatopa inj40mg/ml 148




glipizide/metformin tab2.5-250mg 47

glipizide/metformin tab2.5-500mg 47

glipizide/metformin tab5-500mg 47


glipizide ER tab 2.5mg 50




GLUCAGEN HYPOKIT INJ

1MG 48

GLUCAGON KIT 1MG 48

GLUCOPHAGE TAB

1000MG 48

GLUCOPHAGE TAB 500MG48

GLUCOPHAGE TAB 850MG48

GLUCOPHAGE XR TAB

500MG 48

GLUCOPHAGE XR TAB

750MG 48

GLUCOSE BLOOD TEST

STRIP 113



GLUCOTROL XL TAB

10MG 51

GLUCOTROL XL TAB

2.5MG 51


GLUCOVANCE TAB

2.5-500MG 47

GLUCOVANCE TAB

5-500MG 47

glyburide/metformin tab1.25-250mg 47

glyburide/metformin tab2.5-500mg 47

glyburide/metformin tab5-500mg 47



GLYSET TAB 100MG 47

GLYSET TAB 25MG 47

GLYSET TAB 50MG 47

GLYXAMBI TAB 10-5MG 47

GLYXAMBI TAB 25-5MG 47

GOLYTELY SOLN 236GM 128

granisetron tab 1mg 52

griseofulvin micro tab 500mg 53

griseofulvin susp 125mg/5ml 53





guaifenesin/codeine syrup 103

GUAIFENESIN/CODEINE

SYRUP 103





GUANIDINE TAB 125MG 66

GVOKE INJ 0.5MG/0.1ML 48

GVOKE INJ 1MG/0.2ML 48

GVOKE SYRINGE

0.5MG/0.1ML 48

GVOKE SYRINGE

1MG/0.2ML 48

H

HAEGARDA INJ

2000UNIT 124

HAEGARDA INJ

3000UNIT 124

HALCION TAB 0.25MG 127

HALDOL DECANOATE INJ

100MG/ML 80

HALDOL DECANOATE INJ

50MG/ML 80

HALDOL LACTATE INJ

5MG/ML 80

halobetasol cream 0.05% 110

halobetasol ointment 0.05% 110

haloperidol decanoate inj100mg/ml 80

haloperidol decanoate inj50mg/ml 80

haloperidol lactate inj 5mg/ml80

haloperidol lactate soln2mg/ml 80

haloperidol tab 0.5mg 80






HAVRIX INJ 1440 EL

UNIT/ML 156

HAVRIX INJ 720 EL

UNIT/0.5ML 156

heparin sodium inj (PF)5000unit/0.5ml 35

heparin sodium inj10000unit/ml 35




HEPATAMINE SOLN 8% 138

HEPSERA TAB 10MG 88

HETLIOZ CAP 20MG 128

HEXALEN CAP 50MG 67

HIBERIX INJ 156

HIPREX TAB 1GM 154

HIZENTRA INJ

10GM/50ML 143

HIZENTRA INJ 1GM/5ML 143

HIZENTRA INJ

2GM/10ML 143




HIZENTRA INJ

4GM/20ML 143

homatropine ophth soln 138

HOMATROPINE OPHTH

SOLN 138

HUMIRA AUTO-INJECTOR

40MG/0.8ML 15

HUMIRA INJ 10MG/0.1ML 15





HUMIRA PEDIATRIC

CROHN'S STARTER

PACK SYRINGE (2)

40MG/0.4ML,

80MG/0.8ML 15

HUMIRA PEDIATRIC

CROHN'S STARTER

PACK SYRINGE

40MG/0.8ML 15

HUMIRA PEDIATRIC

CROHN'S STARTER

PACK SYRINGE

80MG/0.8ML 15

HUMIRA PEN INJ

CROHN'S KIT

80MG/0.8ML 15

HUMIRA PEN INJECTOR

40MG/0.4ML 15

HUMIRA PEN INJ

PSORIASIS KIT

80MG/0.8ML,

40MG/0.4ML 15

HUMULIN R U-500 INJ

500UNIT/ML 49

HUMULIN R U-500

KWIKPEN 500UNIT/ML 49

HYCAMTIN CAP 75

HYCET SOLN

7.5-325MG/15ML 22





HYDREA CAP 500MG 74

hydrochlorothiazide cap12.5mg 115

hydrochlorothiazide tab12.5mg 115

hydrochlorothiazide tab25mg 115

hydrochlorothiazide tab50mg 115

hydrocodone/acetaminophensoln 10-325mg/15ml 22

hydrocodone/acetaminophensoln 7.5-325mg/15ml 22

hydrocodone/acetaminophentab 10-300mg 22




hydrocodone/acetaminophentab 7.5-300mg 22

hydrocodone/acetaminophentab 7.5-325mg 22

HYDROCODONE/

CHLORPHENIRAMINE/

PSE LIQUID 104

hydrocodone/chlorpheniramine/pseudoephedrine liquid 104

hydrocodone/chlorpheniramine susp 103

hydrocodone/homatropinesyrup 103

hydrocodone/ibuprofen tab10-200mg 22

hydrocodone/ibuprofen tab5-200mg 22

hydrocodone/ibuprofen tab7.5-200mg 22

hydrocortisone/pramoxinerectal cream 1-1% 24

hydrocortisone/pramoxinerectal cream 2.5-1% 24

hydrocortisone cream 1% 110

hydrocortisone cream 2.5% 110

hydrocortisone enema100mg/60ml 24

hydrocortisone lotion 2.5% 110

hydrocortisone ointment2.5% 110

hydrocortisone supp 24




hydrocortisone valeratecream 0.2% 110

hydrocortisone valerateointment 0.2% 110

hydromorphone inj 2mg/ml 19

HYDROMORPHONE INJ

4MG/ML 19

hydromorphone oral soln1mg/ml 19

hydromorphone PF inj10mg/ml 19

HYDROMORPHONE PF

INJ 10MG/ML 19

hydromorphone PF inj2mg/ml 19

HYDROMORPHONE SUPP 19

hydromorphone tab 2mg 19



hydroxychloroquine tab200mg 65

hydroxyurea cap 500mg 74

HYDROXYZINE PAMOATE

CAP 100MG 29

hydroxyzine pamoate cap25mg 29

hydroxyzine pamoate cap50mg 29

hydroxyzine syrup 10mg/5ml 29







hyoscyamine inj 154

hyoscyamine sulfate CR tab 152

hyoscyamine sulfate elixir 152

hyoscyamine sulfate ODT 152

hyoscyamine sulfate SL tab 152

hyoscyamine sulfate soln 152

hyoscyamine sulfate tab 152

HYPERRAB INJ

1500UNIT/10ML 143

HYPERRAB INJ

1500UNIT/5ML 143

HYPERRAB INJ

300UNIT/2ML 143

HYPERRAB INJ

300UNIT/ML 143

HYPERRAB INJ

900UNIT/3ML 143

HYPER SAL NEB SOLN 104

HYSINGLA ER TAB 100MG20

HYSINGLA ER TAB 120MG20

HYSINGLA ER TAB 20MG 20






HYZAAR TAB 100-25MG 63


I

ibandronate tab 150mg 115

IBRANCE CAP 100MG 71

IBRANCE CAP 125MG 71

IBRANCE CAP 75MG 71

IBRANCE TAB 100MG 71

IBRANCE TAB 125MG 71

IBRANCE TAB 75MG 71

IBUDONE TAB 10-200MG 22

ibuprofen susp (rx only)100mg/5ml 17




icatibant inj 30mg/3ml 124

ICLUSIG TAB 15MG 71

ICLUSIG TAB 45MG 71

IDHIFA TAB 100MG 71

IDHIFA TAB 50MG 71

ILEVRO OPHTH SUSP

0.3% 141



IMBRUVICA CAP 140MG 71

IMBRUVICA CAP 70MG 71

IMBRUVICA TAB 140MG 71




imipramine pamoate cap100mg 46




imipramine tab 10mg 46



imiquimod cream 5% 111

IMITREX INJ 6MG/0.5ML 130

IMITREX NASAL SPRAY

20MG 130

IMITREX NASAL SPRAY

5MG 130

IMITREX STATDOSE INJ

6MG/0.5ML 131

IMITREX STATDOSE

REFILL INJ 6MG/0.5ML 131

IMITREX TAB 100MG 131



IMOVAX RABIES INJ 156

IMPLANON IMPLANT,

NEXPLANON

IMPLANT 101

IMURAN TAB 50MG 90

INCRELEX INJ 40MG/4ML116

INCRUSE ELLIPTA

INHALER 62.5MCG 31







INDOCIN SUPP 50MG 17

INFANRIX INJ 152

INGREZZA CAP 40MG 148

INGREZZA CAP 80MG 148

INLYTA TAB 1MG 71

INLYTA TAB 5MG 71

INNOPRAN XL CAP

120MG 92


INREBIC CAP 100MG 71

INSPRA TAB 25MG 65

INSPRA TAB 50MG 65

INSULIN SYRINGE 130, 130

INSULIN SYRINGE U-500 130




INTRALIPID INJ 20% 137

INTRALIPID INJ 30% 137

INTRON-A INJ

10000000UNIT 74

INTRON-A INJ

18000000UNIT 74

INTRON-A INJ

50000000UNIT 75

INTRON-A INJ

6000000UNIT 75

INTUNIV TAB 1MG 12

INTUNIV TAB 2MG 12

INTUNIV TAB 3MG 12

INTUNIV TAB 4MG 12

INVANZ INJ 1GM 25

INVEGA SUSTENNA INJ

117MG/0.75ML 79




INVEGA SUSTENNA INJ

156MG/ML 79

INVEGA SUSTENNA INJ

234MG/1.5ML 79

INVEGA SUSTENNA INJ

39MG/0.25ML 79

INVEGA SUSTENNA INJ

78MG/0.5ML 79

INVEGA TAB 1.5MG 79

INVEGA TAB 3MG 79

INVEGA TAB 6MG 79

INVEGA TAB 9MG 79

INVEGA TRINZA INJ

273MG/0.875ML 79

INVEGA TRINZA INJ

410MG/1.315ML 80

INVEGA TRINZA INJ

546MG/1.75ML 80

INVEGA TRINZA INJ

819MG/2.625ML 80

INVIRASE CAP 200MG 85

INVIRASE TAB 500MG 85

iodoquinol/hydrocortisonecream 106

IONOSOL-MB INJ/D5W 132

IONOSOL-MB INJ D5W 132

IOPIDINE OPHTH SOLN

1% 139

IPOL INJ 156

ipratropium/albuterol nebsoln 0.5-2.5(3)mg/3ml 33

ipratropium nasal spray0.03% 137

ipratropium nasal spray0.06% 137

ipratropium neb soln 0.02% 31

irbesartan/hydrochlorothiazide tab150-12.5mg 63

irbesartan/hydrochlorothiazide tab300-12.5mg 63




IRESSA TAB 250MG 71

iron/vitamin C/vitaminB12/folic acid tab 127

IRON/VITAMIN

C/VITAMIN B12/FOLIC

ACID TAB 126

IRON

POLYSACCH/

THREONIC

ACID/B12/FA CAP 126

IRON SUSP 127

ISENTRESS CHEW TAB

100MG 85

ISENTRESS CHEW TAB

25MG 85

ISENTRESS HD TAB

600MG 85

ISENTRESS POWDER

PACK 100MG 85

ISENTRESS TAB 400MG 85

ISOLYTE-P INJ/D5W 132

ISOLYTE-S INJ 132

ISOLYTE-S INJ (PH 7.4) 132

isometheptene/caffeine/acetaminophen tab 130

ISOMETHEPTENE/

CAFFEINE/

ACETAMINOPHEN TAB130

ISONIAZID SYRUP

50MG/5ML 66


ISONIAZID TAB 100MG 66


ISOPTO CARBACHOL

OPHTH SOLN 138

ISOPTO CARPINE OPHTH

SOLN 1% 139


SOLN 2% 139


SOLN 4% 139

ISORDIL TAB 40MG 28

ISORDIL TAB 5MG 28

ISOSORBIDE DINITRATE

ER TAB 40MG 28






isosorbide mononitrate ERtab 120mg 28



isosorbide mononitrate tab10mg 28

isosorbide mononitrate tab20mg 28





isoxsuprine tab 96

isradipine cap 2.5mg 94

isradipine cap 5mg 94

ISTALOL OPHTH SOLN

0.5% 138

itraconazole cap 100mg 54

itraconazole oral soln10mg/ml 54

ivermectin tab 3mg 24

IXIARO INJ 156

J

JADENU GRANULE

PACKET 180MG 51

JADENU GRANULE

PACKET 360MG 51

JADENU GRANULE

PACKET 90MG 51

JADENU TAB 180MG 52

JADENU TAB 360MG 52

JADENU TAB 90MG 52

JAKAFI TAB 10MG 71

JAKAFI TAB 15MG 71




JAKAFI TAB 20MG 71

JAKAFI TAB 25MG 71

JAKAFI TAB 5MG 71

JALYN CAP 0.5-0.4MG 123

JANUMET TAB 50-1000MG 47

JANUMET TAB 50-500MG 47

JANUMET XR TAB

100-1000MG 47

JANUMET XR TAB

50-1000MG 47

JANUMET XR TAB

50-500MG 47

JANUVIA TAB 100MG 48

JANUVIA TAB 25MG 48

JANUVIA TAB 50MG 48



JENTADUETO TAB

2.5-1000MG 47

JENTADUETO TAB

2.5-500MG 47

JENTADUETO TAB

2.5-850MG 47

JENTADUETO XR TAB

2.5-1000MG 47

JENTADUETO XR TAB

5-1000MG 47

jinteli tab 1mg/5mcg 119

JULUCA TAB 50-25MG 85

junel FE tab 100

junel tab 100

JUXTAPID CAP 10MG 58




JUXTAPID CAP 5MG 58


JYNARQUE TAB 15MG 118

JYNARQUE TAB 30MG 118

JYNARQUE TAB

THERAPY PACK

30/15MG 118

JYNARQUE TAB

THERAPY PACK

45/15MG 118

JYNARQUE TAB

THERAPY PACK

60/30MG 118

JYNARQUE TAB

THERAPY PACK

90/30MG 118

K

KALETRA ORAL SOLN

400-100MG/5ML 85



KALYDECO PACKET

25MG 149

KALYDECO PACKET

50MG 149

KALYDECO PACKET

75MG 149

KALYDECO TAB 150MG 149

kariva tab 100

kcl/d5w/nacl inj10meq/5%/0.45% 132


KCL/D5W/NACL INJ

20MEQ/5%/0.225% 132


KCL/D5W/NACL INJ

20MEQ/5%/0.33% 132





KCL/D5W/NACL INJ

40MEQ/5%/0.9% 132

kcl/d5w inj 20meq/5% 132


KCL/NACL INJ

20MEQ/0.45% 132



KCL/ NACL INJ

40MEQ/0.9% 132

kelnor tab 100

KENALOG SPRAY

0.147MG/GM 110

KEPPRA ORAL SOLN

100MG/ML 37

KEPPRA TAB 1000MG 37

KEPPRA TAB 250MG 37

KEPPRA TAB 500MG 37

KEPPRA TAB 750MG 37



ketoconazole cream 2% 106

ketoconazole foam 2% 107

ketoconazole shampoo 2% 107

ketoconazole tab 200mg 54

KETO-DIASTIX 113

KETONE BLOOD TEST

STRIP 113

KETOPROFEN CAP 25MG 17

ketoprofen cap 75mg 17

KETOPROFEN ER CAP

200MG 17



ketorolac tromethamine tab10mg 17

KETOSTIX 113

ketotifen ophth soln 141

KEVZARA INJ

150MG/1.14ML 16

KEVZARA INJ

200MG/1.14ML 16

KISQALI/FEMARA TAB

CO-PACK 200MG 69

KISQALI/FEMARA TAB

CO-PACK 400MG 69




KISQALI/FEMARA TAB

CO-PACK 600MG 69

KISQALI DAILY DOSE

PACK 200MG 71

KISQALI DAILY DOSE

PACK 400MG 71

KISQALI DAILY DOSE

PACK 600MG 72

KITABIS NEB SOLN

300MG/5ML 15

KLARON LOTION 10% 105

KLONOPIN TAB 0.5MG 36

KLONOPIN TAB 1MG 36

KLONOPIN TAB 2MG 36


KLOR-CON M15 ER TAB

15MEQ 133


KLOR-CON POWDER

PACKET 133

KORLYM TAB 300MG 48

KOSELUGO CAP 10MG 72

KOSELUGO CAP 25MG 72

K-PHOS NEUTRAL TAB 133

K-PHOS TAB 133

KRINTAFEL TAB 150MG 65

KRISTALOSE PACK 10GM 128

KRISTALOSE PACKET

20GM 128

K-TAB 20MEQ 133

K-TAB ER TAB 8MEQ 133

K-TABS CR TAB 10MEQ 133

KUVAN POWDER PACKET

100MG 117

KUVAN POWDER PACKET

500MG 117

KUVAN TAB 100MG 117

L




LAC-HYDRIN LOTION 111

LACRISERT OPHTH

INSERT 138

lactulose soln 10gm/15ml 122

lactulose soln 10mg/15ml 128

LAMICTAL CHEW TAB

25MG 37

LAMICTAL CHEW TAB

5MG 37





LAMICTAL ODT KIT 37





LAMICTAL TAB STARTER

KIT 38

LAMICTAL XR KIT 38

LAMICTAL XR TAB 100MG38






lamivudine/zidovudine tab150-300mg 85

lamivudine oral soln 10mg/ml 85




















lamotrigine tab starter kit25mg (35) 38

lamotrigine tab starter kit25mg (42)/100mg (7) 38

lamotrigine tab starter kit25mg (84)/100mg (14) 38

LANCET DEVICE 129

LANCET KIT 130

LANCETS 130



lansoprazole/amoxicillin/clarithromycin pack500-500-30mg 154





LANSOPRAZOLE SUSP 153

lanthanum carbonate chewtab 1000mg 122



LANTUS INJ 100UNIT/ML 49

LANTUS SOLOSTAR INJ

100UNIT/ML 49

LASIX TAB 20MG 114

LASIX TAB 40MG 114

LASIX TAB 80MG 114

LASTACAFT OPHTH SOLN

0.25% 141

latanoprost ophth soln0.005% 142

LATUDA TAB 120MG 79

LATUDA TAB 20MG 79

LATUDA TAB 40MG 79

LATUDA TAB 60MG 79

LATUDA TAB 80MG 79




LAZANDA NASAL SPRAY

100MCG 20

LAZANDA NASAL SPRAY

300MCG 20

LAZANDA NASAL SPRAY

400MCG 20



LENVIMA CAP THERAPY

PACK (10MG) 72

LENVIMA CAP THERAPY

PACK (12MG) 72

LENVIMA CAP THERAPY

PACK (14MG) 72

LENVIMA CAP THERAPY

PACK (18MG) 72

LENVIMA CAP THERAPY

PACK (20MG) 72

LENVIMA CAP THERAPY

PACK (24MG) 72

LENVIMA CAP THERAPY

PACK (4MG) 72

LENVIMA CAP THERAPY

PACK (8MG) 72

LESCOL XL TAB 80MG 57

letrozole tab 2.5mg 68





LEUKERAN TAB 2MG 67

LEUKINE INJ 250MCG 126

leuprolide inj 5mg/ml 68

LEVALBUTEROL HFA

INHALER, XOPENEX

HFA INHALER 45MCG 33

levalbuterol neb soln0.31mg/3ml 33


levalbuterol neb soln1.25mg/0.5ml 33


LEVBID TAB 152

LEVEMIR FLEXTOUCH

100UNIT/ML 49

LEVEMIR INJ 100UNIT/ML 49



levetiracetam oral soln100mg/ml 38





levobunolol ophth soln 0.5% 138

LEVOBUNOLOL OPHTH

SOLN 0.5% 138

levocarnitine oral soln1gm/10ml 117

levocarnitine tab 330mg 117

levocetirizine oral soln2.5mg/5ml 55

levocetirizine tab 5mg 55

levofloxacin inj250mg/50ml/D5W 120

levofloxacin inj 25mg/ml 120



levofloxacin ophth soln 0.5%139

levofloxacin oral soln25mg/ml 120




levonorgestrel tab 101

levora-28 tab 100













LEVSIN INJ 154

LEVSIN SL TAB 152

LEVSIN TAB 152

LEXAPRO TAB 10MG 43

LEXAPRO TAB 20MG 43

LEXAPRO TAB 5MG 43

LEXIVA SUSP 50MG/ML 85

LEXIVA TAB 700MG 85

LIBRAX CAP 152

lidocaine/hydrocortisonecream 24

lidocaine/prilocaine cream2.5-2.5% 112

lidocaine cream (rx only)3% 112

lidocaine gel 2% 112

LIDOCAINE GEL 2% 112

lidocaine ointment 5% 112

LIDOCAINE ORAL SOLN

4% 135

lidocaine patch 5% 112

lidocaine topical soln 4% 112

lidocaine viscous soln 2% 135

LIDODERM PATCH 5% 112

lindane shampoo 1% 113

LINDANE SHAMPOO 1% 113

LINEZOLID INJ 2MG/ML 27

linezolid inj 600mg/300ml 27

linezolid susp 100mg/5ml 27

linezolid tab 600mg 27

LINZESS CAP 145MCG 122






LIPITOR TAB 10MG 57

LIPITOR TAB 20MG 57

LIPITOR TAB 40MG 57

LIPITOR TAB 80MG 57




LIPOFEN CAP 150MG 56

LIPOFEN CAP 50MG 56

lisinopril/hydrochlorothiazidetab 10-12.5mg 63

lisinopril/hydrochlorothiazidetab 20-12.5mg 63

lisinopril/hydrochlorothiazidetab 20-25mg 63


lisinopril tab 2.5mg 59






LITHIUM CARBONATE

CAP 150MG 78



LITHIUM CARBONATE

CAP 600MG 78

lithium carbonate ER tab300mg 78

lithium carbonate ER tab450mg 78

lithium carbonate tab 300mg 78

lithium citrate soln 8meq/5ml 78

LITHIUM CITRATE SOLN

8MEQ/5ML 78

LITHOBID CR TAB 300MG 78

LITHOSTAT TAB 250MG 124

LIVALO TAB 1MG 57

LIVALO TAB 2MG 57

LIVALO TAB 4MG 57

LODINE TAB 400MG 17

LODOSYN TAB 25MG 75

LOESTRIN FE TAB 100

LOESTRIN TAB 100

LOKELMA PACKET 10GM134

LOKELMA PACKET 5GM 134

LO LOESTRIN FE TAB 100

LOMOTIL TAB

2.5-0.025MG 51




LONHALA NEB SOLN

0.0025% 31

LONSURF TAB 15-6.14MG 69

LONSURF TAB 20-8.19MG 69

loperamide cap 2mg 51

LOPID TAB 600MG 56

lopinavir/ritonavir oral soln400-100mg/5ml 85

LOPRESSOR HCT TAB

50-25MG 63

LOPRESSOR TAB 100MG 91

LOPROX CREAM 0.77% 107

LOPROX SHAMPOO 1% 107

loratadine/pseudoephedrinetab 104

loratadine cap 55

loratadine chew tab 55

loratadine ODT 55

loratadine syrup 55

loratadine tab 55

lorazepam intensol conc2mg/ml 29

lorazepam tab 0.5mg 30

lorazepam tab 1mg 30

lorazepam tab 2mg 30

LORBRENA TAB 100MG 72

LORBRENA TAB 25MG 72

losartan/hydrochlorothiazidetab 100-12.5mg 63

losartan/hydrochlorothiazidetab 100-25mg 63

losartan/hydrochlorothiazidetab 50-12.5mg 63




LOSEASONIQUE TAB 100

LOTEMAX OPHTH GEL

0.5% 140

LOTEMAX OPHTH

OINTMENT 0.5% 140

LOTEMAX OPHTH SUSP

0.5% 140

LOTENSIN TAB 10MG 59



loteprednol ophth susp 0.5% 140





LOTRISONE CREAM

1-0.05% 107

LOTRONEX TAB 0.5MG 122

LOTRONEX TAB 1MG 122

lovastatin tab 10mg 57



LOVAZA CAP 1GM 55

LOVENOX INJ 100MG/ML 35

LOVENOX INJ

120MG/0.8ML 35

LOVENOX INJ 150MG/ML 35

LOVENOX INJ 300MG/3ML 35

LOVENOX INJ

30MG/0.3ML 35

LOVENOX INJ

40MG/0.4ML 35

LOVENOX INJ

60MG/0.6ML 35

LOVENOX INJ

80MG/0.8ML 35

loxapine cap 10mg 81



loxapine cap 5mg 81

LUCEMYRA TAB 0.18MG 146

LUMIGAN OPHTH SOLN

0.01% 142

LUNESTA TAB 1MG 127

LUNESTA TAB 2MG 127

LUNESTA TAB 3MG 127

LUPANETA PACK

1-MONTH PACK 116




LUPANETA PACK

3-MONTH PACK 116

LUPRON DEPOT INJ

11.25MG 68

LUPRON DEPOT INJ

22.5MG 68

LUPRON DEPOT INJ

3.75MG 68



LUPRON DEPOT INJ 7.5MG68

LUPRON INJ PED KIT

11.25MG (3 MONTH) 116

LUPRON INJ PED KIT

7.5MG (1 MONTH) 116

LURIDE CHEW TAB 132

LURIDE SOLN 132

LYNPARZA CAP 50MG 72

LYNPARZA TAB 100MG 72

LYNPARZA TAB 150MG 72

LYSODREN TAB 500MG 68

LYSTEDA TAB 650MG 127

M

MACROBID CAP 100MG 154

MACRODANTIN CAP

100MG 154

MACRODANTIN CAP

25MG 154

MACRODANTIN CAP

50MG 154

mafenide topical soln 5% 108

MAGNESIUM

SULFATE/D5W 5% IV

SOLN 133

magnesium sulfate/d5w inj 133

MAGNESIUM SULFATE

1%/D5W INJ 133

magnesium sulfate inj20gm/500ml 133





magnesium sulfate inj 50% 133

MALARONE TAB

250-100MG 65

MALARONE TAB

62.5-25MG 65

malathion lotion 0.5% 113




MARINOL CAP 10MG 52

MARINOL CAP 2.5MG 52

MARINOL CAP 5MG 53

MARPLAN TAB 10MG 43

MATULANE CAP 50MG 75

MAVYRET TAB 100-40MG 88

MAXALT MLT TAB 10MG 131

MAXALT MLT TAB 5MG 131

MAXALT TAB 10MG 131

MAXIDEX OPHTH SUSP

0.1% 140

MAXIPIME INJ 1GM 100

MAXIPIME INJ 2GM 100

MAXITROL OPHTH

OINTMENT 0.1% 140

MAXITROL OPHTH SUSP

0.1% 140

MAXZIDE TAB 37.5-25MG114

MAXZIDE TAB 75-50MG 114

MAYZENT TAB 0.25MG 148

MAYZENT TAB 2MG 148

meclizine chew tab 52

meclizine tab 12.5mg 52

meclizine tab 25mg 52

MEDROL TAB 16MG 102

MEDROL TAB 2MG 102

MEDROL TAB 32MG 102

MEDROL TAB 4MG 102

MEDROL TAB 8MG 102

MEDROL TAB DOSE PACK

4MG (21) 102

medroxyprogesterone acetatetab 10mg 145

medroxyprogesterone acetatetab 2.5mg 145

medroxyprogesterone acetatetab 5mg 145

medroxyprogesterone inj150mg/ml 101

MEFLOQUINE TAB 250MG 65

MEGACE ES SUSP

625MG/5ML 145

megestrol acetate susp40mg/ml 68

megestrol acetate tab 20mg 68

megestrol acetate tab 40mg 68

megestrol ES susp325mg/5ml 145

MEKINIST TAB 0.5MG 72

MEKINIST TAB 2MG 72

MEKTOVI TAB 15MG 72

meloxicam tab 15mg 17

meloxicam tab 7.5mg 17

melphalan tab 67





memantine oral soln 2mg/ml 146



memantine tab titration pack5mg/10mg 146

MENACTRA INJ 156




MENOSTAR PATCH

14MCG 120

MENTAX CREAM 1% 107

MENVEO INJ 156

MEPRON SUSP

750MG/5ML 25

mercaptopurine tab 50mg 67




MEROPENEM INJ

0.9%/1GM/50ML 25

meropenem inj 1gm 25

meropenem inj 500mg 25

MEROPENEM INJ

500MG/50ML 25

MERREM INJ 500MG 25

mesalamine DR cap 400mg 122

mesalamine DR tab 1.2gm 122

mesalamine DR tab 800mg 122

mesalamine enema 4gm 122

mesalamine enema kit 4gm 122

mesalamine er cap 0.375gm 122

mesalamine rectal supp1000mg 122

MESNEX TAB 400MG 75

MESTINON TAB 60MG 66

MESTINON TIMESPAN

TAB 180MG 66







METAPROTERENOL

SYRUP 10MG/5ML 11


METAXALONE TAB

400MG 136




metformin hcl soln 500mg/5ml48




methadone conc 10mg/ml 20

methadone oral soln10mg/5ml 20

METHADONE ORAL SOLN

10MG/5ML 20

methadone oral soln 5mg/5ml 20

METHADONE ORAL SOLN

5MG/5ML 20

methadone tab 10mg 20

methadone tab 5mg 20



methenamine hippurate tab1gm 154

methenamine mandelate tab 154



METHITEST TAB 10MG 23



METHOTREXATE INJ

250MG/10ML 67

methotrexate inj 50mg/2ml 67

methotrexate PF inj 50mg/2ml67

methotrexate tab 2.5mg 67

methoxsalen cap 10mg 108

methscopolamine tab 2.5mg 152

methscopolamine tab 5mg 152

METHYCLOTHIAZIDE

TAB 5MG 115

methylergonovine tab 0.2mg 142

METHYLIN SOLN

10MG/5ML 13

METHYLIN SOLN

5MG/5ML 13





methylphenidate CD cap10mg 13






methylphenidate chew tab10mg 13

methylphenidate chew tab2.5mg 13

methylphenidate chew tab5mg 13

methylphenidate ER osmotictab 18mg 13





METHYLPHENIDATE ER

TAB 18MG 14





methylphenidate LA cap 10mg14





methylphenidate soln10mg/5ml 14

methylphenidate soln5mg/5ml 14




methylprednisolone tab16mg 102

methylprednisolone tab32mg 102

methylprednisolone tab 4mg 102

methylprednisolone tab 8mg 102

methylprednisolone tab dosepack 4mg 102




METHYLTESTOSTERONE

CAP 10MG 23

metoclopramide soln5mg/5ml 121




metolazone tab 2.5mg 115


metoprolol/hydrochlorothiazide tab100-25mg 63


METOPROLOL/

HYDROCHLOROTHIAZIDE

TAB 100-50MG 63









METROCREAM 0.75% 112

METROGEL 1% 112

METROGEL VAGINAL

GEL 0.75% 157

METROLOTION 0.75% 112

metronidazole/nacl inj0.74%/500mg/100ml 25

METRONIDAZOLE/NACL

INJ 0.74%/500MG/100ML 25

metronidazole/nacl inj0.79%/500mg/100ml 25

metronidazole cap 375mg 25

metronidazole cream 0.75% 112

metronidazole gel 0.75% 112

metronidazole gel 1% 112

metronidazole lotion 0.75% 112



metronidazole vaginal gel0.75% 157




mibelas chew tab 100



MICARDIS HCT TAB

40-12.5MG 63

MICARDIS HCT TAB

80-12.5MG 63

MICARDIS HCT TAB

80-25MG 63

MICARDIS TAB 20MG 60



MICONAZOLE 3 SUPP

200MG 157

MICROZIDE CAP 12.5MG 115


midodrine tab 2.5mg 157





miglustat cap 100mg 125

MILLIPRED DP PAK 5MG

(21) 102

MILLIPRED DP PAK 5MG

(48) 102

MILLIPRED TAB 5MG 102

mimvey LO tab 0.5-0.1mg 119

mimvey tab 1-0.5mg 119

MINASTRIN CHEW TAB 100

MINIPRESS CAP 1MG 61



MINIVELLE PATCH

0.0375MG 120

MINOCIN CAP 100MG 150

MINOCIN CAP 50MG 150

MINOCIN INJ 100MG 150







minoxidil tab 10mg 65

minoxidil tab 2.5mg 65

MIRAPEX ER TAB

0.375MG 76





MIRAPEX ER TAB 3MG 76







MIRAPEX TAB 1MG 76

MIRENA IUD 101







mirtazapine tab 7.5mg 42



MITIGARE CAP 0.6MG 124

M-M-R II INJ 156

MOBIC TAB 15MG 17

MOBIC TAB 7.5MG 17

modafinil tab 100mg 14

modafinil tab 200mg 14

moexipril/hydrochlorothiazidetab 15-12.5mg 63

moexipril/hydrochlorothiazidetab 15-25mg 63




moexipril/hydrochlorothiazidetab 7.5-12.5mg 63

moexipril tab 15mg 59

moexipril tab 7.5mg 59




mometasone cream 0.1% 110

mometasone furoate ointment0.1% 111

mometasone lotion 0.1% 111



montelukast granules 4mg 31

montelukast tab 10mg 31

MONUROL PACKET 3GM 154

morphine sulfate ER tab100mg 20

morphine sulfate ER tab 15mg20

morphine sulfate ER tab200mg 20



MORPHINE SULFATE INJ

10MG/ML 20



1MG/ML 20



8MG/ML 20

MORPHINE SULFATE IV

SOLN 25MG/ML 20

MORPHINE SULFATE IV

SOLN 50MG/ML 20

MORPHINE SULFATE IV

SOLN 5MG/ML 20

morphine sulfate oral soln100mg/5ml 20



morphine sulfate PF inj10mg/ml 20

MORPHINE SULFATE PF

INJ 10MG/ML 20

MORPHINE SULFATE PF

INJ 2MG/ML 20


MORPHINE SULFATE PF

INJ 4MG/ML 20


MORPHINE SULFATE PF

INJ 8MG/ML 20

MORPHINE SULFATE SUPP20

morphine sulfate tab 15mg 21

MORPHINE SULFATE TAB

15MG 21

morphine sulfate tab 30mg 21

MORPHINE SULFATE TAB

30MG 21

MOTRIN SUSP (OTC) 17

MOVANTIK TAB 12.5MG 122

MOVANTIK TAB 25MG 122

moxifloxacin 0.5% ophthsoln 139

MOXIFLOXACIN IN

SODIUM CHLORIDE INJ

400MG/250ML 121

MOXIFLOXACIN IV SOLN

400MG/250ML 121

moxifloxacin ophth soln0.5% 139

moxifloxacin tab 400mg 121

MS CONTIN TAB 100MG 21





MULPLETA TAB 3MG 126

MULTAQ TAB 400MG 31

MULTIGEN FOLIC TAB 127

MULTIGEN PLUS TAB 127

MULTIGEN TAB 127

multivitamin/minerals tab 135

mupirocin ointment 2% 106

MUSE SUPP 96

MYAMBUTOL TAB 400MG 66



MYCOBUTIN CAP 150MG 66

mycophenolate cap 250mg 90

mycophenolate DR tab 180mg90

mycophenolate DR tab 360mg90

mycophenolate mofetil susp200mg/ml 90

mycophenolate tab 500mg 90

MYFORTIC TAB 180MG 90

MYFORTIC TAB 360MG 90

MYLERAN TAB 67





N



nadolol tab 20mg 92

nadolol tab 40mg 92

nadolol tab 80mg 92








NAFTIFINE CREAM 1% 107


NAFTIN CREAM 2% 107

NAFTIN GEL 1% 107

NAFTIN GEL 2% 107

naloxone inj 0.4mg/ml 51

naloxone prefilled inj2mg/2ml 52

NALOXONE SOLN

CARTRIDGE 0.4MG/ML 52




naltrexone tab 50mg 52

NAMENDA TAB 10MG 146

NAMENDA TAB 5MG 147

NAMENDA TAB

TITRATION PACK 147

NAMENDA XR CAP 14MG147




NAMENDA XR CAP

TITRATION PACK 147








naratriptan tab 1mg 131

naratriptan tab 2.5mg 131

NARCAN NASAL SPRAY

4MG/0.1ML 52

NARDIL TAB 15MG 43

NASACORT NASAL SPRAY

(OTC) 137

NASCOBAL SPRAY 125

NATACYN OPHTH SUSP

5% 139

NATAZIA TAB 100



NATPARA INJ 100MCG 115




NAYZILAM NASAL SPRAY

5MG/0.1ML 36

NEBUPENT NEB SOLN

300MG 25

NEBUSAL NEB SOLN 104

necon tab 100






NEOMYCIN/GRAMICIDIN/

POLYMYXIN B OPHTH

SOLN

1.75-10000UNIT-0.025MG/

ML 139

neomycin/polymyxin/dexamethasone ophthointment 0.1% 140

neomycin/polymyxin/dexamethasone ophth susp0.1% 140

NEOMYCIN/POLYMYXIN/

HYDROCORTISONE

OPHTH SUSP

3.5-10000UNIT-10MG/

ML 140

neomycin/polymyxin/hydrocortisone otic soln1% 142

neomycin/polymyxin/hydrocortisone otic susp3.5-10000unit-1% 142

neomycin tab 500mg 15

NEORAL CAP 100MG 90

NEORAL CAP 25MG 90

NEORAL SOLN 100MG/ML 90

NEOSPORIN OPHTH SOLN

1.75-10000UNIT-0.025MG/

ML 139

NEOTUSS LIQUID 104

NEPHRAMINE INJ 5.4% 138

NEPHRO CAP 135

NEPHRO-VITE TAB 135

NERLYNX TAB 40MG 72

NEUPRO PATCH 1MG 76

NEUPRO PATCH 2MG 76

NEUPRO PATCH 3MG 77

NEUPRO PATCH 4MG 77

NEUPRO PATCH 6MG 77

NEUPRO PATCH 8MG 77




NEURONTIN ORAL SOLN

250MG/5ML 38



NEVANAC OPHTH SUSP

0.1% 141


NEVIRAPINE ER TAB

100MG 86


nevirapine susp 50mg/5ml 86

nevirapine tab 200mg 86

NEXAVAR TAB 200MG 72

NEXIUM DR CAP 20MG

(RX ONLY) 153

NEXIUM DR CAP 40MG

(RX ONLY) 153

niacinamide tab 158

niacin cap (OTC) 158

niacin CR tab 158




niacin tab (OTC) 158

NIACIN TR TAB (OTC) 158






NICORETTE CQ PATCH 149

NICORETTE GUM 149

nicotine gum 149

nicotine lozenge 149

nicotine patch 149

NICOTINE PATCH KIT 149

NICOTROL INHALER

10MG 149

NICOTROL NASAL SPRAY

10MG/ML 149







nikki 28 day tab 100

NILANDRON TAB 150MG 68

nilutamide tab 150mg 68

nimodipine cap 30mg 94

NINLARO CAP 2.3MG 72

NINLARO CAP 3MG 72

NINLARO CAP 4MG 72


NISOLDIPINE ER TAB

20MG 94

NISOLDIPINE ER TAB

30MG 94


NISOLDIPINE ER TAB

40MG 94

nisoldipine ER tab 8.5mg 94

NISOLDIPINE SR TAB

25.5MG 94

nitisinone cap 10mg 117



NITRO-BID OINTMENT 2% 28







nitrofurantoin cap 100mg 155

nitrofurantoin macro cap100mg 155



nitrofurantoin susp25mg/5ml 155

NITROGLYCERIN

AEROSOL 400MCG 28

NITROGLYCERIN CAP 28

nitroglycerin lingual pumpspray 400mcg 28








NITROLINGUAL PUMP

SPRAY 400MCG 28

NITROMIST AEROSOL

400MCG 28




NIVESTYM INJ

300MCG/1ML 126

NIVESTYM INJ

480MCG/1.6ML 126

NIVESTYM PF INJ

300MCG/0.5ML 126

NIVESTYM PF INJ

480MCG/0.8ML 126


NIZATIDINE CAP 150MG 154


NIZATIDINE ORAL SOLN

15MG/ML 153

NIZORAL SHAMPOO 2% 107

NORCO TAB 10-325MG 22

NORCO TAB 5-325MG 22

NORCO TAB 7.5-325MG 22

norethindrone/ethinylestradiol FE chew tab 100

norethindrone/ethinylestradiol FE tab 101

norethindrone acetate/ethinylestradiol tab0.5mg/2.5mcg 119

norethindrone acetate tab5mg 145

norethindrone tab 0.35mg 102

NORINYL TAB 101

NORMOSOL-M INJ/D5W 132

NORMOSOL-R INJ 132

NORMOSOL-R INJ/D5W 132

NORMOSOL-R INJ (PH

7.4) 132

NORPACE CAP 100MG 30

NORPACE CAP 150MG 30

NORPACE CR CAP 100MG 30

NORPACE CR CAP 150MG 30

NORPRAMIN TAB 10MG 46



NOR-QD TAB 0.35MG 102

NORTHERA CAP 100MG 157







NORTRIPTYLINE ORAL

SOLN 10MG/5ML 46

NORVASC TAB 10MG 95

NORVASC TAB 2.5MG 95

NORVASC TAB 5MG 95

NORVIR ORAL SOLN

80MG/ML 86

NORVIR POWDER PACKET

100MG 86

NORVIR TAB 100MG 86

novamine inj 15% 138

NOVOLIN MIX (70/30)

FLEXPEN 100UNIT/ML 49

NOVOLIN MIX (70/30)

VIAL 100UNIT/ML 49

NOVOLIN N FLEXPEN INJ

100UNIT/ML 49

NOVOLIN N INJ

100UNIT/ML 49

NOVOLIN R FLEXPEN INJ

100UNIT/ML 49

NOVOLIN R INJ

100UNIT/ML 49

NOVOLOG CARTRIDGE

100UNIT/ML, INSULIN

ASPART CARTRIDGE

100UNIT/ML 49




NOVOLOG INJ

100UNIT/ML, INSULIN

ASPART INJ

100UNIT/ML 49

NOVOLOG MIX (70/30) INJ

100UNIT/ML, INSULIN

ASPART MIX (70/30) INJ

100UNIT/ML 49

NOVOLOG MIX (70/30)

PEN INJ 100UNIT/ML,

INSULIN ASPART MIX

(70/30) PEN INJ

100UNIT/ML 49

NOVOLOG PEN INJ

100UNIT/ML , INSULIN

ASPART PEN INJ

100UNIT/ML 50

NOXAFIL DR TAB 100MG 54

NOXAFIL SUSP 40MG/ML 54

NUBEQA TAB 300MG 68

NUCALA AUTO-INJECTOR

100MG/ML 31

NUCALA INJ 100MG 31

NUCALA SYRINGE

100MG/ML 31

NUCORT LOTION 111

NUCYNTA ER TAB 100MG 21





NUEDEXTA CAP 20-10MG149

NUPLAZID CAP 34MG 79

NUPLAZID TAB 10MG 79

NUPLAZID TAB 17MG 79

NUVARING

0.120-0.015MG 101

NUVIGIL TAB 150MG 14



NUVIGIL TAB 50MG 14

NUZYRA TAB 150MG 150

nystatin cream100000unit/gm 107

nystatin ointment100000unit/gm 107

nystatin powder100000unit/gm 107

nystatin susp 100000unit/ml 135

nystatin tab 500000unit 53

O

OCALIVA TAB 10MG 121

OCALIVA TAB 5MG 121

ocella tab, zarah tab 101

OCTAGAM INJ 1GM/20ML143

OCTAGAM INJ

2.5GM/50ML 143

OCTAGAM INJ

25GM/500ML 143

OCTAGAM INJ 2GM/20ML143

OCTAGAM INJ

30GM/300ML 143

OCTAGAM INJ

5GM/100ML 143






OCUFLOX OPHTH SOLN

0.3% 139

ODEFSEY TAB

200-25-25MG 86

ODOMZO CAP 200MG 67

OFEV CAP 100MG 150

OFEV CAP 150MG 150

ofloxacin ophth soln 0.3% 139

ofloxacin otic soln 0.3% 142

ofloxacin tab 400mg 121

OGESTREL TAB 101

olanzapine/fluoxetine cap12-25mg 147





olanzapine inj 10mg 81











olmesartan/hydrochlorothiazide tab20-12.5mg 63

olmesartan/hydrochlorothiazide tab40-12.5mg 64

olmesartan/hydrochlorothiazide tab40-25mg 64




olopatadine nasal spray0.6% 137



OLUMIANT TAB 1MG 15

OLUMIANT TAB 2MG 15

OLUX-E FOAM 0.05% 111

OLUX FOAM 0.05% 111

omega-3-acid ethyl esters cap1gm 55




ondansetron ODT 4mg 52

ondansetron ODT 8mg 52

ondansetron oral soln4mg/5ml 52




ondansetron tab 24mg 52

ONDANSETRON TAB

24MG 52



ONEXTON GEL 1.2-3.75% 105

ONFI SUSP 2.5MG/ML 36

ONFI TAB 10MG 36

ONFI TAB 20MG 36

OPANA TAB 10MG 21

OPANA TAB 5MG 21

opium tincture 51

OPSUMIT TAB 10MG 97

ORACIT SOLN 123

ORAPRED ODT 10MG 102



ORAVIG TAB 50MG 135

ORENCIA

AUTO-INJECTOR

125MG/ML 18

ORENCIA SYRINGE

125MG/ML 18

ORENCIA SYRINGE

50MG/0.4ML 18

ORENCIA SYRINGE

87.5MG/0.7ML 18

ORENITRAM ER TAB

0.125MG 96

ORENITRAM ER TAB

0.25MG 97

ORENITRAM ER TAB 1MG 97

ORENITRAM ER TAB

2.5MG 97

ORENITRAM ER TAB 5MG 97

ORFADIN CAP 10MG 117

ORFADIN CAP 20MG 117

ORFADIN CAP 2MG 117

ORFADIN CAP 5MG 117

ORFADIN ORAL SUSP

4MG/ML 117

ORILISSA TAB 150MG 116

ORILISSA TAB 200MG 116

ORKAMBI PACKET

100-125MG 149

ORKAMBI PACKET

150-188MG 149

ORKAMBI TAB

100-125MG 149

ORKAMBI TAB

200-125MG 149

orphenadrine ER tab 100mg 136

ORTHO-CYCLEN TAB 101

ORTHO-NOVUM TAB 101

ORTHO TRI-CYCLEN LO

TAB 101

ORTHO TRI-CYCLEN TAB101

oseltamivir cap 30mg 89



oseltamivir susp 6mg/ml 89

OSPHENA TAB 60MG 116

OTEZLA TAB 28-DAY

STARTER PACK 17

OTEZLA TAB 30MG 17

OVACE CREAM 108

OVACE PLUS SHAMPOO 108

OVACE PLUS WASH 108

OVACE WASH 108

OVIDE LOTION 0.5% 113




oxandrolone tab 10mg 23

oxandrolone tab 2.5mg 23

oxaprozin tab 600mg 17

OXAZEPAM CAP 10MG 30



OXBRYTA TAB 500MG 125

oxcarbazepine susp300mg/5ml 39




OXERVATE OPHTH SOLN

0.002% 140

oxiconazole nitrate cream1% 107

OXISTAT CREAM 1% 107

OXISTAT LOTION 1% 107

OXSORALEN ULTRA CAP

10MG 108

OXTELLAR XR TAB

150MG 39

OXTELLAR XR TAB

300MG 39

OXTELLAR XR TAB

600MG 39




oxybutynin syrup 5mg/5ml 155

oxybutynin tab 5mg 155

oxycodone/acetaminophentab 10-325mg 22

oxycodone/acetaminophentab 2.5-325mg 22

oxycodone/acetaminophentab 5-325mg 21

oxycodone/acetaminophentab 7.5-325mg 22

oxycodone/aspirin tab4.84-325mg 22

OXYCODONE/ASPIRIN

TAB 4.84-325MG 22

OXYCODONE/IBUPROFEN

TAB 5-400MG 22

oxycodone cap 5mg 21

oxycodone oral soln 20mg/ml 21

oxycodone oral soln 5mg/5ml 21

oxycodone tab 10mg 21





oxymorphone tab 10mg 21

oxymorphone tab 5mg 21

OZEMPIC INJ 1MG/DOSE 49

OZEMPIC INJ 2MG/1.5ML 49




P

paliperidone SR tab 1.5mg 80

paliperidone SR tab 3mg 80



PALYNZIQ SYRINGE

10MG/0.5ML 117

PALYNZIQ SYRINGE

2.5MG/0.5ML 117

PALYNZIQ SYRINGE

20MG/ML 117

PAMELOR CAP 10MG 46

PAMELOR CAP 25MG 46

PAMELOR CAP 50MG 46

PAMELOR CAP 75MG 46

PANDEL CREAM 0.1% 111

PANRETIN GEL 0.1% 107



PANZYGA IV SOLN

10GM/100ML 143

PANZYGA IV SOLN

1GM/10ML 143

PANZYGA IV SOLN

2.5GM/25ML 143

PANZYGA IV SOLN

20GM/200ML 143

PANZYGA IV SOLN

30GM/300ML 143

PANZYGA IV SOLN

5GM/50ML 143

PARAGARD IUD 101

paricalcitol cap 1mcg 117



PARLODEL CAP 5MG 77

PARLODEL TAB 2.5MG 77

PARNATE TAB 10MG 43

paromomycin cap 250mg 15

PAROMOMYCIN CAP

250MG 15

paroxetine ER tab 12.5mg 43

paroxetine ER tab 25mg 43

paroxetine ER tab 37.5mg 43

paroxetine tab 10mg 44




PASER GRANULE 4GM 66

PATADAY OPHTH SOLN

0.2% 141

PATANASE NASAL SPRAY

0.6% 137

PATANOL OPHTH SOLN

0.1% 141

PAXIL CR TAB 12.5MG 44

PAXIL CR TAB 25MG 44

PAXIL CR TAB 37.5MG 44

PAXIL ORAL SUSP

10MG/5ML 44

PAXIL TAB 10MG 44

PAXIL TAB 20MG 44

PAXIL TAB 30MG 44

PAXIL TAB 40MG 44

pb-belladonna elixir 153

PEDIARIX INJ 152

PEDIATEX TDM SUSP 104

pediatric multiplevitamins/fluoride/iron soln136

pediatric multiplevitamins/fluoride chewtab 136

pediatric multiplevitamins/fluoride soln 136

PEDVAX HIB INJ 156

peg 3350/electrolytes soln240 gm 128

PEGANONE TAB 250MG 41

PEGASYS PROCLICK INJ

135MCG/0.5ML 88


180MCG/0.5ML 88


180MCG/ML 88

PEMAZYRE TAB 13.5MG 72

PEMAZYRE TAB 4.5MG 72

PEMAZYRE TAB 9MG 72

penicillamine tab 250mg 134

PENICILLIN

GK/DEXTROSE INJ

40000UNIT/ML 144

PENICILLIN

GK/DEXTROSE INJ

60000UNIT/ML 144

penicillin gk inj20000000unit 144


PENICILLIN G PROCAINE

INJ 600000 UNIT/ML 144

PENICILLIN G SODIUM

INJ 5000000UNIT 144

PENICILLIN VK SOLN

125MG/5ML 144

PENICILLIN VK SOLN

250MG/5ML 144



PEN NEEDLE 130, 130

PENTACEL INJ 152

pentamidine inj 300mg 25

pentamidine neb soln 300mg 25

PENTAM INJ 300MG 25

pentoxifylline ER tab 400mg 125

PEPCID SUSP 40MG/5ML 153

PEPCID TAB 20MG 153

PEPCID TAB 40MG 153

PERCOCET TAB 10-325MG 22

PERCOCET TAB 2.5-325MG22

PERCOCET TAB 5-325MG 22

PERCOCET TAB 7.5-325MG22

PERFOROMIST NEB SOLN

20MCG/2ML 33

PERIDEX SOLN 135




periogard soln 0.12% 135

permethrin cream 5% 113

PERPHENAZINE/

AMITRIPTYLINE TAB

2-10MG 147




PERPHENAZINE/

AMITRIPTYLINE TAB

2-25MG 147

PERPHENAZINE/

AMITRIPTYLINE TAB

4-10MG 147

PERPHENAZINE/

AMITRIPTYLINE TAB

4-25MG 147

PERPHENAZINE/

AMITRIPTYLINE TAB

4-50MG 147





PERSERIS SYRINGE

120MG 80

PERSERIS SYRINGE 90MG 80

PERTZYE DR CAP

24000-86250-90750UNIT 113

PEXEVA TAB 10MG 44

PEXEVA TAB 20MG 44

PEXEVA TAB 30MG 44

PEXEVA TAB 40MG 44

phenazopyridine tab 124

phenelzine tab 15mg 43

phenobarbital elixir20mg/5ml 127









phenoxybenzamine cap 10mg 60

phentermine cap 11

phentermine tab 11



phenytoin chew tab 50mg 41




phenytoin susp 125mg/5ml 41

PHOSLO CAP 667MG 122

PHOSLYRA ORAL SOLN

667MG/5ML 122

phospha 250 neutral tab 133

PHOSPHOLINE OPHTH

SOLN 0.125% 139

PICATO GEL 0.015% 107

PICATO GEL 0.05% 107

PIFELTRO TAB 100MG 86




pilocarpine tab 5mg 135

pilocarpine tab 7.5mg 135

pimecrolimus cream 1% 112

PIMOZIDE TAB 1MG 149

PIMOZIDE TAB 2MG 149

pindolol tab 10mg 92

pindolol tab 5mg 92




piperacillin/tazobactam inj12-1.5gm 144





PIQRAY DAILY DOSE

PACK 200MG 72

PIQRAY DAILY DOSE

PACK 250MG 72

PIQRAY DAILY DOSE

PACK 300MG 72



PLAQUENIL TAB 200MG 65

PLASMA-LYTE-A INJ 132

PLASMA-LYTE INJ 148

soln 132

PLAVIX TAB 75MG 125

PLEGRIDY INJ

125MCG/0.5ML 148

PLEGRIDY INJ STARTER

PACK 148

PLEGRIDY PEN INJECTOR

125MCG/0.5ML 148

PLEGRIDY PEN STARTER

PACK 148

PLEXION SCT CREAM 105

PODOCON SOLN 112

podofilox soln 0.5% 112

POLYETHYLENE GLYCOL

8000 GRANULES 145

polymyxin B/trimethoprimophth soln10000unit/ml-0.1% 139

polymyxin B inj 500000unit 27

POLYTRIM OPHTH SOLN

10000UNIT/ML-0.1% 139

POMALYST CAP 1MG 68

POMALYST CAP 2MG 69

POMALYST CAP 3MG 69

POMALYST CAP 4MG 69

posaconazole DR tab 100mg 54

POTABA CAP 158

potassium bicarbonate effertab 133

potassium chloride effer tab 133

POTASSIUM CHLORIDE

EFFER TAB 133

potassium chloride ER cap10meq 133

potassium chloride ER cap8meq 133

potassium chloride ER tab10meq 133

potassium chloride er tab20meq 133

POTASSIUM CHLORIDE

ER TAB 20MEQ 133




potassium chloride ER tab8meq 133

POTASSIUM CHLORIDE

INJ 0.15%/D5W LR 132

POTASSIUM CHLORIDE

INJ 0.3%/D5W LR 132

POTASSIUM CHLORIDE

INJ 10MEQ 133

potassium chloride inj10meq/100ml 133

POTASSIUM CHLORIDE

INJ 10MEQ/50ML 133

POTASSIUM CHLORIDE

INJ 20MEQ 133

potassium chloride inj20meq/100ml 133

POTASSIUM CHLORIDE

INJ 20MEQ/100ML 133

potassium chloride inj2meq/ml 133

POTASSIUM CHLORIDE

INJ 40MEQ 133

POTASSIUM CHLORIDE

INJ 40MEQ/L 5% 132

potassium chloride oral soln10% 134

potassium chloride oral soln20% 134

potassium chloride powder20meq 134

potassium citrate/citric acidgranule 123

potassium citrate/citric acidsoln 123

potassium citrate CR tab10meq 123



PRADAXA CAP 110MG 35

PRADAXA CAP 150MG 35

PRADAXA CAP 75MG 35

PRALUENT INJ 150MG/ML 58

PRALUENT INJ 75MG/ML 58






pramipexole ER tab 3mg 77







pramipexole tab 1mg 77

PRANDIN TAB 0.5MG 50

PRANDIN TAB 1MG 50

PRANDIN TAB 2MG 50



PRAVACHOL TAB 20MG 57



pravastatin tab 10mg 57




praziquantel tab 600mg 24

prazosin cap 1mg 61

prazosin cap 2mg 61

prazosin cap 5mg 61

PRECISION XTRA METER130

PRECOSE TAB 100MG 47

PRECOSE TAB 25MG 47

PRECOSE TAB 50MG 47

PRED FORTE OPHTH SUSP

1% 140

PRED-G OPHTH SUSP

0.3-1% 141

PRED-G S.O.P OPHTH

OINTMENT 0.3-0.6% 141

PRED MILD OPHTH SUSP

0.12% 141

PREDNICARBATE CREAM

0.1% 111

PREDNICARBATE

OINTMENT 0.1% 111

prednisolone ODT 10mg 103



PREDNISOLONE OPHTH

SUSP 1% 141

PREDNISOLONE ORAL

SOLN 25MG/5ML 103

PREDNISOLONE ORAL

SYRUP 15MG/5ML 103

PREDNISOLONE SODIUM

PHOSPHATE OPHTH

SOLN 1% 141

prednisolone sodiumphosphate oral soln10mg/5ml 103



prednisolone sodiumphosphate oral soln6.7mg/5ml 103

PREDNISONE CONC

5MG/ML 103

PREDNISONE ORAL SOLN

5MG/5ML 103

prednisone tab 10mg 103


prednisone tab 2.5mg 103




PREFEST TAB 119












pregabalin soln 20mg/ml 39






PREMARIN VAGINAL

CREAM 0.625MG/GM 157

premasol inj 6% 138

PREMPHASE TAB

0.625-5MG 119


PREMPRO TAB

0.45-1.5MG 119

PREMPRO TAB

0.625-2.5MG 119

PREMPRO TAB 0.625-5MG119



PREVIDENT 5000

BOOSTER PASTE 135

PREVIDENT 5000 DRY

MOUTH GEL 135

PREVIDENT 5000 PASTE 135

PREVIDENT 5000 PLUS

CREAM 135

PREVIDENT RINSE 135

previfem tab 101

PREVPAC CAP THERAPY

PACK 500-500-30MG 154

PREVYMIS TAB 240MG 87

PREVYMIS TAB 480MG 87

PREZCOBIX TAB

800-150MG 86

PREZISTA SUSP

100MG/ML 86





PRIFTIN TAB 150MG 66

primaquine tab 26.3mg 65

PRIMAQUINE TAB 26.3MG 65

PRIMAXIN INJ 500MG 25



PRINIVIL TAB 10MG 59

PRINIVIL TAB 2.5MG 59

PRINIVIL TAB 20-25MG 64




PRINIVIL TAB 5MG 59



PRISTIQ TAB 100MG 45

PRISTIQ TAB 25MG 45

PRISTIQ TAB 50MG 45

PRIVIGEN INJ

40GM/400ML 143

probenecid/colchicine tab0.5-500mg 124

probenecid tab 500mg 124

PROCALAMINE INJ 3% 138

PROCARDIA XL TAB

30MG 95

PROCARDIA XL TAB

60MG 95

PROCARDIA XL TAB

90MG 95

prochlorperazine supp 25mg 83



procto-pak cream 1% 24

proctozone-HC cream 2.5% 24



PROGLYCEM SUSP

50MG/ML 48

PROGRAF CAP 0.5MG 90

PROGRAF CAP 1MG 90

PROGRAF CAP 5MG 90

PROGRAF GRANULES

PACKET 0.2MG 134

PROGRAF GRANULES

PACKET 1MG 134

PROLASTIN-C INJ

1000MG 149

PROLENSA OPHTH SOLN

0.07% 141

PROLIA INJ 60MG/ML 115

PROMACTA POWDER FOR

ORAL SUSP 12.5MG 126

PROMACTA POWDER FOR

ORAL SUSP 25MG 126

PROMACTA TAB 12.5MG 126

PROMACTA TAB 25MG 126



promethazine/codeine syrup 104

promethazine DM syrup 104

promethazine supp 12.5mg 55



promethazine syrup6.25mg/5ml 55

promethazine tab 12.5mg 55



PROMETHAZINE VC

SYRUP 6.25-5MG/5ML 104

promethazine VC w/codeinesyrup 104

PROMETHAZINE VC

W/CODEINE SYRUP 104

PROMETHEGAN SUPP

50MG 55

PROMETRIUM CAP

100MG 145

PROMETRIUM CAP

200MG 146







proparacaine ophth soln0.5% 140




PROPRANOLOL/

HYDROCHLOROTHIAZIDE

TAB 40-25MG 64

PROPRANOLOL/

HYDROCHLOROTHIAZIDE

TAB 80-25MG 64





PROPRANOLOL ORAL

SOLN 20MG/5ML 92

PROPRANOLOL ORAL

SOLN 40MG/5ML 92






propylthiouracil tab 50mg 151

PROQUAD INJ 156

PROSCAR TAB 5MG 123

PROSOL INJ 20% 138

PROTONIX TAB 20MG 154

PROTONIX TAB 40MG 154

PROTOPIC OINTMENT

0.03% 112

PROTOPIC OINTMENT

0.1% 112

protriptyline tab 10mg 46

protriptyline tab 5mg 46

PROVERA TAB 10MG 146

PROVERA TAB 2.5MG 146

PROVERA TAB 5MG 146

PROVIGIL TAB 100MG 14

PROVIGIL TAB 200MG 14

PROZAC CAP 10MG 44

PROZAC CAP 20MG 44

PROZAC CAP 40MG 44

PULMICORT NEB SUSP

0.25MG/2ML 32

PULMICORT NEB SUSP

0.5MG/2ML 32

PULMICORT NEB SUSP

1MG/2ML 32

PULMOZYME

INHALATION SOLN

1MG/ML 149

PURIXAN SUSP 20MG/ML 67

PYLERA CAP

140-125-125MG 154

pyrazinamide tab 500mg 66

PYRIDIUM TAB 124

pyridostigmine CR tab 180mg 66

pyridostigmine oral soln60mg/5ml 66

pyridostigmine tab 60mg 66

pyrimethamine tab 25mg 65

Q

QBRELIS ORAL SOLN

1MG/ML 59

QINLOCK TAB 50MG 72

QSYMIA CAP 11

QUADRACEL INJ 152

QUALAQUIN CAP 324MG 65

QUARTETTE TAB 101

quasense tab 101

QUESTRAN BULK

POWDER 4GM 56

QUESTRAN LIGHT BULK

POWDER 4GM 56

QUESTRAN POWDER

PACKET 4GM 56












QUFLORA PEDIATRIC

CHEW TAB 136

quinapril/hydrochlorothiazidetab 10-12.5mg 64

quinapril/hydrochlorothiazidetab 20-12.5mg 64

quinapril/hydrochlorothiazidetab 20-25mg 64





quinidine gluconate CR tab324mg 30

QUINIDINE SULFATE TAB

200MG 30

QUINIDINE SULFATE TAB

300MG 30

quinine sulfate cap 324mg 65

R

RABAVERT INJ 156

rabeprazole tab 20mg 154

raloxifene tab 60mg 116

ramelteon tab 8 mg 128


ramipril cap 10mg 59


ramipril cap 5mg 59

RANEXA TAB 1000MG 27

RANEXA TAB 500MG 27



ranitidine syrup 15mg/ml 153





RAPAFLO CAP 4MG 123

RAPAFLO CAP 8MG 123

RAPAMUNE ORAL SOLN

1MG/ML 134

RAPAMUNE TAB 0.5MG 90

RAPAMUNE TAB 1MG 90

RAPAMUNE TAB 2MG 90

rasagiline tab 0.5mg 78




rasagiline tab 1mg 78

RAVICTI LIQUID

1.1GM/ML 117

RAZADYNE ER CAP

16MG 147

RAZADYNE ER CAP

24MG 147


RAZADYNE TAB 12MG 147



REBETOL ORAL SOLN

40MG/ML 88

REBIF AUTO-INJECTOR

22MCG/0.5ML 148

REBIF AUTO-INJECTOR

44MCG/0.5ML 148

REBIF INJ 22MCG/0.5ML 148

REBIF INJ 44MCG/0.5ML 148

REBIF INJ TITRATION

PACK 148

REBIF REBIDOSE PACK 148

RECOMBIVAX-HB INJ 156

RECTIV RECTAL

OINTMENT 0.4% 24

REGLAN TAB 10MG 121

REGLAN TAB 5MG 121

REGRANEX GEL 0.01% 113

RELENZA DISKHALER

5MG/BLISTER 89

RELISTOR INJ

12MG/0.6ML 122

RELISTOR INJ

8MG/0.4ML 122

REMERON SOLUTAB

15MG 42

REMERON SOLUTAB

30MG 42

REMERON SOLUTAB

45MG 42

REMERON TAB 15MG 42

REMERON TAB 30MG 42

RENAGEL TAB 800MG 122

renaphro cap 135

RENVELA PACKET 0.8GM122

RENVELA PACKET 2.4GM122

RENVELA TAB 800MG 122

REPAGLINIDE/

METFORMIN TAB

1-500MG 47

REPAGLINIDE/

METFORMIN TAB

2-500MG 47

repaglinide tab 0.5mg 50



REPATHA INJ 120MG/ML 58

REPATHA INJ 140MG/ML 58

REPLIVA TAB 127






RESCON TAB 104

RESCRIPTOR TAB 200MG 86

RESTASIS OPHTH

EMULSION 0.05% 140

RESTORIL CAP 15MG 127


RESTORIL CAP 30MG 127


RETACRIT INJ

10000UNIT/ML 126

RETACRIT INJ

2000UNIT/ML 126

RETACRIT INJ

3000UNIT/ML 126

RETACRIT INJ

40000UNIT/ML 126

RETACRIT INJ

4000UNIT/ML 126

RETEVMO CAP 40MG 72

RETEVMO CAP 80MG 73

RETIN-A CREAM 0.025% 105



RETIN-A GEL 0.01% 105

RETIN-A GEL 0.025% 105

RETIN-A MICRO GEL

0.04% 105

RETIN-A MICRO GEL

0.1% 105

RETROVIR CAP 100MG 86

RETROVIR SYRUP

10MG/ML 86

REVATIO TAB 20MG 97

REVLIMID CAP 10MG 89


REVLIMID CAP 2.5MG 89



REVLIMID CAP 5MG 89

REXULTI TAB 0.25MG 84

REXULTI TAB 0.5MG 84

REXULTI TAB 1MG 84

REXULTI TAB 2MG 84

REXULTI TAB 3MG 84

REXULTI TAB 4MG 84

REYATAZ CAP 150MG 86



REYATAZ POWDER

PACKET 50MG 86

REZIRA SOLN 104

RIBAPAK TAB 400MG 88

RIBAPAK TAB 600MG 88

RIBAPAK TAB DOSE PACK

1000MG/DAY 88

RIBAPAK TAB DOSE PACK

600MG/DAY 88

ribavirin cap 200mg 88

ribavirin inhalation soln 6gm 89



RIBAVIRIN TAB 600MG 88

RIDAURA CAP 3MG 16

rifabutin cap 150mg 66

RIFADIN CAP 150MG 66

RIFADIN CAP 300MG 66

RIFADIN INJ 600MG 66

RIFAMATE CAP 150-300MG66






rifampin inj 600mg 66

RIFATER TAB

50-120-300MG 66

RILUTEK TAB 50MG 137

riluzole tab 50mg 137

RIMANTADINE TAB

100MG 89

RINVOQ ER TAB 15MG 16

RIOMET ER SUSP

500MG/5ML 48

RIOMET ORAL SOLN

500MG/5ML 48





RISPERDAL 12.5MG INJ 80


RISPERDAL INJ 37.5MG 80


RISPERDAL SOLN

1MG/ML 80

RISPERDAL TAB 0.5MG 80

RISPERDAL TAB 1MG 80





RISPERIDONE ODT

0.25MG 80






risperidone soln 1mg/ml 80











RITALIN TAB 10MG 14

RITALIN TAB 20MG 14

RITALIN TAB 5MG 14

ritonavir tab 100mg 86








rivelsa tab 101

rizatriptan ODT 10mg 131

rizatriptan ODT 5mg 131

rizatriptan tab 10mg 131

rizatriptan tab 5mg 131

ROBINUL FORTE TAB

2MG 153

ROBINUL TAB 1MG 153

ROCALTROL CAP

0.25MCG 117

ROCALTROL CAP

0.5MCG 117

ROCALTROL ORAL SOLN

1MCG/ML 117

















ROTARIX SUSP 156

ROTATEQ SOLN 156

roweepra tab 1000mg 39

ROXICODONE TAB 15MG 21



ROZLYTREK CAP 100MG 73

ROZLYTREK CAP 200MG 73

RUBRACA TAB 200MG 73



RUCONEST INJ 2100UNIT 124

RUZURGI TAB 10MG 66

RYBELSUS TAB 14MG 49

RYBELSUS TAB 3MG 49

RYBELSUS TAB 7MG 49

RYDAPT CAP 25MG 73




S

SAFYRAL TAB 101

SALAGEN TAB 5MG 135

SALAGEN TAB 7.5MG 135

SALEX SHAMPOO 112

salicylic acid shampoo 112

salsalate tab 18

SANCUSO PATCH 3.1MG 52

SANDIMMUNE CAP

100MG 90

SANDIMMUNE CAP 25MG 90

SANDIMMUNE ORAL

SOLN 100MG/ML 90

SANDOSTATIN INJ

100MCG/ML 118

SANDOSTATIN INJ

500MCG/ML 118

SANDOSTATIN INJ

50MCG/ML 118

SANTYL OINTMENT

250UNIT/GM 111

SAPHRIS SL TAB 10MG 82




SAPHRIS SL TAB 2.5MG 82

SAPHRIS SL TAB 5MG 82

SAVELLA TAB 100MG 147

SAVELLA TAB 12.5MG 148



SAVELLA TAB TITRATION

PACK 148

scopolamine patch 1mg/3days 52

SEASONIQUE TAB 101

seb-prev cream 108

SECTRAL CAP 200MG 92

SECTRAL CAP 400MG 92

SECUADO PATCH

3.8MG/24HR 82

SECUADO PATCH

5.7MG/24HR 82

SECUADO PATCH

7.6MG/24HR 82

selegiline cap 5mg 78

selegiline tab 5mg 78

SELEGILINE TAB 5MG 78

selenium sulfidelotion/shampoo 2.5% 108

selenium sulfide shampoo2.25% 108

SELZENTRY ORAL SOLN

20MG/ML 86





SENSIPAR TAB 30MG 117



SEREVENT DISK

50MCG/DOSE 33







SEROQUEL XR TAB

150MG 82

SEROQUEL XR TAB

200MG 82

SEROQUEL XR TAB

300MG 82

SEROQUEL XR TAB

400MG 82


sertraline soln 20mg/ml 44




sevelamer carbonate packet0.8gm 123

sevelamer carbonate packet2.4gm 123

sevelamer carbonate tab800mg 123

SEVELAMER TAB 400MG 123

sevelamer tab 800mg 123

SFROWASA ENEMA

4GM/60ML 122

SHINGRIX INJ 156

SIGNIFOR INJ 0.3MG/ML 118



sildenafil tab 20mg 97

sildenafil tab 25mg, 50mg,100mg 96

silodosin cap 4mg 124

silodosin cap 8mg 124

SILVADENE CREAM 1% 108

silver sulfadiazine cream 1% 108

SIMBRINZA OPHTH SUSP

1-0.2% 139

SIMPONI AUTO-INJECTOR

100MG/ML 15

SIMPONI AUTO-INJECTOR

50MG/0.5ML 15

SIMPONI INJ 100MG/ML 15

SIMPONI INJ 50MG/0.5ML 15






SINEMET CR TAB

25-100MG 77

SINEMET CR TAB

50-200MG 77




SINGULAIR CHEW TAB

4MG 31

SINGULAIR CHEW TAB

5MG 31

SINGULAIR GRANULES

4MG 32

SINGULAIR TAB 10MG 32

sirolimus oral soln 1mg/ml 134

sirolimus tab 0.5mg 90

sirolimus tab 1mg 90

sirolimus tab 2mg 90

SIRTURO TAB 100MG 66

SIRTURO TAB 20MG 66

SIVEXTRO INJ 200MG 27

SIVEXTRO TAB 200MG 27

SKELAXIN TAB 800MG 136

SKLICE LOTION 0.5% 113

SKYRIZI SYRINGE DOSE

PACK 150MG 108

SLO-NIACIN TAB 158

SLYND PACK 4MG 102



sodium chloride inj2.5meq/ml 134




sodium chloride irrigationsoln 0.9% 123

sodium chloride neb soln 104

sodium citrate/citric acidsoln 123




sodium fluoride/potassiumnitrate paste 135

sodium fluoride chew tab 132

sodium fluoride cream 135

sodium fluoride gel 135

SODIUM FLUORIDE

LOZENGE 133

sodium fluoride paste 135

sodium fluoride rinse 135

sodium fluoride soln 133

SODIUM FLUORIDE TAB 133

SODIUM LACTATE INJ

5MEQ/ML 131

sodium phenylbutyrate oralpowder 0.94mg/mg 117

sodium polystyrene oral susp15gm/60ml 90

sodium polystyrene powder250mg/ml 90

sodium polystyrene rectalsusp 30gm/120ml 90

SOFOSBUVIR/

VELPATASVIR TAB

400-100MG 88

solifenacin succinate tab10mg 155

solifenacin succinate tab5mg 155

SOLOSEC GRANULE

PACKET 2GM 14

SOLTAMOX ORAL SOLN

10MG/5ML 68

SOMA TAB 350MG 136

SOMATULINE INJ

120MG/0.5ML 118

SOMATULINE INJ

60MG/0.2ML 118

SOMATULINE INJ

90MG/0.3ML 118

SOMAVERT INJ 10MG 116






SORIATANE CAP 17.5MG 108





sotalol tab 120mg 93



sotalol tab 80mg 93

SPIRIVA RESPIMAT

INHALER 1.25MCG 31

spironolactone/hydrochlorothiazide tab25-25mg 114




SPORANOX CAP 100MG 54

SPORANOX SOLN

10MG/ML 54

SPRITAM ODT 1000MG 39




SPRYCEL TAB 100MG 73

SPRYCEL TAB 140MG 73

SPRYCEL TAB 20MG 73

SPRYCEL TAB 50MG 73

SPRYCEL TAB 70MG 73

SPRYCEL TAB 80MG 73

STALEVO TAB

12.5-50-200MG 77

STALEVO TAB

18.75-75-200MG 78

STALEVO TAB

25-100-200MG 78

STALEVO TAB

31.25-125-200MG 78

STALEVO TAB

37.5-150-200MG 78

STALEVO TAB

50-200-200MG 78

STARLIX TAB 120MG 50

STARLIX TAB 60MG 50





STELARA INJ

45MG/0.5ML 108

STELARA SYRINGE

45MG/0.5ML 108

STELARA SYRINGE

90MG/ML 108

STENDRA TAB 96

STIMATE NASAL SPRAY

1.5MG/ML 118

STIOLTO INHALER

2.5-2.5MCG 33

STIVARGA TAB 40MG 73








STREPTOMYCIN INJ 1GM 15

STRIBILD TAB

150-150-200-300MG 86

STROMECTOL TAB 3MG 24

STROVITE TAB 135

SUCRAID ORAL SOLN

8500UNIT/ML 113

sucralfate susp 1gm/10ml 154

sucralfate tab 1gm 153

SULAR TAB 17MG 95

SULAR TAB 34MG 95

SULAR TAB 8.5MG 95

SULCONAZOLE NITRATE

SOLN 1% 107

SULFACETAMIDE/

PREDNISOLONE

OPHTH SOLN 10-0.25% 141

sulfacetamide sodium/sulfurcream 105




sulfacetamide sodium/sulfuremulsion 105

sulfacetamide sodium/sulfurwash 105

sulfacetamide sodium gel 108

sulfacetamide sodium lotion10% 105

SULFACETAMIDE

SODIUM OPHTH

OINTMENT 10% 139

sulfacetamide sodium ophthsoln 10% 140

sulfacetamide sodiumshampoo 108

sulfacetamide sodium wash 108

sulfacleanse susp 106

SULFADIAZINE TAB

500MG 150

sulfamethoxazole/trimethoprim DS tab800-160mg 25

sulfamethoxazole/trimethoprim susp200-40mg/5ml 25

sulfamethoxazole/trimethoprim tab 400-80mg25

SULFAMYLON CREAM

85MG/GM 109

SULFAMYLON PAK 5% 109

sulfasalazine EC tab 500mg 122

sulfasalazine tab 500mg 122



sumatriptan auto-injector4mg/0.5ml 131

sumatriptan auto-injector6mg/0.5ml 131

sumatriptan inj 6mg/0.5ml 131

SUMATRIPTAN INJ

6MG/0.5ML 131

sumatriptan nasal spray20mg/act 131

sumatriptan nasal spray5mg/act 131

sumatriptan refill inj4mg/0.5ml 131

sumatriptan refill inj6mg/0.5ml 131

sumatriptan tab 100mg 131



SUMAXIN TS SUSP 106

SUMAXIN WASH 106

SUNOSI TAB 150MG 12

SUNOSI TAB 75MG 12

SUPRAX CAP 400MG 99

SUPRAX CHEW TAB

100MG 99

SUPRAX CHEW TAB

200MG 99

SUPRAX SUSP 100MG/5ML99



SURMONTIL CAP 100MG 46



SUSTIVA CAP 200MG 86

SUSTIVA CAP 50MG 86

SUSTIVA TAB 600MG 86

SUTENT CAP 12.5MG 73

SUTENT CAP 25MG 73

SUTENT CAP 37.5MG 73

SUTENT CAP 50MG 73

SUTTAR-SF SYRUP 104

SYLATRON INJ KIT

200MCG 75

SYLATRON INJ KIT

300MCG 75

SYLATRON INJ KIT

600MCG 75

SYMAX DUOTAB 153






SYMDEKO TAB 4-WEEK

PACK 149

SYMFI LO TAB

400-300-300MG 86

SYMFI TAB 600-300-300MG86

SYMJEPI INJ

0.15MG/0.3ML 157

SYMJEPI INJ

0.3MG/0.3ML 157

SYMPAZAN STRIP 10MG 36



SYMPROIC TAB 0.2MG 122

SYMTUZA TAB

800-150-200-10MG 86

SYNAREL NASAL SOLN

2MG/ML 116

SYNJARDY TAB

12.5-1000MG 47

SYNJARDY TAB

12.5-500MG 47



SYNJARDY XR TAB

10-1000MG 47

SYNJARDY XR TAB

12.5-1000MG 48

SYNJARDY XR TAB

25-1000MG 48

SYNJARDY XR TAB

5-1000MG 48

SYNRIBO INJ 3.5MG 75

SYNTHROID TAB

100MCG 151

SYNTHROID TAB

112MCG 151

SYNTHROID TAB

125MCG 151

SYNTHROID TAB

137MCG 151

SYNTHROID TAB

150MCG 151

SYNTHROID TAB

175MCG 151

SYNTHROID TAB

200MCG 151





SYNTHROID TAB

300MCG 151




SYPRINE CAP 250MG 134

T

TABLOID TAB 40MG 67

TACLONEX OINTMENT

0.005-0.064% 111

TACLONEX SUSP

0.005-0.064% 111

tacrolimus cap 0.5mg 90

tacrolimus cap 1mg 90

tacrolimus cap 5mg 90

tacrolimus ointment 0.03% 112

tacrolimus ointment 0.1% 112

tadalafil tab (PAH) 20mg 97

tadalafil tab 10mg 96

tadalafil tab 2.5mg 96



TAFINLAR CAP 50MG 73

TAFINLAR CAP 75MG 73

TAGRISSO TAB 40MG 73

TAGRISSO TAB 80MG 73

TAKHZYRO INJ

300MG/2ML 125

TALZENNA CAP 0.25MG 73

TALZENNA CAP 1MG 73

TAMIFLU CAP 30MG 89

TAMIFLU CAP 45MG 89

TAMIFLU CAP 75MG 89

TAMIFLU SUSP 6MG/ML 89

tamoxifen tab 10mg 68

tamoxifen tab 20mg 68

tamsulosin cap 0.4mg 124

TAPAZOLE TAB 10MG 151

TAPAZOLE TAB 5MG 151

TARCEVA TAB 100MG 73

TARCEVA TAB 150MG 73

TARCEVA TAB 25MG 73

TARGRETIN CAP 75MG 75

TARGRETIN GEL 1% 107

TARKA TAB 2-180MG 64



TASIGNA CAP 150MG 73

TASIGNA CAP 200MG 73

TASIGNA CAP 50MG 73

TASMAR TAB 100MG 75

TAVALISSE TAB 100MG 124

TAVALISSE TAB 150MG 124

tazarotene cream 0.1% 108

TAZICEF INJ 1GM 99

TAZICEF INJ 2GM 99



TAZORAC GEL 0.05% 108

TAZORAC GEL 0.1% 108

TAZVERIK TAB 200MG 73

TECFIDERA CAP 120MG 148

TECFIDERA CAP 240MG 148

TECFIDERA CAP

STARTER PACK 148

TEFLARO INJ 400MG 100

TEFLARO INJ 600MG 100

TEGRETOL SUSP

100MG/5ML 39

TEGRETOL TAB 200MG 39

TEGRETOL XR TAB

100MG 39

TEGRETOL XR TAB

200MG 39

TEGRETOL XR TAB

400MG 39

TEGSEDI SYRINGE

189MG/ML 149

TEKTURNA HCT TAB

150-12.5MG 64

TEKTURNA HCT TAB

150-25MG 64

TEKTURNA HCT TAB

300-12.5MG 64

TEKTURNA HCT TAB

300-25MG 64



telmisartan/amlodipine tab40-10mg 64




telmisartan/hydrochlorothiazide tab40-12.5mg 64

telmisartan/hydrochlorothiazide tab80-12.5mg 64

telmisartan/hydrochlorothiazide tab80-25mg 64








TEMODAR CAP 67

TEMOVATE OINTMENT

0.05% 111

temozolomide cap 67

TENIVAC INJ 152

tenofovir disoproxil fumaratetab 300mg 86

TENORETIC TAB

100-25MG 64









terbinafine tab 250mg 53




terbutaline tab 2.5mg 33

terbutaline tab 5mg 33

terconazole cream 0.4% 157

terconazole supp 80mg 157

TERCONAZOLE VAGINAL

CREAM 0.8% 157

TESSALON CAP 100MG 103

TESTOSTERONE

CYPIONATE INJ (1ML)

200MG/ML 23

testosterone cypionate inj100mg/ml 23

testosterone cypionate inj200mg/ml 23

testosterone enanthate inj200mg/ml 23

TESTOSTERONE

ENANTHATE INJ

200MG/ML 24

testosterone gel 1.62%(1.25gm) pouch 24

testosterone gel 1.62%(2.5gm) pouch 24

testosterone gel 1% (25mg)pouch 24

TESTOSTERONE GEL 1%

(25MG) POUCH 24

testosterone gel 1% (50mg)pouch 24

TESTOSTERONE GEL 1%

(50MG) POUCH 24

testosterone gel pump 1.62%bottle 24

testosterone gel pump 1%(12.5mg) bottle 24

TESTOSTERONE GEL

PUMP 1% (12.5MG)

BOTTLE 24

TESTOSTERONE GEL

PUMP 1% BOTTLE 24

TETANUS/DIPHTHERIA

TOXOID INJ 152

tetrabenazine tab 12.5mg 148

tetrabenazine tab 25mg 148



THALOMID CAP 100MG 89











THEOPHYLLINE CR TAB

300MG 34



theophylline soln 80mg/15ml 34

theophylline SR tab 300mg 34



THIOLA TAB 100MG 124









thyroid tab 151










TIAZAC CAP 120MG 95

TIAZAC CAP 180MG 95

TIAZAC CAP 240MG 95

TIAZAC CAP 300MG 95

TIAZAC CAP 360MG 95

TIAZAC CAP 420MG 95

TIBSOVO TAB 250MG 73

TIGAN CAP 300MG 52

tigecycline inj 50mg 150

TIGECYCLINE INJ 50MG 150




TIMOLOL MALEATE

OPHTH GEL 0.5% 138

timolol maleate ophth soln0.25% 138

timolol maleate ophth soln0.5% 138

timolol maleate ophth soln0.5% (24hr) 138




TIMOPTIC OCUDOSE

OPHTH SOLN 0.25% 138

TIMOPTIC OCUDOSE

OPHTH SOLN 0.5% 138

TIMOPTIC OPHTH SOLN

0.25% 138

TIMOPTIC OPHTH SOLN

0.5% 138

TIMOPTIC-XE OPHTH

SOLN 0.25% 138

TINDAMAX TAB 500MG 25



TIVICAY TAB 10MG 86

TIVICAY TAB 25MG 87

TIVICAY TAB 50MG 87






TOBI PODHALER 28MG 15

TOBRADEX OPHTH

OINTMENT 0.3-0.1% 141




TOBRADEX OPHTH SUSP

0.3-0.1% 141

TOBRADEX ST OPHTH

SUSP 0.3-0.05% 141

tobramycin/dexamethasoneophth susp 0.3-0.1% 141

tobramycin inj 1.2gm 15

tobramycin inj 1.2gm/30ml 15

TOBRAMYCIN INJ

10MG/ML 15

TOBRAMYCIN INJ

2GM/50ML 15

tobramycin inj 80mg/2ml 15

tobramycin neb soln300mg/5ml 15

tobramycin ophth soln 0.3% 140

TOBREX OPHTH

OINTMENT 0.3% 140

TOBREX OPHTH SOLN

0.3% 140

TOFRANIL TAB 10MG 46



TOLAK CREAM 4% 107

TOLBUTAMIDE TAB

500MG 51

tolcapone tab 100mg 75

TOLMETIN SODIUM CAP

400MG 17

TOLMETIN SODIUM TAB

200MG 17

TOLMETIN SODIUM TAB

600MG 17



tolterodine tab 1mg 155

tolterodine tab 2mg 155

TOPAMAX SPRINKLE CAP

15MG 39

TOPAMAX SPRINKLE CAP

25MG 39

TOPAMAX TAB 100MG 39

TOPAMAX TAB 200MG 39

TOPAMAX TAB 25MG 39

TOPAMAX TAB 50MG 39



TOPICORT GEL 0.05% 111

TOPICORT OINTMENT

0.05% 111

TOPICORT OINTMENT

0.25% 111

TOPIRAMATE ER CAP

100MG 39

TOPIRAMATE ER CAP

150MG 39

TOPIRAMATE ER CAP

200MG 39

TOPIRAMATE ER CAP

25MG 39

TOPIRAMATE ER CAP

50MG 39











toremifene tab 60mg 68





TOUJEO MAX SOLOSTAR

INJ 300UNIT/ML 50

TOUJEO SOLOSTAR INJ

300UNIT/ML 50

TPN ELECTROL INJ 132

TRACLEER TAB 125MG 97

TRACLEER TAB 62.5MG 97

TRACLEER TAB FOR

ORAL SUSP 32MG 97

TRADJENTA TAB 5MG 49

tramadol/acetaminophen tab37.5-325mg 22

tramadol ER tab 100mg 21

tramadol ER tab 100mg(matrix delivery) 21





tramadol tab 50mg 21

TRANDOLAPRIL/

VERAPAMIL ER TAB

1-240MG 64

trandolapril/verapamil ERtab 2-180mg 64






tranex acid tab 650mg 127

TRANSDERM-SCOP

PATCH 1MG/3 DAYS 52

TRANXENE T TAB 7.5MG 30

tranylcypromine tab 10mg 43

TRAVATAN Z OPHTH

SOLN 0.004% 142

travoprost ophth soln0.004% 142





TRECATOR TAB 250MG 66

TRELEGY ELLIPTA

INHALER 100-

62.5-25MCG 33

TRELSTAR DEPOT INJ

3.75MG 68




TRELSTAR LA INJ

11.25MG 68

TRELSTAR MIX INJ

22.5MG 68

TRESIBA FLEXTOUCH

PEN INJ 100UNIT/ML 50

TRESIBA FLEXTOUCH

PEN INJ 200UNIT/ML 50

TRESIBA INJ (VIAL)

100UNIT/ML 50

tretinoin cap 10mg 75

tretinoin cream 0.025% 106



tretinoin gel 0.01% 106



tretinoin micro gel 0.04% 106

tretinoin micro gel 0.1% 106

TREXALL TAB 10MG 67

TREXALL TAB 15MG 67

TREXALL TAB 5MG 67

TREXALL TAB 7.5MG 67

triamcinolone/oragel paste0.1% 135

triamcinolone cream 0.025%111





triamcinolone nasal spray(OTC) 137

triamcinolone ointment0.025% 111

triamcinolone ointment 0.1%111

triamcinolone ointment 0.5%111

triamcinolone topical spray0.147mg/gm 111

triamterene/hydrochlorothiazide cap37.5-25mg 114

triamterene/hydrochlorothiazide tab37.5-25mg 114

triamterene/hydrochlorothiazide tab75-50mg 114





tricitrates soln 123

tricon cap 127

TRICOR TAB 145MG 56

TRICOR TAB 48MG 56

trientine cap 250mg 134





TRIFLURIDINE OPHTH

SOLN 1% 140

TRIGLIDE TAB 160MG 56

trihexyphenidyl elixir0.4mg/ml 78



TRIJARDY ER TAB

10-5-1000MG 48

TRIJARDY ER TAB

12.5-2.5-1000MG 48

TRIJARDY ER TAB

25-5-1000MG 48

TRIJARDY ER TAB

5-2.5-1000MG 48

TRIKAFTA PACK

100-50-75MG/150MG 149

tri-legest FE tab 101

TRILEPTAL SUSP

300MG/5ML 40






trilyte soln/gavilyte soln420gm 128

trimethobenzamide cap300mg 52

trimethoprim tab 100mg 25

trimipramine cap 100mg 46



tri-nessa lo tab 101

trinessa tab 101

TRI-NORINYL TAB 101

TRINTELLIX TAB 10MG 42



TRIUMEQ TAB

600-50-300MG 87

TRIZIVIR TAB

300-150-300MG 87

TROKENDI XR CAP 100MG40

TROKENDI XR CAP 200MG40

TROKENDI XR CAP 25MG 40

TROKENDI XR CAP 50MG 40

TROPHAMINE INJ 6% 138

trospium chloride SR cap60mg 155

trospium tab 20mg 155

TRULICITY INJ

0.75MG/0.5ML 49

TRULICITY INJ

1.5MG/0.5ML 49

TRUMENBA INJ 156

TRUSOPT OPHTH SOLN

2% 141





TUKYSA TAB 150MG 73

TUKYSA TAB 50MG 74

TURALIO CAP 200MG 74

TUSNEL C SYRUP 104

tussigon tab 103

TUSSIONEX SUSP 104

TUSSI-ORGANI SYRUP 104

TWINRIX INJ 156








TYBOST TAB 150MG 87

tydemy tab 101

TYGACIL INJ 50MG 150

TYKERB TAB 250MG 74

TYLENOL/CODEINE TAB

300-30MG 22

TYLENOL/CODEINE TAB

300-60MG 22

TYMLOS PEN INJECTOR

3120MCG/1.56ML 116

TYPHIM VI INJ 156

U

UCERIS ER TAB 9MG 103

UCERIS RECTAL FOAM

2MG 24

UDENYCA SYRINGE

6MG/0.6ML 126

ULORIC TAB 40MG 124

ULORIC TAB 80MG 124

ULTRACET TAB

37.5-325MG 22

ULTRAM TAB 50MG 21

ULTRAVATE OINTMENT

0.05% 111

UNASYN INJ 15GM 145

UNASYN INJ 3GM 145

UPTRAVI TAB 1000MCG 97








UPTRAVI TAB TITRATION

PACK 97








UROQID #2 TAB 154

UROXATRAL TAB 10MG 124

ursodiol cap 300mg 121



URSO FORTE TAB 500MG 121

URSO TAB 250MG 121

V

VAGIFEM TAB 10MCG 157

valacyclovir tab 1gm 88

valacyclovir tab 500mg 88

VALCHLOR GEL 0.016% 107

VALCYTE ORAL SOLN

50MG/ML 87

VALCYTE TAB 450MG 87

valganciclovir oral soln50mg/ml 87

valganciclovir tab 450mg 87

VALIUM TAB 10MG 30

VALIUM TAB 2MG 30

VALIUM TAB 5MG 30

valproic acid cap 250mg 41

valproic acid oral soln250mg/5ml 41

valsartan/hydrochlorothiazidetab 160-12.5mg 64

valsartan/hydrochlorothiazidetab 160-25mg 64


valsartan/hydrochlorothiazidetab 320-25mg 64






VALTOCO DOSE KIT PACK

10MG/0.1ML 36


5MG/0.1ML 36


7.5MG/0.1ML 36

VALTREX TAB 1GM 88

VALTREX TAB 500MG 88



VANCOMYCIN/

DEXTROSE INJ

5%/1GM/200ML 26

VANCOMYCIN/

DEXTROSE INJ

5%/500MG/100ML 26

VANCOMYCIN/

DEXTROSE INJ

5%/750MG/150ML 26



VANCOMYCIN INJ

0.9%/1GM/200ML 26

VANCOMYCIN INJ

0.9%/500MG/100ML 26

VANCOMYCIN INJ

0.9%/750MG/150ML 26


VANCOMYCIN INJ 100GM 26







VANCOMYCIN IV SOLN

1.25GM 26

VAQTA INJ 25UNIT/0.5ML 156

VAQTA INJ 50 UNIT/ML 156

vardenafil ODT 96

vardenafil tab 96

VARIVAX INJ 156

VARIZIG 124.8/1.2ML INJ 143

VARUBI TAB 90MG 53

VASCEPA CAP 1GM 56

VASCEPA CAP 500MG 56




VASERETIC TAB 10-25MG 64

VASOTEC TAB 10MG 59

VASOTEC TAB 2.5MG 59

VASOTEC TAB 20MG 60

VASOTEC TAB 5MG 60

V-C FORTE CAP 135

VELPHORO CHEW TAB

500MG 123

VELTASSA POWDER PACK

16.8GM 90


25.2GM 90


8.4GM 90

VELTIN GEL 1.2-0.025% 106

VEMLIDY TAB 25MG 88

VENCLEXTA TAB 100MG 67



VENCLEXTA TAB

STARTING PACK 67


venlafaxine ER cap 37.5mg 45




venlafaxine tab 37.5mg 45



VENTAVIS INHALATION

SOLN 10MCG/ML 97

VENTAVIS INHALATION

SOLN 20MCG/ML 97

VENTOLIN HFA INHALER

18GM 33

VENTOLIN HFA INHALER

8GM 33




VERAPAMIL ER CAP

100MG 95




VERAPAMIL ER CAP

200MG 95


VERAPAMIL ER CAP

300MG 95

VERAPAMIL ER CAP

360MG 95




VERELAN CAP 120MG 95



VERELAN SR CAP 360MG 95

VERSACLOZ SUSP

50MG/ML 82

VERZENIO TAB 100MG 74




VFEND INJ 200MG 54

VFEND SUSP 40MG/ML 54

VFEND TAB 200MG 54

VFEND TAB 50MG 54

V-GO KIT 20 130

V-GO KIT 30 130

V-GO KIT 40 130

VIBRAMYCIN CAP

100MG 150

VIBRAMYCIN SUSP

25MG/5ML 150

VIBRAMYCIN SYRUP

50MG/5ML 150

VICTOZA INJ 18MG/3ML 49







vigabatrin powder 500mg 41

vigabatrin tab 500mg 41

VIGAMOX OPHTH SOLN

0.5% 140

VIIBRYD TAB 10MG 43

VIIBRYD TAB 20MG 43

VIIBRYD TAB 40MG 43

VIIBRYD TAB STARTER

KIT 10/20MG 44

VIMPAT INJ 200MG/20ML 40

VIMPAT SOLN 10MG/ML 40

VIMPAT TAB 100MG 40

VIMPAT TAB 150MG 40

VIMPAT TAB 200MG 40

VIMPAT TAB 50MG 40



VIRAMUNE SUSP

50MG/5ML 87

VIRAMUNE TAB 200MG 87

VIRAMUNE XR TAB

400MG 87

VIRAZOLE INHALATION

SOLN 6GM 89

VIREAD POWDER

40MG/GM 87

VIREAD TAB 150MG 87

VIREAD TAB 200MG 87

VIREAD TAB 250MG 87

VIREAD TAB 300MG 87

VISTARIL CAP 25MG 29

VISTARIL CAP 50MG 29

vitamin D3 cap 400unit,1000unit 158

vitamin D cap 50000unit 158

VITAMIN D TAB 400UNIT 158

VITRAKVI CAP 100MG 74

VITRAKVI CAP 25MG 74

VITRAKVI ORAL SOLN

20MG/ML 74

VIVELLE-DOT PATCH

0.025MG 120

VIVELLE-DOT PATCH

0.0375MG 120

VIVELLE-DOT PATCH

0.05MG 120




VIVELLE-DOT PATCH

0.075MG 120

VIVELLE-DOT PATCH

0.1MG 120

VIVITROL INJ 380MG 51

VIVOTIF BERNA CAP 156

VIZIMPRO TAB 15MG 74



VOGELXO GEL 1% (50GM)

POUCH 24

VOGELXO GEL PUMP 1% 24

VOLTAREN GEL 1% 106

voriconazole inj 200mg 54

voriconazole susp 40mg/ml 54

voriconazole tab 200mg 54

voriconazole tab 50mg 54

VOSEVI TAB

400-100-100MG 88

VOTRIENT TAB 200MG 74

VRAYLAR CAP 1.5MG 79

VRAYLAR CAP 3MG 79

VRAYLAR CAP 4.5MG 79

VRAYLAR CAP 6MG 79

VRAYLAR CAP THERAPY

PACK 79

VYNDAMAX CAP 61MG 97

VYTORIN TAB 10-10MG 55




W

WAKIX TAB 17.8MG 12

WAKIX TAB 4.45MG 12

warfarin tab 10mg 34

warfarin tab 1mg 34


warfarin tab 2mg 34

warfarin tab 3mg 34

warfarin tab 4mg 34

warfarin tab 5mg 34

warfarin tab 6mg 34


WELCHOL PACKET

3.75GM 56

WELCHOL TAB 625MG 56

WELLBUTRIN XL TAB

100MG 42

WELLBUTRIN XL TAB

150MG 42

WELLBUTRIN XL TAB

200MG 42

WELLBUTRIN XL TAB

300MG 42

X

XALATAN OPHTH SOLN

0.005% 142

XALKORI CAP 200MG 74

XALKORI CAP 250MG 74

XANAX TAB 0.25MG 30

XANAX TAB 0.5MG 30

XANAX TAB 1MG 30

XANAX TAB 2MG 30

XANAX XR TAB 0.5MG 30

XANAX XR TAB 1MG 30

XANAX XR TAB 2MG 30

XANAX XR TAB 3MG 30

XARELTO TAB 10MG 34

XARELTO TAB 15MG 34

XARELTO TAB 2.5MG 34

XARELTO TAB 20MG 34

XARELTO TAB STARTER

PACK 15MG/20MG 34

XATMEP ORAL SOLN

2.5MG/ML 67

XCOPRI PACK TAB

150/200MG 40

XCOPRI PACK TAB

50/200MG 40

XCOPRI TAB 100MG 40

XCOPRI TAB 150MG 40

XCOPRI TAB 200MG 40

XCOPRI TAB 50MG 40

XCOPRI TITRATION PACK

12.5/25MG 40


150/200MG 40


50/100MG 40

XELJANZ TAB 10MG 16

XELJANZ TAB 5MG 16

XELODA TAB 67

XENLETA TAB 600MG 27

XERESE CREAM 5-1% 108

XGEVA INJ 120MG/1.7ML 116

XIFAXAN TAB 200MG 25

XIFAXAN TAB 550MG 25

XIGDUO XR TAB

10-1000MG 48

XIGDUO XR TAB

10-500MG 48

XIGDUO XR TAB

2.5-1000MG 48

XIGDUO XR TAB

5-1000MG 48

XIGDUO XR TAB 5-500MG 48

XODOL TAB 5-300MG 22

XODOL TAB 7.5-300MG 22

XOFLUZA THERAPY

PACK 20MG 89

XOFLUZA THERAPY

PACK 40MG 89

XOLAIR INJ 150MG 31

XOLAIR SYRINGE

150MG/ML 31

XOLAIR SYRINGE

75MG/0.5ML 31

XOPENEX NEB SOLN

0.31MG/3ML 33

XOPENEX NEB SOLN

0.63MG/3ML 33

XOPENEX NEB SOLN

1.25MG/3ML 33

XOPENEX NEB SOLN

CONC 1.25MG/0.5ML 33

XOSPATA TAB 40MG 74

XPOVIO 40MG ONCE

WEEKLY PACK 69




XPOVIO 40MG TWICE

WEEKLY PACK 69

XPOVIO 60MG TWICE

WEEKLY PACK 69

XPOVIO ONCE WEEKLY

PACK 100MG 69

XPOVIO ONCE WEEKLY

PACK 60MG 69

XPOVIO ONCE WEEKLY

PACK 80MG 69

XPOVIO TWICE WEEKLY

PACK 80MG 69

XTAMPZA ER CAP 13.5MG 21

XTAMPZA ER CAP 18MG 21




XTANDI CAP 40MG 68

XULANE PATCH

150-35MCG 101

XULTOPHY INJ

100-3.6UNIT-MG/ML 48

XYREM SOLN 500MG/ML 146

XYZAL ORAL SOLN

2.5MG/5ML 55

Y

YASMIN TAB 101

YAZ TAB 101

YF-VAX INJ 156

yuvafem tab 10mcg 157

Z



zaleplon cap 10mg 128

zaleplon cap 5mg 128

ZAMICET SOLN

10-325MG/15ML 22

ZANAFLEX CAP 2MG 136



ZANAFLEX TAB 4MG 136

ZANTAC TAB 300MG 153

ZARONTIN CAP 250MG 41

ZARONTIN SOLN

250MG/5ML 41

ZARXIO INJ

300MCG/0.5ML 126

ZARXIO INJ

480MCG/0.8ML 126

ZEGERID CAP (OTC) 154

ZEJULA CAP 100MG 74

ZELAPAR ODT 1.25MG 78

ZELBORAF TAB 240MG 74

ZEMPLAR CAP 1MCG 117

ZEMPLAR CAP 2MCG 117

ZENPEP DR CAP

10000-32000-42000UNIT 113

ZENPEP DR CAP

10000-34000-55000UNIT 113

ZENPEP DR CAP

15000-47000-63000UNIT 113

ZENPEP DR CAP

20000-63000-84000UNIT 113

ZENPEP DR CAP

25000-79000-105000UNIT113

ZENPEP DR CAP

3000-10000-14000UNIT 113

ZENPEP DR CAP

40000-126000-168000UNIT113

ZENPEP DR CAP

5000-17000-24000UNIT 113

zeosa tab 101

ZERBAXA INJ 1.5GM 98

ZERIT CAP 15MG 87

ZERIT CAP 20MG 87

ZERIT CAP 30MG 87

ZERIT CAP 40MG 87

ZETIA TAB 10MG 58


ZIAC TAB 2.5-6.25MG 65


ZIAGEN ORAL SOLN

20MG/ML 87

ZIAGEN TAB 300MG 87

ZIANA GEL 1.2-0.025% 106

zidovudine cap 100mg 87

zidovudine syrup 10mg/ml 87

zidovudine tab 300mg 87

ZIEXTENZO SYRINGE

6MG/0.6M 126

zinc sulfate cap 134

ZIOPTAN OPHTH SOLN

0.0015% 142





ziprasidone mesylate inj 20mg79

ZIRGAN OPHTH GEL

0.15% 140

ZITHROMAX INJ 500MG 128

ZITHROMAX POWDER

PACK 1GM 129

ZITHROMAX SUSP

100MG/5ML 129

ZITHROMAX SUSP

200MG/5ML 129




ZOCOR TAB 10MG 57

ZOCOR TAB 20MG 57

ZOCOR TAB 40MG 58

ZOCOR TAB 5MG 58

ZOCOR TAB 80MG 58

ZOFRAN ODT 4MG 52

ZOFRAN ODT 8MG 52

ZOFRAN ORAL SOLN

4MG/5ML 52

ZOFRAN TAB 4MG 52

ZOFRAN TAB 8MG 52

ZOLINZA CAP 100MG 74

zolmitriptan ODT 2.5mg 131

zolmitriptan ODT 5mg 131

zolmitriptan tab 2.5mg 131

zolmitriptan tab 5mg 131

ZOLOFT ORAL SOLN

20MG/ML 44

ZOLOFT TAB 100MG 44

ZOLOFT TAB 25MG 44

ZOLOFT TAB 50MG 44




zolpidem tab 10mg 128

zolpidem tab 5mg 128

ZOMIG NASAL SPRAY

2.5MG 131

ZOMIG NASAL SPRAY

5MG 131

ZOMIG TAB 2.5MG 131

ZOMIG TAB 5MG 131

ZOMIG ZMT TAB 2.5MG 131

ZOMIG ZMT TAB 5MG 131






ZONTIVITY TAB 2.08MG 125

ZORTRESS 1MG TAB 134

ZORTRESS TAB 0.25MG 134



ZOSTAVAX INJ 156

ZOSYN/DEXTROSE INJ

2-0.25GM/50ML 145

ZOSYN/DEXTROSE INJ

3-0.375GM/50ML 145

ZOSYN/DEXTROSE INJ

4-0.5GM/100ML 145





zovia tab 101

ZOVIRAX CAP 200MG 88

ZOVIRAX CREAM 5% 108

ZOVIRAX OINTMENT 5% 108

ZOVIRAX SUSP

200MG/5ML 88

ZOVIRAX TAB 800MG 88

ZUBSOLV SL TAB

1.4-0.36MG 23

ZUBSOLV SL TAB

11.4-2.9MG 23

ZUBSOLV SL TAB

2.9-0.71MG 23

ZUBSOLV SL TAB

5.7-1.4MG 23

ZUBSOLV SL TAB

8.6-2.1MG 23

ZUTRIPRO LIQUID 104



ZYCLARA PUMP CREAM

3.75% 111

ZYDELIG TAB 100MG 74

ZYDELIG TAB 150MG 74

ZYKADIA CAP 150MG 74

ZYKADIA TAB 150MG 74

ZYLET OPHTH SUSP

0.5-0.3% 141



ZYMAXID OPHTH SOLN

0.5% 140

ZYPREXA INJ 10MG 82

ZYPREXA INJ 210MG 82

ZYPREXA ODT 10MG 82

ZYPREXA ODT 15MG 82

ZYPREXA ODT 20MG 82

ZYPREXA ODT 5MG 82

ZYPREXA TAB 10MG 82

ZYPREXA TAB 15MG 82

ZYPREXA TAB 2.5MG 82

ZYPREXA TAB 20MG 82

ZYPREXA TAB 5MG 82

ZYPREXA TAB 7.5MG 82

ZYRTEC CAP 55

ZYRTEC-D TAB 104

ZYRTEC SYRUP 55

ZYRTEC TAB 55

ZYVOX IV SOLN

200MG/100ML 27

ZYVOX IV SOLN

600MG/300ML 27

ZYVOX SUSP 100MG/5ML 27

ZYVOX TAB 600MG 27

S9701_2020_CCN_FORM_Comp_V01.17_C

This formulary was updated on 08/01/2020. For more recent information or other questions, please contact Navitus MedicareRx Customer Care at 1-866-270-3877 (TTY users should call

711), available 24 hours a day, 7 days a week (except Thanksgiving and Christmas Day) or visit

the member portal at https://medicarerx.navitus.com.

Pharmacies can reach Navitus Customer Care 24 hours a day, 7 days a week.

This plan, Navitus MedicareRx (PDP), is offered by Navitus Health Solutions and underwritten by

Dean Health Insurance, Inc., a Federally-Qualified Medicare Contracting Prescription Drug Plan.

https://medicarerx.navitus.com/

Documents

Navitus MedicareRx (PDP) 2020 Formulary List of …...1 When this formulary refers to “we,” “us”, “our,” “plan,” or “our plan,” it means Navitus MedicareRx (PDP)