HMSA QUEST Integration Managed Medicaid Formulary · 2020. 2. 4. · HMSA QUEST Integration Managed Medicaid Formulary (Effective 02/01/2020) LEGEND AL Age Limit ... drugs, strengths,

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HMSA QUEST Integration Managed Medicaid

Formulary

(Effective 02/01/2020)

LEGEND

AL Age Limit

OB7 Initial prescriptions for opioids and benzodiazepines being filled

concurrently will be limited to a 7 day supply

OTC Over the Counter

PA Prior Authorization

QL Quantity Limit

SP Specialty Drug

ST Step Therapy

120 MME Cumulative morphine milligram equivalent (MME) opioid threshold is 120 MME per day

+ Indicates both the generic is covered as well as the brand-name product equivalent, with dispense as written code 1 (DAW 1). This

includes State-mandated drug classes (HIV and AIDS, Antidepressants, Antipsychotics, Antianxiety Agents, and

Immunosuppressants).

lowercase lowercase type indicates generic availability

UPPERCASE UPPERCASE type indicates brand availability

NOTE

The status of a drug on this list is current as of the date of this publication.

The list serves as a guide to product selection for our providers and members. The list is subject to change. Participating pharmacies have the most

up-to-date formulary information at the time prescriptions are filled. New drugs, strengths, forms, and/or therapeutic categories introduced in the

marketplace will be reflected in the formulary, as applicable, following the completion of HMSA’s review process.

Not all generic drugs may be listed.

Coverage of a drug will depend on your drug plan.

HMSA's mission is to provide the people of Hawaii access to a sustainable, quality health care

system that improves the overall health and well-being of our state.

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HMSA CENTERS

Convenient evening and Saturday hours:

HMSA Center @ Honolulu 818 Keeaumoku St.

Monday through Friday, 8 a.m. - 6 p.m. | Saturday, 9 a.m. - 2 p.m.

HMSA Center @ Pearl City

Pearl City Gateway | 1132 Kuala St., Suite 400 Monday through Friday, 9 a.m. - 7 p.m. | Saturday, 9 a.m. - 2 p.m.

HMSA Center @ Hilo

Waiakea Center | 303A E. Makaala St. Monday through Friday, 9 a.m. - 7 p.m. | Saturday, 9 a.m. - 2 p.m.

OFFICES Visit your local HMSA office Monday through Friday, 8 a.m. - 4 p.m.:

Kailua-Kona, Hawaii Island | 75-1029 Henry St., Suite 301 |

Phone: 329-5291

Kahului, Maui | 33 Lono Ave., Suite 350 | Phone: 871-6295

Lihue, Kauai | 4366 Kukui Grove St., Suite 103 | Phone: 245-3393

PHONE

948-6372 on Oahu

If you are calling from the U.S. Mainland, please call 1 (800) 776-4672. If you need to call a local Hawaii telephone number from the Mainland, the area code

is 808.

Check hmsa.com/contact for our holiday schedule.

The information contained in this document is proprietary. The information may

not be copied in whole or in part without written permission. ©2019. All rights reserved.

This document contains references to brand-name prescription drugs that are

trademarks or registered trademarks of pharmaceutical manufacturers.

Plan member privacy is important to us. Our employees are trained regarding the

appropriate way to handle members' private health information.

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the Counter SP - Specialty Drug OTC - Over the counter + - Both generic and brand-name equivalents are covered with dispense as written code 1 (DAW 1) AL - Age Limit OB7 – Opioid/Benzodiazepine Limit 120 MME – Daily Cumulative MME Limit

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Drug Name Requirements/Limits

ANALGESICS COX-II INHIBITORS

celecoxib cap 50 mg ST (Must have recently been

on 30 days supply of NSAID

or GI protectant OR be

taking a drug that could

cause adverse GI events)


on 30 days supply of NSAID or GI protectant OR be





or GI protectant OR be





or GI protectant OR be taking a drug that could


GOUT allopurinol tab 100 mg

allopurinol tab 300 mg

colchicine tab 0.6 mg QL (30 per month)

probenecid tab 500 mg

NON-OPIOID ANALGESICS acetaminophen cap 500 mg OTC

acetaminophen chew tab 80 mg OTC

acetaminophen chew tab 160 mg OTC

acetaminophen disintegrating tab 80 mg OTC

acetaminophen disintegrating tab 160 mg OTC

acetaminophen elixir 160 mg/5ml OTC

acetaminophen liquid 160 mg/5ml OTC

acetaminophen liquid 167 mg/5ml OTC

acetaminophen soln 160 mg/5ml OTC

acetaminophen suppos 120 mg OTC



acetaminophen susp 80 mg/0.8ml OTC

acetaminophen susp 160 mg/5ml OTC

acetaminophen tab 325 mg OTC

acetaminophen tab 500 mg OTC

acetaminophen tab er 650 mg OTC


4


butalbital-acetaminophen-caffeine cap 50-325-40

mg

QL (60 per month)

butalbital-acetaminophen-caffeine tab 50-325-40

mg

QL (60 per month)

butalbital-aspirin-caffeine cap 50-325-40 mg QL (60 per month)

FEVERALL INF SUP 80MG OTC

FEVERALL SUP 325MG OTC

NSAIDS diclofenac potassium tab 50 mg

diclofenac sodium tab delayed release 25 mg



diclofenac sodium tab er 24hr 100 mg

diflunisal tab 500 mg

etodolac cap 200 mg

etodolac cap 300 mg

etodolac tab 400 mg

etodolac tab 500 mg

etodolac tab er 24hr 400 mg



flurbiprofen tab 50 mg

flurbiprofen tab 100 mg

ibuprofen cap 200 mg OTC

ibuprofen chew tab 100 mg OTC

ibuprofen susp 40 mg/ml OTC

ibuprofen susp 100 mg/5ml

ibuprofen susp 100 mg/5ml OTC

ibuprofen tab 100 mg OTC

ibuprofen tab 200 mg OTC

ibuprofen tab 400 mg



ketorolac tromethamine tab 10 mg QL (20 per month)

meloxicam tab 7.5 mg

meloxicam tab 15 mg

nabumetone tab 500 mg

nabumetone tab 750 mg

naproxen sodium cap 220 mg OTC

naproxen sodium tab 220 mg OTC

naproxen sodium tab 275 mg

naproxen sodium tab 550 mg

naproxen susp 125 mg/5ml

naproxen tab 250 mg


5


naproxen tab 375 mg

naproxen tab 500 mg

naproxen tab ec 375 mg

naproxen tab ec 500 mg

oxaprozin tab 600 mg

sulindac tab 150 mg

sulindac tab 200 mg

NSAIDS, TOPICAL diclofenac sodium gel 1% QL (500 grams per month)

OPIOID ANALGESICS acetaminophen w/ codeine soln 120-12 mg/5ml OB7, 120 MME, QL (5000

mL per month)

acetaminophen w/ codeine tab 300-15 mg OB7, 120 MME, QL (400 per

month)

acetaminophen w/ codeine tab 300-30 mg OB7, 120 MME, QL (400 per

month)

acetaminophen w/ codeine tab 300-60 mg OB7, 120 MME, QL (400 per month)

fentanyl td patch 72hr 12 mcg/hr OB7, 120 MME, QL (20 per month)

fentanyl td patch 72hr 25 mcg/hr OB7, 120 MME, QL (20 per

month)

fentanyl td patch 72hr 50 mcg/hr OB7, 120 MME, QL (20 per

month)

fentanyl td patch 72hr 75 mcg/hr OB7, 120 MME

fentanyl td patch 72hr 100 mcg/hr OB7, 120 MME

hydrocodone-acetaminophen soln 7.5-325

mg/15ml

OB7, 120 MME, QL (5540

mL per month)

hydrocodone-acetaminophen tab 5-325 mg OB7, 120 MME, QL (375 per

month)

hydrocodone-acetaminophen tab 7.5-325 mg OB7, 120 MME, QL (375 per

month)

hydrocodone-acetaminophen tab 10-325 mg OB7, 120 MME, QL (240 per

month)

hydromorphone hcl tab 2 mg OB7, 120 MME, QL (180 per

month)

hydromorphone hcl tab 4 mg OB7, 120 MME, QL (180 per month)

hydromorphone hcl tab 8 mg OB7, 120 MME, QL (90 per month)

methadone hcl tab 5 mg OB7, 120 MME

methadone hcl tab 10 mg OB7, 120 MME

morphine sulfate oral soln 10 mg/5ml OB7, 120 MME, QL (900 mL

per month)


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morphine sulfate oral soln 20 mg/5ml OB7, 120 MME, QL (900 mL

per month)

morphine sulfate oral soln 100 mg/5ml (20 mg/ml) OB7, 120 MME, QL (180 mL

per month)

morphine sulfate tab 15 mg OB7, 120 MME, QL (180 per

month)

morphine sulfate tab 30 mg OB7, 120MME, QL (120 per

month)

morphine sulfate tab er 15 mg OB7, 120 MME, QL (120 per

month)

morphine sulfate tab er 30 mg OB7, 120 MME, QL (120 per month)

morphine sulfate tab er 60 mg OB7, 120 MME, QL (60 per month)

morphine sulfate tab er 100 mg OB7, 120 MME

morphine sulfate tab er 200 mg OB7, 120 MME

oxycodone hcl cap 5 mg OB7, 120 MME, QL (180 per

month)

oxycodone hcl conc 100 mg/5ml (20 mg/ml) OB7, 120 MME, QL (120 mL

per month)

oxycodone hcl soln 5 mg/5ml OB7, 120 MME, QL (180 mL

per month)

oxycodone hcl tab 5 mg OB7, 120 MME, QL (180 per

month)


month)


month)

oxycodone hcl tab 20 mg OB7, 120 MME, QL (120 per month)

oxycodone hcl tab 30 mg OB7, 120 MME, QL (60 per month)

oxycodone w/ acetaminophen tab 2.5-325 mg OB7, 120 MME, QL (375 per

month)

oxycodone w/ acetaminophen tab 5-325 mg OB7, 120 MME, QL (375 per

month)

oxycodone w/ acetaminophen tab 7.5-325 mg OB7, 120 MME, QL (300 per

month)

oxycodone w/ acetaminophen tab 10-325 mg OB7, 120 MME, QL (240 per

month)

oxycodone-aspirin tab 4.8355-325 mg OB7, 120 MME, QL (308 per

month)

tramadol hcl tab 50 mg OB7, 120 MME, QL (240 per

month)

tramadol hcl tab er 24hr 100 mg OB7, 120 MME, QL (30 per

month)


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month)


month)

tramadol hcl tab er 24hr biphasic release 300 mg OB7, 120 MME, QL (30 per

month)

tramadol-acetaminophen tab 37.5-325 mg OB7, 120 MME, QL (240 per

month)

ANTI-INFECTIVES AMINOGLYCOSIDES

neomycin sulfate tab 500 mg

ANTIBACTERIALS, CEPHALOSPORINS, First Generation cefadroxil cap 500 mg

cefadroxil for susp 250 mg/5ml

cefadroxil for susp 500 mg/5ml

cefadroxil tab 1 gm

cephalexin cap 250 mg



cephalexin for susp 125 mg/5ml

cephalexin for susp 250 mg/5ml

cephalexin tab 250 mg

cephalexin tab 500 mg

ANTIBACTERIALS, CEPHALOSPORINS, Second Generation cefprozil for susp 125 mg/5ml

cefprozil for susp 250 mg/5ml

cefprozil tab 250 mg

cefprozil tab 500 mg

cefuroxime axetil tab 250 mg

cefuroxime axetil tab 500 mg

ANTIBACTERIALS, CEPHALOSPORINS, Third Generation cefdinir cap 300 mg

cefdinir for susp 125 mg/5ml

cefdinir for susp 250 mg/5ml

ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 mg/5ml

azithromycin for susp 200 mg/5ml

azithromycin powd pack for susp 1 gm

azithromycin tab 250 mg



clarithromycin for susp 125 mg/5ml

clarithromycin for susp 250 mg/5ml


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clarithromycin tab 250 mg

clarithromycin tab 500 mg

clarithromycin tab er 24hr 500 mg

erythromycin ethylsuccinate for susp 200 mg/5ml

erythromycin ethylsuccinate tab 400 mg

erythromycin stearate tab 250 mg

erythromycin tab 250 mg

erythromycin tab 500 mg

erythromycin tab delayed release 250 mg



erythromycin w/ delayed release particles cap 250

mg

ANTIBACTERIALS, FLUOROQUINOLONES ciprofloxacin hcl tab 100 mg (base equiv)

ciprofloxacin hcl tab 250 mg (base equiv)



levofloxacin oral soln 25 mg/ml

levofloxacin tab 250 mg



ANTIBACTERIALS, PENICILLINS amoxicillin & k clavulanate chew tab 200-28.5 mg

amoxicillin & k clavulanate chew tab 400-57 mg

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

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

amoxicillin & k clavulanate for susp 400-57

mg/5ml

amoxicillin & k clavulanate for susp 600-42.9

mg/5ml

amoxicillin & k clavulanate tab 250-125 mg



amoxicillin (trihydrate) cap 250 mg

amoxicillin (trihydrate) cap 500 mg

amoxicillin (trihydrate) chew tab 125 mg

amoxicillin (trihydrate) chew tab 250 mg

amoxicillin (trihydrate) for susp 125 mg/5ml





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amoxicillin (trihydrate) tab 500 mg

amoxicillin (trihydrate) tab 875 mg

ampicillin cap 500 mg

AUGMENTIN SUS 125/5ML

dicloxacillin sodium cap 250 mg

dicloxacillin sodium cap 500 mg

penicillin v potassium for soln 125 mg/5ml

penicillin v potassium for soln 250 mg/5ml

penicillin v potassium tab 250 mg

penicillin v potassium tab 500 mg

ANTIBACTERIALS, SULFONAMIDES SULFADIAZINE TAB 500MG

sulfamethoxazole-trimethoprim susp 200-40

mg/5ml

sulfamethoxazole-trimethoprim tab 400-80 mg

sulfamethoxazole-trimethoprim tab 800-160 mg

ANTIBACTERIALS, TETRACYCLINES demeclocycline hcl tab 150 mg

demeclocycline hcl tab 300 mg

doxycycline hyclate cap 50 mg

doxycycline hyclate cap 100 mg

doxycycline hyclate tab 20 mg

doxycycline hyclate tab 100 mg

doxycycline monohydrate for susp 25 mg/5ml

minocycline hcl cap 50 mg



tetracycline hcl cap 250 mg

tetracycline hcl cap 500 mg

ANTIFUNGALS clotrimazole troche 10 mg

fluconazole for susp 10 mg/ml

fluconazole for susp 40 mg/ml

fluconazole tab 50 mg




griseofulvin microsize susp 125 mg/5ml

griseofulvin ultramicrosize tab 125 mg

griseofulvin ultramicrosize tab 250 mg

itraconazole cap 100 mg PA

nystatin oral powder

nystatin susp 100000 unit/ml


10


nystatin tab 500000 unit

terbinafine hcl tab 250 mg QL (1 tab per day; 90 days

per year)

voriconazole for susp 40 mg/ml PA

voriconazole tab 50 mg PA

voriconazole tab 200 mg PA

ANTIMALARIALS atovaquone-proguanil hcl tab 62.5-25 mg QL (23 per 6 months)

atovaquone-proguanil hcl tab 250-100 mg QL (23 per 6 months)

chloroquine phosphate tab 250 mg QL (8 per 6 months)

chloroquine phosphate tab 500 mg QL (8 per 6 months)

mefloquine hcl tab 250 mg QL (8 per 6 months)

ANTIRETROVIRALS, ANTIRETROVIRAL ADJUVANTS TYBOST TAB 150MG SP

ANTIRETROVIRALS, ANTIRETROVIRAL COMBINATIONS abacavir sulfate-lamivudine tab 600-300 mg SP

abacavir sulfate-lamivudine-zidovudine tab 300-

150-300 mg

SP

ATRIPLA TAB SP

BIKTARVY TAB SP

CIMDUO TAB 300-300 SP

COMBIVIR TAB 150-300 SP; +

COMPLERA TAB SP

DESCOVY TAB 200/25 SP

EPZICOM TAB 600-300 SP; +

EVOTAZ TAB 300-150 SP

GENVOYA TAB SP

lamivudine-zidovudine tab 150-300 mg SP

ODEFSEY TAB SP

PREZCOBIX TAB 800-150 SP

STRIBILD TAB SP

SYMFI LO TAB SP

SYMFI TAB SP

SYMTUZA TAB SP

TRIUMEQ TAB SP

TRIZIVIR TAB SP; +

TRUVADA TAB 100-150 SP




ANTIRETROVIRALS, CHEMOKINE RECEPTOR ANTAGONISTS SELZENTRY SOL 20MG/ML SP

SELZENTRY TAB 25MG SP


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ANTIRETROVIRALS, FUSION INHIBITORS FUZEON INJ 90MG SP

ANTIRETROVIRALS, INTEGRASE INHIBITORS ISENTRESS CHW 25MG SP

ISENTRESS CHW 100MG SP

ISENTRESS HD TAB 600MG SP

ISENTRESS POW 100MG SP

ISENTRESS TAB 400MG SP

TIVICAY TAB 10MG SP

TIVICAY TAB 25MG SP

TIVICAY TAB 50MG SP

ANTIRETROVIRALS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE

INHIBITORS EDURANT TAB 25MG SP

efavirenz cap 50 mg SP

efavirenz cap 200 mg SP

efavirenz tab 600 mg SP

INTELENCE TAB 25MG SP



nevirapine susp 50 mg/5ml SP

nevirapine tab 200 mg SP

nevirapine tab er 24hr 100 mg SP

nevirapine tab er 24hr 400 mg SP

RESCRIPTOR TAB 200MG SP

SUSTIVA CAP 50MG SP; +

SUSTIVA CAP 200MG SP; +

SUSTIVA TAB 600MG SP; +

VIRAMUNE SUS 50MG/5ML SP; +

VIRAMUNE TAB 200MG SP; +

VIRAMUNE XR TAB 400MG SP; +

ANTIRETROVIRALS, NUCLEOSIDE REVERSE TRANSCRIPTASE

INHIBITORS abacavir sulfate soln 20 mg/ml (base equiv) SP

abacavir sulfate tab 300 mg (base equiv) SP

didanosine delayed release capsule 200 mg SP



EMTRIVA CAP 200MG SP

EMTRIVA SOL 10MG/ML SP


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EPIVIR SOL 10MG/ML SP; +

EPIVIR TAB 150MG SP; +

EPIVIR TAB 300MG SP; +

lamivudine oral soln 10 mg/ml SP

lamivudine tab 150 mg SP

lamivudine tab 300 mg SP

RETROVIR CAP 100MG SP; +

RETROVIR SYP 50MG/5ML SP; +

stavudine cap 15 mg SP




VIDEX EC CAP 125MG SP

VIDEX EC CAP 200MG SP; +



VIDEX SOL 2GM SP

ZIAGEN SOL 20MG/ML SP; +

ZIAGEN TAB 300MG SP; +

zidovudine cap 100 mg SP

zidovudine syrup 10 mg/ml SP

zidovudine tab 300 mg SP

ANTIRETROVIRALS, NUCLEOTIDE REVERSE TRANSCRIPTASE

INHIBITORS tenofovir disoproxil fumarate tab 300 mg SP

VIREAD POW 40MG/GM SP

VIREAD TAB 150MG SP

VIREAD TAB 200MG SP

VIREAD TAB 250MG SP

VIREAD TAB 300MG SP; +

ANTIRETROVIRALS, PROTEASE INHIBITORS APTIVUS CAP 250MG SP

APTIVUS SOL SP

atazanavir sulfate cap 150 mg (base equiv) SP



CRIXIVAN CAP 200MG SP

CRIXIVAN CAP 400MG SP

fosamprenavir calcium tab 700 mg (base equiv) SP

INVIRASE TAB 500MG SP

KALETRA SOL SP; +

KALETRA TAB 100-25MG SP

KALETRA TAB 200-50MG SP


13


LEXIVA SUS 50MG/ML SP

LEXIVA TAB 700MG SP; +

lopinavir-ritonavir soln 400-100 mg/5ml (80-20

mg/ml)

SP

NORVIR POW 100MG SP

NORVIR SOL 80MG/ML SP

NORVIR TAB 100MG SP; +

PREZISTA SUS 100MG/ML SP

PREZISTA TAB 75MG SP




REYATAZ CAP 150MG SP; +



REYATAZ POW 50MG SP

ritonavir tab 100 mg SP

VIRACEPT TAB 250MG SP

VIRACEPT TAB 625MG SP

ANTITUBERCULAR AGENTS ethambutol hcl tab 100 mg

ethambutol hcl tab 400 mg

isoniazid syrup 50 mg/5ml AL (covered for ages 18 and

under; refer to Dept of

Health if > 18 years old)

isoniazid tab 100 mg AL (covered for ages 18 and



isoniazid tab 300 mg AL (covered for ages 18 and



pyrazinamide tab 500 mg

rifampin cap 150 mg

rifampin cap 300 mg

ANTIVIRALS, CYTOMEGALOVIRUS AGENTS valganciclovir hcl for soln 50 mg/ml (base equiv)

valganciclovir hcl tab 450 mg (base equivalent)

ANTIVIRALS, HEPATITIS AGENTS, Hepatitis B adefovir dipivoxil tab 10 mg

BARACLUDE SOL

entecavir tab 0.5 mg

entecavir tab 1 mg

lamivudine tab 100 mg (hbv)


14


ANTIVIRALS, HEPATITIS AGENTS, Hepatitis C MAVYRET TAB 100-40MG SP, PA; for genotypes 1, 2,

3, 4, 5, 6

RIBAPAK PAK 800/DAY SP, PA

RIBAPAK PAK 1200/DAY SP, PA

RIBAPAK TAB 600/DAY SP, PA

RIBAPAK TAB 1000/DAY SP, PA

ribasphere cap 200mg SP, PA

ribasphere tab 200mg SP, PA

RIBASPHERE TAB 400MG SP, PA

ribasphere tab 600mg SP, PA

ribavirin cap 200 mg SP, PA

ribavirin tab 200 mg SP, PA

ANTIVIRALS, HERPES AGENTS acyclovir cap 200 mg

acyclovir susp 200 mg/5ml

acyclovir tab 400 mg

acyclovir tab 800 mg

famciclovir tab 125 mg



valacyclovir hcl tab 1 gm

valacyclovir hcl tab 500 mg

ANTIVIRALS, INFLUENZA AGENTS oseltamivir phosphate cap 30 mg (base equiv) QL (56 caps per 6 months)

oseltamivir phosphate cap 45 mg (base equiv) QL (28 caps per 6 months)

oseltamivir phosphate cap 75 mg (base equiv) QL (28 caps per 6 months)

oseltamivir phosphate for susp 6 mg/ml (base equiv)

QL (360 mL per 6 months)

MISCELLANEOUS atovaquone susp 750 mg/5ml

clindamycin hcl cap 150 mg

clindamycin hcl cap 300 mg

clindamycin palmitate hcl for soln 75 mg/5ml

(base equiv)

dapsone tab 25 mg

dapsone tab 100 mg

DARAPRIM TAB 25MG

EMVERM CHW 100MG QL (12 tabs per 365 days)

ivermectin tab 3 mg

linezolid for susp 100 mg/5ml PA

linezolid tab 600 mg PA

metronidazole cap 375 mg


15


metronidazole tab 250 mg

metronidazole tab 500 mg

nitrofurantoin macrocrystalline cap 25 mg



nitrofurantoin monohydrate macrocrystalline cap

100 mg

nitrofurantoin susp 25 mg/5ml

PINWORM TAB MEDICINE OTC

pyrantel pamoate susp 144 mg/ml (50 mg/ml base

equiv)

OTC

rifabutin cap 150 mg

trimethoprim tab 100 mg

vancomycin hcl cap 125 mg (base equivalent) QL (80 caps per 10 days)

vancomycin hcl cap 250 mg (base equivalent) QL (80 caps per 10 days)

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS

cyclophosphamide cap 25 mg

cyclophosphamide cap 50 mg

GLEOSTINE CAP 10MG

GLEOSTINE CAP 40MG

GLEOSTINE CAP 100MG

LEUKERAN TAB 2MG

melphalan tab 2 mg

MYLERAN TAB 2MG

temozolomide cap 5 mg SP, PA






ANTIMETABOLITES capecitabine tab 150 mg SP, PA

capecitabine tab 500 mg SP, PA

mercaptopurine tab 50 mg

methotrexate sodium tab 2.5 mg (base equiv)

HORMONAL ANTINEOPLASTICS, ANTIANDROGENS abiraterone acetate tab 250 mg SP, PA

bicalutamide tab 50 mg

flutamide cap 125 mg

HORMONAL ANTINEOPLASTICS, ANTIESTROGENS tamoxifen citrate tab 10 mg (base equivalent)

tamoxifen citrate tab 20 mg (base equivalent)


16


toremifene citrate tab 60 mg (base equivalent)

HORMONAL ANTINEOPLASTICS, AROMATASE INHIBITORS anastrozole tab 1 mg

exemestane tab 25 mg

letrozole tab 2.5 mg

HORMONAL ANTINEOPLASTICS, PROGESTINS megestrol acetate tab 20 mg

megestrol acetate tab 40 mg

IMMUNOMODULATORS REVLIMID CAP 2.5MG SP, PA

REVLIMID CAP 5MG SP, PA





KINASE INHIBITORS AFINITOR TAB 2.5MG SP, PA

AFINITOR TAB 5MG SP, PA

AFINITOR TAB 7.5MG SP, PA

AFINITOR TAB 10MG SP, PA

ALECENSA CAP 150MG SP, PA

CABOMETYX TAB 20MG SP, QL (30 per month), PA



CALQUENCE CAP 100MG SP, PA

CAPRELSA TAB 100MG SP, PA

CAPRELSA TAB 300MG SP, PA

COMETRIQ KIT 60MG SP, PA



erlotinib hcl tab 25 mg (base equivalent) SP, PA



GILOTRIF TAB 20MG SP, PA



IBRANCE CAP 75MG SP, PA



IMBRUVICA CAP 70MG SP, PA

IMBRUVICA CAP 140MG SP, PA

IMBRUVICA TAB 140MG SP, PA



17




INLYTA TAB 1MG SP, PA

INLYTA TAB 5MG SP, PA

JAKAFI TAB 5MG SP, PA





LENVIMA CAP 4MG SP, PA

LENVIMA CAP 8 MG SP, PA


LENVIMA CAP 12MG SP, PA





LORBRENA TAB 25MG SP, PA

LORBRENA TAB 100MG SP, PA

MEKINIST TAB 0.5MG SP, PA

MEKINIST TAB 2MG SP, PA

NEXAVAR TAB 200MG SP, PA

RYDAPT CAP 25MG SP, PA

STIVARGA TAB 40MG SP, PA

SUTENT CAP 12.5MG SP, PA

SUTENT CAP 25MG SP, PA

SUTENT CAP 37.5MG SP, PA

SUTENT CAP 50MG SP, PA

TAFINLAR CAP 50MG SP, PA

TAFINLAR CAP 75MG SP, PA

TYKERB TAB 250MG SP, PA

VITRAKVI CAP 25MG SP, PA

VITRAKVI CAP 100MG SP, PA

VITRAKVI SOL 20MG/ML SP, PA

VOTRIENT TAB 200MG SP, PA

ZELBORAF TAB 240MG SP, PA

ZYDELIG TAB 100MG SP, PA

ZYDELIG TAB 150MG SP, PA

ZYKADIA CAP 150MG SP, PA

ZYKADIA TAB 150MG SP, PA

KINASE INHIBITORS FOR CML imatinib mesylate tab 100 mg (base equivalent) SP, PA

imatinib mesylate tab 400 mg (base equivalent) SP, PA


18


MISCELLANEOUS bexarotene cap 75 mg SP, PA

ERIVEDGE CAP 150MG SP, PA

etoposide cap 50 mg

FARYDAK CAP 10MG SP, PA



hydroxyurea cap 500 mg

IDHIFA TAB 50MG SP, PA

IDHIFA TAB 100MG SP, PA

leucovorin calcium tab 5 mg




LYNPARZA TAB 100MG SP, PA

LYNPARZA TAB 150MG SP, PA

LYSODREN TAB 500MG

MATULANE CAP 50MG

RUBRACA TAB 200MG SP, PA



tretinoin cap 10 mg

VENCLEXTA TAB 10MG SP, PA



VENCLEXTA TAB START PK SP, PA

VISTOGARD PAK 10GM

ZEJULA CAP 100MG SP, PA

ZOLINZA CAP 100MG SP, PA

CARDIOVASCULAR ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS

amlodipine besylate-benazepril hcl cap 2.5-10 mg

amlodipine besylate-benazepril hcl cap 5-10 mg





ACE INHIBITOR/DIURETIC COMBINATIONS benazepril & hydrochlorothiazide tab 5-6.25 mg

benazepril & hydrochlorothiazide tab 10-12.5 mg

benazepril & hydrochlorothiazide tab 20-12.5 mg

benazepril & hydrochlorothiazide tab 20-25 mg

captopril & hydrochlorothiazide tab 25-15 mg


19





enalapril maleate & hydrochlorothiazide tab 5-12.5

mg

enalapril maleate & hydrochlorothiazide tab 10-25 mg

fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg

fosinopril sodium & hydrochlorothiazide tab 20-

12.5 mg

lisinopril & hydrochlorothiazide tab 10-12.5 mg

lisinopril & hydrochlorothiazide tab 20-12.5 mg

lisinopril & hydrochlorothiazide tab 20-25 mg

quinapril-hydrochlorothiazide tab 10-12.5 mg

quinapril-hydrochlorothiazide tab 20-12.5 mg

quinapril-hydrochlorothiazide tab 20-25 mg

ACE INHIBITORS benazepril hcl tab 5 mg

benazepril hcl tab 10 mg



captopril tab 12.5 mg

captopril tab 25 mg

captopril tab 50 mg

captopril tab 100 mg

enalapril maleate tab 2.5 mg

enalapril maleate tab 5 mg



fosinopril sodium tab 10 mg



lisinopril tab 2.5 mg

lisinopril tab 5 mg

lisinopril tab 10 mg




quinapril hcl tab 5 mg




ramipril cap 1.25 mg


20


ramipril cap 2.5 mg

ramipril cap 5 mg

ramipril cap 10 mg

trandolapril tab 1 mg



ADRENOLYTICS, CENTRAL clonidine hcl tab 0.1 mg

clonidine hcl tab 0.2 mg

clonidine hcl tab 0.3 mg

clonidine td patch weekly 0.1 mg/24hr



guanfacine hcl tab 1 mg

guanfacine hcl tab 2 mg

methyldopa tab 250 mg

methyldopa tab 500 mg

ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone tab 25 mg

eplerenone tab 50 mg

spironolactone tab 25 mg



ALPHA BLOCKERS doxazosin mesylate tab 1 mg

doxazosin mesylate tab 2 mg



prazosin hcl cap 1 mg



terazosin hcl cap 1 mg (base equivalent)




ANGIOTENSIN II RECEPTOR ANTAGONIST/DIURETIC

COMBINATIONS irbesartan-hydrochlorothiazide tab 150-12.5 mg

irbesartan-hydrochlorothiazide tab 300-12.5 mg

losartan potassium & hydrochlorothiazide tab 50-12.5 mg

losartan potassium & hydrochlorothiazide tab 100-

12.5 mg


21


losartan potassium & hydrochlorothiazide tab 100-

25 mg

valsartan-hydrochlorothiazide tab 80-12.5 mg


valsartan-hydrochlorothiazide tab 160-25 mg


valsartan-hydrochlorothiazide tab 320-25 mg

ANGIOTENSIN II RECEPTOR ANTAGONISTS irbesartan tab 75 mg

irbesartan tab 150 mg

irbesartan tab 300 mg

losartan potassium tab 25 mg



valsartan tab 40 mg

valsartan tab 80 mg

valsartan tab 160 mg

valsartan tab 320 mg

ANTIARRHYTHMICS amiodarone hcl tab 100 mg

amiodarone hcl tab 200 mg

amiodarone hcl tab 400 mg

BETAPACE AF TAB 80MG +



BETAPACE TAB 80MG +

BETAPACE TAB 120MG +

BETAPACE TAB 160MG +

disopyramide phosphate cap 100 mg

disopyramide phosphate cap 150 mg

dofetilide cap 125 mcg (0.125 mg) SP, PA



flecainide acetate tab 50 mg



MULTAQ TAB 400MG

NORPACE CAP 100MG +

NORPACE CAP 100MG CR

NORPACE CAP 150MG +

NORPACE CAP 150MG CR

propafenone hcl cap er 12hr 225 mg




22


propafenone hcl tab 150 mg



RYTHMOL SR CAP 225MG +



sotalol hcl (afib/afl) tab 80 mg



sotalol hcl tab 80 mg




TIKOSYN CAP 125MCG SP, PA; +



ANTILIPEMICS, BILE ACID RESINS cholestyramine light powder 4 gm/dose

cholestyramine light powder packets 4 gm

cholestyramine powder 4 gm/dose

cholestyramine powder packets 4 gm

colestipol hcl granule packets 5 gm

colestipol hcl granules 5 gm

colestipol hcl tab 1 gm

ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITORS ezetimibe tab 10 mg QL (30 per month)

ANTILIPEMICS, FIBRATES fenofibrate micronized cap 67 mg

fenofibrate micronized cap 134 mg

fenofibrate micronized cap 200 mg

fenofibrate tab 48 mg




gemfibrozil tab 600 mg

ANTILIPEMICS, HMG-COA REDUCTASE

INHIBITORS/COMBINATIONS atorvastatin calcium tab 10 mg (base equivalent) QL (30 per month)

atorvastatin calcium tab 20 mg (base equivalent) QL (30 per month)



lovastatin tab 10 mg QL (30 per month)



23



pravastatin sodium tab 10 mg QL (30 per month)




simvastatin tab 5 mg QL (30 per month)





ANTILIPEMICS, NIACINS niacin tab er 500 mg (antihyperlipidemic)

niacin tab er 750 mg (antihyperlipidemic)


BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone tab 50-25 mg

atenolol & chlorthalidone tab 100-25 mg

bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg

bisoprolol & hydrochlorothiazide tab 5-6.25 mg

bisoprolol & hydrochlorothiazide tab 10-6.25 mg

metoprolol & hydrochlorothiazide tab 50-25 mg



BETA-BLOCKERS atenolol tab 25 mg

atenolol tab 50 mg

atenolol tab 100 mg

bisoprolol fumarate tab 5 mg

bisoprolol fumarate tab 10 mg

carvedilol tab 3.125 mg



carvedilol tab 25 mg

labetalol hcl tab 100 mg



metoprolol succinate tab er 24hr 25 mg (tartrate

equiv)

metoprolol succinate tab er 24hr 50 mg (tartrate

equiv)

metoprolol succinate tab er 24hr 100 mg (tartrate equiv)

metoprolol succinate tab er 24hr 200 mg (tartrate equiv)


24


metoprolol tartrate tab 25 mg



nadolol tab 20 mg

nadolol tab 40 mg

nadolol tab 80 mg

pindolol tab 5 mg

pindolol tab 10 mg

propranolol hcl cap er 24hr 60 mg




propranolol hcl oral soln 20 mg/5ml

propranolol hcl oral soln 40 mg/5ml

propranolol hcl tab 10 mg





timolol maleate tab 5 mg



CALCIUM CHANNEL BLOCKERS, DIHYDROPYRIDINES amlodipine besylate tab 2.5 mg (base equivalent)

amlodipine besylate tab 5 mg (base equivalent)

amlodipine besylate tab 10 mg (base equivalent)

felodipine tab er 24hr 2.5 mg

felodipine tab er 24hr 5 mg

felodipine tab er 24hr 10 mg

nifedipine tab er 24hr 30 mg



nifedipine tab er 24hr osmotic release 30 mg



CALCIUM CHANNEL BLOCKERS, NON-DIHYDROPYRIDINES diltiazem hcl cap er 12hr 60 mg

diltiazem hcl cap er 12hr 90 mg





diltiazem hcl coated beads cap er 24hr 120 mg


25






diltiazem hcl coated beads tab er 24hr 180 mg





diltiazem hcl extended release beads cap er 24hr

120 mg


180 mg

diltiazem hcl extended release beads cap er 24hr 240 mg

diltiazem hcl extended release beads cap er 24hr 300 mg


360 mg


420 mg

diltiazem hcl tab 30 mg




verapamil hcl tab er 120 mg



DIGITALIS GLYCOSIDES digoxin oral soln 0.05 mg/ml

digoxin tab 125 mcg (0.125 mg)

digoxin tab 250 mcg (0.25 mg)

LANOXIN TAB 0.0625MG

DIURETICS, CARBONIC ANHYDRASE INHIBITORS acetazolamide cap er 12hr 500 mg

acetazolamide tab 125 mg

acetazolamide tab 250 mg

methazolamide tab 25 mg

methazolamide tab 50 mg

DIURETICS, DIURETIC COMBINATIONS ALDACTAZIDE TAB 50/50

amiloride & hydrochlorothiazide tab 5-50 mg

spironolactone & hydrochlorothiazide tab 25-25 mg

triamterene & hydrochlorothiazide cap 37.5-25 mg


26


triamterene & hydrochlorothiazide tab 37.5-25 mg

triamterene & hydrochlorothiazide tab 75-50 mg

DIURETICS, LOOP DIURETICS bumetanide tab 0.5 mg

bumetanide tab 1 mg

bumetanide tab 2 mg

furosemide oral soln 10 mg/ml

furosemide tab 20 mg



torsemide tab 5 mg

torsemide tab 10 mg

torsemide tab 20 mg

torsemide tab 100 mg

DIURETICS, POTASSIUM-SPARING DIURETICS amiloride hcl tab 5 mg

DIURETICS, THIAZIDES AND THIAZIDE-LIKE DIURETICS chlorthalidone tab 25 mg

chlorthalidone tab 50 mg

hydrochlorothiazide cap 12.5 mg

hydrochlorothiazide tab 12.5 mg

hydrochlorothiazide tab 25 mg

hydrochlorothiazide tab 50 mg

indapamide tab 1.25 mg

indapamide tab 2.5 mg

metolazone tab 2.5 mg

metolazone tab 5 mg

metolazone tab 10 mg

HEART FAILURE CORLANOR TAB 5MG

CORLANOR TAB 7.5MG

ENTRESTO TAB 24-26MG



MISCELLANEOUS hydralazine hcl tab 10 mg

hydralazine hcl tab 25 mg



NITRATES, ORAL ISORDIL TAB 40MG

isosorbide dinitrate tab 5 mg



27




isosorbide dinitrate tab er 40 mg

isosorbide mononitrate tab 10 mg

isosorbide mononitrate tab 20 mg

isosorbide mononitrate tab er 24hr 30 mg



nitroglycerin cap er 2.5 mg

nitroglycerin cap er 6.5 mg

nitroglycerin cap er 9 mg

NITRATES, SUBLINGUAL/TRANSLINGUAL nitroglycerin sl tab 0.3 mg

nitroglycerin sl tab 0.4 mg

nitroglycerin sl tab 0.6 mg

NITRATES, TRANSDERMAL NITRO-BID OIN 2%

NITRO-DUR DIS 0.3MG/HR

NITRO-DUR DIS 0.8MG/HR

nitroglycerin td patch 24hr 0.1 mg/hr




PULMONARY ARTERIAL HYPERTENSION, ENDOTHELIN RECEPTOR

ANTAGONISTS ambrisentan tab 5 mg SP, PA

ambrisentan tab 10 mg SP, PA

bosentan tab 62.5 mg SP, PA

bosentan tab 125 mg SP, PA

OPSUMIT TAB 10MG SP, PA

TRACLEER TAB 32MG SP, PA

PULMONARY ARTERIAL HYPERTENSION, PHOSPHODIESTERASE

INHIBITORS sildenafil citrate for suspension 10 mg/ml SP, QL (90 mL per month),

PA

sildenafil citrate tab 20 mg SP, PA

PULMONARY ARTERIAL HYPERTENSION, PROSTACYCLIN RECEPTOR

AGONISTS UPTRAVI TAB 200/800 SP, PA

UPTRAVI TAB 200MCG SP, PA





28






PULMONARY ARTERIAL HYPERTENSION, PROSTAGLANDIN

VASODILATORS ORENITRAM TAB 0.25MG SP, PA

ORENITRAM TAB 0.125MG SP, PA

ORENITRAM TAB 1MG SP, PA

ORENITRAM TAB 2.5MG SP, PA

ORENITRAM TAB 5MG SP, PA

TYVASO REFIL SOL 0.6MG/ML SP, PA

TYVASO SOL 0.6MG/ML SP, PA

TYVASO START SOL 0.6MG/ML SP, PA

VASOPRESSORS midodrine hcl tab 2.5 mg

midodrine hcl tab 5 mg

midodrine hcl tab 10 mg

CENTRAL NERVOUS SYSTEM ANTIANXIETY, BENZODIAZEPINES

ALPRAZOLAM CON 1 MG/ML OB7

alprazolam orally disintegrating tab 0.5 mg OB7

alprazolam orally disintegrating tab 0.25 mg OB7

alprazolam orally disintegrating tab 1 mg OB7

alprazolam orally disintegrating tab 2 mg OB7

alprazolam tab 0.5 mg OB7

alprazolam tab 0.25 mg OB7

alprazolam tab 1 mg OB7

alprazolam tab 2 mg OB7

alprazolam tab er 24hr 0.5 mg OB7

alprazolam tab er 24hr 1 mg OB7



ATIVAN INJ 2MG/ML +, OB7

ATIVAN INJ 4MG/ML +, OB7

ATIVAN TAB 0.5MG +, OB7

ATIVAN TAB 1MG +, OB7

ATIVAN TAB 2MG +, OB7

chlordiazepoxide hcl cap 5 mg OB7



clonazepam orally disintegrating tab 0.5 mg OB7



29



clonazepam orally disintegrating tab 1 mg OB7

clonazepam orally disintegrating tab 2 mg OB7

clonazepam tab 0.5 mg OB7

clonazepam tab 1 mg OB7

clonazepam tab 2 mg OB7

clorazepate dipotassium tab 3.75 mg OB7

clorazepate dipotassium tab 7.5 mg OB7

clorazepate dipotassium tab 15 mg OB7

diazepam conc 5 mg/ml OB7

diazepam inj 5 mg/ml OB7

DIAZEPAM INJ 10MG/2ML OB7

diazepam oral soln 1 mg/ml OB7

diazepam tab 2 mg OB7



KLONOPIN TAB 0.5MG +, OB7

KLONOPIN TAB 1MG +, OB7

KLONOPIN TAB 2MG +, OB7

lorazepam conc 2 mg/ml OB7

lorazepam inj 2 mg/ml OB7

lorazepam inj 4 mg/ml OB7

lorazepam tab 0.5 mg OB7

lorazepam tab 1 mg OB7

lorazepam tab 2 mg OB7

oxazepam cap 10 mg OB7



TRANXENE T TAB 7.5MG +, OB7

VALIUM TAB 2MG +, OB7



XANAX TAB 0.5MG +, OB7

XANAX TAB 0.25MG +, OB7

XANAX TAB 1MG +, OB7

XANAX TAB 2MG +, OB7

XANAX XR TAB 0.5MG +, OB7

XANAX XR TAB 1MG +, OB7



ANTIANXIETY, MISCELLANEOUS ANAFRANIL CAP 25MG +

ANAFRANIL CAP 50MG +

ANAFRANIL CAP 75MG +


30


buspirone hcl tab 5 mg

buspirone hcl tab 7.5 mg




clomipramine hcl cap 25 mg



fluvoxamine maleate cap er 24hr 100 mg


fluvoxamine maleate tab 25 mg



meprobamate tab 200 mg

meprobamate tab 400 mg

ANTICONVULSANTS APTIOM TAB 200MG

APTIOM TAB 400MG

APTIOM TAB 600MG

APTIOM TAB 800MG

BANZEL SUS 40MG/ML

BANZEL TAB 200MG

BANZEL TAB 400MG

BRIVIACT SOL 10MG/ML

BRIVIACT TAB 10MG

BRIVIACT TAB 25MG

BRIVIACT TAB 50MG

BRIVIACT TAB 75MG

BRIVIACT TAB 100MG

carbamazepine cap er 12hr 100 mg



carbamazepine chew tab 100 mg

carbamazepine susp 100 mg/5ml

carbamazepine tab 200 mg

carbamazepine tab er 12hr 100 mg



CARBATROL CAP 100MG +



CELONTIN CAP 300MG

clobazam suspension 2.5 mg/ml

clobazam tab 10 mg


31


clobazam tab 20 mg

DEPAKENE CAP 250MG +

DEPAKOTE ER TAB 250MG +

DEPAKOTE ER TAB 500MG +

DEPAKOTE SPR CAP 125MG +

DEPAKOTE TAB 125MG DR +



DIASTAT ACDL GEL 5-10MG +

DIASTAT ACDL GEL 12.5-20 +

DIASTAT PED GEL 2.5M GEL +

diazepam rectal gel delivery system 2.5 mg

diazepam rectal gel delivery system 10 mg

diazepam rectal gel delivery system 20 mg

DILANTIN CAP 30MG

DILANTIN CAP 100MG +

DILANTIN CHW 50MG +

DILANTIN-125 SUS 125/5ML +

divalproex sodium cap delayed release sprinkle 125 mg

divalproex sodium tab delayed release 125 mg



divalproex sodium tab er 24 hr 250 mg


epitol tab 200mg

ethosuximide cap 250 mg

ethosuximide soln 250 mg/5ml

FANATREX SUS 25MG/ML

felbamate susp 600 mg/5ml

felbamate tab 400 mg

felbamate tab 600 mg

FELBATOL SUS 600/5ML +

FELBATOL TAB 400MG +

FELBATOL TAB 600MG +

FYCOMPA SUS 0.5MG/ML

FYCOMPA TAB 2MG

FYCOMPA TAB 4MG

FYCOMPA TAB 6MG

FYCOMPA TAB 8MG

FYCOMPA TAB 10MG

FYCOMPA TAB 12MG

gabapentin cap 100 mg QL (1080 per month)



32



gabapentin oral soln 250 mg/5ml QL (2100 mL per month)

gabapentin tab 600 mg QL (180 per month)

gabapentin tab 800 mg QL (120 per month)

GABITRIL TAB 2MG +

GABITRIL TAB 4MG +

GABITRIL TAB 12MG +

GABITRIL TAB 16MG +

KEPPRA SOL 100MG/ML +

KEPPRA TAB 250MG +

KEPPRA TAB 500MG +

KEPPRA TAB 750MG +

KEPPRA TAB 1000MG +

KEPPRA XR TAB 500MG +

KEPPRA XR TAB 750MG +

LAMICTAL CHW 5MG +

LAMICTAL CHW 25MG +

LAMICTAL KIT START 35 +



LAMICTAL ODT KIT

LAMICTAL ODT TAB 25MG +




LAMICTAL TAB 25MG +

LAMICTAL TAB 100MG +



LAMICTAL XR KIT

LAMICTAL XR TAB 25MG +






lamotrigine orally disintegrating tab 25 mg




lamotrigine tab 25 mg

lamotrigine tab 25 mg (35) starter kit

lamotrigine tab 25 mg (42) & 100 mg (7) starter

kit


33


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

kit




lamotrigine tab chewable dispersible 5 mg

lamotrigine tab chewable dispersible 25 mg

lamotrigine tab er 24hr 25 mg






levetiracetam oral soln 100 mg/ml

levetiracetam tab 250 mg




levetiracetam tab er 24hr 500 mg

levetiracetam tab er 24hr 750 mg

MYSOLINE TAB 50MG +

MYSOLINE TAB 250MG +

NEURONTIN CAP 100MG QL (1080 per month); +



NEURONTIN SOL 250/5ML QL (2100 mL per month); +

NEURONTIN TAB 600MG QL (180 per month); +

NEURONTIN TAB 800MG QL (120 per month); +

ONFI SUS 2.5MG/ML +

ONFI TAB 10MG +

ONFI TAB 20MG +

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

oxcarbazepine tab 150 mg



OXTELLAR XR TAB 150MG



PEGANONE TAB 250MG

phenobarbital elixir 20 mg/5ml

phenobarbital tab 15 mg

phenobarbital tab 16.2 mg




34






PHENYTEK CAP 200MG +

PHENYTEK CAP 300MG +

phenytoin chew tab 50 mg

phenytoin sodium extended cap 100 mg



phenytoin susp 125 mg/5ml

pregabalin cap 25 mg QL (120 per month)








pregabalin soln 20 mg/ml QL (900 mL per month)

primidone tab 50 mg

primidone tab 250 mg

SABRIL POW 500MG SP, PA; +

SABRIL TAB 500MG SP, PA; +

TEGRETOL SUS 100/5ML +

TEGRETOL TAB 200MG +

TEGRETOL-XR TAB 100MG +



tiagabine hcl tab 2 mg




TOPAMAX SPR CAP 15MG +

TOPAMAX SPR CAP 25MG +

TOPAMAX TAB 25MG +

TOPAMAX TAB 50MG +

TOPAMAX TAB 100MG +

TOPAMAX TAB 200MG +

topiramate cap er 24hr sprinkle 25 mg






35


topiramate sprinkle cap 15 mg

topiramate sprinkle cap 25 mg

topiramate tab 25 mg




TRILEPTAL SUS 300MG/5M +

TRILEPTAL TAB 150MG +



TROKENDI XR CAP 25MG




valproate sodium oral soln 250 mg/5ml (base equiv)

valproic acid cap 250 mg

vigabatrin powd pack 500 mg SP, PA

vigabatrin tab 500 mg SP, PA

VIMPAT SOL 10MG/ML

VIMPAT TAB 50MG

VIMPAT TAB 100MG

VIMPAT TAB 150MG

VIMPAT TAB 200MG

ZARONTIN CAP 250MG +

ZARONTIN SOL 250/5ML +

ZONEGRAN CAP 25MG +

ZONEGRAN CAP 100MG +

zonisamide cap 25 mg



ANTIDEMENTIA donepezil hydrochloride orally disintegrating tab 5

mg

donepezil hydrochloride orally disintegrating tab 10

mg

donepezil hydrochloride tab 5 mg



galantamine hydrobromide cap er 24hr 8 mg



galantamine hydrobromide oral soln 4 mg/ml

galantamine hydrobromide tab 4 mg


36




memantine hcl oral solution 2 mg/ml PA only applies to members

less than 30 years of age

memantine hcl tab 5 mg PA only applies to members


memantine hcl tab 5 mg (28) & 10 mg (21)

titration pak

PA only applies to members


memantine hcl tab 10 mg PA only applies to members


rivastigmine tartrate cap 1.5 mg (base equivalent) PA

rivastigmine tartrate cap 3 mg (base equivalent) PA

rivastigmine tartrate cap 4.5 mg (base equivalent) PA

rivastigmine tartrate cap 6 mg (base equivalent) PA

rivastigmine td patch 24hr 4.6 mg/24hr PA



ANTIDEPRESSANTS, MISCELLANEOUS APLENZIN TAB 174MG

APLENZIN TAB 348MG

APLENZIN TAB 522MG

bupropion hcl tab 75 mg

bupropion hcl tab 100 mg

bupropion hcl tab er 12hr 100 mg






chlordiazepoxide-amitriptyline tab 5-12.5 mg

chlordiazepoxide-amitriptyline tab 10-25 mg

FORFIVO XL TAB 450MG +

maprotiline hcl tab 25 mg



mirtazapine orally disintegrating tab 15 mg



mirtazapine tab 7.5 mg

mirtazapine tab 15 mg



nefazodone hcl tab 50 mg



37





REMERON SLTB TAB 15MG +



REMERON TAB 15MG +

REMERON TAB 30MG +

trazodone hcl tab 50 mg




WELLBUTRIN TAB 100MG SR +



WELLBUTRIN TAB XL 150MG +

WELLBUTRIN TAB XL 300MG +

ANTIDEPRESSANTS, MONOAMINE OXIDASE INHIBITORS (MAOIs) EMSAM DIS 6MG/24HR

EMSAM DIS 9MG/24HR

EMSAM DIS 12MG/24H

MARPLAN TAB 10MG

NARDIL TAB 15MG +

PARNATE TAB 10MG +

phenelzine sulfate tab 15 mg

tranylcypromine sulfate tab 10 mg

ANTIDEPRESSANTS, SELECTIVE SEROTONIN REUPTAKE

INHIBITORS (SSRIs) CELEXA TAB 10MG +

CELEXA TAB 20MG +

CELEXA TAB 40MG +

citalopram hydrobromide oral soln 10 mg/5ml

citalopram hydrobromide tab 10 mg (base equiv)



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

escitalopram oxalate tab 5 mg (base equiv)



fluoxetine hcl (pmdd) cap 10 mg

fluoxetine hcl (pmdd) cap 20 mg

fluoxetine hcl (pmdd) tab 10 mg

fluoxetine hcl (pmdd) tab 20 mg


38


fluoxetine hcl cap 10 mg



fluoxetine hcl cap delayed release 90 mg

fluoxetine hcl solution 20 mg/5ml

fluoxetine hcl tab 10 mg



FLUOXETINE TAB 60MG +

LEXAPRO TAB 5MG +

LEXAPRO TAB 10MG +

LEXAPRO TAB 20MG +

paroxetine hcl tab 10 mg




paroxetine hcl tab er 24hr 12.5 mg

paroxetine hcl tab er 24hr 25 mg

paroxetine hcl tab er 24hr 37.5 mg

PAXIL CR TAB 12.5MG +

PAXIL CR TAB 25MG +

PAXIL CR TAB 37.5MG +

PAXIL SUS 10MG/5ML

PAXIL TAB 10MG +

PAXIL TAB 20MG +

PAXIL TAB 30MG +

PAXIL TAB 40MG +

PEXEVA TAB 10MG

PEXEVA TAB 20MG

PEXEVA TAB 30MG

PEXEVA TAB 40MG

PROZAC CAP 10MG +

PROZAC CAP 20MG +

PROZAC CAP 40MG +

SARAFEM TAB 10MG +

SARAFEM TAB 20MG +

sertraline hcl oral concentrate for solution 20

mg/ml

sertraline hcl tab 25 mg



TRINTELLIX TAB 5MG

TRINTELLIX TAB 10MG

TRINTELLIX TAB 20MG


39


VIIBRYD KIT STARTER

VIIBRYD TAB 10MG

VIIBRYD TAB 20MG

VIIBRYD TAB 40MG

ZOLOFT TAB 25MG +

ZOLOFT TAB 50MG +

ZOLOFT TAB 100MG +

ANTIDEPRESSANTS, SEROTONIN NOREPINEPHRINE REUPTAKE

INHIBITORS (SNRIs) CYMBALTA CAP 20MG +

CYMBALTA CAP 30MG +

CYMBALTA CAP 60MG +

DESVENLAFAX TAB 50MG ER

DESVENLAFAX TAB 100MG ER

desvenlafaxine succinate tab er 24hr 25 mg (base equiv)

desvenlafaxine succinate tab er 24hr 50 mg (base equiv)

desvenlafaxine succinate tab er 24hr 100 mg

(base equiv)

desvenlafaxine tab er 24hr 50 mg

desvenlafaxine tab er 24hr 100 mg

duloxetine hcl enteric coated pellets cap 20 mg

(base eq)


(base eq)


(base eq)


(base eq)

EFFEXOR XR CAP 37.5MG +

EFFEXOR XR CAP 75MG +

EFFEXOR XR CAP 150MG +

FETZIMA CAP 20MG

FETZIMA CAP 40MG

FETZIMA CAP 80MG

FETZIMA CAP 120MG

FETZIMA CAP TITRATIO

KHEDEZLA TAB 50MG ER +

KHEDEZLA TAB 100MG ER +

PRISTIQ TAB 25MG +

PRISTIQ TAB 50MG +

PRISTIQ TAB 100MG +


40


venlafaxine hcl cap er 24hr 37.5 mg (base

equivalent)

venlafaxine hcl cap er 24hr 75 mg (base

equivalent)

venlafaxine hcl cap er 24hr 150 mg (base

equivalent)

venlafaxine hcl tab 25 mg (base equivalent)

venlafaxine hcl tab 37.5 mg (base equivalent)




venlafaxine hcl tab er 24hr 37.5 mg (base

equivalent)

venlafaxine hcl tab er 24hr 75 mg (base

equivalent)


equivalent)


equivalent)

ANTIDEPRESSANTS, TRICYCLIC ANTIDEPRESSANTS (TCAs) amitriptyline hcl tab 10 mg

amitriptyline hcl tab 25 mg





amoxapine tab 25 mg

amoxapine tab 50 mg

amoxapine tab 100 mg

amoxapine tab 150 mg

desipramine hcl tab 10 mg






doxepin hcl cap 10 mg






doxepin hcl conc 10 mg/ml

imipramine hcl tab 10 mg


41




imipramine pamoate cap 75 mg




NORPRAMIN TAB 10MG +

NORPRAMIN TAB 25MG +

nortriptyline hcl cap 10 mg




nortriptyline hcl soln 10 mg/5ml

PAMELOR CAP 10MG +

PAMELOR CAP 25MG +

PAMELOR CAP 50MG +

PAMELOR CAP 75MG +

protriptyline hcl tab 5 mg

protriptyline hcl tab 10 mg

TOFRANIL TAB 10MG +

TOFRANIL TAB 25MG +

TOFRANIL TAB 50MG +

trimipramine maleate cap 25 mg



ANTIPARKINSONIAN AGENTS amantadine hcl cap 100 mg

amantadine hcl syrup 50 mg/5ml

amantadine hcl tab 100 mg

benztropine mesylate tab 0.5 mg

benztropine mesylate tab 1 mg

benztropine mesylate tab 2 mg

bromocriptine mesylate cap 5 mg (base

equivalent)

bromocriptine mesylate tab 2.5 mg (base

equivalent)

carbidopa & levodopa orally disintegrating tab 10-

100 mg

carbidopa & levodopa orally disintegrating tab 25-

100 mg

carbidopa & levodopa orally disintegrating tab 25-250 mg

carbidopa & levodopa tab 10-100 mg



42



carbidopa & levodopa tab er 25-100 mg


carbidopa-levodopa-entacapone tabs 12.5-50-200

mg

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

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

carbidopa-levodopa-entacapone tabs 31.25-125-

200 mg

carbidopa-levodopa-entacapone tabs 37.5-150-

200 mg

carbidopa-levodopa-entacapone tabs 50-200-200

mg

entacapone tab 200 mg

pramipexole dihydrochloride tab 0.5 mg




pramipexole dihydrochloride tab 1 mg


ropinirole hydrochloride tab 0.5 mg

ropinirole hydrochloride tab 0.25 mg

ropinirole hydrochloride tab 1 mg





selegiline hcl cap 5 mg

selegiline hcl tab 5 mg

trihexyphenidyl hcl elixir 0.4 mg/ml

trihexyphenidyl hcl tab 2 mg

trihexyphenidyl hcl tab 5 mg

ANTIPSYCHOTICS, ATYPICALS ABILIFY MAIN INJ 300MG

ABILIFY MAIN INJ 400MG

ABILIFY TAB 2MG +

ABILIFY TAB 5MG +

ABILIFY TAB 10MG +

ABILIFY TAB 15MG +

ABILIFY TAB 20MG +

ABILIFY TAB 30MG +

aripiprazole oral solution 1 mg/ml


43


aripiprazole orally disintegrating tab 10 mg

aripiprazole orally disintegrating tab 15 mg

aripiprazole tab 2 mg






ARISTADA INJ 441MG/1.

ARISTADA INJ 662MG/2

ARISTADA INJ 882MG/3

ARISTADA INJ 1064MG

ARISTADA INJ INITIO

clozapine orally disintegrating tab 12.5 mg

clozapine orally disintegrating tab 25 mg




clozapine tab 25 mg

clozapine tab 50 mg

clozapine tab 100 mg

clozapine tab 200 mg

CLOZARIL TAB 25MG +

CLOZARIL TAB 100MG +

FANAPT PAK

FANAPT TAB 1MG

FANAPT TAB 2MG

FANAPT TAB 4MG

FANAPT TAB 6MG

FANAPT TAB 8MG

FANAPT TAB 10MG

FANAPT TAB 12MG

FAZACLO TAB 12.5 ODT +

FAZACLO TAB 25MG ODT +

FAZACLO TAB 100 ODT +



GEODON CAP 20MG +

GEODON CAP 40MG +

GEODON CAP 60MG +

GEODON CAP 80MG +

GEODON INJ 20MG

INVEGA SUST INJ 39/0.25

INVEGA SUST INJ 78/0.5ML


44



INVEGA SUST INJ 156MG/ML


INVEGA TAB 1.5MG +

INVEGA TAB 3MG +

INVEGA TAB 6MG +

INVEGA TAB 9MG +

INVEGA TRINZ INJ 273MG




LATUDA TAB 20MG

LATUDA TAB 40MG

LATUDA TAB 60MG

LATUDA TAB 80MG

LATUDA TAB 120MG

olanzapine for im inj 10 mg

olanzapine orally disintegrating tab 5 mg




olanzapine tab 2.5 mg

olanzapine tab 5 mg

olanzapine tab 7.5 mg

olanzapine tab 10 mg



olanzapine-fluoxetine hcl cap 3-25 mg





paliperidone tab er 24hr 1.5 mg

paliperidone tab er 24hr 3 mg



quetiapine fumarate tab 25 mg






quetiapine fumarate tab er 24hr 50 mg



45





REXULTI TAB 0.5MG

REXULTI TAB 0.25MG

REXULTI TAB 1MG

REXULTI TAB 2MG

REXULTI TAB 3MG

REXULTI TAB 4MG

RISPERDAL INJ 12.5MG

RISPERDAL INJ 25MG

RISPERDAL INJ 37.5MG

RISPERDAL INJ 50MG

RISPERDAL SOL 1MG/ML +

RISPERDAL TAB 0.5MG +

RISPERDAL TAB 0.25MG +

RISPERDAL TAB 1MG +

RISPERDAL TAB 2MG +

RISPERDAL TAB 3MG +

RISPERDAL TAB 4MG +

risperidone orally disintegrating tab 0.5 mg

risperidone orally disintegrating tab 0.25 mg

risperidone orally disintegrating tab 1 mg




risperidone soln 1 mg/ml

risperidone tab 0.5 mg

risperidone tab 0.25 mg

risperidone tab 1 mg




SAPHRIS SUB 2.5MG

SAPHRIS SUB 5MG

SAPHRIS SUB 10MG

SEROQUEL TAB 25MG +

SEROQUEL TAB 50MG +

SEROQUEL TAB 100MG +




SEROQUEL XR TAB 50MG +



46





VERSACLOZ SUS 50MG/ML

VRAYLAR CAP 1.5-3MG

VRAYLAR CAP 1.5MG

VRAYLAR CAP 3MG

VRAYLAR CAP 4.5MG

VRAYLAR CAP 6MG

ziprasidone hcl cap 20 mg




ZYPREXA INJ 10MG +

ZYPREXA RELP INJ 210MG



ZYPREXA TAB 2.5MG +

ZYPREXA TAB 5MG +

ZYPREXA TAB 7.5MG +

ZYPREXA TAB 10MG +

ZYPREXA TAB 15MG +

ZYPREXA TAB 20MG +

ZYPREXA ZYDI TAB 5MG +




ANTIPSYCHOTICS, MISCELLANEOUS ADASUVE INH 10MG

CHLORPROMAZ INJ 25MG/ML

CHLORPROMAZ INJ 50MG/2ML

chlorpromazine hcl tab 10 mg





fluphenazine decanoate inj 25 mg/ml

fluphenazine hcl elixir 2.5 mg/5ml

fluphenazine hcl inj 2.5 mg/ml

fluphenazine hcl oral conc 5 mg/ml

fluphenazine hcl tab 1 mg

fluphenazine hcl tab 2.5 mg




47


haloperidol decanoate im soln 50 mg/ml


haloperidol lactate inj 5 mg/ml

haloperidol lactate oral conc 2 mg/ml

haloperidol tab 0.5 mg

haloperidol tab 1 mg





loxapine succinate cap 5 mg




NUPLAZID CAP 34MG SP

NUPLAZID TAB 10MG SP

perphenazine tab 2 mg




perphenazine-amitriptyline tab 2-10 mg





thioridazine hcl tab 10 mg




thiothixene cap 1 mg




trifluoperazine hcl tab 1 mg (base equivalent)




ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine cap er 24hr 5

mg

QL (360 per month)

amphetamine-dextroamphetamine cap er 24hr 10

mg

QL (180 per month)


mg

QL (120 per month)


48



mg

QL (90 per month)


mg

QL (60 per month)


mg

QL (60 per month)

amphetamine-dextroamphetamine tab 5 mg QL (360 per month)

amphetamine-dextroamphetamine tab 7.5 mg QL (240 per month)


amphetamine-dextroamphetamine tab 12.5 mg QL (135 per month)




atomoxetine hcl cap 10 mg (base equiv) QL (120 per month); ST (Must have recently been on

30 days of generic

immediate-release ADHD

drug, methylphenidate cap

cr (cd), amphetamine-

dextroamphetamine cap sr 24hr OR

dextroamphetamine sulfate

cap sr 24hr)

atomoxetine hcl cap 18 mg (base equiv) QL (120 per month); ST

(Must have recently been on

30 days of generic


drug, methylphenidate cap cr (cd), amphetamine-

dextroamphetamine cap sr

24hr OR


cap sr 24hr)



30 days of generic immediate-release ADHD




24hr OR dextroamphetamine sulfate

cap sr 24hr)


49









cap sr 24hr)

atomoxetine hcl cap 60 mg (base equiv) QL (30 per month); ST (Must have recently been on

30 days of generic



cr (cd), amphetamine- dextroamphetamine cap sr

24hr OR


cap sr 24hr)



30 days of generic

immediate-release ADHD drug, methylphenidate cap



24hr OR

dextroamphetamine sulfate cap sr 24hr)


(Must have recently been on 30 days of generic






cap sr 24hr)

dexmethylphenidate hcl tab 2.5 mg QL (600 per month)

dexmethylphenidate hcl tab 5 mg QL (300 per month)

dexmethylphenidate hcl tab 10 mg QL (150 per month)

dextroamphetamine sulfate cap er 24hr 5 mg QL (360 per month)



dextroamphetamine sulfate tab 5 mg QL (360 per month)


50


dextroamphetamine sulfate tab 10 mg QL (180 per month)

metadate tab 20mg er QL (150 per month); ST


30 days of generic




24hr OR


cap sr 24hr)

methylphenidate hcl cap er 10 mg (cd) QL (300 per month)


methylphenidate hcl cap er 24hr 20 mg (la) QL (150 per month); ST







cap sr 24hr)

methylphenidate hcl cap er 24hr 30 mg (la) QL (90 per month); ST (Must have recently been on

30 days of generic




24hr OR


cap sr 24hr)

methylphenidate hcl cap er 24hr 40 mg (la) QL (60 per month); ST


30 days of generic




24hr OR


cap sr 24hr)






51


methylphenidate hcl soln 5 mg/5ml QL (3000 mL per month)

methylphenidate hcl soln 10 mg/5ml QL (1500 mL per month)

methylphenidate hcl tab 5 mg QL (600 per month)



methylphenidate hcl tab er 10 mg QL (300 per month); ST


30 days of generic




24hr OR


cap sr 24hr)

methylphenidate hcl tab er 20 mg QL (150 per month); ST







cap sr 24hr)

methylphenidate hcl tab er 24hr 18 mg QL (180 per month); ST (Must have recently been on

30 days of generic




24hr OR


cap sr 24hr)

methylphenidate hcl tab er 24hr 27 mg QL (120 per month); ST


30 days of generic




24hr OR



52


methylphenidate hcl tab er 24hr 36 mg QL (90 per month); ST







cap sr 24hr)

methylphenidate hcl tab er 24hr 54 mg QL (60 per month); ST (Must have recently been on

30 days of generic




24hr OR


cap sr 24hr)

methylphenidate hcl tab er osmotic release (osm)

18 mg

QL (180 per month); ST


30 days of generic




24hr OR



27 mg


(Must have recently been on 30 days of generic






cap sr 24hr)


53



36 mg








cap sr 24hr)

methylphenidate hcl tab er osmotic release (osm) 54 mg

QL (60 per month); ST (Must have recently been on

30 days of generic




24hr OR


cap sr 24hr)

FIBROMYALGIA SAVELLA MIS TITR PAK PA

SAVELLA TAB 12.5MG PA

SAVELLA TAB 25MG PA

SAVELLA TAB 50MG PA

SAVELLA TAB 100MG PA

HUNTINGTON'S DISEASE AGENTS AUSTEDO TAB 6MG SP, PA

AUSTEDO TAB 9MG SP, PA

AUSTEDO TAB 12MG SP, PA

tetrabenazine tab 12.5 mg SP, PA

tetrabenazine tab 25 mg SP, PA

HYPNOTICS, BENZODIAZEPINES temazepam cap 7.5 mg OB7, QL (15 per month)

temazepam cap 15 mg OB7, QL (15 per month)

temazepam cap 22.5 mg OB7, QL (15 per month)

temazepam cap 30 mg OB7, QL (15 per month)

HYPNOTICS, NON-BENZODIAZEPINES diphenhydramine hcl (sleep) cap 50 mg OTC

diphenhydramine hcl (sleep) tab 25 mg OTC

diphenhydramine hcl (sleep) tab 50 mg OTC

doxylamine succinate (sleep) tab 25 mg OTC

zolpidem tartrate tab 5 mg QL (30 per month)

zolpidem tartrate tab 10 mg QL (30 per month)

zolpidem tartrate tab er 6.25 mg QL (30 per month)


54


zolpidem tartrate tab er 12.5 mg QL (30 per month)

MIGRAINE, ERGOTAMINE DERIVATIVES ergotamine w/ caffeine tab 1-100 mg

MIGRAINE, SELECTIVE SEROTONIN AGONISTS naratriptan hcl tab 1 mg (base equiv) QL (12 per month); ST


9 days of sumatriptan)

naratriptan hcl tab 1 mg (base equiv) QL (12 per month); ST


9 days supply of

sumatriptan)

naratriptan hcl tab 2.5 mg (base equiv) QL (12 per month); ST


9 days of sumatriptan)

naratriptan hcl tab 2.5 mg (base equiv) QL (12 per month); ST

(Must have recently been on 9 days supply of

sumatriptan)

rizatriptan benzoate oral disintegrating tab 5 mg (base eq)

QL (18 per month); ST (Must have recently been on

9 days supply of

sumatriptan)

rizatriptan benzoate oral disintegrating tab 10 mg

(base eq)



9 days supply of

sumatriptan)

rizatriptan benzoate tab 5 mg (base equivalent) QL (18 per month); ST


9 days supply of

sumatriptan)

rizatriptan benzoate tab 10 mg (base equivalent) QL (18 per month); ST

(Must have recently been on 9 days supply of

sumatriptan)

sumatriptan nasal spray 5 mg/act QL (24 per month)

sumatriptan nasal spray 20 mg/act QL (24 per month)

sumatriptan succinate inj 6 mg/0.5ml QL (6 per month)

sumatriptan succinate solution auto-injector 4

mg/0.5ml

QL (6 per month)

sumatriptan succinate solution auto-injector 6

mg/0.5ml

QL (6 per month)

sumatriptan succinate solution cartridge 4

mg/0.5ml

QL (6 per month)

sumatriptan succinate solution cartridge 6

mg/0.5ml

QL (6 per month)

sumatriptan succinate tab 25 mg QL (12 per month)


55




zolmitriptan orally disintegrating tab 2.5 mg QL (12 per month); ST


9 days supply of sumatriptan)

zolmitriptan orally disintegrating tab 5 mg QL (12 per month); ST (Must have recently been on

9 days supply of

sumatriptan)

zolmitriptan tab 2.5 mg QL (12 per month); ST


9 days supply of

sumatriptan)

zolmitriptan tab 5 mg QL (12 per month); ST


9 days supply of

sumatriptan)

MISCELLANEOUS riluzole tab 50 mg

MOOD STABILIZERS EQUETRO CAP 100MG

EQUETRO CAP 200MG

EQUETRO CAP 300MG

lithium carbonate cap 150 mg



lithium carbonate tab 300 mg

lithium carbonate tab er 300 mg

lithium carbonate tab er 450 mg

LITHIUM SOL 8MEQ/5ML

LITHOBID TAB 300MG CR +

MULTIPLE SCLEROSIS AUBAGIO TAB 7MG SP, PA

AUBAGIO TAB 14MG SP, PA

AVONEX PEN KIT 30MCG SP

AVONEX PREFL KIT 30MCG SP

BETASERON INJ 0.3MG SP

COPAXONE INJ 40MG/ML SP; +

dalfampridine tab er 12hr 10 mg SP, PA

EXTAVIA INJ 0.3MG SP

GILENYA CAP 0.5MG SP, PA

glatiramer acetate soln prefilled syringe 20 mg/ml SP

glatiramer acetate soln prefilled syringe 40 mg/ml SP


56


REBIF INJ 22/0.5 SP

REBIF INJ 44/0.5 SP

REBIF REBIDO INJ 22/0.5 SP

REBIF REBIDO INJ 44/0.5 SP

REBIF REBIDO INJ TITRATN SP

REBIF TITRTN INJ PACK SP

TECFIDERA CAP 120MG SP, PA

TECFIDERA CAP 240MG SP, PA

TECFIDERA MIS STARTER SP, PA

MUSCULOSKELETAL THERAPY AGENTS baclofen tab 10 mg

baclofen tab 20 mg

carisoprodol tab 250 mg QL (120 per month)

carisoprodol tab 350 mg QL (120 per month)

chlorzoxazone tab 500 mg

cyclobenzaprine hcl tab 5 mg

cyclobenzaprine hcl tab 10 mg

dantrolene sodium cap 25 mg



methocarbamol tab 500 mg

methocarbamol tab 750 mg

orphenadrine citrate tab er 12hr 100 mg

tizanidine hcl tab 2 mg (base equivalent)

tizanidine hcl tab 4 mg (base equivalent)

MYASTHENIA GRAVIS pyridostigmine bromide oral soln 60 mg/5ml

pyridostigmine bromide tab 60 mg

pyridostigmine bromide tab er 180 mg

NARCOLEPSY armodafinil tab 50 mg PA

armodafinil tab 150 mg PA



modafinil tab 100 mg PA

modafinil tab 200 mg PA

PSYCHOTHERAPEUTIC-MISCELLANEOUS, ALCOHOL DETERRENTS acamprosate calcium tab delayed release 333 mg PA

disulfiram tab 250 mg

disulfiram tab 500 mg

PSYCHOTHERAPEUTIC-MISCELLANEOUS, OPIOID ANTAGONISTS naltrexone hcl tab 50 mg


57


NARCAN SPR QL (2 cartons (4 nasal

sprays) per 180 days)

PSYCHOTHERAPEUTIC-MISCELLANEOUS, PARTIAL OPIOID

AGONIST/OPIOID ANTAGONIST COMBINATIONS buprenorphine hcl-naloxone hcl sl film 2-0.5 mg

(base equiv)

buprenorphine hcl-naloxone hcl sl film 4-1 mg

(base equiv)


(base equiv)


(base equiv)

buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg

(base equiv)

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

ZUBSOLV SUB 0.7-0.18



ZUBSOLV SUB 5.7-1.4

ZUBSOLV SUB 8.6-2.1


PSYCHOTHERAPEUTIC-MISCELLANEOUS, PARTIAL OPIOID

AGONISTS buprenorphine hcl sl tab 2 mg (base equiv)

buprenorphine hcl sl tab 8 mg (base equiv)

PSYCHOTHERAPEUTIC-MISCELLANEOUS, PSEUDOBULBAR AFFECT

AGENTS NUEDEXTA CAP 20-10MG PA

PSYCHOTHERAPEUTIC-MISCELLANEOUS, SMOKING DETERRENTS bupropion hcl (smoking deterrent) tab er 12hr 150

mg

QL (Max 180 days per

year); AL (covered for ages 18 and over)

CHANTIX PAK 0.5& 1MG QL (Max 180 days per


CHANTIX PAK 1MG QL (Max 180 days per year); AL (covered for ages

18 and over)

CHANTIX TAB 0.5MG QL (Max 180 days per year); AL (covered for ages

18 and over)

CHANTIX TAB 1MG QL (Max 180 days per year); AL (covered for ages

18 and over)


58


nicotine polacrilex gum 2 mg OTC, QL (Max 180 days per

year); AL (covered for ages

18 and over)

nicotine polacrilex gum 4 mg OTC, QL (Max 180 days per

year); AL (covered for ages

18 and over)

nicotine td patch 24hr 7 mg/24hr OTC, QL (Max 180 days per


nicotine td patch 24hr 14 mg/24hr OTC, QL (Max 180 days per


nicotine td patch 24hr 21 mg/24hr OTC, QL (Max 180 days per year); AL (covered for ages

18 and over)

ENDOCRINE AND METABOLIC ANDROGENS

danazol cap 50 mg

danazol cap 100 mg

danazol cap 200 mg

testosterone td gel 10mg/act (2%) PA; Males only

testosterone td gel 25 mg/2.5gm (1%) PA

ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITORS acarbose tab 25 mg

acarbose tab 50 mg

acarbose tab 100 mg

ANTIDIABETICS, BIGUANIDE/SULFONYLUREA COMBINATIONS glipizide-metformin hcl tab 2.5-250 mg

glipizide-metformin hcl tab 2.5-500 mg

glipizide-metformin hcl tab 5-500 mg

glyburide-metformin tab 1.25-250 mg

glyburide-metformin tab 2.5-500 mg

glyburide-metformin tab 5-500 mg

ANTIDIABETICS, BIGUANIDES metformin hcl tab 500 mg

metformin hcl tab 850 mg

metformin hcl tab 1000 mg

metformin hcl tab er 24hr 500 mg

metformin hcl tab er 24hr 750 mg

ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4)

INHIBITOR/BIGUANIDE COMBINATIONS JANUMET TAB 50-500MG ST (Must try metformin,

sulfonylurea, or insulin

sensitizer)


59


JANUMET TAB 50-1000 ST (Must try metformin,


sensitizer)

JANUMET XR TAB 50-500MG ST (Must try metformin,


sensitizer)

JANUMET XR TAB 50-1000 ST (Must try metformin,

sulfonylurea, or insulin sensitizer)

JANUMET XR TAB 100-1000 ST (Must try metformin,


ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA TAB 25MG ST (Must try metformin,


JANUVIA TAB 50MG ST (Must try metformin,


JANUVIA TAB 100MG ST (Must try metformin,


ANTIDIABETICS, INCRETIN MIMETIC AGENT/INSULIN

COMBINATIONS SOLIQUA INJ 100/33 ST (Must try metformin AND

long-acting insulin or

another mono incretin

mimetic agent)

ANTIDIABETICS, INCRETIN MIMETIC AGENTS OZEMPIC INJ 2/1.5ML ST (Must have been on 30

days of metformin)

TRULICITY INJ 0.75/0.5 ST (Must have been on 30 days of metformin)

TRULICITY INJ 1.5/0.5 ST (Must have been on 30 days of metformin)

VICTOZA INJ 18MG/3ML ST (Must have been on 30

days of metformin)

ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE

COMBINATIONS pioglitazone hcl-metformin hcl tab 15-500 mg

pioglitazone hcl-metformin hcl tab 15-850 mg

ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA

COMBINATIONS pioglitazone hcl-glimepiride tab 30-2 mg

pioglitazone hcl-glimepiride tab 30-4 mg


60


ANTIDIABETICS, INSULIN SENSITIZERS pioglitazone hcl tab 15 mg (base equiv)

pioglitazone hcl tab 30 mg (base equiv)


ANTIDIABETICS, INSULINS APIDRA INJ SOLOSTAR

APIDRA INJ U-100

BASAGLAR INJ 100UNIT

FIASP FLEX INJ TOUCH

FIASP INJ 100/ML

HUMALOG INJ 100/ML

HUMALOG JR INJ 100/ML

HUMALOG KWIK INJ 100/ML

HUMALOG MIX INJ 50/50

HUMALOG MIX INJ 50/50KWP

HUMALOG MIX INJ 75/25KWP

HUMALOG MIX SUS 75/25

HUMULIN INJ 70/30 OTC

HUMULIN INJ 70/30KWP OTC

HUMULIN N INJ U-100 OTC

HUMULIN N INJ U-100KWP OTC

HUMULIN R INJ U-100 OTC

HUMULIN R INJ U-500

NOVOLIN70/30 INJ RELION OTC

NOVOLIN INJ 70/30 OTC

NOVOLIN INJ FLEXPEN OTC

NOVOLIN N INJ RELION OTC

NOVOLIN N INJ U-100 OTC

NOVOLIN R INJ RELION OTC

NOVOLIN R INJ U-100 OTC

NOVOLOG INJ 100/ML

NOVOLOG INJ FLEXPEN

NOVOLOG INJ PENFILL

NOVOLOG MIX INJ 70/30

NOVOLOG MIX INJ FLEXPEN

ANTIDIABETICS, MEGLITINIDES nateglinide tab 60 mg

nateglinide tab 120 mg

repaglinide tab 0.5 mg

repaglinide tab 1 mg

repaglinide tab 2 mg


61


ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2)

INHIBITOR/BIGUANIDE COMBINATIONS INVOKAMET TAB 50-500MG ST (Must try metformin,


sensitizer)

INVOKAMET TAB 50-1000 ST (Must try metformin,


sensitizer)



sensitizer)



sensitizer)

INVOKAMET XR TAB 50-500MG ST (Must try metformin,


sensitizer)

INVOKAMET XR TAB 50-1000 ST (Must try metformin,


sensitizer)



sensitizer)



ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2)

INHIBITORS INVOKANA TAB 100MG ST (Must try metformin,


sensitizer)

INVOKANA TAB 300MG ST (Must try metformin, sulfonylurea, or insulin

sensitizer)

ANTIDIABETICS, SULFONYLUREAS glimepiride tab 1 mg

glimepiride tab 2 mg

glimepiride tab 4 mg

glipizide tab 5 mg

glipizide tab 10 mg

glipizide tab er 24hr 2.5 mg

glipizide tab er 24hr 5 mg

glipizide tab er 24hr 10 mg

glyburide micronized tab 1.5 mg

glyburide micronized tab 3 mg


62


glyburide micronized tab 6 mg

glyburide tab 1.25 mg

glyburide tab 2.5 mg

glyburide tab 5 mg

ANTIDIABETICS, SUPPLIES ALCOHOL SWAB PAD OTC, QL (400 per month)

BD INSULIN SYRINGE 0.3/30G OTC




BD INSULIN SYRINGE 1ML/30G OTC

BD INSULIN SYRINGE 1ML/31G OTC

BD PEN NEEDL MIS 29GX12.7 OTC

BD PEN NEEDL MIS 31GX5MM OTC




BD U-500 MIS 31GX6MM OTC

FREESTYLE TES OTC

FREESTYLE TES INSULINX OTC

FREESTYLE TES LITE OTC

KETO-DIASTIX TES OTC, QL (100 per month)

LANCETS MIS OTC

PRECISION TES XTRA OTC

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR TAB 30MG SP, PA

SENSIPAR TAB 60MG SP, PA

SENSIPAR TAB 90MG SP, PA

CALCIUM REGULATORS, BISPHOSPHONATES alendronate sodium tab 5 mg

alendronate sodium tab 10 mg




CALCIUM REGULATORS, CALCITONINS calcitonin (salmon) nasal soln 200 unit/act

CALCIUM REGULATORS, PARATHYROID HORMONES FORTEO SOL 600/2.4 SP, PA

CARNITINE DEFICIENCY AGENTS levocarnitine oral soln 1 gm/10ml (10%)

levocarnitine tab 330 mg


63


CONTRACEPTIVES, BIPHASIC desogest-eth estrad & eth estrad tab 0.15-

0.02/0.01 mg(21/5) Females only

CONTRACEPTIVES, EMERGENCY CONTRACEPTION ELLA TAB 30MG QL (2 per year); Females

only

levonorgestrel tab 1.5 mg OTC, QL (2 per year);

Females only

CONTRACEPTIVES, INJECTABLE medroxyprogesterone acetate im susp 150 mg/ml QL (1 mL per 3 months);

Females only

medroxyprogesterone acetate im susp prefilled syr

150 mg/ml

QL (1 mL per 3 months);

Females only

CONTRACEPTIVES, MISCELLANEOUS CONDOMS MIS OTC, QL (24 per month);

Males only

DIAPHRAGM QL (1 per year)

ENCARE SUP 100MG OTC

GYNOL II GEL 3% OTC

nonoxynol-9 gel 4% OTC

SHUR-SEAL GEL 2% OTC

VCF VAGINAL AER CONTRACP OTC

VCF VAGINAL MIS CONTRACP OTC

CONTRACEPTIVES, MONOPHASIC, 20 mcg Estrogen drospirenone-ethinyl estradiol tab 3-0.02 mg Females only

levonorgestrel & ethinyl estradiol tab 0.1 mg-20

mcg

Females only

norethindrone ace & ethinyl estradiol tab 1 mg-20

mcg

Females only

norethindrone ace & ethinyl estradiol-fe tab 1 mg-

20 mcg

Females only

CONTRACEPTIVES, MONOPHASIC, 30 mcg Estrogen desogestrel & ethinyl estradiol tab 0.15 mg-30

mcg

Females only

drospirenone-ethinyl estradiol tab 3-0.03 mg Females only

levonorgestrel & ethinyl estradiol tab 0.15 mg-30

mcg

Females only

norethindrone ace & ethinyl estradiol tab 1.5 mg-

30 mcg

Females only

norethindrone ace & ethinyl estradiol-fe tab 1.5

mg-30 mcg

Females only

norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg Females only


64


CONTRACEPTIVES, MONOPHASIC, 35 mcg Estrogen ethynodiol diacetate & ethinyl estradiol tab 1 mg-

35 mcg Females only

norethindrone & ethinyl estradiol tab 0.4 mg-35

mcg

Females only

norethindrone & ethinyl estradiol tab 0.5 mg-35

mcg

Females only

norethindrone & ethinyl estradiol tab 1 mg-35 mcg Females only

norgestimate & ethinyl estradiol tab 0.25 mg-35

mcg

Females only

CONTRACEPTIVES, MONOPHASIC, 50 mcg Estrogen ethynodiol diacetate & ethinyl estradiol tab 1 mg-

50 mcg

Females only

norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg Females only

CONTRACEPTIVES, PROGESTIN ONLY norethindrone tab 0.35 mg Females only

CONTRACEPTIVES, TRANSDERMAL norelgestromin-ethinyl estradiol td ptwk 150-35

mcg/24hr

Females only

CONTRACEPTIVES, TRIPHASIC desogest-ethin est tab 0.1-0.025/0.125-

0.025/0.15-0.025mg-mg

Females only

levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg

Females only

norethindrone-eth estradiol tab 0.5-35/0.75-35/1-

35 mg-mcg

Females only

norethindrone-eth estradiol tab 0.5-35/1-35/0.5-

35 mg-mcg

Females only

norgestimate-eth estrad tab 0.18-25/0.215-

25/0.25-25 mg-mcg

Females only

norgestimate-eth estrad tab 0.18-35/0.215-

35/0.25-35 mg-mcg

Females only

CONTRACEPTIVES, VAGINAL NUVARING MIS Females only

ENDOMETRIOSIS danazol cap 50 mg

danazol cap 100 mg

danazol cap 200 mg

SYNAREL SOL 2MG/ML

ESTROGEN/PROGESTIN, ORAL estradiol & norethindrone acetate tab 0.5-0.1 mg Females only

estradiol & norethindrone acetate tab 1-0.5 mg Females only

norethindrone acetate-ethinyl estradiol tab 0.5

mg-2.5 mcg

Females only


65


norethindrone acetate-ethinyl estradiol tab 1 mg-5

mcg

Females only

ESTROGEN/PROGESTIN, TRANSDERMAL COMBIPATCH DIS Females only

ESTROGENS, ORAL estradiol tab 0.5 mg Females only

estradiol tab 1 mg Females only

estradiol tab 2 mg Females only

ESTROGENS, TRANSDERMAL estradiol td patch weekly 0.1 mg/24hr Females only

estradiol td patch weekly 0.05 mg/24hr Females only




estradiol td patch weekly 0.0375 mg/24hr (37.5

mcg/24hr)

Females only

ESTROGENS, VAGINAL estradiol vaginal tab 10 mcg

PREMARIN VAG CRE 0.625MG

GAUCHER DISEASE CERDELGA CAP 84MG SP, PA

GLUCOCORTICOIDS dexamethasone elixir 0.5 mg/5ml

dexamethasone soln 0.5 mg/5ml

dexamethasone tab 0.5 mg


dexamethasone tab 1 mg





hydrocortisone tab 5 mg



MEDROL TAB 2MG

methylprednisolone tab 4 mg




methylprednisolone tab therapy pack 4 mg (21)

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


66


prednisolone sod phos orally disintegr tab 15 mg

(base eq)

prednisolone sod phos orally disintegr tab 30 mg

(base eq)

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

mg/5ml base)

prednisolone sod phosphate oral soln 15 mg/5ml

(base equiv)

prednisolone syrup 15 mg/5ml (usp solution

equivalent)

prednisone oral soln 5 mg/5ml

prednisone tab 1 mg

prednisone tab 2.5 mg

prednisone tab 5 mg

prednisone tab 10 mg



prednisone tab therapy pack 5 mg (21)




GLUCOSE ELEVATING AGENTS GLUCAGEN INJ HYPOKIT QL (2 inj per month)

GLUCAGON KIT 1MG QL (2 inj per month)

HEREDITARY TYROSINEMIA TYPE 1 AGENTS NITYR TAB 2MG SP, PA

NITYR TAB 5MG SP, PA

NITYR TAB 10MG SP, PA

HUMAN GROWTH HORMONES GENOTROPIN INJ 0.2MG SP, PA

GENOTROPIN INJ 0.4MG SP, PA







GENOTROPIN INJ 1MG SP, PA




HUMATROPE INJ 5MG SP, PA




67



NORDITROPIN INJ 5/1.5ML SP, PA



NORDITROPIN INJ 30/3ML SP, PA

NUTROPIN AQ INJ 10MG/2ML SP, PA

NUTROPIN AQ INJ 20MG/2ML SP, PA

NUTROPIN AQ INJ NUSPIN 5 SP, PA

OMNITROPE INJ 5.8MG SP, PA

OMNITROPE INJ 5/1.5ML SP, PA

OMNITROPE INJ 10/1.5ML SP, PA

SAIZEN INJ 5MG SP, PA

SAIZEN INJ 8.8MG SP, PA

SAIZENPREP INJ 8.8MG SP, PA

SEROSTIM INJ 4MG SP, PA



ZOMACTON INJ 5MG SP, PA

ZOMACTON INJ 10MG SP, PA

ZORBTIVE INJ 8.8MG SP, PA

HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol cap 0.5 mcg

calcitriol cap 0.25 mcg

calcitriol oral soln 1 mcg/ml

doxercalciferol cap 0.5 mcg

doxercalciferol cap 1 mcg

doxercalciferol cap 2.5 mcg

paricalcitol cap 1 mcg



MINERALOCORTICOIDS fludrocortisone acetate tab 0.1 mg

MISCELLANEOUS cabergoline tab 0.5 mg

CYSTAGON CAP 50MG SP, PA

CYSTAGON CAP 150MG SP, PA

PHENYLKETONURIA TREATMENT AGENTS KUVAN POW 100MG SP, PA

KUVAN TAB 100MG SP, PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) cap 667 mg

(169 mg ca)


68


sevelamer carbonate packet 0.8 gm ST (Must try calcium acetate

(generic PHOSLO))

sevelamer carbonate packet 2.4 gm ST (Must try calcium acetate

(generic PHOSLO))

sevelamer carbonate tab 800 mg ST (Must try calcium acetate

(generic PHOSLO))

POTASSIUM-REMOVING AGENTS sodium polystyrene sulfonate oral susp 15

gm/60ml

sodium polystyrene sulfonate rectal susp 30 gm/120ml

PROGESTINS, ORAL medroxyprogesterone acetate tab 2.5 mg

medroxyprogesterone acetate tab 5 mg

medroxyprogesterone acetate tab 10 mg

megestrol acetate susp 40 mg/ml

norethindrone acetate tab 5 mg

progesterone micronized cap 100 mg

progesterone micronized cap 200 mg

PROGESTINS, VAGINAL CRINONE GEL 4% VAG PA

CRINONE GEL 8% VAG PA

SELECTIVE ESTROGEN RECEPTOR MODULATORS OSPHENA TAB 60MG PA

raloxifene hcl tab 60 mg

THYROID AGENTS, ANTITHYROID AGENTS methimazole tab 5 mg

methimazole tab 10 mg

propylthiouracil tab 50 mg

SSKI SOL 1GM/ML

THYROID AGENTS, THYROID SUPPLEMENTS CYTOMEL TAB 5MCG +

CYTOMEL TAB 25MCG +

CYTOMEL TAB 50MCG +

levothyroxine sodium tab 25 mcg










69





liothyronine sodium tab 5 mcg



SYNTHROID TAB 25MCG +












UREA CYCLE DISORDERS sodium phenylbutyrate oral powder 3

gm/teaspoonful

SP, PA

sodium phenylbutyrate tab 500 mg SP, PA

VASOPRESSIN RECEPTOR ANTAGONISTS SAMSCA TAB 15MG SP, PA

SAMSCA TAB 30MG SP, PA

VASOPRESSINS DDAVP SOL 0.01% PA

desmopressin acetate nasal spray soln 0.01% PA

desmopressin acetate nasal spray soln 0.01% (refrigerated)

PA

desmopressin acetate tab 0.1 mg PA

desmopressin acetate tab 0.2 mg PA

GASTROINTESTINAL ANTACIDS

alum & mag hydroxide-simethicone chew tab 200-200-25 mg

OTC

alum & mag hydroxide-simethicone susp 200-200-20 mg/5ml

OTC

alum & mag hydroxide-simethicone susp 400-400-

40 mg/5ml

OTC

aluminum hydroxide-magnesium carbonate chew

tab 160-105 mg

OTC

aluminum hydroxide-magnesium carbonate susp

95-358 mg/15ml

OTC


70


aluminum hydroxide-magnesium carbonate susp

508-475 mg/10ml

OTC

aluminum hydroxide-magnesium trisilicate chew

tab 80-20 mg

OTC

ANTACID CHW 1177MG OTC

CALCIUM CARB TAB 648MG OTC

calcium carbonate (antacid) chew tab 400 mg OTC





calcium carbonate (antacid) susp 1250 mg/5ml OTC

calcium carbonate-mag hydroxide chew tab 550-

110 mg

OTC

calcium carbonate-mag hydroxide susp 400-135

mg/5ml

OTC

MAALOX CHW 600MG OTC

TUMS CHW DEL CHW 1177MG OTC

ANTIDIARRHEALS bismuth subsalicylate chew tab 262 mg OTC

bismuth subsalicylate susp 262 mg/15ml OTC

bismuth subsalicylate susp 525 mg/15ml OTC

bismuth subsalicylate tab 262 mg OTC

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

diphenoxylate w/ atropine tab 2.5-0.025 mg

loperamide hcl cap 2 mg

loperamide hcl cap 2 mg OTC

loperamide hcl liq 1 mg/5ml (0.2 mg/ml) OTC

loperamide hcl tab 2 mg OTC

ANTIEMETICS aprepitant capsule 40 mg QL (6 caps per 6 months),

PA

aprepitant capsule 80 mg QL (16 caps per 21 days), PA

aprepitant capsule 125 mg QL (4 caps per 21 days), PA

aprepitant capsule therapy pack 80 & 125 mg QL (4 packs per 21 days)

dronabinol cap 2.5 mg QL (60 per month)

dronabinol cap 5 mg QL (60 per month)

dronabinol cap 10 mg QL (60 per month)

fosaprepitant dimeglumine for iv infusion 150 mg

(base eq)

QL (12 kits per 21 days), PA

granisetron hcl tab 1 mg QL (6 per 15 days)

meclizine hcl chew tab 25 mg OTC

meclizine hcl tab 12.5 mg


71


meclizine hcl tab 12.5 mg OTC

meclizine hcl tab 25 mg

meclizine hcl tab 25 mg OTC

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

(base equiv)

metoclopramide hcl tab 5 mg (base equivalent)

metoclopramide hcl tab 10 mg (base equivalent)

ondansetron hcl oral soln 4 mg/5ml QL (100 mL per 15 days)

ondansetron hcl tab 4 mg QL (12 per 15 days)



ondansetron orally disintegrating tab 4 mg QL (12 per 15 days)

ondansetron orally disintegrating tab 8 mg QL (12 per 15 days)

prochlorperazine maleate tab 5 mg (base

equivalent)


equivalent)

prochlorperazine suppos 25 mg

promethazine hcl suppos 12.5 mg

promethazine hcl suppos 25 mg

promethazine hcl suppos 50 mg

promethazine hcl syrup 6.25 mg/5ml

promethazine hcl tab 12.5 mg

promethazine hcl tab 25 mg

promethazine hcl tab 50 mg

trimethobenzamide hcl cap 300 mg

ANTISPASMODICS chlordiazepoxide hcl-clidinium bromide cap 5-2.5

mg

dicyclomine hcl cap 10 mg

dicyclomine hcl oral soln 10 mg/5ml

dicyclomine hcl tab 20 mg

glycopyrrolate tab 1 mg

glycopyrrolate tab 2 mg

CHOLELITHOLYTICS ursodiol cap 300 mg

ursodiol tab 250 mg

ursodiol tab 500 mg

H2-RECEPTOR ANTAGONISTS cimetidine hcl soln 300 mg/5ml

cimetidine tab 200 mg

cimetidine tab 200 mg OTC




72



famotidine for susp 40 mg/5ml

famotidine tab 10 mg OTC

famotidine tab 20 mg

famotidine tab 20 mg OTC

famotidine tab 40 mg

nizatidine cap 150 mg

nizatidine cap 300 mg

nizatidine oral soln 15 mg/ml

ranitidine hcl cap 150 mg

ranitidine hcl cap 300 mg

ranitidine hcl syrup 15 mg/ml (75 mg/5ml)

ranitidine hcl tab 75 mg OTC

ranitidine hcl tab 150 mg

ranitidine hcl tab 150 mg OTC

ranitidine hcl tab 300 mg

INFLAMMATORY BOWEL DISEASE, ORAL AGENTS APRISO CAP 0.375GM ST (Must have recently been

on 30 days of sulfasalazine)

balsalazide disodium cap 750 mg

budesonide delayed release particles cap 3 mg

sulfasalazine tab 500 mg

sulfasalazine tab delayed release 500 mg

INFLAMMATORY BOWEL DISEASE, RECTAL AGENTS hydrocortisone enema 100 mg/60ml

mesalamine enema 4 gm

mesalamine rectal enema 4 gm & cleanser wipe kit

IRRITABLE BOWEL SYNDROME WITH CONSTIPATION/CHRONIC

IDIOPATHIC CONSTIPATION LINZESS CAP 72MCG

LINZESS CAP 145MCG

LINZESS CAP 290MCG

TRULANCE TAB 3MG

LAXATIVES/STOOL SOFTENERS bisacodyl suppos 10 mg OTC

bisacodyl tab delayed release 5 mg OTC

docusate calcium cap 240 mg OTC

docusate sodium cap 50 mg OTC



docusate sodium liquid 150 mg/15ml OTC

docusate sodium syrup 60 mg/15ml OTC

docusate sodium tab 100 mg OTC


73


lactulose solution 10 gm/15ml

PEDIA-LAX LIQ 50MG OTC

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

236 gm

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

240 gm

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

polyethylene glycol 3350 oral packet OTC

polyethylene glycol 3350 oral powder OTC

sennosides chew tab 15 mg OTC

sennosides syrup 8.8 mg/5ml OTC

sennosides tab 8.6 mg OTC

sennosides tab 15 mg OTC

sennosides tab 17.2 mg OTC

sennosides tab 25 mg OTC

sennosides-docusate sodium tab 8.6-50 mg OTC

MISCELLANEOUS CUVPOSA SOL 1MG/5ML AL (covered for ages 3-16)

GAS-X CHILD MIS 40MG OTC

lactulose (encephalopathy) solution 10 gm/15ml

simethicone cap 125 mg OTC

simethicone cap 180 mg OTC

simethicone chew tab 80 mg OTC

simethicone chew tab 125 mg OTC

simethicone liquid 40 mg/0.6ml OTC

simethicone susp 40 mg/0.6ml OTC

sucralfate tab 1 gm

OPIOID-INDUCED CONSTIPATION MOVANTIK TAB 12.5MG

MOVANTIK TAB 25MG

PANCREATIC ENZYMES CREON CAP 3000UNIT

CREON CAP 6000UNIT

CREON CAP 12000UNT

CREON CAP 24000UNT

CREON CAP 36000UNT

VIOKACE TAB 10440

VIOKACE TAB 20880

ZENPEP CAP 3000UNIT

ZENPEP CAP 5000UNIT

ZENPEP CAP 10000UNT

ZENPEP CAP 15000UNT

ZENPEP CAP 20000UNT


74


ZENPEP CAP 25000

ZENPEP CAP 25000UNT

ZENPEP CAP 40000

ZENPEP CAP 40000UNT

PROSTAGLANDINS misoprostol tab 100 mcg

misoprostol tab 200 mcg

PROTON PUMP INHIBITORS esomeprazole magnesium cap delayed release 20

mg (base eq)

QL (30 per month)

lansoprazole cap delayed release 15 mg OTC, QL (30 per month)

NEXIUM 24HR TAB 20MG OTC, QL (30 per month)

NEXIUM GRA 2.5MG DR QL (30 per month); AL

(Covered for ages less than

1 only)

NEXIUM GRA 5MG DR QL (30 per month); AL


1 only)

NEXIUM GRA 10MG DR QL (30 per month); AL


1 only)

omeprazole cap delayed release 10 mg QL (30 per month)



omeprazole delayed release tab 20 mg OTC

omeprazole magnesium cap dr 20.6 mg (20 mg

base equiv)

OTC, QL (30 per month)

omeprazole tab 20mg OTC

omeprazole-sodium bicarbonate cap 20-1100 mg QL (30 per month)

pantoprazole sodium ec tab 20 mg (base equiv) QL (30 per month)

pantoprazole sodium ec tab 40 mg (base equiv) QL (30 per month)

PRILOSEC OTC TAB 20MG OTC

SALIVA STIMULANTS pilocarpine hcl tab 5 mg

pilocarpine hcl tab 7.5 mg

STEROIDS, RECTAL hydrocortisone rectal cream 1%

hydrocortisone rectal cream 2.5%

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA

alfuzosin hcl tab er 24hr 10 mg

finasteride tab 5 mg

tamsulosin hcl cap 0.4 mg


75


MISCELLANEOUS acetic acid vaginal solution OTC

bethanechol chloride tab 5 mg




ELMIRON CAP 100MG

K-PHOS TAB

K-PHOS TAB NO 2

phenazopyridine hcl tab 100 mg

phenazopyridine hcl tab 200 mg

potassium citrate & citric acid powder pack 3300-

1002 mg

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

potassium citrate tab er 5 meq (540 mg)



URINARY ANTISPASMODICS oxybutynin chloride syrup 5 mg/5ml

oxybutynin chloride tab 5 mg

oxybutynin chloride tab er 24hr 5 mg



tolterodine tartrate tab 1 mg

tolterodine tartrate tab 2 mg

trospium chloride cap er 24hr 60 mg

trospium chloride tab 20 mg

VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal cream 2%

clotrimazole vaginal cream 1% OTC

clotrimazole vaginal cream 2% OTC

metronidazole vaginal gel 0.75%

miconazole nitrate vaginal app 200 mg & 2%

cream 9 gm kit

OTC

miconazole nitrate vaginal cream 2% OTC

miconazole nitrate vaginal cream 4% (200

mg/5gm)

OTC

miconazole nitrate vaginal supp 200 mg & 2%

cream 9 gm kit

OTC

miconazole nitrate vaginal supp 1200 mg & 2% cream kit

OTC

miconazole nitrate vaginal suppos 100 mg OTC

miconazole nitrate vaginal suppos 200 mg


76


MONISTAT 3 KIT COMBO PK OTC

MONISTAT 7 KIT COMPLETE OTC

terconazole vaginal cream 0.4%

terconazole vaginal cream 0.8%

terconazole vaginal suppos 80 mg

HEMATOLOGIC ANTICOAGULANTS, ORAL

COUMADIN TAB 1MG +

COUMADIN TAB 2.5MG +

COUMADIN TAB 2MG +

COUMADIN TAB 3MG +

COUMADIN TAB 4MG +

COUMADIN TAB 5MG +

COUMADIN TAB 6MG +

COUMADIN TAB 7.5MG +

COUMADIN TAB 10MG +

ELIQUIS TAB 2.5MG

ELIQUIS TAB 5MG

warfarin sodium tab 1 mg


warfarin sodium tab 2.5 mg





warfarin sodium tab 7.5 mg


XARELTO STAR TAB 15/20MG

XARELTO TAB 2.5MG

XARELTO TAB 10MG

XARELTO TAB 15MG

XARELTO TAB 20MG

HEMOSTATICS, SYSTEMIC aminocaproic acid oral soln 0.25 gm/ml

aminocaproic acid tab 500 mg

aminocaproic acid tab 1000 mg

MISCELLANEOUS CHEMET CAP 100MG

cilostazol tab 50 mg

cilostazol tab 100 mg

ENDARI POW 5GM SP, PA

pentoxifylline tab er 400 mg


77


PLATELET AGGREGATION INHIBITORS aspirin chew tab 81 mg OTC

aspirin tab 325 mg OTC

aspirin tab 500 mg OTC

aspirin tab delayed release 81 mg OTC



BRILINTA TAB 60MG

BRILINTA TAB 90MG

clopidogrel bisulfate tab 75 mg (base equiv)

clopidogrel bisulfate tab 300 mg (base equiv)

dipyridamole tab 25 mg



prasugrel hcl tab 5 mg (base equiv)

prasugrel hcl tab 10 mg (base equiv)

ZONTIVITY TAB 2.08MG

PLATELET SYNTHESIS INHIBITOR anagrelide hcl cap 0.5 mg

anagrelide hcl cap 1 mg

THROMBOCYTOPENIA AGENTS MULPLETA TAB 3MG SP, PA

PROMACTA TAB 12.5MG SP, PA

PROMACTA TAB 25MG SP, PA



IMMUNOLOGIC AGENTS AUTOIMMUNE AGENTS

ENBREL INJ 25/0.5ML SP, PA

ENBREL INJ 25MG SP, PA

ENBREL INJ 50MG/ML SP, PA

ENBREL MINI INJ 50MG/ML SP, PA

ENBREL SRCLK INJ 50MG/ML SP, PA

HUMIRA INJ 10/0.1ML SP, PA

HUMIRA INJ 10MG/0.2 SP, PA



HUMIRA KIT 20MG/0.4 SP, PA

HUMIRA KIT 40MG/0.8 SP, PA

HUMIRA PEDIA INJ CROHNS SP, PA

HUMIRA PEN INJ 40/0.4ML SP, PA

HUMIRA PEN INJ 40MG/0.8 SP, PA

HUMIRA PEN INJ CD/UC/HS SP, PA


78


HUMIRA PEN INJ PS/UV SP, PA

HUMIRA PEN KIT CD/UC/HS SP, PA

HUMIRA PEN KIT PS/UV SP, PA

XELJANZ TAB 5MG SP, PA

XELJANZ TAB 10MG SP, PA

XELJANZ XR TAB 11MG SP, PA

DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) hydroxychloroquine sulfate tab 200 mg

leflunomide tab 10 mg

leflunomide tab 20 mg

IMMUNOMODULATORS, INTERFERONS PEGASYS INJ SP, PA

PEGASYS INJ 180MCG/M SP, PA

PEGASYS INJ PROCLICK SP, PA

PEGINTRON KIT 50MCG SP, PA

IMMUNOSUPPRESSANTS, ANTIMETABOLITES AZASAN TAB 75 MG +

AZASAN TAB 100MG

azathioprine tab 50 mg

CELLCEPT CAP 250MG +

CELLCEPT SUS 200MG/ML +

CELLCEPT TAB 500MG +

IMURAN TAB 50MG +

mycophenolate mofetil cap 250 mg

mycophenolate mofetil for oral susp 200 mg/ml

mycophenolate mofetil tab 500 mg

mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv)

mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv)

MYFORTIC TAB 180MG +

MYFORTIC TAB 360MG +

IMMUNOSUPPRESSANTS, CALCINEURIN INHIBITORS ASTAGRAF XL CAP 0.5MG

ASTAGRAF XL CAP 1MG

ASTAGRAF XL CAP 5MG

cyclosporine cap 25 mg

cyclosporine cap 100 mg

cyclosporine modified cap 25 mg



cyclosporine modified oral soln 100 mg/ml

ENVARSUS XR TAB 0.75MG


79


ENVARSUS XR TAB 1MG

ENVARSUS XR TAB 4MG

gengraf cap 25mg

gengraf cap 100mg

gengraf sol 100mg/ml

NEORAL CAP 25MG +

NEORAL CAP 100MG +

NEORAL SOL 100MG/ML +

PROGRAF CAP 0.5MG +

PROGRAF CAP 1MG +

PROGRAF CAP 5MG +

SANDIMMUNE CAP 25MG +

SANDIMMUNE CAP 100MG +

SANDIMMUNE SOL 100MG/ML

tacrolimus cap 0.5 mg

tacrolimus cap 1 mg

tacrolimus cap 5 mg

IMMUNOSUPPRESSANTS, RAPAMYCIN DERIVATIVE RAPAMUNE SOL 1MG/ML +

RAPAMUNE TAB 0.5MG +

RAPAMUNE TAB 1MG +

RAPAMUNE TAB 2MG +

sirolimus oral soln 1 mg/ml

sirolimus tab 0.5 mg

sirolimus tab 1 mg

sirolimus tab 2 mg

ZORTRESS TAB 0.5MG

ZORTRESS TAB 0.25MG

ZORTRESS TAB 0.75MG

VACCINES ADACEL INJ AL (covered for ages 19 and

over)

BOOSTRIX INJ AL (covered for ages 19 and

over)

DAPTACEL INJ AL (covered for ages 19 and

over)

DIP/TET PED INJ 25-5LFU AL (covered for ages 19 and

over)

ENGERIX-B INJ 10/0.5ML QL (3 vaccines per lifetime);

AL (covered for ages 19 and

over)

ENGERIX-B INJ 20MCG/ML QL (3 vaccines per lifetime);


over)


80


GARDASIL 9 INJ QL (3 vaccines per lifetime);

AL (covered for ages 19-26)

HAVRIX INJ 720UNIT QL (2 vaccines per lifetime);


over)

HAVRIX INJ 1440UNIT QL (2 vaccines per lifetime);


over)

INFANRIX INJ AL (covered for ages 19 and

over)

M-M-R II INJ AL (covered for ages 19 and

over)

MENACTRA INJ AL (covered for ages 19 and

over)

MENVEO INJ AL (covered for ages 19 and

over)

PNEUMOVAX 23 INJ 25/0.5 AL (covered for ages 19 and

over)

RECOMBIVA HB INJ 5MCG/0.5 QL (3 vaccines per lifetime); AL (covered for ages 19 and

over)

RECOMBIVA HB INJ 10MCG/ML QL (3 vaccines per lifetime);


over)

RECOMBIVA-HB INJ 40MCG/ML QL (3 vaccines per lifetime);


over)

TDVAX INJ 2-2 LF AL (covered for ages 19 and

over)

TENIVAC INJ 5-2LF AL (covered for ages 19 and

over)

TWINRIX INJ QL (3 vaccines per lifetime); AL (covered for ages 19 and

over)

VAQTA INJ 25/0.5ML QL (2 vaccines per lifetime); AL (covered for ages 19 and

over)

VAQTA INJ 50UNT/ML QL (2 vaccines per lifetime);


over)

VARIVAX INJ AL (covered for ages 19 and

over)

ZOSTAVAX INJ AL (covered for ages 60 and over)


81


MISCELLANEOUS DIAGNOSTIC AGENTS

CHEMSTRIP 2 TES GP OTC, QL (100 per month)

CHEMSTRIP 5 TES OB OTC, QL (100 per month)

CHEMSTRIP 7 TES OTC, QL (100 per month)

CHEMSTRIP 9 TES STRIPS OTC, QL (100 per month)

CHEMSTRIP 10 TES MD OTC, QL (100 per month)

CHEMSTRIP TES -10 SG OTC, QL (100 per month)

COMBISTIX TES OTC, QL (100 per month)

HEMA-COMBIST TES OTC, QL (100 per month)

LABSTIX TES OTC, QL (100 per month)

MULTISTIX 5 TES OTC, QL (100 per month)


MULTISTIX 8 TES SG OTC, QL (100 per month)




MULTISTIX TES OTC, QL (100 per month)

URISTIX 4 TES OTC, QL (100 per month)

URISTIX TES OTC, QL (100 per month)

MEDICAL SUPPLIES bandages: adhesive; elastic; gauze OTC

NUTRITIONAL / SUPPLEMENTS ELECTROLYTES, MISCELLANEOUS

oral electrolyte solution OTC

ELECTROLYTES, POTASSIUM potassium bicarbonate effer tab 25 meq

potassium chloride cap er 8 meq

potassium chloride cap er 10 meq

potassium chloride microencapsulated crys er tab 10 meq

potassium chloride microencapsulated crys er tab 20 meq

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

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

potassium chloride tab er 8 meq (600 mg)

potassium chloride tab er 10 meq

potassium chloride tab er 20 meq (1500 mg)

VITAMINS AND MINERALS, CALCIUM SUPPLEMENTS calcium carbonate chew tab 1250 mg (500 mg

elemental ca)

OTC

calcium carbonate tab 600 mg OTC


82


calcium carbonate tab 1250 mg (500 mg

elemental ca)

OTC


elemental ca)

OTC

calcium carbonate-cholecalciferol cap 600 mg-500

unit

OTC

calcium carbonate-cholecalciferol chew tab 500

mg-400 unit

OTC

calcium carbonate-cholecalciferol chew tab 500

mg-600 unit

OTC

calcium carbonate-cholecalciferol tab 250 mg-125 unit

OTC

calcium carbonate-cholecalciferol tab 500 mg-125 unit

OTC

calcium carbonate-cholecalciferol tab 500 mg-200

unit

OTC


unit

OTC


unit

OTC


unit

OTC


unit

OTC

calcium carbonate-vitamin d cap 600 mg-200 unit OTC

calcium carbonate-vitamin d chew tab 600 mg-400

unit

OTC

calcium carbonate-vitamin d tab 250 mg-125 unit OTC







calcium citrate tab 950 mg (200 mg elemental ca) OTC

calcium citrate-vitamin d tab 200 mg-250 unit

(elemental ca)

OTC


(elemental ca)

OTC


(elemental ca)

OTC


(elemental ca)

OTC

calcium tab 500 mg OTC

calcium tab 600 mg OTC

calcium w/ magnesium tab 250-125 mg OTC


83




calcium w/ vitamin d & k chew tab 500 mg-100

unit-40 mcg

OTC

calcium w/ vitamin d & k chew tab 500 mg-200

unit-40 mcg

OTC

calcium w/ vitamin d tab 600 mg-200 unit OTC

calcium-mag-vit c-vit d cap 185 mg-28 mg-2.5 mg-200 unit

OTC

calcium-magnesium-zinc tab 333-133-5 mg OTC

calcium-magnesium-zinc tab 333-133-8.3 mg OTC

oyster shell calcium tab 500 mg OTC

VITAMINS AND MINERALS, FOLIC ACID/COMBINATIONS folic acid tab 1 mg

folic acid tab 1 mg OTC

folic acid tab 400 mcg OTC

folic acid tab 800 mcg OTC

folic acid-vitamin b6-vitamin b12 tab 0.8-10-0.115

mg

OTC

folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5

mg

folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg

folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg

VITAMINS AND MINERALS, IRON/COMBINATIONS fe bisglyc-vit c-vit b12-folic acid cap 28-60-0.008-

0.4 mg OTC

fe fum-iron polysacch complex-fa-b cmplx-c-zn-

mn-cu cap

fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-

0.5-240 mg

fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-

0.01-1 mg

ferrous fumarate tab 324 mg (106 mg elemental

fe)

OTC

ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab

106-1 mg

ferrous fumarate-folic acid tab 324-1 mg

ferrous gluconate tab 240 mg (27 mg elemental

fe)

OTC

ferrous gluconate tab 324 mg (37.5 mg elemental

iron)

OTC

ferrous sulfate dried tab 200 mg (65 mg elemental

fe)

OTC

ferrous sulfate dried tab er 45 mg (fe equivalent) OTC


84


ferrous sulfate dried tab er 160 mg (50 mg fe

equivalent)

OTC

ferrous sulfate elixir 220 mg/5ml (44 mg/5ml

elemental fe)

OTC

ferrous sulfate soln 75 mg/ml (15 mg/ml

elemental fe)

OTC

ferrous sulfate tab 27 mg (elemental fe) OTC

ferrous sulfate tab 134 mg (27 mg elemental fe) OTC

ferrous sulfate tab 325 mg (65 mg elemental fe) OTC

ferrous sulfate tab ec 325 mg (65 mg fe

equivalent)

OTC

ferrous sulfate tab er 47.5 mg (elemental fe) OTC

ferrous sulfate tab er 50 mg (elemental fe) OTC

ferrous sulfate tab er 142 mg (45 mg fe

equivalent)

OTC

iron combination cap

iron combination cap OTC

iron polysacch complex-vit b12-fa cap 150-0.025-1

mg

iron polysacch complex-vit b12-fa cap 150-0.025-1

mg

OTC

iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-

1 mg

iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-

1 mg

OTC

iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-

1.25 mg

iron-vit c-vit b12-folic acid tab 100-250-0.025-1 mg

OTC

iron-vitamin c tab 100-250 mg OTC

polysaccharide iron complex cap 150 mg (iron

equivalent)

OTC

VITAMINS AND MINERALS, MISCELLANEOUS b-complex vitamin cap OTC

b-complex vitamin sublingual liquid OTC

b-complex vitamin tab OTC

b-complex vitamin tab er OTC

b-complex w/ c & calcium tab OTC

b-complex w/ c & e + zn tab OTC

b-complex w/ c & folic acid cap 1 mg

b-complex w/ c & folic acid tab

b-complex w/ c & folic acid tab OTC

b-complex w/ c & folic acid tab 0.8 mg OTC

b-complex w/ c & folic acid tab 1 mg

b-complex w/ c & folic acid tab 1 mg OTC


85


b-complex w/ c & folic acid tab 5 mg

b-complex w/ c cap OTC

b-complex w/ c tab OTC

b-complex w/ c tab er OTC

b-complex w/ c-biotin-minerals & folic acid tab 5

mg

b-complex w/ folic acid cap OTC

b-complex w/ folic acid tab OTC

b-complex w/ folic acid tab er OTC

b-complex w/ iron tab OTC

b-complex w/ minerals liq OTC

b-complex w/biotin & folic acid tab OTC

b-complex w/biotin & folic acid tab er OTC

bioflavonoid products tab OTC

bioflavonoid products tab er OTC

brewers yeast tab OTC

calcium ascorbate tab 500 mg OTC

calcium pantothenate tab 500 mg OTC

cholecalciferol cap 1.25 mg (50000 unit) OTC

cholecalciferol cap 10 mcg (400 unit) OTC





cholecalciferol chew tab 10 mcg (400 unit) OTC




cholecalciferol drops 10 mcg/0.03ml (400 unit/0.03ml)

OTC

cholecalciferol drops 50 mcg/0.03ml (2000

unit/0.03ml)

OTC

cholecalciferol drops 125 mcg/ml (5000 unit/ml) OTC

cholecalciferol oral liquid 10 mcg/ml (400 unit/ml) OTC

cholecalciferol tab 1.25 mg (50000 unit) OTC

cholecalciferol tab 10 mcg (400 unit) OTC




cod liver oil cap OTC

cyanocobalamin inj 1000 mcg/ml

ergocalciferol cap 1.25 mg (50000 unit)

ergocalciferol soln 200 mcg/ml (8000 unit/ml) OTC

iron w/ vitamin liq OTC


86


iron w/ vitamin tab OTC

multiple vitamin cap OTC; AL (covered for ages

20 and under)

multiple vitamin tab OTC; AL (covered for ages 20 and under)

multiple vitamins w/ calcium tab OTC; AL (covered for ages 20 and under)

multiple vitamins w/ iron tab OTC; AL (covered for ages

20 and under)

multiple vitamins w/ minerals & fa tab 1.25 mg AL (covered for ages 20 and

under)

multiple vitamins w/ minerals cap AL (covered for ages 20 and

under)

multiple vitamins w/ minerals cap OTC; AL (covered for ages

20 and under)

multiple vitamins w/ minerals chew tab OTC; AL (covered for ages

20 and under)

multiple vitamins w/ minerals effer tab OTC; AL (covered for ages

20 and under)

multiple vitamins w/ minerals liquid OTC; AL (covered for ages 20 and under)

multiple vitamins w/ minerals tab AL (covered for ages 20 and under)

multiple vitamins w/ minerals tab OTC; AL (covered for ages

20 and under)

multiple vitamins w/ minerals tab er OTC; AL (covered for ages

20 and under)

NASCOBAL SPR 500MCG

niacin cap er 250 mg OTC

niacin cap er 500 mg OTC

niacin tab 50 mg OTC




niacin tab er 250 mg OTC



niacin w/ inositol cap 400-100 mg OTC

niacinamide tab 100 mg OTC

niacinamide tab 500 mg OTC

omega-3 fatty acids - oral liquid OTC

omega-3 fatty acids cap 300 mg OTC





87



omega-3 fatty acids chew tab 113.5 mg OTC

pantothenic acid tab 500 mg OTC

pediatric multiple vitamin liq OTC; AL (covered for ages

20 and under)

pediatric multiple vitamin w/ c & fa chew tab OTC; AL (covered for ages 20 and under)

pediatric multiple vitamin w/ c soln 35 mg/ml OTC; AL (covered for ages 20 and under)

pediatric multiple vitamin w/ extra c & fa chew tab OTC; AL (covered for ages

20 and under)

pediatric multiple vitamin w/ minerals & c chew

tab

OTC; AL (covered for ages

20 and under)

pediatric multiple vitamin w/ minerals & c drops 45

mg/ml


under)

pediatric multiple vitamin w/ minerals & c drops 45

mg/ml

OTC; AL (covered for ages

20 and under)

pediatric multiple vitamins w/ fl-fe drops 0.25-6

mg/ml


under)

pediatric multiple vitamins w/ fl-fe drops 0.25-10

mg/ml


under)

pediatric multiple vitamins w/ fluoride chew tab

0.5 mg


under)

pediatric multiple vitamins w/ fluoride chew tab 0.25 mg

AL (covered for ages 20 and under)

pediatric multiple vitamins w/ fluoride chew tab 1

mg


under)

pediatric multiple vitamins w/ fluoride soln 0.5

mg/ml


under)

pediatric multiple vitamins w/ fluoride soln 0.25

mg/ml


under)

pediatric multiple vitamins w/ iron chew tab 15 mg OTC; AL (covered for ages

20 and under)

pediatric multiple vitamins w/ iron drops 10 mg/ml OTC; AL (covered for ages

20 and under)

pediatric vitamins acd w/ fluoride soln 0.5 mg/ml AL (covered for ages 20 and

under)

pediatric vitamins acd w/ fluoride soln 0.25 mg/ml AL (covered for ages 20 and

under)

pediatric vitamins adc drops 1500 unit-400 unit-35 mg/ml

OTC; AL (covered for ages 20 and under)

phytonadione tab 5 mg

pyridoxine hcl tab 25 mg OTC





88



pyridoxine hcl tab er 200 mg OTC

riboflavin tab 25 mg OTC



sodium fluoride chew tab 0.5 mg f (from 1.1 mg

naf)

sodium fluoride chew tab 0.25 mg f (from 0.55 mg

naf)

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

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

naf)

sodium fluoride soln 0.25 mg/drop f (from 0.55

mg/drop naf)

sodium fluoride soln 0.125 mg/drop f (0.275

mg/drop naf)

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

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

thiamine hcl tab 50 mg OTC



thiamine mononitrate tab 100 mg OTC

vitamin e cap 400 unit OTC

vitamin mixture cap OTC

vitamin mixture tab OTC

vitamins a & d cap OTC

vitamins a & d tab OTC

vitamins a & d w/ c chew tab OTC

vitamins c & e cap OTC

vitamins w/ lipotropics cap OTC

vitamins w/ lipotropics tab OTC

vitamins w/ lipotropics tab er OTC

VITAMINS AND MINERALS, PRENATAL VITAMINS CITRANATAL CAP HARMONY

CITRANATAL CAP MEDLEY

CITRANATAL MIS

CITRANATAL MIS 90 DHA

CITRANATAL MIS B-CALM

CITRANATAL PAK ASSURE

CITRANATAL PAK DHA

CITRANATAL TAB BLOOM

CITRANATAL TAB RX

PRENAISSANCE CAP PLUS

prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg


89


prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg

prenatal vit w/ fe fumarate-fa chew tab 29-1 mg

prenatal vit w/ iron carbonyl-fa tab 29-1 mg

RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS

epinephrine solution auto-injector 0.3 mg/0.3ml

(1:1000)

QL (8 per year)

epinephrine solution auto-injector 0.15 mg/0.15ml

(1:1000)

QL (8 per year)

EPIPEN 2-PAK INJ 0.3MG QL (8 per year)

EPIPEN-JR INJ 0.15MG QL (8 per year)

ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, LONG ACTING STIOLTO AER 2.5-2.5 QL (1 inhaler per month)

ANTICHOLINERGIC/BETA AGONIST COMBINATIONS, SHORT

ACTING COMBIVENT AER 20-100 QL (2 inhalers per month)

ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml QL (540 mL per month)

ANTICHOLINERGICS INCRUSE ELPT INH 62.5MCG QL (1 inhaler per month)

ipratropium bromide inhal soln 0.02% QL (313 mL per month)

ANTIHISTAMINE/DECONGESTANT COMBINATIONS brompheniramine & pseudoephedrine elixir 1-15

mg/5ml

OTC

cetirizine-pseudoephedrine tab er 12hr 5-120 mg OTC

fexofenadine-pseudoephedrine tab er 12hr 60-120

mg

OTC

fexofenadine-pseudoephedrine tab er 24hr 180-

240 mg

OTC

loratadine & pseudoephedrine tab er 12hr 5-120

mg

OTC

loratadine & pseudoephedrine tab er 24hr 10-240

mg

OTC

promethazine & phenylephrine syrup 6.25-5

mg/5ml

ANTIHISTAMINES, LOW SEDATING cetirizine hcl cap 10 mg OTC

cetirizine hcl chew tab 5 mg OTC; AL (covered for ages

less than 12 years of age)

cetirizine hcl chew tab 10 mg OTC; AL (covered for ages

less than 12 years of age)

cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)

cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) OTC

cetirizine hcl tab 5 mg OTC

cetirizine hcl tab 10 mg OTC


90


ZYRTEC ALLGY TAB 10MG OTC

ZYRTEC CHILD TAB 10MG OTC

ANTIHISTAMINES, NONSEDATING ALLEGRA ALRG TAB 30MG OTC

CLARITIN RDT TAB 5MG OTC

fexofenadine hcl susp 30 mg/5ml (6 mg/ml) OTC

fexofenadine hcl tab 60 mg OTC

fexofenadine hcl tab 180 mg OTC

loratadine cap 10 mg OTC

loratadine chew tab 5 mg OTC

loratadine rapidly-disintegrating tab 10 mg OTC

loratadine syrup 5 mg/5ml OTC

loratadine tab 10 mg OTC

ANTIHISTAMINES, SEDATING chlorpheniramine maleate syrup 2 mg/5ml OTC

chlorpheniramine maleate tab 4 mg OTC

chlorpheniramine maleate tab er 12 mg OTC

clemastine fumarate tab 1.34 mg (1 mg base

equiv)

OTC

clemastine fumarate tab 2.68 mg

cyproheptadine hcl syrup 2 mg/5ml

cyproheptadine hcl tab 4 mg

diphenhydramine hcl cap 25 mg OTC

diphenhydramine hcl cap 50 mg OTC

diphenhydramine hcl chew tab 12.5 mg OTC

diphenhydramine hcl elixir 12.5 mg/5ml

diphenhydramine hcl elixir 12.5 mg/5ml OTC

diphenhydramine hcl liquid 12.5 mg/5ml OTC

diphenhydramine hcl syrup 12.5 mg/5ml OTC

diphenhydramine hcl tab 25 mg OTC

diphenhydramine hcl tab disint 12.5 mg OTC

hydroxyzine hcl syrup 10 mg/5ml

hydroxyzine hcl tab 10 mg



hydroxyzine pamoate cap 25 mg



VISTARIL CAP 25MG +

VISTARIL CAP 50MG +

ANTITUSSIVE COMBINATIONS, NON-OPIOID dextromethorphan-guaifenesin liquid 5-100

mg/5ml

OTC


91


dextromethorphan-guaifenesin liquid 10-100

mg/5ml

OTC


mg/5ml

OTC


mg/5ml

OTC


mg/5ml

OTC

dextromethorphan-guaifenesin syrup 10-100

mg/5ml

OTC

dextromethorphan-guaifenesin tab er 12hr 30-600 mg

OTC

dextromethorphan-guaifenesin tab er 12hr 60-1200 mg

OTC

MUCINEX CGH GRA 5-100MG OTC

MUCINEX DM TAB 30-600ER OTC

promethazine-dm syrup 6.25-15 mg/5ml

pseudoephed-bromphen-dm syrup 30-2-10

mg/5ml

pseudoephed-bromphen-dm syrup 30-2-10

mg/5ml

OTC

pseudoephedrine w/ dm-gg liquid 30-10-100

mg/5ml

OTC

ANTITUSSIVE COMBINATIONS, OPIOID guaifenesin-codeine soln 100-6.3 mg/5ml OTC

guaifenesin-codeine soln 100-10 mg/5ml OTC

hydrocodone w/ homatropine syrup 5-1.5 mg/5ml

hydrocodone w/ homatropine tab 5-1.5 mg

promethazine w/ codeine syrup 6.25-10 mg/5ml

promethazine-phenylephrine-codeine syrup 6.25-

5-10 mg/5ml

pseudoephedrine w/ cod-gg soln 30-10-100

mg/5ml

OTC

ANTITUSSIVES benzonatate cap 100 mg

benzonatate cap 200 mg

BETA AGONISTS, INHALANTS, Long Acting: Hand-held Active

Inhalation STRIVERDI AER 2.5MCG QL (1 inhaler per month)

BETA AGONISTS, INHALANTS, Short Acting albuterol sulfate inhal aero 108 mcg/act (90mcg

base equiv)

QL (18g - 2 inhalers per

month)

albuterol sulfate soln nebu 0.5% (5 mg/ml)

albuterol sulfate soln nebu 0.63 mg/3ml (base equiv)


92


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

albuterol sulfate soln nebu 1.25 mg/3ml (base

equiv)

PROAIR RESPI AER QL (2 inhalers per month)

VENTOLIN HFA AER QL (18g - 2 inhalers per

month)

VENTOLIN HFA AER QL (3.7g - 6 inhalers per

month)

VENTOLIN HFA AER QL (8g - 4 inhalers per

month)

BETA AGONISTS, ORAL AGENTS albuterol sulfate syrup 2 mg/5ml

albuterol sulfate tab 2 mg

albuterol sulfate tab 4 mg

albuterol sulfate tab er 12hr 4 mg

albuterol sulfate tab er 12hr 8 mg

terbutaline sulfate tab 2.5 mg

terbutaline sulfate tab 5 mg

CYSTIC FIBROSIS BETHKIS NEB 300/4ML SP, PA

KALYDECO PAK 25MG SP, PA



KALYDECO TAB 150MG SP, PA

ORKAMBI GRA 100-125 SP, PA

ORKAMBI GRA 150-188 SP, PA

ORKAMBI TAB 100-125 SP, PA

ORKAMBI TAB 200-125 SP, PA

PULMOZYME SOL 1MG/ML SP, PA

SYMDEKO TAB 50-75MG SP, PA

SYMDEKO TAB 100-150 SP, PA

tobramycin nebu soln 300 mg/5ml SP, PA

DECONGESTANT/EXPECTORANT COMBINATIONS pseudoephedrine-guaifenesin tab er 12hr 60-600

mg OTC

pseudoephedrine-guaifenesin tab er 12hr 120-1200 mg

OTC

DECONGESTANTS pseudoephedrine hcl liq 15 mg/5ml OTC

pseudoephedrine hcl tab 30 mg OTC

pseudoephedrine hcl tab 60 mg OTC

pseudoephedrine hcl tab er 12hr 120 mg OTC, QL (60 per month)

SUDAFED 24HR TAB 240MG OTC, QL (30 per month)


93


EXPECTORANTS guaifenesin liquid 100 mg/5ml OTC

guaifenesin syrup 100 mg/5ml OTC

guaifenesin tab 200 mg OTC

guaifenesin tab 400 mg OTC

guaifenesin tab er 12hr 600 mg OTC

guaifenesin tab er 12hr 1200 mg OTC

MUCINEX/KIDS GRA 100MG OTC

YODEFAN-NF LIQ 200-5ML OTC

LEUKOTRIENE MODULATORS montelukast sodium chew tab 4 mg (base equiv)

montelukast sodium chew tab 5 mg (base equiv)

montelukast sodium oral granules packet 4 mg (base equiv)

montelukast sodium tab 10 mg (base equiv)

MAST CELL STABILIZERS cromolyn sodium nasal aerosol soln 5.2 mg/act

(4%)

OTC

cromolyn sodium soln nebu 20 mg/2ml QL (240 mL per month)

MEDICAL SUPPLIES AERCHMBR PLS MIS LRG MASK QL (2 per year)

AERCHMBR PLS MIS MED MASK QL (2 per year)

AERCHMBR PLS MIS SM MASK QL (2 per year)

AERCHMBR Z- MIS STAT PLS QL (2 per year)

AEROCHAMBER MIS CHAMBER QL (2 per year)

AEROCHAMBER MIS FLOSIGNA QL (2 per year)

AEROCHAMBER MIS MV QL (2 per year)

AEROCHAMBER MIS PLUS QL (2 per year)

MASK VORTEX/ MIS BABY DUC OTC, QL (2 per year)

MASK VORTEX/ MIS DUCK OTC, QL (2 per year)

MASK VORTEX/ MIS FROG OTC, QL (2 per year)

MASK VORTEX/ MIS LADY BUG OTC, QL (2 per year)

NEBULIZER MIS OTC

PEDIATRIC SM MIS MASK OTC

VAPORIZER OTC

VORTEX VALVE MIS CHAMBER QL (2 per year)

VORTEX/MASK MIS CHILDS QL (2 per year)

VORTEX/MASK MIS TODDLER QL (2 per year)

MISCELLANEOUS AYR NASAL DRO 0.65% OTC

CVS NASAL SPR MIST OTC

ipratropium bromide nasal soln 0.03% (21

mcg/spray)


94


ipratropium bromide nasal soln 0.06% (42

mcg/spray)

RHINARIS SPR 0.2% OTC

saline nasal spray 0.65% OTC

SIMPLY SALIN AER 0.9% OTC

sodium chloride aero soln 0.9% OTC

sodium chloride soln nebu 0.9%

sodium chloride soln nebu 3%



NASAL ANTIHISTAMINES azelastine hcl nasal spray 0.1% (137 mcg/spray) QL (2 bottles per month)

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

QL (2 bottles per month)

NASAL STEROIDS budesonide nasal susp 32 mcg/act OTC, QL (1 bottle per

month)

flunisolide nasal soln 25 mcg/act (0.025%) QL (2 bottles per month)

fluticasone propionate nasal susp 50 mcg/act QL (1 bottle per month)

fluticasone propionate nasal susp 50 mcg/act OTC, QL (1 bottle per

month)

triamcinolone acetonide nasal aerosol suspension

55 mcg/act

OTC, QL (1 bottle per

month)

PULMONARY FIBROSIS AGENTS OFEV CAP 100MG SP, PA

OFEV CAP 150MG SP, PA

SEVERE ASTHMA AGENTS XOLAIR INJ 75/0.5 SP, PA

XOLAIR INJ 150MG/ML SP, PA

XOLAIR SOL 150MG SP, PA

STEROID INHALANTS ARNUITY ELPT INH 50MCG QL (1 inhaler per month)

ARNUITY ELPT INH 100MCG QL (1 inhaler per month)

ARNUITY ELPT INH 200MCG QL (1 inhaler per month)

budesonide inhalation susp 0.5 mg/2ml QL (120 mL per month)

budesonide inhalation susp 0.25 mg/2ml QL (120 mL per month)

budesonide inhalation susp 1 mg/2ml QL (60 mL per month)

FLOVENT DISK AER 50MCG QL (3 inhalers per month)



FLOVENT HFA AER 44MCG QL (2 inhalers per month)



QVAR REDIHA AER 80MCG QL (2 inhalers per month)


95


QVAR REDIHAL AER 40MCG QL (2 inhalers per month)

STEROID/BETA AGONIST COMBINATIONS ADVAIR HFA AER 45/21 QL (1 inhaler per month)

ADVAIR HFA AER 115/21 QL (1 inhaler per month)

ADVAIR HFA AER 230/21 QL (1 inhaler per month)

DULERA AER 100-5MCG QL (1 inhaler per month)

DULERA AER 200-5MCG QL (1 inhaler per month)

fluticasone-salmeterol aer powder ba 100-50

mcg/dose

QL (1 inhaler per month)


mcg/dose



mcg/dose


XANTHINES ELIXOPHYLLIN ELX 80/15ML

THEO-24 CAP 100MG CR



THEO-24 CAP 400MG ER

theophylline soln 80 mg/15ml

theophylline tab er 12hr 100 mg






TOPICAL DERMATOLOGY, ACNE, Oral

claravis cap 10mg PA




myorisan cap 10mg PA




zenatane cap 10mg PA




DERMATOLOGY, ACNE, Topical BENZOYL PER GEL 2.5% OTC

benzoyl peroxide cream 2.5% OTC


96


benzoyl peroxide cream 10% OTC

benzoyl peroxide gel 5% OTC

benzoyl peroxide gel 10% OTC

benzoyl peroxide liq 2.5%

benzoyl peroxide liq 4% OTC


benzoyl peroxide liq 5.25%

benzoyl peroxide liq 5.25% OTC


benzoyl peroxide liq 7%


benzoyl peroxide-erythromycin gel 5-3%

clindamycin phosphate gel 1%

clindamycin phosphate lotion 1%

clindamycin phosphate soln 1%

erythromycin gel 2%

erythromycin soln 2%

sulfacetamide sodium lotion 10% (acne)

tretinoin cream 0.1% ST (Members 35 years and older must have recently

been on 30 days of a topical

formulary alternative)

tretinoin cream 0.05% ST (Members 35 years and

older must have recently



tretinoin cream 0.025% ST (Members 35 years and

older must have recently



tretinoin gel 0.01% ST (Members 35 years and

older must have recently been on 30 days of a topical


tretinoin gel 0.025% ST (Members 35 years and older must have recently



DERMATOLOGY, ACTINIC KERATOSIS fluorouracil cream 5%

TOLAK CRE 4%

DERMATOLOGY, ANTIBIOTICS bacitracin oint 500 unit/gm OTC

bacitracin zinc oint 500 unit/gm OTC

bacitracin-polymyxin b oint OTC


97


gentamicin sulfate cream 0.1%

gentamicin sulfate oint 0.1%

mupirocin oint 2%

neomycin-bacitracin-polymyxin oint OTC

silver sulfadiazine cream 1%

DERMATOLOGY, ANTIFUNGALS ciclopirox gel 0.77%

ciclopirox olamine cream 0.77% (base equiv)

ciclopirox olamine susp 0.77% (base equiv)

ciclopirox shampoo 1%

clotrimazole cream 1%

clotrimazole cream 1% OTC

clotrimazole soln 1%

clotrimazole soln 1% OTC

ketoconazole cream 2%

ketoconazole shampoo 2%

miconazole nitrate cream 2% OTC

miconazole nitrate ointment 2% OTC

miconazole nitrate powder 2% OTC

nystatin cream 100000 unit/gm

nystatin oint 100000 unit/gm

nystatin topical powder 100000 unit/gm

tolnaftate aerosol pow 1% OTC

tolnaftate cream 1% OTC

tolnaftate soln 1% OTC

DERMATOLOGY, ANTIPSORIATICS, Topical calcipotriene oint 0.005% QL (120 gm per month); ST

(Must have recently been on 30 days of generic topical

steroid)

calcipotriene soln 0.005% (50 mcg/ml) QL (120 mL per month); ST (Must have recently been on

30 days of generic topical

steroid)

DERMATOLOGY, ANTISEBORRHEICS selenium sulfide lotion 1% OTC

selenium sulfide lotion 2.5%

DERMATOLOGY, ANTISEPTICS/DISINFECTANTS IV PREP WIPE PAD OTC

MICROCLENS PAD WIPES OTC

povidone-iodine oint 10% OTC

povidone-iodine soln 7.5% OTC

povidone-iodine soln 10% OTC

UNI-SOLVE PAD WIPES OTC


98


DERMATOLOGY, ATOPIC DERMATITIS, Topical tacrolimus oint 0.1% ST (Must have recently been

on a generic steroid); AL

(Must be 16 years of age

and older)

tacrolimus oint 0.03% ST (Must have recently been

on a generic steroid); AL

(Must be 2 years of age and

older)

DERMATOLOGY, CORTICOSTEROID COMBINATIONS hydrocortisone-aloe vera cream 1% OTC

DERMATOLOGY, CORTICOSTEROIDS, High Potency betamethasone dipropionate augmented cream

0.05%

QL (120 grams per month)

betamethasone dipropionate augmented lotion

0.05%

QL (120 mL per month)

betamethasone dipropionate cream 0.05% QL (120 grams per month)

betamethasone dipropionate lotion 0.05% QL (120 mL per month)

betamethasone dipropionate oint 0.05% QL (120 grams per month)

desoximetasone cream 0.25% QL (120 grams per month)

desoximetasone gel 0.05% QL (120 grams per month)

desoximetasone oint 0.25% QL (120 grams per month)

fluocinonide cream 0.05% QL (120 grams per month)

fluocinonide gel 0.05% QL (120 grams per month)

fluocinonide oint 0.05% QL (120 grams per month)

fluocinonide soln 0.05%

triamcinolone acetonide cream 0.5% QL (120 grams per month)

triamcinolone acetonide oint 0.5% QL (120 grams per month)

DERMATOLOGY, CORTICOSTEROIDS, Low Potency alclometasone dipropionate cream 0.05% QL (120 grams per month)

alclometasone dipropionate oint 0.05% QL (120 grams per month)

desonide cream 0.05% QL (120 grams per month)

desonide lotion 0.05% QL (120 mL per month)

desonide oint 0.05% QL (120 grams per month)

fluocinolone acetonide soln 0.01%

hydrocortisone acetate cream 1% OTC

hydrocortisone cream 0.5% OTC

hydrocortisone cream 1%

hydrocortisone cream 1% OTC

hydrocortisone cream 2.5% QL (120 grams per month)

hydrocortisone gel 1% OTC

hydrocortisone lotion 1% OTC

hydrocortisone lotion 2.5% QL (120 mL per month)

hydrocortisone oint 0.5% OTC


99


hydrocortisone oint 1%

hydrocortisone oint 1% OTC

hydrocortisone oint 2.5% QL (120 grams per month)

hydrocortisone soln 1% OTC

DERMATOLOGY, CORTICOSTEROIDS, Medium Potency betamethasone valerate cream 0.1% (base

equivalent)


betamethasone valerate lotion 0.1% (base

equivalent)

QL (120 mL per month)

betamethasone valerate oint 0.1% (base

equivalent)

desoximetasone cream 0.05% QL (120 grams per month)

fluocinolone acetonide cream 0.025% QL (120 grams per month)

fluocinolone acetonide oint 0.025% QL (120 grams per month)

fluticasone propionate cream 0.05% QL (120 grams per month)

fluticasone propionate oint 0.005% QL (120 grams per month)

hydrocortisone butyrate cream 0.1% QL (120 grams per month)

hydrocortisone butyrate oint 0.1% QL (120 grams per month)

hydrocortisone butyrate soln 0.1%

hydrocortisone valerate cream 0.2% QL (120 grams per month)

hydrocortisone valerate oint 0.2% QL (120 grams per month)

mometasone furoate cream 0.1% QL (120 grams per month)

mometasone furoate oint 0.1% QL (120 grams per month)

mometasone furoate solution 0.1% (lotion)



triamcinolone acetonide lotion 0.1% QL (120 mL per month)

triamcinolone acetonide lotion 0.025% QL (120 mL per month)



DERMATOLOGY, CORTICOSTEROIDS, Very High Potency betamethasone dipropionate augmented gel

0.05%


betamethasone dipropionate augmented oint

0.05%


clobetasol propionate cream 0.05% QL (120 grams per month)

clobetasol propionate foam 0.05%

clobetasol propionate gel 0.05% QL (120 grams per month)

clobetasol propionate oint 0.05% QL (120 grams per month)

clobetasol propionate soln 0.05%

halobetasol propionate cream 0.05% QL (120 grams per month)

halobetasol propionate oint 0.05% QL (120 grams per month)

DERMATOLOGY, EMOLLIENTS lactic acid (ammonium lactate) cream 12%


100


lactic acid (ammonium lactate) cream 12% OTC

lactic acid (ammonium lactate) lotion 12%

lactic acid (ammonium lactate) lotion 12% OTC

DERMATOLOGY, INSECT REPELLENTS CUTTER BACKW AER 25% OTC, QL (2 per 30 days);

Females aged 14-45 years

old only

NATRAPEL 12H SPR 20% OTC, QL (2 per 30 days);


old only

OFF DEEP WDS AER 25% OTC, QL (2 per 30 days);


old only

REPEL SPORTS AER 25% OTC, QL (2 per 30 days);


old only

SAWYER REPEL SPR 20% OTC, QL (2 per 30 days);


old only

DERMATOLOGY, LOCAL ANALGESICS ARTH PAIN CRE 0.075% OTC, QL (120 grams per

month)

capsaicin cream 0.1% OTC, QL (120 grams per month)

capsaicin cream 0.025% OTC, QL (120 grams per month)

CAPSAICIN LIQ 0.15% OTC, QL (30 grams per

month)

CAPZASIN GEL RELIEF OTC, QL (42.5 grams per

month)

CAPZASIN LIQ 0.15% OTC, QL (30 grams per

month)

CAPZASIN-P CRE 0.035% OTC, QL (120 grams per

month)

CASTIVA LOT OTC, QL (120 grams per

month)

lidocaine hcl soln 4%

lidocaine patch 4% OTC, QL (30 patches per

month)

lidocaine patch 5% PA

ZOSTRIX NAT CRE 0.033% OTC, QL (120 grams per

month)

DERMATOLOGY, LOCAL ANESTHETICS lidocaine-prilocaine cream 2.5-2.5% QL (30 grams per month)

lidocaine-prilocaine cream kit 2.5-2.5%


101


DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CALAMINE LOT OTC

CALAMINE LOT 8-8% OTC

docosanol cream 10% OTC

imiquimod cream 5%

podofilox soln 0.5%

SM CALAMINE LOT OTC

DERMATOLOGY, ROSACEA metronidazole cream 0.75%

metronidazole gel 0.75%

metronidazole gel 1% ST (Must have recently been on 60 days of metronidazole

0.075%)

metronidazole lotion 0.75%

DERMATOLOGY, SCABICIDES AND PEDICULICIDES malathion lotion 0.5% ST (Must have recently been

on 14 days of permethrin)

NIX CREM RIN LIQ 1% OTC

permethrin aerosol 0.5% OTC

permethrin cream 5%

permethrin creme rinse 1% OTC

permethrin lotion 1% OTC

RID AER OTC

spinosad susp 0.9% ST (Must have recently been

on 14 days of permethrin)

MOUTH/THROAT/DENTAL AGENTS, MISCELLANEOUS chlorhexidine gluconate soln 0.12%

lidocaine hcl viscous soln 2%

sodium fluoride cream 1.1%

sodium fluoride gel 1.1% (0.5% f)

sodium fluoride paste 1.1%

sodium fluoride rinse 0.2%

triamcinolone acetonide dental paste 0.1%

OPHTHALMIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY

COMBINATIONS bacitracin-polymyxin-neomycin-hc ophth oint 1%

neomycin-polymyxin-dexamethasone ophth oint

0.1%

neomycin-polymyxin-dexamethasone ophth susp

0.1%

neomycin-polymyxin-hc ophth susp

sulfacetamide sodium-prednisolone ophth soln 10-

0.23(0.25)%


102


OPHTHALMIC, ANTI-INFECTIVES bacitracin ophth oint 500 unit/gm

bacitracin-polymyxin b ophth oint

ciprofloxacin hcl ophth soln 0.3% (base equivalent)

erythromycin ophth oint 5 mg/gm

gentamicin sulfate ophth oint 0.3%

gentamicin sulfate ophth soln 0.3%

levofloxacin ophth soln 0.5%

neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin

neomycin-polymy-gramicid op sol 1.75-10000-

0.025mg-unt-mg/ml

ofloxacin ophth soln 0.3%

polymyxin b-trimethoprim ophth soln 10000

unit/ml-0.1%

sulfacetamide sodium ophth soln 10%

tobramycin ophth soln 0.3%

OPHTHALMIC, ANTI-INFLAMMATORY, Nonsteroidal diclofenac sodium ophth soln 0.1%

ketorolac tromethamine ophth soln 0.4%


OPHTHALMIC, ANTI-INFLAMMATORY, Steroidal dexamethasone sodium phosphate ophth soln

0.1%

fluorometholone ophth susp 0.1%

LOTEMAX GEL 0.5%

PRED SOD PHO SOL 1% OP

prednisolone acetate ophth susp 1%

OPHTHALMIC, ANTIALLERGICS azelastine hcl ophth soln 0.05%

cromolyn sodium ophth soln 4%

ketotifen fumarate ophth soln 0.025% (base

equiv)

OTC

OPHTHALMIC, ANTIFUNGALS NATACYN SUS 5% OP

OPHTHALMIC, ANTIVIRALS trifluridine ophth soln 1%

OPHTHALMIC, ARTIFICIAL TEARS/LUBRICANTS artificial tear ophth ointment OTC

artificial tear ophth solution OTC

carboxymethylcellulose sodium (pf) ophth gel 1% OTC


103


carboxymethylcellulose sodium (pf) ophth soln

0.5%

OTC

carboxymethylcellulose sodium ophth gel 1% OTC

carboxymethylcellulose sodium ophth soln 0.5% OTC

carboxymethylcellulose sodium ophth soln 0.25% OTC

carboxymethylcellulose-glycerin ophth soln 0.5-0.9%

OTC

dextran 70-hypromellose (pf) ophth soln 0.1-0.3% OTC

dextran 70-hypromellose ophth soln 0.1-0.3% OTC

GENTEAL GEL 0.3% OTC

GENTEAL MILD DRO 0.2% OTC

glycerin-hypromellose-peg 400 ophth soln 0.2-0.2-1%

OTC

HYPOTEARS SOL 1-1% OTC

hypromellose ophth soln 0.3% OTC

hypromellose ophth soln 0.4% OTC

LUBRICNT GEL DRO 0.25-0.3 OTC

polyethylene glycol-propylene glycol ophth soln 0.4-0.3%

OTC

polyethylene glycol-propylene glycol pf op soln

0.4-0.3%

OTC

polyvinyl alcohol ophth soln 1.4% OTC

polyvinyl alcohol-povidone (pf) ophth soln 1.4-

0.6%

OTC

polyvinyl alcohol-povidone ophth soln 5-6 mg/ml

(0.5-0.6%)

OTC

propylene glycol ophth soln 0.6% OTC

propylene glycol-glycerin ophth soln 1-0.3% OTC

REFRESH OPTI DRO 0.5-0.9% OTC

REFRESH SOL OPTIVE OTC

SYSTANE GEL 0.3% OTC

THERATEARS SOL 0.25% PF OTC

white petrolatum-mineral oil ophth ointment OTC

OPHTHALMIC, BETA-BLOCKERS, Nonselective levobunolol hcl ophth soln 0.5%

timolol maleate ophth gel forming soln 0.5%

timolol maleate ophth gel forming soln 0.25%

timolol maleate ophth soln 0.5%

timolol maleate ophth soln 0.25%

OPHTHALMIC, BETA-BLOCKERS, Selective betaxolol hcl ophth soln 0.5%


104


OPHTHALMIC, CARBONIC ANHYDRASE INHIBITOR/BETA-BLOCKER

COMBINATIONS dorzolamide hcl-timolol maleate ophth soln 22.3-

6.8 mg/ml

OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS dorzolamide hcl ophth soln 2%

OPHTHALMIC, DRY EYE DISEASE XIIDRA DRO 5%

OPHTHALMIC, MYDRIATICS ATROPINE SUL SOL 1% OP

CYCLOMYDRIL SOL OP

OPHTHALMIC, PROSTAGLANDINS latanoprost ophth soln 0.005%

OPHTHALMIC, SYMPATHOMIMETICS brimonidine tartrate ophth soln 0.2%

brimonidine tartrate ophth soln 0.15%

OTIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS CIPRODEX SUS 0.3-0.1%

neomycin-polymyxin-hc otic soln 1%

neomycin-polymyxin-hc otic susp 3.5 mg/ml-

10000 unit/ml-1%

OTIC, ANTI-INFECTIVES acetic acid otic soln 2%

ofloxacin otic soln 0.3%

105

Index A abacavir sulfate soln 20 mg/ml (base

equiv) ............................................. 11 abacavir sulfate tab 300 mg (base equiv)

..................................................... 11

abacavir sulfate-lamivudine tab 600-300 mg ................................................. 10

abacavir sulfate-lamivudine-zidovudine

tab 300-150-300 mg ........................ 10 ABILIFY MAIN INJ 300MG .................. 42

ABILIFY MAIN INJ 400MG .................. 42

ABILIFY TAB 10MG ........................... 42

ABILIFY TAB 15MG ........................... 42 ABILIFY TAB 20MG ........................... 42

ABILIFY TAB 2MG ............................. 42

ABILIFY TAB 30MG ........................... 42 ABILIFY TAB 5MG ............................. 42

abiraterone acetate tab 250 mg ......... 15 acamprosate calcium tab delayed release 333 mg ........................................... 56

acarbose tab 100 mg ........................ 58

acarbose tab 25 mg .......................... 58 acarbose tab 50 mg .......................... 58

acetaminophen cap 500 mg ................ 3 acetaminophen chew tab 160 mg ........ 3 acetaminophen chew tab 80 mg .......... 3

acetaminophen disintegrating tab 160 mg .................................................. 3

acetaminophen disintegrating tab 80 mg

...................................................... 3

acetaminophen elixir 160 mg/5ml ........ 3 acetaminophen liquid 160 mg/5ml ....... 3

acetaminophen liquid 167 mg/5ml ....... 3

acetaminophen soln 160 mg/5ml ......... 3 acetaminophen suppos 120 mg ........... 3

acetaminophen suppos 325 mg ........... 3

acetaminophen suppos 650 mg ........... 3 acetaminophen susp 160 mg/5ml ........ 3

acetaminophen susp 80 mg/0.8ml ....... 3

acetaminophen tab 325 mg ................ 3 acetaminophen tab 500 mg ................ 3

acetaminophen tab er 650 mg ............. 3

acetaminophen w/ codeine soln 120-12 mg/5ml ............................................ 5

acetaminophen w/ codeine tab 300-15

mg .................................................. 5


mg .................................................. 5


mg .................................................. 5 acetazolamide cap er 12hr 500 mg .... 25

acetazolamide tab 125 mg ................ 25

acetazolamide tab 250 mg ................ 25 acetic acid otic soln 2% ................... 104

acetic acid vaginal solution ............... 75

acyclovir cap 200 mg ....................... 14 acyclovir susp 200 mg/5ml ............... 14

acyclovir tab 400 mg ........................ 14

acyclovir tab 800 mg ........................ 14

ADACEL INJ .................................... 79 ADASUVE INH 10MG ........................ 46

adefovir dipivoxil tab 10 mg .............. 13

ADVAIR HFA AER 115/21 .................. 95 ADVAIR HFA AER 230/21 .................. 95

ADVAIR HFA AER 45/21 .................... 95 AERCHMBR PLS MIS LRG MASK ......... 93 AERCHMBR PLS MIS MED MASK ......... 93

AERCHMBR PLS MIS SM MASK ........... 93

AERCHMBR Z- MIS STAT PLS ............ 93 AEROCHAMBER MIS CHAMBER .......... 93

AEROCHAMBER MIS FLOSIGNA .......... 93 AEROCHAMBER MIS MV .................... 93 AEROCHAMBER MIS PLUS ................. 93

AFINITOR TAB 10MG ........................ 16 AFINITOR TAB 2.5MG ....................... 16

AFINITOR TAB 5MG ......................... 16

AFINITOR TAB 7.5MG ....................... 16

albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) ......................... 91

albuterol sulfate soln nebu 0.083% (2.5

mg/3ml)......................................... 92 albuterol sulfate soln nebu 0.5% (5

mg/ml) .......................................... 91

albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) ................................... 91

albuterol sulfate soln nebu 1.25 mg/3ml

(base equiv) ................................... 92 albuterol sulfate syrup 2 mg/5ml ....... 92

albuterol sulfate tab 2 mg ................. 92

albuterol sulfate tab 4 mg ................. 92 albuterol sulfate tab er 12hr 4 mg ...... 92

albuterol sulfate tab er 12hr 8 mg ...... 92

alclometasone dipropionate cream 0.05%

..................................................... 98

106

alclometasone dipropionate oint 0.05%

..................................................... 98 ALCOHOL SWAB PAD ........................ 62

ALDACTAZIDE TAB 50/50 .................. 25

ALECENSA CAP 150MG ...................... 16

alendronate sodium tab 10 mg ........... 62



alendronate sodium tab 5 mg ............. 62


alfuzosin hcl tab er 24hr 10 mg .......... 74

ALLEGRA ALRG TAB 30MG ................. 90 allopurinol tab 100 mg ....................... 3

allopurinol tab 300 mg ....................... 3

ALPRAZOLAM CON 1 MG/ML .............. 28 alprazolam orally disintegrating tab 0.25

mg ................................................. 28

alprazolam orally disintegrating tab 0.5 mg ................................................. 28

alprazolam orally disintegrating tab 1 mg ..................................................... 28

alprazolam orally disintegrating tab 2 mg

..................................................... 28

alprazolam tab 0.25 mg .................... 28 alprazolam tab 0.5 mg ...................... 28

alprazolam tab 1 mg ......................... 28 alprazolam tab 2 mg ......................... 28

alprazolam tab er 24hr 0.5 mg ........... 28 alprazolam tab er 24hr 1 mg .............. 28

alprazolam tab er 24hr 2 mg .............. 28 alprazolam tab er 24hr 3 mg .............. 28 alum & mag hydroxide-simethicone chew

tab 200-200-25 mg .......................... 69 alum & mag hydroxide-simethicone susp

200-200-20 mg/5ml ......................... 69

alum & mag hydroxide-simethicone susp 400-400-40 mg/5ml ......................... 69

aluminum hydroxide-magnesium

carbonate chew tab 160-105 mg ........ 69


carbonate susp 508-475 mg/10ml ...... 70

aluminum hydroxide-magnesium carbonate susp 95-358 mg/15ml ........ 69


trisilicate chew tab 80-20 mg ............. 70

amantadine hcl cap 100 mg ............... 41 amantadine hcl syrup 50 mg/5ml ....... 41

amantadine hcl tab 100 mg ............... 41

ambrisentan tab 10 mg .................... 27

ambrisentan tab 5 mg ...................... 27 amiloride & hydrochlorothiazide tab 5-50

mg ................................................ 25

amiloride hcl tab 5 mg ..................... 26

aminocaproic acid oral soln 0.25 gm/ml

..................................................... 76

aminocaproic acid tab 1000 mg ......... 76

aminocaproic acid tab 500 mg ........... 76

amiodarone hcl tab 100 mg .............. 21

amiodarone hcl tab 200 mg .............. 21

amiodarone hcl tab 400 mg .............. 21 amitriptyline hcl tab 10 mg ............... 40

amitriptyline hcl tab 100 mg ............. 40

amitriptyline hcl tab 150 mg ............. 40 amitriptyline hcl tab 25 mg ............... 40

amitriptyline hcl tab 50 mg ............... 40

amitriptyline hcl tab 75 mg ............... 40 amlodipine besylate tab 10 mg (base

equivalent) ..................................... 24 amlodipine besylate tab 2.5 mg (base

equivalent) ..................................... 24

amlodipine besylate tab 5 mg (base

equivalent) ..................................... 24 amlodipine besylate-benazepril hcl cap

10-20 mg ....................................... 18 amlodipine besylate-benazepril hcl cap

10-40 mg ....................................... 18 amlodipine besylate-benazepril hcl cap

2.5-10 mg ...................................... 18 amlodipine besylate-benazepril hcl cap 5-10 mg ............................................ 18

amlodipine besylate-benazepril hcl cap 5-20 mg ............................................ 18

amlodipine besylate-benazepril hcl cap 5-

40 mg ............................................ 18 amoxapine tab 100 mg ..................... 40

amoxapine tab 150 mg ..................... 40

amoxapine tab 25 mg ...................... 40

amoxapine tab 50 mg ...................... 40

amoxicillin & k clavulanate chew tab 200-

28.5 mg ........................................... 8 amoxicillin & k clavulanate chew tab 400-

57 mg .............................................. 8

amoxicillin & k clavulanate for susp 200-

28.5 mg/5ml ..................................... 8 amoxicillin & k clavulanate for susp 250-

62.5 mg/5ml ..................................... 8

107

amoxicillin & k clavulanate for susp 400-

57 mg/5ml ....................................... 8 amoxicillin & k clavulanate for susp 600-

42.9 mg/5ml .................................... 8

amoxicillin & k clavulanate tab 250-125

mg .................................................. 8


mg .................................................. 8


mg .................................................. 8

amoxicillin (trihydrate) cap 250 mg ..... 8

amoxicillin (trihydrate) cap 500 mg ..... 8 amoxicillin (trihydrate) chew tab 125 mg

...................................................... 8

amoxicillin (trihydrate) chew tab 250 mg ...................................................... 8

amoxicillin (trihydrate) for susp 125

mg/5ml ............................................ 8 amoxicillin (trihydrate) for susp 200

mg/5ml ............................................ 8 amoxicillin (trihydrate) for susp 250

mg/5ml ............................................ 8

amoxicillin (trihydrate) for susp 400

mg/5ml ............................................ 8 amoxicillin (trihydrate) tab 500 mg ...... 9

amoxicillin (trihydrate) tab 875 mg ...... 9 amphetamine-dextroamphetamine cap er

24hr 10 mg ..................................... 47 amphetamine-dextroamphetamine cap er

24hr 15 mg ..................................... 47 amphetamine-dextroamphetamine cap er 24hr 20 mg ..................................... 48

amphetamine-dextroamphetamine cap er 24hr 25 mg ..................................... 48

amphetamine-dextroamphetamine cap er

24hr 30 mg ..................................... 48 amphetamine-dextroamphetamine cap er

24hr 5 mg ....................................... 47

amphetamine-dextroamphetamine tab

10 mg ............................................ 48


12.5 mg .......................................... 48 amphetamine-dextroamphetamine tab

15 mg ............................................ 48


20 mg ............................................ 48 amphetamine-dextroamphetamine tab

30 mg ............................................ 48

amphetamine-dextroamphetamine tab 5

mg ................................................ 48 amphetamine-dextroamphetamine tab

7.5 mg ........................................... 48

ampicillin cap 500 mg ........................ 9

ANAFRANIL CAP 25MG ..................... 29

ANAFRANIL CAP 50MG ..................... 29

ANAFRANIL CAP 75MG ..................... 29

anagrelide hcl cap 0.5 mg ................. 77

anagrelide hcl cap 1 mg ................... 77

anastrozole tab 1 mg ....................... 16

ANTACID CHW 1177MG .................... 70 APIDRA INJ SOLOSTAR ..................... 60

APIDRA INJ U-100 ........................... 60

APLENZIN TAB 174MG ...................... 36 APLENZIN TAB 348MG ...................... 36

APLENZIN TAB 522MG ...................... 36

aprepitant capsule 125 mg ................ 70 aprepitant capsule 40 mg ................. 70

aprepitant capsule 80 mg ................. 70 aprepitant capsule therapy pack 80 &

125 mg .......................................... 70

APRISO CAP 0.375GM ...................... 72

APTIOM TAB 200MG ......................... 30 APTIOM TAB 400MG ......................... 30

APTIOM TAB 600MG ......................... 30 APTIOM TAB 800MG ......................... 30

APTIVUS CAP 250MG ....................... 12 APTIVUS SOL .................................. 12

aripiprazole oral solution 1 mg/ml ...... 42 aripiprazole orally disintegrating tab 10 mg ................................................ 43

aripiprazole orally disintegrating tab 15 mg ................................................ 43

aripiprazole tab 10 mg ..................... 43

aripiprazole tab 15 mg ..................... 43 aripiprazole tab 2 mg ....................... 43



aripiprazole tab 5 mg ....................... 43

ARISTADA INJ 1064MG .................... 43

ARISTADA INJ 441MG/1. .................. 43 ARISTADA INJ 662MG/2 ................... 43

ARISTADA INJ 882MG/3 ................... 43

ARISTADA INJ INITIO ...................... 43

armodafinil tab 150 mg .................... 56 armodafinil tab 200 mg .................... 56

armodafinil tab 250 mg .................... 56

108

armodafinil tab 50 mg ....................... 56

ARNUITY ELPT INH 100MCG ............... 94 ARNUITY ELPT INH 200MCG ............... 94

ARNUITY ELPT INH 50MCG ................ 94

ARTH PAIN CRE 0.075% .................. 100

artificial tear ophth ointment ............ 102

artificial tear ophth solution ............. 102

aspirin chew tab 81 mg ..................... 77

aspirin tab 325 mg ........................... 77

aspirin tab 500 mg ........................... 77

aspirin tab delayed release 325 mg ..... 77

aspirin tab delayed release 500 mg ..... 77 aspirin tab delayed release 81 mg ...... 77

ASTAGRAF XL CAP 0.5MG .................. 78

ASTAGRAF XL CAP 1MG ..................... 78 ASTAGRAF XL CAP 5MG ..................... 78

atazanavir sulfate cap 150 mg (base

equiv) ............................................. 12 atazanavir sulfate cap 200 mg (base

equiv) ............................................. 12 atazanavir sulfate cap 300 mg (base

equiv) ............................................. 12

atenolol & chlorthalidone tab 100-25 mg

..................................................... 23 atenolol & chlorthalidone tab 50-25 mg

..................................................... 23 atenolol tab 100 mg ......................... 23

atenolol tab 25 mg ........................... 23 atenolol tab 50 mg ........................... 23

ATIVAN INJ 2MG/ML ......................... 28 ATIVAN INJ 4MG/ML ......................... 28 ATIVAN TAB 0.5MG .......................... 28

ATIVAN TAB 1MG ............................. 28 ATIVAN TAB 2MG ............................. 28

atomoxetine hcl cap 10 mg (base equiv)

..................................................... 48 atomoxetine hcl cap 100 mg (base

equiv) ............................................. 49


..................................................... 48


..................................................... 48 atomoxetine hcl cap 40 mg (base equiv)

..................................................... 49


..................................................... 49 atomoxetine hcl cap 80 mg (base equiv)

..................................................... 49

atorvastatin calcium tab 10 mg (base

equivalent) ..................................... 22 atorvastatin calcium tab 20 mg (base

equivalent) ..................................... 22


equivalent) ..................................... 22


equivalent) ..................................... 22

atovaquone susp 750 mg/5ml ........... 14

atovaquone-proguanil hcl tab 250-100

mg ................................................ 10

atovaquone-proguanil hcl tab 62.5-25 mg ................................................ 10

ATRIPLA TAB .................................. 10

ATROPINE SUL SOL 1% OP .............. 104 AUBAGIO TAB 14MG ........................ 55

AUBAGIO TAB 7MG .......................... 55

AUGMENTIN SUS 125/5ML .................. 9 AUSTEDO TAB 12MG ........................ 53

AUSTEDO TAB 6MG .......................... 53 AUSTEDO TAB 9MG .......................... 53

AVONEX PEN KIT 30MCG .................. 55

AVONEX PREFL KIT 30MCG ............... 55

AYR NASAL DRO 0.65% .................... 93 AZASAN TAB 100MG ........................ 78

AZASAN TAB 75 MG ......................... 78 azathioprine tab 50 mg .................... 78

azelastine hcl nasal spray 0.1% (137 mcg/spray) ..................................... 94

azelastine hcl nasal spray 0.15% (205.5 mcg/spray) ..................................... 94 azelastine hcl ophth soln 0.05% ....... 102

azithromycin for susp 100 mg/5ml ....... 7 azithromycin for susp 200 mg/5ml ....... 7

azithromycin powd pack for susp 1 gm . 7

azithromycin tab 250 mg .................... 7 azithromycin tab 500 mg .................... 7

azithromycin tab 600 mg .................... 7

B bacitracin oint 500 unit/gm ............... 96

bacitracin ophth oint 500 unit/gm ..... 102

bacitracin zinc oint 500 unit/gm ......... 96 bacitracin-polymyxin b oint ............... 96

bacitracin-polymyxin b ophth oint ..... 102

bacitracin-polymyxin-neomycin-hc ophth

oint 1% ......................................... 101 baclofen tab 10 mg .......................... 56

baclofen tab 20 mg .......................... 56

109

balsalazide disodium cap 750 mg ........ 72

bandages: adhesive; elastic; gauze .... 81 BANZEL SUS 40MG/ML ...................... 30

BANZEL TAB 200MG ......................... 30

BANZEL TAB 400MG ......................... 30

BARACLUDE SOL .............................. 13

BASAGLAR INJ 100UNIT .................... 60

b-complex vitamin cap ...................... 84

b-complex vitamin sublingual liquid .... 84

b-complex vitamin tab ...................... 84

b-complex vitamin tab er................... 84

b-complex w/ c & calcium tab ............ 84 b-complex w/ c & e + zn tab .............. 84

b-complex w/ c & folic acid cap 1 mg .. 84

b-complex w/ c & folic acid tab ........... 84 b-complex w/ c & folic acid tab 0.8 mg 84

b-complex w/ c & folic acid tab 1 mg ... 84

b-complex w/ c & folic acid tab 5 mg ... 85 b-complex w/ c cap .......................... 85

b-complex w/ c tab ........................... 85 b-complex w/ c tab er ....................... 85

b-complex w/ c-biotin-minerals & folic

acid tab 5 mg .................................. 85

b-complex w/ folic acid cap ................ 85 b-complex w/ folic acid tab ................ 85

b-complex w/ folic acid tab er ............ 85 b-complex w/ iron tab ....................... 85

b-complex w/ minerals liq.................. 85 b-complex w/biotin & folic acid tab ..... 85

b-complex w/biotin & folic acid tab er .. 85 BD INSULIN SYRINGE 0.3/30G ........... 62 BD INSULIN SYRINGE 0.3/31G ........... 62

BD INSULIN SYRINGE 0.5/30G ........... 62 BD INSULIN SYRINGE 0.5/31G ........... 62

BD INSULIN SYRINGE 1ML/30G .......... 62

BD INSULIN SYRINGE 1ML/31G .......... 62 BD PEN NEEDL MIS 29GX12.7 ............ 62

BD PEN NEEDL MIS 31GX5MM ............ 62




BD U-500 MIS 31GX6MM ................... 62 benazepril & hydrochlorothiazide tab 10-

12.5 mg .......................................... 18

benazepril & hydrochlorothiazide tab 20-

12.5 mg .......................................... 18 benazepril & hydrochlorothiazide tab 20-

25 mg ............................................ 18

benazepril & hydrochlorothiazide tab 5-

6.25 mg ......................................... 18 benazepril hcl tab 10 mg .................. 19

benazepril hcl tab 20 mg .................. 19

benazepril hcl tab 40 mg .................. 19

benazepril hcl tab 5 mg .................... 19

benzonatate cap 100 mg .................. 91

benzonatate cap 200 mg .................. 91

BENZOYL PER GEL 2.5% ................... 95

benzoyl peroxide cream 10% ............ 96

benzoyl peroxide cream 2.5% ........... 95

benzoyl peroxide gel 10% ................. 96 benzoyl peroxide gel 5% .................. 96

benzoyl peroxide liq 10% .................. 96

benzoyl peroxide liq 2.5% ................. 96 benzoyl peroxide liq 4% ................... 96

benzoyl peroxide liq 5% ................... 96

benzoyl peroxide liq 5.25% ............... 96 benzoyl peroxide liq 6% ................... 96

benzoyl peroxide liq 7% ................... 96 benzoyl peroxide-erythromycin gel 5-3%

..................................................... 96

benztropine mesylate tab 0.5 mg ....... 41

benztropine mesylate tab 1 mg ......... 41 benztropine mesylate tab 2 mg ......... 41

betamethasone dipropionate augmented cream 0.05% .................................. 98

betamethasone dipropionate augmented gel 0.05% ...................................... 99

betamethasone dipropionate augmented lotion 0.05% ................................... 98 betamethasone dipropionate augmented

oint 0.05% ..................................... 99 betamethasone dipropionate cream

0.05% ........................................... 98

betamethasone dipropionate lotion 0.05% ........................................... 98

betamethasone dipropionate oint 0.05%

..................................................... 98

betamethasone valerate cream 0.1%

(base equivalent) ............................ 99

betamethasone valerate lotion 0.1% (base equivalent) ............................ 99

betamethasone valerate oint 0.1% (base

equivalent) ..................................... 99

BETAPACE AF TAB 120MG ................. 21 BETAPACE AF TAB 160MG ................. 21

BETAPACE AF TAB 80MG .................. 21

110

BETAPACE TAB 120MG ...................... 21

BETAPACE TAB 160MG ...................... 21 BETAPACE TAB 80MG ........................ 21

BETASERON INJ 0.3MG ..................... 55

betaxolol hcl ophth soln 0.5% .......... 103

bethanechol chloride tab 10 mg .......... 75


bethanechol chloride tab 5 mg ........... 75


BETHKIS NEB 300/4ML ..................... 92

bexarotene cap 75 mg ...................... 18

bicalutamide tab 50 mg ..................... 15 BIKTARVY TAB ................................. 10

bioflavonoid products tab .................. 85

bioflavonoid products tab er ............... 85 bisacodyl suppos 10 mg .................... 72

bisacodyl tab delayed release 5 mg ..... 72

bismuth subsalicylate chew tab 262 mg ..................................................... 70

bismuth subsalicylate susp 262 mg/15ml ..................................................... 70

bismuth subsalicylate susp 525 mg/15ml

..................................................... 70

bismuth subsalicylate tab 262 mg ....... 70 bisoprolol & hydrochlorothiazide tab 10-

6.25 mg .......................................... 23 bisoprolol & hydrochlorothiazide tab 2.5-

6.25 mg .......................................... 23 bisoprolol & hydrochlorothiazide tab 5-

6.25 mg .......................................... 23 bisoprolol fumarate tab 10 mg ........... 23 bisoprolol fumarate tab 5 mg ............. 23

BOOSTRIX INJ ................................. 79 bosentan tab 125 mg ........................ 27

bosentan tab 62.5 mg ....................... 27

brewers yeast tab ............................. 85 BRILINTA TAB 60MG ......................... 77

BRILINTA TAB 90MG ......................... 77

brimonidine tartrate ophth soln 0.15%

................................................... 104

brimonidine tartrate ophth soln 0.2% 104

BRIVIACT SOL 10MG/ML ................... 30 BRIVIACT TAB 100MG ....................... 30

BRIVIACT TAB 10MG ......................... 30

BRIVIACT TAB 25MG ......................... 30

BRIVIACT TAB 50MG ......................... 30 BRIVIACT TAB 75MG ......................... 30

bromocriptine mesylate cap 5 mg (base

equivalent) ..................................... 41

bromocriptine mesylate tab 2.5 mg (base equivalent) ..................................... 41

brompheniramine & pseudoephedrine

elixir 1-15 mg/5ml ........................... 89

budesonide delayed release particles cap

3 mg ............................................. 72

budesonide inhalation susp 0.25 mg/2ml

..................................................... 94

budesonide inhalation susp 0.5 mg/2ml

..................................................... 94

budesonide inhalation susp 1 mg/2ml . 94 budesonide nasal susp 32 mcg/act ..... 94

bumetanide tab 0.5 mg .................... 26

bumetanide tab 1 mg ....................... 26 bumetanide tab 2 mg ....................... 26

buprenorphine hcl sl tab 2 mg (base

equiv) ............................................ 57 buprenorphine hcl sl tab 8 mg (base

equiv) ............................................ 57 buprenorphine hcl-naloxone hcl sl film

12-3 mg (base equiv) ...................... 57

buprenorphine hcl-naloxone hcl sl film 2-

0.5 mg (base equiv) ........................ 57 buprenorphine hcl-naloxone hcl sl film 4-

1 mg (base equiv) ........................... 57 buprenorphine hcl-naloxone hcl sl film 8-

2 mg (base equiv) ........................... 57 buprenorphine hcl-naloxone hcl sl tab 2-

0.5 mg (base equiv) ........................ 57 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) ........................... 57

bupropion hcl (smoking deterrent) tab er 12hr 150 mg ................................... 57

bupropion hcl tab 100 mg ................. 36

bupropion hcl tab 75 mg ................... 36 bupropion hcl tab er 12hr 100 mg ...... 36

bupropion hcl tab er 12hr 150 mg ...... 36




bupropion hcl tab er 24hr 450 mg ...... 36 buspirone hcl tab 10 mg ................... 30

buspirone hcl tab 15 mg ................... 30

buspirone hcl tab 30 mg ................... 30

buspirone hcl tab 5 mg ..................... 30 buspirone hcl tab 7.5 mg .................. 30

butalbital-acetaminophen-caffeine cap

111

50-325-40 mg .................................. 4

butalbital-acetaminophen-caffeine tab 50-325-40 mg .................................. 4

butalbital-aspirin-caffeine cap 50-325-40

mg .................................................. 4

C cabergoline tab 0.5 mg ..................... 67

CABOMETYX TAB 20MG ..................... 16

CABOMETYX TAB 40MG ..................... 16

CABOMETYX TAB 60MG ..................... 16

CALAMINE LOT ............................... 101

CALAMINE LOT 8-8% ...................... 101 calcipotriene oint 0.005% .................. 97

calcipotriene soln 0.005% (50 mcg/ml)

..................................................... 97 calcitonin (salmon) nasal soln 200

unit/act ........................................... 62

calcitriol cap 0.25 mcg ...................... 67 calcitriol cap 0.5 mcg ........................ 67

calcitriol oral soln 1 mcg/ml ............... 67 calcium acetate (phosphate binder) cap

667 mg (169 mg ca) ......................... 67

calcium ascorbate tab 500 mg ............ 85

CALCIUM CARB TAB 648MG ............... 70 calcium carbonate (antacid) chew tab

1000 mg ......................................... 70 calcium carbonate (antacid) chew tab

400 mg ........................................... 70 calcium carbonate (antacid) chew tab

420 mg ........................................... 70 calcium carbonate (antacid) chew tab 500 mg ........................................... 70

calcium carbonate (antacid) chew tab 750 mg ........................................... 70

calcium carbonate (antacid) susp 1250

mg/5ml ........................................... 70 calcium carbonate chew tab 1250 mg

(500 mg elemental ca) ...................... 81


elemental ca) .................................. 82


elemental ca) .................................. 82 calcium carbonate tab 600 mg ........... 81

calcium carbonate-cholecalciferol cap

600 mg-500 unit .............................. 82

calcium carbonate-cholecalciferol chew tab 500 mg-400 unit ......................... 82

calcium carbonate-cholecalciferol chew

tab 500 mg-600 unit ........................ 82

calcium carbonate-cholecalciferol tab 250 mg-125 unit ................................... 82

calcium carbonate-cholecalciferol tab 500

mg-125 unit ................................... 82


mg-200 unit ................................... 82


mg-400 unit ................................... 82


mg-200 unit ................................... 82

calcium carbonate-cholecalciferol tab 600 mg-400 unit ................................... 82


mg-800 unit ................................... 82 calcium carbonate-mag hydroxide chew

tab 550-110 mg .............................. 70

calcium carbonate-mag hydroxide susp 400-135 mg/5ml ............................. 70

calcium carbonate-vitamin d cap 600 mg-200 unit ................................... 82

calcium carbonate-vitamin d chew tab

600 mg-400 unit ............................. 82

calcium carbonate-vitamin d tab 250 mg-125 unit ......................................... 82



calcium carbonate-vitamin d tab 500 mg-400 unit ......................................... 82 calcium carbonate-vitamin d tab 600 mg-

125 unit ......................................... 82 calcium carbonate-vitamin d tab 600 mg-

200 unit ......................................... 82


calcium citrate tab 950 mg (200 mg

elemental ca) .................................. 82

calcium citrate-vitamin d tab 200 mg-

250 unit (elemental ca) .................... 82

calcium citrate-vitamin d tab 250 mg-200 unit (elemental ca) .................... 82

calcium citrate-vitamin d tab 315 mg-

200 unit (elemental ca) .................... 82

calcium citrate-vitamin d tab 315 mg-250 unit (elemental ca) .................... 82

calcium pantothenate tab 500 mg ...... 85

112

calcium tab 500 mg .......................... 82

calcium tab 600 mg .......................... 82 calcium w/ magnesium tab 250-125 mg

..................................................... 82

calcium w/ magnesium tab 333-167 mg

..................................................... 83

calcium w/ magnesium tab 500-250 mg

..................................................... 83

calcium w/ vitamin d & k chew tab 500

mg-100 unit-40 mcg ......................... 83

calcium w/ vitamin d & k chew tab 500

mg-200 unit-40 mcg ......................... 83 calcium w/ vitamin d tab 600 mg-200

unit ................................................ 83

calcium-magnesium-zinc tab 333-133-5 mg ................................................. 83

calcium-magnesium-zinc tab 333-133-

8.3 mg ........................................... 83 calcium-mag-vit c-vit d cap 185 mg-28

mg-2.5 mg-200 unit ......................... 83 CALQUENCE CAP 100MG ................... 16

capecitabine tab 150 mg ................... 15

capecitabine tab 500 mg ................... 15

CAPRELSA TAB 100MG ...................... 16 CAPRELSA TAB 300MG ...................... 16

capsaicin cream 0.025% ................. 100 capsaicin cream 0.1% ..................... 100

CAPSAICIN LIQ 0.15% .................... 100 captopril & hydrochlorothiazide tab 25-15

mg ................................................. 18 captopril & hydrochlorothiazide tab 25-25 mg ................................................. 19

captopril & hydrochlorothiazide tab 50-15 mg ................................................. 19

captopril & hydrochlorothiazide tab 50-25

mg ................................................. 19 captopril tab 100 mg ........................ 19

captopril tab 12.5 mg ....................... 19

captopril tab 25 mg .......................... 19

captopril tab 50 mg .......................... 19

CAPZASIN GEL RELIEF .................... 100

CAPZASIN LIQ 0.15% ..................... 100 CAPZASIN-P CRE 0.035% ................ 100

carbamazepine cap er 12hr 100 mg .... 30

carbamazepine cap er 12hr 200 mg .... 30

carbamazepine cap er 12hr 300 mg .... 30 carbamazepine chew tab 100 mg ........ 30

carbamazepine susp 100 mg/5ml ....... 30

carbamazepine tab 200 mg ............... 30

carbamazepine tab er 12hr 100 mg .... 30 carbamazepine tab er 12hr 200 mg .... 30

carbamazepine tab er 12hr 400 mg .... 30

CARBATROL CAP 100MG ................... 30

CARBATROL CAP 200MG ................... 30

CARBATROL CAP 300MG ................... 30

carbidopa & levodopa orally

disintegrating tab 10-100 mg ............ 41

carbidopa & levodopa orally

disintegrating tab 25-100 mg ............ 41

carbidopa & levodopa orally disintegrating tab 25-250 mg ............ 41

carbidopa & levodopa tab 10-100 mg . 41

carbidopa & levodopa tab 25-100 mg . 41 carbidopa & levodopa tab 25-250 mg . 42


..................................................... 42 carbidopa & levodopa tab er 50-200 mg

..................................................... 42 carbidopa-levodopa-entacapone tabs

12.5-50-200 mg .............................. 42

carbidopa-levodopa-entacapone tabs

18.75-75-200 mg ............................ 42 carbidopa-levodopa-entacapone tabs 25-

100-200 mg ................................... 42 carbidopa-levodopa-entacapone tabs

31.25-125-200 mg .......................... 42 carbidopa-levodopa-entacapone tabs

37.5-150-200 mg ............................ 42 carbidopa-levodopa-entacapone tabs 50-200-200 mg ................................... 42

carboxymethylcellulose sodium (pf) ophth gel 1% ................................. 102

carboxymethylcellulose sodium (pf)

ophth soln 0.5% ............................. 103 carboxymethylcellulose sodium ophth gel

1% ............................................... 103

carboxymethylcellulose sodium ophth

soln 0.25% .................................... 103

carboxymethylcellulose sodium ophth

soln 0.5% ...................................... 103 carboxymethylcellulose-glycerin ophth

soln 0.5-0.9% ................................ 103

carisoprodol tab 250 mg ................... 56

carisoprodol tab 350 mg ................... 56 carvedilol tab 12.5 mg ..................... 23

carvedilol tab 25 mg ........................ 23

113

carvedilol tab 3.125 mg ..................... 23

carvedilol tab 6.25 mg ...................... 23 CASTIVA LOT ................................. 100

cefadroxil cap 500 mg ........................ 7

cefadroxil for susp 250 mg/5ml ........... 7

cefadroxil for susp 500 mg/5ml ........... 7

cefadroxil tab 1 gm ............................ 7

cefdinir cap 300 mg ........................... 7

cefdinir for susp 125 mg/5ml .............. 7

cefdinir for susp 250 mg/5ml .............. 7

cefprozil for susp 125 mg/5ml ............. 7

cefprozil for susp 250 mg/5ml ............. 7 cefprozil tab 250 mg .......................... 7

cefprozil tab 500 mg .......................... 7

cefuroxime axetil tab 250 mg .............. 7 cefuroxime axetil tab 500 mg .............. 7

celecoxib cap 100 mg ........................ 3

celecoxib cap 200 mg ........................ 3 celecoxib cap 400 mg ........................ 3

celecoxib cap 50 mg .......................... 3 CELEXA TAB 10MG ........................... 37

CELEXA TAB 20MG ........................... 37

CELEXA TAB 40MG ........................... 37

CELLCEPT CAP 250MG ....................... 78 CELLCEPT SUS 200MG/ML ................. 78

CELLCEPT TAB 500MG ....................... 78 CELONTIN CAP 300MG ...................... 30

cephalexin cap 250 mg ...................... 7 cephalexin cap 500 mg ...................... 7

cephalexin cap 750 mg ...................... 7 cephalexin for susp 125 mg/5ml .......... 7 cephalexin for susp 250 mg/5ml .......... 7

cephalexin tab 250 mg ....................... 7 cephalexin tab 500 mg ....................... 7

CERDELGA CAP 84MG ....................... 65

cetirizine hcl cap 10 mg ..................... 89 cetirizine hcl chew tab 10 mg ............. 89

cetirizine hcl chew tab 5 mg ............... 89

cetirizine hcl oral soln 1 mg/ml (5

mg/5ml) ......................................... 89

cetirizine hcl tab 10 mg ..................... 89

cetirizine hcl tab 5 mg ....................... 89 cetirizine-pseudoephedrine tab er 12hr

5-120 mg ........................................ 89

CHANTIX PAK 0.5& 1MG .................... 57

CHANTIX PAK 1MG ........................... 57 CHANTIX TAB 0.5MG ........................ 57

CHANTIX TAB 1MG ........................... 57

CHEMET CAP 100MG ........................ 76

CHEMSTRIP 10 TES MD .................... 81 CHEMSTRIP 2 TES GP ....................... 81

CHEMSTRIP 5 TES OB ...................... 81

CHEMSTRIP 7 TES ........................... 81

CHEMSTRIP 9 TES STRIPS ................ 81

CHEMSTRIP TES -10 SG ................... 81

chlordiazepoxide hcl cap 10 mg ......... 28

chlordiazepoxide hcl cap 25 mg ......... 28

chlordiazepoxide hcl cap 5 mg ........... 28

chlordiazepoxide hcl-clidinium bromide

cap 5-2.5 mg .................................. 71 chlordiazepoxide-amitriptyline tab 10-25

mg ................................................ 36

chlordiazepoxide-amitriptyline tab 5-12.5 mg ................................................ 36

chlorhexidine gluconate soln 0.12% .. 101

chloroquine phosphate tab 250 mg .... 10 chloroquine phosphate tab 500 mg .... 10

chlorpheniramine maleate syrup 2 mg/5ml .......................................... 90

chlorpheniramine maleate tab 4 mg ... 90

chlorpheniramine maleate tab er 12 mg

..................................................... 90 CHLORPROMAZ INJ 25MG/ML ............ 46

CHLORPROMAZ INJ 50MG/2ML .......... 46 chlorpromazine hcl tab 10 mg ........... 46

chlorpromazine hcl tab 100 mg .......... 46 chlorpromazine hcl tab 200 mg .......... 46

chlorpromazine hcl tab 25 mg ........... 46 chlorpromazine hcl tab 50 mg ........... 46 chlorthalidone tab 25 mg .................. 26

chlorthalidone tab 50 mg .................. 26 chlorzoxazone tab 500 mg ................ 56

cholecalciferol cap 1.25 mg (50000 unit)

..................................................... 85 cholecalciferol cap 10 mcg (400 unit) . 85

cholecalciferol cap 125 mcg (5000 unit)

..................................................... 85

cholecalciferol cap 25 mcg (1000 unit) 85

cholecalciferol cap 250 mcg (10000 unit)

..................................................... 85 cholecalciferol cap 50 mcg (2000 unit) 85

cholecalciferol chew tab 10 mcg (400

unit) .............................................. 85

cholecalciferol chew tab 125 mcg (5000 unit) .............................................. 85

cholecalciferol chew tab 25 mcg (1000

114

unit) ............................................... 85

cholecalciferol chew tab 50 mcg (2000 unit) ............................................... 85

cholecalciferol drops 10 mcg/0.03ml

(400 unit/0.03ml) ............................ 85

cholecalciferol drops 125 mcg/ml (5000

unit/ml) .......................................... 85

cholecalciferol drops 50 mcg/0.03ml

(2000 unit/0.03ml) ........................... 85

cholecalciferol oral liquid 10 mcg/ml (400

unit/ml) .......................................... 85

cholecalciferol tab 1.25 mg (50000 unit) ..................................................... 85

cholecalciferol tab 10 mcg (400 unit) .. 85

cholecalciferol tab 125 mcg (5000 unit) ..................................................... 85

cholecalciferol tab 25 mcg (1000 unit) . 85

cholecalciferol tab 50 mcg (2000 unit) . 85 cholestyramine light powder 4 gm/dose

..................................................... 22 cholestyramine light powder packets 4

gm ................................................. 22

cholestyramine powder 4 gm/dose ...... 22

cholestyramine powder packets 4 gm .. 22 ciclopirox gel 0.77% ......................... 97

ciclopirox olamine cream 0.77% (base equiv) ............................................. 97

ciclopirox olamine susp 0.77% (base equiv) ............................................. 97

ciclopirox shampoo 1% ..................... 97 cilostazol tab 100 mg ........................ 76 cilostazol tab 50 mg .......................... 76

CIMDUO TAB 300-300 ....................... 10 cimetidine hcl soln 300 mg/5ml .......... 71

cimetidine tab 200 mg ...................... 71

cimetidine tab 300 mg ...................... 71 cimetidine tab 400 mg ...................... 71

cimetidine tab 800 mg ...................... 72

CIPRODEX SUS 0.3-0.1% ................ 104

ciprofloxacin hcl ophth soln 0.3% (base

equivalent) .................................... 102

ciprofloxacin hcl tab 100 mg (base equiv) ...................................................... 8


...................................................... 8

ciprofloxacin hcl tab 500 mg (base equiv) ...................................................... 8


....................................................... 8

citalopram hydrobromide oral soln 10 mg/5ml .......................................... 37

citalopram hydrobromide tab 10 mg

(base equiv) ................................... 37


(base equiv) ................................... 37


(base equiv) ................................... 37

CITRANATAL CAP HARMONY .............. 88

CITRANATAL CAP MEDLEY ................. 88

CITRANATAL MIS ............................. 88 CITRANATAL MIS 90 DHA ................. 88

CITRANATAL MIS B-CALM ................. 88

CITRANATAL PAK ASSURE ................ 88 CITRANATAL PAK DHA ...................... 88

CITRANATAL TAB BLOOM .................. 88

CITRANATAL TAB RX ........................ 88 claravis cap 10mg ............................ 95

claravis cap 20mg ............................ 95 claravis cap 30mg ............................ 95

claravis cap 40mg ............................ 95

clarithromycin for susp 125 mg/5ml ..... 7

clarithromycin for susp 250 mg/5ml ..... 7 clarithromycin tab 250 mg .................. 8

clarithromycin tab 500 mg .................. 8 clarithromycin tab er 24hr 500 mg ....... 8

CLARITIN RDT TAB 5MG ................... 90 clemastine fumarate tab 1.34 mg (1 mg

base equiv) .................................... 90 clemastine fumarate tab 2.68 mg ...... 90 clindamycin hcl cap 150 mg .............. 14

clindamycin hcl cap 300 mg .............. 14 clindamycin palmitate hcl for soln 75

mg/5ml (base equiv) ....................... 14

clindamycin phosphate gel 1% .......... 96 clindamycin phosphate lotion 1% ....... 96

clindamycin phosphate soln 1% ......... 96

clindamycin phosphate vaginal cream 2%

..................................................... 75

clobazam suspension 2.5 mg/ml ........ 30

clobazam tab 10 mg ........................ 30 clobazam tab 20 mg ........................ 31

clobetasol propionate cream 0.05% ... 99

clobetasol propionate foam 0.05% ..... 99

clobetasol propionate gel 0.05% ........ 99 clobetasol propionate oint 0.05% ....... 99

clobetasol propionate soln 0.05% ...... 99

115

clomipramine hcl cap 25 mg .............. 30

clomipramine hcl cap 50 mg .............. 30 clomipramine hcl cap 75 mg .............. 30

clonazepam orally disintegrating tab

0.125 mg ........................................ 29

clonazepam orally disintegrating tab 0.25

mg ................................................. 28

clonazepam orally disintegrating tab 0.5

mg ................................................. 28

clonazepam orally disintegrating tab 1

mg ................................................. 29

clonazepam orally disintegrating tab 2 mg ................................................. 29

clonazepam tab 0.5 mg ..................... 29

clonazepam tab 1 mg ........................ 29 clonazepam tab 2 mg ........................ 29

clonidine hcl tab 0.1 mg .................... 20

clonidine hcl tab 0.2 mg .................... 20 clonidine hcl tab 0.3 mg .................... 20

clonidine td patch weekly 0.1 mg/24hr 20 clonidine td patch weekly 0.2 mg/24hr 20

clonidine td patch weekly 0.3 mg/24hr 20

clopidogrel bisulfate tab 300 mg (base

equiv) ............................................. 77 clopidogrel bisulfate tab 75 mg (base

equiv) ............................................. 77 clorazepate dipotassium tab 15 mg ..... 29

clorazepate dipotassium tab 3.75 mg .. 29 clorazepate dipotassium tab 7.5 mg .... 29

clotrimazole cream 1% ..................... 97 clotrimazole soln 1% ........................ 97 clotrimazole troche 10 mg .................. 9

clotrimazole vaginal cream 1% ........... 75 clotrimazole vaginal cream 2% ........... 75

clozapine orally disintegrating tab 100

mg ................................................. 43 clozapine orally disintegrating tab 12.5

mg ................................................. 43


mg ................................................. 43


mg ................................................. 43 clozapine orally disintegrating tab 25 mg

..................................................... 43

clozapine tab 100 mg ........................ 43

clozapine tab 200 mg ........................ 43 clozapine tab 25 mg ......................... 43

clozapine tab 50 mg ......................... 43

CLOZARIL TAB 100MG ...................... 43

CLOZARIL TAB 25MG ....................... 43 cod liver oil cap ............................... 85

colchicine tab 0.6 mg ......................... 3

colestipol hcl granule packets 5 gm .... 22

colestipol hcl granules 5 gm .............. 22

colestipol hcl tab 1 gm ..................... 22

COMBIPATCH DIS ............................ 65

COMBISTIX TES .............................. 81

COMBIVENT AER 20-100 .................. 89

COMBIVIR TAB 150-300 ................... 10

COMETRIQ KIT 100MG ..................... 16 COMETRIQ KIT 140MG ..................... 16

COMETRIQ KIT 60MG ....................... 16

COMPLERA TAB ............................... 10 CONDOMS MIS ................................ 63

COPAXONE INJ 40MG/ML .................. 55

CORLANOR TAB 5MG........................ 26 CORLANOR TAB 7.5MG ..................... 26

COUMADIN TAB 10MG ...................... 76 COUMADIN TAB 1MG ....................... 76

COUMADIN TAB 2.5MG ..................... 76

COUMADIN TAB 2MG ....................... 76

COUMADIN TAB 3MG ....................... 76 COUMADIN TAB 4MG ....................... 76

COUMADIN TAB 5MG ....................... 76 COUMADIN TAB 6MG ....................... 76

COUMADIN TAB 7.5MG ..................... 76 CREON CAP 12000UNT ..................... 73

CREON CAP 24000UNT ..................... 73 CREON CAP 3000UNIT ...................... 73 CREON CAP 36000UNT ..................... 73

CREON CAP 6000UNIT ...................... 73 CRINONE GEL 4% VAG ..................... 68

CRINONE GEL 8% VAG ..................... 68

CRIXIVAN CAP 200MG ...................... 12 CRIXIVAN CAP 400MG ...................... 12

cromolyn sodium nasal aerosol soln 5.2

mg/act (4%) ................................... 93

cromolyn sodium ophth soln 4% ....... 102

cromolyn sodium soln nebu 20 mg/2ml

..................................................... 93 CUTTER BACKW AER 25% ............... 100

CUVPOSA SOL 1MG/5ML ................... 73

CVS NASAL SPR MIST ...................... 93

cyanocobalamin inj 1000 mcg/ml ....... 85 cyclobenzaprine hcl tab 10 mg .......... 56

cyclobenzaprine hcl tab 5 mg ............ 56

116

CYCLOMYDRIL SOL OP .................... 104

cyclophosphamide cap 25 mg............. 15 cyclophosphamide cap 50 mg............. 15

cyclosporine cap 100 mg ................... 78

cyclosporine cap 25 mg ..................... 78

cyclosporine modified cap 100 mg ...... 78

cyclosporine modified cap 25 mg ........ 78

cyclosporine modified cap 50 mg ........ 78

cyclosporine modified oral soln 100

mg/ml ............................................ 78

CYMBALTA CAP 20MG ....................... 39

CYMBALTA CAP 30MG ....................... 39 CYMBALTA CAP 60MG ....................... 39

cyproheptadine hcl syrup 2 mg/5ml .... 90

cyproheptadine hcl tab 4 mg .............. 90 CYSTAGON CAP 150MG ..................... 67

CYSTAGON CAP 50MG ....................... 67

CYTOMEL TAB 25MCG ....................... 68 CYTOMEL TAB 50MCG ....................... 68

CYTOMEL TAB 5MCG ......................... 68 D dalfampridine tab er 12hr 10 mg ........ 55

danazol cap 100 mg ................... 58, 64

danazol cap 200 mg ................... 58, 64 danazol cap 50 mg ..................... 58, 64

dantrolene sodium cap 100 mg .......... 56 dantrolene sodium cap 25 mg ............ 56

dantrolene sodium cap 50 mg ............ 56 dapsone tab 100 mg ......................... 14

dapsone tab 25 mg ........................... 14 DAPTACEL INJ .................................. 79 DARAPRIM TAB 25MG ....................... 14

DDAVP SOL 0.01% ........................... 69 demeclocycline hcl tab 150 mg ............ 9

demeclocycline hcl tab 300 mg ............ 9

DEPAKENE CAP 250MG ..................... 31 DEPAKOTE ER TAB 250MG ................. 31

DEPAKOTE ER TAB 500MG ................. 31

DEPAKOTE SPR CAP 125MG ............... 31

DEPAKOTE TAB 125MG DR ................ 31

DEPAKOTE TAB 250MG DR ................ 31

DEPAKOTE TAB 500MG DR ................ 31 DESCOVY TAB 200/25 ....................... 10

desipramine hcl tab 10 mg ................ 40

desipramine hcl tab 100 mg ............... 40

desipramine hcl tab 150 mg ............... 40 desipramine hcl tab 25 mg ................ 40



desmopressin acetate nasal spray soln 0.01% ........................................... 69

desmopressin acetate nasal spray soln

0.01% (refrigerated) ........................ 69

desmopressin acetate tab 0.1 mg ...... 69

desmopressin acetate tab 0.2 mg ...... 69

desogest-eth estrad & eth estrad tab

0.15-0.02/0.01 mg(21/5) ................. 63

desogest-ethin est tab 0.1-0.025/0.125-

0.025/0.15-0.025mg-mg .................. 64

desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg ..................................... 63

desonide cream 0.05% ..................... 98

desonide lotion 0.05% ...................... 98 desonide oint 0.05% ........................ 98

desoximetasone cream 0.05% ........... 99

desoximetasone cream 0.25% ........... 98 desoximetasone gel 0.05% ............... 98

desoximetasone oint 0.25% .............. 98 DESVENLAFAX TAB 100MG ER ........... 39

DESVENLAFAX TAB 50MG ER ............. 39

desvenlafaxine succinate tab er 24hr 100

mg (base equiv) .............................. 39 desvenlafaxine succinate tab er 24hr 25

mg (base equiv) .............................. 39 desvenlafaxine succinate tab er 24hr 50

mg (base equiv) .............................. 39 desvenlafaxine tab er 24hr 100 mg .... 39

desvenlafaxine tab er 24hr 50 mg ...... 39 dexamethasone elixir 0.5 mg/5ml ...... 65 dexamethasone sodium phosphate ophth

soln 0.1% ...................................... 102 dexamethasone soln 0.5 mg/5ml ....... 65

dexamethasone tab 0.5 mg ............... 65

dexamethasone tab 0.75 mg ............. 65 dexamethasone tab 1 mg ................. 65

dexamethasone tab 1.5 mg ............... 65

dexamethasone tab 2 mg ................. 65



dexmethylphenidate hcl tab 10 mg .... 49 dexmethylphenidate hcl tab 2.5 mg ... 49

dexmethylphenidate hcl tab 5 mg ...... 49

dextran 70-hypromellose (pf) ophth soln

0.1-0.3% ...................................... 103 dextran 70-hypromellose ophth soln 0.1-

0.3% ............................................ 103

117

dextroamphetamine sulfate cap er 24hr

10 mg ............................................ 49 dextroamphetamine sulfate cap er 24hr

15 mg ............................................ 49

dextroamphetamine sulfate cap er 24hr 5

mg ................................................. 49

dextroamphetamine sulfate tab 10 mg 50

dextroamphetamine sulfate tab 5 mg .. 49

dextromethorphan-guaifenesin liquid 10-

100 mg/5ml .................................... 91


200 mg/5ml .................................... 91 dextromethorphan-guaifenesin liquid 20-

300 mg/5ml .................................... 91

dextromethorphan-guaifenesin liquid 30-200 mg/5ml .................................... 91


100 mg/5ml .................................... 90 dextromethorphan-guaifenesin syrup 10-

100 mg/5ml .................................... 91 dextromethorphan-guaifenesin tab er

12hr 30-600 mg ............................... 91

dextromethorphan-guaifenesin tab er

12hr 60-1200 mg ............................. 91 DIAPHRAGM .................................... 63

DIASTAT ACDL GEL 12.5-20 .............. 31 DIASTAT ACDL GEL 5-10MG .............. 31

DIASTAT PED GEL 2.5M GEL .............. 31 diazepam conc 5 mg/ml .................... 29

DIAZEPAM INJ 10MG/2ML .................. 29 diazepam inj 5 mg/ml ....................... 29 diazepam oral soln 1 mg/ml ............... 29

diazepam rectal gel delivery system 10 mg ................................................. 31

diazepam rectal gel delivery system 2.5

mg ................................................. 31 diazepam rectal gel delivery system 20

mg ................................................. 31

diazepam tab 10 mg ......................... 29

diazepam tab 2 mg ........................... 29

diazepam tab 5 mg ........................... 29

diclofenac potassium tab 50 mg .......... 4 diclofenac sodium gel 1% ................... 5

diclofenac sodium ophth soln 0.1% ... 102

diclofenac sodium tab delayed release 25

mg .................................................. 4 diclofenac sodium tab delayed release 50

mg .................................................. 4

diclofenac sodium tab delayed release 75

mg .................................................. 4 diclofenac sodium tab er 24hr 100 mg .. 4

dicloxacillin sodium cap 250 mg ........... 9

dicloxacillin sodium cap 500 mg ........... 9

dicyclomine hcl cap 10 mg ................ 71

dicyclomine hcl oral soln 10 mg/5ml ... 71

dicyclomine hcl tab 20 mg ................ 71

didanosine delayed release capsule 200

mg ................................................ 11

didanosine delayed release capsule 250

mg ................................................ 11 didanosine delayed release capsule 400

mg ................................................ 11

diflunisal tab 500 mg ......................... 4 digoxin oral soln 0.05 mg/ml ............. 25

digoxin tab 125 mcg (0.125 mg)........ 25

digoxin tab 250 mcg (0.25 mg) ......... 25 DILANTIN CAP 100MG ...................... 31

DILANTIN CAP 30MG ........................ 31 DILANTIN CHW 50MG ...................... 31

DILANTIN-125 SUS 125/5ML ............. 31

diltiazem hcl cap er 12hr 120 mg ....... 24

diltiazem hcl cap er 12hr 60 mg ......... 24 diltiazem hcl cap er 12hr 90 mg ......... 24

diltiazem hcl cap er 24hr 120 mg ....... 24 diltiazem hcl cap er 24hr 180 mg ....... 24

diltiazem hcl cap er 24hr 240 mg ....... 24 diltiazem hcl coated beads cap er 24hr

120 mg .......................................... 24 diltiazem hcl coated beads cap er 24hr 180 mg .......................................... 25

diltiazem hcl coated beads cap er 24hr 240 mg .......................................... 25

diltiazem hcl coated beads cap er 24hr

300 mg .......................................... 25 diltiazem hcl coated beads cap er 24hr

360 mg .......................................... 25

diltiazem hcl coated beads tab er 24hr

180 mg .......................................... 25


240 mg .......................................... 25 diltiazem hcl coated beads tab er 24hr

300 mg .......................................... 25


360 mg .......................................... 25 diltiazem hcl coated beads tab er 24hr

420 mg .......................................... 25

118

diltiazem hcl extended release beads cap

er 24hr 120 mg ................................ 25 diltiazem hcl extended release beads cap

er 24hr 180 mg ................................ 25


er 24hr 240 mg ................................ 25


er 24hr 300 mg ................................ 25


er 24hr 360 mg ................................ 25


er 24hr 420 mg ................................ 25 diltiazem hcl tab 120 mg ................... 25

diltiazem hcl tab 30 mg ..................... 25

diltiazem hcl tab 60 mg ..................... 25 diltiazem hcl tab 90 mg ..................... 25

DIP/TET PED INJ 25-5LFU .................. 79

diphenhydramine hcl (sleep) cap 50 mg ..................................................... 53

diphenhydramine hcl (sleep) tab 25 mg ..................................................... 53

diphenhydramine hcl (sleep) tab 50 mg

..................................................... 53

diphenhydramine hcl cap 25 mg ......... 90 diphenhydramine hcl cap 50 mg ......... 90

diphenhydramine hcl chew tab 12.5 mg ..................................................... 90

diphenhydramine hcl elixir 12.5 mg/5ml ..................................................... 90

diphenhydramine hcl liquid 12.5 mg/5ml ..................................................... 90 diphenhydramine hcl syrup 12.5 mg/5ml

..................................................... 90 diphenhydramine hcl tab 25 mg ......... 90

diphenhydramine hcl tab disint 12.5 mg

..................................................... 90 diphenoxylate w/ atropine liq 2.5-0.025

mg/5ml ........................................... 70

diphenoxylate w/ atropine tab 2.5-0.025

mg ................................................. 70

dipyridamole tab 25 mg .................... 77

dipyridamole tab 50 mg .................... 77 dipyridamole tab 75 mg .................... 77

disopyramide phosphate cap 100 mg .. 21

disopyramide phosphate cap 150 mg .. 21

disulfiram tab 250 mg ....................... 56 disulfiram tab 500 mg ....................... 56

divalproex sodium cap delayed release

sprinkle 125 mg .............................. 31

divalproex sodium tab delayed release 125 mg .......................................... 31

divalproex sodium tab delayed release

250 mg .......................................... 31

divalproex sodium tab delayed release

500 mg .......................................... 31


..................................................... 31


..................................................... 31

docosanol cream 10% ..................... 101 docusate calcium cap 240 mg ............ 72

docusate sodium cap 100 mg ............ 72

docusate sodium cap 250 mg ............ 72 docusate sodium cap 50 mg .............. 72

docusate sodium liquid 150 mg/15ml . 72

docusate sodium syrup 60 mg/15ml ... 72 docusate sodium tab 100 mg ............ 72

dofetilide cap 125 mcg (0.125 mg) .... 21 dofetilide cap 250 mcg (0.25 mg) ...... 21

dofetilide cap 500 mcg (0.5 mg) ........ 21

donepezil hydrochloride orally

disintegrating tab 10 mg .................. 35 donepezil hydrochloride orally

disintegrating tab 5 mg .................... 35 donepezil hydrochloride tab 10 mg ..... 35

donepezil hydrochloride tab 23 mg ..... 35 donepezil hydrochloride tab 5 mg ...... 35

dorzolamide hcl ophth soln 2% ......... 104 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml ....................... 104

doxazosin mesylate tab 1 mg ............ 20 doxazosin mesylate tab 2 mg ............ 20

doxazosin mesylate tab 4 mg ............ 20

doxazosin mesylate tab 8 mg ............ 20 doxepin hcl cap 10 mg ..................... 40

doxepin hcl cap 100 mg .................... 40

doxepin hcl cap 150 mg .................... 40

doxepin hcl cap 25 mg ..................... 40

doxepin hcl cap 50 mg ..................... 40

doxepin hcl cap 75 mg ..................... 40 doxepin hcl conc 10 mg/ml ............... 40

doxercalciferol cap 0.5 mcg ............... 67

doxercalciferol cap 1 mcg ................. 67

doxercalciferol cap 2.5 mcg ............... 67 doxycycline hyclate cap 100 mg .......... 9

doxycycline hyclate cap 50 mg ............ 9

119

doxycycline hyclate tab 100 mg ........... 9

doxycycline hyclate tab 20 mg ............ 9 doxycycline monohydrate for susp 25

mg/5ml ............................................ 9

doxylamine succinate (sleep) tab 25 mg

..................................................... 53

dronabinol cap 10 mg ....................... 70

dronabinol cap 2.5 mg ...................... 70

dronabinol cap 5 mg ......................... 70

drospirenone-ethinyl estradiol tab 3-0.02

mg ................................................. 63

drospirenone-ethinyl estradiol tab 3-0.03 mg ................................................. 63

DULERA AER 100-5MCG .................... 95

DULERA AER 200-5MCG .................... 95 duloxetine hcl enteric coated pellets cap

20 mg (base eq) .............................. 39

duloxetine hcl enteric coated pellets cap 30 mg (base eq) .............................. 39

duloxetine hcl enteric coated pellets cap 40 mg (base eq) .............................. 39

duloxetine hcl enteric coated pellets cap

60 mg (base eq) .............................. 39

E EDURANT TAB 25MG ......................... 11

efavirenz cap 200 mg ....................... 11 efavirenz cap 50 mg ......................... 11

efavirenz tab 600 mg ........................ 11 EFFEXOR XR CAP 150MG ................... 39

EFFEXOR XR CAP 37.5MG .................. 39 EFFEXOR XR CAP 75MG ..................... 39 ELIQUIS TAB 2.5MG ......................... 76

ELIQUIS TAB 5MG ............................ 76 ELIXOPHYLLIN ELX 80/15ML .............. 95

ELLA TAB 30MG ............................... 63

ELMIRON CAP 100MG ....................... 75 EMSAM DIS 12MG/24H ..................... 37

EMSAM DIS 6MG/24HR ..................... 37

EMSAM DIS 9MG/24HR ..................... 37

EMTRIVA CAP 200MG ........................ 11

EMTRIVA SOL 10MG/ML .................... 11

EMVERM CHW 100MG ....................... 14 enalapril maleate & hydrochlorothiazide

tab 10-25 mg .................................. 19

enalapril maleate & hydrochlorothiazide

tab 5-12.5 mg ................................. 19 enalapril maleate tab 10 mg .............. 19

enalapril maleate tab 2.5 mg ............. 19

enalapril maleate tab 20 mg .............. 19

enalapril maleate tab 5 mg ............... 19 ENBREL INJ 25/0.5ML ...................... 77

ENBREL INJ 25MG ........................... 77

ENBREL INJ 50MG/ML ...................... 77

ENBREL MINI INJ 50MG/ML ............... 77

ENBREL SRCLK INJ 50MG/ML ............ 77

ENCARE SUP 100MG ........................ 63

ENDARI POW 5GM ........................... 76

ENGERIX-B INJ 10/0.5ML ................. 79

ENGERIX-B INJ 20MCG/ML ................ 79

entacapone tab 200 mg .................... 42 entecavir tab 0.5 mg ........................ 13

entecavir tab 1 mg .......................... 13

ENTRESTO TAB 24-26MG .................. 26 ENTRESTO TAB 49-51MG .................. 26

ENTRESTO TAB 97-103MG ................ 26

ENVARSUS XR TAB 0.75MG ............... 78 ENVARSUS XR TAB 1MG ................... 79

ENVARSUS XR TAB 4MG ................... 79 epinephrine solution auto-injector 0.15

mg/0.15ml (1:1000) ........................ 89

epinephrine solution auto-injector 0.3

mg/0.3ml (1:1000) .......................... 89 EPIPEN 2-PAK INJ 0.3MG .................. 89

EPIPEN-JR INJ 0.15MG ..................... 89 epitol tab 200mg ............................. 31

EPIVIR SOL 10MG/ML ....................... 12 EPIVIR TAB 150MG .......................... 12

EPIVIR TAB 300MG .......................... 12 eplerenone tab 25 mg ...................... 20 eplerenone tab 50 mg ...................... 20

EPZICOM TAB 600-300 ..................... 10 EQUETRO CAP 100MG ...................... 55

EQUETRO CAP 200MG ...................... 55

EQUETRO CAP 300MG ...................... 55 ergocalciferol cap 1.25 mg (50000 unit)

..................................................... 85

ergocalciferol soln 200 mcg/ml (8000

unit/ml) ......................................... 85

ergotamine w/ caffeine tab 1-100 mg . 54

ERIVEDGE CAP 150MG ..................... 18 erlotinib hcl tab 100 mg (base

equivalent) ..................................... 16

erlotinib hcl tab 150 mg (base

equivalent) ..................................... 16 erlotinib hcl tab 25 mg (base equivalent)

..................................................... 16

120

erythromycin ethylsuccinate for susp 200

mg/5ml ............................................ 8 erythromycin ethylsuccinate tab 400 mg

...................................................... 8

erythromycin gel 2% ........................ 96

erythromycin ophth oint 5 mg/gm .... 102

erythromycin soln 2% ....................... 96

erythromycin stearate tab 250 mg ....... 8

erythromycin tab 250 mg ................... 8

erythromycin tab 500 mg ................... 8

erythromycin tab delayed release 250

mg .................................................. 8 erythromycin tab delayed release 333

mg .................................................. 8

erythromycin tab delayed release 500 mg .................................................. 8

erythromycin w/ delayed release

particles cap 250 mg ......................... 8 escitalopram oxalate soln 5 mg/5ml

(base equiv) .................................... 37 escitalopram oxalate tab 10 mg (base

equiv) ............................................. 37

escitalopram oxalate tab 20 mg (base

equiv) ............................................. 37 escitalopram oxalate tab 5 mg (base

equiv) ............................................. 37 esomeprazole magnesium cap delayed

release 20 mg (base eq) ................... 74 estradiol & norethindrone acetate tab

0.5-0.1 mg ...................................... 64 estradiol & norethindrone acetate tab 1-0.5 mg ........................................... 64

estradiol tab 0.5 mg ......................... 65 estradiol tab 1 mg ............................ 65

estradiol tab 2 mg ............................ 65

estradiol td patch weekly 0.025 mg/24hr ..................................................... 65

estradiol td patch weekly 0.0375

mg/24hr (37.5 mcg/24hr) ................. 65

estradiol td patch weekly 0.05 mg/24hr

..................................................... 65

estradiol td patch weekly 0.06 mg/24hr ..................................................... 65

estradiol td patch weekly 0.075 mg/24hr

..................................................... 65

estradiol td patch weekly 0.1 mg/24hr 65 estradiol vaginal tab 10 mcg .............. 65

ethambutol hcl tab 100 mg ................ 13

ethambutol hcl tab 400 mg ............... 13

ethosuximide cap 250 mg ................. 31 ethosuximide soln 250 mg/5ml .......... 31

ethynodiol diacetate & ethinyl estradiol

tab 1 mg-35 mcg ............................. 64

ethynodiol diacetate & ethinyl estradiol

tab 1 mg-50 mcg ............................. 64

etodolac cap 200 mg .......................... 4

etodolac cap 300 mg .......................... 4

etodolac tab 400 mg .......................... 4

etodolac tab 500 mg .......................... 4

etodolac tab er 24hr 400 mg ............... 4 etodolac tab er 24hr 500 mg ............... 4

etodolac tab er 24hr 600 mg ............... 4

etoposide cap 50 mg ........................ 18 EVOTAZ TAB 300-150 ...................... 10

exemestane tab 25 mg ..................... 16

EXTAVIA INJ 0.3MG ......................... 55 ezetimibe tab 10 mg ........................ 22

F famciclovir tab 125 mg ..................... 14

famciclovir tab 250 mg ..................... 14

famciclovir tab 500 mg ..................... 14

famotidine for susp 40 mg/5ml .......... 72 famotidine tab 10 mg ....................... 72

famotidine tab 20 mg ....................... 72 famotidine tab 40 mg ....................... 72

FANAPT PAK ................................... 43 FANAPT TAB 10MG ........................... 43

FANAPT TAB 12MG ........................... 43 FANAPT TAB 1MG ............................ 43 FANAPT TAB 2MG ............................ 43

FANAPT TAB 4MG ............................ 43 FANAPT TAB 6MG ............................ 43

FANAPT TAB 8MG ............................ 43

FANATREX SUS 25MG/ML ................. 31 FARYDAK CAP 10MG ........................ 18

FARYDAK CAP 15MG ........................ 18

FARYDAK CAP 20MG ........................ 18

FAZACLO TAB 100 ODT .................... 43

FAZACLO TAB 12.5 ODT ................... 43

FAZACLO TAB 150 ODT .................... 43 FAZACLO TAB 200 ODT .................... 43

FAZACLO TAB 25MG ODT .................. 43

fe bisglyc-vit c-vit b12-folic acid cap 28-

60-0.008-0.4 mg ............................. 83 fe fumarate w/ b12-vit c-fa-ifc cap 110-

0.015-75-0.5-240 mg ...................... 83

121

fe fumarate-vit c-vit b12-fa cap 460 (151

fe)-60-0.01-1 mg ............................. 83 fe fum-iron polysacch complex-fa-b

cmplx-c-zn-mn-cu cap ...................... 83

felbamate susp 600 mg/5ml .............. 31

felbamate tab 400 mg ....................... 31

felbamate tab 600 mg ....................... 31

FELBATOL SUS 600/5ML .................... 31

FELBATOL TAB 400MG ...................... 31

FELBATOL TAB 600MG ...................... 31

felodipine tab er 24hr 10 mg .............. 24

felodipine tab er 24hr 2.5 mg ............. 24 felodipine tab er 24hr 5 mg ............... 24

fenofibrate micronized cap 134 mg ..... 22

fenofibrate micronized cap 200 mg ..... 22 fenofibrate micronized cap 67 mg ....... 22

fenofibrate tab 145 mg ..................... 22

fenofibrate tab 160 mg ..................... 22 fenofibrate tab 48 mg ....................... 22

fenofibrate tab 54 mg ....................... 22 fentanyl td patch 72hr 100 mcg/hr ...... 5

fentanyl td patch 72hr 12 mcg/hr ........ 5

fentanyl td patch 72hr 25 mcg/hr ........ 5

fentanyl td patch 72hr 50 mcg/hr ........ 5 fentanyl td patch 72hr 75 mcg/hr ........ 5

ferrous fumarate tab 324 mg (106 mg elemental fe) ................................... 83

ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1 mg ......................... 83

ferrous fumarate-folic acid tab 324-1 mg ..................................................... 83 ferrous gluconate tab 240 mg (27 mg

elemental fe) ................................... 83 ferrous gluconate tab 324 mg (37.5 mg

elemental iron) ................................ 83

ferrous sulfate dried tab 200 mg (65 mg elemental fe) ................................... 83

ferrous sulfate dried tab er 160 mg (50

mg fe equivalent) ............................. 84

ferrous sulfate dried tab er 45 mg (fe

equivalent) ...................................... 83

ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental fe) ....................... 84

ferrous sulfate soln 75 mg/ml (15 mg/ml

elemental fe) ................................... 84

ferrous sulfate tab 134 mg (27 mg elemental fe) ................................... 84

ferrous sulfate tab 27 mg (elemental fe)

..................................................... 84

ferrous sulfate tab 325 mg (65 mg elemental fe) .................................. 84

ferrous sulfate tab ec 325 mg (65 mg fe

equivalent) ..................................... 84

ferrous sulfate tab er 142 mg (45 mg fe

equivalent) ..................................... 84

ferrous sulfate tab er 47.5 mg (elemental

fe) ................................................. 84

ferrous sulfate tab er 50 mg (elemental

fe) ................................................. 84

FETZIMA CAP 120MG ....................... 39 FETZIMA CAP 20MG ......................... 39

FETZIMA CAP 40MG ......................... 39

FETZIMA CAP 80MG ......................... 39 FETZIMA CAP TITRATIO .................... 39

FEVERALL INF SUP 80MG .................... 4

FEVERALL SUP 325MG ........................ 4 fexofenadine hcl susp 30 mg/5ml (6

mg/ml) .......................................... 90 fexofenadine hcl tab 180 mg ............. 90

fexofenadine hcl tab 60 mg ............... 90

fexofenadine-pseudoephedrine tab er

12hr 60-120 mg .............................. 89 fexofenadine-pseudoephedrine tab er

24hr 180-240 mg ............................ 89 FIASP FLEX INJ TOUCH ..................... 60

FIASP INJ 100/ML ............................ 60 finasteride tab 5 mg ......................... 74

flecainide acetate tab 100 mg ........... 21 flecainide acetate tab 150 mg ........... 21 flecainide acetate tab 50 mg ............. 21

FLOVENT DISK AER 100MCG ............. 94 FLOVENT DISK AER 250MCG ............. 94

FLOVENT DISK AER 50MCG ............... 94

FLOVENT HFA AER 110MCG .............. 94 FLOVENT HFA AER 220MCG .............. 94

FLOVENT HFA AER 44MCG ................ 94

fluconazole for susp 10 mg/ml ............. 9

fluconazole for susp 40 mg/ml ............. 9

fluconazole tab 100 mg ...................... 9

fluconazole tab 150 mg ...................... 9 fluconazole tab 200 mg ...................... 9

fluconazole tab 50 mg ........................ 9

fludrocortisone acetate tab 0.1 mg ..... 67

flunisolide nasal soln 25 mcg/act (0.025%) ....................................... 94

fluocinolone acetonide cream 0.025% 99

122

fluocinolone acetonide oint 0.025% ..... 99

fluocinolone acetonide soln 0.01% ...... 98 fluocinonide cream 0.05% ................. 98

fluocinonide gel 0.05% ...................... 98

fluocinonide oint 0.05% .................... 98

fluocinonide soln 0.05% .................... 98

fluorometholone ophth susp 0.1% .... 102

fluorouracil cream 5% ....................... 96

fluoxetine hcl (pmdd) cap 10 mg ........ 37

fluoxetine hcl (pmdd) cap 20 mg ........ 37

fluoxetine hcl (pmdd) tab 10 mg ........ 37

fluoxetine hcl (pmdd) tab 20 mg ........ 37 fluoxetine hcl cap 10 mg ................... 38

fluoxetine hcl cap 20 mg ................... 38

fluoxetine hcl cap 40 mg ................... 38 fluoxetine hcl cap delayed release 90 mg

..................................................... 38

fluoxetine hcl solution 20 mg/5ml ....... 38 fluoxetine hcl tab 10 mg .................... 38

fluoxetine hcl tab 20 mg .................... 38 fluoxetine hcl tab 60 mg .................... 38

FLUOXETINE TAB 60MG..................... 38

fluphenazine decanoate inj 25 mg/ml .. 46

fluphenazine hcl elixir 2.5 mg/5ml ...... 46 fluphenazine hcl inj 2.5 mg/ml ........... 46

fluphenazine hcl oral conc 5 mg/ml ..... 46 fluphenazine hcl tab 1 mg .................. 46

fluphenazine hcl tab 10 mg ................ 46 fluphenazine hcl tab 2.5 mg ............... 46

fluphenazine hcl tab 5 mg .................. 46 flurbiprofen tab 100 mg ..................... 4 flurbiprofen tab 50 mg ....................... 4

flutamide cap 125 mg ....................... 15 fluticasone propionate cream 0.05% ... 99

fluticasone propionate nasal susp 50

mcg/act .......................................... 94 fluticasone propionate oint 0.005% ..... 99

fluticasone-salmeterol aer powder ba

100-50 mcg/dose ............................. 95

fluticasone-salmeterol aer powder ba

250-50 mcg/dose ............................. 95

fluticasone-salmeterol aer powder ba 500-50 mcg/dose ............................. 95


..................................................... 30

fluvoxamine maleate cap er 24hr 150 mg ..................................................... 30

fluvoxamine maleate tab 100 mg ........ 30

fluvoxamine maleate tab 25 mg ......... 30

fluvoxamine maleate tab 50 mg ......... 30 folic acid tab 1 mg ........................... 83

folic acid tab 400 mcg ...................... 83

folic acid tab 800 mcg ...................... 83

folic acid-vitamin b6-vitamin b12 tab

0.8-10-0.115 mg ............................. 83


2.2-25-0.5 mg ................................ 83


2.2-25-1 mg ................................... 83

folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg ................................... 83

FORFIVO XL TAB 450MG ................... 36

FORTEO SOL 600/2.4 ....................... 62 fosamprenavir calcium tab 700 mg (base

equiv) ............................................ 12

fosaprepitant dimeglumine for iv infusion 150 mg (base eq) ............................ 70

fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg ............................... 19

fosinopril sodium & hydrochlorothiazide

tab 20-12.5 mg ............................... 19

fosinopril sodium tab 10 mg .............. 19 fosinopril sodium tab 20 mg .............. 19

fosinopril sodium tab 40 mg .............. 19 FREESTYLE TES ............................... 62

FREESTYLE TES INSULINX ................ 62 FREESTYLE TES LITE ........................ 62

furosemide oral soln 10 mg/ml .......... 26 furosemide tab 20 mg ...................... 26 furosemide tab 40 mg ...................... 26

furosemide tab 80 mg ...................... 26 FUZEON INJ 90MG ........................... 11

FYCOMPA SUS 0.5MG/ML .................. 31

FYCOMPA TAB 10MG ........................ 31 FYCOMPA TAB 12MG ........................ 31

FYCOMPA TAB 2MG .......................... 31

FYCOMPA TAB 4MG .......................... 31

FYCOMPA TAB 6MG .......................... 31

FYCOMPA TAB 8MG .......................... 31

G gabapentin cap 100 mg .................... 31

gabapentin cap 300 mg .................... 31

gabapentin cap 400 mg .................... 32

gabapentin oral soln 250 mg/5ml ....... 32 gabapentin tab 600 mg .................... 32

gabapentin tab 800 mg .................... 32

123

GABITRIL TAB 12MG ......................... 32

GABITRIL TAB 16MG ......................... 32 GABITRIL TAB 2MG .......................... 32

GABITRIL TAB 4MG .......................... 32

galantamine hydrobromide cap er 24hr

16 mg ............................................ 35

galantamine hydrobromide cap er 24hr

24 mg ............................................ 35

galantamine hydrobromide cap er 24hr 8

mg ................................................. 35

galantamine hydrobromide oral soln 4

mg/ml ............................................ 35 galantamine hydrobromide tab 12 mg . 36

galantamine hydrobromide tab 4 mg ... 35

galantamine hydrobromide tab 8 mg ... 36 GARDASIL 9 INJ ............................... 80

GAS-X CHILD MIS 40MG ................... 73

gemfibrozil tab 600 mg ..................... 22 gengraf cap 100mg .......................... 79

gengraf cap 25mg ............................ 79 gengraf sol 100mg/ml ....................... 79

GENOTROPIN INJ 0.2MG ................... 66

GENOTROPIN INJ 0.4MG ................... 66

GENOTROPIN INJ 0.6MG ................... 66 GENOTROPIN INJ 0.8MG ................... 66



GENOTROPIN INJ 12MG .................... 66 GENOTROPIN INJ 1MG ...................... 66 GENOTROPIN INJ 2MG ...................... 66

GENOTROPIN INJ 5MG ...................... 66 gentamicin sulfate cream 0.1% .......... 97

gentamicin sulfate oint 0.1% ............. 97

gentamicin sulfate ophth oint 0.3%... 102 gentamicin sulfate ophth soln 0.3% .. 102

GENTEAL GEL 0.3% ........................ 103

GENTEAL MILD DRO 0.2% ............... 103

GENVOYA TAB ................................. 10

GEODON CAP 20MG .......................... 43

GEODON CAP 40MG .......................... 43 GEODON CAP 60MG .......................... 43

GEODON CAP 80MG .......................... 43

GEODON INJ 20MG ........................... 43

GILENYA CAP 0.5MG ......................... 55 GILOTRIF TAB 20MG ......................... 16

GILOTRIF TAB 30MG ......................... 16

GILOTRIF TAB 40MG ........................ 16

glatiramer acetate soln prefilled syringe 20 mg/ml ....................................... 55

glatiramer acetate soln prefilled syringe

40 mg/ml ....................................... 55

GLEOSTINE CAP 100MG ................... 15

GLEOSTINE CAP 10MG ..................... 15

GLEOSTINE CAP 40MG ..................... 15

glimepiride tab 1 mg ........................ 61



glipizide tab 10 mg .......................... 61 glipizide tab 5 mg ............................ 61

glipizide tab er 24hr 10 mg ............... 61

glipizide tab er 24hr 2.5 mg .............. 61 glipizide tab er 24hr 5 mg ................. 61

glipizide-metformin hcl tab 2.5-250 mg

..................................................... 58 glipizide-metformin hcl tab 2.5-500 mg

..................................................... 58 glipizide-metformin hcl tab 5-500 mg . 58

GLUCAGEN INJ HYPOKIT................... 66

GLUCAGON KIT 1MG ........................ 66

glyburide micronized tab 1.5 mg ........ 61 glyburide micronized tab 3 mg .......... 61

glyburide micronized tab 6 mg .......... 62 glyburide tab 1.25 mg ...................... 62

glyburide tab 2.5 mg ........................ 62 glyburide tab 5 mg .......................... 62

glyburide-metformin tab 1.25-250 mg 58 glyburide-metformin tab 2.5-500 mg .. 58 glyburide-metformin tab 5-500 mg .... 58

glycerin-hypromellose-peg 400 ophth soln 0.2-0.2-1% ............................. 103

glycopyrrolate tab 1 mg.................... 71

glycopyrrolate tab 2 mg.................... 71 granisetron hcl tab 1 mg................... 70

griseofulvin microsize susp 125 mg/5ml 9

griseofulvin ultramicrosize tab 125 mg . 9

griseofulvin ultramicrosize tab 250 mg . 9

guaifenesin liquid 100 mg/5ml ........... 93

guaifenesin syrup 100 mg/5ml .......... 93 guaifenesin tab 200 mg .................... 93

guaifenesin tab 400 mg .................... 93

guaifenesin tab er 12hr 1200 mg ....... 93

guaifenesin tab er 12hr 600 mg ......... 93 guaifenesin-codeine soln 100-10 mg/5ml

..................................................... 91

124

guaifenesin-codeine soln 100-6.3

mg/5ml ........................................... 91 guanfacine hcl tab 1 mg .................... 20

guanfacine hcl tab 2 mg .................... 20

GYNOL II GEL 3% ............................ 63

H halobetasol propionate cream 0.05% .. 99

halobetasol propionate oint 0.05% ...... 99


..................................................... 47


..................................................... 47 haloperidol lactate inj 5 mg/ml ........... 47

haloperidol lactate oral conc 2 mg/ml .. 47

haloperidol tab 0.5 mg ...................... 47 haloperidol tab 1 mg ......................... 47

haloperidol tab 10 mg ....................... 47

haloperidol tab 2 mg ......................... 47 haloperidol tab 20 mg ....................... 47

haloperidol tab 5 mg ......................... 47 HAVRIX INJ 1440UNIT ...................... 80

HAVRIX INJ 720UNIT ........................ 80

HEMA-COMBIST TES ......................... 81

HUMALOG INJ 100/ML ....................... 60 HUMALOG JR INJ 100/ML .................. 60

HUMALOG KWIK INJ 100/ML .............. 60 HUMALOG MIX INJ 50/50 .................. 60

HUMALOG MIX INJ 50/50KWP ............ 60 HUMALOG MIX INJ 75/25KWP ............ 60

HUMALOG MIX SUS 75/25 ................. 60 HUMATROPE INJ 12MG ...................... 66 HUMATROPE INJ 24MG ...................... 67

HUMATROPE INJ 5MG ....................... 66 HUMATROPE INJ 6MG ....................... 66

HUMIRA INJ 10/0.1ML ....................... 77

HUMIRA INJ 10MG/0.2 ...................... 77 HUMIRA INJ 20/0.2ML ....................... 77

HUMIRA INJ 40/0.4ML ....................... 77

HUMIRA KIT 20MG/0.4 ...................... 77

HUMIRA KIT 40MG/0.8 ...................... 77

HUMIRA PEDIA INJ CROHNS .............. 77

HUMIRA PEN INJ 40/0.4ML ................ 77 HUMIRA PEN INJ 40MG/0.8 ................ 77

HUMIRA PEN INJ CD/UC/HS ............... 77

HUMIRA PEN INJ PS/UV ..................... 78

HUMIRA PEN KIT CD/UC/HS ............... 78 HUMIRA PEN KIT PS/UV .................... 78

HUMULIN INJ 70/30 .......................... 60

HUMULIN INJ 70/30KWP ................... 60

HUMULIN N INJ U-100 ...................... 60 HUMULIN N INJ U-100KWP ............... 60

HUMULIN R INJ U-100 ...................... 60

HUMULIN R INJ U-500 ...................... 60

hydralazine hcl tab 10 mg ................. 26

hydralazine hcl tab 100 mg ............... 26



hydrochlorothiazide cap 12.5 mg ....... 26

hydrochlorothiazide tab 12.5 mg ........ 26

hydrochlorothiazide tab 25 mg .......... 26 hydrochlorothiazide tab 50 mg .......... 26

hydrocodone w/ homatropine syrup 5-

1.5 mg/5ml .................................... 91 hydrocodone w/ homatropine tab 5-1.5

mg ................................................ 91

hydrocodone-acetaminophen soln 7.5-325 mg/15ml .................................... 5

hydrocodone-acetaminophen tab 10-325 mg .................................................. 5

hydrocodone-acetaminophen tab 5-325

mg .................................................. 5

hydrocodone-acetaminophen tab 7.5-325 mg .................................................. 5

hydrocortisone acetate cream 1% ...... 98 hydrocortisone butyrate cream 0.1% .. 99

hydrocortisone butyrate oint 0.1% ..... 99 hydrocortisone butyrate soln 0.1% ..... 99

hydrocortisone cream 0.5% .............. 98 hydrocortisone cream 1% ................. 98 hydrocortisone cream 2.5% .............. 98

hydrocortisone enema 100 mg/60ml .. 72 hydrocortisone gel 1% ..................... 98

hydrocortisone lotion 1% .................. 98

hydrocortisone lotion 2.5% ............... 98 hydrocortisone oint 0.5% ................. 98

hydrocortisone oint 1% .................... 99

hydrocortisone oint 2.5% ................. 99

hydrocortisone rectal cream 1% ........ 74

hydrocortisone rectal cream 2.5% ...... 74

hydrocortisone soln 1% .................... 99 hydrocortisone tab 10 mg ................. 65

hydrocortisone tab 20 mg ................. 65

hydrocortisone tab 5 mg ................... 65

hydrocortisone valerate cream 0.2% .. 99 hydrocortisone valerate oint 0.2% ..... 99

hydrocortisone-aloe vera cream 1% ... 98

125

hydromorphone hcl tab 2 mg .............. 5

hydromorphone hcl tab 4 mg .............. 5 hydromorphone hcl tab 8 mg .............. 5

hydroxychloroquine sulfate tab 200 mg

..................................................... 78

hydroxyurea cap 500 mg ................... 18

hydroxyzine hcl syrup 10 mg/5ml ....... 90

hydroxyzine hcl tab 10 mg ................. 90



hydroxyzine pamoate cap 100 mg ...... 90

hydroxyzine pamoate cap 25 mg ........ 90 hydroxyzine pamoate cap 50 mg ........ 90

HYPOTEARS SOL 1-1%.................... 103

hypromellose ophth soln 0.3% ......... 103 hypromellose ophth soln 0.4% ......... 103

I IBRANCE CAP 100MG ........................ 16 IBRANCE CAP 125MG ........................ 16

IBRANCE CAP 75MG.......................... 16 ibuprofen cap 200 mg ........................ 4

ibuprofen chew tab 100 mg ................ 4

ibuprofen susp 100 mg/5ml ................ 4

ibuprofen susp 40 mg/ml .................... 4 ibuprofen tab 100 mg ........................ 4

ibuprofen tab 200 mg ........................ 4 ibuprofen tab 400 mg ........................ 4

ibuprofen tab 600 mg ........................ 4 ibuprofen tab 800 mg ........................ 4

IDHIFA TAB 100MG .......................... 18 IDHIFA TAB 50MG ............................ 18 imatinib mesylate tab 100 mg (base

equivalent) ...................................... 17 imatinib mesylate tab 400 mg (base

equivalent) ...................................... 17

IMBRUVICA CAP 140MG .................... 16 IMBRUVICA CAP 70MG ...................... 16

IMBRUVICA TAB 140MG .................... 16

IMBRUVICA TAB 280MG .................... 16

IMBRUVICA TAB 420MG .................... 17

IMBRUVICA TAB 560MG .................... 17

imipramine hcl tab 10 mg .................. 40 imipramine hcl tab 25 mg .................. 41

imipramine hcl tab 50 mg .................. 41

imipramine pamoate cap 100 mg ........ 41

imipramine pamoate cap 125 mg ........ 41 imipramine pamoate cap 150 mg ........ 41

imipramine pamoate cap 75 mg ......... 41

imiquimod cream 5% ...................... 101

IMURAN TAB 50MG .......................... 78 INCRUSE ELPT INH 62.5MCG ............. 89

indapamide tab 1.25 mg ................... 26

indapamide tab 2.5 mg .................... 26

INFANRIX INJ ................................. 80

INLYTA TAB 1MG ............................. 17

INLYTA TAB 5MG ............................. 17

INTELENCE TAB 100MG .................... 11

INTELENCE TAB 200MG .................... 11

INTELENCE TAB 25MG ...................... 11

INVEGA SUST INJ 117/0.75 .............. 44 INVEGA SUST INJ 156MG/ML ............ 44

INVEGA SUST INJ 234/1.5 ................ 44

INVEGA SUST INJ 39/0.25 ................ 43 INVEGA SUST INJ 78/0.5ML .............. 43

INVEGA TAB 1.5MG ......................... 44

INVEGA TAB 3MG ............................ 44 INVEGA TAB 6MG ............................ 44

INVEGA TAB 9MG ............................ 44 INVEGA TRINZ INJ 273MG ................ 44

INVEGA TRINZ INJ 410MG ................ 44

INVEGA TRINZ INJ 546MG ................ 44

INVEGA TRINZ INJ 819MG ................ 44 INVIRASE TAB 500MG ...................... 12

INVOKAMET TAB 150-1000 ............... 61 INVOKAMET TAB 150-500 ................. 61

INVOKAMET TAB 50-1000 ................. 61 INVOKAMET TAB 50-500MG .............. 61

INVOKAMET XR TAB 150-1000 .......... 61 INVOKAMET XR TAB 150-500 ............ 61 INVOKAMET XR TAB 50-1000 ............ 61

INVOKAMET XR TAB 50-500MG ......... 61 INVOKANA TAB 100MG ..................... 61

INVOKANA TAB 300MG ..................... 61

ipratropium bromide inhal soln 0.02% 89 ipratropium bromide nasal soln 0.03%

(21 mcg/spray) ............................... 93

ipratropium bromide nasal soln 0.06%

(42 mcg/spray) ............................... 94

ipratropium-albuterol nebu soln 0.5-

2.5(3) mg/3ml ................................ 89 irbesartan tab 150 mg ...................... 21

irbesartan tab 300 mg ...................... 21

irbesartan tab 75 mg ....................... 21

irbesartan-hydrochlorothiazide tab 150-12.5 mg ......................................... 20

irbesartan-hydrochlorothiazide tab 300-

126

12.5 mg .......................................... 20

iron combination cap ........................ 84 iron polysacch complex-vit b12-fa cap

150-0.025-1 mg ............................... 84

iron w/ vitamin liq ............................ 85

iron w/ vitamin tab ........................... 86

iron-docusate-b12-folic acid-c-e-cu-biotin

tab 150-1 mg .................................. 84

iron-folic acid-vit c-vit b6-vit b12-zinc

tab 150-1.25 mg .............................. 84

iron-vit c-vit b12-folic acid tab 100-250-

0.025-1 mg ..................................... 84 iron-vitamin c tab 100-250 mg ........... 84

ISENTRESS CHW 100MG ................... 11

ISENTRESS CHW 25MG ..................... 11 ISENTRESS HD TAB 600MG ............... 11

ISENTRESS POW 100MG ................... 11

ISENTRESS TAB 400MG .................... 11 isoniazid syrup 50 mg/5ml ................. 13

isoniazid tab 100 mg......................... 13 isoniazid tab 300 mg......................... 13

ISORDIL TAB 40MG .......................... 26

isosorbide dinitrate tab 10 mg ............ 26

isosorbide dinitrate tab 20 mg ............ 27 isosorbide dinitrate tab 30 mg ............ 27

isosorbide dinitrate tab 5 mg ............. 26 isosorbide dinitrate tab er 40 mg ........ 27

isosorbide mononitrate tab 10 mg ...... 27 isosorbide mononitrate tab 20 mg ...... 27

isosorbide mononitrate tab er 24hr 120 mg ................................................. 27 isosorbide mononitrate tab er 24hr 30

mg ................................................. 27 isosorbide mononitrate tab er 24hr 60

mg ................................................. 27

itraconazole cap 100 mg .................... 9 IV PREP WIPE PAD ............................ 97

ivermectin tab 3 mg ......................... 14

J JAKAFI TAB 10MG ............................ 17

JAKAFI TAB 15MG ............................ 17

JAKAFI TAB 20MG ............................ 17 JAKAFI TAB 25MG ............................ 17

JAKAFI TAB 5MG .............................. 17

JANUMET TAB 50-1000 ..................... 59

JANUMET TAB 50-500MG ................... 58 JANUMET XR TAB 100-1000 ............... 59

JANUMET XR TAB 50-1000 ................. 59

JANUMET XR TAB 50-500MG ............. 59

JANUVIA TAB 100MG ....................... 59 JANUVIA TAB 25MG ......................... 59

JANUVIA TAB 50MG ......................... 59

K KALETRA SOL .................................. 12

KALETRA TAB 100-25MG .................. 12

KALETRA TAB 200-50MG .................. 12

KALYDECO PAK 25MG ...................... 92

KALYDECO PAK 50MG ...................... 92

KALYDECO PAK 75MG ...................... 92

KALYDECO TAB 150MG ..................... 92 KEPPRA SOL 100MG/ML .................... 32

KEPPRA TAB 1000MG ....................... 32

KEPPRA TAB 250MG ......................... 32 KEPPRA TAB 500MG ......................... 32

KEPPRA TAB 750MG ......................... 32

KEPPRA XR TAB 500MG .................... 32 KEPPRA XR TAB 750MG .................... 32

ketoconazole cream 2% ................... 97 ketoconazole shampoo 2% ............... 97

KETO-DIASTIX TES .......................... 62


.................................................... 102 ketorolac tromethamine ophth soln 0.5%

.................................................... 102 ketorolac tromethamine tab 10 mg ...... 4

ketotifen fumarate ophth soln 0.025% (base equiv) .................................. 102

KHEDEZLA TAB 100MG ER ................ 39 KHEDEZLA TAB 50MG ER .................. 39 KLONOPIN TAB 0.5MG ...................... 29

KLONOPIN TAB 1MG ........................ 29 KLONOPIN TAB 2MG ........................ 29

K-PHOS TAB ................................... 75

K-PHOS TAB NO 2 ........................... 75 KUVAN POW 100MG ......................... 67

KUVAN TAB 100MG .......................... 67

L labetalol hcl tab 100 mg ................... 23

labetalol hcl tab 200 mg ................... 23

labetalol hcl tab 300 mg ................... 23 LABSTIX TES .................................. 81

lactic acid (ammonium lactate) cream

12% ....................................... 99, 100

lactic acid (ammonium lactate) lotion 12% ............................................. 100

lactulose (encephalopathy) solution 10

127

gm/15ml ......................................... 73

lactulose solution 10 gm/15ml ........... 73 LAMICTAL CHW 25MG ....................... 32

LAMICTAL CHW 5MG ......................... 32

LAMICTAL KIT START 35 ................... 32



LAMICTAL ODT KIT ........................... 32

LAMICTAL ODT TAB 100MG ............... 32

LAMICTAL ODT TAB 200MG ............... 32

LAMICTAL ODT TAB 25MG ................. 32

LAMICTAL ODT TAB 50MG ................. 32 LAMICTAL TAB 100MG ...................... 32

LAMICTAL TAB 150MG ...................... 32

LAMICTAL TAB 200MG ...................... 32 LAMICTAL TAB 25MG ........................ 32

LAMICTAL XR KIT ............................. 32

LAMICTAL XR TAB 100MG .................. 32 LAMICTAL XR TAB 200MG .................. 32

LAMICTAL XR TAB 250MG .................. 32 LAMICTAL XR TAB 25MG ................... 32

LAMICTAL XR TAB 300MG .................. 32

LAMICTAL XR TAB 50MG ................... 32

lamivudine oral soln 10 mg/ml ........... 12 lamivudine tab 100 mg (hbv) ............. 13

lamivudine tab 150 mg ..................... 12 lamivudine tab 300 mg ..................... 12

lamivudine-zidovudine tab 150-300 mg ..................................................... 10

lamotrigine orally disintegrating tab 100 mg ................................................. 32 lamotrigine orally disintegrating tab 200

mg ................................................. 32 lamotrigine orally disintegrating tab 25

mg ................................................. 32

lamotrigine orally disintegrating tab 50 mg ................................................. 32

lamotrigine tab 100 mg ..................... 33



lamotrigine tab 25 mg ....................... 32

lamotrigine tab 25 mg (35) starter kit . 32 lamotrigine tab 25 mg (42) & 100 mg (7)

starter kit ........................................ 32

lamotrigine tab 25 mg (84) & 100 mg

(14) starter kit ................................. 33 lamotrigine tab chewable dispersible 25

mg ................................................. 33

lamotrigine tab chewable dispersible 5

mg ................................................ 33 lamotrigine tab er 24hr 100 mg ......... 33

lamotrigine tab er 24hr 200 mg ......... 33

lamotrigine tab er 24hr 25 mg ........... 33



lamotrigine tab er 24hr 50 mg ........... 33

LANCETS MIS .................................. 62

LANOXIN TAB 0.0625MG .................. 25

lansoprazole cap delayed release 15 mg

..................................................... 74 latanoprost ophth soln 0.005% ......... 104

LATUDA TAB 120MG ........................ 44

LATUDA TAB 20MG .......................... 44 LATUDA TAB 40MG .......................... 44

LATUDA TAB 60MG .......................... 44

LATUDA TAB 80MG .......................... 44 leflunomide tab 10 mg ..................... 78

leflunomide tab 20 mg ..................... 78 LENVIMA CAP 10 MG ........................ 17

LENVIMA CAP 12MG ......................... 17

LENVIMA CAP 14 MG ........................ 17

LENVIMA CAP 18 MG ........................ 17 LENVIMA CAP 20 MG ........................ 17

LENVIMA CAP 24 MG ........................ 17 LENVIMA CAP 4MG .......................... 17

LENVIMA CAP 8 MG.......................... 17 letrozole tab 2.5 mg ......................... 16

leucovorin calcium tab 10 mg ............ 18 leucovorin calcium tab 15 mg ............ 18 leucovorin calcium tab 25 mg ............ 18

leucovorin calcium tab 5 mg .............. 18 LEUKERAN TAB 2MG ........................ 15

levetiracetam oral soln 100 mg/ml ..... 33

levetiracetam tab 1000 mg ............... 33 levetiracetam tab 250 mg ................. 33

levetiracetam tab 500 mg ................. 33

levetiracetam tab 750 mg ................. 33

levetiracetam tab er 24hr 500 mg ...... 33

levetiracetam tab er 24hr 750 mg ...... 33

levobunolol hcl ophth soln 0.5% ....... 103 levocarnitine oral soln 1 gm/10ml (10%)

..................................................... 62

levocarnitine tab 330 mg .................. 62

levofloxacin ophth soln 0.5% ........... 102 levofloxacin oral soln 25 mg/ml ........... 8

levofloxacin tab 250 mg ..................... 8

128

levofloxacin tab 500 mg ..................... 8

levofloxacin tab 750 mg ..................... 8 levonorgestrel & ethinyl estradiol tab 0.1

mg-20 mcg ..................................... 63

levonorgestrel & ethinyl estradiol tab

0.15 mg-30 mcg .............................. 63

levonorgestrel tab 1.5 mg ................. 63

levonorgestrel-eth estra tab 0.05-

30/0.075-40/0.125-30mg-mcg ........... 64

levothyroxine sodium tab 100 mcg ..... 68


levothyroxine sodium tab 125 mcg ..... 68 levothyroxine sodium tab 137 mcg ..... 68


levothyroxine sodium tab 175 mcg ..... 69 levothyroxine sodium tab 200 mcg ..... 69

levothyroxine sodium tab 25 mcg ....... 68

levothyroxine sodium tab 300 mcg ..... 69 levothyroxine sodium tab 50 mcg ....... 68

levothyroxine sodium tab 75 mcg ....... 68 levothyroxine sodium tab 88 mcg ....... 68

LEXAPRO TAB 10MG ......................... 38

LEXAPRO TAB 20MG ......................... 38

LEXAPRO TAB 5MG ........................... 38 LEXIVA SUS 50MG/ML ....................... 13

LEXIVA TAB 700MG .......................... 13 lidocaine hcl soln 4% ...................... 100

lidocaine hcl viscous soln 2% ........... 101 lidocaine patch 4% ......................... 100

lidocaine patch 5% ......................... 100 lidocaine-prilocaine cream 2.5-2.5% . 100 lidocaine-prilocaine cream kit 2.5-2.5%

................................................... 100 linezolid for susp 100 mg/5ml ............ 14

linezolid tab 600 mg ......................... 14

LINZESS CAP 145MCG ...................... 72 LINZESS CAP 290MCG ...................... 72

LINZESS CAP 72MCG ........................ 72

liothyronine sodium tab 25 mcg ......... 69

liothyronine sodium tab 5 mcg ........... 69

liothyronine sodium tab 50 mcg ......... 69

lisinopril & hydrochlorothiazide tab 10-12.5 mg .......................................... 19

lisinopril & hydrochlorothiazide tab 20-

12.5 mg .......................................... 19

lisinopril & hydrochlorothiazide tab 20-25 mg ................................................. 19

lisinopril tab 10 mg ........................... 19

lisinopril tab 2.5 mg ......................... 19

lisinopril tab 20 mg .......................... 19 lisinopril tab 30 mg .......................... 19

lisinopril tab 40 mg .......................... 19

lisinopril tab 5 mg ............................ 19

lithium carbonate cap 150 mg ........... 55



lithium carbonate tab 300 mg ........... 55

lithium carbonate tab er 300 mg ........ 55

lithium carbonate tab er 450 mg ........ 55

LITHIUM SOL 8MEQ/5ML .................. 55 LITHOBID TAB 300MG CR ................. 55

loperamide hcl cap 2 mg ................... 70

loperamide hcl liq 1 mg/5ml (0.2 mg/ml) ..................................................... 70

loperamide hcl tab 2 mg ................... 70

lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) ................................ 13

loratadine & pseudoephedrine tab er 12hr 5-120 mg ................................ 89

loratadine & pseudoephedrine tab er

24hr 10-240 mg .............................. 89

loratadine cap 10 mg ....................... 90 loratadine chew tab 5 mg ................. 90

loratadine rapidly-disintegrating tab 10 mg ................................................ 90

loratadine syrup 5 mg/5ml ................ 90 loratadine tab 10 mg ........................ 90

lorazepam conc 2 mg/ml .................. 29 lorazepam inj 2 mg/ml ..................... 29 lorazepam inj 4 mg/ml ..................... 29

lorazepam tab 0.5 mg ...................... 29 lorazepam tab 1 mg ......................... 29

lorazepam tab 2 mg ......................... 29

LORBRENA TAB 100MG .................... 17 LORBRENA TAB 25MG ...................... 17

losartan potassium & hydrochlorothiazide

tab 100-12.5 mg ............................. 20

losartan potassium & hydrochlorothiazide

tab 100-25 mg ................................ 21

losartan potassium & hydrochlorothiazide tab 50-12.5 mg ............................... 20

losartan potassium tab 100 mg ......... 21

losartan potassium tab 25 mg ........... 21

losartan potassium tab 50 mg ........... 21 LOTEMAX GEL 0.5% ........................ 102

lovastatin tab 10 mg ........................ 22

129

lovastatin tab 20 mg ......................... 22

lovastatin tab 40 mg ......................... 23 loxapine succinate cap 10 mg ............ 47

loxapine succinate cap 25 mg ............ 47

loxapine succinate cap 5 mg .............. 47

loxapine succinate cap 50 mg ............ 47

LUBRICNT GEL DRO 0.25-0.3 ........... 103

LYNPARZA TAB 100MG ...................... 18

LYNPARZA TAB 150MG ...................... 18

LYSODREN TAB 500MG ..................... 18

M MAALOX CHW 600MG ....................... 70 malathion lotion 0.5% ..................... 101

maprotiline hcl tab 25 mg .................. 36

maprotiline hcl tab 50 mg .................. 36 maprotiline hcl tab 75 mg .................. 36

MARPLAN TAB 10MG ......................... 37

MASK VORTEX/ MIS BABY DUC .......... 93 MASK VORTEX/ MIS DUCK ................. 93

MASK VORTEX/ MIS FROG ................. 93 MASK VORTEX/ MIS LADY BUG .......... 93

MATULANE CAP 50MG ....................... 18

MAVYRET TAB 100-40MG .................. 14

meclizine hcl chew tab 25 mg ............ 70 meclizine hcl tab 12.5 mg ............ 70, 71

meclizine hcl tab 25 mg .................... 71 MEDROL TAB 2MG ............................ 65

medroxyprogesterone acetate im susp 150 mg/ml ...................................... 63

medroxyprogesterone acetate im susp prefilled syr 150 mg/ml ..................... 63 medroxyprogesterone acetate tab 10 mg

..................................................... 68 medroxyprogesterone acetate tab 2.5

mg ................................................. 68

medroxyprogesterone acetate tab 5 mg ..................................................... 68

mefloquine hcl tab 250 mg ................ 10

megestrol acetate susp 40 mg/ml ....... 68

megestrol acetate tab 20 mg ............. 16

megestrol acetate tab 40 mg ............. 16

MEKINIST TAB 0.5MG ....................... 17 MEKINIST TAB 2MG .......................... 17

meloxicam tab 15 mg ........................ 4

meloxicam tab 7.5 mg ....................... 4

melphalan tab 2 mg .......................... 15 memantine hcl oral solution 2 mg/ml .. 36

memantine hcl tab 10 mg .................. 36

memantine hcl tab 5 mg ................... 36

memantine hcl tab 5 mg (28) & 10 mg (21) titration pak ............................. 36

MENACTRA INJ ................................ 80

MENVEO INJ ................................... 80

meprobamate tab 200 mg ................ 30

meprobamate tab 400 mg ................ 30

mercaptopurine tab 50 mg ................ 15

mesalamine enema 4 gm .................. 72

mesalamine rectal enema 4 gm &

cleanser wipe kit ............................. 72

metadate tab 20mg er ..................... 50 metformin hcl tab 1000 mg ............... 58

metformin hcl tab 500 mg ................ 58

metformin hcl tab 850 mg ................ 58 metformin hcl tab er 24hr 500 mg ..... 58

metformin hcl tab er 24hr 750 mg ..... 58

methadone hcl tab 10 mg ................... 5 methadone hcl tab 5 mg ..................... 5

methazolamide tab 25 mg ................ 25 methazolamide tab 50 mg ................ 25

methimazole tab 10 mg .................... 68

methimazole tab 5 mg ..................... 68

methocarbamol tab 500 mg .............. 56 methocarbamol tab 750 mg .............. 56

methotrexate sodium tab 2.5 mg (base equiv) ............................................ 15

methyldopa tab 250 mg ................... 20 methyldopa tab 500 mg ................... 20

methylphenidate hcl cap er 10 mg (cd) 50 methylphenidate hcl cap er 20 mg (cd) 50 methylphenidate hcl cap er 24hr 20 mg

(la) ................................................ 50 methylphenidate hcl cap er 24hr 30 mg

(la) ................................................ 50

methylphenidate hcl cap er 24hr 40 mg (la) ................................................ 50

methylphenidate hcl cap er 30 mg (cd) 50




methylphenidate hcl soln 10 mg/5ml .. 51 methylphenidate hcl soln 5 mg/5ml .... 51

methylphenidate hcl tab 10 mg ......... 51

methylphenidate hcl tab 20 mg ......... 51

methylphenidate hcl tab 5 mg ........... 51 methylphenidate hcl tab er 10 mg ...... 51

methylphenidate hcl tab er 20 mg ...... 51

130

methylphenidate hcl tab er 24hr 18 mg

..................................................... 51 methylphenidate hcl tab er 24hr 27 mg

..................................................... 51


..................................................... 52


..................................................... 52

methylphenidate hcl tab er osmotic

release (osm) 18 mg ........................ 52

methylphenidate hcl tab er osmotic

release (osm) 27 mg ........................ 52 methylphenidate hcl tab er osmotic

release (osm) 36 mg ........................ 53

methylphenidate hcl tab er osmotic release (osm) 54 mg ........................ 53

methylprednisolone tab 16 mg ........... 65

methylprednisolone tab 32 mg ........... 65 methylprednisolone tab 4 mg ............. 65

methylprednisolone tab 8 mg ............. 65 methylprednisolone tab therapy pack 4

mg (21) .......................................... 65

metoclopramide hcl soln 5 mg/5ml (10

mg/10ml) (base equiv) ..................... 71 metoclopramide hcl tab 10 mg (base

equivalent) ...................................... 71 metoclopramide hcl tab 5 mg (base

equivalent) ...................................... 71 metolazone tab 10 mg ...................... 26

metolazone tab 2.5 mg ..................... 26 metolazone tab 5 mg ........................ 26 metoprolol & hydrochlorothiazide tab

100-25 mg ...................................... 23 metoprolol & hydrochlorothiazide tab

100-50 mg ...................................... 23

metoprolol & hydrochlorothiazide tab 50-25 mg ............................................ 23

metoprolol succinate tab er 24hr 100 mg

(tartrate equiv) ................................ 23


(tartrate equiv) ................................ 23

metoprolol succinate tab er 24hr 25 mg (tartrate equiv) ................................ 23


(tartrate equiv) ................................ 23

metoprolol tartrate tab 100 mg .......... 24 metoprolol tartrate tab 25 mg ............ 24

metoprolol tartrate tab 50 mg ............ 24

metronidazole cap 375 mg ................ 14

metronidazole cream 0.75% ............ 101 metronidazole gel 0.75% ................. 101

metronidazole gel 1% ..................... 101

metronidazole lotion 0.75% ............. 101

metronidazole tab 250 mg ................ 15

metronidazole tab 500 mg ................ 15

metronidazole vaginal gel 0.75% ....... 75

miconazole nitrate cream 2% ............ 97

miconazole nitrate ointment 2% ........ 97

miconazole nitrate powder 2% .......... 97

miconazole nitrate vaginal app 200 mg & 2% cream 9 gm kit .......................... 75

miconazole nitrate vaginal cream 2% . 75

miconazole nitrate vaginal cream 4% (200 mg/5gm) ................................ 75

miconazole nitrate vaginal supp 1200 mg

& 2% cream kit ............................... 75 miconazole nitrate vaginal supp 200 mg

& 2% cream 9 gm kit ....................... 75 miconazole nitrate vaginal suppos 100

mg ................................................ 75

miconazole nitrate vaginal suppos 200

mg ................................................ 75 MICROCLENS PAD WIPES ................. 97

midodrine hcl tab 10 mg ................... 28 midodrine hcl tab 2.5 mg .................. 28

midodrine hcl tab 5 mg .................... 28 minocycline hcl cap 100 mg ................ 9

minocycline hcl cap 50 mg .................. 9 minocycline hcl cap 75 mg .................. 9 mirtazapine orally disintegrating tab 15

mg ................................................ 36 mirtazapine orally disintegrating tab 30

mg ................................................ 36

mirtazapine orally disintegrating tab 45 mg ................................................ 36

mirtazapine tab 15 mg ..................... 36



mirtazapine tab 7.5 mg .................... 36

misoprostol tab 100 mcg .................. 74 misoprostol tab 200 mcg .................. 74

M-M-R II INJ ................................... 80

modafinil tab 100 mg ....................... 56

modafinil tab 200 mg ....................... 56 mometasone furoate cream 0.1% ...... 99

mometasone furoate oint 0.1% ......... 99

131

mometasone furoate solution 0.1%

(lotion) ........................................... 99 MONISTAT 3 KIT COMBO PK .............. 76

MONISTAT 7 KIT COMPLETE .............. 76

montelukast sodium chew tab 4 mg

(base equiv) .................................... 93

montelukast sodium chew tab 5 mg

(base equiv) .................................... 93

montelukast sodium oral granules packet

4 mg (base equiv) ............................ 93

montelukast sodium tab 10 mg (base

equiv) ............................................. 93 morphine sulfate oral soln 10 mg/5ml .. 5

morphine sulfate oral soln 100 mg/5ml

(20 mg/ml) ...................................... 6 morphine sulfate oral soln 20 mg/5ml .. 6

morphine sulfate tab 15 mg ................ 6

morphine sulfate tab 30 mg ................ 6 morphine sulfate tab er 100 mg .......... 6

morphine sulfate tab er 15 mg ............ 6 morphine sulfate tab er 200 mg .......... 6

morphine sulfate tab er 30 mg ............ 6

morphine sulfate tab er 60 mg ............ 6

MOVANTIK TAB 12.5MG .................... 73 MOVANTIK TAB 25MG ....................... 73

MUCINEX CGH GRA 5-100MG ............. 91 MUCINEX DM TAB 30-600ER .............. 91

MUCINEX/KIDS GRA 100MG .............. 93 MULPLETA TAB 3MG ......................... 77

MULTAQ TAB 400MG ......................... 21 multiple vitamin cap ......................... 86 multiple vitamin tab .......................... 86

multiple vitamins w/ calcium tab ........ 86 multiple vitamins w/ iron tab ............. 86

multiple vitamins w/ minerals & fa tab

1.25 mg .......................................... 86 multiple vitamins w/ minerals cap ....... 86

multiple vitamins w/ minerals chew tab

..................................................... 86

multiple vitamins w/ minerals effer tab 86

multiple vitamins w/ minerals liquid .... 86

multiple vitamins w/ minerals tab ....... 86 multiple vitamins w/ minerals tab er ... 86

MULTISTIX 10 TES SG ...................... 81

MULTISTIX 5 TES ............................. 81

MULTISTIX 7 TES ............................. 81 MULTISTIX 8 TES SG ........................ 81

MULTISTIX 9 TES ............................. 81

MULTISTIX 9 TES SG ....................... 81

MULTISTIX TES ............................... 81 mupirocin oint 2% ........................... 97

mycophenolate mofetil cap 250 mg .... 78

mycophenolate mofetil for oral susp 200

mg/ml ........................................... 78

mycophenolate mofetil tab 500 mg .... 78

mycophenolate sodium tab dr 180 mg

(mycophenolic acid equiv) ................ 78

mycophenolate sodium tab dr 360 mg

(mycophenolic acid equiv) ................ 78

MYFORTIC TAB 180MG ..................... 78 MYFORTIC TAB 360MG ..................... 78

MYLERAN TAB 2MG .......................... 15

myorisan cap 10mg ......................... 95 myorisan cap 20mg ......................... 95

myorisan cap 30mg ......................... 95

myorisan cap 40mg ......................... 95 MYSOLINE TAB 250MG ..................... 33

MYSOLINE TAB 50MG ....................... 33 N nabumetone tab 500 mg .................... 4

nabumetone tab 750 mg .................... 4

nadolol tab 20 mg ........................... 24 nadolol tab 40 mg ........................... 24

nadolol tab 80 mg ........................... 24 naltrexone hcl tab 50 mg .................. 56

naproxen sodium cap 220 mg ............. 4 naproxen sodium tab 220 mg .............. 4

naproxen sodium tab 275 mg .............. 4 naproxen sodium tab 550 mg .............. 4 naproxen susp 125 mg/5ml ................ 4

naproxen tab 250 mg ......................... 4 naproxen tab 375 mg ......................... 5

naproxen tab 500 mg ......................... 5

naproxen tab ec 375 mg ..................... 5 naproxen tab ec 500 mg ..................... 5

naratriptan hcl tab 1 mg (base equiv) . 54

naratriptan hcl tab 2.5 mg (base equiv)

..................................................... 54

NARCAN SPR .................................. 57

NARDIL TAB 15MG ........................... 37 NASCOBAL SPR 500MCG .................. 86

NATACYN SUS 5% OP ..................... 102

nateglinide tab 120 mg .................... 60

nateglinide tab 60 mg ...................... 60 NATRAPEL 12H SPR 20% ................. 100

NEBULIZER MIS .............................. 93

132

nefazodone hcl tab 100 mg ................ 36

nefazodone hcl tab 150 mg ................ 37 nefazodone hcl tab 200 mg ................ 37

nefazodone hcl tab 250 mg ................ 37

nefazodone hcl tab 50 mg ................. 36

neomycin sulfate tab 500 mg .............. 7

neomycin-bacitrac zn-polymyx

5(3.5)mg-400unt-10000unt op oin ... 102

neomycin-bacitracin-polymyxin oint .... 97

neomycin-polymy-gramicid op sol 1.75-

10000-0.025mg-unt-mg/ml ............. 102

neomycin-polymyxin-dexamethasone ophth oint 0.1% ............................. 101

neomycin-polymyxin-dexamethasone

ophth susp 0.1% ............................ 101 neomycin-polymyxin-hc ophth susp .. 101

neomycin-polymyxin-hc otic soln 1% 104

neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% ............... 104

NEORAL CAP 100MG ......................... 79 NEORAL CAP 25MG ........................... 79

NEORAL SOL 100MG/ML .................... 79

NEURONTIN CAP 100MG ................... 33

NEURONTIN CAP 300MG ................... 33 NEURONTIN CAP 400MG ................... 33

NEURONTIN SOL 250/5ML ................. 33 NEURONTIN TAB 600MG ................... 33

NEURONTIN TAB 800MG ................... 33 nevirapine susp 50 mg/5ml ............... 11

nevirapine tab 200 mg ...................... 11 nevirapine tab er 24hr 100 mg ........... 11 nevirapine tab er 24hr 400 mg ........... 11

NEXAVAR TAB 200MG ....................... 17 NEXIUM 24HR TAB 20MG .................. 74

NEXIUM GRA 10MG DR ..................... 74

NEXIUM GRA 2.5MG DR .................... 74 NEXIUM GRA 5MG DR ....................... 74

niacin cap er 250 mg ........................ 86

niacin cap er 500 mg ........................ 86

niacin tab 100 mg ............................ 86

niacin tab 250 mg ............................ 86

niacin tab 50 mg .............................. 86 niacin tab 500 mg ............................ 86

niacin tab er 1000 mg

(antihyperlipidemic) .......................... 23

niacin tab er 250 mg ......................... 86 niacin tab er 500 mg ......................... 86


..................................................... 23

niacin tab er 750 mg ........................ 86 niacin tab er 750 mg (antihyperlipidemic)

..................................................... 23

niacin w/ inositol cap 400-100 mg ...... 86

niacinamide tab 100 mg ................... 86

niacinamide tab 500 mg ................... 86

nicotine polacrilex gum 2 mg ............. 58

nicotine polacrilex gum 4 mg ............. 58

nicotine td patch 24hr 14 mg/24hr ..... 58

nicotine td patch 24hr 21 mg/24hr ..... 58

nicotine td patch 24hr 7 mg/24hr ...... 58 nifedipine tab er 24hr 30 mg ............. 24

nifedipine tab er 24hr 60 mg ............. 24

nifedipine tab er 24hr 90 mg ............. 24 nifedipine tab er 24hr osmotic release 30

mg ................................................ 24

nifedipine tab er 24hr osmotic release 60 mg ................................................ 24

nifedipine tab er 24hr osmotic release 90 mg ................................................ 24

NITRO-BID OIN 2% ......................... 27

NITRO-DUR DIS 0.3MG/HR ............... 27

NITRO-DUR DIS 0.8MG/HR ............... 27 nitrofurantoin macrocrystalline cap 100

mg ................................................ 15 nitrofurantoin macrocrystalline cap 25

mg ................................................ 15 nitrofurantoin macrocrystalline cap 50

mg ................................................ 15 nitrofurantoin monohydrate macrocrystalline cap 100 mg ............. 15

nitrofurantoin susp 25 mg/5ml .......... 15 nitroglycerin cap er 2.5 mg ............... 27

nitroglycerin cap er 6.5 mg ............... 27

nitroglycerin cap er 9 mg .................. 27 nitroglycerin sl tab 0.3 mg ................ 27

nitroglycerin sl tab 0.4 mg ................ 27

nitroglycerin sl tab 0.6 mg ................ 27

nitroglycerin td patch 24hr 0.1 mg/hr . 27

nitroglycerin td patch 24hr 0.2 mg/hr . 27

nitroglycerin td patch 24hr 0.4 mg/hr . 27 nitroglycerin td patch 24hr 0.6 mg/hr . 27

NITYR TAB 10MG ............................. 66

NITYR TAB 2MG............................... 66

NITYR TAB 5MG............................... 66 NIX CREM RIN LIQ 1% .................... 101

nizatidine cap 150 mg ...................... 72

133

nizatidine cap 300 mg ....................... 72

nizatidine oral soln 15 mg/ml ............. 72 nonoxynol-9 gel 4% ......................... 63

NORDITROPIN INJ 10/1.5ML .............. 67

NORDITROPIN INJ 15/1.5ML .............. 67

NORDITROPIN INJ 30/3ML ................. 67

NORDITROPIN INJ 5/1.5ML ................ 67

norelgestromin-ethinyl estradiol td ptwk

150-35 mcg/24hr ............................. 64

norethindrone & ethinyl estradiol tab 0.4

mg-35 mcg ..................................... 64

norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg ..................................... 64

norethindrone & ethinyl estradiol tab 1

mg-35 mcg ..................................... 64 norethindrone ace & ethinyl estradiol tab

1 mg-20 mcg ................................... 63

norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg ................................ 63

norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg ............................. 63

norethindrone ace & ethinyl estradiol-fe

tab 1.5 mg-30 mcg ........................... 63

norethindrone acetate tab 5 mg ......... 68 norethindrone acetate-ethinyl estradiol

tab 0.5 mg-2.5 mcg .......................... 64 norethindrone acetate-ethinyl estradiol

tab 1 mg-5 mcg ............................... 65 norethindrone tab 0.35 mg ................ 64

norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg .................. 64 norethindrone-eth estradiol tab 0.5-

35/1-35/0.5-35 mg-mcg ................... 64 norgestimate & ethinyl estradiol tab 0.25

mg-35 mcg ..................................... 64

norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg ........... 64

norgestimate-eth estrad tab 0.18-

35/0.215-35/0.25-35 mg-mcg ........... 64

norgestrel & ethinyl estradiol tab 0.3 mg-

30 mcg ........................................... 63

norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg ........................................... 64

NORPACE CAP 100MG ....................... 21

NORPACE CAP 100MG CR .................. 21

NORPACE CAP 150MG ....................... 21 NORPACE CAP 150MG CR .................. 21

NORPRAMIN TAB 10MG ..................... 41

NORPRAMIN TAB 25MG .................... 41

nortriptyline hcl cap 10 mg ............... 41 nortriptyline hcl cap 25 mg ............... 41

nortriptyline hcl cap 50 mg ............... 41

nortriptyline hcl cap 75 mg ............... 41

nortriptyline hcl soln 10 mg/5ml ........ 41

NORVIR POW 100MG ....................... 13

NORVIR SOL 80MG/ML ..................... 13

NORVIR TAB 100MG ........................ 13

NOVOLIN INJ 70/30 ......................... 60

NOVOLIN INJ FLEXPEN ..................... 60

NOVOLIN N INJ RELION .................... 60 NOVOLIN N INJ U-100 ...................... 60

NOVOLIN R INJ RELION .................... 60

NOVOLIN R INJ U-100 ...................... 60 NOVOLIN70/30 INJ RELION .............. 60

NOVOLOG INJ 100/ML ...................... 60

NOVOLOG INJ FLEXPEN .................... 60 NOVOLOG INJ PENFILL ..................... 60

NOVOLOG MIX INJ 70/30 .................. 60 NOVOLOG MIX INJ FLEXPEN .............. 60

NUEDEXTA CAP 20-10MG ................. 57

NUPLAZID CAP 34MG ....................... 47

NUPLAZID TAB 10MG ....................... 47 NUTROPIN AQ INJ 10MG/2ML ............ 67

NUTROPIN AQ INJ 20MG/2ML ............ 67 NUTROPIN AQ INJ NUSPIN 5 ............. 67

NUVARING MIS ............................... 64 nystatin cream 100000 unit/gm ......... 97

nystatin oint 100000 unit/gm ............ 97 nystatin oral powder .......................... 9 nystatin susp 100000 unit/ml .............. 9

nystatin tab 500000 unit .................. 10 nystatin topical powder 100000 unit/gm

..................................................... 97

O ODEFSEY TAB ................................. 10

OFEV CAP 100MG ............................ 94

OFEV CAP 150MG ............................ 94

OFF DEEP WDS AER 25%................. 100

ofloxacin ophth soln 0.3% ............... 102

ofloxacin otic soln 0.3% .................. 104 olanzapine for im inj 10 mg ............... 44

olanzapine orally disintegrating tab 10

mg ................................................ 44

olanzapine orally disintegrating tab 15 mg ................................................ 44

olanzapine orally disintegrating tab 20

134

mg ................................................. 44

olanzapine orally disintegrating tab 5 mg ..................................................... 44

olanzapine tab 10 mg ....................... 44


olanzapine tab 2.5 mg ...................... 44


olanzapine tab 5 mg ......................... 44

olanzapine tab 7.5 mg ...................... 44


..................................................... 44

olanzapine-fluoxetine hcl cap 12-50 mg ..................................................... 44

olanzapine-fluoxetine hcl cap 3-25 mg 44

olanzapine-fluoxetine hcl cap 6-25 mg 44 olanzapine-fluoxetine hcl cap 6-50 mg 44

omega-3 fatty acids - oral liquid ......... 86

omega-3 fatty acids cap 1000 mg ....... 86 omega-3 fatty acids cap 1200 mg ....... 87

omega-3 fatty acids cap 300 mg ........ 86 omega-3 fatty acids cap 435 mg ........ 86

omega-3 fatty acids cap 500 mg ........ 86

omega-3 fatty acids chew tab 113.5 mg

..................................................... 87 omeprazole cap delayed release 10 mg74

omeprazole cap delayed release 20 mg74 omeprazole cap delayed release 40 mg74

omeprazole delayed release tab 20 mg 74 omeprazole magnesium cap dr 20.6 mg

(20 mg base equiv) .......................... 74 omeprazole tab 20mg ....................... 74 omeprazole-sodium bicarbonate cap 20-

1100 mg ......................................... 74 OMNITROPE INJ 10/1.5ML ................. 67

OMNITROPE INJ 5.8MG ..................... 67

OMNITROPE INJ 5/1.5ML ................... 67 ondansetron hcl oral soln 4 mg/5ml .... 71

ondansetron hcl tab 24 mg ................ 71

ondansetron hcl tab 4 mg .................. 71

ondansetron hcl tab 8 mg .................. 71

ondansetron orally disintegrating tab 4

mg ................................................. 71 ondansetron orally disintegrating tab 8

mg ................................................. 71

ONFI SUS 2.5MG/ML ......................... 33

ONFI TAB 10MG ............................... 33 ONFI TAB 20MG ............................... 33

OPSUMIT TAB 10MG ......................... 27

oral electrolyte solution .................... 81

ORENITRAM TAB 0.125MG ................ 28 ORENITRAM TAB 0.25MG .................. 28

ORENITRAM TAB 1MG ...................... 28

ORENITRAM TAB 2.5MG ................... 28

ORENITRAM TAB 5MG ...................... 28

ORKAMBI GRA 100-125 .................... 92

ORKAMBI GRA 150-188 .................... 92

ORKAMBI TAB 100-125 .................... 92

ORKAMBI TAB 200-125 .................... 92

orphenadrine citrate tab er 12hr 100 mg

..................................................... 56 oseltamivir phosphate cap 30 mg (base

equiv) ............................................ 14

oseltamivir phosphate cap 45 mg (base equiv) ............................................ 14

oseltamivir phosphate cap 75 mg (base

equiv) ............................................ 14 oseltamivir phosphate for susp 6 mg/ml

(base equiv) ................................... 14 OSPHENA TAB 60MG ........................ 68

oxaprozin tab 600 mg ........................ 5

oxazepam cap 10 mg ....................... 29

oxazepam cap 15 mg ....................... 29 oxazepam cap 30 mg ....................... 29

oxcarbazepine susp 300 mg/5ml (60 mg/ml) .......................................... 33

oxcarbazepine tab 150 mg ................ 33 oxcarbazepine tab 300 mg ................ 33

oxcarbazepine tab 600 mg ................ 33 OXTELLAR XR TAB 150MG ................ 33 OXTELLAR XR TAB 300MG ................ 33

OXTELLAR XR TAB 600MG ................ 33 oxybutynin chloride syrup 5 mg/5ml .. 75

oxybutynin chloride tab 5 mg ............ 75

oxybutynin chloride tab er 24hr 10 mg 75 oxybutynin chloride tab er 24hr 15 mg 75

oxybutynin chloride tab er 24hr 5 mg . 75

oxycodone hcl cap 5 mg ..................... 6

oxycodone hcl conc 100 mg/5ml (20

mg/ml) ............................................ 6

oxycodone hcl soln 5 mg/5ml .............. 6 oxycodone hcl tab 10 mg .................... 6

oxycodone hcl tab 15 mg .................... 6

oxycodone hcl tab 20 mg .................... 6

oxycodone hcl tab 30 mg .................... 6 oxycodone hcl tab 5 mg ..................... 6

oxycodone w/ acetaminophen tab 10-325

135

mg .................................................. 6

oxycodone w/ acetaminophen tab 2.5-325 mg ............................................ 6

oxycodone w/ acetaminophen tab 5-325

mg .................................................. 6

oxycodone w/ acetaminophen tab 7.5-

325 mg ............................................ 6

oxycodone-aspirin tab 4.8355-325 mg . 6

oyster shell calcium tab 500 mg ......... 83

OZEMPIC INJ 2/1.5ML ....................... 59

P paliperidone tab er 24hr 1.5 mg ......... 44 paliperidone tab er 24hr 3 mg ............ 44

paliperidone tab er 24hr 6 mg ............ 44

paliperidone tab er 24hr 9 mg ............ 44 PAMELOR CAP 10MG ......................... 41

PAMELOR CAP 25MG ......................... 41

PAMELOR CAP 50MG ......................... 41 PAMELOR CAP 75MG ......................... 41

pantoprazole sodium ec tab 20 mg (base equiv) ............................................. 74

pantoprazole sodium ec tab 40 mg (base

equiv) ............................................. 74

pantothenic acid tab 500 mg .............. 87 paricalcitol cap 1 mcg ....................... 67

paricalcitol cap 2 mcg ....................... 67 paricalcitol cap 4 mcg ....................... 67

PARNATE TAB 10MG ......................... 37 paroxetine hcl tab 10 mg ................... 38

paroxetine hcl tab 20 mg ................... 38 paroxetine hcl tab 30 mg ................... 38 paroxetine hcl tab 40 mg ................... 38

paroxetine hcl tab er 24hr 12.5 mg ..... 38 paroxetine hcl tab er 24hr 25 mg........ 38

paroxetine hcl tab er 24hr 37.5 mg ..... 38

PAXIL CR TAB 12.5MG ...................... 38 PAXIL CR TAB 25MG ......................... 38

PAXIL CR TAB 37.5MG ...................... 38

PAXIL SUS 10MG/5ML ....................... 38

PAXIL TAB 10MG .............................. 38

PAXIL TAB 20MG .............................. 38

PAXIL TAB 30MG .............................. 38 PAXIL TAB 40MG .............................. 38

PEDIA-LAX LIQ 50MG ........................ 73

pediatric multiple vitamin liq .............. 87

pediatric multiple vitamin w/ c & fa chew tab ................................................. 87

pediatric multiple vitamin w/ c soln 35

mg/ml ........................................... 87

pediatric multiple vitamin w/ extra c & fa chew tab ........................................ 87

pediatric multiple vitamin w/ minerals &

c chew tab ...................................... 87

pediatric multiple vitamin w/ minerals &

c drops 45 mg/ml ............................ 87

pediatric multiple vitamins w/ fl-fe drops

0.25-10 mg/ml ................................ 87

pediatric multiple vitamins w/ fl-fe drops

0.25-6 mg/ml ................................. 87

pediatric multiple vitamins w/ fluoride chew tab 0.25 mg ............................ 87

pediatric multiple vitamins w/ fluoride

chew tab 0.5 mg ............................. 87 pediatric multiple vitamins w/ fluoride

chew tab 1 mg ................................ 87

pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml .............................. 87

pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml................................ 87

pediatric multiple vitamins w/ iron chew

tab 15 mg ...................................... 87

pediatric multiple vitamins w/ iron drops 10 mg/ml ....................................... 87

PEDIATRIC SM MIS MASK ................. 93 pediatric vitamins acd w/ fluoride soln

0.25 mg/ml .................................... 87 pediatric vitamins acd w/ fluoride soln

0.5 mg/ml ...................................... 87 pediatric vitamins adc drops 1500 unit-400 unit-35 mg/ml .......................... 87

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm ............................... 73

peg 3350-kcl-na bicarb-nacl-na sulfate

for soln 240 gm ............................... 73 peg 3350-kcl-sod bicarb-nacl for soln

420 gm .......................................... 73

PEGANONE TAB 250MG .................... 33

PEGASYS INJ .................................. 78

PEGASYS INJ 180MCG/M .................. 78

PEGASYS INJ PROCLICK ................... 78 PEGINTRON KIT 50MCG .................... 78

penicillin v potassium for soln 125

mg/5ml ............................................ 9

penicillin v potassium for soln 250 mg/5ml ............................................ 9

penicillin v potassium tab 250 mg ........ 9

136

penicillin v potassium tab 500 mg ........ 9

pentoxifylline tab er 400 mg .............. 76 permethrin aerosol 0.5% ................. 101

permethrin cream 5% ..................... 101

permethrin creme rinse 1% ............. 101

permethrin lotion 1% ...................... 101

perphenazine tab 16 mg .................... 47

perphenazine tab 2 mg ..................... 47




..................................................... 47 perphenazine-amitriptyline tab 2-25 mg

..................................................... 47

perphenazine-amitriptyline tab 4-10 mg ..................................................... 47


..................................................... 47 perphenazine-amitriptyline tab 4-50 mg

..................................................... 47 PEXEVA TAB 10MG ........................... 38

PEXEVA TAB 20MG ........................... 38

PEXEVA TAB 30MG ........................... 38

PEXEVA TAB 40MG ........................... 38 phenazopyridine hcl tab 100 mg ......... 75

phenazopyridine hcl tab 200 mg ......... 75 phenelzine sulfate tab 15 mg ............. 37

phenobarbital elixir 20 mg/5ml ........... 33 phenobarbital tab 100 mg ................. 34

phenobarbital tab 15 mg ................... 33 phenobarbital tab 16.2 mg ................ 33 phenobarbital tab 30 mg ................... 33

phenobarbital tab 32.4 mg ................ 33 phenobarbital tab 60 mg ................... 34

phenobarbital tab 64.8 mg ................ 34

phenobarbital tab 97.2 mg ................ 34 PHENYTEK CAP 200MG ...................... 34

PHENYTEK CAP 300MG ...................... 34

phenytoin chew tab 50 mg ................ 34


..................................................... 34

phenytoin sodium extended cap 200 mg ..................................................... 34


..................................................... 34

phenytoin susp 125 mg/5ml .............. 34 phytonadione tab 5 mg ..................... 87

pilocarpine hcl tab 5 mg .................... 74

pilocarpine hcl tab 7.5 mg ................. 74

pindolol tab 10 mg ........................... 24 pindolol tab 5 mg ............................ 24

PINWORM TAB MEDICINE ................. 15


..................................................... 60


..................................................... 60


..................................................... 60

pioglitazone hcl-glimepiride tab 30-2 mg

..................................................... 59 pioglitazone hcl-glimepiride tab 30-4 mg

..................................................... 59

pioglitazone hcl-metformin hcl tab 15-500 mg .......................................... 59

pioglitazone hcl-metformin hcl tab 15-

850 mg .......................................... 59 PNEUMOVAX 23 INJ 25/0.5 ............... 80

podofilox soln 0.5% ........................ 101 polyethylene glycol 3350 oral packet .. 73

polyethylene glycol 3350 oral powder . 73

polyethylene glycol-propylene glycol

ophth soln 0.4-0.3% ....................... 103 polyethylene glycol-propylene glycol pf

op soln 0.4-0.3% ........................... 103 polymyxin b-trimethoprim ophth soln

10000 unit/ml-0.1% ....................... 102 polysaccharide iron complex cap 150 mg

(iron equivalent) ............................. 84 polyvinyl alcohol ophth soln 1.4% ..... 103 polyvinyl alcohol-povidone (pf) ophth

soln 1.4-0.6% ................................ 103 polyvinyl alcohol-povidone ophth soln 5-

6 mg/ml (0.5-0.6%) ....................... 103

potassium bicarbonate effer tab 25 meq ..................................................... 81

potassium chloride cap er 10 meq ...... 81

potassium chloride cap er 8 meq ....... 81

potassium chloride microencapsulated

crys er tab 10 meq .......................... 81

potassium chloride microencapsulated crys er tab 20 meq .......................... 81

potassium chloride oral soln 10% (20

meq/15ml) ..................................... 81

potassium chloride oral soln 20% (40 meq/15ml) ..................................... 81

potassium chloride tab er 10 meq ...... 81

137

potassium chloride tab er 20 meq (1500

mg) ................................................ 81 potassium chloride tab er 8 meq (600

mg) ................................................ 81

potassium citrate & citric acid powder

pack 3300-1002 mg ......................... 75

potassium citrate & citric acid soln 1100-

334 mg/5ml .................................... 75

potassium citrate tab er 10 meq (1080

mg) ................................................ 75

potassium citrate tab er 15 meq (1620

mg) ................................................ 75 potassium citrate tab er 5 meq (540 mg)

..................................................... 75

povidone-iodine oint 10% .................. 97 povidone-iodine soln 10% ................. 97

povidone-iodine soln 7.5% ................ 97

pramipexole dihydrochloride tab 0.125 mg ................................................. 42

pramipexole dihydrochloride tab 0.25 mg ..................................................... 42


..................................................... 42

pramipexole dihydrochloride tab 0.75 mg ..................................................... 42

pramipexole dihydrochloride tab 1 mg . 42 pramipexole dihydrochloride tab 1.5 mg

..................................................... 42 prasugrel hcl tab 10 mg (base equiv) .. 77

prasugrel hcl tab 5 mg (base equiv) .... 77 pravastatin sodium tab 10 mg ............ 23 pravastatin sodium tab 20 mg ............ 23

pravastatin sodium tab 40 mg ............ 23 pravastatin sodium tab 80 mg ............ 23

prazosin hcl cap 1 mg ....................... 20

prazosin hcl cap 2 mg ....................... 20 prazosin hcl cap 5 mg ....................... 20

PRECISION TES XTRA ....................... 62

PRED SOD PHO SOL 1% OP ............. 102

prednisolone acetate ophth susp 1% . 102

prednisolone sod phos orally disintegr

tab 10 mg (base eq) ......................... 65 prednisolone sod phos orally disintegr

tab 15 mg (base eq) ......................... 66

prednisolone sod phos orally disintegr

tab 30 mg (base eq) ......................... 66 prednisolone sod phosph oral soln 6.7

mg/5ml (5 mg/5ml base) .................. 66

prednisolone sod phosphate oral soln 15

mg/5ml (base equiv) ....................... 66 prednisolone syrup 15 mg/5ml (usp

solution equivalent) ......................... 66

prednisone oral soln 5 mg/5ml .......... 66

prednisone tab 1 mg ........................ 66

prednisone tab 10 mg ...................... 66

prednisone tab 2.5 mg ..................... 66


prednisone tab 5 mg ........................ 66


prednisone tab therapy pack 10 mg (21) ..................................................... 66


..................................................... 66 prednisone tab therapy pack 5 mg (21)

..................................................... 66

prednisone tab therapy pack 5 mg (48) ..................................................... 66

pregabalin cap 100 mg ..................... 34 pregabalin cap 150 mg ..................... 34

pregabalin cap 200 mg ..................... 34

pregabalin cap 225 mg ..................... 34

pregabalin cap 25 mg ....................... 34 pregabalin cap 300 mg ..................... 34

pregabalin cap 50 mg ....................... 34 pregabalin cap 75 mg ....................... 34

pregabalin soln 20 mg/ml ................. 34 PREMARIN VAG CRE 0.625MG ........... 65

PRENAISSANCE CAP PLUS ................ 88 prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg ......................................... 88

prenatal vit w/ dss-iron carbonyl-fa tab 90-1 mg ......................................... 89

prenatal vit w/ fe fumarate-fa chew tab

29-1 mg ......................................... 89 prenatal vit w/ iron carbonyl-fa tab 29-1

mg ................................................ 89

PREZCOBIX TAB 800-150 ................. 10

PREZISTA SUS 100MG/ML ................ 13

PREZISTA TAB 150MG ...................... 13

PREZISTA TAB 600MG ...................... 13 PREZISTA TAB 75MG ....................... 13

PREZISTA TAB 800MG ...................... 13

PRILOSEC OTC TAB 20MG ................. 74

primidone tab 250 mg ...................... 34 primidone tab 50 mg ........................ 34

PRISTIQ TAB 100MG ........................ 39

138

PRISTIQ TAB 25MG .......................... 39

PRISTIQ TAB 50MG .......................... 39 PROAIR RESPI AER ........................... 92

probenecid tab 500 mg ...................... 3

prochlorperazine maleate tab 10 mg

(base equivalent) ............................. 71


equivalent) ...................................... 71

prochlorperazine suppos 25 mg .......... 71

progesterone micronized cap 100 mg .. 68

progesterone micronized cap 200 mg .. 68

PROGRAF CAP 0.5MG ........................ 79 PROGRAF CAP 1MG ........................... 79

PROGRAF CAP 5MG ........................... 79

PROMACTA TAB 12.5MG .................... 77 PROMACTA TAB 25MG ....................... 77

PROMACTA TAB 50MG ....................... 77

PROMACTA TAB 75MG ....................... 77 promethazine & phenylephrine syrup

6.25-5 mg/5ml ................................ 89 promethazine hcl suppos 12.5 mg ...... 71

promethazine hcl suppos 25 mg ......... 71

promethazine hcl suppos 50 mg ......... 71

promethazine hcl syrup 6.25 mg/5ml .. 71 promethazine hcl tab 12.5 mg ............ 71

promethazine hcl tab 25 mg .............. 71 promethazine hcl tab 50 mg .............. 71

promethazine w/ codeine syrup 6.25-10 mg/5ml ........................................... 91

promethazine-dm syrup 6.25-15 mg/5ml ..................................................... 91 promethazine-phenylephrine-codeine

syrup 6.25-5-10 mg/5ml ................... 91 propafenone hcl cap er 12hr 225 mg ... 21

propafenone hcl cap er 12hr 325 mg ... 21

propafenone hcl cap er 12hr 425 mg ... 21 propafenone hcl tab 150 mg .............. 22

propafenone hcl tab 225 mg .............. 22

propafenone hcl tab 300 mg .............. 22

propranolol hcl cap er 24hr 120 mg .... 24

propranolol hcl cap er 24hr 160 mg .... 24

propranolol hcl cap er 24hr 60 mg ...... 24 propranolol hcl cap er 24hr 80 mg ...... 24

propranolol hcl oral soln 20 mg/5ml .... 24

propranolol hcl oral soln 40 mg/5ml .... 24

propranolol hcl tab 10 mg .................. 24 propranolol hcl tab 20 mg .................. 24

propranolol hcl tab 40 mg .................. 24

propranolol hcl tab 60 mg ................. 24

propranolol hcl tab 80 mg ................. 24 propylene glycol ophth soln 0.6% ..... 103

propylene glycol-glycerin ophth soln 1-

0.3% ............................................ 103

propylthiouracil tab 50 mg ................ 68

protriptyline hcl tab 10 mg ................ 41

protriptyline hcl tab 5 mg ................. 41

PROZAC CAP 10MG .......................... 38

PROZAC CAP 20MG .......................... 38

PROZAC CAP 40MG .......................... 38

pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml ..................................... 91

pseudoephedrine hcl liq 15 mg/5ml .... 92

pseudoephedrine hcl tab 30 mg ......... 92 pseudoephedrine hcl tab 60 mg ......... 92

pseudoephedrine hcl tab er 12hr 120 mg

..................................................... 92 pseudoephedrine w/ cod-gg soln 30-10-

100 mg/5ml .................................... 91 pseudoephedrine w/ dm-gg liquid 30-10-

100 mg/5ml .................................... 91

pseudoephedrine-guaifenesin tab er 12hr

120-1200 mg .................................. 92 pseudoephedrine-guaifenesin tab er 12hr

60-600 mg ..................................... 92 PULMOZYME SOL 1MG/ML ................. 92

pyrantel pamoate susp 144 mg/ml (50 mg/ml base equiv) .......................... 15

pyrazinamide tab 500 mg ................. 13 pyridostigmine bromide oral soln 60 mg/5ml .......................................... 56

pyridostigmine bromide tab 60 mg ..... 56 pyridostigmine bromide tab er 180 mg 56

pyridoxine hcl tab 100 mg ................ 87

pyridoxine hcl tab 25 mg .................. 87 pyridoxine hcl tab 250 mg ................ 87

pyridoxine hcl tab 50 mg .................. 87

pyridoxine hcl tab 500 mg ................ 88

pyridoxine hcl tab er 200 mg ............. 88

Q quetiapine fumarate tab 100 mg ........ 44 quetiapine fumarate tab 200 mg ........ 44

quetiapine fumarate tab 25 mg ......... 44

quetiapine fumarate tab 300 mg ........ 44

quetiapine fumarate tab 400 mg ........ 44 quetiapine fumarate tab 50 mg ......... 44


139

..................................................... 44

quetiapine fumarate tab er 24hr 200 mg ..................................................... 45


..................................................... 45


..................................................... 45


..................................................... 44

quinapril hcl tab 10 mg ..................... 19

quinapril hcl tab 20 mg ..................... 19

quinapril hcl tab 40 mg ..................... 19 quinapril hcl tab 5 mg ....................... 19

quinapril-hydrochlorothiazide tab 10-12.5

mg ................................................. 19 quinapril-hydrochlorothiazide tab 20-12.5

mg ................................................. 19

quinapril-hydrochlorothiazide tab 20-25 mg ................................................. 19

QVAR REDIHA AER 80MCG ................ 94 QVAR REDIHAL AER 40MCG ............... 95

R raloxifene hcl tab 60 mg .................... 68

ramipril cap 1.25 mg ........................ 19 ramipril cap 10 mg ........................... 20

ramipril cap 2.5 mg .......................... 20 ramipril cap 5 mg ............................. 20

ranitidine hcl cap 150 mg .................. 72 ranitidine hcl cap 300 mg .................. 72

ranitidine hcl syrup 15 mg/ml (75 mg/5ml) ......................................... 72 ranitidine hcl tab 150 mg ................... 72

ranitidine hcl tab 300 mg ................... 72 ranitidine hcl tab 75 mg .................... 72

RAPAMUNE SOL 1MG/ML ................... 79

RAPAMUNE TAB 0.5MG ...................... 79 RAPAMUNE TAB 1MG ........................ 79

RAPAMUNE TAB 2MG ........................ 79

REBIF INJ 22/0.5 ............................. 56

REBIF INJ 44/0.5 ............................. 56

REBIF REBIDO INJ 22/0.5 .................. 56

REBIF REBIDO INJ 44/0.5 .................. 56 REBIF REBIDO INJ TITRATN ............... 56

REBIF TITRTN INJ PACK .................... 56

RECOMBIVA HB INJ 10MCG/ML .......... 80

RECOMBIVA HB INJ 5MCG/0.5 ........... 80 RECOMBIVA-HB INJ 40MCG/ML .......... 80

REFRESH OPTI DRO 0.5-0.9% .......... 103

REFRESH SOL OPTIVE ..................... 103

REMERON SLTB TAB 15MG ................ 37 REMERON SLTB TAB 30MG ................ 37

REMERON SLTB TAB 45MG ................ 37

REMERON TAB 15MG ....................... 37

REMERON TAB 30MG ....................... 37

repaglinide tab 0.5 mg ..................... 60

repaglinide tab 1 mg ........................ 60

repaglinide tab 2 mg ........................ 60

REPEL SPORTS AER 25% ................. 100

RESCRIPTOR TAB 200MG .................. 11

RETROVIR CAP 100MG ..................... 12 RETROVIR SYP 50MG/5ML ................ 12

REVLIMID CAP 10MG ....................... 16

REVLIMID CAP 15MG ....................... 16 REVLIMID CAP 2.5MG ...................... 16

REVLIMID CAP 20MG ....................... 16

REVLIMID CAP 25MG ....................... 16 REVLIMID CAP 5MG ......................... 16

REXULTI TAB 0.25MG ....................... 45 REXULTI TAB 0.5MG ........................ 45

REXULTI TAB 1MG ........................... 45

REXULTI TAB 2MG ........................... 45

REXULTI TAB 3MG ........................... 45 REXULTI TAB 4MG ........................... 45

REYATAZ CAP 150MG ....................... 13 REYATAZ CAP 200MG ....................... 13

REYATAZ CAP 300MG ....................... 13 REYATAZ POW 50MG ........................ 13

RHINARIS SPR 0.2% ........................ 94 RIBAPAK PAK 1200/DAY ................... 14 RIBAPAK PAK 800/DAY ..................... 14

RIBAPAK TAB 1000/DAY ................... 14 RIBAPAK TAB 600/DAY ..................... 14

ribasphere cap 200mg ...................... 14

ribasphere tab 200mg ...................... 14 RIBASPHERE TAB 400MG .................. 14

ribasphere tab 600mg ...................... 14

ribavirin cap 200 mg ........................ 14

ribavirin tab 200 mg ........................ 14

riboflavin tab 100 mg ....................... 88

riboflavin tab 25 mg ......................... 88 riboflavin tab 50 mg ......................... 88

RID AER ........................................ 101

rifabutin cap 150 mg ........................ 15

rifampin cap 150 mg ........................ 13 rifampin cap 300 mg ........................ 13

riluzole tab 50 mg ........................... 55

140

RISPERDAL INJ 12.5MG ..................... 45

RISPERDAL INJ 25MG ....................... 45 RISPERDAL INJ 37.5MG ..................... 45

RISPERDAL INJ 50MG ....................... 45

RISPERDAL SOL 1MG/ML ................... 45

RISPERDAL TAB 0.25MG .................... 45

RISPERDAL TAB 0.5MG ..................... 45

RISPERDAL TAB 1MG ........................ 45

RISPERDAL TAB 2MG ........................ 45

RISPERDAL TAB 3MG ........................ 45

RISPERDAL TAB 4MG ........................ 45

risperidone orally disintegrating tab 0.25 mg ................................................. 45

risperidone orally disintegrating tab 0.5

mg ................................................. 45 risperidone orally disintegrating tab 1 mg

..................................................... 45

risperidone orally disintegrating tab 2 mg ..................................................... 45

risperidone orally disintegrating tab 3 mg ..................................................... 45


..................................................... 45

risperidone soln 1 mg/ml ................... 45 risperidone tab 0.25 mg .................... 45

risperidone tab 0.5 mg ...................... 45 risperidone tab 1 mg ......................... 45

risperidone tab 2 mg ......................... 45 risperidone tab 3 mg ......................... 45

risperidone tab 4 mg ......................... 45 ritonavir tab 100 mg ......................... 13 rivastigmine tartrate cap 1.5 mg (base

equivalent) ...................................... 36 rivastigmine tartrate cap 3 mg (base

equivalent) ...................................... 36

rivastigmine tartrate cap 4.5 mg (base equivalent) ...................................... 36

rivastigmine tartrate cap 6 mg (base

equivalent) ...................................... 36

rivastigmine td patch 24hr 13.3 mg/24hr

..................................................... 36

rivastigmine td patch 24hr 4.6 mg/24hr ..................................................... 36

rivastigmine td patch 24hr 9.5 mg/24hr

..................................................... 36

rizatriptan benzoate oral disintegrating tab 10 mg (base eq) ......................... 54

rizatriptan benzoate oral disintegrating

tab 5 mg (base eq) .......................... 54

rizatriptan benzoate tab 10 mg (base equivalent) ..................................... 54

rizatriptan benzoate tab 5 mg (base

equivalent) ..................................... 54

ropinirole hydrochloride tab 0.25 mg .. 42

ropinirole hydrochloride tab 0.5 mg .... 42

ropinirole hydrochloride tab 1 mg ...... 42




ropinirole hydrochloride tab 5 mg ...... 42 RUBRACA TAB 200MG ...................... 18

RUBRACA TAB 250MG ...................... 18

RUBRACA TAB 300MG ...................... 18 RYDAPT CAP 25MG .......................... 17

RYTHMOL SR CAP 225MG ................. 22

RYTHMOL SR CAP 325MG ................. 22 RYTHMOL SR CAP 425MG ................. 22

S SABRIL POW 500MG ........................ 34

SABRIL TAB 500MG ......................... 34

SAIZEN INJ 5MG ............................. 67

SAIZEN INJ 8.8MG ........................... 67 SAIZENPREP INJ 8.8MG .................... 67

saline nasal spray 0.65% .................. 94 SAMSCA TAB 15MG .......................... 69

SAMSCA TAB 30MG .......................... 69 SANDIMMUNE CAP 100MG ................ 79

SANDIMMUNE CAP 25MG .................. 79 SANDIMMUNE SOL 100MG/ML ........... 79 SAPHRIS SUB 10MG ......................... 45

SAPHRIS SUB 2.5MG ........................ 45 SAPHRIS SUB 5MG .......................... 45

SARAFEM TAB 10MG ........................ 38

SARAFEM TAB 20MG ........................ 38 SAVELLA MIS TITR PAK .................... 53

SAVELLA TAB 100MG ....................... 53

SAVELLA TAB 12.5MG ...................... 53

SAVELLA TAB 25MG ......................... 53

SAVELLA TAB 50MG ......................... 53

SAWYER REPEL SPR 20% ................ 100 selegiline hcl cap 5 mg ..................... 42

selegiline hcl tab 5 mg ..................... 42

selenium sulfide lotion 1% ................ 97

selenium sulfide lotion 2.5% ............. 97 SELZENTRY SOL 20MG/ML ................ 10

SELZENTRY TAB 150MG ................... 11

141

SELZENTRY TAB 25MG ...................... 10

SELZENTRY TAB 300MG .................... 11 SELZENTRY TAB 75MG ...................... 11

sennosides chew tab 15 mg ............... 73

sennosides syrup 8.8 mg/5ml ............ 73

sennosides tab 15 mg ....................... 73

sennosides tab 17.2 mg .................... 73

sennosides tab 25 mg ....................... 73

sennosides tab 8.6 mg ...................... 73

sennosides-docusate sodium tab 8.6-50

mg ................................................. 73

SENSIPAR TAB 30MG ........................ 62 SENSIPAR TAB 60MG ........................ 62

SENSIPAR TAB 90MG ........................ 62

SEROQUEL TAB 100MG ..................... 45 SEROQUEL TAB 200MG ..................... 45

SEROQUEL TAB 25MG ....................... 45

SEROQUEL TAB 300MG ..................... 45 SEROQUEL TAB 400MG ..................... 45

SEROQUEL TAB 50MG ....................... 45 SEROQUEL XR TAB 150MG ................ 45

SEROQUEL XR TAB 200MG ................ 46

SEROQUEL XR TAB 300MG ................ 46

SEROQUEL XR TAB 400MG ................ 46 SEROQUEL XR TAB 50MG .................. 45

SEROSTIM INJ 4MG .......................... 67 SEROSTIM INJ 5MG .......................... 67

SEROSTIM INJ 6MG .......................... 67 sertraline hcl oral concentrate for

solution 20 mg/ml ............................ 38 sertraline hcl tab 100 mg................... 38 sertraline hcl tab 25 mg .................... 38

sertraline hcl tab 50 mg .................... 38 sevelamer carbonate packet 0.8 gm .... 68

sevelamer carbonate packet 2.4 gm .... 68

sevelamer carbonate tab 800 mg ........ 68 SHUR-SEAL GEL 2% ......................... 63

sildenafil citrate for suspension 10 mg/ml

..................................................... 27

sildenafil citrate tab 20 mg ................ 27

silver sulfadiazine cream 1% .............. 97

simethicone cap 125 mg .................... 73 simethicone cap 180 mg .................... 73

simethicone chew tab 125 mg ............ 73

simethicone chew tab 80 mg .............. 73

simethicone liquid 40 mg/0.6ml ......... 73 simethicone susp 40 mg/0.6ml ........... 73

SIMPLY SALIN AER 0.9% ................... 94

simvastatin tab 10 mg ...................... 23

simvastatin tab 20 mg ...................... 23 simvastatin tab 40 mg ...................... 23

simvastatin tab 5 mg ....................... 23

simvastatin tab 80 mg ...................... 23

sirolimus oral soln 1 mg/ml ............... 79

sirolimus tab 0.5 mg ........................ 79

sirolimus tab 1 mg ........................... 79

sirolimus tab 2 mg ........................... 79

SM CALAMINE LOT .......................... 101

sodium chloride aero soln 0.9% ......... 94

sodium chloride soln nebu 0.9% ........ 94 sodium chloride soln nebu 10% ......... 94

sodium chloride soln nebu 3% ........... 94

sodium chloride soln nebu 7% ........... 94 sodium fluoride chew tab 0.25 mg f

(from 0.55 mg naf) .......................... 88

sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) .................................... 88

sodium fluoride chew tab 1 mg f (from 2.2 mg naf) .................................... 88

sodium fluoride cream 1.1% ............ 101

sodium fluoride gel 1.1% (0.5% f) .... 101

sodium fluoride paste 1.1% ............. 101 sodium fluoride rinse 0.2% .............. 101

sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf) ........................ 88

sodium fluoride soln 0.25 mg/drop f (from 0.55 mg/drop naf) .................. 88

sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) ............................... 88 sodium fluoride tab 0.5 mg f (from 1.1

mg naf) .......................................... 88 sodium fluoride tab 1 mg f (from 2.2 mg

naf) ............................................... 88

sodium phenylbutyrate oral powder 3 gm/teaspoonful ............................... 69

sodium phenylbutyrate tab 500 mg .... 69

sodium polystyrene sulfonate oral susp

15 gm/60ml .................................... 68

sodium polystyrene sulfonate rectal susp

30 gm/120ml .................................. 68 SOLIQUA INJ 100/33 ....................... 59

sotalol hcl (afib/afl) tab 120 mg ......... 22

sotalol hcl (afib/afl) tab 160 mg ......... 22

sotalol hcl (afib/afl) tab 80 mg .......... 22 sotalol hcl tab 120 mg ...................... 22

sotalol hcl tab 160 mg ...................... 22

142

sotalol hcl tab 240 mg....................... 22

sotalol hcl tab 80 mg ........................ 22 spinosad susp 0.9% ........................ 101

spironolactone & hydrochlorothiazide tab

25-25 mg ........................................ 25

spironolactone tab 100 mg ................ 20

spironolactone tab 25 mg .................. 20

spironolactone tab 50 mg .................. 20

SSKI SOL 1GM/ML ............................ 68

stavudine cap 15 mg ........................ 12

stavudine cap 20 mg ........................ 12

stavudine cap 30 mg ........................ 12 stavudine cap 40 mg ........................ 12

STIOLTO AER 2.5-2.5 ....................... 89

STIVARGA TAB 40MG ........................ 17 STRIBILD TAB .................................. 10

STRIVERDI AER 2.5MCG .................... 91

sucralfate tab 1 gm .......................... 73 SUDAFED 24HR TAB 240MG ............... 92

sulfacetamide sodium lotion 10% (acne) ..................................................... 96

sulfacetamide sodium ophth soln 10%

................................................... 102

sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% ............. 101

SULFADIAZINE TAB 500MG ................ 9 sulfamethoxazole-trimethoprim susp

200-40 mg/5ml ................................. 9 sulfamethoxazole-trimethoprim tab 400-

80 mg ............................................. 9 sulfamethoxazole-trimethoprim tab 800-160 mg ............................................ 9

sulfasalazine tab 500 mg ................... 72 sulfasalazine tab delayed release 500 mg

..................................................... 72

sulindac tab 150 mg .......................... 5 sulindac tab 200 mg .......................... 5

sumatriptan nasal spray 20 mg/act ..... 54

sumatriptan nasal spray 5 mg/act ....... 54

sumatriptan succinate inj 6 mg/0.5ml . 54

sumatriptan succinate solution auto-

injector 4 mg/0.5ml .......................... 54 sumatriptan succinate solution auto-

injector 6 mg/0.5ml .......................... 54

sumatriptan succinate solution cartridge

4 mg/0.5ml ..................................... 54 sumatriptan succinate solution cartridge

6 mg/0.5ml ..................................... 54

sumatriptan succinate tab 100 mg ..... 55

sumatriptan succinate tab 25 mg ....... 54 sumatriptan succinate tab 50 mg ....... 55

SUSTIVA CAP 200MG ....................... 11

SUSTIVA CAP 50MG ......................... 11

SUSTIVA TAB 600MG ....................... 11

SUTENT CAP 12.5MG ....................... 17

SUTENT CAP 25MG .......................... 17

SUTENT CAP 37.5MG ....................... 17

SUTENT CAP 50MG .......................... 17

SYMDEKO TAB 100-150 .................... 92

SYMDEKO TAB 50-75MG ................... 92 SYMFI LO TAB ................................. 10

SYMFI TAB ...................................... 10

SYMTUZA TAB ................................. 10 SYNAREL SOL 2MG/ML ..................... 64

SYNTHROID TAB 100MCG ................. 69

SYNTHROID TAB 112MCG ................. 69 SYNTHROID TAB 125MCG ................. 69

SYNTHROID TAB 137MCG ................. 69 SYNTHROID TAB 150MCG ................. 69



SYNTHROID TAB 25MCG ................... 69 SYNTHROID TAB 300MCG ................. 69

SYNTHROID TAB 50MCG ................... 69 SYNTHROID TAB 75MCG ................... 69

SYNTHROID TAB 88MCG ................... 69 SYSTANE GEL 0.3% ........................ 103

T tacrolimus cap 0.5 mg ...................... 79 tacrolimus cap 1 mg ........................ 79

tacrolimus cap 5 mg ........................ 79 tacrolimus oint 0.03% ...................... 98

tacrolimus oint 0.1% ........................ 98

TAFINLAR CAP 50MG ........................ 17 TAFINLAR CAP 75MG ........................ 17

tamoxifen citrate tab 10 mg (base

equivalent) ..................................... 15

tamoxifen citrate tab 20 mg (base

equivalent) ..................................... 15

tamsulosin hcl cap 0.4 mg ................ 74 TDVAX INJ 2-2 LF ............................ 80

TECFIDERA CAP 120MG .................... 56

TECFIDERA CAP 240MG .................... 56

TECFIDERA MIS STARTER ................. 56 TEGRETOL SUS 100/5ML .................. 34

TEGRETOL TAB 200MG ..................... 34

143

TEGRETOL-XR TAB 100MG ................. 34

TEGRETOL-XR TAB 200MG ................. 34 TEGRETOL-XR TAB 400MG ................. 34

temazepam cap 15 mg ...................... 53

temazepam cap 22.5 mg ................... 53

temazepam cap 30 mg ...................... 53

temazepam cap 7.5 mg ..................... 53

temozolomide cap 100 mg ................. 15



temozolomide cap 20 mg .................. 15

temozolomide cap 250 mg ................. 15 temozolomide cap 5 mg .................... 15

TENIVAC INJ 5-2LF ........................... 80

tenofovir disoproxil fumarate tab 300 mg ..................................................... 12


..................................................... 20 terazosin hcl cap 10 mg (base

equivalent) ...................................... 20 terazosin hcl cap 2 mg (base equivalent)

..................................................... 20


..................................................... 20 terbinafine hcl tab 250 mg ................. 10

terbutaline sulfate tab 2.5 mg ............ 92 terbutaline sulfate tab 5 mg ............... 92

terconazole vaginal cream 0.4% ......... 76 terconazole vaginal cream 0.8% ......... 76

terconazole vaginal suppos 80 mg ...... 76 testosterone td gel 10mg/act (2%) ..... 58 testosterone td gel 25 mg/2.5gm (1%)58

tetrabenazine tab 12.5 mg ................ 53 tetrabenazine tab 25 mg ................... 53

tetracycline hcl cap 250 mg ................ 9

tetracycline hcl cap 500 mg ................ 9 THEO-24 CAP 100MG CR ................... 95

THEO-24 CAP 200MG CR ................... 95

THEO-24 CAP 300MG CR ................... 95

THEO-24 CAP 400MG ER ................... 95

theophylline soln 80 mg/15ml ............ 95

theophylline tab er 12hr 100 mg ........ 95 theophylline tab er 12hr 200 mg ........ 95

theophylline tab er 12hr 300 mg ........ 95

theophylline tab er 12hr 450 mg ........ 95

theophylline tab er 24hr 400 mg ........ 95 theophylline tab er 24hr 600 mg ........ 95

THERATEARS SOL 0.25% PF ............ 103

thiamine hcl tab 100 mg ................... 88

thiamine hcl tab 250 mg ................... 88 thiamine hcl tab 50 mg .................... 88

thiamine mononitrate tab 100 mg ...... 88

thioridazine hcl tab 10 mg ................ 47

thioridazine hcl tab 100 mg ............... 47



thiothixene cap 1 mg ....................... 47

thiothixene cap 10 mg ...................... 47

thiothixene cap 2 mg ....................... 47

thiothixene cap 5 mg ....................... 47 tiagabine hcl tab 12 mg .................... 34

tiagabine hcl tab 16 mg .................... 34

tiagabine hcl tab 2 mg ...................... 34 tiagabine hcl tab 4 mg ...................... 34

TIKOSYN CAP 125MCG ..................... 22

TIKOSYN CAP 250MCG ..................... 22 TIKOSYN CAP 500MCG ..................... 22

timolol maleate ophth gel forming soln 0.25% .......................................... 103

timolol maleate ophth gel forming soln

0.5% ............................................ 103

timolol maleate ophth soln 0.25% ..... 103 timolol maleate ophth soln 0.5% ...... 103

timolol maleate tab 10 mg ................ 24 timolol maleate tab 20 mg ................ 24

timolol maleate tab 5 mg .................. 24 TIVICAY TAB 10MG .......................... 11

TIVICAY TAB 25MG .......................... 11 TIVICAY TAB 50MG .......................... 11 tizanidine hcl tab 2 mg (base equivalent)

..................................................... 56 tizanidine hcl tab 4 mg (base equivalent)

..................................................... 56

tobramycin nebu soln 300 mg/5ml ..... 92 tobramycin ophth soln 0.3% ............ 102

TOFRANIL TAB 10MG ....................... 41

TOFRANIL TAB 25MG ....................... 41

TOFRANIL TAB 50MG ....................... 41

TOLAK CRE 4% ............................... 96

tolnaftate aerosol pow 1% ................ 97 tolnaftate cream 1% ........................ 97

tolnaftate soln 1% ........................... 97

tolterodine tartrate tab 1 mg ............. 75

tolterodine tartrate tab 2 mg ............. 75 TOPAMAX SPR CAP 15MG ................. 34

TOPAMAX SPR CAP 25MG ................. 34

144

TOPAMAX TAB 100MG ....................... 34

TOPAMAX TAB 200MG ....................... 34 TOPAMAX TAB 25MG ......................... 34

TOPAMAX TAB 50MG ......................... 34


..................................................... 34


..................................................... 34


..................................................... 34

topiramate cap er 24hr sprinkle 25 mg 34

topiramate cap er 24hr sprinkle 50 mg 34 topiramate sprinkle cap 15 mg ........... 35

topiramate sprinkle cap 25 mg ........... 35

topiramate tab 100 mg ..................... 35 topiramate tab 200 mg ..................... 35

topiramate tab 25 mg ....................... 35

topiramate tab 50 mg ....................... 35 toremifene citrate tab 60 mg (base

equivalent) ...................................... 16 torsemide tab 10 mg ........................ 26

torsemide tab 100 mg ....................... 26

torsemide tab 20 mg ........................ 26

torsemide tab 5 mg .......................... 26 TRACLEER TAB 32MG ........................ 27

tramadol hcl tab 50 mg ...................... 6 tramadol hcl tab er 24hr 100 mg ......... 6

tramadol hcl tab er 24hr 200 mg ......... 7 tramadol hcl tab er 24hr 300 mg ......... 7

tramadol hcl tab er 24hr biphasic release 300 mg ............................................ 7 tramadol-acetaminophen tab 37.5-325

mg .................................................. 7 trandolapril tab 1 mg ........................ 20

trandolapril tab 2 mg ........................ 20

trandolapril tab 4 mg ........................ 20 TRANXENE T TAB 7.5MG ................... 29

tranylcypromine sulfate tab 10 mg ...... 37

trazodone hcl tab 100 mg .................. 37



trazodone hcl tab 50 mg .................... 37 tretinoin cap 10 mg .......................... 18

tretinoin cream 0.025% .................... 96

tretinoin cream 0.05% ...................... 96

tretinoin cream 0.1% ........................ 96 tretinoin gel 0.01%........................... 96

tretinoin gel 0.025% ......................... 96

triamcinolone acetonide cream 0.025%

..................................................... 99 triamcinolone acetonide cream 0.1% .. 99

triamcinolone acetonide cream 0.5% .. 98

triamcinolone acetonide dental paste

0.1% ............................................ 101

triamcinolone acetonide lotion 0.025% 99

triamcinolone acetonide lotion 0.1% ... 99

triamcinolone acetonide nasal aerosol

suspension 55 mcg/act ..................... 94

triamcinolone acetonide oint 0.025% .. 99

triamcinolone acetonide oint 0.1% ..... 99 triamcinolone acetonide oint 0.5% ..... 98

triamterene & hydrochlorothiazide cap

37.5-25 mg .................................... 25 triamterene & hydrochlorothiazide tab

37.5-25 mg .................................... 26

triamterene & hydrochlorothiazide tab 75-50 mg ....................................... 26

trifluoperazine hcl tab 1 mg (base equivalent) ..................................... 47

trifluoperazine hcl tab 10 mg (base

equivalent) ..................................... 47



trifluridine ophth soln 1% ................ 102 trihexyphenidyl hcl elixir 0.4 mg/ml ... 42

trihexyphenidyl hcl tab 2 mg ............. 42 trihexyphenidyl hcl tab 5 mg ............. 42 TRILEPTAL SUS 300MG/5M ............... 35

TRILEPTAL TAB 150MG ..................... 35 TRILEPTAL TAB 300MG ..................... 35

TRILEPTAL TAB 600MG ..................... 35

trimethobenzamide hcl cap 300 mg .... 71 trimethoprim tab 100 mg .................. 15

trimipramine maleate cap 100 mg ...... 41

trimipramine maleate cap 25 mg ....... 41

trimipramine maleate cap 50 mg ....... 41

TRINTELLIX TAB 10MG ..................... 38

TRINTELLIX TAB 20MG ..................... 38 TRINTELLIX TAB 5MG ....................... 38

TRIUMEQ TAB ................................. 10

TRIZIVIR TAB ................................. 10

TROKENDI XR CAP 100MG ................ 35 TROKENDI XR CAP 200MG ................ 35

TROKENDI XR CAP 25MG .................. 35

145

TROKENDI XR CAP 50MG ................... 35

trospium chloride cap er 24hr 60 mg ... 75 trospium chloride tab 20 mg .............. 75

TRULANCE TAB 3MG ......................... 72

TRULICITY INJ 0.75/0.5 .................... 59

TRULICITY INJ 1.5/0.5 ...................... 59

TRUVADA TAB 100-150 ..................... 10

TRUVADA TAB 133-200 ..................... 10

TRUVADA TAB 167-250 ..................... 10

TRUVADA TAB 200-300 ..................... 10

TUMS CHW DEL CHW 1177MG ........... 70

TWINRIX INJ ................................... 80 TYBOST TAB 150MG ......................... 10

TYKERB TAB 250MG ......................... 17

TYVASO REFIL SOL 0.6MG/ML ............ 28 TYVASO SOL 0.6MG/ML ..................... 28

TYVASO START SOL 0.6MG/ML ........... 28

U UNI-SOLVE PAD WIPES ..................... 97

UPTRAVI TAB 1000MCG .................... 28 UPTRAVI TAB 1200MCG .................... 28

UPTRAVI TAB 1400MCG .................... 28

UPTRAVI TAB 1600MCG .................... 28

UPTRAVI TAB 200/800 ...................... 27 UPTRAVI TAB 200MCG ...................... 27

UPTRAVI TAB 400MCG ...................... 27 UPTRAVI TAB 600MCG ...................... 27

UPTRAVI TAB 800MCG ...................... 27 URISTIX 4 TES ................................. 81

URISTIX TES ................................... 81 ursodiol cap 300 mg ......................... 71 ursodiol tab 250 mg .......................... 71

ursodiol tab 500 mg .......................... 71 V valacyclovir hcl tab 1 gm ................... 14

valacyclovir hcl tab 500 mg ............... 14 valganciclovir hcl for soln 50 mg/ml

(base equiv) .................................... 13

valganciclovir hcl tab 450 mg (base

equivalent) ...................................... 13

VALIUM TAB 10MG ........................... 29

VALIUM TAB 2MG ............................. 29 VALIUM TAB 5MG ............................. 29

valproate sodium oral soln 250 mg/5ml

(base equiv) .................................... 35

valproic acid cap 250 mg ................... 35 valsartan tab 160 mg ........................ 21

valsartan tab 320 mg ........................ 21

valsartan tab 40 mg ......................... 21

valsartan tab 80 mg ......................... 21 valsartan-hydrochlorothiazide tab 160-

12.5 mg ......................................... 21

valsartan-hydrochlorothiazide tab 160-25

mg ................................................ 21

valsartan-hydrochlorothiazide tab 320-

12.5 mg ......................................... 21

valsartan-hydrochlorothiazide tab 320-25

mg ................................................ 21

valsartan-hydrochlorothiazide tab 80-

12.5 mg ......................................... 21 vancomycin hcl cap 125 mg (base

equivalent) ..................................... 15

vancomycin hcl cap 250 mg (base equivalent) ..................................... 15

VAPORIZER .................................... 93

VAQTA INJ 25/0.5ML ........................ 80 VAQTA INJ 50UNT/ML ...................... 80

VARIVAX INJ ................................... 80 VCF VAGINAL AER CONTRACP ........... 63

VCF VAGINAL MIS CONTRACP ........... 63

VENCLEXTA TAB 100MG ................... 18

VENCLEXTA TAB 10MG ..................... 18 VENCLEXTA TAB 50MG ..................... 18

VENCLEXTA TAB START PK ............... 18 venlafaxine hcl cap er 24hr 150 mg

(base equivalent) ............................ 40 venlafaxine hcl cap er 24hr 37.5 mg

(base equivalent) ............................ 40 venlafaxine hcl cap er 24hr 75 mg (base equivalent) ..................................... 40

venlafaxine hcl tab 100 mg (base equivalent) ..................................... 40

venlafaxine hcl tab 25 mg (base

equivalent) ..................................... 40 venlafaxine hcl tab 37.5 mg (base

equivalent) ..................................... 40


equivalent) ..................................... 40


equivalent) ..................................... 40 venlafaxine hcl tab er 24hr 150 mg (base

equivalent) ..................................... 40


equivalent) ..................................... 40 venlafaxine hcl tab er 24hr 37.5 mg

(base equivalent) ............................ 40

146


equivalent) ...................................... 40 VENTOLIN HFA AER .......................... 92

verapamil hcl tab er 120 mg .............. 25



VERSACLOZ SUS 50MG/ML ................ 46

VICTOZA INJ 18MG/3ML .................... 59

VIDEX EC CAP 125MG ....................... 12

VIDEX EC CAP 200MG ....................... 12

VIDEX EC CAP 250MG ....................... 12

VIDEX EC CAP 400MG ....................... 12 VIDEX SOL 2GM ............................... 12

vigabatrin powd pack 500 mg ............ 35

vigabatrin tab 500 mg ....................... 35 VIIBRYD KIT STARTER ...................... 39

VIIBRYD TAB 10MG .......................... 39

VIIBRYD TAB 20MG .......................... 39 VIIBRYD TAB 40MG .......................... 39

VIMPAT SOL 10MG/ML ...................... 35 VIMPAT TAB 100MG .......................... 35

VIMPAT TAB 150MG .......................... 35

VIMPAT TAB 200MG .......................... 35

VIMPAT TAB 50MG ........................... 35 VIOKACE TAB 10440 ......................... 73

VIOKACE TAB 20880 ......................... 73 VIRACEPT TAB 250MG ...................... 13

VIRACEPT TAB 625MG ...................... 13 VIRAMUNE SUS 50MG/5ML ................ 11

VIRAMUNE TAB 200MG ..................... 11 VIRAMUNE XR TAB 400MG ................. 11 VIREAD POW 40MG/GM ..................... 12

VIREAD TAB 150MG .......................... 12 VIREAD TAB 200MG .......................... 12

VIREAD TAB 250MG .......................... 12

VIREAD TAB 300MG .......................... 12 VISTARIL CAP 25MG ......................... 90

VISTARIL CAP 50MG ......................... 90

VISTOGARD PAK 10GM ..................... 18

vitamin e cap 400 unit ...................... 88

vitamin mixture cap .......................... 88

vitamin mixture tab .......................... 88 vitamins a & d cap ............................ 88

vitamins a & d tab ............................ 88

vitamins a & d w/ c chew tab ............. 88

vitamins c & e cap ............................ 88 vitamins w/ lipotropics cap ................ 88

vitamins w/ lipotropics tab ................. 88

vitamins w/ lipotropics tab er ............ 88

VITRAKVI CAP 100MG ...................... 17 VITRAKVI CAP 25MG ........................ 17

VITRAKVI SOL 20MG/ML ................... 17

voriconazole for susp 40 mg/ml ......... 10

voriconazole tab 200 mg .................. 10

voriconazole tab 50 mg .................... 10

VORTEX VALVE MIS CHAMBER ........... 93

VORTEX/MASK MIS CHILDS .............. 93

VORTEX/MASK MIS TODDLER ............ 93

VOTRIENT TAB 200MG ..................... 17

VRAYLAR CAP 1.5-3MG ..................... 46 VRAYLAR CAP 1.5MG ........................ 46

VRAYLAR CAP 3MG .......................... 46

VRAYLAR CAP 4.5MG ........................ 46 VRAYLAR CAP 6MG .......................... 46

W warfarin sodium tab 1 mg ................. 76 warfarin sodium tab 10 mg ............... 76

warfarin sodium tab 2 mg ................. 76 warfarin sodium tab 2.5 mg .............. 76

warfarin sodium tab 3 mg ................. 76

warfarin sodium tab 4 mg ................. 76

warfarin sodium tab 5 mg ................. 76 warfarin sodium tab 6 mg ................. 76

warfarin sodium tab 7.5 mg .............. 76 WELLBUTRIN TAB 100MG SR ............. 37

WELLBUTRIN TAB 150MG SR ............. 37 WELLBUTRIN TAB 200MG SR ............. 37

WELLBUTRIN TAB XL 150MG ............. 37 WELLBUTRIN TAB XL 300MG ............. 37 white petrolatum-mineral oil ophth

ointment ....................................... 103 X XANAX TAB 0.25MG ......................... 29

XANAX TAB 0.5MG ........................... 29 XANAX TAB 1MG ............................. 29

XANAX TAB 2MG ............................. 29

XANAX XR TAB 0.5MG ...................... 29

XANAX XR TAB 1MG ......................... 29

XANAX XR TAB 2MG ......................... 29

XANAX XR TAB 3MG ......................... 29 XARELTO STAR TAB 15/20MG ........... 76

XARELTO TAB 10MG ........................ 76

XARELTO TAB 15MG ........................ 76

XARELTO TAB 2.5MG ....................... 76 XARELTO TAB 20MG ........................ 76

XELJANZ TAB 10MG ......................... 78

147

XELJANZ TAB 5MG ............................ 78

XELJANZ XR TAB 11MG ..................... 78 XIIDRA DRO 5% ............................ 104

XOLAIR INJ 150MG/ML ...................... 94

XOLAIR INJ 75/0.5 ........................... 94

XOLAIR SOL 150MG .......................... 94

Y YODEFAN-NF LIQ 200-5ML ................ 93

Z ZARONTIN CAP 250MG ...................... 35

ZARONTIN SOL 250/5ML ................... 35

ZEJULA CAP 100MG .......................... 18 ZELBORAF TAB 240MG ...................... 17

zenatane cap 10mg .......................... 95

zenatane cap 20mg .......................... 95 zenatane cap 30mg .......................... 95

zenatane cap 40mg .......................... 95

ZENPEP CAP 10000UNT ..................... 73 ZENPEP CAP 15000UNT ..................... 73

ZENPEP CAP 20000UNT ..................... 73 ZENPEP CAP 25000 ........................... 74

ZENPEP CAP 25000UNT ..................... 74

ZENPEP CAP 3000UNIT ..................... 73

ZENPEP CAP 40000 ........................... 74 ZENPEP CAP 40000UNT ..................... 74

ZENPEP CAP 5000UNIT ..................... 73 ZIAGEN SOL 20MG/ML ...................... 12

ZIAGEN TAB 300MG ......................... 12 zidovudine cap 100 mg ..................... 12

zidovudine syrup 10 mg/ml ............... 12 zidovudine tab 300 mg ...................... 12 ziprasidone hcl cap 20 mg ................. 46

ziprasidone hcl cap 40 mg ................. 46 ziprasidone hcl cap 60 mg ................. 46

ziprasidone hcl cap 80 mg ................. 46

ZOLINZA CAP 100MG ........................ 18 zolmitriptan orally disintegrating tab 2.5

mg ................................................. 55

zolmitriptan orally disintegrating tab 5

mg ................................................. 55

zolmitriptan tab 2.5 mg ..................... 55

zolmitriptan tab 5 mg ....................... 55 ZOLOFT TAB 100MG ......................... 39

ZOLOFT TAB 25MG ........................... 39

ZOLOFT TAB 50MG ........................... 39

zolpidem tartrate tab 10 mg .............. 53

zolpidem tartrate tab 5 mg ............... 53 zolpidem tartrate tab er 12.5 mg ....... 54

zolpidem tartrate tab er 6.25 mg ....... 53

ZOMACTON INJ 10MG ...................... 67

ZOMACTON INJ 5MG ........................ 67

ZONEGRAN CAP 100MG .................... 35

ZONEGRAN CAP 25MG ..................... 35

zonisamide cap 100 mg .................... 35

zonisamide cap 25 mg ...................... 35

zonisamide cap 50 mg ...................... 35

ZONTIVITY TAB 2.08MG ................... 77 ZORBTIVE INJ 8.8MG ....................... 67

ZORTRESS TAB 0.25MG ................... 79

ZORTRESS TAB 0.5MG ..................... 79 ZORTRESS TAB 0.75MG ................... 79

ZOSTAVAX INJ ................................ 80

ZOSTRIX NAT CRE 0.033% .............. 100 ZUBSOLV SUB 0.7-0.18 .................... 57

ZUBSOLV SUB 1.4-0.36 .................... 57 ZUBSOLV SUB 11.4-2.9 .................... 57

ZUBSOLV SUB 2.9-0.71 .................... 57

ZUBSOLV SUB 5.7-1.4 ..................... 57

ZUBSOLV SUB 8.6-2.1 ..................... 57 ZYDELIG TAB 100MG ....................... 17

ZYDELIG TAB 150MG ....................... 17 ZYKADIA CAP 150MG ....................... 17

ZYKADIA TAB 150MG ....................... 17 ZYPREXA INJ 10MG .......................... 46

ZYPREXA RELP INJ 210MG ................ 46 ZYPREXA RELP INJ 300MG ................ 46 ZYPREXA RELP INJ 405MG ................ 46

ZYPREXA TAB 10MG ......................... 46 ZYPREXA TAB 15MG ......................... 46

ZYPREXA TAB 2.5MG ........................ 46

ZYPREXA TAB 20MG ......................... 46 ZYPREXA TAB 5MG .......................... 46

ZYPREXA TAB 7.5MG ........................ 46

ZYPREXA ZYDI TAB 10MG ................. 46



ZYPREXA ZYDI TAB 5MG ................... 46 ZYRTEC ALLGY TAB 10MG ................. 90

ZYRTEC CHILD TAB 10MG ................. 90

Documents

HMSA QUEST Integration Managed Medicaid Formulary · 2020. 2. 4. · HMSA QUEST Integration Managed Medicaid Formulary (Effective 02/01/2020) LEGEND AL Age Limit ... drugs, strengths,