Neighborhood Health Plan 4 Tier - Caremark · Neighborhood Health Plan 4 Tier 11/01/2016 ... It is always a good idea to discuss your medication options with your doctor ... sex

Neighborhood Health Plan 4 Tier 11/01/2016

INTRODUCTION

Neighborhood Health Plan (NHP) covers a wide variety of safe and effective medications for treating our members' medical needs. This list of Neighborhood Health Plan's covered medications shows the tier in which medications are placed. You can use this list to find out if your drug is covered and at which tier. Check the plan documents such as the schedule of benefits, the summary of benefits and coverage or the benefit handbook for details on coverage and cost sharing. If you are a member, you also can view your prescription drug coverage information by logging in to mynhp.org. This list of covered medications is continually updated based on recommendations by NHP's Pharmacy & Therapeutics Committee. It is always a good idea to discuss your medication options with your doctor to decide which is the most appropriate to treat your specific medical condition.

LEGEND

$0 Zero Dollar Copay A90 Access 90 drug AL Age Limit M90 Maintenance 90 drug PA Prior Authorization QL Quantity Limit SP Specialty Drug ST Step Therapy CAPITALIZED Indicates a brand name drugItalicized Indicates a generic drug

NOTICE

The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. ©2016. All rights reserved.

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. When viewing the document via the Internet, please be advised that the document is updated periodically and changes may appear prior to their effective date to allow for client notification. This list is subject to change at any time.

Your health plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Your health plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy AL - Age Limit SP - Specialty Drug $0 - Zero Dollar Copay A90 - Access 90 Drug M90 - Maintenance 90 Drug

2

Drug Name Drug Tier Requirements/LimitsANALGESICS COX-II INHIBITORS celecoxib cap 50 mg 2 ST; A90, M90 celecoxib cap 100 mg 2 ST; A90, M90 celecoxib cap 200 mg 2 ST; A90, M90 celecoxib cap 400 mg 2 ST; A90, M90 GOUT allopurinol tab 100 mg 1 A90, M90 allopurinol tab 300 mg 1 A90, M90 colchicine cap 0.6 mg 2 colchicine tab 0.6 mg 2 colchicine w/ probenecid tab 0.5-500 mg 2 A90, M90 KRYSTEXXA INJ 8MG/ML 3 QL (2 inj / 28 days), PA;

SP probenecid tab 500 mg 2 A90, M90 ULORIC TAB 40MG 3 QL (30 tabs / 30 days);

A90, M90 ULORIC TAB 80MG 3 QL (30 tabs / 30 days);

A90, M90 MISCELLANEOUS clonidine hcl inj (for epidural infusion) 100

mcg/ml 2

clonidine hcl inj (for epidural infusion) 500 mcg/ml

2

PRIALT INJ 25MCG/ML 4 SP PRIALT INJ 100MCG 4 SP NON-OPIOID ANALGESICS butalbital-acetaminophen tab 50-325 mg 2 butalbital-acetaminophen-caffeine cap 50-

300-40 mg 2

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

2

butalbital-acetaminophen-caffeine tab 50-325-40 mg

2

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

2

capacet cap 2 ed-flex cap 2 esgic cap 2 margesic cap 2 marten-tab tab 50-325mg 2 tencon tab 50-325mg 2 zebutal cap 2


3

Drug Name Drug Tier Requirements/Limits NSAIDS choline & magnesium salicylates liq 500

mg/5ml 2

choline & magnesium salicylates tab 1000 mg

2

diclofenac potassium tab 50 mg 2 ST; A90, M90 diclofenac sodium tab delayed release 25

mg 2 A90, M90

diclofenac sodium tab delayed release 50 mg

2 A90, M90

diclofenac sodium tab delayed release 75 mg

2 A90, M90

diclofenac sodium tab sr 24hr 100 mg 2 A90, M90 diflunisal tab 500 mg 2 A90, M90 etodolac cap 200 mg 2 A90, M90 etodolac cap 300 mg 2 A90, M90 etodolac tab 400 mg 2 A90, M90 etodolac tab 500 mg 2 A90, M90 etodolac tab sr 24hr 400 mg 2 A90, M90 etodolac tab sr 24hr 500 mg 2 A90, M90 etodolac tab sr 24hr 600 mg 2 A90, M90 fenoprofen calcium cap 400 mg 2 ST; A90, M90 flurbiprofen tab 50 mg 2 A90, M90 flurbiprofen tab 100 mg 2 A90, M90 ibuprofen susp 100 mg/5ml 2 ibuprofen tab 400 mg 1 A90, M90 ibuprofen tab 600 mg 1 A90, M90 ibuprofen tab 800 mg 1 A90, M90 indomethacin cap 25 mg 1 A90, M90 indomethacin cap 50 mg 2 A90, M90 indomethacin cap cr 75 mg 2 A90, M90 ketoprofen cap 50 mg 2 A90, M90 ketoprofen cap 75 mg 2 A90, M90 ketorolac tromethamine tab 10 mg 2 QL (10 tabs / 30 days) meclofenamate sodium cap 50 mg 2 A90, M90 meclofenamate sodium cap 100 mg 2 A90, M90 mefenamic acid cap 250 mg 2 QL (30 caps / 30 days),

ST; A90, M90 meloxicam tab 7.5 mg 1 A90, M90 meloxicam tab 15 mg 1 A90, M90 nabumetone tab 500 mg 2 A90, M90 nabumetone tab 750 mg 2 A90, M90 naproxen dr tab 375mg 2 A90, M90


4

Drug Name Drug Tier Requirements/Limits naproxen dr tab 500mg 2 A90, M90 naproxen sodium tab 275 mg 2 A90, M90 naproxen sodium tab 550 mg 2 A90, M90 naproxen susp 125 mg/5ml 2 A90, M90 naproxen tab 250 mg 2 A90, M90 naproxen tab 375 mg 1 A90, M90 naproxen tab 500 mg 1 A90, M90 oxaprozin tab 600 mg 2 A90, M90 piroxicam cap 10 mg 2 A90, M90 piroxicam cap 20 mg 2 A90, M90 salsalate tab 500 mg 2 A90, M90 salsalate tab 750 mg 2 A90, M90 sulindac tab 150 mg 2 A90, M90 sulindac tab 200 mg 2 A90, M90 tolmetin sodium cap 400 mg 2 A90, M90 tolmetin sodium tab 600 mg 2 A90, M90 NSAIDS, COMBINATIONS diclofenac w/ misoprostol tab delayed

release 50-0.2 mg 2 ST; A90, M90

diclofenac w/ misoprostol tab delayed release 75-0.2 mg

2 ST; A90, M90

NSAIDS, TOPICAL diclofenac sodium soln 1.5% 2 PA VOLTAREN GEL 1% 3 QL (100 gm / 30 days) OPIOID ANALGESICS acetaminophen w/ codeine soln 120-12

mg/5ml 2

acetaminophen w/ codeine tab 300-15 mg 2 acetaminophen w/ codeine tab 300-30 mg 2 acetaminophen w/ codeine tab 300-60 mg 2 alfentanil inj 500 mcg/ml 2 ascomp/cod cap 30mg 2 aspirin-caffeine-dihydrocodeine cap 356.4-

30-16 mg 2

BELBUCA MIS 75MCG 4 ST; QL BELBUCA MIS 150MCG 4 ST; QL BELBUCA MIS 300MCG 4 ST; QL BELBUCA MIS 600MCG 4 ST; QL buprenorphine hcl inj 0.3 mg/ml (base

equiv) 2

butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg

2


5

Drug Name Drug Tier Requirements/Limits butalbital-acetaminophen-caff w/ cod cap

50-325-40-30 mg 2

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

2

butorphanol tartrate inj 1 mg/ml 2 butorphanol tartrate inj 2 mg/ml 2 butorphanol tartrate nasal soln 10 mg/ml 2 BUTRANS DIS 5MCG/HR 3 QL (4 ea / 28 days), PA BUTRANS DIS 7.5/HR 3 QL (4 ea / 28 days), PA BUTRANS DIS 10MCG/HR 3 QL (4 ea / 28 days), PA BUTRANS DIS 15MCG/HR 3 QL (4 ea / 28 days), PA BUTRANS DIS 20MCG/HR 3 QL (4 ea / 28 days), PA codeine sulfate tab 15 mg 2 QL (360 tabs / 30 days) codeine sulfate tab 30 mg 2 QL (360 tabs / 30 days) codeine sulfate tab 60 mg 2 QL (180 tabs / 30 days) duramorph inj 0.5mg/ml 2 duramorph inj 1mg/ml 2 EMBEDA CAP 20-0.8MG Plan

Exclusion

EMBEDA CAP 30-1.2MG Plan Exclusion

EMBEDA CAP 50-2MG Plan Exclusion



EMBEDA CAP 100-4MG Plan Exclusion

endocet tab 2.5-325 2 endocet tab 5-325mg 2 endocet tab 7.5-325 2 endocet tab 10-325mg 2 fentanyl citrate lozenge on a handle 200

mcg 2 PA

fentanyl citrate lozenge on a handle 400 mcg

2 PA


2 PA


2 PA


2 PA


6

Drug Name Drug Tier Requirements/Limits fentanyl citrate lozenge on a handle 1600

mcg 2 PA

FENTANYL DIS 37.5MCG 3 QL (10 per 30 days), ST FENTANYL DIS 62.5MCG 3 QL (10 per 30 days), ST FENTANYL DIS 87.5MCG 3 QL (10 per 30 days), ST fentanyl td patch 72hr 12 mcg/hr 2 QL (10 ea / 30 days), ST fentanyl td patch 72hr 25 mcg/hr 2 QL (10 ea / 30 days), ST fentanyl td patch 72hr 50 mcg/hr 2 QL (10 ea / 30 days), ST fentanyl td patch 72hr 75 mcg/hr 2 QL (10 ea / 30 days), ST fentanyl td patch 72hr 100 mcg/hr 2 QL (10 ea / 30 days), ST hydrocodone-acetaminophen soln 7.5-325

mg/15ml 2

hydrocodone-acetaminophen soln 10-325 mg/15ml

2

hydrocodone-acetaminophen tab 2.5-325 mg

2

hydrocodone-acetaminophen tab 5-300 mg2 hydrocodone-acetaminophen tab 5-325 mg2 hydrocodone-acetaminophen tab 7.5-300

mg 2

hydrocodone-acetaminophen tab 7.5-325 mg

2

hydrocodone-acetaminophen tab 10-300 mg

2

hydrocodone-acetaminophen tab 10-325 mg

2

hydrocodone-ibuprofen tab 5-200 mg 2 hydrocodone-ibuprofen tab 7.5-200 mg 2 hydrocodone-ibuprofen tab 10-200 mg 2 hydromorphone hcl inj 1 mg/ml 2 hydromorphone hcl inj 2 mg/ml 2 hydromorphone hcl inj 4 mg/ml 2 hydromorphone hcl liqd 1 mg/ml 2 hydromorphone hcl preservative free (pf)

inj 10 mg/ml 2

hydromorphone hcl tab 2 mg 2 QL (480 tabs / 30 days), ST



hydromorphone hcl tab er 24hr deter 8 mg 2 QL (60 tabs / 30 days), ST


7

Drug Name Drug Tier Requirements/Limits hydromorphone hcl tab er 24hr deter 12

mg 2 QL (60 tabs / 30 days),

ST hydromorphone hcl tab er 24hr deter 16


ST hydromorphone hcl tab er 24hr deter 32


ST ibudone tab 5-200mg 2 LAZANDA SPR 100MCG 3 PA LAZANDA SPR 400MCG 3 PA levorphanol tartrate tab 2 mg 2 QL (120 tabs / 30 days) lorcet hd tab 10-325mg 2 lorcet plus tab 7.5-325 2 lorcet tab 5-325mg 2 lortab tab 5-325mg 2 lortab tab 7.5-325 2 lortab tab 10-325mg 2 meperidine hcl inj 25 mg/ml 2 meperidine hcl inj 50 mg/ml 2 meperidine hcl inj 100 mg/ml 2 meperidine hcl tab 50 mg 2 QL (360 tabs / 30 days) meperidine hcl tab 100 mg 2 QL (180 tabs / 30 days) methadone hcl conc 10 mg/ml 2 methadone hcl soln 5 mg/5ml 2 methadone hcl soln 10 mg/5ml 2 methadone hcl tab 5 mg 2 QL (180 tabs / 30 days) methadone hcl tab 10 mg 2 QL (180 tabs / 30 days) methadone hcl tab for oral susp 40 mg 2 methadose tab 40mg 2 morphine sulfate beads cap sr 24hr 30 mg 2 QL (30 ea / 30 days) morphine sulfate beads cap sr 24hr 45 mg 2 QL (30 ea / 30 days) morphine sulfate beads cap sr 24hr 60 mg 2 QL (30 ea / 30 days) morphine sulfate beads cap sr 24hr 75 mg 2 QL (30 ea / 30 days) morphine sulfate beads cap sr 24hr 90 mg 2 QL (30 ea / 30 days) morphine sulfate beads cap sr 24hr 120

mg 2 QL (30 ea / 30 days)

morphine sulfate cap sr 24hr 10 mg 2 QL (60 ea / 30 days) morphine sulfate cap sr 24hr 20 mg 2 QL (60 ea / 30 days) morphine sulfate cap sr 24hr 30 mg 2 QL (60 ea / 30 days) morphine sulfate cap sr 24hr 50 mg 2 QL (60 ea / 30 days) morphine sulfate cap sr 24hr 60 mg 2 QL (60 ea / 30 days) morphine sulfate cap sr 24hr 80 mg 2 QL (60 ea / 30 days) morphine sulfate cap sr 24hr 100 mg 2 QL (60 ea / 30 days) morphine sulfate inj 8 mg/ml 2


8

Drug Name Drug Tier Requirements/Limits morphine sulfate inj 10 mg/ml 2 morphine sulfate inj 15 mg/ml 2 morphine sulfate inj pf 0.5 mg/ml 2 morphine sulfate inj pf 1 mg/ml 2 morphine sulfate iv soln 1 mg/ml 2 morphine sulfate iv soln pf 10 mg/ml 2 morphine sulfate iv soln pf 15 mg/ml 2 morphine sulfate oral soln 10 mg/5ml 2 morphine sulfate oral soln 20 mg/5ml 2 morphine sulfate oral soln 100 mg/5ml (20

mg/ml) 2

morphine sulfate suppos 5 mg 2 morphine sulfate suppos 10 mg 2 morphine sulfate suppos 20 mg 2 morphine sulfate tab cr 15 mg 2 QL (90 ea / 30 days) morphine sulfate tab cr 30 mg 2 QL (90 ea / 30 days) morphine sulfate tab cr 60 mg 2 QL (120 ea / 30 days) morphine sulfate tab cr 100 mg 2 QL (60 ea / 30 days) morphine sulfate tab cr 200 mg 2 QL (30 ea / 30 days) nalbuphine hcl inj 10 mg/ml 2 nalbuphine hcl inj 20 mg/ml 2 NUCYNTA ER TAB 50MG 3 NUCYNTA ER TAB 100MG 3 NUCYNTA ER TAB 150MG 3 NUCYNTA ER TAB 200MG 3 NUCYNTA ER TAB 250MG 3 NUCYNTA TAB 50MG 3 NUCYNTA TAB 75MG 3 NUCYNTA TAB 100MG 3 OPANA ER TAB 5MG 3 QL (60 tabs / 30 days) OPANA ER TAB 7.5MG 3 QL (60 tabs / 30 days) OPANA ER TAB 10MG 3 QL (60 tabs / 30 days) OPANA ER TAB 15MG 3 QL (60 tabs / 30 days) OPANA ER TAB 20MG 3 QL (60 tabs / 30 days) OPANA ER TAB 30MG 3 QL (60 tabs / 30 days) OPANA ER TAB 40MG 3 QL (60 tabs / 30 days) oxycodone hcl cap 5 mg 2 QL (480 caps / 30 days) oxycodone hcl conc 100 mg/5ml (20

mg/ml) 2

oxycodone hcl soln 5 mg/5ml 2 oxycodone hcl tab 5 mg 2 QL (480 tabs / 30 days) oxycodone hcl tab 10 mg 2 QL (480 tabs / 30 days) oxycodone hcl tab 15 mg 2 QL (300 tabs / 30 days)


9

Drug Name Drug Tier Requirements/Limits oxycodone hcl tab 20 mg 2 QL (240 tabs / 30 days) oxycodone hcl tab 30 mg 2 QL (150 tabs / 30 days) oxycodone w/ acetaminophen tab 2.5-325

mg 2

oxycodone w/ acetaminophen tab 5-325 mg

2

oxycodone w/ acetaminophen tab 7.5-325 mg

2

oxycodone w/ acetaminophen tab 10-325 mg

2

oxycodone-aspirin tab 4.8355-325 mg 2 oxycodone-ibuprofen tab 5-400 mg 2 OXYCONTIN TAB 10MG CR 3 QL (90 tabs / 30 days),

ST; QL OXYCONTIN TAB 15MG CR 3 QL (90 tabs / 30 days),






ST; QL oxymorphone hcl tab 5 mg 2 oxymorphone hcl tab 10 mg 2 oxymorphone hcl tab sr 12hr 5 mg 2 QL (60 ea / 30 days) oxymorphone hcl tab sr 12hr 7.5 mg 2 QL (60 ea / 30 days) oxymorphone hcl tab sr 12hr 10 mg 2 QL (60 ea / 30 days) oxymorphone hcl tab sr 12hr 15 mg 2 QL (60 ea / 30 days) oxymorphone hcl tab sr 12hr 20 mg 2 QL (60 ea / 30 days) oxymorphone hcl tab sr 12hr 30 mg 2 QL (60 ea / 30 days) oxymorphone hcl tab sr 12hr 40 mg 2 QL (60 ea / 30 days) pentazocine w/ naloxone tab 50-0.5 mg 2 reprexain tab 10-200mg 2 roxicet tab 5-325mg 2 TALWIN INJ 30MG/ML 4 tramadol hcl tab 50 mg 2 tramadol hcl tab sr 24hr 100 mg 2 tramadol hcl tab sr 24hr 200 mg 2 tramadol hcl tab sr 24hr 300 mg 2 tramadol-acetaminophen tab 37.5-325 mg 2


10

Drug Name Drug Tier Requirements/Limits verdrocet tab 2.5-325 2 vicodin es tab 7.5-300 2 vicodin hp tab 10-300mg 2 vicodin tab 5-300mg 2 xylon tab 10-200mg 2 zamicet sol 10-325mg 2 VISCOSUPPLEMENTS MONOVISC INJ 88MG/4ML 3 SP ORTHOVISC INJ 15MG/ML 3 SP SYNVISC INJ 8MG/ML 3 SP SYNVISC ONE INJ 8MG/ML 3 SP ANTI-INFECTIVES AMINOGLYCOSIDES amikacin sulfate inj 500 mg/2ml (250

mg/ml) 2

gentamicin in saline inj 0.8 mg/ml 2 gentamicin in saline inj 1 mg/ml 2 gentamicin in saline inj 1.2 mg/ml 2 gentamicin in saline inj 1.6 mg/ml 2 gentamicin sulfate inj 40 mg/ml 2 gentamicin sulfate iv soln 10 mg/ml 2 neomycin sulfate tab 500 mg 1 paromomycin sulfate cap 250 mg 2 streptomycin sulfate for inj 1 gm 2 tobramycin sulfate inj 10 mg/ml (base

equivalent) 2

tobramycin sulfate inj 80 mg/2ml (40 mg/ml) (base equiv)

2

ANTIBACTERIALS, CARBAPENEMS DORIBAX INJ 500MG 4 imipenem-cilastatin intravenous for soln

250 mg 2

imipenem-cilastatin intravenous for soln 500 mg

2

INVANZ INJ 1GM 4 meropenem iv for soln 500 mg 2 ANTIBACTERIALS, CEPHALOSPORINS 1ST GEN cefadroxil cap 500 mg 2 cefadroxil for susp 250 mg/5ml 2 cefadroxil for susp 500 mg/5ml 2 cefadroxil tab 1 gm 2 cefazolin sodium for inj 1 gm 2


11

Drug Name Drug Tier Requirements/Limits cefazolin sodium for inj 10 gm 2 cefazolin sodium for inj 500 mg 2 cephalexin cap 250 mg 1 cephalexin cap 500 mg 1 cephalexin cap 750 mg 1 cephalexin for susp 125 mg/5ml 2 cephalexin for susp 250 mg/5ml 2 ANTIBACTERIALS, CEPHALOSPORINS, 2ND GEN cefaclor cap 250 mg 2 cefaclor cap 500 mg 2 cefoxitin sodium for inj 10 gm 2 SP cefoxitin sodium for iv soln 1 gm 2 SP cefoxitin sodium for iv soln 2 gm 2 SP cefprozil for susp 125 mg/5ml 2 cefprozil for susp 250 mg/5ml 2 cefprozil tab 250 mg 2 cefprozil tab 500 mg 2 CEFTIN SUS 125/5ML 4 CEFTIN SUS 250/5ML 4 cefuroxime axetil tab 250 mg 2 cefuroxime axetil tab 500 mg 2 cefuroxime sodium for inj 1.5 gm 2 cefuroxime sodium for inj 7.5 gm 2 cefuroxime sodium for inj 750 mg 2 ANTIBACTERIALS, CEPHALOSPORINS, 3RD GEN cefdinir cap 300 mg 2 cefdinir for susp 125 mg/5ml 2 cefdinir for susp 250 mg/5ml 2 cefditoren pivoxil tab 200 mg (base

equivalent) 2

cefditoren pivoxil tab 400 mg (base equivalent)

2

cefixime for susp 100 mg/5ml 2 cefixime for susp 200 mg/5ml 2 cefotaxime sodium for inj 1 gm 2 cefotaxime sodium for inj 2 gm 2 cefotaxime sodium for inj 10 gm 2 cefotaxime sodium for inj 500 mg 2 cefpodoxime proxetil for susp 50 mg/5ml 2 cefpodoxime proxetil for susp 100 mg/5ml 2 cefpodoxime proxetil tab 100 mg 2 cefpodoxime proxetil tab 200 mg 2


12

Drug Name Drug Tier Requirements/Limits ceftazidime for inj 1 gm 2 ceftazidime for inj 2 gm 2 ceftazidime for inj 6 gm 2 ceftibuten cap 400 mg 2 ceftibuten for susp 180 mg/5ml 2 ceftriaxone sodium for inj 2 gm 2 SP ceftriaxone sodium for inj 10 gm 2 SP ceftriaxone sodium for inj 250 mg 2 SP SUPRAX CHW 100MG 4 SUPRAX CHW 200MG 4 SUPRAX SUS 500/5ML 4 tazicef inj 1gm 2 tazicef inj 2gm 2 tazicef inj 6gm 2 ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 mg/5ml 1 azithromycin for susp 200 mg/5ml 1 azithromycin iv for soln 500 mg 1 azithromycin powd pack for susp 1 gm 1 azithromycin tab 250 mg 1 azithromycin tab 500 mg 1 azithromycin tab 600 mg 1 clarithromycin for susp 125 mg/5ml 2 clarithromycin for susp 250 mg/5ml 2 clarithromycin tab 250 mg 2 clarithromycin tab 500 mg 2 clarithromycin tab sr 24hr 500 mg 2 DIFICID TAB 200MG 4 QL (2 fills per 180

days), PA ery-tab tab 333mg ec 2 ERYTHROCIN INJ 500MG 4 erythromycin tab 500 mg 2 erythromycin w/ delayed release particles

cap 250 mg 2

PCE TAB 500MG EC 4 ZITHROMAX POW 1GM PAK 4 ANTIBACTERIALS, FLUOROQUINOLONES AVELOX INJ 3 ciprofloxacin for oral susp 250 mg/5ml

(5%) (5 gm/100ml) 2

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

2

ciprofloxacin hcl tab 100 mg (base equiv) 2


13

Drug Name Drug Tier Requirements/Limits ciprofloxacin hcl tab 250 mg (base equiv) 1 ciprofloxacin hcl tab 500 mg (base equiv) 1 ciprofloxacin hcl tab 750 mg (base equiv) 1 ciprofloxacin iv soln 200 mg/20ml (1%) 2 ciprofloxacin-ciprofloxacin hcl tab sr 24hr

500 mg (base eq) 2

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

2

FACTIVE TAB 320MG 4 levofloxacin iv soln 25 mg/ml 2 levofloxacin oral soln 25 mg/ml 2 levofloxacin tab 250 mg 2 levofloxacin tab 500 mg 2 levofloxacin tab 750 mg 2 moxifloxacin hcl tab 400 mg (base equiv) 2 ofloxacin tab 400 mg 2 ANTIBACTERIALS, KETOLIDES KETEK TAB 300MG 4 KETEK TAB 400MG 4 ANTIBACTERIALS, PENICILLINS amoxicillin & k clavulanate chew tab 200-

28.5 mg 2

amoxicillin & k clavulanate chew tab 400-57 mg

2

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

2


2

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

2


2

amoxicillin & k clavulanate tab 250-125 mg2 amoxicillin & k clavulanate tab 500-125 mg2 amoxicillin & k clavulanate tab 875-125 mg2 amoxicillin & k clavulanate tab sr 12hr

1000-62.5 mg 2

amoxicillin (trihydrate) cap 250 mg 1 amoxicillin (trihydrate) cap 500 mg 1 amoxicillin (trihydrate) for susp 125

mg/5ml 1

amoxicillin (trihydrate) for susp 200 mg/5ml

1


14

Drug Name Drug Tier Requirements/Limits amoxicillin (trihydrate) for susp 250

mg/5ml 1

amoxicillin (trihydrate) for susp 400 mg/5ml

1

amoxicillin (trihydrate) tab 500 mg 1 amoxicillin (trihydrate) tab 875 mg 1 ampicillin & sulbactam sodium for inj 3 (2-

1) gm 2

ampicillin & sulbactam sodium for iv soln 15 (10-5) gm

2

ampicillin cap 250 mg 2 ampicillin cap 500 mg 2 ampicillin sodium for inj 250 mg 2 ampicillin sodium for iv soln 10 gm 2 AUGMENTIN SUS 125/5ML 3 BACTOCILL INJ DEX 1GM 4 BICILLIN C-R INJ 1200000 4 BICILLIN L-A INJ 600000 4 BICILLIN L-A INJ 1200000 4 BICILLIN L-A INJ 2400000 4 dicloxacillin sodium cap 250 mg 1 dicloxacillin sodium cap 500 mg 1 nafcillin sodium for inj 10 gm 2 nafcillin sodium for iv soln 2 gm 2 oxacillin sodium for inj 1 gm 2 oxacillin sodium for inj 10 gm 2 penicillin g potassium for inj 5000000 unit 2 penicillin v potassium for soln 125 mg/5ml 1 penicillin v potassium for soln 250 mg/5ml 1 penicillin v potassium tab 250 mg 1 penicillin v potassium tab 500 mg 1 piperacillin sod-tazobactam na for inj 3.375

gm (3-0.375 gm) 2

piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm)

2

piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm)

2

ANTIBACTERIALS, SULFONAMIDES SULFADIAZINE TAB 500MG 3 sulfamethoxazole-trimethoprim susp 200-

40 mg/5ml 1

sulfamethoxazole-trimethoprim tab 400-80 mg

1


15

Drug Name Drug Tier Requirements/Limits sulfamethoxazole-trimethoprim tab 800-

160 mg 1

sulfatrim sus 200-40/5 1 ANTIBACTERIALS, TETRACYCLINES avidoxy tab 100mg 2 demeclocycline hcl tab 150 mg 2 demeclocycline hcl tab 300 mg 2 doxy 100 inj 100mg 2 doxycycline hyclate cap 50 mg 2 doxycycline hyclate cap 100 mg 2 doxycycline hyclate tab 20 mg 2 doxycycline hyclate tab 100 mg 2 doxycycline hyclate tab delayed release 75

mg 2

doxycycline hyclate tab delayed release 100 mg

2

doxycycline hyclate tab delayed release 150 mg

2

doxycycline monohydrate cap 75 mg 2 doxycycline monohydrate cap 150 mg 2 doxycycline monohydrate for susp 25

mg/5ml 2

doxycycline monohydrate tab 50 mg 2 doxycycline monohydrate tab 75 mg 2 doxycycline monohydrate tab 150 mg 2 minocycline hcl cap 50 mg 2 minocycline hcl cap 75 mg 2 minocycline hcl cap 100 mg 2 minocycline hcl tab 50 mg 2 minocycline hcl tab 75 mg 2 minocycline hcl tab 100 mg 2 minocycline hcl tab sr 24hr 45 mg 2 minocycline hcl tab sr 24hr 90 mg 2 minocycline hcl tab sr 24hr 135 mg 2 morgidox cap 1x100mg 2 tetracycline hcl cap 250 mg 2 tetracycline hcl cap 500 mg 2 ANTIFUNGALS ABELCET INJ 5MG/ML 4 AMBISOME INJ 50MG 4 AMPHOTEC INJ 50MG 4 amphotericin b for inj 50 mg 2


16

Drug Name Drug Tier Requirements/Limits CANCIDAS INJ 50MG Plan

Exclusion

CANCIDAS INJ 70MG Plan Exclusion

clotrimazole troche 10 mg 2 CRESEMBA CAP 186 MG 4 QL, PA ERAXIS INJ 50MG Plan

Exclusion

fluconazole for susp 10 mg/ml 1 fluconazole for susp 40 mg/ml 1 fluconazole in nacl 0.9% inj 200 mg/100ml 2 fluconazole tab 50 mg 1 fluconazole tab 100 mg 1 fluconazole tab 150 mg 1 fluconazole tab 200 mg 1 flucytosine cap 250 mg 2 flucytosine cap 500 mg 2 griseofulvin microsize susp 125 mg/5ml 2 griseofulvin microsize tab 500 mg 2 griseofulvin ultramicrosize tab 125 mg 2 griseofulvin ultramicrosize tab 250 mg 2 itraconazole cap 100 mg 2 QL (170 caps / year), PA ketoconazole tab 200 mg 1 LAMISIL GRA 125MG 3 PA; QL LAMISIL GRA 187.5MG 3 QL (42 paks per year),

PA NOXAFIL INJ 300/16.7 3 A90 NOXAFIL SUS 40MG/ML 3 A90 NOXAFIL TAB 100MG 3 A90 nystatin susp 100000 unit/ml 2 nystatin tab 500000 unit 2 ORAVIG TAB 50MG 4 QL (30 tabs / 30 days),

PA SPORANOX SOL 10MG/ML 3 QL (450 mL / 21 days),

PA terbinafine hcl tab 250 mg 1 QL (84 tabs / year) voriconazole for inj 200 mg 2 voriconazole for susp 40 mg/ml 2 voriconazole tab 50 mg 2 voriconazole tab 200 mg 2 ANTIMALARIALS atovaquone-proguanil hcl tab 62.5-25 mg 2 atovaquone-proguanil hcl tab 250-100 mg 2


17

Drug Name Drug Tier Requirements/Limits chloroquine phosphate tab 250 mg 1 A90, M90 chloroquine phosphate tab 500 mg 1 A90, M90 COARTEM TAB 20-120MG 3 DARAPRIM TAB 25MG 3 mefloquine hcl tab 250 mg 2 A90, M90 PRIMAQUINE TAB 26.3MG 3 quinine sulfate cap 324 mg 2 PA ANTIRETROVIRALS, ANTIRETROVIRAL COMBINATIONS abacavir sulfate-lamivudine-zidovudine tab

300-150-300 mg 2 A90, M90

ATRIPLA TAB 3 A90, M90 COMPLERA TAB 3 QL (30 per 30 days);

A90, M90 DESCOVY TAB 200/25 3 QL (30 per 30 days) EPZICOM TAB 600-300 3 A90, M90 GENVOYA TAB 4 QL (30 per 30 days) lamivudine-zidovudine tab 150-300 mg 2 A90, M90 ODEFSEY TAB 3 QL (30 per 30 days) STRIBILD TAB 4 QL (30 per 30 days);

A90, M90 TRUVADA TAB 200-300 3 QL (30 per 30 days);

A90, M90 ANTIRETROVIRALS, CHEMOKINE RECEPTOR ANTAGONISTS SELZENTRY TAB 150MG 3 A90, M90 SELZENTRY TAB 300MG 3 A90, M90 ANTIRETROVIRALS, FUSION INHIBITORS FUZEON INJ 90MG 3 SP ANTIRETROVIRALS, INTEGRASE INHIBITORS ISENTRESS CHW 25MG 3 A90, M90 ISENTRESS CHW 100MG 3 A90, M90 ISENTRESS POW 100MG 3 A90, M90 ISENTRESS TAB 400MG 3 A90, M90 TIVICAY TAB 50MG 3 A90, M90 ANTIRETROVIRALS, PROTEASE INHIBITORS APTIVUS CAP 250MG 3 A90, M90 APTIVUS SOL 3 A90, M90 CRIXIVAN CAP 200MG 3 A90, M90 CRIXIVAN CAP 400MG 3 A90, M90 INVIRASE CAP 200MG 3 A90, M90 INVIRASE TAB 500MG 3 A90, M90 KALETRA SOL 3 A90, M90 KALETRA TAB 100-25MG 3 A90, M90


18

Drug Name Drug Tier Requirements/Limits KALETRA TAB 200-50MG 3 A90, M90 LEXIVA SUS 50MG/ML 3 A90, M90 LEXIVA TAB 700MG 3 A90, M90 NORVIR CAP 100MG 3 A90, M90 NORVIR SOL 80MG/ML 3 A90, M90 NORVIR TAB 100MG 3 A90, M90 PREZISTA SUS 100MG/ML 3 A90, M90 PREZISTA TAB 75MG 3 A90, M90 PREZISTA TAB 150MG 3 A90, M90 PREZISTA TAB 600MG 3 A90, M90 PREZISTA TAB 800MG 3 A90, M90 REYATAZ CAP 150MG 3 A90, M90 REYATAZ CAP 200MG 3 A90, M90 REYATAZ CAP 300MG 4 A90, M90 REYATAZ POW 50MG 3 A90, M90 VIRACEPT TAB 250MG 3 A90, M90 VIRACEPT TAB 625MG 3 A90, M90 ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS - NON-

NUCLEOSIDE EDURANT TAB 25MG 3 A90, M90 INTELENCE TAB 25MG 3 A90, M90 INTELENCE TAB 100MG 3 A90, M90 INTELENCE TAB 200MG 3 A90, M90 nevirapine susp 50 mg/5ml 2 A90, M90 nevirapine tab 200 mg 2 A90, M90 nevirapine tab sr 24hr 100 mg 2 A90, M90 nevirapine tab sr 24hr 400 mg 2 A90, M90 RESCRIPTOR TAB 100 MG 3 A90, M90 RESCRIPTOR TAB 200MG 3 A90, M90 SUSTIVA CAP 50MG 3 A90, M90 SUSTIVA CAP 200MG 3 A90, M90 SUSTIVA TAB 600MG 3 A90, M90 ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS -

NUCLEOSIDE abacavir sulfate tab 300 mg (base equiv) 2 A90, M90 didanosine delayed release capsule 125 mg2 A90, M90 didanosine delayed release capsule 200 mg2 A90, M90 didanosine delayed release capsule 250 mg2 A90, M90 didanosine delayed release capsule 400 mg2 A90, M90 EMTRIVA CAP 200MG 3 A90, M90 EMTRIVA SOL 10MG/ML 3 A90, M90 lamivudine oral soln 10 mg/ml 2 A90, M90


19

Drug Name Drug Tier Requirements/Limits lamivudine tab 150 mg 2 A90, M90 lamivudine tab 300 mg 2 A90, M90 RETROVIR INJ 10MG/ML 3 stavudine cap 15 mg 2 A90, M90 stavudine cap 20 mg 2 A90, M90 stavudine cap 30 mg 2 A90, M90 stavudine cap 40 mg 2 A90, M90 stavudine for oral soln 1 mg/ml 2 A90, M90 VIDEX SOL 2GM 3 A90, M90 ZIAGEN SOL 20MG/ML 3 A90, M90 zidovudine cap 100 mg 2 A90, M90 zidovudine syrup 10 mg/ml 2 A90, M90 zidovudine tab 300 mg 2 A90, M90 ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS -

NUCLEOTIDE VIREAD POW 40MG/GM 3 A90, M90 VIREAD TAB 150MG 3 A90, M90 VIREAD TAB 200MG 3 A90, M90 VIREAD TAB 250MG 3 A90, M90 VIREAD TAB 300MG 3 A90, M90 ANTITUBERCULAR AGENTS CAPASTAT SUL INJ 1GM 4 cycloserine cap 250 mg 2 ethambutol hcl tab 100 mg 2 ethambutol hcl tab 400 mg 2 isoniazid syrup 50 mg/5ml 3 A90, M90 isoniazid tab 100 mg 2 A90, M90 isoniazid tab 300 mg 2 A90, M90 PASER GRA 4GM 4 PRIFTIN TAB 150MG 3 pyrazinamide tab 500 mg 2 RIFAMATE CAP 4 rifampin cap 150 mg 2 rifampin cap 300 mg 2 rifampin for inj 600 mg 2 RIFATER TAB 4 SIRTURO TAB 100MG 3 TRECATOR TAB 250MG 4 ANTIVIRALS, CMV AGENTS cidofovir iv inj 75 mg/ml 2 ganciclovir sodium for inj 500 mg 2 VALCYTE SOL 50MG/ML 3 A90, M90


20

Drug Name Drug Tier Requirements/Limits valganciclovir hcl tab 450 mg (base

equivalent) 2 A90, M90

ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS B adefovir dipivoxil tab 10 mg 3 QL, SP entecavir tab 0.5 mg 3 QL (30 tabs / 30 days);

SP entecavir tab 1 mg 3 QL (30 tabs / 30 days);

SP lamivudine tab 100 mg (hbv) 2 A90 TYZEKA TAB 600MG 4 QL (30 tabs / 30 days),

PA; A90 ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS C EPCLUSA TAB 400-100 3 PA; SP; only for

genotypes 2 and 3 HARVONI TAB 90-400MG 3 PA; SP; only for

genotypes 1, 4, 5 and 6 MODERIBA PAK 800/DAY 3 PA; SP MODERIBA PAK 1000/DAY 3 PA; SP MODERIBA PAK 1200/DAY 3 PA; SP moderiba tab 200mg 3 PA; SP REBETOL SOL 40MG/ML 4 PA; SP RIBAPAK PAK 600/DAY 3 PA; SP RIBAPAK PAK 800/DAY 3 PA; SP RIBAPAK PAK 1000/DAY 3 PA; SP RIBAPAK PAK 1200/DAY 3 PA; SP ribasphere cap 200mg 3 PA; SP ribasphere tab 200mg 3 PA; SP ribasphere tab 400mg 3 PA; SP ribasphere tab 600mg 3 PA; SP ribavirin cap 200 mg 3 PA; SP ribavirin tab 200 mg 3 PA; SP ANTIVIRALS, HERPES AGENTS acyclovir cap 200 mg 1 acyclovir sodium for inj 500 mg 2 acyclovir susp 200 mg/5ml 1 acyclovir tab 400 mg 1 acyclovir tab 800 mg 1 famciclovir tab 125 mg 2 famciclovir tab 250 mg 2 famciclovir tab 500 mg 2 valacyclovir hcl tab 1 gm 2 valacyclovir hcl tab 500 mg 2


21

Drug Name Drug Tier Requirements/Limits ANTIVIRALS, INFLUENZA AGENTS RELENZA MIS DISKHALE 3 PA rimantadine hydrochloride tab 100 mg 2 TAMIFLU CAP 30MG 3 PA TAMIFLU CAP 45MG 3 PA TAMIFLU CAP 75MG 3 PA TAMIFLU SUS 6MG/ML 3 PA MISCELLANEOUS ALBENZA TAB 200MG 3 ALINIA SUS 100/5ML 3 ALINIA TAB 500MG 3 atovaquone susp 750 mg/5ml 2 aztreonam for inj 1 gm 2 baciim inj 50000unt 2 BILTRICIDE TAB 600MG 4 clindamycin hcl cap 75 mg 2 clindamycin hcl cap 150 mg 2 clindamycin hcl cap 300 mg 2 clindamycin palmitate hcl for soln 75

mg/5ml (base equiv) 2

clindamycin phosphate inj 600 mg/4ml 2 colistimethate sodium for inj 150 mg 2 dapsone tab 25 mg 2 A90 dapsone tab 100 mg 2 A90 FLAGYL ER TAB 750MG 4 ivermectin tab 3 mg 2 linezolid for susp 100 mg/5ml 1 QL (1800 mL / 90 days),

PA linezolid iv soln 600 mg/300ml (2 mg/ml) 2 QL metronidazole cap 375 mg 1 metronidazole tab 250 mg 1 metronidazole tab 500 mg 1 MONUROL PAK GRANULES Plan

Exclusion

NEBUPENT INH 300MG 3 nitrofurantoin macrocrystalline cap 25 mg 2 nitrofurantoin macrocrystalline cap 50 mg 2 nitrofurantoin monohydrate

macrocrystalline cap 100 mg 2

nitrofurantoin susp 25 mg/5ml 2 polymyxin b sulfate for inj 500000 unit 2 PRIMSOL SOL 50MG/5ML 4 rifabutin cap 150 mg 2


22

Drug Name Drug Tier Requirements/Limits SIVEXTRO INJ 200MG 3 STROMECTOL TAB 3MG 4 PA tinidazole tab 250 mg 2 tinidazole tab 500 mg 2 trimethoprim tab 100 mg 1 vancomycin hcl cap 125 mg 2 vancomycin hcl cap 250 mg 2 vancomycin hcl for inj 10 gm 2 vancomycin hcl for inj 500 mg 2 vancomycin hcl for inj 1000 mg 2 VIBATIV INJ 250MG 4 VIRAZOLE INH 6GM 4 XIFAXAN TAB 200MG 4 XIFAXAN TAB 550MG 4 A90 ANTINEOPLASTIC AGENTS ALKYLATING AGENTS ALKERAN TAB 2MG $0 BICNU INJ 100MG $0 SP BUSULFEX INJ 6MG/ML $0 carboplatin iv soln 50 mg/5ml $0 SP cisplatin inj 50 mg/50ml (1 mg/ml) $0 SP CYCLOPHOSPH CAP 25MG $0 CYCLOPHOSPH CAP 50MG $0 cyclophosphamide for inj 2 gm $0 cyclophosphamide for inj 500 mg $0 dacarbazine for inj 200 mg $0 SP EMCYT CAP 140MG $0 SP GLEOSTINE CAP 10MG $0 SP GLEOSTINE CAP 40MG $0 SP GLEOSTINE CAP 100MG $0 SP GLIADEL WAF 7.7MG $0 SP HEXALEN CAP 50MG $0 SP IFEX INJ 1GM $0 SP ifosfamide for inj 1 gm $0 SP LEUKERAN TAB 2MG $0 SP melphalan hcl for inj 50 mg (base equiv) $0 SP MUSTARGEN INJ 10MG $0 SP MYLERAN TAB 2MG $0 oxaliplatin iv soln 50 mg/10ml $0 SP temozolomide cap 5 mg $0 PA; SP temozolomide cap 20 mg $0 PA; SP temozolomide cap 100 mg $0 PA; SP


23

Drug Name Drug Tier Requirements/Limits temozolomide cap 140 mg $0 PA; SP temozolomide cap 180 mg $0 PA; SP temozolomide cap 250 mg $0 PA; SP TREANDA INJ 25MG $0 SP VALCHLOR GEL 0.016% $0 SP ZANOSAR INJ 1GM $0 SP ANTIMETABOLITES adrucil inj 500/10ml $0 ALIMTA INJ 500MG $0 SP azacitidine for inj 100 mg $0 SP capecitabine tab 150 mg $0 SP capecitabine tab 500 mg $0 SP cladribine iv soln 10 mg/10ml (1 mg/ml) $0 SP CLOLAR INJ 1MG/ML $0 SP cytarabine inj pf 20 mg/ml $0 SP cytarabine inj pf 100 mg/ml $0 SP decitabine for inj 50 mg $0 SP DEPOCYT INJ 50MG/5ML $0 SP floxuridine for inj 0.5 gm $0 SP fludarabine phosphate inj 25 mg/ml $0 SP fluorouracil inj 500 mg/10ml (50 mg/ml) $0 SP FOLOTYN INJ 20MG/ML $0 SP gemcitabine hcl for inj 200 mg $0 SP mercaptopurine tab 50 mg $0 SP methotrexate sodium for inj 1 gm $0 methotrexate sodium inj pf 50 mg/2ml (25

mg/ml) $0

methotrexate sodium tab 2.5 mg (base equiv)

$0

PURIXAN SUS 20MG/ML $0 SP TABLOID TAB 40MG $0 SP HORMONAL ANTINEOPLASTICS, ANTIANDROGENS bicalutamide tab 50 mg $0 flutamide cap 125 mg $0 NILANDRON TAB 150MG $0 XTANDI CAP 40MG $0 SP ZYTIGA TAB 250MG $0 SP HORMONAL ANTINEOPLASTICS, ANTIESTROGENS FARESTON TAB 60MG $0 A90, M90 FASLODEX INJ 250MG $0 SP SOLTAMOX SOL 10MG/5ML $0 A90, M90


24

Drug Name Drug Tier Requirements/Limits tamoxifen citrate tab 10 mg (base

equivalent) $0 A90, M90

tamoxifen citrate tab 20 mg (base equivalent)

$0 A90, M90

HORMONAL ANTINEOPLASTICS, AROMATASE INHIBITORS anastrozole tab 1 mg $0 A90, M90 exemestane tab 25 mg $0 A90, M90 letrozole tab 2.5 mg $0 A90, M90 HORMONAL ANTINEOPLASTICS, GONADOTROPIN RELEASING

HORMONE ANTAGONISTS FIRMAGON INJ 80MG 3 PA; SP FIRMAGON INJ 120MG 3 PA; SP HORMONAL ANTINEOPLASTICS, LUTEINIZING HORMONE-

RELEASING HORMONE (LHRH) AGONISTS ELIGARD INJ 7.5MG $0 SP ELIGARD INJ 22.5MG $0 SP ELIGARD INJ 30MG $0 SP ELIGARD INJ 45MG $0 SP leuprolide acetate inj kit 5 mg/ml $0 SP LUPRON DEPOT INJ 3.75MG $0 SP LUPRON DEPOT INJ 11.25MG $0 PA; SP LUPRON DEPOT INJ 22.5MG $0 SP LUPRON DEPOT INJ 30MG $0 PA; SP LUPRON DEPOT INJ 45MG $0 SP TRELSTAR INJ 3.75MG $0 SP TRELSTAR INJ 11.25MG $0 SP TRELSTAR MIX INJ 22.5MG $0 SP VANTAS KIT 50MG $0 SP ZOLADEX IMP 3.6MG $0 SP ZOLADEX IMP 10.8MG $0 SP HORMONAL ANTINEOPLASTICS, PROGESTINS DEPO-PROVERA INJ 400/ML 3 megestrol acetate susp 40 mg/ml $0 megestrol acetate tab 20 mg $0 megestrol acetate tab 40 mg $0 IMMUNOMODULATORS POMALYST CAP 1MG $0 SP POMALYST CAP 2MG $0 SP POMALYST CAP 3MG $0 SP POMALYST CAP 4MG $0 SP REVLIMID CAP 2.5MG 3 PA; SP REVLIMID CAP 5MG 3 PA; SP


25

Drug Name Drug Tier Requirements/Limits REVLIMID CAP 10MG 3 PA; SP REVLIMID CAP 15MG 3 PA; SP REVLIMID CAP 20MG 3 PA; SP REVLIMID CAP 25MG 3 PA; SP THALOMID CAP 50MG 3 PA; SP THALOMID CAP 100MG 3 PA; SP THALOMID CAP 150MG 3 PA; SP THALOMID CAP 200MG 3 PA; SP KINASE INHIBITORS AFINITOR DIS TAB 2MG $0 SP AFINITOR DIS TAB 3MG $0 SP AFINITOR DIS TAB 5MG $0 SP AFINITOR TAB 2.5MG $0 SP AFINITOR TAB 5MG $0 SP AFINITOR TAB 7.5MG $0 SP AFINITOR TAB 10MG $0 SP BOSULIF TAB 100MG $0 SP BOSULIF TAB 500MG $0 SP CAPRELSA TAB 100MG $0 SP CAPRELSA TAB 300MG $0 SP COMETRIQ KIT 100MG $0 SP COMETRIQ KIT 140MG $0 SP GILOTRIF TAB 20MG $0 SP GILOTRIF TAB 30MG $0 SP GILOTRIF TAB 40MG $0 SP IBRANCE CAP 75MG $0 SP IBRANCE CAP 100MG $0 SP IBRANCE CAP 125MG $0 SP ICLUSIG TAB 15MG $0 SP ICLUSIG TAB 45MG $0 SP imatinib mesylate tab 100 mg (base

equivalent) $0 SP

imatinib mesylate tab 400 mg (base equivalent)

$0 SP

IMBRUVICA CAP 140MG $0 SP INLYTA TAB 1MG $0 SP INLYTA TAB 5MG $0 SP JAKAFI TAB 5MG $0 SP JAKAFI TAB 10MG $0 SP JAKAFI TAB 15MG $0 SP JAKAFI TAB 20MG $0 SP JAKAFI TAB 25MG $0 SP


26

Drug Name Drug Tier Requirements/Limits LENVIMA CAP 10 MG $0 SP LENVIMA CAP 14 MG $0 SP LENVIMA CAP 20 MG $0 SP LENVIMA CAP 24 MG $0 SP MEKINIST TAB 0.5MG $0 SP MEKINIST TAB 2MG $0 SP NEXAVAR TAB 200MG $0 SP SPRYCEL TAB 20MG $0 SP SPRYCEL TAB 50MG $0 SP SPRYCEL TAB 70MG $0 SP SPRYCEL TAB 80MG $0 SP SPRYCEL TAB 100MG $0 SP SPRYCEL TAB 140MG $0 SP STIVARGA TAB 40MG $0 SP SUTENT CAP 12.5MG $0 SP SUTENT CAP 25MG $0 SP SUTENT CAP 37.5MG $0 SP SUTENT CAP 50MG $0 SP TAFINLAR CAP 50MG $0 SP TAFINLAR CAP 75MG $0 SP TARCEVA TAB 25MG $0 SP TARCEVA TAB 100MG $0 SP TARCEVA TAB 150MG $0 SP TASIGNA CAP 150MG $0 SP TASIGNA CAP 200MG $0 SP TORISEL SOL 25MG/ML $0 SP TYKERB TAB 250MG $0 SP VELCADE INJ 3.5MG $0 SP VOTRIENT TAB 200MG $0 SP XALKORI CAP 200MG $0 SP XALKORI CAP 250MG $0 SP ZELBORAF TAB 240MG $0 SP ZYDELIG TAB 100MG $0 SP ZYDELIG TAB 150MG $0 SP ZYKADIA CAP 150MG $0 SP MISCELLANEOUS ABRAXANE INJ 100MG $0 SP ADCETRIS INJ 50MG $0 SP amifostine crystalline for inj 500 mg 2 ARRANON INJ 5MG/ML $0 SP ARZERRA CON 1000/50 $0 SP AVASTIN INJ $0 SP


27

Drug Name Drug Tier Requirements/Limits BELEODAQ INJ 500MG $0 SP bexarotene cap 75 mg $0 SP bleomycin sulfate for inj 15 unit $0 SP CAMPTOSAR INJ 40MG/2ML $0 SP daunorubicin hcl inj 5 mg/ml (base equiv) $0 SP dexrazoxane for inj 250 mg 2 DOCEFREZ INJ 20MG $0 SP DOCEFREZ INJ 80MG $0 SP docetaxel for inj conc 20 mg/ml $0 SP DOCETAXEL INJ 20/0.5ML $0 SP DOCETAXEL INJ 20MG/2ML $0 SP docetaxel inj 80mg/4ml $0 SP doxorubicin hcl inj 2 mg/ml $0 SP doxorubicin hcl liposomal inj (for iv

infusion) 2 mg/ml $0 SP

DROXIA CAP 200MG 4 A90, M90 DROXIA CAP 300MG 4 A90, M90 DROXIA CAP 400MG 4 A90, M90 ELITEK INJ 1.5MG 3 SP epirubicin hcl iv soln 50 mg/25ml (2

mg/ml) $0 SP

ERBITUX INJ 100MG $0 SP ERIVEDGE CAP 150MG $0 SP ERWINAZE INJ 10000UNT $0 SP ETOPOPHOS INJ 100MG $0 SP etoposide cap 50 mg $0 SP etoposide inj 100 mg/5ml (20 mg/ml) $0 SP FARYDAK CAP 10MG $0 SP FARYDAK CAP 15MG $0 SP FARYDAK CAP 20MG $0 SP FUSILEV INJ 50MG 3 SP GAZYVA INJ 25MG/ML $0 SP HALAVEN INJ 1MG/2ML $0 SP HERCEPTIN INJ 440MG $0 SP hydroxyurea cap 500 mg 2 idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) $0 SP irinotecan hcl inj 40 mg/2ml (20 mg/ml) $0 SP ISTODAX INJ 10MG $0 SP IXEMPRA KIT INJ 15MG $0 SP JEVTANA INJ 60/1.5ML $0 SP KADCYLA INJ 100MG $0 SP KEYTRUDA INJ 100MG/4M $0 SP KEYTRUDA SOL 50MG $0 SP


28

Drug Name Drug Tier Requirements/Limits KYPROLIS SOL 60MG $0 SP leucovorin calcium for inj 50 mg $0 leucovorin calcium for inj 100 mg $0 leucovorin calcium for inj 350 mg $0 leucovorin calcium tab 5 mg $0 leucovorin calcium tab 25 mg $0 lipodox inj 2mg/ml 3 LYNPARZA CAP 50MG $0 SP LYSODREN TAB 500MG $0 SP MARQIBO INJ 5MG/31ML $0 SP MATULANE CAP 50MG $0 SP mesna inj 100 mg/ml $0 SP MESNEX TAB 400MG $0 SP mitomycin for iv soln 5 mg $0 SP mitomycin for iv soln 20 mg $0 SP mitoxantrone hcl inj conc 25 mg/12.5ml (2

mg/ml) $0 SP

NIPENT INJ 10MG $0 SP ONCASPAR INJ 750/ML $0 SP OPDIVO INJ 40MG/4ML $0 SP OPDIVO INJ 100MG/10 $0 SP paclitaxel iv conc 30 mg/5ml (6 mg/ml) $0 SP PERJETA INJ 420/14ML $0 SP PHOTOFRIN INJ 75MG $0 PROLEUKIN INJ 22MU $0 SP PROVENGE INJ $0 SP RITUXAN INJ 100MG $0 SP SYNRIBO INJ 3.5MG $0 SP TARGRETIN GEL 1% 4 PA; SP TENIPOSIDE INJ 50MG/5ML $0 SP THERACYS INJ $0 SP toposar inj 100/5ml 3 tretinoin cap 10 mg $0 SP TRISENOX SOL 10MG/10M $0 SP UVADEX INJ 20MCG/ML $0 VALSTAR SOL 40MG/ML $0 SP VECTIBIX INJ 100MG $0 SP vinblastine sulfate inj 1 mg/ml $0 SP vincasar pfs inj 1mg/ml 3 vincristine sulfate iv soln 1 mg/ml $0 SP vinorelbine tartrate inj 10 mg/ml (base

equiv) $0 SP

YERVOY INJ 50MG $0 SP


29

Drug Name Drug Tier Requirements/Limits ZALTRAP INJ 100/4ML $0 SP ZOLINZA CAP 100MG $0 QL (120 caps / 30

days); SP TOPOISOMERASE INHIBITORS HYCAMTIN CAP 0.25MG $0 SP HYCAMTIN CAP 1MG $0 SP topotecan hcl for inj 4 mg $0 SP CARDIOVASCULAR ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine besylate-benazepril hcl cap 2.5-

10 mg 2 A90, M90

amlodipine besylate-benazepril hcl cap 5-10 mg

2 A90, M90


2 A90, M90


2 A90, M90


2 A90, M90


2 A90, M90

trandolapril-verapamil hcl tab cr 1-240 mg 2 A90, M90 trandolapril-verapamil hcl tab cr 2-180 mg 2 A90, M90 trandolapril-verapamil hcl tab cr 2-240 mg 2 A90, M90 trandolapril-verapamil hcl tab cr 4-240 mg 2 A90, M90 ACE INHIBITOR/DIURETIC COMBINATIONS benazepril & hydrochlorothiazide tab 5-

6.25 mg 2 A90, M90

benazepril & hydrochlorothiazide tab 10-12.5 mg

2 A90, M90

benazepril & hydrochlorothiazide tab 20-12.5 mg

2 A90, M90

benazepril & hydrochlorothiazide tab 20-25 mg

2 A90, M90

enalapril maleate & hydrochlorothiazide tab 5-12.5 mg

1 A90, M90

enalapril maleate & hydrochlorothiazide tab 10-25 mg

2 A90, M90

fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg

2 A90, M90

fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg

2 A90, M90

lisinopril & hydrochlorothiazide tab 10-12.5 mg

1 A90, M90


30

Drug Name Drug Tier Requirements/Limits lisinopril & hydrochlorothiazide tab 20-12.5

mg 1 A90, M90

lisinopril & hydrochlorothiazide tab 20-25 mg

1 A90, M90

moexipril-hydrochlorothiazide tab 7.5-12.5 mg

2 A90, M90

moexipril-hydrochlorothiazide tab 15-12.5 mg

2 A90, M90

moexipril-hydrochlorothiazide tab 15-25 mg

2 A90, M90

quinapril-hydrochlorothiazide tab 10-12.5 mg

2 A90, M90

quinapril-hydrochlorothiazide tab 20-12.5 mg

2 A90, M90

quinapril-hydrochlorothiazide tab 20-25 mg2 A90, M90 ACE INHIBITORS benazepril hcl tab 5 mg 1 A90, M90 benazepril hcl tab 10 mg 1 A90, M90 benazepril hcl tab 20 mg 1 A90, M90 benazepril hcl tab 40 mg 1 A90, M90 captopril tab 12.5 mg 2 A90, M90 captopril tab 25 mg 2 A90, M90 captopril tab 50 mg 2 A90, M90 captopril tab 100 mg 2 A90, M90 enalapril maleate tab 2.5 mg 1 A90, M90 enalapril maleate tab 5 mg 1 A90, M90 enalapril maleate tab 10 mg 1 A90, M90 enalapril maleate tab 20 mg 1 A90, M90 enalaprilat iv inj 1.25 mg/ml 2 fosinopril sodium tab 10 mg 1 A90, M90 fosinopril sodium tab 20 mg 1 A90, M90 fosinopril sodium tab 40 mg 1 A90, M90 lisinopril tab 2.5 mg 1 A90, M90 lisinopril tab 5 mg 1 A90, M90 lisinopril tab 10 mg 1 A90, M90 lisinopril tab 20 mg 1 A90, M90 lisinopril tab 30 mg 1 A90, M90 lisinopril tab 40 mg 1 A90, M90 moexipril hcl tab 7.5 mg 1 A90, M90 moexipril hcl tab 15 mg 1 A90, M90 perindopril erbumine tab 2 mg 2 A90, M90 perindopril erbumine tab 4 mg 2 A90, M90 perindopril erbumine tab 8 mg 2 A90, M90


31

Drug Name Drug Tier Requirements/Limits quinapril hcl tab 5 mg 1 A90, M90 quinapril hcl tab 10 mg 1 A90, M90 quinapril hcl tab 20 mg 1 A90, M90 quinapril hcl tab 40 mg 1 A90, M90 ramipril cap 1.25 mg 1 A90, M90 ramipril cap 2.5 mg 1 A90, M90 ramipril cap 5 mg 1 A90, M90 ramipril cap 10 mg 1 A90, M90 trandolapril tab 1 mg 1 A90, M90 trandolapril tab 2 mg 1 A90, M90 trandolapril tab 4 mg 1 A90, M90 ADRENOLYTICS, CENTRAL clonidine hcl tab 0.1 mg 1 A90, M90 clonidine hcl tab 0.2 mg 1 A90, M90 clonidine hcl tab 0.3 mg 1 A90, M90 clonidine hcl td patch weekly 0.1 mg/24hr 2 A90, M90 clonidine hcl td patch weekly 0.2 mg/24hr 2 A90, M90 clonidine hcl td patch weekly 0.3 mg/24hr 2 A90, M90 guanfacine hcl tab 1 mg 1 A90, M90 guanfacine hcl tab 2 mg 1 A90, M90 ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone tab 25 mg 2 A90, M90 eplerenone tab 50 mg 2 A90, M90 spironolactone tab 25 mg 1 A90, M90 spironolactone tab 50 mg 1 A90, M90 spironolactone tab 100 mg 1 A90, M90 ALPHA BLOCKERS doxazosin mesylate tab 1 mg 1 A90, M90 doxazosin mesylate tab 2 mg 1 A90, M90 doxazosin mesylate tab 4 mg 1 A90, M90 doxazosin mesylate tab 8 mg 1 A90, M90 prazosin hcl cap 1 mg 1 A90, M90 prazosin hcl cap 2 mg 1 A90, M90 prazosin hcl cap 5 mg 1 A90, M90 terazosin hcl cap 1 mg 1 A90, M90 terazosin hcl cap 2 mg 1 A90, M90 terazosin hcl cap 5 mg 1 A90, M90 terazosin hcl cap 10 mg 1 A90, M90 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL

BLOCKER/DIURETIC COMBINATIONS amlodipine-valsartan-hydrochlorothiazide

tab 5-160-12.5 mg 2 A90, M90


32

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

tab 5-160-25 mg 2 A90, M90

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

2 A90, M90

amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg

2 A90, M90

amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg

2 A90, M90

ANGIOTENSIN II RECEPTOR ANTAGONIST/DIURETIC COMBINATIONS

BENICAR HCT TAB 20-12.5 3 ST; A90, M90 BENICAR HCT TAB 40-12.5 3 ST; A90, M90 BENICAR HCT TAB 40-25MG 3 ST; A90, M90 candesartan cilexetil-hydrochlorothiazide

tab 16-12.5 mg 2 ST; A90, M90

candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg

2 ST; A90, M90

candesartan cilexetil-hydrochlorothiazide tab 32-25 mg

2 ST; A90, M90

irbesartan-hydrochlorothiazide tab 150-12.5 mg

2 A90, M90

irbesartan-hydrochlorothiazide tab 300-12.5 mg

2 A90, M90

losartan potassium & hydrochlorothiazide tab 50-12.5 mg

1 A90, M90

losartan potassium & hydrochlorothiazide tab 100-12.5 mg

1 A90, M90

losartan potassium & hydrochlorothiazide tab 100-25 mg

1 A90, M90

telmisartan-hydrochlorothiazide tab 40-12.5 mg

2 ST; A90, M90

telmisartan-hydrochlorothiazide tab 80-12.5 mg

2 ST; A90, M90

telmisartan-hydrochlorothiazide tab 80-25 mg

2 ST; A90, M90

valsartan-hydrochlorothiazide tab 80-12.5 mg

2 A90, M90


2 A90, M90

valsartan-hydrochlorothiazide tab 160-25 mg

2 A90, M90


2 A90, M90


33

Drug Name Drug Tier Requirements/Limits valsartan-hydrochlorothiazide tab 320-25

mg 2 A90, M90

ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR TAB 5MG 3 ST; A90, M90 BENICAR TAB 20MG 3 ST; A90, M90 BENICAR TAB 40MG 3 ST; A90, M90 candesartan cilexetil tab 4 mg 2 ST; A90, M90 candesartan cilexetil tab 8 mg 2 ST; A90, M90 candesartan cilexetil tab 16 mg 2 ST; A90, M90 candesartan cilexetil tab 32 mg 2 ST; A90, M90 EDARBI TAB 40MG 4 ST; A90, M90 EDARBI TAB 80MG 4 ST; A90, M90 eprosartan mesylate tab 600 mg 2 ST; A90, M90 irbesartan tab 75 mg 2 A90, M90 irbesartan tab 150 mg 2 A90, M90 irbesartan tab 300 mg 2 A90, M90 losartan potassium tab 25 mg 1 A90, M90 losartan potassium tab 50 mg 1 A90, M90 losartan potassium tab 100 mg 1 A90, M90 telmisartan tab 20 mg 2 ST; A90, M90 telmisartan tab 40 mg 2 ST; A90, M90 telmisartan tab 80 mg 2 ST; A90, M90 valsartan tab 40 mg 2 A90, M90 valsartan tab 80 mg 2 A90, M90 valsartan tab 160 mg 2 A90, M90 valsartan tab 320 mg 2 A90, M90 ANTIARRHYTHMICS adenosine iv soln 6 mg/2ml 2 adenosine iv soln 12 mg/4ml 2 amiodarone hcl inj 150 mg/3ml (50

mg/ml) 2

amiodarone hcl tab 100 mg 2 A90, M90 amiodarone hcl tab 200 mg 2 A90, M90 amiodarone hcl tab 400 mg 2 A90, M90 disopyramide phosphate cap 100 mg 2 A90, M90 disopyramide phosphate cap 150 mg 2 A90, M90 dofetilide cap 125 mcg (0.125 mg) 2 A90, M90 dofetilide cap 250 mcg (0.25 mg) 2 A90, M90 dofetilide cap 500 mcg (0.5 mg) 2 A90, M90 flecainide acetate tab 50 mg 2 A90, M90 flecainide acetate tab 100 mg 2 A90, M90 flecainide acetate tab 150 mg 2 A90, M90


34

Drug Name Drug Tier Requirements/Limits ibutilide fumarate inj 1 mg/10ml 2 lidocaine iv infusion in d5w inj 4 mg/ml 2 lidocaine iv infusion in d5w inj 8 mg/ml 2 mexiletine hcl cap 150 mg 2 A90, M90 mexiletine hcl cap 200 mg 2 A90, M90 mexiletine hcl cap 250 mg 2 A90, M90 MULTAQ TAB 400MG 4 A90, M90 NEXTERONE INJ 4 NORPACE CAP 100MG CR 4 A90, M90 pacerone tab 100mg 2 A90, M90 pacerone tab 200mg 2 A90, M90 pacerone tab 400mg 2 A90, M90 propafenone hcl cap sr 12hr 225 mg 2 A90, M90 propafenone hcl cap sr 12hr 325 mg 2 A90, M90 propafenone hcl cap sr 12hr 425 mg 2 A90, M90 propafenone hcl tab 150 mg 2 A90, M90 propafenone hcl tab 225 mg 2 A90, M90 propafenone hcl tab 300 mg 2 A90, M90 quinidine gluconate tab cr 324 mg 2 A90, M90 quinidine sulfate tab 200 mg 2 A90, M90 quinidine sulfate tab 300 mg 2 A90, M90 sorine tab 80mg 1 A90, M90 sorine tab 120mg 2 A90, M90 sorine tab 160mg 2 A90, M90 sorine tab 240mg 2 A90, M90 sotalol hcl tab 80 mg 2 A90, M90 sotalol hcl tab 120 mg 2 A90, M90 sotalol hcl tab 160 mg 2 A90, M90 sotalol hcl tab 240 mg 2 A90, M90 ANTILIPEMICS, BILE ACID RESINS cholestyramine light powder 4 gm/dose 2 A90, M90 colestipol hcl granule packets 5 gm 2 A90, M90 colestipol hcl tab 1 gm 2 A90, M90 prevalite pow 4gm 2 A90, M90 WELCHOL PAK 3.75GM 3 A90, M90 WELCHOL TAB 625MG 3 A90, M90 ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITORS ZETIA TAB 10MG 4 QL (30 tabs / 30 days);

A90, M90 ANTILIPEMICS, FIBRATES choline fenofibrate cap dr 45 mg (fenofibric

acid equiv) 2 A90, M90


35

Drug Name Drug Tier Requirements/Limits choline fenofibrate cap dr 135 mg

(fenofibric acid equiv) 2 A90, M90

fenofibrate cap 150 mg 2 A90, M90 fenofibrate micronized cap 43 mg 2 A90, M90 fenofibrate micronized cap 67 mg 2 A90, M90 fenofibrate micronized cap 130 mg 2 A90, M90 fenofibrate micronized cap 134 mg 2 A90, M90 fenofibrate micronized cap 200 mg 2 A90, M90 fenofibrate tab 40 mg 2 A90, M90 fenofibrate tab 48 mg 2 A90, M90 fenofibrate tab 54 mg 2 A90, M90 fenofibrate tab 120 mg 2 A90, M90 fenofibrate tab 145 mg 2 A90, M90 fenofibrate tab 160 mg 2 A90, M90 fenofibric acid tab 35 mg 2 A90, M90 fenofibric acid tab 105 mg 2 A90, M90 gemfibrozil tab 600 mg 1 A90, M90 ANTILIPEMICS, HMG-COA REDUCTASE

INHIBITORS/COMBINATIONS atorvastatin calcium tab 10 mg (base

equivalent) 1 QL (45 tabs / 30 days);

A90, M90 atorvastatin calcium tab 20 mg (base






A90, M90 fluvastatin sodium cap 20 mg 2 QL (30 caps / 30 days);

A90, M90 fluvastatin sodium cap 40 mg 2 QL (60 caps / 30 days);

A90, M90 LIVALO TAB 1MG 4 QL (30 tabs / 30 days);



A90, M90 lovastatin tab 10 mg 2 QL (30 tabs / 30 days);



A90, M90


36

Drug Name Drug Tier Requirements/Limits pravastatin sodium tab 10 mg 2 QL (30 tabs / 30 days);

A90, M90 pravastatin sodium tab 20 mg 2 QL (30 tabs / 30 days);



A90, M90 rosuvastatin calcium tab 5 mg 1 QL (30 tabs / 30 days);




A90, M90 simvastatin tab 5 mg 1 QL (45 tabs / 30 days);




A90, M90 simvastatin tab 80 mg 1 QL (30 tabs / 30 days),

PA; A90, M90 VYTORIN TAB 10-10MG 3 QL (30 tabs / 30 days),




PA; A90, M90 ANTILIPEMICS, MISCELLANEOUS JUXTAPID CAP 5MG 3 PA; SP JUXTAPID CAP 10MG 3 PA; SP JUXTAPID CAP 20MG 3 PA; SP ANTILIPEMICS, NIACINS niacin tab cr 500 mg (antihyperlipidemic) 2 A90, M90 niacin tab cr 1000 mg (antihyperlipidemic) 2 A90, M90 ANTILIPEMICS, OMEGA-3 FATTY ACIDS VASCEPA CAP 1GM 3 PA; QL, A90, M90 ANTILIPEMICS, PCSK9 INHIBITORS


37

Drug Name Drug Tier Requirements/Limits PRALUENT INJ 75MG/ML 4 PA; QL, SP PRALUENT INJ 150MG/ML 4 PA; QL, SP REPATHA INJ 140MG/ML 4 PA; QL, SP REPATHA SURE INJ 140MG/ML 4 PA; QL, SP BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone tab 50-25 mg 1 A90, M90 atenolol & chlorthalidone tab 100-25 mg 1 A90, M90 bisoprolol & hydrochlorothiazide tab 2.5-

6.25 mg 1 A90, M90

bisoprolol & hydrochlorothiazide tab 5-6.25 mg

1 A90, M90

bisoprolol & hydrochlorothiazide tab 10-6.25 mg

1 A90, M90

metoprolol & hydrochlorothiazide tab 50-25 mg

2 A90, M90


2 A90, M90


2 A90, M90

nadolol & bendroflumethiazide tab 40-5 mg2 A90, M90 nadolol & bendroflumethiazide tab 80-5 mg2 A90, M90 BETA-BLOCKERS acebutolol hcl cap 200 mg 2 A90, M90 acebutolol hcl cap 400 mg 2 A90, M90 atenolol tab 25 mg 1 A90, M90 atenolol tab 50 mg 1 A90, M90 atenolol tab 100 mg 1 A90, M90 betaxolol hcl tab 10 mg 2 A90, M90 betaxolol hcl tab 20 mg 2 A90, M90 bisoprolol fumarate tab 5 mg 1 A90, M90 bisoprolol fumarate tab 10 mg 1 A90, M90 carvedilol tab 3.125 mg 1 A90, M90 carvedilol tab 6.25 mg 1 A90, M90 carvedilol tab 12.5 mg 1 A90, M90 carvedilol tab 25 mg 1 A90, M90 COREG CR CAP 10MG 3 A90, M90 COREG CR CAP 20MG 3 A90, M90 COREG CR CAP 40MG 3 A90, M90 COREG CR CAP 80MG 3 A90, M90 esmolol hcl inj 100 mg/10ml 2 INNOPRAN XL CAP 80MG 4 A90, M90 INNOPRAN XL CAP 120MG 4 A90, M90 labetalol hcl iv soln 5 mg/ml 2


38

Drug Name Drug Tier Requirements/Limits labetalol hcl tab 100 mg 2 A90, M90 labetalol hcl tab 200 mg 2 A90, M90 labetalol hcl tab 300 mg 2 A90, M90 LEVATOL TAB 20MG 4 A90, M90 metoprolol succinate tab sr 24hr 25 mg

(tartrate equiv) 2 A90, M90

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

2 A90, M90


2 A90, M90


2 A90, M90

metoprolol tartrate inj 1 mg/ml 2 metoprolol tartrate tab 25 mg 1 A90, M90 metoprolol tartrate tab 50 mg 1 A90, M90 metoprolol tartrate tab 100 mg 1 A90, M90 nadolol tab 20 mg 2 A90, M90 nadolol tab 40 mg 2 A90, M90 nadolol tab 80 mg 2 A90, M90 pindolol tab 5 mg 2 A90, M90 pindolol tab 10 mg 2 A90, M90 propranolol hcl cap sr 24hr 60 mg 2 A90, M90 propranolol hcl cap sr 24hr 80 mg 2 A90, M90 propranolol hcl cap sr 24hr 120 mg 2 A90, M90 propranolol hcl cap sr 24hr 160 mg 2 A90, M90 propranolol hcl inj 1 mg/ml 2 propranolol hcl tab 10 mg 1 A90, M90 propranolol hcl tab 20 mg 1 A90, M90 propranolol hcl tab 40 mg 1 A90, M90 propranolol hcl tab 60 mg 2 A90, M90 propranolol hcl tab 80 mg 1 A90, M90 timolol maleate tab 5 mg 2 A90, M90 timolol maleate tab 10 mg 2 A90, M90 timolol maleate tab 20 mg 2 A90, M90 CALCIUM CHANNEL BLOCKERS, DIHYDROPYRIDINES afeditab tab 30mg cr 2 A90, M90 afeditab tab 60mg cr 2 A90, M90 amlodipine besylate tab 2.5 mg 1 A90, M90 amlodipine besylate tab 5 mg 1 A90, M90 amlodipine besylate tab 10 mg 1 A90, M90 felodipine tab sr 24hr 2.5 mg 2 A90, M90 felodipine tab sr 24hr 5 mg 2 A90, M90 felodipine tab sr 24hr 10 mg 2 A90, M90


39

Drug Name Drug Tier Requirements/Limits isradipine cap 2.5 mg 2 A90, M90 isradipine cap 5 mg 2 A90, M90 nicardipine hcl cap 20 mg 2 A90, M90 nicardipine hcl cap 30 mg 2 A90, M90 nicardipine hcl iv soln 2.5 mg/ml 2 nifedical xl tab 30mg 2 A90, M90 nifedical xl tab 60mg 2 A90, M90 nifedipine cap 10 mg 2 A90, M90 nifedipine cap 20 mg 2 A90, M90 nifedipine tab sr 24hr 30 mg 2 A90, M90 nifedipine tab sr 24hr 60 mg 2 A90, M90 nifedipine tab sr 24hr 90 mg 2 A90, M90 nimodipine cap 30 mg 2 A90, M90 nisoldipine tab sr 24hr 8.5 mg 2 A90, M90 nisoldipine tab sr 24hr 17 mg 2 A90, M90 nisoldipine tab sr 24hr 34 mg 2 A90, M90 CALCIUM CHANNEL BLOCKERS, NON DIHYDROPYRIDINES CARDIZEM LA TAB 120MG 4 A90, M90 cartia xt cap 120/24hr 2 A90, M90 cartia xt cap 180/24hr 2 A90, M90 cartia xt cap 240/24hr 2 A90, M90 cartia xt cap 300/24hr 2 A90, M90 dilt-xr cap 120mg 2 A90, M90 dilt-xr cap 180mg 2 A90, M90 dilt-xr cap 240mg 2 A90, M90 diltiazem hcl cap sr 12hr 60 mg 2 A90, M90 diltiazem hcl cap sr 12hr 90 mg 2 A90, M90 diltiazem hcl cap sr 12hr 120 mg 2 A90, M90 diltiazem hcl coated beads cap sr 24hr 120

mg 2 A90, M90

diltiazem hcl coated beads cap sr 24hr 180 mg

2 A90, M90


2 A90, M90


2 A90, M90

diltiazem hcl coated beads tab sr 24hr 180 mg

2 A90, M90


2 A90, M90


2 A90, M90


40

Drug Name Drug Tier Requirements/Limits diltiazem hcl coated beads tab sr 24hr 360

mg 2 A90, M90


2 A90, M90

diltiazem hcl extended release beads cap sr 24hr 360 mg

2 A90, M90

diltiazem hcl extended release beads cap sr 24hr 420 mg

2 A90, M90

diltiazem hcl iv soln 25 mg/5ml (5 mg/ml) 2 diltiazem hcl tab 30 mg 2 A90, M90 diltiazem hcl tab 60 mg 2 A90, M90 diltiazem hcl tab 90 mg 2 A90, M90 diltiazem hcl tab 120 mg 2 A90, M90 matzim la tab 180mg/24 2 A90, M90 matzim la tab 240mg/24 2 A90, M90 matzim la tab 300mg/24 2 A90, M90 matzim la tab 360mg/24 2 A90, M90 matzim la tab 420mg/24 2 A90, M90 taztia xt cap 120mg/24 2 A90, M90 taztia xt cap 180mg/24 2 A90, M90 taztia xt cap 240mg/24 2 A90, M90 taztia xt cap 300mg/24 2 A90, M90 taztia xt cap 360mg/24 2 A90, M90 verapamil hcl cap sr 24hr 100 mg 2 A90, M90 verapamil hcl cap sr 24hr 120 mg 2 A90, M90 verapamil hcl cap sr 24hr 180 mg 2 A90, M90 verapamil hcl cap sr 24hr 200 mg 2 A90, M90 verapamil hcl cap sr 24hr 240 mg 2 A90, M90 verapamil hcl cap sr 24hr 300 mg 2 A90, M90 verapamil hcl cap sr 24hr 360 mg 2 A90, M90 verapamil hcl iv soln 2.5 mg/ml 2 verapamil hcl tab 40 mg 2 A90, M90 verapamil hcl tab 80 mg 2 A90, M90 verapamil hcl tab 120 mg 2 A90, M90 verapamil hcl tab cr 120 mg 2 A90, M90 verapamil hcl tab cr 180 mg 2 A90, M90 verapamil hcl tab cr 240 mg 2 A90, M90 DIGITALIS GLYCOSIDES digitek tab 0.25mg 1 A90, M90 digitek tab 0.125mg 1 A90, M90 digox tab 0.25mg 1 A90, M90 digox tab 0.125mg 1 A90, M90 digoxin inj 0.25 mg/ml 2


41

Drug Name Drug Tier Requirements/Limits digoxin tab 125 mcg (0.125 mg) 1 A90, M90 digoxin tab 250 mcg (0.25 mg) 1 A90, M90 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS TEKTURNA HCT TAB 150-12.5 3 QL (30 tabs / 30 days),

PA; A90, M90 TEKTURNA HCT TAB 150-25MG 3 QL (30 tabs / 30 days),

PA; A90, M90 TEKTURNA HCT TAB 300-12.5 3 QL (30 tabs / 30 days),

PA; A90, M90 TEKTURNA HCT TAB 300-25MG 3 QL (30 tabs / 30 days),

PA; A90, M90 TEKTURNA TAB 150MG 3 QL (30 tabs / 30 days),

ST; A90, M90 TEKTURNA TAB 300MG 3 QL (30 tabs / 30 days),

ST; A90, M90 DIURETICS amiloride & hydrochlorothiazide tab 5-50

mg 1 A90, M90

amiloride hcl tab 5 mg 2 A90, M90 bumetanide inj 0.25 mg/ml 1 bumetanide tab 0.5 mg 1 A90, M90 bumetanide tab 1 mg 1 A90, M90 bumetanide tab 2 mg 1 A90, M90 chlorothiazide sodium for inj 500 mg 2 chlorothiazide tab 250 mg 1 A90, M90 chlorothiazide tab 500 mg 1 A90, M90 chlorthalidone tab 25 mg 1 A90, M90 chlorthalidone tab 50 mg 1 A90, M90 DYRENIUM CAP 100MG 4 A90, M90 EDECRIN TAB 25MG 4 A90, M90 furosemide inj 10 mg/ml 1 SP furosemide oral soln 10 mg/ml 1 A90, M90 furosemide tab 20 mg 1 A90, M90 furosemide tab 40 mg 1 A90, M90 furosemide tab 80 mg 1 A90, M90 hydrochlorothiazide cap 12.5 mg 1 A90, M90 hydrochlorothiazide tab 12.5 mg 1 A90, M90 hydrochlorothiazide tab 25 mg 1 A90, M90 hydrochlorothiazide tab 50 mg 1 A90, M90 indapamide tab 1.25 mg 1 A90, M90 indapamide tab 2.5 mg 1 A90, M90 methyclothiazide tab 5 mg 2 A90, M90 metolazone tab 2.5 mg 2 A90, M90


42

Drug Name Drug Tier Requirements/Limits metolazone tab 5 mg 2 A90, M90 metolazone tab 10 mg 2 A90, M90 spironolactone & hydrochlorothiazide tab

25-25 mg 1 A90, M90

torsemide tab 5 mg 1 A90, M90 torsemide tab 10 mg 1 A90, M90 torsemide tab 20 mg 1 A90, M90 torsemide tab 100 mg 1 A90, M90 triamterene & hydrochlorothiazide cap

37.5-25 mg 1 A90, M90

triamterene & hydrochlorothiazide cap 50-25 mg

1 A90, M90

triamterene & hydrochlorothiazide tab 37.5-25 mg

1 A90, M90

triamterene & hydrochlorothiazide tab 75-50 mg

1 A90, M90

MISCELLANEOUS alprostadil inj 500 mcg/ml 2 DEMSER CAP 250MG 4 DIBENZYLINE CAP 10MG 3 fenoldopam mesylate iv inj 10 mg/ml

(base equiv) 2

hydralazine hcl inj 20 mg/ml 2 hydralazine hcl tab 10 mg 1 A90, M90 hydralazine hcl tab 25 mg 1 A90, M90 hydralazine hcl tab 50 mg 1 A90, M90 hydralazine hcl tab 100 mg 1 A90, M90 methyldopa tab 250 mg 1 A90, M90 methyldopa tab 500 mg 1 A90, M90 methyldopate hcl inj 250 mg/5ml 2 midodrine hcl tab 2.5 mg 2 midodrine hcl tab 5 mg 2 midodrine hcl tab 10 mg 2 milrinone in dextrose 5% iv soln 40mg/200

ml 2

milrinone lactate iv soln 50 mg/50ml (base equivalent)

2

minoxidil tab 2.5 mg 2 A90, M90 minoxidil tab 10 mg 2 A90, M90 papaverine hcl inj 30 mg/ml 2 phenoxybenzamine hcl cap 10 mg 2 RANEXA TAB 500MG 3 QL (120 ea / 30 days),

PA; A90, M90


43

Drug Name Drug Tier Requirements/Limits RANEXA TAB 1000MG 3 QL (60 ea / 30 days),

PA; A90, M90 NITRATE/VASODILATOR COMBINATIONS BIDIL TAB Plan

Exclusion A90, M90

NITRATES, INJECTABLE nitroglycerin iv soln 100 mcg/ml in d5w 2 nitroglycerin iv soln 200 mcg/ml in d5w 2 nitroglycerin iv soln 400 mcg/ml in d5w 2 NITRATES, ORAL DILATRATE SR CAP 40MG 3 A90, M90 isosorbide dinitrate tab 5 mg 2 A90, M90 isosorbide dinitrate tab 10 mg 2 A90, M90 isosorbide dinitrate tab 20 mg 2 A90, M90 isosorbide dinitrate tab 30 mg 2 A90, M90 isosorbide dinitrate tab cr 40 mg 2 A90, M90 isosorbide mononitrate tab 10 mg 2 A90, M90 isosorbide mononitrate tab 20 mg 2 A90, M90 isosorbide mononitrate tab sr 24hr 30 mg 1 A90, M90 isosorbide mononitrate tab sr 24hr 60 mg 1 A90, M90 isosorbide mononitrate tab sr 24hr 120 mg 2 A90, M90 NITRATES, SUBLINGUAL/TRANSLINGUAL nitroglycerin lingual aerosol 400 mcg/spray2 A90 nitroglycerin tl soln 0.4 mg/spray (400

mcg/spray) 2 A90

NITROSTAT SUB 0.3MG 3 A90 NITROSTAT SUB 0.4MG 3 A90 NITROSTAT SUB 0.6MG 3 A90 NITRATES, TRANSDERMAL minitran dis 0.1mg/hr 2 A90, M90 minitran dis 0.2mg/hr 2 A90, M90 minitran dis 0.4mg/hr 2 A90, M90 minitran dis 0.6mg/hr 2 A90, M90 NITRO-BID OIN 2% 3 A90, M90 nitroglycerin td patch 24hr 0.1 mg/hr 2 A90, M90 nitroglycerin td patch 24hr 0.2 mg/hr 2 A90, M90 nitroglycerin td patch 24hr 0.4 mg/hr 2 A90, M90 nitroglycerin td patch 24hr 0.6 mg/hr 2 A90, M90 PULMONARY ARTERIAL HYPERTENSION, ENDOTHELIN RECEPTOR

ANTAGONIST LETAIRIS TAB 5MG 3 SP LETAIRIS TAB 10MG 3 SP


44

Drug Name Drug Tier Requirements/Limits OPSUMIT TAB 10MG 3 SP TRACLEER TAB 62.5MG 3 SP TRACLEER TAB 125MG 3 SP PULMONARY ARTERIAL HYPERTENSION, PHOSPHODIESTERASE

INHIBITOR ADCIRCA TAB 20MG 3 PA; SP sildenafil citrate iv soln 10 mg/12.5ml

(base equivalent) 3 PA; SP

sildenafil citrate tab 20 mg 3 PA; SP PULMONARY ARTERIAL HYPERTENSION, PROSTAGLANDIN

VASODILATORS epoprostenol sodium for inj 0.5 mg 3 SP epoprostenol sodium for inj 1.5 mg 3 SP REMODULIN INJ 1MG/ML 3 SP REMODULIN INJ 2.5MG/ML 3 SP REMODULIN INJ 5MG/ML 3 SP REMODULIN INJ 10MG/ML 3 SP TYVASO START SOL 0.6MG/ML 3 SP VELETRI INJ 0.5MG 3 SP VELETRI INJ 1.5MG 3 SP VENTAVIS SOL 10MCG/ML 3 SP VENTAVIS SOL 20MCG/ML 3 SP PULMONARY ARTERIAL HYPERTENSION, SOLUBLE GUANYLATE

CYCLASE STIMULATORS ADEMPAS TAB 0.5MG 3 SP ADEMPAS TAB 1.5MG 3 SP ADEMPAS TAB 1MG 3 SP ADEMPAS TAB 2.5MG 3 SP ADEMPAS TAB 2MG 3 SP VASOPRESSORS dobutamine hcl inj 12.5 mg/ml 2 dobutamine inj 1 mg/ml in d5w 2 dobutamine inj 2 mg/ml in d5w 2 dobutamine inj 4 mg/ml in d5w 2 dopamine hcl inj 40 mg/ml 2 dopamine hcl inj 80 mg/ml 2 dopamine inj 0.8 mg/ml in d5w 2 dopamine inj 1.6 mg/ml in d5w 2 dopamine inj 3.2 mg/ml in d5w 2 ephedrine sulfate inj 50 mg/ml 2 epinephrine hcl inj 1 mg/ml 2


45

Drug Name Drug Tier Requirements/Limits epinephrine hcl soln prefilled syringe 0.1

mg/ml 2

norepinephrine bitartrate iv soln 1 mg/ml 2 phenylephrine hcl inj 10 mg/ml 2 CENTRAL NERVOUS SYSTEM ANTIANXIETY, BENZODIAZEPINES alprazolam orally disintegrating tab 0.5 mg 2 alprazolam orally disintegrating tab 0.25

mg 2

alprazolam orally disintegrating tab 1 mg 2 alprazolam orally disintegrating tab 2 mg 2 alprazolam tab 0.5 mg 2 alprazolam tab 0.25 mg 2 alprazolam tab 1 mg 2 alprazolam tab 2 mg 2 alprazolam tab sr 24hr 0.5 mg 2 alprazolam tab sr 24hr 1 mg 2 alprazolam tab sr 24hr 2 mg 2 alprazolam tab sr 24hr 3 mg 2 chlordiazepoxide hcl cap 5 mg 2 chlordiazepoxide hcl cap 10 mg 2 chlordiazepoxide hcl cap 25 mg 2 clonazepam orally disintegrating tab 0.5

mg 2 A90

clonazepam orally disintegrating tab 0.25 mg

2 A90

clonazepam orally disintegrating tab 0.125 mg

2 A90

clonazepam orally disintegrating tab 1 mg 2 A90 clonazepam orally disintegrating tab 2 mg 2 A90 clonazepam tab 0.5 mg 2 A90, M90 clonazepam tab 1 mg 2 A90, M90 clonazepam tab 2 mg 2 A90, M90 clorazepate dipotassium tab 3.75 mg 2 clorazepate dipotassium tab 7.5 mg 2 clorazepate dipotassium tab 15 mg 2 diazepam con 5mg/ml 2 diazepam inj 5 mg/ml 3 diazepam tab 2 mg 2 diazepam tab 5 mg 2 diazepam tab 10 mg 2 lorazepam con 2mg/ml 2 lorazepam inj 2 mg/ml 2


46

Drug Name Drug Tier Requirements/Limits lorazepam inj 4 mg/ml 2 lorazepam tab 0.5 mg 2 lorazepam tab 1 mg 2 lorazepam tab 2 mg 2 oxazepam cap 10 mg 2 oxazepam cap 15 mg 2 oxazepam cap 30 mg 2 ANTIANXIETY, MISCELLANEOUS buspirone hcl tab 5 mg 2 buspirone hcl tab 7.5 mg 2 buspirone hcl tab 10 mg 2 buspirone hcl tab 15 mg 2 buspirone hcl tab 30 mg 2 clomipramine hcl cap 25 mg 2 A90 clomipramine hcl cap 50 mg 2 A90 clomipramine hcl cap 75 mg 2 A90 fluvoxamine maleate cap sr 24hr 100 mg 2 AL, A90 fluvoxamine maleate cap sr 24hr 150 mg 2 AL, A90 fluvoxamine maleate tab 25 mg 2 QL (45 tabs / 30 days);

AL, A90 fluvoxamine maleate tab 50 mg 2 QL (75 tabs / 30 days);

AL, A90 fluvoxamine maleate tab 100 mg 2 QL (90 tabs / 30 days);

AL, A90 meprobamate tab 200 mg 2 meprobamate tab 400 mg 2 ANTICONVULSANTS BANZEL SUS 40MG/ML 3 QL, A90, M90 BANZEL TAB 200MG 3 QL (120 tabs / 30 days);

A90, M90 BANZEL TAB 400MG 3 QL (240 tabs / 30 days);

A90, M90 carbamazepine cap sr 12hr 100 mg 2 A90, M90 carbamazepine cap sr 12hr 200 mg 2 A90, M90 carbamazepine cap sr 12hr 300 mg 2 A90, M90 carbamazepine chew tab 100 mg 2 A90, M90 carbamazepine susp 100 mg/5ml 2 A90, M90 carbamazepine tab 200 mg 1 A90, M90 carbamazepine tab sr 12hr 100 mg 2 A90, M90 carbamazepine tab sr 12hr 200 mg 2 A90, M90 carbamazepine tab sr 12hr 400 mg 2 A90, M90 CELONTIN CAP 300MG 3 A90, M90 DILANTIN CAP 30MG 3 A90, M90


47

Drug Name Drug Tier Requirements/Limits divalproex sodium cap delayed release

sprinkle 125 mg 2 A90, M90

divalproex sodium tab delayed release 125 mg

2 A90, M90


2 A90, M90


2 A90, M90

divalproex sodium tab sr 24 hr 250 mg 2 A90, M90 divalproex sodium tab sr 24 hr 500 mg 2 A90, M90 epitol tab 200mg 1 A90, M90 ethosuximide cap 250 mg 2 A90, M90 ethosuximide soln 250 mg/5ml 2 A90, M90 felbamate susp 600 mg/5ml 2 A90, M90 felbamate tab 400 mg 2 A90, M90 felbamate tab 600 mg 2 A90, M90 fosphenytoin sodium inj 500 mg/10ml

(phenytoin equiv) 2

FYCOMPA TAB 2MG 3 QL (60 tabs / 30 days); A90, M90






gabapentin cap 100 mg 2 A90, M90 gabapentin cap 300 mg 2 A90, M90 gabapentin cap 400 mg 2 A90, M90 gabapentin oral soln 250 mg/5ml 2 A90, M90 gabapentin tab 600 mg 2 A90, M90 gabapentin tab 800 mg 2 A90, M90 GABITRIL TAB 12MG 3 A90, M90 GABITRIL TAB 16MG 3 A90, M90 LAMICTAL CHW 2MG 4 A90, M90 lamotrigine orally disintegrating tab 25 mg 2 A90, M90 lamotrigine orally disintegrating tab 50 mg 2 A90, M90 lamotrigine orally disintegrating tab 100

mg 2 A90, M90


48

Drug Name Drug Tier Requirements/Limits lamotrigine orally disintegrating tab 200

mg 2 A90, M90

lamotrigine tab 25 mg 2 A90, M90 lamotrigine tab 100 mg 2 A90, M90 lamotrigine tab 150 mg 2 A90, M90 lamotrigine tab 200 mg 2 A90, M90 lamotrigine tab chewable dispersible 5 mg 2 A90, M90 lamotrigine tab chewable dispersible 25 mg2 A90, M90 lamotrigine tab sr 24hr 25 mg 2 A90, M90 lamotrigine tab sr 24hr 50 mg 2 A90, M90 lamotrigine tab sr 24hr 100 mg 2 A90, M90 lamotrigine tab sr 24hr 200 mg 2 A90, M90 lamotrigine tab sr 24hr 250 mg 2 A90, M90 lamotrigine tab sr 24hr 300 mg 2 A90, M90 levetiracetam inj 500 mg/5ml (100 mg/ml) 2 levetiracetam oral soln 100 mg/ml 2 A90, M90 levetiracetam tab 250 mg 2 A90, M90 levetiracetam tab 500 mg 2 A90, M90 levetiracetam tab 750 mg 2 A90, M90 levetiracetam tab 1000 mg 2 A90, M90 levetiracetam tab sr 24hr 500 mg 2 A90, M90 levetiracetam tab sr 24hr 750 mg 2 A90, M90 ONFI SUS 2.5MG/ML 3 QL (4 / 30 days); A90,

M90 ONFI TAB 10MG 3 QL (90 tabs / 30 days);

A90, M90 ONFI TAB 20MG 3 QL (60 tabs / 30 days);

A90, M90 oxcarbazepine susp 300 mg/5ml (60

mg/ml) 2 A90, M90

oxcarbazepine tab 150 mg 2 A90, M90 oxcarbazepine tab 300 mg 2 A90, M90 oxcarbazepine tab 600 mg 2 A90, M90 PEGANONE TAB 250MG 3 A90, M90 phenobarbital elixir 20 mg/5ml 2 A90 phenobarbital sodium inj 130 mg/ml 2 phenobarbital tab 15 mg 2 A90 phenobarbital tab 16.2 mg 2 A90 phenobarbital tab 30 mg 2 A90 phenobarbital tab 32.4 mg 2 A90 phenobarbital tab 60 mg 2 A90 phenobarbital tab 64.8 mg 2 A90 phenobarbital tab 97.2 mg 2 A90


49

Drug Name Drug Tier Requirements/Limits phenobarbital tab 100 mg 2 A90 phenytoin chew tab 50 mg 2 A90, M90 phenytoin sodium extended cap 100 mg 2 A90, M90 phenytoin sodium extended cap 200 mg 2 A90, M90 phenytoin sodium extended cap 300 mg 2 A90, M90 phenytoin sodium inj 50 mg/ml 2 phenytoin susp 125 mg/5ml 2 A90, M90 POTIGA TAB 50MG 3 A90, M90 POTIGA TAB 200MG 3 A90, M90 POTIGA TAB 300MG 3 A90, M90 POTIGA TAB 400MG 3 A90, M90 primidone tab 50 mg 1 A90, M90 primidone tab 250 mg 1 A90, M90 SABRIL POW 500MG 4 PA; SP tiagabine hcl tab 2 mg 2 A90, M90 tiagabine hcl tab 4 mg 2 A90, M90 topiramate cap er 24hr sprinkle 25 mg 2 PA; A90, M90 topiramate cap er 24hr sprinkle 50 mg 2 PA; A90, M90 topiramate cap er 24hr sprinkle 100 mg 2 PA; A90, M90 topiramate cap er 24hr sprinkle 150 mg 2 PA; A90, M90 topiramate cap er 24hr sprinkle 200 mg 2 PA; A90, M90 topiramate sprinkle cap 15 mg 2 A90, M90 topiramate sprinkle cap 25 mg 2 A90, M90 topiramate tab 25 mg 2 A90, M90 topiramate tab 50 mg 2 A90, M90 topiramate tab 100 mg 2 A90, M90 topiramate tab 200 mg 2 A90, M90 valproate sodium inj 100 mg/ml 1 valproate sodium syrup 250 mg/5ml (base

equiv) 1 A90, M90

valproic acid cap 250 mg 1 A90, M90 VIMPAT SOL 10MG/ML 3 QL, A90, M90 VIMPAT TAB 50MG 3 QL (60 tabs / 30 days);

A90, M90 VIMPAT TAB 100MG 3 QL (60 tabs / 30 days);



A90, M90 zonisamide cap 25 mg 2 A90, M90 zonisamide cap 50 mg 2 A90, M90 zonisamide cap 100 mg 2 A90, M90


50

Drug Name Drug Tier Requirements/Limits ANTIDEMENTIA donepezil hydrochloride orally

disintegrating tab 5 mg 2 A90, M90

donepezil hydrochloride orally disintegrating tab 10 mg

2 A90, M90

donepezil hydrochloride tab 5 mg 2 A90, M90 donepezil hydrochloride tab 10 mg 2 A90, M90 donepezil hydrochloride tab 23 mg 2 A90, M90 galantamine hydrobromide cap sr 24hr 8

mg 2 A90, M90

galantamine hydrobromide cap sr 24hr 16 mg

2 A90, M90

galantamine hydrobromide cap sr 24hr 24 mg

2 A90, M90

galantamine hydrobromide oral soln 4 mg/ml

2 A90, M90

galantamine hydrobromide tab 4 mg 2 A90, M90 galantamine hydrobromide tab 8 mg 2 A90, M90 galantamine hydrobromide tab 12 mg 2 A90, M90 memantine hcl oral solution 2 mg/ml 2 A90, M90 memantine hcl tab 5 mg 2 A90, M90 memantine hcl tab 5 mg (28) & 10 mg

(21) titration pak 2

memantine hcl tab 10 mg 2 A90, M90 NAMENDA XR CAP 7MG 3 A90, M90 NAMENDA XR CAP 14MG 3 A90, M90 NAMENDA XR CAP 21MG 3 A90, M90 NAMENDA XR CAP 28MG 3 A90, M90 NAMENDA XR CAP TITRATIO 3 rivastigmine tartrate cap 1.5 mg 2 A90, M90 rivastigmine tartrate cap 3 mg 2 A90, M90 rivastigmine tartrate cap 4.5 mg 2 A90, M90 rivastigmine tartrate cap 6 mg 2 A90, M90 ANTIDEPRESSANTS, MAOIS EMSAM DIS 6MG/24HR 4 PA; A90 EMSAM DIS 9MG/24HR 4 PA; A90 EMSAM DIS 12MG/24H 4 PA; A90 MARPLAN TAB 10MG 4 A90 phenelzine sulfate tab 15 mg 2 A90 tranylcypromine sulfate tab 10 mg 2 A90 ANTIDEPRESSANTS, MISCELLANEOUS bupropion hcl tab 75 mg 2 A90 bupropion hcl tab 100 mg 2 A90


51

Drug Name Drug Tier Requirements/Limits bupropion hcl tab sr 12hr 100 mg 2 A90 bupropion hcl tab sr 12hr 150 mg 2 A90 bupropion hcl tab sr 12hr 200 mg 2 A90 bupropion hcl tab sr 24hr 150 mg 2 A90 bupropion hcl tab sr 24hr 300 mg 2 A90 maprotiline hcl tab 25 mg 2 A90 maprotiline hcl tab 50 mg 2 A90 maprotiline hcl tab 75 mg 2 A90 mirtazapine orally disintegrating tab 15 mg2 A90 mirtazapine orally disintegrating tab 30 mg2 A90 mirtazapine orally disintegrating tab 45 mg2 A90 mirtazapine tab 7.5 mg 1 A90 mirtazapine tab 15 mg 1 A90 mirtazapine tab 30 mg 1 A90 mirtazapine tab 45 mg 1 A90 nefazodone hcl tab 50 mg 2 A90 nefazodone hcl tab 100 mg 2 A90 nefazodone hcl tab 150 mg 2 A90 nefazodone hcl tab 200 mg 2 A90 nefazodone hcl tab 250 mg 2 A90 trazodone hcl tab 50 mg 1 A90 trazodone hcl tab 100 mg 1 A90 trazodone hcl tab 150 mg 1 A90 trazodone hcl tab 300 mg 2 A90 ANTIDEPRESSANTS, SNRIS desvenlafaxine tab sr 24hr 100 mg 2 ST; A90 duloxetine hcl enteric coated pellets cap 20

mg 2 QL (60 ea / 30 days),

ST; A90 duloxetine hcl enteric coated pellets cap 30

mg 2 QL (30 ea / 30 days),

ST; A90 duloxetine hcl enteric coated pellets cap 60

mg 2 QL (30 ea / 30 days),

ST; A90 PRISTIQ TAB 50MG 4 QL (30 ea / 30 days),

ST; A90 venlafaxine hcl cap sr 24hr 37.5 mg (base

equivalent) 2 QL (60 ea / 30 days),

ST; A90 venlafaxine hcl cap sr 24hr 75 mg (base


ST; A90 venlafaxine hcl cap sr 24hr 150 mg (base


ST; A90 venlafaxine hcl tab 25 mg 2 QL (90 tabs / 30 days),

ST; A90


52

Drug Name Drug Tier Requirements/Limits venlafaxine hcl tab 37.5 mg 2 QL (90 tabs / 30 days),




ST; A90 venlafaxine hcl tab sr 24hr 37.5 mg (base


ST; A90 venlafaxine hcl tab sr 24hr 75 mg (base





equivalent) 2 ST; QL, A90

ANTIDEPRESSANTS, SSRIS citalopram hydrobromide oral soln 10

mg/5ml 2 AL, A90

citalopram hydrobromide tab 10 mg (base equiv)

1 QL (90 tabs / 30 days); AL, A90


1 QL (75 tabs / 30 days); AL, A90


1 QL (45 tabs / 30 days); AL, A90

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

2 ST; AL, A90

escitalopram oxalate tab 5 mg (base equiv)

2 QL (30 tabs / 30 days), ST; AL, A90





fluoxetine hcl cap 10 mg 2 QL (90 caps / 30 days); AL, A90

fluoxetine hcl cap 20 mg 2 QL (150 caps / 30 days); AL, A90

fluoxetine hcl solution 20 mg/5ml 2 A90 fluoxetine hcl tab 10 mg 2 QL (90 tabs / 30 days);

A90 paroxetine hcl tab 10 mg 2 QL (45 tabs / 30 days),

ST; AL, A90 paroxetine hcl tab 20 mg 2 QL (45 tabs / 30 days),

ST; AL, A90


53

Drug Name Drug Tier Requirements/Limits paroxetine hcl tab 30 mg 2 QL (75 tabs / 30 days),

ST; AL, A90 paroxetine hcl tab 40 mg 2 QL (60 tabs / 30 days),

ST; AL, A90 paroxetine hcl tab sr 24hr 12.5 mg 2 QL (30 ea / 30 days),

ST; AL, A90 paroxetine hcl tab sr 24hr 25 mg 2 QL (60 ea / 30 days),

ST; AL, A90 paroxetine hcl tab sr 24hr 37.5 mg 2 QL (60 ea / 30 days),

ST; AL, A90 sertraline hcl oral conc 20 mg/ml 2 AL, A90 sertraline hcl tab 25 mg 2 QL (75 tabs / 30 days);

AL, A90 sertraline hcl tab 50 mg 2 QL (75 tabs / 30 days);

AL, A90 sertraline hcl tab 100 mg 2 QL (90 tabs / 30 days);

AL, A90 TRINTELLIX TAB 5MG 4 QL (30 tabs / 30 days),

ST; A90 TRINTELLIX TAB 10MG 4 QL (30 tabs / 30 days),

ST; A90 TRINTELLIX TAB 20MG 4 QL (30 tabs / 30 days),

ST; A90 VIIBRYD TAB 10MG 4 QL (30 tabs / 30 days),



ST; A90 ANTIDEPRESSANTS, TCAS amitriptyline hcl tab 10 mg 1 A90 amitriptyline hcl tab 25 mg 1 A90 amitriptyline hcl tab 50 mg 1 A90 amitriptyline hcl tab 75 mg 1 A90 amitriptyline hcl tab 100 mg 1 A90 amitriptyline hcl tab 150 mg 1 A90 amoxapine tab 25 mg 2 A90 amoxapine tab 50 mg 2 A90 amoxapine tab 100 mg 2 A90 amoxapine tab 150 mg 2 A90 desipramine hcl tab 10 mg 2 A90 desipramine hcl tab 25 mg 2 A90 desipramine hcl tab 50 mg 2 A90 desipramine hcl tab 75 mg 2 A90


54

Drug Name Drug Tier Requirements/Limits desipramine hcl tab 100 mg 2 A90 desipramine hcl tab 150 mg 2 A90 doxepin hcl cap 10 mg 1 A90 doxepin hcl cap 25 mg 1 A90 doxepin hcl cap 50 mg 1 A90 doxepin hcl cap 75 mg 1 A90 doxepin hcl cap 100 mg 1 A90 doxepin hcl cap 150 mg 1 A90 doxepin hcl conc 10 mg/ml 1 A90 imipramine hcl tab 10 mg 2 A90 imipramine hcl tab 25 mg 2 A90 imipramine hcl tab 50 mg 2 A90 imipramine pamoate cap 75 mg 2 A90 imipramine pamoate cap 100 mg 2 A90 imipramine pamoate cap 125 mg 2 A90 imipramine pamoate cap 150 mg 2 A90 nortriptyline hcl cap 10 mg 1 A90 nortriptyline hcl cap 25 mg 1 A90 nortriptyline hcl cap 50 mg 1 A90 nortriptyline hcl cap 75 mg 1 A90 nortriptyline hcl soln 10 mg/5ml 2 A90 protriptyline hcl tab 5 mg 2 A90 protriptyline hcl tab 10 mg 2 A90 trimipramine maleate cap 25 mg 2 A90 trimipramine maleate cap 50 mg 2 A90 trimipramine maleate cap 100 mg 2 A90 ANTIPARKINSONIAN AGENTS amantadine hcl cap 100 mg 2 A90, M90 amantadine hcl syrup 50 mg/5ml 2 A90, M90 amantadine hcl tab 100 mg 2 A90, M90 APOKYN INJ 10MG/ML 3 PA; SP AZILECT TAB 0.5MG 3 QL (30 tabs / 30 days);

A90, M90 AZILECT TAB 1MG 3 QL (30 tabs / 30 days);

A90, M90 benztropine mesylate inj 1 mg/ml 2 benztropine mesylate tab 0.5 mg 1 A90, M90 benztropine mesylate tab 1 mg 1 A90, M90 benztropine mesylate tab 2 mg 1 A90, M90 bromocriptine mesylate cap 5 mg (base

equivalent) 2 A90, M90

bromocriptine mesylate tab 2.5 mg (base equivalent)

2 A90, M90


55

Drug Name Drug Tier Requirements/Limits carbidopa & levodopa orally disintegrating

tab 10-100 mg 2 A90, M90

carbidopa & levodopa orally disintegrating tab 25-100 mg

2 A90, M90

carbidopa & levodopa orally disintegrating tab 25-250 mg

2 A90, M90

carbidopa & levodopa tab 10-100 mg 2 A90, M90 carbidopa & levodopa tab 25-100 mg 2 A90, M90 carbidopa & levodopa tab 25-250 mg 2 A90, M90 carbidopa & levodopa tab cr 25-100 mg 2 A90, M90 carbidopa & levodopa tab cr 50-200 mg 2 A90, M90 carbidopa tab 25 mg 2 A90, M90 entacapone tab 200 mg 2 A90, M90 NEUPRO DIS 1MG/24HR 4 PA; A90, M90 NEUPRO DIS 2MG/24HR 4 PA; A90, M90 NEUPRO DIS 3MG/24HR 4 PA; A90, M90 NEUPRO DIS 4MG/24HR 4 PA; A90, M90 NEUPRO DIS 6MG/24HR 4 PA; A90, M90 NEUPRO DIS 8MG/24HR 4 PA; A90, M90 pramipexole dihydrochloride tab 0.5 mg 2 A90, M90 pramipexole dihydrochloride tab 0.25 mg 2 A90, M90 pramipexole dihydrochloride tab 0.75 mg 2 A90, M90 pramipexole dihydrochloride tab 0.125 mg 2 A90, M90 pramipexole dihydrochloride tab 1 mg 2 A90, M90 pramipexole dihydrochloride tab 1.5 mg 2 A90, M90 ropinirole hydrochloride tab 0.5 mg 2 A90, M90 ropinirole hydrochloride tab 0.25 mg 2 A90, M90 ropinirole hydrochloride tab 1 mg 2 A90, M90 ropinirole hydrochloride tab 2 mg 2 A90, M90 ropinirole hydrochloride tab 3 mg 2 A90, M90 ropinirole hydrochloride tab 4 mg 2 A90, M90 ropinirole hydrochloride tab 5 mg 2 A90, M90 ropinirole hydrochloride tab sr 24hr 2 mg

(base equivalent) 2 A90, M90

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

2 A90, M90


2 A90, M90


2 A90, M90


2 A90, M90

selegiline hcl cap 5 mg 2 A90, M90


56

Drug Name Drug Tier Requirements/Limits selegiline hcl tab 5 mg 2 A90, M90 tolcapone tab 100 mg 2 A90, M90 trihexyphenidyl hcl elixir 0.4 mg/ml 2 A90, M90 trihexyphenidyl hcl tab 2 mg 1 A90, M90 trihexyphenidyl hcl tab 5 mg 2 A90, M90 ANTIPSYCHOTICS, ATYPICALS ABILIFY MAIN INJ 300MG 4 ABILIFY MAIN INJ 400MG 4 aripiprazole oral solution 1 mg/ml 2 QL (150 mL / 30 days),

ST; A90 aripiprazole tab 2 mg 2 QL (60 tabs / 30 days),






ST; A90 ARISTADA INJ 441MG/1. 4 ARISTADA INJ 662MG/2 4 ARISTADA INJ 882MG/3 4 clozapine orally disintegrating tab 12.5 mg 2 clozapine orally disintegrating tab 25 mg 2 clozapine orally disintegrating tab 100 mg 2 clozapine tab 25 mg 2 QL (90 tabs / 30 days) clozapine tab 50 mg 2 QL (135 tabs / 30 days) clozapine tab 100 mg 2 QL (270 tabs / 30 days) clozapine tab 200 mg 2 FANAPT PAK 4 QL (1 pack / 30 days),

ST FANAPT TAB 1MG 4 QL (60 tabs / 30 days),





ST


57

Drug Name Drug Tier Requirements/Limits FANAPT TAB 10MG 4 QL (60 tabs / 30 days),


ST FAZACLO TAB 12.5 ODT 4 FAZACLO TAB 25MG ODT 4 FAZACLO TAB 100 ODT 4 FAZACLO TAB 150 ODT 4 FAZACLO TAB 200 ODT 4 GEODON INJ 20MG 4 INVEGA SUST INJ 39/0.25 4 INVEGA SUST INJ 78/0.5ML 4 INVEGA SUST INJ 117/0.75 4 INVEGA SUST INJ 156MG/ML 4 INVEGA SUST INJ 234/1.5 4 INVEGA TRINZ INJ 273MG 4 INVEGA TRINZ INJ 410MG 4 INVEGA TRINZ INJ 546MG 4 INVEGA TRINZ INJ 819MG 4 LATUDA TAB 20MG 4 QL (30 tabs / 30 days),

ST; A90 LATUDA TAB 40MG 4 QL (30 tabs / 30 days),




ST; A90 loxapine succinate cap 5 mg 2 A90 loxapine succinate cap 10 mg 2 A90 loxapine succinate cap 25 mg 2 A90 loxapine succinate cap 50 mg 2 A90 olanzapine orally disintegrating tab 5 mg 2 QL (30 ea / 30 days);

A90 olanzapine orally disintegrating tab 10 mg 2 QL (30 ea / 30 days);



A90 olanzapine tab 2.5 mg 2 QL (60 tabs / 30 days);

A90


58

Drug Name Drug Tier Requirements/Limits olanzapine tab 5 mg 2 QL (60 tabs / 30 days);

A90 olanzapine tab 7.5 mg 2 QL (30 tabs / 30 days);

A90 olanzapine tab 10 mg 2 QL (30 tabs / 30 days);



A90 olanzapine-fluoxetine hcl cap 3-25 mg 2 A90 olanzapine-fluoxetine hcl cap 6-25 mg 2 A90 olanzapine-fluoxetine hcl cap 6-50 mg 2 A90 olanzapine-fluoxetine hcl cap 12-25 mg 2 A90 olanzapine-fluoxetine hcl cap 12-50 mg 2 A90 paliperidone tab sr 24hr 1.5 mg 2 QL (30 per 30 days),

ST; A90 paliperidone tab sr 24hr 3 mg 2 QL (30 per 30 days),



ST; A90 quetiapine fumarate tab 25 mg 2 QL (120 tabs / 30 days);

A90 quetiapine fumarate tab 50 mg 2 QL (90 tabs / 30 days);





A90 REXULTI TAB 0.5MG 4 ST; QL REXULTI TAB 0.25MG 4 ST; QL REXULTI TAB 1MG 4 ST; QL REXULTI TAB 2MG 4 ST; QL REXULTI TAB 3MG 4 ST; QL REXULTI TAB 4MG 4 ST; QL RISPERDAL INJ 12.5MG 4 RISPERDAL INJ 25MG 4 RISPERDAL INJ 37.5MG 4


59

Drug Name Drug Tier Requirements/Limits RISPERDAL INJ 50MG 4 risperidone orally disintegrating tab 0.5 mg2 QL (90 ea / 30 days);

A90 risperidone orally disintegrating tab 0.25

mg 2 QL (90 ea / 30 days);

A90 risperidone orally disintegrating tab 1 mg 2 QL (90 ea / 30 days);




A90 risperidone soln 1 mg/ml 2 QL (60mL / 30 days);

A90 risperidone tab 0.5 mg 2 QL (90 tabs / 30 days);

A90 risperidone tab 0.25 mg 2 QL (90 tabs / 30 days);

A90 risperidone tab 1 mg 2 QL (90 tabs / 30 days);




A90 SAPHRIS SUB 5MG 4 QL (60 ea / 30 days),

ST; A90 SAPHRIS SUB 10MG 4 QL (60 ea / 30 days),

ST; A90 SEROQUEL XR TAB 50MG 3 QL (60 ea / 30 days),





ST; A90 VRAYLAR CAP 1.5-3MG 4 ST; QL VRAYLAR CAP 1.5MG 4 ST; QL VRAYLAR CAP 3MG 4 ST; QL VRAYLAR CAP 4.5MG 4 ST; QL


60

Drug Name Drug Tier Requirements/Limits VRAYLAR CAP 6MG 4 ST; QL ziprasidone hcl cap 20 mg 2 QL (90 caps / 30 days);

A90 ziprasidone hcl cap 40 mg 2 QL (60 caps / 30 days);



A90 ZYPREXA RELP INJ 210MG 4 ZYPREXA RELP INJ 300MG 4 ZYPREXA RELP INJ 405MG 4 ANTIPSYCHOTICS, MISCELLANEOUS CHLORPROMAZ INJ 25MG/ML 4 CHLORPROMAZ INJ 50MG/2ML 4 chlorpromazine hcl tab 10 mg 2 A90 chlorpromazine hcl tab 25 mg 2 A90 chlorpromazine hcl tab 50 mg 2 A90 chlorpromazine hcl tab 100 mg 2 A90 chlorpromazine hcl tab 200 mg 2 A90 fluphenazine decanoate inj 25 mg/ml 2 fluphenazine hcl elixir 2.5 mg/5ml 4 A90 fluphenazine hcl inj 2.5 mg/ml 2 fluphenazine hcl tab 1 mg 1 A90 fluphenazine hcl tab 2.5 mg 2 A90 fluphenazine hcl tab 5 mg 2 A90 fluphenazine hcl tab 10 mg 2 A90 haloperidol decanoate im soln 50 mg/ml 2 haloperidol decanoate im soln 100 mg/ml 2 haloperidol lactate inj 5 mg/ml 2 haloperidol lactate oral conc 2 mg/ml 2 A90 haloperidol tab 0.5 mg 1 A90 haloperidol tab 1 mg 1 A90 haloperidol tab 2 mg 1 A90 haloperidol tab 5 mg 1 A90 haloperidol tab 10 mg 2 A90 haloperidol tab 20 mg 2 A90 perphenazine tab 2 mg 2 A90 perphenazine tab 4 mg 2 A90 perphenazine tab 8 mg 2 A90 perphenazine tab 16 mg 2 A90 perphenazine-amitriptyline tab 2-10 mg 2 A90 perphenazine-amitriptyline tab 2-25 mg 2 A90


61

Drug Name Drug Tier Requirements/Limits perphenazine-amitriptyline tab 4-25 mg 2 A90 pimozide tab 1 mg 2 A90, M90 pimozide tab 2 mg 2 A90, M90 prochlorperazine edisylate inj 5 mg/ml 2 thioridazine hcl tab 10 mg 2 A90 thioridazine hcl tab 25 mg 2 A90 thioridazine hcl tab 50 mg 2 A90 thioridazine hcl tab 100 mg 2 A90 thiothixene cap 1 mg 2 A90 thiothixene cap 2 mg 2 A90 thiothixene cap 5 mg 2 A90 thiothixene cap 10 mg 2 A90 trifluoperazine hcl tab 1 mg 2 A90 trifluoperazine hcl tab 2 mg 2 A90 trifluoperazine hcl tab 5 mg 2 A90 trifluoperazine hcl tab 10 mg 2 A90 ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine cap sr

24hr 5 mg 2 QL (30 ea / 30 days);

A90 amphetamine-dextroamphetamine cap sr

24hr 10 mg 2 QL (30 ea / 30 days);


24hr 15 mg 2 QL (30 ea / 30 days);


24hr 20 mg 2 QL (60 ea / 30 days);


24hr 25 mg 2 QL (60 ea / 30 days);


24hr 30 mg 2 QL (60 ea / 30 days);

A90 amphetamine-dextroamphetamine tab 5

mg 2 A90

amphetamine-dextroamphetamine tab 7.5 mg

2 A90

amphetamine-dextroamphetamine tab 10 mg

2 A90

amphetamine-dextroamphetamine tab 12.5 mg

2 A90


2 A90


2 A90


2 A90

clonidine hcl tab sr 12hr 0.1 mg 2 ST; A90


62

Drug Name Drug Tier Requirements/Limits CONCERTA TAB 18MG 4 QL (30 ea / 30 days);

A90 DAYTRANA DIS 10MG/9HR 3 QL (30 ptch / 30 days),

ST; A90 DAYTRANA DIS 15MG/9HR 3 QL (30 ptch / 30 days),



ST; A90 dexedrine tab 5mg 2 A90 dexedrine tab 10mg 2 A90 dexmethylphenidate hcl cap sr 24 hr 5 mg 2 QL (30 ea / 30 days);

A90 dexmethylphenidate hcl cap sr 24 hr 10

mg 2 QL (30 ea / 30 days);


mg 2 QL (30 ea / 30 days);


mg 2 QL (30 ea / 30 days);


mg 2 QL (30 ea / 30 days);

A90 dexmethylphenidate hcl tab 2.5 mg 2 A90 dexmethylphenidate hcl tab 5 mg 2 A90 dexmethylphenidate hcl tab 10 mg 2 A90 dextroamphetamine sulfate cap sr 24hr 5

mg 2 A90

dextroamphetamine sulfate cap sr 24hr 10 mg

2 A90

dextroamphetamine sulfate cap sr 24hr 15 mg

2 A90

dextroamphetamine sulfate oral solution 5 mg/5ml

2 A90

dextroamphetamine sulfate tab 5 mg 2 A90 dextroamphetamine sulfate tab 10 mg 2 A90 guanfacine hcl tab sr 24hr 1 mg (base

equiv) 2 ST; A90

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

2 ST; A90


2 ST; A90


2 ST; A90


63

Drug Name Drug Tier Requirements/Limits metadate tab 20mg er 2 QL (30 ea / 30 days);

A90 methamphetamine hcl tab 5 mg 2 A90 methylphenidate hcl cap cr 10 mg (cd) 2 QL (30 ea / 30 days);

A90 methylphenidate hcl cap cr 50 mg (cd) 2 QL (30 ea / 30 days);

A90 methylphenidate hcl cap cr 60 mg (cd) 2 QL (30 ea / 30 days);

A90 methylphenidate hcl cap sr 24hr 20 mg

(la) 2 QL (30 ea / 30 days);


(la) 2 QL (30 ea / 30 days);


(la) 2 QL (30 ea / 30 days);

A90 methylphenidate hcl soln 5 mg/5ml 2 A90 methylphenidate hcl soln 10 mg/5ml 2 A90 methylphenidate hcl tab 5 mg 2 A90 methylphenidate hcl tab 10 mg 2 A90 methylphenidate hcl tab 20 mg 2 A90 methylphenidate hcl tab cr 10 mg 2 A90 methylphenidate hcl tab cr 20 mg 2 QL (30 ea / 30 days);

A90 methylphenidate hcl tab sa osm 18 mg 2 QL (30 ea / 30 days);




A90 QUILLIVANT SUS 25MG/5ML 3 QL (120ml per day), ST;

A90 STRATTERA CAP 10MG 3 QL (30 caps / 30 days),

ST; A90 STRATTERA CAP 18MG 3 QL (30 caps / 30 days),




ST; A90


64

Drug Name Drug Tier Requirements/Limits STRATTERA CAP 80MG 3 QL (30 caps / 30 days),


ST; A90 VYVANSE CAP 10MG 3 QL (30 caps / 30 days);

A90 VYVANSE CAP 20MG 3 QL (30 caps / 30 days);






A90 zenzedi tab 5mg 2 A90 zenzedi tab 10mg 2 A90 FIBROMYALGIA LYRICA CAP 25MG 4 QL (90 caps / 30 days),

ST; A90, M90 LYRICA CAP 50MG 4 QL (90 caps / 30 days),







ST; A90, M90 LYRICA SOL 20MG/ML 4 ST; QL, A90, M90 SAVELLA TAB 12.5MG 3 QL (60 tabs / 30 days),

PA; A90, M90 SAVELLA TAB 25MG 3 QL (60 tabs / 30 days),

PA; A90, M90 SAVELLA TAB 50MG 3 QL (60 tabs / 30 days),

PA; A90, M90


65

Drug Name Drug Tier Requirements/Limits SAVELLA TAB 100MG 3 QL (60 tabs / 30 days),

PA; A90, M90 HUNTINGTON'S DISEASE AGENTS tetrabenazine tab 12.5 mg 4 PA; SP tetrabenazine tab 25 mg 4 PA; SP HYPNOTICS: BENZODIAZEPINES estazolam tab 1 mg 2 estazolam tab 2 mg 2 flurazepam hcl cap 15 mg 2 flurazepam hcl cap 30 mg 2 temazepam cap 7.5 mg 2 temazepam cap 15 mg 2 temazepam cap 22.5 mg 2 temazepam cap 30 mg 2 triazolam tab 0.25 mg 2 triazolam tab 0.125 mg 2 HYPNOTICS: NON-BENZODIAZEPINES dexmedetomidine hcl inj 200 mcg/2ml (for

iv infusion) 2

eq sleep aid cap 50mg 2 eszopiclone tab 1 mg 2 QL (30 tabs / 30 days) eszopiclone tab 2 mg 2 QL (30 tabs / 30 days) eszopiclone tab 3 mg 2 QL (30 tabs / 30 days) ROZEREM TAB 8MG 3 QL (30 tabs / 30 days),

ST; A90 zaleplon cap 5 mg 2 QL (30 caps / 30 days) zaleplon cap 10 mg 2 QL (30 caps / 30 days) zolpidem tartrate tab 5 mg 2 QL (30 tabs / 30 days) zolpidem tartrate tab 10 mg 2 QL (30 tabs / 30 days) zolpidem tartrate tab cr 6.25 mg 2 QL (30 ea / 30 days), ST zolpidem tartrate tab cr 12.5 mg 2 QL (30 ea / 30 days), ST MIGRAINE, ERGOTAMINE DERIVATIVES CAFERGOT TAB 1-100MG 4 dihydroergotamine mesylate inj 1 mg/ml 2 dihydroergotamine mesylate nasal spray 4

mg/ml 2

ERGOMAR SUB 2MG 4 migergot sup 2/100 2 MIGRAINE, SELECTIVE SEROTONIN AGONISTS almotriptan malate tab 6.25 mg 2 QL (12 tabs / 30 days),

ST; QL


66

Drug Name Drug Tier Requirements/Limits almotriptan malate tab 12.5 mg 2 QL (12 tabs / 30 days),

ST; QL frovatriptan succinate tab 2.5 mg (base

equivalent) 2 QL (12 tabs / 30 days),

ST naratriptan hcl tab 1 mg (base equiv) 2 QL (12 tabs / 30 days),

ST naratriptan hcl tab 2.5 mg (base equiv) 2 QL (12 tabs / 30 days),

ST RELPAX TAB 20MG 3 QL (12 tabs / 30 days),

ST RELPAX TAB 40MG 3 QL (12 tabs / 30 days),

ST rizatriptan benzoate oral disintegrating tab

5 mg (base eq) 2 QL (12 ea / 30 days), ST

rizatriptan benzoate oral disintegrating tab 10 mg (base eq)

2 QL (12 ea / 30 days), ST

rizatriptan benzoate tab 5 mg (base equivalent)

2 QL (12 tabs / 30 days), ST

rizatriptan benzoate tab 10 mg (base equivalent)

2 QL (12 tabs / 30 days), ST

sumatriptan nasal spray 5 mg/act 2 QL (12 units per 30 days)

sumatriptan nasal spray 20 mg/act 2 QL (12 units per 30 days)

sumatriptan succinate inj 6 mg/0.5ml 2 QL (12 inj / 30 days) sumatriptan succinate tab 25 mg 2 QL (12 tabs / 30 days) sumatriptan succinate tab 50 mg 2 QL (12 tabs / 30 days) sumatriptan succinate tab 100 mg 2 QL (12 tabs / 30 days) zolmitriptan orally disintegrating tab 2.5

mg 2 QL (12 ea / 30 days), ST

zolmitriptan orally disintegrating tab 5 mg 2 QL (12 ea / 30 days), ST zolmitriptan tab 2.5 mg 2 QL (12 tabs / 30 days),

ST zolmitriptan tab 5 mg 2 QL (12 tabs / 30 days),

ST ZOMIG NASAL SPR 5MG 4 QL (2 / 30 days), ST ZOMIG SPR 2.5MG 4 QL (2 boxes / 30 days),

ST MISCELLANEOUS ADDYI TAB 100MG 4 PA; QL BOTOX INJ 100UNIT 4 PA; SP BOTOX INJ 200UNIT 4 PA; SP DYSPORT INJ 300UNIT 4 PA; SP ergoloid mesylates tab 1 mg 2 A90, M90


67

Drug Name Drug Tier Requirements/Limits GUANIDINE TAB 125MG 3 MYOBLOC INJ 2500/0.5 4 PA; SP riluzole tab 50 mg 2 A90, M90 XEOMIN INJ 50 UNIT 4 PA; SP MOOD STABILIZERS lithium carbonate cap 150 mg 1 A90 lithium carbonate cap 300 mg 1 A90 lithium carbonate cap 600 mg 1 A90 lithium carbonate tab 300 mg 1 A90 lithium carbonate tab cr 300 mg 1 A90 lithium carbonate tab cr 450 mg 1 A90 LITHIUM SOL 8MEQ/5ML 4 A90 MULTIPLE SCLEROSIS AMPYRA TAB 10MG 3 PA; SP AUBAGIO TAB 7MG 4 PA; SP AUBAGIO TAB 14MG 4 PA; SP AVONEX KIT 30MCG 3 SP AVONEX PREFL KIT 30MCG 3 SP BETASERON INJ 0.3MG 4 SP COPAXONE INJ 40MG/ML 3 SP GILENYA CAP 0.5MG 4 PA; SP glatopa inj 20mg/ml 4 SP REBIF INJ 22/0.5 3 SP REBIF INJ 44/0.5 3 SP REBIF TITRTN INJ PACK 3 SP TECFIDERA CAP 120MG 3 PA; SP TECFIDERA CAP 240MG 3 PA; SP TECFIDERA MIS STARTER 3 PA; SP TYSABRI INJ 300/15ML 4 PA; SP MUSCULOSKELETAL THERAPY AGENTS baclofen tab 10 mg 1 A90, M90 baclofen tab 20 mg 2 A90, M90 carisoprodol tab 250 mg Plan

Exclusion

carisoprodol tab 350 mg 1 QL carisoprodol w/ aspirin & codeine tab 200-

325-16 mg 2 ST

carisoprodol w/ aspirin tab 200-325 mg 2 ST chlorzoxazone tab 500 mg 2 ST cyclobenzaprine hcl tab 5 mg 1 cyclobenzaprine hcl tab 7.5 mg 2 cyclobenzaprine hcl tab 10 mg 1


68

Drug Name Drug Tier Requirements/Limits dantrolene sodium cap 25 mg 2 dantrolene sodium cap 50 mg 2 dantrolene sodium cap 100 mg 2 metaxalone tab 800 mg 2 ST methocarbamol inj 1000 mg/10ml 2 methocarbamol tab 500 mg 1 methocarbamol tab 750 mg 1 orphenadrine citrate inj 30 mg/ml 2 orphenadrine citrate tab sr 12hr 100 mg 2 orphenadrine w/ aspirin & caffeine tab 25-

385-30 mg 2

revonto inj 20mg 2 tizanidine hcl cap 2 mg (base equivalent) 2 A90, M90 tizanidine hcl cap 4 mg (base equivalent) 2 A90, M90 tizanidine hcl cap 6 mg (base equivalent) 2 A90, M90 tizanidine hcl tab 2 mg (base equivalent) 2 A90, M90 tizanidine hcl tab 4 mg (base equivalent) 2 A90, M90 MYASTHENIA GRAVIS MESTINON SYP 60MG/5ML 3 pyridostigmine bromide tab 60 mg 2 pyridostigmine bromide tab cr 180 mg 2 NARCOLEPSY/CATAPLEXY armodafinil tab 50 mg 2 QL (60 per 30 days),

PA; A90 armodafinil tab 150 mg 2 QL (30 per 30 days),



PA; A90 modafinil tab 100 mg 2 QL (30 tabs / 30 days),

PA; A90 modafinil tab 200 mg 2 QL (30 tabs / 30 days),

PA; A90 XYREM SOL 500MG/ML 3 PA PSYCHOTHERAPEUTIC-MISC, ALCOHOL DETERRENTS acamprosate calcium tab delayed release

333 mg 2 A90, M90

disulfiram tab 250 mg 2 A90, M90 disulfiram tab 500 mg 2 A90, M90 VIVITROL INJ 380MG 3 PSYCHOTHERAPEUTIC-MISC, OPIOID ANTAGONIST naloxone hcl inj 4 mg/10ml 2


69

Drug Name Drug Tier Requirements/Limits naloxone hcl soln prefilled syringe 2

mg/2ml 2

naltrexone hcl tab 50 mg 2 PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONIST/OPIOID

ANTAGONIST COMBINATIONS buprenorphine hcl-naloxone hcl sl tab 2-

0.5 mg (base equiv) 2 QL (90 tabs / 30 days)

buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv)

2 QL (120 tabs / 30 days)

SUBOXONE MIS 2-0.5MG 3 QL (90 ea / 30 days) SUBOXONE MIS 4-1MG 3 QL (90 ea / 30 days) SUBOXONE MIS 8-2MG 3 QL (120 ea / 30 days) SUBOXONE MIS 12-3MG 3 QL (90 ea / 30 days) PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONISTS buprenorphine hcl sl tab 2 mg (base equiv)2 QL (90 tabs / 30 days),

PA buprenorphine hcl sl tab 8 mg (base equiv)2 QL (120 tabs / 30 days),

PA PSYCHOTHERAPEUTIC-MISC, PSEUDOBULBAR AFFECT NUEDEXTA CAP 20-10MG 3 QL (60 caps / 30 days),

PA; A90, M90 PSYCHOTHERAPEUTIC-MISC, SMOKING DETERRENTS CHANTIX PAK 0.5& 1MG $0 CHANTIX PAK 1MG $0 CHANTIX TAB 0.5MG $0 CHANTIX TAB 1MG $0 eq nicotine dis 7mg/24hr $0 nicorelief gum 2mg orig $0 nicorelief gum 4mg orig $0 nicotine polacrilex gum 2 mg $0 nicotine polacrilex gum 4 mg $0 nicotine polacrilex lozenge 2 mg $0 nicotine polacrilex lozenge 4 mg $0 NICOTINE SYS KIT TRANSDER $0 nicotine td patch 24hr 14 mg/24hr $0 nicotine td patch 24hr 21 mg/24hr $0 NICOTROL INH $0 NICOTROL NS SPR 10MG/ML $0 thrive gum 2mg mint $0 ENDOCRINE AND METABOLIC ANDROGENS ANADROL-50 TAB 50MG 4


70

Drug Name Drug Tier Requirements/Limits ANDRODERM DIS 2MG/24HR 3 A90, M90 ANDRODERM DIS 4MG/24HR 3 A90, M90 ANDROGEL GEL 1%(25MG) 3 A90, M90 ANDROGEL GEL 1.62% 3 A90, M90 ANDROXY TAB 10MG 3 A90, M90 AXIRON SOL 30MG/ACT 3 A90, M90 METHITEST TAB 10MG 3 A90, M90 methyltestosterone cap 10 mg 2 A90, M90 NATESTO GEL 5.5MG 3 A90, M90 oxandrolone tab 2.5 mg 2 oxandrolone tab 10 mg 2 STRIANT MIS 30MG 4 A90, M90 TESTOPEL MIS PELLETS 3 A90, M90 testosterone cypionate im inj in oil 100

mg/ml 2

testosterone cypionate im inj in oil 200 mg/ml

2

testosterone enanthate im inj in oil 200 mg/ml

2

testosterone td gel 25 mg/2.5gm (1%) 2 A90, M90 testosterone td gel 50 mg/5gm (1%) 3 A90, M90 ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITOR acarbose tab 25 mg 2 A90, M90 acarbose tab 50 mg 2 A90, M90 acarbose tab 100 mg 2 A90, M90 miglitol tab 25 mg 2 A90, M90 miglitol tab 50 mg 2 A90, M90 miglitol tab 100 mg 2 A90, M90 ANTIDIABETICS, AMYLIN ANALOGS SYMLINPEN 60 INJ 1000MCG 3 PA; A90, M90 SYMLNPEN 120 INJ 1000MCG 3 PA; A90, M90 ANTIDIABETICS, BIGUANIDE/SULFONYLUREA COMBINATIONS glipizide-metformin hcl tab 2.5-250 mg 2 A90, M90 glipizide-metformin hcl tab 2.5-500 mg 2 A90, M90 glipizide-metformin hcl tab 5-500 mg 2 A90, M90 glyburide-metformin tab 1.25-250 mg 2 A90, M90 glyburide-metformin tab 2.5-500 mg 2 A90, M90 glyburide-metformin tab 5-500 mg 2 A90, M90 ANTIDIABETICS, BIGUANIDES metformin hcl tab 500 mg 1 A90, M90 metformin hcl tab 850 mg 1 A90, M90 metformin hcl tab 1000 mg 1 A90, M90


71

Drug Name Drug Tier Requirements/Limits metformin hcl tab sr 24hr 500 mg 2 A90, M90 metformin hcl tab sr 24hr 750 mg 2 A90, M90 metformin hcl tab sr 24hr osmotic 1000

mg 2 A90, M90

RIOMET SOL 4 A90, M90 ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4)

INHIBITOR/BIGUANIDE COMBINATIONS alogliptin-metformin hcl tab 12.5-500 mg 2 QL (60 per 30 days),

ST; A90, M90 alogliptin-metformin hcl tab 12.5-1000 mg 2 QL (60 per 30 days),

ST; A90, M90 JANUMET TAB 50-500MG 3 QL (60 tabs / 30 days),

ST; A90, M90 JANUMET TAB 50-1000 3 QL (60 tabs / 30 days),

ST; A90, M90 JANUMET XR TAB 50-500MG 3 QL (30 ea / 30 days),

ST; A90, M90 JANUMET XR TAB 50-1000 3 QL (30 ea / 30 days),

ST; A90, M90 JANUMET XR TAB 100-1000 3 QL (30 ea / 30 days),

ST; A90, M90 JENTADUETO TAB 2.5-500 4 QL (60 tabs / 30 days),



ST; A90, M90 KOMBIGLYZE TAB 2.5-1000 3 QL (30 ea / 30 days),

ST; A90, M90 KOMBIGLYZE TAB 5-500MG 3 QL (30 ea / 30 days),

ST; A90, M90 KOMBIGLYZE TAB 5-1000MG 3 QL (30 ea / 30 days),

ST; A90, M90 ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4)

INHIBITOR/INSULIN SENSITIZER COMBINATIONS alogliptin-pioglitazone tab 12.5-15 mg 2 QL (30 per 30 days),

ST; A90, M90 alogliptin-pioglitazone tab 12.5-30 mg 2 QL (30 per 30 days),

ST; A90, M90 alogliptin-pioglitazone tab 12.5-45 mg 2 QL (30 per 30 days),

ST; A90, M90 alogliptin-pioglitazone tab 25-15 mg 2 QL (30 per 30 days),

ST; A90, M90


72

Drug Name Drug Tier Requirements/Limits alogliptin-pioglitazone tab 25-30 mg 2 QL (30 per 30 days),

ST; A90, M90 alogliptin-pioglitazone tab 25-45 mg 2 QL (30 per 30 days),

ST; A90, M90 ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS alogliptin benzoate tab 6.25 mg (base

equiv) 2 QL (30 per 30 days),

ST; A90, M90 alogliptin benzoate tab 12.5 mg (base

equiv) 2 QL (30 per 30 days),

ST; A90, M90 alogliptin benzoate tab 25 mg (base equiv) 2 QL (30 per 30 days),

ST; A90, M90 JANUVIA TAB 25MG 3 QL (30 tabs / 30 days),



ST; A90, M90 ONGLYZA TAB 2.5MG 3 QL (30 tabs / 30 days),

ST; A90, M90 ONGLYZA TAB 5MG 3 QL (30 tabs / 30 days),

ST; A90, M90 TRADJENTA TAB 5MG 3 QL (30 tabs / 30 days),

ST; A90, M90 ANTIDIABETICS, INCRETIN MIMETIC AGENTS BYDUREON INJ 2MG 3 QL, A90, M90 BYDUREON PEN INJ 2MG 3 QL, A90, M90 BYETTA INJ 5MCG 3 QL (1 pen / 30 days);

A90, M90 BYETTA INJ 10MCG 3 QL, A90, M90 VICTOZA INJ 18MG/3ML 4 QL (1 pen / 30 days);

A90, M90 ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATION ACTOPLUS MET TAB XR 3 ST; A90, M90 pioglitazone hcl-metformin hcl tab 15-500

mg 2 ST; A90, M90

pioglitazone hcl-metformin hcl tab 15-850 mg

2 ST; A90, M90

ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA COMBO pioglitazone hcl-glimepiride tab 30-2 mg 2 ST; A90, M90 pioglitazone hcl-glimepiride tab 30-4 mg 2 ST; A90, M90 ANTIDIABETICS, INSULIN SENSITIZERS AVANDIA TAB 2MG 4 A90, M90 AVANDIA TAB 4MG 4 A90, M90


73

Drug Name Drug Tier Requirements/Limits pioglitazone hcl tab 15 mg (base equiv) 2 A90, M90 pioglitazone hcl tab 30 mg (base equiv) 2 A90, M90 pioglitazone hcl tab 45 mg (base equiv) 2 A90, M90 ANTIDIABETICS, INSULINS APIDRA INJ SOLOSTAR 2 A90, M90 APIDRA INJ U-100 2 A90, M90 HUMALOG INJ 100/ML 2 A90, M90 HUMALOG MIX INJ 50/50 2 A90, M90 HUMALOG MIX INJ 50/50KWP 2 A90, M90 HUMALOG MIX INJ 75/25KWP 2 A90, M90 HUMALOG MIX SUS 75/25 2 A90, M90 HUMULIN INJ 70/30 2 A90, M90 HUMULIN INJ 70/30KWP 2 A90, M90 HUMULIN N INJ U-100 2 A90, M90 HUMULIN N INJ U-100KWP 2 A90, M90 HUMULIN R INJ U-100 2 A90, M90 HUMULIN R INJ U-500 2 A90, M90 LANTUS INJ 100/ML 2 A90, M90 LANTUS INJ SOLOSTAR 2 A90, M90 LEVEMIR INJ 2 A90, M90 LEVEMIR INJ FLEXPEN 2 A90, M90 NOVOLIN INJ 70/30 2 A90, M90 NOVOLIN N INJ U-100 2 A90, M90 NOVOLIN R INJ U-100 2 A90, M90 NOVOLOG INJ 100/ML 2 A90, M90 NOVOLOG INJ PENFILL 2 A90, M90 NOVOLOG MIX INJ 70/30 2 A90, M90 NOVOLOG MIX INJ FLEXPEN 2 A90, M90 TRESIBA FLEX INJ 100UNIT 2 A90, M90 TRESIBA FLEX INJ 200UNIT 2 A90, M90 ANTIDIABETICS, MEGLITINIDE nateglinide tab 60 mg 2 A90, M90 nateglinide tab 120 mg 2 A90, M90 repaglinide tab 0.5 mg 2 A90, M90 repaglinide tab 1 mg 2 A90, M90 repaglinide tab 2 mg 2 A90, M90 ANTIDIABETICS, MEGLITINIDE/BIGUANIDE COMBINATIONS repaglinide-metformin hcl tab 1-500 mg 2 A90, M90 repaglinide-metformin hcl tab 2-500 mg 2 A90, M90 ANTIDIABETICS, MISCELLANEOUS CYCLOSET TAB 0.8MG 4 QL (180 tabs / 30 days),

PA; A90, M90


74

Drug Name Drug Tier Requirements/Limits ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2)

INHIBITOR/BIGUANIDE COMBINATIONS XIGDUO XR TAB 5-500MG 3 A90, M90 XIGDUO XR TAB 5-1000MG 3 A90, M90 XIGDUO XR TAB 10-500MG 3 A90, M90 XIGDUO XR TAB 10-1000 3 A90, M90 ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2)

INHIBITORS FARXIGA TAB 5MG 3 QL (30 tabs / 30 days),

ST; A90, M90 FARXIGA TAB 10MG 3 QL (30 tabs / 30 days),

ST; A90, M90 INVOKANA TAB 100MG 3 QL (30 tabs / 30 days),

ST; A90, M90 INVOKANA TAB 300MG 3 QL (30 tabs / 30 days),

ST; A90, M90 JARDIANCE TAB 10MG 3 QL (30 tabs / 30 days),

ST; A90, M90 JARDIANCE TAB 25MG 3 QL (30 tabs / 30 days),

ST; A90, M90 ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2

INHIBITOR/DPP-4 INHIBITOR COMBINATIONS GLYXAMBI TAB 10-5 MG 3 A90, M90 GLYXAMBI TAB 25-5 MG 3 A90, M90 ANTIDIABETICS, SULFONYLUREAS chlorpropamide tab 100 mg 2 A90, M90 chlorpropamide tab 250 mg 2 A90, M90 glimepiride tab 1 mg 1 A90, M90 glimepiride tab 2 mg 1 A90, M90 glimepiride tab 4 mg 1 A90, M90 glipizide tab 5 mg 1 A90, M90 glipizide tab 10 mg 1 A90, M90 glipizide tab sr 24hr 2.5 mg 1 A90, M90 glipizide tab sr 24hr 5 mg 1 A90, M90 glipizide tab sr 24hr 10 mg 1 A90, M90 glyburide micronized tab 1.5 mg 1 A90, M90 glyburide micronized tab 3 mg 1 A90, M90 glyburide micronized tab 6 mg 1 A90, M90 glyburide tab 1.25 mg 1 A90, M90 glyburide tab 2.5 mg 1 A90, M90 glyburide tab 5 mg 1 A90, M90 tolazamide tab 250 mg 2 A90, M90


75

Drug Name Drug Tier Requirements/Limits tolbutamide tab 500 mg 2 A90, M90 ANTIDIABETICS, SUPPLIES ALCOHOL SWABS $0 FREESTYLE TES $0 QL (1 box / 30 days); AL INSULIN PEN NEEDLES $0 INSULIN SYRINGES $0 LANCET DEVICE $0 LANCETS $0 PRECISION TES QID $0 CALCIUM RECEPTOR ANTAGONISTS SENSIPAR TAB 30MG 3 PA; SP SENSIPAR TAB 60MG 3 PA; SP SENSIPAR TAB 90MG 3 PA; SP CALCIUM REGULATORS, BISPHOSPHONATES alendronate sodium oral soln 70 mg/75ml 1 A90, M90 alendronate sodium tab 5 mg 2 QL (30 tabs / 30 days);

A90, M90 alendronate sodium tab 10 mg 2 QL (30 tabs / 30 days);

A90, M90 alendronate sodium tab 35 mg 1 QL (4 tabs / 28 days);

A90, M90 alendronate sodium tab 40 mg 1 QL (30 / 30 days) alendronate sodium tab 70 mg 1 QL (4 tabs / 28 days);

A90, M90 etidronate disodium tab 200 mg 2 etidronate disodium tab 400 mg 2 FOSAMAX + D TAB 70-2800 3 A90, M90 FOSAMAX + D TAB 70-5600 3 A90, M90 ibandronate sodium iv soln 3 mg/3ml

(base equivalent) 2 PA

ibandronate sodium tab 150 mg (base equivalent)

2 QL (1 tab / 28 days), ST; A90, M90

pamidronate disodium iv soln 3 mg/ml 3 SP pamidronate disodium iv soln 9 mg/ml 3 SP PAMIDRONATE INJ 6MG/ML 4 SP risedronate sodium tab 5 mg 2 QL (30 tabs / 30 days),

ST; A90, M90 risedronate sodium tab 30 mg 2 QL (30 tabs / 30 days),

ST risedronate sodium tab 35 mg 2 QL (4 tabs / 28 days),

ST; A90, M90 risedronate sodium tab 150 mg 2 QL (1 tab / 28 days),

ST; A90, M90


76

Drug Name Drug Tier Requirements/Limits zoledronic acid inj conc for iv infusion 4

mg/5ml 4 PA; SP

zoledronic acid iv soln 5 mg/100ml 3 PA; SP ZOLEDRONIC INJ 4MG/100 4 PA; SP ZOMETA INJ 4MG/100 4 PA; SP CALCIUM REGULATORS, CALCITONINS calcitonin (salmon) nasal soln 200 unit/act 2 A90, M90 CALCIUM REGULATORS, PARATHYROID HORMONES FORTEO SOL 600/2.4 3 SP CALCIUM REGULATORS, RANK LIGAND INHIBITORS PROLIA SOL 60MG/ML 4 PA; SP XGEVA INJ 3 PA; SP CONTRACEPTIVES, BIPHASIC azurette tab 28 day $0 A90, M90 kariva tab 28 day $0 A90, M90 pimtrea tab $0 A90, M90 viorele tab $0 A90, M90 CONTRACEPTIVES, EMERGENCY CONTRACEPTION econtra ez tab 1.5mg $0 ELLA TAB 30MG $0 levonorgestrel tab 1.5 mg $0 my way tab 1.5mg $0 next choice tab 1.5mg $0 CONTRACEPTIVES, EXTENDED CYCLE amethia lo tab $0 A90, M90 amethia tab $0 A90, M90 camrese lo tab $0 A90, M90 camrese tab $0 A90, M90 daysee tab $0 A90, M90 introvale tab $0 A90, M90 jolessa tab $0 A90, M90 levonorg-eth est tab 0.1-0.02mg(84) & eth

est tab 0.01mg(7) $0 A90, M90

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

$0 A90, M90

quasense tab $0 A90, M90 CONTRACEPTIVES, FOUR PHASE NATAZIA TAB $0 A90, M90 CONTRACEPTIVES, IMPLANT NEXPLANON IMP 68MG $0 SP CONTRACEPTIVES, INJECTABLE


77

Drug Name Drug Tier Requirements/Limits DEPO-SQ PROV INJ 104 4 medroxyprogesterone acetate im susp 150

mg/ml $0

medroxyprogesterone acetate im susp prefilled syr 150 mg/ml

$0

CONTRACEPTIVES, MISCELLANEOUS CONCEPTROL GEL 4% $0 ENCARE SUP 100MG $0 GYNOL II GEL 3% $0 VCF VAGINAL AER CONTRACP $0 CONTRACEPTIVES, MONOPHASIC altavera tab $0 A90, M90 alyacen tab 1/35 $0 A90, M90 apri tab $0 A90, M90 aubra tab 0.1-0.02 $0 A90, M90 aviane tab $0 A90, M90 balziva tab $0 A90, M90 briellyn tab $0 A90, M90 chateal tab 0.15/30 $0 A90, M90 cryselle-28 tab 28 tabs $0 A90, M90 cyclafem tab 1/35 $0 A90, M90 dasetta tab 1/35 $0 A90, M90 delyla tab 0.1-0.02 $0 A90, M90 drospirenone-ethinyl estradiol tab 3-0.03

mg $0 A90, M90

elinest tab $0 A90, M90 emoquette tab $0 A90, M90 enskyce tab $0 A90, M90 estarylla tab 0.25-35 $0 A90, M90 falmina tab $0 A90, M90 gianvi tab 3-0.02mg $0 A90, M90 gildess 24 tab fe 1/20 $0 A90, M90 gildess fe tab 1.5/30 $0 A90, M90 gildess fe tab 1/20 $0 A90, M90 gildess tab 1.5/30 $0 A90, M90 gildess tab 1/20 $0 A90, M90 junel 1.5/30 tab $0 A90, M90 junel 1/20 tab $0 A90, M90 junel fe tab 1.5/30 $0 A90, M90 junel fe tab 1/20 $0 A90, M90 kelnor tab 1/35 $0 A90, M90 kurvelo tab 0.15/30 $0 A90, M90


78

Drug Name Drug Tier Requirements/Limits larin fe tab 1.5/30 $0 A90, M90 larin fe tab 1/20 $0 A90, M90 larin tab 1.5/30 $0 A90, M90 larin tab 1/20 $0 A90, M90 lessina tab $0 A90, M90 levonorgestrel & ethinyl estradiol tab 0.1

mg-20 mcg $0 A90, M90

levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg

$0 A90, M90

levora-28 tab 0.15/30 $0 A90, M90 LO LOESTRIN TAB $0 A90, M90 lomedia 24 tab fe $0 A90, M90 loryna tab 3-0.02mg $0 A90, M90 low-ogestrel tab $0 A90, M90 lutera tab $0 A90, M90 marlissa tab 0.15/30 $0 A90, M90 microgestin tab 1.5/30 $0 A90, M90 microgestin tab 1/20 $0 A90, M90 microgestin tab fe1.5/30 $0 A90, M90 microgestin tab fe 1/20 $0 A90, M90 MINASTRIN 24 CHW FE $0 A90, M90 mono-linyah tab 0.25-35 $0 A90, M90 mononessa tab $0 A90, M90 necon tab 0.5/35 $0 A90, M90 necon tab 1/35 $0 A90, M90 nikki tab 3-0.02mg $0 A90, M90 norethindrone ace & ethinyl estradiol tab 1

mg-20 mcg $0 A90, M90

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

$0 A90, M90

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

$0 A90, M90

norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg

$0 A90, M90

nortrel tab 0.5/35 $0 A90, M90 nortrel tab 1/35 $0 A90, M90 ocella tab 3-0.03mg $0 A90, M90 ogestrel tab $0 A90, M90 orsythia tab $0 A90, M90 philith tab 0.4-35 $0 A90, M90 pirmella tab 1/35 $0 A90, M90 portia-28 tab $0 A90, M90 previfem tab $0 A90, M90


79

Drug Name Drug Tier Requirements/Limits reclipsen tab $0 A90, M90 sprintec 28 tab 28 day $0 A90, M90 sronyx tab $0 A90, M90 syeda tab 3-0.03mg $0 A90, M90 tarina fe tab 1/20 $0 A90, M90 vestura tab 3-0.02mg $0 A90, M90 vyfemla tab 0.4-35 $0 A90, M90 wera tab 0.5/35 $0 A90, M90 zarah tab 3-0.03mg $0 A90, M90 zenchent fe chw 0.4mg-35 $0 A90, M90 zenchent tab $0 A90, M90 zovia 1/35e tab $0 A90, M90 CONTRACEPTIVES, PROGESTIN INTRAUTERINE DEVICE MIRENA IUD SYSTEM $0 SP SKYLA IUD 13.5MG $0 SP CONTRACEPTIVES, PROGESTIN ONLY camila tab 0.35mg $0 A90, M90 deblitane tab 0.35mg $0 A90, M90 errin tab 0.35mg $0 A90, M90 heather tab 0.35mg $0 A90, M90 jencycla tab 0.35mg $0 A90, M90 jolivette tab 0.35mg $0 A90, M90 lyza tab 0.35mg $0 A90, M90 nora-be tab 0.35mg $0 A90, M90 norethindrone tab 0.35 mg $0 A90, M90 norlyroc tab 0.35mg $0 A90, M90 sharobel tab 0.35mg $0 A90, M90 CONTRACEPTIVES, TRANSDERMAL xulane dis 150-35 $0 A90, M90 CONTRACEPTIVES, TRIPHASIC alyacen tab 7/7/7 $0 A90, M90 aranelle tab $0 A90, M90 caziant pak $0 A90, M90 cyclafem tab 7/7/7 $0 A90, M90 dasetta tab 7/7/7 $0 A90, M90 enpresse-28 tab $0 A90, M90 leena tab $0 A90, M90 levonest tab $0 A90, M90 myzilra tab $0 A90, M90 necon tab 7/7/7 $0 A90, M90 norgestimate-eth estrad tab 0.18-

35/0.215-35/0.25-35 mg-mcg $0 A90, M90


80

Drug Name Drug Tier Requirements/Limits nortrel tab 7/7/7 $0 A90, M90 pirmella tab 7/7/7 $0 A90, M90 tilia fe tab $0 A90, M90 tri-estaryll tab $0 A90, M90 tri-legest tab fe $0 A90, M90 tri-linyah tab $0 A90, M90 tri-previfem tab $0 A90, M90 tri-sprintec tab $0 A90, M90 trinessa tab $0 A90, M90 trivora-28 tab $0 A90, M90 velivet pak $0 A90, M90 CONTRACEPTIVES, VAGINAL NUVARING MIS $0 A90, M90 DETOXIFICATION AGENTS acetylcysteine inj 200 mg/ml 2 flumazenil iv soln 1 mg/10ml (0.1 mg/ml) 2 fomepizole inj 1 gm/ml (for iv infusion) 2 methylene blue inj 1% 2 sodium thiosulfate inj 25% 2 VORAXAZE INJ 1000UNIT 3 SP ENDOMETRIOSIS danazol cap 50 mg 2 danazol cap 100 mg 2 danazol cap 200 mg 2 SYNAREL SOL 2MG/ML 3 SP ESTROGEN/PROGESTIN, ORAL estradiol & norethindrone acetate tab 0.5-

0.1 mg 2 A90, M90

estradiol & norethindrone acetate tab 1-0.5 mg

2 A90, M90

jinteli tab 1mg-5mcg 2 A90, M90 lopreeza tab 0.5-0.1 2 A90, M90 lopreeza tab 1-0.5mg 2 A90, M90 mimvey lo tab 0.5-0.1 2 A90, M90 mimvey tab 1-0.5mg 2 A90, M90 PREMPHASE TAB 3 A90, M90 PREMPRO TAB 0.3-1.5 3 A90, M90 PREMPRO TAB 0.45-1.5 3 A90, M90 PREMPRO TAB 0.625-5 3 A90, M90 PREMPRO TAB .625-2.5 3 A90, M90 ESTROGEN/PROGESTIN, TRANSDERMAL COMBIPATCH DIS .05/.14 3 A90, M90


81

Drug Name Drug Tier Requirements/Limits COMBIPATCH DIS .05/.25 3 A90, M90 ESTROGENS, INJECTABLE estradiol valerate im in oil 10 mg/ml 2 estradiol valerate im in oil 20 mg/ml 2 estradiol valerate im in oil 40 mg/ml 2 ESTROGENS, ORAL ENJUVIA TAB 0.9MG 3 A90, M90 ENJUVIA TAB 0.625MG 3 A90, M90 estradiol tab 0.5 mg 1 A90, M90 estradiol tab 1 mg 1 A90, M90 estradiol tab 2 mg 1 A90, M90 estropipate tab 0.75 mg 1 A90, M90 estropipate tab 1.5 mg 1 A90, M90 MENEST TAB 0.3MG 4 A90, M90 MENEST TAB 0.625MG 4 A90, M90 MENEST TAB 1.25MG 4 A90, M90 MENEST TAB 2.5MG 4 A90, M90 PREMARIN TAB 0.3MG 3 A90, M90 PREMARIN TAB 0.9MG 3 A90, M90 PREMARIN TAB 0.45MG 3 A90, M90 PREMARIN TAB 0.625MG 3 A90, M90 PREMARIN TAB 1.25MG 3 A90, M90 ESTROGENS, TRANSDERMAL estradiol td patch twice weekly 0.1

mg/24hr 2 A90, M90

estradiol td patch twice weekly 0.05 mg/24hr

2 A90, M90


2 A90, M90


2 A90, M90


2 A90, M90

estradiol td patch weekly 0.1 mg/24hr 2 A90, M90 estradiol td patch weekly 0.05 mg/24hr 2 A90, M90 estradiol td patch weekly 0.06 mg/24hr 2 A90, M90 estradiol td patch weekly 0.025 mg/24hr 2 A90, M90 estradiol td patch weekly 0.075 mg/24hr 2 A90, M90 estradiol td patch weekly 0.0375 mg/24hr

(37.5 mcg/24hr) 2 A90, M90

EVAMIST SPR 1.53MG 3 A90, M90 ESTROGENS, VAGINAL


82

Drug Name Drug Tier Requirements/Limits ESTRACE VAG CRE 0.1MG/GM 3 A90, M90 VAGIFEM TAB 10MCG 3 A90, M90 FERTILITY REGULATORS, OVULATION STIMULANTS,

GONADOTROPINS chorionic gonadotropin for inj 10000 unit 3 SP novarel inj 10000unt 3 SP pregnyl inj 10000unt 3 SP FERTILITY REGULATORS, OVULATION STIMULANTS, SYNTHETIC clomiphene citrate tab 50 mg 3 SP GLUCOCORTICOIDS a-hydrocort inj 100mg 2 betamethasone sod phosphate & acetate

inj susp 6 (3-3) mg/ml 2

DEPO-MEDROL INJ 20MG/ML 4 DEXAMETHASON CON 1MG/ML 4 dexamethasone sodium phosphate inj 4

mg/ml 1

dexamethasone sodium phosphate inj 10 mg/ml

1

dexamethasone soln 0.5 mg/5ml 1 dexamethasone tab 0.5 mg 1 dexamethasone tab 0.75 mg 1 dexamethasone tab 1.5 mg 1 dexamethasone tab 2 mg 1 dexamethasone tab 4 mg 1 dexamethasone tab 6 mg 1 DEXPAK PAK 6 DAY 4 DEXPAK PAK 10 DAY 4 DEXPAK PAK 13 DAY 4 fludrocortisone acetate tab 0.1 mg 2 A90, M90 hydrocortisone tab 5 mg 1 hydrocortisone tab 10 mg 1 hydrocortisone tab 20 mg 1 methylprednisolone acetate inj susp 40

mg/ml 1

methylprednisolone acetate inj susp 80 mg/ml

1

methylprednisolone sodium succinate for inj 40 mg

1 SP

methylprednisolone sodium succinate for inj 125 mg

1 SP

methylprednisolone tab 4 mg 1 methylprednisolone tab 8 mg 1


83

Drug Name Drug Tier Requirements/Limits methylprednisolone tab 16 mg 1 methylprednisolone tab 32 mg 1 methylprednisolone tab therapy pack 4 mg

(21) 1

prednisolone sod phos orally disintegr tab 10 mg (base eq)

2


2


2

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

1

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

1

PREDNISONE CON 5MG/ML 4 prednisone tab 1 mg 1 prednisone tab 2.5 mg 1 prednisone tab 5 mg 1 prednisone tab 10 mg 1 prednisone tab 20 mg 1 prednisone tab therapy pack 5 mg (21) 1 prednisone tab therapy pack 5 mg (48) 1 prednisone tab therapy pack 10 mg (21) 1 prednisone tab therapy pack 10 mg (48) 1 SOLU-CORTEF INJ 1000MG 4 GLUCOSE ELEVATING AGENT GLUCAGEN INJ HYPOKIT 3 GLUCAGON KIT 1MG 3 PROGLYCEM SUS 50MG/ML 4 A90, M90 HUMAN GROWTH HORMONES NORDITROPIN INJ 5/1.5ML 4 PA; SP NORDITROPIN INJ 10/1.5ML 4 PA; SP NORDITROPIN INJ 15/1.5ML 4 PA; SP NORDITROPIN INJ 30/3ML 4 PA; SP NUTROPIN AQ INJ 10MG/2ML 4 PA; SP NUTROPIN AQ INJ 20MG/2ML 4 PA; SP NUTROPIN AQ INJ NUSPIN 5 4 PA; SP OMNITROPE INJ 5.8MG 3 PA; SP OMNITROPE INJ 5/1.5ML 3 PA; SP OMNITROPE INJ 10/1.5ML 3 PA; SP SEROSTIM INJ 4MG 4 PA; SP SEROSTIM INJ 5MG 4 PA; SP SEROSTIM INJ 6MG 4 PA; SP


84

Drug Name Drug Tier Requirements/Limits ZORBTIVE INJ 8.8MG 4 PA; SP HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol cap 0.5 mcg 2 A90, M90 calcitriol cap 0.25 mcg 2 A90, M90 calcitriol inj 1 mcg/ml 2 calcitriol oral soln 1 mcg/ml 2 A90, M90 doxercalciferol cap 0.5 mcg 2 A90, M90 doxercalciferol cap 1 mcg 2 A90, M90 doxercalciferol cap 2.5 mcg 2 A90, M90 doxercalciferol inj 4 mcg/2ml (2 mcg/ml) 2 paricalcitol cap 1 mcg 2 A90, M90 paricalcitol cap 2 mcg 2 A90, M90 paricalcitol cap 4 mcg 2 A90, M90 paricalcitol iv soln 5 mcg/ml 2 INSULIN-LIKE GROWTH FACTOR INCRELEX INJ 40MG/4ML 4 PA; SP LYSOSOMAL STORAGE DISORDERS ALDURAZYME INJ 2.9MG/5M 3 SP CEREZYME INJ 400UNIT 3 SP ELAPRASE INJ 6MG/3ML 3 SP ELELYSO INJ 200UNIT 3 SP FABRAZYME INJ 35MG 3 SP LUMIZYME INJ 50MG 3 SP NAGLAZYME INJ 1MG/ML 3 SP VIMIZIM INJ 5MG/5ML 3 SP VPRIV INJ 400UNIT 3 SP ZAVESCA CAP 100MG 4 SP MISCELLANEOUS ADAGEN INJ 250/ML 3 SP cabergoline tab 0.5 mg 2 CARBAGLU TAB 200MG 3 SP CYSTADANE POW 3 SP H.P. ACTHAR INJ 80UNIT 3 SP levocarnitine inj 200 mg/ml 2 levocarnitine oral soln 1 gm/10ml (10%) 2 A90, M90 levocarnitine tab 330 mg 2 A90, M90 LUPR DEP-PED INJ 7.5MG 3 SP LUPR DEP-PED INJ 11.25MG 3 SP LUPR DEP-PED INJ 15MG 3 PA; SP methylergonovine maleate inj 0.2 mg/ml 2 methylergonovine maleate tab 0.2 mg 2 MYALEPT INJ 11.3MG 3 PA; SP


85

Drug Name Drug Tier Requirements/Limits nac 600 cap 2 octreotide acetate inj 50 mcg/ml (0.05

mg/ml) 3 SP

octreotide acetate inj 100 mcg/ml (0.1 mg/ml)

3 SP


3 SP


3 SP

octreotide acetate inj 1000 mcg/ml (1 mg/ml)

3 SP

ORFADIN CAP 2MG 3 SP ORFADIN CAP 5MG 3 SP ORFADIN CAP 10MG 3 SP oxytocin inj 10 unit/ml 2 RAVICTI LIQ 1.1GM/ML 3 PA; SP SANDOSTATIN KIT LAR 10MG 3 SP SANDOSTATIN KIT LAR 20MG 3 SP SANDOSTATIN KIT LAR 30MG 3 SP SIGNIFOR INJ 0.3MG/ML 3 SP SIGNIFOR INJ 0.6MG/ML 3 SP SIGNIFOR INJ 0.9MG/ML 3 SP SOMATULINE INJ 60/0.2ML 3 SP SOMATULINE INJ 90/0.3ML 3 SP SOMATULINE INJ 120/.5ML 3 SP SOMAVERT INJ 10MG 3 PA; SP SOMAVERT INJ 15MG 3 PA; SP SOMAVERT INJ 20MG 3 PA; SP SOMAVERT INJ 25MG 3 PA; SP SOMAVERT INJ 30MG 3 PA; SP SUPPRELIN LA KIT 50MG 3 PA; SP SYPRINE CAP 250MG 4 PHENYLKETONURIA TREATMENT AGENTS KUVAN TAB 100MG 3 SP PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) cap

667 mg (169 mg ca) 2 A90, M90

calcium acetate (phosphate binder) tab 667 mg

2 A90, M90

FOSRENOL CHW 500MG 3 A90, M90 FOSRENOL CHW 750MG 3 A90, M90 FOSRENOL CHW 1000MG 3 A90, M90 PHOSLYRA SOL 4 A90, M90


86

Drug Name Drug Tier Requirements/Limits RENAGEL TAB 400MG 4 A90, M90 RENAGEL TAB 800MG 4 A90, M90 RENVELA PAK 0.8GM 3 A90, M90 RENVELA PAK 2.4GM 3 A90, M90 RENVELA TAB 800MG 3 A90, M90 PROGESTINS, INJECTABLE MAKENA INJ 250MG/ML 3 PA; SP progesterone im in oil 50 mg/ml 2 PROGESTINS, ORAL medroxyprogesterone acetate tab 2.5 mg 1 A90, M90 medroxyprogesterone acetate tab 5 mg 1 A90, M90 medroxyprogesterone acetate tab 10 mg 1 A90, M90 norethindrone acetate tab 5 mg 2 A90, M90 progesterone micronized cap 100 mg 2 A90, M90 progesterone micronized cap 200 mg 2 A90, M90 PROGESTINS, VAGINAL CRINONE GEL 4% VAG 3 SP CRINONE GEL 8% VAG 4 SP SELECTIVE ESTROGEN RECEPTOR MODULATOR raloxifene hcl tab 60 mg $0 A90, M90 THYROID AGENTS, ANTITHYROID AGENTS methimazole tab 5 mg 2 A90, M90 methimazole tab 10 mg 2 A90, M90 propylthiouracil tab 50 mg 2 A90, M90 THYROID AGENTS, THYROID SUPPLEMENTS ARMOUR THYRO TAB 15MG 3 A90, M90 ARMOUR THYRO TAB 120MG 3 A90, M90 ARMOUR THYRO TAB 180MG 3 A90, M90 ARMOUR THYRO TAB 240MG 3 A90, M90 ARMOUR THYRO TAB 300MG 3 A90, M90 levothyroxine sodium tab 25 mcg 1 A90, M90 levothyroxine sodium tab 50 mcg 1 A90, M90 levothyroxine sodium tab 75 mcg 1 A90, M90 levothyroxine sodium tab 88 mcg 1 A90, M90 levothyroxine sodium tab 100 mcg 1 A90, M90 levothyroxine sodium tab 112 mcg 1 A90, M90 levothyroxine sodium tab 125 mcg 1 A90, M90 levothyroxine sodium tab 137 mcg 1 A90, M90 levothyroxine sodium tab 150 mcg 1 A90, M90 levothyroxine sodium tab 175 mcg 1 A90, M90 levothyroxine sodium tab 200 mcg 1 A90, M90


87

Drug Name Drug Tier Requirements/Limits levothyroxine sodium tab 300 mcg 2 A90, M90 levoxyl tab 25mcg 1 A90, M90 levoxyl tab 50mcg 1 A90, M90 levoxyl tab 75mcg 1 A90, M90 levoxyl tab 88mcg 1 A90, M90 levoxyl tab 100mcg 1 A90, M90 levoxyl tab 112mcg 1 A90, M90 levoxyl tab 125mcg 1 A90, M90 levoxyl tab 137mcg 1 A90, M90 levoxyl tab 150mcg 1 A90, M90 levoxyl tab 175mcg 1 A90, M90 levoxyl tab 200mcg 1 A90, M90 liothyronine sodium iv soln 10 mcg/ml 2 liothyronine sodium tab 5 mcg 2 A90, M90 liothyronine sodium tab 25 mcg 2 A90, M90 liothyronine sodium tab 50 mcg 2 A90, M90 np thyroid tab 30mg 2 A90, M90 np thyroid tab 60mg 2 A90, M90 np thyroid tab 90mg 2 A90, M90 THYROLAR-1 TAB 60MG 4 A90, M90 THYROLAR-1/2 TAB 30MG 4 A90, M90 THYROLAR-1/4 TAB 15MG 4 A90, M90 THYROLAR-2 TAB 120MG 4 A90, M90 THYROLAR-3 TAB 180MG 4 A90, M90 TIROSINT CAP 13MCG 4 A90, M90 TIROSINT CAP 25MCG 4 A90, M90 TIROSINT CAP 50MCG 4 A90, M90 TIROSINT CAP 75MCG 4 A90, M90 TIROSINT CAP 88MCG 4 A90, M90 TIROSINT CAP 100MCG 4 A90, M90 TIROSINT CAP 112MCG 4 A90, M90 TIROSINT CAP 125MCG 4 A90, M90 TIROSINT CAP 137MCG 4 A90, M90 TIROSINT CAP 150MCG 4 A90, M90 unithroid tab 25mcg 1 A90, M90 unithroid tab 50mcg 1 A90, M90 unithroid tab 75mcg 1 A90, M90 unithroid tab 88mcg 1 A90, M90 unithroid tab 100mcg 1 A90, M90 unithroid tab 112mcg 1 A90, M90 unithroid tab 125mcg 1 A90, M90 unithroid tab 137mcg 1 A90, M90


88

Drug Name Drug Tier Requirements/Limits unithroid tab 150mcg 1 A90, M90 unithroid tab 175mcg 1 A90, M90 unithroid tab 200mcg 1 A90, M90 unithroid tab 300mcg 2 A90, M90 VASOPRESSIN RECEPTOR ANTAGONISTS SAMSCA TAB 15MG 3 SP SAMSCA TAB 30MG 3 SP VASOPRESSINS desmopressin acetate inj 4 mcg/ml 2 desmopressin acetate nasal soln 0.01%

(refrigerated) 2 A90, M90

desmopressin acetate nasal spray soln 0.01% (refrigerated)

2 A90, M90

desmopressin acetate tab 0.1 mg 2 A90, M90 desmopressin acetate tab 0.2 mg 2 A90, M90 STIMATE SOL 1.5MG/ML 3 SP vasopressin inj 20 unit/ml 2 GASTROINTESTINAL ANTIDIARRHEALS diphenoxylate w/ atropine tab 2.5-0.025

mg 2

opium tincture 1% (10 mg/ml) (morphine equiv)

2

ANTIEMETICS ALOXI INJ 0.25MG/5 3 QL (1 vial / 14 days) ANZEMET TAB 50MG 4 QL (1 tab / 30 days) ANZEMET TAB 100MG 4 QL (1 tab / 30 days) CESAMET CAP 1MG 4 QL (18 caps / 14 days),

PA compazine sup 25mg 2 compro sup 25mg 2 DIMENHYDRIN INJ 50MG/ML 3 dronabinol cap 2.5 mg 2 QL (60 caps / 30 days) dronabinol cap 5 mg 2 QL (60 caps / 30 days) dronabinol cap 10 mg 2 QL (60 caps / 30 days) droperidol inj 2.5 mg/ml 2 EMEND CAP 40MG 3 QL (1 cap / 30 days) EMEND CAP 80MG 3 QL (8 caps / 30 days) EMEND CAP 125MG 3 QL (4 caps / 30 days) EMEND PAK 80 & 125 3 QL (4 packs / 30 days) granisetron hcl inj 0.1 mg/ml 2 granisetron hcl inj 1 mg/ml 2


89

Drug Name Drug Tier Requirements/Limits granisetron hcl tab 1 mg 2 QL (2 tabs / 30 days) metoclopramide hcl inj 5 mg/ml 1 metoclopramide hcl soln 5 mg/5ml (10

mg/10ml) 1

metoclopramide hcl tab 5 mg 1 metoclopramide hcl tab 10 mg 1 ondansetron hcl inj 4 mg/2ml (2 mg/ml) 2 SP ondansetron hcl inj 40 mg/20ml (2 mg/ml) 2 SP ondansetron hcl oral soln 4 mg/5ml 2 QL (150 mL / 30 days) ondansetron hcl tab 4 mg 2 QL (30 tabs / 30 days) ondansetron hcl tab 8 mg 2 QL (30 tabs / 30 days) ondansetron hcl tab 24 mg 2 ondansetron orally disintegrating tab 4 mg 2 QL (30 tabs / 30 days) ondansetron orally disintegrating tab 8 mg 2 QL (30 tabs / 30 days) phenadoz sup 12.5mg 2 phenadoz sup 25mg 2 phenergan sup 12.5mg 2 phenergan sup 25mg 2 prochlorperazine maleate tab 5 mg (base

equivalent) 2 A90

prochlorperazine maleate tab 10 mg (base equivalent)

1 A90

prochlorperazine suppos 25 mg 2 promethazine hcl inj 25 mg/ml 2 promethazine hcl inj 50 mg/ml 2 promethazine hcl suppos 12.5 mg 2 promethazine hcl suppos 25 mg 2 promethazine hcl syrup 6.25 mg/5ml 1 promethazine hcl tab 12.5 mg 2 promethazine hcl tab 25 mg 1 promethazine hcl tab 50 mg 2 promethegan sup 12.5mg 2 promethegan sup 25mg 2 promethegan sup 50mg 2 SANCUSO DIS 3.1MG 3 QL (1 patch / 28 days) TRANSDERM-SC DIS 1MG 3 trimethobenzamide hcl cap 300 mg 2 VARUBI TAB 90MG 4 QL ANTISPASMODICS atropine sulfate inj 0.1 mg/ml 2 atropine sulfate inj 0.4 mg/ml 2 atropine sulfate inj 1 mg/ml 2 CUVPOSA SOL 1MG/5ML 4 PA; A90, M90


90

Drug Name Drug Tier Requirements/Limits dicyclomine hcl cap 10 mg 1 dicyclomine hcl oral soln 10 mg/5ml 1 dicyclomine hcl tab 20 mg 1 ed-spaz tab 0.125mg 2 A90, M90 GASTRINEX NF CAP 4 glycopyrrolate inj 0.2 mg/ml 2 glycopyrrolate tab 1 mg 2 glycopyrrolate tab 2 mg 2 hyoscyamine sulfate elixir 0.125 mg/5ml 2 A90, M90 hyoscyamine sulfate soln 0.125 mg/ml 2 A90, M90 hyoscyamine sulfate tab 0.125 mg 2 A90, M90 hyoscyamine sulfate tab disp 0.125 mg 2 A90, M90 hyoscyamine sulfate tab sl 0.125 mg 2 A90, M90 hyoscyamine sulfate tab sr 12hr 0.375 mg 2 A90, M90 methscopolamine bromide tab 2.5 mg 2 methscopolamine bromide tab 5 mg 2 nulev tab 0.125mg 2 A90, M90 oscimin sr tab 0.375mg 2 A90, M90 oscimin sub 0.125mg 2 A90, M90 oscimin tab 0.125mg 2 A90, M90 symax-sl sub 0.125mg 2 A90, M90 symax-sr tab 0.375mg 2 A90, M90 CHOLELITHOLYTICS CHENODAL TAB 250MG 3 SP ursodiol cap 300 mg 2 A90, M90 ursodiol tab 250 mg 2 A90, M90 ursodiol tab 500 mg 2 A90, M90 H2-RECEPTOR ANTAGONISTS cimetidine hcl soln 300 mg/5ml 2 A90, M90 cimetidine tab 200 mg 1 cimetidine tab 300 mg 1 A90, M90 cimetidine tab 400 mg 1 A90, M90 cimetidine tab 800 mg 1 A90, M90 famotidine for susp 40 mg/5ml 2 A90, M90 famotidine inj 200 mg/20ml 2 SP famotidine tab 20 mg 1 A90, M90 famotidine tab 40 mg 2 A90, M90 nizatidine cap 150 mg 2 A90, M90 nizatidine cap 300 mg 2 A90, M90 nizatidine oral soln 15 mg/ml 2 A90, M90 ranitidine hcl cap 150 mg 2 A90, M90 ranitidine hcl cap 300 mg 2 A90, M90


91

Drug Name Drug Tier Requirements/Limits ranitidine hcl inj 50 mg/2ml (25 mg/ml) 2 SP ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 2 A90, M90 ranitidine hcl tab 150 mg 2 A90, M90 ranitidine hcl tab 300 mg 2 A90, M90 INFLAMMATORY BOWEL DISEASE, ORAL AGENTS ASACOL HD TAB 800MG 3 balsalazide disodium cap 750 mg 2 budesonide delayed release particles cap 3

mg 2

DELZICOL CAP 400MG 4 A90, M90 DIPENTUM CAP 250MG 4 A90, M90 LIALDA TAB 1.2GM 4 PENTASA CAP 250MG CR 3 A90, M90 PENTASA CAP 500MG CR 3 A90, M90 sulfasalazine tab 500 mg 2 A90, M90 sulfasalazine tab delayed release 500 mg 2 A90, M90 INFLAMMATORY BOWEL DISEASE, RECTAL AGENTS CANASA SUP 1000MG 3 colocort ene 100mg 2 CORTIFOAM AER 90MG 3 hydrocortisone enema 100 mg/60ml 2 mesalamine enema 4 gm 2 IRRITABLE BOWEL SYNDROME WITH CONSTIPATION AMITIZA CAP 8MCG 4 QL (60 caps / 30 days),

PA; A90, M90 AMITIZA CAP 24MCG 4 QL (60 caps / 30 days),

PA; A90, M90 LINZESS CAP 145MCG 4 QL (30 caps / 30 days),

PA; A90, M90 LINZESS CAP 290MCG 4 QL (30 caps / 30 days),

PA; A90, M90 IRRITABLE BOWEL SYNDROME WITH DIARRHEA alosetron hcl tab 0.5 mg (base equiv) 2 alosetron hcl tab 1 mg (base equiv) 2 VIBERZI TAB 75MG 4 PA; QL VIBERZI TAB 100MG 4 PA; QL LAXATIVES constulose sol 10gm/15 1 A90, M90 gavilyte-c sol $0 gavilyte-g sol $0 gavilyte-n sol flav pk $0 lactulose solution 10 gm/15ml 2 A90, M90


92

Drug Name Drug Tier Requirements/Limits MOVIPREP SOL $0 OSMOPREP TAB 1.5GM 4 peg 3350-kcl-na bicarb-nacl-na sulfate for

soln 236 gm $0

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

$0

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

$0

pegylax pow 2 polyethylene glycol 3350 oral powder 2 PREPOPIK PAK $0 SUPREP BOWEL SOL PREP $0 trilyte sol $0 MISCELLANEOUS BUPHENYL TAB 500MG 3 SP CARAFATE SUS 1GM/10ML 4 A90, M90 cromolyn sodium oral conc 100 mg/5ml 2 A90, M90 enulose sol 10gm/15 2 A90, M90 GATTEX KIT 5MG 4 PA; SP generlac sol 10gm/15 2 A90, M90 KEPIVANCE INJ 6.25MG 3 SP RECTIV OIN 0.4% 3 sodium phenylbutyrate oral powder 3

gm/teaspoonful 3 SP

SUCRAID SOL 8500/ML 3 A90, M90 sucralfate tab 1 gm 1 A90, M90 OPIOID-INDUCED CONSTIPATION MOVANTIK TAB 12.5MG 4 QL, PA MOVANTIK TAB 25MG 4 QL, PA RELISTOR INJ 8/0.4ML 3 PA RELISTOR INJ 12/0.6ML 3 PA PANCREATIC ENZYMES CREON CAP 3000UNIT 3 A90, M90 CREON CAP 6000UNIT 3 A90, M90 CREON CAP 12000UNT 3 A90, M90 CREON CAP 24000UNT 3 A90, M90 CREON CAP 36000UNT 3 A90, M90 ZENPEP CAP 3000UNIT 4 A90, M90 ZENPEP CAP 5000UNIT 4 A90, M90 ZENPEP CAP 10000UNT 4 A90, M90 ZENPEP CAP 15000UNT 4 A90, M90 ZENPEP CAP 20000UNT 4 A90, M90


93

Drug Name Drug Tier Requirements/Limits ZENPEP CAP 25000UNT 4 A90, M90 ZENPEP CAP 40000UNT 4 A90, M90 PROSTAGLANDINS misoprostol tab 100 mcg 2 A90, M90 misoprostol tab 200 mcg 2 A90, M90 PROTON PUMP INHIBITORS (PPI) ACIPHEX SPR CAP 5MG 4 QL (30 caps / 30 days),

ST; A90, M90 ACIPHEX SPR CAP 10MG 4 QL (30 caps / 30 days),

ST; A90, M90 DEXILANT CAP 30MG DR 4 QL (30 ea / 30 days),

ST; A90, M90 DEXILANT CAP 60MG DR 4 QL (30 ea / 30 days),

ST; A90, M90 esomeprazole sodium for intravenous soln

20 mg (base equiv) 2

esomeprazole sodium for intravenous soln 40 mg (base equiv)

2

lansoprazole cap delayed release 15 mg 2 QL (120 ea / 30 days), ST; A90, M90

NEXIUM 24HR CAP 20MG 1 QL (120 caps / 30 days), ST; A90, M90

NEXIUM GRA 2.5MG DR 3 QL (30 packets / 30 days), ST; A90, M90

NEXIUM GRA 5MG DR 3 QL (30 packets / 30 days), ST; A90, M90




omeprazole cap delayed release 10 mg 1 QL (30 ea / 30 days); A90, M90



omeprazole-sodium bicarbonate cap 20-1100 mg

2 QL (30 caps / 30 days), ST; A90, M90

omeprazole-sodium bicarbonate cap 40-1100 mg

2 QL (30 caps / 30 days), ST; A90, M90

pantoprazole sodium ec tab 20 mg (base equiv)

1 QL (60 ea / 30 days); A90, M90


94

Drug Name Drug Tier Requirements/Limits pantoprazole sodium ec tab 40 mg (base

equiv) 1 QL (60 ea / 30 days);

A90, M90 rabeprazole sodium ec tab 20 mg 2 QL (30 ea / 30 days),

ST; A90, M90 SALIVA STIMULANTS cevimeline hcl cap 30 mg 2 A90, M90 pilocarpine hcl tab 5 mg 2 A90, M90 pilocarpine hcl tab 7.5 mg 2 A90, M90 STEROIDS, RECTAL ana-lex kit 2 hydrocortisone acetate w/ pramoxine rectal

cream 1-1% 2

lidocaine-hydrocortisone acetate rectal cream 3-0.5%

2

lidocaine-hydrocortisone acetate rectal cream kit 2-2%

2

lidocaine-hydrocortisone acetate rectal cream kit 3-1%

2

lidocaine-hydrocortisone acetate rectal gel kit 3-2.5%

2

procto-pak cre 1% 2 proctozone cre -hc 2.5% 2 ULCER THERAPY COMBINATION amoxicillin cap-clarithro tab-lansopraz cap

dr therapy pack 2

OMECLAMOX- MIS PAK 4 PYLERA CAP 4 GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl tab sr 24hr 10 mg 2 QL (30 ea / 30 days);

A90, M90 finasteride tab 5 mg 1 A90, M90 finasteride tab 5 mg 2 A90, M90 RAPAFLO CAP 4MG 3 QL (30 caps / 30 days),

ST; A90, M90 RAPAFLO CAP 8MG 3 QL (30 caps / 30 days),

ST; A90, M90 tamsulosin hcl cap 0.4 mg 1 QL (60 caps / 30 days);

A90, M90 ERECTILE DYSFUNCTION, PHOSPHODIESTERASE INHIBITORS CIALIS TAB 2.5MG 3 QL (4 tabs / 30 days);

A90


95

Drug Name Drug Tier Requirements/Limits CIALIS TAB 5MG 3 QL (4 tabs / 30 days);

A90 CIALIS TAB 10MG 3 QL (4 tabs / 30 days) CIALIS TAB 20MG 3 QL (4 tabs / 30 days) VIAGRA TAB 25MG 3 QL (4 tabs / 30 days) VIAGRA TAB 50MG 3 QL (4 tabs / 30 days) VIAGRA TAB 100MG 3 QL (4 tabs / 30 days) MISCELLANEOUS bethanechol chloride tab 5 mg 2 bethanechol chloride tab 10 mg 2 bethanechol chloride tab 25 mg 2 bethanechol chloride tab 50 mg 2 CYSTAGON CAP 50MG 4 SP CYSTAGON CAP 150MG 4 SP cytra k gra crystals 2 cytra-2 sol 1 ELMIRON CAP 100MG 4 hyophen tab 2 mannitol iv soln 5% 2 mannitol iv soln 10% 2 mannitol iv soln 15% 2 mannitol iv soln 20% 2 mannitol iv soln 25% 2 methenamine hippurate tab 1 gm 2 osmitrol inj 5% 2 osmitrol inj 10% 2 osmitrol inj 15% 2 phenazopyridine hcl tab 100 mg 1 phenazopyridine hcl tab 200 mg 1 phosphasal tab 2 pot & sod citrates w/ cit ac soln 550-500-

334 mg/5ml 2

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

2

potassium citrate tab cr 5 meq (540 mg) 2 potassium citrate tab cr 10 meq (1080 mg)2 potassium citrate tab cr 15 meq (1620 mg)2 PROCYSBI CAP 25MG 4 SP PROCYSBI CAP 75MG 4 SP relagard gel 3 sodium citrate & citric acid soln 500-334

mg/5ml 1

ur n-c tab 2


96

Drug Name Drug Tier Requirements/Limits urelle tab 2 uretron d/s tab 2 uribel cap 118mg 2 uro-mp cap 118mg 2 uroav-81 tab 2 uryl tab 2 ustell cap 2 uta cap 120mg 2 utira-c tab 2 URINARY ANTISPASMODICS darifenacin hydrobromide tab sr 24hr 7.5

mg (base equiv) 2 QL (30 ea / 30 days),

ST; A90, M90 darifenacin hydrobromide tab sr 24hr 15

mg (base equiv) 2 QL (30 ea / 30 days),

ST; A90, M90 flavoxate hcl tab 100 mg 2 A90, M90 GELNIQUE GEL 10% 3 QL (30 gm / 30 days);

A90, M90 MYRBETRIQ TAB 25MG 3 QL (30 ea / 30 days),

ST; A90, M90 MYRBETRIQ TAB 50MG 3 QL (30 ea / 30 days),

ST; A90, M90 oxybutynin chloride syrup 5 mg/5ml 2 A90, M90 oxybutynin chloride tab 5 mg 2 A90, M90 oxybutynin chloride tab sr 24hr 5 mg 2 QL (30 ea / 30 days);

A90, M90 oxybutynin chloride tab sr 24hr 10 mg 2 QL (60 ea / 30 days);

A90, M90 oxybutynin chloride tab sr 24hr 15 mg 2 QL (60 ea / 30 days);

A90, M90 OXYTROL DIS 3.9MG/24 3 QL (8 ea / 28 days);

A90, M90 tolterodine tartrate cap sr 24hr 2 mg 2 QL (30 ea / 30 days);

A90, M90 tolterodine tartrate cap sr 24hr 4 mg 2 QL (30 ea / 30 days);

A90, M90 tolterodine tartrate tab 1 mg 2 A90, M90 tolterodine tartrate tab 2 mg 2 A90, M90 TOVIAZ TAB 4MG 3 QL (30 ea / 30 days),

ST; A90, M90 TOVIAZ TAB 8MG 3 QL (30 ea / 30 days),

ST; A90, M90 trospium chloride cap sr 24hr 60 mg 2 QL (30 ea / 30 days);

A90, M90


97

Drug Name Drug Tier Requirements/Limits trospium chloride tab 20 mg 2 QL (60 tabs / 30 days);

A90, M90 VESICARE TAB 5MG 3 QL (30 tabs / 30 days),

ST; A90, M90 VESICARE TAB 10MG 3 QL (30 tabs / 30 days),

ST; A90, M90 VAGINAL ANTI-INFECTIVES AVC CRE 15% 4 clindamycin phosphate vaginal cream 2% 2 GYNAZOLE-1 CRE 2% 4 metronidazole vaginal gel 0.75% 2 terconazole vaginal cream 0.4% 2 ST terconazole vaginal cream 0.8% 2 ST terconazole vaginal suppos 80 mg 2 ST vandazole gel 0.75% 2 zazole cre 0.8% 2 ST zazole sup 80mg 2 ST HEMATOLOGIC ANTICOAGULANTS, INJECTABLE argatroban inj 250 mg/2.5ml (concentrate

for iv infusion) 2

enoxaparin sodium inj 30 mg/0.3ml 2 SP enoxaparin sodium inj 40 mg/0.4ml 2 SP enoxaparin sodium inj 60 mg/0.6ml 2 SP enoxaparin sodium inj 80 mg/0.8ml 2 SP enoxaparin sodium inj 100 mg/ml 2 SP enoxaparin sodium inj 120 mg/0.8ml 2 SP enoxaparin sodium inj 150 mg/ml 2 SP enoxaparin sodium inj 300 mg/3ml 2 SP fondaparinux sodium subcutaneous inj 2.5

mg/0.5ml 2

fondaparinux sodium subcutaneous inj 5 mg/0.4ml

2

fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml

2

fondaparinux sodium subcutaneous inj 10 mg/0.8ml

2

FRAGMIN INJ 2500/0.2 4 FRAGMIN INJ 5000/0.2 4 FRAGMIN INJ 7500/0.3 4 FRAGMIN INJ 10000/ML 4 FRAGMIN INJ 12500UNT 4 FRAGMIN INJ 15000UNT 4


98

Drug Name Drug Tier Requirements/Limits FRAGMIN INJ 18000UNT 4 FRAGMIN INJ 95000UNT 4 heparin sodium (porcine) inj 1000 unit/ml 2 heparin sodium (porcine) inj 5000 unit/ml 2 heparin sodium (porcine) inj 10000 unit/ml2 heparin sodium (porcine) inj 20000 unit/ml2 heparin sodium (porcine) pf inj 5000

unit/0.5ml 2

ANTICOAGULANTS, ORAL ELIQUIS TAB 2.5MG 3 QL (60 tabs / 30 days),

PA; A90, M90 ELIQUIS TAB 5MG 3 QL (60 tabs / 30 days),

PA; A90, M90 jantoven tab 1mg 1 A90, M90 jantoven tab 2.5mg 1 A90, M90 jantoven tab 2mg 1 A90, M90 jantoven tab 3mg 1 A90, M90 jantoven tab 4mg 1 A90, M90 jantoven tab 5mg 1 A90, M90 jantoven tab 6mg 1 A90, M90 jantoven tab 7.5mg 1 A90, M90 jantoven tab 10mg 1 A90, M90 PRADAXA CAP 75MG 3 QL (60 caps / 30 days),

PA; A90, M90 PRADAXA CAP 150MG 4 QL (60 caps / 30 days),

PA; A90, M90 SAVAYSA TAB 15MG 3 PA; QL; A90, M90 SAVAYSA TAB 30MG 3 PA; QL; A90, M90 SAVAYSA TAB 60MG 3 PA; QL; A90, M90 warfarin sodium tab 1 mg 1 A90, M90 warfarin sodium tab 2 mg 1 A90, M90 warfarin sodium tab 2.5 mg 1 A90, M90 warfarin sodium tab 3 mg 1 A90, M90 warfarin sodium tab 4 mg 1 A90, M90 warfarin sodium tab 5 mg 1 A90, M90 warfarin sodium tab 6 mg 1 A90, M90 warfarin sodium tab 7.5 mg 1 A90, M90 warfarin sodium tab 10 mg 1 A90, M90 XARELTO STAR TAB 15/20MG 3 QL (1 kit / 30 days), PA XARELTO TAB 10MG 3 QL (1 fill per year), PA;

A90, M90 XARELTO TAB 15MG 3 QL (30 tabs / 30 days),

PA; A90, M90


99

Drug Name Drug Tier Requirements/Limits XARELTO TAB 20MG 3 QL (30 tabs / 30 days),

PA; A90, M90 ANTIHEMOPHILIC AGENTS ADVATE INJ 250UNIT 3 SP ADVATE INJ 500UNIT 3 SP ADVATE INJ 1000UNIT 3 SP ADVATE INJ 1500UNIT 3 SP ADVATE INJ 2000UNIT 3 SP ADVATE INJ 3000UNIT 3 SP ADVATE INJ 4000UNIT 3 SP ALPHANATE INJ VWF/HUM 3 SP ALPHANINE SD INJ 500UNIT 3 SP ALPHANINE SD INJ 1000UNIT 3 SP ALPHANINE SD INJ 1500UNIT 3 SP BENEFIX INJ 250UNIT 3 SP BENEFIX INJ 500UNIT 3 SP BENEFIX INJ 1000UNIT 3 SP BENEFIX INJ 2000UNIT 3 SP BENEFIX INJ 3000UNIT 3 SP CORIFACT KIT 3 SP ELOCTATE INJ 250UNIT 4 SP ELOCTATE INJ 500UNIT 4 SP ELOCTATE INJ 750UNIT 4 SP ELOCTATE INJ 1000UNIT 4 SP ELOCTATE INJ 1500UNIT 4 SP ELOCTATE INJ 2000UNIT 4 SP ELOCTATE INJ 3000UNIT 4 SP FEIBA NF INJ 3 SP HELIXATE FS INJ 250UNIT 3 SP HELIXATE FS INJ 500UNIT 3 SP HELIXATE FS INJ 2000UNIT 3 SP HELIXATE FS INJ 3000UNIT 3 SP HEMOFIL M INJ 1000UNIT 3 SP HEMOFIL M INJ 1700UNIT 3 SP HUMATE-P SOL 250-600 3 SP HUMATE-P SOL 2400UNIT 3 SP KOATE-DVI INJ 250UNIT 3 SP KOATE-DVI INJ 1000UNIT 3 SP KOGENATE FS INJ 250UNIT 3 SP KOGENATE FS INJ 500UNIT 3 SP KOGENATE FS INJ 1000UNIT 3 SP KOGENATE FS INJ 3000UNIT 3 SP


100

Drug Name Drug Tier Requirements/Limits MONOCLATE-P INJ 1000UNIT 3 SP MONOCLATE-P INJ 1500UNIT 3 SP MONONINE INJ 500UNIT 3 SP MONONINE INJ 1000UNIT 3 SP NOVOSEVEN RT INJ 1MG 3 SP PROFILNINE INJ 500UNIT 3 SP PROFILNINE INJ 1500UNIT 3 SP RECOMBINATE INJ 3 SP RECOMBINATE INJ 220-400 3 SP RECOMBINATE INJ 401-800 3 SP RECOMBINATE INJ 801-1240 3 SP RIASTAP SOL 1GM 3 SP TRETTEN INJ 3 SP XYNTHA INJ 250UNIT 3 SP XYNTHA INJ 500UNIT 3 SP XYNTHA INJ 1000UNIT 3 SP XYNTHA INJ 2000UNIT 3 SP XYNTHA SOLOF INJ 500UNIT 3 SP XYNTHA SOLOF INJ 1000UNIT 3 SP XYNTHA SOLOF INJ 2000UNIT 3 SP XYNTHA SOLOF INJ 3000UNIT 3 SP XYNTHA SOLOF KIT 250UNIT 3 SP HEMATOPOIETIC GROWTH FACTORS ARANESP INJ 25MCG 4 PA; SP ARANESP INJ 40MCG 4 PA; SP ARANESP INJ 60MCG 4 PA; SP ARANESP INJ 100MCG 4 PA; SP ARANESP INJ 150MCG 4 PA; SP ARANESP INJ 200MCG 4 PA; SP ARANESP INJ 300MCG 4 PA; SP ARANESP INJ 500MCG 4 PA; SP EPOGEN INJ 2000/ML 4 PA; SP EPOGEN INJ 3000/ML 4 PA; SP EPOGEN INJ 4000/ML 4 PA; SP EPOGEN INJ 10000/ML 4 PA; SP EPOGEN INJ 20000/ML 4 PA; SP LEUKINE INJ 250MCG 3 PA; SP NEULASTA INJ 6MG/0.6M 3 PA; SP NEUPOGEN INJ 300/0.5 3 PA; SP NEUPOGEN INJ 300MCG 3 PA; SP NEUPOGEN INJ 480/0.8 3 PA; SP PROCRIT INJ 2000/ML 3 PA; SP


101

Drug Name Drug Tier Requirements/Limits PROCRIT INJ 3000/ML 3 PA; SP PROCRIT INJ 4000/ML 3 PA; SP PROCRIT INJ 10000/ML 3 PA; SP PROCRIT INJ 20000/ML 3 PA; SP PROCRIT INJ 40000/ML 3 PA; SP HEMOSTATICS, SYSTEMIC AMICAR TAB 500MG 3 aminocaproic acid inj 250 mg/ml 2 tranexamic acid iv soln 1000 mg/10ml

(100 mg/ml) 2

tranexamic acid tab 650 mg 2 QL HEREDITARY ANGIOEDEMA AGENTS BERINERT INJ 500UNIT 3 SP CINRYZE SOL 500 UNIT 4 SP FIRAZYR INJ 30MG/3ML 4 SP KALBITOR INJ 10MG/ML 4 SP IDIOPATHIC THROMBOCYTOPENIC PURPURA NPLATE INJ 250MCG 3 PA; SP PROMACTA TAB 12.5MG 3 PA; SP PROMACTA TAB 25MG 3 PA; SP PROMACTA TAB 50MG 3 PA; SP PROMACTA TAB 75MG 3 PA; SP MISCELLANEOUS CEPROTIN INJ 500 UNIT 4 SP CHEMET CAP 100MG 3 cilostazol tab 50 mg 2 A90, M90 cilostazol tab 100 mg 2 A90, M90 deferoxamine mesylate for inj 500 mg 2 SP EXJADE TAB 125MG 3 PA; SP EXJADE TAB 250MG 3 PA; SP EXJADE TAB 500MG 3 PA; SP FERRIPROX TAB 500MG 4 PA; SP pentoxifylline tab cr 400 mg 2 A90, M90 THROMBAT III INJ 500UNIT 4 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS SOLIRIS INJ 10MG/ML 3 PA; SP PLATELET AGGREGATION INHIBITORS AGGRASTAT INJ 5/100ML 4 AGGRENOX CAP 25-200MG 3 A90, M90 aspir-low tab 81mg ec $0 aspirin chew tab 81 mg $0 aspirin low tab 81mg ec $0


102

Drug Name Drug Tier Requirements/Limits aspirin tab 325 mg $0 aspirin tab delayed release 325 mg $0 bayer asa tab 325mg $0 bayer low chw 81mg $0 BRILINTA TAB 90MG 4 QL (60 tabs / 30 days);

A90, M90 clopidogrel bisulfate tab 75 mg (base

equiv) 2 A90, M90

clopidogrel bisulfate tab 300 mg (base equiv)

2

dipyridamole tab 25 mg 2 A90, M90 dipyridamole tab 50 mg 2 A90, M90 dipyridamole tab 75 mg 2 A90, M90 ecpirin tab 325mg ec $0 EFFIENT TAB 5MG 3 A90, M90 EFFIENT TAB 10MG 3 A90, M90 miniprin low tab 81mg ec $0 st joseph chw 75mg adu $0 ZONTIVITY TAB 2.08MG 3 PA; A90, M90 PLATELET SYNTHESIS INHIBITOR anagrelide hcl cap 0.5 mg 2 A90, M90 anagrelide hcl cap 1 mg 2 A90, M90 STEM CELL MOBILIZERS MOZOBIL INJ 3 PA; SP IMMUNOLOGIC AGENTS BIOLOGIC DISEASE-MODIFYING AGENTS CIMZIA KIT 3 PA; SP CIMZIA PREFL KIT 200MG/ML 3 PA; SP ENBREL INJ 25/0.5ML 4 PA; SP ENBREL INJ 25MG 4 PA; SP ENBREL INJ 50MG/ML 4 PA; SP HUMIRA INJ 10MG/0.2 3 PA; SP HUMIRA KIT 20MG/0.4 3 PA; SP HUMIRA KIT 40MG/0.8 3 PA; SP HUMIRA PEN INJ CROHNS 3 PA; SP KINERET INJ 4 PA; SP ORENCIA INJ 125MG/ML 4 PA; SP ORENCIA INJ 250MG 4 PA; SP REMICADE INJ 100MG 4 PA; SP SIMPONI ARIA SOL 50MG/4ML 4 PA; SP SIMPONI INJ 50/0.5ML 4 PA; SP DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDS)


103

Drug Name Drug Tier Requirements/Limits CUPRIMINE CAP 250MG 3 DEPEN TITRA TAB 250MG 4 hydroxychloroquine sulfate tab 200 mg 1 A90, M90 leflunomide tab 10 mg 2 A90, M90 leflunomide tab 20 mg 2 A90, M90 RHEUMATREX TAB 2.5MG 4 A90, M90 RIDAURA CAP 3MG 4 A90, M90 IMMUNE GLOBULINS ATGAM INJ 250MG 4 BIVIGAM INJ 10% 3 PA; SP CARIMUNE NF INJ 6GM 4 PA; SP CYTOGAM INJ 4 PA; SP FLEBOGAMMA INJ DIF 5% 3 PA; SP FLEBOGAMMA INJ DIF 10% 3 PA; SP GAMASTAN S/D INJ 3 PA; SP GAMMAGARD INJ 1GM/10ML 4 PA; SP GAMMAKED INJ 1GM/10ML 3 PA; SP GAMMAPLEX INJ 2.5GM 3 PA; SP GAMUNEX-C INJ 1GM/10ML 3 PA; SP HEPAGAM B INJ 4 SP HIZENTRA INJ 1GM/5ML 3 PA; SP HYPERHEP B INJ S/D 3 SP HYPERRAB S/D INJ 150/ML 3 HYPERRHO S/D INJ 50MCG 3 SP HYPERRHO S/D INJ 300MCG 4 SP MICRHOGAM PL INJ 50MCG 4 SP NABI-HB INJ 3 SP OCTAGAM INJ 1GM 3 PA; SP OCTAGAM INJ 2GM/20ML 3 PA; SP PRIVIGEN INJ 5 GRAMS 3 PA; SP RHOGAM PLUS INJ 300MCG 4 SP RHOPHYLAC INJ 1500/2ML 4 SP THYMOGLOBULN INJ 25MG 4 WINRHO SDF INJ 1500UNIT 4 SP WINRHO SDF INJ 5000UNIT 4 SP IMMUNOMODULATORS, INTERFERONS ACTIMMUNE INJ 2MU/0.5 $0 SP ALFERON N INJ 5MU/ML $0 SP INTRON A INJ 10MU $0 SP INTRON A INJ 18MU $0 SP INTRON A INJ 50MU $0 SP PEGASYS INJ 3 PA; SP


104

Drug Name Drug Tier Requirements/Limits PEGASYS INJ 180MCG/M 3 PA; SP PEGASYS INJ PROCLICK 3 PA; SP SYLATRON KIT 200MCG $0 SP SYLATRON KIT 300MCG $0 SP SYLATRON KIT 600MCG $0 SP IMMUNOMODULATORS, MISCELLANEOUS ARCALYST INJ 220MG 3 PA; SP ILARIS INJ 180MG 4 PA; SP IMMUNOSUPPRESSANTS, ANTIMETABOLITES AZASAN TAB 75 MG 3 A90, M90 AZASAN TAB 100MG 3 A90, M90 azathioprine tab 50 mg 2 A90, M90 CELLCEPT IV INJ 500MG 4 mycophenolate mofetil cap 250 mg 2 A90, M90 mycophenolate mofetil for oral susp 200

mg/ml 2 A90, M90

mycophenolate mofetil tab 500 mg 2 A90, M90 mycophenolate sodium tab dr 180 mg

(mycophenolic acid equiv) 2 A90, M90

mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv)

2 A90, M90

IMMUNOSUPPRESSANTS, CALCINEURIN INHIBITORS cyclosporine cap 25 mg 2 A90, M90 cyclosporine cap 100 mg 2 A90, M90 cyclosporine iv soln 50 mg/ml 2 cyclosporine modified cap 25 mg 2 A90, M90 cyclosporine modified cap 100 mg 2 A90, M90 cyclosporine modified oral soln 100 mg/ml 2 A90, M90 gengraf cap 25mg 2 A90, M90 gengraf cap 100mg 2 A90, M90 gengraf sol 100mg/ml 2 A90, M90 PROGRAF INJ 5MG/ML 4 SANDIMMUNE SOL 100MG/ML 3 A90, M90 tacrolimus cap 0.5 mg 2 A90, M90 tacrolimus cap 1 mg 2 A90, M90 tacrolimus cap 5 mg 2 A90, M90 IMMUNOSUPPRESSANTS, MISCELLANEOUS BENLYSTA INJ 120MG 4 PA; SP NULOJIX INJ 250MG 4 PA SIMULECT INJ 20MG 4 IMMUNOSUPPRESSANTS, RAPAMYCIN DERIVATIVE RAPAMUNE SOL 1MG/ML 3 A90, M90


105

Drug Name Drug Tier Requirements/Limits sirolimus tab 0.5 mg 2 A90, M90 sirolimus tab 2 mg 2 A90, M90 ZORTRESS TAB 0.5MG 4 PA; A90, M90 ZORTRESS TAB 0.25MG 4 PA; A90, M90 ZORTRESS TAB 0.75MG 4 PA; A90, M90 MONOCLONAL ANTIBODIES SYNAGIS INJ 50MG $0 PA; SP SYNAGIS INJ 100MG/ML $0 PA; SP VACCINES ADACEL INJ $0 AFLURIA INJ 2015-16 $0 AFLURIA INJ PF 15-16 $0 BEXSERO INJ $0 BIOTHRAX INJ Plan

Exclusion

BOOSTRIX INJ $0 CERVARIX INJ $0 DAPTACEL INJ $0 DIP/TET PED INJ 25-5LFU $0 ENGERIX-B INJ 10/0.5ML $0 ENGERIX-B INJ 20MCG/ML $0 EZ FLU SHOT INJ 2015-16 $0 FLUARIX PF INJ 2014-15 $0 FLUARIX QUAD INJ 2015-16 $0 FLUBLOK SOL 2015-16 $0 FLUCELVAX INJ 2015-16 $0 FLULAVAL QUA INJ 2015-16 $0 FLUZONE HD INJ PF 15-16 $0 FLUZONE QUAD INJ 15-16 $0 FLUZONE QUAD INJ 2015-16 $0 FLUZONE SPLT INJ 2015-16 $0 GARDASIL 9 INJ $0 GARDASIL INJ $0 HAVRIX INJ 720UNIT $0 HAVRIX INJ 1440UNIT $0 HIBERIX SOL 10MCG $0 IMOVAX RABIE INJ 2.5/ML 3 INFANRIX INJ $0 IPOL INJ INACTIVE $0 IXIARO INJ 3 KINRIX INJ $0 M-M-R II INJ $0


106

Drug Name Drug Tier Requirements/Limits MENACTRA INJ $0 MENHIBRIX INJ $0 MENOMUNE INJ A/C/Y/W $0 MENVEO INJ $0 PEDIARIX INJ 0.5ML $0 PEDVAX HIB INJ $0 PENTACEL INJ $0 PNEUMOVAX 23 INJ 25/0.5 $0 PREVNAR 13 INJ $0 PROQUAD INJ $0 RABAVERT INJ 3 RECOMBIVA HB INJ 5MCG/0.5 $0 RECOMBIVA HB INJ 10MCG/ML $0 RECOMBIVA-HB INJ 40MCG/ML $0 ROTARIX SUS $0 ROTATEQ SOL $0 TENIVAC INJ 5-2LF $0 TET/DIP TOX INJ 2-2 LF $0 TRUMENBA INJ $0 TWINRIX INJ $0 TYPHIM VI INJ 3 VAQTA INJ 25/0.5ML $0 VAQTA INJ 50UNT/ML $0 VARIVAX INJ $0 VIVOTIF CAP EC 3 YF-VAX INJ 3 ZOSTAVAX INJ $0 NUTRITIONAL / SUPPLEMENTS ELECTROLYTES, MISCELLANEOUS K-PHOS TAB 3 A90, M90 phospha 250 tab neutral 2 A90, M90 virt-phos tab 250 neut 2 A90, M90 ELECTROLYTES, POTASSIUM EFFER-K TAB 10MEQ 4 EFFER-K TAB 20MEQ 4 effer-k tab 25meq ef 2 A90, M90 k-effervesce tab 25meq ef 2 A90, M90 k-vescent tab 25meq ef 2 A90, M90 klor-con 8 tab 8meq er 2 A90, M90 klor-con m10 tab 10meq er 2 A90, M90 KLOR-CON M15 TAB 15MEQ ER 4 A90, M90 klor-con m20 tab 20meq er 2 A90, M90


107

Drug Name Drug Tier Requirements/Limits klor-con pow 20meq 2 A90, M90 klor-con/ef tab 25meq fr 2 A90, M90 potassium chloride cap cr 8 meq 2 A90, M90 potassium chloride cap cr 10 meq 2 A90, M90 potassium chloride microencapsulated crys

cr tab 20 meq 2 A90, M90

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

2

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

2

potassium chloride powder packet 20 meq 2 A90, M90 potassium chloride tab cr 8 meq (600 mg) 2 A90, M90 potassium chloride tab cr 10 meq 2 A90, M90 potassium chloride tab cr 20 meq (1500

mg) 2 A90, M90

VITAMINS AND MINERALS, FOLIC ACID / COMBINATIONS FA-8 CAP 800MCG $0 A90, M90 folbee tab 2 folic acid tab 1 mg 2 A90, M90 folic acid tab 400 mcg $0 folic acid tab 800mcg $0 A90, M90 l-methylfolate tab 7.5 mg Plan

Exclusion

l-methylfolate tab 15 mg Plan Exclusion

tl gard rx tab 2 virt-gard tab 2.2-25-1 2 virt-vite tab 2 VITAMINS AND MINERALS, MISCELLANEOUS BABY DDROPS LIQ 400UNIT $0 bio-d-mulsio liq 400unit $0 cholecalciferol cap 400 unit $0 cholecalciferol cap 2000 unit $0 cholecalciferol cap 5000 unit $0 cholecalciferol cap 10000 unit $0 cholecalciferol drops 5000 unit/ml (1000

unit/0.2ml) $0

cholecalciferol oral liquid 400 unit/ml $0 cholecalciferol tab 400 unit $0 cholecalciferol tab 1000 unit $0 cholecalciferol tab 2000 unit $0 cholecalciferol tab 5000 unit $0 cyanocobalamin inj 1000 mcg/ml 2


108

Drug Name Drug Tier Requirements/Limits decara cap 50000unt 2 delta d3 tab 400unit $0 ergocalciferol cap 50000 unit 2 A90, M90 ezfe 200 cap 200mg $0 fe c plus tab 2 FEOSOL TAB 45MG $0 ferotrinsic cap 2 FERRETTS FE CHW 18MG $0 FERRETTS IPS SOL $0 ferretts tab 325mg $0 ferrex 150 cap 150mg $0 FERRIMIN 150 TAB $0 ferrocite tab 324mg $0 ferrogels fo cap forte 2 ferrous fumarate tab 324 mg (106 mg

elemental fe) $0

ferrous gluc tab 324mg $0 ferrous gluconate tab 240 mg (27 mg

elemental fe) $0

ferrous gluconate tab 324 mg (37.5 mg elemental iron)

$0

FERROUS SUL LIQ 220/5ML $0 FERROUS SULF SYP 300/5ML $0 FERROUS SULF TAB 140MG $0 ferrous sulf tab 325mg $0 ferrous sulfate elixir 220 mg/5ml (44

mg/5ml elemental fe) $0

ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe)

$0

ferrous sulfate tab ec 325 mg (65 mg fe equivalent)

$0

FLUOR-A-DAY CHW 0.5MG F Plan Exclusion

A90, M90

FLUOR-A-DAY CHW 0.25MG F Plan Exclusion

A90, M90

fluor-a-day dro 0.125mg $0 A90, M90 FLUORABON DRO $0 A90, M90 fluoritab chw 0.5mg f $0 A90, M90 fluoritab chw 2.2mg $0 A90, M90 fluoritab dro 0.125mg $0 A90, M90 flura-drops dro 0.25mg f $0 A90, M90 folic acid-vitamin b6-vitamin b12 tab 2.2-

25-0.5 mg 2


109

Drug Name Drug Tier Requirements/Limits hematogen cap forte 2 hemocyte-f tab 2 hydroxocobalamin inj 1000 mcg/ml 4 iferex 150 cap $0 iferex 150 cap forte 2 IRON CHEWS CHW PEDIATRI $0 ludent chw 0.5mg f $0 A90, M90 ludent chw 0.25mg f $0 A90, M90 ludent chw 1mg f $0 A90, M90 MEPHYTON TAB 5MG 3 multi-vit/fl dro 0.25mg 2 multivit/fl chw 0.5mg 2 multivit/fl chw 1mg 2 mvc-fluoride chw 0.25mg 2 myferon 150 cap 150mg $0 myferon 150 cap forte 2 MYKIDZ IRON SUS 15/1.5ML $0 NASCOBAL SPR 500MCG 4 A90, M90 NOVAFERRUM DRO 15MG/ML $0 nu-iron 150 cap 150mg $0 omega-3-acid ethyl esters cap 1 gm 2 phytonadione inj 1 mg/0.5ml (2 mg/ml) 2 poly-iron cap 150 fort 2 PROFE CAP 180MG $0 PROFERRIN ES TAB 12 MG $0 QUFLORA PED CHW 0.5MG 2 QUFLORA PED CHW 0.25MG 2 QUFLORA PED CHW 1MG 2 ra iron tab 27mg $0 REPLESTA NX WAF 14000UNT $0 SLOW IRON TAB 50MG $0 sod ferric gluc cmplx in sucrose iv soln

12.5 mg/ml (fe eq) 3

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

$0 A90, M90

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

$0 A90, M90

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

$0 A90, M90

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

$0 A90, M90

thera-d tab 2000unit $0 THERA-D TAB 4000UNIT $0


110

Drug Name Drug Tier Requirements/Limits tl-hem 150 tab 2 tri-vit/fl dro 0.5mg 2 tri-vit/fl dro 0.25mg 2 tricon cap 2 trigels-f cap forte 2 VITAMIN D2 TAB 400UNIT $0 A90, M90 vitamin d3 cap 10000unt $0 vitamin d3 cap 50000unt $0 VITAMIN D3 LIQ 1000UNIT $0 VITAMIN D3 LIQ 1200UNIT $0 VITAMIN D3 TAB 3000UNIT $0 vitamin d cap 1000unit $0 vitamin d chw 400unit $0 vitamin d chw 1000unit $0 VP-ZEL TAB 2 wee care sus 15/1.25 $0 VITAMINS AND MINERALS, PRENATAL VITAMINS CL PRENATAL TAB 28-0.8MG 1 CO-NATAL FA TAB 29-1MG 1 CONCEPT OB CAP 1 CVS PRENATAL TAB 1 EQL PRENATAL TAB FORMULA 1 FOLIVANE-OB CAP 1 GNP PRENATAL TAB 28-0.8MG 1 GOODSENSE TAB 28-0.8MG 1 HM PRENATAL TAB 1 inatal adv tab 1 inatal gt tab 1 inatal ultra tab 1 KP PRENATAL TAB MULTIVIT 1 M-VIT TAB 27-1MG 1 MULTI PRENAT TAB 1 MYNATAL TAB 1 MYNATAL TAB ADVANCE 1 NIVA-PLUS TAB 1 O-CAL FA TAB 1 O-CAL TAB PRENATAL 1 PNV FOLIC AC TAB + IRON 1 PNV PRENATAL TAB PLUS 1 PNV TABS TAB 29-1MG 1 PRENAT PLUS TAB 27-1MG 1 prenatabs fa tab 1


111

Drug Name Drug Tier Requirements/Limits prenatabs rx tab 1 PRENATAL ONE TAB DAILY 1 PRENATAL TAB 1 PRENATAL TAB 27-0.8MG 1 PRENATAL TAB 27-1MG 1 PRENATAL TAB 28-0.8MG 1 PRENATAL TAB LOW IRON 1 PRENATAL TAB VITAMINS 1 PRENATAL VIT TAB 28-0.8MG 1 PRENATAL+FE TAB 29-1MG 1 PREPLUS TAB 27-1MG 1 PRETAB TAB 29-1MG 1 PX PRENATAL TAB MULTIVIT 1 QC PRENATAL TAB 28-0.8MG 1 RA PRENATAL TAB 28-0.8MG 1 RA PRENATAL TAB FORMULA 1 RIGHT STEP TAB PRENATAL 1 SM PRENATAL TAB VITAMINS 1 THERANATAL TAB 27-1 1 THRIVITE RX TAB 29-1MG 1 triadvance tab 1 TRICARE TAB PRENATAL 1 TRINATAL GT TAB 1 TRINATAL RX TAB 1 1 trinate tab 1 ultra tabs tab 1 VINATE M TAB 1 VINATE ONE TAB 1 VIRT NATE TAB 1 VIRT NATE TAB 28-1MG 1 VIRT-ADVANCE TAB 90-1MG 1 VIRT-VITE GT TAB 90-1MG 1 VOL-NATE TAB 1 VOL-PLUS TAB 1 VOL-TAB RX TAB 1 RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS epinephrine solution auto-injector 0.3

mg/0.3ml (1:1000) 2

EPIPEN 2-PAK INJ 0.3MG 3 EPIPEN-JR INJ 2-PAK 3 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS


112

Drug Name Drug Tier Requirements/Limits COMBIVENT AER 20-100 3 A90, M90 ipratropium-albuterol nebu soln 0.5-2.5(3)

mg/3ml 2 A90, M90

STIOLTO AER 2.5-2.5 3 QL (1 inhaler / 30 days); A90, M90

UTIBRON CAP NEOHALER 4 QL ANTICHOLINERGICS ATROVENT HFA AER 17MCG 3 A90, M90 INCRUSE ELPT INH 62.5MCG 3 QL (1 inhaler / 30

days); A90, M90 ipratropium bromide inhal soln 0.02% 1 A90, M90 SEEBRI NEOHA CAP 15.6MCG 4 QL SPIRIVA CAP HANDIHLR 3 A90, M90 SPIRIVA SPR 2.5MCG 3 A90, M90 TUDORZA PRES AER 400/ACT 3 QL (1 kit / 30 days);

A90, M90 ANTIHISTAMINE/DECONGESTANT COMBINATIONS prometh vc syp plain 2 ANTIHISTAMINES, LOW-SEDATING cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) 2 levocetirizine dihydrochloride soln 2.5

mg/5ml (0.5 mg/ml) 2 ST; QL

levocetirizine dihydrochloride tab 5 mg 2 QL (30 tabs / 30 days), ST

ANTIHISTAMINES, NONSEDATING CLARINEX SYP 0.5MG/ML 4 ST; QL desloratadine tab 5 mg 2 QL (30 tabs / 30 days),

ST desloratadine tab orally disintegrating 2.5

mg 2 QL (30 ea / 30 days), ST

desloratadine tab orally disintegrating 5 mg

2 QL (30 ea / 30 days), ST

ANTIHISTAMINES, SEDATING arbinoxa sol 4mg/5ml 2 arbinoxa tab 4mg 2 carbinoxamine maleate soln 4 mg/5ml 2 carbinoxamine maleate tab 4 mg 2 clemastine fumarate tab 2.68 mg 2 cyproheptadine hcl syrup 2 mg/5ml 2 cyproheptadine hcl tab 4 mg 2 diphenhydramine hcl elixir 12.5 mg/5ml 2 diphenhydramine hcl inj 50 mg/ml 2 hydroxyzine hcl im soln 50 mg/ml 1


113

Drug Name Drug Tier Requirements/Limits hydroxyzine hcl syrup 10 mg/5ml 1 hydroxyzine hcl tab 10 mg 1 hydroxyzine hcl tab 25 mg 1 hydroxyzine hcl tab 50 mg 1 hydroxyzine pamoate cap 25 mg 1 hydroxyzine pamoate cap 50 mg 1 hydroxyzine pamoate cap 100 mg 1 wal-dryl cap 25mg $0 ANTITUSSIVE COMBINATIONS, NON-OPIOID promethazine-dm syrup 6.25-15 mg/5ml 1 tusslin liq pediatri 2 ANTITUSSIVE COMBINATIONS, OPIOID hydrocodone w/ homatropine syrup 5-1.5

mg/5ml 2

hydrocodone w/ homatropine tab 5-1.5 mg 2 hydromet syp 5-1.5/5 2 prometh vc/ syp codeine 2 promethazine w/ codeine syrup 6.25-10

mg/5ml 2

tussigon tab 5-1.5mg 2 ANTITUSSIVES benzonatate cap 100 mg 1 benzonatate cap 200 mg 1 BETA AGONISTS, INHALANTS, LONG ACTING ARCAPTA CAP 75MCG 3 QL (30 caps / 30 days);

A90, M90 BROVANA NEB 15MCG 4 QL (30 / 30 days), PA;

A90, M90 PERFOROMIST NEB 20MCG 3 A90, M90 SEREVENT DIS AER 50MCG 3 A90, M90 BETA AGONISTS, INHALANTS, SHORT ACTING albuterol sulfate soln nebu 0.5% (5 mg/ml)1 A90 albuterol sulfate soln nebu 0.63 mg/3ml

(base equiv) 2 A90

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

2 A90

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

2 A90

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

2 A90

levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv)

2 A90


114

Drug Name Drug Tier Requirements/Limits levalbuterol hcl soln nebu conc 1.25

mg/0.5ml (base equiv) 2 A90

metaproterenol sulfate syrup 10 mg/5ml 2 A90 metaproterenol sulfate tab 10 mg 2 A90 metaproterenol sulfate tab 20 mg 2 A90 PROAIR HFA AER 3 QL (8 inhalers per 180

days); A90 PROAIR RESPI AER 3 QL (8 inhalers / 180

days); A90 BETA AGONISTS, INJECTABLE terbutaline sulfate inj 1 mg/ml 2 BETA AGONISTS, ORAL AGENTS albuterol sulfate syrup 2 mg/5ml 2 A90 albuterol sulfate tab 2 mg 2 A90 albuterol sulfate tab 4 mg 2 A90 albuterol sulfate tab sr 12hr 4 mg 2 A90, M90 albuterol sulfate tab sr 12hr 8 mg 2 A90, M90 terbutaline sulfate tab 2.5 mg 2 A90, M90 terbutaline sulfate tab 5 mg 2 A90, M90 CYSTIC FIBROSIS CAYSTON INH 75MG 3 SP KALYDECO TAB 150MG 3 PA; SP ORKAMBI TAB 200-125 3 PA; SP PULMOZYME SOL 1MG/ML 3 PA; SP TOBI PODHALR CAP 28MG 3 PA; SP tobramycin nebu soln 300 mg/5ml 3 PA; SP LEUKOTRIENE RECEPTOR ANTAGONIST montelukast sodium chew tab 4 mg (base

equiv) 2 QL (30 packets / 30

days); A90, M90 montelukast sodium chew tab 5 mg (base

equiv) 2 QL (30 packets / 30

days); A90, M90 montelukast sodium oral granules packet 4

mg (base equiv) 2 QL (1 box / 30 days),

ST; A90, M90 montelukast sodium tab 10 mg (base

equiv) 2 QL (30 tabs / 30 days);

A90, M90 zafirlukast tab 10 mg 2 QL (60 tabs / 30 days),

PA; A90, M90 zafirlukast tab 20 mg 2 QL (60 tabs / 30 days),

PA; A90, M90 ZYFLO CR TAB 600MG 4 QL (120 ea / 30 days),

PA; A90, M90 MAST CELL STABILIZERS cromolyn sodium soln nebu 20 mg/2ml 2 A90, M90


115

Drug Name Drug Tier Requirements/Limits MEDICAL SUPPLIES COOL MIST MIS 1.3 GAL $0 INSPIREASE MIS DD SYST $0 SUDACARE ADV MIS VAPOR-PG $0 TRUZONE PEAK MIS FLOW MTR $0 MISCELLANEOUS acetylcysteine inhal soln 10% 2 acetylcysteine inhal soln 20% 2 ARALAST NP INJ 500MG 4 PA; SP caffeine citrate inj 60 mg/3ml (10 mg/ml

base equiv) 2

caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv)

2

difil-g fort liq 100-100 2 doxapram hcl inj 20 mg/ml 2 GLASSIA INJ 4 PA; SP ipratropium bromide nasal soln 0.03% (21

mcg/spray) 1 A90, M90

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

1 A90, M90

NUCALA INJ 100MG 4 PA, SP, QL PROLASTIN-C INJ 1000MG 3 PA; SP pulmosal neb 7% 2 sodium chloride soln nebu 0.9% 2 sodium chloride soln nebu 3% 2 sodium chloride soln nebu 7% 2 sodium chloride soln nebu 10% 2 XOLAIR SOL 150MG 4 PA; SP ZEMAIRA INJ 1000MG 3 PA; SP NASAL ANTIHISTAMINE/STEROID COMBINATIONS DYMISTA SPR 137-50 Plan

Exclusion

NASAL ANTIHISTAMINES azelastine hcl nasal spray 0.1% (137

mcg/spray) 2

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

2

olopatadine hcl nasal soln 0.6% 2 NASAL STEROIDS budesonide nasal susp 32 mcg/act 2 QL (8.6g per 30 days),

ST flunisolide nasal soln 25 mcg/act (0.025%) 2 QL (1 bottle / 30 days)


116

Drug Name Drug Tier Requirements/Limits fluticasone propionate nasal susp 50

mcg/act 2 QL (1 bottle / 30 days)

mometasone furoate nasal susp 50 mcg/act

2 QL (17g per 30 days), ST

nasal allgy spr 55mcg/ac 1 QL (17 mL / 30 days) rhinocort sus allergy 1 triamcinolone acetonide nasal aerosol

suspension 55 mcg/act 2 QL (17 mL / 30 days),

ST PHOSPHODIESTERASE-4 INHIBITORS DALIRESP TAB 500MCG 3 QL (30 tabs / 30 days),

PA; A90, M90 STEROID INHALANTS ASMANEX 7 AER 110MCG 3 A90, M90 ASMANEX 14 AER 220MCG 3 A90, M90 ASMANEX 30 AER 110MCG 3 A90, M90 ASMANEX 30 AER 220MCG 3 A90, M90 ASMANEX 60 AER 220MCG 3 A90, M90 ASMANEX 120 AER 220MCG 3 A90, M90 ASMANEX HFA AER 100 MCG 3 A90, M90 ASMANEX HFA AER 200 MCG 3 A90, M90 budesonide inhalation susp 0.5 mg/2ml 2 A90, M90 budesonide inhalation susp 0.25 mg/2ml 2 A90, M90 budesonide inhalation susp 1 mg/2ml 2 A90, M90 PULMICORT INH 90MCG 3 A90, M90 PULMICORT INH 180MCG 3 A90, M90 QVAR AER 40MCG 3 A90, M90 QVAR AER 80MCG 3 A90, M90 STEROID/BETA AGONIST COMBINATIONS DULERA AER 100-5MCG 3 A90, M90 DULERA AER 200-5MCG 3 A90, M90 SYMBICORT AER 80-4.5 3 A90, M90 SYMBICORT AER 160-4.5 3 A90, M90 XANTHINES aminophylline inj 25 mg/ml 2 ELIXOPHYLLIN ELX 80/15ML 4 A90, M90 THEO-24 CAP 100MG CR 4 A90, M90 THEO-24 CAP 200MG CR 4 A90, M90 THEO-24 CAP 300MG CR 4 A90, M90 THEO-24 CAP 400MG ER 4 A90, M90 theochron tab 100mg cr 2 A90, M90 theochron tab 200mg cr 2 A90, M90 theochron tab 300mg cr 2 A90, M90


117

Drug Name Drug Tier Requirements/Limits theophylline soln 80 mg/15ml 2 A90, M90 theophylline tab sr 12hr 100 mg 2 A90, M90 theophylline tab sr 12hr 200 mg 2 A90, M90 theophylline tab sr 12hr 300 mg 2 A90, M90 theophylline tab sr 12hr 450 mg 2 A90, M90 theophylline tab sr 24hr 400 mg 2 A90, M90 theophylline tab sr 24hr 600 mg 2 A90, M90 TOPICAL DERMATOLOGY, ACNE: TOPICAL avar cleanse emu 10-5% 2 avar-e emoll cre 10-5% 2 AZELEX CRE 20% 4 ST benzepro aer 5.3% 2 benzepro sc aer 9.8% 2 benzoyl per liq 10% wash 2 benzoyl peroxide foam 5.3% 2 benzoyl peroxide foam 9.8% 2 benzoyl peroxide-erythromycin gel 5-3% Plan

Exclusion

bp cleansing emu 10-4% 2 bp wash liq 2.5% 2 bp wash liq 7% 2 bpo cloths mis 6% 2 BPO CREAMY KIT 8% WASH Plan

Exclusion

cerisa wash emu 10-1% 2 CLINDACIN KIT PAC 1% Plan

Exclusion

clindamax gel 1% 2 clindamycin phosphate foam 1% 2 clindamycin phosphate gel 1% 2 clindamycin phosphate lotion 1% 2 clindamycin phosphate soln 1% 2 clindamycin phosphate swab 1% 2 ery pad 2% 2 erythromycin gel 2% 2 erythromycin pads 2% 2 erythromycin soln 2% 2 NEUAC KIT 1.2-5% Plan

Exclusion

prascion emu 2 PRASCION RA CRE 10-5% Plan

Exclusion


118

Drug Name Drug Tier Requirements/Limits rosanil emu cleanser 2 sss 10-5 aer 10-5% 2 sulfacetamide sodium lotion 10% (acne) 2 sulfacetamide sodium w/ sulfur cleanser

9.8-4.8% 2

sulfacetamide sodium w/ sulfur cleanser 10-2%

2

sulfacetamide sodium w/ sulfur cleansing pad 10-4%

2

sulfacetamide sodium w/ sulfur cream 9.8-4.8%

2

sulfacetamide sodium w/ sulfur cream 10-2%

2

sulfacetamide sodium w/ sulfur cream 10-5%

2

sulfacetamide sodium w/ sulfur lotion 9.8-4.8%

2

sulfacetamide sodium w/ sulfur lotion 10-5%

2

sulfacetamide sodium w/ sulfur susp 8-4% 2 sulfacetamide sodium w/ sulfur wash 9-4%2 sulfacetamide sodium w/ sulfur wash 9-

4.5% 2

TAZORAC CRE 0.1% 3 ST; AL TAZORAC CRE 0.05% 3 ST; AL TAZORAC GEL 0.1% 3 ST; AL TAZORAC GEL 0.05% 3 ST; AL tretinoin gel 0.05% 2 ST zencia liq 9-4% 2 DERMATOLOGY, ACTINIC KERATOSIS diclofenac sodium (actinic keratoses) gel

3% 2 PA

FLUOROPLEX CRE 1% $0 fluorouracil cream 5% $0 SP fluorouracil soln 2% $0 SP fluorouracil soln 5% $0 SP PICATO GEL 0.05% 4 QL (1 ea / 30 days) PICATO GEL 0.015% 4 QL (1 ea / 30 days) DERMATOLOGY, ANTI-INFECTIVE/ANTI-INFLAMMATORY

COMBINATIONS CORTISPORIN CRE 0.5% 4 CORTISPORIN OIN 1% 4 NEO-SYNALAR CRE 4


119

Drug Name Drug Tier Requirements/Limits DERMATOLOGY, ANTIBIOTICS ALTABAX OIN 1% 4 ST BACTROBAN OIN NASAL 2% 4 ST CENTANY OIN 2% 3 mupirocin calcium cream 2% 2 PA silver sulfadiazine cream 1% 2 ssd cre 1% 2 DERMATOLOGY, ANTIFUNGALS ciclodan cre 0.77% 2 ciclodan sol 8% 2 ciclopirox gel 0.77% 2 ciclopirox olamine cream 0.77% (base

equiv) 2

ciclopirox olamine susp 0.77% (base equiv)

2

ciclopirox shampoo 1% 2 ciclopirox solution 8% 2 PA clotrimazole cream 1% 1 clotrimazole soln 1% 1 clotrimazole w/ betamethasone cream 1-

0.05% 2

clotrimazole w/ betamethasone lotion 1-0.05%

2

CNL8 NAIL KIT Plan Exclusion

PA

econazole nitrate cream 1% 2 ERTACZO CRE 2% 4 ST EXELDERM CRE 1% 4 ST EXELDERM SOL 1% 4 ST EXODERM LOT 25-1% 3 ketoconazole cream 2% 2 ketoconazole foam 2% 2 ketoconazole shampoo 2% 2 ketodan aer 2% 2 MENTAX CRE 1% 4 ST naftifine hcl cream 2% 2 ST nyamyc pow 100000 2 nystatin cream 100000 unit/gm 1 nystatin oint 100000 unit/gm 2 nystatin topical powder 2 nystatin-triamcinolone cream 100000-0.1

unit/gm-% 2


120

Drug Name Drug Tier Requirements/Limits nystatin-triamcinolone oint 100000-0.1

unit/gm-% 2

nystop pow 100000 2 oxiconazole nitrate cream 1% 2 ST XOLEGEL GEL 2% 4 ST DERMATOLOGY, ANTIPSORIATICS, INJECTABLE COSENTYX INJ 150MG/ML 4 PA; QL, SP DERMATOLOGY, ANTIPSORIATICS, ORAL acitretin cap 10 mg 2 acitretin cap 17.5 mg 2 acitretin cap 25 mg 2 methoxsalen rapid cap 10 mg 2 8-MOP CAP 10MG 3 DERMATOLOGY, ANTIPSORIATICS, TOPICAL calcipotriene cream 0.005% 2 calcipotriene oint 0.005% 2 calcipotriene soln 0.005% (50 mcg/ml) 2 calcipotriene-betamethasone dipropionate

oint 0.005-0.064% Plan Exclusion

calcitrene oin 0.005% 2 calcitriol oint 3 mcg/gm 2 TACLONEX SUS Plan

Exclusion

DERMATOLOGY, ANTISEBORRHEICS seb-prev liq wash 2 selenium sulfide lotion 2.5% 2 SODIUM SULFA LIQ 10% WASH 4 sulfacetamide sodium liquid 10% 2 sulfacetamide sodium shampoo 10% 2 DERMATOLOGY, CORTICOSTEROIDS: HIGH POTENCY amcinonide cream 0.1% 2 APEXICON E CRE 0.05% 4 ST betamethasone dipropionate augmented

cream 0.05% 2

betamethasone dipropionate augmented lotion 0.05%

2

betamethasone dipropionate cream 0.05% 2 betamethasone dipropionate lotion 0.05% 2 betamethasone dipropionate oint 0.05% 2 desoximetasone cream 0.25% 2 desoximetasone gel 0.05% 2 desoximetasone oint 0.25% 2


121

Drug Name Drug Tier Requirements/Limits fluocinonide cream 0.1% 2 fluocinonide cream 0.05% 2 fluocinonide gel 0.05% 2 fluocinonide oint 0.05% 2 fluocinonide soln 0.05% 2 HALOG CRE 0.1% 4 ST HALOG OIN 0.1% 4 ST triamcinolone acetonide cream 0.5% 1 DERMATOLOGY, CORTICOSTEROIDS: LOW POTENCY ala cort cre 1% 2 alclometasone dipropionate cream 0.05% 2 alclometasone dipropionate oint 0.05% 2 anti-itch cre 1% 2 CAPEX SHA 0.01% 4 ST desonide cream 0.05% 2 desonide lotion 0.05% 2 desonide oint 0.05% 2 fluocin acet oil scalp 2 fluocinolone acetonide cream 0.01% 2 fluocinolone acetonide soln 0.01% 2 hydrocortisone cream 2.5% 1 hydrocortisone lotion 2.5% 2 hydrocortisone oint 1% 2 hydrocortisone oint 2.5% 2 lokara lot 0.05% 2 scalacort lot 2% 2 TEXACORT SOL 2.5% 4 ST DERMATOLOGY, CORTICOSTEROIDS: MEDIUM POTENCY betamethasone valerate aerosol foam

0.12% 2

betamethasone valerate cream 0.1% 2 betamethasone valerate lotion 0.1% 2 betamethasone valerate oint 0.1% 2 CORDRAN 80X3 TAP 4MCG/CM 4 ST CORDRAN LOT 0.05% 4 ST desoximetasone cream 0.05% 2 desoximetasone oint 0.05% 2 fluocinolone acetonide cream 0.025% 2 fluocinolone acetonide oint 0.025% 2 flurandrenolide cream 0.05% 2 ST fluticasone propionate cream 0.05% 2 fluticasone propionate lotion 0.05% 2


122

Drug Name Drug Tier Requirements/Limits fluticasone propionate oint 0.005% 2 hydrocortisone butyrate hydrophilic lipo

base cream 0.1% 2

hydrocortisone butyrate oint 0.1% 2 hydrocortisone butyrate soln 0.1% 2 hydrocortisone valerate cream 0.2% 2 hydrocortisone valerate oint 0.2% 2 LOCOID LOT 0.1% 4 ST mometasone furoate cream 0.1% 2 mometasone furoate oint 0.1% 2 mometasone furoate solution 0.1% (lotion)2 prednicarbate cream 0.1% 2 prednicarbate oint 0.1% 2 triamcinolone acetonide aerosol soln 0.147

mg/gm 2 ST

triamcinolone acetonide cream 0.1% 1 triamcinolone acetonide cream 0.025% 1 triamcinolone acetonide lotion 0.1% 2 triamcinolone acetonide lotion 0.025% 2 triamcinolone acetonide oint 0.1% 1 triamcinolone acetonide oint 0.025% 2 triderm cre 0.1% 1 DERMATOLOGY, CORTICOSTEROIDS: VERY HIGH POTENCY betamethasone dipropionate augmented

gel 0.05% 2

betamethasone dipropionate augmented oint 0.05%

2

clobetasol propionate cream 0.05% 2 clobetasol propionate foam 0.05% 2 clobetasol propionate gel 0.05% 2 clobetasol propionate lotion 0.05% 2 clobetasol propionate oint 0.05% 2 clobetasol propionate shampoo 0.05% 2 clobetasol propionate soln 0.05% 2 clobetasol propionate spray 0.05% 2 cormax scalp sol 0.05% 2 diflorasone diacetate oint 0.05% 2 halobetasol propionate cream 0.05% 2 halobetasol propionate oint 0.05% 2 DERMATOLOGY, EMOLLIENTS lactic acid (ammonium lactate) cream 12% 2 lactic acid (ammonium lactate) lotion 10% 2 lactic acid (ammonium lactate) lotion 12% 2


123

Drug Name Drug Tier Requirements/Limits rea lo 40 cre 40% 2 remeven cre 50% 2 DERMATOLOGY, IMMUNOMODULATORS ELIDEL CRE 1% 3 QL (30 gm / 30 days) tacrolimus oint 0.1% 2 QL (30 gm / 30 days) tacrolimus oint 0.03% 2 QL (30 gm / 30 days) DERMATOLOGY, LOCAL ANALGESIC lidocaine patch 5% 2 QL (90 patches / 30

days), PA DERMATOLOGY, LOCAL ANESTHETICS glydo gel 2% 2 lidocaine hcl cream 3% 2 lidocaine hcl gel 2% 2 lidocaine hcl soln 4% 2 lidocaine oint 5% 2 lidocaine-prilocaine cream 2.5-2.5% 2 DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir oint 5% 2 arzol silver mis nitr app 2 CHLORHEX GLU SOL 20% 4 CONDYLOX GEL 0.5% 3 DENAVIR CRE 1% 3 doxepin hcl cream 5% 2 DRYSOL SOL 20% 3 formadon sol 2 imiquimod cream 5% 2 OXSORALEN LOT 1% 3 PANRETIN GEL 0.1% 4 podofilox soln 0.5% 2 REGRANEX GEL 0.01% 3 QL (1 gm / 30 days) salacyn cre 6% 2 salacyn lot 6% 2 salicylic ac liq 27.5% 2 salicylic acid cream 6% 2 salicylic acid foam 6% 2 salicylic acid gel 6% 2 salicylic acid lotion 6% & cleanser liqd kit 2 salicylic acid shampoo 6% 2 SANTYL OIN 250/GM 4 SULFAMYLON CRE 85MG/GM 3 VEREGEN OIN 15% 4 QL (30 gm / 30 days),

PA


124

Drug Name Drug Tier Requirements/Limits XIAFLEX INJ 0.9MG 3 SP DERMATOLOGY, ROSACEA doxycycline (rosacea) cap delayed release

40 mg 2

FINACEA GEL 15% 3 ST metronidazole cream 0.75% 2 metronidazole gel 0.75% 2 metronidazole gel 1% 2 metronidazole lotion 0.75% 2 ORACEA CAP 40MG Plan

Exclusion

rosadan cre 0.75% 2 rosadan gel 0.75% 2 SOOLANTRA CRE 1% 4 ST DERMATOLOGY, SCABICIDES AND PEDICULICIDES EURAX CRE 10% 4 EURAX LOT 10% 4 lindane shampoo 1% 2 malathion lotion 0.5% 2 permethrin cream 5% 2 SKLICE LOT 0.5% 4 PA ULESFIA LOT 5% 4 MOUTH/THROAT/DENTAL AGENTS, Miscellaneous cavirinse sol 0.2% $0 AL, A90, M90 chlorhexidine gluconate soln 0.12% 1 clinpro 5000 pst 1.1% $0 AL, A90, M90 controlrx cre 1.1% $0 AL, A90, M90 denta 5000 cre plus $0 AL, A90, M90 dentagel gel 1.1% $0 AL, A90, M90 fluoridex gel 1.1% $0 AL, A90, M90 karigel-n gel 1.1% $0 AL, A90, M90 lidocaine hcl laryngotracheal soln 4% 2 lidocaine hcl viscous soln 2% 1 oralone pst 0.1% 2 periogard sol 0.12% 1 phos-flur gel 1.1% $0 AL, A90, M90 sf 5000 plus cre 1.1% $0 AL, A90, M90 sod fluoride sol 0.2% $0 AL, A90, M90 topex topcal spr anesthet 2 triamcinolone acetonide dental paste 0.1% 2 OPHTHALMIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY

COMBINATIONS


125

Drug Name Drug Tier Requirements/Limits bacitracin-polymyxin-neomycin-hc ophth

oint 1% 2

neo-polycin oin hc 1%op 2 neomycin-polymyxin-dexamethasone

ophth oint 0.1% 1

neomycin-polymyxin-dexamethasone ophth susp 0.1%

1

sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%

2

TOBRADEX ST SUS 0.3-0.05 3 tobramycin-dexamethasone ophth susp

0.3-0.1% 2

OPHTHALMIC, ANTI-INFECTIVES bacit/polymy oin op 2 bacitracin ophth oint 500 unit/gm 2 BESIVANCE SUS 0.6% 3 CILOXAN OIN 0.3% OP 4 ciprofloxacin hcl ophth soln 0.3% 2 erythromycin ophth oint 5 mg/gm 2 gatifloxacin ophth soln 0.5% 2 gentak oin 0.3% op 2 gentamicin sulfate ophth oint 0.3% 2 gentamicin sulfate ophth soln 0.3% 2 ilotycin oin op 2 levofloxacin ophth soln 0.5% 2 MOXEZA SOL 0.5% 3 neo-polycin oin op 2 neomycin-bacitrac zn-polymyx 5(3.5)mg-

400unt-10000unt op oin 2

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

2

ofloxacin ophth soln 0.3% 2 polymyxin b-trimethoprim ophth soln

10000 unit/ml-0.1% 1

sulfacetamide sodium ophth soln 10% 2 tobramycin ophth soln 0.3% 1 VIGAMOX DRO 0.5% 3 ZYMAXID SOL 0.5% 4 PA OPHTHALMIC, ANTI-INFLAMMATORY: NONSTEROIDAL ACUVAIL SOL 0.45% 4 QL (2 / 30 days), ST bromfenac sodium ophth soln 0.09% (base

equiv) (once-daily) 2 ST

diclofenac sodium ophth soln 0.1% 2


126

Drug Name Drug Tier Requirements/Limits flurbiprofen sodium ophth soln 0.03% 2 ILEVRO DRO 0.3% OP 3 ketorolac tromethamine ophth soln 0.4% 2 ketorolac tromethamine ophth soln 0.5% 2 NEVANAC SUS 0.1% 3 ST OPHTHALMIC, ANTI-INFLAMMATORY: STEROIDAL ALREX SUS 0.2% 3 dexamethasone sodium phosphate ophth

soln 0.1% 2

DUREZOL EMU 0.05% 4 ST; QL FLAREX SUS 0.1% OP 4 fluorometholone ophth susp 0.1% 2 FML OIN 0.1% OP 3 LOTEMAX GEL 0.5% 3 LOTEMAX OIN 0.5% 3 LOTEMAX SUS 0.5% 3 OZURDEX IMP 0.7MG 4 PRED MILD SUS 0.12% OP 3 prednisolone acetate ophth susp 1% 2 VEXOL SUS 1% OP 4 OPHTHALMIC, ANTIALLERGICS ALOCRIL SOL 2% 4 ALOMIDE SOL 0.1% OP 4 azelastine hcl ophth soln 0.05% 2 ST; QL BEPREVE DRO 1.5% 3 ST; QL cromolyn sodium ophth soln 4% 2 EMADINE SOL 0.05% OP 4 ST; QL epinastine hcl ophth soln 0.05% 2 ST; QL LASTACAFT SOL 0.25% 4 ST; QL olopatadine hcl ophth soln 0.1% (base

equivalent) 2 QL (1 per 25 days), ST

PATADAY SOL 0.2% 3 ST; QL OPHTHALMIC, ANTIFUNGALS NATACYN SUS 5% OP 3 OPHTHALMIC, ANTIVIRAL trifluridine ophth soln 1% 2 ZIRGAN GEL 0.15% 4 OPHTHALMIC, BETA-BLOCKERS: NONSELECTIVE BETIMOL SOL 0.5% 4 A90, M90 BETIMOL SOL 0.25% 4 A90, M90 carteolol hcl ophth soln 1% 2 A90, M90 levobunolol hcl ophth soln 0.5% 2 A90, M90


127

Drug Name Drug Tier Requirements/Limits metipranolol ophth soln 0.3% 2 A90, M90 timolol maleate ophth gel forming soln

0.5% 2 A90, M90

timolol maleate ophth gel forming soln 0.25%

2 A90, M90

timolol maleate ophth soln 0.5% 2 A90, M90 timolol maleate ophth soln 0.25% 2 A90, M90 OPHTHALMIC, BETA-BLOCKERS: SELECTIVE betaxolol hcl ophth soln 0.5% 2 A90, M90 OPHTHALMIC, CARBONIC ANHYDRASE INHIBITOR/BETA-BLOCKER

COMBINATIONS dorzolamide hcl-timolol maleate ophth soln

22.3-6.8 mg/ml 2 A90, M90

OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS, INJECTABLE acetazolamide sodium for inj 500 mg 2 OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS: ORAL acetazolamide cap sr 12hr 500 mg 2 A90, M90 acetazolamide tab 125 mg 2 A90, M90 acetazolamide tab 250 mg 2 A90, M90 methazolamide tab 25 mg 2 A90, M90 methazolamide tab 50 mg 2 A90, M90 OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS: TOPICAL AZOPT SUS 1% OP 4 A90, M90 dorzolamide hcl ophth soln 2% 2 A90, M90 OPHTHALMIC, DECONGESTANTS phenylephrine hcl ophth soln 2.5% 2 phenylephrine hcl ophth soln 10% 2 OPHTHALMIC, DIAGNOSTIC PRODUCTS flucaine sol 0.25-0.5 2 fluorescein w/ proparacaine ophth soln

0.25-0.5% 2

OPHTHALMIC, IMMUNOMODULATOR RESTASIS EMU 0.05% 4 PA; A90, M90 OPHTHALMIC, MISCELLANEOUS altacaine sol 0.5% op 2 CYSTARAN SOL 0.44% 3 SP EYLEA INJ 2/0.05ML 4 SP JETREA INJ 2.5MG/ML 3 SP LACRISERT MIS 5MG OP 3 LUCENTIS SOL 0.3MG 3 SP LUCENTIS SOL 0.5MG 3 SP


128

Drug Name Drug Tier Requirements/Limits MACUGEN INJ 4 SP proparacaine hcl ophth soln 0.5% 2 tetcaine sol 0.5% op 2 tetracaine hcl ophth soln 0.5% 2 tetravisc sol forte 2 VISUDYNE INJ 15MG 4 SP OPHTHALMIC, MYDRIATICS atropine sulfate ophth soln 1% 1 A90, M90 cyclopentolate hcl ophth soln 1% 2 A90, M90 cyclopentolate hcl ophth soln 2% 2 A90, M90 homatropaire sol 5% op 2 A90, M90 homatropine hbr ophth soln 5% 2 A90, M90 tropicamide ophth soln 0.5% 2 A90, M90 tropicamide ophth soln 1% 2 A90, M90 OPHTHALMIC, PARASYMPATHOMIMETICS ISO CARBACHO SOL 1.5% OP 4 A90, M90 ISO CARBACHO SOL 3% OP 4 A90, M90 pilocarpine hcl ophth soln 1% 2 A90, M90 pilocarpine hcl ophth soln 2% 2 A90, M90 pilocarpine hcl ophth soln 4% 2 A90, M90 OPHTHALMIC, PROSTAGLANDINS latanoprost ophth soln 0.005% 2 A90, M90 LUMIGAN SOL 0.01% 4 A90, M90 TRAVATAN Z DRO 0.004% 3 A90, M90 travoprost ophth soln 0.004% 3 A90, M90 OPHTHALMIC, SYMPATHOMIMETIC/BETA-BLOCKER COMBINATIONS COMBIGAN SOL 0.2/0.5% 4 A90, M90 OPHTHALMIC, SYMPATHOMIMETICS ALPHAGAN P SOL 0.1% 4 A90, M90 apraclonidine hcl ophth soln 0.5% (base

equivalent) 2

brimonidine tartrate ophth soln 0.2% 2 A90, M90 brimonidine tartrate ophth soln 0.15% 2 A90, M90 IOPIDINE SOL 1% OP 4 PHOSPHOLINE SOL 0.125%OP 3 A90, M90 OTIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS acetasol hc sol otic 2 CIPRODEX SUS 0.3-0.1% 3 hydrocortisone w/ acetic acid otic soln 1-

2% 2

neomycin-polymyxin-hc otic soln 1% 2


129

Drug Name Drug Tier Requirements/Limits neomycin-polymyxin-hc otic susp 3.5

mg/ml-10000 unit/ml-1% 2

OTIC, ANTI-INFECTIVES ofloxacin otic soln 0.3% 2 OTIC, MISCELLANEOUS antipyrine-benzocaine otic soln 54-14

mg/ml (5.4-1.4%) 2

fluocinolone acetonide (otic) oil 0.01% 2

130

Index 8 8-MOP CAP 10MG ........................... 120 A abacavir sulfate tab 300 mg (base equiv) ..................................................... 18 abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg ........................ 17 ABELCET INJ 5MG/ML ....................... 15 ABILIFY MAIN INJ 300MG .................. 56 ABILIFY MAIN INJ 400MG .................. 56 ABRAXANE INJ 100MG ...................... 26 acamprosate calcium tab delayed release 333 mg ........................................... 68 acarbose tab 100 mg ........................ 70 acarbose tab 25 mg .......................... 70 acarbose tab 50 mg .......................... 70 acebutolol hcl cap 200 mg ................. 37 acebutolol hcl cap 400 mg ................. 37 acetaminophen w/ codeine soln 120-12 mg/5ml ............................................ 4 acetaminophen w/ codeine tab 300-15 mg .................................................. 4 acetaminophen w/ codeine tab 300-30 mg .................................................. 4 acetaminophen w/ codeine tab 300-60 mg .................................................. 4 acetasol hc sol otic ......................... 128 acetazolamide cap sr 12hr 500 mg ... 127 acetazolamide sodium for inj 500 mg 127 acetazolamide tab 125 mg ............... 127 acetazolamide tab 250 mg ............... 127 acetylcysteine inhal soln 10% .......... 115 acetylcysteine inhal soln 20% .......... 115 acetylcysteine inj 200 mg/ml ............. 80 ACIPHEX SPR CAP 10MG ................... 93 ACIPHEX SPR CAP 5MG ..................... 93 acitretin cap 10 mg ........................ 120 acitretin cap 17.5 mg ...................... 120 acitretin cap 25 mg ........................ 120 ACTIMMUNE INJ 2MU/0.5 ................ 103 ACTOPLUS MET TAB XR ..................... 72 ACUVAIL SOL 0.45% ...................... 125 acyclovir cap 200 mg ........................ 20 acyclovir oint 5% ........................... 123

acyclovir sodium for inj 500 mg ......... 20 acyclovir susp 200 mg/5ml ............... 20 acyclovir tab 400 mg ........................ 20 acyclovir tab 800 mg ........................ 20 ADACEL INJ ................................... 105 ADAGEN INJ 250/ML ........................ 84 ADCETRIS INJ 50MG ........................ 26 ADCIRCA TAB 20MG......................... 44 ADDYI TAB 100MG ........................... 66 adefovir dipivoxil tab 10 mg .............. 20 ADEMPAS TAB 0.5MG ....................... 44 ADEMPAS TAB 1.5MG ....................... 44 ADEMPAS TAB 1MG .......................... 44 ADEMPAS TAB 2.5MG ....................... 44 ADEMPAS TAB 2MG .......................... 44 adenosine iv soln 12 mg/4ml ............. 33 adenosine iv soln 6 mg/2ml .............. 33 adrucil inj 500/10ml ......................... 23 ADVATE INJ 1000UNIT ..................... 99 ADVATE INJ 1500UNIT ..................... 99 ADVATE INJ 2000UNIT ..................... 99 ADVATE INJ 250UNIT ....................... 99 ADVATE INJ 3000UNIT ..................... 99 ADVATE INJ 4000UNIT ..................... 99 ADVATE INJ 500UNIT ....................... 99 afeditab tab 30mg cr ........................ 38 afeditab tab 60mg cr ........................ 38 AFINITOR DIS TAB 2MG ................... 25 AFINITOR DIS TAB 3MG ................... 25 AFINITOR DIS TAB 5MG ................... 25 AFINITOR TAB 10MG ........................ 25 AFINITOR TAB 2.5MG ....................... 25 AFINITOR TAB 5MG ......................... 25 AFINITOR TAB 7.5MG ....................... 25 AFLURIA INJ 2015-16 ...................... 105 AFLURIA INJ PF 15-16 ..................... 105 AGGRASTAT INJ 5/100ML ................ 101 AGGRENOX CAP 25-200MG .............. 101 a-hydrocort inj 100mg ..................... 82 ala cort cre 1% .............................. 121 ALBENZA TAB 200MG ....................... 21 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)........................................ 113 albuterol sulfate soln nebu 0.5% (5

131

mg/ml) ......................................... 113 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) .................................. 113 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) .................................. 113 albuterol sulfate syrup 2 mg/5ml ...... 114 albuterol sulfate tab 2 mg ................ 114 albuterol sulfate tab 4 mg ................ 114 albuterol sulfate tab sr 12hr 4 mg ..... 114 albuterol sulfate tab sr 12hr 8 mg ..... 114 alclometasone dipropionate cream 0.05% ................................................... 121 alclometasone dipropionate oint 0.05% ................................................... 121 ALCOHOL SWABS ............................. 75 ALDURAZYME INJ 2.9MG/5M .............. 84 alendronate sodium oral soln 70 mg/75ml ......................................... 75 alendronate sodium tab 10 mg ........... 75 alendronate sodium tab 35 mg ........... 75 alendronate sodium tab 40 mg ........... 75 alendronate sodium tab 5 mg ............. 75 alendronate sodium tab 70 mg ........... 75 alfentanil inj 500 mcg/ml .................... 4 ALFERON N INJ 5MU/ML .................. 103 alfuzosin hcl tab sr 24hr 10 mg .......... 94 ALIMTA INJ 500MG ........................... 23 ALINIA SUS 100/5ML ........................ 21 ALINIA TAB 500MG ........................... 21 ALKERAN TAB 2MG ........................... 22 allopurinol tab 100 mg ....................... 2 allopurinol tab 300 mg ....................... 2 almotriptan malate tab 12.5 mg ......... 66 almotriptan malate tab 6.25 mg ......... 65 ALOCRIL SOL 2% ........................... 126 alogliptin benzoate tab 12.5 mg (base equiv) ............................................. 72 alogliptin benzoate tab 25 mg (base equiv) ............................................. 72 alogliptin benzoate tab 6.25 mg (base equiv) ............................................. 72 alogliptin-metformin hcl tab 12.5-1000 mg ................................................. 71 alogliptin-metformin hcl tab 12.5-500 mg ..................................................... 71

alogliptin-pioglitazone tab 12.5-15 mg 71 alogliptin-pioglitazone tab 12.5-30 mg 71 alogliptin-pioglitazone tab 12.5-45 mg 71 alogliptin-pioglitazone tab 25-15 mg .. 71 alogliptin-pioglitazone tab 25-30 mg .. 72 alogliptin-pioglitazone tab 25-45 mg .. 72 ALOMIDE SOL 0.1% OP ................... 126 alosetron hcl tab 0.5 mg (base equiv) 91 alosetron hcl tab 1 mg (base equiv) ... 91 ALOXI INJ 0.25MG/5 ........................ 88 ALPHAGAN P SOL 0.1% ................... 128 ALPHANATE INJ VWF/HUM ................ 99 ALPHANINE SD INJ 1000UNIT ........... 99 ALPHANINE SD INJ 1500UNIT ........... 99 ALPHANINE SD INJ 500UNIT ............. 99 alprazolam orally disintegrating tab 0.25 mg ................................................ 45 alprazolam orally disintegrating tab 0.5 mg ................................................ 45 alprazolam orally disintegrating tab 1 mg ..................................................... 45 alprazolam orally disintegrating tab 2 mg ..................................................... 45 alprazolam tab 0.25 mg .................... 45 alprazolam tab 0.5 mg ..................... 45 alprazolam tab 1 mg ........................ 45 alprazolam tab 2 mg ........................ 45 alprazolam tab sr 24hr 0.5 mg .......... 45 alprazolam tab sr 24hr 1 mg ............. 45 alprazolam tab sr 24hr 2 mg ............. 45 alprazolam tab sr 24hr 3 mg ............. 45 alprostadil inj 500 mcg/ml ................ 42 ALREX SUS 0.2%............................ 126 ALTABAX OIN 1% ........................... 119 altacaine sol 0.5% op ...................... 127 altavera tab .................................... 77 alyacen tab 1/35 ............................. 77 alyacen tab 7/7/7 ............................ 79 amantadine hcl cap 100 mg .............. 54 amantadine hcl syrup 50 mg/5ml ....... 54 amantadine hcl tab 100 mg .............. 54 AMBISOME INJ 50MG ....................... 15 amcinonide cream 0.1% .................. 120 amethia lo tab ................................. 76 amethia tab .................................... 76

132

AMICAR TAB 500MG ....................... 101 amifostine crystalline for inj 500 mg ... 26 amikacin sulfate inj 500 mg/2ml (250 mg/ml) ........................................... 10 amiloride & hydrochlorothiazide tab 5-50 mg ................................................. 41 amiloride hcl tab 5 mg ...................... 41 aminocaproic acid inj 250 mg/ml ...... 101 aminophylline inj 25 mg/ml ............. 116 amiodarone hcl inj 150 mg/3ml (50 mg/ml) ........................................... 33 amiodarone hcl tab 100 mg ............... 33 amiodarone hcl tab 200 mg ............... 33 amiodarone hcl tab 400 mg ............... 33 AMITIZA CAP 24MCG ........................ 91 AMITIZA CAP 8MCG .......................... 91 amitriptyline hcl tab 10 mg ................ 53 amitriptyline hcl tab 100 mg .............. 53 amitriptyline hcl tab 150 mg .............. 53 amitriptyline hcl tab 25 mg ................ 53 amitriptyline hcl tab 50 mg ................ 53 amitriptyline hcl tab 75 mg ................ 53 amlodipine besylate tab 10 mg ........... 38 amlodipine besylate tab 2.5 mg .......... 38 amlodipine besylate tab 5 mg ............ 38 amlodipine besylate-benazepril hcl cap 10-20 mg ........................................ 29 amlodipine besylate-benazepril hcl cap 10-40 mg ........................................ 29 amlodipine besylate-benazepril hcl cap 2.5-10 mg ....................................... 29 amlodipine besylate-benazepril hcl cap 5-10 mg ............................................ 29 amlodipine besylate-benazepril hcl cap 5-20 mg ............................................ 29 amlodipine besylate-benazepril hcl cap 5-40 mg ............................................ 29 amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg ......................... 32 amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg ............................ 32 amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg ............................ 32 amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg ........................... 31

amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg ............................. 32 amoxapine tab 100 mg ..................... 53 amoxapine tab 150 mg ..................... 53 amoxapine tab 25 mg ...................... 53 amoxapine tab 50 mg ...................... 53 amoxicillin & k clavulanate chew tab 200-28.5 mg ......................................... 13 amoxicillin & k clavulanate chew tab 400-57 mg ............................................ 13 amoxicillin & k clavulanate for susp 200-28.5 mg/5ml ................................... 13 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml ................................... 13 amoxicillin & k clavulanate for susp 400-57 mg/5ml ..................................... 13 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml ................................... 13 amoxicillin & k clavulanate tab 250-125 mg ................................................ 13 amoxicillin & k clavulanate tab 500-125 mg ................................................ 13 amoxicillin & k clavulanate tab 875-125 mg ................................................ 13 amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg ................................. 13 amoxicillin (trihydrate) cap 250 mg .... 13 amoxicillin (trihydrate) cap 500 mg .... 13 amoxicillin (trihydrate) for susp 125 mg/5ml .......................................... 13 amoxicillin (trihydrate) for susp 200 mg/5ml .......................................... 13 amoxicillin (trihydrate) for susp 250 mg/5ml .......................................... 14 amoxicillin (trihydrate) for susp 400 mg/5ml .......................................... 14 amoxicillin (trihydrate) tab 500 mg .... 14 amoxicillin (trihydrate) tab 875 mg .... 14 amoxicillin cap-clarithro tab-lansopraz cap dr therapy pack ......................... 94 amphetamine-dextroamphetamine cap sr 24hr 10 mg .................................... 61 amphetamine-dextroamphetamine cap sr 24hr 15 mg .................................... 61 amphetamine-dextroamphetamine cap sr

133

24hr 20 mg ..................................... 61 amphetamine-dextroamphetamine cap sr 24hr 25 mg ..................................... 61 amphetamine-dextroamphetamine cap sr 24hr 30 mg ..................................... 61 amphetamine-dextroamphetamine cap sr 24hr 5 mg ....................................... 61 amphetamine-dextroamphetamine tab 10 mg ............................................ 61 amphetamine-dextroamphetamine tab 12.5 mg .......................................... 61 amphetamine-dextroamphetamine tab 15 mg ............................................ 61 amphetamine-dextroamphetamine tab 20 mg ............................................ 61 amphetamine-dextroamphetamine tab 30 mg ............................................ 61 amphetamine-dextroamphetamine tab 5 mg ................................................. 61 amphetamine-dextroamphetamine tab 7.5 mg ........................................... 61 AMPHOTEC INJ 50MG ........................ 15 amphotericin b for inj 50 mg .............. 15 ampicillin & sulbactam sodium for inj 3 (2-1) gm ......................................... 14 ampicillin & sulbactam sodium for iv soln 15 (10-5) gm ................................... 14 ampicillin cap 250 mg ....................... 14 ampicillin cap 500 mg ....................... 14 ampicillin sodium for inj 250 mg ......... 14 ampicillin sodium for iv soln 10 gm ..... 14 AMPYRA TAB 10MG ........................... 67 ANADROL-50 TAB 50MG .................... 69 anagrelide hcl cap 0.5 mg ................ 102 anagrelide hcl cap 1 mg .................. 102 ana-lex kit ....................................... 94 anastrozole tab 1 mg ........................ 24 ANDRODERM DIS 2MG/24HR ............. 70 ANDRODERM DIS 4MG/24HR ............. 70 ANDROGEL GEL 1%(25MG) ............... 70 ANDROGEL GEL 1.62% ..................... 70 ANDROXY TAB 10MG ........................ 70 anti-itch cre 1% ............................. 121 antipyrine-benzocaine otic soln 54-14 mg/ml (5.4-1.4%) .......................... 129

ANZEMET TAB 100MG ...................... 88 ANZEMET TAB 50MG ........................ 88 APEXICON E CRE 0.05% .................. 120 APIDRA INJ SOLOSTAR ..................... 73 APIDRA INJ U-100 ........................... 73 APOKYN INJ 10MG/ML ...................... 54 apraclonidine hcl ophth soln 0.5% (base equivalent) .................................... 128 apri tab .......................................... 77 APTIVUS CAP 250MG ....................... 17 APTIVUS SOL .................................. 17 ARALAST NP INJ 500MG .................. 115 aranelle tab .................................... 79 ARANESP INJ 100MCG ..................... 100 ARANESP INJ 150MCG ..................... 100 ARANESP INJ 200MCG ..................... 100 ARANESP INJ 25MCG ...................... 100 ARANESP INJ 300MCG ..................... 100 ARANESP INJ 40MCG ...................... 100 ARANESP INJ 500MCG ..................... 100 ARANESP INJ 60MCG ...................... 100 arbinoxa sol 4mg/5ml ..................... 112 arbinoxa tab 4mg ........................... 112 ARCALYST INJ 220MG ..................... 104 ARCAPTA CAP 75MCG ...................... 113 argatroban inj 250 mg/2.5ml (concentrate for iv infusion) .............. 97 aripiprazole oral solution 1 mg/ml ...... 56 aripiprazole tab 10 mg ..................... 56 aripiprazole tab 15 mg ..................... 56 aripiprazole tab 2 mg ....................... 56 aripiprazole tab 20 mg ..................... 56 aripiprazole tab 30 mg ..................... 56 aripiprazole tab 5 mg ....................... 56 ARISTADA INJ 441MG/1. .................. 56 ARISTADA INJ 662MG/2 ................... 56 ARISTADA INJ 882MG/3 ................... 56 armodafinil tab 150 mg .................... 68 armodafinil tab 200 mg .................... 68 armodafinil tab 250 mg .................... 68 armodafinil tab 50 mg ...................... 68 ARMOUR THYRO TAB 120MG ............. 86 ARMOUR THYRO TAB 15MG ............... 86 ARMOUR THYRO TAB 180MG ............. 86 ARMOUR THYRO TAB 240MG ............. 86

134

ARMOUR THYRO TAB 300MG .............. 86 ARRANON INJ 5MG/ML ...................... 26 ARZERRA CON 1000/50 .................... 26 arzol silver mis nitr app ................... 123 ASACOL HD TAB 800MG .................... 91 ascomp/cod cap 30mg ....................... 4 ASMANEX 120 AER 220MCG ............ 116 ASMANEX 14 AER 220MCG .............. 116 ASMANEX 30 AER 110MCG .............. 116 ASMANEX 30 AER 220MCG .............. 116 ASMANEX 60 AER 220MCG .............. 116 ASMANEX 7 AER 110MCG ................ 116 ASMANEX HFA AER 100 MCG ........... 116 ASMANEX HFA AER 200 MCG ........... 116 aspirin chew tab 81 mg ................... 101 aspirin low tab 81mg ec .................. 101 aspirin tab 325 mg ......................... 102 aspirin tab delayed release 325 mg ... 102 aspirin-caffeine-dihydrocodeine cap 356.4-30-16 mg ................................ 4 aspir-low tab 81mg ec .................... 101 atenolol & chlorthalidone tab 100-25 mg ..................................................... 37 atenolol & chlorthalidone tab 50-25 mg ..................................................... 37 atenolol tab 100 mg ......................... 37 atenolol tab 25 mg ........................... 37 atenolol tab 50 mg ........................... 37 ATGAM INJ 250MG ......................... 103 atorvastatin calcium tab 10 mg (base equivalent) ...................................... 35 atorvastatin calcium tab 20 mg (base equivalent) ...................................... 35 atorvastatin calcium tab 40 mg (base equivalent) ...................................... 35 atorvastatin calcium tab 80 mg (base equivalent) ...................................... 35 atovaquone susp 750 mg/5ml ............ 21 atovaquone-proguanil hcl tab 250-100 mg ................................................. 16 atovaquone-proguanil hcl tab 62.5-25 mg ................................................. 16 ATRIPLA TAB ................................... 17 atropine sulfate inj 0.1 mg/ml ............ 89 atropine sulfate inj 0.4 mg/ml ............ 89

atropine sulfate inj 1 mg/ml .............. 89 atropine sulfate ophth soln 1% ......... 128 ATROVENT HFA AER 17MCG ............. 112 AUBAGIO TAB 14MG ........................ 67 AUBAGIO TAB 7MG .......................... 67 aubra tab 0.1-0.02 .......................... 77 AUGMENTIN SUS 125/5ML ................ 14 AVANDIA TAB 2MG .......................... 72 AVANDIA TAB 4MG .......................... 72 avar cleanse emu 10-5% ................. 117 avar-e emoll cre 10-5% ................... 117 AVASTIN INJ ................................... 26 AVC CRE 15% ................................. 97 AVELOX INJ .................................... 12 aviane tab ...................................... 77 avidoxy tab 100mg .......................... 15 AVONEX KIT 30MCG ........................ 67 AVONEX PREFL KIT 30MCG ............... 67 AXIRON SOL 30MG/ACT ................... 70 azacitidine for inj 100 mg ................. 23 AZASAN TAB 100MG ....................... 104 AZASAN TAB 75 MG ........................ 104 azathioprine tab 50 mg ................... 104 azelastine hcl nasal spray 0.1% (137 mcg/spray) .................................... 115 azelastine hcl nasal spray 0.15% (205.5 mcg/spray) .................................... 115 azelastine hcl ophth soln 0.05% ....... 126 AZELEX CRE 20% ........................... 117 AZILECT TAB 0.5MG ........................ 54 AZILECT TAB 1MG ........................... 54 azithromycin for susp 100 mg/5ml ..... 12 azithromycin for susp 200 mg/5ml ..... 12 azithromycin iv for soln 500 mg ......... 12 azithromycin powd pack for susp 1 gm 12 azithromycin tab 250 mg .................. 12 azithromycin tab 500 mg .................. 12 azithromycin tab 600 mg .................. 12 AZOPT SUS 1% OP ......................... 127 aztreonam for inj 1 gm ..................... 21 azurette tab 28 day ......................... 76 B BABY DDROPS LIQ 400UNIT ............. 107 baciim inj 50000unt ......................... 21 bacit/polymy oin op ........................ 125

135

bacitracin ophth oint 500 unit/gm ..... 125 bacitracin-polymyxin-neomycin-hc ophth oint 1% ........................................ 125 baclofen tab 10 mg ........................... 67 baclofen tab 20 mg ........................... 67 BACTOCILL INJ DEX 1GM .................. 14 BACTROBAN OIN NASAL 2% ............ 119 balsalazide disodium cap 750 mg ........ 91 balziva tab ...................................... 77 BANZEL SUS 40MG/ML ...................... 46 BANZEL TAB 200MG ......................... 46 BANZEL TAB 400MG ......................... 46 bayer asa tab 325mg ...................... 102 bayer low chw 81mg ....................... 102 BELBUCA MIS 150MCG ....................... 4 BELBUCA MIS 300MCG ....................... 4 BELBUCA MIS 600MCG ....................... 4 BELBUCA MIS 75MCG ........................ 4 BELEODAQ INJ 500MG ...................... 27 benazepril & hydrochlorothiazide tab 10-12.5 mg .......................................... 29 benazepril & hydrochlorothiazide tab 20-12.5 mg .......................................... 29 benazepril & hydrochlorothiazide tab 20-25 mg ............................................ 29 benazepril & hydrochlorothiazide tab 5-6.25 mg .......................................... 29 benazepril hcl tab 10 mg ................... 30 benazepril hcl tab 20 mg ................... 30 benazepril hcl tab 40 mg ................... 30 benazepril hcl tab 5 mg ..................... 30 BENEFIX INJ 1000UNIT ..................... 99 BENEFIX INJ 2000UNIT ..................... 99 BENEFIX INJ 250UNIT ....................... 99 BENEFIX INJ 3000UNIT ..................... 99 BENEFIX INJ 500UNIT ....................... 99 BENICAR HCT TAB 20-12.5 ................ 32 BENICAR HCT TAB 40-12.5 ................ 32 BENICAR HCT TAB 40-25MG .............. 32 BENICAR TAB 20MG.......................... 33 BENICAR TAB 40MG.......................... 33 BENICAR TAB 5MG ........................... 33 BENLYSTA INJ 120MG ..................... 104 benzepro aer 5.3% ......................... 117 benzepro sc aer 9.8% ..................... 117

benzonatate cap 100 mg ................. 113 benzonatate cap 200 mg ................. 113 benzoyl per liq 10% wash ................ 117 benzoyl peroxide foam 5.3% ............ 117 benzoyl peroxide foam 9.8% ............ 117 benzoyl peroxide-erythromycin gel 5-3% .................................................... 117 benztropine mesylate inj 1 mg/ml ...... 54 benztropine mesylate tab 0.5 mg ....... 54 benztropine mesylate tab 1 mg ......... 54 benztropine mesylate tab 2 mg ......... 54 BEPREVE DRO 1.5% ....................... 126 BERINERT INJ 500UNIT ................... 101 BESIVANCE SUS 0.6% .................... 125 betamethasone dipropionate augmented cream 0.05% ................................. 120 betamethasone dipropionate augmented gel 0.05% ..................................... 122 betamethasone dipropionate augmented lotion 0.05% .................................. 120 betamethasone dipropionate augmented oint 0.05% .................................... 122 betamethasone dipropionate cream 0.05% .......................................... 120 betamethasone dipropionate lotion 0.05% .......................................... 120 betamethasone dipropionate oint 0.05% .................................................... 120 betamethasone sod phosphate & acetate inj susp 6 (3-3) mg/ml ..................... 82 betamethasone valerate aerosol foam 0.12% .......................................... 121 betamethasone valerate cream 0.1% 121 betamethasone valerate lotion 0.1% . 121 betamethasone valerate oint 0.1% .... 121 BETASERON INJ 0.3MG .................... 67 betaxolol hcl ophth soln 0.5% .......... 127 betaxolol hcl tab 10 mg .................... 37 betaxolol hcl tab 20 mg .................... 37 bethanechol chloride tab 10 mg ......... 95 bethanechol chloride tab 25 mg ......... 95 bethanechol chloride tab 5 mg ........... 95 bethanechol chloride tab 50 mg ......... 95 BETIMOL SOL 0.25% ...................... 126 BETIMOL SOL 0.5% ........................ 126

136

bexarotene cap 75 mg ...................... 27 BEXSERO INJ ................................. 105 bicalutamide tab 50 mg ..................... 23 BICILLIN C-R INJ 1200000 ................ 14 BICILLIN L-A INJ 1200000 ................. 14 BICILLIN L-A INJ 2400000 ................. 14 BICILLIN L-A INJ 600000................... 14 BICNU INJ 100MG ............................ 22 BIDIL TAB ....................................... 43 BILTRICIDE TAB 600MG .................... 21 bio-d-mulsio liq 400unit .................. 107 BIOTHRAX INJ ............................... 105 bisoprolol & hydrochlorothiazide tab 10-6.25 mg .......................................... 37 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg .......................................... 37 bisoprolol & hydrochlorothiazide tab 5-6.25 mg .......................................... 37 bisoprolol fumarate tab 10 mg ........... 37 bisoprolol fumarate tab 5 mg ............. 37 BIVIGAM INJ 10% .......................... 103 bleomycin sulfate for inj 15 unit ......... 27 BOOSTRIX INJ ............................... 105 BOSULIF TAB 100MG ........................ 25 BOSULIF TAB 500MG ........................ 25 BOTOX INJ 100UNIT ......................... 66 BOTOX INJ 200UNIT ......................... 66 bp cleansing emu 10-4% ................. 117 bp wash liq 2.5% ........................... 117 bp wash liq 7% .............................. 117 bpo cloths mis 6% .......................... 117 BPO CREAMY KIT 8% WASH ............ 117 briellyn tab ...................................... 77 BRILINTA TAB 90MG ....................... 102 brimonidine tartrate ophth soln 0.15% ................................................... 128 brimonidine tartrate ophth soln 0.2% 128 bromfenac sodium ophth soln 0.09% (base equiv) (once-daily) ................ 125 bromocriptine mesylate cap 5 mg (base equivalent) ...................................... 54 bromocriptine mesylate tab 2.5 mg (base equivalent) ...................................... 54 BROVANA NEB 15MCG .................... 113 budesonide delayed release particles cap

3 mg ............................................. 91 budesonide inhalation susp 0.25 mg/2ml .................................................... 116 budesonide inhalation susp 0.5 mg/2ml .................................................... 116 budesonide inhalation susp 1 mg/2ml 116 budesonide nasal susp 32 mcg/act .... 115 bumetanide inj 0.25 mg/ml ............... 41 bumetanide tab 0.5 mg .................... 41 bumetanide tab 1 mg ....................... 41 bumetanide tab 2 mg ....................... 41 BUPHENYL TAB 500MG ..................... 92 buprenorphine hcl inj 0.3 mg/ml (base equiv) .............................................. 4 buprenorphine hcl sl tab 2 mg (base equiv) ............................................ 69 buprenorphine hcl sl tab 8 mg (base equiv) ............................................ 69 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) ........................ 69 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) ........................... 69 bupropion hcl tab 100 mg ................. 50 bupropion hcl tab 75 mg ................... 50 bupropion hcl tab sr 12hr 100 mg ...... 51 bupropion hcl tab sr 12hr 150 mg ...... 51 bupropion hcl tab sr 12hr 200 mg ...... 51 bupropion hcl tab sr 24hr 150 mg ...... 51 bupropion hcl tab sr 24hr 300 mg ...... 51 buspirone hcl tab 10 mg ................... 46 buspirone hcl tab 15 mg ................... 46 buspirone hcl tab 30 mg ................... 46 buspirone hcl tab 5 mg ..................... 46 buspirone hcl tab 7.5 mg .................. 46 BUSULFEX INJ 6MG/ML .................... 22 butalbital-acetaminophen tab 50-325 mg ....................................................... 2 butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg .............................. 4 butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg .............................. 5 butalbital-acetaminophen-caffeine cap 50-300-40 mg ................................... 2 butalbital-acetaminophen-caffeine cap 50-325-40 mg ................................... 2

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butalbital-acetaminophen-caffeine tab 50-325-40 mg .................................. 2 butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg .................................. 5 butalbital-aspirin-caffeine cap 50-325-40 mg .................................................. 2 butorphanol tartrate inj 1 mg/ml ......... 5 butorphanol tartrate inj 2 mg/ml ......... 5 butorphanol tartrate nasal soln 10 mg/ml ...................................................... 5 BUTRANS DIS 10MCG/HR ................... 5 BUTRANS DIS 15MCG/HR ................... 5 BUTRANS DIS 20MCG/HR ................... 5 BUTRANS DIS 5MCG/HR ..................... 5 BUTRANS DIS 7.5/HR ........................ 5 BYDUREON INJ 2MG ......................... 72 BYDUREON PEN INJ 2MG ................... 72 BYETTA INJ 10MCG ........................... 72 BYETTA INJ 5MCG ............................ 72 C cabergoline tab 0.5 mg ..................... 84 CAFERGOT TAB 1-100MG .................. 65 caffeine citrate inj 60 mg/3ml (10 mg/ml base equiv) ................................... 115 caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) ......................... 115 calcipotriene cream 0.005% ............. 120 calcipotriene oint 0.005% ................ 120 calcipotriene soln 0.005% (50 mcg/ml) ................................................... 120 calcipotriene-betamethasone dipropionate oint 0.005-0.064% ....... 120 calcitonin (salmon) nasal soln 200 unit/act ........................................... 76 calcitrene oin 0.005% ..................... 120 calcitriol cap 0.25 mcg ...................... 84 calcitriol cap 0.5 mcg ........................ 84 calcitriol inj 1 mcg/ml ....................... 84 calcitriol oint 3 mcg/gm ................... 120 calcitriol oral soln 1 mcg/ml ............... 84 calcium acetate (phosphate binder) cap 667 mg (169 mg ca) ......................... 85 calcium acetate (phosphate binder) tab 667 mg ........................................... 85 camila tab 0.35mg ........................... 79

CAMPTOSAR INJ 40MG/2ML .............. 27 camrese lo tab ................................ 76 camrese tab .................................... 76 CANASA SUP 1000MG ...................... 91 CANCIDAS INJ 50MG ....................... 16 CANCIDAS INJ 70MG ....................... 16 candesartan cilexetil tab 16 mg ......... 33 candesartan cilexetil tab 32 mg ......... 33 candesartan cilexetil tab 4 mg ........... 33 candesartan cilexetil tab 8 mg ........... 33 candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg ............................... 32 candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg ............................... 32 candesartan cilexetil-hydrochlorothiazide tab 32-25 mg .................................. 32 capacet cap ...................................... 2 CAPASTAT SUL INJ 1GM ................... 19 capecitabine tab 150 mg .................. 23 capecitabine tab 500 mg .................. 23 CAPEX SHA 0.01% .......................... 121 CAPRELSA TAB 100MG ..................... 25 CAPRELSA TAB 300MG ..................... 25 captopril tab 100 mg ........................ 30 captopril tab 12.5 mg ....................... 30 captopril tab 25 mg ......................... 30 captopril tab 50 mg ......................... 30 CARAFATE SUS 1GM/10ML ................ 92 CARBAGLU TAB 200MG .................... 84 carbamazepine cap sr 12hr 100 mg .... 46 carbamazepine cap sr 12hr 200 mg .... 46 carbamazepine cap sr 12hr 300 mg .... 46 carbamazepine chew tab 100 mg ....... 46 carbamazepine susp 100 mg/5ml ....... 46 carbamazepine tab 200 mg ............... 46 carbamazepine tab sr 12hr 100 mg .... 46 carbamazepine tab sr 12hr 200 mg .... 46 carbamazepine tab sr 12hr 400 mg .... 46 carbidopa & levodopa orally disintegrating tab 10-100 mg ............ 55 carbidopa & levodopa orally disintegrating tab 25-100 mg ............ 55 carbidopa & levodopa orally disintegrating tab 25-250 mg ............ 55 carbidopa & levodopa tab 10-100 mg . 55

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carbidopa & levodopa tab 25-100 mg .. 55 carbidopa & levodopa tab 25-250 mg .. 55 carbidopa & levodopa tab cr 25-100 mg ..................................................... 55 carbidopa & levodopa tab cr 50-200 mg ..................................................... 55 carbidopa tab 25 mg ......................... 55 carbinoxamine maleate soln 4 mg/5ml ................................................... 112 carbinoxamine maleate tab 4 mg ...... 112 carboplatin iv soln 50 mg/5ml ............ 22 CARDIZEM LA TAB 120MG ................. 39 CARIMUNE NF INJ 6GM ................... 103 carisoprodol tab 250 mg .................... 67 carisoprodol tab 350 mg .................... 67 carisoprodol w/ aspirin & codeine tab 200-325-16 mg ................................ 67 carisoprodol w/ aspirin tab 200-325 mg ..................................................... 67 carteolol hcl ophth soln 1% .............. 126 cartia xt cap 120/24hr ...................... 39 cartia xt cap 180/24hr ...................... 39 cartia xt cap 240/24hr ...................... 39 cartia xt cap 300/24hr ...................... 39 carvedilol tab 12.5 mg ...................... 37 carvedilol tab 25 mg ......................... 37 carvedilol tab 3.125 mg ..................... 37 carvedilol tab 6.25 mg ...................... 37 cavirinse sol 0.2% .......................... 124 CAYSTON INH 75MG ....................... 114 caziant pak ...................................... 79 cefaclor cap 250 mg ......................... 11 cefaclor cap 500 mg ......................... 11 cefadroxil cap 500 mg ....................... 10 cefadroxil for susp 250 mg/5ml .......... 10 cefadroxil for susp 500 mg/5ml .......... 10 cefadroxil tab 1 gm ........................... 10 cefazolin sodium for inj 1 gm ............. 10 cefazolin sodium for inj 10 gm ........... 11 cefazolin sodium for inj 500 mg .......... 11 cefdinir cap 300 mg .......................... 11 cefdinir for susp 125 mg/5ml ............. 11 cefdinir for susp 250 mg/5ml ............. 11 cefditoren pivoxil tab 200 mg (base equivalent) ...................................... 11

cefditoren pivoxil tab 400 mg (base equivalent) ..................................... 11 cefixime for susp 100 mg/5ml ........... 11 cefixime for susp 200 mg/5ml ........... 11 cefotaxime sodium for inj 1 gm ......... 11 cefotaxime sodium for inj 10 gm ........ 11 cefotaxime sodium for inj 2 gm ......... 11 cefotaxime sodium for inj 500 mg ...... 11 cefoxitin sodium for inj 10 gm ........... 11 cefoxitin sodium for iv soln 1 gm ....... 11 cefoxitin sodium for iv soln 2 gm ....... 11 cefpodoxime proxetil for susp 100 mg/5ml .......................................... 11 cefpodoxime proxetil for susp 50 mg/5ml ..................................................... 11 cefpodoxime proxetil tab 100 mg ....... 11 cefpodoxime proxetil tab 200 mg ....... 11 cefprozil for susp 125 mg/5ml ........... 11 cefprozil for susp 250 mg/5ml ........... 11 cefprozil tab 250 mg ........................ 11 cefprozil tab 500 mg ........................ 11 ceftazidime for inj 1 gm .................... 12 ceftazidime for inj 2 gm .................... 12 ceftazidime for inj 6 gm .................... 12 ceftibuten cap 400 mg ...................... 12 ceftibuten for susp 180 mg/5ml ......... 12 CEFTIN SUS 125/5ML ....................... 11 CEFTIN SUS 250/5ML ....................... 11 ceftriaxone sodium for inj 10 gm ....... 12 ceftriaxone sodium for inj 2 gm ......... 12 ceftriaxone sodium for inj 250 mg ...... 12 cefuroxime axetil tab 250 mg ............ 11 cefuroxime axetil tab 500 mg ............ 11 cefuroxime sodium for inj 1.5 gm ...... 11 cefuroxime sodium for inj 7.5 gm ...... 11 cefuroxime sodium for inj 750 mg ...... 11 celecoxib cap 100 mg ......................... 2 celecoxib cap 200 mg ......................... 2 celecoxib cap 400 mg ......................... 2 celecoxib cap 50 mg .......................... 2 CELLCEPT IV INJ 500MG .................. 104 CELONTIN CAP 300MG ..................... 46 CENTANY OIN 2% ........................... 119 cephalexin cap 250 mg ..................... 11 cephalexin cap 500 mg ..................... 11

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cephalexin cap 750 mg ..................... 11 cephalexin for susp 125 mg/5ml ......... 11 cephalexin for susp 250 mg/5ml ......... 11 CEPROTIN INJ 500 UNIT .................. 101 CEREZYME INJ 400UNIT .................... 84 cerisa wash emu 10-1% .................. 117 CERVARIX INJ ................................ 105 CESAMET CAP 1MG ........................... 88 cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) ....................................... 112 cevimeline hcl cap 30 mg .................. 94 CHANTIX PAK 0.5& 1MG .................... 69 CHANTIX PAK 1MG ........................... 69 CHANTIX TAB 0.5MG ........................ 69 CHANTIX TAB 1MG ........................... 69 chateal tab 0.15/30 .......................... 77 CHEMET CAP 100MG ....................... 101 CHENODAL TAB 250MG ..................... 90 chlordiazepoxide hcl cap 10 mg .......... 45 chlordiazepoxide hcl cap 25 mg .......... 45 chlordiazepoxide hcl cap 5 mg ............ 45 CHLORHEX GLU SOL 20% ................ 123 chlorhexidine gluconate soln 0.12% .. 124 chloroquine phosphate tab 250 mg ..... 17 chloroquine phosphate tab 500 mg ..... 17 chlorothiazide sodium for inj 500 mg ... 41 chlorothiazide tab 250 mg ................. 41 chlorothiazide tab 500 mg ................. 41 CHLORPROMAZ INJ 25MG/ML ............. 60 CHLORPROMAZ INJ 50MG/2ML ........... 60 chlorpromazine hcl tab 10 mg ............ 60 chlorpromazine hcl tab 100 mg .......... 60 chlorpromazine hcl tab 200 mg .......... 60 chlorpromazine hcl tab 25 mg ............ 60 chlorpromazine hcl tab 50 mg ............ 60 chlorpropamide tab 100 mg ............... 74 chlorpropamide tab 250 mg ............... 74 chlorthalidone tab 25 mg ................... 41 chlorthalidone tab 50 mg ................... 41 chlorzoxazone tab 500 mg ................. 67 cholecalciferol cap 10000 unit .......... 107 cholecalciferol cap 2000 unit ............ 107 cholecalciferol cap 400 unit .............. 107 cholecalciferol cap 5000 unit ............ 107 cholecalciferol drops 5000 unit/ml (1000

unit/0.2ml) .................................... 107 cholecalciferol oral liquid 400 unit/ml 107 cholecalciferol tab 1000 unit ............. 107 cholecalciferol tab 2000 unit ............. 107 cholecalciferol tab 400 unit .............. 107 cholecalciferol tab 5000 unit ............. 107 cholestyramine light powder 4 gm/dose ..................................................... 34 choline & magnesium salicylates liq 500 mg/5ml ............................................ 3 choline & magnesium salicylates tab 1000 mg .......................................... 3 choline fenofibrate cap dr 135 mg (fenofibric acid equiv) ...................... 35 choline fenofibrate cap dr 45 mg (fenofibric acid equiv) ...................... 34 chorionic gonadotropin for inj 10000 unit ..................................................... 82 CIALIS TAB 10MG ............................ 95 CIALIS TAB 2.5MG ........................... 94 CIALIS TAB 20MG ............................ 95 CIALIS TAB 5MG ............................. 95 ciclodan cre 0.77% ......................... 119 ciclodan sol 8% .............................. 119 ciclopirox gel 0.77% ....................... 119 ciclopirox olamine cream 0.77% (base equiv) ........................................... 119 ciclopirox olamine susp 0.77% (base equiv) ........................................... 119 ciclopirox shampoo 1% ................... 119 ciclopirox solution 8% ..................... 119 cidofovir iv inj 75 mg/ml ................... 19 cilostazol tab 100 mg ...................... 101 cilostazol tab 50 mg ........................ 101 CILOXAN OIN 0.3% OP ................... 125 cimetidine hcl soln 300 mg/5ml ......... 90 cimetidine tab 200 mg ..................... 90 cimetidine tab 300 mg ..................... 90 cimetidine tab 400 mg ..................... 90 cimetidine tab 800 mg ..................... 90 CIMZIA KIT .................................... 102 CIMZIA PREFL KIT 200MG/ML........... 102 CINRYZE SOL 500 UNIT ................... 101 CIPRODEX SUS 0.3-0.1% ................ 128 ciprofloxacin for oral susp 250 mg/5ml

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(5%) (5 gm/100ml) .......................... 12 ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) ...................... 12 ciprofloxacin hcl ophth soln 0.3% ..... 125 ciprofloxacin hcl tab 100 mg (base equiv) ..................................................... 12 ciprofloxacin hcl tab 250 mg (base equiv) ..................................................... 13 ciprofloxacin hcl tab 500 mg (base equiv) ..................................................... 13 ciprofloxacin hcl tab 750 mg (base equiv) ..................................................... 13 ciprofloxacin iv soln 200 mg/20ml (1%) ..................................................... 13 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) ............................ 13 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) ............................. 13 cisplatin inj 50 mg/50ml (1 mg/ml) ..... 22 citalopram hydrobromide oral soln 10 mg/5ml ........................................... 52 citalopram hydrobromide tab 10 mg (base equiv) .................................... 52 citalopram hydrobromide tab 20 mg (base equiv) .................................... 52 citalopram hydrobromide tab 40 mg (base equiv) .................................... 52 CL PRENATAL TAB 28-0.8MG ............ 110 cladribine iv soln 10 mg/10ml (1 mg/ml) ..................................................... 23 CLARINEX SYP 0.5MG/ML ................ 112 clarithromycin for susp 125 mg/5ml .... 12 clarithromycin for susp 250 mg/5ml .... 12 clarithromycin tab 250 mg ................. 12 clarithromycin tab 500 mg ................. 12 clarithromycin tab sr 24hr 500 mg ...... 12 clemastine fumarate tab 2.68 mg ..... 112 CLINDACIN KIT PAC 1% .................. 117 clindamax gel 1% ........................... 117 clindamycin hcl cap 150 mg ............... 21 clindamycin hcl cap 300 mg ............... 21 clindamycin hcl cap 75 mg ................. 21 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) ........................ 21 clindamycin phosphate foam 1% ...... 117

clindamycin phosphate gel 1% ......... 117 clindamycin phosphate inj 600 mg/4ml 21 clindamycin phosphate lotion 1% ...... 117 clindamycin phosphate soln 1% ........ 117 clindamycin phosphate swab 1% ...... 117 clindamycin phosphate vaginal cream 2% ..................................................... 97 clinpro 5000 pst 1.1% ..................... 124 clobetasol propionate cream 0.05% .. 122 clobetasol propionate foam 0.05% .... 122 clobetasol propionate gel 0.05% ....... 122 clobetasol propionate lotion 0.05% ... 122 clobetasol propionate oint 0.05% ...... 122 clobetasol propionate shampoo 0.05% .................................................... 122 clobetasol propionate soln 0.05% ..... 122 clobetasol propionate spray 0.05% ... 122 CLOLAR INJ 1MG/ML ........................ 23 clomiphene citrate tab 50 mg ............ 82 clomipramine hcl cap 25 mg .............. 46 clomipramine hcl cap 50 mg .............. 46 clomipramine hcl cap 75 mg .............. 46 clonazepam orally disintegrating tab 0.125 mg ....................................... 45 clonazepam orally disintegrating tab 0.25 mg ................................................ 45 clonazepam orally disintegrating tab 0.5 mg ................................................ 45 clonazepam orally disintegrating tab 1 mg ................................................ 45 clonazepam orally disintegrating tab 2 mg ................................................ 45 clonazepam tab 0.5 mg .................... 45 clonazepam tab 1 mg ....................... 45 clonazepam tab 2 mg ....................... 45 clonidine hcl inj (for epidural infusion) 100 mcg/ml ...................................... 2 clonidine hcl inj (for epidural infusion) 500 mcg/ml ...................................... 2 clonidine hcl tab 0.1 mg ................... 31 clonidine hcl tab 0.2 mg ................... 31 clonidine hcl tab 0.3 mg ................... 31 clonidine hcl tab sr 12hr 0.1 mg ........ 61 clonidine hcl td patch weekly 0.1 mg/24hr ......................................... 31

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clonidine hcl td patch weekly 0.2 mg/24hr ......................................... 31 clonidine hcl td patch weekly 0.3 mg/24hr ......................................... 31 clopidogrel bisulfate tab 300 mg (base equiv) ........................................... 102 clopidogrel bisulfate tab 75 mg (base equiv) ........................................... 102 clorazepate dipotassium tab 15 mg ..... 45 clorazepate dipotassium tab 3.75 mg .. 45 clorazepate dipotassium tab 7.5 mg .... 45 clotrimazole cream 1% ................... 119 clotrimazole soln 1% ...................... 119 clotrimazole troche 10 mg ................. 16 clotrimazole w/ betamethasone cream 1-0.05% .......................................... 119 clotrimazole w/ betamethasone lotion 1-0.05% .......................................... 119 clozapine orally disintegrating tab 100 mg ................................................. 56 clozapine orally disintegrating tab 12.5 mg ................................................. 56 clozapine orally disintegrating tab 25 mg ..................................................... 56 clozapine tab 100 mg ........................ 56 clozapine tab 200 mg ........................ 56 clozapine tab 25 mg ......................... 56 clozapine tab 50 mg ......................... 56 CNL8 NAIL KIT ............................... 119 COARTEM TAB 20-120MG .................. 17 codeine sulfate tab 15 mg .................. 5 codeine sulfate tab 30 mg .................. 5 codeine sulfate tab 60 mg .................. 5 colchicine cap 0.6 mg ........................ 2 colchicine tab 0.6 mg ......................... 2 colchicine w/ probenecid tab 0.5-500 mg ...................................................... 2 colestipol hcl granule packets 5 gm ..... 34 colestipol hcl tab 1 gm ...................... 34 colistimethate sodium for inj 150 mg .. 21 colocort ene 100mg .......................... 91 COMBIGAN SOL 0.2/0.5% ............... 128 COMBIPATCH DIS .05/.14 ................. 80 COMBIPATCH DIS .05/.25 ................. 81 COMBIVENT AER 20-100 ................. 112

COMETRIQ KIT 100MG ..................... 25 COMETRIQ KIT 140MG ..................... 25 compazine sup 25mg ....................... 88 COMPLERA TAB ............................... 17 compro sup 25mg ............................ 88 CO-NATAL FA TAB 29-1MG ............... 110 CONCEPT OB CAP ........................... 110 CONCEPTROL GEL 4% ...................... 77 CONCERTA TAB 18MG ...................... 62 CONDYLOX GEL 0.5% ..................... 123 constulose sol 10gm/15 .................... 91 controlrx cre 1.1% .......................... 124 COOL MIST MIS 1.3 GAL .................. 115 COPAXONE INJ 40MG/ML .................. 67 CORDRAN 80X3 TAP 4MCG/CM ......... 121 CORDRAN LOT 0.05% ..................... 121 COREG CR CAP 10MG ....................... 37 COREG CR CAP 20MG ....................... 37 COREG CR CAP 40MG ....................... 37 COREG CR CAP 80MG ....................... 37 CORIFACT KIT ................................. 99 cormax scalp sol 0.05% .................. 122 CORTIFOAM AER 90MG .................... 91 CORTISPORIN CRE 0.5% ................. 118 CORTISPORIN OIN 1% .................... 118 COSENTYX INJ 150MG/ML ............... 120 CREON CAP 12000UNT ..................... 92 CREON CAP 24000UNT ..................... 92 CREON CAP 3000UNIT ...................... 92 CREON CAP 36000UNT ..................... 92 CREON CAP 6000UNIT ...................... 92 CRESEMBA CAP 186 MG ................... 16 CRINONE GEL 4% VAG ..................... 86 CRINONE GEL 8% VAG ..................... 86 CRIXIVAN CAP 200MG ...................... 17 CRIXIVAN CAP 400MG ...................... 17 cromolyn sodium ophth soln 4% ....... 126 cromolyn sodium oral conc 100 mg/5ml ..................................................... 92 cromolyn sodium soln nebu 20 mg/2ml .................................................... 114 cryselle-28 tab 28 tabs ..................... 77 CUPRIMINE CAP 250MG ................... 103 CUVPOSA SOL 1MG/5ML ................... 89 CVS PRENATAL TAB ........................ 110

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cyanocobalamin inj 1000 mcg/ml ..... 107 cyclafem tab 1/35 ............................ 77 cyclafem tab 7/7/7 ........................... 79 cyclobenzaprine hcl tab 10 mg ........... 67 cyclobenzaprine hcl tab 5 mg ............. 67 cyclobenzaprine hcl tab 7.5 mg .......... 67 cyclopentolate hcl ophth soln 1% ...... 128 cyclopentolate hcl ophth soln 2% ...... 128 CYCLOPHOSPH CAP 25MG ................. 22 CYCLOPHOSPH CAP 50MG ................. 22 cyclophosphamide for inj 2 gm ........... 22 cyclophosphamide for inj 500 mg ....... 22 cycloserine cap 250 mg ..................... 19 CYCLOSET TAB 0.8MG ....................... 73 cyclosporine cap 100 mg ................. 104 cyclosporine cap 25 mg ................... 104 cyclosporine iv soln 50 mg/ml .......... 104 cyclosporine modified cap 100 mg .... 104 cyclosporine modified cap 25 mg ...... 104 cyclosporine modified oral soln 100 mg/ml .......................................... 104 cyproheptadine hcl syrup 2 mg/5ml .. 112 cyproheptadine hcl tab 4 mg ............ 112 CYSTADANE POW ............................. 84 CYSTAGON CAP 150MG ..................... 95 CYSTAGON CAP 50MG ....................... 95 CYSTARAN SOL 0.44% .................... 127 cytarabine inj pf 100 mg/ml ............... 23 cytarabine inj pf 20 mg/ml ................ 23 CYTOGAM INJ ................................ 103 cytra k gra crystals ........................... 95 cytra-2 sol ....................................... 95 D dacarbazine for inj 200 mg ................ 22 DALIRESP TAB 500MCG ................... 116 danazol cap 100 mg ......................... 80 danazol cap 200 mg ......................... 80 danazol cap 50 mg ........................... 80 dantrolene sodium cap 100 mg .......... 68 dantrolene sodium cap 25 mg ............ 68 dantrolene sodium cap 50 mg ............ 68 dapsone tab 100 mg ......................... 21 dapsone tab 25 mg ........................... 21 DAPTACEL INJ ................................ 105 DARAPRIM TAB 25MG ....................... 17

darifenacin hydrobromide tab sr 24hr 15 mg (base equiv) .............................. 96 darifenacin hydrobromide tab sr 24hr 7.5 mg (base equiv) .............................. 96 dasetta tab 1/35 ............................. 77 dasetta tab 7/7/7 ............................ 79 daunorubicin hcl inj 5 mg/ml (base equiv) ............................................ 27 daysee tab ..................................... 76 DAYTRANA DIS 10MG/9HR ................ 62 DAYTRANA DIS 15MG/9HR ................ 62 DAYTRANA DIS 20MG/9HR ................ 62 DAYTRANA DIS 30MG/9HR ................ 62 deblitane tab 0.35mg ....................... 79 decara cap 50000unt ...................... 108 decitabine for inj 50 mg .................... 23 deferoxamine mesylate for inj 500 mg .................................................... 101 delta d3 tab 400unit ....................... 108 delyla tab 0.1-0.02 .......................... 77 DELZICOL CAP 400MG...................... 91 demeclocycline hcl tab 150 mg .......... 15 demeclocycline hcl tab 300 mg .......... 15 DEMSER CAP 250MG ........................ 42 DENAVIR CRE 1% ........................... 123 denta 5000 cre plus ........................ 124 dentagel gel 1.1% .......................... 124 DEPEN TITRA TAB 250MG ................ 103 DEPOCYT INJ 50MG/5ML .................. 23 DEPO-MEDROL INJ 20MG/ML ............. 82 DEPO-PROVERA INJ 400/ML .............. 24 DEPO-SQ PROV INJ 104 ................... 77 DESCOVY TAB 200/25 ...................... 17 desipramine hcl tab 10 mg ................ 53 desipramine hcl tab 100 mg .............. 54 desipramine hcl tab 150 mg .............. 54 desipramine hcl tab 25 mg ................ 53 desipramine hcl tab 50 mg ................ 53 desipramine hcl tab 75 mg ................ 53 desloratadine tab 5 mg .................... 112 desloratadine tab orally disintegrating 2.5 mg .......................................... 112 desloratadine tab orally disintegrating 5 mg ............................................... 112 desmopressin acetate inj 4 mcg/ml .... 88

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desmopressin acetate nasal soln 0.01% (refrigerated) ................................... 88 desmopressin acetate nasal spray soln 0.01% (refrigerated) ........................ 88 desmopressin acetate tab 0.1 mg ....... 88 desmopressin acetate tab 0.2 mg ....... 88 desonide cream 0.05% ................... 121 desonide lotion 0.05% .................... 121 desonide oint 0.05% ....................... 121 desoximetasone cream 0.05% ......... 121 desoximetasone cream 0.25% ......... 120 desoximetasone gel 0.05% .............. 120 desoximetasone oint 0.05% ............. 121 desoximetasone oint 0.25% ............. 120 desvenlafaxine tab sr 24hr 100 mg ..... 51 DEXAMETHASON CON 1MG/ML ........... 82 dexamethasone sodium phosphate inj 10 mg/ml ............................................ 82 dexamethasone sodium phosphate inj 4 mg/ml ............................................ 82 dexamethasone sodium phosphate ophth soln 0.1% ..................................... 126 dexamethasone soln 0.5 mg/5ml ........ 82 dexamethasone tab 0.5 mg ............... 82 dexamethasone tab 0.75 mg .............. 82 dexamethasone tab 1.5 mg ............... 82 dexamethasone tab 2 mg .................. 82 dexamethasone tab 4 mg .................. 82 dexamethasone tab 6 mg .................. 82 dexedrine tab 10mg ......................... 62 dexedrine tab 5mg ........................... 62 DEXILANT CAP 30MG DR ................... 93 DEXILANT CAP 60MG DR ................... 93 dexmedetomidine hcl inj 200 mcg/2ml (for iv infusion) ................................ 65 dexmethylphenidate hcl cap sr 24 hr 10 mg ................................................. 62 dexmethylphenidate hcl cap sr 24 hr 15 mg ................................................. 62 dexmethylphenidate hcl cap sr 24 hr 30 mg ................................................. 62 dexmethylphenidate hcl cap sr 24 hr 40 mg ................................................. 62 dexmethylphenidate hcl cap sr 24 hr 5 mg ................................................. 62

dexmethylphenidate hcl tab 10 mg .... 62 dexmethylphenidate hcl tab 2.5 mg ... 62 dexmethylphenidate hcl tab 5 mg ...... 62 DEXPAK PAK 10 DAY ........................ 82 DEXPAK PAK 13 DAY ........................ 82 DEXPAK PAK 6 DAY .......................... 82 dexrazoxane for inj 250 mg .............. 27 dextroamphetamine sulfate cap sr 24hr 10 mg ............................................ 62 dextroamphetamine sulfate cap sr 24hr 15 mg ............................................ 62 dextroamphetamine sulfate cap sr 24hr 5 mg ................................................ 62 dextroamphetamine sulfate oral solution 5 mg/5ml ....................................... 62 dextroamphetamine sulfate tab 10 mg 62 dextroamphetamine sulfate tab 5 mg . 62 diazepam con 5mg/ml ...................... 45 diazepam inj 5 mg/ml ...................... 45 diazepam tab 10 mg ........................ 45 diazepam tab 2 mg .......................... 45 diazepam tab 5 mg .......................... 45 DIBENZYLINE CAP 10MG .................. 42 diclofenac potassium tab 50 mg ........... 3 diclofenac sodium (actinic keratoses) gel 3% ............................................... 118 diclofenac sodium ophth soln 0.1% ... 125 diclofenac sodium soln 1.5% ............... 4 diclofenac sodium tab delayed release 25 mg .................................................. 3 diclofenac sodium tab delayed release 50 mg .................................................. 3 diclofenac sodium tab delayed release 75 mg .................................................. 3 diclofenac sodium tab sr 24hr 100 mg .. 3 diclofenac w/ misoprostol tab delayed release 50-0.2 mg ............................. 4 diclofenac w/ misoprostol tab delayed release 75-0.2 mg ............................. 4 dicloxacillin sodium cap 250 mg ......... 14 dicloxacillin sodium cap 500 mg ......... 14 dicyclomine hcl cap 10 mg ................ 90 dicyclomine hcl oral soln 10 mg/5ml ... 90 dicyclomine hcl tab 20 mg ................ 90 didanosine delayed release capsule 125

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mg ................................................. 18 didanosine delayed release capsule 200 mg ................................................. 18 didanosine delayed release capsule 250 mg ................................................. 18 didanosine delayed release capsule 400 mg ................................................. 18 DIFICID TAB 200MG ......................... 12 difil-g fort liq 100-100 ..................... 115 diflorasone diacetate oint 0.05% ...... 122 diflunisal tab 500 mg ......................... 3 digitek tab 0.125mg ......................... 40 digitek tab 0.25mg ........................... 40 digox tab 0.125mg ........................... 40 digox tab 0.25mg ............................. 40 digoxin inj 0.25 mg/ml ...................... 40 digoxin tab 125 mcg (0.125 mg) ........ 41 digoxin tab 250 mcg (0.25 mg) .......... 41 dihydroergotamine mesylate inj 1 mg/ml ..................................................... 65 dihydroergotamine mesylate nasal spray 4 mg/ml .......................................... 65 DILANTIN CAP 30MG ........................ 46 DILATRATE SR CAP 40MG .................. 43 diltiazem hcl cap sr 12hr 120 mg ........ 39 diltiazem hcl cap sr 12hr 60 mg .......... 39 diltiazem hcl cap sr 12hr 90 mg .......... 39 diltiazem hcl coated beads cap sr 24hr 120 mg ........................................... 39 diltiazem hcl coated beads cap sr 24hr 180 mg ........................................... 39 diltiazem hcl coated beads cap sr 24hr 240 mg ........................................... 39 diltiazem hcl coated beads cap sr 24hr 300 mg ........................................... 39 diltiazem hcl coated beads tab sr 24hr 180 mg ........................................... 39 diltiazem hcl coated beads tab sr 24hr 240 mg ........................................... 39 diltiazem hcl coated beads tab sr 24hr 300 mg ........................................... 39 diltiazem hcl coated beads tab sr 24hr 360 mg ........................................... 40 diltiazem hcl coated beads tab sr 24hr 420 mg ........................................... 40

diltiazem hcl extended release beads cap sr 24hr 360 mg ............................... 40 diltiazem hcl extended release beads cap sr 24hr 420 mg ............................... 40 diltiazem hcl iv soln 25 mg/5ml (5 mg/ml) .......................................... 40 diltiazem hcl tab 120 mg .................. 40 diltiazem hcl tab 30 mg .................... 40 diltiazem hcl tab 60 mg .................... 40 diltiazem hcl tab 90 mg .................... 40 dilt-xr cap 120mg ............................ 39 dilt-xr cap 180mg ............................ 39 dilt-xr cap 240mg ............................ 39 DIMENHYDRIN INJ 50MG/ML ............. 88 DIP/TET PED INJ 25-5LFU ................ 105 DIPENTUM CAP 250MG ..................... 91 diphenhydramine hcl elixir 12.5 mg/5ml .................................................... 112 diphenhydramine hcl inj 50 mg/ml .... 112 diphenoxylate w/ atropine tab 2.5-0.025 mg ................................................ 88 dipyridamole tab 25 mg ................... 102 dipyridamole tab 50 mg ................... 102 dipyridamole tab 75 mg ................... 102 disopyramide phosphate cap 100 mg .. 33 disopyramide phosphate cap 150 mg .. 33 disulfiram tab 250 mg ...................... 68 disulfiram tab 500 mg ...................... 68 divalproex sodium cap delayed release sprinkle 125 mg .............................. 47 divalproex sodium tab delayed release 125 mg .......................................... 47 divalproex sodium tab delayed release 250 mg .......................................... 47 divalproex sodium tab delayed release 500 mg .......................................... 47 divalproex sodium tab sr 24 hr 250 mg47 divalproex sodium tab sr 24 hr 500 mg47 dobutamine hcl inj 12.5 mg/ml .......... 44 dobutamine inj 1 mg/ml in d5w ......... 44 dobutamine inj 2 mg/ml in d5w ......... 44 dobutamine inj 4 mg/ml in d5w ......... 44 DOCEFREZ INJ 20MG ....................... 27 DOCEFREZ INJ 80MG ....................... 27 docetaxel for inj conc 20 mg/ml ......... 27

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DOCETAXEL INJ 20/0.5ML ................. 27 DOCETAXEL INJ 20MG/2ML ................ 27 docetaxel inj 80mg/4ml ..................... 27 dofetilide cap 125 mcg (0.125 mg) ..... 33 dofetilide cap 250 mcg (0.25 mg) ....... 33 dofetilide cap 500 mcg (0.5 mg) ......... 33 donepezil hydrochloride orally disintegrating tab 10 mg ................... 50 donepezil hydrochloride orally disintegrating tab 5 mg ..................... 50 donepezil hydrochloride tab 10 mg ..... 50 donepezil hydrochloride tab 23 mg ..... 50 donepezil hydrochloride tab 5 mg ....... 50 dopamine hcl inj 40 mg/ml ................ 44 dopamine hcl inj 80 mg/ml ................ 44 dopamine inj 0.8 mg/ml in d5w .......... 44 dopamine inj 1.6 mg/ml in d5w .......... 44 dopamine inj 3.2 mg/ml in d5w .......... 44 DORIBAX INJ 500MG ........................ 10 dorzolamide hcl ophth soln 2% ......... 127 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml ....................... 127 doxapram hcl inj 20 mg/ml .............. 115 doxazosin mesylate tab 1 mg ............. 31 doxazosin mesylate tab 2 mg ............. 31 doxazosin mesylate tab 4 mg ............. 31 doxazosin mesylate tab 8 mg ............. 31 doxepin hcl cap 10 mg ...................... 54 doxepin hcl cap 100 mg .................... 54 doxepin hcl cap 150 mg .................... 54 doxepin hcl cap 25 mg ...................... 54 doxepin hcl cap 50 mg ...................... 54 doxepin hcl cap 75 mg ...................... 54 doxepin hcl conc 10 mg/ml ................ 54 doxepin hcl cream 5% .................... 123 doxercalciferol cap 0.5 mcg ............... 84 doxercalciferol cap 1 mcg .................. 84 doxercalciferol cap 2.5 mcg ............... 84 doxercalciferol inj 4 mcg/2ml (2 mcg/ml) ..................................................... 84 doxorubicin hcl inj 2 mg/ml ............... 27 doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml ............................. 27 doxy 100 inj 100mg .......................... 15 doxycycline (rosacea) cap delayed

release 40 mg ................................ 124 doxycycline hyclate cap 100 mg ........ 15 doxycycline hyclate cap 50 mg .......... 15 doxycycline hyclate tab 100 mg ......... 15 doxycycline hyclate tab 20 mg ........... 15 doxycycline hyclate tab delayed release 100 mg .......................................... 15 doxycycline hyclate tab delayed release 150 mg .......................................... 15 doxycycline hyclate tab delayed release 75 mg ............................................ 15 doxycycline monohydrate cap 150 mg 15 doxycycline monohydrate cap 75 mg .. 15 doxycycline monohydrate for susp 25 mg/5ml .......................................... 15 doxycycline monohydrate tab 150 mg 15 doxycycline monohydrate tab 50 mg .. 15 doxycycline monohydrate tab 75 mg .. 15 dronabinol cap 10 mg ...................... 88 dronabinol cap 2.5 mg ..................... 88 dronabinol cap 5 mg ........................ 88 droperidol inj 2.5 mg/ml ................... 88 drospirenone-ethinyl estradiol tab 3-0.03 mg ................................................ 77 DROXIA CAP 200MG ........................ 27 DROXIA CAP 300MG ........................ 27 DROXIA CAP 400MG ........................ 27 DRYSOL SOL 20% .......................... 123 DULERA AER 100-5MCG .................. 116 DULERA AER 200-5MCG .................. 116 duloxetine hcl enteric coated pellets cap 20 mg ............................................ 51 duloxetine hcl enteric coated pellets cap 30 mg ............................................ 51 duloxetine hcl enteric coated pellets cap 60 mg ............................................ 51 duramorph inj 0.5mg/ml .................... 5 duramorph inj 1mg/ml ....................... 5 DUREZOL EMU 0.05% ..................... 126 DYMISTA SPR 137-50 ...................... 115 DYRENIUM CAP 100MG ..................... 41 DYSPORT INJ 300UNIT ..................... 66 E econazole nitrate cream 1% ............. 119 econtra ez tab 1.5mg ....................... 76

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ecpirin tab 325mg ec ...................... 102 EDARBI TAB 40MG ........................... 33 EDARBI TAB 80MG ........................... 33 EDECRIN TAB 25MG ......................... 41 ed-flex cap ....................................... 2 ed-spaz tab 0.125mg ........................ 90 EDURANT TAB 25MG ......................... 18 EFFER-K TAB 10MEQ ....................... 106 EFFER-K TAB 20MEQ ....................... 106 effer-k tab 25meq ef ....................... 106 EFFIENT TAB 10MG......................... 102 EFFIENT TAB 5MG .......................... 102 ELAPRASE INJ 6MG/3ML .................... 84 ELELYSO INJ 200UNIT ....................... 84 ELIDEL CRE 1% ............................. 123 ELIGARD INJ 22.5MG ........................ 24 ELIGARD INJ 30MG ........................... 24 ELIGARD INJ 45MG ........................... 24 ELIGARD INJ 7.5MG .......................... 24 elinest tab ....................................... 77 ELIQUIS TAB 2.5MG ......................... 98 ELIQUIS TAB 5MG ............................ 98 ELITEK INJ 1.5MG ............................ 27 ELIXOPHYLLIN ELX 80/15ML ............ 116 ELLA TAB 30MG ............................... 76 ELMIRON CAP 100MG ....................... 95 ELOCTATE INJ 1000UNIT ................... 99 ELOCTATE INJ 1500UNIT ................... 99 ELOCTATE INJ 2000UNIT ................... 99 ELOCTATE INJ 250UNIT .................... 99 ELOCTATE INJ 3000UNIT ................... 99 ELOCTATE INJ 500UNIT .................... 99 ELOCTATE INJ 750UNIT .................... 99 EMADINE SOL 0.05% OP ................. 126 EMBEDA CAP 100-4MG ....................... 5 EMBEDA CAP 20-0.8MG ...................... 5 EMBEDA CAP 30-1.2MG ...................... 5 EMBEDA CAP 50-2MG ........................ 5 EMBEDA CAP 60-2.4MG ...................... 5 EMBEDA CAP 80-3.2MG ...................... 5 EMCYT CAP 140MG ........................... 22 EMEND CAP 125MG .......................... 88 EMEND CAP 40MG ............................ 88 EMEND CAP 80MG ............................ 88 EMEND PAK 80 & 125 ....................... 88

emoquette tab ................................ 77 EMSAM DIS 12MG/24H ..................... 50 EMSAM DIS 6MG/24HR..................... 50 EMSAM DIS 9MG/24HR..................... 50 EMTRIVA CAP 200MG ....................... 18 EMTRIVA SOL 10MG/ML.................... 18 enalapril maleate & hydrochlorothiazide tab 10-25 mg .................................. 29 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg ................................. 29 enalapril maleate tab 10 mg .............. 30 enalapril maleate tab 2.5 mg ............. 30 enalapril maleate tab 20 mg .............. 30 enalapril maleate tab 5 mg ............... 30 enalaprilat iv inj 1.25 mg/ml ............. 30 ENBREL INJ 25/0.5ML ..................... 102 ENBREL INJ 25MG .......................... 102 ENBREL INJ 50MG/ML ..................... 102 ENCARE SUP 100MG ........................ 77 endocet tab 10-325mg ....................... 5 endocet tab 2.5-325 .......................... 5 endocet tab 5-325mg ......................... 5 endocet tab 7.5-325 .......................... 5 ENGERIX-B INJ 10/0.5ML ................ 105 ENGERIX-B INJ 20MCG/ML ............... 105 ENJUVIA TAB 0.625MG ..................... 81 ENJUVIA TAB 0.9MG ........................ 81 enoxaparin sodium inj 100 mg/ml ...... 97 enoxaparin sodium inj 120 mg/0.8ml . 97 enoxaparin sodium inj 150 mg/ml ...... 97 enoxaparin sodium inj 30 mg/0.3ml ... 97 enoxaparin sodium inj 300 mg/3ml .... 97 enoxaparin sodium inj 40 mg/0.4ml ... 97 enoxaparin sodium inj 60 mg/0.6ml ... 97 enoxaparin sodium inj 80 mg/0.8ml ... 97 enpresse-28 tab .............................. 79 enskyce tab .................................... 77 entacapone tab 200 mg .................... 55 entecavir tab 0.5 mg ........................ 20 entecavir tab 1 mg .......................... 20 enulose sol 10gm/15 ........................ 92 EPCLUSA TAB 400-100 ..................... 20 ephedrine sulfate inj 50 mg/ml .......... 44 epinastine hcl ophth soln 0.05% ....... 126 epinephrine hcl inj 1 mg/ml .............. 44

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epinephrine hcl soln prefilled syringe 0.1 mg/ml ............................................ 45 epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) ........................ 111 EPIPEN 2-PAK INJ 0.3MG ................. 111 EPIPEN-JR INJ 2-PAK ...................... 111 epirubicin hcl iv soln 50 mg/25ml (2 mg/ml) ........................................... 27 epitol tab 200mg .............................. 47 eplerenone tab 25 mg ....................... 31 eplerenone tab 50 mg ....................... 31 EPOGEN INJ 10000/ML .................... 100 EPOGEN INJ 2000/ML ..................... 100 EPOGEN INJ 20000/ML .................... 100 EPOGEN INJ 3000/ML ..................... 100 EPOGEN INJ 4000/ML ..................... 100 epoprostenol sodium for inj 0.5 mg ..... 44 epoprostenol sodium for inj 1.5 mg ..... 44 eprosartan mesylate tab 600 mg ........ 33 EPZICOM TAB 600-300 ..................... 17 eq nicotine dis 7mg/24hr ................... 69 eq sleep aid cap 50mg ...................... 65 EQL PRENATAL TAB FORMULA .......... 110 ERAXIS INJ 50MG ............................. 16 ERBITUX INJ 100MG ......................... 27 ergocalciferol cap 50000 unit ........... 108 ergoloid mesylates tab 1 mg .............. 66 ERGOMAR SUB 2MG ......................... 65 ERIVEDGE CAP 150MG ...................... 27 errin tab 0.35mg .............................. 79 ERTACZO CRE 2% .......................... 119 ERWINAZE INJ 10000UNT ................. 27 ery pad 2% ................................... 117 ery-tab tab 333mg ec ....................... 12 ERYTHROCIN INJ 500MG ................... 12 erythromycin gel 2% ...................... 117 erythromycin ophth oint 5 mg/gm .... 125 erythromycin pads 2% .................... 117 erythromycin soln 2% ..................... 117 erythromycin tab 500 mg .................. 12 erythromycin w/ delayed release particles cap 250 mg ........................ 12 escitalopram oxalate soln 5 mg/5ml (base equiv) .................................... 52 escitalopram oxalate tab 10 mg (base

equiv) ............................................ 52 escitalopram oxalate tab 20 mg (base equiv) ............................................ 52 escitalopram oxalate tab 5 mg (base equiv) ............................................ 52 esgic cap .......................................... 2 esmolol hcl inj 100 mg/10ml ............. 37 esomeprazole sodium for intravenous soln 20 mg (base equiv) ................... 93 esomeprazole sodium for intravenous soln 40 mg (base equiv) ................... 93 estarylla tab 0.25-35 ....................... 77 estazolam tab 1 mg ......................... 65 estazolam tab 2 mg ......................... 65 ESTRACE VAG CRE 0.1MG/GM ........... 82 estradiol & norethindrone acetate tab 0.5-0.1 mg ..................................... 80 estradiol & norethindrone acetate tab 1-0.5 mg ........................................... 80 estradiol tab 0.5 mg ......................... 81 estradiol tab 1 mg ........................... 81 estradiol tab 2 mg ........................... 81 estradiol td patch twice weekly 0.025 mg/24hr ......................................... 81 estradiol td patch twice weekly 0.0375 mg/24hr ......................................... 81 estradiol td patch twice weekly 0.05 mg/24hr ......................................... 81 estradiol td patch twice weekly 0.075 mg/24hr ......................................... 81 estradiol td patch twice weekly 0.1 mg/24hr ......................................... 81 estradiol td patch weekly 0.025 mg/24hr ..................................................... 81 estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) ................ 81 estradiol td patch weekly 0.05 mg/24hr ..................................................... 81 estradiol td patch weekly 0.06 mg/24hr ..................................................... 81 estradiol td patch weekly 0.075 mg/24hr ..................................................... 81 estradiol td patch weekly 0.1 mg/24hr 81 estradiol valerate im in oil 10 mg/ml .. 81 estradiol valerate im in oil 20 mg/ml .. 81

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estradiol valerate im in oil 40 mg/ml ... 81 estropipate tab 0.75 mg .................... 81 estropipate tab 1.5 mg ...................... 81 eszopiclone tab 1 mg ........................ 65 eszopiclone tab 2 mg ........................ 65 eszopiclone tab 3 mg ........................ 65 ethambutol hcl tab 100 mg ................ 19 ethambutol hcl tab 400 mg ................ 19 ethosuximide cap 250 mg .................. 47 ethosuximide soln 250 mg/5ml .......... 47 etidronate disodium tab 200 mg ......... 75 etidronate disodium tab 400 mg ......... 75 etodolac cap 200 mg ......................... 3 etodolac cap 300 mg ......................... 3 etodolac tab 400 mg .......................... 3 etodolac tab 500 mg .......................... 3 etodolac tab sr 24hr 400 mg ............... 3 etodolac tab sr 24hr 500 mg ............... 3 etodolac tab sr 24hr 600 mg ............... 3 ETOPOPHOS INJ 100MG .................... 27 etoposide cap 50 mg......................... 27 etoposide inj 100 mg/5ml (20 mg/ml) . 27 EURAX CRE 10% ............................ 124 EURAX LOT 10% ............................ 124 EVAMIST SPR 1.53MG ....................... 81 EXELDERM CRE 1% ........................ 119 EXELDERM SOL 1% ........................ 119 exemestane tab 25 mg ..................... 24 EXJADE TAB 125MG ........................ 101 EXJADE TAB 250MG ........................ 101 EXJADE TAB 500MG ........................ 101 EXODERM LOT 25-1% ..................... 119 EYLEA INJ 2/0.05ML ....................... 127 EZ FLU SHOT INJ 2015-16 ............... 105 ezfe 200 cap 200mg ....................... 108 F FA-8 CAP 800MCG .......................... 107 FABRAZYME INJ 35MG ...................... 84 FACTIVE TAB 320MG ........................ 13 falmina tab ...................................... 77 famciclovir tab 125 mg ...................... 20 famciclovir tab 250 mg ...................... 20 famciclovir tab 500 mg ...................... 20 famotidine for susp 40 mg/5ml .......... 90 famotidine inj 200 mg/20ml ............... 90

famotidine tab 20 mg ....................... 90 famotidine tab 40 mg ....................... 90 FANAPT PAK ................................... 56 FANAPT TAB 10MG ........................... 57 FANAPT TAB 12MG ........................... 57 FANAPT TAB 1MG ............................ 56 FANAPT TAB 2MG ............................ 56 FANAPT TAB 4MG ............................ 56 FANAPT TAB 6MG ............................ 56 FANAPT TAB 8MG ............................ 56 FARESTON TAB 60MG ...................... 23 FARXIGA TAB 10MG ......................... 74 FARXIGA TAB 5MG ........................... 74 FARYDAK CAP 10MG ........................ 27 FARYDAK CAP 15MG ........................ 27 FARYDAK CAP 20MG ........................ 27 FASLODEX INJ 250MG ...................... 23 FAZACLO TAB 100 ODT .................... 57 FAZACLO TAB 12.5 ODT ................... 57 FAZACLO TAB 150 ODT .................... 57 FAZACLO TAB 200 ODT .................... 57 FAZACLO TAB 25MG ODT .................. 57 fe c plus tab ................................... 108 FEIBA NF INJ .................................. 99 felbamate susp 600 mg/5ml .............. 47 felbamate tab 400 mg ...................... 47 felbamate tab 600 mg ...................... 47 felodipine tab sr 24hr 10 mg ............. 38 felodipine tab sr 24hr 2.5 mg ............ 38 felodipine tab sr 24hr 5 mg ............... 38 fenofibrate cap 150 mg .................... 35 fenofibrate micronized cap 130 mg .... 35 fenofibrate micronized cap 134 mg .... 35 fenofibrate micronized cap 200 mg .... 35 fenofibrate micronized cap 43 mg ...... 35 fenofibrate micronized cap 67 mg ...... 35 fenofibrate tab 120 mg ..................... 35 fenofibrate tab 145 mg ..................... 35 fenofibrate tab 160 mg ..................... 35 fenofibrate tab 40 mg ...................... 35 fenofibrate tab 48 mg ...................... 35 fenofibrate tab 54 mg ...................... 35 fenofibric acid tab 105 mg ................ 35 fenofibric acid tab 35 mg .................. 35 fenoldopam mesylate iv inj 10 mg/ml

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(base equiv) .................................... 42 fenoprofen calcium cap 400 mg ........... 3 fentanyl citrate lozenge on a handle 1200 mcg ................................................ 5 fentanyl citrate lozenge on a handle 1600 mcg ................................................ 6 fentanyl citrate lozenge on a handle 200 mcg ................................................ 5 fentanyl citrate lozenge on a handle 400 mcg ................................................ 5 fentanyl citrate lozenge on a handle 600 mcg ................................................ 5 fentanyl citrate lozenge on a handle 800 mcg ................................................ 5 FENTANYL DIS 37.5MCG .................... 6 FENTANYL DIS 62.5MCG .................... 6 FENTANYL DIS 87.5MCG .................... 6 fentanyl td patch 72hr 100 mcg/hr ...... 6 fentanyl td patch 72hr 12 mcg/hr ........ 6 fentanyl td patch 72hr 25 mcg/hr ........ 6 fentanyl td patch 72hr 50 mcg/hr ........ 6 fentanyl td patch 72hr 75 mcg/hr ........ 6 FEOSOL TAB 45MG ......................... 108 ferotrinsic cap ................................ 108 FERRETTS FE CHW 18MG ................ 108 FERRETTS IPS SOL ......................... 108 ferretts tab 325mg ......................... 108 ferrex 150 cap 150mg ..................... 108 FERRIMIN 150 TAB ......................... 108 FERRIPROX TAB 500MG .................. 101 ferrocite tab 324mg ........................ 108 ferrogels fo cap forte ...................... 108 ferrous fumarate tab 324 mg (106 mg elemental fe) ................................. 108 ferrous gluc tab 324mg ................... 108 ferrous gluconate tab 240 mg (27 mg elemental fe) ................................. 108 ferrous gluconate tab 324 mg (37.5 mg elemental iron) .............................. 108 FERROUS SUL LIQ 220/5ML ............. 108 FERROUS SULF SYP 300/5ML ........... 108 FERROUS SULF TAB 140MG ............. 108 ferrous sulf tab 325mg .................... 108 ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) ..................... 108

ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe) ................................. 108 ferrous sulfate tab ec 325 mg (65 mg fe equivalent) .................................... 108 FINACEA GEL 15% .......................... 124 finasteride tab 5 mg ......................... 94 FIRAZYR INJ 30MG/3ML .................. 101 FIRMAGON INJ 120MG ..................... 24 FIRMAGON INJ 80MG ....................... 24 FLAGYL ER TAB 750MG ..................... 21 FLAREX SUS 0.1% OP ..................... 126 flavoxate hcl tab 100 mg .................. 96 FLEBOGAMMA INJ DIF 10% .............. 103 FLEBOGAMMA INJ DIF 5% ............... 103 flecainide acetate tab 100 mg ........... 33 flecainide acetate tab 150 mg ........... 33 flecainide acetate tab 50 mg ............. 33 floxuridine for inj 0.5 gm .................. 23 FLUARIX PF INJ 2014-15 ................. 105 FLUARIX QUAD INJ 2015-16 ............ 105 FLUBLOK SOL 2015-16 .................... 105 flucaine sol 0.25-0.5 ....................... 127 FLUCELVAX INJ 2015-16 .................. 105 fluconazole for susp 10 mg/ml ........... 16 fluconazole for susp 40 mg/ml ........... 16 fluconazole in nacl 0.9% inj 200 mg/100ml ...................................... 16 fluconazole tab 100 mg .................... 16 fluconazole tab 150 mg .................... 16 fluconazole tab 200 mg .................... 16 fluconazole tab 50 mg ...................... 16 flucytosine cap 250 mg .................... 16 flucytosine cap 500 mg .................... 16 fludarabine phosphate inj 25 mg/ml ... 23 fludrocortisone acetate tab 0.1 mg ..... 82 FLULAVAL QUA INJ 2015-16 ............. 105 flumazenil iv soln 1 mg/10ml (0.1 mg/ml) .......................................... 80 flunisolide nasal soln 25 mcg/act (0.025%) ...................................... 115 fluocin acet oil scalp ........................ 121 fluocinolone acetonide (otic) oil 0.01% .................................................... 129 fluocinolone acetonide cream 0.01% . 121 fluocinolone acetonide cream 0.025% 121

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fluocinolone acetonide oint 0.025% ... 121 fluocinolone acetonide soln 0.01% .... 121 fluocinonide cream 0.05% ............... 121 fluocinonide cream 0.1% ................. 121 fluocinonide gel 0.05% .................... 121 fluocinonide oint 0.05% .................. 121 fluocinonide soln 0.05% .................. 121 FLUORABON DRO ........................... 108 FLUOR-A-DAY CHW 0.25MG F .......... 108 FLUOR-A-DAY CHW 0.5MG F ............ 108 fluor-a-day dro 0.125mg ................. 108 fluorescein w/ proparacaine ophth soln 0.25-0.5% .................................... 127 fluoridex gel 1.1% .......................... 124 fluoritab chw 0.5mg f ...................... 108 fluoritab chw 2.2mg ........................ 108 fluoritab dro 0.125mg ..................... 108 fluorometholone ophth susp 0.1% .... 126 FLUOROPLEX CRE 1% ..................... 118 fluorouracil cream 5% ..................... 118 fluorouracil inj 500 mg/10ml (50 mg/ml) ..................................................... 23 fluorouracil soln 2% ........................ 118 fluorouracil soln 5% ........................ 118 fluoxetine hcl cap 10 mg ................... 52 fluoxetine hcl cap 20 mg ................... 52 fluoxetine hcl solution 20 mg/5ml ....... 52 fluoxetine hcl tab 10 mg .................... 52 fluphenazine decanoate inj 25 mg/ml .. 60 fluphenazine hcl elixir 2.5 mg/5ml ...... 60 fluphenazine hcl inj 2.5 mg/ml ........... 60 fluphenazine hcl tab 1 mg .................. 60 fluphenazine hcl tab 10 mg ................ 60 fluphenazine hcl tab 2.5 mg ............... 60 fluphenazine hcl tab 5 mg .................. 60 flura-drops dro 0.25mg f ................. 108 flurandrenolide cream 0.05% ........... 121 flurazepam hcl cap 15 mg .................. 65 flurazepam hcl cap 30 mg .................. 65 flurbiprofen sodium ophth soln 0.03% ................................................... 126 flurbiprofen tab 100 mg ..................... 3 flurbiprofen tab 50 mg ....................... 3 flutamide cap 125 mg ....................... 23 fluticasone propionate cream 0.05% . 121

fluticasone propionate lotion 0.05% .. 121 fluticasone propionate nasal susp 50 mcg/act ........................................ 116 fluticasone propionate oint 0.005% ... 122 fluvastatin sodium cap 20 mg ............ 35 fluvastatin sodium cap 40 mg ............ 35 fluvoxamine maleate cap sr 24hr 100 mg ..................................................... 46 fluvoxamine maleate cap sr 24hr 150 mg ..................................................... 46 fluvoxamine maleate tab 100 mg ....... 46 fluvoxamine maleate tab 25 mg ......... 46 fluvoxamine maleate tab 50 mg ......... 46 FLUZONE HD INJ PF 15-16 ............... 105 FLUZONE QUAD INJ 15-16 ............... 105 FLUZONE QUAD INJ 2015-16 ........... 105 FLUZONE SPLT INJ 2015-16 ............. 105 FML OIN 0.1% OP ........................... 126 folbee tab ...................................... 107 folic acid tab 1 mg .......................... 107 folic acid tab 400 mcg ..................... 107 folic acid tab 800mcg ...................... 107 folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg ............................... 108 FOLIVANE-OB CAP .......................... 110 FOLOTYN INJ 20MG/ML .................... 23 fomepizole inj 1 gm/ml (for iv infusion) ..................................................... 80 fondaparinux sodium subcutaneous inj 10 mg/0.8ml ................................... 97 fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml .................................. 97 fondaparinux sodium subcutaneous inj 5 mg/0.4ml ....................................... 97 fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml .................................. 97 formadon sol.................................. 123 FORTEO SOL 600/2.4 ....................... 76 FOSAMAX + D TAB 70-2800 .............. 75 FOSAMAX + D TAB 70-5600 .............. 75 fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg ............................... 29 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg ............................... 29 fosinopril sodium tab 10 mg .............. 30

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fosinopril sodium tab 20 mg ............... 30 fosinopril sodium tab 40 mg ............... 30 fosphenytoin sodium inj 500 mg/10ml (phenytoin equiv) ............................. 47 FOSRENOL CHW 1000MG .................. 85 FOSRENOL CHW 500MG .................... 85 FOSRENOL CHW 750MG .................... 85 FRAGMIN INJ 10000/ML .................... 97 FRAGMIN INJ 12500UNT ................... 97 FRAGMIN INJ 15000UNT ................... 97 FRAGMIN INJ 18000UNT ................... 98 FRAGMIN INJ 2500/0.2 ..................... 97 FRAGMIN INJ 5000/0.2 ..................... 97 FRAGMIN INJ 7500/0.3 ..................... 97 FRAGMIN INJ 95000UNT ................... 98 FREESTYLE TES ................................ 75 frovatriptan succinate tab 2.5 mg (base equivalent) ...................................... 66 furosemide inj 10 mg/ml ................... 41 furosemide oral soln 10 mg/ml ........... 41 furosemide tab 20 mg ....................... 41 furosemide tab 40 mg ....................... 41 furosemide tab 80 mg ....................... 41 FUSILEV INJ 50MG ........................... 27 FUZEON INJ 90MG ............................ 17 FYCOMPA TAB 10MG ......................... 47 FYCOMPA TAB 12MG ......................... 47 FYCOMPA TAB 2MG ........................... 47 FYCOMPA TAB 4MG ........................... 47 FYCOMPA TAB 6MG ........................... 47 FYCOMPA TAB 8MG ........................... 47 G gabapentin cap 100 mg ..................... 47 gabapentin cap 300 mg ..................... 47 gabapentin cap 400 mg ..................... 47 gabapentin oral soln 250 mg/5ml ....... 47 gabapentin tab 600 mg ..................... 47 gabapentin tab 800 mg ..................... 47 GABITRIL TAB 12MG ......................... 47 GABITRIL TAB 16MG ......................... 47 galantamine hydrobromide cap sr 24hr 16 mg ............................................ 50 galantamine hydrobromide cap sr 24hr 24 mg ............................................ 50 galantamine hydrobromide cap sr 24hr 8

mg ................................................ 50 galantamine hydrobromide oral soln 4 mg/ml ........................................... 50 galantamine hydrobromide tab 12 mg 50 galantamine hydrobromide tab 4 mg .. 50 galantamine hydrobromide tab 8 mg .. 50 GAMASTAN S/D INJ ........................ 103 GAMMAGARD INJ 1GM/10ML ............ 103 GAMMAKED INJ 1GM/10ML .............. 103 GAMMAPLEX INJ 2.5GM ................... 103 GAMUNEX-C INJ 1GM/10ML ............. 103 ganciclovir sodium for inj 500 mg ...... 19 GARDASIL 9 INJ ............................. 105 GARDASIL INJ ................................ 105 GASTRINEX NF CAP ......................... 90 gatifloxacin ophth soln 0.5% ............ 125 GATTEX KIT 5MG ............................. 92 gavilyte-c sol .................................. 91 gavilyte-g sol .................................. 91 gavilyte-n sol flav pk ........................ 91 GAZYVA INJ 25MG/ML ...................... 27 GELNIQUE GEL 10% ........................ 96 gemcitabine hcl for inj 200 mg .......... 23 gemfibrozil tab 600 mg .................... 35 generlac sol 10gm/15 ...................... 92 gengraf cap 100mg ......................... 104 gengraf cap 25mg .......................... 104 gengraf sol 100mg/ml ..................... 104 gentak oin 0.3% op ........................ 125 gentamicin in saline inj 0.8 mg/ml ..... 10 gentamicin in saline inj 1 mg/ml ........ 10 gentamicin in saline inj 1.2 mg/ml ..... 10 gentamicin in saline inj 1.6 mg/ml ..... 10 gentamicin sulfate inj 40 mg/ml ........ 10 gentamicin sulfate iv soln 10 mg/ml ... 10 gentamicin sulfate ophth oint 0.3% ... 125 gentamicin sulfate ophth soln 0.3% .. 125 GENVOYA TAB ................................. 17 GEODON INJ 20MG .......................... 57 gianvi tab 3-0.02mg ........................ 77 gildess 24 tab fe 1/20 ...................... 77 gildess fe tab 1.5/30 ........................ 77 gildess fe tab 1/20 ........................... 77 gildess tab 1.5/30 ............................ 77 gildess tab 1/20 .............................. 77

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GILENYA CAP 0.5MG ......................... 67 GILOTRIF TAB 20MG ......................... 25 GILOTRIF TAB 30MG ......................... 25 GILOTRIF TAB 40MG ......................... 25 GLASSIA INJ .................................. 115 glatopa inj 20mg/ml ......................... 67 GLEOSTINE CAP 100MG .................... 22 GLEOSTINE CAP 10MG ...................... 22 GLEOSTINE CAP 40MG ...................... 22 GLIADEL WAF 7.7MG ........................ 22 glimepiride tab 1 mg ......................... 74 glimepiride tab 2 mg ......................... 74 glimepiride tab 4 mg ......................... 74 glipizide tab 10 mg ........................... 74 glipizide tab 5 mg ............................. 74 glipizide tab sr 24hr 10 mg ................ 74 glipizide tab sr 24hr 2.5 mg ............... 74 glipizide tab sr 24hr 5 mg .................. 74 glipizide-metformin hcl tab 2.5-250 mg ..................................................... 70 glipizide-metformin hcl tab 2.5-500 mg ..................................................... 70 glipizide-metformin hcl tab 5-500 mg .. 70 GLUCAGEN INJ HYPOKIT ................... 83 GLUCAGON KIT 1MG ......................... 83 glyburide micronized tab 1.5 mg ........ 74 glyburide micronized tab 3 mg ........... 74 glyburide micronized tab 6 mg ........... 74 glyburide tab 1.25 mg ....................... 74 glyburide tab 2.5 mg ........................ 74 glyburide tab 5 mg ........................... 74 glyburide-metformin tab 1.25-250 mg . 70 glyburide-metformin tab 2.5-500 mg .. 70 glyburide-metformin tab 5-500 mg ..... 70 glycopyrrolate inj 0.2 mg/ml .............. 90 glycopyrrolate tab 1 mg .................... 90 glycopyrrolate tab 2 mg .................... 90 glydo gel 2% ................................. 123 GLYXAMBI TAB 10-5 MG .................... 74 GLYXAMBI TAB 25-5 MG .................... 74 GNP PRENATAL TAB 28-0.8MG ......... 110 GOODSENSE TAB 28-0.8MG ............ 110 granisetron hcl inj 0.1 mg/ml ............. 88 granisetron hcl inj 1 mg/ml ................ 88 granisetron hcl tab 1 mg ................... 89

griseofulvin microsize susp 125 mg/5ml ..................................................... 16 griseofulvin microsize tab 500 mg ...... 16 griseofulvin ultramicrosize tab 125 mg 16 griseofulvin ultramicrosize tab 250 mg 16 guanfacine hcl tab 1 mg ................... 31 guanfacine hcl tab 2 mg ................... 31 guanfacine hcl tab sr 24hr 1 mg (base equiv) ............................................ 62 guanfacine hcl tab sr 24hr 2 mg (base equiv) ............................................ 62 guanfacine hcl tab sr 24hr 3 mg (base equiv) ............................................ 62 guanfacine hcl tab sr 24hr 4 mg (base equiv) ............................................ 62 GUANIDINE TAB 125MG ................... 67 GYNAZOLE-1 CRE 2% ...................... 97 GYNOL II GEL 3% ............................ 77 H H.P. ACTHAR INJ 80UNIT .................. 84 HALAVEN INJ 1MG/2ML .................... 27 halobetasol propionate cream 0.05% 122 halobetasol propionate oint 0.05% .... 122 HALOG CRE 0.1% ........................... 121 HALOG OIN 0.1% ........................... 121 haloperidol decanoate im soln 100 mg/ml ..................................................... 60 haloperidol decanoate im soln 50 mg/ml ..................................................... 60 haloperidol lactate inj 5 mg/ml .......... 60 haloperidol lactate oral conc 2 mg/ml . 60 haloperidol tab 0.5 mg ..................... 60 haloperidol tab 1 mg ........................ 60 haloperidol tab 10 mg ...................... 60 haloperidol tab 2 mg ........................ 60 haloperidol tab 20 mg ...................... 60 haloperidol tab 5 mg ........................ 60 HARVONI TAB 90-400MG .................. 20 HAVRIX INJ 1440UNIT ..................... 105 HAVRIX INJ 720UNIT ...................... 105 heather tab 0.35mg ......................... 79 HELIXATE FS INJ 2000UNIT .............. 99 HELIXATE FS INJ 250UNIT ................ 99 HELIXATE FS INJ 3000UNIT .............. 99 HELIXATE FS INJ 500UNIT ................ 99

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hematogen cap forte ....................... 109 hemocyte-f tab .............................. 109 HEMOFIL M INJ 1000UNIT ................. 99 HEMOFIL M INJ 1700UNIT ................. 99 HEPAGAM B INJ ............................. 103 heparin sodium (porcine) inj 1000 unit/ml ........................................... 98 heparin sodium (porcine) inj 10000 unit/ml ........................................... 98 heparin sodium (porcine) inj 20000 unit/ml ........................................... 98 heparin sodium (porcine) inj 5000 unit/ml ........................................... 98 heparin sodium (porcine) pf inj 5000 unit/0.5ml ....................................... 98 HERCEPTIN INJ 440MG ..................... 27 HEXALEN CAP 50MG ......................... 22 HIBERIX SOL 10MCG ...................... 105 HIZENTRA INJ 1GM/5ML .................. 103 HM PRENATAL TAB ......................... 110 homatropaire sol 5% op .................. 128 homatropine hbr ophth soln 5% ....... 128 HUMALOG INJ 100/ML ....................... 73 HUMALOG MIX INJ 50/50 .................. 73 HUMALOG MIX INJ 50/50KWP ............ 73 HUMALOG MIX INJ 75/25KWP ............ 73 HUMALOG MIX SUS 75/25 ................. 73 HUMATE-P SOL 2400UNIT ................. 99 HUMATE-P SOL 250-600 .................... 99 HUMIRA INJ 10MG/0.2 .................... 102 HUMIRA KIT 20MG/0.4 .................... 102 HUMIRA KIT 40MG/0.8 .................... 102 HUMIRA PEN INJ CROHNS ............... 102 HUMULIN INJ 70/30 .......................... 73 HUMULIN INJ 70/30KWP ................... 73 HUMULIN N INJ U-100 ...................... 73 HUMULIN N INJ U-100KWP ................ 73 HUMULIN R INJ U-100 ...................... 73 HUMULIN R INJ U-500 ...................... 73 HYCAMTIN CAP 0.25MG ..................... 29 HYCAMTIN CAP 1MG ......................... 29 hydralazine hcl inj 20 mg/ml .............. 42 hydralazine hcl tab 10 mg ................. 42 hydralazine hcl tab 100 mg ................ 42 hydralazine hcl tab 25 mg ................. 42

hydralazine hcl tab 50 mg ................. 42 hydrochlorothiazide cap 12.5 mg ....... 41 hydrochlorothiazide tab 12.5 mg ........ 41 hydrochlorothiazide tab 25 mg .......... 41 hydrochlorothiazide tab 50 mg .......... 41 hydrocodone w/ homatropine syrup 5-1.5 mg/5ml ................................... 113 hydrocodone w/ homatropine tab 5-1.5 mg ............................................... 113 hydrocodone-acetaminophen soln 10-325 mg/15ml .......................................... 6 hydrocodone-acetaminophen soln 7.5-325 mg/15ml .................................... 6 hydrocodone-acetaminophen tab 10-300 mg .................................................. 6 hydrocodone-acetaminophen tab 10-325 mg .................................................. 6 hydrocodone-acetaminophen tab 2.5-325 mg .................................................. 6 hydrocodone-acetaminophen tab 5-300 mg .................................................. 6 hydrocodone-acetaminophen tab 5-325 mg .................................................. 6 hydrocodone-acetaminophen tab 7.5-300 mg .................................................. 6 hydrocodone-acetaminophen tab 7.5-325 mg .................................................. 6 hydrocodone-ibuprofen tab 10-200 mg . 6 hydrocodone-ibuprofen tab 5-200 mg ... 6 hydrocodone-ibuprofen tab 7.5-200 mg 6 hydrocortisone acetate w/ pramoxine rectal cream 1-1% ........................... 94 hydrocortisone butyrate hydrophilic lipo base cream 0.1% ........................... 122 hydrocortisone butyrate oint 0.1% .... 122 hydrocortisone butyrate soln 0.1% .... 122 hydrocortisone cream 2.5% ............. 121 hydrocortisone enema 100 mg/60ml .. 91 hydrocortisone lotion 2.5% .............. 121 hydrocortisone oint 1% ................... 121 hydrocortisone oint 2.5% ................ 121 hydrocortisone tab 10 mg ................. 82 hydrocortisone tab 20 mg ................. 82 hydrocortisone tab 5 mg ................... 82 hydrocortisone valerate cream 0.2% . 122

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hydrocortisone valerate oint 0.2% .... 122 hydrocortisone w/ acetic acid otic soln 1-2% ............................................... 128 hydromet syp 5-1.5/5 ..................... 113 hydromorphone hcl inj 1 mg/ml .......... 6 hydromorphone hcl inj 2 mg/ml .......... 6 hydromorphone hcl inj 4 mg/ml .......... 6 hydromorphone hcl liqd 1 mg/ml ......... 6 hydromorphone hcl preservative free (pf) inj 10 mg/ml .................................... 6 hydromorphone hcl tab 2 mg .............. 6 hydromorphone hcl tab 4 mg .............. 6 hydromorphone hcl tab 8 mg .............. 6 hydromorphone hcl tab er 24hr deter 12 mg .................................................. 7 hydromorphone hcl tab er 24hr deter 16 mg .................................................. 7 hydromorphone hcl tab er 24hr deter 32 mg .................................................. 7 hydromorphone hcl tab er 24hr deter 8 mg .................................................. 6 hydroxocobalamin inj 1000 mcg/ml .. 109 hydroxychloroquine sulfate tab 200 mg ................................................... 103 hydroxyurea cap 500 mg ................... 27 hydroxyzine hcl im soln 50 mg/ml .... 112 hydroxyzine hcl syrup 10 mg/5ml ..... 113 hydroxyzine hcl tab 10 mg ............... 113 hydroxyzine hcl tab 25 mg ............... 113 hydroxyzine hcl tab 50 mg ............... 113 hydroxyzine pamoate cap 100 mg .... 113 hydroxyzine pamoate cap 25 mg ...... 113 hydroxyzine pamoate cap 50 mg ...... 113 hyophen tab .................................... 95 hyoscyamine sulfate elixir 0.125 mg/5ml ..................................................... 90 hyoscyamine sulfate soln 0.125 mg/ml 90 hyoscyamine sulfate tab 0.125 mg ...... 90 hyoscyamine sulfate tab disp 0.125 mg ..................................................... 90 hyoscyamine sulfate tab sl 0.125 mg .. 90 hyoscyamine sulfate tab sr 12hr 0.375 mg ................................................. 90 HYPERHEP B INJ S/D ...................... 103 HYPERRAB S/D INJ 150/ML .............. 103

HYPERRHO S/D INJ 300MCG ............ 103 HYPERRHO S/D INJ 50MCG .............. 103 I ibandronate sodium iv soln 3 mg/3ml (base equivalent) ............................ 75 ibandronate sodium tab 150 mg (base equivalent) ..................................... 75 IBRANCE CAP 100MG ....................... 25 IBRANCE CAP 125MG ....................... 25 IBRANCE CAP 75MG ......................... 25 ibudone tab 5-200mg ......................... 7 ibuprofen susp 100 mg/5ml ................ 3 ibuprofen tab 400 mg ......................... 3 ibuprofen tab 600 mg ......................... 3 ibuprofen tab 800 mg ......................... 3 ibutilide fumarate inj 1 mg/10ml ........ 34 ICLUSIG TAB 15MG ......................... 25 ICLUSIG TAB 45MG ......................... 25 idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) ..................................................... 27 iferex 150 cap ................................ 109 iferex 150 cap forte ........................ 109 IFEX INJ 1GM .................................. 22 ifosfamide for inj 1 gm ..................... 22 ILARIS INJ 180MG .......................... 104 ILEVRO DRO 0.3% OP ..................... 126 ilotycin oin op ................................ 125 imatinib mesylate tab 100 mg (base equivalent) ..................................... 25 imatinib mesylate tab 400 mg (base equivalent) ..................................... 25 IMBRUVICA CAP 140MG ................... 25 imipenem-cilastatin intravenous for soln 250 mg .......................................... 10 imipenem-cilastatin intravenous for soln 500 mg .......................................... 10 imipramine hcl tab 10 mg ................. 54 imipramine hcl tab 25 mg ................. 54 imipramine hcl tab 50 mg ................. 54 imipramine pamoate cap 100 mg ....... 54 imipramine pamoate cap 125 mg ....... 54 imipramine pamoate cap 150 mg ....... 54 imipramine pamoate cap 75 mg ......... 54 imiquimod cream 5% ...................... 123 IMOVAX RABIE INJ 2.5/ML ............... 105

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inatal adv tab ................................ 110 inatal gt tab ................................... 110 inatal ultra tab ............................... 110 INCRELEX INJ 40MG/4ML .................. 84 INCRUSE ELPT INH 62.5MCG ........... 112 indapamide tab 1.25 mg ................... 41 indapamide tab 2.5 mg ..................... 41 indomethacin cap 25 mg .................... 3 indomethacin cap 50 mg .................... 3 indomethacin cap cr 75 mg ................. 3 INFANRIX INJ ................................ 105 INLYTA TAB 1MG .............................. 25 INLYTA TAB 5MG .............................. 25 INNOPRAN XL CAP 120MG ................. 37 INNOPRAN XL CAP 80MG ................... 37 INSPIREASE MIS DD SYST ............... 115 INSULIN PEN NEEDLES ..................... 75 INSULIN SYRINGES .......................... 75 INTELENCE TAB 100MG ..................... 18 INTELENCE TAB 200MG ..................... 18 INTELENCE TAB 25MG ...................... 18 INTRON A INJ 10MU ....................... 103 INTRON A INJ 18MU ....................... 103 INTRON A INJ 50MU ....................... 103 introvale tab .................................... 76 INVANZ INJ 1GM .............................. 10 INVEGA SUST INJ 117/0.75 ............... 57 INVEGA SUST INJ 156MG/ML ............. 57 INVEGA SUST INJ 234/1.5 ................. 57 INVEGA SUST INJ 39/0.25 ................. 57 INVEGA SUST INJ 78/0.5ML ............... 57 INVEGA TRINZ INJ 273MG ................. 57 INVEGA TRINZ INJ 410MG ................. 57 INVEGA TRINZ INJ 546MG ................. 57 INVEGA TRINZ INJ 819MG ................. 57 INVIRASE CAP 200MG ....................... 17 INVIRASE TAB 500MG ....................... 17 INVOKANA TAB 100MG ..................... 74 INVOKANA TAB 300MG ..................... 74 IOPIDINE SOL 1% OP ..................... 128 IPOL INJ INACTIVE ......................... 105 ipratropium bromide inhal soln 0.02% ................................................... 112 ipratropium bromide nasal soln 0.03% (21 mcg/spray) .............................. 115

ipratropium bromide nasal soln 0.06% (42 mcg/spray) .............................. 115 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml ............................... 112 irbesartan tab 150 mg ...................... 33 irbesartan tab 300 mg ...................... 33 irbesartan tab 75 mg ....................... 33 irbesartan-hydrochlorothiazide tab 150-12.5 mg ......................................... 32 irbesartan-hydrochlorothiazide tab 300-12.5 mg ......................................... 32 irinotecan hcl inj 40 mg/2ml (20 mg/ml) ..................................................... 27 IRON CHEWS CHW PEDIATRI ........... 109 ISENTRESS CHW 100MG .................. 17 ISENTRESS CHW 25MG .................... 17 ISENTRESS POW 100MG ................... 17 ISENTRESS TAB 400MG .................... 17 ISO CARBACHO SOL 1.5% OP .......... 128 ISO CARBACHO SOL 3% OP ............. 128 isoniazid syrup 50 mg/5ml ................ 19 isoniazid tab 100 mg ........................ 19 isoniazid tab 300 mg ........................ 19 isosorbide dinitrate tab 10 mg ........... 43 isosorbide dinitrate tab 20 mg ........... 43 isosorbide dinitrate tab 30 mg ........... 43 isosorbide dinitrate tab 5 mg ............. 43 isosorbide dinitrate tab cr 40 mg ....... 43 isosorbide mononitrate tab 10 mg ...... 43 isosorbide mononitrate tab 20 mg ...... 43 isosorbide mononitrate tab sr 24hr 120 mg ................................................ 43 isosorbide mononitrate tab sr 24hr 30 mg ................................................ 43 isosorbide mononitrate tab sr 24hr 60 mg ................................................ 43 isradipine cap 2.5 mg ....................... 39 isradipine cap 5 mg ......................... 39 ISTODAX INJ 10MG ......................... 27 itraconazole cap 100 mg ................... 16 ivermectin tab 3 mg ......................... 21 IXEMPRA KIT INJ 15MG .................... 27 IXIARO INJ .................................... 105 J JAKAFI TAB 10MG ............................ 25

156

JAKAFI TAB 15MG ............................ 25 JAKAFI TAB 20MG ............................ 25 JAKAFI TAB 25MG ............................ 25 JAKAFI TAB 5MG .............................. 25 jantoven tab 10mg ........................... 98 jantoven tab 1mg ............................. 98 jantoven tab 2.5mg .......................... 98 jantoven tab 2mg ............................. 98 jantoven tab 3mg ............................. 98 jantoven tab 4mg ............................. 98 jantoven tab 5mg ............................. 98 jantoven tab 6mg ............................. 98 jantoven tab 7.5mg .......................... 98 JANUMET TAB 50-1000 ..................... 71 JANUMET TAB 50-500MG ................... 71 JANUMET XR TAB 100-1000 ............... 71 JANUMET XR TAB 50-1000 ................. 71 JANUMET XR TAB 50-500MG .............. 71 JANUVIA TAB 100MG ........................ 72 JANUVIA TAB 25MG .......................... 72 JANUVIA TAB 50MG .......................... 72 JARDIANCE TAB 10MG ...................... 74 JARDIANCE TAB 25MG ...................... 74 jencycla tab 0.35mg ......................... 79 JENTADUETO TAB 2.5-1000 ............... 71 JENTADUETO TAB 2.5-500 ................. 71 JENTADUETO TAB 2.5-850 ................. 71 JETREA INJ 2.5MG/ML ..................... 127 JEVTANA INJ 60/1.5ML ...................... 27 jinteli tab 1mg-5mcg ........................ 80 jolessa tab ...................................... 76 jolivette tab 0.35mg ......................... 79 junel 1.5/30 tab ............................... 77 junel 1/20 tab .................................. 77 junel fe tab 1.5/30 ........................... 77 junel fe tab 1/20 .............................. 77 JUXTAPID CAP 10MG ........................ 36 JUXTAPID CAP 20MG ........................ 36 JUXTAPID CAP 5MG .......................... 36 K KADCYLA INJ 100MG ........................ 27 KALBITOR INJ 10MG/ML .................. 101 KALETRA SOL .................................. 17 KALETRA TAB 100-25MG ................... 17 KALETRA TAB 200-50MG ................... 18

KALYDECO TAB 150MG .................... 114 karigel-n gel 1.1% .......................... 124 kariva tab 28 day ............................ 76 k-effervesce tab 25meq ef ............... 106 kelnor tab 1/35 ............................... 77 KEPIVANCE INJ 6.25MG .................... 92 KETEK TAB 300MG ........................... 13 KETEK TAB 400MG ........................... 13 ketoconazole cream 2% .................. 119 ketoconazole foam 2% .................... 119 ketoconazole shampoo 2% .............. 119 ketoconazole tab 200 mg .................. 16 ketodan aer 2% ............................. 119 ketoprofen cap 50 mg ........................ 3 ketoprofen cap 75 mg ........................ 3 ketorolac tromethamine ophth soln 0.4% .................................................... 126 ketorolac tromethamine ophth soln 0.5% .................................................... 126 ketorolac tromethamine tab 10 mg ...... 3 KEYTRUDA INJ 100MG/4M ................ 27 KEYTRUDA SOL 50MG ...................... 27 KINERET INJ .................................. 102 KINRIX INJ .................................... 105 klor-con 8 tab 8meq er .................... 106 klor-con m10 tab 10meq er .............. 106 KLOR-CON M15 TAB 15MEQ ER ........ 106 klor-con m20 tab 20meq er .............. 106 klor-con pow 20meq ....................... 107 klor-con/ef tab 25meq fr ................. 107 KOATE-DVI INJ 1000UNIT ................. 99 KOATE-DVI INJ 250UNIT .................. 99 KOGENATE FS INJ 1000UNIT ............. 99 KOGENATE FS INJ 250UNIT .............. 99 KOGENATE FS INJ 3000UNIT ............. 99 KOGENATE FS INJ 500UNIT .............. 99 KOMBIGLYZE TAB 2.5-1000 .............. 71 KOMBIGLYZE TAB 5-1000MG ............ 71 KOMBIGLYZE TAB 5-500MG .............. 71 KP PRENATAL TAB MULTIVIT ............ 110 K-PHOS TAB .................................. 106 KRYSTEXXA INJ 8MG/ML .................... 2 kurvelo tab 0.15/30 ......................... 77 KUVAN TAB 100MG .......................... 85 k-vescent tab 25meq ef ................... 106

157

KYPROLIS SOL 60MG ........................ 28 L labetalol hcl iv soln 5 mg/ml .............. 37 labetalol hcl tab 100 mg .................... 38 labetalol hcl tab 200 mg .................... 38 labetalol hcl tab 300 mg .................... 38 LACRISERT MIS 5MG OP .................. 127 lactic acid (ammonium lactate) cream 12% ............................................. 122 lactic acid (ammonium lactate) lotion 10% ............................................. 122 lactic acid (ammonium lactate) lotion 12% ............................................. 122 lactulose solution 10 gm/15ml ........... 91 LAMICTAL CHW 2MG ......................... 47 LAMISIL GRA 125MG ........................ 16 LAMISIL GRA 187.5MG ...................... 16 lamivudine oral soln 10 mg/ml ........... 18 lamivudine tab 100 mg (hbv) ............. 20 lamivudine tab 150 mg ..................... 19 lamivudine tab 300 mg ..................... 19 lamivudine-zidovudine tab 150-300 mg ..................................................... 17 lamotrigine orally disintegrating tab 100 mg ................................................. 47 lamotrigine orally disintegrating tab 200 mg ................................................. 48 lamotrigine orally disintegrating tab 25 mg ................................................. 47 lamotrigine orally disintegrating tab 50 mg ................................................. 47 lamotrigine tab 100 mg ..................... 48 lamotrigine tab 150 mg ..................... 48 lamotrigine tab 200 mg ..................... 48 lamotrigine tab 25 mg ....................... 48 lamotrigine tab chewable dispersible 25 mg ................................................. 48 lamotrigine tab chewable dispersible 5 mg ................................................. 48 lamotrigine tab sr 24hr 100 mg .......... 48 lamotrigine tab sr 24hr 200 mg .......... 48 lamotrigine tab sr 24hr 25 mg ............ 48 lamotrigine tab sr 24hr 250 mg .......... 48 lamotrigine tab sr 24hr 300 mg .......... 48 lamotrigine tab sr 24hr 50 mg ............ 48

LANCET DEVICE .............................. 75 LANCETS ........................................ 75 lansoprazole cap delayed release 15 mg ..................................................... 93 LANTUS INJ 100/ML ......................... 73 LANTUS INJ SOLOSTAR .................... 73 larin fe tab 1.5/30 ........................... 78 larin fe tab 1/20 .............................. 78 larin tab 1.5/30 ............................... 78 larin tab 1/20 .................................. 78 LASTACAFT SOL 0.25% ................... 126 latanoprost ophth soln 0.005% ......... 128 LATUDA TAB 120MG ........................ 57 LATUDA TAB 20MG .......................... 57 LATUDA TAB 40MG .......................... 57 LATUDA TAB 60MG .......................... 57 LATUDA TAB 80MG .......................... 57 LAZANDA SPR 100MCG ...................... 7 LAZANDA SPR 400MCG ...................... 7 leena tab ........................................ 79 leflunomide tab 10 mg .................... 103 leflunomide tab 20 mg .................... 103 LENVIMA CAP 10 MG ........................ 26 LENVIMA CAP 14 MG ........................ 26 LENVIMA CAP 20 MG ........................ 26 LENVIMA CAP 24 MG ........................ 26 lessina tab ...................................... 78 LETAIRIS TAB 10MG ........................ 43 LETAIRIS TAB 5MG .......................... 43 letrozole tab 2.5 mg ......................... 24 leucovorin calcium for inj 100 mg ...... 28 leucovorin calcium for inj 350 mg ...... 28 leucovorin calcium for inj 50 mg ........ 28 leucovorin calcium tab 25 mg ............ 28 leucovorin calcium tab 5 mg .............. 28 LEUKERAN TAB 2MG ........................ 22 LEUKINE INJ 250MCG ..................... 100 leuprolide acetate inj kit 5 mg/ml ...... 24 levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) .................................. 113 levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) .................................. 113 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) .................... 114 LEVATOL TAB 20MG ......................... 38

158

LEVEMIR INJ .................................... 73 LEVEMIR INJ FLEXPEN ....................... 73 levetiracetam inj 500 mg/5ml (100 mg/ml) ........................................... 48 levetiracetam oral soln 100 mg/ml ...... 48 levetiracetam tab 1000 mg ................ 48 levetiracetam tab 250 mg .................. 48 levetiracetam tab 500 mg .................. 48 levetiracetam tab 750 mg .................. 48 levetiracetam tab sr 24hr 500 mg ....... 48 levetiracetam tab sr 24hr 750 mg ....... 48 levobunolol hcl ophth soln 0.5% ....... 126 levocarnitine inj 200 mg/ml ............... 84 levocarnitine oral soln 1 gm/10ml (10%) ..................................................... 84 levocarnitine tab 330 mg ................... 84 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) ....................... 112 levocetirizine dihydrochloride tab 5 mg ................................................... 112 levofloxacin iv soln 25 mg/ml ............. 13 levofloxacin ophth soln 0.5% ........... 125 levofloxacin oral soln 25 mg/ml .......... 13 levofloxacin tab 250 mg .................... 13 levofloxacin tab 500 mg .................... 13 levofloxacin tab 750 mg .................... 13 levonest tab .................................... 79 levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg ...................... 76 levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg ..................................... 78 levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg .............................. 78 levonorgestrel tab 1.5 mg ................. 76 levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) ....................... 76 levora-28 tab 0.15/30 ....................... 78 levorphanol tartrate tab 2 mg ............. 7 levothyroxine sodium tab 100 mcg ..... 86 levothyroxine sodium tab 112 mcg ..... 86 levothyroxine sodium tab 125 mcg ..... 86 levothyroxine sodium tab 137 mcg ..... 86 levothyroxine sodium tab 150 mcg ..... 86 levothyroxine sodium tab 175 mcg ..... 86 levothyroxine sodium tab 200 mcg ..... 86

levothyroxine sodium tab 25 mcg ...... 86 levothyroxine sodium tab 300 mcg ..... 87 levothyroxine sodium tab 50 mcg ...... 86 levothyroxine sodium tab 75 mcg ...... 86 levothyroxine sodium tab 88 mcg ...... 86 levoxyl tab 100mcg ......................... 87 levoxyl tab 112mcg ......................... 87 levoxyl tab 125mcg ......................... 87 levoxyl tab 137mcg ......................... 87 levoxyl tab 150mcg ......................... 87 levoxyl tab 175mcg ......................... 87 levoxyl tab 200mcg ......................... 87 levoxyl tab 25mcg ........................... 87 levoxyl tab 50mcg ........................... 87 levoxyl tab 75mcg ........................... 87 levoxyl tab 88mcg ........................... 87 LEXIVA SUS 50MG/ML ...................... 18 LEXIVA TAB 700MG ......................... 18 LIALDA TAB 1.2GM .......................... 91 lidocaine hcl cream 3% ................... 123 lidocaine hcl gel 2% ........................ 123 lidocaine hcl laryngotracheal soln 4% 124 lidocaine hcl soln 4% ...................... 123 lidocaine hcl viscous soln 2% ........... 124 lidocaine iv infusion in d5w inj 4 mg/ml ..................................................... 34 lidocaine iv infusion in d5w inj 8 mg/ml ..................................................... 34 lidocaine oint 5% ............................ 123 lidocaine patch 5% ......................... 123 lidocaine-hydrocortisone acetate rectal cream 3-0.5% ................................. 94 lidocaine-hydrocortisone acetate rectal cream kit 2-2% ............................... 94 lidocaine-hydrocortisone acetate rectal cream kit 3-1% ............................... 94 lidocaine-hydrocortisone acetate rectal gel kit 3-2.5% ................................. 94 lidocaine-prilocaine cream 2.5-2.5% . 123 lindane shampoo 1% ...................... 124 linezolid for susp 100 mg/5ml ........... 21 linezolid iv soln 600 mg/300ml (2 mg/ml) .......................................... 21 LINZESS CAP 145MCG...................... 91 LINZESS CAP 290MCG...................... 91

159

liothyronine sodium iv soln 10 mcg/ml 87 liothyronine sodium tab 25 mcg ......... 87 liothyronine sodium tab 5 mcg ........... 87 liothyronine sodium tab 50 mcg ......... 87 lipodox inj 2mg/ml ........................... 28 lisinopril & hydrochlorothiazide tab 10-12.5 mg .......................................... 29 lisinopril & hydrochlorothiazide tab 20-12.5 mg .......................................... 30 lisinopril & hydrochlorothiazide tab 20-25 mg ................................................. 30 lisinopril tab 10 mg ........................... 30 lisinopril tab 2.5 mg .......................... 30 lisinopril tab 20 mg ........................... 30 lisinopril tab 30 mg ........................... 30 lisinopril tab 40 mg ........................... 30 lisinopril tab 5 mg ............................ 30 lithium carbonate cap 150 mg ............ 67 lithium carbonate cap 300 mg ............ 67 lithium carbonate cap 600 mg ............ 67 lithium carbonate tab 300 mg ............ 67 lithium carbonate tab cr 300 mg ......... 67 lithium carbonate tab cr 450 mg ......... 67 LITHIUM SOL 8MEQ/5ML ................... 67 LIVALO TAB 1MG .............................. 35 LIVALO TAB 2MG .............................. 35 LIVALO TAB 4MG .............................. 35 l-methylfolate tab 15 mg ................. 107 l-methylfolate tab 7.5 mg ................ 107 LO LOESTRIN TAB ............................ 78 LOCOID LOT 0.1% .......................... 122 lokara lot 0.05% ............................ 121 lomedia 24 tab fe ............................. 78 lopreeza tab 0.5-0.1 ......................... 80 lopreeza tab 1-0.5mg ....................... 80 lorazepam con 2mg/ml ..................... 45 lorazepam inj 2 mg/ml ...................... 45 lorazepam inj 4 mg/ml ...................... 46 lorazepam tab 0.5 mg ....................... 46 lorazepam tab 1 mg .......................... 46 lorazepam tab 2 mg .......................... 46 lorcet hd tab 10-325mg ..................... 7 lorcet plus tab 7.5-325 ....................... 7 lorcet tab 5-325mg ............................ 7 lortab tab 10-325mg .......................... 7

lortab tab 5-325mg ............................ 7 lortab tab 7.5-325 ............................. 7 loryna tab 3-0.02mg ........................ 78 losartan potassium & hydrochlorothiazide tab 100-12.5 mg ............................. 32 losartan potassium & hydrochlorothiazide tab 100-25 mg ................................ 32 losartan potassium & hydrochlorothiazide tab 50-12.5 mg ............................... 32 losartan potassium tab 100 mg ......... 33 losartan potassium tab 25 mg ........... 33 losartan potassium tab 50 mg ........... 33 LOTEMAX GEL 0.5% ........................ 126 LOTEMAX OIN 0.5% ........................ 126 LOTEMAX SUS 0.5% ....................... 126 lovastatin tab 10 mg ........................ 35 lovastatin tab 20 mg ........................ 35 lovastatin tab 40 mg ........................ 35 low-ogestrel tab .............................. 78 loxapine succinate cap 10 mg ............ 57 loxapine succinate cap 25 mg ............ 57 loxapine succinate cap 5 mg ............. 57 loxapine succinate cap 50 mg ............ 57 LUCENTIS SOL 0.3MG ..................... 127 LUCENTIS SOL 0.5MG ..................... 127 ludent chw 0.25mg f ....................... 109 ludent chw 0.5mg f ......................... 109 ludent chw 1mg f............................ 109 LUMIGAN SOL 0.01% ...................... 128 LUMIZYME INJ 50MG ........................ 84 LUPR DEP-PED INJ 11.25MG ............. 84 LUPR DEP-PED INJ 15MG .................. 84 LUPR DEP-PED INJ 7.5MG ................. 84 LUPRON DEPOT INJ 11.25MG ............ 24 LUPRON DEPOT INJ 22.5MG .............. 24 LUPRON DEPOT INJ 3.75MG .............. 24 LUPRON DEPOT INJ 30MG ................. 24 LUPRON DEPOT INJ 45MG ................. 24 lutera tab ....................................... 78 LYNPARZA CAP 50MG ....................... 28 LYRICA CAP 100MG ......................... 64 LYRICA CAP 150MG ......................... 64 LYRICA CAP 200MG ......................... 64 LYRICA CAP 225MG ......................... 64 LYRICA CAP 25MG ........................... 64

160

LYRICA CAP 300MG .......................... 64 LYRICA CAP 50MG ............................ 64 LYRICA CAP 75MG ............................ 64 LYRICA SOL 20MG/ML ....................... 64 LYSODREN TAB 500MG ..................... 28 lyza tab 0.35mg ............................... 79 M MACUGEN INJ ................................ 128 MAKENA INJ 250MG/ML .................... 86 malathion lotion 0.5% ..................... 124 mannitol iv soln 10% ........................ 95 mannitol iv soln 15% ........................ 95 mannitol iv soln 20% ........................ 95 mannitol iv soln 25% ........................ 95 mannitol iv soln 5% .......................... 95 maprotiline hcl tab 25 mg .................. 51 maprotiline hcl tab 50 mg .................. 51 maprotiline hcl tab 75 mg .................. 51 margesic cap .................................... 2 marlissa tab 0.15/30......................... 78 MARPLAN TAB 10MG ......................... 50 MARQIBO INJ 5MG/31ML ................... 28 marten-tab tab 50-325mg .................. 2 MATULANE CAP 50MG ....................... 28 matzim la tab 180mg/24 ................... 40 matzim la tab 240mg/24 ................... 40 matzim la tab 300mg/24 ................... 40 matzim la tab 360mg/24 ................... 40 matzim la tab 420mg/24 ................... 40 meclofenamate sodium cap 100 mg ..... 3 meclofenamate sodium cap 50 mg ....... 3 medroxyprogesterone acetate im susp 150 mg/ml ...................................... 77 medroxyprogesterone acetate im susp prefilled syr 150 mg/ml ..................... 77 medroxyprogesterone acetate tab 10 mg ..................................................... 86 medroxyprogesterone acetate tab 2.5 mg ................................................. 86 medroxyprogesterone acetate tab 5 mg ..................................................... 86 mefenamic acid cap 250 mg ............... 3 mefloquine hcl tab 250 mg ................ 17 megestrol acetate susp 40 mg/ml ....... 24 megestrol acetate tab 20 mg ............. 24

megestrol acetate tab 40 mg............. 24 MEKINIST TAB 0.5MG ...................... 26 MEKINIST TAB 2MG ......................... 26 meloxicam tab 15 mg ......................... 3 meloxicam tab 7.5 mg ........................ 3 melphalan hcl for inj 50 mg (base equiv) ..................................................... 22 memantine hcl oral solution 2 mg/ml . 50 memantine hcl tab 10 mg ................. 50 memantine hcl tab 5 mg ................... 50 memantine hcl tab 5 mg (28) & 10 mg (21) titration pak ............................. 50 MENACTRA INJ ............................... 106 MENEST TAB 0.3MG ......................... 81 MENEST TAB 0.625MG ..................... 81 MENEST TAB 1.25MG ....................... 81 MENEST TAB 2.5MG ......................... 81 MENHIBRIX INJ .............................. 106 MENOMUNE INJ A/C/Y/W ................. 106 MENTAX CRE 1% ............................ 119 MENVEO INJ .................................. 106 meperidine hcl inj 100 mg/ml .............. 7 meperidine hcl inj 25 mg/ml ............... 7 meperidine hcl inj 50 mg/ml ............... 7 meperidine hcl tab 100 mg ................. 7 meperidine hcl tab 50 mg ................... 7 MEPHYTON TAB 5MG ....................... 109 meprobamate tab 200 mg ................ 46 meprobamate tab 400 mg ................ 46 mercaptopurine tab 50 mg ................ 23 meropenem iv for soln 500 mg .......... 10 mesalamine enema 4 gm .................. 91 mesna inj 100 mg/ml ....................... 28 MESNEX TAB 400MG ........................ 28 MESTINON SYP 60MG/5ML ................ 68 metadate tab 20mg er ..................... 63 metaproterenol sulfate syrup 10 mg/5ml .................................................... 114 metaproterenol sulfate tab 10 mg ..... 114 metaproterenol sulfate tab 20 mg ..... 114 metaxalone tab 800 mg .................... 68 metformin hcl tab 1000 mg ............... 70 metformin hcl tab 500 mg ................ 70 metformin hcl tab 850 mg ................ 70 metformin hcl tab sr 24hr 500 mg ..... 71

161

metformin hcl tab sr 24hr 750 mg ...... 71 metformin hcl tab sr 24hr osmotic 1000 mg ................................................. 71 methadone hcl conc 10 mg/ml ............ 7 methadone hcl soln 10 mg/5ml ........... 7 methadone hcl soln 5 mg/5ml ............. 7 methadone hcl tab 10 mg ................... 7 methadone hcl tab 5 mg .................... 7 methadone hcl tab for oral susp 40 mg . 7 methadose tab 40mg ......................... 7 methamphetamine hcl tab 5 mg ......... 63 methazolamide tab 25 mg ............... 127 methazolamide tab 50 mg ............... 127 methenamine hippurate tab 1 gm ....... 95 methimazole tab 10 mg .................... 86 methimazole tab 5 mg ...................... 86 METHITEST TAB 10MG ...................... 70 methocarbamol inj 1000 mg/10ml ...... 68 methocarbamol tab 500 mg ............... 68 methocarbamol tab 750 mg ............... 68 methotrexate sodium for inj 1 gm ....... 23 methotrexate sodium inj pf 50 mg/2ml (25 mg/ml) ..................................... 23 methotrexate sodium tab 2.5 mg (base equiv) ............................................. 23 methoxsalen rapid cap 10 mg .......... 120 methscopolamine bromide tab 2.5 mg . 90 methscopolamine bromide tab 5 mg ... 90 methyclothiazide tab 5 mg ................. 41 methyldopa tab 250 mg .................... 42 methyldopa tab 500 mg .................... 42 methyldopate hcl inj 250 mg/5ml ....... 42 methylene blue inj 1% ...................... 80 methylergonovine maleate inj 0.2 mg/ml ..................................................... 84 methylergonovine maleate tab 0.2 mg 84 methylphenidate hcl cap cr 10 mg (cd) 63 methylphenidate hcl cap cr 50 mg (cd) 63 methylphenidate hcl cap cr 60 mg (cd) 63 methylphenidate hcl cap sr 24hr 20 mg (la) ................................................ 63 methylphenidate hcl cap sr 24hr 30 mg (la) ................................................ 63 methylphenidate hcl cap sr 24hr 40 mg (la) ................................................ 63

methylphenidate hcl soln 10 mg/5ml .. 63 methylphenidate hcl soln 5 mg/5ml .... 63 methylphenidate hcl tab 10 mg ......... 63 methylphenidate hcl tab 20 mg ......... 63 methylphenidate hcl tab 5 mg ........... 63 methylphenidate hcl tab cr 10 mg ...... 63 methylphenidate hcl tab cr 20 mg ...... 63 methylphenidate hcl tab sa osm 18 mg 63 methylphenidate hcl tab sa osm 27 mg 63 methylphenidate hcl tab sa osm 36 mg 63 methylphenidate hcl tab sa osm 54 mg 63 methylprednisolone acetate inj susp 40 mg/ml ........................................... 82 methylprednisolone acetate inj susp 80 mg/ml ........................................... 82 methylprednisolone sodium succinate for inj 125 mg ...................................... 82 methylprednisolone sodium succinate for inj 40 mg ....................................... 82 methylprednisolone tab 16 mg .......... 83 methylprednisolone tab 32 mg .......... 83 methylprednisolone tab 4 mg ............ 82 methylprednisolone tab 8 mg ............ 82 methylprednisolone tab therapy pack 4 mg (21) ......................................... 83 methyltestosterone cap 10 mg .......... 70 metipranolol ophth soln 0.3% .......... 127 metoclopramide hcl inj 5 mg/ml ........ 89 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) ....................................... 89 metoclopramide hcl tab 10 mg .......... 89 metoclopramide hcl tab 5 mg ............ 89 metolazone tab 10 mg ..................... 42 metolazone tab 2.5 mg .................... 41 metolazone tab 5 mg ....................... 42 metoprolol & hydrochlorothiazide tab 100-25 mg ..................................... 37 metoprolol & hydrochlorothiazide tab 100-50 mg ..................................... 37 metoprolol & hydrochlorothiazide tab 50-25 mg ............................................ 37 metoprolol succinate tab sr 24hr 100 mg (tartrate equiv) ............................... 38 metoprolol succinate tab sr 24hr 200 mg (tartrate equiv) ............................... 38

162

metoprolol succinate tab sr 24hr 25 mg (tartrate equiv) ................................ 38 metoprolol succinate tab sr 24hr 50 mg (tartrate equiv) ................................ 38 metoprolol tartrate inj 1 mg/ml .......... 38 metoprolol tartrate tab 100 mg .......... 38 metoprolol tartrate tab 25 mg ............ 38 metoprolol tartrate tab 50 mg ............ 38 metronidazole cap 375 mg ................ 21 metronidazole cream 0.75% ............ 124 metronidazole gel 0.75% ................. 124 metronidazole gel 1% ..................... 124 metronidazole lotion 0.75% ............. 124 metronidazole tab 250 mg ................. 21 metronidazole tab 500 mg ................. 21 metronidazole vaginal gel 0.75% ........ 97 mexiletine hcl cap 150 mg ................. 34 mexiletine hcl cap 200 mg ................. 34 mexiletine hcl cap 250 mg ................. 34 MICRHOGAM PL INJ 50MCG ............. 103 microgestin tab 1.5/30 ...................... 78 microgestin tab 1/20 ........................ 78 microgestin tab fe 1/20 ..................... 78 microgestin tab fe1.5/30 ................... 78 midodrine hcl tab 10 mg ................... 42 midodrine hcl tab 2.5 mg .................. 42 midodrine hcl tab 5 mg ..................... 42 migergot sup 2/100 .......................... 65 miglitol tab 100 mg .......................... 70 miglitol tab 25 mg ............................ 70 miglitol tab 50 mg ............................ 70 milrinone in dextrose 5% iv soln 40mg/200 ml ................................... 42 milrinone lactate iv soln 50 mg/50ml (base equivalent) ............................. 42 mimvey lo tab 0.5-0.1 ...................... 80 mimvey tab 1-0.5mg ........................ 80 MINASTRIN 24 CHW FE ..................... 78 miniprin low tab 81mg ec ................ 102 minitran dis 0.1mg/hr ....................... 43 minitran dis 0.2mg/hr ....................... 43 minitran dis 0.4mg/hr ....................... 43 minitran dis 0.6mg/hr ....................... 43 minocycline hcl cap 100 mg ............... 15 minocycline hcl cap 50 mg ................. 15

minocycline hcl cap 75 mg ................ 15 minocycline hcl tab 100 mg ............... 15 minocycline hcl tab 50 mg ................ 15 minocycline hcl tab 75 mg ................ 15 minocycline hcl tab sr 24hr 135 mg .... 15 minocycline hcl tab sr 24hr 45 mg ..... 15 minocycline hcl tab sr 24hr 90 mg ..... 15 minoxidil tab 10 mg ......................... 42 minoxidil tab 2.5 mg ........................ 42 MIRENA IUD SYSTEM ....................... 79 mirtazapine orally disintegrating tab 15 mg ................................................ 51 mirtazapine orally disintegrating tab 30 mg ................................................ 51 mirtazapine orally disintegrating tab 45 mg ................................................ 51 mirtazapine tab 15 mg ..................... 51 mirtazapine tab 30 mg ..................... 51 mirtazapine tab 45 mg ..................... 51 mirtazapine tab 7.5 mg .................... 51 misoprostol tab 100 mcg .................. 93 misoprostol tab 200 mcg .................. 93 mitomycin for iv soln 20 mg .............. 28 mitomycin for iv soln 5 mg ............... 28 mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) ...................................... 28 M-M-R II INJ .................................. 105 modafinil tab 100 mg ....................... 68 modafinil tab 200 mg ....................... 68 MODERIBA PAK 1000/DAY ................ 20 MODERIBA PAK 1200/DAY ................ 20 MODERIBA PAK 800/DAY .................. 20 moderiba tab 200mg ........................ 20 moexipril hcl tab 15 mg .................... 30 moexipril hcl tab 7.5 mg ................... 30 moexipril-hydrochlorothiazide tab 15-12.5 mg ......................................... 30 moexipril-hydrochlorothiazide tab 15-25 mg ................................................ 30 moexipril-hydrochlorothiazide tab 7.5-12.5 mg ......................................... 30 mometasone furoate cream 0.1% ..... 122 mometasone furoate nasal susp 50 mcg/act ........................................ 116 mometasone furoate oint 0.1% ........ 122

163

mometasone furoate solution 0.1% (lotion) ......................................... 122 MONOCLATE-P INJ 1000UNIT ........... 100 MONOCLATE-P INJ 1500UNIT ........... 100 mono-linyah tab 0.25-35 ................... 78 mononessa tab ................................ 78 MONONINE INJ 1000UNIT ............... 100 MONONINE INJ 500UNIT ................. 100 MONOVISC INJ 88MG/4ML ................. 10 montelukast sodium chew tab 4 mg (base equiv) .................................. 114 montelukast sodium chew tab 5 mg (base equiv) .................................. 114 montelukast sodium oral granules packet 4 mg (base equiv) .......................... 114 montelukast sodium tab 10 mg (base equiv) ........................................... 114 MONUROL PAK GRANULES ................. 21 morgidox cap 1x100mg ..................... 15 morphine sulfate beads cap sr 24hr 120 mg .................................................. 7 morphine sulfate beads cap sr 24hr 30 mg .................................................. 7 morphine sulfate beads cap sr 24hr 45 mg .................................................. 7 morphine sulfate beads cap sr 24hr 60 mg .................................................. 7 morphine sulfate beads cap sr 24hr 75 mg .................................................. 7 morphine sulfate beads cap sr 24hr 90 mg .................................................. 7 morphine sulfate cap sr 24hr 10 mg ..... 7 morphine sulfate cap sr 24hr 100 mg ... 7 morphine sulfate cap sr 24hr 20 mg ..... 7 morphine sulfate cap sr 24hr 30 mg ..... 7 morphine sulfate cap sr 24hr 50 mg ..... 7 morphine sulfate cap sr 24hr 60 mg ..... 7 morphine sulfate cap sr 24hr 80 mg ..... 7 morphine sulfate inj 10 mg/ml ............ 8 morphine sulfate inj 15 mg/ml ............ 8 morphine sulfate inj 8 mg/ml .............. 7 morphine sulfate inj pf 0.5 mg/ml ........ 8 morphine sulfate inj pf 1 mg/ml .......... 8 morphine sulfate iv soln 1 mg/ml ........ 8 morphine sulfate iv soln pf 10 mg/ml ... 8

morphine sulfate iv soln pf 15 mg/ml ... 8 morphine sulfate oral soln 10 mg/5ml .. 8 morphine sulfate oral soln 100 mg/5ml (20 mg/ml) ....................................... 8 morphine sulfate oral soln 20 mg/5ml .. 8 morphine sulfate suppos 10 mg ........... 8 morphine sulfate suppos 20 mg ........... 8 morphine sulfate suppos 5 mg ............. 8 morphine sulfate tab cr 100 mg ........... 8 morphine sulfate tab cr 15 mg ............. 8 morphine sulfate tab cr 200 mg ........... 8 morphine sulfate tab cr 30 mg ............. 8 morphine sulfate tab cr 60 mg ............. 8 MOVANTIK TAB 12.5MG.................... 92 MOVANTIK TAB 25MG ...................... 92 MOVIPREP SOL ................................ 92 MOXEZA SOL 0.5% ......................... 125 moxifloxacin hcl tab 400 mg (base equiv) ..................................................... 13 MOZOBIL INJ ................................. 102 MULTAQ TAB 400MG ........................ 34 MULTI PRENAT TAB ......................... 110 multivit/fl chw 0.5mg ...................... 109 multivit/fl chw 1mg ......................... 109 multi-vit/fl dro 0.25mg .................... 109 mupirocin calcium cream 2% ........... 119 MUSTARGEN INJ 10MG ..................... 22 mvc-fluoride chw 0.25mg ................ 109 M-VIT TAB 27-1MG ......................... 110 my way tab 1.5mg ........................... 76 MYALEPT INJ 11.3MG ....................... 84 mycophenolate mofetil cap 250 mg ... 104 mycophenolate mofetil for oral susp 200 mg/ml .......................................... 104 mycophenolate mofetil tab 500 mg ... 104 mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) ............... 104 mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) ............... 104 myferon 150 cap 150mg .................. 109 myferon 150 cap forte ..................... 109 MYKIDZ IRON SUS 15/1.5ML ............ 109 MYLERAN TAB 2MG .......................... 22 MYNATAL TAB ................................ 110 MYNATAL TAB ADVANCE .................. 110

164

MYOBLOC INJ 2500/0.5 ..................... 67 MYRBETRIQ TAB 25MG ...................... 96 MYRBETRIQ TAB 50MG ...................... 96 myzilra tab ...................................... 79 N NABI-HB INJ .................................. 103 nabumetone tab 500 mg .................... 3 nabumetone tab 750 mg .................... 3 nac 600 cap ..................................... 85 nadolol & bendroflumethiazide tab 40-5 mg ................................................. 37 nadolol & bendroflumethiazide tab 80-5 mg ................................................. 37 nadolol tab 20 mg ............................ 38 nadolol tab 40 mg ............................ 38 nadolol tab 80 mg ............................ 38 nafcillin sodium for inj 10 gm ............. 14 nafcillin sodium for iv soln 2 gm ......... 14 naftifine hcl cream 2% .................... 119 NAGLAZYME INJ 1MG/ML ................... 84 nalbuphine hcl inj 10 mg/ml ............... 8 nalbuphine hcl inj 20 mg/ml ............... 8 naloxone hcl inj 4 mg/10ml ............... 68 naloxone hcl soln prefilled syringe 2 mg/2ml ........................................... 69 naltrexone hcl tab 50 mg ................... 69 NAMENDA XR CAP 14MG ................... 50 NAMENDA XR CAP 21MG ................... 50 NAMENDA XR CAP 28MG ................... 50 NAMENDA XR CAP 7MG ..................... 50 NAMENDA XR CAP TITRATIO .............. 50 naproxen dr tab 375mg ...................... 3 naproxen dr tab 500mg ...................... 4 naproxen sodium tab 275 mg .............. 4 naproxen sodium tab 550 mg .............. 4 naproxen susp 125 mg/5ml ................ 4 naproxen tab 250 mg ........................ 4 naproxen tab 375 mg ........................ 4 naproxen tab 500 mg ........................ 4 naratriptan hcl tab 1 mg (base equiv) . 66 naratriptan hcl tab 2.5 mg (base equiv) ..................................................... 66 nasal allgy spr 55mcg/ac ................. 116 NASCOBAL SPR 500MCG ................. 109 NATACYN SUS 5% OP ..................... 126

NATAZIA TAB .................................. 76 nateglinide tab 120 mg .................... 73 nateglinide tab 60 mg ...................... 73 NATESTO GEL 5.5MG ....................... 70 NEBUPENT INH 300MG ..................... 21 necon tab 0.5/35 ............................. 78 necon tab 1/35 ............................... 78 necon tab 7/7/7 .............................. 79 nefazodone hcl tab 100 mg ............... 51 nefazodone hcl tab 150 mg ............... 51 nefazodone hcl tab 200 mg ............... 51 nefazodone hcl tab 250 mg ............... 51 nefazodone hcl tab 50 mg ................. 51 neomycin sulfate tab 500 mg ............ 10 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin ... 125 neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml ............. 125 neomycin-polymyxin-dexamethasone ophth oint 0.1% ............................. 125 neomycin-polymyxin-dexamethasone ophth susp 0.1% ............................ 125 neomycin-polymyxin-hc otic soln 1% 128 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% ................ 129 neo-polycin oin hc 1%op ................. 125 neo-polycin oin op .......................... 125 NEO-SYNALAR CRE ......................... 118 NEUAC KIT 1.2-5% ......................... 117 NEULASTA INJ 6MG/0.6M ................ 100 NEUPOGEN INJ 300/0.5 ................... 100 NEUPOGEN INJ 300MCG .................. 100 NEUPOGEN INJ 480/0.8 ................... 100 NEUPRO DIS 1MG/24HR ................... 55 NEUPRO DIS 2MG/24HR ................... 55 NEUPRO DIS 3MG/24HR ................... 55 NEUPRO DIS 4MG/24HR ................... 55 NEUPRO DIS 6MG/24HR ................... 55 NEUPRO DIS 8MG/24HR ................... 55 NEVANAC SUS 0.1% ....................... 126 nevirapine susp 50 mg/5ml ............... 18 nevirapine tab 200 mg ..................... 18 nevirapine tab sr 24hr 100 mg .......... 18 nevirapine tab sr 24hr 400 mg .......... 18 NEXAVAR TAB 200MG ...................... 26

165

NEXIUM 24HR CAP 20MG .................. 93 NEXIUM GRA 10MG DR ..................... 93 NEXIUM GRA 2.5MG DR .................... 93 NEXIUM GRA 20MG DR ..................... 93 NEXIUM GRA 40MG DR ..................... 93 NEXIUM GRA 5MG DR ....................... 93 NEXPLANON IMP 68MG ..................... 76 next choice tab 1.5mg ...................... 76 NEXTERONE INJ ............................... 34 niacin tab cr 1000 mg (antihyperlipidemic) .......................... 36 niacin tab cr 500 mg (antihyperlipidemic) ..................................................... 36 nicardipine hcl cap 20 mg .................. 39 nicardipine hcl cap 30 mg .................. 39 nicardipine hcl iv soln 2.5 mg/ml ........ 39 nicorelief gum 2mg orig .................... 69 nicorelief gum 4mg orig .................... 69 nicotine polacrilex gum 2 mg ............. 69 nicotine polacrilex gum 4 mg ............. 69 nicotine polacrilex lozenge 2 mg ......... 69 nicotine polacrilex lozenge 4 mg ......... 69 NICOTINE SYS KIT TRANSDER ........... 69 nicotine td patch 24hr 14 mg/24hr ..... 69 nicotine td patch 24hr 21 mg/24hr ..... 69 NICOTROL INH................................. 69 NICOTROL NS SPR 10MG/ML ............. 69 nifedical xl tab 30mg ........................ 39 nifedical xl tab 60mg ........................ 39 nifedipine cap 10 mg ........................ 39 nifedipine cap 20 mg ........................ 39 nifedipine tab sr 24hr 30 mg .............. 39 nifedipine tab sr 24hr 60 mg .............. 39 nifedipine tab sr 24hr 90 mg .............. 39 nikki tab 3-0.02mg ........................... 78 NILANDRON TAB 150MG ................... 23 nimodipine cap 30 mg ....................... 39 NIPENT INJ 10MG ............................. 28 nisoldipine tab sr 24hr 17 mg ............. 39 nisoldipine tab sr 24hr 34 mg ............. 39 nisoldipine tab sr 24hr 8.5 mg ............ 39 NITRO-BID OIN 2% .......................... 43 nitrofurantoin macrocrystalline cap 25 mg ................................................. 21 nitrofurantoin macrocrystalline cap 50

mg ................................................ 21 nitrofurantoin monohydrate macrocrystalline cap 100 mg ............. 21 nitrofurantoin susp 25 mg/5ml .......... 21 nitroglycerin iv soln 100 mcg/ml in d5w ..................................................... 43 nitroglycerin iv soln 200 mcg/ml in d5w ..................................................... 43 nitroglycerin iv soln 400 mcg/ml in d5w ..................................................... 43 nitroglycerin lingual aerosol 400 mcg/spray ...................................... 43 nitroglycerin td patch 24hr 0.1 mg/hr . 43 nitroglycerin td patch 24hr 0.2 mg/hr . 43 nitroglycerin td patch 24hr 0.4 mg/hr . 43 nitroglycerin td patch 24hr 0.6 mg/hr . 43 nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) ..................................... 43 NITROSTAT SUB 0.3MG .................... 43 NITROSTAT SUB 0.4MG .................... 43 NITROSTAT SUB 0.6MG .................... 43 NIVA-PLUS TAB .............................. 110 nizatidine cap 150 mg ...................... 90 nizatidine cap 300 mg ...................... 90 nizatidine oral soln 15 mg/ml ............ 90 nora-be tab 0.35mg ......................... 79 NORDITROPIN INJ 10/1.5ML ............. 83 NORDITROPIN INJ 15/1.5ML ............. 83 NORDITROPIN INJ 30/3ML ................ 83 NORDITROPIN INJ 5/1.5ML ............... 83 norepinephrine bitartrate iv soln 1 mg/ml ..................................................... 45 norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg .................................. 78 norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg ............................. 78 norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24) ...................... 78 norethindrone acetate tab 5 mg ......... 86 norethindrone tab 0.35 mg ............... 79 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg ..................................... 78 norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg ........... 79 norlyroc tab 0.35mg ........................ 79

166

NORPACE CAP 100MG CR .................. 34 nortrel tab 0.5/35 ............................. 78 nortrel tab 1/35 ............................... 78 nortrel tab 7/7/7 .............................. 80 nortriptyline hcl cap 10 mg ................ 54 nortriptyline hcl cap 25 mg ................ 54 nortriptyline hcl cap 50 mg ................ 54 nortriptyline hcl cap 75 mg ................ 54 nortriptyline hcl soln 10 mg/5ml ......... 54 NORVIR CAP 100MG ......................... 18 NORVIR SOL 80MG/ML ...................... 18 NORVIR TAB 100MG ......................... 18 NOVAFERRUM DRO 15MG/ML ........... 109 novarel inj 10000unt ........................ 82 NOVOLIN INJ 70/30 .......................... 73 NOVOLIN N INJ U-100 ...................... 73 NOVOLIN R INJ U-100 ....................... 73 NOVOLOG INJ 100/ML ....................... 73 NOVOLOG INJ PENFILL ...................... 73 NOVOLOG MIX INJ 70/30 .................. 73 NOVOLOG MIX INJ FLEXPEN .............. 73 NOVOSEVEN RT INJ 1MG ................. 100 NOXAFIL INJ 300/16.7 ...................... 16 NOXAFIL SUS 40MG/ML .................... 16 NOXAFIL TAB 100MG ........................ 16 np thyroid tab 30mg ......................... 87 np thyroid tab 60mg ......................... 87 np thyroid tab 90mg ......................... 87 NPLATE INJ 250MCG ....................... 101 NUCALA INJ 100MG ........................ 115 NUCYNTA ER TAB 100MG ................... 8 NUCYNTA ER TAB 150MG ................... 8 NUCYNTA ER TAB 200MG ................... 8 NUCYNTA ER TAB 250MG ................... 8 NUCYNTA ER TAB 50MG ..................... 8 NUCYNTA TAB 100MG ........................ 8 NUCYNTA TAB 50MG .......................... 8 NUCYNTA TAB 75MG .......................... 8 NUEDEXTA CAP 20-10MG .................. 69 nu-iron 150 cap 150mg ................... 109 nulev tab 0.125mg ........................... 90 NULOJIX INJ 250MG ....................... 104 NUTROPIN AQ INJ 10MG/2ML ............. 83 NUTROPIN AQ INJ 20MG/2ML ............. 83 NUTROPIN AQ INJ NUSPIN 5 .............. 83

NUVARING MIS ............................... 80 nyamyc pow 100000 ....................... 119 nystatin cream 100000 unit/gm ........ 119 nystatin oint 100000 unit/gm ........... 119 nystatin susp 100000 unit/ml ............ 16 nystatin tab 500000 unit .................. 16 nystatin topical powder ................... 119 nystatin-triamcinolone cream 100000-0.1 unit/gm-% ............................... 119 nystatin-triamcinolone oint 100000-0.1 unit/gm-% .................................... 120 nystop pow 100000 ........................ 120 O O-CAL FA TAB ................................ 110 O-CAL TAB PRENATAL ..................... 110 ocella tab 3-0.03mg ......................... 78 OCTAGAM INJ 1GM ......................... 103 OCTAGAM INJ 2GM/20ML ................ 103 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) .......................................... 85 octreotide acetate inj 1000 mcg/ml (1 mg/ml) .......................................... 85 octreotide acetate inj 200 mcg/ml (0.2 mg/ml) .......................................... 85 octreotide acetate inj 50 mcg/ml (0.05 mg/ml) .......................................... 85 octreotide acetate inj 500 mcg/ml (0.5 mg/ml) .......................................... 85 ODEFSEY TAB ................................. 17 ofloxacin ophth soln 0.3% ............... 125 ofloxacin otic soln 0.3% .................. 129 ofloxacin tab 400 mg ....................... 13 ogestrel tab .................................... 78 olanzapine orally disintegrating tab 10 mg ................................................ 57 olanzapine orally disintegrating tab 15 mg ................................................ 57 olanzapine orally disintegrating tab 20 mg ................................................ 57 olanzapine orally disintegrating tab 5 mg ..................................................... 57 olanzapine tab 10 mg ....................... 58 olanzapine tab 15 mg ....................... 58 olanzapine tab 2.5 mg ...................... 57 olanzapine tab 20 mg ....................... 58

167

olanzapine tab 5 mg ......................... 58 olanzapine tab 7.5 mg ...................... 58 olanzapine-fluoxetine hcl cap 12-25 mg ..................................................... 58 olanzapine-fluoxetine hcl cap 12-50 mg ..................................................... 58 olanzapine-fluoxetine hcl cap 3-25 mg 58 olanzapine-fluoxetine hcl cap 6-25 mg 58 olanzapine-fluoxetine hcl cap 6-50 mg 58 olopatadine hcl nasal soln 0.6% ....... 115 olopatadine hcl ophth soln 0.1% (base equivalent) .................................... 126 OMECLAMOX- MIS PAK...................... 94 omega-3-acid ethyl esters cap 1 gm . 109 omeprazole cap delayed release 10 mg93 omeprazole cap delayed release 20 mg93 omeprazole cap delayed release 40 mg93 omeprazole-sodium bicarbonate cap 20-1100 mg ......................................... 93 omeprazole-sodium bicarbonate cap 40-1100 mg ......................................... 93 OMNITROPE INJ 10/1.5ML ................. 83 OMNITROPE INJ 5.8MG ..................... 83 OMNITROPE INJ 5/1.5ML ................... 83 ONCASPAR INJ 750/ML ..................... 28 ondansetron hcl inj 4 mg/2ml (2 mg/ml) ..................................................... 89 ondansetron hcl inj 40 mg/20ml (2 mg/ml) ........................................... 89 ondansetron hcl oral soln 4 mg/5ml .... 89 ondansetron hcl tab 24 mg ................ 89 ondansetron hcl tab 4 mg .................. 89 ondansetron hcl tab 8 mg .................. 89 ondansetron orally disintegrating tab 4 mg ................................................. 89 ondansetron orally disintegrating tab 8 mg ................................................. 89 ONFI SUS 2.5MG/ML ......................... 48 ONFI TAB 10MG ............................... 48 ONFI TAB 20MG ............................... 48 ONGLYZA TAB 2.5MG ........................ 72 ONGLYZA TAB 5MG .......................... 72 OPANA ER TAB 10MG ......................... 8 OPANA ER TAB 15MG ......................... 8 OPANA ER TAB 20MG ......................... 8

OPANA ER TAB 30MG ......................... 8 OPANA ER TAB 40MG ......................... 8 OPANA ER TAB 5MG ........................... 8 OPANA ER TAB 7.5MG ........................ 8 OPDIVO INJ 100MG/10 ..................... 28 OPDIVO INJ 40MG/4ML .................... 28 opium tincture 1% (10 mg/ml) (morphine equiv) ............................. 88 OPSUMIT TAB 10MG ........................ 44 ORACEA CAP 40MG ......................... 124 oralone pst 0.1% ............................ 124 ORAVIG TAB 50MG .......................... 16 ORENCIA INJ 125MG/ML .................. 102 ORENCIA INJ 250MG ....................... 102 ORFADIN CAP 10MG ........................ 85 ORFADIN CAP 2MG .......................... 85 ORFADIN CAP 5MG .......................... 85 ORKAMBI TAB 200-125 ................... 114 orphenadrine citrate inj 30 mg/ml ...... 68 orphenadrine citrate tab sr 12hr 100 mg ..................................................... 68 orphenadrine w/ aspirin & caffeine tab 25-385-30 mg ................................. 68 orsythia tab .................................... 78 ORTHOVISC INJ 15MG/ML ................ 10 oscimin sr tab 0.375mg .................... 90 oscimin sub 0.125mg ....................... 90 oscimin tab 0.125mg ....................... 90 osmitrol inj 10% .............................. 95 osmitrol inj 15% .............................. 95 osmitrol inj 5% ............................... 95 OSMOPREP TAB 1.5GM ..................... 92 oxacillin sodium for inj 1 gm ............. 14 oxacillin sodium for inj 10 gm ............ 14 oxaliplatin iv soln 50 mg/10ml ........... 22 oxandrolone tab 10 mg .................... 70 oxandrolone tab 2.5 mg ................... 70 oxaprozin tab 600 mg ........................ 4 oxazepam cap 10 mg ....................... 46 oxazepam cap 15 mg ....................... 46 oxazepam cap 30 mg ....................... 46 oxcarbazepine susp 300 mg/5ml (60 mg/ml) .......................................... 48 oxcarbazepine tab 150 mg ................ 48 oxcarbazepine tab 300 mg ................ 48

168

oxcarbazepine tab 600 mg ................. 48 oxiconazole nitrate cream 1% .......... 120 OXSORALEN LOT 1% ...................... 123 oxybutynin chloride syrup 5 mg/5ml ... 96 oxybutynin chloride tab 5 mg ............. 96 oxybutynin chloride tab sr 24hr 10 mg 96 oxybutynin chloride tab sr 24hr 15 mg 96 oxybutynin chloride tab sr 24hr 5 mg .. 96 oxycodone hcl cap 5 mg ..................... 8 oxycodone hcl conc 100 mg/5ml (20 mg/ml) ............................................ 8 oxycodone hcl soln 5 mg/5ml .............. 8 oxycodone hcl tab 10 mg.................... 8 oxycodone hcl tab 15 mg.................... 8 oxycodone hcl tab 20 mg.................... 9 oxycodone hcl tab 30 mg.................... 9 oxycodone hcl tab 5 mg ..................... 8 oxycodone w/ acetaminophen tab 10-325 mg .................................................. 9 oxycodone w/ acetaminophen tab 2.5-325 mg ............................................ 9 oxycodone w/ acetaminophen tab 5-325 mg .................................................. 9 oxycodone w/ acetaminophen tab 7.5-325 mg ............................................ 9 oxycodone-aspirin tab 4.8355-325 mg . 9 oxycodone-ibuprofen tab 5-400 mg ..... 9 OXYCONTIN TAB 10MG CR ................. 9 OXYCONTIN TAB 15MG CR ................. 9 OXYCONTIN TAB 20MG CR ................. 9 OXYCONTIN TAB 30MG CR ................. 9 OXYCONTIN TAB 40MG CR ................. 9 OXYCONTIN TAB 60MG CR ................. 9 OXYCONTIN TAB 80MG CR ................. 9 oxymorphone hcl tab 10 mg ............... 9 oxymorphone hcl tab 5 mg ................. 9 oxymorphone hcl tab sr 12hr 10 mg .... 9 oxymorphone hcl tab sr 12hr 15 mg .... 9 oxymorphone hcl tab sr 12hr 20 mg .... 9 oxymorphone hcl tab sr 12hr 30 mg .... 9 oxymorphone hcl tab sr 12hr 40 mg .... 9 oxymorphone hcl tab sr 12hr 5 mg ...... 9 oxymorphone hcl tab sr 12hr 7.5 mg ... 9 oxytocin inj 10 unit/ml ...................... 85 OXYTROL DIS 3.9MG/24 .................... 96

OZURDEX IMP 0.7MG ...................... 126 P pacerone tab 100mg ........................ 34 pacerone tab 200mg ........................ 34 pacerone tab 400mg ........................ 34 paclitaxel iv conc 30 mg/5ml (6 mg/ml) ..................................................... 28 paliperidone tab sr 24hr 1.5 mg ......... 58 paliperidone tab sr 24hr 3 mg ........... 58 paliperidone tab sr 24hr 6 mg ........... 58 paliperidone tab sr 24hr 9 mg ........... 58 pamidronate disodium iv soln 3 mg/ml 75 pamidronate disodium iv soln 9 mg/ml 75 PAMIDRONATE INJ 6MG/ML .............. 75 PANRETIN GEL 0.1% ....................... 123 pantoprazole sodium ec tab 20 mg (base equiv) ............................................ 93 pantoprazole sodium ec tab 40 mg (base equiv) ............................................ 94 papaverine hcl inj 30 mg/ml .............. 42 paricalcitol cap 1 mcg ....................... 84 paricalcitol cap 2 mcg ....................... 84 paricalcitol cap 4 mcg ....................... 84 paricalcitol iv soln 5 mcg/ml .............. 84 paromomycin sulfate cap 250 mg ...... 10 paroxetine hcl tab 10 mg .................. 52 paroxetine hcl tab 20 mg .................. 52 paroxetine hcl tab 30 mg .................. 53 paroxetine hcl tab 40 mg .................. 53 paroxetine hcl tab sr 24hr 12.5 mg .... 53 paroxetine hcl tab sr 24hr 25 mg ....... 53 paroxetine hcl tab sr 24hr 37.5 mg .... 53 PASER GRA 4GM ............................. 19 PATADAY SOL 0.2% ........................ 126 PCE TAB 500MG EC .......................... 12 PEDIARIX INJ 0.5ML ....................... 106 PEDVAX HIB INJ ............................. 106 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm ............................... 92 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm ............................... 92 peg 3350-kcl-sod bicarb-nacl for soln 420 gm .......................................... 92 PEGANONE TAB 250MG .................... 48 PEGASYS INJ ................................. 103

169

PEGASYS INJ 180MCG/M ................. 104 PEGASYS INJ PROCLICK .................. 104 pegylax pow .................................... 92 penicillin g potassium for inj 5000000 unit ................................................ 14 penicillin v potassium for soln 125 mg/5ml ........................................... 14 penicillin v potassium for soln 250 mg/5ml ........................................... 14 penicillin v potassium tab 250 mg ....... 14 penicillin v potassium tab 500 mg ....... 14 PENTACEL INJ ................................ 106 PENTASA CAP 250MG CR ................... 91 PENTASA CAP 500MG CR ................... 91 pentazocine w/ naloxone tab 50-0.5 mg 9 pentoxifylline tab cr 400 mg ............ 101 PERFOROMIST NEB 20MCG .............. 113 perindopril erbumine tab 2 mg ........... 30 perindopril erbumine tab 4 mg ........... 30 perindopril erbumine tab 8 mg ........... 30 periogard sol 0.12% ....................... 124 PERJETA INJ 420/14ML ..................... 28 permethrin cream 5% ..................... 124 perphenazine tab 16 mg .................... 60 perphenazine tab 2 mg ..................... 60 perphenazine tab 4 mg ..................... 60 perphenazine tab 8 mg ..................... 60 perphenazine-amitriptyline tab 2-10 mg ..................................................... 60 perphenazine-amitriptyline tab 2-25 mg ..................................................... 60 perphenazine-amitriptyline tab 4-25 mg ..................................................... 61 phenadoz sup 12.5mg ....................... 89 phenadoz sup 25mg ......................... 89 phenazopyridine hcl tab 100 mg ......... 95 phenazopyridine hcl tab 200 mg ......... 95 phenelzine sulfate tab 15 mg ............. 50 phenergan sup 12.5mg ..................... 89 phenergan sup 25mg ........................ 89 phenobarbital elixir 20 mg/5ml ........... 48 phenobarbital sodium inj 130 mg/ml ... 48 phenobarbital tab 100 mg ................. 49 phenobarbital tab 15 mg ................... 48 phenobarbital tab 16.2 mg ................ 48

phenobarbital tab 30 mg .................. 48 phenobarbital tab 32.4 mg ................ 48 phenobarbital tab 60 mg .................. 48 phenobarbital tab 64.8 mg ................ 48 phenobarbital tab 97.2 mg ................ 48 phenoxybenzamine hcl cap 10 mg ..... 42 phenylephrine hcl inj 10 mg/ml ......... 45 phenylephrine hcl ophth soln 10% .... 127 phenylephrine hcl ophth soln 2.5% ... 127 phenytoin chew tab 50 mg ................ 49 phenytoin sodium extended cap 100 mg ..................................................... 49 phenytoin sodium extended cap 200 mg ..................................................... 49 phenytoin sodium extended cap 300 mg ..................................................... 49 phenytoin sodium inj 50 mg/ml ......... 49 phenytoin susp 125 mg/5ml .............. 49 philith tab 0.4-35 ............................ 78 phos-flur gel 1.1% .......................... 124 PHOSLYRA SOL ............................... 85 phospha 250 tab neutral .................. 106 phosphasal tab ................................ 95 PHOSPHOLINE SOL 0.125%OP ......... 128 PHOTOFRIN INJ 75MG ...................... 28 phytonadione inj 1 mg/0.5ml (2 mg/ml) .................................................... 109 PICATO GEL 0.015% ....................... 118 PICATO GEL 0.05% ......................... 118 pilocarpine hcl ophth soln 1% ........... 128 pilocarpine hcl ophth soln 2% ........... 128 pilocarpine hcl ophth soln 4% ........... 128 pilocarpine hcl tab 5 mg ................... 94 pilocarpine hcl tab 7.5 mg ................. 94 pimozide tab 1 mg ........................... 61 pimozide tab 2 mg ........................... 61 pimtrea tab .................................... 76 pindolol tab 10 mg ........................... 38 pindolol tab 5 mg ............................ 38 pioglitazone hcl tab 15 mg (base equiv) ..................................................... 73 pioglitazone hcl tab 30 mg (base equiv) ..................................................... 73 pioglitazone hcl tab 45 mg (base equiv) ..................................................... 73

170

pioglitazone hcl-glimepiride tab 30-2 mg ..................................................... 72 pioglitazone hcl-glimepiride tab 30-4 mg ..................................................... 72 pioglitazone hcl-metformin hcl tab 15-500 mg ........................................... 72 pioglitazone hcl-metformin hcl tab 15-850 mg ........................................... 72 piperacillin sod-tazobactam na for inj 3.375 gm (3-0.375 gm) .................... 14 piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm) ........................ 14 piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) ........................... 14 pirmella tab 1/35 ............................. 78 pirmella tab 7/7/7 ............................ 80 piroxicam cap 10 mg ......................... 4 piroxicam cap 20 mg ......................... 4 PNEUMOVAX 23 INJ 25/0.5 .............. 106 PNV FOLIC AC TAB + IRON .............. 110 PNV PRENATAL TAB PLUS ................ 110 PNV TABS TAB 29-1MG ................... 110 podofilox soln 0.5% ........................ 123 polyethylene glycol 3350 oral powder .. 92 poly-iron cap 150 fort ..................... 109 polymyxin b sulfate for inj 500000 unit 21 polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% ....................... 125 POMALYST CAP 1MG ......................... 24 POMALYST CAP 2MG ......................... 24 POMALYST CAP 3MG ......................... 24 POMALYST CAP 4MG ......................... 24 portia-28 tab ................................... 78 pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml .................................... 95 potassium chloride cap cr 10 meq ..... 107 potassium chloride cap cr 8 meq ...... 107 potassium chloride microencapsulated crys cr tab 20 meq ......................... 107 potassium chloride oral soln 10% (20 meq/15ml) .................................... 107 potassium chloride oral soln 20% (40 meq/15ml) .................................... 107 potassium chloride powder packet 20 meq ............................................. 107

potassium chloride tab cr 10 meq ..... 107 potassium chloride tab cr 20 meq (1500 mg) .............................................. 107 potassium chloride tab cr 8 meq (600 mg) .............................................. 107 potassium citrate & citric acid soln 1100-334 mg/5ml .................................... 95 potassium citrate tab cr 10 meq (1080 mg) ............................................... 95 potassium citrate tab cr 15 meq (1620 mg) ............................................... 95 potassium citrate tab cr 5 meq (540 mg) ..................................................... 95 POTIGA TAB 200MG ......................... 49 POTIGA TAB 300MG ......................... 49 POTIGA TAB 400MG ......................... 49 POTIGA TAB 50MG ........................... 49 PRADAXA CAP 150MG ...................... 98 PRADAXA CAP 75MG ........................ 98 PRALUENT INJ 150MG/ML ................. 37 PRALUENT INJ 75MG/ML ................... 37 pramipexole dihydrochloride tab 0.125 mg ................................................ 55 pramipexole dihydrochloride tab 0.25 mg ..................................................... 55 pramipexole dihydrochloride tab 0.5 mg ..................................................... 55 pramipexole dihydrochloride tab 0.75 mg ..................................................... 55 pramipexole dihydrochloride tab 1 mg 55 pramipexole dihydrochloride tab 1.5 mg ..................................................... 55 prascion emu ................................. 117 PRASCION RA CRE 10-5% ............... 117 pravastatin sodium tab 10 mg ........... 36 pravastatin sodium tab 20 mg ........... 36 pravastatin sodium tab 40 mg ........... 36 pravastatin sodium tab 80 mg ........... 36 prazosin hcl cap 1 mg ...................... 31 prazosin hcl cap 2 mg ...................... 31 prazosin hcl cap 5 mg ...................... 31 PRECISION TES QID ........................ 75 PRED MILD SUS 0.12% OP .............. 126 prednicarbate cream 0.1% ............... 122 prednicarbate oint 0.1% .................. 122

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prednisolone acetate ophth susp 1% . 126 prednisolone sod phos orally disintegr tab 10 mg (base eq) ......................... 83 prednisolone sod phos orally disintegr tab 15 mg (base eq) ......................... 83 prednisolone sod phos orally disintegr tab 30 mg (base eq) ......................... 83 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) .................. 83 prednisolone syrup 15 mg/5ml (usp solution equivalent) .......................... 83 PREDNISONE CON 5MG/ML ................ 83 prednisone tab 1 mg ......................... 83 prednisone tab 10 mg ....................... 83 prednisone tab 2.5 mg ...................... 83 prednisone tab 20 mg ....................... 83 prednisone tab 5 mg ......................... 83 prednisone tab therapy pack 10 mg (21) ..................................................... 83 prednisone tab therapy pack 10 mg (48) ..................................................... 83 prednisone tab therapy pack 5 mg (21) ..................................................... 83 prednisone tab therapy pack 5 mg (48) ..................................................... 83 pregnyl inj 10000unt ........................ 82 PREMARIN TAB 0.3MG ...................... 81 PREMARIN TAB 0.45MG ..................... 81 PREMARIN TAB 0.625MG ................... 81 PREMARIN TAB 0.9MG ...................... 81 PREMARIN TAB 1.25MG ..................... 81 PREMPHASE TAB .............................. 80 PREMPRO TAB .625-2.5 ..................... 80 PREMPRO TAB 0.3-1.5 ...................... 80 PREMPRO TAB 0.45-1.5 ..................... 80 PREMPRO TAB 0.625-5 ...................... 80 PRENAT PLUS TAB 27-1MG .............. 110 prenatabs fa tab ............................. 110 prenatabs rx tab ............................ 111 PRENATAL ONE TAB DAILY .............. 111 PRENATAL TAB ............................... 111 PRENATAL TAB 27-0.8MG ................ 111 PRENATAL TAB 27-1MG ................... 111 PRENATAL TAB 28-0.8MG ................ 111 PRENATAL TAB LOW IRON ............... 111

PRENATAL TAB VITAMINS ................ 111 PRENATAL VIT TAB 28-0.8MG ........... 111 PRENATAL+FE TAB 29-1MG ............. 111 PREPLUS TAB 27-1MG ..................... 111 PREPOPIK PAK ................................ 92 PRETAB TAB 29-1MG ....................... 111 prevalite pow 4gm ........................... 34 previfem tab ................................... 78 PREVNAR 13 INJ ............................. 106 PREZISTA SUS 100MG/ML ................ 18 PREZISTA TAB 150MG ...................... 18 PREZISTA TAB 600MG ...................... 18 PREZISTA TAB 75MG ....................... 18 PREZISTA TAB 800MG ...................... 18 PRIALT INJ 100MCG ........................... 2 PRIALT INJ 25MCG/ML ....................... 2 PRIFTIN TAB 150MG ........................ 19 PRIMAQUINE TAB 26.3MG................. 17 primidone tab 250 mg ...................... 49 primidone tab 50 mg ........................ 49 PRIMSOL SOL 50MG/5ML .................. 21 PRISTIQ TAB 50MG .......................... 51 PRIVIGEN INJ 5 GRAMS ................... 103 PROAIR HFA AER ............................ 114 PROAIR RESPI AER ......................... 114 probenecid tab 500 mg ...................... 2 prochlorperazine edisylate inj 5 mg/ml 61 prochlorperazine maleate tab 10 mg (base equivalent) ............................ 89 prochlorperazine maleate tab 5 mg (base equivalent) ..................................... 89 prochlorperazine suppos 25 mg ......... 89 PROCRIT INJ 10000/ML ................... 101 PROCRIT INJ 2000/ML ..................... 100 PROCRIT INJ 20000/ML ................... 101 PROCRIT INJ 3000/ML ..................... 101 PROCRIT INJ 4000/ML ..................... 101 PROCRIT INJ 40000/ML ................... 101 procto-pak cre 1% ........................... 94 proctozone cre -hc 2.5% .................. 94 PROCYSBI CAP 25MG ....................... 95 PROCYSBI CAP 75MG ....................... 95 PROFE CAP 180MG ......................... 109 PROFERRIN ES TAB 12 MG ............... 109 PROFILNINE INJ 1500UNIT .............. 100

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PROFILNINE INJ 500UNIT ................ 100 progesterone im in oil 50 mg/ml ......... 86 progesterone micronized cap 100 mg .. 86 progesterone micronized cap 200 mg .. 86 PROGLYCEM SUS 50MG/ML ................ 83 PROGRAF INJ 5MG/ML .................... 104 PROLASTIN-C INJ 1000MG .............. 115 PROLEUKIN INJ 22MU ....................... 28 PROLIA SOL 60MG/ML ....................... 76 PROMACTA TAB 12.5MG .................. 101 PROMACTA TAB 25MG ..................... 101 PROMACTA TAB 50MG ..................... 101 PROMACTA TAB 75MG ..................... 101 prometh vc syp plain ...................... 112 prometh vc/ syp codeine ................. 113 promethazine hcl inj 25 mg/ml ........... 89 promethazine hcl inj 50 mg/ml ........... 89 promethazine hcl suppos 12.5 mg ...... 89 promethazine hcl suppos 25 mg ......... 89 promethazine hcl syrup 6.25 mg/5ml .. 89 promethazine hcl tab 12.5 mg ............ 89 promethazine hcl tab 25 mg .............. 89 promethazine hcl tab 50 mg .............. 89 promethazine w/ codeine syrup 6.25-10 mg/5ml ......................................... 113 promethazine-dm syrup 6.25-15 mg/5ml ................................................... 113 promethegan sup 12.5mg .................. 89 promethegan sup 25mg .................... 89 promethegan sup 50mg .................... 89 propafenone hcl cap sr 12hr 225 mg ... 34 propafenone hcl cap sr 12hr 325 mg ... 34 propafenone hcl cap sr 12hr 425 mg ... 34 propafenone hcl tab 150 mg .............. 34 propafenone hcl tab 225 mg .............. 34 propafenone hcl tab 300 mg .............. 34 proparacaine hcl ophth soln 0.5% ..... 128 propranolol hcl cap sr 24hr 120 mg ..... 38 propranolol hcl cap sr 24hr 160 mg ..... 38 propranolol hcl cap sr 24hr 60 mg ...... 38 propranolol hcl cap sr 24hr 80 mg ...... 38 propranolol hcl inj 1 mg/ml ................ 38 propranolol hcl tab 10 mg .................. 38 propranolol hcl tab 20 mg .................. 38 propranolol hcl tab 40 mg .................. 38

propranolol hcl tab 60 mg ................. 38 propranolol hcl tab 80 mg ................. 38 propylthiouracil tab 50 mg ................ 86 PROQUAD INJ ................................ 106 protriptyline hcl tab 10 mg ................ 54 protriptyline hcl tab 5 mg ................. 54 PROVENGE INJ ................................ 28 PULMICORT INH 180MCG ................ 116 PULMICORT INH 90MCG .................. 116 pulmosal neb 7% ........................... 115 PULMOZYME SOL 1MG/ML ................ 114 PURIXAN SUS 20MG/ML ................... 23 PX PRENATAL TAB MULTIVIT ............ 111 PYLERA CAP .................................... 94 pyrazinamide tab 500 mg ................. 19 pyridostigmine bromide tab 60 mg ..... 68 pyridostigmine bromide tab cr 180 mg 68 Q QC PRENATAL TAB 28-0.8MG ........... 111 quasense tab .................................. 76 quetiapine fumarate tab 100 mg ........ 58 quetiapine fumarate tab 200 mg ........ 58 quetiapine fumarate tab 25 mg ......... 58 quetiapine fumarate tab 300 mg ........ 58 quetiapine fumarate tab 400 mg ........ 58 quetiapine fumarate tab 50 mg ......... 58 QUFLORA PED CHW 0.25MG ............. 109 QUFLORA PED CHW 0.5MG .............. 109 QUFLORA PED CHW 1MG ................. 109 QUILLIVANT SUS 25MG/5ML ............. 63 quinapril hcl tab 10 mg ..................... 31 quinapril hcl tab 20 mg ..................... 31 quinapril hcl tab 40 mg ..................... 31 quinapril hcl tab 5 mg ...................... 31 quinapril-hydrochlorothiazide tab 10-12.5 mg ................................................ 30 quinapril-hydrochlorothiazide tab 20-12.5 mg ................................................ 30 quinapril-hydrochlorothiazide tab 20-25 mg ................................................ 30 quinidine gluconate tab cr 324 mg ..... 34 quinidine sulfate tab 200 mg ............. 34 quinidine sulfate tab 300 mg ............. 34 quinine sulfate cap 324 mg ............... 17 QVAR AER 40MCG .......................... 116

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QVAR AER 80MCG .......................... 116 R ra iron tab 27mg ............................ 109 RA PRENATAL TAB 28-0.8MG ........... 111 RA PRENATAL TAB FORMULA ............ 111 RABAVERT INJ ............................... 106 rabeprazole sodium ec tab 20 mg ....... 94 raloxifene hcl tab 60 mg .................... 86 ramipril cap 1.25 mg ........................ 31 ramipril cap 10 mg ........................... 31 ramipril cap 2.5 mg .......................... 31 ramipril cap 5 mg ............................. 31 RANEXA TAB 1000MG ....................... 43 RANEXA TAB 500MG ......................... 42 ranitidine hcl cap 150 mg .................. 90 ranitidine hcl cap 300 mg .................. 90 ranitidine hcl inj 50 mg/2ml (25 mg/ml) ..................................................... 91 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) ......................................... 91 ranitidine hcl tab 150 mg ................... 91 ranitidine hcl tab 300 mg ................... 91 RAPAFLO CAP 4MG ........................... 94 RAPAFLO CAP 8MG ........................... 94 RAPAMUNE SOL 1MG/ML ................. 104 RAVICTI LIQ 1.1GM/ML ..................... 85 rea lo 40 cre 40% .......................... 123 REBETOL SOL 40MG/ML .................... 20 REBIF INJ 22/0.5 ............................. 67 REBIF INJ 44/0.5 ............................. 67 REBIF TITRTN INJ PACK .................... 67 reclipsen tab .................................... 79 RECOMBINATE INJ ......................... 100 RECOMBINATE INJ 220-400 ............. 100 RECOMBINATE INJ 401-800 ............. 100 RECOMBINATE INJ 801-1240 ........... 100 RECOMBIVA HB INJ 10MCG/ML ........ 106 RECOMBIVA HB INJ 5MCG/0.5 ......... 106 RECOMBIVA-HB INJ 40MCG/ML ........ 106 RECTIV OIN 0.4% ............................ 92 REGRANEX GEL 0.01% .................... 123 relagard gel ..................................... 95 RELENZA MIS DISKHALE ................... 21 RELISTOR INJ 12/0.6ML .................... 92 RELISTOR INJ 8/0.4ML ...................... 92

RELPAX TAB 20MG ........................... 66 RELPAX TAB 40MG ........................... 66 remeven cre 50% ........................... 123 REMICADE INJ 100MG ..................... 102 REMODULIN INJ 10MG/ML ................ 44 REMODULIN INJ 1MG/ML .................. 44 REMODULIN INJ 2.5MG/ML ............... 44 REMODULIN INJ 5MG/ML .................. 44 RENAGEL TAB 400MG ....................... 86 RENAGEL TAB 800MG ....................... 86 RENVELA PAK 0.8GM ........................ 86 RENVELA PAK 2.4GM ........................ 86 RENVELA TAB 800MG ....................... 86 repaglinide tab 0.5 mg ..................... 73 repaglinide tab 1 mg ........................ 73 repaglinide tab 2 mg ........................ 73 repaglinide-metformin hcl tab 1-500 mg ..................................................... 73 repaglinide-metformin hcl tab 2-500 mg ..................................................... 73 REPATHA INJ 140MG/ML ................... 37 REPATHA SURE INJ 140MG/ML .......... 37 REPLESTA NX WAF 14000UNT .......... 109 reprexain tab 10-200mg ..................... 9 RESCRIPTOR TAB 100 MG ................. 18 RESCRIPTOR TAB 200MG .................. 18 RESTASIS EMU 0.05% .................... 127 RETROVIR INJ 10MG/ML ................... 19 REVLIMID CAP 10MG ....................... 25 REVLIMID CAP 15MG ....................... 25 REVLIMID CAP 2.5MG ...................... 24 REVLIMID CAP 20MG ....................... 25 REVLIMID CAP 25MG ....................... 25 REVLIMID CAP 5MG ......................... 24 revonto inj 20mg ............................. 68 REXULTI TAB 0.25MG ....................... 58 REXULTI TAB 0.5MG ........................ 58 REXULTI TAB 1MG ........................... 58 REXULTI TAB 2MG ........................... 58 REXULTI TAB 3MG ........................... 58 REXULTI TAB 4MG ........................... 58 REYATAZ CAP 150MG ....................... 18 REYATAZ CAP 200MG ....................... 18 REYATAZ CAP 300MG ....................... 18 REYATAZ POW 50MG ........................ 18

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RHEUMATREX TAB 2.5MG ................ 103 rhinocort sus allergy ....................... 116 RHOGAM PLUS INJ 300MCG ............. 103 RHOPHYLAC INJ 1500/2ML .............. 103 RIASTAP SOL 1GM .......................... 100 RIBAPAK PAK 1000/DAY .................... 20 RIBAPAK PAK 1200/DAY .................... 20 RIBAPAK PAK 600/DAY ...................... 20 RIBAPAK PAK 800/DAY ...................... 20 ribasphere cap 200mg ...................... 20 ribasphere tab 200mg ....................... 20 ribasphere tab 400mg ....................... 20 ribasphere tab 600mg ....................... 20 ribavirin cap 200 mg ......................... 20 ribavirin tab 200 mg ......................... 20 RIDAURA CAP 3MG ......................... 103 rifabutin cap 150 mg ........................ 21 RIFAMATE CAP ................................. 19 rifampin cap 150 mg ......................... 19 rifampin cap 300 mg ......................... 19 rifampin for inj 600 mg ..................... 19 RIFATER TAB ................................... 19 RIGHT STEP TAB PRENATAL ............. 111 riluzole tab 50 mg ............................ 67 rimantadine hydrochloride tab 100 mg 21 RIOMET SOL .................................... 71 risedronate sodium tab 150 mg .......... 75 risedronate sodium tab 30 mg ............ 75 risedronate sodium tab 35 mg ............ 75 risedronate sodium tab 5 mg ............. 75 RISPERDAL INJ 12.5MG ..................... 58 RISPERDAL INJ 25MG ....................... 58 RISPERDAL INJ 37.5MG ..................... 58 RISPERDAL INJ 50MG ....................... 59 risperidone orally disintegrating tab 0.25 mg ................................................. 59 risperidone orally disintegrating tab 0.5 mg ................................................. 59 risperidone orally disintegrating tab 1 mg ..................................................... 59 risperidone orally disintegrating tab 2 mg ..................................................... 59 risperidone orally disintegrating tab 3 mg ..................................................... 59 risperidone orally disintegrating tab 4 mg

..................................................... 59 risperidone soln 1 mg/ml .................. 59 risperidone tab 0.25 mg ................... 59 risperidone tab 0.5 mg ..................... 59 risperidone tab 1 mg ........................ 59 risperidone tab 2 mg ........................ 59 risperidone tab 3 mg ........................ 59 risperidone tab 4 mg ........................ 59 RITUXAN INJ 100MG ........................ 28 rivastigmine tartrate cap 1.5 mg ........ 50 rivastigmine tartrate cap 3 mg .......... 50 rivastigmine tartrate cap 4.5 mg ........ 50 rivastigmine tartrate cap 6 mg .......... 50 rizatriptan benzoate oral disintegrating tab 10 mg (base eq) ........................ 66 rizatriptan benzoate oral disintegrating tab 5 mg (base eq) .......................... 66 rizatriptan benzoate tab 10 mg (base equivalent) ..................................... 66 rizatriptan benzoate tab 5 mg (base equivalent) ..................................... 66 ropinirole hydrochloride tab 0.25 mg .. 55 ropinirole hydrochloride tab 0.5 mg .... 55 ropinirole hydrochloride tab 1 mg ...... 55 ropinirole hydrochloride tab 2 mg ...... 55 ropinirole hydrochloride tab 3 mg ...... 55 ropinirole hydrochloride tab 4 mg ...... 55 ropinirole hydrochloride tab 5 mg ...... 55 ropinirole hydrochloride tab sr 24hr 12 mg (base equivalent) ....................... 55 ropinirole hydrochloride tab sr 24hr 2 mg (base equivalent) ............................ 55 ropinirole hydrochloride tab sr 24hr 4 mg (base equivalent) ............................ 55 ropinirole hydrochloride tab sr 24hr 6 mg (base equivalent) ............................ 55 ropinirole hydrochloride tab sr 24hr 8 mg (base equivalent) ............................ 55 rosadan cre 0.75% ......................... 124 rosadan gel 0.75% ......................... 124 rosanil emu cleanser ....................... 118 rosuvastatin calcium tab 10 mg ......... 36 rosuvastatin calcium tab 20 mg ......... 36 rosuvastatin calcium tab 40 mg ......... 36 rosuvastatin calcium tab 5 mg ........... 36

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ROTARIX SUS ................................ 106 ROTATEQ SOL ................................ 106 roxicet tab 5-325mg .......................... 9 ROZEREM TAB 8MG .......................... 65 S SABRIL POW 500MG ......................... 49 salacyn cre 6% .............................. 123 salacyn lot 6% ............................... 123 salicylic ac liq 27.5% ...................... 123 salicylic acid cream 6% ................... 123 salicylic acid foam 6% ..................... 123 salicylic acid gel 6% ........................ 123 salicylic acid lotion 6% & cleanser liqd kit ................................................... 123 salicylic acid shampoo 6% ............... 123 salsalate tab 500 mg ......................... 4 salsalate tab 750 mg ......................... 4 SAMSCA TAB 15MG .......................... 88 SAMSCA TAB 30MG .......................... 88 SANCUSO DIS 3.1MG ........................ 89 SANDIMMUNE SOL 100MG/ML .......... 104 SANDOSTATIN KIT LAR 10MG ............ 85 SANDOSTATIN KIT LAR 20MG ............ 85 SANDOSTATIN KIT LAR 30MG ............ 85 SANTYL OIN 250/GM ...................... 123 SAPHRIS SUB 10MG ......................... 59 SAPHRIS SUB 5MG ........................... 59 SAVAYSA TAB 15MG ......................... 98 SAVAYSA TAB 30MG ......................... 98 SAVAYSA TAB 60MG ......................... 98 SAVELLA TAB 100MG ........................ 65 SAVELLA TAB 12.5MG ....................... 64 SAVELLA TAB 25MG .......................... 64 SAVELLA TAB 50MG .......................... 64 scalacort lot 2% ............................. 121 seb-prev liq wash ........................... 120 SEEBRI NEOHA CAP 15.6MCG .......... 112 selegiline hcl cap 5 mg ...................... 55 selegiline hcl tab 5 mg ...................... 56 selenium sulfide lotion 2.5% ............ 120 SELZENTRY TAB 150MG .................... 17 SELZENTRY TAB 300MG .................... 17 SENSIPAR TAB 30MG ........................ 75 SENSIPAR TAB 60MG ........................ 75 SENSIPAR TAB 90MG ........................ 75

SEREVENT DIS AER 50MCG .............. 113 SEROQUEL XR TAB 150MG ................ 59 SEROQUEL XR TAB 200MG ................ 59 SEROQUEL XR TAB 300MG ................ 59 SEROQUEL XR TAB 400MG ................ 59 SEROQUEL XR TAB 50MG ................. 59 SEROSTIM INJ 4MG ......................... 83 SEROSTIM INJ 5MG ......................... 83 SEROSTIM INJ 6MG ......................... 83 sertraline hcl oral conc 20 mg/ml ....... 53 sertraline hcl tab 100 mg .................. 53 sertraline hcl tab 25 mg ................... 53 sertraline hcl tab 50 mg ................... 53 sf 5000 plus cre 1.1% ..................... 124 sharobel tab 0.35mg ........................ 79 SIGNIFOR INJ 0.3MG/ML .................. 85 SIGNIFOR INJ 0.6MG/ML .................. 85 SIGNIFOR INJ 0.9MG/ML .................. 85 sildenafil citrate iv soln 10 mg/12.5ml (base equivalent) ............................ 44 sildenafil citrate tab 20 mg ............... 44 silver sulfadiazine cream 1% ............ 119 SIMPONI ARIA SOL 50MG/4ML ......... 102 SIMPONI INJ 50/0.5ML .................... 102 SIMULECT INJ 20MG ....................... 104 simvastatin tab 10 mg ...................... 36 simvastatin tab 20 mg ...................... 36 simvastatin tab 40 mg ...................... 36 simvastatin tab 5 mg ....................... 36 simvastatin tab 80 mg ...................... 36 sirolimus tab 0.5 mg ....................... 105 sirolimus tab 2 mg .......................... 105 SIRTURO TAB 100MG ....................... 19 SIVEXTRO INJ 200MG ...................... 22 SKLICE LOT 0.5% ........................... 124 SKYLA IUD 13.5MG .......................... 79 SLOW IRON TAB 50MG .................... 109 SM PRENATAL TAB VITAMINS ........... 111 sod ferric gluc cmplx in sucrose iv soln 12.5 mg/ml (fe eq) ......................... 109 sod fluoride sol 0.2% ...................... 124 sodium chloride soln nebu 0.9% ....... 115 sodium chloride soln nebu 10% ........ 115 sodium chloride soln nebu 3% .......... 115 sodium chloride soln nebu 7% .......... 115

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sodium citrate & citric acid soln 500-334 mg/5ml ........................................... 95 sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) ......................... 109 sodium fluoride chew tab 1 mg f (from 2.2 mg naf) ................................... 109 sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) .............................. 109 sodium fluoride tab 0.5 mg f (from 1.1 mg naf) ........................................ 109 sodium phenylbutyrate oral powder 3 gm/teaspoonful ................................ 92 SODIUM SULFA LIQ 10% WASH ....... 120 sodium thiosulfate inj 25% ................ 80 SOLIRIS INJ 10MG/ML .................... 101 SOLTAMOX SOL 10MG/5ML ................ 23 SOLU-CORTEF INJ 1000MG ................ 83 SOMATULINE INJ 120/.5ML................ 85 SOMATULINE INJ 60/0.2ML................ 85 SOMATULINE INJ 90/0.3ML................ 85 SOMAVERT INJ 10MG ........................ 85 SOMAVERT INJ 15MG ........................ 85 SOMAVERT INJ 20MG ........................ 85 SOMAVERT INJ 25MG ........................ 85 SOMAVERT INJ 30MG ........................ 85 SOOLANTRA CRE 1% ...................... 124 sorine tab 120mg ............................. 34 sorine tab 160mg ............................. 34 sorine tab 240mg ............................. 34 sorine tab 80mg ............................... 34 sotalol hcl tab 120 mg....................... 34 sotalol hcl tab 160 mg....................... 34 sotalol hcl tab 240 mg....................... 34 sotalol hcl tab 80 mg ........................ 34 SPIRIVA CAP HANDIHLR .................. 112 SPIRIVA SPR 2.5MCG ...................... 112 spironolactone & hydrochlorothiazide tab 25-25 mg ........................................ 42 spironolactone tab 100 mg ................ 31 spironolactone tab 25 mg .................. 31 spironolactone tab 50 mg .................. 31 SPORANOX SOL 10MG/ML ................. 16 sprintec 28 tab 28 day ...................... 79 SPRYCEL TAB 100MG ........................ 26 SPRYCEL TAB 140MG ........................ 26

SPRYCEL TAB 20MG ......................... 26 SPRYCEL TAB 50MG ......................... 26 SPRYCEL TAB 70MG ......................... 26 SPRYCEL TAB 80MG ......................... 26 sronyx tab ...................................... 79 ssd cre 1% .................................... 119 sss 10-5 aer 10-5% ........................ 118 st joseph chw 75mg adu .................. 102 stavudine cap 15 mg ........................ 19 stavudine cap 20 mg ........................ 19 stavudine cap 30 mg ........................ 19 stavudine cap 40 mg ........................ 19 stavudine for oral soln 1 mg/ml ......... 19 STIMATE SOL 1.5MG/ML ................... 88 STIOLTO AER 2.5-2.5 ...................... 112 STIVARGA TAB 40MG ....................... 26 STRATTERA CAP 100MG ................... 64 STRATTERA CAP 10MG ..................... 63 STRATTERA CAP 18MG ..................... 63 STRATTERA CAP 25MG ..................... 63 STRATTERA CAP 40MG ..................... 63 STRATTERA CAP 60MG ..................... 63 STRATTERA CAP 80MG ..................... 64 streptomycin sulfate for inj 1 gm ....... 10 STRIANT MIS 30MG ......................... 70 STRIBILD TAB ................................. 17 STROMECTOL TAB 3MG .................... 22 SUBOXONE MIS 12-3MG ................... 69 SUBOXONE MIS 2-0.5MG .................. 69 SUBOXONE MIS 4-1MG .................... 69 SUBOXONE MIS 8-2MG .................... 69 SUCRAID SOL 8500/ML .................... 92 sucralfate tab 1 gm .......................... 92 SUDACARE ADV MIS VAPOR-PG ........ 115 sulfacetamide sodium liquid 10% ...... 120 sulfacetamide sodium lotion 10% (acne) .................................................... 118 sulfacetamide sodium ophth soln 10% .................................................... 125 sulfacetamide sodium shampoo 10% . 120 sulfacetamide sodium w/ sulfur cleanser 10-2% .......................................... 118 sulfacetamide sodium w/ sulfur cleanser 9.8-4.8% ...................................... 118 sulfacetamide sodium w/ sulfur cleansing

177

pad 10-4% .................................... 118 sulfacetamide sodium w/ sulfur cream 10-2% .......................................... 118 sulfacetamide sodium w/ sulfur cream 10-5% .......................................... 118 sulfacetamide sodium w/ sulfur cream 9.8-4.8% ...................................... 118 sulfacetamide sodium w/ sulfur lotion 10-5% ............................................... 118 sulfacetamide sodium w/ sulfur lotion 9.8-4.8% ...................................... 118 sulfacetamide sodium w/ sulfur susp 8-4% ............................................... 118 sulfacetamide sodium w/ sulfur wash 9-4% ............................................... 118 sulfacetamide sodium w/ sulfur wash 9-4.5% ............................................ 118 sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% ............. 125 SULFADIAZINE TAB 500MG ............... 14 sulfamethoxazole-trimethoprim susp 200-40 mg/5ml ................................ 14 sulfamethoxazole-trimethoprim tab 400-80 mg ............................................ 14 sulfamethoxazole-trimethoprim tab 800-160 mg ........................................... 15 SULFAMYLON CRE 85MG/GM ............ 123 sulfasalazine tab 500 mg ................... 91 sulfasalazine tab delayed release 500 mg ..................................................... 91 sulfatrim sus 200-40/5 ...................... 15 sulindac tab 150 mg .......................... 4 sulindac tab 200 mg .......................... 4 sumatriptan nasal spray 20 mg/act ..... 66 sumatriptan nasal spray 5 mg/act ....... 66 sumatriptan succinate inj 6 mg/0.5ml . 66 sumatriptan succinate tab 100 mg ...... 66 sumatriptan succinate tab 25 mg ........ 66 sumatriptan succinate tab 50 mg ........ 66 SUPPRELIN LA KIT 50MG ................... 85 SUPRAX CHW 100MG ........................ 12 SUPRAX CHW 200MG ........................ 12 SUPRAX SUS 500/5ML ...................... 12 SUPREP BOWEL SOL PREP ................. 92 SUSTIVA CAP 200MG ........................ 18

SUSTIVA CAP 50MG ......................... 18 SUSTIVA TAB 600MG ....................... 18 SUTENT CAP 12.5MG ....................... 26 SUTENT CAP 25MG .......................... 26 SUTENT CAP 37.5MG ....................... 26 SUTENT CAP 50MG .......................... 26 syeda tab 3-0.03mg ......................... 79 SYLATRON KIT 200MCG ................... 104 SYLATRON KIT 300MCG ................... 104 SYLATRON KIT 600MCG ................... 104 symax-sl sub 0.125mg ..................... 90 symax-sr tab 0.375mg ..................... 90 SYMBICORT AER 160-4.5 ................. 116 SYMBICORT AER 80-4.5 .................. 116 SYMLINPEN 60 INJ 1000MCG ............ 70 SYMLNPEN 120 INJ 1000MCG ............ 70 SYNAGIS INJ 100MG/ML .................. 105 SYNAGIS INJ 50MG ......................... 105 SYNAREL SOL 2MG/ML ..................... 80 SYNRIBO INJ 3.5MG ......................... 28 SYNVISC INJ 8MG/ML ...................... 10 SYNVISC ONE INJ 8MG/ML ................ 10 SYPRINE CAP 250MG ....................... 85 T TABLOID TAB 40MG ......................... 23 TACLONEX SUS .............................. 120 tacrolimus cap 0.5 mg ..................... 104 tacrolimus cap 1 mg ....................... 104 tacrolimus cap 5 mg ....................... 104 tacrolimus oint 0.03% ..................... 123 tacrolimus oint 0.1% ....................... 123 TAFINLAR CAP 50MG ........................ 26 TAFINLAR CAP 75MG ........................ 26 TALWIN INJ 30MG/ML ........................ 9 TAMIFLU CAP 30MG ......................... 21 TAMIFLU CAP 45MG ......................... 21 TAMIFLU CAP 75MG ......................... 21 TAMIFLU SUS 6MG/ML ..................... 21 tamoxifen citrate tab 10 mg (base equivalent) ..................................... 24 tamoxifen citrate tab 20 mg (base equivalent) ..................................... 24 tamsulosin hcl cap 0.4 mg ................ 94 TARCEVA TAB 100MG ....................... 26 TARCEVA TAB 150MG ....................... 26

178

TARCEVA TAB 25MG ......................... 26 TARGRETIN GEL 1% ......................... 28 tarina fe tab 1/20 ............................. 79 TASIGNA CAP 150MG ........................ 26 TASIGNA CAP 200MG ........................ 26 tazicef inj 1gm ................................. 12 tazicef inj 2gm ................................. 12 tazicef inj 6gm ................................. 12 TAZORAC CRE 0.05% ..................... 118 TAZORAC CRE 0.1% ....................... 118 TAZORAC GEL 0.05% ...................... 118 TAZORAC GEL 0.1% ....................... 118 taztia xt cap 120mg/24 ..................... 40 taztia xt cap 180mg/24 ..................... 40 taztia xt cap 240mg/24 ..................... 40 taztia xt cap 300mg/24 ..................... 40 taztia xt cap 360mg/24 ..................... 40 TECFIDERA CAP 120MG ..................... 67 TECFIDERA CAP 240MG ..................... 67 TECFIDERA MIS STARTER .................. 67 TEKTURNA HCT TAB 150-12.5 ............ 41 TEKTURNA HCT TAB 150-25MG .......... 41 TEKTURNA HCT TAB 300-12.5 ............ 41 TEKTURNA HCT TAB 300-25MG .......... 41 TEKTURNA TAB 150MG ..................... 41 TEKTURNA TAB 300MG ..................... 41 telmisartan tab 20 mg ....................... 33 telmisartan tab 40 mg ....................... 33 telmisartan tab 80 mg ....................... 33 telmisartan-hydrochlorothiazide tab 40-12.5 mg .......................................... 32 telmisartan-hydrochlorothiazide tab 80-12.5 mg .......................................... 32 telmisartan-hydrochlorothiazide tab 80-25 mg ............................................ 32 temazepam cap 15 mg ...................... 65 temazepam cap 22.5 mg ................... 65 temazepam cap 30 mg ...................... 65 temazepam cap 7.5 mg ..................... 65 temozolomide cap 100 mg ................. 22 temozolomide cap 140 mg ................. 23 temozolomide cap 180 mg ................. 23 temozolomide cap 20 mg .................. 22 temozolomide cap 250 mg ................. 23 temozolomide cap 5 mg .................... 22

tencon tab 50-325mg ......................... 2 TENIPOSIDE INJ 50MG/5ML .............. 28 TENIVAC INJ 5-2LF ......................... 106 terazosin hcl cap 1 mg ..................... 31 terazosin hcl cap 10 mg .................... 31 terazosin hcl cap 2 mg ..................... 31 terazosin hcl cap 5 mg ..................... 31 terbinafine hcl tab 250 mg ................ 16 terbutaline sulfate inj 1 mg/ml ......... 114 terbutaline sulfate tab 2.5 mg .......... 114 terbutaline sulfate tab 5 mg ............. 114 terconazole vaginal cream 0.4% ........ 97 terconazole vaginal cream 0.8% ........ 97 terconazole vaginal suppos 80 mg ..... 97 TESTOPEL MIS PELLETS ................... 70 testosterone cypionate im inj in oil 100 mg/ml ........................................... 70 testosterone cypionate im inj in oil 200 mg/ml ........................................... 70 testosterone enanthate im inj in oil 200 mg/ml ........................................... 70 testosterone td gel 25 mg/2.5gm (1%)70 testosterone td gel 50 mg/5gm (1%) . 70 TET/DIP TOX INJ 2-2 LF .................. 106 tetcaine sol 0.5% op ....................... 128 tetrabenazine tab 12.5 mg ................ 65 tetrabenazine tab 25 mg .................. 65 tetracaine hcl ophth soln 0.5% ......... 128 tetracycline hcl cap 250 mg .............. 15 tetracycline hcl cap 500 mg .............. 15 tetravisc sol forte ........................... 128 TEXACORT SOL 2.5% ...................... 121 THALOMID CAP 100MG ..................... 25 THALOMID CAP 150MG ..................... 25 THALOMID CAP 200MG ..................... 25 THALOMID CAP 50MG ...................... 25 THEO-24 CAP 100MG CR ................. 116 THEO-24 CAP 200MG CR ................. 116 THEO-24 CAP 300MG CR ................. 116 THEO-24 CAP 400MG ER .................. 116 theochron tab 100mg cr .................. 116 theochron tab 200mg cr .................. 116 theochron tab 300mg cr .................. 116 theophylline soln 80 mg/15ml .......... 117 theophylline tab sr 12hr 100 mg ....... 117

179

theophylline tab sr 12hr 200 mg ....... 117 theophylline tab sr 12hr 300 mg ....... 117 theophylline tab sr 12hr 450 mg ....... 117 theophylline tab sr 24hr 400 mg ....... 117 theophylline tab sr 24hr 600 mg ....... 117 THERACYS INJ ................................. 28 thera-d tab 2000unit ...................... 109 THERA-D TAB 4000UNIT ................. 109 THERANATAL TAB 27-1 ................... 111 thioridazine hcl tab 10 mg ................. 61 thioridazine hcl tab 100 mg ............... 61 thioridazine hcl tab 25 mg ................. 61 thioridazine hcl tab 50 mg ................. 61 thiothixene cap 1 mg ........................ 61 thiothixene cap 10 mg ...................... 61 thiothixene cap 2 mg ........................ 61 thiothixene cap 5 mg ........................ 61 thrive gum 2mg mint ........................ 69 THRIVITE RX TAB 29-1MG ............... 111 THROMBAT III INJ 500UNIT ............. 101 THYMOGLOBULN INJ 25MG .............. 103 THYROLAR-1 TAB 60MG .................... 87 THYROLAR-1/2 TAB 30MG ................. 87 THYROLAR-1/4 TAB 15MG ................. 87 THYROLAR-2 TAB 120MG .................. 87 THYROLAR-3 TAB 180MG .................. 87 tiagabine hcl tab 2 mg ...................... 49 tiagabine hcl tab 4 mg ...................... 49 tilia fe tab ....................................... 80 timolol maleate ophth gel forming soln 0.25% .......................................... 127 timolol maleate ophth gel forming soln 0.5% ............................................ 127 timolol maleate ophth soln 0.25% .... 127 timolol maleate ophth soln 0.5% ...... 127 timolol maleate tab 10 mg ................. 38 timolol maleate tab 20 mg ................. 38 timolol maleate tab 5 mg................... 38 tinidazole tab 250 mg ....................... 22 tinidazole tab 500 mg ....................... 22 TIROSINT CAP 100MCG ..................... 87 TIROSINT CAP 112MCG ..................... 87 TIROSINT CAP 125MCG ..................... 87 TIROSINT CAP 137MCG ..................... 87 TIROSINT CAP 13MCG ...................... 87

TIROSINT CAP 150MCG .................... 87 TIROSINT CAP 25MCG ...................... 87 TIROSINT CAP 50MCG ...................... 87 TIROSINT CAP 75MCG ...................... 87 TIROSINT CAP 88MCG ...................... 87 TIVICAY TAB 50MG .......................... 17 tizanidine hcl cap 2 mg (base equivalent) ..................................................... 68 tizanidine hcl cap 4 mg (base equivalent) ..................................................... 68 tizanidine hcl cap 6 mg (base equivalent) ..................................................... 68 tizanidine hcl tab 2 mg (base equivalent) ..................................................... 68 tizanidine hcl tab 4 mg (base equivalent) ..................................................... 68 tl gard rx tab ................................. 107 tl-hem 150 tab ............................... 110 TOBI PODHALR CAP 28MG ............... 114 TOBRADEX ST SUS 0.3-0.05 ............ 125 tobramycin nebu soln 300 mg/5ml .... 114 tobramycin ophth soln 0.3% ............ 125 tobramycin sulfate inj 10 mg/ml (base equivalent) ..................................... 10 tobramycin sulfate inj 80 mg/2ml (40 mg/ml) (base equiv) ........................ 10 tobramycin-dexamethasone ophth susp 0.3-0.1% ...................................... 125 tolazamide tab 250 mg ..................... 74 tolbutamide tab 500 mg ................... 75 tolcapone tab 100 mg ...................... 56 tolmetin sodium cap 400 mg ............... 4 tolmetin sodium tab 600 mg ............... 4 tolterodine tartrate cap sr 24hr 2 mg . 96 tolterodine tartrate cap sr 24hr 4 mg . 96 tolterodine tartrate tab 1 mg ............. 96 tolterodine tartrate tab 2 mg ............. 96 topex topcal spr anesthet ................ 124 topiramate cap er 24hr sprinkle 100 mg ..................................................... 49 topiramate cap er 24hr sprinkle 150 mg ..................................................... 49 topiramate cap er 24hr sprinkle 200 mg ..................................................... 49 topiramate cap er 24hr sprinkle 25 mg 49

180

topiramate cap er 24hr sprinkle 50 mg 49 topiramate sprinkle cap 15 mg ........... 49 topiramate sprinkle cap 25 mg ........... 49 topiramate tab 100 mg ..................... 49 topiramate tab 200 mg ..................... 49 topiramate tab 25 mg ....................... 49 topiramate tab 50 mg ....................... 49 toposar inj 100/5ml .......................... 28 topotecan hcl for inj 4 mg .................. 29 TORISEL SOL 25MG/ML ..................... 26 torsemide tab 10 mg ........................ 42 torsemide tab 100 mg ....................... 42 torsemide tab 20 mg ........................ 42 torsemide tab 5 mg .......................... 42 TOVIAZ TAB 4MG ............................. 96 TOVIAZ TAB 8MG ............................. 96 TRACLEER TAB 125MG ...................... 44 TRACLEER TAB 62.5MG ..................... 44 TRADJENTA TAB 5MG ........................ 72 tramadol hcl tab 50 mg ...................... 9 tramadol hcl tab sr 24hr 100 mg ......... 9 tramadol hcl tab sr 24hr 200 mg ......... 9 tramadol hcl tab sr 24hr 300 mg ......... 9 tramadol-acetaminophen tab 37.5-325 mg .................................................. 9 trandolapril tab 1 mg ........................ 31 trandolapril tab 2 mg ........................ 31 trandolapril tab 4 mg ........................ 31 trandolapril-verapamil hcl tab cr 1-240 mg ................................................. 29 trandolapril-verapamil hcl tab cr 2-180 mg ................................................. 29 trandolapril-verapamil hcl tab cr 2-240 mg ................................................. 29 trandolapril-verapamil hcl tab cr 4-240 mg ................................................. 29 tranexamic acid iv soln 1000 mg/10ml (100 mg/ml) .................................. 101 tranexamic acid tab 650 mg............. 101 TRANSDERM-SC DIS 1MG .................. 89 tranylcypromine sulfate tab 10 mg ...... 50 TRAVATAN Z DRO 0.004% ............... 128 travoprost ophth soln 0.004% .......... 128 trazodone hcl tab 100 mg .................. 51 trazodone hcl tab 150 mg .................. 51

trazodone hcl tab 300 mg ................. 51 trazodone hcl tab 50 mg ................... 51 TREANDA INJ 25MG ......................... 23 TRECATOR TAB 250MG ..................... 19 TRELSTAR INJ 11.25MG .................... 24 TRELSTAR INJ 3.75MG ..................... 24 TRELSTAR MIX INJ 22.5MG ............... 24 TRESIBA FLEX INJ 100UNIT .............. 73 TRESIBA FLEX INJ 200UNIT .............. 73 tretinoin cap 10 mg ......................... 28 tretinoin gel 0.05% ......................... 118 TRETTEN INJ .................................. 100 triadvance tab ................................ 111 triamcinolone acetonide aerosol soln 0.147 mg/gm ................................. 122 triamcinolone acetonide cream 0.025% .................................................... 122 triamcinolone acetonide cream 0.1% . 122 triamcinolone acetonide cream 0.5% . 121 triamcinolone acetonide dental paste 0.1% ............................................ 124 triamcinolone acetonide lotion 0.025% .................................................... 122 triamcinolone acetonide lotion 0.1% .. 122 triamcinolone acetonide nasal aerosol suspension 55 mcg/act .................... 116 triamcinolone acetonide oint 0.025% . 122 triamcinolone acetonide oint 0.1% .... 122 triamterene & hydrochlorothiazide cap 37.5-25 mg .................................... 42 triamterene & hydrochlorothiazide cap 50-25 mg ....................................... 42 triamterene & hydrochlorothiazide tab 37.5-25 mg .................................... 42 triamterene & hydrochlorothiazide tab 75-50 mg ....................................... 42 triazolam tab 0.125 mg .................... 65 triazolam tab 0.25 mg ...................... 65 TRICARE TAB PRENATAL .................. 111 tricon cap ...................................... 110 triderm cre 0.1% ............................ 122 tri-estaryll tab ................................. 80 trifluoperazine hcl tab 1 mg .............. 61 trifluoperazine hcl tab 10 mg ............. 61 trifluoperazine hcl tab 2 mg .............. 61

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trifluoperazine hcl tab 5 mg ............... 61 trifluridine ophth soln 1% ................ 126 trigels-f cap forte ........................... 110 trihexyphenidyl hcl elixir 0.4 mg/ml .... 56 trihexyphenidyl hcl tab 2 mg .............. 56 trihexyphenidyl hcl tab 5 mg .............. 56 tri-legest tab fe ................................ 80 tri-linyah tab ................................... 80 trilyte sol ........................................ 92 trimethobenzamide hcl cap 300 mg .... 89 trimethoprim tab 100 mg .................. 22 trimipramine maleate cap 100 mg ...... 54 trimipramine maleate cap 25 mg ........ 54 trimipramine maleate cap 50 mg ........ 54 TRINATAL GT TAB .......................... 111 TRINATAL RX TAB 1 ........................ 111 trinate tab ..................................... 111 trinessa tab ..................................... 80 TRINTELLIX TAB 10MG ...................... 53 TRINTELLIX TAB 20MG ...................... 53 TRINTELLIX TAB 5MG ....................... 53 tri-previfem tab ................................ 80 TRISENOX SOL 10MG/10M ................ 28 tri-sprintec tab ................................. 80 tri-vit/fl dro 0.25mg ........................ 110 tri-vit/fl dro 0.5mg ......................... 110 trivora-28 tab .................................. 80 tropicamide ophth soln 0.5% ........... 128 tropicamide ophth soln 1% .............. 128 trospium chloride cap sr 24hr 60 mg ... 96 trospium chloride tab 20 mg .............. 97 TRUMENBA INJ .............................. 106 TRUVADA TAB 200-300 ..................... 17 TRUZONE PEAK MIS FLOW MTR ........ 115 TUDORZA PRES AER 400/ACT .......... 112 tussigon tab 5-1.5mg ...................... 113 tusslin liq pediatri ........................... 113 TWINRIX INJ ................................. 106 TYKERB TAB 250MG ......................... 26 TYPHIM VI INJ ............................... 106 TYSABRI INJ 300/15ML ..................... 67 TYVASO START SOL 0.6MG/ML ........... 44 TYZEKA TAB 600MG.......................... 20 U ULESFIA LOT 5% ............................ 124

ULORIC TAB 40MG ............................. 2 ULORIC TAB 80MG ............................. 2 ultra tabs tab ................................. 111 unithroid tab 100mcg ....................... 87 unithroid tab 112mcg ....................... 87 unithroid tab 125mcg ....................... 87 unithroid tab 137mcg ....................... 87 unithroid tab 150mcg ....................... 88 unithroid tab 175mcg ....................... 88 unithroid tab 200mcg ....................... 88 unithroid tab 25mcg ......................... 87 unithroid tab 300mcg ....................... 88 unithroid tab 50mcg ......................... 87 unithroid tab 75mcg ......................... 87 unithroid tab 88mcg ......................... 87 ur n-c tab ....................................... 95 urelle tab ....................................... 96 uretron d/s tab ................................ 96 uribel cap 118mg ............................ 96 uroav-81 tab ................................... 96 uro-mp cap 118mg .......................... 96 ursodiol cap 300 mg ........................ 90 ursodiol tab 250 mg ......................... 90 ursodiol tab 500 mg ......................... 90 uryl tab .......................................... 96 ustell cap ....................................... 96 uta cap 120mg ................................ 96 UTIBRON CAP NEOHALER ................ 112 utira-c tab ...................................... 96 UVADEX INJ 20MCG/ML .................... 28 V VAGIFEM TAB 10MCG ....................... 82 valacyclovir hcl tab 1 gm .................. 20 valacyclovir hcl tab 500 mg ............... 20 VALCHLOR GEL 0.016% ................... 23 VALCYTE SOL 50MG/ML .................... 19 valganciclovir hcl tab 450 mg (base equivalent) ..................................... 20 valproate sodium inj 100 mg/ml ........ 49 valproate sodium syrup 250 mg/5ml (base equiv) ................................... 49 valproic acid cap 250 mg .................. 49 valsartan tab 160 mg ....................... 33 valsartan tab 320 mg ....................... 33 valsartan tab 40 mg ......................... 33

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valsartan tab 80 mg ......................... 33 valsartan-hydrochlorothiazide tab 160-12.5 mg .......................................... 32 valsartan-hydrochlorothiazide tab 160-25 mg ................................................. 32 valsartan-hydrochlorothiazide tab 320-12.5 mg .......................................... 32 valsartan-hydrochlorothiazide tab 320-25 mg ................................................. 33 valsartan-hydrochlorothiazide tab 80-12.5 mg .......................................... 32 VALSTAR SOL 40MG/ML .................... 28 vancomycin hcl cap 125 mg ............... 22 vancomycin hcl cap 250 mg ............... 22 vancomycin hcl for inj 10 gm ............. 22 vancomycin hcl for inj 1000 mg .......... 22 vancomycin hcl for inj 500 mg ........... 22 vandazole gel 0.75% ........................ 97 VANTAS KIT 50MG ........................... 24 VAQTA INJ 25/0.5ML ...................... 106 VAQTA INJ 50UNT/ML ..................... 106 VARIVAX INJ ................................. 106 VARUBI TAB 90MG ........................... 89 VASCEPA CAP 1GM ........................... 36 vasopressin inj 20 unit/ml ................. 88 VCF VAGINAL AER CONTRACP ............ 77 VECTIBIX INJ 100MG ........................ 28 VELCADE INJ 3.5MG ......................... 26 VELETRI INJ 0.5MG .......................... 44 VELETRI INJ 1.5MG .......................... 44 velivet pak ...................................... 80 venlafaxine hcl cap sr 24hr 150 mg (base equivalent) ...................................... 51 venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) ............................. 51 venlafaxine hcl cap sr 24hr 75 mg (base equivalent) ...................................... 51 venlafaxine hcl tab 100 mg ................ 52 venlafaxine hcl tab 25 mg.................. 51 venlafaxine hcl tab 37.5 mg ............... 52 venlafaxine hcl tab 50 mg.................. 52 venlafaxine hcl tab 75 mg.................. 52 venlafaxine hcl tab sr 24hr 150 mg (base equivalent) ...................................... 52 venlafaxine hcl tab sr 24hr 225 mg (base

equivalent) ..................................... 52 venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent) ............................ 52 venlafaxine hcl tab sr 24hr 75 mg (base equivalent) ..................................... 52 VENTAVIS SOL 10MCG/ML ................ 44 VENTAVIS SOL 20MCG/ML ................ 44 verapamil hcl cap sr 24hr 100 mg ...... 40 verapamil hcl cap sr 24hr 120 mg ...... 40 verapamil hcl cap sr 24hr 180 mg ...... 40 verapamil hcl cap sr 24hr 200 mg ...... 40 verapamil hcl cap sr 24hr 240 mg ...... 40 verapamil hcl cap sr 24hr 300 mg ...... 40 verapamil hcl cap sr 24hr 360 mg ...... 40 verapamil hcl iv soln 2.5 mg/ml ......... 40 verapamil hcl tab 120 mg ................. 40 verapamil hcl tab 40 mg ................... 40 verapamil hcl tab 80 mg ................... 40 verapamil hcl tab cr 120 mg .............. 40 verapamil hcl tab cr 180 mg .............. 40 verapamil hcl tab cr 240 mg .............. 40 verdrocet tab 2.5-325 ...................... 10 VEREGEN OIN 15% ......................... 123 VESICARE TAB 10MG ....................... 97 VESICARE TAB 5MG ......................... 97 vestura tab 3-0.02mg ...................... 79 VEXOL SUS 1% OP ......................... 126 VIAGRA TAB 100MG ......................... 95 VIAGRA TAB 25MG .......................... 95 VIAGRA TAB 50MG .......................... 95 VIBATIV INJ 250MG ......................... 22 VIBERZI TAB 100MG ........................ 91 VIBERZI TAB 75MG .......................... 91 vicodin es tab 7.5-300 ...................... 10 vicodin hp tab 10-300mg .................. 10 vicodin tab 5-300mg ........................ 10 VICTOZA INJ 18MG/3ML ................... 72 VIDEX SOL 2GM .............................. 19 VIGAMOX DRO 0.5% ....................... 125 VIIBRYD TAB 10MG ......................... 53 VIIBRYD TAB 20MG ......................... 53 VIIBRYD TAB 40MG ......................... 53 VIMIZIM INJ 5MG/5ML ..................... 84 VIMPAT SOL 10MG/ML ..................... 49 VIMPAT TAB 100MG ......................... 49

183

VIMPAT TAB 150MG .......................... 49 VIMPAT TAB 200MG .......................... 49 VIMPAT TAB 50MG ........................... 49 VINATE M TAB ............................... 111 VINATE ONE TAB ............................ 111 vinblastine sulfate inj 1 mg/ml ........... 28 vincasar pfs inj 1mg/ml ..................... 28 vincristine sulfate iv soln 1 mg/ml ...... 28 vinorelbine tartrate inj 10 mg/ml (base equiv) ............................................. 28 viorele tab ....................................... 76 VIRACEPT TAB 250MG ...................... 18 VIRACEPT TAB 625MG ...................... 18 VIRAZOLE INH 6GM .......................... 22 VIREAD POW 40MG/GM ..................... 19 VIREAD TAB 150MG .......................... 19 VIREAD TAB 200MG .......................... 19 VIREAD TAB 250MG .......................... 19 VIREAD TAB 300MG .......................... 19 VIRT NATE TAB .............................. 111 VIRT NATE TAB 28-1MG .................. 111 VIRT-ADVANCE TAB 90-1MG ............ 111 virt-gard tab 2.2-25-1 ..................... 107 virt-phos tab 250 neut .................... 106 VIRT-VITE GT TAB 90-1MG .............. 111 virt-vite tab ................................... 107 VISUDYNE INJ 15MG....................... 128 vitamin d cap 1000unit ................... 110 vitamin d chw 1000unit ................... 110 vitamin d chw 400unit ..................... 110 VITAMIN D2 TAB 400UNIT ............... 110 vitamin d3 cap 10000unt ................. 110 vitamin d3 cap 50000unt ................. 110 VITAMIN D3 LIQ 1000UNIT .............. 110 VITAMIN D3 LIQ 1200UNIT .............. 110 VITAMIN D3 TAB 3000UNIT ............. 110 VIVITROL INJ 380MG ........................ 68 VIVOTIF CAP EC ............................. 106 VOL-NATE TAB ............................... 111 VOL-PLUS TAB ............................... 111 VOL-TAB RX TAB ............................ 111 VOLTAREN GEL 1% ........................... 4 VORAXAZE INJ 1000UNIT .................. 80 voriconazole for inj 200 mg ............... 16 voriconazole for susp 40 mg/ml .......... 16

voriconazole tab 200 mg .................. 16 voriconazole tab 50 mg .................... 16 VOTRIENT TAB 200MG ..................... 26 VPRIV INJ 400UNIT .......................... 84 VP-ZEL TAB ................................... 110 VRAYLAR CAP 1.5-3MG ..................... 59 VRAYLAR CAP 1.5MG ........................ 59 VRAYLAR CAP 3MG .......................... 59 VRAYLAR CAP 4.5MG ........................ 59 VRAYLAR CAP 6MG .......................... 60 vyfemla tab 0.4-35 .......................... 79 VYTORIN TAB 10-10MG .................... 36 VYTORIN TAB 10-20MG .................... 36 VYTORIN TAB 10-40MG .................... 36 VYTORIN TAB 10-80MG .................... 36 VYVANSE CAP 10MG ........................ 64 VYVANSE CAP 20MG ........................ 64 VYVANSE CAP 30MG ........................ 64 VYVANSE CAP 40MG ........................ 64 VYVANSE CAP 50MG ........................ 64 VYVANSE CAP 60MG ........................ 64 VYVANSE CAP 70MG ........................ 64 W wal-dryl cap 25mg .......................... 113 warfarin sodium tab 1 mg ................. 98 warfarin sodium tab 10 mg ............... 98 warfarin sodium tab 2 mg ................. 98 warfarin sodium tab 2.5 mg .............. 98 warfarin sodium tab 3 mg ................. 98 warfarin sodium tab 4 mg ................. 98 warfarin sodium tab 5 mg ................. 98 warfarin sodium tab 6 mg ................. 98 warfarin sodium tab 7.5 mg .............. 98 wee care sus 15/1.25 ...................... 110 WELCHOL PAK 3.75GM ..................... 34 WELCHOL TAB 625MG ...................... 34 wera tab 0.5/35 .............................. 79 WINRHO SDF INJ 1500UNIT ............. 103 WINRHO SDF INJ 5000UNIT ............. 103 X XALKORI CAP 200MG ....................... 26 XALKORI CAP 250MG ....................... 26 XARELTO STAR TAB 15/20MG ........... 98 XARELTO TAB 10MG ........................ 98 XARELTO TAB 15MG ........................ 98

184

XARELTO TAB 20MG ......................... 99 XEOMIN INJ 50 UNIT ........................ 67 XGEVA INJ ...................................... 76 XIAFLEX INJ 0.9MG ........................ 124 XIFAXAN TAB 200MG ........................ 22 XIFAXAN TAB 550MG ........................ 22 XIGDUO XR TAB 10-1000 .................. 74 XIGDUO XR TAB 10-500MG ............... 74 XIGDUO XR TAB 5-1000MG ............... 74 XIGDUO XR TAB 5-500MG ................. 74 XOLAIR SOL 150MG ........................ 115 XOLEGEL GEL 2% ........................... 120 XTANDI CAP 40MG ........................... 23 xulane dis 150-35 ............................ 79 xylon tab 10-200mg ......................... 10 XYNTHA INJ 1000UNIT .................... 100 XYNTHA INJ 2000UNIT .................... 100 XYNTHA INJ 250UNIT ...................... 100 XYNTHA INJ 500UNIT ...................... 100 XYNTHA SOLOF INJ 1000UNIT .......... 100 XYNTHA SOLOF INJ 2000UNIT .......... 100 XYNTHA SOLOF INJ 3000UNIT .......... 100 XYNTHA SOLOF INJ 500UNIT ........... 100 XYNTHA SOLOF KIT 250UNIT ........... 100 XYREM SOL 500MG/ML ...................... 68 Y YERVOY INJ 50MG ............................ 28 YF-VAX INJ .................................... 106 Z zafirlukast tab 10 mg ...................... 114 zafirlukast tab 20 mg ...................... 114 zaleplon cap 10 mg .......................... 65 zaleplon cap 5 mg ............................ 65 ZALTRAP INJ 100/4ML ...................... 29 zamicet sol 10-325mg ....................... 10 ZANOSAR INJ 1GM ........................... 23 zarah tab 3-0.03mg .......................... 79 ZAVESCA CAP 100MG ....................... 84 zazole cre 0.8% ............................... 97 zazole sup 80mg .............................. 97 zebutal cap ....................................... 2 ZELBORAF TAB 240MG ...................... 26 ZEMAIRA INJ 1000MG ..................... 115 zenchent fe chw 0.4mg-35 ................ 79 zenchent tab ................................... 79

zencia liq 9-4% .............................. 118 ZENPEP CAP 10000UNT .................... 92 ZENPEP CAP 15000UNT .................... 92 ZENPEP CAP 20000UNT .................... 92 ZENPEP CAP 25000UNT .................... 93 ZENPEP CAP 3000UNIT ..................... 92 ZENPEP CAP 40000UNT .................... 93 ZENPEP CAP 5000UNIT ..................... 92 zenzedi tab 10mg ............................ 64 zenzedi tab 5mg .............................. 64 ZETIA TAB 10MG ............................. 34 ZIAGEN SOL 20MG/ML ..................... 19 zidovudine cap 100 mg ..................... 19 zidovudine syrup 10 mg/ml ............... 19 zidovudine tab 300 mg ..................... 19 ziprasidone hcl cap 20 mg ................ 60 ziprasidone hcl cap 40 mg ................ 60 ziprasidone hcl cap 60 mg ................ 60 ziprasidone hcl cap 80 mg ................ 60 ZIRGAN GEL 0.15% ........................ 126 ZITHROMAX POW 1GM PAK ............... 12 ZOLADEX IMP 10.8MG ...................... 24 ZOLADEX IMP 3.6MG ....................... 24 zoledronic acid inj conc for iv infusion 4 mg/5ml .......................................... 76 zoledronic acid iv soln 5 mg/100ml .... 76 ZOLEDRONIC INJ 4MG/100 ............... 76 ZOLINZA CAP 100MG ....................... 29 zolmitriptan orally disintegrating tab 2.5 mg ................................................ 66 zolmitriptan orally disintegrating tab 5 mg ................................................ 66 zolmitriptan tab 2.5 mg .................... 66 zolmitriptan tab 5 mg ....................... 66 zolpidem tartrate tab 10 mg .............. 65 zolpidem tartrate tab 5 mg ............... 65 zolpidem tartrate tab cr 12.5 mg ....... 65 zolpidem tartrate tab cr 6.25 mg ....... 65 ZOMETA INJ 4MG/100 ...................... 76 ZOMIG NASAL SPR 5MG ................... 66 ZOMIG SPR 2.5MG ........................... 66 zonisamide cap 100 mg .................... 49 zonisamide cap 25 mg ...................... 49 zonisamide cap 50 mg ...................... 49 ZONTIVITY TAB 2.08MG .................. 102

185

ZORBTIVE INJ 8.8MG ........................ 84 ZORTRESS TAB 0.25MG .................. 105 ZORTRESS TAB 0.5MG .................... 105 ZORTRESS TAB 0.75MG .................. 105 ZOSTAVAX INJ ............................... 106 zovia 1/35e tab ................................ 79 ZYDELIG TAB 100MG ........................ 26 ZYDELIG TAB 150MG ........................ 26

ZYFLO CR TAB 600MG ..................... 114 ZYKADIA CAP 150MG ....................... 26 ZYMAXID SOL 0.5% ........................ 125 ZYPREXA RELP INJ 210MG ................ 60 ZYPREXA RELP INJ 300MG ................ 60 ZYPREXA RELP INJ 405MG ................ 60 ZYTIGA TAB 250MG ......................... 23

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Neighborhood Health Plan 4 Tier - Caremark · Neighborhood Health Plan 4 Tier 11/01/2016 ... It is always a good idea to discuss your medication options with your doctor ... sex