aetna better health sm fida plan list of covered drugs

www.aetnabetterhealth.com/newyork

List of Covered Drugs/FormularyAETNA BETTER HEALTHSM FIDA PLAN

Aetna Better Health FIDA plan is a managed care plan that contracts with both Medicare and the New York State Department of Health (Medicaid) to provide benefits of both programs to participants through the Fully Integrated Duals Advantage (FIDA) Demonstration.

H8056_14_007R5 CMS APPROVED Last Updated 08/2015 Effective 8/1/2015

ParticipantServices55 W. 125th St., Suite 1300New York, NY 100271-855-494-9945 (toll-free)TTY: New York Relay 711Non-EmergencyTransportation1-866-334-8919

www.aetnabetterhealth.com/newyork

Helpful information

ParticipantServices1-855-494-9945 (toll-free)

Non-EmergencyTransportationMedical Transportation Management (MTM)1-866-334-8919

ServicesforHearingImpaired(TTY)New York Relay 711

AddressAetna Better Health FIDA Plan 55 W. 125th St., Suite 1300New York, NY 10027

Personal information

My ID number

My PCP (primary care provider)

My PCP’s phone number

My care manager’s name and phone number

If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork.com. NY-14-06-06 H8056_14_007R5 CMS APPROVED 1

?

H8056_14_007R5

Aetna Better Health FIDA Plan | 2015 List of Covered Drugs (Formulary) This is a list of drugs that Participants can get in Aetna Better Health FIDA Plan.

Aetna Better Health FIDA Plan is a managed care plan that contracts with both Medicare and the New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration.

Benefits, List of Covered Drugs, and pharmacy and provider networks may change from time to time throughout the year and on January 1 of each year.

You can always check Aetna Better Health FIDA Plan’s up-to-date List of Covered Drugs online at www.aetnabetterhealth.com/newyork or by calling Aetna Better Health FIDA Plan Participant Services at 1-855-494-9945 (TTY 711).

Limitations and restrictions may apply. For more information, call Aetna Better Health FIDA Plan Participant Services or read the Aetna Better Health FIDA Plan Participant Handbook.

There are no copays for any covered drugs.

You can get this information for free in other formats, such as Braille or large print. Call 1-855-494-9945 (TTY 711). The call is free.

You can get this information for free in other languages. Call 1-855-494-9945 and 711 for TTY/TDD, 24 hours a day, 7 days a week. The call is free.

Usted puede recibir esta información en otros idiomas en forma gratuita. Llame al 1-855-494-9945 ó al 711 para TTY/TDD, 24 horas al día, 7 días de la semana. La llamada es gratuita.

È possibile ottenere queste informazioni gratuitamente in altre lingue. Chiamare il numero 1-855-494-9945 e il numero 711 per il servizio TTY/TDD per i non udenti, 24 ore al giorno 7 giorni alla settimana. La chiamata è gratuita.

Ou kapab jwenn enfòmasyon sa a pou gratis nan lòt lang. Rele 1-855-494-9945 ak 711 pou TTY/TDD, 24 èdtan chak jou, 7 jou pa semèn. Apèl la gratis.

您可以免費取得本資訊的其他語言版本。請撥打 1-855-494-9945，若使用 TTY/TDD 請撥打 711，每週 7 天、每天 24 小時均提供服務。此為免費電話。

Вы можете бесплатно получить эту информацию в переводе на другой язык. Позвоните по телефону 1-855-494-9945. Линия работает круглосуточно и без выходных. Звонки бесплатные. Если вы пользуетесь устройством TTY/TDD, звоните по телефону 711.


?

다른 언어로 이 정보를 무료로 받으실 수 있습니다. 연중 무휴 24시간 1-855-494-9945 번 또는 TTY/TDD의 경우 711 번으로 전화해 주십시오. 통화는 무료입니다.

The State of New York has created a Participant Ombudsman Program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by Aetna Better Health FIDA Plan. ICAN may be reached toll-free at 1-844-614-8800 or online at www.icannys.org.


?

Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer.

1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.)

The drugs on the List of Covered Drugs that starts on page 11 are the drugs covered by Aetna Better Health FIDA Plan. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”

→ Aetna Better Health FIDA Plan will cover all drugs on the Drug List if:

• your doctor or other network prescriber says you need them to get better or stay healthy,

• the drug is medically necessary for your condition, and

• you fill the prescription at an Aetna Better Health FIDA Plan network pharmacy.

→ Aetna Better Health FIDA Plan may have additional steps to access certain drugs (see question 5). In some cases, you may have to do something before you can get a drug, like try other drugs first.

You can also see an up-to-date list of drugs that we cover on our website at www.aetnabetterhealth.com/newyork or call Participant Services at 1-855-494-9945 (TTY 711), 24 hours a day, 7 days a week.

2. Does the Drug List ever change?

Yes. Aetna Better Health FIDA Plan may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if:

• a new drug comes along that works as well as a drug on the Drug List now, or

• we learn that a drug is not safe.

We may also change our rules about drugs. For example, we could:

• Decide to require or not require prior approval for a drug. (Prior approval is permission from Aetna Better Health FIDA Plan or your Interdisciplinary Team (IDT) before you can get a drug.)

• Add or change the amount of a drug you can get (called “quantity limits”).


?

• Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)

(For more information on these drug rules, see page 5.)

We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes.

→ You can always check Aetna Better Health FIDA Plan’s up to date Drug List online at www.aetnabetterhealth.com/newyork. You can also call Participant Services to check the current Drug List at 1-855-494-9945 (TTY 711).

3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now?

If a cheaper drug becomes available, that works as well as a drug on the Drug List now:

• Your pharmacist may give you the cheaper drug the next time you fill your prescription. If you and your provider decide that the cheaper drug is not right for you, your provider can tell the pharmacist to continue to give you the drug you take now.

• Aetna Better Health FIDA Plan may decide to take the more expensive drug off of the Drug List. If you are taking a drug that we remove from the Drug List because a cheaper drug that works just as well comes along, we will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. You will be notified by mail if a drug list change will affect you. You can also search for your drug with the online searchable formulary tool as it is updated to reflect current coverage.

4. What happens when we find out a drug is not safe?

If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter and call you to tell you that the unsafe drug was taken off the Drug List. Please contact your doctor if a drug you are taking is removed from the drug list.


?

5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs?

Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you must do something before you can get the drug. For example:

• Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from Aetna Better Health FIDA Plan or your Interdisciplinary Team (IDT) before you fill your prescription. If you don’t get approval, Aetna Better Health FIDA Plan may not cover the drug.

• Quantity limits: Sometimes Aetna Better Health FIDA Plan limits the amount of a drug you can get.

• Step therapy: Sometimes Aetna Better Health FIDA Plan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second.

You can find out if your drug has any additional requirements or limits by looking in the tables beginning on page 11. You can also get more information by visiting our web site at www.aetnabetterhealth.com/newyork. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy.

You can ask for an “exception” from these limits. Please see question 11 for more information on exceptions.

→ If you are in a nursing facility or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new Aetna Better Health FIDA Plan Participant. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see question 11 for more information about exceptions.

6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug?

The List of Covered Drugs on page 11 has a column labeled “Necessary actions, restrictions, or limits on use.”


?

7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug.

We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other prescriber about what to do next.

8. How can you find a drug on the Drug List?

There are two ways to find a drug:

• You can search alphabetically (if you know how to spell the drug), or

• You can search by medical condition.

To search alphabetically, go to the Alphabetical Listing section (Index) on page 143. Then look for the name of your drug in the list.

To search by medical condition, find the section labeled “List of drugs by medical condition” on page 11. Then find your medical condition. For example, if you have a heart condition, you should look in that category. That is where you will find drugs that treat heart conditions.

9. What if the drug you want to take is not on the Drug List?

If you don’t see your drug on the Drug List, call Participant Services at 1-855-494-9945 and ask about it. If you learn that Aetna Better Health FIDA Plan will not cover the drug, you can do one of these things:

• Ask Participant Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or

• You can ask the plan or your Interdisciplinary Team (IDT) to make an exception to cover your drug. Please see question 11 for more information about exceptions.


?

10. What if you are a new Aetna Better Health FIDA Plan Participant and can’t find your drug on the Drug List or have a problem getting your drug?

We can help. We must cover up to 90 days of temporary supplies of your drug, as needed, during the first 90 days you are a Participant of Aetna Better Health FIDA Plan. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception.

We will cover up to 90 days of temporary supplies of your drug if:

• you are taking a drug that is not on our Drug List, or

• health plan rules do not let you get the amount ordered by your prescriber, or

• the drug requires prior approval by Aetna Better Health FIDA Plan or your Interdisciplinary Team (IDT), or

• you are taking a drug that is part of a step therapy restriction.

If you live in a nursing facility or other long-term care facility, you may refill your prescription for as long as 91 and may be up to 98 days. You may refill the drug multiple times during the 91 and may be up to 98 days. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception.

If you are a current participant and you have a change in your level of care (e.g. you are discharged from a hospital to your home or admitted to, or discharged from, a long-term care facility, your pharmacy may obtain an override up to a 90-day supply from Aetna Better Health FIDA Plan.

During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug.

11. Can you ask for an exception to cover your drug?

Yes. You can ask Aetna Better Health FIDA Plan or your Interdisciplinary Team (IDT) to make an exception to cover a drug that is not on the Drug List.

You can also ask Aetna Better Health FIDA Plan or your IDT to change the rules on your drug.

• For example, Aetna Better Health FIDA Plan may limit the amount of a drug we will cover. If your drug has a limit, you can ask us or your IDT to change the limit and cover more.


?

• Other examples: You can ask us or your IDT to drop step therapy restrictions or prior approval requirements.

12. How long does it take to get an exception?

First, Aetna Better Health FIDA Plan or your Interdisciplinary Team (IDT) must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, you will get a decision on your exception request within 72 hours.

If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, you will get a decision within 24 hours of receiving your prescriber’s supporting statement.

13. How can you ask for an exception?

To ask for an exception, call your Care Manager. Your Care Manager will work with you and your provider to help you ask for an exception.

14. What are generic drugs?

Generic drugs are made up of the same ingredients as brand name drugs. They usually cost less than the brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA).

Aetna Better Health FIDA Plan covers both brand name drugs and generic drugs.

15. What are OTC drugs?

OTC stands for “over-the-counter”. Aetna Better Health FIDA Plan covers some OTC drugs when they are written as prescriptions by your provider.

You can read the Aetna Better Health FIDA Plan Drug List to see what OTC drugs are covered.


?

16. Does Aetna Better Health FIDA Plan cover OTC non-drug products?

Aetna Better Health FIDA Plan covers some OTC non-drug products when they are written as prescriptions by your provider.

You can read the Aetna Better Health FIDA Plan Drug List to see what OTC non-drug products are covered.

17. What is your copay?

You will not be charged a copay for drugs on the Drug List.

18. What are drug tiers?

Tiers are groups of drugs with the same copay.

Tier 1 drugs are Medicare Part D prescription generic drugs.

Tier 2 drugs are Medicare Part D prescription brand name drugs.

Tier 3 drugs are Non-Medicare Part D prescription generic and brand name drugs.

All tiers have no copay.


?

List of Covered Drugs The list of covered drugs that begins on the next page gives you information about the drugs covered by Aetna Better Health FIDA Plan If you have trouble finding your drug in the list, turn to the Index that begins on page 143.

The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., CRESTOR) and generic drugs are listed in lower-case italics (e.g., amoxicillin).

The information in the necessary actions, restrictions, or limits on use column tells you if Aetna Better Health FIDA Plan has any rules for covering your drug. Here are the meanings of the codes used in the “Necessary actions, restrictions, or limits on use” column: Note: The * next to a drug means the drug is not a “Part D drug.” These drugs have different rules for appeals. An appeal is a formal way of asking for a review of and change to a coverage decision if you think there was a mistake. For example, Aetna Better Health FIDA Plan or your Interdisciplinary Team (IDT) might decide that a drug that you want is not covered or is no longer covered by Medicare or Medicaid. If you or your doctor or other prescriber disagrees with the decision, you can appeal. To ask for instructions on how to appeal, call Participant Services at 1-855-494-9945 or the Independent Consumer Advocacy Network (ICAN) at 1-844-614-8800. You can also read the Participant Handbook to learn how to appeal a decision.

Abbreviation Necessary actions, restrictions, or limits on use ( * ) Non Medicare Part D drugs, or OTC items that are covered by Medicaid B/D Covered under Medicare B or D PA Prior Authorization QL Quantity Limits ST Step Therapy NM Not available at mail-order LA Limited Access

If you have questions, please call Aetna Better Health FIDA Plan at 1-855-494-9945 (TTY: 711), 24 hours a day, 7 days a week. The call is free. For more information, visit www.aetnabetterhealth.com/newyork. You can find information on what the symbols and abbreviations on this table mean by going to page 10. NY-14-06-06 H8056_14_007R5 Formulary ID 00015337 V11

11

NY_MMP_CY15_2T_STANDARD eff 08/01/2015 Drug Name Drug

Tier WHAT THE DRUG

WILL COST YOU

NECESSARY ACTIONS

RESTRICTIONS OR LIMITS ON USE

ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION GOUT - DRUGS TO TREAT GOUT allopurinol tab 100 mg 1 $0

allopurinol tab 300 mg 1 $0

colchicine w/ probenecid tab

0.5-500 mg

1 $0

COLCRYS TAB 0.6MG 2 $0 QL (120 tabs / 30 days)

probenecid tab 500 mg 1 $0

ULORIC TAB 40MG 2 $0 ST

ULORIC TAB 80MG 2 $0 ST

MISCELLANEOUS acetamin jr tab 160mg rt 3 $0 NM; *

ACETAMINOPHE TAB 650MG 3 $0 NM; *

acetaminophen soln 160 mg/5ml 3 $0 NM; *

ADULT ASA TAB 81MG QM 3 $0 NM; *

ADVIL JR ST TAB 100MG 3 $0 NM; *

all day pain tab 220mg 3 $0 NM; *

APAP 500 LIQ 500/5ML 3 $0 NM; *

ASCRIPTIN TAB 3 $0 NM; *

ASPIRIN SUP 60MG 3 $0 NM; *



aspirin suppos 300 mg 3 $0 NM; *

aspirin suppos 600 mg 3 $0 NM; *

aspirin tab 81 mg 3 $0 NM; *

aspirin tab 325 mg 3 $0 NM; *

ASPIRIN TAB 650MG EC 3 $0 NM; *

aspirin tab delayed release 325 mg 3 $0 NM; *



bayer low chw 81mg 3 $0 NM; *

BUFFERIN TAB 81MG 3 $0 NM; *

BUFFERIN TAB 500MG 3 $0 NM; *

CHILD MOTRIN CHW 50MG 3 $0 NM; *

chld asafree elx 80/2.5ml 3 $0 NM; *

doans ex st tab 580mg 3 $0 NM; *

ed-apap liq 80mg/2.5 3 $0 NM; *

ELIXSURE GEL F/P BGUM 3 $0 NM; *


12

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU

NECESSARY ACTIONS RESTRICTIONS OR

LIMITS ON USE

eq aspirin tab 500mg ec 3 $0 NM; *

FEBROL SOL 325/5ML 3 $0 NM; *

FEVERALL INF SUP 80MG 3 $0 NM; *

FEVERALL SUP 120MG 3 $0 NM; *



8 hour pain tab 650mg 3 $0 NM; *

ibuprofen cap 200 mg 3 $0 NM; *

ibuprofen dro 50/1.25 3 $0 NM; *

ibuprofen jr chw 100mg 3 $0 NM; *

ibuprofen sus 100/5ml 3 $0 NM; *

motrin ib tab 200mg 3 $0 NM; *

NAPROXEN SODIUM CAP 220 MG 3 $0 NM; *

non-asa jr tab 160mg 3 $0 NM; *

non-aspirin chw 80mg 3 $0 NM; *

non-aspirin chw 160mg jr 3 $0 NM; *

NON-ASPIRIN TAB 500MG QM 3 $0 NM; *

pain relief dro 80/0.8ml 3 $0 NM; *

pain relief liq 500/15ml 3 $0 NM; *

pain relief sus 160/5ml 3 $0 NM; *

pain relief tab 325mg 3 $0 NM; *

pain relief tab 500mg 3 $0 NM; *

pain relievr tab 325mg 3 $0 NM; *

q-pap infant dro 80/0.8ml 3 $0 NM; *

ra aspirin tab 500mg 3 $0 NM; *

st joseph as chw 81mg 3 $0 NM; *

ST JOSEPH CHW 75MG ADU 3 $0 NM; *

STANBACK AF POW 950MG 3 $0 NM; *

tri-buff asa tab 325mg 3 $0 NM; *

TRIAMINIC SYP INFANT 3 $0 NM; *

tylenol chld tab 80mg 3 $0 NM; *

NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATION celecoxib cap 50 mg 1 $0 QL (60 caps / 30 days)

celecoxib cap 100 mg 1 $0 QL (60 caps / 30 days)



diclofenac potassium tab 50 mg 1 $0

diclofenac sodium tab delayed

release 25 mg

1 $0


release 50 mg

1 $0


13

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE


release 75 mg

1 $0

diclofenac sodium tab sr 24hr 100

mg

1 $0

diflunisal tab 500 mg 1 $0

etodolac cap 200 mg 1 $0

etodolac cap 300 mg 1 $0

etodolac tab 400 mg 1 $0

etodolac tab 500 mg 1 $0

etodolac tab sr 24hr 400 mg 1 $0



flurbiprofen tab 50 mg 1 $0

flurbiprofen tab 100 mg 1 $0

ibuprofen susp 100 mg/5ml 1 $0

ibuprofen tab 400 mg 1 $0



ketoprofen cap 50 mg 1 $0

ketoprofen cap 75 mg 1 $0

MELOXICAM SUSP 7.5 MG/5ML 1 $0

meloxicam tab 7.5 mg 1 $0

meloxicam tab 15 mg 1 $0

nabumetone tab 500 mg 1 $0

nabumetone tab 750 mg 1 $0

naproxen dr tab 375mg 1 $0

naproxen dr tab 500mg 1 $0

naproxen sodium tab 275 mg 1 $0

naproxen sodium tab 550 mg 1 $0

naproxen susp 125 mg/5ml 1 $0

naproxen tab 250 mg 1 $0



piroxicam cap 10 mg 1 $0

piroxicam cap 20 mg 1 $0

sulindac tab 150 mg 1 $0

sulindac tab 200 mg 1 $0

OPIOID ANALGESICS - DRUGS TO TREAT PAIN acetaminophen w/ codeine soln

120-12 mg/5ml 1 $0 QL (5000 mL / 30 days)


14

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

acetaminophen w/ codeine tab

300-15 mg

1 $0 QL (400 tabs / 30 days)


300-30 mg

1 $0 QL (400 tabs / 30 days)


300-60 mg

1 $0 QL (400 tabs / 30 days)

butorphanol tartrate inj 1 mg/ml 1 $0

butorphanol tartrate inj 2 mg/ml 1 $0

hydrocodone-acetaminophen soln 7.5-325 mg/15ml

1 $0 QL (5400 mL / 30 days)

hydrocodone-acetaminophen tab 5-325 mg

1 $0 QL (360 tabs / 30 days)

hydrocodone-acetaminophen tab

7.5-325 mg

1 $0 QL (360 tabs / 30 days)

hydrocodone-acetaminophen tab

10-325 mg

1 $0 QL (360 tabs / 30 days)

hydrocodone-ibuprofen tab 7.5-200

mg

1 $0 QL (150 tabs / 30 days)

tramadol hcl tab 50 mg 1 $0 QL (240 tabs / 30 days)

tramadol-acetaminophen tab 37.5-325 mg

1 $0 QL (240 tabs / 30 days)

OPIOID ANALGESICS, CII - DRUGS TO TREAT PAIN DURAMORPH INJ 0.5MG/ML 1 $0 B/D

DURAMORPH INJ 1MG/ML 1 $0 B/D

endocet tab 5-325mg 1 $0 QL (360 tabs / 30 days)

endocet tab 7.5-325 1 $0 QL (360 tabs / 30 days)

endocet tab 10-325mg 1 $0 QL (360 tabs / 30 days)

fentanyl citrate lozenge on a handle 200 mcg

2 $0 QL (120 lozenges / 30 days), PA











fentanyl td patch 72hr 12 mcg/hr 1 $0 QL (10 patches / 30 days)


15

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

fentanyl td patch 72hr 25 mcg/hr 1 $0 QL (10 patches / 30

days)


days), PA


days), PA


days), PA

FENTORA TAB 100MCG 2 $0 QL (120 tabs / 30 days),

PA


PA


PA


PA


PA

hydromorphone hcl liqd 1 mg/ml 1 $0

hydromorphone hcl preservative

free (pf) inj 10 mg/ml

1 $0 B/D

hydromorphone hcl tab 2 mg 1 $0 QL (270 tabs / 30 days)



LAZANDA SPR 100MCG 2 $0 QL (30 bottles / 30 days), PA

LAZANDA SPR 400MCG 2 $0 QL (30 bottles / 30 days), PA

methadone con 10mg/ml 1 $0 QL (120 mL / 30 days)

methadone hcl soln 5 mg/5ml 1 $0 QL (600 mL / 30 days)

methadone hcl soln 10 mg/5ml 1 $0 QL (600 mL / 30 days)

methadone hcl tab 5 mg 1 $0 QL (240 tabs / 30 days)

methadone hcl tab 10 mg 1 $0 QL (240 tabs / 30 days)

MORPHINE SUL INJ 2MG/ML 1 $0 B/D



MORPHINE SULFATE (CONCENTRATE) ORAL SOLN 20

MG/ML

1 $0

morphine sulfate beads cap sr 24hr

30 mg

1 $0 QL (60 caps / 30 days)


16

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE


45 mg

1 $0 QL (60 caps / 30 days)


60 mg

1 $0 QL (60 caps / 30 days)


75 mg

1 $0 QL (60 caps / 30 days)


90 mg

1 $0 QL (60 caps / 30 days)


120 mg

1 $0 QL (60 caps / 30 days)

morphine sulfate cap sr 24hr 10 mg 1 $0 QL (60 caps / 30 days)






morphine sulfate cap sr 24hr 100

mg

2 $0 QL (60 caps / 30 days)

morphine sulfate inj pf 0.5 mg/ml 1 $0 B/D

morphine sulfate inj pf 1 mg/ml 1 $0 B/D

MORPHINE SULFATE IV SOLN 1

MG/ML

1 $0 B/D

MORPHINE SULFATE IV SOLN PF 10

MG/ML

1 $0 B/D

MORPHINE SULFATE IV SOLN PF 15

MG/ML

1 $0 B/D

MORPHINE SULFATE ORAL SOLN 10

MG/5ML

1 $0


MG/5ML

1 $0

MORPHINE SULFATE TAB 15 MG 1 $0 QL (180 tabs / 30 days)

MORPHINE SULFATE TAB 30 MG 1 $0 QL (180 tabs / 30 days)

morphine sulfate tab cr 15 mg 1 $0 QL (90 tabs / 30 days)





oxycodone hcl cap 5 mg 1 $0 QL (180 caps / 30 days)

OXYCODONE HCL CONC 100 MG/5ML (20 MG/ML)

1 $0

oxycodone hcl soln 5 mg/5ml 1 $0

oxycodone hcl tab 5 mg 1 $0 QL (180 tabs / 30 days)


17

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE





oxycodone w/ acetaminophen tab 2.5-325 mg

1 $0 QL (360 tabs / 30 days)

oxycodone w/ acetaminophen tab 5-325 mg

1 $0 QL (360 tabs / 30 days)

oxycodone w/ acetaminophen tab 7.5-325 mg

1 $0 QL (360 tabs / 30 days)

oxycodone w/ acetaminophen tab 10-325 mg

1 $0 QL (360 tabs / 30 days)

roxicet sol 5-325/5 2 $0 QL (1800 mL / 30 days soln)

ANESTHETICS - DRUGS FOR NUMBING LOCAL ANESTHETICS lidocaine hcl local inj 0.5% 1 $0 B/D

lidocaine hcl local inj 1% 1 $0 B/D

lidocaine hcl local inj 1.5% 1 $0 B/D

lidocaine hcl local inj 2% 1 $0 B/D

lidocaine hcl local preservative free

(pf) inj 0.5%

1 $0 B/D

lidocaine hcl local preservative free

(pf) inj 1%

1 $0 B/D

ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate inj 1 gm/4ml (250

mg/ml)

1 $0

amikacin sulfate inj 500 mg/2ml

(250 mg/ml)

1 $0

gentam/nacl inj 0.9mg/ml 1 $0

gentam/nacl inj 1.4mg/ml 1 $0

gentamicin in saline inj 0.8 mg/ml 1 $0

gentamicin in saline inj 1 mg/ml 1 $0



gentamicin in saline inj 2 mg/ml 1 $0

gentamicin sulfate inj 10 mg/ml 1 $0

gentamicin sulfate inj 40 mg/ml 1 $0

gentamicin sulfate iv soln 10 mg/ml 1 $0

neomycin sulfate tab 500 mg 1 $0


18

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

paromomycin sulfate cap 250 mg 1 $0

streptomycin sulfate for inj 1 gm 1 $0

sulfadiazine tab 500mg 2 $0

tobra/nacl inj 80/0.9 2 $0

tobramycin nebu soln 300 mg/5ml 2 $0 B/D, NM

tobramycin sulfate for inj 1.2 gm 1 $0

tobramycin sulfate inj 1.2 gm/30ml

(40 mg/ml)

1 $0

tobramycin sulfate inj 2 gm/50ml

(40 mg/ml)

1 $0

tobramycin sulfate inj 10 mg/ml 1 $0

tobramycin sulfate inj 80 mg/2ml

(40 mg/ml)

1 $0

ANTI-INFECTIVES - MISCELLANEOUS ALBENZA TAB 200MG 2 $0

ALINIA SUS 100/5ML 2 $0

ALINIA TAB 500MG 2 $0

atovaquone susp 750 mg/5ml 2 $0

AZACTAM INJ 1GM 2 $0

AZACTAM INJ 2GM 2 $0

AZACTAM/DEX INJ 1GM 2 $0

AZACTAM/DEX INJ 2GM 2 $0

aztreonam for inj 1 gm 1 $0

aztreonam for inj 2 gm 1 $0

BILTRICIDE TAB 600MG 2 $0

CAYSTON INH 75MG 2 $0 NM, LA, PA

clindamycin hcl cap 75 mg 1 $0



clindamycin palmitate hcl for soln

75 mg/5ml (base equiv)

1 $0

clindamycin phosphate inj 9

gm/60ml

1 $0


mg/2ml

1 $0


mg/4ml

1 $0

clindamycin phosphate inj 900 mg/6ml

1 $0

clindamycin phosphate iv soln 300 mg/2ml

1 $0


19

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

clindamycin phosphate iv soln 600

mg/4ml

1 $0


mg/6ml

1 $0

colistimethate sodium for inj 150

mg

1 $0

CUBICIN SOL 500MG 2 $0

dapsone tab 25 mg 1 $0

dapsone tab 100 mg 1 $0

DARAPRIM TAB 25MG 2 $0

imipenem-cilastatin intravenous for soln 250 mg

1 $0

imipenem-cilastatin intravenous for soln 500 mg

1 $0

INVANZ INJ 1GM 2 $0

ivermectin tab 3 mg 1 $0

linezolid iv soln 2 mg/ml 2 $0

meropenem iv for soln 1 gm 1 $0

meropenem iv for soln 500 mg 1 $0

methenamine hippurate tab 1 gm 1 $0

metronidazole in nacl 0.79% iv soln 500 mg/100ml

1 $0

metronidazole tab 250 mg 1 $0

metronidazole tab 500 mg 1 $0

NEBUPENT INH 300MG 2 $0 B/D

nitrofurantoin macrocrystalline cap

50 mg

2 $0 PA; 90 day limit if >64

yr

nitrofurantoin macrocrystalline cap

100 mg


yr

nitrofurantoin monohydrate

macrocrystalline cap 100 mg


yr

PENTAM 300 INJ 300MG 2 $0

SIVEXTRO INJ 200MG 2 $0

SIVEXTRO TAB 200MG 2 $0

sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml

1 $0

sulfamethoxazole-trimethoprim susp 200-40 mg/5ml

1 $0

sulfamethoxazole-trimethoprim tab 400-80 mg

1 $0

sulfamethoxazole-trimethoprim tab 800-160 mg

1 $0


20

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

SYNERCID INJ 500MG 2 $0

trimethoprim tab 100 mg 1 $0

TYGACIL INJ 50MG 2 $0

vancomycin hcl cap 125 mg 2 $0

vancomycin hcl cap 250 mg 2 $0

vancomycin hcl for inj 10 gm 1 $0

vancomycin hcl for inj 500 mg 1 $0



vancomycin inj 750mg 1 $0

ZYVOX SUS 100MG/5M 2 $0

ZYVOX TAB 600MG 2 $0

ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS ABELCET INJ 5MG/ML 2 $0 B/D

AMBISOME INJ 50MG 2 $0 B/D

amphotericin b for inj 50 mg 1 $0 B/D

CANCIDAS INJ 50MG 2 $0

CANCIDAS INJ 70MG 2 $0

ERAXIS INJ 50MG 2 $0

ERAXIS INJ 100MG 2 $0

fluconazole for susp 10 mg/ml 1 $0

fluconazole for susp 40 mg/ml 1 $0

fluconazole in dextrose inj 200 mg/100ml

1 $0

fluconazole in dextrose inj 400 mg/200ml

1 $0

fluconazole in nacl 0.9% inj 200 mg/100ml

1 $0

fluconazole in nacl 0.9% inj 400 mg/200ml

1 $0

fluconazole tab 50 mg 1 $0




flucytosine cap 250 mg 2 $0

flucytosine cap 500 mg 2 $0

griseofulvin microsize susp 125 mg/5ml

1 $0

griseofulvin microsize tab 500 mg 1 $0

griseofulvin ultramicrosize tab 125 mg

1 $0


21

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

griseofulvin ultramicrosize tab 250

mg

1 $0

itraconazole cap 100 mg 1 $0 PA

ketoconazole tab 200 mg 1 $0 PA

MYCAMINE INJ 50MG 2 $0

MYCAMINE INJ 100MG 2 $0

NOXAFIL SUS 40MG/ML 2 $0

NOXAFIL TAB 100MG 2 $0

nystatin tab 500000 unit 1 $0

terbinafine hcl tab 250 mg 1 $0 QL (90 tabs / 365 days)

voriconazole for inj 200 mg 1 $0

voriconazole for susp 40 mg/ml 2 $0

voriconazole tab 50 mg 2 $0

voriconazole tab 200 mg 2 $0

ANTIMALARIALS - DRUGS TO TREAT MALARIA atovaquone-proguanil hcl tab

62.5-25 mg 1 $0

atovaquone-proguanil hcl tab 250-100 mg

1 $0

chloroquine phosphate tab 250 mg 1 $0

chloroquine phosphate tab 500 mg 1 $0

COARTEM TAB 20-120MG 2 $0

mefloquine hcl tab 250 mg 1 $0

PRIMAQUINE TAB 26.3MG 2 $0

quinine sulfate cap 324 mg 1 $0 PA

ANTIRETROVIRAL AGENTS - DRUGS TO SUPPRESS HIV/AIDS

INFECTION abacavir sulfate tab 300 mg (base

equiv)

1 $0

APTIVUS CAP 250MG 2 $0

APTIVUS SOL 2 $0

CRIXIVAN CAP 200MG 2 $0

CRIXIVAN CAP 400MG 2 $0

didanosine delayed release capsule 125 mg

1 $0


1 $0


1 $0


1 $0


22

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

EDURANT TAB 25MG 2 $0

EMTRIVA CAP 200MG 2 $0

EMTRIVA SOL 10MG/ML 2 $0

EPIVIR SOL 10MG/ML 2 $0

FUZEON INJ 90MG 2 $0 NM

INTELENCE TAB 25MG 2 $0



INVIRASE CAP 200MG 2 $0

INVIRASE TAB 500MG 2 $0

ISENTRESS CHW 25MG 2 $0

ISENTRESS CHW 100MG 2 $0

ISENTRESS POW 100MG 1 $0

ISENTRESS TAB 400MG 2 $0

lamivudine oral soln 10 mg/ml 1 $0

lamivudine tab 150 mg 1 $0

lamivudine tab 300 mg 1 $0

LEXIVA SUS 50MG/ML 2 $0

LEXIVA TAB 700MG 2 $0

NEVIRAPINE SUSP 50 MG/5ML 1 $0

nevirapine tab 200 mg 1 $0

nevirapine tab sr 24hr 400 mg 1 $0

NORVIR CAP 100MG 2 $0

NORVIR SOL 80MG/ML 2 $0

NORVIR TAB 100MG 2 $0

PREZISTA SUS 100MG/ML 2 $0

PREZISTA TAB 75MG 2 $0




RESCRIPTOR TAB 100 MG 2 $0

RESCRIPTOR TAB 200MG 2 $0

RETROVIR INJ 10MG/ML 2 $0

REYATAZ CAP 150MG 2 $0



REYATAZ POW 50MG 2 $0

SELZENTRY TAB 150MG 2 $0

SELZENTRY TAB 300MG 2 $0

stavudine cap 15 mg 1 $0



23

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE



stavudine for oral soln 1 mg/ml 1 $0

SUSTIVA CAP 50MG 2 $0

SUSTIVA CAP 200MG 2 $0

SUSTIVA TAB 600MG 2 $0

TIVICAY TAB 50MG 2 $0

TYBOST TAB 150MG 2 $0

VIDEX SOL 2GM 2 $0

VIDEX SOL 4GM 2 $0

VIRACEPT TAB 250MG 2 $0

VIRACEPT TAB 625MG 2 $0

VIRAMUNE XR TAB 100MG 2 $0

VIREAD POW 40MG/GM 2 $0

VIREAD TAB 150MG 2 $0




VITEKTA TAB 85MG 2 $0

VITEKTA TAB 150MG 2 $0

ZIAGEN SOL 20MG/ML 2 $0

zidovudine cap 100 mg 1 $0

zidovudine syrup 10 mg/ml 1 $0

zidovudine tab 300 mg 1 $0

ANTIRETROVIRAL COMBINATION AGENTS - DRUGS TO SUPPRESS

HIV/AIDS INFECTION abacavir

sulfate-lamivudine-zidovudine tab

300-150-300 mg

2 $0

ATRIPLA TAB 2 $0

COMPLERA TAB 2 $0

EPZICOM TAB 600-300 2 $0

EVOTAZ TAB 300-150 2 $0

KALETRA SOL 2 $0

KALETRA TAB 100-25MG 2 $0

KALETRA TAB 200-50MG 2 $0

lamivudine-zidovudine tab 150-300

mg

2 $0

PREZCOBIX TAB 800-150 2 $0

STRIBILD TAB 2 $0

TRIUMEQ TAB 2 $0


24

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

TRUVADA TAB 200-300 2 $0 QL (30 tabs / 30 days)

ANTITUBERCULAR AGENTS - DRUGS TO TREAT TUBERCULOSIS CAPASTAT SUL INJ 1GM 2 $0

cycloserine cap 250 mg 1 $0

ethambutol hcl tab 100 mg 1 $0

ethambutol hcl tab 400 mg 1 $0

isoniazid inj 100 mg/ml 1 $0

isoniazid syrup 50 mg/5ml 1 $0

isoniazid tab 100 mg 1 $0

isoniazid tab 300 mg 1 $0

paser gra 4gm 2 $0

PRIFTIN TAB 150MG 2 $0

pyrazinamide tab 500 mg 1 $0

rifabutin cap 150 mg 1 $0

rifampin cap 150 mg 1 $0

rifampin cap 300 mg 1 $0

rifampin for inj 600 mg 1 $0

RIFATER TAB 2 $0

SIRTURO TAB 100MG 2 $0 LA, PA

TRECATOR TAB 250MG 2 $0

ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONS acyclovir cap 200 mg 1 $0

acyclovir sodium for inj 500 mg 1 $0 B/D

acyclovir sodium for inj 1000 mg 1 $0 B/D

acyclovir sodium iv soln 50 mg/ml 1 $0 B/D

acyclovir susp 200 mg/5ml 1 $0

acyclovir tab 400 mg 1 $0

acyclovir tab 800 mg 1 $0

adefovir dipivoxil tab 10 mg 2 $0

BARACLUDE SOL .05MG/ML 2 $0

entecavir tab 0.5 mg 2 $0

entecavir tab 1 mg 2 $0

EPIVIR HBV SOL 5MG/ML 2 $0

famciclovir tab 125 mg 1 $0



foscarnet sodium inj 24 mg/ml 1 $0

ganciclovir sodium for inj 500 mg 1 $0 B/D

HARVONI TAB 90-400MG 2 $0 NM, PA

lamivudine tab 100 mg (hbv) 1 $0

moderiba pak 600/day 2 $0 NM, PA


25

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE




OLYSIO CAP 150MG 2 $0 NM, PA

REBETOL SOL 40MG/ML 2 $0 NM, PA

RELENZA MIS DISKHALE 2 $0

ribapak pak 600/day 2 $0 NM, PA




ribasphere cap 200mg 1 $0 NM, PA

ribasphere tab 200mg 1 $0 NM, PA



ribavirin cap 200 mg 1 $0 NM, PA

ribavirin tab 200 mg 1 $0 NM, PA

rimantadine hydrochloride tab 100 mg

1 $0

SOVALDI TAB 400MG 2 $0 NM, PA

TAMIFLU CAP 30MG 2 $0



TAMIFLU SUS 6MG/ML 2 $0

TYZEKA TAB 600MG 2 $0

valacyclovir hcl tab 1 gm 1 $0

valacyclovir hcl tab 500 mg 1 $0

VALCYTE SOL 50MG/ML 2 $0

valganciclovir hcl tab 450 mg (base

equivalent)

2 $0

VICTRELIS CAP 200MG 2 $0 NM, PA

CEPHALOSPORINS - DRUGS TO TREAT INFECTIONS cefaclor cap 250 mg 1 $0

cefaclor cap 500 mg 1 $0

cefaclor er tab 500mg 2 $0

cefaclor for susp 125 mg/5ml 1 $0



cefadroxil cap 500 mg 1 $0

cefadroxil for susp 250 mg/5ml 1 $0

cefadroxil for susp 500 mg/5ml 1 $0

cefadroxil tab 1 gm 1 $0


26

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

cefazolin inj 1gm/50ml 2 $0

cefazolin sodium for inj 1 gm 1 $0



cefazolin sodium for inj 500 mg 1 $0

cefazolin sodium for iv soln 1 gm 1 $0

cefdinir cap 300 mg 1 $0

cefdinir for susp 125 mg/5ml 1 $0

cefdinir for susp 250 mg/5ml 1 $0

cefepime hcl for inj 1 gm 1 $0

cefepime hcl for inj 2 gm 1 $0

cefixime for susp 100 mg/5ml 1 $0

cefixime for susp 200 mg/5ml 1 $0

cefotaxime sodium for inj 1 gm 1 $0

cefotaxime sodium for inj 2 gm 1 $0

cefotaxime sodium for inj 500 mg 1 $0

cefoxitin sodium for inj 10 gm 1 $0

cefoxitin sodium for iv soln 1 gm 1 $0

cefoxitin sodium for iv soln 2 gm 1 $0

cefpodoxime proxetil for susp 50

mg/5ml

1 $0

cefpodoxime proxetil for susp 100

mg/5ml

1 $0

cefpodoxime proxetil tab 100 mg 1 $0

cefpodoxime proxetil tab 200 mg 1 $0

cefprozil for susp 125 mg/5ml 1 $0

cefprozil for susp 250 mg/5ml 1 $0

cefprozil tab 250 mg 1 $0

cefprozil tab 500 mg 1 $0

ceftazidime for inj 1 gm 1 $0



CEFTAZIDIME/ SOL D5W 1GM 2 $0

CEFTAZIDIME/ SOL D5W 2GM 2 $0

ceftriaxone sodium for inj 1 gm 1 $0



ceftriaxone sodium for inj 250 mg 1 $0

ceftriaxone sodium for inj 500 mg 1 $0

ceftriaxone sodium for iv soln 1 gm 1 $0

ceftriaxone sodium for iv soln 2 gm 1 $0


27

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

cefuroxime axetil tab 250 mg 1 $0

cefuroxime axetil tab 500 mg 1 $0

cefuroxime inj 7.5gm 1 $0

cefuroxime sodium for inj 1.5 gm 1 $0

cefuroxime sodium for inj 7.5 gm 1 $0

cefuroxime sodium for inj 750 mg 1 $0

cefuroxime sodium for iv soln 1.5

gm

1 $0

cephalexin cap 250 mg 1 $0

cephalexin cap 500 mg 1 $0

cephalexin for susp 125 mg/5ml 1 $0

cephalexin for susp 250 mg/5ml 1 $0

SUPRAX CAP 400MG 2 $0

suprax chw 100mg 2 $0

suprax chw 200mg 2 $0

suprax sus 100/5ml 2 $0

suprax sus 200/5ml 2 $0

SUPRAX SUS 500/5ML 2 $0

tazicef inj 1gm 1 $0



TEFLARO INJ 400MG 2 $0

TEFLARO INJ 600MG 2 $0

ERYTHROMYCINS/MACROLIDES - DRUGS TO TREAT INFECTIONS azithromycin for susp 100 mg/5ml 1 $0

azithromycin for susp 200 mg/5ml 1 $0

azithromycin iv for soln 500 mg 1 $0

AZITHROMYCIN POWD PACK FOR SUSP 1 GM

1 $0

azithromycin tab 250 mg 1 $0



clarithromycin for susp 125 mg/5ml 1 $0

clarithromycin for susp 250 mg/5ml 1 $0

clarithromycin tab 250 mg 1 $0

clarithromycin tab 500 mg 1 $0

clarithromycin tab sr 24hr 500 mg 1 $0

DIFICID TAB 200MG 2 $0

e.e.s. 400 tab 400mg 1 $0

E.E.S. GRAN SUS 200/5ML 2 $0

ery-tab tab 250mg ec 2 $0


28

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE



ERYPED SUS 200/5ML 2 $0

ERYPED SUS 400/5ML 2 $0

erythrocin inj 500mg 2 $0

erythrocin tab 250mg 1 $0

erythromycin ethylsuccinate tab

400 mg

1 $0

erythromycin tab 250 mg 1 $0

erythromycin tab 500 mg 1 $0

erythromycin w/ delayed release particles cap 250 mg

1 $0

ZMAX SUS 2GM 2 $0

FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS ciprofloxacin 200 mg/100ml in d5w 1 $0

ciprofloxacin 400 mg/200ml in d5w 1 $0

ciprofloxacin for oral susp 250

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

1 $0

ciprofloxacin for oral susp 500

mg/5ml (10%) (10 gm/100ml)

1 $0

ciprofloxacin hcl tab 100 mg (base

equiv)

1 $0


equiv)

1 $0


equiv)

1 $0


equiv)

1 $0

ciprofloxacin iv soln 200 mg/20ml

(1%)

1 $0

ciprofloxacin iv soln 400 mg/40ml

(1%)

1 $0

ciprofloxacin-ciprofloxacin hcl tab sr

24hr 500 mg (base eq)

1 $0

ciprofloxacin-ciprofloxacin hcl tab sr

24hr 1000 mg(base eq)

1 $0

levofloxacin in d5w iv soln 250

mg/50ml

1 $0


mg/100ml

1 $0


mg/150ml

1 $0


29

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

levofloxacin iv soln 25 mg/ml 1 $0

levofloxacin oral soln 25 mg/ml 1 $0

levofloxacin tab 250 mg 1 $0



PENICILLINS - DRUGS TO TREAT INFECTIONS amoxicillin & k clavulanate chew tab

200-28.5 mg 1 $0

amoxicillin & k clavulanate chew tab 400-57 mg

1 $0

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

1 $0

amoxicillin & k clavulanate for susp 250-62.5 mg/5ml

1 $0

amoxicillin & k clavulanate for susp

400-57 mg/5ml

1 $0


600-42.9 mg/5ml

1 $0

amoxicillin & k clavulanate tab

250-125 mg

1 $0


500-125 mg

1 $0


875-125 mg

1 $0

amoxicillin & k clavulanate tab sr

12hr 1000-62.5 mg

1 $0

amoxicillin (trihydrate) cap 250 mg 1 $0

amoxicillin (trihydrate) cap 500 mg 1 $0

amoxicillin (trihydrate) chew tab 125 mg

1 $0

amoxicillin (trihydrate) chew tab 250 mg

1 $0

amoxicillin (trihydrate) for susp 125 mg/5ml

1 $0


1 $0


1 $0


1 $0

amoxicillin (trihydrate) tab 500 mg 1 $0

amoxicillin (trihydrate) tab 875 mg 1 $0


30

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

ampicillin & sulbactam sodium for

inj 1-0.5 gm

1 $0


inj 2-1 gm

1 $0


inj 10-5 gm

1 $0

ampicillin & sulbactam sodium for iv

soln 1-0.5 gm

1 $0


soln 2-1 gm

1 $0


soln 10-5 gm

1 $0

ampicillin cap 250 mg 1 $0

ampicillin cap 500 mg 1 $0

ampicillin for susp 125 mg/5ml 1 $0

ampicillin for susp 250 mg/5ml 1 $0

ampicillin sodium for inj 1 gm 1 $0

ampicillin sodium for inj 2 gm 1 $0

ampicillin sodium for inj 125 mg 1 $0



ampicillin sodium for iv soln 1 gm 1 $0



BICILLIN L-A INJ 600000 2 $0



dicloxacillin sodium cap 250 mg 1 $0

dicloxacillin sodium cap 500 mg 1 $0

nafcillin sodium for inj 1 gm 1 $0



nafcillin sodium for iv soln 1 gm 1 $0

nafcillin sodium for iv soln 2 gm 2 $0

oxacillin sodium for inj 1 gm 1 $0



pen g proc inj 600000 2 $0

PENICILL GK/ INJ DEX 2MU 2 $0

PENICILL GK/ INJ DEX 3MU 2 $0

penicillin g potassium for inj 5000000 unit

1 $0


31

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

penicillin g potassium for inj

20000000 unit

1 $0

penicillin g sodium for inj 5000000

unit

1 $0

penicillin v potassium for soln 125

mg/5ml

1 $0

penicillin v potassium for soln 250

mg/5ml

1 $0

penicillin v potassium tab 250 mg 1 $0

penicillin v potassium tab 500 mg 1 $0

piperacillin sodium-tazobactam sodium for inj 2-0.25 gm

1 $0

piperacillin sodium-tazobactam

sodium for inj 3-0.375 gm

1 $0



1 $0



1 $0

TETRACYCLINES - DRUGS TO TREAT INFECTIONS doxycycline hyclate cap 50 mg 1 $0

doxycycline hyclate cap 100 mg 1 $0

doxycycline hyclate for inj 100 mg 1 $0

doxycycline hyclate tab 20 mg 1 $0

doxycycline hyclate tab 100 mg 1 $0

doxycycline monohydrate cap 50 mg

1 $0

doxycycline monohydrate cap 100 mg

1 $0

doxycycline monohydrate tab 50 mg

1 $0


1 $0


1 $0


1 $0

minocycline hcl cap 50 mg 1 $0



VIBRAMYCIN SYP 50MG/5ML 2 $0

ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER ALKYLATING AGENTS


32

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

BICNU INJ 100MG 2 $0 B/D

BUSULFEX INJ 6MG/ML 2 $0 B/D

CYCLOPHOSPH CAP 25MG 2 $0 B/D

CYCLOPHOSPH CAP 50MG 2 $0 B/D

cyclophosphamide for inj 1 gm 1 $0 B/D

cyclophosphamide for inj 2 gm 1 $0 B/D

cyclophosphamide for inj 500 mg 1 $0 B/D

dacarbazine for inj 200 mg 1 $0 B/D

EMCYT CAP 140MG 2 $0

HEXALEN CAP 50MG 2 $0

IFEX INJ 3GM 2 $0 B/D

ifosfamide for inj 1 gm 1 $0 B/D

IFOSFAMIDE INJ 3GM 2 $0 B/D

ifosfamide iv inj 1 gm/20ml (50

mg/ml)

1 $0 B/D

ifosfamide iv inj 3 gm/60ml (50

mg/ml)

1 $0 B/D

LEUKERAN TAB 2MG 2 $0

LOMUSTINE CAP 10 MG 1 $0



melphalan hcl for inj 50 mg (base equiv)

2 $0 B/D

MUSTARGEN INJ 10MG 2 $0 B/D

TREANDA INJ 25MG 2 $0 B/D, NM

TREANDA INJ 45/0.5ML 2 $0 B/D, NM

TREANDA INJ 100MG 2 $0 B/D, NM

TREANDA INJ 180/2ML 2 $0 B/D, NM

ANTHRACYCLINES adriamyc inj 50mg 1 $0 B/D

daunorubicin hcl inj 5 mg/ml (base

equiv)

1 $0 B/D

doxorubicin hcl for inj 50 mg 1 $0 B/D

doxorubicin hcl inj 2 mg/ml 1 $0 B/D

doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml

2 $0 B/D

epirubicin hcl iv soln 50 mg/25ml (2 mg/ml)

1 $0 B/D

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

1 $0 B/D

idarubicin hcl iv inj 5 mg/5ml (1 mg/ml)

2 $0 B/D


33

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

idarubicin hcl iv inj 10 mg/10ml (1

mg/ml)

2 $0 B/D

idarubicin hcl iv inj 20 mg/20ml (1

mg/ml)

2 $0 B/D

ANTIBIOTICS bleomycin sulfate for inj 15 unit 1 $0 B/D

bleomycin sulfate for inj 30 unit 1 $0 B/D

mitomycin for iv soln 5 mg 1 $0 B/D



ANTIMETABOLITES adrucil inj 500/10ml 1 $0 B/D

ALIMTA INJ 100MG 2 $0 B/D

ALIMTA INJ 500MG 2 $0 B/D

azacitidine for inj 100 mg 2 $0 B/D, NM

cladribine inj 1 mg/ml 2 $0 B/D

cytarabine inj 20 mg/ml 1 $0 B/D

fludarabine phosphate for inj 50 mg 1 $0 B/D

fludarabine phosphate inj 25 mg/ml 1 $0 B/D

fluorouracil inj 1 gm/20ml (50

mg/ml)

1 $0 B/D

fluorouracil inj 2.5 gm/50ml (50

mg/ml)

1 $0 B/D

fluorouracil inj 5 gm/100ml (50

mg/ml)

1 $0 B/D

fluorouracil inj 500 mg/10ml (50

mg/ml)

1 $0 B/D

gemcitabine hcl for inj 1 gm 2 $0 B/D

gemcitabine hcl for inj 2 gm 2 $0 B/D

gemcitabine hcl for inj 200 mg 2 $0 B/D

GEMCITABINE INJ 1GM 2 $0 B/D

GEMCITABINE INJ 2GM 2 $0 B/D

GEMCITABINE INJ 200MG 2 $0 B/D

mercaptopurine tab 50 mg 1 $0

methotrexate sodium for inj 1 gm 1 $0 B/D

methotrexate sodium inj 25 mg/ml 1 $0 B/D

methotrexate sodium inj pf 25 mg/ml

1 $0 B/D

NIPENT INJ 10MG 2 $0 B/D

PURIXAN SUS 20MG/ML 2 $0

TABLOID TAB 40MG 2 $0


34

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

ANTIMITOTIC, TAXOIDS DOCETAXEL FOR INJ CONC 20

MG/ML 2 $0 B/D

DOCETAXEL FOR INJ CONC 80 MG/4ML (20 MG/ML)

2 $0 B/D

DOCETAXEL INJ 80MG/8ML 2 $0 B/D

docetaxel inj 140/7ml 2 $0 B/D

DOCETAXEL INJ 200MG/20 2 $0 B/D

paclitaxel iv conc 30 mg/5ml (6

mg/ml)

1 $0 B/D

paclitaxel iv conc 100 mg/16.7ml (6

mg/ml)

1 $0 B/D


mg/ml)

1 $0 B/D


mg/ml)

1 $0 B/D

ANTIMITOTIC, VINCA ALKALOIDS vinblastine inj 1mg/ml 2 $0 B/D

vincasar pfs inj 1mg/ml 1 $0 B/D

vincristine sulfate iv soln 1 mg/ml 1 $0 B/D

vinorelbine tartrate inj 10 mg/ml

(base equiv)

1 $0 B/D

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

1 $0 B/D

BIOLOGIC RESPONSE MODIFIERS AVASTIN INJ 2 $0 B/D, NM

AVASTIN INJ 400/16ML 2 $0 B/D, NM

ERIVEDGE CAP 150MG 2 $0 NM, LA, PA

FARYDAK CAP 10MG 2 $0 NM, LA, PA



HERCEPTIN INJ 440MG 2 $0 B/D, NM

IBRANCE CAP 75MG 2 $0 NM, LA, PA



ISTODAX INJ 10MG 2 $0 B/D, NM

KADCYLA INJ 100MG 2 $0 B/D, NM

KADCYLA INJ 160MG 2 $0 B/D, NM

LYNPARZA CAP 50MG 2 $0 NM, PA

PROLEUKIN INJ 22MU 2 $0 B/D, NM

RITUXAN INJ 500MG 2 $0 NM, PA


35

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

VELCADE INJ 3.5MG 2 $0 B/D, NM

ZOLINZA CAP 100MG 2 $0 NM, PA

HORMONAL ANTINEOPLASTIC AGENTS anastrozole tab 1 mg 1 $0

bicalutamide tab 50 mg 1 $0

DEPO-PROVERA INJ 400/ML 2 $0 B/D

exemestane tab 25 mg 1 $0

FARESTON TAB 60MG 2 $0

FASLODEX INJ 250MG 2 $0 B/D

flutamide cap 125 mg 1 $0

letrozole tab 2.5 mg 1 $0

leuprolide acetate inj kit 5 mg/ml 1 $0 NM, PA

LUPR DEP-PED INJ 7.5MG 2 $0 NM, PA

LUPR DEP-PED INJ 11.25MG 2 $0 NM, PA

LUPR DEP-PED INJ 15MG 2 $0 NM, PA

LUPR DEP-PED INJ 30MG 2 $0 NM, PA

LUPRON DEPOT INJ 3.75MG 2 $0 NM, PA

LUPRON DEPOT INJ 11.25MG 2 $0 NM, PA

LYSODREN TAB 500MG 2 $0

MEGACE ES SUS 625/5ML 2 $0 PA

megestrol acetate susp 40 mg/ml 2 $0 PA

megestrol acetate tab 20 mg 2 $0 PA

megestrol acetate tab 40 mg 2 $0 PA

NILANDRON TAB 150MG 2 $0

SOLTAMOX SOL 10MG/5ML 2 $0

tamoxifen citrate tab 10 mg (base equivalent)

1 $0

tamoxifen citrate tab 20 mg (base equivalent)

1 $0

TRELSTAR MIX INJ 3.75MG 2 $0 NM, PA

TRELSTAR MIX INJ 11.25MG 2 $0 NM, PA

XTANDI CAP 40MG 2 $0 NM, LA, PA

ZYTIGA TAB 250MG 2 $0 NM, PA

KINASE INHIBITORS AFINITOR DIS TAB 2MG 2 $0 NM, PA

AFINITOR DIS TAB 3MG 2 $0 NM, PA

AFINITOR DIS TAB 5MG 2 $0 NM, PA

AFINITOR TAB 2.5MG 2 $0 NM, PA

AFINITOR TAB 5MG 2 $0 NM, PA

AFINITOR TAB 7.5MG 2 $0 NM, PA

AFINITOR TAB 10MG 2 $0 NM, PA


36

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

BOSULIF TAB 100MG 2 $0 NM, PA

BOSULIF TAB 500MG 2 $0 NM, PA

CAPRELSA TAB 100MG 2 $0 NM, LA, PA

CAPRELSA TAB 300MG 2 $0 NM, LA, PA

COMETRIQ KIT 60MG 2 $0 NM, PA



GILOTRIF TAB 20MG 2 $0 NM, LA, PA



GLEEVEC TAB 100MG 2 $0 NM, PA

GLEEVEC TAB 400MG 2 $0 NM, PA

ICLUSIG TAB 15MG 2 $0 NM, LA, PA

ICLUSIG TAB 45MG 2 $0 NM, LA, PA

IMBRUVICA CAP 140MG 2 $0 NM, LA, PA

INLYTA TAB 1MG 2 $0 NM, LA, PA

INLYTA TAB 5MG 2 $0 NM, LA, PA

JAKAFI TAB 5MG 2 $0 NM, LA, PA





LENVIMA CAP 10MG 2 $0 NM, LA, PA




MEKINIST TAB 0.5MG 2 $0 NM, PA

MEKINIST TAB 2MG 2 $0 NM, PA

NEXAVAR TAB 200MG 2 $0 NM, LA, PA

SPRYCEL TAB 20MG 2 $0 NM, PA






STIVARGA TAB 40MG 2 $0 NM, LA, PA

SUTENT CAP 12.5MG 2 $0 NM, PA

SUTENT CAP 25MG 2 $0 NM, PA

SUTENT CAP 37.5MG 2 $0 NM, PA

SUTENT CAP 50MG 2 $0 NM, PA

TAFINLAR CAP 50MG 2 $0 NM, PA


37

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

TAFINLAR CAP 75MG 2 $0 NM, PA

TARCEVA TAB 25MG 2 $0 NM, PA



TASIGNA CAP 150MG 2 $0 NM, PA

TASIGNA CAP 200MG 2 $0 NM, PA

TYKERB TAB 250MG 2 $0 NM, LA, PA

VOTRIENT TAB 200MG 2 $0 NM, PA

XALKORI CAP 200MG 2 $0 NM, LA, PA

XALKORI CAP 250MG 2 $0 NM, LA, PA

ZELBORAF TAB 240MG 2 $0 NM, LA, PA

ZYDELIG TAB 100MG 2 $0 NM, LA, PA

ZYDELIG TAB 150MG 2 $0 NM, LA, PA

ZYKADIA CAP 150MG 1 $0 NM, LA, PA

MISCELLANEOUS DROXIA CAP 200MG 2 $0

DROXIA CAP 300MG 2 $0

DROXIA CAP 400MG 2 $0

hydroxyurea cap 500 mg 1 $0

MATULANE CAP 50MG 2 $0

mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml)

1 $0 B/D, NM

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

1 $0 B/D, NM

mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml)

1 $0 B/D, NM

POMALYST CAP 1MG 2 $0 NM, LA, PA




SYLATRON KIT 200MCG 2 $0 NM, PA



TARGRETIN CAP 75MG 2 $0 NM, PA

tretinoin cap 10 mg 2 $0

TRISENOX SOL 10MG/10M 2 $0 B/D

PLATINUM-BASED AGENTS carboplatin iv soln 50 mg/5ml 1 $0 B/D

carboplatin iv soln 150 mg/15ml 1 $0 B/D




38

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

cisplatin inj 50 mg/50ml (1 mg/ml) 1 $0 B/D

cisplatin inj 100 mg/100ml (1

mg/ml)

1 $0 B/D

cisplatin inj 200 mg/200ml (1

mg/ml)

1 $0 B/D

oxaliplatin for iv inj 50 mg 2 $0 B/D

oxaliplatin for iv inj 100 mg 2 $0 B/D

oxaliplatin iv soln 50 mg/10ml 2 $0 B/D

oxaliplatin iv soln 100 mg/20ml 2 $0 B/D

PROTECTIVE AGENTS amifostine crystalline for inj 500 mg 2 $0 B/D

dexrazoxane for inj 250 mg 2 $0 B/D

ELITEK INJ 1.5MG 2 $0 B/D

ELITEK INJ 7.5MG 2 $0 B/D

leucovorin calcium for inj 50 mg 1 $0 B/D




leucovorin calcium tab 5 mg 1 $0




leucovorin inj calcium 1 $0 B/D

mesna inj 100 mg/ml 1 $0 B/D

MESNEX TAB 400MG 2 $0

TOPOISOMERASE INHIBITORS etoposide inj 500mg/25ml (20

mg/ml)

1 $0 B/D

irinotecan hcl inj 40 mg/2ml (20

mg/ml)

2 $0 B/D


mg/ml)

2 $0 B/D


mg/ml)

2 $0 B/D

toposar inj 1gm/50ml 1 $0 B/D

topotecan hcl for inj 4 mg 2 $0 B/D

CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION

CONDITIONS ACE INHIBITOR COMBINATIONS - DRUGS TO TREAT HIGH BLOOD

PRESSURE


39

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

amlodipine besylate-benazepril hcl

cap 2.5-10 mg

1 $0 QL (30 caps / 30 days)


cap 5-10 mg

1 $0 QL (30 caps / 30 days)


cap 5-20 mg

1 $0 QL (30 caps / 30 days)


cap 5-40 mg

1 $0 QL (30 caps / 30 days)


cap 10-20 mg

1 $0 QL (30 caps / 30 days)


cap 10-40 mg

1 $0

benazepril & hydrochlorothiazide

tab 5-6.25 mg

1 $0


tab 10-12.5 mg

1 $0


tab 20-12.5 mg

1 $0

benazepril & hydrochlorothiazide tab 20-25 mg

1 $0

captopril & hydrochlorothiazide tab 25-15 mg

1 $0


1 $0


1 $0


1 $0

enalapril maleate & hydrochlorothiazide tab 5-12.5 mg

1 $0

enalapril maleate & hydrochlorothiazide tab 10-25 mg

1 $0

fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg

1 $0

fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg

1 $0

lisinopril & hydrochlorothiazide tab 10-12.5 mg

1 $0

lisinopril & hydrochlorothiazide tab 20-12.5 mg

1 $0

lisinopril & hydrochlorothiazide tab 20-25 mg

1 $0


40

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

moexipril-hydrochlorothiazide tab

7.5-12.5 mg

1 $0


15-12.5 mg

1 $0


15-25 mg

1 $0

quinapril-hydrochlorothiazide tab

10-12.5 mg

1 $0


20-12.5 mg

1 $0


20-25 mg

1 $0

ACE INHIBITORS - DRUGS TO TREAT HIGH BLOOD PRESSURE benazepril hcl tab 5 mg 1 $0

benazepril hcl tab 10 mg 1 $0



captopril tab 12.5 mg 1 $0

captopril tab 25 mg 1 $0



enalapril maleate tab 2.5 mg 1 $0

enalapril maleate tab 5 mg 1 $0



fosinopril sodium tab 10 mg 1 $0



lisinopril tab 2.5 mg 1 $0

lisinopril tab 5 mg 1 $0





moexipril hcl tab 7.5 mg 1 $0

moexipril hcl tab 15 mg 1 $0

perindopril erbumine tab 2 mg 1 $0



quinapril hcl tab 5 mg 1 $0



41

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE



ramipril cap 1.25 mg 1 $0

ramipril cap 2.5 mg 1 $0

ramipril cap 5 mg 1 $0

ramipril cap 10 mg 1 $0

trandolapril tab 1 mg 1 $0



ALDOSTERONE RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH

BLOOD PRESSURE eplerenone tab 25 mg 1 $0

eplerenone tab 50 mg 1 $0

spironolactone tab 25 mg 1 $0



ALPHA BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE doxazosin mesylate tab 1 mg 1 $0 QL (30 tabs / 30 days)

doxazosin mesylate tab 2 mg 1 $0 QL (30 tabs / 30 days)

doxazosin mesylate tab 4 mg 1 $0 QL (30 tabs / 30 days)

doxazosin mesylate tab 8 mg 1 $0

prazosin hcl cap 1 mg 1 $0



terazosin hcl cap 1 mg 1 $0




ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS - DRUGS

TO TREAT HIGH BLOOD PRESSURE amlodipine besylate-valsartan tab

5-160 mg

1 $0 QL (30 tabs / 30 days)

amlodipine besylate-valsartan tab

5-320 mg

1 $0 QL (30 tabs / 30 days)


10-160 mg

1 $0 QL (30 tabs / 30 days)


10-320 mg

1 $0

amlodipine-valsartan-hydrochlorot

hiazide tab 5-160-12.5 mg

1 $0 QL (30 tabs / 30 days)


42

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE


hiazide tab 5-160-25 mg

1 $0 QL (60 tabs / 30 days)


hiazide tab 10-160-12.5 mg

1 $0 QL (30 tabs / 30 days)



1 $0 QL (30 tabs / 30 days)



1 $0

AZOR TAB 5-20MG 2 $0 QL (30 tabs / 30 days)



AZOR TAB 10-40MG 2 $0

BENICAR HCT TAB 20-12.5 2 $0 QL (30 tabs / 30 days)

BENICAR HCT TAB 40-12.5 2 $0 QL (30 tabs / 30 days)

BENICAR HCT TAB 40-25MG 2 $0

losartan potassium &

hydrochlorothiazide tab 50-12.5 mg

1 $0 QL (30 tabs / 30 days)

losartan potassium &

hydrochlorothiazide tab 100-12.5 mg

1 $0 QL (30 tabs / 30 days)

losartan potassium & hydrochlorothiazide tab 100-25 mg

1 $0

TRIBENZOR20- TAB 5-12.5MG 2 $0 QL (30 tabs / 30 days)

TRIBENZOR40- TAB 5-12.5MG 2 $0 QL (30 tabs / 30 days)

TRIBENZOR40- TAB 5-25MG 2 $0 QL (30 tabs / 30 days)

TRIBENZOR40- TAB 10-12.5 2 $0 QL (30 tabs / 30 days)

TRIBENZOR40- TAB 10-25MG 2 $0

valsartan-hydrochlorothiazide tab

80-12.5 mg

1 $0 QL (30 tabs / 30 days)


160-12.5 mg

1 $0 QL (30 tabs / 30 days)


160-25 mg

1 $0 QL (30 tabs / 30 days)


320-12.5 mg

1 $0


320-25 mg

1 $0

ANGIOTENSIN II RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH

BLOOD PRESSURE BENICAR TAB 5MG 2 $0 QL (60 tabs / 30 days)

BENICAR TAB 20MG 2 $0 QL (30 tabs / 30 days)

BENICAR TAB 40MG 2 $0


43

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

losartan potassium tab 25 mg 1 $0 QL (60 tabs / 30 days)

losartan potassium tab 50 mg 1 $0 QL (60 tabs / 30 days)

losartan potassium tab 100 mg 1 $0

valsartan tab 40 mg 1 $0 QL (60 tabs / 30 days)



valsartan tab 320 mg 1 $0

ANTIARRHYTHMICS - DRUGS TO CONTROL HEART RHYTHM amiodarone hcl inj 150 mg/3ml (50

mg/ml) 1 $0

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

1 $0

amiodarone hcl inj 900 mg/18ml (50 mg/ml)

1 $0

amiodarone hcl tab 100 mg 1 $0



disopyramide phosphate cap 100

mg

2 $0 PA

disopyramide phosphate cap 150

mg

2 $0 PA

flecainide acetate tab 50 mg 1 $0



mexiletine hcl cap 150 mg 1 $0



MULTAQ TAB 400MG 2 $0

NORPACE CAP 100MG CR 2 $0 PA

NORPACE CAP 150MG CR 2 $0 PA

pacerone tab 100mg 1 $0



propafenone hcl cap sr 12hr 225 mg 1 $0



propafenone hcl tab 150 mg 1 $0



quinidine gluconate tab cr 324 mg 1 $0

quinidine sulfate tab 200 mg 1 $0


44

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

quinidine sulfate tab 300 mg 1 $0

sorine tab 80mg 1 $0




sotalol hcl (afib/afl) tab 80 mg 1 $0



sotalol hcl tab 80 mg 1 $0




TIKOSYN CAP 125MCG 2 $0 NM



ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS - DRUGS TO

TREAT HIGH CHOLESTEROL atorvastatin calcium tab 10 mg

(base equivalent)

1 $0 QL (30 tabs / 30 days)

atorvastatin calcium tab 20 mg

(base equivalent)

1 $0 QL (30 tabs / 30 days)


(base equivalent)

1 $0 QL (30 tabs / 30 days)


(base equivalent)

1 $0 QL (30 tabs / 30 days)

CRESTOR TAB 5MG 2 $0 QL (30 tabs / 30 days)




lovastatin tab 10 mg 1 $0 QL (30 tabs / 30 days)



pravastatin sodium tab 10 mg 1 $0 QL (30 tabs / 30 days)




simvastatin tab 5 mg 1 $0 QL (30 tabs / 30 days)






45

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

ANTILIPEMICS, MISCELLANEOUS - DRUGS TO TREAT HIGH

CHOLESTEROL cholestyramine light powder

packets 4 gm

1 $0

cholestyramine powder 4 gm/dose 1 $0

cholestyramine powder packets 4

gm

1 $0

choline fenofibrate cap dr 45 mg

(fenofibric acid equiv)

1 $0

choline fenofibrate cap dr 135 mg

(fenofibric acid equiv)

1 $0

colestipol hcl granule packets 5 gm 1 $0

colestipol hcl granules 5 gm 1 $0

colestipol hcl tab 1 gm 1 $0

fenofibrate micronized cap 43 mg 1 $0





fenofibrate tab 48 mg 1 $0




gemfibrozil tab 600 mg 1 $0

niacin tab cr 500 mg

(antihyperlipidemic)

1 $0 QL (90 tabs / 30 days)



1 $0



1 $0

niacor tab 500mg 1 $0

omega-3-acid ethyl esters cap 1 gm 1 $0

prevalite pow 4gm 1 $0

VASCEPA CAP 1GM 2 $0

WELCHOL PAK 3.75GM 2 $0

WELCHOL TAB 625MG 2 $0

ZETIA TAB 10MG 2 $0

BETA-BLOCKER/DIURETIC COMBINATIONS - DRUGS TO TREAT HIGH

BLOOD PRESSURE AND HEART CONDITIONS atenolol & chlorthalidone tab 50-25

mg 1 $0


46

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

atenolol & chlorthalidone tab

100-25 mg

1 $0

bisoprolol & hydrochlorothiazide tab

2.5-6.25 mg

1 $0


5-6.25 mg

1 $0


10-6.25 mg

1 $0

metoprolol & hydrochlorothiazide

tab 50-25 mg

1 $0


tab 100-25 mg

1 $0


tab 100-50 mg

1 $0

propranolol & hydrochlorothiazide

tab 40-25 mg

1 $0

propranolol & hydrochlorothiazide

tab 80-25 mg

1 $0

BETA-BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND

HEART CONDITIONS acebutolol hcl cap 200 mg 1 $0

acebutolol hcl cap 400 mg 1 $0

atenolol tab 25 mg 1 $0



bisoprolol fumarate tab 5 mg 1 $0

bisoprolol fumarate tab 10 mg 1 $0

BYSTOLIC TAB 2.5MG 2 $0

BYSTOLIC TAB 5MG 2 $0



carvedilol tab 3.125 mg 1 $0



carvedilol tab 25 mg 1 $0

labetalol hcl tab 100 mg 1 $0



metoprolol succinate tab sr 24hr 25 mg

1 $0 QL (60 tabs / 30 days)

metoprolol succinate tab sr 24hr 50 mg

1 $0 QL (60 tabs / 30 days)


47

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

metoprolol succinate tab sr 24hr

100 mg

1 $0 QL (45 tabs / 30 days)

metoprolol succinate tab sr 24hr

200 mg

1 $0

metoprolol tartrate inj 1 mg/ml 1 $0

metoprolol tartrate tab 25 mg 1 $0



nadolol tab 20 mg 1 $0



pindolol tab 5 mg 1 $0

pindolol tab 10 mg 1 $0

propranolol hcl cap sr 24hr 60 mg 1 $0




propranolol hcl inj 1 mg/ml 1 $0

propranolol hcl oral soln 20 mg/5ml 1 $0

propranolol hcl oral soln 40 mg/5ml 1 $0

propranolol hcl tab 10 mg 1 $0





timolol maleate tab 5 mg 1 $0



CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD

PRESSURE AND HEART CONDITIONS afeditab tab 30mg cr 1 $0 QL (60 tabs / 30 days)

afeditab tab 60mg cr 1 $0

amlodipine besylate tab 2.5 mg 1 $0 QL (45 tabs / 30 days)

amlodipine besylate tab 5 mg 1 $0 QL (45 tabs / 30 days)

amlodipine besylate tab 10 mg 1 $0

diltiazem hcl cap sr 12hr 60 mg 1 $0







48

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

diltiazem hcl coated beads cap sr

24hr 120 mg

1 $0


24hr 180 mg

1 $0


24hr 240 mg

1 $0


24hr 300 mg

1 $0


24hr 360 mg

1 $0

diltiazem hcl extended release

beads cap sr 24hr 120 mg

1 $0



1 $0



1 $0



1 $0

diltiazem hcl extended release beads cap sr 24hr 360 mg

1 $0

diltiazem hcl extended release beads cap sr 24hr 420 mg

1 $0

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

1 $0


1 $0


1 $0

diltiazem hcl tab 30 mg 1 $0




diltzac cap 120mg/24 1 $0




felodipine tab sr 24hr 2.5 mg 1 $0 QL (30 tabs / 30 days)

felodipine tab sr 24hr 5 mg 1 $0 QL (60 tabs / 30 days)

felodipine tab sr 24hr 10 mg 1 $0

isradipine cap 2.5 mg 1 $0

isradipine cap 5 mg 1 $0

nicardipine hcl cap 20 mg 1 $0


49

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

nicardipine hcl cap 30 mg 1 $0

nifedical xl tab 30mg 1 $0 QL (30 tabs / 30 days)

nifedical xl tab 60mg 1 $0

nifedipine tab sr 24hr 30 mg 1 $0 QL (60 tabs / 30 days)

nifedipine tab sr 24hr 60 mg 1 $0

nifedipine tab sr 24hr 90 mg 1 $0

nifedipine tab sr 24hr osmotic 30

mg

1 $0 QL (30 tabs / 30 days)


mg

1 $0


mg

1 $0

nimodipine cap 30 mg 1 $0

NYMALIZE SOL 60/20ML 2 $0

taztia xt cap 120mg/24 1 $0





verapamil hcl cap sr 24hr 100 mg 1 $0






VERAPAMIL HCL CAP SR 24HR 360

MG

1 $0

verapamil hcl iv soln 2.5 mg/ml 1 $0

verapamil hcl tab 40 mg 1 $0



verapamil hcl tab cr 120 mg 1 $0



DIGITALIS GLYCOSIDES - DRUGS TO TREAT HEART CONDITIONS digitek tab 0.25mg 1 $0 PA

digitek tab 0.125mg 1 $0 QL (30 tabs / 30 days)

digoxin inj 0.25 mg/ml 1 $0

DIGOXIN ORAL SOLN 0.05 MG/ML 1 $0 PA

digoxin tab 125 mcg (0.125 mg) 1 $0 QL (30 tabs / 30 days)

digoxin tab 250 mcg (0.25 mg) 1 $0 PA


50

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

LANOXIN TAB 0.25MG 2 $0 PA

LANOXIN TAB 0.125MG 2 $0 QL (30 tabs / 30 days)

DIRECT RENIN INHIBITORS/COMBINATIONS - DRUGS TO TREAT

HEART CONDITIONS TEKAMLO TAB 150-5MG 2 $0 QL (30 tabs / 30 days)

TEKAMLO TAB 150-10MG 2 $0 QL (30 tabs / 30 days)

TEKAMLO TAB 300-5MG 2 $0 QL (30 tabs / 30 days)

TEKAMLO TAB 300-10MG 2 $0

TEKTURNA HCT TAB 150-12.5 2 $0 QL (30 tabs / 30 days)

TEKTURNA HCT TAB 150-25MG 2 $0 QL (60 tabs / 30 days)

TEKTURNA HCT TAB 300-12.5 2 $0 QL (30 tabs / 30 days)

TEKTURNA HCT TAB 300-25MG 2 $0

TEKTURNA TAB 150MG 2 $0 QL (30 tabs / 30 days)

TEKTURNA TAB 300MG 2 $0

DIURETICS - DRUGS TO TREAT HEART CONDITIONS acetazolamide cap sr 12hr 500 mg 1 $0

acetazolamide tab 125 mg 1 $0

acetazolamide tab 250 mg 1 $0

amiloride & hydrochlorothiazide tab 5-50 mg

1 $0

amiloride hcl tab 5 mg 1 $0

bumetanide inj 0.25 mg/ml 1 $0

bumetanide tab 0.5 mg 1 $0

bumetanide tab 1 mg 1 $0

bumetanide tab 2 mg 1 $0

chlorothiazide tab 250 mg 1 $0

chlorothiazide tab 500 mg 1 $0

chlorthalidone tab 25 mg 1 $0

chlorthalidone tab 50 mg 1 $0

DIURIL SUS 250/5ML 2 $0

DYRENIUM CAP 50MG 2 $0

DYRENIUM CAP 100MG 2 $0

EDECRIN TAB 25MG 2 $0

furosemide inj 10 mg/ml 1 $0

furosemide oral soln 10 mg/ml 1 $0

furosemide sol 8mg/ml 1 $0

furosemide tab 20 mg 1 $0



hydrochlorothiazide cap 12.5 mg 1 $0

hydrochlorothiazide tab 12.5 mg 1 $0


51

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

hydrochlorothiazide tab 25 mg 1 $0

hydrochlorothiazide tab 50 mg 1 $0

indapamide tab 1.25 mg 1 $0

indapamide tab 2.5 mg 1 $0

methazolamide tab 25 mg 1 $0

methazolamide tab 50 mg 1 $0

methyclothiazide tab 5 mg 1 $0

metolazone tab 2.5 mg 1 $0

metolazone tab 5 mg 1 $0

metolazone tab 10 mg 1 $0

spironolactone & hydrochlorothiazide tab 25-25 mg

1 $0

torsemide inj 20mg/2ml 1 $0

torsemide inj 50mg/5ml 1 $0

torsemide tab 5 mg 1 $0




triamterene & hydrochlorothiazide cap 37.5-25 mg

1 $0

triamterene & hydrochlorothiazide tab 37.5-25 mg

1 $0

triamterene & hydrochlorothiazide tab 75-50 mg

1 $0

MISCELLANEOUS clonidine hcl tab 0.1 mg 1 $0

clonidine hcl tab 0.2 mg 1 $0

clonidine hcl tab 0.3 mg 1 $0

clonidine hcl td patch weekly 0.1 mg/24hr

1 $0


1 $0


1 $0

DEMSER CAP 250MG 2 $0

hydralazine hcl inj 20 mg/ml 1 $0

hydralazine hcl tab 10 mg 1 $0




midodrine hcl tab 2.5 mg 1 $0

midodrine hcl tab 5 mg 1 $0


52

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

midodrine hcl tab 10 mg 1 $0

minoxidil tab 2.5 mg 1 $0

minoxidil tab 10 mg 1 $0

RANEXA TAB 500MG 2 $0

RANEXA TAB 1000MG 2 $0

NITRATES - DRUGS TO TREAT HEART CONDITIONS isosorbide dinitrate tab 5 mg 1 $0

isosorbide dinitrate tab 10 mg 1 $0



isosorbide dinitrate tab cr 40 mg 1 $0

isosorbide mononitrate tab 10 mg 1 $0

isosorbide mononitrate tab 20 mg 1 $0

isosorbide mononitrate tab sr 24hr 30 mg

1 $0


1 $0


1 $0

minitran dis 0.1mg/hr 1 $0




nitro-bid oin 2% 2 $0

NITRO-DUR DIS 0.3MG/HR 2 $0

NITRO-DUR DIS 0.8MG/HR 2 $0

nitroglycerin td patch 24hr 0.1 mg/hr

1 $0


1 $0


1 $0


1 $0

NITROLINGUAL SPR PUMPSPRA 2 $0

NITROSTAT SUB 0.3MG 2 $0



PULMONARY ARTERIAL HYPERTENSION - DRUGS TO TREAT

PUMONARY HYPERTENSION


53

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

ADCIRCA TAB 20MG 2 $0 QL (60 tabs / 30 days),

NM, PA

ADEMPAS TAB 0.5MG 2 $0 QL (90 tabs / 30 days),

NM, PA


NM, PA

ADEMPAS TAB 1MG 2 $0 QL (90 tabs / 30 days),

NM, PA


NM, PA

ADEMPAS TAB 2MG 2 $0 QL (90 tabs / 30 days),

NM, PA

LETAIRIS TAB 5MG 2 $0 QL (30 tabs / 30 days),

NM, LA, PA

LETAIRIS TAB 10MG 2 $0 QL (30 tabs / 30 days),

NM, LA, PA

REMODULIN INJ 1MG/ML 2 $0 B/D, NM, LA

REMODULIN INJ 2.5MG/ML 2 $0 B/D, NM, LA



REVATIO SUS 10MG/ML 2 $0 QL (2 bottles / 30 days), NM, PA

sildenafil citrate tab 20 mg 2 $0 QL (90 tabs / 30 days), NM, PA

TRACLEER TAB 62.5MG 2 $0 QL (120 tabs / 30 days), NM, LA, PA

TRACLEER TAB 125MG 2 $0 QL (60 tabs / 30 days), NM, LA, PA

CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM

DISORDERS ANTIANXIETY - DRUGS TO TREAT ANXIETY alprazolam con 1 mg/ml 1 $0 QL (300 mL / 30 days)

alprazolam tab 0.5 mg 1 $0 QL (240 tabs / 30 days)

alprazolam tab 0.25 mg 1 $0 QL (480 tabs / 30 days)

alprazolam tab 1 mg 1 $0 QL (120 tabs / 30 days)

alprazolam tab 2 mg 1 $0 QL (150 tabs / 30 days)

buspirone hcl tab 5 mg 1 $0

buspirone hcl tab 7.5 mg 1 $0




fluvoxamine maleate tab 25 mg 1 $0 QL (45 tabs / 30 days)


54

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

fluvoxamine maleate tab 50 mg 1 $0 QL (45 tabs / 30 days)

fluvoxamine maleate tab 100 mg 1 $0

lorazepam con 2mg/ml 1 $0 QL (150 mL / 30 days)

lorazepam inj 2 mg/ml 1 $0

lorazepam inj 4 mg/ml 1 $0

lorazepam tab 0.5 mg 1 $0 QL (150 tabs / 30 days)

lorazepam tab 1 mg 1 $0 QL (150 tabs / 30 days)

lorazepam tab 2 mg 1 $0 QL (150 tabs / 30 days)

ANTICONVULSANTS - DRUGS TO TREAT SEIZURES APTIOM TAB 200MG 2 $0 QL (180 tabs / 30 days)

APTIOM TAB 400MG 2 $0 QL (90 tabs / 30 days)



BANZEL SUS 40MG/ML 2 $0 PA

BANZEL TAB 200MG 2 $0 PA

BANZEL TAB 400MG 2 $0 PA

carbamazepine cap sr 12hr 100 mg 1 $0



carbamazepine chew tab 100 mg 1 $0

carbamazepine susp 100 mg/5ml 1 $0

carbamazepine tab 200 mg 1 $0

carbamazepine tab sr 12hr 200 mg 1 $0

carbamazepine tab sr 12hr 400 mg 1 $0

CELONTIN CAP 300MG 2 $0

clonazepam orally disintegrating tab 0.5 mg

1 $0 QL (1200 tabs / 30 days)


1 $0 QL (2400 tabs / 30 days)


1 $0 QL (4800 tabs / 30 days)

clonazepam orally disintegrating

tab 1 mg

1 $0 QL (600 tabs / 30 days)

clonazepam orally disintegrating

tab 2 mg

1 $0 QL (300 tabs / 30 days)

clonazepam tab 0.5 mg 1 $0 QL (1200 tabs / 30

days)

clonazepam tab 1 mg 1 $0 QL (600 tabs / 30 days)

clonazepam tab 2 mg 1 $0 QL (300 tabs / 30 days)

clorazepate dipotassium tab 3.75 mg

1 $0 QL (120 tabs / 30 days), PA


55

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

clorazepate dipotassium tab 7.5 mg 1 $0 QL (120 tabs / 30 days),

PA

clorazepate dipotassium tab 15 mg 1 $0 QL (180 tabs / 30 days),

PA

diazepam con 5mg/ml 1 $0 QL (240 mL / 30 days),

PA

diazepam inj 5 mg/ml 1 $0

DIAZEPAM RECTAL GEL DELIVERY

SYSTEM 2.5 MG

1 $0


SYSTEM 10 MG

1 $0


SYSTEM 20 MG

1 $0

diazepam soln 1 mg/ml 1 $0 QL (1200 mL / 30 days),

PA

diazepam tab 2 mg 1 $0 QL (120 tabs / 30 days),

PA


PA


PA

dilantin cap 30mg 2 $0

dilantin cap 100mg 2 $0

dilantin chw 50mg 2 $0

DILANTIN-125 SUS 125/5ML 2 $0

divalproex sodium cap sprinkle 125 mg

1 $0

divalproex sodium tab delayed release 125 mg

1 $0


1 $0


1 $0

divalproex sodium tab sr 24 hr 250 mg

1 $0

divalproex sodium tab sr 24 hr 500 mg

1 $0

epitol tab 200mg 1 $0

ethosuximide cap 250 mg 1 $0

ethosuximide soln 250 mg/5ml 1 $0

felbamate susp 600 mg/5ml 2 $0

felbamate tab 400 mg 1 $0

felbamate tab 600 mg 2 $0


56

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

FYCOMPA TAB 2MG 2 $0 QL (180 tabs / 30 days),

PA


PA


PA


PA


PA


PA

gabapentin cap 100 mg 1 $0 QL (1080 caps / 30

days)

gabapentin cap 300 mg 1 $0 QL (360 caps / 30 days)

gabapentin cap 400 mg 1 $0 QL (270 caps / 30 days)

gabapentin oral soln 250 mg/5ml 1 $0 QL (2160 mL / 30 days)

gabapentin tab 600 mg 1 $0 QL (180 tabs / 30 days)

gabapentin tab 800 mg 1 $0 QL (120 tabs / 30 days)

GABITRIL TAB 12MG 2 $0

GABITRIL TAB 16MG 2 $0

lamotrigine tab 25 mg 1 $0




lamotrigine tab chewable dispersible 5 mg

1 $0

lamotrigine tab chewable dispersible 25 mg

1 $0

lamotrigine tab sr 24hr 25 mg 1 $0






LEVETIRACETA INJ 5MG/ML 2 $0



levetiracetam inj 500 mg/5ml (100

mg/ml)

1 $0

levetiracetam oral soln 100 mg/ml 1 $0

levetiracetam tab 250 mg 1 $0


57

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE




levetiracetam tab sr 24hr 500 mg 1 $0

levetiracetam tab sr 24hr 750 mg 1 $0

LYRICA CAP 25MG 2 $0 QL (120 caps / 30 days)








LYRICA SOL 20MG/ML 2 $0 QL (946 mL / 30 days)

ONFI SUS 2.5MG/ML 2 $0 PA

ONFI TAB 10MG 2 $0 PA

ONFI TAB 20MG 2 $0 PA

oxcarbazepine susp 300 mg/5ml (60 mg/ml)

1 $0

oxcarbazepine tab 150 mg 1 $0



PEGANONE TAB 250MG 2 $0

PHENOBARB INJ 65MG/ML 2 $0 PA

phenobarbital elixir 20 mg/5ml 2 $0 PA

phenobarbital sodium inj 130 mg/ml

2 $0 PA

phenobarbital tab 15 mg 2 $0 PA

phenobarbital tab 16.2 mg 2 $0 PA







phenytek cap 200mg 2 $0

phenytek cap 300mg 2 $0

phenytoin chew tab 50 mg 1 $0

phenytoin sodium extended cap 100 mg

1 $0


58

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

phenytoin sodium extended cap

200 mg

1 $0

phenytoin sodium extended cap

300 mg

1 $0

phenytoin sodium inj 50 mg/ml 1 $0

phenytoin susp 125 mg/5ml 1 $0

POTIGA TAB 50MG 2 $0

POTIGA TAB 200MG 2 $0 QL (180 tabs / 30 days)



primidone tab 50 mg 1 $0

primidone tab 250 mg 1 $0

SABRIL POW 500MG 2 $0 QL (180 packets / 30

days), NM, LA, PA

SABRIL TAB 500MG 2 $0 QL (180 tabs / 30 days),

NM, LA, PA

TEGRETOL SUS 100/5ML 2 $0

TEGRETOL TAB 200MG 2 $0

TEGRETOL-XR TAB 100MG 2 $0



tiagabine hcl tab 2 mg 1 $0

tiagabine hcl tab 4 mg 1 $0

topiramate sprinkle cap 15 mg 1 $0

topiramate sprinkle cap 25 mg 1 $0

topiramate tab 25 mg 1 $0




valproate sodium inj 100 mg/ml 1 $0

valproate sodium syrup 250 mg/5ml (base equiv)

1 $0

valproic acid cap 250 mg 1 $0

VIMPAT INJ 200MG/20 2 $0

VIMPAT SOL 10MG/ML 2 $0 QL (1200 mL / 30 days)

VIMPAT TAB 50MG 2 $0 QL (180 tabs / 30 days)




zonisamide cap 25 mg 1 $0



59

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE


ANTIDEMENTIA - DRUGS TO TREAT DEMENTIA AND MEMORY LOSS donepezil hydrochloride orally

disintegrating tab 5 mg 1 $0 QL (30 tabs / 30 days)

donepezil hydrochloride orally disintegrating tab 10 mg

1 $0

donepezil hydrochloride tab 5 mg 1 $0 QL (30 tabs / 30 days)

donepezil hydrochloride tab 10 mg 1 $0

donepezil hydrochloride tab 23 mg 1 $0

EXELON DIS 4.6MG/24 2 $0 QL (30 patches / 30

days)

EXELON DIS 9.5MG/24 2 $0 QL (30 patches / 30

days)

EXELON DIS 13.3/24 2 $0 QL (30 patches / 30

days)

galantamine hydrobromide cap sr

24hr 8 mg

1 $0 QL (30 caps / 30 days)


24hr 16 mg

1 $0 QL (30 caps / 30 days)


24hr 24 mg

1 $0

galantamine hydrobromide oral

soln 4 mg/ml

1 $0

galantamine hydrobromide tab 4

mg

1 $0 QL (180 tabs / 30 days)


mg

1 $0 QL (90 tabs / 30 days)


mg

1 $0

NAMENDA SOL 10MG/5ML 2 $0 PA; PA if <30 yr

NAMENDA TAB 5MG 2 $0 PA; PA if <30 yr

NAMENDA TAB 10MG 2 $0 PA; PA if <30 yr

NAMENDA XR CAP 7MG 2 $0 PA; PA if <30 yr




NAMENDA XR CAP TITRATIO 2 $0 PA; PA if <30 yr

rivastigmine tartrate cap 1.5 mg 1 $0

rivastigmine tartrate cap 3 mg 1 $0

rivastigmine tartrate cap 4.5 mg 1 $0

rivastigmine tartrate cap 6 mg 1 $0

ANTIDEPRESSANTS - DRUGS TO TREAT DEPRESSION


60

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

amitriptyline hcl tab 10 mg 2 $0 PA






amoxapine tab 25 mg 1 $0




BRINTELLIX TAB 5MG 2 $0 QL (120 tabs / 30 days)



bupropion hcl tab 75 mg 1 $0

bupropion hcl tab 100 mg 1 $0

bupropion hcl tab sr 12hr 100 mg 1 $0



bupropion hcl tab sr 24hr 150 mg 1 $0 QL (90 tabs / 30 days)

bupropion hcl tab sr 24hr 300 mg 1 $0 QL (30 tabs / 30 days)

citalopram hydrobromide oral soln

10 mg/5ml

1 $0

citalopram hydrobromide tab 10 mg

(base equiv)

1 $0 QL (45 tabs / 30 days)


(base equiv)

1 $0 QL (45 tabs / 30 days)


(base equiv)

1 $0 QL (30 tabs / 30 days)

clomipramine hcl cap 25 mg 2 $0 PA



desipramine hcl tab 10 mg 1 $0






doxepin hcl cap 10 mg 2 $0 PA





61

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE



doxepin hcl conc 10 mg/ml 2 $0 PA

duloxetine hcl enteric coated pellets cap 20 mg

1 $0 QL (60 caps / 30 days)


1 $0 QL (60 caps / 30 days)


1 $0 QL (60 caps / 30 days)

EMSAM DIS 6MG/24HR 2 $0 QL (30 patches / 30 days), PA

EMSAM DIS 9MG/24HR 2 $0 QL (30 patches / 30 days), PA

EMSAM DIS 12MG/24H 2 $0 QL (30 patches / 30 days), PA

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

1 $0 QL (600 mL / 30 days)

escitalopram oxalate tab 5 mg (base equiv)

1 $0 QL (45 tabs / 30 days)


1 $0 QL (45 tabs / 30 days)


1 $0 QL (60 tabs / 30 days)

FETZIMA CAP 20MG 2 $0 QL (180 caps / 30 days)




FETZIMA CAP TITRATIO 2 $0

fluoxetine hcl cap 10 mg 1 $0 QL (30 caps / 30 days)

fluoxetine hcl cap 20 mg 1 $0 QL (120 caps / 30 days)

fluoxetine hcl cap 40 mg 1 $0

fluoxetine hcl solution 20 mg/5ml 1 $0

fluoxetine hcl tab 10 mg 1 $0 QL (45 tabs / 30 days)

fluoxetine hcl tab 20 mg 1 $0

imipramine hcl tab 10 mg 2 $0 PA



maprotiline hcl tab 25 mg 1 $0



MARPLAN TAB 10MG 2 $0 QL (180 tabs / 30 days)


62

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

mirtazapine orally disintegrating

tab 15 mg

1 $0 QL (30 tabs / 30 days)


tab 30 mg

1 $0


tab 45 mg

1 $0

mirtazapine tab 7.5 mg 1 $0 QL (45 tabs / 30 days)

mirtazapine tab 15 mg 1 $0 QL (45 tabs / 30 days)

mirtazapine tab 30 mg 1 $0

mirtazapine tab 45 mg 1 $0

nefazodone hcl tab 50 mg 1 $0





nortriptyline hcl cap 10 mg 1 $0




nortriptyline hcl soln 10 mg/5ml 1 $0

paroxetine hcl tab 10 mg 1 $0 QL (45 tabs / 30 days)




PAXIL SUS 10MG/5ML 2 $0 QL (900 mL / 30 days)

phenelzine sulfate tab 15 mg 1 $0

PRISTIQ TAB 25MG 2 $0 QL (30 tabs / 30 days)



protriptyline hcl tab 5 mg 1 $0

protriptyline hcl tab 10 mg 1 $0

sertraline hcl oral conc 20 mg/ml 1 $0

sertraline hcl tab 25 mg 1 $0 QL (45 tabs / 30 days)

sertraline hcl tab 50 mg 1 $0 QL (45 tabs / 30 days)

sertraline hcl tab 100 mg 1 $0

SURMONTIL CAP 25MG 2 $0 QL (240 caps / 30 days), PA



tranylcypromine sulfate tab 10 mg 1 $0


63

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

trazodone hcl tab 50 mg 1 $0



venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent)

1 $0 QL (30 caps / 30 days)

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

1 $0 QL (30 caps / 30 days)

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

1 $0 QL (60 caps / 30 days)

venlafaxine hcl tab 25 mg 1 $0

venlafaxine hcl tab 37.5 mg 1 $0




VIIBRYD KIT 2 $0

VIIBRYD TAB 10MG 2 $0 QL (30 tabs / 30 days)



ANTIPARKINSONIAN AGENTS - DRUGS TO TREAT PARKINSONS

DISEASE amantadine hcl cap 100 mg 1 $0

amantadine hcl syrup 50 mg/5ml 1 $0

amantadine hcl tab 100 mg 1 $0

APOKYN INJ 10MG/ML 2 $0 NM, LA, PA

AZILECT TAB 0.5MG 2 $0

AZILECT TAB 1MG 2 $0

benztropine mesylate inj 1 mg/ml 1 $0

benztropine mesylate tab 0.5 mg 2 $0 PA

benztropine mesylate tab 1 mg 2 $0 PA

benztropine mesylate tab 2 mg 2 $0 PA

bromocriptine mesylate cap 5 mg 1 $0

bromocriptine mesylate tab 2.5 mg 1 $0

carbidopa & levodopa orally disintegrating tab 10-100 mg

1 $0


1 $0


1 $0

carbidopa & levodopa tab 10-100 mg

1 $0


64

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

carbidopa & levodopa tab 25-100

mg

1 $0

carbidopa & levodopa tab 25-250

mg

1 $0

carbidopa & levodopa tab cr 25-100

mg

1 $0

carbidopa & levodopa tab cr 50-200

mg

1 $0

CARBIDOPA-LEVODOPA-ENTACAPO

NE TABS 12.5-50-200 MG

1 $0


NE TABS 18.75-75-200 MG

1 $0


NE TABS 25-100-200 MG

1 $0


NE TABS 31.25-125-200 MG

1 $0


NE TABS 37.5-150-200 MG

1 $0

CARBIDOPA-LEVODOPA-ENTACAPONE TABS 50-200-200 MG

1 $0

entacapone tab 200 mg 1 $0

NEUPRO DIS 1MG/24HR 2 $0






pramipexole dihydrochloride tab

0.5 mg

1 $0


0.25 mg

1 $0


0.75 mg

1 $0


0.125 mg

1 $0

pramipexole dihydrochloride tab 1 mg

1 $0

pramipexole dihydrochloride tab 1.5 mg

1 $0

ropinirole hydrochloride tab 0.5 mg 1 $0

ropinirole hydrochloride tab 0.25

mg

1 $0

ropinirole hydrochloride tab 1 mg 1 $0


65

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE





selegiline hcl cap 5 mg 1 $0

selegiline hcl tab 5 mg 1 $0

trihexyphenidyl hcl elixir 0.4 mg/ml 2 $0 PA

trihexyphenidyl hcl tab 2 mg 2 $0 PA

trihexyphenidyl hcl tab 5 mg 2 $0 PA

ANTIPSYCHOTICS - DRUGS TO TREAT PSYCHOSES ABILIFY DISC TAB 10MG 2 $0 QL (60 tabs / 30 days)

ABILIFY DISC TAB 15MG 2 $0 QL (60 tabs / 30 days)

ABILIFY INJ 9.75MG 2 $0 QL (4 mL / 1 day)

ABILIFY MAIN INJ 300MG 2 $0 QL (1 syringe / 28 days)

ABILIFY MAIN INJ 300MG 2 $0 QL (1 vial / 28 days)

ABILIFY MAIN INJ 400MG 2 $0 QL (1 syringe / 28 days)

ABILIFY MAIN INJ 400MG 2 $0 QL (1 vial / 28 days)

ABILIFY TAB 2MG 2 $0 QL (30 tabs / 30 days)






aripiprazole tab 2 mg 2 $0 QL (30 tabs / 30 days)






chlorpromaz inj 50mg/2ml 2 $0

chlorpromazine hcl tab 10 mg 1 $0





CLOZAPINE ORALLY

DISINTEGRATING TAB 12.5 MG

1 $0 PA

CLOZAPINE ORALLY

DISINTEGRATING TAB 25 MG

1 $0 PA

CLOZAPINE ORALLY DISINTEGRATING TAB 100 MG

1 $0 QL (270 tabs / 30 days), PA


66

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

CLOZAPINE ORALLY


1 $0 QL (180 tabs / 30 days),

PA

CLOZAPINE ORALLY


1 $0 QL (135 tabs / 30 days),

PA

clozapine tab 25 mg 1 $0

clozapine tab 50 mg 1 $0

clozapine tab 100 mg 1 $0 QL (270 tabs / 30 days)

clozapine tab 200 mg 1 $0 QL (135 tabs / 30 days)

FANAPT PAK 2 $0 ST

FANAPT TAB 1MG 2 $0 QL (60 tabs / 30 days), ST







FAZACLO TAB 12.5/ODT 2 $0 PA

FAZACLO TAB 25MG ODT 2 $0 PA

FAZACLO TAB 100/ODT 2 $0 QL (270 tabs / 30 days),

PA

FAZACLO TAB 150MG 2 $0 QL (180 tabs / 30 days),

PA

FAZACLO TAB 200MG 2 $0 QL (135 tabs / 30 days),

PA

fluphenazine decanoate inj 25

mg/ml

1 $0

fluphenazine hcl elixir 2.5 mg/5ml 1 $0

fluphenazine hcl inj 2.5 mg/ml 1 $0

fluphenazine hcl oral conc 5 mg/ml 1 $0

fluphenazine hcl tab 1 mg 1 $0

fluphenazine hcl tab 2.5 mg 1 $0



GEODON INJ 20MG 2 $0 QL (6 mL / 3 days)


67

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

haloperidol decanoate im soln 50

mg/ml

1 $0

haloperidol decanoate im soln 100

mg/ml

1 $0

haloperidol lactate inj 5 mg/ml 1 $0

haloperidol lactate oral conc 2

mg/ml

1 $0

haloperidol tab 0.5 mg 1 $0

haloperidol tab 1 mg 1 $0





INVEGA SUST INJ 39/0.25 2 $0 QL (1 injection / 28

days)

INVEGA SUST INJ 78/0.5ML 2 $0 QL (1 injection / 28

days)


days)

INVEGA SUST INJ 156MG/ML 2 $0 QL (1 injection / 28

days)


days)

INVEGA TAB 1.5MG 2 $0 QL (30 tabs / 30 days)

INVEGA TAB 3MG 2 $0 QL (30 tabs / 30 days)



LATUDA TAB 20MG 2 $0 QL (240 tabs / 30 days)





loxapine succinate cap 5 mg 1 $0




olanzapine for im inj 10 mg 1 $0 QL (3 vials / 1 day)

olanzapine orally disintegrating tab

5 mg

1 $0 QL (30 tabs / 30 days)


10 mg

1 $0 QL (60 tabs / 30 days)


68

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE


15 mg

1 $0 QL (60 tabs / 30 days)


20 mg

2 $0 QL (60 tabs / 30 days)

olanzapine tab 2.5 mg 1 $0 QL (30 tabs / 30 days)

olanzapine tab 5 mg 1 $0 QL (30 tabs / 30 days)

olanzapine tab 7.5 mg 1 $0 QL (30 tabs / 30 days)




ORAP TAB 1MG 2 $0

ORAP TAB 2MG 2 $0

perphenazine tab 2 mg 1 $0




quetiapine fumarate tab 25 mg 1 $0 QL (90 tabs / 30 days)






RISPERDAL INJ 12.5MG 2 $0 QL (2 injections / 28 days)

RISPERDAL INJ 25MG 2 $0 QL (2 injections / 28 days)

RISPERDAL INJ 37.5MG 2 $0 QL (2 injections / 28 days)

RISPERDAL INJ 50MG 2 $0 QL (2 injections / 28 days)

risperidone orally disintegrating tab 0.5 mg

1 $0 QL (90 tabs / 30 days)

risperidone orally disintegrating tab 0.25 mg

1 $0 QL (90 tabs / 30 days)

risperidone orally disintegrating tab 1 mg

1 $0 QL (60 tabs / 30 days)


1 $0 QL (60 tabs / 30 days)


1 $0 QL (60 tabs / 30 days)


1 $0 QL (120 tabs / 30 days)


69

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

risperidone soln 1 mg/ml 1 $0 QL (240 mL / 30 days)

risperidone tab 0.5 mg 1 $0 QL (90 tabs / 30 days)

risperidone tab 0.25 mg 1 $0 QL (90 tabs / 30 days)

risperidone tab 1 mg 1 $0 QL (60 tabs / 30 days)




SAPHRIS SUB 2.5MG 2 $0 QL (240 tabs / 30 days)

SAPHRIS SUB 5MG 2 $0 QL (120 tabs / 30 days)

SAPHRIS SUB 10MG 2 $0 QL (60 tabs / 30 days)

SEROQUEL XR TAB 50MG 2 $0 QL (120 tabs / 30 days)





thioridazine hcl tab 10 mg 2 $0 PA




thiothixene cap 1 mg 1 $0




trifluoperazine hcl tab 1 mg 1 $0




VERSACLOZ SUS 50MG/ML 2 $0 QL (600 mL / 30 days), PA

ziprasidone hcl cap 20 mg 1 $0 QL (60 caps / 30 days)




ZYPREXA RELP INJ 210MG 2 $0 B/D



ATTENTION DEFICIT HYPERACTIVITY DISORDER - DRUGS TO TREAT

ADHD amphetamine-dextroamphetamine

cap sr 24hr 5 mg

1 $0 QL (90 caps / 30 days)


70

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

amphetamine-dextroamphetamine

cap sr 24hr 10 mg

1 $0 QL (90 caps / 30 days)


cap sr 24hr 15 mg

1 $0 QL (30 caps / 30 days)


cap sr 24hr 20 mg

1 $0 QL (30 caps / 30 days)


cap sr 24hr 25 mg

1 $0 QL (30 caps / 30 days)


cap sr 24hr 30 mg

1 $0 QL (30 caps / 30 days)


tab 5 mg

1 $0 QL (360 tabs / 30 days)


tab 7.5 mg

1 $0 QL (240 tabs / 30 days)


tab 10 mg

1 $0 QL (180 tabs / 30 days)


tab 12.5 mg

1 $0 QL (144 tabs / 30 days)

amphetamine-dextroamphetamine tab 15 mg

1 $0 QL (120 tabs / 30 days)


1 $0 QL (90 tabs / 30 days)


1 $0 QL (60 tabs / 30 days)

guanfacine hcl tab sr 24hr 1 mg (base equiv)

2 $0


2 $0


2 $0


2 $0

methylphenidate hcl soln 5 mg/5ml 1 $0 QL (1800 mL / 30 days)

methylphenidate hcl soln 10 mg/5ml

1 $0 QL (900 mL / 30 days)

methylphenidate hcl tab 5 mg 1 $0 QL (180 tabs / 30 days)



methylphenidate hcl tab cr 10 mg 1 $0 QL (90 tabs / 30 days)

methylphenidate hcl tab cr 20 mg 1 $0 QL (90 tabs / 30 days)

STRATTERA CAP 10MG 2 $0 QL (120 caps / 30 days)




71

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE





HYPNOTICS - DRUGS TO TREAT INSOMNIA ROZEREM TAB 8MG 2 $0 QL (30 tabs / 30 days)

SILENOR TAB 3MG 2 $0 QL (60 tabs / 30 days)

SILENOR TAB 6MG 2 $0 QL (30 tabs / 30 days)

temazepam cap 7.5 mg 1 $0 QL (30 caps / 30 days), PA; 90 day limit if >64

yr

temazepam cap 15 mg 1 $0 QL (60 caps / 30 days),

PA; 90 day limit if >64 yr

zolpidem tartrate tab 5 mg 2 $0 QL (30 tabs / 30 days), PA; 90 day limit if >64 yr

zolpidem tartrate tab 10 mg 2 $0 QL (30 tabs / 30 days), PA; 90 day limit if >64

yr

MIGRAINE - DRUGS TO TREAT SEVERE HEADACHES cafergot tab 1-100mg 2 $0

dihydroergotamine mesylate inj 1 mg/ml

1 $0

naratriptan hcl tab 1 mg (base equiv)

1 $0 QL (9 tabs / 30 days)

naratriptan hcl tab 2.5 mg (base equiv)

1 $0 QL (9 tabs / 30 days)

RELPAX TAB 20MG 2 $0 QL (12 tabs / 30 days)

RELPAX TAB 40MG 2 $0 QL (12 tabs / 30 days)

rizatriptan benzoate orally

disintegrating tab 5 mg

1 $0 QL (18 tabs / 30 days)

rizatriptan benzoate orally

disintegrating tab 10 mg

1 $0 QL (18 tabs / 30 days)

rizatriptan benzoate tab 5 mg 1 $0 QL (18 tabs / 30 days)

rizatriptan benzoate tab 10 mg 1 $0 QL (18 tabs / 30 days)

SUMATRIPTAN NASAL SPRAY 5 MG/ACT

1 $0 QL (24 inhalers / 30 days)


1 $0 QL (12 inhalers / 30 days)

sumatriptan succinate inj 6 mg/0.5ml

1 $0 QL (6 mL / 30 days)


72

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

SUMATRIPTAN SUCCINATE

SOLUTION AUTO-INJECTOR 4 MG/0.5ML

1 $0 QL (6 mL / 30 days)

sumatriptan succinate solution auto-injector 6 mg/0.5ml

1 $0 QL (6 mL / 30 days)

SUMATRIPTAN SUCCINATE SOLUTION CARTRIDGE 4 MG/0.5ML

1 $0 QL (6 mL / 30 days)

SUMATRIPTAN SUCCINATE SOLUTION CARTRIDGE 6 MG/0.5ML

1 $0 QL (6 mL / 30 days)

sumatriptan succinate solution prefilled syringe 6 mg/0.5ml

1 $0 QL (6 mL / 30 days)

sumatriptan succinate tab 25 mg 1 $0 QL (9 tabs / 30 days)



zolmitriptan orally disintegrating tab 2.5 mg

1 $0 QL (12 tabs / 30 days)

zolmitriptan orally disintegrating tab 5 mg

1 $0 QL (12 tabs / 30 days)

zolmitriptan tab 2.5 mg 1 $0 QL (12 tabs / 30 days)

zolmitriptan tab 5 mg 1 $0 QL (12 tabs / 30 days)

MISCELLANEOUS lithium carbonate cap 150 mg 1 $0

lithium carbonate cap 300 mg 1 $0

lithium carbonate cap 600 mg 1 $0

lithium carbonate tab 300 mg 1 $0

lithium carbonate tab cr 300 mg 1 $0

lithium carbonate tab cr 450 mg 1 $0

LITHIUM SOL 8MEQ/5ML 2 $0

NUEDEXTA CAP 20-10MG 2 $0 PA

pyridostigmine bromide tab 60 mg 1 $0

riluzole tab 50 mg 1 $0

XENAZINE TAB 12.5MG 2 $0 QL (240 tabs / 30 days),

NM, LA, PA

XENAZINE TAB 25MG 2 $0 QL (120 tabs / 30 days),

NM, LA, PA

MULTIPLE SCLEROSIS AGENTS - DRUGS TO TREAT MULTIPLE

SCLEROSIS BETASERON INJ 0.3MG 2 $0 QL (14 syringes / 28

days), NM, PA

COPAXONE INJ 20MG/ML 2 $0 QL (30 syringes / 30

days), NM, PA


73

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

COPAXONE INJ 40MG/ML 2 $0 QL (12 syringes / 28

days), NM, PA

GILENYA CAP 0.5MG 2 $0 QL (28 caps / 28 days),

NM, PA

TYSABRI INJ 300/15ML 2 $0 NM, LA, PA

MUSCULOSKELETAL THERAPY AGENTS - DRUGS TO TREAT MUSCLE

SPASMS baclofen tab 10 mg 1 $0

baclofen tab 20 mg 1 $0

cyclobenzaprine hcl tab 5 mg 1 $0 PA

cyclobenzaprine hcl tab 10 mg 1 $0 PA

dantrolene sodium cap 25 mg 1 $0



tizanidine hcl tab 2 mg (base

equivalent)

1 $0

tizanidine hcl tab 4 mg (base

equivalent)

1 $0

NARCOLEPSY/CATAPLEXY - DRUGS FOR SLEEP DISORDERS NUVIGIL TAB 50MG 2 $0 QL (150 tabs / 30 days),

PA

NUVIGIL TAB 150MG 2 $0 QL (60 tabs / 30 days), PA



XYREM SOL 500MG/ML 2 $0 QL (540 mL / 30 days), LA, PA

PSYCHOTHERAPEUTIC-MISC acamprosate calcium tab delayed

release 333 mg

1 $0

buprenorphine hcl sl tab 2 mg (base

equiv)

1 $0 PA

buprenorphine hcl sl tab 8 mg (base

equiv)

1 $0 PA

buprenorphine hcl-naloxone hcl sl

tab 2-0.5 mg (base equiv)

1 $0 QL (120 tabs / 30 days),

PA

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

1 $0 QL (120 tabs / 30 days), PA

buproban tab 150mg 1 $0

CHANTIX PAK 0.5& 1MG 2 $0 PA


74

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

CHANTIX PAK 1MG 2 $0 PA

CHANTIX TAB 0.5MG 2 $0 PA

CHANTIX TAB 1MG 2 $0 PA

diphenhydramine-acetaminophen tab 25-500 mg (sleep)

3 $0 NM; *

disulfiram tab 250 mg 1 $0

disulfiram tab 500 mg 1 $0

headache tab 25-500mg 3 $0 NM; *

ibuprofen pm tab 200-38mg 3 $0 NM; *

naloxone hcl inj 0.4 mg/ml 1 $0

naloxone hcl inj 1 mg/ml 1 $0

naltrexone hcl tab 50 mg 1 $0

nicotine polacrilex gum 4 mg 3 $0 NM; *

nicotine polacrilex lozenge 2 mg 3 $0 NM; *

NICOTINE POLACRILEX LOZENGE 2

MG

3 $0 NM; *

nicotine polacrilex lozenge 4 mg 3 $0 NM; *

NICOTINE POLACRILEX LOZENGE 4

MG

3 $0 NM; *

NICOTINE SYS KIT TRANSDER 3 $0 NM; *

nicotine td patch 24hr 7 mg/24hr 3 $0 NM; *



NICOTROL INH 2 $0

NICOTROL NS SPR 10MG/ML 2 $0

simply sleep tab 25mg 3 $0 NM; *

sleep aid tab 25mg 3 $0 NM; *

sleep aid tab 50mg 3 $0 NM; *

SUBOXONE MIS 2-0.5MG 2 $0 QL (4 boxes / 30 days), PA

SUBOXONE MIS 4-1MG 2 $0 QL (4 boxes / 30 days), PA



thrive gum 2mg mint 3 $0 NM; *

thrive gum 4mg mint 3 $0 NM; *

wal-som cap 50mg 3 $0 NM; *

ENDOCRINE AND METABOLIC - DRUGS TO TREAT DIABETES AND

REGULATE HORMONES


75

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

ANDROGENS - DRUGS TO REGULATE MALE HORMONES ANDRODERM DIS 2MG/24HR 2 $0 QL (30 patches / 30

days), PA

ANDRODERM DIS 4MG/24HR 2 $0 QL (30 patches / 30 days), PA

oxandrolone tab 2.5 mg 1 $0 PA

oxandrolone tab 10 mg 1 $0 PA

TESTIM GEL 1%(50MG) 2 $0 QL (300 grams / 30 days), PA

testosterone cypionate im inj in oil 100 mg/ml

1 $0

testosterone cypionate im inj in oil 200 mg/ml

1 $0

testosterone enanthate im inj in oil 200 mg/ml

1 $0

ANTIDIABETICS, INJECTABLE - DRUGS TO TREAT DIABETES ALCOHOL SWABS 2 $0

GAUZE PADS 2" X 2" 2 $0

HUMULIN R INJ U-500 2 $0 B/D

INSULIN PEN NEEDLE 2 $0

INSULIN SAFETY NEEDLES 2 $0

INSULIN SYRINGE 2 $0

LANTUS INJ 100/ML 2 $0

LANTUS INJ SOLOSTAR 2 $0

LEVEMIR INJ 2 $0

LEVEMIR INJ FLEXTOUC 2 $0

NOVOLIN INJ 70/30 2 $0 RELION not covered

NOVOLIN N INJ U-100 2 $0 RELION not covered

NOVOLIN R INJ U-100 2 $0 RELION not covered

NOVOLOG INJ 100/ML 2 $0

NOVOLOG INJ FLEXPEN 2 $0

NOVOLOG INJ PENFILL 2 $0

NOVOLOG MIX INJ 70/30 2 $0

NOVOLOG MIX INJ FLEXPEN 2 $0

SYMLINPEN 60 INJ 1000MCG 2 $0 QL (8 pens / 30 days),

PA

SYMLNPEN 120 INJ 1000MCG 2 $0 QL (4 pens / 30 days),

PA

TOUJEO SOLO INJ 300IU/ML 2 $0

VICTOZA INJ 18MG/3ML 2 $0 QL (3 pens / 30 days)

ANTIDIABETICS, ORAL - DRUGS TO TREAT DIABETES


76

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

acarbose tab 25 mg 1 $0



glimepiride tab 1 mg 1 $0 QL (240 tabs / 30 days)



glipizide tab 5 mg 1 $0 QL (240 tabs / 30 days)

glipizide tab 10 mg 1 $0 QL (120 tabs / 30 days)

glipizide tab sr 24hr 2.5 mg 1 $0 QL (240 tabs / 30 days)

glipizide tab sr 24hr 5 mg 1 $0 QL (120 tabs / 30 days)

glipizide tab sr 24hr 10 mg 1 $0 QL (60 tabs / 30 days)

glipizide-metformin hcl tab 2.5-250 mg

1 $0 QL (240 tabs / 30 days)

glipizide-metformin hcl tab 2.5-500 mg

1 $0 QL (120 tabs / 30 days)

glipizide-metformin hcl tab 5-500 mg

1 $0 QL (120 tabs / 30 days)

INVOKAMET TAB 50-500MG 2 $0 QL (120 tabs / 30 days)

INVOKAMET TAB 50-1000 2 $0 QL (60 tabs / 30 days)



INVOKANA TAB 100MG 2 $0 QL (90 tabs / 30 days)

INVOKANA TAB 300MG 2 $0 QL (30 tabs / 30 days)

JANUMET TAB 50-500MG 2 $0 QL (60 tabs / 30 days)

JANUMET TAB 50-1000 2 $0 QL (60 tabs / 30 days)

JANUMET XR TAB 50-500MG 2 $0 QL (60 tabs / 30 days)

JANUMET XR TAB 50-1000 2 $0 QL (60 tabs / 30 days)

JANUMET XR TAB 100-1000 2 $0 QL (30 tabs / 30 days)

JANUVIA TAB 25MG 2 $0 QL (30 tabs / 30 days)



JENTADUETO TAB 2.5-500 2 $0 QL (60 tabs / 30 days)



metformin hcl tab 500 mg 1 $0 QL (150 tabs / 30 days)



metformin hcl tab sr 24hr 500 mg 1 $0 QL (120 tabs / 30 days)

metformin hcl tab sr 24hr 750 mg 1 $0 QL (60 tabs / 30 days)

nateglinide tab 60 mg 1 $0 QL (90 tabs / 30 days)

nateglinide tab 120 mg 1 $0 QL (90 tabs / 30 days)


77

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

pioglitazone hcl tab 15 mg (base

equiv)

1 $0 QL (30 tabs / 30 days)


equiv)

1 $0 QL (30 tabs / 30 days)


equiv)

1 $0 QL (30 tabs / 30 days)

repaglinide tab 0.5 mg 1 $0 QL (120 tabs / 30 days)

repaglinide tab 1 mg 1 $0 QL (120 tabs / 30 days)

repaglinide tab 2 mg 1 $0 QL (240 tabs / 30 days)

RIOMET SOL 2 $0 QL (946 mL / 30 days)

TRADJENTA TAB 5MG 2 $0 QL (30 tabs / 30 days)

BISPHOSPHONATES - DRUGS TO TREAT BONE LOSS alendronate sodium tab 5 mg 1 $0

alendronate sodium tab 10 mg 1 $0

alendronate sodium tab 35 mg 1 $0 QL (4 tabs / 28 days)

alendronate sodium tab 40 mg 1 $0

alendronate sodium tab 70 mg 1 $0 QL (4 tabs / 28 days)

ibandronate sodium tab 150 mg

(base equivalent)

1 $0 B/D, QL (1 tab / 30

days)

pamidronate disodium iv soln 3

mg/ml

1 $0 B/D

pamidronate disodium iv soln 9

mg/ml

1 $0 B/D

pamidronate inj 6mg/ml 1 $0 B/D

zoledronic acid inj conc for iv

infusion 4 mg/5ml

2 $0 B/D, NM

ZOMETA INJ 4MG/100 2 $0 B/D, NM

CALCIUM RECEPTOR AGONISTS SENSIPAR TAB 30MG 2 $0 QL (120 tabs / 30 days),

NM

SENSIPAR TAB 60MG 2 $0 QL (60 tabs / 30 days), NM

SENSIPAR TAB 90MG 2 $0 QL (120 tabs / 30 days), NM

CHELATING AGENTS CHEMET CAP 100MG 2 $0

DEPEN TITRA TAB 250MG 2 $0

EXJADE TAB 125MG 2 $0 NM, LA, PA



kionex pow 1 $0


78

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

kionex sus 15gm/60 1 $0

sodium polystyrene sulfonate oral

susp 15 gm/60ml

1 $0

sps sus 15gm/60 1 $0

SYPRINE CAP 250MG 2 $0

CONTRACEPTIVES - DRUGS FOR BIRTH CONTROL altavera tab 1 $0

apri tab 1 $0

aranelle tab 1 $0

aubra tab 0.1-0.02 1 $0

aviane tab 1 $0

balziva tab 1 $0

briellyn tab 1 $0

camila tab 0.35mg 1 $0

cryselle-28 tab 28 tabs 1 $0

cyclafem tab 1/35 1 $0

cyclafem tab 7/7/7 1 $0

deblitane tab 0.35mg 1 $0

delyla tab 0.1-0.02 1 $0

desogest-eth estrad & eth estrad

tab 0.15-0.02/0.01 mg(21/5)

1 $0

drospirenone-ethinyl estradiol tab

3-0.02 mg

1 $0

DROSPIRENONE-ETHINYL

ESTRADIOL TAB 3-0.02 MG

1 $0

drospirenone-ethinyl estradiol tab

3-0.03 mg

1 $0

DROSPIRENONE-ETHINYL

ESTRADIOL TAB 3-0.03 MG

1 $0

ELLA TAB 30MG 2 $0

emoquette tab 1 $0

enpresse-28 tab 1 $0

errin tab 0.35mg 1 $0

falmina tab 1 $0

gildagia tab 0.4-35 1 $0

gildess tab 1.5/30 1 $0

heather tab 0.35mg 1 $0

introvale tab 1 $0

JOLIVETTE TAB 0.35MG 1 $0

junel 1.5/30 tab 1 $0

junel 1/20 tab 1 $0


79

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

junel fe tab 1.5/30 1 $0

junel fe tab 1/20 1 $0

kariva tab 28 day 1 $0

larin fe tab 1.5/30 1 $0

larin fe tab 1/20 1 $0

larin tab 1.5/30 1 $0

larin tab 1/20 1 $0

lessina tab 1 $0

levonest tab 1 $0

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

1 $0

LEVONORGESTREL & ETHINYL ESTRADIOL (91-DAY) TAB 0.15-0.03 MG

1 $0

levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg

1 $0

levonorgestrel tab 0.75 mg 1 $0

levonorgestrel tab 1.5 mg 1 $0

levora-28 tab 0.15/30 1 $0

loryna tab 3-0.02mg 1 $0

low-ogestrel tab 1 $0

lutera tab 1 $0

lyza tab 0.35mg 1 $0

marlissa tab 0.15/30 1 $0

medroxyprogesterone acetate im

susp 150 mg/ml

1 $0

microgestin tab 1.5/30 1 $0

microgestin tab 1/20 1 $0

microgestin tab fe1.5/30 1 $0

microgestin tab fe 1/20 1 $0

MONONESSA TAB 1 $0

my way tab 1.5mg 1 $0

my way tab 1.5mg 3 $0 NM; *

myzilra tab 1 $0

necon tab 0.5/35 1 $0

necon tab 1/35 1 $0

NECON TAB 1/50-28 1 $0

NECON TAB 7/7/7 1 $0

necon tab 10/11-28 2 $0

next choice tab 1.5mg 1 $0

nikki tab 3-0.02mg 1 $0


80

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

norelgestromin-ethinyl estradiol td

ptwk 150-35 mcg/24hr

1 $0

norethindrone ace & ethinyl

estradiol-fe tab 1 mg-20 mcg

1 $0

norethindrone tab 0.35 mg 1 $0

NORETHINDRONE TAB 0.35 MG 1 $0

NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1-35/0.5-35 MG-MCG

1 $0

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

1 $0

norlyroc tab 0.35mg 1 $0

nortrel tab 0.5/35 1 $0

nortrel tab 1/35 1 $0

nortrel tab 7/7/7 1 $0

NUVARING MIS 2 $0

orsythia tab 1 $0

philith tab 0.4-35 1 $0

pimtrea tab 1 $0

pirmella tab 1/35 1 $0

portia-28 tab 1 $0

previfem tab 1 $0

quasense tab 1 $0

reclipsen tab 1 $0

sharobel tab 0.35mg 1 $0

SOLIA TAB 1 $0

sprintec 28 tab 28 day 1 $0

syeda tab 3-0.03mg 1 $0

tri-legest tab fe 1 $0

tri-previfem tab 1 $0

tri-sprintec tab 1 $0

TRINESSA TAB 1 $0

trivora-28 tab 1 $0

velivet pak 1 $0

viorele tab 1 $0

vyfemla tab 0.4-35 1 $0

zarah tab 3-0.03mg 1 $0

zenchent tab 1 $0

ENDOMETRIOSIS danazol cap 50 mg 1 $0

danazol cap 100 mg 1 $0


81

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

danazol cap 200 mg 1 $0

SYNAREL SOL 2MG/ML 2 $0

ENZYME REPLACEMENTS - DRUGS TO TREAT ENZYME DEFICIENCIES ADAGEN INJ 250/ML 2 $0 NM, LA, PA

ALDURAZYME INJ 2.9MG/5M 2 $0 NM, LA, PA

CARBAGLU TAB 200MG 2 $0 NM, LA, PA

CERDELGA CAP 84MG 2 $0 NM, PA

CEREZYME INJ 200UNIT 2 $0 NM, PA

CEREZYME INJ 400UNIT 2 $0 NM, PA

CYSTADANE POW 2 $0 NM

CYSTAGON CAP 50MG 2 $0 NM, PA

CYSTAGON CAP 150MG 2 $0 NM, PA

FABRAZYME INJ 5MG 2 $0 NM, PA

FABRAZYME INJ 35MG 2 $0 NM, PA

KUVAN POW 100MG 2 $0 NM, PA

KUVAN POW 500MG 2 $0 NM, PA

KUVAN TAB 100MG 2 $0 NM, PA

levocarnitine inj 200 mg/ml 1 $0 B/D

levocarnitine oral soln 1 gm/10ml

(10%)

1 $0 B/D

levocarnitine tab 330 mg 1 $0 B/D

LUMIZYME INJ 50MG 2 $0 NM, PA

MYOZYME INJ 50MG 2 $0 NM, PA

NAGLAZYME INJ 1MG/ML 2 $0 NM, LA, PA

ORFADIN CAP 2MG 2 $0 NM, PA



sodium phenylbutyrate oral powder 3 gm/teaspoonful

2 $0 NM

ZAVESCA CAP 100MG 2 $0 NM, LA, PA

ESTROGENS - DRUGS TO REGULATE FEMALE HORMONES COMBIPATCH DIS .05/.14 2 $0 PA

COMBIPATCH DIS .05/.25 2 $0 PA

estradiol tab 0.5 mg 2 $0 PA

estradiol tab 1 mg 2 $0 PA

estradiol tab 2 mg 2 $0 PA

estradiol td patch weekly 0.1 mg/24hr

2 $0 PA

estradiol td patch weekly 0.05 mg/24hr

2 $0 PA


82

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

estradiol td patch weekly 0.06

mg/24hr

2 $0 PA


mg/24hr

2 $0 PA


mg/24hr

2 $0 PA


mg/24hr (37.5 mcg/24hr)

2 $0 PA

ESTRADIOL VALERATE IM IN OIL 10

MG/ML

1 $0

estradiol valerate im in oil 20 mg/ml 1 $0

ESTRADIOL VALERATE IM IN OIL 40

MG/ML

1 $0

PREMARIN VAG CRE 0.625MG 2 $0

VAGIFEM TAB 10MCG 2 $0

GLUCOCORTICOIDS - DRUGS TO TREAT INFLAMMATORY RESPONSE a-hydrocort inj 100mg 1 $0

cortisone acetate tab 25 mg 1 $0

dexamethason con 1mg/ml 1 $0

dexamethasone elixir 0.5 mg/5ml 1 $0

dexamethasone sod phosphate preservative free inj 10 mg/ml

1 $0

dexamethasone sodium phosphate inj 10 mg/ml

1 $0

dexamethasone sodium phosphate inj 20 mg/5ml

1 $0


1 $0


1 $0

dexamethasone soln 0.5 mg/5ml 1 $0

dexamethasone tab 0.5 mg 1 $0


dexamethasone tab 1 mg 1 $0





fludrocortisone acetate tab 0.1 mg 1 $0

hydrocortisone tab 5 mg 1 $0




83

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

methylprednisolone acetate inj susp

40 mg/ml

1 $0 B/D

methylprednisolone acetate inj susp

80 mg/ml

1 $0 B/D

methylprednisolone sodium

succinate for inj 40 mg

1 $0 B/D



1 $0 B/D



1 $0 B/D

methylprednisolone tab 4 mg 1 $0 B/D

methylprednisolone tab 4 mg dose

pack

1 $0 B/D




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

1 $0 B/D

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

1 $0 B/D

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

1 $0 B/D

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

1 $0 B/D

prednisone con 5mg/ml 2 $0 B/D

prednisone oral soln 5 mg/5ml 1 $0 B/D

prednisone tab 1 mg 1 $0 B/D

prednisone tab 2.5 mg 1 $0 B/D


prednisone tab 5 mg dose pack 1 $0 B/D


prednisone tab 10 mg dose pack 1 $0 B/D



SOLU-CORTEF INJ 250MG 2 $0

GLUCOSE ELEVATING AGENTS - DRUGS TO TREAT LOW BLOOD

SUGAR GLUCAGEN INJ HYPOKIT 2 $0

GLUCAGON KIT 1MG 2 $0

PROGLYCEM SUS 50MG/ML 2 $0


84

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

HUMAN GROWTH HORMONES - DRUGS TO REGULATE PITUITARY

HORMONES NORDITROPIN INJ 5/1.5ML 2 $0 NM, PA

NORDITROPIN INJ 10/1.5ML 2 $0 NM, PA

NORDITROPIN INJ 15/1.5ML 2 $0 NM, PA

NORDITROPIN INJ 30/3ML 2 $0 NM, PA

TEV-TROPIN INJ 5MG 2 $0 NM, PA

MISCELLANEOUS cabergoline tab 0.5 mg 1 $0

calcitonin (salmon) nasal soln 200 unit/act

1 $0

FORTICAL SPR 200/ACT 2 $0

INCRELEX INJ 40MG/4ML 2 $0 NM, LA, PA

methylergonovine maleate tab 0.2 mg

1 $0

MIACALCIN INJ 200/ML 2 $0 B/D

octreotide acetate inj 50 mcg/ml (0.05 mg/ml)

1 $0 NM, PA


1 $0 NM, PA


1 $0 NM, PA


2 $0 NM, PA

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

2 $0 NM, PA

PROLIA SOL 60MG/ML 2 $0 QL (1 syringe / 180 days), NM

raloxifene hcl tab 60 mg 1 $0

SANDOSTATIN KIT LAR 10MG 2 $0 NM, PA



SOMATULINE INJ 60/0.2ML 2 $0 NM, PA

SOMATULINE INJ 90/0.3ML 2 $0 NM, PA

SOMATULINE INJ 120/.5ML 2 $0 NM, PA

SOMAVERT INJ 10MG 2 $0 NM, LA, PA





XGEVA INJ 2 $0 NM, PA


85

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

PARATHYROID HORMONES - DRUGS TO REGULATE PARATHYROID

LEVELS FORTEO SOL 600/2.4 2 $0 QL (1 pen / 28 days),

NM, PA

PHOSPHATE BINDER AGENTS - DRUGS TO REGULATE CALCIUM AND

PHOSPHORUS LEVELS calcium acetate (phosphate binder)

cap 667 mg (169 mg ca) 1 $0

FOSRENOL CHW 500MG 2 $0



PHOSLYRA SOL 2 $0

RENVELA PAK 0.8GM 2 $0

RENVELA PAK 2.4GM 2 $0

RENVELA TAB 800MG 2 $0

PROGESTINS - DRUGS TO REGULATE FEMALE HORMONES medroxyprogesterone acetate tab

2.5 mg 1 $0

medroxyprogesterone acetate tab 5

mg

1 $0

medroxyprogesterone acetate tab

10 mg

1 $0

norethindrone acetate tab 5 mg 1 $0

THYROID AGENTS - DRUGS TO REGULATE THYROID LEVELS levothyroxine sodium tab 25 mcg 1 $0

levothyroxine sodium tab 50 mcg 1 $0











LEVOXYL TAB 25MCG 1 $0






86

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE







liothyronine sodium tab 5 mcg 1 $0



methimazole tab 5 mg 1 $0

methimazole tab 10 mg 1 $0

propylthiouracil tab 50 mg 1 $0

SYNTHROID TAB 25MCG 2 $0












UNITHROID TAB 25MCG 1 $0











VASOPRESSINS - DRUGS TO REGULATE PITUITARY HORMONES desmopressin acetate inj 4 mcg/ml 1 $0

DESMOPRESSIN ACETATE NASAL

SOLN 0.01% (REFRIGERATED)

1 $0

desmopressin acetate nasal spray

soln 0.01%

1 $0


87

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

desmopressin acetate nasal spray

soln 0.01% (refrigerated)

1 $0

desmopressin acetate tab 0.1 mg 1 $0

desmopressin acetate tab 0.2 mg 1 $0

GASTROINTESTINAL - DRUGS TO TREAT STOMACH AND INTESTINAL

DISORDERS ANTACIDS acid gone chw 3 $0 NM; *

acid gone sus 3 $0 NM; *

ALUM HYDROX SUS 320/5ML 3 $0 NM; *

aluminum hydroxide gel susp 600

mg/5ml

3 $0 NM; *

ant/anti-gas chw 1000-60 3 $0 NM; *

antacid sus max st 3 $0 NM; *

cal antacid chw 1000mg 3 $0 NM; *

calc antacid chw 500mg 3 $0 NM; *

calc antacid chw 750mg 3 $0 NM; *

CALCIUM CARB TAB 648MG 3 $0 NM; *

fast dissolv chw antacid 3 $0 NM; *

foam antacid chw 80-20mg 3 $0 NM; *

GAVISCON CHW 3 $0 NM; *

GAVISCON SUS 3 $0 NM; *

maalox child chw 3 $0 NM; *

maalox multi sus symp max 3 $0 NM; *

maalox sus reg st 3 $0 NM; *

MAALOX TC SUS 3 $0 NM; *

MAG OXIDE CAP 400MG 3 $0 NM; *

MAG-AL LIQ 3 $0 NM; *

magnesium oxide tab 250 mg 3 $0 NM; *



mi-acid chw 3 $0 NM; *

mintox plus chw 3 $0 NM; *

ri-mox plus sus 3 $0 NM; *

sodium bicarbonate tab 325 mg 3 $0 NM; *

sodium bicarbonate tab 650 mg 3 $0 NM; *

SODIUM POW BICARBON 3 $0 NM; *

titralac chw 420mg 3 $0 NM; *

URO-MAG CAP 140MG 3 $0 NM; *

ANTI-DIARRHEAL anti-diarrhe liq 1mg/5ml 3 $0 NM; *


88

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

anti-diarrhe tab 2mg 3 $0 NM; *

diges probio cap 250mg 3 $0 NM; *

floranex gra 3 $0 NM; *

FLORASTOR PAK KIDS 3 $0 NM; *

kaopectate sus 262/15ml 3 $0 NM; *

lactobacillus tab 3 $0 NM; *

loperamide hcl liq 1 mg/7.5ml 3 $0 NM; *

peptic relf chw 262mg 3 $0 NM; *

probiotic cap 3 $0 NM; *

PROBIOTIC CAP FORMULA 3 $0 NM; *

RISA-BID TAB PROBIO 3 $0 NM; *

soothe tab 262mg 3 $0 NM; *

stomach relf sus 525/15ml 3 $0 NM; *

ANTIEMETICS - DRUGS FOR NAUSEA AND VOMITING compro sup 25mg 1 $0

dramamine tab 25mg 3 $0 NM; *

dronabinol cap 2.5 mg 1 $0 B/D, QL (60 caps / 30

days)

dronabinol cap 5 mg 1 $0 B/D, QL (60 caps / 30

days)

dronabinol cap 10 mg 2 $0 B/D, QL (60 caps / 30

days)

EMEND CAP 40MG 1 $0 B/D



EMEND PAK 80 & 125 2 $0 B/D

granisetron hcl inj 0.1 mg/ml 1 $0

granisetron hcl inj 1 mg/ml 1 $0

granisetron hcl inj 4 mg/4ml (1 mg/ml)

1 $0

granisetron hcl tab 1 mg 1 $0 B/D

meclizine hcl tab 12.5 mg 1 $0

meclizine hcl tab 25 mg 1 $0

metoclopramide hcl inj 5 mg/ml 1 $0

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

1 $0

metoclopramide hcl tab 5 mg 1 $0

metoclopramide hcl tab 10 mg 1 $0

motion sick chw 25mg 3 $0 NM; *

motion sick tab 50mg 3 $0 NM; *


89

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

ondansetron hcl inj 4 mg/2ml (2

mg/ml)

1 $0

ondansetron hcl inj 40 mg/20ml (2

mg/ml)

1 $0

ondansetron hcl oral soln 4 mg/5ml 1 $0 B/D

ondansetron hcl tab 4 mg 1 $0 B/D



ondansetron orally disintegrating tab 4 mg

1 $0 B/D

ondansetron orally disintegrating tab 8 mg

1 $0 B/D

prochlorperazine edisylate inj 5 mg/ml

1 $0

prochlorperazine maleate tab 5 mg (base equivalent)

1 $0

prochlorperazine maleate tab 10 mg (base equivalent)

1 $0

prochlorperazine suppos 25 mg 1 $0

promethazine hcl inj 25 mg/ml 2 $0 PA

promethazine hcl inj 50 mg/ml 2 $0 PA

TRANSDERM-SC DIS 1MG 2 $0 QL (10 patches / 30

days), PA

vertin-32 tab 3 $0 NM; *

ANTISPASMODICS - DRUGS FOR STOMACH SPASMS CUVPOSA SOL 1MG/5ML 2 $0

dicyclomine hcl cap 10 mg 1 $0

dicyclomine hcl oral soln 10 mg/5ml 1 $0

dicyclomine hcl tab 20 mg 1 $0

glycopyrrolate inj 4 mg/20ml (0.2

mg/ml)

1 $0

glycopyrrolate tab 1 mg 1 $0

glycopyrrolate tab 2 mg 1 $0

H2-RECEPTOR ANTAGONISTS - DRUGS FOR ULCERS AND STOMACH

ACID acid reducer tab 10mg 3 $0 NM; *

acid reducer tab 150mg 3 $0 NM; *

AXID AR TAB 75MG 3 $0 NM; *

cimetidine tab 200 mg 3 $0 NM; *

famotidine for susp 40 mg/5ml 1 $0

famotidine in nacl 0.9% iv soln 20

mg/50ml

1 $0


90

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

famotidine inj 20 mg/2ml 1 $0



famotidine tab 20 mg 1 $0

famotidine tab 20mg 3 $0 NM; *

famotidine tab 40 mg 1 $0

PEPCID AC CHW 10MG 3 $0 NM; *

ranitidine hcl inj 50 mg/2ml (25

mg/ml)

1 $0

ranitidine hcl inj 150 mg/6ml (25

mg/ml)

1 $0

ranitidine hcl syrup 15 mg/ml (75

mg/5ml)

1 $0

ranitidine hcl tab 75 mg 3 $0 NM; *

ranitidine hcl tab 150 mg 1 $0

ranitidine hcl tab 300 mg 1 $0

ranitidine tab 75mg 3 $0 NM; *

INFLAMMATORY BOWEL DISEASE APRISO CAP 0.375GM 2 $0

ASACOL HD TAB 800MG 2 $0

balsalazide disodium cap 750 mg 1 $0

budesonide cap sr 24hr 3 mg 2 $0

CANASA SUP 1000MG 2 $0

DELZICOL CAP 400MG 2 $0

DIPENTUM CAP 250MG 2 $0

hydrocortisone enema 100 mg/60ml

1 $0

HYDROCORTISONE ENEMA 100 MG/60ML

1 $0

LIALDA TAB 1.2GM 2 $0

mesalamine enema 4 gm 1 $0

mesalamine rectal enema 4 gm & cleanser wipe kit

1 $0

PENTASA CAP 250MG CR 2 $0

PENTASA CAP 500MG CR 2 $0

sulfasalazine tab 500 mg 1 $0

sulfazine ec tab 500mg 1 $0

UCERIS TAB 9MG 2 $0

LAXATIVES ALOE VERA LIQ JUICE DR 3 $0 NM; *

BENEFIBER CHW 3 $0 NM; *


91

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

BENEFIBER POW 3 $0 NM; *

bisacodyl tab & peg 3350-kcl-sod

bicarb-nacl for soln kit

1 $0

BLK DRAUGHT CHW 10MG 3 $0 NM; *

BLK DRAUGHT SYP 90/15ML 3 $0 NM; *

constulose sol 10gm/15 1 $0

corn dextrin oral powder 3 $0 NM; *

cvs fiber chw gummies 3 $0 NM; *

d.o.s. cap 250mg 3 $0 NM; *

docusate sodium liquid 150

mg/15ml

3 $0 NM; *

dok tab 100mg 3 $0 NM; *

DULCOLAX KIT BOWEL 3 $0 NM; *

easy fiber/ chw calcium 3 $0 NM; *

enemeez mini ene 3 $0 NM; *

enemeez plus ene 20-283 3 $0 NM; *

enulose sol 10gm/15 1 $0

epsom salt gra 3 $0 NM; *

EQL NATURAL POW FIBER 3 $0 NM; *

EQUALACTIN CHW 625MG 3 $0 NM; *

ex-lax ultra tab 5mg ec 3 $0 NM; *

FIBER CHW 3 $0 NM; *

fiber laxatv tab 625mg 3 $0 NM; *

fiber oral powder 3 $0 NM; *

FIBER POW 3 $0 NM; *

FLEET BISACO ENE 10/30ML 3 $0 NM; *

gavilyte-c sol 1 $0

gavilyte-g sol 1 $0

gavilyte-n sol flav pk 1 $0

generlac sol 10gm/15 1 $0

gentle laxat sup 10mg 3 $0 NM; *

GOLYTELY SOL 2 $0

HYDROCIL INS POW 95% 3 $0 NM; *

konsyl cap 520mg 3 $0 NM; *

konsyl pow 28.3% 3 $0 NM; *

KONSYL POW 28.3% 3 $0 NM; *

konsyl pow 30.9% 3 $0 NM; *

KONSYL POW 60.3% 3 $0 NM; *

KONSYL POW 71.67% 3 $0 NM; *

KONSYL POW 100% 3 $0 NM; *

KONSYL-D POW 52.3% 3 $0 NM; *


92

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

lactulose (encephalopathy) solution

10 gm/15ml

1 $0

lactulose solution 10 gm/15ml 1 $0

lax diet sup tab 500mg 3 $0 NM; *

laxative chw 15mg 3 $0 NM; *

magnesium citrate soln 3 $0 NM; *

METAMUCIL POW 28% 3 $0 NM; *

METAMUCIL POW 63% 3 $0 NM; *

METAMUCIL WAF 3 $0 NM; *

MILK OF MAGN SUS 800/5ML 3 $0 NM; *

MILK OF MAGN SUS 2400MG 3 $0 NM; *

milk of magn sus frsh mnt 3 $0 NM; *

MINERAL OIL 3 $0 NM; *

mineral oil enema 3 $0 NM; *

MOVIPREP SOL 2 $0

nat fiber pow therapy 3 $0 NM; *

naturl fiber pow 68% 3 $0 NM; *

NULYTELY SOL FLAV PKS 2 $0

NUTRISOURCE PAK FIBER 3 $0 NM; *

oral saline sol laxative 3 $0 NM; *

PEDIA-LAX LIQ 50MG 3 $0 NM; *

peg 3350-kcl-na bicarb-nacl-na

sulfate for soln 236 gm

1 $0

PEG 3350-KCL-NA

BICARB-NACL-NA SULFATE FOR SOLN 240 GM

1 $0

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

1 $0

perdiem over tab 15mg 3 $0 NM; *

polyethylene glycol 3350 oral packet

1 $0

polyethylene glycol 3350 oral powder

1 $0

psyldex pow 30% 3 $0 NM; *

psyllium powder 100% 3 $0 NM; *

qc natural pow vegetabl 3 $0 NM; *

ra col-rite cap 50mg 3 $0 NM; *

ra fiber tab 500mg 3 $0 NM; *

reguloid pow 48.57% 3 $0 NM; *

reguloid pow 58.6% 3 $0 NM; *

RELISTOR INJ 8/0.4ML 2 $0 PA

RELISTOR INJ 12/0.6ML 2 $0 PA


93

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

RELISTOR KIT 12/0.6ML 2 $0 PA

sb fib lax pow 33% 3 $0 NM; *

SB NAT FIBER POW 49% 3 $0 NM; *

sen-o-tabs tab 187mg 3 $0 NM; *

SENNA PROMPT CAP 9-500MG 3 $0 NM; *

SENNA SYP 3 $0 NM; *

SENNA TAB 8.6MG 3 $0 NM; *

senna tab 25mg 3 $0 NM; *

senna-extra tab 17.2mg 3 $0 NM; *

sennosides cap 8.6 mg 3 $0 NM; *

sennosides syrup 8.8 mg/5ml 3 $0 NM; *

sennosides tab 8.6 mg 3 $0 NM; *

sennosides-docusate sodium tab

8.6-50 mg

3 $0 NM; *

sodium phosphates - enema 3 $0 NM; *

soluble fib pow therapy 3 $0 NM; *

sorbulax pow 100% 3 $0 NM; *

stool softnr cap 50mg 3 $0 NM; *



stool softnr syp 60/15ml 3 $0 NM; *

stool softnr tab 8.6-50mg 3 $0 NM; *

SUPREP BOWEL SOL PREP 2 $0

total fiber pow 3 $0 NM; *

trilyte sol 1 $0

MISCELLANEOUS alosetron hcl tab 0.5 mg (base

equiv)

2 $0 PA

alosetron hcl tab 1 mg (base equiv) 2 $0 PA

AMITIZA CAP 8MCG 2 $0 QL (60 caps / 30 days)

AMITIZA CAP 24MCG 2 $0 QL (60 caps / 30 days)

cromolyn sodium oral conc 100 mg/5ml

2 $0

diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml

1 $0

diphenoxylate w/ atropine tab 2.5-0.025 mg

1 $0

LINZESS CAP 145MCG 2 $0 QL (60 caps / 30 days)

LINZESS CAP 290MCG 2 $0 QL (30 caps / 30 days)

loperamide hcl cap 2 mg 1 $0

LOTRONEX TAB 0.5MG 2 $0 PA


94

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

LOTRONEX TAB 1MG 2 $0 PA

misoprostol tab 100 mcg 1 $0

misoprostol tab 200 mcg 1 $0

MOVANTIK TAB 12.5MG 2 $0 QL (60 tabs / 30 days)

MOVANTIK TAB 25MG 2 $0 QL (30 tabs / 30 days)

SUCRAID SOL 8500/ML 2 $0

sucralfate tab 1 gm 1 $0

ursodiol cap 300 mg 1 $0

ursodiol tab 250 mg 1 $0

ursodiol tab 500 mg 1 $0

XIFAXAN TAB 550MG 2 $0 PA

PANCREATIC ENZYMES CREON CAP 3000UNIT 2 $0

CREON CAP 6000UNIT 2 $0

CREON CAP 12000UNT 2 $0



ZENPEP CAP 3000UNIT 2 $0

ZENPEP CAP 5000UNIT 2 $0

ZENPEP CAP 10000UNT 2 $0





PROTON PUMP INHIBITORS - DRUGS FOR ULCERS AND STOMACH

ACID DEXILANT CAP 30MG DR 2 $0 QL (30 caps / 30 days)

DEXILANT CAP 60MG DR 2 $0 QL (30 caps / 30 days)

dual action chw complete 3 $0 NM; *

esomeprazole sodium for intravenous soln 20 mg (base

equiv)

1 $0

esomeprazole sodium for intravenous soln 40 mg (base

equiv)

1 $0

lansoprazole cap 15mg dr 3 $0 NM; *

NEXIUM CAP 20MG 2 $0 QL (30 caps / 30 days)

NEXIUM CAP 40MG 2 $0 QL (30 caps / 30 days)

NEXIUM GRA 2.5MG DR 2 $0

NEXIUM GRA 5MG DR 2 $0


95

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

NEXIUM GRA 10MG DR 2 $0 QL (30 packets / 30

days)


days)


days)

omeprazole cap 20.6mgdr 3 $0 NM; *

omeprazole cap delayed release 10

mg

1 $0 QL (30 caps / 30 days)


mg

1 $0 QL (60 caps / 30 days)


mg

1 $0 QL (30 caps / 30 days)

OMEPRAZOLE TAB 20MG 3 $0 NM; *

omeprazole-sodium bicarbonate

cap 20-1100 mg

3 $0 NM; *

pantoprazole sodium ec tab 20 mg

(base equiv)

1 $0 QL (30 tabs / 30 days)

pantoprazole sodium ec tab 40 mg

(base equiv)

1 $0 QL (30 tabs / 30 days)

PRILOSEC OTC TAB 20MG 3 $0 NM; *

GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACT

CONDITIONS BENIGN PROSTATIC HYPERPLASIA - DRUGS TO TREAT ENLARGED

PROSTATE alfuzosin hcl tab sr 24hr 10 mg 1 $0 QL (30 tabs / 30 days)

AVODART CAP 0.5MG 2 $0 QL (30 caps / 30 days)

finasteride tab 5 mg 1 $0

JALYN CAP 2 $0 QL (30 caps / 30 days)

tamsulosin hcl cap 0.4 mg 1 $0 QL (60 caps / 30 days)

MISCELLANEOUS bethanechol chloride tab 5 mg 1 $0

bethanechol chloride tab 10 mg 1 $0



ELMIRON CAP 100MG 2 $0

POTASSIUM CITRATE TAB CR 5

MEQ (540 MG)

1 $0

POTASSIUM CITRATE TAB CR 10

MEQ (1080 MG)

1 $0


96

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

URINARY ANTISPASMODICS - DRUGS TO TREAT URINARY

INCONTINENCE MYRBETRIQ TAB 25MG 2 $0 QL (60 tabs / 30 days)

MYRBETRIQ TAB 50MG 2 $0 QL (30 tabs / 30 days)

oxybutynin chloride syrup 5 mg/5ml 1 $0

oxybutynin chloride tab 5 mg 1 $0

oxybutynin chloride tab sr 24hr 5 mg

1 $0 QL (30 tabs / 30 days)


1 $0 QL (60 tabs / 30 days)


1 $0 QL (60 tabs / 30 days)

TOLTERODINE TARTRATE CAP SR 24HR 2 MG

1 $0 QL (30 caps / 30 days)

TOLTERODINE TARTRATE CAP SR 24HR 4 MG

1 $0 QL (30 caps / 30 days)

tolterodine tartrate tab 1 mg 1 $0

tolterodine tartrate tab 2 mg 1 $0

TOVIAZ TAB 4MG 2 $0 QL (30 tabs / 30 days)

TOVIAZ TAB 8MG 2 $0 QL (30 tabs / 30 days)

trospium chloride tab 20 mg 1 $0 QL (60 tabs / 30 days)

VESICARE TAB 5MG 2 $0 QL (30 tabs / 30 days)

VESICARE TAB 10MG 2 $0 QL (30 tabs / 30 days)

VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal

cream 2%

1 $0

clotrimazole cre 2% 3 $0 NM; *

clotrimazole vaginal cream 1% 3 $0 NM; *

3 day vagnal cre 4% 3 $0 NM; *

metronidazole vaginal gel 0.75% 1 $0

miconazole 3 cre 4% 3 $0 NM; *

miconazole 3 kit combinat 3 $0 NM; *

miconazole 3 kit combo pk 3 $0 NM; *

miconazole 7 cre tube/kit 3 $0 NM; *

miconazole 7 sup 100mg 3 $0 NM; *

miconazole nitrate vaginal supp 1200 mg & 2% cream kit

3 $0 NM; *

povidone/iod sol 10% 3 $0 NM; *

summers eve sol 0.3% 3 $0 NM; *

terconazole vaginal cream 0.4% 1 $0

terconazole vaginal cream 0.8% 1 $0


97

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

terconazole vaginal suppos 80 mg 1 $0

tioconazole oin 6.5% vag 3 $0 NM; *

vagistat-3 kit combo pk 3 $0 NM; *

VANDAZOLE GEL 0.75% 1 $0

zazole cre 0.4% 1 $0

ZAZOLE CRE 0.8% 1 $0

HEMATOLOGIC - DRUGS TO TREAT BLOOD DISORDERS ANTICOAGULANTS - BLOOD THINNERS COUMADIN TAB 1MG 2 $0

COUMADIN TAB 2.5MG 2 $0

COUMADIN TAB 2MG 2 $0





COUMADIN TAB 7.5MG 2 $0


ELIQUIS TAB 2.5MG 2 $0

ELIQUIS TAB 5MG 2 $0

enoxaparin sodium inj 30 mg/0.3ml 1 $0




enoxaparin sodium inj 100 mg/ml 2 $0

enoxaparin sodium inj 120 mg/0.8ml

2 $0

enoxaparin sodium inj 150 mg/ml 2 $0

enoxaparin sodium inj 300 mg/3ml 1 $0

fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml

1 $0

fondaparinux sodium subcutaneous inj 5 mg/0.4ml

2 $0

fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml

2 $0

fondaparinux sodium subcutaneous inj 10 mg/0.8ml

2 $0

HEP SOD/D5W INJ 25000UNT 2 $0

HEP SOD/NACL INJ 25000UNT 2 $0

HEPARIN SOD INJ 2000/ML 2 $0 B/D

HEPARIN SOD INJ 2500/ML 2 $0 B/D


98

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

HEPARIN SODIUM (PORCINE) 40

UNIT/ML IN D5W

2 $0

heparin sodium (porcine) inj 1000

unit/ml

1 $0 B/D


unit/ml

1 $0 B/D


unit/ml

1 $0 B/D


unit/ml

1 $0 B/D

jantoven tab 1mg 1 $0

jantoven tab 2.5mg 1 $0






jantoven tab 7.5mg 1 $0


PRADAXA CAP 75MG 2 $0

PRADAXA CAP 150MG 2 $0

warfarin sodium tab 1 mg 1 $0


warfarin sodium tab 2.5 mg 1 $0





warfarin sodium tab 7.5 mg 1 $0


XARELTO STAR TAB 15/20MG 2 $0

XARELTO TAB 10MG 2 $0



HEMATOPOIETIC GROWTH FACTORS GRANIX INJ 300/0.5 2 $0 NM, PA

GRANIX INJ 480/0.8 2 $0 NM, PA

LEUKINE INJ 250MCG 2 $0 NM, PA

MOZOBIL INJ 2 $0 NM, PA

NEUMEGA INJ 5MG 2 $0 NM

NEUPOGEN INJ 300/0.5 2 $0 NM, PA


99

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

NEUPOGEN INJ 300MCG 2 $0 NM, PA

NEUPOGEN INJ 480/0.8 2 $0 NM, PA

NEUPOGEN INJ 480MCG 2 $0 NM, PA

PROCRIT INJ 2000/ML 2 $0 NM, PA






IRON BIFERA TAB 28MG 3 $0 NM; *

DEXFERRUM INJ 50MG/ML 3 $0 NM; *

ezfe 200 cap 200mg 3 $0 NM; *

FEOSOL TAB 45MG 3 $0 NM; *

fer-iron dro 15mg/ml 3 $0 NM; *

FERRETTS IPS SOL 3 $0 NM; *

ferretts tab 325mg 3 $0 NM; *

FERRIMIN 150 TAB 3 $0 NM; *

FERROUS FUM TAB 29MG 3 $0 NM; *

FERROUS FUMA TAB 3 $0 NM; *

FERROUS GLUC TAB 225MG 3 $0 NM; *

ferrous gluc tab 324mg 3 $0 NM; *

FERROUS GLUC TAB 324MG 3 $0 NM; *

ferrous gluconate tab 240 mg (27

mg elemental fe)

3 $0 NM; *

ferrous gluconate tab 325 mg (36

mg elemental fe)

3 $0 NM; *

FERROUS SUL LIQ 220/5ML 3 $0 NM; *

FERROUS SULF SYP 300/5ML 3 $0 NM; *

FERROUS SULF TAB 140MG 3 $0 NM; *

FERROUS SULF TAB 324MG EC 3 $0 NM; *

ferrous sulf tab 325mg 3 $0 NM; *

ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe)

3 $0 NM; *

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

3 $0 NM; *

FOLGARD TAB 3 $0 NM; *

FOLITAB 500 TAB 3 $0 NM; *

foltabs 800 tab 3 $0 NM; *

gnp iron tab 45mg 3 $0 NM; *

INTEGRA CAP 3 $0 NM; *


100

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

iron 100 tab plus 3 $0 NM; *

iron 100/c tab 100-250 3 $0 NM; *

iron chews chw pediatri 3 $0 NM; *

IRON TAB 18MG 3 $0 NM; *

IRON TAB 18MG CR 3 $0 NM; *

iron tab 28mg 3 $0 NM; *

IRON TAB 28MG 3 $0 NM; *

iron therapy tab 200mg 3 $0 NM; *

IRON UP LIQ 3 $0 NM; *

MYKIDZ IRON SUS 15/1.5ML 3 $0 NM; *

NOVAFERRUM DRO 15MG/ML 3 $0 NM; *

NOVAFERRUM LIQ 125 3 $0 NM; *

nu-iron 150 cap 150mg 3 $0 NM; *

PROFE CAP 180MG 3 $0 NM; *

ra iron tab 27mg 3 $0 NM; *

slow iron tab 50mg 3 $0 NM; *

SLOW REL FE TAB 140MG CR 3 $0 NM; *

SLOW REL FE TAB 143MG CR 3 $0 NM; *

slow release tab 45mg 3 $0 NM; *

slow release tab 47.5mg 3 $0 NM; *

SLOW RELEASE TAB 143MG 3 $0 NM; *

sm iron slow tab 160mg cr 3 $0 NM; *

VIT B12/FA TAB 3 $0 NM; *

wee care sus 15/1.25 3 $0 NM; *

MISCELLANEOUS anagrelide hcl cap 0.5 mg 1 $0

anagrelide hcl cap 1 mg 1 $0

cilostazol tab 50 mg 1 $0

cilostazol tab 100 mg 1 $0

CINRYZE SOL 500 UNIT 2 $0 NM, LA, PA

FIRAZYR INJ 30MG/3ML 2 $0 NM, PA

pentoxifylline tab cr 400 mg 1 $0

PROMACTA TAB 12.5MG 2 $0 QL (360 tabs / 30 days), NM, LA, PA

PROMACTA TAB 25MG 2 $0 QL (180 tabs / 30 days), NM, LA, PA



tranexamic acid inj 100 mg/ml 1 $0


101

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

tranexamic acid tab 650 mg 1 $0

PLATELET AGGREGATION INHIBITORS AGGRENOX CAP 25-200MG 2 $0

BRILINTA TAB 90MG 2 $0

clopidogrel bisulfate tab 75 mg

(base equiv)

1 $0 QL (30 tabs / 30 days)

EFFIENT TAB 5MG 2 $0

EFFIENT TAB 10MG 2 $0

ZONTIVITY TAB 2.08MG 2 $0

IMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THE

IMMUNE SYSTEM DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) - DRUGS

TO TREAT RHEUMATOID ARTHRITIS CIMZIA KIT 2 $0 NM, PA

CIMZIA KIT STARTER 2 $0 NM, PA

CIMZIA PREFL KIT 200MG/ML 2 $0 NM, PA

HUMIRA INJ 10MG/0.2 2 $0 NM, PA

HUMIRA INJ 40MG/0.8 1 $0 NM, PA

HUMIRA KIT 20MG/0.4 2 $0 NM, PA

HUMIRA PEN INJ 40MG/0.8 2 $0 NM, PA

HUMIRA PEN INJ CROHNS 2 $0 NM, PA

HUMIRA PEN INJ PSORIASI 2 $0 NM, PA

hydroxychloroquine sulfate tab 200 mg

1 $0

leflunomide tab 10 mg 1 $0

leflunomide tab 20 mg 1 $0

methotrexate sodium tab 2.5 mg (base equiv)

1 $0

REMICADE INJ 100MG 2 $0 NM, PA

IMMUNOGLOBULINS BIVIGAM INJ 10% 2 $0 NM, PA

CARIMUNE NF INJ 3GM 2 $0 NM, PA



FLEBOGAMMA INJ 5% 2 $0 NM, PA

FLEBOGAMMA INJ 10/200ML 2 $0 NM, PA

FLEBOGAMMA INJ 20/400ML 2 $0 NM, PA

FLEBOGAMMA INJ DIF 5% 2 $0 NM, PA

FLEBOGAMMA INJ DIF 10% 2 $0 NM, PA

GAMASTAN S/D INJ 2 $0 B/D, NM


102

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

GAMMAGARD INJ 1GM/10ML 2 $0 NM, PA

GAMMAGARD INJ 2.5GM/25 2 $0 NM, PA

GAMMAGARD INJ 5GM/50ML 2 $0 NM, PA

GAMMAGARD INJ 10GM/100 2 $0 NM, PA



GAMMAGARD SD INJ 2.5GM HU 2 $0 NM, PA

GAMMAGARD SD INJ 5GM HU 2 $0 NM, PA

GAMMAGARD SD INJ 10GM HU 2 $0 NM, PA

GAMMAKED INJ 1GM/10ML 2 $0 NM, PA

GAMMAKED INJ 2.5GM/25 2 $0 NM, PA

GAMMAKED INJ 5GM/50ML 2 $0 NM, PA

GAMMAKED INJ 10GM/100 2 $0 NM, PA

GAMMAKED INJ 20GM/200 2 $0 NM, PA

GAMMAPLEX INJ 2.5GM 2 $0 NM, PA

GAMMAPLEX INJ 5GM 2 $0 NM, PA

GAMMAPLEX INJ 10GM 2 $0 NM, PA

GAMUNEX-C INJ 1GM/10ML 2 $0 NM, PA

GAMUNEX-C INJ 2.5GM/25 2 $0 NM, PA

GAMUNEX-C INJ 5GM/50ML 2 $0 NM, PA

GAMUNEX-C INJ 10GM/100 2 $0 NM, PA

GAMUNEX-C INJ 20GM/200 2 $0 NM, PA

GAMUNEX-C INJ 40/400ML 2 $0 NM, PA

OCTAGAM INJ 1GM 2 $0 NM, PA

OCTAGAM INJ 2.5GM 2 $0 NM, PA

OCTAGAM INJ 2GM/20ML 2 $0 NM, PA




PRIVIGEN INJ 5 GRAMS 2 $0 NM, PA

PRIVIGEN INJ 10GRAMS 2 $0 NM, PA



IMMUNOMODULATORS ACTIMMUNE INJ 2MU/0.5 2 $0 NM, LA, PA

ARCALYST INJ 220MG 2 $0 NM, PA

INTRON A INJ 10MU 2 $0 B/D, NM




PEG-INTRON KIT 50MCG 2 $0 NM, PA


103

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

PEG-INTRON KIT 50MCG RP 2 $0 NM, PA

PEG-INTRON KIT 80MCG RP 2 $0 NM, PA

PEG-INTRON KIT 120 RP 2 $0 NM, PA

PEG-INTRON KIT 150 RP 2 $0 NM, PA

PEGINTRON KIT 80MCG 2 $0 NM, PA



REVLIMID CAP 2.5MG 2 $0 NM, LA, PA

REVLIMID CAP 5MG 2 $0 NM, LA, PA





THALOMID CAP 50MG 2 $0 NM, PA




IMMUNOSUPPRESSANTS azathioprine tab 50 mg 1 $0 B/D

cyclosporine cap 25 mg 1 $0 B/D

cyclosporine cap 100 mg 1 $0 B/D

cyclosporine iv soln 50 mg/ml 1 $0 B/D

cyclosporine modified cap 25 mg 1 $0 B/D



cyclosporine modified oral soln 100 mg/ml

1 $0 B/D

gengraf cap 25mg 1 $0 B/D

gengraf cap 100mg 1 $0 B/D

gengraf sol 100mg/ml 1 $0 B/D

mycophenolate mofetil cap 250 mg 1 $0 B/D

mycophenolate mofetil for oral susp

200 mg/ml

2 $0 B/D

mycophenolate mofetil tab 500 mg 1 $0 B/D

mycophenolate sodium tab dr 180

mg (mycophenolic acid equiv)

1 $0 B/D

mycophenolate sodium tab dr 360

mg (mycophenolic acid equiv)

2 $0 B/D

NEORAL CAP 25MG 2 $0 B/D

NEORAL CAP 100MG 2 $0 B/D

NEORAL SOL 100MG/ML 2 $0 B/D


104

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

NULOJIX INJ 250MG 2 $0 B/D

PROGRAF CAP 0.5MG 2 $0 B/D

PROGRAF CAP 1MG 2 $0 B/D

PROGRAF CAP 5MG 2 $0 B/D

RAPAMUNE SOL 1MG/ML 2 $0 B/D

SANDIMMUNE CAP 25MG 2 $0 B/D

SANDIMMUNE CAP 100MG 2 $0 B/D

SANDIMMUNE SOL 100MG/ML 2 $0 B/D

sirolimus tab 0.5 mg 1 $0 B/D

SIROLIMUS TAB 1 MG 1 $0 B/D

SIROLIMUS TAB 2 MG 2 $0 B/D

tacrolimus cap 0.5 mg 1 $0 B/D

tacrolimus cap 1 mg 1 $0 B/D

tacrolimus cap 5 mg 2 $0 B/D

ZORTRESS TAB 0.5MG 2 $0 B/D



VACCINES ACTHIB INJ 2 $0

ADACEL INJ 2 $0

BCG VACCINE INJ 2 $0

BEXSERO INJ 2 $0

BOOSTRIX INJ 2 $0

CERVARIX INJ 2 $0

COMVAX INJ 2 $0

DAPTACEL INJ 2 $0

DIP/TET PED INJ 25-5LFU 2 $0 B/D

ENGERIX-B INJ 10/0.5ML 2 $0 B/D

ENGERIX-B INJ 20MCG/ML 2 $0 B/D

GARDASIL 9 INJ 2 $0

GARDASIL INJ 2 $0

HAVRIX INJ 720UNIT 2 $0

HAVRIX INJ 1440UNIT 2 $0

HIBERIX SOL 10MCG 2 $0

IMOVAX RABIE INJ 2.5/ML 2 $0

INFANRIX INJ 2 $0

IPOL INJ INACTIVE 2 $0

IXIARO INJ 2 $0

M-M-R II INJ LIVE 2 $0

MENACTRA INJ 2 $0

MENOMUNE INJ A/C/Y/W 2 $0


105

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

MENVEO INJ 2 $0

PEDVAX HIB INJ 2 $0

PROQUAD INJ 2 $0

RABAVERT INJ 2 $0

RECOMBIVA HB INJ 5MCG/0.5 2 $0 B/D

RECOMBIVA HB INJ 10MCG/ML 2 $0 B/D

RECOMBIVA-HB INJ 40MCG/ML 2 $0 B/D

ROTARIX SUS 2 $0

ROTATEQ SOL 2 $0

SYNAGIS INJ 50MG 2 $0 NM

SYNAGIS INJ 100MG/ML 2 $0 NM

TENIVAC INJ 5-2LF 2 $0 B/D

TET/DIP TOX INJ 2-2 LF 2 $0 B/D

TETANUS TOX INJ 5LF ADS 2 $0 B/D

TRUMENBA INJ 2 $0

TWINRIX INJ 2 $0

TYPHIM VI INJ 2 $0

VAQTA INJ 25/0.5ML 2 $0

VAQTA INJ 50UNT/ML 2 $0

VARIVAX INJ 2 $0

YF-VAX INJ 2 $0

ZOSTAVAX INJ 2 $0 QL (1 vial per lifetime)

NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTS ELECTROLYTES KLOR-CON 8 TAB 8MEQ ER 1 $0

KLOR-CON 10 TAB 10MEQ ER 1 $0

klor-con m15 tab 15meq er 1 $0

klor-con pow 20meq 1 $0

MAGNESIUM SU INJ 20/500ML 2 $0

MAGNESIUM SU INJ 80MG/ML 2 $0

magnesium sulfate inj 50% 1 $0

MAGNESIUM SULFATE INJ 50% 1 $0

MG SO4/D5W INJ 10MG/ML 2 $0

MG SO4/D5W INJ 20MG/ML 2 $0

potassium chloride cap cr 8 meq 1 $0

potassium chloride cap cr 10 meq 1 $0

potassium chloride microencapsulated crys cr tab 10 meq

1 $0


106

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

potassium chloride

microencapsulated crys cr tab 20 meq

1 $0

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

1 $0

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

1 $0

potassium chloride tab cr 8 meq (600 mg)

1 $0

POTASSIUM CHLORIDE TAB CR 10 MEQ

1 $0

POTASSIUM CHLORIDE TAB CR 20 MEQ (1500 MG)

1 $0

rehydralyte sol 3 $0 NM; *

SODIUM CHLORIDE INJ 2.5 MEQ/ML (14.6%)

1 $0

SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN

1 $0

TPN ELECTROL INJ 2 $0 B/D

IV NUTRITION amino acid infusion 6% 1 $0 B/D

AMINOSYN 7% INJ /LYTES 2 $0 B/D

AMINOSYN II INJ 7% 2 $0 B/D

AMINOSYN II INJ 8.5% 2 $0 B/D

AMINOSYN II INJ 8.5/LYTE 2 $0 B/D

AMINOSYN II INJ 10% 2 $0 B/D

AMINOSYN INJ 8.5% 2 $0 B/D

AMINOSYN INJ 8.5/LYTE 2 $0 B/D

AMINOSYN INJ 10% 2 $0 B/D

AMINOSYN M INJ 3.5% 2 $0 B/D

AMINOSYN-HBC INJ 7% 2 $0 B/D

AMINOSYN-PF INJ 7% 2 $0 B/D

AMINOSYN-PF INJ 10% 2 $0 B/D

AMINOSYN-RF INJ 5.2% 2 $0 B/D

CLINIMIX INJ 2.75/D5W 2 $0 B/D

CLINIMIX INJ 4.25/D5W 2 $0 B/D

CLINIMIX INJ 4.25/D10 2 $0 B/D



CLINIMIX INJ 5%/D15W 2 $0 B/D




107

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

FAT EMULSION IV SOLN 20% 2 $0 B/D

FREAMINE HBC INJ 6.9% 2 $0 B/D

FREAMINE III INJ 10% 2 $0 B/D

HEPATAMINE SOL 8% 2 $0 B/D

INTRALIPID INJ 20% 2 $0 B/D

INTRALIPID INJ 30% 2 $0 B/D

NEPHRAMINE INJ 5.4% 2 $0 B/D

premasol sol 10% 2 $0 B/D

PROCALAMINE INJ 3% 2 $0 B/D

PROSOL INJ 20% 2 $0 B/D

travasol inj 10% 2 $0 B/D

TROPHAMINE INJ 10% 2 $0 B/D

IV REPLACEMENT SOLUTIONS D5W/LYTES INJ #48 2 $0

D5W/NACL INJ 0.3% 1 $0

D10W/NACL INJ 0.2% 2 $0

DEXTROSE 2.5% W/ SODIUM

CHLORIDE 0.45%

1 $0

DEXTROSE 5% IN LACTATED

RINGERS

1 $0

DEXTROSE 5% W/ SODIUM

CHLORIDE 0.2%

1 $0

DEXTROSE 5% W/ SODIUM CHLORIDE 0.9%

1 $0


1 $0


1 $0


1 $0


1 $0

DEXTROSE INJ 5% 1 $0



dextrose inj 70% 1 $0

IONOSOL-B/ INJ D5W 2 $0

IONOSOL-MB INJ /D5W 2 $0

ISOLYTE-P INJ /D5W 2 $0

isolyte-s inj 2 $0

KCL 10 MEQ/L (0.075%) IN

DEXTROSE 5% & NACL 0.45% INJ

1 $0


108

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

KCL 20 MEQ/L (0.15%) IN


1 $0

KCL 20 MEQ/L (0.15%) IN


1 $0

KCL 20 MEQ/L (0.15%) IN


1 $0

KCL 20 MEQ/L (0.15%) IN


1 $0

KCL 20 MEQ/L (0.15%) IN NACL

0.9% INJ

1 $0

kcl 20 meq/l (0.15%) in nacl 0.45%

inj

1 $0

KCL 20 MEQ/L (0.15%) IN NACL

0.45% INJ

1 $0

KCL 30 MEQ/L (0.224%) IN


1 $0

KCL 40 MEQ/L (0.3%) IN


1 $0

KCL 40 MEQ/L (0.3%) IN NACL 0.9% INJ

1 $0

KCL/D5W/NACL INJ 0.3/0.9% 1 $0

KCL/D5W/NACL INJ 0.15/0.2 2 $0

LACTATED RINGER'S SOLUTION 1 $0

normosol -m inj /d5w 1 $0

NORMOSOL -R INJ /D5W 2 $0

NORMOSOL-R INJ PH 7.4 2 $0

PLASMA-LYTE INJ 56/D5W 2 $0

PLASMA-LYTE INJ -148 2 $0

PLASMA-LYTE INJ -A 2 $0

POTASSIUM CHLORIDE 20 MEQ/L

(0.15%) IN DEXTROSE 5% INJ

1 $0

POTASSIUM CHLORIDE 40 MEQ/L

(0.3%) IN DEXTROSE 5% INJ

1 $0

potassium chloride inj 2 meq/ml 1 $0

potassium chloride inj 10 meq/50 ml

1 $0

POTASSIUM CHLORIDE INJ 10 MEQ/100 ML

1 $0

potassium chloride inj 20 meq/50 ml

1 $0

POTASSIUM CHLORIDE INJ 20 MEQ/100 ML

1 $0


109

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

potassium chloride inj 40 meq/100

ml

1 $0

RINGER'S SOLUTION 1 $0

SODIUM CHLORIDE INJ 0.45% 1 $0

SODIUM CHLORIDE INJ 3% 1 $0

SODIUM CHLORIDE INJ 5% 1 $0

SODIUM CHLORIDE IV SOLN 0.9% 1 $0

MINERALS BEELITH TAB 3 $0 NM; *

BONE DENSITY TAB 3 $0 NM; *

bone meal w/ vitamin d tab 3 $0 NM; *

buffered tab salt 3 $0 NM; *

CA CITRATE TAB 250MG 3 $0 NM; *

ca citrate tab + d 3 $0 NM; *

CA GLUCONATE TAB 50MG 3 $0 NM; *

CA LACTATE TAB 100MG 3 $0 NM; *

CA/MG TAB 3 $0 NM; *

CA/MG/ZN TAB 3 $0 NM; *

CAL CIT MAL/ TAB VITAMIND 3 $0 NM; *

CAL-CITRATE TAB PLUS D 3 $0 NM; *

CAL-GLU CAP 500MG 3 $0 NM; *

cal-mag aspa tab 333-167 3 $0 NM; *

CAL-QUICK LIQ 500-400 3 $0 NM; *

CAL/MAG TAB CHEW 3 $0 NM; *

CAL/MAG/VITD TAB 3 $0 NM; *

CALC CITRATE TAB 200MG 3 $0 NM; *

calc citrate tab +d 3 $0 NM; *

CALC GUMMIES CHW CHILD 3 $0 NM; *

CALCET CHW BITES 3 $0 NM; *

CALCET PETIT TAB 200-250 3 $0 NM; *

CALCI-MIX CAP 1250MG 3 $0 NM; *

CALCIONATE SYP 1.8GM/5 3 $0 NM; *

CALCIUM 500 TAB 3 $0 NM; *

calcium 500 tab +d 3 $0 NM; *

calcium 600 chw +d/mnrls 3 $0 NM; *

calcium 600 tab 3 $0 NM; *

calcium 600 tab vit d/mi 3 $0 NM; *

CALCIUM 1000 TAB + D 3 $0 NM; *

calcium 1200 chw 3 $0 NM; *

CALCIUM &MAG TAB 3 $0 NM; *

calcium + d chw 3 $0 NM; *


110

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

CALCIUM CARB CHW 260MG 3 $0 NM; *

CALCIUM CARB POW 800/2GM 3 $0 NM; *

calcium carbonate susp 1250 mg/5ml (500 mg/5ml elemental ca)

3 $0 NM; *

calcium carbonate tab 1250 mg (500 mg elemental ca)

3 $0 NM; *

calcium carbonate-cholecalciferol tab 500 mg-400 unit

3 $0 NM; *


3 $0 NM; *


3 $0 NM; *

calcium carbonate-vitamin d tab

500 mg-125 unit

3 $0 NM; *


500 mg-400 unit

3 $0 NM; *


600 mg-125 unit

3 $0 NM; *


600 mg-200 unit

3 $0 NM; *


600 mg-400 unit

3 $0 NM; *

CALCIUM CHW GUMMIES 3 $0 NM; *

CALCIUM CIT/ TAB VIT D 3 $0 NM; *

calcium citrate tab 950 mg (200 mg elemental ca)

3 $0 NM; *

calcium citrate-vitamin d tab 200 mg-250 unit (elemental ca)

3 $0 NM; *

calcium for chw women 3 $0 NM; *

CALCIUM GLUC TAB 500MG 3 $0 NM; *

calcium gluconate tab 500 mg 3 $0 NM; *

CALCIUM GRA CITRATE 3 $0 NM; *

CALCIUM LACT TAB 648MG 3 $0 NM; *

calcium lactate tab 650 mg 3 $0 NM; *

calcium soft chw chocolat 3 $0 NM; *

calcium tab 500 mg 3 $0 NM; *

calcium tab 600 mg 3 $0 NM; *

CALCIUM TAB FORMULA 3 $0 NM; *

calcium w/ magnesium tab 500-250

mg

3 $0 NM; *

calcium w/ vitamin d tab 600

mg-125 unit

3 $0 NM; *


111

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

calcium+d3 tab 600-800 3 $0 NM; *

calcium+d3 tab grad rel 3 $0 NM; *

CALCIUM/C/D CHW 500MG 3 $0 NM; *

CALCIUM/D3 TAB 3 $0 NM; *

calcium/d3 tab 600-800 3 $0 NM; *

calcium/d chw 500-400 3 $0 NM; *

calcium/magn tab zinc 3 $0 NM; *

CALMAG THINS TAB 200-50MG 3 $0 NM; *

caltrate 600 chw 600-800 3 $0 NM; *

CALTRATE 600 CHW +D PLUS 3 $0 NM; *

caltrate 600 tab 3 $0 NM; *

calvite p&d tab 3 $0 NM; *

CHELATED CA TAB 200MG 3 $0 NM; *

cit calc/d tab 315-250 3 $0 NM; *

CITRACAL CAL CHW GUMMIES 3 $0 NM; *

CITRACAL HRT TAB HEALTH 3 $0 NM; *

CORAL CALCIU CAP 3 $0 NM; *

CORAL CALCIU CAP 1000MG 3 $0 NM; *

CORAL CALCIU CAP PLUS 3 $0 NM; *

CORAL CAP CALCIUM 3 $0 NM; *

elite magnes tab 100mg 3 $0 NM; *

EQL CALCIUM CAP VIT D 3 $0 NM; *

kp ca/mg/zn tab 3 $0 NM; *

kp calcium cap 600+d 3 $0 NM; *

kp calcium tab 600+d 3 $0 NM; *

liq ca/vit d cap 600mg 3 $0 NM; *

LIQUID CALCI CAP WITH D3 3 $0 NM; *

LOCALNESIUM TAB 3 $0 NM; *

LOCALNESIUM TAB -C 3 $0 NM; *

MAG CITRATE TAB 100MG 3 $0 NM; *

MAG-200 TAB 3 $0 NM; *

mag-delay tab 3 $0 NM; *

MAG-TAB SR TAB 84MG 3 $0 NM; *

MAGINEX TAB 615 MG 3 $0 NM; *

MAGN SULFATE CAP 70MG 3 $0 NM; *

magnacaps cap 100mg 3 $0 NM; *

MAGNEBIND TAB 200 3 $0 NM; *

MAGNEBIND TAB 300 3 $0 NM; *

MAGNESIUM CAP 300MG 3 $0 NM; *

MAGNESIUM CAP 400MG 3 $0 NM; *

MAGNESIUM GL TAB 550MG 3 $0 NM; *


112

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

magnesium oxide tab 400 mg (240

mg elemental mg)

3 $0 NM; *

magnesium oxide tab 400 mg

(241.3 mg elemental mg)

3 $0 NM; *

magnesium oxide tab 500 mg (mg

supplement)

3 $0 NM; *

MAGNESIUM TAB 30MG 3 $0 NM; *

magnesium tab 200 mg 3 $0 NM; *

magnesium tab 250 mg 3 $0 NM; *

MG GLUCONATE TAB 250MG 3 $0 NM; *

os-cal + d3 tab 500-200 3 $0 NM; *

OSTEO-PORETI TAB 3 $0 NM; *

oys shell+d tab 250-125 3 $0 NM; *

oysco 500 tab 500mg 3 $0 NM; *

OYSCO 500+D CHW 3 $0 NM; *

oyst shell/d tab 500-200 3 $0 NM; *

oyst shell/d tab 500mg 3 $0 NM; *

oyst-cal d tab 250mg 3 $0 NM; *

PARVA-CAL TAB 250-100 3 $0 NM; *

PARVA-CAL TAB 500MG 3 $0 NM; *

PHOS-NAK POW CONCENTR 3 $0 NM; *

RA CA/BORON TAB 3 $0 NM; *

ra coral cap calcium 3 $0 NM; *

ra magnesium cap 500mg 3 $0 NM; *

RA OYS SHL/D TAB 250MG 3 $0 NM; *

ra oys shl/d tab 500mg 3 $0 NM; *

selenium tab 100 mcg 3 $0 NM; *

SELENIUM TAB 200MCG 3 $0 NM; *

slow magnes/ tab calcium 3 $0 NM; *

SLOW-MAG TAB 3 $0 NM; *

sm ca/mg/zn tab 3 $0 NM; *

SM CORAL CAL TAB 1000MG 3 $0 NM; *

sm magnesium tab 250mg 3 $0 NM; *

UPCAL D POW 3 $0 NM; *

VITAMINS A-25 CAP 25000UNT 3 $0 NM; *

ACEROLA C WAF 500MG 3 $0 NM; *

ANTIOXIDANT CAP 3 $0 NM; *

APATATE LIQ 3 $0 NM; *

AQUA-E LIQ 3 $0 NM; *

aquadeks dro 3 $0 NM; *


113

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

ASCORBIC ACD POW 3 $0 NM; *

ascorbic acid cap cr 500 mg 3 $0 NM; *

ascorbic acid chew tab 250 mg 3 $0 NM; *

ascorbic acid syrup 500 mg/5ml 3 $0 NM; *

ascorbic acid tab 100 mg 3 $0 NM; *




ascorbic acid tab cr 500 mg 3 $0 NM; *

b complex tab form 1 3 $0 NM; *

B-1 TAB 500MG 3 $0 NM; *

B-12 DOTS TAB 500MCG 3 $0 NM; *

B-12 TAB 2500MCG 3 $0 NM; *

B-12 TAB 5000MCG 3 $0 NM; *

b-50 tr tab 3 $0 NM; *

b-100 complx tab 3 $0 NM; *

b-complex tab 50 tr 3 $0 NM; *

b-complex vitamin cap 3 $0 NM; *

b-complex vitamin sublingual liquid 3 $0 NM; *

b-complex vitamin tab 3 $0 NM; *

b-complex w/ c & calcium tab 3 $0 NM; *

b-complex w/ c cap 3 $0 NM; *

B-NATAL LOZ 25MG 3 $0 NM; *

bee zee tab 3 $0 NM; *

beta carotene cap 25000 unit 3 $0 NM; *

bio-d-mulsio liq 400unit 3 $0 NM; *

bio-d-mulsio liq 2000unit 3 $0 NM; *

biotin tab 300 mcg 3 $0 NM; *

brewers yeast tab 3 $0 NM; *

c-500 chw 500mg 3 $0 NM; *

calciferol dro 8000/ml 3 $0 NM; *

calcitriol cap 0.5 mcg 1 $0 B/D

calcitriol cap 0.25 mcg 1 $0 B/D

calcitriol inj 1 mcg/ml 1 $0 B/D

calcitriol oral soln 1 mcg/ml 1 $0 B/D

calcium ascorbate tab 500 mg 3 $0 NM; *

calcium pantothenate tab 500 mg 3 $0 NM; *

CALNA TAB 3 $0 NM; *

central-vite tab performa 3 $0 NM; *

CENTRUM CHW SILVER 3 $0 NM; *

centrum kids chw complete 3 $0 NM; *


114

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

cerovite adv liq formula 3 $0 NM; *

chewabl vite chw childrns 3 $0 NM; *

child chew/ chw extra c 3 $0 NM; *

CHILD-MULTI CHW VITAMINS 3 $0 NM; *

CHOLECALCIFEROL CAP 400 UNIT 3 $0 NM; *

cholecalciferol cap 2000 unit 3 $0 NM; *

cholecalciferol cap 5000 unit 3 $0 NM; *

cholecalciferol drops 5000 unit/ml

(1000 unit/0.2ml)

3 $0 NM; *

cholecalciferol oral liquid 400

unit/ml

3 $0 NM; *

cholecalciferol tab 400 unit 3 $0 NM; *



CL PRENATAL TAB 28-0.8MG 3 $0 NM; *

COD LIVER OIL 3 $0 NM; *

cod liver oil cap 3 $0 NM; *

cvs vit b-6 tab 200mg 3 $0 NM; *

cyanocobalamin inj 1000 mcg/ml 3 $0 NM; *

cyanocobalamin liquid 1000 mcg/15ml

3 $0 NM; *

cyanocobalamin tab 50 mcg 3 $0 NM; *






cyanocobalamin tab cr 1000 mcg 3 $0 NM; *

cyanocobalamin tab sl 1000 mcg 3 $0 NM; *

cyanocobalamin tab sl 2500 mcg 3 $0 NM; *

CYTO B2 POW 3 $0 NM; *

D3 DOTS TAB 2000UNIT 3 $0 NM; *

daily-vite/ tab iron 3 $0 NM; *

DECARA CAP 25000UNT 3 $0 NM; *

DIALYVITE 80 TAB ZINC 15 3 $0 NM; *

dialyvite tab 800 3 $0 NM; *

e-oil oil 30000unt 3 $0 NM; *

ecee plus tab 3 $0 NM; *

ELDERTONIC ELX 3 $0 NM; *

energy b-12 tab 1500mcg 3 $0 NM; *

ergocalciferol cap 50000 unit 3 $0 NM; *


115

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

EZFE FORTE CAP 3 $0 NM; *

FA-8 CAP 800MCG 3 $0 NM; *

fa-8 tab 0.8mg 3 $0 NM; *

FOLIC ACID CAP 5MG 3 $0 NM; *

FOLIC ACID CAP 20MG 3 $0 NM; *

folic acid inj 5 mg/ml 3 $0 NM; *

folic acid tab 1 mg 3 $0 NM; *

FOLIC ACID TAB 1 MG 3 $0 NM; *

folic acid tab 400 mcg 3 $0 NM; *

folic acid tab 800 mcg 3 $0 NM; *

folic acid tab 800mcg 3 $0 NM; *

fruit c-100 chw 3 $0 NM; *

geravim liq 3 $0 NM; *

GERIATRIC LIQ VITAMIN 3 $0 NM; *

GNP DAILY MIS PRENATAL 3 $0 NM; *

gummi bear chw multivit 3 $0 NM; *

HONEY BEARS CHW 3 $0 NM; *

HONEY BEARS CHW IRON-ZIN 3 $0 NM; *

hydroxocobalamin inj 1000 mcg/ml 3 $0 NM; *

icaps cap 3 $0 NM; *

ICAPS LUTEIN TAB ZEAXANTH 3 $0 NM; *

icaps mv tab 3 $0 NM; *

iromin-g tab 3 $0 NM; *

kp vitamin e cap 100unit 3 $0 NM; *

KPN PRENATAL TAB 3 $0 NM; *

LUMITENE CAP 30MG 3 $0 NM; *

mega-maratho tab 100 tr 3 $0 NM; *

MEPHYTON TAB 5MG 3 $0 NM; *

meribin cap 5mg 3 $0 NM; *

MISSION PREN TAB 3 $0 NM; *

MISSION PREN TAB HP 3 $0 NM; *

multi-delyn liq 3 $0 NM; *

MULTI-DELYN LIQ /IRON 3 $0 NM; *

multi-vit tab 3 $0 NM; *

MYKIDZ IRON SUS 10MG/2ML 3 $0 NM; *

nail-ex tab 2.5mg 3 $0 NM; *

NASCOBAL SPR 500MCG 3 $0 NM; *

NEPHRONEX LIQ 3 $0 NM; *

neuro-k-250 tab 250mg 3 $0 NM; *

neuro-k-500 tab 3 $0 NM; *

niacin cap cr 250 mg 3 $0 NM; *


116

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

niacin cap cr 500 mg 3 $0 NM; *

niacin tab 50 mg 3 $0 NM; *




niacin tab cr 500 mg 3 $0 NM; *

niacin tab cr 750 mg 3 $0 NM; *

NIACIN TR TAB 1000MG 3 $0 NM; *

niacinamide tab 100 mg 3 $0 NM; *

niacinamide tab 500 mg 3 $0 NM; *

nutr-e-sol liq 400/15ml 3 $0 NM; *

NUTRICION TAB PORVIDA 3 $0 NM; *

pantothenic acid tab 100 mg 3 $0 NM; *

pantothenic acid tab 500 mg 3 $0 NM; *

paricalcitol cap 1 mcg 1 $0 B/D



PERRY PRENAT CAP 3 $0 NM; *

phytonadione inj 1 mg/0.5ml (2

mg/ml)

3 $0 NM; *

phytonadione inj 10 mg/ml 3 $0 NM; *

phytonadione tab 100 mcg 3 $0 NM; *

polyvitamin dro 3 $0 NM; *

polyvitamin dro /iron 3 $0 NM; *

PRENATAL TAB 3 $0 NM; *

PRENATAL TAB 27-0.8MG 3 $0 NM; *

PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC)

1 $0

PROTEXIN SYP 3 $0 NM; *

pyridoxine hcl inj 100 mg/ml 3 $0 NM; *

pyridoxine hcl tab 25 mg 3 $0 NM; *



pyridoxine hcl tab cr 200 mg 3 $0 NM; *

ra b-complex tab vit c tr 3 $0 NM; *

ra beta caro cap 15mg 3 $0 NM; *

ra vit c loz 60mg 3 $0 NM; *

ra vitamin c tab 1000mg 3 $0 NM; *

riboflavin tab 25 mg 3 $0 NM; *




117

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

ROCALTROL CAP 0.5MCG 2 $0 B/D

ROCALTROL CAP 0.25MCG 2 $0 B/D

ROCALTROL SOL 1MCG/ML 2 $0 B/D

SCOOBY-DOO CHW 3 $0 NM; *

slo-niacin tab 250mg cr 3 $0 NM; *

STUART PRENA PAK + DHA 3 $0 NM; *

super b-100 tab 3 $0 NM; *

SUPER POW NU-THERA 3 $0 NM; *

TAB-A-VITE TAB WOMENS 3 $0 NM; *

THERA BETA- TAB CAROTENE 3 $0 NM; *

THERA-D TAB 4000UNIT 3 $0 NM; *

THERANATAL TAB 27-1 3 $0 NM; *

thiamine hcl inj 100 mg/ml 3 $0 NM; *

thiamine hcl tab 50 mg 3 $0 NM; *



thiamine mononitrate tab 100 mg 3 $0 NM; *

total b/c tab 3 $0 NM; *

TRI-VI-SOL DRO /IRON 3 $0 NM; *

TRI-VI-SOL SOL 3 $0 NM; *

tri-vita sol 3 $0 NM; *

tri-vitamin dro 3 $0 NM; *

vit c & e cap combo 3 $0 NM; *

vita-bee/c tab 3 $0 NM; *

VITA-MAG TAB 3 $0 NM; *

vita-plus e cap 400unit 3 $0 NM; *

VITALETS CHW 3 $0 NM; *

vitalize liq ginseng 3 $0 NM; *

vitamin a cap 8000unit 3 $0 NM; *

vitamin a cap 10000 unit 3 $0 NM; *

VITAMIN A TAB 3 $0 NM; *

vitamin a tab 10000 unit 3 $0 NM; *

VITAMIN A TAB 15000UNT 3 $0 NM; *

vitamin b12 tab 2000mcg 3 $0 NM; *

VITAMIN C CHW 1000MG 3 $0 NM; *

VITAMIN C SOL 3 $0 NM; *

VITAMIN D2 TAB 400UNIT 3 $0 NM; *


VITAMIN D3 CAP 4000UNIT 3 $0 NM; *

vitamin d3 cap 10000unt 3 $0 NM; *

vitamin d3 cap 50000unt 3 $0 NM; *


118

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

VITAMIN D3 LIQ 1200UNIT 3 $0 NM; *


vitamin d3 tab 5000unit 3 $0 NM; *

VITAMIN D3 TAB 50000UNT 3 $0 NM; *

vitamin d cap 1000unit 3 $0 NM; *

vitamin d chw 400unit 3 $0 NM; *

vitamin d chw 1000unit 3 $0 NM; *

vitamin e cap 200 unit 3 $0 NM; *



VITAMIN E CHW 400UNIT 3 $0 NM; *

vitamin e soln 15 unit/0.3ml (50 unit/ml)

3 $0 NM; *

VITAMIN E TAB 100UNIT 3 $0 NM; *

VITAMIN E TAB 200UNIT 3 $0 NM; *

vitamin e tab 400 unit 3 $0 NM; *

VITAMIN K TAB 100MCG 3 $0 NM; *

vitamin mixture cap 3 $0 NM; *

vitamins a & d cap 3 $0 NM; *

vitatrum chw 3 $0 NM; *

vite/iron chw children 3 $0 NM; *

yl folic aci tab 400mcg 3 $0 NM; *

ZOO FRIENDS CHW COMPLETE 3 $0 NM; *

OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONS ANTI-INFECTIVE/ANTI-INFLAMMATORY - DRUGS TO TREAT

INFECTIONS AND INFLAMMATION bacitracin-polymyxin-neomycin-hc

ophth oint 1% 1 $0

blephamide oin s.o.p. 2 $0

neomycin-polymyxin-dexamethasone ophth oint 0.1%

1 $0

neomycin-polymyxin-dexamethasone ophth susp 0.1%

1 $0

neomycin-polymyxin-hc ophth susp 1 $0

sulfacetamide sodium-prednisolone

ophth soln 10-0.23(0.25)%

1 $0

TOBRADEX OIN 0.3-0.1% 2 $0

TOBRADEX ST SUS 0.3-0.05 2 $0

tobramycin-dexamethasone ophth

susp 0.3-0.1%

1 $0

ZYLET SUS 0.5-0.3% 2 $0


119

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS bacitracin ophth oint 500 unit/gm 1 $0

bacitracin-polymyxin b ophth oint 1 $0

BESIVANCE SUS 0.6% 2 $0

CILOXAN OIN 0.3% OP 2 $0

ciprofloxacin hcl ophth soln 0.3% 1 $0

erythromycin ophth oint 5 mg/gm 1 $0

gatifloxacin ophth soln 0.5% 1 $0

gentak oin 0.3% op 1 $0

gentamicin sulfate ophth oint 0.3% 1 $0

gentamicin sulfate ophth soln 0.3% 1 $0

ilotycin oin op 1 $0

MOXEZA SOL 0.5% 2 $0

NATACYN SUS 5% OP 2 $0

neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin

1 $0

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

1 $0

ofloxacin ophth soln 0.3% 1 $0

polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%

1 $0

sulfacetamide sodium ophth oint 10%

1 $0

sulfacetamide sodium ophth soln 10%

1 $0

tobramycin ophth soln 0.3% 1 $0

TOBREX OIN 0.3% OP 2 $0

trifluridine ophth soln 1% 1 $0

VIGAMOX DRO 0.5% 2 $0

ANTI-INFLAMMATORIES - DRUGS TO TREAT INFLAMMATION ALREX SUS 0.2% 2 $0

BROMFENAC SODIUM OPHTH SOLN

0.09% (BASE EQUIV) (ONCE-DAILY)

1 $0

bromfenac sodium ophth soln 0.09% (base equivalent)

1 $0

dexamethasone sodium phosphate ophth soln 0.1%

1 $0

diclofenac sodium ophth soln 0.1% 1 $0

DUREZOL EMU 0.05% 2 $0

FLUOROMETHOLONE OPHTH SUSP 0.1%

1 $0


120

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

flurbiprofen sodium ophth soln

0.03%

1 $0

ILEVRO DRO 0.3% OP 2 $0

ketorolac tromethamine ophth soln

0.4%

1 $0

ketorolac tromethamine ophth soln

0.5%

1 $0

LOTEMAX GEL 0.5% 2 $0

LOTEMAX OIN 0.5% 2 $0

LOTEMAX SUS 0.5% 2 $0

MAXIDEX SUS 0.1% OP 2 $0

NEVANAC SUS 0.1% 2 $0

pred sod pho sol 1% op 2 $0

PREDNISOLONE ACETATE OPHTH

SUSP 1%

1 $0

ANTIALLERGICS - DRUGS TO TREAT ALLERGIES altafrin sol 0.12% 3 $0 NM; *

azelastine hcl ophth soln 0.05% 1 $0

BEPREVE DRO 1.5% 2 $0

cromolyn sodium ophth soln 4% 1 $0

EYE ALLERGY SOL RELIEF 3 $0 NM; *

eye drops sol 0.05% op 3 $0 NM; *

eye drops sol a/r 3 $0 NM; *

ketotif fum dro 0.025%op 3 $0 NM; *

LASTACAFT SOL 0.25% 2 $0

PATADAY SOL 0.2% 2 $0

PATANOL SOL 0.1% OP 2 $0

PAZEO DRO 0.7% 2 $0

VASOCLEAR A SOL OP 3 $0 NM; *

visine-a sol op 3 $0 NM; *

VISINE-LR SOL 0.025% 3 $0 NM; *

ANTIGLAUCOMA - DRUGS TO TREAT GLAUCOMA ALPHAGAN P SOL 0.1% 2 $0

AZOPT SUS 1% OP 2 $0

betaxolol hcl ophth soln 0.5% 1 $0

BETOPTIC-S SUS 0.25% OP 2 $0

brimonidine tartrate ophth soln

0.2%

1 $0

BRIMONIDINE TARTRATE OPHTH

SOLN 0.15%

1 $0

carteolol hcl ophth soln 1% 1 $0


121

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

COMBIGAN SOL 0.2/0.5% 2 $0

dorzolamide hcl ophth soln 2% 1 $0

dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml

1 $0

ISTALOL SOL 0.5% OP 2 $0

latanoprost ophth soln 0.005% 1 $0

levobunolol hcl ophth soln 0.5% 1 $0

LEVOBUNOLOL HCL OPHTH SOLN 0.25%

1 $0

LUMIGAN SOL 0.01% 2 $0

metipranolol ophth soln 0.3% 1 $0

PHOSPHOLINE SOL 0.125%OP 2 $0

PILOCARPINE HCL OPHTH SOLN 1% 1 $0



SIMBRINZA SUS 1-0.2% 2 $0

TIMOLOL MALEATE OPHTH GEL

FORMING SOLN 0.5%

1 $0

TIMOLOL MALEATE OPHTH GEL

FORMING SOLN 0.25%

1 $0

timolol maleate ophth soln 0.5% 1 $0

timolol maleate ophth soln 0.25% 1 $0

TRAVATAN Z DRO 0.004% 2 $0

MISCELLANEOUS artifi tears sol op 3 $0 NM; *

artificial sol tears 3 $0 NM; *

BLINK TEARS DRO 0.25% OP 3 $0 NM; *

CLEAR EYES DRO DRY EYES 3 $0 NM; *

COMPUTER EYE SOL DROPS 3 $0 NM; *

ENUCLENE SOL OP 3 $0 NM; *

eye wash sol 3 $0 NM; *

FRESHKOTE SOL 2.7-2% 3 $0 NM; *

GENTEAL GEL 3 $0 NM; *

GENTEAL MILD DRO 0.2% 3 $0 NM; *

goniotaire sol 2.5% op 3 $0 NM; *

GONIOVISC SOL 2% 3 $0 NM; *

HYPOTEARS SOL 1-1% 3 $0 NM; *

ISOPTO TEARS SOL 0.5% OP 3 $0 NM; *

lubr/dry eye dro 0.5-0.9% 3 $0 NM; *

lubricnt eye dro 0.5% op 3 $0 NM; *

lubricnt gel dro 1% 3 $0 NM; *


122

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

MURO 128 SOL 2% OP 3 $0 NM; *

naphazoline hcl ophth soln 0.1% 1 $0

natures tear sol 0.4% 3 $0 NM; *

NUTRATEAR SOL 0.6% 3 $0 NM; *

optics mini dro 3 $0 NM; *

PROLENSA SOL 0.07% 2 $0

proparacaine hcl ophth soln 0.5% 1 $0

pure & gentl dro 0.3% 3 $0 NM; *

ra lubricant dro 0.4-0.3% 3 $0 NM; *

REFRESH CELL DRO 1% OP 3 $0 NM; *

refresh p.m. oin op 3 $0 NM; *

REFRESH SOL OPTIVE 3 $0 NM; *

RESTASIS EMU 0.05% 2 $0 QL (64 vials / 30 days)

RETAINE MGD EMU 0.5-0.5% 3 $0 NM; *

sodium chloride hypertonic ophth

oint 5%

3 $0 NM; *

sodium chloride hypertonic ophth

soln 5%

3 $0 NM; *

SOOTHE DRO 0.6-0.6% 3 $0 NM; *

STERILE LUBR DRO 0.7% 3 $0 NM; *

SYSTANE BAL SOL RESTOR 3 $0 NM; *

systane dro contacts 3 $0 NM; *

SYSTANE GEL 0.3% 3 $0 NM; *

SYSTANE LIQ DRO 0.4-0.3% 3 $0 NM; *

systane oin 3 $0 NM; *

TEARS AGAIN GEL NGHT/DAY 3 $0 NM; *

tgt lubricnt dro eye 3 $0 NM; *

th eye tears dro 3 $0 NM; *

THERATEARS SOL OP 3 $0 NM; *

VIVA DROPS DRO 1% 3 $0 NM; *

RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERS ANTICHOLINERGIC/BETA AGONIST COMBINATIONS - DRUGS TO

TREAT COPD ANORO ELLIPT AER 62.5-25 2 $0 QL (1 inhaler / 30 days)

COMBIVENT AER RESPIMAT 2 $0 QL (2 inhalers / 30 days)

ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml

1 $0 B/D

ANTICHOLINERGICS - DRUGS TO TREAT COPD ATROVENT HFA AER 17MCG 2 $0 QL (2 inhalers / 30

days)


123

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

ipratropium bromide inhal soln

0.02%

1 $0 B/D

ipratropium bromide nasal soln

0.03% (21 mcg/spray)

1 $0

ipratropium bromide nasal soln

0.06% (42 mcg/spray)

1 $0

SPIRIVA CAP HANDIHLR 2 $0 QL (30 caps / 30 days)

SPIRIVA SPR RESPIMAT 2 $0 QL (1 inhaler / 30 days)

TUDORZA PRES AER 60 doses 2 $0 QL (1 inhaler / 30 days)

TUDORZA PRES AER 30 doses 2 $0 QL (2 inhalers / 30 days)

ANTIHISTAMINES - DRUGS TO TREAT ALLERGIES ALA-HIST IR TAB 2MG 3 $0 NM; *

ALDEX AN CHW 5MG 3 $0 NM; *

all day allg tab 10mg 3 $0 NM; *

ALLEGRA ALRG SUS 30MG/5ML 3 $0 NM; *

ALLEGRA ALRG TAB 30MG 3 $0 NM; *

aller-ease tab 60mg 3 $0 NM; *

allergy chld liq 12.5/5ml 3 $0 NM; *

allergy relf cap 25mg 3 $0 NM; *

allergy relf tab 10mg 3 $0 NM; *

allergy relf tab 25mg 3 $0 NM; *

allrgy relf tab 12.5mg 3 $0 NM; *

altaryl elx 12.5/5ml 3 $0 NM; *

ASTEPRO SPR 0.15% 2 $0

azelastine hcl nasal spray 0.1%

(137 mcg/spray)

1 $0

azelastine hcl nasal spray 0.15%

(205.5 mcg/spray)

1 $0

cetirizine hcl chew tab 5 mg 3 $0 NM; *

cetirizine hcl chew tab 10 mg 3 $0 NM; *

cetirizine hcl oral soln 1 mg/ml (5

mg/5ml)

1 $0

cetirizine hcl tab 5 mg 3 $0 NM; *

cetirizine sol 5mg/5ml 3 $0 NM; *

child comple chw allergy 3 $0 NM; *

chlorpheniramine maleate tab 4 mg 3 $0 NM; *

chlorpheniramine maleate tab cr 12 mg

3 $0 NM; *

CLARITIN CAP 10MG 3 $0 NM; *

CLARITIN CHW 5MG 3 $0 NM; *

CLARITIN RDT TAB 5MG 3 $0 NM; *


124

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

dayhist alrg tab 12 hour 3 $0 NM; *

diphenhydramine hcl cap 50 mg 3 $0 NM; *

diphenhydramine hcl inj 50 mg/ml 1 $0

ED CHLORPED LIQ 2MG/ML 3 $0 NM; *

ed chlorped syp jr 3 $0 NM; *

fexofenadine hcl tab 180 mg 3 $0 NM; *

hydroxyzine hcl im soln 25 mg/ml 2 $0 PA

hydroxyzine hcl im soln 50 mg/ml 2 $0 PA

hydroxyzine hcl syrup 10 mg/5ml 2 $0 PA

hydroxyzine hcl tab 10 mg 2 $0 PA



hydroxyzine pamoate cap 25 mg 2 $0 PA



J-TAN PD DRO 1MG/ML 3 $0 NM; *

levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml)

1 $0

levocetirizine dihydrochloride tab 5 mg

1 $0

loratadine tab 10 mg 3 $0 NM; *

olopatadine hcl nasal soln 0.6% 1 $0

TRIAMINIC MIS GRAPE 3 $0 NM; *

triaminic tab 10mg 3 $0 NM; *

wal-itin syp 5mg/5ml 3 $0 NM; *

BETA AGONISTS - DRUGS TO TREAT ASTHMA AND COPD albuterol sulfate soln nebu 0.5% (5

mg/ml) 1 $0 B/D

albuterol sulfate soln nebu 0.63 mg/3ml (base equiv)

1 $0 B/D

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

1 $0 B/D

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

1 $0 B/D

albuterol sulfate syrup 2 mg/5ml 1 $0

albuterol sulfate tab 2 mg 1 $0

albuterol sulfate tab 4 mg 1 $0

albuterol sulfate tab sr 12hr 4 mg 1 $0

albuterol sulfate tab sr 12hr 8 mg 1 $0

FORADIL CAP AEROLIZE 2 $0 QL (60 caps / 30 days)

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

1 $0 B/D


125

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

PERFOROMIST NEB 20MCG 2 $0 B/D

PROAIR HFA AER 2 $0 QL (2 inhalers / 30

days)

SEREVENT DIS AER 50MCG 2 $0 QL (1 inhaler / 30 days)

terbutaline sulfate inj 1 mg/ml 1 $0

terbutaline sulfate tab 2.5 mg 1 $0

terbutaline sulfate tab 5 mg 1 $0

XOPENEX HFA AER 2 $0 QL (2 inhalers / 30 days)

COUGH AND COLD ADVIL ALLERG TAB CONGEST 3 $0 NM; *

ADVIL ALLERG TAB SINUS 3 $0 NM; *

ADVIL COLD/ CAP SINUS 3 $0 NM; *

afrin child spr 0.25% 3 $0 NM; *

AFRIN MENTHL SPR 0.05% 3 $0 NM; *

afrin saline spr 0.65% 3 $0 NM; *

ALA-HIST PE TAB 2-10MG 3 $0 NM; *

ALDEX GS DM TAB 3 $0 NM; *

ALDEX GS TAB 30-190MG 3 $0 NM; *

ALDEX-CT CHW 12.5-5MG 3 $0 NM; *

allergy-d tab 5-120mg 3 $0 NM; *

allergy/cong tab relief 3 $0 NM; *

altarussin syp -pe 3 $0 NM; *

ap-hist dm liq 7.5-4-15 3 $0 NM; *

asthma relf tab 12.5-200 3 $0 NM; *

AYR NASAL DRO 0.65% 3 $0 NM; *

AYR SALINE GEL NASAL 3 $0 NM; *

benzonatate cap 100 mg 3 $0 NM; *

benzonatate cap 200 mg 3 $0 NM; *

BICLORA LIQ 3 $0 NM; *

BICLORA TAB 25-25MG 3 $0 NM; *

BIOSPEC DMX LIQ 3 $0 NM; *

BROHIST D TAB 4-10MG 3 $0 NM; *

BROVEX PSB LIQ 3 $0 NM; *

BROVEX PSB LIQ DM 3 $0 NM; *

CAPCOF SYP 3 $0 NM; *

CAPMIST DM TAB 3 $0 NM; *

cardec dm dro 3 $0 NM; *

cardec dro 3 $0 NM; *

cheratussin sol dac 3 $0 NM; *

CHILD ADVIL SUS COLD 3 $0 NM; *


126

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

childrens sus plus cld 3 $0 NM; *

chld decongs liq 15mg/5ml 3 $0 NM; *

CHLO TUSS EX LIQ 12.5-100 3 $0 NM; *

cld/cgh/sore liq throat 3 $0 NM; *

CLOFERA LIQ 3 $0 NM; *

CNTC CLD/FLU PAK DAY/NGHT 3 $0 NM; *

CNTC CLD/FLU TAB MAX ST 3 $0 NM; *

CODAR AR LIQ 3 $0 NM; *

CODAR D LIQ 3 $0 NM; *

CODAR GF LIQ 3 $0 NM; *

CODITUSS DM SYP 3 $0 NM; *

cold head tab cong dt 3 $0 NM; *

cold medicin cap plus 3 $0 NM; *

cold multi pak day/nght 3 $0 NM; *

cold multi-s tab night 3 $0 NM; *

cold relief tab plus 3 $0 NM; *

cold/allergy elx children 3 $0 NM; *

cold/allery sus child 3 $0 NM; *

cold/cough elx child 3 $0 NM; *

cold/sinus tab relief 3 $0 NM; *

COMPLETE SIN TAB RELIEF 3 $0 NM; *

comtrex sev pak cld/sinu 3 $0 NM; *

CONEX SOL CLD/ALRG 3 $0 NM; *

CONEX TAB 2-60MG 3 $0 NM; *

contac tab cold+flu 3 $0 NM; *

coricidin cap cong/cgh 3 $0 NM; *

coricidin liq hbp 3 $0 NM; *

cough & cold tab 3 $0 NM; *

cough & sore liq thrt day 3 $0 NM; *

cough cont liq dm max 3 $0 NM; *

COUGH D SYP 3 $0 NM; *

cough dm liq 30mg/5ml 3 $0 NM; *

12.5cpd/1dcp liq m/30pse 3 $0 NM; *

cromolyn sodium nasal aerosol soln

5.2 mg/act (4%)

3 $0 NM; *

cvs nasal spr mist 3 $0 NM; *

DALLERGY SYP 3 $0 NM; *

day time liq cough 3 $0 NM; *

day-time cap sinus 3 $0 NM; *

day/nite mis cold/flu 3 $0 NM; *

de-chlor dm liq liquid 3 $0 NM; *


127

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

DECON-A LIQ DROPS 3 $0 NM; *

decongestant tab 120mg er 3 $0 NM; *

delsym child liq cgh/cold 3 $0 NM; *

DELTUSS DP LIQ 1-30/5ML 3 $0 NM; *

DEX-TUSS LIQ 300-10/5 3 $0 NM; *

DEXATREX D ELX CF-NASAL 3 $0 NM; *

dextromethorphan-guaifenesin tab

20-400 mg

3 $0 NM; *

DIABETIC CAP COLD/FLU 3 $0 NM; *

DICEL CD LIQ 3 $0 NM; *

dimetane dx syp 3 $0 NM; *

dimetapp liq nighttim 3 $0 NM; *

DIMETAPP SYP CGH/COLD 3 $0 NM; *

DONATUSSIN SYP 3 $0 NM; *

DRYMAX AF TAB 15-4-25 3 $0 NM; *

DURAFLU TAB 3 $0 NM; *

ed a-hist dm liq 3 $0 NM; *

ed bron gp liq 3 $0 NM; *

ED CHLORPED DRO D 3 $0 NM; *

entre-b sus 6-10mg/5 3 $0 NM; *

entre-cough liq 3 $0 NM; *

entre-hist liq 0.938-10 3 $0 NM; *

ENTSOL NASAL GEL 3 $0 NM; *

exefen dmx tab 3 $0 NM; *

exefen-ir tab 60-400mg 3 $0 NM; *

father johns syp 10mg/5ml 3 $0 NM; *

fexofenadine-pseudoephedrine tab sr 24hr 180-240 mg

3 $0 NM; *

flu/cold/cgh pow daytime 3 $0 NM; *

flu/severe pow cold/cgh 3 $0 NM; *

gnp day time liq cold/flu 3 $0 NM; *

gnp ibuprofn tab cold/sin 3 $0 NM; *

gnp tussin liq nighttim 3 $0 NM; *

guaifenesin syrup 100 mg/5ml 3 $0 NM; *

guaifenesin-codeine soln 100-10 mg/5ml

3 $0 NM; *

intense cold tab /flu med 3 $0 NM; *

intense coug liq reliever 3 $0 NM; *

J-MAX SYP 5-200MG 3 $0 NM; *

J-TAN D PD DRO 1-7.5MG 3 $0 NM; *

kidkare liq cgh/cold 3 $0 NM; *


128

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

liquituss gg liq 200/5ml 3 $0 NM; *

LITTLE NOSES DRO 0.125% 3 $0 NM; *

LODRANE D CAP 4-60MG 3 $0 NM; *

LOHIST-D LIQ 3 $0 NM; *

lohist-dm syp 5-2-10mg 3 $0 NM; *

lohist-peb liq 4-10/5ml 3 $0 NM; *

loratadine & pseudoephedrine tab

sr 24hr 10-240 mg

3 $0 NM; *

LORTUSS DM LIQ 3 $0 NM; *

LORTUSS EX LIQ 3 $0 NM; *

LORTUSS LQ LIQ 3 $0 NM; *

LUSAIR LIQ 3 $0 NM; *

m-clear wc liq 3 $0 NM; *

m-end dm liq 3 $0 NM; *

M-END DMX LIQ 3 $0 NM; *

M-END MAX D LIQ 3 $0 NM; *

M-END PE LIQ 3 $0 NM; *

m-end wc liq 3 $0 NM; *

mapap cold tab 10-5-325 3 $0 NM; *

MAR-COF BP LIQ 3 $0 NM; *

MEDI-GRAINE TAB 3 $0 NM; *

mucaphed tab 10-400mg 3 $0 NM; *

MUCINEX CGH GRA 5-100MG 3 $0 NM; *

mucinex cold tab sinus 3 $0 NM; *

MUCINEX D TAB 60-600MG 3 $0 NM; *

MUCINEX D TAB 120-1200 3 $0 NM; *

MUCINEX TAB 1200MG 3 $0 NM; *

MUCINEX/KIDS GRA 50MG 3 $0 NM; *

MUCINEX/KIDS GRA 100MG 3 $0 NM; *

mucus relief liq 5-100mg 3 $0 NM; *

mucus relief liq cold/sin 3 $0 NM; *

mucus relief tab 400mg 3 $0 NM; *

mucus+chst liq 100/5ml 3 $0 NM; *

mucus-dm max tab 60-1200 3 $0 NM; *

mucus-dm tab 30-600mg 3 $0 NM; *

mucus-er tab 600mg 3 $0 NM; *

multi-sympt liq cld nght 3 $0 NM; *

multi-sympt pak day/nght 3 $0 NM; *

multsym cold liq childrns 3 $0 NM; *

nasal decon liq 15mg/5ml 3 $0 NM; *

nasal decon syp 30mg/5ml 3 $0 NM; *


129

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

NASAL DECONG LIQ 30MG/5ML 3 $0 NM; *

nasal decong tab 10mg 3 $0 NM; *

nasal decong tab 30mg 3 $0 NM; *

nasal relief tab 5-325mg 3 $0 NM; *

nasal relief tab night 3 $0 NM; *

nasal spr 0.05% 3 $0 NM; *

NASOHIST DM DRO 3 $0 NM; *

nasohist dro 1-2mg/ml 3 $0 NM; *

NASOPEN PE LIQ 3 $0 NM; *

NEO-SYNEPHRI SPR 0.5% 3 $0 NM; *

neotuss liq 3 $0 NM; *

neutrahist dro 0.8-9mg 3 $0 NM; *

nexafed tab 30mg 3 $0 NM; *

night time liq cold/flu 3 $0 NM; *

night time liq cough 3 $0 NM; *

night-time cap sinus 3 $0 NM; *

nohist-lq liq 4-10/5ml 3 $0 NM; *

NOREL AD TAB 4-10-325 3 $0 NM; *

NOREL CS LIQ 3 $0 NM; *

ONSET FORTE TAB 3 $0 NM; *

organ-i nr tab 200mg 3 $0 NM; *

pain relief sus pls cold 3 $0 NM; *

pain relieve tab pm 3 $0 NM; *

ped formula liq 100-10/5 3 $0 NM; *

pedi-atric liq niterest 3 $0 NM; *

pediacare liq long-act 3 $0 NM; *

10peh/380gfn tab 3 $0 NM; *

10peh/380gfn tab /15dm 3 $0 NM; *

10peh/400gfn tab /20dm 3 $0 NM; *

PHENAGIL TAB 3.5-10MG 3 $0 NM; *

phenylephrine-brompheniramine-dm liquid 10-4-20 mg/5ml

3 $0 NM; *

PHENYLHIST LIQ DH 3 $0 NM; *

POLY-TUSSIN LIQ 10-9.375 3 $0 NM; *

POLY-TUSSIN LIQ AC 3 $0 NM; *

POLY-TUSSIND LIQ 10-9.375 3 $0 NM; *

PRETZ SOL 3 $0 NM; *

PRO-CHLO LIQ 3 $0 NM; *

PRO-CLEAR AC SYP 3 $0 NM; *

40pse/400gfn tab /20dm 3 $0 NM; *


130

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

pseudoephed-bromphen-dm liquid

20-4-20 mg/5ml

3 $0 NM; *

pseudoephedr tab 60mg 3 $0 NM; *

PYRIL DM SUS 3 $0 NM; *

pyrilamine mal-phenylephrine hcl tann susp 16-5 mg/5ml

3 $0 NM; *

q-tapp dm elx 3 $0 NM; *

refenesen tab chst cng 3 $0 NM; *

RESCON TAB 2-60MG 3 $0 NM; *

RESCON-DM SYP 3 $0 NM; *

RESPAIRE-30 CAP 3 $0 NM; *

RHINARIS GEL 0.2% 3 $0 NM; *

RHINARIS SPR 0.2% 3 $0 NM; *

ritifed syp 1.25-30 3 $0 NM; *

robafen cf syp cgh/cld 3 $0 NM; *

robafen cgh cap 15mg 3 $0 NM; *

robitussin cap cold+flu 3 $0 NM; *

robitussin liq 15mg/5ml 3 $0 NM; *

ROBITUSSIN LIQ CF 3 $0 NM; *

ROBITUSSIN LIQ CGH/COLD 3 $0 NM; *

robitussin liq ms max 3 $0 NM; *

ROBITUSSIN LIQ NIGHT TM 3 $0 NM; *

robitussin liq to go dm 3 $0 NM; *

robitussin syp 7.5/5ml 3 $0 NM; *

robitussin syp 15mg/5ml 3 $0 NM; *

RU-HIST-D LIQ 30-10/5 3 $0 NM; *

RU-HIST-D TAB 30-10MG 3 $0 NM; *

RYMED TAB 2-10MG 3 $0 NM; *

rynex dm liq 3 $0 NM; *

rynex pse liq 3 $0 NM; *

scot-tussin liq dm sf 3 $0 NM; *

SCOT-TUSSIN LIQ ORIGINAL 3 $0 NM; *

SCOT-TUSSIN LIQ SENIOR 3 $0 NM; *

sinus max st tab 30-500mg 3 $0 NM; *

sinus pain/ tab pressure 3 $0 NM; *

sm tussin cf liq 3 $0 NM; *

STAHIST AD LIQ 3 $0 NM; *

STAHIST AD TAB 25-60MG 3 $0 NM; *

STATUSS LIQ GREEN 3 $0 NM; *

sudafed 12hr tab 120mg cr 3 $0 NM; *

SUDAFED 24HR TAB 240MG 3 $0 NM; *


131

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

THERAFLU FLU PAK SORE THR 3 $0 NM; *

theraflu nt liq warm rlf 3 $0 NM; *

THERAFLU POW 3 $0 NM; *

THERAFLU POW MAX-D 3 $0 NM; *

triacting dt liq cold/cgh 3 $0 NM; *

triaminic liq 3 $0 NM; *

TRIAMINIC NT MIS COLD/CGH 3 $0 NM; *

TRIAMINIC SOL COLD/CGH 3 $0 NM; *

TRIAMINIC SYP CHST/NSL 3 $0 NM; *

TRIAMINIC SYP COLD/ALL 3 $0 NM; *

TRIAMINIC SYP COLD/CGH 3 $0 NM; *

TRIAMINIC SYP FEVER 3 $0 NM; *

TRICODE AR LIQ 3 $0 NM; *

TRICODE GF LIQ 3 $0 NM; *

trymine cg liq 225-7.5 3 $0 NM; *

tusnel c syp 3 $0 NM; *

TUSNEL LIQ 3 $0 NM; *

TUSNEL PED DRO 7.5-50 3 $0 NM; *

TUSNEL PEDI LIQ 15-5-50 3 $0 NM; *

TUSNEL-DM DRO PEDIATRC 3 $0 NM; *

tussi-pres liq pe ped 3 $0 NM; *

tussin cf liq cgh/cold 3 $0 NM; *

tussin dm syp 100-10/5 3 $0 NM; *

vcks dayquil liq mucus dm 3 $0 NM; *

VICK VAPORUB OIN 3 $0 NM; *

wal-act tab 2.5-60mg 3 $0 NM; *

wal-dryl all tab sinus 3 $0 NM; *

wal-dryl-d tab alrg/sin 3 $0 NM; *

wal-fex d tab 12 hour 3 $0 NM; *

wal-flu cold pak daytime 3 $0 NM; *

wal-itin d tab 5-120mg 3 $0 NM; *

wal-phed pe tab 4-10mg 3 $0 NM; *

wal-phed tab 4-60mg 3 $0 NM; *

4-way fast spr 1% 3 $0 NM; *

z-cof 12dm liq 3 $0 NM; *

Z-TUSS AC LIQ 2-9/5ML 3 $0 NM; *

Z-TUSS E LIQ 3 $0 NM; *

ZODRYL AC 25 SUS 3 $0 NM; *





132

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

ZODRYL DAC SUS 25 3 $0 NM; *




ZODRYL DEC25 SUS 3 $0 NM; *




zonatuss cap 150mg 3 $0 NM; *

LEUKOTRIENE RECEPTOR ANTAGONISTS - DRUGS TO TREAT ASTHMA

AND ALLERGIES montelukast sodium chew tab 4 mg

(base equiv) 1 $0

montelukast sodium chew tab 5 mg (base equiv)

1 $0

montelukast sodium oral granules

packet 4 mg (base equiv)

1 $0

montelukast sodium tab 10 mg

(base equiv)

1 $0

zafirlukast tab 10 mg 1 $0

zafirlukast tab 20 mg 1 $0

MAST CELL STABILIZERS - DRUGS TO TREAT ALLERGIES cromolyn sodium soln nebu 20

mg/2ml

1 $0 B/D

MISCELLANEOUS acetylcysteine inhal soln 10% 1 $0 B/D

acetylcysteine inhal soln 20% 1 $0 B/D

ARALAST NP INJ 400MG 2 $0 NM, LA, PA




AUVI-Q INJ 0.3MG 2 $0

AUVI-Q INJ 0.15MG 2 $0

DALIRESP TAB 500MCG 2 $0

EPIPEN 2-PAK INJ 0.3MG 2 $0

EPIPEN-JR INJ 2-PAK 2 $0

PROLASTIN-C INJ 1000MG 2 $0 NM, LA, PA

PULMOZYME SOL 1MG/ML 2 $0 B/D, NM

SODIUM CHLOR NEB 0.45% 3 $0 NM; *

XOLAIR SOL 150MG 2 $0 NM, LA, PA

ZEMAIRA INJ 1000MG 2 $0 NM, LA, PA


133

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

NASAL STEROIDS - DRUGS TO TREAT ALLERGIES flunisolide nasal soln 25 mcg/act

(0.025%) 1 $0 QL (2 bottles / 30 days)

fluticasone propionate nasal susp 50 mcg/act

1 $0 QL (1 bottle / 30 days)

NASONEX SPR 50MCG/AC 2 $0 QL (2 bottles / 30 days)

STEROID INHALANTS - DRUGS TO TREAT ASTHMA ASMANEX 14 AER 220MCG 2 $0 QL (2 inhalers / 30

days)

ASMANEX 30 AER 110MCG 2 $0 QL (2 inhalers / 30

days)


days)


days)


days)

budesonide inhalation susp 0.5

mg/2ml

1 $0 B/D

budesonide inhalation susp 0.25

mg/2ml

1 $0 B/D

FLOVENT DISK AER 50MCG 2 $0 QL (2 inhalers / 30

days)


days)


days)

FLOVENT HFA AER 44MCG 2 $0 QL (2 inhalers / 30

days)


days)


days)

QVAR AER 40MCG 2 $0 QL (1 inhaler / 30 days)

QVAR AER 80MCG 2 $0 QL (2 inhalers / 30

days)

STEROID/BETA-AGONIST COMBINATIONS - DRUGS TO TREAT

ASTHMA AND COPD ADVAIR DISKU AER 100/50 2 $0 QL (1 inhaler / 30 days)

ADVAIR DISKU AER 250/50 2 $0 QL (1 inhaler / 30 days)

ADVAIR DISKU AER 500/50 2 $0 QL (1 inhaler / 30 days)

ADVAIR HFA AER 45/21 2 $0 QL (1 inhaler / 30 days)


134

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE



BREO ELLIPTA INH 100-25 2 $0 QL (1 inhaler / 30 days)

BREO ELLIPTA INH 200-25 2 $0 QL (1 inhaler / 30 days)

DULERA AER 100-5MCG 2 $0 QL (1 inhaler / 30 days)

DULERA AER 200-5MCG 2 $0 QL (1 inhaler / 30 days)

SYMBICORT AER 80-4.5 2 $0 QL (1 inhaler / 30 days)

SYMBICORT AER 160-4.5 2 $0 QL (1 inhaler / 30 days)

XANTHINES - DRUGS TO TREAT COPD aminophylline inj 25 mg/ml 1 $0

elixophyllin elx 80/15ml 2 $0

theo-24 cap 100mg cr 2 $0



theo-24 cap 400mg er 2 $0

theophylline soln 80 mg/15ml 1 $0

theophylline tab sr 12hr 100 mg 1 $0






TOPICAL - DRUGS TO TREAT EAR AND SKIN CONDITIONS DERMATOLOGY, ACNE adapalene cream 0.1% 1 $0

adapalene gel 0.1% 1 $0

amnesteem cap 10mg 1 $0



AVITA CRE 0.025% 1 $0

AVITA GEL 0.025% 1 $0

benzoyl peroxide-erythromycin gel

5-3%

1 $0

claravis cap 10mg 1 $0




clindamax gel 1% 1 $0

clindamycin phosphate gel 1% 1 $0

clindamycin phosphate lotion 1% 1 $0

clindamycin phosphate soln 1% 1 $0


135

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

clindamycin phosphate swab 1% 1 $0

erythromycin gel 2% 1 $0

erythromycin pads 2% 1 $0

erythromycin soln 2% 1 $0

myorisan cap 10mg 1 $0



sulfacetamide sodium lotion 10%

(acne)

1 $0

tretinoin cream 0.1% 1 $0



tretinoin gel 0.01% 1 $0

tretinoin gel 0.025% 1 $0

zenatane cap 10mg 1 $0




DERMATOLOGY, ANTIBIOTICS ACNE MEDICAT LOT 5% 3 $0 NM; *

ACNE MEDICAT LOT 10% 3 $0 NM; *

antibiotic cre plus 3 $0 NM; *

bacitracin oint 500 unit/gm 3 $0 NM; *

bacitracin zinc oint 500 unit/gm 3 $0 NM; *

BENZOYL PER GEL 2.5% 3 $0 NM; *

benzoyl per gel 5% 3 $0 NM; *

benzoyl per gel 10% 3 $0 NM; *

benzoyl per liq 5% wash 3 $0 NM; *

benzoyl per lot 6% 3 $0 NM; *

BP CLEANSING LOT 4% 3 $0 NM; *

bp wash liq 5.25% 3 $0 NM; *

clean&clear cre 10% 3 $0 NM; *

double antib oin 3 $0 NM; *

gentamicin sulfate cream 0.1% 1 $0

gentamicin sulfate oint 0.1% 1 $0

mupirocin oint 2% 1 $0

neosporin+pn oin relf max 3 $0 NM; *

PANOXYL BAR 10% 3 $0 NM; *

panoxyl wash liq 10% 3 $0 NM; *

PANOXYL-4 LIQ CREM WSH 3 $0 NM; *

PANOXYL-8 LIQ CREM WSH 3 $0 NM; *


136

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

sb triple oin antibiot 3 $0 NM; *

SILVER SULFADIAZINE CREAM 1% 1 $0

SSD CRE 1% 1 $0

SULFAMYLON CRE 85MG/GM 2 $0

triple antib oin 3 $0 NM; *

DERMATOLOGY, ANTIFUNGALS antifungal cre 1% 3 $0 NM; *

antifungal cre 2% 3 $0 NM; *

ath foot spr aer 1% 3 $0 NM; *

castellani paint 3 $0 NM; *

ciclopirox gel 0.77% 1 $0

ciclopirox olamine cream 0.77%

(base equiv)

1 $0

ciclopirox olamine susp 0.77%

(base equiv)

1 $0

ciclopirox shampoo 1% 1 $0

clotrimazole cream 1% 1 $0

clotrimazole soln 1% 1 $0

desenex aer 2% 3 $0 NM; *

desenex cre 1% 3 $0 NM; *

desenex spry aer liquid 3 $0 NM; *

econazole nitrate cream 1% 1 $0

fungicure spr intens 3 $0 NM; *

FUNGOID TINC KIT 3 $0 NM; *

FUNGOID TINC SOL 2% 3 $0 NM; *

GENTIAN VIOL SOL 1% 3 $0 NM; *

GENTIAN VIOL SOL 2% 3 $0 NM; *

ketoconazole cream 2% 1 $0

LAMISIL ADV GEL 1% 3 $0 NM; *

lamisil af aer 1% 3 $0 NM; *

lamisil af pow defense 3 $0 NM; *

LAMISIL AT SPR 1% 3 $0 NM; *

LOTRIMIN ULT CRE 1% 3 $0 NM; *

mitrazol pow 2% 3 $0 NM; *

NIZORAL A-D SHA 1% 3 $0 NM; *

nyamyc pow 100000 1 $0

nystatin cream 100000 unit/gm 1 $0

nystatin oint 100000 unit/gm 1 $0

nystatin topical powder 1 $0

nystop pow 100000 1 $0

terbinafine cre 1% 3 $0 NM; *


137

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

tolnaftate cream 1% 3 $0 NM; *

tolnaftate soln 1% 3 $0 NM; *

triple paste oin af 2% 3 $0 NM; *

DERMATOLOGY, ANTIPRURITIC hydrocortisone rectal cream 2.5% 1 $0

procto-pak cre 1% 1 $0

proctozone cre -hc 2.5% 1 $0

PRUDOXIN CRE 5% 1 $0

DERMATOLOGY, ANTIPSORIATICS acitretin cap 10 mg 2 $0 PA

acitretin cap 17.5 mg 2 $0 PA

acitretin cap 25 mg 2 $0 PA

calcipotriene cream 0.005% 1 $0

calcipotriene oint 0.005% 1 $0

calcipotriene soln 0.005% (50

mcg/ml)

1 $0

calcitrene oin 0.005% 1 $0

8-MOP CAP 10MG 2 $0

TAZORAC CRE 0.1% 2 $0 PA

TAZORAC CRE 0.05% 2 $0 PA

DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo 2% 1 $0

selenium sulfide lotion 2.5% 1 $0

DERMATOLOGY, ANTIVIRALS acyclovir oint 5% 1 $0

DENAVIR CRE 1% 2 $0

DERMATOLOGY, CORTICOSTEROIDS ala cort cre 1% 1 $0

alclometasone dipropionate cream 0.05%

1 $0

alclometasone dipropionate oint 0.05%

1 $0

amcinonide cream 0.1% 1 $0

amcinonide lotion 0.1% 1 $0

amcinonide oin 0.1% 2 $0

apexicon oin 0.05% 1 $0

aquanil hc lot 1% 3 $0 NM; *

betamethasone dipropionate augmented cream 0.05%

1 $0

betamethasone dipropionate augmented gel 0.05%

1 $0


138

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

betamethasone dipropionate

augmented lotion 0.05%

1 $0

betamethasone dipropionate

augmented oint 0.05%

1 $0

betamethasone dipropionate cream

0.05%

1 $0

betamethasone dipropionate lotion

0.05%

1 $0

betamethasone dipropionate oint

0.05%

1 $0

betamethasone valerate cream

0.1%

1 $0

betamethasone valerate lotion

0.1%

1 $0

betamethasone valerate oint 0.1% 1 $0

clobetasol e cre 0.05% 1 $0

clobetasol propionate cream 0.05% 1 $0

clobetasol propionate gel 0.05% 1 $0

clobetasol propionate oint 0.05% 1 $0

clobetasol propionate soln 0.05% 1 $0

cormax scalp sol 0.05% 1 $0

cortaid spr 1% 3 $0 NM; *

cortizone-10 gel 1% 3 $0 NM; *

demarest cre dricort 3 $0 NM; *

DESONIDE CREAM 0.05% 1 $0

desonide lotion 0.05% 1 $0

desonide oint 0.05% 1 $0

desoximetasone cream 0.05% 1 $0

desoximetasone cream 0.25% 1 $0

desoximetasone gel 0.05% 1 $0

DESOXIMETASONE OINT 0.05% 1 $0

desoximetasone oint 0.25% 1 $0

diflorasone diacetate cream 0.05% 1 $0

diflorasone diacetate oint 0.05% 1 $0

fluocin acet oil scalp 1 $0

fluocinolone acetonide cream

0.01%

1 $0

fluocinolone acetonide cream

0.025%

1 $0

fluocinolone acetonide oil 0.01%

(body oil)

1 $0

fluocinolone acetonide oint 0.025% 1 $0


139

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

fluocinolone acetonide soln 0.01% 1 $0

fluocinonide cream 0.05% 1 $0

fluocinonide emulsified base cream 0.05%

1 $0

fluocinonide gel 0.05% 1 $0

fluocinonide oint 0.05% 1 $0

fluocinonide soln 0.05% 1 $0

fluticasone propionate cream 0.05%

1 $0

fluticasone propionate oint 0.005% 1 $0

halobetasol propionate cream

0.05%

1 $0

halobetasol propionate oint 0.05% 1 $0

hc-1% hemorr oin 1% 3 $0 NM; *

HYDROCORT AC CRE 0.5% 3 $0 NM; *

HYDROCORT/ OIN ALOE 1% 3 $0 NM; *

hydrocortisone butyrate cream 0.1%

1 $0

hydrocortisone butyrate oint 0.1% 1 $0

hydrocortisone butyrate soln 0.1% 1 $0

hydrocortisone cream 0.5% 3 $0 NM; *

hydrocortisone cream 1% 1 $0

hydrocortisone cream 1% 3 $0 NM; *

hydrocortisone cream 2.5% 1 $0

hydrocortisone lotion 2.5% 1 $0

hydrocortisone oint 0.5% 3 $0 NM; *

hydrocortisone oint 1% 1 $0

hydrocortisone oint 2.5% 1 $0

hydrocortisone valerate cream

0.2%

1 $0

hydrocortisone valerate oint 0.2% 1 $0

hydrocortisone-aloe vera cream

0.5%

3 $0 NM; *

hydrocortisone-aloe vera cream 1% 3 $0 NM; *

LOKARA LOT 0.05% 1 $0

mometasone furoate cream 0.1% 1 $0

mometasone furoate oint 0.1% 1 $0

mometasone furoate solution 0.1% (lotion)

1 $0

ra anti-itch oin 1% 3 $0 NM; *

ra hydrocort cre 0.5% 3 $0 NM; *

texacort sol 2.5% 2 $0


140

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

triamcinolone acetonide cream

0.1%

1 $0


0.5%

1 $0


0.025%

1 $0

triamcinolone acetonide lotion

0.1%

1 $0

triamcinolone acetonide lotion

0.025%

1 $0

triamcinolone acetonide oint 0.1% 1 $0

triamcinolone acetonide oint 0.5% 1 $0

triamcinolone acetonide oint

0.025%

1 $0

triderm cre 0.1% 1 $0

TUCKS OIN 1% 3 $0 NM; *

DERMATOLOGY, LOCAL ANESTHETICS lidocaine hcl gel 2% 1 $0

lidocaine hcl soln 4% 1 $0

lidocaine oint 5% 1 $0

lidocaine patch 5% (700 mg) 1 $0 QL (3 patches / 1 day), PA

lidocaine-prilocaine cream 2.5-2.5%

1 $0 B/D

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ABREVA CRE 10% 3 $0 NM; *

BOUDREAUXS OIN 16% 3 $0 NM; *

DESITIN CRE 13% 3 $0 NM; *

diaper rash oin 40% 3 $0 NM; *

diaper rash oin creamy 3 $0 NM; *

ELIDEL CRE 1% 2 $0 PA

fluorouracil cream 5% 1 $0

fluorouracil soln 2% 1 $0

fluorouracil soln 5% 1 $0

imiquimod cream 5% 1 $0

laclotion lot 12% 1 $0

lactic acid (ammonium lactate) cream 12%

1 $0

lactic acid (ammonium lactate) lotion 12%

1 $0

metronidazole cream 0.75% 1 $0

metronidazole gel 0.75% 1 $0


141

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

metronidazole lotion 0.75% 1 $0

MEXSANA POW 3 $0 NM; *

PANRETIN GEL 0.1% 2 $0

podofilox soln 0.5% 1 $0

RA CALAMINE LOT 3 $0 NM; *

risamine oin 3 $0 NM; *

rosadan cre 0.75% 1 $0

SECURA CRE 30.6% 3 $0 NM; *

secura prote cre 10% 3 $0 NM; *

SENSI-CARE OIN 49-15% 3 $0 NM; *

TARGRETIN GEL 1% 2 $0 NM, PA

TRIPLE PASTE OIN 12.8% 3 $0 NM; *

VALCHLOR GEL 0.016% 2 $0 NM, LA, PA

VOLTAREN GEL 1% 2 $0

zinc oxide oint 20% 3 $0 NM; *

ZINC OXIDE PST 25% 3 $0 NM; *

DERMATOLOGY, SCABICIDES AND PEDICULIDES A-200 GEL 0.33-4% 3 $0 NM; *

BARC LIQ 3 $0 NM; *

complete kit lice 3 $0 NM; *

eql lice kit solution 3 $0 NM; *

EURAX CRE 10% 2 $0

EURAX LOT 10% 2 $0

lice killing liq max st 3 $0 NM; *

lice killing sha 0.33-4% 3 $0 NM; *

lice trtmnt liq 3 $0 NM; *

lice trtmnt liq 1% 3 $0 NM; *

licide aer 0.5% 3 $0 NM; *

LICIDE TREAT KIT 3 $0 NM; *

malathion lotion 0.5% 1 $0

permethrin cream 5% 1 $0

permethrin lotion 1% 3 $0 NM; *

PRONTO AER 0.4% 3 $0 NM; *

PYRE/PIPERON LIQ 3 $0 NM; *

rid ess lice kit 0.33-4% 3 $0 NM; *

SCHOOLTIME SHA 3 $0 NM; *

DERMATOLOGY, WOUND CARE AGENTS acetic acid irrigation soln 0.25% 1 $0

REGRANEX GEL 0.01% 2 $0 PA

SANTYL OIN 250/GM 2 $0


142

Drug Name Drug Tier

WHAT THE DRUG WILL

COST YOU


LIMITS ON USE

SODIUM CHLORIDE IRRIGATION

SOLN 0.9%

1 $0

WATER FOR IRRIGATION, STERILE

IRRIGATION SOLN

1 $0

MOUTH/THROAT/DENTAL AGENTS cevimeline hcl cap 30 mg 1 $0

chlorhexidine gluconate soln 0.12% 1 $0

clotrimazole troche 10 mg 1 $0

lidocaine hcl viscous soln 2% 1 $0

nystatin susp 100000 unit/ml 1 $0

periogard sol 0.12% 1 $0

pilocarpine hcl tab 5 mg 1 $0

pilocarpine hcl tab 7.5 mg 1 $0

triamcinolone acetonide dental paste 0.1%

1 $0

OTIC - DRUGS TO TREAT CONDITIONS OF THE EAR acetic acid 2% in aluminum acetate

otic soln

1 $0

acetic acid otic soln 2% 1 $0

CIPRODEX SUS 0.3-0.1% 2 $0

fluocinolone acetonide (otic) oil 0.01%

1 $0

neomycin-polymyxin-hc otic soln 1%

1 $0

neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%

1 $0

ofloxacin otic soln 0.3% 1 $0

143

Index 1 10peh/380gfn tab ........................... 129

10peh/380gfn tab /15dm ................. 129 10peh/400gfn tab /20dm ................. 129

12.5cpd/1dcp liq m/30pse ............... 126 3 3 day vagnal cre 4% ......................... 96

4 40pse/400gfn tab /20dm ................. 129

4-way fast spr 1% .......................... 131 8 8 hour pain tab 650mg ...................... 12 8-MOP CAP 10MG ........................... 137

A A-200 GEL 0.33-4% ........................ 141

A-25 CAP 25000UNT ....................... 112 abacavir sulfate tab 300 mg (base equiv)

...................................................... 21 abacavir sulfate-lamivudine-zidovudine

tab 300-150-300 mg ......................... 23 ABELCET INJ 5MG/ML ........................ 20

ABILIFY DISC TAB 10MG .................... 65

ABILIFY DISC TAB 15MG .................... 65 ABILIFY INJ 9.75MG .......................... 65

ABILIFY MAIN INJ 300MG .................. 65 ABILIFY MAIN INJ 400MG .................. 65

ABILIFY TAB 10MG ............................ 65 ABILIFY TAB 15MG ............................ 65

ABILIFY TAB 20MG ............................ 65 ABILIFY TAB 2MG ............................. 65

ABILIFY TAB 30MG ............................ 65 ABILIFY TAB 5MG ............................. 65

ABREVA CRE 10% ........................... 140 acamprosate calcium tab delayed release

333 mg ........................................... 73 acarbose tab 100 mg ......................... 76

acarbose tab 25 mg .......................... 76

acarbose tab 50 mg .......................... 76 acebutolol hcl cap 200 mg ................. 46

acebutolol hcl cap 400 mg ................. 46 ACEROLA C WAF 500MG .................. 112

acetamin jr tab 160mg rt ................... 11 ACETAMINOPHE TAB 650MG .............. 11

acetaminophen soln 160 mg/5ml ........ 11 acetaminophen w/ codeine soln 120-12

mg/5ml ........................................... 13 acetaminophen w/ codeine tab 300-15 mg

...................................................... 14 acetaminophen w/ codeine tab 300-30 mg

...................................................... 14 acetaminophen w/ codeine tab 300-60 mg

...................................................... 14 acetazolamide cap sr 12hr 500 mg ..... 50

acetazolamide tab 125 mg ................ 50

acetazolamide tab 250 mg ................ 50 acetic acid 2% in aluminum acetate otic

soln .............................................. 142 acetic acid irrigation soln 0.25% ...... 141

acetic acid otic soln 2% ................... 142 acetylcysteine inhal soln 10% .......... 132

acetylcysteine inhal soln 20% .......... 132 acid gone chw .................................. 87

acid gone sus .................................. 87 acid reducer tab 10mg ...................... 89

acid reducer tab 150mg .................... 89 acitretin cap 10 mg ........................ 137

acitretin cap 17.5 mg ...................... 137 acitretin cap 25 mg ........................ 137

ACNE MEDICAT LOT 10% ................ 135

ACNE MEDICAT LOT 5% .................. 135 ACTHIB INJ ................................... 104

ACTIMMUNE INJ 2MU/0.5 ................ 102 acyclovir cap 200 mg ........................ 24

acyclovir oint 5% ........................... 137 acyclovir sodium for inj 1000 mg ....... 24

acyclovir sodium for inj 500 mg ......... 24 acyclovir sodium iv soln 50 mg/ml ...... 24

acyclovir susp 200 mg/5ml ................ 24 acyclovir tab 400 mg ........................ 24

acyclovir tab 800 mg ........................ 24 ADACEL INJ ................................... 104

ADAGEN INJ 250/ML ......................... 81 adapalene cream 0.1% ................... 134

adapalene gel 0.1% ........................ 134

ADCIRCA TAB 20MG ......................... 53 adefovir dipivoxil tab 10 mg .............. 24

ADEMPAS TAB 0.5MG ....................... 53 ADEMPAS TAB 1.5MG ....................... 53

ADEMPAS TAB 1MG .......................... 53 ADEMPAS TAB 2.5MG ....................... 53

ADEMPAS TAB 2MG .......................... 53 adriamyc inj 50mg ........................... 32

adrucil inj 500/10ml ......................... 33 ADULT ASA TAB 81MG QM................. 11

144

ADVAIR DISKU AER 100/50 ............. 133

ADVAIR DISKU AER 250/50 ............. 133 ADVAIR DISKU AER 500/50 ............. 133

ADVAIR HFA AER 115/21 ................. 134 ADVAIR HFA AER 230/21 ................. 134

ADVAIR HFA AER 45/21 ................... 133 ADVIL ALLERG TAB CONGEST........... 125

ADVIL ALLERG TAB SINUS ............... 125 ADVIL COLD/ CAP SINUS ................. 125

ADVIL JR ST TAB 100MG.................... 11 afeditab tab 30mg cr ......................... 47

afeditab tab 60mg cr ......................... 47 AFINITOR DIS TAB 2MG ..................... 35

AFINITOR DIS TAB 3MG ..................... 35 AFINITOR DIS TAB 5MG ..................... 35

AFINITOR TAB 10MG ......................... 35

AFINITOR TAB 2.5MG ........................ 35 AFINITOR TAB 5MG ........................... 35

AFINITOR TAB 7.5MG ........................ 35 afrin child spr 0.25% ....................... 125

AFRIN MENTHL SPR 0.05% .............. 125 afrin saline spr 0.65% ..................... 125

AGGRENOX CAP 25-200MG .............. 101 a-hydrocort inj 100mg ....................... 82

ala cort cre 1% ............................... 137 ALA-HIST IR TAB 2MG ..................... 123

ALA-HIST PE TAB 2-10MG ................ 125 ALBENZA TAB 200MG ........................ 18

albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) ........................................ 124

albuterol sulfate soln nebu 0.5% (5

mg/ml) .......................................... 124 albuterol sulfate soln nebu 0.63 mg/3ml

(base equiv) ................................... 124 albuterol sulfate soln nebu 1.25 mg/3ml

(base equiv) ................................... 124 albuterol sulfate syrup 2 mg/5ml ...... 124

albuterol sulfate tab 2 mg ................ 124 albuterol sulfate tab 4 mg ................ 124

albuterol sulfate tab sr 12hr 4 mg ..... 124 albuterol sulfate tab sr 12hr 8 mg ..... 124

alclometasone dipropionate cream 0.05% .................................................... 137

alclometasone dipropionate oint 0.05% .................................................... 137

ALCOHOL SWABS ............................. 75

ALDEX AN CHW 5MG ....................... 123 ALDEX GS DM TAB .......................... 125

ALDEX GS TAB 30-190MG ............... 125

ALDEX-CT CHW 12.5-5MG ............... 125 ALDURAZYME INJ 2.9MG/5M ............. 81

alendronate sodium tab 10 mg .......... 77 alendronate sodium tab 35 mg .......... 77

alendronate sodium tab 40 mg .......... 77 alendronate sodium tab 5 mg ............ 77

alendronate sodium tab 70 mg .......... 77 alfuzosin hcl tab sr 24hr 10 mg .......... 95

ALIMTA INJ 100MG ........................... 33 ALIMTA INJ 500MG ........................... 33

ALINIA SUS 100/5ML ........................ 18 ALINIA TAB 500MG .......................... 18

all day allg tab 10mg ...................... 123 all day pain tab 220mg ..................... 11

ALLEGRA ALRG SUS 30MG/5ML ........ 123

ALLEGRA ALRG TAB 30MG ............... 123 aller-ease tab 60mg ....................... 123

allergy chld liq 12.5/5ml ................. 123 allergy relf cap 25mg ...................... 123

allergy relf tab 10mg ...................... 123 allergy relf tab 25mg ...................... 123

allergy/cong tab relief ..................... 125 allergy-d tab 5-120mg .................... 125

allopurinol tab 100 mg ...................... 11 allopurinol tab 300 mg ...................... 11

allrgy relf tab 12.5mg ..................... 123 ALOE VERA LIQ JUICE DR .................. 90

alosetron hcl tab 0.5 mg (base equiv) . 93 alosetron hcl tab 1 mg (base equiv) ... 93

ALPHAGAN P SOL 0.1%................... 120

alprazolam con 1 mg/ml ................... 53 alprazolam tab 0.25 mg .................... 53

alprazolam tab 0.5 mg ...................... 53 alprazolam tab 1 mg ......................... 53

alprazolam tab 2 mg ......................... 53 ALREX SUS 0.2% ........................... 119

altafrin sol 0.12% .......................... 120 altarussin syp -pe ........................... 125

altaryl elx 12.5/5ml ........................ 123 altavera tab ..................................... 78

ALUM HYDROX SUS 320/5ML ............. 87 aluminum hydroxide gel susp 600 mg/5ml

...................................................... 87 amantadine hcl cap 100 mg ............... 63

amantadine hcl syrup 50 mg/5ml ....... 63

amantadine hcl tab 100 mg ............... 63 AMBISOME INJ 50MG........................ 20

145

amcinonide cream 0.1% .................. 137

amcinonide lotion 0.1% ................... 137 amcinonide oin 0.1% ....................... 137

amifostine crystalline for inj 500 mg .... 38 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 .................................................. 50 amiloride hcl tab 5 mg ....................... 50

amino acid infusion 6% ................... 106 aminophylline inj 25 mg/ml .............. 134

AMINOSYN 7% INJ /LYTES ............... 106 AMINOSYN II INJ 10%..................... 106

AMINOSYN II INJ 7% ...................... 106

AMINOSYN II INJ 8.5%.................... 106 AMINOSYN II INJ 8.5/LYTE............... 106

AMINOSYN INJ 10% ........................ 106 AMINOSYN INJ 8.5% ....................... 106

AMINOSYN INJ 8.5/LYTE .................. 106 AMINOSYN M INJ 3.5%.................... 106

AMINOSYN-HBC INJ 7% .................. 106 AMINOSYN-PF INJ 10% ................... 106

AMINOSYN-PF INJ 7% ..................... 106 AMINOSYN-RF INJ 5.2% .................. 106

amiodarone hcl inj 150 mg/3ml (50 mg/ml) ............................................ 43

amiodarone hcl inj 450 mg/9ml (50 mg/ml) ............................................ 43

amiodarone hcl inj 900 mg/18ml (50

mg/ml) ............................................ 43 amiodarone hcl tab 100 mg ................ 43

amiodarone hcl tab 200 mg ................ 43 amiodarone hcl tab 400 mg ................ 43

AMITIZA CAP 24MCG ......................... 93 AMITIZA CAP 8MCG .......................... 93

amitriptyline hcl tab 10 mg ................ 60 amitriptyline hcl tab 100 mg .............. 60

amitriptyline hcl tab 150 mg .............. 60 amitriptyline hcl tab 25 mg ................ 60

amitriptyline hcl tab 50 mg ................ 60 amitriptyline hcl tab 75 mg ................ 60

amlodipine besylate tab 10 mg ........... 47 amlodipine besylate tab 2.5 mg .......... 47

amlodipine besylate tab 5 mg ............. 47

amlodipine besylate-benazepril hcl cap 10-20 mg ........................................ 39

amlodipine besylate-benazepril hcl cap

10-40 mg ........................................ 39 amlodipine besylate-benazepril hcl cap

2.5-10 mg ....................................... 39 amlodipine besylate-benazepril hcl cap

5-10 mg .......................................... 39 amlodipine besylate-benazepril hcl cap

5-20 mg .......................................... 39 amlodipine besylate-benazepril hcl cap

5-40 mg .......................................... 39 amlodipine besylate-valsartan tab 10-160

mg ................................................. 41 amlodipine besylate-valsartan tab 10-320

mg ................................................. 41 amlodipine besylate-valsartan tab 5-160

mg ................................................. 41

amlodipine besylate-valsartan tab 5-320 mg ................................................. 41

amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg ......................... 42

amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg ............................ 42

amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg ............................ 42

amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg ........................... 41

amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg.............................. 42

amnesteem cap 10mg .................... 134 amnesteem cap 20mg .................... 134

amnesteem cap 40mg .................... 134

amoxapine tab 100 mg ..................... 60 amoxapine tab 150 mg ..................... 60

amoxapine tab 25 mg ....................... 60 amoxapine tab 50 mg ....................... 60

amoxicillin & k clavulanate chew tab 200-28.5 mg ................................... 29

amoxicillin & k clavulanate chew tab 400-57 mg ...................................... 29

amoxicillin & k clavulanate for susp 200-28.5 mg/5ml ............................. 29

amoxicillin & k clavulanate for susp 250-62.5 mg/5ml ............................. 29

amoxicillin & k clavulanate for susp 400-57 mg/5ml................................ 29


600-42.9 mg/5ml ............................. 29 amoxicillin & k clavulanate tab 250-125

146

mg .................................................. 29

amoxicillin & k clavulanate tab 500-125 mg .................................................. 29

amoxicillin & k clavulanate tab 875-125 mg .................................................. 29

amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg .................................. 29

amoxicillin (trihydrate) cap 250 mg ..... 29 amoxicillin (trihydrate) cap 500 mg ..... 29

amoxicillin (trihydrate) chew tab 125 mg ...................................................... 29

amoxicillin (trihydrate) chew tab 250 mg ...................................................... 29

amoxicillin (trihydrate) for susp 125 mg/5ml ........................................... 29

amoxicillin (trihydrate) for susp 200

mg/5ml ........................................... 29 amoxicillin (trihydrate) for susp 250

mg/5ml ........................................... 29 amoxicillin (trihydrate) for susp 400

mg/5ml ........................................... 29 amoxicillin (trihydrate) tab 500 mg ..... 29

amoxicillin (trihydrate) tab 875 mg ..... 29 amphetamine-dextroamphetamine cap sr

24hr 10 mg ...................................... 70 amphetamine-dextroamphetamine cap sr



24hr 25 mg ...................................... 70

amphetamine-dextroamphetamine cap sr 24hr 30 mg ...................................... 70

amphetamine-dextroamphetamine cap sr 24hr 5 mg ........................................ 69

amphetamine-dextroamphetamine tab 10 mg .................................................. 70

amphetamine-dextroamphetamine tab 12.5 mg .......................................... 70




amphetamine-dextroamphetamine tab 5

mg .................................................. 70 amphetamine-dextroamphetamine tab

7.5 mg ............................................ 70

amphotericin b for inj 50 mg ............. 20 ampicillin & sulbactam sodium for inj

1-0.5 gm ......................................... 30 ampicillin & sulbactam sodium for inj 10-5

gm ................................................. 30 ampicillin & sulbactam sodium for inj 2-1

gm ................................................. 30 ampicillin & sulbactam sodium for iv soln

1-0.5 gm ......................................... 30 ampicillin & sulbactam sodium for iv soln

10-5 gm .......................................... 30 ampicillin & sulbactam sodium for iv soln

2-1 gm ........................................... 30 ampicillin cap 250 mg ....................... 30

ampicillin cap 500 mg ....................... 30

ampicillin for susp 125 mg/5ml .......... 30 ampicillin for susp 250 mg/5ml .......... 30

ampicillin sodium for inj 1 gm ............ 30 ampicillin sodium for inj 125 mg ........ 30

ampicillin sodium for inj 2 gm ............ 30 ampicillin sodium for inj 250 mg ........ 30

ampicillin sodium for inj 500 mg ........ 30 ampicillin sodium for iv soln 1 gm ...... 30

ampicillin sodium for iv soln 10 gm ..... 30 ampicillin sodium for iv soln 2 gm ...... 30

anagrelide hcl cap 0.5 mg ............... 100 anagrelide hcl cap 1 mg .................. 100

anastrozole tab 1 mg ........................ 35 ANDRODERM DIS 2MG/24HR ............. 75

ANDRODERM DIS 4MG/24HR ............. 75

ANORO ELLIPT AER 62.5-25 ............ 122 ant/anti-gas chw 1000-60 ................. 87

antacid sus max st ........................... 87 antibiotic cre plus ........................... 135

anti-diarrhe liq 1mg/5ml ................... 87 anti-diarrhe tab 2mg ........................ 88

antifungal cre 1% ........................... 136 antifungal cre 2% ........................... 136

ANTIOXIDANT CAP ......................... 112 APAP 500 LIQ 500/5ML ..................... 11

APATATE LIQ ................................. 112 apexicon oin 0.05% ........................ 137

ap-hist dm liq 7.5-4-15 ................... 125 APOKYN INJ 10MG/ML ...................... 63

apri tab ........................................... 78

APRISO CAP 0.375GM ....................... 90 APTIOM TAB 200MG ......................... 54

147

APTIOM TAB 400MG .......................... 54

APTIOM TAB 600MG .......................... 54 APTIOM TAB 800MG .......................... 54

APTIVUS CAP 250MG ......................... 21 APTIVUS SOL ................................... 21

aquadeks dro ................................. 112 AQUA-E LIQ ................................... 112

aquanil hc lot 1% ............................ 137 ARALAST NP INJ 1000MG ................. 132

ARALAST NP INJ 400MG .................. 132 ARALAST NP INJ 500MG .................. 132

ARALAST NP INJ 800MG .................. 132 aranelle tab ...................................... 78

ARCALYST INJ 220MG ..................... 102 aripiprazole tab 10 mg ....................... 65

aripiprazole tab 15 mg ....................... 65

aripiprazole tab 2 mg ........................ 65 aripiprazole tab 20 mg ....................... 65

aripiprazole tab 30 mg ....................... 65 aripiprazole tab 5 mg ........................ 65

artifi tears sol op ............................ 121 artificial sol tears ............................ 121

ASACOL HD TAB 800MG .................... 90 ASCORBIC ACD POW ....................... 113

ascorbic acid cap cr 500 mg ............. 113 ascorbic acid chew tab 250 mg ......... 113

ascorbic acid syrup 500 mg/5ml ....... 113 ascorbic acid tab 100 mg ................. 113

ascorbic acid tab 1000 mg ............... 113 ascorbic acid tab 250 mg ................. 113

ascorbic acid tab 500 mg ................. 113

ascorbic acid tab cr 500 mg ............. 113 ASCRIPTIN TAB ................................ 11

ASMANEX 120 AER 220MCG ............. 133 ASMANEX 14 AER 220MCG ............... 133

ASMANEX 30 AER 110MCG ............... 133 ASMANEX 30 AER 220MCG ............... 133

ASMANEX 60 AER 220MCG ............... 133 ASPIRIN SUP 120MG ......................... 11

ASPIRIN SUP 200MG ......................... 11 ASPIRIN SUP 60MG ........................... 11

aspirin suppos 300 mg ...................... 11 aspirin suppos 600 mg ...................... 11

aspirin tab 325 mg ............................ 11 ASPIRIN TAB 650MG EC .................... 11

aspirin tab 81 mg ............................. 11

aspirin tab delayed release 325 mg ..... 11 aspirin tab delayed release 500 mg ..... 11

aspirin tab delayed release 650 mg .... 11

ASTEPRO SPR 0.15% ...................... 123 asthma relf tab 12.5-200 ................ 125

atenolol & chlorthalidone tab 100-25 mg...................................................... 46

atenolol & chlorthalidone tab 50-25 mg...................................................... 45

atenolol tab 100 mg ......................... 46 atenolol tab 25 mg ........................... 46

atenolol tab 50 mg ........................... 46 ath foot spr aer 1% ........................ 136

atorvastatin calcium tab 10 mg (base equivalent) ...................................... 44

atorvastatin calcium tab 20 mg (base equivalent) ...................................... 44

atorvastatin calcium tab 40 mg (base

equivalent) ...................................... 44 atorvastatin calcium tab 80 mg (base

equivalent) ...................................... 44 atovaquone susp 750 mg/5ml ............ 18

atovaquone-proguanil hcl tab 250-100 mg...................................................... 21

atovaquone-proguanil hcl tab 62.5-25 mg...................................................... 21

ATRIPLA TAB ................................... 23 ATROVENT HFA AER 17MCG ............ 122

aubra tab 0.1-0.02 ........................... 78 AUVI-Q INJ 0.15MG ........................ 132

AUVI-Q INJ 0.3MG .......................... 132 AVASTIN INJ ................................... 34

AVASTIN INJ 400/16ML..................... 34

aviane tab ....................................... 78 AVITA CRE 0.025% ........................ 134

AVITA GEL 0.025% ........................ 134 AVODART CAP 0.5MG ....................... 95

AXID AR TAB 75MG .......................... 89 AYR NASAL DRO 0.65% .................. 125

AYR SALINE GEL NASAL .................. 125 azacitidine for inj 100 mg .................. 33

AZACTAM INJ 1GM ........................... 18 AZACTAM INJ 2GM ........................... 18

AZACTAM/DEX INJ 1GM .................... 18 AZACTAM/DEX INJ 2GM .................... 18

azathioprine tab 50 mg ................... 103 azelastine hcl nasal spray 0.1% (137

mcg/spray) ................................... 123

azelastine hcl nasal spray 0.15% (205.5 mcg/spray) ................................... 123

148

azelastine hcl ophth soln 0.05% ....... 120

AZILECT TAB 0.5MG .......................... 63 AZILECT TAB 1MG............................. 63

azithromycin for susp 100 mg/5ml ...... 27 azithromycin for susp 200 mg/5ml ...... 27

azithromycin iv for soln 500 mg .......... 27 AZITHROMYCIN POWD PACK FOR SUSP 1

GM .................................................. 27 azithromycin tab 250 mg ................... 27

azithromycin tab 500 mg ................... 27 azithromycin tab 600 mg ................... 27

AZOPT SUS 1% OP ......................... 120 AZOR TAB 10-20MG .......................... 42

AZOR TAB 10-40MG .......................... 42 AZOR TAB 5-20MG ............................ 42

AZOR TAB 5-40MG ............................ 42

aztreonam for inj 1 gm ...................... 18 aztreonam for inj 2 gm ...................... 18

B b complex tab form 1 ...................... 113

B-1 TAB 500MG .............................. 113 b-100 complx tab ........................... 113

B-12 DOTS TAB 500MCG ................. 113 B-12 TAB 2500MCG......................... 113

B-12 TAB 5000MCG......................... 113 b-50 tr tab ..................................... 113

bacitracin oint 500 unit/gm .............. 135 bacitracin ophth oint 500 unit/gm ..... 119

bacitracin zinc oint 500 unit/gm ........ 135 bacitracin-polymyxin b ophth oint ..... 119

bacitracin-polymyxin-neomycin-hc ophth

oint 1% ......................................... 118 baclofen tab 10 mg ........................... 73

baclofen tab 20 mg ........................... 73 balsalazide disodium cap 750 mg ........ 90

balziva tab ....................................... 78 BANZEL SUS 40MG/ML ...................... 54

BANZEL TAB 200MG .......................... 54 BANZEL TAB 400MG .......................... 54

BARACLUDE SOL .05MG/ML ............... 24 BARC LIQ ....................................... 141

bayer low chw 81mg ......................... 11 BCG VACCINE INJ ........................... 104

b-complex tab 50 tr ........................ 113 b-complex vitamin cap .................... 113

b-complex vitamin sublingual liquid ... 113

b-complex vitamin tab ..................... 113 b-complex w/ c & calcium tab ........... 113

b-complex w/ c cap ........................ 113

bee zee tab ................................... 113 BEELITH TAB ................................. 109

benazepril & hydrochlorothiazide tab 10-12.5 mg ..................................... 39

benazepril & hydrochlorothiazide tab 20-12.5 mg ..................................... 39

benazepril & hydrochlorothiazide tab 20-25 mg ........................................ 39

benazepril & hydrochlorothiazide tab 5-6.25 mg ....................................... 39

benazepril hcl tab 10 mg ................... 40 benazepril hcl tab 20 mg ................... 40

benazepril hcl tab 40 mg ................... 40 benazepril hcl tab 5 mg ..................... 40

BENEFIBER CHW .............................. 90

BENEFIBER POW .............................. 91 BENICAR HCT TAB 20-12.5 ................ 42

BENICAR HCT TAB 40-12.5 ................ 42 BENICAR HCT TAB 40-25MG .............. 42

BENICAR TAB 20MG ......................... 42 BENICAR TAB 40MG ......................... 42

BENICAR TAB 5MG ........................... 42 benzonatate cap 100 mg ................. 125

benzonatate cap 200 mg ................. 125 benzoyl per gel 10% ....................... 135

BENZOYL PER GEL 2.5% ................. 135 benzoyl per gel 5% ........................ 135

benzoyl per liq 5% wash ................. 135 benzoyl per lot 6% ......................... 135

benzoyl peroxide-erythromycin gel 5-3%

.................................................... 134 benztropine mesylate inj 1 mg/ml ...... 63

benztropine mesylate tab 0.5 mg ....... 63 benztropine mesylate tab 1 mg .......... 63

benztropine mesylate tab 2 mg .......... 63 BEPREVE DRO 1.5% ....................... 120

BESIVANCE SUS 0.6% .................... 119 beta carotene cap 25000 unit .......... 113

betamethasone dipropionate augmented cream 0.05% ................................. 137

betamethasone dipropionate augmented gel 0.05% ..................................... 137

betamethasone dipropionate augmented lotion 0.05% ................................. 138

betamethasone dipropionate augmented

oint 0.05% .................................... 138 betamethasone dipropionate cream

149

0.05% ........................................... 138

betamethasone dipropionate lotion 0.05% .................................................... 138

betamethasone dipropionate oint 0.05% .................................................... 138

betamethasone valerate cream 0.1% 138 betamethasone valerate lotion 0.1% . 138

betamethasone valerate oint 0.1%.... 138 BETASERON INJ 0.3MG ...................... 72

betaxolol hcl ophth soln 0.5% .......... 120 bethanechol chloride tab 10 mg .......... 95

bethanechol chloride tab 25 mg .......... 95 bethanechol chloride tab 5 mg ............ 95

bethanechol chloride tab 50 mg .......... 95 BETOPTIC-S SUS 0.25% OP ............. 120

BEXSERO INJ ................................. 104

bicalutamide tab 50 mg ..................... 35 BICILLIN L-A INJ 1200000 ................. 30

BICILLIN L-A INJ 2400000 ................. 30 BICILLIN L-A INJ 600000 ................... 30

BICLORA LIQ .................................. 125 BICLORA TAB 25-25MG ................... 125

BICNU INJ 100MG ............................. 32 BIFERA TAB 28MG ............................ 99

BILTRICIDE TAB 600MG .................... 18 bio-d-mulsio liq 2000unit ................. 113

bio-d-mulsio liq 400unit ................... 113 BIOSPEC DMX LIQ .......................... 125

biotin tab 300 mcg .......................... 113 bisacodyl tab & peg 3350-kcl-sod

bicarb-nacl for soln kit ....................... 91

bisoprolol & hydrochlorothiazide tab 10-6.25 mg ...................................... 46

bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg ..................................... 46

bisoprolol & hydrochlorothiazide tab 5-6.25 mg ....................................... 46

bisoprolol fumarate tab 10 mg ............ 46 bisoprolol fumarate tab 5 mg ............. 46

BIVIGAM INJ 10% ........................... 101 bleomycin sulfate for inj 15 unit .......... 33

bleomycin sulfate for inj 30 unit .......... 33 blephamide oin s.o.p. ...................... 118

BLINK TEARS DRO 0.25% OP ........... 121 BLK DRAUGHT CHW 10MG ................. 91

BLK DRAUGHT SYP 90/15ML .............. 91

B-NATAL LOZ 25MG ........................ 113 BONE DENSITY TAB ........................ 109

bone meal w/ vitamin d tab ............. 109

BOOSTRIX INJ ............................... 104 BOSULIF TAB 100MG ........................ 36

BOSULIF TAB 500MG ........................ 36 BOUDREAUXS OIN 16% .................. 140

BP CLEANSING LOT 4% .................. 135 bp wash liq 5.25% ......................... 135

BREO ELLIPTA INH 100-25 .............. 134 BREO ELLIPTA INH 200-25 .............. 134

brewers yeast tab .......................... 113 briellyn tab ...................................... 78

BRILINTA TAB 90MG ....................... 101 BRIMONIDINE TARTRATE OPHTH SOLN

0.15% .......................................... 120 brimonidine tartrate ophth soln 0.2% 120

BRINTELLIX TAB 10MG ..................... 60

BRINTELLIX TAB 20MG ..................... 60 BRINTELLIX TAB 5MG ....................... 60

BROHIST D TAB 4-10MG ................. 125 BROMFENAC SODIUM OPHTH SOLN

0.09% (BASE EQUIV) (ONCE-DAILY) 119 bromfenac sodium ophth soln 0.09%

(base equivalent) ........................... 119 bromocriptine mesylate cap 5 mg ....... 63

bromocriptine mesylate tab 2.5 mg .... 63 BROVEX PSB LIQ ............................ 125

BROVEX PSB LIQ DM ...................... 125 budesonide cap sr 24hr 3 mg ............. 90

budesonide inhalation susp 0.25 mg/2ml.................................................... 133

budesonide inhalation susp 0.5 mg/2ml

.................................................... 133 buffered tab salt ............................ 109

BUFFERIN TAB 500MG ...................... 11 BUFFERIN TAB 81MG ........................ 11

bumetanide inj 0.25 mg/ml ............... 50 bumetanide tab 0.5 mg ..................... 50

bumetanide tab 1 mg ....................... 50 bumetanide tab 2 mg ....................... 50

buprenorphine hcl sl tab 2 mg (base equiv) ............................................. 73

buprenorphine hcl sl tab 8 mg (base equiv) ............................................. 73

buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) ...................... 73

buprenorphine hcl-naloxone hcl sl tab 8-2

mg (base equiv) ............................... 73 buproban tab 150mg ........................ 73

150

bupropion hcl tab 100 mg .................. 60

bupropion hcl tab 75 mg .................... 60 bupropion hcl tab sr 12hr 100 mg ....... 60

bupropion hcl tab sr 12hr 150 mg ....... 60 bupropion hcl tab sr 12hr 200 mg ....... 60

bupropion hcl tab sr 24hr 150 mg ....... 60 bupropion hcl tab sr 24hr 300 mg ....... 60

buspirone hcl tab 10 mg .................... 53 buspirone hcl tab 15 mg .................... 53

buspirone hcl tab 30 mg .................... 53 buspirone hcl tab 5 mg ...................... 53

buspirone hcl tab 7.5 mg ................... 53 BUSULFEX INJ 6MG/ML ...................... 32

butorphanol tartrate inj 1 mg/ml ........ 14 butorphanol tartrate inj 2 mg/ml ........ 14

BYSTOLIC TAB 10MG ......................... 46

BYSTOLIC TAB 2.5MG ........................ 46 BYSTOLIC TAB 20MG ......................... 46

BYSTOLIC TAB 5MG .......................... 46 C c-500 chw 500mg ........................... 113 ca citrate tab + d ............................ 109

CA CITRATE TAB 250MG .................. 109 CA GLUCONATE TAB 50MG ............... 109

CA LACTATE TAB 100MG .................. 109 CA/MG TAB .................................... 109

CA/MG/ZN TAB ............................... 109 cabergoline tab 0.5 mg ...................... 84

cafergot tab 1-100mg ........................ 71 cal antacid chw 1000mg .................... 87

CAL CIT MAL/ TAB VITAMIND ........... 109

CAL/MAG TAB CHEW ....................... 109 CAL/MAG/VITD TAB ........................ 109

calc antacid chw 500mg ..................... 87 calc antacid chw 750mg ..................... 87

calc citrate tab +d........................... 109 CALC CITRATE TAB 200MG .............. 109

CALC GUMMIES CHW CHILD ............. 109 CALCET CHW BITES ........................ 109

CALCET PETIT TAB 200-250 ............. 109 calciferol dro 8000/ml ..................... 113

CALCI-MIX CAP 1250MG .................. 109 CALCIONATE SYP 1.8GM/5 ............... 109

calcipotriene cream 0.005% ............. 137 calcipotriene oint 0.005% ................ 137

calcipotriene soln 0.005% (50 mcg/ml)

.................................................... 137 calcitonin (salmon) nasal soln 200 unit/act

...................................................... 84

CAL-CITRATE TAB PLUS D ............... 109 calcitrene oin 0.005% ..................... 137

calcitriol cap 0.25 mcg .................... 113 calcitriol cap 0.5 mcg ...................... 113

calcitriol inj 1 mcg/ml ..................... 113 calcitriol oral soln 1 mcg/ml ............. 113

CALCIUM &MAG TAB ....................... 109 calcium + d chw ............................. 109

CALCIUM 1000 TAB + D .................. 109 calcium 1200 chw .......................... 109

CALCIUM 500 TAB .......................... 109 calcium 500 tab +d ........................ 109

calcium 600 chw +d/mnrls .............. 109 calcium 600 tab ............................. 109

calcium 600 tab vit d/mi ................. 109

calcium acetate (phosphate binder) cap 667 mg (169 mg ca)......................... 85

calcium ascorbate tab 500 mg ......... 113 CALCIUM CARB CHW 260MG ........... 110

CALCIUM CARB POW 800/2GM ......... 110 CALCIUM CARB TAB 648MG ............... 87

calcium carbonate susp 1250 mg/5ml (500 mg/5ml elemental ca) ............. 110

calcium carbonate tab 1250 mg (500 mg elemental ca) ................................ 110

calcium carbonate-cholecalciferol tab 500 mg-400 unit .................................. 110

calcium carbonate-cholecalciferol tab 600 mg-200 unit .................................. 110

calcium carbonate-cholecalciferol tab 600

mg-400 unit .................................. 110 calcium carbonate-vitamin d tab 500





mg-400 unit .................................. 110 CALCIUM CHW GUMMIES ................ 110

CALCIUM CIT/ TAB VIT D ................ 110 calcium citrate tab 950 mg (200 mg

elemental ca) ................................ 110

calcium citrate-vitamin d tab 200 mg-250 unit (elemental ca) ......................... 110

151

calcium for chw women ................... 110

CALCIUM GLUC TAB 500MG ............. 110 calcium gluconate tab 500 mg .......... 110

CALCIUM GRA CITRATE ................... 110 CALCIUM LACT TAB 648MG .............. 110

calcium lactate tab 650 mg .............. 110 calcium pantothenate tab 500 mg ..... 113

calcium soft chw chocolat ................ 110 calcium tab 500 mg ........................ 110

calcium tab 600 mg ........................ 110 CALCIUM TAB FORMULA .................. 110

calcium w/ magnesium tab 500-250 mg .................................................... 110

calcium w/ vitamin d tab 600 mg-125 unit .................................................... 110

CALCIUM/C/D CHW 500MG .............. 111

calcium/d chw 500-400 ................... 111 CALCIUM/D3 TAB ............................ 111

calcium/d3 tab 600-800 ................... 111 calcium/magn tab zinc ..................... 111

calcium+d3 tab 600-800 .................. 111 calcium+d3 tab grad rel................... 111

CAL-GLU CAP 500MG....................... 109 cal-mag aspa tab 333-167 ............... 109

CALMAG THINS TAB 200-50MG ........ 111 CALNA TAB .................................... 113

CAL-QUICK LIQ 500-400 .................. 109 CALTRATE 600 CHW +D PLUS .......... 111

caltrate 600 chw 600-800 ................ 111 caltrate 600 tab .............................. 111

calvite p&d tab ............................... 111

camila tab 0.35mg ............................ 78 CANASA SUP 1000MG ....................... 90

CANCIDAS INJ 50MG ......................... 20 CANCIDAS INJ 70MG ......................... 20

CAPASTAT SUL INJ 1GM .................... 24 CAPCOF SYP ................................... 125

CAPMIST DM TAB ............................ 125 CAPRELSA TAB 100MG ...................... 36

CAPRELSA TAB 300MG ...................... 36 captopril & hydrochlorothiazide tab 25-15

mg .................................................. 39 captopril & hydrochlorothiazide tab 25-25

mg .................................................. 39 captopril & hydrochlorothiazide tab 50-15

mg .................................................. 39

captopril & hydrochlorothiazide tab 50-25 mg .................................................. 39

captopril tab 100 mg ........................ 40

captopril tab 12.5 mg ....................... 40 captopril tab 25 mg .......................... 40

captopril tab 50 mg .......................... 40 CARBAGLU TAB 200MG ..................... 81

carbamazepine cap sr 12hr 100 mg .... 54 carbamazepine cap sr 12hr 200 mg .... 54

carbamazepine cap sr 12hr 300 mg .... 54 carbamazepine chew tab 100 mg ....... 54

carbamazepine susp 100 mg/5ml ....... 54 carbamazepine tab 200 mg ............... 54

carbamazepine tab sr 12hr 200 mg .... 54 carbamazepine tab sr 12hr 400 mg .... 54

carbidopa & levodopa orally disintegrating tab 10-100 mg ................................. 63

carbidopa & levodopa orally disintegrating

tab 25-100 mg ................................. 63 carbidopa & levodopa orally disintegrating

tab 25-250 mg ................................. 63 carbidopa & levodopa tab 10-100 mg . 63

carbidopa & levodopa tab 25-100 mg . 64 carbidopa & levodopa tab 25-250 mg . 64

carbidopa & levodopa tab cr 25-100 mg...................................................... 64

carbidopa & levodopa tab cr 50-200 mg...................................................... 64

CARBIDOPA-LEVODOPA-ENTACAPONE TABS 12.5-50-200 MG ...................... 64

CARBIDOPA-LEVODOPA-ENTACAPONE TABS 18.75-75-200 MG .................... 64

CARBIDOPA-LEVODOPA-ENTACAPONE

TABS 25-100-200 MG ....................... 64 CARBIDOPA-LEVODOPA-ENTACAPONE

TABS 31.25-125-200 MG .................. 64 CARBIDOPA-LEVODOPA-ENTACAPONE

TABS 37.5-150-200 MG .................... 64 CARBIDOPA-LEVODOPA-ENTACAPONE

TABS 50-200-200 MG ....................... 64 carboplatin iv soln 150 mg/15ml ........ 37

carboplatin iv soln 450 mg/45ml ........ 37 carboplatin iv soln 50 mg/5ml ............ 37

carboplatin iv soln 600 mg/60ml ........ 37 cardec dm dro ............................... 125

cardec dro ..................................... 125 CARIMUNE NF INJ 12GM ................. 101

CARIMUNE NF INJ 3GM ................... 101

CARIMUNE NF INJ 6GM ................... 101 carteolol hcl ophth soln 1% ............. 120

152

carvedilol tab 12.5 mg ....................... 46

carvedilol tab 25 mg ......................... 46 carvedilol tab 3.125 mg ..................... 46

carvedilol tab 6.25 mg ....................... 46 castellani paint ............................... 136

CAYSTON INH 75MG ......................... 18 cefaclor cap 250 mg .......................... 25

cefaclor cap 500 mg .......................... 25 cefaclor er tab 500mg ....................... 25

cefaclor for susp 125 mg/5ml ............. 25 cefaclor for susp 250 mg/5ml ............. 25

cefaclor for susp 375 mg/5ml ............. 25 cefadroxil cap 500 mg ....................... 25

cefadroxil for susp 250 mg/5ml .......... 25 cefadroxil for susp 500 mg/5ml .......... 25

cefadroxil tab 1 gm ........................... 25

cefazolin inj 1gm/50ml ...................... 26 cefazolin sodium for inj 1 gm.............. 26

cefazolin sodium for inj 10 gm ............ 26 cefazolin sodium for inj 20 gm ............ 26

cefazolin sodium for inj 500 mg .......... 26 cefazolin sodium for iv soln 1 gm ........ 26

cefdinir cap 300 mg .......................... 26 cefdinir for susp 125 mg/5ml .............. 26

cefdinir for susp 250 mg/5ml .............. 26 cefepime hcl for inj 1 gm ................... 26

cefepime hcl for inj 2 gm ................... 26 cefixime for susp 100 mg/5ml ............ 26

cefixime for susp 200 mg/5ml ............ 26 cefotaxime sodium for inj 1 gm .......... 26

cefotaxime sodium for inj 2 gm .......... 26

cefotaxime sodium for inj 500 mg ....... 26 cefoxitin sodium for inj 10 gm ............ 26

cefoxitin sodium for iv soln 1 gm ........ 26 cefoxitin sodium for iv soln 2 gm ........ 26

cefpodoxime proxetil for susp 100 mg/5ml ...................................................... 26

cefpodoxime proxetil for susp 50 mg/5ml ...................................................... 26

cefpodoxime proxetil tab 100 mg ........ 26 cefpodoxime proxetil tab 200 mg ........ 26

cefprozil for susp 125 mg/5ml ............ 26 cefprozil for susp 250 mg/5ml ............ 26

cefprozil tab 250 mg ......................... 26 cefprozil tab 500 mg ......................... 26

ceftazidime for inj 1 gm ..................... 26

ceftazidime for inj 2 gm ..................... 26 ceftazidime for inj 6 gm ..................... 26

CEFTAZIDIME/ SOL D5W 1GM ........... 26

CEFTAZIDIME/ SOL D5W 2GM ........... 26 ceftriaxone sodium for inj 1 gm ......... 26

ceftriaxone sodium for inj 10 gm ........ 26 ceftriaxone sodium for inj 2 gm ......... 26

ceftriaxone sodium for inj 250 mg ...... 26 ceftriaxone sodium for inj 500 mg ...... 26

ceftriaxone sodium for iv soln 1 gm .... 26 ceftriaxone sodium for iv soln 2 gm .... 26

cefuroxime axetil tab 250 mg ............ 27 cefuroxime axetil tab 500 mg ............ 27

cefuroxime inj 7.5gm ........................ 27 cefuroxime sodium for inj 1.5 gm ....... 27

cefuroxime sodium for inj 7.5 gm ....... 27 cefuroxime sodium for inj 750 mg ...... 27

cefuroxime sodium for iv soln 1.5 gm . 27

celecoxib cap 100 mg ....................... 12 celecoxib cap 200 mg ....................... 12

celecoxib cap 400 mg ....................... 12 celecoxib cap 50 mg ......................... 12

CELONTIN CAP 300MG ...................... 54 central-vite tab performa ................ 113

CENTRUM CHW SILVER ................... 113 centrum kids chw complete ............. 113

cephalexin cap 250 mg ..................... 27 cephalexin cap 500 mg ..................... 27

cephalexin for susp 125 mg/5ml ........ 27 cephalexin for susp 250 mg/5ml ........ 27

CERDELGA CAP 84MG ....................... 81 CEREZYME INJ 200UNIT .................... 81

CEREZYME INJ 400UNIT .................... 81

cerovite adv liq formula .................. 114 CERVARIX INJ ................................ 104

cetirizine hcl chew tab 10 mg ........... 123 cetirizine hcl chew tab 5 mg ............ 123

cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) ....................................... 123

cetirizine hcl tab 5 mg .................... 123 cetirizine sol 5mg/5ml .................... 123

cevimeline hcl cap 30 mg ................ 142 CHANTIX PAK 0.5& 1MG ................... 73

CHANTIX PAK 1MG ........................... 74 CHANTIX TAB 0.5MG ........................ 74

CHANTIX TAB 1MG ........................... 74 CHELATED CA TAB 200MG ............... 111

CHEMET CAP 100MG ......................... 77

cheratussin sol dac ......................... 125 chewabl vite chw childrns ................ 114

153

CHILD ADVIL SUS COLD .................. 125

child chew/ chw extra c ................... 114 child comple chw allergy .................. 123

CHILD MOTRIN CHW 50MG ................ 11 CHILD-MULTI CHW VITAMINS .......... 114

childrens sus plus cld ...................... 126 chld asafree elx 80/2.5ml .................. 11

chld decongs liq 15mg/5ml .............. 126 CHLO TUSS EX LIQ 12.5-100 ............ 126

chlorhexidine gluconate soln 0.12% .. 142 chloroquine phosphate tab 250 mg ..... 21

chloroquine phosphate tab 500 mg ..... 21 chlorothiazide tab 250 mg .................. 50

chlorothiazide tab 500 mg .................. 50 chlorpheniramine maleate tab 4 mg .. 123

chlorpheniramine maleate tab cr 12 mg

.................................................... 123 chlorpromaz inj 50mg/2ml ................. 65

chlorpromazine hcl tab 10 mg ............ 65 chlorpromazine hcl tab 100 mg ........... 65

chlorpromazine hcl tab 200 mg ........... 65 chlorpromazine hcl tab 25 mg ............ 65

chlorpromazine hcl tab 50 mg ............ 65 chlorthalidone tab 25 mg ................... 50

chlorthalidone tab 50 mg ................... 50 cholecalciferol cap 2000 unit ............ 114

CHOLECALCIFEROL CAP 400 UNIT .... 114 cholecalciferol cap 5000 unit ............ 114

cholecalciferol drops 5000 unit/ml (1000 unit/0.2ml) .................................... 114

cholecalciferol oral liquid 400 unit/ml 114

cholecalciferol tab 1000 unit ............. 114 cholecalciferol tab 2000 unit ............. 114

cholecalciferol tab 400 unit .............. 114 cholestyramine light powder packets 4 gm

...................................................... 45 cholestyramine powder 4 gm/dose ...... 45

cholestyramine powder packets 4 gm .. 45 choline fenofibrate cap dr 135 mg

(fenofibric acid equiv) ........................ 45 choline fenofibrate cap dr 45 mg

(fenofibric acid equiv) ........................ 45 ciclopirox gel 0.77% ........................ 136

ciclopirox olamine cream 0.77% (base equiv) ........................................... 136

ciclopirox olamine susp 0.77% (base

equiv) ........................................... 136 ciclopirox shampoo 1% .................... 136

cilostazol tab 100 mg ...................... 100

cilostazol tab 50 mg ....................... 100 CILOXAN OIN 0.3% OP ................... 119

cimetidine tab 200 mg ...................... 89 CIMZIA KIT ................................... 101

CIMZIA KIT STARTER ..................... 101 CIMZIA PREFL KIT 200MG/ML .......... 101

CINRYZE SOL 500 UNIT .................. 100 CIPRODEX SUS 0.3-0.1% ................ 142

ciprofloxacin 200 mg/100ml in d5w .... 28 ciprofloxacin 400 mg/200ml in d5w .... 28

ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) .......................... 28

ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) ...................... 28

ciprofloxacin hcl ophth soln 0.3% ..... 119

ciprofloxacin hcl tab 100 mg (base equiv)...................................................... 28




ciprofloxacin iv soln 200 mg/20ml (1%)...................................................... 28

ciprofloxacin iv soln 400 mg/40ml (1%)...................................................... 28

ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) ............................ 28

ciprofloxacin-ciprofloxacin hcl tab sr 24hr

500 mg (base eq) ............................ 28 cisplatin inj 100 mg/100ml (1 mg/ml) . 38

cisplatin inj 200 mg/200ml (1 mg/ml) . 38 cisplatin inj 50 mg/50ml (1 mg/ml) .... 38

cit calc/d tab 315-250 ..................... 111 citalopram hydrobromide oral soln 10

mg/5ml ........................................... 60 citalopram hydrobromide tab 10 mg (base

equiv) ............................................. 60 citalopram hydrobromide tab 20 mg (base

equiv) ............................................. 60 citalopram hydrobromide tab 40 mg (base

equiv) ............................................. 60 CITRACAL CAL CHW GUMMIES ......... 111

CITRACAL HRT TAB HEALTH ............ 111

CL PRENATAL TAB 28-0.8MG ........... 114 cladribine inj 1 mg/ml ....................... 33

154

claravis cap 10mg ........................... 134

claravis cap 20mg ........................... 134 claravis cap 30mg ........................... 134

claravis cap 40mg ........................... 134 clarithromycin for susp 125 mg/5ml .... 27

clarithromycin for susp 250 mg/5ml .... 27 clarithromycin tab 250 mg ................. 27

clarithromycin tab 500 mg ................. 27 clarithromycin tab sr 24hr 500 mg ...... 27

CLARITIN CAP 10MG ....................... 123 CLARITIN CHW 5MG ........................ 123

CLARITIN RDT TAB 5MG .................. 123 cld/cgh/sore liq throat ..................... 126

clean&clear cre 10% ....................... 135 CLEAR EYES DRO DRY EYES ............. 121

clindamax gel 1% ........................... 134

clindamycin hcl cap 150 mg ............... 18 clindamycin hcl cap 300 mg ............... 18

clindamycin hcl cap 75 mg ................. 18 clindamycin palmitate hcl for soln 75

mg/5ml (base equiv) ......................... 18 clindamycin phosphate gel 1% ......... 134

clindamycin phosphate inj 300 mg/2ml 18 clindamycin phosphate inj 600 mg/4ml 18

clindamycin phosphate inj 9 gm/60ml . 18 clindamycin phosphate inj 900 mg/6ml 18

clindamycin phosphate iv soln 300 mg/2ml ........................................... 18

clindamycin phosphate iv soln 600 mg/4ml ........................................... 19


mg/6ml ........................................... 19 clindamycin phosphate lotion 1% ...... 134

clindamycin phosphate soln 1% ........ 134 clindamycin phosphate swab 1% ...... 135

clindamycin phosphate vaginal cream 2% ...................................................... 96

CLINIMIX INJ 2.75/D5W .................. 106 CLINIMIX INJ 4.25/D10 ................... 106

CLINIMIX INJ 4.25/D20 ................... 106 CLINIMIX INJ 4.25/D25 ................... 106

CLINIMIX INJ 4.25/D5W .................. 106 CLINIMIX INJ 5%/D15W .................. 106

CLINIMIX INJ 5%/D20W .................. 106 CLINIMIX INJ 5%/D25W .................. 106

clobetasol e cre 0.05% .................... 138

clobetasol propionate cream 0.05% .. 138 clobetasol propionate gel 0.05% ....... 138

clobetasol propionate oint 0.05% ..... 138

clobetasol propionate soln 0.05% ..... 138 CLOFERA LIQ ................................. 126

clomipramine hcl cap 25 mg .............. 60 clomipramine hcl cap 50 mg .............. 60

clomipramine hcl cap 75 mg .............. 60 clonazepam orally disintegrating tab

0.125 mg ........................................ 54 clonazepam orally disintegrating tab 0.25

mg ................................................. 54 clonazepam orally disintegrating tab 0.5

mg ................................................. 54 clonazepam orally disintegrating tab 1 mg

...................................................... 54 clonazepam orally disintegrating tab 2 mg

...................................................... 54

clonazepam tab 0.5 mg ..................... 54 clonazepam tab 1 mg ....................... 54

clonazepam tab 2 mg ....................... 54 clonidine hcl tab 0.1 mg .................... 51

clonidine hcl tab 0.2 mg .................... 51 clonidine hcl tab 0.3 mg .................... 51

clonidine hcl td patch weekly 0.1 mg/24hr...................................................... 51



clopidogrel bisulfate tab 75 mg (base equiv) ........................................... 101

clorazepate dipotassium tab 15 mg .... 55

clorazepate dipotassium tab 3.75 mg .. 54 clorazepate dipotassium tab 7.5 mg ... 55

clotrimazole cre 2% .......................... 96 clotrimazole cream 1% ................... 136

clotrimazole soln 1% ...................... 136 clotrimazole troche 10 mg ............... 142

clotrimazole vaginal cream 1% .......... 96 CLOZAPINE ORALLY DISINTEGRATING

TAB 100 MG .................................... 65 CLOZAPINE ORALLY DISINTEGRATING

TAB 12.5 MG ................................... 65 CLOZAPINE ORALLY DISINTEGRATING

TAB 150 MG .................................... 66 CLOZAPINE ORALLY DISINTEGRATING

TAB 200 MG .................................... 66

CLOZAPINE ORALLY DISINTEGRATING TAB 25 MG ...................................... 65

155

clozapine tab 100 mg ........................ 66

clozapine tab 200 mg ........................ 66 clozapine tab 25 mg .......................... 66

clozapine tab 50 mg .......................... 66 CNTC CLD/FLU PAK DAY/NGHT ......... 126

CNTC CLD/FLU TAB MAX ST ............. 126 COARTEM TAB 20-120MG .................. 21

COD LIVER OIL ............................... 114 cod liver oil cap .............................. 114

CODAR AR LIQ ............................... 126 CODAR D LIQ ................................. 126

CODAR GF LIQ ............................... 126 CODITUSS DM SYP ......................... 126

colchicine w/ probenecid tab 0.5-500 mg ...................................................... 11

COLCRYS TAB 0.6MG......................... 11

cold head tab cong dt ...................... 126 cold medicin cap plus ...................... 126

cold multi pak day/nght ................... 126 cold multi-s tab night ...................... 126

cold relief tab plus .......................... 126 cold/allergy elx children ................... 126

cold/allery sus child ......................... 126 cold/cough elx child ........................ 126

cold/sinus tab relief ......................... 126 colestipol hcl granule packets 5 gm ..... 45

colestipol hcl granules 5 gm ............... 45 colestipol hcl tab 1 gm ....................... 45

colistimethate sodium for inj 150 mg ... 19 COMBIGAN SOL 0.2/0.5% ................ 121

COMBIPATCH DIS .05/.14 .................. 81

COMBIPATCH DIS .05/.25 .................. 81 COMBIVENT AER RESPIMAT ............. 122

COMETRIQ KIT 100MG ...................... 36 COMETRIQ KIT 140MG ...................... 36

COMETRIQ KIT 60MG ........................ 36 COMPLERA TAB ................................ 23

complete kit lice ............................. 141 COMPLETE SIN TAB RELIEF .............. 126

compro sup 25mg ............................. 88 COMPUTER EYE SOL DROPS ............. 121

comtrex sev pak cld/sinu ................. 126 COMVAX INJ................................... 104

CONEX SOL CLD/ALRG .................... 126 CONEX TAB 2-60MG ........................ 126

constulose sol 10gm/15 ..................... 91

contac tab cold+flu ......................... 126 COPAXONE INJ 20MG/ML ................... 72

COPAXONE INJ 40MG/ML .................. 73

CORAL CALCIU CAP ........................ 111 CORAL CALCIU CAP 1000MG ........... 111

CORAL CALCIU CAP PLUS ................ 111 CORAL CAP CALCIUM ...................... 111

coricidin cap cong/cgh .................... 126 coricidin liq hbp .............................. 126

cormax scalp sol 0.05% .................. 138 corn dextrin oral powder ................... 91

cortaid spr 1% ............................... 138 cortisone acetate tab 25 mg .............. 82

cortizone-10 gel 1% ....................... 138 cough & cold tab ............................ 126

cough & sore liq thrt day ................. 126 cough cont liq dm max .................... 126

COUGH D SYP ................................ 126

cough dm liq 30mg/5ml .................. 126 COUMADIN TAB 10MG ...................... 97

COUMADIN TAB 1MG ........................ 97 COUMADIN TAB 2.5MG ..................... 97

COUMADIN TAB 2MG ........................ 97 COUMADIN TAB 3MG ........................ 97

COUMADIN TAB 4MG ........................ 97 COUMADIN TAB 5MG ........................ 97

COUMADIN TAB 6MG ........................ 97 COUMADIN TAB 7.5MG ..................... 97

CREON CAP 12000UNT...................... 94 CREON CAP 24000UNT...................... 94

CREON CAP 3000UNIT ...................... 94 CREON CAP 36000UNT...................... 94

CREON CAP 6000UNIT ...................... 94

CRESTOR TAB 10MG ......................... 44 CRESTOR TAB 20MG ......................... 44

CRESTOR TAB 40MG ......................... 44 CRESTOR TAB 5MG .......................... 44

CRIXIVAN CAP 200MG ...................... 21 CRIXIVAN CAP 400MG ...................... 21

cromolyn sodium nasal aerosol soln 5.2 mg/act (4%) ................................. 126

cromolyn sodium ophth soln 4% ...... 120 cromolyn sodium oral conc 100 mg/5ml

...................................................... 93 cromolyn sodium soln nebu 20 mg/2ml

.................................................... 132 cryselle-28 tab 28 tabs ..................... 78

CUBICIN SOL 500MG ........................ 19

CUVPOSA SOL 1MG/5ML ................... 89 cvs fiber chw gummies...................... 91

156

cvs nasal spr mist ........................... 126

cvs vit b-6 tab 200mg ..................... 114 cyanocobalamin inj 1000 mcg/ml ...... 114

cyanocobalamin liquid 1000 mcg/15ml .................................................... 114

cyanocobalamin tab 100 mcg ........... 114 cyanocobalamin tab 1000 mcg ......... 114

cyanocobalamin tab 2000 mcg ......... 114 cyanocobalamin tab 250 mcg ........... 114

cyanocobalamin tab 50 mcg ............. 114 cyanocobalamin tab 500 mcg ........... 114

cyanocobalamin tab cr 1000 mcg ...... 114 cyanocobalamin tab sl 1000 mcg ...... 114

cyanocobalamin tab sl 2500 mcg ...... 114 cyclafem tab 1/35 ............................. 78

cyclafem tab 7/7/7 ............................ 78

cyclobenzaprine hcl tab 10 mg ........... 73 cyclobenzaprine hcl tab 5 mg ............. 73

CYCLOPHOSPH CAP 25MG .................. 32 CYCLOPHOSPH CAP 50MG .................. 32

cyclophosphamide for inj 1 gm ........... 32 cyclophosphamide for inj 2 gm ........... 32

cyclophosphamide for inj 500 mg ........ 32 cycloserine cap 250 mg ..................... 24

cyclosporine cap 100 mg ................. 103 cyclosporine cap 25 mg ................... 103

cyclosporine iv soln 50 mg/ml .......... 103 cyclosporine modified cap 100 mg .... 103

cyclosporine modified cap 25 mg ...... 103 cyclosporine modified cap 50 mg ...... 103

cyclosporine modified oral soln 100 mg/ml

.................................................... 103 CYSTADANE POW .............................. 81

CYSTAGON CAP 150MG ..................... 81 CYSTAGON CAP 50MG ....................... 81

cytarabine inj 20 mg/ml .................... 33 CYTO B2 POW ................................ 114

D d.o.s. cap 250mg .............................. 91

D10W/NACL INJ 0.2% ..................... 107 D3 DOTS TAB 2000UNIT .................. 114

D5W/LYTES INJ #48 ....................... 107 D5W/NACL INJ 0.3% ....................... 107

dacarbazine for inj 200 mg ................ 32 daily-vite/ tab iron .......................... 114

DALIRESP TAB 500MCG ................... 132

DALLERGY SYP ............................... 126 danazol cap 100 mg .......................... 80

danazol cap 200 mg ......................... 81

danazol cap 50 mg ........................... 80 dantrolene sodium cap 100 mg .......... 73

dantrolene sodium cap 25 mg ............ 73 dantrolene sodium cap 50 mg ............ 73

dapsone tab 100 mg ......................... 19 dapsone tab 25 mg .......................... 19

DAPTACEL INJ ............................... 104 DARAPRIM TAB 25MG ....................... 19

daunorubicin hcl inj 5 mg/ml (base equiv)...................................................... 32

day time liq cough .......................... 126 day/nite mis cold/flu ....................... 126

dayhist alrg tab 12 hour .................. 124 day-time cap sinus ......................... 126

deblitane tab 0.35mg........................ 78

DECARA CAP 25000UNT .................. 114 de-chlor dm liq liquid ...................... 126

DECON-A LIQ DROPS ...................... 127 decongestant tab 120mg er ............. 127

delsym child liq cgh/cold ................. 127 DELTUSS DP LIQ 1-30/5ML ............. 127

delyla tab 0.1-0.02 ........................... 78 DELZICOL CAP 400MG ...................... 90

demarest cre dricort ....................... 138 DEMSER CAP 250MG ........................ 51

DENAVIR CRE 1% .......................... 137 DEPEN TITRA TAB 250MG ................. 77

DEPO-PROVERA INJ 400/ML .............. 35 desenex aer 2% ............................. 136

desenex cre 1% ............................. 136

desenex spry aer liquid ................... 136 desipramine hcl tab 10 mg ................ 60

desipramine hcl tab 100 mg .............. 60 desipramine hcl tab 150 mg .............. 60

desipramine hcl tab 25 mg ................ 60 desipramine hcl tab 50 mg ................ 60

desipramine hcl tab 75 mg ................ 60 DESITIN CRE 13% ......................... 140

desmopressin acetate inj 4 mcg/ml .... 86 DESMOPRESSIN ACETATE NASAL SOLN

0.01% (REFRIGERATED) ................... 86 desmopressin acetate nasal spray soln

0.01% ............................................ 86 desmopressin acetate nasal spray soln

0.01% (refrigerated) ........................ 87

desmopressin acetate tab 0.1 mg ....... 87 desmopressin acetate tab 0.2 mg ....... 87

157

desogest-eth estrad & eth estrad tab

0.15-0.02/0.01 mg(21/5) .................. 78 DESONIDE CREAM 0.05% ................ 138

desonide lotion 0.05% ..................... 138 desonide oint 0.05% ....................... 138

desoximetasone cream 0.05% .......... 138 desoximetasone cream 0.25% .......... 138

desoximetasone gel 0.05% .............. 138 DESOXIMETASONE OINT 0.05% ....... 138

desoximetasone oint 0.25% ............. 138 dexamethason con 1mg/ml ................ 82

dexamethasone elixir 0.5 mg/5ml ....... 82 dexamethasone sod phosphate

preservative free inj 10 mg/ml ........... 82 dexamethasone sodium phosphate inj 10

mg/ml ............................................. 82

dexamethasone sodium phosphate inj 100 mg/10ml ......................................... 82

dexamethasone sodium phosphate inj 120 mg/30ml ......................................... 82

dexamethasone sodium phosphate inj 20 mg/5ml ........................................... 82

dexamethasone sodium phosphate ophth soln 0.1% ...................................... 119

dexamethasone soln 0.5 mg/5ml ........ 82 dexamethasone tab 0.5 mg ................ 82

dexamethasone tab 0.75 mg .............. 82 dexamethasone tab 1 mg .................. 82

dexamethasone tab 1.5 mg ................ 82 dexamethasone tab 2 mg .................. 82

dexamethasone tab 4 mg .................. 82

dexamethasone tab 6 mg .................. 82 DEXATREX D ELX CF-NASAL ............. 127

DEXFERRUM INJ 50MG/ML ................. 99 DEXILANT CAP 30MG DR ................... 94

DEXILANT CAP 60MG DR ................... 94 dexrazoxane for inj 250 mg ............... 38

dextromethorphan-guaifenesin tab 20-400 mg ..................................... 127

DEXTROSE 10% W/ SODIUM CHLORIDE 0.45% ........................................... 107

DEXTROSE 2.5% W/ SODIUM CHLORIDE 0.45% ........................................... 107

DEXTROSE 5% IN LACTATED RINGERS .................................................... 107

DEXTROSE 5% W/ SODIUM CHLORIDE

0.2% ............................................. 107 DEXTROSE 5% W/ SODIUM CHLORIDE

0.225% ........................................ 107

DEXTROSE 5% W/ SODIUM CHLORIDE 0.33% .......................................... 107

DEXTROSE 5% W/ SODIUM CHLORIDE 0.45% .......................................... 107

DEXTROSE 5% W/ SODIUM CHLORIDE 0.9% ............................................ 107

DEXTROSE INJ 10% ....................... 107 DEXTROSE INJ 5% ......................... 107

DEXTROSE INJ 50% ....................... 107 dextrose inj 70% ........................... 107

DEX-TUSS LIQ 300-10/5 ................. 127 DIABETIC CAP COLD/FLU ................ 127

DIALYVITE 80 TAB ZINC 15 ............. 114 dialyvite tab 800 ............................ 114

diaper rash oin 40% ....................... 140

diaper rash oin creamy ................... 140 diazepam con 5mg/ml ...................... 55

diazepam inj 5 mg/ml ....................... 55 DIAZEPAM RECTAL GEL DELIVERY

SYSTEM 10 MG ................................ 55 DIAZEPAM RECTAL GEL DELIVERY

SYSTEM 2.5 MG ............................... 55 DIAZEPAM RECTAL GEL DELIVERY

SYSTEM 20 MG ................................ 55 diazepam soln 1 mg/ml ..................... 55

diazepam tab 10 mg ......................... 55 diazepam tab 2 mg........................... 55

diazepam tab 5 mg........................... 55 DICEL CD LIQ ................................ 127

diclofenac potassium tab 50 mg ......... 12

diclofenac sodium ophth soln 0.1% .. 119 diclofenac sodium tab delayed release 25

mg ................................................. 12 diclofenac sodium tab delayed release 50

mg ................................................. 12 diclofenac sodium tab delayed release 75

mg ................................................. 13 diclofenac sodium tab sr 24hr 100 mg 13

dicloxacillin sodium cap 250 mg ......... 30 dicloxacillin sodium cap 500 mg ......... 30

dicyclomine hcl cap 10 mg ................ 89 dicyclomine hcl oral soln 10 mg/5ml ... 89

dicyclomine hcl tab 20 mg ................. 89 didanosine delayed release capsule 125

mg ................................................. 21

didanosine delayed release capsule 200 mg ................................................. 21

158

didanosine delayed release capsule 250

mg .................................................. 21 didanosine delayed release capsule 400

mg .................................................. 21 DIFICID TAB 200MG .......................... 27

diflorasone diacetate cream 0.05% ... 138 diflorasone diacetate oint 0.05% ....... 138

diflunisal tab 500 mg ......................... 13 diges probio cap 250mg ..................... 88

digitek tab 0.125mg .......................... 49 digitek tab 0.25mg ............................ 49

digoxin inj 0.25 mg/ml ...................... 49 DIGOXIN ORAL SOLN 0.05 MG/ML ...... 49

digoxin tab 125 mcg (0.125 mg) ......... 49 digoxin tab 250 mcg (0.25 mg) .......... 49

dihydroergotamine mesylate inj 1 mg/ml

...................................................... 71 dilantin cap 100mg ........................... 55

dilantin cap 30mg ............................. 55 dilantin chw 50mg ............................ 55

DILANTIN-125 SUS 125/5ML .............. 55 diltiazem hcl cap sr 12hr 120 mg ........ 47

diltiazem hcl cap sr 12hr 60 mg .......... 47 diltiazem hcl cap sr 12hr 90 mg .......... 47

diltiazem hcl cap sr 24hr 120 mg ........ 47 diltiazem hcl cap sr 24hr 180 mg ........ 47

diltiazem hcl cap sr 24hr 240 mg ........ 47 diltiazem hcl coated beads cap sr 24hr 120

mg .................................................. 48 diltiazem hcl coated beads cap sr 24hr 180

mg .................................................. 48

diltiazem hcl coated beads cap sr 24hr 240 mg .................................................. 48



diltiazem hcl extended release beads cap sr 24hr 120 mg ................................ 48




diltiazem hcl extended release beads cap

sr 24hr 360 mg ................................ 48 diltiazem hcl extended release beads cap

sr 24hr 420 mg ................................ 48

diltiazem hcl iv soln 125 mg/25ml (5 mg/ml) ........................................... 48

diltiazem hcl iv soln 25 mg/5ml (5 mg/ml)...................................................... 48

diltiazem hcl iv soln 50 mg/10ml (5 mg/ml) ........................................... 48

diltiazem hcl tab 120 mg ................... 48 diltiazem hcl tab 30 mg ..................... 48

diltiazem hcl tab 60 mg ..................... 48 diltiazem hcl tab 90 mg ..................... 48

diltzac cap 120mg/24 ....................... 48 diltzac cap 180mg/24 ....................... 48

diltzac cap 240mg/24 ....................... 48 diltzac cap 300mg/24 ....................... 48

dimetane dx syp ............................ 127

dimetapp liq nighttim ...................... 127 DIMETAPP SYP CGH/COLD ............... 127

DIP/TET PED INJ 25-5LFU ............... 104 DIPENTUM CAP 250MG ..................... 90

diphenhydramine hcl cap 50 mg ....... 124 diphenhydramine hcl inj 50 mg/ml ... 124

diphenhydramine-acetaminophen tab 25-500 mg (sleep) ........................... 74

diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml ........................................... 93

diphenoxylate w/ atropine tab 2.5-0.025 mg ................................................. 93

disopyramide phosphate cap 100 mg .. 43 disopyramide phosphate cap 150 mg .. 43

disulfiram tab 250 mg ....................... 74

disulfiram tab 500 mg ....................... 74 DIURIL SUS 250/5ML........................ 50

divalproex sodium cap sprinkle 125 mg...................................................... 55

divalproex sodium tab delayed release 125 mg ........................................... 55



divalproex sodium tab sr 24 hr 250 mg55 divalproex sodium tab sr 24 hr 500 mg55

doans ex st tab 580mg ..................... 11 DOCETAXEL FOR INJ CONC 20 MG/ML 34

DOCETAXEL FOR INJ CONC 80 MG/4ML

(20 MG/ML) ..................................... 34 docetaxel inj 140/7ml ....................... 34

159

DOCETAXEL INJ 200MG/20 ................ 34

DOCETAXEL INJ 80MG/8ML ................ 34 docusate sodium liquid 150 mg/15ml .. 91

dok tab 100mg ................................. 91 DONATUSSIN SYP ........................... 127

donepezil hydrochloride orally disintegrating tab 10 mg .................... 59

donepezil hydrochloride orally disintegrating tab 5 mg ..................... 59

donepezil hydrochloride tab 10 mg ...... 59 donepezil hydrochloride tab 23 mg ...... 59

donepezil hydrochloride tab 5 mg ....... 59 dorzolamide hcl ophth soln 2% ......... 121

dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml ....................... 121

double antib oin .............................. 135

doxazosin mesylate tab 1 mg ............. 41 doxazosin mesylate tab 2 mg ............. 41

doxazosin mesylate tab 4 mg ............. 41 doxazosin mesylate tab 8 mg ............. 41

doxepin hcl cap 10 mg ....................... 60 doxepin hcl cap 100 mg ..................... 61

doxepin hcl cap 150 mg ..................... 61 doxepin hcl cap 25 mg ....................... 60

doxepin hcl cap 50 mg ....................... 60 doxepin hcl cap 75 mg ....................... 60

doxepin hcl conc 10 mg/ml ................ 61 doxorubicin hcl for inj 50 mg .............. 32

doxorubicin hcl inj 2 mg/ml ................ 32 doxorubicin hcl liposomal inj (for iv

infusion) 2 mg/ml ............................. 32

doxycycline hyclate cap 100 mg ......... 31 doxycycline hyclate cap 50 mg ........... 31

doxycycline hyclate for inj 100 mg ...... 31 doxycycline hyclate tab 100 mg .......... 31

doxycycline hyclate tab 20 mg ............ 31 doxycycline monohydrate cap 100 mg . 31

doxycycline monohydrate cap 50 mg ... 31 doxycycline monohydrate tab 100 mg . 31

doxycycline monohydrate tab 150 mg . 31 doxycycline monohydrate tab 50 mg ... 31

doxycycline monohydrate tab 75 mg ... 31 dramamine tab 25mg ........................ 88

dronabinol cap 10 mg ........................ 88 dronabinol cap 2.5 mg ....................... 88

dronabinol cap 5 mg ......................... 88

drospirenone-ethinyl estradiol tab 3-0.02 mg .................................................. 78

DROSPIRENONE-ETHINYL ESTRADIOL

TAB 3-0.02 MG ................................ 78 drospirenone-ethinyl estradiol tab 3-0.03

mg ................................................. 78 DROSPIRENONE-ETHINYL ESTRADIOL

TAB 3-0.03 MG ................................ 78 DROXIA CAP 200MG ......................... 37

DROXIA CAP 300MG ......................... 37 DROXIA CAP 400MG ......................... 37

DRYMAX AF TAB 15-4-25 ................ 127 dual action chw complete .................. 94

DULCOLAX KIT BOWEL ..................... 91 DULERA AER 100-5MCG .................. 134

DULERA AER 200-5MCG .................. 134 duloxetine hcl enteric coated pellets cap

20 mg ............................................. 61

duloxetine hcl enteric coated pellets cap 30 mg ............................................. 61

duloxetine hcl enteric coated pellets cap 60 mg ............................................. 61

DURAFLU TAB ................................ 127 DURAMORPH INJ 0.5MG/ML ............... 14

DURAMORPH INJ 1MG/ML ................. 14 DUREZOL EMU 0.05% ..................... 119

DYRENIUM CAP 100MG ..................... 50 DYRENIUM CAP 50MG ....................... 50

E e.e.s. 400 tab 400mg ....................... 27

E.E.S. GRAN SUS 200/5ML ................ 27 easy fiber/ chw calcium ..................... 91

ecee plus tab ................................. 114

econazole nitrate cream 1% ............ 136 ed a-hist dm liq.............................. 127

ed bron gp liq ................................ 127 ED CHLORPED DRO D ..................... 127

ED CHLORPED LIQ 2MG/ML ............. 124 ed chlorped syp jr .......................... 124

ed-apap liq 80mg/2.5 ....................... 11 EDECRIN TAB 25MG ......................... 50

EDURANT TAB 25MG ........................ 22 EFFIENT TAB 10MG ........................ 101

EFFIENT TAB 5MG .......................... 101 ELDERTONIC ELX ........................... 114

ELIDEL CRE 1% ............................. 140 ELIQUIS TAB 2.5MG ......................... 97

ELIQUIS TAB 5MG ............................ 97

elite magnes tab 100mg ................. 111 ELITEK INJ 1.5MG ............................ 38

160

ELITEK INJ 7.5MG ............................. 38

elixophyllin elx 80/15ml ................... 134 ELIXSURE GEL F/P BGUM ................... 11

ELLA TAB 30MG ................................ 78 ELMIRON CAP 100MG ........................ 95

EMCYT CAP 140MG ........................... 32 EMEND CAP 125MG ........................... 88

EMEND CAP 40MG ............................. 88 EMEND CAP 80MG ............................. 88

EMEND PAK 80 & 125 ........................ 88 emoquette tab .................................. 78

EMSAM DIS 12MG/24H ...................... 61 EMSAM DIS 6MG/24HR ...................... 61

EMSAM DIS 9MG/24HR ...................... 61 EMTRIVA CAP 200MG ........................ 22

EMTRIVA SOL 10MG/ML ..................... 22

enalapril maleate & hydrochlorothiazide tab 10-25 mg ................................... 39

enalapril maleate & hydrochlorothiazide tab 5-12.5 mg .................................. 39

enalapril maleate tab 10 mg ............... 40 enalapril maleate tab 2.5 mg .............. 40

enalapril maleate tab 20 mg ............... 40 enalapril maleate tab 5 mg ................ 40

endocet tab 10-325mg ...................... 14 endocet tab 5-325mg ........................ 14

endocet tab 7.5-325 .......................... 14 enemeez mini ene ............................. 91

enemeez plus ene 20-283 .................. 91 energy b-12 tab 1500mcg ................ 114

ENGERIX-B INJ 10/0.5ML ................. 104

ENGERIX-B INJ 20MCG/ML ............... 104 enoxaparin sodium inj 100 mg/ml ....... 97

enoxaparin sodium inj 120 mg/0.8ml .. 97 enoxaparin sodium inj 150 mg/ml ....... 97

enoxaparin sodium inj 30 mg/0.3ml .... 97 enoxaparin sodium inj 300 mg/3ml ..... 97

enoxaparin sodium inj 40 mg/0.4ml .... 97 enoxaparin sodium inj 60 mg/0.6ml .... 97

enoxaparin sodium inj 80 mg/0.8ml .... 97 enpresse-28 tab ............................... 78

entacapone tab 200 mg ..................... 64 entecavir tab 0.5 mg ......................... 24

entecavir tab 1 mg ............................ 24 entre-b sus 6-10mg/5 ..................... 127

entre-cough liq ............................... 127

entre-hist liq 0.938-10 .................... 127 ENTSOL NASAL GEL ........................ 127

ENUCLENE SOL OP ......................... 121

enulose sol 10gm/15 ........................ 91 e-oil oil 30000unt ........................... 114

EPIPEN 2-PAK INJ 0.3MG ................ 132 EPIPEN-JR INJ 2-PAK ...................... 132

epirubicin hcl iv soln 200 mg/100ml (2 mg/ml) ........................................... 32

epirubicin hcl iv soln 50 mg/25ml (2 mg/ml) ........................................... 32

epitol tab 200mg .............................. 55 EPIVIR HBV SOL 5MG/ML .................. 24

EPIVIR SOL 10MG/ML ....................... 22 eplerenone tab 25 mg ....................... 41

eplerenone tab 50 mg ....................... 41 epsom salt gra ................................. 91

EPZICOM TAB 600-300 ..................... 23

eq aspirin tab 500mg ec .................... 12 EQL CALCIUM CAP VIT D ................. 111

eql lice kit solution ......................... 141 EQL NATURAL POW FIBER ................. 91

EQUALACTIN CHW 625MG ................. 91 ERAXIS INJ 100MG ........................... 20

ERAXIS INJ 50MG ............................ 20 ergocalciferol cap 50000 unit ........... 114

ERIVEDGE CAP 150MG ...................... 34 errin tab 0.35mg .............................. 78

ERYPED SUS 200/5ML ....................... 28 ERYPED SUS 400/5ML ....................... 28

ery-tab tab 250mg ec ....................... 27 ery-tab tab 333mg ec ....................... 28

ery-tab tab 500mg ec ....................... 28

erythrocin inj 500mg ........................ 28 erythrocin tab 250mg ....................... 28

erythromycin ethylsuccinate tab 400 mg...................................................... 28

erythromycin gel 2% ...................... 135 erythromycin ophth oint 5 mg/gm .... 119

erythromycin pads 2% .................... 135 erythromycin soln 2% ..................... 135

erythromycin tab 250 mg .................. 28 erythromycin tab 500 mg .................. 28

erythromycin w/ delayed release particles cap 250 mg ..................................... 28

escitalopram oxalate soln 5 mg/5ml (base equiv) ............................................. 61

escitalopram oxalate tab 10 mg (base

equiv) ............................................. 61 escitalopram oxalate tab 20 mg (base

161

equiv) ............................................. 61

escitalopram oxalate tab 5 mg (base equiv) ............................................. 61

esomeprazole sodium for intravenous soln 20 mg (base equiv) ........................... 94

esomeprazole sodium for intravenous soln 40 mg (base equiv) ........................... 94

estradiol tab 0.5 mg .......................... 81 estradiol tab 1 mg ............................. 81

estradiol tab 2 mg ............................. 81 estradiol td patch weekly 0.025 mg/24hr

...................................................... 82 estradiol td patch weekly 0.0375 mg/24hr

(37.5 mcg/24hr) ............................... 82 estradiol td patch weekly 0.05 mg/24hr

...................................................... 81

estradiol td patch weekly 0.06 mg/24hr ...................................................... 82

estradiol td patch weekly 0.075 mg/24hr ...................................................... 82

estradiol td patch weekly 0.1 mg/24hr 81 ESTRADIOL VALERATE IM IN OIL 10

MG/ML ............................................. 82 estradiol valerate im in oil 20 mg/ml ... 82

ESTRADIOL VALERATE IM IN OIL 40 MG/ML ............................................. 82

ethambutol hcl tab 100 mg ................ 24 ethambutol hcl tab 400 mg ................ 24

ethosuximide cap 250 mg .................. 55 ethosuximide soln 250 mg/5ml ........... 55

etodolac cap 200 mg ......................... 13

etodolac cap 300 mg ......................... 13 etodolac tab 400 mg ......................... 13

etodolac tab 500 mg ......................... 13 etodolac tab sr 24hr 400 mg .............. 13

etodolac tab sr 24hr 500 mg .............. 13 etodolac tab sr 24hr 600 mg .............. 13

etoposide inj 500mg/25ml (20 mg/ml) 38 EURAX CRE 10% ............................. 141

EURAX LOT 10% ............................. 141 EVOTAZ TAB 300-150........................ 23

exefen dmx tab .............................. 127 exefen-ir tab 60-400mg ................... 127

EXELON DIS 13.3/24 ......................... 59 EXELON DIS 4.6MG/24 ...................... 59

EXELON DIS 9.5MG/24 ...................... 59

exemestane tab 25 mg ...................... 35 EXJADE TAB 125MG .......................... 77

EXJADE TAB 250MG .......................... 77

EXJADE TAB 500MG .......................... 77 ex-lax ultra tab 5mg ec ..................... 91

EYE ALLERGY SOL RELIEF ............... 120 eye drops sol 0.05% op .................. 120

eye drops sol a/r ............................ 120 eye wash sol .................................. 121

ezfe 200 cap 200mg ......................... 99 EZFE FORTE CAP ............................ 115

F FA-8 CAP 800MCG .......................... 115

fa-8 tab 0.8mg .............................. 115 FABRAZYME INJ 35MG ...................... 81

FABRAZYME INJ 5MG ........................ 81 falmina tab ...................................... 78

famciclovir tab 125 mg ..................... 24

famciclovir tab 250 mg ..................... 24 famciclovir tab 500 mg ..................... 24

famotidine for susp 40 mg/5ml .......... 89 famotidine in nacl 0.9% iv soln 20

mg/50ml ......................................... 89 famotidine inj 20 mg/2ml .................. 90

famotidine inj 200 mg/20ml .............. 90 famotidine inj 40 mg/4ml .................. 90

famotidine tab 20 mg ....................... 90 famotidine tab 20mg ........................ 90

famotidine tab 40 mg ....................... 90 FANAPT PAK .................................... 66

FANAPT TAB 10MG ........................... 66 FANAPT TAB 12MG ........................... 66

FANAPT TAB 1MG ............................. 66

FANAPT TAB 2MG ............................. 66 FANAPT TAB 4MG ............................. 66

FANAPT TAB 6MG ............................. 66 FANAPT TAB 8MG ............................. 66

FARESTON TAB 60MG ....................... 35 FARYDAK CAP 10MG ......................... 34

FARYDAK CAP 15MG ......................... 34 FARYDAK CAP 20MG ......................... 34

FASLODEX INJ 250MG ...................... 35 fast dissolv chw antacid .................... 87

FAT EMULSION IV SOLN 20% .......... 107 father johns syp 10mg/5ml ............. 127

FAZACLO TAB 100/ODT .................... 66 FAZACLO TAB 12.5/ODT ................... 66

FAZACLO TAB 150MG ....................... 66

FAZACLO TAB 200MG ....................... 66 FAZACLO TAB 25MG ODT .................. 66

162

FEBROL SOL 325/5ML ....................... 12

felbamate susp 600 mg/5ml ............... 55 felbamate tab 400 mg ....................... 55

felbamate tab 600 mg ....................... 55 felodipine tab sr 24hr 10 mg .............. 48

felodipine tab sr 24hr 2.5 mg ............. 48 felodipine tab sr 24hr 5 mg ................ 48

fenofibrate micronized cap 130 mg ..... 45 fenofibrate micronized cap 134 mg ..... 45

fenofibrate micronized cap 200 mg ..... 45 fenofibrate micronized cap 43 mg ....... 45

fenofibrate micronized cap 67 mg ....... 45 fenofibrate tab 145 mg ...................... 45

fenofibrate tab 160 mg ...................... 45 fenofibrate tab 48 mg ........................ 45

fenofibrate tab 54 mg ........................ 45

fentanyl citrate lozenge on a handle 1200 mcg ................................................ 14






fentanyl td patch 72hr 100 mcg/hr ...... 15 fentanyl td patch 72hr 12 mcg/hr ....... 14

fentanyl td patch 72hr 25 mcg/hr ....... 15

fentanyl td patch 72hr 50 mcg/hr ....... 15 fentanyl td patch 72hr 75 mcg/hr ....... 15

FENTORA TAB 100MCG ...................... 15 FENTORA TAB 200MCG ...................... 15

FENTORA TAB 400MCG ...................... 15 FENTORA TAB 600MCG ...................... 15

FENTORA TAB 800MCG ...................... 15 FEOSOL TAB 45MG............................ 99

fer-iron dro 15mg/ml ........................ 99 FERRETTS IPS SOL ............................ 99

ferretts tab 325mg ............................ 99 FERRIMIN 150 TAB ........................... 99

FERROUS FUM TAB 29MG .................. 99 FERROUS FUMA TAB ......................... 99

FERROUS GLUC TAB 225MG ............... 99

ferrous gluc tab 324mg ..................... 99 FERROUS GLUC TAB 324MG ............... 99

ferrous gluconate tab 240 mg (27 mg

elemental fe) ................................... 99 ferrous gluconate tab 325 mg (36 mg

elemental fe) ................................... 99 FERROUS SUL LIQ 220/5ML ............... 99

FERROUS SULF SYP 300/5ML ............. 99 FERROUS SULF TAB 140MG ............... 99

FERROUS SULF TAB 324MG EC .......... 99 ferrous sulf tab 325mg ...................... 99

ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) ....................... 99

ferrous sulfate tab ec 325 mg (65 mg fe equivalent) ...................................... 99

FETZIMA CAP 120MG ........................ 61 FETZIMA CAP 20MG .......................... 61

FETZIMA CAP 40MG .......................... 61

FETZIMA CAP 80MG .......................... 61 FETZIMA CAP TITRATIO .................... 61

FEVERALL INF SUP 80MG .................. 12 FEVERALL SUP 120MG ...................... 12

FEVERALL SUP 325MG ...................... 12 FEVERALL SUP 650MG ...................... 12

fexofenadine hcl tab 180 mg ........... 124 fexofenadine-pseudoephedrine tab sr

24hr 180-240 mg ........................... 127 FIBER CHW ..................................... 91

fiber laxatv tab 625mg ...................... 91 fiber oral powder .............................. 91

FIBER POW ...................................... 91 finasteride tab 5 mg ......................... 95

FIRAZYR INJ 30MG/3ML .................. 100

FLEBOGAMMA INJ 10/200ML ........... 101 FLEBOGAMMA INJ 20/400ML ........... 101

FLEBOGAMMA INJ 5% ..................... 101 FLEBOGAMMA INJ DIF 10% ............. 101

FLEBOGAMMA INJ DIF 5% ............... 101 flecainide acetate tab 100 mg ............ 43

flecainide acetate tab 150 mg ............ 43 flecainide acetate tab 50 mg .............. 43

FLEET BISACO ENE 10/30ML ............. 91 floranex gra ..................................... 88

FLORASTOR PAK KIDS ...................... 88 FLOVENT DISK AER 100MCG ........... 133

FLOVENT DISK AER 250MCG ........... 133 FLOVENT DISK AER 50MCG ............. 133

FLOVENT HFA AER 110MCG ............. 133

FLOVENT HFA AER 220MCG ............. 133 FLOVENT HFA AER 44MCG ............... 133

163

flu/cold/cgh pow daytime ................. 127

flu/severe pow cold/cgh ................... 127 fluconazole for susp 10 mg/ml ............ 20

fluconazole for susp 40 mg/ml ............ 20 fluconazole in dextrose inj 200 mg/100ml

...................................................... 20 fluconazole in dextrose inj 400 mg/200ml

...................................................... 20 fluconazole in nacl 0.9% inj 200

mg/100ml ........................................ 20 fluconazole in nacl 0.9% inj 400

mg/200ml ........................................ 20 fluconazole tab 100 mg ..................... 20

fluconazole tab 150 mg ..................... 20 fluconazole tab 200 mg ..................... 20

fluconazole tab 50 mg ....................... 20

flucytosine cap 250 mg ...................... 20 flucytosine cap 500 mg ...................... 20

fludarabine phosphate for inj 50 mg .... 33 fludarabine phosphate inj 25 mg/ml .... 33

fludrocortisone acetate tab 0.1 mg ...... 82 flunisolide nasal soln 25 mcg/act

(0.025%) ....................................... 133 fluocin acet oil scalp ........................ 138

fluocinolone acetonide (otic) oil 0.01% .................................................... 142

fluocinolone acetonide cream 0.01% . 138 fluocinolone acetonide cream 0.025% 138

fluocinolone acetonide oil 0.01% (body oil) ................................................ 138

fluocinolone acetonide oint 0.025% ... 138

fluocinolone acetonide soln 0.01% .... 139 fluocinonide cream 0.05%................ 139

fluocinonide emulsified base cream 0.05% .................................................... 139

fluocinonide gel 0.05% .................... 139 fluocinonide oint 0.05% ................... 139

fluocinonide soln 0.05%................... 139 FLUOROMETHOLONE OPHTH SUSP 0.1%

.................................................... 119 fluorouracil cream 5% ..................... 140

fluorouracil inj 1 gm/20ml (50 mg/ml). 33 fluorouracil inj 2.5 gm/50ml (50 mg/ml)

...................................................... 33 fluorouracil inj 5 gm/100ml (50 mg/ml)

...................................................... 33

fluorouracil inj 500 mg/10ml (50 mg/ml) ...................................................... 33

fluorouracil soln 2%........................ 140

fluorouracil soln 5%........................ 140 fluoxetine hcl cap 10 mg ................... 61

fluoxetine hcl cap 20 mg ................... 61 fluoxetine hcl cap 40 mg ................... 61

fluoxetine hcl solution 20 mg/5ml ...... 61 fluoxetine hcl tab 10 mg ................... 61

fluoxetine hcl tab 20 mg ................... 61 fluphenazine decanoate inj 25 mg/ml . 66

fluphenazine hcl elixir 2.5 mg/5ml ...... 66 fluphenazine hcl inj 2.5 mg/ml ........... 66

fluphenazine hcl oral conc 5 mg/ml .... 66 fluphenazine hcl tab 1 mg ................. 66

fluphenazine hcl tab 10 mg ............... 66 fluphenazine hcl tab 2.5 mg .............. 66

fluphenazine hcl tab 5 mg ................. 66

flurbiprofen sodium ophth soln 0.03%.................................................... 120

flurbiprofen tab 100 mg .................... 13 flurbiprofen tab 50 mg ...................... 13

flutamide cap 125 mg ....................... 35 fluticasone propionate cream 0.05% . 139

fluticasone propionate nasal susp 50 mcg/act ........................................ 133

fluticasone propionate oint 0.005% .. 139 fluvoxamine maleate tab 100 mg ....... 54

fluvoxamine maleate tab 25 mg ......... 53 fluvoxamine maleate tab 50 mg ......... 54

foam antacid chw 80-20mg ............... 87 FOLGARD TAB .................................. 99

FOLIC ACID CAP 20MG ................... 115

FOLIC ACID CAP 5MG ..................... 115 folic acid inj 5 mg/ml ...................... 115

folic acid tab 1 mg .......................... 115 FOLIC ACID TAB 1 MG .................... 115

folic acid tab 400 mcg ..................... 115 folic acid tab 800 mcg ..................... 115

folic acid tab 800mcg ...................... 115 FOLITAB 500 TAB ............................. 99

foltabs 800 tab ................................ 99 fondaparinux sodium subcutaneous inj 10

mg/0.8ml ........................................ 97 fondaparinux sodium subcutaneous inj

2.5 mg/0.5ml .................................. 97 fondaparinux sodium subcutaneous inj 5

mg/0.4ml ........................................ 97

fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml .................................. 97

164

FORADIL CAP AEROLIZE .................. 124

FORTEO SOL 600/2.4 ........................ 85 FORTICAL SPR 200/ACT ..................... 84

foscarnet sodium inj 24 mg/ml ........... 24 fosinopril sodium & hydrochlorothiazide

tab 10-12.5 mg ................................ 39 fosinopril sodium & hydrochlorothiazide

tab 20-12.5 mg ................................ 39 fosinopril sodium tab 10 mg ............... 40

fosinopril sodium tab 20 mg ............... 40 fosinopril sodium tab 40 mg ............... 40

FOSRENOL CHW 1000MG ................... 85 FOSRENOL CHW 500MG .................... 85

FOSRENOL CHW 750MG .................... 85 FREAMINE HBC INJ 6.9% ................. 107

FREAMINE III INJ 10% .................... 107

FRESHKOTE SOL 2.7-2% ................. 121 fruit c-100 chw ............................... 115

fungicure spr intens ........................ 136 FUNGOID TINC KIT ......................... 136

FUNGOID TINC SOL 2% ................... 136 furosemide inj 10 mg/ml .................... 50

furosemide oral soln 10 mg/ml ........... 50 furosemide sol 8mg/ml ...................... 50

furosemide tab 20 mg ....................... 50 furosemide tab 40 mg ....................... 50

furosemide tab 80 mg ....................... 50 FUZEON INJ 90MG ............................ 22

FYCOMPA TAB 10MG ......................... 56 FYCOMPA TAB 12MG ......................... 56

FYCOMPA TAB 2MG ........................... 56

FYCOMPA TAB 4MG ........................... 56 FYCOMPA TAB 6MG ........................... 56

FYCOMPA TAB 8MG ........................... 56 G gabapentin cap 100 mg ..................... 56 gabapentin cap 300 mg ..................... 56

gabapentin cap 400 mg ..................... 56 gabapentin oral soln 250 mg/5ml ........ 56

gabapentin tab 600 mg ..................... 56 gabapentin tab 800 mg ..................... 56

GABITRIL TAB 12MG ......................... 56 GABITRIL TAB 16MG ......................... 56

galantamine hydrobromide cap sr 24hr 16 mg .................................................. 59

galantamine hydrobromide cap sr 24hr 24

mg .................................................. 59 galantamine hydrobromide cap sr 24hr 8

mg ................................................. 59

galantamine hydrobromide oral soln 4 mg/ml ............................................ 59

galantamine hydrobromide tab 12 mg 59 galantamine hydrobromide tab 4 mg .. 59

galantamine hydrobromide tab 8 mg .. 59 GAMASTAN S/D INJ ........................ 101

GAMMAGARD INJ 10GM/100 ............ 102 GAMMAGARD INJ 1GM/10ML ........... 102

GAMMAGARD INJ 2.5GM/25 ............ 102 GAMMAGARD INJ 20GM/200 ............ 102

GAMMAGARD INJ 30GM/300 ............ 102 GAMMAGARD INJ 5GM/50ML ........... 102

GAMMAGARD SD INJ 10GM HU ........ 102 GAMMAGARD SD INJ 2.5GM HU ....... 102

GAMMAGARD SD INJ 5GM HU .......... 102

GAMMAKED INJ 10GM/100 .............. 102 GAMMAKED INJ 1GM/10ML .............. 102

GAMMAKED INJ 2.5GM/25 ............... 102 GAMMAKED INJ 20GM/200 .............. 102

GAMMAKED INJ 5GM/50ML .............. 102 GAMMAPLEX INJ 10GM.................... 102

GAMMAPLEX INJ 2.5GM................... 102 GAMMAPLEX INJ 5GM ..................... 102

GAMUNEX-C INJ 10GM/100 ............. 102 GAMUNEX-C INJ 1GM/10ML ............. 102

GAMUNEX-C INJ 2.5GM/25 .............. 102 GAMUNEX-C INJ 20GM/200 ............. 102

GAMUNEX-C INJ 40/400ML .............. 102 GAMUNEX-C INJ 5GM/50ML ............. 102

ganciclovir sodium for inj 500 mg ....... 24

GARDASIL 9 INJ ............................. 104 GARDASIL INJ ............................... 104

gatifloxacin ophth soln 0.5% ........... 119 GAUZE PADS 2" X 2" ........................ 75

gavilyte-c sol ................................... 91 gavilyte-g sol ................................... 91

gavilyte-n sol flav pk ........................ 91 GAVISCON CHW ............................... 87

GAVISCON SUS ............................... 87 gemcitabine hcl for inj 1 gm .............. 33

gemcitabine hcl for inj 2 gm .............. 33 gemcitabine hcl for inj 200 mg ........... 33

GEMCITABINE INJ 1GM ..................... 33 GEMCITABINE INJ 200MG ................. 33

GEMCITABINE INJ 2GM ..................... 33

gemfibrozil tab 600 mg ..................... 45 generlac sol 10gm/15 ....................... 91

165

gengraf cap 100mg ......................... 103

gengraf cap 25mg ........................... 103 gengraf sol 100mg/ml ..................... 103

gentak oin 0.3% op ......................... 119 gentam/nacl inj 0.9mg/ml .................. 17

gentam/nacl inj 1.4mg/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% ........ 135 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% ............ 135

gentamicin sulfate ophth oint 0.3% ... 119 gentamicin sulfate ophth soln 0.3% .. 119

GENTEAL GEL ................................. 121 GENTEAL MILD DRO 0.2% ............... 121

GENTIAN VIOL SOL 1% ................... 136 GENTIAN VIOL SOL 2% ................... 136

gentle laxat sup 10mg ....................... 91 GEODON INJ 20MG ........................... 66

geravim liq ..................................... 115 GERIATRIC LIQ VITAMIN ................. 115

gildagia tab 0.4-35 ............................ 78 gildess tab 1.5/30 ............................. 78

GILENYA CAP 0.5MG ......................... 73 GILOTRIF TAB 20MG ......................... 36

GILOTRIF TAB 30MG ......................... 36

GILOTRIF TAB 40MG ......................... 36 GLEEVEC TAB 100MG ........................ 36

GLEEVEC TAB 400MG ........................ 36 glimepiride tab 1 mg ......................... 76

glimepiride tab 2 mg ......................... 76 glimepiride tab 4 mg ......................... 76

glipizide tab 10 mg ........................... 76 glipizide tab 5 mg ............................. 76

glipizide tab sr 24hr 10 mg ................ 76 glipizide tab sr 24hr 2.5 mg ............... 76

glipizide tab sr 24hr 5 mg .................. 76 glipizide-metformin hcl tab 2.5-250 mg

...................................................... 76 glipizide-metformin hcl tab 2.5-500 mg

...................................................... 76

glipizide-metformin hcl tab 5-500 mg .. 76 GLUCAGEN INJ HYPOKIT .................... 83

GLUCAGON KIT 1MG ........................ 83

glycopyrrolate inj 4 mg/20ml (0.2 mg/ml)...................................................... 89

glycopyrrolate tab 1 mg .................... 89 glycopyrrolate tab 2 mg .................... 89

GNP DAILY MIS PRENATAL .............. 115 gnp day time liq cold/flu ................. 127

gnp ibuprofn tab cold/sin ................ 127 gnp iron tab 45mg............................ 99

gnp tussin liq nighttim .................... 127 GOLYTELY SOL ................................. 91

goniotaire sol 2.5% op .................... 121 GONIOVISC SOL 2% ...................... 121

granisetron hcl inj 0.1 mg/ml ............. 88 granisetron hcl inj 1 mg/ml ............... 88

granisetron hcl inj 4 mg/4ml (1 mg/ml)

...................................................... 88 granisetron hcl tab 1 mg ................... 88

GRANIX INJ 300/0.5 ......................... 98 GRANIX INJ 480/0.8 ......................... 98

griseofulvin microsize susp 125 mg/5ml...................................................... 20

griseofulvin microsize tab 500 mg ...... 20 griseofulvin ultramicrosize tab 125 mg 20

griseofulvin ultramicrosize tab 250 mg 21 guaifenesin syrup 100 mg/5ml ......... 127

guaifenesin-codeine soln 100-10 mg/5ml.................................................... 127

guanfacine hcl tab sr 24hr 1 mg (base equiv) ............................................. 70

guanfacine hcl tab sr 24hr 2 mg (base

equiv) ............................................. 70 guanfacine hcl tab sr 24hr 3 mg (base

equiv) ............................................. 70 guanfacine hcl tab sr 24hr 4 mg (base

equiv) ............................................. 70 gummi bear chw multivit ................. 115

H halobetasol propionate cream 0.05% 139

halobetasol propionate oint 0.05% ... 139 haloperidol decanoate im soln 100 mg/ml

...................................................... 67 haloperidol decanoate im soln 50 mg/ml

...................................................... 67 haloperidol lactate inj 5 mg/ml .......... 67

haloperidol lactate oral conc 2 mg/ml . 67

haloperidol tab 0.5 mg ...................... 67 haloperidol tab 1 mg......................... 67

166

haloperidol tab 10 mg ....................... 67

haloperidol tab 2 mg ......................... 67 haloperidol tab 20 mg ....................... 67

haloperidol tab 5 mg ......................... 67 HARVONI TAB 90-400MG ................... 24

HAVRIX INJ 1440UNIT ..................... 104 HAVRIX INJ 720UNIT....................... 104

hc-1% hemorr oin 1% ..................... 139 headache tab 25-500mg .................... 74

heather tab 0.35mg .......................... 78 HEP SOD/D5W INJ 25000UNT ............ 97

HEP SOD/NACL INJ 25000UNT ............ 97 HEPARIN SOD INJ 2000/ML ................ 97

HEPARIN SOD INJ 2500/ML ................ 97 HEPARIN SODIUM (PORCINE) 40 UNIT/ML

IN D5W ........................................... 98

heparin sodium (porcine) inj 1000 unit/ml ...................................................... 98

heparin sodium (porcine) inj 10000 unit/ml ............................................ 98

heparin sodium (porcine) inj 20000 unit/ml ............................................ 98

heparin sodium (porcine) inj 5000 unit/ml ...................................................... 98

HEPATAMINE SOL 8% ..................... 107 HERCEPTIN INJ 440MG ...................... 34

HEXALEN CAP 50MG .......................... 32 HIBERIX SOL 10MCG ....................... 104

HONEY BEARS CHW ........................ 115 HONEY BEARS CHW IRON-ZIN ......... 115

HUMIRA INJ 10MG/0.2 .................... 101

HUMIRA INJ 40MG/0.8 .................... 101 HUMIRA KIT 20MG/0.4 .................... 101

HUMIRA PEN INJ 40MG/0.8 .............. 101 HUMIRA PEN INJ CROHNS ................ 101

HUMIRA PEN INJ PSORIASI .............. 101 HUMULIN R INJ U-500 ....................... 75

hydralazine hcl inj 20 mg/ml .............. 51 hydralazine hcl tab 10 mg .................. 51

hydralazine hcl tab 100 mg ................ 51 hydralazine hcl tab 25 mg .................. 51

hydralazine hcl tab 50 mg .................. 51 hydrochlorothiazide cap 12.5 mg ........ 50

hydrochlorothiazide tab 12.5 mg ......... 50 hydrochlorothiazide tab 25 mg ........... 51

hydrochlorothiazide tab 50 mg ........... 51

HYDROCIL INS POW 95% .................. 91 hydrocodone-acetaminophen soln

7.5-325 mg/15ml ............................. 14

hydrocodone-acetaminophen tab 10-325 mg ................................................. 14

hydrocodone-acetaminophen tab 5-325 mg ................................................. 14

hydrocodone-acetaminophen tab 7.5-325 mg ................................................. 14

hydrocodone-ibuprofen tab 7.5-200 mg...................................................... 14

HYDROCORT AC CRE 0.5% .............. 139 HYDROCORT/ OIN ALOE 1% ............ 139

hydrocortisone butyrate cream 0.1% 139 hydrocortisone butyrate oint 0.1% ... 139

hydrocortisone butyrate soln 0.1% ... 139 hydrocortisone cream 0.5% ............. 139

hydrocortisone cream 1% ............... 139

hydrocortisone cream 2.5% ............. 139 hydrocortisone enema 100 mg/60ml .. 90

HYDROCORTISONE ENEMA 100 MG/60ML...................................................... 90

hydrocortisone lotion 2.5% .............. 139 hydrocortisone oint 0.5% ................ 139

hydrocortisone oint 1% ................... 139 hydrocortisone oint 2.5% ................ 139

hydrocortisone rectal cream 2.5% .... 137 hydrocortisone tab 10 mg ................. 82

hydrocortisone tab 20 mg ................. 82 hydrocortisone tab 5 mg ................... 82

hydrocortisone valerate cream 0.2% 139 hydrocortisone valerate oint 0.2% .... 139

hydrocortisone-aloe vera cream 0.5%139

hydrocortisone-aloe vera cream 1% . 139 hydromorphone hcl liqd 1 mg/ml ........ 15

hydromorphone hcl preservative free (pf) inj 10 mg/ml ................................... 15

hydromorphone hcl tab 2 mg ............. 15 hydromorphone hcl tab 4 mg ............. 15

hydromorphone hcl tab 8 mg ............. 15 hydroxocobalamin inj 1000 mcg/ml .. 115

hydroxychloroquine sulfate tab 200 mg.................................................... 101

hydroxyurea cap 500 mg .................. 37 hydroxyzine hcl im soln 25 mg/ml .... 124

hydroxyzine hcl im soln 50 mg/ml .... 124 hydroxyzine hcl syrup 10 mg/5ml..... 124

hydroxyzine hcl tab 10 mg .............. 124

hydroxyzine hcl tab 25 mg .............. 124 hydroxyzine hcl tab 50 mg .............. 124

167

hydroxyzine pamoate cap 100 mg ..... 124

hydroxyzine pamoate cap 25 mg ...... 124 hydroxyzine pamoate cap 50 mg ...... 124

HYPOTEARS SOL 1-1% .................... 121 I ibandronate sodium tab 150 mg (base equivalent) ...................................... 77

IBRANCE CAP 100MG ........................ 34 IBRANCE CAP 125MG ........................ 34

IBRANCE CAP 75MG .......................... 34 ibuprofen cap 200 mg ....................... 12

ibuprofen dro 50/1.25 ....................... 12 ibuprofen jr chw 100mg ..................... 12

ibuprofen pm tab 200-38mg ............... 74 ibuprofen sus 100/5ml ....................... 12

ibuprofen susp 100 mg/5ml ............... 13

ibuprofen tab 400 mg ........................ 13 ibuprofen tab 600 mg ........................ 13

ibuprofen tab 800 mg ........................ 13 icaps cap ....................................... 115

ICAPS LUTEIN TAB ZEAXANTH .......... 115 icaps mv tab .................................. 115

ICLUSIG TAB 15MG ........................... 36 ICLUSIG TAB 45MG ........................... 36

idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) ...................................................... 33



IFEX INJ 3GM ................................... 32

ifosfamide for inj 1 gm ...................... 32 IFOSFAMIDE INJ 3GM ........................ 32

ifosfamide iv inj 1 gm/20ml (50 mg/ml) ...................................................... 32

ifosfamide iv inj 3 gm/60ml (50 mg/ml) ...................................................... 32

ILEVRO DRO 0.3% OP ..................... 120 ilotycin oin op ................................. 119

IMBRUVICA CAP 140MG ..................... 36 imipenem-cilastatin intravenous for soln

250 mg ........................................... 19 imipenem-cilastatin intravenous for soln

500 mg ........................................... 19 imipramine hcl tab 10 mg .................. 61

imipramine hcl tab 25 mg .................. 61

imipramine hcl tab 50 mg .................. 61 imiquimod cream 5% ...................... 140

IMOVAX RABIE INJ 2.5/ML .............. 104

INCRELEX INJ 40MG/4ML .................. 84 indapamide tab 1.25 mg ................... 51

indapamide tab 2.5 mg ..................... 51 INFANRIX INJ ................................ 104

INLYTA TAB 1MG .............................. 36 INLYTA TAB 5MG .............................. 36

INSULIN PEN NEEDLE ....................... 75 INSULIN SAFETY NEEDLES ................ 75

INSULIN SYRINGE ............................ 75 INTEGRA CAP .................................. 99

INTELENCE TAB 100MG .................... 22 INTELENCE TAB 200MG .................... 22

INTELENCE TAB 25MG ...................... 22 intense cold tab /flu med................. 127

intense coug liq reliever .................. 127

INTRALIPID INJ 20% ...................... 107 INTRALIPID INJ 30% ...................... 107

INTRON A INJ 10MU ....................... 102 INTRON A INJ 18MU ....................... 102

INTRON A INJ 25MU ....................... 102 INTRON A INJ 50MU ....................... 102

introvale tab .................................... 78 INVANZ INJ 1GM .............................. 19

INVEGA SUST INJ 117/0.75 ............... 67 INVEGA SUST INJ 156MG/ML ............. 67

INVEGA SUST INJ 234/1.5 ................ 67 INVEGA SUST INJ 39/0.25 ................ 67

INVEGA SUST INJ 78/0.5ML .............. 67 INVEGA TAB 1.5MG .......................... 67

INVEGA TAB 3MG ............................. 67

INVEGA TAB 6MG ............................. 67 INVEGA TAB 9MG ............................. 67

INVIRASE CAP 200MG ...................... 22 INVIRASE TAB 500MG ...................... 22

INVOKAMET TAB 150-1000 ............... 76 INVOKAMET TAB 150-500 ................. 76

INVOKAMET TAB 50-1000 ................. 76 INVOKAMET TAB 50-500MG .............. 76

INVOKANA TAB 100MG ..................... 76 INVOKANA TAB 300MG ..................... 76

IONOSOL-B/ INJ D5W ..................... 107 IONOSOL-MB INJ /D5W .................. 107

IPOL INJ INACTIVE ......................... 104 ipratropium bromide inhal soln 0.02%

.................................................... 123

ipratropium bromide nasal soln 0.03% (21 mcg/spray) ................................... 123

168

ipratropium bromide nasal soln 0.06% (42

mcg/spray) .................................... 123 ipratropium-albuterol nebu soln

0.5-2.5(3) mg/3ml .......................... 122 irinotecan hcl inj 100 mg/5ml (20 mg/ml)

...................................................... 38 irinotecan hcl inj 40 mg/2ml (20 mg/ml)

...................................................... 38 irinotecan hcl inj 500 mg/25ml (20

mg/ml) ............................................ 38 iromin-g tab ................................... 115

iron 100 tab plus ............................ 100 iron 100/c tab 100-250 ................... 100

iron chews chw pediatri ................... 100 IRON TAB 18MG ............................. 100

IRON TAB 18MG CR ........................ 100

iron tab 28mg ................................ 100 IRON TAB 28MG ............................. 100

iron therapy tab 200mg ................... 100 IRON UP LIQ .................................. 100

ISENTRESS CHW 100MG .................... 22 ISENTRESS CHW 25MG ..................... 22

ISENTRESS POW 100MG .................... 22 ISENTRESS TAB 400MG ..................... 22

ISOLYTE-P INJ /D5W ....................... 107 isolyte-s inj .................................... 107

isoniazid inj 100 mg/ml ..................... 24 isoniazid syrup 50 mg/5ml ................. 24

isoniazid tab 100 mg ......................... 24 isoniazid tab 300 mg ......................... 24

ISOPTO TEARS SOL 0.5% OP ........... 121

isosorbide dinitrate tab 10 mg ............ 52 isosorbide dinitrate tab 20 mg ............ 52

isosorbide dinitrate tab 30 mg ............ 52 isosorbide dinitrate tab 5 mg .............. 52

isosorbide dinitrate tab cr 40 mg ........ 52 isosorbide mononitrate tab 10 mg ....... 52

isosorbide mononitrate tab 20 mg ....... 52 isosorbide mononitrate tab sr 24hr 120

mg .................................................. 52 isosorbide mononitrate tab sr 24hr 30 mg

...................................................... 52 isosorbide mononitrate tab sr 24hr 60 mg

...................................................... 52 isradipine cap 2.5 mg ........................ 48

isradipine cap 5 mg ........................... 48

ISTALOL SOL 0.5% OP .................... 121 ISTODAX INJ 10MG ........................... 34

itraconazole cap 100 mg ................... 21

ivermectin tab 3 mg ......................... 19 IXIARO INJ .................................... 104

J JAKAFI TAB 10MG ............................ 36

JAKAFI TAB 15MG ............................ 36 JAKAFI TAB 20MG ............................ 36

JAKAFI TAB 25MG ............................ 36 JAKAFI TAB 5MG .............................. 36

JALYN CAP ....................................... 95 jantoven tab 10mg ........................... 98

jantoven tab 1mg ............................. 98 jantoven tab 2.5mg .......................... 98

jantoven tab 2mg ............................. 98 jantoven tab 3mg ............................. 98

jantoven tab 4mg ............................. 98

jantoven tab 5mg ............................. 98 jantoven tab 6mg ............................. 98

jantoven tab 7.5mg .......................... 98 JANUMET TAB 50-1000 ..................... 76

JANUMET TAB 50-500MG .................. 76 JANUMET XR TAB 100-1000............... 76

JANUMET XR TAB 50-1000 ................ 76 JANUMET XR TAB 50-500MG .............. 76

JANUVIA TAB 100MG ........................ 76 JANUVIA TAB 25MG .......................... 76

JANUVIA TAB 50MG .......................... 76 JENTADUETO TAB 2.5-1000 ............... 76

JENTADUETO TAB 2.5-500 ................ 76 JENTADUETO TAB 2.5-850 ................ 76

J-MAX SYP 5-200MG ....................... 127

JOLIVETTE TAB 0.35MG .................... 78 J-TAN D PD DRO 1-7.5MG ............... 127

J-TAN PD DRO 1MG/ML ................... 124 junel 1.5/30 tab ............................... 78

junel 1/20 tab .................................. 78 junel fe tab 1.5/30 ........................... 79

junel fe tab 1/20 .............................. 79 K KADCYLA INJ 100MG ........................ 34 KADCYLA INJ 160MG ........................ 34

KALETRA SOL .................................. 23 KALETRA TAB 100-25MG ................... 23

KALETRA TAB 200-50MG ................... 23 kaopectate sus 262/15ml .................. 88

kariva tab 28 day ............................. 79

KCL 10 MEQ/L (0.075%) IN DEXTROSE 5% & NACL 0.45% INJ .................... 107

169

KCL 20 MEQ/L (0.15%) IN DEXTROSE 5%

& NACL 0.2% INJ ............................ 108 KCL 20 MEQ/L (0.15%) IN DEXTROSE 5%

& NACL 0.33% INJ .......................... 108 KCL 20 MEQ/L (0.15%) IN DEXTROSE 5%

& NACL 0.45% INJ .......................... 108 KCL 20 MEQ/L (0.15%) IN DEXTROSE 5%

& NACL 0.9% INJ ............................ 108 kcl 20 meq/l (0.15%) in nacl 0.45% inj

.................................................... 108 KCL 20 MEQ/L (0.15%) IN NACL 0.45%

INJ ................................................ 108 KCL 20 MEQ/L (0.15%) IN NACL 0.9% INJ

.................................................... 108 KCL 30 MEQ/L (0.224%) IN DEXTROSE

5% & NACL 0.45% INJ .................... 108

KCL 40 MEQ/L (0.3%) IN DEXTROSE 5% & NACL 0.45% INJ ............................. 108

KCL 40 MEQ/L (0.3%) IN NACL 0.9% INJ .................................................... 108

KCL/D5W/NACL INJ 0.15/0.2 ............ 108 KCL/D5W/NACL INJ 0.3/0.9% .......... 108

ketoconazole cream 2% ................... 136 ketoconazole shampoo 2% ............... 137

ketoconazole tab 200 mg ................... 21 ketoprofen cap 50 mg ....................... 13

ketoprofen cap 75 mg ....................... 13 ketorolac tromethamine ophth soln 0.4%

.................................................... 120 ketorolac tromethamine ophth soln 0.5%

.................................................... 120

ketotif fum dro 0.025%op ................ 120 kidkare liq cgh/cold ......................... 127

kionex pow ...................................... 77 kionex sus 15gm/60 .......................... 78

KLOR-CON 10 TAB 10MEQ ER ........... 105 KLOR-CON 8 TAB 8MEQ ER .............. 105

klor-con m15 tab 15meq er .............. 105 klor-con pow 20meq........................ 105

konsyl cap 520mg ............................. 91 KONSYL POW 100% .......................... 91

konsyl pow 28.3% ............................ 91 KONSYL POW 28.3% ......................... 91

konsyl pow 30.9% ............................ 91 KONSYL POW 60.3% ......................... 91

KONSYL POW 71.67% ....................... 91

KONSYL-D POW 52.3% ...................... 91 kp ca/mg/zn tab ............................. 111

kp calcium cap 600+d ..................... 111

kp calcium tab 600+d ..................... 111 kp vitamin e cap 100unit ................. 115

KPN PRENATAL TAB ........................ 115 KUVAN POW 100MG ......................... 81

KUVAN POW 500MG ......................... 81 KUVAN TAB 100MG .......................... 81

L labetalol hcl tab 100 mg .................... 46

labetalol hcl tab 200 mg .................... 46 labetalol hcl tab 300 mg .................... 46

laclotion lot 12% ............................ 140 LACTATED RINGER'S SOLUTION ...... 108

lactic acid (ammonium lactate) cream 12% ............................................. 140

lactic acid (ammonium lactate) lotion 12%

.................................................... 140 lactobacillus tab ............................... 88

lactulose (encephalopathy) solution 10 gm/15ml ......................................... 92

lactulose solution 10 gm/15ml ........... 92 LAMISIL ADV GEL 1% ..................... 136

lamisil af aer 1% ............................ 136 lamisil af pow defense .................... 136

LAMISIL AT SPR 1% ....................... 136 lamivudine oral soln 10 mg/ml ........... 22

lamivudine tab 100 mg (hbv) ............. 24 lamivudine tab 150 mg ..................... 22

lamivudine tab 300 mg ..................... 22 lamivudine-zidovudine tab 150-300 mg

...................................................... 23

lamotrigine tab 100 mg ..................... 56 lamotrigine tab 150 mg ..................... 56

lamotrigine tab 200 mg ..................... 56 lamotrigine tab 25 mg ...................... 56

lamotrigine tab chewable dispersible 25 mg ................................................. 56

lamotrigine tab chewable dispersible 5 mg...................................................... 56

lamotrigine tab sr 24hr 100 mg .......... 56 lamotrigine tab sr 24hr 200 mg .......... 56

lamotrigine tab sr 24hr 25 mg ........... 56 lamotrigine tab sr 24hr 250 mg .......... 56

lamotrigine tab sr 24hr 300 mg .......... 56 lamotrigine tab sr 24hr 50 mg ........... 56

LANOXIN TAB 0.125MG ..................... 50

LANOXIN TAB 0.25MG ...................... 50 lansoprazole cap 15mg dr ................. 94

170

LANTUS INJ 100/ML .......................... 75

LANTUS INJ SOLOSTAR ..................... 75 larin fe tab 1.5/30 ............................. 79

larin fe tab 1/20 ............................... 79 larin tab 1.5/30 ................................ 79

larin tab 1/20 ................................... 79 LASTACAFT SOL 0.25% ................... 120

latanoprost ophth soln 0.005% ......... 121 LATUDA TAB 120MG .......................... 67

LATUDA TAB 20MG ........................... 67 LATUDA TAB 40MG ........................... 67

LATUDA TAB 60MG ........................... 67 LATUDA TAB 80MG ........................... 67

lax diet sup tab 500mg ...................... 92 laxative chw 15mg ............................ 92

LAZANDA SPR 100MCG ...................... 15

LAZANDA SPR 400MCG ...................... 15 leflunomide tab 10 mg ..................... 101

leflunomide tab 20 mg ..................... 101 LENVIMA CAP 10MG .......................... 36

LENVIMA CAP 14MG .......................... 36 LENVIMA CAP 20MG .......................... 36

LENVIMA CAP 24MG .......................... 36 lessina tab ....................................... 79

LETAIRIS TAB 10MG .......................... 53 LETAIRIS TAB 5MG ........................... 53

letrozole tab 2.5 mg .......................... 35 leucovorin calcium for inj 100 mg ....... 38

leucovorin calcium for inj 200 mg ....... 38 leucovorin calcium for inj 350 mg ....... 38

leucovorin calcium for inj 50 mg ......... 38

leucovorin calcium tab 10 mg ............. 38 leucovorin calcium tab 15 mg ............. 38

leucovorin calcium tab 25 mg ............. 38 leucovorin calcium tab 5 mg ............... 38

leucovorin inj calcium ........................ 38 LEUKERAN TAB 2MG.......................... 32

LEUKINE INJ 250MCG ........................ 98 leuprolide acetate inj kit 5 mg/ml ....... 35

levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv) .................... 124

LEVEMIR INJ .................................... 75 LEVEMIR INJ FLEXTOUC ..................... 75

LEVETIRACETA INJ 10MG/ML .............. 56 LEVETIRACETA INJ 15MG/ML .............. 56

LEVETIRACETA INJ 5MG/ML ............... 56

levetiracetam inj 500 mg/5ml (100 mg/ml) ............................................ 56

levetiracetam oral soln 100 mg/ml ..... 56

levetiracetam tab 1000 mg ................ 57 levetiracetam tab 250 mg ................. 56

levetiracetam tab 500 mg ................. 57 levetiracetam tab 750 mg ................. 57

levetiracetam tab sr 24hr 500 mg ...... 57 levetiracetam tab sr 24hr 750 mg ...... 57

LEVOBUNOLOL HCL OPHTH SOLN 0.25%.................................................... 121

levobunolol hcl ophth soln 0.5% ....... 121 levocarnitine inj 200 mg/ml ............... 81

levocarnitine oral soln 1 gm/10ml (10%)...................................................... 81

levocarnitine tab 330 mg ................... 81 levocetirizine dihydrochloride soln 2.5

mg/5ml (0.5 mg/ml) ...................... 124

levocetirizine dihydrochloride tab 5 mg.................................................... 124

levofloxacin in d5w iv soln 250 mg/50ml...................................................... 28



levofloxacin iv soln 25 mg/ml ............ 29 levofloxacin oral soln 25 mg/ml.......... 29

levofloxacin tab 250 mg .................... 29 levofloxacin tab 500 mg .................... 29

levofloxacin tab 750 mg .................... 29 levonest tab .................................... 79

levonorgestrel & ethinyl estradiol

(91-day) tab 0.15-0.03 mg ............... 79 LEVONORGESTREL & ETHINYL

ESTRADIOL (91-DAY) TAB 0.15-0.03 MG...................................................... 79

levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg ..................................... 79

levonorgestrel tab 0.75 mg ............... 79 levonorgestrel tab 1.5 mg ................. 79

levora-28 tab 0.15/30 ....................... 79 levothyroxine sodium tab 100 mcg ..... 85

levothyroxine sodium tab 112 mcg ..... 85 levothyroxine sodium tab 125 mcg ..... 85

levothyroxine sodium tab 137 mcg ..... 85 levothyroxine sodium tab 150 mcg ..... 85

levothyroxine sodium tab 175 mcg ..... 85

levothyroxine sodium tab 200 mcg ..... 85 levothyroxine sodium tab 25 mcg ....... 85

171

levothyroxine sodium tab 300 mcg ...... 85

levothyroxine sodium tab 50 mcg ....... 85 levothyroxine sodium tab 75 mcg ....... 85

levothyroxine sodium tab 88 mcg ....... 85 LEVOXYL TAB 100MCG ...................... 85

LEVOXYL TAB 112MCG ...................... 86 LEVOXYL TAB 125MCG ...................... 86



LEVOXYL TAB 25MCG ........................ 85 LEVOXYL TAB 50MCG ........................ 85

LEVOXYL TAB 75MCG ........................ 85 LEVOXYL TAB 88MCG ........................ 85

LEXIVA SUS 50MG/ML ....................... 22

LEXIVA TAB 700MG ........................... 22 LIALDA TAB 1.2GM ........................... 90

lice killing liq max st ........................ 141 lice killing sha 0.33-4% ................... 141

lice trtmnt liq ................................. 141 lice trtmnt liq 1% ............................ 141

licide aer 0.5% ............................... 141 LICIDE TREAT KIT ........................... 141

lidocaine hcl gel 2% ........................ 140 lidocaine hcl local inj 0.5% ................. 17

lidocaine hcl local inj 1%.................... 17 lidocaine hcl local inj 1.5% ................. 17

lidocaine hcl local inj 2%.................... 17 lidocaine hcl local preservative free (pf) inj

0.5% ............................................... 17

lidocaine hcl local preservative free (pf) inj 1% ................................................. 17

lidocaine hcl soln 4% ....................... 140 lidocaine hcl viscous soln 2% ........... 142

lidocaine oint 5% ............................ 140 lidocaine patch 5% (700 mg) ........... 140

lidocaine-prilocaine cream 2.5-2.5% . 140 linezolid iv soln 2 mg/ml .................... 19

LINZESS CAP 145MCG ....................... 93 LINZESS CAP 290MCG ....................... 93

liothyronine sodium tab 25 mcg .......... 86 liothyronine sodium tab 5 mcg ............ 86

liothyronine sodium tab 50 mcg .......... 86 liq ca/vit d cap 600mg ..................... 111

LIQUID CALCI CAP WITH D3 ............ 111

liquituss gg liq 200/5ml ................... 128 lisinopril & hydrochlorothiazide tab

10-12.5 mg ..................................... 39

lisinopril & hydrochlorothiazide tab 20-12.5 mg ..................................... 39

lisinopril & hydrochlorothiazide tab 20-25 mg ................................................. 39

lisinopril tab 10 mg........................... 40 lisinopril tab 2.5 mg ......................... 40

lisinopril tab 20 mg........................... 40 lisinopril tab 30 mg........................... 40

lisinopril tab 40 mg........................... 40 lisinopril tab 5 mg ............................ 40

lithium carbonate cap 150 mg ............ 72 lithium carbonate cap 300 mg ............ 72

lithium carbonate cap 600 mg ............ 72 lithium carbonate tab 300 mg ............ 72

lithium carbonate tab cr 300 mg ........ 72

lithium carbonate tab cr 450 mg ........ 72 LITHIUM SOL 8MEQ/5ML ................... 72

LITTLE NOSES DRO 0.125% ............ 128 LOCALNESIUM TAB ......................... 111

LOCALNESIUM TAB -C .................... 111 LODRANE D CAP 4-60MG ................ 128

LOHIST-D LIQ ................................ 128 lohist-dm syp 5-2-10mg.................. 128

lohist-peb liq 4-10/5ml ................... 128 LOKARA LOT 0.05% ....................... 139

LOMUSTINE CAP 10 MG .................... 32 LOMUSTINE CAP 100 MG ................... 32

LOMUSTINE CAP 40 MG .................... 32 loperamide hcl cap 2 mg ................... 93

loperamide hcl liq 1 mg/7.5ml ........... 88

loratadine & pseudoephedrine tab sr 24hr 10-240 mg .................................... 128

loratadine tab 10 mg ...................... 124 lorazepam con 2mg/ml ..................... 54

lorazepam inj 2 mg/ml ...................... 54 lorazepam inj 4 mg/ml ...................... 54

lorazepam tab 0.5 mg ....................... 54 lorazepam tab 1 mg ......................... 54

lorazepam tab 2 mg ......................... 54 LORTUSS DM LIQ ........................... 128

LORTUSS EX LIQ ............................ 128 LORTUSS LQ LIQ ............................ 128

loryna tab 3-0.02mg ......................... 79 losartan potassium & hydrochlorothiazide

tab 100-12.5 mg .............................. 42

losartan potassium & hydrochlorothiazide tab 100-25 mg ................................. 42

172

losartan potassium & hydrochlorothiazide

tab 50-12.5 mg ................................ 42 losartan potassium tab 100 mg .......... 43

losartan potassium tab 25 mg ............ 43 losartan potassium tab 50 mg ............ 43

LOTEMAX GEL 0.5% ........................ 120 LOTEMAX OIN 0.5% ........................ 120

LOTEMAX SUS 0.5%........................ 120 LOTRIMIN ULT CRE 1% ................... 136

LOTRONEX TAB 0.5MG ...................... 93 LOTRONEX TAB 1MG ......................... 94

lovastatin tab 10 mg ......................... 44 lovastatin tab 20 mg ......................... 44

lovastatin tab 40 mg ......................... 44 low-ogestrel tab................................ 79

loxapine succinate cap 10 mg ............. 67

loxapine succinate cap 25 mg ............. 67 loxapine succinate cap 5 mg............... 67

loxapine succinate cap 50 mg ............. 67 lubr/dry eye dro 0.5-0.9% ............... 121

lubricnt eye dro 0.5% op ................. 121 lubricnt gel dro 1% ......................... 121

LUMIGAN SOL 0.01% ...................... 121 LUMITENE CAP 30MG ...................... 115

LUMIZYME INJ 50MG ......................... 81 LUPR DEP-PED INJ 11.25MG ............... 35

LUPR DEP-PED INJ 15MG ................... 35 LUPR DEP-PED INJ 30MG ................... 35

LUPR DEP-PED INJ 7.5MG .................. 35 LUPRON DEPOT INJ 11.25MG ............. 35

LUPRON DEPOT INJ 3.75MG ............... 35

LUSAIR LIQ .................................... 128 lutera tab ......................................... 79

LYNPARZA CAP 50MG ........................ 34 LYRICA CAP 100MG ........................... 57

LYRICA CAP 150MG ........................... 57 LYRICA CAP 200MG ........................... 57

LYRICA CAP 225MG ........................... 57 LYRICA CAP 25MG ............................ 57

LYRICA CAP 300MG ........................... 57 LYRICA CAP 50MG ............................ 57

LYRICA CAP 75MG ............................ 57 LYRICA SOL 20MG/ML ....................... 57

LYSODREN TAB 500MG ...................... 35 lyza tab 0.35mg ............................... 79

M maalox child chw .............................. 87 maalox multi sus symp max ............... 87

maalox sus reg st ............................. 87

MAALOX TC SUS .............................. 87 MAG CITRATE TAB 100MG ............... 111

MAG OXIDE CAP 400MG .................... 87 MAG-200 TAB ................................ 111

MAG-AL LIQ ..................................... 87 mag-delay tab ............................... 111

MAGINEX TAB 615 MG .................... 111 MAGN SULFATE CAP 70MG .............. 111

magnacaps cap 100mg ................... 111 MAGNEBIND TAB 200 ..................... 111

MAGNEBIND TAB 300 ..................... 111 MAGNESIUM CAP 300MG ................. 111

MAGNESIUM CAP 400MG ................. 111 magnesium citrate soln ..................... 92

MAGNESIUM GL TAB 550MG ............ 111

magnesium oxide tab 250 mg ............ 87 magnesium oxide tab 400 mg ............ 87

magnesium oxide tab 400 mg (240 mg elemental mg) ............................... 112

magnesium oxide tab 400 mg (241.3 mg elemental mg) ............................... 112

magnesium oxide tab 420 mg ............ 87 magnesium oxide tab 500 mg (mg

supplement) .................................. 112 MAGNESIUM SU INJ 20/500ML......... 105

MAGNESIUM SU INJ 80MG/ML ......... 105 magnesium sulfate inj 50% ............. 105

MAGNESIUM SULFATE INJ 50% ....... 105 magnesium tab 200 mg .................. 112

magnesium tab 250 mg .................. 112

MAGNESIUM TAB 30MG .................. 112 MAG-TAB SR TAB 84MG .................. 111

malathion lotion 0.5% .................... 141 mapap cold tab 10-5-325 ................ 128

maprotiline hcl tab 25 mg ................. 61 maprotiline hcl tab 50 mg ................. 61

maprotiline hcl tab 75 mg ................. 61 MAR-COF BP LIQ ............................ 128

marlissa tab 0.15/30 ........................ 79 MARPLAN TAB 10MG ......................... 61

MATULANE CAP 50MG ....................... 37 MAXIDEX SUS 0.1% OP .................. 120

m-clear wc liq ................................ 128 meclizine hcl tab 12.5 mg ................. 88

meclizine hcl tab 25 mg .................... 88

MEDI-GRAINE TAB ......................... 128 medroxyprogesterone acetate im susp

173

150 mg/ml ....................................... 79

medroxyprogesterone acetate tab 10 mg ...................................................... 85

medroxyprogesterone acetate tab 2.5 mg ...................................................... 85

medroxyprogesterone acetate tab 5 mg ...................................................... 85

mefloquine hcl tab 250 mg ................. 21 MEGACE ES SUS 625/5ML .................. 35

mega-maratho tab 100 tr ................ 115 megestrol acetate susp 40 mg/ml ....... 35

megestrol acetate tab 20 mg .............. 35 megestrol acetate tab 40 mg .............. 35

MEKINIST TAB 0.5MG ........................ 36 MEKINIST TAB 2MG .......................... 36

MELOXICAM SUSP 7.5 MG/5ML ........... 13

meloxicam tab 15 mg ........................ 13 meloxicam tab 7.5 mg ....................... 13

melphalan hcl for inj 50 mg (base equiv) ...................................................... 32

MENACTRA INJ ............................... 104 m-end dm liq ................................. 128

M-END DMX LIQ ............................. 128 M-END MAX D LIQ .......................... 128

M-END PE LIQ ................................ 128 m-end wc liq .................................. 128

MENOMUNE INJ A/C/Y/W ................. 104 MENVEO INJ ................................... 105

MEPHYTON TAB 5MG ....................... 115 mercaptopurine tab 50 mg ................. 33

meribin cap 5mg ............................. 115

meropenem iv for soln 1 gm .............. 19 meropenem iv for soln 500 mg ........... 19

mesalamine enema 4 gm ................... 90 mesalamine rectal enema 4 gm & cleanser

wipe kit ........................................... 90 mesna inj 100 mg/ml ........................ 38

MESNEX TAB 400MG ......................... 38 METAMUCIL POW 28% ...................... 92

METAMUCIL POW 63% ...................... 92 METAMUCIL WAF .............................. 92

metformin hcl tab 1000 mg ................ 76 metformin hcl tab 500 mg .................. 76

metformin hcl tab 850 mg .................. 76 metformin hcl tab sr 24hr 500 mg ...... 76

metformin hcl tab sr 24hr 750 mg ...... 76

methadone con 10mg/ml ................... 15 methadone hcl soln 10 mg/5ml .......... 15

methadone hcl soln 5 mg/5ml ............ 15

methadone hcl tab 10 mg ................. 15 methadone hcl tab 5 mg ................... 15

methazolamide tab 25 mg ................. 51 methazolamide tab 50 mg ................. 51

methenamine hippurate tab 1 gm ...... 19 methimazole tab 10 mg .................... 86

methimazole tab 5 mg ...................... 86 methotrexate sodium for inj 1 gm ...... 33

methotrexate sodium inj 25 mg/ml .... 33 methotrexate sodium inj pf 25 mg/ml . 33

methotrexate sodium tab 2.5 mg (base equiv) ........................................... 101

methyclothiazide tab 5 mg ................ 51 methylergonovine maleate tab 0.2 mg 84

methylphenidate hcl soln 10 mg/5ml .. 70

methylphenidate hcl soln 5 mg/5ml .... 70 methylphenidate hcl tab 10 mg .......... 70

methylphenidate hcl tab 20 mg .......... 70 methylphenidate hcl tab 5 mg ............ 70

methylphenidate hcl tab cr 10 mg ...... 70 methylphenidate hcl tab cr 20 mg ...... 70

methylprednisolone acetate inj susp 40 mg/ml ............................................ 83

methylprednisolone acetate inj susp 80 mg/ml ............................................ 83

methylprednisolone sodium succinate for inj 1000 mg ..................................... 83

methylprednisolone sodium succinate for inj 125 mg ...................................... 83

methylprednisolone sodium succinate for

inj 40 mg ........................................ 83 methylprednisolone tab 16 mg ........... 83

methylprednisolone tab 32 mg ........... 83 methylprednisolone tab 4 mg ............ 83

methylprednisolone tab 4 mg dose pack...................................................... 83

methylprednisolone tab 8 mg ............ 83 metipranolol ophth soln 0.3% .......... 121

metoclopramide hcl inj 5 mg/ml ......... 88 metoclopramide hcl soln 5 mg/5ml (10

mg/10ml) ........................................ 88 metoclopramide hcl tab 10 mg ........... 88

metoclopramide hcl tab 5 mg ............ 88 metolazone tab 10 mg ...................... 51

metolazone tab 2.5 mg ..................... 51

metolazone tab 5 mg ........................ 51 metoprolol & hydrochlorothiazide tab

174

100-25 mg ....................................... 46

metoprolol & hydrochlorothiazide tab 100-50 mg ....................................... 46

metoprolol & hydrochlorothiazide tab 50-25 mg ........................................ 46

metoprolol succinate tab sr 24hr 100 mg ...................................................... 47




metoprolol tartrate inj 1 mg/ml .......... 47 metoprolol tartrate tab 100 mg .......... 47

metoprolol tartrate tab 25 mg ............ 47

metoprolol tartrate tab 50 mg ............ 47 metronidazole cream 0.75% ............ 140

metronidazole gel 0.75% ................. 140 metronidazole in nacl 0.79% iv soln 500

mg/100ml ........................................ 19 metronidazole lotion 0.75% ............. 141

metronidazole tab 250 mg ................. 19 metronidazole tab 500 mg ................. 19

metronidazole vaginal gel 0.75% ........ 96 mexiletine hcl cap 150 mg ................. 43

mexiletine hcl cap 200 mg ................. 43 mexiletine hcl cap 250 mg ................. 43

MEXSANA POW ............................... 141 MG GLUCONATE TAB 250MG ............ 112

MG SO4/D5W INJ 10MG/ML ............. 105

MG SO4/D5W INJ 20MG/ML ............. 105 MIACALCIN INJ 200/ML ..................... 84

mi-acid chw ..................................... 87 miconazole 3 cre 4% ......................... 96

miconazole 3 kit combinat .................. 96 miconazole 3 kit combo pk ................. 96

miconazole 7 cre tube/kit ................... 96 miconazole 7 sup 100mg ................... 96

miconazole nitrate vaginal supp 1200 mg & 2% cream kit ................................ 96

microgestin tab 1.5/30 ...................... 79 microgestin tab 1/20 ......................... 79

microgestin tab fe 1/20 ..................... 79 microgestin tab fe1.5/30 .................... 79

midodrine hcl tab 10 mg .................... 52

midodrine hcl tab 2.5 mg ................... 51 midodrine hcl tab 5 mg ...................... 51

MILK OF MAGN SUS 2400MG ............. 92

MILK OF MAGN SUS 800/5ML ............ 92 milk of magn sus frsh mnt ................. 92

MINERAL OIL ................................... 92 mineral oil enema ............................ 92

minitran dis 0.1mg/hr ....................... 52 minitran dis 0.2mg/hr ....................... 52

minitran dis 0.4mg/hr ....................... 52 minitran dis 0.6mg/hr ....................... 52

minocycline hcl cap 100 mg ............... 31 minocycline hcl cap 50 mg ................ 31

minocycline hcl cap 75 mg ................ 31 minoxidil tab 10 mg .......................... 52

minoxidil tab 2.5 mg ......................... 52 mintox plus chw ............................... 87

mirtazapine orally disintegrating tab 15

mg ................................................. 62 mirtazapine orally disintegrating tab 30

mg ................................................. 62 mirtazapine orally disintegrating tab 45

mg ................................................. 62 mirtazapine tab 15 mg ...................... 62

mirtazapine tab 30 mg ...................... 62 mirtazapine tab 45 mg ...................... 62

mirtazapine tab 7.5 mg ..................... 62 misoprostol tab 100 mcg ................... 94

misoprostol tab 200 mcg ................... 94 MISSION PREN TAB ........................ 115

MISSION PREN TAB HP ................... 115 mitomycin for iv soln 20 mg .............. 33

mitomycin for iv soln 40 mg .............. 33

mitomycin for iv soln 5 mg ................ 33 mitoxantrone hcl inj conc 20 mg/10ml (2

mg/ml) ........................................... 37 mitoxantrone hcl inj conc 25 mg/12.5ml

(2 mg/ml) ....................................... 37 mitoxantrone hcl inj conc 30 mg/15ml (2

mg/ml) ........................................... 37 mitrazol pow 2% ............................ 136

M-M-R II INJ LIVE .......................... 104 moderiba pak 1000/day .................... 25

moderiba pak 1200/day .................... 25 moderiba pak 600/day ...................... 24

moderiba pak 800/day ...................... 25 moexipril hcl tab 15 mg .................... 40

moexipril hcl tab 7.5 mg ................... 40

moexipril-hydrochlorothiazide tab 15-12.5 mg ..................................... 40

175

moexipril-hydrochlorothiazide tab 15-25

mg .................................................. 40 moexipril-hydrochlorothiazide tab

7.5-12.5 mg ..................................... 40 mometasone furoate cream 0.1% ..... 139

mometasone furoate oint 0.1% ........ 139 mometasone furoate solution 0.1%

(lotion) .......................................... 139 MONONESSA TAB ............................. 79

montelukast sodium chew tab 4 mg (base equiv) ........................................... 132

montelukast sodium chew tab 5 mg (base equiv) ........................................... 132

montelukast sodium oral granules packet 4 mg (base equiv) .......................... 132

montelukast sodium tab 10 mg (base

equiv) ........................................... 132 MORPHINE SUL INJ 2MG/ML ............... 15

MORPHINE SUL INJ 4MG/ML ............... 15 MORPHINE SUL INJ 8MG/ML ............... 15

MORPHINE SULFATE (CONCENTRATE) ORAL SOLN 20 MG/ML ....................... 15

morphine sulfate beads cap sr 24hr 120 mg .................................................. 16

morphine sulfate beads cap sr 24hr 30 mg ...................................................... 15



morphine sulfate beads cap sr 24hr 75 mg

...................................................... 16 morphine sulfate beads cap sr 24hr 90 mg

...................................................... 16 morphine sulfate cap sr 24hr 10 mg .... 16

morphine sulfate cap sr 24hr 100 mg .. 16 morphine sulfate cap sr 24hr 20 mg .... 16

morphine sulfate cap sr 24hr 30 mg .... 16 morphine sulfate cap sr 24hr 50 mg .... 16

morphine sulfate cap sr 24hr 60 mg .... 16 morphine sulfate cap sr 24hr 80 mg .... 16

morphine sulfate inj pf 0.5 mg/ml ....... 16 morphine sulfate inj pf 1 mg/ml .......... 16

MORPHINE SULFATE IV SOLN 1 MG/ML16 MORPHINE SULFATE IV SOLN PF 10

MG/ML ............................................. 16

MORPHINE SULFATE IV SOLN PF 15 MG/ML ............................................. 16


MG/5ML .......................................... 16 MORPHINE SULFATE ORAL SOLN 20

MG/5ML .......................................... 16 MORPHINE SULFATE TAB 15 MG ........ 16

MORPHINE SULFATE TAB 30 MG ........ 16 morphine sulfate tab cr 100 mg ......... 16

morphine sulfate tab cr 15 mg ........... 16 morphine sulfate tab cr 200 mg ......... 16

morphine sulfate tab cr 30 mg ........... 16 morphine sulfate tab cr 60 mg ........... 16

motion sick chw 25mg ...................... 88 motion sick tab 50mg ....................... 88

motrin ib tab 200mg ......................... 12 MOVANTIK TAB 12.5MG .................... 94

MOVANTIK TAB 25MG ....................... 94

MOVIPREP SOL ................................ 92 MOXEZA SOL 0.5% ........................ 119

MOZOBIL INJ ................................... 98 mucaphed tab 10-400mg ................ 128

MUCINEX CGH GRA 5-100MG .......... 128 mucinex cold tab sinus .................... 128

MUCINEX D TAB 120-1200 .............. 128 MUCINEX D TAB 60-600MG ............. 128

MUCINEX TAB 1200MG ................... 128 MUCINEX/KIDS GRA 100MG ............ 128

MUCINEX/KIDS GRA 50MG .............. 128 mucus relief liq 5-100mg ................ 128

mucus relief liq cold/sin .................. 128 mucus relief tab 400mg .................. 128

mucus+chst liq 100/5ml ................. 128

mucus-dm max tab 60-1200 ........... 128 mucus-dm tab 30-600mg ................ 128

mucus-er tab 600mg ...................... 128 MULTAQ TAB 400MG......................... 43

multi-delyn liq ............................... 115 MULTI-DELYN LIQ /IRON ................. 115

multi-sympt liq cld nght .................. 128 multi-sympt pak day/nght ............... 128

multi-vit tab .................................. 115 multsym cold liq childrns ................. 128

mupirocin oint 2% .......................... 135 MURO 128 SOL 2% OP .................... 122

MUSTARGEN INJ 10MG ..................... 32 my way tab 1.5mg ........................... 79

MYCAMINE INJ 100MG ...................... 21

MYCAMINE INJ 50MG ........................ 21 mycophenolate mofetil cap 250 mg .. 103

176

mycophenolate mofetil for oral susp 200

mg/ml ........................................... 103 mycophenolate mofetil tab 500 mg ... 103

mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv)................ 103

mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv)................ 103

MYKIDZ IRON SUS 10MG/2ML .......... 115 MYKIDZ IRON SUS 15/1.5ML ............ 100

myorisan cap 10mg ......................... 135 myorisan cap 20mg ......................... 135

myorisan cap 40mg ......................... 135 MYOZYME INJ 50MG .......................... 81

MYRBETRIQ TAB 25MG ...................... 96 MYRBETRIQ TAB 50MG ...................... 96

myzilra tab....................................... 79

N nabumetone tab 500 mg .................... 13

nabumetone tab 750 mg .................... 13 nadolol tab 20 mg ............................. 47

nadolol tab 40 mg ............................. 47 nadolol tab 80 mg ............................. 47

nafcillin sodium for inj 1 gm ............... 30 nafcillin sodium for inj 10 gm ............. 30

nafcillin sodium for inj 2 gm ............... 30 nafcillin sodium for iv soln 1 gm ......... 30

nafcillin sodium for iv soln 2 gm ......... 30 NAGLAZYME INJ 1MG/ML ................... 81

nail-ex tab 2.5mg ........................... 115 naloxone hcl inj 0.4 mg/ml................. 74

naloxone hcl inj 1 mg/ml ................... 74

naltrexone hcl tab 50 mg ................... 74 NAMENDA SOL 10MG/5ML ................. 59

NAMENDA TAB 10MG ........................ 59 NAMENDA TAB 5MG .......................... 59

NAMENDA XR CAP 14MG .................... 59 NAMENDA XR CAP 21MG .................... 59

NAMENDA XR CAP 28MG .................... 59 NAMENDA XR CAP 7MG ..................... 59

NAMENDA XR CAP TITRATIO .............. 59 naphazoline hcl ophth soln 0.1% ...... 122

naproxen dr tab 375mg ..................... 13 naproxen dr tab 500mg ..................... 13

NAPROXEN SODIUM CAP 220 MG ........ 12 naproxen sodium tab 275 mg ............. 13

naproxen sodium tab 550 mg ............. 13

naproxen susp 125 mg/5ml ................ 13 naproxen tab 250 mg ........................ 13

naproxen tab 375 mg ....................... 13

naproxen tab 500 mg ....................... 13 naratriptan hcl tab 1 mg (base equiv) . 71

naratriptan hcl tab 2.5 mg (base equiv)...................................................... 71

nasal decon liq 15mg/5ml ............... 128 nasal decon syp 30mg/5ml .............. 128

NASAL DECONG LIQ 30MG/5ML ....... 129 nasal decong tab 10mg ................... 129

nasal decong tab 30mg ................... 129 nasal relief tab 5-325mg ................. 129

nasal relief tab night ....................... 129 nasal spr 0.05% ............................. 129

NASCOBAL SPR 500MCG ................. 115 NASOHIST DM DRO ........................ 129

nasohist dro 1-2mg/ml ................... 129

NASONEX SPR 50MCG/AC ............... 133 NASOPEN PE LIQ ............................ 129

nat fiber pow therapy ....................... 92 NATACYN SUS 5% OP ..................... 119

nateglinide tab 120 mg ..................... 76 nateglinide tab 60 mg ....................... 76

natures tear sol 0.4% ..................... 122 naturl fiber pow 68% ........................ 92

NEBUPENT INH 300MG ..................... 19 necon tab 0.5/35 ............................. 79

necon tab 1/35 ................................ 79 NECON TAB 1/50-28 ......................... 79

necon tab 10/11-28 .......................... 79 NECON TAB 7/7/7 ............................ 79

nefazodone hcl tab 100 mg ............... 62

nefazodone hcl tab 150 mg ............... 62 nefazodone hcl tab 200 mg ............... 62

nefazodone hcl tab 250 mg ............... 62 nefazodone hcl tab 50 mg ................. 62

neomycin sulfate tab 500 mg ............. 17 neomycin-bacitrac zn-polymyx

5(3.5)mg-400unt-10000unt op oin ... 119 neomycin-polymy-gramicid op sol

1.75-10000-0.025mg-unt-mg/ml ..... 119 neomycin-polymyxin-dexamethasone

ophth oint 0.1% ............................. 118 neomycin-polymyxin-dexamethasone

ophth susp 0.1% ............................ 118 neomycin-polymyxin-hc ophth susp .. 118

neomycin-polymyxin-hc otic soln 1% 142

neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% ............... 142

177

NEORAL CAP 100MG........................ 103

NEORAL CAP 25MG ......................... 103 NEORAL SOL 100MG/ML .................. 103

neosporin+pn oin relf max ............... 135 NEO-SYNEPHRI SPR 0.5% ................ 129

neotuss liq ..................................... 129 NEPHRAMINE INJ 5.4% ................... 107

NEPHRONEX LIQ ............................. 115 NEUMEGA INJ 5MG ........................... 98

NEUPOGEN INJ 300/0.5 ..................... 98 NEUPOGEN INJ 300MCG .................... 99

NEUPOGEN INJ 480/0.8 ..................... 99 NEUPOGEN INJ 480MCG .................... 99

NEUPRO DIS 1MG/24HR .................... 64 NEUPRO DIS 2MG/24HR .................... 64

NEUPRO DIS 3MG/24HR .................... 64

NEUPRO DIS 4MG/24HR .................... 64 NEUPRO DIS 6MG/24HR .................... 64

NEUPRO DIS 8MG/24HR .................... 64 neuro-k-250 tab 250mg................... 115

neuro-k-500 tab ............................. 115 neutrahist dro 0.8-9mg ................... 129

NEVANAC SUS 0.1% ....................... 120 NEVIRAPINE SUSP 50 MG/5ML ........... 22

nevirapine tab 200 mg ...................... 22 nevirapine tab sr 24hr 400 mg ........... 22

nexafed tab 30mg ........................... 129 NEXAVAR TAB 200MG ........................ 36

NEXIUM CAP 20MG ........................... 94 NEXIUM CAP 40MG ........................... 94

NEXIUM GRA 10MG DR ...................... 95

NEXIUM GRA 2.5MG DR ..................... 94 NEXIUM GRA 20MG DR ...................... 95

NEXIUM GRA 40MG DR ...................... 95 NEXIUM GRA 5MG DR ........................ 94

next choice tab 1.5mg ....................... 79 niacin cap cr 250 mg ....................... 115

niacin cap cr 500 mg ....................... 116 niacin tab 100 mg ........................... 116

niacin tab 250 mg ........................... 116 niacin tab 50 mg ............................. 116

niacin tab 500 mg ........................... 116 niacin tab cr 1000 mg

(antihyperlipidemic) .......................... 45 niacin tab cr 500 mg ....................... 116

niacin tab cr 500 mg (antihyperlipidemic)

...................................................... 45 niacin tab cr 750 mg ....................... 116

niacin tab cr 750 mg (antihyperlipidemic)

...................................................... 45 NIACIN TR TAB 1000MG .................. 116

niacinamide tab 100 mg .................. 116 niacinamide tab 500 mg .................. 116

niacor tab 500mg ............................. 45 nicardipine hcl cap 20 mg .................. 48

nicardipine hcl cap 30 mg .................. 49 nicotine polacrilex gum 4 mg ............. 74

nicotine polacrilex lozenge 2 mg ........ 74 NICOTINE POLACRILEX LOZENGE 2 MG

...................................................... 74 nicotine polacrilex lozenge 4 mg ........ 74

NICOTINE POLACRILEX LOZENGE 4 MG...................................................... 74

NICOTINE SYS KIT TRANSDER ........... 74

nicotine td patch 24hr 14 mg/24hr ..... 74 nicotine td patch 24hr 21 mg/24hr ..... 74

nicotine td patch 24hr 7 mg/24hr ....... 74 NICOTROL INH ................................ 74

NICOTROL NS SPR 10MG/ML ............. 74 nifedical xl tab 30mg ........................ 49

nifedical xl tab 60mg ........................ 49 nifedipine tab sr 24hr 30 mg.............. 49

nifedipine tab sr 24hr 60 mg.............. 49 nifedipine tab sr 24hr 90 mg.............. 49

nifedipine tab sr 24hr osmotic 30 mg .. 49 nifedipine tab sr 24hr osmotic 60 mg .. 49

nifedipine tab sr 24hr osmotic 90 mg .. 49 night time liq cold/flu ...................... 129

night time liq cough ........................ 129

night-time cap sinus ....................... 129 nikki tab 3-0.02mg ........................... 79

NILANDRON TAB 150MG ................... 35 nimodipine cap 30 mg ...................... 49

NIPENT INJ 10MG ............................. 33 nitro-bid oin 2% ............................... 52

NITRO-DUR DIS 0.3MG/HR ................ 52 NITRO-DUR DIS 0.8MG/HR ................ 52

nitrofurantoin macrocrystalline cap 100 mg ................................................. 19

nitrofurantoin macrocrystalline cap 50 mg...................................................... 19

nitrofurantoin monohydrate macrocrystalline cap 100 mg ............. 19

nitroglycerin td patch 24hr 0.1 mg/hr . 52

nitroglycerin td patch 24hr 0.2 mg/hr . 52 nitroglycerin td patch 24hr 0.4 mg/hr . 52

178

nitroglycerin td patch 24hr 0.6 mg/hr .. 52

NITROLINGUAL SPR PUMPSPRA .......... 52 NITROSTAT SUB 0.3MG ..................... 52

NITROSTAT SUB 0.4MG ..................... 52 NITROSTAT SUB 0.6MG ..................... 52

NIZORAL A-D SHA 1% ..................... 136 nohist-lq liq 4-10/5ml ...................... 129

non-asa jr tab 160mg ........................ 12 non-aspirin chw 160mg jr .................. 12

non-aspirin chw 80mg ....................... 12 NON-ASPIRIN TAB 500MG QM ............ 12

NORDITROPIN INJ 10/1.5ML .............. 84 NORDITROPIN INJ 15/1.5ML .............. 84

NORDITROPIN INJ 30/3ML ................. 84 NORDITROPIN INJ 5/1.5ML ................ 84

NOREL AD TAB 4-10-325 ................. 129

NOREL CS LIQ ................................ 129 norelgestromin-ethinyl estradiol td ptwk

150-35 mcg/24hr ............................. 80 norethindrone ace & ethinyl estradiol-fe

tab 1 mg-20 mcg .............................. 80 norethindrone acetate tab 5 mg .......... 85

norethindrone tab 0.35 mg ................ 80 NORETHINDRONE TAB 0.35 MG .......... 80

NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1-35/0.5-35 MG-MCG ............. 80

norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg .... 80

norlyroc tab 0.35mg .......................... 80 normosol -m inj /d5w ...................... 108

NORMOSOL -R INJ /D5W ................. 108

NORMOSOL-R INJ PH 7.4 ................. 108 NORPACE CAP 100MG CR ................... 43

NORPACE CAP 150MG CR ................... 43 nortrel tab 0.5/35 ............................. 80

nortrel tab 1/35 ................................ 80 nortrel tab 7/7/7 ............................... 80

nortriptyline hcl cap 10 mg ................ 62 nortriptyline hcl cap 25 mg ................ 62

nortriptyline hcl cap 50 mg ................ 62 nortriptyline hcl cap 75 mg ................ 62

nortriptyline hcl soln 10 mg/5ml ......... 62 NORVIR CAP 100MG .......................... 22

NORVIR SOL 80MG/ML ...................... 22 NORVIR TAB 100MG .......................... 22

NOVAFERRUM DRO 15MG/ML ........... 100

NOVAFERRUM LIQ 125 .................... 100 NOVOLIN INJ 70/30 .......................... 75

NOVOLIN N INJ U-100 ...................... 75

NOVOLIN R INJ U-100 ...................... 75 NOVOLOG INJ 100/ML ...................... 75

NOVOLOG INJ FLEXPEN..................... 75 NOVOLOG INJ PENFILL ..................... 75

NOVOLOG MIX INJ 70/30 .................. 75 NOVOLOG MIX INJ FLEXPEN .............. 75

NOXAFIL SUS 40MG/ML .................... 21 NOXAFIL TAB 100MG ........................ 21

NUEDEXTA CAP 20-10MG .................. 72 nu-iron 150 cap 150mg ................... 100

NULOJIX INJ 250MG ....................... 104 NULYTELY SOL FLAV PKS .................. 92

NUTRATEAR SOL 0.6% ................... 122 nutr-e-sol liq 400/15ml ................... 116

NUTRICION TAB PORVIDA ............... 116

NUTRISOURCE PAK FIBER ................. 92 NUVARING MIS ................................ 80

NUVIGIL TAB 150MG ........................ 73 NUVIGIL TAB 200MG ........................ 73

NUVIGIL TAB 250MG ........................ 73 NUVIGIL TAB 50MG .......................... 73

nyamyc pow 100000 ...................... 136 NYMALIZE SOL 60/20ML ................... 49

nystatin cream 100000 unit/gm ....... 136 nystatin oint 100000 unit/gm .......... 136

nystatin susp 100000 unit/ml .......... 142 nystatin tab 500000 unit ................... 21

nystatin topical powder ................... 136 nystop pow 100000 ........................ 136

O OCTAGAM INJ 10GM ....................... 102 OCTAGAM INJ 1GM ......................... 102

OCTAGAM INJ 2.5GM ...................... 102 OCTAGAM INJ 25GM ....................... 102

OCTAGAM INJ 2GM/20ML ................ 102 OCTAGAM INJ 5GM ......................... 102

octreotide acetate inj 100 mcg/ml (0.1 mg/ml) ........................................... 84

octreotide acetate inj 1000 mcg/ml (1 mg/ml) ........................................... 84



octreotide acetate inj 500 mcg/ml (0.5

mg/ml) ........................................... 84 ofloxacin ophth soln 0.3% ............... 119

179

ofloxacin otic soln 0.3% ................... 142

olanzapine for im inj 10 mg ................ 67 olanzapine orally disintegrating tab 10 mg

...................................................... 67 olanzapine orally disintegrating tab 15 mg



...................................................... 67 olanzapine tab 10 mg ........................ 68

olanzapine tab 15 mg ........................ 68 olanzapine tab 2.5 mg ....................... 68

olanzapine tab 20 mg ........................ 68 olanzapine tab 5 mg .......................... 68

olanzapine tab 7.5 mg ....................... 68

olopatadine hcl nasal soln 0.6% ........ 124 OLYSIO CAP 150MG .......................... 25

omega-3-acid ethyl esters cap 1 gm .... 45 omeprazole cap 20.6mgdr .................. 95

omeprazole cap delayed release 10 mg95 omeprazole cap delayed release 20 mg95

omeprazole cap delayed release 40 mg95 OMEPRAZOLE TAB 20MG.................... 95

omeprazole-sodium bicarbonate cap 20-1100 mg ..................................... 95

ondansetron hcl inj 4 mg/2ml (2 mg/ml) ...................................................... 89

ondansetron hcl inj 40 mg/20ml (2 mg/ml) ............................................ 89

ondansetron hcl oral soln 4 mg/5ml .... 89

ondansetron hcl tab 24 mg ................ 89 ondansetron hcl tab 4 mg .................. 89

ondansetron hcl tab 8 mg .................. 89 ondansetron orally disintegrating tab 4

mg .................................................. 89 ondansetron orally disintegrating tab 8

mg .................................................. 89 ONFI SUS 2.5MG/ML ......................... 57

ONFI TAB 10MG ................................ 57 ONFI TAB 20MG ................................ 57

ONSET FORTE TAB .......................... 129 optics mini dro ............................... 122

oral saline sol laxative ....................... 92 ORAP TAB 1MG ................................. 68

ORAP TAB 2MG ................................. 68

ORFADIN CAP 10MG .......................... 81 ORFADIN CAP 2MG ........................... 81

ORFADIN CAP 5MG ........................... 81

organ-i nr tab 200mg ..................... 129 orsythia tab ..................................... 80

os-cal + d3 tab 500-200 ................. 112 OSTEO-PORETI TAB ........................ 112

oxacillin sodium for inj 1 gm .............. 30 oxacillin sodium for inj 10 gm ............ 30

oxacillin sodium for inj 2 gm .............. 30 oxaliplatin for iv inj 100 mg ............... 38

oxaliplatin for iv inj 50 mg ................. 38 oxaliplatin iv soln 100 mg/20ml ......... 38

oxaliplatin iv soln 50 mg/10ml ........... 38 oxandrolone tab 10 mg ..................... 75

oxandrolone tab 2.5 mg .................... 75 oxcarbazepine susp 300 mg/5ml (60

mg/ml) ........................................... 57

oxcarbazepine tab 150 mg ................ 57 oxcarbazepine tab 300 mg ................ 57

oxcarbazepine tab 600 mg ................ 57 oxybutynin chloride syrup 5 mg/5ml ... 96

oxybutynin chloride tab 5 mg ............ 96 oxybutynin chloride tab sr 24hr 10 mg 96

oxybutynin chloride tab sr 24hr 15 mg 96 oxybutynin chloride tab sr 24hr 5 mg . 96

oxycodone hcl cap 5 mg .................... 16 OXYCODONE HCL CONC 100 MG/5ML (20

MG/ML) ........................................... 16 oxycodone hcl soln 5 mg/5ml ............ 16

oxycodone hcl tab 10 mg .................. 17 oxycodone hcl tab 15 mg .................. 17

oxycodone hcl tab 20 mg .................. 17

oxycodone hcl tab 30 mg .................. 17 oxycodone hcl tab 5 mg .................... 16

oxycodone w/ acetaminophen tab 10-325 mg ................................................. 17

oxycodone w/ acetaminophen tab 2.5-325 mg ................................................. 17

oxycodone w/ acetaminophen tab 5-325 mg ................................................. 17

oxycodone w/ acetaminophen tab 7.5-325 mg ................................................. 17

oys shell+d tab 250-125 ................. 112 oysco 500 tab 500mg ..................... 112

OYSCO 500+D CHW ....................... 112 oyst shell/d tab 500-200 ................. 112

oyst shell/d tab 500mg ................... 112

oyst-cal d tab 250mg ...................... 112

180

P pacerone tab 100mg ......................... 43 pacerone tab 200mg ......................... 43

pacerone tab 400mg ......................... 43 paclitaxel iv conc 100 mg/16.7ml (6

mg/ml) ............................................ 34 paclitaxel iv conc 150 mg/25ml (6 mg/ml)

...................................................... 34 paclitaxel iv conc 30 mg/5ml (6 mg/ml)

...................................................... 34 paclitaxel iv conc 300 mg/50ml (6 mg/ml)

...................................................... 34 pain relief dro 80/0.8ml ..................... 12

pain relief liq 500/15ml ...................... 12 pain relief sus 160/5ml ...................... 12

pain relief sus pls cold ..................... 129

pain relief tab 325mg ........................ 12 pain relief tab 500mg ........................ 12

pain relieve tab pm ......................... 129 pain relievr tab 325mg ...................... 12

pamidronate disodium iv soln 3 mg/ml 77 pamidronate disodium iv soln 9 mg/ml 77

pamidronate inj 6mg/ml .................... 77 PANOXYL BAR 10% ......................... 135

panoxyl wash liq 10% ..................... 135 PANOXYL-4 LIQ CREM WSH .............. 135

PANOXYL-8 LIQ CREM WSH .............. 135 PANRETIN GEL 0.1% ....................... 141

pantoprazole sodium ec tab 20 mg (base equiv) ............................................. 95

pantoprazole sodium ec tab 40 mg (base

equiv) ............................................. 95 pantothenic acid tab 100 mg ............ 116

pantothenic acid tab 500 mg ............ 116 paricalcitol cap 1 mcg ...................... 116

paricalcitol cap 2 mcg ...................... 116 paricalcitol cap 4 mcg ...................... 116

paromomycin sulfate cap 250 mg ....... 18 paroxetine hcl tab 10 mg ................... 62

paroxetine hcl tab 20 mg ................... 62 paroxetine hcl tab 30 mg ................... 62

paroxetine hcl tab 40 mg ................... 62 PARVA-CAL TAB 250-100 ................. 112

PARVA-CAL TAB 500MG ................... 112 paser gra 4gm .................................. 24

PATADAY SOL 0.2% ........................ 120

PATANOL SOL 0.1% OP ................... 120 PAXIL SUS 10MG/5ML ....................... 62

PAZEO DRO 0.7% .......................... 120

ped formula liq 100-10/5 ................ 129 pediacare liq long-act ..................... 129

PEDIA-LAX LIQ 50MG ....................... 92 pedi-atric liq niterest ...................... 129

PEDVAX HIB INJ ............................. 105 peg 3350-kcl-na bicarb-nacl-na sulfate for

soln 236 gm .................................... 92 PEG 3350-KCL-NA BICARB-NACL-NA

SULFATE FOR SOLN 240 GM .............. 92 peg 3350-kcl-sod bicarb-nacl for soln 420

gm ................................................. 92 PEGANONE TAB 250MG ..................... 57

PEG-INTRON KIT 120 RP ................. 103 PEGINTRON KIT 120MCG ................ 103

PEG-INTRON KIT 150 RP ................. 103

PEGINTRON KIT 150MCG ................ 103 PEG-INTRON KIT 50MCG ................. 102

PEG-INTRON KIT 50MCG RP ............ 103 PEGINTRON KIT 80MCG .................. 103

PEG-INTRON KIT 80MCG RP ............ 103 pen g proc inj 600000 ....................... 30

PENICILL GK/ INJ DEX 2MU ............... 30 PENICILL GK/ INJ DEX 3MU ............... 30

penicillin g potassium for inj 20000000 unit ................................................ 31

penicillin g potassium for inj 5000000 unit...................................................... 30

penicillin g sodium for inj 5000000 unit...................................................... 31

penicillin v potassium for soln 125 mg/5ml

...................................................... 31 penicillin v potassium for soln 250 mg/5ml

...................................................... 31 penicillin v potassium tab 250 mg ...... 31

penicillin v potassium tab 500 mg ...... 31 PENTAM 300 INJ 300MG .................... 19

PENTASA CAP 250MG CR .................. 90 PENTASA CAP 500MG CR .................. 90

pentoxifylline tab cr 400 mg ............ 100 PEPCID AC CHW 10MG ...................... 90

peptic relf chw 262mg ...................... 88 perdiem over tab 15mg ..................... 92

PERFOROMIST NEB 20MCG ............. 125 perindopril erbumine tab 2 mg ........... 40

perindopril erbumine tab 4 mg ........... 40

perindopril erbumine tab 8 mg ........... 40 periogard sol 0.12% ....................... 142

181

permethrin cream 5% ..................... 141

permethrin lotion 1% ...................... 141 perphenazine tab 16 mg .................... 68

perphenazine tab 2 mg ...................... 68 perphenazine tab 4 mg ...................... 68

perphenazine tab 8 mg ...................... 68 PERRY PRENAT CAP ......................... 116

PHENAGIL TAB 3.5-10MG................. 129 phenelzine sulfate tab 15 mg.............. 62

PHENOBARB INJ 65MG/ML ................. 57 phenobarbital elixir 20 mg/5ml ........... 57

phenobarbital sodium inj 130 mg/ml ... 57 phenobarbital tab 100 mg .................. 57

phenobarbital tab 15 mg .................... 57 phenobarbital tab 16.2 mg ................. 57

phenobarbital tab 30 mg .................... 57

phenobarbital tab 32.4 mg ................. 57 phenobarbital tab 60 mg .................... 57

phenobarbital tab 64.8 mg ................. 57 phenobarbital tab 97.2 mg ................. 57

phenylephrine-brompheniramine-dm liquid 10-4-20 mg/5ml .................... 129

PHENYLHIST LIQ DH ....................... 129 phenytek cap 200mg ......................... 57

phenytek cap 300mg ......................... 57 phenytoin chew tab 50 mg ................. 57

phenytoin sodium extended cap 100 mg ...................................................... 57

phenytoin sodium extended cap 200 mg ...................................................... 58

phenytoin sodium extended cap 300 mg

...................................................... 58 phenytoin sodium inj 50 mg/ml .......... 58

phenytoin susp 125 mg/5ml ............... 58 philith tab 0.4-35 .............................. 80

PHOSLYRA SOL ................................. 85 PHOS-NAK POW CONCENTR ............. 112

PHOSPHOLINE SOL 0.125%OP ......... 121 phytonadione inj 1 mg/0.5ml (2 mg/ml)

.................................................... 116 phytonadione inj 10 mg/ml .............. 116

phytonadione tab 100 mcg ............... 116 PILOCARPINE HCL OPHTH SOLN 1% . 121

PILOCARPINE HCL OPHTH SOLN 2% . 121 PILOCARPINE HCL OPHTH SOLN 4% . 121

pilocarpine hcl tab 5 mg .................. 142

pilocarpine hcl tab 7.5 mg ................ 142 pimtrea tab ...................................... 80

pindolol tab 10 mg ........................... 47

pindolol tab 5 mg ............................. 47 pioglitazone hcl tab 15 mg (base equiv)

...................................................... 77 pioglitazone hcl tab 30 mg (base equiv)

...................................................... 77 pioglitazone hcl tab 45 mg (base equiv)

...................................................... 77 piperacillin sodium-tazobactam sodium

for inj 2-0.25 gm ............................. 31 piperacillin sodium-tazobactam sodium

for inj 3-0.375 gm ............................ 31 piperacillin sodium-tazobactam sodium

for inj 36-4.5 gm ............................. 31 piperacillin sodium-tazobactam sodium

for inj 4-0.5 gm ............................... 31

pirmella tab 1/35 ............................. 80 piroxicam cap 10 mg ........................ 13

piroxicam cap 20 mg ........................ 13 PLASMA-LYTE INJ -148 ................... 108

PLASMA-LYTE INJ 56/D5W .............. 108 PLASMA-LYTE INJ -A ....................... 108

podofilox soln 0.5% ........................ 141 polyethylene glycol 3350 oral packet .. 92

polyethylene glycol 3350 oral powder . 92 polymyxin b-trimethoprim ophth soln

10000 unit/ml-0.1% ....................... 119 POLY-TUSSIN LIQ 10-9.375 ............. 129

POLY-TUSSIN LIQ AC ...................... 129 POLY-TUSSIND LIQ 10-9.375 .......... 129

polyvitamin dro .............................. 116

polyvitamin dro /iron ...................... 116 POMALYST CAP 1MG ......................... 37

POMALYST CAP 2MG ......................... 37 POMALYST CAP 3MG ......................... 37

POMALYST CAP 4MG ......................... 37 portia-28 tab ................................... 80

POTASSIUM CHLORIDE 20 MEQ/L (0.15%) IN DEXTROSE 5% INJ ........ 108

POTASSIUM CHLORIDE 40 MEQ/L (0.3%) IN DEXTROSE 5% INJ ..................... 108

potassium chloride cap cr 10 meq .... 105 potassium chloride cap cr 8 meq ...... 105

POTASSIUM CHLORIDE INJ 10 MEQ/100 ML ................................................ 108

potassium chloride inj 10 meq/50 ml 108

potassium chloride inj 2 meq/ml ...... 108 POTASSIUM CHLORIDE INJ 20 MEQ/100

182

ML ................................................ 108

potassium chloride inj 20 meq/50 ml . 108 potassium chloride inj 40 meq/100 ml

.................................................... 109 potassium chloride microencapsulated

crys cr tab 10 meq .......................... 105 potassium chloride microencapsulated

crys cr tab 20 meq .......................... 106 potassium chloride oral liq 10% (20

meq/15ml) ..................................... 106 potassium chloride oral liq 20% (40

meq/15ml) ..................................... 106 POTASSIUM CHLORIDE TAB CR 10 MEQ

.................................................... 106 POTASSIUM CHLORIDE TAB CR 20 MEQ

(1500 MG) ..................................... 106

potassium chloride tab cr 8 meq (600 mg) .................................................... 106

POTASSIUM CITRATE TAB CR 10 MEQ (1080 MG) ....................................... 95

POTASSIUM CITRATE TAB CR 5 MEQ (540 MG) ................................................ 95

POTIGA TAB 200MG .......................... 58 POTIGA TAB 300MG .......................... 58

POTIGA TAB 400MG .......................... 58 POTIGA TAB 50MG ............................ 58

povidone/iod sol 10% ........................ 96 PRADAXA CAP 150MG ........................ 98

PRADAXA CAP 75MG ......................... 98 pramipexole dihydrochloride tab 0.125

mg .................................................. 64

pramipexole dihydrochloride tab 0.25 mg ...................................................... 64



pramipexole dihydrochloride tab 1 mg . 64 pramipexole dihydrochloride tab 1.5 mg

...................................................... 64 pravastatin sodium tab 10 mg ............ 44

pravastatin sodium tab 20 mg ............ 44 pravastatin sodium tab 40 mg ............ 44

pravastatin sodium tab 80 mg ............ 44 prazosin hcl cap 1 mg ........................ 41

prazosin hcl cap 2 mg ........................ 41

prazosin hcl cap 5 mg ........................ 41 pred sod pho sol 1% op ................... 120

PREDNISOLONE ACETATE OPHTH SUSP

1% ............................................... 120 prednisolone sod phosph oral soln 6.7

mg/5ml (5 mg/5ml base) .................. 83 prednisolone sod phosphate oral soln 15

mg/5ml (base equiv) ........................ 83 prednisolone sodium phosphate oral soln

25 mg/5ml (base eq) ........................ 83 prednisolone syrup 15 mg/5ml (usp

solution equivalent) .......................... 83 prednisone con 5mg/ml .................... 83

prednisone oral soln 5 mg/5ml ........... 83 prednisone tab 1 mg ......................... 83

prednisone tab 10 mg ....................... 83 prednisone tab 10 mg dose pack ........ 83

prednisone tab 2.5 mg ...................... 83

prednisone tab 20 mg ....................... 83 prednisone tab 5 mg ......................... 83

prednisone tab 5 mg dose pack .......... 83 prednisone tab 50 mg ....................... 83

PREMARIN VAG CRE 0.625MG ............ 82 premasol sol 10% .......................... 107

PRENATAL TAB............................... 116 PRENATAL TAB 27-0.8MG ................ 116

PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC) ............................... 116

PRETZ SOL .................................... 129 prevalite pow 4gm............................ 45

previfem tab .................................... 80 PREZCOBIX TAB 800-150 .................. 23

PREZISTA SUS 100MG/ML ................. 22

PREZISTA TAB 150MG ...................... 22 PREZISTA TAB 600MG ...................... 22

PREZISTA TAB 75MG ........................ 22 PREZISTA TAB 800MG ...................... 22

PRIFTIN TAB 150MG ......................... 24 PRILOSEC OTC TAB 20MG ................. 95

PRIMAQUINE TAB 26.3MG ................. 21 primidone tab 250 mg ...................... 58

primidone tab 50 mg ........................ 58 PRISTIQ TAB 100MG ........................ 62

PRISTIQ TAB 25MG .......................... 62 PRISTIQ TAB 50MG .......................... 62

PRIVIGEN INJ 10GRAMS ................. 102 PRIVIGEN INJ 20GRAMS ................. 102

PRIVIGEN INJ 40GRAMS ................. 102

PRIVIGEN INJ 5 GRAMS .................. 102 PROAIR HFA AER ............................ 125

183

probenecid tab 500 mg ...................... 11

probiotic cap .................................... 88 PROBIOTIC CAP FORMULA ................. 88

PROCALAMINE INJ 3% ..................... 107 PRO-CHLO LIQ ............................... 129

prochlorperazine edisylate inj 5 mg/ml 89 prochlorperazine maleate tab 10 mg (base

equivalent) ...................................... 89 prochlorperazine maleate tab 5 mg (base

equivalent) ...................................... 89 prochlorperazine suppos 25 mg .......... 89

PRO-CLEAR AC SYP ......................... 129 PROCRIT INJ 10000/ML ..................... 99

PROCRIT INJ 2000/ML ....................... 99 PROCRIT INJ 20000/ML ..................... 99

PROCRIT INJ 3000/ML ....................... 99

PROCRIT INJ 4000/ML ....................... 99 PROCRIT INJ 40000/ML ..................... 99

procto-pak cre 1% .......................... 137 proctozone cre -hc 2.5% .................. 137

PROFE CAP 180MG .......................... 100 PROGLYCEM SUS 50MG/ML ................ 83

PROGRAF CAP 0.5MG ...................... 104 PROGRAF CAP 1MG ......................... 104

PROGRAF CAP 5MG ......................... 104 PROLASTIN-C INJ 1000MG ............... 132

PROLENSA SOL 0.07% .................... 122 PROLEUKIN INJ 22MU........................ 34

PROLIA SOL 60MG/ML ....................... 84 PROMACTA TAB 12.5MG .................. 100

PROMACTA TAB 25MG ..................... 100

PROMACTA TAB 50MG ..................... 100 PROMACTA TAB 75MG ..................... 100

promethazine hcl inj 25 mg/ml ........... 89 promethazine hcl inj 50 mg/ml ........... 89

PRONTO AER 0.4% ......................... 141 propafenone hcl cap sr 12hr 225 mg ... 43

propafenone hcl cap sr 12hr 325 mg ... 43 propafenone hcl cap sr 12hr 425 mg ... 43

propafenone hcl tab 150 mg ............... 43 propafenone hcl tab 225 mg ............... 43

propafenone hcl tab 300 mg ............... 43 proparacaine hcl ophth soln 0.5% ..... 122

propranolol & hydrochlorothiazide tab 40-25 mg ........................................ 46

propranolol & hydrochlorothiazide tab

80-25 mg ........................................ 46 propranolol hcl cap sr 24hr 120 mg ..... 47

propranolol hcl cap sr 24hr 160 mg .... 47

propranolol hcl cap sr 24hr 60 mg ...... 47 propranolol hcl cap sr 24hr 80 mg ...... 47

propranolol hcl inj 1 mg/ml ............... 47 propranolol hcl oral soln 20 mg/5ml ... 47

propranolol hcl oral soln 40 mg/5ml ... 47 propranolol hcl tab 10 mg ................. 47

propranolol hcl tab 20 mg ................. 47 propranolol hcl tab 40 mg ................. 47

propranolol hcl tab 60 mg ................. 47 propranolol hcl tab 80 mg ................. 47

propylthiouracil tab 50 mg................. 86 PROQUAD INJ ................................ 105

PROSOL INJ 20% ........................... 107 PROTEXIN SYP ............................... 116

protriptyline hcl tab 10 mg ................ 62

protriptyline hcl tab 5 mg .................. 62 PRUDOXIN CRE 5% ........................ 137

pseudoephed-bromphen-dm liquid 20-4-20 mg/5ml ............................ 130

pseudoephedr tab 60mg ................. 130 psyldex pow 30% ............................. 92

psyllium powder 100% ..................... 92 PULMOZYME SOL 1MG/ML ............... 132

pure & gentl dro 0.3% .................... 122 PURIXAN SUS 20MG/ML .................... 33

pyrazinamide tab 500 mg .................. 24 PYRE/PIPERON LIQ ......................... 141

pyridostigmine bromide tab 60 mg ..... 72 pyridoxine hcl inj 100 mg/ml ........... 116

pyridoxine hcl tab 100 mg ............... 116

pyridoxine hcl tab 25 mg ................. 116 pyridoxine hcl tab 50 mg ................. 116

pyridoxine hcl tab cr 200 mg ........... 116 PYRIL DM SUS ............................... 130

pyrilamine mal-phenylephrine hcl tann susp 16-5 mg/5ml .......................... 130

Q qc natural pow vegetabl .................... 92

q-pap infant dro 80/0.8ml ................. 12 q-tapp dm elx ................................ 130

quasense tab ................................... 80 quetiapine fumarate tab 100 mg ........ 68

quetiapine fumarate tab 200 mg ........ 68 quetiapine fumarate tab 25 mg .......... 68

quetiapine fumarate tab 300 mg ........ 68

quetiapine fumarate tab 400 mg ........ 68 quetiapine fumarate tab 50 mg .......... 68

184

quinapril hcl tab 10 mg ...................... 40

quinapril hcl tab 20 mg ...................... 41 quinapril hcl tab 40 mg ...................... 41

quinapril hcl tab 5 mg........................ 40 quinapril-hydrochlorothiazide tab 10-12.5

mg .................................................. 40 quinapril-hydrochlorothiazide tab 20-12.5

mg .................................................. 40 quinapril-hydrochlorothiazide tab 20-25

mg .................................................. 40 quinidine gluconate tab cr 324 mg ...... 43

quinidine sulfate tab 200 mg .............. 43 quinidine sulfate tab 300 mg .............. 44

quinine sulfate cap 324 mg ................ 21 QVAR AER 40MCG ........................... 133

QVAR AER 80MCG ........................... 133

R ra anti-itch oin 1% .......................... 139

ra aspirin tab 500mg ......................... 12 ra b-complex tab vit c tr .................. 116

ra beta caro cap 15mg .................... 116 RA CA/BORON TAB ......................... 112

RA CALAMINE LOT .......................... 141 ra col-rite cap 50mg .......................... 92

ra coral cap calcium ........................ 112 ra fiber tab 500mg ............................ 92

ra hydrocort cre 0.5% ..................... 139 ra iron tab 27mg ............................. 100

ra lubricant dro 0.4-0.3% ................ 122 ra magnesium cap 500mg ................ 112

RA OYS SHL/D TAB 250MG .............. 112

ra oys shl/d tab 500mg ................... 112 ra vit c loz 60mg ............................. 116

ra vitamin c tab 1000mg .................. 116 RABAVERT INJ ................................ 105

raloxifene hcl tab 60 mg .................... 84 ramipril cap 1.25 mg ......................... 41

ramipril cap 10 mg ............................ 41 ramipril cap 2.5 mg ........................... 41

ramipril cap 5 mg ............................. 41 RANEXA TAB 1000MG ........................ 52

RANEXA TAB 500MG ......................... 52 ranitidine hcl inj 150 mg/6ml (25 mg/ml)

...................................................... 90 ranitidine hcl inj 50 mg/2ml (25 mg/ml)

...................................................... 90

ranitidine hcl syrup 15 mg/ml (75 mg/5ml) .......................................... 90

ranitidine hcl tab 150 mg .................. 90

ranitidine hcl tab 300 mg .................. 90 ranitidine hcl tab 75 mg .................... 90

ranitidine tab 75mg .......................... 90 RAPAMUNE SOL 1MG/ML ................. 104

REBETOL SOL 40MG/ML .................... 25 reclipsen tab .................................... 80

RECOMBIVA HB INJ 10MCG/ML ........ 105 RECOMBIVA HB INJ 5MCG/0.5 ......... 105

RECOMBIVA-HB INJ 40MCG/ML ........ 105 refenesen tab chst cng .................... 130

REFRESH CELL DRO 1% OP ............. 122 refresh p.m. oin op ......................... 122

REFRESH SOL OPTIVE ..................... 122 REGRANEX GEL 0.01% ................... 141

reguloid pow 48.57% ........................ 92

reguloid pow 58.6% ......................... 92 rehydralyte sol ............................... 106

RELENZA MIS DISKHALE ................... 25 RELISTOR INJ 12/0.6ML .................... 92

RELISTOR INJ 8/0.4ML ..................... 92 RELISTOR KIT 12/0.6ML ................... 93

RELPAX TAB 20MG ........................... 71 RELPAX TAB 40MG ........................... 71

REMICADE INJ 100MG .................... 101 REMODULIN INJ 10MG/ML ................. 53

REMODULIN INJ 1MG/ML .................. 53 REMODULIN INJ 2.5MG/ML ................ 53

REMODULIN INJ 5MG/ML .................. 53 RENVELA PAK 0.8GM ........................ 85

RENVELA PAK 2.4GM ........................ 85

RENVELA TAB 800MG ....................... 85 repaglinide tab 0.5 mg ...................... 77

repaglinide tab 1 mg......................... 77 repaglinide tab 2 mg......................... 77

RESCON TAB 2-60MG ..................... 130 RESCON-DM SYP ............................ 130

RESCRIPTOR TAB 100 MG ................. 22 RESCRIPTOR TAB 200MG .................. 22

RESPAIRE-30 CAP .......................... 130 RESTASIS EMU 0.05% .................... 122

RETAINE MGD EMU 0.5-0.5% .......... 122 RETROVIR INJ 10MG/ML ................... 22

REVATIO SUS 10MG/ML .................... 53 REVLIMID CAP 10MG ...................... 103

REVLIMID CAP 15MG ...................... 103

REVLIMID CAP 2.5MG ..................... 103 REVLIMID CAP 20MG ...................... 103

185

REVLIMID CAP 25MG ....................... 103

REVLIMID CAP 5MG ........................ 103 REYATAZ CAP 150MG ........................ 22

REYATAZ CAP 200MG ........................ 22 REYATAZ CAP 300MG ........................ 22

REYATAZ POW 50MG ......................... 22 RHINARIS GEL 0.2% ....................... 130

RHINARIS SPR 0.2% ....................... 130 ribapak pak 1000/day ....................... 25

ribapak pak 1200/day ....................... 25 ribapak pak 600/day ......................... 25

ribapak pak 800/day ......................... 25 ribasphere cap 200mg ....................... 25

ribasphere tab 200mg ....................... 25 ribasphere tab 400mg ....................... 25

ribasphere tab 600mg ....................... 25

ribavirin cap 200 mg ......................... 25 ribavirin tab 200 mg .......................... 25

riboflavin tab 100 mg ...................... 116 riboflavin tab 25 mg ........................ 116

riboflavin tab 50 mg ........................ 116 rid ess lice kit 0.33-4% .................... 141

rifabutin cap 150 mg ......................... 24 rifampin cap 150 mg ......................... 24

rifampin cap 300 mg ......................... 24 rifampin for inj 600 mg ...................... 24

RIFATER TAB .................................... 24 riluzole tab 50 mg ............................. 72

rimantadine hydrochloride tab 100 mg 25 ri-mox plus sus ................................. 87

RINGER'S SOLUTION ....................... 109

RIOMET SOL .................................... 77 RISA-BID TAB PROBIO ...................... 88

risamine oin ................................... 141 RISPERDAL INJ 12.5MG ..................... 68

RISPERDAL INJ 25MG ........................ 68 RISPERDAL INJ 37.5MG ..................... 68

RISPERDAL INJ 50MG ........................ 68 risperidone orally disintegrating tab 0.25

mg .................................................. 68 risperidone orally disintegrating tab 0.5

mg .................................................. 68 risperidone orally disintegrating tab 1 mg

...................................................... 68 risperidone orally disintegrating tab 2 mg

...................................................... 68

risperidone orally disintegrating tab 3 mg ...................................................... 68


...................................................... 68 risperidone soln 1 mg/ml .................. 69

risperidone tab 0.25 mg .................... 69 risperidone tab 0.5 mg ...................... 69

risperidone tab 1 mg ........................ 69 risperidone tab 2 mg ........................ 69

risperidone tab 3 mg ........................ 69 risperidone tab 4 mg ........................ 69

ritifed syp 1.25-30 ......................... 130 RITUXAN INJ 500MG......................... 34

rivastigmine tartrate cap 1.5 mg ........ 59 rivastigmine tartrate cap 3 mg ........... 59

rivastigmine tartrate cap 4.5 mg ........ 59 rivastigmine tartrate cap 6 mg ........... 59

rizatriptan benzoate orally disintegrating

tab 10 mg ....................................... 71 rizatriptan benzoate orally disintegrating

tab 5 mg ......................................... 71 rizatriptan benzoate tab 10 mg .......... 71

rizatriptan benzoate tab 5 mg ............ 71 robafen cf syp cgh/cld ..................... 130

robafen cgh cap 15mg .................... 130 robitussin cap cold+flu .................... 130

robitussin liq 15mg/5ml .................. 130 ROBITUSSIN LIQ CF ....................... 130

ROBITUSSIN LIQ CGH/COLD ........... 130 robitussin liq ms max ...................... 130

ROBITUSSIN LIQ NIGHT TM ............ 130 robitussin liq to go dm .................... 130

robitussin syp 15mg/5ml ................. 130

robitussin syp 7.5/5ml .................... 130 ROCALTROL CAP 0.25MCG .............. 117

ROCALTROL CAP 0.5MCG ................ 117 ROCALTROL SOL 1MCG/ML .............. 117

ropinirole hydrochloride tab 0.25 mg .. 64 ropinirole hydrochloride tab 0.5 mg .... 64

ropinirole hydrochloride tab 1 mg ....... 64 ropinirole hydrochloride tab 2 mg ....... 65

ropinirole hydrochloride tab 3 mg ....... 65 ropinirole hydrochloride tab 4 mg ....... 65

ropinirole hydrochloride tab 5 mg ....... 65 rosadan cre 0.75% ......................... 141

ROTARIX SUS ................................ 105 ROTATEQ SOL................................ 105

roxicet sol 5-325/5 ........................... 17

ROZEREM TAB 8MG .......................... 71 RU-HIST-D LIQ 30-10/5 .................. 130

186

RU-HIST-D TAB 30-10MG ................ 130

RYMED TAB 2-10MG ........................ 130 rynex dm liq ................................... 130

rynex pse liq .................................. 130 S SABRIL POW 500MG ......................... 58 SABRIL TAB 500MG ........................... 58

SANDIMMUNE CAP 100MG ............... 104 SANDIMMUNE CAP 25MG ................. 104

SANDIMMUNE SOL 100MG/ML .......... 104 SANDOSTATIN KIT LAR 10MG ............ 84

SANDOSTATIN KIT LAR 20MG ............ 84 SANDOSTATIN KIT LAR 30MG ............ 84

SANTYL OIN 250/GM ....................... 141 SAPHRIS SUB 10MG .......................... 69

SAPHRIS SUB 2.5MG ......................... 69

SAPHRIS SUB 5MG ............................ 69 sb fib lax pow 33% ........................... 93

SB NAT FIBER POW 49% ................... 93 sb triple oin antibiot ........................ 136

SCHOOLTIME SHA .......................... 141 SCOOBY-DOO CHW ......................... 117

scot-tussin liq dm sf ........................ 130 SCOT-TUSSIN LIQ ORIGINAL ........... 130

SCOT-TUSSIN LIQ SENIOR............... 130 SECURA CRE 30.6% ........................ 141

secura prote cre 10% ...................... 141 selegiline hcl cap 5 mg ...................... 65

selegiline hcl tab 5 mg ....................... 65 selenium sulfide lotion 2.5% ............ 137

selenium tab 100 mcg ..................... 112

SELENIUM TAB 200MCG .................. 112 SELZENTRY TAB 150MG ..................... 22

SELZENTRY TAB 300MG ..................... 22 SENNA PROMPT CAP 9-500MG ............ 93

SENNA SYP ...................................... 93 senna tab 25mg ............................... 93

SENNA TAB 8.6MG ............................ 93 senna-extra tab 17.2mg .................... 93

sennosides cap 8.6 mg ...................... 93 sennosides syrup 8.8 mg/5ml ............. 93

sennosides tab 8.6 mg ...................... 93 sennosides-docusate sodium tab 8.6-50

mg .................................................. 93 sen-o-tabs tab 187mg ....................... 93

SENSI-CARE OIN 49-15% ................ 141

SENSIPAR TAB 30MG ........................ 77 SENSIPAR TAB 60MG ........................ 77

SENSIPAR TAB 90MG ........................ 77

SEREVENT DIS AER 50MCG ............. 125 SEROQUEL XR TAB 150MG ................ 69

SEROQUEL XR TAB 200MG ................ 69 SEROQUEL XR TAB 300MG ................ 69

SEROQUEL XR TAB 400MG ................ 69 SEROQUEL XR TAB 50MG .................. 69

sertraline hcl oral conc 20 mg/ml ....... 62 sertraline hcl tab 100 mg .................. 62

sertraline hcl tab 25 mg .................... 62 sertraline hcl tab 50 mg .................... 62

sharobel tab 0.35mg ........................ 80 sildenafil citrate tab 20 mg ................ 53

SILENOR TAB 3MG ........................... 71 SILENOR TAB 6MG ........................... 71

SILVER SULFADIAZINE CREAM 1% ... 136

SIMBRINZA SUS 1-0.2% ................. 121 simply sleep tab 25mg ...................... 74

simvastatin tab 10 mg ...................... 44 simvastatin tab 20 mg ...................... 44

simvastatin tab 40 mg ...................... 44 simvastatin tab 5 mg ........................ 44

simvastatin tab 80 mg ...................... 44 sinus max st tab 30-500mg ............. 130

sinus pain/ tab pressure .................. 130 sirolimus tab 0.5 mg ....................... 104

SIROLIMUS TAB 1 MG ..................... 104 SIROLIMUS TAB 2 MG ..................... 104

SIRTURO TAB 100MG ....................... 24 SIVEXTRO INJ 200MG ....................... 19

SIVEXTRO TAB 200MG ...................... 19

sleep aid tab 25mg ........................... 74 sleep aid tab 50mg ........................... 74

slo-niacin tab 250mg cr .................. 117 slow iron tab 50mg ......................... 100

slow magnes/ tab calcium ............... 112 SLOW REL FE TAB 140MG CR .......... 100

SLOW REL FE TAB 143MG CR .......... 100 SLOW RELEASE TAB 143MG ............ 100

slow release tab 45mg .................... 100 slow release tab 47.5mg ................. 100

SLOW-MAG TAB ............................. 112 sm ca/mg/zn tab ............................ 112

SM CORAL CAL TAB 1000MG ........... 112 sm iron slow tab 160mg cr .............. 100

sm magnesium tab 250mg .............. 112

sm tussin cf liq .............................. 130 sodium bicarbonate tab 325 mg ......... 87

187

sodium bicarbonate tab 650 mg .......... 87

SODIUM CHLOR NEB 0.45% ............. 132 sodium chloride hypertonic ophth oint 5%

.................................................... 122 sodium chloride hypertonic ophth soln 5%

.................................................... 122 SODIUM CHLORIDE INJ 0.45% ......... 109

SODIUM CHLORIDE INJ 2.5 MEQ/ML (14.6%) ........................................ 106

SODIUM CHLORIDE INJ 3% ............. 109 SODIUM CHLORIDE INJ 5% ............. 109

SODIUM CHLORIDE IRRIGATION SOLN 0.9% ............................................. 142

SODIUM CHLORIDE IV SOLN 0.9% ... 109 SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5

F) MG/ML SOLN .............................. 106

sodium phenylbutyrate oral powder 3 gm/teaspoonful ................................ 81

sodium phosphates - enema .............. 93 sodium polystyrene sulfonate oral susp 15

gm/60ml ......................................... 78 SODIUM POW BICARBON ................... 87

SOLIA TAB ....................................... 80 SOLTAMOX SOL 10MG/5ML ................ 35

soluble fib pow therapy ...................... 93 SOLU-CORTEF INJ 250MG .................. 83

SOMATULINE INJ 120/.5ML ................ 84 SOMATULINE INJ 60/0.2ML ................ 84

SOMATULINE INJ 90/0.3ML ................ 84 SOMAVERT INJ 10MG ........................ 84

SOMAVERT INJ 15MG ........................ 84

SOMAVERT INJ 20MG ........................ 84 SOMAVERT INJ 25MG ........................ 84

SOMAVERT INJ 30MG ........................ 84 SOOTHE DRO 0.6-0.6% ................... 122

soothe tab 262mg ............................. 88 sorbulax pow 100% .......................... 93

sorine tab 120mg.............................. 44 sorine tab 160mg.............................. 44

sorine tab 240mg.............................. 44 sorine tab 80mg ............................... 44

sotalol hcl (afib/afl) tab 120 mg .......... 44 sotalol hcl (afib/afl) tab 160 mg .......... 44

sotalol hcl (afib/afl) tab 80 mg ........... 44 sotalol hcl tab 120 mg ....................... 44

sotalol hcl tab 160 mg ....................... 44

sotalol hcl tab 240 mg ....................... 44 sotalol hcl tab 80 mg ......................... 44

SOVALDI TAB 400MG ....................... 25

SPIRIVA CAP HANDIHLR ................. 123 SPIRIVA SPR RESPIMAT .................. 123

spironolactone & hydrochlorothiazide tab 25-25 mg ........................................ 51

spironolactone tab 100 mg ................ 41 spironolactone tab 25 mg .................. 41

spironolactone tab 50 mg .................. 41 sprintec 28 tab 28 day ...................... 80

SPRYCEL TAB 100MG ........................ 36 SPRYCEL TAB 140MG ........................ 36

SPRYCEL TAB 20MG .......................... 36 SPRYCEL TAB 50MG .......................... 36

SPRYCEL TAB 70MG .......................... 36 SPRYCEL TAB 80MG .......................... 36

sps sus 15gm/60.............................. 78

SSD CRE 1% ................................. 136 st joseph as chw 81mg ..................... 12

ST JOSEPH CHW 75MG ADU .............. 12 STAHIST AD LIQ ............................ 130

STAHIST AD TAB 25-60MG .............. 130 STANBACK AF POW 950MG ............... 12

STATUSS LIQ GREEN ...................... 130 stavudine cap 15 mg ........................ 22

stavudine cap 20 mg ........................ 22 stavudine cap 30 mg ........................ 23

stavudine cap 40 mg ........................ 23 stavudine for oral soln 1 mg/ml ......... 23

STERILE LUBR DRO 0.7% ................ 122 STIVARGA TAB 40MG ....................... 36

stomach relf sus 525/15ml ................ 88

stool softnr cap 100mg ..................... 93 stool softnr cap 240mg ..................... 93

stool softnr cap 50mg ....................... 93 stool softnr syp 60/15ml ................... 93

stool softnr tab 8.6-50mg ................. 93 STRATTERA CAP 100MG .................... 71

STRATTERA CAP 10MG ...................... 70 STRATTERA CAP 18MG ...................... 70



streptomycin sulfate for inj 1 gm ........ 18 STRIBILD TAB .................................. 23

STUART PRENA PAK + DHA ............. 117

SUBOXONE MIS 12-3MG ................... 74 SUBOXONE MIS 2-0.5MG .................. 74

188

SUBOXONE MIS 4-1MG ...................... 74

SUBOXONE MIS 8-2MG ...................... 74 SUCRAID SOL 8500/ML ..................... 94

sucralfate tab 1 gm ........................... 94 sudafed 12hr tab 120mg cr .............. 130

SUDAFED 24HR TAB 240MG ............. 130 sulfacetamide sodium lotion 10% (acne)

.................................................... 135 sulfacetamide sodium ophth oint 10%

.................................................... 119 sulfacetamide sodium ophth soln 10%

.................................................... 119 sulfacetamide sodium-prednisolone ophth

soln 10-0.23(0.25)% ....................... 118 sulfadiazine tab 500mg ...................... 18

sulfamethoxazole-trimethoprim iv soln

400-80 mg/5ml ................................ 19 sulfamethoxazole-trimethoprim susp

200-40 mg/5ml ................................ 19 sulfamethoxazole-trimethoprim tab

400-80 mg ....................................... 19 sulfamethoxazole-trimethoprim tab

800-160 mg ..................................... 19 SULFAMYLON CRE 85MG/GM ............ 136

sulfasalazine tab 500 mg ................... 90 sulfazine ec tab 500mg ...................... 90

sulindac tab 150 mg .......................... 13 sulindac tab 200 mg .......................... 13

SUMATRIPTAN NASAL SPRAY 20 MG/ACT ...................................................... 71


...................................................... 71 sumatriptan succinate inj 6 mg/0.5ml . 71

SUMATRIPTAN SUCCINATE SOLUTION AUTO-INJECTOR 4 MG/0.5ML ............. 72

sumatriptan succinate solution auto-injector 6 mg/0.5ml ................... 72

SUMATRIPTAN SUCCINATE SOLUTION CARTRIDGE 4 MG/0.5ML .................... 72

SUMATRIPTAN SUCCINATE SOLUTION CARTRIDGE 6 MG/0.5ML .................... 72

sumatriptan succinate solution prefilled syringe 6 mg/0.5ml ........................... 72

sumatriptan succinate tab 100 mg ...... 72 sumatriptan succinate tab 25 mg ........ 72

sumatriptan succinate tab 50 mg ........ 72

summers eve sol 0.3% ...................... 96 super b-100 tab .............................. 117

SUPER POW NU-THERA ................... 117

SUPRAX CAP 400MG ......................... 27 suprax chw 100mg ........................... 27

suprax chw 200mg ........................... 27 suprax sus 100/5ml .......................... 27

suprax sus 200/5ml .......................... 27 SUPRAX SUS 500/5ML ...................... 27

SUPREP BOWEL SOL PREP ................. 93 SURMONTIL CAP 100MG ................... 62

SURMONTIL CAP 25MG ..................... 62 SURMONTIL CAP 50MG ..................... 62

SUSTIVA CAP 200MG ........................ 23 SUSTIVA CAP 50MG.......................... 23

SUSTIVA TAB 600MG ........................ 23 SUTENT CAP 12.5MG ........................ 36

SUTENT CAP 25MG ........................... 36

SUTENT CAP 37.5MG ........................ 36 SUTENT CAP 50MG ........................... 36

syeda tab 3-0.03mg ......................... 80 SYLATRON KIT 200MCG .................... 37

SYLATRON KIT 300MCG .................... 37 SYLATRON KIT 600MCG .................... 37

SYMBICORT AER 160-4.5 ................ 134 SYMBICORT AER 80-4.5 .................. 134

SYMLINPEN 60 INJ 1000MCG ............. 75 SYMLNPEN 120 INJ 1000MCG ............ 75

SYNAGIS INJ 100MG/ML ................. 105 SYNAGIS INJ 50MG ........................ 105

SYNAREL SOL 2MG/ML ...................... 81 SYNERCID INJ 500MG ....................... 20

SYNTHROID TAB 100MCG ................. 86

SYNTHROID TAB 112MCG ................. 86 SYNTHROID TAB 125MCG ................. 86



SYNTHROID TAB 25MCG ................... 86 SYNTHROID TAB 300MCG ................. 86

SYNTHROID TAB 50MCG ................... 86 SYNTHROID TAB 75MCG ................... 86

SYNTHROID TAB 88MCG ................... 86 SYPRINE CAP 250MG ........................ 78

SYSTANE BAL SOL RESTOR ............. 122 systane dro contacts ....................... 122

SYSTANE GEL 0.3% ........................ 122

SYSTANE LIQ DRO 0.4-0.3% ........... 122 systane oin .................................... 122

189

T TAB-A-VITE TAB WOMENS ............... 117 TABLOID TAB 40MG .......................... 33

tacrolimus cap 0.5 mg ..................... 104 tacrolimus cap 1 mg ........................ 104

tacrolimus cap 5 mg ........................ 104 TAFINLAR CAP 50MG ......................... 36

TAFINLAR CAP 75MG ......................... 37 TAMIFLU CAP 30MG .......................... 25

TAMIFLU CAP 45MG .......................... 25 TAMIFLU CAP 75MG .......................... 25

TAMIFLU SUS 6MG/ML ....................... 25 tamoxifen citrate tab 10 mg (base

equivalent) ...................................... 35 tamoxifen citrate tab 20 mg (base

equivalent) ...................................... 35

tamsulosin hcl cap 0.4 mg ................. 95 TARCEVA TAB 100MG ........................ 37

TARCEVA TAB 150MG ........................ 37 TARCEVA TAB 25MG .......................... 37

TARGRETIN CAP 75MG ...................... 37 TARGRETIN GEL 1% ........................ 141

TASIGNA CAP 150MG ........................ 37 TASIGNA CAP 200MG ........................ 37

tazicef inj 1gm ................................. 27 tazicef inj 2gm ................................. 27

tazicef inj 6gm ................................. 27 TAZORAC CRE 0.05% ...................... 137

TAZORAC CRE 0.1% ........................ 137 taztia xt cap 120mg/24 ..................... 49

taztia xt cap 180mg/24 ..................... 49

taztia xt cap 240mg/24 ..................... 49 taztia xt cap 300mg/24 ..................... 49

taztia xt cap 360mg/24 ..................... 49 TEARS AGAIN GEL NGHT/DAY .......... 122

TEFLARO INJ 400MG ......................... 27 TEFLARO INJ 600MG ......................... 27

TEGRETOL SUS 100/5ML ................... 58 TEGRETOL TAB 200MG ...................... 58

TEGRETOL-XR TAB 100MG ................. 58 TEGRETOL-XR TAB 200MG ................. 58

TEGRETOL-XR TAB 400MG ................. 58 TEKAMLO TAB 150-10MG ................... 50

TEKAMLO TAB 150-5MG ..................... 50 TEKAMLO TAB 300-10MG ................... 50

TEKAMLO TAB 300-5MG ..................... 50

TEKTURNA HCT TAB 150-12.5 ............ 50 TEKTURNA HCT TAB 150-25MG .......... 50

TEKTURNA HCT TAB 300-12.5 ........... 50

TEKTURNA HCT TAB 300-25MG .......... 50 TEKTURNA TAB 150MG ..................... 50

TEKTURNA TAB 300MG ..................... 50 temazepam cap 15 mg ..................... 71

temazepam cap 7.5 mg .................... 71 TENIVAC INJ 5-2LF ......................... 105

terazosin hcl cap 1 mg ...................... 41 terazosin hcl cap 10 mg .................... 41

terazosin hcl cap 2 mg ...................... 41 terazosin hcl cap 5 mg ...................... 41

terbinafine cre 1%.......................... 136 terbinafine hcl tab 250 mg ................ 21

terbutaline sulfate inj 1 mg/ml ......... 125 terbutaline sulfate tab 2.5 mg .......... 125

terbutaline sulfate tab 5 mg ............ 125

terconazole vaginal cream 0.4% ........ 96 terconazole vaginal cream 0.8% ........ 96

terconazole vaginal suppos 80 mg ...... 97 TESTIM GEL 1%(50MG) .................... 75

testosterone cypionate im inj in oil 100 mg/ml ............................................ 75

testosterone cypionate im inj in oil 200 mg/ml ............................................ 75

testosterone enanthate im inj in oil 200 mg/ml ............................................ 75

TET/DIP TOX INJ 2-2 LF .................. 105 TETANUS TOX INJ 5LF ADS ............. 105

TEV-TROPIN INJ 5MG ....................... 84 texacort sol 2.5% ........................... 139

tgt lubricnt dro eye ......................... 122

th eye tears dro ............................. 122 THALOMID CAP 100MG ................... 103

THALOMID CAP 150MG ................... 103 THALOMID CAP 200MG ................... 103

THALOMID CAP 50MG ..................... 103 theo-24 cap 100mg cr .................... 134

theo-24 cap 200mg cr .................... 134 theo-24 cap 300mg cr .................... 134

theo-24 cap 400mg er .................... 134 theophylline soln 80 mg/15ml .......... 134

theophylline tab sr 12hr 100 mg ...... 134 theophylline tab sr 12hr 200 mg ...... 134

theophylline tab sr 12hr 300 mg ...... 134 theophylline tab sr 12hr 450 mg ...... 134

theophylline tab sr 24hr 400 mg ...... 134

theophylline tab sr 24hr 600 mg ...... 134 THERA BETA- TAB CAROTENE .......... 117

190

THERA-D TAB 4000UNIT .................. 117

THERAFLU FLU PAK SORE THR .......... 131 theraflu nt liq warm rlf ..................... 131

THERAFLU POW .............................. 131 THERAFLU POW MAX-D.................... 131

THERANATAL TAB 27-1 .................... 117 THERATEARS SOL OP ...................... 122

thiamine hcl inj 100 mg/ml .............. 117 thiamine hcl tab 100 mg .................. 117

thiamine hcl tab 250 mg .................. 117 thiamine hcl tab 50 mg .................... 117

thiamine mononitrate tab 100 mg ..... 117 thioridazine hcl tab 10 mg .................. 69

thioridazine hcl tab 100 mg ................ 69 thioridazine hcl tab 25 mg .................. 69

thioridazine hcl tab 50 mg .................. 69

thiothixene cap 1 mg ......................... 69 thiothixene cap 10 mg ....................... 69

thiothixene cap 2 mg ......................... 69 thiothixene cap 5 mg ......................... 69

thrive gum 2mg mint ........................ 74 thrive gum 4mg mint ........................ 74

tiagabine hcl tab 2 mg ....................... 58 tiagabine hcl tab 4 mg ....................... 58

TIKOSYN CAP 125MCG ...................... 44 TIKOSYN CAP 250MCG ...................... 44

TIKOSYN CAP 500MCG ...................... 44 TIMOLOL MALEATE OPHTH GEL FORMING

SOLN 0.25% .................................. 121 TIMOLOL MALEATE OPHTH GEL FORMING

SOLN 0.5% .................................... 121

timolol maleate ophth soln 0.25% ..... 121 timolol maleate ophth soln 0.5% ...... 121

timolol maleate tab 10 mg ................. 47 timolol maleate tab 20 mg ................. 47

timolol maleate tab 5 mg ................... 47 tioconazole oin 6.5% vag ................... 97

titralac chw 420mg ........................... 87 TIVICAY TAB 50MG ........................... 23

tizanidine hcl tab 2 mg (base equivalent) ...................................................... 73

tizanidine hcl tab 4 mg (base equivalent) ...................................................... 73

tobra/nacl inj 80/0.9 ......................... 18 TOBRADEX OIN 0.3-0.1% ................ 118

TOBRADEX ST SUS 0.3-0.05 ............ 118

tobramycin nebu soln 300 mg/5ml ...... 18 tobramycin ophth soln 0.3% ............ 119

tobramycin sulfate for inj 1.2 gm ....... 18

tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) ........................................... 18

tobramycin sulfate inj 10 mg/ml ........ 18 tobramycin sulfate inj 2 gm/50ml (40

mg/ml) ........................................... 18 tobramycin sulfate inj 80 mg/2ml (40

mg/ml) ........................................... 18 tobramycin-dexamethasone ophth susp

0.3-0.1% ...................................... 118 TOBREX OIN 0.3% OP .................... 119

tolnaftate cream 1% ....................... 137 tolnaftate soln 1% .......................... 137

TOLTERODINE TARTRATE CAP SR 24HR 2 MG ................................................. 96

TOLTERODINE TARTRATE CAP SR 24HR 4

MG ................................................. 96 tolterodine tartrate tab 1 mg ............. 96

tolterodine tartrate tab 2 mg ............. 96 topiramate sprinkle cap 15 mg ........... 58

topiramate sprinkle cap 25 mg ........... 58 topiramate tab 100 mg ..................... 58

topiramate tab 200 mg ..................... 58 topiramate tab 25 mg ....................... 58

topiramate tab 50 mg ....................... 58 toposar inj 1gm/50ml ....................... 38

topotecan hcl for inj 4 mg ................. 38 torsemide inj 20mg/2ml .................... 51

torsemide inj 50mg/5ml .................... 51 torsemide tab 10 mg ........................ 51

torsemide tab 100 mg ...................... 51

torsemide tab 20 mg ........................ 51 torsemide tab 5 mg .......................... 51

total b/c tab .................................. 117 total fiber pow ................................. 93

TOUJEO SOLO INJ 300IU/ML ............. 75 TOVIAZ TAB 4MG ............................. 96

TOVIAZ TAB 8MG ............................. 96 TPN ELECTROL INJ ......................... 106

TRACLEER TAB 125MG ...................... 53 TRACLEER TAB 62.5MG ..................... 53

TRADJENTA TAB 5MG ....................... 77 tramadol hcl tab 50 mg ..................... 14

tramadol-acetaminophen tab 37.5-325 mg ................................................. 14

trandolapril tab 1 mg ........................ 41

trandolapril tab 2 mg ........................ 41 trandolapril tab 4 mg ........................ 41

191

tranexamic acid inj 100 mg/ml ......... 100

tranexamic acid tab 650 mg ............. 101 TRANSDERM-SC DIS 1MG .................. 89

tranylcypromine sulfate tab 10 mg ...... 62 travasol inj 10% ............................. 107

TRAVATAN Z DRO 0.004% ............... 121 trazodone hcl tab 100 mg .................. 63

trazodone hcl tab 150 mg .................. 63 trazodone hcl tab 50 mg .................... 63

TREANDA INJ 100MG ........................ 32 TREANDA INJ 180/2ML ...................... 32

TREANDA INJ 25MG .......................... 32 TREANDA INJ 45/0.5ML ..................... 32

TRECATOR TAB 250MG ...................... 24 TRELSTAR MIX INJ 11.25MG .............. 35

TRELSTAR MIX INJ 3.75MG ................ 35

tretinoin cap 10 mg ........................... 37 tretinoin cream 0.025% ................... 135

tretinoin cream 0.05%..................... 135 tretinoin cream 0.1% ...................... 135

tretinoin gel 0.01% ......................... 135 tretinoin gel 0.025% ....................... 135

triacting dt liq cold/cgh .................... 131 triamcinolone acetonide cream 0.025%

.................................................... 140 triamcinolone acetonide cream 0.1% . 140

triamcinolone acetonide cream 0.5% . 140 triamcinolone acetonide dental paste

0.1% ............................................. 142 triamcinolone acetonide lotion 0.025%

.................................................... 140

triamcinolone acetonide lotion 0.1% .. 140 triamcinolone acetonide oint 0.025%. 140

triamcinolone acetonide oint 0.1% .... 140 triamcinolone acetonide oint 0.5% .... 140

triaminic liq .................................... 131 TRIAMINIC MIS GRAPE .................... 124

TRIAMINIC NT MIS COLD/CGH ......... 131 TRIAMINIC SOL COLD/CGH .............. 131

TRIAMINIC SYP CHST/NSL ............... 131 TRIAMINIC SYP COLD/ALL ............... 131

TRIAMINIC SYP COLD/CGH .............. 131 TRIAMINIC SYP FEVER ..................... 131

TRIAMINIC SYP INFANT ..................... 12 triaminic tab 10mg .......................... 124

triamterene & hydrochlorothiazide cap

37.5-25 mg ...................................... 51 triamterene & hydrochlorothiazide tab

37.5-25 mg ..................................... 51

triamterene & hydrochlorothiazide tab 75-50 mg ........................................ 51

TRIBENZOR20- TAB 5-12.5MG ........... 42 TRIBENZOR40- TAB 10-12.5 .............. 42

TRIBENZOR40- TAB 10-25MG ............ 42 TRIBENZOR40- TAB 5-12.5MG ........... 42

TRIBENZOR40- TAB 5-25MG .............. 42 tri-buff asa tab 325mg ...................... 12

TRICODE AR LIQ ............................ 131 TRICODE GF LIQ ............................ 131

triderm cre 0.1% ........................... 140 trifluoperazine hcl tab 1 mg ............... 69

trifluoperazine hcl tab 10 mg ............. 69 trifluoperazine hcl tab 2 mg ............... 69

trifluoperazine hcl tab 5 mg ............... 69

trifluridine ophth soln 1% ................ 119 trihexyphenidyl hcl elixir 0.4 mg/ml .... 65

trihexyphenidyl hcl tab 2 mg ............. 65 trihexyphenidyl hcl tab 5 mg ............. 65

tri-legest tab fe ................................ 80 trilyte sol ........................................ 93

trimethoprim tab 100 mg .................. 20 TRINESSA TAB ................................. 80

triple antib oin ............................... 136 TRIPLE PASTE OIN 12.8% ............... 141

triple paste oin af 2% ..................... 137 tri-previfem tab ............................... 80

TRISENOX SOL 10MG/10M ................ 37 tri-sprintec tab ................................. 80

TRIUMEQ TAB .................................. 23

TRI-VI-SOL DRO /IRON ................... 117 TRI-VI-SOL SOL ............................. 117

tri-vita sol ..................................... 117 tri-vitamin dro ............................... 117

trivora-28 tab .................................. 80 TROPHAMINE INJ 10% .................... 107

trospium chloride tab 20 mg .............. 96 TRUMENBA INJ .............................. 105

TRUVADA TAB 200-300 ..................... 24 trymine cg liq 225-7.5 .................... 131

TUCKS OIN 1% .............................. 140 TUDORZA PRES AER 400/ACT .......... 123

tusnel c syp ................................... 131 TUSNEL LIQ ................................... 131

TUSNEL PED DRO 7.5-50 ................ 131

TUSNEL PEDI LIQ 15-5-50 ............... 131 TUSNEL-DM DRO PEDIATRC ............ 131

192

tussin cf liq cgh/cold ....................... 131

tussin dm syp 100-10/5 ................... 131 tussi-pres liq pe ped ........................ 131

TWINRIX INJ .................................. 105 TYBOST TAB 150MG .......................... 23

TYGACIL INJ 50MG ............................ 20 TYKERB TAB 250MG .......................... 37

tylenol chld tab 80mg ........................ 12 TYPHIM VI INJ ................................ 105

TYSABRI INJ 300/15ML...................... 73 TYZEKA TAB 600MG .......................... 25

U UCERIS TAB 9MG .............................. 90

ULORIC TAB 40MG ............................ 11 ULORIC TAB 80MG ............................ 11

UNITHROID TAB 100MCG .................. 86

UNITHROID TAB 112MCG .................. 86 UNITHROID TAB 125MCG .................. 86

UNITHROID TAB 150MCG .................. 86 UNITHROID TAB 175MCG .................. 86

UNITHROID TAB 200MCG .................. 86 UNITHROID TAB 25MCG .................... 86

UNITHROID TAB 300MCG .................. 86 UNITHROID TAB 50MCG .................... 86

UNITHROID TAB 75MCG .................... 86 UNITHROID TAB 88MCG .................... 86

UPCAL D POW ................................ 112 URO-MAG CAP 140MG ....................... 87

ursodiol cap 300 mg .......................... 94 ursodiol tab 250 mg .......................... 94

ursodiol tab 500 mg .......................... 94

V VAGIFEM TAB 10MCG ........................ 82

vagistat-3 kit combo pk ..................... 97 valacyclovir hcl tab 1 gm ................... 25

valacyclovir hcl tab 500 mg ................ 25 VALCHLOR GEL 0.016% ................... 141

VALCYTE SOL 50MG/ML ..................... 25 valganciclovir hcl tab 450 mg (base

equivalent) ...................................... 25 valproate sodium inj 100 mg/ml ......... 58

valproate sodium syrup 250 mg/5ml (base equiv) ..................................... 58

valproic acid cap 250 mg ................... 58 valsartan tab 160 mg ........................ 43

valsartan tab 320 mg ........................ 43

valsartan tab 40 mg .......................... 43 valsartan tab 80 mg .......................... 43


160-12.5 mg ................................... 42 valsartan-hydrochlorothiazide tab 160-25

mg ................................................. 42 valsartan-hydrochlorothiazide tab

320-12.5 mg ................................... 42 valsartan-hydrochlorothiazide tab 320-25

mg ................................................. 42 valsartan-hydrochlorothiazide tab

80-12.5 mg ..................................... 42 vancomycin hcl cap 125 mg ............... 20

vancomycin hcl cap 250 mg ............... 20 vancomycin hcl for inj 10 gm ............. 20

vancomycin hcl for inj 1000 mg ......... 20 vancomycin hcl for inj 500 mg ........... 20

vancomycin hcl for inj 5000 mg ......... 20

vancomycin inj 750mg ...................... 20 VANDAZOLE GEL 0.75% ................... 97

VAQTA INJ 25/0.5ML ...................... 105 VAQTA INJ 50UNT/ML ..................... 105

VARIVAX INJ ................................. 105 VASCEPA CAP 1GM ........................... 45

VASOCLEAR A SOL OP .................... 120 vcks dayquil liq mucus dm ............... 131

VELCADE INJ 3.5MG ......................... 35 velivet pak ...................................... 80

venlafaxine hcl cap sr 24hr 150 mg (base equivalent) ...................................... 63

venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent) ...................................... 63

venlafaxine hcl cap sr 24hr 75 mg (base

equivalent) ...................................... 63 venlafaxine hcl tab 100 mg ............... 63

venlafaxine hcl tab 25 mg ................. 63 venlafaxine hcl tab 37.5 mg .............. 63

venlafaxine hcl tab 50 mg ................. 63 venlafaxine hcl tab 75 mg ................. 63

verapamil hcl cap sr 24hr 100 mg ...... 49 verapamil hcl cap sr 24hr 120 mg ...... 49



VERAPAMIL HCL CAP SR 24HR 360 MG 49 verapamil hcl iv soln 2.5 mg/ml ......... 49

verapamil hcl tab 120 mg .................. 49

verapamil hcl tab 40 mg ................... 49 verapamil hcl tab 80 mg ................... 49

193

verapamil hcl tab cr 120 mg ............... 49

verapamil hcl tab cr 180 mg ............... 49 verapamil hcl tab cr 240 mg ............... 49

VERSACLOZ SUS 50MG/ML ................ 69 vertin-32 tab .................................... 89

VESICARE TAB 10MG ........................ 96 VESICARE TAB 5MG .......................... 96

VIBRAMYCIN SYP 50MG/5ML .............. 31 VICK VAPORUB OIN ........................ 131

VICTOZA INJ 18MG/3ML .................... 75 VICTRELIS CAP 200MG ...................... 25

VIDEX SOL 2GM ............................... 23 VIDEX SOL 4GM ............................... 23

VIGAMOX DRO 0.5% ....................... 119 VIIBRYD KIT .................................... 63

VIIBRYD TAB 10MG ........................... 63

VIIBRYD TAB 20MG ........................... 63 VIIBRYD TAB 40MG ........................... 63

VIMPAT INJ 200MG/20 ...................... 58 VIMPAT SOL 10MG/ML ....................... 58

VIMPAT TAB 100MG .......................... 58 VIMPAT TAB 150MG .......................... 58

VIMPAT TAB 200MG .......................... 58 VIMPAT TAB 50MG ............................ 58

vinblastine inj 1mg/ml ....................... 34 vincasar pfs inj 1mg/ml ..................... 34

vincristine sulfate iv soln 1 mg/ml ....... 34 vinorelbine tartrate inj 10 mg/ml (base

equiv) ............................................. 34 vinorelbine tartrate inj 50 mg/5ml (10

mg/ml) (base equiv) ......................... 34

viorele tab ....................................... 80 VIRACEPT TAB 250MG ....................... 23

VIRACEPT TAB 625MG ....................... 23 VIRAMUNE XR TAB 100MG ................. 23

VIREAD POW 40MG/GM ..................... 23 VIREAD TAB 150MG .......................... 23

VIREAD TAB 200MG .......................... 23 VIREAD TAB 250MG .......................... 23

VIREAD TAB 300MG .......................... 23 visine-a sol op ................................ 120

VISINE-LR SOL 0.025% ................... 120 VIT B12/FA TAB .............................. 100

vit c & e cap combo ......................... 117 vita-bee/c tab ................................. 117

VITALETS CHW ............................... 117

vitalize liq ginseng .......................... 117 VITA-MAG TAB ............................... 117

vitamin a cap 10000 unit................. 117

vitamin a cap 8000unit ................... 117 VITAMIN A TAB .............................. 117

vitamin a tab 10000 unit ................. 117 VITAMIN A TAB 15000UNT .............. 117

vitamin b12 tab 2000mcg ............... 117 VITAMIN C CHW 1000MG ................ 117

VITAMIN C SOL .............................. 117 vitamin d cap 1000unit ................... 118

vitamin d chw 1000unit ................... 118 vitamin d chw 400unit .................... 118

VITAMIN D2 TAB 2000UNIT ............. 117 VITAMIN D2 TAB 400UNIT ............... 117

vitamin d3 cap 10000unt ................ 117 VITAMIN D3 CAP 4000UNIT ............. 117

vitamin d3 cap 50000unt ................ 117

VITAMIN D3 LIQ 1200UNIT ............. 118 VITAMIN D3 TAB 3000UNIT ............. 118

VITAMIN D3 TAB 50000UNT ............ 118 vitamin d3 tab 5000unit .................. 118

vitamin e cap 1000 unit .................. 118 vitamin e cap 200 unit .................... 118

vitamin e cap 600 unit .................... 118 VITAMIN E CHW 400UNIT................ 118

vitamin e soln 15 unit/0.3ml (50 unit/ml).................................................... 118

VITAMIN E TAB 100UNIT ................. 118 VITAMIN E TAB 200UNIT ................. 118

vitamin e tab 400 unit .................... 118 VITAMIN K TAB 100MCG ................. 118

vitamin mixture cap........................ 118

vitamins a & d cap.......................... 118 vita-plus e cap 400unit ................... 117

vitatrum chw ................................. 118 vite/iron chw children ..................... 118

VITEKTA TAB 150MG ........................ 23 VITEKTA TAB 85MG .......................... 23

VIVA DROPS DRO 1% ..................... 122 VOLTAREN GEL 1% ........................ 141

voriconazole for inj 200 mg ............... 21 voriconazole for susp 40 mg/ml ......... 21

voriconazole tab 200 mg ................... 21 voriconazole tab 50 mg ..................... 21

VOTRIENT TAB 200MG ...................... 37 vyfemla tab 0.4-35 ........................... 80

W wal-act tab 2.5-60mg ..................... 131 wal-dryl all tab sinus ...................... 131

194

wal-dryl-d tab alrg/sin ..................... 131

wal-fex d tab 12 hour ...................... 131 wal-flu cold pak daytime .................. 131

wal-itin d tab 5-120mg .................... 131 wal-itin syp 5mg/5ml ...................... 124

wal-phed pe tab 4-10mg .................. 131 wal-phed tab 4-60mg ...................... 131

wal-som cap 50mg ............................ 74 warfarin sodium tab 1 mg .................. 98

warfarin sodium tab 10 mg ................ 98 warfarin sodium tab 2 mg .................. 98

warfarin sodium tab 2.5 mg ............... 98 warfarin sodium tab 3 mg .................. 98

warfarin sodium tab 4 mg .................. 98 warfarin sodium tab 5 mg .................. 98

warfarin sodium tab 6 mg .................. 98

warfarin sodium tab 7.5 mg ............... 98 WATER FOR IRRIGATION, STERILE

IRRIGATION SOLN .......................... 142 wee care sus 15/1.25 ...................... 100

WELCHOL PAK 3.75GM ...................... 45 WELCHOL TAB 625MG ....................... 45

X XALKORI CAP 200MG ........................ 37

XALKORI CAP 250MG ........................ 37 XARELTO STAR TAB 15/20MG ............. 98

XARELTO TAB 10MG .......................... 98 XARELTO TAB 15MG .......................... 98

XARELTO TAB 20MG .......................... 98 XENAZINE TAB 12.5MG ..................... 72

XENAZINE TAB 25MG ........................ 72

XGEVA INJ ....................................... 84 XIFAXAN TAB 550MG ........................ 94

XOLAIR SOL 150MG ........................ 132 XOPENEX HFA AER .......................... 125

XTANDI CAP 40MG ............................ 35 XYREM SOL 500MG/ML ...................... 73

Y YF-VAX INJ .................................... 105

yl folic aci tab 400mcg ..................... 118 Z zafirlukast tab 10 mg ...................... 132 zafirlukast tab 20 mg ...................... 132

zarah tab 3-0.03mg .......................... 80 ZAVESCA CAP 100MG ........................ 81

zazole cre 0.4% ................................ 97

ZAZOLE CRE 0.8% ............................ 97 z-cof 12dm liq ................................ 131

ZELBORAF TAB 240MG...................... 37

ZEMAIRA INJ 1000MG ..................... 132 zenatane cap 10mg ........................ 135

zenatane cap 20mg ........................ 135 zenatane cap 30mg ........................ 135

zenatane cap 40mg ........................ 135 zenchent tab ................................... 80

ZENPEP CAP 10000UNT ..................... 94 ZENPEP CAP 15000UNT ..................... 94

ZENPEP CAP 20000UNT ..................... 94 ZENPEP CAP 25000UNT ..................... 94

ZENPEP CAP 3000UNIT ..................... 94 ZENPEP CAP 40000UNT ..................... 94

ZENPEP CAP 5000UNIT ..................... 94 ZETIA TAB 10MG .............................. 45

ZIAGEN SOL 20MG/ML ...................... 23

zidovudine cap 100 mg ..................... 23 zidovudine syrup 10 mg/ml ............... 23

zidovudine tab 300 mg ..................... 23 zinc oxide oint 20% ........................ 141

ZINC OXIDE PST 25%..................... 141 ziprasidone hcl cap 20 mg ................. 69

ziprasidone hcl cap 40 mg ................. 69 ziprasidone hcl cap 60 mg ................. 69

ziprasidone hcl cap 80 mg ................. 69 ZMAX SUS 2GM ............................... 28

ZODRYL AC 25 SUS ........................ 131 ZODRYL AC 30 SUS ........................ 131

ZODRYL AC 35 SUS ........................ 131 ZODRYL AC 40 SUS ........................ 131

ZODRYL DAC SUS 25 ...................... 132

ZODRYL DAC SUS 30 ...................... 132 ZODRYL DAC SUS 35 ...................... 132

ZODRYL DAC SUS 40 ...................... 132 ZODRYL DEC25 SUS ....................... 132

ZODRYL DEC30 SUS ....................... 132 ZODRYL DEC35 SUS ....................... 132

ZODRYL DEC40 SUS ....................... 132 zoledronic acid inj conc for iv infusion 4

mg/5ml ........................................... 77 ZOLINZA CAP 100MG ........................ 35

zolmitriptan orally disintegrating tab 2.5 mg ................................................. 72

zolmitriptan orally disintegrating tab 5 mg...................................................... 72

zolmitriptan tab 2.5 mg .................... 72

zolmitriptan tab 5 mg ....................... 72 zolpidem tartrate tab 10 mg .............. 71

195

zolpidem tartrate tab 5 mg ................ 71

ZOMETA INJ 4MG/100 ....................... 77 zonatuss cap 150mg ....................... 132

zonisamide cap 100 mg ..................... 59 zonisamide cap 25 mg ....................... 58

zonisamide cap 50 mg ....................... 58 ZONTIVITY TAB 2.08MG .................. 101

ZOO FRIENDS CHW COMPLETE ......... 118 ZORTRESS TAB 0.25MG ................... 104

ZORTRESS TAB 0.5MG .................... 104 ZORTRESS TAB 0.75MG ................... 104

ZOSTAVAX INJ ............................... 105

Z-TUSS AC LIQ 2-9/5ML ................. 131

Z-TUSS E LIQ ................................ 131 ZYDELIG TAB 100MG ........................ 37

ZYDELIG TAB 150MG ........................ 37 ZYKADIA CAP 150MG ........................ 37

ZYLET SUS 0.5-0.3% ...................... 118 ZYPREXA RELP INJ 210MG ................. 69

ZYPREXA RELP INJ 300MG ................. 69 ZYPREXA RELP INJ 405MG ................. 69

ZYTIGA TAB 250MG .......................... 35 ZYVOX SUS 100MG/5M ..................... 20

ZYVOX TAB 600MG ........................... 20

aetna better health sm fida plan list of covered drugs

Documents