Anthem MediBlue Rx Plus (PDP) 2020 Formulary (List of Covered Drugs) · 2020-02-04 · Anthem MediBlue Rx Plus (PDP) 2020 Formulary (List of Covered Drugs) PLEASE READ: This document

Anthem MediBlue Rx Plus (PDP)

2020 Formulary (List of Covered Drugs) PLEASE READ: This document contains information about the drugs we cover in this plan.

This formulary was updated on 1/28/2020. For more recent information or other questions, please contact Anthem MediBlue Rx Plus (PDP) Customer Service, at 1-833-285-4639 or, for TTY users, 711, 24 hours a day, 7 days a week, or visit https://shop.anthem.com/medicare.

S5596_001, 006, 014, 018, 057, 060, 063Y0114_20_107273_I_C_0001 CMS accepted 08/27/2019 Plus_PDP_20240_v8_2002_1

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us,” or “our,” it means Anthem Blue Cross and Blue Shield. When it refers to “plan” or “our plan,” it means Anthem MediBlue Rx Plus (PDP).

This document includes a list of the drugs (formulary) for our plan which is current as of 2/1/2020. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, and/or pharmacy network, and/ or copayments/coinsurance may change on January 1, 2021, and from time to time during the year.

The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

Effective Date 2/1/2020 2 Plus_PDP_20240_v8_2002_1

What is the Anthem MediBlue Rx Plus (PDP) formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the formulary (drug list) change? Most changes in drug coverage happen on January 1, but we may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes.

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

New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made.

If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Anthem MediBlue Rx Plus (PDP)’s Formulary?”

Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug.

If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Anthem MediBlue Rx Plus (PDP)’s Formulary?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2020 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year.

The enclosed formulary is current as of 2/1/2020. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. If any other type of approved formulary change (non-maintenance change) is made during the year, we will notify you by


sending you a list of these changes, or by sending you an updated formulary.

How do I use the formulary? There are two ways to find your drug within the formulary:

Medical Condition

The formulary begins on page 8. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Agents.” If you know what your drug is used for, look for the category name in the list that begins on page 8. Then look under the category name for your drug.

Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the Index that begins on page 69. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs? Our plan covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs.

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

Prior Authorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don't get approval, our plan may not cover the drug.

Quantity Limits: For certain drugs, our plan limits the amount of the drug that our plan will cover. For example, our plan provides 30 tablets per prescription for donepezil. This may be in addition to a standard one-month or three-month supply.

Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, our plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, our plan will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 4. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask our plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Anthem MediBlue Rx Plus (PDP)'s formulary?” on page 5 for information about how to request an exception.

What if my drug is not on the formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered.

If you learn that our plan does not cover your drug, you have two options:

You can ask Customer Service for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan.

You can ask our plan to make an exception and cover your drug. See below for information about how to request an exception.


How do I request an exception to the Anthem MediBlue Rx Plus (PDP)'s formulary? You can ask our plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make:

You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a predetermined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

You can ask us to cover a formulary drug at a lower cost-sharing level. If approved this would lower the amount you must pay for your drug.

You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, our plan will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary, or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we will allow refills to provide up to a maximum 30 day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term-care facility and, you need a drug that is not on our formulary, or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 34-day emergency supply of that drug while you pursue a formulary exception.

During the time when you are getting a temporary supply of a drug, you should talk to your prescriber or prescribing physician to decide what to do when your supply runs out. You can call Customer Service to ask for a list of covered drugs that treat the same medical condition. This list can help your doctor find a covered drug that might work for you while you pursue a formulary exception. Please refer to the Evidence of Coverage for more information about exceptions.

For more information For more detailed information about our plan prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about our plan, please contact us. Our contact information, along with the date we last


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

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day/ 7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

Our plan’s formulary The formulary on page 8 provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 69.

The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., SPIRIVA) and generic drugs are listed in lowercase italics (e.g., atenolol).

The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug.

QLL – Quantity Limits: Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled (most often set on a monthly basis).

PAR – Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved. You, your doctor or other network provider will need to request prior authorization before you fill the prescription.

ST – Step Therapy: The process of first trying a certain drug or drugs to determine if that drug or those drugs will treat your medical condition before your plan will cover another drug for that condition.

B/D PAR – Part B vs. Part D: This drug may be covered under either your Part D prescription drug benefits or as a Part B drug under your medical benefits, as determined by Medicare.

LA – Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at 1-833-285-4639, 24 hours a day, 7 days a week TTY/TDD users should call 711.

NE – Non-Extended Day Supply (NEDS): This prescription cannot be filled for more than a 30-day supply.

MO – Mail Orders: Prescription drugs available through mail order. Allow up to 14 days from the date the prescription is ordered to process and mail. For first time users of the home delivery pharmacy have at least a 30-day supply of medication on hand when a request is placed with home delivery pharmacy.

CG – Coverage Gap: We provide additional coverage of this prescription drug in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage.


Cost-sharing for a one-month supply of a covered Part D prescription drug during the Initial Coverage Stage: Cost-Sharing Tier 1: Preferred Generic

$1.00 Network Pharmacy with preferred cost-sharing (30-day supply)

$9.00 Network Pharmacy with standard cost-sharing (30-day supply) or Long-Term-Care Pharmacy (34-day supply)

Cost-Sharing Tier 2: Generic



Cost-Sharing Tier 3: Preferred Brand



Cost-Sharing Tier 4: Non-Preferred Drug

42% Network Pharmacy with preferred cost-sharing (30-day supply)

50% Network Pharmacy with standard cost-sharing (30-day supply) or Long-Term-Care Pharmacy (34-day supply)

Cost-Sharing Tier 5: Specialty Tier*

33% Network Pharmacy with preferred cost-sharing (30-day supply)

33% Network Pharmacy with standard cost-sharing (30-day supply) or Long-Term-Care Pharmacy (34-day supply)

Please refer to our Evidence of Coverage for more information on cost sharing.

The amount you pay will depend if you qualify for low-income subsidy (LIS), also known as Medicare's "Extra Help" program.

Network Pharmacy with preferred cost-sharing – A network pharmacy that offers covered drugs to members of our plan that may have lower cost-sharing levels than other network pharmacies with standard cost-sharing. * A long-term supply is not available for drugs in the Tier 5: Specialty Tier Mail-Order Pharmacy – Mail-order service allows you to order a 30–90 -day supply of drugs. The drug available through our plan’s mail-order service are marked as “mail-order” drugs in our drug list.


Covered Medications by Therapeutic Category Legend Generic drugs are shown in lowercase italic (e.g., atenolol).

Brand-name drugs are shown in capital letters (e.g., SPIRIVA).

QLL – Quantity Limits: Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled (most often set on a monthly basis). PAR – Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved. You, your doctor or other network provider will need to request prior authorization before you fill the prescription. ST – Step Therapy: The process of first trying a certain drug or drugs to determine if that drug or those drugs will treat your medical condition before your plan will cover another drug for that condition. B/D PAR – Part B vs. Part D: This drug may be covered under either your Part D prescription drug benefits or as a Part B drug under your medical benefits, as determined by Medicare. LA – Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at 1-833-285-4639, 24 hours a day, 7 days a week TTY/TDD users should call 711. NE – Non-Extended Day Supply (NEDS): This prescription cannot be filled for more than a 30-day supply. MO – Mail Orders: Prescription drugs available through mail order. Allow up to 14 days from the date the prescription is ordered to process and mail. For first time users of the home delivery pharmacy have at least a 30-day supply of medication on hand when a request is placed with home delivery pharmacy. CG – Coverage Gap: We provide additional coverage of this prescription drug in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage.

Requirements/ Limits

Drug Tier Drug Name

Analgesics MO; QLL (180 per 30 days); NE

3 acetaminophen-codeine #3

MO; QLL (180 per 30 days); NE

3 acetaminophen-codeine #4


3 acetaminophen-codeine oral solution


2 acetaminophen-codeine oral tablet 300-15 mg


3 acetaminophen-codeine oral tablet 300-60 mg


4 buprenorphine hcl injection

MO; QLL (240 per 30 days)

3 buprenorphine hcl sublingual tablet sublingual 2 mg




4 butorphanol tartrate injection solution 1 mg/ml


Drug Tier Drug Name


4 butorphanol tartrate injection solution 2 mg/ml


4 butorphanol tartrate nasal

PAR; MO 4 celecoxib oral MO; QLL (180 per 30 days); NE

3 CODEINE SULFATE ORAL TABLET 30 MG, 60 MG

MO 2 diclofenac potassium MO 2 diclofenac sodium er MO 2 diclofenac sodium oral PAR; MO; QLL (100 per 30 days)

4 diclofenac sodium transdermal gel 3 %

MO 4 diflunisal oral MO; QLL (180 per 30 days); NE

4 duramorph

PAR; QLL (8 per 28 days)

5 ENBREL MINI


3 endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg

You can find information on what the symbols and abbreviations on this table mean by going to the Legend on page number 8. Plus_PDP_20240_v8_2002_1 8 Effective Date 2/1/2020


Drug Tier Drug Name


3 endocet oral tablet 2.5-325 mg

MO 2 etodolac er MO 4 etodolac oral capsule MO 2 etodolac oral tablet MO 3 fenoprofen calcium oral tablet PAR; MO; QLL (120 per 30 days); NE

5 fentanyl citrate buccal lozenge on a handle

PAR; MO; QLL (120 per 30 days); NE

5 fentanyl citrate buccal lozenge on a handle


4 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 50 mcg/hr, 75 mcg/hr


4 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 50 mcg/hr, 75 mcg/hr


3 fentanyl transdermal patch 72 hour 25 mcg/hr


3 fentanyl transdermal patch 72 hour 25 mcg/hr

MO 2 flurbiprofen oral MO; QLL (2700 per 30 days); NE

4 hydrocodone-acetaminophen oral solution 7.5-325 mg/ 15ml


3 hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg


3 hydrocodone-ibuprofen oral tablet 7.5-200 mg


4 hydromorphone hcl injection solution 1 mg/ml






3 hydromorphone hcl oral tablet


4 HYDROMORPHONE HCL PF INJECTION SOLUTION 1 MG/ML


Drug Tier Drug Name



QLL (180 per 30 days); NE





4 hydromorphone hcl pf injection solution 50 mg/5ml


4 hydromorphone hcl pf injection solution 500 mg/ 50ml

MO; CG 1 ibu oral tablet 600 mg, 800 mg

MO 2 ibuprofen oral suspension MO; CG 1 ibuprofen oral tablet 400 mg,

600 mg, 800 mg PAR; LA 5 ILARIS

SUBCUTANEOUS SOLUTION

MO 2 ketoprofen oral capsule 25 mg PAR; MO 3 ketorolac tromethamine oral MO; QLL (180 per 30 days); NE

3 lorcet


3 lorcet hd


3 lorcet plus oral tablet 7.5-325 mg

MO 3 meclofenamate sodium oral capsule 100 mg

MO 4 meclofenamate sodium oral capsule 50 mg

MO 4 mefenamic acid oral MO; CG 1 meloxicam oral tablet MO; QLL (20 per 30 days); NE

4 METHADONE HCL INJECTION


3 methadone hcl intensol


3 methadone hcl oral concentrate


3 methadone hcl oral solution



Drug Tier Drug Name


3 methadone hcl oral tablet


3 METHADOSE ORAL CONCENTRATE 10 MG/ ML


3 METHADOSE SUGAR- FREE


3 morphine sulfate (concentrate) oral solution 100 mg/5ml


3 morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml


4 morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml


4 MORPHINE SULFATE (PF) INJECTION SOLUTION 4 MG/ML, 8 MG/ML


4 MORPHINE SULFATE (PF) INTRAVENOUS SOLUTION 10 MG/ML, 8 MG/ML


3 MORPHINE SULFATE (PF) INTRAVENOUS SOLUTION 2 MG/ML, 4 MG/ML


4 morphine sulfate er oral tablet extended release 100 mg, 200 mg


3 morphine sulfate er oral tablet extended release 15 mg, 30 mg, 60 mg


4 morphine sulfate intravenous solution 1 mg/ml






3 morphine sulfate oral solution


3 morphine sulfate oral solution


3 morphine sulfate oral tablet


Drug Tier Drug Name


3 morphine sulfate oral tablet

MO 2 nabumetone oral MO; QLL (60 per 30 days)

3 nalbuphine hcl injection solution 10 mg/ml


4 nalbuphine hcl injection solution 20 mg/ml

MO 2 naproxen dr MO 3 naproxen oral suspension MO; CG 1 naproxen oral tablet MO 4 naproxen sodium oral tablet

275 mg, 550 mg MO 3 oxaprozin MO; QLL (180 per 30 days); NE

4 oxycodone hcl oral capsule


4 oxycodone hcl oral concentrate 10 mg/0.5ml


4 oxycodone hcl oral concentrate 100 mg/5ml


3 oxycodone hcl oral solution


3 oxycodone hcl oral tablet


3 oxycodone-acetaminophen oral tablet 10-325 mg, 2.5- 325 mg, 5-325 mg, 7.5-325 mg


3 oxycodone-aspirin oral tablet 4.8355-325 mg


3 oxycodone-ibuprofen

MO 2 piroxicam oral MO 2 sulindac oral PAR; MO; QLL (30 per 30 days); NE

2 tramadol hcl er oral tablet extended release 24 hour 100 mg, 200 mg


2 tramadol hcl oral


3 tramadol-acetaminophen

Anesthetics MO 2 glydo external prefilled syringe PAR; MO; QLL (90 per 30 days)

3 lidocaine external patch 5 %



Drug Tier Drug Name

PAR; MO; QLL (300 per 30 days)

2 lidocaine hcl external solution

MO 2 lidocaine hcl urethral/mucosal MO 2 lidocaine viscous hcl MO; QLL (30 per 30 days)

3 lidocaine-prilocaine external cream Anti-Addiction/ Substance Abuse Treatment Agents

MO 4 acamprosate calcium MO; QLL (240 per 30 days)





4 buprenorphine hcl-naloxone hcl sublingual film 12-3 mg


4 buprenorphine hcl-naloxone hcl sublingual film 2-0.5 mg






2 buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg


2 buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 mg


2 bupropion hcl er (smoking det)


4 CHANTIX CONTINUING MONTH PAK


4 CHANTIX ORAL TABLET 0.5 MG


4 CHANTIX ORAL TABLET 1 MG


4 CHANTIX STARTING MONTH PAK

MO 4 disulfiram oral MO 4 naloxone hcl injection solution

0.4 mg/ml, 4 mg/10ml MO 2 naloxone hcl injection solution

cartridge MO 3 naloxone hcl injection solution

prefilled syringe


Drug Tier Drug Name

MO 2 naltrexone hcl oral MO 2 naltrexone hcl oral MO 3 NARCAN MO; QLL (120 per 30 days)

4 NICOTROL NS

Anti-Inflammatory Agents MO 2 betamethasone dipropionate

aug external cream MO 2 betamethasone dipropionate

aug external gel MO 3 betamethasone dipropionate

aug external lotion MO 3 betamethasone dipropionate

aug external ointment MO 3 betamethasone dipropionate

external cream MO 2 betamethasone dipropionate

external lotion MO 3 betamethasone dipropionate

external ointment MO 2 betamethasone valerate

external cream MO 2 betamethasone valerate

external lotion MO 2 betamethasone valerate

external ointment MO 4 BLEPHAMIDE S.O.P. PAR; MO 4 celecoxib oral MO 3 cortisone acetate oral MO 5 decadron oral tablet 0.5 mg MO 2 decadron oral tablet 0.75 mg,

4 mg, 6 mg MO 3 DEXAMETHASONE

INTENSOL MO 2 dexamethasone oral elixir MO 2 dexamethasone oral solution MO 2 dexamethasone oral tablet MO 4 DEXAMETHASONE

SOD PHOSPHATE PF INJECTION SOLUTION

MO 4 dexamethasone sodium phosphate injection

MO 2 diclofenac potassium MO 2 diclofenac sodium er MO 2 diclofenac sodium oral



Drug Tier Drug Name

MO 4 diflunisal oral MO 2 etodolac er MO 4 etodolac oral capsule 200 mg MO 2 etodolac oral tablet MO 3 fenoprofen calcium oral tablet MO 2 flurbiprofen oral MO 3 hydrocortisone oral tablet 20

mg, 5 mg MO; CG 1 ibu MO 2 ibuprofen oral suspension MO; CG 1 ibuprofen oral tablet 400 mg,

600 mg, 800 mg PAR; MO 3 ketorolac tromethamine oral MO 3 meclofenamate sodium oral

capsule 100 mg MO 4 meclofenamate sodium oral

capsule 50 mg MO 4 mefenamic acid oral MO; CG 1 meloxicam oral tablet MO 4 methylprednisolone acetate

injection suspension 40 mg/ml MO 4 METHYLPREDNISOLONE

ACETATE INJECTION SUSPENSION 80 MG/ML

MO 2 methylprednisolone oral tablet MO 4 methylprednisolone sodium

succ injection solution reconstituted 1000 mg, 125 mg, 40 mg

MO 2 nabumetone oral MO 2 naproxen dr MO 3 naproxen oral suspension MO; CG 1 naproxen oral tablet MO 4 naproxen sodium oral tablet

275 mg, 550 mg MO 3 oxaprozin MO; QLL (28 per 7 days); NE

3 oxycodone-ibuprofen

MO 2 piroxicam oral MO 2 prednisolone acetate

ophthalmic MO 2 prednisolone oral solution MO 3 PREDNISOLONE

SODIUM PHOSPHATE OPHTHALMIC


Drug Tier Drug Name

MO 2 prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml

MO 3 prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml

MO 3 PREDNISONE INTENSOL

MO 2 prednisone oral solution MO 2 prednisone oral tablet 1 mg MO; CG 1 prednisone oral tablet 10 mg,

2.5 mg, 20 mg, 5 mg, 50 mg MO 2 prednisone oral tablet therapy

pack 10 mg (21), 5 mg (21) MO; CG 1 prednisone oral tablet therapy

pack 10 mg (48), 5 mg (48) MO 2 sulfacetamide-prednisolone

ophthalmic solution MO 2 sulfazine MO 2 sulindac oral MO 4 triamcinolone acetonide

injection suspension 40 mg/ml Antibacterials

MO 2 acetic acid otic MO 4 amikacin sulfate injection

solution 1 gm/4ml, 500 mg/ 2ml

MO 2 amoxicillin oral capsule MO 2 amoxicillin oral suspension

reconstituted MO 2 amoxicillin oral tablet MO 2 amoxicillin oral tablet

chewable 125 mg, 250 mg MO 4 amoxicillin-pot clavulanate

er MO 2 amoxicillin-pot clavulanate

oral suspension reconstituted 200-28.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml

MO 3 amoxicillin-pot clavulanate oral suspension reconstituted 250-62.5 mg/5ml

MO 4 amoxicillin-pot clavulanate oral tablet 250-125 mg



Drug Tier Drug Name

MO 2 amoxicillin-pot clavulanate oral tablet 500-125 mg, 875- 125 mg

MO 2 amoxicillin-pot clavulanate oral tablet chewable

MO 2 ampicillin oral capsule 500 mg

MO 4 ampicillin sodium injection solution reconstituted 1 gm, 125 mg, 2 gm, 250 mg, 500 mg

MO 4 ampicillin sodium intravenous

MO 4 ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5) gm, 3 (2-1) gm

MO 4 ampicillin-sulbactam sodium intravenous

MO 4 AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125- 31.25 MG/5ML

MO 4 AVELOX INTRAVENOUS

MO 4 AZACTAM MO 4 azithromycin intravenous MO 4 azithromycin oral packet MO 3 azithromycin oral suspension

reconstituted 100 mg/5ml MO 2 azithromycin oral suspension

reconstituted 200 mg/5ml CG 1 azithromycin oral tablet 250

mg (6 pack) MO 2 azithromycin oral tablet 250

mg, 500 mg, 600 mg MO 4 aztreonam injection solution

reconstituted 1 gm MO 4 aztreonam injection solution

reconstituted 2 gm MO 4 baciim MO 4 bacitracin intramuscular MO 4 bacitracin ophthalmic MO 4 BICILLIN C-R MO 4 BICILLIN C-R 900/300


Drug Tier Drug Name

MO 4 BICILLIN L-A PAR; LA 5 CAYSTON MO 3 CEFACLOR ER MO 4 cefaclor oral capsule MO 2 cefaclor oral suspension

reconstituted 125 mg/5ml, 375 mg/5ml

MO 3 cefaclor oral suspension reconstituted 250 mg/5ml

MO 2 cefadroxil oral capsule MO 2 cefadroxil oral suspension

reconstituted MO 3 cefadroxil oral tablet MO 4 cefazolin sodium injection

solution reconstituted 1 gm, 10 gm, 500 mg

MO 4 CEFAZOLIN SODIUM INJECTION SOLUTION RECONSTITUTED 100 GM, 300 GM

MO 4 cefazolin sodium intravenous solution reconstituted

MO 4 CEFAZOLIN SODIUM- DEXTROSE INTRAVENOUS SOLUTION 1-4 GM/ 50ML-%

MO 4 CEFAZOLIN SODIUM- DEXTROSE INTRAVENOUS SOLUTION RECONSTITUTED 1-4 GM-%(50ML), 2-3 GM- %(50ML)

MO 3 cefdinir MO 4 cefepime hcl injection MO 4 CEFEPIME HCL

INTRAVENOUS MO 4 cefixime oral suspension

reconstituted MO 4 cefotaxime sodium injection

solution reconstituted 1 gm, 500 mg



Drug Tier Drug Name

MO 4 cefotetan disodium injection solution reconstituted 1 gm, 2 gm

MO 4 cefoxitin sodium MO 4 CEFOXITIN SODIUM-

DEXTROSE INTRAVENOUS SOLUTION RECONSTITUTED 1-4 GM-%(50ML), 2-2.2 GM- %(50ML)

MO 4 cefpodoxime proxetil MO 4 cefprozil oral suspension

reconstituted 125 mg/5ml MO 2 cefprozil oral suspension

reconstituted 250 mg/5ml MO 4 cefprozil oral tablet MO 4 CEFTAZIDIME AND

DEXTROSE INTRAVENOUS SOLUTION RECONSTITUTED 1-5 GM-%(50ML), 2-5 GM- %(50ML)

MO 4 ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 gm

MO 4 ceftriaxone sodium in dextrose MO 4 ceftriaxone sodium injection

solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg

MO 4 CEFTRIAXONE SODIUM INJECTION SOLUTION RECONSTITUTED 100 GM

MO 4 ceftriaxone sodium intravenous

MO 4 CEFTRIAXONE SODIUM-DEXTROSE INTRAVENOUS SOLUTION RECONSTITUTED 1- 3.74 GM-%(50ML), 2-2.22 GM-%(50ML)

MO 3 cefuroxime axetil oral tablet


Drug Tier Drug Name

MO 4 cefuroxime sodium injection solution reconstituted 7.5 gm, 750 mg

MO 4 cefuroxime sodium intravenous solution reconstituted 1.5 gm

MO 2 cephalexin oral capsule 250 mg, 500 mg

MO 2 cephalexin oral suspension reconstituted

MO 2 cephalexin oral tablet MO 4 chloramphenicol sod succinate MO; CG 1 ciprofloxacin hcl ophthalmic MO 3 ciprofloxacin hcl oral tablet

100 mg MO 2 ciprofloxacin hcl oral tablet

250 mg, 500 mg, 750 mg MO 4 ciprofloxacin in d5w MO 3 clarithromycin er MO 3 clarithromycin oral MO 2 clindacin-p MO 2 clindamycin hcl oral MO 2 clindamycin phosphate

external gel MO 2 clindamycin phosphate

external lotion MO 2 clindamycin phosphate

external solution MO 2 clindamycin phosphate

external swab MO 4 clindamycin phosphate in

d5w MO 4 clindamycin phosphate

injection solution 300 mg/ 2ml, 600 mg/4ml, 9 gm/ 60ml, 9000 mg/60ml

MO 4 clindamycin phosphate vaginal

MO 4 colistimethate sodium (cba) MO 4 colistimethate sodium (cba) MO 5 DAPTOMYCIN

INTRAVENOUS SOLUTION RECONSTITUTED 350 MG



Drug Tier Drug Name

MO 5 daptomycin intravenous solution reconstituted 500 mg

MO 4 demeclocycline hcl oral MO 2 dicloxacillin sodium MO 4 doxy 100

4 doxycycline hyclate intravenous

MO 4 doxycycline hyclate oral capsule

MO 4 doxycycline hyclate oral tablet 100 mg, 150 mg, 20 mg, 75 mg

MO 2 doxycycline monohydrate oral capsule 100 mg, 50 mg

MO 4 doxycycline monohydrate oral tablet 100 mg, 50 mg, 75 mg

MO 3 doxycycline monohydrate oral tablet 150 mg

MO 4 e.e.s. 400 oral tablet MO 2 ery MO 4 ERYTHROCIN

LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

MO 4 erythrocin stearate oral tablet 250 mg

MO 4 erythromycin base oral capsule delayed release particles

MO 4 erythromycin base oral tablet MO 4 erythromycin ethylsuccinate

oral tablet MO 2 erythromycin external gel MO 2 erythromycin external solution MO 2 erythromycin ophthalmic MO 4 erythromycin stearate oral

tablet 250 mg MO 2 gentak ophthalmic ointment MO 4 gentamicin in saline

intravenous solution 0.8-0.9 mg/ml-%, 1-0.9 mg/ml-%, 1.2-0.9 mg/ml-%, 1.6-0.9 mg/ml-%, 2-0.9 mg/ml-%

MO 3 gentamicin sulfate external


Drug Tier Drug Name

MO 4 gentamicin sulfate injection MO 2 gentamicin sulfate ophthalmic

solution MO; CG 1 GLOBAL ALCOHOL

PREP EASE MO 3 imipenem-cilastatin

intravenous solution reconstituted 250 mg

MO 4 imipenem-cilastatin intravenous solution reconstituted 500 mg

MO 4 levofloxacin in d5w MO 4 levofloxacin intravenous MO 4 levofloxacin ophthalmic MO 4 levofloxacin oral solution MO 2 levofloxacin oral tablet MO 4 linezolid in sodium chloride MO 4 linezolid intravenous solution

600 mg/300ml PAR; MO; QLL (1800 per 30 days)

4 linezolid oral suspension reconstituted


4 linezolid oral tablet

MO 4 meropenem MO 4 methenamine hippurate MO 4 metronidazole external cream MO 2 metronidazole external gel

0.75 % MO 4 metronidazole external lotion MO 4 metronidazole in nacl

intravenous solution 5-0.79 mg/ml-%, 500-0.79 mg/ 100ml-%

MO 4 METRONIDAZOLE IN NACL INTRAVENOUS SOLUTION 500-0.74 MG/100ML-%

MO; CG 1 metronidazole oral tablet 250 mg

MO 2 metronidazole oral tablet 500 mg

MO 2 metronidazole vaginal MO 2 minocycline hcl oral capsule MO 3 minocycline hcl oral tablet



Drug Tier Drug Name

MO 2 mondoxyne nl oral capsule 100 mg

MO 4 morgidox oral capsule 100 mg MO 2 morgidox oral capsule 50 mg MO 4 moxifloxacin hcl in nacl MO 3 moxifloxacin hcl ophthalmic MO 2 mupirocin external MO 4 NAFCILLIN SODIUM IN

DEXTROSE MO 4 nafcillin sodium injection

solution reconstituted 1 gm, 2 gm

MO 4 nafcillin sodium intravenous solution reconstituted 1 gm, 2 gm

MO 2 neomycin sulfate oral MO 3 nitrofurantoin macrocrystal

oral capsule 100 mg, 50 mg MO 3 nitrofurantoin monohyd

macro MO 2 ofloxacin ophthalmic MO 4 ofloxacin otic MO 4 OXACILLIN SODIUM IN

DEXTROSE INTRAVENOUS SOLUTION 1 GM/50ML

MO 4 oxacillin sodium injection solution reconstituted 1 gm, 2 gm

MO 4 paromomycin sulfate oral MO 4 penicillin g potassium MO 4 PENICILLIN G

PROCAINE MO 2 penicillin v potassium MO 4 pfizerpen MO 4 piperacillin sod-tazobactam

so intravenous solution reconstituted 2.25 (2-0.25) gm, 3.375 (3-0.375) gm, 4.5 (4-0.5) gm, 40.5 (36-4.5) gm

MO 4 silver sulfadiazine external MO 4 ssd MO 4 streptomycin sulfate

intramuscular


Drug Tier Drug Name

MO 3 sulfacetamide sodium (acne) MO 3 sulfacetamide sodium

ophthalmic ointment MO 2 sulfacetamide sodium

ophthalmic solution MO 4 SULFADIAZINE ORAL MO 4 sulfamethoxazole-

trimethoprim intravenous MO 3 sulfamethoxazole-

trimethoprim oral suspension 200-40 mg/5ml

MO 2 sulfamethoxazole- trimethoprim oral tablet

MO 4 SULFAMYLON EXTERNAL CREAM

MO 4 SUPRAX ORAL SUSPENSION RECONSTITUTED

MO 5 SYNERCID MO 4 tazicef injection MO 4 TEFLARO MO 4 tetracycline hcl oral capsule

500 mg MO 5 tigecycline MO 2 tinidazole oral tablet 250 mg MO 3 tinidazole oral tablet 500 mg MO 3 TOBRADEX

OPHTHALMIC OINTMENT

B/D PAR; QLL (280 per 28 days)

5 tobramycin inhalation

MO 2 tobramycin ophthalmic MO 4 tobramycin sulfate injection MO 2 trimethoprim oral MO 4 VANCOMYCIN HCL IN

DEXTROSE INTRAVENOUS SOLUTION 1-5 GM/ 200ML-%, 500-5 MG/ 100ML-%, 750-5 MG/ 150ML-%



Drug Tier Drug Name

MO 4 VANCOMYCIN HCL IN NACL INTRAVENOUS SOLUTION 1-0.9 GM/ 200ML-%, 500-0.9 MG/ 100ML-%, 750-0.9 MG/ 150ML-%

MO 4 vancomycin hcl intravenous solution reconstituted 1 gm, 10 gm, 5 gm, 500 mg

MO 4 VANCOMYCIN HCL INTRAVENOUS SOLUTION RECONSTITUTED 1.25 GM, 1.5 GM, 250 MG

B/D PAR; MO 4 vancomycin hcl intravenous solution reconstituted 750 mg


5 vancomycin hcl oral capsule 250 mg

MO 2 vandazole PAR; MO 5 VIBATIV

INTRAVENOUS SOLUTION RECONSTITUTED 750 MG

MO 5 ZYVOX INTRAVENOUS SOLUTION 200 MG/ 100ML Anticonvulsants

ST; MO 4 APTIOM PAR; MO; QLL (2400 per 30 days)

4 BANZEL ORAL SUSPENSION


4 BANZEL ORAL TABLET 200 MG


4 BANZEL ORAL TABLET 400 MG

PAR; MO 4 BRIVIACT INTRAVENOUS


4 BRIVIACT ORAL SOLUTION


4 BRIVIACT ORAL TABLET 10 MG


4 BRIVIACT ORAL TABLET 100 MG, 75 MG




Drug Tier Drug Name



MO 4 carbamazepine er oral tablet extended release 12 hour

MO 4 carbamazepine oral MO 4 CELONTIN PAR; MO; QLL (480 per 30 days)

4 clobazam oral suspension


4 clobazam oral tablet 10 mg


5 clobazam oral tablet 20 mg


2 clonazepam oral tablet 0.5 mg


2 clonazepam oral tablet 1 mg




3 clonazepam oral tablet dispersible 0.125 mg






3 clonazepam oral tablet dispersible 1 mg



MO 3 clorazepate dipotassium MO 4 DIASTAT ACUDIAL MO 4 DIASTAT ACUDIAL MO 4 DIASTAT PEDIATRIC MO 4 DIASTAT PEDIATRIC MO; QLL (240 per 30 days)

3 diazepam oral concentrate




3 diazepam oral solution 5 mg/ 5ml




2 diazepam oral tablet 10 mg





Drug Tier Drug Name









MO 4 diazepam rectal MO 3 DILANTIN INFATABS MO 3 DILANTIN ORAL

CAPSULE 30 MG MO 4 divalproex sodium er oral

tablet extended release 24 hour

MO 3 divalproex sodium oral capsule delayed release sprinkle

MO 4 divalproex sodium oral tablet delayed release

PAR; LA 5 EPIDIOLEX MO 4 epitol MO; QLL (480 per 30 days)

4 EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG





MO 4 ethosuximide oral capsule MO 3 ethosuximide oral solution MO 4 felbamate MO 4 fosphenytoin sodium MO; QLL (720 per 30 days)

4 FYCOMPA ORAL SUSPENSION


4 FYCOMPA ORAL TABLET 10 MG, 12 MG


4 FYCOMPA ORAL TABLET 2 MG


Drug Tier Drug Name








2 gabapentin oral capsule 100 mg






4 gabapentin oral solution


2 gabapentin oral tablet 600 mg


2 gabapentin oral tablet 800 mg

MO 2 lamotrigine oral tablet MO 3 lamotrigine oral tablet

chewable MO; QLL (180 per 30 days)

3 levetiracetam er oral tablet extended release 24 hour 500 mg


3 levetiracetam er oral tablet extended release 24 hour 750 mg

MO 4 levetiracetam intravenous MO 3 levetiracetam oral MO; QLL (300 per 30 days)

2 lorazepam oral concentrate 1 mg/0.5ml


2 lorazepam oral concentrate 2 mg/ml


2 lorazepam oral tablet 0.5 mg, 1 mg


2 lorazepam oral tablet 2 mg

4 NAYZILAM MO 4 oxcarbazepine oral suspension MO 3 oxcarbazepine oral tablet MO 4 PEGANONE PAR; MO; QLL (3000 per 30 days)

3 phenobarbital oral elixir


4 phenobarbital oral tablet 100 mg



Drug Tier Drug Name




4 phenobarbital oral tablet 16.2 mg











MO 4 PHENYTEK MO 3 phenytoin oral suspension 125

mg/5ml MO 2 phenytoin oral tablet

chewable MO 4 phenytoin sodium extended MO 4 phenytoin sodium injection MO; QLL (180 per 30 days)

2 pregabalin oral capsule 100 mg






2 pregabalin oral capsule 225 mg, 300 mg








2 pregabalin oral solution

MO 4 primidone oral MO 3 roweepra MO; QLL (180 per 30 days)

3 roweepra xr oral tablet extended release 24 hour 500 mg


3 roweepra xr oral tablet extended release 24 hour 750 mg


Drug Tier Drug Name

PAR; LA; QLL (180 per 30 days)

4 SABRIL ORAL PACKET


4 SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG, 250 MG, 500 MG


4 SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 750 MG

MO 2 subvenite PAR; MO; QLL (60 per 30 days)

5 SYMPAZAN ORAL FILM 10 MG, 20 MG


4 SYMPAZAN ORAL FILM 5 MG

MO 4 tiagabine hcl MO 3 topiramate oral capsule

sprinkle 15 mg MO 4 topiramate oral capsule

sprinkle 25 mg MO; QLL (480 per 30 days)

4 topiramate oral tablet 100 mg







MO 4 valproate sodium intravenous MO 4 valproic acid oral capsule MO 2 valproic acid oral solution PAR; LA; QLL (180 per 30 days)

5 vigabatrin


5 vigadrone


4 VIMPAT INTRAVENOUS


4 VIMPAT ORAL SOLUTION


4 VIMPAT ORAL TABLET 100 MG


4 VIMPAT ORAL TABLET 150 MG, 200 MG


4 VIMPAT ORAL TABLET 50 MG



Drug Tier Drug Name

MO 4 zonisamide oral capsule 100 mg, 50 mg

MO 2 zonisamide oral capsule 25 mg Antidementia Agents


2 donepezil hcl oral tablet 10 mg, 5 mg

ST; MO; QLL (30 per 30 days)

4 donepezil hcl oral tablet 23 mg


2 donepezil hcl oral tablet dispersible

PAR; MO 4 ergoloid mesylates oral MO; QLL (30 per 30 days)

3 galantamine hydrobromide er


4 galantamine hydrobromide oral solution


3 galantamine hydrobromide oral tablet


3 memantine hcl er


3 memantine hcl oral solution 10 mg/5ml


3 memantine hcl oral solution 2 mg/ml


3 memantine hcl oral tablet 10 mg


3 memantine hcl oral tablet 5 mg

PAR; MO 4 NAMZARIC MO; QLL (30 per 30 days)

4 rivastigmine


4 rivastigmine tartrate

Antidepressants MO; QLL (1 per 28 days)

5 ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE


5 ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER

PAR; MO 4 amitriptyline hcl oral PAR; MO 2 amoxapine MO; QLL (900 per 30 days)

4 aripiprazole oral solution


Drug Tier Drug Name


4 aripiprazole oral tablet 10 mg






4 aripiprazole oral tablet 20 mg, 30 mg




5 aripiprazole oral tablet dispersible 10 mg




2 bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg


2 bupropion hcl er (sr) oral tablet extended release 12 hour 150 mg, 200 mg


2 bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg


2 bupropion hcl er (xl) oral tablet extended release 24 hour 300 mg


2 bupropion hcl oral tablet 100 mg


2 bupropion hcl oral tablet 75 mg


2 citalopram hydrobromide oral solution

MO; CG; QLL (120 per 30 days)

1 citalopram hydrobromide oral tablet 10 mg





PAR; MO 4 clomipramine hcl oral PAR; MO 4 desipramine hcl oral MO; QLL (120 per 30 days)

4 DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG



Drug Tier Drug Name


4 DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 50 MG


4 desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg





PAR; MO 3 doxepin hcl oral capsule PAR; MO 4 doxepin hcl oral concentrate MO; QLL (180 per 30 days)

4 duloxetine hcl oral capsule delayed release particles 20 mg








5 EMSAM


4 escitalopram oxalate oral solution


2 escitalopram oxalate oral tablet 10 mg






4 FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG


4 FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG


4 FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 40 MG


Drug Tier Drug Name


4 FETZIMA TITRATION


1 fluoxetine hcl oral capsule 10 mg






2 fluoxetine hcl oral solution


2 fluvoxamine maleate oral tablet 100 mg





PAR; MO 4 imipramine hcl oral MO; QLL (270 per 30 days)

2 maprotiline hcl oral tablet 25 mg


2 maprotiline hcl oral tablet 50 mg

MO 2 maprotiline hcl oral tablet 75 mg

MO 4 MARPLAN MO; QLL (90 per 30 days)

2 mirtazapine oral tablet 15 mg






2 mirtazapine oral tablet 7.5 mg


4 mirtazapine oral tablet dispersible 15 mg






4 nefazodone hcl oral tablet 100 mg







Drug Tier Drug Name





PAR; MO; CG 1 nortriptyline hcl oral capsule 10 mg, 25 mg

PAR; MO 2 nortriptyline hcl oral capsule 50 mg, 75 mg

PAR; MO 4 nortriptyline hcl oral solution MO; CG; QLL (180 per 30 days)

1 paroxetine hcl oral tablet 10 mg








4 PAXIL ORAL SUSPENSION

MO 3 phenelzine sulfate oral PAR; MO 4 protriptyline hcl PAR; MO; QLL (150 per 30 days)

4 quetiapine fumarate er oral tablet extended release 24 hour 150 mg










2 quetiapine fumarate oral tablet 100 mg








Drug Tier Drug Name






4 sertraline hcl oral concentrate


2 sertraline hcl oral tablet 100 mg






5 SPRAVATO (56 MG DOSE)


5 SPRAVATO (84 MG DOSE)

MO 4 tranylcypromine sulfate MO; CG 1 trazodone hcl oral tablet 100

mg, 150 mg, 50 mg MO 4 trazodone hcl oral tablet 300

mg MO 4 trimipramine maleate oral ST; MO; QLL (60 per 30 days)

4 TRINTELLIX ORAL TABLET 10 MG






2 venlafaxine hcl er oral capsule extended release 24 hour 150 mg


2 venlafaxine hcl er oral capsule extended release 24 hour 37.5 mg




2 venlafaxine hcl oral tablet 100 mg




2 venlafaxine hcl oral tablet 37.5 mg





Drug Tier Drug Name




4 VIIBRYD ORAL TABLET 10 MG





ST; MO 4 VIIBRYD STARTER PACK Antiemetics

B/D PAR; MO; QLL (5 per 30 days)

4 aprepitant oral capsule 125 mg




4 aprepitant oral capsule 80 & 125 mg



MO 3 chlorpromazine hcl oral tablet 10 mg

MO 4 chlorpromazine hcl oral tablet 100 mg, 200 mg, 25 mg, 50 mg

MO 4 compro B/D PAR; MO; QLL (120 per 30 days)

4 dronabinol

MO 4 granisetron hcl intravenous solution 1 mg/ml, 4 mg/4ml


3 granisetron hcl oral

PAR; MO 4 hydroxyzine hcl oral syrup PAR; MO 4 hydroxyzine hcl oral tablet MO 2 meclizine hcl oral tablet MO; CG 1 metoclopramide hcl oral

solution 5 mg/5ml MO; CG 1 metoclopramide hcl oral tablet


Drug Tier Drug Name


2 ondansetron

MO 4 ondansetron hcl injection B/D PAR; MO; QLL (450 per 30 days)

4 ondansetron hcl oral solution


4 ondansetron hcl oral tablet 24 mg


2 ondansetron hcl oral tablet 4 mg, 8 mg

MO 3 perphenazine oral MO 4 prochlorperazine MO 2 prochlorperazine maleate oral PAR; MO 4 promethazine hcl oral tablet MO; QLL (10 per 28 days)

4 scopolamine


4 TRANSDERM SCOP (1.5 MG) Antifungals

B/D PAR; MO 5 ABELCET B/D PAR; MO 4 AMBISOME B/D PAR; MO 4 amphotericin b intravenous B/D PAR; MO 5 CASPOFUNGIN

ACETATE INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

B/D PAR; MO 4 caspofungin acetate intravenous solution reconstituted 70 mg

MO 2 ciclopirox external gel MO 3 ciclopirox external shampoo MO 3 ciclopirox external solution MO 2 ciclopirox olamine external MO 2 clotrimazole external cream MO 2 clotrimazole external solution MO 2 clotrimazole mouth/throat

lozenge MO 3 econazole nitrate external



Drug Tier Drug Name

MO 4 fluconazole in sodium chloride intravenous solution 200-0.9 mg/100ml-%, 400- 0.9 mg/200ml-%

MO 3 fluconazole oral suspension reconstituted

MO 2 fluconazole oral tablet MO 4 flucytosine oral capsule 250

mg MO 5 flucytosine oral capsule 500

mg MO 3 griseofulvin microsize oral

suspension MO 3 griseofulvin ultramicrosize PAR; MO 4 itraconazole oral capsule MO 2 ketoconazole external cream MO 2 ketoconazole external

shampoo 2 % MO 2 ketoconazole oral MO 3 miconazole 3 vaginal

suppository MO 4 NATACYN PAR; MO 5 NOXAFIL ORAL

SUSPENSION MO 2 nyamyc MO 2 nystatin external MO 2 nystatin mouth/throat MO 2 nystatin oral tablet MO 2 nystop MO; CG 1 terbinafine hcl oral MO 2 terconazole vaginal cream MO 3 terconazole vaginal

suppository MO 4 voriconazole intravenous PAR; MO 5 voriconazole oral suspension

reconstituted PAR; MO 5 voriconazole oral tablet 200

mg PAR; MO 4 voriconazole oral tablet 50

mg PAR; QLL (120 per 30 days)

5 ZOLINZA

Antigout Agents MO; CG 1 allopurinol oral MO 4 allopurinol sodium


Drug Tier Drug Name

MO 4 ALOPRIM MO 3 colchicine oral tablet MO 2 colchicine-probenecid MO 3 febuxostat MO 2 probenecid oral ST; MO 3 ULORIC

Antimigraine Agents MO; QLL (8 per 28 days)

5 dihydroergotamine mesylate nasal

MO 4 divalproex sodium er oral tablet extended release 24 hour



MO 3 ERGOMAR MO 3 ergotamine-caffeine MO; QLL (9 per 30 days)

3 naratriptan hcl


3 rizatriptan benzoate

MO 4 sumatriptan nasal MO; QLL (9 per 30 days)

2 sumatriptan succinate oral

MO 4 sumatriptan succinate refill subcutaneous solution cartridge

MO 4 sumatriptan succinate subcutaneous solution 6 mg/ 0.5ml

MO 4 sumatriptan succinate subcutaneous solution auto- injector

MO 4 sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml

MO 4 timolol maleate oral MO 3 topiramate oral capsule

sprinkle 15 mg MO 4 topiramate oral capsule

sprinkle 25 mg MO; QLL (480 per 30 days)




Drug Tier Drug Name







MO 4 valproic acid oral capsule MO 2 valproic acid oral solution

Antimyasthenic Agents MO 3 GUANIDINE HCL ORAL MO 5 MESTINON ORAL

SOLUTION MO 4 pyridostigmine bromide er MO 5 pyridostigmine bromide oral

solution MO 3 PYRIDOSTIGMINE

BROMIDE ORAL TABLET 30 MG

MO 3 pyridostigmine bromide oral tablet 60 mg

MO 4 REGONOL INTRAVENOUS Antimycobacterials

MO 4 CAPASTAT SULFATE MO 3 dapsone oral MO 2 ethambutol hcl oral MO 4 isoniazid injection MO 3 isoniazid oral syrup MO; CG 1 isoniazid oral tablet MO 4 PASER MO 4 PRIFTIN MO 4 pyrazinamide oral MO 4 rifabutin MO 4 rifampin intravenous MO 3 rifampin oral MO 3 RIFATER PAR; MO; LA 5 SIRTURO MO 4 TRECATOR

Antineoplastics PAR; QLL (120 per 30 days)

5 abiraterone acetate

PAR 5 ABRAXANE B/D PAR 4 adriamycin intravenous

solution


Drug Tier Drug Name

B/D PAR 4 adriamycin intravenous solution reconstituted 10 mg, 50 mg

B/D PAR 4 adrucil PAR 5 AFINITOR PAR; LA; QLL (240 per 30 days)

5 ALECENSA

PAR; LA 5 ALIQOPA PAR; LA; QLL (30 per 30 days)

5 ALUNBRIG ORAL TABLET 180 MG





PAR; LA; QLL (30 per 180 days); NE

5 ALUNBRIG ORAL TABLET THERAPY PACK


2 anastrozole oral

B/D PAR 4 ARRANON B/D PAR 5 arsenic trioxide intravenous PAR 5 ARZERRA PAR; LA 5 AVASTIN PAR; MO; QLL (45 per 30 days)

2 avita

PAR 5 azacitidine PAR; LA; QLL (90 per 30 days)

5 BALVERSA ORAL TABLET 3 MG





PAR; LA 5 BAVENCIO PAR 5 BELEODAQ B/D PAR 5 BENDEKA B/D PAR; LA 5 BESPONSA PAR; QLL (300 per 30 days)

5 bexarotene


2 bicalutamide

B/D PAR 4 BICNU B/D PAR 4 bleomycin sulfate PAR 5 BLINCYTO PAR 5 BORTEZOMIB



Drug Tier Drug Name


5 BOSULIF ORAL TABLET 100 MG


5 BOSULIF ORAL TABLET 400 MG, 500 MG


5 BRAFTOVI ORAL CAPSULE 75 MG

B/D PAR 4 busulfan PAR; LA; QLL (30 per 30 days)

5 CABOMETYX

PAR; LA 5 CALQUENCE PAR; LA; QLL (90 per 30 days)

5 CAPRELSA ORAL TABLET 100 MG


5 CAPRELSA ORAL TABLET 300 MG

B/D PAR 4 carboplatin intravenous solution

B/D PAR 4 carmustine B/D PAR 4 cisplatin intravenous solution

100 mg/100ml, 200 mg/ 200ml, 50 mg/50ml

B/D PAR 5 cladribine intravenous solution 10 mg/10ml

B/D PAR 5 clofarabine B/D PAR 5 CLOLAR PAR; LA; QLL (56 per 28 days)

5 COMETRIQ (100 MG DAILY DOSE)






5 COPIKTRA

B/D PAR 5 COSMEGEN PAR; LA; QLL (90 per 30 days)

5 COTELLIC

B/D PAR 3 cyclophosphamide oral capsule PAR; LA 5 CYRAMZA B/D PAR 4 cytarabine (pf) B/D PAR 4 cytarabine injection solution B/D PAR 4 dacarbazine intravenous B/D PAR 5 dactinomycin PAR; LA 5 DARZALEX B/D PAR 4 daunorubicin hcl intravenous

solution 20 mg/4ml


Drug Tier Drug Name

B/D PAR 4 DAUNORUBICIN HCL INTRAVENOUS SOLUTION 50 MG/10ML


5 DAURISMO ORAL TABLET 100 MG


5 DAURISMO ORAL TABLET 25 MG

B/D PAR 5 decitabine B/D PAR 5 dexrazoxane hcl B/D PAR 5 DOCETAXEL

INTRAVENOUS CONCENTRATE 160 MG/8ML, 20 MG/ML, 200 MG/10ML, 80 MG/4ML

B/D PAR 4 DOCETAXEL INTRAVENOUS SOLUTION 160 MG/ 16ML

B/D PAR 5 DOCETAXEL INTRAVENOUS SOLUTION 20 MG/2ML, 80 MG/8ML

B/D PAR 4 doxorubicin hcl intravenous solution

PAR 5 doxorubicin hcl liposomal MO 4 DROXIA PAR 5 ELITEK

4 EMCYT PAR; LA 5 EMPLICITI B/D PAR 4 epirubicin hcl intravenous

solution 200 mg/100ml, 50 mg/25ml

PAR 5 ERBITUX PAR; LA; QLL (30 per 30 days)

5 ERIVEDGE

PAR; LA 5 ERLEADA PAR; QLL (30 per 30 days)

5 erlotinib hcl oral tablet 100 mg, 150 mg


5 erlotinib hcl oral tablet 25 mg

PAR; LA 5 ERWINAZE INJECTION B/D PAR 5 ETOPOPHOS B/D PAR 4 etoposide intravenous solution

1 gm/50ml



Drug Tier Drug Name

B/D PAR 3 etoposide intravenous solution 100 mg/5ml, 500 mg/25ml

PAR 5 everolimus B/D PAR 5 EVOMELA MO; QLL (60 per 30 days)

4 exemestane


5 FARYDAK ORAL CAPSULE 10 MG


5 FARYDAK ORAL CAPSULE 15 MG, 20 MG

PAR 5 FASLODEX INTRAMUSCULAR SOLUTION 250 MG/5ML

B/D PAR 4 fludarabine phosphate B/D PAR 4 fluorouracil intravenous MO 3 flutamide B/D PAR 5 FOLOTYN PAR 5 fulvestrant PAR; LA 5 GAZYVA B/D PAR 5 GEMCITABINE HCL

INTRAVENOUS SOLUTION 1 GM/10ML, 2 GM/20ML

B/D PAR 4 gemcitabine hcl intravenous solution 1 gm/26.3ml, 200 mg/5.26ml

B/D PAR 5 gemcitabine hcl intravenous solution 2 gm/52.6ml, 200 mg/2ml

B/D PAR 4 gemcitabine hcl intravenous solution reconstituted 1 gm, 200 mg

B/D PAR 5 gemcitabine hcl intravenous solution reconstituted 2 gm


5 GILOTRIF

PAR; MO 4 GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG

PAR 5 HALAVEN B/D PAR 5 HERCEPTIN HYLECTA


Drug Tier Drug Name

B/D PAR 5 HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 150 MG

PAR; QLL (25 per 147 days); NE

5 hydroxyprogesterone caproate intramuscular solution

MO 2 hydroxyurea oral PAR; LA; QLL (30 per 30 days)

5 IBRANCE


5 ICLUSIG ORAL TABLET 15 MG


5 ICLUSIG ORAL TABLET 45 MG

B/D PAR 5 idarubicin hcl PAR; LA; QLL (30 per 30 days)

5 IDHIFA ORAL TABLET 100 MG


5 IDHIFA ORAL TABLET 50 MG

B/D PAR 4 IFEX INTRAVENOUS SOLUTION RECONSTITUTED 3 GM

B/D PAR 4 ifosfamide intravenous solution

B/D PAR 4 ifosfamide intravenous solution reconstituted 1 gm

B/D PAR 4 IFOSFAMIDE INTRAVENOUS SOLUTION RECONSTITUTED 3 GM


5 imatinib mesylate oral tablet 100 mg


5 imatinib mesylate oral tablet 400 mg


5 IMBRUVICA ORAL CAPSULE 140 MG


5 IMBRUVICA ORAL CAPSULE 70 MG


5 IMBRUVICA ORAL TABLET 140 MG


5 IMBRUVICA ORAL TABLET 280 MG, 420 MG, 560 MG

PAR; LA 5 IMFINZI PAR; LA; QLL (240 per 30 days)

5 INLYTA ORAL TABLET 1 MG



Drug Tier Drug Name


5 INLYTA ORAL TABLET 5 MG


5 INREBIC

LA 5 IRESSA B/D PAR 4 irinotecan hcl PAR 5 ISTODAX (OVERFILL) PAR 5 IXEMPRA KIT PAR; LA; QLL (150 per 30 days)

5 JAKAFI ORAL TABLET 10 MG









PAR 5 KADCYLA PAR 5 KHAPZORY PAR; QLL (21 per 21 days)

5 KISQALI (200 MG DOSE)






5 KISQALI FEMARA (400 MG DOSE)


5 KISQALI FEMARA (600 MG DOSE)


5 KISQALI FEMARA(200 MG DOSE)

PAR; LA 5 KYPROLIS PAR; LA 5 LARTRUVO

INTRAVENOUS SOLUTION 190 MG/ 19ML


5 LENVIMA (10 MG DAILY DOSE)








Drug Tier Drug Name










2 letrozole oral

MO 4 leucovorin calcium injection solution 100 mg/10ml

B/D PAR; MO 4 leucovorin calcium injection solution reconstituted

MO 2 leucovorin calcium oral tablet 10 mg, 15 mg, 5 mg

MO 2 leucovorin calcium oral tablet 10 mg, 15 mg, 5 mg

MO 3 leucovorin calcium oral tablet 25 mg

MO 3 leucovorin calcium oral tablet 25 mg

MO 4 LEUKERAN PAR 5 levoleucovorin calcium


PAR; LA 5 LIBTAYO PAR 5 LONSURF PAR; LA; QLL (30 per 30 days)

5 LORBRENA ORAL TABLET 100 MG


5 LORBRENA ORAL TABLET 25 MG

PAR; LA 5 LUMOXITI PAR; LA; QLL (120 per 30 days)

5 LYNPARZA ORAL TABLET

5 MARQIBO LA 5 MATULANE PAR; LA; QLL (90 per 30 days)

5 MEKINIST ORAL TABLET 0.5 MG


5 MEKINIST ORAL TABLET 2 MG


5 MEKTOVI

B/D PAR 4 melphalan B/D PAR 3 melphalan hcl



Drug Tier Drug Name

MO 4 mesna MO 4 MESNEX ORAL MO 4 methotrexate sodium (pf)

injection solution 1 gm/40ml, 250 mg/10ml

MO 4 methotrexate sodium injection solution 250 mg/10ml

MO 4 methotrexate sodium injection solution reconstituted

B/D PAR 4 mitomycin intravenous solution reconstituted 20 mg

B/D PAR 5 mitomycin intravenous solution reconstituted 40 mg

B/D PAR 3 mitoxantrone hcl B/D PAR 4 mutamycin intravenous

solution reconstituted 20 mg B/D PAR 5 mutamycin intravenous

solution reconstituted 40 mg PAR; LA 5 MYLOTARG

INTRAVENOUS SOLUTION RECONSTITUTED 4.5 MG


5 NERLYNX


5 NEXAVAR


5 nilutamide


5 NINLARO

B/D PAR 5 NIPENT PAR; LA; QLL (120 per 30 days)

5 NUBEQA


5 ODOMZO


5 OFEV ORAL CAPSULE 150 MG

PAR 5 ONCASPAR INJECTION PAR; LA 5 OPDIVO B/D PAR 4 oxaliplatin intravenous

solution B/D PAR 5 oxaliplatin intravenous

solution reconstituted


Drug Tier Drug Name

B/D PAR 4 paclitaxel intravenous concentrate 100 mg/16.7ml, 150 mg/25ml, 30 mg/5ml

4 paclitaxel intravenous concentrate 300 mg/50ml

5 PANRETIN PAR 5 PERJETA PAR; QLL (28 per 28 days)

5 PIQRAY (200 MG DAILY DOSE)





B/D PAR 5 POLIVY PAR; LA; QLL (120 per 30 days)

5 POMALYST ORAL CAPSULE 1 MG


5 POMALYST ORAL CAPSULE 2 MG


5 POMALYST ORAL CAPSULE 3 MG, 4 MG

LA 5 PORTRAZZA B/D PAR; LA 5 POTELIGEO B/D PAR 5 PROLEUKIN PAR 5 PURIXAN PAR; LA; QLL (60 per 30 days)

5 REVLIMID ORAL CAPSULE 10 MG


5 REVLIMID ORAL CAPSULE 15 MG, 25 MG


5 REVLIMID ORAL CAPSULE 2.5 MG, 20 MG


5 REVLIMID ORAL CAPSULE 5 MG

B/D PAR; MO; LA 5 RITUXAN HYCELA B/D PAR; LA 5 RITUXAN

INTRAVENOUS SOLUTION

PAR 5 romidepsin PAR; LA; QLL (30 per 30 days)

5 ROZLYTREK ORAL CAPSULE 100 MG


5 ROZLYTREK ORAL CAPSULE 200 MG


5 RUBRACA ORAL TABLET 200 MG


5 RUBRACA ORAL TABLET 250 MG, 300 MG



Drug Tier Drug Name


5 RYDAPT

MO 4 SOLTAMOX PAR; QLL (30 per 30 days)

5 SPRYCEL


5 STIVARGA


5 SUTENT ORAL CAPSULE 12.5 MG


5 SUTENT ORAL CAPSULE 25 MG, 37.5 MG, 50 MG

PAR 5 SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG

PAR 5 SYNRIBO MO 4 TABLOID PAR; LA; QLL (120 per 30 days)

5 TAFINLAR


5 TAGRISSO ORAL TABLET 40 MG


5 TAGRISSO ORAL TABLET 80 MG


5 TALZENNA ORAL CAPSULE 0.25 MG


5 TALZENNA ORAL CAPSULE 1 MG

MO 2 tamoxifen citrate oral PAR; QLL (60 per 30 days)

5 TARGRETIN EXTERNAL


5 TASIGNA

B/D PAR 5 TAXOTERE INTRAVENOUS CONCENTRATE 20 MG/ ML, 80 MG/4ML


5 TECENTRIQ INTRAVENOUS SOLUTION 1200 MG/ 20ML


5 TECENTRIQ INTRAVENOUS SOLUTION 840 MG/ 14ML

PAR 5 temsirolimus


Drug Tier Drug Name


5 THALOMID ORAL CAPSULE 100 MG, 50 MG


5 THALOMID ORAL CAPSULE 150 MG, 200 MG

B/D PAR 4 thiotepa injection PAR; LA; QLL (60 per 30 days)

5 TIBSOVO

B/D PAR 4 TICE BCG B/D PAR 4 toposar intravenous solution

1 gm/50ml, 500 mg/25ml B/D PAR 3 toposar intravenous solution

100 mg/5ml B/D PAR 5 TOPOTECAN HCL


B/D PAR 5 topotecan hcl intravenous solution reconstituted

QLL (30 per 30 days)

5 toremifene citrate

PAR 5 TORISEL B/D PAR 5 TREANDA

INTRAVENOUS SOLUTION RECONSTITUTED


2 tretinoin external cream 0.025 %, 0.05 %


4 tretinoin external cream 0.1 %


2 tretinoin external gel 0.01 %, 0.025 %

MO 5 tretinoin oral B/D PAR 5 TRISENOX

INTRAVENOUS SOLUTION 12 MG/6ML


5 TURALIO


5 TYKERB

PAR; LA 5 VALCHLOR PAR 5 VECTIBIX

INTRAVENOUS SOLUTION 100 MG/ 5ML, 400 MG/20ML



Drug Tier Drug Name

PAR 5 VELCADE INJECTION PAR; LA; QLL (60 per 30 days)

3 VENCLEXTA ORAL TABLET 10 MG





PAR; LA; QLL (84 per 365 days); NE

5 VENCLEXTA STARTING PACK


5 VERZENIO

B/D PAR 4 vinblastine sulfate intravenous solution

B/D PAR 4 vincristine sulfate intravenous B/D PAR 4 vinorelbine tartrate PAR; LA; QLL (60 per 30 days)

5 VITRAKVI ORAL CAPSULE 100 MG


5 VITRAKVI ORAL CAPSULE 25 MG


5 VITRAKVI ORAL SOLUTION


5 VIZIMPRO ORAL TABLET 15 MG


5 VIZIMPRO ORAL TABLET 30 MG, 45 MG


5 VOTRIENT

B/D PAR 5 VYXEOS INTRAVENOUS SUSPENSION RECONSTITUTED 44- 100 MG


5 XALKORI


5 XOSPATA


5 XPOVIO (100 MG ONCE WEEKLY)






5 XPOVIO (80 MG TWICE WEEKLY)


5 XTANDI

PAR 5 YERVOY


Drug Tier Drug Name

B/D PAR 5 YONDELIS PAR; QLL (120 per 30 days)

5 YONSA

PAR; LA 5 ZALTRAP B/D PAR 4 ZANOSAR PAR; LA; QLL (90 per 30 days)

5 ZEJULA


5 ZELBORAF


5 ZOLINZA


5 ZYDELIG


5 ZYKADIA ORAL TABLET


5 ZYTIGA ORAL TABLET 500 MG Antiparasitics

MO 4 albendazole oral MO; QLL (180 per 30 days)

4 ALINIA ORAL SUSPENSION RECONSTITUTED


4 ALINIA ORAL TABLET

PAR; MO 5 atovaquone oral MO 4 atovaquone-proguanil hcl MO 2 chloroquine phosphate oral MO 4 COARTEM MO 4 DARAPRIM MO 3 hydroxychloroquine sulfate

oral MO 2 ivermectin oral MO 4 lindane external shampoo MO 4 malathion external MO 2 mefloquine hcl B/D PAR; MO 3 NEBUPENT MO 4 PENTAM B/D PAR; MO 3 pentamidine isethionate

inhalation MO 4 pentamidine isethionate

injection MO 3 permethrin external cream MO 3 primaquine phosphate oral

Antiparkinson Agents MO 2 amantadine hcl oral



Drug Tier Drug Name

PAR; LA 5 APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE

MO 4 benztropine mesylate injection PAR; MO 2 benztropine mesylate oral MO 4 bromocriptine mesylate oral

capsule MO 3 bromocriptine mesylate oral

tablet MO 4 carbidopa oral MO 4 carbidopa oral MO 2 carbidopa-levodopa er oral

tablet extended release 25- 100 mg, 50-200 mg

MO 2 carbidopa-levodopa oral tablet

MO 4 carbidopa-levodopa oral tablet dispersible

MO 4 entacapone MO; QLL (30 per 30 days)

4 NEUPRO

MO 2 pramipexole dihydrochloride MO 3 rasagiline mesylate oral MO 2 ropinirole hcl MO 4 ropinirole hcl er MO 3 selegiline hcl oral PAR; MO; QLL (180 per 30 days)

5 tolcapone

PAR; MO 4 trihexyphenidyl hcl oral solution

PAR; MO 2 trihexyphenidyl hcl oral tablet Antipsychotics


5 ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE


5 ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER


4 aripiprazole oral solution






Drug Tier Drug Name




4 aripiprazole oral tablet 20 mg, 30 mg







MO 4 CHLORPROMAZINE HCL INJECTION

MO 3 chlorpromazine hcl oral tablet 10 mg

MO 4 chlorpromazine hcl oral tablet 100 mg, 200 mg, 25 mg, 50 mg


3 clozapine oral tablet 100 mg








4 clozapine oral tablet dispersible 100 mg


4 clozapine oral tablet dispersible 12.5 mg








4 FANAPT ORAL TABLET 1 MG


4 FANAPT ORAL TABLET 10 MG, 12 MG









Drug Tier Drug Name



ST; MO; QLL (16 per 365 days); NE

4 FANAPT TITRATION PACK

MO 4 fluphenazine decanoate injection

MO 4 fluphenazine hcl injection MO 2 fluphenazine hcl oral

concentrate MO 4 fluphenazine hcl oral elixir MO 2 fluphenazine hcl oral tablet 1

mg, 2.5 mg MO 3 fluphenazine hcl oral tablet

10 mg, 5 mg MO; QLL (6 per 28 days)

4 GEODON INTRAMUSCULAR

4 haloperidol decanoate intramuscular solution 100 mg/ml 1 ml

MO 4 haloperidol decanoate intramuscular solution 100 mg/ml, 50 mg/ml

MO 4 haloperidol lactate injection MO 2 haloperidol lactate oral MO; CG 1 haloperidol oral tablet 0.5 mg MO 2 haloperidol oral tablet 1 mg,

10 mg, 2 mg, 5 mg MO 3 haloperidol oral tablet 20 mg MO; QLL (0.75 per 28 days)

5 INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 117 MG/0.75ML


5 INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 156 MG/ML

MO; QLL (1.5 per 28 days)



Drug Tier Drug Name





MO; QLL (0.875 per 90 days); NE

5 INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 273 MG/0.875ML








4 LATUDA ORAL TABLET 120 MG, 60 MG


4 LATUDA ORAL TABLET 20 MG





MO 2 loxapine succinate oral MO 4 molindone hcl PAR; LA; QLL (30 per 30 days)

5 NUPLAZID ORAL CAPSULE


5 NUPLAZID ORAL TABLET 10 MG


4 olanzapine intramuscular



Drug Tier Drug Name


3 olanzapine oral tablet 10 mg




3 olanzapine oral tablet 2.5 mg








4 olanzapine oral tablet dispersible 10 mg








4 paliperidone er oral tablet extended release 24 hour 1.5 mg


4 paliperidone er oral tablet extended release 24 hour 3 mg





MO 3 perphenazine oral MO 3 pimozide MO 4 prochlorperazine edisylate

injection solution 10 mg/2ml, 50 mg/10ml

MO 2 prochlorperazine maleate oral PAR; MO; QLL (150 per 30 days)







Drug Tier Drug Name


















5 REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG


5 REXULTI ORAL TABLET 3 MG, 4 MG


4 RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 12.5 MG, 25 MG




3 risperidone oral solution


2 risperidone oral tablet 0.25 mg




2 risperidone oral tablet 1 mg







Drug Tier Drug Name




4 risperidone oral tablet dispersible 0.25 mg




4 risperidone oral tablet dispersible 1 mg








4 SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG


4 SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 2.5 MG



ST; MO 2 thioridazine hcl oral MO 4 thiothixene oral MO 2 trifluoperazine hcl oral tablet

1 mg, 2 mg, 5 mg MO 3 trifluoperazine hcl oral tablet

10 mg MO; QLL (600 per 30 days)

4 VERSACLOZ


4 VRAYLAR ORAL CAPSULE


4 VRAYLAR ORAL CAPSULE THERAPY PACK


4 ziprasidone hcl oral capsule 20 mg




4 ziprasidone hcl oral capsule 60 mg, 80 mg


4 ZYPREXA RELPREVV

Antispasticity Agents


Drug Tier Drug Name

MO 2 baclofen oral MO 3 dantrolene sodium oral

capsule 100 mg MO 2 dantrolene sodium oral

capsule 25 mg, 50 mg MO 2 tizanidine hcl oral tablet

Antivirals QLL (960 per 30 days)

4 abacavir sulfate oral solution


4 abacavir sulfate oral tablet


4 abacavir sulfate-lamivudine


5 abacavir-lamivudine- zidovudine


4 acyclovir external ointment

MO 2 acyclovir oral capsule MO 4 acyclovir oral suspension MO 2 acyclovir oral tablet B/D PAR; MO 4 acyclovir sodium intravenous

solution PAR 4 adefovir dipivoxil MO 2 amantadine hcl oral QLL (120 per 30 days)

5 APTIVUS ORAL CAPSULE


5 APTIVUS ORAL SOLUTION


5 atazanavir sulfate oral capsule 150 mg, 200 mg


5 atazanavir sulfate oral capsule 300 mg


5 ATRIPLA

PAR 5 BARACLUDE ORAL SOLUTION


5 BIKTARVY


5 CIMDUO


5 COMPLERA


3 CRIXIVAN ORAL CAPSULE 200 MG



Drug Tier Drug Name


4 CRIXIVAN ORAL CAPSULE 400 MG


5 DELSTRIGO


5 DESCOVY


4 didanosine oral capsule delayed release 200 mg


4 didanosine oral capsule delayed release 250 mg, 400 mg


5 DOVATO


5 EDURANT


4 efavirenz oral capsule 200 mg


4 efavirenz oral capsule 50 mg


5 efavirenz oral tablet


4 EMTRIVA ORAL CAPSULE


4 EMTRIVA ORAL SOLUTION

PAR 4 entecavir PAR; QLL (30 per 30 days)

5 EPCLUSA


5 EPCLUSA

3 EPIVIR HBV ORAL SOLUTION


5 EVOTAZ


3 famciclovir oral tablet 125 mg, 250 mg


3 famciclovir oral tablet 500 mg


5 fosamprenavir calcium


5 FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED


Drug Tier Drug Name

B/D PAR 4 ganciclovir sodium intravenous solution reconstituted


5 GENVOYA


5 HARVONI


5 HARVONI ORAL TABLET 90-400 MG


5 INTELENCE ORAL TABLET 100 MG





B/D PAR 5 INTRON A INJECTION SOLUTION

B/D PAR 5 INTRON A INJECTION SOLUTION 6000000 UNIT/ML

B/D PAR 4 INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT

B/D PAR 4 INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT

B/D PAR 5 INTRON A INJECTION SOLUTION RECONSTITUTED 50000000 UNIT


4 INVIRASE ORAL TABLET


5 ISENTRESS HD


4 ISENTRESS ORAL PACKET


5 ISENTRESS ORAL TABLET


5 ISENTRESS ORAL TABLET CHEWABLE 100 MG



Drug Tier Drug Name


3 ISENTRESS ORAL TABLET CHEWABLE 25 MG


5 JULUCA


4 KALETRA ORAL TABLET 100-25 MG


5 KALETRA ORAL TABLET 200-50 MG


4 lamivudine oral solution


4 lamivudine oral solution

3 lamivudine oral tablet 100 mg











4 lamivudine-zidovudine


4 LEXIVA ORAL SUSPENSION


4 lopinavir-ritonavir


4 nevirapine er oral tablet extended release 24 hour 100 mg


4 nevirapine er oral tablet extended release 24 hour 400 mg


4 nevirapine oral suspension


3 nevirapine oral tablet


4 NORVIR ORAL PACKET


4 NORVIR ORAL SOLUTION


Drug Tier Drug Name


5 ODEFSEY

MO 3 oseltamivir phosphate oral 5 PEGASYS PROCLICK

SUBCUTANEOUS SOLUTION 180 MCG/ 0.5ML

5 PEGASYS SUBCUTANEOUS SOLUTION

5 PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5ML


5 PIFELTRO


5 PREZCOBIX


5 PREZISTA ORAL SUSPENSION


4 PREZISTA ORAL TABLET 150 MG


5 PREZISTA ORAL TABLET 600 MG, 800 MG


4 PREZISTA ORAL TABLET 75 MG


3 RELENZA DISKHALER


4 RESCRIPTOR ORAL TABLET 200 MG

4 RETROVIR INTRAVENOUS


4 REYATAZ ORAL PACKET

PAR 5 ribavirin inhalation MO 3 ribavirin oral capsule MO 3 ribavirin oral capsule

4 ribavirin oral tablet 200 mg 4 ribavirin oral tablet 200 mg

MO 3 rimantadine hcl QLL (360 per 30 days)

3 ritonavir


5 SELZENTRY ORAL SOLUTION



Drug Tier Drug Name


5 SELZENTRY ORAL TABLET 150 MG, 300 MG


3 SELZENTRY ORAL TABLET 25 MG


3 SELZENTRY ORAL TABLET 75 MG


2 stavudine oral capsule 15 mg, 20 mg


3 stavudine oral capsule 30 mg, 40 mg


5 STRIBILD

PAR 5 SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG


5 SYMFI


5 SYMFI LO


5 SYMTUZA

QLL (30 per 30 days); NE

5 TEMIXYS


4 tenofovir disoproxil fumarate


4 tenofovir disoproxil fumarate


4 TIVICAY ORAL TABLET 10 MG


5 TIVICAY ORAL TABLET 25 MG, 50 MG

MO 3 trifluridine ophthalmic QLL (30 per 30 days)

5 TRIUMEQ

PAR; LA; QLL (10.64 per 28 days)

5 TROGARZO


5 TRUVADA


3 TYBOST


2 valacyclovir hcl oral tablet 1 gm


2 valacyclovir hcl oral tablet 500 mg


Drug Tier Drug Name

5 valganciclovir hcl oral tablet PAR; QLL (30 per 30 days); NE

5 VEMLIDY


4 VIDEX EC ORAL CAPSULE DELAYED RELEASE 125 MG


4 VIDEX ORAL SOLUTION RECONSTITUTED 2 GM


5 VIRACEPT ORAL TABLET 250 MG


5 VIRACEPT ORAL TABLET 625 MG

PAR; MO 5 VIRAZOLE QLL (240 per 30 days)

5 VIREAD ORAL POWDER


5 VIREAD ORAL POWDER


5 VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG


5 VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG


5 VOSEVI

MO 3 XOFLUZA QLL (180 per 30 days)

3 zidovudine oral capsule


3 zidovudine oral syrup


2 zidovudine oral tablet

MO 4 ZIRGAN Anxiolytics


2 alprazolam oral tablet

MO; CG 1 buspirone hcl oral tablet 10 mg

MO 2 buspirone hcl oral tablet 15 mg, 5 mg, 7.5 mg

MO 3 buspirone hcl oral tablet 30 mg


2 clonazepam oral tablet 0.5 mg



Drug Tier Drug Name















MO 3 clorazepate dipotassium MO 4 DIASTAT ACUDIAL MO 4 DIASTAT PEDIATRIC MO; QLL (240 per 30 days)










PAR; MO 3 doxepin hcl oral capsule PAR; MO 4 doxepin hcl oral concentrate MO; QLL (180 per 30 days)









4 escitalopram oxalate oral solution








Drug Tier Drug Name

PAR; MO 4 hydroxyzine hcl oral syrup PAR; MO 4 hydroxyzine hcl oral tablet MO; QLL (150 per 30 days)

2 lorazepam oral concentrate 2 mg/ml


2 lorazepam oral tablet 0.5 mg, 1 mg


2 lorazepam oral tablet 2 mg

4 NAYZILAM MO; QLL (120 per 30 days)

2 oxazepam










4 PAXIL ORAL SUSPENSION


4 sertraline hcl oral concentrate










2 venlafaxine hcl er oral capsule extended release 24 hour 37.5 mg








2 venlafaxine hcl oral tablet 37.5 mg



Drug Tier Drug Name




2 venlafaxine hcl oral tablet 75 mg Bipolar Agents

MO 4 carbamazepine er oral capsule extended release 12 hour

MO 4 carbamazepine er oral tablet extended release 12 hour 100 mg

MO 4 carbamazepine oral MO 4 divalproex sodium er oral

tablet extended release 24 hour



MO 4 epitol MO; QLL (480 per 30 days)







4 GEODON INTRAMUSCULAR

MO 2 lamotrigine oral tablet MO 3 lamotrigine oral tablet

chewable MO 4 LITHIUM MO 2 lithium carbonate er MO; CG 1 lithium carbonate oral MO; QLL (60 per 30 days)

4 olanzapine intramuscular




Drug Tier Drug Name











































Drug Tier Drug Name






3 risperidone oral solution




























4 SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 2.5 MG



MO 4 valproic acid oral capsule


Drug Tier Drug Name

MO 2 valproic acid oral solution PAR; MO; QLL (30 per 30 days)

4 VRAYLAR ORAL CAPSULE


4 VRAYLAR ORAL CAPSULE THERAPY PACK






4 ziprasidone hcl oral capsule 60 mg, 80 mg


4 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG Blood Glucose Regulators

MO 3 1ST TIER UNIFINE PENTIPS 29G X 12MM


2 acarbose oral tablet 100 mg






3 ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 1 ML


3 BYDUREON BCISE


3 BYDUREON SUBCUTANEOUS PEN- INJECTOR


3 BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN- INJECTOR


3 BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN- INJECTOR

MO 3 CAREONE UNIFINE PENTIPS PLUS 29G X 12MM



Drug Tier Drug Name

MO 3 CLEVER CHOICE COMFORT EZ 29G X 12MM

MO 4 colesevelam hcl MO; QLL (200 per 30 days)

3 COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 1 ML


1 CVS GAUZE STERILE PAD 2"X2"


4 CYCLOSET

MO 3 DROPLET PEN NEEDLES 30G X 8 MM

MO 3 EASY TOUCH PEN NEEDLES 29G X 12MM

MO 3 EASY TOUCH SAFETY PEN NEEDLES 30G X 8 MM


3 EXEL COMFORT POINT PEN NEEDLE 29G X 12MM


1 glimepiride oral tablet 1 mg






1 glipizide er oral tablet extended release 24 hour 10 mg


1 glipizide er oral tablet extended release 24 hour 2.5 mg


1 glipizide er oral tablet extended release 24 hour 5 mg


1 glipizide oral tablet 10 mg


1 glipizide oral tablet 5 mg


1 glipizide xl oral tablet extended release 24 hour 10 mg


1 glipizide xl oral tablet extended release 24 hour 2.5 mg


Drug Tier Drug Name


1 glipizide xl oral tablet extended release 24 hour 5 mg


2 glipizide-metformin hcl oral tablet 2.5-250 mg


2 glipizide-metformin hcl oral tablet 2.5-500 mg, 5-500 mg

3 GLOBAL EASY GLIDE INSULIN SYR 31G X 15/ 64" 1 ML

MO 3 GLUCAGEN HYPOKIT MO 4 GLUCAGON

EMERGENCY INJECTION KIT


4 glyburide oral tablet 1.25 mg


4 glyburide oral tablet 2.5 mg


4 glyburide oral tablet 5 mg


4 glyburide-metformin oral tablet 1.25-250 mg


4 glyburide-metformin oral tablet 2.5-500 mg, 5-500 mg

MO 3 H-E-B INCONTROL PEN NEEDLES 29G X 12MM

MO 3 HUMALOG JUNIOR KWIKPEN

MO 3 HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 200 UNIT/ ML

MO 3 HUMALOG MIX 50/50 MO 3 HUMALOG MIX 50/50

KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR

MO 3 HUMALOG MIX 75/25 MO 3 HUMALOG MIX 75/25




Drug Tier Drug Name

MO 3 HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE

MO 3 HUMULIN 70/30 MO 3 HUMULIN 70/30


MO 3 HUMULIN N MO 3 HUMULIN N KWIKPEN

SUBCUTANEOUS SUSPENSION PEN- INJECTOR

MO 3 HUMULIN R MO 3 INSULIN LISPRO (1

UNIT DIAL) MO 3 INSULIN LISPRO

SUBCUTANEOUS SOLUTION

MO 3 INSUPEN PEN NEEDLES 29G X 12MM

MO 3 INSUPEN ULTRAFIN 29G X 12MM


3 JANUMET


3 JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100- 1000 MG


3 JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 50- 1000 MG, 50-500 MG


3 JANUVIA ORAL TABLET 100 MG






3 JARDIANCE


3 JENTADUETO


3 JENTADUETO


Drug Tier Drug Name


3 JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5- 1000 MG


3 JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5- 1000 MG


3 JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5- 1000 MG


3 JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5- 1000 MG

PAR; LA 5 KORLYM MO 3 KROGER PEN NEEDLES

31G X 8 MM MO 3 LANTUS MO 3 LANTUS SOLOSTAR

SUBCUTANEOUS SOLUTION PEN- INJECTOR

MO 3 MARATHON MEDICAL PENTIPS 29G X 12MM


1 metformin hcl er oral tablet extended release 24 hour 500 mg


1 metformin hcl er oral tablet extended release 24 hour 750 mg


1 metformin hcl oral tablet 1000 mg






2 nateglinide oral tablet 120 mg


2 nateglinide oral tablet 60 mg

MO 3 PC UNIFINE PENTIPS 29G X 12MM


2 pioglitazone hcl oral tablet 15 mg



Drug Tier Drug Name






3 PREFERRED PLUS INSULIN SYRINGE 28G X 1/2" 0.5 ML

MO 4 PROGLYCEM MO; QLL (200 per 30 days)

3 RELI-ON INSULIN SYRINGE 29G 0.3 ML

MO 3 RELION PEN NEEDLES 29G X 12MM


2 repaglinide oral tablet 0.5 mg


3 repaglinide oral tablet 1 mg


3 repaglinide oral tablet 2 mg


3 SYNJARDY


3 SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10- 1000 MG, 12.5-1000 MG, 5-1000 MG


3 SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 25- 1000 MG

MO 3 TECHLITE PEN NEEDLES 29G X 12MM


2 tolbutamide

MO 3 TOUJEO MAX SOLOSTAR

MO 3 TOUJEO SOLOSTAR MO; QLL (30 per 30 days)

3 TRADJENTA


4 TRULICITY

MO 3 UNIFINE PENTIPS 30G X 5 MM


3 VICTOZA SUBCUTANEOUS SOLUTION PEN- INJECTOR


Drug Tier Drug Name

Blood Products/ Modifiers/ Volume Expanders MO 3 anagrelide hcl ST; MO; QLL (60 per 30 days)

3 aspirin-dipyridamole er


4 BRILINTA

MO 2 cilostazol MO; QLL (1 per 30 days)

2 clopidogrel bisulfate oral tablet 300 mg


2 clopidogrel bisulfate oral tablet 75 mg

MO 4 COUMADIN ORAL MO; QLL (60 per 30 days)

3 ELIQUIS


3 ELIQUIS STARTER PACK


4 enoxaparin sodium injection


4 enoxaparin sodium subcutaneous solution 100 mg/ml, 150 mg/ml


4 enoxaparin sodium subcutaneous solution 120 mg/0.8ml, 80 mg/0.8ml


4 enoxaparin sodium subcutaneous solution 30 mg/ 0.3ml






5 fondaparinux sodium subcutaneous solution 10 mg/ 0.8ml


4 fondaparinux sodium subcutaneous solution 2.5 mg/ 0.5ml


5 fondaparinux sodium subcutaneous solution 5 mg/ 0.4ml


5 fondaparinux sodium subcutaneous solution 7.5 mg/ 0.6ml



Drug Tier Drug Name

PAR; QLL (1.2 per 28 days)

5 FULPHILA

B/D PAR; MO 4 HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 12500-0.45 UT/250ML-%, 25000-0.45 UT/500ML-%

MO 4 HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 25000-0.45 UT/250ML-%

MO 4 HEPARIN SOD (PORCINE) IN D5W INTRAVENOUS SOLUTION 100 UNIT/ ML, 25000-5 UT/500ML- %

MO 4 heparin sod (porcine) in d5w intravenous solution 40-5 unit/ml-%

B/D PAR; MO 3 heparin sodium (porcine) injection solution 1000 unit/ ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml

MO; CG 1 jantoven MO; QLL (60 per 30 days)

4 PRADAXA


3 prasugrel hcl

PAR 4 PROCRIT INJECTION SOLUTION 10000 UNIT/ ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ ML

PAR 5 PROCRIT INJECTION SOLUTION 20000 UNIT/ ML, 40000 UNIT/ML


5 PROMACTA ORAL PACKET


5 PROMACTA ORAL TABLET 12.5 MG, 25 MG, 75 MG


5 PROMACTA ORAL TABLET 50 MG

3 tranexamic acid intravenous solution 1000 mg/10ml


Drug Tier Drug Name

MO 3 tranexamic acid oral MO; CG 1 warfarin sodium oral MO; QLL (30 per 30 days)

3 XARELTO ORAL TABLET 10 MG, 20 MG


3 XARELTO ORAL TABLET 15 MG


3 XARELTO ORAL TABLET 2.5 MG

MO; NE 3 XARELTO STARTER PACK

PAR 5 ZARXIO Cardiovascular Agents

MO 2 acebutolol hcl oral MO 4 acetazolamide er MO 3 acetazolamide oral MO 4 acetazolamide sodium MO 2 afeditab cr oral tablet

extended release 24 hour 30 mg

2 afeditab cr oral tablet extended release 24 hour 60 mg

MO 4 aliskiren fumarate MO 2 amiloride hcl oral MO 2 amiloride-hydrochlorothiazide B/D PAR; MO 4 amiodarone hcl intravenous MO 2 amiodarone hcl oral tablet

100 mg, 200 mg MO 3 amiodarone hcl oral tablet

400 mg MO 2 amlodipine besy-benazepril

hcl MO; CG 1 amlodipine besylate oral MO 2 amlodipine besylate-valsartan

oral tablet 10-160 mg, 5-160 mg, 5-320 mg

MO 3 amlodipine besylate-valsartan oral tablet 10-320 mg

MO 3 amlodipine-olmesartan MO 3 amlodipine-valsartan-hctz MO; CG 1 atenolol oral MO; CG 1 atenolol-chlorthalidone MO; CG 1 atorvastatin calcium oral MO; CG 1 benazepril hcl oral



Drug Tier Drug Name

MO 2 benazepril- hydrochlorothiazide

MO 2 betaxolol hcl oral MO 2 bisoprolol fumarate MO; CG 1 bisoprolol-hydrochlorothiazide MO 4 bumetanide injection MO 2 bumetanide oral MO 4 BYSTOLIC MO 3 candesartan cilexetil MO 3 candesartan cilexetil-hctz MO 2 captopril oral MO 2 captopril-hydrochlorothiazide MO 2 cartia xt MO; CG 1 carvedilol MO 2 chlorothiazide oral MO 4 chlorothiazide sodium MO 2 chlorthalidone oral tablet 25

mg, 50 mg MO 4 cholestyramine light MO 4 cholestyramine oral MO; QLL (4 per 28 days)

4 clonidine

MO; CG 1 clonidine hcl oral MO 4 colesevelam hcl MO 3 colestipol hcl oral granules MO 2 colestipol hcl oral packet MO 2 colestipol hcl oral tablet PAR; MO; QLL (560 per 28 days)

4 CORLANOR ORAL SOLUTION


4 CORLANOR ORAL TABLET

MO 5 DEMSER MO 4 digitek oral tablet 125 mcg PAR; MO 4 digitek oral tablet 250 mcg MO 4 digox oral tablet 125 mcg PAR; MO 4 digox oral tablet 250 mcg PAR; MO 4 digoxin injection MO 4 digoxin oral solution MO 4 digoxin oral tablet 125 mcg PAR; MO 4 digoxin oral tablet 250 mcg MO 2 dilt-xr

2 diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg


Drug Tier Drug Name

MO 2 diltiazem hcl er beads oral capsule extended release 24 hour 360 mg

MO 4 diltiazem hcl er beads oral capsule extended release 24 hour 420 mg

MO 2 diltiazem hcl er coated beads oral capsule extended release 24 hour

MO 4 diltiazem hcl er oral capsule extended release 12 hour

MO 2 diltiazem hcl er oral capsule extended release 24 hour 120 mg

MO 4 diltiazem hcl intravenous solution

MO 4 DILTIAZEM HCL INTRAVENOUS SOLUTION RECONSTITUTED

MO 2 diltiazem hcl oral PAR; MO 3 disopyramide phosphate oral

4 dofetilide MO 2 doxazosin mesylate oral MO; CG 1 enalapril maleate oral MO; CG 1 enalapril-hydrochlorothiazide PAR; MO 3 ENTRESTO MO 4 eplerenone MO 2 eprosartan mesylate MO 4 ezetimibe MO 2 felodipine er MO 3 fenofibrate micronized oral

capsule 130 mg MO 2 fenofibrate micronized oral

capsule 134 mg, 200 mg, 43 mg, 67 mg

MO 2 fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg

MO 3 fenofibric acid oral capsule delayed release 135 mg

MO 2 fenofibric acid oral capsule delayed release 45 mg

MO 4 fenofibric acid oral tablet MO 3 flecainide acetate MO 2 fosinopril sodium



Drug Tier Drug Name

MO 2 fosinopril sodium-hctz MO 4 furosemide injection solution

10 mg/ml 4 furosemide injection solution

10 mg/ml (4ml syringe) MO 4 furosemide oral solution 10

mg/ml, 8 mg/ml MO; CG 1 furosemide oral tablet MO 2 gemfibrozil oral PAR; MO 4 guanfacine hcl oral MO 4 hydralazine hcl injection MO 2 hydralazine hcl oral MO; CG 1 hydrochlorothiazide oral MO 2 indapamide oral MO 2 irbesartan MO 2 irbesartan-

hydrochlorothiazide MO 2 irbesartan-

hydrochlorothiazide MO 3 isosorbide dinitrate er MO 3 isosorbide dinitrate oral tablet

10 mg, 20 mg, 30 mg, 5 mg MO 2 isosorbide mononitrate MO 2 isosorbide mononitrate er MO 2 isradipine MO 4 labetalol hcl intravenous

solution MO 2 labetalol hcl oral MO 4 LANOXIN ORAL

TABLET 125 MCG, 62.5 MCG

PAR; MO 4 LANOXIN ORAL TABLET 250 MCG

MO; CG 1 lisinopril oral MO; CG 1 lisinopril-hydrochlorothiazide MO; CG 1 losartan potassium MO; CG 1 losartan potassium-hctz MO; CG 1 lovastatin MO 4 methazolamide oral PAR; MO 2 methyldopa oral tablet 250

mg PAR; MO 4 methyldopa oral tablet 500

mg MO 3 metolazone MO 2 metoprolol succinate er


Drug Tier Drug Name

MO 4 metoprolol tartrate intravenous solution 5 mg/ 5ml

MO 4 metoprolol tartrate intravenous solution cartridge

MO; CG 1 metoprolol tartrate oral MO 2 metoprolol-

hydrochlorothiazide MO 3 mexiletine hcl oral MO 4 midodrine hcl oral tablet 10

mg MO 3 midodrine hcl oral tablet 2.5

mg, 5 mg MO 2 minitran MO 2 minoxidil oral MO 2 moexipril hcl MO 3 nadolol oral tablet 20 mg, 40

mg, 80 mg MO 3 niacin (antihyperlipidemic) MO 3 niacin er (antihyperlipidemic) MO 3 niacor MO 4 nicardipine hcl intravenous MO 2 nicardipine hcl oral MO 2 nifedical xl oral tablet

extended release 24 hour 60 mg

MO 2 nifedipine er MO 2 nifedipine er osmotic release MO 3 NITRO-BID B/D PAR; MO 4 NITROGLYCERIN

INTRAVENOUS MO 3 nitroglycerin sublingual tablet

sublingual 0.3 mg, 0.6 mg MO 2 nitroglycerin sublingual tablet

sublingual 0.4 mg MO 2 nitroglycerin transdermal

patch 24 hour PAR; LA; QLL (540 per 30 days)

5 NORTHERA ORAL CAPSULE 100 MG





MO 4 olmesartan medoxomil oral MO 4 olmesartan medoxomil-hctz



Drug Tier Drug Name

MO 4 olmesartan medoxomil-hctz MO 3 olmesartan-amlodipine-hctz MO 3 omega-3-acid ethyl esters MO 4 pacerone oral tablet 100 mg MO 2 pacerone oral tablet 200 mg MO 3 pacerone oral tablet 400 mg MO 2 pentoxifylline er MO 2 perindopril erbumine MO 4 pindolol PAR; QLL (2 per 28 days)

4 PRALUENT SUBCUTANEOUS SOLUTION AUTO- INJECTOR

MO; CG 1 pravastatin sodium MO 2 prazosin hcl oral MO 4 prevalite MO 4 procainamide hcl injection MO 3 propafenone hcl MO 4 propranolol hcl er MO 4 propranolol hcl intravenous MO 2 propranolol hcl oral solution

20 mg/5ml MO 4 propranolol hcl oral solution

40 mg/5ml MO 2 propranolol hcl oral tablet MO 2 propranolol-hctz MO 2 quinapril hcl MO 2 quinapril-hydrochlorothiazide MO 2 quinidine sulfate oral MO; CG 1 ramipril ST; MO 4 RANEXA ST; MO 4 ranolazine er MO; QLL (30 per 30 days)

4 RECTIV


3 REPATHA


3 REPATHA PUSHTRONEX SYSTEM


3 REPATHA SURECLICK

MO 3 rosuvastatin calcium MO; CG 1 simvastatin oral MO; CG 1 sorine oral tablet 120 mg, 80

mg


Drug Tier Drug Name

MO 2 sorine oral tablet 160 mg, 240 mg

MO 2 sotalol hcl (af) oral tablet 120 mg

MO 2 sotalol hcl (af) oral tablet 160 mg

MO; CG 1 sotalol hcl (af) oral tablet 80 mg

MO; CG 1 sotalol hcl oral tablet 120 mg, 80 mg

MO 2 sotalol hcl oral tablet 160 mg, 240 mg

MO 2 sotalol hydrochloride oral tablet 120 mg, 160 mg

MO; CG 1 sotalol hydrochloride oral tablet 80 mg

MO 2 spironolactone oral tablet 100 mg, 50 mg

MO; CG 1 spironolactone oral tablet 25 mg

MO 2 spironolactone-hctz MO 2 taztia xt MO 3 telmisartan MO 2 telmisartan-amlodipine MO; CG 1 terazosin hcl oral MO 2 tiadylt er MO 4 timolol maleate oral MO; CG 1 torsemide oral tablet 10 mg MO 2 torsemide oral tablet 100 mg,

20 mg, 5 mg MO 2 trandolapril MO; CG 1 triamterene-hctz oral capsule

37.5-25 mg MO; CG 1 triamterene-hctz oral tablet MO 2 valsartan MO 2 valsartan-hydrochlorothiazide MO 4 VASCEPA MO 4 verapamil hcl er oral capsule

extended release 24 hour MO 2 verapamil hcl er oral tablet

extended release MO 4 verapamil hcl intravenous MO; CG 1 verapamil hcl oral tablet 120

mg, 80 mg



Drug Tier Drug Name

MO 2 verapamil hcl oral tablet 40 mg Central Nervous System Agents

2 acetylcysteine intravenous PAR; MO; QLL (30 per 30 days)

4 amphetamine-dextroamphet er


3 amphetamine- dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg


3 amphetamine- dextroamphetamine oral tablet 30 mg


4 atomoxetine hcl oral capsule 10 mg, 18 mg, 25 mg, 40 mg


4 atomoxetine hcl oral capsule 100 mg, 60 mg, 80 mg


5 BETASERON SUBCUTANEOUS KIT

MO 4 clonidine hcl er PAR; QLL (60 per 30 days)

5 dalfampridine er


4 dextroamphetamine sulfate oral tablet 10 mg


4 dextroamphetamine sulfate oral tablet 5 mg


3 diazepam intensol









MO 5 fomepizole intravenous solution 1.5 gm/1.5ml


5 glatiramer acetate subcutaneous solution prefilled syringe 20 mg/ml


5 glatiramer acetate subcutaneous solution prefilled syringe 40 mg/ml


Drug Tier Drug Name


5 glatopa subcutaneous solution prefilled syringe 20 mg/ml


5 glatopa subcutaneous solution prefilled syringe 40 mg/ml


3 guanfacine hcl er

PAR; MO 4 hydroxyzine hcl intramuscular MO; QLL (150 per 30 days)

2 lorazepam intensol


3 methylphenidate hcl oral tablet


3 NUEDEXTA

4 riluzole MO; QLL (60 per 30 days)

3 SAVELLA ORAL TABLET 100 MG


3 SAVELLA ORAL TABLET 12.5 MG






3 SAVELLA TITRATION PACK

PAR; LA 5 TECFIDERA PAR; QLL (240 per 30 days)

5 tetrabenazine oral tablet 12.5 mg


5 tetrabenazine oral tablet 25 mg

PAR; LA 5 TYSABRI MO 4 VECAMYL MO; QLL (180 per 30 days)

4 zenzedi oral tablet 10 mg


4 zenzedi oral tablet 5 mg

PAR; MO 5 ZULRESSO Dental And Oral Agents

MO; CG 1 chlorhexidine gluconate mouth/throat

MO 2 clotrimazole mouth/throat troche

MO 2 denta 5000 plus MO 2 dentagel MO 4 doxycycline hyclate oral

capsule



Drug Tier Drug Name

MO 4 doxycycline hyclate oral tablet 100 mg, 150 mg, 20 mg, 75 mg

MO 3 doxycycline monohydrate oral tablet 150 mg

MO 4 doxycycline monohydrate oral tablet 50 mg, 75 mg

MO 2 minocycline hcl oral capsule MO 3 minocycline hcl oral tablet MO 2 mondoxyne nl oral capsule

100 mg MO 3 oralone MO; CG 1 paroex MO; CG 1 periogard MO 4 pilocarpine hcl oral MO 2 sf MO 2 sf 5000 plus MO 2 sodium fluoride 5000 plus MO 2 sodium fluoride dental gel 1.1

% MO 3 triamcinolone acetonide

mouth/throat Dermatological Agents

MO 4 acitretin oral capsule 10 mg, 25 mg

MO 5 acitretin oral capsule 17.5 mg MO 4 adapalene external gel 0.1 % MO 2 ammonium lactate external MO 4 amnesteem PAR; MO; QLL (45 per 30 days)

2 avita

MO 4 benzoyl peroxide-erythromycin MO 2 betamethasone dipropionate

external lotion MO; QLL (120 per 30 days)

4 calcipotriene external cream


3 calcipotriene external ointment


4 calcipotriene external solution


4 calcitrene

MO 4 calcitriol external MO 3 ciclodan external solution


Drug Tier Drug Name

MO 4 claravis oral capsule 10 mg, 20 mg, 40 mg

MO 2 clindacin etz external swab MO 3 clindamycin phos-benzoyl

perox external gel 1-5 %, 1.2- 5 %

MO 2 clotrimazole-betamethasone external cream

MO 3 clotrimazole-betamethasone external lotion


5 COSENTYX


5 COSENTYX (300 MG DOSE)





MO 4 doxycycline hyclate oral capsule 50 mg

MO 2 doxycycline monohydrate oral capsule 100 mg, 50 mg

MO 4 doxycycline monohydrate oral tablet 100 mg, 50 mg


2 fluocinonide external cream 0.05 %

MO 3 fluorouracil external cream 5 %

MO 3 fluorouracil external solution MO 2 fluticasone propionate

external cream MO 2 fluticasone propionate

external ointment MO 4 hydrocortisone butyr lipo base MO 3 imiquimod external MO 4 isotretinoin oral capsule 10

mg, 20 mg, 40 mg 5 methoxsalen rapid

MO 2 mondoxyne nl oral capsule 100 mg

MO 4 myorisan oral capsule 10 mg, 20 mg, 40 mg

MO 3 neuac external gel MO 3 nystatin-triamcinolone MO 4 PICATO



Drug Tier Drug Name


4 pimecrolimus

MO 3 podofilox external MO 2 prednicarbate external cream MO 4 rosadan external cream MO 2 rosadan external gel MO; QLL (30 per 30 days); NE

4 SANTYL

MO 2 selenium sulfide external lotion


5 STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 45 MG/0.5ML

PAR; MO 4 tazarotene external PAR; MO 4 TAZORAC EXTERNAL

CREAM 0.05 % PAR; MO 4 TAZORAC EXTERNAL

GEL PAR; MO; QLL (45 per 30 days)

2 tretinoin external cream 0.025 %, 0.05 %


4 tretinoin external cream 0.1 %


2 tretinoin external gel 0.01 %, 0.025 %

MO 2 triderm external cream 0.5 % PAR; LA 5 VALCHLOR MO 4 zenatane oral capsule 10 mg,

20 mg, 40 mg Electrolytes/Minerals/Metals/Vitamins

B/D PAR; MO 4 AMINOSYN II INTRAVENOUS SOLUTION 10 %, 15 %

B/D PAR; MO 4 AMINOSYN-PF MO 4 calcitriol intravenous solution

1 mcg/ml PAR; LA 5 CARBAGLU PAR; LA 5 CEREZYME

INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT

B/D PAR; MO 4 CLINIMIX E/DEXTROSE (2.75/5)


Drug Tier Drug Name



B/D PAR; MO 4 CLINIMIX E/DEXTROSE (5/15)

B/D PAR; MO 4 CLINIMIX E/DEXTROSE (5/20)

B/D PAR; MO 4 CLINIMIX/DEXTROSE (4.25/10)



B/D PAR; MO 4 CLINIMIX/DEXTROSE (5/15)



5 clovique PAR 5 deferasirox oral tablet soluble MO 5 DEPEN TITRATABS MO 4 dextrose in lactated ringers MO 4 dextrose intravenous solution

10 %, 5 % MO 4 dextrose intravenous solution

250 mg/ml, 30 %, 70 % MO 4 DEXTROSE

INTRAVENOUS SOLUTION 40 %

4 dextrose intravenous solution 50 %

MO 4 DEXTROSE-NACL INTRAVENOUS SOLUTION 10-0.2 %

MO 4 dextrose-nacl intravenous solution 10-0.45 %, 2.5-0.45 %, 5-0.2 %, 5-0.225 %, 5- 0.33 %, 5-0.45 %, 5-0.9 %

B/D PAR; MO 4 doxercalciferol intravenous B/D PAR; MO 4 doxercalciferol oral capsule

0.5 mcg MO 2 effer-k oral tablet effervescent

25 meq



Drug Tier Drug Name

MO 2 elite-ob MO 2 fluoritab oral tablet chewable

1.1 (0.5 f) mg 4 fluoritab oral tablet chewable

2.2 (1 f) mg B/D PAR; MO 4 FREAMINE III

INTRAVENOUS SOLUTION 10 %

B/D PAR; MO 4 hepatamine B/D PAR; MO 4 intralipid intravenous

emulsion 20 % B/D PAR; MO 4 INTRALIPID

INTRAVENOUS EMULSION 30 %

MO 4 IONOSOL-MB IN D5W MO 4 ISOLYTE-P IN D5W MO 4 ISOLYTE-S MO 4 ISOLYTE-S PH 7.4 MO 4 K-TAB ORAL TABLET

EXTENDED RELEASE 8 MEQ

MO 4 kcl in dextrose-nacl intravenous solution 10-5- 0.45 meq/l-%-%, 20-5-0.2 meq/l-%-%, 20-5-0.45 meq/ l-%-%, 20-5-0.9 meq/l-%- %, 30-5-0.45 meq/l-%-%, 40-5-0.45 meq/l-%-%

MO 4 KCL IN DEXTROSE- NACL INTRAVENOUS SOLUTION 20-5-0.225 MEQ/L-%-%

MO 4 KCL IN DEXTROSE- NACL INTRAVENOUS SOLUTION 40-5-0.9 MEQ/L-%-%

MO 4 KCL-LACTATED RINGERS-D5W

MO 2 kionex oral suspension MO 2 klor-con 10 MO 2 klor-con 10 MO 2 klor-con m10 MO 2 klor-con m10 MO 2 klor-con m15 MO 2 klor-con m15


Drug Tier Drug Name

MO 2 klor-con m20 MO 2 klor-con m20 MO 2 klor-con oral tablet extended

release MO 2 klor-con oral tablet extended

release MO 2 klor-con sprinkle MO 2 klor-con sprinkle oral capsule

extended release 8 meq MO 2 klor-con/ef MO 4 lactated ringers intravenous MO 4 lactated ringers irrigation B/D PAR; MO 4 levocarnitine oral solution B/D PAR; MO 3 LEVOCARNITINE ORAL

TABLET B/D PAR; MO 4 levocarnitine sf MO 2 ludent oral tablet chewable

0.55 (0.25 f) mg, 1.1 (0.5 f) mg

MO 4 ludent oral tablet chewable 2.2 (1 f) mg

MO 4 magnesium sulfate injection solution 50 %

4 magnesium sulfate injection solution 50 % (10ml syringe)

MO 4 MAGNESIUM SULFATE INTRAVENOUS SOLUTION 2 GM/50ML, 20 GM/500ML, 4 GM/ 100ML, 4 GM/50ML, 40 GM/1000ML

PAR 5 MOZOBIL B/D PAR; MO 4 NEPHRAMINE MO 4 NORMOSOL-M IN D5W MO 4 NORMOSOL-R MO 4 NORMOSOL-R IN D5W MO 4 NORMOSOL-R PH 7.4 B/D PAR; MO 4 nutrilipid MO 4 PLASMA-LYTE 148 MO 4 PLASMA-LYTE A MO 2 pnv-dha MO 2 pnv-select MO 2 potassium bicarbonate oral MO 2 potassium chloride crys er MO 2 potassium chloride er



Drug Tier Drug Name

MO 4 potassium chloride in dextrose intravenous solution 20-5 meq/l-%, 40-5 meq/l-%

MO 4 potassium chloride in nacl intravenous solution 20-0.45 meq/l-%, 20-0.9 meq/l-%, 40-0.9 meq/l-%

MO 4 potassium chloride intravenous solution 10 meq/ 100ml, 2 meq/ml, 20 meq/ 100ml, 40 meq/100ml

MO 4 potassium chloride intravenous solution 10 meq/ 50ml, 20 meq/50ml

4 potassium chloride intravenous solution 2 meq/ ml (20 ml)

MO 4 potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%)

B/D PAR; MO 4 PREMASOL INTRAVENOUS SOLUTION 10 %

B/D PAR; MO 4 premasol intravenous solution 6 %

B/D PAR; MO 4 PROCALAMINE B/D PAR; MO 4 PROSOL MO 4 ringers MO 4 ringers irrigation PAR; QLL (30 per 30 days)

5 SAMSCA ORAL TABLET 15 MG


5 SAMSCA ORAL TABLET 30 MG

4 sodium bicarbonate intravenous solution 4.2 %

MO 4 sodium bicarbonate intravenous solution 8.4 %

MO 4 sodium chloride injection solution 2.5 meq/ml

MO 4 sodium chloride intravenous solution 0.45 %, 0.9 %, 3 %, 5 %

MO 4 sodium chloride intravenous solution 4 meq/ml


Drug Tier Drug Name

MO 4 sodium chloride irrigation solution 0.9 %

MO 4 sodium fluoride oral tablet 2.2 (1 f) mg

2 sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 f) mg

4 sodium fluoride oral tablet chewable 2.2 (1 f) mg

MO 4 SODIUM LACTATE INTRAVENOUS SOLUTION 5 MEQ/ML

2 sodium polystyrene sulfonate oral powder

MO 2 sodium polystyrene sulfonate oral suspension

MO 2 sodium polystyrene sulfonate rectal

MO 2 sps MO 4 sterile water for irrigation MO 3 SUPREP BOWEL PREP

KIT B/D PAR; MO 4 SYNTHAMIN 17 MO 4 tis-u-sol MO 4 TPN ELECTROLYTES


B/D PAR; MO 4 TRAVASOL 5 trientine hcl

B/D PAR; MO 4 TROPHAMINE PAR 5 VPRIV

Gastrointestinal Agents PAR; MO; QLL (60 per 30 days)

5 alosetron hcl


3 AMITIZA

MO 4 atropine sulfate injection solution 0.4 mg/ml, 8 mg/ 20ml

MO 4 atropine sulfate injection solution prefilled syringe 0.25 mg/5ml, 1 mg/10ml

4 atropine sulfate injection solution prefilled syringe 0.5 mg/5ml



Drug Tier Drug Name

MO 4 budesonide oral MO 2 constulose MO 2 dicyclomine hcl oral capsule MO 2 dicyclomine hcl oral solution MO 4 dicyclomine hcl oral tablet MO 2 diphenoxylate-atropine oral

liquid MO 3 diphenoxylate-atropine oral

tablet MO 2 enulose MO 4 esomeprazole sodium


MO 4 famotidine intravenous solution 20 mg/2ml, 200 mg/ 20ml, 40 mg/4ml

MO 3 famotidine oral suspension reconstituted

MO; CG 1 famotidine oral tablet 20 mg MO 2 famotidine oral tablet 40 mg MO 4 famotidine premixed PAR; LA 5 GATTEX MO; CG 1 gavilyte-c MO 2 gavilyte-g MO 3 gavilyte-h MO 2 gavilyte-n with flavor pack MO 2 generlac MO 4 glycopyrrolate injection

solution MO 2 glycopyrrolate oral tablet 1

mg, 2 mg MO 2 lactulose encephalopathy MO 2 lactulose oral solution MO 4 lansoprazole oral capsule

delayed release 15 mg MO; QLL (30 per 30 days)

4 lansoprazole oral capsule delayed release 30 mg


3 LINZESS

MO 3 loperamide hcl oral capsule MO 4 mesalamine-cleanser MO 2 methscopolamine bromide

oral tablet 2.5 mg MO 3 methscopolamine bromide

oral tablet 5 mg


Drug Tier Drug Name

MO 4 metoclopramide hcl injection MO; CG 1 metoclopramide hcl oral

solution 10 mg/10ml, 5 mg/ 5ml

MO; CG 1 metoclopramide hcl oral tablet MO 3 misoprostol oral MO; QLL (30 per 30 days)

3 MOVANTIK

MO 4 MOVIPREP MO 2 nizatidine oral capsule MO; QLL (30 per 30 days)

2 omeprazole oral capsule delayed release

MO 2 opium MO 4 pantoprazole sodium

intravenous MO; QLL (30 per 30 days)

2 pantoprazole sodium oral

MO 2 paregoric MO 2 peg 3350-kcl-na bicarb-nacl MO; CG 1 peg 3350/electrolytes MO 2 peg-3350/electrolytes

2 polyethylene glycol 3350 oral packet

MO 2 polyethylene glycol 3350 oral powder

MO 2 proctozone-hc rectal PAR; MO 2 propantheline bromide oral MO 4 ranitidine hcl injection MO 2 ranitidine hcl oral syrup MO; CG 1 ranitidine hcl oral tablet 150

mg, 300 mg PAR; MO; QLL (18 per 30 days)

5 RELISTOR SUBCUTANEOUS SOLUTION 12 MG/ 0.6ML


5 RELISTOR SUBCUTANEOUS SOLUTION 12 MG/ 0.6ML (0.6ML SYRINGE)


5 RELISTOR SUBCUTANEOUS SOLUTION 8 MG/0.4ML

PAR 5 REMICADE MO; QLL (10 per 28 days)

4 scopolamine



Drug Tier Drug Name

MO 2 sucralfate oral tablet MO 2 trilyte MO 3 ursodiol oral

Genetic Or Enzyme Disorder: Replacement, Modifiers, Treatment

PAR; LA 5 ALDURAZYME PAR 5 CERDELGA MO 3 CREON LA 5 CYSTADANE LA 4 CYSTAGON PAR; LA 5 ELAPRASE PAR; LA 5 FABRAZYME PAR; LA 5 KUVAN ORAL TABLET

SOLUBLE PAR; LA 5 miglustat PAR; LA 5 NAGLAZYME PAR 5 nitisinone PAR; LA 5 ORFADIN PAR; LA; QLL (525 per 30 days)

5 RAVICTI

PAR 5 sodium phenylbutyrate oral tablet

LA 5 SUCRAID Genitourinary Agents

MO 2 acetic acid irrigation MO 2 alfuzosin hcl er MO 2 bethanechol chloride oral

tablet 10 mg, 25 mg, 5 mg MO 3 bethanechol chloride oral

tablet 50 mg MO 3 calcium acetate (phos binder)

oral capsule MO 5 DEPEN TITRATABS MO 2 doxazosin mesylate oral MO; QLL (30 per 30 days)

3 dutasteride oral


3 dutasteride-tamsulosin hcl

MO 4 ELMIRON MO 4 finasteride oral tablet 5 mg MO 3 flavoxate hcl PAR; LA; QLL (30 per 30 days)

5 JYNARQUE ORAL TABLET 15 MG


5 JYNARQUE ORAL TABLET 30 MG


Drug Tier Drug Name

MO 2 methenamine mandelate oral MO; QLL (30 per 30 days)

4 MYRBETRIQ

MO 2 neomycin-polymyxin b gu MO; QLL (60 per 30 days)

2 oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg


2 oxybutynin chloride er oral tablet extended release 24 hour 5 mg


2 oxybutynin chloride oral syrup


2 oxybutynin chloride oral tablet

MO 3 potassium citrate er MO 2 prazosin hcl oral MO; QLL (540 per 30 days)

4 sevelamer carbonate oral packet 0.8 gm


4 sevelamer carbonate oral packet 2.4 gm


3 sevelamer carbonate oral tablet

MO 4 silodosin PAR 5 sodium phenylbutyrate oral

powder 3 gm/tsp MO; QLL (30 per 30 days)

4 solifenacin succinate

MO 4 tamsulosin hcl MO; CG 1 terazosin hcl oral MO; QLL (60 per 30 days)

4 tolterodine tartrate oral tablet 1 mg


3 tolterodine tartrate oral tablet 2 mg


4 TOVIAZ


3 trospium chloride

Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)

MO; CG 1 ala-cort external cream MO 3 alclometasone dipropionate

external cream MO 2 alclometasone dipropionate

external ointment MO 4 amcinonide external lotion



Drug Tier Drug Name

MO 4 AMCINONIDE EXTERNAL OINTMENT

MO 2 betamethasone dipropionate aug external cream

MO 2 betamethasone dipropionate aug external gel

MO 3 betamethasone dipropionate aug external lotion

MO 3 betamethasone dipropionate aug external ointment

MO 3 betamethasone dipropionate external cream

MO 3 betamethasone dipropionate external ointment

MO 2 betamethasone valerate external cream

MO 2 betamethasone valerate external lotion

MO 2 betamethasone valerate external ointment


2 clobetasol prop emollient base


2 clobetasol propionate e


2 clobetasol propionate emulsion


2 clobetasol propionate external cream


3 clobetasol propionate external foam

MO 4 clobetasol propionate external gel

MO 4 clobetasol propionate external lotion


3 clobetasol propionate external ointment

MO 3 clobetasol propionate external shampoo

MO 2 clobetasol propionate external solution

MO 3 clodan external shampoo MO 3 cortisone acetate oral MO 3 desonide external MO 4 desoximetasone external cream MO 4 desoximetasone external gel


Drug Tier Drug Name

MO 4 desoximetasone external ointment 0.25 %

MO 3 DEXAMETHASONE INTENSOL

MO 2 dexamethasone oral elixir MO 2 dexamethasone oral tablet MO 4 diflorasone diacetate external MO 2 fludrocortisone acetate oral MO; QLL (120 per 30 days)

3 fluocinolone acetonide external cream


3 fluocinolone acetonide external ointment


4 fluocinolone acetonide external solution

MO 3 fluocinolone acetonide otic MO; QLL (240 per 30 days)

3 fluocinonide emulsified base


2 fluocinonide external gel


4 fluocinonide external ointment


3 fluocinonide external solution

MO 2 fluticasone propionate external cream

MO 2 fluticasone propionate external ointment

MO 2 halobetasol propionate external cream

MO 2 halobetasol propionate external ointment

MO 4 hydrocortisone butyrate external cream

MO 4 hydrocortisone butyrate external ointment

MO 4 hydrocortisone butyrate external solution

MO; CG 1 hydrocortisone external cream 1 %, 2.5 %

MO 2 hydrocortisone external lotion 2.5 %

MO 2 hydrocortisone external ointment 1 %

MO; CG 1 hydrocortisone external ointment 2.5 %



Drug Tier Drug Name

MO 3 hydrocortisone oral MO 3 hydrocortisone valerate

external cream MO 4 hydrocortisone valerate

external ointment MO 2 methylprednisolone oral MO 2 mometasone furoate external MO 2 prednicarbate external

ointment MO 2 prednisolone oral solution MO 2 prednisolone sodium

phosphate oral solution 25 mg/5ml

MO 3 prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml



2.5 mg, 20 mg, 5 mg, 50 mg MO 2 prednisone oral tablet therapy

pack 10 mg (21), 5 mg (21) MO; CG 1 prednisone oral tablet therapy

pack 10 mg (48), 5 mg (48) MO 2 procto-pak MO 2 proctozone-hc rectal MO 2 triamcinolone acetonide

external cream MO 2 triamcinolone acetonide

external lotion 0.025 % MO 3 triamcinolone acetonide

external lotion 0.1 % MO; CG 1 triamcinolone acetonide

external ointment 0.025 % MO 2 triamcinolone acetonide

external ointment 0.1 %, 0.5 %

MO 2 triderm external cream 0.1 % Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)

MO 4 desmopressin ace spray refrig MO 4 desmopressin acetate injection MO 2 desmopressin acetate oral


Drug Tier Drug Name

MO 3 desmopressin acetate spray PAR; LA 5 INCRELEX PAR 5 NORDITROPIN

FLEXPRO 5 STIMATE

Hormonal Agents, Stimulant/ Replacement/ Modifying (Prostaglandins)

MO 3 misoprostol oral tablet 200 mcg Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers)

MO 3 afirmelle MO 3 altavera MO 3 alyacen 1/35 MO 3 alyacen 7/7/7 PAR; MO 5 ANADROL-50 MO 3 apri MO 3 aranelle MO 3 aubra MO 3 aubra eq MO 3 aurovela 1.5/30 MO 3 aurovela 1/20 MO 3 aurovela fe 1.5/30 MO 3 aurovela fe 1/20 MO 3 aviane MO 3 ayuna MO 3 azurette MO 3 balziva MO 3 bekyree MO 3 blisovi fe 1.5/30 MO 3 blisovi fe 1/20 MO 3 briellyn MO 4 budesonide oral MO 3 camila MO 3 caziant MO 3 chateal MO 3 chateal eq MO 3 cryselle-28 MO 3 cyclafem 1/35 MO 3 cyclafem 7/7/7 MO 3 cyred

3 cyred eq MO 4 danazol oral capsule 100 mg,

200 mg MO 3 danazol oral capsule 50 mg



Drug Tier Drug Name

MO 3 dasetta 1/35 MO 3 dasetta 7/7/7 MO 3 deblitane MO 3 delyla MO 4 DEPO-ESTRADIOL MO 4 DEPO-PROVERA

INTRAMUSCULAR SUSPENSION 400 MG/ ML

MO 3 desogestrel-ethinyl estradiol MO 3 drospirenone-ethinyl estradiol

oral tablet 3-0.03 mg MO 3 elinest

3 ELLA MO 3 emoquette MO 3 enpresse-28 MO 3 enskyce oral tablet 0.15-30

mg-mcg MO 3 errin MO 3 estarylla PAR; MO 2 estradiol oral PAR; MO; QLL (4 per 28 days)

3 estradiol transdermal patch weekly

MO 4 estradiol vaginal cream MO 4 estradiol valerate

intramuscular oil 20 mg/ml MO 4 estradiol valerate

intramuscular oil 40 mg/ml MO; QLL (1 per 90 days); NE

4 ESTRING

MO 3 ethynodiol diac-eth estradiol MO 3 falmina MO; QLL (1 per 90 days); NE

4 FEMRING

MO 3 femynor PAR; MO 4 fyavolv oral tablet 1-5 mg-

mcg 3 hailey 1.5/30

MO 3 heather MO 3 incassia MO 3 introvale MO 3 isibloom MO 3 jencycla PAR; MO 4 jinteli MO 3 jolessa


Drug Tier Drug Name

MO 3 juleber MO 3 junel 1.5/30 MO 3 junel 1/20 MO 3 junel fe 1.5/30 MO 3 junel fe 1/20 MO 3 kalliga MO 3 kariva MO 3 kelnor 1/35 MO 3 kelnor 1/50 MO 3 kurvelo MO 3 larin 1.5/30 MO 3 larin 1/20 MO 3 larin fe 1.5/30 MO 3 larin fe 1/20 MO 3 larissia MO 3 leena MO 3 lessina MO 3 levonest MO 3 levonorg-eth estrad triphasic

oral tablet 50-30/75-40/ 125-30 mcg

MO 3 levonorgest-eth estrad 91-day oral tablet 0.15-0.03 mg

MO 3 levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg

MO 3 levora 0.15/30 (28) MO 3 lillow MO 3 low-ogestrel MO 3 lutera MO 3 lyza MO 3 marlissa MO 3 marlissa MO 3 marlissa MO 3 medroxyprogesterone acetate

intramuscular MO; CG 1 medroxyprogesterone acetate

oral PAR; MO 3 megestrol acetate oral

suspension 40 mg/ml, 400 mg/10ml

PAR; MO 2 megestrol acetate oral tablet PAR; MO 4 MENEST ORAL TABLET

0.3 MG, 0.625 MG, 1.25 MG



Drug Tier Drug Name

MO 3 microgestin 1.5/30 MO 3 microgestin 1/20 MO 3 microgestin fe 1.5/30 MO 3 microgestin fe 1/20 MO 3 mili MO 3 mono-linyah MO 3 mononessa MO 3 necon 0.5/35 (28) MO 3 nora-be MO 3 norethin ace-eth estrad-fe oral

tablet 1-20 mg-mcg MO 3 norethindrone acet-ethinyl est

oral tablet MO 2 norethindrone acetate oral MO 3 norethindrone oral PAR; MO 4 norethindrone-eth estradiol

oral tablet 1-5 mg-mcg MO 3 norgestim-eth estrad triphasic

oral tablet 0.18/0.215/0.25 mg-35 mcg

MO 3 norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg

MO 3 norlyda MO 3 norlyroc MO 3 nortrel 0.5/35 (28) MO 3 nortrel 1/35 (21) MO 3 nortrel 1/35 (28) MO 3 nortrel 7/7/7 MO 3 ocella MO 3 ogestrel MO 3 orsythia PAR; MO; QLL (240 per 30 days)

3 oxandrolone oral tablet 2.5 mg

MO 3 philith MO 3 pimtrea MO 3 pirmella 1/35 MO 3 pirmella 7/7/7 MO 3 portia-28 PAR; MO 3 PREMARIN ORAL MO 3 PREMARIN VAGINAL PAR; MO 4 PREMPRO MO 3 previfem MO 2 progesterone micronized oral MO; QLL (30 per 30 days)

3 raloxifene hcl


Drug Tier Drug Name

MO 3 reclipsen MO 3 setlakin MO 3 sharobel MO 3 sprintec 28 MO 3 sronyx MO 3 syeda MO 3 tarina fe 1/20 MO 3 tarina fe 1/20 eq PAR; MO 4 testosterone cypionate

intramuscular solution 100 mg/ml, 200 mg/ml

PAR; MO 4 testosterone enanthate intramuscular solution

PAR; MO; QLL (112.5 per 30 days)

3 testosterone transdermal gel 20.25 mg/1.25gm (1.62%)


3 testosterone transdermal gel 20.25 mg/act (1.62%), 40.5 mg/2.5gm (1.62%)


3 testosterone transdermal gel 25 mg/2.5gm (1%), 50 mg/ 5gm (1%)

MO 3 tilia fe MO 3 tri femynor MO 3 tri-estarylla MO 3 tri-legest fe MO 3 tri-linyah MO 3 tri-mili MO 3 tri-previfem MO 3 tri-sprintec MO 3 tri-vylibra MO 3 trinessa (28) MO 3 trivora (28) MO 3 tulana MO 3 velivet MO 3 vienva MO 3 viorele MO 3 vyfemla MO 3 vylibra MO 3 wera MO 3 zarah MO 3 zovia 1/35e (28) MO 3 zumandimine

Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid)



Drug Tier Drug Name

MO; CG 1 levo-t oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

MO 4 levo-t oral tablet 300 mcg MO; CG 1 levothyroxine sodium oral

tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

MO 4 levothyroxine sodium oral tablet 300 mcg

MO; CG 1 levoxyl MO 5 liothyronine sodium

intravenous MO 2 liothyronine sodium oral MO 3 SYNTHROID MO; CG 1 unithroid oral tablet 100

mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

MO 4 unithroid oral tablet 300 mcg Hormonal Agents, Suppressant (Adrenal)

MO 3 LYSODREN Hormonal Agents, Suppressant (Pituitary)

MO 4 bromocriptine mesylate oral capsule

MO 3 bromocriptine mesylate oral tablet

MO 4 cabergoline PAR; QLL (4 per 365 days); NE

5 FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG


4 FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG

PAR 4 leuprolide acetate injection PAR; QLL (1 per 28 days)

5 LUPRON DEPOT (1- MONTH)


Drug Tier Drug Name


5 LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 7.5 MG

PAR 4 octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ ml

PAR 5 SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 10 MG, 20 MG

PAR; LA 5 SIGNIFOR PAR 5 SOMATULINE DEPOT PAR; LA 5 SOMAVERT PAR 5 SYNAREL PAR; QLL (1 per 84 days); NE

5 TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 11.25 MG


5 TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 22.5 MG


5 TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 3.75 MG Hormonal Agents, Suppressant (Thyroid)

MO 2 methimazole oral tablet 10 mg

MO; CG 1 methimazole oral tablet 5 mg MO 2 propylthiouracil oral

Immunological Agents MO 3 ACTHIB PAR; LA 5 ACTIMMUNE

3 ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 (PREFILLED SYRINGE)



Drug Tier Drug Name

MO 3 ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 LF-MCG/0.5

PAR 5 AFINITOR DISPERZ PAR 5 AFINITOR ORAL

TABLET 2.5 MG PAR 5 ALIMTA PAR 5 ARCALYST B/D PAR 4 ASTAGRAF XL B/D PAR; MO 2 azathioprine oral B/D PAR; MO 4 AZATHIOPRINE

SODIUM MO 4 BCG VACCINE PAR 5 BENLYSTA MO 3 BEXSERO

3 BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5 (0.5ML SYRINGE)

MO 3 BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5 , 5-2.5-18.5 LF-MCG/0.5

B/D PAR 4 cyclosporine intravenous B/D PAR 4 cyclosporine modified oral

capsule 100 mg B/D PAR 3 cyclosporine modified oral

capsule 25 mg, 50 mg B/D PAR 4 cyclosporine modified oral

solution B/D PAR 4 cyclosporine oral capsule MO 3 DAPTACEL

INTRAMUSCULAR SUSPENSION 23-15-5

MO 5 DEPEN TITRATABS MO 3 DIPHTHERIA-TETANUS

TOXOIDS DT PAR; QLL (4.08 per 28 days)

5 ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML


5 ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML


Drug Tier Drug Name


5 ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED


5 ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO- INJECTOR

B/D PAR; MO 3 ENGERIX-B INJECTION PAR 5 FIRAZYR PAR 5 GAMUNEX-C

INJECTION SOLUTION 1 GM/10ML, 10 GM/ 100ML, 20 GM/200ML, 40 GM/400ML, 5 GM/ 50ML

PAR 4 GAMUNEX-C INJECTION SOLUTION 2.5 GM/25ML

MO 3 GARDASIL 9 B/D PAR 4 gengraf oral capsule 100 mg B/D PAR 3 gengraf oral capsule 25 mg B/D PAR 4 gengraf oral solution

3 HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ ML 1 ML, 720 EL U/ 0.5ML 0.5 ML

MO 3 HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ ML, 720 EL U/0.5ML

MO 3 HIBERIX INJECTION PAR; QLL (6 per 365 days); NE

5 HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 40 MG/0.8ML (6 PACK), 80 MG/0.8ML


5 HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML & 40MG/0.4ML



Drug Tier Drug Name


5 HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT


5 HUMIRA PEN-CD/UC/ HS STARTER SUBCUTANEOUS PEN- INJECTOR KIT 40 MG/ 0.8ML


5 HUMIRA PEN-CD/UC/ HS STARTER SUBCUTANEOUS PEN- INJECTOR KIT 80 MG/ 0.8ML


5 HUMIRA PEN-PS/UV/ ADOL HS START SUBCUTANEOUS PEN- INJECTOR KIT 40 MG/ 0.8ML


5 HUMIRA PEN-PS/UV/ ADOL HS START SUBCUTANEOUS PEN- INJECTOR KIT 80 MG/ 0.8ML & 40MG/0.4ML


5 HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/ 0.2ML, 20 MG/0.4ML


5 HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.4ML, 40 MG/0.8ML

5 HYPERRAB 3 HYPERRAB S/D

INJECTION SOLUTION 300 UNIT/2ML

PAR 5 icatibant acetate 3 IMOGAM RABIES-HT

INJECTION SOLUTION 300 UNIT/2ML

MO 3 IMOVAX RABIES MO 3 INFANRIX MO 3 IPOL MO 3 IXIARO


Drug Tier Drug Name

3 KEDRAB INJECTION SOLUTION 300 UNIT/ 2ML

PAR 5 KEYTRUDA INTRAVENOUS SOLUTION

MO 3 KINRIX INTRAMUSCULAR SUSPENSION

3 KINRIX INTRAMUSCULAR SUSPENSION INJECTION 0.5 ML

MO 2 leflunomide oral MO 2 leflunomide oral MO 3 M-M-R II INJECTION MO 3 MENACTRA MO 3 MENVEO MO 3 mercaptopurine oral MO 2 methotrexate oral MO 4 methotrexate sodium (pf)

injection solution 50 mg/2ml MO 4 methotrexate sodium injection

solution 50 mg/2ml B/D PAR 4 mycophenolate mofetil hcl B/D PAR 3 mycophenolate mofetil oral

capsule B/D PAR 5 mycophenolate mofetil oral

suspension reconstituted B/D PAR 3 mycophenolate mofetil oral

tablet PAR 5 NULOJIX PAR 5 OCTAGAM

INTRAVENOUS SOLUTION 1 GM/20ML, 2 GM/20ML, 2.5 GM/ 50ML, 25 GM/500ML, 30 GM/300ML, 5 GM/100ML

MO 3 PEDIARIX MO 3 PEDVAX HIB

INTRAMUSCULAR SUSPENSION

MO 3 PENTACEL



Drug Tier Drug Name


4 pimecrolimus

B/D PAR 4 PROGRAF INTRAVENOUS

B/D PAR 4 PROGRAF ORAL PACKET

MO 3 PROQUAD SUBCUTANEOUS SUSPENSION RECONSTITUTED

MO 3 QUADRACEL MO 4 RABAVERT B/D PAR 3 RECOMBIVAX HB

INJECTION SUSPENSION 10 MCG/ ML (1ML SYRINGE)

B/D PAR; MO 3 RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ ML, 40 MCG/ML, 5 MCG/0.5ML

MO 3 ROTARIX MO 3 ROTATEQ ORAL

SOLUTION PAR 5 RUCONEST MO 3 SHINGRIX

INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG/0.5ML

B/D PAR 5 SIMULECT B/D PAR 5 sirolimus oral solution B/D PAR 4 sirolimus oral tablet MO 3 STAMARIL PAR 5 SYNAGIS B/D PAR 3 tacrolimus oral capsule 0.5

mg B/D PAR 4 tacrolimus oral capsule 1 mg,

5 mg MO 3 TDVAX MO 3 TENIVAC B/D PAR 5 THYMOGLOBULIN MO 3 TRUMENBA


Drug Tier Drug Name

MO 3 TWINRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

MO 3 TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/ 0.5ML

3 TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/ 0.5ML (0.5ML SYRINGE)

3 VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/ 0.5ML 0.5 ML, 50 UNIT/ ML 1 ML

MO 3 VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/ 0.5ML, 50 UNIT/ML

MO 3 VARIVAX 3 VARIZIG

INTRAMUSCULAR SOLUTION

4 XATMEP PAR; QLL (60 per 30 days)

5 XELJANZ

MO 3 YF-VAX B/D PAR 5 ZORTRESS MO 4 ZOSTAVAX

SUBCUTANEOUS SUSPENSION RECONSTITUTED Inflammatory Bowel Disease Agents

MO 3 APRISO MO 3 balsalazide disodium MO 4 budesonide oral MO 3 colocort MO 3 cortisone acetate oral MO 3 DEXAMETHASONE

INTENSOL MO 2 dexamethasone oral elixir MO 2 dexamethasone oral tablet MO 5 DIPENTUM MO 3 hydrocortisone oral



Drug Tier Drug Name

MO 2 hydrocortisone rectal cream MO 3 hydrocortisone rectal enema MO 3 mesalamine er MO 3 mesalamine oral capsule

delayed release MO 3 mesalamine oral tablet

delayed release 1.2 gm MO 4 mesalamine oral tablet

delayed release 800 mg MO 3 mesalamine rectal enema MO 4 mesalamine rectal suppository MO 2 methylprednisolone oral MO 4 PENTASA MO 2 prednisolone acetate

ophthalmic MO 2 prednisolone oral solution MO 3 prednisolone sodium

phosphate oral solution 6.7 (5 base) mg/5ml



2.5 mg, 20 mg, 5 mg, 50 mg MO 2 procto-med hc MO 2 proctosol hc MO 2 sulfasalazine oral

Metabolic Bone Disease Agents MO; QLL (300 per 28 days)

4 alendronate sodium oral solution


1 alendronate sodium oral tablet 10 mg, 40 mg, 5 mg


1 alendronate sodium oral tablet 35 mg, 70 mg


3 calcitonin (salmon)

B/D PAR; MO 2 calcitriol oral capsule B/D PAR; MO 4 calcitriol oral solution B/D PAR; QLL (60 per 30 days)

5 cinacalcet hcl oral tablet 30 mg, 60 mg

B/D PAR; QLL (120 per 30 days)

5 cinacalcet hcl oral tablet 90 mg

B/D PAR; MO 4 doxercalciferol oral capsule 0.5 mcg


Drug Tier Drug Name


5 FORTEO SUBCUTANEOUS SOLUTION 600 MCG/ 2.4ML


3 FOSAMAX ORAL TABLET 70 MG

B/D PAR 4 ibandronate sodium intravenous


2 ibandronate sodium oral

B/D PAR; MO 4 MIACALCIN INJECTION PAR; QLL (2 per 28 days)

5 NATPARA

4 pamidronate disodium intravenous solution 30 mg/ 10ml, 90 mg/10ml

B/D PAR 4 PAMIDRONATE DISODIUM INTRAVENOUS SOLUTION 6 MG/ML

4 pamidronate disodium intravenous solution reconstituted

B/D PAR; MO 3 paricalcitol oral capsule 1 mcg B/D PAR; MO 4 paricalcitol oral capsule 2

mcg, 4 mcg PAR; QLL (2 per 365 days); NE

4 PROLIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE


5 XGEVA

PAR 4 zoledronic acid intravenous concentrate

PAR 4 zoledronic acid intravenous solution Ophthalmic Agents

MO 3 acetazolamide oral MO 2 ak-poly-bac MO 3 ALPHAGAN P

OPHTHALMIC SOLUTION 0.1 %

MO 2 apraclonidine hcl MO 4 atropine sulfate ophthalmic

solution



Drug Tier Drug Name

MO 2 azelastine hcl ophthalmic MO 4 AZOPT MO 3 bacitra-neomycin-polymyxin-

hc MO 2 bacitracin-polymyxin b

ophthalmic ointment 500- 10000 unit/gm

MO 2 betaxolol hcl ophthalmic MO 4 BETIMOL MO 4 BETOPTIC-S MO 3 bimatoprost ophthalmic MO 3 bimatoprost ophthalmic MO 4 BLEPHAMIDE S.O.P. MO 4 brimonidine tartrate

ophthalmic solution 0.15 % MO 2 brimonidine tartrate

ophthalmic solution 0.2 % MO; CG 1 carteolol hcl MO 3 COMBIGAN MO 2 cromolyn sodium ophthalmic LA 5 CYSTARAN MO 2 dexamethasone sodium

phosphate ophthalmic MO 2 diclofenac sodium ophthalmic MO 2 dorzolamide hcl ophthalmic MO 2 dorzolamide hcl-timolol mal MO 3 DUREZOL MO 2 fluorometholone ophthalmic MO; CG 1 flurbiprofen sodium MO 3 ILEVRO MO 4 ISOPTO ATROPINE MO 2 ketorolac tromethamine

ophthalmic MO; QLL (60 per 30 days)

4 LACRISERT

MO 2 latanoprost ophthalmic MO 2 levobunolol hcl ophthalmic

solution 0.5 % MO 3 LUMIGAN

OPHTHALMIC SOLUTION 0.01 %

MO 4 methazolamide oral MO 2 neo-polycin MO 3 neo-polycin hc


Drug Tier Drug Name

MO 2 neomycin-bacitracin zn- polymyx ophthalmic ointment 5-400-10000

MO 2 neomycin-polymyxin- dexameth ophthalmic ointment

MO 2 neomycin-polymyxin- dexameth ophthalmic suspension 3.5-10000-0.1

MO 2 neomycin-polymyxin- gramicidin ophthalmic solution 1.75-10000-.025

MO 4 neomycin-polymyxin-hc ophthalmic suspension 3.5- 10000-1

MO 3 olopatadine hcl ophthalmic solution 0.2 %

MO 3 PAZEO MO 4 PHOSPHOLINE IODIDE MO 4 pilocarpine hcl ophthalmic

solution 1 %, 2 %, 4 % MO 2 polycin MO; CG 1 polymyxin b-trimethoprim MO 2 prednisolone acetate

ophthalmic MO 3 PREDNISOLONE

SODIUM PHOSPHATE OPHTHALMIC

MO 4 SIMBRINZA MO 3 sulfacetamide sodium

ophthalmic ointment MO 3 sulfacetamide sodium

ophthalmic ointment MO 2 sulfacetamide-prednisolone

ophthalmic solution MO 2 timolol maleate ophthalmic

gel forming solution MO; CG 1 timolol maleate ophthalmic

solution 0.25 %, 0.5 % MO 3 TOBRADEX ST MO 3 tobramycin-dexamethasone MO 3 TRAVATAN Z PAR; MO; QLL (60 per 30 days)

3 XIIDRA

Otic Agents



Drug Tier Drug Name

MO 4 CIPRODEX MO 3 flac MO 4 hydrocortisone-acetic acid MO 2 neomycin-polymyxin-hc otic

solution 1 % MO 2 neomycin-polymyxin-hc otic

suspension Respiratory Tract/ Pulmonary Agents

B/D PAR; MO 2 acetylcysteine inhalation PAR; LA 5 ADEMPAS MO; QLL (12 per 30 days)

3 ADVAIR HFA


3 ADVAIR HFA


3 ADVAIR HFA

MO 2 albuterol sulfate er oral tablet extended release 12 hour 4 mg

MO 3 albuterol sulfate er oral tablet extended release 12 hour 8 mg

MO 3 ALBUTEROL SULFATE HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT


2 albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/ 3ml, 1.25 mg/3ml


2 albuterol sulfate inhalation nebulization solution (5 mg/ ml) 0.5%, 2.5 mg/0.5ml

MO; CG 1 albuterol sulfate oral syrup MO 4 albuterol sulfate oral tablet PAR; LA; QLL (30 per 30 days)

5 ambrisentan

MO 4 aminophylline intravenous MO; QLL (60 per 30 days)

3 ANORO ELLIPTA


3 ARNUITY ELLIPTA


4 ATROVENT HFA


3 azelastine hcl nasal solution 0.1 %, 0.15 %


Drug Tier Drug Name


5 bosentan


5 BROVANA


4 budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml


4 budesonide inhalation suspension 1 mg/2ml

PAR; LA 5 CAYSTON MO 2 cetirizine hcl allergy child MO 2 cetirizine hcl oral solution 1

mg/ml PAR; MO 3 clemastine fumarate oral

tablet 2.68 mg MO; QLL (8 per 30 days)

4 COMBIVENT RESPIMAT


3 cromolyn sodium inhalation

MO 4 cromolyn sodium oral PAR; MO 3 cyproheptadine hcl oral tablet PAR; MO; QLL (30 per 30 days)

4 DALIRESP

MO 4 diphenhydramine hcl injection


3 DULERA

MO 3 ELIXOPHYLLIN MO; QLL (2 per 28 days)

3 epinephrine injection solution auto-injector 0.15 mg/0.3ml, 0.3 mg/0.3ml

MO 4 EPINEPHRINE PF INJECTION SOLUTION

4 epinephrine pf injection solution prefilled syringe


5 ESBRIET ORAL CAPSULE


5 ESBRIET ORAL CAPSULE


5 ESBRIET ORAL TABLET 267 MG



Drug Tier Drug Name








3 FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ BLIST, 50 MCG/BLIST


3 FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250 MCG/ BLIST


3 FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT






2 flunisolide nasal solution 25 mcg/act (0.025%)


2 fluticasone propionate nasal


3 fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/ dose, 250-50 mcg/dose, 500- 50 mcg/dose





PAR; MO 4 hydroxyzine hcl oral syrup PAR; MO 4 hydroxyzine hcl oral tablet


Drug Tier Drug Name

B/D PAR; MO 2 ipratropium bromide inhalation


2 ipratropium bromide nasal


2 ipratropium-albuterol


5 KALYDECO ORAL TABLET


5 LETAIRIS


3 levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml


3 levalbuterol hcl inhalation nebulization solution 0.63 mg/3ml


4 levalbuterol tartrate

MO 2 levocetirizine dihydrochloride oral tablet

MO 2 metaproterenol sulfate oral syrup

MO 4 mometasone furoate nasal MO 4 montelukast sodium oral

packet MO 2 montelukast sodium oral

tablet MO 2 montelukast sodium oral

tablet chewable PAR; QLL (60 per 30 days)





5 ORKAMBI ORAL TABLET


5 PERFOROMIST

MO 3 PROAIR HFA MO 3 PROAIR RESPICLICK PAR; LA 5 PROLASTIN-C PAR; MO 4 promethazine hcl injection PAR; MO 4 promethazine hcl oral tablet



Drug Tier Drug Name

B/D PAR 5 PULMOZYME B/D PAR 5 PULMOZYME MO; QLL (60 per 30 days)

3 SEREVENT DISKUS


3 sildenafil citrate oral tablet 20 mg


3 SPIRIVA HANDIHALER


3 SPIRIVA RESPIMAT

MO 4 terbutaline sulfate injection MO 4 terbutaline sulfate oral MO 3 theophylline MO 2 theophylline er oral tablet

extended release 12 hour 300 mg, 450 mg

MO 2 theophylline er oral tablet extended release 24 hour


5 TRACLEER ORAL TABLET SOLUBLE


5 VENTAVIS


3 wixela inhub


3 wixela inhub


5 XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED

MO 4 zafirlukast Skeletal Muscle Relaxants

PAR; MO 3 cyclobenzaprine hcl oral tablet 10 mg, 5 mg

PAR; MO 4 cyclobenzaprine hcl oral tablet 7.5 mg

MO 2 tizanidine hcl oral tablet Sleep Disorder Agents

PAR; MO 3 doxepin hcl oral capsule 10 mg, 100 mg, 25 mg, 50 mg, 75 mg

PAR; MO 4 doxepin hcl oral concentrate PAR; LA; QLL (30 per 30 days)

5 HETLIOZ

PAR; MO 3 modafinil oral tablet 100 mg


Drug Tier Drug Name


3 modafinil oral tablet 200 mg


4 ramelteon


4 ROZEREM


4 temazepam oral capsule 15 mg, 30 mg


5 XYREM


3 zaleplon oral capsule 10 mg


3 zaleplon oral capsule 5 mg


2 zolpidem tartrate oral


Index of Drugs Legend Generic drugs are shown in lowercase italic (e.g., atenolol).

Brand-name drugs are shown in capital letters (e.g., SPIRIVA).

The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed. Find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

Drug Name Page

1ST TIER UNIFINE PENTIPS 29G X 12MM..............................................................41

abacavir sulfate oral solution..................................35 abacavir sulfate oral tablet.....................................35 abacavir sulfate-lamivudine...................................35 abacavir-lamivudine-zidovudine............................35 ABELCET...........................................................23 ABILIFY MAINTENA INTRAMUSCULAR

PREFILLED SYRINGE...................................20 ABILIFY MAINTENA INTRAMUSCULAR

PREFILLED SYRINGE...................................32 ABILIFY MAINTENA INTRAMUSCULAR

SUSPENSION RECONSTITUTED ER.........20 ABILIFY MAINTENA INTRAMUSCULAR

SUSPENSION RECONSTITUTED ER.........32 abiraterone acetate.................................................25 ABRAXANE........................................................25 acamprosate calcium..............................................11 acarbose oral tablet 100 mg....................................41 acarbose oral tablet 25 mg......................................41 acarbose oral tablet 50 mg......................................41 acebutolol hcl oral..................................................45 acetaminophen-codeine #3.......................................8 acetaminophen-codeine #4.......................................8 acetaminophen-codeine oral solution.........................8 acetaminophen-codeine oral tablet 300-15 mg...........8 acetaminophen-codeine oral tablet 300-60 mg...........8 acetazolamide er....................................................45 acetazolamide oral.................................................45 acetazolamide oral.................................................64 acetazolamide sodium............................................45 acetic acid irrigation..............................................55 acetic acid otic.......................................................12 acetylcysteine inhalation.........................................66 acetylcysteine intravenous.......................................49 acitretin oral capsule 10 mg, 25 mg........................50

acitretin oral capsule 17.5 mg.................................50 ACTHIB..............................................................60 ACTIMMUNE...................................................60 acyclovir external ointment.....................................35 acyclovir oral capsule..............................................35 acyclovir oral suspension.........................................35 acyclovir oral tablet................................................35 acyclovir sodium intravenous solution......................35 ADACEL INTRAMUSCULAR SUSPENSION

5-2-15.5 (PREFILLED SYRINGE)..................60 ADACEL INTRAMUSCULAR SUSPENSION

5-2-15.5 LF-MCG/0.5......................................61 adapalene external gel 0.1 %..................................50 adefovir dipivoxil...................................................35 ADEMPAS..........................................................66 adriamycin intravenous solution.............................25 adriamycin intravenous solution reconstituted 10

mg, 50 mg..........................................................25 adrucil..................................................................25 ADVAIR HFA.....................................................66 ADVAIR HFA.....................................................66 ADVAIR HFA.....................................................66 afeditab cr oral tablet extended release 24 hour 30

mg.....................................................................45 afeditab cr oral tablet extended release 24 hour 60

mg.....................................................................45 AFINITOR..........................................................25 AFINITOR DISPERZ.........................................61 AFINITOR ORAL TABLET 2.5 MG.................61 afirmelle................................................................57 ak-poly-bac............................................................64 ala-cort external cream...........................................55 albendazole oral....................................................31 albuterol sulfate er oral tablet extended release 12

hour 4 mg..........................................................66

Plus_PDP_20240_v8_2002_1 69 Effective Date 2/1/2020

albuterol sulfate er oral tablet extended release 12 hour 8 mg..........................................................66

ALBUTEROL SULFATE HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT.......................................................66

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/ 3ml....................................................................66

albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5%, 2.5 mg/0.5ml...............................66

albuterol sulfate oral syrup......................................66 albuterol sulfate oral tablet.....................................66 alclometasone dipropionate external cream..............55 alclometasone dipropionate external ointment..........55 ALDURAZYME..................................................55 ALECENSA.........................................................25 alendronate sodium oral solution............................64 alendronate sodium oral tablet 10 mg, 40 mg, 5

mg.....................................................................64 alendronate sodium oral tablet 35 mg, 70 mg..........64 alfuzosin hcl er......................................................55 ALIMTA..............................................................61 ALINIA ORAL SUSPENSION

RECONSTITUTED........................................31 ALINIA ORAL TABLET....................................31 ALIQOPA...........................................................25 aliskiren fumarate..................................................45 allopurinol oral......................................................24 allopurinol sodium.................................................24 ALOPRIM...........................................................24 alosetron hcl..........................................................53 ALPHAGAN P OPHTHALMIC SOLUTION

0.1 %................................................................64 alprazolam oral tablet............................................38 altavera.................................................................57 ALUNBRIG ORAL TABLET 180 MG...............25 ALUNBRIG ORAL TABLET 30 MG.................25 ALUNBRIG ORAL TABLET 90 MG.................25 ALUNBRIG ORAL TABLET THERAPY

PACK...............................................................25 alyacen 1/35..........................................................57 alyacen 7/7/7.........................................................57 amantadine hcl oral...............................................31 amantadine hcl oral...............................................35 AMBISOME.......................................................23 ambrisentan..........................................................66 amcinonide external lotion.....................................55

AMCINONIDE EXTERNAL OINTMENT...................................................56

amikacin sulfate injection solution 1 gm/4ml, 500 mg/2ml..............................................................12

amiloride hcl oral..................................................45 amiloride-hydrochlorothiazide................................45 aminophylline intravenous.....................................66 AMINOSYN II INTRAVENOUS SOLUTION

10 %, 15 %.......................................................51 AMINOSYN-PF..................................................51 amiodarone hcl intravenous....................................45 amiodarone hcl oral tablet 100 mg, 200 mg............45 amiodarone hcl oral tablet 400 mg.........................45 AMITIZA............................................................53 amitriptyline hcl oral.............................................20 amlodipine besy-benazepril hcl...............................45 amlodipine besylate oral.........................................45 amlodipine besylate-valsartan oral tablet 10-160

mg, 5-160 mg, 5-320 mg....................................45 amlodipine besylate-valsartan oral tablet 10-320

mg.....................................................................45 amlodipine-olmesartan...........................................45 amlodipine-valsartan-hctz......................................45 ammonium lactate external....................................50 amnesteem.............................................................50 amoxapine............................................................20 amoxicillin oral capsule..........................................12 amoxicillin oral suspension reconstituted.................12 amoxicillin oral tablet............................................12 amoxicillin oral tablet chewable 125 mg, 250

mg.....................................................................12 amoxicillin-pot clavulanate er................................12 amoxicillin-pot clavulanate oral suspension

reconstituted 200-28.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml...............................................12

amoxicillin-pot clavulanate oral suspension reconstituted 250-62.5 mg/5ml...........................12

amoxicillin-pot clavulanate oral tablet 250-125 mg.....................................................................12

amoxicillin-pot clavulanate oral tablet 500-125 mg, 875-125 mg.......................................................13

amoxicillin-pot clavulanate oral tablet chewable......13 amphetamine-dextroamphet er...............................49 amphetamine-dextroamphetamine oral tablet 10

mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg..........49 amphetamine-dextroamphetamine oral tablet 30

mg.....................................................................49 amphotericin b intravenous....................................23


ampicillin oral capsule 500 mg...............................13 ampicillin sodium injection solution reconstituted 1

gm, 125 mg, 2 gm, 250 mg, 500 mg...................13 ampicillin sodium intravenous................................13 ampicillin-sulbactam sodium injection solution

reconstituted 1.5 (1-0.5) gm, 3 (2-1) gm.............13 ampicillin-sulbactam sodium intravenous................13 ANADROL-50....................................................57 anagrelide hcl........................................................44 anastrozole oral.....................................................25 ANORO ELLIPTA.............................................66 APOKYN SUBCUTANEOUS SOLUTION

CARTRIDGE...................................................32 apraclonidine hcl...................................................64 aprepitant oral capsule 125 mg...............................23 aprepitant oral capsule 40 mg.................................23 aprepitant oral capsule 80 & 125 mg......................23 aprepitant oral capsule 80 mg.................................23 apri......................................................................57 APRISO...............................................................63 APTIOM.............................................................17 APTIVUS ORAL CAPSULE...............................35 APTIVUS ORAL SOLUTION...........................35 aranelle.................................................................57 ARCALYST.........................................................61 aripiprazole oral solution........................................20 aripiprazole oral solution........................................32 aripiprazole oral tablet 10 mg................................20 aripiprazole oral tablet 10 mg................................32 aripiprazole oral tablet 15 mg................................20 aripiprazole oral tablet 15 mg................................32 aripiprazole oral tablet 2 mg..................................20 aripiprazole oral tablet 2 mg..................................32 aripiprazole oral tablet 20 mg, 30 mg.....................20 aripiprazole oral tablet 20 mg, 30 mg.....................32 aripiprazole oral tablet 5 mg..................................20 aripiprazole oral tablet 5 mg..................................32 aripiprazole oral tablet dispersible 10 mg................20 aripiprazole oral tablet dispersible 10 mg................32 aripiprazole oral tablet dispersible 15 mg................20 aripiprazole oral tablet dispersible 15 mg................32 ARNUITY ELLIPTA...........................................66 ARRANON.........................................................25 arsenic trioxide intravenous....................................25 ARZERRA...........................................................25 aspirin-dipyridamole er..........................................44 ASSURE ID INSULIN SAFETY SYR 29G X 1/

2" 1 ML............................................................41

ASTAGRAF XL...................................................61 atazanavir sulfate oral capsule 150 mg, 200 mg......35 atazanavir sulfate oral capsule 300 mg....................35 atenolol oral..........................................................45 atenolol-chlorthalidone...........................................45 atomoxetine hcl oral capsule 10 mg, 18 mg, 25 mg,

40 mg................................................................49 atomoxetine hcl oral capsule 100 mg, 60 mg, 80

mg.....................................................................49 atorvastatin calcium oral........................................45 atovaquone oral.....................................................31 atovaquone-proguanil hcl.......................................31 ATRIPLA.............................................................35 atropine sulfate injection solution 0.4 mg/ml, 8 mg/

20ml..................................................................53 atropine sulfate injection solution prefilled syringe

0.25 mg/5ml, 1 mg/10ml....................................53 atropine sulfate injection solution prefilled syringe

0.5 mg/5ml........................................................53 atropine sulfate ophthalmic solution........................64 ATROVENT HFA..............................................66 aubra....................................................................57 aubra eq...............................................................57 AUGMENTIN ORAL SUSPENSION

RECONSTITUTED 125-31.25 MG/ 5ML..................................................................13

aurovela 1.5/30.....................................................57 aurovela 1/20........................................................57 aurovela fe 1.5/30.................................................57 aurovela fe 1/20....................................................57 AVASTIN............................................................25 AVELOX INTRAVENOUS................................13 aviane...................................................................57 avita.....................................................................25 avita.....................................................................50 ayuna...................................................................57 azacitidine............................................................25 AZACTAM.........................................................13 azathioprine oral...................................................61 AZATHIOPRINE SODIUM..............................61 azelastine hcl nasal solution 0.1 %, 0.15 %............66 azelastine hcl ophthalmic........................................65 azithromycin intravenous.......................................13 azithromycin oral packet........................................13 azithromycin oral suspension reconstituted 100 mg/

5ml....................................................................13 azithromycin oral suspension reconstituted 200 mg/

5ml....................................................................13


azithromycin oral tablet 250 mg (6 pack)...............13 azithromycin oral tablet 250 mg, 500 mg, 600

mg.....................................................................13 AZOPT...............................................................65 aztreonam injection solution reconstituted 1 gm.......13 aztreonam injection solution reconstituted 2 gm.......13 azurette.................................................................57 baciim..................................................................13 bacitra-neomycin-polymyxin-hc..............................65 bacitracin intramuscular........................................13 bacitracin ophthalmic............................................13 bacitracin-polymyxin b ophthalmic ointment 500-

10000 unit/gm...................................................65 baclofen oral..........................................................35 balsalazide disodium..............................................63 BALVERSA ORAL TABLET 3 MG...................25 BALVERSA ORAL TABLET 4 MG...................25 BALVERSA ORAL TABLET 5 MG...................25 balziva..................................................................57 BANZEL ORAL SUSPENSION.........................17 BANZEL ORAL TABLET 200 MG....................17 BANZEL ORAL TABLET 400 MG....................17 BARACLUDE ORAL SOLUTION....................35 BAVENCIO........................................................25 BCG VACCINE..................................................61 bekyree..................................................................57 BELEODAQ.......................................................25 benazepril hcl oral.................................................45 benazepril-hydrochlorothiazide...............................46 BENDEKA..........................................................25 BENLYSTA.........................................................61 benzoyl peroxide-erythromycin................................50 benztropine mesylate injection................................32 benztropine mesylate oral.......................................32 BESPONSA.........................................................25 betamethasone dipropionate aug external cream.......11 betamethasone dipropionate aug external cream.......56 betamethasone dipropionate aug external gel............11 betamethasone dipropionate aug external gel............56 betamethasone dipropionate aug external lotion.......11 betamethasone dipropionate aug external lotion.......56 betamethasone dipropionate aug external

ointment............................................................11 betamethasone dipropionate aug external

ointment............................................................56 betamethasone dipropionate external cream.............11 betamethasone dipropionate external cream.............56 betamethasone dipropionate external lotion.............11

betamethasone dipropionate external lotion.............50 betamethasone dipropionate external ointment.........11 betamethasone dipropionate external ointment.........56 betamethasone valerate external cream....................11 betamethasone valerate external cream....................56 betamethasone valerate external lotion....................11 betamethasone valerate external lotion....................56 betamethasone valerate external ointment................11 betamethasone valerate external ointment................56 BETASERON SUBCUTANEOUS KIT.............49 betaxolol hcl ophthalmic.........................................65 betaxolol hcl oral...................................................46 bethanechol chloride oral tablet 10 mg, 25 mg, 5

mg.....................................................................55 bethanechol chloride oral tablet 50 mg....................55 BETIMOL...........................................................65 BETOPTIC-S......................................................65 bexarotene.............................................................25 BEXSERO...........................................................61 bicalutamide.........................................................25 BICILLIN C-R....................................................13 BICILLIN C-R 900/300......................................13 BICILLIN L-A.....................................................13 BICNU................................................................25 BIKTARVY.........................................................35 bimatoprost ophthalmic..........................................65 bimatoprost ophthalmic..........................................65 bisoprolol fumarate................................................46 bisoprolol-hydrochlorothiazide................................46 bleomycin sulfate...................................................25 BLEPHAMIDE S.O.P.........................................11 BLEPHAMIDE S.O.P.........................................65 BLINCYTO........................................................25 blisovi fe 1.5/30.....................................................57 blisovi fe 1/20........................................................57 BOOSTRIX INTRAMUSCULAR

SUSPENSION 5-2.5-18.5 (0.5ML SYRINGE)........................................................61

BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5 , 5-2.5-18.5 LF- MCG/0.5..........................................................61

BORTEZOMIB..................................................25 bosentan................................................................66 BOSULIF ORAL TABLET 100 MG..................26 BOSULIF ORAL TABLET 400 MG, 500

MG...................................................................26 BRAFTOVI ORAL CAPSULE 75 MG...............26 briellyn.................................................................57


BRILINTA..........................................................44 brimonidine tartrate ophthalmic solution 0.15

%......................................................................65 brimonidine tartrate ophthalmic solution 0.2

%......................................................................65 BRIVIACT INTRAVENOUS.............................17 BRIVIACT ORAL SOLUTION.........................17 BRIVIACT ORAL TABLET 10 MG..................17 BRIVIACT ORAL TABLET 100 MG, 75

MG...................................................................17 BRIVIACT ORAL TABLET 25 MG..................17 BRIVIACT ORAL TABLET 50 MG..................17 bromocriptine mesylate oral capsule.........................32 bromocriptine mesylate oral capsule.........................60 bromocriptine mesylate oral tablet...........................32 bromocriptine mesylate oral tablet...........................60 BROVANA..........................................................66 budesonide inhalation suspension 0.25 mg/2ml, 0.5

mg/2ml..............................................................66 budesonide inhalation suspension 1 mg/2ml............66 budesonide oral......................................................54 budesonide oral......................................................57 budesonide oral......................................................63 bumetanide injection.............................................46 bumetanide oral....................................................46 buprenorphine hcl injection......................................8 buprenorphine hcl sublingual tablet sublingual 2

mg.......................................................................8 buprenorphine hcl sublingual tablet sublingual 2

mg.....................................................................11 buprenorphine hcl sublingual tablet sublingual 8

mg.......................................................................8 buprenorphine hcl sublingual tablet sublingual 8

mg.....................................................................11 buprenorphine hcl-naloxone hcl sublingual film 12-

3 mg..................................................................11 buprenorphine hcl-naloxone hcl sublingual film 2-

0.5 mg...............................................................11 buprenorphine hcl-naloxone hcl sublingual film 4-

1 mg..................................................................11 buprenorphine hcl-naloxone hcl sublingual film 8-

2 mg..................................................................11 buprenorphine hcl-naloxone hcl sublingual tablet

sublingual 2-0.5 mg............................................11 buprenorphine hcl-naloxone hcl sublingual tablet

sublingual 8-2 mg...............................................11 bupropion hcl er (smoking det)...............................11

bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg......................................................20

bupropion hcl er (sr) oral tablet extended release 12 hour 150 mg, 200 mg.........................................20

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg......................................................20

bupropion hcl er (xl) oral tablet extended release 24 hour 300 mg......................................................20

bupropion hcl oral tablet 100 mg............................20 bupropion hcl oral tablet 75 mg..............................20 buspirone hcl oral tablet 10 mg...............................38 buspirone hcl oral tablet 15 mg, 5 mg, 7.5 mg.........38 buspirone hcl oral tablet 30 mg...............................38 busulfan................................................................26 butorphanol tartrate injection solution 1 mg/ml.........8 butorphanol tartrate injection solution 2 mg/ml.........8 butorphanol tartrate nasal........................................8 BYDUREON BCISE...........................................41 BYDUREON SUBCUTANEOUS PEN-

INJECTOR......................................................41 BYETTA 10 MCG PEN SUBCUTANEOUS

SOLUTION PEN-INJECTOR........................41 BYETTA 5 MCG PEN SUBCUTANEOUS

SOLUTION PEN-INJECTOR........................41 BYSTOLIC..........................................................46 cabergoline............................................................60 CABOMETYX....................................................26 calcipotriene external cream....................................50 calcipotriene external ointment...............................50 calcipotriene external solution.................................50 calcitonin (salmon)................................................64 calcitrene...............................................................50 calcitriol external...................................................50 calcitriol intravenous solution 1 mcg/ml..................51 calcitriol oral capsule..............................................64 calcitriol oral solution............................................64 calcium acetate (phos binder) oral capsule...............55 CALQUENCE....................................................26 camila...................................................................57 candesartan cilexetil...............................................46 candesartan cilexetil-hctz........................................46 CAPASTAT SULFATE.......................................25 CAPRELSA ORAL TABLET 100 MG................26 CAPRELSA ORAL TABLET 300 MG................26 captopril oral.........................................................46 captopril-hydrochlorothiazide.................................46 CARBAGLU........................................................51


carbamazepine er oral capsule extended release 12 hour...................................................................40

carbamazepine er oral tablet extended release 12 hour...................................................................17

carbamazepine er oral tablet extended release 12 hour 100 mg......................................................40

carbamazepine oral................................................17 carbamazepine oral................................................40 carbidopa oral.......................................................32 carbidopa oral.......................................................32 carbidopa-levodopa er oral tablet extended release

25-100 mg, 50-200 mg......................................32 carbidopa-levodopa oral tablet................................32 carbidopa-levodopa oral tablet dispersible................32 carboplatin intravenous solution.............................26 CAREONE UNIFINE PENTIPS PLUS 29G X

12MM..............................................................41 carmustine............................................................26 carteolol hcl...........................................................65 cartia xt................................................................46 carvedilol..............................................................46 CASPOFUNGIN ACETATE INTRAVENOUS

SOLUTION RECONSTITUTED 50 MG...................................................................23

caspofungin acetate intravenous solution reconstituted 70 mg................................................................23

CAYSTON..........................................................13 CAYSTON..........................................................66 caziant..................................................................57 CEFACLOR ER..................................................13 cefaclor oral capsule................................................13 cefaclor oral suspension reconstituted 125 mg/5ml,

375 mg/5ml.......................................................13 cefaclor oral suspension reconstituted 250 mg/

5ml....................................................................13 cefadroxil oral capsule............................................13 cefadroxil oral suspension reconstituted....................13 cefadroxil oral tablet..............................................13 cefazolin sodium injection solution reconstituted 1

gm, 10 gm, 500 mg............................................13 CEFAZOLIN SODIUM INJECTION

SOLUTION RECONSTITUTED 100 GM, 300 GM............................................................13

cefazolin sodium intravenous solution reconstituted.......................................................13

CEFAZOLIN SODIUM-DEXTROSE INTRAVENOUS SOLUTION 1-4 GM/ 50ML-%...........................................................13

CEFAZOLIN SODIUM-DEXTROSE INTRAVENOUS SOLUTION RECONSTITUTED 1-4 GM-%(50ML), 2-3 GM-%(50ML)..................................................13

cefdinir.................................................................13 cefepime hcl injection.............................................13 CEFEPIME HCL INTRAVENOUS...................13 cefixime oral suspension reconstituted......................13 cefotaxime sodium injection solution reconstituted 1

gm, 500 mg........................................................13 cefotetan disodium injection solution reconstituted

1 gm, 2 gm.........................................................14 cefoxitin sodium....................................................14 CEFOXITIN SODIUM-DEXTROSE

INTRAVENOUS SOLUTION RECONSTITUTED 1-4 GM-%(50ML), 2- 2.2 GM-%(50ML)............................................14

cefpodoxime proxetil...............................................14 cefprozil oral suspension reconstituted 125 mg/

5ml....................................................................14 cefprozil oral suspension reconstituted 250 mg/

5ml....................................................................14 cefprozil oral tablet................................................14 CEFTAZIDIME AND DEXTROSE

INTRAVENOUS SOLUTION RECONSTITUTED 1-5 GM-%(50ML), 2-5 GM-%(50ML)..................................................14

ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 gm............................................................14

ceftriaxone sodium in dextrose................................14 ceftriaxone sodium injection solution reconstituted

1 gm, 2 gm, 250 mg, 500 mg..............................14 CEFTRIAXONE SODIUM INJECTION

SOLUTION RECONSTITUTED 100 GM...................................................................14

ceftriaxone sodium intravenous...............................14 CEFTRIAXONE SODIUM-DEXTROSE

INTRAVENOUS SOLUTION RECONSTITUTED 1-3.74 GM-%(50ML), 2-2.22 GM-%(50ML).......................................14

cefuroxime axetil oral tablet....................................14 cefuroxime sodium injection solution reconstituted

7.5 gm, 750 mg..................................................14 cefuroxime sodium intravenous solution reconstituted

1.5 gm...............................................................14 celecoxib oral...........................................................8 celecoxib oral.........................................................11 CELONTIN........................................................17


cephalexin oral capsule 250 mg, 500 mg.................14 cephalexin oral suspension reconstituted...................14 cephalexin oral tablet.............................................14 CERDELGA........................................................55 CEREZYME INTRAVENOUS SOLUTION

RECONSTITUTED 400 UNIT......................51 cetirizine hcl allergy child.......................................66 cetirizine hcl oral solution 1 mg/ml.........................66 CHANTIX CONTINUING MONTH

PAK..................................................................11 CHANTIX ORAL TABLET 0.5 MG.................11 CHANTIX ORAL TABLET 1 MG....................11 CHANTIX STARTING MONTH PAK............11 chateal..................................................................57 chateal eq..............................................................57 chloramphenicol sod succinate.................................14 chlorhexidine gluconate mouth/throat......................49 chloroquine phosphate oral.....................................31 chlorothiazide oral.................................................46 chlorothiazide sodium............................................46 CHLORPROMAZINE HCL INJECTION........32 chlorpromazine hcl oral tablet 10 mg......................23 chlorpromazine hcl oral tablet 10 mg......................32 chlorpromazine hcl oral tablet 100 mg, 200 mg, 25

mg, 50 mg..........................................................23 chlorpromazine hcl oral tablet 100 mg, 200 mg, 25

mg, 50 mg..........................................................32 chlorthalidone oral tablet 25 mg, 50 mg..................46 cholestyramine light...............................................46 cholestyramine oral................................................46 ciclodan external solution.......................................50 ciclopirox external gel.............................................23 ciclopirox external shampoo....................................23 ciclopirox external solution.....................................23 ciclopirox olamine external.....................................23 cilostazol...............................................................44 CIMDUO...........................................................35 cinacalcet hcl oral tablet 30 mg, 60 mg...................64 cinacalcet hcl oral tablet 90 mg...............................64 CIPRODEX........................................................66 ciprofloxacin hcl ophthalmic...................................14 ciprofloxacin hcl oral tablet 100 mg........................14 ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750

mg.....................................................................14 ciprofloxacin in d5w..............................................14 cisplatin intravenous solution 100 mg/100ml, 200

mg/200ml, 50 mg/50ml......................................26 citalopram hydrobromide oral solution....................20

citalopram hydrobromide oral tablet 10 mg.............20 citalopram hydrobromide oral tablet 20 mg.............20 citalopram hydrobromide oral tablet 40 mg.............20 cladribine intravenous solution 10 mg/10ml............26 claravis oral capsule 10 mg, 20 mg, 40 mg..............50 clarithromycin er...................................................14 clarithromycin oral................................................14 clemastine fumarate oral tablet 2.68 mg..................66 CLEVER CHOICE COMFORT EZ 29G X

12MM..............................................................42 clindacin etz external swab.....................................50 clindacin-p............................................................14 clindamycin hcl oral...............................................14 clindamycin phos-benzoyl perox external gel 1-5 %,

1.2-5 %.............................................................50 clindamycin phosphate external gel..........................14 clindamycin phosphate external lotion.....................14 clindamycin phosphate external solution..................14 clindamycin phosphate external swab......................14 clindamycin phosphate in d5w................................14 clindamycin phosphate injection solution 300 mg/

2ml, 600 mg/4ml, 9 gm/60ml, 9000 mg/ 60ml..................................................................14

clindamycin phosphate vaginal...............................14 CLINIMIX E/DEXTROSE (2.75/5)...................51 CLINIMIX E/DEXTROSE (4.25/10).................51 CLINIMIX E/DEXTROSE (4.25/5)...................51 CLINIMIX E/DEXTROSE (5/15)......................51 CLINIMIX E/DEXTROSE (5/20)......................51 CLINIMIX/DEXTROSE (4.25/10)....................51 CLINIMIX/DEXTROSE (4.25/25)....................51 CLINIMIX/DEXTROSE (4.25/5)......................51 CLINIMIX/DEXTROSE (5/15).........................51 CLINIMIX/DEXTROSE (5/20).........................51 CLINIMIX/DEXTROSE (5/25).........................51 clobazam oral suspension........................................17 clobazam oral tablet 10 mg....................................17 clobazam oral tablet 20 mg....................................17 clobetasol prop emollient base..................................56 clobetasol propionate e............................................56 clobetasol propionate emulsion................................56 clobetasol propionate external cream........................56 clobetasol propionate external foam.........................56 clobetasol propionate external gel.............................56 clobetasol propionate external lotion........................56 clobetasol propionate external ointment...................56 clobetasol propionate external shampoo....................56 clobetasol propionate external solution.....................56


clodan external shampoo........................................56 clofarabine............................................................26 CLOLAR.............................................................26 clomipramine hcl oral............................................20 clonazepam oral tablet 0.5 mg................................17 clonazepam oral tablet 0.5 mg................................38 clonazepam oral tablet 1 mg...................................17 clonazepam oral tablet 1 mg...................................39 clonazepam oral tablet 2 mg...................................17 clonazepam oral tablet 2 mg...................................39 clonazepam oral tablet dispersible 0.125 mg............17 clonazepam oral tablet dispersible 0.125 mg............39 clonazepam oral tablet dispersible 0.25 mg..............17 clonazepam oral tablet dispersible 0.25 mg..............39 clonazepam oral tablet dispersible 0.5 mg................17 clonazepam oral tablet dispersible 0.5 mg................39 clonazepam oral tablet dispersible 1 mg...................17 clonazepam oral tablet dispersible 1 mg...................39 clonazepam oral tablet dispersible 2 mg...................17 clonazepam oral tablet dispersible 2 mg...................39 clonidine...............................................................46 clonidine hcl er......................................................49 clonidine hcl oral...................................................46 clopidogrel bisulfate oral tablet 300 mg...................44 clopidogrel bisulfate oral tablet 75 mg.....................44 clorazepate dipotassium..........................................17 clorazepate dipotassium..........................................39 clotrimazole external cream....................................23 clotrimazole external solution.................................23 clotrimazole mouth/throat lozenge...........................23 clotrimazole mouth/throat troche............................49 clotrimazole-betamethasone external cream..............50 clotrimazole-betamethasone external lotion..............50 clovique................................................................51 clozapine oral tablet 100 mg..................................32 clozapine oral tablet 200 mg..................................32 clozapine oral tablet 25 mg....................................32 clozapine oral tablet 50 mg....................................32 clozapine oral tablet dispersible 100 mg..................32 clozapine oral tablet dispersible 12.5 mg.................32 clozapine oral tablet dispersible 150 mg..................32 clozapine oral tablet dispersible 200 mg..................32 clozapine oral tablet dispersible 25 mg....................32 COARTEM.........................................................31 CODEINE SULFATE ORAL TABLET 30 MG,

60 MG................................................................8 colchicine oral tablet..............................................24 colchicine-probenecid.............................................24

colesevelam hcl.......................................................42 colesevelam hcl.......................................................46 colestipol hcl oral granules......................................46 colestipol hcl oral packet.........................................46 colestipol hcl oral tablet..........................................46 colistimethate sodium (cba)....................................14 colistimethate sodium (cba)....................................14 colocort.................................................................63 COMBIGAN.......................................................65 COMBIVENT RESPIMAT................................66 COMETRIQ (100 MG DAILY DOSE)..............26 COMETRIQ (140 MG DAILY DOSE)..............26 COMETRIQ (60 MG DAILY DOSE)................26 COMFORT ASSIST INSULIN SYRINGE 29G

X 1/2" 1 ML.....................................................42 COMPLERA.......................................................35 compro..................................................................23 constulose..............................................................54 COPIKTRA.........................................................26 CORLANOR ORAL SOLUTION.....................46 CORLANOR ORAL TABLET...........................46 cortisone acetate oral..............................................11 cortisone acetate oral..............................................56 cortisone acetate oral..............................................63 COSENTYX........................................................50 COSENTYX (300 MG DOSE)...........................50 COSMEGEN......................................................26 COTELLIC.........................................................26 COUMADIN ORAL..........................................44 CREON..............................................................55 CRIXIVAN ORAL CAPSULE 200 MG.............35 CRIXIVAN ORAL CAPSULE 400 MG.............36 cromolyn sodium inhalation...................................66 cromolyn sodium ophthalmic..................................65 cromolyn sodium oral.............................................66 cryselle-28.............................................................57 CVS GAUZE STERILE PAD 2"X2"...................42 cyclafem 1/35........................................................57 cyclafem 7/7/7.......................................................57 cyclobenzaprine hcl oral tablet 10 mg, 5 mg............68 cyclobenzaprine hcl oral tablet 7.5 mg.....................68 cyclophosphamide oral capsule.................................26 CYCLOSET........................................................42 cyclosporine intravenous.........................................61 cyclosporine modified oral capsule 100 mg...............61 cyclosporine modified oral capsule 25 mg, 50

mg.....................................................................61 cyclosporine modified oral solution..........................61


cyclosporine oral capsule.........................................61 cyproheptadine hcl oral tablet.................................66 CYRAMZA..........................................................26 cyred.....................................................................57 cyred eq.................................................................57 CYSTADANE.....................................................55 CYSTAGON.......................................................55 CYSTARAN........................................................65 cytarabine (pf).......................................................26 cytarabine injection solution...................................26 dacarbazine intravenous........................................26 dactinomycin.........................................................26 dalfampridine er....................................................49 DALIRESP..........................................................66 danazol oral capsule 100 mg, 200 mg.....................57 danazol oral capsule 50 mg....................................57 dantrolene sodium oral capsule 100 mg...................35 dantrolene sodium oral capsule 25 mg, 50 mg.........35 dapsone oral..........................................................25 DAPTACEL INTRAMUSCULAR

SUSPENSION 23-15-5....................................61 DAPTOMYCIN INTRAVENOUS SOLUTION

RECONSTITUTED 350 MG.........................14 daptomycin intravenous solution reconstituted 500

mg.....................................................................15 DARAPRIM........................................................31 DARZALEX........................................................26 dasetta 1/35..........................................................58 dasetta 7/7/7.........................................................58 daunorubicin hcl intravenous solution 20 mg/

4ml....................................................................26 DAUNORUBICIN HCL INTRAVENOUS

SOLUTION 50 MG/10ML.............................26 DAURISMO ORAL TABLET 100 MG.............26 DAURISMO ORAL TABLET 25 MG...............26 deblitane...............................................................58 decadron oral tablet 0.5 mg....................................11 decadron oral tablet 0.75 mg, 4 mg, 6 mg...............11 decitabine.............................................................26 deferasirox oral tablet soluble..................................51 DELSTRIGO......................................................36 delyla....................................................................58 demeclocycline hcl oral...........................................15 DEMSER.............................................................46 denta 5000 plus....................................................49 dentagel................................................................49 DEPEN TITRATABS.........................................51 DEPEN TITRATABS.........................................55

DEPEN TITRATABS.........................................61 DEPO-ESTRADIOL...........................................58 DEPO-PROVERA INTRAMUSCULAR

SUSPENSION 400 MG/ML............................58 DESCOVY..........................................................36 desipramine hcl oral...............................................20 desmopressin ace spray refrig...................................57 desmopressin acetate injection.................................57 desmopressin acetate oral........................................57 desmopressin acetate spray......................................57 desogestrel-ethinyl estradiol.....................................58 desonide external...................................................56 desoximetasone external cream................................56 desoximetasone external gel.....................................56 desoximetasone external ointment 0.25 %...............56 DESVENLAFAXINE ER ORAL TABLET

EXTENDED RELEASE 24 HOUR 100 MG...................................................................20

DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 50 MG...................................................................21

desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg.......................................21

desvenlafaxine succinate er oral tablet extended release 24 hour 25 mg.........................................21

desvenlafaxine succinate er oral tablet extended release 24 hour 50 mg.........................................21

DEXAMETHASONE INTENSOL....................11 DEXAMETHASONE INTENSOL....................56 DEXAMETHASONE INTENSOL....................63 dexamethasone oral elixir.......................................11 dexamethasone oral elixir.......................................56 dexamethasone oral elixir.......................................63 dexamethasone oral solution...................................11 dexamethasone oral tablet.......................................11 dexamethasone oral tablet.......................................56 dexamethasone oral tablet.......................................63 DEXAMETHASONE SOD PHOSPHATE PF

INJECTION SOLUTION...............................11 dexamethasone sodium phosphate injection..............11 dexamethasone sodium phosphate ophthalmic..........65 dexrazoxane hcl.....................................................26 dextroamphetamine sulfate oral tablet 10 mg..........49 dextroamphetamine sulfate oral tablet 5 mg............49 dextrose in lactated ringers......................................51 dextrose intravenous solution 10 %, 5 %................51 dextrose intravenous solution 250 mg/ml, 30 %, 70

%......................................................................51


DEXTROSE INTRAVENOUS SOLUTION 40 %......................................................................51

dextrose intravenous solution 50 %.........................51 DEXTROSE-NACL INTRAVENOUS

SOLUTION 10-0.2 %.....................................51 dextrose-nacl intravenous solution 10-0.45 %, 2.5-

0.45 %, 5-0.2 %, 5-0.225 %, 5-0.33 %, 5-0.45 %, 5-0.9 %.......................................................51

DIASTAT ACUDIAL.........................................17 DIASTAT ACUDIAL.........................................17 DIASTAT ACUDIAL.........................................39 DIASTAT PEDIATRIC......................................17 DIASTAT PEDIATRIC......................................17 DIASTAT PEDIATRIC......................................39 diazepam intensol..................................................49 diazepam oral concentrate......................................17 diazepam oral concentrate......................................17 diazepam oral concentrate......................................39 diazepam oral solution 5 mg/5ml............................17 diazepam oral solution 5 mg/5ml............................17 diazepam oral solution 5 mg/5ml............................39 diazepam oral tablet 10 mg....................................17 diazepam oral tablet 10 mg....................................17 diazepam oral tablet 10 mg....................................39 diazepam oral tablet 2 mg......................................18 diazepam oral tablet 2 mg......................................18 diazepam oral tablet 2 mg......................................39 diazepam oral tablet 5 mg......................................18 diazepam oral tablet 5 mg......................................18 diazepam oral tablet 5 mg......................................39 diazepam rectal.....................................................18 diclofenac potassium.................................................8 diclofenac potassium...............................................11 diclofenac sodium er.................................................8 diclofenac sodium er...............................................11 diclofenac sodium ophthalmic.................................65 diclofenac sodium oral..............................................8 diclofenac sodium oral............................................11 diclofenac sodium transdermal gel 1 %...................50 diclofenac sodium transdermal gel 3 %.....................8 diclofenac sodium transdermal gel 3 %...................50 dicloxacillin sodium...............................................15 dicyclomine hcl oral capsule....................................54 dicyclomine hcl oral solution...................................54 dicyclomine hcl oral tablet......................................54 didanosine oral capsule delayed release 200 mg........36 didanosine oral capsule delayed release 250 mg, 400

mg.....................................................................36

diflorasone diacetate external..................................56 diflunisal oral..........................................................8 diflunisal oral........................................................12 digitek oral tablet 125 mcg.....................................46 digitek oral tablet 250 mcg.....................................46 digox oral tablet 125 mcg.......................................46 digox oral tablet 250 mcg.......................................46 digoxin injection....................................................46 digoxin oral solution..............................................46 digoxin oral tablet 125 mcg....................................46 digoxin oral tablet 250 mcg....................................46 dihydroergotamine mesylate nasal...........................24 DILANTIN INFATABS.....................................18 DILANTIN ORAL CAPSULE 30 MG...............18 dilt-xr...................................................................46 diltiazem hcl er beads oral capsule extended release

24 hour 120 mg, 180 mg, 240 mg, 300 mg.........46 diltiazem hcl er beads oral capsule extended release

24 hour 360 mg.................................................46 diltiazem hcl er beads oral capsule extended release

24 hour 420 mg.................................................46 diltiazem hcl er coated beads oral capsule extended

release 24 hour...................................................46 diltiazem hcl er oral capsule extended release 12

hour...................................................................46 diltiazem hcl er oral capsule extended release 24 hour

120 mg..............................................................46 diltiazem hcl intravenous solution...........................46 DILTIAZEM HCL INTRAVENOUS

SOLUTION RECONSTITUTED..................46 diltiazem hcl oral...................................................46 DIPENTUM.......................................................63 diphenhydramine hcl injection................................66 diphenoxylate-atropine oral liquid..........................54 diphenoxylate-atropine oral tablet...........................54 DIPHTHERIA-TETANUS TOXOIDS DT.......61 disopyramide phosphate oral...................................46 disulfiram oral.......................................................11 divalproex sodium er oral tablet extended release 24

hour...................................................................18 divalproex sodium er oral tablet extended release 24

hour...................................................................24 divalproex sodium er oral tablet extended release 24

hour...................................................................40 divalproex sodium oral capsule delayed release

sprinkle..............................................................18 divalproex sodium oral capsule delayed release

sprinkle..............................................................24


divalproex sodium oral capsule delayed release sprinkle..............................................................40

divalproex sodium oral tablet delayed release...........18 divalproex sodium oral tablet delayed release...........24 divalproex sodium oral tablet delayed release...........40 DOCETAXEL INTRAVENOUS

CONCENTRATE 160 MG/8ML, 20 MG/ ML, 200 MG/10ML, 80 MG/4ML..................26

DOCETAXEL INTRAVENOUS SOLUTION 160 MG/16ML.................................................26

DOCETAXEL INTRAVENOUS SOLUTION 20 MG/2ML, 80 MG/8ML..............................26

dofetilide...............................................................46 donepezil hcl oral tablet 10 mg, 5 mg......................20 donepezil hcl oral tablet 23 mg...............................20 donepezil hcl oral tablet dispersible.........................20 dorzolamide hcl ophthalmic....................................65 dorzolamide hcl-timolol mal...................................65 DOVATO...........................................................36 doxazosin mesylate oral..........................................46 doxazosin mesylate oral..........................................55 doxepin hcl oral capsule..........................................21 doxepin hcl oral capsule..........................................39 doxepin hcl oral capsule 10 mg, 100 mg, 25 mg, 50

mg, 75 mg..........................................................68 doxepin hcl oral concentrate....................................21 doxepin hcl oral concentrate....................................39 doxepin hcl oral concentrate....................................68 doxercalciferol intravenous.....................................51 doxercalciferol oral capsule 0.5 mcg.........................51 doxercalciferol oral capsule 0.5 mcg.........................64 doxorubicin hcl intravenous solution.......................26 doxorubicin hcl liposomal.......................................26 doxy 100...............................................................15 doxycycline hyclate intravenous...............................15 doxycycline hyclate oral capsule...............................15 doxycycline hyclate oral capsule...............................49 doxycycline hyclate oral capsule 50 mg.....................50 doxycycline hyclate oral tablet 100 mg, 150 mg, 20

mg, 75 mg..........................................................15 doxycycline hyclate oral tablet 100 mg, 150 mg, 20

mg, 75 mg..........................................................50 doxycycline monohydrate oral capsule 100 mg, 50

mg.....................................................................15 doxycycline monohydrate oral capsule 100 mg, 50

mg.....................................................................50 doxycycline monohydrate oral tablet 100 mg, 50

mg.....................................................................50

doxycycline monohydrate oral tablet 100 mg, 50 mg, 75 mg................................................................15

doxycycline monohydrate oral tablet 150 mg............15 doxycycline monohydrate oral tablet 150 mg............50 doxycycline monohydrate oral tablet 50 mg, 75

mg.....................................................................50 dronabinol............................................................23 DROPLET PEN NEEDLES 30G X 8 MM........42 drospirenone-ethinyl estradiol oral tablet 3-0.03

mg.....................................................................58 DROXIA.............................................................26 DULERA.............................................................66 duloxetine hcl oral capsule delayed release particles

20 mg................................................................21 duloxetine hcl oral capsule delayed release particles











60 mg................................................................49 duramorph..............................................................8 DUREZOL..........................................................65 dutasteride oral......................................................55 dutasteride-tamsulosin hcl......................................55 e.e.s. 400 oral tablet...............................................15 EASY TOUCH PEN NEEDLES 29G X

12MM..............................................................42 EASY TOUCH SAFETY PEN NEEDLES 30G

X 8 MM............................................................42 econazole nitrate external.......................................23 EDURANT.........................................................36 efavirenz oral capsule 200 mg.................................36


efavirenz oral capsule 50 mg...................................36 efavirenz oral tablet...............................................36 effer-k oral tablet effervescent 25 meq......................51 ELAPRASE..........................................................55 elinest...................................................................58 ELIQUIS.............................................................44 ELIQUIS STARTER PACK................................44 elite-ob..................................................................52 ELITEK...............................................................26 ELIXOPHYLLIN................................................66 ELLA...................................................................58 ELMIRON..........................................................55 EMCYT...............................................................26 emoquette..............................................................58 EMPLICITI.........................................................26 EMSAM..............................................................21 EMTRIVA ORAL CAPSULE.............................36 EMTRIVA ORAL SOLUTION..........................36 enalapril maleate oral............................................46 enalapril-hydrochlorothiazide.................................46 ENBREL MINI.....................................................8 ENBREL SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 25 MG/0.5ML...........61 ENBREL SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 50 MG/ML................61 ENBREL SUBCUTANEOUS SOLUTION

RECONSTITUTED........................................61 ENBREL SURECLICK SUBCUTANEOUS

SOLUTION AUTO-INJECTOR....................61 endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325

mg.......................................................................8 endocet oral tablet 2.5-325 mg.................................9 ENGERIX-B INJECTION.................................61 enoxaparin sodium injection...................................44 enoxaparin sodium subcutaneous solution 100 mg/

ml, 150 mg/ml...................................................44 enoxaparin sodium subcutaneous solution 120 mg/

0.8ml, 80 mg/0.8ml...........................................44 enoxaparin sodium subcutaneous solution 30 mg/

0.3ml.................................................................44 enoxaparin sodium subcutaneous solution 40 mg/

0.4ml.................................................................44 enoxaparin sodium subcutaneous solution 60 mg/

0.6ml.................................................................44 enpresse-28............................................................58 enskyce oral tablet 0.15-30 mg-mcg........................58 entacapone............................................................32 entecavir...............................................................36

ENTRESTO........................................................46 enulose..................................................................54 EPCLUSA............................................................36 EPCLUSA............................................................36 EPIDIOLEX........................................................18 epinephrine injection solution auto-injector 0.15

mg/0.3ml, 0.3 mg/0.3ml.....................................66 EPINEPHRINE PF INJECTION

SOLUTION.....................................................66 epinephrine pf injection solution prefilled

syringe................................................................66 epirubicin hcl intravenous solution 200 mg/100ml,

50 mg/25ml.......................................................26 epitol....................................................................18 epitol....................................................................40 EPIVIR HBV ORAL SOLUTION......................36 eplerenone.............................................................46 eprosartan mesylate................................................46 EQUETRO ORAL CAPSULE EXTENDED

RELEASE 12 HOUR 100 MG.........................18 EQUETRO ORAL CAPSULE EXTENDED





RELEASE 12 HOUR 300 MG.........................40 ERBITUX............................................................26 ergoloid mesylates oral............................................20 ERGOMAR.........................................................24 ergotamine-caffeine................................................24 ERIVEDGE.........................................................26 ERLEADA...........................................................26 erlotinib hcl oral tablet 100 mg, 150 mg.................26 erlotinib hcl oral tablet 25 mg................................26 errin.....................................................................58 ERWINAZE INJECTION..................................26 ery........................................................................15 ERYTHROCIN LACTOBIONATE

INTRAVENOUS SOLUTION RECONSTITUTED 500 MG.........................15

erythrocin stearate oral tablet 250 mg.....................15 erythromycin base oral capsule delayed release

particles..............................................................15 erythromycin base oral tablet..................................15


erythromycin ethylsuccinate oral tablet....................15 erythromycin external gel........................................15 erythromycin external solution................................15 erythromycin ophthalmic........................................15 erythromycin stearate oral tablet 250 mg.................15 ESBRIET ORAL CAPSULE...............................66 ESBRIET ORAL CAPSULE...............................66 ESBRIET ORAL TABLET 267 MG...................66 ESBRIET ORAL TABLET 267 MG...................67 ESBRIET ORAL TABLET 801 MG...................67 ESBRIET ORAL TABLET 801 MG...................67 escitalopram oxalate oral solution............................21 escitalopram oxalate oral solution............................39 escitalopram oxalate oral tablet 10 mg....................21 escitalopram oxalate oral tablet 10 mg....................39 escitalopram oxalate oral tablet 20 mg....................21 escitalopram oxalate oral tablet 20 mg....................39 escitalopram oxalate oral tablet 5 mg......................21 escitalopram oxalate oral tablet 5 mg......................39 esomeprazole sodium intravenous solution

reconstituted 40 mg............................................54 estarylla.................................................................58 estradiol oral.........................................................58 estradiol transdermal patch weekly..........................58 estradiol vaginal cream...........................................58 estradiol valerate intramuscular oil 20 mg/ml..........58 estradiol valerate intramuscular oil 40 mg/ml..........58 ESTRING............................................................58 ethambutol hcl oral................................................25 ethosuximide oral capsule.......................................18 ethosuximide oral solution......................................18 ethynodiol diac-eth estradiol...................................58 etodolac er...............................................................9 etodolac er.............................................................12 etodolac oral capsule.................................................9 etodolac oral capsule 200 mg..................................12 etodolac oral tablet...................................................9 etodolac oral tablet.................................................12 ETOPOPHOS....................................................26 etoposide intravenous solution 1 gm/50ml................26 etoposide intravenous solution 100 mg/5ml, 500 mg/

25ml..................................................................27 everolimus.............................................................27 EVOMELA..........................................................27 EVOTAZ.............................................................36 EXEL COMFORT POINT PEN NEEDLE 29G

X 12MM...........................................................42 exemestane............................................................27

ezetimibe...............................................................46 FABRAZYME......................................................55 falmina.................................................................58 famciclovir oral tablet 125 mg, 250 mg..................36 famciclovir oral tablet 500 mg................................36 famotidine intravenous solution 20 mg/2ml, 200

mg/20ml, 40 mg/4ml..........................................54 famotidine oral suspension reconstituted..................54 famotidine oral tablet 20 mg..................................54 famotidine oral tablet 40 mg..................................54 famotidine premixed..............................................54 FANAPT ORAL TABLET 1 MG........................32 FANAPT ORAL TABLET 10 MG, 12 MG........32 FANAPT ORAL TABLET 2 MG........................32 FANAPT ORAL TABLET 4 MG........................32 FANAPT ORAL TABLET 6 MG........................32 FANAPT ORAL TABLET 8 MG........................33 FANAPT TITRATION PACK...........................33 FARYDAK ORAL CAPSULE 10 MG.................27 FARYDAK ORAL CAPSULE 15 MG, 20

MG...................................................................27 FASLODEX INTRAMUSCULAR SOLUTION

250 MG/5ML...................................................27 febuxostat..............................................................24 felbamate..............................................................18 felodipine er..........................................................46 FEMRING..........................................................58 femynor.................................................................58 fenofibrate micronized oral capsule 130 mg.............46 fenofibrate micronized oral capsule 134 mg, 200

mg, 43 mg, 67 mg..............................................46 fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54

mg.....................................................................46 fenofibric acid oral capsule delayed release 135

mg.....................................................................46 fenofibric acid oral capsule delayed release 45

mg.....................................................................46 fenofibric acid oral tablet.......................................46 fenoprofen calcium oral tablet...................................9 fenoprofen calcium oral tablet.................................12 fentanyl citrate buccal lozenge on a handle................9 fentanyl citrate buccal lozenge on a handle................9 fentanyl transdermal patch 72 hour 100 mcg/hr, 12

mcg/hr, 50 mcg/hr, 75 mcg/hr...............................9 fentanyl transdermal patch 72 hour 100 mcg/hr, 12

mcg/hr, 50 mcg/hr, 75 mcg/hr...............................9 fentanyl transdermal patch 72 hour 25 mcg/hr..........9 fentanyl transdermal patch 72 hour 25 mcg/hr..........9


FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG...........21

FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG...........................21

FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 40 MG...........................21

FETZIMA TITRATION....................................21 finasteride oral tablet 5 mg.....................................55 FIRAZYR............................................................61 FIRMAGON SUBCUTANEOUS SOLUTION

RECONSTITUTED 120 MG.........................60 FIRMAGON SUBCUTANEOUS SOLUTION

RECONSTITUTED 80 MG...........................60 flac.......................................................................66 flavoxate hcl..........................................................55 flecainide acetate....................................................46 FLOVENT DISKUS INHALATION AEROSOL

POWDER BREATH ACTIVATED 100 MCG/BLIST, 50 MCG/BLIST........................67

FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250 MCG/BLIST....................................................67

FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT................................................67

FLOVENT HFA INHALATION AEROSOL 220 MCG/ACT................................................67

FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT..................................................67

fluconazole in sodium chloride intravenous solution 200-0.9 mg/100ml-%, 400-0.9 mg/200ml- %......................................................................24

fluconazole oral suspension reconstituted..................24 fluconazole oral tablet............................................24 flucytosine oral capsule 250 mg...............................24 flucytosine oral capsule 500 mg...............................24 fludarabine phosphate............................................27 fludrocortisone acetate oral.....................................56 flunisolide nasal solution 25 mcg/act (0.025%).......67 fluocinolone acetonide external cream......................56 fluocinolone acetonide external ointment.................56 fluocinolone acetonide external solution...................56 fluocinolone acetonide otic......................................56 fluocinonide emulsified base...................................56 fluocinonide external cream 0.05 %.......................50 fluocinonide external gel.........................................56 fluocinonide external ointment...............................56 fluocinonide external solution.................................56 fluoritab oral tablet chewable 1.1 (0.5 f) mg...........52

fluoritab oral tablet chewable 2.2 (1 f) mg..............52 fluorometholone ophthalmic...................................65 fluorouracil external cream 5 %.............................50 fluorouracil external solution..................................50 fluorouracil intravenous.........................................27 fluoxetine hcl oral capsule 10 mg............................21 fluoxetine hcl oral capsule 20 mg............................21 fluoxetine hcl oral capsule 40 mg............................21 fluoxetine hcl oral solution......................................21 fluphenazine decanoate injection............................33 fluphenazine hcl injection.......................................33 fluphenazine hcl oral concentrate............................33 fluphenazine hcl oral elixir.....................................33 fluphenazine hcl oral tablet 1 mg, 2.5 mg...............33 fluphenazine hcl oral tablet 10 mg, 5 mg................33 flurbiprofen oral......................................................9 flurbiprofen oral....................................................12 flurbiprofen sodium...............................................65 flutamide..............................................................27 fluticasone propionate external cream......................50 fluticasone propionate external cream......................56 fluticasone propionate external ointment.................50 fluticasone propionate external ointment.................56 fluticasone propionate nasal....................................67 fluticasone-salmeterol inhalation aerosol powder

breath activated 100-50 mcg/dose, 250-50 mcg/ dose, 500-50 mcg/dose.........................................67

fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/ dose, 500-50 mcg/dose.........................................67

fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/ dose, 500-50 mcg/dose.........................................67

fluvoxamine maleate oral tablet 100 mg.................21 fluvoxamine maleate oral tablet 25 mg...................21 fluvoxamine maleate oral tablet 50 mg...................21 FOLOTYN..........................................................27 fomepizole intravenous solution 1.5 gm/1.5ml.........49 fondaparinux sodium subcutaneous solution 10 mg/

0.8ml.................................................................44 fondaparinux sodium subcutaneous solution 2.5 mg/

0.5ml.................................................................44 fondaparinux sodium subcutaneous solution 5 mg/

0.4ml.................................................................44 fondaparinux sodium subcutaneous solution 7.5 mg/

0.6ml.................................................................44 FORTEO SUBCUTANEOUS SOLUTION 600

MCG/2.4ML....................................................64


FOSAMAX ORAL TABLET 70 MG..................64 fosamprenavir calcium...........................................36 fosinopril sodium...................................................46 fosinopril sodium-hctz............................................47 fosphenytoin sodium...............................................18 FREAMINE III INTRAVENOUS SOLUTION

10 %.................................................................52 FULPHILA..........................................................45 fulvestrant.............................................................27 furosemide injection solution 10 mg/ml...................47 furosemide injection solution 10 mg/ml (4ml

syringe)..............................................................47 furosemide oral solution 10 mg/ml, 8 mg/ml............47 furosemide oral tablet.............................................47 FUZEON SUBCUTANEOUS SOLUTION

RECONSTITUTED........................................36 fyavolv oral tablet 1-5 mg-mcg...............................58 FYCOMPA ORAL SUSPENSION.....................18 FYCOMPA ORAL TABLET 10 MG, 12

MG...................................................................18 FYCOMPA ORAL TABLET 2 MG....................18 FYCOMPA ORAL TABLET 4 MG....................18 FYCOMPA ORAL TABLET 6 MG....................18 FYCOMPA ORAL TABLET 8 MG....................18 gabapentin oral capsule 100 mg..............................18 gabapentin oral capsule 300 mg..............................18 gabapentin oral capsule 400 mg..............................18 gabapentin oral solution.........................................18 gabapentin oral tablet 600 mg................................18 gabapentin oral tablet 800 mg................................18 galantamine hydrobromide er.................................20 galantamine hydrobromide oral solution.................20 galantamine hydrobromide oral tablet.....................20 GAMUNEX-C INJECTION SOLUTION 1

GM/10ML, 10 GM/100ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML..........................61

GAMUNEX-C INJECTION SOLUTION 2.5 GM/25ML........................................................61

ganciclovir sodium intravenous solution reconstituted.......................................................36

GARDASIL 9......................................................61 GATTEX.............................................................54 gavilyte-c...............................................................54 gavilyte-g...............................................................54 gavilyte-h..............................................................54 gavilyte-n with flavor pack.....................................54 GAZYVA.............................................................27

GEMCITABINE HCL INTRAVENOUS SOLUTION 1 GM/10ML, 2 GM/20ML........27

gemcitabine hcl intravenous solution 1 gm/26.3ml, 200 mg/5.26ml..................................................27

gemcitabine hcl intravenous solution 2 gm/52.6ml, 200 mg/2ml.......................................................27

gemcitabine hcl intravenous solution reconstituted 1 gm, 200 mg.....................................................27

gemcitabine hcl intravenous solution reconstituted 2 gm..................................................................27

gemfibrozil oral.....................................................47 generlac.................................................................54 gengraf oral capsule 100 mg...................................61 gengraf oral capsule 25 mg.....................................61 gengraf oral solution...............................................61 gentak ophthalmic ointment...................................15 gentamicin in saline intravenous solution 0.8-0.9

mg/ml-%, 1-0.9 mg/ml-%, 1.2-0.9 mg/ml-%, 1.6-0.9 mg/ml-%, 2-0.9 mg/ml-%......................15

gentamicin sulfate external.....................................15 gentamicin sulfate injection....................................15 gentamicin sulfate ophthalmic solution....................15 GENVOYA.........................................................36 GEODON INTRAMUSCULAR........................33 GEODON INTRAMUSCULAR........................40 GILOTRIF..........................................................27 glatiramer acetate subcutaneous solution prefilled

syringe 20 mg/ml................................................49 glatiramer acetate subcutaneous solution prefilled

syringe 40 mg/ml................................................49 glatopa subcutaneous solution prefilled syringe 20

mg/ml................................................................49 glatopa subcutaneous solution prefilled syringe 40

mg/ml................................................................49 GLEOSTINE ORAL CAPSULE 10 MG, 100

MG, 40 MG.....................................................27 glimepiride oral tablet 1 mg...................................42 glimepiride oral tablet 2 mg...................................42 glimepiride oral tablet 4 mg...................................42 glipizide er oral tablet extended release 24 hour 10

mg.....................................................................42 glipizide er oral tablet extended release 24 hour 2.5

mg.....................................................................42 glipizide er oral tablet extended release 24 hour 5

mg.....................................................................42 glipizide oral tablet 10 mg.....................................42 glipizide oral tablet 5 mg.......................................42


glipizide xl oral tablet extended release 24 hour 10 mg.....................................................................42

glipizide xl oral tablet extended release 24 hour 2.5 mg.....................................................................42

glipizide xl oral tablet extended release 24 hour 5 mg.....................................................................42

glipizide-metformin hcl oral tablet 2.5-250 mg.......42 glipizide-metformin hcl oral tablet 2.5-500 mg, 5-

500 mg..............................................................42 GLOBAL ALCOHOL PREP EASE....................15 GLOBAL EASY GLIDE INSULIN SYR 31G X

15/64" 1 ML.....................................................42 GLUCAGEN HYPOKIT....................................42 GLUCAGON EMERGENCY INJECTION

KIT...................................................................42 glyburide oral tablet 1.25 mg.................................42 glyburide oral tablet 2.5 mg...................................42 glyburide oral tablet 5 mg......................................42 glyburide-metformin oral tablet 1.25-250 mg.........42 glyburide-metformin oral tablet 2.5-500 mg, 5-500

mg.....................................................................42 glycopyrrolate injection solution..............................54 glycopyrrolate oral tablet 1 mg, 2 mg.......................54 glydo external prefilled syringe................................10 granisetron hcl intravenous solution 1 mg/ml, 4 mg/

4ml....................................................................23 granisetron hcl oral................................................23 griseofulvin microsize oral suspension......................24 griseofulvin ultramicrosize......................................24 guanfacine hcl er....................................................49 guanfacine hcl oral.................................................47 GUANIDINE HCL ORAL.................................25 H-E-B INCONTROL PEN NEEDLES 29G X

12MM..............................................................42 hailey 1.5/30.........................................................58 HALAVEN..........................................................27 halobetasol propionate external cream.....................56 halobetasol propionate external ointment.................56 haloperidol decanoate intramuscular solution 100

mg/ml 1 ml........................................................33 haloperidol decanoate intramuscular solution 100

mg/ml, 50 mg/ml................................................33 haloperidol lactate injection....................................33 haloperidol lactate oral...........................................33 haloperidol oral tablet 0.5 mg.................................33 haloperidol oral tablet 1 mg, 10 mg, 2 mg, 5

mg.....................................................................33 haloperidol oral tablet 20 mg..................................33

HARVONI..........................................................36 HARVONI ORAL TABLET 90-400 MG...........36 HAVRIX INTRAMUSCULAR SUSPENSION

1440 EL U/ML 1 ML, 720 EL U/0.5ML 0.5 ML....................................................................61

HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ML, 720 EL U/0.5ML...................61

heather..................................................................58 HEPARIN (PORCINE) IN NACL

INTRAVENOUS SOLUTION 12500-0.45 UT/250ML-%, 25000-0.45 UT/500ML- %......................................................................45

HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 25000-0.45 UT/250ML-%..................................................45

HEPARIN SOD (PORCINE) IN D5W INTRAVENOUS SOLUTION 100 UNIT/ ML, 25000-5 UT/500ML-%............................45

heparin sod (porcine) in d5w intravenous solution 40-5 unit/ml-%.................................................45

heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml..............................................................45

hepatamine...........................................................52 HERCEPTIN HYLECTA...................................27 HERCEPTIN INTRAVENOUS SOLUTION

RECONSTITUTED 150 MG.........................27 HETLIOZ...........................................................68 HIBERIX INJECTION......................................61 HUMALOG JUNIOR KWIKPEN.....................42 HUMALOG KWIKPEN SUBCUTANEOUS

SOLUTION PEN-INJECTOR 200 UNIT/ ML....................................................................42

HUMALOG MIX 50/50.....................................42 HUMALOG MIX 50/50 KWIKPEN

SUBCUTANEOUS SUSPENSION PEN- INJECTOR......................................................42

HUMALOG MIX 75/25.....................................42 HUMALOG MIX 75/25 KWIKPEN


HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE...................................................43

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 40 MG/0.8ML (6 PACK), 80 MG/0.8ML..................................................61


HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML & 40MG/0.4ML..............61

HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT..............................................62

HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML.......................................................62

HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML.......................................................62

HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML.......................................................62

HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML...........................62

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/ 0.2ML, 20 MG/0.2ML, 20 MG/0.4ML...........62

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.4ML, 40 MG/ 0.8ML...............................................................62

HUMULIN 70/30...............................................43 HUMULIN 70/30 KWIKPEN


HUMULIN N.....................................................43 HUMULIN N KWIKPEN SUBCUTANEOUS

SUSPENSION PEN-INJECTOR....................43 HUMULIN R.....................................................43 hydralazine hcl injection........................................47 hydralazine hcl oral...............................................47 hydrochlorothiazide oral.........................................47 hydrocodone-acetaminophen oral solution 7.5-325

mg/15ml..............................................................9 hydrocodone-acetaminophen oral tablet 10-325 mg,

5-325 mg, 7.5-325 mg.........................................9 hydrocodone-ibuprofen oral tablet 7.5-200 mg..........9 hydrocortisone butyr lipo base.................................50 hydrocortisone butyrate external cream....................56 hydrocortisone butyrate external ointment...............56 hydrocortisone butyrate external solution.................56 hydrocortisone external cream 1 %, 2.5 %..............56 hydrocortisone external lotion 2.5 %.......................56 hydrocortisone external ointment 1 %.....................56 hydrocortisone external ointment 2.5 %..................56 hydrocortisone oral.................................................57

hydrocortisone oral.................................................63 hydrocortisone oral tablet 20 mg, 5 mg....................12 hydrocortisone rectal cream.....................................64 hydrocortisone rectal enema....................................64 hydrocortisone valerate external cream.....................57 hydrocortisone valerate external ointment................57 hydrocortisone-acetic acid.......................................66 hydromorphone hcl injection solution 1 mg/ml...........9 hydromorphone hcl injection solution 2 mg/ml...........9 hydromorphone hcl injection solution 4 mg/ml...........9 hydromorphone hcl oral tablet..................................9 HYDROMORPHONE HCL PF INJECTION

SOLUTION 1 MG/ML.....................................9 HYDROMORPHONE HCL PF INJECTION

SOLUTION 10 MG/ML...................................9 HYDROMORPHONE HCL PF INJECTION

SOLUTION 2 MG/ML.....................................9 HYDROMORPHONE HCL PF INJECTION

SOLUTION 4 MG/ML.....................................9 hydromorphone hcl pf injection solution 50 mg/

5ml......................................................................9 hydromorphone hcl pf injection solution 500 mg/

50ml....................................................................9 hydroxychloroquine sulfate oral...............................31 hydroxyprogesterone caproate intramuscular

solution..............................................................27 hydroxyurea oral....................................................27 hydroxyzine hcl intramuscular................................49 hydroxyzine hcl oral syrup......................................23 hydroxyzine hcl oral syrup......................................39 hydroxyzine hcl oral syrup......................................67 hydroxyzine hcl oral tablet......................................23 hydroxyzine hcl oral tablet......................................39 hydroxyzine hcl oral tablet......................................67 HYPERRAB........................................................62 HYPERRAB S/D INJECTION SOLUTION

300 UNIT/2ML...............................................62 ibandronate sodium intravenous.............................64 ibandronate sodium oral........................................64 IBRANCE...........................................................27 ibu........................................................................12 ibu oral tablet 600 mg, 800 mg................................9 ibuprofen oral suspension..........................................9 ibuprofen oral suspension........................................12 ibuprofen oral tablet 400 mg, 600 mg, 800 mg.........9 ibuprofen oral tablet 400 mg, 600 mg, 800 mg.......12 icatibant acetate....................................................62 ICLUSIG ORAL TABLET 15 MG.....................27


ICLUSIG ORAL TABLET 45 MG.....................27 idarubicin hcl........................................................27 IDHIFA ORAL TABLET 100 MG.....................27 IDHIFA ORAL TABLET 50 MG.......................27 IFEX INTRAVENOUS SOLUTION

RECONSTITUTED 3 GM.............................27 ifosfamide intravenous solution...............................27 ifosfamide intravenous solution reconstituted 1

gm.....................................................................27 IFOSFAMIDE INTRAVENOUS SOLUTION

RECONSTITUTED 3 GM.............................27 ILARIS SUBCUTANEOUS SOLUTION............9 ILEVRO..............................................................65 imatinib mesylate oral tablet 100 mg......................27 imatinib mesylate oral tablet 400 mg......................27 IMBRUVICA ORAL CAPSULE 140 MG..........27 IMBRUVICA ORAL CAPSULE 70 MG............27 IMBRUVICA ORAL TABLET 140 MG............27 IMBRUVICA ORAL TABLET 280 MG, 420

MG, 560 MG...................................................27 IMFINZI.............................................................27 imipenem-cilastatin intravenous solution

reconstituted 250 mg..........................................15 imipenem-cilastatin intravenous solution

reconstituted 500 mg..........................................15 imipramine hcl oral...............................................21 imiquimod external...............................................50 IMOGAM RABIES-HT INJECTION

SOLUTION 300 UNIT/2ML..........................62 IMOVAX RABIES..............................................62 incassia.................................................................58 INCRELEX.........................................................57 indapamide oral....................................................47 INFANRIX..........................................................62 INLYTA ORAL TABLET 1 MG.........................27 INLYTA ORAL TABLET 5 MG.........................28 INREBIC.............................................................28 INSULIN LISPRO (1 UNIT DIAL)...................43 INSULIN LISPRO SUBCUTANEOUS

SOLUTION.....................................................43 INSUPEN PEN NEEDLES 29G X 12MM........43 INSUPEN ULTRAFIN 29G X 12MM...............43 INTELENCE ORAL TABLET 100 MG............36 INTELENCE ORAL TABLET 200 MG............36 INTELENCE ORAL TABLET 25 MG..............36 intralipid intravenous emulsion 20 %.....................52 INTRALIPID INTRAVENOUS EMULSION

30 %.................................................................52

INTRON A INJECTION SOLUTION.............36 INTRON A INJECTION SOLUTION 6000000

UNIT/ML........................................................36 INTRON A INJECTION SOLUTION

RECONSTITUTED 10000000 UNIT............36 INTRON A INJECTION SOLUTION

RECONSTITUTED 10000000 UNIT, 18000000 UNIT..............................................36

INTRON A INJECTION SOLUTION RECONSTITUTED 50000000 UNIT............36

introvale...............................................................58 INVEGA SUSTENNA INTRAMUSCULAR

SUSPENSION PREFILLED SYRINGE 117 MG/0.75ML.....................................................33

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 156 MG/ML............................................................33

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 234 MG/1.5ML.......................................................33

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 39 MG/0.25ML.....................................................33

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 78 MG/0.5ML.......................................................33

INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 273 MG/0.875ML...................................................33


INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 546 MG/1.75ML.....................................................33


INVIRASE ORAL TABLET...............................36 IONOSOL-MB IN D5W....................................52 IPOL....................................................................62 ipratropium bromide inhalation.............................67 ipratropium bromide nasal.....................................67 ipratropium-albuterol............................................67 irbesartan..............................................................47 irbesartan-hydrochlorothiazide...............................47 irbesartan-hydrochlorothiazide...............................47 IRESSA................................................................28 irinotecan hcl........................................................28


ISENTRESS HD.................................................36 ISENTRESS ORAL PACKET.............................36 ISENTRESS ORAL TABLET.............................36 ISENTRESS ORAL TABLET CHEWABLE 100

MG...................................................................36 ISENTRESS ORAL TABLET CHEWABLE 25

MG...................................................................37 isibloom................................................................58 ISOLYTE-P IN D5W..........................................52 ISOLYTE-S.........................................................52 ISOLYTE-S PH 7.4.............................................52 isoniazid injection.................................................25 isoniazid oral syrup................................................25 isoniazid oral tablet...............................................25 ISOPTO ATROPINE.........................................65 isosorbide dinitrate er.............................................47 isosorbide dinitrate oral tablet 10 mg, 20 mg, 30

mg, 5 mg............................................................47 isosorbide mononitrate...........................................47 isosorbide mononitrate er........................................47 isotretinoin oral capsule 10 mg, 20 mg, 40 mg........50 isradipine..............................................................47 ISTODAX (OVERFILL).....................................28 itraconazole oral capsule.........................................24 ivermectin oral......................................................31 IXEMPRA KIT....................................................28 IXIARO...............................................................62 JAKAFI ORAL TABLET 10 MG........................28 JAKAFI ORAL TABLET 15 MG........................28 JAKAFI ORAL TABLET 20 MG........................28 JAKAFI ORAL TABLET 25 MG........................28 JAKAFI ORAL TABLET 5 MG..........................28 jantoven................................................................45 JANUMET..........................................................43 JANUMET XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 100-1000 MG...............43 JANUMET XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 50-1000 MG, 50-500 MG...................................................................43

JANUVIA ORAL TABLET 100 MG..................43 JANUVIA ORAL TABLET 25 MG....................43 JANUVIA ORAL TABLET 50 MG....................43 JARDIANCE.......................................................43 jencycla.................................................................58 JENTADUETO..................................................43 JENTADUETO..................................................43

JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG...................................................................43

JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG...................................................................43

JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG...................................................................43

JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG...................................................................43

jinteli....................................................................58 jolessa....................................................................58 juleber...................................................................58 JULUCA..............................................................37 junel 1.5/30..........................................................58 junel 1/20.............................................................58 junel fe 1.5/30.......................................................58 junel fe 1/20..........................................................58 JYNARQUE ORAL TABLET 15 MG................55 JYNARQUE ORAL TABLET 30 MG................55 K-TAB ORAL TABLET EXTENDED RELEASE

8 MEQ.............................................................52 KADCYLA..........................................................28 KALETRA ORAL TABLET 100-25 MG............37 KALETRA ORAL TABLET 200-50 MG............37 kalliga...................................................................58 KALYDECO ORAL TABLET............................67 kariva...................................................................58 kcl in dextrose-nacl intravenous solution 10-5-0.45

meq/l-%-%, 20-5-0.2 meq/l-%-%, 20-5-0.45 meq/l-%-%, 20-5-0.9 meq/l-%-%, 30-5-0.45 meq/l-%-%, 40-5-0.45 meq/l-%-%....................52

KCL IN DEXTROSE-NACL INTRAVENOUS SOLUTION 20-5-0.225 MEQ/L-%-%...........52

KCL IN DEXTROSE-NACL INTRAVENOUS SOLUTION 40-5-0.9 MEQ/L-%-%...............52

KCL-LACTATED RINGERS-D5W...................52 KEDRAB INJECTION SOLUTION 300

UNIT/2ML......................................................62 kelnor 1/35...........................................................58 kelnor 1/50...........................................................58 ketoconazole external cream....................................24 ketoconazole external shampoo 2 %........................24 ketoconazole oral...................................................24 ketoprofen oral capsule 25 mg...................................9 ketorolac tromethamine ophthalmic........................65


ketorolac tromethamine oral.....................................9 ketorolac tromethamine oral...................................12 KEYTRUDA INTRAVENOUS

SOLUTION.....................................................62 KHAPZORY.......................................................28 KINRIX INTRAMUSCULAR

SUSPENSION.................................................62 KINRIX INTRAMUSCULAR SUSPENSION

INJECTION 0.5 ML.......................................62 kionex oral suspension............................................52 KISQALI (200 MG DOSE)................................28 KISQALI (400 MG DOSE)................................28 KISQALI (600 MG DOSE)................................28 KISQALI FEMARA (400 MG DOSE)................28 KISQALI FEMARA (600 MG DOSE)................28 KISQALI FEMARA(200 MG DOSE).................28 klor-con 10...........................................................52 klor-con 10...........................................................52 klor-con m10.........................................................52 klor-con m10.........................................................52 klor-con m15.........................................................52 klor-con m15.........................................................52 klor-con m20.........................................................52 klor-con m20.........................................................52 klor-con oral tablet extended release........................52 klor-con oral tablet extended release........................52 klor-con sprinkle....................................................52 klor-con sprinkle oral capsule extended release 8

meq...................................................................52 klor-con/ef.............................................................52 KORLYM............................................................43 KROGER PEN NEEDLES 31G X 8 MM..........43 kurvelo..................................................................58 KUVAN ORAL TABLET SOLUBLE.................55 KYPROLIS..........................................................28 labetalol hcl intravenous solution............................47 labetalol hcl oral....................................................47 LACRISERT........................................................65 lactated ringers intravenous....................................52 lactated ringers irrigation.......................................52 lactulose encephalopathy.........................................54 lactulose oral solution.............................................54 lamivudine oral solution........................................37 lamivudine oral solution........................................37 lamivudine oral tablet 100 mg...............................37 lamivudine oral tablet 100 mg...............................37 lamivudine oral tablet 150 mg...............................37 lamivudine oral tablet 150 mg...............................37

lamivudine oral tablet 300 mg...............................37 lamivudine oral tablet 300 mg...............................37 lamivudine-zidovudine..........................................37 lamotrigine oral tablet............................................18 lamotrigine oral tablet............................................40 lamotrigine oral tablet chewable.............................18 lamotrigine oral tablet chewable.............................40 LANOXIN ORAL TABLET 125 MCG, 62.5

MCG................................................................47 LANOXIN ORAL TABLET 250 MCG..............47 lansoprazole oral capsule delayed release 15 mg........54 lansoprazole oral capsule delayed release 30 mg........54 LANTUS.............................................................43 LANTUS SOLOSTAR SUBCUTANEOUS

SOLUTION PEN-INJECTOR........................43 larin 1.5/30..........................................................58 larin 1/20.............................................................58 larin fe 1.5/30.......................................................58 larin fe 1/20..........................................................58 larissia..................................................................58 LARTRUVO INTRAVENOUS SOLUTION

190 MG/19ML.................................................28 latanoprost ophthalmic...........................................65 LATUDA ORAL TABLET 120 MG, 60

MG...................................................................33 LATUDA ORAL TABLET 20 MG.....................33 LATUDA ORAL TABLET 40 MG.....................33 LATUDA ORAL TABLET 80 MG.....................33 leena.....................................................................58 leflunomide oral....................................................62 leflunomide oral....................................................62 LENVIMA (10 MG DAILY DOSE)...................28 LENVIMA (12 MG DAILY DOSE)...................28 LENVIMA (14 MG DAILY DOSE)...................28 LENVIMA (18 MG DAILY DOSE)...................28 LENVIMA (20 MG DAILY DOSE)...................28 LENVIMA (24 MG DAILY DOSE)...................28 LENVIMA (4 MG DAILY DOSE).....................28 LENVIMA (8 MG DAILY DOSE).....................28 lessina...................................................................58 LETAIRIS............................................................67 letrozole oral..........................................................28 leucovorin calcium injection solution 100 mg/

10ml..................................................................28 leucovorin calcium injection solution

reconstituted.......................................................28 leucovorin calcium oral tablet 10 mg, 15 mg, 5

mg.....................................................................28


leucovorin calcium oral tablet 10 mg, 15 mg, 5 mg.....................................................................28

leucovorin calcium oral tablet 25 mg......................28 leucovorin calcium oral tablet 25 mg......................28 LEUKERAN........................................................28 leuprolide acetate injection.....................................60 levalbuterol hcl inhalation nebulization solution

0.31 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml........67 levalbuterol hcl inhalation nebulization solution

0.63 mg/3ml......................................................67 levalbuterol tartrate...............................................67 levetiracetam er oral tablet extended release 24 hour

500 mg..............................................................18 levetiracetam er oral tablet extended release 24 hour

750 mg..............................................................18 levetiracetam intravenous.......................................18 levetiracetam oral..................................................18 levo-t oral tablet 100 mcg, 112 mcg, 125 mcg, 137

mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg..........................................60

levo-t oral tablet 300 mcg.......................................60 levobunolol hcl ophthalmic solution 0.5 %..............65 levocarnitine oral solution......................................52 LEVOCARNITINE ORAL TABLET.................52 levocarnitine sf......................................................52 levocetirizine dihydrochloride oral tablet.................67 levofloxacin in d5w................................................15 levofloxacin intravenous.........................................15 levofloxacin ophthalmic..........................................15 levofloxacin oral solution........................................15 levofloxacin oral tablet...........................................15 levoleucovorin calcium intravenous solution

reconstituted 50 mg............................................28 levonest.................................................................58 levonorg-eth estrad triphasic oral tablet 50-30/75-

40/ 125-30 mcg.................................................58 levonorgest-eth estrad 91-day oral tablet 0.15-0.03

mg.....................................................................58 levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-

mcg, 0.15-30 mg-mcg.........................................58 levora 0.15/30 (28)...............................................58 levothyroxine sodium oral tablet 100 mcg, 112 mcg,

125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg........................60

levothyroxine sodium oral tablet 300 mcg................60 levoxyl...................................................................60 LEXIVA ORAL SUSPENSION..........................37 LIBTAYO............................................................28

lidocaine external patch 5 %..................................10 lidocaine hcl external solution.................................11 lidocaine hcl urethral/mucosal................................11 lidocaine viscous hcl...............................................11 lidocaine-prilocaine external cream.........................11 lillow....................................................................58 lindane external shampoo.......................................31 linezolid in sodium chloride...................................15 linezolid intravenous solution 600 mg/300ml..........15 linezolid oral suspension reconstituted.....................15 linezolid oral tablet................................................15 LINZESS.............................................................54 liothyronine sodium intravenous.............................60 liothyronine sodium oral........................................60 lisinopril oral.........................................................47 lisinopril-hydrochlorothiazide.................................47 LITHIUM...........................................................40 lithium carbonate er..............................................40 lithium carbonate oral...........................................40 LONSURF..........................................................28 loperamide hcl oral capsule.....................................54 lopinavir-ritonavir.................................................37 lorazepam intensol.................................................49 lorazepam oral concentrate 1 mg/0.5ml...................18 lorazepam oral concentrate 2 mg/ml........................18 lorazepam oral concentrate 2 mg/ml........................39 lorazepam oral tablet 0.5 mg, 1 mg........................18 lorazepam oral tablet 0.5 mg, 1 mg........................39 lorazepam oral tablet 2 mg.....................................18 lorazepam oral tablet 2 mg.....................................39 LORBRENA ORAL TABLET 100 MG..............28 LORBRENA ORAL TABLET 25 MG................28 lorcet.......................................................................9 lorcet hd..................................................................9 lorcet plus oral tablet 7.5-325 mg.............................9 losartan potassium.................................................47 losartan potassium-hctz..........................................47 lovastatin..............................................................47 low-ogestrel............................................................58 loxapine succinate oral...........................................33 ludent oral tablet chewable 0.55 (0.25 f) mg, 1.1

(0.5 f) mg..........................................................52 ludent oral tablet chewable 2.2 (1 f) mg..................52 LUMIGAN OPHTHALMIC SOLUTION 0.01

%......................................................................65 LUMOXITI.........................................................28 LUPRON DEPOT (1-MONTH).......................60


LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 7.5 MG..................60

lutera....................................................................58 LYNPARZA ORAL TABLET.............................28 LYSODREN........................................................60 lyza.......................................................................58 M-M-R II INJECTION......................................62 magnesium sulfate injection solution 50 %..............52 magnesium sulfate injection solution 50 % (10ml

syringe)..............................................................52 MAGNESIUM SULFATE INTRAVENOUS

SOLUTION 2 GM/50ML, 20 GM/500ML, 4 GM/100ML, 4 GM/50ML, 40 GM/ 1000ML............................................................52

malathion external.................................................31 maprotiline hcl oral tablet 25 mg............................21 maprotiline hcl oral tablet 50 mg............................21 maprotiline hcl oral tablet 75 mg............................21 MARATHON MEDICAL PENTIPS 29G X

12MM..............................................................43 marlissa................................................................58 marlissa................................................................58 marlissa................................................................58 MARPLAN..........................................................21 MARQIBO..........................................................28 MATULANE.......................................................28 meclizine hcl oral tablet.........................................23 meclofenamate sodium oral capsule 100 mg...............9 meclofenamate sodium oral capsule 100 mg.............12 meclofenamate sodium oral capsule 50 mg.................9 meclofenamate sodium oral capsule 50 mg...............12 medroxyprogesterone acetate intramuscular..............58 medroxyprogesterone acetate oral.............................58 mefenamic acid oral.................................................9 mefenamic acid oral...............................................12 mefloquine hcl.......................................................31 megestrol acetate oral suspension 40 mg/ml, 400 mg/

10ml..................................................................58 megestrol acetate oral tablet....................................58 MEKINIST ORAL TABLET 0.5 MG.................28 MEKINIST ORAL TABLET 2 MG....................28 MEKTOVI..........................................................28 meloxicam oral tablet...............................................9 meloxicam oral tablet.............................................12 melphalan.............................................................28 melphalan hcl........................................................28 memantine hcl er...................................................20 memantine hcl oral solution 10 mg/5ml..................20

memantine hcl oral solution 2 mg/ml......................20 memantine hcl oral tablet 10 mg............................20 memantine hcl oral tablet 5 mg..............................20 MENACTRA......................................................62 MENEST ORAL TABLET 0.3 MG, 0.625 MG,

1.25 MG...........................................................58 MENVEO...........................................................62 mercaptopurine oral...............................................62 meropenem............................................................15 mesalamine er.......................................................64 mesalamine oral capsule delayed release...................64 mesalamine oral tablet delayed release 1.2 gm..........64 mesalamine oral tablet delayed release 800 mg.........64 mesalamine rectal enema........................................64 mesalamine rectal suppository.................................64 mesalamine-cleanser...............................................54 mesna...................................................................29 MESNEX ORAL.................................................29 MESTINON ORAL SOLUTION......................25 metaproterenol sulfate oral syrup.............................67 metformin hcl er oral tablet extended release 24 hour

500 mg..............................................................43 metformin hcl er oral tablet extended release 24 hour

750 mg..............................................................43 metformin hcl oral tablet 1000 mg.........................43 metformin hcl oral tablet 500 mg...........................43 metformin hcl oral tablet 850 mg...........................43 METHADONE HCL INJECTION.....................9 methadone hcl intensol.............................................9 methadone hcl oral concentrate.................................9 methadone hcl oral solution......................................9 methadone hcl oral tablet.......................................10 METHADOSE ORAL CONCENTRATE 10

MG/ML............................................................10 METHADOSE SUGAR-FREE...........................10 methazolamide oral...............................................47 methazolamide oral...............................................65 methenamine hippurate.........................................15 methenamine mandelate oral..................................55 methimazole oral tablet 10 mg...............................60 methimazole oral tablet 5 mg.................................60 methotrexate oral...................................................62 methotrexate sodium (pf) injection solution 1 gm/

40ml, 250 mg/10ml...........................................29 methotrexate sodium (pf) injection solution 50 mg/

2ml....................................................................62 methotrexate sodium injection solution 250 mg/

10ml..................................................................29


methotrexate sodium injection solution 50 mg/ 2ml....................................................................62

methotrexate sodium injection solution reconstituted.......................................................29

methoxsalen rapid..................................................50 methscopolamine bromide oral tablet 2.5 mg...........54 methscopolamine bromide oral tablet 5 mg..............54 methyldopa oral tablet 250 mg...............................47 methyldopa oral tablet 500 mg...............................47 methylphenidate hcl oral tablet...............................49 methylprednisolone acetate injection suspension 40

mg/ml................................................................12 METHYLPREDNISOLONE ACETATE

INJECTION SUSPENSION 80 MG/ML.......12 methylprednisolone oral..........................................57 methylprednisolone oral..........................................64 methylprednisolone oral tablet................................12 methylprednisolone sodium succ injection solution

reconstituted 1000 mg, 125 mg, 40 mg................12 metoclopramide hcl injection..................................54 metoclopramide hcl oral solution 10 mg/10ml, 5 mg/

5ml....................................................................54 metoclopramide hcl oral solution 5 mg/5ml.............23 metoclopramide hcl oral tablet................................23 metoclopramide hcl oral tablet................................54 metolazone............................................................47 metoprolol succinate er...........................................47 metoprolol tartrate intravenous solution 5 mg/

5ml....................................................................47 metoprolol tartrate intravenous solution

cartridge.............................................................47 metoprolol tartrate oral..........................................47 metoprolol-hydrochlorothiazide...............................47 metronidazole external cream.................................15 metronidazole external gel 0.75 %..........................15 metronidazole external lotion.................................15 metronidazole in nacl intravenous solution 5-0.79

mg/ml-%, 500-0.79 mg/100ml-%......................15 METRONIDAZOLE IN NACL

INTRAVENOUS SOLUTION 500-0.74 MG/ 100ML-%.........................................................15

metronidazole oral tablet 250 mg...........................15 metronidazole oral tablet 500 mg...........................15 metronidazole vaginal............................................15 mexiletine hcl oral.................................................47 MIACALCIN INJECTION................................64 miconazole 3 vaginal suppository............................24 microgestin 1.5/30.................................................59

microgestin 1/20....................................................59 microgestin fe 1.5/30.............................................59 microgestin fe 1/20................................................59 midodrine hcl oral tablet 10 mg.............................47 midodrine hcl oral tablet 2.5 mg, 5 mg...................47 miglustat...............................................................55 mili......................................................................59 minitran...............................................................47 minocycline hcl oral capsule....................................15 minocycline hcl oral capsule....................................50 minocycline hcl oral tablet......................................15 minocycline hcl oral tablet......................................50 minoxidil oral.......................................................47 mirtazapine oral tablet 15 mg................................21 mirtazapine oral tablet 30 mg................................21 mirtazapine oral tablet 45 mg................................21 mirtazapine oral tablet 7.5 mg...............................21 mirtazapine oral tablet dispersible 15 mg................21 mirtazapine oral tablet dispersible 30 mg................21 mirtazapine oral tablet dispersible 45 mg................21 misoprostol oral.....................................................54 misoprostol oral tablet 200 mcg..............................57 mitomycin intravenous solution reconstituted 20

mg.....................................................................29 mitomycin intravenous solution reconstituted 40

mg.....................................................................29 mitoxantrone hcl....................................................29 modafinil oral tablet 100 mg..................................68 modafinil oral tablet 200 mg..................................68 moexipril hcl.........................................................47 molindone hcl........................................................33 mometasone furoate external...................................57 mometasone furoate nasal.......................................67 mondoxyne nl oral capsule 100 mg.........................16 mondoxyne nl oral capsule 100 mg.........................50 mondoxyne nl oral capsule 100 mg.........................50 mono-linyah..........................................................59 mononessa.............................................................59 montelukast sodium oral packet..............................67 montelukast sodium oral tablet...............................67 montelukast sodium oral tablet chewable.................67 morgidox oral capsule 100 mg................................16 morgidox oral capsule 50 mg..................................16 morphine sulfate (concentrate) oral solution 100 mg/

5ml....................................................................10 morphine sulfate (concentrate) oral solution 100 mg/

5ml, 20 mg/ml...................................................10


morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml.............................................................10

MORPHINE SULFATE (PF) INJECTION SOLUTION 4 MG/ML, 8 MG/ML................10

MORPHINE SULFATE (PF) INTRAVENOUS SOLUTION 10 MG/ML, 8 MG/ML..............10

MORPHINE SULFATE (PF) INTRAVENOUS SOLUTION 2 MG/ML, 4 MG/ML................10

morphine sulfate er oral tablet extended release 100 mg, 200 mg........................................................10

morphine sulfate er oral tablet extended release 15 mg, 30 mg, 60 mg..............................................10

morphine sulfate intravenous solution 1 mg/ml........10 morphine sulfate intravenous solution 25 mg/ml......10 morphine sulfate intravenous solution 50 mg/ml......10 morphine sulfate oral solution.................................10 morphine sulfate oral solution.................................10 morphine sulfate oral tablet....................................10 morphine sulfate oral tablet....................................10 MOVANTIK.......................................................54 MOVIPREP........................................................54 moxifloxacin hcl in nacl.........................................16 moxifloxacin hcl ophthalmic...................................16 MOZOBIL..........................................................52 mupirocin external.................................................16 mutamycin intravenous solution reconstituted 20

mg.....................................................................29 mutamycin intravenous solution reconstituted 40

mg.....................................................................29 mycophenolate mofetil hcl.......................................62 mycophenolate mofetil oral capsule..........................62 mycophenolate mofetil oral suspension

reconstituted.......................................................62 mycophenolate mofetil oral tablet............................62 MYLOTARG INTRAVENOUS SOLUTION

RECONSTITUTED 4.5 MG..........................29 myorisan oral capsule 10 mg, 20 mg, 40 mg............50 MYRBETRIQ.....................................................55 nabumetone oral....................................................10 nabumetone oral....................................................12 nadolol oral tablet 20 mg, 40 mg, 80 mg................47 NAFCILLIN SODIUM IN DEXTROSE...........16 nafcillin sodium injection solution reconstituted 1

gm, 2 gm............................................................16 nafcillin sodium intravenous solution reconstituted

1 gm, 2 gm.........................................................16 NAGLAZYME....................................................55 nalbuphine hcl injection solution 10 mg/ml.............10

nalbuphine hcl injection solution 20 mg/ml.............10 naloxone hcl injection solution 0.4 mg/ml, 4 mg/

10ml..................................................................11 naloxone hcl injection solution cartridge..................11 naloxone hcl injection solution prefilled syringe........11 naltrexone hcl oral.................................................11 naltrexone hcl oral.................................................11 NAMZARIC.......................................................20 naproxen dr...........................................................10 naproxen dr...........................................................12 naproxen oral suspension........................................10 naproxen oral suspension........................................12 naproxen oral tablet...............................................10 naproxen oral tablet...............................................12 naproxen sodium oral tablet 275 mg, 550 mg.........10 naproxen sodium oral tablet 275 mg, 550 mg.........12 naratriptan hcl......................................................24 NARCAN............................................................11 NATACYN..........................................................24 nateglinide oral tablet 120 mg................................43 nateglinide oral tablet 60 mg..................................43 NATPARA..........................................................64 NAYZILAM........................................................18 NAYZILAM........................................................39 NEBUPENT.......................................................31 necon 0.5/35 (28)..................................................59 nefazodone hcl oral tablet 100 mg..........................21 nefazodone hcl oral tablet 150 mg..........................21 nefazodone hcl oral tablet 200 mg..........................21 nefazodone hcl oral tablet 250 mg..........................22 nefazodone hcl oral tablet 50 mg............................22 neo-polycin............................................................65 neo-polycin hc........................................................65 neomycin sulfate oral..............................................16 neomycin-bacitracin zn-polymyx ophthalmic

ointment 5-400-10000.......................................65 neomycin-polymyxin b gu.......................................55 neomycin-polymyxin-dexameth ophthalmic

ointment............................................................65 neomycin-polymyxin-dexameth ophthalmic

suspension 3.5-10000-0.1...................................65 neomycin-polymyxin-gramicidin ophthalmic solution

1.75-10000-.025...............................................65 neomycin-polymyxin-hc ophthalmic suspension 3.5-

10000-1............................................................65 neomycin-polymyxin-hc otic solution 1 %................66 neomycin-polymyxin-hc otic suspension....................66 NEPHRAMINE..................................................52


NERLYNX..........................................................29 neuac external gel..................................................50 NEUPRO............................................................32 nevirapine er oral tablet extended release 24 hour

100 mg..............................................................37 nevirapine er oral tablet extended release 24 hour

400 mg..............................................................37 nevirapine oral suspension......................................37 nevirapine oral tablet.............................................37 NEXAVAR..........................................................29 niacin (antihyperlipidemic)....................................47 niacin er (antihyperlipidemic)................................47 niacor...................................................................47 nicardipine hcl intravenous....................................47 nicardipine hcl oral................................................47 NICOTROL NS.................................................11 nifedical xl oral tablet extended release 24 hour 60

mg.....................................................................47 nifedipine er..........................................................47 nifedipine er osmotic release....................................47 nilutamide............................................................29 NINLARO..........................................................29 NIPENT..............................................................29 nitisinone..............................................................55 NITRO-BID.......................................................47 nitrofurantoin macrocrystal oral capsule 100 mg, 50

mg.....................................................................16 nitrofurantoin monohyd macro...............................16 NITROGLYCERIN INTRAVENOUS..............47 nitroglycerin sublingual tablet sublingual 0.3 mg,

0.6 mg...............................................................47 nitroglycerin sublingual tablet sublingual 0.4

mg.....................................................................47 nitroglycerin transdermal patch 24 hour..................47 nizatidine oral capsule...........................................54 nora-be.................................................................59 NORDITROPIN FLEXPRO..............................57 norethin ace-eth estrad-fe oral tablet 1-20 mg-

mcg....................................................................59 norethindrone acet-ethinyl est oral tablet.................59 norethindrone acetate oral......................................59 norethindrone oral.................................................59 norethindrone-eth estradiol oral tablet 1-5 mg-

mcg....................................................................59 norgestim-eth estrad triphasic oral tablet 0.18/0.215/

0.25 mg-35 mcg.................................................59 norgestimate-eth estradiol oral tablet 0.25-35 mg-

mcg....................................................................59

norlyda.................................................................59 norlyroc.................................................................59 NORMOSOL-M IN D5W.................................52 NORMOSOL-R..................................................52 NORMOSOL-R IN D5W..................................52 NORMOSOL-R PH 7.4.....................................52 NORTHERA ORAL CAPSULE 100 MG..........47 NORTHERA ORAL CAPSULE 200 MG..........47 NORTHERA ORAL CAPSULE 300 MG..........47 nortrel 0.5/35 (28)................................................59 nortrel 1/35 (21)...................................................59 nortrel 1/35 (28)...................................................59 nortrel 7/7/7..........................................................59 nortriptyline hcl oral capsule 10 mg, 25 mg.............22 nortriptyline hcl oral capsule 50 mg, 75 mg.............22 nortriptyline hcl oral solution..................................22 NORVIR ORAL PACKET.................................37 NORVIR ORAL SOLUTION............................37 NOXAFIL ORAL SUSPENSION.......................24 NUBEQA............................................................29 NUEDEXTA.......................................................49 NULOJIX............................................................62 NUPLAZID ORAL CAPSULE...........................33 NUPLAZID ORAL TABLET 10 MG.................33 nutrilipid..............................................................52 nyamyc..................................................................24 nystatin external....................................................24 nystatin mouth/throat............................................24 nystatin oral tablet.................................................24 nystatin-triamcinolone...........................................50 nystop...................................................................24 ocella....................................................................59 OCTAGAM INTRAVENOUS SOLUTION 1

GM/20ML, 2 GM/20ML, 2.5 GM/50ML, 25 GM/500ML, 30 GM/300ML, 5 GM/ 100ML..............................................................62

octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml................60

ODEFSEY...........................................................37 ODOMZO..........................................................29 OFEV ORAL CAPSULE 150 MG......................29 OFEV ORAL CAPSULE 150 MG......................67 OFEV ORAL CAPSULE 150 MG......................67 ofloxacin ophthalmic..............................................16 ofloxacin otic.........................................................16 ogestrel..................................................................59 olanzapine intramuscular.......................................33 olanzapine intramuscular.......................................40


olanzapine oral tablet 10 mg..................................34 olanzapine oral tablet 10 mg..................................40 olanzapine oral tablet 15 mg..................................34 olanzapine oral tablet 15 mg..................................40 olanzapine oral tablet 2.5 mg.................................34 olanzapine oral tablet 2.5 mg.................................40 olanzapine oral tablet 20 mg..................................34 olanzapine oral tablet 20 mg..................................40 olanzapine oral tablet 5 mg....................................34 olanzapine oral tablet 5 mg....................................40 olanzapine oral tablet 7.5 mg.................................34 olanzapine oral tablet 7.5 mg.................................40 olanzapine oral tablet dispersible 10 mg..................34 olanzapine oral tablet dispersible 10 mg..................40 olanzapine oral tablet dispersible 15 mg..................34 olanzapine oral tablet dispersible 15 mg..................40 olanzapine oral tablet dispersible 20 mg..................34 olanzapine oral tablet dispersible 20 mg..................40 olanzapine oral tablet dispersible 5 mg....................34 olanzapine oral tablet dispersible 5 mg....................40 olmesartan medoxomil oral.....................................47 olmesartan medoxomil-hctz....................................47 olmesartan medoxomil-hctz....................................48 olmesartan-amlodipine-hctz...................................48 olopatadine hcl ophthalmic solution 0.2 %..............65 omega-3-acid ethyl esters........................................48 omeprazole oral capsule delayed release....................54 ONCASPAR INJECTION.................................29 ondansetron...........................................................23 ondansetron hcl injection........................................23 ondansetron hcl oral solution..................................23 ondansetron hcl oral tablet 24 mg...........................23 ondansetron hcl oral tablet 4 mg, 8 mg...................23 OPDIVO.............................................................29 opium...................................................................54 oralone..................................................................50 ORFADIN..........................................................55 ORKAMBI ORAL TABLET...............................67 orsythia.................................................................59 oseltamivir phosphate oral......................................37 OXACILLIN SODIUM IN DEXTROSE

INTRAVENOUS SOLUTION 1 GM/ 50ML................................................................16

oxacillin sodium injection solution reconstituted 1 gm, 2 gm............................................................16

oxaliplatin intravenous solution..............................29 oxaliplatin intravenous solution reconstituted..........29 oxandrolone oral tablet 2.5 mg...............................59

oxaprozin..............................................................10 oxaprozin..............................................................12 oxazepam..............................................................39 oxcarbazepine oral suspension.................................18 oxcarbazepine oral tablet........................................18 oxybutynin chloride er oral tablet extended release

24 hour 10 mg, 15 mg........................................55 oxybutynin chloride er oral tablet extended release

24 hour 5 mg.....................................................55 oxybutynin chloride oral syrup................................55 oxybutynin chloride oral tablet................................55 oxycodone hcl oral capsule.......................................10 oxycodone hcl oral concentrate 10 mg/0.5ml............10 oxycodone hcl oral concentrate 100 mg/5ml.............10 oxycodone hcl oral solution.....................................10 oxycodone hcl oral tablet.........................................10 oxycodone-acetaminophen oral tablet 10-325 mg,

2.5-325 mg, 5-325 mg, 7.5-325 mg...................10 oxycodone-aspirin oral tablet 4.8355-325 mg..........10 oxycodone-ibuprofen..............................................10 oxycodone-ibuprofen..............................................12 pacerone oral tablet 100 mg...................................48 pacerone oral tablet 200 mg...................................48 pacerone oral tablet 400 mg...................................48 paclitaxel intravenous concentrate 100 mg/16.7ml,

150 mg/25ml, 30 mg/5ml...................................29 paclitaxel intravenous concentrate 300 mg/

50ml..................................................................29 paliperidone er oral tablet extended release 24 hour

1.5 mg...............................................................34 paliperidone er oral tablet extended release 24 hour

3 mg..................................................................34 paliperidone er oral tablet extended release 24 hour

6 mg..................................................................34 paliperidone er oral tablet extended release 24 hour

9 mg..................................................................34 pamidronate disodium intravenous solution 30 mg/

10ml, 90 mg/10ml.............................................64 PAMIDRONATE DISODIUM

INTRAVENOUS SOLUTION 6 MG/ ML....................................................................64

pamidronate disodium intravenous solution reconstituted.......................................................64

PANRETIN.........................................................29 pantoprazole sodium intravenous............................54 pantoprazole sodium oral.......................................54 paregoric...............................................................54 paricalcitol oral capsule 1 mcg................................64


paricalcitol oral capsule 2 mcg, 4 mcg.....................64 paroex...................................................................50 paromomycin sulfate oral.......................................16 paroxetine hcl oral tablet 10 mg..............................22 paroxetine hcl oral tablet 10 mg..............................39 paroxetine hcl oral tablet 20 mg..............................22 paroxetine hcl oral tablet 20 mg..............................39 paroxetine hcl oral tablet 30 mg..............................22 paroxetine hcl oral tablet 30 mg..............................39 paroxetine hcl oral tablet 40 mg.............................22 paroxetine hcl oral tablet 40 mg.............................39 PASER.................................................................25 PAXIL ORAL SUSPENSION.............................22 PAXIL ORAL SUSPENSION.............................39 PAZEO................................................................65 PC UNIFINE PENTIPS 29G X 12MM.............43 PEDIARIX...........................................................62 PEDVAX HIB INTRAMUSCULAR

SUSPENSION.................................................62 peg 3350-kcl-na bicarb-nacl...................................54 peg 3350/electrolytes...............................................54 peg-3350/electrolytes..............................................54 PEGANONE.......................................................18 PEGASYS PROCLICK SUBCUTANEOUS

SOLUTION 180 MCG/0.5ML.......................37 PEGASYS SUBCUTANEOUS SOLUTION......37 PEGINTRON SUBCUTANEOUS KIT 50

MCG/0.5ML....................................................37 penicillin g potassium.............................................16 PENICILLIN G PROCAINE.............................16 penicillin v potassium.............................................16 PENTACEL........................................................62 PENTAM............................................................31 pentamidine isethionate inhalation.........................31 pentamidine isethionate injection............................31 PENTASA...........................................................64 pentoxifylline er.....................................................48 PERFOROMIST.................................................67 perindopril erbumine.............................................48 periogard...............................................................50 PERJETA.............................................................29 permethrin external cream......................................31 perphenazine oral..................................................23 perphenazine oral..................................................34 pfizerpen...............................................................16 phenelzine sulfate oral............................................22 phenobarbital oral elixir.........................................18 phenobarbital oral tablet 100 mg...........................18

phenobarbital oral tablet 15 mg.............................19 phenobarbital oral tablet 16.2 mg..........................19 phenobarbital oral tablet 30 mg.............................19 phenobarbital oral tablet 32.4 mg..........................19 phenobarbital oral tablet 60 mg.............................19 phenobarbital oral tablet 64.8 mg..........................19 phenobarbital oral tablet 97.2 mg..........................19 PHENYTEK........................................................19 phenytoin oral suspension 125 mg/5ml....................19 phenytoin oral tablet chewable................................19 phenytoin sodium extended.....................................19 phenytoin sodium injection.....................................19 philith...................................................................59 PHOSPHOLINE IODIDE.................................65 PICATO..............................................................50 PIFELTRO..........................................................37 pilocarpine hcl ophthalmic solution 1 %, 2 %, 4

%......................................................................65 pilocarpine hcl oral................................................50 pimecrolimus.........................................................51 pimecrolimus.........................................................63 pimozide...............................................................34 pimtrea.................................................................59 pindolol................................................................48 pioglitazone hcl oral tablet 15 mg...........................43 pioglitazone hcl oral tablet 30 mg...........................44 pioglitazone hcl oral tablet 45 mg...........................44 piperacillin sod-tazobactam so intravenous solution

reconstituted 2.25 (2-0.25) gm, 3.375 (3-0.375) gm, 4.5 (4-0.5) gm, 40.5 (36-4.5) gm................16

PIQRAY (200 MG DAILY DOSE).....................29 PIQRAY (250 MG DAILY DOSE).....................29 PIQRAY (300 MG DAILY DOSE).....................29 pirmella 1/35........................................................59 pirmella 7/7/7.......................................................59 piroxicam oral.......................................................10 piroxicam oral.......................................................12 PLASMA-LYTE 148............................................52 PLASMA-LYTE A...............................................52 pnv-dha................................................................52 pnv-select..............................................................52 podofilox external..................................................51 POLIVY...............................................................29 polycin..................................................................65 polyethylene glycol 3350 oral packet........................54 polyethylene glycol 3350 oral powder.......................54 polymyxin b-trimethoprim......................................65 POMALYST ORAL CAPSULE 1 MG................29


POMALYST ORAL CAPSULE 2 MG................29 POMALYST ORAL CAPSULE 3 MG, 4

MG...................................................................29 portia-28..............................................................59 PORTRAZZA.....................................................29 potassium bicarbonate oral.....................................52 potassium chloride crys er.......................................52 potassium chloride er..............................................52 potassium chloride in dextrose intravenous solution

20-5 meq/l-%, 40-5 meq/l-%.............................53 potassium chloride in nacl intravenous solution 20-

0.45 meq/l-%, 20-0.9 meq/l-%, 40-0.9 meq/l- %......................................................................53

potassium chloride intravenous solution 10 meq/ 100ml, 2 meq/ml, 20 meq/100ml, 40 meq/ 100ml................................................................53

potassium chloride intravenous solution 10 meq/ 50ml, 20 meq/50ml............................................53

potassium chloride intravenous solution 2 meq/ml (20 ml)..............................................................53

potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%)..............................53

potassium citrate er................................................55 POTELIGEO......................................................29 PRADAXA...........................................................45 PRALUENT SUBCUTANEOUS SOLUTION

AUTO-INJECTOR..........................................48 pramipexole dihydrochloride...................................32 prasugrel hcl..........................................................45 pravastatin sodium................................................48 prazosin hcl oral....................................................48 prazosin hcl oral....................................................55 prednicarbate external cream..................................51 prednicarbate external ointment.............................57 prednisolone acetate ophthalmic..............................12 prednisolone acetate ophthalmic..............................64 prednisolone acetate ophthalmic..............................65 prednisolone oral solution.......................................12 prednisolone oral solution.......................................57 prednisolone oral solution.......................................64 PREDNISOLONE SODIUM PHOSPHATE

OPHTHALMIC...............................................12 PREDNISOLONE SODIUM PHOSPHATE

OPHTHALMIC...............................................65 prednisolone sodium phosphate oral solution 15 mg/

5ml, 25 mg/5ml.................................................12 prednisolone sodium phosphate oral solution 25 mg/

5ml....................................................................57

prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml......................................................12



PREDNISONE INTENSOL..............................12 PREDNISONE INTENSOL..............................57 PREDNISONE INTENSOL..............................64 prednisone oral solution..........................................12 prednisone oral solution..........................................57 prednisone oral solution..........................................64 prednisone oral tablet 1 mg....................................12 prednisone oral tablet 1 mg....................................57 prednisone oral tablet 1 mg....................................64 prednisone oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg,

50 mg................................................................12 prednisone oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg,

50 mg................................................................57 prednisone oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg,

50 mg................................................................64 prednisone oral tablet therapy pack 10 mg (21), 5

mg (21).............................................................12 prednisone oral tablet therapy pack 10 mg (21), 5



mg (48).............................................................57 PREFERRED PLUS INSULIN SYRINGE 28G

X 1/2" 0.5 ML..................................................44 pregabalin oral capsule 100 mg..............................19 pregabalin oral capsule 150 mg..............................19 pregabalin oral capsule 200 mg..............................19 pregabalin oral capsule 225 mg, 300 mg.................19 pregabalin oral capsule 25 mg................................19 pregabalin oral capsule 50 mg................................19 pregabalin oral capsule 75 mg................................19 pregabalin oral solution..........................................19 PREMARIN ORAL.............................................59 PREMARIN VAGINAL......................................59 PREMASOL INTRAVENOUS SOLUTION 10

%......................................................................53 premasol intravenous solution 6 %..........................53 PREMPRO..........................................................59 prevalite................................................................48 previfem................................................................59 PREZCOBIX.......................................................37


PREZISTA ORAL SUSPENSION......................37 PREZISTA ORAL TABLET 150 MG.................37 PREZISTA ORAL TABLET 600 MG, 800

MG...................................................................37 PREZISTA ORAL TABLET 75 MG...................37 PRIFTIN.............................................................25 primaquine phosphate oral.....................................31 primidone oral.......................................................19 PROAIR HFA.....................................................67 PROAIR RESPICLICK.......................................67 probenecid oral......................................................24 procainamide hcl injection.....................................48 PROCALAMINE................................................53 prochlorperazine....................................................23 prochlorperazine edisylate injection solution 10 mg/

2ml, 50 mg/10ml...............................................34 prochlorperazine maleate oral.................................23 prochlorperazine maleate oral.................................34 PROCRIT INJECTION SOLUTION 10000

UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML...............................................45

PROCRIT INJECTION SOLUTION 20000 UNIT/ML, 40000 UNIT/ML..........................45

procto-med hc........................................................64 procto-pak.............................................................57 proctosol hc............................................................64 proctozone-hc rectal...............................................54 proctozone-hc rectal...............................................57 progesterone micronized oral...................................59 PROGLYCEM....................................................44 PROGRAF INTRAVENOUS.............................63 PROGRAF ORAL PACKET...............................63 PROLASTIN-C...................................................67 PROLEUKIN......................................................29 PROLIA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE...................................64 PROMACTA ORAL PACKET...........................45 PROMACTA ORAL TABLET 12.5 MG, 25

MG, 75 MG.....................................................45 PROMACTA ORAL TABLET 50 MG...............45 promethazine hcl injection.....................................67 promethazine hcl oral tablet...................................23 promethazine hcl oral tablet...................................67 propafenone hcl.....................................................48 propantheline bromide oral....................................54 propranolol hcl er...................................................48 propranolol hcl intravenous....................................48 propranolol hcl oral solution 20 mg/5ml..................48

propranolol hcl oral solution 40 mg/5ml..................48 propranolol hcl oral tablet......................................48 propranolol-hctz....................................................48 propylthiouracil oral..............................................60 PROQUAD SUBCUTANEOUS SUSPENSION

RECONSTITUTED........................................63 PROSOL.............................................................53 protriptyline hcl.....................................................22 PULMOZYME...................................................68 PULMOZYME...................................................68 PURIXAN...........................................................29 pyrazinamide oral..................................................25 pyridostigmine bromide er......................................25 pyridostigmine bromide oral solution.......................25 PYRIDOSTIGMINE BROMIDE ORAL

TABLET 30 MG..............................................25 pyridostigmine bromide oral tablet 60 mg...............25 QUADRACEL....................................................63 quetiapine fumarate er oral tablet extended release

24 hour 150 mg.................................................22 quetiapine fumarate er oral tablet extended release












24 hour 50 mg...................................................22 quetiapine fumarate er oral tablet extended release

24 hour 50 mg...................................................34 quetiapine fumarate er oral tablet extended release

24 hour 50 mg...................................................40


quetiapine fumarate oral tablet 100 mg..................22 quetiapine fumarate oral tablet 100 mg..................34 quetiapine fumarate oral tablet 100 mg..................40 quetiapine fumarate oral tablet 200 mg..................22 quetiapine fumarate oral tablet 200 mg..................34 quetiapine fumarate oral tablet 200 mg..................40 quetiapine fumarate oral tablet 25 mg....................22 quetiapine fumarate oral tablet 25 mg....................34 quetiapine fumarate oral tablet 25 mg....................40 quetiapine fumarate oral tablet 300 mg..................22 quetiapine fumarate oral tablet 300 mg..................34 quetiapine fumarate oral tablet 300 mg..................40 quetiapine fumarate oral tablet 400 mg..................22 quetiapine fumarate oral tablet 400 mg..................34 quetiapine fumarate oral tablet 400 mg..................40 quetiapine fumarate oral tablet 50 mg....................22 quetiapine fumarate oral tablet 50 mg....................34 quetiapine fumarate oral tablet 50 mg....................40 quinapril hcl.........................................................48 quinapril-hydrochlorothiazide................................48 quinidine sulfate oral.............................................48 RABAVERT........................................................63 raloxifene hcl.........................................................59 ramelteon..............................................................68 ramipril................................................................48 RANEXA.............................................................48 ranitidine hcl injection...........................................54 ranitidine hcl oral syrup.........................................54 ranitidine hcl oral tablet 150 mg, 300 mg..............54 ranolazine er.........................................................48 rasagiline mesylate oral...........................................32 RAVICTI.............................................................55 reclipsen................................................................59 RECOMBIVAX HB INJECTION

SUSPENSION 10 MCG/ML (1ML SYRINGE)........................................................63

RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML.................................................63

RECTIV..............................................................48 REGONOL INTRAVENOUS...........................25 RELENZA DISKHALER....................................37 RELI-ON INSULIN SYRINGE 29G 0.3

ML....................................................................44 RELION PEN NEEDLES 29G X 12MM...........44 RELISTOR SUBCUTANEOUS SOLUTION

12 MG/0.6ML..................................................54

RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML (0.6ML SYRINGE)..................54

RELISTOR SUBCUTANEOUS SOLUTION 8 MG/0.4ML....................................................54

REMICADE........................................................54 repaglinide oral tablet 0.5 mg.................................44 repaglinide oral tablet 1 mg....................................44 repaglinide oral tablet 2 mg....................................44 REPATHA...........................................................48 REPATHA PUSHTRONEX SYSTEM...............48 REPATHA SURECLICK....................................48 RESCRIPTOR ORAL TABLET 200 MG..........37 RETROVIR INTRAVENOUS...........................37 REVLIMID ORAL CAPSULE 10 MG...............29 REVLIMID ORAL CAPSULE 15 MG, 25

MG...................................................................29 REVLIMID ORAL CAPSULE 2.5 MG, 20

MG...................................................................29 REVLIMID ORAL CAPSULE 5 MG.................29 REXULTI ORAL TABLET 0.25 MG, 0.5 MG,

1 MG, 2 MG....................................................34 REXULTI ORAL TABLET 3 MG, 4 MG..........34 REYATAZ ORAL PACKET...............................37 ribavirin inhalation...............................................37 ribavirin oral capsule.............................................37 ribavirin oral capsule.............................................37 ribavirin oral tablet 200 mg...................................37 ribavirin oral tablet 200 mg...................................37 rifabutin...............................................................25 rifampin intravenous.............................................25 rifampin oral.........................................................25 RIFATER............................................................25 riluzole.................................................................49 rimantadine hcl.....................................................37 ringers...................................................................53 ringers irrigation....................................................53 RISPERDAL CONSTA INTRAMUSCULAR

SUSPENSION RECONSTITUTED ER 12.5 MG, 25 MG.....................................................34

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 12.5 MG, 25 MG.....................................................41




risperidone oral solution.........................................34 risperidone oral solution.........................................41 risperidone oral tablet 0.25 mg...............................34 risperidone oral tablet 0.25 mg...............................41 risperidone oral tablet 0.5 mg.................................34 risperidone oral tablet 0.5 mg.................................41 risperidone oral tablet 1 mg....................................34 risperidone oral tablet 1 mg....................................41 risperidone oral tablet 2 mg....................................34 risperidone oral tablet 2 mg....................................41 risperidone oral tablet 3 mg....................................34 risperidone oral tablet 3 mg....................................41 risperidone oral tablet 4 mg....................................35 risperidone oral tablet 4 mg....................................41 risperidone oral tablet dispersible 0.25 mg...............35 risperidone oral tablet dispersible 0.25 mg...............41 risperidone oral tablet dispersible 0.5 mg.................35 risperidone oral tablet dispersible 0.5 mg.................41 risperidone oral tablet dispersible 1 mg....................35 risperidone oral tablet dispersible 1 mg....................41 risperidone oral tablet dispersible 2 mg....................35 risperidone oral tablet dispersible 2 mg....................41 risperidone oral tablet dispersible 3 mg....................35 risperidone oral tablet dispersible 3 mg....................41 risperidone oral tablet dispersible 4 mg....................35 risperidone oral tablet dispersible 4 mg....................41 ritonavir...............................................................37 RITUXAN HYCELA..........................................29 RITUXAN INTRAVENOUS SOLUTION........29 rivastigmine..........................................................20 rivastigmine tartrate..............................................20 rizatriptan benzoate...............................................24 romidepsin............................................................29 ropinirole hcl.........................................................32 ropinirole hcl er.....................................................32 rosadan external cream...........................................51 rosadan external gel...............................................51 rosuvastatin calcium..............................................48 ROTARIX...........................................................63 ROTATEQ ORAL SOLUTION........................63 roweepra...............................................................19 roweepra xr oral tablet extended release 24 hour 500

mg.....................................................................19 roweepra xr oral tablet extended release 24 hour 750

mg.....................................................................19 ROZEREM.........................................................68 ROZLYTREK ORAL CAPSULE 100 MG.........29 ROZLYTREK ORAL CAPSULE 200 MG.........29

RUBRACA ORAL TABLET 200 MG................29 RUBRACA ORAL TABLET 250 MG, 300

MG...................................................................29 RUCONEST.......................................................63 RYDAPT.............................................................30 SABRIL ORAL PACKET....................................19 SAMSCA ORAL TABLET 15 MG.....................53 SAMSCA ORAL TABLET 30 MG.....................53 SANDOSTATIN LAR DEPOT

INTRAMUSCULAR KIT 10 MG, 20 MG...................................................................60

SANTYL..............................................................51 SAPHRIS SUBLINGUAL TABLET

SUBLINGUAL 10 MG....................................35 SAPHRIS SUBLINGUAL TABLET

SUBLINGUAL 10 MG....................................41 SAPHRIS SUBLINGUAL TABLET

SUBLINGUAL 2.5 MG...................................35 SAPHRIS SUBLINGUAL TABLET

SUBLINGUAL 2.5 MG...................................41 SAPHRIS SUBLINGUAL TABLET

SUBLINGUAL 5 MG......................................35 SAPHRIS SUBLINGUAL TABLET

SUBLINGUAL 5 MG......................................41 SAVELLA ORAL TABLET 100 MG..................49 SAVELLA ORAL TABLET 12.5 MG.................49 SAVELLA ORAL TABLET 25 MG....................49 SAVELLA ORAL TABLET 50 MG....................49 SAVELLA TITRATION PACK..........................49 scopolamine...........................................................23 scopolamine...........................................................54 selegiline hcl oral....................................................32 selenium sulfide external lotion...............................51 SELZENTRY ORAL SOLUTION.....................37 SELZENTRY ORAL TABLET 150 MG, 300

MG...................................................................38 SELZENTRY ORAL TABLET 25 MG...............38 SELZENTRY ORAL TABLET 75 MG...............38 SEREVENT DISKUS.........................................68 sertraline hcl oral concentrate.................................22 sertraline hcl oral concentrate.................................39 sertraline hcl oral tablet 100 mg.............................22 sertraline hcl oral tablet 100 mg.............................39 sertraline hcl oral tablet 25 mg...............................22 sertraline hcl oral tablet 25 mg...............................39 sertraline hcl oral tablet 50 mg...............................22 sertraline hcl oral tablet 50 mg...............................39 setlakin.................................................................59


sevelamer carbonate oral packet 0.8 gm...................55 sevelamer carbonate oral packet 2.4 gm...................55 sevelamer carbonate oral tablet...............................55 sf..........................................................................50 sf 5000 plus...........................................................50 sharobel.................................................................59 SHINGRIX INTRAMUSCULAR

SUSPENSION RECONSTITUTED 50 MCG/ 0.5ML...............................................................63

SIGNIFOR..........................................................60 sildenafil citrate oral tablet 20 mg..........................68 silodosin................................................................55 silver sulfadiazine external.....................................16 SIMBRINZA.......................................................65 SIMULECT.........................................................63 simvastatin oral.....................................................48 sirolimus oral solution............................................63 sirolimus oral tablet...............................................63 SIRTURO...........................................................25 sodium bicarbonate intravenous solution 4.2 %.......53 sodium bicarbonate intravenous solution 8.4 %.......53 sodium chloride injection solution 2.5 meq/ml.........53 sodium chloride intravenous solution 0.45 %, 0.9

%, 3 %, 5 %.....................................................53 sodium chloride intravenous solution 4 meq/ml........53 sodium chloride irrigation solution 0.9 %...............53 sodium fluoride 5000 plus......................................50 sodium fluoride dental gel 1.1 %............................50 sodium fluoride oral tablet 2.2 (1 f) mg..................53 sodium fluoride oral tablet chewable 0.55 (0.25 f)

mg, 1.1 (0.5 f) mg..............................................53 sodium fluoride oral tablet chewable 2.2 (1 f)

mg.....................................................................53 SODIUM LACTATE INTRAVENOUS

SOLUTION 5 MEQ/ML.................................53 sodium phenylbutyrate oral powder 3 gm/tsp...........55 sodium phenylbutyrate oral tablet...........................55 sodium polystyrene sulfonate oral powder.................53 sodium polystyrene sulfonate oral suspension............53 sodium polystyrene sulfonate rectal..........................53 solifenacin succinate...............................................55 SOLTAMOX.......................................................30 SOMATULINE DEPOT....................................60 SOMAVERT.......................................................60 sorine oral tablet 120 mg, 80 mg............................48 sorine oral tablet 160 mg, 240 mg..........................48 sotalol hcl (af) oral tablet 120 mg...........................48 sotalol hcl (af) oral tablet 160 mg...........................48

sotalol hcl (af) oral tablet 80 mg.............................48 sotalol hcl oral tablet 120 mg, 80 mg......................48 sotalol hcl oral tablet 160 mg, 240 mg....................48 sotalol hydrochloride oral tablet 120 mg, 160

mg.....................................................................48 sotalol hydrochloride oral tablet 80 mg....................48 SPIRIVA HANDIHALER...................................68 SPIRIVA RESPIMAT..........................................68 spironolactone oral tablet 100 mg, 50 mg................48 spironolactone oral tablet 25 mg.............................48 spironolactone-hctz................................................48 SPRAVATO (56 MG DOSE).............................22 SPRAVATO (84 MG DOSE).............................22 sprintec 28............................................................59 SPRITAM ORAL TABLET

DISINTEGRATING SOLUBLE 1000 MG, 250 MG, 500 MG............................................19

SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 750 MG.......19

SPRYCEL............................................................30 sps.........................................................................53 sronyx...................................................................59 ssd.........................................................................16 STAMARIL.........................................................63 stavudine oral capsule 15 mg, 20 mg.......................38 stavudine oral capsule 30 mg, 40 mg......................38 STELARA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 45 MG/0.5ML...........51 sterile water for irrigation.......................................53 STIMATE...........................................................57 STIVARGA.........................................................30 streptomycin sulfate intramuscular..........................16 STRIBILD...........................................................38 subvenite...............................................................19 SUCRAID...........................................................55 sucralfate oral tablet...............................................55 sulfacetamide sodium (acne)...................................16 sulfacetamide sodium ophthalmic ointment.............16 sulfacetamide sodium ophthalmic ointment.............65 sulfacetamide sodium ophthalmic ointment.............65 sulfacetamide sodium ophthalmic solution...............16 sulfacetamide-prednisolone ophthalmic solution.......12 sulfacetamide-prednisolone ophthalmic solution.......65 SULFADIAZINE ORAL.....................................16 sulfamethoxazole-trimethoprim intravenous............16 sulfamethoxazole-trimethoprim oral suspension 200-

40 mg/5ml.........................................................16 sulfamethoxazole-trimethoprim oral tablet...............16


SULFAMYLON EXTERNAL CREAM..............16 sulfasalazine oral...................................................64 sulfazine................................................................12 sulindac oral..........................................................10 sulindac oral..........................................................12 sumatriptan nasal..................................................24 sumatriptan succinate oral......................................24 sumatriptan succinate refill subcutaneous solution

cartridge.............................................................24 sumatriptan succinate subcutaneous solution 6 mg/

0.5ml.................................................................24 sumatriptan succinate subcutaneous solution auto-

injector..............................................................24 sumatriptan succinate subcutaneous solution prefilled

syringe 6 mg/0.5ml.............................................24 SUPRAX ORAL SUSPENSION

RECONSTITUTED........................................16 SUPREP BOWEL PREP KIT.............................53 SUTENT ORAL CAPSULE 12.5 MG................30 SUTENT ORAL CAPSULE 25 MG, 37.5 MG,

50 MG..............................................................30 syeda.....................................................................59 SYLATRON SUBCUTANEOUS KIT 200

MCG, 300 MCG, 600 MCG...........................30 SYLATRON SUBCUTANEOUS KIT 200

MCG, 300 MCG, 600 MCG...........................38 SYMFI.................................................................38 SYMFI LO...........................................................38 SYMPAZAN ORAL FILM 10 MG, 20 MG........19 SYMPAZAN ORAL FILM 5 MG.......................19 SYMTUZA..........................................................38 SYNAGIS............................................................63 SYNAREL...........................................................60 SYNERCID.........................................................16 SYNJARDY.........................................................44 SYNJARDY XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 10-1000 MG, 12.5-1000 MG, 5-1000 MG..............................................44

SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 25-1000 MG.................44

SYNRIBO............................................................30 SYNTHAMIN 17................................................53 SYNTHROID.....................................................60 TABLOID...........................................................30 tacrolimus oral capsule 0.5 mg................................63 tacrolimus oral capsule 1 mg, 5 mg.........................63 TAFINLAR.........................................................30 TAGRISSO ORAL TABLET 40 MG..................30

TAGRISSO ORAL TABLET 80 MG..................30 TALZENNA ORAL CAPSULE 0.25 MG..........30 TALZENNA ORAL CAPSULE 1 MG...............30 tamoxifen citrate oral.............................................30 tamsulosin hcl........................................................55 TARGRETIN EXTERNAL................................30 tarina fe 1/20........................................................59 tarina fe 1/20 eq....................................................59 TASIGNA...........................................................30 TAXOTERE INTRAVENOUS

CONCENTRATE 20 MG/ML, 80 MG/ 4ML..................................................................30

tazarotene external.................................................51 tazicef injection.....................................................16 TAZORAC EXTERNAL CREAM 0.05 %.........51 TAZORAC EXTERNAL GEL............................51 taztia xt................................................................48 TDVAX...............................................................63 TECENTRIQ INTRAVENOUS SOLUTION

1200 MG/20ML...............................................30 TECENTRIQ INTRAVENOUS SOLUTION

840 MG/14ML.................................................30 TECFIDERA.......................................................49 TECHLITE PEN NEEDLES 29G X 12MM......44 TEFLARO...........................................................16 telmisartan............................................................48 telmisartan-amlodipine..........................................48 temazepam oral capsule 15 mg, 30 mg....................68 TEMIXYS............................................................38 temsirolimus..........................................................30 TENIVAC...........................................................63 tenofovir disoproxil fumarate..................................38 tenofovir disoproxil fumarate..................................38 terazosin hcl oral...................................................48 terazosin hcl oral...................................................55 terbinafine hcl oral................................................24 terbutaline sulfate injection....................................68 terbutaline sulfate oral...........................................68 terconazole vaginal cream.......................................24 terconazole vaginal suppository...............................24 testosterone cypionate intramuscular solution 100

mg/ml, 200 mg/ml..............................................59 testosterone enanthate intramuscular solution..........59 testosterone transdermal gel 20.25 mg/1.25gm

(1.62%)............................................................59 testosterone transdermal gel 20.25 mg/act (1.62%),

40.5 mg/2.5gm (1.62%).....................................59


testosterone transdermal gel 25 mg/2.5gm (1%), 50 mg/5gm (1%).....................................................59

tetrabenazine oral tablet 12.5 mg...........................49 tetrabenazine oral tablet 25 mg..............................49 tetracycline hcl oral capsule 500 mg........................16 THALOMID ORAL CAPSULE 100 MG, 50

MG...................................................................30 THALOMID ORAL CAPSULE 150 MG, 200

MG...................................................................30 theophylline...........................................................68 theophylline er oral tablet extended release 12 hour

300 mg, 450 mg.................................................68 theophylline er oral tablet extended release 24

hour...................................................................68 thioridazine hcl oral..............................................35 thiotepa injection...................................................30 thiothixene oral.....................................................35 THYMOGLOBULIN.........................................63 tiadylt er...............................................................48 tiagabine hcl..........................................................19 TIBSOVO...........................................................30 TICE BCG..........................................................30 tigecycline..............................................................16 tilia fe...................................................................59 timolol maleate ophthalmic gel forming solution......65 timolol maleate ophthalmic solution 0.25 %, 0.5

%......................................................................65 timolol maleate oral...............................................24 timolol maleate oral...............................................48 tinidazole oral tablet 250 mg.................................16 tinidazole oral tablet 500 mg.................................16 tis-u-sol.................................................................53 TIVICAY ORAL TABLET 10 MG.....................38 TIVICAY ORAL TABLET 25 MG, 50 MG.......38 tizanidine hcl oral tablet........................................35 tizanidine hcl oral tablet........................................68 TOBRADEX OPHTHALMIC

OINTMENT...................................................16 TOBRADEX ST..................................................65 tobramycin inhalation...........................................16 tobramycin ophthalmic..........................................16 tobramycin sulfate injection....................................16 tobramycin-dexamethasone.....................................65 tolbutamide...........................................................44 tolcapone...............................................................32 tolterodine tartrate oral tablet 1 mg........................55 tolterodine tartrate oral tablet 2 mg........................55 topiramate oral capsule sprinkle 15 mg...................19

topiramate oral capsule sprinkle 15 mg...................24 topiramate oral capsule sprinkle 25 mg...................19 topiramate oral capsule sprinkle 25 mg...................24 topiramate oral tablet 100 mg................................19 topiramate oral tablet 100 mg................................24 topiramate oral tablet 200 mg................................19 topiramate oral tablet 200 mg................................25 topiramate oral tablet 25 mg..................................19 topiramate oral tablet 25 mg..................................25 topiramate oral tablet 50 mg..................................19 topiramate oral tablet 50 mg..................................25 toposar intravenous solution 1 gm/50ml, 500 mg/

25ml..................................................................30 toposar intravenous solution 100 mg/5ml................30 TOPOTECAN HCL INTRAVENOUS

SOLUTION.....................................................30 topotecan hcl intravenous solution reconstituted.......30 toremifene citrate...................................................30 TORISEL............................................................30 torsemide oral tablet 10 mg....................................48 torsemide oral tablet 100 mg, 20 mg, 5 mg.............48 TOUJEO MAX SOLOSTAR..............................44 TOUJEO SOLOSTAR........................................44 TOVIAZ..............................................................55 TPN ELECTROLYTES INTRAVENOUS

SOLUTION.....................................................53 TRACLEER ORAL TABLET SOLUBLE...........68 TRADJENTA......................................................44 tramadol hcl er oral tablet extended release 24 hour

100 mg, 200 mg.................................................10 tramadol hcl oral...................................................10 tramadol-acetaminophen........................................10 trandolapril...........................................................48 tranexamic acid intravenous solution 1000 mg/

10ml..................................................................45 tranexamic acid oral..............................................45 TRANSDERM SCOP (1.5 MG).........................23 tranylcypromine sulfate..........................................22 TRAVASOL........................................................53 TRAVATAN Z....................................................65 trazodone hcl oral tablet 100 mg, 150 mg, 50

mg.....................................................................22 trazodone hcl oral tablet 300 mg............................22 TREANDA INTRAVENOUS SOLUTION

RECONSTITUTED........................................30 TRECATOR.......................................................25


TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 11.25 MG...................................................................60



tretinoin external cream 0.025 %, 0.05 %.............30 tretinoin external cream 0.025 %, 0.05 %.............51 tretinoin external cream 0.1 %...............................30 tretinoin external cream 0.1 %...............................51 tretinoin external gel 0.01 %, 0.025 %..................30 tretinoin external gel 0.01 %, 0.025 %..................51 tretinoin oral.........................................................30 tri femynor............................................................59 tri-estarylla............................................................59 tri-legest fe.............................................................59 tri-linyah..............................................................59 tri-mili.................................................................59 tri-previfem...........................................................59 tri-sprintec............................................................59 tri-vylibra.............................................................59 triamcinolone acetonide external cream...................57 triamcinolone acetonide external lotion 0.025

%......................................................................57 triamcinolone acetonide external lotion 0.1 %.........57 triamcinolone acetonide external ointment 0.025

%......................................................................57 triamcinolone acetonide external ointment 0.1 %,

0.5 %................................................................57 triamcinolone acetonide injection suspension 40 mg/

ml......................................................................12 triamcinolone acetonide mouth/throat.....................50 triamterene-hctz oral capsule 37.5-25 mg...............48 triamterene-hctz oral tablet....................................48 triderm external cream 0.1 %................................57 triderm external cream 0.5 %................................51 trientine hcl...........................................................53 trifluoperazine hcl oral tablet 1 mg, 2 mg, 5 mg......35 trifluoperazine hcl oral tablet 10 mg.......................35 trifluridine ophthalmic...........................................38 trihexyphenidyl hcl oral solution.............................32 trihexyphenidyl hcl oral tablet.................................32 trilyte....................................................................55 trimethoprim oral..................................................16 trimipramine maleate oral.....................................22

trinessa (28)..........................................................59 TRINTELLIX ORAL TABLET 10 MG..............22 TRINTELLIX ORAL TABLET 20 MG..............22 TRINTELLIX ORAL TABLET 5 MG................22 TRISENOX INTRAVENOUS SOLUTION 12

MG/6ML..........................................................30 TRIUMEQ..........................................................38 trivora (28)...........................................................59 TROGARZO......................................................38 TROPHAMINE..................................................53 trospium chloride...................................................55 TRULICITY........................................................44 TRUMENBA......................................................63 TRUVADA.........................................................38 tulana...................................................................59 TURALIO...........................................................30 TWINRIX INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE...................................63 TYBOST.............................................................38 TYKERB..............................................................30 TYPHIM VI INTRAMUSCULAR SOLUTION

25 MCG/0.5ML...............................................63 TYPHIM VI INTRAMUSCULAR SOLUTION

25 MCG/0.5ML (0.5ML SYRINGE)...............63 TYSABRI.............................................................49 ULORIC.............................................................24 UNIFINE PENTIPS 30G X 5 MM....................44 unithroid oral tablet 100 mcg, 112 mcg, 125 mcg,

137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg.....................................60

unithroid oral tablet 300 mcg.................................60 ursodiol oral..........................................................55 valacyclovir hcl oral tablet 1 gm..............................38 valacyclovir hcl oral tablet 500 mg..........................38 VALCHLOR.......................................................30 VALCHLOR.......................................................51 valganciclovir hcl oral tablet...................................38 valproate sodium intravenous.................................19 valproic acid oral capsule........................................19 valproic acid oral capsule........................................25 valproic acid oral capsule........................................41 valproic acid oral solution......................................19 valproic acid oral solution......................................25 valproic acid oral solution......................................41 valsartan...............................................................48 valsartan-hydrochlorothiazide.................................48 VANCOMYCIN HCL IN DEXTROSE

INTRAVENOUS SOLUTION 1-5 GM/


200ML-%, 500-5 MG/100ML-%, 750-5 MG/ 150ML-%.........................................................16

VANCOMYCIN HCL IN NACL INTRAVENOUS SOLUTION 1-0.9 GM/ 200ML-%, 500-0.9 MG/100ML-%, 750-0.9 MG/150ML-%.................................................17

vancomycin hcl intravenous solution reconstituted 1 gm, 10 gm, 5 gm, 500 mg...................................17

VANCOMYCIN HCL INTRAVENOUS SOLUTION RECONSTITUTED 1.25 GM, 1.5 GM, 250 MG.............................................17

vancomycin hcl intravenous solution reconstituted 750 mg..............................................................17

vancomycin hcl oral capsule 250 mg.......................17 vandazole..............................................................17 VAQTA INTRAMUSCULAR SUSPENSION

25 UNIT/0.5ML 0.5 ML, 50 UNIT/ML 1 ML....................................................................63

VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/0.5ML, 50 UNIT/ML......................63

VARIVAX............................................................63 VARIZIG INTRAMUSCULAR

SOLUTION.....................................................63 VASCEPA............................................................48 VECAMYL..........................................................49 VECTIBIX INTRAVENOUS SOLUTION 100

MG/5ML, 400 MG/20ML...............................30 VELCADE INJECTION....................................31 velivet...................................................................59 VEMLIDY...........................................................38 VENCLEXTA ORAL TABLET 10 MG.............31 VENCLEXTA ORAL TABLET 100 MG...........31 VENCLEXTA ORAL TABLET 50 MG.............31 VENCLEXTA STARTING PACK.....................31 venlafaxine hcl er oral capsule extended release 24

hour 150 mg......................................................22 venlafaxine hcl er oral capsule extended release 24

hour 150 mg......................................................39 venlafaxine hcl er oral capsule extended release 24

hour 37.5 mg.....................................................22 venlafaxine hcl er oral capsule extended release 24

hour 37.5 mg.....................................................39 venlafaxine hcl er oral capsule extended release 24

hour 75 mg........................................................22 venlafaxine hcl er oral capsule extended release 24

hour 75 mg........................................................39 venlafaxine hcl oral tablet 100 mg..........................22 venlafaxine hcl oral tablet 100 mg..........................39

venlafaxine hcl oral tablet 25 mg............................22 venlafaxine hcl oral tablet 25 mg............................39 venlafaxine hcl oral tablet 37.5 mg.........................22 venlafaxine hcl oral tablet 37.5 mg.........................39 venlafaxine hcl oral tablet 50 mg............................22 venlafaxine hcl oral tablet 50 mg............................40 venlafaxine hcl oral tablet 75 mg............................23 venlafaxine hcl oral tablet 75 mg............................40 VENTAVIS.........................................................68 verapamil hcl er oral capsule extended release 24

hour...................................................................48 verapamil hcl er oral tablet extended release.............48 verapamil hcl intravenous......................................48 verapamil hcl oral tablet 120 mg, 80 mg.................48 verapamil hcl oral tablet 40 mg..............................49 VERSACLOZ......................................................35 VERZENIO........................................................31 VIBATIV INTRAVENOUS SOLUTION

RECONSTITUTED 750 MG.........................17 VICTOZA SUBCUTANEOUS SOLUTION

PEN-INJECTOR.............................................44 VIDEX EC ORAL CAPSULE DELAYED

RELEASE 125 MG...........................................38 VIDEX ORAL SOLUTION

RECONSTITUTED 2 GM.............................38 vienva...................................................................59 vigabatrin.............................................................19 vigadrone..............................................................19 VIIBRYD ORAL TABLET 10 MG.....................23 VIIBRYD ORAL TABLET 20 MG.....................23 VIIBRYD ORAL TABLET 40 MG.....................23 VIIBRYD STARTER PACK...............................23 VIMPAT INTRAVENOUS................................19 VIMPAT ORAL SOLUTION............................19 VIMPAT ORAL TABLET 100 MG....................19 VIMPAT ORAL TABLET 150 MG, 200

MG...................................................................19 VIMPAT ORAL TABLET 50 MG......................19 vinblastine sulfate intravenous solution...................31 vincristine sulfate intravenous.................................31 vinorelbine tartrate................................................31 viorele...................................................................59 VIRACEPT ORAL TABLET 250 MG................38 VIRACEPT ORAL TABLET 625 MG................38 VIRAZOLE.........................................................38 VIREAD ORAL POWDER................................38 VIREAD ORAL POWDER................................38


VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG............................................................38

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG............................................................38

VITRAKVI ORAL CAPSULE 100 MG..............31 VITRAKVI ORAL CAPSULE 25 MG................31 VITRAKVI ORAL SOLUTION.........................31 VIZIMPRO ORAL TABLET 15 MG.................31 VIZIMPRO ORAL TABLET 30 MG, 45

MG...................................................................31 voriconazole intravenous........................................24 voriconazole oral suspension reconstituted................24 voriconazole oral tablet 200 mg..............................24 voriconazole oral tablet 50 mg................................24 VOSEVI..............................................................38 VOTRIENT........................................................31 VPRIV.................................................................53 VRAYLAR ORAL CAPSULE..............................35 VRAYLAR ORAL CAPSULE..............................41 VRAYLAR ORAL CAPSULE THERAPY

PACK...............................................................35 VRAYLAR ORAL CAPSULE THERAPY

PACK...............................................................41 vyfemla.................................................................59 vylibra..................................................................59 VYXEOS INTRAVENOUS SUSPENSION

RECONSTITUTED 44-100 MG....................31 warfarin sodium oral.............................................45 wera.....................................................................59 wixela inhub.........................................................68 wixela inhub.........................................................68 XALKORI...........................................................31 XARELTO ORAL TABLET 10 MG, 20

MG...................................................................45 XARELTO ORAL TABLET 15 MG...................45 XARELTO ORAL TABLET 2.5 MG..................45 XARELTO STARTER PACK.............................45 XATMEP.............................................................63 XELJANZ............................................................63 XGEVA...............................................................64 XIIDRA...............................................................65 XOFLUZA..........................................................38 XOLAIR SUBCUTANEOUS SOLUTION

RECONSTITUTED........................................68 XOSPATA...........................................................31 XPOVIO (100 MG ONCE WEEKLY)...............31 XPOVIO (60 MG ONCE WEEKLY).................31 XPOVIO (80 MG ONCE WEEKLY).................31 XPOVIO (80 MG TWICE WEEKLY)...............31

XTANDI.............................................................31 XYREM...............................................................68 YERVOY.............................................................31 YF-VAX...............................................................63 YONDELIS.........................................................31 YONSA...............................................................31 zafirlukast.............................................................68 zaleplon oral capsule 10 mg....................................68 zaleplon oral capsule 5 mg......................................68 ZALTRAP...........................................................31 ZANOSAR..........................................................31 zarah....................................................................59 ZARXIO..............................................................45 ZEJULA...............................................................31 ZELBORAF.........................................................31 zenatane oral capsule 10 mg, 20 mg, 40 mg............51 zenzedi oral tablet 10 mg.......................................49 zenzedi oral tablet 5 mg.........................................49 zidovudine oral capsule..........................................38 zidovudine oral syrup.............................................38 zidovudine oral tablet............................................38 ziprasidone hcl oral capsule 20 mg..........................35 ziprasidone hcl oral capsule 20 mg..........................41 ziprasidone hcl oral capsule 40 mg..........................35 ziprasidone hcl oral capsule 40 mg..........................41 ziprasidone hcl oral capsule 60 mg, 80 mg...............35 ziprasidone hcl oral capsule 60 mg, 80 mg...............41 ZIRGAN.............................................................38 zoledronic acid intravenous concentrate...................64 zoledronic acid intravenous solution........................64 ZOLINZA...........................................................24 ZOLINZA...........................................................31 zolpidem tartrate oral............................................68 zonisamide oral capsule 100 mg, 50 mg..................20 zonisamide oral capsule 25 mg...............................20 ZORTRESS.........................................................63 ZOSTAVAX SUBCUTANEOUS SUSPENSION

RECONSTITUTED........................................63 zovia 1/35e (28)....................................................59 ZULRESSO.........................................................49 zumandimine........................................................59 ZYDELIG............................................................31 ZYKADIA ORAL TABLET................................31 ZYPREXA RELPREVV.......................................35 ZYPREXA RELPREVV INTRAMUSCULAR

SUSPENSION RECONSTITUTED 210 MG...................................................................41

ZYTIGA ORAL TABLET 500 MG....................31


ZYVOX INTRAVENOUS SOLUTION 200 MG/100ML......................................................17


Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin (BCBSWI), Compcare Health Services Insurance Corporation (Compcare) and Wisconsin Collaborative Insurance Company (WCIC). BCBSWI underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc., Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent licensee of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc., Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. Independent licensee of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc., Anthem Blue Cross and Blue Shield is the trade name of: in Indiana: Anthem Insurance Companies, Inc. and in Kentucky: Anthem Health Plans of Kentucky, Inc. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc., Anthem Blue Cross and Blue Shield is the trade name of: in Maine: Anthem Health Plans of Maine, Inc. and in New Hampshire: Anthem Health Plans of New Hampshire, Inc. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc., Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

This formulary was updated on 1/28/2020. For more recent information or other questions, please contact Anthem MediBlue Rx Plus (PDP) Customer Service, at 1-833-285-4639 or, for TTY users, 711, 24 hours a day, 7 days a week, or visit https://shop.anthem.com/medicare.

Y0114_20_107273_I_C_0001 S5596_001, 006, 014, 018, 057, 060, 063 CO,IN,KY,ME,NH,NV,OH,VA,WI

Documents

Anthem MediBlue Rx Plus (PDP) 2020 Formulary (List of Covered Drugs) · 2020-02-04 · Anthem MediBlue Rx Plus (PDP) 2020 Formulary (List of Covered Drugs) PLEASE READ: This document