Please read: This document contains information about the ...€¦ · Please read: This document contains information about the drugs covered under your pharmacy benefit plan. For

1

Please read: This document contains information about the drugs

covered under your pharmacy benefit plan.

For a complete list of covered drugs or if you have questions:

Call the toll-free member phone number

on the back of your ID card.

• Locate a participating retail pharmacy by zip code.

• Look up possible lower-cost medication alternatives.

• Compare medication pricing and options.

OptumRx Version 2

Last updated April 14, 2017

2

Your Formulary

This Formulary includes medications from your plan’s complete pharmacy benefit

coverage list. A formulary identifies the drugs available for certain conditions and

organizes them into cost levels, also known as tiers. An important part of the

Formulary is giving you choices so you and your doctor can choose the best course

of treatment for you.

Your formulary utilizes a Pharmacy and Therapeutics Committee made up of practicing

physicians, pharmacists, and nurses to help ensure that your formulary is medically

sound and that it supports patient health. This committee reviews and evaluates

medications on the formulary based on safety and efficacy to help maintain clinical

integrity in all therapeutic categories.

Go to your plan’s member website for complete and up-to-date drug information

Since the Formulary may change, we encourage you to visit your plan’s member website.

This website is the best source for up-to-date information about all of the medications

your pharmacy benefit covers, possible lower-cost options and cost comparisons.

What is a Formulary?

This document is a list of medications preferred by your plan sponsor for their safety, cost

and effectiveness. Drugs are listed by common categories or class. They are placed into

cost levels known as tiers. It includes both brand and generic prescription medications

approved by the U.S. Food and Drug Administration (FDA).

Please note: Where differences are noted between this Formulary and your benefit

plan documents, the benefit plan documents will rule. Please look at your benefit plan

documents provided by your employer or plan sponsor to see what medications are

covered under your plan. You may also log on to your plan’s member website or call the

toll-free member phone number on the back of your ID card for more information.

How do I use my Formulary?

When choosing a medication, you and your doctor should consult the Formulary. It

will help you and your doctor choose the most cost-effective prescription drugs. This

guide tells you if a medication is generic or brand, and if special rules apply. Bring this

list with you when you see your doctor. It is organized by common medical conditions.

Medications are then listed alphabetically.

If your medication is not listed in this document, please visit your plan’s member website

or call the toll-free member phone number on the back of your ID card.

3

Table of Contents

What are tiers? ..................................................................... 6

Programs and Limits ........................................................... 7

Drugs by category

Analgesics ........................................................................... 10

Analgesics : Nonsteroidal Anti-inflammatory Drugs ............. 10

Analgesics : Opioid Analgesics, Long-acting ....................... 11

Analgesics : Opioid Analgesics, Short-acting ...................... 12

Anesthetics : Local Anesthetics ........................................... 12

Anti-Addiction/Substance Abuse Treatment Agents : Alcohol Deterrents/Anti-craving ........................................................ 13

Anti-Addiction/Substance Abuse Treatment Agents : Opioid Reversal Agents .................................................................. 13

Anti-Addiction/Substance Abuse Treatment Agents : Smoking Cessation Agents .................................................. 13

Anti-infective Agents : Antibacterials ................................... 14

Anti-infective Agents : Antivirals .......................................... 14

Anti-inflammatory Agents : Nonsteroidal Anti-inflammatory Drugs ................................................................................... 14

Antibacterials : Aminoglycosides ......................................... 14

Antibacterials : Antibacterials, Other .................................... 14

Antibacterials : Beta-lactam, Cephalosporins ...................... 15

Antibacterials : Beta-lactam, Other ...................................... 16

Antibacterials : Beta-lactam, Penicillins ............................... 16

Antibacterials : Macrolides ................................................... 16

Antibacterials : Quinolones .................................................. 17

Antibacterials : Sulfonamides .............................................. 17

Antibacterials : Tetracyclines ............................................... 17

Anticonvulsants : Anticonvulsants, Other............................. 17

Anticonvulsants : Calcium Channel Modifying Agents ......... 17

Anticonvulsants : Gamma-aminobutyric Acid (GABA) Augmenting Agents ............................................................. 18

Anticonvulsants : Glutamate Reducing Agents .................... 18

Anticonvulsants : Sodium Channel Agents .......................... 18

Antidementia Agents : Antidementia Agents, Other ............. 18

Antidementia Agents : Cholinesterase Inhibitors ................. 18

Antidementia Agents : N-methyl-D-aspartate (NMDA) Receptor Antagonist ............................................................ 18

Antidepressants : Antidepressants, Other ........................... 19

Antidepressants : Monoamine Oxidase Inhibitors ................ 19

Antidepressants : SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) ............................................................................. 19

Antidepressants : Tricyclics ................................................. 19

Antiemetics : Antiemetics, Other .......................................... 19

Antiemetics : Emetogenic Therapy Adjuncts ....................... 20

Antifungals .......................................................................... 20

Antigout Agents ................................................................... 21

Antimigraine Agents : Ergot Alkaloids ................................. 21

Antimigraine Agents : Serotonin (5-HT) 1b/1d Receptor Agonists .............................................................................. 21

Antimyasthenic Agents : Parasympathomimetics ................ 21

Antimycobacterials : Antimycobacterials, Other .................. 21

Antimycobacterials : Antituberculars ................................... 21

Antineoplastic Agents .......................................................... 21

Antineoplastics : Alkylating Agents ...................................... 21

Antineoplastics : Antiandrogens .......................................... 22

Antineoplastics : Antiangiogenic Agents.............................. 22

Antineoplastics : Antiestrogens/Modifiers ............................ 22

Antineoplastics : Antimetabolites ......................................... 22

Antineoplastics : Antineoplastics, Other .............................. 22

Antineoplastics : Aromatase Inhibitors, 3rd Generation ...... 22

Antineoplastics : Enzyme Inhibitors ..................................... 22

Antineoplastics : Molecular Target Inhibitors ....................... 23

Antineoplastics : Monoclonal Antibodies ............................. 23

Antineoplastics : Retinoids .................................................. 23

Antiparasitics : Anthelmintics ............................................... 23

Antiparasitics : Antiprotozoals ............................................. 23

Antiparasitics : Pediculicides/Scabicides ............................. 23

Antiparkinson Agents : Anticholinergics .............................. 23

Antiparkinson Agents : Antiparkinson Agents, Other ........... 23

Antiparkinson Agents : Dopamine Agonists ........................ 23

Antiparkinson Agents : Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors ..................................................... 24

Antiparkinson Agents : Monoamine Oxidase B (MAO-B) Inhibitors .............................................................................. 24

Antipsychotics : 1st Generation/Typical .............................. 24

Antipsychotics : 2nd Generation/Atypical ............................ 24

Antipsychotics : Treatment-Resistant .................................. 24

Antispasticity Agents ........................................................... 24

Antitoxins, Immune Globulins, Toxoids, and Vaccines : Vaccines .............................................................................. 24

Antivirals : Anti-cytomegalovirus (CMV) Agents .................. 24

Antivirals : Anti-hepatitis B (HBV) Agents ............................ 24

Antivirals : Anti-hepatitis C (HCV) Agents ........................... 24

Antivirals : Anti-HIV Agents, Integrase Inhibitors (INSTI) .... 25

Antivirals : Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) ......................................... 25

Antivirals : Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) ............................. 25

Antivirals : Anti-HIV Agents, Other ...................................... 25

Antivirals : Anti-HIV Agents, Protease Inhibitors ................. 25

Antivirals : Anti-influenza Agents ......................................... 25

4

Antivirals : Antiherpetic Agents ............................................ 25

Anxiolytics : Anxiolytics, Other ............................................. 26

Anxiolytics : Benzodiazepines ............................................. 26

Autonomic Drugs : Sympathomimetic (Adrenergic) Agents . 26

Bipolar Agents : Bipolar Agents, Other ................................ 26

Bipolar Agents : Mood Stabilizers ........................................ 26

Blood Formation,Coagulation & Thrombosis : Antithrombotic Agents ................................................................................. 26

Blood Formation,Coagulation & Thrombosis : Hematopoietic Agents ................................................................................. 26

Blood Glucose Regulators : Antidiabetic Agents ................. 26

Blood Glucose Regulators : Glycemic Agents ..................... 27

Blood Glucose Regulators : Insulins .................................... 27

Blood Products/Modifiers/Volume Expanders : Anticoagulants ..................................................................... 27

Blood Products/Modifiers/Volume Expanders : Blood Formation Modifiers ............................................................. 27

Blood Products/Modifiers/Volume Expanders ...................... 28

Blood Products/Modifiers/Volume Expanders : Coagulants 28

Blood Products/Modifiers/Volume Expanders : Platelet Modifying Agents ................................................................. 28

Cardiovascular Agents : Alpha-adrenergic Agonists ............ 28

Cardiovascular Agents : Alpha-adrenergic Blocking Agents 28

Cardiovascular Agents : Angiotensin II Receptor Antagonists ............................................................................................. 28

Cardiovascular Agents : Angiotensin-converting Enzyme (ACE) Inhibitors ................................................................... 29

Cardiovascular Agents : Antiarrhythmics ............................. 29

Cardiovascular Agents : Beta-adrenergic Blocking Agents . 29

Cardiovascular Agents : Calcium Channel Blocking Agents 30

Cardiovascular Agents ......................................................... 30

Cardiovascular Agents : Cardiovascular Agents, Other ....... 30

Cardiovascular Agents : Diuretics, Carbonic Anhydrase Inhibitors .............................................................................. 30

Cardiovascular Agents : Diuretics, Loop .............................. 31

Cardiovascular Agents : Diuretics, Potassium-sparing ........ 31

Cardiovascular Agents : Diuretics, Thiazide ........................ 31

Cardiovascular Agents : Dyslipidemics, Fibric Acid Derivatives ........................................................................... 31

Cardiovascular Agents : Dyslipidemics, HMG CoA Reductase Inhibitors .............................................................................. 31

Cardiovascular Agents : Dyslipidemics, Other ..................... 31

Cardiovascular Agents : Vasodilators, Direct-acting Arterial 31

Cardiovascular Agents : Vasodilators, Direct-acting Arterial/Venous .................................................................... 31

Central Nervous System Agents : Analgesics and Antipyretics .......................................................................... 32

Central Nervous System Agents : Attention Deficit Hyperactivity Disorder Agents, Amphetamines .................... 32

Central Nervous System Agents : Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines ............ 32

Central Nervous System Agents : Central Nervous System, Other ................................................................................... 32

Central Nervous System Agents : Fibromyalgia Agents ...... 32

Central Nervous System Agents : Multiple Sclerosis Agents ............................................................................................ 32

Dental and Oral Agents ....................................................... 32

Dermatological Agents ........................................................ 33

Devices ............................................................................... 34

Electrolytic, Caloric, and Water Balance : Replacement Preparations ........................................................................ 34

Enzyme Replacement/Modifiers .......................................... 34

Gastrointestinal Agents : Antispasmodics, Gastrointestinal 35

Gastrointestinal Agents : Gastrointestinal Agents, Other .... 35

Gastrointestinal Agents : Histamine2 (H2) Receptor Antagonists ......................................................................... 35

Gastrointestinal Agents : Irritable Bowel Syndrome Agents 35

Gastrointestinal Agents : Laxatives ..................................... 35

Gastrointestinal Agents : Protectants .................................. 36

Gastrointestinal Agents : Proton Pump Inhibitors ................ 36

Gastrointestinal Drugs : GI Drugs, Miscellaneous ............... 36

Genitourinary Agents : Antispasmodics, Urinary ................. 36

Genitourinary Agents : Benign Prostatic Hypertrophy Agents ............................................................................................ 37

Genitourinary Agents : Genitourinary Agents, Other ........... 37

Genitourinary Agents : Phosphate Binders ......................... 37

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) ............................................................................. 37

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) ............................................................................. 38

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) .................................................................. 38

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) : Anabolic Steroids ............................ 38

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) : Androgens ....................................... 38

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) : Estrogens ........................................ 38

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) ........................................................... 40

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) : Progesterone Agonists/Antagonists 40

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) : Progestins ....................................... 40

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) : Selective Estrogen Receptor Modifying Agents ................................................................. 40

Hormonal Agents, Stimulant/Replacement/Modifying

5

(Thyroid) .............................................................................. 40

Hormonal Agents, Suppressant (Adrenal) ........................... 40

Hormonal Agents, Suppressant (Parathyroid) ..................... 40

Hormonal Agents, Suppressant (Pituitary) ........................... 40

Hormonal Agents, Suppressant (Thyroid) : Antithyroid Agents ............................................................................................. 41

Hormones and Synthetic Substitutes : Adrenals .................. 41

Hormones and Synthetic Substitutes : Antidiabetic Agents . 41

Immunological Agents : Immune Suppressants ................... 41

Immunological Agents : Immunizing Agents, Passive ......... 41

Immunological Agents : Immunomodulators ........................ 42

Immunological Agents : Vaccines ........................................ 42

Inflammatory Bowel Disease Agents : Aminosalicylates ..... 42

Inflammatory Bowel Disease Agents : Glucocorticoids ........ 42

Inflammatory Bowel Disease Agents : Sulfonamides .......... 42

Local Anesthetics ................................................................. 42

Metabolic Bone Disease Agents .......................................... 42

Miscellaneous Therapeutic Agents : Antidotes .................... 43

Miscellaneous Therapeutic Agents : Disease-modifying Antirheumatic Drugs ............................................................ 43

Miscellaneous Therapeutic Agents ...................................... 43

Multiple Classifications ........................................................ 47

Ophthalmic Agents : Ophthalmic Prostaglandin and Prostamide Analogs ............................................................. 49

Ophthalmic Agents : Ophthalmic Agents, Other .................. 49

Ophthalmic Agents : Ophthalmic Anti-allergy Agents .......... 49

Ophthalmic Agents : Ophthalmic Anti-inflammatories .......... 49

Ophthalmic Agents : Ophthalmic Antiglaucoma Agents ...... 49

Otic Agents .......................................................................... 50

Oxytocics ............................................................................. 50

Respiratory Tract/Pulmonary Agents : Anti-inflammatories, Inhaled Corticosteroids ........................................................ 50

Respiratory Tract/Pulmonary Agents : Antihistamines ......... 50

Respiratory Tract/Pulmonary Agents : Antileukotrienes ...... 50

Respiratory Tract/Pulmonary Agents : Bronchodilators, Anticholinergic ..................................................................... 50

Respiratory Tract/Pulmonary Agents : Bronchodilators, Sympathomimetic ................................................................ 50

Respiratory Tract/Pulmonary Agents : Cystic Fibrosis Agents ............................................................................................. 51

Respiratory Tract/Pulmonary Agents : Mast Cell Stabilizers 51

Respiratory Tract/Pulmonary Agents : Phosphodiesterase Inhibitors, Airways Disease .................................................. 51

Respiratory Tract/Pulmonary Agents : Pulmonary Antihypertensives ................................................................ 51

Respiratory Tract/Pulmonary Agents : Respiratory Tract Agents, Other....................................................................... 51

Skeletal Muscle Relaxants ................................................... 52

Sleep Disorder Agents : GABA Receptor Modulators ......... 52

Sleep Disorder Agents : Sleep Disorders, Other ................. 52

Therapeutic Nutrients/Minerals/Electrolytes : Electrolyte/Mineral Modifiers ............................................... 52

Therapeutic Nutrients/Minerals/Electrolytes : Electrolyte/Mineral Replacement ......................................... 52

Therapeutic Nutrients/Minerals/Electrolytes ........................ 53

Therapeutic Nutrients/Minerals/Electrolytes : Vitamins ....... 53

Vitamins : Vitamin D ............................................................ 56

Index of Covered Drugs ...................................................... 57

Nondiscrimination Notice and Access to Communication Services ............................................................................. 81

Multi-language Interpreter Services ................................ 82

6

What are tiers?

Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost,

which is determined by your employer or plan sponsor. This is how much you will

pay when you fill a prescription. Generally, medications in a lower tier cost less than

medications in higher tiers. If your medication is placed in a higher tier, look to see if

there is a lower cost option available. Discuss these options with your doctor.

Check your benefit plan documents to find out your specific pharmacy plan costs.

Refer to your enrollment and plan materials on your plan’s member website, or call the

toll-free member phone number on the back of your ID card for more information

about your benefit plan.

When does the Formulary change?

• Medications may move to a lower tier at any time.

• Medications may move to nonformulary tier when its generic becomes available.

• Medications may move to a higher tier or be excluded from coverage

on January 1 of each year.

When a medication changes tiers, you may have to pay a different amount

for that medication.

Drug Tier

$

Tier 1

$$

Tier 2

$$$

Tier 3

$$$$

Tier 4

$$$$$

7

For the most up-to-date list, please visit your plan’s member website or call the toll-

free member phone number on the back of your ID card.

Programs and Limits

Some medications are noted with letters or symbols next to them. The letters and

symbols refer to our pharmacy benefit programs and are provided to help you check

which medications may have a program or limit. Your benefit plan determines how

these medications may be covered for you.

PA Prior Authorization – Your doctor is required to provide additional

information to determine coverage.

ST Step Therapy – Trial of lower cost medication(s) is required before

a higher-cost medication is covered.

QL Quantity Limits – Amount of medication covered per copayment

or in a specific time period is limited.

AR

Age Restrictions – Some restrictions may apply based on patient age.

PV

Preventive drugs – May have coverage and no co-payment when health

care reform requirements are met.

PV* – Available at $0 if prior authorization is approved.

ST* – Available at $0 if step criteria is met or coverage exception is

approved. If criteria are not met, copays will apply per plan benefit.

Optum’s formulary uses medical and utilization management functions to determine

whether a prescription is medically necessary. These industry recognized and accepted

management functions include but are not limited to quantity limits, step therapy, and

prior authorization and help Optum and its clients determine whether the medication

was prescribed in accordance with generally accepted medical practice standards, is

clinically appropriate, and confirm that the prescribed medication is not more costly

than an alternative product that is as likely to produce therapeutically equivalent

results. As recommended by the United States Department of Labor, Optum’s

reasonable medical and utilization management functions apply to ACA

preventive drugs.

To learn more about a pharmacy program or to find out if it applies to you, please

visit your plan’s member website or call the toll-free member phone number on the

back of your ID card.

8

Why are some medications excluded from coverage?

Medications may be excluded from coverage under your pharmacy benefit when it

works the same as or similar to another prescription medication or an over-the-counter

(OTC) medication. There may be other medication options available.

What if I don’t agree with a decision about an excluded medication?

You (or your authorized representative) and your doctor can ask for an initial coverage

decision by calling the toll-free member phone number on the back of your ID card.

Should I talk to my doctor about OTC medications?

An OTC medication may be the right treatment option for some conditions. Talk to

your doctor about available OTC options. Even though these medications may not be

covered under your pharmacy benefit, they may cost less than your out-of-pocket

expense for prescription medications.

What is the difference between brand-name and generic medications?

Generic medications contain the same active ingredients (what makes the medication

work) as brand-name medications, but they often cost less. Once the patent of a

brand-name medication ends, the FDA can approve a generic version with the same

active ingredients. These types of medications are known as generic medications.

Sometimes the same company that makes a brand-name medication also makes the

generic version.

Is it a generic or brand-name drug?

The drug list shows brand-name drugs in bold type (for example, Lamictal)

and generic drugs in plain type (for example, lamotrigine).

What if my doctor writes a brand-name prescription?

The next time your doctor gives you a prescription for a brand-name medication,

ask if a generic equivalent or lower-cost option is available and if it might be right

for you. Generic medications are usually your lowest-cost option, but not always.

Visit your plan’s member website to make sure.

9

Are you taking a specialty medication?

Specialty medications treat rare or complex conditions and are typically higher

cost medications.

BriovaRx®, the OptumRx specialty pharmacy, can provide most of your specialty

medications along with helpful programs and services. Call BriovaRx® at 1-888-702-

8423 and have your prescriptions delivered right to your home or office.

Is home delivery available?

Convenient home delivery service is available through OptumRx Home Delivery.

Call the toll-free member phone number on the back of your ID card.

Customer Service is available 24 hours a day, 7 days a week.

How do I get updated information about my pharmacy benefit?

Since the Formulary may change during your plan year, we encourage you to visit

your plan’s member website or call the toll-free member phone number on

the back of your ID card for more current information.

When you register at your plan’s member website and open an account, you can use the

website’s helpful tools and features to:

• Look up the price of drugs covered by your plan

• Find lower-cost options

• Refill and renew mail service prescriptions

• View your order status and claims history

• Sign up for text reminders to take and refill your medicine

• View your benefits in real time

• Order medical supplies

• Shop for health and wellness products

More information

If you have additional questions please call customer service, 24 hours

a day, 7 days a week using the toll-free member phone number on the

back of your ID card. Or visit your plan’s member website.

10

Drug Name Drug

Tier

Requirements

& Limits

Butalbital/Acetaminophen (300mg-

50mg Tablet, 50mg-325mg Tablet) 1

Capacet (Capsule) 1

Esgic (Capsule) 1

Gralise (Tablet) 3 QL,ST

Gralise ST 3 QL,ST

Marten-Tab (Tablet) 1

Prialt (Injection) 4

Tencon (Tablet) 1

Zebutal (Capsule) 1

Aspir-81 (Tablet Delayed-Release) 1 PV

Aspir-Low (Tablet Delayed-

Release) 1 PV

Aspirin (325mg Tablet, 81mg Tablet

Chewable, 81mg Tablet Delayed-

Release)

1 PV

Aspirin 81 (Tablet Delayed-Release) 1 PV

Aspirin 81 Low Dose (Tablet

Chewable) 1 PV

Aspirin Adult Low Dose (Tablet

Delayed-Release) 1 PV

Aspirin Childrens (Tablet

Chewable) 1 PV

Aspirin EC (Tablet Delayed-

Release) 1 PV

Aspirin EC Low Dose (Tablet


Aspirin Low Dose (Tablet

Chewable) 1 PV

Aspirtab (Tablet Delayed-Release) 1 PV

Bayer Advanced Aspirin Regular

Strength (Tablet) 1 PV

Bayer Aspirin EC Low Dose (Tablet


Bayer Aspirin Regimen (Tablet


Bayer Chewable Low Dose (Tablet

Chewable) 1 PV

Bayer Low Dose (Tablet Delayed-

Release)

1 PV

Butalbital/Acetaminophen/Caffeine

(325mg-50mg-40mg Tablet, 50mg-

300mg-40mg Capsule)

1

Butalbital/Aspirin/Caffeine

(Capsule) 1

Celecoxib (Capsule) 1 QL

Childrens Aspirin (Tablet

Chewable) 1 PV

Childrens Aspirin Low Strength

(Tablet Chewable) 1 PV

Choline Magnesium Trisalicylate

(500mg/5ml Liquid) (MANUF

CYPRESS PH)

1

Drug Name Drug

Tier

Requirements

& Limits

CVS Aspirin (325mg Tablet, 325mg

Tablet Delayed-Release) 1 PV

CVS Aspirin Low Dose (Tablet


CVS Childrens Aspirin (Tablet

Chewable) 1 PV

Diclofenac Potassium (Tablet) 1

Diclofenac Sodium DR (Tablet

Delayed-Release) 1

Diclofenac Sodium ER (Tablet

Extended-Release 24 Hour) 1

Diclofenac Sodium/Misoprostol

(Tablet Delayed-Release) 1

Diflunisal (Tablet) 1

Duraxin (Capsule) 1

Ecotrin (Tablet Delayed-Release) 1 PV

Ecotrin Low Strength (Tablet


Ecpirin (Tablet Delayed-Release) 1 PV

ED-Flex (Capsule) 1

EQ Aspirin (325mg Tablet, 325mg


EQ Childrens Aspirin (Tablet

Chewable) 1 PV

EQL Aspirin (Tablet) 1 PV

EQL Aspirin EC (Tablet Delayed-

Release) 1 PV

Etodolac (200mg Capsule, 300mg

Capsule, 400mg Tablet, 500mg

Tablet)

1

Etodolac ER (Tablet Extended-

Release 24 Hour) 1

Fenoprofen Calcium (200mg

Capsule, 400mg Capsule, 600mg

Tablet)

1

Fenortho (Capsule) 3

Flurbiprofen (100mg Tablet, 50mg

Tablet) 1

GNP Adult Aspirin Low Strength


GNP Aspirin (325mg Tablet, 325mg

Tablet Delayed-Release, 81mg

Tablet Delayed-Release)

1 PV

GNP Aspirin Low Dose (Tablet


HM Aspirin (325mg Tablet, 81mg

Tablet Chewable) 1 PV

Hydrocodone/Ibuprofen (Tablet) 1

Ibudone (5mg-200mg Tablet) 1

Ibuprofen (100mg/5ml Suspension -

RX, 400mg Tablet, 600mg Tablet,

800mg Tablet)

1

Indomethacin (25mg Capsule, 50mg

Capsule) 1

Indomethacin ER (Capsule

Extended-Release) 1

Ketoprofen (Capsule Immediate-

Release) 1

11

Drug Name Drug

Tier

Requirements

& Limits

Ketoprofen ER (Capsule Extended-

Release 24 Hour) 1

Ketorolac Tromethamine (10mg

Tablet) 1 QL

KLS Aspirin EC (Tablet Delayed-

Release) 1 PV

KLS Aspirin Low Dose (Tablet


KP Aspirin (Tablet Delayed-

Release) 1 PV

Meclofenamate Sodium (100mg

Capsule, 50mg Capsule) 1

Mefenamic Acid (250mg Capsule) 1

Meijer Aspirin EC (Tablet Delayed-

Release) 1 PV

Meloxicam (Tablet) 1

Miniprin Low Dose (Tablet


Mm Aspirin (Tablet) 1 PV

Nabumetone (Tablet) 1

Nalfon (Capsule) 3

Naprelan (750mg Tablet

Extended-Release 24 Hour)

3

Naproxen (125mg/5ml Suspension,

250mg Tablet, 375mg Tablet,

500mg Tablet)

1

Naproxen DR (Tablet Delayed-

Release) 1

Naproxen Sodium (275mg Tablet,

550mg Tablet) 1

Naproxen Sodium CR (Tablet


Naproxen Sodium ER (Tablet


Norwich Aspirin (Tablet) 1 PV

Oxaprozin (Tablet) 1

Oxycodone/Ibuprofen (Tablet) 1

Piroxicam (10mg Capsule, 20mg

Capsule) 1

PX Aspirin (325mg Tablet, 81mg


PX Enteric Aspirin (Tablet Delayed-

Release) 1 PV

QC Aspirin (325mg Tablet, 325mg


QC Childrens Aspirin (Tablet

Chewable) 1 PV

QC Enteric Aspirin (Tablet


RA Aspirin (Tablet) 1 PV

RA Aspirin Adult Low Strength


RA Aspirin EC (Tablet Delayed-

Release) 1 PV

RA Childrens Aspirin (Tablet

Chewable) 1 PV

Reprexain (10mg-200mg Tablet) 1

Drug Name Drug

Tier

Requirements

& Limits

Salsalate (500mg Tablet, 750mg

Tablet) (MANUF MARLEX) 1

SB Aspirin (Tablet) 1 PV

SB Aspirin EC (Tablet Delayed-

Release) 1 PV

SB Childrens Aspirin (Tablet

Chewable) 1 PV

SM Aspirin (Tablet) 1 PV

SM Aspirin Adult Low Strength


SM Aspirin EC Low Strength

(Tablet Delayed-Release) 1 PV

SM Aspirin Enteric Coated (Tablet


SM Childrens Aspirin (Tablet

Chewable) 1 PV

Sprix (Nasal Solution) 3 PA,QL

St Joseph Low Dose Aspirin (Tablet

Chewable) 1 PV

Sulindac (150mg Tablet, 200mg

Tablet) 1

TGT Aspirin (325mg Tablet, 81mg

Tablet Chewable, 81mg Tablet

Delayed-Release)

1 PV

TGT Aspirin Low Dose (Tablet


TGT Childrens Aspirin (Tablet

Chewable) 1 PV

Tolmetin Sodium (200mg Tablet,

600mg Tablet, 400mg Capsule) 1

Xylon (Tablet) 1

Buprenorphine HCl (0.3mg/ml

Solution) 1

Buprenorphine HCl (2mg Tablet

Sublingual, 8mg Tablet Sublingual) 1 QL

Buprenorphine HCl/Naloxone HCl

(Tablet Sublingual) 1 QL

Butrans (Patch Weekly) 3 QL

Embeda (Capsule Extended-

Release)

2 QL

Fentanyl (Patch 72 Hour) 1 QL

Hydromorphone HCl ER (Tablet

Extended-Release 24 Hour Abuse-

Deterrent)

1 QL

Hysingla ER (Tablet Extended-

Release 24 Hour Abuse-Deterrent)

3 QL,ST

Methadone HCl (Tablet, Oral

Solution, Concentrate, 40mg Tablet

Soluble)

1

Methadose (40mg Tablet Soluble) 1

Morphine Sulfate ER (Capsule

Extended-Release 24 Hour, Tablet

Extended-Release)

1 QL

Nucynta ER (Tablet Extended-

Release 12 Hour)

3 QL,ST

Opana ER (Tablet Extended-


3 QL

12

Drug Name Drug

Tier

Requirements

& Limits

Oxycodone HCl ER (10mg, 15mg,

20mg, 30mg, 40mg, 60mg Tablet


Deterrent)

1 QL

Oxycodone HCl ER (80mg Tablet


Deterrent)

2 QL

OxyContin (Tablet Extended-


2 QL

Oxymorphone HCl ER (Tablet

Extended-Release 12 Hour) 1 QL

Suboxone (Film) 2 QL

Tramadol HCl ER (150mg Capsule


Tramadol HCl ER (Tablet

Extended-Release 24 Hour) 1 QL,ST

Acetaminophen/Caffeine/Dihydroco

deine (Capsule) 1

Acetaminophen/Codeine (Oral

Solution, Tablet) 1

Alfentanil (Injection) 1

Ascomp/Codeine (Capsule) 1

Aspirin-Caffeine-Dihydrocodeine

(Capsule) 1

Butalbital/Acetaminophen/Caffeine/

Codeine (Capsule) 1

Butalbital/Aspirin/Caffeine/Codeine

(Capsule) 1

Butorphanol Tartrate (Nasal

Solution, Injection) 1

Codeine Sulfate (Tablet) 1

Duramorph (Injection) 1

Endocet (Tablet) 1

Fentanyl Citrate Oral Transmucosal

(Lollipop) 1 PA,QL

Hydrocodone

Bitartrate/Acetaminophen (Tablet,

Oral Solution)

1

Hydrocodone/Acetaminophen

(Tablet) 1

Hydromorphone HCl (1mg/ml

Injection, 2mg/ml Injection, 4mg/ml

Injection, 500mg/50ml Injection,

1mg/ml Liquid, 2mg Tablet, 4mg

Tablet, 8mg Tablet)

1

Hydromorphone HCl/Sodium

Chloride (10mg/50ml-0.9%

Injection, 15mg/30ml-0.9%

Injection, 5mg/25ml-0.9% Injection)

1

Lorcet (Tablet) 1

Lorcet HD (Tablet) 1

Lorcet Plus (Tablet) 1

Lortab (10mg-325mg Tablet, 5mg-

325mg Tablet, 7.5mg-325mg

Tablet)

1

Meperidine HCl (100mg Tablet,

50mg Tablet, 100mg/ml Injection, 1

Drug Name Drug

Tier

Requirements

& Limits

10mg/ml Injection, 25mg/ml

Injection, 50mg/ml Injection,

50mg/5ml Oral Solution)

Meperidine HCl/Sodium Chloride

(Injection) 1

Morphine Sulfate (0.5mg/ml

Injection, 100mg/5ml Oral Solution,

10mg/5ml Oral Solution, 20mg/5ml

Oral Solution, 10mg/ml Injection,

1mg/ml Injection, 4mg/ml Injection,

8mg/ml Injection, 15mg Tablet,

30mg Tablet)

1

Morphine Sulfate/Sodium Chloride

(0.5mg/ml-0.9% Injection,

50mg/50ml-0.9% Injection)

1

Nalbuphine HCl (Injection) 1

Nucynta (Tablet) 3

Oxaydo (5mg Tablet Abuse-

Deterrent)

3

Oxycodone HCl (100mg/5ml

Concentrate, 10mg Tablet, 15mg

Tablet, 20mg Tablet, 30mg Tablet,

5mg Tablet, 5mg Capsule, 5mg/5ml

Oral Solution)

1

Oxycodone/Acetaminophen (2.5mg-

325mg Tablet, 325mg-10mg Tablet,

325mg-5mg Tablet, 325mg-7.5mg

Tablet)

1

Oxycodone/Aspirin (Tablet) 1

Oxymorphone HCl (Tablet

Immediate-Release) 1

Pentazocine/Naloxone HCl (Tablet) 1

Tramadol HCl (Tablet Immediate-

Release) 1

Tramadol HCl/Acetaminophen

(Tablet) 1

Verdrocet (Tablet) 1

Vicodin (Tablet) 1

Vicodin ES (Tablet) 1

Vicodin HP (Tablet) 1

Bupivacaine HCl (Injection) 1

Bupivacaine Spinal (Injection) 1

Bupivacaine/Dextrose Spinal

(Injection) 1

Bupivacaine/Epinephrine (0.25%-

1:200000 Injection) 1

DermacinRx Empricaine (Kit) 1

DermacinRx Prizopak (Kit) 1

Glydo (Gel) 1

Leva Set/Occlusive Dressing (Kit) 1

Lidocaine (3% Cream, 5%

Ointment, 5% Patch) 1

Lidocaine HCl (0.5% Injection, 1%

Injection, 1.5% Injection, 2%

Injection, 4% Injection, 2% Gel, 4%

External Solution)

1

Lidocaine HCl (Gel) 1

13

Drug Name Drug

Tier

Requirements

& Limits

Lidocaine Pak (Ointment) 1

Lidocaine Viscous (Solution) 1

Lidocaine/Epinephrine (Injection) 1

Lidocaine/Prilocaine (2.5%-2.5%

Cream, 2.5%-2.5% Kit) 1

Lidopril (Kit) 1

Lidopril XR (Kit) 1

Livixil Pak (Kit) 1

Polocaine (Injection) 1

Polocaine-Mpf (Injection) 1

Relador Pak (Kit) 1

Relador Pak Plus (Kit) 1

Ropivacaine (Injection) 1

Ropivacaine HCl (Injection) 1

Ropivacaine HCl/Sodium Chloride

(0.1%-0.9% Solution, 0.2%-0.9%

Injection)

1

Sensorcaine (Injection) 1

Sensorcaine-MPF (Injection) 1

Sensorcaine-MPF Spinal (Injection) 1

Sensorcaine/Epinephrine (Injection) 1

Synera (Patch) 3

Xylocaine Dental (Injection) 1

Acamprosate Calcium DR (Tablet

Delayed-Release) 1

Disulfiram (Tablet) 1

Naltrexone HCl (Tablet) 1

Vivitrol (Injection) 4 PA

Naloxone HCl (Injection) 1

Narcan (Liquid) 3

Bupropion HCl (Tablet) 1

Bupropion HCl SR (150mg Tablet

Extended-Release 12 Hour) 1 PV,QL

Bupropion HCl XL (Tablet


Chantix (Tablet) 2 PV,QL,ST*

Chantix Continuing Month Pak

(Tablet)

2 PV,QL,ST*

Chantix ST 2 PV,QL,ST*

CVS Nicotine (Patch 24 Hour) 1 PV,QL

CVS Nicotine Polacrilex (2mg

Gum, 4mg Gum, 2mg Lozenge, 4mg

Lozenge)

1 PV,QL

CVS Nicotine Transdermal System

(Patch 24 Hour) 1 PV,QL

CVS NTS Step 1 (Patch 24 Hour) 1 PV,QL

EQ Nicotine (14mg/24hr Patch 24

Hour, 21mg/24hr Patch 24 Hour, 1 PV,QL

Drug Name Drug

Tier

Requirements

& Limits

7mg/24hr Patch 24 Hour, 4mg

Lozenge)

EQ Nicotine Gum Refill (Gum) 1 PV,QL

EQ Nicotine Gum Starter (Gum) 1 PV,QL

EQ Nicotine Polacrilex (2mg Gum,

4mg Gum, 2mg Lozenge, 4mg

Lozenge)

1 PV,QL

EQL Nicotine (Lozenge) 1 PV,QL

EQL Nicotine Polacrilex (2mg


Lozenge)

1 PV,QL

GNP Nicotine Mini Lozenge

(Lozenge) 1 PV,QL

GNP Nicotine Polacrilex (2mg


Lozenge)

1 PV,QL

GNP Nicotine Transdermal System


Goodsense Nicotine Gum (Gum) 1 PV,QL

HM Nicotine Polacrilex (2mg Gum,


Lozenge)

1 PV,QL

HM Nicotine Transdermal System


HM Nicotine Transdermal System


KLS Quit2 (2mg Gum, 2mg

Lozenge) 1 PV,QL

KLS Quit4 (4mg Gum, 4mg

Lozenge) 1 PV,QL

NICOrelief (Gum) 1 PV,QL

Nicotine (14mg/24hr Patch 24 Hour,

21mg/24hr Patch 24 Hour,

7mg/24hr Patch 24 Hour, 2mg Gum,

2mg Lozenge, 4mg Lozenge)

1 PV,QL

Nicotine Mini Lozenge (Lozenge) 1 PV,QL

Nicotine Polacrilex (2mg Gum, 4mg

Gum, 2mg Lozenge, 4mg Lozenge,

4mg Lozenge)

1 PV,QL

Nicotine Polacrilex Refill (Gum) 1 PV,QL

Nicotine Polacrilex Starter Kit

(Gum) 1 PV,QL

Nicotine Step 1 (Patch 24 Hour) 1 PV,QL



Nicotine Transdermal System

(14mg/24hr Patch 24 Hour,

21mg/24hr Patch 24 Hour,

7mg/24hr Patch 24 Hour)

1 PV,QL

Nicotine Transdermal System

(Kit)

2 PV,QL

Nicotrol Inhaler (Inhaler) 3 PV,QL,ST*

Nicotrol NS (Nasal Solution) 3 PV,QL,ST*

PX Stop Smoking Aid (2mg Gum,


Lozenge, 4mg Lozenge)

1 PV,QL

QC Nicotine Polacrilex (Gum) 1 PV,QL

14

Drug Name Drug

Tier

Requirements

& Limits

RA Nicotine (14mg/24hr Patch 24

Hour, 21mg/24hr Patch 24 Hour,

2mg Gum, 4mg Gum)

1 PV,QL

RA Nicotine Gum (Gum) 1 PV,QL

RA Nicotine Polacrilex (2mg Gum,

2mg Lozenge, 4mg Lozenge) 1 PV,QL

SM Nicotine (14mg/24hr Patch 24

Hour, 21mg/24hr Patch 24 Hour,

7mg/24hr Patch 24 Hour, 2mg

Lozenge, 4mg Gum)

1 PV,QL

SM Nicotine Polacrilex (2mg Gum,

4mg Gum, 4mg Lozenge) 1 PV,QL

SM Nicotine Transdermal System


SR Nicotine Gum (Gum) 1 PV,QL

SW Nicotine Polacrilex (2mg Gum,


Lozenge)

1 PV,QL

TGT Nicotine Gum (Gum) 1 PV,QL

TGT Nicotine Polacrilex (2mg


Lozenge)

1 PV,QL

TGT Nicotine Step One (Patch 24

Hour) 1 PV,QL

TGT Nicotine Step Three (Patch 24

Hour) 1 PV,QL

TGT Nicotine Step Two (Patch 24

Hour) 1 PV,QL

Thrive (Gum) 1 PV,QL

Ofloxacin (300mg Tablet) 1

Vancomycin HCl/Dextrose (5%-

1.5gm/250ml Injection) 1

Vancomycin HCl/Sodium Chloride

(0.9%-1.5gm/500ml Injection) 1

Selzentry (25mg Tablet, 75mg

Tablet)

2 PA

Diclofenac Sodium (3% Gel) 1 QL

Amikacin Sulfate (1gm/4ml

Injection, 500mg/2ml Injection) 1

Gentak (Ophthalmic Ointment) 1

Gentamicin Sulfate (0.1% Cream,

0.1% Ointment, 0.3% Ophthalmic

Ointment, 0.3% Ophthalmic

Solution, 10mg/ml Injection,

40mg/ml Injection)

1

Gentamicin Sulfate/0.9% Sodium

Chloride (0.8mg/ml-0.9% Injection,

1.2mg/ml-0.9% Injection, 1mg/ml-

0.9% Injection)

1

Isotonic Gentamicin (Injection) 1

Neomycin Sulfate (Tablet) 1

Drug Name Drug

Tier

Requirements

& Limits

Neomycin/Polymyxin B Sulfates

(Irrigation Solution) 1

Neomycin/Polymyxin/Gramicidin

(Ophthalmic Solution) 1

Paromomycin Sulfate (Capsule) 1

Streptomycin Sulfate (1gm

Injection) 1

Tobradex (0.3%-0.1%

Ophthalmic Ointment)

3

Tobradex ST (Ophthalmic

Suspension)

3

Tobramycin (300mg/5ml Nebulized

Solution) 4

Tobramycin Sulfate (0.3%

Ophthalmic Solution, 1.2gm

Injection, 1.2gm/30ml Injection,

10mg/ml Injection, 80mg/2ml

Injection)

1

Tobramycin/Dexamethasone

(Ophthalmic Suspension) 1

Tobrex (0.3% Ophthalmic

Ointment)

3

Alcoh-Glove Contoured Wipe 2

Alcoh-Wipe 12" X 12" 2

Alcohol Prep Pads 2

Alcohol Prep Pads 2

Alcohol Prep Pads 2

Alcohol Prep Pads 2

Alcohol Swabs 2

Alcohol Swabstick 2

Altabax (Ointment) 3

BACiiM (Injection) 1

Bacitracin (50000unit Injection,

500unit/gm Ophthalmic Ointment) 1

Bacitracin/Polymyxin B

(Ophthalmic Ointment) 1

Bactroban Nasal (Ointment) 3

BD Swabs Single Use 2

BD Swabs Single Use Butterfly 2

Caretouch Alcohol Prep Pads 2

Clindamycin HCl (Capsule


Clindamycin Palmitate HCl (Oral

Solution) 1

Clindamycin Phosphate (2% Cream,

300mg/2ml Injection, 600mg/4ml


900mg/6ml Injection)

1

Clindamycin Phosphate in D5W

(Injection) 1

Colistimethate Sodium (Injection) 1

Curity Alcohol Prep

Pads/Medium 2 Ply

2

Curity Alcohol Swabs 2

CVS Prep Pads 2

Daptomycin (Solution) 1

15

Drug Name Drug

Tier

Requirements

& Limits

Easy Touch Alcohol Prep

Pads/Medium

2

EQL Alcohol Swabs 2

Fifty50 Alcohol Prep Pads 2

Global Alcohol Prep Ease Pads 2

GNP Alcohol Swabs 2

H-E-B Incontrol Alcohol Prep

Pads

2

Impavido (Capsule) 3

IV Prep Wipes 3

Lincomycin HCl (Injection) 1

Linezolid (100mg/5ml Suspension,

600mg Tablet) 1 QL

Linezolid (600mg/300ml Injection) 1

Meijer Alcohol Swabs Extra-

Thick

2

Methenamine Hippurate (Tablet) 1

Metronidazole (0.75% Cream,

0.75% Gel, 1% Gel, 0.75% Lotion,


375mg Capsule)

1

Metronidazole in NaCl 0.79%

(Injection) 1

Metronidazole Vaginal (Gel) 1

Microclens Wipes 3

Monurol (Packet) 3

Mupirocin (2% Cream, 2%

Ointment) 1

Neo-Polycin (Ointment) 1

Neo-Polycin HC (Ointment) 1

Neomycin/Bacitracin/Polymyxin

(Ointment) 1

Neomycin/Polymyxin/Bacitracin/Hy

drocortisone (Ointment) 1

Neomycin/Polymyxin/Dexamethaso

ne (0.1% Ophthalmic Suspension,

0.1%-3.5mg/gm-10000unit/gm

Ointment)

1

Neomycin/Polymyxin/Hydrocortiso

ne (1% Ophthalmic Suspension) 1

Nitrofurantoin (Suspension) 1

Nitrofurantoin Macrocrystals

(Capsule) 1

Nitrofurantoin Monohydrate (100mg

Capsule) 1

Polycin (Ointment) 1

Polymyxin B Sulfate (500000unit

Injection) 1

Polymyxin B Sulfate/Trimethoprim

Sulfate (Ophthalmic Solution) 1

Primsol (Oral Solution) 3

Pro Comfort Alcohol Prep Pads 2

QC Alcohol Swabs 2

RA Alcohol Swabs 2

Reality Swabs 2

Rosadan (0.75% Cream, 0.75% Gel) 1

Saps Care Alcohol Prep Pads 2

Drug Name Drug

Tier

Requirements

& Limits

SB Alcohol Prep Pads 2

Silver Sulfadiazine (Cream) 1

Sivextro (200mg Tablet) 3 QL

SM Alcohol Prep Pads 2

SSD (Cream) 1

Sulfamylon (85mg/gm Cream) 3

Sure Comfort Alcohol Prep Pads 2

Trimethoprim (100mg Tablet) 1

Trimethoprim Sulfate/Polymyxin B

Sulfate (Ophthalmic Solution) 1

Tygacil (Injection) 3

Ulticare Alcohol Swabs 2

Uni-Solve Wipes 3

Vancomycin (Injection) 1

Vancomycin HCl (0.9%-1gm/200ml

Injection, 1000mg Injection, 10gm

Injection, 5000mg Injection, 125mg

Capsule, 250mg Capsule)

1

Vancomycin HCl/Dextrose (5%-

1gm/250ml Injection, 5%-

2gm/500ml Injection)

1

Vancomycin HCl/Sodium Chloride

(0.9%-1.5gm/150ml Injection,

0.9%-1.5gm/250ml Injection, 0.9%-

1gm/150ml Injection, 0.9%-

1gm/250ml Injection, 0.9%-


1

Vandazole (Gel) 1

Vibativ (Injection) 3

Webcol Alcohol Prep Large 1 Ply 2

Webcol Alcohol Prep Medium 2

Ply

2

Xifaxan (Tablet) 3 PA

Zyvox (200mg/100ml Injection) 3

Cedax (180mg/5ml Suspension,

400mg Capsule)

3

Cefaclor (250mg Capsule

Immediate-Release, 500mg Capsule

Immediate-Release, 250mg/5ml

Suspension, 375mg/5ml

Suspension)

1

Cefaclor ER (Tablet Extended-

Release 12 Hour) 1

Cefadroxil (1gm Tablet, 250mg/5ml

Suspension, 500mg/5ml Suspension,

500mg Capsule)

1

Cefazolin Sodium (10gm Injection,

1gm Injection, 20gm Injection,

500mg Injection)

1

Cefazolin Sodium/Sodium Chloride

(Injection) 1

Cefazolin/D5W (Injection) 1

Cefazolin/Dextrose (Injection) 1

Cefazolin/Sodium Chloride

(Injection) 1

16

Drug Name Drug

Tier

Requirements

& Limits

Cefdinir (125mg/5ml Suspension,

250mg/5ml Suspension, 300mg

Capsule)

1

Cefditoren Pivoxil (Tablet) 1

Cefepime (1gm Injection, 2gm

Injection) 1

Cefixime (Suspension) 1

Cefotaxime Sodium (Injection) 1

Cefotetan/Dextrose (Injection) 1

Cefoxitin Sodium (10gm Injection,

1gm Injection, 2gm Injection) 1

Cefpodoxime Proxetil (100mg

Tablet, 200mg Tablet, 100mg/5ml

Suspension, 50mg/5ml Suspension)

1

Cefprozil (125mg/5ml Suspension,


Tablet, 500mg Tablet)

1

Ceftazidime (Injection) 1

Ceftin (Suspension) 3

Ceftriaxone in Iso-Osmotic

Dextrose (Injection) 1

Ceftriaxone Sodium (100gm

Injection, 1gm Injection, 250mg

Injection, 500mg Injection, 10gm

Injection, 2gm Solution)

1

Cefuroxime Axetil (Tablet) 1

Cefuroxime Sodium (Injection) 1

Cephalexin (125mg/5ml


250mg Capsule, 500mg Capsule,

750mg Capsule, 250mg Tablet,

500mg Tablet)

1

Claforan (1gm Injection) 3

Maxipime (2gm Injection) 3

Suprax (100mg Tablet Chewable,

200mg Tablet Chewable,

500mg/5ml Suspension)

3

Tazicef (1gm Injection, 2gm

Injection, 6gm Injection) 1

Teflaro (Injection) 3

Zinacef (1.5gm-0 Injection) 3

Azactam in Iso-Osmotic Dextrose

(1gm-0 Injection)

3

Aztreonam (Injection) 1

Cayston (Inhalation Solution) 4 PA

Cefotetan (Injection) 1

Doribax (500mg Injection) 3

Doripenem (500mg Injection) 3

Imipenem/Cilastatin (Injection) 1

Invanz (Injection) 3

Meropenem (Injection) 1

Meropenem/Sodium Chloride

(Injection) 1

Amoxicillin (125mg Tablet

Chewable, 250mg Tablet Chewable, 1

Drug Name Drug

Tier

Requirements

& Limits

125mg/5ml Suspension, 200mg/5ml





Amoxicillin/Clavulanate Potassium

(Tablet Chewable, Oral Suspension,

Tablet Immediate-Release)

1

Amoxicillin/Clavulanate Potassium

ER (Tablet Extended-Release 12

Hour)

1

Ampicillin (125mg/5ml Suspension,



1

Ampicillin Sodium (10gm Injection,

1gm Injection, 250mg Injection,

2gm Injection, 500mg Injection)

1

Ampicillin-Sulbactam (10gm-5gm

Injection, 1gm-0.5gm Injection,

2gm-1gm Injection)

1

Augmentin (125mg/5ml-

31.25mg/5ml Suspension)

2

Bactocill in Dextrose (0-1gm/50ml

Injection)

3

Bicillin C-R (300000unit/ml-

300000unit/ml Injection)

3

Bicillin L-A (Injection) 3

Dicloxacillin Sodium (Capsule) 1

Moxatag (Tablet Extended-

Release 24 Hour)

3

Nafcillin (Injection) 1

Nafcillin Sodium (10gm Injection,

1gm Injection, 2gm Injection) 1

Oxacillin Sodium (Injection) 1

Penicillin G Potassium (Injection) 1

Penicillin V Potassium (125mg/5ml

Oral Solution, 250mg/5ml Oral

Solution, 250mg Tablet, 500mg

Tablet)

1

Piperacillin/Tazobactam (2gm-

0.25gm Injection, 3gm-0.375gm

Injection, 4gm-0.5gm Injection,

36gm-4.5gm Solution)

1

Azasite (Ophthalmic Solution) 3

Azithromycin (100mg/5ml


1gm Packet, 250mg Tablet, 500mg

Tablet, 600mg Tablet, 500mg

Injection)

1

Clarithromycin (125mg/5ml


250mg Tablet, 500mg Tablet)

1

Clarithromycin ER (Tablet


Dificid (Tablet) 3

E.E.S. 400 (Tablet) 1

Ery-Tab (333mg Tablet Delayed-

Release)

3

17

Drug Name Drug

Tier

Requirements

& Limits

Erythrocin Lactobionate

(Injection)

3

Erythromycin (250mg Capsule

Delayed-Release, 5mg/gm

Ointment)

1

Erythromycin Base (Tablet) 1

Erythromycin Ethylsuccinate

(200mg/5ml Suspension, 400mg

Tablet)

1

PCE (500mg Tablet Delayed-

Release)

3

Zithromax (1gm Packet) 2

Avelox (400mg/250ml-0.8%

Injection)

3

Besivance (Suspension) 3

Ciloxan (0.3% Ointment) 3

Ciprofloxacin (250mg/5ml

Suspension, 500mg/5ml

Suspension)

1

Ciprofloxacin ER (Tablet Extended-

Release 24 Hour) 1

Ciprofloxacin HCl (0.3%

Ophthalmic Solution, Tablet

Immediate-Release)

1

Ciprofloxacin I.V. in D5W

(Injection) 1

Factive (Tablet) 3

Gatifloxacin (Ophthalmic Solution) 1

Levofloxacin (0.5% Ophthalmic


Tablet, 750mg Tablet, 25mg/ml

Injection, 25mg/ml Oral Solution)

1

Levofloxacin in D5W (Injection) 1

Moxeza (Ophthalmic Solution) 2

Moxifloxacin HCl (400mg Tablet,

400mg/250ml Injection) 1

Ofloxacin (0.3% Ophthalmic

Solution, 0.3% Otic Solution,

400mg Tablet)

1

Vigamox (Ophthalmic Solution) 2

AVC (Cream) 3

Sodium Sulfacetamide (Ophthalmic

Solution) 1

Sulfacetamide Sodium (10%

Ophthalmic Solution) 1

Sulfacetamide Sodium/Prednisolone

Sodium Phosphate (Ophthalmic

Solution)

1

Sulfadiazine (500mg Tablet) 1

Sulfamethoxazole/Trimethoprim

(200mg/5ml-40mg/5ml Suspension,

400mg-80mg Tablet)

1

Sulfamethoxazole/Trimethoprim DS

(Tablet) 1

Sulfatrim Pediatric (Suspension) 1

Drug Name Drug

Tier

Requirements

& Limits

Avidoxy (Tablet) 1

Demeclocycline HCl (150mg

Tablet, 300mg Tablet) 1

Doxy 100 (Injection) 1

Doxycycline (25mg/5ml

Suspension) 1

Doxycycline Hyclate (100mg


Injection, 100mg Tablet, 20mg

Tablet)

1

Doxycycline Hyclate DR (Tablet

Delayed-Release) 1

Doxycycline Monohydrate (100mg




75mg Tablet)

1

Minocycline HCl (100mg Capsule,


100mg Tablet, 50mg Tablet, 75mg

Tablet)

1

Minocycline HCl ER (Tablet


Mondoxyne NL (Capsule) 1

Morgidox 1x100mg (100mg

Capsule) 1

Morgidox 1x50mg (Capsule) 1

Morgidox 2x100mg (100mg

Capsule) 1

Tetracycline HCl (Capsule) 1

Aptiom (Tablet) 3

Fycompa (0.5mg/ml Suspension,



8mg Tablet)

3

Levetiracetam (Tablet Immediate-

Release, Oral Solution, 500mg/5ml

Injection)

1

Levetiracetam ER (Tablet Extended-

Release 24 Hour) 1

Magnesium Sulfate in D5W (5%-

10mg/ml Injection) 1

Potiga (Tablet) 3

Roweepra (Tablet) 1

Celontin (Capsule) 3

Ethosuximide (250mg Capsule,

250mg/5ml Oral Solution) 1

Lyrica (100mg Capsule, 150mg




Capsule)

2 QL

Lyrica (20mg/ml Oral Solution) 3 QL

18

Drug Name Drug

Tier

Requirements

& Limits

Zonisamide (Capsule) 1

Clonazepam (Tablet Immediate-

Release) 1 QL

Clonazepam ODT (Tablet

Dispersible) 1 QL

Clorazepate Dipotassium (Tablet) 1 QL

Diazepam (10mg Gel, 2.5mg Gel,

20mg Gel, 10mg Tablet, 2mg

Tablet, 5mg Tablet, 1mg/ml Oral

Solution, 5mg/ml Injection)

1

Diazepam Intensol (5mg/ml

Concentrate)

1

Divalproex Sodium (Capsule

Sprinkle Delayed-Release) 1

Divalproex Sodium DR (Tablet

Delayed-Release) 1

Divalproex Sodium ER (Tablet


Gabitril (12mg Tablet, 16mg

Tablet)

3

Gene-Xene Tab 15mg (Tablet) 1 QL

Gene-Xene Tab 3.75mg (Tablet) 1 QL

Gene-Xene Tab 7.5mg (Tablet) 1 QL

Lorazepam (0.5mg Tablet, 1mg

Tablet, 2mg Tablet) 1 QL

Onfi (10mg Tablet, 20mg Tablet,

2.5mg/ml Suspension)

3 PA

Phenobarbital (100mg Tablet, 15mg

Tablet, 16.2mg Tablet, 30mg Tablet,

32.4mg Tablet, 60mg Tablet,

64.8mg Tablet, 97.2mg Tablet,

20mg/5ml Elixir, 20mg/5ml Oral

Solution)

1

Primidone (Tablet) 1

Sabril (500mg Packet) 4 PA

Tiagabine HCl (Tablet) 1

Valproate Sodium (100mg/ml

Injection) 1

Valproic Acid (250mg Capsule,

250mg/5ml Oral Solution,

250mg/5ml Syrup)

1

Felbamate (400mg Tablet, 600mg

Tablet, 600mg/5ml Suspension) 1

Lamotrigine (Tablet Immediate-

Release, Tablet Chewable) 1

Lamotrigine ER (Tablet Extended-

Release 24 Hour) 1

Lamotrigine ODT (Tablet

Dispersible) 1

Lamotrigine Titration (Kit) 1

Topiramate (Tablet Immediate-

Release, Capsule Sprinkle

Immediate-Release)

1

Drug Name Drug

Tier

Requirements

& Limits

Topiramate ER (Capsule Extended-

Release 24 Hour Sprinkle) 1

Banzel (200mg Tablet, 400mg

Tablet, 40mg/ml Suspension)

3

Carbamazepine (100mg Tablet

Chewable, 100mg/5ml Suspension,

200mg Tablet Immediate-Release)

1

Carbamazepine ER (100mg, 200mg,

300mg Capsule Extended-Release

12 Hour; 100mg, 200mg, 400mg

Tablet Extended-Release 12 Hour)

1

Dilantin (30mg Capsule) 3

Epitol (Tablet) 1

Fosphenytoin Sodium (Injection) 1

Oxcarbazepine (150mg Tablet,


60mg/ml Suspension)

1

Peganone (Tablet) 3

Phenytoin (125mg/5ml Suspension,

50mg Tablet Chewable) 1

Phenytoin Sodium (50mg/ml

Injection) 1

Phenytoin Sodium Extended

(Capsule) 1

Vimpat (100mg Tablet, 150mg


Tablet, 10mg/ml Oral Solution)

3

Ergoloid Mesylates (Tablet) 1

Donepezil HCl (10mg Tablet

Dispersible, 5mg Tablet Dispersible,


Tablet)

1

Galantamine HBr (12mg Tablet,

4mg Tablet, 8mg Tablet, 4mg/ml

Oral Solution)

1

Galantamine HBr ER (Capsule


Rivastigmine Tartrate (Capsule


Rivastigmine Transdermal System

(Patch 24 Hour) 1

Memantine HCl (10mg Tablet, 5mg

Tablet, 2mg/ml Oral Solution) 1

Memantine HCl Titration Pak

(Tablet) 1

Namenda XR (Capsule Extended-

Release 24 Hour)

2 QL

Namenda XR Titration Pack

(Capsule Extended-Release 24

Hour)

2 QL

19

Drug Name Drug

Tier

Requirements

& Limits

Aplenzin (Tablet Extended-

Release 24 Hour)

3 QL,ST

Aripiprazole (10mg Tablet, 15mg



Oral Solution)

1 QL

Bupropion HCl ER (Tablet


Bupropion HCl SR (100mg Tablet

Extended-Release 12 Hour, 150mg

Tablet Extended-Release 12 Hour,

200mg Tablet Extended-Release 12

Hour)

1 QL

Maprotiline HCl (Tablet) 1

Mirtazapine (Tablet) 1

Mirtazapine ODT (Tablet

Dispersible) 1

Nefazodone HCl (Tablet) 1

Quetiapine Fumarate (Tablet) 1 QL

Quetiapine Fumarate ER (Tablet


Seroquel XR (150mg Tablet



300mg Tablet Extended-Release

24 Hour, 50mg Tablet Extended-

Release 24 Hour)

2 QL

Trazodone HCl (100mg Tablet,


Tablet)

1

Trintellix (Tablet) 3 QL,ST

Emsam (Patch 24 Hour) 3 QL

Marplan (Tablet) 3

Phenelzine Sulfate (Tablet) 1

Citalopram HBr (10mg Tablet,



1

Desvenlafaxine ER (100mg Tablet



50mg Tablet Extended-Release 24

Hour)

1 QL

Duloxetine HCl (20mg Capsule

Delayed-Release, 30mg Capsule

Delayed-Release, 60mg Capsule

Delayed-Release)

1 QL

Duloxetine HCl (40mg Capsule

Delayed-Release)

3 QL

Escitalopram Oxalate (10mg Tablet,

20mg Tablet, 5mg Tablet, 5mg/5ml

Oral Solution)

1

Drug Name Drug

Tier

Requirements

& Limits

Fetzima (Capsule Extended-

Release 24 Hour)

3 QL,ST

Fluoxetine (Capsule) 1

Fluoxetine DR (Capsule Delayed-

Release) 1 QL

Fluoxetine HCl (10mg Tablet, 20mg

Tablet, 60mg Tablet, 20mg/5ml Oral

Solution, 40mg Capsule)

1

Fluvoxamine Maleate (Tablet) 1

Fluvoxamine Maleate ER (Capsule


Paroxetine HCl (Tablet) 1

Paroxetine HCl ER (Tablet


Paxil (10mg/5ml Suspension) 2

Sertraline HCl (100mg Tablet, 25mg

Tablet, 50mg Tablet, 20mg/ml

Concentrate)

1

Venlafaxine HCl (Tablet Immediate-

Release) 1

Venlafaxine HCl ER (150mg,

37.5mg, 75mg Capsule Extended-

Release 24 Hour; 150mg, 225mg,

37.5mg, 75mg Tablet Extended-

Release 24 Hour)

1

Viibryd (Tablet) 3 QL,ST

Viibryd ST 3 QL,ST

Amitriptyline HCl (100mg Tablet,


Tablet, 50mg Tablet, 75mg Tablet)

1

Amoxapine (Tablet) 1

Chlordiazepoxide/Amitriptyline

(Tablet) 1

Clomipramine HCl (Capsule) 1

Desipramine HCl (100mg Tablet,



1

Doxepin HCl (100mg Capsule,


25mg Capsule, 50mg Capsule, 75mg

Capsule, 10mg/ml Concentrate)

1

Imipramine HCl (10mg Tablet,

25mg Tablet, 50mg Tablet) 1

Imipramine Pamoate (Capsule) 1

Nortriptyline HCl (10mg Capsule,

25mg Capsule, 50mg Capsule, 75mg

Capsule, 10mg/5ml Oral Solution)

1

Perphenazine/Amitriptyline (10mg-

2mg Tablet, 25mg-2mg Tablet,

25mg-4mg Tablet)

1

Protriptyline HCl (Tablet) 1

Trimipramine Maleate (100mg


Capsule)

1

Akynzeo (Capsule) 3 QL

20

Drug Name Drug

Tier

Requirements

& Limits

Chlorpromazine HCl (100mg



1

Compro (Suppository) 1

Diphenhydramine HCl (12.5mg/5ml

Elixir, 50mg/ml Injection) 1

Droperidol (2.5mg/ml Injection) 1

Hydroxyzine HCl (10mg Tablet,


10mg/5ml Syrup, 50mg/ml

Injection)

1

Hydroxyzine Pamoate (100mg


Capsule)

1

Metoclopramide HCl (10mg Tablet,

5mg Tablet, 5mg/5ml Oral Solution) 1

Metoclopramide ODT (5mg Tablet

Dispersible) 1

Perphenazine (Tablet) 1

Pharbedryl (Capsule) (RX) 1

Phenadoz (Suppository) 1

Phenergan (12.5mg Suppository,

25mg Suppository, 50mg

Suppository)

1

Prochlorperazine (Suppository) 1

Prochlorperazine Edisylate

(Injection) 1

Prochlorperazine Maleate (10mg


Promethazine HCl (12.5mg

Suppository, 25mg Suppository,

50mg Suppository, 12.5mg Tablet,


Injection, 6.25mg/5ml Oral

Solution)

1

Promethazine HCl Plain (Syrup) 1

Promethegan (Suppository) 1

Transderm-Scop (Patch 72 Hour) 3

Aloxi (Injection) 2

Anzemet (Tablet) 3 QL

Aprepitant (Capsule) 1 QL

Cesamet (Capsule) 3 PA,QL

Dronabinol (Capsule) 1 PA,QL

Granisetron HCl (0.1mg/ml


4mg/4ml Injection)

1

Granisetron HCl (1mg Tablet) 1 QL

Meclizine HCl (12.5mg Tablet,

25mg Tablet) (RX) 1

Ondansetron HCl (24mg Tablet,

4mg Tablet, 8mg Tablet, 4mg/5ml

Oral Solution)

1 QL

Ondansetron HCl (40mg/20ml


Ondansetron HCl/Sodium Chloride

(Injection) 1

Drug Name Drug

Tier

Requirements

& Limits

Ondansetron ODT (Tablet

Dispersible) 1 QL

Sancuso (Patch) 3 QL

Trimethobenzamide HCl (Capsule) 1

Abelcet (Injection) 3

AmBisome (Injection) 3

Amphotericin B (50mg Injection) 1

Bio-Statin (Powder) 1

Ciclodan (0.77% Cream, 8%

External Solution) 1

Ciclopirox (0.77% Gel, 0.77%

Suspension, 1% Shampoo) 1

Ciclopirox Nail Lacquer (External

Solution) 1

Ciclopirox Olamine (0.77% Cream) 1

Clotrimazole (1% Cream, 1%

External Solution - RX, 10mg

Lozenge, 10mg Troche)

1

Clotrimazole/Betamethasone

Dipropionate (0.05%-1% Cream,

1%-0.05% Lotion)

1

Cresemba (186mg Capsule, 372mg

Injection)

3

Econazole Nitrate (1% Cream) 1

Eraxis (50mg Injection) 3

Ertaczo (Cream) 3

Exelderm (1% Cream, 1%

External Solution)

3

Fluconazole (100mg Tablet, 150mg


10mg/ml Suspension, 40mg/ml

Suspension)

1

Fluconazole in Dextrose (Injection) 1

Fluconazole in NaCl

(200mg/100ml-0.9% Injection,

400mg/200ml-0.9% Injection)

1

Flucytosine (Capsule) 1

Griseofulvin Microsize (125mg/5ml

Suspension, 500mg Tablet) 1

Griseofulvin Ultramicrosize (Tablet) 1

Gynazole-1 (Cream) 3

Itraconazole (Capsule) 1 PA

Jublia (External Solution) 3 PA

Kerydin (External Solution) 3 PA

Ketoconazole (2% Cream, 2%

Foam, 2% Shampoo, 200mg Tablet) 1

Ketodan (Foam) 1

Luzu (Cream) 3

Mentax (Cream) 3

Miconazole 3 (Suppository) 1

Mycamine (Injection) 3

Naftifine HCl (Cream) 1

Naftifine HCl (Cream) 1

Natacyn (Suspension) 2

Noxafil (100mg Tablet Delayed-

Release)

3

21

Drug Name Drug

Tier

Requirements

& Limits

Nyamyc (Powder) 1

Nystatin (100000unit/gm Cream,

100000unit/gm Ointment,

100000unit/gm Powder,

100000unit/ml Suspension,

500000unit Tablet)

1

Nystatin/Triamcinolone

(100000unit/gm-0.1% Ointment,

100000unit/gm-1mg/gm Cream)

1

Nystop (Powder) 1

Oxiconazole Nitrate (Cream) 1

Oxistat (1% Lotion) 3

Terbinafine HCl (Tablet) 1 QL

Terconazole (0.4% Cream, 0.8%

Cream, 80mg Suppository) 1

Voriconazole (200mg Injection,


40mg/ml Suspension)

1

Xolegel (Gel) 3

Zazole (0.8% Cream, 80mg

Suppository) 1

Allopurinol (Tablet) 1

Allopurinol Sodium (Injection) 1

Colchicine (0.6mg Tablet) 1

Colcrys (Tablet) 2

Krystexxa (Injection) 4 PA

Probenecid (Tablet) 1

Probenecid/Colchicine (Tablet) 1

Uloric (Tablet) 2 ST

Dihydroergotamine Mesylate

(1mg/ml Injection) 1

Dihydroergotamine Mesylate

(4mg/ml Nasal Solution) 1 QL

Ergomar (Tablet Sublingual) 3

Ergotamine Tartrate/Caffeine

(Tablet) 1

Almotriptan Malate (Tablet) 1 QL

Frovatriptan Succinate (Tablet) 1 QL

Naratriptan HCl (Tablet) 1 QL

Relpax (Tablet) 3 QL

Rizatriptan Benzoate (Tablet) 1 QL

Rizatriptan Benzoate ODT (Tablet

Dispersible) 1 QL

Sumatriptan (Nasal Solution) 1 QL

Sumatriptan Succinate (100mg


4mg/0.5ml Injection, 6mg/0.5ml

Injection)

1 QL

Zolmitriptan (Tablet) 1 QL

Zolmitriptan ODT (Tablet

Dispersible) 1 QL

Drug Name Drug

Tier

Requirements

& Limits

Zomig (2.5mg Nasal Solution, 5mg

Nasal Solution)

2 QL

Guanidine HCl (Tablet) 1

Mestinon (60mg/5ml Syrup) 2

Neostigmine Methylsulfate

(10mg/10ml Injection, 5mg/10ml

Injection, 5mg/5ml Solution

Prefilled Syringe)

1

Pyridostigmine Bromide (Tablet) 1

Pyridostigmine Bromide ER (Tablet

Extended-Release) 1

Dapsone (Tablet) 1

Rifabutin (Capsule) 1

Capastat Sulfate (Injection) 3

Cycloserine (Capsule) 1

Ethambutol HCl (100mg Tablet,

400mg Tablet) 1

Isoniazid (100mg Tablet, 300mg

Tablet, 50mg/5ml Syrup) 1

Paser (Packet) 3

Priftin (Tablet) 3

Pyrazinamide (Tablet) 1

Rifamate (Capsule) 3

Rifampin (150mg Capsule, 300mg

Capsule, 600mg Injection) 1

Rifater (Tablet) 3

Sirturo (Tablet) 3

Trecator (Tablet) 3

Campath (Injection) 2

Imlygic (Suspension) 4

Lartruvo (500mg/50ml Injection) 4 PA

Adriamycin (Injection) 4

Alkeran (2mg Tablet) CM

Bendeka (Injection) 4

BiCNU (Injection) 4

Busulfex (Injection) 4

Carboplatin (Injection) 4

Cisplatin (100mg/100ml Injection,


Cisplatin (200mg/200ml Injection) 4

Cyclophosphamide (1gm Injection,

2gm Injection, 500mg Injection) 4

Cyclophosphamide (25mg


CM

Dacarbazine (100mg Injection) 4

Dacarbazine (200mg Injection) 4

Doxorubicin HCl (Injection) 4

22

Drug Name Drug

Tier

Requirements

& Limits

Gleostine (Capsule) CM

Gliadel Wafer (Wafer) 4

Hexalen (Capsule) CM

Ifex (3gm Injection) 4

Ifosfamide (1gm Injection,

1gm/20ml Injection, 3gm/60ml

Injection)

4

Ifosfamide (3gm Injection) 4

Leukeran (Tablet) CM

Matulane (Capsule) CM

Melphalan HCl (Injection) 4

Mitoxantrone HCl (Injection) 4 PA

Mustargen (Injection) 4

Myleran (Tablet) CM

Temodar (100mg Injection) 4

Temozolomide (Capsule) CM PA

Thiotepa (Injection) 1

Treanda (Injection) 4

Yondelis (Injection) 4

Zanosar (Injection) 4

Bicalutamide (Tablet) CM

Flutamide (Capsule) CM

Nilutamide (Tablet) CM

Xtandi (Capsule) CM PA

Caprelsa (100mg Tablet) CM PA,QL

Caprelsa (300mg Tablet) CM PA

Pomalyst (Capsule) CM PA

Revlimid (Capsule) CM PA

Thalomid (Capsule) CM PA

Emcyt (Capsule) CM

Fareston (Tablet) CM

Faslodex (Injection) 4

Soltamox (Oral Solution) CM

Tamoxifen Citrate (Tablet) CM PV*

Adrucil (Injection) 4

Arranon (Injection) 4

Capecitabine (Tablet) CM PA

Cladribine (Injection) 4

Clolar (Injection) 4

Cytarabine Aqueous (Injection) 4

Depocyt (Injection) 4

Droxia (Capsule) 3

Elitek (Injection) 3

Floxuridine (Injection) 4

Fluorouracil (1gm/20ml Injection,

2.5gm/50ml Injection, 500mg/10ml

Injection, 5gm/100ml Injection)

4

Fluorouracil (5% Cream) 1

Folotyn (Injection) 4 PA

Gemcitabine (Injection) 4

Drug Name Drug

Tier

Requirements

& Limits

Hydroxyurea (Capsule) CM

Lonsurf (Tablet) CM PA,QL

Mercaptopurine (Tablet) CM

Nipent (Injection) 4

Tabloid (Tablet) CM

Alferon N (Injection) 4

Cotellic (Tablet) CM PA,QL

Decitabine (Injection) 4 PA

Docetaxel (160mg/16ml Injection,




Injection)

4

Docetaxel (Non-Alcohol Formula)

(Injection)

4

Farydak (Capsule) CM PA,QL

Ibrance (Capsule) CM PA

Intron A (Injection) 4 PA

Jakafi (10mg Tablet) CM PA,QL

Jakafi (15mg Tablet, 20mg Tablet,


CM PA

Leucovorin Calcium (10mg


CM

Leucovorin Calcium (25mg Tablet,

5mg Tablet) CM

Levoleucovorin (175mg/17.5ml

Injection) 4

Levoleucovorin (250mg/25ml

Injection)

4

Lynparza (Capsule) CM PA

Marqibo (Injection) 4

Mesna (Injection) 4

Ninlaro (Capsule) CM PA,QL

Paclitaxel (100mg/16.7ml Injection,


Injection)

4

Paclitaxel (150mg/25ml Injection) 4

Portrazza (Injection) 4 PA

Sylatron (Injection) 4 PA

Teniposide (Injection) 4

Venclexta (Tablet) CM PA

Venclexta Starting Pack (Tablet

Therapy Pack)

CM PA

Vinblastine Sulfate (Injection) 4

Vinorelbine Tartrate (Injection) 4

Zolinza (Capsule) CM PA

Zytiga (Tablet) CM PA

Anastrozole (Tablet) CM

Exemestane (Tablet) CM

Letrozole (Tablet) CM

Etopophos (Injection) 4

23

Drug Name Drug

Tier

Requirements

& Limits

Etoposide (100mg/5ml Injection,

1gm/50ml Injection, 500mg/25ml

Injection)

4

Etoposide (50mg Capsule) CM

Hycamtin (0.25mg Capsule, 1mg

Capsule)

CM

Kyprolis (30mg Injection) 4 PA

Toposar (Injection) 4

Topotecan HCl (4mg Injection) 4

Topotecan HCl (4mg/4ml

Injection)

4

Zydelig (Tablet) CM PA

Afinitor (Tablet) CM PA,QL

Afinitor Disperz (Tablet Soluble) CM PA

Bosulif (Tablet) CM PA

Cabometyx (Tablet) CM PA

Cometriq (Kit) CM PA

Erivedge (Capsule) CM PA

Gilotrif (Tablet) CM PA,QL

Iclusig (15mg Tablet) CM PA,QL

Iclusig (45mg Tablet) CM PA

Imatinib Mesylate (Tablet) CM PA

Imbruvica (Capsule) CM PA

Inlyta (Tablet) CM PA

Lenvima (Capsule Therapy Pack) CM PA

Mekinist (Tablet) CM PA

Nexavar (Tablet) CM PA

Sprycel (Tablet) CM PA

Stivarga (Tablet) CM PA

Sutent (Capsule) CM PA

Tafinlar (Capsule) CM PA

Tarceva (Tablet) CM PA,QL

Tasigna (Capsule) CM PA

Tykerb (Tablet) CM PA

Votrient (Tablet) CM PA

Xalkori (Capsule) CM PA

Zelboraf (Tablet) CM PA,QL

Zykadia (Capsule) CM PA

Adcetris (Injection) 4 PA

Arzerra (Injection) 4 PA

Avastin (Injection) 4

Blincyto (Injection) 4 PA

Darzalex (Injection) 4 PA

Empliciti (Injection) 4 PA

Erbitux (Injection) 4 PA

Gazyva (Injection) 4 PA

Herceptin (Injection) 4 PA

Opdivo (Injection) 4 PA

Perjeta (Injection) 4 PA

Rituxan (Injection) 4 PA

Tagrisso (Tablet) CM PA,QL

Tecentriq (Injection) 4

Unituxin (Injection) 4

Drug Name Drug

Tier

Requirements

& Limits

Vectibix (Injection) 4

Yervoy (Injection) 4 PA

Bexarotene (Capsule) CM PA

Panretin (Gel) 3

Targretin (1% Gel) 3

Tretinoin (10mg Capsule) CM

Albenza (Tablet) 3

Biltricide (Tablet) 2

Ivermectin (Tablet) 1

Alinia (100mg/5ml Suspension,

500mg Tablet)

2

Atovaquone (Suspension) 1

Atovaquone/Proguanil HCl (Tablet) 1

Chloroquine Phosphate (250mg


Coartem (Tablet) 3

DARAPRIM (Tablet) 3 PA

Hydroxychloroquine Sulfate

(Tablet) 1

Mefloquine HCl (Tablet) 1

Nebupent (Inhalation Solution) 2

Primaquine Phosphate (Tablet) 1

Quinine Sulfate (324mg Capsule) 1 PA

Tinidazole (Tablet) 1

Eurax (10% Cream, 10% Lotion) 2

Lindane (Shampoo) 1

Malathion (Lotion) 1

Permethrin (Cream) 1

Sklice (Lotion) 3

Spinosad (Suspension) 1

Ulesfia (Lotion) 3

Benztropine Mesylate (0.5mg


1mg/ml Injection)

1

Trihexyphenidyl HCl (0.4mg/ml

Elixir, 2mg Tablet, 5mg Tablet) 1

Amantadine HCl (100mg Capsule,

100mg Tablet, 50mg/5ml Syrup) 1

Entacapone (Tablet) 1

Tolcapone (Tablet) 1

Apokyn (Injection) 4 PA,QL

Neupro (Patch 24 Hour) 3

Pramipexole Dihydrochloride

(Tablet Immediate-Release) 1

Pramipexole Dihydrochloride ER

(Tablet Extended-Release 24 Hour) 1

24

Drug Name Drug

Tier

Requirements

& Limits

Ropinirole ER (Tablet Extended-

Release 24 Hour) 1

Ropinirole HCl (Tablet) 1

Carbidopa (Tablet) 1

Carbidopa/Levodopa (Tablet


Carbidopa/Levodopa ER (Tablet

Extended-Release) 1

Carbidopa/Levodopa/Entacapone

(Tablet) 1

Rasagiline Mesylate (Tablet) 1

Selegiline HCl (5mg Capsule, 5mg

Tablet) 1

Fluphenazine Decanoate (Injection) 1

Fluphenazine HCl (10mg Tablet,

1mg Tablet, 2.5mg Tablet, 5mg

Tablet)

1

Haloperidol (0.5mg Tablet, 10mg



Concentrate)

1

Haloperidol Decanoate (Injection) 1

Haloperidol Lactate (Injection) 1

Loxapine Succinate (Capsule) 1

Molindone HCl (Tablet) 1

Pimozide (Tablet) 1

Thioridazine HCl (Tablet) 1

Thiothixene (Capsule) 1

Trifluoperazine HCl (Tablet) 1

Fanapt (Tablet) 3 QL,ST

Fanapt Titration Pack (Tablet) 3 QL,ST

Invega Sustenna (Injection) 3

Invega Trinza (Injection) 3

Latuda (Tablet) 3 QL,ST

Olanzapine (Tablet Immediate-

Release) 1 QL

Olanzapine ODT (Tablet

Dispersible) 1 QL

Paliperidone ER (Tablet Extended-

Release 24 Hour) 1

Rexulti (Tablet) 3 QL

Risperidone (0.25mg Tablet, 0.5mg



Oral Solution)

1 QL

Risperidone ODT (Tablet

Dispersible) 1 QL

Saphris (10mg Tablet Sublingual) 2

Drug Name Drug

Tier

Requirements

& Limits

Ziprasidone HCl (Capsule) 1 QL

Clozapine (Tablet Immediate-

Release) 1 QL

Clozapine ODT (Tablet Dispersible) 1 QL

Fazaclo (12.5mg Tablet

Dispersible, 150mg Tablet

Dispersible, 200mg Tablet

Dispersible)

3 QL

Baclofen (10mg Tablet, 20mg

Tablet) 1

Cyproheptadine HCl (2mg/5ml

Syrup, 4mg Tablet)

1

Dantrolene Sodium (Capsule) 1

Gabapentin (100mg Capsule, 300mg

Capsule, 400mg Capsule,

250mg/5ml Oral Solution, 600mg


1

Tizanidine HCl (2mg Capsule, 4mg

Capsule, 6mg Capsule, 2mg Tablet,

4mg Tablet)

1

Fluzone Quadrivalent 2016-2017

(Injection)

2 PV

Cidofovir (Injection) 1

Ganciclovir (Injection) 1

Valganciclovir (Tablet) 4

Valganciclovir Hydrochlorde (Oral

Solution) 4

Zirgan (Gel) 3

Adefovir Dipivoxil (Tablet) 4

Baraclude (0.05mg/ml Oral

Solution)

4 QL

Entecavir (Tablet) 4 QL

Epivir HBV (5mg/ml Oral

Solution)

2

Lamivudine (100mg Tablet) 1

Daklinza (Tablet) 4 PA,QL

Epclusa (Tablet) 4 PA,QL

Harvoni (Tablet) 4 PA

Moderiba 4

Moderiba (200mg Tablet) 4

Moderiba 1200 Dose Pack

(Tablet)

4

Moderiba 800 Dose Pack (Tablet) 4

Olysio (Capsule) 4 PA,QL

Peg intron Redipen (Injection) 4 PA

PegIntron (Injection) 4 PA

Rebetol (40mg/ml Oral Solution) 4

25

Drug Name Drug

Tier

Requirements

& Limits

Ribasphere (200mg Capsule, 200mg

Tablet) 4

Ribasphere (400mg Tablet, 600mg

Tablet)

4

Ribasphere Ribapak (Tablet) 4

Ribavirin (200mg Capsule, 200mg

Tablet) 4

Sovaldi (Tablet) 4 PA,QL

Viekira Pak (Tablet Therapy

Pack)

4 PA,QL

Zepatier (Tablet) 4 PA,QL

Atripla (Tablet) 2

Isentress (100mg Packet, 100mg

Tablet Chewable, 25mg Tablet

Chewable, 400mg Tablet)

2

Tivicay (Tablet) 2

Complera (Tablet) 2

Edurant (Tablet) 2

Intelence (Tablet) 2

Nevirapine (200mg Tablet,

50mg/5ml Suspension) 1

Nevirapine ER (Tablet Extended-

Release 24 Hour) 1

Odefsey (Tablet) 2

Rescriptor (Tablet) 2

Stribild (Tablet) 2

Sustiva (200mg Capsule, 50mg

Capsule, 600mg Tablet)

2

Viramune (50mg/5ml Suspension) 2

Abacavir (Tablet) 1

Abacavir

Sulfate/Lamivudine/Zidovudine

(Tablet)

1

Abacavir/Lamivudine (Tablet) 1

Didanosine (Capsule Delayed-

Release) 1

Emtriva (10mg/ml Oral Solution,

200mg Capsule)

2

Lamivudine (10mg/ml Oral


Tablet)

1

Lamivudine/Zidovudine (Tablet) 1

Retrovir IV Infusion (Solution) 2

Stavudine (Capsule) 1

Triumeq (Tablet) 2

Truvada (Tablet) 2

Videx Pediatric (Oral Solution) 2

Drug Name Drug

Tier

Requirements

& Limits

Viread (150mg Tablet, 200mg


Tablet, 40mg/gm Powder)

2

Zerit (1mg/ml Oral Solution) 2

Ziagen (20mg/ml Oral Solution) 2

Zidovudine (100mg Capsule, 300mg


Fuzeon (Injection) 2 QL

Selzentry (150mg Tablet, 300mg

Tablet)

2 PA

Tybost (Tablet) 2

Aptivus (100mg/ml Oral Solution,

250mg Capsule)

2

Crixivan (Capsule) 2

Evotaz (Tablet) 2

Invirase (200mg Capsule, 500mg

Tablet)

2

Kaletra (100mg-25mg Tablet,

200mg-50mg Tablet)

2

Lexiva (50mg/ml Suspension,

700mg Tablet)

2

Lopinavir/Ritonavir (Solution) 1

Norvir (100mg Capsule, 100mg

Tablet, 80mg/ml Oral Solution)

2

Prezcobix (Tablet) 2

Prezista (100mg/ml Suspension,



2

Reyataz (150mg Capsule, 200mg


Packet)

2

Viracept (Tablet) 2

Flulaval Quadrivalent 2016-2017

(Injection)

2 PV

Flumist Quadrivalent

(Suspension)

2 PV

Medical Provider Single Use EZ

Flu Shot (Injection)

2 PV

Oseltamivir Phosphate (Capsule) 1 QL

Relenza Diskhaler (Aerosol

Powder)

3 QL

Rimantadine HCl (Tablet) 1

Tamiflu (6mg/ml Suspension) 3 QL

Acyclovir (200mg Capsule,


Tablet, 800mg Tablet, 5%

Ointment)

1

Acyclovir Sodium (Injection) 1

Denavir (Cream) 3

Famciclovir (Tablet) 1

Trifluridine (Ophthalmic Solution) 1

26

Drug Name Drug

Tier

Requirements

& Limits

Valacyclovir HCl (Tablet) 1 QL

Zovirax (5% Cream) 2

Buspirone HCl (Tablet) 1

Dexmedetomidine HCl (Injection) 1

Meprobamate (Tablet) 1

Alprazolam (Tablet Immediate-

Release) 1 QL

Alprazolam ER (Tablet Extended-

Release 24 Hour) 1 QL

Alprazolam ODT (Tablet

Dispersible) 1

Alprazolam XR (Tablet Extended-

Release 24 Hour) 1 QL

Chlordiazepoxide HCl (Capsule) 1 QL

Estazolam (Tablet) 1 QL

Flurazepam HCl (Capsule) 1 PA,QL

Lorazepam (20mg/10ml Injection,

4mg/ml Injection) 1

Lorazepam Intensol (2mg/ml

Concentrate) 1

Oxazepam (Capsule) 1 QL

Quazepam (Tablet) 1 QL

Temazepam (Capsule) 1 QL

Triazolam (Tablet) 1 QL

Ephedrine Sulfate (Solution) 1

Phenylephrine HCl/Sodium

Chloride (50mg/250ml-0.9%

Solution)

1

Olanzapine/Fluoxetine (Capsule) 1 QL

Lithium (Oral Solution) 1

Lithium Carbonate (150mg Capsule,


300mg Tablet)

1

Lithium Carbonate ER (Tablet

Extended-Release) 1

Heparin Sodium/Sodium Chloride

(2000unit/500ml-0.9% Solution) 1

Mircera (150mcg/0.3ml Injection,

30mcg/0.3ml Injection)

4 PA

Acarbose (Tablet) 1

Alogliptin (Tablet) 3 ST

Avandia (Tablet) 3 ST

Drug Name Drug

Tier

Requirements

& Limits

Bydureon Pen (Injection) 2 QL,ST

Bydureon Vial (Injection) 2 QL,ST

Byetta (Injection) 2 QL,ST

Chlorpropamide (Tablet) 1

Cycloset (Tablet) 3 ST

Farxiga (Tablet) 3 ST

Glimepiride (Tablet) 1

Glipizide (Tablet Immediate-

Release) 1

Glipizide ER (Tablet Extended-

Release 24 Hour) 1

Glipizide XL (Tablet Extended-

Release 24 Hour) 1

Glipizide/Metformin HCl (Tablet) 1

Glyburide (1.25mg Tablet, 2.5mg


Glyburide Micronized (Tablet) 1

Glyburide/Metformin HCl (Tablet) 1

Invokamet (Tablet) 2 ST

Invokamet XR (Tablet Extended-

Release 24 Hour)

2 ST

Invokana (Tablet) 2 ST

Janumet (Tablet) 2 ST

Janumet XR (Tablet Extended-

Release 24 Hour)

2 ST

Januvia (Tablet) 2 ST

Jardiance (Tablet) 3 ST

Kombiglyze XR (Tablet


2 ST

Metformin HCl (Tablet) 1

Metformin HCl ER (Tablet


(Generic for Fortamet, Generic for

Glucophage XR)

1

Metformin HCl ER (Tablet


(Generic for Glumetza)

1 PA

Miglitol (Tablet) 1

Nateglinide (Tablet) 1

Nesina (Tablet) 3 ST

Onglyza (Tablet) 2 ST

Pioglitazone HCl (Tablet) 1

Pioglitazone HCl/Glimepiride

(Tablet)

1

Pioglitazone HCl/Metformin HCl

(Tablet) 1

Repaglinide (Tablet) 1

Repaglinide/Metformin HCl

(Tablet) 1

Riomet (Oral Solution) 3

SymlinPen 120 (Injection) 3 PA

SymlinPen 60 (Injection) 3 PA

Synjardy (Tablet), Synjardy XR

(Tablet)

2 ST

Tolazamide (Tablet) 1

Tolbutamide (Tablet) 1

Tradjenta (Tablet) 3 ST

27

Drug Name Drug

Tier

Requirements

& Limits

Tranylcypromine Sulfate (Tablet) 1

Trulicity (Injection) 2 QL,ST

Victoza (Injection) 2 QL,ST

Welchol (3.75gm Packet, 625mg

Tablet)

2

Xigduo XR (Tablet Extended-

Release 24 Hour)

3 ST

Dextrose 70% (Injection) 1

GlucaGen HypoKit (Injection) 2

Glucagon Emergency Kit

(Injection)

2

Proglycem (Suspension) 2

Apidra (Injection) 3 ST

Apidra SoloST 3 ST

Humalog (Injection) 2

Humalog KwikPen (Injection) 2

Humalog Mix 50/50 (Injection) 2

Humalog Mix 50/50 KwikPen

(Injection)

2

Humalog Mix 75/25 (Injection) 2

Humalog Mix 75/25 KwikPen

(Injection)

2

Humulin 70/30 (Injection) 2

Humulin 70/30 KwikPen

(Injection)

2

Humulin N (Injection) 2

Humulin N KwikPen (Injection) 2

Humulin R (Injection) 2

Humulin R U-500 (Concentrated)

(Injection)

2

Lantus (Injection) 2

Lantus SoloStar (Injection) 2

Levemir (Injection) 3

Levemir FlexTouch (Injection) 3

Novolin 70/30 (Injection) 2

Novolin 70/30 Relion (Injection) 2

Novolin N (Injection) 2

Novolin N Relion (Injection) 2

Novolin R (Injection) 2

Novolin R Relion (Injection) 2

NovoLog (Injection) 2

NovoLog FlexPen (Injection) 2

NovoLog Mix 70/30 (Injection) 2

NovoLog Mix 70/30 Prefilled

FlexPen (Injection)

2

NovoLog PenFill (Injection) 2

Toujeo SoloStar (Injection) 2

Argatroban (125mg/125ml-0.9%

Injection, 250mg/250ml-0.9%

Injection)

3

Argatroban (250mg/2.5ml Injection) 1

Drug Name Drug

Tier

Requirements

& Limits

Bivalirudin (Injection) 1

Ceprotin (Injection) 4

Eliquis (Tablet) 3 QL

Enoxaparin Sodium (100mg/ml

Injection, 120mg/0.8ml Injection,

150mg/ml Injection, 30mg/0.3ml

Injection, 40mg/0.4ml Injection,

60mg/0.6ml Injection, 80mg/0.8ml

Injection, 300mg/3ml Injection)

1 QL

Fondaparinux Sodium (Injection) 1 QL

Fragmin (Injection) 3 QL

Heparin Lock Flush (Injection) 1

Heparin Sodium (10000unit/10ml

Injection, 3000unit/3ml Injection,

5000unit/5ml Injection,

10000unit/ml Injection, 1000unit/ml

Injection, 20000unit/ml Injection,

5000unit/0.5ml Injection,

5000unit/ml Injection)

1

Heparin Sodium Lock Flush (Kit) 1

Heparin Sodium/D5W (5%-

40unit/ml Injection, 5%-50unit/ml

Injection)

1

Heparin Sodium/NaCl 0.9%

(Injection) 1

Heparin Sodium/Sodium Ch Loride

(Injection) 1


(20unit/20ml-0.9% Injection,

25000unit/250ml-0.45% Injection,

30000unit/L-0.9% Injection,

4000unit/L-0.9% Injection,

50unit/50ml-0.45% Injection)

1


0.9% Premix (Injection) 1

Jantoven (Tablet) 1

Pradaxa (Capsule) 2 QL

Sash Kit for Flushing Vascular

Access Devices (Kit) 1

Thrombate III (Injection) 4

Thrombate III w/20 Ml Sterile

Water (Injection)

4

Warfarin Sodium (Tablet) 1

Xarelto (Tablet) 2 QL

Xarelto Starter Pack (Tablet

Therapy Pack)

2 QL

Anagrelide HCl (Capsule) 1

Leukine (Injection) 4 PA

Mircera (100mcg/0.3ml Injection,

200mcg/0.3ml Injection,

50mcg/0.3ml Injection,

75mcg/0.3ml Injection)

4 PA

Mozobil (Injection) 4 PA,QL

Neulasta (Injection) 4 PA

Neulasta Onpro Kit (Injection) 4 PA

Neupogen (Injection) 4 PA

28

Drug Name Drug

Tier

Requirements

& Limits

Nplate (Injection) 4 PA

Procrit (Injection) 4 PA

Promacta (Tablet) 4 PA

Albuked 25 (Injection) 1

Albuked 5 (Injection) 1

Albumin Human (Injection) 1

Albumin-Zlb (Injection) 1

Albuminar-25 (Injection) 1

Albuminar-5 (Injection) 1

Alburx (Injection) 1

Albutein (Injection) 1

Buminate (Injection) 1

Flexbumin (Injection) 1

Hetastarch 6%/NaCl (Injection) 1

Kedbumin (Injection) 1

Plasbumin-25 (Injection) 1

Plasbumin-5 (Injection) 1

Advate (Injection) 4

Alphanate/Von Willebrand Factor

Complex/Human (Injection)

4

Alphanine SD (Injection) 4

Bebulin (Injection) 4

Benefix (Injection) 4

Brilinta (90mg Tablet) 2

Coagadex (Injection) 4

Corifact (Injection) 4

Eloctate (Injection) 4

Feiba (Injection) 4

Helixate FS (Injection) 4

Hemofil M (Injection) 4

Humate-P (Injection) 4

Idelvion (Injection) 4

Koate (Solution) 4

Koate-Dvi (Injection) 4

Kogenate FS (Injection) 4

Kogenate FS Bio-Set (Injection) 4

Monoclate-P (Injection) 4

Mononine (Injection) 4

Novoseven (Solution) 4

Novoseven RT (Injection) 4

Obizur (Injection) 4

Profilnine (Injection) 4

Recombinate (Injection) 4

Riastap (Injection) 4

Rixubis (Injection) 4

Tranexamic Acid (1000mg/10ml

Injection, 1000mg/10ml Solution,

650mg Tablet)

1

Tretten (Injection) 4

Vonvendi (Injection) 4

Drug Name Drug

Tier

Requirements

& Limits

Xyntha (Injection) 4

Xyntha Solofuse (Injection) 4

Aggrastat (Injection) 3

Aspirin/Dipyridamole (Capsule


Brilinta (60mg Tablet) 2

Cilostazol (Tablet) 1

Clopidogrel (Tablet) 1

Dipyridamole (25mg Tablet, 50mg


Effient (Tablet) 2

Eptifibatide (Injection) 1

Zontivity (Tablet) 3

Clonidine HCl (0.1mg Tablet,


0.1mg/24hr Patch Weekly,



100mcg/ml Injection, 500mcg/ml

Injection)

1

Guanfacine HCl (Tablet Immediate-

Release) 1

Methyldopa (Tablet) 1

Methyldopa/Hydrochlorothiazide

(Tablet) 1

Methyldopate HCl (Injection) 1

Midodrine HCl (Tablet) 1

Phenylephrine HCl (10mg/ml

Injection) 1

Doxazosin (Tablet) 1

Doxazosin Mesylate (Tablet) 1

Phenoxybenzamine HCl (Capsule) 1

Prazosin HCl (1mg Capsule, 2mg


Terazosin HCl (Capsule) 1

Amlodipine Besylate/Valsartan

(Tablet) 1

Amlodipine/Olmesartan Medoxomil

(Tablet) 1

Amlodipine/Valsartan/Hydrochlorot

hiazide (Tablet) 1

Candesartan Cilexetil (Tablet) 1

Candesartan

Cilexetil/Hydrochlorothiazide

(Tablet)

1

Edarbi (Tablet) 3

Eprosartan Mesylate (Tablet) 1

29

Drug Name Drug

Tier

Requirements

& Limits

Irbesartan (Tablet) 1

Irbesartan/Hydrochlorothiazide

(Tablet) 1

Losartan Potassium (Tablet) 1

Losartan

Potassium/Hydrochlorothiazide

(Tablet)

1

Olmesartan Medoxomil (Tablet) 1

Olmesartan

Medoxomil/Amlodipine/Hydrochlor

othiazide (Tablet)

1

Olmesartan

Medoxomil/Hydrochlorothiazide

(Tablet)

1

Telmisartan (Tablet) 1

Telmisartan/Amlodipine (Tablet) 1

Telmisartan/Hydrochlorothiazide

(Tablet) 1

Valsartan (Tablet) 1

Valsartan/Hydrochlorothiazide

(Tablet) 1

Amlodipine Besylate/Benazepril

HCl (Capsule) 1

Benazepril HCl (Tablet) 1

Benazepril

HCl/Hydrochlorothiazide (Tablet) 1

Captopril (Tablet) 1

Captopril/Hydrochlorothiazide

(Tablet) 1

Enalapril Maleate (Tablet) 1

Enalapril

Maleate/Hydrochlorothiazide

(Tablet)

1

Enalaprilat (Injection) 1

Fosinopril Sodium (Tablet) 1

Fosinopril

Sodium/Hydrochlorothiazide

(Tablet)

1

Lisinopril (Tablet) 1

Lisinopril/Hydrochlorothiazide

(Tablet) 1

Moexipril HCl (Tablet) 1

Moexipril/Hydrochlorothiazide

(Tablet) 1

Perindopril Erbumine (Tablet) 1

Quinapril HCl (Tablet) 1

Quinapril/Hydrochlorothiazide

(Tablet) 1

Ramipril (Capsule) 1

Trandolapril (Tablet) 1

Trandolapril/Verapamil HCl (Tablet

Extended-Release) 1

Trandolapril/Verapamil HCl ER

(Tablet Extended-Release) 1

Drug Name Drug

Tier

Requirements

& Limits

Adenosine (12mg/4ml Injection,


Amiodarone HCl (100mg Tablet,


50mg/ml Injection)

1

Amiodarone HCl/Dextrose

(Injection) 1

Dilt-XR (Capsule Extended-Release

24 Hour) 1

Diltiazem HCl (Tablet Immediate-

Release) 1

Diltiazem HCl ER (Capsule

Extended-Release 24 Hour; Capsule


1

Disopyramide Phosphate (Capsule) 1

Dofetilide (Capsule) 1

Flecainide Acetate (Tablet) 1

Ibutilide Fumarate (Injection) 1

Lidocaine HCl (10mg/ml Injection,


Lidocaine HCl in D5W (Injection) 1

Mexiletine HCl (Capsule) 1

Multaq (Tablet) 3

Nexterone (150mg/100ml-

42.1mg/ml Injection)

3

Norpace CR (100mg Capsule


2

Pacerone (Tablet) 1

Procainamide HCl (500mg/ml

Solution) 1

Propafenone HCl (Tablet) 1

Propafenone HCl ER (Capsule


Quinidine Gluconate CR (Tablet

Extended-Release) 1

Quinidine Gluconate ER (Tablet

Extended-Release) 1

Quinidine Sulfate (Tablet) 1

Sorine (Tablet) 1

Sotalol HCl (AF) (Tablet) 1

Sotalol HCl (Tablet) 1

Taztia XT (Capsule Extended-

Release 24 Hour) 1

Acebutolol HCl (200mg Capsule,

400mg Capsule) 1

Atenolol (100mg Tablet, 25mg


Atenolol/Chlorthalidone (Tablet) 1

Betaxolol HCl (10mg Tablet, 20mg

Tablet) 1

Bisoprolol Fumarate (Tablet) 1

Bisoprolol

Fumarate/Hydrochlorothiazide

(Tablet)

1

Bystolic (Tablet) 2

30

Drug Name Drug

Tier

Requirements

& Limits

Carvedilol (Tablet) 1

Coreg CR (Capsule Extended-

Release 24 Hour)

3 ST

Esmolol HCl (Injection) 1

Hemangeol (Oral Solution) 3

Inderal XL (Capsule Extended-

Release 24 Hour)

3

Innopran XL (Capsule Extended-

Release 24 Hour)

3

Labetalol HCl (100mg Tablet,


5mg/ml Injection)

1

Metoprolol Succinate ER (Tablet


Metoprolol Tartrate (100mg Tablet,

25mg Tablet, 37.5mg Tablet, 50mg


Injection)

1

Metoprolol/Hydrochlorothiazide

(Tablet) 1

Nadolol (20mg Tablet, 40mg Tablet,

80mg Tablet) 1

Nadolol/Bendroflumethiazide

(Tablet) 1

Pindolol (Tablet) 1

Propranolol HCl (Tablet Immediate-

Release, 1mg/ml Injection, Oral

Solution)

1

Propranolol HCl (Tablet) 1

Propranolol HCl ER (Capsule


Propranolol/Hydrochlorothiazide

(Tablet) 1

Timolol Maleate (10mg Tablet,


Afeditab CR (Tablet Extended-

Release 24 Hour) 1

Amlodipine Besylate (Tablet) 1

Amlodipine Besylate/Atorvastatin

Calcium (Tablet) 1

Cardene IV (20mg/200ml-0.86%

Injection)

3

Cardizem LA (120mg Tablet


3

Cartia XT (Capsule Extended-

Release 24 Hour) 1

Diltiazem CD (Capsule Extended-

Release 24 Hour) 1

Diltiazem HCl CD (Capsule


Diltiazem HCl ER (Capsule

Extended-Release 24 Hour, Tablet


1

Felodipine ER (Tablet Extended-

Release 24 Hour) 1

Isradipine (Capsule) 1

Drug Name Drug

Tier

Requirements

& Limits

Matzim LA (Tablet Extended-

Release 24 Hour) 1

Nicardipine HCl (2.5mg/ml

Injection, 20mg Capsule, 30mg

Capsule)

1

Nifedipine (10mg Capsule, 20mg

Capsule) 1

Nifedipine ER (Tablet Extended-

Release 24 Hour) 1

Nimodipine (Capsule) 1

Nisoldipine (Tablet Extended-

Release 24 Hour) 1

Nisoldipine ER (Tablet Extended-

Release 24 Hour) 1

Verapamil HCl (Tablet Immediate-

Release, 2.5mg/ml Injection) 1

Verapamil HCl ER (100mg, 120mg,

180mg, 200mg, 240mg, 300mg

Capsule Extended-Release 24 Hour;

120mg, 180mg, 240mg Tablet

Extended-Release)

1

Verapamil HCl SR (Capsule


Norepinephrine Bitartrate (Injection) 1

Demser (Capsule) 3

Digitek (Tablet) 1

Digox (Tablet) 1

Digoxin (0.05mg/ml Oral Solution,

0.25mg/ml Injection, 125mcg

Tablet, 250mcg Tablet)

1

Dobutamine HCl (Injection) 1

Dobutamine HCl/D5W (Injection) 1

Dopamine HCl (40mg/ml Injection,


Dopamine/D5W (Injection) 1

Mannitol (Injection) 1

Milrinone in Dextrose (5%-

20mg/100ml Injection, 5%-

40mg/200ml Solution)

1

Milrinone Lactate (Injection) 1

Osmitrol Viaflex (15% Injection,

20% Injection) 1

Pentoxifylline ER (Tablet Extended-

Release) 1

Praluent (Injection) 4 PA,QL

Ranexa (Tablet Extended-Release

12 Hour)

2 ST

Repatha (Injection) 4 PA,QL

Repatha Pushtronex System

(Injection)

4 PA,QL

Repatha SureClick (Injection) 4 PA,QL

Tekturna (Tablet) 2 ST

Vecamyl (Tablet) 3

31

Drug Name Drug

Tier

Requirements

& Limits

Acetazolamide (Tablet Immediate-

Release) 1

Dorzolamide HCl (Ophthalmic

Solution) 1

Methazolamide (Tablet) 1

Bumetanide (0.25mg/ml Injection,

0.5mg Tablet, 1mg Tablet, 2mg

Tablet)

1

Ethacrynate Sodium (Injection) 1

Ethacrynic Acid (Tablet) 1

Furosemide (10mg/ml Injection,

10mg/ml Oral Solution, 8mg/ml

Oral Solution, 20mg Tablet, 40mg


1

Torsemide (Tablet) 1

Amiloride HCl (5mg Tablet) 1

Amiloride/Hydrochlorothiazide

(Tablet) 1

Dyrenium (0-100mg Capsule) 3

Eplerenone (Tablet) 1

Spironolactone (100mg Tablet,


Spironolactone/Hydrochlorothiazide

(Tablet) 1

Triamterene/Hydrochlorothiazide

(25mg-37.5mg Tablet, 50mg-75mg

Tablet, 37.5mg-25mg Capsule,

50mg-25mg Capsule)

1

Chlorothiazide (Tablet) 1

Chlorothiazide Sodium (Injection) 1

Chlorthalidone (25mg Tablet, 50mg

Tablet) 1

Hydrochlorothiazide (12.5mg

Capsule, 12.5mg Tablet, 25mg


1

Indapamide (Tablet) 1

Methyclothiazide (5mg Tablet) 1

Metolazone (Tablet) 1

Tekturna HCT (Tablet) 2 ST

Fenofibrate (120mg Tablet, 145mg





1

Fenofibrate Micronized (Capsule) 1

Fenofibric Acid (Tablet) 1

Fenofibric Acid DR (Capsule

Delayed-Release) 1

Fibricor (35mg Tablet) 2

Drug Name Drug

Tier

Requirements

& Limits

Gemfibrozil (600mg Tablet) 1

Triglide (Tablet) 3

Atorvastatin Calcium (Tablet) 1

Fluvastatin (Capsule) 1

Fluvastatin Sodium ER (Tablet


Livalo (Tablet) 3

Lovastatin (Tablet) 1

Pravastatin Sodium (Tablet) 1

Rosuvastatin Calcium (Tablet) 1

Simvastatin (10mg Tablet, 20mg


1

Simvastatin (80mg Tablet) 1 PA

Cholestyramine (Powder) 1

Cholestyramine Light (Powder) 1

Colestipol HCl (1gm Tablet, 5gm

Packet) 1

Ezetimibe (Tablet) 1

Juxtapid (Capsule) 4 PA,QL

Niacin ER (Tablet Extended-

Release) 1

Omega-3-Acid Ethyl Esters

(Capsule) 1

Prevalite (4gm Packet, 4gm/dose

Powder) 1

Vascepa (Capsule) 2

Hydralazine HCl (100mg Tablet,


Tablet, 20mg/ml Injection)

1

Minoxidil (Tablet) 1

BiDil (Tablet) 3

Dilatrate SR (Capsule Extended-

Release)

2

Isosorbide Dinitrate (Tablet


Isosorbide Dinitrate ER (Tablet

Extended-Release) 1

Isosorbide Mononitrate (Tablet


Isosorbide Mononitrate ER (Tablet


Minitran (Patch 24 Hour) 1

Nitro-Bid (Ointment) 2

Nitroglycerin (0.3mg Tablet

Sublingual, 0.4mg Tablet


Sublingual)

1

32

Drug Name Drug

Tier

Requirements

& Limits

Nitroglycerin ER (Capsule

Extended-Release) (MANUF

TRIMARC)

1

Nitroglycerin in 5% Dextrose

(Injection) 1

Nitroglycerin in Dextrose 5% (5%-

100mcg/ml Injection) 1

Nitroglycerin Lingual

(0.4mg/sprayTranslingual Solution,

400mcg/spray Aerosol Solution)

1

Nitroglycerin Transdermal (Patch 24

Hour) 1

NitroMist (Aerosol Solution) 3

Rectiv (Ointment) 3

Sodium Nitroprusside (Injection) 1

Fentanyl Citrate/Bupivacaine

HCl/Sodium Chloride (Solution) 1

Hydromorphone HCl/Sodium

Chloride (10mg/25ml-0.9% Solution

Prefilled Syringe, 1mg/5ml-0.9%

Solution Prefilled Syringe,

3mg/30ml-0.9% Solution Prefilled

Syringe, 15mg/50ml-0.9% Injection)

1

Amphetamine/Dextroamphetamine

(10mg, 12.5mg, 15mg, 20mg, 30mg,

5mg, 7.5mg Tablet; 10mg, 15mg,

20mg, 25mg, 30mg, 5mg Capsule


1 QL

Dexedrine (10mg Tablet, 5mg

Tablet) 1 QL

Dextroamphetamine Sulfate (10mg

Tablet, 5mg Tablet, 5mg/5ml Oral

Solution)

1 QL

Dextroamphetamine Sulfate ER

(10mg Capsule Extended-Release

24 Hour, 5mg Capsule Extended-

Release 24 Hour)

1

Dextroamphetamine Sulfate ER

(15mg Capsule Extended-Release

24 Hour)

1 QL

Methamphetamine HCl (Tablet) 1 QL

Vyvanse (Capsule) 2 QL

Zenzedi (10mg Tablet, 5mg Tablet) 1 QL

Clonidine HCl ER (Tablet


Daytrana (Patch) 3 QL

Dexmethylphenidate HCl (Tablet

Immediate-Release) 1 QL

Drug Name Drug

Tier

Requirements

& Limits

Dexmethylphenidate HCl ER

(10mg, 15mg, 20mg, 30mg, 40mg,

5mg, 25mg, 35mg Capsule


1 QL

Guanfacine ER (Tablet Extended-

Release 24 Hour) 1

Metadate ER (Tablet Extended-

Release) 1 QL

Methylphenidate HCl (Tablet

Immediate-Release, Tablet

Chewable, Oral Solution)

1 QL

Methylphenidate HCl CD (Capsule

Extended-Release) 1 QL

Methylphenidate HCl ER (Tablet

Extended-Release, Capsule


1 QL

Methylphenidate HCl SR (Tablet


Quillivant XR (Suspension) 3 QL

Strattera (Capsule) 2 QL

Caffeine Citrate (20mg/ml Oral

Solution, 60mg/3ml Injection) 1

Flumazenil (Injection) 1

Hetlioz (Capsule) 4 PA,QL

Horizant (Tablet Extended-

Release)

3 PA,QL

Namzaric (Capsule Extended-

Release 24 Hour)

2 QL

Nuedexta (Capsule) 3

Riluzole (Tablet) 1 PA,QL

Tetrabenazine (Tablet) 4 PA

Savella (Tablet) 3 QL,ST

Ampyra (Tablet Extended-Release

12 Hour)

4 PA,QL

Aubagio (Tablet) 4 PA,QL

Avonex (Injection) 4 PA,QL

Avonex Pen (Injection) 4 PA,QL

Betaseron (Injection) 4 PA,QL

Copaxone (Injection) 4 PA,QL

Gilenya (Capsule) 4 PA,QL

Glatopa (Injection) 4 PA,QL

Tecfidera (Capsule Delayed-

Release)

4 PA,QL

Tecfidera Starter Pack 4 PA,QL

Cavarest (Gel) 1

Cevimeline HCl (Capsule) 1

Chlorhexidine Gluconate (0.12%

Solution) 1

33

Drug Name Drug

Tier

Requirements

& Limits

Easygel (Gel) 1

Karigel (Gel) 1

Karigel-N (Gel) 1

Kepivance (Injection) 4

Neutragard Advanced (Gel) 1

Neutral Sodium Fluoride (Solution) 1

Oralone (Paste) 1

Paroex (Solution) 1

Periogard (Solution) 1

Phos-Flur (Gel) 1

Pilocarpine HCl (5mg Tablet, 7.5mg

Tablet) 1

Topex Topical Anesthetic (Solution) 1

Triamcinolone Acetonide (0.1%

Paste) 1

Triamcinolone in Orabase (Paste) 1

Acitretin (Capsule) 1

Adapalene (0.1% Cream, 0.1% Gel,

0.3% Gel) 1 PA

Adapalene Pump (Gel) 1 PA

Ala-Cort (Cream) 1

Alclometasone Dipropionate (0.05%

Cream, 0.05% Ointment) 1

Alphatrex (Gel) 1

Amcinonide (0.1% Cream, 0.1%

Lotion, 0.1% Ointment) 1

Ammonium Lactate (12% Cream,

12% Lotion) (RX) 1

Ana-Lex (Kit) 1

ApexiCon E (Cream) 1

Augmented Betamethasone

Dipropionate (0.05% Cream, 0.05%

Gel, 0.05% Lotion, 0.05%

Ointment)

1

Avita (0.025% Cream, 0.025% Gel) 1 PA

Azelex (Cream) 3

Betamethasone Dipropionate

(0.05% Cream, 0.05% Lotion,

0.05% Ointment)

1

Betamethasone Valerate (0.1%

Cream, 0.1% Lotion, 0.1%

Ointment, 0.12% Foam)

1

BP Cleansing Wash (Emulsion) 3

Calcipotriene (0.005% Cream,

0.005% External Solution, 0.005%

Ointment)

1

Calcipotriene/Betamethasone

Dipropionate (Ointment) 1 QL

Calcitrene (Ointment) 1

Calcitriol (3mcg/gm Ointment) 1

Capex (Shampoo) 3

Cerovel (40% Gel, 40% Lotion) 1

Claravis (Capsule) 1 PA

Clindacin ETZ Pledgets (Swab) 1

Clindacin-P (Swab) 1

Clindamax (Gel) 1

Drug Name Drug

Tier

Requirements

& Limits

Clindamycin Phosphate (1%

External Solution, 1% Foam, 1%

Gel, 1% Lotion, 1% Swab)

1

Clindamycin Phosphate/Tretinoin

(Gel) 1

Clindamycin/Benzoyl Peroxide

(Gel) 1

Clobetasol Propionate (0.05%

Cream, 0.05% External Solution,

0.05% Foam, 0.05% Gel, 0.05%

Liquid, 0.05% Lotion, 0.05%

Ointment, 0.05% Shampoo)

1

Clobetasol Propionate Emollient

(Cream) 1

Clocortolone Pivalate (Cream) 1

Clodan (Shampoo) 1

Condylox (0.5% Gel) 3

Cordran (4mcg/sqcm Tape) 3

Cormax Scalp Application (External

Solution) 1

Cortisporin (0.5%-0.5% Cream,

1%-0.5% Ointment)

3

Cosentyx (Injection) 4 PA

Cosentyx Sensoready Pen

(Injection)

4 PA

Desonide (0.05% Cream, 0.05%

Lotion, 0.05% Ointment) 1

Desoximetasone (0.05% Cream,

0.25% Cream, 0.05% Gel, 0.05%

Ointment, 0.25% Ointment)

1

Diclofenac Sodium (1% Gel) 1 QL

Diclofenac Sodium (1.5%

Transdermal Solution) 1 PA

Diflorasone Diacetate (0.05%


Doxepin HCl (Cream) 1

Doxycycline (40mg Capsule

Delayed-Release) 1

Elidel (Cream) 2 ST

Epiduo (Gel) 3

Epiduo Forte (Gel) 3

Ery 1

Erythromycin (2% External

Solution, 2% Gel, 2% Pad) 1

Erythromycin/Benzoyl Peroxide

(Gel) 1

Finacea (15% Foam, 15% Gel) 2

Fluocinolone Acetonide (0.01%

Cream, 0.025% Cream, 0.01%

External Solution, 0.01% Oil,

0.025% Ointment)

1

Fluocinolone Acetonide Body (Oil) 1

Fluocinolone Acetonide Ear Drops

(Oil) 1

Fluocinolone Acetonide Scalp (Oil) 1

Fluocinonide (0.05% Cream, 0.1%


0.05% Gel, 0.05% Ointment)

1

34

Drug Name Drug

Tier

Requirements

& Limits

Fluocinonide-E (Cream) 1

Fluoroplex (Cream) 3

Fluorouracil (0.5% Cream) 1

Fluorouracil (2% External Solution,

5% External Solution) 4

Flurandrenolide (0.05% Cream,

0.05% Lotion, 0.05% Ointment) 1

Fluticasone Propionate (0.005%

Ointment, 0.05% Cream, 0.05%

Lotion)

1

Halobetasol Propionate (0.05%


Halog (0.1% Cream, 0.1%

Ointment)

3

Hydrocortisone (1% Cream RX,

2.5% Cream, 1% Ointment RX,

2.5% Ointment, 2.5% Cream, 2.5%

Lotion)

1

Hydrocortisone 1% in Absorbase

(Ointment) 1

Hydrocortisone Butyrate (0.1%


0.1% Ointment)

1

Hydrocortisone in Absorbase

(Ointment) 1

Hydrocortisone Valerate (0.2%


Imiquimod (Cream) 1

Klofensaid II (Transdermal

Solution) 1 PA

Lactic Acid (Lotion) 1

Lactic Acid E (Cream) 1

Lactic Acid with Vitamin E (Cream) 1

Lidazone HC (Cream) 1

Lidocaine HCl/Hydrocortisone

Acetate (0.5%-3% Cream, 0.5%-3%

Kit, 1%-3% Kit, 2%-2% Kit, 2.5%-

3% Kit)

1

Locoid (0.1% Lotion) 3

LoKara (Lotion) 1

Methoxsalen (10mg Capsule) 1

Mirvaso (Gel) 2

Mometasone Furoate (0.1% External

Solution) 1

Myorisan (Capsule) 1 PA

Neo-Synalar (Cream) 3

Neuac (Gel) 1

Oracea (Capsule Delayed-Release) 3

Picato (Gel) 3 ST

Podofilox (External Solution) 1

Prednicarbate (0.1% Cream, 0.1%

Ointment) 1

Procto-Med HC (Cream) 1

Procto-Pak (Cream) 1

Proctosol HC (Cream) 1

Proctozone-HC (Cream) 1

Regranex (Gel) 3 PA

Drug Name Drug

Tier

Requirements

& Limits

Salicylic Acid (6% Cream, 6% Gel,

6% Lotion) 1

Salicylic Acid Cream (Kit) 1

Salicylic Acid Lotion (Kit) 1

Salitech Forte (Lotion) 1

Santyl (Ointment) 3

Scalacort (Lotion) 1

Selenium Sulfide (Lotion) 1

Stelara (45mg/0.5ml Injection,

90mg/ml Injection)

4 PA

Sulfacetamide Sodium (10% Lotion,

10% Suspension) 1

Taclonex (0.064%-0.005%

Suspension)

3 QL

Tacrolimus (0.03% Ointment, 0.1%

Ointment) 1

Tazorac (0.05% Cream, 0.1%

Cream, 0.05% Gel, 0.1% Gel)

3 QL

Texacort (External Solution) 3

Tretinoin (0.01% Gel, 0.025% Gel,

0.05% Gel, 0.025% Cream, 0.05%

Cream, 0.1% Cream)

1 PA

Tretinoin Microsphere (Gel) 1 PA

Tretinoin Microsphere Pump (Gel) 1 PA

Triamcinolone Acetonide (0.025%

Cream, 0.1% Cream, 0.5% Cream,

0.025% Lotion, 0.1% Lotion,

0.025% Ointment, 0.1% Ointment,

0.5% Ointment, 0.147mg/gm

Aerosol Solution)

1

Triderm (Cream) 1

Urea (40% Cream, 45% Lotion) 1

Urea Nail Gel (Gel) 1

Urea Topical (Suspension) 1

Urea-C40 (Lotion) 1

Uvadex (Injection) 3

Valchlor (Gel) 4 PA

Vectical (Ointment) 2

Veltin (Gel) 3

Veregen (Ointment) 3

Zenatane (Capsule) 1 PA

Insulin Syringes, Needles (BD

MEDICAL)

2

Vanishpoint Insulin

Syringe/1ml/29g X 5/16"

3

Magnesium Sulfate/Lactated

Ringers (100mg/500ml-

20gm/500ml-150mg/500ml-

3gm/500ml-1.55gm/500ml Solution)

1

Magnesium Sulfate/Sodium

Chloride (4gm/100ml-0.9%

Solution)

1

35

Drug Name Drug

Tier

Requirements

& Limits

Adagen (Injection) 4

Aldurazyme (Injection) 4 PA

Buphenyl (500mg Tablet) 4

Cerdelga (Capsule) 4 PA

Cerezyme (Injection) 4 PA

Creon (Capsule Delayed-Release) 2

Cystadane (Powder) 4

Cystagon (Capsule) 4

Elaprase (Injection) 4 PA

Elelyso (Injection) 4 PA

Fabrazyme (Injection) 4 PA

Kanuma (Injection) 4 PA

Kuvan (100mg Packet, 500mg

Packet, 100mg Tablet Soluble)

4 PA

Lumizyme (Injection) 4 PA

Naglazyme (Injection) 4 PA

Orfadin (10mg Capsule, 20mg


Capsule)

4

RAVICTI (Liquid) 4 PA

Sodium Phenylbutyrate (Powder) 4

Strensiq (Injection) 4 PA

Sucraid (Oral Solution) 4

Vimizim (Injection) 4 PA

VPRIV (Injection) 4 PA

Xiaflex (Injection) 4 PA

Zavesca (Capsule) 4 PA

Zenpep (Capsule Delayed-

Release)

2

Atropen (0.5mg/0.7ml Injection) 3

Atropine Sulfate (0.1mg/ml

Injection, 0.4mg/ml Injection,

1mg/ml Injection, 1mg/2.5ml

Solution Prefilled Syringe)

1

Chlordiazepoxide HCl/Clidinium

Bromide (Capsule) 1

Cuvposa (Oral Solution) 3

Dicyclomine HCl (10mg Capsule,

10mg/5ml Oral Solution, 10mg/ml

Injection, 20mg Tablet)

1

Glycopyrrolate (0.4mg/2ml


4mg/20ml Injection, 1mg Tablet,

2mg Tablet)

1

Hyoscyamine Sulfate (0.125mg

Tablet Dispersible) (MANUF

MARLEX, TRIGEN)

1

Methscopolamine Bromide (Tablet) 1

Propantheline Bromide (15mg

Tablet) 1

Cromolyn Sodium (100mg/5ml

Concentrate) 1

Drug Name Drug

Tier

Requirements

& Limits

Diphenoxylate/Atropine (2.5mg-

0.025mg Tablet, 2.5mg-

0.025mg/5ml Liquid)

1

GaviLyte-H (Kit) 1

Lansoprazole/Amoxicillin/Clarithro

mycin (Therapy Pack) 1

Lofene (Tablet) 1

Loperamide HCl (2mg Capsule)

(RX) 1

Mytesi (Tablet Delayed-Release) 3 QL

Omeclamox-Pak (Therapy Pack) 2

OsmoPrep (Tablet) 3

Peg-Prep (Kit) 1

Pylera (Capsule) 2

Relistor (12mg/0.6ml Injection,

8mg/0.4ml Injection)

2 PA,QL

Ursodiol (250mg Tablet, 500mg

Tablet, 300mg Capsule) 1

Cimetidine (200mg Tablet RX,


800mg Tablet)

1

Cimetidine HCl (Oral Solution) 1

Famotidine (200mg/20ml Injection,



Tablet, 40mg/5ml Suspension)

1

Nizatidine (150mg Capsule, 300mg

Capsule, 15mg/ml Oral Solution) 1

Ranitidine HCl (150mg Capsule,

300mg Capsule, 150mg Tablet RX,

300mg Tablet, 150mg/6ml Injection,

50mg/2ml Injection, 15mg/ml

Syrup, 75mg/5ml Syrup)

1

Alosetron HCl (Tablet) 1 PA

Amitiza (Capsule) 2 QL,ST

Gattex (Injection) 4 PA

Linzess (145mcg Capsule, 290mcg

Capsule)

2 QL,ST

Alophen (Tablet Delayed-Release) 1 PV

Bisacodyl EC (Tablet Delayed-

Release) 1 PV

Carters Little Pills (Tablet Delayed-

Release) 1 PV

Citroma (Oral Solution) 1 PV

ClearLax (Powder) 1 PV

Constulose (Oral Solution) 1

Correct (Tablet Delayed-Release) 1 PV

Correctol (Tablet Delayed-Release) 1 PV

CVS Purelax (Powder) 1 PV

Ducodyl (Tablet Delayed-Release) 1 PV

Dulcolax Balance (Powder) 1 PV

36

Drug Name Drug

Tier

Requirements

& Limits

Enulose (Oral Solution) 1

EQ ClearLax (Powder) 1 PV

EQL ClearLax (Powder) 1 PV

EQL Gentle Laxative (Tablet


EQL Laxative (Tablet Delayed-

Release) 1 PV

Ex-Lax Ultra (Tablet Delayed-

Release) 1 PV

Feenamint (Tablet Delayed-Release) 1 PV

Fleet Laxative (Tablet Delayed-

Release) 1 PV

GaviLAX (Powder) 1 PV

GaviLyte-C (Oral Solution) 1 PV,QL

GaviLyte-G (Oral Solution) 1 PV,QL

GaviLyte-N/Flavor Pack (Oral

Solution) 1 PV,QL

Generlac (Oral Solution) 1

Gentle Laxative (Tablet Delayed-

Release) 1 PV

Gentlelax (Powder) 1 PV

Glycolax (Powder) 1 PV

GNP Bisa-Lax (Tablet Delayed-

Release) 1 PV

GNP ClearLax (Powder) 1 PV

GNP Womens Laxative (Tablet


Goodsense Magnesium Citrate

(Solution) 1 PV

HM ClearLax (Powder) 1 PV

HM Laxative (Tablet Delayed-

Release) 1 PV

KLS LaxaClear (Powder) 1 PV

KP Bisacodyl (Tablet Delayed-

Release) 1 PV

Lactulose (Oral Solution) 1

Laxative (Tablet Delayed-Release) 1 PV

Laxative Feminine (Tablet Delayed-

Release) 1 PV

Magnesium Citrate (Oral Solution) 1 PV

Mineral Oil Heavy (RX) 1

MoviPrep (Oral Solution) 3

PEG 3350 (Powder) 1 PV

PEG 3350 (Powder) 1 PV

PEG 3350/Electrolytes (Oral

Solution) 1 PV,QL

PEG-3350/Electrolytes (Oral

Solution) 1 PV,QL

PEG-3350/NaCl/Na

Bicarbonate/KCl (Oral Solution) 1 PV,QL

Pegylax (Powder) 1 PV

Polyethylene Glycol 3350 (Packet,

Powder) RX 1

Prepopik (Packet) 3

QC Gentle Laxative (Tablet


QC Natura-Lax (Powder) 1 PV

Drug Name Drug

Tier

Requirements

& Limits

RA Laxative (Powder, 5mg Tablet


SB Bisacodyl Laxative EC (Tablet


SM ClearLax (Powder) 1 PV

SM Gentle Laxative (Tablet


Smooth Lax (Powder) 1 PV

Stimulant Laxative (Tablet Delayed-

Release) 1 PV

Suprep Bowel Prep (Oral

Solution)

3

SW ClearLax (Powder) 1 PV

TGT Powderlax (Powder) 1 PV

TriLyte (Oral Solution) 1 PV,QL

Veracolate (Tablet Delayed-

Release) 1 PV

Womans Laxative (Tablet Delayed-

Release) 1 PV

Womens Laxative (Tablet Delayed-

Release) 1 PV

Carafate (1gm/10ml Suspension) 2

Misoprostol (Tablet) 1

Sucralfate (1gm Tablet) 1

Aciphex Sprinkle (Capsule

Sprinkle)

3 QL

Dexilant (Capsule Delayed-

Release)

2 QL

Esomeprazole Magnesium (Capsule

Delayed-Release) 1 QL

Esomeprazole Sodium (40mg

Injection) 1

Esomeprazole Strontium (Capsule

Delayed-Release)

3 QL

Lansoprazole (Capsule Delayed-

Release) RX 1 QL

Omeprazole (Capsule Delayed-

Release) 1 QL

Omeprazole/Sodium Bicarbonate

(20mg-1100mg Capsule RX, 40mg-

1100mg Capsule, 20mg-1680mg

Packet, 40mg-1680mg Packet)

1 QL

Pantoprazole Sodium (20mg Tablet

Delayed-Release, 40mg Tablet

Delayed-Release, 40mg Injection)

1 QL

Rabeprazole Sodium (Tablet


Linzess (72mcg Capsule) 2 QL,ST

Relistor (150mg Tablet) 2 PA

37

Drug Name Drug

Tier

Requirements

& Limits

Darifenacin HBr ER (Tablet


Flavoxate HCl (Tablet) 1

Gelnique (Gel) 2

Myrbetriq (Tablet Extended-

Release 24 Hour)

2 ST

Oxybutynin Chloride (5mg Tablet,

5mg/5ml Syrup) 1

Oxybutynin Chloride ER (Tablet


Tolterodine Tartrate (Tablet) 1

Tolterodine Tartrate ER (Capsule


Toviaz (Tablet Extended-Release

24 Hour)

3

Trospium Chloride (Tablet) 1

Trospium Chloride ER (Capsule


Vesicare (Tablet) 2

Alfuzosin HCl ER (Tablet


Cardura XL (4mg Tablet


3

Cialis (2.5mg Tablet, 5mg Tablet) 2 PA,QL

Dutasteride (Capsule) 1

Dutasteride/Tamsulosin HCl

(Capsule) 1

Finasteride (5mg Tablet) 1

Rapaflo (Capsule) 2

Tamsulosin HCl (Capsule) 1

Acetic Acid 0.25% (Irrigation

Solution) 1

Aminoacetic Acid (Irrigation

Solution) 1

Bethanechol Chloride (Tablet) 1

Cuprimine (Capsule) 3 PA

Depen Titratabs (Tablet) 3

Elmiron (Capsule) 2

Encare (Suppository) 3 PV

Glycine (1.5% Irrigation Solution) 1

Options Gynol II Vaginal

Contraceptive (Gel)

3 PV

Phenazo (Tablet) 1

Shur-Seal (Gel) 3 PV

Today Sponge 3 PV

VCF Vaginal Contraceptive Film

(Film)

3 PV

VCF Vaginal Contraceptive Foam

(Foam)

3 PV

VCF Vaginal Contraceptive Gel

(Gel) 1 PV

Drug Name Drug

Tier

Requirements

& Limits

Calcium Acetate (667mg Capsule,

667mg Tablet) 1

Fosrenol (1000mg Packet, 750mg

Packet, 1000mg Tablet Chewable,

500mg Tablet Chewable, 750mg

Tablet Chewable)

3

Phoslyra (Oral Solution) 3

Renagel (Tablet) 3

Renvela (0.8gm Packet, 2.4gm

Packet)

3

Renvela (800mg Tablet) 2

Velphoro (Tablet Chewable) 3

Betamethasone Sodium

Phosphate/Betamethasone Acetate

(Injection)

1

Colocort (Enema) 1

Cortisone Acetate (25mg Tablet) 1

Deltasone (Tablet) 1

Depo-Medrol (20mg/ml Injection) 3

Dexamethasone (0.5mg Tablet,

0.75mg Tablet, 1.5mg Tablet, 1mg


6mg Tablet, 0.5mg/5ml Elixir,

0.5mg/5ml Oral Solution)

1

Dexamethasone Intensol (1mg/ml

Concentrate)

3

Dexamethasone Sodium Phosphate

(120mg/30ml Injection, 20mg/5ml

Solution)

1

DexPak 10 Day (Tablet Therapy

Pack)

3


Pack)

3


Pack)

3

Fludrocortisone Acetate (0.1mg

Tablet) 1

Hydrocort Enema 100mg (Enema) 1

Hydrocortisone (10mg Tablet, 20mg


Methylprednisolone (16mg Tablet,


Tablet)

1

Methylprednisolone Acetate

(40mg/ml Injection, 80mg/ml

Injection)

1

Mometasone Furoate (0.1% Cream,

0.1% Ointment) 1

Prednisolone (15mg/5ml Oral

Solution, 15mg/5ml Syrup) 1

Prednisolone Sodium Phosphate

(10mg/5ml Solution, 20mg/5ml

Solution, 25mg/5ml Oral Solution,


1


ODT (Tablet Dispersible) 1

38

Drug Name Drug

Tier

Requirements

& Limits

Prednisone (10mg Tablet, 1mg

Tablet, 2.5mg Tablet, 20mg Tablet,


1

Prednisone Intensol (5mg/ml

Concentrate)

2

Triamcinolone (Injection) 1

Chorionic Gonadotropin (Injection) 4 PA

Desmopressin Acetate (0.01% Nasal

Solution, 0.1mg/ml Nasal Solution,


4mcg/ml Injection)

1

Egrifta (Injection) 4 PA,QL

H.P. Acthar (Injection) 4 PA

Increlex (Injection) 4 PA

Norditropin FlexPro (Injection) 4 PA

Novarel (Injection) 4 PA

Nutropin AQ (Injection) 4 PA

Oxytocin (Injection) 1

Pregnyl w/Diluent Benzyl

Alcohol/NaCl (Injection) 4 PA

Serostim (Injection) 4 PA

Stimate (Nasal Solution) 4

Zorbtive (Injection) 4 PA

Alprostadil (Injection) 1

Anadrol-50 (Tablet) 3 PA

Oxandrolone (Tablet) 1 PA,QL

AndroGel (40.5mg/2.5gm Gel) 2 PA

Androxy (Tablet) 2 PA

Danazol (100mg Capsule, 200mg


Methitest (Tablet) 3 PA

Methyltestosterone (10mg Capsule) 1 PA,QL

Striant 3 PA

Testosterone Cypionate (Injection) 1 PA

Testosterone Enanthate (Injection) 1 PA

Altavera (Tablet) 1 PV

Alyacen 1/35 (Tablet) 1 PV

Alyacen 7/7/7 (Tablet) 1 PV

Amabelz (Tablet) 1

Drug Name Drug

Tier

Requirements

& Limits

Amethia (Tablet) 1 PV,QL

Amethia Lo (Tablet) 1 PV,QL

Amethyst (Tablet) 1 PV

Apri (Tablet) 1 PV

Aranelle (Tablet) 1 PV

Ashlyna (Tablet) 1 PV,QL

Aubra (Tablet) 1 PV

Aviane (Tablet) 1 PV

Azurette (Tablet) 1 PV

Balziva (Tablet) 1 PV

Bekyree (Tablet) 1 PV

Blisovi 24 Fe (Tablet) 1 PV

Blisovi Fe 1.5/30 (Tablet) 1 PV

Blisovi Fe 1/20 (Tablet) 1 PV

Briellyn (Tablet) 1 PV

Camrese (Tablet) 1 PV,QL

Camrese Lo (Tablet) 1 PV,QL

Caziant (Tablet) 1 PV

Chateal (Tablet) 1 PV

Combipatch (Patch Twice

Weekly)

3

Cryselle-28 (Tablet) 1 PV

Cyclafem (Tablet) 1 PV

Cyred (Tablet) 1 PV

Dasetta 1/35 (Tablet) 1 PV

Dasetta 7/7/7 (Tablet) 1 PV

Daysee (Tablet) 1 PV,QL

Delyla (Tablet) 1 PV

Desogestrel/Ethinyl Estradiol

(Tablet) 1 PV

Drospirenone/Ethinyl Estradiol

(Tablet) 1 PV

Drospirenone/Ethinyl

Estradiol/Levomefolate Calcium

(Tablet)

1 PV

Elinest (Tablet) 1 PV

Emoquette (Tablet) 1 PV

Enpresse-28 (Tablet) 1 PV

Enskyce (Tablet) 1 PV

Estarylla (Tablet) 1 PV

Estrace (0.1mg/gm Cream) 3

Estradiol (0.025mg/24hr Patch

Weekly, 0.05mg/24hr Patch



Weekly, 37.5mcg/24hr Patch

Weekly, 0.1mg/24hr Patch Weekly,

0.5mg Tablet, 1mg Tablet, 2mg

Tablet)

1

Estradiol Valerate (Injection) 1

Estradiol/Norethindrone Acetate

(Tablet) 1

Estropipate (Tablet) 1

Ethynodiol Diacetate/Ethinyl

Estradiol (Tablet) 1 PV

Evamist (Transdermal Solution) 3

Falmina (Tablet) 1 PV

39

Drug Name Drug

Tier

Requirements

& Limits

Femynor (Tablet) 1 PV

Fyavolv (Tablet) 1

Gianvi (Tablet) 1 PV

Gildagia (Tablet) 1 PV

Introvale (Tablet) 1 PV,QL

Jevantique Lo (Tablet) 1

Jinteli (Tablet) 1

Jolessa (Tablet) 1 PV,QL

Juleber (Tablet) 1 PV

Junel 1.5/30 (Tablet) 1 PV

Junel 1/20 (Tablet) 1 PV

Junel Fe 1.5/30 (Tablet) 1 PV

Junel Fe 1/20 (Tablet) 1 PV

Junel Fe 24 (Tablet) 1 PV

Kaitlib Fe (Tablet Chewable) 1 PV

Kariva (Tablet) 1 PV

Kelnor 1/35 (Tablet) 1 PV

Kimidess (Tablet) 1 PV

Kurvelo (Tablet) 1 PV

LARIN 1.5/30 (Tablet) 1 PV

LARIN 1/20 (Tablet) 1 PV

LARIN 24 Fe (Tablet) 1 PV

LARIN Fe 1.5/30 (Tablet) 1 PV

LARIN Fe 1/20 (Tablet) 1 PV

Larissia (Tablet) 1 PV

Layolis Fe (Tablet Chewable) 1 PV

Leena (Tablet) 1 PV

Lessina (Tablet) 1 PV

Levonest (Tablet) 1 PV

Levonorgestrel and Ethinyl

Estradiol (Tablet) 1 PV

Levonorgestrel/Ethinyl Estradiol (0-

Tablet, 20mcg-0.1mg Tablet) 1 PV

Levonorgestrel/Ethinyl Estradiol

(0.03mg-0.15mg Tablet) 1 PV,QL

Levora 0.15/30-28 (Tablet) 1 PV

Lo Loestrin Fe (Tablet) 3

Lomedia 24 Fe (Tablet) 1 PV

Loryna (Tablet) 1 PV

Low-Ogestrel (Tablet) 1 PV

Lutera (Tablet) 1 PV

Marlissa (Tablet) 1 PV

Menest (Tablet) 2

Microgestin 1.5/30 (Tablet) 1 PV

Microgestin 1/20 (Tablet) 1 PV

Microgestin 24 Fe (Tablet) 1 PV

Microgestin Fe (Tablet) 1 PV

Microgestin Fe 1.5/30 (Tablet) 1 PV

Mimvey (Tablet) 1

Mimvey Lo (Tablet) 1

Minastrin 24 Fe (Tablet

Chewable)

3

Mono-Linyah (Tablet) 1 PV

MonoNessa (Tablet) 1 PV

Myzilra (Tablet) 1 PV

Drug Name Drug

Tier

Requirements

& Limits

Natazia (Tablet) 2 PV

Necon 0.5/35-28 (Tablet) 1 PV

Necon 1/50-28 (Tablet) 1 PV

Necon 7/7/7 (Tablet) 1 PV

Nikki (Tablet) 1 PV

Norethindrone Acetate/Ethinyl

Estradiol (Tablet) 1

Norethindrone Acetate/Ethinyl

Estradiol/Ferrous Fumarate (Tablet) 1 PV

Norethindrone/Ethinyl

Estradiol/Ferrous Fumarate (Tablet

Chewable)

1 PV

Norgestimate/Ethinyl Estradiol (0-

Tablet, 35mcg-0.25mg Tablet) 1 PV

Nortrel 0.5/35 (28) (Tablet) 1 PV

Nortrel 1/35 (Tablet) 1 PV

Nortrel 7/7/7 (Tablet) 1 PV

NuvaRing (Ring) 2 PV

Ocella (Tablet) 1 PV

Ogestrel (Tablet) 1 PV

Orsythia (Tablet) 1 PV

Philith (Tablet) 1 PV

Pimtrea (Tablet) 1 PV

Pirmella 1/35 (Tablet) 1 PV

Pirmella 7/7/7 (Tablet) 1 PV

Portia-28 (Tablet) 1 PV

Premarin (0.3mg Tablet, 0.45mg

Tablet, 0.625mg Tablet, 0.9mg

Tablet, 1.25mg Tablet)

2

Premphase (Tablet) 2

Prempro (Tablet) 2

Previfem (Tablet) 1 PV

Quasense (Tablet) 1 PV,QL

Rajani (Tablet) 1 PV

Reclipsen (Tablet) 1 PV

Setlakin (Tablet) 1 PV,QL

Sprintec 28 (Tablet) 1 PV

Sronyx (Tablet) 1 PV

Syeda (Tablet) 1 PV

Tarina Fe 1/20 (Tablet) 1 PV

Tilia Fe (Tablet) 1 PV

Tri-Estarylla (Tablet) 1 PV

Tri-Legest Fe (Tablet) 1 PV

Tri-Linyah (Tablet) 1 PV

Tri-Lo-Estarylla (Tablet) 1 PV

Tri-Lo-Marzia (Tablet) 1 PV

Tri-Lo-Sprintec (Tablet) 1 PV

Tri-Previfem (Tablet) 1 PV

Tri-Sprintec (Tablet) 1 PV

Trinessa (Tablet) 1 PV

Trinessa Lo (Tablet) 1 PV

Trivora-28 (Tablet) 1 PV

Velivet (Tablet) 1 PV

Vestura (Tablet) 1 PV

Vienva (Tablet) 1 PV

Viorele (Tablet) 1 PV

40

Drug Name Drug

Tier

Requirements

& Limits

Vyfemla (Tablet) 1 PV

Wera (Tablet) 1 PV

WYMZYA Fe (Tablet Chewable) 1 PV

Xulane (Patch Weekly) 1 PV

Yuvafem (Tablet) 1

Zarah (Tablet) 1 PV

Zenchent (Tablet) 1 PV

Zenchent Fe (Tablet Chewable) 1 PV

Zovia 1/35E (Tablet) 1 PV

Zovia 1/50E (Tablet) 1 PV

Kyleena (IUD) 4 PV

Liletta (IUD) 4 PV

Ella (Tablet) 3 PV

Aftera (Tablet) 1 PV

Camila (Tablet) 1 PV

Crinone (Gel) 4 QL

Deblitane (Tablet) 1 PV

Depo-Provera (Injection) 3

Depo-SubQ Provera104

(Injection)

3 QL

Econtra EZ (Tablet) 1 PV

Errin (Tablet) 1 PV

Fallback Solo (Tablet) 1 PV

Heather (Tablet) 1 PV

Jencycla (Tablet) 1 PV

Jolivette (Tablet) 1 PV

Levonorgestrel (Tablet) 1 PV

Lyza (Tablet) 1 PV

Makena (Injection) 4 PA

Medroxyprogesterone Acetate

(10mg Tablet, 2.5mg Tablet, 5mg

Tablet)

1

Medroxyprogesterone Acetate

(150mg/ml Injection) 1 PV,QL

Megestrol Acetate (20mg Tablet,

40mg Tablet, 40mg/ml Suspension) CM

Megestrol Acetate (625mg/5ml

Suspension) 1

Mirena (IUD) 3 PV

My Way (Tablet) 1 PV

Nexplanon (Injection) 4 PV

Next Choice One Dose (Tablet) 1 PV

Nora-BE (Tablet) 1 PV

Norethindrone (Tablet) 1 PV

Drug Name Drug

Tier

Requirements

& Limits

Norethindrone Acetate (5mg Tablet) 1

Norlyroc (Tablet) 1 PV

Opcicon One-Step (Tablet) 1 PV

Option 2 (Tablet) 1 PV

Progesterone (100mg Capsule,

200mg Capsule) 1

Progesterone (50mg/ml Injection) 4

React (Tablet) 1 PV

Sharobel (Tablet) 1 PV

Skyla (IUD) 3 PV

Take Action (Tablet) 1 PV

Osphena (Tablet) 3

Raloxifene HCl (Tablet) 1 PV*

Armour Thyroid (120mg Tablet,


300mg Tablet)

3

Levo-T (Tablet) 1

Levothyroxine Sodium (100mcg

Tablet, 112mcg Tablet, 125mcg






1

Levoxyl (Tablet) 1

Liothyronine Sodium (10mcg/ml

Injection, 25mcg Tablet, 50mcg


1

NP Thyroid 15 (Tablet) 1



Thyrolar (Tablet) 3

Unithroid (Tablet) 1

Unithroid Direct (Tablet) 1

WP Thyroid (Tablet) 3

Lysodren (Tablet) CM

Sensipar (Tablet) 3 PA

Bromocriptine Mesylate (2.5mg

Tablet, 5mg Capsule) 1

Cabergoline (Tablet) 1

Eligard (Injection) 4 PA,QL

Firmagon (Injection) 4 PA,QL

Leuprolide Acetate (Injection) 4 PA

Lupaneta Pack (Kit) 4 PA,QL

Lupron Depot (Injection) 4 PA

41

Drug Name Drug

Tier

Requirements

& Limits

Lupron Depot-PED (Injection) 4 PA

Octreotide Acetate (Injection) 4 PA

Sandostatin LAR Depot

(Injection)

4 PA

Signifor (Injection) 4 PA,QL

Somatuline Depot (Injection) 4 PA

Somavert (Injection) 4 PA

Supprelin LA (Injection) 4 PA,QL

Synarel (Nasal Solution) 2

Trelstar (Injection) 4 PA,QL

Trelstar Mixject (Injection) 4 PA,QL

Vantas (Injection) 4 PA,QL

Zoladex (Injection) 4 QL

Methimazole (10mg Tablet, 5mg

Tablet) 1

Propylthiouracil (Tablet) 1


(10mg/ml Injection) 1

Prednisone (10mg Tablet Therapy

Pack, 5mg Tablet Therapy Pack) 1

Actoplus Met XR (Tablet


3 ST

Azasan (Tablet) 3

Azathioprine (100mg Injection,

50mg Tablet) 1

Benlysta (Injection) 4 PA

Cimzia (Injection) 4 PA

Cimzia Starter Kit (Injection) 4 PA

Cyclosporine (100mg Capsule,

25mg Capsule, 50mg/ml Injection) 1

Cyclosporine Modified (100mg


Capsule, 100mg/ml Oral Solution)

1

Enbrel (25mg Injection) 4 PA

Gengraf (100mg Capsule, 25mg

Capsule, 50mg Capsule, 100mg/ml

Oral Solution)

1

Humira (20mg/0.4ml Injection,

40mg/0.8ml Injection)

4 PA

Humira Pediatric Crohns Disease

Starter Pack (Injection)

4 PA

Humira Pen (Injection) 4 PA

Humira Pen Crohns Disease

Starter Pack (Injection)

4 PA

Humira Pen-Psoriasis Starter

(Injection)

4 PA

Methotrexate (2.5mg Tablet) CM

Drug Name Drug

Tier

Requirements

& Limits

Methotrexate Sodium (Injection) 1

Mycophenolate Mofetil (200mg/ml

Suspension, 250mg Capsule, 500mg

Injection, 500mg Tablet)

1

Mycophenolic Acid DR (Tablet

Delayed-Release) 1

Nulojix (Injection) 3 PA

Orencia (125mg/ml Injection,

250mg Injection)

4 PA

Orencia Clickject (Injection) 4 PA

Prograf (5mg/ml Injection) 3

Rapamune (1mg/ml Oral

Solution)

3

Remicade (Injection) 4 PA

Sandimmune (100mg/ml Oral

Solution)

2

Simponi (Injection) 4 PA

Simponi Aria (Injection) 4 PA

Sirolimus (Tablet) 1

Tacrolimus (0.5mg Capsule, 1mg


Torisel (Injection) 4

Trexall (Tablet) CM

Zortress (Tablet) 3 PA

Atgam (Injection) 4

BIVIGAM (Injection) 4 PA

Carimune Nanofiltered (Injection) 4 PA

Cuvitru (Injection) 4 PA

Cytogam (Injection) 4 PA

Flebogamma DIF (Injection) 4 PA

Gamastan S/D (Injection) 4 PA

Gammagard Liquid (Injection) 4 PA

Gammagard S/D IGA Less Than

1 mcg/ml (Injection)

4 PA

Gammaked (Injection) 4 PA

Gammaplex (Injection) 4 PA

Gamunex-C (Injection) 4 PA

Hepagam B (Injection) 4

Hizentra (Injection) 4 PA

Hyperhep B S/D (Injection) 4

Hyperrab S/D (Injection) 2

Hyperrho S/D (Injection) 4

Hyperrho S/D Mini-Dose

(Injection)

4

Micrhogam Ultra-Filtered Plus

(Injection)

4

Nabi-Hb (Injection) 4

Octagam (Injection) 4 PA

Privigen (Injection) 4 PA

Rhogam Ultra-Filtered Plus

(Injection)

4

Rhophylac (Injection) 4

Thymoglobulin (Injection) 3

WinRho SDF (Injection) 4

42

Drug Name Drug

Tier

Requirements

& Limits

Actimmune (Injection) 4

Arcalyst (Injection) 4 PA

Ilaris (Injection) 4 PA,QL

Leflunomide (Tablet) 1

Lemtrada (Injection) 4 PA

Otezla (30mg Tablet) 4 PA

Ridaura (Capsule) 3

Simulect (20mg Injection) 3

Sodium Hyaluronate (Gel) 1

Stelara (130mg/26ml Injection) 4 PA

Synagis (Injection) 4 PA

Xeljanz (Tablet) 4 PA

ActHIB (Injection) 2 PV

Adacel (Injection) 2 PV

Afluria 2016-2017 (Injection) 2 PV

BCG Vaccine (Injection) 3

Bexsero (Injection) 2 PV

Biothrax (Injection) 3

Boostrix (Injection) 2 PV

Daptacel (Injection) 2 PV

Diphtheria/Tetanus Toxoids

Adsorbed Pediatric (Injection)

2 PV

Engerix-B (Injection) 2 PV

Fluvirin 2016-2017 (Injection) 2 PV

Gardasil (Injection) 2 PV

Gardasil 9 (Injection) 2 PV

Havrix (Injection) 2 PV

Hiberix (Injection) 2 PV

Hyqvia (Injection) 4 PA

Imovax Rabies (H.D.C.V.)

(Injection)

3

Infanrix (Injection) 2 PV

IPOL Inactivated IPV (Injection) 2 PV

Ixiaro (Injection) 3

Kinrix (Injection) 2 PV

M-M-R II (Injection) 2 PV

Menactra (Injection) 2 PV

MENHIBRIX (Injection) 2 PV

Menomune-A/C/Y/W-135

(Injection)

2 PV

Menveo (Injection) 2 PV

Pediarix (Injection) 2 PV

Pedvax HIB (Injection) 2 PV

Pentacel (Injection) 2 PV

Pneumovax 23 (Injection) 2 PV

Prevnar 13 (Injection) 2 PV

ProQuad (Injection) 2 PV

Quadracel (Injection) 2 PV

Rabavert (Injection) 3

Recombivax HB (Injection) 2 PV

Rotarix (Suspension) 2 PV

RotaTeq (Oral Solution) 2 PV

Tenivac (Injection) 2 PV

Drug Name Drug

Tier

Requirements

& Limits

Tetanus/Diphtheria Toxoids-

Adsorbed (Injection)

2 PV

Theracys (Injection) 4

Trumenba (Injection) 2 PV

Twinrix (Injection) 2 PV

Typhim VI (Injection) 3

VAQTA (Injection) 2 PV

Varivax (Injection) 2 PV

Vivotif (Capsule Delayed-Release) 3

YF-Vax (Injection) 3

Zostavax (Injection) 2 PV

Apriso (Capsule Extended-Release

24 Hour)

2

Balsalazide Disodium (Capsule) 1

Canasa (Suppository) 2

Dipentum (Capsule) 3

Lialda (Tablet Delayed-Release) 2

Mesalamine (4gm Enema, 4gm Kit) 1

Mesalamine DR (Tablet Delayed-

Release) 1

Pentasa (Capsule Extended-

Release)

3

Budesonide (3mg Capsule Delayed-

Release) 1

Cortifoam (Foam) 3

Sulfasalazine (500mg Tablet, 500mg

Tablet Delayed-Release) 1

Bupivacaine HCl/Sodium Chloride

(Solution Prefilled Syringe) 1

Bupivacaine/Epinephrine (0.5%-

1:200000 Injection) 1

Lidocaine HCl (Prefilled Syringe) 1

Sensorcaine-Mpf/Epinephrine

(Injection) 1

Alendronate Sodium (10mg Tablet,


Alendronate Sodium (35mg Tablet,

70mg Tablet) 1 QL

Alendronate Sodium (70mg/75ml

Oral Solution)

2

Calcitonin-Salmon (Nasal Solution) 1 QL

Calcitriol (0.25mcg Capsule, 0.5mcg

Capsule, 1mcg/ml Injection,

1mcg/ml Oral Solution)

1

Doxercalciferol (0.5mcg Capsule,

1mcg Capsule, 2.5mcg Capsule,

4mcg/2ml Injection)

1

43

Drug Name Drug

Tier

Requirements

& Limits

Etidronate Disodium (Tablet) 1

Forteo (Injection) 4 PA

Fosamax Plus D (Tablet) 3 QL

Hectorol (2mcg/ml Injection) 3

Ibandronate Sodium (150mg Tablet,

3mg/3ml Injection) 1 QL

Miacalcin (200unit/ml Injection) 3

Pamidronate Disodium (30mg


90mg Injection, 90mg/10ml

Injection)

4

Pamidronate Disodium (6mg/ml

Injection)

4

Paricalcitol (1mcg Capsule, 2mcg

Capsule, 4mcg Capsule, 2mcg/ml

Injection, 5mcg/ml Injection)

1

Prolia (Injection) 4 PA,QL

Risedronate Sodium (150mg Tablet,

35mg Tablet) 1 QL

Risedronate Sodium (30mg Tablet,

5mg Tablet) 1

Risedronate Sodium DR (Tablet


Xgeva (Injection) 4 PA

Zoledronic Acid (4mg Injection,


4

Zoledronic Acid (4mg/5ml


Zometa (4mg/100ml Injection) 4

Levoleucovorin (175mg Solution) 4

Inflectra (Injection) 4 PA

1st Tier Unifine Pentips

/Mini/31gx5mm

3

1st Tier Unifine Pentips

29gx12mm

3

1st Tier Unifine Pentips 31gx6mm 3



1st Tier Unifine Pentips Plus

31gx8mm

3

AeroChamber Mini Aerosol

Chamber

2

AeroChamber MV 2

AeroChamber Plus Flow Vu 2

AeroChamber Plus Flow-Vu 2

AeroChamber Plus Flow-

Vu/Large Mask

2


Vu/Mask

2


Vu/Medium Mask

2

Drug Name Drug

Tier

Requirements

& Limits


Vu/Small Mask

2

AeroChamber Z-Stat

Plus/Medium Mask

2

AeroChamber/FlowSignal 2

Aerovent Plus Holding

Chamber/Collapsible

2

Argyle Sterile Saline 100ml

(Solution) 1

Argyle Sterile Water 100ml

(Solution) 1

Arial Chamber 2

Asilnasal Rms (Capsule) 1

Aurora Pen Needles 29gx12mm 3

Aurora Pen Needles 31g X 8mm 3

Aurora Unifine Pentips/32gx5/32" 3

Aurora Unifine

Pentips/Mini/31gx3/16"

3

Autopen 3

BD Autoshield 29g X 3/16" 2

BD Autoshield 29g X 5/16" 2

BD Autoshield Duo 30g X 3/16" 2

Bd insul Syr Mis Lo Dose 2

BD Pen 3

BD Pen Mini 3

Botox (Injection) 4 PA

BreatheRite 2

BreatheRite Collapsible Spacer

w/ Neonate Mask

2

BreatheRite Rigid Spacer w/Mask 2

BreatheRite w/Large Mask 2

BreatheRite w/Medium Mask 2

BreatheRite w/Small Mask 2

Carefine Pen Needle 32gx4mm 3

Carefine Pen Needles 31gx8mm 3



Careone Unifine Pentips

29gx12mm

3

Careone Unifine Pentips

31gx8mm

3

Careone Unifine Pentips Pen

Needles 32gx4mm

3

Caretouch Pen Needles 31 G X 6

Mm

3

Caretouch Pen Needles 31gx 5mm 3




Caya 3 PV

Chek-Stix Control 3

Chemstrip 10 MD 3

Chemstrip 2 GP Strips 3

Chemstrip 5 OB 3

Chemstrip 7 3

Chemstrip 9 Strips 3

44

Drug Name Drug

Tier

Requirements

& Limits

Chemstrip UGK 3

Chemstrip-10 with SG 3

Chemstrip-K 3

Clever Choice Anti-Static Valved

Holding Chamber/Adult Large

2


Holding Chamber/Medium

2


Holding Chamber/Small

2

Clever Choice Comfort EZ Insulin

Pen Needles 31gx8mm

3

Clever Choice Comfort EZ Pen

Needles 29gx12mm

3


Needles 31gx5mm

3


Needles 31gx6mm

3


Needles 32gx4mm

3


Needles 32gx5mm

3


Needles 32gx6mm

3


Needles 32gx8mm

3


Needles 33gx4mm

3


Needles 33gx5mm

3


Needles 33gx6mm

3


Needles 33gx8mm

3

Clickfine Pen Needle 32gx5/32" 3

Clickfine Pen Needles/31gx1/4" 3

Clickfine Pen Needles/31gx5/16" 3

Combistix 3

Compact Space Chamber/Anti-

Static

2


Static/Large Mask

2


Static/Medium Mask

2

Curity Sterile Saline (Solution) 1

CVS Ketone Care 3

Deferoxamine Mesylate (Injection) 4

Delflex-Sm/1.5% Dextrose

(Injection) 1

Delflex-Sm/2.5% Dextrose

(Injection) 1

Diascreen 10 3

Diascreen 1B 3

Diascreen 1G 3

Diascreen 1K 3

Diascreen 2GK 3

Diascreen 2GP 3

Diascreen 3 3

Drug Name Drug

Tier

Requirements

& Limits

Diascreen 4NL 3

Diascreen 4OBL 3

Diascreen 4PH 3

Diascreen 5 3

Diascreen 6 3

Diascreen 7 3

Diascreen 8 3

Diascreen 9 3

Diascreen Liquid Urine Controls 3

Diastix 3

Droplet Pen Needles 29gx10mm 3

Droplet Pen Needles 32gx5mm 3

E-Z Spacer 2

E-Z Spacer the Body Guards Pack 2

Easivent 2

Easivent/Mask-Large 2

Easivent/Mask-Medium 2

Easivent/Mask-Small 2

Easy Comfort Pen Needles

31gx1/4"

3


31gx3/16"

3


31gx5/16"

3


32gx5/32"

3

Easy Touch 32gx5mm 3

Easy Touch 32gx6mm 3

Easy Touch Insulin Syringe/U-

100/1ml/31g X 5/16"

3

Easy Touch Pen Needles 29gx1/2" 3


Easy Touch Pen Needles

31gx5/16"

3



32gx3/16"

3


32gx5/32"

3

Easy Touch Pen Needles/31g X

3/16"

3

Excel Comfort Point Insulin Pen

Needles 31g X 4mm

3

Exel Comfort Point Insulin Pen

Needles 29g X 12mm

3

Exel Comfort Point Insulin Pen

Needles 31g X 8mm

3

Exel Comfort Point Insulin

Syringe/0.3ml/29g X 1/2"

3

Exel Comfort Point Insulin


3

FC Female Condom 3 PV

FC2 Female Condom 3 PV

Femcap 3 PV

Ferriprox (500mg Tablet) 4 PA

Fifty50 Pen Needles 31g X3/16"

(5mm)

3

45

Drug Name Drug

Tier

Requirements

& Limits

Fifty50 Pen Needles 31g X5/16"

(8mm)

3

Fifty50 Pen Needles 31gx5mm 3

Fifty50 Pen Needles/31gx8mm 3



Flexichamber 2

Flexichamber Child Mask/Large 2

Flexichamber Child Mask/Small 2

Fomepizole (Injection) 1

GlucoCom Autolink

Telemonitoring System

3

H-E-B in Control Pen Needles

31gx6mm

3

H-E-B in Control Pen Needles

31gx8mm

3

H-E-B in Control Pen

Needles/Nano/32gx4mm

3

H-E-B in Control Unifine Pentips

Plus 31gx5mm

3

H-E-B Incontrol Pen Needles

29gx12mm

3

Hema-Combistix 3

Humapen Luxura HD 3

In Touch Diabetes Management

Software

2

InspiraChamber/Anti-Static

Valved/Mouthpiece

2

InspiraChamber/Large 2

InspiraChamber/Soother

Mask/InspiraMask/Medium

2

InspiraChamber/Soother

Mask/InspiraMask/Small

2

Inspirease Bags 2

Inspirease Drug Delivery System 2

Inspirease Mouthpiece 2

Inspirease Reservoir Bags 2

Insulin Syringe/0.5ml/27g X 1/2" 3

Insulin Syringe/U-100/1ml/28g X

1/2"

3

Insulin Syringes, Needles (BD

MEDICAL)

2

Insupen 33gx4mm 3

Insupen Pen Needles 32g X4mm 3

Insupen Sensitive 32gx6mm 3

Insupen Sensitive 32gx8mm 3

Insupen Ultrafin 29gx12mm 3




Intralipid (20gm/100ml Injection) 1

J-Tip Kit w/Vial Adapters (Kit) 3

Kalbitor (Injection) 4 PA

Keto-Diastix 3

Ketocare 3

Ketone Test Strips 3

Ketostix 3

Drug Name Drug

Tier

Requirements

& Limits

Labstix 3

Lactated Ringers Irrigation

(Solution) 1

Leader Unifine Pentips

Plus/Short/31gx5/16"

3

Levocarnitine (1gm/10ml Oral

Solution, 200mg/ml Injection,

330mg Tablet)

1

Lifescan Unistik 2 Deep

Penetration

2 QL

Lifescan Unistik II Lancets 2 QL

LiteAire 2

LiteTouch Pen Needles

29gx12.7mm

3

LiteTouch Pen Needles 31gx8mm

Short

3

Mask Vortex/Baby Whirl

Duckling

2

Mask Vortex/Child/Frog 2

Mask Vortex/Spinner the Duck 2

Mask Vortex/Toddler/Lady Bug 2

Meijer Pen Needles 31g X 6mm 3

Methergine (Tablet) 1

Methylergonovine Maleate

(Injection) 1

Microchamber 2

Microspacer 2

Monoject Insulin Syringe/1ml 3

Monoject Insulin Syringe/Detach

Needle/1ml/25g X 5/8"

3

Monoject Insulin

Syringe/Softpack/1ml/27g X 1/2"

3

Monoject Insulin

Syringe/Softpack/U-100/0.5ml/28g

X 1/2"

3

Monoject Ultra Comfort Insulin


3

Monovisc (Injection) 4 PA

Multistix 3

Multistix 10 Sg 3

Multistix 5 3

Multistix 7 3

Multistix 8 SG 3

Multistix 9 3

Multistix 9 SG 3

Myalept (Injection) 4 PA

Myobloc (Injection) 4 PA

N-Acetyl-L-Cysteine (Capsule) 1

Novofine 30gx8mm 3

Novofine 32gx6mm 3

Novofine Autocover 30gx8mm 3

Novofine Plus 32gx4mm 3

NovoPen Echo 3

Novotwist 32gx5mm 3

Nutrilipid (Injection) 1

Omniflex Diaphragm 3 PV

Onetouch Club Lancets Fine Point 2 QL

46

Drug Name Drug

Tier

Requirements

& Limits

Onetouch Combo Pack 2 QL

Onetouch Delica Lancets Extra

Fine 33g

2 QL

Onetouch Delica Lancets Fine 30g 2 QL

Onetouch Delica Lancing Device 2

Onetouch Ping Meter Remote 2

Onetouch Ultra 2 (Kit) 2

Onetouch Ultra Blue 2 QL

Onetouch Ultra Control (In Vitro

Solution)

2

Onetouch Ultra Mini (Kit) 2

Onetouch Ultralink System (Hex)

(Kit)

2

Onetouch Ultrasoft Lancets 2 QL

Onetouch Verio (Kit) 2

Onetouch Verio Control Solution

High (Solution)

2

Onetouch Verio Flex Bloodglucose

Monitoring System (Kit)

2

Onetouch Verio Iq Blood Glucose

Monitoring System (Kit)

2

Onetouch Verio Mid Control

Solution (Solution)

2

Onetouch Verio Sync

Bloodglucose Monitoring System

(Kit)

2

Onetouch Verio Test Strips 2 QL

OptiChamber Advantage 2

OptiChamber Advantage/Large

Mask

2

OptiChamber Advantage/Medium

Face Mask

2

OptiChamber Advantage/Small

Face Mask

2

OptiChamber Diamond 2

OptiChamber Diamond/Large

Face Mask

2

OptiChamber Diamond/Medium

Face Mask

2

OptiChamber Diamond/Small

Face Mask

2

OptiChamber Face Mask/Small 2

Optihaler MDI Drug Delivery

System

2

Orthovisc (Injection) 4 PA

Panda Mask Large 2

Panda Mask Medium 2

Panda Mask Small 2

Paragard Intrauterine Copper

Contraceptive T380a (IUD)

4 PV

PC Unifine Pentips 29g X 1/2" 3

PC Unifine Pentips 31g X 5mm

Mini

3

PC Unifine Pentips 31g X 6mm

Ultra Short

3

Pediatric Panda Mask 2

Pen Needles 30gx5/16" 3

Drug Name Drug

Tier

Requirements

& Limits

Pen Needles 30gx5mm 3

Pen Needles 30gx8mm 3

Penlet II Automatic Blood

Sampler (Kit)

2

Penlet II Replacement Caps-Deep 2

Pentips 29gx12mm 3

Pentips 31gx5mm 3

Pentips 31gx6mm 3

Pentips 31gx8mm 3

Pentips 32gx4mm 3

Physiolyte (Irrigation Solution) 1

Physiosol Irrigation (Solution) 1

Pocket Chamber 2

Pocket Spacer 2

Pro Comfort Pen Needles/ 32g X

5mm

3

Pro Comfort Pen Needles/ 32g X

6mm

3

PX Mini Pen Needles 31gx5mm 3

RA Pen Needles 31g X 5mm 3/16" 3

Relion Ketone 3

Relion Ketone Test Strips 3

Relion Pen Needles 29gx12mm 3




Ringers Irrigation (Solution) 1

RiteFlo 2

Safety Insulin Syringes

1ml/27gx1/2"

3

Safety Insulin Syringes

1ml/30gx1/2"

3

Safety-Glide Insulin


2

Sodium Chloride 0.9% (Irrigation

Solution) 1

Sodium Phenylacetate/Sodium

Benzoate (Injection) 1

Sterile Diluent for Epoprostenol

Sodium (Injection) 1

Sterile Water for Injection 1

Sterile Water Irrigation (Solution) 1

Super Daily D3 (2000UT/0.028ml

Liquid)

3 PV

Supreme II Confidence Paddles 3

Sure Comfort Pen Needles

29gx1/2" 12.7mm

3


30gx5/16" Short

3


31gx3/16" (5mm)

3


31gx5/16" (8mm)

3


32gx5/32"

3


32gx6mm

3

47

Drug Name Drug

Tier

Requirements

& Limits

Sure-Fine Pen Needles 29gx1/2"

12.7mm

3


5mm

3


8mm

3

Surestep Glucose Control (In

Vitro Solution)

2

Surestep Glucose Control Solution

(In Vitro Solution)

2

Surestep Pro High Glucosecontrol

(Liquid)

2

Surestep Pro Linearity Kit (Kit) 2

Surestep Pro Low Glucose

Control (Liquid)

2

Surestep Pro Normal Glucose

Control (Liquid)

2

Synvisc (Injection) 4 PA

Synvisc One (Injection) 4 PA

Techlite Pen Needles/32g X 6mm 3

Techlite Pen Needles/32g X 8mm 3

Tis-U-Sol (Irrigation Solution) 1

Todays Health Mini Pen Needles

31g X 1/4"

3

Todays Health Original Pen

Needles 29g X 1/2"

3

Todays Health Short Pen Needles

31g X 5/16"

3

Tracer II 3 Volt Battery 3

Ulticare Insulin Safety


3

Ulticare Insulin Safety


3

Ulticare Insulin Syringe/0.5ml/28g

X 1/2"

3

Ulticare Insulin Syringe/U-

100/0.3ml/29g X 1/2"

3


100/0.3ml/30g X 1/2"

3


100/0.3ml/31g X 5/16"

3


100/0.5ml/31g X 5/16"

3

Ulticare Pen Needles/29g X

12.7mm

3

Ulticare U-100 Insulin

Syringes/0.3ml/31g X1/4"

3


Syringes/0.5ml/31g X 1/4"

3


Syringes/1ml/31g X 1/4"

3

Ultiguard Insulin Syringe/U-

100/0.5ml/30g X 5/16"

3

Ultilet Insulin

Syringe/Short/1ml/31g X 5/16"

3

Ultilet Pen Needle 32gx4mm/Short 3

Ultilet Short Pen

Needles31gx3/16"

3

Drug Name Drug

Tier

Requirements

& Limits

Ultra-Thin II Pen Needles

29gx1/2"

3

Urin-Tek (Kit, 0 Misc) 3

Uristix 3

Uristix 4 3

Valved Holding Chamber 2

Vanishpoint Insulin


3

Vanishpoint Insulin


3

Voraxaze (Injection) 3

Vortex Valved Holding Chamber 2

WatchHaler 2

Wegmans Unifine Pentips Plus

32gx4mm

3

Wide-Seal Silicone Diaphragm Kit

60

3 PV


65

3 PV


70

3 PV


75

3 PV


80

3 PV


85

3 PV


90

3 PV


95

3 PV

Xeomin (100unit Injection, 50unit

Injection)

4 PA

Abilify Maintena (Injection) 3

Abraxane (Injection) 4

Acetazolamide Sodium (Injection) 1

Afluria PF 2016-2017 (Injection) 2 PV

Afluria Quadrivalent 2016-2017

(Injection)

2 PV

Alimta (Injection) 4

Amifostine (Injection) 4

Aripiprazole ODT (Tablet

Dispersible)

1 QL

Azacitidine (Injection) 4

Berinert (Injection) 4 PA

Bethkis (Nebulized Solution) 4

Bleomycin Sulfate (Injection) 4

Camptosar (300mg/15ml

Injection)

4

Cinryze (Injection) 4 PA

Daunorubicin HCl (Injection) 4


(4mg/ml Solution) 1

Dexrazoxane (Injection) 4


48

Drug Name Drug

Tier

Requirements

& Limits

Dextrose 2.5%/NaCl 0.45%

(Injection) 1


Dextrose 5%/NaCl 0.2% (Injection) 1

Dextrose 5%/NaCl 0.33%

(Injection) 1

Dextrose 5%/NaCl 0.45%

(Injection) 1

Dextrose 5%/NaCl 0.9% (Injection) 1


Diltiazem HCl (125mg/25ml



1

Diltiazem HCl/Dextrose (Injection) 1

Diltiazem HCl/Sodium Chloride

(Injection) 1

Docefrez (Injection) 4

Docetaxel (20mg/0.5ml Injection,

80mg/2ml Injection)

4

Duavee (Tablet) 2

Dysport (Injection) 4 PA

Enbrel (25mg/0.5ml Injection,

50mg/ml Injection)

4 PA

Enbrel SureClick (Injection) 4 PA

Epirubicin HCl (Injection) 4

Erwinaze (Injection) 4

Firazyr (Injection) 4 PA

Fluad 2016-2017 (Injection) 2 PV

Fluarix Quadrivalent 2016-2017

(Injection)

2 PV

Flublok 2016-2017 (Injection) 2 PV

Flucelvax Quadrivalent 2016-2017

(Injection)

2 PV

Fludarabine Phosphate (Injection) 4

Fluzone High-Dose Pf 2016-2017

(Injection)

2 PV

Geodon (Injection) 3

Halaven (Injection) 4 PA

Hematinic/Folic Acid (Tablet) 1

Hemocyte-F (Tablet) 1

Humira (10mg/0.2ml Injection) 4 PA

Ibuprofen Lysine (Injection) 1

Idarubicin HCl (Injection) 4

Indomethacin (1mg Solution) 1

Intron A w/Diluent (Injection) 4 PA

Ipratropium Bromide/Albuterol

Sulfate (Inhalation Solution) 1 QL

Irinotecan (40mg/2ml Injection) 4

Irinotecan (500mg/25ml Injection) 4

Irinotecan HCl (Injection) 4

Istodax (Injection) 4 PA

Istodax (Overfill) (Injection) 4 PA

Ixempra Kit (Injection) 4

Jevtana (Injection) 4 PA

Kadcyla (Injection) 4 PA

KCl 0.075%/D5W/NaCl 0.45%

(Injection) 1

Drug Name Drug

Tier

Requirements

& Limits

KCl 0.15%/D5W/NaCl 0.2%

(Injection) 1

KCl 0.15%/D5W/NaCl 0.45%

(Injection) 1

KCl 0.15%/D5W/NaCl 0.9%

(Injection) 1

KCl 0.3%/D5W/NaCl 0.45%

(Injection) 1

Ketorolac Tromethamine (15mg/ml


30mg/ml Injection)

1

Kineret (Injection) 4 PA

Kyprolis (60mg Injection) 4 PA

Leucovorin Calcium (100mg

Injection, 200mg Injection, 350mg

Injection, 50mg Injection)

1

Levoleucovorin (50mg Injection) 4

Lipodox 50 (Injection) 4

Mesnex (Tablet) CM

Methylprednisolone Sodium

Succinate (Injection) 1

Metoclopramide HCl (5mg/ml

Injection) 1

Mitomycin (20mg Injection, 40mg

Injection) 4

Mitomycin (5mg Injection) 4

Nucala (Injection) 4 PA,QL

Olanzapine (10mg Injection) 1

Oncaspar (Injection) 4

Onivyde (Injection) 4

Oxaliplatin (IV Solution

100mg/20ml) 4

Pegasys (Injection) 4 PA

Pegasys ProClick (Injection) 4 PA

Photofrin (Injection) 4

Plegridy (Injection) 4 PA,QL

Plegridy Starter Pack (Injection) 4 PA,QL

Potassium Chloride 0.15%

D5W/NaCl 0.33% (Injection) 1





Potassium Chloride

0.224%D5W/NaCl 0.45% Viaflex

(Injection)

1

Potassium Chloride/Dextrose (5%-

20meq/L Injection) 1

Proleukin (Injection) 4

Promethazine HCl (25mg/ml

Injection) 1

Pulmozyme (Inhalation Solution) 4 PA

Risperdal Consta (Injection) 3

Saphris (2.5mg Tablet Sublingual,

5mg Tablet Sublingual)

2

Soliris (Injection) 4 PA

Solu-Cortef (1000mg Injection) 3

49

Drug Name Drug

Tier

Requirements

& Limits

Synribo (Injection) 4 PA

Tice BCG (Injection) 4

Trigels-F Forte (Capsule) 1

Trisenox (Injection) 4

Valstar (Injection) 4

Velcade (Injection) 4 PA

Vincasar PFS (Injection) 4

Vincristine Sulfate (Injection) 4

Xeomin (200unit Injection) 4 PA

Zaltrap (Injection) 4 PA

Zyprexa Relprevv (Injection) 3

Bimatoprost (0.03% Ophthalmic

Solution) 1 QL

Latanoprost (Ophthalmic Solution) 1 QL

Lumigan (Ophthalmic Solution) 2 QL

Rescula (Ophthalmic Solution) 3 QL

Travatan Z (Ophthalmic Solution) 2 QL

Zioptan (Ophthalmic Solution) 3 QL

Altacaine (Ophthalmic Solution) 1

Altafrin (Ophthalmic Solution) 1

Atropine Sulfate (1% Ophthalmic

Solution) 1

Balanced Salt (Injection) 1

Balanced Salt Solution (Injection) 1

BSS (Injection) 1

Cyclopentolate HCl (Ophthalmic

Solution) 1

Cyclopentolate HCl (Ophthalmic

Solution) 1

Cystaran (Ophthalmic Solution) 4 PA,QL

Eylea (Injection) 4

Jetrea (Injection) 4

Lacrisert (Insert) 3

Lucentis (Injection) 4

Macugen (Injection) 4

Phenylephrine HCl (10%

Ophthalmic Solution, 2.5%

Ophthalmic Solution)

1

Procysbi (Capsule Delayed-

Release)

4 PA

Proparacaine HCl (Ophthalmic

Solution) 1

Restasis (Emulsion) 2 PA

Restasis Multidose (Emulsion) 2 PA

Tetcaine (Ophthalmic Solution) 1

Tetracaine HCl (Ophthalmic

Solution) 1

Visudyne (Injection) 4

Alocril (Ophthalmic Solution) 3

Drug Name Drug

Tier

Requirements

& Limits

Alomide (Ophthalmic Solution) 3

Azelastine HCl (0.05% Ophthalmic

Solution) 1

Bepreve (Ophthalmic Solution) 3 ST

Cromolyn Sodium (4% Ophthalmic

Solution) 1

Emadine (Ophthalmic Solution) 3

Epinastine HCl (Ophthalmic

Solution) 1

LaST 3 ST

Olopatadine HCl (0.1% Ophthalmic

Solution) 1

Pataday (Ophthalmic Solution) 2

Pazeo (Ophthalmic Solution) 2

Acuvail (Ophthalmic Solution) 3

Alrex (Suspension) 3

Bromfenac (0.09% Ophthalmic

Solution) 1

Bromfenac (0.09% Ophthalmic

Solution) 1 QL


(0.1% Ophthalmic Solution) 1

Diclofenac Sodium (0.1%

Ophthalmic Solution) 1

Durezol (Emulsion) 3

Flarex (Suspension) 3

Fluorometholone (Ophthalmic

Suspension) 1

Flurbiprofen Sodium (Ophthalmic

Solution) 1

FML (Ointment) 2

Ilevro (Suspension) 3 QL

Ketorolac Tromethamine (0.4%



1

Lotemax (0.5% Gel, 0.5%

Ointment)

3 QL

Lotemax (0.5% Suspension) 3

Nevanac (Suspension) 3 QL

Ozurdex (Injection) 4

Pred Mild (Suspension) 2

Prednisolone Acetate (Suspension) 1


(1% Ophthalmic Solution) 1

Acetazolamide ER (Capsule


Alphagan P (0.1% Ophthalmic

Solution)

2

Apraclonidine (Ophthalmic

Solution) 1

Azopt (Suspension) 2

50

Drug Name Drug

Tier

Requirements

& Limits

Betaxolol HCl (0.5% Ophthalmic

Solution) 1

Betimol (Ophthalmic Solution) 3

Brimonidine Tartrate (Ophthalmic

Solution) 1

Carteolol HCl (Ophthalmic

Solution) 1

Combigan (Ophthalmic Solution) 2

Dorzolamide HCl/Timolol Maleate

(Ophthalmic Solution) 1

Iopidine (1% Ophthalmic

Solution)

3

Keveyis (Tablet) 4 PA,QL

Levobunolol HCl (Ophthalmic

Solution)

1

Metipranolol (Ophthalmic Solution) 1

Phospholine Iodide (Ophthalmic

Solution)

2

Pilocarpine HCl (1% Ophthalmic

Solution, 2% Ophthalmic Solution,

4% Ophthalmic Solution)

1

Simbrinza (Suspension) 3

Timolol Maleate (0.25%



1

Timolol Maleate Ophthalmic Gel

Forming (Solution) 1

Acetasol HC (Otic Solution) 1

Acetic Acid (Otic Solution) 1

Acetic Acid/Aluminum Acetate

(Otic Solution) 1

Cipro HC (Suspension) 3

Ciprodex (Otic Suspension) 2

Coly-Mycin S (Suspension) 3

Hydrocortisone/Acetic Acid (Otic

Solution) 1

Neomycin/Polymyxin/Hydrocortiso

ne (1% Otic Solution, 1% Otic

Suspension)

1

Oxytocin/Sodium Chloride

(30unit/500ml-0.9% Solution) 1

Advair Diskus (Aerosol Powder) 2 QL

Advair HFA (Aerosol) 2 QL

Arnuity Ellipta (Aerosol Powder) 2 QL

Beconase AQ (Suspension) 3 QL

Breo Ellipta (Aerosol Powder) 2 QL

Budesonide (0.25mg/2ml

Suspension, 0.5mg/2ml Suspension) 1

Budesonide (1mg/2ml Suspension,

32mcg/act Suspension) RX 1 QL

Flovent Diskus (Aerosol Powder) 2 QL

Flovent HFA (Aerosol) 2 QL

Drug Name Drug

Tier

Requirements

& Limits

Flunisolide (Nasal Solution) 1 QL

Fluticasone Propionate (50mcg/act

Suspension) RX 1

Mometasone Furoate (50mcg/act

Suspension) 1 QL

Omnaris (Suspension) 3 QL

Pulmicort Flexhaler (Aerosol

Powder)

2 QL

Symbicort (Aerosol) 2 QL

Triamcinolone Acetonide

(55mcg/act Aerosol) RX 1

Arbinoxa (Tablet) 1

Azelastine HCl (0.1% Nasal

Solution, 0.15% Nasal Solution) 1 QL

Carbinoxamine Maleate (4mg

Tablet, 4mg/5ml Oral Solution) 1

Cetirizine HCl (Syrup) RX 1

Clarinex (0.5mg/ml Syrup) 3

Desloratadine (Tablet) 1

Desloratadine ODT (Tablet

Dispersible) 1

Dymista (Suspension) 3 QL

Levocetirizine Dihydrochloride

(2.5mg/5ml Oral Solution, 5mg

Tablet)

1

Olopatadine HCl (0.6% Nasal

Solution) 1 QL

Vituz (Oral Solution) 3

Montelukast Sodium (10mg Tablet,

4mg Packet, 4mg Tablet Chewable,

5mg Tablet Chewable)

1

Zafirlukast (Tablet) 1

Zyflo CR (Tablet Extended-

Release 12 Hour)

3 ST

Anoro Ellipta (Aerosol Powder) 2 QL

Atrovent HFA (Aerosol Solution) 3 QL

Combivent Respimat (Aerosol

Solution)

2 QL

Incruse Ellipta (Aerosol Powder) 3 QL

Ipratropium Bromide (0.02%

Inhalation Solution) 1 QL

Ipratropium Bromide (0.03% Nasal

Solution, 0.06% Nasal Solution) 1

Spiriva HandiHaler (Capsule) 2 QL

Spiriva Respimat (Aerosol

Solution)

2 QL

51

Drug Name Drug

Tier

Requirements

& Limits

Adrenaclick (0.3mg/0.3ml

Injection)

2

Albuterol Sulfate (0.083%

Nebulized Solution, 0.5% Nebulized

Solution, 0.63mg/3ml Nebulized

Solution, 1.25mg/3ml Nebulized

Solution)

1 QL

Albuterol Sulfate (2mg Tablet, 4mg


Albuterol Sulfate ER (Tablet


Arcapta Neohaler (Capsule) 3 QL,ST

Brovana (Nebulized Solution) 3 QL

Ephedrine Sulfate/Sodium Chloride

(50mg/5ml-0.9% Solution Prefilled

Syringe)

1

Epinephrine (0.15mg/0.3ml

Injection, 0.3mg/0.3ml Injection)

(authorized generic Epi-Pen made

by Mylan)

2

EpiPen (Injection) 2

Levalbuterol (Nebulized Solution) 1 QL

Metaproterenol Sulfate (10mg


Syrup)

1

Perforomist (Nebulized Solution) 3 QL

ProAir HFA (Aerosol Solution) 2 QL

ProAir RespiClick (Aerosol

Powder)

2 QL

Serevent Diskus (Aerosol Powder) 2 QL

ST 3 QL,ST

Terbutaline Sulfate (1mg/ml

Injection, 2.5mg Tablet, 5mg

Tablet)

1

Ventolin HFA (Aerosol Solution) 2 QL

Kalydeco (150mg Tablet, 50mg

Packet, 75mg Packet)

4 PA

Orkambi (125mg-100mg Tablet) 4 PA,QL

Cromolyn Sodium (20mg/2ml

Nebulized Solution) 1

Aminophylline (Injection) 1

Daliresp (Tablet) 3 PA

Difil-G Forte (Liquid) 1

Elixophyllin (Elixir) 2

Theo-24 (Capsule Extended-

Release 24 Hour)

3

Theochron (Tablet Extended-

Release 12 Hour) 1

Theophylline (Oral Solution) 1

Drug Name Drug

Tier

Requirements

& Limits

Theophylline CR (Tablet Extended-

Release 12 Hour) 1

Theophylline ER (100mg Tablet ER

12 Hour, 200mg Tablet ER 12 Hour,

300mg Tablet ER 12 Hour, 450mg

Tablet ER 12 Hour, 400mg Tablet

ER 24 Hour, 600mg Tablet ER 24

Hour)

1

Adcirca (Tablet) 4 PA,QL

Adempas (Tablet) 4 PA,QL

Epoprostenol Sodium (Injection) 4 PA

Letairis (Tablet) 4 PA,QL

Opsumit (Tablet) 4 PA,QL

Orenitram (Tablet Extended-

Release)

4 PA

Remodulin (Injection) 4 PA

Sildenafil (10mg/12.5ml Injection) 4 PA

Sildenafil (20mg Tablet) 4 PA,QL

Tracleer (Tablet) 4 PA,QL

Tyvaso (Inhalation Solution) 4 PA,QL

Tyvaso Refill (Inhalation

Solution)

4 PA,QL

Tyvaso Starter (Inhalation

Solution)

4 PA,QL

Uptravi (Tablet Therapy Pack,

1000mcg Tablet, 1200mcg Tablet,



600mcg Tablet, 800mcg Tablet)

4 PA,QL

Veletri (Injection) 4 PA

Ventavis (Inhalation Solution) 4 PA,QL

Acetylcysteine (10% Inhalation

Solution, 20% Inhalation Solution,

200mg/ml Injection)

1

Aralast NP (Injection) 4 PA

Benzonatate (Capsule) 1

Esbriet (Capsule) 4 PA

Flowtuss (Oral Solution) 3

Glassia (Injection) 4 PA

Hydrocodone

Bitartrate/Homatropine

Methylbromide (1.5mg-5mg Tablet,

1.5mg/5ml-5mg/5ml Syrup)

1

Hydromet (Syrup) 1

Nebusal (3% Nebulized Solution) 1

Obredon (Oral Solution) 3

Ofev (Capsule) 4 PA

Prolastin-C (Injection) 4 PA

Pulmosal (Nebulized Solution) 1

Ribavirin (6gm Solution) 4

Sodium Chloride (0.9% Nebulized

Solution, 10% Nebulized Solution, 1

52

Drug Name Drug

Tier

Requirements

& Limits

3% Nebulized Solution, 7%

Nebulized Solution)

SSKI (Oral Solution) 3

Stiolto Respimat (Aerosol

Solution)

2 QL

Tussigon (Tablet) 1

Xolair (Injection) 4 PA

Zemaira (Injection) 4 PA

Atracurium Besylate (Injection) 1

Carisoprodol (250mg Tablet, 350mg

Tablet) 1

Chlorzoxazone (Tablet) 1

Cisatracurium Besylate (Injection) 1

Cyclobenzaprine HCl (Tablet) 1

Lorzone (Tablet) 3

Metaxall (Tablet) 1

Metaxalone (Tablet) 1

Methocarbamol (1000mg/10ml


Tablet)

1

Orphenadrine Citrate (30mg/ml

Injection) 1

Orphenadrine Citrate ER (Tablet


Pancuronium Bromide (Injection) 1

Revonto (Injection) 1

Rocuronium Bromide (100mg/10ml


Vecuronium Bromide (10mg

Injection, 20mg Injection) 1

Eszopiclone (Tablet) 1 QL

Zaleplon (Capsule) 1 QL

Zolpidem Tartrate (1.75mg Tablet


Sublingual)

1

Zolpidem Tartrate (10mg Tablet,

5mg Tablet) 1 QL

Zolpidem Tartrate ER (Tablet


Armodafinil (Tablet) 1 PA,QL

Belsomra (Tablet) 3 QL,ST

Modafinil (Tablet) 1 PA,QL

Rozerem (Tablet) 3 QL

Xyrem (Oral Solution) 4 PA,QL

Carbaglu (Tablet) 4

Chemet (Capsule) 3

Exjade (Tablet Soluble) 4 PA

Jadenu (Tablet) 4 PA

Drug Name Drug

Tier

Requirements

& Limits

Kionex (Powder, 15gm/60ml

Suspension) 1

Samsca (Tablet) 4 QL

Sodium Acetate (2meq/ml Injection) 1

Sodium Bicarbonate (7.5%

Injection) 1

Sodium Polystyrene Sulfonate

(Powder, 15gm/60ml Suspension,

30gm/120ml Suspension,

50gm/200ml Suspension)

1

SPS (Suspension) 1

Syprine (Capsule) 4 PA

Veltassa (Packet) 3

Aminosyn 8.5%/Electrolytes

(Injection) 1

Aminosyn II 8.5%/Electrolytes

(Injection) 1

AV-Phos 250 Neutral (Tablet) 1

BD Posiflush (Solution) 1

Calcium Chloride (Injection) 1

Cardioplegic (Injection) 1

Chromagen (Capsule) 1

Chromium Chloride (Injection) 1

Clinisol SF 15% (Injection) 1

Corvita 150 (Tablet) 1

Dextrose 5%/Lactated Ringers

(Injection) 1

Effer-K (Tablet Effervescent) 1

Effervescent Potassium/Chloride

(Tablet Effervescent) 1

Ferocon (Capsule) 1

Ferotrinsic (Capsule) 1

Ferrocite Plus (Tablet) 1

Fluor-A-Day (Oral Solution) 1 PV

Fluoride (Tablet Chewable) 1 PV

Fluoritab (0.125mg/drop Oral

Solution, 0.25mg Tablet Chewable,

0.5mg Tablet Chewable, 1mg Tablet

Chewable)

1 PV

Flura-Drops (Oral Solution) 1 PV

Foltrin (Capsule) 1

Hematinic Plus Vitamins/Minerals

(Tablet) 1

Hemocyte-Plus (Tablet) 1

Iferex 150 Forte (Capsule) 1

Isolyte-S (Injection) 3

K-Effervescent (Tablet

Effervescent) 3

K-Prime (Tablet Effervescent) 1

K-Tan Plus (Capsule) 1

Karidium (Oral Solution) 1 PV

Klor-Con 10 (Tablet Extended-

Release) 1

53

Drug Name Drug

Tier

Requirements

& Limits

Klor-Con 8 (Tablet Extended-

Release) 1

Klor-Con M10 (Tablet Extended-

Release) 1


Release)

3


Release) 1

Klor-Con Sprinkle (Capsule

Extended-Release) 1

Lactated Ringers (Injection) 1

Ludent (Tablet Chewable) 1 PV

Magnesium Chloride (200mg/ml

Injection) 1

Magnesium Sulfate (20gm/500ml

Injection, 2gm/50ml Injection,

40gm/1000ml Injection, 4gm/100ml

Injection, 4gm/50ml Injection, 50%

Injection)

1

Monoject Pharma Grade Flush

Syringe (Solution) 1

Nafrinse (Tablet Chewable) 1 PV

Nafrinse Drops (Oral Solution) 1 PV

Normal Saline Flush (Solution) 1

Nutrilyte (Injection) 1

Plasma-Lyte A (Injection) 3

Plasma-Lyte-148 (Injection) 3

Plasma-Lyte-56/D5W (Injection) 3

Plenamine (Injection) 1

Poly-Iron 150 Forte (Capsule) 1

Polysaccharide Iron Forte (Capsule) 1

Potassium Acetate (2meq/ml

Injection) 1

Potassium Chloride (10% Oral

Solution, 20% Oral Solution,

10meq/100ml Injection,

20meq/50ml Injection, 2meq/ml

Injection, 40meq/100ml Injection,

20meq Packet)

1

Potassium Chloride CR (Tablet

Extended-Release) 1

Potassium Chloride ER (10meq

Capsule Extended-Release, 8meq

Capsule Extended-Release, 10meq

Tablet Extended-Release, 20meq

Tablet Extended-Release, 8meq

Tablet Extended-Release)

1

Potassium Chloride SR (Tablet

Extended-Release) 1

Potassium Chloride/Lidocaine HCl

(Injection) 1

Potassium Chloride/Sodium

Chloride (20meq/L-0.9% Injection,

40meq/L-0.9% Injection)

1

Potassium Citrate ER (Tablet

Extended-Release) 1

Premasol (6% Injection) 1

Prenatal Multi +DHA (Capsule) 3 PV

Drug Name Drug

Tier

Requirements

& Limits

PureVitamin Dualfe Plus (Capsule) 1

Ringers Injection 1

Saline Flush (Injection) 1

Saline Flush Zr/Sterile Field

(Injection) 1

Sodium Chloride (2.5meq/ml

Injection, 3% Injection, 5%

Injection)

1

Sodium Chloride 0.45% (Injection) 1

Sodium Chloride Bacteriostatic

(Injection) 1

Sodium Chloride Flush (Injection) 1

Sodium Ferric Gluconate

Complex/Sucrose (Injection) 4

Sodium Fluoride (0.25mg Tablet

Chewable, 1.1mg Tablet Chewable,

1mg Tablet Chewable, 0.5mg/ml

Oral Solution, 1mg Tablet)

1 PV

Sodium Phosphate (Injection) 1

Swabflush Saline Flush (Injection) 1

Taron-Crystals (Packet) 1

TL Icon (Capsule) 1

TPN Electrolytes (Injection) 1

Tricon (Capsule) 1

Virt-Phos 250 Neutral (Tablet) 1

Virtrate-2 (Oral Solution) 1

Virtrate-3 (Oral Solution) 1

Virtrate-K (Oral Solution) 1

Aminoam Rms (Capsule) 1

Aminorelief Rms (Capsule) 1

Airavite (Tablet) 1

Atabex Prenatal (Tablet

Chewable)

3 PV

AV-Vite FB (Tablet) 1

B-Plex (Tablet) 1

B-Plex Plus (Tablet) 1

Baby Super Daily D3 (Liquid) 3 PV

Baby Vitamin D3 Drops (Liquid) 3 PV

Bio-D-Mulsion (Liquid) 1 PV

Bio-D-Mulsion Forte (Liquid) 1 PV

Biocel (Tablet) 1

BP Folinatal Plus B (Tablet) 1

BP Multinatal Plus (Tablet, Tablet

Chewable) 1

BP Vit 3 (Capsule) 1

Bprotected Pedia D-Vite (Liquid) 1 PV

Brainstrong Prenatal 3 PV

Cadeau DHA (Capsule) 3 PV

Calcidol (Oral Solution) 1 PV

Calciferol (Oral Solution) 1 PV

Centrum Specialist Prenatal 3 PV

Classic Prenatal (Tablet) 1 PV

54

Drug Name Drug

Tier

Requirements

& Limits

Co-Natal FA (Tablet) 1

Complete Natal DHA 1

Completenate (Tablet Chewable) 1

Corvita (Tablet) 1

Corvite Free (Tablet) 1

CVS D3 (1000unit Capsule,

2000unit Capsule, 400unit Capsule,

5000unit Capsule, 1000unit Tablet

Chewable)

1 PV

CVS Prenatal (Tablet) 1 PV

CVS Prenatal Gummy/DHA/Folic

Acid (Tablet Chewable)

3 PV

CVS Prenatal Multi+DHA

(Capsule)

3 PV

CVS Vitamin D Childrens Gummies


CVS Vitamin D3 Drops/Infants

(Liquid)

3 PV

Cyanocobalamin (1000mcg/ml

Injection) 1

D 1000 (1000unit Capsule, 1000unit


D 10000 (Capsule) 1 PV

D 2000 (Tablet) 1 PV

D 400 (400unit Tablet, 400unit


D-Vita (Liquid) 1 PV

D3 (1000unit Capsule, 2000unit

Capsule, 400unit Capsule, 1000unit

Tablet, 2000unit Tablet)

1 PV

D3 2000 (Tablet) 1 PV

D3 Adult (Tablet Chewable) 1 PV

D3 Dots (Tablet Dispersible) 3 PV

D3 High Potency (Tablet) 1 PV

D3 Kids (Tablet Chewable) 1 PV

D3 Maximum Strength (5000unit

Capsule, 5000unit/ml Liquid) 1 PV

D3 Super Strength (Capsule) 1 PV

D3-1000 (Capsule) 1 PV

D3-50 (Capsule) 1 PV

Ddrops (Liquid) 3 PV

Ddrops Booster (Liquid) 3 PV

Decara (25000unit Capsule) 3 PV

Decara (50000unit Capsule) 1 PV

Delta D3 (Tablet) 1 PV

Dialyvite Vitamin D 5000 (Capsule) 1 PV

Dialyvite Vitamin D3 Max (Tablet) 1 PV

Elite-Ob (Tablet) 1

Enfamil Expecta 3 PV

EQL Prenatal Formula (Tablet) 1 PV

EQL Vitamin D3 (Capsule) 1 PV

EQL Vitamin D3 Gummies (Tablet

Chewable) 1 PV

Ergocalciferol (8000unit/ml Oral

Solution) 1 PV

FA-8 (0.8mg Capsule, 800mcg

Tablet) 1 PV

Drug Name Drug

Tier

Requirements

& Limits

Fabb (Tablet) 1

Folbee (Tablet) 1

Folbee Plus (Tablet) 1

Folic Acid (1mg Tablet, 400mcg

Tablet, 800mcg Capsule) RX 1

Folic Acid/Vitamin B-6/Vitamin B-

12 (Tablet) 1

Folplex 2.2 (Tablet) 1

GNP D 1000 (Capsule) 1 PV

GNP D 2000 (Tablet Chewable) 1 PV

GNP Daily Prenatal 3 PV

GNP Prenatal (Tablet) 3 PV

GNP Vitamin D (Tablet) 1 PV

GNP Vitamin D Super Strength

(Tablet) 1 PV

GNP Vitamin D3 Extra Strength

(Tablet) 1 PV

Goodsense Prenatal Vitamins

(Tablet)

3 PV

Healthy Kids Vitamin D3 (Tablet

Chewable) 1 PV

Healthy Mama Be Well Rounded

(Therapy Pack)

3 PV

HM One Daily Prenatal Combo 3 PV

HM Prenatal (Tablet) 3 PV

HM Vitamin D (Tablet) 1 PV

HM Vitamin D3 (Capsule) 1 PV

Inatal GT (Tablet) 1

Just D (Liquid) 1 PV

KP Folic Acid (Tablet) 1 PV

KP Prenatal Multivitamins

(Tablet)

3 PV

KP Vitamin D (1000unit Capsule,

2000unit Capsule, 400unit Tablet

Chewable)

1 PV

Lysiplex Plus (Tablet) 1

M-Vit (Tablet) 1

MacNatal CN DHA (Capsule) 1

Mephyton (Tablet) 2

Mission Prenatal (Tablet) 3 PV

Mission Prenatal HP (Tablet) 1 PV

Multi Prenatal (Tablet) 1 PV

Multi-Vit/Fluoride (32mg/ml-

3mcg/ml-1mg/ml-400unit/ml-

2mcg/ml-5unit/ml-29.7mcg/ml-

2mg/ml-0.4mg/ml-0.6mg/ml-

0.25mg/ml-0.5mg/ml-1150unit/ml

Oral Solution)

1

Multi-Vit/Iron/Fluoride (Solution) 1

Multivitamin with Fluoride (32-3-1-

400-2-5-29.7-2-0.4-0.6-0.25-0.5-

1150 Solution; 35mg/ml-

400unit/ml-2mcg/ml-5unit/ml-



Solution)

1

Multivitamins/Fluoride (Tablet

Chewable) 1

55

Drug Name Drug

Tier

Requirements

& Limits

Mynatal Advance (Tablet) 1

Mynatal Plus (Tablet) 1

Mynatal Ultracaplet (Tablet) 1

Mynatal-Z (Tablet) 1

Mynate 90 Plus (Tablet Extended-

Release) 1

NascoBAL (Nasal Solution) 3

Nat-Rul Prenatal Vitamins

(Tablet)

3 PV

Nat-Rul Vitamin D (Tablet) 1 PV

Natural Vitamin D-3 (Tablet) 1 PV

Nephronex (Tablet) 1

Nufol (Tablet) 1

Nutrifac ZX (Tablet) 1

Obstetrix EC (Tablet) 1

One A Day Womens

Prenatal/DHA

3 PV

One A Day Womens Prenatal1

(Capsule)

3 PV

One-A-Day Womens Prenatal 3 PV

Optimal D3 M (Capsule) 3 PV

Optimal-D Pack (Capsule) 1 PV

Opurity Vitamin D (Tablet

Chewable) 1 PV

Ortho-CS 250 (Injection) 1

PA Prenatal Formula (Tablet) 3 PV

PA Vitamin D-3 (Capsule) 1 PV

PA Vitamin D-3 Gummy (Tablet

Chewable) 1 PV

Perry Prenatal (Capsule) 1 PV

Phytonadione (Injection) 1

Pre-Natal Formula (Tablet) 1 PV

Prenatabs Rx (Tablet) 1

Prenatal (100mg-0-0-263mg-

400unit-4mcg-27mg-0.8mg-18mg-

2.6mg-1.7mg-1.5mg-11unit-

4000unit-25mg Tablet)

1 PV

Prenatal (120mg-4000unit-200mg-

400unit-8mcg-28mg-800mcg-

20mg-2.6mg-1.7mg-1.8mg-30unit-

25mg Tablet)

3 PV

Prenatal 19 (Tablet, Tablet

Chewable) 1

Prenatal and Iron (Tablet) 1 PV

Prenatal Complete (Tablet) 3 PV

Prenatal Formula (Capsule) 3 PV

Prenatal Forte (Tablet) 1 PV

Prenatal Low Iron (Tablet) 1 PV

Prenatal Multi + DHA (Capsule) 3 PV

Prenatal Multivitamin + DHA 3 PV

Prenatal Multivitamin Plus DHA

(Capsule)

3 PV

Prenatal One Daily (Tablet) 3 PV

Prenatal Vitamin/Iron (Tablet) 3 PV

Prenatal Vitamins (Tablet) 1 PV

Prenatal-U (Capsule) 1

Drug Name Drug

Tier

Requirements

& Limits

Prenatal/Omega-3/Folic Acid/Iron

(Capsule)

3 PV

Pronutrients Vitamin D3 (Capsule) 1 PV

PX Prenatal Multivitamins (Tablet) 1 PV

Pyridoxine HCl (100mg/ml

Injection) 1

QC Prenatal (Tablet) 3 PV

Quflora Pediatric (32mg/ml-

3mcg/ml-1mg/ml-400unit/ml-

2mcg/ml-5unit/ml-29.7mcg/ml-



Oral Solution)

1

RA One Daily 3 PV

RA Prenatal (Tablet) 1 PV

RA Prenatal Formula/Folic Acid

(Tablet)

3 PV

RA Vitamin D-3 (1000unit Tablet,

2000unit Capsule) 1 PV

Rena-Vite Rx (Tablet) 1

Replesta (Wafer) 3 PV

Replesta Childrens (Wafer) 3 PV

Replesta Nx (Wafer) 3 PV

Right Step Prenatal (Tablet) 3 PV

Similac Prenatal Early Shield 3 PV

SM Folic Acid (Tablet) 1 PV

SM One Daily Prenatal 3 PV

SM Vitamin D (Tablet) 1 PV

SM Vitamin D3 Maximum

Strength (Capsule)

3 PV

Stuart One (Capsule) 3 PV

Super Daily D3 (1000unit/0.03ml

Liquid)

3 PV

Taron-Prex (Capsule) 1

Thera-D 2000 (Tablet) 1 PV

Thera-D 4000 (Tablet) 3 PV

Thiamine HCl (100mg/ml Injection) 1

TL Gard Rx (Tablet) 1

Trinatal Rx 1 (Tablet) 1

Trinate (Tablet) 1

Triphrocaps (Capsule) 1

Ultimatecare One (Capsule) 1

Urosex (Tablet) 1

V-C Forte (Capsule) 1

Vic-Forte (Capsule) 1

Vinate II (Tablet) 1

Vinate M (Tablet) 1

Vinate One (Tablet) 1

Virt-Caps (Capsule) 1

Virt-Gard (Tablet) 1

Virt-Vite (Tablet) 1

Virt-Vite Plus (Tablet) 1

Vita S Forte (Tablet) 1

Vita-Min (Capsule) RX 1

Vitacel (Tablet) 1

56

Drug Name Drug

Tier

Requirements

& Limits

Vitajoy Daily D Gummies (Tablet

Chewable) 1 PV

Vitamax Pediatric (Oral Solution) 1

Vitamelts Vitamin D (Tablet

Dispersible)

3 PV

Vitamin C 222mg (Injection) 1

Vitamin D (2000unit Tablet, 400unit

Capsule, 400unit Tablet, 400unit/ml

Liquid, 50000unit Capsule)

1 PV

Vitamin D-1000 (Tablet) 1 PV

Vitamin D-3 (1000unit Capsule,

1000unit Tablet, 400unit Tablet,

2000unit Tablet)

1 PV

Vitamin D2 (Tablet) 3 PV

Vitamin D3 (10000unit Tablet,

1000unit/spray Liquid,

1200unit/15ml Liquid, 3000unit

Tablet)

3 PV

Vitamin D3 (Capsule, Tablet, Tablet

Chewable, 400unit/ml Liquid,

5000unit/ml Liquid)

1 PV

Vitamin D3 Gummies (Tablet

Chewable) 1 PV

Vitamin K1 (1mg/0.5ml Injection) 1

Vitamins A/C/D/Fluoride (Solution) 1

Vol-Care Rx (Tablet) 1

VP-Vite Rx (Tablet) 1

Wellesse Vitamin D3 (Liquid) 3 PV

YL Folic Acid (Tablet) 1 PV

Your Life Multi Prenatal

(Capsule)

3 PV

Rayaldee (Capsule Extended-

Release)

3

Upspringbaby Vitamin D3

(Liquid)

3 PV

Vitamin D3 (5000unit Tablet

Dispersible)

3 PV

57

1

1st Tier Unifine Pentips /Mini/31gx5mm ... 43 1st Tier Unifine Pentips 29gx12mm ........... 43 1st Tier Unifine Pentips 31gx6mm ............. 43 1st Tier Unifine Pentips 31gx8mm ............. 43 1st Tier Unifine Pentips 32gx4mm ............. 43 1st Tier Unifine Pentips Plus 31gx8mm ...... 43

A

Abacavir (Tablet) ......................................... 25 Abacavir Sulfate/Lamivudine/Zidovudine

(Tablet) ................................................... 25 Abacavir/Lamivudine (Tablet) ..................... 25 Abelcet (Injection) ...................................... 20 Abilify Maintena (Injection)........................ 47 Abraxane (Injection) ................................... 47 Acamprosate Calcium DR (Tablet Delayed-

Release) .................................................. 13 Acarbose (Tablet) ........................................ 26 Acebutolol HCl (200mg Capsule, 400mg

Capsule) .................................................. 29 Acetaminophen/Caffeine/Dihydrocodeine

(Capsule) ................................................. 12 Acetaminophen/Codeine (Oral Solution,

Tablet)..................................................... 12 Acetasol HC (Otic Solution) .......................... 50 Acetazolamide (Tablet Immediate-Release) 30 Acetazolamide ER (Capsule Extended-Release

12 Hour) .................................................. 49 Acetazolamide Sodium (Injection) ............... 47 Acetic Acid (Otic Solution) ........................... 50 Acetic Acid 0.25% (Irrigation Solution) ........ 37 Acetic Acid/Aluminum Acetate (Otic Solution)

................................................................ 50 Acetylcysteine (10% Inhalation Solution, 20%

Inhalation Solution, 200mg/ml Injection) ................................................................ 51

Aciphex Sprinkle (Capsule Sprinkle) ........... 36 Acitretin (Capsule) ....................................... 33 ActHIB (Injection) ........................................ 42 Actimmune (Injection) ................................ 41 Actoplus Met XR (Tablet Extended-Release

24 Hour).................................................. 41 Acuvail (Ophthalmic Solution) .................... 49 Acyclovir (200mg Capsule, 200mg/5ml

Suspension, 400mg Tablet, 800mg Tablet, 5% Ointment) ......................................... 25

Acyclovir Sodium (Injection) ........................ 25 Adacel (Injection) ........................................ 42 Adagen (Injection) ...................................... 34 Adapalene (0.1% Cream, 0.1% Gel, 0.3% Gel)

................................................................ 33 Adapalene Pump (Gel) ................................. 33 Adcetris (Injection) ..................................... 23 Adcirca (Tablet) ........................................... 51 Adefovir Dipivoxil (Tablet) ........................... 24

Adempas (Tablet) ....................................... 51 Adenosine (12mg/4ml Injection, 6mg/2ml

Injection) ................................................ 29 Adrenaclick (0.3mg/0.3ml Injection) ......... 50 Adriamycin (Injection) ................................. 21 Adrucil (Injection)........................................ 22 Advair Diskus (Aerosol Powder) ................ 50 Advair HFA (Aerosol) .................................. 50 Advate (Injection) ....................................... 28 AeroChamber Mini Aerosol Chamber ........ 43 AeroChamber MV ....................................... 43 AeroChamber Plus Flow Vu ........................ 43 AeroChamber Plus Flow-Vu ....................... 43 AeroChamber Plus Flow-Vu/Large Mask ... 43 AeroChamber Plus Flow-Vu/Mask ............. 43 AeroChamber Plus Flow-Vu/Medium Mask

............................................................... 43 AeroChamber Plus Flow-Vu/Small Mask ... 43 AeroChamber Z-Stat Plus/Medium Mask .. 43 AeroChamber/FlowSignal .......................... 43 Aerovent Plus Holding Chamber/Collapsible

............................................................... 43 Afeditab CR (Tablet Extended-Release 24

Hour) ...................................................... 30 Afinitor (Tablet) .......................................... 23 Afinitor Disperz (Tablet Soluble) ................ 23 Afluria 2016-2017 (Injection) ..................... 42 Afluria PF 2016-2017 (Injection) ................ 47 Afluria Quadrivalent 2016-2017 (Injection) 47 Aftera (Tablet) ............................................. 40 Aggrastat (Injection) ................................... 28 Airavite (Tablet) .......................................... 53 Akynzeo (Capsule) ...................................... 19 Ala-Cort (Cream) ......................................... 33 Albenza (Tablet) ......................................... 23 Albuked 25 (Injection) ................................. 27 Albuked 5 (Injection) ................................... 27 Albumin Human (Injection) ......................... 27 Albuminar-25 (Injection) ............................. 27 Albuminar-5 (Injection) ............................... 28 Albumin-Zlb (Injection) ............................... 27 Alburx (Injection) ........................................ 28 Albutein (Injection) ..................................... 28 Albuterol Sulfate (0.083% Nebulized Solution,

0.5% Nebulized Solution, 0.63mg/3ml Nebulized Solution, 1.25mg/3ml Nebulized Solution) ................................................. 50

Albuterol Sulfate (2mg Tablet, 4mg Tablet, 2mg/5ml Syrup)...................................... 50

Albuterol Sulfate ER (Tablet Extended-Release 12 Hour) .................................... 50

Alclometasone Dipropionate (0.05% Cream, 0.05% Ointment) .................................... 33

Alcoh-Glove Contoured Wipe .................... 14 Alcohol Prep Pads ....................................... 14 Alcohol Swabs ............................................ 14 Alcohol Swabstick ....................................... 14 Alcoh-Wipe 12" X 12" ................................. 14

Aldurazyme (Injection) ............................... 34 Alendronate Sodium (10mg Tablet, 40mg

Tablet, 5mg Tablet) ................................. 42 Alendronate Sodium (35mg Tablet, 70mg

Tablet) ..................................................... 42 Alendronate Sodium (70mg/75ml Oral

Solution) ................................................. 42 Alfentanil (Injection) .................................... 12 Alferon N (Injection) ................................... 22 Alfuzosin HCl ER (Tablet Extended-Release 24

Hour) ....................................................... 37 Alimta (Injection) ........................................ 47 Alinia (100mg/5ml Suspension, 500mg

Tablet) .................................................... 23 Alkeran (2mg Tablet) .................................. 21 Allopurinol (Tablet) ...................................... 21 Allopurinol Sodium (Injection) ..................... 21 Almotriptan Malate (Tablet) ........................ 21 Alocril (Ophthalmic Solution) ..................... 49 Alogliptin (Tablet) ....................................... 26 Alomide (Ophthalmic Solution) .................. 49 Alophen (Tablet Delayed-Release) .............. 35 Alosetron HCl (Tablet) ................................. 35 Aloxi (Injection) ........................................... 20 Alphagan P (0.1% Ophthalmic Solution) .... 49 Alphanate/Von Willebrand Factor

Complex/Human (Injection) .................. 28 Alphanine SD (Injection) ............................. 28 Alphatrex (Gel) ............................................ 33 Alprazolam (Tablet Immediate-Release) ..... 25 Alprazolam ER (Tablet Extended-Release 24

Hour) ....................................................... 25 Alprazolam ODT (Tablet Dispersible) ........... 26 Alprazolam XR (Tablet Extended-Release 24

Hour) ....................................................... 26 Alprostadil (Injection) .................................. 38 Alrex (Suspension) ...................................... 49 Altabax (Ointment) ..................................... 14 Altacaine (Ophthalmic Solution) .................. 49 Altafrin (Ophthalmic Solution) ..................... 49 Altavera (Tablet) .......................................... 38 Alyacen 1/35 (Tablet) .................................. 38 Alyacen 7/7/7 (Tablet) ................................. 38 Amabelz (Tablet) ......................................... 38 Amantadine HCl (100mg Capsule, 100mg

Tablet, 50mg/5ml Syrup) ........................ 23 AmBisome (Injection) ................................. 20 Amcinonide (0.1% Cream, 0.1% Lotion, 0.1%

Ointment) ............................................... 33 Amethia (Tablet) .......................................... 38 Amethia Lo (Tablet) ..................................... 38 Amethyst (Tablet) ........................................ 38 Amifostine (Injection) .................................. 47 Amikacin Sulfate (1gm/4ml Injection,

500mg/2ml Injection) ............................. 14 Amiloride HCl (5mg Tablet) ......................... 31 Amiloride/Hydrochlorothiazide (Tablet) ..... 31 Aminoacetic Acid (Irrigation Solution) ......... 37

58

Aminoam Rms (Capsule).............................. 53 Aminophylline (Injection) ............................ 51 Aminorelief Rms (Capsule) .......................... 53 Aminosyn 8.5%/Electrolytes (Injection) ...... 52 Aminosyn II 8.5%/Electrolytes (Injection).... 52 Amiodarone HCl (100mg Tablet, 200mg

Tablet, 400mg Tablet, 50mg/ml Injection) ................................................................ 29

Amiodarone HCl/Dextrose (Injection) ......... 29 Amitiza (Capsule) ........................................ 35 Amitriptyline HCl (100mg Tablet, 10mg

Tablet, 150mg Tablet, 25mg Tablet, 50mg Tablet, 75mg Tablet) ............................... 19

Amlodipine Besylate (Tablet) ...................... 30 Amlodipine Besylate/Atorvastatin Calcium

(Tablet) ................................................... 30 Amlodipine Besylate/Benazepril HCl (Capsule)

................................................................ 29 Amlodipine Besylate/Valsartan (Tablet) ...... 28 Amlodipine/Olmesartan Medoxomil (Tablet)

................................................................ 28 Amlodipine/Valsartan/Hydrochlorothiazide

(Tablet) ................................................... 28 Ammonium Lactate (12% Cream, 12% Lotion)

(RX) ......................................................... 33 Amoxapine (Tablet) ..................................... 19 Amoxicillin (125mg Tablet Chewable, 250mg

Tablet Chewable, 125mg/5ml Suspension, 200mg/5ml Suspension, 250mg/5ml Suspension, 400mg/5ml Suspension, 250mg Capsule, 500mg Capsule, 500mg Tablet, 875mg Tablet) ............................. 16

Amoxicillin/Clavulanate Potassium (Tablet Chewable, Oral Suspension, Tablet Immediate-Release) ................................ 16

Amoxicillin/Clavulanate Potassium ER (Tablet Extended-Release 12 Hour) .................... 16

Amphetamine/Dextroamphetamine (10mg, 12.5mg, 15mg, 20mg, 30mg, 5mg, 7.5mg Tablet ...................................................... 32

Amphotericin B (50mg Injection) ................ 20 Ampicillin (125mg/5ml Suspension,

250mg/5ml Suspension, 250mg Capsule, 500mg Capsule) ...................................... 16

Ampicillin Sodium (10gm Injection, 1gm Injection, 250mg Injection, 2gm Injection, 500mg Injection) ..................................... 16

Ampicillin-Sulbactam (10gm-5gm Injection, 1gm-0.5gm Injection, 2gm-1gm Injection) ................................................................ 16

Ampyra (Tablet Extended-Release 12 Hour) ................................................................ 32

Anadrol-50 (Tablet) ..................................... 38 Anagrelide HCl (Capsule) ............................. 27 Ana-Lex (Kit) ................................................ 33 Anastrozole (Tablet) .................................... 22 AndroGel (40.5mg/2.5gm Gel) ................... 38 Androxy (Tablet) ......................................... 38 Anoro Ellipta (Aerosol Powder) .................. 50 Anzemet (Tablet) ........................................ 20 ApexiCon E (Cream) ..................................... 33

Apidra (Injection) ....................................... 27 Apidra SoloST ............................................. 27 Aplenzin (Tablet Extended-Release 24 Hour)

............................................................... 18 Apokyn (Injection) ...................................... 23 Apraclonidine (Ophthalmic Solution) .......... 49 Aprepitant (Capsule) ................................... 20 Apri (Tablet) ................................................ 38 Apriso (Capsule Extended-Release 24 Hour)

............................................................... 42 Aptiom (Tablet) .......................................... 17 Aptivus (100mg/ml Oral Solution, 250mg

Capsule) ................................................. 25 Aralast NP (Injection) ................................. 51 Aranelle (Tablet) ......................................... 38 Arbinoxa (Tablet) ........................................ 50 Arcalyst (Injection) ..................................... 41 Arcapta Neohaler (Capsule) ....................... 50 Argatroban (125mg/125ml-0.9% Injection,

250mg/250ml-0.9% Injection) ............... 27 Argatroban (250mg/2.5ml Injection) .......... 27 Argyle Sterile Saline 100ml (Solution) ......... 43 Argyle Sterile Water 100ml (Solution) ........ 43 Arial Chamber ............................................. 43 Aripiprazole (10mg Tablet, 15mg Tablet,

20mg Tablet, 2mg Tablet, 30mg Tablet, 5mg Tablet, 1mg/ml Oral Solution) ........ 18

Aripiprazole ODT (Tablet Dispersible) ......... 47 Armodafinil (Tablet) .................................... 52 Armour Thyroid (120mg Tablet, 180mg

Tablet, 240mg Tablet, 300mg Tablet) ... 40 Arnuity Ellipta (Aerosol Powder) ............... 50 Arranon (Injection) ..................................... 22 Arzerra (Injection) ...................................... 23 Ascomp/Codeine (Capsule) ......................... 12 Ashlyna (Tablet) .......................................... 38 Asilnasal Rms (Capsule) ............................... 43 Aspir-81 (Tablet Delayed-Release) .............. 10 Aspirin (325mg Tablet, 81mg Tablet

Chewable, 81mg Tablet Delayed-Release) ............................................................... 10

Aspirin 81 (Tablet Delayed-Release) ........... 10 Aspirin 81 Low Dose (Tablet Chewable) ...... 10 Aspirin Adult Low Dose (Tablet Delayed-

Release) .................................................. 10 Aspirin Childrens (Tablet Chewable) ........... 10 Aspirin EC (Tablet Delayed-Release) ........... 10 Aspirin EC Low Dose (Tablet Delayed-Release)

............................................................... 10 Aspirin Low Dose (Tablet Chewable) ........... 10 Aspirin/Dipyridamole (Capsule Extended-

Release 12 Hour) .................................... 28 Aspirin-Caffeine-Dihydrocodeine (Capsule) 12 Aspir-Low (Tablet Delayed-Release) ........... 10 Aspirtab (Tablet Delayed-Release) .............. 10 Atabex Prenatal (Tablet Chewable) ........... 53 Atenolol (100mg Tablet, 25mg Tablet, 50mg

Tablet) .................................................... 29 Atenolol/Chlorthalidone (Tablet) ................ 29 Atgam (Injection) ........................................ 41 Atorvastatin Calcium (Tablet) ..................... 31

Atovaquone (Suspension) ............................ 23 Atovaquone/Proguanil HCl (Tablet) ............. 23 Atracurium Besylate (Injection) ................... 51 Atripla (Tablet) ............................................ 25 Atropen (0.5mg/0.7ml Injection) ............... 35 Atropine Sulfate (0.1mg/ml Injection,

0.4mg/ml Injection, 1mg/ml Injection, 1mg/2.5ml Solution Prefilled Syringe) .... 35

Atropine Sulfate (1% Ophthalmic Solution) . 49 Atrovent HFA (Aerosol Solution) ................ 50 Aubagio (Tablet) ......................................... 32 Aubra (Tablet) .............................................. 38 Augmented Betamethasone Dipropionate

(0.05% Cream, 0.05% Gel, 0.05% Lotion, 0.05% Ointment)..................................... 33

Augmentin (125mg/5ml-31.25mg/5ml Suspension) ............................................ 16

Aurora Pen Needles 29gx12mm ................. 43 Aurora Pen Needles 31g X 8mm ................. 43 Aurora Unifine Pentips/32gx5/32" ............ 43 Aurora Unifine Pentips/Mini/31gx3/16" ... 43 Autopen ...................................................... 43 Avandia (Tablet) .......................................... 26 Avastin (Injection) ....................................... 23 AVC (Cream) ................................................ 17 Avelox (400mg/250ml-0.8% Injection) ....... 17 Aviane (Tablet) ............................................ 38 Avidoxy (Tablet) ........................................... 17 Avita (0.025% Cream, 0.025% Gel) .............. 33 Avonex (Injection) ....................................... 32 Avonex Pen (Injection)................................ 32 AV-Phos 250 Neutral (Tablet) ...................... 52 AV-Vite FB (Tablet) ...................................... 53 Azacitidine (Injection) .................................. 47 Azactam in Iso-Osmotic Dextrose (1gm-0

Injection) ................................................ 16 Azasan (Tablet) ........................................... 41 Azasite (Ophthalmic Solution) .................... 16 Azathioprine (100mg Injection, 50mg Tablet)

................................................................ 41 Azelastine HCl (0.05% Ophthalmic Solution)49 Azelastine HCl (0.1% Nasal Solution, 0.15%

Nasal Solution) ........................................ 50 Azelex (Cream) ............................................ 33 Azithromycin (100mg/5ml Suspension,

200mg/5ml Suspension, 1gm Packet, 250mg Tablet, 500mg Tablet, 600mg Tablet, 500mg Injection) ......................... 16

Azopt (Suspension) ..................................... 49 Aztreonam (Injection) .................................. 16 Azurette (Tablet) ......................................... 38

B

Baby Super Daily D3 (Liquid) ...................... 53 Baby Vitamin D3 Drops (Liquid) ................. 53 BACiiM (Injection) ........................................ 14 Bacitracin (50000unit Injection, 500unit/gm

Ophthalmic Ointment) ............................ 14 Bacitracin/Polymyxin B (Ophthalmic

Ointment) ............................................... 14

59

Baclofen (10mg Tablet, 20mg Tablet) .......... 24 Bactocill in Dextrose (0-1gm/50ml Injection)

................................................................ 16 Bactroban Nasal (Ointment) ....................... 14 Balanced Salt (Injection) .............................. 49 Balanced Salt Solution (Injection) ................ 49 Balsalazide Disodium (Capsule) ................... 42 Balziva (Tablet) ............................................ 38 Banzel (200mg Tablet, 400mg Tablet,

40mg/ml Suspension) ............................ 18 Baraclude (0.05mg/ml Oral Solution) ........ 24 Bayer Advanced Aspirin Regular Strength

(Tablet) ................................................... 10 Bayer Aspirin EC Low Dose (Tablet Delayed-

Release) .................................................. 10 Bayer Aspirin Regimen (Tablet Delayed-

Release) .................................................. 10 Bayer Chewable Low Dose (Tablet Chewable)

................................................................ 10 Bayer Low Dose (Tablet Delayed-Release) .. 10 BCG Vaccine (Injection)............................... 42 BD Autoshield 29g X 3/16" ......................... 43 BD Autoshield 29g X 5/16" ......................... 43 BD Autoshield Duo 30g X 3/16".................. 43 Bd insul Syr Mis Lo Dose ............................. 43 BD Pen ......................................................... 43 BD Pen Mini ................................................ 43 BD Posiflush (Solution) ................................ 52 BD Swabs Single Use ................................... 14 BD Swabs Single Use Butterfly ................... 14 Bebulin (Injection) ...................................... 28 Beconase AQ (Suspension) ......................... 50 Bekyree (Tablet) .......................................... 38 Belsomra (Tablet)........................................ 52 Benazepril HCl (Tablet) ................................ 29 Benazepril HCl/Hydrochlorothiazide (Tablet)

................................................................ 29 Bendeka (Injection) ..................................... 21 Benefix (Injection)....................................... 28 Benlysta (Injection) ..................................... 41 Benzonatate (Capsule) ................................ 51 Benztropine Mesylate (0.5mg Tablet, 1mg

Tablet, 2mg Tablet, 1mg/ml Injection) ... 23 Bepreve (Ophthalmic Solution) .................. 49 Berinert (Injection) ..................................... 47 Besivance (Suspension) .............................. 17 Betamethasone Dipropionate (0.05% Cream,

0.05% Lotion, 0.05% Ointment) .............. 33 Betamethasone Sodium

Phosphate/Betamethasone Acetate (Injection) ............................................... 37

Betamethasone Valerate (0.1% Cream, 0.1% Lotion, 0.1% Ointment, 0.12% Foam) ..... 33

Betaseron (Injection) .................................. 32 Betaxolol HCl (0.5% Ophthalmic Solution) .. 49 Betaxolol HCl (10mg Tablet, 20mg Tablet) .. 29 Bethanechol Chloride (Tablet) ..................... 37 Bethkis (Nebulized Solution) ...................... 47 Betimol (Ophthalmic Solution) ................... 49 Bexarotene (Capsule) .................................. 23 Bexsero (Injection) ...................................... 42

Bicalutamide (Tablet) .................................. 22 Bicillin C-R (300000unit/ml-300000unit/ml

Injection) ................................................ 16 Bicillin L-A (Injection) ................................. 16 BiCNU (Injection) ........................................ 21 BiDil (Tablet) ............................................... 31 Biltricide (Tablet) ........................................ 23 Bimatoprost (0.03% Ophthalmic Solution) . 48 Biocel (Tablet) ............................................. 53 Bio-D-Mulsion (Liquid) ................................ 53 Bio-D-Mulsion Forte (Liquid) ....................... 53 Bio-Statin (Powder) ..................................... 20 Biothrax (Injection) .................................... 42 Bisacodyl EC (Tablet Delayed-Release) ....... 35 Bisoprolol Fumarate (Tablet) ...................... 29 Bisoprolol Fumarate/Hydrochlorothiazide

(Tablet) ................................................... 29 Bivalirudin (Injection) .................................. 27 BIVIGAM (Injection) ................................... 41 Bleomycin Sulfate (Injection) ...................... 47 Blincyto (Injection) ..................................... 23 Blisovi 24 Fe (Tablet) ................................... 38 Blisovi Fe 1.5/30 (Tablet) ............................ 38 Blisovi Fe 1/20 (Tablet) ............................... 38 Boostrix (Injection) ..................................... 42 Bosulif (Tablet) ........................................... 23 Botox (Injection) ......................................... 43 BP Cleansing Wash (Emulsion) ................... 33 BP Folinatal Plus B (Tablet) ......................... 53 BP Multinatal Plus (Tablet, Tablet Chewable)

............................................................... 53 BP Vit 3 (Capsule) ........................................ 53 B-Plex (Tablet) ............................................. 53 B-Plex Plus (Tablet) ..................................... 53 Bprotected Pedia D-Vite (Liquid) ................ 53 Brainstrong Prenatal .................................. 53 BreatheRite ................................................. 43 BreatheRite Collapsible Spacer w/ Neonate

Mask ...................................................... 43 BreatheRite Rigid Spacer w/Mask ............. 43 BreatheRite w/Large Mask ........................ 43 BreatheRite w/Medium Mask ................... 43 BreatheRite w/Small Mask ........................ 43 Breo Ellipta (Aerosol Powder) .................... 50 Briellyn (Tablet) ........................................... 38 Brilinta (60mg Tablet)................................. 28 Brilinta (90mg Tablet)................................. 28 Brimonidine Tartrate (Ophthalmic Solution)

............................................................... 49 Bromfenac (0.09% Ophthalmic Solution) .... 49 Bromocriptine Mesylate (2.5mg Tablet, 5mg

Capsule) .................................................. 40 Brovana (Nebulized Solution) .................... 50 BSS (Injection) ............................................. 49 Budesonide (0.25mg/2ml Suspension,

0.5mg/2ml Suspension) ......................... 50 Budesonide (1mg/2ml Suspension, 32mcg/act

Suspension) RX ....................................... 50 Budesonide (3mg Capsule Delayed-Release)

............................................................... 42 Bumetanide (0.25mg/ml Injection, 0.5mg

Tablet, 1mg Tablet, 2mg Tablet) ............. 30 Buminate (Injection) .................................... 28 Buphenyl (500mg Tablet) ........................... 34 Bupivacaine HCl (Injection) .......................... 12 Bupivacaine HCl/Sodium Chloride (Solution

Prefilled Syringe) ..................................... 42 Bupivacaine Spinal (Injection) ..................... 12 Bupivacaine/Dextrose Spinal (Injection)...... 12 Bupivacaine/Epinephrine (0.25%-1

200000 Injection) .................................... 12 Bupivacaine/Epinephrine (0.5%-1

200000 Injection) .................................... 42 Buprenorphine HCl (0.3mg/ml Solution) ..... 11 Buprenorphine HCl (2mg Tablet Sublingual,

8mg Tablet Sublingual) ........................... 11 Buprenorphine HCl/Naloxone HCl (Tablet

Sublingual) .............................................. 11 Bupropion HCl (Tablet) ................................ 13 Bupropion HCl ER (Tablet Extended-Release

12 Hour) .................................................. 19 Bupropion HCl SR (100mg Tablet Extended-

Release 12 Hour, 150mg Tablet Extended-Release 12 Hour, 200mg Tablet Extended-Release 12 Hour) .................................... 19

Bupropion HCl SR (150mg Tablet Extended-Release 12 Hour) .................................... 13

Bupropion HCl XL (Tablet Extended-Release 24 Hour) .................................................. 13

Buspirone HCl (Tablet) ................................. 25 Busulfex (Injection) ..................................... 21 Butalbital/Acetaminophen (300mg-50mg

Tablet, 50mg-325mg Tablet) .................. 10 Butalbital/Acetaminophen/Caffeine (325mg-

50mg-40mg Tablet, 50mg-300mg-40mg Capsule) .................................................. 10

Butalbital/Acetaminophen/Caffeine/Codeine (Capsule) ................................................. 12

Butalbital/Aspirin/Caffeine (Capsule) .......... 10 Butalbital/Aspirin/Caffeine/Codeine (Capsule)

................................................................ 12 Butorphanol Tartrate (Nasal Solution,

Injection) ................................................. 12 Butrans (Patch Weekly) .............................. 11 Bydureon Pen (Injection) ............................ 26 Bydureon Vial (Injection) ............................ 26 Byetta (Injection) ........................................ 26 Bystolic (Tablet) .......................................... 29

C

Cabergoline (Tablet) .................................... 40 Cabometyx (Tablet) .................................... 23 Cadeau DHA (Capsule) ................................ 53 Caffeine Citrate (20mg/ml Oral Solution,

60mg/3ml Injection) ............................... 32 Calcidol (Oral Solution) ................................ 53 Calciferol (Oral Solution) ............................. 53 Calcipotriene (0.005% Cream, 0.005%

External Solution, 0.005% Ointment) ..... 33 Calcipotriene/Betamethasone Dipropionate

(Ointment) .............................................. 33

60

Calcitonin-Salmon (Nasal Solution) ............. 42 Calcitrene (Ointment) .................................. 33 Calcitriol (0.25mcg Capsule, 0.5mcg Capsule,

1mcg/ml Injection, 1mcg/ml Oral Solution) ................................................................ 42

Calcitriol (3mcg/gm Ointment) .................... 33 Calcium Acetate (667mg Capsule, 667mg

Tablet)..................................................... 37 Calcium Chloride (Injection) ........................ 52 Camila (Tablet) ............................................ 40 Campath (Injection) .................................... 21 Camptosar (300mg/15ml Injection) ........... 47 Camrese (Tablet) ......................................... 38 Camrese Lo (Tablet) ..................................... 38 Canasa (Suppository) .................................. 42 Candesartan Cilexetil (Tablet) ..................... 28 Candesartan Cilexetil/Hydrochlorothiazide

(Tablet) ................................................... 28 Capacet (Capsule) ........................................ 10 Capastat Sulfate (Injection) ........................ 21 Capecitabine (Tablet) .................................. 22 Capex (Shampoo) ........................................ 33 Caprelsa (100mg Tablet) ............................. 22 Caprelsa (300mg Tablet) ............................. 22 Diltiazem HCl ER (Capsule Extended-Release

24 Hour ................................................... 29 Captopril (Tablet)......................................... 29 Captopril/Hydrochlorothiazide (Tablet) ...... 29 Carafate (1gm/10ml Suspension) ............... 36 Carbaglu (Tablet) ........................................ 52 Carbamazepine (100mg Tablet Chewable,

100mg/5ml Suspension, 200mg Tablet Immediate-Release) ................................ 18

Carbamazepine ER (100mg, 200mg, 300mg Capsule Extended-Release 12 Hour ........ 18

Carbidopa (Tablet) ....................................... 23 Carbidopa/Levodopa (Tablet Immediate-

Release) .................................................. 23 Carbidopa/Levodopa ER (Tablet Extended-

Release) .................................................. 23 Carbidopa/Levodopa/Entacapone (Tablet) . 24 Carbinoxamine Maleate (4mg Tablet,

4mg/5ml Oral Solution) .......................... 50 Carboplatin (Injection) ................................. 21 Cardene IV (20mg/200ml-0.86% Injection) 30 Cardioplegic (Injection)................................ 52 Cardizem LA (120mg Tablet Extended-

Release 24 Hour) .................................... 30 Cardura XL (4mg Tablet Extended-Release 24

Hour) ...................................................... 37 Carefine Pen Needle 32gx4mm .................. 43 Carefine Pen Needles 31gx8mm ................. 43 Carefine Pen Needles 32gx5mm ................. 43 Carefine Pen Needles 32gx6mm ................. 43 Careone Unifine Pentips 29gx12mm .......... 43 Careone Unifine Pentips 31gx8mm ............ 43 Careone Unifine Pentips Pen Needles

32gx4mm ................................................ 43 Caretouch Alcohol Prep Pads ..................... 14 Caretouch Pen Needles 31 G X 6 Mm ......... 43 Caretouch Pen Needles 31gx 5mm ............. 43

Caretouch Pen Needles 31gx 8mm ............ 43 Caretouch Pen Needles 32gx 4mm ............ 43 Caretouch Pen Needles 32gx 5mm ............ 43 Carimune Nanofiltered (Injection) ............. 41 Carisoprodol (250mg Tablet, 350mg Tablet)51 Carteolol HCl (Ophthalmic Solution) ........... 49 Carters Little Pills (Tablet Delayed-Release) 35 Cartia XT (Capsule Extended-Release 24 Hour)

............................................................... 30 Carvedilol (Tablet) ....................................... 29 Cavarest (Gel) .............................................. 32 Caya ............................................................ 43 Cayston (Inhalation Solution) .................... 16 Caziant (Tablet) ........................................... 38 Cedax (180mg/5ml Suspension, 400mg

Capsule) ................................................. 15 Cefaclor (250mg Capsule Immediate-Release,

500mg Capsule Immediate-Release, 250mg/5ml Suspension, 375mg/5ml Suspension) ............................................ 15

Cefaclor ER (Tablet Extended-Release 12 Hour) ...................................................... 15

Cefadroxil (1gm Tablet, 250mg/5ml Suspension, 500mg/5ml Suspension, 500mg Capsule) ...................................... 15

Cefazolin Sodium (10gm Injection, 1gm Injection, 20gm Injection, 500mg Injection) ............................................................... 15

Cefazolin Sodium/Sodium Chloride (Injection) ............................................................... 15

Cefazolin/D5W (Injection) ........................... 15 Cefazolin/Dextrose (Injection) .................... 15 Cefazolin/Sodium Chloride (Injection) ........ 15 Cefdinir (125mg/5ml Suspension, 250mg/5ml

Suspension, 300mg Capsule) .................. 15 Cefditoren Pivoxil (Tablet) .......................... 15 Cefepime (1gm Injection, 2gm Injection) .... 15 Cefixime (Suspension) ................................. 15 Cefotaxime Sodium (Injection).................... 16 Cefotetan (Injection) ................................... 16 Cefotetan/Dextrose (Injection) ................... 16 Cefoxitin Sodium (10gm Injection, 1gm

Injection, 2gm Injection) ........................ 16 Cefpodoxime Proxetil (100mg Tablet, 200mg

Tablet, 100mg/5ml Suspension, 50mg/5ml Suspension) ............................................ 16

Cefprozil (125mg/5ml Suspension, 250mg/5ml Suspension, 250mg Tablet, 500mg Tablet) ........................................ 16

Ceftazidime (Injection) ................................ 16 Ceftin (Suspension) .................................... 16 Ceftriaxone in Iso-Osmotic Dextrose

(Injection) ............................................... 16 Ceftriaxone Sodium (100gm Injection, 1gm

Injection, 250mg Injection, 500mg Injection, 10gm Injection, 2gm Solution) 16

Cefuroxime Axetil (Tablet) .......................... 16 Cefuroxime Sodium (Injection) ................... 16 Celecoxib (Capsule) ..................................... 10 Celontin (Capsule) ...................................... 17 Centrum Specialist Prenatal ....................... 53

Cephalexin (125mg/5ml Suspension, 250mg/5ml Suspension, 250mg Capsule, 500mg Capsule, 750mg Capsule, 250mg Tablet, 500mg Tablet) ............................. 16

Ceprotin (Injection) ..................................... 27 Cerdelga (Capsule) ...................................... 34 Cerezyme (Injection) ................................... 34 Cerovel (40% Gel, 40% Lotion) .................... 33 Cesamet (Capsule) ...................................... 20 Cetirizine HCl (Syrup) RX .............................. 50 Cevimeline HCl (Capsule) ............................. 32 Chantix (Tablet) ........................................... 13 Chantix Continuing Month Pak (Tablet) ..... 13 Chantix ST.................................................... 13 Chateal (Tablet) ........................................... 38 Chek-Stix Control ........................................ 43 Chemet (Capsule) ........................................ 52 Chemstrip 10 MD ........................................ 43 Chemstrip 2 GP Strips ................................. 43 Chemstrip 5 OB ........................................... 43 Chemstrip 7 ................................................. 43 Chemstrip 9 Strips ....................................... 43 Chemstrip UGK ............................................ 43 Chemstrip-10 with SG ................................. 43 Chemstrip-K ................................................ 43 Childrens Aspirin (Tablet Chewable) ............ 10 Childrens Aspirin Low Strength (Tablet

Chewable) ............................................... 10 Chlordiazepoxide HCl (Capsule) ................... 26 Chlordiazepoxide HCl/Clidinium Bromide

(Capsule) ................................................. 35 Chlordiazepoxide/Amitriptyline (Tablet) ..... 19 Chlorhexidine Gluconate (0.12% Solution) .. 32 Chloroquine Phosphate (250mg Tablet,

500mg Tablet) ......................................... 23 Chlorothiazide (Tablet) ................................ 31 Chlorothiazide Sodium (Injection) ............... 31 Chlorpromazine HCl (100mg Tablet, 10mg

Tablet, 200mg Tablet, 25mg Tablet, 50mg Tablet) ..................................................... 19

Chlorpropamide (Tablet) ............................. 26 Chlorthalidone (25mg Tablet, 50mg Tablet) 31 Chlorzoxazone (Tablet) ................................ 51 Cholestyramine (Powder) ............................ 31 Cholestyramine Light (Powder) ................... 31 Choline Magnesium Trisalicylate (500mg/5ml

Liquid) (MANUF CYPRESS PH) ................. 10 Chorionic Gonadotropin (Injection) ............. 37 Chromagen (Capsule) .................................. 52 Chromium Chloride (Injection) .................... 52 Cialis (2.5mg Tablet, 5mg Tablet) ............... 37 Ciclodan (0.77% Cream, 8% External Solution)

................................................................ 20 Ciclopirox (0.77% Gel, 0.77% Suspension, 1%

Shampoo) ............................................... 20 Ciclopirox Nail Lacquer (External Solution) . 20 Ciclopirox Olamine (0.77% Cream) .............. 20 Cidofovir (Injection) ..................................... 24 Cilostazol (Tablet) ........................................ 28 Ciloxan (0.3% Ointment) ............................. 17 Cimetidine (200mg Tablet RX, 300mg Tablet,

61

400mg Tablet, 800mg Tablet) ................. 35 Cimetidine HCl (Oral Solution) ..................... 35 Cimzia (Injection) ........................................ 41 Cimzia Starter Kit (Injection) ...................... 41 Cinryze (Injection) ....................................... 47 Cipro HC (Suspension)................................. 50 Ciprodex (Otic Suspension)......................... 50 Ciprofloxacin (250mg/5ml Suspension,

500mg/5ml Suspension) ......................... 17 Ciprofloxacin ER (Tablet Extended-Release 24

Hour) ....................................................... 17 Ciprofloxacin HCl (0.3% Ophthalmic Solution,

Tablet Immediate-Release) ..................... 17 Ciprofloxacin I.V. in D5W (Injection)............ 17 Cisatracurium Besylate (Injection) ............... 51 Cisplatin (100mg/100ml Injection,

50mg/50ml Injection) ............................. 21 Cisplatin (200mg/200ml Injection) ............. 21 Citalopram HBr (10mg Tablet, 20mg Tablet,

40mg Tablet, 10mg/5ml Oral Solution) .. 19 Citroma (Oral Solution) ................................ 35 Cladribine (Injection) ................................... 22 Claforan (1gm Injection) ............................. 16 Claravis (Capsule) ........................................ 33 Clarinex (0.5mg/ml Syrup) .......................... 50 Clarithromycin (125mg/5ml Suspension,

250mg/5ml Suspension, 250mg Tablet, 500mg Tablet) ......................................... 16

Clarithromycin ER (Tablet Extended-Release 24 Hour) .................................................. 16

Classic Prenatal (Tablet) .............................. 53 ClearLax (Powder) ....................................... 35 Clever Choice Anti-Static Valved Holding

Chamber/Adult Large ............................ 43 Clever Choice Anti-Static Valved Holding

Chamber/Medium ................................. 43 Clever Choice Anti-Static Valved Holding

Chamber/Small ...................................... 43 Clever Choice Comfort EZ Insulin Pen

Needles 31gx8mm .................................. 43 Clever Choice Comfort EZ Pen Needles

29gx12mm .............................................. 43 Clever Choice Comfort EZ Pen Needles

31gx5mm ................................................ 43 Clever Choice Comfort EZ Pen Needles









33gx8mm ............................................... 44 Clickfine Pen Needle 32gx5/32" ................. 44 Clickfine Pen Needles/31gx1/4" ................ 44 Clickfine Pen Needles/31gx5/16" .............. 44 Clindacin ETZ Pledgets (Swab)..................... 33 Clindacin-P (Swab) ...................................... 33 Clindamax (Gel) ........................................... 33 Clindamycin HCl (Capsule Immediate-Release)

............................................................... 14 Clindamycin Palmitate HCl (Oral Solution) .. 14 Clindamycin Phosphate (1% External Solution,

1% Foam, 1% Gel, 1% Lotion, 1% Swab) . 33 Clindamycin Phosphate (2% Cream,

300mg/2ml Injection, 600mg/4ml Injection, 9000mg/60ml Injection, 900mg/6ml Injection) ............................. 14

Clindamycin Phosphate in D5W (Injection) . 14 Clindamycin Phosphate/Tretinoin (Gel) ...... 33 Clindamycin/Benzoyl Peroxide (Gel) ........... 33 Clinisol SF 15% (Injection) ........................... 52 Clobetasol Propionate (0.05% Cream, 0.05%

External Solution, 0.05% Foam, 0.05% Gel, 0.05% Liquid, 0.05% Lotion, 0.05% Ointment, 0.05% Shampoo) ................... 33

Clobetasol Propionate Emollient (Cream) ... 33 Clocortolone Pivalate (Cream) .................... 33 Clodan (Shampoo) ....................................... 33 Clolar (Injection) ......................................... 22 Clomipramine HCl (Capsule) ....................... 19 Clonazepam (Tablet Immediate-Release) ... 17 Clonazepam ODT (Tablet Dispersible) ......... 17 Clonidine HCl (0.1mg Tablet, 0.2mg Tablet,

0.3mg Tablet, 0.1mg/24hr Patch Weekly, 0.2mg/24hr Patch Weekly, 0.3mg/24hr Patch Weekly, 100mcg/ml Injection, 500mcg/ml Injection) ............................. 28

Clonidine HCl ER (Tablet Extended-Release 12 Hour) ...................................................... 32

Clopidogrel (Tablet) .................................... 28 Clorazepate Dipotassium (Tablet) ............... 18 Clotrimazole (1% Cream, 1% External Solution

- RX, 10mg Lozenge, 10mg Troche) ........ 20 Clotrimazole/Betamethasone Dipropionate

(0.05%-1% Cream, 1%-0.05% Lotion) ..... 20 Clozapine (Tablet Immediate-Release) ....... 24 Clozapine ODT (Tablet Dispersible) ............. 24 Coagadex (Injection)................................... 28 Coartem (Tablet) ........................................ 23 Codeine Sulfate (Tablet).............................. 12 Colchicine (0.6mg Tablet)............................ 21 Colcrys (Tablet) ........................................... 21 Colestipol HCl (1gm Tablet, 5gm Packet) .... 31 Colistimethate Sodium (Injection) .............. 14 Colocort (Enema) ........................................ 37 Coly-Mycin S (Suspension) ......................... 50 Combigan (Ophthalmic Solution) ............... 49 Combipatch (Patch Twice Weekly) ............ 38 Combistix .................................................... 44 Combivent Respimat (Aerosol Solution).... 50 Cometriq (Kit) ............................................. 23 Compact Space Chamber/Anti-Static ........ 44

Compact Space Chamber/Anti-Static/Large Mask ....................................................... 44

Compact Space Chamber/Anti-Static/Medium Mask ............................. 44

Complera (Tablet) ....................................... 25 Complete Natal DHA .................................... 53 Completenate (Tablet Chewable) ................ 53 Compro (Suppository) ................................. 19 Co-Natal FA (Tablet) .................................... 53 Condylox (0.5% Gel) .................................... 33 Constulose (Oral Solution) ........................... 35 Copaxone (Injection) ................................... 32 Cordran (4mcg/sqcm Tape) ........................ 33 Coreg CR (Capsule Extended-Release 24

Hour) ...................................................... 29 Corifact (Injection) ...................................... 28 Cormax Scalp Application (External Solution)

................................................................ 33 Correct (Tablet Delayed-Release) ................ 35 Correctol (Tablet Delayed-Release) ............. 35 Cortifoam (Foam) ........................................ 42 Cortisone Acetate (25mg Tablet) ................. 37 Cortisporin (0.5%-0.5% Cream, 1%-0.5%

Ointment) ............................................... 33 Corvita (Tablet) ............................................ 53 Corvita 150 (Tablet) ..................................... 52 Corvite Free (Tablet) .................................... 53 Cosentyx (Injection) .................................... 33 Cosentyx Sensoready Pen (Injection) ......... 33 Cotellic (Tablet) ........................................... 22 Creon (Capsule Delayed-Release) ............... 34 Cresemba (186mg Capsule, 372mg Injection)

................................................................ 20 Crinone (Gel) ............................................... 40 Crixivan (Capsule) ....................................... 25 Cromolyn Sodium (100mg/5ml Concentrate)

................................................................ 35 Cromolyn Sodium (20mg/2ml Nebulized

Solution) ................................................. 51 Cromolyn Sodium (4% Ophthalmic Solution)

................................................................ 49 Cryselle-28 (Tablet) ...................................... 38 Cuprimine (Capsule).................................... 37 Curity Alcohol Prep Pads/Medium 2 Ply .... 14 Curity Alcohol Swabs .................................. 14 Curity Sterile Saline (Solution) ..................... 44 Cuvitru (Injection) ....................................... 41 Cuvposa (Oral Solution) .............................. 35 CVS Aspirin (325mg Tablet, 325mg Tablet

Delayed-Release) .................................... 10 CVS Aspirin Low Dose (Tablet Delayed-

Release) .................................................. 10 CVS Childrens Aspirin (Tablet Chewable)..... 10 CVS D3 (1000unit Capsule, 2000unit Capsule,

400unit Capsule, 5000unit Capsule, 1000unit Tablet Chewable) ..................... 53

CVS Ketone Care ......................................... 44 CVS Nicotine (Patch 24 Hour) ...................... 13 CVS Nicotine Polacrilex (2mg Gum, 4mg Gum,

2mg Lozenge, 4mg Lozenge) ................... 13 CVS Nicotine Transdermal System (Patch 24

62

Hour) ....................................................... 13 CVS NTS Step 1 (Patch 24 Hour) .................. 13 CVS Prenatal (Tablet) ................................... 53 CVS Prenatal Gummy/DHA/Folic Acid (Tablet

Chewable) .............................................. 53 CVS Prenatal Multi+DHA (Capsule) ............ 53 CVS Prep Pads ............................................. 14 CVS Purelax (Powder) .................................. 35 CVS Vitamin D Childrens Gummies (Tablet

Chewable) ............................................... 53 CVS Vitamin D3 Drops/Infants (Liquid) ...... 53 Cyanocobalamin (1000mcg/ml Injection) .... 54 Cyclafem (Tablet) ......................................... 38 Cyclobenzaprine HCl (Tablet) ...................... 51 Cyclopentolate HCl (Ophthalmic Solution) .. 49 Cyclophosphamide (1gm Injection, 2gm

Injection, 500mg Injection) ..................... 21 Cyclophosphamide (25mg Capsule, 50mg

Capsule) .................................................. 21 Cycloserine (Capsule) .................................. 21 Cycloset (Tablet) ......................................... 26 Cyclosporine (100mg Capsule, 25mg Capsule,

50mg/ml Injection) ................................. 41 Cyclosporine Modified (100mg Capsule, 25mg

Capsule, 50mg Capsule, 100mg/ml Oral Solution) ................................................. 41

Cyproheptadine HCl (2mg/5ml Syrup, 4mg Tablet)..................................................... 24

Cyred (Tablet) .............................................. 38 Cystadane (Powder) .................................... 34 Cystagon (Capsule)...................................... 34 Cystaran (Ophthalmic Solution) ................. 49 Cytarabine Aqueous (Injection) ................... 22 Cytogam (Injection) .................................... 41

D

D 1000 (1000unit Capsule, 1000unit Tablet Chewable) ............................................... 54

D 10000 (Capsule) ....................................... 54 D 2000 (Tablet) ............................................ 54 D 400 (400unit Tablet, 400unit Tablet

Chewable) ............................................... 54 D3 (1000unit Capsule, 2000unit Capsule,

400unit Capsule, 1000unit Tablet, 2000unit Tablet) ..................................... 54

D3 2000 (Tablet) .......................................... 54 D3 Adult (Tablet Chewable) ......................... 54 D3 Dots (Tablet Dispersible) ....................... 54 D3 High Potency (Tablet) ............................. 54 D3 Kids (Tablet Chewable) ........................... 54 D3 Maximum Strength (5000unit Capsule,

5000unit/ml Liquid) ................................ 54 D3 Super Strength (Capsule) ....................... 54 D3-1000 (Capsule) ....................................... 54 D3-50 (Capsule) ........................................... 54 Dacarbazine (100mg Injection) ................... 21 Dacarbazine (200mg Injection) .................... 21 Daklinza (Tablet) ......................................... 24 Daliresp (Tablet) ......................................... 51 Danazol (100mg Capsule, 200mg Capsule,

50mg Capsule) ........................................ 38 Dantrolene Sodium (Capsule) ..................... 24 Dapsone (Tablet) ......................................... 21 Daptacel (Injection) .................................... 42 Daptomycin (Solution) ................................ 14 DARAPRIM (Tablet) .................................... 23 Darifenacin HBr ER (Tablet Extended-Release

24 Hour) ................................................. 36 Darzalex (Injection) .................................... 23 Dasetta 1/35 (Tablet) .................................. 38 Dasetta 7/7/7 (Tablet) ................................ 38 Daunorubicin HCl (Injection) ....................... 47 Daysee (Tablet) ........................................... 38 Daytrana (Patch)......................................... 32 Ddrops (Liquid) ........................................... 54 Ddrops Booster (Liquid) ............................. 54 Deblitane (Tablet) ....................................... 40 Decara (25000unit Capsule) ....................... 54 Decara (50000unit Capsule) ........................ 54 Decitabine (Injection) .................................. 22 Deferoxamine Mesylate (Injection) ............ 44 Delflex-Sm/1.5% Dextrose (Injection) ......... 44 Delflex-Sm/2.5% Dextrose (Injection) ......... 44 Delta D3 (Tablet) ......................................... 54 Deltasone (Tablet) ....................................... 37 Delyla (Tablet) ............................................. 38 Demeclocycline HCl (150mg Tablet, 300mg

Tablet) .................................................... 17 Demser (Capsule) ....................................... 30 Denavir (Cream) ......................................... 25 Depen Titratabs (Tablet) ............................ 37 Depocyt (Injection) ..................................... 22 Depo-Medrol (20mg/ml Injection) ............. 37 Depo-Provera (Injection) ............................ 40 Depo-SubQ Provera104 (Injection) ............ 40 DermacinRx Empricaine (Kit) ...................... 12 DermacinRx Prizopak (Kit) ........................... 12 Desipramine HCl (100mg Tablet, 10mg Tablet,

150mg Tablet, 25mg Tablet, 50mg Tablet, 75mg Tablet) .......................................... 19

Desloratadine (Tablet) ................................ 50 Desloratadine ODT (Tablet Dispersible) ...... 50 Desmopressin Acetate (0.01% Nasal Solution,

0.1mg/ml Nasal Solution, 0.1mg Tablet, 0.2mg Tablet, 4mcg/ml Injection) .......... 37

Desogestrel/Ethinyl Estradiol (Tablet) ........ 38 Desonide (0.05% Cream, 0.05% Lotion, 0.05%

Ointment) ............................................... 33 Desoximetasone (0.05% Cream, 0.25%

Cream, 0.05% Gel, 0.05% Ointment, 0.25% Ointment) ............................................... 33

Desvenlafaxine ER (100mg Tablet Extended-Release 24 Hour, 25mg Tablet Extended-Release 24 Hour, 50mg Tablet Extended-Release 24 Hour) .................................... 19

Dexamethasone (0.5mg Tablet, 0.75mg Tablet, 1.5mg Tablet, 1mg Tablet, 2mg Tablet, 4mg Tablet, 6mg Tablet, 0.5mg/5ml Elixir, 0.5mg/5ml Oral Solution) ............................................................... 37

Dexamethasone Intensol (1mg/ml

Concentrate) .......................................... 37 Dexamethasone Sodium Phosphate (0.1%

Ophthalmic Solution) .............................. 49 Dexamethasone Sodium Phosphate

(10mg/ml Injection) ................................ 41 Dexamethasone Sodium Phosphate

(120mg/30ml Injection, 20mg/5ml Solution) ................................................. 37

Dexamethasone Sodium Phosphate (4mg/ml Solution) ................................................. 47

Dexedrine (10mg Tablet, 5mg Tablet) ......... 32 Dexilant (Capsule Delayed-Release) ........... 36 Dexmedetomidine HCl (Injection) ............... 25 Dexmethylphenidate HCl (Tablet Immediate-

Release) .................................................. 32 Dexmethylphenidate HCl ER (10mg, 15mg,

20mg, 30mg, 40mg, 5mg, 25mg, 35mg Capsule Extended-Release 24 Hour) ....... 32

DexPak 10 Day (Tablet Therapy Pack) ........ 37 DexPak 13 Day (Tablet Therapy Pack) ........ 37 DexPak 6 Day (Tablet Therapy Pack) .......... 37 Dexrazoxane (Injection) ............................... 47 Dextroamphetamine Sulfate (10mg Tablet,

5mg Tablet, 5mg/5ml Oral Solution) ...... 32 Dextroamphetamine Sulfate ER (10mg

Capsule Extended-Release 24 Hour, 5mg Capsule Extended-Release 24 Hour) ....... 32

Dextroamphetamine Sulfate ER (15mg Capsule Extended-Release 24 Hour) ....... 32

Dextrose 10% (Injection) ............................. 47 Dextrose 2.5%/NaCl 0.45% (Injection) ......... 47 Dextrose 5% (Injection) ............................... 47 Dextrose 5%/Lactated Ringers (Injection) ... 52 Dextrose 5%/NaCl 0.2% (Injection) .............. 47 Dextrose 5%/NaCl 0.33% (Injection) ............ 47 Dextrose 5%/NaCl 0.45% (Injection) ............ 47 Dextrose 5%/NaCl 0.9% (Injection) .............. 47 Dextrose 50% (Injection) ............................. 47 Dextrose 70% (Injection) ............................. 26 Dialyvite Vitamin D 5000 (Capsule) ............. 54 Dialyvite Vitamin D3 Max (Tablet) ............... 54 Diascreen 10 ................................................ 44 Diascreen 1B ............................................... 44 Diascreen 1G ............................................... 44 Diascreen 1K................................................ 44 Diascreen 2GK ............................................. 44 Diascreen 2GP ............................................. 44 Diascreen 3 .................................................. 44 Diascreen 4NL ............................................. 44 Diascreen 4OBL ........................................... 44 Diascreen 4PH ............................................. 44 Diascreen 5 .................................................. 44 Diascreen 6 .................................................. 44 Diascreen 7 .................................................. 44 Diascreen 8 .................................................. 44 Diascreen 9 .................................................. 44 Diascreen Liquid Urine Controls ................. 44 Diastix.......................................................... 44 Diazepam (10mg Gel, 2.5mg Gel, 20mg Gel,

10mg Tablet, 2mg Tablet, 5mg Tablet, 1mg/ml Oral Solution, 5mg/ml Injection)

63

................................................................ 18 Diazepam Intensol (5mg/ml Concentrate) .. 18 Diclofenac Potassium (Tablet) ..................... 10 Diclofenac Sodium (0.1% Ophthalmic

Solution) ................................................. 49 Diclofenac Sodium (1% Gel) ........................ 33 Diclofenac Sodium (1.5% Transdermal

Solution) ................................................. 33 Diclofenac Sodium (3% Gel) ........................ 14 Diclofenac Sodium DR (Tablet Delayed-

Release) .................................................. 10 Diclofenac Sodium ER (Tablet Extended-

Release 24 Hour) .................................... 10 Diclofenac Sodium/Misoprostol (Tablet

Delayed-Release) .................................... 10 Dicloxacillin Sodium (Capsule) ..................... 16 Dicyclomine HCl (10mg Capsule, 10mg/5ml

Oral Solution, 10mg/ml Injection, 20mg Tablet)..................................................... 35

Didanosine (Capsule Delayed-Release) ....... 25 Dificid (Tablet)............................................. 16 Difil-G Forte (Liquid) .................................... 51 Diflorasone Diacetate (0.05% Cream, 0.05%

Ointment) ............................................... 33 Diflunisal (Tablet) ........................................ 10 Digitek (Tablet) ............................................ 30 Digox (Tablet) .............................................. 30 Digoxin (0.05mg/ml Oral Solution, 0.25mg/ml

Injection, 125mcg Tablet, 250mcg Tablet) ................................................................ 30

Dihydroergotamine Mesylate (1mg/ml Injection) ................................................. 21

Dihydroergotamine Mesylate (4mg/ml Nasal Solution) ................................................. 21

Dilantin (30mg Capsule).............................. 18 Dilatrate SR (Capsule Extended-Release) ... 31 Diltiazem CD (Capsule Extended-Release 24

Hour) ....................................................... 30 Diltiazem HCl (125mg/25ml Injection,

25mg/5ml Injection, 50mg/10ml Injection) ................................................................ 47

Diltiazem HCl (Tablet Immediate-Release) .. 29 Diltiazem HCl CD (Capsule Extended-Release

24 Hour) .................................................. 30 Diltiazem HCl ER (Capsule Extended-Release

24 Hour, Tablet Extended-Release 24 Hour) ....................................................... 30

Diltiazem HCl/Dextrose (Injection) .............. 47 Diltiazem HCl/Sodium Chloride (Injection) .. 47 Dilt-XR (Capsule Extended-Release 24 Hour)

................................................................ 29 Dipentum (Capsule) .................................... 42 Diphenhydramine HCl (12.5mg/5ml Elixir,

50mg/ml Injection) ................................. 19 Diphenoxylate/Atropine (2.5mg-0.025mg

Tablet, 2.5mg-0.025mg/5ml Liquid) ....... 35 Diphtheria/Tetanus Toxoids Adsorbed

Pediatric (Injection)................................ 42 Dipyridamole (25mg Tablet, 50mg Tablet,

75mg Tablet) ........................................... 28 Disopyramide Phosphate (Capsule) ............. 29

Disulfiram (Tablet) ...................................... 13 Divalproex Sodium (Capsule Sprinkle Delayed-

Release) .................................................. 18 Divalproex Sodium DR (Tablet Delayed-

Release) .................................................. 18 Divalproex Sodium ER (Tablet Extended-

Release 24 Hour) .................................... 18 Dobutamine HCl (Injection)......................... 30 Dobutamine HCl/D5W (Injection) ............... 30 Docefrez (Injection) .................................... 48 Docetaxel (160mg/16ml Injection,

160mg/8ml Injection, 20mg/2ml Injection, 20mg/ml Injection, 80mg/4ml Injection, 80mg/8ml Injection).............. 22

Docetaxel (20mg/0.5ml Injection, 80mg/2ml Injection) ................................................ 48

Docetaxel (Non-Alcohol Formula) (Injection) ............................................................... 22

Dofetilide (Capsule) ..................................... 29 Donepezil HCl (10mg Tablet Dispersible, 5mg

Tablet Dispersible, 10mg Tablet, 23mg Tablet, 5mg Tablet) ................................ 18

Dopamine HCl (40mg/ml Injection, 80mg/ml Injection) ................................................ 30

Dopamine/D5W (Injection) ......................... 30 Doribax (500mg Injection) .......................... 16 Doripenem (500mg Injection) .................... 16 Dorzolamide HCl (Ophthalmic Solution) ..... 30 Dorzolamide HCl/Timolol Maleate

(Ophthalmic Solution) ............................ 49 Doxazosin (Tablet)....................................... 28 Doxazosin Mesylate (Tablet) ....................... 28 Doxepin HCl (100mg Capsule, 10mg Capsule,

150mg Capsule, 25mg Capsule, 50mg Capsule, 75mg Capsule, 10mg/ml Concentrate) .......................................... 19

Doxepin HCl (Cream) ................................... 33 Doxercalciferol (0.5mcg Capsule, 1mcg

Capsule, 2.5mcg Capsule, 4mcg/2ml Injection) ................................................ 42

Doxorubicin HCl (Injection) ......................... 21 Doxy 100 (Injection) .................................... 17 Doxycycline (25mg/5ml Suspension) .......... 17 Doxycycline (40mg Capsule Delayed-Release)

............................................................... 33 Doxycycline Hyclate (100mg Capsule, 50mg

Capsule, 100mg Injection, 100mg Tablet, 20mg Tablet) .......................................... 17

Doxycycline Hyclate DR (Tablet Delayed-Release) .................................................. 17

Doxycycline Monohydrate (100mg Capsule, 150mg Capsule, 50mg Capsule, 75mg Capsule, 100mg Tablet, 150mg Tablet, 50mg Tablet, 75mg Tablet) .................... 17

Dronabinol (Capsule) .................................. 20 Droperidol (2.5mg/ml Injection) ................. 19 Droplet Pen Needles 29gx10mm ............... 44 Droplet Pen Needles 32gx5mm ................. 44 Drospirenone/Ethinyl Estradiol (Tablet) ..... 38 Drospirenone/Ethinyl Estradiol/Levomefolate

Calcium (Tablet) ..................................... 38

Droxia (Capsule) .......................................... 22 Duavee (Tablet) ........................................... 48 Ducodyl (Tablet Delayed-Release) ............... 35 Dulcolax Balance (Powder) .......................... 35 Duloxetine HCl (20mg Capsule Delayed-

Release, 30mg Capsule Delayed-Release, 60mg Capsule Delayed-Release) ............. 19

Duloxetine HCl (40mg Capsule Delayed-Release) .................................................. 19

Duramorph (Injection) ................................. 12 Duraxin (Capsule) ........................................ 10 Durezol (Emulsion) ...................................... 49 Dutasteride (Capsule) .................................. 37 Dutasteride/Tamsulosin HCl (Capsule) ........ 37 D-Vita (Liquid) .............................................. 54 Dymista (Suspension) ................................. 50 Dyrenium (0-100mg Capsule) ..................... 31 Dysport (Injection) ...................................... 48

E

E.E.S. 400 (Tablet) ........................................ 16 Easivent ....................................................... 44 Easivent/Mask-Large .................................. 44 Easivent/Mask-Medium ............................. 44 Easivent/Mask-Small .................................. 44 Easy Comfort Pen Needles 31gx1/4" .......... 44 Easy Comfort Pen Needles 31gx3/16" ........ 44 Easy Comfort Pen Needles 31gx5/16" ........ 44 Easy Comfort Pen Needles 32gx5/32" ........ 44 Easy Touch 32gx5mm.................................. 44 Easy Touch 32gx6mm.................................. 44 Easy Touch Alcohol Prep Pads/Medium ..... 14 Easy Touch Insulin Syringe/U-100/1ml/31g X

5/16" ...................................................... 44 Easy Touch Pen Needles 29gx1/2" ............. 44 Easy Touch Pen Needles 31gx1/4" ............. 44 Easy Touch Pen Needles 31gx5/16" ........... 44 Easy Touch Pen Needles 32gx1/4" ............. 44 Easy Touch Pen Needles 32gx3/16" ........... 44 Easy Touch Pen Needles 32gx5/32" ........... 44 Easy Touch Pen Needles/31g X 3/16" ........ 44 Easygel (Gel) ................................................ 32 Econazole Nitrate (1% Cream) ..................... 20 Econtra EZ (Tablet) ...................................... 40 Ecotrin (Tablet Delayed-Release) ................ 10 Ecotrin Low Strength (Tablet Delayed-

Release) .................................................. 10 Ecpirin (Tablet Delayed-Release) ................. 10 Edarbi (Tablet)............................................. 28 ED-Flex (Capsule) ......................................... 10 Edurant (Tablet) .......................................... 25 Effer-K (Tablet Effervescent) ....................... 52 Effervescent Potassium/Chloride (Tablet

Effervescent) ........................................... 52 Effient (Tablet) ............................................ 28 Egrifta (Injection) ........................................ 38 Elaprase (Injection) ..................................... 34 Elelyso (Injection)........................................ 34 Elidel (Cream) .............................................. 33 Eligard (Injection) ........................................ 40

64

Elinest (Tablet) ............................................. 38 Eliquis (Tablet) ............................................ 27 Elitek (Injection) .......................................... 22 Elite-Ob (Tablet) .......................................... 54 Elixophyllin (Elixir) ...................................... 51 Ella (Tablet) ................................................. 40 Elmiron (Capsule) ........................................ 37 Eloctate (Injection)...................................... 28 Emadine (Ophthalmic Solution) ................. 49 Embeda (Capsule Extended-Release) ......... 11 Emcyt (Capsule) .......................................... 22 Emoquette (Tablet) ..................................... 38 Empliciti (Injection) ..................................... 23 Emsam (Patch 24 Hour) .............................. 19 Emtriva (10mg/ml Oral Solution, 200mg

Capsule) .................................................. 25 Enalapril Maleate (Tablet) ........................... 29 Enalapril Maleate/Hydrochlorothiazide

(Tablet) ................................................... 29 Enalaprilat (Injection) .................................. 29 Enbrel (25mg Injection) .............................. 41 Enbrel (25mg/0.5ml Injection, 50mg/ml

Injection) ................................................ 48 Enbrel SureClick (Injection)......................... 48 Encare (Suppository) ................................... 37 Endocet (Tablet) .......................................... 12 Enfamil Expecta........................................... 54 Engerix-B (Injection) ................................... 42 Enoxaparin Sodium (100mg/ml Injection,

120mg/0.8ml Injection, 150mg/ml Injection, 30mg/0.3ml Injection, 40mg/0.4ml Injection, 60mg/0.6ml Injection, 80mg/0.8ml Injection, 300mg/3ml Injection) ............................. 27

Enpresse-28 (Tablet) .................................... 38 Enskyce (Tablet)........................................... 38 Entacapone (Tablet) .................................... 23 Entecavir (Tablet) ........................................ 24 Enulose (Oral Solution) ................................ 35 Epclusa (Tablet) ........................................... 24 Ephedrine Sulfate (Solution) ........................ 26 Ephedrine Sulfate/Sodium Chloride

(50mg/5ml-0.9% Solution Prefilled Syringe) ................................................... 50

Epiduo (Gel) ................................................ 33 Epiduo Forte (Gel) ....................................... 33 Epinastine HCl (Ophthalmic Solution) ......... 49 Epinephrine (0.15mg/0.3ml Injection,

0.3mg/0.3ml Injection) (authorized generic Epi-Pen made by Mylan) ........... 51

EpiPen (Injection) ........................................ 51 Epirubicin HCl (Injection) ............................. 48 Epitol (Tablet) .............................................. 18 Epivir HBV (5mg/ml Oral Solution) ............. 24 Eplerenone (Tablet) ..................................... 31 Epoprostenol Sodium (Injection) ................. 51 Eprosartan Mesylate (Tablet) ...................... 28 Eptifibatide (Injection) ................................. 28 EQ Aspirin (325mg Tablet, 325mg Tablet

Delayed-Release) .................................... 10 EQ Childrens Aspirin (Tablet Chewable) ...... 10

EQ ClearLax (Powder).................................. 35 EQ Nicotine (14mg/24hr Patch 24 Hour,

21mg/24hr Patch 24 Hour, 7mg/24hr Patch 24 Hour, 4mg Lozenge) ................ 13

EQ Nicotine Gum Refill (Gum) ..................... 13 EQ Nicotine Gum Starter (Gum) .................. 13 EQ Nicotine Polacrilex (2mg Gum, 4mg Gum,

2mg Lozenge, 4mg Lozenge) .................. 13 EQL Alcohol Swabs ..................................... 14 EQL Aspirin (Tablet) .................................... 10 EQL Aspirin EC (Tablet Delayed-Release) .... 10 EQL ClearLax (Powder) ................................ 35 EQL Gentle Laxative (Tablet Delayed-Release)

............................................................... 35 EQL Laxative (Tablet Delayed-Release) ....... 35 EQL Nicotine (Lozenge) ............................... 13 EQL Nicotine Polacrilex (2mg Gum, 4mg Gum,

2mg Lozenge, 4mg Lozenge) .................. 13 EQL Prenatal Formula (Tablet) .................... 54 EQL Vitamin D3 (Capsule) ........................... 54 EQL Vitamin D3 Gummies (Tablet Chewable)

............................................................... 54 Eraxis (50mg Injection) ............................... 20 Erbitux (Injection) ....................................... 23 Ergocalciferol (8000unit/ml Oral Solution) . 54 Ergoloid Mesylates (Tablet) ........................ 18 Ergomar (Tablet Sublingual) ....................... 21 Ergotamine Tartrate/Caffeine (Tablet) ....... 21 Erivedge (Capsule) ...................................... 23 Errin (Tablet) ............................................... 40 Ertaczo (Cream) .......................................... 20 Erwinaze (Injection).................................... 48 Ery ............................................................... 33 Ery-Tab (333mg Tablet Delayed-Release) .. 16 Erythrocin Lactobionate (Injection) ........... 16 Erythromycin (2% External Solution, 2% Gel,

2% Pad) .................................................. 33 Erythromycin (250mg Capsule Delayed-

Release, 5mg/gm Ointment) .................. 16 Erythromycin Base (Tablet) ......................... 16 Erythromycin Ethylsuccinate (200mg/5ml

Suspension, 400mg Tablet) .................... 17 Erythromycin/Benzoyl Peroxide (Gel) ......... 33 Esbriet (Capsule) ......................................... 51 Escitalopram Oxalate (10mg Tablet, 20mg

Tablet, 5mg Tablet, 5mg/5ml Oral Solution) ................................................. 19

Esgic (Capsule) ............................................ 10 Esmolol HCl (Injection) ................................ 29 Esomeprazole Magnesium (Capsule Delayed-

Release) .................................................. 36 Esomeprazole Sodium (40mg Injection) ..... 36 Esomeprazole Strontium (Capsule Delayed-

Release) ................................................. 36 Estarylla (Tablet) ......................................... 38 Estazolam (Tablet)....................................... 26 Estrace (0.1mg/gm Cream) ........................ 38 Estradiol (0.025mg/24hr Patch Weekly,

0.05mg/24hr Patch Weekly, 0.06mg/24hr Patch Weekly, 0.075mg/24hr Patch Weekly, 37.5mcg/24hr Patch Weekly,

0.1mg/24hr Patch Weekly, 0.5mg Tablet, 1mg Tablet, 2mg Tablet) ......................... 38

Estradiol Valerate (Injection) ....................... 38 Estradiol/Norethindrone Acetate (Tablet)... 38 Estropipate (Tablet) ..................................... 38 Eszopiclone (Tablet)..................................... 52 Ethacrynate Sodium (Injection) ................... 31 Ethacrynic Acid (Tablet) ............................... 31 Ethambutol HCl (100mg Tablet, 400mg

Tablet) ..................................................... 21 Ethosuximide (250mg Capsule, 250mg/5ml

Oral Solution) .......................................... 17 Ethynodiol Diacetate/Ethinyl Estradiol

(Tablet) ................................................... 38 Etidronate Disodium (Tablet) ...................... 42 Etodolac (200mg Capsule, 300mg Capsule,

400mg Tablet, 500mg Tablet) ................. 10 Etodolac ER (Tablet Extended-Release 24

Hour) ....................................................... 10 Etopophos (Injection) ................................. 22 Etoposide (100mg/5ml Injection, 1gm/50ml

Injection, 500mg/25ml Injection) ........... 22 Etoposide (50mg Capsule) .......................... 22 Eurax (10% Cream, 10% Lotion) .................. 23 Evamist (Transdermal Solution) ................. 38 Evotaz (Tablet) ............................................ 25 Excel Comfort Point Insulin Pen Needles 31g

X 4mm .................................................... 44 Exel Comfort Point Insulin Pen Needles 29g X

12mm ..................................................... 44 Exel Comfort Point Insulin Pen Needles 31g X

8mm ....................................................... 44 Exel Comfort Point Insulin

Syringe/0.3ml/29g X 1/2" ...................... 44 Exel Comfort Point Insulin

Syringe/0.3ml/30g X 5/16" .................... 44 Exelderm (1% Cream, 1% External Solution)

................................................................ 20 Exemestane (Tablet) .................................... 22 Exjade (Tablet Soluble) ............................... 52 Ex-Lax Ultra (Tablet Delayed-Release) ......... 35 Eylea (Injection) .......................................... 49 E-Z Spacer .................................................... 44 E-Z Spacer the Body Guards Pack ............... 44 Ezetimibe (Tablet)........................................ 31

F

FA-8 (0.8mg Capsule, 800mcg Tablet) ......... 54 Fabb (Tablet) ............................................... 54 Fabrazyme (Injection) ................................. 34 Factive (Tablet) ........................................... 17 Fallback Solo (Tablet) ................................... 40 Falmina (Tablet) ........................................... 38 Famciclovir (Tablet) ..................................... 25 Famotidine (200mg/20ml Injection,

20mg/2ml Injection, 40mg/4ml Injection, 20mg Tablet, 40mg Tablet, 40mg/5ml Suspension) ............................................ 35

Fanapt (Tablet) ............................................ 24 Fanapt Titration Pack (Tablet) .................... 24

65

Fareston (Tablet) ......................................... 22 Farxiga (Tablet) ........................................... 26 Farydak (Capsule) ....................................... 22 Faslodex (Injection)..................................... 22 Fazaclo (12.5mg Tablet Dispersible, 150mg

Tablet Dispersible, 200mg Tablet Dispersible) ............................................ 24

FC Female Condom ..................................... 44 FC2 Female Condom ................................... 44 Feenamint (Tablet Delayed-Release) ........... 35 Feiba (Injection) .......................................... 28 Felbamate (400mg Tablet, 600mg Tablet,

600mg/5ml Suspension) ......................... 18 Felodipine ER (Tablet Extended-Release 24

Hour) ....................................................... 30 Femcap ........................................................ 44 Femynor (Tablet) ......................................... 38 Fenofibrate (120mg Tablet, 145mg Tablet,

160mg Tablet, 40mg Tablet, 48mg Tablet, 54mg Tablet, 130mg Capsule, 150mg Capsule, 43mg Capsule, 50mg Capsule) . 31

Fenofibrate Micronized (Capsule) ............... 31 Fenofibric Acid (Tablet) ............................... 31 Fenofibric Acid DR (Capsule Delayed-Release)

................................................................ 31 Fenoprofen Calcium (200mg Capsule, 400mg

Capsule, 600mg Tablet) .......................... 10 Fenortho (Capsule) ..................................... 10 Fentanyl (Patch 72 Hour) ............................. 11 Fentanyl Citrate Oral Transmucosal (Lollipop)

................................................................ 12 Fentanyl Citrate/Bupivacaine HCl/Sodium

Chloride (Solution) .................................. 32 Ferocon (Capsule) ........................................ 52 Ferotrinsic (Capsule) .................................... 52 Ferriprox (500mg Tablet) ............................ 44 Ferrocite Plus (Tablet) ................................. 52 Fetzima (Capsule Extended-Release 24 Hour)

................................................................ 19 Fibricor (35mg Tablet)................................. 31 Fifty50 Alcohol Prep Pads ........................... 14 Fifty50 Pen Needles 31g X3/16" (5mm) ..... 44 Fifty50 Pen Needles 31g X5/16" (8mm) ..... 44 Fifty50 Pen Needles 31gx5mm ................... 44 Fifty50 Pen Needles/31gx8mm .................. 44 Fifty50 Pen Needles/32gx4mm .................. 44 Fifty50 Pen Needles/32gx6mm .................. 44 Finacea (15% Foam, 15% Gel) ..................... 33 Finasteride (5mg Tablet).............................. 37 Firazyr (Injection) ........................................ 48 Firmagon (Injection) ................................... 40 Flarex (Suspension) ..................................... 49 Flavoxate HCl (Tablet).................................. 36 Flebogamma DIF (Injection) ....................... 41 Flecainide Acetate (Tablet) .......................... 29 Fleet Laxative (Tablet Delayed-Release) ...... 35 Flexbumin (Injection) ................................... 28 Flexichamber ............................................... 44 Flexichamber Child Mask/Large ................. 44 Flexichamber Child Mask/Small ................. 44 Flovent Diskus (Aerosol Powder) ............... 50

Flovent HFA (Aerosol) ................................ 50 Flowtuss (Oral Solution) ............................. 51 Floxuridine (Injection) ................................ 22 Fluad 2016-2017 (Injection) ....................... 48 Fluarix Quadrivalent 2016-2017 (Injection) 48 Flublok 2016-2017 (Injection) .................... 48 Flucelvax Quadrivalent 2016-2017 (Injection)

............................................................... 48 Fluconazole (100mg Tablet, 150mg Tablet,

200mg Tablet, 50mg Tablet, 10mg/ml Suspension, 40mg/ml Suspension) ........ 20

Fluconazole in Dextrose (Injection) ............. 20 Fluconazole in NaCl (200mg/100ml-0.9%

Injection, 400mg/200ml-0.9% Injection) 20 Flucytosine (Capsule) .................................. 20 Fludarabine Phosphate (Injection) .............. 48 Fludrocortisone Acetate (0.1mg Tablet) ..... 37 Flulaval Quadrivalent 2016-2017 (Injection)

............................................................... 25 Flumazenil (Injection) .................................. 32 Flumist Quadrivalent (Suspension) ............ 25 Flunisolide (Nasal Solution) ......................... 50 Fluocinolone Acetonide (0.01% Cream,

0.025% Cream, 0.01% External Solution, 0.01% Oil, 0.025% Ointment) ................. 33

Fluocinolone Acetonide Body (Oil) .............. 33 Fluocinolone Acetonide Ear Drops (Oil) ...... 33 Fluocinolone Acetonide Scalp (Oil) ............. 33 Fluocinonide (0.05% Cream, 0.1% Cream,

0.05% External Solution, 0.05% Gel, 0.05% Ointment) ............................................... 33

Fluocinonide-E (Cream) ............................... 33 Fluor-A-Day (Oral Solution) ......................... 52 Fluoride (Tablet Chewable) ......................... 52 Fluoritab (0.125mg/drop Oral Solution,

0.25mg Tablet Chewable, 0.5mg Tablet Chewable, 1mg Tablet Chewable) .......... 52

Fluorometholone (Ophthalmic Suspension) 49 Fluoroplex (Cream) ..................................... 33 Fluorouracil (0.5% Cream)........................... 33 Fluorouracil (1gm/20ml Injection,

2.5gm/50ml Injection, 500mg/10ml Injection, 5gm/100ml Injection) ............. 22

Fluorouracil (2% External Solution, 5% External Solution) ................................... 33

Fluorouracil (5% Cream).............................. 22 Fluoxetine (Capsule) ................................... 19 Fluoxetine DR (Capsule Delayed-Release)... 19 Fluoxetine HCl (10mg Tablet, 20mg Tablet,

60mg Tablet, 20mg/5ml Oral Solution, 40mg Capsule) ........................................ 19

Fluphenazine Decanoate (Injection) ........... 24 Fluphenazine HCl (10mg Tablet, 1mg Tablet,

2.5mg Tablet, 5mg Tablet) ..................... 24 Flura-Drops (Oral Solution) ......................... 52 Flurandrenolide (0.05% Cream, 0.05% Lotion,

0.05% Ointment) .................................... 33 Flurazepam HCl (Capsule) ........................... 26 Flurbiprofen (100mg Tablet, 50mg Tablet) . 10 Flurbiprofen Sodium (Ophthalmic Solution) 49 Flutamide (Capsule) .................................... 22

Fluticasone Propionate (0.005% Ointment, 0.05% Cream, 0.05% Lotion) ................... 33

Fluticasone Propionate (50mcg/act Suspension) RX ....................................... 50

Fluvastatin (Capsule) ................................... 31 Fluvastatin Sodium ER (Tablet Extended-

Release 24 Hour) .................................... 31 Fluvirin 2016-2017 (Injection) ..................... 42 Fluvoxamine Maleate (Tablet) ..................... 19 Fluvoxamine Maleate ER (Capsule Extended-

Release 24 Hour) .................................... 19 Fluzone High-Dose Pf 2016-2017 (Injection)

................................................................ 48 Fluzone Quadrivalent 2016-2017 (Injection)

................................................................ 24 FML (Ointment) ........................................... 49 Folbee (Tablet)............................................. 54 Folbee Plus (Tablet) ..................................... 54 Folic Acid (1mg Tablet, 400mcg Tablet,

800mcg Capsule) RX ............................... 54 Folic Acid/Vitamin B-6/Vitamin B-12 (Tablet)

................................................................ 54 Folotyn (Injection)....................................... 22 Folplex 2.2 (Tablet) ...................................... 54 Foltrin (Capsule) .......................................... 52 Fomepizole (Injection) ................................. 44 Fondaparinux Sodium (Injection) ................ 27 Forteo (Injection) ........................................ 42 Fosamax Plus D (Tablet).............................. 42 Fosinopril Sodium (Tablet) ........................... 29 Fosinopril Sodium/Hydrochlorothiazide

(Tablet) ................................................... 29 Fosphenytoin Sodium (Injection) ................. 18 Fosrenol (1000mg Packet, 750mg Packet,

1000mg Tablet Chewable, 500mg Tablet Chewable, 750mg Tablet Chewable) ..... 37

Fragmin (Injection) ...................................... 27 Frovatriptan Succinate (Tablet) ................... 21 Furosemide (10mg/ml Injection, 10mg/ml

Oral Solution, 8mg/ml Oral Solution, 20mg Tablet, 40mg Tablet, 80mg Tablet) ......... 31

Fuzeon (Injection) ....................................... 25 Fyavolv (Tablet) ........................................... 38 Fycompa (0.5mg/ml Suspension, 10mg

Tablet, 12mg Tablet, 2mg Tablet, 4mg Tablet, 6mg Tablet, 8mg Tablet) ............ 17

G

Gabapentin (100mg Capsule, 300mg Capsule, 400mg Capsule, 250mg/5ml Oral Solution, 600mg Tablet, 800mg Tablet) ................. 24

Gabitril (12mg Tablet, 16mg Tablet)........... 18 Galantamine HBr (12mg Tablet, 4mg Tablet,

8mg Tablet, 4mg/ml Oral Solution) ........ 18 Galantamine HBr ER (Capsule Extended-

Release 24 Hour) .................................... 18 Gamastan S/D (Injection) ........................... 41 Gammagard Liquid (Injection) .................... 41 Gammagard S/D IGA Less Than 1 mcg/ml

(Injection) ............................................... 41

66

Gammaked (Injection) ................................ 41 Gammaplex (Injection) ............................... 41 Gamunex-C (Injection) ................................ 41 Ganciclovir (Injection) .................................. 24 Gardasil (Injection) ..................................... 42 Gardasil 9 (Injection)................................... 42 Gatifloxacin (Ophthalmic Solution) ............. 17 Gattex (Injection) ........................................ 35 GaviLAX (Powder) ........................................ 36 GaviLyte-C (Oral Solution) ........................... 36 GaviLyte-G (Oral Solution) ........................... 36 GaviLyte-H (Kit) ............................................ 35 GaviLyte-N/Flavor Pack (Oral Solution) ....... 36 Gazyva (Injection) ....................................... 23 Gelnique (Gel) ............................................. 36 Gemcitabine (Injection) ............................... 22 Gemfibrozil (600mg Tablet) ......................... 31 Generlac (Oral Solution) .............................. 36 Gene-Xene Tab 15mg (Tablet) ..................... 18 Gene-Xene Tab 3.75mg (Tablet) .................. 18 Gene-Xene Tab 7.5mg (Tablet) .................... 18 Gengraf (100mg Capsule, 25mg Capsule,

50mg Capsule, 100mg/ml Oral Solution) 41 Gentak (Ophthalmic Ointment) ................... 14 Gentamicin Sulfate (0.1% Cream, 0.1%

Ointment, 0.3% Ophthalmic Ointment, 0.3% Ophthalmic Solution, 10mg/ml Injection, 40mg/ml Injection) ................. 14

Gentamicin Sulfate/0.9% Sodium Chloride (0.8mg/ml-0.9% Injection, 1.2mg/ml-0.9% Injection, 1mg/ml-0.9% Injection) .......... 14

Gentle Laxative (Tablet Delayed-Release) ... 36 Gentlelax (Powder) ...................................... 36 Geodon (Injection) ...................................... 48 Gianvi (Tablet) ............................................. 38 Gildagia (Tablet) .......................................... 38 Gilenya (Capsule) ........................................ 32 Gilotrif (Tablet) ........................................... 23 Glassia (Injection) ....................................... 51 Glatopa (Injection) ....................................... 32 Gleostine (Capsule) ..................................... 21 Gliadel Wafer (Wafer) ................................. 21 Glimepiride (Tablet)..................................... 26 Glipizide (Tablet Immediate-Release) .......... 26 Glipizide ER (Tablet Extended-Release 24

Hour) ....................................................... 26 Glipizide XL (Tablet Extended-Release 24

Hour) ....................................................... 26 Glipizide/Metformin HCl (Tablet) ................ 26 Global Alcohol Prep Ease Pads ................... 14 GlucaGen HypoKit (Injection) ..................... 26 Glucagon Emergency Kit (Injection) ........... 27 GlucoCom Autolink Telemonitoring System

................................................................ 44 Glyburide (1.25mg Tablet, 2.5mg Tablet, 5mg

Tablet)..................................................... 26 Glyburide Micronized (Tablet) ..................... 26 Glyburide/Metformin HCl (Tablet) .............. 26 Glycine (1.5% Irrigation Solution) ................ 37 Glycolax (Powder)........................................ 36 Glycopyrrolate (0.4mg/2ml Injection,

1mg/5ml Injection, 4mg/20ml Injection, 1mg Tablet, 2mg Tablet) ........................ 35

Glydo (Gel) .................................................. 12 GNP Adult Aspirin Low Strength (Tablet

Chewable) .............................................. 10 GNP Alcohol Swabs .................................... 15 GNP Aspirin (325mg Tablet, 325mg Tablet

Delayed-Release, 81mg Tablet Delayed-Release) .................................................. 10

GNP Aspirin Low Dose (Tablet Delayed-Release) .................................................. 10

GNP Bisa-Lax (Tablet Delayed-Release) ...... 36 GNP ClearLax (Powder) ............................... 36 GNP D 1000 (Capsule) ................................. 54 GNP D 2000 (Tablet Chewable) ................... 54 GNP Daily Prenatal ..................................... 54 GNP Nicotine Mini Lozenge (Lozenge) ........ 13 GNP Nicotine Polacrilex (2mg Gum, 4mg

Gum, 2mg Lozenge, 4mg Lozenge) ........ 13 GNP Nicotine Transdermal System (Patch 24

Hour) ...................................................... 13 GNP Prenatal (Tablet)................................. 54 GNP Vitamin D (Tablet) ............................... 54 GNP Vitamin D Super Strength (Tablet) ...... 54 GNP Vitamin D3 Extra Strength (Tablet) ..... 54 GNP Womens Laxative (Tablet Delayed-

Release) .................................................. 36 Goodsense Magnesium Citrate (Solution) .. 36 Goodsense Nicotine Gum (Gum) ................ 13 Goodsense Prenatal Vitamins (Tablet) ...... 54 Gralise (Tablet) ........................................... 10 Gralise ST .................................................... 10 Granisetron HCl (0.1mg/ml Injection, 1mg/ml

Injection, 4mg/4ml Injection) ................. 20 Granisetron HCl (1mg Tablet) ..................... 20 Griseofulvin Microsize (125mg/5ml

Suspension, 500mg Tablet) .................... 20 Griseofulvin Ultramicrosize (Tablet) ........... 20 Guanfacine ER (Tablet Extended-Release 24

Hour) ...................................................... 32 Guanfacine HCl (Tablet Immediate-Release)

............................................................... 28 Guanidine HCl (Tablet) ................................ 21 Gynazole-1 (Cream) .................................... 20

H

H.P. Acthar (Injection) ................................ 38 Halaven (Injection) ..................................... 48 Halobetasol Propionate (0.05% Cream, 0.05%

Ointment) ............................................... 33 Halog (0.1% Cream, 0.1% Ointment) ......... 34 Haloperidol (0.5mg Tablet, 10mg Tablet, 1mg

Tablet, 20mg Tablet, 2mg Tablet, 5mg Tablet, 2mg/ml Concentrate) ................. 24

Haloperidol Decanoate (Injection) .............. 24 Haloperidol Lactate (Injection).................... 24 Harvoni (Tablet).......................................... 24 Havrix (Injection) ........................................ 42 Healthy Kids Vitamin D3 (Tablet Chewable) 54 Healthy Mama Be Well Rounded (Therapy

Pack) ....................................................... 54 Heather (Tablet) .......................................... 40 H-E-B in Control Pen Needles 31gx6mm .... 44 H-E-B in Control Pen Needles 31gx8mm .... 45 H-E-B in Control Pen

Needles/Nano/32gx4mm ...................... 45 H-E-B in Control Unifine Pentips Plus

31gx5mm ................................................ 45 H-E-B Incontrol Alcohol Prep Pads ............. 15 H-E-B Incontrol Pen Needles 29gx12mm .... 45 Hectorol (2mcg/ml Injection) ..................... 42 Helixate FS (Injection) ................................. 28 Hema-Combistix .......................................... 45 Hemangeol (Oral Solution) ......................... 29 Hematinic Plus Vitamins/Minerals (Tablet) . 52 Hematinic/Folic Acid (Tablet) ...................... 48 Hemocyte-F (Tablet) .................................... 48 Hemocyte-Plus (Tablet) ............................... 52 Hemofil M (Injection) .................................. 28 Hepagam B (Injection) ................................ 41 Heparin Lock Flush (Injection) ..................... 27 Heparin Sodium (10000unit/10ml Injection,

3000unit/3ml Injection, 5000unit/5ml Injection, 10000unit/ml Injection, 1000unit/ml Injection, 20000unit/ml Injection, 5000unit/0.5ml Injection, 5000unit/ml Injection) ............................ 27

Heparin Sodium Lock Flush (Kit) .................. 27 Heparin Sodium/D5W (5%-40unit/ml

Injection, 5%-50unit/ml Injection) .......... 27 Heparin Sodium/NaCl 0.9% (Injection) ........ 27 Heparin Sodium/Sodium Ch Loride (Injection)

................................................................ 27 Heparin Sodium/Sodium Chloride

(2000unit/500ml-0.9% Solution) ............ 26 Heparin Sodium/Sodium Chloride

(20unit/20ml-0.9% Injection, 25000unit/250ml-0.45% Injection, 30000unit/L-0.9% Injection, 4000unit/L-0.9% Injection, 50unit/50ml-0.45% Injection) ................................................. 27

Heparin Sodium/Sodium Chloride 0.9% Premix (Injection) ................................... 27

Herceptin (Injection) ................................... 23 Hetastarch 6%/NaCl (Injection) ................... 28 Hetlioz (Capsule) ......................................... 32 Hexalen (Capsule) ....................................... 21 Hiberix (Injection) ....................................... 42 Hizentra (Injection) ..................................... 41 HM Aspirin (325mg Tablet, 81mg Tablet

Chewable) ............................................... 10 HM ClearLax (Powder) ................................. 36 HM Laxative (Tablet Delayed-Release) ........ 36 HM Nicotine Polacrilex (2mg Gum, 4mg Gum,

2mg Lozenge, 4mg Lozenge) ................... 13 HM Nicotine Transdermal System (Patch 24

Hour) ....................................................... 13 HM Nicotine Transdermal System (Patch 24

Hour) ....................................................... 13 HM One Daily Prenatal Combo ................... 54 HM Prenatal (Tablet) .................................. 54

67

HM Vitamin D (Tablet) ................................. 54 HM Vitamin D3 (Capsule) ............................ 54 Horizant (Tablet Extended-Release) ........... 32 Humalog (Injection) .................................... 27 Humalog KwikPen (Injection) ..................... 27 Humalog Mix 50/50 (Injection) .................. 27 Humalog Mix 50/50 KwikPen (Injection) ... 27 Humalog Mix 75/25 (Injection) .................. 27 Humalog Mix 75/25 KwikPen (Injection) ... 27 Humapen Luxura HD ................................... 45 Humate-P (Injection) .................................. 28 Humira (10mg/0.2ml Injection) .................. 48 Humira (20mg/0.4ml Injection, 40mg/0.8ml

Injection) ................................................ 41 Humira Pediatric Crohns Disease Starter

Pack (Injection) ...................................... 41 Humira Pen (Injection) ................................ 41 Humira Pen Crohns Disease Starter Pack

(Injection) ............................................... 41 Humira Pen-Psoriasis Starter (Injection) .... 41 Humulin 70/30 (Injection) .......................... 27 Humulin 70/30 KwikPen (Injection) ........... 27 Humulin N (Injection) ................................. 27 Humulin N KwikPen (Injection) .................. 27 Humulin R (Injection) .................................. 27 Humulin R U-500 (Concentrated) (Injection)

................................................................ 27 Hycamtin (0.25mg Capsule, 1mg Capsule) . 22 Hydralazine HCl (100mg Tablet, 10mg Tablet,

25mg Tablet, 50mg Tablet, 20mg/ml Injection) ................................................. 31

Hydrochlorothiazide (12.5mg Capsule, 12.5mg Tablet, 25mg Tablet, 50mg Tablet) ................................................................ 31

Hydrocodone Bitartrate/Acetaminophen (Tablet, Oral Solution) ............................ 12

Hydrocodone Bitartrate/Homatropine Methylbromide (1.5mg-5mg Tablet, 1.5mg/5ml-5mg/5ml Syrup) ................... 51

Hydrocodone/Acetaminophen (Tablet) ...... 12 Hydrocodone/Ibuprofen (Tablet) ................ 10 Hydrocort Enema 100mg (Enema) .............. 37 Hydrocortisone (1% Cream RX, 2.5% Cream,

1% Ointment RX, 2.5% Ointment, 2.5% Cream, 2.5% Lotion) ............................... 34

Hydrocortisone (10mg Tablet, 20mg Tablet, 5mg Tablet) ............................................. 37

Hydrocortisone 1% in Absorbase (Ointment) ................................................................ 34

Hydrocortisone Butyrate (0.1% Cream, 0.1% External Solution, 0.1% Ointment) ......... 34

Hydrocortisone in Absorbase (Ointment).... 34 Hydrocortisone Valerate (0.2% Cream, 0.2%

Ointment) ............................................... 34 Hydrocortisone/Acetic Acid (Otic Solution) . 50 Hydromet (Syrup) ........................................ 51 Hydromorphone HCl (1mg/ml Injection,

2mg/ml Injection, 4mg/ml Injection, 500mg/50ml Injection, 1mg/ml Liquid, 2mg Tablet, 4mg Tablet, 8mg Tablet) ..... 12

Hydromorphone HCl ER (Tablet Extended-

Release 24 Hour Abuse-Deterrent) ........ 11 Hydromorphone HCl/Sodium Chloride

(10mg/25ml-0.9% Solution Prefilled Syringe, 1mg/5ml-0.9% Solution Prefilled Syringe, 3mg/30ml-0.9% Solution Prefilled Syringe, 15mg/50ml-0.9% Injection) ...... 32

Hydromorphone HCl/Sodium Chloride (10mg/50ml-0.9% Injection, 15mg/30ml-0.9% Injection, 5mg/25ml-0.9% Injection) ............................................................... 12

Hydroxychloroquine Sulfate (Tablet) .......... 23 Hydroxyurea (Capsule) ................................ 22 Hydroxyzine HCl (10mg Tablet, 25mg Tablet,

50mg Tablet, 10mg/5ml Syrup, 50mg/ml Injection) ................................................ 19

Hydroxyzine Pamoate (100mg Capsule, 25mg Capsule, 50mg Capsule) ......................... 20

Hyoscyamine Sulfate (0.125mg Tablet Dispersible) (MANUF MARLEX, TRIGEN) 35

Hyperhep B S/D (Injection) ........................ 41 Hyperrab S/D (Injection) ............................ 41 Hyperrho S/D (Injection) ............................ 41 Hyperrho S/D Mini-Dose (Injection) .......... 41 Hyqvia (Injection) ....................................... 42 Hysingla ER (Tablet Extended-Release 24

Hour Abuse-Deterrent).......................... 11

I

Ibandronate Sodium (150mg Tablet, 3mg/3ml Injection) ................................................ 42

Ibrance (Capsule) ........................................ 22 Ibudone (5mg-200mg Tablet) ..................... 10 Ibuprofen (100mg/5ml Suspension - RX,

400mg Tablet, 600mg Tablet, 800mg Tablet) .................................................... 10

Ibuprofen Lysine (Injection) ........................ 48 Ibutilide Fumarate (Injection) ..................... 29 Iclusig (15mg Tablet) .................................. 23 Iclusig (45mg Tablet) .................................. 23 Idarubicin HCl (Injection) ............................ 48 Idelvion (Injection) ..................................... 28 Iferex 150 Forte (Capsule) ........................... 52 Ifex (3gm Injection) .................................... 21 Ifosfamide (1gm Injection, 1gm/20ml

Injection, 3gm/60ml Injection) ............... 21 Ifosfamide (3gm Injection) ......................... 21 Ilaris (Injection) .......................................... 41 Ilevro (Suspension) ..................................... 49 Imatinib Mesylate (Tablet) .......................... 23 Imbruvica (Capsule) .................................... 23 Imipenem/Cilastatin (Injection) .................. 16 Imipramine HCl (10mg Tablet, 25mg Tablet,

50mg Tablet) .......................................... 19 Imipramine Pamoate (Capsule) ................... 19 Imiquimod (Cream) ..................................... 34 Imlygic (Suspension) ................................... 21 Imovax Rabies (H.D.C.V.) (Injection) .......... 42 Impavido (Capsule) ..................................... 15 In Touch Diabetes Management Software 45 Inatal GT (Tablet) ........................................ 54

Increlex (Injection) ...................................... 38 Incruse Ellipta (Aerosol Powder) ................ 50 Indapamide (Tablet) .................................... 31 Inderal XL (Capsule Extended-Release 24

Hour) ...................................................... 29 Indomethacin (1mg Solution) ...................... 48 Indomethacin (25mg Capsule, 50mg Capsule)

................................................................ 10 Indomethacin ER (Capsule Extended-Release)

................................................................ 10 Infanrix (Injection) ...................................... 42 Inflectra (Injection) ..................................... 43 Inlyta (Tablet) .............................................. 23 Innopran XL (Capsule Extended-Release 24

Hour) ...................................................... 29 InspiraChamber/Anti-Static

Valved/Mouthpiece ............................... 45 InspiraChamber/Large ................................ 45 InspiraChamber/Soother

Mask/InspiraMask/Medium .................. 45 InspiraChamber/Soother

Mask/InspiraMask/Small ....................... 45 Inspirease Bags ........................................... 45 Inspirease Drug Delivery System ................ 45 Inspirease Mouthpiece ............................... 45 Inspirease Reservoir Bags ........................... 45 Insulin Syringe/0.5ml/27g X 1/2" ............... 45 Insulin Syringe/U-100/1ml/28g X 1/2" ...... 45 Insulin Syringes, Needles (BD MEDICAL) ... 34,

45 Insupen 33gx4mm ....................................... 45 Insupen Pen Needles 32g X4mm ................ 45 Insupen Sensitive 32gx6mm ....................... 45 Insupen Sensitive 32gx8mm ....................... 45 Insupen Ultrafin 29gx12mm ....................... 45 Insupen Ultrafin 30gx8mm ......................... 45 Insupen Ultrafin 31gx6mm ......................... 45 Insupen Ultrafin 31gx8mm ......................... 45 Intelence (Tablet) ........................................ 25 Intralipid (20gm/100ml Injection) ............... 45 Intron A (Injection) ..................................... 22 Intron A w/Diluent (Injection) .................... 48 Introvale (Tablet) ......................................... 38 Invanz (Injection) ........................................ 16 Invega Sustenna (Injection) ........................ 24 Invega Trinza (Injection) ............................. 24 Invirase (200mg Capsule, 500mg Tablet) ... 25 Invokamet (Tablet) ..................................... 26 Invokamet XR (Tablet Extended-Release 24

Hour) ...................................................... 26 Invokana (Tablet) ........................................ 26 Iopidine (1% Ophthalmic Solution) ............ 49 IPOL Inactivated IPV (Injection) .................. 42 Ipratropium Bromide (0.02% Inhalation

Solution) ................................................. 50 Ipratropium Bromide (0.03% Nasal Solution,

0.06% Nasal Solution) ............................. 50 Ipratropium Bromide/Albuterol Sulfate

(Inhalation Solution) ............................... 48 Irbesartan (Tablet) ....................................... 28 Irbesartan/Hydrochlorothiazide (Tablet) ..... 28

68

Irinotecan (40mg/2ml Injection) ................. 48 Irinotecan (500mg/25ml Injection) ............ 48 Irinotecan HCl (Injection) ............................. 48 Isentress (100mg Packet, 100mg Tablet

Chewable, 25mg Tablet Chewable, 400mg Tablet) .................................................... 25

Isolyte-S (Injection) ..................................... 52 Isoniazid (100mg Tablet, 300mg Tablet,

50mg/5ml Syrup) .................................... 21 Isosorbide Dinitrate (Tablet Immediate-

Release) .................................................. 31 Isosorbide Dinitrate ER (Tablet Extended-

Release) .................................................. 31 Isosorbide Mononitrate (Tablet Immediate-

Release) .................................................. 31 Isosorbide Mononitrate ER (Tablet Extended-

Release 24 Hour) .................................... 31 Isotonic Gentamicin (Injection) ................... 14 Isradipine (Capsule) ..................................... 30 Istodax (Injection) ....................................... 48 Istodax (Overfill) (Injection) ....................... 48 Itraconazole (Capsule) ................................. 20 IV Prep Wipes .............................................. 15 Ivermectin (Tablet) ...................................... 23 Ixempra Kit (Injection) ................................ 48 Ixiaro (Injection) .......................................... 42

J

Jadenu (Tablet) ........................................... 52 Jakafi (10mg Tablet) .................................... 22 Jakafi (15mg Tablet, 20mg Tablet, 25mg

Tablet, 5mg Tablet) ................................ 22 Jantoven (Tablet) ......................................... 27 Janumet (Tablet) ......................................... 26 Janumet XR (Tablet Extended-Release 24

Hour) ...................................................... 26 Januvia (Tablet) ........................................... 26 Jardiance (Tablet) ....................................... 26 Jencycla (Tablet) .......................................... 40 Jetrea (Injection) ......................................... 49 Jevantique Lo (Tablet) ................................. 38 Jevtana (Injection) ...................................... 48 Jinteli (Tablet) .............................................. 38 Jolessa (Tablet) ............................................ 38 Jolivette (Tablet) .......................................... 40 J-Tip Kit w/Vial Adapters (Kit) .................... 45 Jublia (External Solution) ............................ 20 Juleber (Tablet) ............................................ 38 Junel 1.5/30 (Tablet) .................................... 38 Junel 1/20 (Tablet) ....................................... 38 Junel Fe 1.5/30 (Tablet) ............................... 38 Junel Fe 1/20 (Tablet) .................................. 39 Junel Fe 24 (Tablet) ..................................... 39 Just D (Liquid) .............................................. 54 Juxtapid (Capsule) ....................................... 31

K

Kadcyla (Injection) ...................................... 48 Kaitlib Fe (Tablet Chewable) ........................ 39 Kalbitor (Injection) ...................................... 45

Kaletra (100mg-25mg Tablet, 200mg-50mg Tablet) .................................................... 25

Kalydeco (150mg Tablet, 50mg Packet, 75mg Packet) ................................................... 51

Kanuma (Injection) ..................................... 35 Karidium (Oral Solution).............................. 52 Karigel (Gel) ................................................. 32 Karigel-N (Gel) ............................................. 32 Kariva (Tablet) ............................................. 39 KCl 0.075%/D5W/NaCl 0.45% (Injection) .... 48 KCl 0.15%/D5W/NaCl 0.2% (Injection) ........ 48 KCl 0.15%/D5W/NaCl 0.45% (Injection) ...... 48 KCl 0.15%/D5W/NaCl 0.9% (Injection) ........ 48 KCl 0.3%/D5W/NaCl 0.45% (Injection) ........ 48 Kedbumin (Injection) .................................. 28 K-Effervescent (Tablet Effervescent) ........... 52 Kelnor 1/35 (Tablet) .................................... 39 Kepivance (Injection) .................................. 32 Kerydin (External Solution) ........................ 20 Ketocare...................................................... 45 Ketoconazole (2% Cream, 2% Foam, 2%

Shampoo, 200mg Tablet) ....................... 20 Ketodan (Foam) .......................................... 20 Keto-Diastix ................................................ 45 Ketone Test Strips ...................................... 45 Ketoprofen (Capsule Immediate-Release) .. 10 Ketoprofen ER (Capsule Extended-Release 24

Hour) ...................................................... 10 Ketorolac Tromethamine (0.4% Ophthalmic

Solution, 0.5% Ophthalmic Solution) ..... 49 Ketorolac Tromethamine (10mg Tablet) ..... 11 Ketorolac Tromethamine (15mg/ml Injection,

30mg/ml Injection, 30mg/ml Injection) . 48 Ketostix ....................................................... 45 Keveyis (Tablet) .......................................... 49 Kimidess (Tablet) ......................................... 39 Kineret (Injection) ...................................... 48 Kinrix (Injection) ......................................... 42 Kionex (Powder, 15gm/60ml Suspension) .. 52 Klofensaid II (Transdermal Solution) ........... 34 Klor-Con 10 (Tablet Extended-Release) ...... 52 Klor-Con 8 (Tablet Extended-Release) ........ 52 Klor-Con M10 (Tablet Extended-Release) ... 52 Klor-Con M15 (Tablet Extended-Release) .. 52 Klor-Con M20 (Tablet Extended-Release) ... 52 Klor-Con Sprinkle (Capsule Extended-Release)

............................................................... 52 KLS Aspirin EC (Tablet Delayed-Release) ..... 11 KLS Aspirin Low Dose (Tablet Delayed-

Release) .................................................. 11 KLS LaxaClear (Powder) ............................... 36 KLS Quit2 (2mg Gum, 2mg Lozenge) ........... 13 KLS Quit4 (4mg Gum, 4mg Lozenge) ........... 13 Koate (Solution) .......................................... 28 Koate-Dvi (Injection) .................................. 28 Kogenate FS (Injection) .............................. 28 Kogenate FS Bio-Set (Injection) .................. 28 Kombiglyze XR (Tablet Extended-Release 24

Hour) ...................................................... 26 KP Aspirin (Tablet Delayed-Release) ........... 11 KP Bisacodyl (Tablet Delayed-Release) ....... 36

KP Folic Acid (Tablet) ................................... 54 KP Prenatal Multivitamins (Tablet) ............ 54 KP Vitamin D (1000unit Capsule, 2000unit

Capsule, 400unit Tablet Chewable) ........ 54 K-Prime (Tablet Effervescent) ...................... 52 Krystexxa (Injection) ................................... 21 K-Tan Plus (Capsule) .................................... 52 Kurvelo (Tablet) ........................................... 39 Kuvan (100mg Packet, 500mg Packet, 100mg

Tablet Soluble) ....................................... 35 Kyleena (IUD) .............................................. 40 Kyprolis (30mg Injection) ............................ 22 Kyprolis (60mg Injection) ............................ 48

L

Labetalol HCl (100mg Tablet, 200mg Tablet, 300mg Tablet, 5mg/ml Injection) ........... 29

Labstix ......................................................... 45 Lacrisert (Insert) .......................................... 49 Lactated Ringers (Injection) ......................... 52 Lactated Ringers Irrigation (Solution) .......... 45 Lactic Acid (Lotion) ...................................... 34 Lactic Acid E (Cream) ................................... 34 Lactic Acid with Vitamin E (Cream) .............. 34 Lactulose (Oral Solution) ............................. 36 Lamivudine (100mg Tablet) ......................... 24 Lamivudine (10mg/ml Oral Solution, 150mg

Tablet, 300mg Tablet) ............................. 25 Lamivudine/Zidovudine (Tablet).................. 25 Lamotrigine (Tablet Immediate-Release,

Tablet Chewable) .................................... 18 Lamotrigine ER (Tablet Extended-Release 24

Hour) ....................................................... 18 Lamotrigine ODT (Tablet Dispersible) .......... 18 Lamotrigine Titration (Kit) ........................... 18 Lansoprazole (Capsule Delayed-Release) RX36 Lansoprazole/Amoxicillin/Clarithromycin

(Therapy Pack) ........................................ 35 Lantus (Injection) ........................................ 27 Lantus SoloStar (Injection) .......................... 27 LARIN 1.5/30 (Tablet) .................................. 39 LARIN 1/20 (Tablet) ..................................... 39 LARIN 24 Fe (Tablet) .................................... 39 LARIN Fe 1.5/30 (Tablet) .............................. 39 LARIN Fe 1/20 (Tablet) ................................. 39 Larissia (Tablet) ............................................ 39 Lartruvo (500mg/50ml Injection) ............... 21 LaST ............................................................. 49 Latanoprost (Ophthalmic Solution) ............. 49 Latuda (Tablet) ............................................ 24 Laxative (Tablet Delayed-Release) ............... 36 Laxative Feminine (Tablet Delayed-Release)

................................................................ 36 Layolis Fe (Tablet Chewable) ....................... 39 Leader Unifine Pentips

Plus/Short/31gx5/16" ............................ 45 Leena (Tablet) .............................................. 39 Leflunomide (Tablet) ................................... 41 Lemtrada (Injection) ................................... 41 Lenvima (Capsule Therapy Pack) ................ 23

69

Lessina (Tablet) ............................................ 39 Letairis (Tablet) ........................................... 51 Letrozole (Tablet) ........................................ 22 Leucovorin Calcium (100mg Injection, 200mg

Injection, 350mg Injection, 50mg Injection) ................................................................ 48

Leucovorin Calcium (10mg Tablet, 15mg Tablet) .................................................... 22

Leucovorin Calcium (25mg Tablet, 5mg Tablet)..................................................... 22

Leukeran (Tablet) ........................................ 21 Leukine (Injection) ...................................... 27 Leuprolide Acetate (Injection) ..................... 40 Leva Set/Occlusive Dressing (Kit)................. 12 Levalbuterol (Nebulized Solution) ............... 51 Levemir (Injection) ...................................... 27 Levemir FlexTouch (Injection) .................... 27 Levetiracetam (Tablet Immediate-Release,

Oral Solution, 500mg/5ml Injection) ...... 17 Levetiracetam ER (Tablet Extended-Release

24 Hour) .................................................. 17 Levobunolol HCl (Ophthalmic Solution) ...... 49 Levocarnitine (1gm/10ml Oral Solution,

200mg/ml Injection, 330mg Tablet) ....... 45 Levocetirizine Dihydrochloride (2.5mg/5ml

Oral Solution, 5mg Tablet) ...................... 50 Levofloxacin (0.5% Ophthalmic Solution,

250mg Tablet, 500mg Tablet, 750mg Tablet, 25mg/ml Injection, 25mg/ml Oral Solution) ................................................. 17

Levofloxacin in D5W (Injection) ................... 17 Levoleucovorin (175mg Solution) ............... 43 Levoleucovorin (175mg/17.5ml Injection) .. 22 Levoleucovorin (250mg/25ml Injection) .... 22 Levoleucovorin (50mg Injection) ................. 48 Levonest (Tablet) ......................................... 39 Levonorgestrel (Tablet) ............................... 40 Levonorgestrel and Ethinyl Estradiol (Tablet)

................................................................ 39 Levonorgestrel/Ethinyl Estradiol (0.03mg-

0.15mg Tablet) ........................................ 39 Levonorgestrel/Ethinyl Estradiol (0-Tablet,

20mcg-0.1mg Tablet) .............................. 39 Levora 0.15/30-28 (Tablet) .......................... 39 Levo-T (Tablet) ............................................. 40 Levothyroxine Sodium (100mcg Tablet,

112mcg Tablet, 125mcg Tablet, 137mcg Tablet, 150mcg Tablet, 175mcg Tablet, 200mcg Tablet, 25mcg Tablet, 300mcg Tablet, 50mcg Tablet, 75mcg Tablet, 88mcg Tablet) ......................................... 40

Levoxyl (Tablet) ........................................... 40 Lexiva (50mg/ml Suspension, 700mg Tablet)

................................................................ 25 Lialda (Tablet Delayed-Release) ................. 42 Lidazone HC (Cream) ................................... 34 Lidocaine (3% Cream, 5% Ointment, 5%

Patch) ...................................................... 12 Lidocaine HCl (0.5% Injection, 1% Injection,

1.5% Injection, 2% Injection, 4% Injection, 2% Gel, 4% External Solution) ................. 12

Lidocaine HCl (10mg/ml Injection, 20mg/ml Injection) ................................................ 29

Lidocaine HCl (Gel) ...................................... 12 Lidocaine HCl (Prefilled Syringe) ................. 42 Lidocaine HCl in D5W (Injection)................. 29 Lidocaine HCl/Hydrocortisone Acetate (0.5%-

3% Cream, 0.5%-3% Kit, 1%-3% Kit, 2%-2% Kit, 2.5%-3% Kit) ..................................... 34

Lidocaine Pak (Ointment) ............................ 12 Lidocaine Viscous (Solution) ....................... 12 Lidocaine/Epinephrine (Injection) ............... 13 Lidocaine/Prilocaine (2.5%-2.5% Cream,

2.5%-2.5% Kit) ........................................ 13 Lidopril (Kit) ................................................. 13 Lidopril XR (Kit)............................................ 13 Lifescan Unistik 2 Deep Penetration .......... 45 Lifescan Unistik II Lancets .......................... 45 Liletta (IUD) ................................................ 40 Lincomycin HCl (Injection) .......................... 15 Lindane (Shampoo) ..................................... 23 Linezolid (100mg/5ml Suspension, 600mg

Tablet) .................................................... 15 Linezolid (600mg/300ml Injection) ............. 15 Linzess (145mcg Capsule, 290mcg Capsule)35 Linzess (72mcg Capsule) ............................. 36 Liothyronine Sodium (10mcg/ml Injection,

25mcg Tablet, 50mcg Tablet, 5mcg Tablet) ............................................................... 40

Lipodox 50 (Injection) ................................. 48 Lisinopril (Tablet) ........................................ 29 Lisinopril/Hydrochlorothiazide (Tablet) ...... 29 LiteAire ....................................................... 45 LiteTouch Pen Needles 29gx12.7mm ......... 45 LiteTouch Pen Needles 31gx8mm Short .... 45 Lithium (Oral Solution) ................................ 26 Lithium Carbonate (150mg Capsule, 300mg

Capsule, 600mg Capsule, 300mg Tablet) 26 Lithium Carbonate ER (Tablet Extended-

Release) .................................................. 26 Livalo (Tablet) ............................................. 31 Livixil Pak (Kit) ............................................. 13 Lo Loestrin Fe (Tablet) ................................ 39 Locoid (0.1% Lotion) ................................... 34 Lofene (Tablet) ............................................ 35 LoKara (Lotion) ............................................ 34 Lomedia 24 Fe (Tablet) ............................... 39 Lonsurf (Tablet) .......................................... 22 Loperamide HCl (2mg Capsule) (RX) ........... 35 Lopinavir/Ritonavir (Solution) ..................... 25 Lorazepam (0.5mg Tablet, 1mg Tablet, 2mg

Tablet) .................................................... 18 Lorazepam (20mg/10ml Injection, 4mg/ml

Injection) ................................................ 26 Lorazepam Intensol (2mg/ml Concentrate) 26 Lorcet (Tablet) ............................................. 12 Lorcet HD (Tablet) ....................................... 12 Lorcet Plus (Tablet) ..................................... 12 Lortab (10mg-325mg Tablet, 5mg-325mg

Tablet, 7.5mg-325mg Tablet) ................. 12 Loryna (Tablet) ............................................ 39 Lorzone (Tablet) ......................................... 52

Losartan Potassium (Tablet) ........................ 28 Losartan Potassium/Hydrochlorothiazide

(Tablet) ................................................... 28 Lotemax (0.5% Gel, 0.5% Ointment) .......... 49 Lotemax (0.5% Suspension) ........................ 49 Lovastatin (Tablet) ....................................... 31 Low-Ogestrel (Tablet) .................................. 39 Loxapine Succinate (Capsule) ...................... 24 Lucentis (Injection) ..................................... 49 Ludent (Tablet Chewable) ........................... 52 Lumigan (Ophthalmic Solution) .................. 49 Lumizyme (Injection) .................................. 35 Lupaneta Pack (Kit) ..................................... 40 Lupron Depot (Injection) ............................ 40 Lupron Depot-PED (Injection) ..................... 40 Lutera (Tablet) ............................................. 39 Luzu (Cream) ............................................... 20 Lynparza (Capsule) ...................................... 22 Lyrica (100mg Capsule, 150mg Capsule,

200mg Capsule, 225mg Capsule, 25mg Capsule, 300mg Capsule, 50mg Capsule, 75mg Capsule) ........................................ 17

Lyrica (20mg/ml Oral Solution) .................. 17 Lysiplex Plus (Tablet) ................................... 54 Lysodren (Tablet) ........................................ 40 Lyza (Tablet) ................................................ 40

M

MacNatal CN DHA (Capsule) ........................ 54 Macugen (Injection) .................................... 49 Magnesium Chloride (200mg/ml Injection) . 52 Magnesium Citrate (Oral Solution) .............. 36 Magnesium Sulfate (20gm/500ml Injection,

2gm/50ml Injection, 40gm/1000ml Injection, 4gm/100ml Injection, 4gm/50ml Injection, 50% Injection) ......................... 52

Magnesium Sulfate in D5W (5%-10mg/ml Injection) ................................................. 17

Magnesium Sulfate/Lactated Ringers (100mg/500ml-20gm/500ml-150mg/500ml-3gm/500ml-1.55gm/500ml Solution) ................................................. 34

Magnesium Sulfate/Sodium Chloride (4gm/100ml-0.9% Solution) .................... 34

Makena (Injection) ...................................... 40 Malathion (Lotion) ....................................... 23 Mannitol (Injection) ..................................... 30 Maprotiline HCl (Tablet) .............................. 19 Marlissa (Tablet) .......................................... 39 Marplan (Tablet) ......................................... 19 Marqibo (Injection) ..................................... 22 Marten-Tab (Tablet) .................................... 10 Mask Vortex/Baby Whirl Duckling ............. 45 Mask Vortex/Child/Frog ............................. 45 Mask Vortex/Spinner the Duck .................. 45 Mask Vortex/Toddler/Lady Bug ................. 45 Matulane (Capsule) ..................................... 21 Matzim LA (Tablet Extended-Release 24

Hour) ....................................................... 30 Maxipime (2gm Injection) .......................... 16

70

Meclizine HCl (12.5mg Tablet, 25mg Tablet) (RX) ......................................................... 20

Meclofenamate Sodium (100mg Capsule, 50mg Capsule) ........................................ 11

Medical Provider Single Use EZ Flu Shot (Injection) ............................................... 25

Medroxyprogesterone Acetate (10mg Tablet, 2.5mg Tablet, 5mg Tablet) ...................... 40

Medroxyprogesterone Acetate (150mg/ml Injection) ................................................. 40

Mefenamic Acid (250mg Capsule) ............... 11 Mefloquine HCl (Tablet) .............................. 23 Megestrol Acetate (20mg Tablet, 40mg

Tablet, 40mg/ml Suspension) ................. 40 Megestrol Acetate (625mg/5ml Suspension)

................................................................ 40 Meijer Alcohol Swabs Extra-Thick .............. 15 Meijer Aspirin EC (Tablet Delayed-Release) 11 Meijer Pen Needles 31g X 6mm ................. 45 Mekinist (Tablet) ......................................... 23 Meloxicam (Tablet) ...................................... 11 Melphalan HCl (Injection) ............................ 21 Memantine HCl (10mg Tablet, 5mg Tablet,

2mg/ml Oral Solution) ............................ 18 Memantine HCl Titration Pak (Tablet) ......... 18 Menactra (Injection) ................................... 42 Menest (Tablet) .......................................... 39 MENHIBRIX (Injection) ................................ 42 Menomune-A/C/Y/W-135 (Injection) ........ 42 Mentax (Cream) .......................................... 20 Menveo (Injection) ..................................... 42 Meperidine HCl (100mg Tablet, 50mg Tablet,

100mg/ml Injection, 10mg/ml Injection, 25mg/ml Injection, 50mg/ml Injection, 50mg/5ml Oral Solution) ........................ 12

Meperidine HCl/Sodium Chloride (Injection) ................................................................ 12

Mephyton (Tablet) ...................................... 54 Meprobamate (Tablet) ................................ 25 Mercaptopurine (Tablet) ............................. 22 Meropenem (Injection) ............................... 16 Meropenem/Sodium Chloride (Injection) ... 16 Mesalamine (4gm Enema, 4gm Kit) ............. 42 Mesalamine DR (Tablet Delayed-Release) ... 42 Mesna (Injection) ........................................ 22 Mesnex (Tablet) .......................................... 48 Mestinon (60mg/5ml Syrup) ...................... 21 Metadate ER (Tablet Extended-Release) ..... 32 Metaproterenol Sulfate (10mg Tablet, 20mg

Tablet, 10mg/5ml Syrup) ........................ 51 Metaxall (Tablet) ......................................... 52 Metaxalone (Tablet) .................................... 52 Metformin HCl (Tablet) ............................... 26 Metformin HCl ER (Tablet Extended-Release

24 Hour) (Generic for Fortamet, Generic for Glucophage XR) ................................. 26

Metformin HCl ER (Tablet Extended-Release 24 Hour) (Generic for Glumetza) ............ 26

Methadone HCl (Tablet, Oral Solution, Concentrate, 40mg Tablet Soluble) ........ 11

Methadose (40mg Tablet Soluble) .............. 11

Methamphetamine HCl (Tablet) ................. 32 Methazolamide (Tablet) .............................. 30 Methenamine Hippurate (Tablet) ............... 15 Methergine (Tablet) .................................... 45 Methimazole (10mg Tablet, 5mg Tablet) .... 41 Methitest (Tablet) ...................................... 38 Methocarbamol (1000mg/10ml Injection,

500mg Tablet, 750mg Tablet) ................ 52 Methotrexate (2.5mg Tablet)...................... 41 Methotrexate Sodium (Injection) ............... 41 Methoxsalen (10mg Capsule)...................... 34 Methscopolamine Bromide (Tablet) ........... 35 Methyclothiazide (5mg Tablet) ................... 31 Methyldopa (Tablet) ................................... 28 Methyldopa/Hydrochlorothiazide (Tablet) . 28 Methyldopate HCl (Injection) ...................... 28 Methylergonovine Maleate (Injection) ....... 45 Methylphenidate HCl (Tablet Immediate-

Release, Tablet Chewable, Oral Solution) ............................................................... 32

Methylphenidate HCl CD (Capsule Extended-Release) .................................................. 32

Methylphenidate HCl ER (Tablet Extended-Release, Capsule Extended-Release 24 Hour) ...................................................... 32

Methylphenidate HCl SR (Tablet Extended-Release) .................................................. 32

Methylprednisolone (16mg Tablet, 32mg Tablet, 4mg Tablet, 8mg Tablet) ............ 37

Methylprednisolone Acetate (40mg/ml Injection, 80mg/ml Injection) ................. 37

Methylprednisolone Sodium Succinate (Injection) ............................................... 48

Methyltestosterone (10mg Capsule) .......... 38 Metipranolol (Ophthalmic Solution) ........... 50 Metoclopramide HCl (10mg Tablet, 5mg

Tablet, 5mg/5ml Oral Solution) .............. 20 Metoclopramide HCl (5mg/ml Injection) .... 48 Metoclopramide ODT (5mg Tablet

Dispersible) ............................................ 20 Metolazone (Tablet) .................................... 31 Metoprolol Succinate ER (Tablet Extended-

Release 24 Hour) .................................... 30 Metoprolol Tartrate (100mg Tablet, 25mg

Tablet, 37.5mg Tablet, 50mg Tablet, 75mg Tablet, 5mg/5ml Injection) ..................... 30

Metoprolol/Hydrochlorothiazide (Tablet) .. 30 Metronidazole (0.75% Cream, 0.75% Gel, 1%

Gel, 0.75% Lotion, 250mg Tablet, 500mg Tablet, 375mg Capsule) .......................... 15

Metronidazole in NaCl 0.79% (Injection) .... 15 Metronidazole Vaginal (Gel) ....................... 15 Mexiletine HCl (Capsule) ............................. 29 Miacalcin (200unit/ml Injection) ............... 42 Miconazole 3 (Suppository) ........................ 20 Micrhogam Ultra-Filtered Plus (Injection) . 41 Microchamber ............................................ 45 Microclens Wipes ....................................... 15 Microgestin 1.5/30 (Tablet) ........................ 39 Microgestin 1/20 (Tablet) ........................... 39 Microgestin 24 Fe (Tablet) .......................... 39

Microgestin Fe (Tablet) ................................ 39 Microgestin Fe 1.5/30 (Tablet) .................... 39 Microspacer ................................................ 45 Midodrine HCl (Tablet) ................................ 28 Miglitol (Tablet) ........................................... 26 Milrinone in Dextrose (5%-20mg/100ml

Injection, 5%-40mg/200ml Solution) ...... 30 Milrinone Lactate (Injection) ....................... 30 Mimvey (Tablet) .......................................... 39 Mimvey Lo (Tablet) ...................................... 39 Minastrin 24 Fe (Tablet Chewable) ............ 39 Mineral Oil Heavy (RX) ................................. 36 Miniprin Low Dose (Tablet Delayed-Release)

................................................................ 11 Minitran (Patch 24 Hour) ............................. 31 Minocycline HCl (100mg Capsule, 50mg

Capsule, 75mg Capsule, 100mg Tablet, 50mg Tablet, 75mg Tablet) ..................... 17

Minocycline HCl ER (Tablet Extended-Release 24 Hour) .................................................. 17

Minoxidil (Tablet) ........................................ 31 Mircera (100mcg/0.3ml Injection,

200mcg/0.3ml Injection, 50mcg/0.3ml Injection, 75mcg/0.3ml Injection) ......... 27

Mircera (150mcg/0.3ml Injection, 30mcg/0.3ml Injection) .......................... 26

Mirena (IUD) ............................................... 40 Mirtazapine (Tablet) .................................... 19 Mirtazapine ODT (Tablet Dispersible).......... 19 Mirvaso (Gel)............................................... 34 Misoprostol (Tablet) .................................... 36 Mission Prenatal (Tablet) ........................... 54 Mission Prenatal HP (Tablet) ....................... 54 Mitomycin (20mg Injection, 40mg Injection)

................................................................ 48 Mitomycin (5mg Injection) ......................... 48 Mitoxantrone HCl (Injection) ....................... 22 Mm Aspirin (Tablet) ..................................... 11 M-M-R II (Injection) .................................... 42 Modafinil (Tablet) ........................................ 52 Moderiba ..................................................... 24 Moderiba (200mg Tablet) ............................ 24 Moderiba 1200 Dose Pack (Tablet) ............ 24 Moderiba 800 Dose Pack (Tablet) .............. 24 Moexipril HCl (Tablet) .................................. 29 Moexipril/Hydrochlorothiazide (Tablet) ...... 29 Molindone HCl (Tablet) ............................... 24 Mometasone Furoate (0.1% Cream, 0.1%

Ointment) ............................................... 37 Mometasone Furoate (0.1% External

Solution) ................................................. 34 Mometasone Furoate (50mcg/act

Suspension) ............................................ 50 Mondoxyne NL (Capsule)............................. 17 Monoclate-P (Injection) .............................. 28 Monoject Insulin Syringe/1ml .................... 45 Monoject Insulin Syringe/Detach

Needle/1ml/25g X 5/8" ......................... 45 Monoject Insulin Syringe/Softpack/1ml/27g

X 1/2" ..................................................... 45 Monoject Insulin Syringe/Softpack/U-

71

100/0.5ml/28g X 1/2" ............................ 45 Monoject Pharma Grade Flush Syringe

(Solution) ................................................ 53 Monoject Ultra Comfort Insulin

Syringe/1ml/30g X 5/16" ....................... 45 Mono-Linyah (Tablet) .................................. 39 MonoNessa (Tablet) .................................... 39 Mononine (Injection) .................................. 28 Monovisc (Injection) ................................... 45 Montelukast Sodium (10mg Tablet, 4mg

Packet, 4mg Tablet Chewable, 5mg Tablet Chewable) ............................................... 50

Monurol (Packet) ........................................ 15 Morgidox 1x100mg (100mg Capsule) .......... 17 Morgidox 1x50mg (Capsule) ........................ 17 Morgidox 2x100mg (100mg Capsule) .......... 17 Morphine Sulfate (0.5mg/ml Injection,

100mg/5ml Oral Solution, 10mg/5ml Oral Solution, 20mg/5ml Oral Solution, 10mg/ml Injection, 1mg/ml Injection, 4mg/ml Injection, 8mg/ml Injection, 15mg Tablet, 30mg Tablet) ............................... 12

Morphine Sulfate ER (Capsule Extended-Release 24 Hour, Tablet Extended-Release) .................................................. 11

Morphine Sulfate/Sodium Chloride (0.5mg/ml-0.9% Injection, 50mg/50ml-0.9% Injection) ........................................ 12

MoviPrep (Oral Solution) ............................ 36 Moxatag (Tablet Extended-Release 24 Hour)

................................................................ 16 Moxeza (Ophthalmic Solution) ................... 17 Moxifloxacin HCl (400mg Tablet,

400mg/250ml Injection) ......................... 17 Mozobil (Injection) ...................................... 27 Multaq (Tablet) ........................................... 29 Multi Prenatal (Tablet) ................................ 54 Multistix ...................................................... 45 Multistix 10 Sg............................................. 45 Multistix 5 ................................................... 45 Multistix 7 ................................................... 45 Multistix 8 SG .............................................. 45 Multistix 9 ................................................... 45 Multistix 9 SG .............................................. 45 Multi-Vit/Fluoride (32mg/ml-3mcg/ml-

1mg/ml-400unit/ml-2mcg/ml-5unit/ml-29.7mcg/ml-2mg/ml-0.4mg/ml-0.6mg/ml-0.25mg/ml-0.5mg/ml-1150unit/ml Oral Solution) ................................................. 54

Multi-Vit/Iron/Fluoride (Solution) ............... 54 Multivitamins/Fluoride (Tablet Chewable) .. 54 Multivitamin with Fluoride (32-3-1-400-2-5-

29.7-2-0.4-0.6-0.25-0.5-1150 Solution ... 54 Mupirocin (2% Cream, 2% Ointment) .......... 15 Mustargen (Injection) ................................. 22 M-Vit (Tablet) .............................................. 54 My Way (Tablet) .......................................... 40 Myalept (Injection) ..................................... 45 Mycamine (Injection) .................................. 20 Mycophenolate Mofetil (200mg/ml

Suspension, 250mg Capsule, 500mg

Injection, 500mg Tablet) ........................ 41 Mycophenolic Acid DR (Tablet Delayed-

Release) .................................................. 41 Myleran (Tablet) ......................................... 22 Mynatal Advance (Tablet) ........................... 54 Mynatal Plus (Tablet) .................................. 54 Mynatal Ultracaplet (Tablet) ....................... 54 Mynatal-Z (Tablet) ...................................... 54 Mynate 90 Plus (Tablet Extended-Release) 54 Myobloc (Injection) .................................... 45 Myorisan (Capsule) ..................................... 34 Myrbetriq (Tablet Extended-Release 24

Hour) ...................................................... 36 Mytesi (Tablet Delayed-Release) ............... 35 Myzilra (Tablet) ........................................... 39

N

Nabi-Hb (Injection) ..................................... 41 Nabumetone (Tablet) .................................. 11 N-Acetyl-L-Cysteine (Capsule) ..................... 45 Nadolol (20mg Tablet, 40mg Tablet, 80mg

Tablet) .................................................... 30 Nadolol/Bendroflumethiazide (Tablet) ....... 30 Nafcillin (Injection) ...................................... 16 Nafcillin Sodium (10gm Injection, 1gm

Injection, 2gm Injection) ........................ 16 Nafrinse (Tablet Chewable) ......................... 53 Nafrinse Drops (Oral Solution) .................... 53 Naftifine HCl (Cream) .................................. 20 Naglazyme (Injection) ................................ 35 Nalbuphine HCl (Injection) .......................... 12 Nalfon (Capsule) ......................................... 11 Naloxone HCl (Injection) ............................. 13 Naltrexone HCl (Tablet) ............................... 13 Namenda XR (Capsule Extended-Release 24

Hour) ...................................................... 18 Namenda XR Titration Pack (Capsule

Extended-Release 24 Hour) ................... 18 Namzaric (Capsule Extended-Release 24

Hour) ...................................................... 32 Naprelan (750mg Tablet Extended-Release

24 Hour) ................................................. 11 Naproxen (125mg/5ml Suspension, 250mg

Tablet, 375mg Tablet, 500mg Tablet) .... 11 Naproxen DR (Tablet Delayed-Release) ...... 11 Naproxen Sodium (275mg Tablet, 550mg

Tablet) .................................................... 11 Naproxen Sodium CR (Tablet Extended-

Release 24 Hour) .................................... 11 Naproxen Sodium ER (Tablet Extended-

Release 24 Hour) .................................... 11 Naratriptan HCl (Tablet) .............................. 21 Narcan (Liquid) ........................................... 13 NascoBAL (Nasal Solution) ......................... 54 Natacyn (Suspension) ................................. 20 Natazia (Tablet) .......................................... 39 Nateglinide (Tablet) .................................... 26 Nat-Rul Prenatal Vitamins (Tablet) ............ 54 Nat-Rul Vitamin D (Tablet) .......................... 54 Natural Vitamin D-3 (Tablet) ....................... 54

Nebupent (Inhalation Solution) .................. 23 Nebusal (3% Nebulized Solution) ................ 51 Necon 0.5/35-28 (Tablet) ............................ 39 Necon 1/50-28 (Tablet) ............................... 39 Necon 7/7/7 (Tablet) ................................... 39 Nefazodone HCl (Tablet).............................. 19 Neomycin Sulfate (Tablet) ........................... 14 Neomycin/Bacitracin/Polymyxin (Ointment)

................................................................ 15 Neomycin/Polymyxin B Sulfates (Irrigation

Solution) ................................................. 14 Neomycin/Polymyxin/Bacitracin/Hydrocortis

one (Ointment) ....................................... 15 Neomycin/Polymyxin/Dexamethasone (0.1%

Ophthalmic Suspension, 0.1%-3.5mg/gm-10000unit/gm Ointment) ....................... 15

Neomycin/Polymyxin/Gramicidin (Ophthalmic Solution) ............................. 14

Neomycin/Polymyxin/Hydrocortisone (1% Ophthalmic Suspension) ......................... 15

Neomycin/Polymyxin/Hydrocortisone (1% Otic Solution, 1% Otic Suspension) ......... 50

Neo-Polycin (Ointment) ............................... 15 Neo-Polycin HC (Ointment) ......................... 15 Neostigmine Methylsulfate (10mg/10ml

Injection, 5mg/10ml Injection, 5mg/5ml Solution Prefilled Syringe) ...................... 21

Neo-Synalar (Cream) ................................... 34 Nephronex (Tablet) ..................................... 54 Nesina (Tablet) ............................................ 26 Neuac (Gel) .................................................. 34 Neulasta (Injection) .................................... 27 Neulasta Onpro Kit (Injection) .................... 27 Neupogen (Injection) .................................. 27 Neupro (Patch 24 Hour) .............................. 23 Neutragard Advanced (Gel) ......................... 32 Neutral Sodium Fluoride (Solution) ............. 32 Nevanac (Suspension) ................................. 49 Nevirapine (200mg Tablet, 50mg/5ml

Suspension) ............................................ 25 Nevirapine ER (Tablet Extended-Release 24

Hour) ....................................................... 25 Nexavar (Tablet) ......................................... 23 Nexplanon (Injection) ................................. 40 Next Choice One Dose (Tablet) .................... 40 Nexterone (150mg/100ml-42.1mg/ml

Injection) ................................................ 29 Niacin ER (Tablet Extended-Release) ........... 31 Nicardipine HCl (2.5mg/ml Injection, 20mg

Capsule, 30mg Capsule) .......................... 30 NICOrelief (Gum) ......................................... 13 Nicotine (14mg/24hr Patch 24 Hour,

21mg/24hr Patch 24 Hour, 7mg/24hr Patch 24 Hour, 2mg Gum, 2mg Lozenge, 4mg Lozenge) .......................................... 13

Nicotine Mini Lozenge (Lozenge) ................. 13 Nicotine Polacrilex (2mg Gum, 4mg Gum,

2mg Lozenge, 4mg Lozenge, 4mg Lozenge) ................................................................ 13

Nicotine Polacrilex Refill (Gum) ................... 13 Nicotine Polacrilex Starter Kit (Gum) ........... 13

72

Nicotine Step 1 (Patch 24 Hour) .................. 13 Nicotine Step 2 (Patch 24 Hour) .................. 13 Nicotine Step 3 (Patch 24 Hour) .................. 13 Nicotine Transdermal System (14mg/24hr

Patch 24 Hour, 21mg/24hr Patch 24 Hour, 7mg/24hr Patch 24 Hour) ....................... 13

Nicotine Transdermal System (Kit) ............. 13 Nicotrol Inhaler (Inhaler) ............................ 13 Nicotrol NS (Nasal Solution) ....................... 13 Nifedipine (10mg Capsule, 20mg Capsule) .. 30 Nifedipine ER (Tablet Extended-Release 24

Hour) ....................................................... 30 Nikki (Tablet) ............................................... 39 Nilutamide (Tablet)...................................... 22 Nimodipine (Capsule) .................................. 30 Ninlaro (Capsule) ........................................ 22 Nipent (Injection) ........................................ 22 Nisoldipine (Tablet Extended-Release 24

Hour) ....................................................... 30 Nisoldipine ER (Tablet Extended-Release 24

Hour) ....................................................... 30 Nitro-Bid (Ointment) .................................. 31 Nitrofurantoin (Suspension) ........................ 15 Nitrofurantoin Macrocrystals (Capsule) ...... 15 Nitrofurantoin Monohydrate (100mg

Capsule) .................................................. 15 Nitroglycerin (0.3mg Tablet Sublingual, 0.4mg

Tablet Sublingual, 0.6mg Tablet Sublingual) .............................................. 31

Nitroglycerin ER (Capsule Extended-Release) (MANUF TRIMARC) ................................. 31

Nitroglycerin in 5% Dextrose (Injection) ...... 31 Nitroglycerin in Dextrose 5% (5%-100mcg/ml

Injection) ................................................. 31 Nitroglycerin Lingual

(0.4mg/sprayTranslingual Solution, 400mcg/spray Aerosol Solution) ............ 31

Nitroglycerin Transdermal (Patch 24 Hour) . 32 NitroMist (Aerosol Solution) ...................... 32 Nizatidine (150mg Capsule, 300mg Capsule,

15mg/ml Oral Solution) .......................... 35 Nora-BE (Tablet) .......................................... 40 Norditropin FlexPro (Injection) .................. 38 Norepinephrine Bitartrate (Injection) ......... 30 Norethindrone (Tablet) ............................... 40 Norethindrone Acetate (5mg Tablet) .......... 40 Norethindrone Acetate/Ethinyl Estradiol

(Tablet) ................................................... 39 Norethindrone Acetate/Ethinyl

Estradiol/Ferrous Fumarate (Tablet) ...... 39 Norethindrone/Ethinyl Estradiol/Ferrous

Fumarate (Tablet Chewable) .................. 39 Norgestimate/Ethinyl Estradiol (0-Tablet,

35mcg-0.25mg Tablet) ............................ 39 Norlyroc (Tablet) ......................................... 40 Normal Saline Flush (Solution) .................... 53 Norpace CR (100mg Capsule Extended-

Release 12 Hour) .................................... 29 Nortrel 0.5/35 (28) (Tablet) ......................... 39 Nortrel 1/35 (Tablet) ................................... 39 Nortrel 7/7/7 (Tablet) .................................. 39

Nortriptyline HCl (10mg Capsule, 25mg Capsule, 50mg Capsule, 75mg Capsule, 10mg/5ml Oral Solution) ........................ 19

Norvir (100mg Capsule, 100mg Tablet, 80mg/ml Oral Solution) ......................... 25

Norwich Aspirin (Tablet) ............................. 11 Novarel (Injection) ...................................... 38 Novofine 30gx8mm .................................... 45 Novofine 32gx6mm .................................... 45 Novofine Autocover 30gx8mm .................. 45 Novofine Plus 32gx4mm ............................ 45 Novolin 70/30 (Injection) ........................... 27 Novolin 70/30 Relion (Injection) ................ 27 Novolin N (Injection) .................................. 27 Novolin N Relion (Injection) ....................... 27 Novolin R (Injection)................................... 27 Novolin R Relion (Injection) ....................... 27 NovoLog (Injection) .................................... 27 NovoLog FlexPen (Injection) ...................... 27 NovoLog Mix 70/30 (Injection) .................. 27 NovoLog Mix 70/30 Prefilled FlexPen

(Injection) .............................................. 27 NovoLog PenFill (Injection) ........................ 27 NovoPen Echo............................................. 45 Novoseven (Solution) ................................. 28 Novoseven RT (Injection) ........................... 28 Novotwist 32gx5mm .................................. 45 Noxafil (100mg Tablet Delayed-Release) ... 20 NP Thyroid 15 (Tablet) ................................ 40 NP Thyroid 60 (Tablet) ................................ 40 NP Thyroid 90 (Tablet) ................................ 40 Nplate (Injection) ....................................... 27 Nucala (Injection) ....................................... 48 Nucynta (Tablet) ......................................... 12 Nucynta ER (Tablet Extended-Release 12

Hour) ...................................................... 11 Nuedexta (Capsule) .................................... 32 Nufol (Tablet) .............................................. 54 Nulojix (Injection) ....................................... 41 Nutrifac ZX (Tablet) ..................................... 54 Nutrilipid (Injection) .................................... 45 Nutrilyte (Injection) ..................................... 53 Nutropin AQ (Injection) .............................. 38 NuvaRing (Ring) .......................................... 39 Nyamyc (Powder) ........................................ 20 Nystatin (100000unit/gm Cream,

100000unit/gm Ointment, 100000unit/gm Powder, 100000unit/ml Suspension, 500000unit Tablet) ................................. 20

Nystatin/Triamcinolone (100000unit/gm-0.1% Ointment, 100000unit/gm-1mg/gm Cream) .................................................... 20

Nystop (Powder) ......................................... 20

O

Obizur (Injection) ........................................ 28 Obredon (Oral Solution) ............................. 51 Obstetrix EC (Tablet) ................................... 54 Ocella (Tablet) ............................................. 39 Octagam (Injection) .................................... 41

Octreotide Acetate (Injection) ..................... 40 Odefsey (Tablet).......................................... 25 Ofev (Capsule) ............................................. 51 Ofloxacin (0.3% Ophthalmic Solution, 0.3%

Otic Solution, 400mg Tablet) .................. 17 Ofloxacin (300mg Tablet) ............................ 14 Ogestrel (Tablet) .......................................... 39 Olanzapine (10mg Injection)........................ 48 Olanzapine (Tablet Immediate-Release) ..... 24 Olanzapine ODT (Tablet Dispersible) ........... 24 Olanzapine/Fluoxetine (Capsule)................. 26 Olmesartan Medoxomil (Tablet) ................. 28 Olmesartan

Medoxomil/Amlodipine/Hydrochlorothiazide (Tablet) .............................................. 28

Olmesartan Medoxomil/Hydrochlorothiazide (Tablet) ................................................... 29

Olopatadine HCl (0.1% Ophthalmic Solution) ................................................................ 49

Olopatadine HCl (0.6% Nasal Solution) ........ 50 Olysio (Capsule) .......................................... 24 Omeclamox-Pak (Therapy Pack) ................. 35 Omega-3-Acid Ethyl Esters (Capsule)........... 31 Omeprazole (Capsule Delayed-Release) ...... 36 Omeprazole/Sodium Bicarbonate (20mg-

1100mg Capsule RX, 40mg-1100mg Capsule, 20mg-1680mg Packet, 40mg-1680mg Packet) ...................................... 36

Omnaris (Suspension) ................................. 50 Omniflex Diaphragm ................................... 45 Oncaspar (Injection).................................... 48 Ondansetron HCl (24mg Tablet, 4mg Tablet,

8mg Tablet, 4mg/5ml Oral Solution) ...... 20 Ondansetron HCl (40mg/20ml Injection,

4mg/2ml Injection) ................................. 20 Ondansetron HCl/Sodium Chloride (Injection)

................................................................ 20 Ondansetron ODT (Tablet Dispersible) ........ 20 One A Day Womens Prenatal/DHA ............ 54 One A Day Womens Prenatal1 (Capsule) ... 55 One-A-Day Womens Prenatal ..................... 55 Onetouch Club Lancets Fine Point .............. 45 Onetouch Combo Pack ............................... 45 Onetouch Delica Lancets Extra Fine 33g .... 45 Onetouch Delica Lancets Fine 30g .............. 45 Onetouch Delica Lancing Device................. 45 Onetouch Ping Meter Remote .................... 45 Onetouch Ultra 2 (Kit) ................................. 45 Onetouch Ultra Blue ................................... 45 Onetouch Ultra Control (In Vitro Solution) 45 Onetouch Ultra Mini (Kit) ........................... 45 Onetouch Ultralink System (Hex) (Kit) ....... 45 Onetouch Ultrasoft Lancets ........................ 46 Onetouch Verio (Kit) ................................... 46 Onetouch Verio Control Solution High

(Solution) ................................................ 46 Onetouch Verio Flex Bloodglucose

Monitoring System (Kit) ......................... 46 Onetouch Verio Iq Blood Glucose Monitoring

System (Kit) ............................................ 46 Onetouch Verio Mid Control Solution

73

(Solution) ................................................ 46 Onetouch Verio Sync Bloodglucose

Monitoring System (Kit) ......................... 46 Onetouch Verio Test Strips ......................... 46 Onfi (10mg Tablet, 20mg Tablet, 2.5mg/ml

Suspension) ............................................ 18 Onglyza (Tablet) .......................................... 26 Onivyde (Injection) ..................................... 48 Opana ER (Tablet Extended-Release 12 Hour

Abuse-Deterrent) ................................... 11 Opcicon One-Step (Tablet) .......................... 40 Opdivo (Injection) ....................................... 23 Opsumit (Tablet) ......................................... 51 OptiChamber Advantage ............................ 46 OptiChamber Advantage/Large Mask ........ 46 OptiChamber Advantage/Medium Face

Mask ....................................................... 46 OptiChamber Advantage/Small Face Mask 46 OptiChamber Diamond ............................... 46 OptiChamber Diamond/Large Face Mask .. 46 OptiChamber Diamond/Medium Face Mask

................................................................ 46 OptiChamber Diamond/Small Face Mask .. 46 OptiChamber Face Mask/Small .................. 46 Optihaler MDI Drug Delivery System ......... 46 Optimal D3 M (Capsule) ............................. 55 Optimal-D Pack (Capsule) ............................ 55 Option 2 (Tablet) ......................................... 40 Options Gynol II Vaginal Contraceptive (Gel)

................................................................ 37 Opurity Vitamin D (Tablet Chewable) .......... 55 Oracea (Capsule Delayed-Release) ............. 34 Oralone (Paste) ............................................ 32 Orencia (125mg/ml Injection, 250mg

Injection) ................................................ 41 Orencia Clickject (Injection) ........................ 41 Orenitram (Tablet Extended-Release) ........ 51 Orfadin (10mg Capsule, 20mg Capsule, 2mg

Capsule, 5mg Capsule) ........................... 35 Orkambi (125mg-100mg Tablet) ................ 51 Orphenadrine Citrate (30mg/ml Injection) .. 52 Orphenadrine Citrate ER (Tablet Extended-

Release 12 Hour) .................................... 52 Orsythia (Tablet) .......................................... 39 Ortho-CS 250 (Injection) .............................. 55 Orthovisc (Injection) ................................... 46 Oseltamivir Phosphate (Capsule) ................ 25 Osmitrol Viaflex (15% Injection, 20%

Injection) ................................................. 30 OsmoPrep (Tablet) ...................................... 35 Osphena (Tablet) ........................................ 40 Otezla (30mg Tablet) .................................. 41 Oxacillin Sodium (Injection) ......................... 16 Oxaliplatin (IV Solution 100mg/20ml) ......... 48 Oxandrolone (Tablet) .................................. 38 Oxaprozin (Tablet) ....................................... 11 Oxaydo (5mg Tablet Abuse-Deterrent) ...... 12 Oxazepam (Capsule) .................................... 26 Oxcarbazepine (150mg Tablet, 300mg Tablet,

600mg Tablet, 60mg/ml Suspension) ..... 18 Oxiconazole Nitrate (Cream) ....................... 21

Oxistat (1% Lotion) ..................................... 21 Oxybutynin Chloride (5mg Tablet, 5mg/5ml

Syrup) ..................................................... 36 Oxybutynin Chloride ER (Tablet Extended-

Release 24 Hour) .................................... 36 Oxycodone HCl (100mg/5ml Concentrate,

10mg Tablet, 15mg Tablet, 20mg Tablet, 30mg Tablet, 5mg Tablet, 5mg Capsule, 5mg/5ml Oral Solution) .......................... 12

Oxycodone HCl ER (10mg, 15mg, 20mg, 30mg, 40mg, 60mg Tablet Extended-Release 12 Hour Abuse-Deterrent) ........ 11

Oxycodone HCl ER (80mg Tablet Extended-Release 12 Hour Abuse-Deterrent) ....... 12

Oxycodone/Acetaminophen (2.5mg-325mg Tablet, 325mg-10mg Tablet, 325mg-5mg Tablet, 325mg-7.5mg Tablet) ................. 12

Oxycodone/Aspirin (Tablet) ........................ 12 Oxycodone/Ibuprofen (Tablet) ................... 11 OxyContin (Tablet Extended-Release 12

Hour Abuse-Deterrent).......................... 12 Oxymorphone HCl (Tablet Immediate-

Release) .................................................. 12 Oxymorphone HCl ER (Tablet Extended-

Release 12 Hour) .................................... 12 Oxytocin (Injection) ..................................... 38 Oxytocin/Sodium Chloride (30unit/500ml-

0.9% Solution) ........................................ 50 Ozurdex (Injection) ..................................... 49

P

PA Prenatal Formula (Tablet) ..................... 55 PA Vitamin D-3 (Capsule) ............................ 55 PA Vitamin D-3 Gummy (Tablet Chewable) 55 Pacerone (Tablet) ........................................ 29 Paclitaxel (100mg/16.7ml Injection,

300mg/50ml Injection, 30mg/5ml Injection) ................................................ 22

Paclitaxel (150mg/25ml Injection) ............. 22 Paliperidone ER (Tablet Extended-Release 24

Hour) ...................................................... 24 Pamidronate Disodium (30mg Injection,

30mg/10ml Injection, 90mg Injection, 90mg/10ml Injection) ............................. 42

Pamidronate Disodium (6mg/ml Injection) 42 Pancuronium Bromide (Injection) ............... 52 Panda Mask Large ...................................... 46 Panda Mask Medium ................................. 46 Panda Mask Small ...................................... 46 Panretin (Gel) ............................................. 23 Pantoprazole Sodium (20mg Tablet Delayed-

Release, 40mg Tablet Delayed-Release, 40mg Injection) ...................................... 36

Paragard Intrauterine Copper Contraceptive T380a (IUD) ............................................ 46

Paricalcitol (1mcg Capsule, 2mcg Capsule, 4mcg Capsule, 2mcg/ml Injection, 5mcg/ml Injection) ................................. 42

Paroex (Solution)......................................... 32 Paromomycin Sulfate (Capsule) .................. 14

Paroxetine HCl (Tablet) ................................ 19 Paroxetine HCl ER (Tablet Extended-Release

24 Hour) .................................................. 19 Paser (Packet) ............................................. 21 Pataday (Ophthalmic Solution) .................. 49 Paxil (10mg/5ml Suspension) ..................... 19 Pazeo (Ophthalmic Solution) ...................... 49 PC Unifine Pentips 29g X 1/2" .................... 46 PC Unifine Pentips 31g X 5mm Mini ........... 46 PC Unifine Pentips 31g X 6mm Ultra Short 46 PCE (500mg Tablet Delayed-Release) ......... 17 Pediarix (Injection) ...................................... 42 Pediatric Panda Mask ................................. 46 Pedvax HIB (Injection) ................................ 42 PEG 3350 (Powder) ...................................... 36 PEG 3350/Electrolytes (Oral Solution) ......... 36 Peg intron Redipen (Injection) .................... 24 PEG-3350/Electrolytes (Oral Solution) ........ 36 PEG-3350/NaCl/Na Bicarbonate/KCl (Oral

Solution) ................................................. 36 Peganone (Tablet) ....................................... 18 Pegasys (Injection) ...................................... 48 Pegasys ProClick (Injection) ........................ 48 PegIntron (Injection) ................................... 24 Peg-Prep (Kit) ............................................... 35 Pegylax (Powder) ......................................... 36 Pen Needles 30gx5/16" .............................. 46 Pen Needles 30gx5mm ............................... 46 Pen Needles 30gx8mm ............................... 46 Penicillin G Potassium (Injection) ................ 16 Penicillin V Potassium (125mg/5ml Oral

Solution, 250mg/5ml Oral Solution, 250mg Tablet, 500mg Tablet) ............................. 16

Penlet II Automatic Blood Sampler (Kit) .... 46 Penlet II Replacement Caps-Deep .............. 46 Pentacel (Injection) ..................................... 42 Pentasa (Capsule Extended-Release) ......... 42 Pentazocine/Naloxone HCl (Tablet) ............. 12 Pentips 29gx12mm ..................................... 46 Pentips 31gx5mm ....................................... 46 Pentips 31gx6mm ....................................... 46 Pentips 31gx8mm ....................................... 46 Pentips 32gx4mm ....................................... 46 Pentoxifylline ER (Tablet Extended-Release)

................................................................ 30 Perforomist (Nebulized Solution) ............... 51 Perindopril Erbumine (Tablet) ..................... 29 Periogard (Solution) ..................................... 32 Perjeta (Injection) ....................................... 23 Permethrin (Cream) ..................................... 23 Perphenazine (Tablet) ................................. 20 Perphenazine/Amitriptyline (10mg-2mg

Tablet, 25mg-2mg Tablet, 25mg-4mg Tablet) ..................................................... 19

Perry Prenatal (Capsule) .............................. 55 Pharbedryl (Capsule) (RX) ............................ 20 Phenadoz (Suppository)............................... 20 Phenazo (Tablet) .......................................... 37 Phenelzine Sulfate (Tablet) .......................... 19 Phenergan (12.5mg Suppository, 25mg

Suppository, 50mg Suppository) ............. 20

74

Phenobarbital (100mg Tablet, 15mg Tablet, 16.2mg Tablet, 30mg Tablet, 32.4mg Tablet, 60mg Tablet, 64.8mg Tablet, 97.2mg Tablet, 20mg/5ml Elixir, 20mg/5ml Oral Solution) .......................................... 18

Phenoxybenzamine HCl (Capsule) ............... 28 Phenylephrine HCl (10% Ophthalmic Solution,

2.5% Ophthalmic Solution) ..................... 49 Phenylephrine HCl (10mg/ml Injection) ...... 28 Phenylephrine HCl/Sodium Chloride

(50mg/250ml-0.9% Solution) .................. 26 Phenytoin (125mg/5ml Suspension, 50mg

Tablet Chewable) .................................... 18 Phenytoin Sodium (50mg/ml Injection) ...... 18 Phenytoin Sodium Extended (Capsule) ....... 18 Philith (Tablet) ............................................. 39 Phos-Flur (Gel) ............................................. 32 Phoslyra (Oral Solution) .............................. 37 Phospholine Iodide (Ophthalmic Solution) 50 Photofrin (Injection) ................................... 48 Physiolyte (Irrigation Solution) .................... 46 Physiosol Irrigation (Solution) ..................... 46 Phytonadione (Injection) ............................. 55 Picato (Gel) .................................................. 34 Pilocarpine HCl (1% Ophthalmic Solution, 2%

Ophthalmic Solution, 4% Ophthalmic Solution) ................................................. 50

Pilocarpine HCl (5mg Tablet, 7.5mg Tablet) 33 Pimozide (Tablet) ......................................... 24 Pimtrea (Tablet) ........................................... 39 Pindolol (Tablet) .......................................... 30 Pioglitazone HCl (Tablet) ............................. 26 Pioglitazone HCl/Glimepiride (Tablet) ......... 26 Pioglitazone HCl/Metformin HCl (Tablet) .... 26 Piperacillin/Tazobactam (2gm-0.25gm

Injection, 3gm-0.375gm Injection, 4gm-0.5gm Injection, 36gm-4.5gm Solution) . 16

Pirmella 1/35 (Tablet) .................................. 39 Pirmella 7/7/7 (Tablet) ................................ 39 Piroxicam (10mg Capsule, 20mg Capsule) ... 11 Plasbumin-25 (Injection) ............................. 28 Plasbumin-5 (Injection) ............................... 28 Plasma-Lyte A (Injection) ............................ 53 Plasma-Lyte-148 (Injection) ........................ 53 Plasma-Lyte-56/D5W (Injection) ................ 53 Plegridy (Injection) ...................................... 48 Plegridy Starter Pack (Injection) ................. 48 Plenamine (Injection) .................................. 53 Pneumovax 23 (Injection) ........................... 42 Pocket Chamber .......................................... 46 Pocket Spacer .............................................. 46 Podofilox (External Solution) ....................... 34 Polocaine (Injection) .................................... 13 Polocaine-Mpf (Injection) ............................ 13 Polycin (Ointment) ...................................... 15 Polyethylene Glycol 3350 (Packet, Powder)

RX ............................................................ 36 Poly-Iron 150 Forte (Capsule) ...................... 53 Polymyxin B Sulfate (500000unit Injection). 15 Polymyxin B Sulfate/Trimethoprim Sulfate

(Ophthalmic Solution) ............................. 15

Polysaccharide Iron Forte (Capsule) ............ 53 Pomalyst (Capsule) ..................................... 22 Portia-28 (Tablet) ........................................ 39 Portrazza (Injection) ................................... 22 Potassium Acetate (2meq/ml Injection) ..... 53 Potassium Chloride (10% Oral Solution, 20%

Oral Solution, 10meq/100ml Injection, 20meq/50ml Injection, 2meq/ml Injection, 40meq/100ml Injection, 20meq Packet) 53

Potassium Chloride 0.15% D5W/NaCl 0.33% (Injection) ............................................... 48



Potassium Chloride 0.224%D5W/NaCl 0.45% Viaflex (Injection) ................................... 48

Potassium Chloride CR (Tablet Extended-Release) .................................................. 53

Potassium Chloride ER (10meq Capsule Extended-Release, 8meq Capsule Extended-Release, 10meq Tablet Extended-Release, 20meq Tablet Extended-Release, 8meq Tablet Extended-Release) .................................................. 53

Potassium Chloride SR (Tablet Extended-Release) .................................................. 53

Potassium Chloride/Dextrose (5%-20meq/L Injection) ................................................ 48

Potassium Chloride/Lidocaine HCl (Injection) ............................................................... 53

Potassium Chloride/Sodium Chloride (20meq/L-0.9% Injection, 40meq/L-0.9% Injection) ................................................ 53

Potassium Citrate ER (Tablet Extended-Release) .................................................. 53

Potiga (Tablet) ............................................ 17 Pradaxa (Capsule) ....................................... 27 Praluent (Injection) .................................... 30 Pramipexole Dihydrochloride (Tablet

Immediate-Release) ............................... 23 Pramipexole Dihydrochloride ER (Tablet

Extended-Release 24 Hour) .................... 23 Pravastatin Sodium (Tablet) ........................ 31 Prazosin HCl (1mg Capsule, 2mg Capsule, 5mg

Capsule) .................................................. 28 Pred Mild (Suspension) .............................. 49 Prednicarbate (0.1% Cream, 0.1% Ointment)

............................................................... 34 Prednisolone (15mg/5ml Oral Solution,

15mg/5ml Syrup).................................... 37 Prednisolone Acetate (Suspension) ............ 49 Prednisolone Sodium Phosphate (1%

Ophthalmic Solution) ............................. 49 Prednisolone Sodium Phosphate (10mg/5ml

Solution, 20mg/5ml Solution, 25mg/5ml Oral Solution, 5mg/5ml Oral Solution) ... 37

Prednisolone Sodium Phosphate ODT (Tablet Dispersible) ............................................ 37

Prednisone (10mg Tablet Therapy Pack, 5mg Tablet Therapy Pack) .............................. 41

Prednisone (10mg Tablet, 1mg Tablet, 2.5mg Tablet, 20mg Tablet, 50mg Tablet, 5mg Tablet) ..................................................... 37

Prednisone Intensol (5mg/ml Concentrate) ................................................................ 37

Pregnyl w/Diluent Benzyl Alcohol/NaCl (Injection) ............................................... 38

Premarin (0.3mg Tablet, 0.45mg Tablet, 0.625mg Tablet, 0.9mg Tablet, 1.25mg Tablet) .................................................... 39

Premasol (6% Injection) ............................... 53 Premphase (Tablet)..................................... 39 Prempro (Tablet) ......................................... 39 Prenatabs Rx (Tablet) .................................. 55 Prenatal (100mg-0-0-263mg-400unit-4mcg-

27mg-0.8mg-18mg-2.6mg-1.7mg-1.5mg-11unit-4000unit-25mg Tablet) ............... 55

Prenatal (120mg-4000unit-200mg-400unit-8mcg-28mg-800mcg-20mg-2.6mg-1.7mg-1.8mg-30unit-25mg Tablet) ................... 55

Prenatal 19 (Tablet, Tablet Chewable) ........ 55 Prenatal and Iron (Tablet)............................ 55 Prenatal Complete (Tablet) ........................ 55 Prenatal Formula (Capsule) ........................ 55 Pre-Natal Formula (Tablet) .......................... 55 Prenatal Forte (Tablet) ................................ 55 Prenatal Low Iron (Tablet) ........................... 55 Prenatal Multi + DHA (Capsule) .................. 55 Prenatal Multi +DHA (Capsule) ................... 53 Prenatal Multivitamin + DHA ..................... 55 Prenatal Multivitamin Plus DHA (Capsule). 55 Prenatal One Daily (Tablet) ........................ 55 Prenatal Vitamin/Iron (Tablet) ................... 55 Prenatal Vitamins (Tablet) ........................... 55 Prenatal/Omega-3/Folic Acid/Iron (Capsule)

................................................................ 55 Prenatal-U (Capsule) .................................... 55 Prepopik (Packet) ........................................ 36 Prevalite (4gm Packet, 4gm/dose Powder) . 31 Previfem (Tablet) ......................................... 39 Prevnar 13 (Injection) ................................. 42 Prezcobix (Tablet) ....................................... 25 Prezista (100mg/ml Suspension, 150mg

Tablet, 600mg Tablet, 75mg Tablet, 800mg Tablet) ........................................ 25

Prialt (Injection) .......................................... 10 Priftin (Tablet) ............................................. 21 Primaquine Phosphate (Tablet) ................... 23 Primidone (Tablet) ....................................... 18 Primsol (Oral Solution) ............................... 15 Privigen (Injection) ...................................... 41 Pro Comfort Alcohol Prep Pads .................. 15 Pro Comfort Pen Needles/ 32g X 5mm....... 46 Pro Comfort Pen Needles/ 32g X 6mm....... 46 ProAir HFA (Aerosol Solution) .................... 51 ProAir RespiClick (Aerosol Powder) ........... 51 Probenecid (Tablet) ..................................... 21 Probenecid/Colchicine (Tablet) ................... 21 Procainamide HCl (500mg/ml Solution) ...... 29 Prochlorperazine (Suppository) ................... 20 Prochlorperazine Edisylate (Injection) ......... 20

75

Prochlorperazine Maleate (10mg Tablet, 5mg Tablet)..................................................... 20

Procrit (Injection) ........................................ 27 Procto-Med HC (Cream) .............................. 34 Procto-Pak (Cream) ..................................... 34 Proctosol HC (Cream) .................................. 34 Proctozone-HC (Cream) ............................... 34 Procysbi (Capsule Delayed-Release)........... 49 Profilnine (Injection) ................................... 28 Progesterone (100mg Capsule, 200mg

Capsule) .................................................. 40 Progesterone (50mg/ml Injection) .............. 40 Proglycem (Suspension).............................. 27 Prograf (5mg/ml Injection) ......................... 41 Prolastin-C (Injection) ................................. 51 Proleukin (Injection) ................................... 48 Prolia (Injection) ......................................... 43 Promacta (Tablet) ....................................... 27 Promethazine HCl (12.5mg Suppository,

25mg Suppository, 50mg Suppository, 12.5mg Tablet, 25mg Tablet, 50mg Tablet, 50mg/ml Injection, 6.25mg/5ml Oral Solution) ................................................. 20

Promethazine HCl (25mg/ml Injection) ....... 48 Promethazine HCl Plain (Syrup) ................... 20 Promethegan (Suppository) ........................ 20 Pronutrients Vitamin D3 (Capsule) .............. 55 Propafenone HCl (Tablet) ............................ 29 Propafenone HCl ER (Capsule Extended-

Release 12 Hour) .................................... 29 Propantheline Bromide (15mg Tablet) ........ 35 Proparacaine HCl (Ophthalmic Solution) ..... 49 Propranolol HCl (Tablet Immediate-Release,

1mg/ml Injection, Oral Solution) ............ 30 Propranolol HCl (Tablet) .............................. 30 Propranolol HCl ER (Capsule Extended-

Release 24 Hour) .................................... 30 Propranolol/Hydrochlorothiazide (Tablet) .. 30 Propylthiouracil (Tablet) .............................. 41 ProQuad (Injection) .................................... 42 Protriptyline HCl (Tablet) ............................. 19 Pulmicort Flexhaler (Aerosol Powder) ....... 50 Pulmosal (Nebulized Solution)..................... 51 Pulmozyme (Inhalation Solution) ............... 48 PureVitamin Dualfe Plus (Capsule) .............. 53 PX Aspirin (325mg Tablet, 81mg Tablet

Chewable) ............................................... 11 PX Enteric Aspirin (Tablet Delayed-Release) 11 PX Mini Pen Needles 31gx5mm .................. 46 PX Prenatal Multivitamins (Tablet) .............. 55 PX Stop Smoking Aid (2mg Gum, 4mg Gum,

2mg Lozenge, 2mg Lozenge, 4mg Lozenge) ................................................................ 13

Pylera (Capsule) .......................................... 35 Pyrazinamide (Tablet) .................................. 21 Pyridostigmine Bromide (Tablet) ................. 21 Pyridostigmine Bromide ER (Tablet Extended-

Release) .................................................. 21 Pyridoxine HCl (100mg/ml Injection)........... 55

Q

QC Alcohol Swabs ....................................... 15 QC Aspirin (325mg Tablet, 325mg Tablet

Delayed-Release).................................... 11 QC Childrens Aspirin (Tablet Chewable) ..... 11 QC Enteric Aspirin (Tablet Delayed-Release)

............................................................... 11 QC Gentle Laxative (Tablet Delayed-Release)

............................................................... 36 QC Natura-Lax (Powder) ............................. 36 QC Nicotine Polacrilex (Gum) ...................... 13 QC Prenatal (Tablet) ................................... 55 Quadracel (Injection) .................................. 42 Quasense (Tablet) ....................................... 39 Quazepam (Tablet)...................................... 26 Quetiapine Fumarate (Tablet) ..................... 19 Quetiapine Fumarate ER (Tablet Extended-

Release 24 Hour) .................................... 19 Quflora Pediatric (32mg/ml-3mcg/ml-

1mg/ml-400unit/ml-2mcg/ml-5unit/ml-29.7mcg/ml-2mg/ml-0.4mg/ml-0.6mg/ml-0.25mg/ml-0.5mg/ml-1150unit/ml Oral Solution) ................................................. 55

Quillivant XR (Suspension) ......................... 32 Quinapril HCl (Tablet) .................................. 29 Quinapril/Hydrochlorothiazide (Tablet) ...... 29 Quinidine Gluconate CR (Tablet Extended-

Release) .................................................. 29 Quinidine Gluconate ER (Tablet Extended-

Release) .................................................. 29 Quinidine Sulfate (Tablet) ........................... 29 Quinine Sulfate (324mg Capsule) ................ 23

R

RA Alcohol Swabs ....................................... 15 RA Aspirin (Tablet) ...................................... 11 RA Aspirin Adult Low Strength (Tablet

Chewable) .............................................. 11 RA Aspirin EC (Tablet Delayed-Release) ...... 11 RA Childrens Aspirin (Tablet Chewable) ...... 11 RA Laxative (Powder, 5mg Tablet Delayed-

Release) .................................................. 36 RA Nicotine (14mg/24hr Patch 24 Hour,

21mg/24hr Patch 24 Hour, 2mg Gum, 4mg Gum) ...................................................... 13

RA Nicotine Gum (Gum) .............................. 13 RA Nicotine Polacrilex (2mg Gum, 2mg

Lozenge, 4mg Lozenge) .......................... 14 RA One Daily ............................................... 55 RA Pen Needles 31g X 5mm 3/16" ............. 46 RA Prenatal (Tablet) .................................... 55 RA Prenatal Formula/Folic Acid (Tablet) ... 55 RA Vitamin D-3 (1000unit Tablet, 2000unit

Capsule) .................................................. 55 Rabavert (Injection).................................... 42 Rabeprazole Sodium (Tablet Delayed-

Release) .................................................. 36 Rajani (Tablet) ............................................. 39 Raloxifene HCl (Tablet) ................................ 40 Ramipril (Capsule) ....................................... 29

Ranexa (Tablet Extended-Release 12 Hour) ................................................................ 30

Ranitidine HCl (150mg Capsule, 300mg Capsule, 150mg Tablet RX, 300mg Tablet, 150mg/6ml Injection, 50mg/2ml Injection, 15mg/ml Syrup, 75mg/5ml Syrup).......... 35

Rapaflo (Capsule) ........................................ 37 Rapamune (1mg/ml Oral Solution) ............ 41 Rasagiline Mesylate (Tablet) ........................ 24 RAVICTI (Liquid) .......................................... 35 Rayaldee (Capsule Extended-Release) ....... 56 React (Tablet) .............................................. 40 Reality Swabs .............................................. 15 Rebetol (40mg/ml Oral Solution) ............... 24 Reclipsen (Tablet) ........................................ 39 Recombinate (Injection) ............................. 28 Recombivax HB (Injection) ......................... 42 Rectiv (Ointment) ....................................... 32 Regranex (Gel)............................................. 34 Relador Pak (Kit) .......................................... 13 Relador Pak Plus (Kit) ................................... 13 Relenza Diskhaler (Aerosol Powder) .......... 25 Relion Ketone .............................................. 46 Relion Ketone Test Strips ............................ 46 Relion Pen Needles 29gx12mm .................. 46 Relion Pen Needles 31gx6mm .................... 46 Relion Pen Needles 31gx8mm .................... 46 Relion Pen Needles 32gx4mm .................... 46 Relistor (12mg/0.6ml Injection, 8mg/0.4ml

Injection) ................................................ 35 Relistor (150mg Tablet) .............................. 36 Relpax (Tablet) ............................................ 21 Remicade (Injection) ................................... 41 Remodulin (Injection) ................................. 51 Renagel (Tablet) .......................................... 37 Rena-Vite Rx (Tablet) ................................... 55 Renvela (0.8gm Packet, 2.4gm Packet) ...... 37 Renvela (800mg Tablet) .............................. 37 Repaglinide (Tablet) ..................................... 26 Repaglinide/Metformin HCl (Tablet) ........... 26 Repatha (Injection) ..................................... 30 Repatha Pushtronex System (Injection) ..... 30 Repatha SureClick (Injection) ..................... 30 Replesta (Wafer) ......................................... 55 Replesta Childrens (Wafer) ......................... 55 Replesta Nx (Wafer) .................................... 55 Reprexain (10mg-200mg Tablet) ................. 11 Rescriptor (Tablet) ...................................... 25 Rescula (Ophthalmic Solution) ................... 49 Restasis (Emulsion) ..................................... 49 Restasis Multidose (Emulsion).................... 49 Retrovir IV Infusion (Solution) .................... 25 Revlimid (Capsule) ...................................... 22 Revonto (Injection) ...................................... 52 Rexulti (Tablet)............................................ 24 Reyataz (150mg Capsule, 200mg Capsule,

300mg Capsule, 50mg Packet) ............... 25 Rhogam Ultra-Filtered Plus (Injection) ....... 41 Rhophylac (Injection) .................................. 41 Riastap (Injection) ....................................... 28 Ribasphere (200mg Capsule, 200mg Tablet)24

76

Ribasphere (400mg Tablet, 600mg Tablet) 24 Ribasphere Ribapak (Tablet) ...................... 24 Ribavirin (200mg Capsule, 200mg Tablet) ... 24 Ribavirin (6gm Solution) .............................. 51 Ridaura (Capsule) ........................................ 41 Rifabutin (Capsule) ...................................... 21 Rifamate (Capsule) ...................................... 21 Rifampin (150mg Capsule, 300mg Capsule,

600mg Injection) ..................................... 21 Rifater (Tablet) ............................................ 21 Right Step Prenatal (Tablet) ....................... 55 Riluzole (Tablet) ........................................... 32 Rimantadine HCl (Tablet)............................. 25 Ringers Injection .......................................... 53 Ringers Irrigation (Solution)......................... 46 Riomet (Oral Solution) ................................ 26 Risedronate Sodium (150mg Tablet, 35mg

Tablet)..................................................... 43 Risedronate Sodium (30mg Tablet, 5mg

Tablet)..................................................... 43 Risedronate Sodium DR (Tablet Delayed-

Release) .................................................. 43 Risperdal Consta (Injection) ....................... 48 Risperidone (0.25mg Tablet, 0.5mg Tablet,

1mg Tablet, 2mg Tablet, 3mg Tablet, 4mg Tablet, 1mg/ml Oral Solution) ................ 24

Risperidone ODT (Tablet Dispersible) .......... 24 RiteFlo ......................................................... 46 Rituxan (Injection) ...................................... 23 Rivastigmine Tartrate (Capsule Immediate-

Release) .................................................. 18 Rivastigmine Transdermal System (Patch 24

Hour) ....................................................... 18 Rixubis (Injection) ....................................... 28 Rizatriptan Benzoate (Tablet) ...................... 21 Rizatriptan Benzoate ODT (Tablet Dispersible)

................................................................ 21 Rocuronium Bromide (100mg/10ml Injection,

50mg/5ml Injection) ............................... 52 Ropinirole ER (Tablet Extended-Release 24

Hour) ....................................................... 23 Ropinirole HCl (Tablet) ................................ 23 Ropivacaine (Injection) ................................ 13 Ropivacaine HCl (Injection) .......................... 13 Ropivacaine HCl/Sodium Chloride (0.1%-0.9%

Solution, 0.2%-0.9% Injection) ................ 13 Rosadan (0.75% Cream, 0.75% Gel)............. 15 Rosuvastatin Calcium (Tablet) ..................... 31 Rotarix (Suspension) ................................... 42 RotaTeq (Oral Solution) .............................. 42 Roweepra (Tablet) ....................................... 17 Rozerem (Tablet) ........................................ 52

S

Sabril (500mg Packet) ................................. 18 Safety Insulin Syringes 1ml/27gx1/2" ........ 46 Safety Insulin Syringes 1ml/30gx1/2" ........ 46 Safety-Glide Insulin Syringe/0.3ml/29g X

1/2" ........................................................ 46 Salicylic Acid (6% Cream, 6% Gel, 6% Lotion)

............................................................... 34 Salicylic Acid Cream (Kit) ............................. 34 Salicylic Acid Lotion (Kit) ............................. 34 Saline Flush (Injection) ................................ 53 Saline Flush Zr/Sterile Field (Injection)........ 53 Salitech Forte (Lotion) ................................. 34 Salsalate (500mg Tablet, 750mg Tablet)

(MANUF MARLEX) .................................. 11 Samsca (Tablet) .......................................... 52 Sancuso (Patch) .......................................... 20 Sandimmune (100mg/ml Oral Solution) .... 41 Sandostatin LAR Depot (Injection) ............. 40 Santyl (Ointment) ....................................... 34 Saphris (10mg Tablet Sublingual)............... 24 Saphris (2.5mg Tablet Sublingual, 5mg

Tablet Sublingual) .................................. 48 Saps Care Alcohol Prep Pads ...................... 15 Sash Kit for Flushing Vascular Access Devices

(Kit) ......................................................... 27 Savella (Tablet) ........................................... 32 SB Alcohol Prep Pads .................................. 15 SB Aspirin (Tablet) ....................................... 11 SB Aspirin EC (Tablet Delayed-Release) ...... 11 SB Bisacodyl Laxative EC (Tablet Delayed-

Release) .................................................. 36 SB Childrens Aspirin (Tablet Chewable) ...... 11 Scalacort (Lotion) ........................................ 34 Selegiline HCl (5mg Capsule, 5mg Tablet) ... 24 Selenium Sulfide (Lotion) ............................ 34 Selzentry (150mg Tablet, 300mg Tablet) ... 25 Selzentry (25mg Tablet, 75mg Tablet) ....... 14 Sensipar (Tablet) ........................................ 40 Sensorcaine (Injection) ............................... 13 Sensorcaine/Epinephrine (Injection)........... 13 Sensorcaine-MPF (Injection) ....................... 13 Sensorcaine-MPF Spinal (Injection) ............ 13 Sensorcaine-Mpf/Epinephrine (Injection) ... 42 Serevent Diskus (Aerosol Powder) ............. 51 Seroquel XR (150mg Tablet Extended-

Release 24 Hour, 200mg Tablet Extended-Release 24 Hour, 300mg Tablet Extended-Release 24 Hour, 50mg Tablet Extended-Release 24 Hour) ................................... 19

Serostim (Injection) .................................... 38 Sertraline HCl (100mg Tablet, 25mg Tablet,

50mg Tablet, 20mg/ml Concentrate) ..... 19 Setlakin (Tablet) .......................................... 39 Sharobel (Tablet) ......................................... 40 Shur-Seal (Gel) ............................................ 37 Signifor (Injection) ...................................... 40 Sildenafil (10mg/12.5ml Injection) .............. 51 Sildenafil (20mg Tablet) .............................. 51 Silver Sulfadiazine (Cream) ......................... 15 Simbrinza (Suspension) .............................. 50 Similac Prenatal Early Shield ...................... 55 Simponi (Injection) ..................................... 41 Simponi Aria (Injection) ............................. 41 Simulect (20mg Injection) .......................... 41 Simvastatin (10mg Tablet, 20mg Tablet, 40mg

Tablet, 5mg Tablet) ................................ 31 Simvastatin (80mg Tablet) .......................... 31

Sirolimus (Tablet) ......................................... 41 Sirturo (Tablet) ............................................ 21 Sivextro (200mg Tablet) .............................. 15 Sklice (Lotion) .............................................. 23 Skyla (IUD) ................................................... 40 SM Alcohol Prep Pads ................................. 15 SM Aspirin (Tablet) ...................................... 11 SM Aspirin Adult Low Strength (Tablet

Chewable) ............................................... 11 SM Aspirin EC Low Strength (Tablet Delayed-

Release) .................................................. 11 SM Aspirin Enteric Coated (Tablet Delayed-

Release) .................................................. 11 SM Childrens Aspirin (Tablet Chewable) ..... 11 SM ClearLax (Powder) ................................. 36 SM Folic Acid (Tablet) .................................. 55 SM Gentle Laxative (Tablet Delayed-Release)

................................................................ 36 SM Nicotine (14mg/24hr Patch 24 Hour,

21mg/24hr Patch 24 Hour, 7mg/24hr Patch 24 Hour, 2mg Lozenge, 4mg Gum) 14

SM Nicotine Polacrilex (2mg Gum, 4mg Gum, 4mg Lozenge) .......................................... 14

SM Nicotine Transdermal System (Patch 24 Hour) ....................................................... 14

SM One Daily Prenatal ................................ 55 SM Vitamin D (Tablet) ................................. 55 SM Vitamin D3 Maximum Strength (Capsule)

................................................................ 55 Smooth Lax (Powder) .................................. 36 Sodium Acetate (2meq/ml Injection) .......... 52 Sodium Bicarbonate (7.5% Injection) .......... 52 Sodium Chloride 0.9% (Irrigation Solution) 46 Sodium Chloride (0.9% Nebulized Solution,

10% Nebulized Solution, 3% Nebulized Solution, 7% Nebulized Solution) ............ 51

Sodium Chloride (2.5meq/ml Injection, 3% Injection, 5% Injection) ........................... 53

Sodium Chloride 0.45% (Injection) .............. 53 Sodium Chloride Bacteriostatic (Injection) .. 53 Sodium Chloride Flush (Injection) ................ 53 Sodium Ferric Gluconate Complex/Sucrose

(Injection) ............................................... 53 Sodium Fluoride (0.25mg Tablet Chewable,

1.1mg Tablet Chewable, 1mg Tablet Chewable, 0.5mg/ml Oral Solution, 1mg Tablet) ..................................................... 53

Sodium Hyaluronate (Gel) ........................... 41 Sodium Nitroprusside (Injection) ................. 32 Sodium Phenylacetate/Sodium Benzoate

(Injection) ............................................... 46 Sodium Phenylbutyrate (Powder) ............... 35 Sodium Phosphate (Injection) ..................... 53 Sodium Polystyrene Sulfonate (Powder,

15gm/60ml Suspension, 30gm/120ml Suspension, 50gm/200ml Suspension) ... 52

Sodium Sulfacetamide (Ophthalmic Solution) ................................................................ 17

Soliris (Injection) ......................................... 48 Soltamox (Oral Solution) ............................ 22 Solu-Cortef (1000mg Injection) .................. 48

77

Somatuline Depot (Injection) ..................... 40 Somavert (Injection) ................................... 40 Sorine (Tablet) ............................................. 29 Sotalol HCl (AF) (Tablet)............................... 29 Sotalol HCl (Tablet) ...................................... 29 Sovaldi (Tablet) ........................................... 24 Spinosad (Suspension) ................................. 23 Spiriva HandiHaler (Capsule) ...................... 50 Spiriva Respimat (Aerosol Solution) ........... 50 Spironolactone (100mg Tablet, 25mg Tablet,

50mg Tablet) ........................................... 31 Spironolactone/Hydrochlorothiazide (Tablet)

................................................................ 31 Sprintec 28 (Tablet) ..................................... 39 Sprix (Nasal Solution).................................. 11 Sprycel (Tablet) ........................................... 23 SPS (Suspension).......................................... 52 SR Nicotine Gum (Gum) ............................... 14 Sronyx (Tablet) ............................................ 39 SSD (Cream) ................................................. 15 SSKI (Oral Solution) ..................................... 51 ST 51 St Joseph Low Dose Aspirin (Tablet Chewable)

................................................................ 11 Stavudine (Capsule) ..................................... 25 Stelara (130mg/26ml Injection).................. 41 Stelara (45mg/0.5ml Injection, 90mg/ml

Injection) ................................................ 34 Sterile Diluent for Epoprostenol Sodium

(Injection) ............................................... 46 Sterile Water for Injection ........................... 46 Sterile Water Irrigation (Solution) ............... 46 Stimate (Nasal Solution) ............................. 38 Stimulant Laxative (Tablet Delayed-Release)

................................................................ 36 Stiolto Respimat (Aerosol Solution) ........... 51 Stivarga (Tablet) .......................................... 23 Strattera (Capsule) ...................................... 32 Strensiq (Injection) ..................................... 35 Streptomycin Sulfate (1gm Injection) .......... 14 Striant .......................................................... 38 Stribild (Tablet) ........................................... 25 Stuart One (Capsule) ................................... 55 Suboxone (Film) .......................................... 12 Sucraid (Oral Solution) ................................ 35 Sucralfate (1gm Tablet) ............................... 36 Sulfacetamide Sodium (10% Lotion, 10%

Suspension) ............................................ 34 Sulfacetamide Sodium (10% Ophthalmic

Solution) ................................................. 17 Sulfacetamide Sodium/Prednisolone Sodium

Phosphate (Ophthalmic Solution) ........... 17 Sulfadiazine (500mg Tablet) ........................ 17 Sulfamethoxazole/Trimethoprim

(200mg/5ml-40mg/5ml Suspension, 400mg-80mg Tablet) .............................. 17

Sulfamethoxazole/Trimethoprim DS (Tablet) ................................................................ 17

Sulfamylon (85mg/gm Cream) ................... 15 Sulfasalazine (500mg Tablet, 500mg Tablet

Delayed-Release) .................................... 42

Sulfatrim Pediatric (Suspension) ................. 17 Sulindac (150mg Tablet, 200mg Tablet) ...... 11 Sumatriptan (Nasal Solution) ...................... 21 Sumatriptan Succinate (100mg Tablet, 25mg

Tablet, 50mg Tablet, 4mg/0.5ml Injection, 6mg/0.5ml Injection) .............................. 21

Super Daily D3 (1000unit/0.03ml Liquid) .. 55 Super Daily D3 (2000UT/0.028ml Liquid) .. 46 Supprelin LA (Injection) .............................. 40 Suprax (100mg Tablet Chewable, 200mg

Tablet Chewable, 500mg/5ml Suspension)............................................ 16

Supreme II Confidence Paddles ................. 46 Suprep Bowel Prep (Oral Solution) ............ 36 Sure Comfort Alcohol Prep Pads ................ 15 Sure Comfort Pen Needles 29gx1/2" 12.7mm

............................................................... 46 Sure Comfort Pen Needles 30gx5/16" Short

............................................................... 46 Sure Comfort Pen Needles 31gx3/16" (5mm)

............................................................... 46 Sure Comfort Pen Needles 31gx5/16" (8mm)

............................................................... 46 Sure Comfort Pen Needles 32gx5/32" ....... 46 Sure Comfort Pen Needles 32gx6mm ........ 46 Sure-Fine Pen Needles 29gx1/2" 12.7mm . 46 Sure-Fine Pen Needles 31gx3/16" 5mm .... 46 Sure-Fine Pen Needles 31gx5/16" 8mm .... 46 Surestep Glucose Control (In Vitro Solution)

............................................................... 46 Surestep Glucose Control Solution (In Vitro

Solution) ................................................ 46 Surestep Pro High Glucosecontrol (Liquid) 46 Surestep Pro Linearity Kit (Kit) ................... 46 Surestep Pro Low Glucose Control (Liquid) 46 Surestep Pro Normal Glucose Control

(Liquid) ................................................... 47 Sustiva (200mg Capsule, 50mg Capsule,

600mg Tablet) ........................................ 25 Sutent (Capsule) ......................................... 23 SW ClearLax (Powder) ................................. 36 SW Nicotine Polacrilex (2mg Gum, 4mg Gum,

2mg Lozenge, 4mg Lozenge) .................. 14 Swabflush Saline Flush (Injection) ............... 53 Syeda (Tablet) ............................................. 39 Sylatron (Injection) ..................................... 22 Symbicort (Aerosol) .................................... 50 SymlinPen 120 (Injection) .......................... 26 SymlinPen 60 (Injection) ............................ 26 Synagis (Injection) ...................................... 41 Synarel (Nasal Solution) ............................. 40 Synera (Patch) ............................................ 13 Synjardy (Tablet), Synjardy XR (Tablet) ..... 26 Synribo (Injection) ...................................... 48 Synvisc (Injection) ...................................... 47 Synvisc One (Injection) ............................... 47 Syprine (Capsule) ........................................ 52

T

Tabloid (Tablet) .......................................... 22

Taclonex (0.064%-0.005% Suspension) ...... 34 Tacrolimus (0.03% Ointment, 0.1% Ointment)

................................................................ 34 Tacrolimus (0.5mg Capsule, 1mg Capsule,

5mg Capsule) .......................................... 41 Tafinlar (Capsule) ........................................ 23 Tagrisso (Tablet) .......................................... 23 Take Action (Tablet)..................................... 40 Tamiflu (6mg/ml Suspension) .................... 25 Tamoxifen Citrate (Tablet) ........................... 22 Tamsulosin HCl (Capsule) ............................ 37 Tarceva (Tablet) .......................................... 23 Targretin (1% Gel) ....................................... 23 Tarina Fe 1/20 (Tablet) ................................ 39 Taron-Crystals (Packet) ................................ 53 Taron-Prex (Capsule) ................................... 55 Tasigna (Capsule) ........................................ 23 Tazicef (1gm Injection, 2gm Injection, 6gm

Injection) ................................................. 16 Tazorac (0.05% Cream, 0.1% Cream, 0.05%

Gel, 0.1% Gel) ......................................... 34 Taztia XT (Capsule Extended-Release 24 Hour)

................................................................ 29 Tecentriq (Injection) ................................... 23 Tecfidera (Capsule Delayed-Release) ......... 32 Tecfidera Starter Pack ................................. 32 Techlite Pen Needles/32g X 6mm............... 47 Techlite Pen Needles/32g X 8mm............... 47 Teflaro (Injection) ....................................... 16 Tekturna (Tablet) ........................................ 30 Tekturna HCT (Tablet) ................................. 31 Telmisartan (Tablet) .................................... 29 Telmisartan/Amlodipine (Tablet) ................ 29 Telmisartan/Hydrochlorothiazide (Tablet) .. 29 Temazepam (Capsule) ................................. 26 Temodar (100mg Injection) ........................ 22 Temozolomide (Capsule) ............................. 22 Tencon (Tablet)............................................ 10 Teniposide (Injection) ................................. 22 Tenivac (Injection) ...................................... 42 Terazosin HCl (Capsule) ............................... 28 Terbinafine HCl (Tablet) ............................... 21 Terbutaline Sulfate (1mg/ml Injection, 2.5mg

Tablet, 5mg Tablet) ................................. 51 Terconazole (0.4% Cream, 0.8% Cream, 80mg

Suppository)............................................ 21 Testosterone Cypionate (Injection) ............. 38 Testosterone Enanthate (Injection) ............. 38 Tetanus/Diphtheria Toxoids-Adsorbed

(Injection) ............................................... 42 Tetcaine (Ophthalmic Solution) ................... 49 Tetrabenazine (Tablet) ................................ 32 Tetracaine HCl (Ophthalmic Solution) ......... 49 Tetracycline HCl (Capsule) ........................... 17 Texacort (External Solution) ....................... 34 TGT Aspirin (325mg Tablet, 81mg Tablet

Chewable, 81mg Tablet Delayed-Release) ................................................................ 11

TGT Aspirin Low Dose (Tablet Delayed-Release) .................................................. 11

TGT Childrens Aspirin (Tablet Chewable) .... 11

78

TGT Nicotine Gum (Gum) ............................ 14 TGT Nicotine Polacrilex (2mg Gum, 4mg Gum,

2mg Lozenge, 4mg Lozenge) ................... 14 TGT Nicotine Step One (Patch 24 Hour) ...... 14 TGT Nicotine Step Three (Patch 24 Hour) .... 14 TGT Nicotine Step Two (Patch 24 Hour) ...... 14 TGT Powderlax (Powder) ............................. 36 Thalomid (Capsule) ..................................... 22 Theo-24 (Capsule Extended-Release 24 Hour)

................................................................ 51 Theochron (Tablet Extended-Release 12

Hour) ....................................................... 51 Theophylline (Oral Solution) ........................ 51 Theophylline CR (Tablet Extended-Release 12

Hour) ....................................................... 51 Theophylline ER (100mg Tablet ER 12 Hour,

200mg Tablet ER 12 Hour, 300mg Tablet ER 12 Hour, 450mg Tablet ER 12 Hour, 400mg Tablet ER 24 Hour, 600mg Tablet ER 24 Hour) ............................................. 51

Theracys (Injection) .................................... 42 Thera-D 2000 (Tablet).................................. 55 Thera-D 4000 (Tablet) ................................. 55 Thiamine HCl (100mg/ml Injection) ............. 55 Thioridazine HCl (Tablet) ............................. 24 Thiotepa (Injection) ..................................... 22 Thiothixene (Capsule) .................................. 24 Thrive (Gum) ................................................ 14 Thrombate III (Injection) ............................. 27 Thrombate III w/20 Ml Sterile Water

(Injection) ............................................... 27 Thymoglobulin (Injection) .......................... 41 Thyrolar (Tablet) ......................................... 40 Tiagabine HCl (Tablet) ................................. 18 Tice BCG (Injection) ..................................... 48 Tilia Fe (Tablet) ............................................ 39 Timolol Maleate (0.25% Ophthalmic Solution,

0.5% Ophthalmic Solution) ..................... 50 Timolol Maleate (10mg Tablet, 20mg Tablet,

5mg Tablet) ............................................. 30 Timolol Maleate Ophthalmic Gel Forming

(Solution) ................................................ 50 Tinidazole (Tablet) ....................................... 23 Tis-U-Sol (Irrigation Solution) ...................... 47 Tivicay (Tablet) ............................................ 25 Tizanidine HCl (2mg Capsule, 4mg Capsule,

6mg Capsule, 2mg Tablet, 4mg Tablet) .. 24 TL Gard Rx (Tablet) ...................................... 55 TL Icon (Capsule) ......................................... 53 Tobradex (0.3%-0.1% Ophthalmic Ointment)

................................................................ 14 Tobradex ST (Ophthalmic Suspension) ...... 14 Tobramycin (300mg/5ml Nebulized Solution)

................................................................ 14 Tobramycin Sulfate (0.3% Ophthalmic

Solution, 1.2gm Injection, 1.2gm/30ml Injection, 10mg/ml Injection, 80mg/2ml Injection) ................................................. 14

Tobramycin/Dexamethasone (Ophthalmic Suspension) ............................................ 14

Tobrex (0.3% Ophthalmic Ointment) ......... 14

Today Sponge ............................................. 37 Todays Health Mini Pen Needles 31g X 1/4"

............................................................... 47 Todays Health Original Pen Needles 29g X

1/2" ........................................................ 47 Todays Health Short Pen Needles 31g X

5/16" ...................................................... 47 Tolazamide (Tablet) .................................... 26 Tolbutamide (Tablet) .................................. 26 Tolcapone (Tablet) ...................................... 23 Tolmetin Sodium (200mg Tablet, 600mg

Tablet, 400mg Capsule) .......................... 11 Tolterodine Tartrate (Tablet) ...................... 36 Tolterodine Tartrate ER (Capsule Extended-

Release 24 Hour) .................................... 36 Topex Topical Anesthetic (Solution)............ 33 Topiramate (Tablet Immediate-Release,

Capsule Sprinkle Immediate-Release) .... 18 Topiramate ER (Capsule Extended-Release 24

Hour Sprinkle) ........................................ 18 Toposar (Injection) ...................................... 22 Topotecan HCl (4mg Injection) ................... 22 Topotecan HCl (4mg/4ml Injection) ........... 22 Torisel (Injection) ....................................... 41 Torsemide (Tablet) ...................................... 31 Toujeo SoloStar (Injection)......................... 27 Toviaz (Tablet Extended-Release 24 Hour) 37 TPN Electrolytes (Injection) ......................... 53 Tracer II 3 Volt Battery ............................... 47 Tracleer (Tablet) ......................................... 51 Tradjenta (Tablet) ....................................... 26 Tramadol HCl (Tablet Immediate-Release) . 12 Tramadol HCl ER (150mg Capsule Extended-

Release 24 Hour) .................................... 12 Tramadol HCl ER (Tablet Extended-Release 24

Hour) ...................................................... 12 Tramadol HCl/Acetaminophen (Tablet) ...... 12 Trandolapril (Tablet) ................................... 29 Trandolapril/Verapamil HCl (Tablet Extended-

Release) .................................................. 29 Trandolapril/Verapamil HCl ER (Tablet

Extended-Release) ................................. 29 Tranexamic Acid (1000mg/10ml Injection,

1000mg/10ml Solution, 650mg Tablet) . 28 Transderm-Scop (Patch 72 Hour) ............... 20 Tranylcypromine Sulfate (Tablet) ................ 26 Travatan Z (Ophthalmic Solution) .............. 49 Trazodone HCl (100mg Tablet, 150mg Tablet,

300mg Tablet, 50mg Tablet) .................. 19 Treanda (Injection) ..................................... 22 Trecator (Tablet) ......................................... 21 Trelstar (Injection) ...................................... 40 Trelstar Mixject (Injection) ......................... 40 Tretinoin (0.01% Gel, 0.025% Gel, 0.05% Gel,

0.025% Cream, 0.05% Cream, 0.1% Cream) ............................................................... 34

Tretinoin (10mg Capsule) ............................ 23 Tretinoin Microsphere (Gel) ........................ 34 Tretinoin Microsphere Pump (Gel) ............. 34 Tretten (Injection) ...................................... 28 Trexall (Tablet) ........................................... 41

Triamcinolone (Injection) ............................ 37 Triamcinolone Acetonide (0.025% Cream,

0.1% Cream, 0.5% Cream, 0.025% Lotion, 0.1% Lotion, 0.025% Ointment, 0.1% Ointment, 0.5% Ointment, 0.147mg/gm Aerosol Solution) .................................... 34

Triamcinolone Acetonide (0.1% Paste) ........ 33 Triamcinolone Acetonide (55mcg/act

Aerosol) RX ............................................. 50 Triamcinolone in Orabase (Paste)................ 33 Triamterene/Hydrochlorothiazide (25mg-

37.5mg Tablet, 50mg-75mg Tablet, 37.5mg-25mg Capsule, 50mg-25mg Capsule) .................................................. 31

Triazolam (Tablet) ........................................ 26 Tricon (Capsule) ........................................... 53 Triderm (Cream) .......................................... 34 Tri-Estarylla (Tablet) .................................... 39 Trifluoperazine HCl (Tablet) ......................... 24 Trifluridine (Ophthalmic Solution) ............... 25 Trigels-F Forte (Capsule) .............................. 48 Triglide (Tablet) ........................................... 31 Trihexyphenidyl HCl (0.4mg/ml Elixir, 2mg

Tablet, 5mg Tablet) ................................. 23 Tri-Legest Fe (Tablet) ................................... 39 Tri-Linyah (Tablet)........................................ 39 Tri-Lo-Estarylla (Tablet) ............................... 39 Tri-Lo-Marzia (Tablet) .................................. 39 Tri-Lo-Sprintec (Tablet) ................................ 39 TriLyte (Oral Solution).................................. 36 Trimethobenzamide HCl (Capsule) .............. 20 Trimethoprim (100mg Tablet) ..................... 15 Trimethoprim Sulfate/Polymyxin B Sulfate

(Ophthalmic Solution) ............................. 15 Trimipramine Maleate (100mg Capsule, 25mg

Capsule, 50mg Capsule) .......................... 19 Trinatal Rx 1 (Tablet) ................................... 55 Trinate (Tablet) ............................................ 55 Trinessa (Tablet) .......................................... 39 Trinessa Lo (Tablet) ..................................... 39 Trintellix (Tablet) ........................................ 19 Triphrocaps (Capsule) .................................. 55 Tri-Previfem (Tablet).................................... 39 Trisenox (Injection) ..................................... 48 Tri-Sprintec (Tablet) ..................................... 39 Triumeq (Tablet) ......................................... 25 Trivora-28 (Tablet) ....................................... 39 Trospium Chloride (Tablet) .......................... 37 Trospium Chloride ER (Capsule Extended-

Release 24 Hour) .................................... 37 Trulicity (Injection) ...................................... 26 Trumenba (Injection) .................................. 42 Truvada (Tablet) .......................................... 25 Tussigon (Tablet) ......................................... 51 Twinrix (Injection) ....................................... 42 Tybost (Tablet) ............................................ 25 Tygacil (Injection) ........................................ 15 Tykerb (Tablet) ............................................ 23 Typhim VI (Injection) .................................. 42 Tyvaso (Inhalation Solution) ....................... 51 Tyvaso Refill (Inhalation Solution) ............. 51

79

Tyvaso Starter (Inhalation Solution) .......... 51

U

Ulesfia (Lotion) ............................................ 23 Uloric (Tablet) ............................................. 21 Ulticare Alcohol Swabs ............................... 15 Ulticare Insulin Safety Syringe/0.5ml/29g X

1/2" ........................................................ 47 Ulticare Insulin Safety Syringe/1ml/29g X

1/2" ........................................................ 47 Ulticare Insulin Syringe/0.5ml/28g X 1/2" . 47 Ulticare Insulin Syringe/U-100/0.3ml/29g X

1/2" ........................................................ 47 Ulticare Insulin Syringe/U-100/0.3ml/30g X

1/2" ........................................................ 47 Ulticare Insulin Syringe/U-100/0.3ml/31g X

5/16" ...................................................... 47 Ulticare Insulin Syringe/U-100/0.5ml/31g X

5/16" ...................................................... 47 Ulticare Pen Needles/29g X 12.7mm.......... 47 Ulticare U-100 Insulin Syringes/0.3ml/31g

X1/4" ...................................................... 47 Ulticare U-100 Insulin Syringes/0.5ml/31g X

1/4" ........................................................ 47 Ulticare U-100 Insulin Syringes/1ml/31g X

1/4" ........................................................ 47 Ultiguard Insulin Syringe/U-100/0.5ml/30g X

5/16" ...................................................... 47 Ultilet Insulin Syringe/Short/1ml/31g X

5/16" ...................................................... 47 Ultilet Pen Needle 32gx4mm/Short ........... 47 Ultilet Short Pen Needles31gx3/16" .......... 47 Ultimatecare One (Capsule) ........................ 55 Ultra-Thin II Pen Needles 29gx1/2" ............ 47 Uni-Solve Wipes .......................................... 15 Unithroid (Tablet) ........................................ 40 Unithroid Direct (Tablet) ............................. 40 Unituxin (Injection) ..................................... 23 Upspringbaby Vitamin D3 (Liquid) ............. 56 Uptravi (Tablet Therapy Pack, 1000mcg

Tablet, 1200mcg Tablet, 1400mcg Tablet, 1600mcg Tablet, 200mcg Tablet, 400mcg Tablet, 600mcg Tablet, 800mcg Tablet) 51

Urea (40% Cream, 45% Lotion) .................... 34 Urea Nail Gel (Gel) ....................................... 34 Urea Topical (Suspension) ........................... 34 Urea-C40 (Lotion) ........................................ 34 Urin-Tek (Kit, 0 Misc) .................................. 47 Uristix .......................................................... 47 Uristix 4 ....................................................... 47 Urosex (Tablet) ............................................ 55 Ursodiol (250mg Tablet, 500mg Tablet,

300mg Capsule) ...................................... 35 Uvadex (Injection) ....................................... 34

V

Valacyclovir HCl (Tablet) .............................. 25 Valchlor (Gel) .............................................. 34 Valganciclovir (Tablet) ................................. 24 Valganciclovir Hydrochlorde (Oral Solution) 24

Valproate Sodium (100mg/ml Injection) ..... 18 Valproic Acid (250mg Capsule, 250mg/5ml

Oral Solution, 250mg/5ml Syrup) ........... 18 Valsartan (Tablet) ........................................ 29 Valsartan/Hydrochlorothiazide (Tablet) ..... 29 Valstar (Injection) ....................................... 48 Valved Holding Chamber ............................ 47 Vancomycin (Injection) ............................... 15 Vancomycin HCl (0.9%-1gm/200ml Injection,

1000mg Injection, 10gm Injection, 5000mg Injection, 125mg Capsule, 250mg Capsule) ............................................................... 15

Vancomycin HCl/Dextrose (5%-1.5gm/250ml Injection) ................................................ 14

Vancomycin HCl/Dextrose (5%-1gm/250ml Injection, 5%-2gm/500ml Injection) ....... 15

Vancomycin HCl/Sodium Chloride (0.9%-1.5gm/150ml Injection, 0.9%-1.5gm/250ml Injection, 0.9%-1gm/150ml Injection, 0.9%-1gm/250ml Injection, 0.9%-750mg/150ml Injection) ................ 15

Vancomycin HCl/Sodium Chloride (0.9%-1.5gm/500ml Injection) .......................... 14

Vandazole (Gel) ........................................... 15 Vanishpoint Insulin Syringe/0.5ml/30g X

5/16" ...................................................... 47 Vanishpoint Insulin Syringe/1ml/29g X 5/16"

............................................................... 34 Vanishpoint Insulin Syringe/1ml/30g X 5/16"

............................................................... 47 Vantas (Injection) ....................................... 40 VAQTA (Injection) ....................................... 42 Varivax (Injection) ...................................... 42 Vascepa (Capsule) ...................................... 31 V-C Forte (Capsule) ..................................... 55 VCF Vaginal Contraceptive Film (Film) ....... 37 VCF Vaginal Contraceptive Foam (Foam) ... 37 VCF Vaginal Contraceptive Gel (Gel) ........... 37 Vecamyl (Tablet) ........................................ 30 Vectibix (Injection) ..................................... 23 Vectical (Ointment) .................................... 34 Vecuronium Bromide (10mg Injection, 20mg

Injection) ................................................ 52 Velcade (Injection) ..................................... 48 Veletri (Injection) ....................................... 51 Velivet (Tablet) ............................................ 39 Velphoro (Tablet Chewable) ...................... 37 Veltassa (Packet) ........................................ 52 Veltin (Gel) .................................................. 34 Venclexta (Tablet) ...................................... 22 Venclexta Starting Pack (Tablet Therapy

Pack) ...................................................... 22 Venlafaxine HCl (Tablet Immediate-Release)

............................................................... 19 Venlafaxine HCl ER (150mg, 37.5mg, 75mg

Capsule Extended-Release 24 Hour ....... 19 Ventavis (Inhalation Solution) ................... 51 Ventolin HFA (Aerosol Solution) ................ 51 Veracolate (Tablet Delayed-Release) .......... 36 Verapamil HCl (Tablet Immediate-Release,

2.5mg/ml Injection) ................................ 30

Verapamil HCl ER (100mg, 120mg, 180mg, 200mg, 240mg, 300mg Capsule Extended-Release 24 Hour ...................................... 30

Verapamil HCl SR (Capsule Extended-Release 24 Hour) .................................................. 30

Verdrocet (Tablet) ....................................... 12 Veregen (Ointment) .................................... 34 Vesicare (Tablet) ......................................... 37 Vestura (Tablet) ........................................... 39 Vibativ (Injection) ....................................... 15 Vic-Forte (Capsule) ...................................... 55 Vicodin (Tablet) ........................................... 12 Vicodin ES (Tablet) ....................................... 12 Vicodin HP (Tablet) ...................................... 12 Victoza (Injection) ....................................... 26 Videx Pediatric (Oral Solution) ................... 25 Viekira Pak (Tablet Therapy Pack) .............. 24 Vienva (Tablet) ............................................ 39 Vigamox (Ophthalmic Solution) ................. 17 Viibryd (Tablet) ........................................... 19 Viibryd ST .................................................... 19 Vimizim (Injection) ...................................... 35 Vimpat (100mg Tablet, 150mg Tablet, 200mg

Tablet, 50mg Tablet, 10mg/ml Oral Solution) ................................................. 18

Vinate II (Tablet) .......................................... 55 Vinate M (Tablet) ......................................... 55 Vinate One (Tablet) ..................................... 55 Vinblastine Sulfate (Injection) .................... 22 Vincasar PFS (Injection) ............................... 48 Vincristine Sulfate (Injection) ...................... 48 Vinorelbine Tartrate (Injection) ................... 22 Viorele (Tablet) ............................................ 39 Viracept (Tablet) ......................................... 25 Viramune (50mg/5ml Suspension) ............. 25 Viread (150mg Tablet, 200mg Tablet, 250mg

Tablet, 300mg Tablet, 40mg/gm Powder) ................................................................ 25

Virt-Caps (Capsule) ...................................... 55 Virt-Gard (Tablet) ........................................ 55 Virt-Phos 250 Neutral (Tablet) ..................... 53 Virtrate-2 (Oral Solution) ............................. 53 Virtrate-3 (Oral Solution) ............................. 53 Virtrate-K (Oral Solution) ............................. 53 Virt-Vite (Tablet) .......................................... 55 Virt-Vite Plus (Tablet) .................................. 55 Visudyne (Injection) .................................... 49 Vita S Forte (Tablet) ..................................... 55 Vitacel (Tablet) ............................................ 55 Vitajoy Daily D Gummies (Tablet Chewable)55 Vitamax Pediatric (Oral Solution) ................ 55 Vitamelts Vitamin D (Tablet Dispersible) ... 55 Vita-Min (Capsule) RX .................................. 55 Vitamin C 222mg (Injection) ........................ 55 Vitamin D (2000unit Tablet, 400unit Capsule,

400unit Tablet, 400unit/ml Liquid, 50000unit Capsule) ................................. 55

Vitamin D-1000 (Tablet) .............................. 55 Vitamin D2 (Tablet) ..................................... 55 Vitamin D3 (10000unit Tablet,

1000unit/spray Liquid, 1200unit/15ml

80

Liquid, 3000unit Tablet) ......................... 55 Vitamin D-3 (1000unit Capsule, 1000unit

Tablet, 400unit Tablet, 2000unit Tablet) 55 Vitamin D3 (5000unit Tablet Dispersible) .. 56 Vitamin D3 (Capsule, Tablet, Tablet

Chewable, 400unit/ml Liquid, 5000unit/ml Liquid) ..................................................... 55

Vitamin D3 Gummies (Tablet Chewable) ..... 56 Vitamin K1 (1mg/0.5ml Injection) ............... 56 Vitamins A/C/D/Fluoride (Solution) ............. 56 Vituz (Oral Solution) ................................... 50 Vivitrol (Injection) ....................................... 13 Vivotif (Capsule Delayed-Release) ............. 42 Vol-Care Rx (Tablet) ..................................... 56 Vonvendi (Injection) ................................... 28 Voraxaze (Injection) .................................... 47 Voriconazole (200mg Injection, 200mg

Tablet, 50mg Tablet, 40mg/ml Suspension) ................................................................ 21

Vortex Valved Holding Chamber ................ 47 Votrient (Tablet) ......................................... 23 VPRIV (Injection) ......................................... 35 VP-Vite Rx (Tablet) ....................................... 56 Vyfemla (Tablet) .......................................... 39 Vyvanse (Capsule) ....................................... 32

W

Warfarin Sodium (Tablet) ............................ 27 WatchHaler ................................................. 47 Webcol Alcohol Prep Large 1 Ply ................ 15 Webcol Alcohol Prep Medium 2 Ply ........... 15 Wegmans Unifine Pentips Plus 32gx4mm .. 47 Welchol (3.75gm Packet, 625mg Tablet) .... 26 Wellesse Vitamin D3 (Liquid) ..................... 56 Wera (Tablet)............................................... 39 Wide-Seal Silicone Diaphragm Kit 60 ......... 47 Wide-Seal Silicone Diaphragm Kit 65 ......... 47 Wide-Seal Silicone Diaphragm Kit 70 ......... 47 Wide-Seal Silicone Diaphragm Kit 75 ......... 47 Wide-Seal Silicone Diaphragm Kit 80 ......... 47 Wide-Seal Silicone Diaphragm Kit 85 ......... 47 Wide-Seal Silicone Diaphragm Kit 90 ......... 47 Wide-Seal Silicone Diaphragm Kit 95 ......... 47 WinRho SDF (Injection) ............................... 41 Womans Laxative (Tablet Delayed-Release) 36 Womens Laxative (Tablet Delayed-Release) 36

WP Thyroid (Tablet) ................................... 40 WYMZYA Fe (Tablet Chewable) ................... 39

X

Xalkori (Capsule)......................................... 23 Xarelto (Tablet) .......................................... 27 Xarelto Starter Pack (Tablet Therapy Pack) 27 Xeljanz (Tablet) ........................................... 41 Xeomin (100unit Injection, 50unit Injection)

............................................................... 47 Xeomin (200unit Injection) ........................ 48 Xgeva (Injection) ......................................... 43 Xiaflex (Injection) ....................................... 35 Xifaxan (Tablet) .......................................... 15 Xigduo XR (Tablet Extended-Release 24

Hour) ...................................................... 26 Xolair (Injection) ......................................... 51 Xolegel (Gel) ............................................... 21 Xtandi (Capsule) ......................................... 22 Xulane (Patch Weekly) ................................ 39 Xylocaine Dental (Injection) ........................ 13 Xylon (Tablet) .............................................. 11 Xyntha (Injection) ....................................... 28 Xyntha Solofuse (Injection) ........................ 28 Xyrem (Oral Solution) ................................. 52

Y

Yervoy (Injection) ....................................... 23 YF-Vax (Injection) ....................................... 42 YL Folic Acid (Tablet) ................................... 56 Yondelis (Injection) .................................... 22 Your Life Multi Prenatal (Capsule) ............. 56 Yuvafem (Tablet) ......................................... 39

Z

Zafirlukast (Tablet) ...................................... 50 Zaleplon (Capsule) ....................................... 52 Zaltrap (Injection) ....................................... 48 Zanosar (Injection) ..................................... 22 Zarah (Tablet) .............................................. 39 Zavesca (Capsule) ....................................... 35 Zazole (0.8% Cream, 80mg Suppository)..... 21 Zebutal (Capsule) ........................................ 10 Zelboraf (Tablet) ......................................... 23 Zemaira (Injection) ..................................... 51

Zenatane (Capsule) ...................................... 34 Zenchent (Tablet) ........................................ 39 Zenchent Fe (Tablet Chewable) ................... 39 Zenpep (Capsule Delayed-Release) ............ 35 Zenzedi (10mg Tablet, 5mg Tablet) ............. 32 Zepatier (Tablet) ......................................... 25 Zerit (1mg/ml Oral Solution) ...................... 25 Ziagen (20mg/ml Oral Solution) ................. 25 Zidovudine (100mg Capsule, 300mg Tablet,

50mg/5ml Syrup) .................................... 25 Zinacef (1.5gm-0 Injection) ......................... 16 Zioptan (Ophthalmic Solution) ................... 49 Ziprasidone HCl (Capsule) ............................ 24 Zirgan (Gel) .................................................. 24 Zithromax (1gm Packet) .............................. 17 Zoladex (Injection) ...................................... 40 Zoledronic Acid (4mg Injection, 4mg/100ml

Injection) ................................................ 43 Zoledronic Acid (4mg/5ml Injection,

5mg/100ml Injection) ............................. 43 Zolinza (Capsule) ......................................... 22 Zolmitriptan (Tablet) ................................... 21 Zolmitriptan ODT (Tablet Dispersible) ......... 21 Zolpidem Tartrate (1.75mg Tablet Sublingual,

3.5mg Tablet Sublingual) ........................ 52 Zolpidem Tartrate (10mg Tablet, 5mg Tablet)

................................................................ 52 Zolpidem Tartrate ER (Tablet Extended-

Release) .................................................. 52 Zometa (4mg/100ml Injection) ................... 43 Zomig (2.5mg Nasal Solution, 5mg Nasal

Solution) ................................................. 21 Zonisamide (Capsule) .................................. 17 Zontivity (Tablet) ........................................ 28 Zorbtive (Injection) ..................................... 38 Zortress (Tablet) .......................................... 41 Zostavax (Injection) .................................... 42 Zovia 1/35E (Tablet) .................................... 39 Zovia 1/50E (Tablet) .................................... 39 Zovirax (5% Cream) ..................................... 25 Zydelig (Tablet) ........................................... 22 Zyflo CR (Tablet Extended-Release 12 Hour)

................................................................ 50 Zykadia (Capsule) ........................................ 23 Zyprexa Relprevv (Injection) ....................... 48 Zytiga (Tablet) ............................................. 22 Zyvox (200mg/100ml Injection).................. 15

81

Nondiscrimination Notice and Access to Communication Services

OptumRx and its family of affiliated Optum companies does not discriminate on the basis of

race, color, national origin, age, disability, or sex in its health programs or activities.

We provide assistance free of charge to people with disabilities or whose primary language is

not English. To request a document in another format such as large print or to get language

assistance such as a qualified interpreter, please call the number located on the back of your

prescription ID card, TTY 711. Representatives are available 24 hours a day, seven days a week.

If you believe that we have failed to provide these services or discriminated in another way on

the basis of race, color, national origin, age, disability, or sex, you can send a complaint to

OptumRx Civil Rights Coordinator

11000 Optum Circle

Eden Prairie, MN 55344

Phone: 1-800-562-6223, TTY 711

Fax: 855-351-5495

Email: [email protected]

If you need help filing a complaint, please call the number located on the back of your

prescription ID card, TTY 711. Representatives are available 24 hours a day, seven days a week.

You can also file a complaint directly with the U.S. Dept. of Health and Human services online,

by phone, or by mail:

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD)

Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue,

SW Room 509F, HHH Building Washington, D.C. 20201

This information is available in other formats like large print.

To ask for another format, please call the telephone number

listed on your health plan ID card.

82

Multi-language Interpreter Services

ATTENTION: If you speak English, language assistance services, free of charge, are available to

you.

Please call the toll-free phone number listed on your identification card.

ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al número de teléfono gratuito que aparece en su tarjeta de identificación.

請注意：如果您說中文 (Chinese)，我們免費為您提供語言協助服務。請撥打會員卡所列

的免付費會員電話號碼。

XIN LƯU Ý: Nếu quý vị nói tiếng Việt (Vietnamese), quý vị sẽ được cung cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Vui lòng gọi số điện thoại miễn phí ở mặt sau thẻ hội viên của quý vị.

알림: 한국어(Korean)를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수

있습니다. 귀하의 신분증 카드에 기재된 무료 회원 전화번호로 문의하십시오. PAALALA: Kung nagsasalita ka ng Tagalog (Tagalog), may makukuha kang mga libreng

serbisyo ng tulong sa wika. Pakitawagan ang toll-free na numero ng telepono na nasa iyong

identification card.

ВНИМАНИЕ: бесплатные услуги перевода доступны для людей, чей родной язык является русском (Russian). Позвоните по бесплатному номеру телефона, указанному на вашей идентификационной карте.

على رقم الهاتف االتصال الرجاءساعدة اللغوية المجانية متاحة لك. ، فإن خدمات الم(Arabic) العربيةتنبيه: إذا كنت تتحدث العضوية. معّرف المجاني الموجود على

ATANSYON: Si w pale Kreyòl ayisyen (Haitian Creole), ou kapab benefisye sèvis ki gratis pou ede w nan lang pa w. Tanpri rele nimewo gratis ki sou kat idantifikasyon w. ATTENTION : Si vous parlez français (French), des services d’aide linguistique vous sont proposés gratuitement. Veuillez appeler le numéro de téléphone gratuit figurant sur votre carte d’identification. UWAGA: Jeżeli mówisz po polsku (Polish), udostępniliśmy darmowe usługi tłumacza. Prosimy zadzwonić pod bezpłatny numer telefonu podany na karcie identyfikacyjnej. ATENÇÃO: Se você fala português (Portuguese), contate o serviço de assistência de idiomas gratuito. Ligue gratuitamente para o número encontrado no seu cartão de identificação.

83

ATTENZIONE: in caso la lingua parlata sia l’italiano (Italian), sono disponibili servizi di assistenza linguistica gratuiti. Per favore chiamate il numero di telefono verde indicato sulla vostra tessera identificativa. ACHTUNG: Falls Sie Deutsch (German) sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Bitte rufen Sie die gebührenfreie Rufnummer auf der Rückseite Ihres Mitgliedsausweises an.

注意事項：日本語(Japanese)を話される場合、無料の言語支援サービスをご利用いただ

けます。健康保険証に記載されているフリーダイヤルにお電話ください。

تلفن شماره با است، خدمات امداد زبانی به طور رايگان در اختيار شما می باشد. لطفا (Farsi) فارسیتوجه: اگر زبان شما

بگيريد. شما قيد شده تماس شناسايی کارت رايگانی که روی

ध्यान दें: यदद आप ह िंदी (Hindi) बोलते है, आपको भाषा सहायता सेबाए,ं नन:शुल्क उपलब्ध हैं। कृपया अपने पहचान पत्र पर सूचीबद्ध टोल-फ्री फोन नंबर पर कॉल करें। CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj.

Thov hu rau tus xov tooj hu deb dawb uas teev muaj nyob rau ntawm koj daim yuaj cim qhia tus

kheej.

ចំណាប់អារម្មណ ៍ៈ បបើសិនអ្នកនិយាយភាសាខ្មមរ(Khmer)បសវាជំនួយភាសាបោយឥតគិតថ្លៃ គឺមានសំរាប់អ្នក។ សូម្ទូរស័ព្ទបៅបេមឥតគិតថ្លៃ ខ្ែេមានបៅបេើអ្តដសញ្ញា ណប័ណណ របស់អ្នក។

PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe nga

awanan bayadna, ket sidadaan para kenyam. Maidawat nga awagan iti toll-free a numero ti

telepono nga nakalista ayan iti identification card mo.

DÍÍ BAA'ÁKONÍNÍZIN: Diné (Navajo) bizaad bee yániłti'go, saad bee áka'anída'awo'ígíí, t'áá

jíík'eh, bee ná'ahóót'i'. T'áá shǫǫdí ninaaltsoos nitł'izí bee nééhozinígíí bine'dę́ę́' t'áá jíík'ehgo

béésh bee hane'í biká'ígíí bee hodíilnih.

OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash

ah, ayaad heli kartaa. Fadlan wac lambarka telefonka khadka bilaashka ee ku yaalla kaarkaaga

aqoonsiga.

84

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