Preferred Drug List - passporthealthplan.compassporthealthplan.com/wp-content/uploads/2018/02/Evolent-Passport... · • Mail to: U.S. Department of Health and Human Services

PASS-13169 APP_2/10/2014

Preferred Drug List (List of Covered Drugs)

This document includes Passport Health Plan’s complete 2018 formulary.

What is the Passport Health Plan formulary?The formulary is a list of preferred drugs covered by Passport. To get a drug on our formulary, you must:

• Be a Passport member;

• Need a drug that is medically necessary;

• GettheprescriptionfilledataPassportHealthPlannetworkpharmacy.AnetworkpharmacyisonethatissignedupwithPassport;and

• FollowallPassportrules(seelimitsbelow).

The formulary is not a complete list of covered drugs by Passport. Some drugs not listed may be covered, if medically necessary. These drugs may or may not need prior-authorization.

How do I find my drug on the formulary? • Youcansearchforadrugusingtheonlinesearchableformularyonourwebsiteat

www.passporthealthplan.com.

Are there any limits to the drugs you have been prescribed? Some covered drugs may have limits on them. This could include:

• Prior-Authorization:SomemedicinesmustbeapprovedbyPassportbeforePassportwillcoverorpayforthem.Thismeansyourproviderwillneedtogetapprovalbeforeyoucanhaveyourprescriptionsfilled.Ifyoudonotgetapproval,Passportmaynotcoverthedrug.

• Quantity Limits:Forsomedrugs,therearelimitsontheamountPassportwillcover.Thismeansyou may not get the standard one month supply.

• Step Therapy:SometimesPassportrequiresyoutotrycertaindrugsfirsttotreatyourmedicalconditionbeforewewillcoveranotherdrugforthatcondition.Forexample,ifDrugAandDrugBbothtreatyourmedicalcondition,PassportmaynotcoverdrugBunlessyoutryDrugAfirst.IfDrugAdoesnotworkforyou,PassportwillthencoverDrugB.

• Too Early to Refill:Ifyouaregivenamonthsupplyofamedicine,Passportwillnotcoverarefillofthe prescription until 30 days has passed.

What if my drug is not on the formulary?Remember,notalldrugsarelistedontheformulary.IfPassportdoesnotcoveryourdrug,youhave3options:

1. Workwithyourpharmacyorprovidertofindthepreferreddrug.

2. YoucancallMemberServicesat1-800-578-0603andaskforalistofsimilardrugsthatareonPassport’s Preferred Drug List.

3. IfadrugisnotcoveredbyPassportorisnotlistedonourPreferredDrugList,yourdoctorcanrequestapproval for it.

Can the formulary change? Yes. Passport may add or remove drugs from the formulary during the year. To get updated informationaboutcovereddrugs,pleasevisitourwebsiteatwww.passporthealthplan.comorcallMember Services at 1-800-578-0603.

What are generic drugs?Passport covers both brand-name and generic drugs. A generic drug has the same active ingredient asthebrand-namedrug.Thismeanstheyworkthesameandhavethesameeffect.Genericdrugsusually cost less than brand name drugs and are approved by the Food and Drug Administration (FDA).

How much are my copays?Aslongasyoutakegenericmedicines,youwillpay$0.Ifyoutakeapreferredbrandnamemedicine,yourcopaywillbe$2.Ifyoutakeanon-preferrednamebrandmedicine,yourcopaywillbe$4.

DRUG TIERTier 1 = Generic

Tier 2 = Preferred Brand

Tier 3 = Non-Preferred Brand

Nondiscrimination NoticePassport Health Plan DOES: • Follow federal civil rights laws

• Provide free aids and services to people with disabilities such as:- Qualified sign language interpreters- Written information in other formats

(large print, audio, accessible electronic formats)

• Provide free language services to people whose primary language is not English such as: - Qualified interpreters - Information written in

other languages

Passport Health Plan DOES NOT:• Discriminate on the basis of

race, color, national origin, age, disability, sex, health status, need for health services, religion, sexual orientation, or gender identity.

• Exclude people or treat them differently because of race, color, national origin, age, disability, sex, health status, need for health services, religion, sexual orientation, or gender identity.

If you need any of these services listed above, you may contact:

Passport’s Member Services Team 1-800-578-0603Passport’s Care Connectors Team 1-877-903-0082

If you believe Passport has not provided these services or has discriminated against you, you may file a grievance. You can file a grievance by contacting:

Director of Compliance5100 Commerce Crossings Drive, Louisville, KY 40229(502) 212-6767 | Fax: (502) 585-7985 | [email protected]

You may file in person or by mail, fax or email. If you need help filing a grievance, the Director of Compliance can help you.

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

• Visit the Office for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

• Mail to: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

• Call 1-800-368-1019 (TDD 1-800-537-7697)

If you need a complaint form, please visit http://www.hhs.gov/ocr/office/file/index.html

PASS73862 APP_8/23/2017

PASS73862 APP_8/23/2017

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter

1

LIST OF COVERED PRESCRIPTION MEDICATIONS Effective 02/01/2018 Drug Name Drug Tier Requirements/LimitsANALGESICS ANALGESICS, OTHER acetaminophen suppos 650 mg 1 OTC apap rapid tab tab 80mg 1 OTC chld asafree elx 80/2.5ml 1 OTC eql acetamin tab 160mg 1 OTC fever reduce sup 120mg 1 OTC FEVERALL INF SUP 80MG 2 OTC feverall sup 325mg 1 OTC 8 hour pain tab 650mg 1 OTC inf silapap dro 80/0.8ml 1 OTC little remed liq 160/5ml 1 OTC OFIRMEV INJ 10MG/ML 3 PA pain relief dro 80/0.8ml 1 OTC pain relief liq 500/15ml 1 OTC pain relief sus 160/5ml 1 OTC pain relief tab 325mg 1 OTC pain relief tab 500mg 1 OTC pain relieve chw 160mg jr 1 OTC pain relievr chw 80mg 1 OTC sm pain rel cap 500mg 1 OTC COX-II INHIBITORS CELEBREX CAP 50MG 3 PA, ST CELEBREX CAP 100MG 3 PA, ST CELEBREX CAP 200MG 3 PA, ST CELEBREX CAP 400MG 3 PA, ST celecoxib cap 50 mg 1 PA, ST celecoxib cap 100 mg 1 PA, ST celecoxib cap 200 mg 1 PA, ST celecoxib cap 400 mg 1 PA, ST GOUT allopurinol tab 100 mg 1 allopurinol tab 300 mg 1 ALOPRIM INJ 500MG 3 colchicine cap 0.6 mg 1 QL (60 caps / 30 days) colchicine tab 0.6 mg 1 QL (60 tabs / 30 days) colchicine w/ probenecid tab 0.5-500 mg 1 DUZALLO TAB 200-200 3 QL (30 tabs / 30 days),

ST DUZALLO TAB 200-300 3 QL (30 tabs / 30 days),

ST probenecid tab 500 mg 1


2

Drug Name Drug Tier Requirements/Limits ULORIC TAB 40MG 3 QL (30 tabs / 30 days),

ST ULORIC TAB 80MG 3 ST ZURAMPIC TAB 200MG 3 QL (30 tabs / 30 days),

ST MISCELLANEOUS CARTICEL IMP 3 PA clonidine hcl inj (for epidural infusion) 100

mcg/ml 1

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

1

DURACLON INJ 3 PA NON-OPIOID ANALGESICS BUPAP TAB 50-300MG 3 PA butalbital-acetaminophen tab 50-325 mg 1 butalbital-acetaminophen-caffeine cap 50-

300-40 mg 1 QL (180 caps / 25 days)

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

1 QL (180 caps / 25 days)

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

1 QL (180 tabs / 25 days)

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

1

duraxin cap 1 ESGIC TAB 3 QL (180 tabs / 25 days),

PA FIORICET CAP 3 QL (180 caps / 25

days), PA FIORINAL CAP 3 PA LEVACET TAB 3 migraine tab formula 1 OTC PAIN RELIEF TAB 3 OTC NSAIDS all day pain tab 220mg 1 OTC ANAPROX DS TAB 550MG 3 PA, ST aspirin suppos 300 mg 1 OTC aspirin suppos 600 mg 1 OTC CALDOLOR INJ 400/4ML 3 PA CALDOLOR INJ 800/8ML 3 PA choline & magnesium salicylates liq 500

mg/5ml 1

choline & magnesium salicylates tab 1000 mg

1

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

mg 1


3

Drug Name Drug Tier Requirements/Limits diclofenac sodium tab delayed release 50

mg 1

diclofenac sodium tab delayed release 75 mg

1

diclofenac sodium tab er 24hr 100 mg 1 diflunisal tab 500 mg 1 DYLOJECT INJ 37.5MG/M 3 PA EC-NAPROSYN TAB 375MG 3 PA, ST EC-NAPROSYN TAB 500MG 3 PA, ST etodolac cap 200 mg 1 etodolac cap 300 mg 1 etodolac tab 400 mg 1 etodolac tab 500 mg 1 etodolac tab er 24hr 400 mg 1 etodolac tab er 24hr 500 mg 1 etodolac tab er 24hr 600 mg 1 FELDENE CAP 10MG 3 PA, ST FELDENE CAP 20MG 3 PA, ST fenoprofen calcium cap 400 mg 1 fenoprofen calcium tab 600 mg 1 FENORTHO CAP 200MG 3 PA flurbiprofen tab 50 mg 1 flurbiprofen tab 100 mg 1 ibuprofen cap 200 mg 1 OTC ibuprofen dro 50/1.25 1 OTC ibuprofen jr chw 100mg 1 OTC ibuprofen susp 100 mg/5ml 1 ibuprofen tab 200 mg 1 OTC ibuprofen tab 400 mg 1 ibuprofen tab 600 mg 1 ibuprofen tab 800 mg 1 INDOCIN SUP 50MG 3 ST indomethacin cap 25 mg 1 indomethacin cap 50 mg 1 indomethacin cap er 75 mg 1 QL (90 caps / 30 days) ketoprofen cap 50 mg 1 ketoprofen cap 75 mg 1 ketoprofen cap er 24hr 200 mg 1 ketorolac tromethamine tab 10 mg 1 QL (5 days per fill) meclofenamate sodium cap 50 mg 1 meclofenamate sodium cap 100 mg 1 mefenamic acid cap 250 mg 1 meloxicam tab 7.5 mg 1 meloxicam tab 15 mg 1 MOBIC TAB 7.5MG 3 PA, ST MOBIC TAB 15MG 3 PA, ST


4

Drug Name Drug Tier Requirements/Limits nabumetone tab 500 mg 1 nabumetone tab 750 mg 1 NALFON CAP 400MG 3 ST NAPRELAN TAB 375MG CR 3 PA, ST NAPRELAN TAB 500MG CR 3 PA, ST NAPRELAN TAB 750MG CR 3 ST NAPROSYN SUS 125/5ML 3 PA, ST NAPROSYN TAB 500MG 3 PA, ST naproxen dr tab 375mg 1 naproxen dr tab 500mg 1 naproxen sodium cap 220 mg 1 OTC naproxen sodium tab 275 mg 1 naproxen sodium tab 550 mg 1 naproxen sodium tab er 24hr 375 mg

(base equiv) 1

naproxen susp 125 mg/5ml 1 naproxen tab 250 mg 1 naproxen tab 375 mg 1 naproxen tab 500 mg 1 oxaprozin tab 600 mg 1 piroxicam cap 10 mg 1 piroxicam cap 20 mg 1 PONSTEL CAP 250MG 3 PA, ST sm ibuprofen tab 100mg jr 1 OTC SPRIX SPR 15.75MG 3 QL (5 / 25 days), ST sulindac tab 150 mg 1 sulindac tab 200 mg 1 TIVORBEX CAP 20MG 3 QL (90 caps / 30 days),

PA TIVORBEX CAP 40MG 3 QL (90 caps / 30 days),

PA tolmetin sodium cap 400 mg 1 tolmetin sodium tab 200 mg 1 tolmetin sodium tab 600 mg 1 tri-buff asa tab 325mg 1 OTC VIVLODEX CAP 5MG 3 ST VIVLODEX CAP 10MG 3 ST ZIPSOR CAP 25MG 3 ST ZORVOLEX CAP 18MG 3 ST ZORVOLEX CAP 35MG 3 ST NSAIDS, COMBINATIONS ARTHROTEC 50 TAB 3 QL (120 tabs / 30 days),

PA ARTHROTEC 75 TAB 3 QL (120 tabs / 30 days),

PA


5

Drug Name Drug Tier Requirements/Limits diclofenac w/ misoprostol tab delayed

release 50-0.2 mg 1 QL (120 tabs / 30 days),

PA diclofenac w/ misoprostol tab delayed

release 75-0.2 mg 1 QL (120 tabs / 30 days),

PA DUEXIS TAB 800-26.6 3 ST inflammacin mis 75-0.025 1 PA MELOXICAM KIT COMFORT 3 PA NAPROXEN KIT COMFORT 3 PA VIMOVO TAB 375-20MG 3 ST VIMOVO TAB 500-20MG 3 ST NSAIDS, TOPICAL diclofenac sodium gel 1% 1 diclofenac sodium soln 1.5% 1 DS PREP PAK PAK 1%-0.13% 3 PA FLECTOR DIS 1.3% 3 QL (30 ptch / 25 days),

PA PENNSAID SOL 2% 3 PA VOLTAREN GEL 1% 3 PA OPIOID ANALGESICS ABSTRAL SUB 100MCG 3 QL (360 tabs / 25 days),

ST ABSTRAL SUB 200MCG 3 QL (180 tabs / 25 days),





ST acetaminophen w/ codeine soln 120-12

mg/5ml 1 QL (2700 ml / 25 days)

acetaminophen w/ codeine tab 300-15 mg 1 QL (390 tabs / 30 days) acetaminophen w/ codeine tab 300-30 mg 1 QL (360 tabs / 30 days) acetaminophen w/ codeine tab 300-60 mg 1 QL (180 tabs / 30 days) acetaminophen-caffeine-dihydrocodeine

cap 320.5-30-16 mg 1 QL (120 caps / 30 days)

ACTIQ LOZ 200MCG 3 QL (180 lpop / 25 days), PA, ST





6

Drug Name Drug Tier Requirements/Limits ACTIQ LOZ 1200MCG 3 QL (30 lpop / 30 days),

PA, ST ACTIQ LOZ 1600MCG 3 QL (30 lpop / 30 days),

PA, ST alfentanil inj 500 mcg/ml 1 ALFENTANIL INJ 500/ML 3 PA ascomp/cod cap 30mg 1 QL (180 caps / 30 days) aspirin-caffeine-dihydrocodeine cap 356.4-

30-16 mg 1 QL (300 caps / 30 days)

BELBUCA MIS 75MCG 3 QL (90 films / 30 days), PA







BUPRENEX INJ 0.3MG/ML 3 PA buprenorphine hcl inj 0.3 mg/ml (base

equiv) 1

buprenorphine td patch weekly 5 mcg/hr 1 PA buprenorphine td patch weekly 10 mcg/hr 1 PA buprenorphine td patch weekly 15 mcg/hr 1 PA buprenorphine td patch weekly 20 mcg/hr 1 PA butalbital-acetaminophen-caff w/ cod cap

50-300-40-30 mg 1 QL (360 caps / 25 days)

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


butorphanol tartrate inj 1 mg/ml 1 butorphanol tartrate inj 2 mg/ml 1 PA butorphanol tartrate nasal soln 10 mg/ml 1 QL (30 / 30 days) BUTRANS DIS 5MCG/HR 3 PA BUTRANS DIS 10MCG/HR 3 PA BUTRANS DIS 15MCG/HR 3 PA BUTRANS DIS 20MCG/HR 3 PA CAPITAL/COD SUS 120-12/5 3 QL (2700 ml / 25 days),

ST codeine sulfate tab 15 mg 1 QL (720 tabs / 30 days) codeine sulfate tab 30 mg 1 QL (360 tabs / 30 days) codeine sulfate tab 60 mg 1 QL (180 tabs / 30 days)


7

Drug Name Drug Tier Requirements/Limits CONZIP CAP 100MG 3 QL (90 caps / 25 days),

PA CONZIP CAP 200MG 3 QL (30 caps / 25 days),

PA CONZIP CAP 300MG 3 QL (30 caps / 25 days),

PA DEMEROL INJ 25MG/0.5 3 ST DEMEROL INJ 25MG/ML 3 PA, ST DEMEROL INJ 50MG/ML 3 PA, ST DEMEROL INJ 75MG/1.5 3 ST DEMEROL INJ 75MG/ML 3 ST DEMEROL INJ 100/2ML 3 ST DEMEROL INJ 100MG/ML 3 PA, ST DEMEROL TAB 100MG 3 QL (180 tabs / 30 days),

PA, ST DEPODUR INJ 10MG/ML 3 PA DEPODUR INJ 15/1.5ML 3 PA DILAUDID LIQ 1MG/ML 3 QL (960 ml / 30 days),

PA, ST DILAUDID TAB 2MG 3 QL (480 tabs / 30 days),



PA, ST DOLOPHINE TAB 5MG 3 QL (240 tabs / 30 days),

PA DOLOPHINE TAB 10MG 3 QL (240 tabs / 30 days),

PA DURAGESIC DIS 12MCG/HR 3 QL (10 patches / 25

days), PA DURAGESIC DIS 25MCG/HR 3 QL (10 patches / 25



days), PA DURAGESIC DIS 100MCG/H 3 QL (10 patches / 25

days), PA EMBEDA CAP 20-0.8MG 3 QL (60 caps / 25 days),

PA EMBEDA CAP 30-1.2MG 3 QL (60 caps / 25 days),

PA EMBEDA CAP 50-2MG 3 QL (60 caps / 25 days),

PA EMBEDA CAP 60-2.4MG 3 QL (60 caps / 25 days),

PA


8

Drug Name Drug Tier Requirements/Limits EMBEDA CAP 80-3.2MG 3 QL (60 caps / 25 days),

PA EMBEDA CAP 100-4MG 3 QL (60 caps / 25 days),

PA endocet tab 2.5-325 1 QL (360 tabs / 30 days) EXALGO TAB 8MG 3 QL (120 tabs / 30 days),

PA EXALGO TAB 12MG 3 QL (60 tabs / 30 days),



PA fentanyl citrate lozenge on a handle 200

mcg 1 QL (180 lpop / 25 days)

fentanyl citrate lozenge on a handle 400 mcg

1 QL (90 lpop / 25 days)









fentanyl citrate pf soln cartridge 100 mcg/2ml

1

fentanyl citrate preservative free (pf) inj 100 mcg/2ml

1


1


1


1


1

FENTANYL DIS 37.5MCG 3 QL (10 patches / 25 days)



fentanyl td patch 72hr 12 mcg/hr 1 QL (10 patches / 25 days), PA

fentanyl td patch 72hr 25 mcg/hr 1 QL (10 patches / 25 days), PA


9

Drug Name Drug Tier Requirements/Limits fentanyl td patch 72hr 50 mcg/hr 1 QL (10 patches / 25

days), PA fentanyl td patch 72hr 75 mcg/hr 1 QL (10 patches / 25

days), PA fentanyl td patch 72hr 100 mcg/hr 1 QL (10 patches / 25

days), PA FENTORA TAB 100MCG 3 QL (360 tabs / 25 days),

ST FENTORA TAB 200MCG 3 QL (180 tabs / 25 days),




ST FIORICET CAP CODEINE 3 QL (360 caps / 25

days), PA, ST FIORINAL/COD CAP 30MG 3 QL (180 caps / 30

days), PA, ST HYCET SOL 7.5-325 3 QL (960 ml / 30 days),

PA, ST hydrocodone-acetaminophen soln 7.5-325

mg/15ml 1 QL (960 ml / 30 days)

hydrocodone-acetaminophen soln 10-325 mg/15ml

1 PA

hydrocodone-acetaminophen tab 5-300 mg1 QL (360 tabs / 25 days) hydrocodone-acetaminophen tab 5-325 mg1 QL (360 tabs / 25 days) hydrocodone-acetaminophen tab 7.5-300

mg 1 QL (360 tabs / 25 days)

hydrocodone-acetaminophen tab 7.5-325 mg


hydrocodone-acetaminophen tab 10-300 mg


hydrocodone-acetaminophen tab 10-325 mg


hydrocodone-ibuprofen tab 7.5-200 mg 1 QL (360 tabs / 25 days) hydromorphone hcl inj 1 mg/ml 1 PA hydromorphone hcl inj 2 mg/ml 1 hydromorphone hcl inj 4 mg/ml 1 hydromorphone hcl liqd 1 mg/ml 1 QL (960 ml / 30 days) hydromorphone hcl preservative free (pf)

inj 10 mg/ml 1

hydromorphone hcl tab 2 mg 1 QL (480 tabs / 30 days) hydromorphone hcl tab 4 mg 1 QL (240 tabs / 30 days) hydromorphone hcl tab 8 mg 1 QL (120 tabs / 30 days) hydromorphone hcl tab er 24hr deter 8 mg 1 QL (120 tabs / 30 days)


10

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


hydromorphone hcl tab er 24hr deter 16 mg


hydromorphone hcl tab er 24hr deter 32 mg


HYSINGLA ER TAB 20 MG 3 QL (180 tabs / 25 days), PA







ibudone tab 5-200mg 1 ibudone tab 10-200mg 1 QL (360 tabs / 25 days) INFUMORPH INJ 10MG/ML 3 PA INFUMORPH INJ 25MG/ML 3 PA IONSYS PAD 40MCG/AC 3 PA KADIAN CAP 10MG ER 3 QL (360 caps / 25

days), PA KADIAN CAP 20MG ER 3 QL (180 caps / 25

days), PA KADIAN CAP 30MG ER 3 QL (120 caps / 25

days), PA KADIAN CAP 40MG ER 3 QL (90 caps / 25 days),

PA KADIAN CAP 50MG ER 3 QL (60 caps / 25 days),





PA LAZANDA SPR 100MCG 3 QL (120 sprays / 25

days), ST LAZANDA SPR 300MCG 3 QL (120 sprays / 25

days), ST


11

Drug Name Drug Tier Requirements/Limits LAZANDA SPR 400MCG 3 QL (120 sprays / 25

days), ST levorphanol tartrate tab 2 mg 1 LORTAB ELX 10-300MG 3 QL (960 ml / 30 days),

ST meperidine hcl inj 10 mg/ml 1 meperidine hcl inj 25 mg/ml 1 meperidine hcl inj 50 mg/ml 1 meperidine hcl inj 100 mg/ml 1 meperidine hcl oral soln 50 mg/5ml 1 QL (1800 ml / 30 days) meperidine hcl tab 50 mg 1 QL (360 tabs / 30 days) meperidine hcl tab 100 mg 1 QL (180 tabs / 30 days) methadone hcl conc 10 mg/ml 1 QL (60 ml / 25 days) methadone hcl soln 5 mg/5ml 1 QL (720 ml / 30 days) methadone hcl soln 10 mg/5ml 1 QL (360 ml / 30 days) methadone hcl tab 5 mg 1 QL (240 tabs / 30 days) methadone hcl tab 10 mg 1 QL (240 tabs / 30 days) methadone hcl tab for oral susp 40 mg 1 QL (60 / 30 days) METHADONE INJ 10MG/ML 3 QL (200 ml / 30 days) MORPHINE SUL INJ 2MG/ML 3 MORPHINE SUL INJ 4MG/ML 3 MORPHINE SUL INJ 5MG/ML 3 MORPHINE SUL INJ 8MG/ML 3 MORPHINE SUL INJ 10/0.7ML 3 MORPHINE SUL INJ 150/30ML 3 MORPHINE SUL SUP 30MG 3 morphine sulfate beads cap er 24hr 30 mg 1 QL (120 caps / 25 days) morphine sulfate beads cap er 24hr 45 mg 1 QL (90 caps / 25 days) morphine sulfate beads cap er 24hr 60 mg 1 QL (60 caps / 25 days) morphine sulfate beads cap er 24hr 75 mg 1 QL (30 caps / 25 days) morphine sulfate beads cap er 24hr 90 mg 1 QL (30 caps / 25 days) morphine sulfate beads cap er 24hr 120

mg 1 QL (30 caps / 25 days)

morphine sulfate cap er 24hr 10 mg 1 QL (360 caps / 25 days) morphine sulfate cap er 24hr 20 mg 1 QL (180 caps / 25 days) morphine sulfate cap er 24hr 30 mg 1 QL (120 caps / 25 days) morphine sulfate cap er 24hr 50 mg 1 QL (60 caps / 25 days) morphine sulfate cap er 24hr 60 mg 1 QL (60 caps / 25 days),

PA morphine sulfate cap er 24hr 80 mg 1 QL (30 caps / 25 days) morphine sulfate cap er 24hr 100 mg 1 QL (30 caps / 25 days) morphine sulfate inj 8 mg/ml 1 morphine sulfate inj 10 mg/ml 1 morphine sulfate inj 15 mg/ml 1 morphine sulfate inj pf 0.5 mg/ml 1 PA morphine sulfate inj pf 1 mg/ml 1 PA


12

Drug Name Drug Tier Requirements/Limits morphine sulfate iv soln 1 mg/ml 1 morphine sulfate iv soln 25 mg/ml 1 morphine sulfate iv soln 50 mg/ml 1 morphine sulfate iv soln pf 4 mg/ml 1 morphine sulfate iv soln pf 8 mg/ml 1 morphine sulfate iv soln pf 10 mg/ml 1 morphine sulfate iv soln pf 15 mg/ml 1 morphine sulfate oral soln 10 mg/5ml 1 QL (1800 ml / 30 days) morphine sulfate oral soln 20 mg/5ml 1 QL (900 ml / 30 days) morphine sulfate oral soln 100 mg/5ml (20

mg/ml) 1 QL (180 ml / 30 days),

PA morphine sulfate suppos 5 mg 1 morphine sulfate suppos 10 mg 1 morphine sulfate suppos 20 mg 1 morphine sulfate tab 15 mg 1 QL (240 tabs / 30 days) morphine sulfate tab 30 mg 1 QL (120 tabs / 30 days) morphine sulfate tab er 15 mg 1 QL (240 tabs / 25 days),

PA morphine sulfate tab er 30 mg 1 QL (120 tabs / 25 days),




PA MS CONTIN TAB 15MG ER 3 QL (240 tabs / 25 days),





PA nalbuphine hcl inj 10 mg/ml 1 nalbuphine hcl inj 20 mg/ml 1 NORCO TAB 5-325MG 3 QL (360 tabs / 25 days),

PA, ST NORCO TAB 7.5-325 3 QL (360 tabs / 25 days),

PA, ST NORCO TAB 10-325MG 3 QL (360 tabs / 25 days),

PA, ST NUCYNTA ER TAB 50MG 3 QL (180 tabs / 30 days),

PA


13

Drug Name Drug Tier Requirements/Limits NUCYNTA ER TAB 100MG 3 QL (90 tabs / 30 days),

PA NUCYNTA ER TAB 150MG 3 QL (60 tabs / 30 days),



PA NUCYNTA TAB 50MG 3 QL (180 tabs / 30 days),

ST NUCYNTA TAB 75MG 3 QL (120 tabs / 30 days),

ST NUCYNTA TAB 100MG 3 QL (90 tabs / 30 days),

ST OPANA INJ 1MG/ML 3 PA OPANA TAB 5MG 3 QL (240 tabs / 30 days),

PA, ST OPANA TAB 10MG 3 QL (120 tabs / 30 days),

PA, ST OXAYDO TAB 5MG 3 QL (90 tabs / 30 days),

PA OXAYDO TAB 7.5MG 3 QL (90 tabs / 30 days),

PA oxycodone hcl cap 5 mg 1 QL (480 caps / 25 days) oxycodone hcl conc 100 mg/5ml (20

mg/ml) 1 QL (120 ml / 30 days)

oxycodone hcl soln 5 mg/5ml 1 QL (2400 ml / 30 days) oxycodone hcl tab 5 mg 1 QL (480 tabs / 25 days) oxycodone hcl tab 10 mg 1 QL (240 tabs / 30 days) oxycodone hcl tab 15 mg 1 QL (150 tabs / 30 days) oxycodone hcl tab 20 mg 1 QL (120 tabs / 30 days) oxycodone hcl tab 30 mg 1 QL (60 tabs / 25 days) oxycodone hcl tab er 12hr deter 10 mg 1 QL (240 tabs / 30 days),

PA oxycodone hcl tab er 12hr deter 15 mg 1 QL (150 tabs / 30 days) oxycodone hcl tab er 12hr deter 20 mg 1 QL (120 tabs / 30 days),



PA oxycodone w/ acetaminophen soln 5-325

mg/5ml 1 QL (1830 ml / 30 days)

oxycodone w/ acetaminophen tab 5-325 mg



14

Drug Name Drug Tier Requirements/Limits oxycodone w/ acetaminophen tab 7.5-325


oxycodone w/ acetaminophen tab 10-325 mg


oxycodone-aspirin tab 4.8355-325 mg 1 QL (360 tabs / 30 days) oxycodone-ibuprofen tab 5-400 mg 1 QL (240 tabs / 30 days) OXYCONTIN TAB 10MG CR 3 QL (240 tabs / 30 days),

PA OXYCONTIN TAB 15MG CR 3 QL (150 tabs / 30 days),






PA oxymorphone hcl tab 5 mg 1 QL (240 tabs / 30 days) oxymorphone hcl tab 10 mg 1 QL (120 tabs / 30 days) oxymorphone hcl tab er 12hr 5 mg 1 QL (60 tabs / 30 days),

PA oxymorphone hcl tab er 12hr 7.5 mg 1 QL (60 tabs / 30 days),

PA oxymorphone hcl tab er 12hr 10 mg 1 QL (60 tabs / 30 days),





PA PERCOCET TAB 2.5-325 3 QL (360 tabs / 30 days),

PA, ST PERCOCET TAB 5-325MG 3 QL (360 tabs / 25 days),

PA, ST PERCOCET TAB 7.5-325 3 QL (300 tabs / 25 days),

PA, ST PERCOCET TAB 10-325MG 3 QL (240 tabs / 25 days),

PA, ST PRIMLEV TAB 5-300MG 3 QL (360 tabs / 25 days),

ST PRIMLEV TAB 7.5-300 3 QL (300 tabs / 25 days),

ST


15

Drug Name Drug Tier Requirements/Limits PRIMLEV TAB 10-300MG 3 QL (240 tabs / 25 days),

ST ROXICODONE TAB 5MG 3 QL (480 tabs / 25 days),

PA, ST ROXICODONE TAB 15MG 3 QL (150 tabs / 30 days),

PA, ST ROXICODONE TAB 30MG 3 QL (60 tabs / 25 days),

PA, ST SUBSYS SPR 100MCG 3 QL (120 sprays / 30

days), ST SUBSYS SPR 200MCG 3 QL (120 sprays / 30




days), ST SUBSYS SPR 1200MCG 3 QL (60 / 30 days), ST SUBSYS SPR 1600MCG 3 QL (60 / 30 days), ST sufentanil citrate inj 50 mcg/ml 1 PA sufentanil citrate inj 100 mcg/2ml (50

mcg/ml) 1 PA

sufentanil citrate inj 250 mcg/5ml (50 mcg/ml)

1 PA

SYNALGOS-DC CAP 3 QL (300 caps / 30 days), PA, ST

TALWIN INJ 30MG/ML 3 PA TRAMADOL HCL CAP 150MG ER 3 PA tramadol hcl cap er 24hr biphasic release

100 mg 1 QL (90 caps / 25 days)

tramadol hcl cap er 24hr biphasic release 200 mg


tramadol hcl cap er 24hr biphasic release 300 mg


tramadol hcl tab 50 mg 1 QL (240 tabs / 30 days) tramadol hcl tab er 24hr 100 mg 1 QL (90 tabs / 25 days) tramadol hcl tab er 24hr 200 mg 1 QL (30 tabs / 25 days) tramadol hcl tab er 24hr 300 mg 1 QL (30 tabs / 25 days) tramadol hcl tab er 24hr biphasic release

100 mg 1 QL (90 tabs / 25 days)

tramadol hcl tab er 24hr biphasic release 200 mg


tramadol hcl tab er 24hr biphasic release 300 mg


tramadol-acetaminophen tab 37.5-325 mg 1 QL (300 tabs / 30 days) TYLENOL/COD TAB #3 3 QL (360 tabs / 30 days),

PA, ST


16

Drug Name Drug Tier Requirements/Limits TYLENOL/COD TAB #4 3 QL (180 tabs / 30 days),

PA, ST ULTIVA INJ 1MG 3 PA ULTIVA INJ 2MG 3 PA ULTIVA INJ 5MG 3 PA ULTRACET TAB 37.5-325 3 QL (300 tabs / 30 days),

PA, ST ULTRAM ER TAB 300MG 3 QL (30 tabs / 25 days),

PA ULTRAM TAB 50MG 3 QL (240 tabs / 30 days),

PA, ST verdrocet tab 2.5-325 1 QL (360 tabs / 25 days) XODOL TAB 5-300MG 3 QL (360 tabs / 25 days),

PA, ST XODOL TAB 7.5-300 3 QL (360 tabs / 25 days),

PA, ST XODOL TAB 10-300MG 3 QL (360 tabs / 25 days),

PA, ST XTAMPZA ER CAP 9MG 3 QL (240 caps / 30

days), PA XTAMPZA ER CAP 13.5MG 3 QL (150 caps / 30

days), PA XTAMPZA ER CAP 18MG 3 QL (120 caps / 30

days), PA XTAMPZA ER CAP 27MG 3 QL (60 caps / 30 days),

PA XTAMPZA ER CAP 36MG 3 QL (60 caps / 30 days),

PA ZOHYDRO ER CAP 10MG 3 QL (360 caps / 25

days), PA ZOHYDRO ER CAP 15MG 3 QL (240 caps / 25



days), PA ZOHYDRO ER CAP 40MG 3 QL (90 caps / 25 days),

PA ZOHYDRO ER CAP 50MG 3 QL (60 caps / 25 days),

PA VISCOSUPPLEMENTS EUFLEXXA INJ 10MG/ML 2 PA GENVISC 850 INJ 25/2.5 2 PA HYALGAN INJ 20MG/2ML 2 PA SUPARTZ FX INJ 25/2.5ML 3 PA SUPARTZ INJ 25/2.5ML 3 PA ANTI-INFECTIVES


17

Drug Name Drug Tier Requirements/Limits AMINOGLYCOSIDES amikacin sulfate inj 1 gm/4ml (250 mg/ml)1 amikacin sulfate inj 500 mg/2ml (250

mg/ml) 1

GENTAM/NACL INJ 0.9MG/ML 3 gentamicin in saline inj 0.8 mg/ml 1 gentamicin in saline inj 1 mg/ml 1 gentamicin in saline inj 1.2 mg/ml 1 PA gentamicin in saline inj 1.6 mg/ml 1 gentamicin in saline inj 2 mg/ml 1 PA gentamicin sulfate inj 10 mg/ml 1 gentamicin sulfate inj 40 mg/ml 1 gentamicin sulfate iv soln 10 mg/ml 1 PA neomycin sulfate tab 500 mg 1 paromomycin sulfate cap 250 mg 1 streptomycin sulfate for inj 1 gm 1 PA tobramycin sulfate for inj 1.2 gm 1 tobramycin sulfate inj 1.2 gm/30ml (40

mg/ml) (base equiv) 1

tobramycin sulfate inj 2 gm/50ml (40 mg/ml) (base equiv)

1

tobramycin sulfate inj 10 mg/ml (base equivalent)

1

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

1

ANTIBACTERIALS, CARBAPENEMS DORIBAX INJ 250MG 3 PA DORIBAX INJ 500MG 3 PA imipenem-cilastatin intravenous for soln

250 mg 1

imipenem-cilastatin intravenous for soln 500 mg

1

INVANZ INJ 1GM 3 MEROP/NACL INJ 1GM/50ML 3 MEROP/NACL INJ 500/50ML 3 meropenem iv for soln 1 gm 1 PA meropenem iv for soln 500 mg 1 PA MERREM INJ 1GM 3 PA MERREM INJ 500MG 3 PA PRIMAXIN IV INJ 250MG 3 PA PRIMAXIN IV INJ 500MG 3 PA ANTIBACTERIALS, CEPHALOSPORIN COMBINATIONS AVYCAZ INJ 2-0.5GM 3 PA ANTIBACTERIALS, CEPHALOSPORINS 1ST GEN cefadroxil cap 500 mg 1 cefadroxil for susp 250 mg/5ml 1


18

Drug Name Drug Tier Requirements/Limits cefadroxil for susp 500 mg/5ml 1 cefadroxil tab 1 gm 1 CEFAZOL/DEX SOL 1GM 3 CEFAZOL/DEX SOL 2GM 3 CEFAZOLIN INJ 1GM/50ML 3 CEFAZOLIN INJ 100GM 3 CEFAZOLIN INJ 300GM 3 cefazolin sodium for inj 1 gm 1 cefazolin sodium for inj 10 gm 1 cefazolin sodium for inj 20 gm 1 cefazolin sodium for inj 500 mg 1 cefazolin sodium for iv soln 1 gm 1 cephalexin cap 250 mg 1 cephalexin cap 500 mg 1 cephalexin cap 750 mg 1 cephalexin for susp 125 mg/5ml 1 cephalexin for susp 250 mg/5ml 1 cephalexin tab 250 mg 1 cephalexin tab 500 mg 1 ANTIBACTERIALS, CEPHALOSPORINS, 2ND GEN cefaclor cap 250 mg 1 cefaclor cap 500 mg 1 CEFACLOR ER TAB 500MG 3 cefaclor for susp 125 mg/5ml 1 cefaclor for susp 250 mg/5ml 1 cefaclor for susp 375 mg/5ml 1 CEFOTET/DEX INJ 1-3.58% 3 PA CEFOTET/DEX INJ 2-2.08% 3 PA cefotetan disodium for inj 1 gm 1 cefotetan disodium for inj 2 gm 1 cefotetan disodium for inj 10 gm 1 CEFOXITIN INJ 1GM 3 CEFOXITIN INJ 2GM 3 cefoxitin sodium for inj 10 gm 1 cefoxitin sodium for iv soln 1 gm 1 cefoxitin sodium for iv soln 2 gm 1 cefprozil for susp 125 mg/5ml 1 cefprozil for susp 250 mg/5ml 1 cefprozil tab 250 mg 1 cefprozil tab 500 mg 1 CEFTIN SUS 125/5ML 3 CEFTIN SUS 250/5ML 3 cefuroxime axetil tab 250 mg 1 cefuroxime axetil tab 500 mg 1 CEFUROXIME INJ 7.5GM 2


19

Drug Name Drug Tier Requirements/Limits CEFUROXIME INJ 75GM 3 cefuroxime sodium for inj 1.5 gm 1 cefuroxime sodium for inj 7.5 gm 1 cefuroxime sodium for inj 750 mg 1 cefuroxime sodium for iv soln 1.5 gm 1 ZINACEF INJ 1.5GM 3 PA ZINACEF INJ 7.5GM 3 PA ZINACEF INJ 750MG 3 PA ZINACEF/H20 INJ 1.5GM PB 3 PA ANTIBACTERIALS, CEPHALOSPORINS, 3RD GEN cefdinir cap 300 mg 1 cefdinir for susp 125 mg/5ml 1 cefdinir for susp 250 mg/5ml 1 cefditoren pivoxil tab 200 mg (base

equivalent) 1

cefditoren pivoxil tab 400 mg (base equivalent)

1

cefixime for susp 100 mg/5ml 1 cefixime for susp 200 mg/5ml 1 cefotaxime sodium for inj 1 gm 1 cefotaxime sodium for inj 2 gm 1 cefotaxime sodium for inj 10 gm 1 cefotaxime sodium for inj 500 mg 1 cefpodoxime proxetil for susp 50 mg/5ml 1 cefpodoxime proxetil for susp 100 mg/5ml 1 cefpodoxime proxetil tab 100 mg 1 cefpodoxime proxetil tab 200 mg 1 ceftazidime for inj 1 gm 1 PA ceftazidime for inj 2 gm 1 PA ceftazidime for inj 6 gm 1 PA CEFTAZIDIME/ SOL D5W 1GM 3 PA CEFTAZIDIME/ SOL D5W 2GM 3 PA ceftibuten cap 400 mg 1 ceftibuten for susp 180 mg/5ml 1 CEFTRIAX/DEX INJ 1GM 3 CEFTRIAX/DEX INJ 2GM 3 ceftriaxone sodium for inj 1 gm 1 ceftriaxone sodium for inj 2 gm 1 ceftriaxone sodium for inj 10 gm 1 ceftriaxone sodium for inj 250 mg 1 ceftriaxone sodium for inj 500 mg 1 ceftriaxone sodium for iv soln 1 gm 1 ceftriaxone sodium for iv soln 2 gm 1 ceftriaxone sodium in dextrose inj 20

mg/ml 1


20

Drug Name Drug Tier Requirements/Limits ceftriaxone sodium in dextrose inj 40

mg/ml 1

CLAFORAN INJ 1GM 3 PA CLAFORAN INJ 2GM 3 PA CLAFORAN INJ 10GM 3 PA CLAFORAN INJ 500MG 3 PA FORTAZ INJ 1GM 3 PA FORTAZ INJ 2GM 3 PA FORTAZ INJ 6GM 3 PA FORTAZ INJ 500MG 3 PA SUPRAX CAP 400MG 3 SUPRAX CHW 100MG 3 SUPRAX CHW 200MG 3 SUPRAX SUS 500/5ML 3 tazicef inj 1gm 1 PA tazicef inj 2gm 1 PA ANTIBACTERIALS, CEPHALOSPORINS, 4TH GEN cefepime hcl for inj 1 gm 1 cefepime hcl for inj 2 gm 1 CEFEPIME INJ 1GM 3 CEFEPIME INJ 2GM 3 CEFEPIME/DEX INJ 1GM 3 PA CEFEPIME/DEX INJ 2GM 3 PA MAXIPIME INJ 1GM 3 PA MAXIPIME INJ 2GM 3 PA ANTIBACTERIALS, CEPHALOSPORINS, 5TH GEN TEFLARO INJ 400MG 3 PA TEFLARO INJ 600MG 3 PA ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 mg/5ml 1 azithromycin for susp 200 mg/5ml 1 azithromycin iv for soln 500 mg 1 azithromycin powd pack for susp 1 gm 1 azithromycin tab 250 mg 1 QL (36 tabs / 30 days) azithromycin tab 500 mg 1 QL (36 tabs / 30 days) azithromycin tab 600 mg 1 QL (36 tabs / 30 days) clarithromycin for susp 125 mg/5ml 1 clarithromycin for susp 250 mg/5ml 1 clarithromycin tab 250 mg 1 QL (60 tabs / 30 days) clarithromycin tab 500 mg 1 QL (60 tabs / 30 days) clarithromycin tab er 24hr 500 mg 1 QL (30 tabs / 30 days) DIFICID TAB 200MG 3 QL (20 tabs / 10 days),

ST e.e.s. 400 tab 400mg 1 ery-tab tab 250mg ec 1


21

Drug Name Drug Tier Requirements/Limits ery-tab tab 333mg ec 1 ery-tab tab 500mg ec 1 ERYPED SUS 400/5ML 2 PA ERYTHROCIN INJ 500MG 3 PA erythrocin tab 250mg 1 ERYTHROMYCIN ETHYLSUCCINATE FOR

SUSP 200 MG/5ML 1

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

cap 250 mg 1

PCE TAB 333MG EC 3 PA PCE TAB 500MG EC 3 PA ZMAX SUS 2GM 3 ANTIBACTERIALS, FLUOROQUINOLONES AVELOX INJ 3 BAXDELA TAB 450MG 3 QL (28 tabs / 14 days),

PA ciprofloxacin 200 mg/100ml in d5w 1 ciprofloxacin 400 mg/200ml in d5w 1 ciprofloxacin hcl tab 100 mg (base equiv) 1 QL (60 tabs / 30 days) ciprofloxacin hcl tab 250 mg (base equiv) 1 QL (60 tabs / 30 days) ciprofloxacin hcl tab 500 mg (base equiv) 1 QL (60 tabs / 30 days) ciprofloxacin hcl tab 750 mg (base equiv) 1 QL (60 tabs / 30 days) ciprofloxacin iv soln 200 mg/20ml (1%) 1 ciprofloxacin iv soln 400 mg/40ml (1%) 1 ciprofloxacin-ciprofloxacin hcl tab er 24hr

500 mg (base eq) 1 QL (30 tabs / 30 days)

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


FACTIVE TAB 320MG 3 QL (7 tabs per fill) levofloxacin in d5w iv soln 250 mg/50ml 1 levofloxacin in d5w iv soln 500 mg/100ml 1 levofloxacin in d5w iv soln 750 mg/150ml 1 levofloxacin iv soln 25 mg/ml 1 levofloxacin oral soln 25 mg/ml 1 levofloxacin tab 250 mg 1 QL (30 tabs / 30 days) levofloxacin tab 500 mg 1 QL (30 tabs / 30 days) levofloxacin tab 750 mg 1 QL (30 tabs / 30 days) moxifloxacin hcl 400 mg/250ml in sodium

chloride 0.8% inj 1

moxifloxacin hcl tab 400 mg (base equiv) 1 QL (30 tabs / 30 days) MOXIFLOXACIN INJ 3 ofloxacin tab 400 mg 1 ANTIBACTERIALS, PENICILLINS


22

Drug Name Drug Tier Requirements/Limits amoxicillin & k clavulanate chew tab 200-

28.5 mg 1

amoxicillin & k clavulanate chew tab 400-57 mg

1

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

1


1

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

1


1

amoxicillin & k clavulanate tab 250-125 mg1 amoxicillin & k clavulanate tab 500-125 mg1 amoxicillin & k clavulanate tab 875-125 mg1 amoxicillin & k clavulanate tab er 12hr

1000-62.5 mg 1

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

mg/5ml 1

amoxicillin (trihydrate) for susp 200 mg/5ml

1


1


1

amoxicillin (trihydrate) tab 500 mg 1 amoxicillin (trihydrate) tab 875 mg 1 ampicillin & sulbactam sodium for inj 1.5

(1-0.5) gm 1

ampicillin & sulbactam sodium for inj 3 (2-1) gm

1

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

1

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

1

ampicillin cap 250 mg 1 ampicillin cap 500 mg 1 ampicillin for susp 125 mg/5ml 1 ampicillin for susp 250 mg/5ml 1 ampicillin sodium for inj 1 gm 1 ampicillin sodium for inj 2 gm 1 ampicillin sodium for inj 10 gm 1 ampicillin sodium for inj 125 mg 1


23

Drug Name Drug Tier Requirements/Limits ampicillin sodium for inj 250 mg 1 ampicillin sodium for inj 500 mg 1 ampicillin sodium for iv soln 1 gm 1 ampicillin sodium for iv soln 10 gm 1 AUGMENTIN SUS 125/5ML 3 BACTOCILL INJ DEX 1GM 3 BACTOCILL INJ DEX 2GM 3 BICILLIN C-R INJ 900/300 3 PA BICILLIN C-R INJ 1200000 3 PA BICILLIN L-A INJ 600000 3 PA BICILLIN L-A INJ 1200000 3 PA BICILLIN L-A INJ 2400000 3 PA dicloxacillin sodium cap 250 mg 1 dicloxacillin sodium cap 500 mg 1 MOXATAG TAB 775MG 3 PA NAFCILLIN INJ 1GM/50ML 3 NAFCILLIN INJ 2GM/100 3 nafcillin sodium for inj 1 gm 1 nafcillin sodium for inj 2 gm 1 nafcillin sodium for inj 10 gm 1 nafcillin sodium for iv soln 1 gm 1 nafcillin sodium for iv soln 2 gm 1 oxacillin sodium for inj 1 gm (base

equivalent) 1

oxacillin sodium for inj 2 gm (base equivalent)

1

oxacillin sodium for inj 10 gm (base equivalent)

1

PEN G PROC INJ 600000 3 PENICILL GK/ INJ DEX 1MU 3 PA PENICILL GK/ INJ DEX 2MU 3 PA PENICILL GK/ INJ DEX 3MU 3 PA penicillin g potassium for inj 5000000 unit 1 penicillin g potassium for inj 20000000 unit1 penicillin g sodium for inj 5000000 unit 1 penicillin v potassium for soln 125 mg/5ml 1 penicillin v potassium for soln 250 mg/5ml 1 penicillin v potassium tab 250 mg 1 penicillin v potassium tab 500 mg 1 piperacillin sod-tazobactam na for inj 3.375

gm (3-0.375 gm) 1

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

1

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

1


24

Drug Name Drug Tier Requirements/Limits piperacillin sod-tazobactam sod for inj 40.5

gm (36-4.5 gm) 1

UNASYN INJ 1.5GM 3 PA UNASYN INJ 3GM 3 PA UNASYN INJ 15GM 3 PA ZOSYN INJ 2-0.25GM 3 PA ZOSYN INJ 3-0.375G 3 PA ZOSYN INJ 4-0.5GM 3 PA ZOSYN INJ 36-4.5GM 3 PA ZOSYN SOL 2-0.25GM 3 PA ZOSYN SOL 3-0.375G 3 PA ZOSYN SOL 4-0.50GM 3 PA ANTIBACTERIALS, SULFONAMIDES BACTRIM DS TAB 800-160 3 PA BACTRIM TAB 400-80MG 3 PA sulfamethoxazole-trimethoprim iv soln

400-80 mg/5ml 1

sulfamethoxazole-trimethoprim susp 200-40 mg/5ml

1

sulfamethoxazole-trimethoprim tab 400-80 mg

1

sulfamethoxazole-trimethoprim tab 800-160 mg

1

ANTIBACTERIALS, TETRACYCLINES ADOXA CAP 150MG 3 PA, ST AVIDOXY DK KIT 3 PA avidoxy tab 100mg 1 BENZODOX 30 MIS 3 PA BENZODOX 60 MIS 3 PA demeclocycline hcl tab 150 mg 1 demeclocycline hcl tab 300 mg 1 DORYX TAB 50MG 3 PA, ST DORYX TAB 200MG 3 PA, ST DORYX TAB 200MG 3 ST doxy 100 inj 100mg 1 PA doxycycline hyclate cap 50 mg 1 ST doxycycline hyclate cap 100 mg 1 ST doxycycline hyclate tab 20 mg 1 ST doxycycline hyclate tab 75 mg 1 ST doxycycline hyclate tab 100 mg 1 ST doxycycline hyclate tab 150 mg 1 ST doxycycline hyclate tab delayed release 75

mg 1 PA

doxycycline hyclate tab delayed release 100 mg

1 PA


25

Drug Name Drug Tier Requirements/Limits doxycycline hyclate tab delayed release

150 mg 1 PA

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

mg/5ml 1

doxycycline monohydrate tab 50 mg 1 doxycycline monohydrate tab 75 mg 1 doxycycline monohydrate tab 150 mg 1 MINOCIN CAP 50MG 3 PA MINOCIN CAP 75MG 3 PA MINOCIN CAP 100MG 3 PA MINOCIN INJ 100MG 3 PA minocycline hcl cap 50 mg 1 minocycline hcl cap 75 mg 1 minocycline hcl cap 100 mg 1 minocycline hcl tab 50 mg 1 minocycline hcl tab 75 mg 1 minocycline hcl tab 100 mg 1 minocycline hcl tab er 24hr 45 mg 1 minocycline hcl tab er 24hr 90 mg 1 minocycline hcl tab er 24hr 135 mg 1 MONODOX CAP 75MG 3 PA MONODOX CAP 100MG 3 PA MORGIDOX KIT 1X100MG 3 ST MORGIDOX KIT 2X100MG 3 ST SOLODYN TAB 55MG 3 ST SOLODYN TAB 65MG 3 ST SOLODYN TAB 80MG 3 ST SOLODYN TAB 105MG 3 ST SOLODYN TAB 115MG 3 ST tetracycline hcl cap 250 mg 1 tetracycline hcl cap 500 mg 1 VIBRAMYCIN CAP 100MG 3 PA, ST VIBRAMYCIN SUS 25MG/5ML 3 PA, ST VIBRAMYCIN SYP 50MG/5ML 3 ST ANTIFUNGALS ABELCET INJ 5MG/ML 3 PA AMBISOME INJ 50MG 3 PA amphotericin b for inj 50 mg 1 CANCIDAS INJ 50MG 3 CANCIDAS INJ 70MG 2 caspofungin acetate for iv soln 50 mg 1 clotrimazole troche 10 mg 1


26

Drug Name Drug Tier Requirements/Limits CRESEMBA CAP 186 MG 3 QL (100 days per 365

days), PA CRESEMBA INJ 372MG 3 QL (100 days per 365

days), PA DIFLUCAN SUS 10MG/ML 3 PA, ST DIFLUCAN SUS 40MG/ML 3 PA, ST DIFLUCAN TAB 50MG 3 QL (10 tabs / 25 days),

PA, ST DIFLUCAN TAB 100MG 3 QL (10 tabs / 25 days),



PA, ST ERAXIS INJ 50MG 3 PA ERAXIS INJ 100MG 3 PA fluconazole for susp 10 mg/ml 1 fluconazole for susp 40 mg/ml 1 fluconazole in dextrose inj 200 mg/100ml 1 fluconazole in dextrose inj 400 mg/200ml 1 fluconazole in nacl 0.9% inj 200 mg/100ml 1 fluconazole in nacl 0.9% inj 400 mg/200ml 1 fluconazole tab 50 mg 1 QL (10 tabs / 25 days) fluconazole tab 100 mg 1 QL (10 tabs / 25 days) fluconazole tab 150 mg 1 QL (10 tabs / 25 days) fluconazole tab 200 mg 1 QL (10 tabs / 25 days) FLUCONAZOLE/ INJ NACL 100 3 flucytosine cap 250 mg 1 PA flucytosine cap 500 mg 1 PA GRIS-PEG TAB 125MG 3 PA, ST GRIS-PEG TAB 250MG 3 PA, ST griseofulvin microsize susp 125 mg/5ml 1 griseofulvin microsize tab 500 mg 1 griseofulvin ultramicrosize tab 125 mg 1 griseofulvin ultramicrosize tab 250 mg 1 itraconazole cap 100 mg 1 QL (60 caps / 30 days) ketoconazole tab 200 mg 1 QL (60 tabs / 30 days) LAMISIL TAB 250MG 3 QL (30 tabs / 30 days),

PA, ST MYCAMINE INJ 50MG 2 MYCAMINE INJ 100MG 2 NOXAFIL INJ 300/16.7 2 NOXAFIL SUS 40MG/ML 2 NOXAFIL TAB 100MG 2 QL (93 tabs / 25 days),

ST nystatin oral powder 1


27

Drug Name Drug Tier Requirements/Limits nystatin susp 100000 unit/ml 1 nystatin tab 500000 unit 1 ONMEL TAB 200MG 3 QL (30 tabs / 30 days),

ST ORAVIG TAB 50MG 3 QL (14 tabs / 14 days),

ST SPORANOX CAP 100MG 3 QL (60 caps / 30 days),

PA, ST SPORANOX SOL 10MG/ML 2 ST terbinafine hcl tab 250 mg 1 QL (30 tabs / 30 days) VFEND IV INJ 200MG 3 QL (30 days per 100

days), PA VFEND SUS 40MG/ML 3 QL (30 days per 100

days), PA, ST VFEND TAB 50MG 3 QL (60 tabs / 30 days),

PA, ST VFEND TAB 200MG 3 QL (60 tabs / 30 days),

PA, ST voriconazole for inj 200 mg 1 QL (30 days per 100

days) voriconazole for susp 40 mg/ml 1 QL (30 days per 100

days) voriconazole tab 50 mg 1 QL (60 tabs / 30 days) voriconazole tab 200 mg 1 QL (60 tabs / 30 days) ANTIMALARIALS atovaquone-proguanil hcl tab 62.5-25 mg 1 atovaquone-proguanil hcl tab 250-100 mg 1 chloroquine phosphate tab 250 mg 1 chloroquine phosphate tab 500 mg 1 COARTEM TAB 20-120MG 2 DARAPRIM TAB 25MG 3 PA mefloquine hcl tab 250 mg 1 PRIMAQUINE TAB 26.3MG 3 quinine sulfate cap 324 mg 1 ANTIRETROVIRALS, ANTIRETROVIRAL ADJUVANTS abacavir sulfate-lamivudine tab 600-300

mg 1

DESCOVY TAB 200/25 2 QL (30 tabs / 30 days) EVOTAZ TAB 300-150 3 QL (30 tabs / 30 days),

PA PREZCOBIX TAB 800-150 3 QL (30 tabs / 30 days),

PA TYBOST TAB 150MG 3 QL (30 tabs / 30 days),

PA ANTIRETROVIRALS, ANTIRETROVIRAL COMBINATIONS abacavir sulfate-lamivudine-zidovudine tab

300-150-300 mg 1 QL (60 tabs / 30 days)


28

Drug Name Drug Tier Requirements/Limits ATRIPLA TAB 2 QL (30 tabs / 30 days) COMBIVIR TAB 150-300 3 QL (60 tabs / 30 days),

PA COMPLERA TAB 2 QL (30 tabs / 30 days) GENVOYA TAB 2 PA lamivudine-zidovudine tab 150-300 mg 1 QL (60 tabs / 30 days) ODEFSEY TAB 2 STRIBILD TAB 2 QL (30 tabs / 30 days) TRIUMEQ TAB 3 QL (30 tabs / 30 days) TRIZIVIR TAB 3 QL (60 tabs / 30 days),

PA TRUVADA TAB 200-300 2 QL (30 tabs / 30 days) ANTIRETROVIRALS, CHEMOKINE RECEPTOR ANTAGONISTS SELZENTRY SOL 20MG/ML 2 QL (450 ml / 30 days),

PA SELZENTRY TAB 25MG 2 QL (60 tabs / 30 days),




PA ANTIRETROVIRALS, FUSION INHIBITORS FUZEON INJ 90MG 2 QL (60 / 30 days) ANTIRETROVIRALS, INTEGRASE INHIBITORS ISENTRESS CHW 25MG 2 QL (120 ea / 30 days),

PA ISENTRESS CHW 100MG 2 QL (120 ea / 30 days),

PA ISENTRESS HD TAB 600MG 2 QL (60 tabs / 30 days),

PA ISENTRESS POW 100MG 2 QL (60 / 30 days), PA ISENTRESS TAB 400MG 2 QL (60 tabs / 30 days),

PA TIVICAY TAB 10MG 2 QL (60 tabs / 30 days) TIVICAY TAB 25MG 2 QL (60 tabs / 30 days) TIVICAY TAB 50MG 2 QL (60 tabs / 30 days) ANTIRETROVIRALS, PROTEASE INHIBITORS APTIVUS CAP 250MG 2 QL (120 caps / 30 days) APTIVUS SOL 2 QL (300 / 30 days) CRIXIVAN CAP 200MG 2 QL (90 caps / 30 days) CRIXIVAN CAP 400MG 2 QL (180 caps / 30 days) fosamprenavir calcium tab 700 mg (base

equiv) 1 QL (120 tabs / 30 days)

INVIRASE CAP 200MG 2 QL (300 caps / 30 days)


29

Drug Name Drug Tier Requirements/Limits INVIRASE TAB 500MG 2 QL (120 tabs / 30 days) KALETRA SOL 3 QL (480 ml / 30 days) KALETRA TAB 100-25MG 2 QL (30 tabs / 30 days) KALETRA TAB 200-50MG 2 QL (120 tabs / 30 days) LEXIVA SUS 50MG/ML 2 QL (1680 ml / 25 days) LEXIVA TAB 700MG 2 QL (120 tabs / 30 days) lopinavir-ritonavir soln 400-100 mg/5ml

(80-20 mg/ml) 1 QL (480 ml / 30 days)

NORVIR CAP 100MG 2 QL (360 caps / 30 days) NORVIR SOL 80MG/ML 2 QL (480 ml / 25 days) NORVIR TAB 100MG 2 QL (360 tabs / 30 days) PREZISTA SUS 100MG/ML 2 QL (400 ml / 25 days) PREZISTA TAB 75MG 2 QL (60 tabs / 30 days) PREZISTA TAB 150MG 2 QL (60 tabs / 30 days) PREZISTA TAB 600MG 2 QL (60 tabs / 30 days) PREZISTA TAB 800MG 2 QL (60 tabs / 30 days) REYATAZ CAP 150MG 2 QL (30 caps / 30 days) REYATAZ CAP 200MG 2 QL (30 caps / 30 days) REYATAZ CAP 300MG 2 QL (30 caps / 30 days) VIRACEPT TAB 250MG 2 QL (270 tabs / 30 days) VIRACEPT TAB 625MG 2 QL (120 tabs / 30 days) ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS - NON-

NUCLEOSIDE EDURANT TAB 25MG 2 QL (30 tabs / 30 days) INTELENCE TAB 25MG 2 QL (60 tabs / 30 days) INTELENCE TAB 100MG 2 QL (60 tabs / 30 days) INTELENCE TAB 200MG 2 QL (60 tabs / 30 days) nevirapine susp 50 mg/5ml 1 QL (1200 ml / 30 days) nevirapine tab 200 mg 1 QL (60 tabs / 30 days) nevirapine tab er 24hr 100 mg 1 QL (30 tabs / 30 days) nevirapine tab er 24hr 400 mg 1 QL (30 tabs / 30 days) RESCRIPTOR TAB 100 MG 2 QL (180 tabs / 30 days) RESCRIPTOR TAB 200MG 2 QL (180 tabs / 30 days) SUSTIVA CAP 50MG 2 QL (90 caps / 30 days) SUSTIVA CAP 200MG 2 QL (60 caps / 30 days) SUSTIVA TAB 600MG 2 QL (30 tabs / 30 days) VIRAMUNE SUS 50MG/5ML 3 QL (1200 ml / 30 days),

PA VIRAMUNE TAB 200MG 3 QL (60 tabs / 30 days),

PA ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS -

NUCLEOSIDE abacavir sulfate soln 20 mg/ml (base

equiv) 1 QL (900 ml / 30 days)

abacavir sulfate tab 300 mg (base equiv) 1 QL (30 tabs / 30 days)


30

Drug Name Drug Tier Requirements/Limits didanosine delayed release capsule 125 mg1 QL (60 caps / 30 days) didanosine delayed release capsule 200 mg1 QL (60 caps / 30 days) didanosine delayed release capsule 250 mg1 QL (30 caps / 30 days) didanosine delayed release capsule 400 mg1 QL (30 caps / 30 days) EMTRIVA CAP 200MG 2 QL (30 caps / 30 days) EMTRIVA SOL 10MG/ML 2 QL (720 / 25 days) EPIVIR TAB 150MG 3 QL (60 tabs / 30 days),

PA EPIVIR TAB 300MG 3 QL (30 tabs / 30 days),

PA lamivudine oral soln 10 mg/ml 1 QL (900 ml / 30 days) lamivudine tab 150 mg 1 QL (60 tabs / 30 days) lamivudine tab 300 mg 1 QL (30 tabs / 30 days) RETROVIR CAP 100MG 3 QL (180 caps / 30

days), PA RETROVIR SYP 50MG/5ML 3 QL (1800 / 30 days), PA stavudine cap 15 mg 1 QL (60 caps / 30 days) stavudine cap 20 mg 1 QL (60 caps / 30 days) stavudine cap 30 mg 1 QL (60 caps / 30 days) stavudine cap 40 mg 1 QL (60 caps / 30 days) stavudine for oral soln 1 mg/ml 1 QL (2400 / 30 days) VIDEX EC CAP 125MG 3 QL (60 caps / 30 days),

PA VIDEX EC CAP 200MG 3 QL (60 caps / 30 days),



PA VIDEX SOL 2GM 2 QL (1200 / 30 days) VIDEX SOL 4GM 2 QL (1200 / 30 days) ZERIT CAP 15MG 3 QL (60 caps / 30 days),

PA ZERIT CAP 20MG 3 QL (60 caps / 30 days),



PA ZERIT SOL 1MG/ML 3 QL (2400 / 30 days), PA ZIAGEN SOL 20MG/ML 3 QL (900 ml / 30 days) ZIAGEN TAB 300MG 3 QL (60 tabs / 30 days),

PA zidovudine cap 100 mg 1 QL (180 caps / 30 days) zidovudine syrup 10 mg/ml 1 QL (1800 / 30 days) zidovudine tab 300 mg 1 QL (60 tabs / 30 days)


31

Drug Name Drug Tier Requirements/Limits ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS -

NUCLEOTIDE VIREAD POW 40MG/GM 2 QL (240 / 30 days) VIREAD TAB 150MG 2 QL (30 tabs / 30 days) VIREAD TAB 200MG 2 QL (30 tabs / 30 days) VIREAD TAB 250MG 2 QL (30 tabs / 30 days) VIREAD TAB 300MG 2 QL (30 tabs / 30 days) ANTITUBERCULAR AGENTS CAPASTAT SUL INJ 1GM 3 PA cycloserine cap 250 mg 1 PA ethambutol hcl tab 100 mg 1 ethambutol hcl tab 400 mg 1 isoniazid inj 100 mg/ml 1 isoniazid syrup 50 mg/5ml 1 isoniazid tab 100 mg 1 isoniazid tab 300 mg 1 MYAMBUTOL TAB 400MG 3 PA PASER GRA 4GM 3 PA PRIFTIN TAB 150MG 2 pyrazinamide tab 500 mg 1 RIFADIN CAP 150MG 3 PA RIFADIN CAP 300MG 3 PA RIFADIN INJ 600 MG 3 PA RIFAMATE CAP 3 PA rifampin cap 150 mg 1 rifampin cap 300 mg 1 rifampin for inj 600 mg 1 RIFATER TAB 3 PA SIRTURO TAB 100MG 2 TRECATOR TAB 250MG 3 PA ANTIVIRALS, CMV AGENTS cidofovir iv inj 75 mg/ml 1 CYTOVENE INJ 500MG 2 PA FOSCAVIR INJ 24MG/ML 3 PA ganciclovir sodium for inj 500 mg 1 valganciclovir hcl for soln 50 mg/ml (base

equiv) 1

valganciclovir hcl tab 450 mg (base equivalent)

1

ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS B adefovir dipivoxil tab 10 mg 1 BARACLUDE SOL .05MG/ML 2 BARACLUDE TAB 0.5MG 3 QL (30 tabs / 30 days),

PA, ST


32

Drug Name Drug Tier Requirements/Limits BARACLUDE TAB 1MG 3 QL (30 tabs / 30 days),

PA, ST entecavir tab 0.5 mg 1 QL (30 tabs / 30 days) entecavir tab 1 mg 1 QL (30 tabs / 30 days) EPIVIR HBV SOL 5MG/ML 2 EPIVIR HBV TAB 100MG 3 PA, ST HEPSERA TAB 10MG 3 PA lamivudine tab 100 mg (hbv) 1 ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS C COPEGUS TAB 200MG 3 QL (180 tabs / 30 days),

PA DAKLINZA TAB 30MG 3 QL (30 tabs / 30 days),



PA EPCLUSA TAB 400-100 3 QL (30 tabs / 30 days),

PA HARVONI TAB 90-400MG 3 QL (30 tabs / 30 days),

PA MAVYRET TAB 100-40MG 2 QL (84 tabs / 28 days),

PA MODERIBA PAK 800/DAY 3 QL (56 tabs / 25 days),

PA MODERIBA PAK 1200/DAY 3 QL (56 tabs / 25 days),

PA MODERIBA TAB 600/DAY 3 QL (1 kit / 25 days), PA MODERIBA TAB 1000/DAY 3 QL (1 kit / 25 days), PA OLYSIO CAP 150MG 3 QL (30 caps / 30 days),

PA REBETOL CAP 200MG 3 QL (180 caps / 30

days), PA REBETOL SOL 40MG/ML 3 QL (900 ml / 30 days),

PA RIBAPAK PAK 800/DAY 2 QL (56 tabs / 25 days),

PA RIBAPAK PAK 1200/DAY 2 QL (56 tabs / 25 days),

PA RIBAPAK TAB 600/DAY 2 QL (1 kit / 25 days), PA RIBAPAK TAB 600/DAY 2 QL (4 / 25 days), PA RIBAPAK TAB 1000/DAY 2 QL (1 kit / 25 days), PA RIBAPAK TAB 1000/DAY 2 QL (4 / 25 days), PA ribasphere tab 400mg 1 QL (56 tabs / 25 days) ribasphere tab 600mg 1 QL (56 tabs / 25 days) ribavirin cap 200 mg 1 QL (180 caps / 30 days) ribavirin tab 200 mg 1 QL (180 tabs / 30 days)


33

Drug Name Drug Tier Requirements/Limits SOVALDI TAB 400MG 3 QL (30 tabs / 30 days),

PA TECHNIVIE TAB 3 QL (30 tabs / 30 days),

PA VIEKIRA PAK TAB 3 QL (84 tabs / 30 days),

PA VIEKIRA XR TAB 3 QL (84 tabs / 30 days),

PA VOSEVI TAB 3 QL (28 tabs / 28 days),

PA ZEPATIER TAB 50-100MG 3 QL (30 tabs / 30 days),

PA ANTIVIRALS, HERPES AGENTS acyclovir cap 200 mg 1 acyclovir sodium for inj 500 mg 1 acyclovir sodium for inj 1000 mg 1 acyclovir sodium iv soln 50 mg/ml 1 acyclovir susp 200 mg/5ml 1 acyclovir tab 400 mg 1 acyclovir tab 800 mg 1 famciclovir tab 125 mg 1 QL (21 tabs / 25 days) famciclovir tab 250 mg 1 QL (70 tabs / 25 days) famciclovir tab 500 mg 1 QL (21 tabs / 25 days) FAMVIR TAB 125MG 3 QL (21 tabs / 25 days),

PA, ST FAMVIR TAB 250MG 3 QL (70 tabs / 25 days),

PA, ST FAMVIR TAB 500MG 3 QL (21 tabs / 25 days),

PA, ST SITAVIG TAB 50MG 3 PA valacyclovir hcl tab 1 gm 1 QL (30 tabs / 30 days) valacyclovir hcl tab 500 mg 1 QL (42 tabs / 25 days) VALTREX TAB 1GM 3 QL (30 tabs / 30 days),

PA, ST VALTREX TAB 500MG 3 QL (42 tabs / 25 days),

PA, ST ZOVIRAX CAP 200MG 3 PA, ST ZOVIRAX SUS 200/5ML 3 PA, ST ZOVIRAX TAB 400MG 3 PA, ST ZOVIRAX TAB 800MG 3 PA, ST ANTIVIRALS, INFLUENZA AGENTS FLUMADINE TAB 100MG 3 PA oseltamivir phosphate cap 30 mg (base

equiv) 1 QL (10 caps / 180 days)

oseltamivir phosphate cap 45 mg (base equiv)



34

Drug Name Drug Tier Requirements/Limits oseltamivir phosphate cap 75 mg (base

equiv) 1 QL (10 caps / 180 days)

RELENZA MIS DISKHALE 2 QL (1 inhaler / 180 days)

rimantadine hydrochloride tab 100 mg 1 TAMIFLU CAP 30MG 3 QL (10 caps / 180 days) TAMIFLU CAP 45MG 3 QL (10 caps / 180 days) TAMIFLU CAP 75MG 3 QL (10 caps / 180 days) TAMIFLU SUS 6MG/ML 2 QL (120 mL / 180 days),

PA MISCELLANEOUS ALBENZA TAB 200MG 2 ALINIA SUS 100/5ML 2 ALINIA TAB 500MG 2 atovaquone susp 750 mg/5ml 1 AZACTAM INJ 1GM 3 PA AZACTAM INJ 2GM 3 PA AZACTAM/DEX INJ 1GM 3 PA AZACTAM/DEX INJ 2GM 3 PA aztreonam for inj 1 gm 1 aztreonam for inj 2 gm 1 baciim inj 50000unt 1 BILTRICIDE TAB 600MG 3 PA chloramphenicol sodium succinate for iv inj

1 gm 1

CLEOCIN CAP 75MG 3 PA CLEOCIN CAP 150MG 3 PA CLEOCIN CAP 300MG 3 PA CLEOCIN PED SOL 75MG/5ML 3 PA CLEOCIN PHOS INJ 9GM/60ML 3 PA CLEOCIN PHOS INJ 300/2ML 3 PA CLEOCIN PHOS INJ 600/4ML 3 PA CLEOCIN PHOS INJ 900/6ML 3 PA CLEOCIN/D5W INJ 300MG 3 PA CLEOCIN/D5W INJ 600MG 3 PA CLEOCIN/D5W INJ 900MG 3 PA CLIN SINGLE KIT USE 3 PA clindamycin hcl cap 75 mg 1 clindamycin hcl cap 150 mg 1 clindamycin hcl cap 300 mg 1 clindamycin palmitate hcl for soln 75

mg/5ml (base equiv) 1

clindamycin phosphate in d5w iv soln 300 mg/50ml

1

clindamycin phosphate in d5w iv soln 600 mg/50ml

1


35

Drug Name Drug Tier Requirements/Limits clindamycin phosphate in d5w iv soln 900

mg/50ml 1

clindamycin phosphate inj 9 gm/60ml 1 clindamycin phosphate inj 300 mg/2ml 1 clindamycin phosphate inj 600 mg/4ml 1 clindamycin phosphate inj 900 mg/6ml 1 clindamycin phosphate iv soln 300 mg/2ml 1 clindamycin phosphate iv soln 900 mg/6ml 1 colistimethate sodium for inj 150 mg 1 COLY-MYCIN M INJ 150MG 3 PA CUBICIN SOL 500MG 3 PA dapsone tab 25 mg 1 dapsone tab 100 mg 1 FLAGYL CAP 375MG 3 PA, ST FLAGYL ER TAB 750MG 3 ST FLAGYL TAB 250MG 3 PA, ST FLAGYL TAB 500MG 3 PA, ST FURADANTIN SUS 25MG/5ML 3 PA LINCOCIN INJ 300MG/ML 3 PA lincomycin hcl inj 300 mg/ml 1 linezolid for susp 100 mg/5ml 1 QL (1650 / year) linezolid in sodium chloride iv soln 600

mg/300ml-0.9% 1

linezolid iv soln 600 mg/300ml (2 mg/ml) 1 linezolid tab 600 mg 1 QL (56 tabs / year) MACROBID CAP 100MG 3 PA MACRODANTIN CAP 25MG 3 PA MACRODANTIN CAP 50MG 3 PA MACRODANTIN CAP 100MG 3 PA MEPRON SUS 3 PA METRO IV INJ 5MG/ML 3 metronidazole cap 375 mg 1 metronidazole in nacl 0.79% iv soln 500

mg/100ml 1

metronidazole tab 250 mg 1 metronidazole tab 500 mg 1 NEBUPENT INH 300MG 2 nitrofurantoin macrocrystalline cap 25 mg 1 nitrofurantoin macrocrystalline cap 50 mg 1 nitrofurantoin macrocrystalline cap 100 mg 1 nitrofurantoin monohydrate

macrocrystalline cap 100 mg 1

nitrofurantoin susp 25 mg/5ml 1 PENTAM 300 INJ 300MG 3 PA PIN-X CHW 250MG 2 OTC polymyxin b sulfate for inj 500000 unit 1


36

Drug Name Drug Tier Requirements/Limits PRIMSOL SOL 50MG/5ML 3 PA reeses med sus pinworm 1 OTC rifabutin cap 150 mg 1 SIVEXTRO INJ 200MG 3 QL (6 / 25 days), PA SIVEXTRO TAB 200MG 3 QL (6 tabs / 25 days),

PA SYNERCID INJ 500MG 3 PA TINDAMAX TAB 500MG 3 PA tinidazole tab 250 mg 1 tinidazole tab 500 mg 1 trimethoprim tab 100 mg 1 TYGACIL INJ 50MG 2 VANCOCIN HCL CAP 125MG 3 PA, ST VANCOCIN HCL CAP 250MG 3 PA, ST VANCOMYC/DEX INJ 1GM 2 VANCOMYC/DEX INJ 500MG 2 vancomycin hcl cap 125 mg 1 vancomycin hcl cap 250 mg 1 vancomycin hcl for inj 10 gm 1 vancomycin hcl for inj 500 mg 1 vancomycin hcl for inj 1000 mg 1 vancomycin hcl for inj 5000 mg 1 VIBATIV INJ 250MG 3 PA VIRAZOLE INH 6GM 3 PA XIFAXAN TAB 200MG 3 QL (9 tabs / 30 days),

PA XIFAXAN TAB 550MG 3 QL (60 tabs / 30 days),

PA ZYVOX SOL 2MG/ML 3 ANTINEOPLASTIC AGENTS ALKYLATING AGENTS ALKERAN INJ 50MG 3 PA ALKERAN TAB 2MG 3 BENDEKA INJ 100/4ML 3 PA BICNU INJ 100MG 2 BUSULFEX INJ 6MG/ML 2 carboplatin iv soln 50 mg/5ml 1 carboplatin iv soln 150 mg/15ml 1 carboplatin iv soln 450 mg/45ml 1 carboplatin iv soln 600 mg/60ml 1 cisplatin inj 50 mg/50ml (1 mg/ml) 1 cisplatin inj 100 mg/100ml (1 mg/ml) 1 cisplatin inj 200 mg/200ml (1 mg/ml) 1 cyclophosphamide for inj 1 gm 1 cyclophosphamide for inj 2 gm 1 cyclophosphamide for inj 500 mg 1


37

Drug Name Drug Tier Requirements/Limits dacarbazine for inj 100 mg 1 dacarbazine for inj 200 mg 1 EMCYT CAP 140MG 2 GLEOSTINE CAP 5MG 2 GLEOSTINE CAP 10MG 2 GLEOSTINE CAP 40MG 2 GLEOSTINE CAP 100MG 2 GLIADEL WAF 7.7MG 3 PA HEXALEN CAP 50MG 2 IFEX INJ 1GM 3 PA IFEX INJ 3GM 3 PA ifosfamide for inj 1 gm 1 ifosfamide iv inj 1 gm/20ml (50 mg/ml) 1 ifosfamide iv inj 3 gm/60ml (50 mg/ml) 1 LEUKERAN TAB 2MG 2 melphalan hcl for inj 50 mg (base equiv) 1 melphalan tab 2 mg 1 MYLERAN TAB 2MG 2 oxaliplatin for iv inj 50 mg 1 oxaliplatin for iv inj 100 mg 1 oxaliplatin iv soln 50 mg/10ml 1 oxaliplatin iv soln 100 mg/20ml 1 TEMODAR CAP 5MG 3 PA TEMODAR CAP 20MG 3 PA TEMODAR CAP 100MG 3 PA TEMODAR CAP 140MG 3 PA TEMODAR CAP 180MG 3 PA TEMODAR CAP 250MG 3 PA TEMODAR INJ 100MG 2 temozolomide cap 5 mg 1 temozolomide cap 20 mg 1 temozolomide cap 100 mg 1 temozolomide cap 140 mg 1 temozolomide cap 180 mg 1 temozolomide cap 250 mg 1 thiotepa for inj 15 mg 1 PA TREANDA INJ 25MG 2 TREANDA INJ 100MG 2 VALCHLOR GEL 0.016% 2 ZANOSAR INJ 1GM 2 ANTIMETABOLITES ALIMTA INJ 100MG 2 ALIMTA INJ 500MG 2 capecitabine tab 150 mg 1 capecitabine tab 500 mg 1


38

Drug Name Drug Tier Requirements/Limits cladribine iv soln 10 mg/10ml (1 mg/ml) 1 cytarabine inj 20 mg/ml 1 cytarabine inj pf 20 mg/ml 1 cytarabine inj pf 100 mg/ml 1 DACOGEN INJ 50MG 3 PA decitabine for inj 50 mg 1 FLUDARA INJ 50MG 3 PA fludarabine phosphate for inj 50 mg 1 fludarabine phosphate inj 25 mg/ml 1 fluorouracil inj 1 gm/20ml (50 mg/ml) 1 fluorouracil inj 2.5 gm/50ml (50 mg/ml) 1 fluorouracil inj 5 gm/100ml (50 mg/ml) 1 fluorouracil inj 500 mg/10ml (50 mg/ml) 1 FOLOTYN INJ 20MG/ML 2 FOLOTYN INJ 40MG/2ML 2 gemcitabine hcl for inj 1 gm 1 gemcitabine hcl for inj 2 gm 1 gemcitabine hcl for inj 200 mg 1 gemcitabine hcl inj 1 gm/26.3ml (38

mg/ml) (base equiv) 1

gemcitabine hcl inj 2 gm/52.6ml (38 mg/ml) (base equiv)

1

gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml) (base equiv)

1

GEMZAR INJ 1GM 3 PA GEMZAR INJ 200MG 3 PA mercaptopurine tab 50 mg 1 methotrexate sodium for inj 1 gm 1 methotrexate sodium inj 50 mg/2ml (25

mg/ml) 1

methotrexate sodium inj 250 mg/10ml (25 mg/ml)

1

methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)

1


1


1


1


1

methotrexate sodium tab 2.5 mg (base equiv)

1

PURIXAN SUS 20MG/ML 2 PA TABLOID TAB 40MG 2 TREXALL TAB 5MG 2


39

Drug Name Drug Tier Requirements/Limits TREXALL TAB 7.5MG 2 TREXALL TAB 10MG 2 TREXALL TAB 15MG 2 XELODA TAB 150MG 3 PA XELODA TAB 500MG 3 PA HORMONAL ANTINEOPLASTICS, ANTIANDROGENS bicalutamide tab 50 mg 1 CASODEX TAB 50MG 3 PA flutamide cap 125 mg 1 nilutamide tab 150 mg 1 XTANDI CAP 40MG 2 QL (120 caps / 30 days) ZYTIGA TAB 250MG 2 QL (120 tabs / 30 days) ZYTIGA TAB 500MG 2 QL (60 tabs / 30 days) HORMONAL ANTINEOPLASTICS, ANTIESTROGENS FARESTON TAB 60MG 2 SOLTAMOX SOL 10MG/5ML 3 PA tamoxifen citrate tab 10 mg (base

equivalent) 1

tamoxifen citrate tab 20 mg (base equivalent)

1

HORMONAL ANTINEOPLASTICS, AROMATASE INHIBITORS anastrozole tab 1 mg 1 ARIMIDEX TAB 1MG 3 PA AROMASIN TAB 25MG 3 PA exemestane tab 25 mg 1 FEMARA TAB 2.5MG 3 PA letrozole tab 2.5 mg 1 HORMONAL ANTINEOPLASTICS, LUTEINIZING HORMONE-

RELEASING HORMONE (LHRH) AGONISTS ELIGARD INJ 22.5MG 3 QL (1 box / 84 days), PA leuprolide acetate inj kit 5 mg/ml 1 QL (2 boxes / 21 days) LUPRON DEPOT INJ 3.75MG 2 QL (1 box / 21 days), PA LUPRON DEPOT INJ 7.5MG 2 QL (1 box / 21 days), PA LUPRON DEPOT INJ 11.25MG 2 QL (1 box / 84 days), PA LUPRON DEPOT INJ 22.5MG 2 QL (1 box / 84 days), PA LUPRON DEPOT INJ 30MG 2 PA LUPRON DEPOT INJ 45MG 2 QL (1 box / 168 days),

PA TRELSTAR INJ 11.25MG 3 PA VANTAS KIT 50MG 2 QL (1 box / year), PA HORMONAL ANTINEOPLASTICS, PROGESTINS DEPO-PROVERA INJ 400/ML 2 MEGACE ORAL SUS 40MG/ML 3 PA megestrol acetate susp 40 mg/ml 1 megestrol acetate tab 20 mg 1


40

Drug Name Drug Tier Requirements/Limits megestrol acetate tab 40 mg 1 IMMUNOMODULATORS POMALYST CAP 1MG 2 QL (21 caps / 21 days) POMALYST CAP 2MG 2 QL (21 caps / 21 days) POMALYST CAP 3MG 2 QL (21 caps / 21 days) POMALYST CAP 4MG 2 QL (21 caps / 21 days) REVLIMID CAP 2.5MG 2 QL (30 caps / 30 days) REVLIMID CAP 5MG 2 QL (30 caps / 30 days) REVLIMID CAP 10MG 2 QL (30 caps / 30 days) REVLIMID CAP 15MG 2 QL (30 caps / 30 days) REVLIMID CAP 20MG 2 QL (30 caps / 30 days) REVLIMID CAP 25MG 2 QL (30 caps / 30 days) THALOMID CAP 50MG 2 QL (30 caps / 30 days) THALOMID CAP 100MG 2 QL (30 caps / 30 days) THALOMID CAP 150MG 2 QL (60 caps / 30 days) THALOMID CAP 200MG 2 QL (60 caps / 30 days) KINASE INHIBITOR /AROMATASE INHIBITOR COMBINATIONS KISQALI 200 PAK FEMARA 2 QL (63 / 28), PA KISQALI 400 PAK FEMARA 2 QL (63 / 28), PA KISQALI 600 PAK FEMARA 2 QL (63 / 28), PA KINASE INHIBITORS AFINITOR DIS TAB 2MG 2 QL (30 / 30 days) AFINITOR DIS TAB 3MG 2 QL (30 / 30 days) AFINITOR DIS TAB 5MG 2 QL (30 / 30 days) AFINITOR TAB 2.5MG 2 QL (30 tabs / 30 days) AFINITOR TAB 5MG 2 QL (30 tabs / 30 days) AFINITOR TAB 7.5MG 2 QL (30 tabs / 30 days) AFINITOR TAB 10MG 2 QL (30 tabs / 30 days) ALECENSA CAP 150MG 2 QL (240 caps / 30

days), PA ALUNBRIG TAB 30MG 2 QL (180 / 30), PA BOSULIF TAB 100MG 2 QL (120 tabs / 30 days) BOSULIF TAB 500MG 2 QL (30 tabs / 30 days) CABOMETYX TAB 20MG 2 QL (30 tabs / 30 days),

PA CABOMETYX TAB 40MG 2 QL (30 tabs / 30 days),

PA CABOMETYX TAB 60MG 2 QL (30 tabs / 30 days),

PA CAPRELSA TAB 100MG 2 QL (60 tabs / 30 days) CAPRELSA TAB 300MG 2 QL (30 tabs / 30 days) COMETRIQ KIT 60MG 2 QL (1 box / 21 days), PA COMETRIQ KIT 100MG 2 QL (1 box / 21 days), PA COMETRIQ KIT 140MG 2 QL (1 box / 21 days), PA COTELLIC TAB 20MG 2 QL (63 tabs / 30 days),

PA


41

Drug Name Drug Tier Requirements/Limits GILOTRIF TAB 20MG 2 QL (30 tabs / 30 days) GILOTRIF TAB 30MG 2 QL (30 tabs / 30 days) GILOTRIF TAB 40MG 2 QL (30 tabs / 30 days) IBRANCE CAP 75MG 2 PA IBRANCE CAP 100MG 2 PA IBRANCE CAP 125MG 2 PA ICLUSIG TAB 15MG 2 QL (60 tabs / 30 days) ICLUSIG TAB 45MG 2 QL (30 tabs / 30 days) imatinib mesylate tab 100 mg (base

equivalent) 1 QL (90 tabs / 30 days)

imatinib mesylate tab 400 mg (base equivalent)


IMBRUVICA CAP 140MG 2 QL (120 caps / 30 days) INLYTA TAB 1MG 2 QL (180 tabs / 30 days) INLYTA TAB 5MG 2 QL (120 tabs / 30 days) IRESSA TAB 250MG 2 QL (30 tabs / 30 days) JAKAFI TAB 5MG 2 QL (60 tabs / 30 days) JAKAFI TAB 10MG 2 QL (60 tabs / 30 days) JAKAFI TAB 15MG 2 QL (60 tabs / 30 days) JAKAFI TAB 20MG 2 QL (60 tabs / 30 days) JAKAFI TAB 25MG 2 QL (60 tabs / 30 days) KISQALI TAB 200DOSE 2 QL (63 / 28), PA KISQALI TAB 400DOSE 2 QL (63 / 28), PA KISQALI TAB 600DOSE 2 QL (63 / 28), PA LENVIMA CAP 10 MG 2 QL (5 / 25 days), PA LENVIMA CAP 14 MG 2 QL (10 / 25 days), PA LENVIMA CAP 20 MG 2 QL (10 / 25 days), PA LENVIMA CAP 24 MG 2 QL (15 / 25 days), PA MEKINIST TAB 0.5MG 2 QL (30 tabs / 30 days) MEKINIST TAB 2MG 2 QL (30 tabs / 30 days) NERLYNX TAB 40MG 2 QL (180 tabs / 30 days),

PA NEXAVAR TAB 200MG 2 QL (120 tabs / 30 days) RYDAPT CAP 25MG 2 QL (224 / 28), PA SPRYCEL TAB 20MG 2 QL (30 tabs / 30 days) SPRYCEL TAB 50MG 2 QL (30 tabs / 30 days) SPRYCEL TAB 70MG 2 QL (30 tabs / 30 days) SPRYCEL TAB 80MG 2 QL (30 tabs / 30 days) SPRYCEL TAB 100MG 2 QL (30 tabs / 30 days) SPRYCEL TAB 140MG 2 QL (30 tabs / 30 days) STIVARGA TAB 40MG 2 QL (84 tabs / 25 days) SUTENT CAP 12.5MG 2 QL (90 caps / 30 days) SUTENT CAP 25MG 2 QL (30 caps / 30 days) SUTENT CAP 50MG 2 QL (30 caps / 30 days) TAFINLAR CAP 50MG 2 QL (120 caps / 30 days) TAFINLAR CAP 75MG 2 QL (120 caps / 30 days)


42

Drug Name Drug Tier Requirements/Limits TAGRISSO TAB 40MG 2 QL (30 tabs / 30 days),

PA TAGRISSO TAB 80MG 2 QL (30 tabs / 30 days),

PA TARCEVA TAB 25MG 2 QL (30 tabs / 30 days) TARCEVA TAB 100MG 2 QL (30 tabs / 30 days) TARCEVA TAB 150MG 2 QL (30 tabs / 30 days) TASIGNA CAP 150MG 2 QL (120 caps / 30 days) TASIGNA CAP 200MG 2 QL (120 caps / 30 days) TORISEL SOL 25MG/ML 2 TYKERB TAB 250MG 2 QL (180 tabs / 30 days),

PA VERZENIO TAB 50MG 2 QL (60 tabs / 30 days),




PA VOTRIENT TAB 200MG 2 QL (120 tabs / 30 days) XALKORI CAP 200MG 2 QL (60 caps / 30 days) XALKORI CAP 250MG 2 QL (60 caps / 30 days) ZELBORAF TAB 240MG 2 QL (240 tabs / 25 days) ZYDELIG TAB 100MG 2 QL (60 tabs / 30 days),

PA ZYDELIG TAB 150MG 2 QL (60 tabs / 30 days),

PA ZYKADIA CAP 150MG 2 QL (150 caps / 30

days), PA MISCELLANEOUS ABRAXANE INJ 100MG 2 amifostine for inj 500 mg 1 ARZERRA CON 100/5ML 2 AVASTIN INJ 2 AVASTIN INJ 400/16ML 2 bexarotene cap 75 mg 1 COSMEGEN INJ 0.5MG 3 PA daunorubicin hcl inj 5 mg/ml (base equiv) 1 dexrazoxane for inj 250 mg 1 dexrazoxane for inj 500 mg 1 docetaxel for inj conc 20 mg/ml 1 docetaxel for inj conc 80 mg/4ml (20

mg/ml) 1

DOCETAXEL INJ 20/0.5ML 3 PA DOCETAXEL INJ 20MG/2ML 3 DOCETAXEL INJ 80MG/2ML 3 PA


43

Drug Name Drug Tier Requirements/Limits DOCETAXEL INJ 80MG/8ML 3 DOCETAXEL INJ 140/7ML 3 DOCETAXEL INJ 160/8ML 3 DOCETAXEL INJ 160/16ML 3 DOCETAXEL INJ 200MG/20 3 DOCETAXEL INJ NON-ALCO 3 doxorubicin hcl for inj 10 mg 1 doxorubicin hcl for inj 50 mg 1 doxorubicin hcl inj 2 mg/ml 1 doxorubicin hcl liposomal inj (for iv

infusion) 2 mg/ml 1

DROXIA CAP 200MG 2 DROXIA CAP 300MG 2 DROXIA CAP 400MG 2 ELITEK INJ 1.5MG 2 ELITEK INJ 7.5MG 2 ELLENCE INJ 2MG/ML 3 PA EMPLICITI INJ 300MG 3 PA EMPLICITI INJ 400MG 3 PA epirubicin hcl iv soln 50 mg/25ml (2

mg/ml) 1

epirubicin hcl iv soln 200 mg/100ml (2 mg/ml)

1

ERBITUX INJ 100MG 2 ERBITUX INJ 200MG 2 ERIVEDGE CAP 150MG 2 QL (30 caps / 30 days) ETHYOL INJ 500MG 2 PA etoposide cap 50 mg 1 etoposide inj 1 gm/50ml (20 mg/ml) 1 etoposide inj 100 mg/5ml (20 mg/ml) 1 etoposide inj 500 mg/25ml (20 mg/ml) 1 FARYDAK CAP 10MG 2 PA FARYDAK CAP 15MG 2 PA FARYDAK CAP 20MG 2 PA HALAVEN INJ 1MG/2ML 3 PA HERCEPTIN INJ 150MG 2 PA HERCEPTIN INJ 440MG 2 PA HYDREA CAP 500MG 3 PA hydroxyurea cap 500 mg 1 IDAMYCIN PFS INJ 5MG/5ML 3 PA IDAMYCIN PFS INJ 10/10ML 3 PA IDAMYCIN PFS INJ 20/20ML 3 PA idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) 1 idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 1 idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) 1


44

Drug Name Drug Tier Requirements/Limits IDHIFA TAB 50MG 2 QL (30 tabs / 30 days),

PA IDHIFA TAB 100MG 2 QL (30 tabs / 30 days),

PA ISTODAX INJ 10MG 2 IXEMPRA KIT INJ 15MG 2 IXEMPRA KIT INJ 45MG 2 JEVTANA INJ 60/1.5ML 3 PA KADCYLA INJ 100MG 2 PA KADCYLA INJ 160MG 2 PA KEYTRUDA INJ 100MG/4M 3 PA KEYTRUDA SOL 50MG 3 PA KYPROLIS SOL 60MG 3 PA leucovorin calcium for inj 50 mg 1 leucovorin calcium for inj 100 mg 1 leucovorin calcium for inj 200 mg 1 leucovorin calcium for inj 350 mg 1 leucovorin calcium for inj 500 mg 1 leucovorin calcium tab 5 mg 1 leucovorin calcium tab 10 mg 1 leucovorin calcium tab 15 mg 1 leucovorin calcium tab 25 mg 1 LEVOLEUCOVOR SOL 250MG/25 2 levoleucovorin calcium for iv inj 50 mg

(base equiv) 1

levoleucovorin calcium inj 175 mg/17.5ml (base equiv)

1

LONSURF TAB 15-6.14 2 PA LONSURF TAB 20-8.19 2 PA LYNPARZA CAP 50MG 2 QL (480 caps / 30

days), PA LYSODREN TAB 500MG 2 MARQIBO INJ 5MG/31ML 2 MATULANE CAP 50MG 2 mesna inj 100 mg/ml 1 MESNEX INJ 1GM 3 PA MESNEX TAB 400MG 2 METASTRON INJ 3 PA mitomycin for iv soln 5 mg 1 mitomycin for iv soln 20 mg 1 mitomycin for iv soln 40 mg 1 mitoxantrone hcl inj conc 20 mg/10ml (2

mg/ml) 1

mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml)

1


45

Drug Name Drug Tier Requirements/Limits mitoxantrone hcl inj conc 30 mg/15ml (2

mg/ml) 1

NAVELBINE INJ 10MG/ML 3 PA NAVELBINE INJ 50MG/5ML 3 PA NINLARO CAP 2.3MG 2 QL (3 caps / 28 days),

PA NINLARO CAP 3MG 2 QL (3 caps / 28 days),

PA NINLARO CAP 4MG 2 QL (3 caps / 28 days),

PA NIPENT INJ 10MG 3 PA ODOMZO CAP 200MG 2 QL (30 caps / 30 days),

PA paclitaxel iv conc 30 mg/5ml (6 mg/ml) 1 paclitaxel iv conc 100 mg/16.7ml (6

mg/ml) 1

paclitaxel iv conc 150 mg/25ml (6 mg/ml) 1 paclitaxel iv conc 300 mg/50ml (6 mg/ml) 1 PERJETA INJ 420/14ML 2 PHOTOFRIN INJ 75MG 2 PORTRAZZA INJ 800/50ML 3 PA QUADRAMET INJ 3 RITUXAN INJ 100MG 2 PA RITUXAN INJ 500MG 2 PA RITUXAN INJ HYCELA 2 QL (4 vials / 30), PA RUBRACA TAB 200MG 2 QL (180 tabs / 30 days),

PA RUBRACA TAB 250MG 2 QL (120 tabs / 30 days),

PA RUBRACA TAB 300MG 2 QL (120 tabs / 30 days),

PA SYNRIBO INJ 3.5MG 3 PA TARGRETIN GEL 1% 2 TAXOTERE INJ 20MG/ML 3 PA TAXOTERE INJ 80MG/4ML 3 PA TENIPOSIDE INJ 50MG/5ML 2 tretinoin cap 10 mg 1 TRISENOX SOL 10MG/10M 2 UNITUXIN INJ 3 PA VECTIBIX INJ 100MG 2 VECTIBIX INJ 400MG 2 VENCLEXTA TAB 10MG 2 QL (60 tabs / 30 days),

PA VENCLEXTA TAB 50MG 2 QL (30 tabs / 30 days),

PA VENCLEXTA TAB 100MG 2 QL (120 tabs / 30 days),

PA


46

Drug Name Drug Tier Requirements/Limits VENCLEXTA TAB START PK 2 QL (1 box in lifetime),

PA vinblastine sulfate inj 1 mg/ml 1 vincristine sulfate iv soln 1 mg/ml 1 vinorelbine tartrate inj 10 mg/ml (base

equiv) 1

vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) (base equiv)

1

YERVOY INJ 50MG 3 PA YERVOY INJ 200MG 3 PA ZALTRAP INJ 100/4ML 3 PA ZALTRAP INJ 200/8ML 3 PA ZEVALIN KIT Y-90 2 ZINECARD INJ 250MG 3 PA ZINECARD INJ 500MG 3 PA ZOLINZA CAP 100MG 2 QL (120 caps / 30 days) TOPOISOMERASE INHIBITORS CAMPTOSAR INJ 40MG/2ML 3 PA CAMPTOSAR INJ 100/5ML 3 PA CAMPTOSAR INJ 300/15ML 3 PA irinotecan hcl inj 40 mg/2ml (20 mg/ml) 1 irinotecan hcl inj 100 mg/5ml (20 mg/ml) 1 irinotecan hcl inj 500 mg/25ml (20 mg/ml) 1 ONIVYDE INJ 4.3MG/ML 3 PA CARDIOVASCULAR ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine besylate-benazepril hcl cap 2.5-

10 mg 1

amlodipine besylate-benazepril hcl cap 5-10 mg

1


1


1


1


1

LOTREL CAP 5-10MG 3 PA, ST LOTREL CAP 5-20MG 3 PA, ST LOTREL CAP 10-20MG 3 PA, ST LOTREL CAP 10-40MG 3 PA, ST PRESTALIA TAB 3.5-2.5 3 ST PRESTALIA TAB 7-5MG 3 ST PRESTALIA TAB 14-10MG 3 ST TARKA TAB 1-240 CR 3 PA, ST


47

Drug Name Drug Tier Requirements/Limits TARKA TAB 2-180 CR 3 PA, ST TARKA TAB 2-240 CR 3 PA, ST TARKA TAB 4-240 CR 3 PA, ST trandolapril-verapamil hcl tab er 1-240 mg 1 trandolapril-verapamil hcl tab er 2-180 mg 1 trandolapril-verapamil hcl tab er 2-240 mg 1 trandolapril-verapamil hcl tab er 4-240 mg 1 ACE INHIBITOR/DIURETIC COMBINATIONS ACCURETIC TAB 10-12.5 3 PA, ST ACCURETIC TAB 20-12.5 3 PA, ST ACCURETIC TAB 20-25MG 3 PA, ST benazepril & hydrochlorothiazide tab 5-

6.25 mg 1

benazepril & hydrochlorothiazide tab 10-12.5 mg

1

benazepril & hydrochlorothiazide tab 20-12.5 mg

1

benazepril & hydrochlorothiazide tab 20-25 mg

1

captopril & hydrochlorothiazide tab 25-15 mg

1


1


1


1

enalapril maleate & hydrochlorothiazide tab 5-12.5 mg

1

enalapril maleate & hydrochlorothiazide tab 10-25 mg

1

fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg

1

fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg

1

lisinopril & hydrochlorothiazide tab 10-12.5 mg

1

lisinopril & hydrochlorothiazide tab 20-12.5 mg

1

lisinopril & hydrochlorothiazide tab 20-25 mg

1

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

mg 1


48

Drug Name Drug Tier Requirements/Limits moexipril-hydrochlorothiazide tab 15-12.5

mg 1

moexipril-hydrochlorothiazide tab 15-25 mg

1

quinapril-hydrochlorothiazide tab 10-12.5 mg

1

quinapril-hydrochlorothiazide tab 20-12.5 mg

1

quinapril-hydrochlorothiazide tab 20-25 mg1 VASERETIC TAB 10-25MG 3 PA, ST ZESTORETIC TAB 10-12.5 3 PA, ST ZESTORETIC TAB 20-12.5 3 PA, ST ZESTORETIC TAB 20-25MG 3 PA, ST ACE INHIBITORS ACCUPRIL TAB 5MG 3 PA, ST ACCUPRIL TAB 10MG 3 PA, ST ACCUPRIL TAB 20MG 3 PA, ST ACCUPRIL TAB 40MG 3 PA, ST ACEON TAB 4MG 3 PA, ST ACEON TAB 8MG 3 PA, ST ALTACE CAP 1.25MG 3 PA, ST ALTACE CAP 2.5MG 3 PA, ST ALTACE CAP 5MG 3 PA, ST ALTACE CAP 10MG 3 PA, ST benazepril hcl tab 5 mg 1 benazepril hcl tab 10 mg 1 benazepril hcl tab 20 mg 1 benazepril hcl tab 40 mg 1 captopril tab 12.5 mg 1 captopril tab 25 mg 1 captopril tab 50 mg 1 captopril tab 100 mg 1 enalapril maleate tab 2.5 mg 1 enalapril maleate tab 5 mg 1 enalapril maleate tab 10 mg 1 enalapril maleate tab 20 mg 1 enalaprilat iv inj 1.25 mg/ml 1 EPANED SOL 1MG/ML 3 PA fosinopril sodium tab 10 mg 1 fosinopril sodium tab 20 mg 1 fosinopril sodium tab 40 mg 1 lisinopril tab 2.5 mg 1 lisinopril tab 5 mg 1 lisinopril tab 10 mg 1 lisinopril tab 20 mg 1 lisinopril tab 30 mg 1


49

Drug Name Drug Tier Requirements/Limits lisinopril tab 40 mg 1 LOTENSIN TAB 10MG 3 PA, ST LOTENSIN TAB 20MG 3 PA, ST LOTENSIN TAB 40MG 3 PA, ST MAVIK TAB 1MG 3 PA, ST MAVIK TAB 2MG 3 PA, ST moexipril hcl tab 7.5 mg 1 moexipril hcl tab 15 mg 1 perindopril erbumine tab 2 mg 1 perindopril erbumine tab 4 mg 1 perindopril erbumine tab 8 mg 1 quinapril hcl tab 5 mg 1 quinapril hcl tab 10 mg 1 quinapril hcl tab 20 mg 1 quinapril hcl tab 40 mg 1 ramipril cap 1.25 mg 1 ramipril cap 2.5 mg 1 ramipril cap 5 mg 1 ramipril cap 10 mg 1 trandolapril tab 1 mg 1 trandolapril tab 2 mg 1 trandolapril tab 4 mg 1 VASOTEC TAB 2.5MG 3 PA, ST VASOTEC TAB 5MG 3 PA, ST VASOTEC TAB 10MG 3 PA, ST VASOTEC TAB 20MG 3 PA, ST ZESTRIL TAB 2.5MG 3 PA, ST ZESTRIL TAB 5MG 3 PA, ST ZESTRIL TAB 10MG 3 PA, ST ZESTRIL TAB 20MG 3 PA, ST ZESTRIL TAB 30MG 3 PA, ST ZESTRIL TAB 40MG 3 PA, ST ADRENOLYTICS, CENTRAL CATAPRES TAB 0.1MG 3 PA, ST CATAPRES TAB 0.2MG 3 PA, ST CATAPRES TAB 0.3MG 3 PA, ST CATAPRES-TTS DIS 0.1/24HR 3 PA, ST CATAPRES-TTS DIS 0.2/24HR 3 PA, ST CATAPRES-TTS DIS 0.3/24HR 3 PA, ST clonidine hcl tab 0.1 mg 1 clonidine hcl tab 0.2 mg 1 clonidine hcl tab 0.3 mg 1 clonidine hcl td patch weekly 0.1 mg/24hr 1 clonidine hcl td patch weekly 0.2 mg/24hr 1 clonidine hcl td patch weekly 0.3 mg/24hr 1


50

Drug Name Drug Tier Requirements/Limits guanfacine hcl tab 1 mg 1 guanfacine hcl tab 2 mg 1 TENEX TAB 1MG 3 PA, ST TENEX TAB 2MG 3 PA, ST AGENTS FOR PHEOCHROMOCYTOMA DEMSER CAP 250MG 2 phenoxybenzamine hcl cap 10 mg 1 PHENTOLAMINE INJ 5MG 2 ALDOSTERONE RECEPTOR ANTAGONISTS ALDACTONE TAB 25MG 3 PA ALDACTONE TAB 50MG 3 PA ALDACTONE TAB 100MG 3 PA eplerenone tab 25 mg 1 eplerenone tab 50 mg 1 INSPRA TAB 25MG 3 PA INSPRA TAB 50MG 3 PA spironolactone tab 25 mg 1 spironolactone tab 50 mg 1 spironolactone tab 100 mg 1 ALPHA BLOCKERS CARDURA TAB 1MG 3 PA, ST CARDURA TAB 2MG 3 PA, ST CARDURA TAB 4MG 3 PA, ST CARDURA TAB 8MG 3 PA, ST doxazosin mesylate tab 1 mg 1 doxazosin mesylate tab 2 mg 1 doxazosin mesylate tab 4 mg 1 doxazosin mesylate tab 8 mg 1 MINIPRESS CAP 1MG 3 PA MINIPRESS CAP 2MG 3 PA MINIPRESS CAP 5MG 3 PA prazosin hcl cap 1 mg 1 prazosin hcl cap 2 mg 1 prazosin hcl cap 5 mg 1 terazosin hcl cap 1 mg 1 terazosin hcl cap 2 mg 1 terazosin hcl cap 5 mg 1 terazosin hcl cap 10 mg 1 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL

BLOCKER COMBINATIONS amlodipine besylate-olmesartan medoxomil

tab 5-20 mg 1 ST

amlodipine besylate-olmesartan medoxomil tab 5-40 mg

1 ST


51

Drug Name Drug Tier Requirements/Limits amlodipine besylate-olmesartan medoxomil

tab 10-20 mg 1 ST

amlodipine besylate-olmesartan medoxomil tab 10-40 mg

1 ST

amlodipine besylate-valsartan tab 5-160 mg








AZOR TAB 5-20MG 3 PA, ST AZOR TAB 5-40MG 3 PA, ST AZOR TAB 10-20MG 3 PA, ST AZOR TAB 10-40MG 3 PA, ST EXFORGE TAB 5-160MG 3 QL (30 tabs / 30 days),

PA, ST EXFORGE TAB 5-320MG 3 QL (30 tabs / 30 days),



PA, ST telmisartan-amlodipine tab 40-5 mg 1 telmisartan-amlodipine tab 40-10 mg 1 telmisartan-amlodipine tab 80-5 mg 1 telmisartan-amlodipine tab 80-10 mg 1 TWYNSTA TAB 40-5MG 3 PA, ST TWYNSTA TAB 40-10MG 3 PA, ST TWYNSTA TAB 80-5MG 3 PA, ST TWYNSTA TAB 80-10MG 3 PA, ST ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL

BLOCKER/DIURETIC COMBINATIONS amlodipine-valsartan-hydrochlorothiazide

tab 5-160-12.5 mg 1 QL (30 tabs / 30 days)

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


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






EXFORGEH/5- TAB 160-12.5 3 QL (30 tabs / 30 days), PA, ST


52

Drug Name Drug Tier Requirements/Limits EXFORGEH/5- TAB 160-25 3 QL (30 tabs / 30 days),

PA, ST EXFORGEH/10- TAB 160-12.5 3 QL (30 tabs / 30 days),

PA, ST EXFORGEH/10- TAB 160-25 3 QL (30 tabs / 30 days),

PA, ST EXFORGEH/10- TAB 320-25 3 QL (30 tabs / 30 days),

PA, ST olmesartan-amlodipine-hydrochlorothiazide

tab 40-5-12.5 mg 1 ST

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

1 ST

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

1 ST

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

1 ST

TRIBENZOR20- TAB 5-12.5MG 3 ST TRIBENZOR40- TAB 5-12.5MG 3 PA, ST TRIBENZOR40- TAB 5-25MG 3 PA, ST TRIBENZOR40- TAB 10-12.5 3 PA, ST TRIBENZOR40- TAB 10-25MG 3 PA, ST ANGIOTENSIN II RECEPTOR ANTAGONIST/DIURETIC

COMBINATIONS ATACAND HCT TAB 16-12.5 3 PA, ST ATACAND HCT TAB 32-12.5 3 PA, ST ATACAND HCT TAB 32-25MG 3 PA, ST AVALIDE TAB 150-12.5 3 PA, ST AVALIDE TAB 300-12.5 3 PA, ST BENICAR HCT TAB 20-12.5 3 PA, ST BENICAR HCT TAB 40-12.5 3 PA, ST BENICAR HCT TAB 40-25MG 3 PA, ST candesartan cilexetil-hydrochlorothiazide

tab 16-12.5 mg 1

candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg

1

candesartan cilexetil-hydrochlorothiazide tab 32-25 mg

1

DIOVAN HCT TAB 80/12.5 3 PA, ST DIOVAN HCT TAB 160-12.5 3 PA, ST DIOVAN HCT TAB 160-25MG 3 PA, ST DIOVAN HCT TAB 320-12.5 3 PA, ST DIOVAN HCT TAB 320-25MG 3 PA, ST EDARBYCLOR TAB 40-12.5 3 ST EDARBYCLOR TAB 40-25MG 3 ST HYZAAR TAB 50-12.5 3 PA, ST HYZAAR TAB 100-12.5 3 PA, ST HYZAAR TAB 100-25 3 PA, ST


53

Drug Name Drug Tier Requirements/Limits irbesartan-hydrochlorothiazide tab 150-

12.5 mg 1

irbesartan-hydrochlorothiazide tab 300-12.5 mg

1

losartan potassium & hydrochlorothiazide tab 50-12.5 mg

1

losartan potassium & hydrochlorothiazide tab 100-12.5 mg

1

losartan potassium & hydrochlorothiazide tab 100-25 mg

1

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

tab 20-12.5 mg 1 ST

olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg

1 ST

olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg

1 ST

telmisartan-hydrochlorothiazide tab 40-12.5 mg

1

telmisartan-hydrochlorothiazide tab 80-12.5 mg

1

telmisartan-hydrochlorothiazide tab 80-25 mg

1

valsartan-hydrochlorothiazide tab 80-12.5 mg

1


1

valsartan-hydrochlorothiazide tab 160-25 mg

1


1

valsartan-hydrochlorothiazide tab 320-25 mg

1

ANGIOTENSIN II RECEPTOR ANTAGONISTS ATACAND TAB 4MG 3 PA, ST ATACAND TAB 8MG 3 PA, ST ATACAND TAB 16MG 3 PA, ST ATACAND TAB 32MG 3 PA, ST AVAPRO TAB 75MG 3 PA, ST AVAPRO TAB 150MG 3 PA, ST AVAPRO TAB 300MG 3 PA, ST BENICAR TAB 5MG 3 PA, ST BENICAR TAB 20MG 3 PA, ST BENICAR TAB 40MG 3 PA, ST candesartan cilexetil tab 4 mg 1


54

Drug Name Drug Tier Requirements/Limits candesartan cilexetil tab 8 mg 1 candesartan cilexetil tab 16 mg 1 candesartan cilexetil tab 32 mg 1 COZAAR TAB 25MG 3 PA, ST COZAAR TAB 50MG 3 PA, ST COZAAR TAB 100MG 3 PA, ST DIOVAN TAB 40MG 3 QL (60 tabs / 30 days),

PA, ST DIOVAN TAB 80MG 3 QL (60 tabs / 30 days),



PA, ST EDARBI TAB 40MG 3 ST EDARBI TAB 80MG 3 ST eprosartan mesylate tab 600 mg 1 irbesartan tab 75 mg 1 irbesartan tab 150 mg 1 irbesartan tab 300 mg 1 losartan potassium tab 25 mg 1 losartan potassium tab 50 mg 1 losartan potassium tab 100 mg 1 MICARDIS TAB 20MG 3 PA, ST MICARDIS TAB 40MG 3 PA, ST MICARDIS TAB 80MG 3 PA, ST olmesartan medoxomil tab 5 mg 1 ST olmesartan medoxomil tab 20 mg 1 ST olmesartan medoxomil tab 40 mg 1 ST telmisartan tab 20 mg 1 telmisartan tab 40 mg 1 telmisartan tab 80 mg 1 valsartan tab 40 mg 1 QL (60 tabs / 30 days) valsartan tab 80 mg 1 QL (60 tabs / 30 days) valsartan tab 160 mg 1 QL (60 tabs / 30 days) valsartan tab 320 mg 1 QL (60 tabs / 30 days) ANTIARRHYTHMICS ADENOCARD INJ 3MG/ML 3 PA ADENOCARD INJ 12MG/4ML 3 PA adenosine iv soln 6 mg/2ml 1 adenosine iv soln 12 mg/4ml 1 amiodarone hcl inj 150 mg/3ml (50

mg/ml) 1 PA

amiodarone hcl inj 450 mg/9ml (50 mg/ml)

1


55

Drug Name Drug Tier Requirements/Limits amiodarone hcl inj 900 mg/18ml (50

mg/ml) 1

amiodarone hcl tab 100 mg 1 amiodarone hcl tab 200 mg 1 amiodarone hcl tab 400 mg 1 BETAPACE AF TAB 80MG 3 PA, ST BETAPACE AF TAB 120MG 3 PA, ST BETAPACE AF TAB 160MG 3 PA, ST BETAPACE TAB 80MG 3 PA, ST BETAPACE TAB 120MG 3 PA, ST BETAPACE TAB 160MG 3 PA, ST CORDARONE TAB 200MG 3 PA CORVERT INJ 1MG/10ML 3 PA disopyramide phosphate cap 100 mg 1 disopyramide phosphate cap 150 mg 1 dofetilide cap 125 mcg (0.125 mg) 1 dofetilide cap 250 mcg (0.25 mg) 1 dofetilide cap 500 mcg (0.5 mg) 1 flecainide acetate tab 50 mg 1 flecainide acetate tab 100 mg 1 flecainide acetate tab 150 mg 1 ibutilide fumarate inj 1 mg/10ml 1 lidocaine hcl iv inj 10 mg/ml 1 lidocaine hcl iv inj 20 mg/ml 1 lidocaine iv infusion in d5w inj 4 mg/ml 1 lidocaine iv infusion in d5w inj 8 mg/ml 1 MULTAQ TAB 400MG 3 PA NEXTERONE INJ 3 PA NORPACE CAP 100MG 3 PA NORPACE CAP 100MG CR 3 PA NORPACE CAP 150MG 3 PA NORPACE CAP 150MG CR 3 PA propafenone hcl cap er 12hr 225 mg 1 propafenone hcl cap er 12hr 325 mg 1 propafenone hcl cap er 12hr 425 mg 1 propafenone hcl tab 150 mg 1 propafenone hcl tab 225 mg 1 propafenone hcl tab 300 mg 1 RYTHMOL SR CAP 225MG 3 PA RYTHMOL SR CAP 325MG 3 PA RYTHMOL SR CAP 425MG 3 PA RYTHMOL TAB 225MG 3 PA sotalol hcl (afib/afl) tab 80 mg 1 sotalol hcl (afib/afl) tab 120 mg 1 sotalol hcl (afib/afl) tab 160 mg 1 SOTALOL HCL INJ 150/10ML 3 PA


56

Drug Name Drug Tier Requirements/Limits sotalol hcl tab 80 mg 1 sotalol hcl tab 120 mg 1 sotalol hcl tab 160 mg 1 sotalol hcl tab 240 mg 1 SOTYLIZE SOL 5MG/ML 3 PA XYLOCAINE INJ 2% 3 PA ANTILIPEMICS, BILE ACID RESINS cholestyramine light powder 4 gm/dose 1 cholestyramine light powder packets 4 gm 1 cholestyramine powder 4 gm/dose 1 cholestyramine powder packets 4 gm 1 COLESTID GRA 5GM 3 PA, ST COLESTID POW 5GM 3 PA, ST COLESTID TAB 1GM 3 PA, ST colestipol hcl granule packets 5 gm 1 colestipol hcl granules 5 gm 1 colestipol hcl tab 1 gm 1 QUESTRAN POW 4GM 3 PA, ST QUESTRAN POW 4GM LITE 3 PA, ST WELCHOL PAK 3.75GM 3 ST WELCHOL TAB 625MG 3 ST ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITORS ezetimibe tab 10 mg 1 PA ZETIA TAB 10MG 3 PA ANTILIPEMICS, FIBRATES ANTARA CAP 30MG 3 ST ANTARA CAP 90MG 3 ST choline fenofibrate cap dr 45 mg (fenofibric

acid equiv) 1

choline fenofibrate cap dr 135 mg (fenofibric acid equiv)

1

fenofibrate cap 50 mg 1 fenofibrate cap 150 mg 1 fenofibrate micronized cap 43 mg 1 fenofibrate micronized cap 67 mg 1 fenofibrate micronized cap 130 mg 1 fenofibrate micronized cap 134 mg 1 fenofibrate micronized cap 200 mg 1 fenofibrate tab 40 mg 1 fenofibrate tab 48 mg 1 fenofibrate tab 54 mg 1 fenofibrate tab 120 mg 1 ST fenofibrate tab 145 mg 1 fenofibrate tab 160 mg 1 fenofibric acid tab 35 mg 1


57

Drug Name Drug Tier Requirements/Limits fenofibric acid tab 105 mg 1 FENOGLIDE TAB 40MG 3 PA, ST FENOGLIDE TAB 120MG 3 PA, ST FIBRICOR TAB 35MG 3 PA, ST FIBRICOR TAB 105MG 3 PA, ST gemfibrozil tab 600 mg 1 LIPOFEN CAP 50MG 3 PA, ST LIPOFEN CAP 150MG 3 PA, ST LOFIBRA CAP 67MG 3 PA, ST LOFIBRA CAP 134MG 3 PA, ST LOFIBRA CAP 200MG 3 PA, ST LOFIBRA TAB 54MG 3 PA, ST LOFIBRA TAB 160MG 3 PA, ST LOPID TAB 600MG 3 PA, ST TRICOR TAB 48MG 3 PA, ST TRICOR TAB 145MG 3 PA, ST TRIGLIDE TAB 160MG 3 ST TRILIPIX CAP 45MG 3 PA, ST TRILIPIX CAP 135MG 3 PA, ST ANTILIPEMICS, HMG-COA REDUCTASE

INHIBITORS/COMBINATIONS ALTOPREV TAB 20MG ER 3 ST ALTOPREV TAB 40MG ER 3 ST ALTOPREV TAB 60MG ER 3 ST atorvastatin calcium tab 10 mg (base

equivalent) 1

atorvastatin calcium tab 20 mg (base equivalent)

1


1


1

CRESTOR TAB 5MG 3 PA, ST CRESTOR TAB 10MG 3 PA, ST CRESTOR TAB 20MG 3 PA, ST CRESTOR TAB 40MG 3 PA, ST ezetimibe-simvastatin tab 10-10 mg 1 PA ezetimibe-simvastatin tab 10-20 mg 1 PA ezetimibe-simvastatin tab 10-40 mg 1 PA ezetimibe-simvastatin tab 10-80 mg 1 PA fluvastatin sodium cap 20 mg 1 fluvastatin sodium cap 40 mg 1 fluvastatin sodium tab er 24 hr 80 mg 1 LESCOL XL TAB 80MG 3 PA, ST LIPITOR TAB 10MG 3 PA, ST LIPITOR TAB 20MG 3 PA, ST


58

Drug Name Drug Tier Requirements/Limits LIPITOR TAB 40MG 3 PA, ST LIPITOR TAB 80MG 3 PA, ST LIVALO TAB 1MG 3 ST LIVALO TAB 2MG 3 ST LIVALO TAB 4MG 3 ST lovastatin tab 10 mg 1 lovastatin tab 20 mg 1 lovastatin tab 40 mg 1 PRAVACHOL TAB 20MG 3 PA, ST PRAVACHOL TAB 40MG 3 PA, ST PRAVACHOL TAB 80MG 3 PA, ST pravastatin sodium tab 10 mg 1 pravastatin sodium tab 20 mg 1 pravastatin sodium tab 40 mg 1 pravastatin sodium tab 80 mg 1 rosuvastatin calcium tab 5 mg 1 ST rosuvastatin calcium tab 10 mg 1 ST rosuvastatin calcium tab 20 mg 1 ST rosuvastatin calcium tab 40 mg 1 ST simvastatin tab 5 mg 1 simvastatin tab 10 mg 1 simvastatin tab 20 mg 1 simvastatin tab 40 mg 1 simvastatin tab 80 mg 1 VYTORIN TAB 10-10MG 3 PA VYTORIN TAB 10-20MG 3 PA VYTORIN TAB 10-40MG 3 PA VYTORIN TAB 10-80MG 3 PA ZOCOR TAB 5MG 3 PA, ST ZOCOR TAB 10MG 3 PA, ST ZOCOR TAB 20MG 3 PA, ST ZOCOR TAB 40MG 3 PA, ST ZOCOR TAB 80MG 3 PA, ST ANTILIPEMICS, MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN

INHIBITORS JUXTAPID CAP 5MG 2 QL (30 caps / 30 days),

PA JUXTAPID CAP 10MG 2 QL (30 caps / 30 days),




PA


59

Drug Name Drug Tier Requirements/Limits JUXTAPID CAP 60MG 2 QL (30 caps / 30 days),

PA ANTILIPEMICS, MISCELLANEOUS KYNAMRO INJ 200MG/ML 3 QL (4 / 21 days), PA ANTILIPEMICS, NIACINS/COMBINATIONS niacin tab er 500 mg (antihyperlipidemic) 1 niacin tab er 750 mg (antihyperlipidemic) 1 niacin tab er 1000 mg (antihyperlipidemic) 1 niacor tab 500mg 1 NIASPAN TAB 500MG ER 3 PA, ST NIASPAN TAB 750MG ER 3 PA, ST NIASPAN TAB 1000 ER 3 PA, ST ANTILIPEMICS, OMEGA-3 FATTY ACIDS LOVAZA CAP 1GM 3 PA, ST omega-3-acid ethyl esters cap 1 gm 1 VASCEPA CAP 0.5GM 3 ST VASCEPA CAP 1GM 3 ST ANTILIPEMICS, PCSK9 INHIBITORS PRALUENT INJ 75MG/ML 3 QL (2 / 21 days), PA PRALUENT INJ 150MG/ML 3 QL (2 / 21 days), PA REPATHA INJ 140MG/ML 3 QL (2 / 21 days), PA REPATHA SURE INJ 140MG/ML 3 QL (2 / 21 days), PA BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone tab 50-25 mg 1 atenolol & chlorthalidone tab 100-25 mg 1 bisoprolol & hydrochlorothiazide tab 2.5-

6.25 mg 1

bisoprolol & hydrochlorothiazide tab 5-6.25 mg

1

bisoprolol & hydrochlorothiazide tab 10-6.25 mg

1

CORZIDE TAB 40-5MG 3 PA, ST CORZIDE TAB 80-5MG 3 PA, ST DUTOPROL TAB 25-12.5 3 ST DUTOPROL TAB 50-12.5 3 ST DUTOPROL TAB 100-12.5 3 ST LOPRESS HCT TAB 50-25MG 3 PA, ST LOPRESS HCT TAB 100-25MG 3 PA, ST metoprolol & hydrochlorothiazide tab 50-

25 mg 1

metoprolol & hydrochlorothiazide tab 100-25 mg

1

metoprolol & hydrochlorothiazide tab 100-50 mg

1

nadolol & bendroflumethiazide tab 40-5 mg1 nadolol & bendroflumethiazide tab 80-5 mg1


60

Drug Name Drug Tier Requirements/Limits propranolol & hydrochlorothiazide tab 40-

25 mg 1

propranolol & hydrochlorothiazide tab 80-25 mg

1

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


61

Drug Name Drug Tier Requirements/Limits INDERAL LA CAP 160MG 3 PA, ST INDERAL XL CAP 80MG 3 ST INDERAL XL CAP 120MG 3 ST KERLONE TAB 10MG 3 PA, ST KERLONE TAB 20MG 3 PA, ST labetalol hcl iv soln 5 mg/ml 1 labetalol hcl tab 100 mg 1 labetalol hcl tab 200 mg 1 labetalol hcl tab 300 mg 1 LEVATOL TAB 20MG 3 ST LOPRESSOR TAB 50MG 3 PA, ST LOPRESSOR TAB 100MG 3 PA, ST metoprolol succinate tab er 24hr 25 mg

(tartrate equiv) 1

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

1


1


1

metoprolol tartrate iv soln 5 mg/5ml 1 metoprolol tartrate tab 25 mg 1 metoprolol tartrate tab 50 mg 1 metoprolol tartrate tab 75 mg 1 metoprolol tartrate tab 100 mg 1 nadolol tab 20 mg 1 nadolol tab 40 mg 1 nadolol tab 80 mg 1 pindolol tab 5 mg 1 pindolol tab 10 mg 1 propranolol hcl cap er 24hr 60 mg 1 propranolol hcl cap er 24hr 80 mg 1 propranolol hcl cap er 24hr 120 mg 1 propranolol hcl cap er 24hr 160 mg 1 propranolol hcl inj 1 mg/ml 1 propranolol hcl oral soln 20 mg/5ml 1 propranolol hcl oral soln 40 mg/5ml 1 propranolol hcl tab 10 mg 1 propranolol hcl tab 20 mg 1 propranolol hcl tab 40 mg 1 propranolol hcl tab 60 mg 1 propranolol hcl tab 80 mg 1 SECTRAL CAP 200MG 3 PA, ST SECTRAL CAP 400MG 3 PA, ST TENORMIN TAB 25MG 3 PA, ST TENORMIN TAB 50MG 3 PA, ST


62

Drug Name Drug Tier Requirements/Limits TENORMIN TAB 100MG 3 PA, ST timolol maleate tab 5 mg 1 timolol maleate tab 10 mg 1 timolol maleate tab 20 mg 1 TOPROL XL TAB 25MG 3 PA, ST TOPROL XL TAB 50MG 3 PA, ST TOPROL XL TAB 100MG 3 PA, ST TOPROL XL TAB 200MG 3 PA, ST ZEBETA TAB 5MG 3 PA, ST CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine besylate-atorvastatin calcium

tab 2.5-10 mg 1

amlodipine besylate-atorvastatin calcium tab 2.5-20 mg

1

amlodipine besylate-atorvastatin calcium tab 2.5-40 mg

1

amlodipine besylate-atorvastatin calcium tab 5-10 mg

1 PA


1


1


1


1


1


1


1

CADUET TAB 2.5-10MG 3 PA CADUET TAB 2.5-20MG 3 PA CADUET TAB 2.5-40MG 3 PA CADUET TAB 5-10MG 3 PA CADUET TAB 5-20MG 3 PA CADUET TAB 5-40MG 3 PA CADUET TAB 5-80MG 3 PA CADUET TAB 10-10MG 3 PA CADUET TAB 10-20MG 3 PA CADUET TAB 10-40MG 3 PA CADUET TAB 10-80MG 3 PA CALCIUM CHANNEL BLOCKERS, DIHYDROPYRIDINES ADALAT CC TAB 30MG ER 3 PA, ST ADALAT CC TAB 60MG ER 3 PA, ST


63

Drug Name Drug Tier Requirements/Limits ADALAT CC TAB 90MG ER 3 PA, ST amlodipine besylate tab 2.5 mg 1 amlodipine besylate tab 5 mg 1 amlodipine besylate tab 10 mg 1 CARDENE IV INJ 40/200ML 3 PA CARDENE IV SOL 20/200ML 3 PA CLEVIPREX EMU 0.5MG/ML 3 PA felodipine tab er 24hr 2.5 mg 1 felodipine tab er 24hr 5 mg 1 felodipine tab er 24hr 10 mg 1 isradipine cap 2.5 mg 1 isradipine cap 5 mg 1 nicardipine hcl cap 20 mg 1 nicardipine hcl cap 30 mg 1 nicardipine hcl iv soln 2.5 mg/ml 1 nifedipine tab er 24hr 30 mg 1 nifedipine tab er 24hr 60 mg 1 nifedipine tab er 24hr 90 mg 1 nifedipine tab er 24hr osmotic release 30

mg 1

nifedipine tab er 24hr osmotic release 60 mg

1

nifedipine tab er 24hr osmotic release 90 mg

1

nimodipine cap 30 mg 1 nisoldipine tab er 24hr 8.5 mg 1 nisoldipine tab er 24hr 17 mg 1 nisoldipine tab er 24hr 20 mg 1 nisoldipine tab er 24hr 25.5 mg 1 nisoldipine tab er 24hr 30 mg 1 nisoldipine tab er 24hr 34 mg 1 nisoldipine tab er 24hr 40 mg 1 NORVASC TAB 2.5MG 3 PA, ST NORVASC TAB 5MG 3 PA, ST NORVASC TAB 10MG 3 PA, ST NYMALIZE SOL 60/20ML 3 ST PROCARDIA XL TAB 30MG CR 3 PA, ST PROCARDIA XL TAB 60MG CR 3 PA, ST PROCARDIA XL TAB 90MG CR 3 PA, ST SULAR TAB 8.5MG 3 PA, ST SULAR TAB 17MG 3 PA, ST SULAR TAB 34MG 3 PA, ST CALCIUM CHANNEL BLOCKERS, NON DIHYDROPYRIDINES CALAN SR TAB 120MG 3 PA, ST CALAN SR TAB 180MG 3 PA, ST CALAN SR TAB 240MG 3 PA, ST


64

Drug Name Drug Tier Requirements/Limits CALAN TAB 80MG 3 PA, ST CALAN TAB 120MG 3 PA, ST CARDIZEM CD CAP 120MG/24 3 PA, ST CARDIZEM CD CAP 180MG/24 3 PA, ST CARDIZEM CD CAP 240MG/24 3 PA, ST CARDIZEM CD CAP 300MG/24 3 PA, ST CARDIZEM CD CAP 360MG/24 3 PA, ST CARDIZEM LA TAB 120MG 3 ST CARDIZEM LA TAB 180MG 3 PA, ST CARDIZEM LA TAB 240MG 3 PA, ST CARDIZEM LA TAB 300MG/24 3 PA, ST CARDIZEM LA TAB 360MG 3 PA, ST CARDIZEM LA TAB 420MG/24 3 PA, ST CARDIZEM TAB 30MG 3 PA, ST CARDIZEM TAB 60MG 3 PA, ST CARDIZEM TAB 120MG 3 PA, ST diltiazem cap 240mg cd 1 diltiazem cap 300mg cd 1 diltiazem hcl cap er 12hr 60 mg 1 diltiazem hcl cap er 12hr 90 mg 1 diltiazem hcl cap er 12hr 120 mg 1 diltiazem hcl cap er 24hr 120 mg 1 diltiazem hcl cap er 24hr 180 mg 1 diltiazem hcl cap er 24hr 240 mg 1 diltiazem hcl coated beads cap er 24hr 120

mg 1

diltiazem hcl coated beads cap er 24hr 180 mg

1

diltiazem hcl coated beads cap er 24hr 360 mg

1

diltiazem hcl extended release beads cap er 24hr 120 mg

1


1


1


1


1


1

diltiazem hcl iv soln 25 mg/5ml (5 mg/ml) 1 diltiazem hcl iv soln 50 mg/10ml (5

mg/ml) 1

diltiazem hcl iv soln 125 mg/25ml (5 mg/ml)

1


65

Drug Name Drug Tier Requirements/Limits diltiazem hcl tab 30 mg 1 diltiazem hcl tab 60 mg 1 diltiazem hcl tab 90 mg 1 diltiazem hcl tab 120 mg 1 DILTIAZEM INJ 100MG 3 matzim la tab 180mg/24 1 matzim la tab 240mg/24 1 matzim la tab 300mg/24 1 matzim la tab 360mg/24 1 matzim la tab 420mg/24 1 TIAZAC CAP 120MG/24 3 PA, ST TIAZAC CAP 180MG/24 3 PA, ST TIAZAC CAP 240MG/24 3 PA, ST TIAZAC CAP 300MG/24 3 PA, ST TIAZAC CAP 360MG/24 3 PA, ST TIAZAC CAP 420MG/24 3 PA, ST verapamil hcl cap er 24hr 100 mg 1 verapamil hcl cap er 24hr 120 mg 1 verapamil hcl cap er 24hr 180 mg 1 verapamil hcl cap er 24hr 200 mg 1 verapamil hcl cap er 24hr 240 mg 1 verapamil hcl cap er 24hr 300 mg 1 verapamil hcl cap er 24hr 360 mg 1 verapamil hcl iv soln 2.5 mg/ml 1 verapamil hcl tab 40 mg 1 verapamil hcl tab 80 mg 1 verapamil hcl tab 120 mg 1 verapamil hcl tab er 120 mg 1 verapamil hcl tab er 180 mg 1 verapamil hcl tab er 240 mg 1 VERELAN CAP 120MG SR 3 PA, ST VERELAN CAP 180MG SR 3 PA, ST VERELAN CAP 240MG SR 3 PA, ST VERELAN CAP 360MG SR 3 PA, ST VERELAN PM CAP 100MG ER 3 PA, ST VERELAN PM CAP 200MG ER 3 PA, ST VERELAN PM CAP 300MG ER 3 PA, ST DIGITALIS GLYCOSIDES digitek tab 0.25mg 1 digitek tab 0.125mg 1 digoxin inj 0.25 mg/ml 1 digoxin oral soln 0.05 mg/ml 1 LANOXIN INJ 0.25MG/1 3 PA LANOXIN PED INJ 0.1MG/ML 3 PA LANOXIN TAB 0.25MG 3 PA


66

Drug Name Drug Tier Requirements/Limits LANOXIN TAB 0.125MG 3 PA LANOXIN TAB 0.0625MG 3 PA LANOXIN TAB 0.1875MG 3 PA DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS TEKTURNA HCT TAB 150-12.5 3 PA TEKTURNA HCT TAB 150-25MG 3 PA TEKTURNA HCT TAB 300-12.5 3 PA TEKTURNA HCT TAB 300-25MG 3 PA TEKTURNA TAB 150MG 3 PA TEKTURNA TAB 300MG 3 PA DIURETICS ALDACTAZIDE TAB 25/25 3 PA ALDACTAZIDE TAB 50/50 3 PA amiloride & hydrochlorothiazide tab 5-50

mg 1

amiloride hcl tab 5 mg 1 bumetanide inj 0.25 mg/ml 1 bumetanide tab 0.5 mg 1 bumetanide tab 1 mg 1 bumetanide tab 2 mg 1 chlorothiazide sodium for inj 500 mg 1 chlorothiazide tab 250 mg 1 chlorothiazide tab 500 mg 1 chlorthalidone tab 25 mg 1 chlorthalidone tab 50 mg 1 DEMADEX TAB 10MG 3 PA DEMADEX TAB 20MG 3 PA DIURIL SUS 250/5ML 3 PA DYAZIDE CAP 37.5-25 3 PA DYRENIUM CAP 50MG 3 PA DYRENIUM CAP 100MG 3 PA EDECRIN TAB 25MG 3 PA, ST ethacrynate sodium for inj 50 mg 1 ethacrynic acid tab 25 mg 1 furosemide inj 10 mg/ml 1 furosemide oral soln 8 mg/ml 1 furosemide oral soln 10 mg/ml 1 furosemide tab 20 mg 1 furosemide tab 40 mg 1 furosemide tab 80 mg 1 hydrochlorothiazide cap 12.5 mg 1 hydrochlorothiazide tab 12.5 mg 1 hydrochlorothiazide tab 25 mg 1 hydrochlorothiazide tab 50 mg 1 indapamide tab 1.25 mg 1


67

Drug Name Drug Tier Requirements/Limits indapamide tab 2.5 mg 1 LASIX TAB 20MG 3 PA LASIX TAB 40MG 3 PA LASIX TAB 80MG 3 PA MAXZIDE TAB 75-50 3 PA MAXZIDE-25 TAB 3 PA methyclothiazide tab 5 mg 1 metolazone tab 2.5 mg 1 metolazone tab 5 mg 1 metolazone tab 10 mg 1 MICROZIDE CAP 12.5MG 3 PA SOD DIURIL INJ 500MG 3 PA SOD EDECRIN INJ 50MG 3 PA spironolactone & hydrochlorothiazide tab

25-25 mg 1

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

37.5-25 mg 1

triamterene & hydrochlorothiazide cap 50-25 mg

1

triamterene & hydrochlorothiazide tab 37.5-25 mg

1

triamterene & hydrochlorothiazide tab 75-50 mg

1

HEART FAILURE BIDIL TAB 3 PA CORLANOR TAB 5MG 2 QL (60 tabs / 30 days),

PA CORLANOR TAB 7.5MG 2 QL (60 tabs / 30 days),

PA ENTRESTO TAB 24-26MG 3 QL (60 tabs / 30 days),



PA MISCELLANEOUS alprostadil inj 500 mcg/ml 1 ASCLERA INJ 0.5% 3 PA ASCLERA INJ 1% 3 PA atropine sulfate inj 1 mg/ml 1 atropine sulfate inj 8 mg/20ml (0.4 mg/ml)1


68

Drug Name Drug Tier Requirements/Limits atropine sulfate preservative free (pf) inj

0.4 mg/0.5ml 1

atropine sulfate soln prefill syr 0.25 mg/5ml (0.05 mg/ml)

1

atropine sulfate soln prefill syr 1 mg/10ml (0.1 mg/ml)

1

cardioplegic soln 1 clorpres tab 0.1-15mg 1 ST clorpres tab 0.2-15mg 1 ST clorpres tab 0.3-15mg 1 ST CORLOPAM INJ 10MG/ML 3 PA ETHAMOLIN INJ 5% 3 PA fenoldopam mesylate iv inj 10 mg/ml

(base equiv) 1

fenoldopam mesylate iv inj 20 mg/2ml (base equiv)

1

hydralazine hcl inj 20 mg/ml 1 hydralazine hcl tab 10 mg 1 hydralazine hcl tab 25 mg 1 hydralazine hcl tab 50 mg 1 hydralazine hcl tab 100 mg 1 methyldopa & hydrochlorothiazide tab 250-

15 mg 1

methyldopa & hydrochlorothiazide tab 250-25 mg

1

methyldopa tab 250 mg 1 methyldopa tab 500 mg 1 methyldopate hcl inj 250 mg/5ml 1 midodrine hcl tab 2.5 mg 1 midodrine hcl tab 5 mg 1 midodrine hcl tab 10 mg 1 milrinone lactate in dextrose 5% iv soln 20

mg/100ml 1

milrinone lactate in dextrose 5% iv soln 40 mg/200ml

1

milrinone lactate iv soln 10 mg/10ml (base equivalent)

1


1


1

minoxidil tab 2.5 mg 1 minoxidil tab 10 mg 1 NATRECOR INJ 1.5MG 3 PA NEOPROFEN SOL 10MG/ML 3 PA niacin cap 500mg 1 OTC NIACIN FLUSH CAP FREE 2 OTC


69

Drug Name Drug Tier Requirements/Limits NITROPRESS INJ 25MG/ML 3 PA NORTHERA CAP 100MG 2 QL (540 caps in

lifetime), PA NORTHERA CAP 200MG 2 QL (180 caps / 30

days), PA NORTHERA CAP 300MG 2 QL (180 caps / 30

days), PA papaverine hcl inj 30 mg/ml 1 PLEGISOL SOL 3 PA PROSTIN VR INJ 500MCG 3 PA RANEXA TAB 500MG 3 PA RANEXA TAB 1000MG 3 PA SOTRADECOL INJ 1% 3 PA SOTRADECOL INJ 3% 3 PA VARITHENA AER 10MG/ML 3 PA NITRATES, INJECTABLE NITROGLYCER INJ 5MG/ML 3 nitroglycerin iv soln 100 mcg/ml in d5w 1 nitroglycerin iv soln 200 mcg/ml in d5w 1 nitroglycerin iv soln 400 mcg/ml in d5w 1 NITRONAL SOL 1MG/ML 3 PA NITRATES, ORAL DILATRATE SR CAP 40MG 3 PA ISORDIL TAB 5MG 3 PA ISORDIL TAB 40MG 3 PA isosorbide dinitrate tab 5 mg 1 isosorbide dinitrate tab 10 mg 1 isosorbide dinitrate tab 20 mg 1 isosorbide dinitrate tab 30 mg 1 isosorbide dinitrate tab er 40 mg 1 isosorbide mononitrate tab 10 mg 1 isosorbide mononitrate tab 20 mg 1 isosorbide mononitrate tab er 24hr 30 mg 1 isosorbide mononitrate tab er 24hr 60 mg 1 isosorbide mononitrate tab er 24hr 120 mg 1 nitro-time cap 2.5mg cr 1 nitro-time cap 6.5mg cr 1 nitro-time cap 9mg cr 1 NITRATES, SUBLINGUAL/TRANSLINGUAL nitroglycerin lingual aerosol 400 mcg/spray1 nitroglycerin sl tab 0.3 mg 1 nitroglycerin sl tab 0.4 mg 1 nitroglycerin sl tab 0.6 mg 1 nitroglycerin tl soln 0.4 mg/spray (400

mcg/spray) 1

NITROLINGUAL SPR PUMPSPRA 3 PA


70

Drug Name Drug Tier Requirements/Limits NITROMIST AER 400MCG 3 PA NITRATES, TRANSDERMAL NITRO-BID OIN 2% 3 NITRO-DUR DIS 0.3MG/HR 3 PA NITRO-DUR DIS 0.8MG/HR 3 PA nitroglycerin td patch 24hr 0.1 mg/hr 1 nitroglycerin td patch 24hr 0.2 mg/hr 1 nitroglycerin td patch 24hr 0.4 mg/hr 1 nitroglycerin td patch 24hr 0.6 mg/hr 1 PULMONARY ARTERIAL HYPERTENSION, ENDOTHELIN RECEPTOR

ANTAGONIST LETAIRIS TAB 5MG 2 QL (30 tabs / 30 days),

PA LETAIRIS TAB 10MG 2 QL (30 tabs / 30 days),

PA OPSUMIT TAB 10MG 2 QL (30 tabs / 30 days),

PA TRACLEER TAB 62.5MG 2 QL (60 tabs / 30 days),

PA TRACLEER TAB 125MG 2 QL (60 tabs / 30 days),

PA PULMONARY ARTERIAL HYPERTENSION, PHOSPHODIESTERASE

INHIBITOR ADCIRCA TAB 20MG 2 QL (60 tabs / 30 days),

PA REVATIO INJ 2 QL (1125 / 25 days), PA REVATIO SUS 10MG/ML 3 PA REVATIO TAB 20MG 3 QL (90 tabs / 30 days),

PA sildenafil citrate iv soln 10 mg/12.5ml

(base equivalent) 1 QL (1125 / 25 days), PA

sildenafil citrate tab 20 mg 1 QL (90 tabs / 30 days), PA

PULMONARY ARTERIAL HYPERTENSION, PROSTACYCLIN RECEPTOR AGONISTS

UPTRAVI TAB 200/800 3 PA UPTRAVI TAB 200MCG 3 PA UPTRAVI TAB 400MCG 3 PA UPTRAVI TAB 600MCG 3 PA UPTRAVI TAB 800MCG 3 PA UPTRAVI TAB 1000MCG 3 PA UPTRAVI TAB 1200MCG 3 PA UPTRAVI TAB 1400MCG 3 PA UPTRAVI TAB 1600MCG 3 PA


71

Drug Name Drug Tier Requirements/Limits PULMONARY ARTERIAL HYPERTENSION, PROSTAGLANDIN

VASODILATORS epoprostenol sodium for inj 0.5 mg 1 PA epoprostenol sodium for inj 1.5 mg 1 PA FLOLAN INJ 0.5MG 3 PA FLOLAN INJ 1.5MG 3 PA ORENITRAM TAB 0.25MG 3 QL (90 tabs / 30 days),

PA ORENITRAM TAB 0.125MG 3 QL (90 tabs / 30 days),

PA ORENITRAM TAB 1MG 3 QL (120 tabs / 30 days),

PA ORENITRAM TAB 2.5MG 3 QL (180 tabs / 30 days),

PA ORENITRAM TAB 5MG 3 PA REMODULIN INJ 1MG/ML 2 PA REMODULIN INJ 2.5MG/ML 2 REMODULIN INJ 5MG/ML 2 PA REMODULIN INJ 10MG/ML 2 PA TYVASO START SOL 0.6MG/ML 2 PA VELETRI INJ 0.5MG 3 PA VELETRI INJ 1.5MG 3 PA VENTAVIS SOL 10MCG/ML 2 PA VENTAVIS SOL 20MCG/ML 2 PA PULMONARY ARTERIAL HYPERTENSION, SOLUBLE GUANYLATE

CYCLASE STIMULATORS ADEMPAS TAB 0.5MG 2 QL (90 tabs / 30 days),

PA ADEMPAS TAB 1.5MG 2 QL (90 tabs / 30 days),

PA ADEMPAS TAB 1MG 2 QL (90 tabs / 30 days),

PA ADEMPAS TAB 2.5MG 2 QL (90 tabs / 30 days),

PA ADEMPAS TAB 2MG 2 QL (90 tabs / 30 days),

PA VASOPRESSORS dobutamine hcl inj 12.5 mg/ml 1 dobutamine inj 1 mg/ml in d5w 1 dobutamine inj 2 mg/ml in d5w 1 dobutamine inj 4 mg/ml in d5w 1 dopamine hcl inj 40 mg/ml 1 dopamine hcl inj 80 mg/ml 1 dopamine hcl inj 160 mg/ml 1 dopamine inj 0.8 mg/ml in d5w 1 dopamine inj 1.6 mg/ml in d5w 1


72

Drug Name Drug Tier Requirements/Limits dopamine inj 3.2 mg/ml in d5w 1 ephedrine sulfate inj 50 mg/ml 1 EPINEPHRINE INJ 1MG/ML 3 LEVOPHED INJ 1MG/ML 3 PA norepinephrine bitartrate iv soln 1 mg/ml 1 PHENYL/NACL INJ 1MG/10ML 2 PHENYLEPHRIN INJ 10MG/ML 3 PA phenylephrine hcl inj 10 mg/ml 1 VAZCULEP INJ 10MG/ML 3 PA CENTRAL NERVOUS SYSTEM ANTIANXIETY, BENZODIAZEPINES ALPRAZOLAM CON 1 MG/ML 3 alprazolam orally disintegrating tab 0.5 mg 1 alprazolam orally disintegrating tab 0.25

mg 1

alprazolam orally disintegrating tab 1 mg 1 alprazolam orally disintegrating tab 2 mg 1 alprazolam tab 0.5 mg 1 alprazolam tab 0.5mg xr 1 alprazolam tab 0.25 mg 1 alprazolam tab 1 mg 1 alprazolam tab 1mg xr 1 alprazolam tab 2 mg 1 alprazolam tab 2mg xr 1 alprazolam tab 3mg xr 1 ATIVAN INJ 2MG/ML 3 PA ATIVAN INJ 4MG/ML 3 PA ATIVAN TAB 0.5MG 3 PA ATIVAN TAB 1MG 3 PA ATIVAN TAB 2MG 3 PA chlordiazepoxide hcl cap 5 mg 1 chlordiazepoxide hcl cap 10 mg 1 chlordiazepoxide hcl cap 25 mg 1 clonazepam orally disintegrating tab 0.5

mg 1

clonazepam orally disintegrating tab 0.25 mg

1

clonazepam orally disintegrating tab 0.125 mg

1

clonazepam orally disintegrating tab 1 mg 1 clonazepam orally disintegrating tab 2 mg 1 clonazepam tab 0.5 mg 1 clonazepam tab 1 mg 1 clonazepam tab 2 mg 1 clorazepate dipotassium tab 3.75 mg 1 clorazepate dipotassium tab 7.5 mg 1


73

Drug Name Drug Tier Requirements/Limits clorazepate dipotassium tab 15 mg 1 diazepam con 5mg/ml 1 diazepam inj 5 mg/ml 1 DIAZEPAM INJ 10MG/2ML 3 diazepam oral soln 1 mg/ml 1 diazepam tab 2 mg 1 diazepam tab 5 mg 1 diazepam tab 10 mg 1 KLONOPIN TAB 0.5MG 3 PA, ST KLONOPIN TAB 1MG 3 PA, ST KLONOPIN TAB 2MG 3 PA, ST lorazepam conc 2 mg/ml 1 lorazepam inj 2 mg/ml 1 PA lorazepam inj 4 mg/ml 1 PA lorazepam tab 0.5 mg 1 lorazepam tab 1 mg 1 lorazepam tab 2 mg 1 oxazepam cap 10 mg 1 oxazepam cap 15 mg 1 oxazepam cap 30 mg 1 TRANXENE T TAB 7.5MG 3 PA VALIUM TAB 2MG 3 PA VALIUM TAB 5MG 3 PA VALIUM TAB 10MG 3 PA XANAX TAB 0.5MG 3 PA XANAX TAB 0.25MG 3 PA XANAX TAB 1MG 3 PA XANAX TAB 2MG 3 PA XANAX XR TAB 0.5MG 3 PA XANAX XR TAB 1MG 3 PA XANAX XR TAB 2MG 3 PA XANAX XR TAB 3MG 3 PA ANTIANXIETY, MISCELLANEOUS buspirone hcl tab 5 mg 1 buspirone hcl tab 7.5 mg 1 buspirone hcl tab 10 mg 1 buspirone hcl tab 15 mg 1 buspirone hcl tab 30 mg 1 clomipramine hcl cap 25 mg 1 clomipramine hcl cap 50 mg 1 clomipramine hcl cap 75 mg 1 fluvoxamine maleate cap er 24hr 100 mg 1 fluvoxamine maleate cap er 24hr 150 mg 1 fluvoxamine maleate tab 25 mg 1 fluvoxamine maleate tab 50 mg 1


74

Drug Name Drug Tier Requirements/Limits fluvoxamine maleate tab 100 mg 1 meprobamate tab 200 mg 1 PA meprobamate tab 400 mg 1 PA ANTICONVULSANTS APTIOM TAB 200MG 3 QL (30 tabs / 30 days),

ST APTIOM TAB 400MG 3 QL (30 tabs / 30 days),



ST BANZEL SUS 40MG/ML 2 PA BANZEL TAB 200MG 2 PA BANZEL TAB 400MG 2 PA BRIVIACT SOL 10MG/ML 3 QL (2 / 30 days), PA BRIVIACT TAB 10MG 3 QL (60 tabs in lifetime),

PA BRIVIACT TAB 25MG 3 QL (60 tabs / 30 days),




PA carbamazepine cap er 12hr 100 mg 1 carbamazepine cap er 12hr 200 mg 1 carbamazepine cap er 12hr 300 mg 1 carbamazepine chew tab 100 mg 1 carbamazepine susp 100 mg/5ml 1 carbamazepine tab 200 mg 1 carbamazepine tab er 12hr 200 mg 1 carbamazepine tab er 12hr 400 mg 1 CARBATROL CAP 100MG 3 PA, ST CARBATROL CAP 200MG 3 PA, ST CARBATROL CAP 300MG 3 PA, ST CELONTIN CAP 300MG 2 PA CEREBYX INJ 100/2ML 3 PA CEREBYX INJ 500/10ML 3 PA DEPACON INJ 100MG/ML 3 PA DEPAKENE CAP 250MG 3 PA, ST DEPAKENE SOL 250/5ML 3 PA, ST DEPAKOTE ER TAB 250MG 3 PA, ST DEPAKOTE ER TAB 500MG 3 PA, ST DEPAKOTE SPR CAP 125MG 3 PA, ST


75

Drug Name Drug Tier Requirements/Limits DEPAKOTE TAB 125MG DR 3 PA, ST DEPAKOTE TAB 250MG DR 3 PA, ST DEPAKOTE TAB 500MG DR 3 PA, ST DIASTAT ACDL GEL 5-10MG 3 QL (2 ea / 25 days), PA,

ST DIASTAT ACDL GEL 12.5-20 3 QL (2 ea / 25 days), PA,

ST DIASTAT PED GEL 2.5M GEL 3 QL (2 ea / 25 days), PA,

ST diazepam rectal gel delivery system 2.5

mg 1 QL (2 ea / 25 days)

diazepam rectal gel delivery system 10 mg 1 QL (2 ea / 25 days) diazepam rectal gel delivery system 20 mg 1 QL (2 ea / 25 days) DILANTIN CAP 30MG 2 DILANTIN CAP 100MG 3 PA, ST DILANTIN CHW 50MG 3 PA, ST DILANTIN-125 SUS 125/5ML 3 PA divalproex sodium cap delayed release

sprinkle 125 mg 1

divalproex sodium tab delayed release 125 mg

1


1


1

divalproex sodium tab er 24 hr 250 mg 1 divalproex sodium tab er 24 hr 500 mg 1 ethosuximide cap 250 mg 1 ethosuximide soln 250 mg/5ml 1 felbamate susp 600 mg/5ml 1 felbamate tab 400 mg 1 felbamate tab 600 mg 1 FELBATOL SUS 600/5ML 3 PA, ST FELBATOL TAB 400MG 3 PA, ST FELBATOL TAB 600MG 3 PA, ST fosphenytoin sodium inj 100 mg/2ml

(phenytoin equiv) 1

fosphenytoin sodium inj 500 mg/10ml (phenytoin equiv)

1

FYCOMPA TAB 2MG 3 QL (30 tabs / 30 days), ST





76

Drug Name Drug Tier Requirements/Limits FYCOMPA TAB 10MG 3 QL (30 tabs / 30 days),

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

ST gabapentin cap 100 mg 1 QL (1080 / 30) gabapentin cap 300 mg 1 QL (360 / 30) gabapentin cap 400 mg 1 QL (270 / 30) gabapentin oral soln 250 mg/5ml 1 gabapentin tab 600 mg 1 QL (180 / 30) gabapentin tab 800 mg 1 QL (120 / 30) GABITRIL TAB 2MG 3 PA, ST GABITRIL TAB 4MG 3 PA, ST GABITRIL TAB 12MG 2 PA GABITRIL TAB 16MG 2 PA KEPPRA INJ 500/5ML 3 PA KEPPRA SOL 100MG/ML 3 PA, ST KEPPRA TAB 250MG 3 PA, ST KEPPRA TAB 500MG 3 PA, ST KEPPRA TAB 750MG 3 PA, ST KEPPRA TAB 1000MG 3 PA, ST KEPPRA XR TAB 500MG 3 QL (180 tabs / 30 days),

PA, ST KEPPRA XR TAB 750MG 3 QL (120 tabs / 30 days),

PA, ST LAMICTAL CHW 5MG 3 PA, ST LAMICTAL CHW 25MG 3 PA, ST LAMICTAL KIT START 35 3 ST LAMICTAL KIT START 49 3 ST LAMICTAL KIT START 98 3 ST LAMICTAL ODT KIT 3 QL (1 box in lifetime),

PA, ST LAMICTAL ODT TAB 25MG 3 QL (90 tabs / 30 days),




PA, ST LAMICTAL TAB 25MG 3 PA, ST LAMICTAL TAB 100MG 3 PA, ST LAMICTAL TAB 150MG 3 PA, ST LAMICTAL TAB 200MG 3 PA, ST LAMICTAL XR KIT 3 QL (1 box in lifetime),

ST LAMICTAL XR TAB 25MG 3 QL (90 tabs / 30 days),

PA, ST


77

Drug Name Drug Tier Requirements/Limits LAMICTAL XR TAB 50MG 3 QL (90 tabs / 30 days),

PA, ST LAMICTAL XR TAB 100MG 3 QL (60 tabs / 30 days),

PA, ST LAMICTAL XR TAB 200MG 3 QL (60 tabs / 30 days),

PA, ST LAMICTAL XR TAB 250MG 3 PA, ST LAMICTAL XR TAB 300MG 3 PA, ST lamotrigine orally disintegrating tab 25 mg 1 QL (90 tabs / 30 days) lamotrigine orally disintegrating tab 50 mg 1 QL (90 tabs / 30 days) lamotrigine orally disintegrating tab 100


lamotrigine orally disintegrating tab 200 mg


lamotrigine tab 25 mg 1 lamotrigine tab 25 mg (35) starter kit 1 QL (1 kit in lifetime), ST lamotrigine tab 25 mg (42) & 100 mg (7)

starter kit 1 QL (1 kit in lifetime), ST

lamotrigine tab 25 mg (84) & 100 mg (14) starter kit

1 QL (1 kit in lifetime), ST

lamotrigine tab 100 mg 1 lamotrigine tab 150 mg 1 lamotrigine tab 200 mg 1 lamotrigine tab chewable dispersible 5 mg 1 lamotrigine tab chewable dispersible 25 mg1 lamotrigine tab disint 25 (14) & 50 mg

(14) & 100 mg (7) kit 1 QL (1 box in lifetime)

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

1 QL (1 box in lifetime)

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

1 QL (1 box in lifetime)

lamotrigine tab er 24hr 25 mg 1 QL (90 tabs / 30 days) lamotrigine tab er 24hr 50 mg 1 QL (90 tabs / 30 days) lamotrigine tab er 24hr 100 mg 1 QL (60 tabs / 30 days) lamotrigine tab er 24hr 200 mg 1 QL (60 tabs / 30 days) lamotrigine tab er 24hr 250 mg 1 lamotrigine tab er 24hr 300 mg 1 LEVETIRACETA INJ 5MG/ML 3 PA LEVETIRACETA INJ 10MG/ML 3 PA LEVETIRACETA INJ 15MG/ML 3 PA levetiracetam inj 500 mg/5ml (100 mg/ml) 1 levetiracetam oral soln 100 mg/ml 1 levetiracetam tab 250 mg 1 levetiracetam tab 500 mg 1 levetiracetam tab 750 mg 1 levetiracetam tab 1000 mg 1 levetiracetam tab er 24hr 500 mg 1 QL (180 tabs / 30 days)


78

Drug Name Drug Tier Requirements/Limits levetiracetam tab er 24hr 750 mg 1 QL (120 tabs / 30 days) MYSOLINE TAB 50MG 3 PA, ST MYSOLINE TAB 250MG 3 PA, ST NEURONTIN CAP 100MG 3 QL (1080 / 30), ST NEURONTIN CAP 300MG 3 QL (360 / 30), ST NEURONTIN CAP 400MG 3 QL (270 / 30), ST NEURONTIN SOL 250/5ML 3 PA, ST NEURONTIN TAB 600MG 3 QL (180 / 30), ST NEURONTIN TAB 800MG 3 QL (120 / 30), ST ONFI SUS 2.5MG/ML 2 QL (480 ml / 25 days),

PA ONFI TAB 10MG 2 QL (60 tabs / 30 days),

PA ONFI TAB 20MG 2 QL (60 tabs / 30 days),

PA oxcarbazepine susp 300 mg/5ml (60

mg/ml) 1

oxcarbazepine tab 150 mg 1 oxcarbazepine tab 300 mg 1 oxcarbazepine tab 600 mg 1 OXTELLAR XR TAB 150MG 3 ST OXTELLAR XR TAB 300MG 3 ST OXTELLAR XR TAB 600MG 3 ST PEGANONE TAB 250MG 2 PA phenobarbital elixir 20 mg/5ml 1 phenobarbital sodium inj 130 mg/ml 1 phenobarbital tab 15 mg 1 phenobarbital tab 16.2 mg 1 phenobarbital tab 30 mg 1 phenobarbital tab 32.4 mg 1 phenobarbital tab 60 mg 1 phenobarbital tab 64.8 mg 1 phenobarbital tab 97.2 mg 1 phenobarbital tab 100 mg 1 PHENYTEK CAP 200MG 3 PA, ST PHENYTEK CAP 300MG 3 PA, ST phenytoin chew tab 50 mg 1 phenytoin sodium extended cap 100 mg 1 phenytoin sodium extended cap 200 mg 1 phenytoin sodium extended cap 300 mg 1 phenytoin sodium inj 50 mg/ml 1 phenytoin susp 125 mg/5ml 1 POTIGA TAB 50MG 2 QL (270 tabs / 30 days),

PA POTIGA TAB 200MG 2 QL (90 tabs / 30 days),

PA


79

Drug Name Drug Tier Requirements/Limits POTIGA TAB 300MG 2 QL (90 tabs / 30 days),

PA POTIGA TAB 400MG 2 QL (60 tabs / 30 days),

PA primidone tab 50 mg 1 primidone tab 250 mg 1 QUDEXY XR CAP 25/24HR 3 QL (30 / 30 days), PA,

ST QUDEXY XR CAP 50/24HR 3 QL (30 / 30 days), PA,




ST SABRIL POW 500MG 3 QL (180 packets / 30

days), PA SABRIL TAB 500MG 2 QL (180 tabs / 30 days),

PA TEGRETOL SUS 100/5ML 3 PA, ST TEGRETOL TAB 200MG 3 PA, ST TEGRETOL-XR TAB 200MG 3 PA, ST TEGRETOL-XR TAB 400MG 3 PA, ST tiagabine hcl tab 2 mg 1 tiagabine hcl tab 4 mg 1 TOPAMAX SPR CAP 15MG 3 QL (180 / 30 days), PA,

ST TOPAMAX SPR CAP 25MG 3 QL (180 / 30 days), PA,

ST TOPAMAX TAB 25MG 3 PA, ST TOPAMAX TAB 50MG 3 PA, ST TOPAMAX TAB 100MG 3 PA, ST TOPAMAX TAB 200MG 3 PA, ST topiramate cap er 24hr sprinkle 25 mg 1 QL (30 / 30 days) topiramate cap er 24hr sprinkle 50 mg 1 QL (30 / 30 days) topiramate cap er 24hr sprinkle 100 mg 1 QL (30 / 30 days) topiramate cap er 24hr sprinkle 150 mg 1 QL (30 / 30 days) topiramate cap er 24hr sprinkle 200 mg 1 QL (30 / 30 days) topiramate sprinkle cap 15 mg 1 QL (180 / 30 days) topiramate sprinkle cap 25 mg 1 QL (180 / 30 days) topiramate tab 25 mg 1 topiramate tab 50 mg 1 topiramate tab 100 mg 1 topiramate tab 200 mg 1 TRILEPTAL SUS 300MG/5M 3 PA, ST TRILEPTAL TAB 150MG 3 PA, ST


80

Drug Name Drug Tier Requirements/Limits TRILEPTAL TAB 300MG 3 PA, ST TRILEPTAL TAB 600MG 3 PA, ST TROKENDI XR CAP 25MG 3 QL (30 caps / 30 days),

PA TROKENDI XR CAP 50MG 3 QL (30 caps / 30 days),



PA valproate sodium inj 100 mg/ml 1 valproate sodium oral soln 250 mg/5ml

(base equiv) 1

valproic acid cap 250 mg 1 vigabatrin powd pack 500 mg 1 QL (180 packets / 30

days), PA VIMPAT INJ 200MG/20 2 PA VIMPAT SOL 10MG/ML 2 PA VIMPAT TAB 50MG 2 PA VIMPAT TAB 100MG 2 PA VIMPAT TAB 150MG 2 PA VIMPAT TAB 200MG 2 PA ZARONTIN CAP 250MG 3 PA, ST ZARONTIN SOL 250/5ML 3 PA, ST ZONEGRAN CAP 25MG 3 PA, ST ZONEGRAN CAP 100MG 3 PA, ST zonisamide cap 25 mg 1 zonisamide cap 50 mg 1 zonisamide cap 100 mg 1 ANTIDEMENTIA ARICEPT TAB 5MG 3 ST ARICEPT TAB 10MG 3 ST ARICEPT TAB 23MG 3 ST donepezil hydrochloride orally

disintegrating tab 5 mg 1

donepezil hydrochloride orally disintegrating tab 10 mg

1

donepezil hydrochloride tab 5 mg 1 donepezil hydrochloride tab 10 mg 1 donepezil hydrochloride tab 23 mg 1 EXELON CAP 1.5MG 3 ST EXELON CAP 3MG 3 ST EXELON CAP 4.5MG 3 ST EXELON CAP 6MG 3 ST EXELON DIS 4.6MG/24 3 ST EXELON DIS 9.5MG/24 3 ST


81

Drug Name Drug Tier Requirements/Limits EXELON DIS 13.3/24 3 ST galantamine hydrobromide cap er 24hr 8

mg 1

galantamine hydrobromide cap er 24hr 16 mg

1

galantamine hydrobromide cap er 24hr 24 mg

1

galantamine hydrobromide oral soln 4 mg/ml

1

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

(21) titration pak 1

memantine hcl tab 10 mg 1 NAMENDA XR CAP 7MG 3 QL (30 caps / 30 days),

ST NAMENDA XR CAP 14MG 3 QL (30 caps / 30 days),



ST NAMENDA XR CAP TITRATIO 3 QL (30 caps / 30 days),

ST NAMZARIC CAP 7-10MG 3 QL (30 caps / 30 days),




ST RAZADYNE ER CAP 8MG 3 ST RAZADYNE ER CAP 16MG 3 ST RAZADYNE ER CAP 24MG 3 ST RAZADYNE TAB 4MG 3 ST RAZADYNE TAB 8MG 3 ST RAZADYNE TAB 12MG 3 ST rivastigmine tartrate cap 1.5 mg 1 rivastigmine tartrate cap 3 mg 1 rivastigmine tartrate cap 4.5 mg 1 rivastigmine tartrate cap 6 mg 1 rivastigmine td patch 24hr 4.6 mg/24hr 1 rivastigmine td patch 24hr 9.5 mg/24hr 1


82

Drug Name Drug Tier Requirements/Limits rivastigmine td patch 24hr 13.3 mg/24hr 1 ANTIDEPRESSANTS, MAOIS EMSAM DIS 6MG/24HR 3 QL (30 ea / 30 days), ST EMSAM DIS 9MG/24HR 3 QL (30 ea / 30 days), ST EMSAM DIS 12MG/24H 3 QL (30 ea / 30 days), ST MARPLAN TAB 10MG 3 ST NARDIL TAB 15MG 3 PA, ST PARNATE TAB 10MG 3 PA, ST phenelzine sulfate tab 15 mg 1 tranylcypromine sulfate tab 10 mg 1 ANTIDEPRESSANTS, MISCELLANEOUS APLENZIN TAB 174MG 3 ST APLENZIN TAB 348MG 3 ST APLENZIN TAB 522MG 3 ST bupropion hcl tab 75 mg 1 bupropion hcl tab 100 mg 1 bupropion hcl tab er 12hr 100 mg 1 bupropion hcl tab er 12hr 150 mg 1 bupropion hcl tab er 12hr 200 mg 1 bupropion hcl tab er 24hr 150 mg 1 bupropion hcl tab er 24hr 300 mg 1 chlordiazepoxide-amitriptyline tab 5-12.5

mg 1

chlordiazepoxide-amitriptyline tab 10-25 mg

1

FORFIVO XL TAB 450MG 3 ST maprotiline hcl tab 25 mg 1 maprotiline hcl tab 50 mg 1 maprotiline hcl tab 75 mg 1 mirtazapine orally disintegrating tab 15 mg1 mirtazapine orally disintegrating tab 30 mg1 mirtazapine orally disintegrating tab 45 mg1 mirtazapine tab 7.5 mg 1 mirtazapine tab 15 mg 1 mirtazapine tab 30 mg 1 mirtazapine tab 45 mg 1 REMERON SLTB TAB 15MG 3 PA, ST REMERON SLTB TAB 30MG 3 PA, ST REMERON SLTB TAB 45MG 3 PA, ST REMERON TAB 15MG 3 PA, ST REMERON TAB 30MG 3 PA, ST REMERON TAB 45MG 3 PA, ST trazodone hcl tab 50 mg 1 trazodone hcl tab 100 mg 1 trazodone hcl tab 150 mg 1


83

Drug Name Drug Tier Requirements/Limits trazodone hcl tab 300 mg 1 WELLBUTRIN TAB 100MG SR 3 PA, ST WELLBUTRIN TAB 150MG SR 3 PA, ST WELLBUTRIN TAB 200MG SR 3 PA, ST WELLBUTRIN TAB XL 150MG 3 PA, ST WELLBUTRIN TAB XL 300MG 3 PA, ST ANTIDEPRESSANTS, SNRIS CYMBALTA CAP 20MG 3 QL (60 ea / 30 days), PA CYMBALTA CAP 30MG 3 QL (30 ea / 30 days), PA CYMBALTA CAP 60MG 3 QL (60 / 30), PA DESVENLAFAX TAB 50MG ER 3 QL (30 tabs / 30 days),

ST DESVENLAFAX TAB 100MG ER 3 QL (30 tabs / 30 days),

ST desvenlafaxine succinate tab er 24hr 25

mg (base equiv) 1 QL (30 tabs / 30 days),





ST desvenlafaxine tab er 24hr 50 mg 1 QL (30 tabs / 30 days),

ST desvenlafaxine tab er 24hr 100 mg 1 QL (30 tabs / 30 days),

ST duloxetine hcl enteric coated pellets cap 20

mg (base eq) 1 QL (60 ea / 30 days)

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

1 QL (30 ea / 30 days)


1 QL (30 ea / 30 days)


1 QL (60 / 30)

EFFEXOR XR CAP 37.5MG 3 QL (30 caps / 30 days), PA

EFFEXOR XR CAP 75MG 3 QL (90 caps / 30 days), PA

EFFEXOR XR CAP 150MG 3 QL (60 caps / 30 days), PA

FETZIMA CAP 20MG 3 QL (30 caps / 30 days), PA




FETZIMA CAP TITRATIO 3 QL (1 kit in lifetime), PA


84

Drug Name Drug Tier Requirements/Limits KHEDEZLA TAB 50MG ER 3 QL (30 tabs / 30 days),

ST KHEDEZLA TAB 100MG ER 3 QL (30 tabs / 30 days),

ST PRISTIQ TAB 25MG 3 QL (30 tabs / 30 days),



ST venlafaxine hcl cap er 24hr 37.5 mg (base

equivalent) 1 QL (30 caps / 30 days)

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


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


venlafaxine hcl tab 25 mg 1 QL (180 tabs / 30 days) venlafaxine hcl tab 37.5 mg 1 QL (180 tabs / 30 days) venlafaxine hcl tab 50 mg 1 QL (180 tabs / 30 days) venlafaxine hcl tab 75 mg 1 QL (180 tabs / 30 days) venlafaxine hcl tab 100 mg 1 QL (120 tabs / 30 days) venlafaxine hcl tab er 24hr 37.5 mg (base

equivalent) 1 QL (30 tabs / 30 days)

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






VENLAFAXINE TAB 37.5 ER 3 QL (30 tabs / 30 days), PA

VENLAFAXINE TAB 75MG ER 3 QL (30 tabs / 30 days), PA

VENLAFAXINE TAB 150MG ER 3 QL (60 tabs / 30 days), PA

ANTIDEPRESSANTS, SSRIS CELEXA TAB 10MG 3 QL (45 tabs / 25 days),

PA, ST CELEXA TAB 20MG 3 QL (45 tabs / 25 days),

PA, ST CELEXA TAB 40MG 3 QL (30 tabs / 30 days),

PA, ST citalopram hydrobromide oral soln 10

mg/5ml 1

citalopram hydrobromide tab 10 mg (base equiv)


citalopram hydrobromide tab 20 mg (base equiv)



85

Drug Name Drug Tier Requirements/Limits citalopram hydrobromide tab 40 mg (base


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

1 QL (600 / 30 days)

escitalopram oxalate tab 5 mg (base equiv)






fluoxetine hcl (pmdd) cap 10 mg 1 fluoxetine hcl (pmdd) cap 20 mg 1 fluoxetine hcl cap 10 mg 1 fluoxetine hcl cap 20 mg 1 fluoxetine hcl cap 40 mg 1 fluoxetine hcl cap delayed release 90 mg 1 QL (4 caps / 21 days) fluoxetine hcl solution 20 mg/5ml 1 fluoxetine hcl tab 10 mg 1 fluoxetine hcl tab 20 mg 1 FLUOXETINE TAB 60MG 3 ST LEXAPRO SOL 5MG/5ML 3 QL (600 ml / 30 days),

PA, ST LEXAPRO TAB 5MG 3 QL (30 tabs / 30 days),



PA, ST paroxetine hcl tab 10 mg 1 paroxetine hcl tab 20 mg 1 paroxetine hcl tab 30 mg 1 paroxetine hcl tab 40 mg 1 paroxetine hcl tab er 24hr 12.5 mg 1 QL (30 tabs / 30 days) paroxetine hcl tab er 24hr 25 mg 1 QL (60 tabs / 30 days) paroxetine hcl tab er 24hr 37.5 mg 1 QL (60 tabs / 30 days) PAXIL CR TAB 12.5MG 3 QL (30 tabs / 30 days),

PA, ST PAXIL CR TAB 25MG 3 QL (60 tabs / 30 days),

PA, ST PAXIL CR TAB 37.5MG 3 QL (60 tabs / 30 days),

PA, ST PAXIL SUS 10MG/5ML 3 ST PAXIL TAB 10MG 3 PA, ST PAXIL TAB 20MG 3 PA, ST PAXIL TAB 30MG 3 PA, ST PAXIL TAB 40MG 3 PA, ST


86

Drug Name Drug Tier Requirements/Limits PEXEVA TAB 10MG 3 QL (30 tabs / 30 days),

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



ST PROZAC CAP 10MG 3 PA, ST PROZAC CAP 20MG 3 PA, ST PROZAC CAP 40MG 3 PA, ST PROZAC WEEKL CAP 90MG 3 QL (4 caps / 21 days),

PA, ST SARAFEM TAB 10MG 3 ST SARAFEM TAB 20MG 3 ST sertraline hcl oral conc 20 mg/ml 1 sertraline hcl tab 25 mg 1 sertraline hcl tab 50 mg 1 sertraline hcl tab 100 mg 1 TRINTELLIX TAB 5MG 3 QL (30 tabs / 30 days),

ST TRINTELLIX TAB 10MG 3 QL (30 tabs / 30 days),

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

ST VIIBRYD KIT STARTER 3 QL (1 box in lifetime),

ST VIIBRYD TAB 10MG 3 QL (30 tabs / 30 days),



ST ZOLOFT CON 20MG/ML 3 PA, ST ZOLOFT TAB 25MG 3 PA, ST ZOLOFT TAB 50MG 3 PA, ST ZOLOFT TAB 100MG 3 PA, ST ANTIDEPRESSANTS, TCAS amitriptyline hcl tab 10 mg 1 amitriptyline hcl tab 25 mg 1 amitriptyline hcl tab 50 mg 1 amitriptyline hcl tab 75 mg 1 amitriptyline hcl tab 100 mg 1 amitriptyline hcl tab 150 mg 1 amoxapine tab 25 mg 1 amoxapine tab 50 mg 1 amoxapine tab 100 mg 1


87

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


88

Drug Name Drug Tier Requirements/Limits bromocriptine mesylate cap 5 mg (base

equivalent) 1

bromocriptine mesylate tab 2.5 mg (base equivalent)

1

carbidopa & levodopa orally disintegrating tab 10-100 mg

1


1


1

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

50-200 mg 1

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

1

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

1


1


1

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

1

COGENTIN INJ 1MG/ML 3 PA COMTAN TAB 200MG 3 PA ELDEPRYL CAP 5MG 3 PA entacapone tab 200 mg 1 PA LODOSYN TAB 25MG 3 PA MIRAPEX ER TAB 0.75MG 3 PA, ST MIRAPEX ER TAB 0.375MG 3 PA, ST MIRAPEX ER TAB 1.5MG 3 PA, ST MIRAPEX ER TAB 2.25MG 3 PA, ST MIRAPEX ER TAB 3.75MG 3 PA, ST MIRAPEX ER TAB 3MG 3 PA, ST MIRAPEX ER TAB 4.5MG 3 PA, ST MIRAPEX TAB 0.5MG 3 PA, ST MIRAPEX TAB 0.25MG 3 PA, ST MIRAPEX TAB 0.75MG 3 PA, ST MIRAPEX TAB 0.125MG 3 PA, ST MIRAPEX TAB 1.5MG 3 PA, ST MIRAPEX TAB 1MG 3 PA, ST NEUPRO DIS 1MG/24HR 3 ST


89

Drug Name Drug Tier Requirements/Limits NEUPRO DIS 2MG/24HR 3 ST NEUPRO DIS 3MG/24HR 3 ST NEUPRO DIS 4MG/24HR 3 ST NEUPRO DIS 6MG/24HR 3 ST NEUPRO DIS 8MG/24HR 3 ST PARLODEL CAP 5MG 3 PA pramipexole dihydrochloride tab 0.5 mg 1 pramipexole dihydrochloride tab 0.25 mg 1 pramipexole dihydrochloride tab 0.75 mg 1 pramipexole dihydrochloride tab 0.125 mg 1 pramipexole dihydrochloride tab 1 mg 1 pramipexole dihydrochloride tab 1.5 mg 1 pramipexole dihydrochloride tab er 24hr

0.75 mg 1 ST

pramipexole dihydrochloride tab er 24hr 0.375 mg

1


1 ST


1

pramipexole dihydrochloride tab er 24hr 3 mg

1


1

rasagiline mesylate tab 0.5 mg (base equiv)

1

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


90

Drug Name Drug Tier Requirements/Limits ropinirole hydrochloride tab er 24hr 2 mg

(base equivalent) 1

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

1


1


1


1

RYTARY CAP 95MG 3 PA RYTARY CAP 145MG 3 PA RYTARY CAP 195MG 3 PA RYTARY CAP 245MG 3 PA selegiline hcl cap 5 mg 1 selegiline hcl tab 5 mg 1 SINEMET CR TAB 25-100MG 3 PA SINEMET CR TAB 50-200MG 3 PA SINEMET TAB 10-100MG 3 PA SINEMET TAB 25-100MG 3 PA SINEMET TAB 25-250MG 3 PA STALEVO 50 TAB 3 PA STALEVO 75 TAB 3 PA STALEVO 100 TAB 3 PA STALEVO 125 TAB 3 PA STALEVO 150 TAB 3 PA STALEVO 200 TAB 3 PA tolcapone tab 100 mg 1 trihexyphenidyl hcl elixir 0.4 mg/ml 1 trihexyphenidyl hcl tab 2 mg 1 trihexyphenidyl hcl tab 5 mg 1 XADAGO TAB 50MG 3 QL (30 tabs / 30 days),

PA XADAGO TAB 100MG 3 QL (30 tabs / 30 days),

PA ZELAPAR TAB 1.25MG 3 PA ANTIPSYCHOTICS, ATYPICALS ABILIFY MAIN INJ 300MG 2 QL (1 vial / 21 days), PA ABILIFY MAIN INJ 400MG 2 QL (1 vial / 21 days), PA ADASUVE INH 10MG 3 PA aripiprazole oral solution 1 mg/ml 1 QL (750 per 25 days) aripiprazole orally disintegrating tab 10 mg 1 QL (60 tabs / 30 days) aripiprazole orally disintegrating tab 15 mg 1 QL (60 tabs / 30 days) aripiprazole tab 2 mg 1 QL (30 tabs / 30 days) aripiprazole tab 5 mg 1 QL (30 tabs / 30 days) aripiprazole tab 10 mg 1 QL (30 tabs / 30 days)


91

Drug Name Drug Tier Requirements/Limits aripiprazole tab 15 mg 1 QL (30 tabs / 30 days) aripiprazole tab 20 mg 1 QL (30 tabs / 30 days) aripiprazole tab 30 mg 1 QL (30 tabs / 30 days) ARISTADA INJ 441MG/1. 3 QL (1 / 25 days), PA ARISTADA INJ 662MG/2 3 QL (1 syringe / 25

days), PA ARISTADA INJ 882MG/3 3 QL (1 syringe / 25

days), PA ARISTADA INJ 1064MG 2 QL (3.9 / 60), PA clozapine orally disintegrating tab 12.5 mg 1 QL (60 tabs / 30 days) clozapine orally disintegrating tab 25 mg 1 QL (90 tabs / 30 days) clozapine orally disintegrating tab 100 mg 1 QL (270 tabs / 30 days) clozapine orally disintegrating tab 150 mg 1 QL (180 tabs / 30 days) clozapine orally disintegrating tab 200 mg 1 QL (120 tabs / 30 days) clozapine tab 25 mg 1 clozapine tab 50 mg 1 clozapine tab 100 mg 1 clozapine tab 200 mg 1 CLOZARIL TAB 25MG 3 PA, ST CLOZARIL TAB 100MG 3 PA, ST FANAPT PAK 3 QL (8 tabs in lifetime),

ST FANAPT TAB 1MG 3 QL (60 tabs / 30 days),







ST FAZACLO TAB 12.5 ODT 3 QL (60 tabs / 30 days),

PA, ST FAZACLO TAB 25MG ODT 3 QL (90 tabs / 30 days),

PA, ST FAZACLO TAB 100 ODT 3 QL (270 tabs / 30 days),



PA, ST


92

Drug Name Drug Tier Requirements/Limits GEODON CAP 20MG 3 QL (60 caps / 30 days),

PA, ST GEODON CAP 40MG 3 QL (60 caps / 30 days),



PA, ST GEODON INJ 20MG 2 PA INVEGA SUST INJ 39/0.25 2 PA INVEGA SUST INJ 78/0.5ML 2 PA INVEGA SUST INJ 117/0.75 2 PA INVEGA SUST INJ 156MG/ML 2 QL (1 syringe / 21

days), PA INVEGA SUST INJ 234/1.5 2 QL (1 syringe / 21

days), PA INVEGA TAB 1.5MG 3 QL (30 tabs / 30 days),

PA, ST INVEGA TAB 3MG 3 QL (30 tabs / 30 days),



PA, ST INVEGA TRINZ INJ 273MG 2 QL (1 syringe / 84

days), PA INVEGA TRINZ INJ 410MG 2 QL (1 syringe / 84



days), PA LATUDA TAB 20MG 2 QL (30 tabs / 30 days),

ST LATUDA TAB 40MG 2 QL (30 tabs / 30 days),




ST loxapine succinate cap 5 mg 1 loxapine succinate cap 10 mg 1 loxapine succinate cap 25 mg 1 loxapine succinate cap 50 mg 1 NUPLAZID TAB 17MG 3 QL (60 tabs / 30 days),

PA


93

Drug Name Drug Tier Requirements/Limits olanzapine for im inj 10 mg 1 QL (30 / 30 days) olanzapine orally disintegrating tab 5 mg 1 QL (30 tabs / 30 days) olanzapine orally disintegrating tab 10 mg 1 QL (30 tabs / 30 days) olanzapine orally disintegrating tab 15 mg 1 QL (30 tabs / 30 days) olanzapine orally disintegrating tab 20 mg 1 QL (30 tabs / 30 days) olanzapine tab 2.5 mg 1 QL (30 tabs / 30 days) olanzapine tab 5 mg 1 QL (30 tabs / 30 days) olanzapine tab 7.5 mg 1 QL (30 tabs / 30 days) olanzapine tab 10 mg 1 QL (30 tabs / 30 days) olanzapine tab 15 mg 1 QL (30 tabs / 30 days) olanzapine tab 20 mg 1 QL (30 tabs / 30 days) paliperidone tab er 24hr 1.5 mg 1 QL (30 tabs / 30 days) paliperidone tab er 24hr 3 mg 1 QL (30 tabs / 30 days) paliperidone tab er 24hr 6 mg 1 QL (60 tabs / 30 days) paliperidone tab er 24hr 9 mg 1 QL (30 tabs / 30 days) quetiapine fumarate tab 25 mg 1 QL (90 tabs / 30 days) quetiapine fumarate tab 50 mg 1 QL (90 tabs / 30 days) quetiapine fumarate tab 100 mg 1 QL (90 tabs / 30 days) quetiapine fumarate tab 200 mg 1 QL (90 tabs / 30 days) quetiapine fumarate tab 300 mg 1 QL (90 tabs / 30 days) quetiapine fumarate tab 400 mg 1 QL (90 tabs / 30 days) quetiapine fumarate tab er 24hr 50 mg 1 PA quetiapine fumarate tab er 24hr 150 mg 1 PA quetiapine fumarate tab er 24hr 200 mg 1 PA quetiapine fumarate tab er 24hr 300 mg 1 PA quetiapine fumarate tab er 24hr 400 mg 1 PA REXULTI TAB 0.5MG 3 QL (30 tabs / 30 days),

PA REXULTI TAB 0.25MG 3 QL (30 tabs / 30 days),

PA REXULTI TAB 1MG 3 QL (30 tabs / 30 days),




PA RISPERDAL INJ 12.5MG 2 QL (2 / 21 days), PA RISPERDAL INJ 25MG 2 QL (2 / 21 days), PA RISPERDAL INJ 37.5MG 2 QL (2 / 21 days), PA RISPERDAL INJ 50MG 2 QL (2 / 21 days), PA RISPERDAL M TAB 0.5MG 3 QL (60 tabs / 30 days),

PA, ST RISPERDAL M TAB 1MG 3 QL (60 tabs / 30 days),

PA, ST


94

Drug Name Drug Tier Requirements/Limits RISPERDAL M TAB 2MG 3 QL (60 tabs / 30 days),



PA, ST RISPERDAL SOL 1MG/ML 3 QL (240 ml / 30 days),

PA, ST RISPERDAL TAB 0.5MG 3 QL (60 tabs / 30 days),

PA, ST RISPERDAL TAB 0.25MG 3 QL (60 tabs / 30 days),

PA, ST RISPERDAL TAB 1MG 3 QL (60 tabs / 30 days),




PA, ST risperidone orally disintegrating tab 0.5 mg1 QL (60 tabs / 30 days) risperidone orally disintegrating tab 0.25


risperidone orally disintegrating tab 1 mg 1 QL (60 tabs / 30 days) risperidone orally disintegrating tab 2 mg 1 QL (60 tabs / 30 days) risperidone orally disintegrating tab 3 mg 1 QL (60 tabs / 30 days) risperidone orally disintegrating tab 4 mg 1 QL (60 tabs / 30 days) risperidone soln 1 mg/ml 1 QL (240 ml / 30 days) risperidone tab 0.5 mg 1 QL (60 tabs / 30 days) risperidone tab 0.25 mg 1 QL (60 tabs / 30 days) risperidone tab 1 mg 1 QL (60 tabs / 30 days) risperidone tab 2 mg 1 QL (60 tabs / 30 days) risperidone tab 3 mg 1 QL (60 tabs / 30 days) risperidone tab 4 mg 1 QL (60 tabs / 30 days) SAPHRIS SUB 2.5MG 3 QL (60 ea / 30 days), PA SAPHRIS SUB 5MG 3 QL (60 ea / 30 days), PA SAPHRIS SUB 10MG 3 QL (60 ea / 30 days), PA SEROQUEL TAB 25MG 3 QL (90 tabs / 30 days),

PA SEROQUEL TAB 50MG 3 QL (90 tabs / 30 days),




PA


95

Drug Name Drug Tier Requirements/Limits SEROQUEL TAB 400MG 3 QL (90 tabs / 30 days),

PA SEROQUEL XR TAB 50MG 3 QL (60 tabs / 30 days),





PA VERSACLOZ SUS 50MG/ML 3 QL (540 ml / 25 days),

ST VRAYLAR CAP 1.5-3MG 3 PA VRAYLAR CAP 1.5MG 3 PA VRAYLAR CAP 3MG 3 PA VRAYLAR CAP 4.5MG 3 PA VRAYLAR CAP 6MG 3 PA ziprasidone hcl cap 20 mg 1 QL (60 caps / 30 days) ziprasidone hcl cap 40 mg 1 QL (60 caps / 30 days) ziprasidone hcl cap 60 mg 1 QL (60 caps / 30 days) ziprasidone hcl cap 80 mg 1 QL (60 caps / 30 days) ZYPREXA INJ 10MG 3 QL (30 / 30 days), PA ZYPREXA RELP INJ 210MG 3 QL (2 vials / 21 days),

PA ZYPREXA RELP INJ 300MG 3 QL (2 vials / 21 days),

PA ZYPREXA RELP INJ 405MG 3 QL (1 vial / 21 days), PA ZYPREXA TAB 2.5MG 3 QL (30 tabs / 30 days),

PA, ST ZYPREXA TAB 5MG 3 QL (30 tabs / 30 days),

PA, ST ZYPREXA TAB 7.5MG 3 QL (30 tabs / 30 days),




PA, ST ZYPREXA ZYDI TAB 5MG 3 QL (30 tabs / 30 days),



PA, ST


96

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

PA, ST ANTIPSYCHOTICS, MISCELLANEOUS CHLORPROMAZ INJ 25MG/ML 3 CHLORPROMAZ INJ 50MG/2ML 3 chlorpromazine hcl tab 10 mg 1 chlorpromazine hcl tab 25 mg 1 chlorpromazine hcl tab 50 mg 1 chlorpromazine hcl tab 100 mg 1 chlorpromazine hcl tab 200 mg 1 fluphenazine decanoate inj 25 mg/ml 1 fluphenazine hcl elixir 2.5 mg/5ml 1 fluphenazine hcl inj 2.5 mg/ml 1 fluphenazine hcl oral conc 5 mg/ml 1 fluphenazine hcl tab 1 mg 1 fluphenazine hcl tab 2.5 mg 1 fluphenazine hcl tab 5 mg 1 fluphenazine hcl tab 10 mg 1 HALDOL DECAN INJ 50MG/ML 3 PA HALDOL DECAN INJ 100MG/ML 3 PA HALDOL INJ 5MG/ML 3 PA haloperidol decanoate im soln 50 mg/ml 1 haloperidol decanoate im soln 100 mg/ml 1 haloperidol lactate inj 5 mg/ml 1 haloperidol lactate oral conc 2 mg/ml 1 haloperidol tab 0.5 mg 1 haloperidol tab 1 mg 1 haloperidol tab 2 mg 1 haloperidol tab 5 mg 1 haloperidol tab 10 mg 1 haloperidol tab 20 mg 1 ORAP TAB 1MG 3 PA ORAP TAB 2MG 3 PA perphenazine tab 2 mg 1 perphenazine tab 4 mg 1 perphenazine tab 8 mg 1 perphenazine tab 16 mg 1 perphenazine-amitriptyline tab 2-10 mg 1 perphenazine-amitriptyline tab 2-25 mg 1 perphenazine-amitriptyline tab 4-10 mg 1 perphenazine-amitriptyline tab 4-25 mg 1 perphenazine-amitriptyline tab 4-50 mg 1 pimozide tab 1 mg 1 pimozide tab 2 mg 1 thioridazine hcl tab 10 mg 1


97

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

equivalent) 1

trifluoperazine hcl tab 2 mg (base equivalent)

1


1


1

ATTENTION DEFICIT HYPERACTIVITY DISORDER ADDERALL TAB 5MG 3 QL (90 tabs / 30 days),

PA, ST ADDERALL TAB 7.5MG 3 QL (90 tabs / 30 days),

PA, ST ADDERALL TAB 10MG 3 QL (90 tabs / 30 days),

PA, ST ADDERALL TAB 12.5MG 3 QL (90 tabs / 30 days),




PA, ST ADDERALL XR CAP 5MG 3 QL (30 caps / 30 days),




PA, ST ADDERALL XR CAP 25MG 3 PA, ST ADDERALL XR CAP 30MG 3 QL (60 caps / 30 days),

PA, ST amphetamine-dextroamphetamine cap er

24hr 5 mg 1 QL (30 caps / 30 days)

amphetamine-dextroamphetamine cap er 24hr 10 mg





98

Drug Name Drug Tier Requirements/Limits amphetamine-dextroamphetamine cap er

24hr 20 mg 1 QL (60 caps / 30 days)


1



amphetamine-dextroamphetamine tab 5 mg


amphetamine-dextroamphetamine tab 7.5 mg




amphetamine-dextroamphetamine tab 12.5 mg








APTENSIO XR CAP 10MG 3 QL (30 caps / 30 days), ST







atomoxetine hcl cap 10 mg (base equiv) 1 QL (30 caps / 30 days), PA








99

Drug Name Drug Tier Requirements/Limits clonidine hcl tab er 12hr 0.1 mg 1 QL (120 tabs / 30 days) CONCERTA TAB 18MG 3 QL (30 tabs / 30 days),

PA, ST CONCERTA TAB 27MG 3 QL (30 tabs / 30 days),



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

PA DAYTRANA DIS 15MG/9HR 3 QL (30 ptch / 30 days),



PA DEXEDRINE CAP 5MG CR 3 QL (30 caps / 30 days),

PA, ST DEXEDRINE CAP 10MG CR 3 QL (120 caps / 30

days), PA, ST DEXEDRINE CAP 15MG CR 3 QL (120 caps / 30

days), PA, ST dexmethylphenidate hcl cap er 24 hr 5 mg 1 QL (30 caps / 30 days) dexmethylphenidate hcl cap er 24 hr 10


dexmethylphenidate hcl cap er 24 hr 15 mg












dexmethylphenidate hcl tab 2.5 mg 1 QL (60 tabs / 30 days) dexmethylphenidate hcl tab 5 mg 1 QL (60 tabs / 30 days) dexmethylphenidate hcl tab 10 mg 1 QL (60 tabs / 30 days) dextroamphetamine sulfate cap er 24hr 5


dextroamphetamine sulfate cap er 24hr 10 mg


dextroamphetamine sulfate cap er 24hr 15 mg



100

Drug Name Drug Tier Requirements/Limits dextroamphetamine sulfate oral solution 5

mg/5ml 1

dextroamphetamine sulfate tab 5 mg 1 QL (360 tabs / 30 days) dextroamphetamine sulfate tab 10 mg 1 QL (180 tabs / 30 days) DYANAVEL XR SUS 2.5MG/ML 3 QL (240 / 30 days), PA EVEKEO TAB 5MG 3 QL (90 tabs / 30 days),

PA EVEKEO TAB 10MG 3 QL (90 tabs / 30 days),

PA FOCALIN TAB 2.5MG 3 QL (60 tabs / 30 days),

PA, ST FOCALIN TAB 5MG 3 QL (60 tabs / 30 days),

PA, ST FOCALIN TAB 10MG 3 QL (60 tabs / 30 days),

PA, ST FOCALIN XR CAP 5MG 3 QL (30 caps / 30 days),




PA, ST FOCALIN XR CAP 25MG 3 ST FOCALIN XR CAP 30MG 3 PA, ST FOCALIN XR CAP 35MG 3 ST FOCALIN XR CAP 40MG 3 PA, ST guanfacine hcl tab er 24hr 1 mg (base


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






INTUNIV TAB 1MG 3 QL (30 tabs / 30 days), PA




KAPVAY TAB 0.1 MG 3 QL (120 tabs / 30 days), PA, ST

METADATE CD CAP 10MG 3 QL (30 caps / 30 days), PA, ST


101

Drug Name Drug Tier Requirements/Limits METADATE CD CAP 20MG 3 QL (30 caps / 30 days),

PA, ST METADATE CD CAP 30MG 3 QL (30 caps / 30 days),




PA, ST METHYLIN CHW 2.5MG 3 QL (90 ea / 30 days),

PA, ST METHYLIN CHW 5MG 3 QL (90 ea / 30 days),

PA, ST METHYLIN CHW 10MG 3 QL (90 ea / 30 days),

PA, ST METHYLIN SOL 5MG/5ML 3 QL (1800 ml / 30 days),

PA, ST METHYLIN SOL 10MG/5ML 3 QL (900 ml / 30 days),

PA, ST methylphenidate hcl cap er 10 mg (cd) 1 QL (30 caps / 30 days) methylphenidate hcl cap er 20 mg (cd) 1 QL (30 caps / 30 days) methylphenidate hcl cap er 24hr 20 mg

(la) 1 QL (30 caps / 30 days)

methylphenidate hcl cap er 24hr 30 mg (la)


methylphenidate hcl cap er 24hr 40 mg (la)


methylphenidate hcl cap er 30 mg (cd) 1 QL (30 caps / 30 days) methylphenidate hcl cap er 40 mg (cd) 1 QL (30 caps / 30 days) methylphenidate hcl cap er 50 mg (cd) 1 QL (30 caps / 30 days) methylphenidate hcl cap er 60 mg (cd) 1 QL (30 caps / 30 days) methylphenidate hcl chew tab 2.5 mg 1 QL (90 ea / 30 days) methylphenidate hcl chew tab 5 mg 1 QL (90 ea / 30 days) methylphenidate hcl chew tab 10 mg 1 QL (90 ea / 30 days) methylphenidate hcl soln 5 mg/5ml 1 QL (1800 ml / 30 days) methylphenidate hcl soln 10 mg/5ml 1 QL (900 ml / 30 days) methylphenidate hcl tab 5 mg 1 QL (90 tabs / 30 days) methylphenidate hcl tab 10 mg 1 QL (90 tabs / 30 days) methylphenidate hcl tab 20 mg 1 QL (90 tabs / 30 days) methylphenidate hcl tab er 10 mg 1 methylphenidate hcl tab er 20 mg 1 QL (90 tabs / 30 days) methylphenidate hcl tab er 24hr 18 mg 1 methylphenidate hcl tab er 24hr 27 mg 1 methylphenidate hcl tab er 24hr 36 mg 1 methylphenidate hcl tab er 24hr 54 mg 1


102

Drug Name Drug Tier Requirements/Limits methylphenidate hcl tab er osmotic release

(osm) 18 mg 1 QL (30 tabs / 30 days)

methylphenidate hcl tab er osmotic release (osm) 27 mg






QUILLICHEW CHW 20MG ER 3 QL (30 / 30 days), PA, ST



QUILLIVANT SUS 25MG/5ML 3 QL (360 / 30 days), ST RITALIN LA CAP 10MG 3 QL (30 caps / 30 days),

PA RITALIN LA CAP 20MG 3 QL (30 caps / 30 days),

PA, ST RITALIN LA CAP 30MG 3 QL (30 caps / 30 days),



ST RITALIN TAB 5MG 3 QL (90 tabs / 30 days),

PA, ST RITALIN TAB 10MG 3 QL (90 tabs / 30 days),

PA, ST RITALIN TAB 20MG 3 QL (90 tabs / 30 days),

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

PA STRATTERA CAP 18MG 3 QL (60 caps / 30 days),






PA VYVANSE CAP 10MG 2 VYVANSE CAP 20MG 2 QL (30 caps / 30 days) VYVANSE CAP 30MG 2 QL (30 caps / 30 days)


103

Drug Name Drug Tier Requirements/Limits VYVANSE CAP 40MG 2 QL (30 caps / 30 days) VYVANSE CAP 50MG 2 VYVANSE CAP 60MG 2 QL (30 caps / 30 days) VYVANSE CAP 70MG 2 QL (30 caps / 30 days) zenzedi tab 2.5mg 1 QL (480 tabs / 25 days),

ST zenzedi tab 7.5mg 1 QL (240 tabs / 30 days),

ST zenzedi tab 15mg 1 QL (120 tabs / 30 days),



ST FIBROMYALGIA LYRICA CAP 25MG 2 QL (90 caps / 30 days),

PA LYRICA CAP 50MG 2 QL (90 caps / 30 days),







PA LYRICA SOL 20MG/ML 2 QL (900 ml / 25 days),

PA SAVELLA MIS TITR PAK 2 QL (1 kit in lifetime), PA SAVELLA TAB 12.5MG 2 QL (60 tabs / 30 days),

PA SAVELLA TAB 25MG 2 QL (60 tabs / 30 days),



PA HYPNOTICS, BENZODIAZEPINES DORAL TAB 15MG 3 PA, ST estazolam tab 1 mg 1 estazolam tab 2 mg 1 HALCION TAB 0.25MG 3 PA, ST


104

Drug Name Drug Tier Requirements/Limits midazolam hcl inj 2 mg/2ml (base

equivalent) 1 PA

midazolam hcl inj 5 mg/5ml (base equivalent)

1 PA

midazolam hcl inj 5 mg/ml (base equivalent)

1 PA


1 PA


1


1


1

midazolam hcl syrup 2 mg/ml (base equivalent)

1 PA

quazepam tab 15 mg 1 RESTORIL CAP 7.5MG 3 PA, ST RESTORIL CAP 15MG 3 PA, ST RESTORIL CAP 22.5MG 3 PA, ST RESTORIL CAP 30MG 3 PA, ST temazepam cap 7.5 mg 1 temazepam cap 15 mg 1 temazepam cap 22.5 mg 1 temazepam cap 30 mg 1 triazolam tab 0.25 mg 1 triazolam tab 0.125 mg 1 HYPNOTICS, NON-BENZODIAZEPINES AMBIEN CR TAB 6.25MG 3 QL (30 tabs / 30 days),

PA AMBIEN CR TAB 12.5MG 3 QL (30 tabs / 30 days),

PA AMBIEN TAB 5MG 3 QL (30 tabs / 30 days),

PA AMBIEN TAB 10MG 3 QL (30 tabs / 30 days),

PA AMYTAL SOD INJ 500MG 3 PA BELSOMRA TAB 5MG 3 QL (30 tabs / 30 days),

PA BELSOMRA TAB 10MG 3 QL (30 tabs / 30 days),



PA BUTISOL SOD TAB 30MG 3 PA


105

Drug Name Drug Tier Requirements/Limits dexmedetomidine hcl inj 200 mcg/2ml (for

iv infusion) 1

diphenhydramine hcl (sleep) tab 50 mg 1 OTC EDLUAR SUB 5MG 3 QL (30 ea / 30 days), PA EDLUAR SUB 10MG 3 QL (30 ea / 30 days), PA eszopiclone tab 1 mg 1 QL (30 tabs / 30 days) eszopiclone tab 2 mg 1 QL (30 tabs / 30 days) eszopiclone tab 3 mg 1 QL (30 tabs / 30 days) HETLIOZ CAP 20MG 2 QL (30 caps / 30 days),

PA INTERMEZZO SUB 1.75MG 3 QL (30 ea / 30 days), PA INTERMEZZO SUB 3.5MG 3 QL (30 ea / 30 days), PA LUNESTA TAB 1MG 3 QL (30 tabs / 30 days),

PA LUNESTA TAB 2MG 3 QL (30 tabs / 30 days),

PA LUNESTA TAB 3MG 3 QL (30 tabs / 30 days),

PA NEMBUTAL SOD INJ 50MG/ML 3 PA PRECEDEX INJ 80/20ML 3 PA PRECEDEX INJ 100MCG 3 PA PRECEDEX INJ 200/50ML 3 PA PRECEDEX INJ 400/100 3 PA ROZEREM TAB 8MG 3 QL (30 tabs / 30 days),

PA sleep aid tab 25mg 1 OTC sm sleep aid cap 50mg 1 OTC sm z-sleep cap 25mg 1 PA; OTC sm z-sleep liq 50mg/30 1 OTC SONATA CAP 5MG 3 QL (30 caps / 30 days),

PA SONATA CAP 10MG 3 QL (30 caps / 30 days),

PA UNISOM SLEEP TAB 25MG 3 PA; OTC wal-som tab 25mg 1 PA; OTC zaleplon cap 5 mg 1 QL (30 caps / 30 days) zaleplon cap 10 mg 1 QL (30 caps / 30 days) zolpidem tartrate tab 5 mg 1 QL (30 tabs / 30 days) zolpidem tartrate tab 10 mg 1 QL (30 tabs / 30 days) zolpidem tartrate tab er 6.25 mg 1 QL (30 tabs / 30 days) zolpidem tartrate tab er 12.5 mg 1 QL (30 tabs / 30 days) ZOLPIMIST SPR 5MG 3 QL (1 bottle / 25 days),

PA ZZZQUIL CAP 25MG 3 PA; OTC ZZZQUIL LIQ 50MG/30 2 PA; OTC HYPNOTICS, TRICYCLICS


106

Drug Name Drug Tier Requirements/Limits SILENOR TAB 3MG 3 PA SILENOR TAB 6MG 3 PA MIGRAINE, ERGOTAMINE DERIVATIVES CAFERGOT TAB 1-100MG 3 PA D.H.E. 45 INJ 1MG/ML 3 PA dihydroergotamine mesylate inj 1 mg/ml 1 dihydroergotamine mesylate nasal spray 4

mg/ml 1

ERGOMAR SUB 2MG 3 PA migergot sup 2/100 1 MIGRANAL SPR 4MG/ML 3 PA MIGRAINE, SELECTIVE SEROTONIN AGONIST/NSAID TREXIMET TAB 85-500MG 3 QL (9 tabs / 25 days),

PA, ST MIGRAINE, SELECTIVE SEROTONIN AGONISTS almotriptan malate tab 6.25 mg 1 QL (6 tabs / 25 days) almotriptan malate tab 12.5 mg 1 QL (6 tabs / 25 days) AMERGE TAB 1MG 3 QL (9 tabs / 25 days),

PA, ST AMERGE TAB 2.5MG 3 QL (9 tabs / 25 days),

PA, ST AXERT TAB 6.25MG 3 QL (6 tabs / 25 days),

PA, ST AXERT TAB 12.5MG 3 QL (6 tabs / 25 days),

PA, ST eletriptan hydrobromide tab 20 mg (base

equivalent) 1 QL (6 / 30)

eletriptan hydrobromide tab 40 mg (base equivalent)

1 QL (6 / 30)

FROVA TAB 2.5MG 3 QL (9 tabs / 25 days), PA, ST

frovatriptan succinate tab 2.5 mg (base equivalent)


IMITREX INJ 4MG/0.5 3 PA, ST IMITREX INJ 4MG/0.5 3 QL (4 / 25 days), PA, ST IMITREX INJ 6MG/0.5 3 PA, ST IMITREX INJ 6MG/0.5 3 QL (4 / 25 days), PA, ST IMITREX SPR 5MG/ACT 3 QL (6 / 25 days), PA, ST IMITREX SPR 20MG/ACT 3 QL (6 / 25 days), PA, ST IMITREX TAB 25MG 3 QL (9 tabs / 25 days),

PA, ST IMITREX TAB 50MG 3 QL (9 tabs / 25 days),

PA, ST IMITREX TAB 100MG 3 QL (9 tabs / 25 days),

PA, ST MAXALT TAB 5MG 3 QL (9 tabs / 25 days),

PA, ST


107

Drug Name Drug Tier Requirements/Limits MAXALT TAB 10MG 3 QL (9 tabs / 25 days),

PA, ST MAXALT-MLT TAB 5MG 3 QL (9 tabs / 25 days),

PA, ST MAXALT-MLT TAB 10MG 3 QL (9 tabs / 25 days),

PA, ST naratriptan hcl tab 1 mg (base equiv) 1 QL (9 tabs / 25 days) naratriptan hcl tab 2.5 mg (base equiv) 1 QL (9 tabs / 25 days) RELPAX TAB 20MG 3 QL (6 tabs / 25 days),

ST RELPAX TAB 40MG 3 QL (6 tabs / 25 days),

ST rizatriptan benzoate oral disintegrating tab

5 mg (base eq) 1 QL (9 tabs / 25 days)

rizatriptan benzoate oral disintegrating tab 10 mg (base eq)


rizatriptan benzoate tab 5 mg (base equivalent)


rizatriptan benzoate tab 10 mg (base equivalent)


sumatriptan nasal spray 5 mg/act 1 QL (6 / 25 days) sumatriptan nasal spray 20 mg/act 1 QL (6 / 25 days) sumatriptan succinate inj 6 mg/0.5ml 1 QL (4 / 25 days) sumatriptan succinate solution auto-

injector 4 mg/0.5ml 1 QL (4 / 25 days)

sumatriptan succinate solution auto-injector 6 mg/0.5ml

1 QL (4 / 25 days)

sumatriptan succinate solution cartridge 4 mg/0.5ml

1

sumatriptan succinate solution cartridge 6 mg/0.5ml

1

sumatriptan succinate solution prefilled syringe 6 mg/0.5ml

1 QL (8 / 25 days)

sumatriptan succinate tab 25 mg 1 QL (9 tabs / 25 days) sumatriptan succinate tab 50 mg 1 QL (9 tabs / 25 days) sumatriptan succinate tab 100 mg 1 QL (9 tabs / 25 days) SUMAVEL DOSE INJ 4MG/0.5 3 ST SUMAVEL DOSE INJ 6MG/0.5 3 ST zolmitriptan orally disintegrating tab 2.5


zolmitriptan orally disintegrating tab 5 mg 1 QL (6 tabs / 25 days) zolmitriptan tab 2.5 mg 1 QL (6 tabs / 25 days) zolmitriptan tab 5 mg 1 QL (6 tabs / 25 days) ZOMIG SPR 2.5MG 3 QL (1 box / 25 days), ST ZOMIG SPR 5MG 2 QL (1 bottle / 25 days) ZOMIG TAB 2.5MG 3 QL (6 tabs / 25 days),

PA, ST


108

Drug Name Drug Tier Requirements/Limits ZOMIG TAB 5MG 3 QL (6 tabs / 25 days),

PA, ST ZOMIG ZMT TAB 2.5 MG 3 QL (6 tabs / 25 days),

PA, ST ZOMIG ZMT TAB 5MG 3 QL (6 tabs / 25 days),

PA, ST MISCELLANEOUS BLOXIVERZ INJ 5MG/10ML 3 PA BLOXIVERZ INJ 10/10ML 3 PA caffeine & sodium benzoate inj 125-125

mg/ml (500 mg/2ml) 1

DOPRAM INJ 20MG/ML 3 PA doxapram hcl inj 20 mg/ml 1 GUANIDINE TAB 125MG 3 HYLENEX INJ 150 UNIT 3 PA NEOSTIG METH INJ 10/10ML 3 PA NEOSTIGMINE INJ 5MG/10ML 3 PA neostigmine methylsulfate inj 0.5 mg/ml

(1:2000) 1

neostigmine methylsulfate inj 1 mg/ml 1 neostigmine methylsulfate iv soln 5 mg/10

ml (0.5 mg/ml) 1

neostigmine methylsulfate iv soln 10 mg/10 ml (1 mg/ml)

1

REGONOL INJ 5MG/ML 3 RILUTEK TAB 50MG 3 QL (60 tabs / 30 days),

PA riluzole tab 50 mg 1 QL (60 tabs / 30 days) VITRASE INJ 200/ML 3 PA MOOD STABILIZERS EQUETRO CAP 100MG 3 ST EQUETRO CAP 200MG 3 ST EQUETRO CAP 300MG 3 ST lithium carbonate cap 150 mg 1 lithium carbonate cap 300 mg 1 lithium carbonate cap 600 mg 1 lithium carbonate tab 300 mg 1 lithium carbonate tab er 300 mg 1 lithium carbonate tab er 450 mg 1 LITHIUM SOL 8MEQ/5ML 3 LITHOBID TAB 300MG CR 3 PA MOVEMENT DISORDER DRUGS AUSTEDO TAB 6MG 3 QL (60 / 30), PA AUSTEDO TAB 9MG 3 QL (60 / 30), PA AUSTEDO TAB 12MG 3 QL (120 / 30), PA INGREZZA CAP 40MG 3 QL (60 / 30), PA


109

Drug Name Drug Tier Requirements/Limits tetrabenazine tab 12.5 mg 1 QL (90 tabs / 30 days) tetrabenazine tab 25 mg 1 QL (120 tabs / 30 days) MULTIPLE SCLEROSIS AMPYRA TAB 10MG 2 QL (60 tabs / 30 days),

PA AUBAGIO TAB 7MG 2 QL (30 tabs / 30 days),

PA AUBAGIO TAB 14MG 2 QL (30 tabs / 30 days),

PA AVONEX KIT 30MCG 2 QL (4 boxes / 25 days),

PA AVONEX PEN KIT 30MCG 2 QL (4 boxes / 25 days),

PA AVONEX PREFL KIT 30MCG 2 QL (4 boxes / 25 days),

PA BETASERON INJ 0.3MG 3 QL (15 / 25 days), PA BETASERON INJ 0.3MG 3 QL (15 boxes / 25

days), PA COPAXONE INJ 20MG/ML 3 QL (30 / 30 days), PA COPAXONE INJ 40MG/ML 3 QL (12 / 30 days), PA EXTAVIA INJ 0.3MG 2 QL (15 boxes / 25

days), PA GILENYA CAP 0.5MG 2 QL (30 caps / 30 days),

PA glatiramer acetate soln prefilled syringe 20

mg/ml 1 QL (30 / 30 days), PA

glatiramer acetate soln prefilled syringe 40 mg/ml

1 QL (12 / 30 days), PA

glatopa inj 20mg/ml 1 QL (30 / 30 days), PA PLEGRIDY INJ 3 QL (1 / 21 days), PA PLEGRIDY INJ PEN 3 QL (1 / 21 days), PA PLEGRIDY INJ STARTER 3 QL (1 box / 21 days), PA PLEGRIDY PEN INJ STARTER 3 QL (1 box / 21 days), PA REBIF INJ 22/0.5 2 QL (12 / 25 days), PA REBIF INJ 44/0.5 2 QL (12 / 25 days), PA REBIF REBIDO INJ 22/0.5 2 QL (6 / 25 days), PA REBIF REBIDO INJ 44/0.5 2 QL (6 / 25 days), PA REBIF REBIDO INJ TITRATN 2 QL (1 box in lifetime),

PA REBIF TITRTN INJ PACK 2 QL (1 box in lifetime),

PA TECFIDERA CAP 120MG 2 QL (60 caps / 30 days),

PA TECFIDERA CAP 240MG 2 QL (60 caps / 30 days),

PA TECFIDERA MIS STARTER 2 QL (1 box in lifetime),

PA


110

Drug Name Drug Tier Requirements/Limits ZINBRYTA INJ 150MG/ML 3 QL (1 syringe / 28

days), PA MUSCULOSKELETAL THERAPY AGENTS AMRIX CAP 15MG 3 ST AMRIX CAP 30MG 3 ST baclofen tab 10 mg 1 baclofen tab 20 mg 1 carisoprodol tab 250 mg 1 QL (120 tabs / year), ST carisoprodol tab 350 mg 1 QL (120 tabs / year), ST carisoprodol w/ aspirin & codeine tab 200-

325-16 mg 1 PA

carisoprodol w/ aspirin tab 200-325 mg 1 ST chlorzoxazone tab 500 mg 1 cyclobenzaprine hcl tab 5 mg 1 cyclobenzaprine hcl tab 7.5 mg 1 cyclobenzaprine hcl tab 10 mg 1 DANTRIUM CAP 25MG 3 PA, ST DANTRIUM CAP 50MG 3 PA, ST DANTRIUM IV INJ 20MG 3 PA, ST dantrolene sodium cap 25 mg 1 dantrolene sodium cap 50 mg 1 dantrolene sodium cap 100 mg 1 PA FEXMID TAB 7.5MG 3 PA, ST GABLOFEN INJ 50MCG/ML 2 GABLOFEN INJ 10000/20 3 PA GABLOFEN INJ 20000/20 3 PA GABLOFEN INJ 40000/20 3 PA LORZONE TAB 375MG 3 ST LORZONE TAB 750MG 3 ST metaxalone tab 400 mg 1 metaxalone tab 800 mg 1 methocarbamol tab 500 mg 1 methocarbamol tab 750 mg 1 orphenadrine citrate inj 30 mg/ml 1 orphenadrine citrate tab er 12hr 100 mg 1 PARAFON FORT TAB 500MG 3 PA, ST revonto inj 20mg 1 ROBAXIN INJ 100MG/ML 3 PA, ST ROBAXIN TAB 500MG 3 PA, ST ROBAXIN-750 TAB 750MG 3 PA, ST SKELAXIN TAB 800MG 3 PA, ST SOMA TAB 250MG 3 QL (120 tabs / year),

PA, ST SOMA TAB 350MG 3 QL (120 tabs / year),

PA, ST tizanidine hcl cap 2 mg (base equivalent) 1


111

Drug Name Drug Tier Requirements/Limits tizanidine hcl cap 4 mg (base equivalent) 1 tizanidine hcl cap 6 mg (base equivalent) 1 tizanidine hcl tab 2 mg (base equivalent) 1 tizanidine hcl tab 4 mg (base equivalent) 1 ZANAFLEX CAP 2MG 3 PA, ST ZANAFLEX CAP 4MG 3 PA, ST ZANAFLEX CAP 6MG 3 PA, ST ZANAFLEX TAB 4MG 3 PA, ST MYASTHENIA GRAVIS ENLON INJ 150/15ML 3 MESTINON SYP 60MG/5ML 2 MESTINON TAB 60MG 3 PA pyridostigmine bromide tab 60 mg 1 pyridostigmine bromide tab er 180 mg 1 NARCOLEPSY/CATAPLEXY armodafinil tab 50 mg 1 QL (30 tabs / 30 days) armodafinil tab 150 mg 1 QL (30 tabs / 30 days) armodafinil tab 200 mg 1 QL (30 tabs / 30 days),

ST armodafinil tab 250 mg 1 QL (30 tabs / 30 days) modafinil tab 100 mg 1 QL (30 tabs / 30 days),

PA modafinil tab 200 mg 1 QL (60 tabs / 30 days),

PA NUVIGIL TAB 50MG 3 QL (30 tabs / 30 days),

PA, ST NUVIGIL TAB 150MG 3 QL (30 tabs / 30 days),



PA, ST PROVIGIL TAB 100MG 3 QL (30 tabs / 30 days),

PA PROVIGIL TAB 200MG 3 QL (60 tabs / 30 days),

PA XYREM SOL 500MG/ML 2 QL (540 mL / 30 days),

PA NONDEPOLARIZING MUSCLE RELAXANTS pancuronium bromide inj 1 mg/ml 1 QUELICIN INJ 20MG/ML 3 PA rocuronium bromide iv soln 50 mg/5ml (10

mg/ml) 1

rocuronium bromide iv soln 100 mg/10ml (10 mg/ml)

1

vecuronium bromide for inj 10 mg 1


112

Drug Name Drug Tier Requirements/Limits vecuronium bromide for inj 20 mg 1 POSTHERPETIC NEURALGIA GRALISE STAR MIS 300/600 3 QL (1 in lifetime), PA GRALISE TAB 300MG 3 QL (30 tabs / 30 days),

PA GRALISE TAB 600MG 3 QL (90 tabs / 30 days),

PA PSYCHOTHERAPEUTIC-MISC, ALCOHOL DETERRENTS acamprosate calcium tab delayed release

333 mg 1

ANTABUSE TAB 250MG 3 PA ANTABUSE TAB 500MG 3 PA disulfiram tab 250 mg 1 disulfiram tab 500 mg 1 VIVITROL INJ 380MG 3 PA PSYCHOTHERAPEUTIC-MISC, OPIOID ANTAGONIST EVZIO INJ 3 QL (2 / 180 days), PA naloxone hcl inj 0.4 mg/ml 1 QL (2 / 25 days), PA naloxone hcl inj 4 mg/10ml 1 QL (2 / 25 days), PA naloxone hcl soln cartridge 0.4 mg/ml 1 QL (2 / 25 days), PA naloxone hcl soln prefilled syringe 2

mg/2ml 1 QL (2 / 25 days)

naltrexone hcl tab 50 mg 1 NARCAN SPR 2 QL (2 / 30 days); $0

Copay PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONIST/OPIOID

ANTAGONIST COMBINATIONS BUNAVAIL MIS 2.1-0.3 3 QL (60 / 30 days), PA BUNAVAIL MIS 4.2-0.7 3 QL (60 / 30 days), PA BUNAVAIL MIS 6.3-1MG 3 QL (30 / 30 days), PA buprenorphine hcl-naloxone hcl sl tab 2-

0.5 mg (base equiv) 1 QL (60 ea / 30 days), PA

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

1 QL (60 ea / 30 days), PA

SUBOXONE MIS 2-0.5MG 3 QL (60 / 30 days), PA SUBOXONE MIS 4-1MG 3 QL (60 / 30 days), PA SUBOXONE MIS 8-2MG 3 QL (60 / 30 days), PA SUBOXONE MIS 12-3MG 3 QL (30 / 30 days), PA ZUBSOLV SUB 0.7-0.18 3 QL (30 ea / 30 days), PA ZUBSOLV SUB 1.4-0.36 3 QL (60 ea / 30 days), PA ZUBSOLV SUB 2.9-0.71 3 QL (60 ea / 30 days), PA ZUBSOLV SUB 5.7-1.4 3 QL (60 ea / 30 days), PA ZUBSOLV SUB 8.6-2.1 3 QL (30 ea / 30 days), PA ZUBSOLV SUB 11.4-2.9 3 QL (30 ea / 30 days), PA PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONISTS


113

Drug Name Drug Tier Requirements/Limits buprenorphine hcl sl tab 2 mg (base equiv)1 QL (60 ea / 30 days), PA buprenorphine hcl sl tab 8 mg (base equiv)1 QL (60 ea / 30 days), PA PSYCHOTHERAPEUTIC-MISC, PSEUDOBULBAR AFFECT NUEDEXTA CAP 20-10MG 2 QL (60 caps / 30 days),

PA PSYCHOTHERAPEUTIC-MISC, SMOKING DETERRENTS bupropion hcl (smoking deterrent) tab er

12hr 150 mg 1

CHANTIX PAK 0.5& 1MG 2 CHANTIX PAK 1MG 2 CHANTIX TAB 0.5MG 2 nicotine polacrilex gum 2 mg 1 OTC nicotine polacrilex gum 4 mg 1 OTC nicotine polacrilex lozenge 2 mg 1 OTC nicotine polacrilex lozenge 4 mg 1 OTC NICOTINE SYS KIT TRANSDER 2 OTC nicotine td patch 24hr 14 mg/24hr 1 OTC NICOTROL INH 3 NICOTROL NS SPR 10MG/ML 3 sm nicotine dis 7mg/24hr 1 OTC sm nicotine dis 21mg 1 OTC ZYBAN TAB 150MG SR 3 PSYCHOTHERAPEUTIC-MISC, VASOMOTOR SYMPTOM AGENTS BRISDELLE CAP 7.5MG 3 QL (30 caps / 30 days),

PA paroxetine mesylate cap 7.5 mg (base

equiv) 1 QL (30 caps / 30 days),

PA RESTLESS LEGS SYNDROME HORIZANT TAB 300MG 3 QL (60 tabs / 30 days),

PA HORIZANT TAB 600MG 3 QL (60 tabs / 30 days),

PA ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM DIS 2MG/24HR 3 PA ANDRODERM DIS 4MG/24HR 3 PA ANDROGEL GEL 1%(25MG) 3 QL (150 gm / 30 days),

PA ANDROGEL GEL 1%(50MG) 3 QL (150 gm / 30 days),

PA ANDROGEL GEL 1.62% 3 PA AXIRON SOL 30MG/ACT 3 PA DEPO-TESTOST INJ 100MG/ML 3 PA DEPO-TESTOST INJ 200MG/ML 3 PA FORTESTA GEL 10MG/ACT 3 PA NATESTO GEL 5.5MG 3 PA


114

Drug Name Drug Tier Requirements/Limits OXANDRIN TAB 2.5MG 3 PA, ST OXANDRIN TAB 10MG 3 PA, ST oxandrolone tab 2.5 mg 1 oxandrolone tab 10 mg 1 STRIANT MIS 30MG 3 PA TESTIM GEL 1%(50MG) 3 QL (150 gm / 30 days),

PA TESTONE CIK KIT 200MG/ML 3 PA testosterone cypionate im inj in oil 100

mg/ml 1

testosterone cypionate im inj in oil 200 mg/ml

1

testosterone enanthate im inj in oil 200 mg/ml

1

testosterone td gel 10mg/act (2%) 1 PA testosterone td gel 12.5 mg/act (1%) 1 QL (150 gm / 30 days),

PA testosterone td gel 25 mg/2.5gm (1%) 1 QL (150 gm / 30 days),

PA testosterone td gel 50 mg/5gm (1%) 1 QL (150 gm / 30 days),

PA testosterone td soln 30 mg/act 1 ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITOR acarbose tab 25 mg 1 acarbose tab 50 mg 1 acarbose tab 100 mg 1 GLYSET TAB 25MG 1 ST GLYSET TAB 50MG 1 ST GLYSET TAB 100MG 1 ST ANTIDIABETICS, AMYLIN ANALOGS SYMLINPEN 60 INJ 1000MCG 2 QL (4 / 25 days) SYMLNPEN 120 INJ 1000MCG 2 QL (4 / 25 days) ANTIDIABETICS, BIGUANIDE/SULFONYLUREA COMBINATIONS glipizide-metformin hcl tab 2.5-250 mg 1 glipizide-metformin hcl tab 2.5-500 mg 1 glipizide-metformin hcl tab 5-500 mg 1 glyburide-metformin tab 1.25-250 mg 1 glyburide-metformin tab 2.5-500 mg 1 glyburide-metformin tab 5-500 mg 1 ANTIDIABETICS, BIGUANIDES FORTAMET TAB 500MG 3 ST FORTAMET TAB 1000MG 3 ST GLUMETZA TAB 500MG 3 ST GLUMETZA TAB 1000MG 3 ST metformin hcl tab 500 mg 1 metformin hcl tab 850 mg 1


115

Drug Name Drug Tier Requirements/Limits metformin hcl tab 1000 mg 1 metformin hcl tab er 24hr 500 mg 1 metformin hcl tab er 24hr 750 mg 1 metformin hcl tab er 24hr modified release

500 mg 3 ST

metformin hcl tab er 24hr modified release 1000 mg

3 ST

metformin hcl tab er 24hr osmotic 500 mg 3 ST metformin hcl tab er 24hr osmotic 1000

mg 1

RIOMET SOL 2 ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4)

INHIBITOR/BIGUANIDE COMBINATIONS JANUMET TAB 50-500MG 2 ST JANUMET TAB 50-1000 2 ST JANUMET XR TAB 50-500MG 2 ST JANUMET XR TAB 50-1000 2 ST JANUMET XR TAB 100-1000 2 ST JENTADUETO TAB 2.5-500 3 PA JENTADUETO TAB 2.5-850 3 PA JENTADUETO TAB 2.5-1000 3 PA JENTADUETO TAB XR 3 QL (30 tabs / 30 days),

PA, ST KAZANO 12.5- TAB 500MG 3 PA KAZANO 12.5- TAB 1000MG 3 PA KOMBIGLYZ XR TAB 2.5-1000 3 PA KOMBIGLYZ XR TAB 5-500MG 3 PA KOMBIGLYZ XR TAB 5-1000MG 3 PA ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4)

INHIBITOR/INSULIN SENSITIZER COMBINATIONS OSENI TAB 12.5-15 3 PA OSENI TAB 12.5-30 3 PA OSENI TAB 12.5-45 3 PA OSENI TAB 25-15MG 3 PA OSENI TAB 25-30MG 3 PA OSENI TAB 25-45MG 3 PA ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA TAB 25MG 2 ST JANUVIA TAB 50MG 2 ST JANUVIA TAB 100MG 2 ST NESINA TAB 6.25MG 3 PA NESINA TAB 12.5MG 3 PA NESINA TAB 25MG 3 PA ONGLYZA TAB 2.5MG 3 PA ONGLYZA TAB 5MG 3 PA


116

Drug Name Drug Tier Requirements/Limits TRADJENTA TAB 5MG 3 PA ANTIDIABETICS, INCRETIN MIMETIC AGENT/INSULIN

COMBINATIONS SOLIQUA INJ 100/33 3 QL (30 ml / 30 days),

ST XULTOPHY INJ 100/3.6 3 QL (15 / 28), PA ANTIDIABETICS, INCRETIN MIMETIC AGENTS ADLYXIN INJ 10/20MCG 3 QL (1 per lifetime), PA,

ST ADLYXIN INJ 20MCG 3 QL (2 pens / 30), PA, ST BYDUREON INJ 2MG 3 QL (4 / 21 days), PA, ST BYDUREON PEN INJ 2MG 3 QL (4 / 21 days), PA, ST BYETTA INJ 5MCG 3 QL (1 pen / 25 days),

PA, ST BYETTA INJ 10MCG 3 QL (1 pen / 25 days),

PA, ST TANZEUM INJ 30MG 2 QL (4.5 ml / 30 days),

ST TANZEUM INJ 50MG 2 QL (4.5 ml / 30 days),

ST TRULICITY INJ 0.75/0.5 2 QL (6 / 30 days), ST TRULICITY INJ 1.5/0.5 2 QL (6 / 30 days), ST VICTOZA INJ 18MG/3ML 2 QL (3 / 30 days), ST ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATION ACTOPLUS MET TAB XR 2 pioglitazone hcl-metformin hcl tab 15-500

mg 1

pioglitazone hcl-metformin hcl tab 15-850 mg

1

ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA COMBO pioglitazone hcl-glimepiride tab 30-2 mg 1 pioglitazone hcl-glimepiride tab 30-4 mg 1 ANTIDIABETICS, INSULIN SENSITIZERS AVANDIA TAB 2MG 3 AVANDIA TAB 4MG 3 pioglitazone hcl tab 15 mg (base equiv) 1 pioglitazone hcl tab 30 mg (base equiv) 1 pioglitazone hcl tab 45 mg (base equiv) 1 ANTIDIABETICS, INSULINS AFREZZA POW 4&8 UNIT 3 QL (3 boxes / 30 days),

ST AFREZZA POW 4&8 UNIT 3 QL (90 / 30 days), ST AFREZZA POW 4/8/12UN 3 Refers to 4 & 8 & 12

UNIT pack; ST AFREZZA POW 4UNIT 3 QL (90 / 30 days), ST AFREZZA POW 8 UNIT 3 QL (90 / 30), ST


117

Drug Name Drug Tier Requirements/Limits AFREZZA POW 8&12UNIT 3 QL (3 boxes / 30 days),

ST AFREZZA POW 12 UNIT 3 QL (90 / 30), ST APIDRA INJ SOLOSTAR 3 ST APIDRA INJ U-100 3 ST BASAGLAR INJ 100UNIT 2 QL (45 ml / 30 days) HUMALOG INJ 100/ML 2 QL (50 ml / 30 days) HUMALOG KWIK INJ 100/ML 2 QL (45 ml / 30 days) HUMALOG KWIK INJ 200/ML 2 QL (24 ml / 30 days) HUMALOG MIX INJ 50/50 2 QL (50 ml / 30 days) HUMALOG MIX INJ 50/50KWP 2 QL (45 ml / 30 days) HUMALOG MIX INJ 75/25KWP 2 QL (45 ml / 30 days) HUMALOG MIX SUS 75/25 2 QL (50 ml / 30 days) HUMULIN INJ 70/30 2 QL (50 ml / 30 days);

OTC HUMULIN INJ 70/30KWP 2 QL (45 ml / 30 days);

OTC HUMULIN N INJ U-100 2 QL (50 ml / 30 days);

OTC HUMULIN N INJ U-100KWP 2 QL (45 ml / 30 days);

OTC HUMULIN R INJ U-100 2 QL (50 ml / 30 days);

OTC HUMULIN R INJ U-500 2 HUMULIN R INJ U-500 2 QL (1 vial / 30 days) LANTUS INJ 100/ML 3 QL (50 ml / 30 days),

ST LANTUS INJ SOLOSTAR 3 QL (45 ml / 30 days),

ST LEVEMIR INJ 3 QL (50 ml / 30 days),

ST LEVEMIR INJ FLEXTOUC 3 QL (45 ml / 30 days),

ST NOVOLIN INJ 70/30 3 QL (50 ml / 30 days),

ST; OTC NOVOLIN N INJ U-100 3 QL (50 ml / 30 days),

ST; OTC NOVOLIN R INJ U-100 3 QL (50 ml / 30 days),

ST; OTC NOVOLOG INJ 100/ML 3 QL (50 ml / 30 days),

ST NOVOLOG INJ FLEXPEN 3 QL (45 ml / 30 days),

ST NOVOLOG INJ PENFILL 3 QL (45 ml / 30 days),

ST NOVOLOG MIX INJ 70/30 3 QL (50 ml / 30 days),

ST


118

Drug Name Drug Tier Requirements/Limits NOVOLOG MIX INJ FLEXPEN 3 QL (45 ml / 30 days),

ST TOUJEO SOLO INJ 300IU/ML 3 QL (9 ml / 30 days), ST TRESIBA FLEX INJ 100UNIT 2 QL (45 ml / 30 days) TRESIBA FLEX INJ 200UNIT 2 QL (27 ml / 30 days) ANTIDIABETICS, MEGLITINIDE nateglinide tab 60 mg 1 nateglinide tab 120 mg 1 repaglinide tab 0.5 mg 1 repaglinide tab 1 mg 1 repaglinide tab 2 mg 1 ANTIDIABETICS, MEGLITINIDE/BIGUANIDE COMBINATIONS repaglinide-metformin hcl tab 1-500 mg 1 repaglinide-metformin hcl tab 2-500 mg 1 ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2)

INHIBITOR/BIGUANIDE COMBINATIONS INVOKAMET TAB 50-500MG 2 QL (60 tabs / 30 days),

ST (step through metformin)

INVOKAMET TAB 50-1000 2 QL (60 tabs / 30 days), ST (step through metformin)



INVOKAMET XR TAB 50-500MG 2 QL (60 tabs / 30 days), ST (step through metformin)

INVOKAMET XR TAB 50-1000 2 QL (60 tabs / 30 days), ST (step through metformin)



SYNJARDY TAB 2 ST (step through metformin)

SYNJARDY TAB 5-500MG 2 ST (step through metformin)

SYNJARDY TAB 5-1000MG 2 ST (step through metformin)


119

Drug Name Drug Tier Requirements/Limits SYNJARDY TAB 12.5-500 2 ST (step through

metformin) SYNJARDY XR TAB 2 ST (step through

metformin) SYNJARDY XR TAB 5-1000MG 2 ST (step through

metformin) SYNJARDY XR TAB 10-1000 2 ST (step through

metformin) SYNJARDY XR TAB 25-1000 2 ST (step through

metformin) XIGDUO XR TAB 5-500MG 3 ST XIGDUO XR TAB 5-1000MG 3 ST XIGDUO XR TAB 10-500MG 3 ST XIGDUO XR TAB 10-1000 3 ST ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2)

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

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

ST INVOKANA TAB 100MG 2 QL (60 tabs / 30 days),

ST (step through metformin)

INVOKANA TAB 300MG 2 QL (30 tabs / 30 days), ST (step through metformin)

JARDIANCE TAB 10MG 2 QL (60 / 30), ST (step through metformin)

JARDIANCE TAB 25MG 2 QL (30 / 30), ST (step through metformin)

ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR/DPP-4 INHIBITOR COMBINATIONS

GLYXAMBI TAB 10-5 MG 3 QL (30 tabs / 30 days), ST

GLYXAMBI TAB 25-5 MG 3 QL (30 tabs / 30 days), ST

ANTIDIABETICS, SULFONYLUREAS chlorpropamide tab 100 mg 1 chlorpropamide tab 250 mg 1 glimepiride tab 1 mg 1 glimepiride tab 2 mg 1 glimepiride tab 4 mg 1 glipizide tab 5 mg 1 glipizide tab 10 mg 1 glipizide tab er 24hr 5 mg 1 glipizide tab er 24hr 10 mg 1


120

Drug Name Drug Tier Requirements/Limits glipizide xl tab 2.5mg 1 glyburide micronized tab 1.5 mg 1 glyburide micronized tab 3 mg 1 glyburide micronized tab 6 mg 1 glyburide tab 1.25 mg 1 glyburide tab 2.5 mg 1 glyburide tab 5 mg 1 tolazamide tab 250 mg 1 tolazamide tab 500 mg 1 tolbutamide tab 500 mg 1 ANTIDIABETICS, SUPPLIES ACCU-CHEK IN LIQ CONTROL 2 OTC ACCU-CHEK KIT AVA CONN 2 QL (1 kit / year); OTC ACCU-CHEK KIT AVIVA PL 2 QL (1 kit / year); OTC ACCU-CHEK KIT COMBO 2 ACCU-CHEK KIT COMPACT 2 QL (1 kit / year); OTC ACCU-CHEK KIT FASTCLIX 2 OTC ACCU-CHEK KIT MLTICLIX 2 OTC ACCU-CHEK KIT NANO 2 QL (1 kit / year); OTC ACCU-CHEK KIT SOFTCLIX 2 OTC ACCU-CHEK KIT VOICEMAT 2 QL (1 kit / year); OTC ACCU-CHEK LIQ COMPACT 2 OTC ACCU-CHEK LIQ SMART 2 OTC ACCU-CHEK SOL 2 OTC ACCU-CHEK SOL COMPACT 2 OTC ACCU-CHEK TES AVIVA PL 2 QL (210 strips / 30

days); OTC ACCU-CHEK TES COMPACT 2 QL (210 strips / 30

days); OTC ACCU-CHEK TES SMART 2 QL (210 strips / 30

days); OTC ACCUTREND TES GLUCOSE 2 QL (210 strips / 30

days); OTC ACETEST TAB TABLETS 2 OTC ADVOCATE ARM MIS BPM LRG 3 QL (1 kit / year), PA;

OTC ALCOH-WIPE MIS 12"X12" 3 QL (3 boxes / 30 days) AUTOSHIELD MIS 29X3/16" 2 OTC AUTOSHIELD MIS 29X5/16" 2 OTC AUTOSHIELD MIS 30GX3/16 2 OTC CAREFINE MIS 32GX5MM 2 OTC CARTRIDGE MIS PUMP 3 CHEMSTRIP TES STRIPS 2 OTC CLINITEST TAB 2 DROP 2 OTC COMFORT EZ MIS 33GX5MM 2 OTC COMFORT EZ MIS 33GX6MM 2 OTC


121

Drug Name Drug Tier Requirements/Limits COMFORT EZ MIS 33GX8MM 2 OTC CVS KETONE TES CARE 2 QL (210 strips / 30

days); OTC DELTEC COZMO MIS INL PUMP 2 DIASTIX TES STRIPS 2 QL (210 strips / 30

days); OTC FREESTYLE KIT FREEDOM 2 QL (1 kit / year); OTC FREESTYLE KIT INSULINX 2 QL (1 kit / year); OTC FREESTYLE KIT SIDEKICK 2 QL (1 kit / year); OTC FREESTYLE KIT SYSTEM 2 QL (1 kit / year); OTC FREESTYLE LIQ CONTROL 2 OTC FREESTYLE MIS LITE 2 QL (1 kit / year); OTC FREESTYLE TES 2 QL (210 strips / 30

days); OTC FREESTYLE TES INSULINX 2 QL (210 strips / 30

days); OTC FREESTYLE TES LITE 2 QL (210 strips / 30

days); OTC G4 SENSOR MIS 3 QL (1 kit / year), PA GENTLE-LET MIS PLATFORM 2 QL (210 lancets / 30

days); OTC GUARDIAN RT MIS REPLACE 3 QL (1 kit / year), PA H-TRON PLUS MIS INS PUMP 2 OTC HUMAPEN MIS LUXURA 3 PA INFUSION SET MIS 23" 6MM 2 INFUSION SET MIS 23" 8MM 2 INFUSION SET MIS 23"/6MM 2 INFUSION SET MIS 23"/9MM 2 INFUSION SET MIS 24" 6MM 2 INFUSION SET MIS 24" 9MM 2 INFUSION SET MIS 31" 9MM 2 INFUSION SET MIS 32" 8MM 2 INFUSION SET MIS 43"/6MM 2 INFUSION SET MIS 43"/9MM 2 INSUL-TRAY MIS 3 PA; OTC INSULIN PEN MIS 31GX4MM 2 OTC INSULIN PUMP KIT IR2020 2 INSULIN PUMP KIT IR2020 2 PA INSULIN SYR MIS 0.3/31G 2 QL (210 syringes / 30

days); OTC INSULIN SYR MIS 0.5/31G 2 QL (210 syringes / 30

days); OTC INSULIN SYR MIS 1ML/31G 2 QL (210 syringes / 30

days); OTC INSULIN SYRG MIS 0.3/28G 2 QL (210 syringes / 30

days); OTC


122

Drug Name Drug Tier Requirements/Limits INSULIN SYRG MIS 0.3/29G 2 QL (210 syringes / 30

days) INSULIN SYRG MIS 0.3/29G 2 QL (210 syringes / 30












days); OTC INSULIN SYRG MIS 1ML 2 QL (210 syringes / 30

days) INSULIN SYRG MIS 1ML/25G 2 QL (210 syringes / 30

days); OTC INSULIN SYRG MIS 1ML/26G 2 QL (210 syringes / 30









days); OTC


123

Drug Name Drug Tier Requirements/Limits INSULIN SYRG MIS 1ML/31G 2 QL (210 syringes / 30

days); OTC INSULIN SYRG MIS 2/27.5G 2 QL (210 syringes / 30


days); OTC INSUPEN MIS 32GX4MM 2 OTC INSUPEN MIS 33GX4MM 2 OTC INSUPEN SENS MIS 32GX6MM 2 OTC INSUPEN SENS MIS 32GX8MM 2 OTC INSUPEN ULTR MIS 30GX8MM 2 OTC KETONE TEST TES 3 OTC LANCETS MIS 2 QL (210 lancets / 30

days); OTC LANCING DEVI MIS 2 OTC LITETOUCH MIS 29GX12.7 2 OTC MICRO-BUMIN KIT 3 PA; OTC MINILINK RT KIT STARTER 3 PA NOVOTWIST MIS 32GX5MM 2 OMNIPOD KIT STARTER 2 OMNIPOD MIS 2 ONETOUCH PNG KIT INS PUMP 2 PA PEN NEEDLES MIS 29GX1/2" 2 OTC PEN NEEDLES MIS 29GX10MM 2 OTC PEN NEEDLES MIS 31GX1/4" 2 OTC PEN NEEDLES MIS 31GX5/16 2 OTC SOF-SENSOR MIS 3 PA UNIFINE PNTP MIS 31GX3/16 2 OTC ANTIDOTES ACETADOTE INJ 200MG/ML 3 PA acetylcysteine inj 200 mg/ml 1 PA ATROPEN INJ 0.5MG 3 PA ATROPEN INJ 1MG 3 PA ATROPEN INJ 2MG 3 PA BAL IN OIL INJ 100MG/ML 3 PA CA-DTPA SOL 1000MG 3 PA CALCIUM DISO INJ 1GM/5ML 3 PA CYANOKIT INJ 5GM 3 PA DIGIFAB INJ 40MG 3 PA DUODOTE INJ 3 PA flumazenil iv soln 0.5 mg/5ml (0.1 mg/ml) 1 flumazenil iv soln 1 mg/10ml (0.1 mg/ml) 1 fomepizole inj 1 gm/ml (for iv infusion) 1 methylene blue inj 1% 1 NITHIODOTE KIT 3 PA PHYSOS SALIC INJ 1MG/ML 3


124

Drug Name Drug Tier Requirements/Limits PRALIDOXIME INJ 600/2ML 3 PA PROTOPAM CHL INJ 1GM 2 SOD NITRITE INJ 30MG/ML 3 PA sodium thiosulfate inj 25% 1 ZN-DTPA SOL 1000MG 3 PA CALCIUM RECEPTOR ANTAGONISTS SENSIPAR TAB 30MG 2 QL (60 tabs / 30 days),

PA SENSIPAR TAB 60MG 2 QL (60 tabs / 30 days),

PA SENSIPAR TAB 90MG 2 QL (120 tabs / 30 days),

PA CALCIUM REGULATORS, BISPHOSPHONATES ACTONEL TAB 5MG 3 PA, ST ACTONEL TAB 30MG 3 PA, ST ACTONEL TAB 35MG 3 QL (4 tabs / 25 days),

PA, ST ACTONEL TAB 150MG 3 QL (1 tab / 25 days),

PA, ST alendronate sodium oral soln 70 mg/75ml 1 QL (300 / 30 days) alendronate sodium tab 5 mg 1 alendronate sodium tab 10 mg 1 alendronate sodium tab 35 mg 1 alendronate sodium tab 40 mg 1 alendronate sodium tab 70 mg 1 ATELVIA TAB 3 QL (4 tab / 25 days),

PA, ST BINOSTO TAB 70MG 3 ST BONIVA TAB 150MG 3 QL (1 tab / 25 days),

PA, ST etidronate disodium tab 200 mg 1 etidronate disodium tab 400 mg 1 FOSAMAX + D TAB 70-2800 3 QL (4 tabs / 25 days),

ST FOSAMAX + D TAB 70-5600 3 QL (4 tabs / 25 days),

ST FOSAMAX TAB 70MG 3 PA, ST ibandronate sodium tab 150 mg (base

equivalent) 1 QL (1 tab / 25 days)

risedronate sodium tab 5 mg 1 risedronate sodium tab 30 mg 1 risedronate sodium tab 35 mg 1 QL (4 tabs / 25 days) risedronate sodium tab 150 mg 1 QL (1 tab / 25 days) risedronate sodium tab delayed release 35


CALCIUM REGULATORS, CALCITONINS


125

Drug Name Drug Tier Requirements/Limits calcitonin (salmon) nasal soln 200 unit/act 1 MIACALCIN SPR 200/ACT 3 PA, ST CALCIUM REGULATORS, PARATHYROID HORMONES FORTEO SOL 600/2.4 2 QL (1 pen / 28 days), PA NATPARA INJ 25MCG 3 QL (2 pens / 28 days),

PA NATPARA INJ 50MCG 3 QL (2 pens / 28 days),



PA TYMLOS INJ 2 QL (1 pen / 30 days), PA CALCIUM REGULATORS, RANK LIGAND INHIBITORS PROLIA SOL 60MG/ML 3 QL (1 syringe / 180

days), PA CONTRACEPTIVES, BIPHASIC azurette tab 28 day 1 MIRCETTE TAB 28 DAY 3 PA NECON TAB 10/11-28 3 PA CONTRACEPTIVES, EMERGENCY CONTRACEPTION ELLA TAB 30MG 3 PA levonorgestrel tab 1.5 mg 1 my way tab 1.5mg 1 OTC PLAN B TAB 1.5MG 3 PA; OTC CONTRACEPTIVES, EXTENDED CYCLE amethia tab 1 QL (91 tabs / 91 days) fayosim tab 1 QL (91 tabs / 91 days) levonorg-eth est tab 0.1-0.02mg(84) & eth

est tab 0.01mg(7) 1 QL (91 tabs / 91 days)

LOSEASONIQUE TAB 3 QL (91 tabs / 91 days), PA

QUARTETTE TAB 3 QL (91 tabs / 91 days), PA

quasense tab 1 QL (91 tabs / 91 days) rivelsa tab 1 QL (91 tabs / 91 days) SEASONIQUE TAB 3 QL (91 tabs / 91 days),

PA CONTRACEPTIVES, FOUR PHASE NATAZIA TAB 3 PA CONTRACEPTIVES, IMPLANT NEXPLANON IMP 68MG 2 CONTRACEPTIVES, INJECTABLE DEPO-PROVERA INJ 150MG/ML 3 QL (1 syringe / 75

days), PA


126

Drug Name Drug Tier Requirements/Limits DEPO-PROVERA INJ 150MG/ML 3 QL (1 vial / 75 days), PA DEPO-SQ PROV INJ 104 3 PA medroxyprogesterone acetate im susp 150

mg/ml 1 QL (1 vial / 75 days)

medroxyprogesterone acetate im susp prefilled syr 150 mg/ml

1 QL (1 syringe / 75 days)

CONTRACEPTIVES, INTRAUTERINE DEVICE PARAGARD IUD T380A 2 CONTRACEPTIVES, MISCELLANEOUS CONCEPTION KIT 2 FEMCAP MIS 22MM 3 FEMCAP MIS 26MM 2 FEMCAP MIS 30MM 2 WIDE-SEAL DPR KIT 60 3 PA WIDE-SEAL DPR KIT 65 3 PA WIDE-SEAL DPR KIT 70 3 PA WIDE-SEAL DPR KIT 75 3 PA WIDE-SEAL DPR KIT 80 3 PA WIDE-SEAL DPR KIT 85 3 PA WIDE-SEAL DPR KIT 90 3 PA WIDE-SEAL DPR KIT 95 3 PA CONTRACEPTIVES, MONOPHASIC aubra tab 0.1-0.02 1 QL (30 tabs / 30 days) BEYAZ TAB 3 QL (30 tabs / 30 days),

PA chateal tab 0.15/30 1 QL (30 tabs / 30 days) cyred tab 1 QL (30 tabs / 30 days) DESOGEN-28 TAB 3 QL (30 tabs / 30 days),

PA drospirenone-ethinyl estrad-levomefolate

tab 3-0.02-0.451 mg 1 QL (30 tabs / 30 days)

drospirenone-ethinyl estrad-levomefolate tab 3-0.03-0.451 mg


drospirenone-ethinyl estradiol tab 3-0.03 mg


FEMCON FE CHW 3 QL (30 ea / 30 days), PA GENERESS FE CHW 3 QL (30 ea / 30 days), PA layolis fe chw 1 QL (30 ea / 30 days) LO LOESTRIN TAB 3 PA LOESTRIN 21 TAB 1.5/30 3 QL (30 tabs / 30 days),

PA LOESTRIN FE TAB 1.5/30 3 QL (30 tabs / 30 days),

PA LOESTRIN FE TAB 1/20 3 QL (30 tabs / 30 days),

PA


127

Drug Name Drug Tier Requirements/Limits LOESTRIN TAB 1/20-21 3 QL (30 tabs / 30 days),

PA low-ogestrel tab 1 QL (30 tabs / 30 days) micrgstin 24 tab fe 1/20 1 QL (30 tabs / 30 days) microgestin tab 1.5/30 1 QL (30 tabs / 30 days) microgestin tab 1/20 1 QL (30 tabs / 30 days) microgestin tab fe1.5/30 1 QL (30 tabs / 30 days) MINASTRIN 24 CHW FE 3 QL (30 ea / 30 days), PA MODICON TAB 0.5/35 3 QL (30 tabs / 30 days),

PA mononessa tab 1 QL (30 tabs / 30 days) necon tab 0.5/35 1 QL (30 tabs / 30 days) necon tab 1/35 1 QL (30 tabs / 30 days) necon tab 1/50-28 1 QL (30 tabs / 30 days) ogestrel tab 1 QL (30 tabs / 30 days) ORTHO-CYCLEN TAB 0.25/35 3 QL (30 tabs / 30 days),

PA ORTHO-NOVUM TAB 1/35 3 QL (30 tabs / 30 days),

PA OVCON-35 TAB 3 QL (30 tabs / 30 days),

PA SAFYRAL TAB 3 QL (30 tabs / 30 days),

PA tarina fe tab 1/20 1 QL (30 tabs / 30 days) vestura tab 3-0.02mg 1 QL (30 tabs / 30 days) YASMIN 28 TAB 3-0.03MG 3 QL (30 tabs / 30 days),

PA YAZ TAB 3-0.02MG 3 QL (30 tabs / 30 days),

PA zenchent fe chw 0.4mg-35 1 QL (30 ea / 30 days) zenchent tab 1 QL (30 tabs / 30 days) zovia 1/35e tab 1 QL (30 tabs / 30 days) zovia 1/50e tab 1 QL (30 tabs / 30 days) CONTRACEPTIVES, PROGESTIN INTRAUTERINE DEVICE LILETTA IUD 52MG 2 MIRENA IUD SYSTEM 2 SKYLA IUD 13.5MG 2 CONTRACEPTIVES, PROGESTIN ONLY lyza tab 0.35mg 1 ORTHO MICRON TAB 0.35MG 3 PA CONTRACEPTIVES, TRANSDERMAL xulane dis 150-35 1 QL (3 ea / 25 days) CONTRACEPTIVES, TRIPHASIC caziant pak 1 CYCLESSA PAK 3 PA enpresse-28 tab 1


128

Drug Name Drug Tier Requirements/Limits ESTROSTEP FE TAB 3 PA leena tab 1 necon tab 7/7/7 1 ORTHO TRI- TAB CYCLEN 3 PA ORTHO TRI- TAB CYCLN LO 3 PA ORTHO-NOVUM TAB 7/7/7 3 PA tilia fe tab 1 TRI-NORINYL TAB 28 3 PA trinessa lo tab 1 trinessa tab 1 CONTRACEPTIVES, VAGINAL NUVARING MIS 3 QL (1 ring / 21 days) ENDOMETRIOSIS danazol cap 50 mg 1 danazol cap 100 mg 1 danazol cap 200 mg 1 SYNAREL SOL 2MG/ML 3 QL (40 / 25 days), PA ESTROGEN/PROGESTIN, ORAL ACTIVELLA TAB 0.5-0.1 3 PA, ST ACTIVELLA TAB 1-0.5MG 3 PA, ST estradiol & norethindrone acetate tab 0.5-

0.1 mg 1

estradiol & norethindrone acetate tab 1-0.5 mg

1

FEMHRT TAB 0.5-2.5 3 PA, ST fyavolv tab 1-5 1 jevantique l tab 0.5-2.5 1 PREFEST TAB 3 ST PREMPHASE TAB 2 PREMPRO TAB 0.3-1.5 2 PREMPRO TAB 0.45-1.5 2 PREMPRO TAB 0.625-5 2 PREMPRO TAB .625-2.5 2 ESTROGEN/PROGESTIN, TRANSDERMAL CLIMARA PRO DIS WEEKLY 3 ST COMBIPATCH DIS .05/.14 3 QL (8 ea / 25 days), ST COMBIPATCH DIS .05/.25 3 QL (84 per 365 days),

ST ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR

COMBINATIONS DUAVEE TAB 0.45-20 3 ST ESTROGENS, INJECTABLE DELESTROGEN INJ 10MG/ML 3 PA DELESTROGEN INJ 20MG/ML 3 PA DELESTROGEN INJ 40MG/ML 3 PA


129

Drug Name Drug Tier Requirements/Limits DEPO-ESTRADI INJ 5MG/ML 3 PA estradiol valerate im in oil 20 mg/ml 1 estradiol valerate im in oil 40 mg/ml 1 PREMARIN INJ 25MG 3 PA ESTROGENS, ORAL ESTRACE TAB 0.5MG 3 PA, ST ESTRACE TAB 1MG 3 PA, ST ESTRACE TAB 2MG 3 PA, ST estradiol tab 0.5 mg 1 estradiol tab 1 mg 1 estradiol tab 2 mg 1 estropipate tab 0.75 mg 1 estropipate tab 1.5 mg 1 estropipate tab 3 mg 1 MENEST TAB 0.3MG 2 MENEST TAB 0.625MG 2 MENEST TAB 1.25MG 2 MENEST TAB 2.5MG 2 PREMARIN TAB 0.3MG 3 ST PREMARIN TAB 0.9MG 3 ST PREMARIN TAB 0.45MG 3 ST PREMARIN TAB 0.625MG 3 ST PREMARIN TAB 1.25MG 3 ST ESTROGENS, TRANSDERMAL ALORA DIS 0.1MG 3 QL (8 ea / 25 days), ST ALORA DIS 0.05MG 3 QL (8 ea / 25 days), ST ALORA DIS 0.025MG 3 QL (8 ea / 25 days), ST ALORA DIS 0.075MG 3 QL (8 ea / 25 days), ST CLIMARA DIS 0.1MG 3 PA, ST CLIMARA DIS 0.05MG 3 PA, ST CLIMARA DIS 0.06MG 3 QL (4 ea / 25 days), PA,

ST CLIMARA DIS 0.025MG 3 QL (4 ea / 25 days), PA,



ST DIVIGEL GEL 0.5MG 3 ST DIVIGEL GEL 0.25MG 3 ST DIVIGEL GEL 1MG/GM 3 ST ELESTRIN GEL 0.06% 3 QL (26 gm / 25 days),

ST estradiol td patch twice weekly 0.1

mg/24hr 1 QL (8 ea / 25 days)


130

Drug Name Drug Tier Requirements/Limits estradiol td patch twice weekly 0.05

mg/24hr 1 QL (8 ea / 25 days)

estradiol td patch twice weekly 0.025 mg/24hr

1 QL (8 ea / 25 days)


1 QL (8 ea / 25 days)


1 QL (8 ea / 25 days)

estradiol td patch weekly 0.1 mg/24hr 1 QL (4 ea / 25 days) estradiol td patch weekly 0.05 mg/24hr 1 QL (4 ea / 25 days) estradiol td patch weekly 0.06 mg/24hr 1 QL (4 ea / 25 days) estradiol td patch weekly 0.025 mg/24hr 1 QL (4 ea / 25 days) estradiol td patch weekly 0.075 mg/24hr 1 QL (4 ea / 25 days) estradiol td patch weekly 0.0375 mg/24hr

(37.5 mcg/24hr) 1 QL (4 ea / 25 days)

ESTROGEL GEL 3 QL (50 gm / 25 days), ST

EVAMIST SPR 1.53MG 3 ST MENOSTAR DIS 14MCG 3 QL (4 ea / 25 days), ST MINIVELLE DIS 0.0375MG 3 QL (8 ea / 25 days), ST VIVELLE-DOT DIS 0.1MG 3 QL (8 ea / 25 days), PA,

ST VIVELLE-DOT DIS 0.05MG 3 QL (8 ea / 25 days), PA,




ST ESTROGENS, VAGINAL ESTRACE VAG CRE 0.01% 3 PA ESTRING MIS 2MG 3 QL (1 ring / 91 days),

ST FEMRING MIS 0.1MG/24 3 ST FEMRING MIS 0.05/24H 3 ST PREMARIN VAG CRE 0.625MG 3 PA yuvafem tab 10mcg 1 FERTILITY REGULATORS, OVULATION STIMULANTS,

GONADOTROPINS novarel inj 10000unt 3 PA PREGNYL INJ 10000UNT 1 PA GLUCOCORTICOID COMBINATIONS ACTIVE INJEC KIT KL-3 3 PA betamethasone sod phosphate & acetate

inj susp 6 (3-3) mg/ml 1


131

Drug Name Drug Tier Requirements/Limits CELESTONE INJ SOLUSPAN 3 PA PHYS EZ USE KIT M-PRED 3 PA GLUCOCORTICOIDS CORTEF TAB 5MG 3 PA, ST CORTEF TAB 10MG 3 PA, ST CORTEF TAB 20MG 3 PA, ST cortisone acetate tab 25 mg 1 DEPO-MEDROL INJ 20MG/ML 3 PA DEPO-MEDROL INJ 40MG/ML 3 PA DEPO-MEDROL INJ 80MG/ML 3 PA dexamethasone elixir 0.5 mg/5ml 1 dexamethasone sod phosphate

preservative free inj 10 mg/ml 1

dexamethasone sodium phosphate inj 4 mg/ml

1

dexamethasone sodium phosphate inj 10 mg/ml

1

dexamethasone sodium phosphate inj 20 mg/5ml

1


1


1

dexamethasone soln 0.5 mg/5ml 1 dexamethasone tab 0.5 mg 1 dexamethasone tab 0.75 mg 1 dexamethasone tab 1 mg 1 dexamethasone tab 1.5 mg 1 dexamethasone tab 2 mg 1 dexamethasone tab 4 mg 1 dexamethasone tab 6 mg 1 DEXPAK PAK 6 DAY 3 ST DEXPAK PAK 10 DAY 3 ST DEXPAK PAK 13 DAY 3 ST EMFLAZA TAB 6MG 3 PA EMFLAZA TAB 18MG 3 PA EMFLAZA TAB 30MG 3 PA EMFLAZA TAB 36MG 3 PA fludrocortisone acetate tab 0.1 mg 1 hydrocortisone tab 5 mg 1 hydrocortisone tab 10 mg 1 hydrocortisone tab 20 mg 1 KENALOG-10 INJ 10MG/ML 3 PA KENALOG-40 INJ 40MG/ML 3 PA MEDROL TAB 2MG 3 ST MEDROL TAB 4MG 3 PA, ST


132

Drug Name Drug Tier Requirements/Limits MEDROL TAB 8MG 3 PA, ST MEDROL TAB 16MG 3 PA, ST MEDROL TAB 32MG 3 PA, ST methylprednisolone acetate inj susp 40

mg/ml 1

methylprednisolone acetate inj susp 80 mg/ml

1

methylprednisolone sod succ for inj 40 mg (base equiv)

1


1


1

methylprednisolone tab 4 mg 1 methylprednisolone tab 8 mg 1 methylprednisolone tab 16 mg 1 methylprednisolone tab 32 mg 1 methylprednisolone tab therapy pack 4 mg

(21) 1

MILLIPRED DP PAK 5MG 3 MILLIPRED SOL 10MG/5ML 3 ST MILLIPRED TAB 5MG 3 PA ORAPRED ODT TAB 10MG 3 PA, ST ORAPRED ODT TAB 15MG 3 PA, ST ORAPRED ODT TAB 30MG 3 PA, ST PEDIAPRED SOL 6.7/5ML 3 PA, ST prednisolone sod phos orally disintegr tab

10 mg (base eq) 1

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

1

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

1

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

1

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

1

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

1

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

1

prednisone oral soln 5 mg/5ml 1 prednisone tab 1 mg 1 prednisone tab 2.5 mg 1 prednisone tab 5 mg 1 prednisone tab 10 mg 1 prednisone tab 20 mg 1 prednisone tab 50 mg 1


133

Drug Name Drug Tier Requirements/Limits prednisone tab therapy pack 5 mg (21) 1 prednisone tab therapy pack 5 mg (48) 1 prednisone tab therapy pack 10 mg (21) 1 prednisone tab therapy pack 10 mg (48) 1 RAYOS TAB 1MG 3 ST RAYOS TAB 2MG 3 ST RAYOS TAB 5MG 3 ST SOLU-CORTEF INJ 100MG 3 PA SOLU-CORTEF INJ 250MG 3 PA SOLU-CORTEF INJ 500MG 3 PA SOLU-CORTEF INJ 1000MG 3 PA SOLU-MEDROL INJ 2GM 3 PA SOLU-MEDROL INJ 40MG 3 PA SOLU-MEDROL INJ 125MG 3 PA SOLU-MEDROL INJ 500MG 3 PA SOLU-MEDROL INJ 1000MG 3 PA GLUCOSE ELEVATING AGENT GLUCAGEN INJ 1MG 2 GLUCAGEN INJ HYPOKIT 2 QL (2 boxes / 25 days) GLUCAGON KIT 1MG 2 QL (2 boxes / 25 days) glucose drnk liq 15/59ml 1 OTC glucose gel 40% 1 OTC PROGLYCEM SUS 50MG/ML 2 SM GLUCOSE CHW SOUR APP 3 OTC HUMAN GROWTH HORMONES GENOTROPIN INJ 0.2MG 3 PA GENOTROPIN INJ 0.4MG 3 PA GENOTROPIN INJ 0.6MG 3 PA GENOTROPIN INJ 0.8MG 3 PA GENOTROPIN INJ 1.2MG 3 PA GENOTROPIN INJ 1.4MG 3 PA GENOTROPIN INJ 1.6MG 3 PA GENOTROPIN INJ 1.8MG 3 PA GENOTROPIN INJ 1MG 3 PA GENOTROPIN INJ 2MG 3 PA GENOTROPIN INJ 12MG 3 PA HUMATROPE INJ 5MG 3 PA HUMATROPE INJ 6MG 3 PA HUMATROPE INJ 12MG 3 PA HUMATROPE INJ 24MG 3 PA NORDITROPIN INJ 5/1.5ML 2 PA NORDITROPIN INJ 10/1.5ML 2 PA NORDITROPIN INJ 15/1.5ML 2 PA NORDITROPIN INJ 30/3ML 2 PA NUTROPIN AQ INJ 10MG/2ML 3 PA


134

Drug Name Drug Tier Requirements/Limits NUTROPIN AQ INJ 20MG/2ML 3 PA NUTROPIN AQ INJ NUSPIN 5 3 PA OMNITROPE INJ 5.8MG 3 PA OMNITROPE INJ 10/1.5ML 3 PA SAIZEN INJ 5MG 3 PA SAIZEN INJ 8.8MG 3 PA SEROSTIM INJ 4MG 2 PA SEROSTIM INJ 5MG 3 PA SEROSTIM INJ 6MG 3 PA ZOMACTON INJ 5MG 3 PA ZOMACTON INJ 10MG 3 PA ZORBTIVE INJ 8.8MG 3 PA HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol cap 0.5 mcg 1 calcitriol cap 0.25 mcg 1 calcitriol inj 1 mcg/ml 1 calcitriol oral soln 1 mcg/ml 1 doxercalciferol cap 0.5 mcg 1 doxercalciferol cap 1 mcg 1 doxercalciferol cap 2.5 mcg 1 HECTOROL CAP 0.5MCG 3 PA HECTOROL CAP 1MCG 3 PA HECTOROL CAP 2.5MCG 3 PA HECTOROL INJ 2MCG/ML 2 paricalcitol cap 1 mcg 1 paricalcitol cap 2 mcg 1 paricalcitol cap 4 mcg 1 paricalcitol iv soln 5 mcg/ml 1 ROCALTROL CAP 0.5MCG 3 PA ROCALTROL CAP 0.25MCG 3 PA ROCALTROL SOL 1MCG/ML 3 PA ZEMPLAR CAP 1MCG 3 PA ZEMPLAR CAP 2MCG 3 PA ZEMPLAR INJ 5MCG/ML 2 PA INSULIN-LIKE GROWTH FACTOR INCRELEX INJ 40MG/4ML 2 LYSOSOMAL STORAGE DISORDERS ALDURAZYME INJ 2.9MG/5M 2 CERDELGA CAP 84MG 3 QL (30 caps / 30 days),

PA ELAPRASE INJ 6MG/3ML 2 ELELYSO INJ 200UNIT 2 PA FABRAZYME INJ 5MG 2 FABRAZYME INJ 35MG 2 LUMIZYME INJ 50MG 2


135

Drug Name Drug Tier Requirements/Limits NAGLAZYME INJ 1MG/ML 2 VPRIV INJ 400UNIT 2 ZAVESCA CAP 100MG 2 MISCELLANEOUS AMMONUL INJ 10% 3 PA cabergoline tab 0.5 mg 1 CARBAGLU TAB 200MG 2 CERVIDIL VAG MIS 10MG INS 3 PA CYSTADANE POW 2 EGRIFTA SOL 1MG 2 QL (60 / 30 days), PA EGRIFTA SOL 2MG 2 QL (60 / 30 days), PA H.P. ACTHAR INJ 80UNIT 2 QL (15 ml / 25 days),

PA HEMABATE INJ 250MCG 2 LUPR DEP-PED INJ 3M 30MG 2 QL (1 box / 84 days), PA LUPR DEP-PED INJ 7.5MG 2 QL (1 box / 21 days), PA LUPR DEP-PED INJ 11.25MG 2 QL (1 box / 21 days), PA LUPR DEP-PED INJ 11.25MG 2 QL (1 box / 70 days), PA LUPR DEP-PED INJ 15MG 2 QL (1 box / 21 days), PA methylergonovine maleate inj 0.2 mg/ml 1 PA methylergonovine maleate tab 0.2 mg 1 MYALEPT INJ 11.3MG 3 QL (30 / 30 days), PA octreotide acetate inj 50 mcg/ml (0.05

mg/ml) 1 PA

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

1 PA

octreotide acetate inj 500 mcg/ml (0.5 mg/ml)

1 PA

ORFADIN CAP 2MG 2 QL (600 caps / 30 days), PA




ORFADIN SUS 4MG/ML 2 PA oxytocin inj 10 unit/ml 1 PITOCIN INJ 10UNT/ML 3 PA PREPIDIL GEL 0.5MG/3G 3 PA PROSTIN E2 SUP 20MG 3 PA RAVICTI LIQ 1.1GM/ML 3 QL (525 / 25 days), PA SIGNIFOR INJ 0.3MG/ML 2 QL (60 / 30 days) SIGNIFOR INJ 0.6MG/ML 2 QL (60 / 30 days) SIGNIFOR INJ 0.9MG/ML 2 QL (60 / 30 days) SIGNIFOR LAR INJ 20MG 2 QL (1 vial / 30 days)


136

Drug Name Drug Tier Requirements/Limits SIGNIFOR LAR INJ 40MG 2 QL (1 vial / 30 days) SIGNIFOR LAR INJ 60MG 2 QL (1 vial / 30 days) STRENSIQ INJ 18/0.45 2 PA STRENSIQ INJ 28/0.7ML 2 PA STRENSIQ INJ 40MG/ML 2 PA STRENSIQ INJ 80/0.8ML 2 PA SYPRINE CAP 250MG 3 PA TRIPTODUR SUS 22.5MG 3 QL (1 syringe / 180

days), PA XURIDEN POW 2GM 3 PA PHENYLKETONURIA TREATMENT AGENTS KUVAN POW 100MG 2 PA KUVAN POW 500MG 2 PA KUVAN TAB 100MG 2 PA PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) cap

667 mg (169 mg ca) 1

calcium acetate (phosphate binder) tab 667 mg

1

FOSRENOL CHW 500MG 3 ST FOSRENOL CHW 750MG 3 ST FOSRENOL CHW 1000MG 3 ST lanthanum carbonate chew tab 500 mg

(elemental) 1 ST

lanthanum carbonate chew tab 750 mg (elemental)

1 ST

PHOSLO CAP 667MG 3 PA, ST PHOSLYRA SOL 3 ST RENAGEL TAB 400MG 3 ST RENAGEL TAB 800MG 3 ST RENVELA PAK 0.8GM 3 RENVELA PAK 2.4GM 3 RENVELA TAB 800MG 3 sevelamer carbonate packet 0.8 gm 1 sevelamer carbonate packet 2.4 gm 1 VELPHORO CHW 500MG 3 ST POTASSIUM-REMOVING AGENTS KAYEXALATE POW 3 PA sodium polystyrene sulfonate powder 1 sodium polystyrene sulfonate rectal susp

30 gm/120ml 1

sps sus 15gm/60 1 VELTASSA POW 8.4GM 3 PA VELTASSA POW 16.8GM 3 PA VELTASSA POW 25.2GM 3 PA PROGESTINS, INJECTABLE


137

Drug Name Drug Tier Requirements/Limits MAKENA INJ 250MG/ML 2 PA progesterone im in oil 50 mg/ml 1 PROGESTINS, ORAL AYGESTIN TAB 5MG 3 PA medroxyprogesterone acetate tab 2.5 mg 1 medroxyprogesterone acetate tab 5 mg 1 medroxyprogesterone acetate tab 10 mg 1 MEGACE ES SUS 625/5ML 3 PA megestrol acetate susp 625 mg/5ml 1 norethindrone acetate tab 5 mg 1 progesterone micronized cap 100 mg 1 progesterone micronized cap 200 mg 1 PROMETRIUM CAP 100MG 3 PA PROMETRIUM CAP 200MG 3 PA PROVERA TAB 2.5MG 3 PA PROVERA TAB 5MG 3 PA PROVERA TAB 10MG 3 PA PROGESTINS, VAGINAL CRINONE GEL 4% VAG 3 PA SELECTIVE ESTROGEN RECEPTOR MODULATOR EVISTA TAB 60MG 3 PA OSPHENA TAB 60MG 3 QL (30 tabs / 30 days),

PA raloxifene hcl tab 60 mg 1 THYROID AGENTS, ANTITHYROID AGENTS iodine solution strong 5% (lugol's) 1 methimazole tab 5 mg 1 methimazole tab 10 mg 1 propylthiouracil tab 50 mg 1 SSKI SOL 1GM/ML 3 PA TAPAZOLE TAB 5MG 3 PA TAPAZOLE TAB 10MG 3 PA THYROID SUPPLEMENTS ARMOUR THYRO TAB 15MG 2 PA ARMOUR THYRO TAB 120MG 2 ARMOUR THYRO TAB 180MG 2 ARMOUR THYRO TAB 240MG 2 ARMOUR THYRO TAB 300MG 2 CYTOMEL TAB 5MCG 3 PA, ST CYTOMEL TAB 25MCG 3 PA, ST CYTOMEL TAB 50MCG 3 PA, ST levo-t tab 88mcg 1 levo-t tab 112mcg 1 levo-t tab 137mcg 1 levo-t tab 175mcg 1


138

Drug Name Drug Tier Requirements/Limits levo-t tab 200 mcg 1 levo-t tab 300 mcg 1 levothyroxine sodium tab 25 mcg 1 levothyroxine sodium tab 50 mcg 1 levothyroxine sodium tab 75 mcg 1 levothyroxine sodium tab 100 mcg 1 levothyroxine sodium tab 125 mcg 1 levothyroxine sodium tab 150 mcg 1 liothyronine sodium iv soln 10 mcg/ml 1 liothyronine sodium tab 5 mcg 1 liothyronine sodium tab 25 mcg 1 liothyronine sodium tab 50 mcg 1 NATURE THROI TAB 162.5MG 2 NATURE-THROI TAB 16.25MG 2 PA NATURE-THROI TAB 32.5MG 2 PA NATURE-THROI TAB 48.75MG 2 PA NATURE-THROI TAB 65MG 2 PA NATURE-THROI TAB 81.25MG 2 PA NATURE-THROI TAB 97.5MG 2 PA NATURE-THROI TAB 113.75MG 2 PA NATURE-THROI TAB 130MG 2 PA NATURE-THROI TAB 146.25MG 2 NATURE-THROI TAB 195MG 2 NATURE-THROI TAB 260MG 2 NATURE-THROI TAB 325MG 2 np thyroid tab 15mg 1 np thyroid tab 30mg 1 np thyroid tab 60mg 1 np thyroid tab 90mg 1 SYNTHROID TAB 25MCG 3 PA, ST SYNTHROID TAB 50MCG 3 PA, ST SYNTHROID TAB 75MCG 3 PA, ST SYNTHROID TAB 88MCG 3 PA, ST SYNTHROID TAB 100MCG 3 PA, ST SYNTHROID TAB 112MCG 3 PA, ST SYNTHROID TAB 125MCG 3 PA, ST SYNTHROID TAB 137MCG 3 PA, ST SYNTHROID TAB 150MCG 3 PA, ST SYNTHROID TAB 175MCG 3 PA, ST SYNTHROID TAB 200MCG 3 PA, ST SYNTHROID TAB 300MCG 3 PA, ST THYROLAR-1 TAB 60MG 2 THYROLAR-1/2 TAB 30MG 2 THYROLAR-1/4 TAB 15MG 2 THYROLAR-2 TAB 120MG 2 THYROLAR-3 TAB 180MG 2


139

Drug Name Drug Tier Requirements/Limits TIROSINT CAP 13MCG 3 ST TIROSINT CAP 25MCG 3 ST TIROSINT CAP 50MCG 3 ST TIROSINT CAP 75MCG 3 ST TIROSINT CAP 88MCG 3 ST TIROSINT CAP 100MCG 3 ST TIROSINT CAP 112MCG 3 ST TIROSINT CAP 125MCG 3 ST TIROSINT CAP 137MCG 3 ST TIROSINT CAP 150MCG 3 ST TRIOSTAT INJ 10MCG/ML 3 PA WESTHROID TAB 32.5MG 2 PA WESTHROID TAB 65MG 2 PA WESTHROID TAB 97.5MG 2 PA WESTHROID TAB 130MG 2 PA VASOPRESSIN RECEPTOR ANTAGONISTS SAMSCA TAB 15MG 2 QL (30 tabs / 30 days) SAMSCA TAB 30MG 2 QL (60 tabs / 30 days) VAPRISOL INJ 20/100ML 3 PA VASOPRESSINS DDAVP INJ 4MCG/ML 3 PA DDAVP SOL 0.01% 3 PA DDAVP SPR 0.01% 3 PA DDAVP TAB 0.1MG 3 PA DDAVP TAB 0.2MG 3 PA desmopressin acetate inj 4 mcg/ml 1 desmopressin acetate nasal soln 0.01%

(refrigerated) 1

desmopressin acetate nasal spray soln 0.01%

1

desmopressin acetate nasal spray soln 0.01% (refrigerated)

1

desmopressin acetate tab 0.1 mg 1 desmopressin acetate tab 0.2 mg 1 STIMATE SOL 1.5MG/ML 2 GASTROINTESTINAL ANTACIDS alamag-plus chw 1 OTC ALUM HYDROX SUS 320/5ML 3 OTC ant/anti-gas chw 1000-60 1 OTC antacid chw 500mg 1 OTC antacid chw 550-110 1 OTC antacid chw 750mg 1 OTC antacid extr chw 675-135 1 OTC antacid mult chw -symptom 1 OTC


140

Drug Name Drug Tier Requirements/Limits antacid plus sus anti-gas 1 OTC antacid plus sus gas rel 1 OTC ANTACID ULTR CHW 1000-200 3 OTC calcium carbonate (antacid) tab 648 mg 1 OTC childrens chw pepto 1 OTC cvs antacid sus supreme 1 OTC DI-GEL SUS 3 OTC foam antacid chw 80-20mg 1 OTC foam antacid sus 1 OTC GAVISCON CHW 2 OTC GAVISCON SUS CHERRY 2 OTC GELUSIL CHW 3 PA; OTC MAG OXIDE CAP 400MG 3 PA; OTC magnesium oxide tab 250 mg 1 OTC magnesium oxide tab 400 mg 1 OTC magnesium oxide tab 420 mg 1 OTC sm antacid chw ex-str 1 OTC sodium bicarbonate tab 325 mg 1 OTC sodium bicarbonate tab 650 mg 1 OTC tgt antacid chw 1000mg 1 OTC titralac chw 420mg 1 OTC TUMS CHW 500MG 2 PA; OTC URO-MAG CAP 140MG 2 OTC ANTIDIARRHEALS anti-diarrhe liq 1mg/5ml 1 OTC anti-diarrhe tab 2mg 1 OTC diphenoxylate w/ atropine liq 2.5-0.025

mg/5ml 1

diphenoxylate w/ atropine tab 2.5-0.025 mg

1

LOMOTIL TAB 2.5MG 3 PA loperamide hcl cap 2 mg 1 loperamide sus 1mg/7.5 1 OTC MOTOFEN TAB 1-0.025 3 PA MYTESI TAB 125MG 3 QL (60 tabs / 30 days),

PA paregoric tincture 2 mg/5ml (morphine

equivalent) 1

stomach relf chw 262mg 1 OTC stomach relf sus 262/15ml 1 OTC stomach relf sus 525/15ml 1 OTC stomach relf tab 262mg 1 OTC ANTIEMETICS AKYNZEO CAP 300-0.5 3 QL (2 caps / 25 days),

ST aprepitant capsule 40 mg 1 QL (1 cap / 30 days)


141

Drug Name Drug Tier Requirements/Limits aprepitant capsule 80 mg 1 QL (4 caps / 30 days) aprepitant capsule 125 mg 1 QL (2 caps / 30 days) aprepitant capsule therapy pack 80 & 125

mg 1 QL (2 paks / 30 days)

CESAMET CAP 1MG 3 PA compro sup 25mg 1 PA DICLEGIS TAB 10-10MG 3 QL (60 tabs / 30 days),

ST dronabinol cap 2.5 mg 1 dronabinol cap 5 mg 1 dronabinol cap 10 mg 1 EMEND CAP 40MG 3 QL (1 cap / 30 days) EMEND CAP 80MG 3 QL (4 caps / 30 days) EMEND CAP 125MG 3 QL (2 caps / 30 days) EMEND SOL 150MG 2 EMEND SUS 125MG 2 EMEND TRIPAC PAK 80 & 125 3 QL (2 paks / 30 days) granisetron hcl inj 0.1 mg/ml 1 PA granisetron hcl inj 1 mg/ml 1 PA granisetron hcl inj 4 mg/4ml (1 mg/ml) 1 PA granisetron hcl tab 1 mg 1 QL (14 tabs / 25 days) MARINOL CAP 2.5MG 3 PA MARINOL CAP 5MG 3 PA MARINOL CAP 10MG 3 PA meclizine hcl tab 12.5 mg 1 meclizine hcl tab 25 mg 1 METOCLOPRAMI TAB 10MG ODT 3 ST metoclopramide hcl inj 5 mg/ml 1 metoclopramide hcl orally disintegrating

tab 5 mg (base eq) 1

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

1

metoclopramide hcl tab 5 mg 1 metoclopramide hcl tab 10 mg 1 ondansetron hcl inj 4 mg/2ml (2 mg/ml) 1 PA ondansetron hcl inj 40 mg/20ml (2 mg/ml) 1 PA ondansetron hcl oral soln 4 mg/5ml 1 ondansetron hcl tab 4 mg 1 QL (90 tabs / 30 days) ondansetron hcl tab 8 mg 1 QL (90 tabs / 30 days) ondansetron hcl tab 24 mg 1 QL (15 tabs / 30 days) ondansetron orally disintegrating tab 4 mg 1 QL (90 tabs / 30 days) ondansetron orally disintegrating tab 8 mg 1 QL (90 tabs / 30 days) PHENERGAN INJ 25MG/ML 3 PA PHENERGAN INJ 50MG/ML 3 PA phenergan sup 12.5mg 1 phenergan sup 25mg 1


142

Drug Name Drug Tier Requirements/Limits phenergan sup 50mg 1 prochlorperazine edisylate inj 5 mg/ml 1 prochlorperazine maleate tab 5 mg (base

equivalent) 1

prochlorperazine maleate tab 10 mg (base equivalent)

1

promethazine hcl inj 25 mg/ml 1 promethazine hcl inj 50 mg/ml 1 promethazine hcl syrup 6.25 mg/5ml 1 promethazine hcl tab 12.5 mg 1 promethazine hcl tab 25 mg 1 promethazine hcl tab 50 mg 1 REGLAN TAB 5MG 3 PA REGLAN TAB 10MG 3 PA SANCUSO DIS 3.1MG 3 QL (1 ptch / 5 days), PA scopolamine td patch 72hr 1 mg/3days 1 TIGAN CAP 300MG 3 PA, ST TIGAN INJ 100MG/ML 3 ST TRANSDERM-SC DIS 1.5MG 3 ST trimethobenzamide hcl cap 300 mg 1 VARUBI TAB 90MG 3 QL (4 tabs / 25 days),

ST ZOFRAN INJ 40/20ML 3 PA ZOFRAN SOL 4MG/5ML 3 PA, ST ZOFRAN TAB 4MG 3 QL (90 tabs / 30 days),

PA, ST ZOFRAN TAB 4MG ODT 3 QL (90 tabs / 30 days),

PA, ST ZOFRAN TAB 8MG 3 QL (90 tabs / 30 days),

PA, ST ZOFRAN TAB 8MG ODT 3 QL (90 tabs / 30 days),

PA, ST ZUPLENZ MIS 4MG 3 ST ZUPLENZ MIS 8MG 3 ST ANTISPASMODICS BENTYL CAP 10MG 3 PA, ST BENTYL INJ 10MG/ML 3 PA, ST BENTYL TAB 20MG 3 PA, ST chlordiazepoxide hcl-clidinium bromide cap

5-2.5 mg 1

CUVPOSA SOL 1MG/5ML 3 PA dicyclomine hcl cap 10 mg 1 dicyclomine hcl inj 10 mg/ml 1 dicyclomine hcl oral soln 10 mg/5ml 1 dicyclomine hcl tab 20 mg 1 glycopyrrolate inj 0.2 mg/ml 1


143

Drug Name Drug Tier Requirements/Limits glycopyrrolate inj 0.4 mg/2ml (0.2 mg/ml) 1 glycopyrrolate inj 1 mg/5ml (0.2 mg/ml) 1 glycopyrrolate inj 4 mg/20ml (0.2 mg/ml) 1 glycopyrrolate tab 1 mg 1 glycopyrrolate tab 2 mg 1 hyoscyamine sulfate elixir 0.125 mg/5ml 1 hyoscyamine sulfate soln 0.125 mg/ml 1 hyoscyamine sulfate tab 0.125 mg 1 hyoscyamine sulfate tab disint 0.125 mg 1 ST hyoscyamine sulfate tab er 12hr 0.375 mg 1 hyoscyamine sulfate tab sl 0.125 mg 1 LEVBID TAB 0.375 ER 3 PA LEVSIN INJ 0.5MG/ML 3 PA LEVSIN TAB 0.125MG 3 PA LEVSIN/SL SUB 0.125MG 3 PA LIBRAX CAP 5-2.5MG 3 PA methscopolamine bromide tab 2.5 mg 1 ST methscopolamine bromide tab 5 mg 1 ST PAMINE FORTE TAB 5MG 3 PA, ST PAMINE TAB 2.5MG 3 PA, ST propantheline bromide tab 15 mg 1 ST ROBINUL FORT TAB 2MG 3 PA, ST ROBINUL INJ 0.2MG/ML 3 PA, ST ROBINUL INJ 0.4/2ML 3 PA, ST ROBINUL TAB 1MG 3 PA, ST SYMAX DUOTAB TAB 3 ST CHOLELITHOLYTICS ACTIGALL CAP 300MG 3 PA CHENODAL TAB 250MG 2 URSO 250 TAB 250MG 3 PA URSO FORTE TAB 500MG 3 PA ursodiol cap 300 mg 1 ursodiol tab 250 mg 1 ursodiol tab 500 mg 1 H2-RECEPTOR ANTAGONISTS acid reducer tab 10mg 1 OTC cimetidine hcl soln 300 mg/5ml 1 cimetidine tab 200 mg 1 cimetidine tab 300 mg 1 cimetidine tab 400 mg 1 cimetidine tab 800 mg 1 famotidine for susp 40 mg/5ml 1 famotidine in nacl 0.9% iv soln 20

mg/50ml 1

famotidine inj 20 mg/2ml 1


144

Drug Name Drug Tier Requirements/Limits famotidine inj 40 mg/4ml 1 famotidine inj 200 mg/20ml 1 famotidine inj 500 mg/50ml 1 famotidine tab 20 mg 1 QL (30 tabs / 30 days) famotidine tab 40 mg 1 heartbrn rel tab 75mg 1 OTC nizatidine cap 150 mg 1 nizatidine cap 300 mg 1 nizatidine oral soln 15 mg/ml 1 PEPCID AC CHW MAX ST 3 OTC PEPCID SUS 40MG/5ML 3 PA, ST PEPCID TAB 20MG 3 QL (30 tabs / 30 days),

PA, ST PEPCID TAB 40MG 3 PA, ST ranitidine hcl cap 150 mg 1 ranitidine hcl cap 300 mg 1 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 1 ranitidine hcl tab 150 mg 1 ranitidine hcl tab 300 mg 1 ZANTAC INJ 25MG/ML 3 ST ZANTAC INJ 50MG/2ML 3 ST ZANTAC TAB 150MG 3 PA, ST ZANTAC TAB 300MG 3 PA, ST INFLAMMATORY BOWEL DISEASE, ORAL AGENTS APRISO CAP 0.375GM 2 ASACOL HD TAB 800MG 3 ST AZULFIDINE TAB 500MG 3 ST AZULFIDINE TAB 500MG EN 3 ST balsalazide disodium cap 750 mg 1 budesonide delayed release particles cap 3

mg 1

COLAZAL CAP 750MG 3 ST DELZICOL CAP 400MG 3 ST DIPENTUM CAP 250MG 3 ST GIAZO TAB 1.1GM 3 ST LIALDA TAB 1.2GM 3 mesalamine tab delayed release 1.2 gm 1 mesalamine tab delayed release 800 mg 1 PENTASA CAP 250MG CR 3 ST PENTASA CAP 500MG CR 3 ST sulfasalazine tab 500 mg 1 sulfasalazine tab delayed release 500 mg 1 UCERIS TAB 9MG 3 ST INFLAMMATORY BOWEL DISEASE, RECTAL AGENTS CANASA SUP 1000MG 2


145

Drug Name Drug Tier Requirements/Limits CORTENEMA ENE 100MG 3 PA CORTIFOAM AER 90MG 2 hydrocortisone enema 100 mg/60ml 1 mesalamine enema 4 gm 1 mesalamine rectal enema 4 gm & cleanser

wipe kit 1

ROWASA KIT 4GM 3 PA, ST SFROWASA ENE 4GM 3 ST UCERIS AER 2MG/ACT 3 ST IRRITABLE BOWEL SYNDROME WITH CONSTIPATION AMITIZA CAP 8MCG 3 QL (60 caps / 30 days),

ST AMITIZA CAP 24MCG 3 QL (60 caps / 30 days),

PA LINZESS CAP 72MCG 2 QL (30 caps / 30 days) LINZESS CAP 145MCG 2 QL (30 caps / 30 days) LINZESS CAP 290MCG 2 QL (30 caps / 30 days) IRRITABLE BOWEL SYNDROME WITH DIARRHEA alosetron hcl tab 0.5 mg (base equiv) 1 PA alosetron hcl tab 1 mg (base equiv) 1 PA LOTRONEX TAB 0.5MG 2 PA LOTRONEX TAB 1MG 2 PA VIBERZI TAB 75MG 3 QL (60 tabs / 30 days),

PA VIBERZI TAB 100MG 3 QL (60 tabs / 30 days),

PA LAXATIVES/STOOL SOFTENERS CEO-TWO SUP 3 PA; OTC COLYTE/FLAVR SOL PACKS 3 PA, ST constulose sol 10gm/15 1 docusate cal cap 240mg 1 OTC docusate sodium liquid 150 mg/15ml 1 OTC docusate sodium syrup 60 mg/15ml 1 OTC ENEMEEZ MINI ENE 2 OTC epsom salt gra 1 OTC eql castor oil 100% 1 OTC EQUALACTIN CHW 625MG 3 OTC EVAC POW 3 PA; OTC FIBER CHOICE CHW 1.5GM 3 PA; OTC fiber laxatv tab 625mg 1 OTC fiber laxtiv cap 0.52gm 1 OTC fiber select chw gummies 1 OTC FLEET LIQUID ENE GLYCERIN 2 OTC gavilyte-c sol 1 gavilyte-g sol 1 gavilyte-h kit 1


146

Drug Name Drug Tier Requirements/Limits gavilyte-n sol flav pk 1 geri-mucil pow 68% 1 OTC glycerin ped sup 1.2gm 1 OTC glycerin sup 1gm 1 OTC glycerin sup 2.1gm 1 OTC glycerin sup 2gm 1 OTC GOLYTELY SOL 3 PA, ST GOLYTELY SOL 3 ST HYDROCIL INS POW 95% 3 OTC KONDREMUL EMU 50% 3 OTC KONSYL POW 28.3% 2 OTC KONSYL POW 60.3% 3 OTC KONSYL POW 60.3% 3 PA; OTC KONSYL POW 71.67% 3 OTC KONSYL POW 100% 3 OTC KRISTALOSE PAK 10GM 3 ST KRISTALOSE PAK 20GM 3 ST lax diet sup tab 500mg 1 OTC laxative chw 15mg 1 OTC laxative tab 5mg ec 1 OTC laxative tab 15mg 1 OTC laxative tab 25mg 1 OTC magnesium citrate soln 1 OTC METAMUCIL POW 28% 3 OTC metamucil pow 28.3%org 1 OTC METAMUCIL POW 55.46% 3 OTC metamucil pow 58.6%org 1 OTC METAMUCIL POW 58.12% 3 OTC METAMUCIL POW 63% 3 OTC MILK OF MAGN SUS 800/5ML 3 ST; OTC milk of magn sus 1200/15 1 OTC mineral oil enema 1 OTC MIRALAX POW 3350 NF 3 PA, ST; OTC move along tab 100mg 1 OTC MOVIPREP SOL 3 ST NAT FIBER POW 58.6% 3 OTC naturl fiber pow 30.9% 1 OTC NULYTELY SOL FLAV PKS 3 PA, ST oral saline sol laxative 1 OTC OSMOPREP TAB 1.5GM 3 ST PEDIA-LAX LIQ 50MG 3 OTC PEDIA-LAX SUP 2.8GM 2 OTC polyethylene glycol 3350 oral packet 1 polyethylene glycol 3350 oral powder 1 PREPOPIK PAK 3 QL (30 boxes / 30

days), ST


147

Drug Name Drug Tier Requirements/Limits qc natural pow vegetabl 1 OTC ra col-rite cap 50mg 1 OTC sb fib lax pow 30% 1 OTC sb fib lax pow 33% 1 OTC sb nat fiber pow 49% 1 OTC SENNA PROMPT CAP 9-500MG 3 OTC senna tab 8.6mg 1 OTC senna-extra tab 17.2mg 1 OTC sennosides cap 8.6 mg 1 OTC sennosides syrup 8.8 mg/5ml 1 OTC sm fiber lax tab 500mg 1 OTC sm fiber pow 48.57% 1 OTC sm glycerin sup 80.7% 1 OTC sm laxative sup 10mg 1 OTC sodium phosphates - enema 1 OTC soluble fib pow therapy 1 OTC stool softnr cap 100mg 1 OTC stool softnr cap 250mg 1 OTC stool softnr tab 8.6-50mg 1 OTC SUPREP BOWEL SOL PREP KIT 3 PA total fiber pow 1 OTC UNIFIBER POW 3 OTC wal-mucil cap plus ca 1 OTC wal-mucil pow 100% 1 OTC MISCELLANEOUS ACIDOPH/PROB TAB FORMULA 3 PA; OTC ACIDOPHILUS CAP 2 OTC ACIDOPHILUS/ WAF BIFIDUS 3 OTC BIOGAIA DRO PROBIOTI 3 PA; OTC BIOGAIA MIS PROBIOTI 3 PA; OTC CARAFATE SUS 1GM/10ML 3 CARAFATE TAB 1GM 3 PA CHOLBAM CAP 50MG 3 PA CHOLBAM CAP 250MG 3 PA cromolyn sodium oral conc 100 mg/5ml 1 CULTURELLE CHW KIDS 3 OTC CULTURELLE PAK KIDS 3 OTC digestive chw advantag 1 OTC ENTEREG CAP 12MG 3 PA enulose sol 10gm/15 1 floranex tab 1 OTC FLORASTOR CAP 250MG 2 PA; OTC FLORASTOR PAK KIDS 2 OTC gas relief cap 125mg 1 OTC gas relief cap 180mg 1 OTC


148

Drug Name Drug Tier Requirements/Limits gas relief chw 80mg 1 OTC gas relief dro 40/0.6ml 1 OTC gas relief liq infants 1 OTC GAS-X EX-STR MIS 62.5MG 3 OTC GASTROCROM CON 100/5ML 3 PA GATTEX KIT 5MG 3 QL (30 boxes / 30

days), PA hemorrhoidal sup 1 OTC hemorrhoidal sup 0.25% 1 OTC KEPIVANCE INJ 6.25MG 2 LACTINEX CHW 3 PA; OTC lactobacillus acidophilus-pectin cap 1 OTC lidocaine anorectal cream 5% 1 OTC MORE-DOPHILU POW ACIDOPHI 2 PA; OTC OCALIVA TAB 5MG 3 QL (30 tabs / 30 days),

PA OCALIVA TAB 10MG 3 QL (30 tabs / 30 days),

PA PREB-2 PAK 2 PA; OTC probiotic cap 1 OTC PROBIOTIC CAP 2 PA; OTC probiotic cap gold 1 OTC probiotic pak children 1 OTC PROBIOTIC TAB 2 OTC probiotic w/ cap prebioti 1 OTC RECTIV OIN 0.4% 2 sm gas rel chw 125mg 1 OTC sm hemorrhoi oin 1 OTC sm probiotic cap 250mg 1 OTC sodium phenylbutyrate oral powder 3

gm/teaspoonful 1 PA

sodium phenylbutyrate tab 500 mg 1 PA SUCRAID SOL 8500/ML 2 sucralfate tab 1 gm 1 TRULANCE TAB 3MG 3 QL (30 / 30 days), PA VSL#3 DS PAK 900BIL 3 XERMELO TAB 250MG 2 QL (90 / 30 days), PA OPIOID-INDUCED CONSTIPATION MOVANTIK TAB 12.5MG 2 QL (30 tabs / 30 days) MOVANTIK TAB 25MG 2 QL (30 tabs / 30 days) RELISTOR INJ 8/0.4ML 3 QL (12 / 30 days), PA RELISTOR INJ 12/0.6ML 3 QL (18 / 30 days), PA RELISTOR TAB 150MG 3 QL (90 tabs / 30 days),

PA SYMPROIC TAB 0.2MG 3 QL (30 tabs / 30 days),

PA


149

Drug Name Drug Tier Requirements/Limits PANCREATIC ENZYMES CREON CAP 3000UNIT 2 CREON CAP 6000UNIT 2 CREON CAP 12000UNT 2 CREON CAP 24000UNT 2 CREON CAP 36000UNT 2 PANCREAZE CAP 4200UNIT 3 ST PANCREAZE CAP 10500UNT 3 ST PANCREAZE CAP 16800UNT 3 ST PANCREAZE CAP 21000UNT 3 ST PERTZYE CAP 3 ST VIOKACE TAB 2 VIOKACE TAB 20880 2 ZENPEP CAP 3000UNIT 2 ZENPEP CAP 5000UNIT 2 ZENPEP CAP 10000UNT 2 ZENPEP CAP 15000UNT 2 ZENPEP CAP 20000UNT 2 ZENPEP CAP 25000UNT 2 ZENPEP CAP 40000UNT 2 PROSTAGLANDINS CYTOTEC TAB 100MCG 3 PA CYTOTEC TAB 200MCG 3 PA misoprostol tab 100 mcg 1 misoprostol tab 200 mcg 1 PROTON PUMP INHIBITORS (PPI) ACIPHEX SPR CAP 5MG 3 QL (30 / 30 days), ST ACIPHEX SPR CAP 10MG 3 QL (30 / 30 days), ST ACIPHEX TAB 20MG 3 QL (30 tabs / 30 days),

PA, ST DEXILANT CAP 30MG DR 3 QL (30 caps / 30 days),

ST DEXILANT CAP 60MG DR 3 QL (30 caps / 30 days),

ST esomeprazole magnesium cap delayed

release 20 mg (base eq) 1 QL (30 caps / 30 days),

ST esomeprazole magnesium cap delayed

release 40 mg (base eq) 1 QL (30 caps / 30 days),

ST esomeprazole sodium for intravenous soln

20 mg (base equiv) 1 QL (30 / 30 days)

esomeprazole sodium for intravenous soln 40 mg (base equiv)

1 QL (30 / 30 days)

lansoprazole cap delayed release 15 mg 1 QL (30 caps / 30 days), ST

lansoprazole cap delayed release 15 mg 1 QL (30 caps / 30 days), ST; OTC


150

Drug Name Drug Tier Requirements/Limits lansoprazole cap delayed release 30 mg 1 QL (30 caps / 30 days),

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

ST; OTC NEXIUM CAP 20MG 3 QL (30 caps / 30 days),

PA, ST NEXIUM CAP 40MG 3 QL (30 caps / 30 days),

PA, ST NEXIUM GRA 2.5MG DR 3 QL (1 box / 30 days), ST NEXIUM GRA 5MG DR 3 QL (1 box / 30 days), ST NEXIUM GRA 10MG DR 3 QL (1 box / 30 days), ST NEXIUM GRA 20MG DR 3 QL (1 box / 30 days), ST NEXIUM GRA 40MG DR 3 QL (1 box / 30 days), ST NEXIUM I.V. INJ 40MG 3 QL (30 / 30 days), PA omeprazole cap delayed release 10 mg 1 QL (60 caps / 30 days) omeprazole cap delayed release 20 mg 1 QL (60 caps / 30 days) omeprazole cap delayed release 40 mg 1 QL (60 caps / 30 days) omeprazole magnesium cap dr 20.6 mg

(20 mg base equiv) 1 QL (30 caps / 30 days);

OTC OMEPRAZOLE TAB 20MG 3 QL (30 tabs / 30 days);

OTC omeprazole-sodium bicarbonate cap 20-

1100 mg 1 QL (30 caps / 30 days),

ST omeprazole-sodium bicarbonate cap 20-

1100 mg 1 QL (30 caps / 30 days),

ST; OTC omeprazole-sodium bicarbonate cap 40-

1100 mg 1 QL (30 caps / 30 days),

ST pantoprazole sodium ec tab 20 mg (base


pantoprazole sodium ec tab 40 mg (base equiv)


pantoprazole sodium for iv soln 40 mg (base equiv)

1 QL (30 / 30 days)

PREVACID CAP 15MG DR 3 QL (30 caps / 30 days), PA, ST

PREVACID CAP 30MG DR 3 QL (30 caps / 30 days), PA, ST

PREVACID TAB 15MG STB 3 QL (30 tabs / 30 days), ST

PREVACID TAB 30MG STB 3 QL (30 tabs / 30 days), ST

PRILOSEC CAP 10MG 3 QL (60 caps / 30 days), PA, ST



PRILOSEC OTC TAB 20MG 3 OTC


151

Drug Name Drug Tier Requirements/Limits PRILOSEC POW 2.5MG 3 QL (2 / 30 days), ST PRILOSEC POW 10MG 3 QL (2 / 30 days), ST PROTONIX INJ 40MG 3 QL (30 / 30 days), PA PROTONIX PAK 3 QL (30 / 30 days), ST PROTONIX TAB 20MG 3 QL (60 tabs / 30 days),

PA, ST PROTONIX TAB 40MG 3 QL (60 tabs / 30 days),

PA, ST rabeprazole sodium ec tab 20 mg 1 QL (30 tabs / 30 days),

ST ZEGERID CAP 20-1100 3 QL (30 caps / 30 days),

PA, ST ZEGERID CAP 40-1100 3 QL (30 caps / 30 days),

PA, ST ZEGERID OTC CAP 20-1100 3 QL (30 caps / 30 days),

PA, ST; OTC ZEGERID POW 20-1680 3 QL (30 / 30 days), PA,

ST ZEGERID POW 40-1680 3 QL (30 / 30 days), PA,

ST SALIVA STIMULANTS cevimeline hcl cap 30 mg 1 EVOXAC CAP 30MG 3 PA pilocarpine hcl tab 5 mg 1 pilocarpine hcl tab 7.5 mg 1 SALAGEN TAB 5MG 3 PA SALAGEN TAB 7.5MG 3 PA STEROIDS, RECTAL ANALPRAM KIT ADVANCED 3 PA EPIFOAM AER 1% 3 PA hydrocortisone acetate w/ pramoxine rectal

cream 1-1% 1

hydrocortisone rectal cream 1% 1 hydrocortisone rectal cream 2.5% 1 LIDO-HYDRO GEL 2.8-0.55 3 lidocaine-hydrocortisone acetate rectal

cream 3-0.5% 1

lidocaine-hydrocortisone acetate rectal cream kit 2-2%

1

lidocaine-hydrocortisone acetate rectal cream kit 3-0.5%

1

lidocaine-hydrocortisone acetate rectal cream kit 3-1%

1 PA

lidocaine-hydrocortisone acetate rectal gel kit 3-2.5%

1 PA

PROCORT CRE 3 PA PROCTOCORT CRE 1% 3 PA


152

Drug Name Drug Tier Requirements/Limits PROCTOFOAM AER HC 1% 3 PA ULCER THERAPY COMBINATION amoxicillin cap-clarithro tab-lansopraz cap

dr therapy pack 1

dual action chw complete 1 OTC OMECLAMOX- MIS PAK 3 PA PREVPAC MIS 3 PA PYLERA CAP 3 PA GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl tab er 24hr 10 mg 1 AVODART CAP 0.5MG 3 QL (30 caps / 30 days),

PA, ST CARDURA XL TAB 4MG 3 QL (30 tabs / 30 days),

ST CARDURA XL TAB 8MG 3 QL (30 tabs / 30 days),

ST dutasteride cap 0.5 mg 1 QL (30 caps / 30 days) dutasteride-tamsulosin hcl cap 0.5-0.4 mg 1 finasteride tab 5 mg 1 FLOMAX CAP 0.4MG 3 PA, ST JALYN CAP 3 PA, ST PROSCAR TAB 5MG 3 PA, ST RAPAFLO CAP 4MG 3 ST RAPAFLO CAP 8MG 3 ST tamsulosin hcl cap 0.4 mg 1 UROXATRAL TAB 10MG 3 PA, ST GENITOURINARY IRRIGANTS acetic acid irrigation soln 0.25% 1 argyl saline sol 0.9% 1 neomycin-polymyxin b gu irrigation soln 1 NEOSPORIN GU SOL 40/ML IR 3 PA RENACIDIN SOL 2 RESECTISOL SOL 5% 3 PA SORBITOL SOL 3% IRR 3 PA SORBITOL SOL 3.3% IRR 3 PA SORBITOL-MAN SOL 3 PA MISCELLANEOUS anti-itch cre 5-2% 1 OTC azuphen mb cap 120mg 1 PA bethanechol chloride tab 5 mg 1 bethanechol chloride tab 10 mg 1 bethanechol chloride tab 25 mg 1 bethanechol chloride tab 50 mg 1 CYSTAGON CAP 50MG 2


153

Drug Name Drug Tier Requirements/Limits CYSTAGON CAP 150MG 2 cytra k gra crystals 1 cytra-3 syp 1 ELMIRON CAP 100MG 2 HIPREX TAB 1GM 3 PA hyolev mb tab 81mg 1 PA indiomin mb cap 120mg 1 PA INTRAROSA SUP 6.5MG 3 QL (30 ea / 30 days), PA LITHOSTAT TAB 250MG 3 PA mannitol iv soln 20% 1 mannitol iv soln 25% 1 methenamine hippurate tab 1 gm 1 methenamine mandelate tab 0.5 gm 1 methenamine mandelate tab 1 gm 1 ORACIT SOL 3 PA osmitrol inj 5% 1 PA osmitrol inj 10% 1 PA osmitrol inj 15% 1 phenazopyridine hcl tab 100 mg 1 phenazopyridine hcl tab 200 mg 1 pot & sod citrates w/ cit ac soln 550-500-

334 mg/5ml 1

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

1

potassium citrate tab er 5 meq (540 mg) 1 potassium citrate tab er 10 meq (1080 mg)1 potassium citrate tab er 15 meq (1620 mg)1 PROCYSBI CAP 25MG 3 QL (900 caps / 30

days), PA PROCYSBI CAP 75MG 3 QL (900 caps / 30

days), PA PYRIDIUM TAB 100MG 3 PA PYRIDIUM TAB 200MG 3 PA relagard gel 1 PA RIMSO-50 SOL 50% 3 PA SHOHLS SOL MODIFIED 3 PA sodium citrate & citric acid soln 500-334

mg/5ml 1

THIOLA TAB 100MG 3 PA ur n-c tab 1 uramit mb cap 118mg 1 QL (120 caps / 30

days), PA URECHOLINE TAB 5MG 3 PA URECHOLINE TAB 10MG 3 PA URECHOLINE TAB 25MG 3 PA URECHOLINE TAB 50MG 3 PA


154

Drug Name Drug Tier Requirements/Limits urimar-t tab 1 UROCIT-K 5 TAB 3 PA UROCIT-K 10 TAB 3 PA UROCIT-K 15 TAB 3 PA urolet mb tab 1 urophen mb tab 81.6mg 1 PERITONEAL DIALYSIS SOLUTION DELFLEX-LC/ SOL 2.5% DEX 3 URINARY ANTISPASMODICS DETROL LA CAP 2MG 3 PA, ST DETROL LA CAP 4MG 3 PA, ST DETROL TAB 1MG 3 PA, ST DETROL TAB 2MG 3 PA, ST DITROPAN XL TAB 5MG 3 PA, ST DITROPAN XL TAB 10MG 3 PA, ST DITROPAN XL TAB 15MG 3 PA, ST ENABLEX TAB 7.5MG 3 PA, ST ENABLEX TAB 15MG 3 PA, ST flavoxate hcl tab 100 mg 1 GELNIQUE GEL 10% 3 ST MYRBETRIQ TAB 25MG 3 QL (30 tabs / 30 days),

ST MYRBETRIQ TAB 50MG 3 QL (30 tabs / 30 days),

ST oxybutynin chloride syrup 5 mg/5ml 1 oxybutynin chloride tab 5 mg 1 oxybutynin chloride tab er 24hr 5 mg 1 oxybutynin chloride tab er 24hr 10 mg 1 oxybutynin chloride tab er 24hr 15 mg 1 OXYTROL DIS 3.9MG/24 3 ST OXYTROL/WOMN DIS 3.9MG/24 3 OTC tolterodine tartrate cap er 24hr 2 mg 1 tolterodine tartrate cap er 24hr 4 mg 1 tolterodine tartrate tab 1 mg 1 tolterodine tartrate tab 2 mg 1 TOVIAZ TAB 4MG 3 ST TOVIAZ TAB 8MG 3 ST trospium chloride cap er 24hr 60 mg 1 trospium chloride tab 20 mg 1 VESICARE TAB 5MG 3 ST VESICARE TAB 10MG 3 ST VAGINAL ANTI-INFECTIVES AVC CRE 15% 3 PA CLEOCIN CRE 2% VAG 3 PA CLEOCIN SUP 100MG 3 PA


155

Drug Name Drug Tier Requirements/Limits clindamycin phosphate vaginal cream 2% 1 CLINDESSE CRE 2% 3 PA clotrimazole cre 1% vag 1 OTC clotrimazole cre 2% 1 OTC GYNAZOLE-1 CRE 2% 3 PA METROGEL-VAG GEL 0.75% 3 PA metronidazole vaginal gel 0.75% 1 miconazole 3 kit combinat 1 OTC miconazole 3 kit combo pk 1 OTC miconazole 3 sup 200mg 1 miconazole 7 cre 2% 1 OTC miconazole nitrate vaginal supp 1200 mg &

2% cream kit 1 OTC

MONISTAT 3 KIT COMBO PK 3 PA; OTC NUVESSA GEL 1.3% 3 PA sm micon 7 sup 100mg 1 OTC TERAZOL 3 CRE 0.8% 3 PA TERAZOL 7 CRE 0.4% 3 PA terconazole vaginal cream 0.4% 1 terconazole vaginal cream 0.8% 1 terconazole vaginal suppos 80 mg 1 HEMATOLOGIC ANTICOAGULANTS, INJECTABLE ANGIOMAX INJ 250MG 3 PA ARGATROBAN INJ 50MG/50M 2 PA ARGATROBAN INJ 125/125 3 PA argatroban inj 250 mg/2.5ml (concentrate

for iv infusion) 1 PA

ARIXTRA INJ 2.5/0.5 3 QL (60 per 365 days), PA

ARIXTRA INJ 5/0.4ML 3 QL (60 per 365 days), PA

ARIXTRA INJ 7.5/0.6 3 QL (60 per 365 days), PA

ARIXTRA INJ 10/0.8ML 3 QL (60 per 365 days), PA

bivalirudin for iv soln 250 mg 1 enoxaparin sodium inj 30 mg/0.3ml 1 QL (60 per 365 days) enoxaparin sodium inj 40 mg/0.4ml 1 QL (60 per 365 days) enoxaparin sodium inj 60 mg/0.6ml 1 QL (60 per 365 days) enoxaparin sodium inj 80 mg/0.8ml 1 QL (60 per 365 days) enoxaparin sodium inj 100 mg/ml 1 QL (60 per 365 days) enoxaparin sodium inj 120 mg/0.8ml 1 QL (60 per 365 days) enoxaparin sodium inj 150 mg/ml 1 QL (60 per 365 days) enoxaparin sodium inj 300 mg/3ml 1 QL (60 per 365 days)


156

Drug Name Drug Tier Requirements/Limits fondaparinux sodium subcutaneous inj 2.5

mg/0.5ml 1 QL (60 per 365 days),

PA fondaparinux sodium subcutaneous inj 5


PA fondaparinux sodium subcutaneous inj 7.5


PA fondaparinux sodium subcutaneous inj 10


PA FRAGMIN INJ 2500/0.2 3 QL (60 per 365 days),



PA FRAGMIN INJ 10000/ML 3 QL (60 per 365 days),

PA FRAGMIN INJ 12500UNT 3 QL (60 per 365 days),




PA HEP SOD/NACL INJ 25000UNT 3 PA HEPARIN SOD INJ 2000/ML 3 heparin sodium (porcine) inj 1000 unit/ml 1 heparin sodium (porcine) inj 5000 unit/ml 1 heparin sodium (porcine) inj 10000 unit/ml1 heparin sodium (porcine) inj 20000 unit/ml1 heparin sodium (porcine) pf inj 5000

unit/0.5ml 1

IPRIVASK INJ 15MG 3 QL (10 days per 365 days), PA

LOVENOX INJ 30/0.3ML 3 QL (60 per 365 days), PA




LOVENOX INJ 100MG/ML 3 QL (60 per 365 days), PA

LOVENOX INJ 120/0.8 3 QL (60 per 365 days), PA

LOVENOX INJ 150MG/ML 3 QL (60 per 365 days), PA


157

Drug Name Drug Tier Requirements/Limits LOVENOX INJ 300/3ML 3 QL (60 per 365 days),

PA ANTICOAGULANTS, ORAL BEVYXXA CAP 40MG 3 QL (86 tabs / 365 days),

PA BEVYXXA CAP 80MG 3 QL (86 tabs / 365 days),

PA COUMADIN TAB 1MG 3 PA, ST COUMADIN TAB 2.5MG 3 PA, ST COUMADIN TAB 2MG 3 PA, ST COUMADIN TAB 3MG 3 PA, ST COUMADIN TAB 4MG 3 PA, ST COUMADIN TAB 5MG 3 PA, ST COUMADIN TAB 6MG 3 PA, ST COUMADIN TAB 7.5MG 3 PA, ST COUMADIN TAB 10MG 3 PA, ST ELIQUIS TAB 2.5MG 2 QL (60 tabs / 30 days) ELIQUIS TAB 5MG 2 QL (74 tabs / 25 days) PRADAXA CAP 75MG 3 QL (60 caps / 30 days),

PA PRADAXA CAP 110MG 3 QL (120 caps / 365

days), PA PRADAXA CAP 150MG 3 QL (60 caps / 30 days),

PA SAVAYSA TAB 15MG 3 QL (30 tabs / 30 days),

ST SAVAYSA TAB 30MG 3 QL (30 tabs / 30 days),

ST SAVAYSA TAB 60MG 3 QL (30 tabs / 30 days),

ST warfarin sodium tab 1 mg 1 warfarin sodium tab 2 mg 1 warfarin sodium tab 2.5 mg 1 warfarin sodium tab 3 mg 1 warfarin sodium tab 4 mg 1 warfarin sodium tab 5 mg 1 warfarin sodium tab 6 mg 1 warfarin sodium tab 7.5 mg 1 warfarin sodium tab 10 mg 1 XARELTO STAR TAB 15/20MG 2 QL (1 kit / year) XARELTO TAB 10MG 2 QL (60 tabs / year) XARELTO TAB 15MG 2 QL (42 tabs / 25 days) XARELTO TAB 20MG 2 QL (30 tabs / 30 days) ANTIHEMOPHILIC AGENTS ADVATE INJ 250UNIT 2 ADVATE INJ 500UNIT 2


158

Drug Name Drug Tier Requirements/Limits ADVATE INJ 1000UNIT 2 ADVATE INJ 1500UNIT 2 ADVATE INJ 2000UNIT 2 ADVATE INJ 3000UNIT 2 ADVATE INJ 4000UNIT 2 ADYNOVATE INJ 250UNIT 3 ST ADYNOVATE INJ 500UNIT 3 ST ADYNOVATE INJ 1000UNIT 3 ST ADYNOVATE INJ 2000UNIT 3 ST ADYNOVATE INJ 3000UNIT 3 ST ALPHANATE INJ VWF/HUM 2 ALPHANINE SD INJ 1000UNIT 3 PA ALPHANINE SD INJ 1500UNIT 3 PA ALPROLIX INJ 500UNIT 3 PA ALPROLIX INJ 1000UNIT 3 PA ALPROLIX INJ 2000UNIT 3 PA ALPROLIX INJ 3000UNIT 3 PA BEBULIN INJ 200-1200 2 BENEFIX INJ 250UNIT 2 PA BENEFIX INJ 500UNIT 2 PA BENEFIX INJ 1000UNIT 2 PA BENEFIX INJ 2000UNIT 2 PA BENEFIX INJ 3000UNIT 2 PA COAGADEX INJ 250UNIT 3 ST COAGADEX INJ 500UNIT 3 ST CORIFACT KIT 2 ELOCTATE INJ 250UNIT 3 PA ELOCTATE INJ 500UNIT 3 PA ELOCTATE INJ 750UNIT 3 PA ELOCTATE INJ 1000UNIT 3 PA ELOCTATE INJ 1500UNIT 3 PA ELOCTATE INJ 2000UNIT 3 PA ELOCTATE INJ 3000UNIT 3 PA ELOCTATE INJ 4000UNIT 3 PA ELOCTATE INJ 5000UNIT 3 PA ELOCTATE INJ 6000UNIT 3 PA FEIBA INJ 2 HELIXATE FS INJ 250UNIT 2 HELIXATE FS INJ 500UNIT 2 HELIXATE FS INJ 1000UNIT 2 HELIXATE FS INJ 2000UNIT 2 HELIXATE FS INJ 3000UNIT 2 HEMOFIL M INJ 250UNIT 3 ST HEMOFIL M INJ 500UNIT 3 ST HEMOFIL M INJ 1000UNIT 3 ST HEMOFIL M INJ 1700UNIT 3 ST


159

Drug Name Drug Tier Requirements/Limits HUMATE-P SOL 250-600 2 HUMATE-P SOL 500-1200 2 HUMATE-P SOL 2400UNIT 2 IXINITY INJ 500UNIT 2 PA IXINITY INJ 1000UNIT 2 PA IXINITY INJ 1500UNIT 2 KOATE-DVI INJ 250UNIT 2 KOATE-DVI INJ 500UNIT 2 KOATE-DVI INJ 1000UNIT 2 KOGENATE FS INJ 250/BS 3 ST KOGENATE FS INJ 250UNIT 3 ST KOGENATE FS INJ 500/BS 3 ST KOGENATE FS INJ 500UNIT 3 ST KOGENATE FS INJ 1000/BS 3 ST KOGENATE FS INJ 1000UNIT 3 ST KOGENATE FS INJ 2000/BS 3 ST KOGENATE FS INJ 2000UNIT 3 ST KOGENATE FS INJ 3000/BS 3 ST KOGENATE FS INJ 3000UNIT 3 ST KOVALTRY INJ 250UNIT 2 KOVALTRY INJ 500UNIT 2 KOVALTRY INJ 1000UNIT 2 KOVALTRY INJ 2000UNIT 3 KOVALTRY INJ 3000UNIT 2 MONOCLATE-P INJ 1000UNIT 3 ST MONOCLATE-P INJ 1500UNIT 3 ST MONONINE INJ 500UNIT 3 PA MONONINE INJ 1000UNIT 2 PA NOVOEIGHT INJ 250UNIT 2 NOVOEIGHT INJ 500UNIT 2 NOVOEIGHT INJ 1000UNIT 2 NOVOEIGHT INJ 1500UNIT 2 NOVOEIGHT INJ 2000UNIT 2 NOVOSEVEN RT INJ 1MG 2 NOVOSEVEN RT INJ 2MG 2 NOVOSEVEN RT INJ 5MG 2 NOVOSEVEN RT INJ 8MG 2 NUWIQ INJ 250UNIT 3 ST NUWIQ INJ 500UNIT 3 ST NUWIQ INJ 1000UNIT 3 ST NUWIQ INJ 2000UNIT 2 ST NUWIQ KIT 250UNIT 3 ST NUWIQ KIT 500UNIT 3 ST NUWIQ KIT 1000UNIT 3 ST NUWIQ KIT 2000UNIT 3 ST OBIZUR INJ 500 UNIT 3 PA


160

Drug Name Drug Tier Requirements/Limits PROFILNINE INJ 500UNIT 2 PA PROFILNINE INJ 1000UNIT 2 PA PROFILNINE INJ 1500UNIT 2 PA RECOMBINATE INJ 2 RECOMBINATE INJ 220-400 2 PA RECOMBINATE INJ 401-800 2 PA RECOMBINATE INJ 801-1240 2 PA RIASTAP SOL 1GM 2 RIXUBIS INJ 250 UNIT 3 PA RIXUBIS INJ 500UNIT 3 PA RIXUBIS INJ 1000UNIT 3 PA RIXUBIS INJ 2000UNIT 3 PA RIXUBIS INJ 3000UNIT 3 PA TRETTEN INJ 2 XYNTHA INJ 250UNIT 2 XYNTHA INJ 500UNIT 2 XYNTHA INJ 1000UNIT 2 XYNTHA INJ 2000UNIT 2 XYNTHA SOLOF INJ 3000UNIT 2 HEMATOPOIETIC GROWTH FACTORS ARANESP INJ 10MCG 3 PA ARANESP INJ 25MCG 3 PA ARANESP INJ 40MCG 3 PA ARANESP INJ 60MCG 3 PA ARANESP INJ 100MCG 3 PA ARANESP INJ 150MCG 3 PA ARANESP INJ 200MCG 3 PA ARANESP INJ 300MCG 3 PA ARANESP INJ 500MCG 3 PA EPOGEN INJ 2000/ML 3 PA EPOGEN INJ 3000/ML 3 PA EPOGEN INJ 4000/ML 3 PA EPOGEN INJ 10000/ML 3 PA EPOGEN INJ 20000/ML 3 PA GRANIX INJ 300/0.5 3 PA GRANIX INJ 480/0.8 3 PA LEUKINE INJ 250MCG 2 PA MIRCERA INJ 50MCG 3 PA MIRCERA INJ 75MCG 3 PA MIRCERA INJ 100MCG 3 PA MIRCERA INJ 200MCG 3 PA NEULASTA KIT 6MG/0.6M 3 PA NEUPOGEN INJ 300/0.5 3 PA NEUPOGEN INJ 300MCG 3 PA NEUPOGEN INJ 480/0.8 3 PA


161

Drug Name Drug Tier Requirements/Limits NEUPOGEN INJ 480MCG 3 PA PROCRIT INJ 2000/ML 2 PA PROCRIT INJ 3000/ML 2 PA PROCRIT INJ 4000/ML 2 PA PROCRIT INJ 10000/ML 2 PA PROCRIT INJ 20000/ML 2 PA PROCRIT INJ 40000/ML 2 PA ZARXIO INJ 300/0.5 2 PA ZARXIO INJ 480/0.8 2 PA HEMOSTATICS, SYSTEMIC AMICAR SOL 0.25/ML 3 PA AMICAR TAB 500MG 2 PA AMICAR TAB 1000MG 2 PA aminocaproic acid inj 250 mg/ml 1 CYKLOKAPRON INJ 100MG/ML 3 PA LYSTEDA TAB 650MG 3 QL (30 tabs / 21 days),

PA tranexamic acid iv soln 1000 mg/10ml

(100 mg/ml) 1

tranexamic acid tab 650 mg 1 QL (30 tabs / 21 days) HEMOSTATICS, TOPICAL AVITENE PAD 35X35MM 3 PA AVITENE POW FLOUR 3 PA ENDO AVITENE MIS 5MM DIA 3 PA EVICEL KIT 2ML 3 PA GELFILM MIS ENVELOPE 3 PA GELFOAM MIS DENTAL 4 3 PA GELFOAM MIS SPON COM 3 PA GELFOAM MIS SPONG200 3 PA GELFOAM MIS SPONG 50 3 PA GELFOAM POW 3 PA RECOTHROM SOL 5000UNIT 3 PA RECOTHROM SOL 20000UNT 3 PA SURGICEL PAD 3"X4" 3 PA SURGIFOAM MIS 12-7MM 3 PA SURGIFOAM MIS SIZE 100 3 PA TACHOSIL PAD 3 PA THROMBI-GEL PAD 10 3 PA THROMBI-PAD PAD 3"X3" 3 PA THROMBIN KIT 5000UNIT 3 PA THROMBIN-JMI KIT 20000UNT 3 PA THROMBIN-JMI SOL 5000UNIT 3 PA THROMBIN-JMI SOL 20000UNT 3 PA TISSEEL SOL 3 PA TISSEEL VH KIT 4ML 3 PA


162

Drug Name Drug Tier Requirements/Limits TISSEEL VH KIT 10ML 3 PA ULTRAFOAM MIS 2X6.25X7 3 PA ULTRAFOAM MIS 8X6.25X1 3 PA ULTRAFOAM MIS 8X12.5X1 3 PA ULTRAFOAM MIS 8X12.5X3 3 PA HEREDITARY ANGIOEDEMA AGENTS BERINERT INJ 500UNIT 3 ST CINRYZE SOL 500 UNIT 2 QL (16 / 25 days) FIRAZYR INJ 30MG/3ML 2 QL (3 / 25 days) HAEGARDA INJ 2000UNIT 2 QL (16 vials / 30) HAEGARDA INJ 3000UNIT 2 QL (16 vials / 30) RUCONEST INJ 2100UNIT 3 PA IDIOPATHIC THROMBOCYTOPENIC PURPURA PROMACTA TAB 25MG 2 QL (30 tabs / 30 days) PROMACTA TAB 50MG 2 QL (60 tabs / 30 days) PROMACTA TAB 75MG 2 QL (60 tabs / 30 days) MISCELLANEOUS ACD FORMULA SOL A 2 albumin, human inj 25% 1 alburx inj 5% 1 PA ANTICOAG CPD SOL 2 ANTICOAGULNT SOL SOD CITR 3 PA CATHFLO ACTI INJ VASE 3 PA CEPROTIN INJ 500 UNIT 3 PA CEPROTIN INJ 1000UNIT 3 PA CHEMET CAP 100MG 2 cilostazol tab 50 mg 1 cilostazol tab 100 mg 1 deferoxamine mesylate for inj 2 gm 1 deferoxamine mesylate for inj 500 mg 1 DESFERAL INJ 500MG 3 PA EXJADE TAB 125MG 2 PA EXJADE TAB 250MG 2 PA EXJADE TAB 500MG 2 PA FERRIPROX SOL 100MG/ML 3 PA FERRIPROX TAB 500MG 2 JADENU TAB 90MG 3 PA JADENU TAB 180MG 3 PA JADENU TAB 360MG 3 PA lmd 10%/d5w inj 1 lmd 10%/nacl inj 0.9% 1 PANHEMATIN INJ 313MG 2 PANHEMATIN INJ 350MG 2 pentoxifylline tab er 400 mg 1 protamine sulfate inj 10 mg/ml 1


163

Drug Name Drug Tier Requirements/Limits THROMBAT III INJ 500UNIT 3 PA THROMBAT III INJ 1000UNIT 3 PA TNKASE KIT 50MG 3 PA TRICITRASOL CON 2 PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS SOLIRIS INJ 10MG/ML 2 PA PLATELET AGGREGATION INHIBITORS AGGRASTAT INJ 5/100ML 3 PA AGGRASTAT INJ 12.5/250 3 PA AGGRENOX CAP 25-200MG 3 QL (60 caps / 30 days),

PA, ST aspirin chw 81mg 1 OTC aspirin low tab 81mg ec 1 OTC aspirin tab 325 mg 1 OTC aspirin tab delayed release 325 mg 1 OTC aspirin-dipyridamole cap er 12hr 25-200


bayer adv tab 500mg 1 OTC BRILINTA TAB 60MG 2 QL (60 tabs / 30 days) BRILINTA TAB 90MG 2 QL (60 tabs / 30 days) clopidogrel bisulfate tab 75 mg (base

equiv) 1

clopidogrel bisulfate tab 300 mg (base equiv)

1

dipyridamole tab 25 mg 1 dipyridamole tab 50 mg 1 dipyridamole tab 75 mg 1 DURLAZA CAP 162.5MG 3 QL (30 caps / 30 days),

PA EFFIENT TAB 5MG 3 QL (30 tabs / 30 days) EFFIENT TAB 10MG 3 QL (30 tabs / 30 days) eptifibatide iv soln 20 mg/10ml (2 mg/ml) 1 PA eptifibatide iv soln 75 mg/100ml (0.75

mg/ml) 1 PA

eptifibatide iv soln 200 mg/100ml (2 mg/ml)

1 PA

eq aspirin tab 500mg ec 1 OTC INTEGRILIN INJ 3 PA INTEGRILIN INJ 0.75MG/1 3 PA INTEGRILIN INJ 20/10ML 3 PA KCENTRA KIT 500UNIT 3 PA KCENTRA KIT 1000UNIT 3 PA PLAVIX TAB 75MG 3 PA, ST PLAVIX TAB 300MG 3 PA, ST prasugrel hcl tab 5 mg (base equiv) 1 QL (30 / 30) prasugrel hcl tab 10 mg (base equiv) 1 QL (30 / 30)


164

Drug Name Drug Tier Requirements/Limits REOPRO INJ 2MG/ML 3 PA ZONTIVITY TAB 2.08MG 2 QL (30 tabs / 30 days),

PA PLATELET SYNTHESIS INHIBITOR AGRYLIN CAP 0.5MG 3 PA anagrelide hcl cap 0.5 mg 1 anagrelide hcl cap 1 mg 1 STEM CELL MOBILIZERS MOZOBIL INJ 2 QL (8 / 3 days) IMMUNOLOGIC AGENTS ANTITOXINS/ANTIVENINS ANASCORP INJ 3 PA ANTIVENIN KIT LAT MACT 3 PA CROFAB INJ 3 PA AUTOIMMUNE AGENTS ACTEMRA INJ 162/0.9 2 QL (4 / 21 days), PA CIMZIA KIT 3 QL (2 boxes / 25 days),

PA CIMZIA KIT STARTER 3 QL (1 box in lifetime),

PA CIMZIA PREFL KIT 200MG/ML 3 QL (2 boxes / 25 days),

PA COSENTYX INJ 150MG/ML 3 QL (2 / 30 days), PA COSENTYX PEN INJ 300DOSE 3 QL (2 / 30 days), PA ENBREL INJ 25/0.5ML 2 PA ENBREL INJ 25MG 2 QL (8 boxes / 25 days),

PA ENBREL INJ 50MG/ML 2 QL (4 / 25 days), PA ENBREL SRCLK INJ 50MG/ML 2 QL (4 / 25 days), PA HUMIRA INJ 10MG/0.2 2 PA HUMIRA KIT 20MG/0.4 2 QL (2 boxes / 25 days),

PA HUMIRA KIT 40MG/0.8 2 QL (2 boxes / 25 days),

PA HUMIRA PEN INJ 40MG/0.8 2 QL (2 boxes / 25 days),

PA INFLECTRA INJ 100MG 2 PA KEVZARA INJ 150/1.14 2 QL (2 syringes / 28

days), PA KEVZARA INJ 200/1.14 2 QL (2 syringes / 28

days), PA KINERET INJ 3 QL (30 / 25 days), PA ORENCIA CLCK INJ 125MG/ML 3 QL (4 / 30 days), PA ORENCIA INJ 50/0.4 3 QL (1.6 ml / 28 days),

PA


165

Drug Name Drug Tier Requirements/Limits ORENCIA INJ 87.5/0.7 3 QL (2.8 ml / 28 days),

PA ORENCIA INJ 125MG/ML 3 QL (4 / 30 days), PA REMICADE INJ 100MG 2 RENFLEXIS INJ 100MG 3 PA SILIQ INJ 210/1.5 3 QL (2 / 28 days), PA SIMPONI ARIA SOL 50MG/4ML 3 PA SIMPONI INJ 50/0.5ML 3 PA SIMPONI INJ 50/0.5ML 3 QL (0.5 ml / 21 days),

PA SIMPONI INJ 100MG/ML 3 PA SIMPONI INJ 100MG/ML 3 QL (1 syringe / 21

days), PA STELARA INJ 5MG/ML 3 QL (104 mL vial per

lifetime), PA STELARA INJ 45MG/0.5 3 QL (0.5 mL / 63 days),

PA STELARA INJ 90MG/ML 3 QL (1 mL / 63 days), PA TREMFYA INJ 100MG/ML 3 QL (1 syringe / 56

days), PA XELJANZ TAB 5MG 3 QL (60 tabs / 30 days),

PA DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDS) ARAVA TAB 10MG 3 PA ARAVA TAB 20MG 3 PA hydroxychloroquine sulfate tab 200 mg 1 leflunomide tab 10 mg 1 leflunomide tab 20 mg 1 OTREXUP INJ 7.5/0.4 3 QL (4 / 21 days), PA OTREXUP INJ 10MG 3 QL (4 / 21 days), PA OTREXUP INJ 15MG 3 QL (4 / 21 days), PA OTREXUP INJ 20MG 3 QL (4 / 21 days), PA OTREXUP INJ 25MG 3 QL (4 / 21 days), PA RASUVO INJ 7.5MG 2 QL (4 / 21 days), PA RASUVO INJ 10MG 2 QL (4 / 21 days), PA RASUVO INJ 12.5MG 2 QL (4 / 21 days), PA RASUVO INJ 15MG 2 QL (4 / 21 days), PA RASUVO INJ 17.5MG 2 QL (4 / 21 days), PA RASUVO INJ 20MG 2 PA RASUVO INJ 22.5MG 2 QL (4 / 21 days), PA RASUVO INJ 25MG 2 QL (4 / 21 days), PA RASUVO INJ 27.5MG 2 QL (4 / 21 days), PA RASUVO INJ 30MG 2 QL (4 / 21 days), PA IMMUNE GLOBULINS BIVIGAM INJ 10% 2 PA CARIMUNE NF INJ 6GM 3 PA


166

Drug Name Drug Tier Requirements/Limits CARIMUNE NF INJ 12GM 3 PA CYTOGAM INJ 3 PA FLEBOGAMMA INJ 5GM/50ML 2 PA FLEBOGAMMA INJ 10/100ML 2 PA FLEBOGAMMA INJ 10/200ML 2 PA FLEBOGAMMA INJ 20/200ML 2 PA FLEBOGAMMA INJ 20/400ML 2 PA FLEBOGAMMA INJ DIF 5% 2 PA GAMASTAN S/D INJ 3 PA GAMMAGARD INJ 1GM/10ML 2 PA GAMMAGARD INJ 2.5GM/25 2 PA GAMMAGARD INJ 5GM/50ML 2 PA GAMMAGARD INJ 10GM/100 2 PA GAMMAGARD INJ 20GM/200 2 PA GAMMAGARD INJ 30GM/300 2 PA GAMMAGARD SD INJ 5GM HU 3 PA GAMMAGARD SD INJ 10GM HU 3 PA GAMMAKED INJ 1GM/10ML 3 PA GAMMAKED INJ 2.5GM/25 3 PA GAMMAKED INJ 5GM/50ML 3 PA GAMMAKED INJ 10GM/100 3 PA GAMMAKED INJ 20GM/200 3 PA GAMMAPLEX INJ 5% 2 PA GAMUNEX-C INJ 1GM/10ML 2 PA GAMUNEX-C INJ 2.5GM/25 2 PA GAMUNEX-C INJ 5GM/50ML 2 PA GAMUNEX-C INJ 10GM/100 2 PA GAMUNEX-C INJ 20GM/200 2 PA HEPAGAM B INJ 3 PA HIZENTRA INJ 1GM/5ML 2 HIZENTRA INJ 2GM/10ML 2 HIZENTRA INJ 4GM/20ML 2 HIZENTRA INJ 10/50ML 2 HYQVIA INJ 2.5-200 3 PA HYQVIA INJ 5-400 3 PA HYQVIA INJ 10-800 3 PA HYQVIA INJ 20-1600 3 PA HYQVIA INJ 30-2400 3 PA OCTAGAM INJ 1GM 3 PA OCTAGAM INJ 2.5GM 3 PA OCTAGAM INJ 2GM/20ML 3 PA OCTAGAM INJ 5GM 3 PA OCTAGAM INJ 5GM/50ML 3 PA OCTAGAM INJ 10/100ML 3 PA OCTAGAM INJ 10GM 3 PA OCTAGAM INJ 20/200ML 3 PA


167

Drug Name Drug Tier Requirements/Limits OCTAGAM INJ 25GM 3 PA PRIVIGEN INJ 5 GRAMS 2 PA PRIVIGEN INJ 10GRAMS 2 PA PRIVIGEN INJ 20GRAMS 2 PA PRIVIGEN INJ 40GRAMS 2 PA RHOPHYLAC INJ 1500/2ML 3 PA THYMOGLOBULN INJ 25MG 3 PA VARIZIG INJ 125UNIT 2 IMMUNOMODULATORS, INTERFERONS ACTIMMUNE INJ 2MU/0.5 2 INTRON A INJ 10MU 2 INTRON A INJ 18MU 2 INTRON A INJ 25MU 2 INTRON A INJ 50MU 2 PEG-INTRON KIT 50MCG RP 3 QL (4 boxes / 25 days),

PA PEG-INTRON KIT 80MCG RP 3 QL (4 boxes / 25 days),

PA PEG-INTRON KIT 120 RP 3 QL (4 boxes / 25 days),

PA PEG-INTRON KIT 150 RP 3 QL (4 boxes / 25 days),

PA PEGASYS INJ 2 QL (2 / 25 days), PA PEGASYS INJ 180MCG/M 2 QL (4 / 25 days), PA PEGASYS INJ PROCLICK 2 QL (2 / 25 days), PA SYLATRON KIT 200MCG 2 SYLATRON KIT 300MCG 2 SYLATRON KIT 600MCG 2 IMMUNOMODULATORS, MISCELLANEOUS ARCALYST INJ 220MG 2 QL (4 / 30 days) ILARIS (150) INJ 180MG 2 QL (2 / 30 days), PA ILARIS INJ 150MG/ML 2 QL (2 / 30 days), PA OTEZLA TAB 10/20/30 3 QL (1 in lifetime), PA OTEZLA TAB 30MG 3 QL (60 tabs / 30 days),

PA IMMUNOSUPPRESSANTS, ANTIMETABOLITES AZASAN TAB 75 MG 2 AZASAN TAB 100MG 2 azathioprine tab 50 mg 1 CELLCEPT IV INJ 500MG 3 mycophenolate mofetil cap 250 mg 1 mycophenolate mofetil for oral susp 200

mg/ml 1

MYCOPHENOLATE MOFETIL HCL FOR IV SOLN 500 MG (BASE EQUIV)

1

mycophenolate mofetil tab 500 mg 1


168

Drug Name Drug Tier Requirements/Limits mycophenolate sodium tab dr 180 mg

(mycophenolic acid equiv) 1

mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv)

1

IMMUNOSUPPRESSANTS, CALCINEURIN INHIBITORS ASTAGRAF XL CAP 0.5MG 3 ASTAGRAF XL CAP 1MG 3 ASTAGRAF XL CAP 5MG 3 cyclosporine cap 25 mg 1 cyclosporine cap 100 mg 1 cyclosporine iv soln 50 mg/ml 1 cyclosporine modified cap 25 mg 1 cyclosporine modified cap 100 mg 1 ENVARSUS XR TAB 0.75MG 3 ST ENVARSUS XR TAB 1MG 3 ST ENVARSUS XR TAB 4MG 3 ST gengraf cap 50mg 1 gengraf sol 100mg/ml 1 PROGRAF INJ 5MG/ML 2 SANDIMMUNE SOL 100MG/ML 3 tacrolimus cap 0.5 mg 1 tacrolimus cap 1 mg 1 tacrolimus cap 5 mg 1 IMMUNOSUPPRESSANTS, MISCELLANEOUS BENLYSTA INJ 120MG 2 BENLYSTA INJ 200MG/ML 2 BENLYSTA INJ 400MG 2 NULOJIX INJ 250MG 2 IMMUNOSUPPRESSANTS, RAPAMYCIN DERIVATIVE RAPAMUNE SOL 1MG/ML 2 sirolimus tab 0.5 mg 1 sirolimus tab 1 mg 1 ZORTRESS TAB 0.5MG 2 ZORTRESS TAB 0.25MG 2 ZORTRESS TAB 0.75MG 2 MONOCLONAL ANTIBODIES SYNAGIS INJ 50MG 2 QL (1 / 25 days), PA SYNAGIS INJ 100MG/ML 2 QL (1 vial / 25 days), PAMISCELLANEOUS MEDICAL SUPPLIES ANESTH NEEDL MIS 20GX6" 2 OTC ANESTH NEEDL MIS 22GX2" 2 OTC AXILLARY NDL MIS 22GX1" 2 OTC AXILLARY NDL MIS 25GX1" 2 OTC BD ECLIPSE MIS 1ML/30G 2 OTC


169

Drug Name Drug Tier Requirements/Limits BD ECLIPSE MIS 25GX5/8" 2 OTC BP ARM CUFF MIS LARGE 2 OTC 5ML CONTROL MIS SANA-LOK 2 OTC 3ML CTRL SYR MIS LL ZONE1 2 OTC HUBER NEEDLE MIS 20GX1" 2 OTC HYPO NEEDLE MIS 18GX1" 3 HYPO NEEDLE MIS 19GX1.5" 3 HYPO NEEDLE MIS 21GX1" 3 HYPO NEEDLE MIS 22GX1.5" 3 HYPO NEEDLE MIS 23GX1" 3 HYPO NEEDLE MIS 23GX1.5" 2 OTC HYPO NEEDLE MIS 23GX1/2" 2 HYPO NEEDLE MIS 25GX1" 2 HYPO NEEDLE MIS 25GX1.5" 3 HYPO NEEDLE MIS 25GX5/8" 3 HYPO NEEDLE MIS 26GX1.5" 2 HYPO NEEDLE MIS 26GX1/2" 3 HYPO NEEDLE MIS 27GX1/2" 3 HYPO NEEDLE MIS 30GX3/4" 2 INFUS SYRING MIS 100ML 2 OTC 3ML LL SYRNG MIS 20GX1" 2 OTC 6ML LL SYRNG MIS 20GX1.5" 2 OTC 3ML LL SYRNG MIS 21GX1.25 2 OTC 3ML LL SYRNG MIS 22GX1.25 3 OTC 3ML LL SYRNG MIS 22GX3/4" 3 OTC 3ML LL SYRNG MIS 23GX1.25 2 OTC 3ML LL SYRNG MIS 24GX1" 3 OTC MULIT-DRAW MIS 22GX1.5" 2 OTC MULTI-DRAW MIS 20GX1.5 2 OTC MULTI-DRAW MIS 21GX1.5" 2 OTC NEEDLES MIS 19GX1" 2 OTC NEEDLES MIS 25GX1.5" 2 OTC NEEDLES MIS 26X1/2" 2 OTC NEEDLES MIS 27GX1/2" 2 OTC OSGOOD BIOPS MIS 18GX1" 3 SAFETYGLIDE MIS 27GX5/8" 3 OTC SPINAL NEEDL MIS 22GX3.5" 2 OTC 5-6ML SYRING MIS LUER SLP 2 OTC 3ML SYRINGE MIS 20GX1" 3 3ML SYRINGE MIS 20GX1.5" 2 12ML SYRINGE MIS 20GX1.5" 2 OTC 6ML SYRINGE MIS 20GX1.5" 3 3ML SYRINGE MIS 21GX1" 2 3ML SYRINGE MIS 21GX1" 2 OTC 3ML SYRINGE MIS 21GX1.5" 2 12ML SYRINGE MIS 21GX1.5" 2 OTC


170

Drug Name Drug Tier Requirements/Limits 3ML SYRINGE MIS 22GX1" 3 3ML SYRINGE MIS 22GX1" 3 PA; OTC 6ML SYRINGE MIS 22GX1.5" 2 3ML SYRINGE MIS 22GX1.5" 3 3 ML SYRINGE MIS 22X1-1/2 2 OTC 3ML SYRINGE MIS 23GX1" 2 3ML SYRINGE MIS 23GX1" 2 OTC 3ML SYRINGE MIS 23GX1.5" 3 OTC 3ML SYRINGE MIS 25GX1" 2 1ML SYRINGE MIS 25GX1" 2 OTC 3ML SYRINGE MIS 25GX5/8" 2 1ML SYRINGE MIS 25GX5/8" 2 1ML SYRINGE MIS 25GX5/8" 2 OTC 1ML SYRINGE MIS 26GX3/8" 2 OTC 30ML SYRINGE MIS GL ZONE1 2 OTC 20ML SYRINGE MIS LL ZONE1 2 OTC 30ML SYRINGE MIS LUER LOC 3 5ML SYRINGE MIS LUER SLP 2 OTC 1ML SYRINGE MIS LUER SLP 3 50ML SYRINGE MIS ML ZONE1 2 OTC 3ML SYRINGE MIS REG TIP 3 10-12ML SYRN MIS LUER SLP 2 OTC 1.5 ML SYRNG MIS 22X1-1/2 3 PA; OTC 2ML TB SYRNG MIS LL ZONE1 2 OTC 1ML TB SYRNG MIS LUER SLP 3 TOOMEY SYRIN MIS 70ML 2 VENT NEEDLE MIS 18GX1.5" 2 OTC YALE NEEDLE MIS 15GX1.5" 3 OTC YALE NEEDLE MIS 15GX2" 3 OTC YALE NEEDLE MIS 16GX2" 3 OTC YALE NEEDLES MIS 13X3-1/2 3 OTC YALE NEEDLES MIS 15X3-1/2 3 OTC YALE NEEDLES MIS 17G X 2" 3 OTC YALE NEEDLES MIS 18G X 2" 3 OTC YALE NEEDLES MIS 18X1-1/2 3 OTC YALE NEEDLES MIS 19X1-1/2 3 OTC YALE NEEDLES MIS 20G X 1" 3 OTC YALE NEEDLES MIS 20G X 2" 3 OTC YALE NEEDLES MIS 20X1-1/2 3 OTC YALE NEEDLES MIS 21G X 1" 3 OTC YALE NEEDLES MIS 21X1-1/2 3 OTC YALE NEEDLES MIS 22G X 1" 3 OTC YALE NEEDLES MIS 22G X 2" 3 OTC YALE NEEDLES MIS 22G X 3" 3 OTC YALE NEEDLES MIS 22X1-1/2 3 OTC YALE NEEDLES MIS 23G X 1" 3 OTC


171

Drug Name Drug Tier Requirements/Limits YALE NEEDLES MIS 23G X 2" 3 OTC YALE NEEDLES MIS 23GX1/2" 3 OTC YALE NEEDLES MIS 23X1-1/2 3 OTC YALE NEEDLES MIS 24G X 1" 3 OTC YALE NEEDLES MIS 24GX1/2" 3 OTC YALE NEEDLES MIS 24GX3/4" 3 OTC YALE NEEDLES MIS 24X1-1/2 3 OTC YALE NEEDLES MIS 25G X 1" 3 OTC YALE NEEDLES MIS 25GX1/2" 3 OTC YALE NEEDLES MIS 25GX3/8" 3 OTC YALE NEEDLES MIS 25GX5/8" 3 OTC YALE NEEDLES MIS 25X1-1/2 3 OTC YALE NEEDLES MIS 26G X 1" 3 OTC YALE NEEDLES MIS 26GX1/2" 3 OTC YALE NEEDLES MIS 26GX3/8" 3 OTC YALE NEEDLES MIS 26GX5/8" 3 OTC YALE NEEDLES MIS 26X1-1/2 3 OTC YALE NEEDLES MIS 27G X 1" 3 OTC YALE NEEDLES MIS 27GX1/2" 3 OTC YALE NEEDLES MIS 27GX1/4" 3 OTC YALE NEEDLES MIS 27GX3/8" 3 OTC YALE NEEDLES MIS 30G X 1" 3 OTC YALE NEEDLES MIS 30X1-1/2 3 OTC YALE TB SYRN MIS GL 1/4ML 2 OTC YALE TB SYRN MIS GL 1ML 2 OTC NUTRITIONAL / SUPPLEMENTS DIETARY MANAGEMENT PRODUCTS BLADDER 2.2 TAB 2 OTC ELFOLATE TAB 7.5MG 3 ST ELFOLATE TAB 15MG 3 ST ELFOLATE TAB PLUS 3 ST estro supprt tab es 1 OTC FALESSA TAB 1MG 3 PA L-METHYL- TAB B6-B12 3 PA L-METHYL-MC TAB NAC 3 METAFOLBIC TAB PLUS RF 3 NUTR DRINK POW MIX VAN 2 OTC PODIAPN CAP 3 PURALOR CI TAB 3 PA TEARS AGAIN CAP HYDRATE 3 OTC VASCAZEN CAP 1GM 3 VAYAROL CAP 3 vp-precip cap 1 ELECTROLYTES, MISCELLANEOUS av-phos 250 tab neutral 1


172

Drug Name Drug Tier Requirements/Limits CERALYTE 70 LIQ 2 QL (5000 / 30 days);

OTC K-PHOS TAB 2 K-PHOS TAB NO 2 2 oral electrolyte solution 1 QL (5000 ml / 30 days);

OTC ELECTROLYTES, POTASSIUM EFFER-K TAB 10MEQ 3 PA EFFER-K TAB 20MEQ 3 PA K-TAB TAB 10MEQ CR 3 PA K-TAB TAB 20MEQ 3 PA klor-con 8 tab 8meq er 1 KLOR-CON M15 TAB 15MEQ ER 3 MICRO-K CAP 8MEQ CR 3 PA MICRO-K CAP 10MEQ CR 3 PA pot bicarbonate & chloride effer tab 25

meq 1

potassium bicarbonate effer tab 25 meq 1 potassium chloride cap er 8 meq 1 potassium chloride cap er 10 meq 1 potassium chloride microencapsulated crys

er tab 10 meq 1

potassium chloride microencapsulated crys er tab 20 meq

1

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

1

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

1

potassium chloride powder packet 20 meq 1 potassium chloride tab er 10 meq 1 potassium chloride tab er 20 meq (1500

mg) 1

INTRAVENOUS NUTRITION, CALORIC AGENTS AMINOSYN 7% INJ /LYTES 3 PA AMINOSYN II INJ 7% 3 PA AMINOSYN II INJ 8.5% 3 PA aminosyn ii inj 8.5/lyte 1 PA AMINOSYN II INJ 15% 3 PA AMINOSYN M INJ 3.5% 3 PA AMINOSYN-RF INJ 5.2% 3 PA CLINIMIX E INJ 2.75/D5W 3 PA CLINIMIX E INJ 2.75/D10 3 PA CLINIMIX E INJ 4.25/D5W 3 PA CLINIMIX E INJ 4.25/D10 3 PA CLINIMIX E INJ 4.25/D25 3 PA CLINIMIX E INJ 5%/D15W 3 PA


173

Drug Name Drug Tier Requirements/Limits CLINIMIX E INJ 5%/D20W 3 PA CLINIMIX E INJ 5%/D25W 3 PA CLINIMIX INJ 2.75/D5W 3 PA CLINIMIX INJ 4.25/D5W 3 PA CLINIMIX INJ 4.25/D10 3 PA CLINIMIX INJ 4.25/D20 3 PA CLINIMIX INJ 4.25/D25 3 PA CLINIMIX INJ 5%/D15W 3 PA CLINIMIX INJ 5%/D20W 3 PA CLINIMIX INJ 5%/D25W 3 PA cysteine hcl inj 50 mg/ml 1 dextrose inj 5% 1 dextrose inj 10% 1 PA DEXTROSE INJ 20% 3 dextrose inj 25% 1 dextrose inj 30% 1 DEXTROSE INJ 40% 3 dextrose inj 50% 1 dextrose inj 70% 1 FREAMINE HBC INJ 6.9% 3 PA FREAMINE III INJ 10% 3 PA gluco shot liq 1 OTC hepatamine sol 8% 1 PA INTRALIPID INJ 30% 3 PA LIPOCHOL TAB PLUS 3 PA; OTC MICROLIPID EMU 50% 2 OTC NEPHRAMINE INJ 5.4% 3 PA nutrilipid emu 20% 1 PA plenamine inj 15% 1 PA premasol sol 6% 1 PA PROCALAMINE INJ 3% 3 PA PROSOL INJ 20% 3 PA TROPHAMINE INJ 6% 3 PA INTRAVENOUS NUTRITION, ELECTROLYTES alcohol absolute inj 98% 1 PA D5W/LYTES INJ #48 3 D5W/NACL INJ 0.3% 3 D10W/NACL INJ 0.2% 3 D10W/NACL INJ 0.225% 2 dextrose 2.5% w/ sodium chloride 0.45% 1 dextrose 5% in lactated ringers 1 dextrose 5% w/ sodium chloride 0.2% 1 dextrose 5% w/ sodium chloride 0.9% 1 dextrose 5% w/ sodium chloride 0.33% 1 dextrose 5% w/ sodium chloride 0.45% 1


174

Drug Name Drug Tier Requirements/Limits dextrose 5% w/ sodium chloride 0.225% 1 dextrose 10% w/ sodium chloride 0.45% 1 ELLIOTTS B INJ 3 PA hyperlyte-cr inj 1 PA IONOSOL-B/ INJ D5W 3 PA IONOSOL-MB INJ /D5W 3 PA ISOLYTE-P INJ /D5W 3 PA ISOLYTE-S INJ 3 PA ISOLYTE-S INJ PH 7.4 3 PA kcl 10 meq/l (0.075%) in dextrose 5% &

nacl 0.45% inj 1

kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj

1


1


1


1

kcl 20 meq/l (0.15%) in nacl 0.9% inj 1 kcl 20 meq/l (0.15%) in nacl 0.45% inj 1 kcl 30 meq/l (0.224%) in dextrose 5% &

nacl 0.45% inj 1


1

kcl 40 meq/l (0.3%) in nacl 0.9% inj 1 KCL/D5W/LACT INJ 20MEQ/L 3 KCL/D5W/LACT INJ 40MEQ/L 3 KCL/D5W/NACL INJ 0.3/0.9% 3 KCL/D5W/NACL INJ 0.15/0.2 3 lactated ringer's solution 1 NORMOSOL -M INJ /D5W 3 PA NORMOSOL -R INJ 3 PA NORMOSOL -R INJ /D5W 3 PA NORMOSOL-R INJ PH 7.4 3 PA PLASMA-LYTE INJ 56/D5W 3 PA PLASMA-LYTE INJ -148 3 PA PLASMA-LYTE INJ -A 3 PA potassium acetate inj 2 meq/ml 1 potassium acetate inj 4 meq/ml 1 potassium chloride 20 meq/l (0.15%) in

dextrose 5% inj 1

potassium chloride 40 meq/l (0.3%) in dextrose 5% inj

1

potassium chloride inj 2 meq/ml 1 PA potassium chloride inj 10 meq/50ml 1 potassium chloride inj 10 meq/100ml 1


175

Drug Name Drug Tier Requirements/Limits potassium chloride inj 20 meq/50ml 1 potassium chloride inj 20 meq/100ml 1 potassium chloride inj 40 meq/100ml 1 ringer's solution 1 sodium chloride inj 0.9% 1 sodium chloride inj 0.45% 1 sodium chloride inj 2.5 meq/ml (14.6%) 1 sodium chloride inj 3% 1 sodium chloride inj 4 meq/ml (23.4%) 1 sodium chloride inj 5% 1 sodium chloride iv soln 0.9% 1 sodium chloride tab 1 gm 1 OTC tpn electrol inj 1 PA INTRAVENOUS NUTRITION, VITAMINS AND MINERALS ADDAMEL N INJ 3 PA ascorbic acid inj 500 mg/ml 1 calcium chloride inj 10% 1 calcium gluconate inj 10% 1 chromic chloride inj 40 mcg/10ml (4

mcg/ml) (elemental cr) 1

cupric chloride inj 0.4 mg/ml 1 GLYCOPHOS SOL 1MM/ML 3 PA INFUVITE INJ 1 PA IODOPEN INJ 100MCG 3 PA magnesium chloride inj 200 mg/ml 1 magnesium sulfate inj 50% 1 manganese chloride inj 0.1 mg/ml 1 manganese sulfate inj 0.1 mg/ml 1 MANGANESE TAB 50MG 3 PA; OTC MG SO4/D5W INJ 10MG/ML 3 PA MULTITRACE-4 INJ 2 multitrace-4 inj conc 1 MULTITRACE-4 INJ NEONATAL 3 PA MULTITRACE-4 INJ PED 3 multitrace-5 inj conc 1 MULTITRACE-5 INJ REGULAR 3 PA PEDITRACE INJ 3 PA potassium phosphates inj 15 mm/5ml

(phos) 22 meq/5ml (k) 1

potassium phosphates inj 45 mm/15ml (phos) 66 meq/15ml (k)

1

potassium phosphates inj 150 mm/50ml (phos) 220 meq/50ml (k)

1

selenious acid inj 40 mcg/ml 1 sodium phosphates inj 15 mm/5ml (phos)

20 meq/5ml (na) 1


176

Drug Name Drug Tier Requirements/Limits TRACE ELEM 4 INJ PED 3 PA zinc chloride inj 1 mg/ml 1 zinc sulfate inj 1 mg/ml 1 zinc sulfate inj 5 mg/ml 1 VITAMINS AND MINERALS, FOLIC ACID / COMBINATIONS ANIMI-3 CAP VIT D 3 PA DIVISTA CAP 3 PA DURACHOL CAP 1-3775IU 2 folic acid inj 5 mg/ml 1 folic acid tab 1 mg 1 folic acid tab 400 mcg 1 PA; OTC folic acid tab 800 mcg 1 PA; OTC PUREFOLIX TAB 1-5000 3 PA REVESTA CAP 1MG-5750 3 PA VITAMINS AND MINERALS, MISCELLANEOUS ABANEU-SL SUB 2 abatron af tab 1 PA; OTC abatron liq 1 OTC ACTIVE FE TAB 75-1.25 3 PA ACTIVE OB CAP 2 ADVANCED MIS AM/PM 3 AMMONIUM CHL INJ 5MEQ/ML 3 PA animal shape chw complete 1 OTC AP-ZEL TAB 3 ascorbic acid cap er 500 mg 1 OTC ascorbic acid chew tab 250 mg 1 OTC ascorbic acid chew tab 500 mg 1 OTC ascorbic acid tab 250 mg 1 OTC ascorbic acid tab 1000 mg 1 OTC ascorbic acid tab er 500 mg 1 OTC ascorbic acid tab er 1000 mg 1 OTC ascorbic acid tab er 1500 mg 1 OTC ATABEX CHW PRENATAL 2 OTC ATABEX EC TAB 2 B12 COMPLNCE KIT INJ KIT 3 PA b-100 tab tr 1 OTC b-complex tab 1 OTC B-COMPLEX TAB C/FA/BIO 3 OTC b-complex vitamin cap 1 OTC b-complex vitamin tab 1 OTC b-complex w/ c & calcium tab 1 OTC b-complex w/ c cap 1 OTC b-complex w/ folic acid cap 1 OTC b-plex tab 1 BAL-CARE MIS DHA 2


177

Drug Name Drug Tier Requirements/Limits balance b-50 tab tr 1 OTC balanced b tab complex 1 OTC balanced tab b-100 tr 1 OTC bdy/hair/skn cap nails 1 PA; OTC BE WELL PAK ROUNDED 2 OTC berocca tab 1 OTC BIFERARX TAB 3 PA bio-d-mulsio liq 400unit 1 OTC bio-d-mulsio liq 2000unit 1 OTC biocel tab 1 BIOSUPP LIQ 3 PA; OTC BIOVOL SYP 3 OTC BONE DENSITY TAB BUILDER 2 OTC bp folinatal tab plus b 1 bp multinatl chw plus 1 bp multinatl tab plus 1 bprotected sol tri-vite 1 OTC BRAINSTRONG MIS PRENATAL 2 OTC c complex tab 1000mg 1 OTC ca citrate tab plus 1 OTC CA HI-CAL/D TAB 500MG 2 OTC CADEAU DHA CAP 2 OTC CAL-QUICK LIQ 500-400 3 PA; OTC calc citr/d3 tab 200-250 1 OTC calc citrate tab +d 1 OTC CALCET BITES CHW 500-400 3 PA; OTC calcidol dro 8000/ml 1 OTC calcium 500 tab +d 1 OTC calcium 600 chw +d/miner 1 OTC calcium 600 chw w/vit d 1 OTC calcium 600 tab + d 1 OTC calcium 600 tab +d 1 OTC calcium 600 tab +d3 1 OTC calcium 600/ tab vit d 1 OTC CALCIUM 1000 TAB + D 2 OTC calcium 1200 chw 1 OTC calcium + d chw 1 OTC CALCIUM CARB CHW 260MG 3 PA; OTC CALCIUM CARB POW 800/2GM 3 PA; OTC calcium carbonate (antacid) susp 1250

mg/5ml 1 OTC

calcium carbonate tab 600 mg 1 OTC calcium carbonate tab 1250 mg (500 mg

elemental ca) 1 OTC

calcium carbonate tab 1500 mg (600 mg elemental ca)

1 OTC


178

Drug Name Drug Tier Requirements/Limits calcium carbonate-cholecalciferol chew tab

500 mg-100 unit 1 OTC

calcium carbonate-vitamin d tab 250 mg-125 unit

1 OTC


1 OTC


1 OTC

CALCIUM CHW GUMMIES 3 OTC CALCIUM CIT/ TAB VIT D 3 OTC calcium citr tab +d 1 OTC calcium citrate-vitamin d tab 315 mg-200

unit (elemental ca) 1 OTC

calcium plus cap d3 1 OTC calcium tab 500/d 1 OTC calcium tab 600mg 1 OTC calcium+d3 tab 600-800 1 OTC calcium+d3 tab grad rel 1 OTC CALCIUM-FA WAF PLUS D 3 PA calcium-magnesium-zinc tab 333-133-5

mg 1 OTC

CALCIUM/C/D CHW 500MG 3 OTC calcium/d3 tab 1 OTC calcium/d3 tab 600-800 1 OTC CALCIUM/VITD CAP 600-400 3 OTC CALNA TAB 2 OTC CALTRATE 600 CHW 600-800 2 OTC CALTRATE 600 CHW +D PLUS 2 PA; OTC CALTRATE + D TAB 300-800 2 OTC CELLULAR CAP SECURITY 3 PA; OTC CENTRUM LIQ 3 PA; OTC CHEWABLE CHW IRON 3 OTC cholecalciferol cap 400 unit 1 OTC cholecalciferol cap 5000 unit 1 OTC cholecalciferol oral liquid 400 unit/ml 1 OTC cholecalciferol tab 2000 unit 1 OTC cholecalciferol tab 50000 unit 1 OTC CITRACAL+D3 CHW 250-500 3 PA; OTC CITRANATAL CAP HARMONY 2 CITRANATAL TAB RX 2 cod liver chw w/vit 1 OTC COMP PRNATAL MIS DHA 2 OTC COMPLETE NAT PAK DHA 2 CONCEPT DHA CAP 2 CONCEPT OB CAP 2 corvita 150 tab 1


179

Drug Name Drug Tier Requirements/Limits corvita tab 1 CORVITE 150 TAB 3 PA CORVITE FE TAB 3 PA CORVITE TAB 3 PA CVS PRENATAL CHW GUMMY 2 OTC cyanocobalamin inj 1000 mcg/ml 1 d3 cap 1000unit 1 OTC d3 max st dro 5000unit 1 OTC d3 super str cap 2000unit 1 OTC d 400 chw 400unit 1 OTC d 400 tab 400unit 1 OTC DDROPS LIQ 1000UNIT 2 OTC DECARA CAP 25000UNT 2 OTC DIABETIC CAP VITAMIN 3 PA DIALYVITE TAB 800/IRON 3 PA; OTC DIALYVITE TAB 3000 3 PA DUET DHA 400 MIS 25-1-400 2 DUET DHA MIS BALANCED 2 elite-ob tab 1 ENBRACE HR CAP 2 EQL CALCIUM CAP VIT D 3 PA; OTC ergocalciferol cap 50000 unit 1 essent one tab daily 1 OTC ezfe 200 cap 200mg 1 OTC fe c plus tab 1 OTC fe gluconate tab 239mg 1 OTC FE PLUS TAB PROTEIN 3 OTC fe tabs tab 325mg ec 1 OTC FER-IN-SOL DRO 15MG/ML 2 PA; OTC FERIVA CAP 75-1MG 3 PA FERIVAFA CAP 110-1MG 3 PA ferocon cap 1 ferrex 28 mis 1 ferrex 150 cap 150mg 1 OTC ferrex 150 cap forte pl 1 FERRIMIN 150 TAB 2 OTC ferrocite tab 324mg 1 OTC ferrocite tab plus 1 FERROUS SULF TAB 140MG 2 OTC ferrous sulfate elixir 220 mg/5ml (44

mg/5ml elemental fe) 1 OTC

ferrous sulfate tab 325 mg (65 mg elemental fe)

1 OTC

ferrous sulfate tab er 142 mg (45 mg fe equivalent)

1 OTC

FLINTSTONES CHW COMPLETE 3 PA; OTC


180

Drug Name Drug Tier Requirements/Limits FLINTSTONES CHW GUMMIES 3 PA; OTC FLORICAL CAP 2 OTC FLORICAL TAB 2 OTC FLORIVA CHW 0.25MG 3 PA FLUOR-A-DAY CHW 0.25MG F 3 FLUOR-A-DAY CHW 1MG F 3 FLUORABON DRO 3 PA flura-drops dro 0.25mg f 1 PA flura-drops dro 0.125mg 1 PA FOCALGIN 90 MIS DHA 2 FOCALGIN CA MIS 2 FOCALGIN DSS TAB 90-1MG 3 PA folbee plus tab 1 FOLCAPS CAP OMEGA 3 2 FOLET DHA PAK 2 FOLET ONE CAP 38-1-225 2 FOLGARD OS TAB 3 PA FORTAVIT CAP 3 PA FUSION PLUS CAP 3 PA GALZIN CAP 25MG 3 PA GALZIN CAP 50MG 3 PA gnp iron tab 65mg 1 OTC healthy kids chw overall 1 OTC hematogen cap 1 hematogen cap forte 1 HEMATOGEN FA CAP 2 HEMATRON-AF TAB 3 PA HEMENATAL OB MIS + DHA 2 hemocyte-f tab 1 PA HONEY BEARS CHW 3 OTC HONEY BEARS CHW IRON-ZIN 3 OTC icar-c plus tab 1 PA inatal adv tab 1 INFANATE CAP BALANCE 2 INTEGRA F CAP 3 PA INTEGRA PLUS CAP 3 PA iron slow tab 45mg 1 OTC iron supplmt dro 15mg/ml 1 OTC IRON UP LIQ 3 PA; OTC IS 24/6 MIS 3 PA KOSHR PRENAT TAB 30-1MG 2 KPN PRENATAL TAB 2 OTC LEVOMEFOLATE CAP DHA 2 liq ca/vit d cap 600mg 1 OTC LIQUID CALCI CAP WITH D3 3 PA; OTC LOZI-FLUR LOZ 1MG F 2


181

Drug Name Drug Tier Requirements/Limits ludent chw 0.5mg f 1 ludent chw 0.25mg f 1 ludent chw 1mg f 1 mag64 tab 64mg 1 OTC MAGNEBIND TAB 400 3 PA MAGNESIUM CAP 400MG 3 PA; OTC magnesium oxide cap 500 mg (elemental

mg) 1 OTC

magnesium oxide tab 400 mg (240 mg elemental mg)

1 OTC

magnesium oxide tab 500 mg (mg supplement)

1 OTC

magnesium tab 250 mg 1 OTC MARNATAL-F CAP 2 MAXFE LIQ 3 PA; OTC MEGA MULTIVI TAB WOMEN 3 OTC MEPHYTON TAB 5MG 2 methacholine cap /liver 1 OTC mgo tab 400mg 1 OTC MISSION PREN TAB 2 OTC MISSION PREN TAB HP 2 OTC MTERYTI TAB 2 OTC MTERYTI TAB FOLIC 5 2 OTC MULTI PRENAT TAB 2 OTC multi vit/fl dro 0.5mg/ml 1 PA multi-delyn liq 1 OTC MULTI-DELYN LIQ /IRON 3 OTC multi-vit/fe dro /fl 0.25 1 PA multi-vit/fl dro 0.25mg 1 PA MULTIGEN PLS TAB 3 MULTIGEN TAB 3 multiple minerals tab 1 OTC multivitamin dro pediatrc 1 OTC multivitamin liq mineral 1 PA; OTC mv-one cap 1 OTC myferon 150 cap forte 1 MYKIDZ IRON SUS 10MG/2ML 2 OTC MYNATAL CAP 2 MYNATAL TAB 2 MYNATAL-Z TAB 2 MYNATE 90 TAB PLUS 2 mynephrocaps cap 1 PA NANOVM T/F LIQ 2 OTC NANOVM T/F POW 2 OTC NATACHEW CHW 2 NATALVIT TAB 75-1MG 2


182

Drug Name Drug Tier Requirements/Limits NATELLE ONE CAP 2 NEPHROCAPS CAP 3 PA NEPHRON FA TAB 3 PA nephronex tab 1mg 1 NESTABS ABC MIS 2 NESTABS DHA PAK 2 NEUT INJ 4% 3 PA NEWGEN TAB 32-1MG 2 NEXA PLUS CAP 2 niacin cap 400mg 1 OTC niacin cap er 250 mg 1 OTC niacin cap er 500 mg 1 OTC niacin tab 50 mg 1 OTC niacin tab 100 mg 1 OTC niacin tab 250 mg 1 OTC niacin tab 500 mg 1 OTC niacin tab er 500 mg 1 OTC niacin tab er 750 mg 1 OTC NIACIN TR TAB 1000MG 3 OTC niacinamide tab 100 mg 1 OTC niacinamide tab 500 mg 1 OTC NIACINAMIDE TAB 500MG PR 3 PA; OTC NOVAFERRUM CAP 50MG 2 OTC novaferrum dro 10mg/ml 1 OTC NOVAFERRUM DRO 15MG/ML 2 OTC NOVAFERRUM LIQ 125 2 OTC NUTRICION TAB PORVIDA 2 OTC NUTRIENTS TAB PRENATAL 2 OTC NUTRIVIT LIQ 800-15-1 2 O-CAL TAB PRENATAL 2 OB COMPLETE CAP GOLD 2 OB COMPLETE CAP ONE 2 OB COMPLETE CAP PETITE 2 OB COMPLETE TAB 2 OB COMPLETE TAB PREMIER 2 OB COMPLETE/ CAP DHA 2 OBSTETRIX EC TAB 2 OBSTETRIX PAK DHA 2 OBTREX DHA PAK 2 OTC OBTREX TAB 2 OTC ONE A DAY CAP PRENATAL 2 OTC ONE A DAY MIS PRENATAL 2 OTC one daily tab 1 OTC one daily tab plus iro 1 OTC ONE-A-DAY TAB WOMENS 3 PA; OTC optimal-d cap 50000unt 1 OTC


183

Drug Name Drug Tier Requirements/Limits OSTEO-PORETI TAB 3 PA; OTC oys shell+d chw 500-400 1 OTC oys shell+d tab 250-125 1 OTC oysco 500+d tab 1 OTC oyst shell/d tab 500mg 1 OTC oyster shell calcium tab 500 mg 1 OTC oyster-cal tab 500mg 1 OTC PERRY PRENAT CAP 2 OTC phytonadione inj 1 mg/0.5ml (2 mg/ml) 1 PA phytonadione inj 10 mg/ml 1 PNV OB+DHA PAK 2 pnv-dha cap 1 PNV-DHA CAP DOCUSATE 2 PNV-OMEGA CAP 2 pnv-select tab 1 PNV-TOTAL CAP 2 poly-vite dro 1 OTC PR NATAL 400 PAK 2 PR NATAL 400 PAK EC 2 PR NATAL 430 PAK 2 PR NATAL 430 PAK EC 2 PREFERA OB TAB 2 PREFERAOB CAP ONE 2 PREFERAOB MIS +DHA 2 PRENA1 CHW 2 PRENA1 PEARL CAP 2 PRENA 1 TRUE MIS 2 PRENAISSANCE CAP 2 PRENAISSANCE CAP BALANCE 2 PRENAISSANCE CAP PLUS 2 PRENAISSANCE MIS HARMONY 2 PRENAISSANCE TAB NEXT 2 PRENAISSANCE TAB NEXT-B 2 PRENATA CHW 29-1MG 2 prenatabs rx tab 1 PRENATAL 1 CAP 2 OTC PRENATAL 19 CHW 29-1MG 2 prenatal 19 chw tab 1 prenatal 19 tab 1 PRENATAL 19 TAB 29-1MG 2 PRENATAL CAP FORMULA 2 OTC PRENATAL CAP OMEGA-3 2 OTC PRENATAL FRM TAB A-FREE 2 OTC PRENATAL MIS COMPLEAT 2 PRENATAL MUL CAP +DHA 2 OTC PRENATAL MV MIS + DHA 2 OTC


184

Drug Name Drug Tier Requirements/Limits PRENATAL TAB 2 OTC PRENATAL TAB 27-1MG 2 PRENATAL TAB COMPLETE 2 OTC PRENATAL TAB FORMULA 2 OTC PRENATAL+DHA MIS 2 OTC PRENATAL+FE TAB 29-1MG 2 PRENATAL-U CAP 106.5-1 2 PRENATE AM TAB 1MG 2 PRENATE CAP ENHANCE 2 PRENATE CAP ESSENTIA 2 PRENATE CAP PIXIE 2 PRENATE CAP RESTORE 2 PRENATE CHW 0.6-0.4 2 PRENATE DHA CAP 2 PRENATE MINI CAP 2 PRENATE TAB ELITE 2 PRENATL MULT CAP + DHA 2 OTC PRETAB TAB 29-1MG 2 PROFE CAP 180MG 2 OTC PROFE FORTE CAP 155-1MG 2 OTC PROFERRIN- TAB FORTE 2 PRONUTRIENTS TAB SUPER B 2 OTC PROTECTIRON TAB 3 PA PROVIDA DHA CAP 2 PROVIDA OB CAP 2 PUREFE CAP PLUS 2 PUREFE OB CAP PLUS 2 purevit dual cap fe plus 1 px iron tab 27mg 1 OTC pyridoxine hcl tab 25 mg 1 OTC pyridoxine hcl tab 50 mg 1 OTC pyridoxine hcl tab 100 mg 1 OTC QUINTABS TAB 3 OTC RA OYS SHL/D TAB 250MG 3 OTC RAYALDEE CAP 30MCG 3 ST RELNATE DHA CAP 2 REPLESTA NX WAF 14000UNT 2 OTC REPLESTA WAF 50000UNT 3 OTC RULAVITE DHA CAP 2 s.s.s. tonic tab 1 OTC SCOOBY-DOO CHW 2 OTC SE-TAN DHA CAP 2 SELECT-OB CHW 2 SELECT-OB+ PAK DHA 2 SIMILAC PREN PAK EARLY SH 2 OTC slow release tab 47.5mg 1 OTC


185

Drug Name Drug Tier Requirements/Limits sm b super tab vita com 1 OTC sm b-complex tab 1 OTC SM B-COMPLEX TAB /VIT C 3 OTC sm balanced tab b-100 1 OTC SM CORAL CAL TAB 1000MG 3 PA; OTC sm iron slow tab 160mg cr 1 OTC sm iron tab 1 OTC sm magnesium tab 250mg 1 OTC sm multiple tab vit/iron 1 OTC sm niacin tab 250mg cr 1 OTC SM ONE DAILY MIS PRENATAL 2 OTC SM ONE DAILY TAB ESSENTIA 3 PA; OTC sm vit b-1 tab 100mg 1 OTC SOD LACTATE INJ 5MEQ/ML 3 sodium acetate inj 2 meq/ml 1 sodium acetate inj 4 meq/ml 1 sodium bicarbonate inj 4.2% 1 sodium bicarbonate inj 7.5% 1 sodium bicarbonate inj 8.4% 1 sodium fluoride soln 0.5 mg/ml f (from 1.1

mg/ml naf) 1

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

1

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

1

stress b com tab vit c/zn 1 OTC STUART ONE CAP 2 OTC super b comp tab vit c 1 OTC superior 35 tab 1 OTC SUPPORT LIQ 3 PA TANDEM F CAP 3 PA TANDEM PLUS CAP 3 PA TARON-BC MIS 2 TARON-PREX CAP 2 THERA-D TAB 4000UNIT 3 PA; OTC THERAMILL CAP FORTE 3 PA; OTC THERANATAL CAP ONE 2 OTC THERANATAL MIS COMPLETE 2 OTC THERANATAL PAK OVAVITE 2 OTC THERANATAL TAB 27-1 2 OTC thiamine hcl inj 100 mg/ml 1 thiamine hcl tab 100 mg 1 OTC TL FOLATE TAB 2 tl-hem 150 tab 1 PA TRI-VI-SOL SOL 3 PA; OTC TRICARE PAK PRENATAL 2


186

Drug Name Drug Tier Requirements/Limits TRICARE PRE CAP 27-1-500 2 TRIFERIC SOL 3 PA trinate tab 1 TRISTART DHA CAP 2 UDAMIN SP TAB 3 PA ULTIMATECARE CAP ONE NF 2 ultra b-100 tab complex 1 OTC ULTRA MAN TAB 2 OTC UPCAL D POW 3 PA; OTC urosex tab 1 PA v-c forte cap 1 PA vigor cap 1 OTC VINACAL B MIS 2 VINATE C TAB 2 VINATE CAL TAB 2 VINATE CARE CHW 40-1MG 2 VINATE DHA CAP 27-1.13 2 VINATE II TAB 2 VINATE M TAB 2 VINATE ONE TAB 2 VIRT NATE TAB 2 VIRT-PN TAB 2 VIRTPREX CAP 2 vit c gummie chw 125mg 1 OTC VITA-PREN TAB 2 VITACRAVES CHW +OMEGA-3 3 PA; OTC VITAFOL CAP ULTRA 2 VITAFOL CHW GUMMIES 2 VITAFOL FE+ CAP 2 VITAFOL TAB 3 PA VITAFOL-NANO TAB 2 VITAFOL-OB PAK +DHA 2 VITAFOL-ONE CAP 2 VITAL-D RX TAB 3 PA VITALETS CHW 3 OTC VITAMAX CHW 3 PA; OTC vitamax ped dro 1 VITAMEDMD CAP ONE RX 2 VITAMEDMD MIS PLUS RX 2 vitamin c + tab echinace 1 OTC vitamin c tab 500mg 1 OTC VITAMIN D2 TAB 400UNIT 3 OTC VITAMIN D2 TAB 2000UNIT 2 OTC VITAMIN D3 CAP 4000UNIT 3 PA; OTC vitamin d3 cap 10000unt 1 OTC VITAMIN D3 LIQ 1200UNIT 3 PA; OTC


187

Drug Name Drug Tier Requirements/Limits VITAMIN D3 SPR 1000UNIT 3 PA; OTC VITAMIN D3 TAB 3000UNIT 3 PA; OTC vitamin d chw 1000unit 1 OTC VITAMIN D TAB 400 3 OTC vitamin d tab 1000unit 1 OTC vitamin d-3 tab 5000unit 1 OTC vitamins a & d cap 1 OTC vitatrum chw 1 OTC VP-HEME OB TAB 2 VP-PNV-DHA CAP 2 weight loss tab multi 1 PA; OTC ZATEAN-CH CAP 2 zoo friends chw extra c 1 OTC zoo friends chw gummies 1 OTC zoo friends chw pls iron 1 OTC RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS ADRENALIN INJ 1MG/ML 3 epinephrine hcl inj 1 mg/ml 1 epinephrine hcl soln prefilled syringe 0.1

mg/ml 1

epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)

1 QL (2 pens / 30 days)

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

1 QL (2 pens / 30 days)

EPIPEN 2-PAK INJ 0.3MG 2 QL (2 pens / 30 days) EPIPEN-JR INJ 2-PAK 2 QL (2 pens / 30 days) EPISNAP KIT 3 PA ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, LONG ACTING ANORO ELLIPT AER 62.5-25 2 QL (1 / 30 days) STIOLTO AER 2.5-2.5 2 QL (1 / 30 days) UTIBRON CAP NEOHALER 3 ST ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, SHORT

ACTING COMBIVENT AER 20-100 2 ipratropium-albuterol nebu soln 0.5-2.5(3)

mg/3ml 1

ANTICHOLINERGICS ATROVENT HFA AER 17MCG 2 INCRUSE ELPT INH 62.5MCG 2 ipratropium bromide inhal soln 0.02% 1 SPIRIVA AER 1.25MCG 2 SPIRIVA CAP HANDIHLR 3 ST SPIRIVA SPR 2.5MCG 2 TUDORZA PRES AER 400/ACT 3 ST


188

Drug Name Drug Tier Requirements/Limits ANTIHISTAMINE/DECONGESTANT COMBINATIONS ALLEGRA-D TAB 24 HOUR 2 PA; OTC allergy d tab 5-120mg 1 OTC allergy tab multi-sy 1 OTC allrgy rel-d tab 10-240mg 1 OTC allrgy rlf-d tab 5-120mg 1 OTC CLARINEX-D TAB 2.5-120 3 PA cold & flu liq nighttim 1 OTC cold/allergy elx children 1 OTC entre-b sus 6-10mg/5 1 OTC fexofenadine-pseudoephedrine tab er 12hr

60-120 mg 1 PA

GLENAX PEB LIQ 3 PA; OTC promethazine & phenylephrine syrup 6.25-

5 mg/5ml 1

pyrilamine mal-phenylephrine hcl tann susp 16-5 mg/5ml

1 OTC

RELHIST CHW 3 SEMPREX-D CAP 8-60MG 3 PA sinus/allrgy tab max st 1 OTC TRIAMINIC NT MIS COLD/CGH 3 PA; OTC TRIAMINIC SYP CLD/ALRG 2 OTC wal-fex d tab 24 hour 1 PA; OTC ANTIHISTAMINES, LOW-SEDATING all day allg cap 10mg 1 OTC all day allg tab 10mg 1 OTC allergy relf chw 10mg 1 OTC cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) 1 cetirizine hcl tab 5 mg 1 OTC CLARITIN CAP 10MG 2 OTC levocetirizine dihydrochloride soln 2.5

mg/5ml (0.5 mg/ml) 1 ST

levocetirizine dihydrochloride tab 5 mg 1 ST wal-zyr chw 5mg 1 OTC XYZAL SOL 2.5/5ML 3 PA, ST XYZAL TAB 5MG 3 PA, ST ZYRTEC ALLGY TAB 10MG 2 OTC ZYRTEC ALLGY TAB 10MG 3 PA; OTC ANTIHISTAMINES, NONSEDATING ALLEGRA ALRG TAB 30MG 3 OTC ALLEGRA ALRG TAB 30MG 3 PA; OTC allergy relf tab 10mg 1 OTC CLARINEX SYP 0.5MG/ML 3 ST CLARINEX TAB 5MG 3 PA, ST CLARITIN CHW 5MG 2 OTC CLARITIN RDT TAB 5MG 2 OTC


189

Drug Name Drug Tier Requirements/Limits desloratadine tab 5 mg 1 ST desloratadine tab orally disintegrating 2.5

mg 1 ST

desloratadine tab orally disintegrating 5 mg

1 ST

fexofenadine hcl tab 60 mg 1 ST; OTC fexofenadine hcl tab 180 mg 1 ST; OTC loratadine sol 5mg/5ml 1 OTC wal-fex chld sus 30mg/5ml 1 ST; OTC ANTIHISTAMINES, SEDATING allergy cap 25mg 1 OTC allergy tab 4mg 1 OTC allergy tab 12mg cr 1 OTC allergy tab 25mg 1 OTC allrgy relf tab 12.5mg 1 OTC brompheniramine tannate chew tab 12 mg 1 carbinoxamine maleate soln 4 mg/5ml 1 carbinoxamine maleate tab 4 mg 1 chld allergy liq 12.5/5ml 1 OTC clemastine fumarate tab 2.68 mg 1 cvs allergy chw 12.5mg 1 OTC cyproheptadine hcl syrup 2 mg/5ml 1 cyproheptadine hcl tab 4 mg 1 dayhist alrg tab 12 hour 1 OTC diabet tuss syp allergy 1 PA; OTC diphenhydramine hcl cap 50 mg 1 OTC diphenhydramine hcl elixir 12.5 mg/5ml 1 diphenhydramine hcl inj 50 mg/ml 1 ED CHLORPED LIQ 2MG/ML 2 OTC hydroxyzine hcl im soln 25 mg/ml 1 hydroxyzine hcl im soln 50 mg/ml 1 hydroxyzine hcl syrup 10 mg/5ml 1 hydroxyzine hcl tab 10 mg 1 hydroxyzine hcl tab 25 mg 1 hydroxyzine hcl tab 50 mg 1 hydroxyzine pamoate cap 25 mg 1 hydroxyzine pamoate cap 50 mg 1 hydroxyzine pamoate cap 100 mg 1 J-TAN PD DRO 1MG/ML 3 PA; OTC KARBINAL ER SUS 4MG/5ML 3 PA RESPA-BR TAB 11MG 3 PA silphen coug syp 12.5/5ml 1 OTC VISTARIL CAP 25MG 3 PA VISTARIL CAP 50MG 3 PA ANTITUSSIVE COMBINATIONS


190

Drug Name Drug Tier Requirements/Limits a-s pls nght cap cld/flu 1 OTC ALDEX GS TAB 30-190MG 2 OTC ambi 60pse/ tab 400gfn 1 OTC bio t pres-b liq 10-4-20 1 OTC bio-rytuss liq 5-2-10/5 1 OTC BIONEL LIQ PEDIATRC 3 PA; OTC BIOSPEC DMX LIQ 3 PA; OTC BROVEX PEB LIQ DM 3 PA; OTC CARBAPHEN 12 LIQ 3 PA CARBAPHEN 12 SUS PED 3 PA cgh control syp pe 1 OTC CHERACOL-D LIQ 100-10/5 3 PA; OTC chest conges tab 20-400mg 1 OTC CODAR AR LIQ 2-8/5ML 3 CODAR D LIQ 30-8/5ML 2 OTC codar gf liq 200-8/5 1 OTC cold & flu liq day/nght 1 OTC cold head tab cong dt 1 OTC cold mult-sy tab daytime 1 OTC cold/cough elx child 1 OTC cold/cough elx children 1 OTC CONGESTAC TAB 60-400MG 3 PA; OTC cough & sore liq thrt day 1 OTC day time liq cold/flu 1 OTC dayquil sev liq cold/flu 1 OTC desgen dm tab 1 OTC dibromm chld liq 2.5-1-5 1 OTC DOUBLE-TUSSN LIQ DM 3 PA; OTC ED BRON GP LIQ 2 OTC ENTEX T TAB 60-375MG 2 OTC GNP DAY TIME LIQ MUCUS DM 3 PA; OTC gnp tussin syp cf 1 OTC guaiatussin syp 100-10/5 1 OTC HYCOFENIX SOL 3 PA hydrocod polst-chlorphen polst er susp 10-

8 mg/5ml 1

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

1

hydrocodone w/ homatropine tab 5-1.5 mg 1 intense coug liq reliever 1 OTC lohist-dm syp 5-2-10mg 1 OTC MUCINEX CGH GRA 5-100MG 2 OTC mucus & cong cap 10-200 1 OTC mucus d tab 120/1200 1 OTC mucus relief liq 5-100mg 1 OTC mucus relief tab d 1 OTC


191

Drug Name Drug Tier Requirements/Limits mucus rlf d tab 60-600mg 1 OTC mucus-dm max tab 60-1200 1 OTC mucus-dm tab 30-600mg 1 OTC OBREDON SOL 2.5-200 3 QL (1800 ml / 30 days),

PA PECGEN DMX LIQ 10-187MG 3 PA; OTC PECGEN DMX LIQ 15-125MG 2 OTC pecgen liq pse 1 OTC POLY-VENT IR TAB 60-380MG 3 PA; OTC promethazine w/ codeine syrup 6.25-10

mg/5ml 1

promethazine-dm syrup 6.25-15 mg/5ml 1 45PSE/400GFN TAB 3 PA; OTC 60PSE/400GFN TAB /20DM 3 PA; OTC pseudoephed-bromphen-dm syrup 30-2-10

mg/5ml 1

pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml

1 OTC

relcof c sol 100-6.3 1 OTC relcof dm liq 1 OTC RESPA C&C IR TAB 3 PA; OTC RESPAIRE-30 CAP 3 PA; OTC REZIRA SOL 60-5/5ML 3 PA ROBITUSSIN LIQ CGH/CLD 3 PA; OTC ROBITUSSIN LIQ DM MAX 3 PA; OTC ROBITUSSN DM SYP 3 PA; OTC RYDEX G TAB 38.5-398 2 OTC SCOT-TUSSIN LIQ SENIOR 2 OTC sm tussin cf liq 1 OTC stuffy nose liq & cold 1 OTC supress dm dro 5-50/ml 1 OTC TGQ 15DM/5PE SYP H/2CPM 3 TGQ 30/ SYP 150/15 3 TGQ 30/PSE/3 SYP BRM/15DM 3 tgq 50pse/3 syp brm/30dm 1 TRIAMINIC CHW 3 PA; OTC TRICODE AR LIQ 30-2-8 2 OTC TRICODE GF LIQ 30-8-200 2 OTC trymine cg liq 225-7.5 1 OTC TUSNEL PED DRO 7.5-50 3 OTC tussin cf liq 1 OTC tussin cf liq max/m-s 1 OTC tussin dm liq 100-10/5 1 OTC tussin dm liq max 1 OTC tussin dm syp 100-10/5 1 OTC TUSSIONEX SUS 10-8/5ML 3 PA


192

Drug Name Drug Tier Requirements/Limits TUZISTRA XR SUS 3 PA vcks dayquil liq mucus dm 1 OTC VICKS NATURE LIQ COLD/FLU 3 OTC VICKS NATURE LIQ CONGEST 3 PA; OTC virtussin sol dac 1 OTC ZYNCOF SYP 20-400/5 2 OTC ANTITUSSIVES benzonatate cap 100 mg 1 benzonatate cap 150 mg 1 benzonatate cap 200 mg 1 BUCKLEYS LIQ COUGH 2 OTC cough dm sus 30mg/5ml 1 OTC CREO-TERPIN SYP 10/15ML 3 PA; OTC day time liq cough 1 OTC HOLD LOZ 5MG ORIG 3 PA; OTC SCOT-TUSSIN LIQ DIBTS/CF 2 PA; OTC st joseph co syp 7.5/5ml 1 OTC TESSALON PER CAP 100MG 3 PA tussin cough syp 15mg/5ml 1 OTC wal-tussin cap cough 1 OTC WAL-TUSSIN CHW 7.5MG 3 OTC wal-tussin liq 15mg/5ml 1 OTC BETA AGONISTS, INHALANTS, LONG ACTING, Hand-held Active

Inhalation ARCAPTA CAP 75MCG 3 ST SEREVENT DIS AER 50MCG 3 ST STRIVERDI AER 2.5MCG 2 QL (1 / 30 days), PA BETA AGONISTS, INHALANTS, LONG ACTING, Nebulized Passive

Inhalation BROVANA NEB 15MCG 3 ST PERFOROMIST NEB 20MCG 2 BETA AGONISTS, INHALANTS, SHORT ACTING albuterol sulfate soln nebu 0.5% (5 mg/ml)1 albuterol sulfate soln nebu 0.63 mg/3ml

(base equiv) 1

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

1

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

1

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

1


1


1


193

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

mg/0.5ml (base equiv) 1

levalbuterol tartrate inhal aerosol 45 mcg/act (base equiv)

1

metaproterenol sulfate syrup 10 mg/5ml 1 metaproterenol sulfate tab 10 mg 1 metaproterenol sulfate tab 20 mg 1 PROAIR HFA AER 3 QL (2 / 30 days), ST PROAIR RESPI AER 2 VENTOLIN HFA AER 2 QL (2 / 30 days) XOPENEX CONC NEB 1.25/0.5 3 PA, ST XOPENEX HFA AER 3 QL (1 inhaler / 25 days),

PA, ST XOPENEX NEB 0.31MG 3 PA, ST XOPENEX NEB 0.63MG 3 PA, ST XOPENEX NEB 1.25/3ML 3 PA, ST BETA AGONISTS, INJECTABLE ISUPREL INJ 0.2MG/ML 3 PA terbutaline sulfate inj 1 mg/ml 1 BETA AGONISTS, ORAL AGENTS albuterol sulfate syrup 2 mg/5ml 1 albuterol sulfate tab 2 mg 1 albuterol sulfate tab 4 mg 1 albuterol sulfate tab er 12hr 4 mg 1 albuterol sulfate tab er 12hr 8 mg 1 terbutaline sulfate tab 2.5 mg 1 terbutaline sulfate tab 5 mg 1 VOSPIRE ER TAB 4MG 3 PA, ST VOSPIRE ER TAB 8MG 3 PA, ST CYSTIC FIBROSIS BETHKIS NEB 300/4ML 3 QL (60 / 30 days), PA CAYSTON INH 75MG 2 QL (84 / 60) KALYDECO PAK 50MG 2 QL (60 / 30 days), PA KALYDECO PAK 75MG 2 QL (60 / 30 days), PA KALYDECO TAB 150MG 2 QL (60 tabs / 30 days),

PA KITABIS PAK NEB 300/5ML 3 QL (56 / 56 days), PA ORKAMBI TAB 100-125 3 QL (120 tabs / 30 days),

PA ORKAMBI TAB 200-125 3 QL (120 tabs / 30 days),

PA PULMOZYME SOL 1MG/ML 2 QL (30 / 25 days), PA TOBI NEB 300/5ML 2 QL (56 / 56 days) TOBI PODHALR CAP 28MG 2 QL (240 caps / 30 days) tobramycin nebu soln 300 mg/5ml 1 QL (56 / 56 days) DECONGESTANTS


194

Drug Name Drug Tier Requirements/Limits child silfed liq 15mg/5ml 1 OTC decongestant tab 120mg er 1 OTC nasal decon syp 30mg/5ml 1 OTC nasal decong tab 10mg 1 OTC nasal decong tab 30mg 1 OTC nexafed tab 30mg 1 OTC pseudoephedrine hcl tab 60 mg 1 OTC SUDAFED 24HR TAB 240MG 2 OTC EXPECTORANTS chest conges tab 400mg 1 OTC coughtab tab 200mg 1 OTC guaifenesin tab er 12hr 1200 mg 1 OTC mucus relief liq 100/5ml 1 OTC mucus-er tab 600mg 1 OTC tussin chest syp 100/5ml 1 OTC yodefan-nf liq 200-5ml 1 OTC LEUKOTRIENE MODULATORS ACCOLATE TAB 10MG 3 PA ACCOLATE TAB 20MG 3 PA montelukast sodium chew tab 4 mg (base


montelukast sodium chew tab 5 mg (base equiv)


montelukast sodium oral granules packet 4 mg (base equiv)

1 QL (1 box / 30 days)

montelukast sodium tab 10 mg (base equiv)


SINGULAIR CHW 4MG 3 QL (30 tabs / 30 days), ST

SINGULAIR CHW 5MG 3 QL (30 tabs / 30 days), ST

SINGULAIR GRA 4MG 3 QL (1 box / 30 days), ST SINGULAIR TAB 10MG 3 QL (30 tabs / 30 days),

ST zafirlukast tab 10 mg 1 zafirlukast tab 20 mg 1 zileuton tab er 12hr 600 mg 1 ST ZYFLO CR TAB 600MG 3 ST ZYFLO TAB 600MG 3 ST MAST CELL STABILIZERS cromolyn sodium soln nebu 20 mg/2ml 1 MEDICAL SUPPLIES AERCHMBR Z- MIS STAT PLS 2 QL (1 / year for

members > 18 yo; 2 / year for members < 18 yo)


195

Drug Name Drug Tier Requirements/Limits AEROCHAMBER KIT ACTION 3 AIRZONE PEAK MIS FLOW MTR 2 OTC ASSESS METER MIS FULL RNG 2 OTC ASSESS METER MIS LOW RANG 2 OTC ASTHMA CHECK MIS SYSTEM 2 OTC ASTHMAMENTOR MIS 2 OTC ASTHMAPACK KIT CHILD 2 OTC FACE MASK MIS EARLOOP 3 FLEXICHAMBER MIS MASK SM 3 QL (1 / year for

members > 18 yo; 2 / year for members < 18 yo)

INSPIREASE MIS RES BAG 2 QL (1 / year for members > 18 yo; 2 / year for members < 18 yo)

MICROLIFE MIS PEAK FLO 2 OTC MINI WRIGHT MIS PFM 3 OTC MINI WRIGHT MIS PFM 3 PA; OTC MINI WRIGHT MIS PFM LOW 3 PA; OTC NASONEB NSL MIS STARTER 2 PA NEBULIZER MIS COMPRESS 3 PARI LC MIS SPRINT 2 PEAK AIR FLO MIS ADLT/PED 2 OTC PERSONAL BES MIS FULL RNG 2 OTC PERSONAL BES MIS LOW RANG 2 OTC PIKO 1 MIS ELECTRON 2 OTC POCKET PEAK MIS METER 2 OTC POCKETPEAK MIS UNIVERSA 3 OTC SINUSTAR MIS NEBULIZE 2 PA TRUZONE PEAK MIS FLOW MTR 3 PA VIOS LC MIS SPRINT 2 MISCELLANEOUS acetylcysteine inhal soln 10% 1 acetylcysteine inhal soln 20% 1 ARALAST NP INJ 500MG 2 AYR ALLERGY SPR & SINUS 3 PA; OTC AYR NASAL DRO 0.65% 3 OTC CAFCIT INJ 60MG/3ML 3 PA caffeine citrate inj 60 mg/3ml (10 mg/ml

base equiv) 1

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

1

CUROSURF SUS 120/1.5 3 PA GLASSIA INJ 3 PA HYPER-SAL NEB 7% 3 PA


196

Drug Name Drug Tier Requirements/Limits HYPERSAL NEB 3.5% 3 PA INFASURF SUS 35MG/ML 3 PA ipratropium bromide nasal soln 0.03% (21

mcg/spray) 1

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

1

NASADROPS DRO 0.9% 3 PA; OTC nasal moist spr 0.65% 1 OTC nebusal neb 3% 1 NEBUSAL NEB 6% 3 PA RHINARIS SPR 0.2% 2 OTC SCLEROSOL AER INTRAPLE 3 PA sinus congst tab /pain dt 1 OTC sodium chloride soln nebu 0.9% 1 sodium chloride soln nebu 7% 1 sodium chloride soln nebu 10% 1 STERIL TALC SUS 5GM 3 PA SURVANTA INH 3 PA tgt cough oin suppress 2 OTC VICKS OIN VAPORUB 2 OTC XOLAIR SOL 150MG 2 QL (6 / 28 days), PA ZEMAIRA INJ 1000MG 2 NASAL ANTIHISTAMINES ASTEPRO SPR 0.15% 3 PA, ST azelastine hcl nasal spray 0.1% (137

mcg/spray) 1

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

1

olopatadine hcl nasal soln 0.6% 1 QL (31 / 25 days) PATANASE SPR 0.6% 3 QL (31 / 25 days), PA,

ST NASAL STEROIDS / COMBINATIONS BECONASE AQ SUS 0.042% 3 ST budesonide nasal susp 32 mcg/act 1 budesonide nasal susp 32 mcg/act 1 OTC DYMISTA SPR 137-50 3 ST flunisolide nasal soln 25 mcg/act (0.025%) 1 fluticasone propionate nasal susp 50

mcg/act 1 QL (1 bottle / 25 days)

mometasone furoate nasal susp 50 mcg/act

1 PA

NASACORT ALR SPR 55MCG/AC 3 PA, ST; OTC NASONEX SPR 50MCG/AC 3 PA OMNARIS SPR 3 ST QNASL AER 80MCG 3 ST QNASL CHILD SPR 40MCG 3 ST


197

Drug Name Drug Tier Requirements/Limits RHINOCORT SUS AQUA 3 PA, ST triamcinolone acetonide nasal aerosol

suspension 55 mcg/act 1

triamcinolone acetonide nasal aerosol suspension 55 mcg/act

1 OTC

VERAMYST SPR 27.5MCG 3 ST ZETONNA AER 37MCG 3 ST PHOSPHODIESTERASE-4 INHIBITORS DALIRESP TAB 500MCG 3 PA PULMONARY FIBROSIS AGENTS ESBRIET CAP 267MG 3 QL (270 caps / 30

days), PA ESBRIET TAB 801MG 3 QL (90 tabs / 30 days),

PA OFEV CAP 100MG 2 QL (60 caps / 30 days),

PA OFEV CAP 150MG 2 QL (60 caps / 30 days),

PA STEROID INHALANTS AEROSPAN AER 80MCG 3 QL (2 / 25 days) ALVESCO AER 80MCG 3 ST ALVESCO AER 160MCG 3 ST ARNUITY ELPT INH 100MCG 2 QL (1 inhaler / 30 days) ARNUITY ELPT INH 200MCG 2 QL (1 inhaler / 30 days) ASMANEX 14 AER 220MCG 3 QL (1 inhaler / 25 days),

PA; No UM required for members under age 12

ASMANEX 30 AER 110MCG 3 QL (1 inhaler / 25 days), PA; No UM required for members under age 12

ASMANEX HFA AER 100 MCG 3 QL (1 inhaler / 25 days), PA; No UM required for members under age 12

ASMANEX HFA AER 200 MCG 3 QL (1 inhaler / 25 days), PA; No UM required for members under age 12

budesonide inhalation susp 0.5 mg/2ml 1 QL (60 / 30 days) budesonide inhalation susp 0.25 mg/2ml 1 QL (60 / 30 days) budesonide inhalation susp 1 mg/2ml 1 QL (60 / 30 days) FLOVENT DISK AER 50MCG 3 ST FLOVENT DISK AER 100MCG 3 ST FLOVENT DISK AER 250MCG 3 ST FLOVENT HFA AER 44MCG 3 QL (2 inhalers / 25

days), ST FLOVENT HFA AER 110MCG 3 QL (2 inhalers / 25

days), ST


198

Drug Name Drug Tier Requirements/Limits FLOVENT HFA AER 220MCG 3 QL (2 inhalers / 25

days), ST PULMICORT INH 90MCG 3 ST PULMICORT INH 180MCG 3 ST PULMICORT SUS 0.5MG/2 3 QL (60 / 30 days), PA,

ST PULMICORT SUS 0.25MG/2 3 QL (60 / 30 days), PA,

ST PULMICORT SUS 1MG/2ML 3 QL (60 / 30 days), PA,

ST QVAR AER 40MCG 3 PA; No UM required for

members under age 12 QVAR AER 80MCG 3 PA; No UM required for

members under age 12 STEROID/BETA AGONIST COMBINATIONS ADVAIR DISKU AER 100/50 2 ADVAIR DISKU AER 250/50 2 ADVAIR DISKU AER 500/50 2 ADVAIR HFA AER 45/21 2 ADVAIR HFA AER 115/21 2 ADVAIR HFA AER 230/21 2 BEVESPI AER 9-4.8MCG 3 ST BREO ELLIPTA INH 100-25 2 BREO ELLIPTA INH 200-25 2 DULERA AER 100-5MCG 3 ST DULERA AER 200-5MCG 3 ST fluticasone-salmeterol aer powder ba 55-

14 mcg/act 1

fluticasone-salmeterol aer powder ba 113-14 mcg/act

1

fluticasone-salmeterol aer powder ba 232-14 mcg/act

1

SYMBICORT AER 80-4.5 3 ST SYMBICORT AER 160-4.5 3 ST TOPICAL DECONGESTANTS ADRENALIN SOL 1:1000 3 PA nasal 12 hr spr 0.05% 1 PA; OTC nose dro 1% 1 OTC TYZINE SOL 0.1% 3 PA XANTHINES aminophylline inj 25 mg/ml 1 PA ELIXOPHYLLIN ELX 80/15ML 3 PA THEO-24 CAP 100MG CR 3 ST THEO-24 CAP 200MG CR 3 ST THEO-24 CAP 300MG CR 3 ST THEO-24 CAP 400MG ER 3 ST


199

Drug Name Drug Tier Requirements/Limits THEOPHYL/D5W INJ 0.8MG/ML 3 theophylline soln 80 mg/15ml 1 theophylline tab er 12hr 100 mg 1 theophylline tab er 12hr 200 mg 1 theophylline tab er 12hr 300 mg 1 theophylline tab er 12hr 450 mg 1 theophylline tab er 24hr 400 mg 1 theophylline tab er 24hr 600 mg 1 TOPICAL DERMATOLOGY, ACNE, ORAL ABSORICA CAP 10MG 2 ABSORICA CAP 20MG 2 ABSORICA CAP 25MG 2 ABSORICA CAP 30MG 2 ABSORICA CAP 35MG 2 ABSORICA CAP 40MG 2 zenatane cap 10mg 1 zenatane cap 20mg 1 zenatane cap 30mg 1 zenatane cap 40mg 1 DERMATOLOGY, ACNE, TOPICAL ACANYA GEL 1.2-2.5% 3 ST acne cleansi bar 10% 1 OTC ACNE MEDICAT LOT 10% 3 PA; OTC acne treatme cre 10% 1 OTC ACZONE GEL 5% 3 PA adapalene cream 0.1% 1 adapalene gel 0.1% 1 QL (48 gm / 30 days) adapalene gel 0.3% 1 QL (48 gm / 30 days) adapalene lotion 0.1% 1 adapalene-benzoyl peroxide gel 0.1-2.5% 1 ST ADV ACNE WSH LIQ 4.4% 3 PA; OTC ATRALIN GEL 0.05% 3 QL (48 gm / 30 days),

PA AZELEX CRE 20% 3 ST BENZAC AC LIQ 5% WASH 3 PA, ST BENZACLIN GEL 1-5% 3 PA, ST BENZAMYCIN GEL 5-3% 3 PA BENZAMYCIN GEL PAK 3 PA BENZEFOAM AER 5.3% 3 PA BENZEFOAM AER 9.8% 3 PA benzepro liq creamy 1 PA benzepro sc aer 9.8% 1 BENZIQ GEL 5.25% 3 PA BENZIQ LS GEL 2.75% 3 PA


200

Drug Name Drug Tier Requirements/Limits benziq wash liq 5.25% 1 PA BENZOYL PER GEL 2.5% 3 OTC benzoyl per liq 5% wash 1 OTC benzoyl per liq 10% wash 1 OTC benzoyl pero kit acne pck 1 OTC benzoyl peroxide gel 10% 1 OTC benzoyl peroxide-erythromycin gel 5-3% 1 BENZYL PEROX LOT CLNSR 3% 3 OTC benzyl perox lot clnsr 6% 1 OTC bp 10-1 emu 1 bp cleansing emu 10-4% 1 bp foaming liq wash 10% 1 BP GEL GEL 5.5% 3 OTC bp wash liq 5.25% 1 OTC bpo cloths mis 6% 1 bpo creamy kit 4% wash 1 OTC BPO GEL 4% 3 PA BPO GEL 8% 3 PA clearplex v gel 5% 1 OTC CLEOCIN-T GEL 1% 3 PA, ST CLEOCIN-T LOT 1% 3 PA, ST CLEOCIN-T PAD 1% 3 PA, ST CLEOCIN-T SOL 1% 3 PA, ST CLINDACIN KIT PAC 1% 3 PA clindacin-p pad 1% 1 CLINDAGEL GEL 1% 3 ST clindamycin phosphate foam 1% 1 clindamycin phosphate gel 1% 1 clindamycin phosphate lotion 1% 1 clindamycin phosphate soln 1% 1 clindamycin phosphate-benzoyl peroxide

gel 1-5% 1

clindamycin phosphate-tretinoin gel 1.2-0.025%

1

creamy face liq wash 4% 1 OTC dapsone gel 5% 1 DIFFERIN CRE 0.1% 3 PA, ST DIFFERIN GEL 0.1% 3 QL (48 gm / 30 days),

PA, ST DIFFERIN GEL 0.3% 3 QL (48 gm / 30 days),

PA, ST DIFFERIN LOT 0.1% 3 PA DUAC GEL 1.2-5% 3 PA, ST EPIDUO FORTE GEL 0.3-2.5% 3 ST EPIDUO GEL 0.1-2.5% 3 ST ery pad 2% 1


201

Drug Name Drug Tier Requirements/Limits erythromycin gel 2% 1 erythromycin soln 2% 1 EVOCLIN AER 1% 3 PA, ST FABIOR AER 0.1% 3 PA INOVA 4/1 KIT ACNE CON 3 PA INOVA 8/2 KIT ACNE CON 3 PA INOVA KIT 4% 3 PA INOVA KIT 8% 3 PA KLARON LOT 10% 3 PA neuac gel 1.2-5% 1 NUOX GEL 6-3% 3 ST OC8 GEL 7% 3 OTC ONEXTON GEL 1.2-3.75 3 ST oscion clnsr lot 6% 1 PANOXYL GEL 3% 2 OTC PANOXYL-4 LIQ CREM WSH 3 PA; OTC PRASCION RA CRE 10-5% 2 RETIN-A CRE 0.1% 3 QL (48 gm / 30 days),

PA RETIN-A CRE 0.05% 3 QL (48 gm / 30 days),

PA RETIN-A CRE 0.025% 3 QL (48 gm / 30 days),

PA RETIN-A GEL 0.01% 3 QL (48 gm / 30 days),

PA RETIN-A GEL 0.025% 3 QL (48 gm / 30 days),

PA RETIN-A MICR GEL 0.1% 3 PA RETIN-A MICR GEL 0.04% 3 PA RIAX AER 5.5% 3 PA RIAX AER 9.5% 3 PA SOD SUL/SULF EMU 10-5% 3 PA SOD SUL/SULF SUS 10-5% 3 sss 10-5 aer 10-5% 1 sss cre 10%-5% 1 sulfacetamide sod-sulfur wash 9-4.5% &

skin cleanser kit 1

sulfacetamide sodium lotion 10% (acne) 1 sulfacetamide sodium w/ sulfur cleanser

9.8-4.8% 1

sulfacetamide sodium w/ sulfur cleanser 10-2%

1

sulfacetamide sodium w/ sulfur cleansing pad 10-4%

1

sulfacetamide sodium w/ sulfur cream 10-2%

1


202

Drug Name Drug Tier Requirements/Limits sulfacetamide sodium w/ sulfur emulsion

10-5% 1

sulfacetamide sodium w/ sulfur lotion 10-5%

1

sulfacetamide sodium w/ sulfur susp 8-4% 1 sulfacetamide sodium w/ sulfur wash 9-4%1 sulfacetamide sodium w/ sulfur wash 9-

4.5% 1

sulfacetamide sodium-sulfur in urea gel 10-5%

1 PA

SUMADAN KIT 3 PA SUMADAN WASH LIQ 9-4.5% 3 PA SUMADAN XLT KIT 9-4.5% 3 PA targetd acne cre 2.5% 1 OTC tazarotene cream 0.1% 1 ST TAZORAC CRE 0.1% 3 PA TAZORAC CRE 0.05% 2 TAZORAC GEL 0.1% 2 TAZORAC GEL 0.05% 2 TRETIN-X CRE 0.075% 3 PA TRETIN-X CRE 0.0375% 3 PA TRETIN-X CRE KIT 0.05% 3 PA tretinoin cream 0.1% 1 QL (48 gm / 30 days) tretinoin cream 0.05% 1 QL (48 gm / 30 days) tretinoin cream 0.025% 1 QL (48 gm / 30 days) tretinoin gel 0.01% 1 QL (48 gm / 30 days) tretinoin gel 0.05% 1 QL (48 gm / 30 days),

PA tretinoin gel 0.025% 1 QL (48 gm / 30 days),

PA tretinoin microsphere gel 0.1% 1 tretinoin microsphere gel 0.04% 1 VELTIN GEL 3 ST ZACARE KIT KIT 4% 3 PA ZIANA GEL 3 PA, ST DERMATOLOGY, ACTINIC KERATOSIS CARAC CRE 0.5% 3 PA diclofenac sodium (actinic keratoses) gel

3% 1

EFUDEX CRE 5% 3 PA EUCRISA OIN 2% 3 QL (60 gm / 30 days),

PA FLUOROPLEX CRE 1% 3 PA fluorouracil cream 5% 1 fluorouracil soln 2% 1 fluorouracil soln 5% 1


203

Drug Name Drug Tier Requirements/Limits LEVULAN KERA SOL 20% 3 PA PICATO GEL 0.05% 3 PA PICATO GEL 0.015% 3 PA SOLARAZE GEL 3% W/W 3 PA TOLAK CRE 4% 3 PA ZYCLARA CRE 3.75% 3 PA ZYCLARA PUMP CRE 2.5% 3 PA DERMATOLOGY, ANTI-INFECTIVE/ANTI-INFLAMMATORY

COMBINATIONS CORTISPORIN CRE 0.5% 3 PA CORTISPORIN OIN 1% 3 PA DERMATOLOGY, ANTI-INFLAMMATORY COMBINATIONS DERMACINRX PAK LEXITRAL 3 PA DERMATOLOGY, ANTIBIOTICS ALTABAX OIN 1% 3 bacitracin oint 500 unit/gm 1 OTC bacitracin zinc oint 500 unit/gm 1 OTC BACTROBAN OIN NASAL 2% 2 CENTANY AT KIT 2% 3 CENTANY OIN 2% 3 double antib oin 1 OTC gentamicin sulfate cream 0.1% 1 gentamicin sulfate oint 0.1% 1 mupirocin calcium cream 2% 1 mupirocin oint 2% 1 NEOSPORIN CRE PLUS 2 PA; OTC NEOSPORIN OIN ORIGINAL 3 PA; OTC sb triple oin antibiot 1 OTC SILVADENE CRE 1% 3 PA sm antibioti cre plus 1 OTC ssd cre 1% 1 triple antib oin 1 OTC triple antib oin plus 1 OTC DERMATOLOGY, ANTIFUNGALS antifungal aer 1% 1 OTC antifungal cre 1% 1 OTC ath foot pow aer 1% 1 OTC athlete foot cre af 1 OTC AZOLEN TINC SOL 2% 2 OTC blis-to-sol liq 1% 1 OTC ciclodan cre 0.77% 1 CICLODAN CRE KIT 0.77% 3 ST ciclodan sol 8% 1 CICLODAN SOL KIT 8% 3 PA, ST ciclopirox gel 0.77% 1


204

Drug Name Drug Tier Requirements/Limits ciclopirox kit 8% 1 ciclopirox olamine susp 0.77% (base

equiv) 1

ciclopirox shampoo 1% 1 clotrimazole cream 1% 1 clotrimazole soln 1% 1 clotrimazole soln 1% 1 OTC clotrimazole w/ betamethasone cream 1-

0.05% 1

clotrimazole w/ betamethasone lotion 1-0.05%

1

econazole nitrate cream 1% 1 ECOZA AER 1% 3 PA ERTACZO CRE 2% 3 ST EXELDERM CRE 1% 3 ST EXELDERM SOL 1% 3 ST EXODERM LOT 25-1% 3 PA EXTINA AER 2% 3 PA, ST JUBLIA SOL 10% 3 QL (12 / 30 days), ST ketoconazole cream 2% 1 ketoconazole shampoo 2% 1 ketodan aer 2% 1 LAMISIL ADV GEL 1% 2 OTC LOPROX SHA 1% 3 PA, ST lotrimin af aer 2% 1 OTC LUZU CRE 1% 3 ST MENTAX CRE 1% 3 ST miconazole nitrate aerosol pow 2% 1 OTC miconazorb pow af 2% 1 OTC NAFTIN CRE 2% 3 PA, ST NAFTIN GEL 1% 3 ST NAFTIN GEL 2% 3 ST NIZORAL A-D SHA 1% 2 OTC NIZORAL SHA 2% 3 PA, ST nystatin cream 100000 unit/gm 1 nystatin oint 100000 unit/gm 1 nystatin topical powder 100000 unit/gm 1 nystatin-triamcinolone cream 100000-0.1

unit/gm-% 1

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

1

odor eaters pow 1% 1 OTC OXISTAT CRE 1% 3 PA, ST OXISTAT LOT 1% 3 ST sm antifungl cre 2% 1 OTC tetterine oin 2% 1 OTC


205

Drug Name Drug Tier Requirements/Limits VUSION OIN 3 ST XOLEGEL GEL 2% 3 ST DERMATOLOGY, ANTIPSORIATICS, ORAL acitretin cap 10 mg 1 acitretin cap 17.5 mg 1 acitretin cap 25 mg 1 METHOXSALEN CAP 10 MG 1 SORIATANE CAP 10MG 3 PA SORIATANE CAP 17.5MG 3 PA SORIATANE CAP 25MG 3 PA DERMATOLOGY, ANTIPSORIATICS, TOPICAL calcipotriene cream 0.005% 1 calcipotriene oint 0.005% 1 calcipotriene soln 0.005% (50 mcg/ml) 1 calcipotriene-betamethasone dipropionate

oint 0.005-0.064% 1

calcitriol oint 3 mcg/gm 1 QL (800 gm / 25 days) DOVONEX CRE 0.005% 3 PA, ST ENSTILAR AER 3 ST SORILUX AER 0.005% 3 ST TACLONEX OIN 3 PA, ST TACLONEX SUS 3 ST VECTICAL OIN 3MCG/GM 3 QL (800 gm / 25 days),

PA, ST ZITHRANOL SHA 1% 3 PA DERMATOLOGY, ANTISEBORRHEICS dandruff sha 1% 1 OTC LOUTREX CRE 3 PA PROMISEB KIT COMPLETE 3 PA selenium sulfide lotion 2.5% 1 selenium sulfide-pyrithione zinc in urea

shampoo 2.25% 1

SODIUM SULFA LIQ 10% WASH 3 sulfacetamide sodium cleansing gel 10% 1 sulfacetamide sodium liquid 10% 1 sulfacetamide sodium shampoo 10% 1 TERSI FOAM AER 2.25% 3 PA DERMATOLOGY, ANTISEPTICS/DISINFECTANTS DI-DAK-SOL SOL 0.0125% 2 OTC forma-ray sol 20% 1 formaldehyde solution 10% 1 PA GLUTARALDEHY SOL 25% 2 h-chlor 12 sol 0.125% 1 OTC hysept sol 0.5% 1 OTC hysept sol 0.25% 1 OTC


206

Drug Name Drug Tier Requirements/Limits IODOFLEX PAD PAD 3 PA IODOSORB GEL 3 PA; OTC KERR TRIPLE MIS DYE SWAB 3 PA triple dye solution 1 PA DERMATOLOGY, ATOPIC DERMATITIS, INJECTABLE DUPIXENT INJ 300/2ML 3 QL (4 mL / 28 days, 6

mL allowed first month of therapy), PA

DERMATOLOGY, ATOPIC DERMATITIS, TOPICAL ELIDEL CRE 1% 3 QL (30 gm / 30 days),

PA PROTOPIC OIN 0.1% 3 QL (30 gm / 30 days),

PA PROTOPIC OIN 0.03% 3 QL (30 gm / 30 days),

PA tacrolimus oint 0.1% 1 QL (30 gm / 30 days),

PA tacrolimus oint 0.03% 1 QL (30 gm / 30 days),

PA DERMATOLOGY, CORTICOSTEROID COMBINATIONS HALAC KIT 3 PA hydrocortisone-aloe vera cream 0.5% 1 OTC hydrocortisone-aloe vera cream 1% 1 OTC PRAMOSONE CRE 1-1% 3 PA PRAMOSONE LOT 1% 3 PA PRAMOSONE LOT 2.5% 3 PA SCALACORT DK KIT 3 PA SILAZONE PAK PHARMAPA 3 ST SYNALAR KIT 0.025% 3 ST SYNALAR TS KIT 0.01% 3 ST DERMATOLOGY, CORTICOSTEROIDS, HIGH POTENCY amcinonide cream 0.1% 1 amcinonide lotion 0.1% 1 APEXICON E CRE 0.05% 3 betamethasone dipropionate augmented

cream 0.05% 1

betamethasone dipropionate augmented lotion 0.05%

1

betamethasone dipropionate cream 0.05% 1 betamethasone dipropionate lotion 0.05% 1 betamethasone dipropionate oint 0.05% 1 desoximetasone cream 0.25% 1 desoximetasone gel 0.05% 1 desoximetasone oint 0.25% 1 diflorasone diacetate cream 0.05% 1 DIPROLENE AF CRE 0.05% 3 PA, ST


207

Drug Name Drug Tier Requirements/Limits DIPROLENE LOT 0.05% 3 PA, ST fluocinonide cream 0.1% 1 fluocinonide cream 0.05% 1 fluocinonide emulsified base cream 0.05% 1 fluocinonide gel 0.05% 1 fluocinonide oint 0.05% 1 fluocinonide soln 0.05% 1 HALOG CRE 0.1% 3 ST HALOG OIN 0.1% 3 ST PSORCON CRE 0.05% 3 ST TOPICORT CRE 0.25% 3 PA, ST TOPICORT GEL 0.05% 3 PA, ST TOPICORT OIN 0.25% 3 PA, ST TOPICORT SPR 0.25% 3 ST triamcinolone acetonide cream 0.5% 1 triamcinolone acetonide oint 0.5% 1 VANOS CRE 0.1% 3 PA, ST DERMATOLOGY, CORTICOSTEROIDS, LOW POTENCY ADV ALLERGY KIT COLLECTI 3 PA ALA SCALP LOT 2% 3 PA alclometasone dipropionate cream 0.05% 1 alclometasone dipropionate oint 0.05% 1 anti-itch lot 1% 1 OTC CAPEX SHA 0.01% 3 ST DERMA-SMOOTH OIL /FS BODY 3 PA, ST DERMA-SMOOTH OIL /FS SCLP 3 PA, ST DERMASORB HC KIT 2% 3 PA DESONATE GEL 0.05% 3 ST desonide cream 0.05% 1 desonide lotion 0.05% 1 desonide oint 0.05% 1 DESOWEN CRE 0.05% 3 PA, ST DESOWEN LOT 0.05% 3 PA, ST fluocinolone acetonide cream 0.01% 1 fluocinolone acetonide oil 0.01% (body oil) 1 fluocinolone acetonide oil 0.01% (scalp oil) 1 fluocinolone acetonide soln 0.01% 1 hydrocort cre 0.5% 1 OTC hydrocort oin 0.5% 1 OTC hydrocortisone cream 1% 1 hydrocortisone cream 1% 1 OTC hydrocortisone cream 2.5% 1 hydrocortisone lotion 2.5% 1 hydrocortisone oint 1% 1 hydrocortisone oint 2.5% 1


208

Drug Name Drug Tier Requirements/Limits lanacort 10 cre 1% 1 OTC scalacort lot 2% 1 SYNALAR SOL 0.01% 3 PA, ST TEXACORT SOL 2.5% 3 PA VERDESO AER 0.05% 3 ST DERMATOLOGY, CORTICOSTEROIDS, MEDIUM POTENCY betamethasone valerate aerosol foam

0.12% 1

betamethasone valerate cream 0.1% (base equivalent)

1

betamethasone valerate lotion 0.1% (base equivalent)

1

betamethasone valerate oint 0.1% (base equivalent)

1

clocortolone pivalate cream 0.1% 1 CLODERM CRE 0.1% PMP 3 PA, ST CORDRAN CRE 0.05% 3 QL (120 gm / 30 days),

PA, ST CORDRAN LOT 0.05% 3 PA, ST CUTIVATE CRE 0.05% 3 PA, ST CUTIVATE LOT 0.05% 3 PA, ST DERMASORB TA KIT 0.1% 3 PA DERMATOP CRE 0.1% 3 PA, ST DERMATOP OIN 0.1% 3 PA, ST desoximetasone cream 0.05% 1 desoximetasone oint 0.05% 1 ELOCON CRE 0.1% 3 PA, ST ELOCON LOT 0.1% 3 PA, ST ELOCON OIN 0.1% 3 PA, ST fluocinolone acetonide cream 0.025% 1 fluocinolone acetonide oint 0.025% 1 flurandrenolide cream 0.05% 1 ST flurandrenolide lotion 0.05% 1 ST flurandrenolide oint 0.05% 1 ST fluticasone propionate cream 0.05% 1 fluticasone propionate lotion 0.05% 1 fluticasone propionate oint 0.005% 1 hydrocortisone butyrate cream 0.1% 1 hydrocortisone butyrate hydrophilic lipo

base cream 0.1% 1

hydrocortisone butyrate oint 0.1% 1 hydrocortisone butyrate soln 0.1% 1 hydrocortisone valerate cream 0.2% 1 hydrocortisone valerate oint 0.2% 1 KENALOG AER SPRAY 3 PA, ST LOCOID CRE 0.1% 3 PA


209

Drug Name Drug Tier Requirements/Limits LOCOID LIPO CRE 0.1% 3 PA LOCOID LOT 0.1% 3 PA LOCOID OIN 0.1% 3 PA LOCOID SOL 0.1% 3 PA LUXIQ AER 0.12% 3 PA, ST mometasone furoate cream 0.1% 1 mometasone furoate oint 0.1% 1 mometasone furoate solution 0.1% (lotion)1 PANDEL CRE 0.1% 3 ST prednicarbate cream 0.1% 1 prednicarbate oint 0.1% 1 SYNALAR CRE 0.025% 3 PA, ST SYNALAR OIN 0.025% 3 PA, ST TOPICORT CRE 0.05% 3 PA, ST TOPICORT OIN 0.05% 3 PA, ST triamcinolone acetonide aerosol soln 0.147

mg/gm 1

triamcinolone acetonide cream 0.1% 1 triamcinolone acetonide cream 0.025% 1 triamcinolone acetonide lotion 0.1% 1 triamcinolone acetonide lotion 0.025% 1 triamcinolone acetonide oint 0.1% 1 triamcinolone acetonide oint 0.025% 1 TRIANEX OIN 0.05% 3 DERMATOLOGY, CORTICOSTEROIDS, VERY HIGH POTENCY betamethasone dipropionate augmented

gel 0.05% 1

betamethasone dipropionate augmented oint 0.05%

1

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

0.05% 1 QL (1 can / 25 days)

clobetasol propionate foam 0.05% 1 clobetasol propionate gel 0.05% 1 clobetasol propionate lotion 0.05% 1 clobetasol propionate oint 0.05% 1 clobetasol propionate soln 0.05% 1 clobetasol propionate spray 0.05% 1 CLOBEX LOT 0.05% 3 PA, ST CLOBEX SHA 0.05% 3 PA, ST CLOBEX SPR 0.05% 3 PA, ST clodan sha 0.05% 1 diflorasone diacetate oint 0.05% 1 PA DIPROLENE OIN 0.05% 3 PA, ST halobetasol propionate cream 0.05% 1


210

Drug Name Drug Tier Requirements/Limits halobetasol propionate oint 0.05% 1 OLUX AER 0.05% 3 PA, ST OLUX-E AER 0.05% 3 QL (1 can / 25 days),

PA, ST TEMOVATE CRE 0.05% 3 PA, ST TEMOVATE GEL 0.05% 3 PA, ST TEMOVATE OIN 0.05% 3 PA, ST ULTRAVATE CRE 0.05% 3 PA, ST ULTRAVATE OIN 0.05% 3 PA, ST DERMATOLOGY, EMOLLIENTS DERMASORB XM KIT 39% 3 PA glycerin topical liquid 1 OTC gnp glycerin sol rosewatr 1 OTC GORDONS UREA OIN 22% 3 PA; OTC GORDONS UREA OIN 40% 3 PA hyaluronate sodium (emollient) gel 0.2% 1 LAC-HYDRIN CRE 12% 2 PA LAC-HYDRIN LOT 12% 3 PA LAC-HYDRIN LOT 12% 3 PA; OTC lactic acid (ammonium lactate) cream 12% 1 lactic acid (ammonium lactate) cream 12% 1 OTC lactic acid (ammonium lactate) lotion 12% 1 lactic acid (ammonium lactate) lotion 12% 1 OTC LATRIX XM EMU 45% 3 PA sm dry skin lot therapy 1 OTC TROPAZONE LOT 3 UREVAZ CRE 44% 3 PA DERMATOLOGY, LOCAL ANALGESIC lidocaine patch 5% 1 PA LIDODERM DIS 5% 3 PA DERMATOLOGY, LOCAL ANESTHETICS ANACAINE OIN 3 PA BACTINE SPR 3 PA; OTC capsaicin cream 0.1% 1 OTC capsaicin cream 0.025% 1 OTC CAPSAICIN LIQ 0.15% 3 PA; OTC capsaicin pad hot ptch 1 OTC CAPZASIN GEL RELIEF 2 OTC CAPZASIN-P CRE 0.035% 3 OTC cocaine hcl soln 4% 1 cooling burn spr relief 1 OTC dermacinrx kit prizopak 1 PA first aid spr 1 PA; OTC LDO PLUS GEL 4% 3 PA LIDO-K LOT 3% 3 PA


211

Drug Name Drug Tier Requirements/Limits lidocaine cream 4% 1 OTC lidocaine cream 4% & transparent dressing

kit 1 OTC

lidocaine hcl cream 3% 1 PA lidocaine hcl gel 2% 1 lidocaine hcl lotion 3% 1 lidocaine hcl soln 4% 1 lidocaine oint 5% 1 lidocaine-prilocaine cream 2.5-2.5% 1 LIDORX GEL 3% 3 PA LIDOVEX CRE 3.75% 3 PA NEO TO GO SPR 1-0.13% 3 PA; OTC QUTENZA KIT 8% 1-PCH 3 QL (4 boxes / 91 days),

PA tgt cold/hot cre pain rel 1 OTC theragen hp cre 0.075% 1 OTC XYLOCAINE SOL 4% 3 PA zeruvia pad 4-1% 1 PA DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ABREVA CRE 10% 2 QL (2 gm / 30 days);

OTC ACLARO EMU 3 PA acyclovir oint 5% 1 QL (30 gm / 30 days) ALDARA CRE 5% 3 PA anti-itch cre 1-01% 1 OTC anti-itch cre 2-0.1% 1 OTC anti-itch spr 2% 1 OTC APLIGRAF MIS 2 arzol silver mis nitr app 1 benadryl itc gel 2% 1 OTC BENSAL HP OIN 3 PA BOUDREAUXS OIN 16% 3 OTC BUCALSEP SOL 3 PA BUCALSEP SPR 3 PA calamine med lot 1-8% 1 OTC ceramax cre 1 clear away liq 17% 1 OTC CONDYLOX GEL 0.5% 3 PA CONDYLOX SOL 0.5% 3 PA corn&callus kit 17% 1 OTC DENAVIR CRE 1% 3 QL (5 gm / 30 days), ST DERMAGRAFT MIS 3 PA DERMAWERX KIT SURGICAL 3 PA diaper rash cre 10% 1 OTC diaper rash cre 13% 1 OTC diaper rash oin 40% 1 OTC


212

Drug Name Drug Tier Requirements/Limits diaper rash oin creamy 1 OTC DR SMITHS OIN DIAPER 2 PA; OTC DRYSOL SOL 20% 2 duofilm sol 17% 1 OTC EMULSION SB EMU 3 PA GENADUR LIQ 3 PA GENTIAN VIOL SOL 2% 3 OTC high power liq body wsh 1 OTC HPR PLUS CRE 3 PA hydrocerin cre plus 1 OTC imiquimod cream 5% 1 IV PREP WIPE PAD 3 QL (300 pads / 30

days); OTC KERALYT GEL 6% 3 PA KERALYT KIT SCALP 6% 3 PA lip balm oin strawber 1 OTC MB HYDROGEL KIT 3 PA MEXSANA POW 2 OTC neutrogena gel rainbath 1 OTC OXSORALEN LOT 1% 3 PA PALOMAR E OIN 2 OTC PANRETIN GEL 0.1% 3 PA PHARMABASE OIN BARRIER 2 OTC PODOCON SOL 25% 3 PA podofilox soln 0.5% 1 PRUDOXIN CRE 5% 3 PA PYROGALL ACD OIN 3 PA REGRANEX GEL 0.01% 2 QL (45 gm / year) RENOVA CRE 0.02% 3 PA SALEX CREAM KIT 6% 3 PA SALEX LOTION KIT 6% 3 PA SALEX SHA 6% 3 PA salicylic ac liq 27.5% 1 salicylic acid cream 6% 1 salicylic acid cream 6% & cleanser liqd kit 1 salicylic acid foam 6% 1 salicylic acid gel 6% 1 salicylic acid in ammonium lactate vehicle

foam 6% 1

salicylic acid lotion 6% 1 salicylic acid lotion 6% & cleanser liqd kit 1 salicylic acid shampoo 6% 1 SALICYLIC ACID SOLN 26% 3 PA SANTYL OIN 250/GM 2 SECURA CRE 30.6% 2 OTC SENSI-CARE CRE MOISTURI 3 OTC


213

Drug Name Drug Tier Requirements/Limits SILVER NITRA OIN 10% 3 SKIN PROTECT CRE 12% 3 PA; OTC sm allergy cre 2% 1 OTC strip ease liq adh remv 1 OTC SULFAMYLON CRE 85MG/GM 2 SULFAMYLON PAK 5% 3 PA TERSASEPTIC LIQ 3 OTC therapeutic gel 2% 1 OTC TRI-LUMA CRE 3 PA TRIPLE PASTE OIN 12.8% 2 OTC ultra-derm lot 1 OTC VIRASAL LIQ 27.5% 3 PA wal-dryl spr 1 OTC XERAC-AC SOL 6.25% 3 PA XERESE CRE 5-1% 3 ST YALE CLEANER POW 3 PA; OTC zinc oxide oin 20% 1 OTC ZINC OXIDE PST 25% 2 OTC ZOVIRAX CRE 5% 2 QL (5 gm / 30 days) ZOVIRAX OIN 5% 3 QL (30 gm / 30 days),

PA, ST DERMATOLOGY, ROSACEA doxycycline (rosacea) cap delayed release

40 mg 1 QL (30 caps / 30 days)

FINACEA AER 15% 3 ST FINACEA GEL 15% 3 ST METROCREAM CRE 0.75% 3 PA METROGEL GEL 1% 3 PA, ST METROLOTION LOT 0.75% 3 PA metronidazole gel 0.75% 1 metronidazole gel 1% 1 metronidazole lotion 0.75% 1 MIRVASO GEL 0.33% 3 ST NORITATE CRE 1% 3 ST ORACEA CAP 40MG 3 QL (30 caps / 30 days),

PA, ST RHOFADE CRE 1% 3 PA rosadan cre 0.75% 1 ROSADAN KIT 0.75% 3 PA DERMATOLOGY, SCABICIDES AND PEDICULICIDES bedding spra aer 0.5% 1 OTC complete kit lice 1 OTC ELIMITE CRE 5% 3 PA eql lice kit solution 1 OTC EURAX CRE 10% 2 EURAX LOT 10% 2


214

Drug Name Drug Tier Requirements/Limits lice killing sha 1 OTC lice md gel 1 PA; OTC lice trtmnt liq 1% 1 QL (120 / 30 days); OTC lice trtmnt liq crm rnse 1 QL (120 / 30 days); OTC LYCELLE GEL 3 PA; OTC malathion lotion 0.5% 1 NATROBA SUS 0.9% 3 QL (1420 ml per fill),

PA, ST OVIDE LOT 0.5% 3 PA, ST permethrin cream 5% 1 RID COMPLETE KIT LICE 2 PA; OTC SKLICE LOT 0.5% 3 ST sm lice lot treatmnt 1 OTC spinosad susp 0.9% 1 QL (1420 ml per fill) ULESFIA LOT 5% 3 ST DERMATOLOGY, WOUND CARE PRODUCTS ACTICOAT 7 MIS 1"X24" 3 PA ACTICOAT 7 MIS 2"X2" 3 ACTICOAT 7 MIS 4"X5" 3 PA ACTICOAT 7 MIS 6"X6" 3 PA ACTICOAT MIS 5"X5" 3 PA ALGICELL AG PAD 4"X5" 3 OTC ALLEVYN AG PAD 3"X3" 3 PA ATRAPRO DERM SPR 3 PA ATRAPRO GEL HYDROGEL 3 PA BIOSTEP AG MIS 2"X2" 3 PA BIOSTEP AG MIS 4"X4" 3 PA BIOSTEP MIS 2"X2" 3 PA BIOSTEP MIS 4"X4" 3 PA carracolloid pad 4"x4" 1 OTC DIAB CRE 3 OTC ENDO DERMAL MIS 5X5 CM 3 PA ENDO DERMAL MIS 10X12.7 3 PA HYDROGEL DRE PAD 2"X3" 3 PA HYDROGEL DRE PAD 4"X5" 3 PA HYGEL GEL 2.5% 3 PA LUXAMEND CRE 3 PA OASIS MATRIX MIS 3X7CM 3 PA OASIS ULTRA MIS 3X3.5CM 3 PA OASIS ULTRA MIS 5 X 7CM 3 PA OASIS ULTRA MIS TRI MESH 3 PICO WOUND KIT THER SYS 3 PA PRUTECT EMU 3 PA REGENECARE GEL 3 PA SILVRSTAT GEL DRESSING 3 PA


215

Drug Name Drug Tier Requirements/Limits vashe wound sol therapy 1 OTC VENELEX OIN 3 PA XEROFRM GAUZ MIS 1"X8" 2 XEROFRM PETR PAD 2"X2" 2 IRRIGATION SOLUTIONS argyl saline sol 100ml 1 lactated ringer's for irrigation 1 PA physiolyte sol 1 PA ringer's solution for irrigation 1 MOUTH/THROAT/DENTAL AGENTS, MISCELLANEOUS act dry loz mouth 1 OTC ANTI-SNORE LIQ THROAT 2 OTC antiseptic liq original 1 OTC AQUORAL AER 3 PA ARESTIN MIS 1MG 3 PA CAPHOSOL SOL 3 PA cavarest gel 1.1% 1 CEPACOL SORE LOZ COATING 2 OTC CHLORASEPTIC LOZ TOTAL 3 OTC clinpro 5000 pst 1.1% 1 cough drops loz 5.4mg 1 OTC cough drops loz menthol 1 OTC cvs sore loz throat 1 OTC DEBACTEROL SOL 30-50% 2 easygel gel 0.4%citr 1 fluorid sens pst 1.1-5% 1 fluoridex dd pst sensitiv 1 PA GEL-KAM CON 0.63% 3 PA GELCLAIR GEL 3 PA just for kid gel 0.4% grp 1 OTC lidocaine hcl laryngotracheal soln 4% 1 lidocaine hcl viscous soln 2% 1 NAFRINSE DLY SOL /NEUTRAL 2 NAFRINSE SOL DAILY 2 NAFRINSE WK SOL 0.2% 3 PA NEUTRASAL POW 3 PA NUMOISYN LOZ 3 PA OASIS MOUTH SPR 35% 2 OTC ORAFATE PST 10% 3 PA PERIDEX SOL 0.12% 3 PA periogard sol 0.12% 1 periomed con 0.63% 1 OTC PHOS-FLUR SOL 0.044% 2 OTC PREVDNT 5000 PST 1.1-5% 3 PA PREVIDENT GEL 1.1% MIN 3 PA


216

Drug Name Drug Tier Requirements/Limits PREVIDENT PST 5000 BST 3 PA Q4 ORAL CLEA KIT SYSTEM 3 PA sf 5000 plus cre 1.1% 1 sod fluoride sol 0.2% 1 PA sore throat loz 15-3.6mg 1 OTC sore throat loz cherry 1 OTC sore throat spr 1.4% 1 OTC triamcinolone acetonide dental paste 0.1% 1 MOUTH/THROAT/DENTAL AGENTS, PROTECTANTS EPISIL LIQ 3 PA MUCOTROL WAF 3 PA MUGARD LIQ 3 PA SALICEPT SUS 3 PA OPHTHALMIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY

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

ophth oint 0.1% 1

neomycin-polymyxin-dexamethasone ophth susp 0.1%

1

neomycin-polymyxin-hc ophth susp 1 PRED-G S.O.P OIN OP 3 ST PRED-G SUS OP 3 ST sulfacetamide sodium-prednisolone ophth

soln 10-0.23(0.25)% 1

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

0.3-0.1% 1

ZYLET SUS 0.5-0.3% 3 PA OPHTHALMIC, ANTI-INFECTIVES AZASITE SOL 1% 3 ST bacitracin ophth oint 500 unit/gm 1 BESIVANCE SUS 0.6% 3 ST BETADINE SOL 5% OP 3 PA BLEPH-10 SOL 10% OP 3 PA, ST CILOXAN OIN 0.3% OP 3 ST CILOXAN SOL 0.3% OP 3 PA, ST ciprofloxacin hcl ophth soln 0.3% 1 gatifloxacin ophth soln 0.5% 1


217

Drug Name Drug Tier Requirements/Limits gentamicin sulfate ophth oint 0.3% 1 gentamicin sulfate ophth soln 0.3% 1 ilotycin oin op 1 levofloxacin ophth soln 0.5% 1 MITOSOL KIT 0.2MG 3 PA MOXEZA SOL 0.5% 3 ST moxifloxacin hcl ophth soln 0.5% (base

equiv) 1 ST

neo-polycin oin op 1 neomycin-polymy-gramicid op sol 1.75-

10000-0.025mg-unt-mg/ml 1

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

10000 unit/ml-0.1% 1

POLYTRIM SOL OP 3 PA, ST sulfacetamide sodium ophth oint 10% 1 sulfacetamide sodium ophth soln 10% 1 tobramycin ophth soln 0.3% 1 TOBREX OIN 0.3% OP 3 ST TOBREX SOL 0.3% OP 3 PA, ST VIGAMOX DRO 0.5% 3 ST ZYMAXID SOL 0.5% 3 PA, ST OPHTHALMIC, ANTI-INFLAMMATORY, NONSTEROIDAL ACULAR LS SOL 0.4% 3 PA, ST ACULAR SOL 0.5% OP 3 PA ACUVAIL SOL 0.45% 3 QL (30 / 365 days), ST bromfenac sodium ophth soln 0.09% (base

equiv) (once-daily) 1

bromfenac sodium ophth soln 0.09% (base equivalent)

1

diclofenac sodium ophth soln 0.1% 1 flurbiprofen sodium ophth soln 0.03% 1 ILEVRO DRO 0.3% OP 3 ST ketorolac tromethamine ophth soln 0.4% 1 ketorolac tromethamine ophth soln 0.5% 1 NEVANAC SUS 0.1% 3 ST OCUFEN SOL 0.03% OP 3 PA, ST PROLENSA SOL 0.07% 3 ST OPHTHALMIC, ANTI-INFLAMMATORY, STEROIDAL ALREX SUS 0.2% 3 PA dexamethasone sodium phosphate ophth

soln 0.1% 1

DUREZOL EMU 0.05% 3 PA


218

Drug Name Drug Tier Requirements/Limits FLAREX SUS 0.1% OP 3 PA fluorometholone ophth susp 0.1% 1 FML FORTE SUS 0.25% OP 3 PA FML LIQUIFLM SUS 0.1% OP 3 PA FML OIN 0.1% OP 3 PA LOTEMAX GEL 0.5% 3 ST LOTEMAX OIN 0.5% 3 ST LOTEMAX SUS 0.5% 3 ST MAXIDEX SUS 0.1% OP 3 PA OMNIPRED SUS 1% OP 3 PA PRED MILD SUS 0.12% OP 2 PRED SOD PHO SOL 1% OP 3 prednisolone acetate ophth susp 1% 1 TRIESENCE INJ 40MG/ML 3 PA OPHTHALMIC, ANTIALLERGICS alaway dro 0.025%op 1 OTC ALOCRIL SOL 2% 3 ST ALOMIDE SOL 0.1% OP 3 ST azelastine hcl ophth soln 0.05% 1 BEPREVE DRO 1.5% 3 ST cromolyn sodium ophth soln 4% 1 ELESTAT DRO 0.05% 3 PA, ST EMADINE SOL 0.05% OP 3 ST epinastine hcl ophth soln 0.05% 1 LASTACAFT SOL 0.25% 3 ST olopatadine hcl ophth soln 0.1% (base

equivalent) 1

olopatadine hcl ophth soln 0.2% (base equivalent)

1

PATADAY SOL 0.2% 3 ST PATANOL SOL 0.1% OP 3 ST PAZEO DRO 0.7% 3 PA OPHTHALMIC, ANTIFUNGALS NATACYN SUS 5% OP 2 OPHTHALMIC, ANTIVIRAL trifluridine ophth soln 1% 1 VIROPTIC SOL 1% OP 3 PA, ST ZIRGAN GEL 0.15% 3 ST OPHTHALMIC, BETA-BLOCKERS, NONSELECTIVE BETAGAN SOL 0.5% OP 3 PA, ST BETIMOL SOL 0.5% 3 ST BETIMOL SOL 0.25% 3 ST carteolol hcl ophth soln 1% 1 ISTALOL SOL 0.5% OP 3 ST levobunolol hcl ophth soln 0.5% 1


219

Drug Name Drug Tier Requirements/Limits metipranolol ophth soln 0.3% 1 timolol maleate ophth gel forming soln

0.5% 1

timolol maleate ophth gel forming soln 0.25%

1

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

COMBINATIONS COSOPT PF SOL 3 ST COSOPT SOL 22.3-6.8 3 PA, ST dorzolamide hcl-timolol maleate ophth soln

22.3-6.8 mg/ml 1

OPHTHALMIC, CARBONIC ANHYDRASE INHIBITOR/SYMPATHOMIMETIC COMBINATIONS

SIMBRINZA SUS 1-0.2% 3 ST OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS, INJECTABLE acetazolamide sodium for inj 500 mg 1 KEVEYIS TAB 50MG 3 QL (120 tabs / 30 days),

PA OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS, ORAL acetazolamide cap er 12hr 500 mg 1 acetazolamide tab 125 mg 1 acetazolamide tab 250 mg 1 DIAMOX SEQUE CAP 500MG CR 3 PA methazolamide tab 25 mg 1 methazolamide tab 50 mg 1 NEPTAZANE TAB 25MG 3 PA NEPTAZANE TAB 50MG 3 PA OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS, TOPICAL AZOPT SUS 1% OP 3 ST dorzolamide hcl ophth soln 2% 1 TRUSOPT SOL 2% OP 3 PA, ST OPHTHALMIC, DIAGNOSTIC PRODUCTS ak-fluor inj 10% op 1 PA AK-FLUOR INJ 25% OP 3 PA


220

Drug Name Drug Tier Requirements/Limits bio glo tes 1mg op 1 flucaine sol 0.25-0.5 1 FLURA-SAFE SOL 3 PA flurox sol op 1 PA FUL-GLO TES 0.6MG OP 3 PA PAREMYD SOL 1-0.25% 3 PA OPHTHALMIC, DRY EYE DISEASE RESTASIS EMU 0.05% 3 QL (60 ea / 30 days), PA XIIDRA DRO 5% 2 QL (12 / 30 days) OPHTHALMIC, LOCAL ANESTHETIC AKTEN GEL 3.5% 3 QL (1 ml / year), PA OPHTHALMIC, MISCELLANEOUS adv formula dro eye 1 OTC advanced sol lubrican 1 OTC ALCAINE SOL 0.5% OP 3 PA AMVISC INJ 12MG/ML 3 PA AMVISC PLUS INJ 16MG/ML 3 PA artificial dro tears 1 OTC artificial sol tears 1 OTC artificial sol tears op 1 OTC bal salt sol op 1 BSS PLUS SOL OP 3 PA CELLUGEL SOL 2% 3 PA CYSTARAN SOL 0.44% 2 QL (60 / 30 days) DISCOVISC SOL 3 PA DUOVISC KIT 0.5/0.55 3 PA DUOVISC KIT 0.35/0.4 3 PA eq gentle dro 0.3% 1 OTC eye drops dro 0.5-0.9% 1 OTC eye drops sol 0.05% op 1 OTC eye drops sol a/r 1 OTC GELFILM MIS OP 3 PA GENTEAL MILD DRO 0.2% 3 OTC HYPOTEARS SOL 1-1% 2 OTC ISOPTO TEARS SOL 0.5% OP 3 OTC LACRISERT MIS 5MG OP 3 PA lubricant dro eye 0.6% 1 OTC lubricnt eye dro 0.4-0.3% 1 OTC lubricnt eye dro 0.5% op 1 OTC lubricnt eye oin fast act 1 OTC lubricnt gel dro 0.25-0.3 1 OTC lubricnt gel dro 1% 2 OTC MEMBRANEBLUE SOL 0.15% 3 PA ocucoat sol 2% op 1 phenylephrine hcl ophth soln 2.5% 1


221

Drug Name Drug Tier Requirements/Limits phenylephrine hcl ophth soln 10% 1 polyvinyl alcohol ophth soln 1.4% 1 OTC proparacaine hcl ophth soln 0.5% 1 PROVISC INJ 1% 3 PA REFRESH CELL DRO 1% OP 3 OTC REFRESH GEL OPTIVE 2 OTC REFRESH OPTI DRO 0.5-0.9% 2 PA; OTC REFRESH PLUS DRO 0.5% OP 3 PA; OTC REFRESH SOL OPTIVE 3 OTC ROSE BENGAL TES 1.3MG 3 OTC sm dry eye sol relief 1 OTC sm multi-pur sol 1 OTC sm redness dro relief 1 OTC soothe night oin time 1 OTC STERILE LUBR DRO 0.7% 3 PA; OTC SYSTANE GEL 0.3% 3 OTC SYSTANE GEL DRO 0.4-0.3% 3 OTC tears pure sol 1 OTC tetcaine sol 0.5% op 1 PA THERATEARS GEL 1% 3 PA; OTC THERATEARS SOL OP 3 OTC VISCOAT SOL 3 PA VISIONBLUE SOL 0.06% 3 PA OPHTHALMIC, MYDRIATICS ATROPINE SUL OIN 1% OP 3 atropine sulfate ophth soln 1% 1 CYCLOGYL SOL 0.5% OP 3 PA CYCLOGYL SOL 1% OP 3 PA CYCLOGYL SOL 2% OP 3 PA CYCLOMYDRIL SOL OP 3 PA cyclopentolate hcl ophth soln 1% 1 cyclopentolate hcl ophth soln 2% 1 homatropine hbr ophth soln 5% 1 MYDRIACYL SOL 1% OP 3 PA tropicamide ophth soln 0.5% 1 tropicamide ophth soln 1% 1 OPHTHALMIC, PARASYMPATHOMIMETICS MIOCHOL-E SOL 1:100 3 PA MIOSTAT INJ 0.01% OP 3 OPHTHALMIC, PROSTAGLANDINS bimatoprost ophth soln 0.03% 1 latanoprost ophth soln 0.005% 1 LUMIGAN SOL 0.01% 3 ST TRAVATAN Z DRO 0.004% 3 ST XALATAN SOL 0.005% 3 PA, ST


222

Drug Name Drug Tier Requirements/Limits ZIOPTAN DRO 0.0015% 3 ST OPHTHALMIC, SYMPATHOMIMETIC/BETA-BLOCKER COMBINATIONS COMBIGAN SOL 0.2/0.5% 3 ST OPHTHALMIC, SYMPATHOMIMETICS ALPHAGAN P SOL 0.1% 2 ALPHAGAN P SOL 0.15% 3 PA, ST apraclonidine hcl ophth soln 0.5% (base

equivalent) 1

brimonidine tartrate ophth soln 0.2% 1 brimonidine tartrate ophth soln 0.15% 1 PHOSPHOLINE SOL 0.125%OP 2 OTIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS CIPRO HC SUS OTIC 3 CIPRODEX SUS 0.3-0.1% 2 COLY-MYCIN S SUS OTIC 3 hydrocortisone w/ acetic acid otic soln 1-

2% 1

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

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

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

soln 1

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

equivalent) 1

ofloxacin otic soln 0.3% 1 OTIC, MISCELLANEOUS DERMOTIC OIL 0.01% 3 PA fluocinolone acetonide (otic) oil 0.01% 1 PRAMOTIC DRO 1-0.1% 3 PA

223

Index 1 1.5 ML SYRNG MIS 22X1-1/2 ........... 170 10-12ML SYRN MIS LUER SLP .......... 170 12ML SYRINGE MIS 20GX1.5" .......... 169 12ML SYRINGE MIS 21GX1.5" .......... 169 1ML SYRINGE MIS 25GX1" .............. 170 1ML SYRINGE MIS 25GX5/8"............ 170 1ML SYRINGE MIS 26GX3/8"............ 170 1ML SYRINGE MIS LUER SLP ............ 170 1ML TB SYRNG MIS LUER SLP .......... 170 2 20ML SYRINGE MIS LL ZONE1 .......... 170 2ML TB SYRNG MIS LL ZONE1 .......... 170 3 3 ML SYRINGE MIS 22X1-1/2 ........... 170 30ML SYRINGE MIS GL ZONE1 ......... 170 30ML SYRINGE MIS LUER LOC ......... 170 3ML CTRL SYR MIS LL ZONE1 .......... 169 3ML LL SYRNG MIS 20GX1" ............. 169 3ML LL SYRNG MIS 21GX1.25 .......... 169 3ML LL SYRNG MIS 22GX1.25 .......... 169 3ML LL SYRNG MIS 22GX3/4" .......... 169 3ML LL SYRNG MIS 23GX1.25 .......... 169 3ML LL SYRNG MIS 24GX1" ............. 169 3ML SYRINGE MIS 20GX1" .............. 169 3ML SYRINGE MIS 20GX1.5" ............ 169 3ML SYRINGE MIS 21GX1" .............. 169 3ML SYRINGE MIS 21GX1.5" ............ 169 3ML SYRINGE MIS 22GX1" .............. 170 3ML SYRINGE MIS 22GX1.5" ............ 170 3ML SYRINGE MIS 23GX1" .............. 170 3ML SYRINGE MIS 23GX1.5" ............ 170 3ML SYRINGE MIS 25GX1" .............. 170 3ML SYRINGE MIS 25GX5/8"............ 170 3ML SYRINGE MIS REG TIP .............. 170 4 45PSE/400GFN TAB ........................ 191 5 50ML SYRINGE MIS ML ZONE1 ......... 170 5-6ML SYRING MIS LUER SLP ........... 169 5ML CONTROL MIS SANA-LOK .......... 169 5ML SYRINGE MIS LUER SLP ............ 170 6 60PSE/400GFN TAB /20DM .............. 191 6ML LL SYRNG MIS 20GX1.5" ........... 169 6ML SYRINGE MIS 20GX1.5" ............ 169 6ML SYRINGE MIS 22GX1.5" ............ 170

8 8 hour pain tab 650mg ....................... 1 A abacavir sulfate soln 20 mg/ml (base equiv) ............................................ 29 abacavir sulfate tab 300 mg (base equiv) ..................................................... 29 abacavir sulfate-lamivudine tab 600-300 mg ................................................ 27 abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg ........................ 27 ABANEU-SL SUB ............................. 176 abatron af tab ................................ 176 abatron liq ..................................... 176 ABELCET INJ 5MG/ML ....................... 25 ABILIFY MAIN INJ 300MG ................. 90 ABILIFY MAIN INJ 400MG ................. 90 ABRAXANE INJ 100MG ..................... 42 ABREVA CRE 10% .......................... 211 ABSORICA CAP 10MG ...................... 199 ABSORICA CAP 20MG ...................... 199 ABSORICA CAP 25MG ...................... 199 ABSORICA CAP 30MG ...................... 199 ABSORICA CAP 35MG ...................... 199 ABSORICA CAP 40MG ...................... 199 ABSTRAL SUB 100MCG ....................... 5 ABSTRAL SUB 200MCG ....................... 5 ABSTRAL SUB 300MCG ....................... 5 ABSTRAL SUB 400MCG ....................... 5 ABSTRAL SUB 600MCG ....................... 5 ABSTRAL SUB 800MCG ....................... 5 acamprosate calcium tab delayed release 333 mg ......................................... 112 ACANYA GEL 1.2-2.5% .................... 199 acarbose tab 100 mg ...................... 114 acarbose tab 25 mg ........................ 114 acarbose tab 50 mg ........................ 114 ACCOLATE TAB 10MG ...................... 194 ACCOLATE TAB 20MG ...................... 194 ACCU-CHEK IN LIQ CONTROL ........... 120 ACCU-CHEK KIT AVA CONN .............. 120 ACCU-CHEK KIT AVIVA PL ................ 120 ACCU-CHEK KIT COMBO .................. 120 ACCU-CHEK KIT COMPACT ............... 120 ACCU-CHEK KIT FASTCLIX ............... 120 ACCU-CHEK KIT MLTICLIX ............... 120 ACCU-CHEK KIT NANO .................... 120

224

ACCU-CHEK KIT SOFTCLIX .............. 120 ACCU-CHEK KIT VOICEMAT ............. 120 ACCU-CHEK LIQ COMPACT .............. 120 ACCU-CHEK LIQ SMART .................. 120 ACCU-CHEK SOL ............................ 120 ACCU-CHEK SOL COMPACT .............. 120 ACCU-CHEK TES AVIVA PL ............... 120 ACCU-CHEK TES COMPACT .............. 120 ACCU-CHEK TES SMART .................. 120 ACCUPRIL TAB 10MG ........................ 48 ACCUPRIL TAB 20MG ........................ 48 ACCUPRIL TAB 40MG ........................ 48 ACCUPRIL TAB 5MG .......................... 48 ACCURETIC TAB 10-12.5 ................... 47 ACCURETIC TAB 20-12.5 ................... 47 ACCURETIC TAB 20-25MG ................. 47 ACCUTREND TES GLUCOSE .............. 120 ACD FORMULA SOL A ...................... 162 acebutolol hcl cap 200 mg ................. 60 acebutolol hcl cap 400 mg ................. 60 ACEON TAB 4MG .............................. 48 ACEON TAB 8MG .............................. 48 ACETADOTE INJ 200MG/ML ............. 123 acetaminophen suppos 650 mg ........... 1 acetaminophen w/ codeine soln 120-12 mg/5ml ............................................ 5 acetaminophen w/ codeine tab 300-15 mg .................................................. 5 acetaminophen w/ codeine tab 300-30 mg .................................................. 5 acetaminophen w/ codeine tab 300-60 mg .................................................. 5 acetaminophen-caffeine-dihydrocodeine cap 320.5-30-16 mg .......................... 5 acetazolamide cap er 12hr 500 mg ... 219 acetazolamide sodium for inj 500 mg 219 acetazolamide tab 125 mg ............... 219 acetazolamide tab 250 mg ............... 219 ACETEST TAB TABLETS ................... 120 acetic acid 2% in aluminum acetate otic soln .............................................. 222 acetic acid irrigation soln 0.25% ....... 152 acetic acid otic soln 2% ................... 222 acetylcysteine inhal soln 10% .......... 195 acetylcysteine inhal soln 20% .......... 195 acetylcysteine inj 200 mg/ml ........... 123 acid reducer tab 10mg .................... 143 ACIDOPH/PROB TAB FORMULA ......... 147

ACIDOPHILUS CAP .......................... 147 ACIDOPHILUS/ WAF BIFIDUS ........... 147 ACIPHEX SPR CAP 10MG .................. 149 ACIPHEX SPR CAP 5MG ................... 149 ACIPHEX TAB 20MG ........................ 149 acitretin cap 10 mg ......................... 205 acitretin cap 17.5 mg ...................... 205 acitretin cap 25 mg ......................... 205 ACLARO EMU ................................. 211 acne cleansi bar 10% ...................... 199 ACNE MEDICAT LOT 10% ................ 199 acne treatme cre 10% ..................... 199 act dry loz mouth ........................... 215 ACTEMRA INJ 162/0.9 ..................... 164 ACTICOAT 7 MIS 1"X24" .................. 214 ACTICOAT 7 MIS 2"X2" ................... 214 ACTICOAT 7 MIS 4"X5" ................... 214 ACTICOAT 7 MIS 6"X6" ................... 214 ACTICOAT MIS 5"X5" ...................... 214 ACTIGALL CAP 300MG ..................... 143 ACTIMMUNE INJ 2MU/0.5 ................ 167 ACTIQ LOZ 1200MCG ......................... 6 ACTIQ LOZ 1600MCG ......................... 6 ACTIQ LOZ 200MCG ........................... 5 ACTIQ LOZ 400MCG ........................... 5 ACTIQ LOZ 600MCG ........................... 5 ACTIQ LOZ 800MCG ........................... 5 ACTIVE FE TAB 75-1.25 ................... 176 ACTIVE INJEC KIT KL-3 ................... 130 ACTIVE OB CAP .............................. 176 ACTIVELLA TAB 0.5-0.1 ................... 128 ACTIVELLA TAB 1-0.5MG ................. 128 ACTONEL TAB 150MG ...................... 124 ACTONEL TAB 30MG ....................... 124 ACTONEL TAB 35MG ....................... 124 ACTONEL TAB 5MG ......................... 124 ACTOPLUS MET TAB XR ................... 116 ACULAR LS SOL 0.4% ..................... 217 ACULAR SOL 0.5% OP ..................... 217 ACUVAIL SOL 0.45% ....................... 217 acyclovir cap 200 mg ....................... 33 acyclovir oint 5% ............................ 211 acyclovir sodium for inj 1000 mg ....... 33 acyclovir sodium for inj 500 mg ......... 33 acyclovir sodium iv soln 50 mg/ml ..... 33 acyclovir susp 200 mg/5ml ............... 33 acyclovir tab 400 mg ........................ 33 acyclovir tab 800 mg ........................ 33

225

ACZONE GEL 5% ............................ 199 ADALAT CC TAB 30MG ER .................. 62 ADALAT CC TAB 60MG ER .................. 62 ADALAT CC TAB 90MG ER .................. 63 adapalene cream 0.1% ................... 199 adapalene gel 0.1% ........................ 199 adapalene gel 0.3% ........................ 199 adapalene lotion 0.1% .................... 199 adapalene-benzoyl peroxide gel 0.1-2.5% ............................................ 199 ADASUVE INH 10MG ......................... 90 ADCIRCA TAB 20MG ......................... 70 ADDAMEL N INJ ............................. 175 ADDERALL TAB 10MG ....................... 97 ADDERALL TAB 12.5MG ..................... 97 ADDERALL TAB 15MG ....................... 97 ADDERALL TAB 20MG ....................... 97 ADDERALL TAB 30MG ....................... 97 ADDERALL TAB 5MG ......................... 97 ADDERALL TAB 7.5MG ...................... 97 ADDERALL XR CAP 10MG ................... 97 ADDERALL XR CAP 15MG ................... 97 ADDERALL XR CAP 20MG ................... 97 ADDERALL XR CAP 25MG ................... 97 ADDERALL XR CAP 30MG ................... 97 ADDERALL XR CAP 5MG .................... 97 adefovir dipivoxil tab 10 mg ............... 31 ADEMPAS TAB 0.5MG ........................ 71 ADEMPAS TAB 1.5MG ........................ 71 ADEMPAS TAB 1MG .......................... 71 ADEMPAS TAB 2.5MG ........................ 71 ADEMPAS TAB 2MG .......................... 71 ADENOCARD INJ 12MG/4ML .............. 54 ADENOCARD INJ 3MG/ML .................. 54 adenosine iv soln 12 mg/4ml ............. 54 adenosine iv soln 6 mg/2ml ............... 54 ADLYXIN INJ 10/20MCG .................. 116 ADLYXIN INJ 20MCG ....................... 116 ADOXA CAP 150MG .......................... 24 ADRENALIN INJ 1MG/ML ................. 187 ADRENALIN SOL 1:1000 .................. 198 ADV ACNE WSH LIQ 4.4% ............... 199 ADV ALLERGY KIT COLLECTI ............ 207 adv formula dro eye ....................... 220 ADVAIR DISKU AER 100/50 ............. 198 ADVAIR DISKU AER 250/50 ............. 198 ADVAIR DISKU AER 500/50 ............. 198 ADVAIR HFA AER 115/21 ................. 198

ADVAIR HFA AER 230/21 ................. 198 ADVAIR HFA AER 45/21 ................... 198 ADVANCED MIS AM/PM ................... 176 advanced sol lubrican ...................... 220 ADVATE INJ 1000UNIT .................... 158 ADVATE INJ 1500UNIT .................... 158 ADVATE INJ 2000UNIT .................... 158 ADVATE INJ 250UNIT ...................... 157 ADVATE INJ 3000UNIT .................... 158 ADVATE INJ 4000UNIT .................... 158 ADVATE INJ 500UNIT ...................... 157 ADVOCATE ARM MIS BPM LRG .......... 120 ADYNOVATE INJ 1000UNIT .............. 158 ADYNOVATE INJ 2000UNIT .............. 158 ADYNOVATE INJ 250UNIT ................ 158 ADYNOVATE INJ 3000UNIT .............. 158 ADYNOVATE INJ 500UNIT ................ 158 AERCHMBR Z- MIS STAT PLS ........... 194 AEROCHAMBER KIT ACTION ............. 195 AEROSPAN AER 80MCG ................... 197 AFINITOR DIS TAB 2MG ................... 40 AFINITOR DIS TAB 3MG ................... 40 AFINITOR DIS TAB 5MG ................... 40 AFINITOR TAB 10MG ........................ 40 AFINITOR TAB 2.5MG ....................... 40 AFINITOR TAB 5MG ......................... 40 AFINITOR TAB 7.5MG ....................... 40 AFREZZA POW 12 UNIT ................... 117 AFREZZA POW 4&8 UNIT ................. 116 AFREZZA POW 4/8/12UN ................. 116 AFREZZA POW 4UNIT ...................... 116 AFREZZA POW 8 UNIT ..................... 116 AFREZZA POW 8&12UNIT ................ 117 AGGRASTAT INJ 12.5/250 ............... 163 AGGRASTAT INJ 5/100ML ................ 163 AGGRENOX CAP 25-200MG .............. 163 AGRYLIN CAP 0.5MG ....................... 164 AIRZONE PEAK MIS FLOW MTR ......... 195 ak-fluor inj 10% op ......................... 219 AK-FLUOR INJ 25% OP .................... 219 AKTEN GEL 3.5% ............................ 220 AKYNZEO CAP 300-0.5 .................... 140 ALA SCALP LOT 2% ........................ 207 alamag-plus chw ............................ 139 alaway dro 0.025%op ..................... 218 ALBENZA TAB 200MG ....................... 34 albumin, human inj 25% ................. 162 alburx inj 5% ................................. 162

226

albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) ....................................... 192 albuterol sulfate soln nebu 0.5% (5 mg/ml) ......................................... 192 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) .................................. 192 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) .................................. 192 albuterol sulfate syrup 2 mg/5ml ...... 193 albuterol sulfate tab 2 mg ................ 193 albuterol sulfate tab 4 mg ................ 193 albuterol sulfate tab er 12hr 4 mg .... 193 albuterol sulfate tab er 12hr 8 mg .... 193 ALCAINE SOL 0.5% OP ................... 220 alclometasone dipropionate cream 0.05% ................................................... 207 alclometasone dipropionate oint 0.05% ................................................... 207 alcohol absolute inj 98% ................. 173 ALCOH-WIPE MIS 12"X12" ............... 120 ALDACTAZIDE TAB 25/25 .................. 66 ALDACTAZIDE TAB 50/50 .................. 66 ALDACTONE TAB 100MG ................... 50 ALDACTONE TAB 25MG ..................... 50 ALDACTONE TAB 50MG ..................... 50 ALDARA CRE 5% ............................ 211 ALDEX GS TAB 30-190MG ............... 190 ALDURAZYME INJ 2.9MG/5M ............ 134 ALECENSA CAP 150MG ...................... 40 alendronate sodium oral soln 70 mg/75ml ....................................... 124 alendronate sodium tab 10 mg ......... 124 alendronate sodium tab 35 mg ......... 124 alendronate sodium tab 40 mg ......... 124 alendronate sodium tab 5 mg ........... 124 alendronate sodium tab 70 mg ......... 124 alfentanil inj 500 mcg/ml .................... 6 ALFENTANIL INJ 500/ML ..................... 6 alfuzosin hcl tab er 24hr 10 mg ........ 152 ALGICELL AG PAD 4"X5" .................. 214 ALIMTA INJ 100MG ........................... 37 ALIMTA INJ 500MG ........................... 37 ALINIA SUS 100/5ML ........................ 34 ALINIA TAB 500MG ........................... 34 ALKERAN INJ 50MG .......................... 36 ALKERAN TAB 2MG ........................... 36 all day allg cap 10mg ...................... 188 all day allg tab 10mg ...................... 188

all day pain tab 220mg ....................... 2 ALLEGRA ALRG TAB 30MG ............... 188 ALLEGRA-D TAB 24 HOUR ................ 188 allergy cap 25mg ............................ 189 allergy d tab 5-120mg ..................... 188 allergy relf chw 10mg ...................... 188 allergy relf tab 10mg ....................... 188 allergy tab 12mg cr ........................ 189 allergy tab 25mg ............................ 189 allergy tab 4mg .............................. 189 allergy tab multi-sy ......................... 188 ALLEVYN AG PAD 3"X3" ................... 214 allopurinol tab 100 mg ....................... 1 allopurinol tab 300 mg ....................... 1 allrgy rel-d tab 10-240mg ................ 188 allrgy relf tab 12.5mg ..................... 189 allrgy rlf-d tab 5-120mg .................. 188 almotriptan malate tab 12.5 mg ....... 106 almotriptan malate tab 6.25 mg ....... 106 ALOCRIL SOL 2% ........................... 218 ALOMIDE SOL 0.1% OP ................... 218 ALOPRIM INJ 500MG .......................... 1 ALORA DIS 0.025MG ....................... 129 ALORA DIS 0.05MG ........................ 129 ALORA DIS 0.075MG ....................... 129 ALORA DIS 0.1MG .......................... 129 alosetron hcl tab 0.5 mg (base equiv) 145 alosetron hcl tab 1 mg (base equiv) .. 145 ALPHAGAN P SOL 0.1% ................... 222 ALPHAGAN P SOL 0.15% ................. 222 ALPHANATE INJ VWF/HUM ............... 158 ALPHANINE SD INJ 1000UNIT .......... 158 ALPHANINE SD INJ 1500UNIT .......... 158 ALPRAZOLAM CON 1 MG/ML .............. 72 alprazolam orally disintegrating tab 0.25 mg ................................................ 72 alprazolam orally disintegrating tab 0.5 mg ................................................ 72 alprazolam orally disintegrating tab 1 mg ..................................................... 72 alprazolam orally disintegrating tab 2 mg ..................................................... 72 alprazolam tab 0.25 mg .................... 72 alprazolam tab 0.5 mg ..................... 72 alprazolam tab 0.5mg xr .................. 72 alprazolam tab 1 mg ........................ 72 alprazolam tab 1mg xr ..................... 72 alprazolam tab 2 mg ........................ 72

227

alprazolam tab 2mg xr ...................... 72 alprazolam tab 3mg xr ...................... 72 ALPROLIX INJ 1000UNIT ................. 158 ALPROLIX INJ 2000UNIT ................. 158 ALPROLIX INJ 3000UNIT ................. 158 ALPROLIX INJ 500UNIT ................... 158 alprostadil inj 500 mcg/ml ................. 67 ALREX SUS 0.2% ........................... 217 ALTABAX OIN 1% ........................... 203 ALTACE CAP 1.25MG ......................... 48 ALTACE CAP 10MG ........................... 48 ALTACE CAP 2.5MG .......................... 48 ALTACE CAP 5MG ............................. 48 ALTOPREV TAB 20MG ER ................... 57 ALTOPREV TAB 40MG ER ................... 57 ALTOPREV TAB 60MG ER ................... 57 ALUM HYDROX SUS 320/5ML ........... 139 ALUNBRIG TAB 30MG ....................... 40 ALVESCO AER 160MCG ................... 197 ALVESCO AER 80MCG ..................... 197 amantadine hcl cap 100 mg ............... 87 amantadine hcl syrup 50 mg/5ml ....... 87 amantadine hcl tab 100 mg ............... 87 ambi 60pse/ tab 400gfn .................. 190 AMBIEN CR TAB 12.5MG ................. 104 AMBIEN CR TAB 6.25MG ................. 104 AMBIEN TAB 10MG ......................... 104 AMBIEN TAB 5MG ........................... 104 AMBISOME INJ 50MG ........................ 25 amcinonide cream 0.1% .................. 206 amcinonide lotion 0.1% ................... 206 AMERGE TAB 1MG .......................... 106 AMERGE TAB 2.5MG ....................... 106 amethia tab ................................... 125 AMICAR SOL 0.25/ML ..................... 161 AMICAR TAB 1000MG...................... 161 AMICAR TAB 500MG ....................... 161 amifostine for inj 500 mg .................. 42 amikacin sulfate inj 1 gm/4ml (250 mg/ml) ........................................... 17 amikacin sulfate inj 500 mg/2ml (250 mg/ml) ........................................... 17 amiloride & hydrochlorothiazide tab 5-50 mg ................................................. 66 amiloride hcl tab 5 mg ...................... 66 aminocaproic acid inj 250 mg/ml ...... 161 aminophylline inj 25 mg/ml ............. 198 AMINOSYN 7% INJ /LYTES .............. 172

AMINOSYN II INJ 15% .................... 172 AMINOSYN II INJ 7% ...................... 172 AMINOSYN II INJ 8.5% ................... 172 aminosyn ii inj 8.5/lyte .................... 172 AMINOSYN M INJ 3.5% ................... 172 AMINOSYN-RF INJ 5.2% .................. 172 amiodarone hcl inj 150 mg/3ml (50 mg/ml) .......................................... 54 amiodarone hcl inj 450 mg/9ml (50 mg/ml) .......................................... 54 amiodarone hcl inj 900 mg/18ml (50 mg/ml) .......................................... 55 amiodarone hcl tab 100 mg .............. 55 amiodarone hcl tab 200 mg .............. 55 amiodarone hcl tab 400 mg .............. 55 AMITIZA CAP 24MCG ...................... 145 AMITIZA CAP 8MCG ........................ 145 amitriptyline hcl tab 10 mg ............... 86 amitriptyline hcl tab 100 mg ............. 86 amitriptyline hcl tab 150 mg ............. 86 amitriptyline hcl tab 25 mg ............... 86 amitriptyline hcl tab 50 mg ............... 86 amitriptyline hcl tab 75 mg ............... 86 amlodipine besylate tab 10 mg .......... 63 amlodipine besylate tab 2.5 mg ......... 63 amlodipine besylate tab 5 mg ............ 63 amlodipine besylate-atorvastatin calcium tab 10-10 mg .................................. 62 amlodipine besylate-atorvastatin calcium tab 10-20 mg .................................. 62 amlodipine besylate-atorvastatin calcium tab 10-40 mg .................................. 62 amlodipine besylate-atorvastatin calcium tab 10-80 mg .................................. 62 amlodipine besylate-atorvastatin calcium tab 2.5-10 mg ................................. 62 amlodipine besylate-atorvastatin calcium tab 2.5-20 mg ................................. 62 amlodipine besylate-atorvastatin calcium tab 2.5-40 mg ................................. 62 amlodipine besylate-atorvastatin calcium tab 5-10 mg ................................... 62 amlodipine besylate-atorvastatin calcium tab 5-20 mg ................................... 62 amlodipine besylate-atorvastatin calcium tab 5-40 mg ................................... 62 amlodipine besylate-atorvastatin calcium tab 5-80 mg ................................... 62

228

amlodipine besylate-benazepril hcl cap 10-20 mg ........................................ 46 amlodipine besylate-benazepril hcl cap 10-40 mg ........................................ 46 amlodipine besylate-benazepril hcl cap 2.5-10 mg ....................................... 46 amlodipine besylate-benazepril hcl cap 5-10 mg ............................................ 46 amlodipine besylate-benazepril hcl cap 5-20 mg ............................................ 46 amlodipine besylate-benazepril hcl cap 5-40 mg ............................................ 46 amlodipine besylate-olmesartan medoxomil tab 10-20 mg .................. 51 amlodipine besylate-olmesartan medoxomil tab 10-40 mg .................. 51 amlodipine besylate-olmesartan medoxomil tab 5-20 mg .................... 50 amlodipine besylate-olmesartan medoxomil tab 5-40 mg .................... 50 amlodipine besylate-valsartan tab 10-160 mg ........................................... 51 amlodipine besylate-valsartan tab 10-320 mg ........................................... 51 amlodipine besylate-valsartan tab 5-160 mg ................................................. 51 amlodipine besylate-valsartan tab 5-320 mg ................................................. 51 amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg ......................... 51 amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg ............................ 51 amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg ............................ 51 amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg ........................... 51 amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg .............................. 51 AMMONIUM CHL INJ 5MEQ/ML ......... 176 AMMONUL INJ 10% ........................ 135 amoxapine tab 100 mg ..................... 86 amoxapine tab 150 mg ..................... 87 amoxapine tab 25 mg ....................... 86 amoxapine tab 50 mg ....................... 86 amoxicillin & k clavulanate chew tab 200-28.5 mg .......................................... 22 amoxicillin & k clavulanate chew tab 400-57 mg ............................................ 22

amoxicillin & k clavulanate for susp 200-28.5 mg/5ml ................................... 22 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml ................................... 22 amoxicillin & k clavulanate for susp 400-57 mg/5ml ..................................... 22 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml ................................... 22 amoxicillin & k clavulanate tab 250-125 mg ................................................ 22 amoxicillin & k clavulanate tab 500-125 mg ................................................ 22 amoxicillin & k clavulanate tab 875-125 mg ................................................ 22 amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg ................................. 22 amoxicillin (trihydrate) cap 250 mg .... 22 amoxicillin (trihydrate) cap 500 mg .... 22 amoxicillin (trihydrate) chew tab 125 mg ..................................................... 22 amoxicillin (trihydrate) chew tab 250 mg ..................................................... 22 amoxicillin (trihydrate) for susp 125 mg/5ml .......................................... 22 amoxicillin (trihydrate) for susp 200 mg/5ml .......................................... 22 amoxicillin (trihydrate) for susp 250 mg/5ml .......................................... 22 amoxicillin (trihydrate) for susp 400 mg/5ml .......................................... 22 amoxicillin (trihydrate) tab 500 mg .... 22 amoxicillin (trihydrate) tab 875 mg .... 22 amoxicillin cap-clarithro tab-lansopraz cap dr therapy pack ........................ 152 amphetamine-dextroamphetamine cap er 24hr 10 mg .................................... 97 amphetamine-dextroamphetamine cap er 24hr 15 mg .................................... 97 amphetamine-dextroamphetamine cap er 24hr 20 mg .................................... 98 amphetamine-dextroamphetamine cap er 24hr 25 mg .................................... 98 amphetamine-dextroamphetamine cap er 24hr 30 mg .................................... 98 amphetamine-dextroamphetamine cap er 24hr 5 mg ...................................... 97 amphetamine-dextroamphetamine tab 10 mg ............................................ 98

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amphetamine-dextroamphetamine tab 12.5 mg .......................................... 98 amphetamine-dextroamphetamine tab 15 mg ............................................ 98 amphetamine-dextroamphetamine tab 20 mg ............................................ 98 amphetamine-dextroamphetamine tab 30 mg ............................................ 98 amphetamine-dextroamphetamine tab 5 mg ................................................. 98 amphetamine-dextroamphetamine tab 7.5 mg ........................................... 98 amphotericin b for inj 50 mg .............. 25 ampicillin & sulbactam sodium for inj 1.5 (1-0.5) gm ...................................... 22 ampicillin & sulbactam sodium for inj 15 (10-5) gm ....................................... 22 ampicillin & sulbactam sodium for inj 3 (2-1) gm ......................................... 22 ampicillin & sulbactam sodium for iv soln 15 (10-5) gm ................................... 22 ampicillin cap 250 mg ....................... 22 ampicillin cap 500 mg ....................... 22 ampicillin for susp 125 mg/5ml .......... 22 ampicillin for susp 250 mg/5ml .......... 22 ampicillin sodium for inj 1 gm ............ 22 ampicillin sodium for inj 10 gm........... 22 ampicillin sodium for inj 125 mg ......... 22 ampicillin sodium for inj 2 gm ............ 22 ampicillin sodium for inj 250 mg ......... 23 ampicillin sodium for inj 500 mg ......... 23 ampicillin sodium for iv soln 1 gm ....... 23 ampicillin sodium for iv soln 10 gm ..... 23 AMPYRA TAB 10MG ......................... 109 AMRIX CAP 15MG ........................... 110 AMRIX CAP 30MG ........................... 110 AMVISC INJ 12MG/ML ..................... 220 AMVISC PLUS INJ 16MG/ML ............. 220 AMYTAL SOD INJ 500MG ................. 104 ANACAINE OIN .............................. 210 anagrelide hcl cap 0.5 mg ................ 164 anagrelide hcl cap 1 mg .................. 164 ANALPRAM KIT ADVANCED .............. 151 ANAPROX DS TAB 550MG ................... 2 ANASCORP INJ ............................... 164 anastrozole tab 1 mg ........................ 39 ANDRODERM DIS 2MG/24HR ........... 113 ANDRODERM DIS 4MG/24HR ........... 113

ANDROGEL GEL 1%(25MG) .............. 113 ANDROGEL GEL 1%(50MG) .............. 113 ANDROGEL GEL 1.62% .................... 113 ANESTH NEEDL MIS 20GX6" ............ 168 ANESTH NEEDL MIS 22GX2" ............ 168 ANGIOMAX INJ 250MG .................... 155 animal shape chw complete ............. 176 ANIMI-3 CAP VIT D ......................... 176 ANORO ELLIPT AER 62.5-25 ............. 187 ant/anti-gas chw 1000-60 ................ 139 ANTABUSE TAB 250MG .................... 112 ANTABUSE TAB 500MG .................... 112 antacid chw 500mg ......................... 139 antacid chw 550-110....................... 139 antacid chw 750mg ......................... 139 antacid extr chw 675-135 ................ 139 antacid mult chw -symptom ............. 139 antacid plus sus anti-gas ................. 140 antacid plus sus gas rel ................... 140 ANTACID ULTR CHW 1000-200 ......... 140 ANTARA CAP 30MG .......................... 56 ANTARA CAP 90MG .......................... 56 ANTICOAG CPD SOL ........................ 162 ANTICOAGULNT SOL SOD CITR ........ 162 anti-diarrhe liq 1mg/5ml .................. 140 anti-diarrhe tab 2mg ....................... 140 antifungal aer 1% ........................... 203 antifungal cre 1% ........................... 203 anti-itch cre 1-01%......................... 211 anti-itch cre 2-0.1%........................ 211 anti-itch cre 5-2% .......................... 152 anti-itch lot 1% .............................. 207 anti-itch spr 2% ............................. 211 antiseptic liq original ....................... 215 ANTI-SNORE LIQ THROAT ................ 215 ANTIVENIN KIT LAT MACT ............... 164 apap rapid tab tab 80mg .................... 1 APEXICON E CRE 0.05% .................. 206 APIDRA INJ SOLOSTAR .................... 117 APIDRA INJ U-100 .......................... 117 APLENZIN TAB 174MG ...................... 82 APLENZIN TAB 348MG ...................... 82 APLENZIN TAB 522MG ...................... 82 APLIGRAF MIS ................................ 211 APOKYN INJ 10MG/ML ...................... 87 apraclonidine hcl ophth soln 0.5% (base equivalent) .................................... 222 aprepitant capsule 125 mg ............... 141

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aprepitant capsule 40 mg ................ 140 aprepitant capsule 80 mg ................ 141 aprepitant capsule therapy pack 80 & 125 mg ......................................... 141 APRISO CAP 0.375GM ..................... 144 APTENSIO XR CAP 10MG ................... 98 APTENSIO XR CAP 15MG ................... 98 APTENSIO XR CAP 20MG ................... 98 APTENSIO XR CAP 30MG ................... 98 APTENSIO XR CAP 40MG ................... 98 APTENSIO XR CAP 50MG ................... 98 APTENSIO XR CAP 60MG ................... 98 APTIOM TAB 200MG ......................... 74 APTIOM TAB 400MG ......................... 74 APTIOM TAB 600MG ......................... 74 APTIOM TAB 800MG ......................... 74 APTIVUS CAP 250MG ........................ 28 APTIVUS SOL ................................... 28 AP-ZEL TAB ................................... 176 AQUORAL AER ............................... 215 ARALAST NP INJ 500MG .................. 195 ARANESP INJ 100MCG .................... 160 ARANESP INJ 10MCG ...................... 160 ARANESP INJ 150MCG .................... 160 ARANESP INJ 200MCG .................... 160 ARANESP INJ 25MCG ...................... 160 ARANESP INJ 300MCG .................... 160 ARANESP INJ 40MCG ...................... 160 ARANESP INJ 500MCG .................... 160 ARANESP INJ 60MCG ...................... 160 ARAVA TAB 10MG ........................... 165 ARAVA TAB 20MG ........................... 165 ARCALYST INJ 220MG ..................... 167 ARCAPTA CAP 75MCG ..................... 192 ARESTIN MIS 1MG .......................... 215 ARGATROBAN INJ 125/125 .............. 155 argatroban inj 250 mg/2.5ml (concentrate for iv infusion) ............. 155 ARGATROBAN INJ 50MG/50M ........... 155 argyl saline sol 0.9% ...................... 152 argyl saline sol 100ml ..................... 215 ARICEPT TAB 10MG .......................... 80 ARICEPT TAB 23MG .......................... 80 ARICEPT TAB 5MG ............................ 80 ARIMIDEX TAB 1MG .......................... 39 aripiprazole oral solution 1 mg/ml ....... 90 aripiprazole orally disintegrating tab 10 mg ................................................. 90

aripiprazole orally disintegrating tab 15 mg ................................................ 90 aripiprazole tab 10 mg ..................... 90 aripiprazole tab 15 mg ..................... 91 aripiprazole tab 2 mg ....................... 90 aripiprazole tab 20 mg ..................... 91 aripiprazole tab 30 mg ..................... 91 aripiprazole tab 5 mg ....................... 90 ARISTADA INJ 1064MG .................... 91 ARISTADA INJ 441MG/1. .................. 91 ARISTADA INJ 662MG/2 ................... 91 ARISTADA INJ 882MG/3 ................... 91 ARIXTRA INJ 10/0.8ML .................... 155 ARIXTRA INJ 2.5/0.5 ....................... 155 ARIXTRA INJ 5/0.4ML ...................... 155 ARIXTRA INJ 7.5/0.6 ....................... 155 armodafinil tab 150 mg ................... 111 armodafinil tab 200 mg ................... 111 armodafinil tab 250 mg ................... 111 armodafinil tab 50 mg ..................... 111 ARMOUR THYRO TAB 120MG ............ 137 ARMOUR THYRO TAB 15MG .............. 137 ARMOUR THYRO TAB 180MG ............ 137 ARMOUR THYRO TAB 240MG ............ 137 ARMOUR THYRO TAB 300MG ............ 137 ARNUITY ELPT INH 100MCG ............. 197 ARNUITY ELPT INH 200MCG ............. 197 AROMASIN TAB 25MG ...................... 39 ARTHROTEC 50 TAB ........................... 4 ARTHROTEC 75 TAB ........................... 4 artificial dro tears ........................... 220 artificial sol tears ............................ 220 artificial sol tears op ........................ 220 ARZERRA CON 100/5ML ................... 42 arzol silver mis nitr app ................... 211 a-s pls nght cap cld/flu .................... 190 ASACOL HD TAB 800MG .................. 144 ASCLERA INJ 0.5% .......................... 67 ASCLERA INJ 1% ............................. 67 ascomp/cod cap 30mg ....................... 6 ascorbic acid cap er 500 mg ............. 176 ascorbic acid chew tab 250 mg ......... 176 ascorbic acid chew tab 500 mg ......... 176 ascorbic acid inj 500 mg/ml ............. 175 ascorbic acid tab 1000 mg ............... 176 ascorbic acid tab 250 mg ................. 176 ascorbic acid tab er 1000 mg ........... 176 ascorbic acid tab er 1500 mg ........... 176

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ascorbic acid tab er 500 mg ............. 176 ASMANEX 14 AER 220MCG .............. 197 ASMANEX 30 AER 110MCG .............. 197 ASMANEX HFA AER 100 MCG ........... 197 ASMANEX HFA AER 200 MCG ........... 197 aspirin chw 81mg ........................... 163 aspirin low tab 81mg ec .................. 163 aspirin suppos 300 mg ....................... 2 aspirin suppos 600 mg ....................... 2 aspirin tab 325 mg ......................... 163 aspirin tab delayed release 325 mg ... 163 aspirin-caffeine-dihydrocodeine cap 356.4-30-16 mg ................................ 6 aspirin-dipyridamole cap er 12hr 25-200 mg ............................................... 163 ASSESS METER MIS FULL RNG ......... 195 ASSESS METER MIS LOW RANG ....... 195 ASTAGRAF XL CAP 0.5MG ................ 168 ASTAGRAF XL CAP 1MG ................... 168 ASTAGRAF XL CAP 5MG ................... 168 ASTEPRO SPR 0.15% ...................... 196 ASTHMA CHECK MIS SYSTEM ........... 195 ASTHMAMENTOR MIS ..................... 195 ASTHMAPACK KIT CHILD ................. 195 ATABEX CHW PRENATAL ................. 176 ATABEX EC TAB ............................. 176 ATACAND HCT TAB 16-12.5 ............... 52 ATACAND HCT TAB 32-12.5 ............... 52 ATACAND HCT TAB 32-25MG ............. 52 ATACAND TAB 16MG ......................... 53 ATACAND TAB 32MG ......................... 53 ATACAND TAB 4MG .......................... 53 ATACAND TAB 8MG .......................... 53 ATELVIA TAB ................................. 124 atenolol & chlorthalidone tab 100-25 mg ..................................................... 59 atenolol & chlorthalidone tab 50-25 mg ..................................................... 59 atenolol tab 100 mg ......................... 60 atenolol tab 25 mg ........................... 60 atenolol tab 50 mg ........................... 60 ath foot pow aer 1% ....................... 203 athlete foot cre af ........................... 203 ATIVAN INJ 2MG/ML ......................... 72 ATIVAN INJ 4MG/ML ......................... 72 ATIVAN TAB 0.5MG .......................... 72 ATIVAN TAB 1MG ............................. 72 ATIVAN TAB 2MG ............................. 72

atomoxetine hcl cap 10 mg (base equiv) ..................................................... 98 atomoxetine hcl cap 100 mg (base equiv) ............................................ 98 atomoxetine hcl cap 18 mg (base equiv) ..................................................... 98 atomoxetine hcl cap 25 mg (base equiv) ..................................................... 98 atomoxetine hcl cap 40 mg (base equiv) ..................................................... 98 atomoxetine hcl cap 60 mg (base equiv) ..................................................... 98 atomoxetine hcl cap 80 mg (base equiv) ..................................................... 98 atorvastatin calcium tab 10 mg (base equivalent) ..................................... 57 atorvastatin calcium tab 20 mg (base equivalent) ..................................... 57 atorvastatin calcium tab 40 mg (base equivalent) ..................................... 57 atorvastatin calcium tab 80 mg (base equivalent) ..................................... 57 atovaquone susp 750 mg/5ml ........... 34 atovaquone-proguanil hcl tab 250-100 mg ................................................ 27 atovaquone-proguanil hcl tab 62.5-25 mg ................................................ 27 ATRALIN GEL 0.05% ....................... 199 ATRAPRO DERM SPR ....................... 214 ATRAPRO GEL HYDROGEL ................ 214 ATRIPLA TAB .................................. 28 ATROPEN INJ 0.5MG ....................... 123 ATROPEN INJ 1MG .......................... 123 ATROPEN INJ 2MG .......................... 123 ATROPINE SUL OIN 1% OP .............. 221 atropine sulfate inj 1 mg/ml .............. 67 atropine sulfate inj 8 mg/20ml (0.4 mg/ml) .......................................... 67 atropine sulfate ophth soln 1% ......... 221 atropine sulfate preservative free (pf) inj 0.4 mg/0.5ml .................................. 68 atropine sulfate soln prefill syr 0.25 mg/5ml (0.05 mg/ml) ...................... 68 atropine sulfate soln prefill syr 1 mg/10ml (0.1 mg/ml) ...................... 68 ATROVENT HFA AER 17MCG ............. 187 AUBAGIO TAB 14MG ....................... 109 AUBAGIO TAB 7MG ......................... 109

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aubra tab 0.1-0.02 ......................... 126 AUGMENTIN SUS 125/5ML ................. 23 AUSTEDO TAB 12MG ....................... 108 AUSTEDO TAB 6MG ........................ 108 AUSTEDO TAB 9MG ........................ 108 AUTOSHIELD MIS 29X3/16" ............. 120 AUTOSHIELD MIS 29X5/16" ............. 120 AUTOSHIELD MIS 30GX3/16 ............ 120 AVALIDE TAB 150-12.5 ..................... 52 AVALIDE TAB 300-12.5 ..................... 52 AVANDIA TAB 2MG ......................... 116 AVANDIA TAB 4MG ......................... 116 AVAPRO TAB 150MG ......................... 53 AVAPRO TAB 300MG ......................... 53 AVAPRO TAB 75MG ........................... 53 AVASTIN INJ ................................... 42 AVASTIN INJ 400/16ML ..................... 42 AVC CRE 15% ................................ 154 AVELOX INJ ..................................... 21 AVIDOXY DK KIT .............................. 24 avidoxy tab 100mg ........................... 24 AVITENE PAD 35X35MM .................. 161 AVITENE POW FLOUR ...................... 161 AVODART CAP 0.5MG ...................... 152 AVONEX KIT 30MCG ....................... 109 AVONEX PEN KIT 30MCG ................. 109 AVONEX PREFL KIT 30MCG .............. 109 av-phos 250 tab neutral .................. 171 AVYCAZ INJ 2-0.5GM ........................ 17 AXERT TAB 12.5MG ........................ 106 AXERT TAB 6.25MG ........................ 106 AXILLARY NDL MIS 22GX1" ............. 168 AXILLARY NDL MIS 25GX1" ............. 168 AXIRON SOL 30MG/ACT .................. 113 AYGESTIN TAB 5MG ........................ 137 AYR ALLERGY SPR & SINUS ............. 195 AYR NASAL DRO 0.65% .................. 195 AZACTAM INJ 1GM ........................... 34 AZACTAM INJ 2GM ........................... 34 AZACTAM/DEX INJ 1GM .................... 34 AZACTAM/DEX INJ 2GM .................... 34 AZASAN TAB 100MG ....................... 167 AZASAN TAB 75 MG ........................ 167 AZASITE SOL 1% ........................... 216 azathioprine tab 50 mg ................... 167 azelastine hcl nasal spray 0.1% (137 mcg/spray) ................................... 196 azelastine hcl nasal spray 0.15% (205.5

mcg/spray) .................................... 196 azelastine hcl ophth soln 0.05% ....... 218 AZELEX CRE 20% ........................... 199 AZILECT TAB 0.5MG ........................ 87 AZILECT TAB 1MG ........................... 87 azithromycin for susp 100 mg/5ml ..... 20 azithromycin for susp 200 mg/5ml ..... 20 azithromycin iv for soln 500 mg ......... 20 azithromycin powd pack for susp 1 gm 20 azithromycin tab 250 mg .................. 20 azithromycin tab 500 mg .................. 20 azithromycin tab 600 mg .................. 20 AZOLEN TINC SOL 2% .................... 203 AZOPT SUS 1% OP ......................... 219 AZOR TAB 10-20MG ......................... 51 AZOR TAB 10-40MG ......................... 51 AZOR TAB 5-20MG .......................... 51 AZOR TAB 5-40MG .......................... 51 aztreonam for inj 1 gm ..................... 34 aztreonam for inj 2 gm ..................... 34 AZULFIDINE TAB 500MG ................. 144 AZULFIDINE TAB 500MG EN ............. 144 azuphen mb cap 120mg .................. 152 azurette tab 28 day ........................ 125 B b-100 tab tr ................................... 176 B12 COMPLNCE KIT INJ KIT ............. 176 baciim inj 50000unt ......................... 34 bacitracin oint 500 unit/gm .............. 203 bacitracin ophth oint 500 unit/gm ..... 216 bacitracin zinc oint 500 unit/gm ........ 203 baclofen tab 10 mg ......................... 110 baclofen tab 20 mg ......................... 110 BACTINE SPR ................................. 210 BACTOCILL INJ DEX 1GM .................. 23 BACTOCILL INJ DEX 2GM .................. 23 BACTRIM DS TAB 800-160 ................ 24 BACTRIM TAB 400-80MG .................. 24 BACTROBAN OIN NASAL 2% ............ 203 BAL IN OIL INJ 100MG/ML ............... 123 bal salt sol op ................................ 220 balance b-50 tab tr ......................... 177 balanced b tab complex ................... 177 balanced tab b-100 tr ...................... 177 BAL-CARE MIS DHA ........................ 176 balsalazide disodium cap 750 mg ...... 144 BANZEL SUS 40MG/ML ..................... 74 BANZEL TAB 200MG ......................... 74

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BANZEL TAB 400MG ......................... 74 BARACLUDE SOL .05MG/ML ............... 31 BARACLUDE TAB 0.5MG .................... 31 BARACLUDE TAB 1MG ....................... 32 BASAGLAR INJ 100UNIT .................. 117 BAXDELA TAB 450MG ....................... 21 bayer adv tab 500mg ...................... 163 b-complex tab ............................... 176 B-COMPLEX TAB C/FA/BIO ............... 176 b-complex vitamin cap .................... 176 b-complex vitamin tab .................... 176 b-complex w/ c & calcium tab .......... 176 b-complex w/ c cap ........................ 176 b-complex w/ folic acid cap .............. 176 BD ECLIPSE MIS 1ML/30G ............... 168 BD ECLIPSE MIS 25GX5/8" .............. 169 bdy/hair/skn cap nails ..................... 177 BE WELL PAK ROUNDED .................. 177 BEBULIN INJ 200-1200 ................... 158 BECONASE AQ SUS 0.042% ............ 196 bedding spra aer 0.5% .................... 213 BELBUCA MIS 150MCG ....................... 6 BELBUCA MIS 300MCG ....................... 6 BELBUCA MIS 450MCG ....................... 6 BELBUCA MIS 600MCG ....................... 6 BELBUCA MIS 750MCG ....................... 6 BELBUCA MIS 75MCG ........................ 6 BELBUCA MIS 900MCG ....................... 6 BELSOMRA TAB 10MG ..................... 104 BELSOMRA TAB 15MG ..................... 104 BELSOMRA TAB 20MG ..................... 104 BELSOMRA TAB 5MG ...................... 104 benadryl itc gel 2% ........................ 211 benazepril & hydrochlorothiazide tab 10-12.5 mg .......................................... 47 benazepril & hydrochlorothiazide tab 20-12.5 mg .......................................... 47 benazepril & hydrochlorothiazide tab 20-25 mg ............................................ 47 benazepril & hydrochlorothiazide tab 5-6.25 mg .......................................... 47 benazepril hcl tab 10 mg ................... 48 benazepril hcl tab 20 mg ................... 48 benazepril hcl tab 40 mg ................... 48 benazepril hcl tab 5 mg ..................... 48 BENDEKA INJ 100/4ML ...................... 36 BENEFIX INJ 1000UNIT ................... 158 BENEFIX INJ 2000UNIT ................... 158

BENEFIX INJ 250UNIT ..................... 158 BENEFIX INJ 3000UNIT ................... 158 BENEFIX INJ 500UNIT ..................... 158 BENICAR HCT TAB 20-12.5 ............... 52 BENICAR HCT TAB 40-12.5 ............... 52 BENICAR HCT TAB 40-25MG ............. 52 BENICAR TAB 20MG ......................... 53 BENICAR TAB 40MG ......................... 53 BENICAR TAB 5MG .......................... 53 BENLYSTA INJ 120MG ..................... 168 BENLYSTA INJ 200MG/ML ................ 168 BENLYSTA INJ 400MG ..................... 168 BENSAL HP OIN .............................. 211 BENTYL CAP 10MG .......................... 142 BENTYL INJ 10MG/ML ...................... 142 BENTYL TAB 20MG .......................... 142 BENZAC AC LIQ 5% WASH ............... 199 BENZACLIN GEL 1-5% .................... 199 BENZAMYCIN GEL 5-3% .................. 199 BENZAMYCIN GEL PAK .................... 199 BENZEFOAM AER 5.3% ................... 199 BENZEFOAM AER 9.8% ................... 199 benzepro liq creamy ........................ 199 benzepro sc aer 9.8% ..................... 199 BENZIQ GEL 5.25% ........................ 199 BENZIQ LS GEL 2.75% .................... 199 benziq wash liq 5.25% .................... 200 BENZODOX 30 MIS .......................... 24 BENZODOX 60 MIS .......................... 24 benzonatate cap 100 mg ................. 192 benzonatate cap 150 mg ................. 192 benzonatate cap 200 mg ................. 192 BENZOYL PER GEL 2.5% .................. 200 benzoyl per liq 10% wash ................ 200 benzoyl per liq 5% wash .................. 200 benzoyl pero kit acne pck ................ 200 benzoyl peroxide gel 10% ................ 200 benzoyl peroxide-erythromycin gel 5-3% .................................................... 200 benztropine mesylate inj 1 mg/ml ...... 87 benztropine mesylate tab 0.5 mg ....... 87 benztropine mesylate tab 1 mg ......... 87 benztropine mesylate tab 2 mg ......... 87 BENZYL PEROX LOT CLNSR 3% ........ 200 benzyl perox lot clnsr 6% ................ 200 BEPREVE DRO 1.5% ....................... 218 BERINERT INJ 500UNIT ................... 162 berocca tab ................................... 177

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BESIVANCE SUS 0.6% .................... 216 BETADINE SOL 5% OP .................... 216 BETAGAN SOL 0.5% OP .................. 218 betamethasone dipropionate augmented cream 0.05% ................................. 206 betamethasone dipropionate augmented gel 0.05% ..................................... 209 betamethasone dipropionate augmented lotion 0.05% .................................. 206 betamethasone dipropionate augmented oint 0.05% .................................... 209 betamethasone dipropionate cream 0.05% .......................................... 206 betamethasone dipropionate lotion 0.05% .......................................... 206 betamethasone dipropionate oint 0.05% ................................................... 206 betamethasone sod phosphate & acetate inj susp 6 (3-3) mg/ml .................... 130 betamethasone valerate aerosol foam 0.12% .......................................... 208 betamethasone valerate cream 0.1% (base equivalent) ........................... 208 betamethasone valerate lotion 0.1% (base equivalent) ........................... 208 betamethasone valerate oint 0.1% (base equivalent) .................................... 208 BETAPACE AF TAB 120MG .................. 55 BETAPACE AF TAB 160MG .................. 55 BETAPACE AF TAB 80MG ................... 55 BETAPACE TAB 120MG ...................... 55 BETAPACE TAB 160MG ...................... 55 BETAPACE TAB 80MG ........................ 55 BETASERON INJ 0.3MG ................... 109 betaxolol hcl ophth soln 0.5% .......... 219 betaxolol hcl tab 10 mg ..................... 60 betaxolol hcl tab 20 mg ..................... 60 bethanechol chloride tab 10 mg ........ 152 bethanechol chloride tab 25 mg ........ 152 bethanechol chloride tab 5 mg ......... 152 bethanechol chloride tab 50 mg ........ 152 BETHKIS NEB 300/4ML ................... 193 BETIMOL SOL 0.25% ...................... 218 BETIMOL SOL 0.5% ........................ 218 BETOPTIC-S SUS 0.25% OP ............. 219 BEVESPI AER 9-4.8MCG .................. 198 BEVYXXA CAP 40MG ....................... 157 BEVYXXA CAP 80MG ....................... 157

bexarotene cap 75 mg ..................... 42 BEYAZ TAB .................................... 126 bicalutamide tab 50 mg .................... 39 BICILLIN C-R INJ 1200000 ................ 23 BICILLIN C-R INJ 900/300 ................ 23 BICILLIN L-A INJ 1200000 ................ 23 BICILLIN L-A INJ 2400000 ................ 23 BICILLIN L-A INJ 600000 .................. 23 BICNU INJ 100MG ........................... 36 BIDIL TAB ...................................... 67 BIFERARX TAB ............................... 177 BILTRICIDE TAB 600MG ................... 34 bimatoprost ophth soln 0.03% ......... 221 BINOSTO TAB 70MG ....................... 124 bio glo tes 1mg op .......................... 220 bio t pres-b liq 10-4-20 ................... 190 biocel tab ...................................... 177 bio-d-mulsio liq 2000unit ................. 177 bio-d-mulsio liq 400unit ................... 177 BIOGAIA DRO PROBIOTI ................. 147 BIOGAIA MIS PROBIOTI .................. 147 BIONEL LIQ PEDIATRC .................... 190 bio-rytuss liq 5-2-10/5 .................... 190 BIOSPEC DMX LIQ .......................... 190 BIOSTEP AG MIS 2"X2" ................... 214 BIOSTEP AG MIS 4"X4" ................... 214 BIOSTEP MIS 2"X2" ........................ 214 BIOSTEP MIS 4"X4" ........................ 214 BIOSUPP LIQ ................................. 177 BIOVOL SYP ................................... 177 bisoprolol & hydrochlorothiazide tab 10-6.25 mg ......................................... 59 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg ......................................... 59 bisoprolol & hydrochlorothiazide tab 5-6.25 mg ......................................... 59 bisoprolol fumarate tab 10 mg ........... 60 bisoprolol fumarate tab 5 mg ............ 60 bivalirudin for iv soln 250 mg ........... 155 BIVIGAM INJ 10% .......................... 165 BLADDER 2.2 TAB ........................... 171 BLEPH-10 SOL 10% OP ................... 216 BLEPHAMIDE OIN S.O.P. .................. 216 BLEPHAMIDE SUS OP ...................... 216 blis-to-sol liq 1% ............................ 203 BLOXIVERZ INJ 10/10ML ................. 108 BLOXIVERZ INJ 5MG/10ML .............. 108 BONE DENSITY TAB BUILDER ........... 177

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BONIVA TAB 150MG ....................... 124 BOSULIF TAB 100MG ........................ 40 BOSULIF TAB 500MG ........................ 40 BOUDREAUXS OIN 16% .................. 211 bp 10-1 emu ................................. 200 BP ARM CUFF MIS LARGE ................ 169 bp cleansing emu 10-4% ................. 200 bp foaming liq wash 10% ................ 200 bp folinatal tab plus b ..................... 177 BP GEL GEL 5.5% ........................... 200 bp multinatl chw plus ...................... 177 bp multinatl tab plus ....................... 177 bp wash liq 5.25% .......................... 200 b-plex tab ..................................... 176 bpo cloths mis 6% .......................... 200 bpo creamy kit 4% wash ................. 200 BPO GEL 4% .................................. 200 BPO GEL 8% .................................. 200 bprotected sol tri-vite ..................... 177 BRAINSTRONG MIS PRENATAL ......... 177 BREO ELLIPTA INH 100-25 .............. 198 BREO ELLIPTA INH 200-25 .............. 198 BREVIBLOC INJ 10MG/ML .................. 60 BREVIBLOC SOL ............................... 60 BREVIBLOC SOL 10MG/ML ................. 60 BRILINTA TAB 60MG ....................... 163 BRILINTA TAB 90MG ....................... 163 brimonidine tartrate ophth soln 0.15% ................................................... 222 brimonidine tartrate ophth soln 0.2% 222 BRISDELLE CAP 7.5MG .................... 113 BRIVIACT SOL 10MG/ML ................... 74 BRIVIACT TAB 100MG ....................... 74 BRIVIACT TAB 10MG ......................... 74 BRIVIACT TAB 25MG ......................... 74 BRIVIACT TAB 50MG ......................... 74 BRIVIACT TAB 75MG ......................... 74 bromfenac sodium ophth soln 0.09% (base equiv) (once-daily) ................ 217 bromfenac sodium ophth soln 0.09% (base equivalent) ........................... 217 bromocriptine mesylate cap 5 mg (base equivalent) ...................................... 88 bromocriptine mesylate tab 2.5 mg (base equivalent) ...................................... 88 brompheniramine tannate chew tab 12 mg ............................................... 189 BROVANA NEB 15MCG .................... 192

BROVEX PEB LIQ DM ....................... 190 BSS PLUS SOL OP ........................... 220 BUCALSEP SOL ............................... 211 BUCALSEP SPR ............................... 211 BUCKLEYS LIQ COUGH .................... 192 budesonide delayed release particles cap 3 mg ............................................ 144 budesonide inhalation susp 0.25 mg/2ml .................................................... 197 budesonide inhalation susp 0.5 mg/2ml .................................................... 197 budesonide inhalation susp 1 mg/2ml 197 budesonide nasal susp 32 mcg/act .... 196 bumetanide inj 0.25 mg/ml ............... 66 bumetanide tab 0.5 mg .................... 66 bumetanide tab 1 mg ....................... 66 bumetanide tab 2 mg ....................... 66 BUNAVAIL MIS 2.1-0.3 .................... 112 BUNAVAIL MIS 4.2-0.7 .................... 112 BUNAVAIL MIS 6.3-1MG .................. 112 BUPAP TAB 50-300MG ........................ 2 BUPRENEX INJ 0.3MG/ML ................... 6 buprenorphine hcl inj 0.3 mg/ml (base equiv) .............................................. 6 buprenorphine hcl sl tab 2 mg (base equiv) ........................................... 113 buprenorphine hcl sl tab 8 mg (base equiv) ........................................... 113 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) ....................... 112 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) .......................... 112 buprenorphine td patch weekly 10 mcg/hr ............................................. 6 buprenorphine td patch weekly 15 mcg/hr ............................................. 6 buprenorphine td patch weekly 20 mcg/hr ............................................. 6 buprenorphine td patch weekly 5 mcg/hr ....................................................... 6 bupropion hcl (smoking deterrent) tab er 12hr 150 mg .................................. 113 bupropion hcl tab 100 mg ................. 82 bupropion hcl tab 75 mg ................... 82 bupropion hcl tab er 12hr 100 mg ...... 82 bupropion hcl tab er 12hr 150 mg ...... 82 bupropion hcl tab er 12hr 200 mg ...... 82 bupropion hcl tab er 24hr 150 mg ...... 82

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bupropion hcl tab er 24hr 300 mg ....... 82 buspirone hcl tab 10 mg .................... 73 buspirone hcl tab 15 mg .................... 73 buspirone hcl tab 30 mg .................... 73 buspirone hcl tab 5 mg ..................... 73 buspirone hcl tab 7.5 mg ................... 73 BUSULFEX INJ 6MG/ML ..................... 36 butalbital-acetaminophen tab 50-325 mg ...................................................... 2 butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg .............................. 6 butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg .............................. 6 butalbital-acetaminophen-caffeine cap 50-300-40 mg .................................. 2 butalbital-acetaminophen-caffeine cap 50-325-40 mg .................................. 2 butalbital-acetaminophen-caffeine tab 50-325-40 mg .................................. 2 butalbital-aspirin-caffeine cap 50-325-40 mg .................................................. 2 BUTISOL SOD TAB 30MG ................. 104 butorphanol tartrate inj 1 mg/ml ......... 6 butorphanol tartrate inj 2 mg/ml ......... 6 butorphanol tartrate nasal soln 10 mg/ml ...................................................... 6 BUTRANS DIS 10MCG/HR ................... 6 BUTRANS DIS 15MCG/HR ................... 6 BUTRANS DIS 20MCG/HR ................... 6 BUTRANS DIS 5MCG/HR ..................... 6 BYDUREON INJ 2MG ....................... 116 BYDUREON PEN INJ 2MG ................. 116 BYETTA INJ 10MCG ......................... 116 BYETTA INJ 5MCG .......................... 116 BYSTOLIC TAB 10MG ........................ 60 BYSTOLIC TAB 2.5MG ....................... 60 BYSTOLIC TAB 20MG ........................ 60 BYSTOLIC TAB 5MG .......................... 60 C c complex tab 1000mg .................... 177 ca citrate tab plus .......................... 177 CA HI-CAL/D TAB 500MG ................ 177 cabergoline tab 0.5 mg ................... 135 CABOMETYX TAB 20MG ..................... 40 CABOMETYX TAB 40MG ..................... 40 CABOMETYX TAB 60MG ..................... 40 CADEAU DHA CAP .......................... 177 CA-DTPA SOL 1000MG .................... 123

CADUET TAB 10-10MG ..................... 62 CADUET TAB 10-20MG ..................... 62 CADUET TAB 10-40MG ..................... 62 CADUET TAB 10-80MG ..................... 62 CADUET TAB 2.5-10MG .................... 62 CADUET TAB 2.5-20MG .................... 62 CADUET TAB 2.5-40MG .................... 62 CADUET TAB 5-10MG ....................... 62 CADUET TAB 5-20MG ....................... 62 CADUET TAB 5-40MG ....................... 62 CADUET TAB 5-80MG ....................... 62 CAFCIT INJ 60MG/3ML .................... 195 CAFERGOT TAB 1-100MG ................. 106 caffeine & sodium benzoate inj 125-125 mg/ml (500 mg/2ml) ...................... 108 caffeine citrate inj 60 mg/3ml (10 mg/ml base equiv) ................................... 195 caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) ......................... 195 calamine med lot 1-8% ................... 211 CALAN SR TAB 120MG ...................... 63 CALAN SR TAB 180MG ...................... 63 CALAN SR TAB 240MG ...................... 63 CALAN TAB 120MG .......................... 64 CALAN TAB 80MG ............................ 64 calc citr/d3 tab 200-250 .................. 177 calc citrate tab +d .......................... 177 CALCET BITES CHW 500-400 ........... 177 calcidol dro 8000/ml ....................... 177 calcipotriene cream 0.005% ............. 205 calcipotriene oint 0.005% ................ 205 calcipotriene soln 0.005% (50 mcg/ml) .................................................... 205 calcipotriene-betamethasone dipropionate oint 0.005-0.064% ....... 205 calcitonin (salmon) nasal soln 200 unit/act ......................................... 125 calcitriol cap 0.25 mcg .................... 134 calcitriol cap 0.5 mcg ...................... 134 calcitriol inj 1 mcg/ml ...................... 134 calcitriol oint 3 mcg/gm ................... 205 calcitriol oral soln 1 mcg/ml ............. 134 calcium + d chw ............................. 177 CALCIUM 1000 TAB + D .................. 177 calcium 1200 chw ........................... 177 calcium 500 tab +d ......................... 177 calcium 600 chw +d/miner .............. 177 calcium 600 chw w/vit d .................. 177

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calcium 600 tab + d ....................... 177 calcium 600 tab +d ........................ 177 calcium 600 tab +d3 ....................... 177 calcium 600/ tab vit d ..................... 177 calcium acetate (phosphate binder) cap 667 mg (169 mg ca) ....................... 136 calcium acetate (phosphate binder) tab 667 mg ......................................... 136 CALCIUM CARB CHW 260MG ............ 177 CALCIUM CARB POW 800/2GM ......... 177 calcium carbonate (antacid) susp 1250 mg/5ml ......................................... 177 calcium carbonate (antacid) tab 648 mg ................................................... 140 calcium carbonate tab 1250 mg (500 mg elemental ca) ................................ 177 calcium carbonate tab 1500 mg (600 mg elemental ca) ................................ 177 calcium carbonate tab 600 mg ......... 177 calcium carbonate-cholecalciferol chew tab 500 mg-100 unit ....................... 178 calcium carbonate-vitamin d tab 250 mg-125 unit ........................................ 178 calcium carbonate-vitamin d tab 500 mg-400 unit ........................................ 178 calcium carbonate-vitamin d tab 600 mg-125 unit ........................................ 178 calcium chloride inj 10% ................. 175 CALCIUM CHW GUMMIES ................ 178 CALCIUM CIT/ TAB VIT D ................ 178 calcium citr tab +d ......................... 178 calcium citrate-vitamin d tab 315 mg-200 unit (elemental ca) ................... 178 CALCIUM DISO INJ 1GM/5ML ........... 123 calcium gluconate inj 10% ............... 175 calcium plus cap d3 ........................ 178 calcium tab 500/d .......................... 178 calcium tab 600mg ......................... 178 CALCIUM/C/D CHW 500MG .............. 178 calcium/d3 tab ............................... 178 calcium/d3 tab 600-800 .................. 178 CALCIUM/VITD CAP 600-400 ........... 178 calcium+d3 tab 600-800 ................. 178 calcium+d3 tab grad rel .................. 178 CALCIUM-FA WAF PLUS D ................ 178 calcium-magnesium-zinc tab 333-133-5 mg ............................................... 178 CALDOLOR INJ 400/4ML ..................... 2

CALDOLOR INJ 800/8ML ..................... 2 CALNA TAB .................................... 178 CAL-QUICK LIQ 500-400 ................. 177 CALTRATE + D TAB 300-800 ............ 178 CALTRATE 600 CHW +D PLUS .......... 178 CALTRATE 600 CHW 600-800 ........... 178 CAMPTOSAR INJ 100/5ML ................. 46 CAMPTOSAR INJ 300/15ML ............... 46 CAMPTOSAR INJ 40MG/2ML .............. 46 CANASA SUP 1000MG ..................... 144 CANCIDAS INJ 50MG ....................... 25 CANCIDAS INJ 70MG ....................... 25 candesartan cilexetil tab 16 mg ......... 54 candesartan cilexetil tab 32 mg ......... 54 candesartan cilexetil tab 4 mg ........... 53 candesartan cilexetil tab 8 mg ........... 54 candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg ............................... 52 candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg ............................... 52 candesartan cilexetil-hydrochlorothiazide tab 32-25 mg .................................. 52 CAPASTAT SUL INJ 1GM ................... 31 capecitabine tab 150 mg .................. 37 capecitabine tab 500 mg .................. 37 CAPEX SHA 0.01% .......................... 207 CAPHOSOL SOL .............................. 215 CAPITAL/COD SUS 120-12/5 ............... 6 CAPRELSA TAB 100MG ..................... 40 CAPRELSA TAB 300MG ..................... 40 capsaicin cream 0.025% .................. 210 capsaicin cream 0.1% ..................... 210 CAPSAICIN LIQ 0.15% .................... 210 capsaicin pad hot ptch ..................... 210 captopril & hydrochlorothiazide tab 25-15 mg ................................................ 47 captopril & hydrochlorothiazide tab 25-25 mg ................................................ 47 captopril & hydrochlorothiazide tab 50-15 mg ................................................ 47 captopril & hydrochlorothiazide tab 50-25 mg ................................................ 47 captopril tab 100 mg ........................ 48 captopril tab 12.5 mg ....................... 48 captopril tab 25 mg ......................... 48 captopril tab 50 mg ......................... 48 CAPZASIN GEL RELIEF .................... 210 CAPZASIN-P CRE 0.035% ................ 210

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CARAC CRE 0.5% ........................... 202 CARAFATE SUS 1GM/10ML .............. 147 CARAFATE TAB 1GM ....................... 147 CARBAGLU TAB 200MG ................... 135 carbamazepine cap er 12hr 100 mg .... 74 carbamazepine cap er 12hr 200 mg .... 74 carbamazepine cap er 12hr 300 mg .... 74 carbamazepine chew tab 100 mg ........ 74 carbamazepine susp 100 mg/5ml ....... 74 carbamazepine tab 200 mg ................ 74 carbamazepine tab er 12hr 200 mg .... 74 carbamazepine tab er 12hr 400 mg .... 74 CARBAPHEN 12 LIQ ........................ 190 CARBAPHEN 12 SUS PED ................. 190 CARBATROL CAP 100MG .................... 74 CARBATROL CAP 200MG .................... 74 CARBATROL CAP 300MG .................... 74 carbidopa & levodopa orally disintegrating tab 10-100 mg ............. 88 carbidopa & levodopa orally disintegrating tab 25-100 mg ............. 88 carbidopa & levodopa orally disintegrating tab 25-250 mg ............. 88 carbidopa & levodopa tab 10-100 mg .. 88 carbidopa & levodopa tab 25-100 mg .. 88 carbidopa & levodopa tab 25-250 mg .. 88 carbidopa & levodopa tab er 25-100 mg ..................................................... 88 carbidopa & levodopa tab er 50-200 mg ..................................................... 88 carbidopa tab 25 mg ......................... 88 carbidopa-levodopa-entacapone tabs 12.5-50-200 mg ............................... 88 carbidopa-levodopa-entacapone tabs 18.75-75-200 mg ............................. 88 carbidopa-levodopa-entacapone tabs 25-100-200 mg .................................... 88 carbidopa-levodopa-entacapone tabs 31.25-125-200 mg ........................... 88 carbidopa-levodopa-entacapone tabs 37.5-150-200 mg ............................. 88 carbidopa-levodopa-entacapone tabs 50-200-200 mg .................................... 88 carbinoxamine maleate soln 4 mg/5ml ................................................... 189 carbinoxamine maleate tab 4 mg ...... 189 carboplatin iv soln 150 mg/15ml ........ 36 carboplatin iv soln 450 mg/45ml ........ 36

carboplatin iv soln 50 mg/5ml ........... 36 carboplatin iv soln 600 mg/60ml ........ 36 CARDENE IV INJ 40/200ML ............... 63 CARDENE IV SOL 20/200ML .............. 63 cardioplegic soln .............................. 68 CARDIZEM CD CAP 120MG/24 ........... 64 CARDIZEM CD CAP 180MG/24 ........... 64 CARDIZEM CD CAP 240MG/24 ........... 64 CARDIZEM CD CAP 300MG/24 ........... 64 CARDIZEM CD CAP 360MG/24 ........... 64 CARDIZEM LA TAB 120MG ................ 64 CARDIZEM LA TAB 180MG ................ 64 CARDIZEM LA TAB 240MG ................ 64 CARDIZEM LA TAB 300MG/24 ............ 64 CARDIZEM LA TAB 360MG ................ 64 CARDIZEM LA TAB 420MG/24 ............ 64 CARDIZEM TAB 120MG ..................... 64 CARDIZEM TAB 30MG ...................... 64 CARDIZEM TAB 60MG ...................... 64 CARDURA TAB 1MG ......................... 50 CARDURA TAB 2MG ......................... 50 CARDURA TAB 4MG ......................... 50 CARDURA TAB 8MG ......................... 50 CARDURA XL TAB 4MG .................... 152 CARDURA XL TAB 8MG .................... 152 CAREFINE MIS 32GX5MM ................ 120 CARIMUNE NF INJ 12GM .................. 166 CARIMUNE NF INJ 6GM ................... 165 carisoprodol tab 250 mg .................. 110 carisoprodol tab 350 mg .................. 110 carisoprodol w/ aspirin & codeine tab 200-325-16 mg .............................. 110 carisoprodol w/ aspirin tab 200-325 mg .................................................... 110 carracolloid pad 4"x4" ..................... 214 carteolol hcl ophth soln 1% .............. 218 CARTICEL IMP ................................... 2 CARTRIDGE MIS PUMP .................... 120 carvedilol tab 12.5 mg ..................... 60 carvedilol tab 25 mg ........................ 60 carvedilol tab 3.125 mg .................... 60 carvedilol tab 6.25 mg ..................... 60 CASODEX TAB 50MG ........................ 39 caspofungin acetate for iv soln 50 mg . 25 CATAPRES TAB 0.1MG ...................... 49 CATAPRES TAB 0.2MG ...................... 49 CATAPRES TAB 0.3MG ...................... 49 CATAPRES-TTS DIS 0.1/24HR ........... 49

239

CATAPRES-TTS DIS 0.2/24HR ............ 49 CATAPRES-TTS DIS 0.3/24HR ............ 49 CATHFLO ACTI INJ VASE ................. 162 cavarest gel 1.1% .......................... 215 CAYSTON INH 75MG ....................... 193 caziant pak .................................... 127 cefaclor cap 250 mg ......................... 18 cefaclor cap 500 mg ......................... 18 CEFACLOR ER TAB 500MG ................. 18 cefaclor for susp 125 mg/5ml ............. 18 cefaclor for susp 250 mg/5ml ............. 18 cefaclor for susp 375 mg/5ml ............. 18 cefadroxil cap 500 mg ....................... 17 cefadroxil for susp 250 mg/5ml .......... 17 cefadroxil for susp 500 mg/5ml .......... 18 cefadroxil tab 1 gm ........................... 18 CEFAZOL/DEX SOL 1GM .................... 18 CEFAZOL/DEX SOL 2GM .................... 18 CEFAZOLIN INJ 100GM ..................... 18 CEFAZOLIN INJ 1GM/50ML ................ 18 CEFAZOLIN INJ 300GM ..................... 18 cefazolin sodium for inj 1 gm ............. 18 cefazolin sodium for inj 10 gm ........... 18 cefazolin sodium for inj 20 gm ........... 18 cefazolin sodium for inj 500 mg .......... 18 cefazolin sodium for iv soln 1 gm ........ 18 cefdinir cap 300 mg .......................... 19 cefdinir for susp 125 mg/5ml ............. 19 cefdinir for susp 250 mg/5ml ............. 19 cefditoren pivoxil tab 200 mg (base equivalent) ...................................... 19 cefditoren pivoxil tab 400 mg (base equivalent) ...................................... 19 cefepime hcl for inj 1 gm ................... 20 cefepime hcl for inj 2 gm ................... 20 CEFEPIME INJ 1GM ........................... 20 CEFEPIME INJ 2GM ........................... 20 CEFEPIME/DEX INJ 1GM .................... 20 CEFEPIME/DEX INJ 2GM .................... 20 cefixime for susp 100 mg/5ml ............ 19 cefixime for susp 200 mg/5ml ............ 19 cefotaxime sodium for inj 1 gm .......... 19 cefotaxime sodium for inj 10 gm ........ 19 cefotaxime sodium for inj 2 gm .......... 19 cefotaxime sodium for inj 500 mg ....... 19 CEFOTET/DEX INJ 1-3.58% ............... 18 CEFOTET/DEX INJ 2-2.08% ............... 18 cefotetan disodium for inj 1 gm .......... 18

cefotetan disodium for inj 10 gm ....... 18 cefotetan disodium for inj 2 gm ......... 18 CEFOXITIN INJ 1GM ......................... 18 CEFOXITIN INJ 2GM ......................... 18 cefoxitin sodium for inj 10 gm ........... 18 cefoxitin sodium for iv soln 1 gm ....... 18 cefoxitin sodium for iv soln 2 gm ....... 18 cefpodoxime proxetil for susp 100 mg/5ml .......................................... 19 cefpodoxime proxetil for susp 50 mg/5ml ..................................................... 19 cefpodoxime proxetil tab 100 mg ....... 19 cefpodoxime proxetil tab 200 mg ....... 19 cefprozil for susp 125 mg/5ml ........... 18 cefprozil for susp 250 mg/5ml ........... 18 cefprozil tab 250 mg ........................ 18 cefprozil tab 500 mg ........................ 18 ceftazidime for inj 1 gm .................... 19 ceftazidime for inj 2 gm .................... 19 ceftazidime for inj 6 gm .................... 19 CEFTAZIDIME/ SOL D5W 1GM ........... 19 CEFTAZIDIME/ SOL D5W 2GM ........... 19 ceftibuten cap 400 mg ...................... 19 ceftibuten for susp 180 mg/5ml ......... 19 CEFTIN SUS 125/5ML ....................... 18 CEFTIN SUS 250/5ML ....................... 18 CEFTRIAX/DEX INJ 1GM ................... 19 CEFTRIAX/DEX INJ 2GM ................... 19 ceftriaxone sodium for inj 1 gm ......... 19 ceftriaxone sodium for inj 10 gm ....... 19 ceftriaxone sodium for inj 2 gm ......... 19 ceftriaxone sodium for inj 250 mg ...... 19 ceftriaxone sodium for inj 500 mg ...... 19 ceftriaxone sodium for iv soln 1 gm .... 19 ceftriaxone sodium for iv soln 2 gm .... 19 ceftriaxone sodium in dextrose inj 20 mg/ml ........................................... 19 ceftriaxone sodium in dextrose inj 40 mg/ml ........................................... 20 cefuroxime axetil tab 250 mg ............ 18 cefuroxime axetil tab 500 mg ............ 18 CEFUROXIME INJ 7.5GM ................... 18 CEFUROXIME INJ 75GM .................... 19 cefuroxime sodium for inj 1.5 gm ...... 19 cefuroxime sodium for inj 7.5 gm ...... 19 cefuroxime sodium for inj 750 mg ...... 19 cefuroxime sodium for iv soln 1.5 gm . 19 CELEBREX CAP 100MG ....................... 1

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CELEBREX CAP 200MG ....................... 1 CELEBREX CAP 400MG ....................... 1 CELEBREX CAP 50MG ......................... 1 celecoxib cap 100 mg ........................ 1 celecoxib cap 200 mg ........................ 1 celecoxib cap 400 mg ........................ 1 celecoxib cap 50 mg .......................... 1 CELESTONE INJ SOLUSPAN.............. 131 CELEXA TAB 10MG ........................... 84 CELEXA TAB 20MG ........................... 84 CELEXA TAB 40MG ........................... 84 CELLCEPT IV INJ 500MG .................. 167 CELLUGEL SOL 2% ......................... 220 CELLULAR CAP SECURITY ................ 178 CELONTIN CAP 300MG ...................... 74 CENTANY AT KIT 2% ...................... 203 CENTANY OIN 2% .......................... 203 CENTRUM LIQ ................................ 178 CEO-TWO SUP ............................... 145 CEPACOL SORE LOZ COATING ......... 215 cephalexin cap 250 mg ..................... 18 cephalexin cap 500 mg ..................... 18 cephalexin cap 750 mg ..................... 18 cephalexin for susp 125 mg/5ml ......... 18 cephalexin for susp 250 mg/5ml ......... 18 cephalexin tab 250 mg ...................... 18 cephalexin tab 500 mg ...................... 18 CEPROTIN INJ 1000UNIT ................. 162 CEPROTIN INJ 500 UNIT .................. 162 CERALYTE 70 LIQ ........................... 172 ceramax cre .................................. 211 CERDELGA CAP 84MG ..................... 134 CEREBYX INJ 100/2ML ...................... 74 CEREBYX INJ 500/10ML .................... 74 CERVIDIL VAG MIS 10MG INS .......... 135 CESAMET CAP 1MG ......................... 141 cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) ....................................... 188 cetirizine hcl tab 5 mg ..................... 188 cevimeline hcl cap 30 mg ................ 151 cgh control syp pe .......................... 190 CHANTIX PAK 0.5& 1MG .................. 113 CHANTIX PAK 1MG ......................... 113 CHANTIX TAB 0.5MG ...................... 113 chateal tab 0.15/30 ........................ 126 CHEMET CAP 100MG ....................... 162 CHEMSTRIP TES STRIPS .................. 120 CHENODAL TAB 250MG ................... 143

CHERACOL-D LIQ 100-10/5 ............. 190 chest conges tab 20-400mg ............. 190 chest conges tab 400mg .................. 194 CHEWABLE CHW IRON .................... 178 child silfed liq 15mg/5ml .................. 194 childrens chw pepto ........................ 140 chld allergy liq 12.5/5ml .................. 189 chld asafree elx 80/2.5ml ................... 1 chloramphenicol sodium succinate for iv inj 1 gm ......................................... 34 CHLORASEPTIC LOZ TOTAL .............. 215 chlordiazepoxide hcl cap 10 mg ......... 72 chlordiazepoxide hcl cap 25 mg ......... 72 chlordiazepoxide hcl cap 5 mg ........... 72 chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg ................................. 142 chlordiazepoxide-amitriptyline tab 10-25 mg ................................................ 82 chlordiazepoxide-amitriptyline tab 5-12.5 mg ................................................ 82 chloroquine phosphate tab 250 mg .... 27 chloroquine phosphate tab 500 mg .... 27 chlorothiazide sodium for inj 500 mg .. 66 chlorothiazide tab 250 mg ................ 66 chlorothiazide tab 500 mg ................ 66 CHLORPROMAZ INJ 25MG/ML ............ 96 CHLORPROMAZ INJ 50MG/2ML .......... 96 chlorpromazine hcl tab 10 mg ........... 96 chlorpromazine hcl tab 100 mg .......... 96 chlorpromazine hcl tab 200 mg .......... 96 chlorpromazine hcl tab 25 mg ........... 96 chlorpromazine hcl tab 50 mg ........... 96 chlorpropamide tab 100 mg ............. 119 chlorpropamide tab 250 mg ............. 119 chlorthalidone tab 25 mg .................. 66 chlorthalidone tab 50 mg .................. 66 chlorzoxazone tab 500 mg ............... 110 CHOLBAM CAP 250MG ..................... 147 CHOLBAM CAP 50MG ....................... 147 cholecalciferol cap 400 unit .............. 178 cholecalciferol cap 5000 unit ............ 178 cholecalciferol oral liquid 400 unit/ml 178 cholecalciferol tab 2000 unit ............. 178 cholecalciferol tab 50000 unit ........... 178 cholestyramine light powder 4 gm/dose ..................................................... 56 cholestyramine light powder packets 4 gm ................................................ 56

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cholestyramine powder 4 gm/dose ...... 56 cholestyramine powder packets 4 gm .. 56 choline & magnesium salicylates liq 500 mg/5ml ............................................ 2 choline & magnesium salicylates tab 1000 mg .......................................... 2 choline fenofibrate cap dr 135 mg (fenofibric acid equiv) ....................... 56 choline fenofibrate cap dr 45 mg (fenofibric acid equiv) ....................... 56 chromic chloride inj 40 mcg/10ml (4 mcg/ml) (elemental cr) ................... 175 ciclodan cre 0.77% ......................... 203 CICLODAN CRE KIT 0.77% .............. 203 ciclodan sol 8% .............................. 203 CICLODAN SOL KIT 8% ................... 203 ciclopirox gel 0.77% ....................... 203 ciclopirox kit 8% ............................ 204 ciclopirox olamine susp 0.77% (base equiv) ........................................... 204 ciclopirox shampoo 1% ................... 204 cidofovir iv inj 75 mg/ml ................... 31 cilostazol tab 100 mg ...................... 162 cilostazol tab 50 mg ........................ 162 CILOXAN OIN 0.3% OP ................... 216 CILOXAN SOL 0.3% OP ................... 216 cimetidine hcl soln 300 mg/5ml ........ 143 cimetidine tab 200 mg .................... 143 cimetidine tab 300 mg .................... 143 cimetidine tab 400 mg .................... 143 cimetidine tab 800 mg .................... 143 CIMZIA KIT ................................... 164 CIMZIA KIT STARTER ...................... 164 CIMZIA PREFL KIT 200MG/ML .......... 164 CINRYZE SOL 500 UNIT .................. 162 CIPRO HC SUS OTIC ....................... 222 CIPRODEX SUS 0.3-0.1% ................ 222 ciprofloxacin 200 mg/100ml in d5w ..... 21 ciprofloxacin 400 mg/200ml in d5w ..... 21 ciprofloxacin hcl ophth soln 0.3% ..... 216 ciprofloxacin hcl otic soln 0.2% (base equivalent) .................................... 222 ciprofloxacin hcl tab 100 mg (base equiv) ..................................................... 21 ciprofloxacin hcl tab 250 mg (base equiv) ..................................................... 21 ciprofloxacin hcl tab 500 mg (base equiv) ..................................................... 21

ciprofloxacin hcl tab 750 mg (base equiv) ..................................................... 21 ciprofloxacin iv soln 200 mg/20ml (1%) ..................................................... 21 ciprofloxacin iv soln 400 mg/40ml (1%) ..................................................... 21 ciprofloxacin-ciprofloxacin hcl tab er 24hr 1000 mg(base eq) ........................... 21 ciprofloxacin-ciprofloxacin hcl tab er 24hr 500 mg (base eq) ............................ 21 cisplatin inj 100 mg/100ml (1 mg/ml) 36 cisplatin inj 200 mg/200ml (1 mg/ml) 36 cisplatin inj 50 mg/50ml (1 mg/ml) .... 36 citalopram hydrobromide oral soln 10 mg/5ml .......................................... 84 citalopram hydrobromide tab 10 mg (base equiv) ................................... 84 citalopram hydrobromide tab 20 mg (base equiv) ................................... 84 citalopram hydrobromide tab 40 mg (base equiv) ................................... 85 CITRACAL+D3 CHW 250-500 ........... 178 CITRANATAL CAP HARMONY ............. 178 CITRANATAL TAB RX ....................... 178 cladribine iv soln 10 mg/10ml (1 mg/ml) ..................................................... 38 CLAFORAN INJ 10GM ....................... 20 CLAFORAN INJ 1GM ......................... 20 CLAFORAN INJ 2GM ......................... 20 CLAFORAN INJ 500MG ...................... 20 CLARINEX SYP 0.5MG/ML ................ 188 CLARINEX TAB 5MG ........................ 188 CLARINEX-D TAB 2.5-120 ................ 188 clarithromycin for susp 125 mg/5ml ... 20 clarithromycin for susp 250 mg/5ml ... 20 clarithromycin tab 250 mg ................ 20 clarithromycin tab 500 mg ................ 20 clarithromycin tab er 24hr 500 mg ..... 20 CLARITIN CAP 10MG ....................... 188 CLARITIN CHW 5MG ....................... 188 CLARITIN RDT TAB 5MG .................. 188 clear away liq 17% ......................... 211 clearplex v gel 5% .......................... 200 clemastine fumarate tab 2.68 mg ..... 189 CLEOCIN CAP 150MG ....................... 34 CLEOCIN CAP 300MG ....................... 34 CLEOCIN CAP 75MG ......................... 34 CLEOCIN CRE 2% VAG .................... 154

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CLEOCIN PED SOL 75MG/5ML ............ 34 CLEOCIN PHOS INJ 300/2ML .............. 34 CLEOCIN PHOS INJ 600/4ML .............. 34 CLEOCIN PHOS INJ 900/6ML .............. 34 CLEOCIN PHOS INJ 9GM/60ML ........... 34 CLEOCIN SUP 100MG ...................... 154 CLEOCIN/D5W INJ 300MG ................. 34 CLEOCIN/D5W INJ 600MG ................. 34 CLEOCIN/D5W INJ 900MG ................. 34 CLEOCIN-T GEL 1% ........................ 200 CLEOCIN-T LOT 1% ........................ 200 CLEOCIN-T PAD 1% ........................ 200 CLEOCIN-T SOL 1% ........................ 200 CLEVIPREX EMU 0.5MG/ML ................ 63 CLIMARA DIS 0.025MG ................... 129 CLIMARA DIS 0.0375MG .................. 129 CLIMARA DIS 0.05MG ..................... 129 CLIMARA DIS 0.06MG ..................... 129 CLIMARA DIS 0.075MG ................... 129 CLIMARA DIS 0.1MG ....................... 129 CLIMARA PRO DIS WEEKLY .............. 128 CLIN SINGLE KIT USE ....................... 34 CLINDACIN KIT PAC 1% .................. 200 clindacin-p pad 1% ......................... 200 CLINDAGEL GEL 1% ....................... 200 clindamycin hcl cap 150 mg ............... 34 clindamycin hcl cap 300 mg ............... 34 clindamycin hcl cap 75 mg ................. 34 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) ........................ 34 clindamycin phosphate foam 1% ...... 200 clindamycin phosphate gel 1% ......... 200 clindamycin phosphate in d5w iv soln 300 mg/50ml ................................... 34 clindamycin phosphate in d5w iv soln 600 mg/50ml ................................... 34 clindamycin phosphate in d5w iv soln 900 mg/50ml ................................... 35 clindamycin phosphate inj 300 mg/2ml 35 clindamycin phosphate inj 600 mg/4ml 35 clindamycin phosphate inj 9 gm/60ml . 35 clindamycin phosphate inj 900 mg/6ml 35 clindamycin phosphate iv soln 300 mg/2ml ........................................... 35 clindamycin phosphate iv soln 900 mg/6ml ........................................... 35 clindamycin phosphate lotion 1% ...... 200 clindamycin phosphate soln 1% ........ 200

clindamycin phosphate vaginal cream 2% .................................................... 155 clindamycin phosphate-benzoyl peroxide gel 1-5% ....................................... 200 clindamycin phosphate-tretinoin gel 1.2-0.025% ......................................... 200 CLINDESSE CRE 2% ....................... 155 CLINIMIX E INJ 2.75/D10 ................ 172 CLINIMIX E INJ 2.75/D5W ............... 172 CLINIMIX E INJ 4.25/D10 ................ 172 CLINIMIX E INJ 4.25/D25 ................ 172 CLINIMIX E INJ 4.25/D5W ............... 172 CLINIMIX E INJ 5%/D15W ............... 172 CLINIMIX E INJ 5%/D20W ............... 173 CLINIMIX E INJ 5%/D25W ............... 173 CLINIMIX INJ 2.75/D5W .................. 173 CLINIMIX INJ 4.25/D10 ................... 173 CLINIMIX INJ 4.25/D20 ................... 173 CLINIMIX INJ 4.25/D25 ................... 173 CLINIMIX INJ 4.25/D5W .................. 173 CLINIMIX INJ 5%/D15W .................. 173 CLINIMIX INJ 5%/D20W .................. 173 CLINIMIX INJ 5%/D25W .................. 173 CLINITEST TAB 2 DROP ................... 120 clinpro 5000 pst 1.1% ..................... 215 clobetasol e cre 0.05% .................... 209 clobetasol propionate cream 0.05% .. 209 clobetasol propionate emulsion foam 0.05% .......................................... 209 clobetasol propionate foam 0.05% .... 209 clobetasol propionate gel 0.05% ....... 209 clobetasol propionate lotion 0.05% ... 209 clobetasol propionate oint 0.05% ...... 209 clobetasol propionate soln 0.05% ..... 209 clobetasol propionate spray 0.05% ... 209 CLOBEX LOT 0.05% ........................ 209 CLOBEX SHA 0.05% ........................ 209 CLOBEX SPR 0.05% ........................ 209 clocortolone pivalate cream 0.1% ..... 208 clodan sha 0.05% ........................... 209 CLODERM CRE 0.1% PMP ................ 208 clomipramine hcl cap 25 mg .............. 73 clomipramine hcl cap 50 mg .............. 73 clomipramine hcl cap 75 mg .............. 73 clonazepam orally disintegrating tab 0.125 mg ....................................... 72 clonazepam orally disintegrating tab 0.25 mg ................................................ 72

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clonazepam orally disintegrating tab 0.5 mg ................................................. 72 clonazepam orally disintegrating tab 1 mg ................................................. 72 clonazepam orally disintegrating tab 2 mg ................................................. 72 clonazepam tab 0.5 mg ..................... 72 clonazepam tab 1 mg ........................ 72 clonazepam tab 2 mg ........................ 72 clonidine hcl inj (for epidural infusion) 100 mcg/ml ...................................... 2 clonidine hcl inj (for epidural infusion) 500 mcg/ml ...................................... 2 clonidine hcl tab 0.1 mg .................... 49 clonidine hcl tab 0.2 mg .................... 49 clonidine hcl tab 0.3 mg .................... 49 clonidine hcl tab er 12hr 0.1 mg ......... 99 clonidine hcl td patch weekly 0.1 mg/24hr ......................................... 49 clonidine hcl td patch weekly 0.2 mg/24hr ......................................... 49 clonidine hcl td patch weekly 0.3 mg/24hr ......................................... 49 clopidogrel bisulfate tab 300 mg (base equiv) ........................................... 163 clopidogrel bisulfate tab 75 mg (base equiv) ........................................... 163 clorazepate dipotassium tab 15 mg ..... 73 clorazepate dipotassium tab 3.75 mg .. 72 clorazepate dipotassium tab 7.5 mg .... 72 clorpres tab 0.1-15mg ...................... 68 clorpres tab 0.2-15mg ...................... 68 clorpres tab 0.3-15mg ...................... 68 clotrimazole cre 1% vag .................. 155 clotrimazole cre 2% ........................ 155 clotrimazole cream 1% ................... 204 clotrimazole soln 1% ...................... 204 clotrimazole troche 10 mg ................. 25 clotrimazole w/ betamethasone cream 1-0.05% .......................................... 204 clotrimazole w/ betamethasone lotion 1-0.05% .......................................... 204 clozapine orally disintegrating tab 100 mg ................................................. 91 clozapine orally disintegrating tab 12.5 mg ................................................. 91 clozapine orally disintegrating tab 150 mg ................................................. 91

clozapine orally disintegrating tab 200 mg ................................................ 91 clozapine orally disintegrating tab 25 mg ..................................................... 91 clozapine tab 100 mg ....................... 91 clozapine tab 200 mg ....................... 91 clozapine tab 25 mg ......................... 91 clozapine tab 50 mg ......................... 91 CLOZARIL TAB 100MG ...................... 91 CLOZARIL TAB 25MG ....................... 91 COAGADEX INJ 250UNIT ................. 158 COAGADEX INJ 500UNIT ................. 158 COARTEM TAB 20-120MG ................. 27 cocaine hcl soln 4% ........................ 210 cod liver chw w/vit .......................... 178 CODAR AR LIQ 2-8/5ML................... 190 CODAR D LIQ 30-8/5ML .................. 190 codar gf liq 200-8/5 ........................ 190 codeine sulfate tab 15 mg ................... 6 codeine sulfate tab 30 mg ................... 6 codeine sulfate tab 60 mg ................... 6 COGENTIN INJ 1MG/ML .................... 88 COLAZAL CAP 750MG ...................... 144 colchicine cap 0.6 mg ......................... 1 colchicine tab 0.6 mg ......................... 1 colchicine w/ probenecid tab 0.5-500 mg ....................................................... 1 cold & flu liq day/nght ..................... 190 cold & flu liq nighttim ...................... 188 cold head tab cong dt ...................... 190 cold mult-sy tab daytime ................. 190 cold/allergy elx children ................... 188 cold/cough elx child ........................ 190 cold/cough elx children .................... 190 COLESTID GRA 5GM ........................ 56 COLESTID POW 5GM ........................ 56 COLESTID TAB 1GM ......................... 56 colestipol hcl granule packets 5 gm .... 56 colestipol hcl granules 5 gm .............. 56 colestipol hcl tab 1 gm ..................... 56 colistimethate sodium for inj 150 mg .. 35 COLY-MYCIN M INJ 150MG ................ 35 COLY-MYCIN S SUS OTIC ................ 222 COLYTE/FLAVR SOL PACKS .............. 145 COMBIGAN SOL 0.2/0.5% ............... 222 COMBIPATCH DIS .05/.14 ................ 128 COMBIPATCH DIS .05/.25 ................ 128 COMBIVENT AER 20-100 ................. 187

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COMBIVIR TAB 150-300 .................... 28 COMETRIQ KIT 100MG ...................... 40 COMETRIQ KIT 140MG ...................... 40 COMETRIQ KIT 60MG ........................ 40 COMFORT EZ MIS 33GX5MM ............ 120 COMFORT EZ MIS 33GX6MM ............ 120 COMFORT EZ MIS 33GX8MM ............ 121 COMP PRNATAL MIS DHA ................ 178 COMPLERA TAB ................................ 28 complete kit lice ............................. 213 COMPLETE NAT PAK DHA ................. 178 compro sup 25mg .......................... 141 COMTAN TAB 200MG ........................ 88 CONCEPT DHA CAP ......................... 178 CONCEPT OB CAP ........................... 178 CONCEPTION KIT ........................... 126 CONCERTA TAB 18MG ....................... 99 CONCERTA TAB 27MG ....................... 99 CONCERTA TAB 36MG ....................... 99 CONCERTA TAB 54MG ....................... 99 CONDYLOX GEL 0.5% ..................... 211 CONDYLOX SOL 0.5% ..................... 211 CONGESTAC TAB 60-400MG ............ 190 constulose sol 10gm/15 .................. 145 CONZIP CAP 100MG .......................... 7 CONZIP CAP 200MG .......................... 7 CONZIP CAP 300MG .......................... 7 cooling burn spr relief ..................... 210 COPAXONE INJ 20MG/ML................. 109 COPAXONE INJ 40MG/ML................. 109 COPEGUS TAB 200MG ....................... 32 CORDARONE TAB 200MG .................. 55 CORDRAN CRE 0.05% ..................... 208 CORDRAN LOT 0.05% ..................... 208 COREG CR CAP 10MG ....................... 60 COREG CR CAP 20MG ....................... 60 COREG CR CAP 40MG ....................... 60 COREG CR CAP 80MG ....................... 60 COREG TAB 12.5MG ......................... 60 COREG TAB 25MG ............................ 60 COREG TAB 3.125MG ........................ 60 COREG TAB 6.25MG ......................... 60 CORGARD TAB 20MG ........................ 60 CORGARD TAB 40MG ........................ 60 CORGARD TAB 80MG ........................ 60 CORIFACT KIT ............................... 158 CORLANOR TAB 5MG ........................ 67 CORLANOR TAB 7.5MG ...................... 67

CORLOPAM INJ 10MG/ML .................. 68 corn&callus kit 17% ........................ 211 CORTEF TAB 10MG ......................... 131 CORTEF TAB 20MG ......................... 131 CORTEF TAB 5MG ........................... 131 CORTENEMA ENE 100MG ................. 145 CORTIFOAM AER 90MG ................... 145 cortisone acetate tab 25 mg ............. 131 CORTISPORIN CRE 0.5% ................. 203 CORTISPORIN OIN 1% .................... 203 CORVERT INJ 1MG/10ML .................. 55 corvita 150 tab ............................... 178 corvita tab ..................................... 179 CORVITE 150 TAB........................... 179 CORVITE FE TAB ............................ 179 CORVITE TAB ................................. 179 CORZIDE TAB 40-5MG ..................... 59 CORZIDE TAB 80-5MG ..................... 59 COSENTYX INJ 150MG/ML ............... 164 COSENTYX PEN INJ 300DOSE ........... 164 COSMEGEN INJ 0.5MG ..................... 42 COSOPT PF SOL ............................. 219 COSOPT SOL 22.3-6.8 ..................... 219 COTELLIC TAB 20MG ........................ 40 cough & sore liq thrt day ................. 190 cough dm sus 30mg/5ml ................. 192 cough drops loz 5.4mg .................... 215 cough drops loz menthol .................. 215 coughtab tab 200mg ....................... 194 COUMADIN TAB 10MG ..................... 157 COUMADIN TAB 1MG ...................... 157 COUMADIN TAB 2.5MG .................... 157 COUMADIN TAB 2MG ...................... 157 COUMADIN TAB 3MG ...................... 157 COUMADIN TAB 4MG ...................... 157 COUMADIN TAB 5MG ...................... 157 COUMADIN TAB 6MG ...................... 157 COUMADIN TAB 7.5MG .................... 157 COZAAR TAB 100MG ........................ 54 COZAAR TAB 25MG .......................... 54 COZAAR TAB 50MG .......................... 54 creamy face liq wash 4% ................. 200 CREON CAP 12000UNT .................... 149 CREON CAP 24000UNT .................... 149 CREON CAP 3000UNIT ..................... 149 CREON CAP 36000UNT .................... 149 CREON CAP 6000UNIT ..................... 149 CREO-TERPIN SYP 10/15ML ............. 192

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CRESEMBA CAP 186 MG .................... 26 CRESEMBA INJ 372MG ...................... 26 CRESTOR TAB 10MG ......................... 57 CRESTOR TAB 20MG ......................... 57 CRESTOR TAB 40MG ......................... 57 CRESTOR TAB 5MG ........................... 57 CRINONE GEL 4% VAG ................... 137 CRIXIVAN CAP 200MG ...................... 28 CRIXIVAN CAP 400MG ...................... 28 CROFAB INJ ................................... 164 cromolyn sodium ophth soln 4% ....... 218 cromolyn sodium oral conc 100 mg/5ml ................................................... 147 cromolyn sodium soln nebu 20 mg/2ml ................................................... 194 CUBICIN SOL 500MG ........................ 35 CULTURELLE CHW KIDS .................. 147 CULTURELLE PAK KIDS ................... 147 cupric chloride inj 0.4 mg/ml ........... 175 CUROSURF SUS 120/1.5 ................. 195 CUTIVATE CRE 0.05% ..................... 208 CUTIVATE LOT 0.05% ..................... 208 CUVPOSA SOL 1MG/5ML ................. 142 cvs allergy chw 12.5mg ................... 189 cvs antacid sus supreme ................. 140 CVS KETONE TES CARE ................... 121 CVS PRENATAL CHW GUMMY ........... 179 cvs sore loz throat .......................... 215 cyanocobalamin inj 1000 mcg/ml ..... 179 CYANOKIT INJ 5GM ........................ 123 CYCLESSA PAK............................... 127 cyclobenzaprine hcl tab 10 mg ......... 110 cyclobenzaprine hcl tab 5 mg ........... 110 cyclobenzaprine hcl tab 7.5 mg ........ 110 CYCLOGYL SOL 0.5% OP ................. 221 CYCLOGYL SOL 1% OP .................... 221 CYCLOGYL SOL 2% OP .................... 221 CYCLOMYDRIL SOL OP .................... 221 cyclopentolate hcl ophth soln 1% ...... 221 cyclopentolate hcl ophth soln 2% ...... 221 cyclophosphamide for inj 1 gm ........... 36 cyclophosphamide for inj 2 gm ........... 36 cyclophosphamide for inj 500 mg ....... 36 cycloserine cap 250 mg ..................... 31 cyclosporine cap 100 mg ................. 168 cyclosporine cap 25 mg ................... 168 cyclosporine iv soln 50 mg/ml .......... 168 cyclosporine modified cap 100 mg .... 168

cyclosporine modified cap 25 mg ...... 168 CYKLOKAPRON INJ 100MG/ML .......... 161 CYMBALTA CAP 20MG ...................... 83 CYMBALTA CAP 30MG ...................... 83 CYMBALTA CAP 60MG ...................... 83 cyproheptadine hcl syrup 2 mg/5ml .. 189 cyproheptadine hcl tab 4 mg ............ 189 cyred tab ....................................... 126 CYSTADANE POW ........................... 135 CYSTAGON CAP 150MG ................... 153 CYSTAGON CAP 50MG ..................... 152 CYSTARAN SOL 0.44% .................... 220 cysteine hcl inj 50 mg/ml................. 173 cytarabine inj 20 mg/ml ................... 38 cytarabine inj pf 100 mg/ml .............. 38 cytarabine inj pf 20 mg/ml ................ 38 CYTOGAM INJ ................................ 166 CYTOMEL TAB 25MCG ..................... 137 CYTOMEL TAB 50MCG ..................... 137 CYTOMEL TAB 5MCG ....................... 137 CYTOTEC TAB 100MCG .................... 149 CYTOTEC TAB 200MCG .................... 149 CYTOVENE INJ 500MG ...................... 31 cytra k gra crystals ......................... 153 cytra-3 syp .................................... 153 D d 400 chw 400unit .......................... 179 d 400 tab 400unit ........................... 179 D.H.E. 45 INJ 1MG/ML ..................... 106 D10W/NACL INJ 0.2% ..................... 173 D10W/NACL INJ 0.225% ................. 173 d3 cap 1000unit ............................. 179 d3 max st dro 5000unit ................... 179 d3 super str cap 2000unit ................ 179 D5W/LYTES INJ #48 ....................... 173 D5W/NACL INJ 0.3% ....................... 173 dacarbazine for inj 100 mg ............... 37 dacarbazine for inj 200 mg ............... 37 DACOGEN INJ 50MG ........................ 38 DAKLINZA TAB 30MG ....................... 32 DAKLINZA TAB 60MG ....................... 32 DAKLINZA TAB 90MG ....................... 32 DALIRESP TAB 500MCG ................... 197 danazol cap 100 mg ........................ 128 danazol cap 200 mg ........................ 128 danazol cap 50 mg ......................... 128 dandruff sha 1% ............................ 205 DANTRIUM CAP 25MG ..................... 110

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DANTRIUM CAP 50MG ..................... 110 DANTRIUM IV INJ 20MG .................. 110 dantrolene sodium cap 100 mg ........ 110 dantrolene sodium cap 25 mg .......... 110 dantrolene sodium cap 50 mg .......... 110 dapsone gel 5% ............................. 200 dapsone tab 100 mg ......................... 35 dapsone tab 25 mg ........................... 35 DARAPRIM TAB 25MG ....................... 27 daunorubicin hcl inj 5 mg/ml (base equiv) ............................................. 42 day time liq cold/flu ........................ 190 day time liq cough .......................... 192 dayhist alrg tab 12 hour .................. 189 DAYPRO TAB 600MG .......................... 2 dayquil sev liq cold/flu .................... 190 DAYTRANA DIS 10MG/9HR ................ 99 DAYTRANA DIS 15MG/9HR ................ 99 DAYTRANA DIS 20MG/9HR ................ 99 DAYTRANA DIS 30MG/9HR ................ 99 DDAVP INJ 4MCG/ML ...................... 139 DDAVP SOL 0.01% ......................... 139 DDAVP SPR 0.01% ......................... 139 DDAVP TAB 0.1MG ......................... 139 DDAVP TAB 0.2MG ......................... 139 DDROPS LIQ 1000UNIT ................... 179 DEBACTEROL SOL 30-50% .............. 215 DECARA CAP 25000UNT .................. 179 decitabine for inj 50 mg .................... 38 decongestant tab 120mg er ............. 194 deferoxamine mesylate for inj 2 gm .. 162 deferoxamine mesylate for inj 500 mg ................................................... 162 DELESTROGEN INJ 10MG/ML ........... 128 DELESTROGEN INJ 20MG/ML ........... 128 DELESTROGEN INJ 40MG/ML ........... 128 DELFLEX-LC/ SOL 2.5% DEX ............ 154 DELTEC COZMO MIS INL PUMP ......... 121 DELZICOL CAP 400MG .................... 144 DEMADEX TAB 10MG ........................ 66 DEMADEX TAB 20MG ........................ 66 demeclocycline hcl tab 150 mg ........... 24 demeclocycline hcl tab 300 mg ........... 24 DEMEROL INJ 100/2ML ...................... 7 DEMEROL INJ 100MG/ML .................... 7 DEMEROL INJ 25MG/0.5 ..................... 7 DEMEROL INJ 25MG/ML ..................... 7 DEMEROL INJ 50MG/ML ..................... 7

DEMEROL INJ 75MG/1.5 ..................... 7 DEMEROL INJ 75MG/ML ...................... 7 DEMEROL TAB 100MG ........................ 7 DEMSER CAP 250MG ........................ 50 DENAVIR CRE 1% ........................... 211 DEPACON INJ 100MG/ML .................. 74 DEPAKENE CAP 250MG ..................... 74 DEPAKENE SOL 250/5ML .................. 74 DEPAKOTE ER TAB 250MG ................ 74 DEPAKOTE ER TAB 500MG ................ 74 DEPAKOTE SPR CAP 125MG .............. 74 DEPAKOTE TAB 125MG DR ................ 75 DEPAKOTE TAB 250MG DR ................ 75 DEPAKOTE TAB 500MG DR ................ 75 DEPODUR INJ 10MG/ML ..................... 7 DEPODUR INJ 15/1.5ML ..................... 7 DEPO-ESTRADI INJ 5MG/ML ............. 129 DEPO-MEDROL INJ 20MG/ML ............ 131 DEPO-MEDROL INJ 40MG/ML ............ 131 DEPO-MEDROL INJ 80MG/ML ............ 131 DEPO-PROVERA INJ 150MG/ML . 125, 126 DEPO-PROVERA INJ 400/ML .............. 39 DEPO-SQ PROV INJ 104 .................. 126 DEPO-TESTOST INJ 100MG/ML ......... 113 DEPO-TESTOST INJ 200MG/ML ......... 113 dermacinrx kit prizopak ................... 210 DERMACINRX PAK LEXITRAL ............ 203 DERMAGRAFT MIS .......................... 211 DERMA-SMOOTH OIL /FS BODY ........ 207 DERMA-SMOOTH OIL /FS SCLP ......... 207 DERMASORB HC KIT 2% ................. 207 DERMASORB TA KIT 0.1% ............... 208 DERMASORB XM KIT 39% ................ 210 DERMATOP CRE 0.1% ..................... 208 DERMATOP OIN 0.1% ..................... 208 DERMAWERX KIT SURGICAL ............ 211 DERMOTIC OIL 0.01% ..................... 222 DESCOVY TAB 200/25 ...................... 27 DESFERAL INJ 500MG ..................... 162 desgen dm tab ............................... 190 desipramine hcl tab 10 mg ................ 87 desipramine hcl tab 100 mg .............. 87 desipramine hcl tab 150 mg .............. 87 desipramine hcl tab 25 mg ................ 87 desipramine hcl tab 50 mg ................ 87 desipramine hcl tab 75 mg ................ 87 desloratadine tab 5 mg .................... 189 desloratadine tab orally disintegrating

247

2.5 mg ......................................... 189 desloratadine tab orally disintegrating 5 mg ............................................... 189 desmopressin acetate inj 4 mcg/ml ... 139 desmopressin acetate nasal soln 0.01% (refrigerated) ................................. 139 desmopressin acetate nasal spray soln 0.01% .......................................... 139 desmopressin acetate nasal spray soln 0.01% (refrigerated) ...................... 139 desmopressin acetate tab 0.1 mg ..... 139 desmopressin acetate tab 0.2 mg ..... 139 DESOGEN-28 TAB .......................... 126 DESONATE GEL 0.05% .................... 207 desonide cream 0.05% ................... 207 desonide lotion 0.05% .................... 207 desonide oint 0.05% ....................... 207 DESOWEN CRE 0.05% .................... 207 DESOWEN LOT 0.05% .................... 207 desoximetasone cream 0.05% ......... 208 desoximetasone cream 0.25% ......... 206 desoximetasone gel 0.05% .............. 206 desoximetasone oint 0.05% ............. 208 desoximetasone oint 0.25% ............. 206 DESVENLAFAX TAB 100MG ER ............ 83 DESVENLAFAX TAB 50MG ER ............. 83 desvenlafaxine succinate tab er 24hr 100 mg (base equiv) ............................... 83 desvenlafaxine succinate tab er 24hr 25 mg (base equiv) ............................... 83 desvenlafaxine succinate tab er 24hr 50 mg (base equiv) ............................... 83 desvenlafaxine tab er 24hr 100 mg ..... 83 desvenlafaxine tab er 24hr 50 mg ....... 83 DETROL LA CAP 2MG ...................... 154 DETROL LA CAP 4MG ...................... 154 DETROL TAB 1MG ........................... 154 DETROL TAB 2MG ........................... 154 dexamethasone elixir 0.5 mg/5ml ..... 131 dexamethasone sod phosphate preservative free inj 10 mg/ml ......... 131 dexamethasone sodium phosphate inj 10 mg/ml .......................................... 131 dexamethasone sodium phosphate inj 100 mg/10ml ................................. 131 dexamethasone sodium phosphate inj 120 mg/30ml ................................. 131 dexamethasone sodium phosphate inj 20

mg/5ml ......................................... 131 dexamethasone sodium phosphate inj 4 mg/ml .......................................... 131 dexamethasone sodium phosphate ophth soln 0.1% ...................................... 217 dexamethasone soln 0.5 mg/5ml ...... 131 dexamethasone tab 0.5 mg .............. 131 dexamethasone tab 0.75 mg ............ 131 dexamethasone tab 1 mg ................ 131 dexamethasone tab 1.5 mg .............. 131 dexamethasone tab 2 mg ................ 131 dexamethasone tab 4 mg ................ 131 dexamethasone tab 6 mg ................ 131 DEXEDRINE CAP 10MG CR ................ 99 DEXEDRINE CAP 15MG CR ................ 99 DEXEDRINE CAP 5MG CR .................. 99 DEXILANT CAP 30MG DR ................. 149 DEXILANT CAP 60MG DR ................. 149 dexmedetomidine hcl inj 200 mcg/2ml (for iv infusion) .............................. 105 dexmethylphenidate hcl cap er 24 hr 10 mg ................................................ 99 dexmethylphenidate hcl cap er 24 hr 15 mg ................................................ 99 dexmethylphenidate hcl cap er 24 hr 20 mg ................................................ 99 dexmethylphenidate hcl cap er 24 hr 25 mg ................................................ 99 dexmethylphenidate hcl cap er 24 hr 30 mg ................................................ 99 dexmethylphenidate hcl cap er 24 hr 35 mg ................................................ 99 dexmethylphenidate hcl cap er 24 hr 40 mg ................................................ 99 dexmethylphenidate hcl cap er 24 hr 5 mg ................................................ 99 dexmethylphenidate hcl tab 10 mg .... 99 dexmethylphenidate hcl tab 2.5 mg ... 99 dexmethylphenidate hcl tab 5 mg ...... 99 DEXPAK PAK 10 DAY ....................... 131 DEXPAK PAK 13 DAY ....................... 131 DEXPAK PAK 6 DAY ......................... 131 dexrazoxane for inj 250 mg .............. 42 dexrazoxane for inj 500 mg .............. 42 dextroamphetamine sulfate cap er 24hr 10 mg ............................................ 99 dextroamphetamine sulfate cap er 24hr 15 mg ............................................ 99

248

dextroamphetamine sulfate cap er 24hr 5 mg ................................................. 99 dextroamphetamine sulfate oral solution 5 mg/5ml ...................................... 100 dextroamphetamine sulfate tab 10 mg ................................................... 100 dextroamphetamine sulfate tab 5 mg 100 dextrose 10% w/ sodium chloride 0.45% ................................................... 174 dextrose 2.5% w/ sodium chloride 0.45% .......................................... 173 dextrose 5% in lactated ringers ........ 173 dextrose 5% w/ sodium chloride 0.2% ................................................... 173 dextrose 5% w/ sodium chloride 0.225% ................................................... 174 dextrose 5% w/ sodium chloride 0.33% ................................................... 173 dextrose 5% w/ sodium chloride 0.45% ................................................... 173 dextrose 5% w/ sodium chloride 0.9% ................................................... 173 dextrose inj 10% ............................ 173 DEXTROSE INJ 20% ....................... 173 dextrose inj 25% ............................ 173 dextrose inj 30% ............................ 173 DEXTROSE INJ 40% ....................... 173 dextrose inj 5% ............................. 173 dextrose inj 50% ............................ 173 dextrose inj 70% ............................ 173 DIAB CRE ...................................... 214 diabet tuss syp allergy .................... 189 DIABETIC CAP VITAMIN .................. 179 DIALYVITE TAB 3000 ...................... 179 DIALYVITE TAB 800/IRON ............... 179 DIAMOX SEQUE CAP 500MG CR ........ 219 diaper rash cre 10% ....................... 211 diaper rash cre 13% ....................... 211 diaper rash oin 40% ....................... 211 diaper rash oin creamy ................... 212 DIASTAT ACDL GEL 12.5-20 .............. 75 DIASTAT ACDL GEL 5-10MG .............. 75 DIASTAT PED GEL 2.5M GEL .............. 75 DIASTIX TES STRIPS ...................... 121 diazepam con 5mg/ml ....................... 73 DIAZEPAM INJ 10MG/2ML .................. 73 diazepam inj 5 mg/ml ....................... 73 diazepam oral soln 1 mg/ml ............... 73

diazepam rectal gel delivery system 10 mg ................................................ 75 diazepam rectal gel delivery system 2.5 mg ................................................ 75 diazepam rectal gel delivery system 20 mg ................................................ 75 diazepam tab 10 mg ........................ 73 diazepam tab 2 mg .......................... 73 diazepam tab 5 mg .......................... 73 dibromm chld liq 2.5-1-5 ................. 190 DICLEGIS TAB 10-10MG .................. 141 diclofenac potassium tab 50 mg ........... 2 diclofenac sodium (actinic keratoses) gel 3% ............................................... 202 diclofenac sodium gel 1% ................... 5 diclofenac sodium ophth soln 0.1% ... 217 diclofenac sodium soln 1.5% ............... 5 diclofenac sodium tab delayed release 25 mg .................................................. 2 diclofenac sodium tab delayed release 50 mg .................................................. 3 diclofenac sodium tab delayed release 75 mg .................................................. 3 diclofenac sodium tab er 24hr 100 mg .. 3 diclofenac w/ misoprostol tab delayed release 50-0.2 mg ............................. 5 diclofenac w/ misoprostol tab delayed release 75-0.2 mg ............................. 5 dicloxacillin sodium cap 250 mg ......... 23 dicloxacillin sodium cap 500 mg ......... 23 dicyclomine hcl cap 10 mg ............... 142 dicyclomine hcl inj 10 mg/ml ............ 142 dicyclomine hcl oral soln 10 mg/5ml .. 142 dicyclomine hcl tab 20 mg ............... 142 DI-DAK-SOL SOL 0.0125% .............. 205 didanosine delayed release capsule 125 mg ................................................ 30 didanosine delayed release capsule 200 mg ................................................ 30 didanosine delayed release capsule 250 mg ................................................ 30 didanosine delayed release capsule 400 mg ................................................ 30 DIFFERIN CRE 0.1% ....................... 200 DIFFERIN GEL 0.1% ........................ 200 DIFFERIN GEL 0.3% ........................ 200 DIFFERIN LOT 0.1% ........................ 200 DIFICID TAB 200MG ........................ 20

249

diflorasone diacetate cream 0.05% ... 206 diflorasone diacetate oint 0.05% ...... 209 DIFLUCAN SUS 10MG/ML .................. 26 DIFLUCAN SUS 40MG/ML .................. 26 DIFLUCAN TAB 100MG ...................... 26 DIFLUCAN TAB 150MG ...................... 26 DIFLUCAN TAB 200MG ...................... 26 DIFLUCAN TAB 50MG ........................ 26 diflunisal tab 500 mg ......................... 3 DI-GEL SUS ................................... 140 digestive chw advantag ................... 147 DIGIFAB INJ 40MG ......................... 123 digitek tab 0.125mg ......................... 65 digitek tab 0.25mg ........................... 65 digoxin inj 0.25 mg/ml ...................... 65 digoxin oral soln 0.05 mg/ml ............. 65 dihydroergotamine mesylate inj 1 mg/ml ................................................... 106 dihydroergotamine mesylate nasal spray 4 mg/ml ........................................ 106 DILANTIN CAP 100MG ....................... 75 DILANTIN CAP 30MG ........................ 75 DILANTIN CHW 50MG ....................... 75 DILANTIN-125 SUS 125/5ML ............. 75 DILATRATE SR CAP 40MG .................. 69 DILAUDID LIQ 1MG/ML ...................... 7 DILAUDID TAB 2MG ........................... 7 DILAUDID TAB 4MG ........................... 7 DILAUDID TAB 8MG ........................... 7 diltiazem cap 240mg cd .................... 64 diltiazem cap 300mg cd .................... 64 diltiazem hcl cap er 12hr 120 mg ........ 64 diltiazem hcl cap er 12hr 60 mg ......... 64 diltiazem hcl cap er 12hr 90 mg ......... 64 diltiazem hcl cap er 24hr 120 mg ........ 64 diltiazem hcl cap er 24hr 180 mg ........ 64 diltiazem hcl cap er 24hr 240 mg ........ 64 diltiazem hcl coated beads cap er 24hr 120 mg ........................................... 64 diltiazem hcl coated beads cap er 24hr 180 mg ........................................... 64 diltiazem hcl coated beads cap er 24hr 360 mg ........................................... 64 diltiazem hcl extended release beads cap er 24hr 120 mg ................................ 64 diltiazem hcl extended release beads cap er 24hr 180 mg ................................ 64 diltiazem hcl extended release beads cap

er 24hr 240 mg ............................... 64 diltiazem hcl extended release beads cap er 24hr 300 mg ............................... 64 diltiazem hcl extended release beads cap er 24hr 360 mg ............................... 64 diltiazem hcl extended release beads cap er 24hr 420 mg ............................... 64 diltiazem hcl iv soln 125 mg/25ml (5 mg/ml) .......................................... 64 diltiazem hcl iv soln 25 mg/5ml (5 mg/ml) .......................................... 64 diltiazem hcl iv soln 50 mg/10ml (5 mg/ml) .......................................... 64 diltiazem hcl tab 120 mg .................. 65 diltiazem hcl tab 30 mg .................... 65 diltiazem hcl tab 60 mg .................... 65 diltiazem hcl tab 90 mg .................... 65 DILTIAZEM INJ 100MG ..................... 65 DIOVAN HCT TAB 160-12.5 ............... 52 DIOVAN HCT TAB 160-25MG ............. 52 DIOVAN HCT TAB 320-12.5 ............... 52 DIOVAN HCT TAB 320-25MG ............. 52 DIOVAN HCT TAB 80/12.5 ................ 52 DIOVAN TAB 160MG ........................ 54 DIOVAN TAB 320MG ........................ 54 DIOVAN TAB 40MG .......................... 54 DIOVAN TAB 80MG .......................... 54 DIPENTUM CAP 250MG .................... 144 diphenhydramine hcl (sleep) tab 50 mg .................................................... 105 diphenhydramine hcl cap 50 mg ....... 189 diphenhydramine hcl elixir 12.5 mg/5ml .................................................... 189 diphenhydramine hcl inj 50 mg/ml .... 189 diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml ......................................... 140 diphenoxylate w/ atropine tab 2.5-0.025 mg ............................................... 140 DIPROLENE AF CRE 0.05% .............. 206 DIPROLENE LOT 0.05% ................... 207 DIPROLENE OIN 0.05% ................... 209 dipyridamole tab 25 mg ................... 163 dipyridamole tab 50 mg ................... 163 dipyridamole tab 75 mg ................... 163 DISCOVISC SOL ............................. 220 disopyramide phosphate cap 100 mg .. 55 disopyramide phosphate cap 150 mg .. 55 disulfiram tab 250 mg ..................... 112

250

disulfiram tab 500 mg ..................... 112 DITROPAN XL TAB 10MG ................. 154 DITROPAN XL TAB 15MG ................. 154 DITROPAN XL TAB 5MG ................... 154 DIURIL SUS 250/5ML ........................ 66 divalproex sodium cap delayed release sprinkle 125 mg ............................... 75 divalproex sodium tab delayed release 125 mg ........................................... 75 divalproex sodium tab delayed release 250 mg ........................................... 75 divalproex sodium tab delayed release 500 mg ........................................... 75 divalproex sodium tab er 24 hr 250 mg ..................................................... 75 divalproex sodium tab er 24 hr 500 mg ..................................................... 75 DIVIGEL GEL 0.25MG ...................... 129 DIVIGEL GEL 0.5MG ....................... 129 DIVIGEL GEL 1MG/GM .................... 129 DIVISTA CAP ................................. 176 dobutamine hcl inj 12.5 mg/ml........... 71 dobutamine inj 1 mg/ml in d5w .......... 71 dobutamine inj 2 mg/ml in d5w .......... 71 dobutamine inj 4 mg/ml in d5w .......... 71 docetaxel for inj conc 20 mg/ml ......... 42 docetaxel for inj conc 80 mg/4ml (20 mg/ml) ........................................... 42 DOCETAXEL INJ 140/7ML .................. 43 DOCETAXEL INJ 160/16ML ................. 43 DOCETAXEL INJ 160/8ML .................. 43 DOCETAXEL INJ 20/0.5ML ................. 42 DOCETAXEL INJ 200MG/20 ................ 43 DOCETAXEL INJ 20MG/2ML ................ 42 DOCETAXEL INJ 80MG/2ML ................ 42 DOCETAXEL INJ 80MG/8ML ................ 43 DOCETAXEL INJ NON-ALCO ............... 43 docusate cal cap 240mg .................. 145 docusate sodium liquid 150 mg/15ml 145 docusate sodium syrup 60 mg/15ml .. 145 dofetilide cap 125 mcg (0.125 mg) ..... 55 dofetilide cap 250 mcg (0.25 mg) ....... 55 dofetilide cap 500 mcg (0.5 mg) ......... 55 DOLOPHINE TAB 10MG ...................... 7 DOLOPHINE TAB 5MG ........................ 7 donepezil hydrochloride orally disintegrating tab 10 mg ................... 80 donepezil hydrochloride orally

disintegrating tab 5 mg .................... 80 donepezil hydrochloride tab 10 mg ..... 80 donepezil hydrochloride tab 23 mg ..... 80 donepezil hydrochloride tab 5 mg ...... 80 dopamine hcl inj 160 mg/ml .............. 71 dopamine hcl inj 40 mg/ml ............... 71 dopamine hcl inj 80 mg/ml ............... 71 dopamine inj 0.8 mg/ml in d5w ......... 71 dopamine inj 1.6 mg/ml in d5w ......... 71 dopamine inj 3.2 mg/ml in d5w ......... 72 DOPRAM INJ 20MG/ML .................... 108 DORAL TAB 15MG ........................... 103 DORIBAX INJ 250MG ........................ 17 DORIBAX INJ 500MG ........................ 17 DORYX TAB 200MG .......................... 24 DORYX TAB 50MG............................ 24 dorzolamide hcl ophth soln 2% ......... 219 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml ....................... 219 double antib oin ............................. 203 DOUBLE-TUSSN LIQ DM .................. 190 DOVONEX CRE 0.005% ................... 205 doxapram hcl inj 20 mg/ml .............. 108 doxazosin mesylate tab 1 mg ............ 50 doxazosin mesylate tab 2 mg ............ 50 doxazosin mesylate tab 4 mg ............ 50 doxazosin mesylate tab 8 mg ............ 50 doxepin hcl cap 10 mg ..................... 87 doxepin hcl cap 100 mg .................... 87 doxepin hcl cap 150 mg .................... 87 doxepin hcl cap 25 mg ..................... 87 doxepin hcl cap 50 mg ..................... 87 doxepin hcl cap 75 mg ..................... 87 doxepin hcl conc 10 mg/ml ............... 87 doxercalciferol cap 0.5 mcg .............. 134 doxercalciferol cap 1 mcg ................ 134 doxercalciferol cap 2.5 mcg .............. 134 doxorubicin hcl for inj 10 mg ............. 43 doxorubicin hcl for inj 50 mg ............. 43 doxorubicin hcl inj 2 mg/ml ............... 43 doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml ............................ 43 doxy 100 inj 100mg ......................... 24 doxycycline (rosacea) cap delayed release 40 mg ................................ 213 doxycycline hyclate cap 100 mg ........ 24 doxycycline hyclate cap 50 mg .......... 24 doxycycline hyclate tab 100 mg ......... 24

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doxycycline hyclate tab 150 mg .......... 24 doxycycline hyclate tab 20 mg ........... 24 doxycycline hyclate tab 75 mg ........... 24 doxycycline hyclate tab delayed release 100 mg ........................................... 24 doxycycline hyclate tab delayed release 150 mg ........................................... 25 doxycycline hyclate tab delayed release 75 mg ............................................ 24 doxycycline monohydrate cap 100 mg . 25 doxycycline monohydrate cap 150 mg . 25 doxycycline monohydrate cap 50 mg ... 25 doxycycline monohydrate cap 75 mg ... 25 doxycycline monohydrate for susp 25 mg/5ml ........................................... 25 doxycycline monohydrate tab 150 mg . 25 doxycycline monohydrate tab 50 mg ... 25 doxycycline monohydrate tab 75 mg ... 25 DR SMITHS OIN DIAPER .................. 212 dronabinol cap 10 mg ..................... 141 dronabinol cap 2.5 mg .................... 141 dronabinol cap 5 mg ....................... 141 drospirenone-ethinyl estradiol tab 3-0.03 mg ............................................... 126 drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg ...................... 126 drospirenone-ethinyl estrad-levomefolate tab 3-0.03-0.451 mg ...................... 126 DROXIA CAP 200MG ......................... 43 DROXIA CAP 300MG ......................... 43 DROXIA CAP 400MG ......................... 43 DRYSOL SOL 20% .......................... 212 DS PREP PAK PAK 1%-0.13% .............. 5 DUAC GEL 1.2-5% .......................... 200 dual action chw complete ................ 152 DUAVEE TAB 0.45-20 ...................... 128 DUET DHA 400 MIS 25-1-400 .......... 179 DUET DHA MIS BALANCED ............... 179 DUEXIS TAB 800-26.6 ....................... 5 DULERA AER 100-5MCG .................. 198 DULERA AER 200-5MCG .................. 198 duloxetine hcl enteric coated pellets cap 20 mg (base eq) .............................. 83 duloxetine hcl enteric coated pellets cap 30 mg (base eq) .............................. 83 duloxetine hcl enteric coated pellets cap 40 mg (base eq) .............................. 83 duloxetine hcl enteric coated pellets cap

60 mg (base eq) .............................. 83 DUODOTE INJ ................................ 123 duofilm sol 17% ............................. 212 DUOVISC KIT 0.35/0.4 .................... 220 DUOVISC KIT 0.5/0.55 .................... 220 DUPIXENT INJ 300/2ML ................... 206 DURACHOL CAP 1-3775IU................ 176 DURACLON INJ .................................. 2 DURAGESIC DIS 100MCG/H ................ 7 DURAGESIC DIS 12MCG/HR ................ 7 DURAGESIC DIS 25MCG/HR ................ 7 DURAGESIC DIS 50MCG/HR ................ 7 DURAGESIC DIS 75MCG/HR ................ 7 duraxin cap ...................................... 2 DUREZOL EMU 0.05% ..................... 217 DURLAZA CAP 162.5MG ................... 163 dutasteride cap 0.5 mg ................... 152 dutasteride-tamsulosin hcl cap 0.5-0.4 mg ............................................... 152 DUTOPROL TAB 100-12.5 ................. 59 DUTOPROL TAB 25-12.5 ................... 59 DUTOPROL TAB 50-12.5 ................... 59 DUZALLO TAB 200-200 ...................... 1 DUZALLO TAB 200-300 ...................... 1 DYANAVEL XR SUS 2.5MG/ML .......... 100 DYAZIDE CAP 37.5-25 ...................... 66 DYLOJECT INJ 37.5MG/M .................... 3 DYMISTA SPR 137-50 ...................... 196 DYRENIUM CAP 100MG ..................... 66 DYRENIUM CAP 50MG ...................... 66 E e.e.s. 400 tab 400mg ....................... 20 easygel gel 0.4%citr ....................... 215 EC-NAPROSYN TAB 375MG ................. 3 EC-NAPROSYN TAB 500MG ................. 3 econazole nitrate cream 1% ............. 204 ECOZA AER 1% .............................. 204 ED BRON GP LIQ ............................ 190 ED CHLORPED LIQ 2MG/ML .............. 189 EDARBI TAB 40MG ........................... 54 EDARBI TAB 80MG ........................... 54 EDARBYCLOR TAB 40-12.5 ................ 52 EDARBYCLOR TAB 40-25MG .............. 52 EDECRIN TAB 25MG ......................... 66 EDLUAR SUB 10MG ......................... 105 EDLUAR SUB 5MG........................... 105 EDURANT TAB 25MG ........................ 29 EFFER-K TAB 10MEQ ....................... 172

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EFFER-K TAB 20MEQ ....................... 172 EFFEXOR XR CAP 150MG ................... 83 EFFEXOR XR CAP 37.5MG .................. 83 EFFEXOR XR CAP 75MG ..................... 83 EFFIENT TAB 10MG......................... 163 EFFIENT TAB 5MG .......................... 163 EFUDEX CRE 5% ............................ 202 EGRIFTA SOL 1MG .......................... 135 EGRIFTA SOL 2MG .......................... 135 ELAPRASE INJ 6MG/3ML .................. 134 ELDEPRYL CAP 5MG .......................... 88 ELELYSO INJ 200UNIT ..................... 134 ELESTAT DRO 0.05% ...................... 218 ELESTRIN GEL 0.06% ..................... 129 eletriptan hydrobromide tab 20 mg (base equivalent) .................................... 106 eletriptan hydrobromide tab 40 mg (base equivalent) .................................... 106 ELFOLATE TAB 15MG ...................... 171 ELFOLATE TAB 7.5MG ..................... 171 ELFOLATE TAB PLUS ....................... 171 ELIDEL CRE 1% ............................. 206 ELIGARD INJ 22.5MG ........................ 39 ELIMITE CRE 5% ............................ 213 ELIQUIS TAB 2.5MG ....................... 157 ELIQUIS TAB 5MG .......................... 157 ELITEK INJ 1.5MG ............................ 43 ELITEK INJ 7.5MG ............................ 43 elite-ob tab ................................... 179 ELIXOPHYLLIN ELX 80/15ML ............ 198 ELLA TAB 30MG ............................. 125 ELLENCE INJ 2MG/ML ....................... 43 ELLIOTTS B INJ .............................. 174 ELMIRON CAP 100MG ..................... 153 ELOCON CRE 0.1% ......................... 208 ELOCON LOT 0.1% ......................... 208 ELOCON OIN 0.1% ......................... 208 ELOCTATE INJ 1000UNIT ................. 158 ELOCTATE INJ 1500UNIT ................. 158 ELOCTATE INJ 2000UNIT ................. 158 ELOCTATE INJ 250UNIT .................. 158 ELOCTATE INJ 3000UNIT ................. 158 ELOCTATE INJ 4000UNIT ................. 158 ELOCTATE INJ 5000UNIT ................. 158 ELOCTATE INJ 500UNIT .................. 158 ELOCTATE INJ 6000UNIT ................. 158 ELOCTATE INJ 750UNIT .................. 158 EMADINE SOL 0.05% OP ................. 218

EMBEDA CAP 100-4MG ....................... 8 EMBEDA CAP 20-0.8MG ...................... 7 EMBEDA CAP 30-1.2MG ...................... 7 EMBEDA CAP 50-2MG ......................... 7 EMBEDA CAP 60-2.4MG ...................... 7 EMBEDA CAP 80-3.2MG ...................... 8 EMCYT CAP 140MG .......................... 37 EMEND CAP 125MG ......................... 141 EMEND CAP 40MG .......................... 141 EMEND CAP 80MG .......................... 141 EMEND SOL 150MG ........................ 141 EMEND SUS 125MG ........................ 141 EMEND TRIPAC PAK 80 & 125 .......... 141 EMFLAZA TAB 18MG ....................... 131 EMFLAZA TAB 30MG ....................... 131 EMFLAZA TAB 36MG ....................... 131 EMFLAZA TAB 6MG ......................... 131 EMPLICITI INJ 300MG ...................... 43 EMPLICITI INJ 400MG ...................... 43 EMSAM DIS 12MG/24H ..................... 82 EMSAM DIS 6MG/24HR..................... 82 EMSAM DIS 9MG/24HR..................... 82 EMTRIVA CAP 200MG ....................... 30 EMTRIVA SOL 10MG/ML.................... 30 EMULSION SB EMU ......................... 212 ENABLEX TAB 15MG ........................ 154 ENABLEX TAB 7.5MG ....................... 154 enalapril maleate & hydrochlorothiazide tab 10-25 mg .................................. 47 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg ................................. 47 enalapril maleate tab 10 mg .............. 48 enalapril maleate tab 2.5 mg ............. 48 enalapril maleate tab 20 mg .............. 48 enalapril maleate tab 5 mg ............... 48 enalaprilat iv inj 1.25 mg/ml ............. 48 ENBRACE HR CAP ........................... 179 ENBREL INJ 25/0.5ML ..................... 164 ENBREL INJ 25MG .......................... 164 ENBREL INJ 50MG/ML ..................... 164 ENBREL SRCLK INJ 50MG/ML ........... 164 ENDO AVITENE MIS 5MM DIA ........... 161 ENDO DERMAL MIS 10X12.7 ............ 214 ENDO DERMAL MIS 5X5 CM ............. 214 endocet tab 2.5-325 .......................... 8 ENEMEEZ MINI ENE ........................ 145 ENLON INJ 150/15ML ...................... 111 enoxaparin sodium inj 100 mg/ml ..... 155

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enoxaparin sodium inj 120 mg/0.8ml 155 enoxaparin sodium inj 150 mg/ml..... 155 enoxaparin sodium inj 30 mg/0.3ml .. 155 enoxaparin sodium inj 300 mg/3ml ... 155 enoxaparin sodium inj 40 mg/0.4ml .. 155 enoxaparin sodium inj 60 mg/0.6ml .. 155 enoxaparin sodium inj 80 mg/0.8ml .. 155 enpresse-28 tab ............................. 127 ENSTILAR AER ............................... 205 entacapone tab 200 mg .................... 88 entecavir tab 0.5 mg ........................ 32 entecavir tab 1 mg ........................... 32 ENTEREG CAP 12MG ....................... 147 ENTEX T TAB 60-375MG .................. 190 entre-b sus 6-10mg/5 ..................... 188 ENTRESTO TAB 24-26MG .................. 67 ENTRESTO TAB 49-51MG .................. 67 ENTRESTO TAB 97-103MG ................. 67 enulose sol 10gm/15 ...................... 147 ENVARSUS XR TAB 0.75MG ............. 168 ENVARSUS XR TAB 1MG .................. 168 ENVARSUS XR TAB 4MG .................. 168 EPANED SOL 1MG/ML ....................... 48 EPCLUSA TAB 400-100 ...................... 32 ephedrine sulfate inj 50 mg/ml ........... 72 EPIDUO FORTE GEL 0.3-2.5% .......... 200 EPIDUO GEL 0.1-2.5% .................... 200 EPIFOAM AER 1% ........................... 151 epinastine hcl ophth soln 0.05% ....... 218 epinephrine hcl inj 1 mg/ml ............. 187 epinephrine hcl soln prefilled syringe 0.1 mg/ml .......................................... 187 EPINEPHRINE INJ 1MG/ML ................. 72 epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000) ....................... 187 epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) ........................ 187 EPIPEN 2-PAK INJ 0.3MG ................. 187 EPIPEN-JR INJ 2-PAK ...................... 187 epirubicin hcl iv soln 200 mg/100ml (2 mg/ml) ........................................... 43 epirubicin hcl iv soln 50 mg/25ml (2 mg/ml) ........................................... 43 EPISIL LIQ .................................... 216 EPISNAP KIT .................................. 187 EPIVIR HBV SOL 5MG/ML .................. 32 EPIVIR HBV TAB 100MG .................... 32 EPIVIR TAB 150MG ........................... 30

EPIVIR TAB 300MG .......................... 30 eplerenone tab 25 mg ...................... 50 eplerenone tab 50 mg ...................... 50 EPOGEN INJ 10000/ML .................... 160 EPOGEN INJ 2000/ML ...................... 160 EPOGEN INJ 20000/ML .................... 160 EPOGEN INJ 3000/ML ...................... 160 EPOGEN INJ 4000/ML ...................... 160 epoprostenol sodium for inj 0.5 mg .... 71 epoprostenol sodium for inj 1.5 mg .... 71 eprosartan mesylate tab 600 mg ....... 54 epsom salt gra ............................... 145 eptifibatide iv soln 20 mg/10ml (2 mg/ml) ......................................... 163 eptifibatide iv soln 200 mg/100ml (2 mg/ml) ......................................... 163 eptifibatide iv soln 75 mg/100ml (0.75 mg/ml) ......................................... 163 eq aspirin tab 500mg ec .................. 163 eq gentle dro 0.3% ......................... 220 eql acetamin tab 160mg ..................... 1 EQL CALCIUM CAP VIT D ................. 179 eql castor oil 100% ......................... 145 eql lice kit solution .......................... 213 EQUALACTIN CHW 625MG ............... 145 EQUETRO CAP 100MG ..................... 108 EQUETRO CAP 200MG ..................... 108 EQUETRO CAP 300MG ..................... 108 ERAXIS INJ 100MG .......................... 26 ERAXIS INJ 50MG ............................ 26 ERBITUX INJ 100MG ........................ 43 ERBITUX INJ 200MG ........................ 43 ergocalciferol cap 50000 unit ........... 179 ERGOMAR SUB 2MG ........................ 106 ERIVEDGE CAP 150MG ..................... 43 ERTACZO CRE 2% .......................... 204 ery pad 2% ................................... 200 ERYPED SUS 400/5ML ...................... 21 ery-tab tab 250mg ec ...................... 20 ery-tab tab 333mg ec ...................... 21 ery-tab tab 500mg ec ...................... 21 ERYTHROCIN INJ 500MG .................. 21 erythrocin tab 250mg ....................... 21 ERYTHROMYCIN ETHYLSUCCINATE FOR SUSP 200 MG/5ML ........................... 21 erythromycin gel 2% ....................... 201 erythromycin soln 2% ..................... 201 erythromycin tab 250 mg ................. 21

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erythromycin tab 500 mg .................. 21 erythromycin w/ delayed release particles cap 250 mg ........................ 21 ESBRIET CAP 267MG ...................... 197 ESBRIET TAB 801MG ...................... 197 escitalopram oxalate soln 5 mg/5ml (base equiv) .................................... 85 escitalopram oxalate tab 10 mg (base equiv) ............................................. 85 escitalopram oxalate tab 20 mg (base equiv) ............................................. 85 escitalopram oxalate tab 5 mg (base equiv) ............................................. 85 ESGIC TAB ....................................... 2 esmolol hcl inj 100 mg/10ml .............. 60 esomeprazole magnesium cap delayed release 20 mg (base eq) ................. 149 esomeprazole magnesium cap delayed release 40 mg (base eq) ................. 149 esomeprazole sodium for intravenous soln 20 mg (base equiv) .................. 149 esomeprazole sodium for intravenous soln 40 mg (base equiv) .................. 149 essent one tab daily ........................ 179 estazolam tab 1 mg ........................ 103 estazolam tab 2 mg ........................ 103 ESTRACE TAB 0.5MG ...................... 129 ESTRACE TAB 1MG ......................... 129 ESTRACE TAB 2MG ......................... 129 ESTRACE VAG CRE 0.01% ............... 130 estradiol & norethindrone acetate tab 0.5-0.1 mg .................................... 128 estradiol & norethindrone acetate tab 1-0.5 mg ......................................... 128 estradiol tab 0.5 mg ....................... 129 estradiol tab 1 mg .......................... 129 estradiol tab 2 mg .......................... 129 estradiol td patch twice weekly 0.025 mg/24hr ....................................... 130 estradiol td patch twice weekly 0.0375 mg/24hr ....................................... 130 estradiol td patch twice weekly 0.05 mg/24hr ....................................... 130 estradiol td patch twice weekly 0.075 mg/24hr ....................................... 130 estradiol td patch twice weekly 0.1 mg/24hr ....................................... 129 estradiol td patch weekly 0.025 mg/24hr

.................................................... 130 estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) ............... 130 estradiol td patch weekly 0.05 mg/24hr .................................................... 130 estradiol td patch weekly 0.06 mg/24hr .................................................... 130 estradiol td patch weekly 0.075 mg/24hr .................................................... 130 estradiol td patch weekly 0.1 mg/24hr .................................................... 130 estradiol valerate im in oil 20 mg/ml . 129 estradiol valerate im in oil 40 mg/ml . 129 ESTRING MIS 2MG .......................... 130 estro supprt tab es ......................... 171 ESTROGEL GEL .............................. 130 estropipate tab 0.75 mg .................. 129 estropipate tab 1.5 mg .................... 129 estropipate tab 3 mg ....................... 129 ESTROSTEP FE TAB ......................... 128 eszopiclone tab 1 mg ...................... 105 eszopiclone tab 2 mg ...................... 105 eszopiclone tab 3 mg ...................... 105 ethacrynate sodium for inj 50 mg ...... 66 ethacrynic acid tab 25 mg ................. 66 ethambutol hcl tab 100 mg ............... 31 ethambutol hcl tab 400 mg ............... 31 ETHAMOLIN INJ 5% ......................... 68 ethosuximide cap 250 mg ................. 75 ethosuximide soln 250 mg/5ml .......... 75 ETHYOL INJ 500MG .......................... 43 etidronate disodium tab 200 mg ....... 124 etidronate disodium tab 400 mg ....... 124 etodolac cap 200 mg .......................... 3 etodolac cap 300 mg .......................... 3 etodolac tab 400 mg .......................... 3 etodolac tab 500 mg .......................... 3 etodolac tab er 24hr 400 mg ............... 3 etodolac tab er 24hr 500 mg ............... 3 etodolac tab er 24hr 600 mg ............... 3 etoposide cap 50 mg ........................ 43 etoposide inj 1 gm/50ml (20 mg/ml) .. 43 etoposide inj 100 mg/5ml (20 mg/ml) 43 etoposide inj 500 mg/25ml (20 mg/ml) ..................................................... 43 EUCRISA OIN 2% ........................... 202 EUFLEXXA INJ 10MG/ML ................... 16 EURAX CRE 10% ............................ 213

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EURAX LOT 10% ............................ 213 EVAC POW .................................... 145 EVAMIST SPR 1.53MG ..................... 130 EVEKEO TAB 10MG ......................... 100 EVEKEO TAB 5MG ........................... 100 EVICEL KIT 2ML ............................. 161 EVISTA TAB 60MG .......................... 137 EVOCLIN AER 1% ........................... 201 EVOTAZ TAB 300-150 ....................... 27 EVOXAC CAP 30MG ......................... 151 EVZIO INJ ..................................... 112 EXALGO TAB 12MG ............................ 8 EXALGO TAB 16MG ............................ 8 EXALGO TAB 32MG ............................ 8 EXALGO TAB 8MG ............................. 8 EXELDERM CRE 1% ........................ 204 EXELDERM SOL 1% ........................ 204 EXELON CAP 1.5MG .......................... 80 EXELON CAP 3MG ............................. 80 EXELON CAP 4.5MG .......................... 80 EXELON CAP 6MG ............................. 80 EXELON DIS 13.3/24 ........................ 81 EXELON DIS 4.6MG/24...................... 80 EXELON DIS 9.5MG/24...................... 80 exemestane tab 25 mg ..................... 39 EXFORGE TAB 10-160MG .................. 51 EXFORGE TAB 10-320MG .................. 51 EXFORGE TAB 5-160MG .................... 51 EXFORGE TAB 5-320MG .................... 51 EXFORGEH/10- TAB 160-12.5 ............ 52 EXFORGEH/10- TAB 160-25 ............... 52 EXFORGEH/10- TAB 320-25 ............... 52 EXFORGEH/5- TAB 160-12.5 .............. 51 EXFORGEH/5- TAB 160-25 ................. 52 EXJADE TAB 125MG ........................ 162 EXJADE TAB 250MG ........................ 162 EXJADE TAB 500MG ........................ 162 EXODERM LOT 25-1% ..................... 204 EXTAVIA INJ 0.3MG ........................ 109 EXTINA AER 2% ............................. 204 eye drops dro 0.5-0.9% .................. 220 eye drops sol 0.05% op .................. 220 eye drops sol a/r ............................ 220 ezetimibe tab 10 mg ......................... 56 ezetimibe-simvastatin tab 10-10 mg ... 57 ezetimibe-simvastatin tab 10-20 mg ... 57 ezetimibe-simvastatin tab 10-40 mg ... 57 ezetimibe-simvastatin tab 10-80 mg ... 57

ezfe 200 cap 200mg ....................... 179 F FABIOR AER 0.1% .......................... 201 FABRAZYME INJ 35MG..................... 134 FABRAZYME INJ 5MG ...................... 134 FACE MASK MIS EARLOOP ............... 195 FACTIVE TAB 320MG ........................ 21 FALESSA TAB 1MG .......................... 171 famciclovir tab 125 mg ..................... 33 famciclovir tab 250 mg ..................... 33 famciclovir tab 500 mg ..................... 33 famotidine for susp 40 mg/5ml ......... 143 famotidine in nacl 0.9% iv soln 20 mg/50ml ....................................... 143 famotidine inj 20 mg/2ml ................ 143 famotidine inj 200 mg/20ml ............. 144 famotidine inj 40 mg/4ml ................ 144 famotidine inj 500 mg/50ml ............. 144 famotidine tab 20 mg ...................... 144 famotidine tab 40 mg ...................... 144 FAMVIR TAB 125MG ......................... 33 FAMVIR TAB 250MG ......................... 33 FAMVIR TAB 500MG ......................... 33 FANAPT PAK ................................... 91 FANAPT TAB 10MG ........................... 91 FANAPT TAB 12MG ........................... 91 FANAPT TAB 1MG ............................ 91 FANAPT TAB 2MG ............................ 91 FANAPT TAB 4MG ............................ 91 FANAPT TAB 6MG ............................ 91 FANAPT TAB 8MG ............................ 91 FARESTON TAB 60MG ...................... 39 FARXIGA TAB 10MG ........................ 119 FARXIGA TAB 5MG .......................... 119 FARYDAK CAP 10MG ........................ 43 FARYDAK CAP 15MG ........................ 43 FARYDAK CAP 20MG ........................ 43 fayosim tab ................................... 125 FAZACLO TAB 100 ODT .................... 91 FAZACLO TAB 12.5 ODT ................... 91 FAZACLO TAB 150 ODT .................... 91 FAZACLO TAB 200 ODT .................... 91 FAZACLO TAB 25MG ODT .................. 91 fe c plus tab ................................... 179 fe gluconate tab 239mg ................... 179 FE PLUS TAB PROTEIN .................... 179 fe tabs tab 325mg ec ...................... 179 FEIBA INJ ...................................... 158

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felbamate susp 600 mg/5ml .............. 75 felbamate tab 400 mg ....................... 75 felbamate tab 600 mg ....................... 75 FELBATOL SUS 600/5ML .................... 75 FELBATOL TAB 400MG ...................... 75 FELBATOL TAB 600MG ...................... 75 FELDENE CAP 10MG ........................... 3 FELDENE CAP 20MG ........................... 3 felodipine tab er 24hr 10 mg .............. 63 felodipine tab er 24hr 2.5 mg ............. 63 felodipine tab er 24hr 5 mg ............... 63 FEMARA TAB 2.5MG .......................... 39 FEMCAP MIS 22MM ......................... 126 FEMCAP MIS 26MM ......................... 126 FEMCAP MIS 30MM ......................... 126 FEMCON FE CHW ............................ 126 FEMHRT TAB 0.5-2.5 ...................... 128 FEMRING MIS 0.05/24H .................. 130 FEMRING MIS 0.1MG/24 .................. 130 fenofibrate cap 150 mg ..................... 56 fenofibrate cap 50 mg ....................... 56 fenofibrate micronized cap 130 mg ..... 56 fenofibrate micronized cap 134 mg ..... 56 fenofibrate micronized cap 200 mg ..... 56 fenofibrate micronized cap 43 mg ....... 56 fenofibrate micronized cap 67 mg ....... 56 fenofibrate tab 120 mg ..................... 56 fenofibrate tab 145 mg ..................... 56 fenofibrate tab 160 mg ..................... 56 fenofibrate tab 40 mg ....................... 56 fenofibrate tab 48 mg ....................... 56 fenofibrate tab 54 mg ....................... 56 fenofibric acid tab 105 mg ................. 57 fenofibric acid tab 35 mg ................... 56 FENOGLIDE TAB 120MG .................... 57 FENOGLIDE TAB 40MG ...................... 57 fenoldopam mesylate iv inj 10 mg/ml (base equiv) .................................... 68 fenoldopam mesylate iv inj 20 mg/2ml (base equiv) .................................... 68 fenoprofen calcium cap 400 mg ........... 3 fenoprofen calcium tab 600 mg ........... 3 FENORTHO CAP 200MG ...................... 3 fentanyl citrate lozenge on a handle 1200 mcg ................................................ 8 fentanyl citrate lozenge on a handle 1600 mcg ................................................ 8 fentanyl citrate lozenge on a handle 200

mcg ................................................. 8 fentanyl citrate lozenge on a handle 400 mcg ................................................. 8 fentanyl citrate lozenge on a handle 600 mcg ................................................. 8 fentanyl citrate lozenge on a handle 800 mcg ................................................. 8 fentanyl citrate pf soln cartridge 100 mcg/2ml .......................................... 8 fentanyl citrate preservative free (pf) inj 100 mcg/2ml .................................... 8 fentanyl citrate preservative free (pf) inj 1000 mcg/20ml ................................. 8 fentanyl citrate preservative free (pf) inj 250 mcg/5ml .................................... 8 fentanyl citrate preservative free (pf) inj 2500 mcg/50ml ................................. 8 fentanyl citrate preservative free (pf) inj 500 mcg/10ml .................................. 8 FENTANYL DIS 37.5MCG ..................... 8 FENTANYL DIS 62.5MCG ..................... 8 FENTANYL DIS 87.5MCG ..................... 8 fentanyl td patch 72hr 100 mcg/hr ....... 9 fentanyl td patch 72hr 12 mcg/hr ........ 8 fentanyl td patch 72hr 25 mcg/hr ........ 8 fentanyl td patch 72hr 50 mcg/hr ........ 9 fentanyl td patch 72hr 75 mcg/hr ........ 9 FENTORA TAB 100MCG ....................... 9 FENTORA TAB 200MCG ....................... 9 FENTORA TAB 400MCG ....................... 9 FENTORA TAB 600MCG ....................... 9 FENTORA TAB 800MCG ....................... 9 FER-IN-SOL DRO 15MG/ML .............. 179 FERIVA CAP 75-1MG ....................... 179 FERIVAFA CAP 110-1MG .................. 179 ferocon cap .................................... 179 ferrex 150 cap 150mg ..................... 179 ferrex 150 cap forte pl..................... 179 ferrex 28 mis ................................. 179 FERRIMIN 150 TAB ......................... 179 FERRIPROX SOL 100MG/ML ............. 162 FERRIPROX TAB 500MG ................... 162 ferrocite tab 324mg ........................ 179 ferrocite tab plus ............................ 179 FERROUS SULF TAB 140MG ............. 179 ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) ..................... 179 ferrous sulfate tab 325 mg (65 mg

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elemental fe) ................................. 179 ferrous sulfate tab er 142 mg (45 mg fe equivalent) .................................... 179 FETZIMA CAP 120MG ........................ 83 FETZIMA CAP 20MG .......................... 83 FETZIMA CAP 40MG .......................... 83 FETZIMA CAP 80MG .......................... 83 FETZIMA CAP TITRATIO .................... 83 fever reduce sup 120mg ..................... 1 FEVERALL INF SUP 80MG ................... 1 feverall sup 325mg ............................ 1 FEXMID TAB 7.5MG ........................ 110 fexofenadine hcl tab 180 mg ............ 189 fexofenadine hcl tab 60 mg .............. 189 fexofenadine-pseudoephedrine tab er 12hr 60-120 mg ............................. 188 FIBER CHOICE CHW 1.5GM .............. 145 fiber laxatv tab 625mg .................... 145 fiber laxtiv cap 0.52gm ................... 145 fiber select chw gummies ................ 145 FIBRICOR TAB 105MG ....................... 57 FIBRICOR TAB 35MG ........................ 57 FINACEA AER 15% ......................... 213 FINACEA GEL 15% ......................... 213 finasteride tab 5 mg ....................... 152 FIORICET CAP ................................... 2 FIORICET CAP CODEINE ..................... 9 FIORINAL CAP................................... 2 FIORINAL/COD CAP 30MG .................. 9 FIRAZYR INJ 30MG/3ML .................. 162 first aid spr .................................... 210 FLAGYL CAP 375MG .......................... 35 FLAGYL ER TAB 750MG ..................... 35 FLAGYL TAB 250MG .......................... 35 FLAGYL TAB 500MG .......................... 35 FLAREX SUS 0.1% OP ..................... 218 flavoxate hcl tab 100 mg ................. 154 FLEBOGAMMA INJ 10/100ML ............ 166 FLEBOGAMMA INJ 10/200ML ............ 166 FLEBOGAMMA INJ 20/200ML ............ 166 FLEBOGAMMA INJ 20/400ML ............ 166 FLEBOGAMMA INJ 5GM/50ML ........... 166 FLEBOGAMMA INJ DIF 5% ............... 166 flecainide acetate tab 100 mg ............ 55 flecainide acetate tab 150 mg ............ 55 flecainide acetate tab 50 mg .............. 55 FLECTOR DIS 1.3% ........................... 5 FLEET LIQUID ENE GLYCERIN .......... 145

FLEXICHAMBER MIS MASK SM .......... 195 FLINTSTONES CHW COMPLETE ......... 179 FLINTSTONES CHW GUMMIES .......... 180 FLOLAN INJ 0.5MG ........................... 71 FLOLAN INJ 1.5MG ........................... 71 FLOMAX CAP 0.4MG ........................ 152 floranex tab ................................... 147 FLORASTOR CAP 250MG .................. 147 FLORASTOR PAK KIDS .................... 147 FLORICAL CAP ............................... 180 FLORICAL TAB ............................... 180 FLORIVA CHW 0.25MG .................... 180 FLOVENT DISK AER 100MCG ............ 197 FLOVENT DISK AER 250MCG ............ 197 FLOVENT DISK AER 50MCG .............. 197 FLOVENT HFA AER 110MCG ............. 197 FLOVENT HFA AER 220MCG ............. 198 FLOVENT HFA AER 44MCG ............... 197 flucaine sol 0.25-0.5 ....................... 220 fluconazole for susp 10 mg/ml ........... 26 fluconazole for susp 40 mg/ml ........... 26 fluconazole in dextrose inj 200 mg/100ml ...................................... 26 fluconazole in dextrose inj 400 mg/200ml ...................................... 26 fluconazole in nacl 0.9% inj 200 mg/100ml ...................................... 26 fluconazole in nacl 0.9% inj 400 mg/200ml ...................................... 26 fluconazole tab 100 mg .................... 26 fluconazole tab 150 mg .................... 26 fluconazole tab 200 mg .................... 26 fluconazole tab 50 mg ...................... 26 FLUCONAZOLE/ INJ NACL 100 ........... 26 flucytosine cap 250 mg .................... 26 flucytosine cap 500 mg .................... 26 FLUDARA INJ 50MG ......................... 38 fludarabine phosphate for inj 50 mg ... 38 fludarabine phosphate inj 25 mg/ml ... 38 fludrocortisone acetate tab 0.1 mg .... 131 FLUMADINE TAB 100MG ................... 33 flumazenil iv soln 0.5 mg/5ml (0.1 mg/ml) ......................................... 123 flumazenil iv soln 1 mg/10ml (0.1 mg/ml) ......................................... 123 flunisolide nasal soln 25 mcg/act (0.025%) ...................................... 196 fluocinolone acetonide (otic) oil 0.01%

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................................................... 222 fluocinolone acetonide cream 0.01% . 207 fluocinolone acetonide cream 0.025% 208 fluocinolone acetonide oil 0.01% (body oil) ............................................... 207 fluocinolone acetonide oil 0.01% (scalp oil) ............................................... 207 fluocinolone acetonide oint 0.025% ... 208 fluocinolone acetonide soln 0.01% .... 207 fluocinonide cream 0.05% ............... 207 fluocinonide cream 0.1% ................. 207 fluocinonide emulsified base cream 0.05% .......................................... 207 fluocinonide gel 0.05% .................... 207 fluocinonide oint 0.05% .................. 207 fluocinonide soln 0.05% .................. 207 FLUORABON DRO ........................... 180 FLUOR-A-DAY CHW 0.25MG F .......... 180 FLUOR-A-DAY CHW 1MG F ............... 180 fluorid sens pst 1.1-5% ................... 215 fluoridex dd pst sensitiv .................. 215 fluorometholone ophth susp 0.1% .... 218 FLUOROPLEX CRE 1% ..................... 202 fluorouracil cream 5% ..................... 202 fluorouracil inj 1 gm/20ml (50 mg/ml) 38 fluorouracil inj 2.5 gm/50ml (50 mg/ml) ..................................................... 38 fluorouracil inj 5 gm/100ml (50 mg/ml) ..................................................... 38 fluorouracil inj 500 mg/10ml (50 mg/ml) ..................................................... 38 fluorouracil soln 2% ........................ 202 fluorouracil soln 5% ........................ 202 fluoxetine hcl (pmdd) cap 10 mg ........ 85 fluoxetine hcl (pmdd) cap 20 mg ........ 85 fluoxetine hcl cap 10 mg ................... 85 fluoxetine hcl cap 20 mg ................... 85 fluoxetine hcl cap 40 mg ................... 85 fluoxetine hcl cap delayed release 90 mg ..................................................... 85 fluoxetine hcl solution 20 mg/5ml ....... 85 fluoxetine hcl tab 10 mg .................... 85 fluoxetine hcl tab 20 mg .................... 85 FLUOXETINE TAB 60MG..................... 85 fluphenazine decanoate inj 25 mg/ml .. 96 fluphenazine hcl elixir 2.5 mg/5ml ...... 96 fluphenazine hcl inj 2.5 mg/ml ........... 96 fluphenazine hcl oral conc 5 mg/ml ..... 96

fluphenazine hcl tab 1 mg ................. 96 fluphenazine hcl tab 10 mg ............... 96 fluphenazine hcl tab 2.5 mg .............. 96 fluphenazine hcl tab 5 mg ................. 96 flura-drops dro 0.125mg .................. 180 flura-drops dro 0.25mg f ................. 180 flurandrenolide cream 0.05% ........... 208 flurandrenolide lotion 0.05% ............ 208 flurandrenolide oint 0.05% .............. 208 FLURA-SAFE SOL ............................ 220 flurbiprofen sodium ophth soln 0.03% .................................................... 217 flurbiprofen tab 100 mg ...................... 3 flurbiprofen tab 50 mg ....................... 3 flurox sol op .................................. 220 flutamide cap 125 mg ...................... 39 fluticasone propionate cream 0.05% . 208 fluticasone propionate lotion 0.05% .. 208 fluticasone propionate nasal susp 50 mcg/act ........................................ 196 fluticasone propionate oint 0.005% ... 208 fluticasone-salmeterol aer powder ba 113-14 mcg/act ............................. 198 fluticasone-salmeterol aer powder ba 232-14 mcg/act ............................. 198 fluticasone-salmeterol aer powder ba 55-14 mcg/act .................................... 198 fluvastatin sodium cap 20 mg ............ 57 fluvastatin sodium cap 40 mg ............ 57 fluvastatin sodium tab er 24 hr 80 mg 57 fluvoxamine maleate cap er 24hr 100 mg ..................................................... 73 fluvoxamine maleate cap er 24hr 150 mg ..................................................... 73 fluvoxamine maleate tab 100 mg ....... 74 fluvoxamine maleate tab 25 mg ......... 73 fluvoxamine maleate tab 50 mg ......... 73 FML FORTE SUS 0.25% OP .............. 218 FML LIQUIFLM SUS 0.1% OP ............ 218 FML OIN 0.1% OP ........................... 218 foam antacid chw 80-20mg .............. 140 foam antacid sus ............................ 140 FOCALGIN 90 MIS DHA ................... 180 FOCALGIN CA MIS .......................... 180 FOCALGIN DSS TAB 90-1MG ............ 180 FOCALIN TAB 10MG ........................ 100 FOCALIN TAB 2.5MG ....................... 100 FOCALIN TAB 5MG .......................... 100

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FOCALIN XR CAP 10MG ................... 100 FOCALIN XR CAP 15MG ................... 100 FOCALIN XR CAP 20MG ................... 100 FOCALIN XR CAP 25MG ................... 100 FOCALIN XR CAP 30MG ................... 100 FOCALIN XR CAP 35MG ................... 100 FOCALIN XR CAP 40MG ................... 100 FOCALIN XR CAP 5MG ..................... 100 folbee plus tab ............................... 180 FOLCAPS CAP OMEGA 3 .................. 180 FOLET DHA PAK ............................. 180 FOLET ONE CAP 38-1-225 ............... 180 FOLGARD OS TAB ........................... 180 folic acid inj 5 mg/ml ...................... 176 folic acid tab 1 mg .......................... 176 folic acid tab 400 mcg ..................... 176 folic acid tab 800 mcg ..................... 176 FOLOTYN INJ 20MG/ML ..................... 38 FOLOTYN INJ 40MG/2ML ................... 38 fomepizole inj 1 gm/ml (for iv infusion) ................................................... 123 fondaparinux sodium subcutaneous inj 10 mg/0.8ml ................................. 156 fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml ................................ 156 fondaparinux sodium subcutaneous inj 5 mg/0.4ml ...................................... 156 fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml ................................ 156 FORFIVO XL TAB 450MG.................... 82 formaldehyde solution 10% ............. 205 forma-ray sol 20% ......................... 205 FORTAMET TAB 1000MG .................. 114 FORTAMET TAB 500MG ................... 114 FORTAVIT CAP ............................... 180 FORTAZ INJ 1GM .............................. 20 FORTAZ INJ 2GM .............................. 20 FORTAZ INJ 500MG .......................... 20 FORTAZ INJ 6GM .............................. 20 FORTEO SOL 600/2.4 ...................... 125 FORTESTA GEL 10MG/ACT ............... 113 FOSAMAX + D TAB 70-2800 ............ 124 FOSAMAX + D TAB 70-5600 ............ 124 FOSAMAX TAB 70MG ...................... 124 fosamprenavir calcium tab 700 mg (base equiv) ............................................. 28 FOSCAVIR INJ 24MG/ML .................... 31 fosinopril sodium & hydrochlorothiazide

tab 10-12.5 mg ............................... 47 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg ............................... 47 fosinopril sodium tab 10 mg .............. 48 fosinopril sodium tab 20 mg .............. 48 fosinopril sodium tab 40 mg .............. 48 fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv) ............................ 75 fosphenytoin sodium inj 500 mg/10ml (phenytoin equiv) ............................ 75 FOSRENOL CHW 1000MG ................. 136 FOSRENOL CHW 500MG .................. 136 FOSRENOL CHW 750MG .................. 136 FRAGMIN INJ 10000/ML .................. 156 FRAGMIN INJ 12500UNT .................. 156 FRAGMIN INJ 15000UNT .................. 156 FRAGMIN INJ 18000UNT .................. 156 FRAGMIN INJ 2500/0.2 ................... 156 FRAGMIN INJ 5000/0.2 ................... 156 FRAGMIN INJ 7500/0.3 ................... 156 FRAGMIN INJ 95000UNT .................. 156 FREAMINE HBC INJ 6.9% ................. 173 FREAMINE III INJ 10% .................... 173 FREESTYLE KIT FREEDOM ................ 121 FREESTYLE KIT INSULINX ................ 121 FREESTYLE KIT SIDEKICK ................ 121 FREESTYLE KIT SYSTEM .................. 121 FREESTYLE LIQ CONTROL ................ 121 FREESTYLE MIS LITE ....................... 121 FREESTYLE TES .............................. 121 FREESTYLE TES INSULINX ............... 121 FREESTYLE TES LITE ....................... 121 FROVA TAB 2.5MG .......................... 106 frovatriptan succinate tab 2.5 mg (base equivalent) .................................... 106 FUL-GLO TES 0.6MG OP .................. 220 FURADANTIN SUS 25MG/5ML ............ 35 furosemide inj 10 mg/ml .................. 66 furosemide oral soln 10 mg/ml .......... 66 furosemide oral soln 8 mg/ml ............ 66 furosemide tab 20 mg ...................... 66 furosemide tab 40 mg ...................... 66 furosemide tab 80 mg ...................... 66 FUSION PLUS CAP .......................... 180 FUZEON INJ 90MG ........................... 28 fyavolv tab 1-5 ............................... 128 FYCOMPA TAB 10MG ........................ 76 FYCOMPA TAB 12MG ........................ 76

260

FYCOMPA TAB 2MG ........................... 75 FYCOMPA TAB 4MG ........................... 75 FYCOMPA TAB 6MG ........................... 75 FYCOMPA TAB 8MG ........................... 75 G G4 SENSOR MIS ............................. 121 gabapentin cap 100 mg ..................... 76 gabapentin cap 300 mg ..................... 76 gabapentin cap 400 mg ..................... 76 gabapentin oral soln 250 mg/5ml ....... 76 gabapentin tab 600 mg ..................... 76 gabapentin tab 800 mg ..................... 76 GABITRIL TAB 12MG ......................... 76 GABITRIL TAB 16MG ......................... 76 GABITRIL TAB 2MG .......................... 76 GABITRIL TAB 4MG .......................... 76 GABLOFEN INJ 10000/20 ................. 110 GABLOFEN INJ 20000/20 ................. 110 GABLOFEN INJ 40000/20 ................. 110 GABLOFEN INJ 50MCG/ML ............... 110 galantamine hydrobromide cap er 24hr 16 mg ............................................ 81 galantamine hydrobromide cap er 24hr 24 mg ............................................ 81 galantamine hydrobromide cap er 24hr 8 mg ................................................. 81 galantamine hydrobromide oral soln 4 mg/ml ............................................ 81 galantamine hydrobromide tab 12 mg . 81 galantamine hydrobromide tab 4 mg ... 81 galantamine hydrobromide tab 8 mg ... 81 GALZIN CAP 25MG ......................... 180 GALZIN CAP 50MG ......................... 180 GAMASTAN S/D INJ ........................ 166 GAMMAGARD INJ 10GM/100 ............ 166 GAMMAGARD INJ 1GM/10ML ............ 166 GAMMAGARD INJ 2.5GM/25 ............. 166 GAMMAGARD INJ 20GM/200 ............ 166 GAMMAGARD INJ 30GM/300 ............ 166 GAMMAGARD INJ 5GM/50ML ............ 166 GAMMAGARD SD INJ 10GM HU ......... 166 GAMMAGARD SD INJ 5GM HU .......... 166 GAMMAKED INJ 10GM/100 .............. 166 GAMMAKED INJ 1GM/10ML .............. 166 GAMMAKED INJ 2.5GM/25 ............... 166 GAMMAKED INJ 20GM/200 .............. 166 GAMMAKED INJ 5GM/50ML .............. 166 GAMMAPLEX INJ 5% ....................... 166

GAMUNEX-C INJ 10GM/100 .............. 166 GAMUNEX-C INJ 1GM/10ML ............. 166 GAMUNEX-C INJ 2.5GM/25 .............. 166 GAMUNEX-C INJ 20GM/200 .............. 166 GAMUNEX-C INJ 5GM/50ML ............. 166 ganciclovir sodium for inj 500 mg ...... 31 gas relief cap 125mg ....................... 147 gas relief cap 180mg ....................... 147 gas relief chw 80mg ........................ 148 gas relief dro 40/0.6ml .................... 148 gas relief liq infants ........................ 148 GASTROCROM CON 100/5ML ............ 148 GAS-X EX-STR MIS 62.5MG ............. 148 gatifloxacin ophth soln 0.5% ............ 216 GATTEX KIT 5MG ............................ 148 gavilyte-c sol ................................. 145 gavilyte-g sol ................................. 145 gavilyte-h kit ................................. 145 gavilyte-n sol flav pk ....................... 146 GAVISCON CHW ............................. 140 GAVISCON SUS CHERRY .................. 140 GELCLAIR GEL ............................... 215 GELFILM MIS ENVELOPE .................. 161 GELFILM MIS OP............................. 220 GELFOAM MIS DENTAL 4 ................. 161 GELFOAM MIS SPON COM ................ 161 GELFOAM MIS SPONG 50 ................. 161 GELFOAM MIS SPONG200 ................ 161 GELFOAM POW ............................... 161 GEL-KAM CON 0.63% ...................... 215 GELNIQUE GEL 10% ....................... 154 GELUSIL CHW ................................ 140 gemcitabine hcl for inj 1 gm .............. 38 gemcitabine hcl for inj 2 gm .............. 38 gemcitabine hcl for inj 200 mg .......... 38 gemcitabine hcl inj 1 gm/26.3ml (38 mg/ml) (base equiv) ........................ 38 gemcitabine hcl inj 2 gm/52.6ml (38 mg/ml) (base equiv) ........................ 38 gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml) (base equiv) ........................ 38 gemfibrozil tab 600 mg .................... 57 GEMZAR INJ 1GM ............................ 38 GEMZAR INJ 200MG ......................... 38 GENADUR LIQ ................................ 212 GENERESS FE CHW ......................... 126 gengraf cap 50mg .......................... 168 gengraf sol 100mg/ml ..................... 168

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GENOTROPIN INJ 0.2MG ................. 133 GENOTROPIN INJ 0.4MG ................. 133 GENOTROPIN INJ 0.6MG ................. 133 GENOTROPIN INJ 0.8MG ................. 133 GENOTROPIN INJ 1.2MG ................. 133 GENOTROPIN INJ 1.4MG ................. 133 GENOTROPIN INJ 1.6MG ................. 133 GENOTROPIN INJ 1.8MG ................. 133 GENOTROPIN INJ 12MG .................. 133 GENOTROPIN INJ 1MG .................... 133 GENOTROPIN INJ 2MG .................... 133 GENTAM/NACL INJ 0.9MG/ML ............. 17 gentamicin in saline inj 0.8 mg/ml ...... 17 gentamicin in saline inj 1 mg/ml ......... 17 gentamicin in saline inj 1.2 mg/ml ...... 17 gentamicin in saline inj 1.6 mg/ml ...... 17 gentamicin in saline inj 2 mg/ml ......... 17 gentamicin sulfate cream 0.1% ........ 203 gentamicin sulfate inj 10 mg/ml ......... 17 gentamicin sulfate inj 40 mg/ml ......... 17 gentamicin sulfate iv soln 10 mg/ml .... 17 gentamicin sulfate oint 0.1% ........... 203 gentamicin sulfate ophth oint 0.3%... 217 gentamicin sulfate ophth soln 0.3% .. 217 GENTEAL MILD DRO 0.2% ............... 220 GENTIAN VIOL SOL 2% ................... 212 GENTLE-LET MIS PLATFORM ............ 121 GENVISC 850 INJ 25/2.5 ................... 16 GENVOYA TAB ................................. 28 GEODON CAP 20MG .......................... 92 GEODON CAP 40MG .......................... 92 GEODON CAP 60MG .......................... 92 GEODON CAP 80MG .......................... 92 GEODON INJ 20MG ........................... 92 geri-mucil pow 68% ....................... 146 GIAZO TAB 1.1GM .......................... 144 GILENYA CAP 0.5MG ....................... 109 GILOTRIF TAB 20MG ......................... 41 GILOTRIF TAB 30MG ......................... 41 GILOTRIF TAB 40MG ......................... 41 GLASSIA INJ .................................. 195 glatiramer acetate soln prefilled syringe 20 mg/ml ...................................... 109 glatiramer acetate soln prefilled syringe 40 mg/ml ...................................... 109 glatopa inj 20mg/ml ....................... 109 GLENAX PEB LIQ ............................ 188 GLEOSTINE CAP 100MG .................... 37

GLEOSTINE CAP 10MG ..................... 37 GLEOSTINE CAP 40MG ..................... 37 GLEOSTINE CAP 5MG ....................... 37 GLIADEL WAF 7.7MG ....................... 37 glimepiride tab 1 mg ....................... 119 glimepiride tab 2 mg ....................... 119 glimepiride tab 4 mg ....................... 119 glipizide tab 10 mg ......................... 119 glipizide tab 5 mg ........................... 119 glipizide tab er 24hr 10 mg .............. 119 glipizide tab er 24hr 5 mg ................ 119 glipizide xl tab 2.5mg ...................... 120 glipizide-metformin hcl tab 2.5-250 mg .................................................... 114 glipizide-metformin hcl tab 2.5-500 mg .................................................... 114 glipizide-metformin hcl tab 5-500 mg 114 GLUCAGEN INJ 1MG ........................ 133 GLUCAGEN INJ HYPOKIT.................. 133 GLUCAGON KIT 1MG ....................... 133 gluco shot liq ................................. 173 glucose drnk liq 15/59ml ................. 133 glucose gel 40% ............................. 133 GLUMETZA TAB 1000MG .................. 114 GLUMETZA TAB 500MG ................... 114 GLUTARALDEHY SOL 25%................ 205 glyburide micronized tab 1.5 mg ....... 120 glyburide micronized tab 3 mg ......... 120 glyburide micronized tab 6 mg ......... 120 glyburide tab 1.25 mg ..................... 120 glyburide tab 2.5 mg ....................... 120 glyburide tab 5 mg ......................... 120 glyburide-metformin tab 1.25-250 mg .................................................... 114 glyburide-metformin tab 2.5-500 mg . 114 glyburide-metformin tab 5-500 mg ... 114 glycerin ped sup 1.2gm ................... 146 glycerin sup 1gm ............................ 146 glycerin sup 2.1gm ......................... 146 glycerin sup 2gm ............................ 146 glycerin topical liquid ...................... 210 GLYCOPHOS SOL 1MM/ML ............... 175 glycopyrrolate inj 0.2 mg/ml ............ 142 glycopyrrolate inj 0.4 mg/2ml (0.2 mg/ml) ......................................... 143 glycopyrrolate inj 1 mg/5ml (0.2 mg/ml) .................................................... 143 glycopyrrolate inj 4 mg/20ml (0.2

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mg/ml) ......................................... 143 glycopyrrolate tab 1 mg .................. 143 glycopyrrolate tab 2 mg .................. 143 GLYSET TAB 100MG ........................ 114 GLYSET TAB 25MG ......................... 114 GLYSET TAB 50MG ......................... 114 GLYXAMBI TAB 10-5 MG .................. 119 GLYXAMBI TAB 25-5 MG .................. 119 GNP DAY TIME LIQ MUCUS DM ......... 190 gnp glycerin sol rosewatr ................. 210 gnp iron tab 65mg .......................... 180 gnp tussin syp cf ............................ 190 GOLYTELY SOL ............................... 146 GORDONS UREA OIN 22% ............... 210 GORDONS UREA OIN 40% ............... 210 GRALISE STAR MIS 300/600 ............ 112 GRALISE TAB 300MG ...................... 112 GRALISE TAB 600MG ...................... 112 granisetron hcl inj 0.1 mg/ml ........... 141 granisetron hcl inj 1 mg/ml .............. 141 granisetron hcl inj 4 mg/4ml (1 mg/ml) ................................................... 141 granisetron hcl tab 1 mg ................. 141 GRANIX INJ 300/0.5 ....................... 160 GRANIX INJ 480/0.8 ....................... 160 griseofulvin microsize susp 125 mg/5ml ..................................................... 26 griseofulvin microsize tab 500 mg ....... 26 griseofulvin ultramicrosize tab 125 mg 26 griseofulvin ultramicrosize tab 250 mg 26 GRIS-PEG TAB 125MG ...................... 26 GRIS-PEG TAB 250MG ...................... 26 guaiatussin syp 100-10/5 ................ 190 guaifenesin tab er 12hr 1200 mg ...... 194 guanfacine hcl tab 1 mg .................... 50 guanfacine hcl tab 2 mg .................... 50 guanfacine hcl tab er 24hr 1 mg (base equiv) ........................................... 100 guanfacine hcl tab er 24hr 2 mg (base equiv) ........................................... 100 guanfacine hcl tab er 24hr 3 mg (base equiv) ........................................... 100 guanfacine hcl tab er 24hr 4 mg (base equiv) ........................................... 100 GUANIDINE TAB 125MG .................. 108 GUARDIAN RT MIS REPLACE ............ 121 GYNAZOLE-1 CRE 2% ..................... 155

H H.P. ACTHAR INJ 80UNIT ................. 135 HAEGARDA INJ 2000UNIT ................ 162 HAEGARDA INJ 3000UNIT ................ 162 HALAC KIT ..................................... 206 HALAVEN INJ 1MG/2ML .................... 43 HALCION TAB 0.25MG ..................... 103 HALDOL DECAN INJ 100MG/ML .......... 96 HALDOL DECAN INJ 50MG/ML ........... 96 HALDOL INJ 5MG/ML ........................ 96 halobetasol propionate cream 0.05% 209 halobetasol propionate oint 0.05% .... 210 HALOG CRE 0.1% ........................... 207 HALOG OIN 0.1% ........................... 207 haloperidol decanoate im soln 100 mg/ml ..................................................... 96 haloperidol decanoate im soln 50 mg/ml ..................................................... 96 haloperidol lactate inj 5 mg/ml .......... 96 haloperidol lactate oral conc 2 mg/ml . 96 haloperidol tab 0.5 mg ..................... 96 haloperidol tab 1 mg ........................ 96 haloperidol tab 10 mg ...................... 96 haloperidol tab 2 mg ........................ 96 haloperidol tab 20 mg ...................... 96 haloperidol tab 5 mg ........................ 96 HARVONI TAB 90-400MG .................. 32 h-chlor 12 sol 0.125% ..................... 205 healthy kids chw overall .................. 180 heartbrn rel tab 75mg ..................... 144 HECTOROL CAP 0.5MCG .................. 134 HECTOROL CAP 1MCG ..................... 134 HECTOROL CAP 2.5MCG .................. 134 HECTOROL INJ 2MCG/ML ................. 134 HELIXATE FS INJ 1000UNIT ............. 158 HELIXATE FS INJ 2000UNIT ............. 158 HELIXATE FS INJ 250UNIT ............... 158 HELIXATE FS INJ 3000UNIT ............. 158 HELIXATE FS INJ 500UNIT ............... 158 HEMABATE INJ 250MCG .................. 135 HEMANGEOL SOL 4.28/ML ................ 60 hematogen cap .............................. 180 hematogen cap forte ....................... 180 HEMATOGEN FA CAP ....................... 180 HEMATRON-AF TAB ......................... 180 HEMENATAL OB MIS + DHA ............. 180 hemocyte-f tab .............................. 180 HEMOFIL M INJ 1000UNIT................ 158

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HEMOFIL M INJ 1700UNIT ............... 158 HEMOFIL M INJ 250UNIT ................. 158 HEMOFIL M INJ 500UNIT ................. 158 hemorrhoidal sup ........................... 148 hemorrhoidal sup 0.25% ................. 148 HEP SOD/NACL INJ 25000UNT ......... 156 HEPAGAM B INJ ............................. 166 HEPARIN SOD INJ 2000/ML ............. 156 heparin sodium (porcine) inj 1000 unit/ml ......................................... 156 heparin sodium (porcine) inj 10000 unit/ml ......................................... 156 heparin sodium (porcine) inj 20000 unit/ml ......................................... 156 heparin sodium (porcine) inj 5000 unit/ml ......................................... 156 heparin sodium (porcine) pf inj 5000 unit/0.5ml ..................................... 156 hepatamine sol 8% ......................... 173 HEPSERA TAB 10MG ......................... 32 HERCEPTIN INJ 150MG ..................... 43 HERCEPTIN INJ 440MG ..................... 43 HETLIOZ CAP 20MG ........................ 105 HEXALEN CAP 50MG ......................... 37 high power liq body wsh .................. 212 HIPREX TAB 1GM ........................... 153 HIZENTRA INJ 10/50ML ................... 166 HIZENTRA INJ 1GM/5ML .................. 166 HIZENTRA INJ 2GM/10ML ................ 166 HIZENTRA INJ 4GM/20ML ................ 166 HOLD LOZ 5MG ORIG ..................... 192 homatropine hbr ophth soln 5% ....... 221 HONEY BEARS CHW ........................ 180 HONEY BEARS CHW IRON-ZIN ......... 180 HORIZANT TAB 300MG.................... 113 HORIZANT TAB 600MG.................... 113 HPR PLUS CRE ............................... 212 H-TRON PLUS MIS INS PUMP ........... 121 HUBER NEEDLE MIS 20GX1" ............ 169 HUMALOG INJ 100/ML ..................... 117 HUMALOG KWIK INJ 100/ML ............ 117 HUMALOG KWIK INJ 200/ML ............ 117 HUMALOG MIX INJ 50/50 ................ 117 HUMALOG MIX INJ 50/50KWP .......... 117 HUMALOG MIX INJ 75/25KWP .......... 117 HUMALOG MIX SUS 75/25 ............... 117 HUMAPEN MIS LUXURA ................... 121 HUMATE-P SOL 2400UNIT ............... 159

HUMATE-P SOL 250-600 .................. 159 HUMATE-P SOL 500-1200 ................ 159 HUMATROPE INJ 12MG .................... 133 HUMATROPE INJ 24MG .................... 133 HUMATROPE INJ 5MG ...................... 133 HUMATROPE INJ 6MG ...................... 133 HUMIRA INJ 10MG/0.2 .................... 164 HUMIRA KIT 20MG/0.4 .................... 164 HUMIRA KIT 40MG/0.8 .................... 164 HUMIRA PEN INJ 40MG/0.8 .............. 164 HUMULIN INJ 70/30 ........................ 117 HUMULIN INJ 70/30KWP .................. 117 HUMULIN N INJ U-100 ..................... 117 HUMULIN N INJ U-100KWP .............. 117 HUMULIN R INJ U-100 ..................... 117 HUMULIN R INJ U-500 ..................... 117 HYALGAN INJ 20MG/2ML .................. 16 hyaluronate sodium (emollient) gel 0.2% .................................................... 210 HYCET SOL 7.5-325 ........................... 9 HYCOFENIX SOL ............................. 190 hydralazine hcl inj 20 mg/ml ............. 68 hydralazine hcl tab 10 mg ................. 68 hydralazine hcl tab 100 mg ............... 68 hydralazine hcl tab 25 mg ................. 68 hydralazine hcl tab 50 mg ................. 68 HYDREA CAP 500MG ........................ 43 hydrocerin cre plus ......................... 212 hydrochlorothiazide cap 12.5 mg ....... 66 hydrochlorothiazide tab 12.5 mg ........ 66 hydrochlorothiazide tab 25 mg .......... 66 hydrochlorothiazide tab 50 mg .......... 66 HYDROCIL INS POW 95% ................ 146 hydrocod polst-chlorphen polst er susp 10-8 mg/5ml ................................. 190 hydrocodone w/ homatropine syrup 5-1.5 mg/5ml ................................... 190 hydrocodone w/ homatropine tab 5-1.5 mg ............................................... 190 hydrocodone-acetaminophen soln 10-325 mg/15ml .......................................... 9 hydrocodone-acetaminophen soln 7.5-325 mg/15ml .................................... 9 hydrocodone-acetaminophen tab 10-300 mg .................................................. 9 hydrocodone-acetaminophen tab 10-325 mg .................................................. 9 hydrocodone-acetaminophen tab 5-300

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mg .................................................. 9 hydrocodone-acetaminophen tab 5-325 mg .................................................. 9 hydrocodone-acetaminophen tab 7.5-300 mg .................................................. 9 hydrocodone-acetaminophen tab 7.5-325 mg .................................................. 9 hydrocodone-ibuprofen tab 7.5-200 mg 9 hydrocort cre 0.5% ........................ 207 hydrocort oin 0.5% ......................... 207 hydrocortisone acetate w/ pramoxine rectal cream 1-1% ......................... 151 hydrocortisone butyrate cream 0.1% 208 hydrocortisone butyrate hydrophilic lipo base cream 0.1% ........................... 208 hydrocortisone butyrate oint 0.1% .... 208 hydrocortisone butyrate soln 0.1% ... 208 hydrocortisone cream 1% ................ 207 hydrocortisone cream 2.5% ............. 207 hydrocortisone enema 100 mg/60ml . 145 hydrocortisone lotion 2.5% .............. 207 hydrocortisone oint 1% ................... 207 hydrocortisone oint 2.5% ................ 207 hydrocortisone rectal cream 1% ....... 151 hydrocortisone rectal cream 2.5% .... 151 hydrocortisone tab 10 mg ................ 131 hydrocortisone tab 20 mg ................ 131 hydrocortisone tab 5 mg ................. 131 hydrocortisone valerate cream 0.2% . 208 hydrocortisone valerate oint 0.2% .... 208 hydrocortisone w/ acetic acid otic soln 1-2% ............................................... 222 hydrocortisone-aloe vera cream 0.5%206 hydrocortisone-aloe vera cream 1% .. 206 HYDROGEL DRE PAD 2"X3" .............. 214 HYDROGEL DRE PAD 4"X5" .............. 214 hydromorphone hcl inj 1 mg/ml .......... 9 hydromorphone hcl inj 2 mg/ml .......... 9 hydromorphone hcl inj 4 mg/ml .......... 9 hydromorphone hcl liqd 1 mg/ml ......... 9 hydromorphone hcl preservative free (pf) inj 10 mg/ml .................................... 9 hydromorphone hcl tab 2 mg .............. 9 hydromorphone hcl tab 4 mg .............. 9 hydromorphone hcl tab 8 mg .............. 9 hydromorphone hcl tab er 24hr deter 12 mg ................................................. 10 hydromorphone hcl tab er 24hr deter 16

mg ................................................ 10 hydromorphone hcl tab er 24hr deter 32 mg ................................................ 10 hydromorphone hcl tab er 24hr deter 8 mg .................................................. 9 hydroxychloroquine sulfate tab 200 mg .................................................... 165 hydroxyurea cap 500 mg .................. 43 hydroxyzine hcl im soln 25 mg/ml ..... 189 hydroxyzine hcl im soln 50 mg/ml ..... 189 hydroxyzine hcl syrup 10 mg/5ml ..... 189 hydroxyzine hcl tab 10 mg ............... 189 hydroxyzine hcl tab 25 mg ............... 189 hydroxyzine hcl tab 50 mg ............... 189 hydroxyzine pamoate cap 100 mg ..... 189 hydroxyzine pamoate cap 25 mg ...... 189 hydroxyzine pamoate cap 50 mg ...... 189 HYGEL GEL 2.5% ............................ 214 HYLENEX INJ 150 UNIT ................... 108 hyolev mb tab 81mg ....................... 153 hyoscyamine sulfate elixir 0.125 mg/5ml .................................................... 143 hyoscyamine sulfate soln 0.125 mg/ml .................................................... 143 hyoscyamine sulfate tab 0.125 mg .... 143 hyoscyamine sulfate tab disint 0.125 mg .................................................... 143 hyoscyamine sulfate tab er 12hr 0.375 mg ............................................... 143 hyoscyamine sulfate tab sl 0.125 mg . 143 hyperlyte-cr inj .............................. 174 HYPERSAL NEB 3.5% ...................... 196 HYPER-SAL NEB 7% ........................ 195 HYPO NEEDLE MIS 18GX1" .............. 169 HYPO NEEDLE MIS 19GX1.5" ............ 169 HYPO NEEDLE MIS 21GX1" .............. 169 HYPO NEEDLE MIS 22GX1.5" ............ 169 HYPO NEEDLE MIS 23GX1" .............. 169 HYPO NEEDLE MIS 23GX1.5" ............ 169 HYPO NEEDLE MIS 23GX1/2" ........... 169 HYPO NEEDLE MIS 25GX1" .............. 169 HYPO NEEDLE MIS 25GX1.5" ............ 169 HYPO NEEDLE MIS 25GX5/8" ........... 169 HYPO NEEDLE MIS 26GX1.5" ............ 169 HYPO NEEDLE MIS 26GX1/2" ........... 169 HYPO NEEDLE MIS 27GX1/2" ........... 169 HYPO NEEDLE MIS 30GX3/4" ........... 169 HYPOTEARS SOL 1-1% .................... 220

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HYQVIA INJ 10-800 ........................ 166 HYQVIA INJ 2.5-200 ....................... 166 HYQVIA INJ 20-1600 ...................... 166 HYQVIA INJ 30-2400 ...................... 166 HYQVIA INJ 5-400 .......................... 166 hysept sol 0.25% ........................... 205 hysept sol 0.5% ............................. 205 HYSINGLA ER TAB 100 MG ................ 10 HYSINGLA ER TAB 120 MG ................ 10 HYSINGLA ER TAB 20 MG .................. 10 HYSINGLA ER TAB 30 MG .................. 10 HYSINGLA ER TAB 40 MG .................. 10 HYSINGLA ER TAB 60 MG .................. 10 HYSINGLA ER TAB 80 MG .................. 10 HYZAAR TAB 100-12.5 ...................... 52 HYZAAR TAB 100-25 ......................... 52 HYZAAR TAB 50-12.5 ........................ 52 I ibandronate sodium tab 150 mg (base equivalent) .................................... 124 IBRANCE CAP 100MG ........................ 41 IBRANCE CAP 125MG ........................ 41 IBRANCE CAP 75MG.......................... 41 ibudone tab 10-200mg ...................... 10 ibudone tab 5-200mg ....................... 10 ibuprofen cap 200 mg ........................ 3 ibuprofen dro 50/1.25 ........................ 3 ibuprofen jr chw 100mg ..................... 3 ibuprofen susp 100 mg/5ml ................ 3 ibuprofen tab 200 mg ........................ 3 ibuprofen tab 400 mg ........................ 3 ibuprofen tab 600 mg ........................ 3 ibuprofen tab 800 mg ........................ 3 ibutilide fumarate inj 1 mg/10ml ........ 55 icar-c plus tab ................................ 180 ICLUSIG TAB 15MG .......................... 41 ICLUSIG TAB 45MG .......................... 41 IDAMYCIN PFS INJ 10/10ML ............... 43 IDAMYCIN PFS INJ 20/20ML ............... 43 IDAMYCIN PFS INJ 5MG/5ML .............. 43 idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) ........................................... 43 idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) ........................................... 43 idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) ..................................................... 43 IDHIFA TAB 100MG .......................... 44 IDHIFA TAB 50MG ............................ 44

IFEX INJ 1GM .................................. 37 IFEX INJ 3GM .................................. 37 ifosfamide for inj 1 gm ..................... 37 ifosfamide iv inj 1 gm/20ml (50 mg/ml) ..................................................... 37 ifosfamide iv inj 3 gm/60ml (50 mg/ml) ..................................................... 37 ILARIS (150) INJ 180MG ................. 167 ILARIS INJ 150MG/ML ..................... 167 ILEVRO DRO 0.3% OP ..................... 217 ilotycin oin op ................................ 217 imatinib mesylate tab 100 mg (base equivalent) ..................................... 41 imatinib mesylate tab 400 mg (base equivalent) ..................................... 41 IMBRUVICA CAP 140MG ................... 41 imipenem-cilastatin intravenous for soln 250 mg .......................................... 17 imipenem-cilastatin intravenous for soln 500 mg .......................................... 17 imipramine hcl tab 10 mg ................. 87 imipramine hcl tab 25 mg ................. 87 imipramine hcl tab 50 mg ................. 87 imipramine pamoate cap 100 mg ....... 87 imipramine pamoate cap 125 mg ....... 87 imipramine pamoate cap 150 mg ....... 87 imipramine pamoate cap 75 mg ......... 87 imiquimod cream 5% ...................... 212 IMITREX INJ 4MG/0.5 ..................... 106 IMITREX INJ 6MG/0.5 ..................... 106 IMITREX SPR 20MG/ACT .................. 106 IMITREX SPR 5MG/ACT ................... 106 IMITREX TAB 100MG ....................... 106 IMITREX TAB 25MG ........................ 106 IMITREX TAB 50MG ........................ 106 inatal adv tab ................................. 180 INCRELEX INJ 40MG/4ML ................. 134 INCRUSE ELPT INH 62.5MCG ............ 187 indapamide tab 1.25 mg ................... 66 indapamide tab 2.5 mg .................... 67 INDERAL LA CAP 120MG ................... 60 INDERAL LA CAP 160MG ................... 61 INDERAL LA CAP 60MG ..................... 60 INDERAL LA CAP 80MG ..................... 60 INDERAL XL CAP 120MG ................... 61 INDERAL XL CAP 80MG ..................... 61 indiomin mb cap 120mg .................. 153 INDOCIN SUP 50MG ........................... 3

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indomethacin cap 25 mg .................... 3 indomethacin cap 50 mg .................... 3 indomethacin cap er 75 mg ................ 3 inf silapap dro 80/0.8ml ..................... 1 INFANATE CAP BALANCE ................. 180 INFASURF SUS 35MG/ML ................. 196 inflammacin mis 75-0.025 .................. 5 INFLECTRA INJ 100MG .................... 164 INFUMORPH INJ 10MG/ML ................. 10 INFUMORPH INJ 25MG/ML ................. 10 INFUS SYRING MIS 100ML ............... 169 INFUSION SET MIS 23" 6MM ............ 121 INFUSION SET MIS 23" 8MM ............ 121 INFUSION SET MIS 23"/6MM ........... 121 INFUSION SET MIS 23"/9MM ........... 121 INFUSION SET MIS 24" 6MM ............ 121 INFUSION SET MIS 24" 9MM ............ 121 INFUSION SET MIS 31" 9MM ............ 121 INFUSION SET MIS 32" 8MM ............ 121 INFUSION SET MIS 43"/6MM ........... 121 INFUSION SET MIS 43"/9MM ........... 121 INFUVITE INJ ................................. 175 INGREZZA CAP 40MG ..................... 108 INLYTA TAB 1MG .............................. 41 INLYTA TAB 5MG .............................. 41 INOVA 4/1 KIT ACNE CON ............... 201 INOVA 8/2 KIT ACNE CON ............... 201 INOVA KIT 4% ............................... 201 INOVA KIT 8% ............................... 201 INSPIREASE MIS RES BAG ............... 195 INSPRA TAB 25MG............................ 50 INSPRA TAB 50MG............................ 50 INSULIN PEN MIS 31GX4MM ............ 121 INSULIN PUMP KIT IR2020 .............. 121 INSULIN SYR MIS 0.3/31G .............. 121 INSULIN SYR MIS 0.5/31G .............. 121 INSULIN SYR MIS 1ML/31G ............. 121 INSULIN SYRG MIS 0.3/28G ............ 121 INSULIN SYRG MIS 0.3/29G ............ 122 INSULIN SYRG MIS 0.3/30G ............ 122 INSULIN SYRG MIS 0.3/31G ............ 122 INSULIN SYRG MIS 0.5/27G ............ 122 INSULIN SYRG MIS 0.5/28G ............ 122 INSULIN SYRG MIS 0.5/29G ............ 122 INSULIN SYRG MIS 0.5/30G ............ 122 INSULIN SYRG MIS 0.5/31G ............ 122 INSULIN SYRG MIS 1ML .................. 122 INSULIN SYRG MIS 1ML/25G ........... 122

INSULIN SYRG MIS 1ML/26G ........... 122 INSULIN SYRG MIS 1ML/27G ........... 122 INSULIN SYRG MIS 1ML/28G ........... 122 INSULIN SYRG MIS 1ML/29G ........... 122 INSULIN SYRG MIS 1ML/30G ........... 122 INSULIN SYRG MIS 1ML/31G ........... 123 INSULIN SYRG MIS 2/27.5G ............. 123 INSULIN SYRG MIS 2ML/29G ........... 123 INSUL-TRAY MIS ............................ 121 INSUPEN MIS 32GX4MM .................. 123 INSUPEN MIS 33GX4MM .................. 123 INSUPEN SENS MIS 32GX6MM ......... 123 INSUPEN SENS MIS 32GX8MM ......... 123 INSUPEN ULTR MIS 30GX8MM .......... 123 INTEGRA F CAP .............................. 180 INTEGRA PLUS CAP ......................... 180 INTEGRILIN INJ .............................. 163 INTEGRILIN INJ 0.75MG/1 ............... 163 INTEGRILIN INJ 20/10ML ................. 163 INTELENCE TAB 100MG .................... 29 INTELENCE TAB 200MG .................... 29 INTELENCE TAB 25MG ...................... 29 intense coug liq reliever ................... 190 INTERMEZZO SUB 1.75MG ............... 105 INTERMEZZO SUB 3.5MG ................ 105 INTRALIPID INJ 30% ...................... 173 INTRAROSA SUP 6.5MG ................... 153 INTRON A INJ 10MU ........................ 167 INTRON A INJ 18MU ........................ 167 INTRON A INJ 25MU ........................ 167 INTRON A INJ 50MU ........................ 167 INTUNIV TAB 1MG .......................... 100 INTUNIV TAB 2MG .......................... 100 INTUNIV TAB 3MG .......................... 100 INTUNIV TAB 4MG .......................... 100 INVANZ INJ 1GM ............................. 17 INVEGA SUST INJ 117/0.75 .............. 92 INVEGA SUST INJ 156MG/ML ............ 92 INVEGA SUST INJ 234/1.5 ................ 92 INVEGA SUST INJ 39/0.25 ................ 92 INVEGA SUST INJ 78/0.5ML .............. 92 INVEGA TAB 1.5MG ......................... 92 INVEGA TAB 3MG ............................ 92 INVEGA TAB 6MG ............................ 92 INVEGA TAB 9MG ............................ 92 INVEGA TRINZ INJ 273MG ................ 92 INVEGA TRINZ INJ 410MG ................ 92 INVEGA TRINZ INJ 546MG ................ 92

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INVEGA TRINZ INJ 819MG ................. 92 INVIRASE CAP 200MG ....................... 28 INVIRASE TAB 500MG ....................... 29 INVOKAMET TAB 150-1000 .............. 118 INVOKAMET TAB 150-500 ............... 118 INVOKAMET TAB 50-1000 ............... 118 INVOKAMET TAB 50-500MG ............. 118 INVOKAMET XR TAB 150-1000 ......... 118 INVOKAMET XR TAB 150-500 ........... 118 INVOKAMET XR TAB 50-1000 ........... 118 INVOKAMET XR TAB 50-500MG ........ 118 INVOKANA TAB 100MG ................... 119 INVOKANA TAB 300MG ................... 119 iodine solution strong 5% (lugol's) .... 137 IODOFLEX PAD PAD ........................ 206 IODOPEN INJ 100MCG .................... 175 IODOSORB GEL .............................. 206 IONOSOL-B/ INJ D5W ..................... 174 IONOSOL-MB INJ /D5W ................... 174 IONSYS PAD 40MCG/AC .................... 10 ipratropium bromide inhal soln 0.02% ................................................... 187 ipratropium bromide nasal soln 0.03% (21 mcg/spray) .............................. 196 ipratropium bromide nasal soln 0.06% (42 mcg/spray) .............................. 196 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml ............................... 187 IPRIVASK INJ 15MG ........................ 156 irbesartan tab 150 mg ...................... 54 irbesartan tab 300 mg ...................... 54 irbesartan tab 75 mg ........................ 54 irbesartan-hydrochlorothiazide tab 150-12.5 mg .......................................... 53 irbesartan-hydrochlorothiazide tab 300-12.5 mg .......................................... 53 IRESSA TAB 250MG .......................... 41 irinotecan hcl inj 100 mg/5ml (20 mg/ml) ........................................... 46 irinotecan hcl inj 40 mg/2ml (20 mg/ml) ..................................................... 46 irinotecan hcl inj 500 mg/25ml (20 mg/ml) ........................................... 46 iron slow tab 45mg ......................... 180 iron supplmt dro 15mg/ml ............... 180 IRON UP LIQ .................................. 180 IS 24/6 MIS ................................... 180 ISENTRESS CHW 100MG ................... 28

ISENTRESS CHW 25MG .................... 28 ISENTRESS HD TAB 600MG .............. 28 ISENTRESS POW 100MG ................... 28 ISENTRESS TAB 400MG .................... 28 ISOLYTE-P INJ /D5W ....................... 174 ISOLYTE-S INJ ............................... 174 ISOLYTE-S INJ PH 7.4 ..................... 174 isoniazid inj 100 mg/ml .................... 31 isoniazid syrup 50 mg/5ml ................ 31 isoniazid tab 100 mg ........................ 31 isoniazid tab 300 mg ........................ 31 ISOPTO TEARS SOL 0.5% OP ........... 220 ISORDIL TAB 40MG ......................... 69 ISORDIL TAB 5MG ........................... 69 isosorbide dinitrate tab 10 mg ........... 69 isosorbide dinitrate tab 20 mg ........... 69 isosorbide dinitrate tab 30 mg ........... 69 isosorbide dinitrate tab 5 mg ............. 69 isosorbide dinitrate tab er 40 mg ....... 69 isosorbide mononitrate tab 10 mg ...... 69 isosorbide mononitrate tab 20 mg ...... 69 isosorbide mononitrate tab er 24hr 120 mg ................................................ 69 isosorbide mononitrate tab er 24hr 30 mg ................................................ 69 isosorbide mononitrate tab er 24hr 60 mg ................................................ 69 isradipine cap 2.5 mg ....................... 63 isradipine cap 5 mg ......................... 63 ISTALOL SOL 0.5% OP .................... 218 ISTODAX INJ 10MG ......................... 44 ISUPREL INJ 0.2MG/ML ................... 193 itraconazole cap 100 mg ................... 26 IV PREP WIPE PAD .......................... 212 IXEMPRA KIT INJ 15MG .................... 44 IXEMPRA KIT INJ 45MG .................... 44 IXINITY INJ 1000UNIT ..................... 159 IXINITY INJ 1500UNIT ..................... 159 IXINITY INJ 500UNIT ...................... 159 J JADENU TAB 180MG ....................... 162 JADENU TAB 360MG ....................... 162 JADENU TAB 90MG ......................... 162 JAKAFI TAB 10MG ............................ 41 JAKAFI TAB 15MG ............................ 41 JAKAFI TAB 20MG ............................ 41 JAKAFI TAB 25MG ............................ 41 JAKAFI TAB 5MG ............................. 41

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JALYN CAP..................................... 152 JANUMET TAB 50-1000 ................... 115 JANUMET TAB 50-500MG ................. 115 JANUMET XR TAB 100-1000 ............. 115 JANUMET XR TAB 50-1000 ............... 115 JANUMET XR TAB 50-500MG ............ 115 JANUVIA TAB 100MG ...................... 115 JANUVIA TAB 25MG ........................ 115 JANUVIA TAB 50MG ........................ 115 JARDIANCE TAB 10MG .................... 119 JARDIANCE TAB 25MG .................... 119 JENTADUETO TAB 2.5-1000 ............. 115 JENTADUETO TAB 2.5-500 ............... 115 JENTADUETO TAB 2.5-850 ............... 115 JENTADUETO TAB XR ...................... 115 jevantique l tab 0.5-2.5 ................... 128 JEVTANA INJ 60/1.5ML ...................... 44 J-TAN PD DRO 1MG/ML ................... 189 JUBLIA SOL 10% ............................ 204 just for kid gel 0.4% grp ................. 215 JUXTAPID CAP 10MG ........................ 58 JUXTAPID CAP 20MG ........................ 58 JUXTAPID CAP 30MG ........................ 58 JUXTAPID CAP 40MG ........................ 58 JUXTAPID CAP 5MG .......................... 58 JUXTAPID CAP 60MG ........................ 59 K KADCYLA INJ 100MG ........................ 44 KADCYLA INJ 160MG ........................ 44 KADIAN CAP 100MG ER ..................... 10 KADIAN CAP 10MG ER ...................... 10 KADIAN CAP 200MG ER ..................... 10 KADIAN CAP 20MG ER ...................... 10 KADIAN CAP 30MG ER ...................... 10 KADIAN CAP 40MG ER ...................... 10 KADIAN CAP 50MG ER ...................... 10 KADIAN CAP 60MG ER ...................... 10 KADIAN CAP 80MG ER ...................... 10 KALETRA SOL .................................. 29 KALETRA TAB 100-25MG ................... 29 KALETRA TAB 200-50MG ................... 29 KALYDECO PAK 50MG ..................... 193 KALYDECO PAK 75MG ..................... 193 KALYDECO TAB 150MG ................... 193 KAPVAY TAB 0.1 MG ....................... 100 KARBINAL ER SUS 4MG/5ML ............ 189 KAYEXALATE POW .......................... 136 KAZANO 12.5- TAB 1000MG ............ 115

KAZANO 12.5- TAB 500MG .............. 115 KCENTRA KIT 1000UNIT .................. 163 KCENTRA KIT 500UNIT .................... 163 kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj ............................... 174 kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj ................................. 174 kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.33% inj ............................... 174 kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45% inj ............................... 174 kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.9% inj ................................. 174 kcl 20 meq/l (0.15%) in nacl 0.45% inj .................................................... 174 kcl 20 meq/l (0.15%) in nacl 0.9% inj .................................................... 174 kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45% inj ............................... 174 kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45% inj ............................... 174 kcl 40 meq/l (0.3%) in nacl 0.9% inj . 174 KCL/D5W/LACT INJ 20MEQ/L ........... 174 KCL/D5W/LACT INJ 40MEQ/L ........... 174 KCL/D5W/NACL INJ 0.15/0.2 ........... 174 KCL/D5W/NACL INJ 0.3/0.9% .......... 174 KENALOG AER SPRAY ...................... 208 KENALOG-10 INJ 10MG/ML .............. 131 KENALOG-40 INJ 40MG/ML .............. 131 KEPIVANCE INJ 6.25MG ................... 148 KEPPRA INJ 500/5ML ....................... 76 KEPPRA SOL 100MG/ML .................... 76 KEPPRA TAB 1000MG ....................... 76 KEPPRA TAB 250MG ......................... 76 KEPPRA TAB 500MG ......................... 76 KEPPRA TAB 750MG ......................... 76 KEPPRA XR TAB 500MG .................... 76 KEPPRA XR TAB 750MG .................... 76 KERALYT GEL 6% ........................... 212 KERALYT KIT SCALP 6% .................. 212 KERLONE TAB 10MG ........................ 61 KERLONE TAB 20MG ........................ 61 KERR TRIPLE MIS DYE SWAB ........... 206 ketoconazole cream 2% .................. 204 ketoconazole shampoo 2% .............. 204 ketoconazole tab 200 mg .................. 26 ketodan aer 2% ............................. 204 KETONE TEST TES .......................... 123

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ketoprofen cap 50 mg ........................ 3 ketoprofen cap 75 mg ........................ 3 ketoprofen cap er 24hr 200 mg ........... 3 ketorolac tromethamine ophth soln 0.4% ................................................... 217 ketorolac tromethamine ophth soln 0.5% ................................................... 217 ketorolac tromethamine tab 10 mg ...... 3 KEVEYIS TAB 50MG ........................ 219 KEVZARA INJ 150/1.14 ................... 164 KEVZARA INJ 200/1.14 ................... 164 KEYTRUDA INJ 100MG/4M ................. 44 KEYTRUDA SOL 50MG ....................... 44 KHEDEZLA TAB 100MG ER ................. 84 KHEDEZLA TAB 50MG ER ................... 84 KINERET INJ .................................. 164 KISQALI 200 PAK FEMARA ................. 40 KISQALI 400 PAK FEMARA ................. 40 KISQALI 600 PAK FEMARA ................. 40 KISQALI TAB 200DOSE ..................... 41 KISQALI TAB 400DOSE ..................... 41 KISQALI TAB 600DOSE ..................... 41 KITABIS PAK NEB 300/5ML .............. 193 KLARON LOT 10% .......................... 201 KLONOPIN TAB 0.5MG ...................... 73 KLONOPIN TAB 1MG ......................... 73 KLONOPIN TAB 2MG ......................... 73 klor-con 8 tab 8meq er ................... 172 KLOR-CON M15 TAB 15MEQ ER ........ 172 KOATE-DVI INJ 1000UNIT ............... 159 KOATE-DVI INJ 250UNIT ................. 159 KOATE-DVI INJ 500UNIT ................. 159 KOGENATE FS INJ 1000/BS ............. 159 KOGENATE FS INJ 1000UNIT ........... 159 KOGENATE FS INJ 2000/BS ............. 159 KOGENATE FS INJ 2000UNIT ........... 159 KOGENATE FS INJ 250/BS ............... 159 KOGENATE FS INJ 250UNIT ............. 159 KOGENATE FS INJ 3000/BS ............. 159 KOGENATE FS INJ 3000UNIT ........... 159 KOGENATE FS INJ 500/BS ............... 159 KOGENATE FS INJ 500UNIT ............. 159 KOMBIGLYZ XR TAB 2.5-1000 .......... 115 KOMBIGLYZ XR TAB 5-1000MG ........ 115 KOMBIGLYZ XR TAB 5-500MG .......... 115 KONDREMUL EMU 50% ................... 146 KONSYL POW 100% ....................... 146 KONSYL POW 28.3% ...................... 146

KONSYL POW 60.3% ....................... 146 KONSYL POW 71.67% ..................... 146 KOSHR PRENAT TAB 30-1MG............ 180 KOVALTRY INJ 1000UNIT ................. 159 KOVALTRY INJ 2000UNIT ................. 159 KOVALTRY INJ 250UNIT .................. 159 KOVALTRY INJ 3000UNIT ................. 159 KOVALTRY INJ 500UNIT .................. 159 K-PHOS TAB .................................. 172 K-PHOS TAB NO 2 .......................... 172 KPN PRENATAL TAB ........................ 180 KRISTALOSE PAK 10GM ................... 146 KRISTALOSE PAK 20GM ................... 146 K-TAB TAB 10MEQ CR ..................... 172 K-TAB TAB 20MEQ .......................... 172 KUVAN POW 100MG ........................ 136 KUVAN POW 500MG ........................ 136 KUVAN TAB 100MG ......................... 136 KYNAMRO INJ 200MG/ML .................. 59 KYPROLIS SOL 60MG ....................... 44 L labetalol hcl iv soln 5 mg/ml ............. 61 labetalol hcl tab 100 mg ................... 61 labetalol hcl tab 200 mg ................... 61 labetalol hcl tab 300 mg ................... 61 LAC-HYDRIN CRE 12% .................... 210 LAC-HYDRIN LOT 12% .................... 210 LACRISERT MIS 5MG OP .................. 220 lactated ringer's for irrigation ........... 215 lactated ringer's solution.................. 174 lactic acid (ammonium lactate) cream 12% ............................................. 210 lactic acid (ammonium lactate) lotion 12% ............................................. 210 LACTINEX CHW .............................. 148 lactobacillus acidophilus-pectin cap ... 148 LAMICTAL CHW 25MG ...................... 76 LAMICTAL CHW 5MG ........................ 76 LAMICTAL KIT START 35 ................... 76 LAMICTAL KIT START 49 ................... 76 LAMICTAL KIT START 98 ................... 76 LAMICTAL ODT KIT .......................... 76 LAMICTAL ODT TAB 100MG ............... 76 LAMICTAL ODT TAB 200MG ............... 76 LAMICTAL ODT TAB 25MG ................ 76 LAMICTAL ODT TAB 50MG ................ 76 LAMICTAL TAB 100MG ...................... 76 LAMICTAL TAB 150MG ...................... 76

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LAMICTAL TAB 200MG ...................... 76 LAMICTAL TAB 25MG ........................ 76 LAMICTAL XR KIT ............................. 76 LAMICTAL XR TAB 100MG .................. 77 LAMICTAL XR TAB 200MG .................. 77 LAMICTAL XR TAB 250MG .................. 77 LAMICTAL XR TAB 25MG ................... 76 LAMICTAL XR TAB 300MG .................. 77 LAMICTAL XR TAB 50MG ................... 77 LAMISIL ADV GEL 1% ..................... 204 LAMISIL TAB 250MG ......................... 26 lamivudine oral soln 10 mg/ml ........... 30 lamivudine tab 100 mg (hbv) ............. 32 lamivudine tab 150 mg ..................... 30 lamivudine tab 300 mg ..................... 30 lamivudine-zidovudine tab 150-300 mg ..................................................... 28 lamotrigine orally disintegrating tab 100 mg ................................................. 77 lamotrigine orally disintegrating tab 200 mg ................................................. 77 lamotrigine orally disintegrating tab 25 mg ................................................. 77 lamotrigine orally disintegrating tab 50 mg ................................................. 77 lamotrigine tab 100 mg ..................... 77 lamotrigine tab 150 mg ..................... 77 lamotrigine tab 200 mg ..................... 77 lamotrigine tab 25 mg ....................... 77 lamotrigine tab 25 mg (35) starter kit . 77 lamotrigine tab 25 mg (42) & 100 mg (7) starter kit ........................................ 77 lamotrigine tab 25 mg (84) & 100 mg (14) starter kit ................................. 77 lamotrigine tab chewable dispersible 25 mg ................................................. 77 lamotrigine tab chewable dispersible 5 mg ................................................. 77 lamotrigine tab disint 25 (14) & 50 mg (14) & 100 mg (7) kit ....................... 77 lamotrigine tab disint 25 mg (21) & 50 mg (7) titration kit ........................... 77 lamotrigine tab disint 50 mg (42)- 100 mg(14) titration kit ........................... 77 lamotrigine tab er 24hr 100 mg .......... 77 lamotrigine tab er 24hr 200 mg .......... 77 lamotrigine tab er 24hr 25 mg ........... 77 lamotrigine tab er 24hr 250 mg .......... 77

lamotrigine tab er 24hr 300 mg ......... 77 lamotrigine tab er 24hr 50 mg ........... 77 lanacort 10 cre 1% ......................... 208 LANCETS MIS ................................. 123 LANCING DEVI MIS ......................... 123 LANOXIN INJ 0.25MG/1 .................... 65 LANOXIN PED INJ 0.1MG/ML ............. 65 LANOXIN TAB 0.0625MG .................. 66 LANOXIN TAB 0.125MG .................... 66 LANOXIN TAB 0.1875MG .................. 66 LANOXIN TAB 0.25MG ...................... 65 lansoprazole cap delayed release 15 mg .................................................... 149 lansoprazole cap delayed release 30 mg .................................................... 150 lanthanum carbonate chew tab 500 mg (elemental).................................... 136 lanthanum carbonate chew tab 750 mg (elemental).................................... 136 LANTUS INJ 100/ML ........................ 117 LANTUS INJ SOLOSTAR ................... 117 LASIX TAB 20MG ............................. 67 LASIX TAB 40MG ............................. 67 LASIX TAB 80MG ............................. 67 LASTACAFT SOL 0.25% ................... 218 latanoprost ophth soln 0.005% ......... 221 LATRIX XM EMU 45% ...................... 210 LATUDA TAB 120MG ........................ 92 LATUDA TAB 20MG .......................... 92 LATUDA TAB 40MG .......................... 92 LATUDA TAB 60MG .......................... 92 LATUDA TAB 80MG .......................... 92 lax diet sup tab 500mg .................... 146 laxative chw 15mg .......................... 146 laxative tab 15mg ........................... 146 laxative tab 25mg ........................... 146 laxative tab 5mg ec ........................ 146 layolis fe chw ................................. 126 LAZANDA SPR 100MCG .................... 10 LAZANDA SPR 300MCG .................... 10 LAZANDA SPR 400MCG .................... 11 LDO PLUS GEL 4% .......................... 210 leena tab ....................................... 128 leflunomide tab 10 mg .................... 165 leflunomide tab 20 mg .................... 165 LENVIMA CAP 10 MG ........................ 41 LENVIMA CAP 14 MG ........................ 41 LENVIMA CAP 20 MG ........................ 41

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LENVIMA CAP 24 MG ......................... 41 LESCOL XL TAB 80MG ....................... 57 LETAIRIS TAB 10MG ......................... 70 LETAIRIS TAB 5MG ........................... 70 letrozole tab 2.5 mg ......................... 39 leucovorin calcium for inj 100 mg ....... 44 leucovorin calcium for inj 200 mg ....... 44 leucovorin calcium for inj 350 mg ....... 44 leucovorin calcium for inj 50 mg ......... 44 leucovorin calcium for inj 500 mg ....... 44 leucovorin calcium tab 10 mg ............. 44 leucovorin calcium tab 15 mg ............. 44 leucovorin calcium tab 25 mg ............. 44 leucovorin calcium tab 5 mg .............. 44 LEUKERAN TAB 2MG ......................... 37 LEUKINE INJ 250MCG ..................... 160 leuprolide acetate inj kit 5 mg/ml ....... 39 LEVACET TAB .................................... 2 levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv) .................................. 192 levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv) .................................. 192 levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) .................................. 192 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) .................... 193 levalbuterol tartrate inhal aerosol 45 mcg/act (base equiv) ...................... 193 LEVATOL TAB 20MG .......................... 61 LEVBID TAB 0.375 ER ..................... 143 LEVEMIR INJ .................................. 117 LEVEMIR INJ FLEXTOUC .................. 117 LEVETIRACETA INJ 10MG/ML ............. 77 LEVETIRACETA INJ 15MG/ML ............. 77 LEVETIRACETA INJ 5MG/ML ............... 77 levetiracetam inj 500 mg/5ml (100 mg/ml) ........................................... 77 levetiracetam oral soln 100 mg/ml ...... 77 levetiracetam tab 1000 mg ................ 77 levetiracetam tab 250 mg .................. 77 levetiracetam tab 500 mg .................. 77 levetiracetam tab 750 mg .................. 77 levetiracetam tab er 24hr 500 mg ....... 77 levetiracetam tab er 24hr 750 mg ....... 78 levobunolol hcl ophth soln 0.5% ....... 218 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) ....................... 188 levocetirizine dihydrochloride tab 5 mg

.................................................... 188 levofloxacin in d5w iv soln 250 mg/50ml ..................................................... 21 levofloxacin in d5w iv soln 500 mg/100ml ...................................... 21 levofloxacin in d5w iv soln 750 mg/150ml ...................................... 21 levofloxacin iv soln 25 mg/ml ............ 21 levofloxacin ophth soln 0.5% ........... 217 levofloxacin oral soln 25 mg/ml ......... 21 levofloxacin tab 250 mg ................... 21 levofloxacin tab 500 mg ................... 21 levofloxacin tab 750 mg ................... 21 LEVOLEUCOVOR SOL 250MG/25 ........ 44 levoleucovorin calcium for iv inj 50 mg (base equiv) ................................... 44 levoleucovorin calcium inj 175 mg/17.5ml (base equiv) ................... 44 LEVOMEFOLATE CAP DHA ................ 180 levonorgestrel tab 1.5 mg ................ 125 levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) ..................... 125 LEVOPHED INJ 1MG/ML .................... 72 levorphanol tartrate tab 2 mg ............ 11 levo-t tab 112mcg .......................... 137 levo-t tab 137mcg .......................... 137 levo-t tab 175mcg .......................... 137 levo-t tab 200 mcg ......................... 138 levo-t tab 300 mcg ......................... 138 levo-t tab 88mcg ............................ 137 levothyroxine sodium tab 100 mcg .... 138 levothyroxine sodium tab 125 mcg .... 138 levothyroxine sodium tab 150 mcg .... 138 levothyroxine sodium tab 25 mcg ..... 138 levothyroxine sodium tab 50 mcg ..... 138 levothyroxine sodium tab 75 mcg ..... 138 LEVSIN INJ 0.5MG/ML ..................... 143 LEVSIN TAB 0.125MG ...................... 143 LEVSIN/SL SUB 0.125MG ................. 143 LEVULAN KERA SOL 20% ................. 203 LEXAPRO SOL 5MG/5ML ................... 85 LEXAPRO TAB 10MG ......................... 85 LEXAPRO TAB 20MG ......................... 85 LEXAPRO TAB 5MG .......................... 85 LEXIVA SUS 50MG/ML ...................... 29 LEXIVA TAB 700MG ......................... 29 LIALDA TAB 1.2GM ......................... 144 LIBRAX CAP 5-2.5MG ...................... 143

272

lice killing sha ................................ 214 lice md gel .................................... 214 lice trtmnt liq 1% ........................... 214 lice trtmnt liq crm rnse .................... 214 lidocaine anorectal cream 5% .......... 148 lidocaine cream 4% ........................ 211 lidocaine cream 4% & transparent dressing kit ................................... 211 lidocaine hcl cream 3% ................... 211 lidocaine hcl gel 2% ........................ 211 lidocaine hcl iv inj 10 mg/ml .............. 55 lidocaine hcl iv inj 20 mg/ml .............. 55 lidocaine hcl laryngotracheal soln 4% 215 lidocaine hcl lotion 3% .................... 211 lidocaine hcl soln 4% ...................... 211 lidocaine hcl viscous soln 2% ........... 215 lidocaine iv infusion in d5w inj 4 mg/ml ..................................................... 55 lidocaine iv infusion in d5w inj 8 mg/ml ..................................................... 55 lidocaine oint 5% ........................... 211 lidocaine patch 5% ......................... 210 lidocaine-hydrocortisone acetate rectal cream 3-0.5% ............................... 151 lidocaine-hydrocortisone acetate rectal cream kit 2-2% .............................. 151 lidocaine-hydrocortisone acetate rectal cream kit 3-0.5% ........................... 151 lidocaine-hydrocortisone acetate rectal cream kit 3-1% .............................. 151 lidocaine-hydrocortisone acetate rectal gel kit 3-2.5% ............................... 151 lidocaine-prilocaine cream 2.5-2.5% . 211 LIDODERM DIS 5% ......................... 210 LIDO-HYDRO GEL 2.8-0.55 .............. 151 LIDO-K LOT 3% ............................. 210 LIDORX GEL 3% ............................. 211 LIDOVEX CRE 3.75% ...................... 211 LILETTA IUD 52MG ......................... 127 LINCOCIN INJ 300MG/ML .................. 35 lincomycin hcl inj 300 mg/ml ............. 35 linezolid for susp 100 mg/5ml ............ 35 linezolid in sodium chloride iv soln 600 mg/300ml-0.9% .............................. 35 linezolid iv soln 600 mg/300ml (2 mg/ml) ........................................... 35 linezolid tab 600 mg ......................... 35 LINZESS CAP 145MCG .................... 145

LINZESS CAP 290MCG..................... 145 LINZESS CAP 72MCG ...................... 145 liothyronine sodium iv soln 10 mcg/ml .................................................... 138 liothyronine sodium tab 25 mcg ........ 138 liothyronine sodium tab 5 mcg ......... 138 liothyronine sodium tab 50 mcg ........ 138 lip balm oin strawber ...................... 212 LIPITOR TAB 10MG .......................... 57 LIPITOR TAB 20MG .......................... 57 LIPITOR TAB 40MG .......................... 58 LIPITOR TAB 80MG .......................... 58 LIPOCHOL TAB PLUS ....................... 173 LIPOFEN CAP 150MG ........................ 57 LIPOFEN CAP 50MG ......................... 57 liq ca/vit d cap 600mg ..................... 180 LIQUID CALCI CAP WITH D3 ............ 180 lisinopril & hydrochlorothiazide tab 10-12.5 mg ......................................... 47 lisinopril & hydrochlorothiazide tab 20-12.5 mg ......................................... 47 lisinopril & hydrochlorothiazide tab 20-25 mg ................................................ 47 lisinopril tab 10 mg .......................... 48 lisinopril tab 2.5 mg ......................... 48 lisinopril tab 20 mg .......................... 48 lisinopril tab 30 mg .......................... 48 lisinopril tab 40 mg .......................... 49 lisinopril tab 5 mg ............................ 48 LITETOUCH MIS 29GX12.7 ............... 123 lithium carbonate cap 150 mg .......... 108 lithium carbonate cap 300 mg .......... 108 lithium carbonate cap 600 mg .......... 108 lithium carbonate tab 300 mg .......... 108 lithium carbonate tab er 300 mg ....... 108 lithium carbonate tab er 450 mg ....... 108 LITHIUM SOL 8MEQ/5ML ................. 108 LITHOBID TAB 300MG CR ................ 108 LITHOSTAT TAB 250MG ................... 153 little remed liq 160/5ml ...................... 1 LIVALO TAB 1MG ............................. 58 LIVALO TAB 2MG ............................. 58 LIVALO TAB 4MG ............................. 58 lmd 10%/d5w inj ............................ 162 lmd 10%/nacl inj 0.9% ................... 162 L-METHYL- TAB B6-B12 ................... 171 L-METHYL-MC TAB NAC ................... 171 LO LOESTRIN TAB .......................... 126

273

LOCOID CRE 0.1% ......................... 208 LOCOID LIPO CRE 0.1% .................. 209 LOCOID LOT 0.1% .......................... 209 LOCOID OIN 0.1% .......................... 209 LOCOID SOL 0.1% ......................... 209 LODOSYN TAB 25MG ........................ 88 LOESTRIN 21 TAB 1.5/30 ................ 126 LOESTRIN FE TAB 1.5/30 ................ 126 LOESTRIN FE TAB 1/20 ................... 126 LOESTRIN TAB 1/20-21 ................... 127 LOFIBRA CAP 134MG ........................ 57 LOFIBRA CAP 200MG ........................ 57 LOFIBRA CAP 67MG .......................... 57 LOFIBRA TAB 160MG ........................ 57 LOFIBRA TAB 54MG .......................... 57 lohist-dm syp 5-2-10mg .................. 190 LOMOTIL TAB 2.5MG ...................... 140 LONSURF TAB 15-6.14 ...................... 44 LONSURF TAB 20-8.19 ...................... 44 loperamide hcl cap 2 mg ................. 140 loperamide sus 1mg/7.5 .................. 140 LOPID TAB 600MG ............................ 57 lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) ................................. 29 LOPRESS HCT TAB 100-25MG ............ 59 LOPRESS HCT TAB 50-25MG .............. 59 LOPRESSOR TAB 100MG ................... 61 LOPRESSOR TAB 50MG ..................... 61 LOPROX SHA 1% ............................ 204 loratadine sol 5mg/5ml ................... 189 lorazepam conc 2 mg/ml ................... 73 lorazepam inj 2 mg/ml ...................... 73 lorazepam inj 4 mg/ml ...................... 73 lorazepam tab 0.5 mg ....................... 73 lorazepam tab 1 mg .......................... 73 lorazepam tab 2 mg .......................... 73 LORTAB ELX 10-300MG ..................... 11 LORZONE TAB 375MG ..................... 110 LORZONE TAB 750MG ..................... 110 losartan potassium & hydrochlorothiazide tab 100-12.5 mg .............................. 53 losartan potassium & hydrochlorothiazide tab 100-25 mg ................................. 53 losartan potassium & hydrochlorothiazide tab 50-12.5 mg ................................ 53 losartan potassium tab 100 mg .......... 54 losartan potassium tab 25 mg ............ 54 losartan potassium tab 50 mg ............ 54

LOSEASONIQUE TAB ....................... 125 LOTEMAX GEL 0.5% ........................ 218 LOTEMAX OIN 0.5% ........................ 218 LOTEMAX SUS 0.5% ....................... 218 LOTENSIN HCT TAB 10-12.5 ............. 47 LOTENSIN HCT TAB 20-12.5 ............. 47 LOTENSIN HCT TAB 20-25MG ............ 47 LOTENSIN TAB 10MG ....................... 49 LOTENSIN TAB 20MG ....................... 49 LOTENSIN TAB 40MG ....................... 49 LOTREL CAP 10-20MG ...................... 46 LOTREL CAP 10-40MG ...................... 46 LOTREL CAP 5-10MG ........................ 46 LOTREL CAP 5-20MG ........................ 46 lotrimin af aer 2% .......................... 204 LOTRONEX TAB 0.5MG .................... 145 LOTRONEX TAB 1MG ....................... 145 LOUTREX CRE ................................ 205 lovastatin tab 10 mg ........................ 58 lovastatin tab 20 mg ........................ 58 lovastatin tab 40 mg ........................ 58 LOVAZA CAP 1GM ............................ 59 LOVENOX INJ 100MG/ML ................. 156 LOVENOX INJ 120/0.8 ..................... 156 LOVENOX INJ 150MG/ML ................. 156 LOVENOX INJ 30/0.3ML ................... 156 LOVENOX INJ 300/3ML .................... 157 LOVENOX INJ 40/0.4ML ................... 156 LOVENOX INJ 60/0.6ML ................... 156 LOVENOX INJ 80/0.8ML ................... 156 low-ogestrel tab ............................. 127 loxapine succinate cap 10 mg ............ 92 loxapine succinate cap 25 mg ............ 92 loxapine succinate cap 5 mg ............. 92 loxapine succinate cap 50 mg ............ 92 LOZI-FLUR LOZ 1MG F .................... 180 lubricant dro eye 0.6% .................... 220 lubricnt eye dro 0.4-0.3% ................ 220 lubricnt eye dro 0.5% op ................. 220 lubricnt eye oin fast act ................... 220 lubricnt gel dro 0.25-0.3 .................. 220 lubricnt gel dro 1% ......................... 220 ludent chw 0.25mg f ....................... 181 ludent chw 0.5mg f ......................... 181 ludent chw 1mg f............................ 181 LUMIGAN SOL 0.01% ...................... 221 LUMIZYME INJ 50MG ....................... 134 LUNESTA TAB 1MG ......................... 105

274

LUNESTA TAB 2MG ......................... 105 LUNESTA TAB 3MG ......................... 105 LUPR DEP-PED INJ 11.25MG ............ 135 LUPR DEP-PED INJ 15MG ................. 135 LUPR DEP-PED INJ 3M 30MG ............ 135 LUPR DEP-PED INJ 7.5MG ................ 135 LUPRON DEPOT INJ 11.25MG ............. 39 LUPRON DEPOT INJ 22.5MG ............... 39 LUPRON DEPOT INJ 3.75MG ............... 39 LUPRON DEPOT INJ 30MG ................. 39 LUPRON DEPOT INJ 45MG ................. 39 LUPRON DEPOT INJ 7.5MG ................ 39 LUXAMEND CRE ............................. 214 LUXIQ AER 0.12% .......................... 209 LUZU CRE 1% ................................ 204 LYCELLE GEL ................................. 214 LYNPARZA CAP 50MG ........................ 44 LYRICA CAP 100MG ........................ 103 LYRICA CAP 150MG ........................ 103 LYRICA CAP 200MG ........................ 103 LYRICA CAP 225MG ........................ 103 LYRICA CAP 25MG .......................... 103 LYRICA CAP 300MG ........................ 103 LYRICA CAP 50MG .......................... 103 LYRICA CAP 75MG .......................... 103 LYRICA SOL 20MG/ML ..................... 103 LYSODREN TAB 500MG ..................... 44 LYSTEDA TAB 650MG ...................... 161 lyza tab 0.35mg ............................. 127 M MACROBID CAP 100MG ..................... 35 MACRODANTIN CAP 100MG ............... 35 MACRODANTIN CAP 25MG ................. 35 MACRODANTIN CAP 50MG ................. 35 MAG OXIDE CAP 400MG .................. 140 mag64 tab 64mg ............................ 181 MAGNEBIND TAB 400 ..................... 181 MAGNESIUM CAP 400MG ................. 181 magnesium chloride inj 200 mg/ml ... 175 magnesium citrate soln ................... 146 magnesium oxide cap 500 mg (elemental mg) .............................................. 181 magnesium oxide tab 250 mg .......... 140 magnesium oxide tab 400 mg .......... 140 magnesium oxide tab 400 mg (240 mg elemental mg) ............................... 181 magnesium oxide tab 420 mg .......... 140 magnesium oxide tab 500 mg (mg

supplement) .................................. 181 magnesium sulfate inj 50% .............. 175 magnesium tab 250 mg ................... 181 MAKENA INJ 250MG/ML ................... 137 malathion lotion 0.5% ..................... 214 manganese chloride inj 0.1 mg/ml .... 175 manganese sulfate inj 0.1 mg/ml ...... 175 MANGANESE TAB 50MG ................... 175 mannitol iv soln 20% ...................... 153 mannitol iv soln 25% ...................... 153 maprotiline hcl tab 25 mg ................. 82 maprotiline hcl tab 50 mg ................. 82 maprotiline hcl tab 75 mg ................. 82 MARINOL CAP 10MG ....................... 141 MARINOL CAP 2.5MG ...................... 141 MARINOL CAP 5MG ......................... 141 MARNATAL-F CAP ........................... 181 MARPLAN TAB 10MG ........................ 82 MARQIBO INJ 5MG/31ML .................. 44 MATULANE CAP 50MG ...................... 44 matzim la tab 180mg/24 .................. 65 matzim la tab 240mg/24 .................. 65 matzim la tab 300mg/24 .................. 65 matzim la tab 360mg/24 .................. 65 matzim la tab 420mg/24 .................. 65 MAVIK TAB 1MG .............................. 49 MAVIK TAB 2MG .............................. 49 MAVYRET TAB 100-40MG .................. 32 MAXALT TAB 10MG ......................... 107 MAXALT TAB 5MG ........................... 106 MAXALT-MLT TAB 10MG .................. 107 MAXALT-MLT TAB 5MG .................... 107 MAXFE LIQ .................................... 181 MAXIDEX SUS 0.1% OP ................... 218 MAXIPIME INJ 1GM .......................... 20 MAXIPIME INJ 2GM .......................... 20 MAXITROL OIN 0.1% OP .................. 216 MAXITROL SUS 0.1% OP ................. 216 MAXZIDE TAB 75-50 ........................ 67 MAXZIDE-25 TAB ............................ 67 MB HYDROGEL KIT ......................... 212 meclizine hcl tab 12.5 mg ................ 141 meclizine hcl tab 25 mg ................... 141 meclofenamate sodium cap 100 mg ..... 3 meclofenamate sodium cap 50 mg ....... 3 MEDROL TAB 16MG......................... 132 MEDROL TAB 2MG .......................... 131 MEDROL TAB 32MG......................... 132

275

MEDROL TAB 4MG .......................... 131 MEDROL TAB 8MG .......................... 132 medroxyprogesterone acetate im susp 150 mg/ml .................................... 126 medroxyprogesterone acetate im susp prefilled syr 150 mg/ml ................... 126 medroxyprogesterone acetate tab 10 mg ................................................... 137 medroxyprogesterone acetate tab 2.5 mg ............................................... 137 medroxyprogesterone acetate tab 5 mg ................................................... 137 mefenamic acid cap 250 mg ............... 3 mefloquine hcl tab 250 mg ................ 27 MEGA MULTIVI TAB WOMEN ............ 181 MEGACE ES SUS 625/5ML ............... 137 MEGACE ORAL SUS 40MG/ML............. 39 megestrol acetate susp 40 mg/ml ....... 39 megestrol acetate susp 625 mg/5ml . 137 megestrol acetate tab 20 mg ............. 39 megestrol acetate tab 40 mg ............. 40 MEKINIST TAB 0.5MG ....................... 41 MEKINIST TAB 2MG .......................... 41 MELOXICAM KIT COMFORT ................. 5 meloxicam tab 15 mg ........................ 3 meloxicam tab 7.5 mg ....................... 3 melphalan hcl for inj 50 mg (base equiv) ..................................................... 37 melphalan tab 2 mg .......................... 37 memantine hcl oral solution 2 mg/ml .. 81 memantine hcl tab 10 mg .................. 81 memantine hcl tab 5 mg ................... 81 memantine hcl tab 5 mg (28) & 10 mg (21) titration pak ............................. 81 MEMBRANEBLUE SOL 0.15% ............ 220 MENEST TAB 0.3MG ........................ 129 MENEST TAB 0.625MG .................... 129 MENEST TAB 1.25MG ...................... 129 MENEST TAB 2.5MG ........................ 129 MENOSTAR DIS 14MCG ................... 130 MENTAX CRE 1% ............................ 204 meperidine hcl inj 10 mg/ml .............. 11 meperidine hcl inj 100 mg/ml ............ 11 meperidine hcl inj 25 mg/ml .............. 11 meperidine hcl inj 50 mg/ml .............. 11 meperidine hcl oral soln 50 mg/5ml .... 11 meperidine hcl tab 100 mg ................ 11 meperidine hcl tab 50 mg .................. 11

MEPHYTON TAB 5MG ....................... 181 meprobamate tab 200 mg ................ 74 meprobamate tab 400 mg ................ 74 MEPRON SUS .................................. 35 mercaptopurine tab 50 mg ................ 38 MEROP/NACL INJ 1GM/50ML ............. 17 MEROP/NACL INJ 500/50ML .............. 17 meropenem iv for soln 1 gm ............. 17 meropenem iv for soln 500 mg .......... 17 MERREM INJ 1GM ............................ 17 MERREM INJ 500MG ......................... 17 mesalamine enema 4 gm ................. 145 mesalamine rectal enema 4 gm & cleanser wipe kit ............................ 145 mesalamine tab delayed release 1.2 gm .................................................... 144 mesalamine tab delayed release 800 mg .................................................... 144 mesna inj 100 mg/ml ....................... 44 MESNEX INJ 1GM ............................ 44 MESNEX TAB 400MG ........................ 44 MESTINON SYP 60MG/5ML ............... 111 MESTINON TAB 60MG ..................... 111 METADATE CD CAP 10MG ................ 100 METADATE CD CAP 20MG ................ 101 METADATE CD CAP 30MG ................ 101 METADATE CD CAP 40MG ................ 101 METADATE CD CAP 50MG ................ 101 METADATE CD CAP 60MG ................ 101 METAFOLBIC TAB PLUS RF ............... 171 METAMUCIL POW 28% .................... 146 metamucil pow 28.3%org ................ 146 METAMUCIL POW 55.46% ................ 146 METAMUCIL POW 58.12% ................ 146 metamucil pow 58.6%org ................ 146 METAMUCIL POW 63% .................... 146 metaproterenol sulfate syrup 10 mg/5ml .................................................... 193 metaproterenol sulfate tab 10 mg ..... 193 metaproterenol sulfate tab 20 mg ..... 193 METASTRON INJ .............................. 44 metaxalone tab 400 mg ................... 110 metaxalone tab 800 mg ................... 110 metformin hcl tab 1000 mg .............. 115 metformin hcl tab 500 mg ............... 114 metformin hcl tab 850 mg ............... 114 metformin hcl tab er 24hr 500 mg .... 115 metformin hcl tab er 24hr 750 mg .... 115

276

metformin hcl tab er 24hr modified release 1000 mg ............................ 115 metformin hcl tab er 24hr modified release 500 mg .............................. 115 metformin hcl tab er 24hr osmotic 1000 mg ............................................... 115 metformin hcl tab er 24hr osmotic 500 mg ............................................... 115 methacholine cap /liver ................... 181 methadone hcl conc 10 mg/ml ........... 11 methadone hcl soln 10 mg/5ml .......... 11 methadone hcl soln 5 mg/5ml ............ 11 methadone hcl tab 10 mg .................. 11 methadone hcl tab 5 mg ................... 11 methadone hcl tab for oral susp 40 mg 11 METHADONE INJ 10MG/ML ................ 11 methazolamide tab 25 mg ............... 219 methazolamide tab 50 mg ............... 219 methenamine hippurate tab 1 gm ..... 153 methenamine mandelate tab 0.5 gm . 153 methenamine mandelate tab 1 gm ... 153 methimazole tab 10 mg .................. 137 methimazole tab 5 mg .................... 137 methocarbamol tab 500 mg ............. 110 methocarbamol tab 750 mg ............. 110 methotrexate sodium for inj 1 gm ....... 38 methotrexate sodium inj 250 mg/10ml (25 mg/ml) ..................................... 38 methotrexate sodium inj 50 mg/2ml (25 mg/ml) ........................................... 38 methotrexate sodium inj pf 100 mg/4ml (25 mg/ml) ..................................... 38 methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml) ........................ 38 methotrexate sodium inj pf 200 mg/8ml (25 mg/ml) ..................................... 38 methotrexate sodium inj pf 250 mg/10ml (25 mg/ml) ..................................... 38 methotrexate sodium inj pf 50 mg/2ml (25 mg/ml) ..................................... 38 methotrexate sodium tab 2.5 mg (base equiv) ............................................. 38 METHOXSALEN CAP 10 MG .............. 205 methscopolamine bromide tab 2.5 mg ................................................... 143 methscopolamine bromide tab 5 mg . 143 methyclothiazide tab 5 mg ................. 67 methyldopa & hydrochlorothiazide tab

250-15 mg ..................................... 68 methyldopa & hydrochlorothiazide tab 250-25 mg ..................................... 68 methyldopa tab 250 mg ................... 68 methyldopa tab 500 mg ................... 68 methyldopate hcl inj 250 mg/5ml ...... 68 methylene blue inj 1% .................... 123 methylergonovine maleate inj 0.2 mg/ml .................................................... 135 methylergonovine maleate tab 0.2 mg .................................................... 135 METHYLIN CHW 10MG ..................... 101 METHYLIN CHW 2.5MG .................... 101 METHYLIN CHW 5MG ....................... 101 METHYLIN SOL 10MG/5ML ............... 101 METHYLIN SOL 5MG/5ML ................. 101 methylphenidate hcl cap er 10 mg (cd) .................................................... 101 methylphenidate hcl cap er 20 mg (cd) .................................................... 101 methylphenidate hcl cap er 24hr 20 mg (la) ............................................... 101 methylphenidate hcl cap er 24hr 30 mg (la) ............................................... 101 methylphenidate hcl cap er 24hr 40 mg (la) ............................................... 101 methylphenidate hcl cap er 30 mg (cd) .................................................... 101 methylphenidate hcl cap er 40 mg (cd) .................................................... 101 methylphenidate hcl cap er 50 mg (cd) .................................................... 101 methylphenidate hcl cap er 60 mg (cd) .................................................... 101 methylphenidate hcl chew tab 10 mg 101 methylphenidate hcl chew tab 2.5 mg 101 methylphenidate hcl chew tab 5 mg .. 101 methylphenidate hcl soln 10 mg/5ml . 101 methylphenidate hcl soln 5 mg/5ml ... 101 methylphenidate hcl tab 10 mg ........ 101 methylphenidate hcl tab 20 mg ........ 101 methylphenidate hcl tab 5 mg .......... 101 methylphenidate hcl tab er 10 mg ..... 101 methylphenidate hcl tab er 20 mg ..... 101 methylphenidate hcl tab er 24hr 18 mg .................................................... 101 methylphenidate hcl tab er 24hr 27 mg .................................................... 101

277

methylphenidate hcl tab er 24hr 36 mg ................................................... 101 methylphenidate hcl tab er 24hr 54 mg ................................................... 101 methylphenidate hcl tab er osmotic release (osm) 18 mg ...................... 102 methylphenidate hcl tab er osmotic release (osm) 27 mg ...................... 102 methylphenidate hcl tab er osmotic release (osm) 36 mg ...................... 102 methylphenidate hcl tab er osmotic release (osm) 54 mg ...................... 102 methylprednisolone acetate inj susp 40 mg/ml .......................................... 132 methylprednisolone acetate inj susp 80 mg/ml .......................................... 132 methylprednisolone sod succ for inj 1000 mg (base equiv) ............................. 132 methylprednisolone sod succ for inj 125 mg (base equiv) ............................. 132 methylprednisolone sod succ for inj 40 mg (base equiv) ............................. 132 methylprednisolone tab 16 mg ......... 132 methylprednisolone tab 32 mg ......... 132 methylprednisolone tab 4 mg ........... 132 methylprednisolone tab 8 mg ........... 132 methylprednisolone tab therapy pack 4 mg (21) ........................................ 132 metipranolol ophth soln 0.3% .......... 219 METOCLOPRAMI TAB 10MG ODT ....... 141 metoclopramide hcl inj 5 mg/ml ....... 141 metoclopramide hcl orally disintegrating tab 5 mg (base eq) ......................... 141 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) ...................................... 141 metoclopramide hcl tab 10 mg ......... 141 metoclopramide hcl tab 5 mg ........... 141 metolazone tab 10 mg ...................... 67 metolazone tab 2.5 mg ..................... 67 metolazone tab 5 mg ........................ 67 metoprolol & hydrochlorothiazide tab 100-25 mg ...................................... 59 metoprolol & hydrochlorothiazide tab 100-50 mg ...................................... 59 metoprolol & hydrochlorothiazide tab 50-25 mg ............................................ 59 metoprolol succinate tab er 24hr 100 mg (tartrate equiv) ................................ 61

metoprolol succinate tab er 24hr 200 mg (tartrate equiv) ............................... 61 metoprolol succinate tab er 24hr 25 mg (tartrate equiv) ............................... 61 metoprolol succinate tab er 24hr 50 mg (tartrate equiv) ............................... 61 metoprolol tartrate iv soln 5 mg/5ml .. 61 metoprolol tartrate tab 100 mg ......... 61 metoprolol tartrate tab 25 mg ........... 61 metoprolol tartrate tab 50 mg ........... 61 metoprolol tartrate tab 75 mg ........... 61 METRO IV INJ 5MG/ML ..................... 35 METROCREAM CRE 0.75% ............... 213 METROGEL GEL 1% ........................ 213 METROGEL-VAG GEL 0.75% ............. 155 METROLOTION LOT 0.75% ............... 213 metronidazole cap 375 mg ................ 35 metronidazole gel 0.75% ................. 213 metronidazole gel 1% ..................... 213 metronidazole in nacl 0.79% iv soln 500 mg/100ml ...................................... 35 metronidazole lotion 0.75% ............. 213 metronidazole tab 250 mg ................ 35 metronidazole tab 500 mg ................ 35 metronidazole vaginal gel 0.75% ...... 155 MEXSANA POW .............................. 212 MG SO4/D5W INJ 10MG/ML ............. 175 mgo tab 400mg .............................. 181 MIACALCIN SPR 200/ACT ................ 125 MICARDIS HCT TAB 40/12.5 ............. 53 MICARDIS HCT TAB 80/12.5 ............. 53 MICARDIS HCT TAB 80-25MG ............ 53 MICARDIS TAB 20MG ....................... 54 MICARDIS TAB 40MG ....................... 54 MICARDIS TAB 80MG ....................... 54 miconazole 3 kit combinat ............... 155 miconazole 3 kit combo pk ............... 155 miconazole 3 sup 200mg ................. 155 miconazole 7 cre 2% ....................... 155 miconazole nitrate aerosol pow 2% ... 204 miconazole nitrate vaginal supp 1200 mg & 2% cream kit .............................. 155 miconazorb pow af 2% .................... 204 micrgstin 24 tab fe 1/20 .................. 127 MICRO-BUMIN KIT .......................... 123 microgestin tab 1.5/30 .................... 127 microgestin tab 1/20 ....................... 127 microgestin tab fe1.5/30 ................. 127

278

MICRO-K CAP 10MEQ CR ................. 172 MICRO-K CAP 8MEQ CR ................... 172 MICROLIFE MIS PEAK FLO ............... 195 MICROLIPID EMU 50% .................... 173 MICROZIDE CAP 12.5MG ................... 67 midazolam hcl inj 10 mg/10ml (base equivalent) .................................... 104 midazolam hcl inj 10 mg/2ml (base equivalent) .................................... 104 midazolam hcl inj 2 mg/2ml (base equivalent) .................................... 104 midazolam hcl inj 25 mg/5ml (base equivalent) .................................... 104 midazolam hcl inj 5 mg/5ml (base equivalent) .................................... 104 midazolam hcl inj 5 mg/ml (base equivalent) .................................... 104 midazolam hcl inj 50 mg/10ml (base equivalent) .................................... 104 midazolam hcl syrup 2 mg/ml (base equivalent) .................................... 104 midodrine hcl tab 10 mg ................... 68 midodrine hcl tab 2.5 mg .................. 68 midodrine hcl tab 5 mg ..................... 68 migergot sup 2/100 ........................ 106 migraine tab formula ......................... 2 MIGRANAL SPR 4MG/ML .................. 106 milk of magn sus 1200/15 ............... 146 MILK OF MAGN SUS 800/5ML ........... 146 MILLIPRED DP PAK 5MG .................. 132 MILLIPRED SOL 10MG/5ML .............. 132 MILLIPRED TAB 5MG ....................... 132 milrinone lactate in dextrose 5% iv soln 20 mg/100ml ................................... 68 milrinone lactate in dextrose 5% iv soln 40 mg/200ml ................................... 68 milrinone lactate iv soln 10 mg/10ml (base equivalent) ............................. 68 milrinone lactate iv soln 20 mg/20ml (base equivalent) ............................. 68 milrinone lactate iv soln 50 mg/50ml (base equivalent) ............................. 68 MINASTRIN 24 CHW FE ................... 127 mineral oil enema ........................... 146 MINI WRIGHT MIS PFM ................... 195 MINI WRIGHT MIS PFM LOW ............ 195 MINILINK RT KIT STARTER .............. 123 MINIPRESS CAP 1MG ........................ 50

MINIPRESS CAP 2MG ....................... 50 MINIPRESS CAP 5MG ....................... 50 MINIVELLE DIS 0.0375MG ............... 130 MINOCIN CAP 100MG ....................... 25 MINOCIN CAP 50MG ........................ 25 MINOCIN CAP 75MG ........................ 25 MINOCIN INJ 100MG ........................ 25 minocycline hcl cap 100 mg .............. 25 minocycline hcl cap 50 mg ................ 25 minocycline hcl cap 75 mg ................ 25 minocycline hcl tab 100 mg ............... 25 minocycline hcl tab 50 mg ................ 25 minocycline hcl tab 75 mg ................ 25 minocycline hcl tab er 24hr 135 mg ... 25 minocycline hcl tab er 24hr 45 mg ..... 25 minocycline hcl tab er 24hr 90 mg ..... 25 minoxidil tab 10 mg ......................... 68 minoxidil tab 2.5 mg ........................ 68 MIOCHOL-E SOL 1:100 .................... 221 MIOSTAT INJ 0.01% OP .................. 221 MIRALAX POW 3350 NF ................... 146 MIRAPEX ER TAB 0.375MG ................ 88 MIRAPEX ER TAB 0.75MG ................. 88 MIRAPEX ER TAB 1.5MG ................... 88 MIRAPEX ER TAB 2.25MG ................. 88 MIRAPEX ER TAB 3.75MG ................. 88 MIRAPEX ER TAB 3MG ...................... 88 MIRAPEX ER TAB 4.5MG ................... 88 MIRAPEX TAB 0.125MG .................... 88 MIRAPEX TAB 0.25MG ...................... 88 MIRAPEX TAB 0.5MG ........................ 88 MIRAPEX TAB 0.75MG ...................... 88 MIRAPEX TAB 1.5MG ........................ 88 MIRAPEX TAB 1MG .......................... 88 MIRCERA INJ 100MCG ..................... 160 MIRCERA INJ 200MCG ..................... 160 MIRCERA INJ 50MCG ....................... 160 MIRCERA INJ 75MCG ....................... 160 MIRCETTE TAB 28 DAY .................... 125 MIRENA IUD SYSTEM ...................... 127 mirtazapine orally disintegrating tab 15 mg ................................................ 82 mirtazapine orally disintegrating tab 30 mg ................................................ 82 mirtazapine orally disintegrating tab 45 mg ................................................ 82 mirtazapine tab 15 mg ..................... 82 mirtazapine tab 30 mg ..................... 82

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mirtazapine tab 45 mg ...................... 82 mirtazapine tab 7.5 mg ..................... 82 MIRVASO GEL 0.33% ...................... 213 misoprostol tab 100 mcg ................. 149 misoprostol tab 200 mcg ................. 149 MISSION PREN TAB ........................ 181 MISSION PREN TAB HP ................... 181 mitomycin for iv soln 20 mg ............... 44 mitomycin for iv soln 40 mg ............... 44 mitomycin for iv soln 5 mg ................ 44 MITOSOL KIT 0.2MG ....................... 217 mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml) ........................................... 44 mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) ....................................... 44 mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml) ........................................... 45 MOBIC TAB 15MG .............................. 3 MOBIC TAB 7.5MG ............................. 3 modafinil tab 100 mg ...................... 111 modafinil tab 200 mg ...................... 111 MODERIBA PAK 1200/DAY ................. 32 MODERIBA PAK 800/DAY ................... 32 MODERIBA TAB 1000/DAY ................. 32 MODERIBA TAB 600/DAY ................... 32 MODICON TAB 0.5/35 ..................... 127 moexipril hcl tab 15 mg ..................... 49 moexipril hcl tab 7.5 mg .................... 49 moexipril-hydrochlorothiazide tab 15-12.5 mg .......................................... 48 moexipril-hydrochlorothiazide tab 15-25 mg ................................................. 48 moexipril-hydrochlorothiazide tab 7.5-12.5 mg .......................................... 47 mometasone furoate cream 0.1% ..... 209 mometasone furoate nasal susp 50 mcg/act ........................................ 196 mometasone furoate oint 0.1% ........ 209 mometasone furoate solution 0.1% (lotion) ......................................... 209 MONISTAT 3 KIT COMBO PK ............ 155 MONOCLATE-P INJ 1000UNIT ........... 159 MONOCLATE-P INJ 1500UNIT ........... 159 MONODOX CAP 100MG ..................... 25 MONODOX CAP 75MG ....................... 25 mononessa tab .............................. 127 MONONINE INJ 1000UNIT ............... 159 MONONINE INJ 500UNIT ................. 159

montelukast sodium chew tab 4 mg (base equiv) .................................. 194 montelukast sodium chew tab 5 mg (base equiv) .................................. 194 montelukast sodium oral granules packet 4 mg (base equiv) .......................... 194 montelukast sodium tab 10 mg (base equiv) ........................................... 194 MORE-DOPHILU POW ACIDOPHI ....... 148 MORGIDOX KIT 1X100MG ................. 25 MORGIDOX KIT 2X100MG ................. 25 MORPHINE SUL INJ 10/0.7ML ............ 11 MORPHINE SUL INJ 150/30ML ........... 11 MORPHINE SUL INJ 2MG/ML.............. 11 MORPHINE SUL INJ 4MG/ML.............. 11 MORPHINE SUL INJ 5MG/ML.............. 11 MORPHINE SUL INJ 8MG/ML.............. 11 MORPHINE SUL SUP 30MG ................ 11 morphine sulfate beads cap er 24hr 120 mg ................................................ 11 morphine sulfate beads cap er 24hr 30 mg ................................................ 11 morphine sulfate beads cap er 24hr 45 mg ................................................ 11 morphine sulfate beads cap er 24hr 60 mg ................................................ 11 morphine sulfate beads cap er 24hr 75 mg ................................................ 11 morphine sulfate beads cap er 24hr 90 mg ................................................ 11 morphine sulfate cap er 24hr 10 mg ... 11 morphine sulfate cap er 24hr 100 mg . 11 morphine sulfate cap er 24hr 20 mg ... 11 morphine sulfate cap er 24hr 30 mg ... 11 morphine sulfate cap er 24hr 50 mg ... 11 morphine sulfate cap er 24hr 60 mg ... 11 morphine sulfate cap er 24hr 80 mg ... 11 morphine sulfate inj 10 mg/ml .......... 11 morphine sulfate inj 15 mg/ml .......... 11 morphine sulfate inj 8 mg/ml ............ 11 morphine sulfate inj pf 0.5 mg/ml ...... 11 morphine sulfate inj pf 1 mg/ml ......... 11 morphine sulfate iv soln 1 mg/ml ....... 12 morphine sulfate iv soln 25 mg/ml ..... 12 morphine sulfate iv soln 50 mg/ml ..... 12 morphine sulfate iv soln pf 10 mg/ml . 12 morphine sulfate iv soln pf 15 mg/ml . 12 morphine sulfate iv soln pf 4 mg/ml ... 12

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morphine sulfate iv soln pf 8 mg/ml .... 12 morphine sulfate oral soln 10 mg/5ml . 12 morphine sulfate oral soln 100 mg/5ml (20 mg/ml) ..................................... 12 morphine sulfate oral soln 20 mg/5ml . 12 morphine sulfate suppos 10 mg .......... 12 morphine sulfate suppos 20 mg .......... 12 morphine sulfate suppos 5 mg ........... 12 morphine sulfate tab 15 mg ............... 12 morphine sulfate tab 30 mg ............... 12 morphine sulfate tab er 100 mg ......... 12 morphine sulfate tab er 15 mg ........... 12 morphine sulfate tab er 200 mg ......... 12 morphine sulfate tab er 30 mg ........... 12 morphine sulfate tab er 60 mg ........... 12 MOTOFEN TAB 1-0.025 ................... 140 MOVANTIK TAB 12.5MG .................. 148 MOVANTIK TAB 25MG ..................... 148 move along tab 100mg ................... 146 MOVIPREP SOL .............................. 146 MOXATAG TAB 775MG ...................... 23 MOXEZA SOL 0.5% ......................... 217 moxifloxacin hcl 400 mg/250ml in sodium chloride 0.8% inj ................... 21 moxifloxacin hcl ophth soln 0.5% (base equiv) ........................................... 217 moxifloxacin hcl tab 400 mg (base equiv) ..................................................... 21 MOXIFLOXACIN INJ .......................... 21 MOZOBIL INJ ................................. 164 MS CONTIN TAB 100MG ER................ 12 MS CONTIN TAB 15MG ER ................. 12 MS CONTIN TAB 200MG ER................ 12 MS CONTIN TAB 30MG ER ................. 12 MS CONTIN TAB 60MG ER ................. 12 MTERYTI TAB ................................. 181 MTERYTI TAB FOLIC 5 ..................... 181 MUCINEX CGH GRA 5-100MG ........... 190 MUCOTROL WAF ............................. 216 mucus & cong cap 10-200 ............... 190 mucus d tab 120/1200 .................... 190 mucus relief liq 100/5ml .................. 194 mucus relief liq 5-100mg ................. 190 mucus relief tab d .......................... 190 mucus rlf d tab 60-600mg ............... 191 mucus-dm max tab 60-1200 ............ 191 mucus-dm tab 30-600mg ................ 191 mucus-er tab 600mg ...................... 194

MUGARD LIQ ................................. 216 MULIT-DRAW MIS 22GX1.5"............. 169 MULTAQ TAB 400MG ........................ 55 MULTI PRENAT TAB ......................... 181 multi vit/fl dro 0.5mg/ml ................. 181 multi-delyn liq ................................ 181 MULTI-DELYN LIQ /IRON ................. 181 MULTI-DRAW MIS 20GX1.5 .............. 169 MULTI-DRAW MIS 21GX1.5"............. 169 MULTIGEN PLS TAB ......................... 181 MULTIGEN TAB ............................... 181 multiple minerals tab ...................... 181 MULTITRACE-4 INJ ......................... 175 multitrace-4 inj conc ....................... 175 MULTITRACE-4 INJ NEONATAL ......... 175 MULTITRACE-4 INJ PED ................... 175 multitrace-5 inj conc ....................... 175 MULTITRACE-5 INJ REGULAR ........... 175 multi-vit/fe dro /fl 0.25 ................... 181 multi-vit/fl dro 0.25mg .................... 181 multivitamin dro pediatrc ................. 181 multivitamin liq mineral ................... 181 mupirocin calcium cream 2% ........... 203 mupirocin oint 2% .......................... 203 mv-one cap ................................... 181 my way tab 1.5mg .......................... 125 MYALEPT INJ 11.3MG ...................... 135 MYAMBUTOL TAB 400MG .................. 31 MYCAMINE INJ 100MG ..................... 26 MYCAMINE INJ 50MG ....................... 26 mycophenolate mofetil cap 250 mg ... 167 mycophenolate mofetil for oral susp 200 mg/ml .......................................... 167 MYCOPHENOLATE MOFETIL HCL FOR IV SOLN 500 MG (BASE EQUIV) ............ 167 mycophenolate mofetil tab 500 mg ... 167 mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) ............... 168 mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) ............... 168 MYDRIACYL SOL 1% OP .................. 221 myferon 150 cap forte ..................... 181 MYKIDZ IRON SUS 10MG/2ML .......... 181 MYLERAN TAB 2MG .......................... 37 MYNATAL CAP ................................ 181 MYNATAL TAB ................................ 181 MYNATAL-Z TAB ............................. 181 MYNATE 90 TAB PLUS ..................... 181

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mynephrocaps cap ......................... 181 MYRBETRIQ TAB 25MG .................... 154 MYRBETRIQ TAB 50MG .................... 154 MYSOLINE TAB 250MG ...................... 78 MYSOLINE TAB 50MG ........................ 78 MYTESI TAB 125MG ........................ 140 N nabumetone tab 500 mg .................... 4 nabumetone tab 750 mg .................... 4 nadolol & bendroflumethiazide tab 40-5 mg ................................................. 59 nadolol & bendroflumethiazide tab 80-5 mg ................................................. 59 nadolol tab 20 mg ............................ 61 nadolol tab 40 mg ............................ 61 nadolol tab 80 mg ............................ 61 NAFCILLIN INJ 1GM/50ML ................. 23 NAFCILLIN INJ 2GM/100 ................... 23 nafcillin sodium for inj 1 gm ............... 23 nafcillin sodium for inj 10 gm ............. 23 nafcillin sodium for inj 2 gm ............... 23 nafcillin sodium for iv soln 1 gm ......... 23 nafcillin sodium for iv soln 2 gm ......... 23 NAFRINSE DLY SOL /NEUTRAL ......... 215 NAFRINSE SOL DAILY ..................... 215 NAFRINSE WK SOL 0.2% ................. 215 NAFTIN CRE 2% ............................. 204 NAFTIN GEL 1% ............................. 204 NAFTIN GEL 2% ............................. 204 NAGLAZYME INJ 1MG/ML ................. 135 nalbuphine hcl inj 10 mg/ml .............. 12 nalbuphine hcl inj 20 mg/ml .............. 12 NALFON CAP 400MG .......................... 4 naloxone hcl inj 0.4 mg/ml .............. 112 naloxone hcl inj 4 mg/10ml ............. 112 naloxone hcl soln cartridge 0.4 mg/ml ................................................... 112 naloxone hcl soln prefilled syringe 2 mg/2ml ......................................... 112 naltrexone hcl tab 50 mg ................. 112 NAMENDA XR CAP 14MG ................... 81 NAMENDA XR CAP 21MG ................... 81 NAMENDA XR CAP 28MG ................... 81 NAMENDA XR CAP 7MG ..................... 81 NAMENDA XR CAP TITRATIO .............. 81 NAMZARIC CAP 14-10MG .................. 81 NAMZARIC CAP 21-10MG .................. 81 NAMZARIC CAP 28-10MG .................. 81

NAMZARIC CAP 7-10MG ................... 81 NANOVM T/F LIQ ............................ 181 NANOVM T/F POW .......................... 181 NAPRELAN TAB 375MG CR .................. 4 NAPRELAN TAB 500MG CR .................. 4 NAPRELAN TAB 750MG CR .................. 4 NAPROSYN SUS 125/5ML .................... 4 NAPROSYN TAB 500MG ...................... 4 naproxen dr tab 375mg ...................... 4 naproxen dr tab 500mg ...................... 4 NAPROXEN KIT COMFORT ................... 5 naproxen sodium cap 220 mg ............. 4 naproxen sodium tab 275 mg .............. 4 naproxen sodium tab 550 mg .............. 4 naproxen sodium tab er 24hr 375 mg (base equiv) ..................................... 4 naproxen susp 125 mg/5ml ................ 4 naproxen tab 250 mg ......................... 4 naproxen tab 375 mg ......................... 4 naproxen tab 500 mg ......................... 4 naratriptan hcl tab 1 mg (base equiv) 107 naratriptan hcl tab 2.5 mg (base equiv) .................................................... 107 NARCAN SPR ................................. 112 NARDIL TAB 15MG ........................... 82 NASACORT ALR SPR 55MCG/AC ........ 196 NASADROPS DRO 0.9% ................... 196 nasal 12 hr spr 0.05% ..................... 198 nasal decon syp 30mg/5ml .............. 194 nasal decong tab 10mg ................... 194 nasal decong tab 30mg ................... 194 nasal moist spr 0.65% .................... 196 NASONEB NSL MIS STARTER ............ 195 NASONEX SPR 50MCG/AC ................ 196 NAT FIBER POW 58.6% ................... 146 NATACHEW CHW ............................ 181 NATACYN SUS 5% OP ..................... 218 NATALVIT TAB 75-1MG .................... 181 NATAZIA TAB ................................. 125 nateglinide tab 120 mg ................... 118 nateglinide tab 60 mg ..................... 118 NATELLE ONE CAP .......................... 182 NATESTO GEL 5.5MG ...................... 113 NATPARA INJ 100MCG ..................... 125 NATPARA INJ 25MCG ...................... 125 NATPARA INJ 50MCG ...................... 125 NATPARA INJ 75MCG ...................... 125 NATRECOR INJ 1.5MG ...................... 68

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NATROBA SUS 0.9% ....................... 214 NATURE THROI TAB 162.5MG .......... 138 NATURE-THROI TAB 113.75MG ........ 138 NATURE-THROI TAB 130MG ............. 138 NATURE-THROI TAB 146.25MG ........ 138 NATURE-THROI TAB 16.25MG .......... 138 NATURE-THROI TAB 195MG ............. 138 NATURE-THROI TAB 260MG ............. 138 NATURE-THROI TAB 32.5MG ............ 138 NATURE-THROI TAB 325MG ............. 138 NATURE-THROI TAB 48.75MG .......... 138 NATURE-THROI TAB 65MG ............... 138 NATURE-THROI TAB 81.25MG .......... 138 NATURE-THROI TAB 97.5MG ............ 138 naturl fiber pow 30.9% ................... 146 NAVELBINE INJ 10MG/ML .................. 45 NAVELBINE INJ 50MG/5ML ................ 45 NEBULIZER MIS COMPRESS ............. 195 NEBUPENT INH 300MG ...................... 35 nebusal neb 3% ............................. 196 NEBUSAL NEB 6% .......................... 196 necon tab 0.5/35 ............................ 127 necon tab 1/35 .............................. 127 necon tab 1/50-28 .......................... 127 NECON TAB 10/11-28 ..................... 125 necon tab 7/7/7 ............................. 128 NEEDLES MIS 19GX1" ..................... 169 NEEDLES MIS 25GX1.5" .................. 169 NEEDLES MIS 26X1/2" .................... 169 NEEDLES MIS 27GX1/2" .................. 169 NEMBUTAL SOD INJ 50MG/ML .......... 105 NEO TO GO SPR 1-0.13% ................ 211 neomycin sulfate tab 500 mg ............. 17 neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml ............. 217 neomycin-polymyxin b gu irrigation soln ................................................... 152 neomycin-polymyxin-dexamethasone ophth oint 0.1% ............................. 216 neomycin-polymyxin-dexamethasone ophth susp 0.1% ............................ 216 neomycin-polymyxin-hc ophth susp .. 216 neomycin-polymyxin-hc otic soln 1% 222 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% ............... 222 neo-polycin oin hc 1%op ................. 216 neo-polycin oin op .......................... 217 NEOPROFEN SOL 10MG/ML ................ 68

NEOSPORIN CRE PLUS .................... 203 NEOSPORIN GU SOL 40/ML IR .......... 152 NEOSPORIN OIN ORIGINAL .............. 203 NEOSPORIN SOL OP........................ 217 NEOSTIG METH INJ 10/10ML ............ 108 NEOSTIGMINE INJ 5MG/10ML .......... 108 neostigmine methylsulfate inj 0.5 mg/ml (1:2000) ....................................... 108 neostigmine methylsulfate inj 1 mg/ml .................................................... 108 neostigmine methylsulfate iv soln 10 mg/10 ml (1 mg/ml) ....................... 108 neostigmine methylsulfate iv soln 5 mg/10 ml (0.5 mg/ml) .................... 108 NEPHRAMINE INJ 5.4% ................... 173 NEPHROCAPS CAP .......................... 182 NEPHRON FA TAB ........................... 182 nephronex tab 1mg ........................ 182 NEPTAZANE TAB 25MG .................... 219 NEPTAZANE TAB 50MG .................... 219 NERLYNX TAB 40MG ........................ 41 NESINA TAB 12.5MG ....................... 115 NESINA TAB 25MG.......................... 115 NESINA TAB 6.25MG ....................... 115 NESTABS ABC MIS .......................... 182 NESTABS DHA PAK ......................... 182 neuac gel 1.2-5% ........................... 201 NEULASTA KIT 6MG/0.6M ................ 160 NEUPOGEN INJ 300/0.5 ................... 160 NEUPOGEN INJ 300MCG .................. 160 NEUPOGEN INJ 480/0.8 ................... 160 NEUPOGEN INJ 480MCG .................. 161 NEUPRO DIS 1MG/24HR ................... 88 NEUPRO DIS 2MG/24HR ................... 89 NEUPRO DIS 3MG/24HR ................... 89 NEUPRO DIS 4MG/24HR ................... 89 NEUPRO DIS 6MG/24HR ................... 89 NEUPRO DIS 8MG/24HR ................... 89 NEURONTIN CAP 100MG ................... 78 NEURONTIN CAP 300MG ................... 78 NEURONTIN CAP 400MG ................... 78 NEURONTIN SOL 250/5ML ................ 78 NEURONTIN TAB 600MG ................... 78 NEURONTIN TAB 800MG ................... 78 NEUT INJ 4% ................................. 182 NEUTRASAL POW ............................ 215 neutrogena gel rainbath .................. 212 NEVANAC SUS 0.1% ....................... 217

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nevirapine susp 50 mg/5ml ............... 29 nevirapine tab 200 mg ...................... 29 nevirapine tab er 24hr 100 mg ........... 29 nevirapine tab er 24hr 400 mg ........... 29 NEWGEN TAB 32-1MG ..................... 182 NEXA PLUS CAP ............................. 182 nexafed tab 30mg .......................... 194 NEXAVAR TAB 200MG ....................... 41 NEXIUM 24HR CAP 20MG ................ 150 NEXIUM CAP 20MG ......................... 150 NEXIUM CAP 40MG ......................... 150 NEXIUM GRA 10MG DR ................... 150 NEXIUM GRA 2.5MG DR .................. 150 NEXIUM GRA 20MG DR ................... 150 NEXIUM GRA 40MG DR ................... 150 NEXIUM GRA 5MG DR ..................... 150 NEXIUM I.V. INJ 40MG .................... 150 NEXPLANON IMP 68MG ................... 125 NEXTERONE INJ ............................... 55 niacin cap 400mg ........................... 182 niacin cap 500mg ............................. 68 niacin cap er 250 mg ...................... 182 niacin cap er 500 mg ...................... 182 NIACIN FLUSH CAP FREE ................... 68 niacin tab 100 mg .......................... 182 niacin tab 250 mg .......................... 182 niacin tab 50 mg ............................ 182 niacin tab 500 mg .......................... 182 niacin tab er 1000 mg (antihyperlipidemic) .......................... 59 niacin tab er 500 mg ....................... 182 niacin tab er 500 mg (antihyperlipidemic) ..................................................... 59 niacin tab er 750 mg ....................... 182 niacin tab er 750 mg (antihyperlipidemic) ..................................................... 59 NIACIN TR TAB 1000MG .................. 182 niacinamide tab 100 mg .................. 182 niacinamide tab 500 mg .................. 182 NIACINAMIDE TAB 500MG PR .......... 182 niacor tab 500mg ............................. 59 NIASPAN TAB 1000 ER ...................... 59 NIASPAN TAB 500MG ER ................... 59 NIASPAN TAB 750MG ER ................... 59 nicardipine hcl cap 20 mg .................. 63 nicardipine hcl cap 30 mg .................. 63 nicardipine hcl iv soln 2.5 mg/ml ........ 63 nicotine polacrilex gum 2 mg ........... 113

nicotine polacrilex gum 4 mg ............ 113 nicotine polacrilex lozenge 2 mg ....... 113 nicotine polacrilex lozenge 4 mg ....... 113 NICOTINE SYS KIT TRANSDER ......... 113 nicotine td patch 24hr 14 mg/24hr .... 113 NICOTROL INH ............................... 113 NICOTROL NS SPR 10MG/ML ............ 113 nifedipine tab er 24hr 30 mg ............. 63 nifedipine tab er 24hr 60 mg ............. 63 nifedipine tab er 24hr 90 mg ............. 63 nifedipine tab er 24hr osmotic release 30 mg ................................................ 63 nifedipine tab er 24hr osmotic release 60 mg ................................................ 63 nifedipine tab er 24hr osmotic release 90 mg ................................................ 63 nilutamide tab 150 mg ..................... 39 nimodipine cap 30 mg ...................... 63 NINLARO CAP 2.3MG ........................ 45 NINLARO CAP 3MG .......................... 45 NINLARO CAP 4MG .......................... 45 NIPENT INJ 10MG ............................ 45 nisoldipine tab er 24hr 17 mg ............ 63 nisoldipine tab er 24hr 20 mg ............ 63 nisoldipine tab er 24hr 25.5 mg ......... 63 nisoldipine tab er 24hr 30 mg ............ 63 nisoldipine tab er 24hr 34 mg ............ 63 nisoldipine tab er 24hr 40 mg ............ 63 nisoldipine tab er 24hr 8.5 mg ........... 63 NITHIODOTE KIT ............................ 123 NITRO-BID OIN 2% ......................... 70 NITRO-DUR DIS 0.3MG/HR ............... 70 NITRO-DUR DIS 0.8MG/HR ............... 70 nitrofurantoin macrocrystalline cap 100 mg ................................................ 35 nitrofurantoin macrocrystalline cap 25 mg ................................................ 35 nitrofurantoin macrocrystalline cap 50 mg ................................................ 35 nitrofurantoin monohydrate macrocrystalline cap 100 mg ............. 35 nitrofurantoin susp 25 mg/5ml .......... 35 NITROGLYCER INJ 5MG/ML ............... 69 nitroglycerin iv soln 100 mcg/ml in d5w ..................................................... 69 nitroglycerin iv soln 200 mcg/ml in d5w ..................................................... 69 nitroglycerin iv soln 400 mcg/ml in d5w

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..................................................... 69 nitroglycerin lingual aerosol 400 mcg/spray ....................................... 69 nitroglycerin sl tab 0.3 mg ................. 69 nitroglycerin sl tab 0.4 mg ................. 69 nitroglycerin sl tab 0.6 mg ................. 69 nitroglycerin td patch 24hr 0.1 mg/hr .. 70 nitroglycerin td patch 24hr 0.2 mg/hr .. 70 nitroglycerin td patch 24hr 0.4 mg/hr .. 70 nitroglycerin td patch 24hr 0.6 mg/hr .. 70 nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) ..................................... 69 NITROLINGUAL SPR PUMPSPRA .......... 69 NITROMIST AER 400MCG .................. 70 NITRONAL SOL 1MG/ML .................... 69 NITROPRESS INJ 25MG/ML ................ 69 nitro-time cap 2.5mg cr .................... 69 nitro-time cap 6.5mg cr .................... 69 nitro-time cap 9mg cr ....................... 69 nizatidine cap 150 mg ..................... 144 nizatidine cap 300 mg ..................... 144 nizatidine oral soln 15 mg/ml ........... 144 NIZORAL A-D SHA 1% .................... 204 NIZORAL SHA 2% .......................... 204 NORCO TAB 10-325MG ..................... 12 NORCO TAB 5-325MG ....................... 12 NORCO TAB 7.5-325 ......................... 12 NORDITROPIN INJ 10/1.5ML ............ 133 NORDITROPIN INJ 15/1.5ML ............ 133 NORDITROPIN INJ 30/3ML ............... 133 NORDITROPIN INJ 5/1.5ML .............. 133 norepinephrine bitartrate iv soln 1 mg/ml ..................................................... 72 norethindrone acetate tab 5 mg ....... 137 NORITATE CRE 1% ......................... 213 NORMOSOL -M INJ /D5W ................ 174 NORMOSOL -R INJ .......................... 174 NORMOSOL -R INJ /D5W ................. 174 NORMOSOL-R INJ PH 7.4 ................ 174 NORPACE CAP 100MG ....................... 55 NORPACE CAP 100MG CR .................. 55 NORPACE CAP 150MG ....................... 55 NORPACE CAP 150MG CR .................. 55 NORTHERA CAP 100MG ..................... 69 NORTHERA CAP 200MG ..................... 69 NORTHERA CAP 300MG ..................... 69 nortriptyline hcl cap 10 mg ................ 87 nortriptyline hcl cap 25 mg ................ 87

nortriptyline hcl cap 50 mg ............... 87 nortriptyline hcl cap 75 mg ............... 87 nortriptyline hcl soln 10 mg/5ml ........ 87 NORVASC TAB 10MG ........................ 63 NORVASC TAB 2.5MG ....................... 63 NORVASC TAB 5MG ......................... 63 NORVIR CAP 100MG ........................ 29 NORVIR SOL 80MG/ML ..................... 29 NORVIR TAB 100MG ........................ 29 nose dro 1% .................................. 198 NOVAFERRUM CAP 50MG ................. 182 novaferrum dro 10mg/ml ................. 182 NOVAFERRUM DRO 15MG/ML ........... 182 NOVAFERRUM LIQ 125 .................... 182 novarel inj 10000unt ....................... 130 NOVOEIGHT INJ 1000UNIT .............. 159 NOVOEIGHT INJ 1500UNIT .............. 159 NOVOEIGHT INJ 2000UNIT .............. 159 NOVOEIGHT INJ 250UNIT ................ 159 NOVOEIGHT INJ 500UNIT ................ 159 NOVOLIN INJ 70/30 ........................ 117 NOVOLIN N INJ U-100 ..................... 117 NOVOLIN R INJ U-100 ..................... 117 NOVOLOG INJ 100/ML ..................... 117 NOVOLOG INJ FLEXPEN ................... 117 NOVOLOG INJ PENFILL .................... 117 NOVOLOG MIX INJ 70/30 ................. 117 NOVOLOG MIX INJ FLEXPEN ............. 118 NOVOSEVEN RT INJ 1MG ................. 159 NOVOSEVEN RT INJ 2MG ................. 159 NOVOSEVEN RT INJ 5MG ................. 159 NOVOSEVEN RT INJ 8MG ................. 159 NOVOTWIST MIS 32GX5MM ............. 123 NOXAFIL INJ 300/16.7 ..................... 26 NOXAFIL SUS 40MG/ML .................... 26 NOXAFIL TAB 100MG ....................... 26 np thyroid tab 15mg ....................... 138 np thyroid tab 30mg ....................... 138 np thyroid tab 60mg ....................... 138 np thyroid tab 90mg ....................... 138 NUCYNTA ER TAB 100MG .................. 13 NUCYNTA ER TAB 150MG .................. 13 NUCYNTA ER TAB 200MG .................. 13 NUCYNTA ER TAB 250MG .................. 13 NUCYNTA ER TAB 50MG ................... 12 NUCYNTA TAB 100MG ...................... 13 NUCYNTA TAB 50MG ........................ 13 NUCYNTA TAB 75MG ........................ 13

285

NUEDEXTA CAP 20-10MG ................ 113 NULOJIX INJ 250MG ....................... 168 NULYTELY SOL FLAV PKS ................. 146 NUMOISYN LOZ ............................. 215 NUOX GEL 6-3% ............................ 201 NUPLAZID TAB 17MG ........................ 92 NUTR DRINK POW MIX VAN ............. 171 NUTRICION TAB PORVIDA ............... 182 NUTRIENTS TAB PRENATAL ............. 182 nutrilipid emu 20% ......................... 173 NUTRIVIT LIQ 800-15-1 .................. 182 NUTROPIN AQ INJ 10MG/2ML ........... 133 NUTROPIN AQ INJ 20MG/2ML ........... 134 NUTROPIN AQ INJ NUSPIN 5 ............ 134 NUVARING MIS .............................. 128 NUVESSA GEL 1.3% ....................... 155 NUVIGIL TAB 150MG ...................... 111 NUVIGIL TAB 200MG ...................... 111 NUVIGIL TAB 250MG ...................... 111 NUVIGIL TAB 50MG ........................ 111 NUWIQ INJ 1000UNIT ..................... 159 NUWIQ INJ 2000UNIT ..................... 159 NUWIQ INJ 250UNIT ....................... 159 NUWIQ INJ 500UNIT ....................... 159 NUWIQ KIT 1000UNIT ..................... 159 NUWIQ KIT 2000UNIT ..................... 159 NUWIQ KIT 250UNIT ...................... 159 NUWIQ KIT 500UNIT ...................... 159 NYMALIZE SOL 60/20ML .................... 63 nystatin cream 100000 unit/gm ....... 204 nystatin oint 100000 unit/gm ........... 204 nystatin oral powder ......................... 26 nystatin susp 100000 unit/ml ............. 27 nystatin tab 500000 unit ................... 27 nystatin topical powder 100000 unit/gm ................................................... 204 nystatin-triamcinolone cream 100000-0.1 unit/gm-% ............................... 204 nystatin-triamcinolone oint 100000-0.1 unit/gm-% .................................... 204 O OASIS MATRIX MIS 3X7CM .............. 214 OASIS MOUTH SPR 35% ................. 215 OASIS ULTRA MIS 3X3.5CM ............. 214 OASIS ULTRA MIS 5 X 7CM .............. 214 OASIS ULTRA MIS TRI MESH ........... 214 OB COMPLETE CAP GOLD ................ 182 OB COMPLETE CAP ONE .................. 182

OB COMPLETE CAP PETITE ............... 182 OB COMPLETE TAB ......................... 182 OB COMPLETE TAB PREMIER ............ 182 OB COMPLETE/ CAP DHA ................. 182 OBIZUR INJ 500 UNIT ..................... 159 OBREDON SOL 2.5-200 ................... 191 OBSTETRIX EC TAB ......................... 182 OBSTETRIX PAK DHA ...................... 182 OBTREX DHA PAK ........................... 182 OBTREX TAB .................................. 182 OC8 GEL 7% .................................. 201 O-CAL TAB PRENATAL ..................... 182 OCALIVA TAB 10MG ........................ 148 OCALIVA TAB 5MG .......................... 148 OCTAGAM INJ 10/100ML ................. 166 OCTAGAM INJ 10GM ....................... 166 OCTAGAM INJ 1GM ......................... 166 OCTAGAM INJ 2.5GM ...................... 166 OCTAGAM INJ 20/200ML ................. 166 OCTAGAM INJ 25GM ....................... 167 OCTAGAM INJ 2GM/20ML ................ 166 OCTAGAM INJ 5GM ......................... 166 OCTAGAM INJ 5GM/50ML ................ 166 octreotide acetate inj 100 mcg/ml (0.1 mg/ml) ......................................... 135 octreotide acetate inj 50 mcg/ml (0.05 mg/ml) ......................................... 135 octreotide acetate inj 500 mcg/ml (0.5 mg/ml) ......................................... 135 ocucoat sol 2% op .......................... 220 OCUFEN SOL 0.03% OP ................... 217 OCUFLOX DRO 0.3% OP .................. 217 ODEFSEY TAB ................................. 28 ODOMZO CAP 200MG ....................... 45 odor eaters pow 1% ........................ 204 OFEV CAP 100MG ........................... 197 OFEV CAP 150MG ........................... 197 OFIRMEV INJ 10MG/ML ...................... 1 ofloxacin ophth soln 0.3% ............... 217 ofloxacin otic soln 0.3% .................. 222 ofloxacin tab 400 mg ....................... 21 ogestrel tab ................................... 127 olanzapine for im inj 10 mg ............... 93 olanzapine orally disintegrating tab 10 mg ................................................ 93 olanzapine orally disintegrating tab 15 mg ................................................ 93 olanzapine orally disintegrating tab 20

286

mg ................................................. 93 olanzapine orally disintegrating tab 5 mg ..................................................... 93 olanzapine tab 10 mg ....................... 93 olanzapine tab 15 mg ....................... 93 olanzapine tab 2.5 mg ...................... 93 olanzapine tab 20 mg ....................... 93 olanzapine tab 5 mg ......................... 93 olanzapine tab 7.5 mg ...................... 93 olmesartan medoxomil tab 20 mg ....... 54 olmesartan medoxomil tab 40 mg ....... 54 olmesartan medoxomil tab 5 mg ........ 54 olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg .... 53 olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg .... 53 olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg ...... 53 olmesartan-amlodipine-hydrochlorothiazide tab 40-10-12.5 mg ..................................................... 52 olmesartan-amlodipine-hydrochlorothiazide tab 40-10-25 mg .. 52 olmesartan-amlodipine-hydrochlorothiazide tab 40-5-12.5 mg . 52 olmesartan-amlodipine-hydrochlorothiazide tab 40-5-25 mg ... 52 olopatadine hcl nasal soln 0.6% ....... 196 olopatadine hcl ophth soln 0.1% (base equivalent) .................................... 218 olopatadine hcl ophth soln 0.2% (base equivalent) .................................... 218 OLUX AER 0.05% ........................... 210 OLUX-E AER 0.05% ........................ 210 OLYSIO CAP 150MG .......................... 32 OMECLAMOX- MIS PAK.................... 152 omega-3-acid ethyl esters cap 1 gm ... 59 omeprazole cap delayed release 10 mg ................................................... 150 omeprazole cap delayed release 20 mg ................................................... 150 omeprazole cap delayed release 40 mg ................................................... 150 omeprazole magnesium cap dr 20.6 mg (20 mg base equiv) ........................ 150 OMEPRAZOLE TAB 20MG ................. 150 omeprazole-sodium bicarbonate cap 20-1100 mg ....................................... 150

omeprazole-sodium bicarbonate cap 40-1100 mg ....................................... 150 OMNARIS SPR ................................ 196 OMNIPOD KIT STARTER ................... 123 OMNIPOD MIS ................................ 123 OMNIPRED SUS 1% OP ................... 218 OMNITROPE INJ 10/1.5ML ............... 134 OMNITROPE INJ 5.8MG ................... 134 ondansetron hcl inj 4 mg/2ml (2 mg/ml) .................................................... 141 ondansetron hcl inj 40 mg/20ml (2 mg/ml) ......................................... 141 ondansetron hcl oral soln 4 mg/5ml .. 141 ondansetron hcl tab 24 mg .............. 141 ondansetron hcl tab 4 mg ................ 141 ondansetron hcl tab 8 mg ................ 141 ondansetron orally disintegrating tab 4 mg ............................................... 141 ondansetron orally disintegrating tab 8 mg ............................................... 141 ONE A DAY CAP PRENATAL .............. 182 ONE A DAY MIS PRENATAL ............... 182 one daily tab .................................. 182 one daily tab plus iro ....................... 182 ONE-A-DAY TAB WOMENS ............... 182 ONETOUCH PNG KIT INS PUMP ......... 123 ONEXTON GEL 1.2-3.75 ................... 201 ONFI SUS 2.5MG/ML ........................ 78 ONFI TAB 10MG .............................. 78 ONFI TAB 20MG .............................. 78 ONGLYZA TAB 2.5MG ...................... 115 ONGLYZA TAB 5MG ......................... 115 ONIVYDE INJ 4.3MG/ML ................... 46 ONMEL TAB 200MG .......................... 27 OPANA INJ 1MG/ML ......................... 13 OPANA TAB 10MG ............................ 13 OPANA TAB 5MG ............................. 13 OPSUMIT TAB 10MG ........................ 70 optimal-d cap 50000unt .................. 182 ORACEA CAP 40MG ......................... 213 ORACIT SOL .................................. 153 ORAFATE PST 10% ......................... 215 oral electrolyte solution ................... 172 oral saline sol laxative ..................... 146 ORAP TAB 1MG ............................... 96 ORAP TAB 2MG ............................... 96 ORAPRED ODT TAB 10MG ................ 132 ORAPRED ODT TAB 15MG ................ 132

287

ORAPRED ODT TAB 30MG ................ 132 ORAVIG TAB 50MG ........................... 27 ORENCIA CLCK INJ 125MG/ML ......... 164 ORENCIA INJ 125MG/ML ................. 165 ORENCIA INJ 50/0.4 ....................... 164 ORENCIA INJ 87.5/0.7 .................... 165 ORENITRAM TAB 0.125MG ................. 71 ORENITRAM TAB 0.25MG .................. 71 ORENITRAM TAB 1MG ....................... 71 ORENITRAM TAB 2.5MG .................... 71 ORENITRAM TAB 5MG ....................... 71 ORFADIN CAP 10MG ....................... 135 ORFADIN CAP 20MG ....................... 135 ORFADIN CAP 2MG ......................... 135 ORFADIN CAP 5MG ......................... 135 ORFADIN SUS 4MG/ML .................... 135 ORKAMBI TAB 100-125 ................... 193 ORKAMBI TAB 200-125 ................... 193 orphenadrine citrate inj 30 mg/ml .... 110 orphenadrine citrate tab er 12hr 100 mg ................................................... 110 ORTHO MICRON TAB 0.35MG ........... 127 ORTHO TRI- TAB CYCLEN ................ 128 ORTHO TRI- TAB CYCLN LO ............. 128 ORTHO-CYCLEN TAB 0.25/35 ........... 127 ORTHO-NOVUM TAB 1/35 ................ 127 ORTHO-NOVUM TAB 7/7/7 ............... 128 oscion clnsr lot 6% ......................... 201 oseltamivir phosphate cap 30 mg (base equiv) ............................................. 33 oseltamivir phosphate cap 45 mg (base equiv) ............................................. 33 oseltamivir phosphate cap 75 mg (base equiv) ............................................. 34 OSENI TAB 12.5-15 ........................ 115 OSENI TAB 12.5-30 ........................ 115 OSENI TAB 12.5-45 ........................ 115 OSENI TAB 25-15MG ...................... 115 OSENI TAB 25-30MG ...................... 115 OSENI TAB 25-45MG ...................... 115 OSGOOD BIOPS MIS 18GX1" ........... 169 osmitrol inj 10% ............................ 153 osmitrol inj 15% ............................ 153 osmitrol inj 5% .............................. 153 OSMOPREP TAB 1.5GM .................... 146 OSPHENA TAB 60MG ....................... 137 OSTEO-PORETI TAB ........................ 183 OTEZLA TAB 10/20/30 .................... 167

OTEZLA TAB 30MG ......................... 167 OTREXUP INJ 10MG ........................ 165 OTREXUP INJ 15MG ........................ 165 OTREXUP INJ 20MG ........................ 165 OTREXUP INJ 25MG ........................ 165 OTREXUP INJ 7.5/0.4 ...................... 165 OVCON-35 TAB .............................. 127 OVIDE LOT 0.5% ............................ 214 oxacillin sodium for inj 1 gm (base equivalent) ..................................... 23 oxacillin sodium for inj 10 gm (base equivalent) ..................................... 23 oxacillin sodium for inj 2 gm (base equivalent) ..................................... 23 oxaliplatin for iv inj 100 mg .............. 37 oxaliplatin for iv inj 50 mg ................ 37 oxaliplatin iv soln 100 mg/20ml ......... 37 oxaliplatin iv soln 50 mg/10ml ........... 37 OXANDRIN TAB 10MG ..................... 114 OXANDRIN TAB 2.5MG .................... 114 oxandrolone tab 10 mg ................... 114 oxandrolone tab 2.5 mg .................. 114 oxaprozin tab 600 mg ........................ 4 OXAYDO TAB 5MG ........................... 13 OXAYDO TAB 7.5MG ........................ 13 oxazepam cap 10 mg ....................... 73 oxazepam cap 15 mg ....................... 73 oxazepam cap 30 mg ....................... 73 oxcarbazepine susp 300 mg/5ml (60 mg/ml) .......................................... 78 oxcarbazepine tab 150 mg ................ 78 oxcarbazepine tab 300 mg ................ 78 oxcarbazepine tab 600 mg ................ 78 OXISTAT CRE 1% ........................... 204 OXISTAT LOT 1% ........................... 204 OXSORALEN LOT 1% ...................... 212 OXTELLAR XR TAB 150MG ................ 78 OXTELLAR XR TAB 300MG ................ 78 OXTELLAR XR TAB 600MG ................ 78 oxybutynin chloride syrup 5 mg/5ml . 154 oxybutynin chloride tab 5 mg ........... 154 oxybutynin chloride tab er 24hr 10 mg .................................................... 154 oxybutynin chloride tab er 24hr 15 mg .................................................... 154 oxybutynin chloride tab er 24hr 5 mg 154 oxycodone hcl cap 5 mg ................... 13 oxycodone hcl conc 100 mg/5ml (20

288

mg/ml) ........................................... 13 oxycodone hcl soln 5 mg/5ml ............. 13 oxycodone hcl tab 10 mg................... 13 oxycodone hcl tab 15 mg................... 13 oxycodone hcl tab 20 mg................... 13 oxycodone hcl tab 30 mg................... 13 oxycodone hcl tab 5 mg .................... 13 oxycodone hcl tab er 12hr deter 10 mg ..................................................... 13 oxycodone hcl tab er 12hr deter 15 mg ..................................................... 13 oxycodone hcl tab er 12hr deter 20 mg ..................................................... 13 oxycodone hcl tab er 12hr deter 30 mg ..................................................... 13 oxycodone hcl tab er 12hr deter 40 mg ..................................................... 13 oxycodone hcl tab er 12hr deter 60 mg ..................................................... 13 oxycodone hcl tab er 12hr deter 80 mg ..................................................... 13 oxycodone w/ acetaminophen soln 5-325 mg/5ml ........................................... 13 oxycodone w/ acetaminophen tab 10-325 mg ................................................. 14 oxycodone w/ acetaminophen tab 5-325 mg ................................................. 13 oxycodone w/ acetaminophen tab 7.5-325 mg ........................................... 14 oxycodone-aspirin tab 4.8355-325 mg 14 oxycodone-ibuprofen tab 5-400 mg .... 14 OXYCONTIN TAB 10MG CR ................ 14 OXYCONTIN TAB 15MG CR ................ 14 OXYCONTIN TAB 20MG CR ................ 14 OXYCONTIN TAB 30MG CR ................ 14 OXYCONTIN TAB 40MG CR ................ 14 OXYCONTIN TAB 60MG CR ................ 14 OXYCONTIN TAB 80MG CR ................ 14 oxymorphone hcl tab 10 mg .............. 14 oxymorphone hcl tab 5 mg ................ 14 oxymorphone hcl tab er 12hr 10 mg ... 14 oxymorphone hcl tab er 12hr 15 mg ... 14 oxymorphone hcl tab er 12hr 20 mg ... 14 oxymorphone hcl tab er 12hr 30 mg ... 14 oxymorphone hcl tab er 12hr 40 mg ... 14 oxymorphone hcl tab er 12hr 5 mg ..... 14 oxymorphone hcl tab er 12hr 7.5 mg .. 14 oxytocin inj 10 unit/ml .................... 135

OXYTROL DIS 3.9MG/24 .................. 154 OXYTROL/WOMN DIS 3.9MG/24 ....... 154 oys shell+d chw 500-400 ................. 183 oys shell+d tab 250-125 .................. 183 oysco 500+d tab ............................ 183 oyst shell/d tab 500mg .................... 183 oyster shell calcium tab 500 mg ....... 183 oyster-cal tab 500mg ...................... 183 P paclitaxel iv conc 100 mg/16.7ml (6 mg/ml) .......................................... 45 paclitaxel iv conc 150 mg/25ml (6 mg/ml) .......................................... 45 paclitaxel iv conc 30 mg/5ml (6 mg/ml) ..................................................... 45 paclitaxel iv conc 300 mg/50ml (6 mg/ml) .......................................... 45 pain relief dro 80/0.8ml ...................... 1 pain relief liq 500/15ml ...................... 1 pain relief sus 160/5ml ....................... 1 PAIN RELIEF TAB ............................... 2 pain relief tab 325mg ......................... 1 pain relief tab 500mg ......................... 1 pain relieve chw 160mg jr ................... 1 pain relievr chw 80mg ........................ 1 paliperidone tab er 24hr 1.5 mg ........ 93 paliperidone tab er 24hr 3 mg ........... 93 paliperidone tab er 24hr 6 mg ........... 93 paliperidone tab er 24hr 9 mg ........... 93 PALOMAR E OIN ............................. 212 PAMINE FORTE TAB 5MG ................. 143 PAMINE TAB 2.5MG ........................ 143 PANCREAZE CAP 10500UNT ............. 149 PANCREAZE CAP 16800UNT ............. 149 PANCREAZE CAP 21000UNT ............. 149 PANCREAZE CAP 4200UNIT .............. 149 pancuronium bromide inj 1 mg/ml .... 111 PANDEL CRE 0.1% .......................... 209 PANHEMATIN INJ 313MG ................. 162 PANHEMATIN INJ 350MG ................. 162 PANOXYL GEL 3% ........................... 201 PANOXYL-4 LIQ CREM WSH ............. 201 PANRETIN GEL 0.1% ....................... 212 pantoprazole sodium ec tab 20 mg (base equiv) ........................................... 150 pantoprazole sodium ec tab 40 mg (base equiv) ........................................... 150 pantoprazole sodium for iv soln 40 mg

289

(base equiv) .................................. 150 papaverine hcl inj 30 mg/ml .............. 69 PARAFON FORT TAB 500MG ............. 110 PARAGARD IUD T380A .................... 126 paregoric tincture 2 mg/5ml (morphine equivalent) .................................... 140 PAREMYD SOL 1-0.25% .................. 220 PARI LC MIS SPRINT ....................... 195 paricalcitol cap 1 mcg ..................... 134 paricalcitol cap 2 mcg ..................... 134 paricalcitol cap 4 mcg ..................... 134 paricalcitol iv soln 5 mcg/ml ............. 134 PARLODEL CAP 5MG ......................... 89 PARNATE TAB 10MG ......................... 82 paromomycin sulfate cap 250 mg ....... 17 paroxetine hcl tab 10 mg ................... 85 paroxetine hcl tab 20 mg ................... 85 paroxetine hcl tab 30 mg ................... 85 paroxetine hcl tab 40 mg ................... 85 paroxetine hcl tab er 24hr 12.5 mg ..... 85 paroxetine hcl tab er 24hr 25 mg........ 85 paroxetine hcl tab er 24hr 37.5 mg ..... 85 paroxetine mesylate cap 7.5 mg (base equiv) ........................................... 113 PASER GRA 4GM .............................. 31 PATADAY SOL 0.2% ........................ 218 PATANASE SPR 0.6% ...................... 196 PATANOL SOL 0.1% OP ................... 218 PAXIL CR TAB 12.5MG ...................... 85 PAXIL CR TAB 25MG ......................... 85 PAXIL CR TAB 37.5MG ...................... 85 PAXIL SUS 10MG/5ML ....................... 85 PAXIL TAB 10MG .............................. 85 PAXIL TAB 20MG .............................. 85 PAXIL TAB 30MG .............................. 85 PAXIL TAB 40MG .............................. 85 PAZEO DRO 0.7% .......................... 218 PCE TAB 333MG EC .......................... 21 PCE TAB 500MG EC .......................... 21 PEAK AIR FLO MIS ADLT/PED ........... 195 PECGEN DMX LIQ 10-187MG ............ 191 PECGEN DMX LIQ 15-125MG ............ 191 pecgen liq pse ................................ 191 PEDIA-LAX LIQ 50MG ...................... 146 PEDIA-LAX SUP 2.8GM .................... 146 PEDIAPRED SOL 6.7/5ML ................. 132 PEDITRACE INJ .............................. 175 PEGANONE TAB 250MG ..................... 78

PEGASYS INJ ................................. 167 PEGASYS INJ 180MCG/M ................. 167 PEGASYS INJ PROCLICK .................. 167 PEG-INTRON KIT 120 RP ................. 167 PEG-INTRON KIT 150 RP ................. 167 PEG-INTRON KIT 50MCG RP ............. 167 PEG-INTRON KIT 80MCG RP ............. 167 PEN G PROC INJ 600000 ................... 23 PEN NEEDLES MIS 29GX1/2" ............ 123 PEN NEEDLES MIS 29GX10MM .......... 123 PEN NEEDLES MIS 31GX1/4" ............ 123 PEN NEEDLES MIS 31GX5/16 ........... 123 PENICILL GK/ INJ DEX 1MU .............. 23 PENICILL GK/ INJ DEX 2MU .............. 23 PENICILL GK/ INJ DEX 3MU .............. 23 penicillin g potassium for inj 20000000 unit ............................................... 23 penicillin g potassium for inj 5000000 unit ............................................... 23 penicillin g sodium for inj 5000000 unit ..................................................... 23 penicillin v potassium for soln 125 mg/5ml .......................................... 23 penicillin v potassium for soln 250 mg/5ml .......................................... 23 penicillin v potassium tab 250 mg ...... 23 penicillin v potassium tab 500 mg ...... 23 PENNSAID SOL 2% ............................ 5 PENTAM 300 INJ 300MG ................... 35 PENTASA CAP 250MG CR ................. 144 PENTASA CAP 500MG CR ................. 144 pentoxifylline tab er 400 mg ............ 162 PEPCID AC CHW MAX ST ................. 144 PEPCID SUS 40MG/5ML ................... 144 PEPCID TAB 20MG .......................... 144 PEPCID TAB 40MG .......................... 144 PERCOCET TAB 10-325MG ................ 14 PERCOCET TAB 2.5-325 .................... 14 PERCOCET TAB 5-325MG .................. 14 PERCOCET TAB 7.5-325 .................... 14 PERFOROMIST NEB 20MCG .............. 192 PERIDEX SOL 0.12% ....................... 215 perindopril erbumine tab 2 mg .......... 49 perindopril erbumine tab 4 mg .......... 49 perindopril erbumine tab 8 mg .......... 49 periogard sol 0.12% ....................... 215 periomed con 0.63% ....................... 215 PERJETA INJ 420/14ML ..................... 45

290

permethrin cream 5% ..................... 214 perphenazine tab 16 mg .................... 96 perphenazine tab 2 mg ..................... 96 perphenazine tab 4 mg ..................... 96 perphenazine tab 8 mg ..................... 96 perphenazine-amitriptyline tab 2-10 mg ..................................................... 96 perphenazine-amitriptyline tab 2-25 mg ..................................................... 96 perphenazine-amitriptyline tab 4-10 mg ..................................................... 96 perphenazine-amitriptyline tab 4-25 mg ..................................................... 96 perphenazine-amitriptyline tab 4-50 mg ..................................................... 96 PERRY PRENAT CAP ........................ 183 PERSONAL BES MIS FULL RNG ......... 195 PERSONAL BES MIS LOW RANG ....... 195 PERTZYE CAP ................................. 149 PEXEVA TAB 10MG ........................... 86 PEXEVA TAB 20MG ........................... 86 PEXEVA TAB 30MG ........................... 86 PEXEVA TAB 40MG ........................... 86 PHARMABASE OIN BARRIER ............. 212 phenazopyridine hcl tab 100 mg ....... 153 phenazopyridine hcl tab 200 mg ....... 153 phenelzine sulfate tab 15 mg ............. 82 PHENERGAN INJ 25MG/ML ............... 141 PHENERGAN INJ 50MG/ML ............... 141 phenergan sup 12.5mg ................... 141 phenergan sup 25mg ...................... 141 phenergan sup 50mg ...................... 142 phenobarbital elixir 20 mg/5ml ........... 78 phenobarbital sodium inj 130 mg/ml ... 78 phenobarbital tab 100 mg ................. 78 phenobarbital tab 15 mg ................... 78 phenobarbital tab 16.2 mg ................ 78 phenobarbital tab 30 mg ................... 78 phenobarbital tab 32.4 mg ................ 78 phenobarbital tab 60 mg ................... 78 phenobarbital tab 64.8 mg ................ 78 phenobarbital tab 97.2 mg ................ 78 phenoxybenzamine hcl cap 10 mg ...... 50 PHENTOLAMINE INJ 5MG ................... 50 PHENYL/NACL INJ 1MG/10ML ............. 72 PHENYLEPHRIN INJ 10MG/ML ............. 72 phenylephrine hcl inj 10 mg/ml .......... 72 phenylephrine hcl ophth soln 10% .... 221

phenylephrine hcl ophth soln 2.5% ... 220 PHENYTEK CAP 200MG ..................... 78 PHENYTEK CAP 300MG ..................... 78 phenytoin chew tab 50 mg ................ 78 phenytoin sodium extended cap 100 mg ..................................................... 78 phenytoin sodium extended cap 200 mg ..................................................... 78 phenytoin sodium extended cap 300 mg ..................................................... 78 phenytoin sodium inj 50 mg/ml ......... 78 phenytoin susp 125 mg/5ml .............. 78 PHOS-FLUR SOL 0.044% ................. 215 PHOSLO CAP 667MG ....................... 136 PHOSLYRA SOL .............................. 136 PHOSPHOLINE SOL 0.125%OP ......... 222 PHOTOFRIN INJ 75MG ...................... 45 PHYS EZ USE KIT M-PRED ............... 131 physiolyte sol ................................. 215 PHYSOS SALIC INJ 1MG/ML ............. 123 phytonadione inj 1 mg/0.5ml (2 mg/ml) .................................................... 183 phytonadione inj 10 mg/ml .............. 183 PICATO GEL 0.015% ....................... 203 PICATO GEL 0.05% ......................... 203 PICO WOUND KIT THER SYS ............ 214 PIKO 1 MIS ELECTRON .................... 195 pilocarpine hcl tab 5 mg .................. 151 pilocarpine hcl tab 7.5 mg ................ 151 pimozide tab 1 mg ........................... 96 pimozide tab 2 mg ........................... 96 pindolol tab 10 mg ........................... 61 pindolol tab 5 mg ............................ 61 PIN-X CHW 250MG .......................... 35 pioglitazone hcl tab 15 mg (base equiv) .................................................... 116 pioglitazone hcl tab 30 mg (base equiv) .................................................... 116 pioglitazone hcl tab 45 mg (base equiv) .................................................... 116 pioglitazone hcl-glimepiride tab 30-2 mg .................................................... 116 pioglitazone hcl-glimepiride tab 30-4 mg .................................................... 116 pioglitazone hcl-metformin hcl tab 15-500 mg ......................................... 116 pioglitazone hcl-metformin hcl tab 15-850 mg ......................................... 116

291

piperacillin sod-tazobactam na for inj 3.375 gm (3-0.375 gm) .................... 23 piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm) ........................ 23 piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) ........................... 23 piperacillin sod-tazobactam sod for inj 40.5 gm (36-4.5 gm) ........................ 24 piroxicam cap 10 mg ......................... 4 piroxicam cap 20 mg ......................... 4 PITOCIN INJ 10UNT/ML ................... 135 PLAN B TAB 1.5MG ......................... 125 PLASMA-LYTE INJ -148 ................... 174 PLASMA-LYTE INJ 56/D5W ............... 174 PLASMA-LYTE INJ -A ....................... 174 PLAVIX TAB 300MG ........................ 163 PLAVIX TAB 75MG .......................... 163 PLEGISOL SOL ................................. 69 PLEGRIDY INJ ................................ 109 PLEGRIDY INJ PEN .......................... 109 PLEGRIDY INJ STARTER .................. 109 PLEGRIDY PEN INJ STARTER ............ 109 plenamine inj 15% ......................... 173 PNV OB+DHA PAK .......................... 183 pnv-dha cap .................................. 183 PNV-DHA CAP DOCUSATE ................ 183 PNV-OMEGA CAP ............................ 183 pnv-select tab ................................ 183 PNV-TOTAL CAP ............................. 183 POCKET PEAK MIS METER ............... 195 POCKETPEAK MIS UNIVERSA ........... 195 PODIAPN CAP ................................ 171 PODOCON SOL 25% ....................... 212 podofilox soln 0.5% ........................ 212 polycin oin op ................................ 217 polyethylene glycol 3350 oral packet . 146 polyethylene glycol 3350 oral powder 146 polymyxin b sulfate for inj 500000 unit 35 polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% ....................... 217 POLYTRIM SOL OP .......................... 217 POLY-VENT IR TAB 60-380MG .......... 191 polyvinyl alcohol ophth soln 1.4% ..... 221 poly-vite dro .................................. 183 POMALYST CAP 1MG ......................... 40 POMALYST CAP 2MG ......................... 40 POMALYST CAP 3MG ......................... 40 POMALYST CAP 4MG ......................... 40

PONSTEL CAP 250MG ......................... 4 PORTRAZZA INJ 800/50ML ................ 45 pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml ................................... 153 pot bicarbonate & chloride effer tab 25 meq .............................................. 172 potassium acetate inj 2 meq/ml ........ 174 potassium acetate inj 4 meq/ml ........ 174 potassium bicarbonate effer tab 25 meq .................................................... 172 potassium chloride 20 meq/l (0.15%) in dextrose 5% inj .............................. 174 potassium chloride 40 meq/l (0.3%) in dextrose 5% inj .............................. 174 potassium chloride cap er 10 meq ..... 172 potassium chloride cap er 8 meq ...... 172 potassium chloride inj 10 meq/100ml 174 potassium chloride inj 10 meq/50ml .. 174 potassium chloride inj 2 meq/ml ....... 174 potassium chloride inj 20 meq/100ml 175 potassium chloride inj 20 meq/50ml .. 175 potassium chloride inj 40 meq/100ml 175 potassium chloride microencapsulated crys er tab 10 meq ......................... 172 potassium chloride microencapsulated crys er tab 20 meq ......................... 172 potassium chloride oral soln 10% (20 meq/15ml) .................................... 172 potassium chloride oral soln 20% (40 meq/15ml) .................................... 172 potassium chloride powder packet 20 meq .............................................. 172 potassium chloride tab er 10 meq ..... 172 potassium chloride tab er 20 meq (1500 mg) .............................................. 172 potassium citrate & citric acid soln 1100-334 mg/5ml ................................... 153 potassium citrate tab er 10 meq (1080 mg) .............................................. 153 potassium citrate tab er 15 meq (1620 mg) .............................................. 153 potassium citrate tab er 5 meq (540 mg) .................................................... 153 potassium phosphates inj 15 mm/5ml (phos) 22 meq/5ml (k) .................... 175 potassium phosphates inj 150 mm/50ml (phos) 220 meq/50ml (k) ................ 175 potassium phosphates inj 45 mm/15ml

292

(phos) 66 meq/15ml (k) .................. 175 POTIGA TAB 200MG .......................... 78 POTIGA TAB 300MG .......................... 79 POTIGA TAB 400MG .......................... 79 POTIGA TAB 50MG ........................... 78 PR NATAL 400 PAK ......................... 183 PR NATAL 400 PAK EC ..................... 183 PR NATAL 430 PAK ......................... 183 PR NATAL 430 PAK EC ..................... 183 PRADAXA CAP 110MG ..................... 157 PRADAXA CAP 150MG ..................... 157 PRADAXA CAP 75MG ....................... 157 PRALIDOXIME INJ 600/2ML ............. 124 PRALUENT INJ 150MG/ML .................. 59 PRALUENT INJ 75MG/ML ................... 59 pramipexole dihydrochloride tab 0.125 mg ................................................. 89 pramipexole dihydrochloride tab 0.25 mg ..................................................... 89 pramipexole dihydrochloride tab 0.5 mg ..................................................... 89 pramipexole dihydrochloride tab 0.75 mg ..................................................... 89 pramipexole dihydrochloride tab 1 mg . 89 pramipexole dihydrochloride tab 1.5 mg ..................................................... 89 pramipexole dihydrochloride tab er 24hr 0.375 mg ........................................ 89 pramipexole dihydrochloride tab er 24hr 0.75 mg .......................................... 89 pramipexole dihydrochloride tab er 24hr 1.5 mg ........................................... 89 pramipexole dihydrochloride tab er 24hr 2.25 mg .......................................... 89 pramipexole dihydrochloride tab er 24hr 3 mg .............................................. 89 pramipexole dihydrochloride tab er 24hr 4.5 mg ........................................... 89 PRAMOSONE CRE 1-1% .................. 206 PRAMOSONE LOT 1% ...................... 206 PRAMOSONE LOT 2.5% ................... 206 PRAMOTIC DRO 1-0.1% .................. 222 PRASCION RA CRE 10-5% ............... 201 prasugrel hcl tab 10 mg (base equiv) 163 prasugrel hcl tab 5 mg (base equiv) .. 163 PRAVACHOL TAB 20MG ..................... 58 PRAVACHOL TAB 40MG ..................... 58 PRAVACHOL TAB 80MG ..................... 58

pravastatin sodium tab 10 mg ........... 58 pravastatin sodium tab 20 mg ........... 58 pravastatin sodium tab 40 mg ........... 58 pravastatin sodium tab 80 mg ........... 58 prazosin hcl cap 1 mg ...................... 50 prazosin hcl cap 2 mg ...................... 50 prazosin hcl cap 5 mg ...................... 50 PREB-2 PAK ................................... 148 PRECEDEX INJ 100MCG ................... 105 PRECEDEX INJ 200/50ML ................. 105 PRECEDEX INJ 400/100 ................... 105 PRECEDEX INJ 80/20ML .................. 105 PRED MILD SUS 0.12% OP .............. 218 PRED SOD PHO SOL 1% OP ............. 218 PRED-G S.O.P OIN OP ..................... 216 PRED-G SUS OP ............................. 216 prednicarbate cream 0.1% ............... 209 prednicarbate oint 0.1% .................. 209 prednisolone acetate ophth susp 1% . 218 prednisolone sod phos orally disintegr tab 10 mg (base eq) ....................... 132 prednisolone sod phos orally disintegr tab 15 mg (base eq) ....................... 132 prednisolone sod phos orally disintegr tab 30 mg (base eq) ....................... 132 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) ................ 132 prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) ...................... 132 prednisolone sodium phosphate oral soln 25 mg/5ml (base eq) ...................... 132 prednisolone syrup 15 mg/5ml (usp solution equivalent) ........................ 132 prednisone oral soln 5 mg/5ml ......... 132 prednisone tab 1 mg ....................... 132 prednisone tab 10 mg ..................... 132 prednisone tab 2.5 mg .................... 132 prednisone tab 20 mg ..................... 132 prednisone tab 5 mg ....................... 132 prednisone tab 50 mg ..................... 132 prednisone tab therapy pack 10 mg (21) .................................................... 133 prednisone tab therapy pack 10 mg (48) .................................................... 133 prednisone tab therapy pack 5 mg (21) .................................................... 133 prednisone tab therapy pack 5 mg (48) .................................................... 133

293

PREFERA OB TAB............................ 183 PREFERAOB CAP ONE ...................... 183 PREFERAOB MIS +DHA ................... 183 PREFEST TAB ................................. 128 PREGNYL INJ 10000UNT .................. 130 PREMARIN INJ 25MG ...................... 129 PREMARIN TAB 0.3MG .................... 129 PREMARIN TAB 0.45MG ................... 129 PREMARIN TAB 0.625MG ................. 129 PREMARIN TAB 0.9MG .................... 129 PREMARIN TAB 1.25MG ................... 129 PREMARIN VAG CRE 0.625MG .......... 130 premasol sol 6% ............................ 173 PREMPHASE TAB ............................ 128 PREMPRO TAB .625-2.5 ................... 128 PREMPRO TAB 0.3-1.5 .................... 128 PREMPRO TAB 0.45-1.5 ................... 128 PREMPRO TAB 0.625-5 .................... 128 PRENA 1 TRUE MIS ......................... 183 PRENA1 CHW ................................. 183 PRENA1 PEARL CAP ........................ 183 PRENAISSANCE CAP ....................... 183 PRENAISSANCE CAP BALANCE ......... 183 PRENAISSANCE CAP PLUS ............... 183 PRENAISSANCE MIS HARMONY ........ 183 PRENAISSANCE TAB NEXT ............... 183 PRENAISSANCE TAB NEXT-B ............ 183 PRENATA CHW 29-1MG ................... 183 prenatabs rx tab ............................ 183 PRENATAL 1 CAP ............................ 183 PRENATAL 19 CHW 29-1MG ............. 183 prenatal 19 chw tab ........................ 183 prenatal 19 tab .............................. 183 PRENATAL 19 TAB 29-1MG .............. 183 PRENATAL CAP FORMULA ................ 183 PRENATAL CAP OMEGA-3 ................ 183 PRENATAL FRM TAB A-FREE ............. 183 PRENATAL MIS COMPLEAT ............... 183 PRENATAL MUL CAP +DHA ............... 183 PRENATAL MV MIS + DHA ............... 183 PRENATAL TAB ............................... 184 PRENATAL TAB 27-1MG ................... 184 PRENATAL TAB COMPLETE ............... 184 PRENATAL TAB FORMULA ................ 184 PRENATAL+DHA MIS ...................... 184 PRENATAL+FE TAB 29-1MG ............. 184 PRENATAL-U CAP 106.5-1 ............... 184 PRENATE AM TAB 1MG .................... 184

PRENATE CAP ENHANCE .................. 184 PRENATE CAP ESSENTIA .................. 184 PRENATE CAP PIXIE ........................ 184 PRENATE CAP RESTORE ................... 184 PRENATE CHW 0.6-0.4 .................... 184 PRENATE DHA CAP ......................... 184 PRENATE MINI CAP ......................... 184 PRENATE TAB ELITE ........................ 184 PRENATL MULT CAP + DHA .............. 184 PREPIDIL GEL 0.5MG/3G ................. 135 PREPOPIK PAK ............................... 146 PRESTALIA TAB 14-10MG ................. 46 PRESTALIA TAB 3.5-2.5 .................... 46 PRESTALIA TAB 7-5MG ..................... 46 PRETAB TAB 29-1MG ....................... 184 PREVACID CAP 15MG DR ................. 150 PREVACID CAP 30MG DR ................. 150 PREVACID TAB 15MG STB ................ 150 PREVACID TAB 30MG STB ................ 150 PREVDNT 5000 PST 1.1-5% ............. 215 PREVIDENT GEL 1.1% MIN .............. 215 PREVIDENT PST 5000 BST ............... 216 PREVPAC MIS ................................. 152 PREZCOBIX TAB 800-150 ................. 27 PREZISTA SUS 100MG/ML ................ 29 PREZISTA TAB 150MG ...................... 29 PREZISTA TAB 600MG ...................... 29 PREZISTA TAB 75MG ....................... 29 PREZISTA TAB 800MG ...................... 29 PRIFTIN TAB 150MG ........................ 31 PRILOSEC CAP 10MG ...................... 150 PRILOSEC CAP 20MG ...................... 150 PRILOSEC CAP 40MG ...................... 150 PRILOSEC OTC TAB 20MG ................ 150 PRILOSEC POW 10MG ..................... 151 PRILOSEC POW 2.5MG .................... 151 PRIMAQUINE TAB 26.3MG................. 27 PRIMAXIN IV INJ 250MG ................... 17 PRIMAXIN IV INJ 500MG ................... 17 primidone tab 250 mg ...................... 79 primidone tab 50 mg ........................ 79 PRIMLEV TAB 10-300MG ................... 15 PRIMLEV TAB 5-300MG .................... 14 PRIMLEV TAB 7.5-300 ...................... 14 PRIMSOL SOL 50MG/5ML .................. 36 PRISTIQ TAB 100MG ........................ 84 PRISTIQ TAB 25MG .......................... 84 PRISTIQ TAB 50MG .......................... 84

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PRIVIGEN INJ 10GRAMS .................. 167 PRIVIGEN INJ 20GRAMS .................. 167 PRIVIGEN INJ 40GRAMS .................. 167 PRIVIGEN INJ 5 GRAMS .................. 167 PROAIR HFA AER ............................ 193 PROAIR RESPI AER ......................... 193 probenecid tab 500 mg ...................... 1 probiotic cap .................................. 148 PROBIOTIC CAP ............................. 148 probiotic cap gold ........................... 148 probiotic pak children ...................... 148 PROBIOTIC TAB ............................. 148 probiotic w/ cap prebioti .................. 148 PROCALAMINE INJ 3% .................... 173 PROCARDIA XL TAB 30MG CR ............ 63 PROCARDIA XL TAB 60MG CR ............ 63 PROCARDIA XL TAB 90MG CR ............ 63 prochlorperazine edisylate inj 5 mg/ml ................................................... 142 prochlorperazine maleate tab 10 mg (base equivalent) ........................... 142 prochlorperazine maleate tab 5 mg (base equivalent) .................................... 142 PROCORT CRE ............................... 151 PROCRIT INJ 10000/ML ................... 161 PROCRIT INJ 2000/ML..................... 161 PROCRIT INJ 20000/ML ................... 161 PROCRIT INJ 3000/ML..................... 161 PROCRIT INJ 4000/ML..................... 161 PROCRIT INJ 40000/ML ................... 161 PROCTOCORT CRE 1% .................... 151 PROCTOFOAM AER HC 1% ............... 152 PROCYSBI CAP 25MG ...................... 153 PROCYSBI CAP 75MG ...................... 153 PROFE CAP 180MG ......................... 184 PROFE FORTE CAP 155-1MG ............ 184 PROFERRIN- TAB FORTE .................. 184 PROFILNINE INJ 1000UNIT .............. 160 PROFILNINE INJ 1500UNIT .............. 160 PROFILNINE INJ 500UNIT ................ 160 progesterone im in oil 50 mg/ml ....... 137 progesterone micronized cap 100 mg 137 progesterone micronized cap 200 mg 137 PROGLYCEM SUS 50MG/ML .............. 133 PROGRAF INJ 5MG/ML .................... 168 PROLENSA SOL 0.07% .................... 217 PROLIA SOL 60MG/ML ..................... 125 PROMACTA TAB 25MG ..................... 162

PROMACTA TAB 50MG ..................... 162 PROMACTA TAB 75MG ..................... 162 promethazine & phenylephrine syrup 6.25-5 mg/5ml ............................... 188 promethazine hcl inj 25 mg/ml ......... 142 promethazine hcl inj 50 mg/ml ......... 142 promethazine hcl syrup 6.25 mg/5ml 142 promethazine hcl tab 12.5 mg .......... 142 promethazine hcl tab 25 mg ............. 142 promethazine hcl tab 50 mg ............. 142 promethazine w/ codeine syrup 6.25-10 mg/5ml ......................................... 191 promethazine-dm syrup 6.25-15 mg/5ml .................................................... 191 PROMETRIUM CAP 100MG ................ 137 PROMETRIUM CAP 200MG ................ 137 PROMISEB KIT COMPLETE ............... 205 PRONUTRIENTS TAB SUPER B .......... 184 propafenone hcl cap er 12hr 225 mg .. 55 propafenone hcl cap er 12hr 325 mg .. 55 propafenone hcl cap er 12hr 425 mg .. 55 propafenone hcl tab 150 mg ............. 55 propafenone hcl tab 225 mg ............. 55 propafenone hcl tab 300 mg ............. 55 propantheline bromide tab 15 mg ..... 143 proparacaine hcl ophth soln 0.5% ..... 221 propranolol & hydrochlorothiazide tab 40-25 mg ....................................... 60 propranolol & hydrochlorothiazide tab 80-25 mg ....................................... 60 propranolol hcl cap er 24hr 120 mg .... 61 propranolol hcl cap er 24hr 160 mg .... 61 propranolol hcl cap er 24hr 60 mg ..... 61 propranolol hcl cap er 24hr 80 mg ..... 61 propranolol hcl inj 1 mg/ml ............... 61 propranolol hcl oral soln 20 mg/5ml ... 61 propranolol hcl oral soln 40 mg/5ml ... 61 propranolol hcl tab 10 mg ................. 61 propranolol hcl tab 20 mg ................. 61 propranolol hcl tab 40 mg ................. 61 propranolol hcl tab 60 mg ................. 61 propranolol hcl tab 80 mg ................. 61 propylthiouracil tab 50 mg ............... 137 PROSCAR TAB 5MG ......................... 152 PROSOL INJ 20% ........................... 173 PROSTIN E2 SUP 20MG ................... 135 PROSTIN VR INJ 500MCG ................. 69 protamine sulfate inj 10 mg/ml ........ 162

295

PROTECTIRON TAB ......................... 184 PROTONIX INJ 40MG ...................... 151 PROTONIX PAK .............................. 151 PROTONIX TAB 20MG ..................... 151 PROTONIX TAB 40MG ..................... 151 PROTOPAM CHL INJ 1GM ................. 124 PROTOPIC OIN 0.03% ..................... 206 PROTOPIC OIN 0.1% ...................... 206 protriptyline hcl tab 10 mg ................ 87 protriptyline hcl tab 5 mg .................. 87 PROVERA TAB 10MG ....................... 137 PROVERA TAB 2.5MG ...................... 137 PROVERA TAB 5MG ......................... 137 PROVIDA DHA CAP ......................... 184 PROVIDA OB CAP ........................... 184 PROVIGIL TAB 100MG ..................... 111 PROVIGIL TAB 200MG ..................... 111 PROVISC INJ 1% ............................ 221 PROZAC CAP 10MG ........................... 86 PROZAC CAP 20MG ........................... 86 PROZAC CAP 40MG ........................... 86 PROZAC WEEKL CAP 90MG ................ 86 PRUDOXIN CRE 5% ........................ 212 PRUTECT EMU ................................ 214 pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml .................................... 191 pseudoephedrine hcl tab 60 mg ........ 194 PSORCON CRE 0.05% ..................... 207 PULMICORT INH 180MCG ................ 198 PULMICORT INH 90MCG .................. 198 PULMICORT SUS 0.25MG/2 .............. 198 PULMICORT SUS 0.5MG/2 ............... 198 PULMICORT SUS 1MG/2ML .............. 198 PULMOZYME SOL 1MG/ML ............... 193 PURALOR CI TAB ............................ 171 PUREFE CAP PLUS .......................... 184 PUREFE OB CAP PLUS ..................... 184 PUREFOLIX TAB 1-5000 .................. 176 purevit dual cap fe plus ................... 184 PURIXAN SUS 20MG/ML .................... 38 px iron tab 27mg ........................... 184 PYLERA CAP ................................... 152 pyrazinamide tab 500 mg .................. 31 PYRIDIUM TAB 100MG .................... 153 PYRIDIUM TAB 200MG .................... 153 pyridostigmine bromide tab 60 mg ... 111 pyridostigmine bromide tab er 180 mg ................................................... 111

pyridoxine hcl tab 100 mg ............... 184 pyridoxine hcl tab 25 mg ................. 184 pyridoxine hcl tab 50 mg ................. 184 pyrilamine mal-phenylephrine hcl tann susp 16-5 mg/5ml .......................... 188 PYROGALL ACD OIN ........................ 212 Q Q4 ORAL CLEA KIT SYSTEM ............. 216 qc natural pow vegetabl .................. 147 QNASL AER 80MCG ......................... 196 QNASL CHILD SPR 40MCG ............... 196 QUADRAMET INJ ............................. 45 QUARTETTE TAB ............................. 125 quasense tab ................................. 125 quazepam tab 15 mg ...................... 104 QUDEXY XR CAP 100/24HR ............... 79 QUDEXY XR CAP 150/24HR ............... 79 QUDEXY XR CAP 200/24HR ............... 79 QUDEXY XR CAP 25/24HR ................. 79 QUDEXY XR CAP 50/24HR ................. 79 QUELICIN INJ 20MG/ML .................. 111 QUESTRAN POW 4GM ....................... 56 QUESTRAN POW 4GM LITE ................ 56 quetiapine fumarate tab 100 mg ........ 93 quetiapine fumarate tab 200 mg ........ 93 quetiapine fumarate tab 25 mg ......... 93 quetiapine fumarate tab 300 mg ........ 93 quetiapine fumarate tab 400 mg ........ 93 quetiapine fumarate tab 50 mg ......... 93 quetiapine fumarate tab er 24hr 150 mg ..................................................... 93 quetiapine fumarate tab er 24hr 200 mg ..................................................... 93 quetiapine fumarate tab er 24hr 300 mg ..................................................... 93 quetiapine fumarate tab er 24hr 400 mg ..................................................... 93 quetiapine fumarate tab er 24hr 50 mg ..................................................... 93 QUILLICHEW CHW 20MG ER ............ 102 QUILLICHEW CHW 30MG ER ............ 102 QUILLICHEW CHW 40MG ER ............ 102 QUILLIVANT SUS 25MG/5ML ............ 102 quinapril hcl tab 10 mg ..................... 49 quinapril hcl tab 20 mg ..................... 49 quinapril hcl tab 40 mg ..................... 49 quinapril hcl tab 5 mg ...................... 49 quinapril-hydrochlorothiazide tab 10-12.5

296

mg ................................................. 48 quinapril-hydrochlorothiazide tab 20-12.5 mg ................................................. 48 quinapril-hydrochlorothiazide tab 20-25 mg ................................................. 48 quinine sulfate cap 324 mg ................ 27 QUINTABS TAB .............................. 184 QUTENZA KIT 8% 1-PCH ................. 211 QVAR AER 40MCG .......................... 198 QVAR AER 80MCG .......................... 198 R ra col-rite cap 50mg ....................... 147 RA OYS SHL/D TAB 250MG .............. 184 rabeprazole sodium ec tab 20 mg ..... 151 raloxifene hcl tab 60 mg .................. 137 ramipril cap 1.25 mg ........................ 49 ramipril cap 10 mg ........................... 49 ramipril cap 2.5 mg .......................... 49 ramipril cap 5 mg ............................. 49 RANEXA TAB 1000MG ....................... 69 RANEXA TAB 500MG ......................... 69 ranitidine hcl cap 150 mg ................ 144 ranitidine hcl cap 300 mg ................ 144 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) ....................................... 144 ranitidine hcl tab 150 mg ................. 144 ranitidine hcl tab 300 mg ................. 144 RAPAFLO CAP 4MG ......................... 152 RAPAFLO CAP 8MG ......................... 152 RAPAMUNE SOL 1MG/ML ................. 168 rasagiline mesylate tab 0.5 mg (base equiv) ............................................. 89 rasagiline mesylate tab 1 mg (base equiv) ............................................. 89 RASUVO INJ 10MG ......................... 165 RASUVO INJ 12.5MG ....................... 165 RASUVO INJ 15MG ......................... 165 RASUVO INJ 17.5MG ....................... 165 RASUVO INJ 20MG ......................... 165 RASUVO INJ 22.5MG ....................... 165 RASUVO INJ 25MG ......................... 165 RASUVO INJ 27.5MG ....................... 165 RASUVO INJ 30MG ......................... 165 RASUVO INJ 7.5MG ........................ 165 RAVICTI LIQ 1.1GM/ML ................... 135 RAYALDEE CAP 30MCG .................... 184 RAYOS TAB 1MG ............................ 133 RAYOS TAB 2MG ............................ 133

RAYOS TAB 5MG ............................ 133 RAZADYNE ER CAP 16MG .................. 81 RAZADYNE ER CAP 24MG .................. 81 RAZADYNE ER CAP 8MG ................... 81 RAZADYNE TAB 12MG ...................... 81 RAZADYNE TAB 4MG ........................ 81 RAZADYNE TAB 8MG ........................ 81 REBETOL CAP 200MG ....................... 32 REBETOL SOL 40MG/ML ................... 32 REBIF INJ 22/0.5 ............................ 109 REBIF INJ 44/0.5 ............................ 109 REBIF REBIDO INJ 22/0.5 ................ 109 REBIF REBIDO INJ 44/0.5 ................ 109 REBIF REBIDO INJ TITRATN ............. 109 REBIF TITRTN INJ PACK .................. 109 RECOMBINATE INJ .......................... 160 RECOMBINATE INJ 220-400 ............. 160 RECOMBINATE INJ 401-800 ............. 160 RECOMBINATE INJ 801-1240 ........... 160 RECOTHROM SOL 20000UNT ............ 161 RECOTHROM SOL 5000UNIT ............ 161 RECTIV OIN 0.4% ........................... 148 reeses med sus pinworm .................. 36 REFRESH CELL DRO 1% OP .............. 221 REFRESH GEL OPTIVE ..................... 221 REFRESH OPTI DRO 0.5-0.9% .......... 221 REFRESH PLUS DRO 0.5% OP .......... 221 REFRESH SOL OPTIVE ..................... 221 REGENECARE GEL .......................... 214 REGLAN TAB 10MG ......................... 142 REGLAN TAB 5MG ........................... 142 REGONOL INJ 5MG/ML .................... 108 REGRANEX GEL 0.01% .................... 212 relagard gel ................................... 153 relcof c sol 100-6.3 ......................... 191 relcof dm liq .................................. 191 RELENZA MIS DISKHALE .................. 34 RELHIST CHW ................................ 188 RELISTOR INJ 12/0.6ML .................. 148 RELISTOR INJ 8/0.4ML .................... 148 RELISTOR TAB 150MG ..................... 148 RELNATE DHA CAP .......................... 184 RELPAX TAB 20MG .......................... 107 RELPAX TAB 40MG .......................... 107 REMERON SLTB TAB 15MG ................ 82 REMERON SLTB TAB 30MG ................ 82 REMERON SLTB TAB 45MG ................ 82 REMERON TAB 15MG ....................... 82

297

REMERON TAB 30MG ........................ 82 REMERON TAB 45MG ........................ 82 REMICADE INJ 100MG ..................... 165 REMODULIN INJ 10MG/ML ................. 71 REMODULIN INJ 1MG/ML ................... 71 REMODULIN INJ 2.5MG/ML ................ 71 REMODULIN INJ 5MG/ML ................... 71 RENACIDIN SOL ............................. 152 RENAGEL TAB 400MG ..................... 136 RENAGEL TAB 800MG ..................... 136 RENFLEXIS INJ 100MG .................... 165 RENOVA CRE 0.02% ....................... 212 RENVELA PAK 0.8GM ...................... 136 RENVELA PAK 2.4GM ...................... 136 RENVELA TAB 800MG ...................... 136 REOPRO INJ 2MG/ML ...................... 164 repaglinide tab 0.5 mg .................... 118 repaglinide tab 1 mg ....................... 118 repaglinide tab 2 mg ....................... 118 repaglinide-metformin hcl tab 1-500 mg ................................................... 118 repaglinide-metformin hcl tab 2-500 mg ................................................... 118 REPATHA INJ 140MG/ML ................... 59 REPATHA SURE INJ 140MG/ML ........... 59 REPLESTA NX WAF 14000UNT .......... 184 REPLESTA WAF 50000UNT ............... 184 REQUIP TAB 0.25MG ......................... 89 REQUIP TAB 0.5MG .......................... 89 REQUIP TAB 1MG ............................. 89 REQUIP TAB 2MG ............................. 89 REQUIP TAB 3MG ............................. 89 REQUIP TAB 4MG ............................. 89 REQUIP TAB 5MG ............................. 89 REQUIP XL TAB 12MG ....................... 89 REQUIP XL TAB 2MG ......................... 89 REQUIP XL TAB 4MG ......................... 89 REQUIP XL TAB 6MG ......................... 89 REQUIP XL TAB 8MG ......................... 89 RESCRIPTOR TAB 100 MG ................. 29 RESCRIPTOR TAB 200MG .................. 29 RESECTISOL SOL 5% ...................... 152 RESPA C&C IR TAB ......................... 191 RESPA-BR TAB 11MG ...................... 189 RESPAIRE-30 CAP .......................... 191 RESTASIS EMU 0.05% .................... 220 RESTORIL CAP 15MG ...................... 104 RESTORIL CAP 22.5MG ................... 104

RESTORIL CAP 30MG ...................... 104 RESTORIL CAP 7.5MG ..................... 104 RETIN-A CRE 0.025% ..................... 201 RETIN-A CRE 0.05% ....................... 201 RETIN-A CRE 0.1% ......................... 201 RETIN-A GEL 0.01% ....................... 201 RETIN-A GEL 0.025% ...................... 201 RETIN-A MICR GEL 0.04% ............... 201 RETIN-A MICR GEL 0.1% ................. 201 RETROVIR CAP 100MG ..................... 30 RETROVIR SYP 50MG/5ML ................ 30 REVATIO INJ ................................... 70 REVATIO SUS 10MG/ML ................... 70 REVATIO TAB 20MG ......................... 70 REVESTA CAP 1MG-5750 ................. 176 REVLIMID CAP 10MG ....................... 40 REVLIMID CAP 15MG ....................... 40 REVLIMID CAP 2.5MG ...................... 40 REVLIMID CAP 20MG ....................... 40 REVLIMID CAP 25MG ....................... 40 REVLIMID CAP 5MG ......................... 40 revonto inj 20mg ............................ 110 REXULTI TAB 0.25MG ....................... 93 REXULTI TAB 0.5MG ........................ 93 REXULTI TAB 1MG ........................... 93 REXULTI TAB 2MG ........................... 93 REXULTI TAB 3MG ........................... 93 REXULTI TAB 4MG ........................... 93 REYATAZ CAP 150MG ....................... 29 REYATAZ CAP 200MG ....................... 29 REYATAZ CAP 300MG ....................... 29 REZIRA SOL 60-5/5ML .................... 191 RHINARIS SPR 0.2% ....................... 196 RHINOCORT SUS AQUA ................... 197 RHOFADE CRE 1% .......................... 213 RHOPHYLAC INJ 1500/2ML ............... 167 RIASTAP SOL 1GM .......................... 160 RIAX AER 5.5% .............................. 201 RIAX AER 9.5% .............................. 201 RIBAPAK PAK 1200/DAY ................... 32 RIBAPAK PAK 800/DAY ..................... 32 RIBAPAK TAB 1000/DAY ................... 32 RIBAPAK TAB 600/DAY ..................... 32 ribasphere tab 400mg ...................... 32 ribasphere tab 600mg ...................... 32 ribavirin cap 200 mg ........................ 32 ribavirin tab 200 mg ........................ 32 RID COMPLETE KIT LICE .................. 214

298

rifabutin cap 150 mg ........................ 36 RIFADIN CAP 150MG ........................ 31 RIFADIN CAP 300MG ........................ 31 RIFADIN INJ 600 MG ........................ 31 RIFAMATE CAP ................................. 31 rifampin cap 150 mg ......................... 31 rifampin cap 300 mg ......................... 31 rifampin for inj 600 mg ..................... 31 RIFATER TAB ................................... 31 RILUTEK TAB 50MG ........................ 108 riluzole tab 50 mg .......................... 108 rimantadine hydrochloride tab 100 mg 34 RIMSO-50 SOL 50% ....................... 153 ringer's solution ............................. 175 ringer's solution for irrigation ........... 215 RIOMET SOL .................................. 115 risedronate sodium tab 150 mg ........ 124 risedronate sodium tab 30 mg .......... 124 risedronate sodium tab 35 mg .......... 124 risedronate sodium tab 5 mg ........... 124 risedronate sodium tab delayed release 35 mg .......................................... 124 RISPERDAL INJ 12.5MG ..................... 93 RISPERDAL INJ 25MG ....................... 93 RISPERDAL INJ 37.5MG ..................... 93 RISPERDAL INJ 50MG ....................... 93 RISPERDAL M TAB 0.5MG .................. 93 RISPERDAL M TAB 1MG ..................... 93 RISPERDAL M TAB 2MG ..................... 94 RISPERDAL M TAB 3MG ..................... 94 RISPERDAL M TAB 4MG ..................... 94 RISPERDAL SOL 1MG/ML ................... 94 RISPERDAL TAB 0.25MG .................... 94 RISPERDAL TAB 0.5MG ..................... 94 RISPERDAL TAB 1MG ........................ 94 RISPERDAL TAB 2MG ........................ 94 RISPERDAL TAB 3MG ........................ 94 RISPERDAL TAB 4MG ........................ 94 risperidone orally disintegrating tab 0.25 mg ................................................. 94 risperidone orally disintegrating tab 0.5 mg ................................................. 94 risperidone orally disintegrating tab 1 mg ..................................................... 94 risperidone orally disintegrating tab 2 mg ..................................................... 94 risperidone orally disintegrating tab 3 mg ..................................................... 94

risperidone orally disintegrating tab 4 mg ..................................................... 94 risperidone soln 1 mg/ml .................. 94 risperidone tab 0.25 mg ................... 94 risperidone tab 0.5 mg ..................... 94 risperidone tab 1 mg ........................ 94 risperidone tab 2 mg ........................ 94 risperidone tab 3 mg ........................ 94 risperidone tab 4 mg ........................ 94 RITALIN LA CAP 10MG ..................... 102 RITALIN LA CAP 20MG ..................... 102 RITALIN LA CAP 30MG ..................... 102 RITALIN LA CAP 40MG ..................... 102 RITALIN LA CAP 60MG ..................... 102 RITALIN TAB 10MG ......................... 102 RITALIN TAB 20MG ......................... 102 RITALIN TAB 5MG ........................... 102 RITUXAN INJ 100MG ........................ 45 RITUXAN INJ 500MG ........................ 45 RITUXAN INJ HYCELA ....................... 45 rivastigmine tartrate cap 1.5 mg ........ 81 rivastigmine tartrate cap 3 mg .......... 81 rivastigmine tartrate cap 4.5 mg ........ 81 rivastigmine tartrate cap 6 mg .......... 81 rivastigmine td patch 24hr 13.3 mg/24hr ..................................................... 82 rivastigmine td patch 24hr 4.6 mg/24hr ..................................................... 81 rivastigmine td patch 24hr 9.5 mg/24hr ..................................................... 81 rivelsa tab ..................................... 125 RIXUBIS INJ 1000UNIT ................... 160 RIXUBIS INJ 2000UNIT ................... 160 RIXUBIS INJ 250 UNIT .................... 160 RIXUBIS INJ 3000UNIT ................... 160 RIXUBIS INJ 500UNIT ..................... 160 rizatriptan benzoate oral disintegrating tab 10 mg (base eq) ....................... 107 rizatriptan benzoate oral disintegrating tab 5 mg (base eq) ......................... 107 rizatriptan benzoate tab 10 mg (base equivalent) .................................... 107 rizatriptan benzoate tab 5 mg (base equivalent) .................................... 107 ROBAXIN INJ 100MG/ML .................. 110 ROBAXIN TAB 500MG ...................... 110 ROBAXIN-750 TAB 750MG ............... 110 ROBINUL FORT TAB 2MG ................. 143

299

ROBINUL INJ 0.2MG/ML .................. 143 ROBINUL INJ 0.4/2ML ..................... 143 ROBINUL TAB 1MG ......................... 143 ROBITUSSIN LIQ CGH/CLD .............. 191 ROBITUSSIN LIQ DM MAX ............... 191 ROBITUSSN DM SYP ....................... 191 ROCALTROL CAP 0.25MCG ............... 134 ROCALTROL CAP 0.5MCG ................ 134 ROCALTROL SOL 1MCG/ML .............. 134 rocuronium bromide iv soln 100 mg/10ml (10 mg/ml) ................................... 111 rocuronium bromide iv soln 50 mg/5ml (10 mg/ml) ................................... 111 ropinirole hydrochloride tab 0.25 mg ... 89 ropinirole hydrochloride tab 0.5 mg .... 89 ropinirole hydrochloride tab 1 mg ....... 89 ropinirole hydrochloride tab 2 mg ....... 89 ropinirole hydrochloride tab 3 mg ....... 89 ropinirole hydrochloride tab 4 mg ....... 89 ropinirole hydrochloride tab 5 mg ....... 89 ropinirole hydrochloride tab er 24hr 12 mg (base equivalent) ........................ 90 ropinirole hydrochloride tab er 24hr 2 mg (base equivalent) ............................. 90 ropinirole hydrochloride tab er 24hr 4 mg (base equivalent) ............................. 90 ropinirole hydrochloride tab er 24hr 6 mg (base equivalent) ............................. 90 ropinirole hydrochloride tab er 24hr 8 mg (base equivalent) ............................. 90 rosadan cre 0.75% ......................... 213 ROSADAN KIT 0.75% ...................... 213 ROSE BENGAL TES 1.3MG ............... 221 rosuvastatin calcium tab 10 mg .......... 58 rosuvastatin calcium tab 20 mg .......... 58 rosuvastatin calcium tab 40 mg .......... 58 rosuvastatin calcium tab 5 mg ............ 58 ROWASA KIT 4GM .......................... 145 ROXICODONE TAB 15MG ................... 15 ROXICODONE TAB 30MG ................... 15 ROXICODONE TAB 5MG ..................... 15 ROZEREM TAB 8MG ........................ 105 RUBRACA TAB 200MG ....................... 45 RUBRACA TAB 250MG ....................... 45 RUBRACA TAB 300MG ....................... 45 RUCONEST INJ 2100UNIT ................ 162 RULAVITE DHA CAP ........................ 184 RYDAPT CAP 25MG ........................... 41

RYDEX G TAB 38.5-398 ................... 191 RYTARY CAP 145MG ......................... 90 RYTARY CAP 195MG ......................... 90 RYTARY CAP 245MG ......................... 90 RYTARY CAP 95MG .......................... 90 RYTHMOL SR CAP 225MG ................. 55 RYTHMOL SR CAP 325MG ................. 55 RYTHMOL SR CAP 425MG ................. 55 RYTHMOL TAB 225MG ...................... 55 S s.s.s. tonic tab ............................... 184 SABRIL POW 500MG ........................ 79 SABRIL TAB 500MG ......................... 79 SAFETYGLIDE MIS 27GX5/8" ............ 169 SAFYRAL TAB ................................. 127 SAIZEN INJ 5MG ............................ 134 SAIZEN INJ 8.8MG .......................... 134 SALAGEN TAB 5MG ......................... 151 SALAGEN TAB 7.5MG ...................... 151 SALEX CREAM KIT 6% ..................... 212 SALEX LOTION KIT 6% .................... 212 SALEX SHA 6% .............................. 212 SALICEPT SUS ............................... 216 salicylic ac liq 27.5% ....................... 212 salicylic acid cream 6% ................... 212 salicylic acid cream 6% & cleanser liqd kit ................................................ 212 salicylic acid foam 6% ..................... 212 salicylic acid gel 6% ........................ 212 salicylic acid in ammonium lactate vehicle foam 6% ............................ 212 salicylic acid lotion 6% .................... 212 salicylic acid lotion 6% & cleanser liqd kit .................................................... 212 salicylic acid shampoo 6% ............... 212 SALICYLIC ACID SOLN 26% ............. 212 SAMSCA TAB 15MG ......................... 139 SAMSCA TAB 30MG ......................... 139 SANCUSO DIS 3.1MG ...................... 142 SANDIMMUNE SOL 100MG/ML .......... 168 SANTYL OIN 250/GM ....................... 212 SAPHRIS SUB 10MG ......................... 94 SAPHRIS SUB 2.5MG ........................ 94 SAPHRIS SUB 5MG .......................... 94 SARAFEM TAB 10MG ........................ 86 SARAFEM TAB 20MG ........................ 86 SAVAYSA TAB 15MG ....................... 157 SAVAYSA TAB 30MG ....................... 157

300

SAVAYSA TAB 60MG ....................... 157 SAVELLA MIS TITR PAK ................... 103 SAVELLA TAB 100MG ...................... 103 SAVELLA TAB 12.5MG ..................... 103 SAVELLA TAB 25MG ........................ 103 SAVELLA TAB 50MG ........................ 103 sb fib lax pow 30% ......................... 147 sb fib lax pow 33% ......................... 147 sb nat fiber pow 49% ...................... 147 sb triple oin antibiot ........................ 203 SCALACORT DK KIT ........................ 206 scalacort lot 2% ............................. 208 SCLEROSOL AER INTRAPLE .............. 196 SCOOBY-DOO CHW ........................ 184 scopolamine td patch 72hr 1 mg/3days ................................................... 142 SCOT-TUSSIN LIQ DIBTS/CF ............ 192 SCOT-TUSSIN LIQ SENIOR .............. 191 SEASONIQUE TAB .......................... 125 SECTRAL CAP 200MG ........................ 61 SECTRAL CAP 400MG ........................ 61 SECURA CRE 30.6% ....................... 212 SELECT-OB CHW ............................ 184 SELECT-OB+ PAK DHA .................... 184 selegiline hcl cap 5 mg ...................... 90 selegiline hcl tab 5 mg ...................... 90 selenious acid inj 40 mcg/ml ............ 175 selenium sulfide lotion 2.5% ............ 205 selenium sulfide-pyrithione zinc in urea shampoo 2.25% ............................. 205 SELZENTRY SOL 20MG/ML ................. 28 SELZENTRY TAB 150MG .................... 28 SELZENTRY TAB 25MG ...................... 28 SELZENTRY TAB 300MG .................... 28 SELZENTRY TAB 75MG ...................... 28 SEMPREX-D CAP 8-60MG ................. 188 SENNA PROMPT CAP 9-500MG ......... 147 senna tab 8.6mg ............................ 147 senna-extra tab 17.2mg .................. 147 sennosides cap 8.6 mg .................... 147 sennosides syrup 8.8 mg/5ml .......... 147 SENSI-CARE CRE MOISTURI ............ 212 SENSIPAR TAB 30MG ...................... 124 SENSIPAR TAB 60MG ...................... 124 SENSIPAR TAB 90MG ...................... 124 SEREVENT DIS AER 50MCG ............. 192 SEROQUEL TAB 100MG ..................... 94 SEROQUEL TAB 200MG ..................... 94

SEROQUEL TAB 25MG ...................... 94 SEROQUEL TAB 300MG .................... 94 SEROQUEL TAB 400MG .................... 95 SEROQUEL TAB 50MG ...................... 94 SEROQUEL XR TAB 150MG ................ 95 SEROQUEL XR TAB 200MG ................ 95 SEROQUEL XR TAB 300MG ................ 95 SEROQUEL XR TAB 400MG ................ 95 SEROQUEL XR TAB 50MG ................. 95 SEROSTIM INJ 4MG ........................ 134 SEROSTIM INJ 5MG ........................ 134 SEROSTIM INJ 6MG ........................ 134 sertraline hcl oral conc 20 mg/ml ....... 86 sertraline hcl tab 100 mg .................. 86 sertraline hcl tab 25 mg ................... 86 sertraline hcl tab 50 mg ................... 86 SE-TAN DHA CAP ............................ 184 sevelamer carbonate packet 0.8 gm .. 136 sevelamer carbonate packet 2.4 gm .. 136 sf 5000 plus cre 1.1% ..................... 216 SFROWASA ENE 4GM ...................... 145 SHOHLS SOL MODIFIED .................. 153 SIGNIFOR INJ 0.3MG/ML ................. 135 SIGNIFOR INJ 0.6MG/ML ................. 135 SIGNIFOR INJ 0.9MG/ML ................. 135 SIGNIFOR LAR INJ 20MG ................. 135 SIGNIFOR LAR INJ 40MG ................. 136 SIGNIFOR LAR INJ 60MG ................. 136 SILAZONE PAK PHARMAPA ............... 206 sildenafil citrate iv soln 10 mg/12.5ml (base equivalent) ............................ 70 sildenafil citrate tab 20 mg ............... 70 SILENOR TAB 3MG .......................... 106 SILENOR TAB 6MG .......................... 106 SILIQ INJ 210/1.5 .......................... 165 silphen coug syp 12.5/5ml ............... 189 SILVADENE CRE 1% ....................... 203 SILVER NITRA OIN 10% .................. 213 SILVRSTAT GEL DRESSING .............. 214 SIMBRINZA SUS 1-0.2% ................. 219 SIMILAC PREN PAK EARLY SH .......... 184 SIMPONI ARIA SOL 50MG/4ML ......... 165 SIMPONI INJ 100MG/ML .................. 165 SIMPONI INJ 50/0.5ML .................... 165 simvastatin tab 10 mg ...................... 58 simvastatin tab 20 mg ...................... 58 simvastatin tab 40 mg ...................... 58 simvastatin tab 5 mg ....................... 58

301

simvastatin tab 80 mg ...................... 58 SINEMET CR TAB 25-100MG .............. 90 SINEMET CR TAB 50-200MG .............. 90 SINEMET TAB 10-100MG ................... 90 SINEMET TAB 25-100MG ................... 90 SINEMET TAB 25-250MG ................... 90 SINGULAIR CHW 4MG ..................... 194 SINGULAIR CHW 5MG ..................... 194 SINGULAIR GRA 4MG ...................... 194 SINGULAIR TAB 10MG .................... 194 sinus congst tab /pain dt ................. 196 sinus/allrgy tab max st .................... 188 SINUSTAR MIS NEBULIZE ................ 195 sirolimus tab 0.5 mg ....................... 168 sirolimus tab 1 mg .......................... 168 SIRTURO TAB 100MG ........................ 31 SITAVIG TAB 50MG .......................... 33 SIVEXTRO INJ 200MG ....................... 36 SIVEXTRO TAB 200MG ...................... 36 SKELAXIN TAB 800MG .................... 110 SKIN PROTECT CRE 12% ................. 213 SKLICE LOT 0.5% .......................... 214 SKYLA IUD 13.5MG ......................... 127 sleep aid tab 25mg ......................... 105 slow release tab 47.5mg ................. 184 sm allergy cre 2% .......................... 213 sm antacid chw ex-str ..................... 140 sm antibioti cre plus ....................... 203 sm antifungl cre 2% ....................... 204 sm b super tab vita com .................. 185 sm balanced tab b-100 ................... 185 sm b-complex tab .......................... 185 SM B-COMPLEX TAB /VIT C .............. 185 SM CORAL CAL TAB 1000MG ............ 185 sm dry eye sol relief ....................... 221 sm dry skin lot therapy ................... 210 sm fiber lax tab 500mg ................... 147 sm fiber pow 48.57% ...................... 147 sm gas rel chw 125mg .................... 148 SM GLUCOSE CHW SOUR APP .......... 133 sm glycerin sup 80.7% ................... 147 sm hemorrhoi oin ........................... 148 sm ibuprofen tab 100mg jr ................. 4 sm iron slow tab 160mg cr .............. 185 sm iron tab .................................... 185 sm laxative sup 10mg ..................... 147 sm lice lot treatmnt ........................ 214 sm magnesium tab 250mg .............. 185

sm micon 7 sup 100mg ................... 155 sm multiple tab vit/iron ................... 185 sm multi-pur sol ............................. 221 sm niacin tab 250mg cr ................... 185 sm nicotine dis 21mg ...................... 113 sm nicotine dis 7mg/24hr ................ 113 SM ONE DAILY MIS PRENATAL .......... 185 SM ONE DAILY TAB ESSENTIA .......... 185 sm pain rel cap 500mg ....................... 1 sm probiotic cap 250mg .................. 148 sm redness dro relief ...................... 221 sm sleep aid cap 50mg .................... 105 sm tussin cf liq ............................... 191 sm vit b-1 tab 100mg ..................... 185 sm z-sleep cap 25mg ...................... 105 sm z-sleep liq 50mg/30 ................... 105 SOD DIURIL INJ 500MG .................... 67 SOD EDECRIN INJ 50MG ................... 67 sod fluoride sol 0.2% ...................... 216 SOD LACTATE INJ 5MEQ/ML ............. 185 SOD NITRITE INJ 30MG/ML .............. 124 SOD SUL/SULF EMU 10-5% ............. 201 SOD SUL/SULF SUS 10-5% .............. 201 sodium acetate inj 2 meq/ml ............ 185 sodium acetate inj 4 meq/ml ............ 185 sodium bicarbonate inj 4.2% ............ 185 sodium bicarbonate inj 7.5% ............ 185 sodium bicarbonate inj 8.4% ............ 185 sodium bicarbonate tab 325 mg ........ 140 sodium bicarbonate tab 650 mg ........ 140 sodium chloride inj 0.45% ............... 175 sodium chloride inj 0.9% ................. 175 sodium chloride inj 2.5 meq/ml (14.6%) .................................................... 175 sodium chloride inj 3% .................... 175 sodium chloride inj 4 meq/ml (23.4%) .................................................... 175 sodium chloride inj 5% .................... 175 sodium chloride iv soln 0.9%............ 175 sodium chloride soln nebu 0.9% ....... 196 sodium chloride soln nebu 10% ........ 196 sodium chloride soln nebu 7% .......... 196 sodium chloride tab 1 gm ................ 175 sodium citrate & citric acid soln 500-334 mg/5ml ......................................... 153 sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) .............................. 185 sodium fluoride tab 0.5 mg f (from 1.1

302

mg naf) ........................................ 185 sodium fluoride tab 1 mg f (from 2.2 mg naf) .............................................. 185 sodium phenylbutyrate oral powder 3 gm/teaspoonful .............................. 148 sodium phenylbutyrate tab 500 mg ... 148 sodium phosphates - enema ............ 147 sodium phosphates inj 15 mm/5ml (phos) 20 meq/5ml (na) .................. 175 sodium polystyrene sulfonate powder 136 sodium polystyrene sulfonate rectal susp 30 gm/120ml ................................. 136 SODIUM SULFA LIQ 10% WASH ....... 205 sodium thiosulfate inj 25% .............. 124 SOF-SENSOR MIS ........................... 123 SOLARAZE GEL 3% W/W ................. 203 SOLIQUA INJ 100/33 ...................... 116 SOLIRIS INJ 10MG/ML .................... 163 SOLODYN TAB 105MG ....................... 25 SOLODYN TAB 115MG ....................... 25 SOLODYN TAB 55MG ........................ 25 SOLODYN TAB 65MG ........................ 25 SOLODYN TAB 80MG ........................ 25 SOLTAMOX SOL 10MG/5ML ................ 39 soluble fib pow therapy ................... 147 SOLU-CORTEF INJ 1000MG .............. 133 SOLU-CORTEF INJ 100MG ............... 133 SOLU-CORTEF INJ 250MG ............... 133 SOLU-CORTEF INJ 500MG ............... 133 SOLU-MEDROL INJ 1000MG ............. 133 SOLU-MEDROL INJ 125MG ............... 133 SOLU-MEDROL INJ 2GM .................. 133 SOLU-MEDROL INJ 40MG ................ 133 SOLU-MEDROL INJ 500MG ............... 133 SOMA TAB 250MG .......................... 110 SOMA TAB 350MG .......................... 110 SONATA CAP 10MG ........................ 105 SONATA CAP 5MG .......................... 105 soothe night oin time ...................... 221 SORBITOL SOL 3% IRR ................... 152 SORBITOL SOL 3.3% IRR ................ 152 SORBITOL-MAN SOL ....................... 152 sore throat loz 15-3.6mg ................. 216 sore throat loz cherry ...................... 216 sore throat spr 1.4% ...................... 216 SORIATANE CAP 10MG .................... 205 SORIATANE CAP 17.5MG ................. 205 SORIATANE CAP 25MG .................... 205

SORILUX AER 0.005% ..................... 205 sotalol hcl (afib/afl) tab 120 mg ......... 55 sotalol hcl (afib/afl) tab 160 mg ......... 55 sotalol hcl (afib/afl) tab 80 mg .......... 55 SOTALOL HCL INJ 150/10ML ............. 55 sotalol hcl tab 120 mg ...................... 56 sotalol hcl tab 160 mg ...................... 56 sotalol hcl tab 240 mg ...................... 56 sotalol hcl tab 80 mg ....................... 56 SOTRADECOL INJ 1% ....................... 69 SOTRADECOL INJ 3% ....................... 69 SOTYLIZE SOL 5MG/ML .................... 56 SOVALDI TAB 400MG ....................... 33 SPINAL NEEDL MIS 22GX3.5" ........... 169 spinosad susp 0.9% ........................ 214 SPIRIVA AER 1.25MCG .................... 187 SPIRIVA CAP HANDIHLR .................. 187 SPIRIVA SPR 2.5MCG ...................... 187 spironolactone & hydrochlorothiazide tab 25-25 mg ....................................... 67 spironolactone tab 100 mg ................ 50 spironolactone tab 25 mg ................. 50 spironolactone tab 50 mg ................. 50 SPORANOX CAP 100MG .................... 27 SPORANOX SOL 10MG/ML................. 27 SPRIX SPR 15.75MG .......................... 4 SPRYCEL TAB 100MG ....................... 41 SPRYCEL TAB 140MG ....................... 41 SPRYCEL TAB 20MG ......................... 41 SPRYCEL TAB 50MG ......................... 41 SPRYCEL TAB 70MG ......................... 41 SPRYCEL TAB 80MG ......................... 41 sps sus 15gm/60 ............................ 136 ssd cre 1% .................................... 203 SSKI SOL 1GM/ML .......................... 137 sss 10-5 aer 10-5% ........................ 201 sss cre 10%-5% ............................. 201 st joseph co syp 7.5/5ml ................. 192 STALEVO 100 TAB ........................... 90 STALEVO 125 TAB ........................... 90 STALEVO 150 TAB ........................... 90 STALEVO 200 TAB ........................... 90 STALEVO 50 TAB ............................. 90 STALEVO 75 TAB ............................. 90 stavudine cap 15 mg ........................ 30 stavudine cap 20 mg ........................ 30 stavudine cap 30 mg ........................ 30 stavudine cap 40 mg ........................ 30

303

stavudine for oral soln 1 mg/ml .......... 30 STELARA INJ 45MG/0.5 ................... 165 STELARA INJ 5MG/ML ..................... 165 STELARA INJ 90MG/ML ................... 165 STERIL TALC SUS 5GM .................... 196 STERILE LUBR DRO 0.7% ................ 221 STIMATE SOL 1.5MG/ML.................. 139 STIOLTO AER 2.5-2.5 ..................... 187 STIVARGA TAB 40MG ........................ 41 stomach relf chw 262mg ................. 140 stomach relf sus 262/15ml .............. 140 stomach relf sus 525/15ml .............. 140 stomach relf tab 262mg .................. 140 stool softnr cap 100mg ................... 147 stool softnr cap 250mg ................... 147 stool softnr tab 8.6-50mg ................ 147 STRATTERA CAP 100MG .................. 102 STRATTERA CAP 10MG .................... 102 STRATTERA CAP 18MG .................... 102 STRATTERA CAP 25MG .................... 102 STRATTERA CAP 40MG .................... 102 STRATTERA CAP 60MG .................... 102 STRATTERA CAP 80MG .................... 102 STRENSIQ INJ 18/0.45 .................... 136 STRENSIQ INJ 28/0.7ML ................. 136 STRENSIQ INJ 40MG/ML ................. 136 STRENSIQ INJ 80/0.8ML ................. 136 streptomycin sulfate for inj 1 gm ........ 17 stress b com tab vit c/zn ................. 185 STRIANT MIS 30MG ........................ 114 STRIBILD TAB .................................. 28 strip ease liq adh remv .................... 213 STRIVERDI AER 2.5MCG .................. 192 STUART ONE CAP ........................... 185 stuffy nose liq & cold ...................... 191 SUBOXONE MIS 12-3MG ................. 112 SUBOXONE MIS 2-0.5MG ................ 112 SUBOXONE MIS 4-1MG ................... 112 SUBOXONE MIS 8-2MG ................... 112 SUBSYS SPR 100MCG ....................... 15 SUBSYS SPR 1200MCG ..................... 15 SUBSYS SPR 1600MCG ..................... 15 SUBSYS SPR 200MCG ....................... 15 SUBSYS SPR 400MCG ....................... 15 SUBSYS SPR 600MCG ....................... 15 SUBSYS SPR 800MCG ....................... 15 SUCRAID SOL 8500/ML ................... 148 sucralfate tab 1 gm ........................ 148

SUDAFED 24HR TAB 240MG ............. 194 sufentanil citrate inj 100 mcg/2ml (50 mcg/ml) ......................................... 15 sufentanil citrate inj 250 mcg/5ml (50 mcg/ml) ......................................... 15 sufentanil citrate inj 50 mcg/ml ......... 15 SULAR TAB 17MG ............................ 63 SULAR TAB 34MG ............................ 63 SULAR TAB 8.5MG ........................... 63 sulfacetamide sodium cleansing gel 10% .................................................... 205 sulfacetamide sodium liquid 10% ...... 205 sulfacetamide sodium lotion 10% (acne) .................................................... 201 sulfacetamide sodium ophth oint 10% .................................................... 217 sulfacetamide sodium ophth soln 10% .................................................... 217 sulfacetamide sodium shampoo 10% . 205 sulfacetamide sodium w/ sulfur cleanser 10-2% .......................................... 201 sulfacetamide sodium w/ sulfur cleanser 9.8-4.8% ...................................... 201 sulfacetamide sodium w/ sulfur cleansing pad 10-4% .................................... 201 sulfacetamide sodium w/ sulfur cream 10-2% .......................................... 201 sulfacetamide sodium w/ sulfur emulsion 10-5% .......................................... 202 sulfacetamide sodium w/ sulfur lotion 10-5% ............................................... 202 sulfacetamide sodium w/ sulfur susp 8-4% ............................................... 202 sulfacetamide sodium w/ sulfur wash 9-4% ............................................... 202 sulfacetamide sodium w/ sulfur wash 9-4.5% ............................................ 202 sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% ............. 216 sulfacetamide sodium-sulfur in urea gel 10-5% .......................................... 202 sulfacetamide sod-sulfur wash 9-4.5% & skin cleanser kit ............................. 201 sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml ............................... 24 sulfamethoxazole-trimethoprim susp 200-40 mg/5ml ............................... 24 sulfamethoxazole-trimethoprim tab 400-

304

80 mg ............................................ 24 sulfamethoxazole-trimethoprim tab 800-160 mg ........................................... 24 SULFAMYLON CRE 85MG/GM ............ 213 SULFAMYLON PAK 5% ..................... 213 sulfasalazine tab 500 mg ................. 144 sulfasalazine tab delayed release 500 mg ................................................... 144 sulindac tab 150 mg .......................... 4 sulindac tab 200 mg .......................... 4 SUMADAN KIT ............................... 202 SUMADAN WASH LIQ 9-4.5% ........... 202 SUMADAN XLT KIT 9-4.5% .............. 202 sumatriptan nasal spray 20 mg/act ... 107 sumatriptan nasal spray 5 mg/act ..... 107 sumatriptan succinate inj 6 mg/0.5ml 107 sumatriptan succinate solution auto-injector 4 mg/0.5ml ........................ 107 sumatriptan succinate solution auto-injector 6 mg/0.5ml ........................ 107 sumatriptan succinate solution cartridge 4 mg/0.5ml ................................... 107 sumatriptan succinate solution cartridge 6 mg/0.5ml ................................... 107 sumatriptan succinate solution prefilled syringe 6 mg/0.5ml ........................ 107 sumatriptan succinate tab 100 mg .... 107 sumatriptan succinate tab 25 mg ...... 107 sumatriptan succinate tab 50 mg ...... 107 SUMAVEL DOSE INJ 4MG/0.5 ........... 107 SUMAVEL DOSE INJ 6MG/0.5 ........... 107 SUPARTZ FX INJ 25/2.5ML ................. 16 SUPARTZ INJ 25/2.5ML ..................... 16 super b comp tab vit c .................... 185 superior 35 tab .............................. 185 SUPPORT LIQ ................................. 185 SUPRAX CAP 400MG ......................... 20 SUPRAX CHW 100MG ........................ 20 SUPRAX CHW 200MG ........................ 20 SUPRAX SUS 500/5ML ...................... 20 SUPREP BOWEL SOL PREP KIT ......... 147 supress dm dro 5-50/ml .................. 191 SURGICEL PAD 3"X4" ...................... 161 SURGIFOAM MIS 12-7MM ................ 161 SURGIFOAM MIS SIZE 100 .............. 161 SURMONTIL CAP 25MG ..................... 87 SURMONTIL CAP 50MG ..................... 87 SURVANTA INH .............................. 196

SUSTIVA CAP 200MG ....................... 29 SUSTIVA CAP 50MG ......................... 29 SUSTIVA TAB 600MG ....................... 29 SUTENT CAP 12.5MG ....................... 41 SUTENT CAP 25MG .......................... 41 SUTENT CAP 50MG .......................... 41 SYLATRON KIT 200MCG ................... 167 SYLATRON KIT 300MCG ................... 167 SYLATRON KIT 600MCG ................... 167 SYMAX DUOTAB TAB ....................... 143 SYMBICORT AER 160-4.5 ................. 198 SYMBICORT AER 80-4.5 .................. 198 SYMLINPEN 60 INJ 1000MCG ........... 114 SYMLNPEN 120 INJ 1000MCG ........... 114 SYMPROIC TAB 0.2MG ..................... 148 SYNAGIS INJ 100MG/ML .................. 168 SYNAGIS INJ 50MG ......................... 168 SYNALAR CRE 0.025% .................... 209 SYNALAR KIT 0.025% ..................... 206 SYNALAR OIN 0.025% ..................... 209 SYNALAR SOL 0.01% ...................... 208 SYNALAR TS KIT 0.01% .................. 206 SYNALGOS-DC CAP .......................... 15 SYNAREL SOL 2MG/ML .................... 128 SYNERCID INJ 500MG ...................... 36 SYNJARDY TAB ............................... 118 SYNJARDY TAB 12.5-500 ................. 119 SYNJARDY TAB 5-1000MG ............... 118 SYNJARDY TAB 5-500MG ................. 118 SYNJARDY XR TAB .......................... 119 SYNJARDY XR TAB 10-1000 ............. 119 SYNJARDY XR TAB 25-1000 ............. 119 SYNJARDY XR TAB 5-1000MG ........... 119 SYNRIBO INJ 3.5MG ......................... 45 SYNTHROID TAB 100MCG ................ 138 SYNTHROID TAB 112MCG ................ 138 SYNTHROID TAB 125MCG ................ 138 SYNTHROID TAB 137MCG ................ 138 SYNTHROID TAB 150MCG ................ 138 SYNTHROID TAB 175MCG ................ 138 SYNTHROID TAB 200MCG ................ 138 SYNTHROID TAB 25MCG .................. 138 SYNTHROID TAB 300MCG ................ 138 SYNTHROID TAB 50MCG .................. 138 SYNTHROID TAB 75MCG .................. 138 SYNTHROID TAB 88MCG .................. 138 SYPRINE CAP 250MG ...................... 136 SYSTANE GEL 0.3% ........................ 221

305

SYSTANE GEL DRO 0.4-0.3% ........... 221 T TABLOID TAB 40MG .......................... 38 TACHOSIL PAD .............................. 161 TACLONEX OIN .............................. 205 TACLONEX SUS .............................. 205 tacrolimus cap 0.5 mg .................... 168 tacrolimus cap 1 mg ....................... 168 tacrolimus cap 5 mg ....................... 168 tacrolimus oint 0.03% ..................... 206 tacrolimus oint 0.1% ...................... 206 TAFINLAR CAP 50MG ........................ 41 TAFINLAR CAP 75MG ........................ 41 TAGRISSO TAB 40MG ....................... 42 TAGRISSO TAB 80MG ....................... 42 TALWIN INJ 30MG/ML ....................... 15 TAMIFLU CAP 30MG .......................... 34 TAMIFLU CAP 45MG .......................... 34 TAMIFLU CAP 75MG .......................... 34 TAMIFLU SUS 6MG/ML ...................... 34 tamoxifen citrate tab 10 mg (base equivalent) ...................................... 39 tamoxifen citrate tab 20 mg (base equivalent) ...................................... 39 tamsulosin hcl cap 0.4 mg ............... 152 TANDEM F CAP ............................... 185 TANDEM PLUS CAP ......................... 185 TANZEUM INJ 30MG ....................... 116 TANZEUM INJ 50MG ....................... 116 TAPAZOLE TAB 10MG ...................... 137 TAPAZOLE TAB 5MG ....................... 137 TARCEVA TAB 100MG ....................... 42 TARCEVA TAB 150MG ....................... 42 TARCEVA TAB 25MG ......................... 42 targetd acne cre 2.5% .................... 202 TARGRETIN GEL 1% ......................... 45 tarina fe tab 1/20 ........................... 127 TARKA TAB 1-240 CR ........................ 46 TARKA TAB 2-180 CR ........................ 47 TARKA TAB 2-240 CR ........................ 47 TARKA TAB 4-240 CR ........................ 47 TARON-BC MIS .............................. 185 TARON-PREX CAP ........................... 185 TASIGNA CAP 150MG ........................ 42 TASIGNA CAP 200MG ........................ 42 TAXOTERE INJ 20MG/ML ................... 45 TAXOTERE INJ 80MG/4ML .................. 45 tazarotene cream 0.1% ................... 202

tazicef inj 1gm ................................ 20 tazicef inj 2gm ................................ 20 TAZORAC CRE 0.05% ...................... 202 TAZORAC CRE 0.1% ....................... 202 TAZORAC GEL 0.05% ...................... 202 TAZORAC GEL 0.1% ....................... 202 TEARS AGAIN CAP HYDRATE ............ 171 tears pure sol ................................. 221 TECFIDERA CAP 120MG ................... 109 TECFIDERA CAP 240MG ................... 109 TECFIDERA MIS STARTER ................ 109 TECHNIVIE TAB ............................... 33 TEFLARO INJ 400MG ........................ 20 TEFLARO INJ 600MG ........................ 20 TEGRETOL SUS 100/5ML .................. 79 TEGRETOL TAB 200MG ..................... 79 TEGRETOL-XR TAB 200MG ................ 79 TEGRETOL-XR TAB 400MG ................ 79 TEKTURNA HCT TAB 150-12.5 ........... 66 TEKTURNA HCT TAB 150-25MG ......... 66 TEKTURNA HCT TAB 300-12.5 ........... 66 TEKTURNA HCT TAB 300-25MG ......... 66 TEKTURNA TAB 150MG ..................... 66 TEKTURNA TAB 300MG ..................... 66 telmisartan tab 20 mg ...................... 54 telmisartan tab 40 mg ...................... 54 telmisartan tab 80 mg ...................... 54 telmisartan-amlodipine tab 40-10 mg . 51 telmisartan-amlodipine tab 40-5 mg ... 51 telmisartan-amlodipine tab 80-10 mg . 51 telmisartan-amlodipine tab 80-5 mg ... 51 telmisartan-hydrochlorothiazide tab 40-12.5 mg ......................................... 53 telmisartan-hydrochlorothiazide tab 80-12.5 mg ......................................... 53 telmisartan-hydrochlorothiazide tab 80-25 mg ............................................ 53 temazepam cap 15 mg .................... 104 temazepam cap 22.5 mg ................. 104 temazepam cap 30 mg .................... 104 temazepam cap 7.5 mg ................... 104 TEMODAR CAP 100MG ...................... 37 TEMODAR CAP 140MG ...................... 37 TEMODAR CAP 180MG ...................... 37 TEMODAR CAP 20MG ....................... 37 TEMODAR CAP 250MG ...................... 37 TEMODAR CAP 5MG ......................... 37 TEMODAR INJ 100MG ....................... 37

306

TEMOVATE CRE 0.05% .................... 210 TEMOVATE GEL 0.05% .................... 210 TEMOVATE OIN 0.05% .................... 210 temozolomide cap 100 mg ................. 37 temozolomide cap 140 mg ................. 37 temozolomide cap 180 mg ................. 37 temozolomide cap 20 mg .................. 37 temozolomide cap 250 mg ................. 37 temozolomide cap 5 mg .................... 37 TENEX TAB 1MG ............................... 50 TENEX TAB 2MG ............................... 50 TENIPOSIDE INJ 50MG/5ML ............... 45 TENORETIC TAB 100 ......................... 60 TENORETIC TAB 50 .......................... 60 TENORMIN TAB 100MG ..................... 62 TENORMIN TAB 25MG ....................... 61 TENORMIN TAB 50MG ....................... 61 TERAZOL 3 CRE 0.8% ..................... 155 TERAZOL 7 CRE 0.4% ..................... 155 terazosin hcl cap 1 mg ...................... 50 terazosin hcl cap 10 mg .................... 50 terazosin hcl cap 2 mg ...................... 50 terazosin hcl cap 5 mg ...................... 50 terbinafine hcl tab 250 mg ................. 27 terbutaline sulfate inj 1 mg/ml ......... 193 terbutaline sulfate tab 2.5 mg .......... 193 terbutaline sulfate tab 5 mg ............. 193 terconazole vaginal cream 0.4% ....... 155 terconazole vaginal cream 0.8% ....... 155 terconazole vaginal suppos 80 mg .... 155 TERSASEPTIC LIQ .......................... 213 TERSI FOAM AER 2.25% ................. 205 TESSALON PER CAP 100MG ............. 192 TESTIM GEL 1%(50MG) .................. 114 TESTONE CIK KIT 200MG/ML ........... 114 testosterone cypionate im inj in oil 100 mg/ml .......................................... 114 testosterone cypionate im inj in oil 200 mg/ml .......................................... 114 testosterone enanthate im inj in oil 200 mg/ml .......................................... 114 testosterone td gel 10mg/act (2%) ... 114 testosterone td gel 12.5 mg/act (1%) 114 testosterone td gel 25 mg/2.5gm (1%) ................................................... 114 testosterone td gel 50 mg/5gm (1%) 114 testosterone td soln 30 mg/act ......... 114 tetcaine sol 0.5% op ....................... 221

tetrabenazine tab 12.5 mg ............... 109 tetrabenazine tab 25 mg ................. 109 tetracycline hcl cap 250 mg .............. 25 tetracycline hcl cap 500 mg .............. 25 tetterine oin 2% ............................. 204 TEXACORT SOL 2.5% ...................... 208 TGQ 15DM/5PE SYP H/2CPM ............ 191 TGQ 30/ SYP 150/15 ....................... 191 TGQ 30/PSE/3 SYP BRM/15DM ......... 191 tgq 50pse/3 syp brm/30dm .............. 191 tgt antacid chw 1000mg .................. 140 tgt cold/hot cre pain rel ................... 211 tgt cough oin suppress .................... 196 THALOMID CAP 100MG ..................... 40 THALOMID CAP 150MG ..................... 40 THALOMID CAP 200MG ..................... 40 THALOMID CAP 50MG ...................... 40 THEO-24 CAP 100MG CR ................. 198 THEO-24 CAP 200MG CR ................. 198 THEO-24 CAP 300MG CR ................. 198 THEO-24 CAP 400MG ER .................. 198 THEOPHYL/D5W INJ 0.8MG/ML ......... 199 theophylline soln 80 mg/15ml .......... 199 theophylline tab er 12hr 100 mg ....... 199 theophylline tab er 12hr 200 mg ....... 199 theophylline tab er 12hr 300 mg ....... 199 theophylline tab er 12hr 450 mg ....... 199 theophylline tab er 24hr 400 mg ....... 199 theophylline tab er 24hr 600 mg ....... 199 THERA-D TAB 4000UNIT .................. 185 theragen hp cre 0.075% .................. 211 THERAMILL CAP FORTE ................... 185 THERANATAL CAP ONE .................... 185 THERANATAL MIS COMPLETE ........... 185 THERANATAL PAK OVAVITE .............. 185 THERANATAL TAB 27-1 ................... 185 therapeutic gel 2% ......................... 213 THERATEARS GEL 1% ..................... 221 THERATEARS SOL OP ...................... 221 thiamine hcl inj 100 mg/ml .............. 185 thiamine hcl tab 100 mg .................. 185 THIOLA TAB 100MG ........................ 153 thioridazine hcl tab 10 mg ................ 96 thioridazine hcl tab 100 mg ............... 97 thioridazine hcl tab 25 mg ................ 97 thioridazine hcl tab 50 mg ................ 97 thiotepa for inj 15 mg ...................... 37 thiothixene cap 1 mg ....................... 97

307

thiothixene cap 10 mg ...................... 97 thiothixene cap 2 mg ........................ 97 thiothixene cap 5 mg ........................ 97 THROMBAT III INJ 1000UNIT ........... 163 THROMBAT III INJ 500UNIT ............. 163 THROMBI-GEL PAD 10 .................... 161 THROMBIN KIT 5000UNIT ................ 161 THROMBIN-JMI KIT 20000UNT ......... 161 THROMBIN-JMI SOL 20000UNT ........ 161 THROMBIN-JMI SOL 5000UNIT ......... 161 THROMBI-PAD PAD 3"X3" ................ 161 THYMOGLOBULN INJ 25MG .............. 167 THYROLAR-1 TAB 60MG .................. 138 THYROLAR-1/2 TAB 30MG ............... 138 THYROLAR-1/4 TAB 15MG ............... 138 THYROLAR-2 TAB 120MG ................ 138 THYROLAR-3 TAB 180MG ................ 138 tiagabine hcl tab 2 mg ...................... 79 tiagabine hcl tab 4 mg ...................... 79 TIAZAC CAP 120MG/24 ..................... 65 TIAZAC CAP 180MG/24 ..................... 65 TIAZAC CAP 240MG/24 ..................... 65 TIAZAC CAP 300MG/24 ..................... 65 TIAZAC CAP 360MG/24 ..................... 65 TIAZAC CAP 420MG/24 ..................... 65 TIGAN CAP 300MG ......................... 142 TIGAN INJ 100MG/ML ..................... 142 tilia fe tab ..................................... 128 timolol maleate ophth gel forming soln 0.25% .......................................... 219 timolol maleate ophth gel forming soln 0.5% ............................................ 219 timolol maleate ophth soln 0.25% .... 219 timolol maleate ophth soln 0.5% ...... 219 timolol maleate tab 10 mg ................. 62 timolol maleate tab 20 mg ................. 62 timolol maleate tab 5 mg................... 62 TIMOPTIC OCU SOL 0.25% OP ......... 219 TIMOPTIC OCU SOL 0.5% OP ........... 219 TIMOPTIC SOL 0.25% OP ................ 219 TIMOPTIC SOL 0.5% OP .................. 219 TIMOPTIC-XE SOL 0.25% OP ........... 219 TIMOPTIC-XE SOL 0.5% OP ............. 219 TINDAMAX TAB 500MG ..................... 36 tinidazole tab 250 mg ....................... 36 tinidazole tab 500 mg ....................... 36 TIROSINT CAP 100MCG ................... 139 TIROSINT CAP 112MCG ................... 139

TIROSINT CAP 125MCG ................... 139 TIROSINT CAP 137MCG ................... 139 TIROSINT CAP 13MCG ..................... 139 TIROSINT CAP 150MCG ................... 139 TIROSINT CAP 25MCG ..................... 139 TIROSINT CAP 50MCG ..................... 139 TIROSINT CAP 75MCG ..................... 139 TIROSINT CAP 88MCG ..................... 139 TISSEEL SOL ................................. 161 TISSEEL VH KIT 10ML ..................... 162 TISSEEL VH KIT 4ML ....................... 161 titralac chw 420mg ......................... 140 TIVICAY TAB 10MG .......................... 28 TIVICAY TAB 25MG .......................... 28 TIVICAY TAB 50MG .......................... 28 TIVORBEX CAP 20MG ......................... 4 TIVORBEX CAP 40MG ......................... 4 tizanidine hcl cap 2 mg (base equivalent) .................................................... 110 tizanidine hcl cap 4 mg (base equivalent) .................................................... 111 tizanidine hcl cap 6 mg (base equivalent) .................................................... 111 tizanidine hcl tab 2 mg (base equivalent) .................................................... 111 tizanidine hcl tab 4 mg (base equivalent) .................................................... 111 TL FOLATE TAB .............................. 185 tl-hem 150 tab ............................... 185 TNKASE KIT 50MG .......................... 163 TOBI NEB 300/5ML ......................... 193 TOBI PODHALR CAP 28MG ............... 193 TOBRADEX OIN 0.3-0.1% ................ 216 TOBRADEX ST SUS 0.3-0.05 ............ 216 TOBRADEX SUS 0.3-0.1% ............... 216 tobramycin nebu soln 300 mg/5ml .... 193 tobramycin ophth soln 0.3% ............ 217 tobramycin sulfate for inj 1.2 gm ....... 17 tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) (base equiv) ........................ 17 tobramycin sulfate inj 10 mg/ml (base equivalent) ..................................... 17 tobramycin sulfate inj 2 gm/50ml (40 mg/ml) (base equiv) ........................ 17 tobramycin sulfate inj 80 mg/2ml (40 mg/ml) (base equiv) ........................ 17 tobramycin-dexamethasone ophth susp 0.3-0.1% ...................................... 216

308

TOBREX OIN 0.3% OP ..................... 217 TOBREX SOL 0.3% OP .................... 217 TOLAK CRE 4% .............................. 203 tolazamide tab 250 mg ................... 120 tolazamide tab 500 mg ................... 120 tolbutamide tab 500 mg .................. 120 tolcapone tab 100 mg ....................... 90 tolmetin sodium cap 400 mg ............... 4 tolmetin sodium tab 200 mg ............... 4 tolmetin sodium tab 600 mg ............... 4 tolterodine tartrate cap er 24hr 2 mg 154 tolterodine tartrate cap er 24hr 4 mg 154 tolterodine tartrate tab 1 mg ............ 154 tolterodine tartrate tab 2 mg ............ 154 TOOMEY SYRIN MIS 70ML ............... 170 TOPAMAX SPR CAP 15MG .................. 79 TOPAMAX SPR CAP 25MG .................. 79 TOPAMAX TAB 100MG ....................... 79 TOPAMAX TAB 200MG ....................... 79 TOPAMAX TAB 25MG ......................... 79 TOPAMAX TAB 50MG ......................... 79 TOPICORT CRE 0.05% .................... 209 TOPICORT CRE 0.25% .................... 207 TOPICORT GEL 0.05% .................... 207 TOPICORT OIN 0.05% ..................... 209 TOPICORT OIN 0.25% ..................... 207 TOPICORT SPR 0.25% .................... 207 topiramate cap er 24hr sprinkle 100 mg ..................................................... 79 topiramate cap er 24hr sprinkle 150 mg ..................................................... 79 topiramate cap er 24hr sprinkle 200 mg ..................................................... 79 topiramate cap er 24hr sprinkle 25 mg 79 topiramate cap er 24hr sprinkle 50 mg 79 topiramate sprinkle cap 15 mg ........... 79 topiramate sprinkle cap 25 mg ........... 79 topiramate tab 100 mg ..................... 79 topiramate tab 200 mg ..................... 79 topiramate tab 25 mg ....................... 79 topiramate tab 50 mg ....................... 79 TOPROL XL TAB 100MG ..................... 62 TOPROL XL TAB 200MG ..................... 62 TOPROL XL TAB 25MG ....................... 62 TOPROL XL TAB 50MG ....................... 62 TORISEL SOL 25MG/ML ..................... 42 torsemide tab 10 mg ........................ 67 torsemide tab 100 mg ....................... 67

torsemide tab 20 mg ........................ 67 torsemide tab 5 mg ......................... 67 total fiber pow ................................ 147 TOUJEO SOLO INJ 300IU/ML ............ 118 TOVIAZ TAB 4MG ........................... 154 TOVIAZ TAB 8MG ........................... 154 tpn electrol inj ................................ 175 TRACE ELEM 4 INJ PED .................... 176 TRACLEER TAB 125MG ..................... 70 TRACLEER TAB 62.5MG .................... 70 TRADJENTA TAB 5MG ...................... 116 TRAMADOL HCL CAP 150MG ER ......... 15 tramadol hcl cap er 24hr biphasic release 100 mg .......................................... 15 tramadol hcl cap er 24hr biphasic release 200 mg .......................................... 15 tramadol hcl cap er 24hr biphasic release 300 mg .......................................... 15 tramadol hcl tab 50 mg .................... 15 tramadol hcl tab er 24hr 100 mg ....... 15 tramadol hcl tab er 24hr 200 mg ....... 15 tramadol hcl tab er 24hr 300 mg ....... 15 tramadol hcl tab er 24hr biphasic release 100 mg .......................................... 15 tramadol hcl tab er 24hr biphasic release 200 mg .......................................... 15 tramadol hcl tab er 24hr biphasic release 300 mg .......................................... 15 tramadol-acetaminophen tab 37.5-325 mg ................................................ 15 trandolapril tab 1 mg ....................... 49 trandolapril tab 2 mg ....................... 49 trandolapril tab 4 mg ....................... 49 trandolapril-verapamil hcl tab er 1-240 mg ................................................ 47 trandolapril-verapamil hcl tab er 2-180 mg ................................................ 47 trandolapril-verapamil hcl tab er 2-240 mg ................................................ 47 trandolapril-verapamil hcl tab er 4-240 mg ................................................ 47 tranexamic acid iv soln 1000 mg/10ml (100 mg/ml) .................................. 161 tranexamic acid tab 650 mg ............. 161 TRANSDERM-SC DIS 1.5MG ............. 142 TRANXENE T TAB 7.5MG ................... 73 tranylcypromine sulfate tab 10 mg ..... 82 TRAVATAN Z DRO 0.004% ............... 221

309

trazodone hcl tab 100 mg .................. 82 trazodone hcl tab 150 mg .................. 82 trazodone hcl tab 300 mg .................. 83 trazodone hcl tab 50 mg .................... 82 TREANDA INJ 100MG ........................ 37 TREANDA INJ 25MG .......................... 37 TRECATOR TAB 250MG ..................... 31 TRELSTAR INJ 11.25MG .................... 39 TREMFYA INJ 100MG/ML ................. 165 TRESIBA FLEX INJ 100UNIT ............. 118 TRESIBA FLEX INJ 200UNIT ............. 118 tretinoin cap 10 mg .......................... 45 tretinoin cream 0.025% .................. 202 tretinoin cream 0.05% .................... 202 tretinoin cream 0.1% ...................... 202 tretinoin gel 0.01%......................... 202 tretinoin gel 0.025% ....................... 202 tretinoin gel 0.05%......................... 202 tretinoin microsphere gel 0.04% ....... 202 tretinoin microsphere gel 0.1% ........ 202 TRETIN-X CRE 0.0375% .................. 202 TRETIN-X CRE 0.075% .................... 202 TRETIN-X CRE KIT 0.05% ................ 202 TRETTEN INJ ................................. 160 TREXALL TAB 10MG .......................... 39 TREXALL TAB 15MG .......................... 39 TREXALL TAB 5MG ............................ 38 TREXALL TAB 7.5MG ......................... 39 TREXIMET TAB 85-500MG ............... 106 triamcinolone acetonide aerosol soln 0.147 mg/gm ................................ 209 triamcinolone acetonide cream 0.025% ................................................... 209 triamcinolone acetonide cream 0.1% 209 triamcinolone acetonide cream 0.5% 207 triamcinolone acetonide dental paste 0.1% ............................................ 216 triamcinolone acetonide lotion 0.025% ................................................... 209 triamcinolone acetonide lotion 0.1% . 209 triamcinolone acetonide nasal aerosol suspension 55 mcg/act ................... 197 triamcinolone acetonide oint 0.025% 209 triamcinolone acetonide oint 0.1% .... 209 triamcinolone acetonide oint 0.5% .... 207 TRIAMINIC CHW ............................ 191 TRIAMINIC NT MIS COLD/CGH ......... 188 TRIAMINIC SYP CLD/ALRG ............... 188

triamterene & hydrochlorothiazide cap 37.5-25 mg .................................... 67 triamterene & hydrochlorothiazide cap 50-25 mg ....................................... 67 triamterene & hydrochlorothiazide tab 37.5-25 mg .................................... 67 triamterene & hydrochlorothiazide tab 75-50 mg ....................................... 67 TRIANEX OIN 0.05% ....................... 209 triazolam tab 0.125 mg ................... 104 triazolam tab 0.25 mg ..................... 104 TRIBENZOR20- TAB 5-12.5MG .......... 52 TRIBENZOR40- TAB 10-12.5 ............. 52 TRIBENZOR40- TAB 10-25MG ........... 52 TRIBENZOR40- TAB 5-12.5MG .......... 52 TRIBENZOR40- TAB 5-25MG ............. 52 tri-buff asa tab 325mg ....................... 4 TRICARE PAK PRENATAL .................. 185 TRICARE PRE CAP 27-1-500 ............. 186 TRICITRASOL CON .......................... 163 TRICODE AR LIQ 30-2-8 .................. 191 TRICODE GF LIQ 30-8-200............... 191 TRICOR TAB 145MG ......................... 57 TRICOR TAB 48MG ........................... 57 TRIESENCE INJ 40MG/ML ................ 218 TRIFERIC SOL ................................ 186 trifluoperazine hcl tab 1 mg (base equivalent) ..................................... 97 trifluoperazine hcl tab 10 mg (base equivalent) ..................................... 97 trifluoperazine hcl tab 2 mg (base equivalent) ..................................... 97 trifluoperazine hcl tab 5 mg (base equivalent) ..................................... 97 trifluridine ophth soln 1% ................ 218 TRIGLIDE TAB 160MG ...................... 57 trihexyphenidyl hcl elixir 0.4 mg/ml ... 90 trihexyphenidyl hcl tab 2 mg ............. 90 trihexyphenidyl hcl tab 5 mg ............. 90 TRILEPTAL SUS 300MG/5M ............... 79 TRILEPTAL TAB 150MG ..................... 79 TRILEPTAL TAB 300MG ..................... 80 TRILEPTAL TAB 600MG ..................... 80 TRILIPIX CAP 135MG ....................... 57 TRILIPIX CAP 45MG ......................... 57 TRI-LUMA CRE ............................... 213 trimethobenzamide hcl cap 300 mg ... 142 trimethoprim tab 100 mg .................. 36

310

trimipramine maleate cap 100 mg ...... 87 trimipramine maleate cap 25 mg ........ 87 trimipramine maleate cap 50 mg ........ 87 trinate tab ..................................... 186 trinessa lo tab ................................ 128 trinessa tab ................................... 128 TRI-NORINYL TAB 28 ...................... 128 TRINTELLIX TAB 10MG ...................... 86 TRINTELLIX TAB 20MG ...................... 86 TRINTELLIX TAB 5MG ....................... 86 TRIOSTAT INJ 10MCG/ML ................ 139 triple antib oin ............................... 203 triple antib oin plus ......................... 203 triple dye solution........................... 206 TRIPLE PASTE OIN 12.8% ............... 213 TRIPTODUR SUS 22.5MG ................. 136 TRISENOX SOL 10MG/10M ................ 45 TRISTART DHA CAP ........................ 186 TRIUMEQ TAB .................................. 28 TRI-VI-SOL SOL ............................. 185 TRIZIVIR TAB .................................. 28 TROKENDI XR CAP 100MG ................. 80 TROKENDI XR CAP 200MG ................. 80 TROKENDI XR CAP 25MG ................... 80 TROKENDI XR CAP 50MG ................... 80 TROPAZONE LOT ............................ 210 TROPHAMINE INJ 6% ...................... 173 tropicamide ophth soln 0.5% ........... 221 tropicamide ophth soln 1% .............. 221 trospium chloride cap er 24hr 60 mg . 154 trospium chloride tab 20 mg ............ 154 TRULANCE TAB 3MG ....................... 148 TRULICITY INJ 0.75/0.5 .................. 116 TRULICITY INJ 1.5/0.5 .................... 116 TRUSOPT SOL 2% OP ..................... 219 TRUVADA TAB 200-300 ..................... 28 TRUZONE PEAK MIS FLOW MTR ........ 195 trymine cg liq 225-7.5 .................... 191 TUDORZA PRES AER 400/ACT .......... 187 TUMS CHW 500MG ......................... 140 TUSNEL PED DRO 7.5-50 ................. 191 tussin cf liq .................................... 191 tussin cf liq max/m-s ...................... 191 tussin chest syp 100/5ml ................. 194 tussin cough syp 15mg/5ml ............. 192 tussin dm liq 100-10/5 .................... 191 tussin dm liq max ........................... 191 tussin dm syp 100-10/5 .................. 191

TUSSIONEX SUS 10-8/5ML .............. 191 TUZISTRA XR SUS .......................... 192 TWYNSTA TAB 40-10MG ................... 51 TWYNSTA TAB 40-5MG ..................... 51 TWYNSTA TAB 80-10MG ................... 51 TWYNSTA TAB 80-5MG ..................... 51 TYBOST TAB 150MG ......................... 27 TYGACIL INJ 50MG .......................... 36 TYKERB TAB 250MG ......................... 42 TYLENOL/COD TAB #3 ..................... 15 TYLENOL/COD TAB #4 ..................... 16 TYMLOS INJ ................................... 125 TYVASO START SOL 0.6MG/ML .......... 71 TYZINE SOL 0.1% .......................... 198 U UCERIS AER 2MG/ACT ..................... 145 UCERIS TAB 9MG ........................... 144 UDAMIN SP TAB ............................. 186 ULESFIA LOT 5% ............................ 214 ULORIC TAB 40MG ............................. 2 ULORIC TAB 80MG ............................. 2 ULTIMATECARE CAP ONE NF ............ 186 ULTIVA INJ 1MG .............................. 16 ULTIVA INJ 2MG .............................. 16 ULTIVA INJ 5MG .............................. 16 ultra b-100 tab complex .................. 186 ULTRA MAN TAB ............................. 186 ULTRACET TAB 37.5-325 .................. 16 ultra-derm lot ................................ 213 ULTRAFOAM MIS 2X6.25X7 .............. 162 ULTRAFOAM MIS 8X12.5X1 .............. 162 ULTRAFOAM MIS 8X12.5X3 .............. 162 ULTRAFOAM MIS 8X6.25X1 .............. 162 ULTRAM ER TAB 300MG .................... 16 ULTRAM TAB 50MG .......................... 16 ULTRAVATE CRE 0.05% ................... 210 ULTRAVATE OIN 0.05% ................... 210 UNASYN INJ 1.5GM .......................... 24 UNASYN INJ 15GM ........................... 24 UNASYN INJ 3GM ............................ 24 UNIFIBER POW ............................... 147 UNIFINE PNTP MIS 31GX3/16 ........... 123 UNISOM SLEEP TAB 25MG ............... 105 UNITUXIN INJ ................................. 45 UPCAL D POW ................................ 186 UPTRAVI TAB 1000MCG .................... 70 UPTRAVI TAB 1200MCG .................... 70 UPTRAVI TAB 1400MCG .................... 70

311

UPTRAVI TAB 1600MCG .................... 70 UPTRAVI TAB 200/800 ...................... 70 UPTRAVI TAB 200MCG ...................... 70 UPTRAVI TAB 400MCG ...................... 70 UPTRAVI TAB 600MCG ...................... 70 UPTRAVI TAB 800MCG ...................... 70 ur n-c tab ...................................... 153 uramit mb cap 118mg ..................... 153 URECHOLINE TAB 10MG .................. 153 URECHOLINE TAB 25MG .................. 153 URECHOLINE TAB 50MG .................. 153 URECHOLINE TAB 5MG.................... 153 UREVAZ CRE 44% .......................... 210 urimar-t tab .................................. 154 UROCIT-K 10 TAB .......................... 154 UROCIT-K 15 TAB .......................... 154 UROCIT-K 5 TAB ............................ 154 urolet mb tab ................................. 154 URO-MAG CAP 140MG ..................... 140 urophen mb tab 81.6mg .................. 154 urosex tab ..................................... 186 UROXATRAL TAB 10MG ................... 152 URSO 250 TAB 250MG .................... 143 URSO FORTE TAB 500MG ................ 143 ursodiol cap 300 mg ....................... 143 ursodiol tab 250 mg ........................ 143 ursodiol tab 500 mg ........................ 143 UTIBRON CAP NEOHALER ................ 187 V valacyclovir hcl tab 1 gm ................... 33 valacyclovir hcl tab 500 mg ............... 33 VALCHLOR GEL 0.016% .................... 37 valganciclovir hcl for soln 50 mg/ml (base equiv) .................................... 31 valganciclovir hcl tab 450 mg (base equivalent) ...................................... 31 VALIUM TAB 10MG ........................... 73 VALIUM TAB 2MG ............................. 73 VALIUM TAB 5MG ............................. 73 valproate sodium inj 100 mg/ml ......... 80 valproate sodium oral soln 250 mg/5ml (base equiv) .................................... 80 valproic acid cap 250 mg ................... 80 valsartan tab 160 mg ........................ 54 valsartan tab 320 mg ........................ 54 valsartan tab 40 mg ......................... 54 valsartan tab 80 mg ......................... 54 valsartan-hydrochlorothiazide tab 160-

12.5 mg ......................................... 53 valsartan-hydrochlorothiazide tab 160-25 mg ................................................ 53 valsartan-hydrochlorothiazide tab 320-12.5 mg ......................................... 53 valsartan-hydrochlorothiazide tab 320-25 mg ................................................ 53 valsartan-hydrochlorothiazide tab 80-12.5 mg ......................................... 53 VALTREX TAB 1GM........................... 33 VALTREX TAB 500MG ....................... 33 VANCOCIN HCL CAP 125MG .............. 36 VANCOCIN HCL CAP 250MG .............. 36 VANCOMYC/DEX INJ 1GM ................. 36 VANCOMYC/DEX INJ 500MG .............. 36 vancomycin hcl cap 125 mg .............. 36 vancomycin hcl cap 250 mg .............. 36 vancomycin hcl for inj 10 gm ............ 36 vancomycin hcl for inj 1000 mg ......... 36 vancomycin hcl for inj 500 mg ........... 36 vancomycin hcl for inj 5000 mg ......... 36 VANOS CRE 0.1% ........................... 207 VANTAS KIT 50MG ........................... 39 VAPRISOL INJ 20/100ML ................. 139 VARITHENA AER 10MG/ML ................ 69 VARIZIG INJ 125UNIT ..................... 167 VARUBI TAB 90MG .......................... 142 VASCAZEN CAP 1GM ....................... 171 VASCEPA CAP 0.5GM ....................... 59 VASCEPA CAP 1GM .......................... 59 VASERETIC TAB 10-25MG ................. 48 vashe wound sol therapy ................. 215 VASOTEC TAB 10MG ........................ 49 VASOTEC TAB 2.5MG ....................... 49 VASOTEC TAB 20MG ........................ 49 VASOTEC TAB 5MG .......................... 49 VAYAROL CAP ................................ 171 VAZCULEP INJ 10MG/ML ................... 72 v-c forte cap .................................. 186 vcks dayquil liq mucus dm ............... 192 VECTIBIX INJ 100MG ....................... 45 VECTIBIX INJ 400MG ....................... 45 VECTICAL OIN 3MCG/GM ................. 205 vecuronium bromide for inj 10 mg .... 111 vecuronium bromide for inj 20 mg .... 112 VELETRI INJ 0.5MG .......................... 71 VELETRI INJ 1.5MG .......................... 71 VELPHORO CHW 500MG .................. 136

312

VELTASSA POW 16.8GM .................. 136 VELTASSA POW 25.2GM .................. 136 VELTASSA POW 8.4GM .................... 136 VELTIN GEL ................................... 202 VENCLEXTA TAB 100MG .................... 45 VENCLEXTA TAB 10MG ...................... 45 VENCLEXTA TAB 50MG ...................... 45 VENCLEXTA TAB START PK ................ 46 VENELEX OIN ................................ 215 venlafaxine hcl cap er 24hr 150 mg (base equivalent) ............................. 84 venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) ............................. 84 venlafaxine hcl cap er 24hr 75 mg (base equivalent) ...................................... 84 venlafaxine hcl tab 100 mg ................ 84 venlafaxine hcl tab 25 mg.................. 84 venlafaxine hcl tab 37.5 mg ............... 84 venlafaxine hcl tab 50 mg.................. 84 venlafaxine hcl tab 75 mg.................. 84 venlafaxine hcl tab er 24hr 150 mg (base equivalent) ...................................... 84 venlafaxine hcl tab er 24hr 225 mg (base equivalent) ...................................... 84 venlafaxine hcl tab er 24hr 37.5 mg (base equivalent) ............................. 84 venlafaxine hcl tab er 24hr 75 mg (base equivalent) ...................................... 84 VENLAFAXINE TAB 150MG ER ............ 84 VENLAFAXINE TAB 37.5 ER ................ 84 VENLAFAXINE TAB 75MG ER .............. 84 VENT NEEDLE MIS 18GX1.5" ............ 170 VENTAVIS SOL 10MCG/ML ................. 71 VENTAVIS SOL 20MCG/ML ................. 71 VENTOLIN HFA AER ........................ 193 VERAMYST SPR 27.5MCG ................ 197 verapamil hcl cap er 24hr 100 mg ...... 65 verapamil hcl cap er 24hr 120 mg ...... 65 verapamil hcl cap er 24hr 180 mg ...... 65 verapamil hcl cap er 24hr 200 mg ...... 65 verapamil hcl cap er 24hr 240 mg ...... 65 verapamil hcl cap er 24hr 300 mg ...... 65 verapamil hcl cap er 24hr 360 mg ...... 65 verapamil hcl iv soln 2.5 mg/ml.......... 65 verapamil hcl tab 120 mg .................. 65 verapamil hcl tab 40 mg .................... 65 verapamil hcl tab 80 mg .................... 65 verapamil hcl tab er 120 mg .............. 65

verapamil hcl tab er 180 mg ............. 65 verapamil hcl tab er 240 mg ............. 65 VERDESO AER 0.05% ...................... 208 verdrocet tab 2.5-325 ...................... 16 VERELAN CAP 120MG SR .................. 65 VERELAN CAP 180MG SR .................. 65 VERELAN CAP 240MG SR .................. 65 VERELAN CAP 360MG SR .................. 65 VERELAN PM CAP 100MG ER ............. 65 VERELAN PM CAP 200MG ER ............. 65 VERELAN PM CAP 300MG ER ............. 65 VERSACLOZ SUS 50MG/ML ............... 95 VERZENIO TAB 100MG ..................... 42 VERZENIO TAB 150MG ..................... 42 VERZENIO TAB 200MG ..................... 42 VERZENIO TAB 50MG ....................... 42 VESICARE TAB 10MG ...................... 154 VESICARE TAB 5MG ........................ 154 vestura tab 3-0.02mg ..................... 127 VFEND IV INJ 200MG ....................... 27 VFEND SUS 40MG/ML....................... 27 VFEND TAB 200MG .......................... 27 VFEND TAB 50MG ............................ 27 VIBATIV INJ 250MG ......................... 36 VIBERZI TAB 100MG ....................... 145 VIBERZI TAB 75MG ......................... 145 VIBRAMYCIN CAP 100MG .................. 25 VIBRAMYCIN SUS 25MG/5ML ............ 25 VIBRAMYCIN SYP 50MG/5ML ............. 25 VICKS NATURE LIQ COLD/FLU .......... 192 VICKS NATURE LIQ CONGEST .......... 192 VICKS OIN VAPORUB ...................... 196 VICTOZA INJ 18MG/3ML .................. 116 VIDEX EC CAP 125MG ...................... 30 VIDEX EC CAP 200MG ...................... 30 VIDEX EC CAP 250MG ...................... 30 VIDEX EC CAP 400MG ...................... 30 VIDEX SOL 2GM .............................. 30 VIDEX SOL 4GM .............................. 30 VIEKIRA PAK TAB ............................ 33 VIEKIRA XR TAB .............................. 33 vigabatrin powd pack 500 mg ............ 80 VIGAMOX DRO 0.5% ....................... 217 vigor cap ....................................... 186 VIIBRYD KIT STARTER ..................... 86 VIIBRYD TAB 10MG ......................... 86 VIIBRYD TAB 20MG ......................... 86 VIIBRYD TAB 40MG ......................... 86

313

VIMOVO TAB 375-20MG ..................... 5 VIMOVO TAB 500-20MG ..................... 5 VIMPAT INJ 200MG/20 ...................... 80 VIMPAT SOL 10MG/ML ...................... 80 VIMPAT TAB 100MG .......................... 80 VIMPAT TAB 150MG .......................... 80 VIMPAT TAB 200MG .......................... 80 VIMPAT TAB 50MG ........................... 80 VINACAL B MIS .............................. 186 VINATE C TAB ................................ 186 VINATE CAL TAB ............................ 186 VINATE CARE CHW 40-1MG ............. 186 VINATE DHA CAP 27-1.13 ................ 186 VINATE II TAB ............................... 186 VINATE M TAB ............................... 186 VINATE ONE TAB ............................ 186 vinblastine sulfate inj 1 mg/ml ........... 46 vincristine sulfate iv soln 1 mg/ml ...... 46 vinorelbine tartrate inj 10 mg/ml (base equiv) ............................................. 46 vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) (base equiv) ......................... 46 VIOKACE TAB ................................ 149 VIOKACE TAB 20880 ....................... 149 VIOS LC MIS SPRINT ...................... 195 VIRACEPT TAB 250MG ...................... 29 VIRACEPT TAB 625MG ...................... 29 VIRAMUNE SUS 50MG/5ML ................ 29 VIRAMUNE TAB 200MG ..................... 29 VIRASAL LIQ 27.5% ....................... 213 VIRAZOLE INH 6GM .......................... 36 VIREAD POW 40MG/GM ..................... 31 VIREAD TAB 150MG .......................... 31 VIREAD TAB 200MG .......................... 31 VIREAD TAB 250MG .......................... 31 VIREAD TAB 300MG .......................... 31 VIROPTIC SOL 1% OP ..................... 218 VIRT NATE TAB .............................. 186 VIRT-PN TAB ................................. 186 VIRTPREX CAP ............................... 186 virtussin sol dac ............................. 192 VISCOAT SOL ................................ 221 VISIONBLUE SOL 0.06% ................. 221 VISTARIL CAP 25MG ....................... 189 VISTARIL CAP 50MG ....................... 189 vit c gummie chw 125mg ................ 186 VITACRAVES CHW +OMEGA-3.......... 186 VITAFOL CAP ULTRA ....................... 186

VITAFOL CHW GUMMIES .................. 186 VITAFOL FE+ CAP ........................... 186 VITAFOL TAB ................................. 186 VITAFOL-NANO TAB ........................ 186 VITAFOL-OB PAK +DHA ................... 186 VITAFOL-ONE CAP .......................... 186 VITAL-D RX TAB ............................. 186 VITALETS CHW .............................. 186 VITAMAX CHW ............................... 186 vitamax ped dro ............................. 186 VITAMEDMD CAP ONE RX ................ 186 VITAMEDMD MIS PLUS RX ............... 186 vitamin c + tab echinace ................. 186 vitamin c tab 500mg ....................... 186 vitamin d chw 1000unit ................... 187 vitamin d tab 1000unit .................... 187 VITAMIN D TAB 400 ........................ 187 VITAMIN D2 TAB 2000UNIT ............. 186 VITAMIN D2 TAB 400UNIT ............... 186 vitamin d3 cap 10000unt ................. 186 VITAMIN D3 CAP 4000UNIT ............. 186 VITAMIN D3 LIQ 1200UNIT .............. 186 VITAMIN D3 SPR 1000UNIT ............. 187 VITAMIN D3 TAB 3000UNIT ............. 187 vitamin d-3 tab 5000unit ................. 187 vitamins a & d cap .......................... 187 VITA-PREN TAB .............................. 186 vitatrum chw ................................. 187 VITRASE INJ 200/ML ....................... 108 VIVELLE-DOT DIS 0.025MG ............. 130 VIVELLE-DOT DIS 0.0375MG ............ 130 VIVELLE-DOT DIS 0.05MG ............... 130 VIVELLE-DOT DIS 0.075MG ............. 130 VIVELLE-DOT DIS 0.1MG ................. 130 VIVITROL INJ 380MG ...................... 112 VIVLODEX CAP 10MG ......................... 4 VIVLODEX CAP 5MG ........................... 4 VOLTAREN GEL 1% ............................ 5 voriconazole for inj 200 mg ............... 27 voriconazole for susp 40 mg/ml ......... 27 voriconazole tab 200 mg .................. 27 voriconazole tab 50 mg .................... 27 VOSEVI TAB ................................... 33 VOSPIRE ER TAB 4MG ..................... 193 VOSPIRE ER TAB 8MG ..................... 193 VOTRIENT TAB 200MG ..................... 42 VP-HEME OB TAB ............................ 187 VP-PNV-DHA CAP ........................... 187

314

vp-precip cap ................................. 171 VPRIV INJ 400UNIT ........................ 135 VRAYLAR CAP 1.5-3MG ..................... 95 VRAYLAR CAP 1.5MG ........................ 95 VRAYLAR CAP 3MG ........................... 95 VRAYLAR CAP 4.5MG ........................ 95 VRAYLAR CAP 6MG ........................... 95 VSL#3 DS PAK 900BIL .................... 148 VUSION OIN .................................. 205 VYTORIN TAB 10-10MG ..................... 58 VYTORIN TAB 10-20MG ..................... 58 VYTORIN TAB 10-40MG ..................... 58 VYTORIN TAB 10-80MG ..................... 58 VYVANSE CAP 10MG ....................... 102 VYVANSE CAP 20MG ....................... 102 VYVANSE CAP 30MG ....................... 102 VYVANSE CAP 40MG ....................... 103 VYVANSE CAP 50MG ....................... 103 VYVANSE CAP 60MG ....................... 103 VYVANSE CAP 70MG ....................... 103 W wal-dryl spr ................................... 213 wal-fex chld sus 30mg/5ml .............. 189 wal-fex d tab 24 hour ..................... 188 wal-mucil cap plus ca ...................... 147 wal-mucil pow 100% ...................... 147 wal-som tab 25mg ......................... 105 wal-tussin cap cough ...................... 192 WAL-TUSSIN CHW 7.5MG ................ 192 wal-tussin liq 15mg/5ml .................. 192 wal-zyr chw 5mg ............................ 188 warfarin sodium tab 1 mg ................ 157 warfarin sodium tab 10 mg .............. 157 warfarin sodium tab 2 mg ................ 157 warfarin sodium tab 2.5 mg ............. 157 warfarin sodium tab 3 mg ................ 157 warfarin sodium tab 4 mg ................ 157 warfarin sodium tab 5 mg ................ 157 warfarin sodium tab 6 mg ................ 157 warfarin sodium tab 7.5 mg ............. 157 weight loss tab multi ....................... 187 WELCHOL PAK 3.75GM ...................... 56 WELCHOL TAB 625MG ....................... 56 WELLBUTRIN TAB 100MG SR ............. 83 WELLBUTRIN TAB 150MG SR ............. 83 WELLBUTRIN TAB 200MG SR ............. 83 WELLBUTRIN TAB XL 150MG .............. 83 WELLBUTRIN TAB XL 300MG .............. 83

WESTHROID TAB 130MG ................. 139 WESTHROID TAB 32.5MG ................ 139 WESTHROID TAB 65MG ................... 139 WESTHROID TAB 97.5MG ................ 139 WIDE-SEAL DPR KIT 60 ................... 126 WIDE-SEAL DPR KIT 65 ................... 126 WIDE-SEAL DPR KIT 70 ................... 126 WIDE-SEAL DPR KIT 75 ................... 126 WIDE-SEAL DPR KIT 80 ................... 126 WIDE-SEAL DPR KIT 85 ................... 126 WIDE-SEAL DPR KIT 90 ................... 126 WIDE-SEAL DPR KIT 95 ................... 126 X XADAGO TAB 100MG ....................... 90 XADAGO TAB 50MG ......................... 90 XALATAN SOL 0.005% .................... 221 XALKORI CAP 200MG ....................... 42 XALKORI CAP 250MG ....................... 42 XANAX TAB 0.25MG ......................... 73 XANAX TAB 0.5MG ........................... 73 XANAX TAB 1MG ............................. 73 XANAX TAB 2MG ............................. 73 XANAX XR TAB 0.5MG ...................... 73 XANAX XR TAB 1MG ......................... 73 XANAX XR TAB 2MG ......................... 73 XANAX XR TAB 3MG ......................... 73 XARELTO STAR TAB 15/20MG .......... 157 XARELTO TAB 10MG ....................... 157 XARELTO TAB 15MG ....................... 157 XARELTO TAB 20MG ....................... 157 XELJANZ TAB 5MG .......................... 165 XELODA TAB 150MG ........................ 39 XELODA TAB 500MG ........................ 39 XERAC-AC SOL 6.25% ..................... 213 XERESE CRE 5-1% .......................... 213 XERMELO TAB 250MG ..................... 148 XEROFRM GAUZ MIS 1"X8" .............. 215 XEROFRM PETR PAD 2"X2" ............... 215 XIFAXAN TAB 200MG ....................... 36 XIFAXAN TAB 550MG ....................... 36 XIGDUO XR TAB 10-1000 ................ 119 XIGDUO XR TAB 10-500MG .............. 119 XIGDUO XR TAB 5-1000MG .............. 119 XIGDUO XR TAB 5-500MG ............... 119 XIIDRA DRO 5% ............................. 220 XODOL TAB 10-300MG ..................... 16 XODOL TAB 5-300MG ....................... 16 XODOL TAB 7.5-300 ........................ 16

315

XOLAIR SOL 150MG ........................ 196 XOLEGEL GEL 2% ........................... 205 XOPENEX CONC NEB 1.25/0.5 .......... 193 XOPENEX HFA AER ......................... 193 XOPENEX NEB 0.31MG .................... 193 XOPENEX NEB 0.63MG .................... 193 XOPENEX NEB 1.25/3ML .................. 193 XTAMPZA ER CAP 13.5MG.................. 16 XTAMPZA ER CAP 18MG .................... 16 XTAMPZA ER CAP 27MG .................... 16 XTAMPZA ER CAP 36MG .................... 16 XTAMPZA ER CAP 9MG ...................... 16 XTANDI CAP 40MG ........................... 39 xulane dis 150-35 .......................... 127 XULTOPHY INJ 100/3.6 ................... 116 XURIDEN POW 2GM ........................ 136 XYLOCAINE INJ 2% .......................... 56 XYLOCAINE SOL 4% ....................... 211 XYNTHA INJ 1000UNIT .................... 160 XYNTHA INJ 2000UNIT .................... 160 XYNTHA INJ 250UNIT ...................... 160 XYNTHA INJ 500UNIT ...................... 160 XYNTHA SOLOF INJ 3000UNIT .......... 160 XYREM SOL 500MG/ML .................... 111 XYZAL SOL 2.5/5ML ........................ 188 XYZAL TAB 5MG ............................. 188 Y YALE CLEANER POW ....................... 213 YALE NEEDLE MIS 15GX1.5" ............ 170 YALE NEEDLE MIS 15GX2" ............... 170 YALE NEEDLE MIS 16GX2" ............... 170 YALE NEEDLES MIS 13X3-1/2 .......... 170 YALE NEEDLES MIS 15X3-1/2 .......... 170 YALE NEEDLES MIS 17G X 2" ........... 170 YALE NEEDLES MIS 18G X 2" ........... 170 YALE NEEDLES MIS 18X1-1/2 .......... 170 YALE NEEDLES MIS 19X1-1/2 .......... 170 YALE NEEDLES MIS 20G X 1" ........... 170 YALE NEEDLES MIS 20G X 2" ........... 170 YALE NEEDLES MIS 20X1-1/2 .......... 170 YALE NEEDLES MIS 21G X 1" ........... 170 YALE NEEDLES MIS 21X1-1/2 .......... 170 YALE NEEDLES MIS 22G X 1" ........... 170 YALE NEEDLES MIS 22G X 2" ........... 170 YALE NEEDLES MIS 22G X 3" ........... 170 YALE NEEDLES MIS 22X1-1/2 .......... 170 YALE NEEDLES MIS 23G X 1" ........... 170 YALE NEEDLES MIS 23G X 2" ........... 171

YALE NEEDLES MIS 23GX1/2" .......... 171 YALE NEEDLES MIS 23X1-1/2 ........... 171 YALE NEEDLES MIS 24G X 1" ........... 171 YALE NEEDLES MIS 24GX1/2" .......... 171 YALE NEEDLES MIS 24GX3/4" .......... 171 YALE NEEDLES MIS 24X1-1/2 ........... 171 YALE NEEDLES MIS 25G X 1" ........... 171 YALE NEEDLES MIS 25GX1/2" .......... 171 YALE NEEDLES MIS 25GX3/8" .......... 171 YALE NEEDLES MIS 25GX5/8" .......... 171 YALE NEEDLES MIS 25X1-1/2 ........... 171 YALE NEEDLES MIS 26G X 1" ........... 171 YALE NEEDLES MIS 26GX1/2" .......... 171 YALE NEEDLES MIS 26GX3/8" .......... 171 YALE NEEDLES MIS 26GX5/8" .......... 171 YALE NEEDLES MIS 26X1-1/2 ........... 171 YALE NEEDLES MIS 27G X 1" ........... 171 YALE NEEDLES MIS 27GX1/2" .......... 171 YALE NEEDLES MIS 27GX1/4" .......... 171 YALE NEEDLES MIS 27GX3/8" .......... 171 YALE NEEDLES MIS 30G X 1" ........... 171 YALE NEEDLES MIS 30X1-1/2 ........... 171 YALE TB SYRN MIS GL 1/4ML ........... 171 YALE TB SYRN MIS GL 1ML .............. 171 YASMIN 28 TAB 3-0.03MG ............... 127 YAZ TAB 3-0.02MG ......................... 127 YERVOY INJ 200MG ......................... 46 YERVOY INJ 50MG ........................... 46 yodefan-nf liq 200-5ml .................... 194 yuvafem tab 10mcg ........................ 130 Z ZACARE KIT KIT 4% ....................... 202 zafirlukast tab 10 mg ...................... 194 zafirlukast tab 20 mg ...................... 194 zaleplon cap 10 mg ......................... 105 zaleplon cap 5 mg .......................... 105 ZALTRAP INJ 100/4ML ...................... 46 ZALTRAP INJ 200/8ML ...................... 46 ZANAFLEX CAP 2MG ........................ 111 ZANAFLEX CAP 4MG ........................ 111 ZANAFLEX CAP 6MG ........................ 111 ZANAFLEX TAB 4MG ........................ 111 ZANOSAR INJ 1GM .......................... 37 ZANTAC INJ 25MG/ML ..................... 144 ZANTAC INJ 50MG/2ML ................... 144 ZANTAC TAB 150MG ....................... 144 ZANTAC TAB 300MG ....................... 144 ZARONTIN CAP 250MG ..................... 80

316

ZARONTIN SOL 250/5ML ................... 80 ZARXIO INJ 300/0.5 ....................... 161 ZARXIO INJ 480/0.8 ....................... 161 ZATEAN-CH CAP ............................. 187 ZAVESCA CAP 100MG ..................... 135 ZEBETA TAB 5MG ............................. 62 ZEGERID CAP 20-1100 .................... 151 ZEGERID CAP 40-1100 .................... 151 ZEGERID OTC CAP 20-1100 ............. 151 ZEGERID POW 20-1680 ................... 151 ZEGERID POW 40-1680 ................... 151 ZELAPAR TAB 1.25MG ....................... 90 ZELBORAF TAB 240MG ...................... 42 ZEMAIRA INJ 1000MG ..................... 196 ZEMPLAR CAP 1MCG ....................... 134 ZEMPLAR CAP 2MCG ....................... 134 ZEMPLAR INJ 5MCG/ML ................... 134 zenatane cap 10mg ........................ 199 zenatane cap 20mg ........................ 199 zenatane cap 30mg ........................ 199 zenatane cap 40mg ........................ 199 zenchent fe chw 0.4mg-35 .............. 127 zenchent tab ................................. 127 ZENPEP CAP 10000UNT ................... 149 ZENPEP CAP 15000UNT ................... 149 ZENPEP CAP 20000UNT ................... 149 ZENPEP CAP 25000UNT ................... 149 ZENPEP CAP 3000UNIT ................... 149 ZENPEP CAP 40000UNT ................... 149 ZENPEP CAP 5000UNIT ................... 149 zenzedi tab 15mg ........................... 103 zenzedi tab 2.5mg .......................... 103 zenzedi tab 20mg ........................... 103 zenzedi tab 30mg ........................... 103 zenzedi tab 7.5mg .......................... 103 ZEPATIER TAB 50-100MG .................. 33 ZERIT CAP 15MG .............................. 30 ZERIT CAP 20MG .............................. 30 ZERIT CAP 30MG .............................. 30 ZERIT CAP 40MG .............................. 30 ZERIT SOL 1MG/ML .......................... 30 zeruvia pad 4-1% ........................... 211 ZESTORETIC TAB 10-12.5 ................. 48 ZESTORETIC TAB 20-12.5 ................. 48 ZESTORETIC TAB 20-25MG ................ 48 ZESTRIL TAB 10MG .......................... 49 ZESTRIL TAB 2.5MG ......................... 49 ZESTRIL TAB 20MG .......................... 49

ZESTRIL TAB 30MG ......................... 49 ZESTRIL TAB 40MG ......................... 49 ZESTRIL TAB 5MG ........................... 49 ZETIA TAB 10MG ............................. 56 ZETONNA AER 37MCG ..................... 197 ZEVALIN KIT Y-90 ........................... 46 ZIAC TAB 10/6.25 ........................... 60 ZIAC TAB 2.5/6.25 .......................... 60 ZIAC TAB 5-6.25MG ......................... 60 ZIAGEN SOL 20MG/ML ..................... 30 ZIAGEN TAB 300MG ......................... 30 ZIANA GEL .................................... 202 zidovudine cap 100 mg ..................... 30 zidovudine syrup 10 mg/ml ............... 30 zidovudine tab 300 mg ..................... 30 zileuton tab er 12hr 600 mg ............. 194 ZINACEF INJ 1.5GM ......................... 19 ZINACEF INJ 7.5GM ......................... 19 ZINACEF INJ 750MG ........................ 19 ZINACEF/H20 INJ 1.5GM PB .............. 19 ZINBRYTA INJ 150MG/ML ................ 110 zinc chloride inj 1 mg/ml ................. 176 zinc oxide oin 20% ......................... 213 ZINC OXIDE PST 25% ..................... 213 zinc sulfate inj 1 mg/ml ................... 176 zinc sulfate inj 5 mg/ml ................... 176 ZINECARD INJ 250MG ...................... 46 ZINECARD INJ 500MG ...................... 46 ZIOPTAN DRO 0.0015% .................. 222 ziprasidone hcl cap 20 mg ................ 95 ziprasidone hcl cap 40 mg ................ 95 ziprasidone hcl cap 60 mg ................ 95 ziprasidone hcl cap 80 mg ................ 95 ZIPSOR CAP 25MG ............................. 4 ZIRGAN GEL 0.15% ........................ 218 ZITHRANOL SHA 1% ....................... 205 ZMAX SUS 2GM ............................... 21 ZN-DTPA SOL 1000MG .................... 124 ZOCOR TAB 10MG ........................... 58 ZOCOR TAB 20MG ........................... 58 ZOCOR TAB 40MG ........................... 58 ZOCOR TAB 5MG ............................. 58 ZOCOR TAB 80MG ........................... 58 ZOFRAN INJ 40/20ML ...................... 142 ZOFRAN SOL 4MG/5ML .................... 142 ZOFRAN TAB 4MG ........................... 142 ZOFRAN TAB 4MG ODT .................... 142 ZOFRAN TAB 8MG ........................... 142

317

ZOFRAN TAB 8MG ODT ................... 142 ZOHYDRO ER CAP 10MG ................... 16 ZOHYDRO ER CAP 15MG ................... 16 ZOHYDRO ER CAP 20MG ................... 16 ZOHYDRO ER CAP 30MG ................... 16 ZOHYDRO ER CAP 40MG ................... 16 ZOHYDRO ER CAP 50MG ................... 16 ZOLINZA CAP 100MG ........................ 46 zolmitriptan orally disintegrating tab 2.5 mg ............................................... 107 zolmitriptan orally disintegrating tab 5 mg ............................................... 107 zolmitriptan tab 2.5 mg ................... 107 zolmitriptan tab 5 mg ..................... 107 ZOLOFT CON 20MG/ML ..................... 86 ZOLOFT TAB 100MG ......................... 86 ZOLOFT TAB 25MG ........................... 86 ZOLOFT TAB 50MG ........................... 86 zolpidem tartrate tab 10 mg ............ 105 zolpidem tartrate tab 5 mg .............. 105 zolpidem tartrate tab er 12.5 mg ...... 105 zolpidem tartrate tab er 6.25 mg ...... 105 ZOLPIMIST SPR 5MG ...................... 105 ZOMACTON INJ 10MG ..................... 134 ZOMACTON INJ 5MG ....................... 134 ZOMIG SPR 2.5MG ......................... 107 ZOMIG SPR 5MG ............................ 107 ZOMIG TAB 2.5MG ......................... 107 ZOMIG TAB 5MG ............................ 108 ZOMIG ZMT TAB 2.5 MG .................. 108 ZOMIG ZMT TAB 5MG ..................... 108 ZONEGRAN CAP 100MG..................... 80 ZONEGRAN CAP 25MG ...................... 80 zonisamide cap 100 mg ..................... 80 zonisamide cap 25 mg ...................... 80 zonisamide cap 50 mg ...................... 80 ZONTIVITY TAB 2.08MG .................. 164 zoo friends chw extra c ................... 187 zoo friends chw gummies ................ 187 zoo friends chw pls iron ................... 187 ZORBTIVE INJ 8.8MG ...................... 134 ZORTRESS TAB 0.25MG .................. 168 ZORTRESS TAB 0.5MG .................... 168 ZORTRESS TAB 0.75MG .................. 168 ZORVOLEX CAP 18MG ........................ 4 ZORVOLEX CAP 35MG ........................ 4 ZOSYN INJ 2-0.25GM ........................ 24 ZOSYN INJ 3-0.375G ........................ 24

ZOSYN INJ 36-4.5GM ....................... 24 ZOSYN INJ 4-0.5GM ......................... 24 ZOSYN SOL 2-0.25GM ...................... 24 ZOSYN SOL 3-0.375G ...................... 24 ZOSYN SOL 4-0.50GM ...................... 24 zovia 1/35e tab .............................. 127 zovia 1/50e tab .............................. 127 ZOVIRAX CAP 200MG ....................... 33 ZOVIRAX CRE 5% ........................... 213 ZOVIRAX OIN 5% ........................... 213 ZOVIRAX SUS 200/5ML .................... 33 ZOVIRAX TAB 400MG ....................... 33 ZOVIRAX TAB 800MG ....................... 33 ZUBSOLV SUB 0.7-0.18 ................... 112 ZUBSOLV SUB 1.4-0.36 ................... 112 ZUBSOLV SUB 11.4-2.9 ................... 112 ZUBSOLV SUB 2.9-0.71 ................... 112 ZUBSOLV SUB 5.7-1.4 .................... 112 ZUBSOLV SUB 8.6-2.1 .................... 112 ZUPLENZ MIS 4MG ......................... 142 ZUPLENZ MIS 8MG ......................... 142 ZURAMPIC TAB 200MG ....................... 2 ZYBAN TAB 150MG SR .................... 113 ZYCLARA CRE 3.75% ...................... 203 ZYCLARA PUMP CRE 2.5% ............... 203 ZYDELIG TAB 100MG ....................... 42 ZYDELIG TAB 150MG ....................... 42 ZYFLO CR TAB 600MG ..................... 194 ZYFLO TAB 600MG .......................... 194 ZYKADIA CAP 150MG ....................... 42 ZYLET SUS 0.5-0.3% ...................... 216 ZYMAXID SOL 0.5% ........................ 217 ZYNCOF SYP 20-400/5 .................... 192 ZYPREXA INJ 10MG .......................... 95 ZYPREXA RELP INJ 210MG ................ 95 ZYPREXA RELP INJ 300MG ................ 95 ZYPREXA RELP INJ 405MG ................ 95 ZYPREXA TAB 10MG ......................... 95 ZYPREXA TAB 15MG ......................... 95 ZYPREXA TAB 2.5MG ........................ 95 ZYPREXA TAB 20MG ......................... 95 ZYPREXA TAB 5MG .......................... 95 ZYPREXA TAB 7.5MG ........................ 95 ZYPREXA ZYDI TAB 10MG ................. 95 ZYPREXA ZYDI TAB 15MG ................. 95 ZYPREXA ZYDI TAB 20MG ................. 96 ZYPREXA ZYDI TAB 5MG ................... 95 ZYRTEC ALLGY TAB 10MG ................ 188

318

ZYTIGA TAB 250MG .......................... 39 ZYTIGA TAB 500MG .......................... 39 ZYVOX SOL 2MG/ML ......................... 36

ZZZQUIL CAP 25MG ........................ 105 ZZZQUIL LIQ 50MG/30 .................... 105

Documents

Preferred Drug List - passporthealthplan.compassporthealthplan.com/wp-content/uploads/2018/02/Evolent-Passport... · • Mail to: U.S. Department of Health and Human Services